PMID- 10150199 TI - Residencies and health reform. PMID- 10150200 TI - Curbing costs in your microbiology lab. PMID- 10150201 TI - Getting in on the deal. PMID- 10150202 TI - Melanoma's problems are more than cosmetic. PMID- 10150203 TI - Exporting medical know-how. PMID- 10150204 TI - Labs assess transfusions. PMID- 10150205 TI - Bringing glucose testing to the bedside. PMID- 10150206 TI - Blood supply: weighing which tests stay. PMID- 10150207 TI - Uncovering the unexpected. PMID- 10150208 TI - Surface treatment of alloys for resin adhesion: an in-vitro study. AB - Successful adhesive dentistry is reliant on the strength and durability of the resin-bond. This is affected by the alloy and its preparation, the properties of the luting resin, and the condition of the tooth. This in-vitro study investigated three months of preparation of the alloy surfaces and three different types of one resin luting cement. Results demonstrated that alumina blasted nickel-chromium alloy specimens were significantly more resistant to failure under tensile loading than gold alloy samples however prepared. Alumina blasted, heat-treated gold alloy specimens showed significantly higher tensile failure loads than those of alumina-blasted gold. The performance of the different resins with the alumina-blasted nickel-chromium or the alumina-blasted, heat-treated gold alloy specimens was similar. However, for the alumina-blasted gold alloy specimens, there was a significant difference when comparing resin types. PMID- 10150209 TI - The response of cultured bone cells to resorbable polyglycolic acid and silicone membranes for use in orbital floor fracture repair. AB - Two membranes intended for use in repairing fractures of the orbital floor- reinforced silicone and biodegradable polyglycolic acid (PGA)--were evaluated in vitro using a rat bone cell culture model. After two weeks in culture, cells had colonised the surface of both materials. Bone cells penetrated the weave of the PGA membrane after three weeks in culture, forming a calcified collagenous bone like tissue within the weave of the PGA at the same time as there was evidence of resorption of the PGA. In contrast, cells could easily be dislodged from the surface of the reinforced silicone membrane and there was less evidence of mineralised extra cellular matrix production. The production of a bone-like tissue within the weave of the PGA membrane supported previous reports of osteoconductive activity of this material. PMID- 10150210 TI - Some characteristics of new DNA-bearing plasmoimmunoadsorbents based on fibrous activated carbon. AB - A new dual adsorbent containing from 1 to 8 mg of native or denatured thymic DNA per 1 g of the fibrous activated carbon matrix has demonstrated sufficient biocompatibility and good selectivity for DNA-binding plasma substances. At the same time, this dual adsorbent exhibits a full scale of coupling modalities characteristic of the highest quality activated carbons. All these features of DNA-coated fibrous activated carbons allow them to be considered as promising plasmosorbents for the treatment of numerous immuno-dependent diseases and metabolic disorders. PMID- 10150211 TI - An in-vitro evaluation of coralline porous hydroxyapatite as a scaffold for osteoblast growth. AB - The purpose of this study was to determine the potential of coralline calcium phosphate ceramics to support osteoblast growth for a proposed bone-ceramic composite for skeletal tissue repair. The goal was the development of a matrix with both osteogenic and osteoconductive properties, as compared to ceramic alone, which is solely osteoconductive. MC3T3-E1 osteoblast-like cells were seeded onto sintered and non-sintered porous coralline hydroxyapatite (HA), and onto non-porous hydroxyapatite discs. These in-vitro studies demonstrated that coralline HA supported the growth of osteoblast-like cells. Porous discs supported higher numbers of cells than non-porous discs. Sintering encouraged cell growth, with higher numbers of cells adhered to sintered porous HA discs by day seven. The results suggest that HA can provide a support for osteoblast cells as part of a matrix which may prove to be osteogenic in vivo and may, accordingly, enhance the bone repair process. PMID- 10150212 TI - Compliance of an apatitic calcium phosphate cement with the short-term clinical requirements in bone surgery, orthopaedics and dentistry. AB - An apatitic calcium phosphate cement was developed containing a nucleator in its powder and an accelerator in the liquid and having an initial setting time of 7.5 min and a final setting time of 12.5 min according to testing with Gillmore needles at room temperature. At body temperature the initial setting time is 6 min, after which the wound can be closed. The dough time (during which it can be deformed without damaging its microstructure) is 4 min. Therefore, the time lost during an operation with this material is 2 min. The product does not shrink or expand during setting, neither is there a thermal effect; it does not swell or disintegrate upon exposure to aqueous fluids after initial setting. Upon soaking in Ringer's solution the product obtains a final compressive strength of 40 MPa and 65% of that strength is reached within 6 h at body temperature. Cytotoxicity is absent. Applications are envisaged in bone surgery, orthopaedics and dentistry, a.o. for acceleration of the osseointegration of metal endoprostheses. PMID- 10150213 TI - Caring for chronic pain patients. PMID- 10150214 TI - Planning for home TPN. PMID- 10150215 TI - TBI rehabilitation program assessment: putting a yardstick to quality and efficacy. PMID- 10150216 TI - Wave of the future. PMID- 10150217 TI - High risk pregnancy. PMID- 10150218 TI - Sleep disorders: treatment options and trends. PMID- 10150219 TI - Cancer services. Helping patients through the maze. PMID- 10150220 TI - Early intervention, physical therapy and industrial rehabilitation: prescription for success. PMID- 10150221 TI - Outcomes measurements--tools for case management decisions. PMID- 10150222 TI - A comparison of once daily versus twice daily nisoldipine as monotherapy in patients over 65 years of age. AB - The antihypertensive effect of the calcium antagonist nisoldipine was investigated in 33 elderly hypertensive patients. This randomised double-blind study involved a dose titration of both once and twice daily nisoldipine from 5 mg up to a maximum of 20 mg/day, with placebo treatment both before and after nisoldipine. Blood pressure measurements were made 12/24 h post-dose to assess 24 h blood pressure control. The majority of patients required a daily dose of 20 mg. There were no significant differences seen between the two treatment regimens. Nisoldipine given either once or twice daily, significantly reduced blood pressure when compared to baseline values. Three patients withdrew from the study because of adverse events whilst on nisoldipine once daily treatment. Overall the incidence of adverse event was higher on once daily treatment, although the majority were mild and did not require withdrawal of treatment. Nisoldipine effectively lowered the blood pressure of these elderly hypertensive patients and was reasonably well-tolerated. PMID- 10150223 TI - Pre-hospital treatment of patients with suspected acute myocardial using a beta blocking agent: a double-blind feasibility study. EMIP-BB Pilot Study Group. AB - The efficacy of intravenous beta-blocker treatment in hospital patients with acute myocardial infarction (AMI) in reducing short-term mortality and morbidity has been demonstrated; the efficacy seems to be higher the earlier the treatment is administered. We assessed the feasibility of pre-hospital treatment of patients in a randomised, double-blind, controlled pilot study. Eligible patients (symptoms suggestive of AMI for less than 2 h) were randomised by mobile emergency unit staff to receive either pre-hospital beta-blocker treatment (intravenous injection of atenolol) immediately, followed by placebo in hospital, or the opposite. All patients received a 7-day course of oral atenolol at the discretion of the hospital physician. A total of 77 patients were included (41 in the pre-hospital beta-blocker group and 36 in the pre-hospital placebo group). Sixteen patients in each group received active treatment, but only 9 and 11 patients, respectively, received full treatment. The reasons for the non administration of the second injection included the occurrence of adverse events after the first injection, and a certain reserve on the part of the hospital physicians to administer beta-blocker treatment in patients with suspected myocardial infarction. Three patients in each group died; the minor adverse event rate was similar in the two groups. The findings of the study suggest that this approach would be feasible in terms of safety. However, a large number of patients did not receive any hospital treatment for a number of reasons which must be considered if a large-scale trial is to be undertaken. PMID- 10150224 TI - Surrogate end-points: the case of trials on coronary atherosclerotic plaque regression. AB - The experimental progression-regression human model offers an excellent opportunity for testing the pathophysiological hypotheses that have arisen in the study of atherosclerosis. Nevertheless, it is still necessary to demonstrate that the modifications of angiographic patterns are strictly related to changes in coronary events, and this evidence is not yet supported to date by performed trials. Ten randomized controlled trials designed with the aim of angiographically evaluating the evolution of coronary lesions in patients with coronary heart disease made over the past 13 years were reviewed to perform a meta-analysis. Quality of design and execution of the trials, and the analysis of the primary and secondary end-points chosen for each trial, as well as the methods used to measure the changes in atherosclerotic plaques were also assessed. The phenomenon of plaque regression in human beings seems to occur, but clinical, methodological and physiopathologic heterogeneity between examined trials made it unfeasible to perform a meta-analysis. Coronary events are the consequence of the interaction of known and unknown factors, and coronary arterial narrowing from a mild to moderate degree is only one of these factors. The choice of the regression of atherosclerotic plaques as the primary end-point of a trial should probably be confined to phase 2 studies, while proof of clinical efficacy should be based on harder end-points that are representative of the very objective of medical interventions: amelioration and/or prolongation of a patient's life. PMID- 10150225 TI - Meta-analysis of phenobarbital usage for prevention of intraventricular hemorrhage in premature infants: factors related to variation in outcome. AB - PURPOSE: To assess the efficacy of phenobarbital for the prevention of intraventricular hemorrhage (IVH) in premature infants and to identify study characteristics that were associated with beneficial or adverse effects. DATA IDENTIFICATION: Studies published from 1981 to 1994 were identified through a computerized search, and by searching the bibliographies of all identified articles. STUDY SELECTION: Ten randomized, controlled clinical trials were selected. DATA EXTRACTION: Data were extracted from each article, including the percentage of patients in the control and treatment groups with IVH, and key patient and study characteristics. RESULTS OF DATA ANALYSIS: Seven studies showed no statistically significant effects, two studies showed a beneficial effect of phenobarbital, and one study showed an adverse effect. The meta-analysis showed no significant difference in the percentage of IVH in treated and untreated infants when treatment effects were combined across all studies. However, prenatal administration of phenobarbital in two studies was associated with a beneficial effect. CONCLUSIONS: Overall, we did not find a significant beneficial effect of postnatal phenobarbital administration. The data suggests that prenatal phenobarbital is beneficial. Further evaluations of the efficacy of prenatal phenobarbital are warranted. PMID- 10150226 TI - The Lifestyle Criminality Screening Form and Antisocial Personality Disorder: predicting release outcome in a state prison sample. AB - The Lifestyle Criminality Screening Form (LCSF) was compared with a clinical diagnosis of Antisocial Personality Disorder for the purposes of determining the relative efficiency of each measure in predicting the release outcome of 100 medium security New Mexico state prisoners. An 18-month follow-up revealed that high LCSF scores (total score > or = 10) and clinical diagnoses of Antisocial Personality Disorder effectively identified inmates who were eventually reincarcerated for a parole violation or new offense. However, because substantial overlap occurred between these two predictors (kappa = .58) partial correlations were calculated and revealed that only the LCSF displayed a robust relationship with release outcome independent of the other predictor measure. PMID- 10150227 TI - Therapeutic jurisprudence and conflicts among values in mental health law. AB - Therapeutic Jurisprudence provides a conceptual framework for a research agenda designed to promote development of legal rules, procedures, and roles in a manner consistent with the therapeutic mission of the mental health system. As such, it draws attention to the tension between the jurisprudential values of autonomy and well-being that permeates mental health law specifically and the law and ethics of health care generally. This article advances an analysis of these values in the context of the patient-centered approach to health care. The article endorses a priority for the deontic aspect of autonomy over well-being but allows balancing of the consequentialist component of autonomy against well-being. Finally, it applies this framework to several traditionally difficult types of cases. PMID- 10150228 TI - The normative and conceptual foundations of a clinical duty to protect. AB - The continuing controversy surrounding the Tarasoff inspired duty to protect as developed by the courts and legislatures has not adequately weighed the jurisprudential foundations of such an obligation. The authors argue that the duty's misguided thrust of social control grounded in character and status seriously violates broad principles of political morality underlying the law of social control. They conceptualize an alternative--a clinical duty to protect- that coheres with these underlying values and the limits of professional abilities. They contend that any extra-clinical intervention on the part of the psychotherapist entails a role transformation requiring independent justification. PMID- 10150229 TI - Child abuse and the limits of confidentiality: forewarning practices. AB - Confidentiality is widely considered to be of great importance in psychotherapy. With few exceptions, the breaching of confidentiality is an ethical violation and grounds for litigation. One such exception is the mandated reporting of known or suspected child abuse, representing a legally sanctioned limitation of confidentiality. Because clients generally expect unlimited confidentiality in therapeutic relationships, many therapists have begun to "forewarn" clients as a matter of informed consent. This research report: (a) briefly reviews issues surrounding mandatory reporting and confidentiality as they relate to forewarning, (b) defines and discusses forewarning as contrasted with "informing," (c) examines state statutes, case law and ethical guidelines relevant to forewarning, and (d) presents a survey of 428 mental health providers (MHPs) on their forewarning practices in which 36.9% forewarned all clients, 36.4% informed clients only upon suspicion of abuse, and 20.6% informed only after receiving a disclosure of abuse. The implications of these findings are discussed. PMID- 10150230 TI - The use of mental health professional consultants to police hostage negotiation teams. AB - Three hundred law enforcement agencies in the United States that employ a negotiator in hostage incidents responded to a survey regarding the use of mental health professionals as consultants to the negotiation team. Thirty-nine percent of the agencies with a negotiator use a mental health professional consultant to the negotiation team. Police agencies that use a mental health professional as a consultant on negotiation techniques reported more hostage incidents ending by negotiated surrender and fewer hostage incidents ending by tactical team assault and arrest of the perpetrator. Also, police agencies that use a mental health professional as a consultant on the assessment of the perpetrator reported fewer hostage incidents resulting in the serious injury or death of a hostage. Although these results are only correlational, they raise the possibility that the use of mental health professionals as consultants to police hostage negotiation teams may decrease the risk of hostage injury and death. PMID- 10150231 TI - Patient, family, and staff perceptions of coercion in mental hospital admission: an exploratory study. AB - Little is known about the coercive pressures brought to bear on psychiatric patients in the hospitalization process. Significant methodological hurdles stand in the way of this research. Most notably, reliable and valid methods of ascertaining and quantifying perceptions of coercion have not been developed. This report summarizes the findings of an exploratory study designed to gather data needed to refine the conceptualization and measurement of coercion. Multiple perspectives on admission incidents for forty-three patients (26% of whom were involuntarily hospitalized) were obtained. Patients were administered research interviews and completed a self-administered inventory shortly after the admission decision. The admitting clinician and a family member involved in the admission were administered parallel interviews. In addition, focus groups comprised of outpatients, former patients, family members, and clinical staff were conducted to uncover the terminology and description of coercion commonly used. The implications of these preliminary quantitative and qualitative findings for future research are discussed. PMID- 10150232 TI - Inclusion, motivation, and good faith: the morality of coercion in mental hospital admission. AB - We administered a semi-structured interview to 157 patients shortly after their admission to a psychiatric hospital. In the first, and open-ended, part of the interview, patients were asked to talk about what had been going on in their lives that led to their coming into the hospital. Then, in a more structured format, they were asked more specific details about who was involved, the patients' relationships with those involved, whether any attempts were made to influence the patient to come into the hospital, and whether such attempts were perceived as fair by the patient. This article presents a qualitative review of the transcripts of a subset of these interviews. It attends specifically to patients' perceptions of the morality of attempts by others--primarily family members, friends and mental health professionals--to influence them to be admitted to the hospital, and of the morality of the process by which these influence attempts resulted in admission. PMID- 10150233 TI - Two scales for measuring patients' perceptions for coercion during mental hospital admission. AB - Legal and extra-legal coercion are pervasive in mental hospital admission and there are sharp disputes about its appropriate role. This article presents two scales for measuring psychiatric patients' perceptions of coercion during hospital admission and reports data on these scales' internal consistency. We measure patients' perceptions of coercion by asking questions, in either an interview or questionnaire format, about their experience of lack of control, choice, influence, and freedom in hospital admission. Patients' responses to questions about their perceptions of coercion were highly internally consistent. The internal consistency of the scale was robust with respect to variation in site, instrument format, patient population, and interview procedure. Correspondence analysis was used to construct two numerical scales of perceived coercion. PMID- 10150234 TI - Treatment of suicidal patients: a risk-benefit analysis. AB - A therapist may be held liable when a patient commits suicide if previous suicidal tendencies were observed but reasonable precautions were not taken. In order to reduce liability and enhance treatment effectiveness, therapeutic decisions can be critiqued by estimating the risks and benefits associated with different courses of action. An evaluation of risks and benefits can be used to guide decisions regarding assessment, hospitalization, medications, and discharge from the hospital. A risk-benefit analysis can help therapists utilize a broad range of treatment options while allowing patients the maximum degree of autonomy. Additionally, all aspects of treatment should be well documented, including information about the specific course of action chosen, other treatment options considered, and the therapeutic rationale for deciding which treatment plan was best suited to the patient's needs. PMID- 10150235 TI - A review of ventilatory modalities used in the intensive care unit. AB - Mechanical ventilation of the lungs is an integral component of modern medical practice in the operating room and intensive care unit settings. Most ventilators available in the operating room are capable of providing only controlled mechanical ventilation. With the increasing use of the microprocessor-controlled ventilators in the intensive care unit, there are now a wide variety of ventilatory types and mode choices available to the clinician. This paper summarizes some of the ventilatory choices currently available and mentions some of the newer and experimental modalities available in larger centers. PMID- 10150236 TI - Do not resuscitate in the operating room: more than rights and wrongs. PMID- 10150237 TI - The laryngeal mask airway. Safety, efficacy, and current use. AB - In 1983, the laryngeal mask airway (LMA) was introduced as a new airway device. It can be inserted without the aid of a laryngoscope or neuromuscular blockade. Compared with the face mask, the LMA allows for a more "hands-free approach" to airway management providing the anesthesiologist the freedom of not holding a mask. In addition, the LMA is more effective than the face mask, with or without a Guedel airway, during emergency resuscitation in situations where endotracheal intubation is difficult or not possible. The LMA seems to provide better oxygenation than the face mask; but unlike the endotracheal tube, it does not protect the airway from aspiration of gastric contents if regurgitation occurs. For this reason, it is believed that the LMA should not be used in place of an endotracheal tube during emergency rescue, but rather as an adjunct to airway management prior to intubation. It is possible that the risk of regurgitation with or without aspiration may be minimized if proper screening of patients is employed prior to use of the LMA. The current literature concerning its safety and efficacy is reviewed. PMID- 10150238 TI - Small-volume resuscitation. Crystalloid solutions for intravascular volume replacement. AB - There is growing interest in the use of hypertonic crystalloid solutions for intravascular volume replacement. Such solutions rapidly restore nutrient blood flow to vital organs by a combination of increased perfusion pressure and vascular dilation. The addition of colloid to the solution appears to improve survival by limiting the tissue damage caused by ischemic injury and may avert the development of multisystem organ failure. Low cost and long shelf life make hypertonic solutions attractive for acute resuscitation after major trauma, but further investigations are warranted as to their efficacy and safety in the clinical setting. PMID- 10150239 TI - Hip dysplasia in spastic cerebral palsy. AB - Previous reports have noted a relationship between pelvic obliquity and hip dysplasia in spastic cerebral palsy but did not confirm its existence by scientific study. A study is reported that confirms the association of pelvic obliquity with hip dysplasia in spastic cerebral palsy. At presentation of subluxation or dislocation prior to surgery, 80 patients were indexed into five body alignment types. Reclassifications were performed with passage of time in order to study the natural history and effects of surgery. In all cases, hip dysplasia was found to be consistent with the forces related to pelvic obliquity. PMID- 10150240 TI - Osteophyte formation in the vertebral column: a review of the etiologic factors- Part II. AB - Osteophyte formation in the vertebral column is a well documented phenomenon that is poorly understood. The most commonly identified etiologic factors are degeneration and altered mechanics of the spine, either of which in turn have been considered to be a result of the natural aging process or the pathogenesis of spinal disease. In Part I [Contemporary Orthopaedics, 29(1): 31-37, 1994], the process of osteophyte formation was reviewed. In Part II, the sequential and consequential changes from the finely interwoven events of aging, degeneration, mechanical instability, and disease are described. PMID- 10150241 TI - The locked metacarpophalangeal joint: report of four cases and review of the literature. AB - Four cases of locked finger metacarpophalangeal joints are reported. Two of these cases were caused by entrapment of the sesamoid behind an exostosis off the second metacarpal head. The third was from subluxation of the dorsal interosseous tendon over a dorsal osteophyte on the metacarpal. The fourth was from an exostosis tethering the accessory collateral ligament. Surgical exploration using a palmar approach was the treatment of choice. All patients regained full range of motion within two months. A review of the various causes and treatment options for this unusual condition is presented. PMID- 10150242 TI - Ewing's sarcoma of the foot bones: an analysis of seven cases. AB - Seven cases of Ewing's sarcoma presenting with primary lesions of the foot bones are described. Difficulty and delay in making the initial diagnosis are the hallmarks of the problems encountered at this site. Although radiation therapy plays an important role for control of disease in Ewing's sarcoma, surgery along with chemotherapy appears to give better results. Lesions of the forefoot are amenable to surgery; however, no guidelines are available in the literature for hindfoot lesions. Chemotherapy has revolutionized the outcome, and its use along with surgical intervention is recommended in all cases of Ewing's sarcoma of foot bones. PMID- 10150243 TI - Symposium: partial foot amputations. PMID- 10150244 TI - Prognostic factors in lumbar spinal fusion. AB - The charts of 234 patients who underwent 260 spinal fusions for degenerative spinal disease were reviewed to determine prognostic factors for predicting successful surgical outcome. All patients were evaluated for fusion success and symptomatic relief. Pseudarthrosis occurred in 26 patients (10%) and 14 others failed to have symptomatic improvement despite successful fusion. Outcome was found to be significantly related to smoking status, diagnosis, use of hardware, insurance status, preoperative SGPT level, prior operations or decompressions, and age. The relative risk associated with smoking was 2.9. The association with smoking was present for both subjective and objective poor outcomes. A predictive function based on smoking status and diagnosis was developed. Ninety-two percent of nonsmokers with favorable diagnoses had a good outcome, compared to 77% of those with unfavorable diagnoses. The percentages for the comparable groups of smokers were 77% and 54%. PMID- 10150245 TI - Injuries of the distal radioulnar joint. AB - Injuries of the distal radioulnar (DRU) joint are common. If the joint is unstable or discongruous, attempts should be made to restore anatomic alignment and stability. Although most acute injuries of the DRU joint are easily treated, they are often overlooked or misdiagnosed because they usually occur in association with other major injuries of the upper limb. Acute and chronic abnormalities are described briefly and the treatment for each is discussed. Appropriate diagnosis and management of the acute injury will yield a much higher success rate than reconstructive procedures to correct a chronic disorder. A differentiation should be made between DRU joint dysfunction and ulnar impingement against the carpus; ulnar shortening is the most commonly used technique to treat the latter condition. In an elderly patient, a Darrach procedure is the preferred treatment for a DRU joint dysfunction; in younger patients, the treatment of choice appears to be resection arthroplasty of the DRU joint with preservation of the ulnar length, the ulnar styloid, and the triangular fibrocartilage complex (TFCC). In cases of malunion of the distal radius with involvement of the DRU joint, the recommended treatment is corrective osteotomy and soft tissue reconstruction of the ligamentous support of the joint. PMID- 10150246 TI - Symposium: subtrochanteric femoral fractures: current concepts in treatment. PMID- 10150247 TI - Thoracic and lumbar spine injuries in children: different than in adults. AB - A study of 38 patients, ages birth through 17 years, is reported that was performed to identify patterns of thoracic and lumbar spine injuries and healing in children in order to make appropriate treatment recommendations and avoid unnecessary surgery. This retrospective/prospective study, which is the largest review of children's thoracic and lumbar spine injuries in the orthopaedic literature, supports several accepted concepts regarding children's spine fractures. In addition, the periosteal sleeve fracture mimicking lumbar dislocations in small children, which has not been reported previously in the clinical setting, is described. Thoracic and lumbar spine injuries in children have distinct differences from these injuries in adults, and the treatment should take these differences into consideration. PMID- 10150248 TI - Patellofemoral resurfacing at total knee arthroplasty. AB - A retrospective review of 268 primary total knee arthroplasties (TKAs) with a mean follow-up of four years is presented. The patellae were resurfaced in all cases. There were six complications (2.2%) referable to the patellofemoral articulation: three subluxations, one patellar fracture, one loosening of a metal backed patellar component, and one patellar tendon avulsion. Successful patellofemoral resurfacing (PFR) can be accomplished with minimal complications if the following technical considerations are met: 5-7 degrees of valgus alignment; medial placement of the patellar component; taking care not to increase either the AP diameter of the knee or the thickness of the patella; avoiding internal rotation of either the tibial or femoral components and proper soft tissue balancing. A thorough review of patellofemoral complications after TKA is presented, and technical considerations relevant to the successful performance of PFR are discussed. PMID- 10150249 TI - Protected early motion versus cast immobilization in postoperative management of ankle fractures. AB - Sixty-one active-duty military personnel with operatively treated ankle fractures were randomized into two postoperative immobilization regimens: Group I--six weeks short-leg cast, nonweight-bearing; Group II--six weeks removable orthosis, nonweightbearing. Group I began physical therapy at six weeks postoperatively, and Group II began physical therapy within the first postoperative week. Objective measurements of swelling, strength, range of motion, and functional tests were examined. Subjective scores of pain, function, cosmesis, and motion were recorded. Patients in Group II (early mobilization) had significantly better subjective scores at three and six months postoperatively; however, time to return to duty was not significantly different. Objective tests of swelling, strength, range of motion, and functional tests were not significantly different at three months postoperatively for either group. Early mobilization in a removable orthosis, while not objectively altering the postoperative course, provides a safe, preferable method of treatment in the reliable and cooperative patient. PMID- 10150250 TI - Reflex sympathetic dystrophy following total knee replacement. AB - Twenty-nine patients who eventually had a diagnosis of reflex sympathetic dystrophy (RSD) following total knee replacement were treated with lumbar sympathetic blocks with local anesthetic. The diagnosis was made based on the complaint of constant pain unrelated to physical activity in the absence of overt sepsis or implant loosening. In six of these cases, other factors may have clouded the diagnosis. Thirteen (44.8%) patients obtained complete relief following an average of 1.8 blocks. Three of these patients had symptoms for more than two years. Twelve patients had complete or partial relief for varying periods of time, but the relief was not sustained. Three obtained no relief at all, and in one the block could not be successfully carried out. This success rate, while shedding no light on the etiology or diagnostic accuracy, has encouraged the authors to continue with this method of treatment in such cases. PMID- 10150251 TI - Symposium: options in transfusion therapy. PMID- 10150252 TI - Comparison of computerized tomography parameters of the thoracolumbar spine in normal control subjects and spinal cord injured patients. AB - The cross-sectional area and the sagittal and transverse diameters of the spinal canal at the thoracolumbar junction were measured using high resolution thin section computerized tomography images in 15 control subjects and 28 patients with traumatic injury to the spinal cord at the thoracolumbar junction. No significant difference between the control and study groups was found with regard to any of the three measures taken. With the exception of the sagittal canal diameter for the first lumbar vertebra, all the mean values were higher for the spinal cord injured group. The ratio of the sagittal to transverse diameter was larger for the control group; however, this difference also was not significant. These findings suggest no significant differences in the dimensions and shape of the canal at the thoracolumbar region between the spinal cord injured and control groups. In contrast to the cervical spinal canal, there appears to be no correlation between the spinal cord injury and the dimensions of the thoracolumbar spinal canal. PMID- 10150253 TI - Timing of internal fixation in low-velocity extremity gunshot fractures. AB - A ten-year retrospective review of extremity long bone gunshot fractures treated operatively at the Elmhurst City Hospital Center, New York, was performed to examine the operative outcomes with regard to immediate, intermediate, and delayed fixation. A total of 121 low-velocity gunshot fractures were evaluated in 107 patients. Cases were separated into three groups according to the actual timing of the internal fixation procedure. The results revealed a total deep infection rate of 2.6% (3/121) and a nonunion rate of 3.3% (4/121), with no significant differences among the three groups. Early internal fixation reduced comparative hospital stay length and overall costs for operative patients. PMID- 10150254 TI - The effect of recombinant human erythropoietin therapy on red cell expansion during autologous blood donation. AB - As the result of the institution of coordinated programs involving regional blood centers, hospital blood banks, information services, and physicians, preoperative autologous blood donation, a previously underutilized practice, has become a standard of care in a number of elective surgical procedures. In addition, the administration of recombinant human erythropoietin has been shown to facilitate the collection of autologous blood from patients scheduled for elective orthopaedic surgery. An analysis of the findings in a study of 263 orthopaedic surgical patients in which the relationship between autologous blood ordering, collection and storage, and subsequent blood transfusion was studied indicates that both blood ordering and blood procurement practices are significant factors with regard to allogeneic blood exposure. PMID- 10150255 TI - Symposium: lumbar spine fixation--the pedicle screw controversy. PMID- 10150256 TI - Conversion of hip arthrodesis to total joint arthroplasty. AB - Conversion of a hip arthrodesis to a total joint arthroplasty is an uncommon procedure compared to the standard or revision total hip replacement. In this report, two illustrative cases are presented in which conversion to a total joint arthroplasty was performed, and a review of the literature for indications, complications, contraindications, and outcomes of this procedure is provided. PMID- 10150257 TI - Symposium: the relationship between polyethylene quality and wear. PMID- 10150258 TI - New options for nitrocefin-based beta-lactamase testing. PMID- 10150259 TI - Simultaneous multianalyte immunoassay of drugs of abuse by CE. PMID- 10150260 TI - Effect of different ventilator settings on lung mechanics: with special reference to the surfactant system. PMID- 10150261 TI - Stress: an overview of the literature with emphasis on job-related strain and intervention. AB - Maintained stress produces a constellation of neurochemical and hormonal changes that involve both the hypothalamic-pituitary-adrenal axis and a variety of brain regions. Long-term stress can produce psychological and physiologic consequences including anxiety, depression, hypertension, impaired immune system function, and an increased risk of cancer and coronary heart disease. Negative responses to perceived job-related stress usually occur when an individual has relatively little control over the means to meet high job demands. Among the approaches to reduce workplace stress, changing the coping strategies of challenged employees, particularly by increasing decision latitude, can significantly relieve both the psychological and physiologic consequences. Nevertheless, behavioral intervention is not invariably successful, and benzodiazepines are often prescribed to manage inadequately alleviated anxiety. Evidence that excessive serotonergic neurotransmission may underlie anxiety has prompted the use of compounds such as buspirone. This partial agonist of the 5-HT1A receptor has been demonstrated to be as effective as benzodiazepines in controlling generalized anxiety symptoms and to have a more favorable side-effect profile. PMID- 10150262 TI - A comparison of ampicillin/sulbactam and cefoxitin in the treatment of bacterial skin and skin-structure infections. AB - Seventy-six hospitalized patients with complicated skin/soft-tissue infections were enrolled in this randomized, prospective, third-party-blinded, comparative study of the effectiveness and safety of intravenous or intramuscular administration of ampicillin/sulbactam (1.0 to 2.0 g ampicillin plus 0.5 to 1.0 g sulbactam every 6 hours) and cefoxitin (1.0 to 2.0 g every 6 hours). Twenty-five of 36 ampicillin/sulbactam patients and 33 of 39 cefoxitin patients were evaluable. Clinical and bacteriologic effectiveness did not differ significantly between the two treatment groups (P = .674, P = .118, respectively); neither did duration of hospitalization (P = .894). Twenty-one (84%) ampicillin/sulbactam patients were cured, 2 (8%) were improved, and 2 (8%) were treatment failures. Twenty-eight (85%) cefoxitin patients were cured, 4 (12%) were improved, and 1 (3%) was a treatment failure. All primary pathogens were eradicated in 6 (24%) ampicillin/sulbactam patients; partial eradication occurred in 9 (36%). Primary pathogens were eradicated in 15 (47%) cefoxitin patients and partially eradicated in 8 (25%). Both treatments were well tolerated, with a small number of adverse reactions in each group. The overall incidence of adverse events was similar in the two groups. PMID- 10150263 TI - Consulting with the anxious patient, Part I: Complexities of the consultation process and problems of referral. AB - At least 20% of medical patients have anxiety disorders and are in need of treatment, but work with anxious patients is complicated by their distortions and often negative attitudes toward physicians and hospitals. Consultation is complicated by inconsistent referral patterns. Most anxious medical patients accept psychiatric consultation: only 15% to 20% have negative attitudes toward psychiatry. Guidelines for referral are presented. PMID- 10150264 TI - Reducing the dose of oral NSAIDs by use of Feldene Gel: an open study in elderly patients with osteoarthritis. AB - This open, parallel-group, multicenter study enrolled 191 general practice patients with mild to moderate osteoarthritis (OA) who were taking oral nonsteroidal anti-inflammatory drugs (NSAIDs). One group continued their usual NSAID treatment for 28 days without change in drug or dose. The other group reduced their dose of oral NSAID by a factor of two and concomitantly used 1 g of Feldene Gel, applied topically three or four times daily for 14 days. At the end of this period, if symptoms of OA remained controlled, the oral NSAID was stopped and patients used only the topical preparation for a further 14 days. Symptom scores as assessed by patients and investigators were similar for the two groups 14 and 28 days after Feldene Gel was started, except for tenderness and restriction of active movement. These parameters were significantly different in favor of the group treated topically. An assessment of quality of life also favored treatment with Feldene Gel. Both groups tolerated treatments well. Similar control of symptoms was observed in both groups when the oral NSAID was supplemented with Feldene Gel and when Feldene Gel was the only treatment. PMID- 10150265 TI - Effectiveness of bromochlorophene on gingival health. AB - The effect of a commercial toothpaste containing 0.2% bromochlorophene (BCP) on established plaque and gingivitis was compared with placebo. The two toothpastes were similar in packaging, taste, consistency, and color. Thirty-two patients with chronic gingivitis were enrolled in this randomized, double-blind comparison and were asked to brush twice a day with the given toothpaste without changing their oral hygiene habits. Plaque index, gingival index, gingival crevicular fluid, and papillary bleeding index were recorded at baseline and after 3 weeks. Significant decreases in gingival and papillary bleeding indices were noted in the BCP group, as compared with the placebo group. Plaque index significantly decreased in both groups. No significant change was noted in the volume of gingival crevicular fluid. PMID- 10150266 TI - Analgesic efficacy and safety of two oral controlled-release morphine preparations in orthopedic postoperative pain. AB - This single-dose, double-blind, randomized, parallel-group study compared the analgesic efficacy and safety of MS Contin (MSC) and Oramorph SR (OSR), two controlled-release preparations of oral morphine sulfate, in patients following orthopedic surgery. One hundred patients received MSC 30 mg, MSC 60 mg, or OSR 60 mg (two 30-mg tablets) when postoperative pain became moderate or severe. Patients self-rated pain intensity and relief on categorical (CAT) and visual analogue scales (VAS) hourly for up to 12 hours. MSC 60 mg produced the greatest peak analgesic effect and was more efficacious than OSR 60 mg through the sixth hour, with statistical significance achieved at 1, 2, and 3 hours postdosage. Compared with OSR 60 mg, both MSC dosages provided significantly more rapid times to peak effect by CAT and VAS ratings. The OSR group experienced almost twice as many adverse events as did the two MSC groups and also reported somnolence and dizziness more frequently. MSC 60 mg provided more rapid and greater peak analgesia with fewer adverse effects than did OSR 60 mg. PMID- 10150267 TI - Ready-to-use pefloxacin infusion for surgical prophylaxis. AB - The efficacy of pefloxacin in preventing postsurgical infection was demonstrated in an open, comparative, randomized clinical trial. The 120 evaluable patients were divided into four groups of 30 each. Group A served as controls. Groups B, C, and D received one, two, and six doses, respectively, of pefloxacin 400 mg in 100-mL solution as an intravenous infusion. The majority of treated patients benefited from pefloxacin therapy, with only 3% to 7% developing infection. In contrast, 20% of the placebo group developed infection within 5 days after surgery. Two of the 90 treated patients experienced mild side effects. One to six doses of ready-to-use pefloxacin infusion may be administered safely to provide antibacterial coverage during surgery. PMID- 10150268 TI - The fluoroquinolones for urinary tract infections: a review. AB - The fluoroquinolones are a rapidly growing class of antibiotics with a broad spectrum of activity against gram-negative and some gram-positive aerobic bacteria. These agents, including norfloxacin, ciprofloxacin, ofloxacin, enoxacin, and lomefloxacin, have been extensively studied and have demonstrated efficacy and safety profiles comparable to those of other traditional agents for the treatment of complicated or uncomplicated urinary tract infections and prostatitis. Advantages offered by this class of antibiotics include optimal pharmacokinetics, effectiveness against multidrug-resistant organisms, and oral administration even when parenteral antibiotics are generally used. The fluoroquinolones are also extensively used in urologic surgery. PMID- 10150269 TI - The comfort factor: assessing patient satisfaction with Opti-Free vs other contact lens cleaning products. AB - Many patients cite comfort as a primary factor in their success or failure with soft contact lenses. In an effort to further meet the needs of these patients, eye-care professionals must place more emphasis on dispensing a lens type and lens-care system that maximize patient satisfaction and thus provide a higher quality of service. This study delineated patient-defined quality and comfort as they relate to lens-care solutions. Five hundred ninety-nine U.S. practices were each asked to switch 25 of their patients to Opti-Free Lens Care from their currently used lens-care system (52% ReNu Multi-Purpose Solution, 20% AOSept System) for 2 weeks. Data were collected from 14,455 patients who completed the post-trial interview. At the time of the callback interview, 81% of respondents (78% ReNu users, 82% AOSept users) were using the Opti-Free System. Of these patients, 85% (84% previous ReNu users, 87% previous AOSept users) rated Opti Free Lens Care more comfortable than or as comfortable as their previous system. These findings demonstrate differences in patient comfort among Opti-Free, AOSept, and ReNu. Eye-care professionals should consider relative comfort when dispensing lens-care systems, as this may affect patient-defined quality. PMID- 10150270 TI - Treatment of nonresectable hepatocellular carcinoma: review of the literature and meta-analysis. AB - Many doubts surround the numerous forms of nonsurgical treatment of nonresectable hepatocellular carcinoma (HCC). Our study aimed to reach reliable conclusions on the actual efficacy of these treatments. We examined 85 studies involving a total of 6746 patients: 6113 were treated; the remaining 633 were not. We applied the Mantel-Haenszel-Peto method to the extrapolated data, based on the reported 1- and 3-year survival rates. The results confirm that percutaneous ethanol injection achieved survival exceeding 5 years in many cases of HCC characterized by small nodules (diameter < 3 cm). The most efficacious nonsurgical treatment options were transcatheter arterial embolization and transcatheter arterial chemoembolization. Systemic chemotherapy and hepatic intra-arterial chemotherapy were not very effective. PMID- 10150271 TI - Consulting with anxious medical patients. Part II: Diagnostic and therapeutic considerations. AB - In consulting with anxious medical patients, the psychiatrist needs to consider the possibility of organic disease, differentiate anxiety and depression, and ascertain whether comorbid conditions are present. Guidelines for differential diagnosis are presented. With the anxious patient, treatment goals are to establish rapport, help the patient mobilize intellectual defenses, and enhance self-esteem. Many anxious medical patients will benefit from benzodiazepines, selective serotonin reuptake inhibitors, or doxepin. The therapeutic potential of the consultation is increased by the psychiatrist's meeting with the nursing staff and by a humanistic approach to the patient. PMID- 10150272 TI - Latex allergy. Prevention and treatment. AB - Latex allergy is a significant, life-threatening problem for some patients and health care workers. This article identifies those individuals at greatest risk for latex allergy and describes measures that can be implemented in order to provide a latex-free environment. Currently accepted pretreatment protocols are presented and guidelines for the treatment of anaphylaxis, should it occur, are reviewed. PMID- 10150273 TI - HMOs and CHCs join forces. PMID- 10150274 TI - Case management meets the computer age. PMID- 10150275 TI - Oxygen therapy in the home. PMID- 10150276 TI - New pathways to movement. Physiotherapists put theories of brain plasticity to the test. PMID- 10150277 TI - Nutrition screening in the elderly. PMID- 10150278 TI - Case management challenges, present and future. PMID- 10150279 TI - High-tech home care solutions. PMID- 10150280 TI - New light on sinusitis. AB - More precise diagnostic techniques and better understanding of sinus physiology have improved detection and treatment of sinusitis in children. The author reviews what we know now, and outlines a practical plan of management. PMID- 10150281 TI - DES exposure: an update. AB - Little is known about DES grandchildren except that they're often born before term. While we wait for information to accumulate on this third generation, pediatricians need to keep current on the status of DES mothers and daughters. Here's the latest on risks and recommended management. PMID- 10150282 TI - Standardized forms in pediatrics: an idea whose time has come. AB - Want to practice better medicine, insure third-party reimbursement, and help educate residents in primary care? A standardized encounter form can do all this, and more. Here's how. PMID- 10150283 TI - Managing ADHD. AB - Medication can help, but a multimodal approach that also includes educational and psychological services works best for most children. Second of two parts. PMID- 10150284 TI - Are we really doing all we can to promote breastfeeding? AB - Breast is best--few pediatricians would disagree. But when a nursing mother encounters lactation problems, many doctors rush to recommend formula. Here are some ideas about what to do instead. PMID- 10150285 TI - Diagnosing allergies: when to test, when to refer. AB - Recent progress in allergy diagnosis has produced a bewildering variety of tests. These guidelines will help you sort out which ones you can perform and which are best left to a specialist. PMID- 10150286 TI - Bacterial resistance in the '90s. AB - The lesson of the antibiotic era is, the microbe always wins. Pediatricians need to understand why, to take the threat seriously, and to mobilize to fight back. PMID- 10150287 TI - Better guidance through studies and technologic advances. PMID- 10150288 TI - Diagnosis and management of diabetic retinopathy. AB - More frequent testing may sometimes be required, but annual comprehensive eye examinations generally seem best for uncovering early diabetic retinopathy and initiating treatment. Prevention and stabilization may be aided by tightly controlled diabetes. PMID- 10150289 TI - Diabetic nephropathy: pathogenetic basis for treatment. AB - For maximal effectiveness, interventions to prevent diabetic nephropathy are initiated prior to clinically detectable proteinuria--during the microalbuminuria stage. Effects of therapy in relation to pathologic processes are described. PMID- 10150290 TI - Preventive measures and treatment options for diabetic neuropathy. PMID- 10150291 TI - Understanding and using antinuclear antibody testing. AB - What are antinuclear antibodies, and how do the antibodies to specific nuclear antigens relate to the various autoimmune diseases? what nonrheumatic conditions are associated with positive test results? PMID- 10150292 TI - Exercise for rheumatoid arthritis. AB - The approach to treating rheumatoid arthritis is changing. Greater emphasis on the exercise component of physical therapy can improve patients' muscle strength, endurance, and emotional well-being, and may even result in decreased joint inflammation. PMID- 10150293 TI - Evaluation and management of syncope. AB - The history and physical examination still provide the best basis for the initial evaluation of syncope. In addition to revealing the possibility of a serious- even life-threatening--condition, they also point the way for specific testing. PMID- 10150294 TI - Pulmonary manifestations of GI diseases. PMID- 10150295 TI - Early markers for the multiple endocrine neoplasia syndromes. PMID- 10150296 TI - IBD and IBS: are there congruencies? PMID- 10150297 TI - Recognizing and treating depression. AB - The increasing number of antidepressant agents available presents the problem of selecting the right one for a given patient. The choice is guided by the benefits and risks of these drugs within the context of the recommended treatment strategy. PMID- 10150298 TI - Evaluation of perplexing pleural effusions. AB - Recommendations on diagnostic testing are followed by brief reviews of the potential etiologies. General guidelines for the management of undiagnosed cases are described as well. PMID- 10150299 TI - Adenosine in the diagnosis of wide complex tachycardias. PMID- 10150300 TI - Highlights of the new recommendations for hypercholesterolemia. AB - The patient who benefits most by aggressive efforts to reduce elevated LDL cholesterol is the one who is at greatest risk for a coronary event in the next 5 to 10 years. Thus, treatment decisions are based on risk-factor analysis and personal history. PMID- 10150301 TI - Comparing drugs for short-term sedation. AB - Selected benzodiazepines and a phenol derivative are reviewed in relation to their appropriateness as short-term sedatives in settings such as noninvasive and invasive medical procedures. Terminating sedation with flumazenil is also a focus of interest. PMID- 10150302 TI - Current approach to sinusitis. PMID- 10150303 TI - Identifying and managing early melanoma. PMID- 10150304 TI - Clinical implications of visceral hyperalgesia. AB - Based on clinical experience and our understanding of chronic pain, both affective and sensory pathways may be involved in the visceral hyperalgesia seen in most patients with functional bowel disorders. This new awareness has changed the focus of treatment. PMID- 10150305 TI - The evolution and resolution of hypoxemia and COPD. PMID- 10150306 TI - Stabilizing seizure disorders. AB - Scientific understanding of seizures and epilepsy is rapidly evolving. Recent advances in diagnosis, classification, and medical and surgical treatment have significantly altered our approach to patients with these conditions. PMID- 10150307 TI - Current management recommendations for rheumatoid arthritis. PMID- 10150308 TI - Postmenopausal estrogen and cardiovascular disease. AB - When data from the significant studies are assembled and analyzed, what is known about the impact of supplemental estrogen on the risk of cardiovascular disease in women after the menopause? What are the best clinical guidelines today? PMID- 10150309 TI - Comparing newer and older analgesics and delivery systems. AB - The newer opioids, rather than replacing older agents, add to the options for treating pain. The particular pharmacodynamic and pharmacokinetic features of these drugs determine the best choice for a given patient. PMID- 10150310 TI - Confronting antibiotic resistance in enterococcal infections. AB - The increase in enterococcal infections, particularly nosocomial, and the resistance of many species to multiple antibiotics challenge treatment decisions. Resistance screening and synergistic combinations of antimicrobials may be effective. PMID- 10150311 TI - Roadblocks to home care. PMID- 10150312 TI - Subacute standards. PMID- 10150313 TI - Complicated, recurrent, and geriatric UTI. AB - If the patient is older or has certain underlying diseases, urinary tract infection can persist or recur, and unusual pathogens may be at work. Consider broader-spectrum coverage and a longer treatment course. PMID- 10150314 TI - Uncomplicated UTI in young women. AB - Acute, uncomplicated cystitis and pyelonephritis will readily yield to promptly instituted antimicrobial therapy. First, however, you need to rule out other causes of dysuria, including urethritis and vaginitis. PMID- 10150315 TI - Sideswipe elbow fractures. AB - A retrospective review of all cases of sideswipe elbow fractures (SSEFs) treated at two community hospitals from 1982 to 1992 was conducted to determine the functional outcome of the operative treatment of SSEFs. All five injuries involved the left elbow, and they included open fractures of the olecranon, the radius and ulna, the ulna and humerus, the humerus, and traumatic amputation of the arm. Concomitant injuries included three radial nerve palsies and two injuries each to the median nerve, ulnar nerve, and brachial artery. Treatment included irrigation, debridement (repeated if necessary), open reduction and internal fixation, external fixation (one case), and delayed amputation (one case). An average of 130/-10 degrees elbow flexion/extension, and 60/60 degrees supination/pronation was obtained for the three of four patients with reconstructions who returned for follow-up. PMID- 10150316 TI - Type 4 acromion: a new classification. AB - The three types of acromial processes previously described in the literature include type 1, in which the undersurface is straight, and types 2 and 3, in which the undersurface is concave. In this report, a fourth type of acromion is described in which the undersurface is convex near its distal end. The frequency of a type 4 acromion in the normal population is discussed based on a retrospective review of the MR examinations of 30 patients that originally were read as normal. PMID- 10150317 TI - Comparative study of a biochemical index for the estimation of bone demineralization and dual photon absorptiometry. AB - Multivariate classification methods were used to create an early detection technique for determining bone density. This biochemical index (QuiOs) is clinically useful as a potential adjunct in identifying the presence of biochemical deficiencies known to cause osteopenia and the devastating effects of osteoporosis. The test uses the following serum concentrations of a predetermined set of blood constituents: calcium, phosphorus, alkaline phosphatase (ALP), two alkaline phosphatase isoenzymes (liver and intestine), estradiol, and progesterone. Using the results of these six biochemical and hormonal tests, a correlation equation was developed that demonstrates a nonlinear relationship between QuiOs and Ward's triangle of DPA. A sensitivity of 86% and a specificity of 80% was demonstrated for this biochemical index against DPA in this clinical trial. PMID- 10150318 TI - Symposium: revision total knee replacement. PMID- 10150319 TI - Cefadroxil in skin and skin-structure foot infections: a retrospective review. AB - The efficacy and safety of cefadroxil in eradicating localized skin and skin structure infections of the foot were investigated in a retrospective chart review of 222 consecutive patients from two private practices seen over a 10-year period. Of the 189 patients for whom follow-up data were available, 187 (99%) received cefadroxil 500 mg twice daily, and 2 patients (1%) received 250 mg twice daily. The duration of therapy was 2 weeks or less in 87% of patients, with a median duration of therapy of 11.4 days (range, 5 to 35 days). Of the 189 clinically evaluable patients, 179 (95%) achieved a favorable clinical response to treatment; of the 57 patients with microbiologic cultures, 54 (95%) experienced a satisfactory bacteriologic response to therapy; no adverse events related to cefadroxil therapy were identified during the review. The overall results from this retrospective study suggest that cefadroxil is an effective agent with a favorable safety profile for the treatment of skin and skin structure infections of the foot. PMID- 10150320 TI - Effect of acute and long-term administration of ramipril on circadian rhythm of blood pressure in essential hypertension. AB - Ambulatory monitoring was used to evaluate the antihypertensive efficacy and effect on circadian rhythms of blood pressure and heart rate of a single dose and long-term administration of ramipril in 20 patients with mild to moderate essential hypertension. Patients initially were randomized to receive either placebo or a single 5-mg dose of ramipril, followed 1 week later by 5 mg of ramipril daily for 6 months. Systolic (SBP) and diastolic blood pressure (DBP) and heart rate were measured every 20 minutes for 24 hours. Single-dose ramipril reduced both SBP and DBP (P < .001) without affecting heart rate. Long-term treatment produced a small additional antihypertensive effect, again without modifying heart rate. Cosinor analysis demonstrated that both administrations of ramipril effectively lowered SBP and DBP mesors (P < .001), compared to placebo; circadian rhythms remained undisturbed. Heart rate also was not modified on any circadian parameter. A significant reduction (P < .001) of blood pressure amplitude, however, occurred after long-term treatment and may have importance in terms of preventing cardiac damage. PMID- 10150321 TI - Conversion of treatment from cefoxitin to ampicillin/sulbactam: experience in a university teaching hospital. AB - A 12-month trial, conducted in a 650-bed university teaching hospital, evaluated the conversion from cefoxitin to ampicillin/sulbactam. This report discusses the methodology used to evaluate the feasibility of the change and the challenges encountered during the trial period. The effect of cost and overall therapeutic outcome were other aspects of the evaluation. Results indicate that a conversion from cefoxitin to ampicillin/sulbactam is not only feasible but is also a realistic approach to achieving high-quality, cost-effective care. PMID- 10150322 TI - Ampicillin/sulbactam compared with cefotaxime in the treatment of lower respiratory tract infections of bacterial etiology. AB - This was a randomized, prospective, parallel study of the efficacy and safety of ampicillin/sulbactam (2 g/1 g) and cefotaxime (2 g), administered intravenously every 6 hours, in 53 hospitalized patients with lower respiratory tract infections. Thirty-four of the 36 patients treated with ampicillin/sulbactam and 16 of the 17 patients treated with cefotaxime were evaluable. Clinical and bacteriologic effectiveness did not differ significantly between the two groups (P = .828, P = .648, respectively). Of the ampicillin/sulbactam-treated patients, 21 (61.8%) were cured, 8 (23.5%) were improved, and 4 (11.8%) were treatment failures. In the cefotaxime group, 9 patients (56.3%) were cured, 4 (25%) were improved, and 2 (12.5%) were treatment failures. All primary pathogens were eradicated in 19 (55.9%) ampicillin/sulbactam-treated patients and partially eradicated in 7 (20.6%); in cefotaxime-treated patients, all primary pathogens were eradicated in 10 (62.5%) patients and partially eradicated in 2 (12.5%). Both study drugs were well tolerated, with the overall incidence of adverse events similarly low in the two groups. PMID- 10150323 TI - A double-blind comparison of topical capsaicin and oral amitriptyline in painful diabetic neuropathy. AB - An 8-week double-blind, multicenter, parallel study compared the safety and efficacy of topical capsaicin and oral amitriptyline in patients with painful diabetic neuropathy involving the feet. Two hundred thirty-five patients were randomized to treatment with either capsaicin cream or amitriptyline capsules. Capsaicin-treated patients received inactive capsules, and amitriptyline-treated patients applied vehicle cream. A visual analogue scale of pain intensity and measurements of interference by pain with functional activities were recorded at onset and at 2-week intervals. A visual analogue scale of pain relief and physicians' global evaluation assessed changes in pain status from baseline. Topical capsaicin and oral amitriptyline produced equal and statistically significant improvements in pain over the course of the study. By the end of week 8, 76% of patients in each group experienced less pain, with a mean reduction in intensity of more than 40%. By the end of the study, the interference with daily activities by pain had diminished significantly (P = .001) in both groups, including improvements in sleeping and walking. No systemic side effects were observed in patients treated with topical capsaicin. Most patients receiving amitriptyline experienced at least one systemic side effect, ranging from somnolence (46%) to neuromuscular (23%) and cardiovascular (9%) adverse effects. Topically applied capsaicin is an equally effective but considerably safer alternative to amitriptyline for relief of the pain of diabetic neuropathy. PMID- 10150324 TI - Ampicillin/sulbactam versus cefazolin or cefoxitin in the treatment of skin and skin-structure infections of bacterial etiology. AB - This randomized, double-blind study compared 1 g of ampicillin plus 0.5 g of sulbactam with 0.5 g of cefazolin in the treatment of cellulitis and with 1 g of cefoxitin in other skin and skin-structure infections. Study drugs were administered intravenously every 6 hours to 58 hospitalized patients. Each indication was evaluated separately. In cellulitis, ampicillin/sulbactam and cefazolin produced clinical cure or improvement in 100% and 91.7% of patients, respectively; duration of hospitalization was 7.7 and 7.2 days. In other skin and skin-structure infections, results for ampicillin/sulbactam and cefoxitin, respectively, were clinical cure or improvement, 80% and 64.7%; treatment failures, 0% and 11.8%; bacterial eradication, 40% and 53%; and duration of hospitalization, 7.7 and 9.4 days. No unusual or unexpected adverse experiences related to any study drug occurred. One patient treated with ampicillin/sulbactam died of a pulmonary embolism, and 1 patient treated with cefoxitin was discontinued from the study following amputation of an infected foot. These events were not considered drug-related. The treatment groups showed no statistically significant differences in efficacy or safety. PMID- 10150325 TI - Effect of atenolol and ramipril on regression of left ventricular hypertrophy: comparative echocardiographic assessment. AB - Left ventricular hypertrophy (LVH) dramatically worsens hypertensive illness. Because the genesis of LVH appears to be multifactorial, antihypertensive treatment should aim to reduce not only pressor values but also the hypertrophic ventricular mass. This result can be obtained only when drugs able to act on both pathogenetic factors are used. To evaluate the effectiveness of antihypertensive therapy on regression of LVH, 21 patients with stage 2 essential hypertension were treated for a year with either atenolol (120 mg/d orally), a cardioselective beta-blocker without intrinsic sympathomimetic activity, or ramipril (5 mg/d orally), an angiotensin-converting enzyme inhibitor with high tissue activity. Both treatments produced significant control of hypertension and regression of LVH. No statistically significant difference between treatments was noted, except for heart rate, which was substantially unchanged by ramipril but significantly decreased by atenolol. Both drugs were well tolerated. Atenolol and ramipril have a major role in the long-term treatment of hypertension and in the regression of hypertension-associated LVH. PMID- 10150326 TI - The selection and use of cephalosporins: a review. AB - Cephalosporins are among the most frequently prescribed antibiotics as a result of their broad spectrum of microbiologic activity, favorable pharmacokinetics, low incidence of adverse reactions, and proven clinical efficacy for a wide variety of infections. Cephalosporins differ in their gram-positive, gram negative, and anaerobic spectra, serum half-lives, penetration of the cerebrospinal fluid, and resistance to beta-lactamases. The first-generation and some second-generation agents maintain excellent activity against streptococci and staphylococci, while the third-generation agents have expanded gram-negative coverage. Two third-generation cephalosporins, ceftazidime and cefoperazone, are active against Pseudomonas. Ceftizoxime has become the workhorse third-generation cephalosporin. The fourth-generation agent cefepime provides excellent activity against gram-positive and gram-negative pathogens, including antibiotic-resistant Enterobacteriaceae. A major dilemma facing the practitioner is how to select the "right" cephalosporin for a particular patient, as no one drug will satisfy all clinical needs. This review describes a practical approach to selecting an appropriate cephalosporin for common infectious disease problems. PMID- 10150327 TI - A study of the responsibilities of chief residents in anesthesiology with a suggested job description. AB - We requested information concerning the job description for the chief resident in anesthesiology from 50 different programs. Thirty-two responses were returned, with 9 responses that no such job description existed at their institutions. Eighteen of the remaining 23 respondents had a written job description for the position. Considerable variation existed in the various aspects of the position among institutions. Differences were found in the selection process, administrative duties, number of committee memberships, and educational responsibilities. We present a suggested description of the responsibilities for a chief resident in anesthesiology. PMID- 10150328 TI - [Evaluation of the effectiveness of a program for prevention of pregnancy in adolescence: speak up for responsible sexuality]. PMID- 10150329 TI - Hypertension management in renal insufficiency. AB - Renal failure is on the rise in the elderly, in those with diabetes and hypertension, and in some minority groups. Recognizing mild renal impairment, correcting reversible causes, and controlling blood pressure can serve as deterrents. PMID- 10150330 TI - Diagnostic steps for suspected Parkinson's disease. AB - The diagnosis is made clinically, often independent of special tests, through a series of simple, carefully planned observations and maneuvers. The objective is to separate true Parkinson's disease from other conditions with parkinsonian features. PMID- 10150331 TI - Fever and neutropenia: still a challenge. AB - Neutropenia is a double-edged sword. Fever may be the only manifestation of serious bacterial and fungal infection in neutropenic patients, and untreated occult infection can rapidly progress to septic shock and death. PMID- 10150332 TI - Managing IDDM during pregnancy. PMID- 10150333 TI - New insights into gouty arthritis. PMID- 10150334 TI - Cost as a factor in the treatment of hypertension. PMID- 10150336 TI - Attaining maximum benefit from insulin therapy. PMID- 10150335 TI - Practical management for hyperlipidemia. AB - Risk assessment, known coronary and other atherosclerotic disease, and lipid levels determine the potential need for drug therapy. Specific lifestyle objectives are strongly emphasized. Indications and regimens for newer and older drugs are offered. PMID- 10150337 TI - Current recommendations for community-acquired pneumonia. AB - The question of which antimicrobial agents to use is compounded by the imprecision of presenting signs and symptoms and the limitations of diagnostic tests. The use of empiric therapy is explored along with suggested management if treatment fails. PMID- 10150338 TI - Adjuvant therapy for colon cancer. AB - More tightly defined and controlled studies have found definite benefit associated with adjuvant therapy following surgery for stage III colon cancer. The decision for those with stage II disease is best made on an individual basis. PMID- 10150339 TI - A practical work-up for vertigo. AB - Specific elements in the history and physical examination direct the work-up of the "dizzy" patient toward or away from a vestibular disorder. When a disorder of this type is suspected, the differential diagnosis includes benign positional vertigo, vestibular neuritis, vertebrobasilar insufficiency, migraine, and endolymphatic hydrops, which is the pathologic condition thought to underlie Meniere's disease. Anxiety is well recognized as a potential component of vestibular abnormalities or as the primary problem. PMID- 10150340 TI - A practical guide to antiretroviral drug use. AB - These agents seem beneficial in all HIV-infected patients with CD4 counts under 500 cells/mm3, but the effects are time limited and related to baseline immune status. Active viral replication is now known to occur even during periods of clinical latency. PMID- 10150341 TI - Managing hypertension in patients with diabetes mellitus. PMID- 10150343 TI - Controversies in mechanical ventilation. PMID- 10150342 TI - An antimicrobial approach to nosocomial pneumonia. PMID- 10150344 TI - Drug therapy for inflammatory bowel disease. AB - Ulcerative colitis and Crohn's disease continue to be frustrating to manage, but the treatment armamentarium has grown. Newer drugs and recent studies on all agents have resulted in a more defined approach based specifically on the patient's condition. PMID- 10150345 TI - Therapy guided by symptoms for Parkinson's disease. AB - Low-dose combinations of medications that work in slightly different ways constitute optimal management of Parkinson's disease. Surgical approaches are being perfected for patients who stop responding favorably to pharmacologic treatment. PMID- 10150346 TI - Secondary prevention of cardiovascular disease. AB - In addition to proven approaches, new possibilities generate excitement in the medical community and in the press. Refinements of accepted options for secondary prevention and current data about others that are promising are the focus of this review. PMID- 10150347 TI - Using noninvasive tests and thrombolytics for pulmonary embolism. AB - Obstructed pulmonary circulation from an embolism results in dilatation of the right ventricle, which becomes hypokinetic. The subsequent decline in forward cardiac output leads to diminished left ventricular preload. Combined with the reduction in the size of the left ventricular cavity from the flattening of the septum, there is a fall in total systemic cardiac output. PMID- 10150348 TI - Improved management of unstable angina and non-Q-wave MI. AB - A clearer understanding of the underlying dynamics of the acute coronary syndromes and of the drugs that are useful in these conditions has modified recommendations on drug selection and regimens. These changes have led to better clinical outcomes. PMID- 10150349 TI - Using oral antifungal agents for severe fungal infections. AB - The azole antifungal drugs fluconazole and itraconazole have changed our approach to the treatment of serious fungal infections. Increased use of these drugs has generated information of value for clinical practice. PMID- 10150350 TI - Clinical insights from the etiopathology of osteoporosis. AB - Bone resorption may be stimulated by increased parathyroid hormone secretion, certain cytokines, and other bone-resorbing mediators. Low serum calcium levels promote parathyroid hormone secretion, and estrogen deficiency is associated with a rise in cytokine production and activity. An abnormal proliferation of mast cells may also release cytokines, heparin, and other mediators of bone resorption. PMID- 10150351 TI - Accidental needlesticks: do anesthesiologists practice proper infection control precautions? AB - Anesthesiologists as well as patients are at risk for acquiring blood-borne infections such as hepatitis and AIDS. We surveyed 2,530 anesthesiologists, a 10% random sample of the members of the American Society of Anesthesiologists, with a response rate of 57.1%, to determine the incidence of accidental needlestick exposure among anesthesia personnel and whether anesthesiologists are adhering to infection control guidelines to protect themselves and their patients from exposure to infectious diseases. Eighty-eight percent of respondents reported at least 1 accidental needlestick in the past 10 years; 21% received a needlestick from a high-risk patient and 4.5% a needlestick from a known HIV-positive patients. Residents reported significantly more accidental needlesticks from known HIV-positive patients (8.5%). Mucous membrane, open cut, eye, or other significant exposure to HIV-contaminated blood or body fluids was sustained by 8.34% of respondents in the past 10 years. Sixty percent of respondents reported they almost never reuse common syringes now compared with a 40.8% non-reuse rate (P < 0.001) in a similar survey on infection control practices conducted in 1990. Sixty-three percent reported they almost never reuse a vasopressor syringe compared with the 1990 non-reuse rate of 52.5% (P < 0.001). In the current survey, 39% of anesthesiologists reported reusing syringes from one patient to another and 36% reported reusing the same vasopressor syringes for different patients.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150352 TI - Leak rate of latex gloves after tearing adhesive tape. AB - Anesthesiologists use latex gloves to provide barrier protection against infectious disease or contamination while providing anesthetic services. The performance of these services often involves tearing tape. The purpose of this study was to test the effect of tearing adhesive tape on permeability of latex examination gloves and to test the effect of an adhesive-sparing moisturizing cream on permeability of latex gloves used to tear adhesive tape. In a blinded, randomized, controlled laboratory experiment, 48 nonsterile latex examination gloves (24 pairs) were randomized to 1 of 2 groups. Adhesive-sparing moisturizing cream, 0.1 mL, was applied to 12 glove pairs; the remaining 12 pairs served as controls. Each of the 24 pairs of gloves were used to tear five 4-cm strips of cloth adhesive tape from a standard 1 1/2-inch roll. After initial inspection for obvious tears, each glove was tested for leaks using the watertight test as specified by the American Society for Testing and Materials (ASTM). Data recorded included the identity of the investigator tearing tape, number of holes initially observed, number of holes observed from the ASTM test, location of holes, glove classification as right or left hand, and treatment group. Based on the study, the authors concluded that health care providers who tear adhesive tape while wearing latex gloves should be aware that there is a high probability that the gloves no longer form a protective barrier and that adhesive-sparing moisturizing cream applied before tape is torn increases barrier protection. PMID- 10150353 TI - Older anesthetic agents: should they be removed from clinical use? PMID- 10150354 TI - Cotrel Dubousset and Wisconsin segmental spine instrumentation: comparison of results in adolescents with idiopathic scoliosis King Type II. AB - When introduced, the Wisconsin segmental spine instrumentation (WSSI) and the Cotrel Dubousset instrumentation (CDI) were promoted as technical advances for the correction of spinal deformities. Both systems provide acceptable correction and greatly reduce the need for postoperative immobilization. A retrospective study of a homogeneous group of 53 adolescent patients with idiopathic scoliosis with King Type II curves who had reached skeletal maturity at follow-up was conducted to compare and analyze the results of these two systems. Thirty-six of these patients had been operated on using WSSI and 17 had been operated on using CDI. CDI and WSSI were found to be equally effective in treating King Type II curves. No difference was found between the two groups in the fusion rates, spinal balance, time required for surgery, or amount of curve correction. The answer to the question of which system is "better" depends on the surgeon's experience and familiarity with the equipment. PMID- 10150355 TI - Evaluation of a new biochemical index for the estimation of bone demineralization using artificial intelligence. AB - The use of artificial neural networks (ANN) for the identification of a positive correlation between the QuiOs quotient, a single-valued indicator of bone mineral density, and multisite dual energy x-ray absorptiometry (DEXA) measurements is described. The measurements were obtained using the Hologic QDRR-2000 x-ray bone densitometer in a multicenter clinical trial including 374 female patients. The QuiOs quotient estimates bone mineral density and determines the severity of bone density loss. This quotient is calculated by using a proprietary software program to perform a multivariate analysis of the results of testing of serum levels of calcium, phosphate, total alkaline phosphate, two alkaline phosphatase isoenzymes (liver and intestine), estradiol, and progesterone. The results show that given the four DEXA measurements obtained from the bone densitometer, the trained neural network can predict whether the corresponding QuiOs score of the same patient will be below the cutoff score of 0.690. The findings in this study indicate a positive correlation between DEXA measurements and the QuiOs quotient obtained from two different sources. PMID- 10150356 TI - Intraoperative latex anaphylaxis in children: early detection, treatment, and prevention. AB - During the past five years, systemic IgE-mediated anaphylactic reactions to latex have been reported more frequently, and a significant proportion of these anaphylactic reactions have occurred intraoperatively. Anaphylactic reactions under general anesthesia occur without warning, and early signs often are obscured by surgical drapes. Therefore, early recognition of symptoms and prevention are essential to avoid catastrophic results. Orthopaedic surgeons must be aware of the risk, diagnosis, prevention, and treatment of latex anaphylaxis. Patients at risk, testing, and prevention are discussed in this review. Additionally, a classification system and the corresponding regimen for prophylaxis that is currently being used at Children's Hospital of Philadelphia is described. PMID- 10150357 TI - Symposium: Current concepts and controversies in tissue banking. PMID- 10150358 TI - Removal of a well-fixed cementless femoral component with an extended proximal femoral osteotomy. AB - Removal of a stable, well-fixed cementless femoral arthroplasty component occasionally is necessary because of infection, component malposition, persistent pain, or incompatibility with a femoral revision component. Restricted access to ingrowth surfaces may make implant removal exceedingly difficult and increases the risk of iatrogenic damage to the proximal femur. A new extended proximal femoral osteotomy technique is described for use in removing well-fixed cementless femoral components. Previous techniques have been modified to allow access to the bone-implant interface and to provide straight-shot access to the femoral canal for proper sizing and positioning of the revision implant. The osteotomy can be extended to accommodate the entire length of the porous coating on the revision component. If a shorter osteotomy is desired, access to the prosthesis for transection with a metal-cutting burr is possible. The osteotomy is easily repositioned with cerclage wires or cables and reliable healing has been demonstrated. PMID- 10150359 TI - NSAIDs in orthopaedic practice: management guidelines for arthritis patients. AB - Guidelines are provided for prescribing nonsteroidal antiinflammatory drugs (NSAIDs) pre- and postoperatively for arthritis patients. Most NSAIDs impair platelet aggregation and prolong bleeding time, increasing the risk of complications during and immediately following surgery; thus, the effects of individual NSAIDs must be considered prior to surgery. Postoperative treatment issues that must be considered include gastrointestinal safety, renal and hepatic safety, safety in the elderly, and efficacy of various NSAIDs. Various strategies to improve gastrointestinal safety, including use of NSAIDs with low ulcerogenic potential such as nabumetone, low-dose ibuprofen, and etodolac, are discussed. As all NSAIDs can reduce pain and inflammation, selection of a particular NSAID should be based on careful consideration of pharmacologic and clinical differences. PMID- 10150360 TI - Symposium: femoral fractures in children. PMID- 10150361 TI - Clinical benefits of early post-injury enteral feeding. AB - Over the past two decades, clinical studies have provided convincing evidence that early nutritional support benefits metabolically stressed surgical patients by preventing acute protein malnutrition. However, the optimal route of substrate delivery (ie, enteral versus parenteral) continues to be debated. Recent basic and clinical investigation offers the exciting possibility that the beneficial effects of traditional nutritional support can be amplified by supplementing specific nutrients that exert pharmacological immune-enhancing effects. Over the past 15 years, the Department of Surgery at the Denver General Hospital has focused clinical research efforts on defining optimal nutrition following major torso trauma. The purpose of this paper is to review our studies as well as other clinical studies in order to answer three questions: 1) Does early post-injury nutritional support improve patient outcome? 2) What is the preferred route of substrate delivery? 3) Do new 'immune-enhancing' diets offer additional clinical benefits? PMID- 10150363 TI - Neurorehabilitation. Issues in post-concussive disorders. PMID- 10150362 TI - Comparison of APACHE III, II and the Glasgow Coma Scale for prediction of mortality in a neurosurgical intensive care unit. AB - OBJECTIVES: This study examined the efficacy of predicting power for hospital mortality of three different scoring systems in a neurosurgical intensive care unit (NICU). SETTING: An eight-bed NICU in a 1,270-bed medical centre (Taichung Veterans General Hospital). SUBJECTS: Two hundred patients with head injury, brain tumour, hypertensive intracerebral haemorrhage, rupture of aneurysm or arteriovenous malformation, or other categories were included in our study in a consecutive period of 14 months. Patients less than 14 years old were not included. DESIGN: On the first day of admission, data were collected from each patient to compute the Acute Physiology and Chronic Health (APACHE) II and III, and Glasgow Coma Scale (GCS) scores. Hospital mortality was defined as when death occurred before discharge from hospital. INTERVENTIONS: none. MEASUREMENTS: Sensitivity, specificity and correct prediction outcomes were measured by logistic regression in three scoring systems. The Youden index was also obtained. The best cutoff point in each scoring system was determined by logistic regression or by the Youden index. Data obtained by logistic regression were compared by McNemar's test. The differences in Youden index were calculated by the Student's t-test. The area under the Receiver Operating Characteristic (ROC) curve was computed and the area of each scoring system was then compared by the Wilcoxon Mann-Whitney test. MAIN RESULTS: The correct prediction of outcome was 85.5% in APACHE III, 77.5% in APACHE II and 75.0% in GCS. The area under the Receiver Operating Characteristic (ROC) curve was 0.892 in APACHE III, 0.826 in APACHE II and 0.868 in GCS. For the prediction of dead patients at the best cutoff point, APACHE III and GCS were better than APACHE II, (both p < 0.01 respectively). For the prediction of alive patients at the best cutoff point, APACHE III was better than GCS and APACHE II (p < 0.01 respectively). CONCLUSION: The APACHE III system seems to be the most reliable. The results reveal that the APACHE III system is better in predicting power for hospital mortality than either the GCS or APACHE II systems in our NICU patients. PMID- 10150364 TI - Difficult choices. PMID- 10150365 TI - Recent advances in toxic shock syndrome. AB - The pathogenesis and treatment of toxic shock has become clearer even as its epidemiology has evolved. Nonmenstrual cases due to Staphylococcus aureus can be difficult to diagnose and treat. Invasive Streptococcus pyogenes infections are life threatening. PMID- 10150366 TI - Current practice in viral sexually transmitted diseases. PMID- 10150367 TI - Heart failure: clinical implications of recent trials. AB - The frustration has been in identifying drugs that have a positive impact on cardiac performance and a negative effect on mortality. ACE inhibitors, often with diuretics and possibly with digoxin, continue to show impressive outcomes in major studies. PMID- 10150368 TI - Monitoring alcoholic liver injury. AB - Evidence for the economic, social, and health benefits of a more aggressive policy towards alcoholism is beginning to overcome nihilistic attitudes. Psychological, clinical, and laboratory measures are integrated in an algorithm for management. PMID- 10150369 TI - Sudden infant death: a reappraisal. PMID- 10150370 TI - Progress in pain control for very young infants. PMID- 10150371 TI - Keeping adolescents healthy. AB - Most physicians agree that adolescents need routine health supervision, but many aren't sure how often to provide it or what to include. This review of the latest guidelines shows the way. PMID- 10150372 TI - TVP: a new modification of TURP. PMID- 10150373 TI - LIS expert systems: feature evaluation. PMID- 10150374 TI - The determination of free urinary catecholamines using LCEC. PMID- 10150375 TI - A system for automated microbial growth detection. PMID- 10150376 TI - Predicting the present: expert testimony and civil commitment. AB - This article uses the Supreme Court's decision in Daubert as an opportunity to address a chronic concern regarding the disparity between mental health law as officially enunciated and the practical application of that law. After Daubert, admissibility of expert evidence under the federal rules requires a qualified expert, a reliable basis for the testimony, and relevance to the legal issue. Ongoing psychological research pursues empirical data that expands the scope of psychological expertise and clarifies its limits. This article addresses the requirement of relevance by examining the logical relationship between the psychologist's actuarial and clinical expertise and the legal issues addressed by the court in civil commitment proceedings. Ideally, Daubert might stimulate a process of cooperative analysis in which psychologists and lawyers clarify the proper roles of psychological experts and of the courts with which those experts interact. This article begins that project by clarifying the legal determination required in civil commitment proceedings and by explicating the relationship between the responsibilities of experts and those of courts. PMID- 10150377 TI - A hybrid decision framework for evaluating psychometric evidence. AB - The United States Supreme Court in Daubert v. Merrell Dow Pharmaceuticals (1993) directed federal trial judges to preliminarily evaluate the scientific bases of proffered expert evidence. This article presents a decision flowchart for evaluating psychometric data, and attempts to operationalize existing evidentiary standards in hybrid (part science/part law) terms. The resulting framework should better assist courts and forensic experts to understand, evaluate, and apply scientific reasoning in determining the admissibility and probative value of psychometric evidence. PMID- 10150378 TI - Expert psychological testimony on eyewitness reliability before and after Daubert: the state of the law and the science. AB - This article examines the legal and scientific issues inherent in the use of expert psychological testimony on the factors that affect eyewitness reliability. First, the history of the use of such expert testimony is traced. Next, we look at the criteria that state and federal courts have used in determining whether to admit such testimony, as well as the grounds upon which the testimony has been excluded. We then examine the Daubert decision and discuss its implications for the use of expert eyewitness testimony. We conclude by reviewing eyewitness research and research on jury decision-making that is likely to assume new importance in the post-Daubert era. PMID- 10150379 TI - Varus tension testing of fixation devices used in proximal tibial osteotomy. AB - Varus tension testing was performed on 26 matched pairs of tibias after high tibial osteotomy with three different fixation techniques--Coventry stepped staple, Mansat staple blade, and modified tension-band. Biomechanical testing revealed that in group I the Coventry stepped staple and Mansat staple blade yielded similar force at failure values of 132.44 +/- 29.29 and 137.34 +/- 40.84, respectively. In group II, the varus force at failure value was 170.45 +/- 83.95 for the modified tension band device versus 115.27 +/- 67.21 for the Coventry stepped staple device. In group III, the varus force at failure value was 180.26 +/- 82.36 for the modified tension band device versus 109.14 +/- 60.96 for the Mansat staple blade. The findings in this study suggest that the modified tension band technique provides a greater varus force at failure value, approximately 160 170%, compared to the other two techniques. In addition, this device is easy to apply and less expensive, and most orthopaedic surgeons are already familiar with its use. PMID- 10150380 TI - The importance of the blood supply in the healing of tibial fractures. AB - A clinical study of the effects of nonischemic arterial injuries to the leg on tibial fracture healing is presented. In addition, the literature published during the past 100 years describing the vascular supply to the tibia is reviewed, and the San Francisco General Hospital treatment protocol for difficult open tibial fractures is outlined. Based on the finding that the delayed and nonunion rate is three times higher when one of the three arteries of the leg is disrupted, a modification of the Gustilo fracture classification is proposed. PMID- 10150381 TI - Symposium: spinal cord resuscitation. PMID- 10150382 TI - Chronic fatigue syndrome: a diagnostic challenge for the laboratory. AB - OBJECTIVE: To review the literature and current research about the causes of chronic fatigue syndrome (CFS). DATA SOURCES: Recent research articles about CFS and data gathered by the author. STUDY SELECTION: Performed by the author. DATA EXTRACTION: Performed by the author. DATA SYNTHESIS: Chronic fatigue syndrome (CFS) is a disease of pain, excessive fatigue after minor exertion, cognitive difficulties, and other symptoms-all occurring in cycles. While its etiology is unclear, CFS is associated with abnormal results of immune system tests. There is no specific marker for the illness. Treatment is symptomatic, and the long-term outlook for recovery is good. CONCLUSION: A rational, symptomatic approach to treating CFS patients can be made using the model developed at the author's institution. Research into the causes of CFS must continue. PMID- 10150383 TI - Lyme disease: the cause, diagnosis, and treatment. AB - OBJECTIVE: To present a brief history of Lyme disease, identify its vectors, examine its pathogenesis, and discuss current methods of testing for and treating the disease. DATA SOURCES: Current literature. STUDY SELECTION: Determined by the author. DATA EXTRACTION: Determined by the author. DATA SYNTHESIS: Lyme disease is the most commonly reported vector-transmitted disease in the United States. The Borrelia burgdorferi spirochete has been identified as the infectious agent of the disease. Although symptoms vary, stage 1 Lyme disease is most often characterized by erythema chronicum migrans, stage 2 by Bell's palsy, and stage 3 by chronic shoulder, knee, and wrist pain. Diagnostic tests currently in use, which include indirect immunofluorescent assay and enzyme-linked immunosorbent assay, often show false-positive results. Antibiotic treatment is recommended. CONCLUSION: Further study is needed to develop an accurate test for Lyme disease. PMID- 10150384 TI - Assessing the educational preparation of clinical laboratory scientists. AB - OBJECTIVE: To assess the educational preparation of clinical laboratory science (CLS) graduates using an approach that addresses the general education and professional components of the curriculum and includes multiple programs. DESIGN: Survey of a convenience sample. SETTING: Four CLS programs in North Carolina. PARTICIPANTS: CLS graduates with one, three, and five years of experience. MAIN OUTCOME MEASURE: Results of 48 competency statements rated by graduates for level of preparation and importance in current jobs. RESULTS: Graduates indicated that they were well prepared in most conceptual and technical competencies with the exception of computers and management. Preparation in career marketability skills (interviewing, writing resumes, and career planning), contextual competence (understanding socioeconomic and governmental issues), and scholarly concern for professional improvement (research skills) was rated relatively low. Graduates considered the conceptual and technical competencies related to their current specialty as very important for their jobs. They also rated professional ethics, communication skills, and integrative competencies as very important for practice. Graduates in supervisory positions rated communication competencies significantly higher in importance than did graduates in other positions. Graduates rated as relatively unimportant competencies in conceptual and technical skills unrelated to their current specialties and scholarly concern for professional improvement. CONCLUSION: In the professional component of the curriculum, educators should review the amount of conceptual and technical content required and the level of preparation in career marketability skills. In the general education component of the curriculum, CLS students' preparation in contextual competencies and communication skills should be reviewed and strengthened. PMID- 10150385 TI - Fear of AIDS among clinical laboratory scientists: a follow-up survey. AB - OBJECTIVE: To compare attitudes and behaviors about acquired immunodeficiency syndrome (AIDS) of clinical laboratory scientists (CLSs) who are considering leaving the profession with those of CLSs planning to stay in the profession. DESIGN: Survey of a convenience sample of conference attendees. SETTING: Annual meetings of the New Jersey Society for Medical Technologists held April 4-5, 1990, in Woodbridge, New Jersey, and April 9-10, 1988, in Asbury Park, New Jersey. PARTICIPANTS: A total of 212 attendees at each conference. OUTCOME MEASURES: Scales measuring CLSs' knowledge of AIDS, fear of acquiring AIDS, satisfaction with employers' AIDS policies, and degree of compliance with universal blood precautions; and comparison of demographic data. RESULTS: Both surveys showed that, compared with CLSs planning to stay in the profession, CLSs considering leaving the field were more afraid of acquiring AIDS, less confident about their employers' AIDS policies, and equally knowledgeable about AIDS. CONCLUSIONS: CLSs who are considering leaving the profession are more cautious than those planning to stay, and the determinants that shape the fear of AIDS require further definition. PMID- 10150386 TI - Urine specific gravity measurement: reagent strip versus refractometer. AB - OBJECTIVE: To compare the results of urinalysis screenings for specific gravity (SG) using the reagent strip and the refractometer. SETTING: United Hospital, Grand Forks, North Dakota. PRACTICE DESCRIPTION: United Hospital is a 384-bed teaching hospital. PRODUCT COMPARISON: The Ames Multistix 10 SG reagent strip (Miles, Inc., Elkhart, IN 46515) was compared with the TS Meter (Leica, Inc., Deerfield, IL 60015). MAIN OUTCOME MEASUREMENT: The degree of correlation between the results produced by each method. RESULTS: The percentage of difference between the means of the direct strip readings and the refractometer readings was 9.68%. The percentage of difference between the means of the adjusted strip readings and the refractometer readings was 22.58%, which was significantly different. When the direct strip readings and the refractometer readings were plotted together on a graph, the points were widely scattered; this fact, and a correlation coefficient of 0.725, suggest that random error occurred in both methods. Analysis of the slope and intercept of the correlation indicated systematic error. CONCLUSION: The reagent strip method of measuring SG is accurate only in a narrow range of "average" values, and should not be used as the basis for medical diagnoses. PMID- 10150387 TI - Evaluation of a commercial latex agglutination assay for screening for Clostridium difficile-associated disease. AB - OBJECTIVE: To determine if the Clostridium difficile latex agglutination assay is an effective screening procedure for the diagnosis of C. difficile-associated disease (CDAD). DESIGN: Convenience sample. SETTING: The Washington Hospital, a 364-bed, secondary, acute-care center in Washington, Pennsylvania. PARTICIPANTS: A total of 321 women and 195 men aged 21 days to 100 years. INTERVENTIONS: Diarrheal stool specimens from patients on antibiotic therapy were randomly tested for the presence of C. difficile-associated antigen by CULTURETTE brand latex agglutination assay (Beckton Dickinson Microbiology Systems, Cockeyesville, MD 21030). Latex-positive samples were confirmed or negated by cytotoxin assay using the Toxi-titer microtiter plate system (Baxter Healthcare Corp., Bartels Diagnostic Division, Issaquah, WA 98027). MAIN OUTCOME MEASURES: Comparative statistical analysis of the raw data to develop the sensitivity and specificity of the latex screening assay. RESULTS: Stool specimens of 403 patients (78.1%) were negative for C. difficile-associated antigen. Of the latex-positive specimens, 70 (69.3%) were also cytotoxin-positive. Of the indeterminate latex specimens, four (33.3%) were cytotoxin-positive. A total of 70 specimens (13.6%) were positive by both methods and 74 patients (14.3%) were diagnosed with CDAD. Based on this data, the latex agglutination screening assay had a sensitivity of 77.1% and a specificity of 93.4%. CONCLUSION: Latex agglutination for C. difficile-associated antigen is a moderately sensitive screening test for a presumptive diagnosis of CDAD. However, it is not the best screening test for CDAD compared with the new enzyme-linked immunosorbent assay (ELISA) techniques for toxins A and B. PMID- 10150388 TI - Echocardiography in patients with constrictive pericarditis before and after pericardiectomy: Are there predictors of surgical outcome? AB - Fifteen patients with constrictive pericarditis were prospectively evaluated with echocardiography and Doppler recordings during respiratory monitoring. Eleven who agreed to surgery also underwent right heart catheterization and a repeat echocardiography with Doppler 10 days after pericardiectomy. Preoperatively, there was a significant inspiratory decrease in the mitral E wave (P < 0.05) and increase in the tricuspid E wave velocities (P < 0.05), which both normalized after pericardiectomy. The mitral deceleration times increased from 110 +/- 40 to 149 +/- 46 msec (P < 0.05) postoperatively. The preoperative hepatic vein velocities showed an accentuated systolic flow pattern. The systolic to diastolic ratio of the hepatic vein velocities was higher in patients who improved with surgery (1.42 +/- 0.31 vs 0.65 +/- 0.13) (P < 0.05). Postoperatively the diastolic flow became more pronounced. There was a 100% expiratory diastolic flow reversal in eight patients preoperatively, which normalized after pericardiectomy. Clinically these patients improved significantly postoperatively. Left atrial size, ejection fraction, and mitral and tricuspid filling velocities during respiratory monitoring could not predict surgical outcome. Pericardiectomy improved Doppler filling dynamics in all patients although this was not parallel to clinical improvement. PMID- 10150389 TI - Transthoracic real-time three-dimensional echocardiography using a fan-like scanning approach for data acquisition: methods, strengths, problems, and initial clinical experience. AB - Three-dimensional echocardiography is an emerging clinical method to assess cardiovascular disorders. The feasibility of using a linear mode scanning (parallel slicing) for transthoracic data acquisition has been demonstrated. In this study, we evaluated the feasibility of real-time transthoracic three dimensional imaging of the heart using a fan-like scanning mode of echocardiographic data acquisition. We used a computer-driven motor to sequentially angulate transthoracic transducers over a fan-like arc up to 90 degrees. With careful ECG and respiratory gating, we acquired basic two dimensional data set via parasternal and subcostal windows and performed dynamic three-dimensional reconstructions. The problems encountered included the need to repeat data acquisition sequences because of transducer movement or inappropriate gain and gray scale settings. From 15 scanning sequences in four patients, we were able to use ten sets of data. These yielded good quality three-dimensional studies projecting normal valves, a stenotic mitral valve, and an atrial septal defect, in a number of novel views. The valves could be visualized from above and from below as well as in other orientations, and the detailed anatomy appraised. Spatial relationships of the atrial septal defect with inferior and superior vena cava, coronary sinus, or tricuspid annulus could be uniquely displayed through views from the right side of the heart. This technique provided adequate new imaging planes not available from two-dimensional echocardiography. This experience demonstrates for the first time that transthoracic three-dimensional echocardiography using a fan-like scanning mode of data acquisition is feasible, and that it provides adequate visualization of intracardiac structures in unique projections.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150390 TI - A new device for mechanical ventilation of infants and small children. AB - A new device for use with adult ventilators to allow neonatal and paediatric mechanical ventilation is described. It met International Standards Organisation standards during in vitro evaluation and gave good results when applied in vivo to ten children undergoing elective surgery. The device provided a safe and cost effective means of delivering mechanical ventilation by an adult ventilator to neonatal and paediatric patients receiving general anaesthesia. PMID- 10150391 TI - The difficulty of reprocessing reusable rigid endoscopic instruments: are disposables the solution? PMID- 10150392 TI - Pain after laparoscopy: an observational study and a randomized trial of local anesthetic. AB - Our objective was to determine if local anesthesia reduces pain after a laparoscopy. Eighty women were assigned randomly 10 ml of 0.5% bupivacaine or 0.9% saline flushed over the peritoneal folds and into the abdominal wall after laparoscopy under general anesthesia. Pain scores from the deep abdomen, skin, shoulder, and back were collected 30 min, 2 h, 4 h, and the day following laparoscopy. Pain scores also were correlated with patients' height, weight, operative findings, surgical technique and procedure, and volume of gas insufflated into the abdomen. Bupivacaine has a small effect on abdominal and skin pain 2 h after surgery (p = 0.01) but has no effect on shoulder or back discomfort. Women who have been sterilized, have not had previous abdominal surgery, or have evidence of old pelvic inflammation report more postoperative backache and deep abdominal pain but no greater skin or shoulder discomfort. Weight, height, whether the abdominal wall was picked up, and the volume of gas used to insufflate the abdomen are independent of all postoperative pain scores. Local anaesthetic instilled down the laparoscopy trocar reduces skin discomfort 2 h after surgery, but this beneficial effect is small compared with other factors influencing pain after laparoscopy. PMID- 10150393 TI - The effect of surgical glove powder on proliferation of human skin fibroblast and monocyte/macrophage. AB - The effect of surgical glove powders (Biosorb, Keoflo, and CaCO3) and Hydrocote (powder-free lubricating agent, Biogel) was examined on human skin fibroblasts and monocyte/macrophage cell lines (U937 and HL-60). Glove powders (0.1-100 micrograms/ml) in the presence of 10% fetal bovine serum (FBS) had no significant effect on the rate of 3H-thymidine uptake and proliferation of these cells after 48 h and 7 days of exposure, respectively. However, they inhibited HL-60 growth after 10 days, and Biosorb and CaCO3 inhibited U937 after 10-21 days of exposure compared with control. In the presence of low serum (0.5%), Biosorb, but not Keoflo, CaCO3, and Hydrocote, inhibited HL-60 cells after the third day of exposure (p < 0.05), whereas they were without any effect on U937 cells. Further incubation resulted in a significant decrease in cell density in all treatments, as well as controls, because of cell death. In the presence of 2% serum, glove powder-treated HL-60 significantly increased in cell numbers during the first 3 days, and the cells became stationary thereafter, whereas Keoflo and CaCO3 stimulated U937 reached a maximal by 9 days of treatment. Coculturing of fibroblasts directly with macrophages (0.4-5 x 10(5) cells per dish) or incubation with macrophage culture-conditioned media (CCM) stimulated quiescent fibroblast growth equal to that induced by 10% and 0.5% serum, respectively (p < 0.05). However, incubation of fibroblasts with glove powder-treated HL-60 CCM (except CaCO3) inhibited (p < 0.05) and CCM from Biosorb-treated U937 stimulated (p < 0.05) fibroblast proliferation. The CCM from glove powder-treated HL-60 and U937 did not have any significant effect on the rate of 3H-thymidine incorporation into fibroblasts compared with controls. The present observations suggest that glove powder action on fibroblast and macrophage growth in vitro depends on both the serum concentration of the culture medium and the length of exposure. The results imply that glove powders may have an adverse effect in vivo by directly influencing the biologic activity of macrophages, as well as other cell types, leading to alterations in the early phases of wound healing. PMID- 10150394 TI - Diagnosis of endometrial carcinoma: predictive value of transvaginal color Doppler. AB - The objective of this study was to determine whether transvaginal ultrasound plus color Doppler flow improve the ability to diagnose endometrial carcinoma and allow better discrimination between benign and malignant endometrial lesions. One hundred thirty women with abnormal uterine bleeding were evaluated with transvaginal color Doppler before fractional dilatation and curettage (D&C). The endometrial line thickness and endometrial characteristics were evaluated by endosonography. The resistive and pulsatile indices of the uterine arteries and of the endometrium were evaluated with transvaginal color Doppler. Following D&C and tissue diagnosis, women were divided into two groups, 62 with a histologic diagnosis of endometrial adenocarcinoma and 68 with benign endometrial tissue. All women with endometrial carcinoma underwent TAH and BSO. A complete histopathologic study was done an all surgical specimens. The International Federation of Gynecology and Obstetrics (FIGO) stage and tissue grading were determined in all cases. The histopathologic findings were correlated with ultrasound and transvaginal color Doppler results. Patients with adenocarcinoma had an average endometrial thickness of 26.13 mm (range 8-87 mm). The average thickness for functional endometrium (proliferative) was 10.5 mm (range 6-23 mm). There was no case of carcinoma where the endometrial thickness was less than 8 mm. Intraendometrial neovascularization was not observed in any case with functional or atrophic endometrium. The flow indices in patients with endometrial adenocarcinomas are significantly different from the flow indices of patients with benign endometrial tissue. Transvaginal color Doppler increases the sensitivity of endometrial malignancy diagnosis. The method is capable of detecting important differences in flow indices and endometrial line characteristics between benign and malignant endometrial tissue. PMID- 10150396 TI - It's about time. PMID- 10150395 TI - Select dressings that promote healing. PMID- 10150397 TI - Orthotopic urinary diversion. AB - Internal reservoirs constructed from segments of stomach, ileum, the ileocecal region, and the sigmoid colon provide a reliable form of continent diversion. PMID- 10150398 TI - Imaging cystic renal masses. AB - Determining whether a renal mass is benign or malignant usually is possible with proper use of imaging. A few lesions will defy classification without surgery. PMID- 10150399 TI - Investigating the causes of fever in critically ill patients. Are you overlooking noninfectious causes? AB - Fever is common in the ICU because of patients' underlying chronic and critical illnesses, their tendency to receive multiple medications, and their frequent need for invasive procedures. Precise data on the etiology of fever in the ICU are lacking. However, common noninfectious causes include postoperative fever, drug fever, intramuscular injections, hemorrhage, and pulmonary atelectasis. Urinary tract infection appears to be the most common infectious cause, followed by pneumonia and sepsis. Many noninfectious conditions are potentially life threatening; nevertheless, it is crucial to first exclude an infectious cause, since an untreated infection may cause rapid deterioration. PMID- 10150400 TI - Techniques for evaluating fever in the ICU. A stepwise approach for detecting infectious and noninfectious causes. AB - The initial work-up of a critically ill patient with fever begins with a hunt for an infectious cause. A positive urine culture, or the presence of dysuria or suprapubic tenderness, suggests urinary tract infection. Diagnosing pneumonia in ventilated patients is particularly difficult; CT may be helpful when chest films are hard to interpret. Blood cultures can rule out septicemia. Other common causes of fever in the ICU include abdominal abscesses and catheter-related infections; atelectasis has not been shown to cause fever. If the initial work-up fails to establish a cause of postoperative fever, and the fever resolves within 4 days, no further work-up is required. PMID- 10150401 TI - H. pylori infection and GI disease: what critical care physicians need to know. Who should be tested for H. pylori? When is treatment needed? AB - Helicobacter (Campylobacter) pylori infection has emerged as a major cause of gastritis, peptic ulcers, and gastric malignancies. Not all patients with H. pylori infection require treatment; however, for those with ulcer disease (particularly those with bleeding), antibiotic therapy can be curative. To confirm infection (or its eradication), use the rapid urease assay, serologic examination or, when available, the urea breath test. Treatment options include triple therapy (with bismuth subsalicylate, metronidazole, and either tetracycline or amoxicillin) and dual therapy (with omeprazole and either amoxicillin or clarithromycin). For patients with an active ulcer, follow antibiotic therapy with ranitidine or omeprazole. PMID- 10150402 TI - Techniques for evaluating the cause of bleeding in the ICU. Diagnostic clues and keys to interpreting hemostatic tests. AB - Begin by obtaining both a bleeding and a family history to help ascertain whether the disorder is acquired or inherited. On physical examination, look for multiple bleeding sites or profuse bleeding; these can indicate a systemic bleeding diathesis. Order hemostatic tests. Prolonged aPTT points to a defect in the intrinsic or common coagulation pathway; prolonged PT, to a defect in the extrinsic or common pathway. Thrombin time is abnormal when hypofibrinogenemia, afibrinogenemia, or thrombin inhibitors are present. Bleeding time is prolonged in thrombocytopenia, platelet dysfunction, severe hypofibrinogenemia, and von Willebrand's disease. Factor assays also may be needed to further define the defect. PMID- 10150403 TI - Selecting candidates for cardiac transplantation. How to assess exclusion criteria and predict who will benefit. AB - The fundamental indication for cardiac transplantation is advanced heart failure that is unresponsive to medical therapy in patients with coronary artery disease or dilated cardiomyopathy. Other potential indications include advanced valvular or congenital heart disease and, more rarely, hypertrophic or restrictive cardiomyopathy, sarcoidosis, myocarditis, and primary unresectable cardiac tumors. Determining which patients have symptoms that are truly refractory to medical therapy is difficult. Ejection fraction or clinical status during acute decompensation is not a sufficient criterion for candidacy. PMID- 10150404 TI - How to determine decisional capacity in critically ill patients. Presume the patient can make decisions unless proven otherwise. AB - Decisional capacity includes ability to comprehend information, to make an informed choice, and to communicate that choice; it is specific to the decision at hand. Presume a patient has decisional capacity; an evaluation of incapacity must be justified. Administer a standardized mental status test to help assess alertness, attention, memory, and reasoning ability. A patient scoring below 10 on the Folstein Mini-Mental State Examination (maximum score, 30) probably does not have decisional capacity; one scoring from 10 to 15 probably can designate a proxy but not make complex health care decisions. Obtain psychiatric consultations for a patient who exhibits psychological barriers to decision making. PMID- 10150414 TI - Underwriting psychiatric impairments, with emphasis on depression. Part I: Psychiatric mortality and common underwriting parameters. PMID- 10150417 TI - The importance of careful measurement in health education research, theory and practice. PMID- 10150418 TI - The art and science of scale development in health education research. AB - This conceptually-based article focuses on the value of the complementary or integrative use of qualitative and quantitative research methods in health education research. Specifically, the article describes a model for developing measurement scales using both qualitative and quantitative techniques. The qualitative methods of open-ended interviews and focus groups are used to develop questionnaire items. Quantitative methods (e.g. factor analysis) are used to test and refine questionnaire subscales. A discussion of reliability and scale validation is offered along with illustrative examples from recent health education research. PMID- 10150419 TI - Measuring the implementation of health promotion programs: the case of the Breast and Cervical Cancer Program in Maryland. AB - This paper introduces critically important issues and benefits for measuring the extent and processes of program implementation when conducting and studying health education and health promotion programs. These methods are illustrated with reference to the Breast and Cervical Cancer Program in Maryland. We suggest using a chain of events research paradigm rather than confining community intervention research to the more frequently used experimental model. Combined roles as researchers and technical advisors serve complementary functions of gathering relevant, valid information about implementation and making these data useful to program managers. Measures of implementation should be used to examine the detailed delivery of program components, to assess organizational and environmental processes influencing the extent of implementation and to analytically link variations in program delivery to desired short-term outcomes. Measuring these processes is needed to move implementation research for health promotion programs beyond an anecdotal set of case stories about implementation problems to a fully developed area of research-based knowledge. PMID- 10150420 TI - Measuring community leaders' perceived ownership of health education programs: initial tests of reliability and validity. AB - Development of community ownership is often identified as an important intermediate objective of community health education programs. Community ownership is assumed to be important to program effectiveness and long-term maintenance, but validated measures of this construct have not been available to test this proposition. A measure of community leaders' perceived ownership of health education programs was developed and tested. The Community Ownership Scale identified key functions within a program and asked community leaders to rate the amount of control the leaders themselves, the external sponsoring agency and the local program staff had in each area. The measure was tested with the volunteer leadership of three community health education programs. Predictions about scores were based on the conceptual framework from which the ownership construct was derived. Results of these tests were consistent with predictions, providing evidence for the validity of the measure. Subscale scores showed high levels of internal consistency reliability. This measure could be applied at different stages in the life of a program to monitor the success of efforts to foster community ownership, and to test the relationships between perceived ownership and program effectiveness and maintenance. PMID- 10150421 TI - The development and validation of the Perceived Health Competence Scale. AB - A sense of competence or self-efficacy is associated with many positive outcomes, particularly in the area of health behavior. A measure of a sense of competence in the domain of health behavior has not been developed. Most measures are either general measures of a general sense of self-efficacy or are very specific to a particular health behavior. The Perceived Health Competence Scale (PHCS), a domain-specific measure of the degree to which an individual feels capable of effectively managing his or her health outcomes, was developed to provide a measure of perceived competence at an intermediate level of specificity. Five studies using three different types of samples (students, adults and persons with a chronic illness) provide evidence for the reliability and validity of the PHCS. The eight items of the PHCS combine both outcome and behavioral expectancies. Results from the five studies indicate that the scale has good internal consistency and test-retest reliability. The construct validity of the scale is demonstrated through the support obtained for substantive hypotheses regarding the correlates of perceived health competence, such as health behavior intentions, general sense of competence and health locus of control. PMID- 10150422 TI - How to manage risk in breast screening. PMID- 10150423 TI - Long-term outlook for MRI appears positive. PMID- 10150424 TI - SPECT reveals causes of painful lumbar spine. AB - SPECT greatly enhances the utility of radionuclide bone scanning and is superior to planar techniques in many instances. Its unique ability to localize sites of increased metabolic activity to specific anatomic sites is a significant advance in clinical science, with meaningful applications to daily patient care. PMID- 10150425 TI - Echocardiography practice issues: reimbursement, quality control, training, and credentialing. AB - With the major changes in the delivery of medical care brought about by "health care reform," the American Society of Echocardiography has become active in dealing with a variety of issues related to reimbursement, continuing quality improvement, training, examination, and certification outcomes research, and strengthening of relations with local societies. These efforts will undoubtedly continue to occupy a major role in the Society's agenda. The importance of cooperation among echocardiographers, sonographers, and other cardiac ultrasound professionals in ensuring the proper role of echocardiography in the practice of medicine cannot be overemphasized. PMID- 10150426 TI - Cost-effectiveness of echocardiography for evaluation of children with murmurs. AB - Echocardiography is widely accepted as an accurate diagnostic test to evaluate heart murmurs in children, however its costs, and the ubiquity of murmurs in children, discourage its universal application. The purpose of this article is to identify some clinical circumstances in which the cost of echocardiography is justified for the evaluation of heart murmurs in infants and children. Eight common clinical problems were selected in which a heart murmur is present and a diagnosis is called for. Effectiveness of echocardiography and less costly clinical diagnostic methods in these settings were compared. In some circumstances, echocardiography is worth the cost, because clinical evaluation is unacceptably insensitive to important disease (the premature infant with a murmur which might represent a patent ductus arteriosus, the infant with a dysmorphic syndrome and a murmur). In others, the expert clinical examination is highly accurate (the asymptomatic child with a heart murmur) and is preferred over the echocardiogram as the initial diagnostic approach on the grounds of cost. When the expert clinical examination suggests minor structural heart disease, a continuum of echocardiographic cost-effectiveness relative to the expert clinical examination exists between these extremes depending on the working diagnosis. A threshold has not yet been defined at any point on this continuum above which the public will demand the greater diagnostic detail available echocardiographically, and below which the public will refuse to accept its greater cost. Quantitative formal cost-effectiveness analysis of echocardiography for evaluation of heart murmur in infants and children is not yet feasible because the benefits of echocardiography are indirect, dependent upon the as yet unmeasured benefits of correct management of congenital heart defects. To go beyond simple comparison of efficacy of echocardiography with less costly methods, further work is required in outcomes research in congenital heart disease. PMID- 10150427 TI - Echocardiography in the emergency room: is it feasible, beneficial, and cost effective? AB - Echocardiography in the emergency room presents exciting practice possibilities that can facilitate prompt and reliable diagnostic evaluations in patients with suspected cardiovascular emergencies. Echocardiography has the diagnostic potentials to evaluate the entire spectrum of cardiovascular abnormalities short of delineating coronary anatomy and evaluation of the conduction system. By reliably assessing the global and regional function, visualizing the cardiovascular structures from multiple tomographic planes, and quantitating hemodynamic abnormalities, echocardiography should be able to assist emergency room physician's evaluation and triage of the patients with chest pain syndrome, unexplained dyspnea, hypotension, shock, chest trauma, and cardiac arrest, whereby hopefully minimizing the unnecessary admission to the hospital and facilitating inhospital evaluation of the admitted patients with echocardiographic information. However, the optimal echocardiography practice in the emergency room requires well trained sonographers and echocardiographers who can respond to the clinical needs at anytime. Whether an emergency room physician can perform and interpret echocardiographic examinations satisfactorily will depend on his/her level of training and continuing education in this area. Currently, there is no established guideline for performing echocardiography in the emergency room. Further clinical investigations are necessary to define the most optimal and economical utilization of this versatile imaging and hemodynamic diagnostic modality in the emergency room. PMID- 10150428 TI - Left ventricular mass estimation by echocardiography: is it clinically useful? AB - Echocardiographic determination of left ventricular mass provides prognostic information that is independent of blood pressure. This prognostic information has a graded and continuous relationship with outcome, and is independent of traditional risk factors. This article addresses the prognostic and clinical utility of echocardiography for detection of left ventricular mass. Recommendations will be offered regarding the use of echocardiography for screening in select individuals. PMID- 10150429 TI - Is cardiac catheterization necessary in the era of echocardiography? Cost effective approach combining echocardiography and cardiac catheterization. AB - Definitive evaluation of cardiovascular disease is traditionally accomplished by cardiac catheterization. Advances in transthoracic and transesophageal Doppler echocardiography provides an accurate and cost-effective approach when compared to cardiac catheterization. Recent data suggests that for most adult patients with aortic or mitral valve disease, Doppler echocardiographic data enables the clinician to make the same decision reached with catheterization data. Echo and Doppler studies are useful in guiding certain therapeutic interventional procedures, and in the diagnosis of aortic dissection, mechanical complications of myocardial infarction, and in identifying aortic atheromas as a potential source of embolism. Future research will need to demonstrate that not only is echocardiography cost-effective, but that it will change the outcome of the patient. PMID- 10150430 TI - Fee-for-service versus capitation-based reimbursement: how the payment method affects utilization of echocardiographic services by referring physicians. AB - Historically, health insurance carriers (HIC) have reimbursed physicians on a fee for-service basis for echocardiographic studies. With the emergence of managed care, the HIC now may have the option of paying on a capitation basis. To determine whether the method of reimbursement had any bearing on the types of patients referred for echocardiographic services, we conducted a two-phase (retrospective) study. In Phase One, we assessed two groups of ambulatory patients with regard to patient characteristics, medical reason for referral, and echocardiographic results. Group A (4,066 patients) had insurance plans that stipulated reimbursement for echocardiographic services as part of capitation for cardiology services. Group B (3,061 patients) had plans that reimbursed for echocardiographic services on a fee-for-service basis. In Phase Two, we assessed a total of 5,947 patients (3,833 from Group A and 2,114 from Group B) over a period of 40 months to determine the frequency of referral for a second echocardiogram within 2 years of a normal one and the repeat normalcy rate. The results showed that the capitation reimbursement group included younger, predominantly female patients who were referred more often for a more benign reason and who more frequently were diagnosed echocardiographically with less severe disease, higher rates of normalcy, and repeat normalcy. These findings suggest that in our geographic area the capitation method of reimbursement permitted more liberal utilization of echocardiographic services. In this era of cost awareness, the study suggests the need for better screening of patients referred for echocardiographic services. PMID- 10150431 TI - Cost-effectiveness of echocardiography: a private practice perspective. AB - Echocardiography is essential to the modern practice of cardiology. It is a robust, noninvasive technique, with proven effectiveness in the diagnosis of a multitude of cardiac disorders. However, the true costs of echocardiography and the charges, reimbursement, and collection rates, plus the overall economic value of echocardiography relative to other technical and cognitive services provided by cardiologists, are not so clearly understood or established. The purpose of this article is to provoke thought among echocardiographers about these economical issues. PMID- 10150432 TI - Factors influencing the outcome of endometrial laser ablation. AB - There have been more than 1000 endometrial laser ablations (ELA) performed at South Cleveland Hospital. The procedure has a high success rate in relieving the symptoms of dysfunctional uterine bleeding (83% sustained improvement over 1-4 years), and there has been no associated major morbidity. To identify factors that are associated with poor outcome, we have reviewed our data on women who progressed to hysterectomy after ELA. Twenty-nine of the first 524 women (5.5%) undergoing ELA have required subsequent hysterectomy. After excluding 3 cases where extensive endometriosis had been diagnosed at concomitant laparoscopy, these women were compared to 26 matched controls who had excellent outcomes. It was observed that young age, dysmenorrhea, and atypical pelvic pain at admission were factors associated with an increased chance of failure. Operative data, including uterine length and treatment times, were similar in both groups, and more than half the poor outcome group had entirely normal uteri. We conclude that good patient selection based on careful history and preoperative examination is of paramount importance in ensuring good treatment outcome. PMID- 10150433 TI - Microsurgical treatment of tubal sterility using the CO2 laser: a reasonable alternative to IVF in cases of tubal sterility. AB - A retrospective analysis of women treated microsurgically using the CO2 laser in sterility treatment was performed. The aim of the study was to determine women's personal feeling about the procedure, prognostic factors, success rates, and complications. Included were 192 patients with tubal occlusions or pelvic adhesions treated by means of CO2 laser microsurgery between February 1984 and July 1992. A standardized questionnaire was used to evaluate women's procedure related stress, extrauterine and intrauterine pregnancy rates, pregnancy complications, and postoperative complaints. In 75 cases, records and questionnaires contained sufficient data and were included for further analysis. Adhesiolysis alone, unilateral neosalpingostomy, bilateral neosalpingostomy, or new implantation was done in 7%, 52%, 33%, and 8%, respectively. In the range of 1-10, a medium degree procedure-related stress (mean 4.3, range 1-10) was expressed by the treated women. No surgery-related complications were observed. The overall pregnancy rate was 37.3%, and 10.7% were tubal pregnancies. In 26.7%, fertility surgery resulted in intrauterine pregnancies, and 21.3% of the treated women delivered living children. Three women had two consecutive pregnancies after surgery. Women with intrauterine pregnancy, extrauterine pregnancy, and no pregnancy had a mean age of 29.5 +/- 3.8, 27.3 +/- 5.3, and 32.3 +/- 4.2 years, respectively (p = NS). Mean duration of infertility before start of surgical treatment was 42.4 +/- 34.6, 41.6 +/- 25.8, and 48.8 +/- 33.2 months, respectively (p = NS). Intraabdominal instillation of streptokinase to prevent reformation of adhesions had no significant impact on tubal patency results or pregnancy rates.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150434 TI - A comparison of cold knife, CO2 laser, and electrosurgical loop conization in the treatment of cervical intraepithelial neoplasia. AB - Thirty patients with histologically confirmed high-grade squamous intraepithelial lesions (SIL) were treated by either cold knife, laser, or electrosurgical loop conization, all of which were performed under general anesthesia. The three methods were compared with respect to the immediate surgical complications, ease of performance, delayed complications, and quality of histologic specimens. The electrosurgical loop conization had decreased blood loss and reduced operative time and proved to be tissue sparing. There were no significant differences in the three groups in the persistence rates of cervical intraepithelial neoplasia (CN) after treatment. Histologic analysis revealed comparable coagulation artifact in the laser and electrosurgical loop groups that the cold knife group did not have. The endocervical component of the electrocautery showed extensive denudation and coagulation artifact that made recognition of CIN extremely difficult. We conclude that the electrocautery should be used only as an excisional method of the transformation zone for lesions well defined on the ectocervix, since it is unreliable if the lesion extends into the endocervix. PMID- 10150435 TI - A comparison of laparotomy and laparoscopy in the management of ovarian masses. AB - To compare the results of laparoscopy with laparotomy in the management of ovarian masses not suspected of being malignant, a retrospective review was made of 115 patients with ovarian masses operated on, 50 by laparotomy and 65 by laparoscopy, in the Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Hong Kong, from November 1, 1992, to October 31, 1993. In the laparoscopy group, the average size of the ovarian masses was smaller, and there was a significant reduction in the intraoperative blood loss, postoperative analgesic requirement, morbidity (particularly febrile morbidity and urinary retention), length of hospital stay, and recuperation period. The incidence of rupture of the ovarian mass was not related to the operative approach but to the underlying pathology. Two patients in the laparoscopy group were converted to laparotomy, and 1 in the laparotomy group required a second laparotomy. The operating time was longer in the laparoscopic approach, but this could be reduced with experience and improved technique in specimen removal. Laparoscopy appears to be a better approach than laparotomy in the management of ovarian masses where malignancy is not suspected and a competent surgeon is available. PMID- 10150436 TI - A comparison of preoperative ultrasound images of surgically proven endometriomas scanned by both transabdominal and transvaginal techniques. AB - The echo patterns of endometriomas have been described by both transabdominal and transvaginal scanning. This retrospective study was undertaken to evaluate the degree of internal echogenicity in endometriomas preoperatively scanned by both techniques. Transvaginal ultrasound scanning should be added to the diagnostic armamentarium. PMID- 10150437 TI - Treating vaginal and external anogenital condylomas with electrosurgery vs CO2 laser ablation. AB - Our objective was to assess the technical characteristics, side effects, complications, and effectiveness of electrosurgery vs continuous wave CO2 laser in the treatment of genital warts. This open clinical trial was made up of 208 evaluable patients (135 women and 73 men) with vaginal and external anogenital condylomas. To avoid selection bias, in each patient half of the lesions measuring 2 cm2 or greater total linear area were treated with loop electroexcision and ball electrofulguration, and the other half were treated with CO2 laser excision and vaporization in a continuous wave mode spot welding. All patients were followed for at least 6 months (maximum 18 months, mean 8 months) after the last treatment received. The average operative time was 6 min for electrosurgery and 8 min for laser. Healing was completed in 95% of patients with a lesional area of 5 cm2 or less and 100% of patients with 5 cm2 or larger by the third and sixth postoperative week, respectively. Severe discomfort occurred in 12% of patients, and 4% of patients developed delayed complications, including vitiligo and scarring, irrespective of treatment modalities used. Complete clearance of warts in women and men after a single (51% and 38%) and multiple (75% and 64%) treatments were similar in areas treated with electrosurgery and CO2 laser. Electrosurgery appears to be as effective as continuous wave CO2 laser for treating vaginal and external anogenital condylomas, particularly those limited to a 5 cm2 or less area. PMID- 10150438 TI - Clinical pathogenesis and diagnosis of osteoarthritis. AB - New insights into the metabolism of cartilage have increased respect for efforts designed to prevent osteoarthritis. The aging of the population adds to the desire to diagnose and manage the disease before patients become seriously disabled. PMID- 10150439 TI - Medical management of osteoarthritis. AB - Appropriate use and timing of the options aimed at ameliorating symptoms are outlined. Study results of nonpharmacologic methods as well as drug trial conclusions guide the recommended approach. Adjunctive and investigational treatments are also described. PMID- 10150440 TI - Joint replacement for osteoarthritis. PMID- 10150441 TI - Lung cancer and time-related exposure to residential radon in the air. PMID- 10150442 TI - Radon's daughters. PMID- 10150443 TI - Marketing and the mass media: theory and myth. PMID- 10150444 TI - Changing Swedish students' attitudes in relation to the AIDS epidemic. AB - In the present study we have evaluated the knowledge, attitudes and intention to act in relation to HIV/AIDS related issues among Swedish students aged 15-18 years. An intervention group (n = 368) and a comparison group (n = 180) were followed for 2 years between 1989 and 1991. The teachers of the intervention group were obliged to specifically give a continuous and in-depth education while the comparison group received ordinary traditional education. We present the results from questionnaires given to all students before and after the study. There was a significant increase in knowledge of facts in the intervention group, and also changes in attitudes towards, for example, gay people, drug users and HIV infected individuals, in a desirable direction. In sex related issues there was also a desirable change in intention to act, but this was not seen in students' relation to alcohol. No significant changes at all in knowledge, attitudes or intention to act were seen in the comparison group. Our results show that it is indeed possible to influence students' attitudes and intention to act in HIV/AIDS related issues provided teachers start by defining the students' central conceptions and their relation to each other, and promote individual thinking and reflection. PMID- 10150445 TI - Young adolescents' intention to use seat belts: the role of attitudinal and normative beliefs. AB - In this study, the Theory of Reasoned Action was applied for two different purposes: (i) to explain and predict seat-belt usage among young adolescents, and (ii) to investigate the specific cognitions underlying the decision to use seat belts. A detailed analysis of these cognitions may provide clues as to which beliefs one should try to change in order to improve seat-belt usage among young adolescents. The decision to wear seat belts was under attitudinal control in the front seat, while it was under both attitudinal and normative control in the back seat. However, prior use of seat belts was the single most powerful predictor of intention. There was a striking consistency in the difference between high intenders and low intenders with regard to the specific underlying cognitions. The most promising 'messages' for persuasive communication appears to be that use of seat belts has an injury reducing effect and makes one feel safe when driving. PMID- 10150446 TI - Effects of health facilitator performance and attendance at training sessions on the acquisition of tobacco refusal skills among multi-ethnic, high-risk adolescents. AB - The study examined the effectiveness of a psycho-social tobacco use prevention intervention with a refusal skills training component on the refusal skills of high-risk adolescents, and investigated skill acquisition as related to subject demographics, performance of health facilitators and attendance at skills training sessions. Tobacco refusal skills were assessed for a group (n = 389) of high-risk, seventh-grade students participating as intervention and control subjects in Project SHOUT, a large tobacco use prevention program in the San Diego area. In addition, subject demographics, ratings of health facilitator performance and information about subjects' attendance at skills training sessions were collected. Subjects' responses to audiotaped peer offers of cigarettes and smokeless tobacco were coded for content and quality. Greater tobacco refusal skills among intervention subjects was hypothesized. Further health facilitator performance, attendance at training sessions and subject demographics were thought to be related to skill acquisition. High-risk intervention subjects gave significantly higher quality tobacco-refusal responses than did controls, although the differences between means were small. Results suggested that Hispanic adolescents were particularly receptive to the refusal skills training. The association between health facilitator performance and skill acquisition varied by subject ethnicity, as did the relationship between attendance at training sessions and skill acquisition. PMID- 10150447 TI - Patient education for sickle cell disease: a national survey of health care professionals. AB - Despite emphasis on including patient and parent education in sickle cell comprehensive clinical care, literature on the use of such materials is scarce. To discover the availability of, satisfaction with, use of and interest in patient and parent education materials for sickle cell disease, we surveyed, with a 176-item self-administered questionnaire, 209 sickle cell professionals nationwide. Respondents came from 74 sickle cell programs, were 63.4% female and 37.7% African American, and represented many health professions. We found that materials about patient behavior and psycho-social issues, as opposed to those about the disease and treatment, were more often unavailable and, when available, more often unsatisfactory and less frequently used. When available, use of materials was unrelated to satisfaction and perceptions of patient problems for most topics. For each of 10 topics, over 90% of the respondents were interested in materials covering the topic. Future research should examine the low to moderate use of psycho-social and behavioral materials with sickle cell patients, and should assess the appropriateness and effectiveness of existing and new materials. PMID- 10150448 TI - Community ownership and program continuation following a health demonstration project. AB - Community ownership and maintenance of heart health programs was a major study goal of the Minnesota Heart Health Program (MHHP), a community-based National Heart, Blood and Lung Institute (NIH)-funded demonstration project. A partnership between the University of Minnesota and three Upper Midwest intervention communities was initiated in 1981. Local citizen boards were instrumental in planning, implementing and incorporating programs. Through an 8 year process of community organization, training and volunteer involvement, MHHP educational program responsibility was transferred to existing community-based groups and organizations. In 1989, when federal funding was withdrawn, 70% of all heart health intervention programs initiated by MHHP were being continued by local sponsors and supported by local funds. By 1992, maintenance of programs had decreased to an average 60%. Differential results of program incorporation among the three intervention communities are presented including findings on community sectors that most frequently sponsored programs. Factors that facilitate or impede local ownership are discussed. Research on longer-term maintenance of heart health programs in the three communities continues. PMID- 10150449 TI - Pile sorts as a means of improving the quality of survey data: malaria illness symptoms. AB - Much social research data on locally endemic diseases has been gathered in from surveys. In this form, the data may not yield insight into indigenous illness concepts and the relationships among the findings that is needed for a full understanding on how people classify and respond to illnesses. This paper reports on a trial effort to use the pile sort technique to strengthen quantitative survey data on malaria. Respondents sorted common malaria symptoms, previously reported on surveys conducted in southwestern Nigeria. Computer analysis of the 22 sortings with ANTHROPAC software produced a mapping of symptoms that corresponded with three locally perceived forms of malaria illness, as confirmed through discussions with key informants. This simple procedure improved the quality of survey data and enhanced its value for use for culturally appropriate communication in patient and community health education programmes. PMID- 10150450 TI - Reflections on the relationship between theory and practice. AB - The paper presents an analysis of the problems that have created a gulf between theory and practice in health education. Drawing on the classical distinction made by Aristotle between theoria (natural processes) and praxis (social practices), the analysis traces the roots of the problem to the inadequacy and inappropriateness of the natural sciences model for studying human behavior. Because of the limits of the positivist methodology, the results of experimental, hypothesis-testing research can at best provide only minimal guidance to practitioners in program development. The paper then describes an alternative conceptualization of theory, and concludes with the implications of this alternative model for closing the gap between theory, research and practice. PMID- 10150451 TI - Results from a lifestyle survey: Trent health. AB - The objective of this work was to examine the efficiency of a postal survey in generating data relevant to Trent Regional Health Authority's need for baseline measures as indicators for health promotion, as specified in its strategy for health promotion. A representative sample, by District, was identified using Family Health Service Authority registers as the sampling frame, stratified by age (16-70 years) and gender. Data were collected from the resulting sample of 21,603 using a self-completion illustrated questionnaire. Delivery was postal with two reminders. Prepaid envelopes were supplied for returns. Questions about lifestyle, e.g. behaviour, attitudes and beliefs about smoking. The survey took place in each of the 12 Districts of Trent Region, the total population of which is over 4.5 million. The main outcome measures were behaviour, attitudes and beliefs about health by age and gender and by social class. The response was 61% after exclusions. Young males were under-represented in response. Sixty four per cent of respondents were non-smokers, 14% took optimal exercise on a monthly basis and 15% never drank alcohol. In the week prior to the study males were more likely to have drunk more than the recommended units of alcohol (24%) than women (9%). Over two-thirds of respondents (72%) had three key elements of social support. The postal survey generated data directly relevant to indicators embedded within Trent Health's health promotion strategy. Across the Region it was possible to examine patterns of response by age, gender and by social class. Data were adequate as baseline measures and repeat studies will monitor change. However, data are biased with sub-groups under-represented. In addition, non responders are known to be different from responders. Data are therefore limited, but can be used to describe general patterns amongst responders. Other methods of data collection are required for the collection of more sensitive and/or qualitative data. PMID- 10150452 TI - Co-operation, participation and conflicts faced in public health--lessons learned from a long-term prevention programme in Sweden. AB - A comprehensive community-based programme for prevention of cardiovascular diseases (CVD) and diabetes was established in 1985 in a small municipality in northern Sweden. A cross-sectional survey to the general public was performed and semi-structured open-ended interviews were taken of actors at different levels. Notes from official records were also included in the study. The aim was to describe and discuss some factors that promote or constrain community participation in health programmes. The results generally confirmed that the right of definition concerning the health programme mainly remained with the health professionals. Community participation was mainly defined by the actors based on the medical and health planning approach and, thereby, as a means to transform health policy plans into reality by transmitting health knowledge and increasing consciousness among the citizens of the need for changing lifestyles. However, participation as a means of identifying problems and demonstrating power relationships and as elements in promoting local democracy was hardly represented among the actors at all. Overall, the CVD health programme was characterized by consensus between the actors. Despite this, debates and arguments about interpretations, social interests, personal conflicts and ideological constraints were observed. However, a majority of the public wanted the CVD preventive programme to continue. PMID- 10150453 TI - A study of breast cancer detection practices and beliefs in black women attending public health clinics. AB - In this study, breast cancer knowledge, beliefs and practices in low income black women were examined. First, focus groups were held with a total of 33 participants. Information gathered from the focus groups was used to develop a telephone survey which was partially based on the Health Belief Model (HBM) and administered to 92 subjects. Utilization rates of mammography and breast self examination (BSE) were quite high; 66.3% of survey participants reported having at least one mammogram and 72.5% performed BSE. Because low-cost mammograms were available to the survey participants, these results suggest that women in this target population will utilize accessible and affordable mammograms. Several knowledge deficiencies that need to be addressed were also identified. Most of the health beliefs were not significantly associated with mammography or BSE utilization. Because the HBM has never been extensively tested on this population, its appropriateness as a behavior model for low-income women is examined. Implications for future research and interventions are discussed. PMID- 10150454 TI - Reducing alcohol consumption among university students: recruitment and program design strategies based on Social Marketing Theory. AB - Recruitment of program participants and development of appealing comprehensive alcohol abuse prevention programs is an exigent priority for university campuses due to the serious physical and emotional consequences related to alcohol consumption. A sample of 67 students from a large midwestern university completed a survey based on Social Marketing Theory (SMT) which was developed to improve recruitment and enhance the design of comprehensive alcohol abuse prevention programs. The results indicate that recruitment may be optimized by providing a flexible, convenient, low-cost program that encourages friends' participation, communicates alcohol-related risks and offers university credit or refund as participation incentives. The design of alcohol abuse prevention programs may be enhanced by emphasizing the positive outcomes of reducing alcohol consumption, improving the quality and quantity of alternatives to the social atmosphere connected with drinking, and soliciting respected opinion leaders (physicians and parents) to communicate alcohol reduction messages. This project is a first initiative to 'fill the gap' in the social marketing research literature by providing formative information pertinent to recruitment and design of alcohol reduction programs specifically for college students. PMID- 10150455 TI - The capacity-building approach to intervention maintenance implemented by the Stanford Five-City Project. AB - Increasingly, agencies supporting community health promotion interventions require participating communities and evaluators to specify how the intervention will be maintained once agency funding ends. The Stanford Five-City Project (FCP) implemented two different strategies to maintain its heart disease education program, with the second strategy designed to overcome the barriers to implementation that were encountered by the first. This paper provides a practice oriented description of the initial 'community network' maintenance strategy of the FCP, the barriers that were encountered as this network strategy was implemented, the alternative 'capacity-building' strategy directed at local health educators and the successful implementation of this alternative. Also discussed are the community organization issues underlying the shift in intervention maintenance strategies and the specific components of the capacity building strategy, including its focus on health educators, and its application of a training of trainers model and cooperative learning methods to provide professional development, technical assistance and other resources to a target group of community health educators. Our experience indicates that capacity building is a viable method for intervention maintenance and that it may also facilitate efforts to disseminate model health promotion programs to communities lacking experience in community health promotion intervention. PMID- 10150456 TI - Can we build on, or must we replace, the theories and models in health education? PMID- 10150457 TI - The Forsyth County Cervical Cancer Prevention Project--I. Cervical cancer screening for black women. AB - The Forsyth County Cervical Cancer Prevention Project was a 5 year National Cancer Institute-funded community-based public health education program implemented to address the problem of excess mortality from cervical cancer among black women in Forsyth County, North Carolina. The intervention was a community based public health education program that included mass media, direct education workshops, and provision of education on cervical cancer and screening to health care providers. The intervention was implemented from November 1988 to September 1991. Evaluation of the community intervention used a quasi-experimental design, with Forsyth County, North Carolina, receiving the program and Durham County, North Carolina, serving as the control. Comparison of pre- and post-intervention telephone survey data revealed that, overall, awareness of cervical cancer and the Pap smear increased. Knowledge, attitudes and behaviors showed little change, considering those interviewed in aggregate. Among women defined as high-risk (elderly, low socioeconomic status, public health clinic patients and/or those who do not receive regular care), a significant trend toward greater participation in screening was detected for the 6 month period following the intervention. These results suggest that awareness of cervical cancer can be increased by public health education, but that the additional attention coming to patients through the actions of health care providers and health care delivery systems may supply the additional input needed to produce behavior change. PMID- 10150458 TI - The Forsyth County Cervical Cancer Prevention Project--II. Compliance with screening follow-up of abnormal cervical smears. AB - The Forsyth County Cervical Cancer Prevention Project was a community-wide cancer education program to address the problem of cervical cancer incidence and mortality among minority women in Forsyth County, North Carolina. This paper reports program results with regard to increasing compliance with follow-up for abnormal cervical smears. An analysis of trends prior to and after implementation of the educational program was conducted in one private and two public health primary care clinics to provide an assessment of impact of the project in improving compliance with follow-up among black women. A similar analysis also was conducted for white women. The results of medical record reviews of follow-up procedures for 878 abnormal cervical smears suggested a modest program effect among black women. The percentage of black women who returned for follow-up and treatment of an abnormal cervical smear significantly increased during the time the program was in effect. The trend analysis further indicated that the decline did not begin prior to the intervention period and was maintained throughout the duration of the intervention. No significant change in the percentage who returned for follow-up was found for white women. PMID- 10150459 TI - The role of age and an expanded Health Belief Model in predicting skin cancer protective behavior. AB - Skin cancer (SC), the most common form of cancer in the US, with a rapidly growing incidence, has become a target for health education. Sun exposure protective behavior (SEPB) is currently believed to be the best means to prevent it. Focusing on age differences, this paper applies an expansion of the Health Belief Model (HBM) to the prediction of engagement in SC protective behaviors in four age-groups, following an intervention program. It is based on data collected by a structured questionnaire completed by 509 members of four kibbutzim in Israel. The results indicate that the proposed model explains the SC-related protective behaviors of the older age-groups (45+) much better than that of the younger groups (15-44). The older age-groups are also more likely to change risky behavior following the intervention. The youngest age-group (15-29), although being highest at risk for SC due to sun exposure habits, is least likely to change them and least likely to participate in the intervention. Beliefs about sun tanning, sun exposure habits (barriers) and degree of exposure to the intervention are the best predictors of the likelihood to engage in SEPB in the younger age-groups, while among the older groups the best predictors are the value of health and appearance. These findings suggest that health education programs should develop different messages for different age-groups. Regarding SC, it seems especially important to focus prevention efforts on adolescents and young adults by recruiting the beauty and fashion industries as well as legislation. The merits of age group analyses in the research of health behavior are discussed. PMID- 10150461 TI - Relating health education research to health policy. AB - This paper argues that research in health education is being driven by a set of implicit values that emphasize formality, rigor and objectivity, and that relatively little attention is being paid to the ways in which research findings are subsequently used. A critique of a detached and formal research perspective is developed around the problems of 'pure' knowledge and the potential incompatibility between this and policy-making processes. In this light, it is suggested that the pursuit of academic research rigor at the expense of practical utility is hindering the development of a stronger research-policy link. The paper then goes on to suggest that in adopting a sharper political orientation, health education research could legitimately become less concerned with the restrictive nature of academic formalism with research. The nature of this type of research, the potential it has as well as its limitations are subsequently explored. PMID- 10150460 TI - Risk-taking behaviors and AIDS knowledge: experiences and beliefs of minority adolescent mothers. AB - Using a qualitative focus-group methodology, this study investigated risk-taking behaviors and AIDS knowledge among minority pregnant and parenting adolescents at risk for heterosexual and perinatal transmission of HIV. Seven focus groups were conducted with a total of 48 young women recruited from alternative schools and residential facilities for pregnant adolescents and young mothers in Southern California. Participants also completed a background questionnaire soliciting sociodemographic information and an AIDS knowledge test. The sample included 33 Latinas and 15 African-Americans, ranging in age from 12 to 19 years. There were bipolar findings regarding risk-taking behaviors. At one end of the continuum were young women with a history of one of more of the following behaviors: multiple sex partners, drug and alcohol use, carrying weapons, and participating in gang-related activities. Contrasting with these, were those who had one or two sex partners and no history of alcohol or drug abuse. A majority of the participants were having unprotected sex. A variety of factors affected condom use, including gender inequality, embarrassment, and personal preferences and values. Risk-taking was also influenced by lack of security and safety in daily living, emotion-focused coping and peer pressure. PMID- 10150462 TI - Ten commitments for community health education. PMID- 10150463 TI - Comparison of three rapid test kits for detection of human immunodeficiency virus in blood. PMID- 10150464 TI - Nutritional assessment in the elderly: biochemical analyses. AB - OBJECTIVE: To describe briefly the anthropometric, biochemical, clinical, and dietary components of a complete nutritional assessment and to examine four common nutritional concerns in the elderly and the biochemical tests that aid in the identification and treatment of these disorders. DATA SOURCES: Clinical expertise/practice, recent professional journals, and textbooks. STUDY SELECTION: Not applicable. DATA EXTRACTION: Clinical practice and literature review. DATA SYNTHESIS: Biochemical assays are one aspect of a complete nutritional assessment that provides valuable information in the determination of an individual's nutritional status and the identification of any nutrient deficiencies or excesses. As part of this nutritional assessment, specific biochemical tests are ordered to substantiate further or to rule out nutrient deficiencies or excesses gleaned from the clinical, dietary, and anthropometric components of the complete nutritional assessment. CONCLUSION: Given the increased potential for nutritional problems in the elderly, a comprehensive nutritional assessment should be performed as a routine part of elderly care. This assessment includes anthropometric measurements, biochemical assays, a clinical examination for signs of deficiencies or excesses, and a complete dietary evaluation to determine current intake and make necessary recommendations. PMID- 10150465 TI - Medication monitoring in the elderly. AB - OBJECTIVE: To review changes associated with aging that affect medication use and to outline medication-monitoring guidelines. DATA SOURCES: Recent medical literature including journals and texts. STUDY SELECTION: Determined by the author. DATA EXTRACTION: By the author. DATA SYNTHESIS: There are many changes that occur in the aging individual that may affect medication use. Alterations in organ function, especially that of the liver and kidneys, may potentiate drug effects. Appropriate use of serum-drug concentrations, used in conjunction with standard clinical observations, is an effective means of monitoring the patient. Medications with a high risk of toxicity in the elderly, such as phenytoin, theophylline, and digoxin, may be used with a much higher degree of safety if serum concentrations are obtained. Blood samples must be obtained at appropriate times to ensure accurate interpretation of the drug concentration. CONCLUSION: When performed appropriately, serum-concentration monitoring of medications is a valuable method of reducing toxicity in the elderly. PMID- 10150466 TI - Case report of zinc deficiency in an elderly woman. AB - Zinc deficiency is not an uncommon nutritional disorder in the elderly. It should be suspected in patients who have conditions associated with zinc deficiency (Table 1) or who have one of the potential causes of zinc deficiency (Table 2). A low serum-zinc level indicates zinc deficiency unless an acute phase response is present. The acute-phase response should be suspected in a patient with an acute illness. A C-reactive protein level is helpful in identifying the acute-phase response. Our initial treatment of zinc deficiency centers on increasing dietary zinc. Often, however, because of other common problems of geriatric patients such as dementia or depression, the patient is unable to alter his or her diet. Then, zinc supplementation may be required. Copper, iron, and lipoprotein status should be monitored if long-term zinc supplementation is needed because they may be effected by the zinc supplementation. PMID- 10150467 TI - Recruitment strategies used by an allied health education program to increase student enrollment. AB - OBJECTIVE: To increase student enrollment in and public awareness of a Clinical Laboratory Science (CLS) program so that the program would not be eliminated by the University. SETTING: The Medical Technology (MT) program at the University of Delaware (UD). PRACTICE DESCRIPTION: The MT program is a 2 + 2 university-based program established in 1948. The program is accredited for 26 students. PRACTICE INNOVATIONS: Various recruitment activities were used to increase enrollment including presentation at high schools, and panel discussions and open houses held on campus. Extensive publicity on and off campus was used to inform the community about CLS. MAIN OUTCOME MEASURE: Student enrollment in the program and the results of a survey administered to students enrolled in a CLS introductory course. RESULTS: There were 22 students in the 1993-1994 graduating class compared to 10 in the 1992-1993 class. The enrollment also increased for the junior, sophomore, and freshman classes. Because of increased student enrollment and public awareness, the University decided not to eliminate the MT program. CONCLUSION: No single recruitment activity contributed to the increased numbers; rather, it appears that all of the activities contributed to the rise in enrollment of MT majors at UD. PMID- 10150468 TI - Detection of undiagnosed coagulopathies using routine rapid heparin neutralization. AB - OBJECTIVE: To determine the most frequent clinical causes of a prolonged activated partial thromboplastin time (APTT) result, and to determine whether a new heparin-removal device (the Hepchek, Pall Biomedical, Glen Cove, NY 11542) is capable of efficiently detecting the causes of these values. DESIGN: A combination of chart review and laboratory testing comparing the criterion standard--the heparin chromogenic substrate assay--with the Hepchek. Laboratory investigations were blinded and controlled. SETTING: Inpatient, acute-care hospital. PATIENTS: A total of 1,000 hospital patients with a variety of hemostatic disorders. MAIN OUTCOME MEASURE: The extent to which the Hepchek accurately identified the etiology of a prolonged APTT result. RESULTS: The APTT was prolonged in 25.2% of samples. The presence of heparin in the sample was confirmed by chromogenic assay or by using the Hepchek heparin-removal filter. The presence of heparin was confirmed in 12.8% of all samples and in more than 50% of all abnormal samples. The cause of the abnormal APTT was often unappreciated by the clinician. Bayesian analysis of the Hepchek's ability to diagnose heparin correctly as the cause of the abnormal APTT showed a sensitivity of 100% and specificity of 99.9%. CONCLUSION: Use of the Hepchek in the routine clinical laboratory is an efficient and rapid method of detecting heparin as a cause of isolated prolonged APTT results, and should reduce demands for unwarranted coagulation analyses and inappropriate treatment with blood products. PMID- 10150469 TI - Automation of steroid radioimmunoassays using a robotics workstation. AB - OBJECTIVE: To automate the radioimmunoassay (RIA) of steroids in a diagnostic clinical laboratory. SETTING: The Laboratory of Pediatric Endocrinology, Cornell Medical Center-New York Hospital. PRACTICE DESCRIPTION: A tertiary-care center supporting the diagnosis and treatment of pediatric patients with endocrine disorders. PRODUCT COMPARISON: The Packard MultiPROBE Model 100 Automated Liquid Handling System (Packard Instrument Company, Meriden, CT 06450) was compared with the assays typically used to assist in the diagnosis of steroidogenic disorders in children: extraction of biologic fluids, celite partition chromatography, and RIA. MAIN OUTCOME MEASUREMENT: The comparative efficiency, cost-effectiveness, specificity, and sensitivity of the two methods. RESULT: The automated RIAs correlated (r = 0.963) with the established manual assays for steroids. The specificity and sensitivity of the assays were uniformly maintained after automation. CONCLUSION: The automation of steroid RIAs has made the method a highly efficient and cost-effective one for diagnostic clinical laboratories. PMID- 10150470 TI - University-based clinical laboratory science programs: strategies for survival. AB - OBJECTIVE: To describe the current status of clinical laboratory science (CLS)/medical technology (MT) programs regarding the impact of budgetary cutbacks and to identify successful strategies for program survival. DESIGN: Mail survey. SETTING: University-based CLS/MT programs accredited by the Committee on Allied Health Education and Accreditation (CAHEA). PARTICIPANTS: All CAHEA-accredited, university-based CLS/MT programs in Ohio and bordering states and all "big-ten" programs as listed in the Allied Health Education Directory 21st edition (n = 19). INTERVENTION: None. OUTCOME MEASURES: Program directors' perceptions of: the potential threat of program closure, the impact of budget cutbacks, and successful strategies to enhance program viability. RESULTS: A total of 13 programs responded, for a response rate of 68%. The majority of the respondents (66%) indicated that they were experiencing budget cutbacks that affected either their operating budgets or their staffing configurations, or both. Although program closure had been discussed in many programs, directors felt that their programs would not be threatened with closure in the next three years. Only one program had intentionally decreased student enrollment. Strategies implemented by program directors fall into one of four categories: curriculum restructure, use of nontraditional instructional staff, revenue generation, and use of innovative teaching strategies. CONCLUSION: CLS/MT programs are experiencing budget cutbacks consistent with the overall trend in institutions of higher education. In light of the trend toward program closures and decreasing entering practitioners, educators must address issues that relate to program viability. CLS/MT program directors are seeking and instituting changes to enhance the status of their programs in their respective institutions. These strategies are similar to those reported by other higher-education administrators. Further research and evaluation are necessary to determine the outcomes of such measures. PMID- 10150471 TI - Student retention methods in clinical laboratory education programs. AB - OBJECTIVE: To document the use of student retention methods in clinical laboratory scientist (CLS) and clinical laboratory technician (CLT) education programs sponsored by academic institutions. DESIGN: Mailed survey. SETTING: Not applicable. PARTICIPANTS: Program directors of 182 CLS and CLT education programs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Responses to a 52 item, forced-choice s survey of retention methods used and program enrollment data provided by survey respondents. RESULTS: All programs are using retention methods, although only 36% of the programs have official retention programs for all students, while 14% have programs targeting minorities. A wide variety of retention methods are used, maintenance-phase activities being used with the greatest frequency. CLS and CLT programs differ in their use of certain retention methods and in some of the phases of the retention process emphasized. CONCLUSION: This study describes the use of a wide variety of retention methods currently employed nationwide. Educators can use the results of this study as a baseline for evaluating their own programs' retention efforts in attempting to address the problem of student attrition. PMID- 10150472 TI - Doppler echocardiography in familial hypertrophic cardiomyopathy: the French Cooperative Study. AB - Familial hypertrophic cardiomyopathy (HCM) has been poorly studied, although it may represent 50% of all HCM. We studied 346 subjects belonging to 20 unrelated families. Patients were considered affected in view of left ventricular (LV) wall thickness. One hundred twenty-seven adults were considered affected, id est. had a left ventricular wall thickness (LVWT) > 13 mm, whereas 123 had a LVWT > 15 mm, suggesting that the cut-off value is usually not critical. Within affected patients, 95% had an asymmetrical HCM (interventricular septum/left posterior wall thickness > 1.3 mm), whereas 84% had a ratio > 1.5. Distribution of the affected patients according with Maron's classification are in keeping with published studies about sporadic forms. Doppler derived isovolumetric relaxation time was prolonged in HCM (105 +/- 23 vs 88 +/- 16 msec, P < 0.001), and the ratio peak velocity of A wave over peak velocity of E wave was significantly lower in affected individuals (0.99 +/- 0.56 vs 0.83 +/- 0.46, P < 0.05). None of the 24 children studied (10 +/- 3 years) were considered affected according to echocardiographic criteria. CONCLUSION: Echocardiography is the obligatory first step during genetic study for recognizing familial HCM. It allows classification in adults but not in children. Doppler estimate of diastolic function may be helpful in the future to recognize genetically affected subjects with normal or subnormal echocardiographic examination. PMID- 10150473 TI - Precordial three-dimensional echocardiography with a rotational imaging probe: methods and initial clinical experience. AB - We report our initial experience with a precordial hand-held transducer assembly allowing computer controlled acquisition of cardiac images for dynamic three dimensional tissue reconstruction in adult patients. A commercially available transducer and imaging system were used and its video output interfaced with the three-dimensional reconstruction unit. For this feasibility study, 20 patients in sinus rhythm and with good image quality were examined. The dynamic motion of the valves and ventricles was visualized in three-dimensional formats as well as relationships of complex pathology. Although the acquisition time in patients in sinus rhythm is relatively short, the reconstruction time is still too long and requires an experienced and dedicated operator. However, with further developments in computer technology dynamic three-dimensional echocardiography will undoubtedly become an integral if not the principal part of our routine echocardiographic examination in the future. PMID- 10150474 TI - Future directions in intravascular ultrasound: from micro-motors to imaging guidewire systems. PMID- 10150475 TI - Myocardial viability: nuclear medicine versus stress echocardiography. AB - The failure of nonimaging techniques in the identification of myocardial viability has promoted the clinical application of radioisotopic and echocardiographic methods. Unfortunately, none of these techniques provides, per se, a 100% predictive accuracy and only few studies have been based on the postoperative improvement in regional wall motion, the absolute "gold standard" for myocardial viability. The recent thallium-201 protocols (reinjection, late redistribution, rest studies) have provided nuclear cardiology with a cell membrane integrity image able to unmask viable myocardium in more than 85% of viable segments. Sestamibi has been introduced as a nonrecirculating flow tracer able to detect transient ischemia as well as thallium-201. Its main limit, a high sensitivity to intermediate reductions in coronary blood flow, determines a high incidence of false positive studies. Positron emission tomography allows the evaluation of regional myocardial blood flow and metabolism. The marker of viable myocardium is the mismatch between reduced blood flow and normal or increased uptake of 18-F fluorodeoxyglucose. This technique allows the detection of viable tissue in most segments showing improved postoperative function. In our experience, applying a multiparametric approach, rest thallium-201 scan, rest sestamibi, dobutamine, and dipyridamole echocardiography showed a sensitivity and a specificity of 86%, 75%, 82%, 75% and 92%, 84%, 92%, and 89%, respectively, in the detection of residual viability. The main advantages of thallium-201 are reproducibility and standardization; those of stress echo are low cost and availability. In patients with severely depressed ventricular function, positron emission tomography retains a primary role when compared to thallium-201 and stress echocardiography. PMID- 10150476 TI - Strategy of diagnostic imaging before and after PTCA. AB - It is now widely accepted that percutaneous transluminal coronary angioplasty (PTCA) is an effective nonsurgical technique for achieving coronary revascularization. Exercise electrocardiography remains the standard procedure for functional evaluation before, early, and late after angioplasty because of its availability, safety, and limited cost. The drawback of exercise testing is its low specificity and the fact that the attainment of diagnostically useful data requires a level of exercise that substantially increases myocardial oxygen demand. Exercise thallium imaging has been shown to be highly predictive of restenosis and adverse events after angioplasty, but it is possible that myocardial perfusion may not return to normal immediately after successful revascularization. Stress echocardiography has many practical advantages over scanning tests, as result of its lower cost, shorter imaging time, and the absence of radiation exposure. Dipyridamole echocardiography testing (DET) is an exercise-independent method of evaluating patients who have to undergo coronary angioplasty. Before PTCA, DET allows the clinician to localize the site and extent of myocardial ischemia anatomically. Early after a successful procedure, DET identifies a group at high risk for the late recurrence of symptoms. Late after PTCA, DET is more accurate than exercise electrocardiography in detecting restenosis or disease progression. In asymptomatic patients with exercise-induced ST depression, DET has the same good diagnostic accuracy as thallium scintigraphy. For these reasons, as well as because of its noninvasive nature and availability, DET should be considered an attractive option for the evaluation of patients after anatomically successful angioplasty. PMID- 10150477 TI - Risk stratification after myocardial infarction: targets and tools. AB - The increasing use of thrombolytic therapy and coronary revascularization, either as acute therapy or early thereafter, has ushered in the "interventional era" of management of myocardial infarction (MI). This new scenario has at least two clear cut clinical implications. First, the cardiologist can intervene earlier to change the "natural history" of MI, not only to improve the immediate inhospital prognosis but also to prevent the development of those factors affecting the clinical outcome after discharge. Second, patients currently selected for predischarge evaluation are at lower risk for subsequent cardiac events. The critical management decision is with the majority of patients who have an uncomplicated MI. Two approaches may be applied to this large cohort to assess cardiac risk before hospital discharge. One method is the initial use of noninvasive tests reserving coronary angiography for patients with abnormal test results. The second approach comprises early cardiac catheterization in virtually all survivors. The routine use of angiography after MI does not appear to lead to an improved course compared to a more selective approach. Based on observation of an excellent 1-year outcome of patients in the conservative group of the large TIMI-2 and SWIFT trials, one could conclude that predischarge risk stratification by stress testing and clinical assessment has been empirically, albeit not experimentally, validated. On the other hand, if a noninvasive test proved to be highly predictive of subsequent cardiac events, the need for doing routine coronary angiography would in large part be obviated. Developing or refining such a test should take into account several caveats.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150478 TI - Application and perspectives of transesophageal stress echocardiography using monoplane and biplane instruments. AB - Transesophageal stress echocardiography has been reported to have a high sensitivity and specificity for noninvasive identification and assessment of coronary artery disease. Its advantage is the virtually never obstructed acoustic window on the heart yielding superior image quality in almost all patients. Pharmacological stress as well as simultaneous atrial pacing--attaching electrodes to the echoscope--have been applied as stress modalities. Both transesophageal stress echocardiography modalities have been shown to be well tolerated, safe, and feasible in most patients. These promising initial experiences led to clinical application of this method for preoperative risk evaluation, for detection of restenosis after PTCA, and for evaluation of hibernating myocardium. This technique was also successful for evaluation of stress induced changes of transmitral and pulmonary venous flow in patients with left ventricular hypertrophy and coronary artery disease. Although all studies published so far were performed with monoplane technique, the sensitivity for detection of one-vessel and, even more so, multivessel disease was high. However, apical and basal wall-motion abnormalities may go undetected using monoplane equipment. The advent of biplane transesophageal imaging enables the visualization of more ventricular segments. Future studies will show to which degree biplane transesophageal stress echocardiography improves the diagnostic accuracy. PMID- 10150479 TI - Drug delivery by nebulization: "reality testing". PMID- 10150480 TI - Assessment of antibiotic aerosol generation using commercial jet nebulizers. AB - The performance of 14 commercial jet nebulisers has been assessed; Unineb, Suremist (Unimed (UK) Ltd), Micro-Cirrus (Intersurgical Ltd), Pulmo-Neb (DeVilbiss Health Care UK Ltd), Side-Stream (Medic-Aid Ltd), Micro-Neb III (Lifecare Ltd), RespirGard (Marquest Medical Products Inc), Aeromist, Venticaire (S and W Vickers Ltd), Up-Draft II, Ava-Neb, Up-Draft (Hudson Respiratory Care Inc), Bennett/Twin, Raindrop (Puritan-Bennett Corporation). The units were operated with a high flow compressor (Maxi III, Medix Ltd) at 101/min. Performance was assessed by measuring the fraction of the initial mass of drug released as an aerosol and nebulisation time for initial drug volume of 2-6mls, and the mass median diameter and mass fraction of the aerosol in particles < 5.17 microns diameter. The Side-Stream nebuliser gave the best performance, although incorporation of a filter to trap exhaled antibiotic may prove difficult. The Micro-Cirrus generated a particularly fine aerosol. The Raindrop nebuliser performed well, while the Up-Draft II nebulised efficiently but was associated with extended nebulisation times which may limit its utility. PMID- 10150481 TI - A nebulizer system for highly reproducible aerosol delivery. AB - The output characteristics of current nebulizer systems are influenced by factors such as inspiratory flow, temperature and relative humidity of the ambient air as well as surface tension of the nebulizing solutions. Due to the resulting alteration of droplet characteristics the delivery of aerosolized drugs is variable. A nebulizer system, the PARI IS-2, has been designed for the delivery of aerosolized potent drugs. It is characterized by a highly consistent aerosol output and a high proportion of droplet mass in the respirable range. Laboratory testing was performed with a Malvern Particle Sizer and by measurement of total and effective output rates. Preconditioned air was supplied to the system in order to simulate different inspiratory flows (steady state) at varying ambient conditions. There was only a small effect on droplet sizes (MMD 3.0 to 3.6 microns) over the investigated range of inspiratory flow, ambient conditions and drug solutions. Total and effective output rates of the nebulizer were found to be linearly proportional between 5 and 20 l/min inspiratory flow thereby compensating for the dilution of aerosol by entrained air. Total output, at a relative humidity between 20% and 80% and at fixed inspiratory flow, varied only by +/- 6% with respect to 50% relative humidity (r.h.). The proportion of the dose delivered from the system ranged from 28% to 67% for an initial fill volume between 0.5 and 3 ml, respectively. Thus, for standardized breathing and by using the manual interrupter for on-command therapy, a highly effective delivery and deposition of therapeutic aerosols in the lungs may be achieved with the PARI IS 2 nebulizer system.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150482 TI - Evaporation of aqueous aerosols produced by jet nebulizers: effects on particle size and concentration of solution in the droplets. AB - Aqueous droplets produced by jet nebulizers can lose water by evaporation prior to entry into the patient's mouth, or a sizing device. Evaporation causes increase in the concentration of the solution in the droplet and reduction in size. These changes can complicate interpretation of results from experiments such as in vitro particle sizing or human respiratory tract deposition. We present experimental data obtained by nebulization of isotonic saline using a variety of aerosol delivery systems employing jet nebulizers. The impact of the evaporation phenomena is particularly great when a large volume of dry dilution air is mixed with the aerosol stream--a situation that is quite common in aerosol experiments. The experimental results approach the values calculated from the theoretical mass balance models in the limit of equilibrium between the droplets and the surrounding atmosphere. PMID- 10150483 TI - Why do medical nebulizers differ in their output and particle size characteristics? AB - Previous work done on the characterisation of nebulizers has focused on gravimetrical output and particle/droplet size distribution at various air flow rates. This paper investigates six different nebulizers, with regard to droplet generation and separation properties, at a single air flow rate. Droplet generation and separation properties were measured with laser diffraction and impactor techniques. For each of the nebulizers the air velocity was calculated and both liquid and air volumetric flow rate was measured. The primary generated droplets (nebulizer without impaction baffle) had a mean size of between 15 microns and > 500 microns. The secondary generated droplets (nebulizer with baffle) were in the size range of 1 to 10 microns. It was found that the baffle system of the investigated nebulizers could be described according to ordinary impaction theory. The mass median diameters (MMD) of these nebulizers were found to be dependent on air velocity (vg), and ratio of liquid to air volumetric flow rate (Ql/Qa). In all of the nebulizers, between 93% and 99% of the generated primary droplets were caught by the baffle system which resulted in a very low output. Thus, the nebulizers examined do not appear to be optimised, with regard to observed droplet generation and baffle arrangements, if secondary droplets with a size approximately 1 micron are desired. By changing the design at the primary generation point, air velocity (vg) and liquid to air flow rate (Ql/Qa), the primary generated droplet size could be decreased. This would result in an increase in the number concentration of smaller droplets that pass the baffle system.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150484 TI - Aerosolized heparin. PMID- 10150485 TI - Selective deposition of inhaled aerosols to mechanically ventilated rabbits. AB - We have studied selective deposition of tracer aerosols to specific sites in airways and peripheral regions of the rabbit lung by varying droplet size and breathing pattern. The different breathing patterns were controlled by a Servo Ventilator 900C and different droplet sizes (polydisperse) were generated by an air jet nebulizer (MA2) using two types of impactor vessels (MMD 2.3 and 4.1 microns). Three tracer aerosols were evaluated; Evans blue dye, 99mTc-DTPA and monodisperse fluorescent polylatex spheres (PLS). When we combined large droplets with "rapid-shallow" breathing (central deposition mode, CDM), 30% of the aerosol was deposited in the central airways. When small droplets were combined with "deep-slow" breathing (peripheral deposition mode, PDM) 60% was deposited in the peripheral part of the lung. The different detection techniques showed similar results but gave complementary information. Since detection of the radiolabelled aerosol was more sensitive than the other methods, less aerosol could be given allowing a more precise evaluation of the deposition, both from the macro autoradiographic images as well as from the well counter measurements. In order to investigate how far into the lung periphery the aerosol could be detected, we used PSL microspheres. PLS could be detected in the alveolar region by a fluorescent light microscope. However, a complete selectivity can not be obtained by aerosol delivery. The different technique used to reach selective deposition, showed that it is only possible to deposit the aerosol either more to the central or more to the peripheral parts of the respiratory tract in small subjects. PMID- 10150486 TI - An in vitro method for determining regional dosages delivered by jet nebulizers. AB - A methodology for determining the regional dosages delivered to the respiratory tract by a jet nebulizer is presented and applied to the DeVilbiss PulmoNeb disposable nebulizer delivering a 2.5 ml nebule of Ventolin (1 mg/ml salbutamol sulphate). Results are obtained both with tapping of the nebulizer, which enhances nebulizer performance, and without tapping. The nebulizer output is characterised by measuring the total mass and the mass of solids leaving the nebulizer per minute, and performing a control volume analysis of the nebulizer. Particle size distributions are determined by phased Doppler anemometry. Deposition probabilities are calculated using a semi-empirical model for the deposition of hygroscopic aerosol particles in healthy adult Caucasian males. Deposition probabilities are then converted to regional dosages using the measured nebulizer output characteristics. The regional dosages (% of initial dose in nebulizer) of Ventolin delivered to the extrathoracic, bronchial, and alveolar regions of the respiratory tract are 0.248 +/- 0.005 mg (9.9%), 0.034 +/ 0.001 mg (1.4%), and 0.071 +/- 0.002 mg (2.8%) respectively when the nebulizer was tapped during operation, and 0.184 +/- 0.005 mg (7.4%), 0.025 +/- 0.001 mg (1.0%), and 0.052 +/- 0.002 mg (2.1%) when tapping was not used. This methodology provides a well controlled and rapid means of comparing the effectiveness of different nebulizers for use in aerosol therapy. PMID- 10150487 TI - Nebulizer therapy with antibiotics in chronic suppurative lung disease. AB - Aerosolized antibiotics have been shown to be a useful modality of treatment in patients with cystic fibrosis. In this investigation we examined the utility of this treatment in patients with other chronic suppurative lung disorders. These included forty patients, thirty men and ten women with chronic airway infection (27 with bronchiectasis, 6 with chronic abscess and 7 with chronic suppurative bronchitis). Pathogenic organisms were isolated from the affected part of the lung by a fiberoptic bronchoscopy using a sterile disposable bronchial microbiology brush. Cultures from these specimens were used to determine the appropriate antibiotic. A second control group of 20 patients was treated with systemic antibiotics alone. Both systemic and aerosolized antibiotics were administered in 20 patients. A statistically significant improvement in clinical, and ventilatory functions was recorded in the first group compared to the second. Nebulized antibiotics used as adjunctive therapy in association with systemic antibiotics may offer a therapeutic advantage in chronic suppurative lung diseases. PMID- 10150488 TI - The role of the tracheobronchial circulation in aerosol clearance. AB - In summary, the airway is provided with a dense vascular network on either side of the airway smooth muscle throughout the bronchial tree. It is likely that this circulation can provide an important clearance function for the removal of smooth muscle agonists. However its supportive role for other airway structures such as ciliated cells and mucus glands has not been studied. For this reason it is unclear whether this circulation plays a significant part in maintaining mucociliary clearance. Consequently the capacity of the airway circulation to influence the clearance of soluble and insoluble particles remains ill-defined and requires investigation at a fundamental level. PMID- 10150489 TI - The effect of a new expectorant drug on mucus transport in chronic bronchitis. AB - The expectorant effect of two weeks treatment with cistinexine dihydrochloride (Rec 15/1884/2, Recordati S.p.A, Milano), on mucus transport rate (MTR) was evaluated in a double-blind study on 30 chronic bronchitis patients, 20 treated with active drug (group D), 10 with placebo (group P). After inhalation of nebulized 99mTc labelled human albumin minimicrospheres (HAMM), MTR was determined by external gamma-camera counting over the thorax. To control initial particle deposition a penetration index (PI) was determined as the ratio of activity between peripheral and hilar regions of equal size. Before treatment no differences were found between groups in spirometry, PI, and MTR. After treatment spirometry and PI remained unchanged in both groups. MTR expressed as the half time (T1/2) of the exponential fitting between 0 and 40 minutes showed an interesting behaviour, particularly in group D. Considering the group as a whole, T1/2 did not vary significantly (381 +/- 400 min. before, vs 224 +/- 132 min. after treatment, p = 0.090). However, a statistically significant reduction of the index (815 +/- 396 min. before vs. 258 +/- 120 min. after treatment, p < 0.01) occurred in the seven patients showing at baseline a T1/2 higher than 338 +/- 182 min. (the reference value observed in our laboratory for 8 asymptomatic non smoker subjects). Therefore, the beneficial effect of the drug is seen only in patients with a severe impairment of MTR. PMID- 10150490 TI - The Montreal Protocol and essential use exemptions. AB - The Montreal Protocol is an international treaty to phase out chlorofluorocarbons (CFCs) and other substances which destroy stratospheric ozone. The target date for the ban in developed countries, 1 January 2000, was subsequently advanced to 1 January 1996, with CFC production allowed temporarily for uses deemed 'essential' by the Parties. Seventeen governments submitted nominations to the United Nations (UN) Environment Programme requesting essential use exemptions for metered dose inhalers (MDIs). The nominations were reviewed by committees of technical experts and recommendations were considered at the Sixth Meeting of the Parties to the Protocol in October 1994. The Parties granted an exemption for the use of CFCs in MDIs for the treatment of asthma and chronic obstructive pulmonary disease (COPD) during 1996 and 1997. The European Union (EU) accelerated its own CFC phase-out date to 1 January 1995, also building in the possibility of 'essential use' exemptions. In July 1994 the European Commission announced exemption for MDIs from this deadline. Patients and physicians can be confident that MDIs will remain available for the foreseeable future. Furthermore, the small quantity of CFCs which has been exempted for use in MDIs will add very little to the existing environmental burden in the atmosphere. PMID- 10150491 TI - The challenge of reformulation. AB - All current metered dose inhalers (MDIs) contain chlorofluorocarbons (CFCs) as the propellant. Two alternative hydrofluoroalkane propellants, HFA134a (tetrafluoroethane) and HFA227 (heptafluoropropane), are being investigated. The replacement of CFCs by HFAs has a major impact on all aspects of the MDI from the basic formulation to the tests required to assess performance. All commonly used surfactants are essentially insoluble in the HFA propellants. The performance of the metering valve is critical to reproducible delivery of drug from an MDI. However, the properties of the two HFA propellants are so different from CFCs that new elastomeric seals have had to be developed. The current CFC11 propellant, which is a liquid at low room temperatures, allows the drug to be introduced into the MDI as a liquid suspension before the metering valve is sealed to the canister. Both HFAs are gases at normal temperature and atmospheric pressure, therefore all handling as a liquefied propellant must be performed under high pressure in totally sealed systems. To ensure adequate performance of non-CFC MDIs new tests and standards have been developed and introduced. The development of non-CFC MDIs represents a challenging task to provide new, safe and efficacious MDI products with the minimum environmental impact. PMID- 10150492 TI - Safety of propellants. AB - Chlorofluorocarbon (CFC) propellants used in metered dose inhalers (MDI) must be replaced under the terms of the Montreal Protocol. Following a review of the available data, HFA134a (1,1,1,2 tetrafluoroethane) was selected as a potential alternative propellant. However, because this data was insufficient to satisfy the stringent requirements for pharmaceuticals, additional toxicological assessments were performed. These included genotoxicology, animal inhalation studies, reproductive toxicology, local tolerability and safety pharmacology studies. A special grade of HFA134a, containing relatively high concentrations of all likely impurities, was used for all pivotal studies. HFA134a was devoid of genotoxicity and had exceptional low acute toxicity. No toxicity was seen in rats or dogs exposed to concentrations of up to 5% or 12% respectively for up to one year. No fetotoxicity, effects on reproductive performance, peri- or postnatal development was demonstrated. HFA134a was devoid of oncogenic potential in rats and mice. There was no evidence of sensitisation or local irritation to the skin or eyes. All species demonstrated high systemic HFA134a concentrations. An extensive toxicological evaluation, at very high multiples of the likely patient exposure, has indicated that HFA134a is a suitable alternative to CFC propellants for MDIs. PMID- 10150493 TI - CFCs, their replacements, and the ozone layer. AB - Chlorofluorocarbons (CFCs) have become widely used in a variety of applications, ranging from aerosols to refrigeration, through their unique combination of the properties of nonflammability and general inertness. However, their chemical stability, which makes CFCs relatively safe and non-toxic, is also responsible for their potential to damage the environment. From 1974 opinion developed that CFCs might indirectly affect the stratospheric 'ozone layer' through their ability to transport halogens, particularly chlorine, to this level. By the mid 1980s a consensus emerged that atmospheric CFCs could contribute significantly to ozone depletion and an annual thinning (a 'hole') in the ozone layer over the Antarctic was reported. Some of the atmospheric chemistry which is believed to occur, and some of the measurements made on the ozone 'layer' are reviewed together with the environmental regulatory actions that have been taken. These are leading to a controlled rapid phase out of a number of industrial chemicals, including CFCs. The pharmaceutical industry uses significant quantities of CFCs as propellants in metered dose inhalers (MDIs). Two suitable alternative molecules, the hydrofluoroalkanes (HFAs) HFA134a and HFA227, which have the required properties but are not ozone depleting, are introduced. PMID- 10150494 TI - Clinical pharmacology of HFA134a. AB - The safety, tolerability and pharmacokinetics of the chlorine-free propellant HFA134a were assessed in healthy subjects after single and repeat doses. Absorption and disposition were investigated in healthy subjects and severe chronic obstructive pulmonary disease (COPD) patients using labelled HFA134a. There were no clinically significant changes in vital signs, ECG, pulmonary function tests and laboratory parameters measured. No serious adverse events were reported. In both subjects and patients HFA134a was mainly eliminated by exhalation within the first few minutes after administration and was distributed throughout the body with no obvious accumulation in any specific region. HFA134a was rapidly absorbed after inhalation with dose-related blood concentrations which declined rapidly after dosing (t1/2 = 31 min). Metabolism was not a significant route of elimination of HFA134a. Studies were also performed with salmeterol and salbutamol MDIs reformulated with HFA134a. The results showed that these MDIs were safe and well tolerated in healthy subjects and gave a similar pharmacodynamic response to the current MDIs. PMID- 10150495 TI - Clinical evaluation of CFC-free metered dose inhalers. AB - Current metered dose inhalers (MDIs) contain chlorofluorocarbon (CFC) propellants. A new propellant HFA134a, with no effect on ozone, may be a suitable alternative. Four asthma medications, salbutamol, salmeterol, fluticasone propionate (FP) and beclomethasone dipropionate (BDP), currently containing standard CFC propellants, were formulated with HFA134a for investigation. Single doses of salbutamol (200 micrograms) and salmeterol (50 micrograms, 100 micrograms) provided equivalent protection against bronchial provocation, after histamine and methacholine respectively, compared with the current preparation. A double-blind 4 week study comparing the two formulations of salbutamol, used as required in mild to moderate asthma, showed similar effects on morning peak expiratory flow rates (PEFR) and inhaler use. Salmeterol (50 micrograms) twice daily was compared with the current formulation in a 4 week trial. Improvement in morning PEFR was similar for both formulations. A double-blind study compared the two formulations of FP (250 micrograms) twice daily in moderate asthmatics previously taking 400-1,000 micrograms of inhaled corticosteroid daily. Morning PEFR improved in both groups. Safety and tolerability of the HFA134a product were similar to current formulations. The HFA134a formulations of salbutamol, salmeterol and FP provide equivalent efficacy with a similar safety profile to the existing formulations at equivalent doses. PMID- 10150496 TI - Prescribers' and users' perspective of CFCs: a market research survey. AB - Focus groups were conducted with physicians, pharmacists and patients prior to semi-structured interviews with physicians and patients. The survey was conducted in Spain, Germany and the UK. There were high levels of awareness of environmental issues, with ozone layer damage and global warming being of particular concern. Most respondents were aware of chlorofluorocarbon (CFC) use in aerosols and in refrigerators. However, their presence in asthma metered dose inhalers (MDIs) was much less widely known. German physicians had the highest awareness (78%) while only 1 in 10 of UK patients was aware. Patients expressed concern on learning that they inhale CFCs. Reaction to the concept of a non-CFC propellant was universally favourable, though sometimes qualified with the need for adequate safety and efficacy data. Patients expected to be informed of the change by doctors, pharmacists or patient information leaflets. Physicians expected to receive information as soon as possible but did not want patients informed until launch. Manufacturers and representatives would be the primary information sources for physicians. Pack changes should be minimised. Communicating the change to non-CFC propellants to physicians, pharmacists and patients is all important. PMID- 10150497 TI - The continued need for metered dose inhalers. AB - The metered dose inhaler (MDI) is currently the most widely used device in the treatment of adult asthma. It is the delivery system of choice in general practice throughout the world where both MDIs and powder inhalers are available. Up to 70% of all UK adult asthma prescriptions are for an MDI and worldwide the figures are likely to be higher. The MDI can be used to dispense a variety of medications and is currently the most economical device available. The cost of converting all MDIs to equivalent powder inhalers would be prohibitive. Patients, who have difficulty coordinating the operation of an MDI, can use it with a spacer device. This obviates the need for hand-lung coordination and the requirement for more than minimal inspiratory effort. In acute attacks, there is currently no alternative to an MDI with a spacer device for effective, easily administered, emergency treatment outside the hospital environment. In an emergency, an MDI with a spacer can act more rapidly than a nebulizer because it is quicker to set up and use. The MDI is inexpensive, requires no power source and is easily portable. It is therefore important that the MDI continues to be available. PMID- 10150498 TI - Using transesophageal echocardiography to manage critically ill patients. What role in hemodynamic instability, MI, embolic disease, trauma? AB - When transthoracic echocardiographic images are suboptimal, transesophageal echocardiography offers a new window for visualization of the heart and thoracic aorta. It can be performed at bedside in 15 to 20 minutes. Complications (emesis, hypoxemia, hypotension) are rare and easily reversed or averted by administration of naloxone or flumazenil. Indications include evaluation of hemodynamic instability, ventricular function, mitral regurgitation, ventricular septal defects, aneurysm, endocarditis, intracardiac sources of embolus, valve pathology, aortic dissection, intra-aortic debris, and trauma. Results can be analyzed immediately and used to guide further evaluation, medical therapy, or surgery. PMID- 10150499 TI - A rational approach to giving antibiotic prophylaxis before endoscopy. Who needs it? Which procedures pose the greatest risk? AB - Although transient bacteremia occasionally occurs after many GI endoscopic procedures, the incidence of actual infection is low. However, in addition to endocarditis, peritonitis, abscesses, meningitis, portacaval anastomotic infection, and sepsis have been reported. Prophylaxis may reduce the risk of infection; whether it is needed depends on two factors: Is the procedure to be performed associated with an increased likelihood of infection? Does the patient have an underlying condition (such as valvular heart disease or immune system incompetence) that increases the risk of such an infection? Antibiotics that are frequently used for prophylaxis include amoxicillin or gentamicin and ampicillin. PMID- 10150500 TI - How to transfer a postoperative patient to the intensive care unit. Strategies for documentation, evaluation, and management. AB - Postoperative intensive care is often required for patients who have underlying cardiac or respiratory dysfunction, who undergo major surgery, or who experience major perioperative complications. The initial report should list the patient's intravenous lines, catheters, and surgical drains or tubes, as well as whether ventilation is needed; this allows the intensive care unit (ICU) staff to set up appropriate equipment. On the patient's arrival in the ICU, document the medical history, anesthetics given, surgery performed, and intraoperative events. Perform an organ system review with ongoing assessment at 15-minute intervals. Residual effects of anesthetic agents can include respiratory depression, hypotension, and bradycardia. PMID- 10150501 TI - The technique of managing asystole. High-dose or standard-dose epinephrine: which is better? AB - Early, aggressive treatment is essential if patients with asystolic cardiac arrest are to survive. To maximize chances for success, use a five-phase protocol. Phase I: Confirm the diagnosis with a series of checks. Phase II: Intubate and hyperventilate the patient with 100% oxygen. Use an end-tidal carbon dioxide (ETCO2) detector to confirm tracheal intubation. Phase III: Initiate therapy with 1 mg of epinephrine and 1 mg of atropine. Consider defibrillation with a 360-wsec shock to reverse occult ventricular fibrillation. Phase IV: Repeat doses of epinephrine and atropine every 3 minutes. Phase V: Reevaluate the patient's chances of survival. If ETCO2 levels are undetectable or barely detectable (below 0.5%), survival is unlikely. PMID- 10150502 TI - Strategies for maximizing your chances for weaning success. Limitations--and advantages--of common predictive indices. AB - Using indices to predict weaning outcome can avoid premature extubation and unnecessary prolongation of ventilatory support. Unfortunately, none of the indices is consistently able to predict outcome. The key to successful weaning is to assess respiratory function repeatedly with several indices, not just one. The patient should be able to sustain spontaneous breathing for at least 24 hours on minimal partial ventilatory support (a pressure support or a continuous positive airway pressure of 5 cm H2O or a T piece, for example). Indices of maximal inspiratory pressure; work of breathing; and rapid, shallow breathing are useful in evaluating a patient's respiratory muscle performance; airway occlusion pressure is helpful as well when increased neuromuscular drive is a problem. PMID- 10150503 TI - The technique of radial artery cannulation. Tips for maximizing results while minimizing the risk of complications. AB - Arterial cannulation is usually performed to allow continuous blood pressure monitoring or frequent arterial blood sampling. Relative contraindications to the procedure include bleeding abnormalities and peripheral vascular disease. The radial artery is the site most frequently used because the hand generally has good collateral circulation. Percutaneous cannulation is the preferred method of insertion. To avoid transecting the artery, advance the needle-catheter assembly slowly; blood return confirms arterial placement. there should be no resistance to needle advancement. Bleeding is the most common complication of arterial cannulation, but ischemia and infection have greater clinical significance. PMID- 10150504 TI - Q.ed. PMID- 10150505 TI - Morbidity, mortality, and the C-2 risk. PMID- 10150506 TI - A 'quick hit' method to assess insurance mortality from a clinical article. PMID- 10150507 TI - Effect of smoking cessation on mortality of older men and women with coronary artery disease. PMID- 10150508 TI - Additional follow-up of patients with coronary bypass reoperation at Cleveland Clinic. PMID- 10150509 TI - Pitfalls of inferring annual mortality from inspection of published survival curves. AB - In many FU articles currently published, results are given primarily in the form of graphs of survival curves, rather than in the form of life table data. Sometimes the authors may comment on the slope of the survival curve as though it were equal to the annual mortality rate (after reversal of the minus sign to a plus sign). Even if no comment of this sort is made, medical directors and underwriters may be tempted to think along similar lines in trying to interpret the significance of the survival curve in terms of mortality. However it is a very serious error of life table methodology to conceive of mortality rate as equal to the negative slope of the survival curve. The nature of the error is demonstrated in this article. An annual mortality rate derived from the survival curve actually depends on two variables: a quotient with the negative slope (sign reversed), delta P/ delta as the numerator, and the survival rate, P, itself as the denominator. The implications of this relationship are discussed. If there are two "parallel" survival curves with the same slope at a given time duration, the lower curve will have a higher mortality rate than the upper curve. A constant slope with increasing duration means that the annual mortality rate also increases with duration. Some characteristics of high initial mortality are also discussed and their relation to different units of FU time.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150510 TI - Odds and ends. PMID- 10150511 TI - Post-acute rehabilitation outcome: relationship to case-management techniques and strategy. AB - Successful outcome for the traumatically brain-injured (TBI) patient is dependent on both a productive clinical therapy program and an effective case-management strategy by the carrier. This retrospective study focuses on identifying those case-management techniques which contributed to improvement in the disability, living, and occupational status of patients in a post-acute rehabilitation program. Statistical analysis indicated a positive relationship between two case management factors and improved patient outcome. Additional analysis demonstrated predictive qualities of specific admission data for patient program cost. A review of these case-management techniques and their impact on discharge disability, living, and occupational status will be discussed. PMID- 10150512 TI - Underwriting psychiatric impairments, with emphasis on depression. Part III: Morbidity and estimating degree of impairment. PMID- 10150513 TI - Extramarital relations and perceptions of HIV/AIDS in Nigeria. AB - Data from a 1991 survey of five Nigerian towns are used to examine currently married men's and women's perceptions of AIDS which, together with other socioeconomic factors, are then related to extramarital sexual behaviour. An overwhelming majority of the respondents have accurate information about AIDS. In particular, most associate HIV/AIDS transmission with multiple sexual partners, though only one-third of them think that the fear of AIDS has limited casual sex in their communities. About 54 per cent of men and 39 per cent of women have had extramarital relations, with 18 per cent of men and 11 per cent of women having done so in the previous week. The incidence of extramarital relations varies considerably by respondents' level of education, type of marriage, religion, and spousal closeness. More importantly, knowledge of multiple sexual partners as a risk factor for HIV/AIDS is inversely related to extramarital affairs. The study underscores the link between knowledge and behaviour, and calls for a well articulated campaign designed to educate the populace about the threat of AIDS, with the aim of modifying both premarital and extramarital sexual behaviour, thereby reducing the risk factor for HIV through heterosexual relations which is the main mode of transmission in Nigeria. PMID- 10150514 TI - The impact of rural-urban migration on child survival. AB - Large rural-urban child mortality differentials in many developing countries suggest that rural families can improve their children's survival chances by leaving the countryside and settling in towns and cities. This study uses data from Demographic and Health Surveys in 17 countries to assess the impact of maternal rural-urban migration on the survival chances of children under age two in the late 1970s and 1980s. Results show that, before migration, children of migrant women had similar or slightly higher mortality risks than children of women who remained in the village. In the two-year period surrounding their mother's migration, their chances of dying increased sharply as a result of accompanying their mothers or being left behind, to levels well above those of rural and urban non-migrant children. Children born after migrants had settled in the urban area, however, gradually experienced much better survival chances than children of rural non-migrants, as well as lower mortality risks than migrants' children born in rural areas before migration. The study concludes that many disadvantaged urban children would probably have been much worse off had their mothers remained in the village, and that millions of children's lives may have been saved in the 1980s as a result of mothers moving to urban areas. PMID- 10150515 TI - Use of health services in Hill villages in central Nepal. AB - This paper reports the use and non-use of health care facilities in the Hill villages in central Nepal. The health behaviour model (HBM) is applied to test the significance of socioeconomic variables on the use of the modern health care system. The study finds that all three characteristics of the HBM model, predisposing, enabling and need, are significantly related to use and non-use of the modern health care system. The analysis shows that number of living children, respondent's education, nearness to the road and service centre, value of land, knowledge about health workers and experience of child loss are some of the variables that are positively and significantly related to the use of modern health care. Age of the respondents and household size were found to be negatively associated with health-care use. Contrary to expectation, caste is unimportant. Making use of the qualitative data, this paper argues that the health care system is unnecessarily bureaucratic and patriarchal, which favours the socio-economically well-off. PMID- 10150516 TI - The effect of physician training on treatment of respiratory infections: evidence from rural Egypt. AB - A three-round survey of child mortality, morbidity and treatment conducted in rural lower Egypt in 1990-91 found relatively poor treatment practices for respiratory infections. Only about 56 per cent of children with a respiratory infection received appropriate treatment. Antibiotics were prescribed for more than half of all mild coughs and colds, but were not prescribed for a quarter or more of serious cases. A training program for government physicians conducted midway through the survey improved treatment practice slightly in government facilities. However, training alone is unlikely to improve treatment much. Better supervision, and information campaigns focused directly on mothers, are suggested as necessary components of a successful project. PMID- 10150517 TI - Maternal literacy and health care in three countries: a preliminary report. PMID- 10150518 TI - Parental education and child survival: can the DHS tell us anything new? PMID- 10150519 TI - Maternal education and child survival: anthropological responses to demographic evidence. PMID- 10150520 TI - State of our knowledge: the epidemiology of HIV/AIDS. AB - The first part of this paper describes the current global situation of the AIDS pandemic, and the second part the dynamics of the heterosexual transmission of the HIV virus in a population. Risk factors for HIV infection are presented in three different categories: environmental risk factors, including all epidemiological and socio-economic variables which modify the HIV prevalence in a community and operate beyond the control of individuals taken separately; personal risk factors, including the behavioural variables which determine an individual's probability of being exposed to an HIV-positive sexual partner; and biological risk factors, including the known and putative variables which facilitate the transmission of the virus between two partners of differing serostatus. As preventive strategies should be targeted against risk factors which are both preventable and responsible for a large number of HIV transmissions, an attempt is made in this paper to identify in four different populations the risk factors which account for the largest proportion of HIV infections. PMID- 10150521 TI - The evaluation of surveys of sexual behaviour: a study of couples in rural Senegal. AB - The reliability of self-reported answers about sexual behaviour is assessed by means of a survey of couples in rural Senegal, Africa, carried out in 1992. A total of 51 married couples were followed weekly over a five-week period. Reports for a recall period of seven days are reliable: dates of sexual acts differed by no more than a day in 73 per cent of cases. Reports over longer periods are less reliable. Retrospective recall of coital frequency for a four-week period yields much higher estimates than those obtained with a seven-day recall, particularly for men. PMID- 10150522 TI - HIV transmission and the balance of power between women and men: a global view. AB - This paper presents a logical analysis of the paths by which gender inequality is likely to affect the heterosexual transmission of HIV. Non-use of condoms, the combination of a sexual double standard and frequent use of female prostitutes, and a high prevalence of curable sexually transmitted diseases are considered. The 'circulation' of women as sexual and reproductive gifts, which is a near universal feature of human societies, explains men's use of prostitutes and promiscuity, and contributes to high STD prevalence. It may also contribute to the non-use of condoms, although a separate analysis suggests this is not always the case. The empowerment of women thus might help to slow the spread of HIV/AIDS. Even more effective in countries with large commercial sex sectors would be the empowerment of female sex workers. PMID- 10150523 TI - Relationship between AIDS and family planning programmes: a rationale for developing integrated reproductive health services. AB - This paper examines the potential links between family planning and maternal and child health programmes and the emerging needs of the global AIDS epidemic; and assesses the feasibility of organizing comprehensive reproductive health programmes in developing countries to include the prevention and control of reproductive tract infections including sexually transmitted infections as well as HIV/AIDS. The paper discusses arguments opposing the integration of programmes against sexually transmitted infections within family planning and MCH programmes, as well as the programmatic and epidemiological reasons for considering such integration. It is important to determine what elements can be realistically integrated within programmes of varying organizational capacity without compromising their effectiveness. PMID- 10150524 TI - A research-based HIV intervention in northeast Thailand. AB - This paper presents a case study of the development, implementation and evaluation of an HIV prevention strategy for rural, married women in the northeastern, Isan region of Thailand. The strategy is based on established principles of behaviour change, social learning, and community health promotion; grounded in baseline research, that identifies relevant contextual factors; community-based; evaluated; and applicable elsewhere. The methodology of the project includes four phases: data collection, strategy design, implementation, and evaluation. Baseline data were collected from an age-stratified sample of married women from 24 randomly chosen villages in Khon Kaen province in two waves. A total of 654 women participated in structured face-to-face interviews and 150 also participated in focus groups. Using the baseline data, a health promotion strategy including three components was designed: meetings with and training of village leaders and health workers; a five-part week long audio drama, together with posters and other publicity conducted in villages; and village meetings to discuss the potential impact of HIV/AIDS on the village and to establish a village strategy to address this. This paper reports the results of the baseline data collection, how the data were used to produce an HIV prevention initiative for rural villages, results of the process evaluation and future development in HIV/AIDS prevention initiatives in this region. PMID- 10150525 TI - The impact of HIV/AIDS on adult and child mortality in the developing world. AB - At the beginning of the AIDS epidemic some observers predicted that this disease would increase mortality so much that it would cause population decline in many countries. Others have said that the mortality impact of AIDS would not be large. This report reviews the evidence available to date in this issue and presents a simple methodology for assessing the magnitude of the impact at the country level, given a few pieces of readily available information. The paper also presents projections of the likely impact of HIV-AIDS on adult and child mortality in the developing world and for a number of specific developing countries. PMID- 10150526 TI - Determinants of the demographic impact of HIV-1 in sub-Saharan Africa: the effect of a shorter mean adult incubation period on trends in orphanhood. AB - Recent evidence suggests that the adult HIV-1 incubation period may be shorter in some sub-Saharan African populations than in Western populations. In this article we use mathematical-model-based simulations to show that, other things being equal, a shorter incubation period can result in smaller but more pronounced HIV 1 epidemics and faster, more acute, changes in demographic features, such as adult mortality, orphanhood and population structure. Empirical studies of orphanhood reveal similar patterns to those found in the simulations, but suggest that migration patterns and structural factors can give rise to greater concentrations of orphans in areas of relatively low HIV-1 prevalence. PMID- 10150527 TI - Reliability and validity of survey data on sexual behaviour. AB - The contribution of structured interview surveys to the monitoring of changes in risk behaviour is a crucial issue for the evaluation of HIV control programmes. A review is made of studies that have attempted to assess the reliability and validity of self-reported sexual behaviour. Evidence from developed-country studies is encouraging; in general the quality of responses appears to be as high as that found in studies of other topics. In developing countries, there have been fewer studies and results are more varied. One clear lesson is that survey execution must be of a very high standard; as in all survey research, but particularly in the case of sex surveys, poor standards of design and execution will yield untrustworthy data. PMID- 10150528 TI - Social inequality and children's growth in Guatemala. AB - This paper is an investigation of the effects of social inequality in Guatemala on children's health and nutritional status as measured by attained height. Guatemala remains a highly stratified and poor society. We examine the association of land distribution, land tenure, occupation, and other aspects of family social and economic status with children's height between the ages of three months and 36 months, using data from a cross-sectional survey. An important consequence of the poverty and poor living conditions of the majority of the Guatemalan population is substantial deficits in children's growth. Our results suggest that children's growth is affected by ethnicity, their father's occupation, land distribution in the area where they live, and maternal education. Substantial growth deficits are observed among children living at altitudes above 1500 metres; we hypothesize that this is because, in Guatemala, higher altitude is associated with land scarcity, poorer agricultural conditions, and greater remoteness from transport networks and other public services. PMID- 10150529 TI - Early-age mortality, socio-economic development and the health system in Mongolia. AB - Since the 1920s Mongolia has developed an extensive and well-staffed health care system that has made modern health technologies accessible to most of its population. In addition, the country experienced rapid economic and social development whose benefits were equitably distributed among the population. In spite of this progress, infant and child mortality levels are high by contemporary standards and during the past 20 years these rates have remained virtually constant. The modern health care delivery system, externally imposed, failed to take into account the specific characteristics of the Mongolian culture; this fact is identified as one of the major determinants of the unexpected levels of early-age mortality. The excessive orientation toward curative medicine, the lack of health prevention and promotion activities and the lack of community participation have resulted in the people continuing to believe in traditional therapeutic patterns and self-care. They perceive the modern system exclusively in curative terms and not with regard to health preservation and disease prevention. Most Mongolians do not fully understand the health care system, and use its services mainly because they have no alternative, or because of coercion rather than conviction based on the learning and internalization of its basic principles. In practices and ideas of child care, preservation of health and disease prevention, people seem to identify more with the traditional health care system. Like other former socialist countries, Mongolia is experiencing deep economic and social transformations, whose implications for the health care system are discussed. An economic crisis whose end is nowhere in sight, emergent social inequalities, a vague health insurance model with unclear financing sources, and lack of concern by most policy-makers in strengthening the preventive component of the health system, are not positive factors for substantial infant and child mortality decline in the near future. A clear advantage is, however, the fact that there is a wide space for major improvements with existing internal and external resources. PMID- 10150530 TI - Old-age mortality in Israel: analysis of variation and change. AB - This study analyses differentials in life expectancy and cause-specific death rates among the elderly Jewish population in Israel in the early 1970s and early 1980s. We find substantial inequality in old-age mortality levels across subpopulations in geographic units and show that this inequality increased between the two periods. Much of the variation in old-age mortality is explained by differences in economic and social status, ethnicity and religiosity. The importance of religiosity is of particular interest in the context of Israeli society. PMID- 10150531 TI - The negotiating strategies determining coitus in stable heterosexual relationships. AB - Heterosexual behaviour is a complex subject and one which is aggravated by confounding variables. Few studies have investigated the way in which one variable, namely coitus, is initiated and negotiated in stable marital relationships. As the HIV/AIDS pandemic spreads in sub-Saharan Africa, the subject of marital coitus becomes of increasing concern. This study tests a methodology of semi-structured interviews and diary-keeping techniques to investigate how the activity is initiated and negotiated. A research team monitored the study and evaluated the research techniques. The study concluded that the HIV/AIDS pandemic is affecting the initiation and negotiation of coitus between marital partners and that the partners wish to renegotiate the relationship, but the mechanisms for renegotiation are not at present available. PMID- 10150532 TI - Health impacts of AT&T's Total Life Concept (TLC) program after five years. AB - For study group participants who returned for measurement in 1988, the health promotion program appeared to have a limited effect on health risk indicators and a positive effect on health-related attitudes. The data suggest that decreases in smoking and alcohol consumption may be attributed to the program. The combined evidence after 5 years of improved health behaviors, better health attitudes, and self-reports of lifestyle improvements suggests that the program has a positive impact on habit and attitude changes. PMID- 10150533 TI - Perceptions and beliefs about exercise, rest, and health among African-Americans. PMID- 10150534 TI - Prospective analysis of stage-of-exercise movement following mail-delivered, self instructional exercise packets. AB - This study investigated the efficacy of mail-delivered, self-instructional exercise packets designed to motivate, encourage, and support women's movement through the stages of exercise. The study took place within the subjects' natural work environment and involved no formal exercise classes or programs. Besides mailing each subject her individualized packet, no contact occurred between the researchers and study participants except for data collection at 1 month and 7 months after baseline. For the sample as a whole, a significant time effect was found; yet no significant within-group or between-group differences were observed. However, a general pattern that favored the LEP group over both the SEP and FFP groups was identified and, interestingly, the FFP over the SEP. For example, study adherence rates were 81.1%, 71.1%, 63.2% for the LEP, FFP, and SEP groups, respectively. Although speculative, it is tenable that subjects from the LEP group had better adherence to the study because they were more satisfied with their intervention than subjects from the other two groups. Also in favor of the LEP and FFP groups was the percentage of participants who improved their stage-of exercise status from baseline to 1 month (i.e., 45.8%, 42.1%, and 27.8%, respectively, for the LEP, FFP, and SEP groups [precontemplation through action stages only]). Similar results were seen from baseline through 7 months (i.e., 58.3%, 57.9%, and 55.5%, respectively, for the LEP, FFP, and SEP groups [precontemplation through action stages only]). Independent of group, subjects in the earlier stages of exercise at baseline responded favorably to the intervention; 90% of precontemplators and contemplators combined improved their stage-of-exercise status.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150535 TI - Evaluation of the Heart To Heart Project: lessons from a community-based chronic disease prevention project. AB - PURPOSE: To present an evaluation of a 5-year, community-based, chronic disease prevention project managed by a state health department to determine whether the department could replicate similar previous projects that had received more funding and other resources. DESIGN: The evaluation used a matched comparison design and a review of archive and interview data. SETTING: Florence, South Carolina (population: 56,240). SUBJECTS: A random sample of 1642 persons in Florence (and 1551 in the comparison) who responded to a risk factor questionnaire and underwent a physical assessment; 70.7% of baseline subjects participated in the postintervention. Forty key persons were interviewed concerning project effectiveness. INTERVENTIONS BY PROJECT: Walk-a-thons, a speakers' bureau, media messages, restaurant food labeling, and cooking seminars. More than 31,000 participants were involved in 585 activities. MEASURES: Questionnaires focused on hypertension, obesity, high cholesterol, smoking, and exercise. Physical assessments determined lipid, lipoprotein, apolipoprotein, and blood pressure levels. Analysis of covariance was used for baseline and postintervention comparisons. Content analysis was used on archive and interview data. RESULTS: The project had a slightly favorable intervention effect on cholesterol and smoking, but failed to have an effect on other risk factors for cardiovascular disease. The project influenced community awareness, enlisted influential community members, and fostered linkages among local health services. CONCLUSIONS: Health departments can be instrumental in community risk reduction programming; however, they may not replicate projects having greater resources. PMID- 10150536 TI - Evaluation of the 1990 Centers for Disease Control and Prevention smoke-free policy. AB - PURPOSE: To determine the prevalence of tobacco use among Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR) employees and the effect of the smoke-free policy on smoking behavior and air quality at work. DESIGN: A stratified telephone survey of 1181 CDC/ATSDR employees randomly selected from employee rosters. SETTING: CDC/ATSDR work sites in Atlanta, Georgia, and other major CDC locations throughout the United States and Puerto Rico. SUBJECTS: Randomly selected employees of CDC/ATSDR1, or about 22% of the total CDC/ATSDR population; 98% of eligible persons selected agreed to participate. MEASURES: Demographic and smoking history variables, attitudes toward and impact of the smoke-free policy on smoking behavior, and self-report changes in air quality were the measures used. RESULTS: Overall cigarette smoking prevalence was only 11.1%. One percent reported using chewing tobacco, 1.1% reported smoking a pipe, and 1.4% reported smoking cigars. Average self-reported, daily cigarette consumption significantly decreased after the smoking ban took effect. Overall, 90% of the employees supported the smoke-free policy, and 80% of the employees believed that smokers were complying with the smoke-free policy. Most employees believed that the air quality of work areas and nonwork areas (65% and 69%, respectively) had improved since the smoke-free policy was implemented. CONCLUSIONS: These findings are consistent with previous evaluations of smoke free policies and suggest that most employees are generally supportive of workplace smoking restrictions. Such policies can also have a positive impact on smoking behavior and perceived air quality. PMID- 10150537 TI - Efficacy of computerized health risk appraisal as part of a periodic health examination at the worksite. AB - PURPOSE: To evaluate the efficacy of computerized health risk appraisal (HRA) when it is incorporated into a periodic health examination at the worksite. DESIGN: A randomized, controlled trial comparing change in health behaviors for a 6-month follow-up period was conducted. SETTING: A large financial services firm in New York City. SUBJECTS: A total of 161 employees who volunteered for a worksite periodic health examination. INTERVENTION: All employees received a physician-based history and physical examination, including laboratory tests, and were counseled on the basis of the results. Half the employees were randomly assigned to receive an HRA report with counseling from the 1984 version of the Centers for Disease Control HRA, whereas the other half completed the HRA questionnaire but received no HRA report or counseling. MEASURES: Blood pressure, cholesterol, and weight were measured by project staff, physical activity and seatbelt use were measured by self-report, and change in computerized appraised age was calculated by the HRA program. RESULTS: Evaluation of the 90 participants who returned for follow-up revealed a statistically significant improvement in computerized appraised age and physical activity in those who has received the HRA report and counseling compared with those who had not (p < or = .05), and also showed trends toward greater improvement in blood pressure, weight, and seatbelt use. CONCLUSIONS: Results provide support for the efficacy of HRA when incorporated into a periodic health examination at the worksite. PMID- 10150538 TI - Impaired glucose and lipid metabolism seen in intensive care patients is related to severity of illness and survival. AB - OBJECTIVE: To relate glucose and lipid metabolism to the severity of illness and survival in critically ill patients. DESIGN: Cross-sectional and prospective cohort study. SETTING: Secondary referral ICU. PATIENTS: Forty-four consecutive patients admitted to the ICU. MEASUREMENTS AND MAIN RESULTS: An intravenous glucose tolerance test (IVGTT) and serum lipoprotein determinations were performed within the first 24 hours in the ICU. An APACHE II score was also determined. Basal serum lactate, glucose and insulin were all elevated in ICU patients compared to healthy controls (p < 0.001) and were all correlated to indices of severity of illness (r = 0.36-0.42, p < 0.05-0.01 vs the APACHE II score). However, the early insulin response to IVGTT was inversely correlated to the APACHE II score (r = -0.50, p < 0.01). Triglyceride and cholesterol levels in serum were generally decreased when compared to controls (0.88 +/- 0.63 mmol/l for serum triglycerides and 2.46 +/- 0.97 mmol/l for serum cholesterol, p < 0.01 vs controls). However, as could be judged from the levels of free serum glycerol (0.27 +/- 0.23 mmol/l), lipolysis was increased in the critically ill. Serum triglyceride levels, as well as serum FFA and glycerol, correlated to the severity of illness (r = 0.36-0.62, p < 0.05-0.001), HDL-cholesterol was inversely related to the APACHE II score (r = -0.40, p < 0.05). Serum glucose, FFA, glycerol and triglycerides in serum, VLDL and LDL were all elevated (p < 0.05-0.001), while HDL-cholesterol was decreased (p < 0.05) in septic patients (n = 17) compared to those without sepsis. Serum lactate (p < 0.05) and free glycerol (p < 0.01) were both elevated in patients who did not survive (n = 6) when compared to survivors. Multiple logistic regression analysis showed free glycerol (p < 0.05) to be additive to the APACHE II score (p < 0.01) in predicting mortality. CONCLUSION: In a sample of unselected critically ill patients indices of both glucose and lipid metabolism were found to be related to the severity of illness as well as to the occurrence of sepsis and survival. PMID- 10150539 TI - The value of serum C-reactive protein levels as a marker of sepsis in intensive care unit patients. AB - A one-year prospective study was carried out to assess the value of routine serum C-reactive protein (CRP) measurement in the early diagnosis of infection in ICU patients of a District General Hospital. Ninety-one patients were included in the study. Sixty-eight patients yielded 28 proved and 77 suspected episodes of infection. Control data were drawn from 23 uninfected ICU patients. Both absolute values and percentage rates of change were examined for the following variables: serum CRP, maximum daily temperature and peripheral white blood cell count. Neither absolute CRP levels nor rates of change in CRP were found to relate significantly to proved infection. In the group in whom infection was suspected but not proved, absolute CRP levels were higher than controls on the day before the suspected infection (p = 0.019), but were not significantly raised on the day of infection nor the day after. The only significant rises in CRP (> 25%) were found in the suspected infection group from the day before to the day of infection, when compared with controls (p = 0.04). Traditional markers of infection--maximum temperature and peripheral white blood cell count--were significantly associated with infection. Maximum temperature was significantly higher in both proved and suspected infection on the day before infection (p = 0.000 and 0.001), and on the day of infection (p = 0.025 and 0.03), compared with controls.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150540 TI - Pressure controlled ventilation--a true advance? PMID- 10150541 TI - The paediatric chest tube. AB - Chest tubes are placed to empty the pleural space of air or fluid which prohibits full lung expansion. The function of these tubes is dependent on adequate placement, effective drainage and frequent re-evaluation of the patient and the chest drainage system. Knowledge of the principles of chest tube drainage is important to evaluate adequately the function of a tube thoracostomy. PMID- 10150542 TI - Non-invasive measurement of cardiac output in patients with acute lung injury using the carbon dioxide rebreathing method. AB - STUDY OBJECTIVE: To compare measurement of cardiac output by the CO2 rebreathing method with the thermodilution cardiac output technique in mechanically ventilated patients with acute lung injury. DESIGN: Prospective study comparing two methods of cardiac output measurement in 22 consecutive patients with acute lung injury. SETTING: Intensive care unit of a university hospital. PATIENTS: Twenty-two mechanically ventilated patients with acute lung injury monitored with systemic and pulmonary artery catheters. MEASUREMENTS AND RESULTS: Cardiac output was determined using both the thermodilution technique and an indirect CO2 Fick method. Veno-arterial CO2 content difference was calculated from an estimated mixed venous CO2 tension obtained by an equilibrium CO2 rebreathing method and measured arterial CO2 tension. Carbon dioxide pressure was converted to content using the equation of the CO2 dissociation curve described by McHardy. A wide range of cardiac index was studied from 2.7-5.7 l/min/m2. There was a significant correlation between thermodilution and CO2 rebreathing methods (r2 = 0.82, p < 0.01). The mean difference between the CO2 rebreathing method and thermodilution was 0.05 l/min/m2, with a standard deviation for the bias of 0.38 l/min/m2. CONCLUSION: Our results suggest that the CO2 rebreathing method may be a reliable non-invasive technique to determine cardiac output in mechanically ventilated patients with acute lung injury. PMID- 10150543 TI - Providing psychological support for patients after critical illness. AB - The majority of patients have little or no memory of their stay in ICU or remember only pain, suctioning or lack of sleep. Dreams and nightmares while in the intensive care unit (ICU) and after discharge home have also been reported. The few studies investigating the longer-term psychological problems of critical illness point to a picture of social isolation with patients avoiding company and showing less affection to their partners. Our own experience, running a special outpatient clinic and following up patients by post, showed a picture of depression, anxiety, irritability and social isolation. This led to the setting up of an ICU staff-led support group for patients recovering from critical illness. This article outlines the possible problems and pitfalls of setting up and running a support group for patients recovering from critical illness. The type of patients suitable to attend such a group is examined. Two case histories give an illustration of the type of problems ICU patients experience during their recovery and how an informal support group can help. In addition to possible benefits to the patients, support groups can also give ICU staff a chance to understand the process of recovery from critical illness and to examine the effects on patients of their own practice. However, they must also have enough insight to know when a patient needs professional help; for example, a patient displaying symptoms of post-traumatic stress disorder should be referred, with their agreement, to a clinical psychologist. PMID- 10150544 TI - Post-operative management of the heart transplant patient. PMID- 10150545 TI - The role of the microcirculation in the multi-organ dysfunction syndrome. AB - The systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) are significant causes of morbidity and mortality in the intensive care unit. The pathogenesis of MODS is poorly understood; however, endotoxin (LPS) and cytokines (for example interleukins, tumor necrosis factor and platelet activating factor) are thought to play a major role by inducing microvascular injury. A crucial step in the normal functioning of the immune system is the adhesion of cells to each other and, via extravasation, penetration of the extracellular matrix. This is an essential process for normal host defence against injury and infection. In SIRS this process becomes uncontrolled, leading to extravasation of neutrophils causing tissue injury and inflammation. In addition there is increased capillary permeability. It is this disturbance of the microcirculation that is responsible, either wholly or in part, for the development of SIRS and MODS. PMID- 10150546 TI - A multi-disciplinary approach to families of brain dead children. AB - OBJECTIVE: To relate our multi-disciplinary approach to families of brain dead children. DATA SOURCES: The professional experiences of critical care health care providers and the review of the medical and legal literature. SETTING: Paediatric Intensive Care Unit. PARTICIPANTS: Paediatric critical care physicians, primary paediatricians, paediatric critical care nurses, social worker, hospital chaplain and organ procurement coordinator. RESULTS: We describe our multi-disciplinary approach towards education of families of children who have suffered severe brain injury likely to result in brain death. We feel this approach has resulted in better understanding and acceptance of brain death. We also discuss methods of addressing special circumstances around child abuse, religious exemption and organ procurement. CONCLUSION: Our multi-disciplinary approach may assist clinicians and other health care providers in successfully dealing with families of brain dead children. PMID- 10150547 TI - Prevention of atmospheric contamination during isoflurane sedation. AB - With a view to minimising staff exposure to exhaled isoflurane which had been used for sedation, we assessed the efficacy of either activated charcoal adsorption or active or passive mechanical scavenging systems in intensive care units (ICUs). Personal monitoring revealed minimal exposure of staff to the sedating agent. Infra-red analyses of ambient air rarely showed isoflurane levels greater than 26 ppm, with mean concentrations of around 1 ppm. Small spillages during vaporiser filling were of no polluting significance. The activated charcoal adsorbers functioned highly efficiently for at least 12-hour periods. With simple scavenging techniques, atmospheric isoflurane contamination during sedation with the agent remains well within an acceptable range and is unlikely to pose a health risk to nursing and medical staff. PMID- 10150548 TI - Lower anion gap increases sensitivity in predicting elevated lactate. AB - OBJECTIVE: The normal reference range for the anion gap (AG) has recently been questioned by several authors. Lowering the upper limit of normal of the AG has been found to be more sensitive in predicting elevated lactate in critically ill adults. The objectives of this study are i) to define a new upper limit of normal of the AG in a study population of healthy adult volunteers, ii) to determine the sensitivity, specificity, the positive predictive value and the negative predictive value of the new upper limit for AG in detecting elevated lactate in critically ill children and to compare these results to the old upper limit of normal of AG (16 mmol/l), iii) to construct a receiver-operating-characteristic (ROC) curve for anion gap as a predictor of elevated lactate, iv) to determine the relationship between anion gap and serum lactate levels in critically ill patients. DESIGN: A prospective, cohort study. SETTING: Paediatric Intensive Care Unit of a University Hospital. SUBJECTS: Part I: Convenience sample of healthy adult volunteers to provide a reference range for anion gap calculation. Part II: Consecutive children admitted to the Paediatric Intensive Care Unit who had lactate levels measured for clinical reasons. MEASUREMENTS: Part I: Electrolytes and blood gases were measured from blood samples drawn from 25 adult volunteers. The reference range for AG was calculated using the equation, AG = Na - (Cl + HCO3). The upper limit of normal was calculated as mean + 2 SD. Part II: Eligible ICU patients were included in this study if they had lactate, electrolytes and blood gases obtained simultaneously. The AG was calculated as above. The new upper limit of normal AG was compared to an AG of 16 for diagnosing an elevated plasma lactate. RESULTS: The mean anion gap in the normal population was 9.4 +/- 1 mmol/l with 11 mmol/l being used as the new upper limit of normal. Thirty-six ICU patients had 189 arterial blood samples from which lactate, electrolytes and blood gas were measured simultaneously. The sensitivity, specificity, positive predictive value and negative predictive value of using an AG of 11 mmol/l as the upper limit of normal were 86%, 40%, 65% and 69% respectively, compared to 49%, 84%, 80% and 55% respectively using the upper limit of normal of AG of 16 mmol/l. The ROC curve supported lowering the upper limit of normal for the anion gap to predict an elevated lactate. There was a linear relationship between anion gap and serum lactate levels. CONCLUSIONS: An AG of 11 mmol/l as the upper limit of normal has a higher sensitivity and higher negative predictive value but lower specificity and lower positive predictive value for detecting elevated lactate in critically ill children. PMID- 10150549 TI - Long-term sedation in the ICU: enteral versus parenteral feeding. AB - An open, prospective study was carried out on 45 patients with multiple injuries to compare the mortality and incidence of sepsis between those given early total enteral nutrition (TEN) when sedated with propofol and historical controls who had been given total parenteral nutrition (TPN) and sedated with midazolam. TEN was instituted immediately after surgery via gastrostomy and/or jejunostomy tube inserted during laparotomy or via an endoscope and was continued for the whole stay in the intensive care unit (ICU). Dramatic reductions in both mortality (24.4% vs 35.1% in the controls; p = 0.025) and the incidence of sepsis (8.9% vs 23.8% in the controls; p = 0.025) were found when early enteral feeding was given. The absence of pressure sores and gastro-intestinal bleeding (for example, stress ulcus), which had previously been a common occurrence in this intensive care unit, was remarkable with the introduction of TEN and propofol sedation. Tolerance problems (mainly diarrhoea) arose in only 17% of patients in the study group. PMID- 10150550 TI - Cost of ICU sedation: comparison of empirical and controlled sedation methods. AB - A randomised crossover study was undertaken to compare the quality and cost of controlled versus empirical sedation with midazolam in critically ill patients. Patients (n = 40) entering the ICU were enrolled provided they satisfied the strict entry criteria. During 90 hours of midazolam sedation, patients received randomly allocated 10-hour periods of controlled or empirical sedation. With empirical sedation, the mean dose of midazolam and the cost of sedation were almost double those with controlled sedation. The quality of sedation was superior with the controlled method. In a separate study on 352 patients, a cost benefit analysis of controlled sedation with midazolam or propofol infusion or bolus injections of morphine plus diazepam showed that the quality of sedation achieved with propofol was superior to the other two regimens and that, with morphine plus diazepam, the quality of sedation was unacceptably poor. Although the direct purchase price of propofol was higher than that of other agents, the total cost of sedation with propofol was lower than that for midazolam for short term intensive care (less than 24 hours) and comparable to midazolam for longer term use. However, indirect benefits of sedation with propofol include a much shorter ICU stay with the attendant reduced nursing costs and greater throughout the patients, and this more than compensates for the higher purchase price of the agent. PMID- 10150551 TI - New horizons in ICU sedation: exploring non-sedative effects of ICU sedation. AB - Sedative drugs are widely used in intensive care, primarily in ventilated patients. The common actions and side-effects of these agents are widely recognised. However, recent evidence suggests that opiates and other sedative agents that are used in this situation also have important, but not widely appreciated, effects on metabolism, physiological signalling and disease mechanisms. Some of these effects are an extension of their expected therapeutic actions; these are being elucidated as the biological consequences of stress, and its suppression is now being clarified. An example is the central effects of benzodiazepines and opioids on metabolism and immune function. In other instances these drugs have important peripheral actions, with immunomodulatory or metabolic roles. Furthermore, some drugs may modify disease processes--an example being the antioxidant effect of propofol. Finally, basic cellular mechanisms, such as immediate early gene expression and transcription factor activation, may involve processes that may be susceptible to modification by sedative agents. Such secondary effects of sedative agents need to be investigated for three reasons. First, they provide explanations for some phenomena observed during their use. Second, some of the undesirable side-effects may be avoided by judicious use of drugs in certain clinical situations. Finally, there is the prospect that we may be able to harness some actions for novel therapeutic purposes. PMID- 10150552 TI - Controlling sedation rather than sedation controlling you. AB - Sedation in the intensive care unit (ICU) aims to improve patient comfort and facilitate treatment procedures. Most units still rely on a combination of opioid and benzodiazepines with the addition of other drugs for specific requirements. However, the effect of sedative agents in critically ill patients is often unpredictable, so frequent assessment of the depth of sedation is essential to match the depth to patient requirements. In the 1990s, heavy sedation and paralysis is not considered appropriate for many ICU patients; a minimum sedation approach limits cardiovascular or respiratory depression and enables earlier weaning and extubation of patients. Administering sedative agents by continuous infusion is convenient but, unless the level of sedation is reassessed regularly, many patients may become over-sedated. The use of propofol for short-term sedation in ICUs has allowed the maintenance of sedation to continue until just a few hours before extubation but the benefits of propofol for longer-term indications are more debatable. Closer titration of dose and desired effects could also be achieved by a patient-controlled system. The technique may not be suitable for a large number of patients, particularly early in their ICU stay but, for long-term sedation and in the weaning phase--of sedation as well as ventilation--the utility of a drug delivery system truly controlled by the patient should be further explored. The ICU has been succinctly described as an environment in which 'anxiety is prevalent, pain frequent, rest difficult and sleep impossible'. Sedation in the ICU has the double objective of relieving patient distress as well as facilitating treatment procedures.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150553 TI - Sedation during weaning from mechanical ventilation. AB - The transition from mechanical ventilation to spontaneous breathing in the intensive care unit is a two-stage process: weaning and extubation. Certain parameters require consideration before the commencement of weaning, namely respiratory function (both pulmonary gas exchange and respiratory muscle strength), cardiovascular status, stability of clinical condition, low metabolic demands, psychological factors and, possibly, patient collaboration. Appropriate sedation is crucial for successful weaning to keep the patient rested and to maintain the oxygen consumption and carbon dioxide production low. In this review, three types of patient are considered: patients having short-term ventilation after trauma or surgery, those having long-term ventilation for chronic pulmonary disease, and those with other associated severe organ dysfunction, such as heart failure. Strategies for weaning are outlined for each of these situations and the role of sedation is discussed. Making the transition from mechanical ventilation to unassisted spontaneous breathing can be a difficult process, particularly for those patients in the intensive care unit (ICU) requiring prolonged ventilatory assistance for severe respiratory failure secondary to: exacerbation of chronic obstructive airways disease (COAD) acute respiratory distress syndrome (ARDS) underlying diseases affecting cardiac function. This transition may be considered to comprise two separate stages, namely weaning and extubation. Weaning consists of preparation for spontaneous breathing supported and monitored by a mechanical ventilator and attendant monitoring of all the important vital parameters, while extubation marks the final switch to unsupported spontaneous breathing, which may be quite a big step for the patient. Important weaning parameters. PMID- 10150554 TI - Quality of life at three months following admission to intensive and coronary care units. AB - OBJECTIVE: Measurement of quality of life three months following critical illness, to assess impact on health expectations. DESIGN: Continuous quantitative study of patients admitted to a combined intensive and coronary care unit during a nine-month period. Questionnaires giving baseline information were completed soon after admission, and postal questionnaires incorporating the Nottingham Health Profile were sent to surviving patients three months following discharge from the unit. SETTING: District General Hospital. SUBJECTS: ICU sample included 60 patients, male n = 31, female n = 29. Twenty-nine patients received surgical treatment, 31 patients received medical treatment. Coronary Care Unit (CCU) sample included 112 patients, male n = 74, female n = 38. Fifty-four patients admitted following acute myocardial infarction (MI), 58 patients non-MI admission. MEASUREMENTS AND MAIN RESULTS: Hospital mortality for ICU patients was 31%, increasing to 34% at three months. Hospital mortality for CCU patients was 14%, increasing to 19% at three months. Significant differences in mean NHP scores between ICU and CCU patients were noted with higher CCU scores in the areas of sleep (p = 0.04), and social isolation (p = 0.01). Within the ICU group surgical patients had a higher mean NHP score in the area of pain (p = 0.02). There were no significant differences in the scores of male and female ICU patients. Within the CCU group non-MI patients had significantly higher mean scores than MI patients in the areas of energy (p = 0.007), pain (p = 0.04), emotion (p = 0.05), social isolation (p = 0.01) and physical ability (p = 0.003). Female CCU patients had higher mean NHP scores than male patients with significant differences in the areas of pain (p = 0.04), sleep (p = 0.009) and physical ability (p = 0.006). CONCLUSION: ICU patient quality of life three months after admission compares favourably with a corresponding group of CCU patients, particularly in areas of sleep and social isolation. CCU patients' general functional status deteriorated significantly compared to their pre admission status. Critical illness is a costly area of medicine, but the results suggest that outcomes are beneficial in terms of quality of life for those surviving acute illness. PMID- 10150555 TI - Treatment of acute respiratory failure with non-invasive intermittent positive pressure ventilation in haematological patients. AB - OBJECTIVE: The aim of this study was to assess whether non-invasive positive pressure ventilation delivered intermittently (Ni-IPPV) by means of a facial or nasal mask is beneficial in haematological patients suffering from acute respiratory failure. DESIGN: Prospective, open, non-randomised study. SETTING: University Hospital, medical intensive care unit. PATIENTS AND METHOD: Eighteen haematological patients with acute respiratory failure which occurred before, during or just after therapeutic aplasia were ventilated with Ni-IPPV delivered via an individual nasal mask or a standard facial mask. Non-invasive ventilation was achieved until weaning (success (S)) or intubation (failure (F)). RESULTS: Twelve patients were ultimately intubated and died (F group). Seven needed intubation within 3 hours following admission because of the inability of Ni-IPPV to provide adequate ventilation in six patients and after cardiac arrest, probably related to cardiac aspergillosis in one patient. Six patients were not intubated and were discharged alive (S group). Of 11 patients who received Ni IPPV for more than 3 hours, the respiratory rate decreased significantly (p < 0.05) from 33 +/- 7 breaths/min to 24 +/- 5 breaths/min with Ni-IPPV and the PaO2 increased significantly from 6.6 +/- 1.7 kPa upon admission to 17.7 +/- 5.5 kPa during Ni-IPPV. Mean daily ventilation was 12 +/- 7 hours for a mean duration of 5.5 +/- 4.4 days. Pressure support was used in nine patients and appeared the most efficient ventilation mode of non-invasive ventilation. The duration per day of Ni-IPPV was shorter and PaCO2 values during Ni-IPPV were lower in the S group than in the F group. CONCLUSIONS: This technique is able to provide adequate ventilatory support for many haematological patients and allows avoidance of ventilation in some. PMID- 10150556 TI - A heat and moisture exchanging filter in long-term ventilation. AB - We report our experience of using the Pall BB50T heat and moisture exchanging filter (HMEF) in critically ill patients undergoing long-term ventilation. Three hundred and sixty-four ventilated patients humidified with the Pall HMEF were studied prospectively. Thirty-five patients (mean APACHE II score 24.6, mean predicted mortality 50.9%) were ventilated for more than 10 days (mean 18.9), accounting for 661 patient-ventilated days. During this period two patients suffered tracheal tube occlusion. No other complications could be attributed to the filter. We conclude that the Pall BB50T heat and moisture exchanging filter is safe in patients undergoing long-term ventilation. However, its use demands a high degree of respiratory care. PMID- 10150557 TI - Metabolic effects of continuous veno-venous haemofiltration in critically ill patients. AB - OBJECTIVE: To evaluate the short-term metabolic and haemodynamic effects of continuous veno-venous haemofiltration (CVVH) in critically ill patients with acute renal failure (ARF). DESIGN: Prospective study of nine consecutive critically ill patients with established acute oliguric renal failure. SETTING: A general ICU in an 800-bed university hospital. PATIENTS: Critically ill patients, mean age 56 +/- 6 years. Four had multi-organ failure, one had acute haemolytic uraemic syndrome, one had idiopathic lactic acidosis, two had haemorrhagic pancreatitis and one had urinary sepsis. INTERVENTIONS: All patients were mechanically ventilated with arterial and pulmonary artery catheters in situ. MEASUREMENTS AND MAIN RESULTS: Oxygen consumption (VO2), CO2 production (VCO2) resting energy expenditure (REE), continuous blood pressure, heart rate, central venous pressure (CVP), pulmonary artery pressure (PAP), and cardiac output (CO), as well as tidal and minute volumes, end-tidal CO2 and arterial blood gases, were continuously measured for one hour prior to and one hour following the institution of CVVH. Body temperature, arterial blood pressure, heart rate, CVP and pulmonary artery catheter data remained stable throughout the study period. Prior to CVVH, VO2 was 326 +/- 33 ml/min, VCO2 was 245 +/- 27 ml/min and REE was 2241 +/- 231 kcal/24 hours. Following institution of CVVH, VO2 was 324 +/- 33 ml/min, VCO2 was 244 +/- 27 ml/min and REE was 2227 +/- 230 kcal/24 hours. CONCLUSIONS: CVVH does not affect metabolic rate and haemodynamic stability in critically ill patients. The lack of any effect on the metabolic rate and haemodynamic parameters in such patients may have significant clinical importance and it further attests to the suitability of CVVH for the treatment of critically ill patients. PMID- 10150558 TI - Near infrared spectroscopy during and after cardiac arrest--preliminary results. AB - OBJECTIVE: To evaluate if regional cerebrovascular oxygen saturation (rSO2) is linked to systemic oxygenation and if impaired regional cerebral oxygenation affects outcome in cardiac arrest patients. DESIGN: Prospective, observational study. SETTING: Emergency department of a University Hospital. SUBJECTS: Patients during cardiac arrest or after restoration of spontaneous circulation. INTERVENTIONS: To measure rSO2 an infrared light-emitting probe was applied to the patient's forehead after arrival in the emergency department. Data were collected continuously together with blood pressure and pulse oximetry. Each variable measured immediately after arrival was used for calculation. ENDPOINTS: Best outcome (cerebral performance category) or death within one week. MEASUREMENTS AND MAIN RESULTS: Regional SO2 was measured in 18 consecutive patients. Six patients presented with cardiac arrest on arrival and rSO2 was measured during chest compression. Twelve patients had achieved restoration of spontaneous circulation before they arrived in the emergency department. No association was found between rSO2 and pulse oximetry or rSO2 and blood pressure. All patients surviving for one week (n = 9) achieved a significantly higher median rSO2 on arrival than nonsurvivors (n = 9) (63% and 46%, respectively; p = 0.003). Median rSO2 was lower in the group arriving without spontaneous circulation (n = 6) than in patients after restoration of spontaneous circulation (n = 12) (44% and 63%, respectively; p = 0.009). This difference was not found in pulse oximetry readings. Patients with restoration of spontaneous circulation surviving the first week after cardiac arrest (n = 8) had a higher rSO2 than patients with restoration of spontaneous circulation who did not survive (n = 4) (65% and 48%, respectively). Time from restoration of spontaneous circulation to arrival was not different between the two groups. CONCLUSION: By showing that low rSO2 readings after cardiac arrest are associated with a higher mortality, this new, non-invasive and easily applicable technique might help to prognosticate outcome and offers new insights into monitoring cerebral oxygenation after cardiac arrest. PMID- 10150559 TI - Markers of ventilator-associated pneumonia. AB - The diagnosis of ventilator-associated pneumonia (VAP) is difficult for several reasons. Firstly, clinical markers show a large percentage of false-positive and false-negative results. Secondly, microbiological diagnosis based on quantitative cultures of protected specimen brush (PSB), bronchoalveolar lavage (BAL), and endotracheal aspirates also present false-positive and false-negative results. Furthermore, definite results are delayed for 48-72 hours. For all these reasons it would be an advantage to have a biological marker of ventilator-associated pneumonia in clinical practice. Since clinical features of pneumonia in mechanically ventilated patients are neither specific nor sensitive, rapid markers of pneumonia might be of great assistance to the clinician in deciding whether to start an empiric antibiotic regimen. A marker of ventilator-associated pneumonia could be a rapid alternative diagnostic method which permits the definite diagnosis of pneumonia. Accordingly, specific markers of VAP, namely the presence of intracellular microorganisms, the detection of elastin fibres, the antibody-coated bacteria test, the level of endotoxin in bronchoalveolar lavage fluid, the local production of interleukin-8, the levels of lactate dehydrogenase, and decreased surfactant protein A, may be important as they can provide a rapid diagnosis of VAP. Among the markers alluded to above, the search for intracellular bacteria in polymorphonuclear leukocytes or macrophages is the most widely validated technique with an excellent specificity, provided that prior antibiotics are not given. However, this technique has its own limitations; it requires a considerable time effort for the microbiologist, and also compels the performance of BAL, a technique not always harmless to the patient. PMID- 10150560 TI - Post-hospital outcome following intensive care. PMID- 10150561 TI - Left ventricular volume and mass: Comparative study of two-dimensional echocardiography and ultrafast computed tomography. AB - This study was undertaken to define the accuracy of two-dimensional echocardiography in the determination of left ventricular end-diastolic and end systolic volumes, stroke volume, ejection fraction, and mass when compared to ultrafast cine computed tomography in the same 56 patients. Single-plane and biplane modified Simpson's rule, single-plane and biplane ellipsoidal formula, bullet formula (biplane only), and biapical Simpson's rule methods were utilized. Linear regression analysis showed the strongest correlation with the modified biplane Simpson's rule (mean r = 0.897). In valvular heart disease (n = 12) and dilated cardiomyopathy (n = 6), the mean correlation coefficients for all methods were high (r = 0.894 and 0.911, respectively). The mean correlation coefficient for all methods in patients with prior myocardial infarction (n = 25) was relatively poor (r = 0.643). Intraobserver and interobserver variabilities for all methods were low (r = 0.980 and 0.965, respectively). It is concluded that calculations of left ventricular volumes and mass by two-dimensional echocardiography are accurate and reproducible in patients with a global effect on the left ventricle and were less acceptable in patients with segmental (ischemic) left ventricular involvement. The best measurement technique is a modified biplane Simpson's rule. PMID- 10150562 TI - The transesophageal echocardiographic examination: is it safe? PMID- 10150563 TI - Real-time, automated echocardiographic measures of ventricular area and area change: comparison with radionuclide technique. AB - Echocardiography now permits tracking of the blood-endocardial border and automatic measurement of ventricular area throughout the cardiac cycle. To determine the accuracy of this technique, we compared echocardiographic measurements of area with similar measurements made by radionuclide technique in 19 children, ages 4-24 years (mean 13 years). The blood-endocardial border was tracked from the apical two-chamber view and radionuclide measurements were made from the left anterior oblique view. We measured echocardiographic end-diastolic area, end-systolic area, and fractional area change from the average of five cardiac cycles. The radionuclide area measurements were made from a gated blood pool study incorporating 700-1200 cardiac cycles. Results were compared by bias analysis. The mean differences (+/- 1 S.D.) between left ventricular area measurements were: end-diastole 1.13 +/- 2.3 cm2, end-systole -0.90 +/- 1.33 cm2, and fractional area change 7.4 +/- 9.3 (%). Differences between the measurements were within the limit of agreement (mean +/- 2 S.D.) in 55 of 57 measurements. The area measurements were not free from bias; the mean differences of area measurements were significantly different from zero for end-diastolic area (P < or = 0.05), end-systolic area (P < or = 0.01), and fractional area change (P < or = 0.002). Echocardiography tended to underestimate end-diastolic area and fractional area change and it tended to overestimate end-systolic area. Real-time tracking of the blood-endocardial border is possible and allows accurate measurement of ventricular area. PMID- 10150565 TI - Quantification of cardiac jets: theory and limitations. AB - Jet flows are consequences of many cardiac lesions. With the advent of color Doppler flow mapping, these jet flows can be visualized noninvasively. Currently, an intense effort is underway to quantify cardiac jet flows as a means to assess the severity of jet forming lesions. Two techniques, PISA and jet centerline decay, have been suggested as methods to quantify jet flow volume. Although both techniques are theoretically sound, both formulations are based on ideal flow conditions that may not be completely realized in cardiac chambers. Thus, the complex dynamics of cardiac jet flows must be considered as they may diminish the accuracy of flow rate calculations. However, realistic in vitro experiments that mimic the impact of cardiac flow conditions on converging flows and jets, combined with carefully controlled in vivo testing of both PISA and centerline techniques, may eventually produce clinically useful quantification formulations. PMID- 10150566 TI - Quantitative evaluation of left ventricular systolic function by Doppler echocardiographic techniques. AB - Doppler echocardiography provides the ability to measure blood flow velocities noinvasively. These blood flow velocities can be used to obtain powerful hemodynamic information about systolic contractility of the left ventricle, which in the past could only be determined from invasive cardiac catheterization or cumbersome pulse recordings. Volumetric flow rates can be measured using the hydraulic principle of flow through a rigid tube, providing a measurement of stroke volume and cardiac output. The rate of the left ventricular pressure rise derived from a mitral regurgitation velocity curve provides a nonejection phase index of systolic contractility. Acceleration time can be obtained from an ascending aortic velocity and is an indicator of maximum myocardial force. Systolic time intervals can now be quickly and accurately obtained from the standard Doppler tracings. These quantitative measurements of the status of the left ventricular are accurate, reproducible, and should be incorporated into the routine noninvasive assessment of patients with cardiac disease. PMID- 10150567 TI - Free autogenous soft tissue graft with the argon laser. AB - A sufficient amount of dense keratinized connective tissue attached to bone and the cervical area of the tooth is required for functional masticatory mucosa. Periodontal plastic surgery has furnished numerous reconstructive and regenerative techniques to correct the mucogingival defect. Laser technology has provided the ability for tissue fusion and incisions with better visual and mechanical access, decreased intraoperative time, improved hemostasis, and less postoperative discomfort. This article describes a technique for incisions and tissue fusion for gingival grafts with an argon laser. PMID- 10150568 TI - A comparative histological study of wound healing following Nd:YAG laser with different energy parameters and conventional surgical incision in rat skin. AB - Wound healing following the use of Nd:YAG laser with different frequencies and energy parameters (20 pps and 1.75 W/30 pps and 3.0 W), and the conventional scalpel incision were studied over a period of 4, 7, 14, 21, and 28 days in the rat skin. The low-energy laser wounds could not be significantly differentiated from the conventional incisions although less damage and inflammatory reaction, increased matrix production, and only a little wound contraction could be demonstrated. In the high-energy lased tissues extensive damage and an increased inflammatory reaction were present. The low-energy Nd:YAG and scalpel incisions established a normal wound healing without scar tissue formation compared to the high-energy Nd:YAG, where the necrosis was higher. PMID- 10150569 TI - Percutaneous laser disc decompression (PLDD): 352 cases with an 8 1/2-year follow up. AB - Percutaneous laser disc decompression (PLDD) was pioneered by Dr. Peter Ascher and myself in 1986. This report describes patient selection, operative technique, laser dosimetry, and results in 352 cases with an 8 1/2-year follow-up. The conclusion is that PLDD is relatively non-invasive, safe, simple and effective. PMID- 10150570 TI - Laser-assisted disc decompression: a clinical trial of the holmium:YAG laser with side-firing fiber. AB - In order to evaluate the efficacy of laser-assisted disc decompression (LADD) as an alternative treatment modality for nonsequestered herniated nucleus pulposus of the lumbar spine, we used the Holmium:YAG laser with Sidefire laser fiber on 223 consecutive patients who met inclusion criteria. Patients were evaluated by an independent interviewer postoperatively, and at 1 week, 3 months, 6 months, and 1 year. Ratings were based upon the modified Macnab criteria. All patients presented with leg pain with or without back pain that had failed a minimum of 6 weeks conservative treatment (e.g., rest, NSAIDs, physical therapy, epidural steroid injections). Patients were not considered for LADD if the primary source of neurologic findings was a result of scar tissue from a previous discectomy, lateral recess or central stenosis, or sequestered discs. At 1 year postoperative follow-up, the surgical success rate was 84%. For patients requiring an additional LADD procedure, results at 6 month follow-up yielded surgical success rates of 92.3% and 90% for additional level and index level LADD, respectively. LADD appears to be a viable treatment modality for nonsequestered herniated nucleus pulposus recalcitrant to conservative treatment. LADD may represent a more cost-effective and safer treatment alternative to traditional invasive surgical procedures and other percutaneous methods. PMID- 10150571 TI - A new multipurpose CO2 laser therapy instrument. AB - A new multipurpose CO2 laser therapy instrument has been developed. It is a highly efficient medical instrument. By use of high laser power density to coagulate, evaporate, and cut body tissue on the nidus, the operation can be controlled and has obvious curative effects. Unlike other kinds of CO2 laser therapy instruments, this device has an advanced switching power supply (SPS) and red guiding light system. With an overcurrent protective device, an overvoltage protective device, and a high-voltage shield device, it provides efficiency, stability, reliability, and low loss. The plastic casing does not leak electricity and the film switches are designed for clinical practice convenience. Additionally, the laser power is numerically displayed and can be set prior to the procedure. The distinct visible guiding light of the laser output makes the operation more convenient and accurate. Because of this unique design and properties, it is a leading model in China. The instrument can be widely used for surgery, gynecology, dermatology, and otolaryngology. The radiation therapy of low laser power density has the effect of being antiinflamatory, analgesic, and antipruritic, and promotes cure of the epithelium. Moreover, it is effective to treat all sorts of sprains, scapulohumeral periarthritis, arthritis, sciatica, and surface ulcers. PMID- 10150572 TI - Endoscopic laser ablation of duodenal carcinoids: a new treatment modality. AB - Four cases of polypoidal carcinoid tumors in the duodenum were treated with Nd:YAG laser ablation after histological confirmation. None of the patients had any distant spread of the tumor. All the four tumors were less than 2 cm in size. In each case, the tumor was fully ablated in a single endoscopic laser sitting. All cases were done under local anesthesia and the patients were hospitalized for 1 day. All patients have been symptom free over a mean follow up period of 13 months (6 to 20 months). There has been no endoscopic evidence of local recurrence. Laser therapy is safe and effective and carries no mortality or morbidity. Endoscopic laser ablation is an effective alternative to surgical resection of small carcinoid tumors. PMID- 10150573 TI - A Fourier-transform infrared spectroscopic comparison of cultured human fibroblast and fibrosarcoma cells: a new method for detection of malignancies. AB - Infrared vibration spectroscopy appears to be a more powerful technique for tumor diagnosis than visible or UV spectroscopy. In the present work, Fourier-transform infrared (FTIR) spectroscopy was used to compare cultured normal fibroblast and fibrosarcoma cells. Significant differences were observed by comparing the spectra of the normal human cells with that of the cancer cells. The PO2 symmetric stretching mode at 1082 cm-1 is shifted to a higher frequency in the cancer cell and a broad band, whose center is located at 1064 cm-1 in the cancer cell is reduced in intensity. In addition, the decrease in intensity of the CH2 bending mode relative to that of CH3 mode is detectable only in the fibrosarcoma cell. This FTIR difference between fibroblast and fibrosarcoma cells suggests that either fatty acid chains or protein side chains of the cancer cells are partially degraded resulting in more terminal carbon (e.g., CH3). It is also possible that changes in the environment upon carcinogenesis induces a change in the relative absorption cross section for CH3 and CH2 bending vibrations. These results suggest that FTIR spectroscopy may become a promising and sensitive technique for tumor identification. PMID- 10150574 TI - Damage to dental composite restorations following exposure to CO2 laser radiation. AB - Damage to tooth structure is a major hazard in the use of infrared lasers for oral surgical procedures. While the effects of laser exposure on dental enamel and dentine are well characterized, there are no data on the effects of laser exposure on dental composite materials, which are widely used in tooth-colored restorations. This study examined surface changes in several dental composites exposed to CO2 laser radiation for 200 msec. Surface changes, such as ablation, combustion, and melting, occurred even at relatively low power densities (340 W/cm2), with greater effects occurring in composites than in "compomers" (glass iomomer-composite mixtures). These findings indicate that nonmetallic dental restorations are prone to damage from inadvertent laser exposure. Clinicians must be aware of this hazard and employ measures to protect both natural tooth structure and restorations when performing intraoral laser surgery. PMID- 10150575 TI - SilkTouch: a new technology for skin resurfacing in aesthetic surgery. AB - We describe layer-by-layer char-free facial skin resurfacing at very low CO2 laser power levels with a miniature "SilkTouch" microprocessor-controlled optomechanical flashscanner. This device provides excellent ablation depth control with minimal thermal damage to the dermis. Indications for the laser in aesthetic surgery include perioral, lips, and periorbital wrinkles, among others. PMID- 10150576 TI - An intermediate approach to impotence evaluation. PMID- 10150577 TI - Point and counterpoint. Radical cystectomy or multimodality therapy for TCC of the bladder? PMID- 10150578 TI - How to analyze reports on new clinical tests. AB - Several concepts can be used by the critical reader to evaluate reports about new diagnostic tests. Patient population, comparison to a gold standard, test performance, and sensitivity, specificity, and predictive values all should be analyzed. PMID- 10150579 TI - Using advance directives effectively in the intensive care unit. Terminating care in the presence--or absence--of directives. AB - When a patient is admitted to the ICU, determine whether the person has decisional capacity and whether an advance directive exists. If so, discuss treatment options and the directive with the patient--as well as with family members and appointed surrogates; clarify the patient's wishes. If no directive has been drawn up, encourage the patient to do so. If a patient lacks decisional capacity but has a directive, determine whether it applies to the current situation. If it does, follow its instructions. If no directive exists or if it does not apply, consult with family members to determine the patient's wishes, and ascertain whether these substitute judgments meet state laws. PMID- 10150580 TI - Today's strategies for treating postoperative hypertension. Immediate evaluation and targeted treatment are required. AB - Postoperative hypertension, though transient, requires immediate attention. Clinical variables include the patient's preoperative blood pressure, medications, and acute medical status; the surgical procedure performed; and the physiologic changes induced by surgery. Evaluate and treat any reversible causes of hypertension. Initiate drug therapy when organ failure or dysfunction is present or when the patient is at high risk for such complications. In choosing an agent, look for ease of administration, titratability of blood pressure response, rapid onset and cessation of action, and a low incidence of adverse effects. Options are nitrovasodilators, calcium channel blockers, ACE inhibitors, direct-acting vasodilators, adrenergic blockers, and neuromodulators (narcotics and anesthetics). PMID- 10150581 TI - The technique of dorsalis pedis cannulation. An overlooked option when the radial artery cannot be used. AB - When arterial cannulation is required, but the radial artery cannot be used, five alternatives can be considered: the ulnar, brachial, axillary, femoral, and dorsalis pedis arteries. Of these, the dorsalis pedis may be the next best choice: Collateral flow is excellent, and cannulation here is easy to perform, presents minimal patient inconvenience, and has a very low incidence of complications. Systolic pressure readings obtained at the dorsalis pedis artery are 5 to 20 mm Hg higher than measurements obtained at the radial artery; however, by comparing the dorsalis pedis reading with a cuff pressure, you can quickly determine the extent of overshoot and correct the invasive measurement. PMID- 10150582 TI - Closing in on Chlamydia. PMID- 10150583 TI - Amplification assays: now it's a horserace. PMID- 10150584 TI - For reliable culture results, take multiple specimens. PMID- 10150585 TI - Stalking antibiotic-resistant bacteria. PMID- 10150586 TI - Prescriptions by mail: past, present and future. PMID- 10150587 TI - Optimizing drug benefit design before implementation. PMID- 10150588 TI - Mental health care reform--can everyone win? PMID- 10150589 TI - Health economic issues and the future treatment and management of hypertension. PMID- 10150590 TI - A definition of managed care. PMID- 10150591 TI - Provider satisfaction: a critical element for the success of vision care plans. PMID- 10150592 TI - Managed eyecare: a vision for the future. PMID- 10150593 TI - Why oppose any willing provider legislation? PMID- 10150595 TI - Who's giving managed care a bad name? PMID- 10150594 TI - The community pharmacist: delivering quality care and lower costs. PMID- 10150596 TI - Modeling and forecasting health care consumption. PMID- 10150597 TI - Absorbable membranes for bone repair: an experimental study on rabbits. AB - To study the use of absorbable self-reinforced polyglycolide (SR-PGA) membranes for bone repair, distal femoral metaphyseal osteotomies were created in 10 rabbits and diaphyseal osteotomies in five. Osteotomies were fixed with intramedullary PLLA rods and PGA membranes were applied over the osteotomy. They were followed up for 6, 12 and 24 weeks. Radiography, histology, microradiography and oxytetracycline fluorescence labelling studies were used to evaluate the outcome. Healing occurred without complications in the metaphyseal series while failure was recorded in the diaphyseal series. In metaphyseal osteotomies, new bone formation was seen medially (on the side of PGA membrane), more proximal and medial to the membrane than at the inlet of osteotomy. PMID- 10150598 TI - Absorbable self-reinforced polyglycolide (SR-PGA) screws for the fixation of fractures and osteotomies: strength and strength retention in vitro and in vivo. AB - The initial mechanical strength and strength retention in vitro and in vivo of novel absorbable and self-reinforced polyglycolide (SR-PGA) screws for the fixation of fractures and osteotomies were determined. The SR-PGA screws showed initial bending strength values comparable with those of yield strength of standard stainless steel. The SR-PGA screws lost all their bending and shear strengths in 6 weeks in vivo. The strength retention properties of SR-PGA screws are sufficient for safe fixation of relatively rapidly consolidating fractures and osteotomies of cancellous bone that are not exposed to hard mechanical stresses. PMID- 10150599 TI - The physical properties of a polyacetal denture resin. AB - A polyacetal injection-moulded resin is being marketed for the construction of retentive and supportive components of removable partial dentures (RPDs). Specimens of poly(oxymethylene) cast by commercial laboratories were tested to examine the following physical characteristics: the modulus of elasticity in compression, extension and flexure, stress relaxation, the force displacement behaviour of clasp forms, impact strength and glass transition temperature. Results showed that the material has a flexural modulus lower than that of poly(methylmethacrylate) and is insufficiently rigid to be used as a supporting element for partial dentures. Resin clasps may be resilient enough to engage undercuts for the retention of RPDs but the low flexural modulus requires that the resin be used in greater cross-sectional area than metal alloys in order to gain useful retention. This greater bulk has implications for plaque accumulation and maintenance of periodontal health. PMID- 10150600 TI - Evaluation of experimental and finite element models of synthetic and cadaveric femora for pre-clinical design-analysis. AB - The aim of this study was to determine the validity with which the finite element method could model synthetic bone and thereby determine the appropriateness of such femur analogues for application in pre-clinical tests. The performance of these synthetic femora was compared with cadaveric bone when employing the same geometric and material definition protocols. A four-point bend loading configuration was selected for this analysis. Four synthetic femurs and an embalmed cadaveric bone were tested experimentally to determine the structural bending stiffness (k) for the diaphysis of these bones. A finite element (FE) model was generated and an analysis performed for each bone type to estimate the Young's modulus (E) required to obtain a model stiffness equivalent to that obtained experimentally. The estimated material elastic modulus in the FE model for the synthetic femur was found to be very similar to available data for this bone analogue. The estimated cadaveric bone modulus however was found to differ significantly from documented values for cortical bone. A theoretical analysis demonstrated the great sensitivity of the estimated modulus value to the accuracy of the geometric definition. The very low variability found in the experimental test on the synthetic bones together with their more regular geometry and the possibility of achieving greater accuracy in geometric definition was shown to enable the production of a valid FE model of this bone for an isotropic homogeneous material description. Conversely, the greater irregularity of geometry, together with the less obvious differentiation between the cortical and cancellous bone in the cadaveric specimen makes accurate geometric description of this bone very difficult. This fact, together with the uncertainty concerning the quality of the cadaveric bone and its viscoelastic response during mechanical testing, makes reproduction of its behaviour in a FE model a much more demanding task. It is suggested that this greater capability of reproducing the experimental behaviour of the synthetic bone makes them a very useful model for both experimental and numerical studies which involve in-vitro pre-clinical testing of implant design and stem-bone behaviour. PMID- 10150601 TI - The in-vivo effects of an intramedullary implant evoking a constant radial stress to bone. An animal study in the tibia of the goat. AB - Initial stability is essential for successful bone ingrowth into non-cemented prostheses. An entire new concept to increase the initial stability directly after implantation of intramedullary stems was developed (the tension rod prosthesis). The concept is based on a tension rod made out of memory metal that pulls a proximal stem of a prosthesis towards a distal anchor with a constant force. The stress generated along the long axis of the bone produces a radial stress around the prosthesis in the proximal femur. The main goal of this design is to increase the primary stability of the prosthesis during the ingrowth phase and to prevent stress shielding and bone resorption, as realized by the radial force applied to the proximal endosteum of the bone. To assess the efficacy of this concept and to collect data for the anchor design, an implant was developed for implantation into the tibia of the goat. Analyses of push-out strength and bone reactions were performed postoperatively. After 48 weeks the push-out strength of this implant was increased and the histological evaluation showed almost complete osseousintegration. Histomorphometrical analysis showed pronounced, permanent periosteal reactions, located around the anchor of the implant, which generates the radial stress. These first results showed that the bone can withstand the radial stress provoked by the anchor of the tension rod. It is concluded that the concept of a tension rod prosthesis is viable. PMID- 10150602 TI - Mechanical performance of dental amalgam--composite interfaces. AB - Composite veneering of amalgam is the most aesthetical solution to extensive direct tooth restoration and is applied with success in specific clinical situations. An in-vitro technique has been used to evaluate the mechanical performance of one amalgam bonded to four different composites. The amalgam composite interfaces were subjected to tensile stress and shear stress at break tests, using dumb-bell and sandwich specimens in a PC-controlled electronic dynamometer equipped with innovative grips. Mean values were higher for tensile stress than for shear stress. Further studies and clinical experimentation will be necessary to explore the question of long-term reliability. PMID- 10150603 TI - Fluoride concentration in ancient teeth measured by nuclear reaction. AB - Fluoride content in the enamel and dentine of ancient teeth has been measured using a nuclear analysis technique. Analysed teeth were found in a vast necropolis of Sicily (Italy) which is archeologically datable between the 13th and the 8th century B.C. Measurements gave high fluoride concentrations, of the order of 10 mg per gram of hydroxyapatite, comparable with the content of fluorotic teeth of patients living nowadays in regions rich in fluorinated drinking water. Results suggest that the dental caries process was probably unknown to the tribal population living in this geographical area. PMID- 10150604 TI - How imaging can thrive in managed-care markets. PMID- 10150605 TI - Ensuring confidentiality on computer networks. PMID- 10150606 TI - Electronic consultations promote smarter imaging. PMID- 10150607 TI - Clinical pathways for case management. AB - Clinical pathways define a series of events that are expected to occur within an anticipated time, which sequence and monitor a patient's progress and treatment. They are used to project an individual's response to care and prospectively address alterations to these goals or outcomes. PMID- 10150608 TI - Embracing system integration. PMID- 10150609 TI - A transformation to real-life rehabilitation. PMID- 10150610 TI - 10 key questions answered on chronic fatigue syndrome. PMID- 10150611 TI - Reperfusion and antithrombotic strategies for acute MI. PMID- 10150612 TI - Diagnosis and management of osteoporosis. AB - Risk factors for osteoporosis, bone densitometry, and biochemical testing can identify those most in need of preventive measures to optimize calcium metabolism and reduce bone loss. Treatment options for established disease are evaluated. PMID- 10150613 TI - Score one for drug screeners. PMID- 10150614 TI - Health care takes on the CHIN. PMID- 10150616 TI - Due diligence in the delegation of credentialing. PMID- 10150615 TI - Reducing lab test use. PMID- 10150617 TI - Stemming the risk of capitated contracts: what providers should consider when buying stop loss insurance. AB - Whether an organization decides to purchase stop loss insurance from an HMO or a stop loss specialist, the decision-makers should read and understand each proposal. This information is best obtained by working with a qualified insurance expert who understands stop loss insurance and managed care and health care contracting practices. The stop loss carrier's overall commitment to the organization purchasing its policy should be to provide the best possible service and protection against the financial consequences of catastrophic claims. PMID- 10150618 TI - Integrating managed care and workers' compensation: what has happened, what can happen. PMID- 10150619 TI - Health care reformation: where will it end? Who will survive? PMID- 10150620 TI - Communication tips: understanding what all your audiences need to hear. PMID- 10150622 TI - Three-dimensional echocardiography for quantitative left ventricular wall motion analysis: a method for reconstruction of endocardial surface and evaluation of regional dysfunction. AB - A method for quantitative LV wall motion analysis based on 3-D reconstruction of the LV endocardial surface is presented. The reconstruction is based on a minimum of three transthoracic apical 2-D cineloops of the LV, digitally transferred from the ultrasound scanner to a computer. Images are obtained by rotating the transducer around the LV long axis. Endocardial borders are traced with an automatic edge detection algorithm with manual correction. These borders are used with a specially designed computer algorithm for reconstruction of LV cavity 3-D shape, and LV volumes, ejection fraction, and endocardial surface area can be determined. The end-diastolic and end-systolic endocardial surfaces are compared for analysis of regional wall motion. A threshold value is selected to discriminate between normal and abnormal wall motion. Regional wall motion abnormalities are displayed in a bull's eye plot, and the corresponding endocardial surface area is expressed in percent of the total endocardial area. Phase analysis is performed from reconstruction of the endocardial surface throughout the cardiac cycle, and displays regions with abnormal wall motion as being out of phase with LV volume variation. Thus, LV 3-D reconstruction performed by this method can be used for quantitative analysis of wall motion in several clinical situations, and due to the simplicity of processing the data, can be useful outside the research laboratory. PMID- 10150623 TI - Model-based estimation of vascular parameters: evaluation of robustness and suitability of models. AB - Left ventricular performance depends not only on myocardial state, but also on the properties of the systemic arterial tree. These properties can be assessed from recordings of aortic root pressure and flow by the use of appropriate vascular models. Noninvasive estimates of aortic root pressure and flow can be obtained by the combined use of calibrated external subclavian artery pulse tracing and Doppler echocardiography. With recent advances in computer technology, estimation of model parameters are thus accessible in the clinical setting. We discuss the suitability of different parametric vascular models together with methods for adapting these models to the measured aortic root pressure. We compared the results obtained with simple vascular models (three component modified Windkessel models) with those of five-component models. The simpler models gave less accurate approximation of the measured pressure waveform, but for a representative set of aortic root pressure and flow data, the simpler models provided adequate estimates of the peripheral arterial resistance, the total arterial compliance, and the proximal aortic area compliance. Furthermore, the simpler models are robust for measurement noise with simple estimation algorithms. Distal arterial pressure and flow waveforms are more oscillatory, and for these the five-component model has more robust estimation schemes with more accurate estimated parameters. Hence, we conclude that for clinical noninvasive assessment of aortic vascular properties, the simpler three component models provide adequate information. For assessment of the peripheral arteries with large oscillations in the flow, the three-component models can give more than 10% error in the compliance estimate and more complex models can be appropriate. PMID- 10150624 TI - The paradoxical pulse in tamponade: mechanisms and echocardiographic correlates. AB - Pulsus paradoxus is an exaggerated fall in systolic blood pressure with inspiration (usually greater than 10 mm). Understanding the accuracy of pulsus paradoxus for a diagnosis of cardiac tamponade requires a consideration of the mechanisms underlying its genesis, and a knowledge of its presence in other conditions and its variable absence in cardiac tamponade with associated disease states. Echocardiography (M-mode, 2-D, and Doppler) has aided considerably our understanding of pulsus paradoxus. Inspiratory increases in right heart filling and output are widely accepted as necessary for pulsus paradoxus to occur; inspiration causes increases in right ventricular dimensions and pulmonic and tricuspid velocities, and decreases in left ventricular (LV) dimensions and aortic and mitral velocities and LV diastolic compliance. Doppler studies of pulmonary venous inflow confirm that an inspiratory fall in left atrial filling is necessary for pulsus paradoxus. Pulsus paradoxus is complex and multifactorial in origin; it may be absent in cardiac tamponade when certain conditions (e.g., LV dysfunction) coexist and may accompany disease states other than cardiac tamponade (e.g., obstructive airway disease). Thus, the significance of pulsus paradoxus (and its Doppler echo correlates) must be considered in the clinical context. PMID- 10150625 TI - Can pleural effusions cause tamponade-like effects? AB - Experimental studies have confirmed the clinical impression that large bilateral pleural effusions are able to raise the pressure in an otherwise hemodynamically insignificant pericardial effusion to a level sufficient to produce right ventricular diastolic collapse (RVDC). The hemodynamic consequences of this syndrome are not as severe as when the intrapericardial pressure is raised to the same level by excess intrapericardial fluid in the absence of pleural effusions. RVDC caused by excess pleural fluid with a minor pericardial effusion is a false positive indication for pericardial fluid drainage. Thoracentesis is more appropriate. PMID- 10150626 TI - Transesophageal echocardiography in pericardial disease and tamponade. AB - While most pericardial disorders can be imaged by transthoracic echocardiography, transesophageal echocardiography may be required in those cases where pericardial pathology is clinically suspected, but cannot be imaged adequately with transthoracic echocardiography. Transesophageal echocardiography is especially helpful in patients after heart or chest surgery, with cardiac compression by a loculated pericardial hematoma, in patients with dissection, endocarditis, or interatrial shunting associated with pericardial effusion, in patients with pericardial tumors, and in the differential diagnosis between constrictive pericarditis and restrictive cardiomyopathy. PMID- 10150627 TI - Doppler echocardiography in cardiac tamponade and constrictive pericarditis. AB - Doppler echocardiography has greatly facilitated the assessment of patients with compressive cardiac disease. Patients in whom cardiac tamponade or pericardial constriction are suspected should undergo a complete echocardiographic examination including careful Doppler analysis of transmitral flow and inflow through the hepatic vein or superior vena cava (SVC). Monitoring of both the electrocardiogram and the phase of respiration are an integral part of this examination. Patients with cardiac tamponade exhibit a > 25% reduction in E wave velocity during the first inspiratory cardiac cycle; they exhibit predominant systolic inflow through the hepatic vein or SVC (with a predominant X descent with little or no Y descent). In constrictive pericarditis the pattern of transmitral flow variation is comparable to that observed in cardiac tamponade, however, a prominent Y descent is often observed on hepatic vein or SVC Doppler study. Similar changes with respiration may be observed in mitral inflow in obese patients or in those with chronic obstructive pulmonary disease, however, in these conditions the nadir of E wave velocity is observed 2-3 cardiac cycles after the first inspiratory beat. Restrictive cardiomyopathy may produce a similar systemic venous flow pattern, but increased inspiratory flow reversals and lack of respiratory variation in transmitral flow velocity distinguish it from constrictive pericarditis. PMID- 10150628 TI - Echocardiographic manifestations of mediastinal masses compressing or encroaching on the heart. AB - Because of its central position within the thorax, the heart can be encroached upon by masses originating in either anterior, posterior, or superior mediastinum. A distinction may be made between (A) Encroachment: distortion or partial displacement of one or more cardiac chambers by a contiguous mediastinal mass, without adverse hemodynamic effects, and (B) Compression: resulting in clinical manifestations similar to tamponade. Transthoracic and, recently, transesophageal echocardiography have been found useful in detecting mediastinal masses, the information obtained being complementary or preliminary to more complete imaging by CT or MRI. Anterior masses tend to compress the right heart chambers; posterior masses impinge on or compress the left atrium or ventricle, particularly the former. The wide variety of echographic appearances are briefly reviewed. Recently TEE has made it possible to diagnose masses obstructing the superior vena cava or pulmonary veins. A common, though little known, type of posterior mediastinal encroachment that echocardiographers need to be aware of is that of abnormal esophageal/gastric masses including hiatus hernia and esophageal carcinoma, which have typical two-dimensional echo features and may sometimes simulate left atrial masses. PMID- 10150629 TI - Transthoracic real-time three-dimensional echocardiography using the rotational scanning approach for data acquisition. AB - Transthoracic real-time three-dimensional echocardiography using the rational scanning approach for data acquisition became a feasible modality for cardiac imaging during the last 4 years. Several attempts for reconstruction of the heart have been made using different methods. In this study we evaluate the data acquisition using the rotational approach from the transthoracic window. Thirty five children with congenital heart disease were enrolled in the study. All of them underwent complete two-dimensional and Doppler echocardiogram followed by three-dimensional reconstruction using rotational image acquisition. The rotational approach enabled us to acquire good data from subcostal, apical, and suprasternal notch positions by rotating the transducer from 0 degrees-180 degrees. Novel views of the atrioventricular valve, semilunar valve, atrial, and ventricular septi were established by spatial plane imaging from the three dimensional echocardiography. This reconstruction enables spatial imaging of cardiac structures and deficiencies. Three-dimensional echocardiography will enhance the understanding of complex congenital heart disease. PMID- 10150630 TI - Left ventricular outflow tract obstruction defined by active three-dimensional echocardiography using rotational transthoracic acquisition. AB - A rotational data acquisition system was used to create three-dimensional images from thoracic and subxiphoid echocardiographic windows in children with various types of subaortic stenosis. Thirteen patients, ranging in age from 2 days to 17 years, were examined. Subaortic obstruction was caused by a discrete fibrous ridge in six patients, hypertrophic cardiomyopathy in two patients, subaortic tunnel in two patients, and septal malalignment, restrictive VSD, and abnormal suture placement each in one patient. Unique views could be obtained equivalent to surgical or autopsy dissections, and allowed more complete understanding of morphology than conventional imaging techniques. PMID- 10150631 TI - Quantitative assessment of normal and stenotic aortic valve using transesophageal three-dimensional echocardiography. AB - The present study demonstrates the feasibility of transesophageal three dimensional reconstruction of normal, sclerotic, and stenotic aortic valves using a computed tomographic ultrasound system. The study also shows the potential clinical usefulness of this technique in delineating aortic valve morphology (extent and severity of valve thickening and calcification and size and number of cusps) and assessing aortic orifice areas by direct planimetry of the three dimensional images. PMID- 10150632 TI - Enhanced comprehension of dynamic cardiovascular anatomy by three-dimensional echocardiography with the use of mixed shading techniques. AB - Advances in ultrasound instrumentation and computer technology provide us an opportunity to develop methods to perform three-dimensional echocardiography in patients. Optimal methods of displaying three-dimensional images are critical for the perception of depth and distances. We examined the utility of various shading techniques in volume-rendered three-dimensional images in 22 patients with a variety of cardiac defects. Distance coding, gray level gradient shading, texture shading, and mixtures of these shading techniques were used. Our observations suggest that the mixture of shading techniques portray the dynamic three dimensional anatomy better than a single type of shading. Appropriate mix of shadings could provide dynamic three-dimensional echocardiograms of clinical utility. PMID- 10150633 TI - Diagnostic performance of two-dimensional versus three-dimensional transesophageal echocardiographic images of selected pathologies evaluated by receiver operating characteristic analysis. AB - The sensitivity and specificity of 2-D and 3-D echocardiographic images for the detection of selected morphological abnormalities were compared using receiver operating characteristic (ROC) analysis. Five experienced clinical echocardiographers blinded to the patients' diagnoses evaluated the 20 original static 2-D image sets and 20 corresponding 3-D reconstructions using a five point categorical scale that ranged from definitely abnormal to definitely normal. The ROC curve for the 3-D images was significantly (P < 0.05) closer to the ideal discrimination function than was the ROC curve for the 2-D transesophageal images (i.e., the sensitivity of the 3-D images was higher than that of the 2-D sequential images at the same specificity). IN CONCLUSION: 3-D transesophageal images provided better visual clues for the identification of morphological abnormalities than did serial 2-D echocardiographic images despite the same input information in both image formats. The use of ROC analysis assisted in the comparison of these two imaging techniques. PMID- 10150634 TI - Percutaneous laser disc decompression. AB - Herniated disc disease has an incidence of 1.7% in the U.S. Heretofore, open operative procedures were the rule for this condition when conservative measures were ineffective. Choy and Ascher introduced this new technique in February 1986 using a Nd:YAG laser introduced into the disc through an optical fiber in a needle. Percutaneous laser disc decompression is based on the principle that in an enclosed hydraulic space, such as an intact disc, a small reduction in volume is associated with a disproportionate fall in pressure. In the disc, this partial vacuum causes the herniated portion to move away from the nerve root back toward the center of the disc. This technique has been taught worldwide and is being performed in most of Europe, Japan, the United States, and Korea. In this special issue devoted to percutaneous laser disc decompression (PLDD), we will set forth the basic science of PLDD, patient selection, use of the holmium:YAG, and the Nd:YAG lasers, operative technique, and results. PMID- 10150635 TI - Principles of lasers. AB - The physics of lasers is described: a laser is light amplication by stimulation of emitted radiation. The laser beam is monochromatic, highly collimated, and delivers very high energy. PMID- 10150636 TI - Anatomy of intervertebral disc and pathophysiology of herniated disc disease. AB - This discussion reviews developments in normal and abnormal disc biology over the past decade. The anatomic and biochemical structure of the disc is reviewed. Emphasis is placed on recent neurochemical changes identified in disc degeneration and disc herniation. Biomechanical considerations for the normal disc are presented. Influence of mechanical factors on disc nutrition, disc degeneration and disc herniation is reviewed. Biologic events underlying the diagnostic methods used in evaluating disorders of the intervertebral disc are presented. The biologic consequences of iatrogenic disc injury in discectomy are also discussed. PMID- 10150637 TI - Change of intradisc pressure versus volume change. AB - To gain further insight into the biomechanics of the intervertebral disc and determine a potential mechanism for causation and relief of symptoms related to a herniated disc, the pressure-volume relationship was determined within the nucleus pulposus (NP). In 17 intact human cadaver lumbar discs, pressure was measured continuously within the NP by means of a miniature strain gauge at the tip of a size 4 French (1.3 mm) catheter inserted into the NP. The volume of the NP was increased at the slow, continuous rate of 0.034 ml/min by the pump regulated infusion of saline colored with methylene blue. In 12 unloaded discs, NP pressure rose in a linear fashion (linear r2 = 0.96) from an initial mean pressure of 174 +/- 81 kPa. The mean rate of pressure rise was 327 +/- 109 kPa/ml of volume increase. The peak pressure reached was limited to 550 kPa by the capacity of the strain gauge. Similar linear relationships were obtained during saline infusion into 5 vertically loaded discs. The data define the pressure volume relationship within the disc and show that the NP, surrounded by the relatively inelastic annulus and the solid vertebral end-plates, has the properties of a tight hydraulic space in which a large pressure rise will regularly result from a small increase in volume. Presumably, the opposite is also true. The data may provide a biomechanical basis for variation in symptoms related to physiological changes in disc volume, and for any benefit obtained from interventions designed to remove disc tissue. PMID- 10150638 TI - Fall of intradiscal pressure with laser ablation. AB - In an experimental system where intradiscal pressure could be measured before and after laser ablation, we found that there was a significant fall of intradiscal pressure after 1000 J of Nd:YAG laser energy was delivered to fresh cadaver discs. That this was not due to fenestration was demonstrated by control experiments using an identical system, but without turning on the laser. Here, there was no significant fall of intradiscal pressure. PMID- 10150639 TI - Efficiency of disc ablation with lasers of various wavelengths. AB - In testing the CO2 lasers in CW and pulse mode, the erbium:YAG, the Nd:YAG 1318 microns and 1064 microns, the argon, the holmium:YAG, and the excimer, we found the greatest efficiency in the CO2 CW and pulse mode, and the lowest efficiency in the argon. Data with the holmium:YAG were unreliable because of the early generation laser tested. The Nd:YAG was second only to the CO2 laser, and because the latter has no waveguide, we deemed the Nd:YAG the laser of choice for PLDD. PMID- 10150640 TI - Patient selection: indications and contraindications. AB - Patient selection is critical to the success of PLDD. In general, the herniation must have continuity with the parent disc; rupture of the annulus is not a contraindication. Several other orthopedic conditions constitute absolute or relative contraindications. All patients must be individualized. Our criteria for inclusion is undergoing continuing change. What is unacceptable now may, with modifications, become acceptable in the future. It is important not to adopt a fixed position at this early stage of PLDD. PMID- 10150641 TI - The neurological examination. AB - This chapter describes methods of clinical history taking and examination of the PLDD candidate with lumbar radicular symptoms. It stresses features of the classical neurological examination of the back and lower extremities in a concise, systematic fashion. PMID- 10150642 TI - Clinical neurological evaluation. AB - The importance of the neurological evaluation for PLDD procedures is discussed. Elements of the basic examination are outlined and the reason for specific methods of testing are offered. The physician should pay attention to patient complaints, mechanical signs, and patient capabilities. PMID- 10150643 TI - A neurosurgical perspective on PLDD. AB - This paper discusses the evolution of PLDD and its risks and complications, and points out some advantages and disadvantages. It presents data from a clinical study of 81 patients in which three technologies--automated percutaneous discectomy, KTP, and Nd:YAG laser instruments--were used. The study concludes that PLDD is safe and cost-effective. If the patients are properly chosen PLDD can be a good choice for treatment of herniated lumbar discs. PMID- 10150644 TI - The role of radiology in percutaneous laser disc decompression. AB - Diagnostic imaging has always played a key role in the evaluation of patients with suspected lumbar disc herniation. With the development of percutaneous laser disc decompression (PLDD), radiology is now equally important in its treatment. All physicians involved with the PLDD candidate must be familiar with the imaging techniques unique to this procedure to ensure a successful outcome. The following review is based on the cumulative experience gained in performing over 200 PLDD procedures. It discusses the function of diagnostic radiology in all facets of PLDD including patient selection, intraoperative imaging, postoperative evaluation, and analysis of complications. Fundamental radiologic concepts that apply to PLDD are explained and protocols suggested to optimize results and avoid complications. PMID- 10150645 TI - Techniques of percutaneous laser disc decompression with the Nd:YAG laser. AB - The great importance of correct needle placement with appropriate radiologic monitoring is emphasized. The needle tip must be just past the annulus, and the needle itself must be parallel to the disc axis, and preferably halfway between the superior and inferior end-plates. Dosimetry is described. A novel (extrathecal) approach to the L5-S1 disc when this cannot be entered from a dorsolateral angle is described. Our technique for cervical disc PLDD is briefly described. PMID- 10150646 TI - Percutaneous laser disc decompression with the holmium: YAG laser. AB - This article discusses the evolution of the percutaneous laser disc decompression (PLDD) method using a holmium:YAG laser. Advantages of using this wavelength and several techniques for its use in PLDD are reviewed. The article also discusses the current devices and delivery systems available for this application. PMID- 10150647 TI - Percutaneous laser discectomy of cervical discs: preliminary clinical results. AB - Thirty-one patients with herniated cervical discs were treated with PLDD from 1991 to 1993. In 1990, a few of these patients were treated with the Nd:YAG laser with no complications. Since 1991 we have used the holmium:YAG laser; 28 of the 31 patients experienced pain relief in a 6-week follow-up. PLDD for the cervical discs is a viable therapy. PMID- 10150648 TI - Clinical experience and results with 389 PLDD procedures with the Nd:YAG laser, 1986 to 1995. AB - From 1986 to the present, a period of 9 years, our group has performed 389 PLDD procedures in 322 patients with an overall success rate according the MacNab criteria of 75% and a complication rate of 1%. This compares to the 2.4% of traditional open surgery. Of our patients 33 required subsequent surgery, an incidence of approximately 10%. PMID- 10150649 TI - The PLDD registry. AB - The rapid acceptance of minimally invasive surgery in the United States has largely occurred without statistical proof of its superiority over traditional methods. All players in the healthcare field now see the need for valid outcome studies supporting the efficacy of new treatment techniques. Percutaneous laser disc decompression (PLDD) will gain wide acceptance only if it is statistically shown to be a safe and effective alternative treatment of a lumbar disc herniation. To that end, a central PLDD registry has been developed and implemented into clinical practice at several centers. This article reviews healthcare trends that motivated the creation of this data repository and discusses the history of its development. The currently used PLDD evaluation form is outlined and its utility is discussed. Most importantly, preliminary PLDD results and complications based on the data received are presented and analyzed. PMID- 10150651 TI - Sapphire fibers for erbium: YAG continue to evolve. PMID- 10150650 TI - Ho:YAG and fluoride resin increases resistance to caries. PMID- 10150652 TI - Preventing restenosis is a major goal for PDT. PMID- 10150653 TI - Endometrial laser ablation seen as good replacement for hysterectomy in pioneering study. PMID- 10150654 TI - A new, laparoscopic full-thickness slice ovarian biopsy (from antimesenteric to mesenteric margin). AB - This article introduces a new laparoscopic surgical technique of full-thickness slice biopsy, from antimesenteric margin to mesenteric area, of the ovary. The uteroovarian ligament with mesenteric vasculature and the infundibulopelvic ligament with its artery and veins are transitionally obliterated with atraumatic 5-mm laparoscopic clamps. This part of the operation stabilizes and decreases the blood supply to the ovary. A desirable width of full-thickness slice in the middle part of the ovary is excised from antimesenteric to mesenteric region with 5-mm laparoscopic scissors. The full-thickness slice ovarian excision stops before the mesenteric vasculature to avoid surgical injury to that area that may compromise the ovarian blood supply or return. The presence of primordial follicles in the ovary differentiates the resistant ovary syndrome from premature ovarian failure. In hypergonadotropic hypogonadism, a classic minilaparotomy is performed to obtain enough ovarian tissue for the definitive histologic diagnosis of premature ovarian failure versus resistant ovary syndrome. Simplicity and good outcome make this laparoscopic technique suitable for many clinical predicaments when a deep lesion in the ovary must be removed. PMID- 10150655 TI - A laparoscopic complication? A medical legal case analysis. Part I. AB - This article describes a case of a laparoscopic injury and the ensuing litigation. Data from the hospital report and the testimony of witnesses are presented. In the next issue of this Journal, the results of the jury finding will be presented as Part II. PMID- 10150656 TI - Endometrial electrosurgical resection by hysteroscopy in 32 menorrhagic patients: endometrial preparation with a GnRH agonist may have some effect on results. AB - Our objective was to evaluate the effect of endometrial thinning by GnRH agonists on the results of hysteroscopic endometrial electrosurgical resection. In a prospective study, 32 women were treated with the GnRH agonist goserelin (Zoladex) before hysteroscopic endometrial resection. Endometrial thickness was measured before and after GnRH-a therapy by ultrasound. Short-term results in diminished vaginal blood loss and patient satisfaction were registered. The mean endometrial thickness (ET) before GnRH-a is 3.7 mm and after GnRH-a is 1.9 mm. In 24 cases, ET was reduced by a mean of 2.6 mm, in 1 case, no change was seen, and in 7 cases, ET increased by a mean 1.1 mm. The mean thickness rate (TR = ET before and after GnRH) is 2.7 (range 0.3-11). Fluid resorption during hysteroscopic surgery does not relate to ET or TR. Although the ET after GnRH-a therapy is not related to success or failure of the endometrial resection, there is some evidence that the TR is, probably expressing a more active state of the endometrium. Endometrial thinning by GnRH-a may have an effect on the results of hysteroscopic endometrial resection. In light of the present study and the literature, there seems to be no justification for abandoning preparation of the endometrium before hysteroscopic surgery. PMID- 10150657 TI - Assessing the impact of introducing laparoscopically assisted vaginal hysterectomy into a community-based gynecology practice. AB - This study was undertaken to determine the effects of introducing laparoscopically assisted vaginal hysterectomy (LAVH) into a community-based gynecology practice on the route of hysterectomy, operating time, patient costs, length of hospitalization, and morbidity, including complications and blood loss. All patients in the author's practice who had hysterectomies during the 10 months before completion of an advanced operative laparoscopy course were compared with the patients having a hysterectomy in the 10 months after the course. The route of hysterectomy, surgery time, length of hospital stay, preoperative and postoperative hemoglobin, uterine weight, diagnoses, and historical clinical data were compared between the two groups using a level of significance (alpha = 0.01) to assess statistical relevance. The rate of vaginal hysterectomy was remarkably higher in the AFTER group (53.2%, n = 62) vs the BEFORE group (27.7%, n = 65). The AFTER group had a significantly shorter hospital stay (3.4 days +/- 1.22 vs 4 days +/- 1.26, p < or = 0.01) but a much longer surgery time (115.9 min +/- 38.98 vs 80.1 min +/- 27.95, p < or = 0.01). There was no real difference in complication rates or fall in hemoglobin between the two groups. When LAVH was compared with TAH, the LAVH patients tended to be younger (37.4 +/- 8.66 vs 46.2 +/- 16.5 years) and to have a shorter hospital stay (3.1 +/- 0.99 vs 4.1 +/- 1.27 days), a longer surgery time (114.9 +/- 37.45 vs 85.3 +/- 33.74 min), and a bigger hospital bill ($6245 +/- 380 vs $5140 +/- 410) than patients with TAH.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150658 TI - Rabbit fallopian tube reanastomosis using a microvascular stapling device. AB - The 3M Precise Microvascular Anastomotic System (MAS), a microvascular stapling device, was compared with microsurgery for the reanastomosis of rabbit fallopian tubes. Differences in operative time, tubal patency, adhesion formation, and fertility rate were studied in 18 rabbits. Only 17% of tubes repaired by MAS were subsequently patent by chromopertubation, compared with 72% with microsurgery. Mean nidation indices were 0.05 for MAS and 0.22 for microsurgery. Sixty-one percent of adnexae repaired by MAS were adhesion stage I, whereas 83% of microsurgically repaired adnexae were stage I. Mean operative time was 28.2 min for MAS vs 21.6 min for microsurgery. Only the differences in patency rate and operative time were statistically significant, but the trends suggest that fallopian tube reanastomosis by MAS offers no advantage over conventional microsurgical technique. PMID- 10150659 TI - Advances in the treatment of acute MI. PMID- 10150660 TI - Prevention and management of vascular catheter infections. PMID- 10150661 TI - Managing life-threatening bronchospasm. PMID- 10150662 TI - Diabetes-related foot infections. AB - The best choices for diagnostic studies in evaluating patients with possible soft tissue infections, osteomyelitis, and Charcot's foot are presented. The role of surgery with drug therapy and the most appropriate antibiotics are considered. PMID- 10150663 TI - New challenges in critical care medicine. PMID- 10150664 TI - Environmental toxins: cutting the risks. AB - From pesticides to PCBs, the chemical residues of modern life are all around us- and children are at high risk of harm. The authors describe some of the major culprits and suggest ways to reduce your patients' exposure. PMID- 10150665 TI - Making the most of pulse oximetry. AB - A noninvasive device that gives continuous oxygenation readings has great appeal, and pulse oximetry has enjoyed wide acceptance. To use it most effectively, though, you need to understand the principles it's based on and know its limitations. PMID- 10150666 TI - Technology assessment and coverage decision making. AB - In the health care decision-making cascade, technology assessment renders the initial evaluative judgement about the contribution of a technology to patient care. As such, it has a major impact on coverage policy, clinical guidelines and utilization management. This impact necessitates that technology assessment have a scientific, defensible process. There are four basic components of a scientific, defensible process for both clinical and coverage decision making. These are: 1. Outcomes data that are derived preferably from controlled clinical trials and that support the safety and effectiveness of a specific indication 2. Evidence of acceptance by the practicing medical community of specific applications of a technology 3. A rigorous, evaluative process that synthesizes and analyzes outcomes data and expert opinion 4. Consistency in the use of terminology, as it is translated from the technology assessment process to coverage policy The process must be designed to assure scientific and methodological defensibility. Also, it must be designed to facilitate and substantiate the medical and coverage decision-making processes. Finally, it must be designed to enable and expedite the implementation of the managed care philosophy (i.e., outcomes-based decision making) within a particular health plan. PMID- 10150667 TI - Combining medical technology and practical patient care: the MRI evaluation. PMID- 10150668 TI - Implications for managed care: patient preferences in health screening and health promotion services in a military population. PMID- 10150669 TI - Out of the emergency room and into the doctor's office: what happens when Medicaid patients join HMOs. PMID- 10150670 TI - Updating drug formularies to serve a changing patient population. PMID- 10150671 TI - Radiological considerations: patient selection for percutaneous laser disc decompression. AB - Percutaneous laser disc decompression (PLDD) is an effective method of treating the lumbar herniated nucleus pulposis (HNP) that is both contained by the annular/posterior longitudinal ligament (PLL) complex and connected to the parent disc of origin. Not all radiological studies have the same ability to diagnose this specific type of herniation and therefore are not equally useful in the preoperative evaluation of the PLDD candidate. Ninety PLDD treated patients were retrospectively reviewed to determine which of the four most commonly performed lumbar imaging exams, when abnormal, correlated with a successful outcome. Overall MacNab criteria improvement occurred in 73.3% of PLDD-treated patients. An abnormal CT discogram correlated with PLDD success in all patients treated (100%). An abnormal MRI, CT, or myelogram correlated with success in 75% or less of patients treated. The theoretical reasons for the superiority of CT discography are discussed and the diagnostic potential of all major lumbar imaging modalities is reviewed. A diagnostic decision scheme for the evaluation of the prospective PLDD patient is presented. PMID- 10150672 TI - Comparative study of microepineural suture, microepineural suture-aided CO2 laser, and laser only anastomoses in rat sciatic nerves. AB - The cut sciatic nerves of 33 rats were anastomosed by three different methods under the operation microscope; microepineural suture technique, CO2 laser technique, and laser-aided microepineural suture technique. On histologic examination at the end of 3 months postoperatively, in the CO2 laser and suture aided CO2 laser groups, the degrees of inflammation, fibrosis, and Schwann cell vacuolar degeneration were significantly higher than in the microepineural suture anastomosis group. At the end of 3 months sciatic nerve function was absent in 3 of 11 rats anastomosed by only CO2 laser, however, sciatic nerve functions were found to be normal in the other two groups. PMID- 10150673 TI - The use of high-power lasers in oral surgery. AB - This study describes the treatment of 2989 patients with different type of lasers. The argon laser beam was used in 57 cases for procedures ranging from portwine stains, telangiectasias, and angiofibromas to other vascular lesions. Eighty-four operations including treatment of leukoplakia and hemangioma were performed using the Nd YAG laser. An additional 53 operations were performed using the combined Nd:YAG laser beam and 2795 operations were done using the carbon dioxide laser on precancerous states and other white lesions, benign tumors and tumor-like states, malignant tumors, and other lesions. The laser procedures were performed under local anesthesia. Operations were rapid and bloodless yielding both excellent cosmetic and functional results. The experience gained with this group of patients suggests that the ideal cases for laser treatment were leukoplakia, hemangiomas, and other vascular tumors and lesions of the face and the oral cavity, and clotting disturbance. PMID- 10150674 TI - Clinical studies of carbon dioxide laser etching. AB - Carbon dioxide (CO2) lasers are capable of altering the physical and chemical properties of enamel. Using repetitively pulsed modes, it is possible to produce surface irregularities that resemble those resulting from etching of enamel with orthophosphoric acid. The present report presents the results of a split mouth clinical study that compared laser etching and acid etching. The clinical success rate for laser etching (98.9%) was comparable to that for acid etching (98.9 vs. 98.5%, respectively; mean follow-up 9.7 months, range 3-24 months). These studies demonstrate that CO2 laser etching may provide a viable alternative to acid etching for particular applications such as fissure sealing. PMID- 10150675 TI - The problem of the L5-S1 disc solved by needle entry with an extrathecal approach. AB - The author describes a posterior, extrathecal approach to the L5-S1 disc for percutaneous laser disc decompression that is safe, simple, and without neurologic sequelae. The conclusion is that the extrathecal approach is safe and preferable to repeated unsuccessful attempts to enter the L5-S1 disc with a curved needle. PMID- 10150676 TI - Functional Aqualaser sinuscopy: a safe technique for the treatment of severe nasal polyposis. AB - All degrees of sinonasal polyposis now can be surgically treated with minimal bleeding, no packing, and no vasoconstrictors. The Aqualaser technique uses warmed isotonic irrigation to produce vasoconstriction of the mucosa and to clear the field of debris and secretions. This results in an improvement in visualization of the anatomical landmarks and of the pathologic process(es) present. The contact YAG laser is used as a heating element. This "laserized water" results in "cooking" of the polyps (controlling the bleeding) prior to gently coddling away the abnormal tissues with Aquadissection (warm water dissection). The instrumentation used and the technique is explained. Over 2,000 procedures were reviewed resulting in no major ocular or intracranial complications. PMID- 10150677 TI - A comparison of the benefits of roller pump versus constrained vortex pump in adult open-heart operations utilizing outcomes research. AB - The purpose of this study was to compare roller pump and centrifugal pump technologies in routine adult open-heart operations to demonstrate the usefulness of applying a proven method of uniform risk stratification (outcomes research). Objective and readily available preoperative patient data was collected retrospectively on 102 non-randomized and consecutive adult open-heart operations. Group 1 consisted of 51 adult open-heart operations utilizing a roller pump for arterial blood perfusion. Group 2 consisted of 51 adult open heart procedures utilizing a constrained vortex pump for arterial blood perfusion. A comparison between the frequency of occurrence of 53 different preoperative risk factors in the roller pump group and the centrifugal pump group found no statistically significant differences (p < 0.05). Outcome data for the roller pump and centrifugal pump groups included such data comparisons as intensive care unit length of stay (LOS), post operative LOS, total LOS, total patient charge, reimbursement, morbidity, and mortality, which revealed no statistically significant differences (p < 0.05). Further comparison studies of roller pumps versus centrifugal pumps for arterial blood perfusion should incorporate this kind of comprehensive data comparison and analysis to reasonably assure that both pump groups are very similar before outcomes research is performed. PMID- 10150678 TI - Predicting oxygenator clinical performance from laboratory in-vitro testing. AB - Knowledge and predictability of oxygenator performance is vital to safe and effective conduct of cardiopulmonary bypass. The determination of oxygenator performance in the laboratory, however, is carried out under a strict set of conditions established by the Association for the Advancement of Medical Instrumentation (AAMI). This performance data is of limited value in the clinical setting where the perfusionist generally operates outside this set of parameters. This study (1) reports the laboratory performance characteristics of a hollow fiber membrane oxygenator (Sorin Monolyth), (2) uses this data to develop a model to predict performance under a wide range of clinical conditions, (3) compares predicted performance with clinical data collected at two open heart centers, and (4) reviews the complexities of comparing laboratory and clinical performance. An in-vitro "oxygenator-deoxygenator" circuit was utilized to determine O2 and CO2 gas exchange, blood path pressure drop, and heat exchanger efficiency at a variety of blood and gas flows, under standard (AAMI) blood inlet conditions: [table: see text] This laboratory performance data was compared to hospital and computer modeling data. Simple numerical comparison and analysis of variance of regression coefficients over groups indicated that some clinical parameters of performance (oxygen transfer and coefficient of heat exchange) were not predicted with the laboratory data. It is concluded that the laboratory performance data determined under strict controlled conditions may be of limited value in predicting clinical performance unless modeled to allow for variances in operating conditions. PMID- 10150679 TI - Nafamostat mesilate reduces blood cell adhesion to cardiopulmonary bypass circuits: an in-vitro study. AB - Nafamostat mesilate (FUT-175) is a protease inhibitor, working as an inactivator of coagulation, fibrinolysis and platelet aggregation. Although FUT-175 directly blocks contact factors in coagulation, it also may decrease activation of humoral cascade systems when used in cardiopulmonary bypass circuits. We performed an in vitro study using fresh human blood in the following cardiopulmonary bypass circuits: standard circuit (C), biosurfaced circuit (B) and standard circuit containing FUT-175 (F). Each circuit was primed with 500 ml of electrolyte solution and 500 ml of fresh blood. Cardiopulmonary bypass was performed using a roller pump for four hours in two sets of each circuit configuration. Platelet factors (platelet count and beta-thromboglobulin), coagulation factors (thrombin antithrombin III complex and fibrinopeptide A), fibrinolysis factors (alpha 2 plasmin inhibitor complex and alpha 2-plasmin inhibitor), complement factors (C3a, C4a), free hemoglobin, and granulocyte elastase were measured at the beginning and end of the study. Hemocytograms were measured concurrently. The FUT 175 group showed significantly lower levels of the measured indices than the biosurfaced group in thrombin-antithrombin III complex (7.4 +/- 2.1 vs. 54.9 +/- 38.1 ng/ml), fibrinopeptide A (7.2 +/- 2.0 vs. 20.2 +/- 14.6 ng/ml), beta thromboglobulin (1940 +/- 250 vs. 2438 +/- 314 ng/ml) and free hemoglobin (25.2 +/- 14.3 vs. 73.8 +/- 18.4 mg/dl). There were no significant differences between Group F and Group B in platelet count, C3a, C4a and granulocyte elastase, although these indices were significantly lower in Groups F and B when compared to Group C.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150680 TI - Innovations in intra-aortic balloon pump management: computer modem technology. AB - The computer modem technology being developed by Datascope Corporation for the purpose of off-site intra-aortic balloon pump (IABP) monitoring was clinically evaluated in 30 patients requiring IABP support. The Datascope System 95 model IABP with built-in modem was used on all patients. Remote communications via a personal computer with modem were conducted under both routine and emergency settings. The Datascope PC IABP software was evaluated for its user compatibility, efficiency, diagnostic capability and overall usefulness as a clinical tool. During the eight month evaluation period, 87 remote communications were conducted for both routine and emergency IABP evaluation checks. Adjustments were recommended on 22 occasions relevant to balloon timing, trigger mode selection and augmentation volume settings. Eight communications were initiated in emergency settings due to a variety of patient conditions. Emergency intervention was successful in diagnosing and resolving critical situations including atrial arrhythmias, pacemaker timing, low cardiac output syndrome, loss of trigger source, catheter malpositioning and poor augmentation. The diagnostic capabilities and efficient means of data collection by the computer software provide the clinician with a valuable tool for routine IABP clinical monitoring, as well as emergency problem resolution. PMID- 10150681 TI - Comparative study of five blood cardioplegia systems. AB - Five blood cardioplegia delivery systems (Gish Straight Shot, Sorin BCD Advanced, Avecor MYOtherm, Baxter-Bentley HE-30, and Baxter-Bentley HE-30 Gold) were evaluated with respect to ease of rapid priming, coefficient of heat exchange, pressure drop, bubble trap capacity, and priming volume. Each system was placed in a roller pump circuit consisting of source and collection reservoirs, cardioplegia solution, and pre-post system pressure and temperature monitoring sites. A trial was performed on four units of each brand by first priming the circuit with 0.9% NaCl at 200 ml/min. Bovine blood (hematocrit 22%) was then introduced simulating use during bypass. Pressure drops across the heat exchanger were measured at flows of 200, 300, and 400 ml/min and at temperatures of 37 degrees, 19 degrees, and 4 degrees C. Coefficient of heat exchange was determined at 300 ml/min flow. Air was infused into the system to quantify the bubble trap capacity of the heat exchanger module. Priming volume of the entire system and of the heat exchanger module were determined by draining each into a graduated cylinder. The Sorin system had significantly less priming volume when compared to all others. The HE-30 units had significantly higher heat exchange coefficients compared to all other systems. Variability was noted in pressure drop at the highest flows and lowest temperatures. PMID- 10150682 TI - Continuous venous oximetry: a comparative study between the CDI 100 and the Bentley OxySat II. AB - Two in-line oxygen saturation monitors, the CDI 100 and OxySat II, were evaluated in the clinical setting. Eighty-seven venous blood samples were drawn during 20 elective cardiopulmonary bypass procedures. Monitor readings were compared to OSM III co-oximeter values. The results revealed that saturation (%) determination was biased, -3.16 +/- 2.21 SD for the CDI 100 and -0.34 +/- 2.17 SD for the OxySat II. Hemoglobin (g/dl) and hematocrit (%) measurement, available only for the CDI 100, resulted in a bias of +5.54 +/- 5.68 SD and +1.94 +/- 1.78 SD, respectively. It was concluded that both monitors operated within clinically acceptable limits, with a more favorable outcome for the OxySat II. PMID- 10150683 TI - In vitro evaluation of continuous mixed venous oxygen saturation and hematocrit monitors. AB - Four venous hemoglobin oxygen saturation monitors, two of which provide hemoglobin monitoring, were evaluated and compared to a performance standard (control) during cardiopulmonary bypass (CPB). The CDI 100 Hematocrit/Saturation Monitor, CDI 400, Cobe Hematocrit/Saturation Monitor, and the Baxter Bentley OxySat values were compared to the Radiometer Copenhagen OSM3 Hemoximeter and the Damon International Equipment Company Microbore Centrifuge Hematocrit. The Bentley OxySat meter was found to be the most accurate venous oxygen saturation monitor, with the CDI 100 and the Cobe Hct/Sat monitors correlating closely with the control. Only the CDI 400 failed to correlate with the control. The hematocrit monitors, although useful as trending devices, demonstrated inaccuracies in measurements requiring further refinement. PMID- 10150684 TI - Comparative analysis of recovery of cardiopulmonary bypass residual blood: cell saver vs. hemoconcentrator. AB - For surgical bleeding problems, the cell saver has been used to return shed blood; however, overuse can lead to a deficit in coagulation factors. Its usefulness has gained widespread use in many surgical settings. The hemoconcentrator can aid in raising the hematocrit level while reducing blood utilization where large blood volume and/or large amounts of irrigation are returned to the perfusion circuit. The hemoconcentrator returns red blood cells without removing coagulation factors, unlike the cell saver. In order to determine which method of returning residual blood from the cardiopulmonary bypass circuit is more desirable, blood samples were drawn both pre and post transfusion from 15 cell saver patients, and 14 hemoconcentrator patients. Twelve hour blood loss was recorded in 40 patients within each group. The fibrinogen, platelet count, total protein, albumin and white blood cell count were similar between the two groups, as was the blood loss. The only significant differences found were the post red blood cell count, post hemoglobin, and the delta hematocrit, all being higher in autotransfusion group. In conclusion, returning blood through the hemoconcentrator in the average adult perfusion circuit was not able to significantly raise certain coagulation parameters, nor reduce postoperative bleeding. PMID- 10150685 TI - Evaluation of a rapid infusion system. AB - Operative cases where there is a potential for massive blood loss necessitates a system to rapidly warm and transfuse large volumes of blood over short periods of time. An in-house system in which both crystalloid solutions and blood products can be quickly added, warmed and available for infusion was developed to meet this need. The purpose of this study was to evaluate how blood products are affected when warmed and recirculated for an extended period of time. A recirculating rapid infusion system was assembled utilizing two filtered cardiotomy reservoirs, a centrifugal pump, a stainless steel blood heat exchanger, and 1/4 inch tubing, and applied in six adult orthotopic liver transplantations. The system was primed with 2 to 4 units each of fresh frozen plasma and packed red blood cells. The prime was recirculated and warmed to 37 degrees C. Samples for blood gases, oxygen saturation, hematocrit, plasma free hemoglobin, sodium and potassium levels were drawn after initial priming and then every 30 minutes until additional blood products were added. Results show no significant change in pH (6.57 +/- 0.21), pO2 (56 mmHg +/- 23 mmHg), pCO2 (173 mmHg +/- 138 mmHg), hematocrit (27% +/- 8.7%) and plasma free hemoglobin values (125 mg/dl +/- 9.4 mg/dl), following 3 hours of recirculation. However, potassium levels significantly decreased from 11.6 meq/L +/- 2.6 meq/L to 10.0 meq/L +/- 2.3 meq/L (p < 0.05), sodium levels significantly increased from 144 meq/L +/- 5.9 meq/L to 147 meq/L +/- 5.3 meq/L (p < 0.05) and oxygen saturations significantly increased from 59% +/- 9.1% to 70% +/- 16% (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150686 TI - Low back pain: cost-effective diagnosis and treatment. AB - This systematic approach to low back pain limits the use of imaging studies and surgery. The natural history of this condition and its resolution show that such modalities are best restricted to a minority of patients. PMID- 10150687 TI - Current status of alternative health practices in the United States. PMID- 10150688 TI - At last: a unified schedule for childhood immunization. PMID- 10150689 TI - Recurrent pain syndromes in children: a streamlined approach. AB - Healthy-appearing children with recurring aches or pains are a frustrating part of pediatric practice. The authors share their 20-year experience in a diagnostic dilemmas clinic, helpful hints from the literature, and a simplified approach that uses checklists to streamline diagnosis and treat children with nonorganic syndromes. PMID- 10150690 TI - Imagination training: a tool with many uses. AB - Guided imagery, self-hypnosis, and related strategies can help improve patient comfort during medical procedures. Use them to relieve pain and nausea, control heightened anxiety and phobias, and generally make the office visit easier for everyone. PMID- 10150691 TI - Onward and upward with managed care. AB - Pediatricians are among the big gainers from managed care, according to the latest Medical Economics Continuing Survey. These findings will let you compare your managed-care participation and earnings with those of your colleagues. PMID- 10150692 TI - Outcomes and obstacles of urodynamics. AB - Urodynamic testing provides information on bladder function and bladder outlet and sphincteric competence. The author explains when patients should be referred and provides some insight into these tests. PMID- 10150693 TI - Remodeling for Peyronie's disease with implants. AB - Surgical correction of penile deformity and use of an implant can be effective, but both patient and urologist must be aware of the potential drawbacks of this approach. PMID- 10150694 TI - Optimizing treatment for middle and distal ureteral calculi. PMID- 10150695 TI - Aminoglycoside nephrotoxicity: keys to prevention. AB - The kidneys are the primary site of aminoglycoside clearance; any factor that permits renal parenchymal accumulation increases the risk of aminoglycoside nephrotoxicity. The most common underlying cause is excessive aminoglycoside administration (especially in women or elderly patients). To minimize the risk of nephrotoxicity, select loading and maintenance aminoglycoside dosages based on estimated creatinine clearance. Also, monitor peak and trough serum aminoglycoside levels, replenish volume, and correct potassium and magnesium abnormalities. If possible, avoid giving aminoglycosides to patients with hepatic dysfunction or to those receiving other nephrotoxic drugs or radiocontrast agents. PMID- 10150696 TI - The technique of percutaneous transthoracic needle aspiration biopsy. AB - Consider percutaneous transthoracic needle aspiration biopsy when specimens of pulmonary malignancies or infections are needed and bronchoscopy is contraindicated or the lesion is in a peripheral location. Percutaneous needle aspiration biopsy can be performed rapidly, and its diagnostic yield is good to excellent. The chief limitation of this procedure is the high incidence of pneumothorax, which makes the technique unsuitable for ventilated patients. A needle is inserted through the chest wall under fluoroscopic or CT guidance; a small sample is then aspirated through the needle. Operator skill and the use of thin needles help reduce the incidence of complications. PMID- 10150697 TI - Techniques for ventilating patients with obstructive pulmonary disease. AB - In patients with obstructive lung disease, a strategy of mechanical ventilation that prolongs expiratory time and limits lung hyperinflation can decrease barotrauma. To prolong expiratory time, decrease minute ventilation and inspiratory time. Side effects of this strategy--high peak pressures and hypercapnia--are generally well tolerated. Additional goals for COPD patients include resting and strengthening respiratory muscles and decreasing load on the respiratory system. Short-acting benzodiazepines and morphine are effective for sedation and analgesia. Paralytic agents should be considered only if adequate control of the patient's cardiopulmonary status cannot be achieved by sedation alone. PMID- 10150698 TI - Pulmonary embolism in the critically ill: strategies for prevention and treatment. AB - Most ICU patients are at high risk for developing deep venous thrombosis; thus, they should be considered candidates for prophylaxis against pulmonary emboli (PE). If early ambulation is not an option, give low-dose heparin or apply lower extremity pneumatic compression. When PE cannot be prevented, rapid treatment is mandatory. Inotropic agents can be used to improve right ventricular contractility; however, the role of volume loading for augmenting preload is controversial. Heparin is the first-line therapy for halting ongoing thrombosis; administer a 5,000- to 10,000-U bolus, followed by a continuous infusion of about 35,000 U/d. Thrombolysis, embolectomy, and occlusive devices are other therapeutic options. PMID- 10150699 TI - How to identify the cause of antibiotic-associated diarrhea. AB - Most cases of antibiotic-associated diarrhea are due to Clostridium difficile or are of enigmatic etiology. The antibiotics most often implicated are clindamycin, ampicillin or amoxicillin, and the cephalosporins. Clinical signs of antibiotic associated diarrhea may be limited to watery stools; however, evidence of colitis (fever, cramps, leukocytosis, fecal leukocytes) suggests C. difficile infection. The tissue culture assay for C. difficile toxin remains the gold standard for diagnosis, but the enzyme immunoassay is a practical and reasonably accurate alternative. Anatomic changes, such as pseudomembranes, can be confirmed with endoscopy, but such evaluation is not required for diagnosis of C. difficile associated pseudomembranous colitis. PMID- 10150700 TI - The technique of pleurodesis. AB - Pleurodesis may be indicated for pleural effusions (with careful patient evaluation) or recurrent pneumothoraces. It is contraindicated if tube thoracostomy fails to reexpand the lung and, possibly, if patients are candidates for lung transplantation or have congestive heart failure. We perform pleurodesis through an indwelling chest tube (alternative methods are thoracoscopy and thoracotomy). Common sclerosants include talc, doxycycline, minocycline, and bleomycin. Intrapleural administration of lidocaine may control pain, but injections of morphine or meperidine almost always are needed. PMID- 10150701 TI - Children in war and its aftermath: mental health issues in the development of international law. AB - Children now experience war as they never have in the past. This article presents clinical impressions of children from war zones and suggests interventions that might ameliorate the horrors of war for some of these children. It also describes the evolving framework in international law (i.e., the United Nations) that provides a context for implementing some of these interventions and for insulating children from some of the devastating effects of war. PMID- 10150702 TI - Damage awards and jurors' responsibility ascriptions in medical versus automobile negligence cases. AB - Many critics of the tort system have accused juries of assessing larger awards against defendants perceived to have the ability to pay. Juries are said to be particularly prone to go after the 'deep pockets' of doctors in medical malpractice cases as compared to defendants found negligent in automobile accidents. This hypothesis was put to a test in an experiment that manipulated cause of the injury (medical malpractice versus negligent driving) and degree of possible contributing responsibility by the plaintiff (mandatory versus elective surgery and plaintiff as another driver or as a passenger). Responsibility ascriptions to the plaintiff differed across conditions, but jurors did not differentially award pain and suffering damages across conditions. PMID- 10150703 TI - Posttraumatic stress disorder among battered women: analysis of legal implications. AB - The diagnosis of posttraumatic stress disorder (PTSD) has recently been applied to the psychological experiences of victims of intimate violence, including physical and sexual assault. The use of trauma theory to explain battered women's responses to violence has laid a foundation for expert testimony on PTSD, where relevant, within more general testimony concerning partner violence. This article discusses the relevance of the PTSD diagnosis within the legal context for explaining battered women's responses to violence. PMID- 10150704 TI - Managed mental health care. PMID- 10150705 TI - Caring about patients and caring about money: the American Psychiatric Association code of ethics meets managed care. AB - Although the medical profession's codes of ethics have rightly been criticized for having claimed authority to decide questions of medical ethics for society, codes continue to provide crucial guidance to the individual clinician in matters of ethics. Examination of the code of the American Psychiatric Association (APA) shows that while it emphasizes the psychiatrist's fiduciary responsibility to individual patients, it ignores the crucial dimension of stewardship responsibilities to society. As a result, the ethical pronouncements of the APA have thus far been of little use to clinicians with regard to the major issues posed by managed care. In contrast, the code of the National Association of Social Workers considers the ethics of social institutions as well as those of individual practitioners, and advises clinicians on how to manage the inevitable and legitimate tensions between fiduciary and stewardship commitments. Until the APA extends the scope of its ethical vision, it will not be able to help clinicians struggle constructively with the question of how it is possible to "care about patients" and "care about money." PMID- 10150706 TI - Eavesdropping on the 50-minute hour: managed mental health care and confidentiality. AB - This article discusses managed care, recent case law developments, and the legal basis of confidentiality in the patient-therapist relationship. It discusses how managed care intrudes into the confidential treatment relationship with prospective and retrospective utilization reviews. Some of the areas adversely impacted include public policy, the patient-therapist relationship, and informed consent. In order to be a program in the interest of patients and not simply cost containment, managed care must accommodate patients' reasonable expectations of confidentiality. Suggestions are delineated for the protection of confidentiality by managed care, including expanding the duty of confidentiality to managed care, obligating managed care to secure patients' informational privacy, obtaining informed consent to disclose as little information as necessary, and involving the patient in the cost containment and quality assurance process. PMID- 10150707 TI - Managed mental health care and professional compensation. AB - Managed care and organized systems of care are restructuring the delivery of care in the United States. As care is reorganized, physician practice styles, autonomy, and compensation are undergoing profound changes. To successfully integrate physicians into the new managed systems of care, their organizational relationship to and their compensation within these systems must be carefully considered. This paper first explores physician motivation as it is related to compensation. The paper then describes a variety of emerging organizational designs aimed at aligning the interests of physicians and hospitals. The author considers fully integrated, physician-hospital organizations with target income compensation arrangements to be most suitable to the collective success of professionals and organized systems of care. The paper concludes with a discussion of the many dilemmas and challenges posed by the intertwining of managed care, organized networks of care, and professional compensation. PMID- 10150708 TI - Serious mental illness and capitation financing. AB - Traditional organization and financing of mental health care has not adequately served the needs of persons with serious mental illness. Capitation financing is being tested in several localities, but little experimental data has been yielded to date, and it is mixed. The results from the Rochester experiment were positive but limited, and some other pilots also reported positive experiences with capitation. Others have ended prematurely or confronted obstacles. Experimental findings are also anticipated from the Philadelphia and California pilots, and others are just beginning. Existing financing mechanisms, cost-shifting efforts, and professional cultures represent powerful obstacles to successfully implementing capitation financing for care of persons with long-term mental illnesses, and potential incentives to underserve enrollees require adequate accountability structures. In spite of obstacles, the goodness of fit between the needs of persons with serious mental illness and capitation flexibility warrant further exploration of this financing modality. PMID- 10150709 TI - Patients' interpretations of verbal expressions of probability: implications for securing informed consent to medical interventions. AB - Physicians often use verbal expressions of probability to characterize their uncertainty about outcomes and the risks or side effects of proposed therapies. However, there is an extensive literature that documents the inherent vagueness of such expressions. Because of the potential importance of probability terms to physician-patient communication and decision-making, we asked patients to tell us the odds they thought applicable to the term "rare," as used by their physician to discuss the likelihood of an adverse outcome from surgery. Patients were randomly assigned to one of three outcome groups: death, severe heart attack, or severe pneumonia. Demographic data were elicited from each subject, as were indicators of present health status, medical history for certain diseases and surgery, and life expectancy. Linear regression and ANOVA analyses of the responses indicate that patient age, education level, perceived health status, and recency of experience with disease and medical care influence patients' numeric interpretations. We discuss the implications of these results. PMID- 10150710 TI - Announcement of the 1994 C. Everett Koop Awards for outstanding health care programs. PMID- 10150711 TI - Creating a smoke-free hospital: attitudes and smoking behaviors of nurses and physicians. AB - PURPOSE: To assess smoking prevalence and attitudes of physicians and nurses before a smoking ban. The relationship between pre-ban attitudes and post-ban smoking behavior was also studied. DESIGN: This is a prospective descriptive study of a cohort of nurses and physicians who were surveyed six months before and six months after a ban on smoking was implemented. SETTING: A large, 1,000 bed teaching hospital in the Northeast of the United States. SUBJECTS: All full time members of the medical (n = 1,496) and nursing staff (n = 1,500) were surveyed. The overall response rate for the cohort was 41% for physicians and 39% for nurses. MEASURES: Surveys included standardized questions on current smoking behavior, and sociodemographic variables. Attitudes toward quitting and the smoking policy and attitudes about implementation and enforcement of the smoking ban were included. RESULTS: Both physicians and nurses were supportive of a smoke free policy, but the two groups differed significantly on attitudes related to implementation and enforcement, with nurses being more accommodating toward smoking and less likely to enforce a ban on smoking. Physicians were more likely than nurses to quit smoking after implementation of the ban. Pre-ban attitudes were not predictive of post-ban changes in smoking behavior. CONCLUSIONS: Physicians and nurses agreed with establishing a smoke-free environment but disagreed over the efforts needed to maintain the smoke-free environment. Quitting behavior was not influenced by pre-ban attitudes. PMID- 10150712 TI - Relationship between cumulative exposure to health messages and awareness and behavior-related drinking during pregnancy. AB - PURPOSE: This paper describes the relationship between exposure to multiple sources of health messages about the risk of drinking during pregnancy and respondents' awareness and behavior related to this risk. DESIGN: Observational study using telephone interview data. SETTING: Exposure to this message occurs via a government warning on alcoholic beverage containers, warning posters in restaurants and bars, and media advertisements. SUBJECTS: Representative nationwide samples of adults were interviewed in 1990 (n = 2,000) and 1991 (n = 2,017), with response rates of 64% and 62%, respectively. MEASURES: Outcomes assessed are knowledge of the alcohol-related risk of birth defects, conversations about drinking during pregnancy, and self-reported reduction of alcohol consumption due to health concerns. RESULTS: Multivariate logistic regression models were used. In the total sample, respondents exposed to one, two, and three different message sources were more likely to converse about drinking during pregnancy than those exposed to no messages (odds ratio = 2.6, 3.8, and 4.1, respectively), while reduced alcohol consumption due to health concerns associated with exposure to two and three different sources (odds ratio = 1.6 and 2.0, respectively). Among women aged 18 to 40, a similar relationship is found for conversations, but it was only among those seeing all three message types that a reduction in consumption was observed (odds ratio = 2.8). Interpretation of these findings are limited because of respondent bias in alcohol consumption, message source exposure, and the cross-sectional nature of the data employed. CONCLUSIONS: These findings support the public health approach of implementing multi-faceted strategies to maximize risk reduction interventions. PMID- 10150713 TI - Grassroots efforts pursue alcohol policy reform: refocusing upstream in New Mexico. AB - ORGANIZATION SETTING. The New Mexico Alcohol Issues Consortium (NMAIC) originated in January 1989 as a grassroots effort to focus on the reduction of driving-while intoxicated (DWI) in New Mexico. It was the brainchild of three state health department officials and grew to include in its membership representatives from education, medicine, law enforcement, neighborhood associations, business, and local and state government. RATIONALE. New Mexico ranks at or near the top in several alcohol-related statistics, including motor vehicle fatalities, cirrhosis, and alcoholism. Furthermore, the 'alcohol environment' in New Mexico included the allowance for the purchase of alcoholic beverages at drive-up windows, lax enforcement of DWI laws, and even state legislators with DWI records. Theoretical bases upon which NMAIC goals and strategies were based include the public health model, the public health/dynamic systems, model of alcohol and other drug use, and 'refocusing upstream,' all of which give attention to the environment as a determinant of health status. IMPLEMENTATION. While the NMAIC's activities addressed a variety of alcohol-related problems in New Mexico, the bulk of the organization's efforts for four years were directed toward increasing the excise tax on alcohol, either as a statewide measure or via county-level local option referenda. Strategies which were enacted to support this legislative activity included collaboration with other programs and organizations with similar DWI-prevention goals, and staged media events to solicit public support. IMPACT. In four years, the NMAIC had established itself as a credible organization which was successful in publicly and systematically challenging existing alcohol policies in New Mexico. The NMAIC was also instrumental in empowering individuals and communities to speak and act against the alcohol problems in their own communities. Finally, during the 1993 New Mexico Legislative Session, a bill was passed which mandated a statewide excise tax increase on alcohol. For its efforts, the NMAIC has won one national level award and one state level award for its contribution to the public health of New Mexico. DISCUSSION. The NMAIC is now pursuing passage of the local option version of the excise tax increase bill, because it could generate up to three times as much revenue as the new statewide increase. Additionally, Consortium members have escalated discussions regarding nonprofit status for the NMAIC, and developing a more formal mechanism for determining leadership. Members continue their participation in trainings on community organizing, media advocacy, and alcohol policy reform. PMID- 10150714 TI - Simulated lifetime costs of three types of employer-based, periodic, breast cancer screening programs for working-age women. AB - PURPOSE: To estimate the lifetime cost of three types of employer-sponsored breast cancer screening programs and to identify factors influencing cost. DESIGN: A computerized decision analysis model was constructed to compare lifetime costs of providing breast cancer screening in each of three screening programs: on-site within an employer, mobile unit visiting the employer, and off site. SUBJECTS: Three hypothetical cohorts of 10,000 female employees 38 years of age at time of first screening. INTERVENTION: A cohort was enrolled in each screening program and received screening from age 38 through age 64. Employees continued to receive benefits related to breast cancer until age 100 or death. MEASURES: Costs in the model included those for screening, workup for a suspicious mammogram, treatment for breast cancer, short-term losses in employee productivity, and disability due to breast cancer. APPROACH: The model was used to estimate the mean lifetime cost per employee, to the employer, of the On-Site program. This cost was compared to the cost of the other programs. RESULTS: Mean lifetime cost per employee was $5,485 for the On-Site screening program. This cost was significantly (P < .0001) lower than in the Off-Site program (by $311) or the Mobile program (by $212). The baseline results for the On-Site program were quite sensitive to the cost of screening, the sensitivity and specificity of screening, age at initiation of screening, and the underlying incidence of breast cancer in the population. CONCLUSION: Employers and other entities should consider these factors such as location and content in selecting the most efficient and effective breast cancer screening program. PMID- 10150715 TI - The Minnesota Heart Health Program community Quit and Win contests. PMID- 10150716 TI - Assessing the validity of a survey of the restaurant health promotion environment. AB - Our primary question was whether a telephone survey of restaurant personnel could provide accurate community-level measures of the restaurant health promotion environment. An obvious concern was that restaurant personnel might exaggerate the extent to which their establishment had a positive health promotion environment. Comparison with the most obvious "gold standard"--direct observation -showed fairly accurate reporting about nonsmoking seating arrangements, but restaurant personnel exaggerated the extent to which menu items were designated as low in fat. We also compared the restaurant-survey measures of nonsmoking seating availability at the community level with measures of the restrictiveness of local no-smoking ordinances. We found a positive relationship, as expected, between measures of the restrictiveness of ordinances and the amount of nonsmoking seating indicated by the restaurant survey. PMID- 10150717 TI - Participation in a telephone-based tobacco use prevention program for adolescents. PMID- 10150718 TI - Factors which explain amount of participation in rural adolescent alcohol use prevention task forces. AB - Project Northland task force members are typically female, have children, and belong to a number of other community or social groups. Members were likely to participate more in the task forces if they were relative newcomers to the community and if they got satisfaction from their participation. While explaining only a modest amount of the variance (15.5%), the explanatory power of the results are comparable to other studies of this nature, where 23% of explained variance predicting participation has been considered informative. Future models will need to consider other factors to increase the explained variance. Satisfaction with being a task force member was associated with the amount of control and ownership each member felt and the extent of agreement with the direction of the task force. These variables explained 26% of the variance. It may be that relative newcomers to the community, who tended to participate more, have lived elsewhere and been exposed to environments where alcohol was less frequently used, and this contrast contributed to their motivation and preparedness to work towards change. They may not be as integrated into the community as task force members who have lived in their communities for their entire lives, and may not be part of the dominant "alcohol culture" that exists in the region. If membership in community or social groups is an indicator of integration into the community, then the results suggest less integrated task force members were more active participants.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150719 TI - Effect of a brief retailer intervention to reduce the sale of single cigarettes. AB - A surprising finding from the present study was the occasional retailer practice of giving singles away upon confederates' requests to purchase singles. This practice was not expected, and additional data related to its occurrence (i.e., under what circumstances it occurred) were not collected. Although the prevalence of giving away singles was not high (approximately 6% of stores at pretest and 3% at posttest), the practice raises concern in that it may greatly facilitate experimental smoking and undermine cessation attempts. Availability (i.e., sales and giving) of single cigarettes dropped significantly during the four-month period of this study (34% to 10%), suggesting that a brief educational intervention followed by a "booster" mailing of materials effectively reduced single cigarette availability. The overall reduction in availability of singles was also seen for the two store types individually. It is noteworthy, however, that at both assessments, liquor stores were more likely than independent markets to have singles available. The finding that location of singles changed from on top of and behind the counter to exclusively behind the counter indicated that retailers may have become aware that providing singles is illegal, and made attempts to be less obvious about their availability. Although the ultimate goal was to completely eliminate the availability of single cigarettes, the change in location may be positive in that impulse buying could be diminished when singles are hidden. PMID- 10150720 TI - Impact of a daily 10-minute strength and flexibility program in a manufacturing plant. AB - In summary, employees' flexibility and mood showed modest improvements following the implementation of a plant-wide, 10-minute, daily flexibility and strength program. The initial six-week pilot study, administered prior to the plant-wide program implementation, successfully assessed program feasibility, assessed the efficiency of program implementation, identified administrative and logistical concerns, and generated pilot data needed to secure managerial support. Despite the noted significant increases in grip strength in the pilot study, no increases were observed following the six months of plant-wide implementation. This may be related to the differences in low average pretest grip strength for the pilot study compared to the higher scores for the main study population. The pilot study subjects may have received a sufficient exercise stimulus to increase grip strength over the course of six weeks. In contrast, this may not have been the case for the main study subjects due to their higher initial mean grip strength. An increased number of exercises designed to directly impact grip strength may be needed to improve this parameter. PMID- 10150721 TI - Ten years of anti-smoking programs in Italy: a review. AB - A diverse anti-smoking program for the prevention of cancer and cardiovascular diseases has been ongoing in Italy since 1981, coordinated by the National Cancer Institute of Genoa and the Italian League Against Cancer of Genoa. The program includes several initiatives addressed to different target groups; schoolchildren and teachers, military personnel, doctors and nurses, and women. A preliminary inquiry on the attitudes and habits towards smoking was implemented by the distribution of questionnaires to the various groups involved in the program. An annual school-based anti-smoking program involves about 10,000 students aged four to 18 and their teachers. Meetings are delivered by experts to groups of 20 to 40 students with the aid of specific audiovisual material, which are periodically updated. Additional informative material, leaflets, and posters are distributed to both schoolchildren and teachers. Another educational program on primary prevention of smoking-related health hazards is addressed to military recruits, career soldiers, and medical officers. It consists of several initiatives: training of military doctors and nurses, lectures to military recruits, and distribution of informative material in the barracks. An annual meeting is organized to discuss program implementation and results. Surveys are carried out by distributing an anonymous questionnaire to health professionals in several Italian hospitals to assess the smoking habits of doctors and their attitudes and practices towards counseling patients against smoking. The results show marked differences in smoking habits in the cities under study. Annually since 1983, an updated course is organized and addressed to teachers of primary and secondary schools in Genoa. The aim of the course is to train school personnel and to help them to implement prevention programs in the schools, with the aid of experts in the field of prevention. A series of initiatives are addressed to women at different ages to sensitize them not only to the more common tobacco risks but also those regarding pregnancy, oral contraception, and so on. The survey was conducted on a representative sample of 12- to 65-year-old female population groups. It is the first of this kind in Italy to ascertain trends in smoking behavior among Italian women in relation to age, educational achievement, and occupation. PMID- 10150722 TI - Cigarette smoking control strategies of firms with small work forces in two Northeastern States. AB - PURPOSE: Cigarette smoking control strategies of firms with small work forces were assessed and compared with those of larger firms. DESIGN: A cross-sectional telephone survey was conducted in 1990 among private employers systematically selected from a proprietary database. SETTING: These firms were located in four counties of two northeastern states. SUBJECTS: Interviews were conducted with managers of 470 small (< or = 25 employees; n = 262), medium (26-50; n = 87), and larger (> 50; n = 121) firms. MEASURES: Interviews assessed characteristics of the firms and their cigarette smoking policies and cessation programs. RESULTS: Small firms differed from larger firms in several areas. They were less likely to have written policies, used fewer methods to communicate their policies, and their policies were consistently less restrictive. Small firms also offered less assistance to employees who wished to quit. CONCLUSIONS: The less restrictive smoking policies reported here may be relatively ineffective in protecting nonsmokers in small firms. Small firms may encounter difficulties introducing more restrictive smoking policies because of the relative closeness of employee relations, smaller work spaces, and inability to deliver smoking cessation services to employees. Methods should be developed to assist managers of smaller firms to implement stronger smoking policies and to devise ways of making cessation assistance more easily available to their employees. PMID- 10150723 TI - Diffusion of innovations in schools: a study of adoption and implementation of school-based tobacco prevention curricula. AB - PURPOSE: The purpose of this study was to determine the extent of implementation of school health education curricula, to identify factors which enhanced or impeded implementation, and to examine the link between the adoption and implementation phases of the diffusion process. DESIGN: The study used an experimental design; 22 school districts were randomly assigned to intervention and control conditions. SETTING: The study was conducted in North Carolina. SUBJECTS: All teachers in the study districts identified by their schools as "eligible to teach health" were included in the sample. INTERVENTION: An in-depth training was conducted on the use of the middle school tobacco prevention curriculum that had been adopted. MEASURES: Three measures were used to assess implementation of the curricula. Independent variables of interest included organizational size and climate, teacher training, how long it took to make the adoption decision, and attitudes toward tobacco use prevention curricula. Response rates for these measures ranged from 44% to 78%. RESULTS: Nonparametric correlations and regression modeling indicated that larger organizational size and teacher training were the strongest predictors of curricula implementation. A favorable organizational climate within school districts also improved implementation. CONCLUSIONS: While interventions to increase adoption of school health education curricula should focus on larger school districts, the majority of efforts to improve implementation should focus on smaller districts. PMID- 10150724 TI - Psychometric testing of the reduced Laffrey Health Conception Scale. AB - PURPOSE: Laffrey's Health Conception Scale (LHCS), an instrument designed to measure personal definitions of health, was reduced with the intent of creating a useful yet less cumbersome version of the LHCS. DESIGN: The original form of the LHCS was tested in a preliminary study, and results were used as a basis for the reduction of the instrument. The original clinical and new overall wellness subscales were subsequently tested with a larger population of manufacturing plant workers. SETTING: One chemical plant and three Midwestern manufacturing plants. SUBJECTS: The sample for the preliminary study comprised 94 chemical plant workers. For the larger study, the sample comprised 892 subjects; because this instrument was part of a larger questionnaire to identify predictors of workers' use of hearing protection, only those workers who spent some part of their work time in areas of the plant which required hearing protection use were eligible to participate. MEASURES: The original LHCS was used in the preliminary study. The reduced LHCS was used in the larger study and psychometrically evaluated. RESULTS: The reduced LHCS accounted for 51% of the variance in definition of health; all but one item had loaded on one of the two factors with a loading of .41 or greater. The revised LHCS demonstrated excellent internal consistency. Two distinct factors, the clinical subscale and the overall wellness subscale, were isolated. CONCLUSIONS: The researchers recommend the reduced LHCS be used for assessing subjects' definition of health; the reduced instrument requires fewer items, and therefore less time, to measure individuals' definitions of health with excellent reliability. PMID- 10150725 TI - A commentary on minority health as a paradigm shift in the United States. PMID- 10150726 TI - The Massachusetts Farmers' Market Coupon Program for low income elders. PMID- 10150727 TI - Cigarette smoking among Vietnamese immigrants in California. PMID- 10150728 TI - The impact of a videotape on smoking cessation among African-American women. AB - The African-American female smokers identified stress, pleasure, and addiction as the reasons that they smoked. These reasons were similar to those provided by the other smokers. The African-American female smokers reported greater addiction to nicotine than the other smokers, as indicated by greater incidence of smoking within 30 minutes of waking. The African-American female smokers also identified with the characters depicted in the videotape more strongly than did the other smokers. African-American female smokers identified behavioral coping strategies as those that they would use in their quit attempts more frequently than did the other smokers. Cessation rates were similar for the African-American females and other smokers. Although low, the 9.7% reported cessation rate, or the 4.6% conservative cessation rate estimate, is higher than the 3% 3-month quit rate observed among a group of 50 African-American female smokers living in South Central Los Angeles during the same time period who were not participating in a quit-smoking program. Therefore the present data suggest an effect above mere testing. PMID- 10150729 TI - A debunking of the myth of healthy Asian Americans and Pacific Islanders. AB - PURPOSE: To present evidence that the model of healthy Asian Americans and Pacific Islanders (AAPIs) stereotype is a myth. SEARCH METHOD: The authors retrieved literature from the National Library of Medicine's compact disk databases (Cancerlit, CINAHL, Health, and MEDLINE), and examined pertinent federal government publications supplemented by the authors' knowledge of other published materials. IMPORTANT FINDINGS: This review paper presents three reasons why AAPIs are underserved: (1) the population growth rate has been unusually rapid and recent; (2) data regarding the health status of AAPIs are inadequate; and (3) the myth that AAPIs are model minority populations in terms of their health status was promulgated. MAJOR CONCLUSIONS: The conclusions are as follows: (1) AAPIs are heterogenous with respect to demographic factors and health risk factors; (2) because the current databases on the health status of AAPIs include small sample sizes, both the quantity and quality of these data need to be improved with respect to appropriate gender and ethnic group representation; (3) Risk factor and mortality data for AAPIs suggest that the burden of certain preventable diseases, namely, tuberculosis, hepatitis-B, liver cancer, and lung cancer may be higher than those of any other racial and ethnic population. The model healthy AAPI stereotype is a myth. PMID- 10150730 TI - Use of cultural themes in promoting health among Southeast Asian refugees. AB - PURPOSE: Vietnamese, Cambodian, and Hmong refugee populations in the United States face serious physical and psychosocial health issues. Literature on these populations is largely descriptive of illnesses and of cultural beliefs or behavior patterns related to illness. There is minimal literature linking beliefs and behaviors to the underlying cultural themes. The purpose of this paper was to search the literature for cultural themes from which culturally relevant health promotion strategies could be designed. SEARCH METHODS: Literature was reviewed from the fields of health, social, and political science, history, and Southeast Asian folklore. Search methods included review of 147 writings from library and MEDLINE search and 123 interviews with refugees and key professionals in the field. This manuscript includes 106 selections as well as content from 93 interviews. FINDINGS AND CONCLUSIONS: From the literature emerged two cultural themes common to these population, kinship solidarity and the search for equilibrium. The use of these cultural themes as carriers of health messages is suggested. Examples of ways to link the message with the cultural theme are presented, including the use of folklore, recognition of cultural illnesses, and use of cultural knowledge in addressing new situations such as inner city urban survival. Cultural themes are a means of conveying health messages addressing such issues as transition in family structure, depression, and substance abuse. PMID- 10150731 TI - Health promotion and African-Americans: from personal empowerment to community action. AB - PURPOSE: Self-help among African-Americans is that tradition of individual and group efforts aimed toward racial progress and defending against a hostile society. The purpose of this paper is to encourage African-Americans, regardless of income, to take personal responsibility for their health. This review discusses each side of the individual versus societal responsibility issue and provides a rationale for integrating these two perspectives. It argues that the tradition of community-based self-help among African-Americans is a mechanism for personal empowerment that can lead to collective action; it therefore has important implications for the improvement of African-American health. SEARCH METHODS: The search made use of a computer-based inquiry with self-help, community health empowerment, and African-American or blacks used as descriptors. We also used a computerized search by the last names of key authors writing in the area of minority health. The review was limited to references between 1964 and 1994. The review also relied on our own professional libraries. Finally, 15 knowledgeable individuals employed at universities around the country were queried about their work, focusing on this subject. They were asked about their perceptions of the issues pertinent to the role of personal and societal responsibility in modifying health behaviors of African-Americans. SUMMARY OF IMPORTANT POINTS: Effective health behavior change strategies with black populations will require an integration of personal responsibility and advocacy for social systems change. The formation of effective self-help community-based coalition partnerships is viable strategy for forging systemic changes to address the health disparity problem. MAJOR CONCLUSIONS: The discussion concludes that blacks should hold themselves more personally responsible for solving their own problems while rejecting debilitating forms of extreme self-blame. Affiliation with self-help organizations and community coalitions for health empowerment is offered as a strategy for community infrastructure development with potential for improving quality of life. PMID- 10150732 TI - Prevention of alcohol misuse: a review of health promotion efforts among American Indians. AB - PURPOSE: The purpose of this review is to provide an overview of a wide range of potentially useful strategies to address the prevention of alcohol misuse among American Indians. This broad approach to the review is useful because the extreme heterogeneity of the American Indian population requires that health promotion professionals explore many options and tailor their activities to specific communities. SEARCH METHOD: A literature search was initiated through MEDLINE using the following key words: prevention, alcohol, substance abuse, American Indian, and Native American. The search yielded 29 articles from the years 1982 through 1994. These articles, along with 45 previously identified in three overview articles, form the basis of the review and discussion in this paper. SUMMARY OF FINDINGS: As a group, American Indians experience many health problems that are related to alcohol misuse. Comparison of Indians to non-Indians shows that the age of first involvement with alcohol is younger, the frequency and amount of drinking is greater, and negative consequences are more common. Health promotion programs that address these issues must take into account American Indian heterogeneity and should use a comprehensive approach that addresses both heavy drinking and the sequelae of problems related to alcohol misuse. MAJOR CONCLUSIONS: Important concepts for providing health promotion services to this population are: cultural relevance must be carefully planned and monitored; individuals in the local community must be involved; the drunken Indian stereotype must be addressed; and community empowerment should be an important goal. PMID- 10150733 TI - Meeting the health promotion needs of Hispanic communities. Policy and Research, National Coalition of Hispanic Health and Human Services Organizations (COSSMHO). AB - This paper conducts a review of the demographic and health status data for Hispanic communities and relates them to the role of culture in health care. The author's recommend that promotion programs for Hispanic communities should focus on specific community data (morbidity rather than mortality), understand the impact of culture and language (cultural competency training and staffing), develop strong outreach components (establish community advisory boards, identify credible community spokespersons and incorporate community residents as health educators), and work in partnership (sharing funds and resources) with community based organizations. PMID- 10150734 TI - 3-D CT aids planning of craniofacial surgery. PMID- 10150735 TI - CTA offers alternative in carotid angiography. PMID- 10150736 TI - Managed-care contracts take skillful negotiating. PMID- 10150737 TI - Assessment of adaptive transportation technology: a survey of users and equipment vendors. AB - In order to define the state of adaptive transportation equipment, wheelchair users with spinal cord injury (SCI) and equipment vendors were surveyed about equipment, funding, maintenance, and repair. SCI registries from two states, Virginia and Arkansas, were used to create the sample pool of users and 225 responses were received. A list of equipment vendors and vehicle modifiers was compiled from several national resources, and 123 responses were received from 36 states. User respondents were generally satisfied with their adaptive equipment, which typically required only minor inexpensive (< $100) repairs, if any. Personal or family money was used by over 90% of the respondents for equipment funding. Vendors reported that a substantial amount of custom modification or fabrication of equipment is required to meet the needs of their clients. Lifts, external controls, and six-way power seats were cited by vendors as the equipment requiring the most frequent repair. The survey results provide an examination of the opinions and experiences of users and vendors of adaptive transportation equipment, which should prove useful to those involved in evaluating equipment, equipment availability, and the need for industry-wide standards. PMID- 10150739 TI - Selection of rural assistive technology using a HyperCard-based knowledge system. AB - Resources and expertise on selecting assistive technology appropriate for an agricultural work setting are scarce. To meet this need a prototype knowledge system for the selection and documentation of rural assistive technology (BNG DATA) was developed to aid professionals working with farmers, ranchers, and agricultural workers with physical disabilities. The knowledge system consists of a hypertext database of technology examples and a decision support system that helps users identify solution alternatives to meet consumers' needs. End-user acceptance of BNG DATA was determined through field trials and an evaluation questionnaire administered to staff of the U.S. Department of Agriculture's AgrAbility Project. Using a statistical experiment in conjunction with the questionnaire, it was concluded that BNG DATA significantly reduced the time required by end users to find acceptable solution alternatives for consumers and increased the end users' confidence in the solutions they obtained. This manuscript describes the development and testing of BNG DATA, focusing on the selection of appropriate technology. PMID- 10150738 TI - Measuring quality and performance of assistive technology: results of a prospective monitoring program. AB - A crucial need in assistive technology delivery is follow-up to determine device performance and satisfaction from the individual with a disability's perception. As part of an overall research project on technology transfer, this investigation was designed to measure and document service delivery outcomes, first in a pilot study at the Rehabilitation Engineering Center (REC), Lucile Salter Packard Children's Hospital at Stanford (LSPCH) with 60 consumers and then in a replication study in four other service delivery centers providing devices to 103 clients. One hundred sixty-three devices were delivered to 163 consumers by five service delivery centers. The results of this investigation indicate that user feedback can be documented through prospective and standardized data collection forms; outcome measures can be helpful in determining user satisfaction and device performance; user responses, compared with clinician evaluations, are reliable perceptions of device performance; provision of the selected assistive devices was demonstrably positive for the majority of device users; and for those individuals not initiating return visits, the phone-call follow-up provided information that would not have been available otherwise to the service providers. PMID- 10150740 TI - The need for information on assistive devices by older persons. AB - Analyzing the results of the first 110 interviews from the Rehabilitation Engineering Research Center on Aging's Consumer Assessments Project, this study examined subjects' responses to the question, "Can you think of a device you would like to have that you haven't been able to find--a device that may not have yet been developed?" Each response was compared to the results of a Hyper ABLEDATA search for similar existing products. When asked to propose a new device, 43 subjects (39% of the sample) responded with suggestions. In all instances, however, the respondents suggested devices that are already available. These findings indicate that subjects did not have up-to-date or complete information on the assistive devices that could improve their quality of life. PMID- 10150741 TI - Design of hand-held remotes for older persons with impairments. AB - The University at Buffalo Rehabilitation Engineering Research Center on Aging (RERC) developed two prototype television remote control devices (remotes), designed to address the needs of older persons with some visual and/or fine motor impairment. The prototype remotes have large buttons, large numbers and characters on the buttons, and high color contrast between the buttons and background. One remote has 15 buttons, and one has 6 buttons. The purpose of this study was to test these prototype remotes against two commercially available remotes for user speed, accuracy, and satisfaction. One of the commercially available remotes has small buttons and small print but more features than the prototype remotes; this device came with the television used in the study. The second commercially available remote has somewhat larger buttons, but still smaller than the ones on the RERC prototypes. Thirty elders with impairments participated in testing the remotes in a simulated living room setting. The order in which the remote devices were presented to the subjects was randomly determined. Results indicated a significant difference among remotes in number of errors made; subjects made the fewest number of errors on the 15-button prototype remote. There was no significant difference among remotes in speed. There were significant differences in user satisfaction: users preferred the 15-button prototype device. Subjects were asked if they would rather have more features and small buttons on their remote, or fewer features and larger buttons; almost three fourths of the sample desired fewer features and larger buttons. PMID- 10150742 TI - Evaluation of a device to exercise hip extensor muscles in children with cerebral palsy: a clinical and field study. AB - This research includes the effectiveness of a tricycle (hip extensor tricycle) designed to isolate and exercise the hip extensor muscles in children with cerebral palsy. Five children diagnosed with cerebral palsy were given hip extensor tricycles for home use during an 8-week test period. The hip extensor strength and gait pattern of the subjects were recorded at 2-week intervals. Additional recorded information included the time and duration of subject use and a parent evaluation that noted subjective physical and psychological improvements. A panel of experts judged that the gait patterns of four subjects improved during the course of the study. There was an assignable cause for the lack of improvement in the fifth subject. The results of the strength testing were found to be inconclusive. The subjects used the device on a regular basis and enjoyed doing so. Parent evaluations indicated that the use of the hip extensor tricycle improved the subjects' physical condition, coordination, sense of accomplishment, and self esteem. It is recommended that future research implement a longer test period along with improved hip extensor strength measurement methods and focus on improvements in evaluation of gait and physical condition. PMID- 10150743 TI - A new augmentative communication device. PMID- 10150744 TI - Positioning and securement of riders and their mobility aids in transit vehicles: an analytical review. AB - Individuals are transported daily in transit vehicles while seated on their mobility aids. Although federal standards exist to regulate this practice, controversy exists over whether the regulations are effective or practical. This article describes an objective and analytical review of information available in several areas relevant to positioning and securing riders and their mobility aids in transit vehicles. The objective of the study was to present the current status of knowledge and to identify gaps in knowledge and related problems. As a result, recommendations are provided on future research needs and options for improvement of policy. PMID- 10150745 TI - Assistive technology research: is our time running out? PMID- 10150746 TI - Review of the efficacy and effectiveness of adaptive seating for children with cerebral palsy. AB - The purpose of this article is to review the published research evidence for the efficacy and effectiveness of adaptive seating in the management of children with cerebral palsy. This review is undertaken to determine whether adaptive seating outcomes proposed in the clinical literature have been substantiated. The literature search was confined to English-language publications between 1982 and 1994. Thirty-seven research studies were identified through: 1) on-line search of Index Medicus, Cumulative Index to Nursing and Allied Health Literature, and Psychological Abstracts; 2) scanning conference proceedings and article reference lists; and, 3) tracking of author citations through the Science Citations Index. Eight studies met the selection criteria of using subjects who were children with cerebral palsy, including adaptive seating as an independent variable, and including an unsupported sitting comparison condition. Study quality was evaluated using an adaptation of Sackett's validity criteria. Sackett's classification system was utilized to identify levels of evidence and to grade recommendations. Grade A, B, and C recommendations were generated from Level I to Level V evidence for some of the clinically proposed seating outcomes. Additional seating research is required to strengthen the recommendations and investigate unexplored outcomes. Limitations of the review are potential reviewer and publication bias. PMID- 10150747 TI - Development of a physical characteristics assessment (PCA): a checklist for determining appropriate computer access for individuals with cerebral palsy. AB - The physical characteristics assessment (PCA), a newly developed illustrated checklist, is designed for use by allied health and education professionals to identify a viable method for an individual with cerebral palsy to access a computer. The PCA was developed in response to a documented void of such assessments in the literature. The value of PCA was assessed with respect to content validity, clinical utility, reliability (inter-rater), and opinion of persons with cerebral palsy and health and education professionals. Professionals (n = 72) and persons with cerebral palsy (n = 78) from 20 sites in Canada, Chile, England, Israel, Spain, and the United States participated in the study. Statistically, the PCA produced a highly significant (p < 0.001) assessment time savings compared with non-PCA methods. A statistically significant difference in the number of user/computer interface changes during five post-assessment computer training sessions was not shown between the PCA and non-PCA methods. Inter-rater reliability ranged between 90% and 100% (n = 33 pairs). Both persons with cerebral palsy assessed via the PCA and professionals using the PCA gave positive opinions. Overall results support the value of the PCA. PMID- 10150748 TI - Evaluating outcomes in assistive technology: do we understand the commitment? AB - Evaluating assistive technology (AT) services to demonstrate quality or to measure outcomes is the ethical obligation of the entire AT community. Accountability must be accepted by all stakeholders in order to evaluate all aspects of service delivery. Developing an integrated system will require addressing issues that the AT community has not previously had to face. These challenges have been highlighted. PMID- 10150749 TI - An evaluation of grab bars to meet the needs of elderly people. AB - This paper reports the findings of a study that evaluated the ability of 66 ambulatory and 50 nonambulatory older people to toilet independently and safely. A repeated measures research design included eight test trials in which participants got on and off a toilet using four different grab bar configurations each at two different toilet seat heights. Each trial was video-taped in order to determine patterns of grab bar use for each toilet height/grab bar configuration. In addition, pretrial and posttrial interviews were conducted to determine participant preferences and perceived safety. Results of this study indicate that some grab bar configurations that were not code-compliant were preferred and were used more often than configurations that were designed to meet Americans with Disabilities Act Accessibility Guidelines. These findings raise questions as to whether legally mandated grab bar requirements are appropriate for older individuals. PMID- 10150750 TI - Demonstrating a model approach to independent living center-based assistive technology services. AB - This project examined the effectiveness of an assistive technology preventive maintenance service for consumers. Sixteen independent living centers that offer mobility equipment repair services for consumers were surveyed. Thirty-seven consumers and 22 vendors supplying mobility equipment and repair services within the Houston area were interviewed. Problems identified included lack of available services to maintain mobility equipment in good working order, no centralized information and evaluation system, denials of needed equipment by third party payers, and high equipment costs. A collaborative effort between the Independent Living Research Utilization Research and Training Center on Independent Living at The Institute for Rehabilitation and Research in the Texas Medical Center, and the Houston Center for Independent Living designed and implemented a model preventive maintenance service--The Wheelchair Maintenance Clinic. Evaluation after the first year of operating the clinic showed 111 service visits were delivered to 50 consumers. Consumers reported high levels of satisfaction with the service. PMID- 10150751 TI - Consumer participation in identifying research and development priorities for power wheelchair input devices and controllers. AB - A focus group comprised of persons who use power wheelchairs and professionals working in the field were asked to participate in a brainstorming session to determine priorities for the development and application of power mobility input devices and control concepts. The group consensus was that durability and reliability are the most important criteria. Essentially, the expectation is that a power wheelchair must work everyday in the way a person needs it and wants it. At the same time, there is a desire to enhance and advance the features of input devices and control systems. Many would say these changes constitute designing "smarter" power wheelchairs, such as systems that can independently detect obstacles and can provide users with more feedback. This paper presents the rationale behind forming this focus group and details of the results of a brainstorming session where ideas were generated and prioritized. The five most important issues as determined by the group are discussed in depth. PMID- 10150752 TI - Intensive care in developing countries. PMID- 10150753 TI - Intensive care in Nigeria: problems and prospects. PMID- 10150754 TI - Six standard panels for hepatoviral diagnosis. AB - From the many available tests for hepatoviral diagnosis the most reliable and established were incorporated into a series of panels. Six groups or batteries of tests are proposed, each directed to one clinical question. These are hepatitis B detection and chronic hepatitis B monitoring, hepatitis detection and chronic hepatitis monitoring, as well as a hepatitis and chronic hepatitis monitoring, as well as a hepatitis screening panel for blood banks and an immune status panel to determine individual immune status and risk. This approach limits the number of immuno-diagnostic tests needed and simplifies laboratory workflow. The limitations, including specificity problems encountered with tests based on the polymerase chain reaction (PCR), and probable future developments of tests excluded from the simplified panel concept are discussed. PMID- 10150755 TI - Vascular access in neonates and infants--indications, routes, techniques and devices, complications. AB - Venous cannulation has been in regular use in neonates since the 1940s. This was at first through the umbilical vein, but the frequency of complications lead to other central and peripheral routes being used for infusion of fluid, nutrients and drugs. Today, peripheral venous access is preferred except for high volume fluid resuscitation, reliable infusion of irritant drugs and long-term parenteral nutrition. Intraosseous infusion provides a reliable alternative to peripheral veins for rapid infusion of fluid. Long, thin silastic catheters can be inserted through a peripheral venous cannulae for parenteral nutrition or other central venous infusions as an alternative to direct central venous cannulation using the Seldinger or other techniques. Broviac or Hickman catheters, inserted through a subcutaneous tunnel are only considered when central venous cannulation is likely to be needed for more than six weeks. The most common serious complication of vascular access is infection. Infection associated with central venous catheters is reduced by prophylactic vancomycin or teicoplanin. Other complications of central venous infusion are associated with cannulae malpositioning, bleeding and thrombosis. Distal hypoperfusion may follow arterial cannulation. Modern emergency and intensive care paediatrics is impossible without adequate venous and arterial vascular access. However no other skill for neonatal intensive care causes more anxiety in primary care providers or is more difficult to teach. PMID- 10150756 TI - Oxygenator evaluation: Maxima 1380 versus Maxima Plus. AB - Continual improvement of oxygenators has been important in the growing demands of patient safety and support during cardiopulmonary bypass. The purpose of this study was to compare the Maxima 1380 oxygenator to the upgraded Maxima Plus oxygenator. Thirty-two adult patients were randomized to either the 1380 group or the Plus group. Information was recorded on the patients' weight, age, body surface area, esophageal temperature, arterial temperature, venous oxygen saturation, arterial pO2, arterial pCO2, blood flow, hematocrit, gas sweep, and FiO2. No significant difference was found between the two groups' mean weight, body surface area, arterial pO2 arterial pCO2, age, esophageal temperature, arterial temperature, venous oxygen saturation, and blood flow (p > 0.05). The Plus group demonstrated significantly lower mean gas sweep rates and FiO2 settings than the 1380 group. FiO2 of the 1380 was dependent on age, body surface area, blood flow, and esophageal temperature (r = 0.89, p < 0.001). FiO2 of the Plus was correlated with weight, esophageal temperature, arterial temperature, and arterial pO2 (r = 0.93, p < 0.001). Gas sweep rate of the 1380 was dependent on age, weight, esophageal temperature, blood flow, arterial temperature, and arterial pCO2 (r = 0.84, p < 0.001). The gas sweep rate of the Plus was dependent on weight and esophageal temperature (r = 0.55, p < 0.001). Based on these analyses, the new Maxima Plus oxygenator is more efficient in oxygen and carbon dioxide transport than the Maxima 1380. PMID- 10150757 TI - A perfluorocarbon emulsion prime additive improves the electroencephalogram and cerebral blood flow at the initiation of cardiopulmonary bypass. AB - Depression in electroencephalogram (EEG) has been documented clinically and is reproducible in swine at the initiation of cardiopulmonary bypass (CPB) utilizing a crystalloid prime. The physiological cause of this transient alteration in electrical brain activity appears to be associated with the transient drop in arterial pressure. The etiology is unknown but may be attributable to the bolus of the crystalloid prime or micro emboli, either air or fibrin-platelet. Thirteen swine (17-26 kg) were anesthetized and received 4 mg/kg dexamethasone, and following a tracheotomy were ventilated with halothane in 100% O2. Surgical preparation included: sternotomy and preparation for right atrial-aortic CPB. The CPB circuit consisted of a hollow fiber membrane oxygenator, a hard-shell venous reservoir, a roller pump, and PVC tubing. The circuit was randomly primed with either 1200 ml Plasmalyte-A or 10 ml/kg perfluorocarbon emulsion (PFE) and Plasmalyte-A to total 1200 ml. The animals were monitored continuously for systemic hemodynamics and electrocardiogram, and cerebral monitoring included blood flow and bitemporal EEG. Arterial blood gases were measured and PaCO2 was kept between 30-45 mmHg both before and during CPB. Cerebral blood flow (CBF) was measured pre-CPB and at 10 minutes after initiation of CPB. Bitemporal computerized EEG was analyzed every 60 seconds. Total power of each hemisphere, power in frequency bands, and spectral edge were recorded. All animals demonstrated a relative decrease in EEG total power at the onset of CPB. Animals that received PFE demonstrated a more stable arterial blood pressure, an increased CBF, and a lesser decrease and an earlier recovery of the EEG power.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150758 TI - Comparing today's revascularization strategies for CAD. Benefits and drawbacks of thrombolytics, PTCA, CABG. AB - A number of factors must be considered when selecting a revascularization strategy for a patient with CAD: Is the patient's condition stable or unstable? How many vessels are affected? What are the benefits and drawbacks of each technique? For patients with an evolving infarction, either thrombolysis or PTCA can achieve early reperfusion. PTCA is also often helpful for those with one- or two-vessel disease; however, restenosis develops in 30% to 50% of patients, usually within 6 months. Although CABG can produce excellent long-term results for patients with three-vessel or left main artery disease and for those with proximal stenosis, the risk of perioperative complications and bypass graft disease remains significant. PMID- 10150759 TI - Is there a role for gastric tonometry in critical care? Weighing the evidence for and against the procedure. AB - Gastric tonometry is a noninvasive technique for early detection of splanchnic ischemia. Some studies have found that measurement of intramucosal pH (pHi) is able to predict outcome in critically ill patients. However, factors unrelated to splanchnic ischemia (for example, the presence of acid-base disorders or an intraluminal source of carbon dioxide) may skew results. Furthermore, accurate pHi measurement requires administration of an H2 blocker 60 to 90 minutes before patients undergo the procedure. Therefore, the role of gastric pHi in guiding therapy remains undefined. PMID- 10150760 TI - Understanding the neurohumoral causes of anxiety in the ICU. Clinical consequences include agitation, brain failure, delirium. AB - Severe anxiety can disrupt neurohumoral metabolism and lead to agitation and brain failure, which may result in delirium. Predisposing factors include cerebral vascular or endocrine insufficiency, cardiopulmonary decompensation, poor tissue perfusion, multiple medications, and sleep-wake cycle disruption; the stressful ICU environment puts patients especially at risk. Stress-induced noradrenergic hyperactivity can precipitate panic attacks; dopaminergic hyperactivity can lead to delirium (marked by paranoid delusions, visual or auditory hallucinations, and psychomotor agitation). The underlying cause of anxiety must be identified to guide appropriate therapy. PMID- 10150761 TI - The technique of tracheotomy and cricothyroidotomy. When to operate--and how to manage complications. AB - Tracheotomy can relieve upper airway obstruction, improve pulmonary hygiene, and support long-term mechanical ventilation. Consider performing a tracheotomy whenever the need for more than 14 days of ventilatory support is anticipated. When emergent airway access is needed and translaryngeal intubation is not possible, consider cricothyroidotomy. For a tracheotomy, make a transverse incision 1 cm above the suprasternal notch or, for cricothyroidotomy, through the superficial cricothyroid membrane. Accidental tube displacement within 5 days of surgery is potentially tracheotomy's most lethal early complication. Many late complications can be prevented by careful management and expert nursing support. PMID- 10150762 TI - Hemodynamic changes with initiation of veno-venous bypass in orthotopic liver transplant patients. AB - Removal of the liver to start the anhepatic stage of liver transplantation requires cross-clamping of the portal vein, inferior vena cava, and hepatic artery. Adverse effects occur from engorged splanchnic beds and decreased venous return. A veno-venous bypass from the inferior vena cava and portal vein to the axillary vein is used in an attempt to ameliorate these changes. The purpose of this study was to evaluate the effect of institution of veno-venous bypass on hemodynamics. Eight randomly selected adult patients undergoing orthotopic liver transplantation had general anesthesia induced with thiamylal and maintained with nitrous oxide and isoflurane. Cardiopulmonary data and arterial and mixed venous blood gases were measured prospectively using radial artery and pulmonary artery catheters. Measurements were taken under four conditions: (1) 10 minutes before bypass; (2) after partial bypass (vena cava to the axillary vein); (3) after partial bypass with portal vein clamping; and (4) after full bypass (vena cava and portal vein to the axillary vein). Statistically significant changes seen were a 22% decrease in cardiac output and a 47% increase in systemic vascular resistance (SVR). Bypass flow was lower than predicted. Venovenous bypass ameliorates, but does not fully prevent, the reduction of cardiac output and rise in SVR seen with initiation of the anhepatic stage. However, bypass does prevent the hypotension experienced during cross-clamping and for these reasons should be used routinely. PMID- 10150763 TI - Church-based health promotion: an untapped resource for women 65 and older. PMID- 10150764 TI - Low-intensity smoking cessation intervention among African-American women cigarette smokers: a pilot study. PMID- 10150765 TI - Social relationships and physical activity in health club members. AB - The results of this study support the hypothesis that social variables are related to exercise behavior and satisfaction. Exercise frequency was related to having friends at the health club and socializing outside the club with people met at the club. Frequency of skipping workouts was negatively associated with having friends at the club. The results shown in Table 2 suggest that of the three social variables, socializing outside the club with people met at the club was the best predictor of exercise frequency, having friends at the club was the best predictor of frequency of skipping, and exercising with a friend was the best predictor of exercise satisfaction. The three social variables explained 11% of the variance in exercise frequency, 8% of the variance in skipping frequency, and 4% of the variance in satisfaction. These findings suggest that friendships that involve exercising together and the social contacts that result from exercising in public places such as health clubs may motivate exercise behavior. A large segment of the population may derive social, as well as physical, benefits from exercise, and these social benefits may encourage them to adhere to their exercise programs. The significant interaction of marital status and socialization with people met at the club in the prediction of exercise frequency suggests that social interaction may be a more important motivator of exercise behavior for single people than for people who are married or have significant others. Exercise programs involving social interaction may be especially effective for single, divorced, or widowed people. PMID- 10150766 TI - Smoking in Europe; facts and figures. PMID- 10150767 TI - Fruit and vegetable intake in the United States: the baseline survey of the Five A Day for Better Health Program. AB - PURPOSE: The purpose of the Five A Day Baseline Survey was to assess fruit and vegetable intake and associated factors among US adults. DESIGN: Questionnaires querying frequency of intake of 33 fruits and vegetables, as well as demographics, attitudes, and knowledge related to fruits and vegetables were administered by telephone. SETTING: The study was a nationally representative random digit dial survey conducted by telephone in the summer of 1991; response rate was 42.8%. SUBJECTS: Respondents were 2811 US adults (including an oversample of African-Americans and Hispanics). MEASURES: Mean and median self reported intakes of fruits and vegetables were calculated. Estimated servings per week were adjusted on the basis of responses to summary questions regarding overall fruit and vegetable intakes. RESULTS: Median intake of fruits and vegetables was 3.4 servings per day. Linear regressions (accounting for no more than 10% of the variation) showed that education, income, and smoking status were predictors of fruit and vegetable intake and that intake increased with education, income, and nonsmoking status. Women had higher intakes than men at all ages; these differences between men and women increased with age. Fruit and vegetable intakes increased with age for whites and Hispanics, but not for African-Americans. CONCLUSIONS: Fruit and vegetable intake among adults in the United States is lower than the recommended minimum of five daily servings. These data will be useful in targeting campaign efforts and in assessing progress of the Five A Day for Better Health Program. PMID- 10150768 TI - Effect of a hospital nonsmoking policy on patients' knowledge, attitudes, and smoking behavior. AB - PURPOSE: To explore patients' knowledge of and attitudes toward a hospital nonsmoking policy and to examine changes in patients' smoking behavior before admission and after discharge. DESIGN: Patients were surveyed by mail 1 week after hospitalization. SETTING: A 379-bed Boston tertiary teaching hospital. SUBJECTS: Seven hundred twenty-six patients were surveyed. There were 337 respondents, yielding a response rate of 59%. OUTCOME MEASURES: Policy knowledge, policy satisfaction, and smoking cessation assistance. Smoking status was assessed retrospectively by self-report 1 week before admission and at the time of the survey. RESULTS: Bivariate and multiple logistic regression techniques were used to explore relationships among explanatory variables and outcomes. Knowledge of the policy was fair, although satisfaction with the policy was high. Twenty percent of patients reported that they had quit smoking at the time of the survey; 53% of quitters said they quit because of the policy. Thirty-nine percent of patients reported receiving assistance from medical providers, and 88% were satisfied with this help. Smoking cessation assistance was not associated with quitting but was related to smoking less (p < 0.02). CONCLUSIONS: A hospital nonsmoking policy was well accepted by patients and may have had a favorable impact on patients' smoking behavior. Because intervention by health care providers was limited but appeared to be effective, smoking cessation assistance programs need to be developed and implemented in other hospitals so that these results can be generalizable. PMID- 10150769 TI - Review of spiritual health: definition, role, and intervention strategies in health promotion. AB - PURPOSE OF THE REVIEW. Recognition of the spiritual dimension as a vital component of human wellness has led to an increased interest in spirituality education, yet very little progress has been made in identifying possible intervention methods for enhancing spirituality. The purpose of this article is to review current definitions of spiritual health; provide an overview of several successful intervention methods that may enhance spiritual health; and outline potential relationships between spiritual health interventions and behavioral, emotional, and physical health outcomes. SEARCH METHOD USED. Research and review articles were identified through a CD-ROM computer search of ERIC (1966 to 1994), PSYCHLIT (1974 to 1994), and MEDLINE (1991 to 1994) databases using appropriate key words. Cumulative indexes from Advances (1984 to 1993) were manually searched, and reference lists from identified studies and literature reviews were analyzed. A total of 71 articles were identified and considered. Model interventions were chosen for presentation on the basis of soundness of research design, peer-review publication, clear description of intervention method, and relationship to spiritual health components. SUMMARY OF IMPORTANT FINDINGS. Imagery, meditation, and group support activities may address various components of spiritual health such as meaning and purpose in life; self-awareness; and connectedness with self, others, and a larger reality. In turn, positive changes in health behaviors such as communication, diet activity, and treatment compliance were noted, and a variety of beneficial physical and emotional health outcomes such as heart disease reversal, decreased cancer mortality, reduced anxiety, and improved mood states were reported. MAJOR CONCLUSIONS. Health educators are in a position to develop, implement, and evaluate spiritual health interventions within the context of comprehensive programs. There is a need for training in the theoretical and methodologic foundations of interventions like meditation, imagery, and group support and a need for more evaluation research in the impact of such interventions. PMID- 10150770 TI - Impact of behavior management programs on exercise adherence. PMID- 10150771 TI - Basic principles of quantitative practice. PMID- 10150772 TI - Practical guides for the use of low flow and closed circuit anesthesia. Working Panel. PMID- 10150773 TI - Gas monitoring and uptake. AB - The breath-by-breath monitoring of anesthetic gases can provide information, beyond the usual safety control. The study of the decay and concentration effects along the circuit can be useful to evaluate their kinetics. The presence of unexpected gases coming from the patient's tissues is another important topic. By means of gas monitoring devices we can study the physiologic changes consequent to the modifications to the patient position, or the respiratory variations due to V/Q mismatching. The end-expired fraction of the anesthetic (FE') is not so close to MAC as first proposed in the 1960s, but it remains the most precise index of the depth of anesthesia. The traditional concept of quantitative anesthesia is still sufficiently actual to be considered in the design of new anesthesia machines. PMID- 10150774 TI - Experiences with the new inhalational agents in low-flow anesthesia and closed circuit technique. Monitoring and technical equipment. AB - During recent years interest has focused on two completely fluorinated ethers, desflurane and sevoflurane, which promise a shorter induction of and emergence from anesthesia. Their physicochemical properties differ from isoflurane, enflurane and halothane, thus requiring new technical equipment and leading to a change in anesthesiological procedures. Low-flow anesthesia with desflurane can be performed, the technical equipment is available, especially vaporizers and gas analyzers. In contrast to anesthesia with isoflurane, enflurane and halothane, the initial high-flow wash-in period with desflurane can be shorter and the vaporizer setting can remain unchanged after fresh gas flow reduction. In order to administer desflurane and sevoflurane in closed circuit technique, new technical equipment is needed. Therefore, a computer controlled anesthesia machine was modified and the feedback mechanism to maintain the end-tidal anesthetic concentration was simulated. Isoflurane, desflurane or sevoflurane needed the same time for wash-in. Wash-out was slower with isoflurane; however, the technical equipment should be adapted to increase the elimination of the new agents. The consumption of desflurane and sevoflurane is effectively reduced by low-flow and closed circuit anesthesia. PMID- 10150775 TI - From the theory to the practice of 'near-closed system' anesthesia. PMID- 10150776 TI - Xenon anesthesia: prerequisite for its use in a closed circuit system. PMID- 10150777 TI - Closed circuit anesthesia: preservation of the environment. AB - Closed circuit anesthesia must be considered as a primary contributor enabling to reduce the damaging effect of anesthetic agents on the environment. Halogenated vapors and nitrous oxide damage both the macro-environment, i.e. the earth's atmosphere layer and the micro-environment, i.e. the operating room ambience. As nitrous oxide is one of the most toxic agents, and as pure oxygen is harmful to the lungs, a technique of closed circuit anesthesia has been developed which employs oxygen/air (0.35:0.35 l/min) as a carrier of isoflurane. The safety of this oxygen-air technique of closed circuit anesthesia has been demonstrated by the greater stability of oxygen concentrations in the circuit in comparison to the more extensively used oxygen-nitrous oxide technique. PMID- 10150778 TI - An analysis of costs of closed circuit anesthesia in Italy (January-June 1992). PMID- 10150779 TI - Evaluation of the costs of anesthesia gases. PMID- 10150780 TI - Preimplantation echo Doppler evaluation of VVI versus DDD pacing. AB - This study was carried out to select before permanent pacemaker implantation patients with complete atrioventricular block (CHB) who would benefit best from DDD pacing, and to determine the optimal atrioventricular delay (AVD) for each of those patients. This was achieved with the aid of Doppler echocardiography. The effect of different AVDs on both the systolic and diastolic function of the normal and failing heart was also delineated in this study. METHODS: Thirty patients with CHB and normal sinoatrial function were selected, with no age or sex predilection. These patients were categorized into three equal groups: groups A, B, and C with normal left ventricular (LV) systolic and diastolic function, LV diastolic dysfunction, and LV systolic dysfunction, respectively. For each patient, systolic and diastolic function was calculated utilizing echo Doppler during CHB, temporary VDD pacing with different AVDs, and temporary VVI pacing with a rate matching that during VDD mode. Temporary VDD mode of pacing was performed utilizing a temporary bipolar ventricular lead for ventricular pacing and an esophageal lead for atrial sensing to trigger ventricular pacing. RESULTS: Qualitatively the most obvious change in the pattern of LV filling as AVD is increased in the three groups, is the earlier occurrence of active atrial filling A wave due to progressive approximation of the ECG P wave toward the previous QRS. As the AV interval is increased, the following changes occur: (a) A wave occurs progressively earlier with superimposition onto the early filling E wave resulting in a progressive increase in its velocity (VA), its FVI, and its percent atrial contribution (%AC); (b) the three times diastolic filling time (DFT), mitral valve opening to Q wave (MVO-Q), and closure (Q-MVC) progressively shorten; (c) since DFT decreases, less passive filling occurs early during diastole, thus E.FVI decrease with longer AV intervals; (d) the ratios VE/VA and FVI E/A decrease subsequently to the previous described changes. Compared to CHB, percent ejection fraction (% EF) was not significantly changed during VVI pacing. Percent EF increased significantly during VDD in comparison to VVI pacing modes. Percent EF was highest at optimal AVD and decreased as this AVD increased or decreased. The cardiac output (CO) increment during VDD in comparison to VVI pacing modes differed much among the three groups. In group A, a 10.29% increase in CO was seen when comparing VDD pacing (with optimal AVD) with that of VII one; in group B, this increment was much greater and reached 29.48%; in group C it reached 23.68%.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10150781 TI - The role of transesophageal echocardiography in the management of patients with acute and chronic pulmonary thromboembolism. AB - Acute and chronic pulmonary thromboembolism carry high mortality. The role of transesophageal echocardiography (TEE), however, has not been well delineated in patients with suspected pulmonary thromboembolism. The aim of the present study was to demonstrate the value of Tee in patients with various clinical manifestations of pulmonary thromboembolic disease. Twelve patients--ten males and two females, age 47-85 years--are presented in whom central pulmonary thromboembolism was found by TEE. Six patients were referred for breathlessness and had moderate to severe pulmonary hypertension (PH) with (3) or without (1) right atrial thrombus or had right heart dilatation (1) or right ventricular myxoma (1) on transthoracic echocardiography (TTE). Thrombolysis (2), surgery (2), and heparin (2) treatment was performed without angiography. All but one patient recovered. Six patients had severe PH by TTE, one of them had a right atrial thrombus. Angiography was done in five patients in whom surgery was considered. Pulmonary thromboendarterectomy was successfully performed in two patients, it was contraindicated in two patients for advanced age or severe left ventricular dysfunction, both patients died during follow-up, and two patients were waiting for surgery. IN CONCLUSION: TEE has a definite role in the management of patients with acute pulmonary thromboembolism or in pulmonary embolism associated with right-sided intracardiac masses and in the selection of patients with PH for pulmonary thromboendarterectomy. PMID- 10150782 TI - Noninvasive visualization of an apparent patent intracoronary stent by transesophageal echocardiography. AB - In the area of increasing interventional techniques there is a need for noninvasive imaging modalities to provide postinterventional follow-up. We were able to visualize the apparent patency and measure the dimensions of an intracoronary Palmaz-Schatz stent in the left circumflex coronary artery using transesophageal two-dimensional echocardiography. This report indicates the potential of echocardiography to directly assess coronary stents. PMID- 10150783 TI - Doppler color flow echocardiography: indispensable application to congenital heart disease. AB - Doppler color flow imaging has become indispensable in the diagnosis and management of patients with congenital heart disease. Certain defects may not be possible, or may be very difficult to diagnose by two-dimensional echocardiography alone. Such examples include multiple ventricular septal defects, anomalous pulmonary venous connection, coronary artery malformations, and the hypertensive patent ductus arteriosus. Additionally, color flow Doppler echocardiography significantly provides additional information, and reduces the time for fetal and transesophageal echocardiographic studies. Doppler color flow imaging has become an essential part of the echocardiographic examination. Experience has broadened the use of this important technological advance, with anticipation of an ever expanding future for its clinical application. PMID- 10150784 TI - Pulmonary venous flow as assessed by Doppler echocardiography: potential clinical applications. AB - During the past few years Doppler assessment of pulmonary venous flow has gained increasing interest. The growing experience with the use of transesophageal echocardiography, the approach that nearly always yields registrations adequate for quantitative analysis, has markedly contributed in this respect. The Doppler derived pulmonary venous flow pattern can be regarded as a measure of left atrial inflow and it augments the clinical significance of Doppler transmitral flow in the evaluation of diastolic left ventricular function. This article summarizes physiological background, possible applications, and limitations of Doppler echocardiography of pulmonary venous flow in clinical cardiology. PMID- 10150785 TI - How medical reviewers can avoid bad faith claims and ERISA violations. PMID- 10150786 TI - Health care fraud: a primer on the schemes and the tools to fight health care fraud. AB - As the national debate over health care reform moves forward, one issue with which policy makers must grapple is the percentage of health care dollars lost to fraud and abuse. The General Accounting Office estimates that as much as ten percent of total health care dollars are lost to the inappropriate, and in some cases criminal, practices of health care providers. This article discusses the characteristics of the health care industry that make it particularly susceptible to abuse and then reviews the efforts by the Office of Inspector General, Department of Health and Human Services, to deter and punish those who defraud the federal health care programs. PMID- 10150787 TI - Health system reform: from concept to action. PMID- 10150788 TI - Community based structure: an integrated approach to health system reform. PMID- 10150789 TI - Ankle/arm blood pressure index: an insurance perspective. AB - Recent studies conclude that the ankle/arm blood pressure index (AAI) is a useful clinical tool for refining cardiovascular risk classification in the elderly. A reduction in the AAI to 0.9 or less is associated with increased risk for both coronary heart disease and total cardiovascular disease morbidity and mortality, as well as all-cause mortality. This relationship persists after adjusting for traditional risk factors and known cardiovascular disease. AAI will appear more common in attending physician's statements, prompting a need to educate underwriters about this technology. AAI may be of particular interest to insurers dealing in the elderly market, to those with strong physician examiner systems, and in markets where blood or urine tests are not commonly used in underwriting. PMID- 10150790 TI - Carbohydrate deficient transferrin in alcoholism. PMID- 10150791 TI - Children with Kawasaki disease in Japan. PMID- 10150792 TI - Long-term mortality in patients after a British trial of anticoagulants in acute myocardial infarction. PMID- 10150793 TI - Risk of colorectal cancer following rectosigmoid adenomas. PMID- 10150794 TI - PPOs: key part of the Medicare solution. PMID- 10150795 TI - Billing by medical practitioners. PMID- 10150796 TI - Specialty physician networks in managed care. PMID- 10150797 TI - Managed care, elder care and Medicare. PMID- 10150798 TI - New benefit options balance choice and cost. PMID- 10150799 TI - Pilot clinical trial of an anti-TNF alpha monoclonal antibody for the treatment of septic shock. AB - OBJECTIVE: To determine the safety and pharmacokinetics of an anti-tumour necrosis factor (TNF alpha) monoclonal antibody in the treatment of septic shock, and to evaluate the biological evolution of cytokine response. DESIGN: Open label, prospective, pilot trial with escalating doses of a murine monoclonal antibody (B-C7) directed against TNF alpha. SETTING: University medical centre intensive care unit. PATIENTS: Nine patients with septic shock, who received standard supportive care and antimicrobial therapy in addition to the anti-TNF alpha antibody. INTERVENTIONS: Patients were treated intravenously with one of three escalating doses of B-C7 monoclonal antibody (MoAb): 0.4 mg/kg, 0.8 mg/kg, 1 mg/kg. RESULTS: MoAb was well tolerated despite the development of human anti mouse antibodies (HAMA) for each patient; B-C7 plasma levels were dose-dependent. At study entry, TNF alpha and IL-6 levels were detected in six and seven patients respectively; IL-1 levels were low and interferon-gamma was undetectable. CONCLUSIONS: No side effects were noted during treatment regardless of the dose used; however, further studies are needed to determine the clinical efficacy of this agent in septic shock. PMID- 10150800 TI - Subjective psychological status of severely ill patients discharged from mechanical ventilation. AB - OBJECTIVE: To evaluate psychological status in consecutive survivors of ICU who needed mechanical ventilation (MV). DESIGN: Prospective study. SETTING: Twenty four bed intensive care unit. PATIENTS: Fifty-four mechanically ventilated patients were considered for the study; 43 patients were included, but 11 refused or were unable to fill in the form. INTERVENTIONS: A 32-question form was filled out by the patients 48-96 hours after weaning from mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: The mean characteristics of the patients were: age 51.6 years, simplified acute physiologic score (SAPS) 14, organ system failure (OSF) 1.57, OMEGA score 277, length of stay 29 days, length of mechanical ventilation 14 days. Thirty-three required sedation, 30 analgesia, 20 paralysis. The results were as follows: Pain: 13 suffered intolerable pain with a mean intensity of pain during care of 3.5/10. Comfort: 25 felt an inability to communicate, 18 were bothered by noise and 15 by light, while nine feared to be abandoned by staff. Sleep disorders: 28 remember dreaming with a personal judgement about these dreams (0 = pleasant, 10 = nightmare) of 7.6/10; 17 noticed increasing sleep disorders during their stay. Anxiety: 22 felt diffuse anxiety disorder and 16 described intense fear of dying at least once. Mood: 38 felt physical depression and 18 intellectual depression. Delirium or confusion: 33 had delirium or a confused state at the time of weaning and nine suffered hallucinations. Nine correctly appreciated their length of stay and 18 knew the date when they were interviewed. CONCLUSIONS: These results showed that psychological status is poor in ventilated ICU patients, which should be considered in their care. PMID- 10150801 TI - Recent advances in the treatment of ARDS. AB - Despite more than 25 years of extensive research the mortality of ARDS patients remains high. Besides the often deleterious course of the underlying disease, another reason for this high mortality lies in the aggressive ventilatory regimen which is required to maintain arterial blood gases in a more or less normal range. Therapeutic methods which are used to reduce iatrogenic damage to the lungs are pressure controlled ventilation with permissive hypercapnia, differential lung ventilation, positioning therapy, dehydration, and extracorporeal gas exchange with membrane lungs. Nevertheless, many of these patients still die following hypoxaemia or multiple organ failure. Therefore, the need remains to develop new therapeutic strategies and to investigate their influence on the morbidity and mortality of this life-threatening disease. First experiences with nitric oxide (NO) inhalation, intravenous application of antioxidants, intratracheal instillation of surfactant, tracheal gas insufflation and combined fluid/gas ventilation with perfluorocarbon are presented. All these new methods have proved their efficacy, at least in animal studies, however, they should still be regarded as experimental. PMID- 10150802 TI - Cardiopulmonary resuscitation in cancer patients: indications and limits. AB - A presumption based on the literature obtained from general hospitals is widespread among physicians, namely that patients with active malignant disease, particularly if metastatic, should not be resuscitated if they have a cardiorespiratory arrest. This attitude is not supported by studies performed on cardiopulmonary resuscitation (CPR) in cancer centres which report results similar to those obtained in non-cancer patients. In fact, cancer, even if metastatic, is not a contraindication in itself to CPR. The stage of the neoplastic disease, the cause of the cardiac arrest and the patient's choice have to be taken into consideration in order to decide whether or not to perform CPR. PMID- 10150803 TI - Assessment of splanchnic tissue perfusion. PMID- 10150804 TI - Evaluation of survival in medically treated patients with homozygous beta thalassemia by the quick hit method. AB - Articles published in medical journals often evaluate the survival and/or prognosis of a medical impairment. The conclusions of these articles can be very misleading if correct mortality methodology is not utilized. Authors evaluating survival in a cohort of individuals with Thalassemia Major concluded the prognosis was excellent. This was based solely on observed mortality. When the cohort is properly compared to the expected mortality of a similar nonimpaired population the result is quite different. Their survival is far from excellent. This article uses the quick hit method to evaluate the survival of this cohort having Thalassemia Major. PMID- 10150805 TI - Acute myocardial infarction in Medicare patients, 1987-1990. PMID- 10150806 TI - Genetic information and life insurance risk classification and antiselection (1). PMID- 10150807 TI - Brain injury rehabilitation; the continuum of care. AB - The continuum of care for individuals with traumatic brain injury has become quite complex. Medical technology has increased survival rates leaving many individuals with severe deficits. Quality treatment programs have been developed that are proving cost effective with good outcomes for many. To insure maximal recovery from traumatic brain injury, the patient should be provided the opportunity for treatment in the setting which is most conducive to maximal recovery. The acute hospital, the subacute program, the postacute program, the home program and the others should all be considered as part of the continuum of care for the brain injured individual. Timely movement to the appropriate setting will facilitate maximum recovery of a traumatic brain injured individual. Many patients have the potential to improve with quality treatment, appropriate setting and sufficient time to be treated. The article describes the levels of care that are available, with the goals and objectives of each level. It describes the patient that would best fit into each level. It further identifies assessment tools that are useful in measuring progress and outcomes. PMID- 10150808 TI - Comitant strabismus. AB - This article briefly overviews the recent literature regarding comitant strabismus. The evaluation and management of esodeviations and exodeviations, which are still topical questions today, are discussed. Several relevant basic studies focus on the prevalence and the role of sensory mechanisms in the clinical findings of essential infantile esotropia. Data reported on by the authors reinforce the validity of early surgery in congenital strabismus. Other articles deal with the accommodative esotropia. The beneficial effect of adequate corrective eyeglasses in accommodative esotropia is emphasized, in both children and adult patients. A major informative review of intermittent exotropia and a worldwide survey of current management of intermittent exotropia are also presented. PMID- 10150810 TI - Nystagmus. AB - Ophthalmologic nystagmus can be congenital and manifest/latent both of whose waveforms, compensatory mechanisms, and treatment are different. Physiologically, latent nystagmus may be reversed at will, whereas nystagmus and head nodding may be simultaneously triggered at will. Occasional oscillopsia is more frequent than is usually believed; extraretinal signals may be a reason for their absence in congenital nystagmus. Astigmatism could be the consequence of nystagmus, myopia is present in most of the cases of congenital nystagmus with blocking convergence, whereas depth-of-focus anomalies are probably due to the presence of nystagmus during its critical period of development. As for treatment, botulinum toxin injection, because of its temporary effect, is not used to treat nystagmus but to help in decision-making for surgery. Four large horizontal recti recession is the last-resort surgery which may be combined with other surgical procedures and can give unexpected results. Artificial divergence surgery by contrast is one of the most valuable procedures used in congenital nystagmus. PMID- 10150809 TI - Paralytic strabismus and syndromes. AB - In the past year, there have been interesting communications regarding third nerve palsies in children and acquired fourth nerve palsy. Several interesting articles have confirmed the benign natural history of untreated Brown's syndrome and addressed its management. Two major reviews, one on vertical diplopia and one on Duane's retraction syndrome, have provided a wealth of information and useful bibliographies. PMID- 10150811 TI - Strabismus management. AB - In this article, three topics of current interest in strabismus are covered. These include strabismus after glaucoma implant surgery, management of accommodative esotropia, and the timing of treatment for strabismic amblyopia. Glaucoma implants have improved our results with difficult glaucoma syndromes, however, a high incidence of postoperative strabismus has been associated with this procedure. The mechanism of the strabismus has not been clearly defined in previous literature, but in this article we describe three mechanisms that cause strabismus after glaucoma implant surgery and describe methods for managing this problem. The standard management of accommodative esotropia has historically resulted in a large number of undercorrections. Patients with accommodative esotropia have good fusion potential as the strabismus is acquired and binocular visual development occurred during the critical period. Recent studies indicate that we should increase our surgical numbers when managing patients with accommodative esotropia. Various treatment strategies are covered in the section on accommodative esotropia. Finally, a discussion on the management of strabismic amblyopia is presented. The importance of treating amblyopia first, then secondarily correcting the strabismus is emphasized. PMID- 10150812 TI - Pathophysiology of binocular vision and amblyopia. AB - This article focuses on three important issues that have received much attention during the past year. The first is sensitive periods for amblyopia. Recent physiological studies suggest a surprising degree of neural plasticity in the adult visual cortex. A review of the literature suggests that at least some human amblyopes retain cortical plasticity into adulthood. The second issue is new methods of treatment for amblyopia. Certain neurotransmitters have been implicated in neuronal plasticity. Based on this finding, a potentially promising new method for treating amblyopia, levodopa, is being tested in adults and children with amblyopia. Unfortunately the early results provide more questions than answers. The third topic is neural mechanisms of amblyopia. In primates and humans, the weight of evidence suggests that the neural effects of strabismus and anisometropia are expressed primarily in the cortex. These cortical effects are expressed in a loss of cortical neurons and in alterations in the contrast sensitivity and range of preferred spatial frequencies of the neurons dominated by the amblyopic eye. The relationship between these physiological effects and psychophysical performance is reviewed. PMID- 10150813 TI - Doctor, will my insurance pay for this? Commentary. PMID- 10150814 TI - Endoscopic surgery for lacrimal and orbital disease. AB - Recent interest in the application of endoscopic surgical techniques to the field of ophthalmic plastic and reconstructive surgery has occurred primarily in the areas of lacrimal and orbital disease. Examples of important innovations include endoscopic intranasal laser-assisted dacryocystorhinostomy (DCR), transcanalicular laser-assisted DCR, microendoscopy of the lacrimal drainage system, endoscopic orbital decompression, orbital endoscopy, and computer assisted surgery. The evolution of these exciting and promising innovations is reviewed with emphasis on the need for continued critical evaluation of these techniques by rigorous clinical research prior to forming specific recommendations for their widespread general use. PMID- 10150815 TI - The surgical management of Graves' ophthalmopathy. AB - The underlying cause of Graves' ophthalmopathy is unknown and therefore all treatment is palliative rather than preventive. The proximate cause of the retrobulbar swelling is an accumulation of glycosaminoglycans with subsequent water binding. Treatment, in a general sense, either attempts to shrink swollen tissues or to expand orbital volume. Expanding the orbital volume by decompression can be accomplished by many different techniques. Removal of bone is central to this theme. Another type of "decompression" removes orbital fat without any bone removal. This review highlights results of decompression by the antral-ethmoidal (transantral and anterior), transfrontal, endoscopic, and orbital defatting techniques. Diplopia can be a major source of morbidity. From a surgical perspective recessions are the most frequently performed procedure. The results of adjustable versus nonadjustable sutures are compared in one report. Various methods of performing eyelid surgery including a technique to harvest hard palate mucosa are also briefly discussed. PMID- 10150816 TI - Thyroid ophthalmopathy. AB - Thyroid ophthalmopathy, idiopathic orbital inflammation, and orbital infection can occasionally demonstrate overlapping clinical features. It is essential to distinguish between these processes because appropriate treatments are distinct in each case. In the past year, the pathophysiology of thyroid ophthalmopathy has been the topic of many reports. Orbital inflammation, particularly the fibrotic form, has been recognized to represent a distinct disease entity that may require more specifically directed treatment. In some cases cytotoxic therapies may be indicated. Orbital infection, particularly in the setting of orbital abscess, may be treated conservatively with antibiotic therapy and observation or more aggressively with surgical drainage procedures. In several recent studies, appropriate management of such infectious processes appears to be related to patient age, as well as to the specific clinical pattern of presentation. PMID- 10150817 TI - Basic research in orbital and oculoplastic surgery. AB - This review summarizes basic research in orbital and oculoplastic surgery during the past year. Innovative and exciting projects have been undertaken elucidating microscopic anatomy of the orbital septum, orbital lymphatics, and levator elastic fiber network. Eyelid anatomy as assessed by magnetic resonance imaging has been beautifully demonstrated. In the realm of orbital disease, several studies have provided potential alternative therapeutic modalities in the management of the anophthalmic socket. These particular studies range from the use of demineralized bone in the rabbit anophthalmic socket, to the use of bone graft to reconstruct the monkey orbital floor. Further elegant studies outline the velocity of ophthalmic artery flow, and potential applications of ocular thermography. PMID- 10150818 TI - Etiology and management of facial palsy. AB - Palsy of the facial nerve can result in severe debilitation. The physical disfigurement has a disastrous effect on self-image. Asymmetry of facial expression, drooling, and difficulty with speech may occur. Additionally, impaired closure of the eye can result in exposure of the cornea with not only discomfort, but also loss of vision. If the nerve injury is proximal, loss of salivation, lacrimation, and changes in taste can occur. Clearly, an understanding of facial palsy and a framework for management are needed by the clinician who encounters this condition. The recent literature is surveyed for various causes of seventh nerve palsy and for therapeutic modalities available to the physician. PMID- 10150819 TI - Blepharoplasty and ptosis. AB - Recent advances in local anesthetic techniques have led to suggestions that buffered solutions for infiltration increase patient comfort. The use of an eutectic mixture of local anesthetics cream has however proved to be disappointing. The use of monopolar electrocautery, carbon dioxide lasers, and high-frequency radio wave electrosection provide the surgeon with new modes of cutting and coagulation. Lower lid blepharoplasty via a conjunctival approach may avoid many of the complications of the anterior approach. Such complications may also be minimized by careful preoperative planning and frequently the inclusion of a lateral canthopexy in the surgical procedure. The lid height after anterior and posterior levator resection can now be set more accurately with adjustable suture techniques. A new technique combining a superior tarsectomy with levator resection is described. A range of materials for brow suspension are now available. Autogenous fascia lata remains the material of choice when available. PMID- 10150820 TI - Burns of the ocular adnexa. AB - Ocular and periocular burns continue to be very complicated problems to manage clinically. Significant contributions have been made over the last year regarding the care and rehabilitation of the patient with this type of injury. N acetylglucose aminidase activity in burned corneoscleral tissues may prove to be a good clinical indicator to assess the severity of ocular burns. Tenonplasty and split-thickness dermal grafts offer alternatives to conjunctival flaps when the latter is not practical or possible. Split-thickness dermal grafts are useful for treating persistent corneoscleral defects when an environment conducive to free grafts exists. Tenonplasty is a useful procedure in patients with persistent corneoscleral defects in whom no conjunctiva is available and a free graft is not advisable. Oversized soft contact lenses may prove useful in the care of the burn patient predisposed to forniceal foreshortening. An algorithm has been presented to aid in the management of the patient with periocular burns. High-density porous polyethylene can be successfully utilized in the reconstruction of the facial skeleton in burn patients. Useful guidelines have been proposed for the use of tissue expanders in the lower face and neck in pediatric burn patients. PMID- 10150821 TI - Lacrimal disease. AB - Several authors have investigated the success of nasolacrimal duct intubation in children as well as the length of time for tubes to remain in place. The treatment of congenital amniocele with potential for life-threatening septicemia has been investigated. Other topics have included the bacteriology of dacryocystitis emphasizing the risk of endophthalmitis after intraocular surgery, balloon treatment for functional nasolacrimal duct obstruction, anatomical measurements of the lacrimal system relative to intracranial space, and new procedures for punctal stenosis. Diagnostic tests for epiphora and methods of punctal occlusion are evaluated. PMID- 10150822 TI - Ocular manifestations of various systemic disorders. AB - Diode laser photoablation of the retinal periphery is an effective treatment for zone 1 or 2 threshold retinopathy of prematurity. Patients with small cell carcinoma of the lung and cancer-associated retinopathy have immunoreactivity with the 23-kD retinal cancer-associated antigen and a similar antigen is secreted by in vitro propagated cultures of small cell carcinoma of the lung. This cancer-associated autoimmune retinopathy is characterized by rapid visual loss, night blindness, color loss, and reduced electroretinograms. Angioid streaks start as narrow, short discontinuous hypopigmented streaks that enlarge and widen with the end stage being disciform macular degeneration, helicoid peripapillary atrophy, or diffuse choroidal sclerosis. In the setting of neonatal cholestasis, the findings of microcornea, posterior embryotoxon, mosaic iris stromal hypoplasia, anomalous optic discs, and regional peripapillary retinal depigmentation suggest the diagnosis of Alagille syndrome (arteriohepatic dysplasia). PMID- 10150823 TI - Tumors of the optic nerve and chiasm. AB - Optic nerve gliomas and meningiomas, which remain puzzling to clinicians, are reviewed with special attention to natural history, magnetic resonance findings, and appropriate management. New histopathological insights established the true neoplastic nature of optic nerve gliomas considered by most clinicians to be benign hamartomas. Unusual presenting manifestations and therapeutic alternatives of optic glioma have been also considered. Since the association of optic nerve gliomas and meningiomas with neurofibromatosis has long been recognized, special attention has been drawn to clinical, genetic, and ophthalmologic aspects of neurofibromatosis. New and unusual presenting manifestations, diagnostic and treatment opportunities concerning optic nerve involvement in metastatic disease, and lymphomatous proliferation are also described. PMID- 10150824 TI - Neuro-ophthalmic aspects of vascular disease. AB - One of the most susceptible sites to vascular diseases is the optic nerve head. By innovative approaches using morphometry and in situ hybridization, vascular and extracellular characteristics of the human optic nerve head were examined. Nonarteritic ischemic optic neuropathy occurs due to vascular insufficiency within the optic nerve head. Various local and systemic risk factors have been proposed among which smoking and acute hypotension are now included. Anatomically abnormal discs such as the small optic disc, tilted disc, and optic nerve drusen are recognized as "disks at risk" and hyperopia may be an additional predisposing factor. Ocular, neurological, and vascular disorders due to giant cell arteritis were reviewed. Intravenous high-dose methylprednine should be administered in certain cases. Differentiating nonarteritic from arteritic ischemic optic neuropathy is sometimes difficult. Isolated choroidal ischemia or choroidal filling delay may be an indication of giant cell arteritis. Studies have been conducted on the vascular event, amaurosis fugax (transient monocular visual loss), and the results of some of these studies are discussed. PMID- 10150825 TI - Peripheral ocular motor disorders. AB - In the reviewed period, articles on peripheral eye movement disorders covered interesting aspects. Localizing value of associated signs, repetitive presentations of palsies, and classical quotations are stressed for the oculomotor nerve. The superior oblique is correlated to central nervous system disorders when overacting in pediatric patients or when ocular torsion is matched to the perceived vertical tilt. The family "pseudo" brought two of its members: "pseudo" myasthenia and "pseudo" myotonia. Mitochondrial citopathies with ocular manifestations can overlap among the different clinical types, eg, Kearns-Sayre, MELAS (mitochondrial encephalopathy-lactic acidosis and strokelike episodes), MERFF (myoclonic epilepsy and ragged red fibers). The diagnostic value of DNA mutations is emphasized in those syndromes. Imaging of the carotid arteries provides useful hints in cases where the lumen is narrowed due to internal processes or external compression; its interpretation is not only of diagnostic but of prognostic value. Certain otorhinolaryngology surgical procedures can damage the orbital muscles and produce serious inconvenience to the ocular motility. Analyzing the involved structures the therapeutic gesture can be determined. Diplopia after cataract surgery or retinal detachment repair is due to different factors, anesthetics, or implant location and is implied in every case. PMID- 10150826 TI - Assessment of higher-order visual function. AB - Ophthalmologists and neuro-ophthalmologists may be confronted with patients whose complaints go beyond problems with acuity or clarity of vision, raising the question of defects affecting higher-order aspects of visual function, such as reading, recognition, imagery, and visuospatial and visuoconstructional abilities. Standard neuro-ophthalmologic procedures are not designed to measure these functions. This article overviews several neuropsychological procedures that were designed to measure higher-order visual function, and proposes brief adaptations of these procedures that could be used in the office of the ophthalmologist or neuro-ophthalmologist, to provide economical, sensitive screening tests for detecting defects in reading, recognition, imagery, and other complex visual functions. PMID- 10150827 TI - Traumatic neuropathies of the optic nerve, optic chiasm, and ocular motor nerves. AB - This review focuses on traumatic chiasmal syndrome and traumatic neuropathies of cranial nerves II, III, IV, and VI. The review highlights common anatomical sites of injury to the above structures. Special emphasis is placed on review of recent literature. Other review of related material include. PMID- 10150828 TI - Central ocular motor disorders. AB - Our understanding of the complexities of the central mechanisms that control human eye movements continues to expand rapidly under the twin impetus of more widespread use of high-resolution eye movement recording techniques and improved anatomical localization of lesions using magnetic resonance imaging. In parallel, there has been continued expansion of sophisticated neurophysiological studies in monkeys examining basic ocular motor control mechanisms. Another important area that is now rapidly expanding is the application to human diseases of more complex and cognitively demanding saccadic eye movement stimulus paradigms such as antisaccades, memory-guided saccades, and express saccades. Finally, a much clearer understanding and exposition of the complexities of central vestibular function appears to be gathering pace. PMID- 10150829 TI - Recent advances in neuro-imaging and the impact on neuro-ophthalmology. AB - Neuro-imaging is an essential part of the evaluation in patients with neuro ophthalmologic disorders. Over the last two decades enormous advances in this area have been made allowing noninvasive evaluation of the orbit and brain. The idea of using nuclear magnetic resonance technology to produce images rather than the ionizing radiation of computed tomography (CT) began to emerge clinically in the late 1970s and early 1980s. Although the quality of early magnetic resonance imaging (MRI) scans was not much better than CT images, by the early 1990s, it became obvious that MRI had particular strength in identifying lesions in the posterior fossa, and demyelinating plaques. With advances in magnetic strength, computer software, surface coils, contrast medium, and more attention to the basic physics of magnet technology, the clarity of MR images improved dramatically. Recent advances in CT scanning (spiral and three-dimensional CT) and MRI (functional MRI and cine MRI) continue to affect significant changes in the discipline of neuro-ophthalmology. Furthermore, advances in MR angiography promise to allow excellent and noninvasive analysis of the cerebral vasculature. This review highlights the recent advances in neuro-imaging. PMID- 10150830 TI - Diabetes and thyroid-related eye disease. AB - Diabetes and thyroid-related eye disease cause significant morbidity. Although these are endocrine disorders, they cause different ocular manifestations. Previously unexamined epidemiologic factors offer new insight to diabetic eye disease. The association of hyperglycemia, systemic medical therapy, and visual loss is reviewed. Although retinopathy remains the leading cause of blindness, multiple "nonretinal" diabetic ocular problems occur and how these correspond with retinopathy is examined. Thyroid-related eye disease, as seen in Graves' ophthalmopathy, is an autoimmune process. This is reexamined and new ultrasound techniques to measure disease activity are described. The advantage of therapies directed against these features is reported. PMID- 10150831 TI - Ocular manifestations of genetic and developmental diseases. AB - Significant advances were reported this year in our understanding of the association of lens opacities with neurofibromatosis type 2 and the genetics of the aniridia-Wilms' tumor association. The first successful surgical reattachment of detached retinas in patients with incontinentia pigmenti are reported. An important retrospective review of young adults with congenital rubella syndrome implies that the timing of infection during gestation is not related to the incidence of individual ocular conditions. The ophthalmic features of the MELAS syndrome, a mitochondrially inherited encephalomyopathy, are described. Cytogenetic techniques are utilized for the first time to investigate the association between conjunctival and uveal melanomas with the dysplastic nevus syndrome. Familial Duane's syndrome and urogenital abnormalities were associated with a bisatellited marker derived from chromosome 22. Finally, another case of the newly described association of microphthalmia, dermal aplasia, and sclerocornea (MIDAS syndrome) is reported. PMID- 10150832 TI - Ocular manifestations of metabolic disorders. AB - Articles published during the past year on the ocular manifestations of metabolic diseases and related issues are reviewed. The focus is on clarifying the genetic or molecular basis of various metabolic disorders. Mutations of the P gene were reported in tyrosinase-positive oculocutaneous albinism and autosomal recessive ocular albinism, and were associated with a wide range of clinical phenotypes. This finding should aid in more accurate diagnosis and facilitate genetic counseling. There is no consensus but the horizontal supranuclear gaze palsy in Gaucher's disease may aid in subtyping. The report of a family with Morquio syndrome suggests that lenticular opacities should be considered as an additional finding in this syndrome. Patients with nephropathic cystinosis, which had been a fatal disease in childhood, are now surviving to adulthood. Serious ocular complications were described in adults. PMID- 10150833 TI - Ocular manifestations of systemic infection. AB - Increased research and awareness of various systemic infections places a greater emphasis on the ophthalmologist's knowledge of ocular manifestations of these diseases. New advances in the diagnosis and treatment, as well as studies of the pathogenesis and histological features of different infectious processes are continually being reported. Recent publications focusing on ophthalmic findings of infectious diseases are reviewed. This article discusses new reports on herpes simplex, herpes zoster, Lyme disease, malaria, onchocerciasis, cysticercosis, and toxocariasis. PMID- 10150835 TI - Ocular manifestations of cardiovascular and hematologic disorders. AB - The past year's important advancements in the ocular manifestations of cardiovascular and hematologic diseases are reviewed. Systemic changes related to blood pressure and carotid artery disease are commonly manifested on the ophthalmic examination. Ocular ischemic changes have been observed in patients with unusual aortic or congenital cardiac disorders. The ophthalmologist plays an important role in the detection of patients who are at risk for cardiovascular and cerebrovascular events. The hematologic disorders affecting the eye are subdivided into benign and malignant categories. A spectrum of diseases that include sickle cell hemoglobinopathy, aplastic anemia, leukemia, lymphoma, and multiple myeloma are discussed. With increased patient survival time after bone marrow transplantation, secondary ophthalmic complications are being identified. Although the ocular findings in the hematologic maladies are diverse, they may be an indication of serious systemic complications and have significant visual consequences. PMID- 10150834 TI - Ocular manifestations of immunologic and rheumatologic inflammatory disorders. AB - Exciting new discoveries into the pathophysiological mechanisms of immunologic and inflammatory ocular disease continue. The genetic locus for susceptibility to Behcet's disease and Sjogrens syndrome has been further characterized. Important guidelines for serial slit-lamp examinations for the early detection of iridocyclitis in juvenile rheumatoid arthritis is suggested. In ocular allergy, further investigation of the interaction between mast cell and eosinophil sheds more light on the pathophysiological mechanism of vernal keratoconjunctivitis and vernal corneal ulcers. Unusual manifestations of Behcet's disease, sarcoidosis, scleritis, and Wegener's granulomatosis are reported. A possible pathophysiological mechanism for lacrimal gland destruction in Sjogrens syndrome is presented. PMID- 10150836 TI - Evolving techniques and changing indications for combined cataract extraction and trabeculectomy. Commentary. PMID- 10150837 TI - Management of coincident glaucoma and cataract. AB - The glaucoma combined procedure continues to evolve and improve. The use of antimetabolites as pharmacologic modulators of wound healing in conjunction with argon laser suture lysis and small-incision phacoemulsification techniques has revolutionized the glaucoma combined procedure. This discussion describes the current trends in the management of coincident glaucoma and cataract. The literature from the past year is reviewed with respect to this important topic. The role of antimetabolites in combined glaucoma surgery, the implications of the pseudoexfoliation syndrome, and the various options available for small pupil phacoemulsification are addressed. The intention is not to provide a comprehensive review of this topic but to discuss current opinion on the various issues that have been addressed in literature during the past year. PMID- 10150838 TI - Laser therapy in cataract surgery. AB - In the more than 25 years since the development of ultrasound phacoemulsification, enormous change has occurred in cataract surgery. One of the latest and most significant changes in cataract surgery has been the development of devices that utilize laser energy for the removal of cataracts. Both ultraviolet (excimer) and infrared wavelengths have been studied, but in 1994, we have seen significant progress only with the infrared wavelengths. The lack of progress in the devices utilizing ultraviolet wavelengths are due to concerns with safety. Two infrared laser devices, one developed by Dodick and the other developed by Colvard have been used successfully for the removal of cataracts under Investigational Device Exemptions from the Food and Drug Administration. These developments have brought us a step closer to realizing the dream of laser cataract surgery. PMID- 10150839 TI - Epidemiology, pathophysiology, and world blindness. AB - This year the role of diabetes and therefore of sugars in cataract has remained a dominant theme in the literature, but there has been a renewed interest in lens enzymes. Epidemiological studies have confirmed that cataract is the overwhelming cause of blindness in the third world, and identified association with another age-related disease. The possible protective effect of estrogens was surprising. The role of poor nutrition in cataract development, and conversely the possibility of decreasing the burden of cataract by improving nutrition or providing vitamin supplements has attracted much attention although we must await clinical trials for definitive answers. PMID- 10150840 TI - Cataracts in systemic diseases and syndromes. AB - A comprehensive review of the ophthalmic literature on cataracts during the past year is presented. Topics covered include new epidemiologic associations, diabetic cataracts, and syndromes involving cataracts. Data from the Beaver Dam Eye Study suggest the presence of a recessive gene for nuclear sclerosis. Estrogen exposure may decrease the risk of nuclear sclerosis. The effects of amiodarone, propranolol, and lovastatin on the lens are discussed. Electron microscopy studies have furthered our understanding of diabetic cataracts and the rare Christmas tree cataract. Two new studies support the adverse effect of extracapsular cataract extraction on diabetic retinopathy. New associations between neurofibromatosis 2 and the lens will aid in the diagnosis of this condition. Other ocular and systemic syndromes are discussed. PMID- 10150842 TI - Refractive aspects of cataract surgery. AB - Cataract surgery has progressed to the point where it can now be performed so as to leave most patients emmetropic or with a predetermined amount of ametropia. The two major factors responsible for this prediction accuracy are intraocular lens power calculation and the control of surgically induced astigmatism. Recent theoretical intraocular lens power formulas are more accurate owing to their improved methods for predicting the postoperative anterior chamber depth. Additionally, there are more reliable methods for determining surgically induced astigmatism as well as methods for its control. Various combinations of wound architecture, wound closure, and astigmatic keratotomy and their effect on surgically induced astigmatism are reviewed. PMID- 10150841 TI - Anesthesia, preoperative, and postoperative medications. AB - Retrobulbar and peribulbar anesthesia remain the principle means of ophthalmic anesthesia. Methods, needles, and medications continue to vary in the search for what works best, and that is a very individual preference as is seen by the literature over the past year. The increased role of nonsteroidal anti inflammatory drugs is discussed, along with prophylactic antibiotic use. PMID- 10150843 TI - New techniques for cataract surgery. AB - Several new techniques have been described to facilitate nucleus removal all of which share a common theme. Each technique seeks to avoid excessive tissue manipulation; avoid stress on the zonules, thereby minimizing the potential for related complications, such as vitreous loss; and simplify the operation to further reduce surgical morbidity. Nucleus expression is facilitated by the gliding nucleus, using anterior chamber hydrostatic pressure to push the nucleus out. Phacoemulsification is made simpler with "V-style" sculpting, and with the split and lift, crack and flip, and stop and chop techniques. PMID- 10150844 TI - New techniques and instruments for lens implantation. AB - Although most of the new techniques and new instrumentation for intraocular lens implantation are related to foldable intraocular lenses or sutured posterior chamber lenses, there are some intriguing new concepts in intraocular lens techniques unrelated to these two areas. PMID- 10150845 TI - Complications of intraocular lens surgery. AB - Complications of cataract surgery and intraocular lens implantation are increasingly rare. New problems are emerging with foldable intraocular lenses. This annual review gives importance only to documented complications published during the last 14 months. Older complications can still be observed and the reader is referred to our last two articles in this journal, which are still fully valuable (Lebuisson and Weiser, Curr Opin Ophthalmol 1993, 4:75-82 and Lebuisson. PMID- 10150846 TI - The use of collagen shields for drug delivery in cataract and intraocular lens surgery. AB - Collagen shields are an appealing route of drug administration because they avoid complications associated with periocular injections and frequent topical drug application. A review of past studies establishes the capability of collagen shields to reach therapeutic aqueous drug levels in animal models. More recent studies on human subjects reaffirm the capability of collagen shields to provide adequate prophylaxis against the most common pathogens of postoperative endophthalmitis. Research on the use of collagen shields after routine cataract surgery shows that patients receiving the collagen shields had less postoperative anterior chamber reaction, less corneal edema, and fewer subconjunctival hemorrhages when compared with patients receiving the same medication through subconjunctival injection. Collagen shields may also be useful as a means to deliver other medications such as antivirals, antifungals, and immunosuppressive agents. PMID- 10150847 TI - Nonsteroidal anti-inflammatory agents in cataract intraocular lens surgery. AB - In recent years various well-controlled, prospective trials using several clinical parameters have shown nonsteroidal eye drops to be effective in treating postimplantation surgical inflammation. The efficacy of nonsteroidal drugs, however, is influenced by several factors such as the patient's race and other criteria. For this reason, further randomized clinical trials with a larger number of cases are necessary to determine the effectiveness of nonsteroidal eye drops compared with steroids. The effects of nonsteroidal agents in preventing intraoperative miosis and treating chronic cystoid macular edema are still especially controversial. PMID- 10150848 TI - Pediatric cataract and lens implantation. AB - Cataracts in children present a greater management challenge, compared with cataracts in adults, because of the wider variety of causes and the vulnerability of the developing visual system. The fundamental principles--early diagnosis and treatment for visually significant cataracts--have not changed. Amblyopia remains a major problem in children with unilateral and asymmetrical cataracts. The use of vitrectomy instrumentation in the removal of infantile cataracts has become relatively standard; however, the tendency now is to leave a rim of posterior capsule sufficient to allow secondary placement of a posterior chamber intraocular lens at a later date. Intraocular lens implantation is being aggressively pursued in children and, with modern microsurgical techniques, may be desirable in children as young as 2 years of age or younger in special circumstances. Contact lenses continue to be ideal for the infant and growing child to provide flexibility as the refraction changes. PMID- 10150849 TI - Glaucoma. Commentary. PMID- 10150850 TI - The impact of exfoliation syndrome on therapeutic efficacy in open-angle glaucoma. AB - Exfoliation syndrome is the most common identifiable cause leading to chronic open-angle glaucoma. It affects the treatment of glaucoma in various ways. The prognosis of capsular glaucoma (exfoliative glaucoma) is worse than that of open angle glaucoma. Medical therapy and the long-term effect of laser treatment seem to be unsatisfactory in capsular glaucoma. Surgical intervention may be needed early, although eyes with exfoliation syndrome are prone to surgical complications. Finally, absolute glaucoma and blindness are more common in capsular glaucoma than in primary open-angle glaucoma. This article deals with the impact of exfoliation syndrome on therapeutic efficacy in open-angle glaucoma. It reviews the literature between October 1993 and September 1994; only a few studies concerning this important subject have been published during the given period. PMID- 10150851 TI - The role of laser sclerostomy in glaucoma surgery. AB - With the recent propagation of laser systems for the treatment of glaucoma, we logically seek to understand the rationale for the application of laser energy to glaucoma filtering procedures. If lasers can provide a better means of controlling open-angle glaucoma than is currently available by the use of medications, topically or orally, or by the currently employed surgical methods, we must then ask-which lasers and techniques are currently employed to utilize this technology? In particular what is the role of laser sclerostomy in treating glaucoma? What are the advantages and disadvantages of the various lasers, procedures, and techniques for treating glaucoma? What information does it provide us for future applications of laser surgery in glaucoma? This article addresses these issues. PMID- 10150852 TI - Surgical consequences in coexisting cataract and glaucoma. AB - Of the three classical approaches to surgery for coexisting cataract and glaucoma, last year's publications dealt with the surgical consequences of combined cataract and glaucoma operations only. When used in combined cataract and glaucoma surgery, a small-incision extracapsular cataract extraction (ECCE) with phacoemulsification (PHACO) was found to be only slightly superior to the standard manual ECCE in terms of postoperative intraocular pressure (IOP) control. Injections of 5-fluorouracil postoperatively did not improve IOP control in PHACO-ECCE-trabeculectomy or manual ECCE-trabeculectomy. A preliminary uncontrolled report suggests, however, that intraoperative mitomycin C application in PHACO-ECCE-trabeculectomy may result in excellent postoperative IOP control without antiglaucomatous medications, and with no significant mitomycin C-related complications. Controlled studies on mitomycin C application in small-incision cataract and glaucoma surgery are needed to assess its long term effect on IOP and astigmatism. PMID- 10150853 TI - Endoscopic cyclophotocoagulation in glaucoma management. AB - Laser endoscopy is an exciting development that affords ophthalmologists new opportunities in the management of retinal disease, oculoplastics, and glaucoma. This report elucidates the technology and its application in the treatment of glaucoma, as well as highlighting the differences between conventional glaucoma therapy and endoscopic laser management. PMID- 10150854 TI - The effect of lifestyle on the relative risk to develop open-angle glaucoma. AB - Patients may inquire how lifestyle or emotions may influence their intraocular pressure or risk for developing chronic open-angle glaucoma. Currently, little modification of lifestyle (including diet, drugs, emotion, activity, or risk factors for cardiovascular disease or diabetes) can be advised to reduce the risk of developing chronic open-angle glaucoma. In appropriate patients, however, suggesting limiting total-body inversion or isotonic exercise may help prevent a transient intraocular pressure increase. In patients who are in good general health, and are motivated, an aerobic exercise program might provide a small decrease in the intraocular pressure. Also, limiting cigarette smoking or alcohol consumption several hours before an ocular examination may help prevent a falsely altered intraocular pressure measurement. In the future, modifiable risk factors for chronic open-angle glaucoma may become known. This may give the patient more control over the disease by altering their lifestyle. PMID- 10150855 TI - Fluorescein angiographic characteristics of the optic disc in ischemic and glaucomatous optic neuropathy. AB - Fluorescein angiography has been utilized to study the microvascular supply of the prelaminar optic disc and the peripapillary choroid. Observation of hypofluorescence of these structures both in patients with anterior ischemic optic neuropathy (AION) and with chronic open-angle glaucoma (COAG) has led to speculation as to the pathogenetic mechanism in each disorder. In AION, studies consistently show defective filling of the disc without atrophy, suggesting hypoperfusion as a primary mechanism. In COAG, defective filling is common, but typically occurs in regions of atrophy or increased cupping, which may show hypofluorescence as a nonspecific sequela of disc tissue loss. The hypofluorescence seen in some ocular hypertensive patients supports but does not confirm a primary vascular role in the pathogenesis of COAG. Peripapillary choroidal filling delay outside the range of normal is consistently seen in arteritic AION, but not in either nonarteritic AION or COAG. This finding suggests that any vasculopathy present in these disorders is distal within the branches of the posterior ciliary artery system. PMID- 10150856 TI - Pattern of visual field defects in normal-tension and high-tension glaucoma. AB - There are probably two major types of causative factors in open-angle glaucoma: pressure-dependent and pressure-independent. If clinical features such as the pattern of visual field defects differ between normal-tension and high-tension glaucoma, the differences may provide an insight for discriminating between the pressure-dependent and the pressure-independent damage in open-angle glaucoma. This article gives a brief review of the most recent studies including reports wherein progression or pattern of visual field defects in normal-tension and high tension glaucoma or primary open-angle glaucoma are addressed. Further deterioration of the visual field in 5 years is expected in about 50% of eyes with normal-tension glaucoma in which intraocular pressure is one of the contributing factors. This figure may be greater than that seen in eyes with primary open-angle glaucoma where intraocular pressure is controlled with surgery in the middle teens. When eyes with normal-tension glaucoma and high-tension glaucoma or primary open-angle glaucoma were matched for extent of overall visual field loss, many studies noted a difference in the pattern of visual field defects between the two groups. Visual field defects in normal-tension glaucoma are relatively more localized and closer to fixation, especially in the nasal superior quadrant and may be more predominant in the lower hemifield. Results of other psychophysical tests also appear to support the above findings. PMID- 10150857 TI - Pitfalls of automated perimetry in glaucoma diagnosis. AB - Perimetry is a cornerstone in glaucoma management. The detection of glaucomatous visual field loss is of crucial importance for diagnosing the disease. Automated threshold perimetry makes thorough testing of the central visual field very possible and high-quality data are often achieved. Certain factors, however, may hamper the visual field examination or visual field interpretation. Many diseases other than glaucoma are known to influence the visual field in more or less predictable ways. Of interest is also low patient reliability, learning and fatigue effects, as well as test artifacts and suboptimal test strategies or parameters. Finally, statistical aids provided by the built-in computer of the perimeter must be judged keeping in mind the population from which the patient is derived. We describe such pitfalls in glaucoma perimetry, how they can be identified, and dealt with clinically. PMID- 10150858 TI - The value of trabeculotomy in glaucoma surgery. AB - Trabeculotomy has received increasing interest as a glaucoma procedure not only in congenital glaucoma but also in adult-onset open-angle glaucoma. In this review, the development, surgical technique, mechanism of action, and results after trabeculotomy in different types of glaucoma are described. Combined trabeculotomy and trabeculectomy and combined cataract and trabeculotomy techniques are discussed. Some remarks are given on laser trabeculotomy ab interno and other developments of trabecular surgery. PMID- 10150859 TI - Advances in the assessment of optic disc changes in early glaucoma. AB - Looking for early glaucomatous changes in the morphology of the optic disc and retinal nerve fiber layer, ocular hypertensive subjects should be checked to determine 1) whether the neuroretinal rim has its characteristic physiologic form with its largest parts in the inferior and superior disc regions and its smaller part in the temporal disc sector; 2) whether zone beta of the parapapillary chorioretinal atrophy is present or whether zone alpha is abnormally large; 3) whether the visibility of the retinal nerve fiber layer is diffusely reduced; and 4) whether localized defects of the retinal nerve fiber layer can be detected. Usually not occurring in normal eyes, an optic disc hemorrhage also indicates abnormality. These variables can be evaluated in every routine ophthalmoscopic examination, or by applying sophisticated techniques such as the scanning laser tomography and measurement of the height and contour of the parapapillary retinal nerve fiber layer. PMID- 10150860 TI - Therapeutic rationale for normal-tension glaucoma. AB - Three problems exist when assessing the effectiveness of treatment for normal tension glaucoma. Firstly, it is a common type of primary open-angle glaucoma. Secondly, the extent to which it is a pressure-sensitive disease remains to be seen. Thirdly, it is possible that normal-tension glaucoma is a collection of different disease entities. This review will look at the therapeutic options available for treatment and divide them into these which attempt to moderate IOP, and those which attempt to alter blood flow. PMID- 10150861 TI - Vascular concepts in glaucoma. AB - A relationship has been found among vascular risk factors, normal-tension glaucoma (NTG), and visual field progression. All these factors have been measured qualitatively. These factors are disc hemorrhages, peripapillary atrophy, myopic disc, choroidal sclerosis, slow filling of the choroid and veins, and vasospasms. Now we are in a transition period where more and more quantitative methods are becoming available: pulsatile ocular blood flow measurement (POBF), scanning laser angiography of the peripapillary choroid (SLAPPC), scanning laser angiography of the retinal circulation (SLARC), scanning laser Doppler flowmetry (SLDF), and color Doppler imaging. With POBF, SLAPPC, SLARC, and SLDF a deficient blood flow was found in at least 50% of patients with NTG. With these results a vascular pathogenesis of NTG becomes more and more evident. PMID- 10150862 TI - The risk profile of the glaucomatous patient. AB - This article briefly overviews risk factors involved in the multifactorial glaucomatous disease such as hypotension, preexisting field damage, location of scotomas, intraocular pressure, vasospasm, vasoactive agents, and less connective tissue of the optic disc. We summarize some of these risk factors in a formula allowing the calculation of a glaucoma progression risk index. This index helps to identify patients who are at risk for further visual field deterioration already at the time of the initial perimetric examination. Diagnostic and therapeutic aspects are highlighted. PMID- 10150863 TI - Optical coherence tomography: a new tool for glaucoma diagnosis. AB - Optical coherence tomography (OCT) is a novel technique that allows cross sectional imaging of the anterior and posterior eye. OCT has a resolution of approximately 10 microns, with extremely high sensitivity (approximately 10(-10) of incident light). OCT is analogous to computed tomography, which uses x-rays, magnetic resonance imaging, which uses spin resonance, or B-scan ultrasound, which uses sound waves, but OCT uses only light to derive its image. OCT is a noncontact, noninvasive system by which retinal substructure may be analyzed in vivo. OCT is useful in the evaluation of retinal pathologies and glaucoma. In retinal disease, entities such as macular holes, macular edema, central serous chorioretinopathy, retinal vascular occlusion and other factors have been examined. Separation between the posterior vitreous and retina, or lack thereof, are seen and quantitated. In glaucoma, retinal nerve fiber layer (NFL) thickness is measured at standardized locations around the optic nerve head. A circular scan produces a cylindrical cross-section of the retina, from which the NFL can be analyzed. In addition, radial scans through the optic nerve head are used to evaluate cupping and juxtapapillary NFL thickness. OCT, a new imaging technology by which the anterior and posterior segment are seen in cross-section, may permit the early diagnosis of glaucoma, and the early detection of glaucomatous progression. PMID- 10150864 TI - Pathophysiology of pigment dispersion syndrome and pigmentary glaucoma. AB - Pigmentary glaucoma results from zonular-pigment dispersion, primarily in young, myopic, white individuals. The concavity of the midperipheral iris allows iridozonular contact. Released pigment is carried to the trabecular meshwork where it resides: (1) benignly, not affecting the intraocular pressure, as in pigment dispersion syndrome; or (2) malignantly, elevating the intraocular pressure, as in pigmentary glaucoma. Small amounts of pigment are quickly phagocytized. If the particulate load is heavy, the cells migrate further along the outflow pathway. The flattening of the iris in pigmentary glaucoma patients receiving iridotomies, along with the backward flow of pigment observed during treatment, demonstrates a greater pressure in the anterior than the posterior chamber. This reverse pupillary block may be due to temporary ocular deformations caused by blinking, as small aqueous aliquots are forced into the anterior chamber. Flattening of the concave iris is the key to current and future management of these patients. PMID- 10150865 TI - Recent advances in the molecular genetics of retinitis pigmentosa. AB - In recent years a rapid development in gene cloning techniques has been seen which has, in part, been responsible for the elucidation of the molecular mechanisms involved in many hereditary diseases. Most noteworthy is the rapid detection of mutations in various genes Most noteworthy is the rapid detection of mutations in various genes associated with various retinal degenerations and disorders. There is an increasing need for ophthalmologists to keep abreast with these new developments to better understand disease processes and recognize new opportunities for the diagnosis and treatment of these conditions. In addition, more recent discoveries in molecular genetics have revealed previously unrecognized associations between different clinical entities that share common gene mutations (gene sharing), as well as distinctly different molecular alterations within the spectrum of what traditionally was believed to be the same disease (locus heterogeneity). These findings will most likely, in the future, invoke the need to redefine disease categories at the molecular level. This article reviews basic molecular genetics useful to ophthalmologists and examines in detail these concepts with regard to one representative hereditary retinal disease--retinitis pigmentosa. PMID- 10150866 TI - The role of magnetic resonance imaging in vitreoretinal disorders. AB - Magnetic resonance imaging (MRI) is becoming a very useful diagnostic tool for the ophthalmologist. However, there is still some confusion among ophthalmologists and other clinicians regarding ordering and interpreting imaging studies. The role of MRI in the evaluation of vitreoretinal lesions is reviewed in this article by emphasizing the MR features of retinal tumors and simulating retinal or vitreal lesions. A special description of MR requirements for imaging the intraocular structures is provided as well as a review of the MR features of solid and fluid materials used in retinal surgery. PMID- 10150867 TI - Nutritional supplement use and age-related macular degeneration. AB - Age-related macular degeneration is one of the leading causes of visual loss among people aged 65 years or older. The causes and factors associated with the progression of age-related macular degeneration are unknown presently. Basic research and epidemiologic data support the hypotheses that higher levels of antioxidant vitamins and minerals may protect the eye from the development of age related macular degeneration. For this reason and also because of the lack of effective treatment for most cases of age-related macular degeneration, nutritional supplements with antioxidants have emerged as possible therapy for age-related macular degeneration. Nutritional supplements are not proven therapy for age-related macular degeneration. The potential beneficial effects and adverse side effects of the nutritional supplements have not yet been fully evaluated in carefully conducted clinical trials. Several randomized placebo controlled clinical trials are presently underway. Results of these studies will provide important data to clarify the potential beneficial and adverse effects of such treatment. Until these results are available, it would be premature to make recommendations in favor of vitamin or mineral supplements. PMID- 10150868 TI - Eye injury and the air bag. AB - Although traffic-related mortality and morbidity figures have improved in recent years in the United States, motor vehicle crash remains a leading source of death and injury, requiring additional efforts to reduce its toll. The rationale for equipping passenger vehicles with air bags was to introduce a mechanical cushion between occupants and the car's hard interior surfaces. Although air bags have proven to be effective in saving lives and preventing injuries, a growing number of reports indicate that the air bag is also a potential source of ocular trauma. This article analyzes 24 eye injuries alleged to be air bag-related. The posterior segment was injured in less than half of cases, and only one eye sustained severe visual impairment. Although such reports may help to improve air bag design, the air bag should remain "innocent until proven guilty." We report that in motor vehicle crashes, the rate of ocular trauma increases 2.5 times if the car is not air bag-equipped. In contrast to injuries seen in vehicles without air bags, eye trauma sustained in vehicles with air bags is typically closed globe. PMID- 10150869 TI - Ocular manifestations of congenital rubella. AB - Ocular disease is a major component of the congenital rubella syndrome (CRS). Interest in this condition has been renewed after identification of a spectrum of delayed manifestations and the realization that sporadic cases of CRS will continue to occur despite vaccination programs due to reinfection in the immune patient. Work is continuing on strategies and planning of vaccination programs for disease prevention and control, refinements of diagnosis with particular emphasis on the prenatal diagnosis of fetal infection, and fundamental research into the pathogenic and immunologic mechanisms underlying CRS and its late manifestations. PMID- 10150870 TI - Prevalence of age-related macular degeneration. AB - Early and late age-related macular degeneration (AMD) have a high prevalence in elderly patients but may be differentiated by medical or environmental factors, eg, hypertension, geographic area, or antioxidant agents. Because nuclear sclerotic cataract is associated with AMD both aging changes may share a common pathogenesis. The genetic predisposition for AMD is indicated by the identical appearance in monozygotic twins, but genetics may be also important for the explanation of the low incidence of late AMD in black individuals. Specific ocular characteristics like light or depigmented iris color, prolonged dark adaptation, and decreased foveal flicker sensitivity are also risk factors for AMD. Early AMD characteristics with high risk for late AMD are confluent drusen, focal hyperpigmentation, or atrophy and slow choroidal fluorescein filling. Therefore specific genetic, environmental, medical, and ocular characteristics determine the individual appearance and progress of AMD. The knowledge of these factors may result in new prophylactic and specific treatments for AMD. PMID- 10150871 TI - Epidemiology of uveitis. AB - The prevalence and distribution of uveitis varies in different parts of the world due to geographic, genetic, alimentary, and demographic factors. Literature on the epidemiology of uveitis is rare, but it can give us a new insight in the etiology and pathogenesis of the disease. After a short summary of literature on the epidemiology of uveitis before the second half of 1993 a review of the more recent literature is given. PMID- 10150872 TI - Local resection and other conservative therapies for intraocular melanoma. AB - Mortality after enucleation for intraocular melanoma is 50% in 10 to 15 years. Death rates after conservative management by local resection, proton beam irradiation, or plaque radiotherapy appear to be similar to post-enucleation mortality in retrospective studies. Risk factors for metastatic death include tumor size, location, cell type, and age of patient and are common to all forms of management including enucleation. The eye and vision can be retained in most cases treated conservatively but choice of conservative management is dependent on patient and tumor characteristics. Any adverse effect on survival posed by conservative management is likely to be slight. Randomized prospective trials that would be needed to establish whether this is true in the case of local resection or proton beam irradiation would be difficult to mount and are unlikely to be conducted. PMID- 10150873 TI - Risk factors for proliferative vitreoretinopathy. AB - Despite the recent progress in vitreous surgery, treatment of proliferative vitreoretinopathy (PVR) is still difficult. Even if the reattachment of the retina is successful, visual prognosis is often unsatisfactory. Identification of clinical risk factors for PVR provides useful guidelines for planning the management of rhegmatogeneous retinal detachment. This review summarized the current concept for pathogenesis, clinical risk factors, and medical treatment for PVR. The presence of retinal breaks and the breakdown of the blood-retinal barrier are prerequisite to development of PVR. Almost all risk factors for PVR are associated with intravitreal dispersion of retinal pigment epithelial cells or the breakdown of the blood-retinal barrier. PMID- 10150874 TI - Comparison of pars plana vitrectomy and scleral buckling for uncomplicated rhegmatogenous retinal detachment. AB - Retinal detachment surgery can now achieve a final reattachment rate in over 90% of cases. The operation of choice in most cases is that of external scleral buckling with or without drainage of subretinal fluid. However, in a minority of cases these techniques are difficult to apply either when the breaks are unseen due to media opacities or when the breaks are complex, eg, posterior, large, or multiple breaks at different distances from the ora. Improvements in the technique of pars plana vitrectomy for retinal detachment now offers us an alternative method for treating these difficult cases. Pars plana vitrectomy for retinal detachments with unseen or complex breaks has a final attachment rate of over 90%, is technically easier to perform than conventional surgery, and avoids the refractive and ocular motility problems associated with complicated buckles. For these reasons and despite the high risk of nuclear sclerosis in phakic eyes, a pars plana vitrectomy may be the preferred option in selected cases of primary retinal detachment. PMID- 10150875 TI - Use of the polymerase chain reaction in the diagnosis of ocular disease. AB - The polymerase chain reaction is a recently introduced laboratory technique that allows for the identification of extremely small quantities of DNA. This technique offers significant advantages over more traditional methods of identifying infectious organisms causing ocular pathology. Increasing numbers of immunosuppressed and immunocompromised patients have led to the emergence of posterior segment infection from unusual and sometimes difficult to diagnose organisms. Improvements in antibiotic and antiviral therapy for specific organisms will require increasingly accurate diagnosis. Polymerase chain reaction is capable of providing this and is increasingly being used in the diagnosis of unusual vitreoretinal pathology. PMID- 10150876 TI - Tear film, pharmacology of eye drops, and toxicity. AB - Various new topical ophthalmic drug delivery systems show promise for increasing bioavailability, reducing epithelial toxicity, and improving patient compliance. Microparticulates are drug-containing polymeric particles that are placed in the fornix and release ocular medication by diffusion, chemical reaction, polymer degradation, or ion exchange and can be used to deliver many topical ophthalmic medications, including antibiotics and antimetabolites. Soft drugs are activated enzymatically at the site of application and are rapidly converted to inactive metabolites when exposed to the ocular environment, improving bioavailability at the target site, and reducing the potential for ocular and systemic side effects. Applications include soft beta-blockers, soft corticosteroids, and soft anticholinergics. Collasomes are made up of collagen pieces suspended in a viscous vehicle; this formulation is similar to that of corneal collagen shields, but is more useful for chronic therapy because the collasomes can be instilled by the patient and cause less blurring of vision. Potential uses include delivery of hydrophobic antimetabolites such as cyclosporine to prevent graft rejection and delivery of lipids for the therapy of dry eyes. Ideal replacements for dysfunctional tear layers, especially the lipid layer, have not yet been developed. The toxic effects of preservatives in topical ocular medications, particularly in artificial tears, often outweigh the benefits and preservative free tear preparations are almost always preferable. PMID- 10150877 TI - The cornea and systemic diseases. AB - Corneal involvement in systemic diseases is multifold. Dry eye syndrome may be associated with autoimmune diseases. Type I diabetes mellitus shows a positive correlation between HbA1c-level and dry eye syndrome. Autoimmune diseases and occasionally malignancies may be associated with ulcerative keratitis. Opportunistic infections do not only occur in the immunocompromised patient. Storage diseases can cause corneal deposits that may be of great diagnostic halp. Dermatologic diseases can cause various corneal lesions or opacifications. PMID- 10150878 TI - Allergic and atopic diseases of the lid, conjunctiva, and cornea. AB - Ocular allergies are commonly encountered in clinical practice. The familiarity with the typical constellation of signs and symptoms, as well as the pathophysiology of these syndromes, is of utmost importance in diagnosing and treating these diseases. Several new therapeutic options have been tested in clinical settings in recent time. Lodoxamine tromethamine is a mast cell stabilizer at least as effective as cromolyn sodium, which is currently not available in the United States. Nedocromil sodium in addition to its mast cell stabilizing effect, has anti-inflammatory properties. Levocabastine hydrochloride is a very selective and potent H1 antihistamine. Ketorolac tromethamine is a topical nonsteroidal anti-inflammatory agent. PMID- 10150879 TI - Corneal and external disorders and refractive surgery. AB - A review of disorders of the anterior segment of the eye may show new avenues of research as well as clinical perspectives arising from recently accumulated data. It will have to select new theoretical and clinical findings, which may most probably be apt to survive the test of time, thus providing a long-standing stimulus in science. This body of scientific work in corneal and external disorders may be divided into infectious and noninfectious entities as well as refractive and tectonic or structural problems. In this review, we will focus on the inflammatory implications of anterior segment ocular disease, and mention some evolving diagnostic features and new treatment modalities, as well as opinions on refractive surgery complicated by inflammation. PMID- 10150880 TI - Extracellular matrix and growth factors in corneal wound healing. AB - Healing of corneal wounds is a complex process involving epithelial, keratocyte, and endothelial interactions that are affected by their associations with wound bed matrix and by cytokine availability and activation. The spectrum of possible cellular-matrix-growth factor interactions is indeed great and growing. Several of the significant contributions made during the past year include development of an organotypic organ culture model of the cornea that allows in vitro assembly of the epithelial extracellular matrix-anchoring complex, demonstration of epithelial synthesis of Bowman's layer collagens, demonstration of transforming growth factor-beta 2's inhibition of stromal cell collagenase synthesis, and demonstration of the paracrine pathway of keratinocyte growth factor action in the cornea. PMID- 10150881 TI - Diseases of the eyelid-conjunctival complex and corneal complications of lid disease. AB - The vascular anatomy of the eyelids has been studied in more detail with regard to possible applications in eyelid surgery. The recognition of different subtypes of eyelid laxity, eg, floppy eyelid, lax eyelid, and eyelid imbrication syndromes, as underlying causes of conjunctival and corneal irritation will contribute to their successful management. Involvement of eyelid, conjunctiva, or cornea has been reported in association with systemic diseases such as Wegener's granulomatosis, xeroderma pigmentosum, scleromyxedema, sarcoidosis, and abnormalities of mitochondrial DNA. The ocular manifestations may be the presenting feature of the underlying disease. Results in two series of patients with ocular surface diseases such as chemical and thermal eye burns suggest that the use of autologous nasal mucosa transplantation is promising for the management of this disorder. Clinical features and results of cryotherapy are reviewed in two series of patients with congenital distichiasis and trichiasis due to ocular cicatricial pemphigoid. PMID- 10150882 TI - Corneal dystrophies and keratoconus. AB - Knowledge about keratoconus (KC) and the corneal dystrophies continues to advance at a steady pace in view of the wide interest in these topics to basic scientists and clinical ophthalmologists. As in the past the articles on KC outnumber those on all of the other corneal dystrophies combined. Major advances have been made mainly regarding several specific corneal dystrophies, but KC remains a perplexing disorder with many unanswered questions. As we learn more and more about the corneal dystrophies from genetic linkage analyses and molecular biological techniques it will eventually be possible to understand the fundamental defect that causes these conditions. PMID- 10150883 TI - Corneal topography. AB - As more clinicians utilize videokeratography, an understanding of corneal topography is assuming an increasing role in the practice of ophthalmology. During this past year investigators have critically examined the methods employed in the utility of these devices as well as the accuracy and reproducibility of the algorithms embodied in videokeratoscopes. Clinical studies of patients undergoing incisional surgery and excimer laser photoablation have yielded new information about the effects of surgery on corneal shape. This has resulted in new methods being devised to improve the ultimate refractive outcome of these procedures. Videokeratography screening prior to refractive surgery has received significant attention during this past year with articles focussing on screening for keratoconus, hypotheses about the effects of surgery on undetected keratoconus "suspects," and results of incisional surgery on patients with atypical inferior steepening. Additionally, a new software program devised to screen for keratoconus on an automated basis has been developed. Corneal pachymetric topography, a novel technique of corneal analysis, is described for the first time this year. PMID- 10150884 TI - Storage, surgery outcome, and complications of corneal and conjunctival grafts. AB - Recent articles related to corneal storage, surgery outcome, and complications of corneal and conjunctival grafts are reviewed. It appears that the addition of insulin and human epidermal growth factor may benefit storage solutions. Several multivariant analyses of risks for graft rejections are included, and include corneal vascularization, failed previous grafts, and preoperative endothelial damage. Transverse keratotomy as a method of controlling astigmatism after grafting may be effective. The incidence of acute hydrops in patients with keratoconus is about 2.8%. Free conjunctival grafts are reported to be useful in repairing failed filtering blebs and persistent bleb leaks. PMID- 10150885 TI - Indications, results, and complications of refractive corneal surgery with mechanical methods. AB - Radial keratotomy (RK) incisions permanently weaken the cornea. This structural weakening can cause several complications and side effects, including diurnal fluctuation, progressive hyperopic shift, and the potential for traumatic rupture of the keratotomy scars. Minimally invasive-RK may be a useful alternative to reduce the invasiveness of RK while retaining its efficacy. Mild myopia can be treated by either RK or photorefractive keratectomy. Patients treated by RK in the first eye and photorefractive keratectomy in the second eye preferred the speed of recovery and the clarity of vision with RK. Combining the microkeratome and the excimer laser appears to be an ideal technique to correct high myopia. Laser ablation of the corneal lenticule while securely fixed by the suction ring in the Berlin microkeratome offers the advantage of perfect centration and fixation. Hexagonal keratotomy, used to treat hyperopia, appears to be an unpredictable, unsafe surgical procedure. PMID- 10150886 TI - Indications, results, and complications of refractive corneal surgery with lasers. AB - The use of lasers to correct refractive errors has become an established clinical procedure in many countries. Excimer laser photorefractive keratectomy (PRK) has been performed on an estimated 400,000 to 500,000 eyes worldwide. For myopia up to about 6.0 D, PRK appears to be generally safe, exhibiting acceptable accuracy, predictability, and stability. Complications of PRK can occur intraoperatively, and early or late postoperatively. For higher degrees of myopia, laser in situ keratomileusis may prove to be a more appropriate procedure, but long-term follow up is needed. Hyperopic PRK and holmium:yttrium-aluminum-garnet thermokeratoplasty are still considered investigational methods, and for newer technologies, such as solid-state lasers, human trials are being launched. PMID- 10150887 TI - Corneal complications of intraocular surgery. AB - Advances in intraocular surgery have decreased the incidence of corneal complications that result in corneal failure requiring transplantation. Interest continues in further refining surgery to minimize endothelial cell damage. New irrigating solutions, viscoelastic substances, and even new techniques have been introduced. Debate continues over certain issues, such as intraocular lens choice in the absence of capsular support. Improved design has prompted many early critics to regain confidence in the anterior chamber lens. Literature of recent years also reflects a shift in focus toward hastening recovery time and maximizing uncorrected visual acuity through the advantageous control of corneal astigmatism. Several reports this year may herald the next wave of interest, that surrounding intraocular surgery after refractive corneal surgery. PMID- 10150889 TI - Lack of clarity fuels debate over outcomes. PMID- 10150888 TI - Basic science and applications of in vivo microscopy. AB - Confocal microscopy creates a scanned image from a point light source and point detection or a scanning slit to remove scattered light and improve optical resolution. This also results in optical sectioning of tissues. These capabilities can be employed to image structures in the human cornea, in vivo, both for research and for the diagnosis and treatment of human disease. Optical sections, when recombined, can lead to three-dimensional reconstructions from which very useful information is obtained. Investigators have found keratocyte density decreases from anterior to posterior in the stroma of the rabbit cornea. Surface epithelial desquamation can also be studied and the effects of contact lens use can be demonstrated. The instrument is also useful for diagnosing and guiding therapy for some human diseases such as Acanthamoeba keratitis. Colonies of bacteria may also be observed and treatment evaluated in patients with infectious crystalline keratopathy. Confocal microscopy can also image the retina. PMID- 10150891 TI - PACS: right place at the right time? PMID- 10150890 TI - Main assessment issue: how do you get there? PMID- 10150892 TI - Are PACS predictions finally coming true? PMID- 10150893 TI - Health-care alliances boost interest in PACS. PMID- 10150894 TI - PACS presents medicolegal challenges. PMID- 10150895 TI - 'Critical paths' add value to practice guidelines. PMID- 10150896 TI - Pediatric ultrasound cost-effective in ER. AB - To provide emergency ultrasound service, there must be 24-hour access to state-of the-art equipment, including high-resolution transducers and color-flow Doppler. The radiologist must be available to monitor the ultrasound and scan the patient, since attention to real-time aspects, rather than just anatomy, requires a hands on approach. PMID- 10150897 TI - Buying a mini-PACS for today and tomorrow. PMID- 10150898 TI - Proper protocols key to CT of lumbar spine. AB - MRI is clearly superior to CT in imaging the lumbar spine for evaluation of the postoperative back. The one area in which CT has been shown to be superior to MRI in the lumbar spine is in diagnosing spondylolysis. Pars defects can be very difficult to appreciate with MRI, yet are easily seen with CT. Other than spondylolysis, the postoperative spine, and bone marrow imaging, CT and MRI appear to be diagnostically equivalent. PMID- 10150899 TI - Five-step process to quality mammography. PMID- 10150900 TI - Spiral imaging methods assure survival of CT. PMID- 10150901 TI - Peptide tracers excel at disease localization. PMID- 10150902 TI - Cost containment drives utilization management. PMID- 10150903 TI - MQSA: thou shalt raise mammography quality. PMID- 10150904 TI - Canadian test screens mammogram readers. PMID- 10150905 TI - Imaging plays essential role in cholecystectomy. PMID- 10150906 TI - [Penal aspects of psychiatric intervention: management modes and impact of new criminal legislation]. AB - Psychiatry and criminal justice have been closely related for a long time. Traces of such ties can already be found during the 19th century through the establishment of the contemporary systems of social control. Various questions that will mark the development of policies in this domain were important objects of discussion and analysis: Is mental illness a cause of criminality? Should the "insane" be held responsible for their crimes? What are the appropriate measures to heal, reform, control? In other words, should we consider the individual as sick or as criminal? If these questions are formulated differently nowadays they haven't lost any of their relevance. In this article, we will briefly present the forms of intervention available to the criminal justice system when dealing with persons suffering from mental health problems. This presentation is based on recent studies conducted in Montreal, elsewhere in Canada, as well as in the United States. The main stages of the criminal justice process will be examined, taking into account the recent modifications to the Canadian Criminal Code and its impact on the relations between the courts and psychiatric facilities. This type of situation is not without impact on community mental health for two main reasons. First, with the diminishing public funding of various health services there seems to be a growing practice of criminalization of persons suffering from mental health problems, especially the most vulnerable segments of this population. Secondly, there is a growing trend, in the criminal justice system, of requiring support from community groups or facilities to deal with these criminalized individuals. In the coming years criminalization will constitute an increasing and complex challenge for community mental health. PMID- 10150907 TI - [Psychiatric and medical specialists in community health: 2 solitary fields]. AB - The fields of psychiatry and community health have much in common. Specialists in these two disciplines do not use sophisticated technology; the results of their research are not spectacular; and psychiatrists, like physicians specializing in community health, have a poor public image. Representatives of these two medical specialties must work more closely together and develop alliances to promote mental health in areas including: behavioral problems in children, alcoholism and substance abuse, adolescent suicide, community integration of the mentally ill, mental health problems among the elderly, and violence and sexual abuse. The author believes these two solitudes must be brought together and a work team established to improve community mental health. PMID- 10150908 TI - [Suicide in Abitibi-Temiscamingue: epidemiologic studies for 1986-1991]. AB - A permanent register on suicide cases was created and has produced a quantitative description of suicide in Abitibi-Temiscamingue over the period 1986-1991. This study reviews 218 suicide cases reported by the Coroner's Office of Quebec. A content analysis grid was applied on the Coroner's files and has facilitated the study of 87 variables potentially related to suicide. The results present the evolution of the suicide rates in this region in relation to those of other parts of Quebec, and the differences between parts of the region. Many variables were related to suicide (age, gender, urban setting, methods, suicide sites, seasons, etc.). A review of recent literature on suicide throughout the world indicates that patterns of suicide in Abitibi-Temiscamingue follow trends in North America with certain differences. PMID- 10150909 TI - Peripheral blood smears: preparation and staining are still important. PMID- 10150910 TI - Robotic arm use by very young motorically disabled children. AB - This paper reports on a study carried out to determine if very young children would interact with a small computer-controlled robotic arm. Six disabled and three normal children were used in the study. All children were less than 38 months in age. The arm was trained to carry out movements on activation of a single switch by the child. Fifty percent of the disabled children and 100% of the normal children did interact with the arm and use it as a tool to obtain objects out of reach. Possible relationships between the use of the arm and developmental levels in various areas are discussed. PMID- 10150911 TI - Low rectum inoperable carcinoma. Advantages of direct access in palliative laser treatment. PMID- 10150912 TI - Interstitial thermotherapy of central brain tumors with the Nd:YAG laser under real-time monitoring by MRI. PMID- 10150913 TI - Continuous flow cell separator use for bone marrow processing. AB - Many techniques have been described for processing bone marrow prior to transplantation, purging or cryopreservation. Effective techniques incorporate centrifugation and, or, density separation to produce an ideal marrow concentrate. We report on the use of a continuous flow cell separator (COBE Spectra) for marrow processing. Preliminary results indicate that the improved technology incorporated in this machine together with the new algorithm control of its collection functions allows for rapid collection of an ideal marrow concentrate. The addition of an inert sedimenting agent prior to processing enhances differential mononuclear cell collection and elimination of red blood cells and granulocytes. By this technique a volume depletion of 87% was achieved with recovery of 76.4% mononuclear cells and 86.5% CFU-GM progenitor cells. Marrow processed in this manner has been successfully transplanted; patients receiving such marrow show no delay in engraftment and their grafts have been sustained. PMID- 10150914 TI - The use of vitreoretinal surgical techniques in subfoveal choroidal neovascularization. AB - Subfoveal choroidal neovascularization generally carries a poor visual prognosis. This review traces the evolving vitreoretinal surgical techniques for the treatment of this entity. Extensive retinotomies to expose large submacular scars caused frequent complications and poor visual results. More recently, small retinotomy techniques with manipulation of subfoveal membranes behind neurosensory retina have been described. Removal of subfoveal neovascularization with this latter approach is summarized. Visual results are variable. If foveal retinal pigment epithelium can be preserved, excellent central visual function can be regained. In the majority of subfoveal membranes, surgical removal creates retinal pigment epithelium defects, and acuity is limited. These approaches merit further evaluation. PMID- 10150915 TI - Modest advances refine biliary interventions. PMID- 10150916 TI - Coronary directional atherectomy: rescue for failed balloon angioplasty and treatment of complicated lesions. AB - Balloon angioplasty of the coronaries is still limited by the problems of acute complication and restenosis. Percutaneous directional atherectomy was conceived as a method to remove obstructive material from within the vessel. After encouraging results were obtained in peripheral vessels, coronary atherectomy has been selectively performed in 25 patients with lesions either not well suited for PTCA [n = 11], or as a bail-out after resistant [n = 2] or failed PTCA [n = 12]. Twenty-one LAD lesions [4 ostial, 13 proximal, 2 mid, and 2 bifurcation] and four right coronary artery [RCA] lesions with a mean length of 9 +/- 6 mm (19 eccentric, and 6 concentric) could be effectively reduced from 90% +/- 12% to 18% +/- 22%. Seventy-five percent of rescue cases could be spared emergency bypass operation. At 6 months, angiographic restenosis has been documented in 3 out of 11 patients studied to date (27%). Histologically, rescue procedures resulted in the removal of obstructing plaque material and only minimal thrombus. The occurrence of two perforations during rescue procedures, although clinically insignificant, emphasizes the need for judicious excision. In summary, directional atherectomy appears to be useful to treat lesions not well suited for PTCA, and important as a bail-out method after failed PTCA. PMID- 10150917 TI - Outcome following coronary balloon angioplasty in young adults aged 35 years or less. AB - The natural history of symptomatic young patients with coronary artery disease is often far from benign. Follow-up studies of young patients who have undergone coronary bypass graft surgery show frequent recurrence of symptoms and need for reoperation. Prompted by these considerations, we reviewed the records of 23 consecutive patients aged less than or equal to 35 years with symptomatic coronary artery disease, who underwent coronary balloon angioplasty at our center between August, 1984 and November, 1989. Mean patient age was 32 (3) (mean [SD]) years. Acute myocardial infarction was the first symptom of coronary artery disease in 7 (30%) of the 23 patients. At the time of angioplasty, 17 (74%) patients, had functional Class 3 or 4 anginal symptoms. Eight (35%) had multivessel coronary artery disease (stenoses greater than or equal to 70% in two or more major coronary arteries). Overall, a total of 36 critical coronary lesions were identified in 32 vessels of the 23 patients (mean of 1.6 lesions and 1.4 diseased vessels per patient). At angioplasty, dilatation of 31 lesions in 27 vessels was attempted. Multilesion angioplasty was attempted in 7 (30%) patients. Successful dilatation was achieved in 29 of the 31 (94%) lesions, and 25 of the 27 (93%) vessels. Primary clinical success (successful dilatation of all attempted lesions without any complications) was achieved in 21 of 23 (91%) patients. Three of the 21 patients with successful initial angioplasty had repeat angioplasty for restenosis.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150918 TI - Experimental studies on coronary laser angioplasty. AB - To establish the method of coronary laser angioplasty using the argon laser, we investigated the optimal condition of laser ablation and the relationship between the size of laser probe and the diameter of the vessel. First, the relationship between laser energy and tissue reaction to the laser was examined using human cadaveric arteries. Subsequently, we recognized that repeated laser ablation is the optimal method with each shot being limited to 5 10 watts (W) in output and 2 seconds of ablation time when using a metal tip probe (MTP) of 1.5 mm in diameter. According to the experimental condition described above, we examined the response of normal coronary arteries to the laser in vivo. If the size of MTP was not suitable for the diameter of the vessel, thermal constriction of the coronary artery was observed; MTP/vessel diameter ratio should be 0.7 or less to avoid vessel constriction by thermal damage from the laser. Neither perforation nor spasm of the coronary artery was found in this experiment. In addition, the ablated area on the coronary artery was healed completely without thrombus formation and coronary stenosis, and it was covered with new endothelium 8 weeks after laser thermal ablation. PMID- 10150919 TI - Peripheral laser angioplasty with sapphire tip. AB - To improve the result of peripheral laser recanalization (less perforation with wider tunnels of vaporization), we used the technique of sapphire laser angioplasty. A Nd:YAG laser with continuous emission was connected to a catheter with a 600 mum fiber and a sapphire probe to its extremity (1.8-3 mm in diameter). Treatment was performed on 127 patients with severe stenosis or occlusion of peripheral arteries (iliac, femoral, or popliteal arteries). Recanalization was obtained in 102 cases (80%) and was further embellished by balloon dilatation. The rate of success decreased proportionally with the length of occlusions (93% for 3 cm, 33% for 15 cm and more). Most failures were due to wall perforation or wall entry of the probe; passage of the sapphire tip was rarely blocked by the occlusion. At follow-up, 26.4% of arteries were reoccluded after 2 months. IN CONCLUSION: laser angioplasty with a sapphire tip can totally recanalize occluded arteries with low rate of failure and complications. PMID- 10150920 TI - Intravascular ultrasound and vascular intervention. AB - An intravascular ultrasonic imaging device (40 MHz) was used to obtain in vitro ultrasonic images and matching histologic cross-sections, derived from human vascular specimens. The feasibility of assessing vessel wall morphology as well as the ability to accurately document plaque thickness was determined. Based on the echogenicity of the arterial media, intravascular ultrasound could distinguish muscular arteries from elastic arteries, veins, and bypass grafts. The hypoechoic media only present in the muscular type of artery proved to be an essential landmark to document superimposed atherosclerosis. Plaque thickness calculated in these arteries showed close relationship with the corresponding histologic cross-section. Using real-time in vivo intravascular imaging (30 MHz), the morphology of the vessels interrogated was studied. The dynamic change of the arterial wall, as well as the outcome after intervention, is discussed. PMID- 10150921 TI - Complications of intraaortic balloon counterpulsation insertion in patients receiving thrombolytic therapy for acute myocardial infarction. AB - This study retrospectively examines 38 patients who presented with acute myocardial infarction requiring intraaortic balloon pump counterpulsation. Two groups of patients were identified. Group I consisted of patients with acute myocardial infarction treated with intraaortic balloon pump without thrombolytic therapy. Group II consisted of patients treated with intraaortic balloon pump after receiving intravenous thrombolytic therapy. These groups were compared and contrasted with regard to previously identified complications associated with intraaortic balloon pump counterpulsation including loss of limb and mortality. The need for surgery, embolectomy, and drainage of hematoma were also evaluated. The need for surgery in group II (11%) and in both groups combined (7%) is lower than is generally reported in literature (range 11.6% to 34%). In addition, no patients experienced a loss of limb and no patients in the study had severe life threatening iatrogenic morbidity or mortality. While mortality was not an end point in this study, it was noted that there was an increased survival rate in group II patients with 61% surviving until the time of hospital discharge. Also, eight out of 14 patients in group II who underwent intraaortic balloon pump counterpulsation for cardiogenic shock survived until the time of discharge. This represents a 57% survival rate for patients presenting with cardiogenic shock. We conclude that intraaortic balloon pumps can be inserted safely following thrombolytic therapy in a community hospital. PMID- 10150922 TI - Controlled reperfusion during emergency coronary artery bypass surgery after angioplasty failure restores immediate segmental contractility. AB - This study tests the hypothesis that careful control of the composition of the initial reperfusate and the conditions of the reperfusion during emergency CABG will restore immediate segmental contractility in the previously ischemia area despite ischemic intervals of greater than 2 hours. Between January 1987, and October 1990, 41 consecutive patients with acute coronary occlusion (90% due to PTCA failures) were reperfused during emergency myocardial revascularization according to one of two different protocols: in 25 patients the reperfusate was normal blood given at systemic pressure ("uncontrolled reperfusion"); in 16 patients the ischemic segment was reperfused during the first 20 minutes with a regional blood cardioplegic solution (substrate-enriched, hyperosmotic, hypocalcemic, alkalotic, diltiazem-containing) at 37 degrees C at a pressure of 50 mmHg. Thereafter, total bypass was prolonged for an additional 30 minutes before extracorporeal circulation was discontinued ("controlled reperfusion"). Assessment of regional contractility (echocardiography, radionuclide ventriculography), electrocardiographic evidence of myocardial infarction, release of CK and CK-MB enzymes, and hospital mortality were performed. Quantification of regional contractility was done with a scoring system from 0 (normokinesis) to 4 (dyskinesis). Data are expressed as mean +/- standard error of the mean. Both groups were well matched for age, sex, and the distribution of the occluded artery. In the controlled reperfusion group there was a higher incidence of previous infarctions (50% vs 30%), additional significant stenosis (1.1 +/- 0.2 vs 0.8 +/- 0.1), and cardiogenic shock (38% vs 20%) as compared to uncontrolled reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150923 TI - Successful treatment of massive pulmonary embolism by combined mechanical and thrombolytic therapy. AB - In two patients with massive pulmonary embolism and cardiogenic shock requiring mechanical ventilation and prolonged external cardiac massage, occluded pulmonary arteries were recanalized by primary mechanical fragmentation of thrombi using a percutaneously inserted catheter followed by fibrinolytic therapy. The hemodynamic and respiratory parameters rapidly and greatly improved. Pulmonary angiography before discharge revealed normal results in both patients. No central neurological abnormalities were detected. It is concluded that patients with cardiogenic shock due to massive pulmonary embolism may benefit from immediate mechanical thrombus fragmentation followed by fibrinolysis when thrombolysis or surgical embolectomy are strictly contraindicated or not available. PMID- 10150924 TI - Percutaneous coronary angioplasty in 1,001 multivessel coronary disease patients: an analysis of different patient subsets. AB - The prospectively collected data of 1,001 multivessel coronary disease patients who underwent percutaneous transluminal angioplasty (PTCA) was analyzed after categorization into single vessel angioplasty (SVA; group I) and multiple vessel angioplasty (MVA; group II) PTCA groups, which were each compartmentalized into "simple" (group A) and "complex" (group B) cohorts. Patients were assigned to the SVA or MVA group according to the physician's pre-PTCA assessment of how many lesions would be attempted (intention to treat) and not the number of lesions actually attempted. A "simple" patient was more likely than a "complex" patient to be clinically improved after PTCA whether or not the patient had a single dilatation (90% vs 78%; P less than 0.05) or multiple dilatations (97% vs 94%; P<0.05). Similarly, a lesion(s) was more likely to be successfully dilated in the "simple" than in the "complex" group (SVA: 90% vs 82%, P less than 0.05; MVA: 97% vs 91%, P<0.05). In addition, occluded vessels in the MVA group were more likely to be recanalized than in the SVA group (73% vs 44%, P less than 0.05). Group I-A patients had a significantly increased (10%) incidence of emergency bypass surgery. Follow-up, at 84 months, showed that "simple" cohorts had a better survival than the "complex" cohorts (MVA: 95% vs 71%, P less than 0.05; SVA: 90% vs 72%, P less than 0.05); and, nearly two thirds of all successful PTCA patients were angina free.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150925 TI - Transluminal balloon dilatation for discrete subaortic stenosis in adults and children: early and intermediate results. AB - Seven patients (four adults, three children) with discrete subaortic membranous stenosis underwent balloon dilatation using a single or double balloon technique with reduction in systolic gradient across the membrane from 100.42 +/- 19.23 to 29.14 +/- 12.54 mmHg (P less than 0.001). Echocardiography demonstrated thin membranes in all the patients and postprocedure torn fragments could be visualized. The excellent hemodynamic benefits are sustained during 4-24 months follow-up. The results indicate that transluminal balloon dilatation can be a safe and effective treatment for thin subaortic membrane. PMID- 10150926 TI - Laser angioplasty in miniature swine: advantages of a modified fiber tip delivery system. AB - Laser angioplasty using a spherical lensed fiber-tip laser delivery catheter and a 200 mum bare silica fiber tip was performed in occluded atherosclerotic iliac arteries of miniature swine. Group I consisted of 8 animals with 11 totally occluded arteries in which the bare silica fiber was used. Group II included 22 animals with occlusive lesions in 41 arteries in which the silica lens tip was used. In vivo laser angioplasty was performed in both groups using an argon ion laser delivering 2 to 3 watts of power in 1 to 5 second intervals. Successful recanalization occurred in 7/11 (64%) in group I arteries and 35/41 (85%) in group II arteries. Vascular perforation occurred in 36% (4/11) in group I compared to 10% (4/41) in group II (P less than 0.05). Mechanical perforation due to the bare fiber alone accounted for 50% of the perforations in group I and did not occur with the silica lens-tip device (group II). We conclude that the atraumatic lensed fiber is more effective in recanalizing occlusive lesions and is a safer delivery system than the bare silica fiber. PMID- 10150927 TI - Transcatheter radiofrequency ablation in the canine right atrium. AB - The feasibility of using radiofrequency energy for potential ablation of atrial tachycardia foci was assessed by performing transcatheter ablation in the right atrium in 11 closed-chest dogs. Single-pulsed radiofrequency (750 kHz) energy was delivered to the right atrium (29-254 J) between the tip electrode of a standard 6 Fr quadripolar catheter and a chest patch electrode. There were no significant arrhythmias or complications noted. Dogs were sacrificed 0-29 days after ablation to assess acute and subacute effects of this technique. Of 47 attempted ablations, 36 well-delineated coagulative lesions were identified. The lesions had a mean dimension of 5.2 +/- 0.57 mm (+/- SE) in length, 3.9 +/- 0.27 mm in width, and 2.6 +/- 0.17 mm in depth. Transmural necrosis was noted in 6 of 36 lesions (17%) without perforation. A thin layer of mural thrombus was found in 5 of 36 lesions (14%). Thus, this technique appears to be feasible and relatively safe for right atrial ablations in a short-term follow-up period. The potential application of this method to ablate right atrial tachycardia foci needs to be further investigated. PMID- 10150928 TI - The Gusto trial: is it necessary? PMID- 10150929 TI - Recanalization of chronic coronary occlusions by low speed rotational angioplasty (ROTACS). AB - From 1988 to 1990 chronic coronary occlusions were treated with a newly developed slowly rotating angioplasty system (ROTACS), which is designed for atraumatic passage of arterial obstructions. In all 152 patients (mean age 55 years, ranging from 29 to 78 years) attempts to recanalize the coronary occlusion with conventional guidewire systems had failed. In 74/152 patients the age of the occlusion could be estimated because of a previous angiogram or clinical event. It ranged from 1-192 months (median 6 months, mean value 14 months; in 20% of patients it was 1-3, in 37% 4-6, in 28% 7-12, and in 15% greater than 12 months). The occlusion was localized in the right coronary artery (RCA) in 86 cases, in the left anterior descending coronary artery (LAD) in 37 cases, and in the circumflex branch of the left coronary artery in 17 cases. Eleven bypass occlusions were treated. One patient had a LAD and RCA occlusion. Out of 152 patients 84 could be recanalized. The success rate rose with experience from 30% to 60%. It was 55% in the LAD, 52% in the RCA, 70% in the circumflex branch, and 63% in bypass grafts. The success rate in relation to the age of the occlusion was 93% in occlusions of 1-3 month duration, 74% in occlusions of 4-6 months duration, 52% in occlusions of 6-12 months duration, and 8% in occlusions older than 12 months. Seventy-six of the successfully treated patients underwent follow-up angiography after 4 months. In 56/76 (74%) the vessel remained open. Twenty-two patients (29%) had restenosis that was successfully dilated in 21 patients. Twenty patients (26%) had reocclusion. Thus, the angiographically determined long-term success rate was 72%. Emergency operation was necessary in two patients in whom reopening of the LAD was attempted although the occlusion was located directly at the take-off of the LAD from the left main. Since this type of occlusion was consequently considered a contraindication, no further serious complications occurred. There was one myocardial infarction, no death, no vessel wall perforation or other complications in the 152 patients. It is concluded that low speed ROTACS is a safe technique that can be applied in chronic coronary occlusions even if the duration of occlusion exceeds 6 months. PMID- 10150930 TI - Holmium YAG laser coronary angioplasty with multifiber catheters. AB - Excimer lasers are being extensively used for coronary angioplasty along with multifiber over-the-wire catheters. To determine whether another wavelength could be an alternative, the laser-tissue interaction and the clinical usefulness of an infrared laser were studied. The laser consisted of a Holmium YAG pulsed laser coupled into a multifiber catheter. Experimental data from our laboratory showed that this solid state laser had the ability to cut calcified tissue, to be preferentially absorbed by atheroma, and to ablate tissue even when the catheter tip was positioned at a distance from the target. These results were obtained with only minimal thermal effects. After assessment of the efficacy and safety of this technique, laser angioplasty was performed in 53 consecutive patients with totally occluded (40%) or stenosed (mean percent 94) coronary arteries with a mean length of 6 mm. The primary laser and the procedure success rate were 64% and 94%, respectively. Failures were due to inability to advance the catheter against the lesion or to cross the obstruction. Stand-alone laser therapy could be achieved in only 18% of patients. In previous dilatation failures, laser irradiation allowed for subsequent balloon angioplasty to be successfully performed at a lower inflation pressure than that used in the failed dilatation. Complications included abrupt (during the procedure) and early (within 24 hours) vessel closure in 19% of cases, dissection without hemodynamic consequence in 28% and spasm. Reoccluded arteries could all be recanalized with dilatation.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150931 TI - The influence of balloon inflation duration on the acute angiographic result of percutaneous transluminal coronary angioplasty. AB - This study was performed to evaluate the importance of the duration of balloon inflation during PTCA, by comparing two common inflation durations. Patients were randomized to a 30-second inflation protocol (group I, 83 procedures, 109 lesions), or a 60-second protocol (group II, 83 procedures, 115 lesions). There were no differences in baseline characteristics between the two groups, and no subsequent differences in mean inflation number (3.4 +/- 1.6 vs 3.1 +/- 1.6), residual stenosis (34% +/- 17% vs 33% +/- 16%), presence of dissection (29% vs 34%), or clinical success (89% vs 84%), group I versus group II, respectively. The 30-second inflations caused significantly less chest pain score (147 +/- 239 vs 399 +/- 516, P less than 0.001), and ST segment alteration (75 +/- 94 seconds vs 136 +/- 163, P less than 0.05). These results indicate that 60-second inflations do not produce a superior result to 30-second inflations. Furthermore, shorter inflations are much better tolerated. PMID- 10150932 TI - Coronary laser thermal angioplasty in the swine: reduced complications with shorter laser delivery time. AB - Although laser thermal angioplasty (LTA) with a laser heated metal probe has been tolerated in diseased human coronary arteries, definition of a safety threshold is lacking. Determination of safer operation parameters for coronary LTA using a new "over the wire" 1.3-mm laser probe catheter was attempted in seven normal pigs in which platelets were labeled with indium-111. Argon laser power of 10 watts was used for 1, 2, 3, and 5 seconds. Macroscopic findings, platelet deposition and histologic changes were compared between the laser treated coronary segments and controls, the nonheated laser probe, and the wire alone segments. After 1-second LTA, there was no vessel perforation or occlusive thrombi and only infrequent nonocclusive thrombi; platelet deposition was minimal; and histologic alterations rare and superficial. These findings were comparable to controls, the nonheated laser probe, and the wire alone segments. In contrast, vessels treated for 2, 3, and 5 seconds had more frequent perforation, and occlusive and nonocclusive thrombi that was accompanied by platelet deposition significantly greater than vessels treated with LTA for 1 second. A deep histologic injury was present in most of these segments. Additionally, the safety of laser delivery of 1 second repeated for five times was tested in two additional pigs. On macroscopic and histologic analysis the incidence of vessel perforation, occlusive and nonocclusive thrombi appeared slightly less when compared to the 2-, 3-, and 5-second LTA groups, and more than the 1-second LTA group.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150933 TI - Benefits of implantable defibrillators are overestimated by sudden death rates. PMID- 10150934 TI - "How do you spell relief?". PMID- 10150935 TI - The dilemma of "success". PMID- 10150936 TI - How to define success with coronary angioplasty? PMID- 10150937 TI - Can percutaneous transluminal coronary angioplasty be considered successful for managing coronary artery disease? PMID- 10150938 TI - Double-umbrella device for transvenous closure of patent ductus arteriosus and atrial septal defect: first experience. AB - A new device for transcatheter closure of heart defects was constructed and used to close a patent ductus arteriosus (PDA) in seven adult patients and an atrial septal defect (ASD) in six adult patients. The device consisted of two self opening umbrellas and a piece of Ivalon. A Dacron patch was sewn on the "male" umbrella for the ASD closure. The device required a 9 Fr introducing venous sheath for PDA and a 14 Fr sheath for the ASD. The venoarterial (right femoral vein-PDA or ASD-left femoral artery) long wire track was arranged. The "male" umbrella and the Ivalon were inserted transvenously one after another, advanced over the long wire across the PDA or ASD and extruded into the aorta or left atrium, respectively. The "female" umbrella was advanced transvenously over the long wire into the pulmonary artery (for PDA) or into the right atrium (for ASD). The metal conus on the long wire was used to pull the "male" umbrella while a special stiff pusher was used to bring the "female" umbrella to the "male" umbrella along the long wire. By these means the umbrellas interlocked at the defect level and closed it. The long wire was then removed through the left femoral artery. Protrusion of the interlocked device through the PDA occurred in one patient and through the ASD in two patients. In all three patients the device was kept on the wire until surgery and an early postrelease device embolization was avoided. In all other patients the defects were successfully closed. The follow-up of 3-27 months was uneventful in all patients. These results indicate that the described procedure is effective and safe, and warrants further clinical trial. PMID- 10150939 TI - Transfemoral plug closure of patent ductus arteriosus: experiences at Osaka Prefectural Hospital. AB - Transfemoral plug closure of PDA (patent ductus arteriosus), which was originally introduced by Porstmann in 1968, was successful in 73 of 74 consecutive patients at Osaka Prefectural Hospital. Some instrumental and technical modifications were made. There has been no mortality, and no dislodgment of the plug occurred after the modified plug with a barbed head was used although a major complication during the procedure was the dislodgment of the plug into the aorta, which occurred early in three cases. There was no recurrence of shunting or any other complications in the long-term follow-up studies. For the patient with a simple isolated PDA over 3 years of age, the catheter technique is considered to be the method of choice to close the ductus. PMID- 10150940 TI - Twenty-five years of experience from transfemoral catheter closure of patent ductus arteriosus. PMID- 10150941 TI - Indocyanine green angiography and dye-enhanced diode laser photocoagulation. PMID- 10150942 TI - Sensitivity of potassium iodide for hematologic staining. PMID- 10150943 TI - Transurethral laser resection of the prostate. AB - Transurethral laser resection of the prostate was performed on 25 patients for the management of bladder outlet obstruction secondary to prostatic hyperplasia. All of the patients in our series were treated on an outpatient basis and the majority of these under IV sedation. Patient selection was limited to older, high-risk patients who were poor surgical candidates for transurethral resection of the prostate or suprapubic prostatectomy because of underlying medical problems. Successful results were noted in 20 of the 25 cases (80%). Five procedures were unsuccessful because the patients were unable to spontaneously void after laser resection. Transurethral laser resection of the prostate utilizing the contact laser system is an acceptable alternative to transurethral resection of the prostate in advanced age, high-risk patients with small gland volumes. PMID- 10150944 TI - Immediate changes in stenosis geometry following stent implantation: comparison between a self-expanding and a balloon-expandable stent. AB - The immediate changes in stenosis geometry following Wallstent and Wiktor stent implantation in native coronary arteries were compared in 92 patients (46 in each group) using automated edge detection. Patients with comparable baseline stenosis characteristics were selected. Lesions were matched for lesion site, reference diameter, and minimal luminal diameter. In both groups, the stented coronary artery was the left anterior descending artery in 27 patients (59%), the left circumflex artery in four patients (9%), and the right coronary artery in 15 patients (33%). The baseline reference diameter was 2.86 +/- 0.39 mm and 2.87 +/ 0.42 mm in the Wallstent and Wiktor stent study group, respectively (NS). The baseline minimal luminal diameter was identical in both groups (1.13 +/- 0.24 mm). The nominal size (mean +/- SD) of the unconstrained Wallstent was 3.5 +/- 0.3 mm and 3.3 +/- 0.3 mm for the Wiktor stent (P less than 0.05). Both types of stents resulted in a similar increase in minimal luminal diameter immediately following implantation (Wallstent: 2.34 +/- 0.38 mm, Wiktor stent: 2.43 +/- 0.27 mm, NS). Furthermore, there was a similar decrease in diameter stenosis and increase in minimal luminal cross-section area following implantation of both stents. These morphological changes were associated with a normalization of the hemodynamic parameters in both groups. It is concluded that, although the Wallstent and Wiktor stent are different in design and mechanical characteristics, there is a similar immediate improvement in stenosis geometry following implantation of both devices. PMID- 10150945 TI - Femoral arterial hemostasis using a collagen plug after coronary artery stent implantation. AB - We have investigated the safety and efficacy of sealing the femoral arterial puncture site using purified bovine collagen in the catheter laboratory immediately after coronary stent implantation. Ten consecutive patients, mean age 64.6 years, pretreated with heparin, aspirin, and dextran underwent the insertion of a collagen plug immediately after coronary stent implantation. The mean activated clotting time was 512 seconds (range 320-999). Femoral arterial hemostasis was achieved before leaving the catheterization laboratory in nine of ten patients. Seven of these patients received additional mild groin compression with an air cushion compression device after hemostasis was successful. One of ten patients had persistent bleeding after delivery of the collagen plug and later required blood transfusion. The collagen plug may be a useful adjunct to obtaining hemostasis following coronary stent implantation, but further trials are required to test its reliability in fully anticoagulated patients. PMID- 10150946 TI - Nonoperative closure of the patent ductus arteriosus: the Frankfurt experience. AB - Nonoperative closure of patent ductus arteriosus (PDA) by means of Ivalon plugs (according to the technique of Porstmann) was performed in 101 patients. Sixty five patients were symptomatic, the Q p/Q s ratio exceeded 1.5 in 56 patients, and pulmonary hypertension (mean pulmonary artery pressure greater than 20 mmHg) was present in 50 patients. In 100/101 patients the PDA could be closed successfully. Ninety-nine patients were without any evidence of residual left-to right shunt. In one patient a hemodynamically insignificant left-to-right shunt was found with color Doppler echocardiography. Complications were pulmonary embolism due to plug dislocation in two patients (12th and 14th patient; 2 and 7 weeks after the procedure, respectively). One of these patients underwent elective surgery with patch closure of the ductus and removal of the embolized plug. In the other patient the ductus was successfully closed with a second larger plug while the first plug was left in a peripheral pulmonary artery. Surgical revision of the femoral artery was required in six and blood transfusion in two patients. Deep venous thrombosis developed in two patients. During follow-up (total follow-up time more than 200 patient years) no late complications were observed. In conclusion, transfemoral catheter closure of PDA by means of Ivalon plugs is an effective method. It is applicable to adolescents and adults with a low complication rate. The ductus can be closed without residual left-to-right shunt. Long-term results are excellent. PMID- 10150947 TI - Dissection following balloon angioplasty of aortic coarctation: review of the literature. AB - Balloon angioplasty of the coarctation of the aorta can result in intimal or medial or even adventitial dissections as demonstrated by in vitro studies and animal experiments. As a typical sign of stretching of the aortic wall, patients complain of pain during the angioplasty procedure. In the literature, aortic wall rupture and ventricular fibrillation during the procedure are reported. Additional sudden deaths can occur within 40 hours after the procedure. Mortality ranges from 0.1% to 2.5%. By transesophageal echocardiography, monitoring of balloon angioplasty, control of the positioning of the balloon, and control of the results and detection of complications are possible. Intimal as well as medial dissections can be detected with observed healing for intimal but also medial dissections. In order to avoid the patient's discomfort, intraaortic ultrasound will be used in the future, when major methodological improvements are done. Computed tomography demonstrates medial dissections but is not able to visualize intimal dissections. Using computed tomography and magnetic resonance after angioplasty of the coarctation of the aorta, irregularities are described in up to 17% of the patients. For angiography, a low detection rate of medial dissections has to be expected, when not biplane angiographies of the whole thoracic aorta are performed. Medial dissections can be seen, but intimal dissections are missed. In conclusion, a review of the literature demonstrates a high incidence of intimal and medial dissections after angioplasty of the coarctation of the aorta with spontaneous healing in most patients. As is the way with coronary angioplasty, aortic wall ruptures are rare, but stand-by surgery is necessary. PMID- 10150948 TI - Success rate and incidence of restenosis following coronary excimer laser angioplasty: results of a single center experience. AB - The initial single center experience of percutaneous coronary excimer laser angioplasty is described for the first three series of 147 patients. Sixty patients were treated with a prototype 1.4-mm laser catheter, 40 patients with improved transmission devices, and the third series of 47 patients with an increased pulse width of the laser system allowing improved energy transmission. In 17 patients (12%) laser angioplasty could not be initiated due to inability to cross the lesion with the guidewire or to place the catheter coaxially within the vessel. In 32 patients (58%) of series 1, 11 patients (31%) of series 2, and 17 patients (43%) of series 3, additional balloon dilatation following laser treatment was necessary due to vessel closure (24%) or due to an insufficient angiographic result (35%). There was one death in series 1 (2%) and 2 (3%) each, one perforation in series 2 (3%), two transmural myocardial infarctions in series 1 (4%), and one myocardial infarction in series 2 (3%). During the 6-month follow-up period one patient in series 2 (2%), and one patient in series 3 (3%) died. Angiographic restenosis was found in 22, 12, and 11 patients of series 1 (40%), 2 (34%), and 3 (27%), respectively. No patient developed a transmural myocardial infarction. Thus, percutaneous coronary excimer laser angioplasty can be performed as a safe and feasible procedure in patients with coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150949 TI - Acronyms in angioplasty and restenosis: a summary of recent and ongoing clinical randomized trials. AB - Trials that pertain to angioplasty and restenosis are a major focus of clinical research in cardiology at present. Investigators, especially those involved in multicenter studies, have become experts in the derivation of acronyms to identify these trials. Meant to capture the spirit of the trial and the attention of those reading the eventual publication of the results, these abbreviations have proliferated in recent times. This article summarizes the major trials with acronym titles, spells out what they stand for, defines what was investigated, and reviews the reported results. PMID- 10150950 TI - Evaluating the success of new devices for coronary intervention. PMID- 10150951 TI - New devices versus conventional balloon technology in patients with coronary artery disease. PMID- 10150952 TI - Impact of new technology on interventional cardiology. PMID- 10150953 TI - Percutaneous balloon coarctation angioplasty: long-term results. AB - One hundred and ten patients, age 2 days to 35 years (mean 7.0 +/- 7.0 years), have undergone 118 percutaneous balloon angioplasty procedures for discrete coarctation of the aorta since April 1982. The mean systolic gradient was significantly decreased from 48 +/- 22 to 8 +/- 7 mmHg after angioplasty (P less than 0.0001). Long-term results were evaluated in 95 patients, by follow-up catheterization in 30 and Doppler echocardiography in 65 patients. The follow-up period was 1-9 years (4.2 +/- 2.1). At follow-up the mean residual gradient was 9 +/- 8 mmHg. On the basis of follow-up data, four groups of patients were identified: group I consisted of 53 patients over 3 months of age with native coarctation of the aorta; group II consisted of 13 patients with postoperative coarctation restenosis; group III consisted of 21 infants 3 months of age or younger with native coarctation of the aorta; and group IV consisted of eight infants who developed postdilatation restenosis. Patients in groups I and II had good results and required no redilatation or surgical repair. In group III successful redilatation in eight and surgical repair in seven infants were performed 1 month to 5 years after the initial dilatation. There were no mortalities related to the 118 dilatation procedures. Of the seven patients who had surgical repair of the coarctation and the associated cardiac anomalies, four expired in the immediate postoperative period.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150954 TI - Cardiovascular product update and evaluation. What's hot, what's not, what's in, what's out. PMID- 10150955 TI - Acute and mid-term experiences with the Wiktor stent in acute complications and restenosis after coronary angioplasty. AB - We report about the 6-month follow-up of 28 consecutive patients treated with a new tantalum stent (Wiktor? stent, Medtronic, Inc.). Indication for stenting was the prevention of restenosis in eight patients (restenosis group), and threatening or acute closure after PTCA in 20 patients (acute closure group). Twenty-eight of 30 stents were successfully positioned in 27 of 28 patients (96%), whereas implantation failed twice in one patient. Immediate stent occlusion developed in two patients in the acute closure group (7.4%) Subacute stent occlusion was observed in three patients (11%), one in the restenosis group, two in the acute closure group, between 3 and 5 days after implantation. Coronary bypass surgery had to be performed in four patients (15%): one patient after failed stent placement, two after acute, and one after subacute stent thrombosis. Major bleeding complications related to the anticoagulative drug regimen occurred in nine patients (33%). Three patients (11%) died for reasons most probably not related to stent implantation. A 6-month angiographic follow up revealed restenosis in two of 19 patients (11%), one patient in each group. Sixteen of the 27 stented patients (59%) reached 6-month follow-up without death, acute or subacute stent thrombosis, or restenosis. It is concluded that the Wiktor stent can be placed with a high rate of success. It may also reduce the risk of restenosis. The stent also offers the possibility to circumvent emergency bypass surgery in case of PTCA related vessel occlusion. Acute and subacute stent occlusion still remains an unsolved topic. PMID- 10150956 TI - Early and long-term results of catheter ablation in patients with incessant ventricular tachycardia. AB - Catheter ablation of sustained monomorphic ventricular tachycardia (VT) with high energy DC shock (360-400 J) was performed in 11 patients with incessant VT (duration greater than 24 hours), refractory to antiarrhythmic drugs, and DC cardioversion. There were ten patients with coronary disease and one patient had dilated cardiomyopathy. Direct current energy was delivered at the earliest endocardial activation in six patients (group I) or at the area of slow conduction in five patients (group II). Incessant VT was terminated by DC ablation in nine patients (82%). After the ablation procedure VT remained inducible in four patients in group I (67%) and in one patient (20%) in group II. Two patients in group II had to go to emergent surgery. During the mean follow up of 31 +/- 26 (1-66) months nonfatal VT recurrences occurred in five patients in group I and in one patient in group II. PMID- 10150957 TI - Development of a polymer endovascular prosthesis and its implantation in porcine arteries. AB - A polyethylene-terephthalate braided mesh stent has been developed for application in the (coronary) arterial tree. In vitro measurements showed that the radial pressure delivered by this device was in the same range as that of a stainless steel stent. Hysteresis-like behavior, however, occurred after constraining the polyester stent for a period of only 15 minutes on a delivery system for percutaneous implantation. This implies that the polymer stent must be mounted on this delivery system immediately before the placement procedure, and that either a diameter in the unconstrained condition must be selected, which is considerably larger than the diameter of the target vessel, or stent expansion has to be enhanced by balloon expansion. Taking into account the results obtained during the in vitro studies, we investigated the angiographic patency and histologic features after implantation of this polyester stent in peripheral arteries of pigs. In four animals eight stents were placed. Except for heparin during the implantation procedure only, antithrombotic or antiplatelet drugs were not administered. After 4 weeks repeat angiography was performed. Angiography revealed that five of the six correctly placed stents were patent. At autopsy, two additional patent stents proved to be located in the aortic bifurcation, probably due to failure of the delivery system. Quantitative assessment showed that the mean luminal diameters of the site of stent placement were 3.3 +/- 0.2 mm before, 3.2 +/- 0.2 mm immediately after, and 3.1 +/- 0.3 mm at 4 weeks after implantation. Histology demonstrated an inflammatory reaction of variable severity around the stent fibers. Quantitative histologic measurements showed that the thickness of the neointima was 114 +/- 38 mum after 4 weeks. In conclusion, polyester stents can be constructed with mechanical properties similar to stainless steel stents. Hysteresis-like behavior of polyester stents, however, influences the selection of the nominal stent diameter as well as the forces exerted to the vessel wall. After implantation in porcine peripheral arteries, five of six correctly placed stents were patent at 4 weeks. The extent of neointimal proliferation was similar to that observed after placement of metal stents in swine, despite the presence of a more pronounced inflammatory reaction. PMID- 10150958 TI - A new bioabsorbable intravascular stent: in vitro assessment of hemodynamic and morphometric characteristics. AB - Currently available intracoronary stents are permanent and their placement may be complicated by thrombosis and restenosis. We have developed a new bioresorbable stent constructed of type I collagen. This stent has a compliant tubular structure that is self expanding and carries a net negative surface charge to increase hemocompatibility. In vitro histologic and morphometric examination was performed by deploying the stent in six pressure fixed explanted porcine arteries. Morphometry revealed a close relationship between the stent external diameter 2.9 +/- 0.4 mm) and the arterial lumen diameter (3.0 +/- 0.4 mm). A relative reduction in arterial lumen diameter secondary to stent placement of 17% to 26% was observed. Folding of the stent wall was noted in those preparations where the stent external diameter was larger than the arterial lumen diameter. Polyvinyl chloride (PVC) tubing was used as a mock arterial segment for flow studies. Flow at baseline and following stent placement was determined at perfusion pressures of 10, 50, and 80 mmHg. A modest reduction in flow following stent placement of between 2% and 6% was observed. Thus, type I collagen may be used to construct a self expanding tubular stent. Morphometric and hemodynamic evaluation reveals a modest impact on arterial lumen dimensions and flow. PMID- 10150959 TI - Surgical repair of coarctation: early and late results. PMID- 10150960 TI - Transcatheter closure of the patent ductus arteriosus in adults. PMID- 10150961 TI - Catheter ablation for cardiac arrhythmias, personnel, and facilities. The NASPE Ad Hoc Committee on Catheter Ablation. PMID- 10150962 TI - Progress in interventional cardiology. Restenosis after elective percutaneous transluminal coronary angioplasty. PMID- 10150963 TI - MRM promises earlier breast cancer diagnosis. PMID- 10150964 TI - Maternal serum screening for neural tube defects and Down syndrome. PMID- 10150965 TI - Epidemiologic aspects of global blindness prevention. AB - The number of blind persons in the world is not accurately known. However, taking into account previous estimates by the World Health Organization and adjusting to the world population of 1990, it is likely that there are at least 35 million blind people if we apply the internationally accepted definition of blindness as vision less than 3/60 ( less than 20/400 or 0.05) in the better eye. If the threshold of vision less than 6/60 ( less than 20/200 or 0.1) is applied, the above figure can be increased by roughly 50%, ie, going well beyond 50 million blind people. To this somber picture should be added the effects of aging on populations in both developed and developing countries. Longer life expectancy is going to dramatically increase the need for eye care to prevent visual loss from such conditions as cataract, glaucoma, diabetic retinopathy, and macular degenerations. Corneal blindness, resulting mainly from trachoma and other infections, is apparently showing a downward trend, but there are still foci of severe disease. Thus the need for trichiasis surgery remains, and some recently evaluated techniques offer particularly good results. On the other hand, xerophthalmia due to vitamin A deficiency is still a major public health problem, causing both visual loss and increased mortality. It should be possible, by targeting ivermectin distribution programs to high-risk populations, to gradually eliminate onchocerciasis as a cause of blindness; however, the long-term sight saving effect of ivermectin in cases of established ocular lesions needs to be confirmed. PMID- 10150966 TI - Tissue ablation with excimer laser and multiple fiber catheters: effects of optical fiber density and fluence. AB - This study was performed to assess the ablational properties of 1.4-, 1.7-, and 2.0-mm wire-guided multiple fiber catheters coupled to a XeCl excimer laser. Samples of postmortem human aorta were irradiated in blood at fluences of 40, 50, and 60 mJ/mm 2. Our results indicate that: 1) an increase in the active irradiation coverage results in an increase in the ablation efficiency; 2) the ablation efficiency is not fluence related using the 1.4- or 1.7-mm multiple fiber catheter but efficiency is fluence dependent using the 2.0-mm multiple fiber catheter; 3) the depth of tissue ablated with a multiple fiber catheter depends primarily upon the proportion of the active irradiation coverage at the catheter tip; 4) the 2.0-mm multiple fiber catheter induces craters surrounded by a larger zone of tissue damage than that observed with the 1.4- or 1.7-mm multiple fiber catheter; and 5) the 2.0-mm multiple fiber catheter should be used cautiously for laser angioplasty because of its high penetration and its risk of arterial wall damage. PMID- 10150967 TI - Wire-guided excimer laser coronary angioplasty: instrument selection, lesion characterization, and operator technique. AB - Laser angioplasty has now been successfully performed on over 2,000 patients worldwide. Two systems (Advanced Interventional Systems, and Spectranetics, Corp.) have now received initial approval from the Food and Drug Administration. As with all new interventional techniques designed as an alternative to balloon angioplasty, there are a variety of instrument related issues that merit consideration in terms of patient selection as well as operator technique. While the ultimate role of laser angioplasty in the percutaneous revascularization of coronary artery disease remains to be established with certainty, laser angioplasty is, in fact, being currently used on a widespread basis as an alternative or an adjunct to balloon angioplasty in a large number of centers worldwide. Industry projections suggest that the use of this technique will increase further over the next decade. Accordingly, the purpose of this article is to discuss specific issues regarding instrumentation, native anatomical considerations, operator technique, and complications that relate specifically to the applied use of this technology as it is currently being used. PMID- 10150968 TI - The use of the holmium:YAG laser in coronary disease: the utility of a unique lensed fiber catheter. AB - Alternatives to balloon angioplasty, which has a restenosis rate of 25%-68%, are being sought for patients at high risk for restenosis. The mid-infrared holmium laser may have properties more advantageous for coronary angioplasty than the ultraviolet excimer laser. The Coronary HaloCath (Trimedyne, Inc.) has a diverging lens that allows the beam diameter to approximate the catheter tip diameter, increasing the size of the channel that can be created by laser ablation. This unique ability may make it more efficacious in treating arteriosclerotic disease. This device was used to treat: 1) a chronic total occlusion, creating a recanalized diameter larger than the catheter diameter; and 2) an ostial right coronary stenosis, which opened more readily than would have been expected with balloon angioplasty. The Coronary HaloCath may prove useful in difficult-to-treat coronary lesions. PMID- 10150969 TI - Percutaneous angioplasty of chronic obstruction of peripheral arteries by a temperature-controlled Nd:YAG laser system. AB - The feasibility of an Nd:YAG laser system with automatic control of hot-tip probe temperature was examined in 15 segments (14.7 +/- 6 cm in length) of iliofemoral arteries from 13 patients. The hot-tip temperature to be attained and the upper limit temperature at which lasing was to be stopped were preset. A catheter with a 1.8-mm hot-tip probe was introduced into the obstructed segment and angioplasty (lasing time 5-10 sec) was performed under angioscopic guidance. Recanalization was observed in all segments without obvious complications. No thermal effects below 50 degrees C, coagulation at 100 degrees C, carbonization at 200 degrees C, or sticking of the hot-tip to the luminal surface at 300 degrees C or over, were observed by angioscopy. Rapid recanalization was obtained between 200 degrees C and 300 degrees C. The results indicate that this novel laser system is feasible and hot-tip temperature between 200 degrees C and 300 degrees C is ideal for treatment of chronic arterial obstruction in Japanese patients. PMID- 10150970 TI - Current status of holmium laser coronary angioplasty. PMID- 10150971 TI - Rotational angioplasty and directional atherectomy to treat complex lesions of the right coronary artery. AB - A combination of interventional devices including the Rotablator and directional coronary atherectomy (DCA) was used to treat a 39-year-old patient with a complex lesion of the right coronary artery. The devices enabled the recanalization and reconstruction of the diseased vessel without laceration or dissection, leaving a smooth-edged segment. The histological analysis of the tissue obtained from DCA revealed no predictors of restenosis, like highly cellular material or media. Thus, combination of mechanical interventional devices allowed to treat a highly complex lesion without lacerating the vessel and leaving an excellent acute and long-term outcome. PMID- 10150972 TI - Hockey stick guiding catheter. AB - Guiding catheter strategies form an important component of successful PTCA. Selection of appropriate guiding catheters is essential for providing adequate back-up support and visualization. Hockey stick guiding catheters are an excellent choice for performing PTCA of the right coronary artery and for saphenous vein grafts. PMID- 10150973 TI - Progress in interventional cardiology. PMID- 10150974 TI - Transrectal ultrasonography of BPH. PMID- 10150975 TI - Pediatric cardiac surgery. AB - Although there is fair agreement in many areas of pediatric cardiac surgery, issues of controversy and uncertainty persist. The role of the Fontan procedure in the treatment of complex congenital heart lesions is expanding, mainly by necessity, because an alternative biventricular repair is often not available. Reports on medium- and long-term results after Fontan's operation clearly demonstrate the palliative nature of the procedure, even in good candidates, and do not seem to support the widening of its indications. The purpose of this paper is to highlight this controversy, as well as to report on the state of affairs in the treatment of hypoplastic left heart syndrome, transposition of the great arteries, and tetralogy of Fallot. PMID- 10150976 TI - Rhodamine-auramine O versus Kinyoun-carbolfuchsin acid-fast stains for detection of Cryptosporidium oocysts. AB - The rhodamine-auramine O stain was compared with the Kinyoun carbolfuchsin acid fast stain for detection of Cryptosporidium oocysts in samples from patients infected with the human immunodeficiency virus (HIV). A total of 283 fecal specimens from HIV-infected patients were examined for the presence of Cryptosporidium oocysts. Duplicate smears of the fecal concentrates, prepared by the formalin ethyl acetate procedure, were stained by the Kinyoun carbolfuchsin and fluorescent rhodamine-auramine O acid-fast methods. The Kinyoun stain detected 13 positive specimens, while the rhodamine-auramine O stain detected 14 positive specimens. The average time required to survey a stained smear was 2.5 minutes with the fluorescent method, compared with 6.0 minutes with the Kinyoun technique. The rhodamine-auramine O stain is a dependable and efficient method of examining fecal smears for the presence of Cryptosporidium oocysts in a high-risk population. PMID- 10150977 TI - Transurethral microwave thermotherapy (TUMT). PMID- 10150978 TI - Problems for improving performance in immunoassay. PMID- 10150979 TI - Plasma exchange for Refsum's disease. AB - Five patients with Refsum's disease were treated by plasma exchange. Lowering the plasma phytanic acid by plasma exchange in patients acutely ill with Refsum's disease produced clinical improvement. Plasma exchange is indicated in Refsum's disease when there is a worsening clinical condition. Occasionally, failure of dietary control of Refsum's disease may necessitate plasma exchange. PMID- 10150980 TI - The Gram stain: still a diagnostic tool? PMID- 10150981 TI - Hyperthermia for BPH: acceptance uncertain despite apparent safety. PMID- 10150982 TI - Aortic balloon dilatation as a treatment of aortic stenosis: what are the indications? PMID- 10150983 TI - The treatment of aortic stenosis: is valvuloplasty ever an alternative to surgery? AB - The desire to extend the principle of balloon angioplasty to cardiac valve disease is understandable and commendable. Aortic valvuloplasty is associated, however, with an excessive complication rate, as reported by the Mansfield Scientific Aortic Valvuloplasty Registry (20.5% overall, including a 4.9% death rate within 24 hours and an additional 2.6% rate within 7 days for a 7.5% 1-week mortality). In contrast, the operative mortality for aortic valve replacement now ranges from 3%-5%, with perioperative complications far less than the one in five associated with valvuloplasty. Even if the two procedures had equivalent morbidity and mortality rates, the high incidence of restenosis (30%-60% range at 6 months) for the balloon technique precludes its widespread use for aortic stenosis. Despite the poor mid- and long-term results for balloon valvuloplasty, the procedure may have limited application in some clinical situations. Indeed, there are patients with concomitant systemic illnesses or advanced age ( greater than 80 years) who would not be good surgical candidates. In particular, valvular balloon dilation may be useful in bridging a seriously ill patient to a condition more favorable for replacement therapy. With few exceptions, however, valve replacement remains the gold standard for treatment of adult aortic stenosis. PMID- 10150984 TI - Percutaneous coronary intervention for diffuse coronary artery disease. AB - Patients with diffuse coronary artery disease present a significant management problem. It has been proposed that diffuse coronary disease is unsuitable for balloon angioplasty and surgical treatment is not ideal either. We review the evidence that coronary balloon angioplasty is not a suitable treatment for diffuse coronary disease and examine the role of alternative interventional techniques. New techniques including long angioplasty balloon catheters and atherectomy devices have shown promise. If this is confirmed by prospective randomized trials then coronary angioplasty may yet prove an attractive treatment for diffuse coronary disease. PMID- 10150985 TI - Mechanical dilatation rather than plaque removal as major mechanism of transluminal coronary extraction atherectomy. AB - Atherectomy with the transluminal extraction endarterectomy catheter (TEC) is a new approach for treatment of coronary artery disease, which continues to undergo FDA investigational studies. The major mechanism of the TEC device should be excision of plaque and its removal due to suction applied through an attached vacuum. We report about the acute results in 24 patients treated with TEC atherectomy in native vessels and the outcome of 18 patients who, until recently, underwent follow-up catheterization after 6 months. The procedure was successful (residual stenosis less than 50%) in 7 of 24 patients with TEC atherectomy alone (29%); 15 of 24 patients (65%) required additional PTCA in order to achieve angiographic success (10 of 24) or to treat total occlusion (2 of 24) or distal embolization (3 of 24) following atherectomy. One TEC attempt failed due to guiding catheter problems, another major complication was a vessel perforation leading to a non-Q wave infarction. The minimal residual diameter after passage of the stenosis (prior to additional PTCA) with the 5.5 Fr catheter (n = 14) was 1.5 +/- 0.2 mm, with the 6 Fr catheter (n = 9) 1.8 +/- 0.4 mm, and 2.2 +/- 0.2 mm using the 7 Fr catheter (n = 10). The histologic findings revealed intimal cells, fibrous tissue, and homogenate with no identifiable tissue in five cases (21%), whereas in 17 patients (72%) light microscopy could only assess blood cells.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150986 TI - The Bard Rotary Atherectomy System (BRAS): initial experience in patients with peripheral vascular disease. AB - Sixteen patients with a mean age of 65.4 +/- 9.8 years and suffering from peripheral vascular disease underwent peripheral atherectomy using a new mechanical device--the BARD Rotary Atherectomy System (BRAS). The BRAS is an "over the wire" system that consists of a spiral guidewire and a handheld motor drive unit, which rotates at 1,500 rpm. Prior to the procedure angiography demonstrated the presence of 18 obstructions (1 tibial, 2 popliteal, 15 superficial femoral arteries) with a mean stenosis of 95.7 +/- 8%. Successful atherectomy was achieved in 16 of 18 lesions and resulted in an 89% immediate success rate and a significant (P less than 0.01) reduction of stenosis to 37.8 +/- 12.5%. There were no significant complications. The excised and removed material embedded over the spiral guidewire demonstrated the presence of fibrotic tissue, fatty lesions, and calcium deposits. Medial or adventitial layers were not present in the removed atherosclerotic material. Mean ABI was significantly (P less than 0.01) increased from 0.38 +/- 0.17 to 0.55 +/- 0.21 following atherectomy. Angiographic follow-up obtained in ten patients 8.8 +/- 5.2 months following the procedure demonstrated restenosis in six of those ten patients. The ABI at this time remained unchanged. These results demonstrated that the new BRAS mechanical atherectomy system is feasible and safe for recanalization of severely stenosed arteries in patients with peripheral vascular disease. PMID- 10150987 TI - Percutaneous coronary angioscopy: applications in interventional cardiology. AB - We performed percutaneous coronary angioscopy in 35 patients to study the surface morphology of coronary artery lesions. Twenty-five patients had angioscopy performed in conjunction with PTCA, including 20 patients with de novo lesions (16 patients with unstable angina, four patients with stable angina), and five patients with restenosis lesions. Ten cardiac transplant patients had angioscopy performed in conjunction with annual follow-up angiography in attempt to identify accelerated atherosclerotic lesions. There were no complications of angioscopy in any patient. There were no intracoronary thrombi seen either by angiography or angioscopy in the stable angina patients. In the unstable angina group, angiography identified thrombus in 2 out of 16 (12.5%) versus 15 out of 16 (94%) (P less than 0.001) with angioscopy. Following angioplasty, dissections were seen angiographically in 7 out of 16 (44%) of patients versus 16 of 16 (100%) of the patients by angioscopy (P less than 0.01). Restenosis lesions were characterized by a white, fibrous appearance instead of the usual yellow color of primary atherosclerotic lesions. In the ten cardiac transplant patients, angioscopy appeared to be more sensitive than angiography for the detection of atherosclerosis. Yellow (atherosclerotic) and white (fibrotic) plaques were seen in the transplant patients, which often were not detected by angiography. In summary, angioscopy is an excellent tool for visualizing the surface morphology of coronary artery lesions. The clinical indications for angioscopy remain undefined at present.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150988 TI - Ultrasonic thrombus ablation: in vitro assessment of a novel device for intracoronary use. AB - An ultrasonic thrombolysis device designed for intracoronary use was developed and evaluated in vitro to assess efficacy in achieving clot ablation without deleterious effects, such as heat generation and production of large particles during clot ablation. Studies on 31 samples with a bench-top version demonstrated that clot ablation was rapid (typically 2 mL in under 2 minutes) and no macroscopic particles were released. The fluid produced did not reclot. Studies with a clinical version of the device that can be passed through a 10 Fr PTCA guiding catheter confirmed that clot ablation was rapidly achieved. Little particulate material was produced and the maximum temperature achieved did not exceed 52 degrees C. The device functions well in vitro, releasing little particulate material and causing limited local heating. It seems suitable for intracoronary use and will undergo further in vivo testing. PMID- 10150989 TI - Ultrasound angioplasty--a review. PMID- 10150990 TI - Progress in interventional cardiology. PMID- 10150991 TI - Can a stent succeed in keeping the prostatic urethra open? PMID- 10150992 TI - MRI and ultrasound guided interstitial Nd:YAG laser phototherapy for palliative treatment of advanced head and neck tumors: clinical experience. AB - Interstitial laser phototherapy (ILP) is a technique whereby laser energy is directly applied into tumors at variable depths. This technique is attractive, since it is minimally invasive and carries a low morbidity. It may allow treatment of deep and difficult to reach tumors in the head and neck and other areas when improved noninvasive monitoring techniques of laser-tissue interactions are developed. Recent studies demonstrate, respectively, the efficiency of ultrasound (UTZ) and magnetic resonance imaging (MRI) for real time interstitial needle placement in tumors, identification of vessels, monitoring and quantifying laser-induced tissue damages. We present a case in which a patient with recurrent, metastatic base of skull carcinoma has managed successfully with repeat ILP using MRI and UTZ guidance. Under heavy sedation, needles were placed in the tumor using MRI or UTZ guidance. Tumors were treated with a 600 mum flexible Nd:YAG laser fiberoptic passed through the needles. Laser-induced tissue photoablation was monitored using real time color flow Doppler UTZ or near real time fast spin-echo T2-weighted MRI. Posttreatment fine needle aspiration cytologic study demonstrated the presence of cellular debris and no viable cancer cells. Posttreatment follow-up MRI scans showed significant reduction of tumor size, and positron emission tomography (PET) revealed interval decrease in tumor metabolism. Treatments were accompanied by pain relief and improved functional abilities. ILP has now evolved into minimally invasive outpatient surgical procedure.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10150993 TI - Transurethral laser prostatectomy: a comparison of contact tip mode and lateral firing free beam mode. AB - Transurethral laser prostatectomy was performed on 66 patients for the management of bladder outlet obstruction secondary to prostatic hyperplasia. All of the patients were treated on an outpatient basis primarily using IV sedation or spinal anesthesia. Selection consisted of patients with obstructive voiding symptoms who would be considered candidates for transurethral resection of the prostate (TURP). Thirty procedures were performed with the contact tip laser probe, with successful results noted in 24 cases (80%). Thirty-one of the 36 patients who underwent laser prostatectomy using the lateral firing free beam probe experienced a significant improvement in their obstructive voiding symptoms, for a success rate of 86%. Transurethral laser prostatectomy using the contact tip laser system or the lateral firing free beam mode appears to be an acceptable alternative to TURP in individuals with obstructive voiding symptoms. PMID- 10150994 TI - Histologic identification of polyethylene wear debris using Oil Red O stain. AB - Ultra high molecular weight polyethylene (UHMWPE) wear particles are frequently implicated in causing failure of total joint arthroplasties by eliciting a foreign body reaction. The majority of these particles are subcellular and many are submicron in size. Identification of these small particles of UHMWPE by conventional histologic techniques is difficult. We have therefore investigated the utility of Oil Red O (ORO) stain to identify UHMWPE on histologic sections. A wide variety of specimens was studied including an experimental rabbit model with subcutaneous implantation of polyethylene particles as well as specimens from clinical cases with joint arthroplasties. The sensitivity and specificity of ORO stain was compared to conventional polarized light microscopy for the identification of particulate UHMWPE debris. The ORO stain was found to be as sensitive in identifying particulate UHMWPE debris as polarized light microscopy. However, ORO stain was less specific: two specimens did not contain any UHMWPE also stained with ORO. Careful examination of standard hematoxylin and eosin stained sections with polarized light was therefore more specific for the identification of particulate UHMWPE. As a single test, the ORO stain does not appear to offer any clear advantage specifically for the identification of UHMWPE. PMID- 10150995 TI - Strong future for imaging-guided minimally invasive surgery. PMID- 10150996 TI - Echocardiography in the management of single ventricle: fetal through adult life. AB - Echocardiography contributes to the management of patients with single ventricle by providing an initial comprehensive evaluation in fetal and neonatal life. This allows planning of the initial surgical palliation, usually without the need for cardiac catheterization. Serial surveillance for problems such as subaortic stenosis, valvar insufficiency, or complications of the mitral palliation aids in planning for the timing and type of subsequent surgical procedures. Evaluation of single ventricle size, shape, and mass provides some indication of risk for a Fontan procedure. Transesophageal echocardiography provides an excellent window for the evaluation of the interatrial baffle for shunts, thrombi, or occlusion in the early postoperative period. Later, studies of ventricular and valve function help to direct medical management such as afterload reduction and diuretic therapy. PMID- 10150997 TI - Bigger is not necessarily better: in search of an optimal (not maximal) atherectomy result. PMID- 10150998 TI - Balloon-expandable stent treatment of experimental coarctation of the aorta: early hemodynamic and pathological evaluation. AB - The present study was intended to evaluate the acute and short-term hemodynamic, angiographic, and pathological response to balloon-expandable stent treatment of experimental coarctation of the aorta. A discrete thoracic coarctation was surgically created in six mongrel dogs (two adults, four puppies). Two months postoperatively all six dogs (8.9-30 kg) underwent left heart catheterization and coarctation stenting performed through a femoral artery cutdown. A Palmaz PS-30 stent was advanced to the coarctation through a 10 French sheath, and expanded with an angioplasty balloon chosen to equal the diameter of the proximal aorta (9 12 mm). Stent implantation was successful in each dog. The systolic pressure gradient decreased from 26.3 +/- 9.1 mmHg (mean +/- SE) to 0.5 +/- 0.5 mmHg (P = 0.04), and the coarctation diameter improved from 50 +/- 6% to 82 +/- 6% of the diameter of the proximal descending aorta (P less than 0.01). Follow-up catheterization 4-7 weeks after stenting documented no stent migration, early restenosis, thrombosis, obstruction of arterial side branches, or aneurysm formation. Pathological evaluation of the explanted segments of stented aorta documented that by 6-7 weeks the stents are covered by a neointima composed of intimal proliferation and fibrosis with an endothelial cell surface. These data suggest that balloon-expandable stainless steel stents provide excellent acute and short-term relief of coarctation in this experimental model. Larger and longer-term studies are needed to better assess the incidence of restenosis or aneurysm formation following stenting of coarctation of the aorta. PMID- 10150999 TI - Selective coronary angiography in intracardiac tumors. AB - Cardiac catheterization and selective coronary angiography were performed in ten patients with intra-cardiac tumors [left atrial myxoma (7), right atrial myxoma (1), angiosarcoma of right heart (1), and right ventricular tumor (1)]. The patient with angiosarcoma had characteristic hemodynamics suggesting cardiac compression. The coronary arteriographic finding included: neovascularization (8); filling defect due to emboli (1); and displacement of coronary artery (1). Tumor neovascularization from branches of the left circumflex or right coronary artery was invariably observed in patients with myxoma. We conclude that invasive studies are safe, provide additional information of academic interest, and occasionally aid in the diagnosis. PMID- 10151000 TI - Coronary angiography with 5 French diagnostic catheters may miss an ostial left main stenosis. AB - Critical ostial left main disease may lead rapidly to sudden death and is, therefore, of paramount importance to diagnose. While the number of cardiac catheterizations is increasing, government and third party reimbursement sources are imposing pressure to perform more studies in an outpatient setting, as the economic resources for medical procedures are shrinking. Outpatient cardiac catheterization requires the patient to ambulate within several hours after the procedure. In order to allow patients to safely ambulate early after their procedures, 5 French catheters are often used (whether the femoral or brachial approach is used) rather than the standard 7 French catheters. We describe a patient with an ostial left main stenosis that was not visualized when coronary arteriography was performed using a diagnostic 5 French catheter. Selective intubation of the left main coronary artery was easily achieved without damping of the pressure tracing. Selective coronary angiography did not demonstrate the ostial stenosis, and there appeared to be a normal amount of contrast refluxing into the aortic root. When the patient returned for an angioplasty and a guiding angiogram was performed with an 8 French catheter, an ostial stenosis was evident with coronary angiography. PMID- 10151001 TI - Comparison of catheter ablation using direct current energy versus radiofrequency: observations in 147 patients with supraventricular tachyarrhythmias. AB - We studied the follow-up of 147 patients who underwent catheter ablation because of drug resistant supraventricular tachyarrhythmias. Direct current (DC) ablation was performed in 116 patients, while 31 patients underwent radiofrequency (RF) ablation. In 101 patients (87%) with DC ablation and in 28 patients (90%) with RF ablation, complete atrioventricular (AV) block was achieved initially. Fifteen patients (13%) with DC ablation and three patients (11%) with RF ablation resumed AV conduction. Serious complications occurred in eight patients (7%) with DC ablation and in none of the patients with RF ablation. During the mean follow-up of 45 +/- 24 months, 13 patients died (11%) who underwent DC ablation; during the mean follow-up of 11 plus or minus 3 months, no patient died who had had RF ablation. Transcatheter ablation using DC or RF is an effective treatment in patients with drug resistant supraventricular arrhythmias, providing a beneficial long-term outcome including an improved quality of life. Although the risk of complications is low, this procedure should be reserved for patients with supraventricular arrhythmias who do not respond to conventional drug therapy. PMID- 10151002 TI - Effects of ultrasound energy on total peripheral artery occlusions: initial angiographic and angioscopic results. AB - Ultrasonic energy has been shown to ablate atherosclerotic plaques and arterial and venous thrombi. We used an ultrasonic angioplasty device developed by our group in ten patients with totally occluded femoral artery during surgical bypass. Ultrasonic angioplasty was performed with a 130-cm long and 0.8-cm diameter titanium probe with a 2- or 2.5-mm titanium ball-tip. In one patient, angioplasty could not be performed. Angiographic and angioscopic examination were performed before and after angioplasty in nine patients. Before ultrasound recanalization, angioscopic examination showed that the proximal end of the occlusion was formed by atheromatous material in 3 cases, red thrombus in 3 cases, amd white thrombus in 3 cases. After ultrasound recanalization, angioscopy showed residual stenosis at the site of entry in only one case. In three other cases, the artery was free of residual stenosis without persistent clot. In the five other patients, a residual stenosis was present beyond the proximal occlusion point with some fibrin mesh and small clots. At angiography, flow was restored in 4 cases; in 4 patients flow rate of entry was slow in the distal segment; and in 1 patient, the distal arterial bed could not be opacified. Altogether, ultrasonic angioplasty was able to recanalize a complete occlusion in nine out of ten patients, with partial or complete dissolution of clots and with no complication. At its present stage of development, adjunctive balloon angioplasty would be needed in most cases to obtain unrestricted flow and unsignificant residual stenosis.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10151003 TI - Is the left main angulated, stenosed, or "bent" by the guiding catheter? AB - Exact angiographic and identification of significant stenosis of the left main coronary artery is imperative prior to performing elective percutaneous transluminal coronary angioplasty. A patient is presented with an apparent angiographically significant, but physiologically insignificant, left main stenosis. Both angiographic and physiological methods of detecting "false positive and negative" left main stenoses are discussed. PMID- 10151004 TI - Percutaneous coronary angioplasty in patients over 75 years old: immediate and mid-term results. AB - Ninety-five patients 75 years or older (range 75-90, mean 79) underwent PTCA from 1987 to 1991. Forty-two patients were 80 years or older. Forty-four had prior MI, 5% had prior coronary bypass surgery (CBS), 13% had a prior history of recent cardiac failure, and 81% (77/95) presented with unstable angina, refractory to intravenous treatment in 31 cases. The mean left ventricular ejection fraction was 62% (range 34%-80%). Thirty-nine percent had single vessel disease, 41% had two vessel disease, and 20% had three vessel disease. Coronary calcifications were present in 28%. A single vessel was dilated in 81 patients, two vessels in 14 patients; complete revascularization was achieved in 41%. The clinical angiographic primary success rate was 79% (75/95). There were five procedural deaths, five MI, five CBS and, ten hematomas. Follow-up data were obtained in 100% cases, with a mean follow-up duration of 12 months (ranging from 1-36). There were four deaths, one MI, and two CBS. Twenty percent (15/74) of patients had a second PTCA with a 73% success rate. Finally, 70% of the initial population was asymptomatic after first or second PTCA at mid-term follow-up. We conclude that PTCA is safe and effective in elderly patients, with 70% clinical success rate at mid-term follow-up in spite of frequent incomplete revascularization limited to the culprit lesion. PMID- 10151005 TI - Progress in interventional cardiology. PMID- 10151006 TI - Fluorescent detection of acid-fast bacteria including M. tuberculosis. PMID- 10151007 TI - A semiquantitative image analysis program for the surgical pathologist. PMID- 10151008 TI - The status of indocyanine-green videoangiography. AB - The use of indocyanine-green videoangiography as an adjunctive technique to fluorescein angiography in the diagnosis of choroidal neovascularization has recently gained widespread attention. In January 1993, the first international symposium on indocyanine-green angiography was sponsored by the Manhattan Eye, Ear, and Throat Hospital. Approximately 300 retina specialists from all over the world convened at this meeting. Our current knowledge of indocyanine-green videoangiography is reviewed. PMID- 10151010 TI - Surgical excision of subfoveal choroidal neovascular membranes. AB - The possibility for visual improvement after the treatment of subfoveal choroidal neovascular membranes with laser photocoagulation is poor. The surgical excision of these membranes in age-related macular degeneration, the presumed ocular histoplasmosis syndrome, idiopathic neovascularization, and myopia is the focus of current study. This review covers the rationale for considering a surgical approach, the techniques currently used to perform these procedures, and the clinical pathological correlation of the surgically excised specimens. Initial results of this surgery warrant a national randomized clinical trial of its efficacy. PMID- 10151009 TI - Laser management of subfoveal choroidal neovascularization in age-related macular degeneration. AB - Subfoveal choroidal neovascularization in eyes with age-related macular degeneration is associated with a poor natural prognosis. The Macular Photocoagulation Study Group recently has demonstrated that subfoveal photocoagulation in select cases of subfoveal choroidal neovascularization for patients with age-related macular degeneration effectively prevents severe visual acuity loss and reduces the average loss of contrast sensitivity and reading speed associated with this condition. Eligibility criteria and treatment recommendations from the Macular Photocoagulation Study will be reviewed. Results of alternative strategies for laser photocoagulation of such lesions are also discussed; however, the Macular Photocoagulation Study results stand alone in documenting a long-term treatment benefit of photocoagulation for subfoveal choroidal neovascularization. PMID- 10151011 TI - New culture and identification procedures in mycobacteriology--part I. PMID- 10151013 TI - A functional analytical technique for monitoring nutrient status and repletion. PMID- 10151012 TI - Flow cytometry: basic concepts and clinical applications in immunodiagnostics. AB - OBJECTIVE: To review current and possible future clinical applications of flow cytometry in immunodiagnostic procedures. DATA SOURCES: Recent research and review articles and textbooks on laboratory diagnosis and flow cytometry. STUDY SELECTION: Not applicable. DATA EXTRACTION: Performed by the author. DATA SYNTHESIS: Flow cytometry is the measurement of cellular and fluorescent properties of stained cells in a fluid stream as they move past a set of fixed detectors. The instruments are capable of measuring these properties on thousands of cells in but a few seconds. Many specimen types can be analyzed on the flow cytometer. CONCLUSION: Flow cytometry is especially useful in monitoring immunodeficiencies, leukemias, and other malignancies, but it has other uses, as well. Improvements in instruments, reagents, and methods will cause an increase in the number of applications for flow cytometry. More laboratories will be able to purchase the equipment as it becomes less expensive. Flow cytometry provides the clinician valuable information in the diagnosis and treatment of disease. PMID- 10151014 TI - TULIP: a less invasive approach to prostatectomy. PMID- 10151015 TI - Continuous passive motion: just the ticket. PMID- 10151016 TI - Restenosis after coronary angioplasty. AB - Coronary angioplasty is used to treat coronary atherosclerotic disease in many patients. One problem with coronary angioplasty is the phenomenon of restenosis. Restenosis appears to be a universal response to arterial wall injury. The biological events that underlie restenosis are characterized by: platelet adhesion and aggregation at sites of damaged endothelium, and within dissections into the medial layers, release of platelet derived growth-promoting substances, inflammation of the injured medial zone, transformation, migration, and proliferation of smooth muscle cells of the media following their activation by growth-promoting substances, secretion of copious amounts of extracellular matrix material, and finally, termination of the growth process following regrowth of endothelium over the damaged area. More than a decade of research work has helped identify clinical correlates of restenosis after coronary angioplasty. Patient-related correlates include male gender, unstable angina, diabetes, and continued smoking after angioplasty. Lesion-related correlates include multilesion and multivessel procedures, higher post-angioplasty residual stenosis, proximal vessel location, location in the left anterior descending coronary artery, location in a vein graft, long lesions, and total occlusions. However, for the purposes of individual patient care, clinical correlates are not particularly helpful. No group of variables has predicted complete freedom from restenosis, and conversely no group of variables has reliably indicated its presence. All patients undergoing angioplasty will require some form of follow-up evaluation. Symptom status by itself has not been found to be useful for predicting restenosis. However, when symptom status is combined with exercise thallium-201 scintigraphy, performed 4-6 months after angioplasty, it is less than ideal, but has a negative predictive value of over 90%. This means that over 90% of patients who are asymptomatic and have no evidence of ischemia by thallium-201 scintigraphy, will not have angiographic restenosis. Numerous clinical trials have been performed in order to reduce or prevent restenosis. Almost all have been disappointing, while a few have been encouraging. Studies of antiplatelet agents such as aspirin, dipyridamole (Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA), and Ticlopidine (Syntex, Humgcao, Puerto Rico) have not shown efficacy, yet studies of an inhibitor of platelet derived growth factor have been provocatively encouraging. No reduction in restenosis rates was found with the anticoagulants Coumadin (Du Pont Pharmaceuticals, Wilmington, DE, USA) and Heparin (Wyeth-Ayerst, Philadelphia, PA, USA). Fish oils (omega fatty acids) have been found in several clinical trials to provide modest, but encouraging, reductions in restenosis, but await further confirmation.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10151017 TI - 15 years of PTCA: evolution and expectations {editorial}. PMID- 10151018 TI - Results of balloon aortic valvuloplasty in patients with aortic stenosis associated with significant aortic regurgitation. AB - The influence of balloon aortic valvuloplasty (BAV) on aortic regurgitation (AR) in patients with severe aortic stenosis associated with greater than or equal to grade II AR was studied by supraaortic angiogram before and after BAV. The results of 50 patients aged 72 +/- 12 years with significant AR before BAV (group A) were compared to 297 patients (mean age 76 +/- 10 years) with no or mild AR (group B). In group A, the patients had a higher left ventricular end diastolic volume (96 +/- 19 mL/m 2 vs 81 +/- 32 mL/m 2, P less than 0.01) and left ventricular end diastolic pressure (23 +/- 9 mmHg vs 19 +/- 9 mmHg, P less than 0.01). The aortic valve area was similar in both groups. Following BAV, the improvement in aortic valve area and hemodynamics were similar in both groups. In group A, AR remained unchanged in 31 patients (62%), increased by 1 grade in 13 patients (26%), and decreased by 1 grade in 6 patients (12%). In group B, AR increased by greater than 1 grade in 34 patients (11%) and greater than 2 grades in 4 patients (1.3%) post-BAV. Two patients in group B underwent emergency aortic valve replacement following BAV because of severe acute AR. In conclusion, when it is indicated, BAV can be performed with similar risk in patients with significant AR. PMID- 10151019 TI - A prospective randomized trial of Novoste right versus Judkins catheters for engagement of the right coronary artery during diagnostic catheterization. AB - There has been little technical advancement in catheter shape for diagnostic cardiac catheterization since the early reports of Sones and colleagues during the development of the procedure. In order to determine the utility of a new catheter that directly, without torque or rotation, engages the right coronary artery (RCA), one hundred patients were randomized between 6Fr standard RCA Judkins (6Fr R4) (Cordis Corporation, Miami, FL, USA) or 6Fr Novoste RCA catheters (Novoste Corporation, Aguadilla, Puerto Rico). Endpoints included the duration of the various aspects of the procedure and a qualitative and quantitative assessment of angiographic quality. The Novoste RCA catheters were associated with statistically decreased times of catheter insertion (42 +/- 37 vs 90 +/- 119 secs), and engagement (31 +/- 35 vs 77 +/- 117 secs), of the right coronary artery as compared to Judkins catheters. Judkins RCA catheters had a significantly higher primary success rate (96%) than the Novoste group (84%, P = 0.045). There was no difference in angiographic quality in either group and no complications occurred during the study. While taller patients (mean 68 in) had increased success with the Novoste catheter, no other clinical, demographic, or anatomical characteristics of the RCA orifice predicted successful engagement and angiography. The direct engagement Novoste RCA catheter is associated with a more expeditious procedure than Judkins catheters when they can engage the RCA orifice. However, Novoste catheters were less successful and required more frequent exchanges to complete the procedure. PMID- 10151020 TI - Double balloon mitral valvuloplasty through dual femoral vein punctures and a single atrial septal puncture. AB - A modification of a previously described double balloon mitral valvuloplasty procedure is described. This involves dual femoral vein punctures with a single atrial septal puncture. After initial transseptal catheterization and predilatation of the interatrial septum with an 8-mm balloon, a second catheter is advanced through the resulting atrial septal defect allowing access to the left atrium and left ventricle through the mitral valve via two separate femoral vein puncture sites. In comparison with the previously described technique using two balloon catheters inserted through a single femoral vein puncture site, this modification has reduced the amount of bleeding from the femoral vein and the need for transfusion. Furthermore, the potential for subsequent interatrial shunting is less than with the alternative previously described technique utilizing two femoral vein punctures with two separate punctures in the interatrial septum. In utilizing two separate femoral vein punctures with only one atrial septal puncture this technique combines advantages of the two previously described techniques. PMID- 10151021 TI - Simultaneous implantation of two Palmaz-Schatz stents mounted on a long angioplasty balloon. AB - Three cases are presented in which two Palmaz-Schatz stents were implanted simultaneously in a native coronary artery or saphenous vein graft. The two stents were mounted in tandem on a long angioplasty balloon. This technique has advantages in ease of delivery and positioning, with prevention of stent overlap, and when deployment of multiple stents is clinically appropriate. PMID- 10151022 TI - Pursuit of large lumen dimensions after coronary intervention {editorial}. PMID- 10151023 TI - Percutaneous transluminal coronary angioplasty in patients undergoing chronic dialysis. AB - Very limited data on percutaneous transluminal coronary angioplasty in patients with chronic renal failure is available. We describe the short- and long-term results of percutaneous transluminal coronary angioplasty (PTCA) in a group of seven patients undergoing chronic dialysis. Percutaneous transluminal coronary angioplasty was undertaken because of poorly controlled symptoms in five patients and reversible defects on thallium scintigraphy prior to major surgery in two patients. There were five men and two women, the mean age was 51 years (range 36 75). Six patients were on hemodialysis and one was receiving peritoneal dialysis. All seven patients had complicated baseline coronary stenosis morphology ( greater than or equal to AHA/ACC Class B-1). Percutaneous transluminal coronary angioplasty was successful in four patients (57%) and associated with complications in two patients (29%) including one death. Surviving patients were followed for a mean of 6 months (range 3-23 months). Of three surviving patients with initially successful PTCA, two developed restenosis. All three patients with unsuccessful PTCA underwent bypass surgery with one late death. Patients with chronic renal failure compose a high risk population for PTCA with a reduced success rate, an increased complication rate, and a high restenosis rate. PMID- 10151024 TI - A new, safer lasing technique for laser-facilitated coronary angioplasty. AB - In vitro studies during cold pulsed-wave laser angioplasty have demonstrated production of gas bubbles within the target tissue, creation of shock wave and formation of multi-layer dissections accompanied by an increase in the plaque and vessel wall temperature. These processes account for certain complications of coronary lasing, including acute vessel closure, dissections, spasm, and even perforation. The traditional lasing technique in which a large number of pulses is continually emitted across the lesion, may in fact contribute to the development and acceleration of the above mentioned processes. To overcome the shortcomings we have developed a new, safe lasing technique that consists of multiple trains of a small number of pulses each. Between laser sessions the laser catheter is retracted into the guiding catheter and nitroglycerin is injected intracoronary, thus providing time for dispersion of produced gas bubbles, cooling of the target artery, and adequate coronary vasodilatation. This new technique results in a significant reduction of laser associated complications. PMID- 10151025 TI - Treatment of acute myocardial infarction with prolonged intracoronary urokinase delivery through intracoronary infusion catheter. AB - Severe acute myocardial infarction in young patients is plagued by high mortality. We report the case of a 25-year-old man, with a family history of ischemic heart disease, who was treated with acute and prolonged intracoronary urokinase infused through a miniaturized catheter engaged in a large thrombus occluding the left anterior descending artery. Rapid and stable recanalization was achieved with complete lysis of thrombotic material. PMID- 10151026 TI - New diagnostic methods in interventional cardiology. PMID- 10151027 TI - Clinical applications of the Doppler coronary flow velocity guidewire for interventional procedures. PMID- 10151028 TI - Is intravascular ultrasound a new standard for coronary artery imaging? PMID- 10151029 TI - What will replace TURP? AB - Benign prostatic hyperplasia (BPH) is almost ubiquitous. About 25% to 40% of men in their lifetime will undergo treatment for BPH. Surgical therapy produces in excess of 400,000 prostatectomies a year at a cost of more than 4 billion dollars. Given the magnitude of the clinical problem and its overall impact on health care in the United States, the interest in alternatives to transurethral resection of the prostate (TURP) is intense. From the panoply of contenders, the panel nominates those most likely to succeed. PMID- 10151030 TI - What is the AUA symptom index for BPH, and how is it used? PMID- 10151031 TI - PTCA: is surgical back-up necessary? The view of a surgeon and a lawyer. PMID- 10151032 TI - Statistical analysis of invasive cardiology for Austria in 1992 as an approach to quality assessment. AB - Quality Control in Interventional Cardiology requires perfect documentation. We, therefore, report a mutual controlling system, which has been initiated in Austria 3 years ago. An all round inquiry within all the 28 Austrian catheterization laboratories was successful with a feedback rate of 100%, controlled by visiting the centers, random tests, and several phone calls. This year was the first time that an entire European country followed the guidelines for statistical documentation that the European Society of Cardiology has suggested. Within the year 1992, 3,780 percutaneous coronary angioplasties were performed in Austria, which is 19.7% more, compared to the year before. At the same time 18,806 coronary angiographies, 102 percutaneous valvuloplasties, and 138 electrophysiological ablations took place. Austria reached 84% of the number of angiographies and 50% of the percutaneous transluminal coronary angioplasty (PTCA) numbers, the World Health Organization (WHO) has provided for a country of 7.82 million inhabitants. One hundred and fifty-two "new devices" (stent/n = 89, atherectomy/n = 44, laser/n = 6, etc.) were used during this year, which was 4.0% of all PTCA procedures. Angioscopy (n = 11) and intracoronary ultrasound (n = 82) accounted for another 2.5% of "new devices". Complication rate was 0.48% hospital deaths, 0.93% emergency bypass surgery, and 1.88% myocardial infarction in 3,780 PTCAs. The individual data of each center were treated confidentially and anonymously and the evaluated questionnaire was sent back to the respective center only, including an individual recommendation for quality improvement.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10151033 TI - New diagnostic methods in interventional cardiology. PMID- 10151034 TI - Advantages and limitations of intracoronary ultrasound for the assessment of vascular dimensions. PMID- 10151035 TI - The use of angioscopy in percutaneous coronary interventions. PMID- 10151036 TI - Progress in interventional cardiology {news}. PMID- 10151037 TI - Improving the results of facial dermal lesions elimination by laser. AB - Argon laser therapy of superficial pigmented lesions in both young and old people is associated with a risk of complications including delayed wound closure and hypo/hypertrophic scarring. Problems may also occur after treatment of lesions located on the eyelid. To minimize the risk of these problems coagulation of deep tissue should be avoided. We discuss a technique using mercurochrome, a red colored compound that absorbs the blue and green lines of the argon laser, as a barrier for the irradiated light that eliminates these complications and we provide probable reasons for this technique's effectiveness. PMID- 10151038 TI - Coronary stents: growing up? PMID- 10151039 TI - Intracoronary stents: a review of the experience with five different devices in clinical use. AB - Atherosclerotic cardiovascular disease remains one of the most important causes of morbidity and mortality in the industrialized world. Treatment is basically aimed at palliation and consists of either pharmacological intervention or revascularization. The first significant advances in the latter were largely surgical. However, the pressing need for treatment with less invasive and potentially less expensive techniques, have stimulated the development of nonsurgical revascularization techniques. Percutaneous transluminal coronary balloon angioplasty, which was first performed by Andreas Gruentzig in 1977, is one of the most successful examples and provided the stimulus for a rapid technological growth of interventional cardiology. It is now widely accepted as a safe and effective treatment of obstructive coronary artery disease. However, the risk of abrupt vessel closure during or immediately after the intervention and the risk of late luminal renarrowing or restenosis continue to compromise its overall safety and efficacy. To improve the immediate and long-term results of balloon angioplasty, a number of new technologies such as intracoronary stenting, directional or rotational atherectomy, and laser therapy have been developed and represent the leading edge in the battle against atherosclerosis. The purpose of this paper is to review the experience and results of the various types of stents in clinical use. PMID- 10151040 TI - Long-term clinical and angiographic follow-up after placement of Palmaz-Schatz coronary stent: a single center experience. AB - The purpose of this study is to evaluate long-term clinical and angiographic follow-up results after placement of the Palmaz-Schatz stent and angiographic follow-up results of repeat interventions for stent restenosis. From June 1990 to September 1993, the Palmaz-Schatz stent was placed in 411 patients, 427 lesions. Follow-up angiography was performed in 307 lesions at 3-6 months and in 189 lesions at 1 year. Palmaz-Schatz stent implantation resulted in 97.2% procedure success and 94.6% clinical success. Stent thrombosis was observed in 2.2%. Angiographic restenosis rate was 16.3% at 3-6 months study. At 1 year study, "new" restenosis occurred only in 2.3%. Minimal lumen diameter did not change between 6 months and 1 year (2.32 +/- 0.51 mm vs 2.30 +/- 0.54 mm). With the mean follow-up interval of 22 +/- 9 months, cardiac event-free survival was achieved in 74.3%. Among 50 lesions with restenosis, stent restenosis occurred diffusely in 15 lesions (30%), focally inside the stent in 22 lesions (44%) and focally at the stent border in 13 lesions (26%). Repeat interventions were performed in 35 lesions. Restenosis at 3 months after repeat intervention was demonstrated in 9 (32.1%) out of 28 lesions restudied. Restenosis rate after repeat intervention for diffuse stent restenosis was significantly higher than that for focal in-stent restenosis (75% vs 7.7%). Palmaz-Schatz stent implantation was associated with a high initial success rate and a low late restenosis rate. Luminal renarrowing did not occur beyond 6 months up to 1 year. PMID- 10151041 TI - Preliminary experience with intravascular ultrasound guided Palmaz-Schatz coronary stenting: the acute and short-term results on a consecutive series of patients. AB - The purpose of this study was to prospectively test the hypothesis that systemic anticoagulation is not needed following coronary stenting when adequate stent expansion is achieved and documented and other flow limitations eliminated. Intravascular ultrasound (IVUS) was used to confirm adequate stent expansion, which was defined as good plaque compression together with the achievement of an intrastent lumen cross-sectional area (CSA) that was greater than 40% of the average reference vessel CSA. In this prospective study, Palmaz-Schatz coronary stenting was performed on 343 lesions in 263 consecutive patients. Primary stenting was successful in 254 patients (96.6%) and 332 lesions (96.8%). All patients with successful primary stenting underwent IVUS imaging except nine patients (13 lesions) that did not have an IVUS evaluation for technical reasons and three patients (4 lesions) in which IVUS was unsuccessful. The initial IVUS performed after achieving an acceptable angiographic result revealed inadequate stent expansion in 191 patients (79%) and 244 lesions (77%). After further dilatation, final adequate stent expansion was accomplished in 230 patients and 301 lesions. These patients were treated with Ticlopidine 250 mg twice per day for 2 months and did not receive postprocedure anticoagulation. There was one acute stent thrombosis (0.3%) that occurred in a lesion with slow flow and an inadequately expanded stent. There was no subacute stent thrombosis and no bleeding or vascular complications. We conclude that when adequate stent expansion is achieved and confirmed and other flow limiting lesions eliminated, that systemic anticoagulation after the stent procedure is not necessary. PMID- 10151042 TI - Self-expanding stents for emergency treatment of acute vessel closure following coronary angioplasty: immediate and long-term results. AB - Intracoronary stents may be used to treat acute coronary occlusion following balloon angioplasty. We report the immediate and long-term results of emergency implantation of the self-expanding stent (Wallstent) in 39 patients with acute vessel closure. Stents were successfully deployed in 38 patients (97%). Procedural complications occurred in 14 patients (36%); one patient died, two required emergency coronary artery bypass graft surgery, nine sustained myocardial infarcts (one Q wave), and two had acute stent thrombosis successfully treated by intracoronary thrombolysis and repeat angioplasty. Four patients (10%) had femoral artery bleeding, two required surgery. Angiographic follow-up was performed after 6 months in all 34 eligible patients, or earlier for symptoms. Two patients died prior to follow-up angiography. The stented segment was widely patent in 27 of the 34 patients (79%); restenosis within the stent was detected in 4 (12%) and thrombotic stent occlusion occurred in three (9%). Twenty-six of the 39 patients (67%) were free from major cardiac events and symptoms at 1 year. These results suggest that the self-expanding stent provides an attractive alternative to emergency surgery for the treatment of acute coronary occlusion following coronary angioplasty. PMID- 10151043 TI - Single 80-mm peripheral Wallstent for saphenous vein coronary artery bypass graft. PMID- 10151044 TI - Management of the arterial puncture site. AB - With more complex interventional procedures, such as intracoronary stent placement, there is a higher incidence of procedural related peripheral vascular complications including pseudoaneurysm and hemorrhage. In these procedures, the amount of anticoagulation as well as the use of thrombolytic agents intraprocedurally increases the risk of complication. Meticulous care during vascular access, careful use and monitoring of anticoagulation, and patient selection are helpful in reducing the risk. Newer vascular hemostatic devices utilizing biodegradable collagen plugs might be of advantage since they allow early sheath removal without interrupting anticoagulation and, therefore, early ambulation. However, it remains to be determined, whether these devices are effective in reducing complications, duration of bed rest and hospitalization, or improvement of stent patency. Newer designs, e.g., coated or biodegradable stents, or different deployment strategies might reduce the need of anticoagulation and lower the risk of peripheral vascular complications. PMID- 10151045 TI - Experience with a 6 French double loop catheter for right coronary angiography. AB - A 6Fr double loop diagnostic catheter was developed for angiography of the right coronary artery and tested in 101 patients. Its primary use was employed in 60 patients, and after failure of a 6Fr right Judkins diagnostic catheter in 41 patients. Primary use was successful in 56 out of 60 patients (93%); four failures were cannulated with 6Fr right Judkins diagnostic catheters. After failure of 6Fr right Judkins diagnostic catheters, 36 out of 41 patients (88%) were successfully cannulated with 6Fr double loop diagnostic catheters. Causes of failure of 6Fr right Judkins diagnostic catheters were: inadequate torque control in 24 patients, because of tortuosity of femoro iliac arteries or aorta; dilatation of the ascending aorta, abnormal origin or course of the initial segment of the right coronary artery in 17 patients. Three out of five patients in whom right Judkins diagnostic and double loop diagnostic catheters failed to intubate the right coronary artery were successfully cannulated with 7Fr diagnostic catheters (right Judkins one patient; El Gamal one patient; right coronary bypass one patient). CONCLUSION. 6Fr double loop diagnostic catheters increased the success rate of right coronary angiography after failure of 6Fr right Judkins diagnostic catheters. PMID- 10151046 TI - Cardiovascular product update and evaluation. What's hot, what's not, what's in, what's out. PMID- 10151047 TI - Acute myocardial infarction. PMID- 10151048 TI - Annual costs of benign prostatic hyperplasia in New Zealand. AB - Benign prostatic hyperplasia (BPH) has been regarded as part of the normal aging process in men and little attention has been focused on the cost of the disease in New Zealand. The purpose of this study was to estimate the direct and indirect costs of treating BPH in both the public and the private sectors in New Zealand. The costs of treatment were estimated from public and private hospital data on admissions for BPH, obtained from the New Zealand Department of Health, medical insurance reimbursement schedules, hospital ward costs at one centre, and urology and general practitioner consultation fees. The length of time spent off work, as a measure of indirect costs, during urological investigations or treatment was estimated from interviews with urologists. The annual 1991 total direct medical costs of treated BPH as primary diagnosis in New Zealand were estimated at $NZ16 million (the average of the end-month mid-point exchange rate for the first quarter of 1992 was $US0.5457 per $NZ1), and the costs of lost production plus loss of leisure time by patients was estimated at $NZ4 million (1992 dollars). Patients with a principal diagnosis of BPH stayed on average 8.9 days in a public hospital and 4.6 days in a private hospital. Based on the above costs, if the average length of stay of public hospital patients could be reduced to that of private hospital patients, then hospital ward costs for BPH could fall by 37% and the total direct medical costs by 21%. The most commonly performed surgical operation for BPH was transurethral prostatectomy (TURP). For operations performed in a public hospital, patients stayed on average 8.5 days, while patients whose operations were performed in private hospitals stayed 4.3 days. The mean age of these public hospital patients was 71 years compared with 67 years for those in private hospitals. A complication rate of 2.02% was recorded for TURP in public hospitals but audits (conducted by the researchers) in both public and private settings indicated that the complication rate was substantially under-recorded. PMID- 10151049 TI - Minimally invasive palliative tumor therapy guided by imaging techniques: the UCLA experience. AB - Imaging-guided palliative therapy of recurrent and/or inaccessible head and neck tumors may soon become clinically practical since sensitive and noninvasive monitoring techniques of energy deposition in tissues are now available. Interstitial tumor therapy (ITT) is a technique whereby a source of energy (laser, radiofrequency, ultrasonic, cryoenergy, etc.) is directly applied into tumors at various depths. Recent studies have demonstrated the efficiency of ultrasound (UTZ) and magnetic resonance imaging (MRI) for real and/or "near" real time tumor and vessel identification as well as monitoring and quantifying energy induced tissue damage. We now report our initial clinical experience with patients in which UTZ and/or MRI-guided ITT techniques were successfully applied for the treatment of recurrent, nonresectable, local, and/or metastatic head and neck carcinomas. Patients were treated on an outpatient basis either in the operating room or in an upgraded specially equipped SIGNA 1.5T MR suite. Most patients tolerated these procedures well and were successfully palliated for periods ranging from 3 months to 5 years posttreatment. The upgrades introduced in a standard MRI suite, the clinical experience, and future perspectives will be reviewed. PMID- 10151050 TI - Prostalase: basic clinical research and preliminary clinical results with laser thermotherapy for symptomatic benign prostatic hyperplasia. AB - Prostalase? has a probe that emits a laser beam at 360 degrees . Targeted obstructive prostatic adenoma tissue was heated to above the cytotoxic threshold temperature of 45 degrees C. After successful canine prostate study, from September 1992 to April 1993, 45 patients were treated. This paper reports the 9 months results of this initial cohort of patients. Prostatic and periprostatic temperature mapping showed the mean temperature within the adenoma zone was 49 degrees C, while the periprostatic tissue remained within the safety level of less than 42.5 degrees C. The mean prostate volume reductions at 3, 6, and 9 months were 36, 33, and 38%, respectively. Those patients whose surgery was unsuccessful had prostatic tissue removed by TURP at 2 to 3 months. This tissue revealed a definite zone of coagulative necrosis. For the clinical assessment, patients were divided into urine retention (UR) and nonretention (NR) subgroups. At 9 months, 20 of the 32 UR subgroup and 10 of the 13 NR subgroup patients were available for assessment. Due to poor response or complications, 6 of the 26 UR patients (23%) required ancillary treatment. Hence, 20 of the 26 cases (77%) remained catheter free and their mean maximum uroflow +/- SE was 9.6 +/- 0.7 ml/sec. Based on a Siroky normogram only 7 of these 26 patients (27%) became unobstructed. Two of the 12 NR subgroup patients (17%) required ancillary treatment. The mean maximum uroflow +/- SE was 10.7 +/- 1.2 ml/sec.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10151051 TI - Distance education: a learner-centered paradigm. AB - OBJECTIVE: To describe distance education and present an overview of current and future applications of the technologies used. DATA SOURCES: Current literature and the authors' experience. STUDY SELECTION: Determined by the authors. DATA EXTRACTION: Determined by the authors. DATA SYNTHESIS: Distance education is characterized by the physical separation of the learner and the instructor during instruction. Instructors and learners shift roles; the method and the technology combine to create a learner-centered paradigm. CONCLUSION: With improved technology and the increased demand for professional training, distance education promises to become a part of the mainstream of education. PMID- 10151052 TI - The role of noninvasive cardiac imaging in the evaluation of the postcoronary intervention patient. AB - Noninvasive diagnostic techniques are playing an increasingly prominent role in the evaluation of the postcoronary interventional patient. Radionuclide myocardial perfusion imaging has proved to be of value in assessing procedural success in patients with suboptimal angiographic results and/or multivessel coronary artery disease. However, in asymptomatic patients with single vessel disease, the use of myocardial perfusion imaging may not be cost-effective for follow-up after successful coronary intervention. The timing of these studies is important when used to predict coronary restenosis. Radionuclide ventriculography and echocardiography are two imaging modalities that, in conjunction with exercise stress, can be used to predict patient outcome and clinical events postcoronary intervention. A high degree of operator expertise is required for the optimal interpretation of the echocardiographic studies. PMID- 10151053 TI - In-hospital monitoring after coronary angioplasty. AB - At the University Hospital of Geneva there are three postcoronary angioplasty monitoring levels: (A) intensive care unit; (B) optional ECG monitoring (cardiology unit); and (C) no monitoring (other unit). To assess the adequacy of patient monitoring after coronary angioplasty, we studied the clinical outcome of 200 consecutive patients undergoing coronary angioplasty at different monitoring levels. Thirty-nine patients (20%) were in level A. Their outcome was 1 death, 1 emergency bypass operation, and 7 acute myocardial infarcts. Ninety-six patients (48%) were in level B: no major complication, no transfer of monitoring level, and mean hospital stay 2.7 +/- 1.3 days. Sixty-five patients (32%) were in level C: 1 death, 2 elective bypass operations, 6 transfers to level A, and mean hospital stay 5.9 +/- 4.6 days. Electrocardiogram monitoring of 135 patients yielded 23 significant findings (17%), 22 of which occurred in patients with complicated or failed procedure. In the 122 patients with successful coronary angioplasty without angiographic visible local complications and without clinical symptoms at the end of the procedure, no significant arrhythmia or acute myocardial infarction was documented. For this type of patient, ECG monitoring is not a prerequisite after coronary angioplasty. Surveying all patients after coronary angioplasty in the coronary care unit would not significantly reduce complications. Aftercare in a cardiology unit results in a shorter hospital stay. PMID- 10151054 TI - Coronary angioplasty in octogenarians: immediate and long-term results and comparison with a younger population. AB - The safety and efficacy of percutaneous transluminal coronary angioplasty (PTCA) was examined in a group of 91 octogenarians during 133 consecutive procedures and compared to the younger part of our PTCA population (3,443 procedures) during an 8-year study period. Most octogenarians presented with refractory or unstable angina pectoris and multivessel involvement, but had normal left ventricular function. The angiographic success rate was 84%. Technical failure was observed in 12% of cases and complications in 14%. Two early procedure related deaths were observed. Restenosis was estimated at 24%. The proportion surviving and the proportion without cardiac event estimated by the Kaplan-Meier method at 2 years were 0.89 and 0.60, respectively. In comparison to the younger population, the immediate angiographic success was lower as a result of a higher incidence of technical failure (P less than 0.05). Otherwise, no difference in terms of restenosis or overall related complication rate was noted (P greater than 0.1). It is concluded that PTCA is an efficient and safe therapeutic option for octogenarians with severe or refractory angina pectoris. Technical failure is more frequently observed than in younger patients and explains a lower immediate angiographic success. Nevertheless, at 2-years follow-up, a large majority of patients are alive and asymptomatic. PMID- 10151055 TI - Angioplasty of large diameter coronary arteries and saphenous vein grafts utilizing modified appropriately large diameter balloon dilatation catheters. AB - Standard coronary angioplasty balloons have generally not been available in diameters exceeding 4 mm. Consequently angioplasty of larger arteries and grafts is commonly performed with undersized balloons. "Hugging balloon" techniques and the use of peripheral angioplasty balloons introduced without a guiding catheter have been advocated. We utilized oversized (4.5--6.0-mm diameter) modified angioplasty balloons to perform angioplasty in 20 patients with large coronary arteries and saphenous vein grafts. Oversize balloons were used in conjunction with otherwise standard coronary angioplasty equipment and intracoronary stents. PMID- 10151056 TI - Percutaneous angioscopy in patients with restenosis after excimer laser coronary angioplasty. AB - Coronary angioscopy was performed in two patients with restenosis after excimer laser coronary angioplasty to improve our knowledge of restenosis after excimer laser angioplasty. The characteristics of the angioscopic findings in restenosis after excimer laser angioplasty consisted of smooth white plaques, which were distinctly different from the yellow plaques commonly observed in primary lesions. These findings indicate that restenosis in these patients after excimer laser angioplasty may be associated with smooth muscle cell proliferation and fibrosis. PMID- 10151057 TI - Resource utilization in the diagnosis and treatment of coronary artery disease. PMID- 10151058 TI - The cost of performing diagnostic cardiac catheterization. PMID- 10151059 TI - An introduction to clinical microeconomic analysis: purposes and analytic methods. AB - The recent concern with health care economics has fostered the development of a new discipline that is generally called clinical microeconomics. This is a discipline in which microeconomic methods are used to study the economics of specific medical therapies. It is possible to perform stand alone cost analyses, but more profound insight into the medical decision making process may be accomplished by combining cost studies with measures of outcome. This is most often accomplished with cost-effectiveness or cost-utility studies. In cost effectiveness studies there is one measure of outcome, often death. In cost utility studies there are multiple measures of outcome, which must be grouped together to give an overall picture of outcome or utility. There are theoretical limitations to the determination of utility that must be accepted to perform this type of analysis. A summary statement of outcome is quality adjusted life years (QALYs), which is utility time socially discounted survival. Discounting is used because people value a year of future life less than a year of present life. Costs are made up of in-hospital direct, professional, follow-up direct, and follow-up indirect costs. Direct costs are for medical services. Indirect costs reflect opportunity costs such as lost time at work. Cost estimates are often based on marginal costs, or the cost for one additional procedure of the same type. Finally an overall statistic may be generated as cost per unit increase in effectiveness, such as dollars per QALY.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10151060 TI - Economic aspects of using alternative diagnostic techniques in addition to angiography during percutaneous coronary artery revascularization. PMID- 10151061 TI - Progress in interventional cardiology {news}. PMID- 10151062 TI - Pathologic acetabular fractures: new concepts in surgical management. AB - Pathologic fracture of the pelvis and acetabulum secondary to metastases is a disabling condition for cancer patients. Management has for the most part remained nonoperative because the complexities of pelvic anatomy and reconstruction yield risks which have outweighed potential benefits. No advances in surgical reconstruction have been reported in one and a half decades. Previous reports and ideas addressing surgical reconstruction have focused on which type of total hip arthroplasty best suits the acetabular bone stock remaining following removal of the tumor. As improving medical management of metastatic cancer increases longevity, improved methods for surgical management of pathologic fractures are required. A new concept for surgically managing periacetabular fractures due to metastases is introduced whose premise is based on pelvic rather than hip pathology. Resection of tumor-infiltrated acetabular columns creates reconstructive challenges best met by the techniques and knowledge gained from trauma surgeons repairing acetabular fractures. The additional use of reinforced polymethylmethacrylate and subchondral bone cement augments fixation. These concepts have been incorporated into a new classification system and treatment strategy which is critically examined in 13 individuals. Tumor resection and pelvic-periacetabular reconstruction can satisfactorily be performed through extensile pelvic approaches without necessarily performing a hip arthroplasty. A more complete oncologic resection, superior reconstruction, and quicker rehabilitation for affected individuals can result in approximately one half of individuals. PMID- 10151063 TI - Temporary stents: the ACS RX flow support catheter. AB - Although permanent stents have been successfully used as bail-out devices in the treatment of abrupt occlusion, the risk of stent thrombosis and of bleeding complications, as well as the cost of a prolonged hospitalization, have been deterrents to their universal acceptance. Temporary stents were conceived to provide internal scaffolding of the coronary arteries, which could stabilize occlusive dissections, yet still allow the stent to be removed before the time of peak incidence of subacute thrombosis. The ACS RX flow support catheter is a prototype temporary stent which has been recently evaluated in phase I and II clinical trials. The device is effective in improving angina score, coronary flow, and decreasing residual stenosis when used in cases of suboptimal percutaneous interventional results. However, the incidence of major complications and the need for adjunctive percutaneous interventions remain significant. Further studies are needed to define the optimal time of cage expansion as well as the clinical, anatomical, and procedural factors that predict efficacy and safety of this new device. PMID- 10151064 TI - Gianturco-Roubin coronary flexible coil stent: present state of the art. PMID- 10151065 TI - Coronary stenting for the treatment of restenosis after percutaneous transluminal coronary angioplasty. PMID- 10151066 TI - The Spanish trial: are national randomized trials a necessary evil? PMID- 10151067 TI - Costs of interventional cardiac procedures. PMID- 10151068 TI - Hospital resource utilization during coronary artery bypass surgery. AB - OBJECTIVE: To predict hospital resource utilization for coronary surgery (CABG) from preoperative characteristics and to determine the influence of previous CABG on the results. DESIGN: Two analyses of the data were used to predict hospital costs: 1) a univariate analysis of each preoperative variable; and 2) a multivariate analysis of preoperative variables, and interaction terms with previous CABG. PATIENTS: A sample of 418 patients who received CABG at Emory University during 1990. RESULTS: From the multivariate analysis, the determinants of costs were previous CABG (P = 0.0653), female sex (P = 0.1005), diabetes (P = 0.0805), older age (P = 0.0062), and a combination of previous CABG with female sex (P = 0.0017), previous myocardial infarction (P = 0.0636), low ejection fraction (P = 0.0001), and younger age (P = 0.0363). For the univariate analysis, the determinants of increased costs were similar to those from the multivariate analysis. CONCLUSION: The correlation between patients with potential medical difficulties or previous cardiovascular surgery show a positive impact on higher hospital costs. PMID- 10151069 TI - Implications of managed care networks for invasive and interventional cardiology. PMID- 10151070 TI - News & views: progress in interventional cardiology {news}. PMID- 10151071 TI - Randomized trials of coronary stenting. PMID- 10151072 TI - BPH: what really works? PMID- 10151073 TI - Exploratory study of the decongestive effect of Rhinopront syrup in adults and in children with acute rhinitis. AB - The decongestive effect of Rhinopront syrup was assessed in 18 adults and 18 children with acute rhinitis, by comparison to a matching placebo syrup and to a commercial standard decongestant (Triaminic tablets or drops). The evolution of symptoms following single dose administration of each treatment was estimated both by objective measurements of nasal resistance using bilateral rhinomanometry and by subjective evaluation of nasal congestion and aspect of the mucosa. In children, the treatment was continued over the next 4 days and the global clinical efficacy of the formulations was subjectively evaluated by the parents. In adult patients, a significant decrease in nasal resistance was obtained after a single dose of Rhinopront (15 g). The effect was already important after 0.5 h and reached a minimum of approximately 50% of baseline within 1 to 2 h; the drop in nasal resistance was significantly less intense for Triaminic (p < 0.05; 0.5-1 h period) and for the placebo (p < 0.05; 0.5-2-h period). In children, the scatter of rhinomanometric measurements precluded the observation of any significant within- or between-group differences; however, a significantly lower nasal congestion score was observed for Rhinopront than placebo, between 4 and 10 h after single dose administration (1 g per year of age). The present work suggests that Rhinopront is an effective nasal decongestant in adults and children with acute congestive rhinitis and supports the adequacy of the proposed twice-daily dosing rate. PMID- 10151074 TI - Better Beginnings, Better Futures: a community-based approach to primary prevention. AB - Better Beginnings, Better Futures is a 25-year primary prevention policy research demonstration project. Its major purpose is to assess the extent to which community-based primary prevention programs can be effective in preventing emotional, behavioural, physical and cognitive problems in children from economically disadvantaged communities. The project grew out of a number of primary prevention initiatives introduced by the Ontario Ministry of Community and Social Services (MCSS) since the late 1970s. Eleven sites, four of them located on native reserves, received funding in January, 1991 to establish programs in their communities. From the beginning, a qualitative, naturalistic research approach has been utilized to document and understand the ways in which the programs have developed in the various Better Beginnings communities. PMID- 10151075 TI - The planning and implementation of government-sponsored community-based primary prevention: a case study. AB - Governments at all levels have become increasingly involved in initiating and funding projects within which community residents work collaboratively with local service providers in the development of programs for the betterment of themselves, their families, and their community. Inherent in these initiatives, however, are a number of possible sources of tension which, left unresolved, may hamper the intentions of governments to seed grass-roots solutions to community problems. A qualitative research methodology was used to examine the nature of the relationship between government and community representatives (both residents and local service providers) in establishing community-based primary prevention programs under the auspices of the Better Beginnings, Better Futures initiative of the Government of Ontario. We examine a number of issues and tensions that have arisen from this project, both during the development of the program model by the government, and through to its implementation in several communities in the province. PMID- 10151076 TI - Resident participation in the Better Beginnings, Better Futures prevention project: Part I--The impacts of involvement. AB - What impact does the involvement of community residents in developing prevention programs have on the residents themselves, the programs they help to create, and the communities in which they live? The research literature suggests that resident involvement in program decision making can enhance residents' sense of control or empowerment, improve programs and services, and provide a better match between the needs of the community and the kinds of services provided. Much of this literature, however, has focused on relatively few of the benefits and costs that residents can experience as a result of their involvement. The investigation reported in this paper utilized a qualitative research methodology to discover the outcomes, both positive and negative, that residents derive from their involvement. Prevention programs operating in seven Ontario communities under the auspices of the Better Beginnings, Better Futures primary prevention initiative are featured in the discussion. PMID- 10151077 TI - Resident participation in the Better Beginnings, Better Futures prevention project: Part II--Factors that facilitate and hinder involvement. AB - Resident participation is the cornerstone of any community-based prevention program. However, many challenges exist which make it difficult to involve residents in a meaningful way in the development of such programs. How can programs be organized so as to provide for significant participation of community residents in the process of program development? This article outlines the procedures that were utilized in seven community-based prevention programs established under the Better Beginnings, Better Futures initiative of the Government of Ontario to enlist the participation of community residents in program decision making and implementation. PMID- 10151078 TI - Community-based action research in a multi-site prevention project: challenges and resolutions. AB - This article examines the use of action research strategies over a four-year period in developing and evaluating a prevention program for children and their families. This research has taken place in a low-income multi-cultural neighbourhood in Sudbury. Strategies to foster participation and the practical relevance of findings are described, both for the initial proposal development stage, and for the period after a local program was funded as part of a multi site evaluation project. After reviewing the challenges inherent in doing action research within a multicultural neighbourhood, and within a multi-site design, we discuss which strategies have worked, and what remains to be resolved. PMID- 10151079 TI - Current management options for benign prostatic hyperplasia. PMID- 10151080 TI - A high-performance upgrade for ELISAs. PMID- 10151082 TI - Hospice in a managed care environment: an integrated team approach. PMID- 10151081 TI - Propellant-driven aerosols for delivery of proteins in the respiratory tract. AB - Metered-dose propellant-driven aerosols of an antigenically reactive protein were produced by combining bovine gammaglobulin (BGG) with one of several surfactants soluble in Freon or dimethylether propellants. Small-particle protein aerosols were most effectively produced by lyophilizing surfactants and proteins prior to the addition of propellants. Up to 26% of the total aerosolized protein was of respirable size. Aerosol metering valves delivering small volumes were most effective in producing respirable-sized (< or = 4 micron median mass aerodynamic diameter) protein aerosols. Proteins were suspended in liquified propellants as both propellant-soluble molecules and visible sedimenting clusters which both contributed to making respirable-sized protein aerosol particles. Electron microscopy showed that respirable-sized protein particles were composed of variable-sized chain aggregates of spherical subunits. Proteins were antigenic after suspension in liquified propellant and release as aerosols, but antigenicity diminished with extended propellant exposure. Local immunity in the respiratory tract is a key factor in resistance to respiratory infections. Metered-dose propellant-driven aerosols offer a potentially attractive method for delivering small-particle aerosols of immunizing antigens or other therapeutic proteins to the respiratory tract. PMID- 10151083 TI - Improving access to supportive therapies for cancer patients. PMID- 10151084 TI - Use of the prostate specific antigen (P.S.A.) in early detection of prostate cancer in males over the age of 50. AB - A total of 469 males over the age of 50 years were tested by the prostate specific antigen (PSA) with follow-up evaluations on those that exceeded 4.0 ng/ml. Thirty six (7.7 percent) of the participants had abnormal results, 23 (63.9 percent) had abnormal digital rectal examinations (DRE) and had biopsies done. Ten of the 23 biopsied participants had positive findings of prostate malignancy and 16 participants had benign prostatic hyperplasia. Three participants with abnormal PSA had negative DRE and no evidence of malignancy by ultrasound. Based on age-specific reference ranges, only one positive biopsy would have been missed while five of the 16 males who had negative biopsies would not have had to undergo this procedure. This would have resulted in a significant savings of medical costs as well as undue worry by the patient. PMID- 10151085 TI - Indocyanine-green angiography. AB - Indocyanine-green angiography represents a major advance in imaging of the choroidal circulation. Recent technical innovations have permitted this diagnostic technique to find clinical application in many chorioretinal conditions. The indocyanine-green molecule has proven to be safe for human study. In age-related macular degeneration, indocyanine-green angiography may play an important role in the diagnosis of patients with occult choroidal neovascularization, leading to eventual increased efficacy with laser photocoagulation treatment. Histopathologic confirmation of a lesion noted by ICG angiography has been made. In multiple inflammatory conditions, as well as with central serous chorioretinopathy, distinct ICG patterns have emerged that may facilitate better understanding of the disease processes. With greater experience, ICG angiography may provide improved imaging, a better understanding of the pathogenesis, and new treatment approaches for various chorioretinal conditions. PMID- 10151086 TI - New findings in ocular histoplasmosis. AB - The ocular histoplasmosis syndrome consists of punched-out, atrophic chorioretinal lesions, and peripapillary scarring in the absence of vitreal inflammation. Choroidal neovascularization is the cause of significant visual loss in involved eyes and is estimated to occur in up to 5% of affected eyes. An experimental primate model has given us a better understanding of the possible etiology and pathogenesis. Laser therapy for extrafoveal and juxtafoveal choroidal neovascularization has been shown to be effective. Recent advances in surgical technique and instrumentation have demonstrated the potential for the successful treatment of subfoveal choroidal neovascularization. The surgical specimens obtained from this approach have allowed for the study of the active process of neovascularization in this disease. This report summarizes our current knowledge regarding the pathogenesis and epidemiology of ocular histoplasmosis and the treatments currently utilized in the management of its associated choroidal neovascularization. PMID- 10151087 TI - The development of measures of organizational citizenship behaviour and changes in job behaviours related to quality management in health care. AB - A study was conducted at two tertiary care hospitals in Canada for the purpose of developing instruments to measure organizational citizenship behaviours (OCB) and changes in job behaviours that occur as a result of participation on hospital quality improvement (CQI) teams. Semi structured interviews were conducted among 52 hospital employees in order to elicit critical incidents of OCB and changes in job behaviours related to CQI. The results of the staff interviews were used to develop a measure of OCB in the hospital setting, and a measure of changes in job behaviours related to CQI. 39 employees, who were drawn from the major departments within the two hospitals on the basis of their membership on CQI teams, participated in a test of the psychometric properties of the two research instruments. Exploratory factor analysis, employing an orthogonal rotation, yielded two factors that accounted for 30% of the variation among the OCB items. The Cronbach alpha for items loading highly on the first factor was .88. The factor was labelled 'OCB directed towards individuals within the organization'. This factor was dominated by items reflecting the kinds of extra-role job behaviours employees engage in to assist patients, family members, visitors, and other employees within the organization. The Cronbach alpha for items loading highly on the second factor was 0.71. The second factor was labelled 'organizationally directed OCB', and consisted of behaviours that reflected an impersonal form of OCB in the hospital setting. Factor analysis, employing an orthogonal rotation, yielded four factors that accounted for 48% of the variation among the items measuring changes in job behaviours related to CQI. The four factors were labelled 'problem-solving', Cronbach alpha 0.82; 'customer awareness', Cronbach alpha 0.79; 'use of CQI knowledge', Cronbach alpha 0.77; and 'organizational interests', Cronbach alpha 0.79. The two OCB factors were moderately correlated, there were no significant correlations among any of the factors measuring changes in job behaviours related to CQI, and the problem solving job behaviours factor was moderately correlated with the two OCB factors. Directions for future research are discussed. PMID- 10151088 TI - Hospital service scope expansion and market share improvement: a dynamic modeling and multivariate approach. AB - In a national trend, large, acute-care hospitals located in urban areas of the nation were continuously broadening their service scope, adding services at the rate of one each year, from 1982 to 1987. This study proposes that the underlying rationale of hospital service-scope expansion is status-gap minimization. This perspective was quantitatively interpreted and tested by a dynamic modeling analysis. Findings support status-gap minimization as the rationale for service scope expansion. Using multivariate regression and dynamic modeling analysis, the study demonstrates that the cross-sectional relationship between two steady states--the relationship between service scope and market share--is positive and statistically significant. However, the market share change is not related to hospital service scope. The interpretation offered is that hospitals expand the scope of services looking not so much to increase their market share benefit in the short run as to raise their organizational status. In the long run, higher organizational status such as broader service scope then benefits market share. PMID- 10151089 TI - Organizational change, patient-focused care: an Australian perspective. AB - Hospitals throughout the world are attempting to improve organizational performance through a variety of means. The focus in this paper is on a leading teaching hospital in Australia for a review of current management strategy. In a time of shrinking resources, management adopted a multi-faceted change management program including restructuring the organization, becoming more patient-focused via a product-line management approach and emphasising efficiency and cost reduction measures. The next stage in management thinking is to place greater emphasis on patient-focused care. It is concluded this has the propensity to yield substantial further benefits, including improved financial and quality of care outcomes, in the Australian as well as the British and wider Organization for Economic Co-operation and Development (OECD) context. 'Professionally, we have committed ourselves to creating caring environments that promote healing. We cannot meet this goal until we make a commitment to be patient-focused and give up being nurse-focused or facility-focused' (Kerfort and LeClair, 1991). 'In a customer-driven [organization], the distribution of roles is different. The organization is decentralized, with responsibility delegated to those who until now have comprised the order-obeying bottom level of the pyramid. The traditional, hierarchical corporate structure, in other words, is beginning to give way to a flattened, more horizontal structure' (Carlzon, 1987). PMID- 10151090 TI - Types of work stress and implications for the role of general practitioners. AB - This study investigated a wide range of job-related characteristics which had the potential of acting as stressors for General Practitioners (GPs). Three hundred and four GPs completed a detailed questionnaire which sought audit information including practice workload factors, coping approaches and attitudinal information including sources of stress and the value of management training. Ten independent factors were identified as underpinning GP stress and using multi variate analysis, it was shown that each of these factors is predicted by a separate and distinct set of variables. This finding suggests that it is inappropriate to simply talk about GP stress since it is a multi-dimensional concept. This finding has important implications for identifying potentially successful mechanisms of coping and support. PMID- 10151091 TI - Fundraising, government grants and donations to nonprofit hospital charities. AB - Using 1982-1987 tax return data from California hospital charities, this paper investigates the relationship between fundraising expenditures, government grants and donations, during a time in which significant changes were being made in the system of hospital reimbursement. Empirical results suggest that while donations have been declining, charities have been efficient in their solicitation of donations. Results also suggest that government grants worked to reduce charitable contributions in the period before the institution of Medicare's Prospective Payment System. In more recent years, government grants have been associated with increases in donations to hospital charities. PMID- 10151092 TI - Practicing population-based care in an HMO: evaluation after 18 months. AB - OBJECTIVE: To determine whether population-based care in a primary care practice results in improvement in compliance with patient care guidelines. DESIGN: Time series analysis. SETTING: One primary care practice in Group Health Cooperative of Puget Sound (GHC). PARTICIPANTS: Approximately 1500 enrollees cared for by the practice. INTERVENTIONS: An ongoing approach to aid clinical planning at the level of the primary care team--population-based care--that depends on clinical guidelines, a computing system to provide epidemiologic data on guideline performance in the practice and reminders, and a process whereby the practice team analyzed and designs interventions for specific clinical problems. MAIN OUTCOME MEASURES: We compared compliance with practice guidelines for preventive care and chronic illness management at baseline and after 18 months in the intervention population with other patients in the same clinic and with patients in GHC as a whole. RESULTS: Compliance with breast cancer screening and colorectal cancer screening guidelines in the intervention population increased from baseline 32% and 18% respectively. These increases were significantly greater than in the remainder of the clinic or in GHC as a whole. CONCLUSIONS: The availability of practice-based data, clinical guidelines and a local intervention design process resulted in significant improvements in compliance with patient care guidelines. PMID- 10151093 TI - The small group consensus process for changing physician practices: influenza vaccination. AB - OBJECTIVE: To evaluate the effectiveness of a small group consensus process in enhancing compliance with guidelines for influenza vaccination among older HMO members. DESIGN: A controlled study of the practice of primary care physicians, with pre/post comparisons and a 2-year follow-up. SETTING: An 84,000 member prepaid staff model HMO group practice. PARTICIPANTS: Primary care clinicians (N = 36) practicing in a staff model HMO. INTERVENTION: A small-group process, including opinion leader, feedback, and group decision making. MAIN OUTCOME MEASURE: Percentage of patients in a given physician-panel who received influenza immunization. RESULTS: Improvement in vaccination rate from 60.8% to 72.35% (with further increases over 2 successive years), in the intervention group as compared with improvement in the control from 60.7% to 65.93%. CONCLUSION: In this model, the small group consensus process resulted in an alteration in physician practice pattern, yielding a significant improvement in immunization rates above the already-established level of 60%. PMID- 10151094 TI - Primary care HMO clinicians' opinions about clinical practice guidelines. AB - OBJECTIVE: To assess primary care clinicians' opinions about the principal goals that national guideline developers foresee for clinical practice guidelines, and about possible effects of guideline implementation that are known to concern practicing clinicians. DESIGN: Preintervention survey of attitudes conducted as part of a larger study to evaluate alternative strategies for implementing clinical practice guidelines. SETTING: Kaiser Permanente, Northwest Region, a large, group model HMO. PARTICIPANTS: Primary care clinicians (N = 211) with at least 1 year of work experience in the HMO. The response rate was 80% (N = 168). RESULTS: Clinicians' responses suggest they will not object to the implementation of specific practice guidelines in the HMO. Guidelines' information-synthesizing and consensus-building functions are likely to be welcomed. Increased guideline implementation is apparently not perceived as a threat to professional autonomy. CONCLUSIONS: Further research is recommended, using this measure, or refined versions of it, in diverse practice settings. In addition, studies are needed of the relationship between clinicians' general expectations about the effects of guidelines and their level of adherence to specific guidelines. PMID- 10151095 TI - HMO physician attitudes toward drug cost containment strategies. AB - OBJECTIVE: To compare network and group model physician attitudes toward prescription drug cost containment strategies. DESIGN: Mailed survey with two reminders for non-respondents. SETTING: Mixed model (network and group) HMO in metropolitan Washington, DC. MAIN OUTCOME MEASURE: Response on agreement scale to questions regarding receptivity to drug cost containment strategies. PARTICIPANTS: All primary care providers (N = 311) affiliated with the George Washington University Health Plan. The response rate was 78% (N = 243). RESULTS: Almost all clinicians believed that education and feedback were appropriate methods to control costs in an HMO. Network physicians were significantly less likely to agree with more intrusive administrative interventions. Both groups generally believed that patient expectations often dictate more costly prescribing than is necessary. CONCLUSIONS: Managed care physicians were generally amenable to cooperative behavior change strategies (i.e., education and feedback) and often opposed to mandated administrative or incentive approaches, especially physicians from the network setting. It remains to be seen whether use of cooperative methods to promote cost-conscious physician behavior can result in substantial savings. PMID- 10151096 TI - The emergence of population-based medicine. PMID- 10151097 TI - Health plans helping smokers. AB - Tobacco use is the leading cause of preventable mortality in the United States. Therefore, health care organizations have an important role to play in the control of tobacco use both among their plan members and in the communities that they serve. To be effective, they need to adopt a policy that all tobacco users will be identified and provided with advice to quit smoking (or chewing) at each contact with a health care professional. This same policy ought to be adopted for parents of pediatric patients. The policy can be implemented by defining tobacco use as a "vital sign" and periodically assessing implementation rates with a chart review. Patients who express an interest in quitting should be supported through individual or group follow-up. To make clinical interventions more effective, to counteract tobacco promotion that is directed at youth, and to protect the health of non-smokers, HMOs will want to support local and regional tobacco control coalitions that are taking action against tobacco promotion and are promoting smoke-free public areas. PMID- 10151098 TI - Report of two smoking cessation programs: telephone intervention and group sessions. AB - Matthew Thornton Health Plan (MTHP) offered two separate smoking cessation programs within the HMO setting. The two programs, telephone intervention with self-help materials and group counseling/education sessions, were evaluated over a 12-month period: both programs allowed members (n = 226) the option of choosing nicotine replacement therapy (NRT). As an incentive, MTHP reimbursed members who were successful quitters at 6 months for the NRT or offered them a $50 savings bond. At 12 months, cessation rates for both groups were at or above 30% except among patients participating in group counseling/education and not receiving NRT where quit rates were about 20%. Though not a controlled research project, results suggest that active HMO intervention in smoking cessation can be successful. In these programs, the combination of behavioral support and a reimbursement plan were associated with high quit rates. PMID- 10151100 TI - Telephone smoking cessation intervention: the free and clear program. PMID- 10151099 TI - Awakening the sleeping giant: mainstreaming efforts to decrease tobacco use in an HMO. AB - Group Health Cooperative (GHC) of Puget Sound is developing, within a framework of quality improvement, a comprehensive population-based approach to decreasing the prevalence of tobacco use. Broad organizational support has been obtained, centralized support is being integrated with clinic-level activity, local ownership of outcomes is encouraged with empowerment of health care teams, and support for community and policy-based activities is being provided. GHC's smoking prevalence has decreased from 25% to 15.5% over the past decade, while the state of Washington's prevalence declined from 23.7% to 21.8%. PMID- 10151101 TI - Religious perspectives and the work of the ethics committee. PMID- 10151102 TI - Casuistry and narrative: of what relevance to HECs? PMID- 10151103 TI - Praying for miracles: practical responses to requests for medically futile treatments in the ICU setting. PMID- 10151104 TI - Ethics committees across a continuum of care. PMID- 10151105 TI - Hospital ethics committees as community educators: a model for institutions. PMID- 10151106 TI - A corporate ethics committee in the making. PMID- 10151107 TI - Perspectives. PSNs (provider sponsored networks): nifty concept, thorny complications. PMID- 10151108 TI - Perspectives. PHOs abound, but most are works in progress. PMID- 10151109 TI - MGMA: physicians practicing for the future. Medical Group Management Association. PMID- 10151110 TI - Spending more time with the patients. PMID- 10151111 TI - Integrating physician group practices. PMID- 10151112 TI - Practice management solutions: trends & potentials. PMID- 10151113 TI - Home healthcare on the move. PMID- 10151114 TI - Home care is: choosing the very best. PMID- 10151115 TI - Healthcare decision-making: clarifying with fuzzy logic. PMID- 10151116 TI - Integrating for the clinical workstation. PMID- 10151117 TI - Power in the palm of your hand. PMID- 10151118 TI - The evolving role of pharmacy benefits management firms in a managed care environment. AB - The next five to seven years will see a major shake-up in the pharmacy benefits management industry. A highly competitive race is underway between independent, retail pharmacy chain-sponsored and pharmaceutical manufacturer-controlled PBMs to see who will develop and monitor prescription drug efficacy protocols that reduce the total costs associated with an episode of illness. PMID- 10151119 TI - Capitated chronic disease management programs: a new market for pharmaceutical companies. AB - With corporatism of the medical care delivery system, the pharmaceutical industry is searching for new ways to market prescription drug product lines. A new strategy focuses on developing chronic disease management programs. In doing so, pharmaceutical companies work with clinical leaders of HMOs or large physician groups on disease management guidelines to reduce practice pattern variations and improve the quality of patient care. In addition, pharmaceutical companies capitate payment to physicians treating chronic disease patients to give them financial incentives to comply with the disease management guidelines. PMID- 10151120 TI - A global trend: privatization and reform of social security pension plans. AB - Ten years ago Chile successfully privatized its social security system, beginning a worldwide trend to solve the problem of an increasing burden on government supported social security programs. Contributing factors include an aging population, fewer workers to support retirees, government budget deficits and the influence of politics. PMID- 10151121 TI - Executive compensation in excess of $1 million: shareholder approval and corporate waste. AB - A careful decision making process is needed when considering whether to forgo the shareholder approval needed to permit compensation to be tax deductible or to deviate from an established plan. [It] should include adequate investigations of costs and benefits and should be thoroughly documented. PMID- 10151122 TI - From idea to ideal. A medical transcription department ahead of its time. Interview by Pat Forbis. PMID- 10151123 TI - Findings from the 1995 AAMT employer survey. PMID- 10151124 TI - A few thoughts on downsizing, outsourcing, and capsizing ... a reader shares her experience as a displaced MT. PMID- 10151125 TI - AAMT code of ethics, adopted July 10, 1995. American Association for Medical Transcription. PMID- 10151126 TI - Issues in managed care reimbursement and medical education. PMID- 10151127 TI - Downsizing administrative staff without causing burnout. AB - In sum, the most direct route to avoiding burnout in downsizing is to change the philosophy of the department and organization. Narrowly defined jobs cannot persist when positions are being eliminated. Managers need to find ways to accomplish the goals of the hospital within the available financial resources. To gain the staff support and commitment for doing that, the hospital must become much more receptive to seeking advice from the employees themselves on how it can be done. PMID- 10151128 TI - Practice brief. Issue: patient photography, videotaping, and other imaging. American Health Information Management Association. PMID- 10151129 TI - Managing health information in a jail setting. PMID- 10151130 TI - Expanding horizons--a growth in ambulatory care means new HIM opportunities. PMID- 10151131 TI - Relational databases--the foundation of today's data analysis. PMID- 10151132 TI - Turning data into information. PMID- 10151133 TI - The health information manager: the next generation. PMID- 10151134 TI - FORE library rolls out online database. PMID- 10151135 TI - When hospital networks form, alliances feel the aftershocks. PMID- 10151136 TI - Down the road to product analysis, step by step. Medical Alley's Cost Effectiveness Task Force. PMID- 10151137 TI - Inside outsourcing. PMID- 10151138 TI - Know how to manage your service contracts. The view from a multihospital system. PMID- 10151139 TI - Know how to manage your service contracts. The view from a single facility. PMID- 10151140 TI - Put those nagging sterilization worries to rest, once and for all. PMID- 10151141 TI - Dirty dozen: common mistakes when managing part-time workers. PMID- 10151142 TI - 10 challenges to event-related sterility programs. PMID- 10151143 TI - Successful forms control comes in byte-sized packages. PMID- 10151144 TI - Stats. What does the future hold for GPOs? PMID- 10151145 TI - It's middle-class warfare. PMID- 10151146 TI - Linking credentialing and quality improvement. PMID- 10151147 TI - Network credentialing and recredentialing checklist. PMID- 10151148 TI - New surveys seek to measure managed care quality. PMID- 10151149 TI - Building a high-quality, cost-effective physician network. PMID- 10151150 TI - A clearing in the crowd: innovations in emergency services. AB - Emergency department overcrowding may not be so much a result of inappropriate use of the emergency department as it is a problem of the unavailability and inaccessibility of primary care services in the community. The prevailing theory that people use the emergency department because they cannot afford care elsewhere does not hold true. The vast majority of patients surveyed as part of the Emergency Services Initiative had some type of coverage, primarily Medicare or Medicaid. Without additional primary care capacity to accommodate walk-in patients and to make appointments available within one to two weeks, emergency departments will remain over-crowded. In addition to increasing primary care capacity, services must be structured to be as convenient and amenable to patient use as the emergency department. The findings of the Emergency Services Initiative supports the Preferred Primary Care Provider guidelines for the assignment of a primary practitioner or team to each patient, 24-hour telephone access for medical advice, evening and weekend hours, accommodation of walk-in patients, and the provision of nonurgent appointments within a maximum of two to four weeks. In addition, easy access to ancillary services for lab tests and X rays is beneficial for attracting patients. Patient education is also necessary. Questioning by counselors indicated that patients often do not understand that primary care settings are more appropriate than the emergency department for treatment of minor health problems. The most effective way to implement change in the health care system may not be through broad, generic prescriptions but through well-designed programs tailored to specific sites and communities. Changing staff behavior is often as challenging as changing patient behavior. Pre project planning and communication about purpose, scope, and procedures are necessary if projects are to begin and continue smoothly. Ongoing evaluation is also key. PMID- 10151152 TI - Transitioning from quality assurance to continuous quality improvement in air medical programs. PMID- 10151151 TI - Analysis of prehospital pediatric and adult intubation. AB - PURPOSE: Pediatric airway control, including endotracheal intubation (ETI), presents a clinical challenge in the prehospital setting. Endotracheal intubation is recommended for serious head injury (Glasgow Coma Scale score <=8). We evaluated the frequency of ETI in pediatric and adult patients with <=8 in the field, subsequently transported by a hospital-based, helicopter emergency medical service (HHEMS). METHODS: A retrospective, descriptive study of pediatric patients (<=14 years) and adult patients with GCS <=8 transported by HHEMS from January 1988 through March 1994 was conducted. Significance was determined by chi square analysis. RESULTS: Inclusion criteria were met by 63 (15%) pediatric patients and 353 (85%) adults. Of the pediatric patients, 38 (60%) were intubated endotracheally; mean age was 7; mean injury severity score (ISS) was 28. Of adults, 267 (76%) were intubated endotracheally; mean age was 35; mean ISS was 33. A 16-percentage-point difference in frequency of successful ETI between groups was found to be significant (p <=0.01). Of 25 nonintubated pediatric (PED) patients, unsuccessful attempts were made on 20 (80%); 14 of 25 (56%) had significant head injuries evident on computerized tomography (CT) scan. Of 86 nonintubated adults, unsuccessful attempts were made on 29 (34%); 61 (71%) had significant head injuries. CONCLUSIONS: Pediatric coma patients were not intubated with the same frequency as adults. This discrepancy between groups was secondary to a higher failure rate in the pediatric group. Intubation was attempted in 92% of pediatric patients versus 84% of the adults. Unsuccessful intubation attempts in the pediatric group, 20 of 58 (34%), were compared with 29 of 296 (9.8%) in the adult group. Difficulty in pediatric airway control may require an increased level of training and experience. PMID- 10151153 TI - Preparing for Medicare single-provider contracting: becoming a center of excellence. AB - Hospitals and physicians participating in the CABG Surgery Demonstration Project will certainly have an advantage over the competition. Although HCFA has not issued specifics of the process to be applied for the expansion of the project, a review of the program goals and events leading the initial selection is instructive. PMID- 10151154 TI - Early detection is the key to successful treatment. AB - In the United States today, healthcare reform is prompting an increase in education, community awareness, and early detection, as well as a decrease in healthcare costs and days missed at work due to illness. A program like the HVE Program accomplishes all of these things. People are starting to take a more active role in their healthcare. The advantages and benefits of preventive and alternative medicine are now recognized as a way to lower the cost of healthcare and as a way to minimize the loss of human life via early detection and treatment of disease. Continuous improvement, support from hospital administration, dedication of staff members, and community participation have enabled the Heart and Vascular Evaluation Program to evolve into the valuable service it is today- and the kind of service that will lead us into the future of healthcare. PMID- 10151156 TI - Mergers in medical mecca. PMID- 10151155 TI - Quantifying the economic benefits of the cineless cath lab department. PMID- 10151157 TI - MediScare. PMID- 10151158 TI - Getting serious. PMID- 10151159 TI - Medical innovations and ethics: a state government perspective. PMID- 10151160 TI - Former AHA executive plots new course for Atlanta Health Care Alliance. PMID- 10151161 TI - Recent Medicare reimbursement developments impact hospitals, other providers. PMID- 10151162 TI - Use of a prospectively measured incidence rate of nosocomial diarrhea in an infant/toddler ward as a meaningful quality assessment tool. AB - OBJECTIVE: To determine the incidence of nosocomial diarrhea as a quality assessment tool, to compare such a rate with a standard rate based on results reported in the literature, and to estimate the hospital cost of narrowing the gap between both. METHODS: This was a prospective hospital-based surveillance study of patients in a 16-cradle ward of a 316-bed public-owned children's hospital in Buenos Aires, Argentina. One hundred six pediatric patients were enrolled during the 3-month surveillance period. Data were collected by a non attending physician under the usual conditions of care. The clinical staff members were blinded to the objectives of the investigation. RESULTS: The detected incidence rate was 22.6 episodes of nosocomial diarrhea per 100 admissions. This was 6.4-fold higher than the standard rate. Each day of nosocomial diarrhea lengthened the duration of hospitalization and thereby increased the total hospital bill of each patient. The potential savings from narrowing the gap between both rates was as much as $302,400 per year. CONCLUSIONS: Nosocomial diarrhea stands out as a relevant target both for quality improvement opportunity assessment and for cost-containment-oriented efforts. PMID- 10151163 TI - Developing condition-specific measures of functional status and well-being for children. AB - This paper describes the American Academy of Pediatrics' program to develop several condition-specific measures to assess the functional status and well being of children with chronic conditions. The development of a measure for children between 5 and 12 years of age with asthma serves as a template for the development of measures for other conditions and is the focus of this paper. The processes followed in the drafting of content, refinement, and pilot testing of the measure are discussed in this paper. The domains addressed in the asthma measure include physical symptoms; the child's physical activity; the child's social activity; the family's social activity; the emotional impact on the child; the emotional impact on the family; and health care utilization. Each domain is represented by a subscale in the measure. Content for individual items within subscales was established by conducting focus groups with parents and physicians and by reviewing the literature. The measure was tested through an in-depth cognitive interview process and pilot tested by administering the measure to 95 parents of children with mild, moderate, and severe asthma. Five of the seven subscales had acceptable internal consistency reliability as measured by coefficient alpha. Construct validity was shown for some scales by significantly different scores for children with mildly versus moderately severe asthma. PMID- 10151164 TI - Multi-city study of quality of care for HIV-related Pneumocystis carinii pneumonia: successfully collecting highly sensitive information. AB - Pneumocystis carinii pneumonia (PCP) has been the major cause of death and the most common opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS), with in-hospital mortality rates as high as 60% in some hospitals. To investigate whether there were large variations in quality of care for hospitalized patients with PCP, researchers at RAND Corporation, in 1989, designed and initiated a multi-city study of patterns of care. Mounting a successful primary data collection effort in several cities requires a substantial effort from collaborators in many different settings. In addition, studies of persons with AIDS require careful consideration of issues related to the highly sensitive nature of data sources such as medical records of persons with AIDS, collection of reliable and accurate information, and protection of hospital and patient confidentiality and anonymity. The research team developed an interactive well-coordinated program to select hospitals and patients for evaluation, ensure confidentiality and anonymity, prepare materials, recruit collaborators, and obtain detailed clinical data about the care of patients with PCP. This paper summarizes major data collection and related project activities including design and sampling decisions, fieldwork preparation and implementation, and patient and hospital characteristics. PMID- 10151165 TI - Occupational risk of acquiring HIV infection through needlestick injuries. AB - Accidental needlestick exposures occur frequently among hospital personnel and account for most incidents of percutaneous injuries. Even if universal precautions were followed routinely, it is unlikely that multiple needlestick exposures could be avoided completely. Despite the likelihood of persons incurring multiple needlestick exposures, relatively little information is available on the cumulative risk of human immunodeficiency virus (HIV) infection for health care workers attending unrecognized HIV-infected patients. A quantitative method to estimate annual cumulative risk from multiple exposures is offered, and the risk of HIV infection is estimated by use of a probability model for health care workers in both hospital and emergency department settings. PMID- 10151166 TI - Can a house call by a public health nurse improve the quality of the discharge process for geriatric patients? AB - OBJECTIVE: To determine whether there was any benefit from a single house call by a health visitor (a public health nurse) to an elderly person after discharge home from a geriatric hospital. METHODS: A randomized controlled trial with blind assessments at 28 days was conducted. Subjects included residents of Bath, England, with an average age of 83 years, who were discharged consecutively from a geriatric hospital to their homes. Intervention was a single visit by a health visitor 72 hours after discharge, to ensure the patient was settled at home, or normal post-discharge care. Outcome measures taken at 28 days by a research nurse included survival, hospital readmissions, nursing home admissions, cognitive and physical function, services requested and supplied, and drug therapy. RESULTS: There were no important differences between the intervention and control groups at 28 days on any of the outcome measurements. The control subjects did better than the study subjects on many of the outcome measures. CONCLUSION: A house call by a health visitor to elderly patients after discharge from geriatric wards does not measurably improve the quality of the discharge. PMID- 10151167 TI - Cost-effectiveness models of clinical trials of new pharmaceuticals for AIDS related Pneumocystis carinii pneumonia: are they helpful to policy makers? AB - BACKGROUND: Pneumocystis carinii pneumonia (PCP) has been the most common and most costly complication of acquired immunodeficiency syndrome (AIDS). Because of concern over the high costs of care for persons with AIDS, policy makers have instituted a number of new measures to encourage cost-effectiveness. Although the clinical efficacy of new pharmaceutical agents is evaluated extensively before approval, comparative trials of a new agent with its major competitor are sometimes not carried out, and estimates of cost-effectiveness are therefore difficult to obtain. METHODS: We describe methodologic issues associated with the development of economic models of new pharmaceutical agents and illustrate these issues with an analysis of second-line therapeutic options for PCP. RESULTS: A new drug, trimetrexate, and the standard second-line therapy, pentamidine, are both inferior to the standard first-line therapy, trimethoprim/sulfamethoxazole, as initial therapy for moderate to severe PCP. However, as many as half of the patients with PCP are either intolerant or refractory to trimethoprim/sulfamethoxazole therapy for PCP. Economic models suggest that, if the two drugs have identical survival rates, then trimetrexate, despite a higher acquisition cost, is both less expensive and more effective in achieving toxicity free survival than pentamidine in patients who require second-line therapy for PCP. Sensitivity analyses indicate that trimetrexate is less expensive than pentamidine over a wide range of estimates of costs and effectiveness. CONCLUSIONS: To make well-informed therapeutic decisions, policy makers and physicians require head-to-head studies of a new pharmaceutical agent with its major competitor. However, economic models can be used to derive estimates of cost-effectiveness of new pharmaceutical agents when such data are lacking. The interpretation of these models raises general issues related to the perspective of the investigators, study design, estimation of costs of care, rates of response, toxicity, and survival, and generalizability of the results to other settings as well as methodologic issues that are unique to human immunodeficiency virus (HIV) disease. If a comparative trial found better survival rates, then cost-effectiveness models would be of limited usefulness; almost all physicians would use the drug with the higher survival rate. PMID- 10151169 TI - Junior doctors prescribe digital dictation as the healthy option. PMID- 10151168 TI - The impact of computer-based information systems on quality patient care. PMID- 10151170 TI - Medical records in transition. PMID- 10151171 TI - Inequity in the distribution of urban health care infrastructure in Kenya: the Kisumu Municipality as an example. AB - This paper discusses the phenomenon of the intra-urban inequities in the provision of health care. Using the example of Kisumu municipality in Kenya, the author demonstrates that the current gross differentials in the state of health and access to health care are neither inevitable nor unavoidable. The author however contends that the crisis is not insurmountable. What it requires is the willingness and readiness by the political superstructure to stimulate, institute and enforce appropriate changes in the legislative policies affecting the very basis upon which appropriate and innovative application of various policy alternatives to urban health planning and the overall domain of physical planning and urban renewal should take place. PMID- 10151172 TI - The impact of HIV on the University Teaching Hospital, Lusaka, Zambia. AB - The article examines the impact of admission of AIDS (and related TB) patients to an African Teaching Hospital. Because of limited resources available in general but also because of the gravity of the AIDS patients' state, non-HIV patients are being discharged too early. The article explains patient management techniques for minimizing the general negative impact on the quality of patient care. PMID- 10151173 TI - Hospital accreditation--a universal perspective. AB - Hospital accreditation is professional and national recognition reserved for hospitals that provide high-quality health care. From the United States to the United Kingdom, many countries have introduced a hospital accreditation programme for the purpose of assuring high-quality health services. The standards used in accreditation programmes previously focused on structural evaluation, but recently attention is being turned to outcome evaluation. Initially discussing the international experiences of accreditation programmes, the author goes on to examine Korea and its Government's plans to implement a new accreditation programme in the near future, which will constitute an important part of the governmental healthcare reform plan. PMID- 10151174 TI - Planning the culture of a children's hospital. PMID- 10151175 TI - A model hospital standards and accreditation system for Pakistan. AB - This article treats the use of a system of hospital standards and accreditation as a means to improve the quality of health care services in Pakistan. In it the author stresses the importance of nationwide standards for accreditation as an educational measure and an incentive to improve, as opposed to a punitive measure. The author outlines a series of recommendations, which followed from the Workshop on Hospital Standards and Accreditation, on the implementation of an accreditation system. These recommendations include the establishment of a National Council, composed of representatives from the government, the private sector and professional organizations, with the authority to oversee the system. The recommendations also stress that the accreditation system should be voluntary, in keeping with the system's educational rather than punitive goal. Finally, the author details a methodology for developing standards in specialized areas through corresponding standards committees. PMID- 10151176 TI - Evaluating the benefits and limitations of an accreditation system. AB - While accreditation programmes are not a quality assurance panacea, long experience has shown their benefits to substantially outweigh real or perceived negative impacts. It is argued that such systems are an essential basis for more sophisticated quality assurance programmes. Accreditation programmes also have unexpected benefits in the general management of hospitals. PMID- 10151177 TI - Medicare program; Medicare secondary payer for individuals entitled to Medicare and also covered under group health plans--HCFA. Final rule with comment period. AB - These regulations establish limits on Medicare payment for services furnished to individuals who are entitled to Medicare on the basis of disability and who are covered under large group health plans (LGHPs) by virtue of their own or a family member's current employment status with an employer; and prohibit LGHPs from taking into account that those individuals are entitled to Medicare on the basis of disability. They also implement certain other provisions of section 1862(b) of the Social Security Act, as amended by the Omnibus Budget Reconciliation Acts of 1986, 1989, 1990, and 1993 and the Social Security Act Amendments of 1994. Those amendments affect the Medicare secondary payer rules for individuals who are entitled to Medicare on the basis of age or who are eligible or entitled on the basis of end stage renal disease and who are also covered under group health plans (GHPs). The provisions that apply to all three groups include-- The rules under which HCFA determines that a GHP or LGHP is not in conformance with the requirements and prohibitions of the statute; The appeals procedures respecting GHPs and LGHPs that HCFA finds to be nonconforming. The referral of nonconforming plans to the Internal Revenue Service; and The rules for recovery of conditional or mistaken Medicare payments made by HCFA. The intent of the MSP provisions is to ensure that Medicare does not pay primary benefits for services for which a GHP or LGHP is the proper primary payer and that beneficiaries covered under these plans are not disadvantaged vis-a-vis other individuals who are covered under the plan but are not entitled to Medicare. PMID- 10151178 TI - Full reporting by health maintenance organizations (HMOs) and competitive medical plans (CMPs) paid on a cost basis--HCFA. Correction notice. AB - Federal Register document No. 95-16411, beginning on page 34885 of the issue of July 5, 1995 amended part 417 of the HCFA regulations to require full reporting by HMOs and CMPs of the costs of all services furnished to their Medicare enrollees. In that final rule we amended section 417.546 to remove paragraph (b). However, we failed to remove, from the introductory text of the section, a reference to the paragraph (b) that we removed. This notice corrects our oversight. PMID- 10151179 TI - Medicare program; contracts with health maintenance organizations (HMOs) and competitive medical plans (CMPs)--HCFA. Final rule with comment period. AB - This rule clarifies and updates portions of the HCFA regulations that pertain to the following: The conditions that an HMO or CMP must meet to qualify for a Medicare contract (Subpart J). The contract requirements (Subpart L). The rules for enrollment, entitlement, and disenrollment of Medicare beneficiaries in a contracting HMO or CMP (Subpart K). How a Medicare contract is affected when there is change of ownership or leasing of facilities of a contracting HMO or CMP (Subpart M). These are technical and editorial changes that do not affect the substance of the regulations. They are intended to make it easier to find particular provisions, to provide overviews of the different program aspects, and to better ensure uniform understanding of the rules. PMID- 10151180 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1996 rates--HCFA. Final rule with comment period. AB - We are revising the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes arising from our continuing experience with the system. In addition, in the addendum to this final rule, we are describing changes in the amounts and factors necessary to determine prospective payment rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes are applicable to discharges occurring on or after October 1, 1995. We are also setting forth rate of-increase limits as well as policy changes for hospitals and hospital units excluded from the prospective payment systems. Finally, we are setting forth several requirements concerning Essential Access Community Hospitals (EACHs) and Rural Primary Care Hospitals (RPCHs), in accordance with provisions of the Social Security Act Amendments of 1994. PMID- 10151181 TI - Medicare program; payments to HMOs and CMPs and appeals: technical amendments- HCFA. Final rule with comment period. AB - This rule clarifies and updates portions of the HCFA regulations that pertain to payment for services furnished to Medicare enrollees by health maintenance organizations (HMOs) and competitive medical plans (CMPs); appeals by Medicare enrollees concerning payment for those services; and appeals by HMOs and CMPs with regard to their Medicare contracts. This rule completes the special project aimed at the total technical revision of part 417. Part 417 contains the regulations applicable to all prepaid health care organizations, that is, HMOs, CMPs, and health care prepayment plans (HCPPs). These are technical and editorial changes that do not affect the substance of the regulations. They are intended to make it easier to find particular provisions, to eliminate needless repetition and remove obsolete content, and to better ensure uniform understanding of the rules. PMID- 10151182 TI - Medicaid program; limitations on aggregate payments to disproportionate share hospitals: federal fiscal year 1995--HCFA. Notice. AB - This notice announces the final Federal fiscal year (FFY) 1995 national target and individual State allotments for Medicaid payment adjustments made to hospitals that serve a disproportionate number of Medicaid recipients and low income patients with special needs. We are publishing this notice in accordance with the provisions of section 1923(f)(1)(C) of the Social Security Act (the Act) and implementing regulations at 42 CFR 447.297 through 447.299. The final FFY 1995 State disproportionate share hospital (DSH) allotments published in this notice supersede the preliminary FFY 1995 DSH allotments that were published in the Federal Register on January 13, 1995 (60 FR 3250). PMID- 10151183 TI - Records and reports regulations for radiation emitting electronic products--FDA. Final rule. AB - The Food and Drug Administration (FDA) is amending its regulations regarding the requirements for recordkeeping and reporting of adverse experiences and other information relating to radiation emitting electronic products. This rule reduces recordkeeping and reporting requirements for some products, requires only abbreviated reporting for other products, and clarifies certain requirements. The timing and content of certain reports will be revised to enhance the usefulness of the information. These amendments will improve protection of the public health while reducing regulatory burdens on manufacturers, dealers, and distributors of radiation emitting electronic products. PMID- 10151184 TI - Medicare program; criteria and procedures for extending coverage to certain devices and related services--HCFA. Final rule with comment period. AB - This final rule establishes in regulations that certain devices with an investigational device exemption (IDE) approved by the Food and Drug Administration (FDA) and certain services related to those devices may be covered under Medicare. Specifically, it sets forth the process by which the FDA will assist HCFA in identifying non-experimental investigational devices that are potentially covered under Medicare. This rule responds to the mandate that Federal agencies streamline their regulatory processes to make them less burdensome and more customer-focused. It is intended to provide Medicare beneficiaries with greater access to advances in medical technology and encourage clinical researchers to conduct high quality studies of newer technologies. PMID- 10151185 TI - Medical administration of radiation and radioactive materials--NRC. Final rule. AB - The Nuclear Regulatory Commission is amending its regulations to clarify that the medical administration of radiation or radioactive materials to any individual, even an individual not supposed to receive a medical administration, is regulated by the NRC's provisions governing the medical use of byproduct material rather than by the dose limits in the NRC's regulations concerning standards for protection against radiation. The rule does not represent a change in policy, but is necessary to indicate clearly that this is the NRC's policy and to clarify the relationship of NRC's regulations. PMID- 10151186 TI - Infectious substances--DOT. Final rule. AB - RSPA published a notice of proposed rulemaking (NPRM) in December 1994 that proposed to revise the regulations pertaining to infectious substances, including regulated medical waste (RMW). In this final rule, RSPA is revising requirements for Division 6.2 materials (infectious substances). This rule clarifies the scope of regulation for infectious substances, provides relief for certain shipments of RMW that conform to other Federal agency regulations, allows certain quantities of RMW to be transported by aircraft, and makes other changes to clarify regulatory provisions applicable to infectious substances. This rulemaking action is necessary to ensure that the regulations for infectious substances and regulated medical waste are cost effective and provide an adequate level of safety in transportation. PMID- 10151187 TI - Medicare and Medicaid programs; survey, certification and enforcement of skilled nursing facilities and nursing facilities--HCFA. Final rule and correction to final regulations. AB - In the November 10, 1994 issue of the Federal Register (FR Doc. 94-27703) (59 FR 56116), we established rules for survey of skilled nursing facilities that participate in the Medicare program, and nursing facilities that participate in the Medicaid program. We also established remedies that we impose on facilities that do not comply with Federal participation requirements, as alternatives to program termination. This document corrects errors made in that document. PMID- 10151188 TI - Notice regarding Section 602 of the Veterans Health Care Act of 1992; new drug pricing--PHS. Final notice. AB - Section 602 of Public Law 102-585, the "Veterans Health Care Act of 1992," enacted section 340B of the Public Health Service Act ("PHS Act"), "Limitation on Prices of Drugs Purchased by Covered Entities." Section 340B provides that a manufacturer who sells covered outpatient drugs to eligible entities must sign a pharmaceutical pricing agreement with the Secretary of Health and Human Services in which the manufacturer agrees to charge a price for covered outpatient drugs that will not exceed an amount determined under a statutory formula. The purpose of this notice is to inform interested parties of final guidelines regarding new drug pricing. PMID- 10151189 TI - Lists of designated primary medical care, mental health, and dental health professional shortage areas--HRSA. Notice. AB - This notice provides lists of all areas, population groups, and facilities designated as primary medical care, mental health, and dental health professional shortage areas (HPSAs) as of June 15, 1995. HPSAs are designated or withdrawn by the Secretary of Health and Human Services (HHS) under the authority of section 332 of the Public Health Service (PHS) Act. PMID- 10151190 TI - Devolution. Will the states be left holding the bag? PMID- 10151191 TI - Prescription for relief stirs debate. PMID- 10151192 TI - Pinching pennies. PMID- 10151193 TI - A Medicare fistfight. PMID- 10151194 TI - From hospitals to fitness centers--maintaining community health. AB - Healthcare today is moving from intervention to prevention, from curing illness to promoting wellness. Because of this focus, many hospitals are building fitness centers as an extension of community outreach services, both for therapy after rehabilitation and for lifestyle health maintenance. But what are the interconnections between the hospital and the fitness center? The following article describes the approach taken by the Lake Forest Health & Fitness Institute (Lake Forest, IL). PMID- 10151195 TI - Getting ready for capitation: prepare, prepare, prepare. PMID- 10151196 TI - A test of political spin control. PMID- 10151197 TI - Deming's ideas applied to healthcare. PMID- 10151198 TI - In closing ... change is modification, reformation, reorganization, and transformation. PMID- 10151199 TI - The future of wellness care. AB - The current restructuring of the US healthcare system will result in a new emphasis on wellness services. Hospitals are challenged to define the wellness role they will play within managed care. This article reports on interviews with wellness experts and hospital CEOs, who reflect on these challenges and define strategic priorities. The interviews highlight the need to understand that this challenge requires a powerful paradigm shift from illness to preventive services, and a major rethinking of how hospitals operate to offer cost-effective preventive services. The interviewees see great opportunity, but also great need for thorough planning, careful design, and implementation. Hospital leaders must understand clearly what wellness means, and how best to position their hospital for strategic advantage. In the final analysis, wellness emerges as an integral strategy in the overall process of managing change. PMID- 10151200 TI - Merging the minds of the doctor and engineer. Interview by Fred Bazzoli. PMID- 10151201 TI - Provider automation. Starting engine saves money. PMID- 10151202 TI - Will paper ever go away? Document imagers bet it won't. AB - Health care providers and payers alike would like to eliminate their paperwork, converting all information to digital form. Many provider organizations are attempting to implement computerized patient record systems designed to eventually eliminate the traditional file folders crammed with paper records. And a widespread movement to electronic data interchange for financial transactions holds out hope of eliminating paper claims and related financial transactions. But moving from a paper-intensive world to a computer world takes time, and the transition will never be complete. PMID- 10151203 TI - CHIN building, step one: create a consensus. AB - The Big Three automakers long have wanted Michigan health care providers to give them outcomes data so the care companies could gauge the cost-effectiveness of the care their workers get in the Detroit area. At first, the car companies saw the fledgling Michigan Health Management Information System as the way to finally get the data they've wanted. Eventually, though, after long discussions with other network participants, the carmakers opted to scale back expectations, agreeing that the network should focus first on moving administrative transactions between health care purchasers, payers and providers. PMID- 10151204 TI - Assessing the role of the Blues plans' all-payer clearinghouses. AB - A growing number of the nation's 67 Blue Cross and Blue Shield plans, many of which are dominant health insurers in their markets, are attempting to expand their electronic health care transactions business. At least a dozen plans have created claims clearinghouses designed to handle claims and other electronic transactions destined for any payer. PMID- 10151205 TI - Where does the CIO fit? PMID- 10151206 TI - The role of digital dictation. PMID- 10151207 TI - Utilization management programs evolve. PMID- 10151208 TI - Clinton proposes dose of deregulation for LTC. PMID- 10151209 TI - Hospitals eye revenues from assisted living. PMID- 10151210 TI - How have higher-acuity residents affected your operations? PMID- 10151211 TI - Rethinking regulations. LTC leaders discuss nursing home law with a regulatory reform advocate. Panel discussion. PMID- 10151212 TI - Salaries and acuity levels rise. Executive directors in retirement housing reveal current salary trends. PMID- 10151213 TI - The Boren amendment by any other name. PMID- 10151214 TI - Agencies & vendors. Friends, foes, or partners? AB - Communication is the key to making vendor-agency relationships work. This communication needs to start from the very beginning, with planning, and continue through installation, training, and support. With good communication, the change brought on by automation will be positive. PMID- 10151215 TI - Planning for the future: the implementation of an automated clinical system. AB - Preparing for automation is as important to the whole automation process as choosing the correct system. Planning should start some time before actual purchase. Once the strategic planning is complete, staff can begin researching what applications are available, what they do, what vendors are reputable, etc. Then the agency can begin the actual implementation. PMID- 10151216 TI - Staying one step ahead--development of an electronic record. AB - Participation in a demonstration program allowed the VNS of New York to develop its own electronic records system. This description of the process and the resulting system should give a good picture of the ultimate benefits of such a system. PMID- 10151217 TI - Computer conversion & user group participation. AB - A small, hand-held computer seemed to be the answer to many challenges of home care automation. When users came together to discuss their success and problems, their combined attention only improved the product and helped them use it more effectively. PMID- 10151218 TI - Managing data by phone. AB - Information collection for home care poses more of a problem than it does for institution-based health care organizations. Many versions of smaller computers have been developed, but these pose their own problems. Another technology, already widely available, may be the answer for some agencies. PMID- 10151219 TI - Home monitoring for congestive heart failure patients. AB - Congestive heart failure eats up a lot of this country's health care dollars. Posthospitalization care is important to preclude readmissions and keep costs down. Telemedicine offers a solution to this challenge. PMID- 10151220 TI - Computerized charting--an essential tool for survival. AB - Clinical documentation is becoming increasingly important, not only for patient care, but for satisfying payors' need for proof of efficient and cost-effective care. What factors are involved in a computerized documentation system and what should providers look for? PMID- 10151221 TI - Automating payroll, billing, and medical records. Using technology to do more with less. AB - As home care agencies grow, so does the need to streamline the paperwork involved in running an agency. One agency found a way to reduce its payroll, billing, and medical records paperwork by implementing an automated, image-based data collection system that saves time, money, and paper. PMID- 10151223 TI - Calculating capitation rates. Designs for information systems. PMID- 10151222 TI - Using clinical information to manage managed care. AB - Clinical records management has always been a sore spot for home care providers. Innovations in computer database management, however, may hold the key to bringing records management under control. PMID- 10151224 TI - The Medicare Transaction System Initiative. AB - The Health Care Financing Administration is developing a system that will effectively use information technology to reduce paperwork and streamline the processing of claims. This system, targeted to be up and running by late 1997, will usher in a new model of convenience for providers, payers, and clients. PMID- 10151225 TI - Home care information systems: strategies for the future. AB - As market reform of the US health care system propels home care providers onto center stage, savvy home care leaders are quietly preparing a new information technology strategy to cope with the challenges that lie ahead. PMID- 10151226 TI - Grappling with information-sharing strategies. AB - Every provider has heard that home care agencies will have to become partners in alliances or members of a network to survive in the future health care continuum. But this poses problems for information sharing, which could affect that continuum. What will it take to hook into the community health care services network? PMID- 10151227 TI - Information technology for home care--a promising future. AB - Home care faces challenges in the automation arena from changing regulations to improved software and hardware. The past has had its ups and downs in relations between agencies and those vendors from whom they must purchase these necessities. What have been the problems? How can agencies avoid them? PMID- 10151228 TI - Directory of computer vendors and services. PMID- 10151229 TI - Managed care: liability exposures for home care. AB - There are certainly advantages for home care agencies in joining with managed care organizations (MCOs). Agencies do need to be aware, however, of risks inherent in contracting with MCOs, and of what they can do to address those risks before they become problems. PMID- 10151230 TI - Ethical delivery of specialized care beyond hospital walls. PMID- 10151231 TI - Can managed care save Medicare? AB - Managed care has been offered as the savior of the Medicare program. But is it really the answer to Medicare's cost problems? What are the difficulties involved in this controversial issue, and what must be done before managed care can truly be considered a viable option for Medicare patients? PMID- 10151232 TI - The modernization of Medicare. AB - The Group Health Association of America, which represents the nation's health maintenance organizations, believes that modernizing and strengthening Medicare are among America's most urgent priorities. HMOs, which offer health care to more than 50 million Americans, are prepared to play a key role in modernizing Medicare. PMID- 10151233 TI - Reverse mortgages. AB - Elders and their families are often caught in a financial bind when it comes to paying for much-needed home care services. Reverse mortgages may offer a solution to elderly home care clients who own their homes but have a limited income with which to maintain their independence. PMID- 10151234 TI - Fire and burn safety: important issues for caregivers. AB - Homebound older Americans have a fire fatality rate that is two to three times higher than the national average. An innovative community outreach program trains caregivers to familiarize their elderly patients with fire safety techniques. PMID- 10151235 TI - Dollars, dilemmas, and the deliverance of care: strategies to promote ethical awareness. AB - In the face of fiscal restraints, shrinking resources, and a bottom line emphasis, the imperative question is how home care agencies and hospices can promote ethical practice, awareness, and concern. By establishing an ethics committee and encouraging discussions on ethical dilemmas, home care and hospice providers can ensure that dollars do not overshadow care delivery. PMID- 10151236 TI - Medicare risk HMOs: careful consideration can yield rewards. AB - Enlightened employers have discovered that Medicare HMOs, especially risk HMOs, offer employees and retirees a win-win alternative. They lower today's costs, controlling-term increases and offer the broadest, quality coverage. Implementing a "winning" Medicare risk HMO requires careful scrutiny of how the HMO operates and delivers care to the Medicare audience and depends on effective communication that is sensitive to the special needs of retirees. PMID- 10151237 TI - Retiree health care benefits: a new standard of care. AB - Solving the problem of continually rising retiree health care costs may ultimately require a new type of health care system. By monitoring individual behavior and intervening when necessary to modify potentially harmful behavior, we can reduce the present system's wasteful emphasis on hospitals and drugs. PMID- 10151238 TI - Converting a deli to self-service. PMID- 10151239 TI - Challenge: how to improve nutrition in dysphagic patients. PMID- 10151240 TI - Targeting the trends. A meeting of the minds. Roundtable discussion. PMID- 10151241 TI - Managed care liability and the capitated provider. AB - While there have been no reported cases as yet on the subject of ERISA preemption of claims arising from utilization review decisions by providers, it will unquestionably be a significant issue facing providers that participate in capitated arrangements. If preemption is determined not to be available, providers will be exposed to risks from which health plans are currently shielded. Providers conducting utilization review should be following this issue as it develops, but should also be obtaining insurance for this risk to the extent it is available (e.g., it will not be available for punitive damages). Providers should also consider negotiating provisions in their contracts with health plans to the effect that any utilization review conducted by the provider is on behalf of the health plan and that the provider's utilization review activities will be covered under the health plan's liability insurance. PMID- 10151242 TI - Questions concerning the process of requesting exceptions from the skilled nursing facility cost limits. AB - The new PRM provisions provide helpful guidance to SNFs in submitting requests for exceptions to cost limits. However, they also make the process more rigid and create procedural traps for the unwary. Accordingly, SNFs are advised to study the PRM sections to assure that their exception requests contain the required information. However, they should not feel bound by the limits in the PRM. When submitting requests, SNFs should think creatively about why their facilities are atypical and how to best quantify their higher costs. They should then protect their rights by including these more creative theories or calculations in the materials they submit to the intermediaries. PMID- 10151243 TI - Pulling the coverage trigger: the temporal condition of liability insurance. AB - Timing issues will continue to be at the forefront of insurance coverage disputes for a long time, and may impact not only the question of which insurer is responsible for a particular loss, but also whether any coverage exists at all. For example, if a policyholder has self-insured for any period, the timing issue may well determine whether purchased liability insurance will afford any protection for the loss. Though courts have provided useful guidelines, in order to determine coverage the facts of each case must be carefully examined, particularly the policy language and the nature of the injury on which the claim is founded. When there are difficult timing questions, one viable approach may be for the policyholder to select a "target" insurer to sue for coverage, based in part on the timing analysis, and leave to the targeted insurer the task of seeking contribution from all other carriers potentially responsible for covering the loss. PMID- 10151244 TI - Physician organizations: two years under the FTC/DOJ guidelines. AB - The joint antitrust enforcement statement for physician networks was designed in part to dispel uncertainty in the physician community about antitrust agency law enforcement intentions. In the two years since its issuance, the antitrust agencies have generally, but not always, been consistent in applying the methodology and standards set forth in their enforcement statement. Even though agency pronouncements like the enforcement statement are not binding on private parties or the federal courts, both the statement and subsequent advisory opinions and business review letters have been exceptionally helpful, if not always encouraging, to health care providers in their antitrust planning efforts. PMID- 10151245 TI - Data trends. October 1995. PMID- 10151246 TI - New antitrust issues in provider network pricing. PMID- 10151247 TI - Managed care. Understanding the law of large numbers. PMID- 10151248 TI - Alternative sources of injury account recovery. AB - Obtaining full, prompt payment for healthcare services rendered is critical for physicians and healthcare organizations. A little-known type of insurance- medical payments insurance--can help providers obtain payment for services provided to injured patients. Medical payments insurance riders are attached to some automobile insurance policies and to virtually all residential and commercial property insurance policies. In some instances, medical payments insurance can be collected directly from an injured patient's insurer, and determining fault is not an issue. PMID- 10151249 TI - Supreme Court ruling reduces GAAP's authority in Medicare cases. AB - Before March 6, 1995, the Federal courts routinely required that generally accepted accounting principles (GAAP) be applied when Medicare cost reimbursement decisions were made, even if the Health Care Financing Administration (HCFA) had contrary reimbursement policies in place. On March 6, however, the U.S. Supreme Court handed down a ruling in Shalala v. Guernsey Memorial Hospital that rejected prior court decisions and thus dismantled the body of case law that deferred to GAAP. As a result, hospitals, nursing homes, and other Medicare providers no longer can expect reimbursement decisions to be made in accordance with GAAP. The ruling also bestows greater discretionary power on HCFA and lessens its public accountability, which means that providers will face new reimbursement challenges in pending disputes with HCFA and its representatives. PMID- 10151250 TI - CFO compensation influenced by organizational size, ownership. AB - Results of a 1995 compensation survey of healthcare organization chief financial officers (CFOs) indicate that the larger the organization for which the CFO works (as measured by operating revenues), the larger the CFO's compensation package. The survey findings show that CFOs who work for organizations with annual operating revenues of more than $199 million earn an average of $189,300 annually, while CFOs at organizations with operating revenues less than $50 million earn $76,400. Other factors influencing CFOs compensation, according to survey results, include education level, gender, and job responsibilities; geographic location of the employing organization; organizational type (multi unit system, stand-alone hospital, etc.); and organizational ownership (physician owned, not-for-profit, etc.) The survey was co-sponsored by the Healthcare Financial Management Association (HFMA) and Aetna Life Insurance and Annuity Company and conducted by Management Compensation Services, a division of Hewitt Associates LLC. It is the first HFMA survey to be devoted entirely to compensation. In previous years, compensation data were obtained as part of CFO profile survey findings. PMID- 10151251 TI - Managing risk to reduce costs. AB - Historically, medical malpractice has been the focus of risk management because of the high cost of malpractice insurance premiums and claims. By employing risk control and risk financing in nonclinical as well as clinical areas, however, risk management also can be used to reduce costs associated with workers' compensation and liabilities arising from purchasing arrangements and managed care contracting. PMID- 10151252 TI - Is subacute care feasible? AB - As healthcare executives attempt to control costs and enhance revenue in an increasingly competitive market, many are considering converting acute care units into subacute care units (Medicare-certified skilled nursing units). Such a conversion can help control costs by providing care in a less expensive setting that is appropriate for patients who require less intensive care than traditional acute care. In addition, converting an acute care unit into a subacute care unit can optimize reimbursement for Medicare patients. A detailed feasibility analysis that addresses clinical, regulatory, space, and financial considerations should be conducted before healthcare executives decide to convert acute care beds into subacute care beds. Only after a feasibility analysis is performed can healthcare executives determine whether creating a subacute care unit is a realistic, beneficial option. PMID- 10151253 TI - Getting started with subacute care. AB - Subacute care programs serve patients who require less intensive care than traditional acute care, but more intensive care than traditional nursing home care. For hospitals, skilled nursing facilities, and other facilities, subacute care programs may be a means to better serve patients along the continuum of care while cutting costs and enhancing payment. Before launching a subacute care program, healthcare executives must determine potential benefits; payment mechanisms; equipment, space, and staffing requirements; and financial risks. With this knowledge, executives can make an informed decision about whether to develop a subacute care program. PMID- 10151254 TI - Requesting an exception to Medicare's routine cost limit. AB - Because many subacute care patients are Medicare beneficiaries, managers of subacute care facilities must be familiar with Medicare reimbursement methods. Medicare reimburses for skilled nursing care--a form of subacute care--based on a "routine cost limit." However, many subacute care skilled nursing facilities exceed the cost limit because they provide more intensive services than those covered by the routine cost limit. Facilities can recover some of their excess costs by filing for an exception to the routine cost limit. Recently revised guidelines for this exception define eligibility, types of costs included, documentation requirements, time frame for filing, and procedure for filing repeat requests. PMID- 10151255 TI - Managing financial pressures with subacute care. AB - Many healthcare organizations have found that converting acute care beds to subacute care beds has enabled them to control costs, enhance payments, and better serve patients along the full continuum of care. Conversion to subacute care, however, requires careful planning and sufficient resources. Healthcare executives contemplating converting an acute care unit to a subacute care unit must determine the cost of conversion, the types of services to be offered, licensing requirements, the types of patients to be served, and reimbursement implications. PMID- 10151256 TI - Electronic data interchange. The role of edits. PMID- 10151257 TI - Asset allocation: the first step to improved returns. PMID- 10151258 TI - Rapist accesses patient records; MA hospitals mull criminal screening. PMID- 10151259 TI - Hospital security should 'expand boundaries'. PMID- 10151260 TI - Hospital officials who give security contractors unfair bidding advantages. PMID- 10151261 TI - How one community provides crisis intervention/mental health services. PMID- 10151263 TI - The spoken menu--should you try it? PMID- 10151262 TI - Special report. The Oklahoma City bombing: mass casualties and the local hospital response. AB - A morning blast at the Alfred P. Murrah Federal Building, Oklahoma City, OK, on April 19, 1995, killed 168 persons and injured more than 500 in the worst terrorist attack in U.S. history. Hospital workers, physicians, and volunteers at nine hospitals there mobilized, put their disaster emergency plans into operation, and treated 466 persons in emergency rooms--many of them later being admitted as patients. To complicate matters, two of the hospitals received bomb threats called in after the disaster. This report will look at the security plans put into force by each of the nine hospitals; the handling of the great influx of persons, including victims, relatives, friends, concerned persons, volunteers, and the news media; and the lessons hospital officials learned from their experiences. PMID- 10151264 TI - Treatment of diabetic patients. Implementing the 1994 guidelines. PMID- 10151265 TI - "Hotel-style services" evolve in hospital setting. AB - Glenn Schirg has been the director of nutrition services at Vanderbilt University Medical Center in Nashville, Tennessee for the past 11 years. Besides taking full responsibility for his department, he now acts as a team leader responsible for facilitating one of the medical center's 10 major initiatives. PMID- 10151266 TI - The taste panel: a valuable tool for quality assessment. PMID- 10151267 TI - Informed consent in the context of nutrition services. PMID- 10151268 TI - Purchasing--rosy outlook. PMID- 10151269 TI - Consumer view. Looking after mother. PMID- 10151270 TI - Communications. Reading matters. PMID- 10151271 TI - User involvement. Public opinion. PMID- 10151272 TI - Data briefing. What's the NHS ever done for us? PMID- 10151273 TI - Nurse management. New world for the brave. PMID- 10151275 TI - Counsel of perfection. PMID- 10151274 TI - Waiting lists. Life in the slow lane. PMID- 10151276 TI - Primary care. Biting the bullet--what drove dentistry into the private sector. PMID- 10151277 TI - Dentistry. Filling in. PMID- 10151278 TI - Data collection. Recorded delivery. PMID- 10151279 TI - Audit. Risky business. PMID- 10151280 TI - Inventory management to reduce costs: a case study. AB - This paper presents the 2-year goals that were set by the Department of Pharmaceutical Services at Sioux Valley Hospital in 1992 regarding inventory cost savings. These goals included decreasing inventory by 10%, increasing turnover rate, controlling formulary additions, removing low-usage drugs from the formulary, ensuring compliance with group contracts, and the appropriate selection of generic equivalents for all multisource drugs. By using available computer technology offered by the prime vendor wholesaler, these objectives were accomplished. Cost containment was monitored from May 1, 1992 to April 30, 1994, two fiscal years. Inventory decreased by 16%, turnover rate increased on the top 90% of dollar-volume pharmaceuticals from 31 to 46, 72 drugs were removed from the formulary, and savings generated by using group contracts was 32% of purchase cost. PMID- 10151281 TI - The adverse drug reaction: a clinical opportunity for pharmacists. AB - A program is presented that gives the pharmacist the clinical opportunity to assess and evaluate adverse drug reactions in the hospital setting. An adverse drug reaction protocol is discussed that addresses reporting and patient care issues. The pharmacist performs adverse drug reaction assessment at the patient bedside as part of a multidisciplinary team consisting of the pharmacist, nurse, and physician. The protocol provides a method of concurrent adverse drug reaction monitoring and involves the patient in the reporting process. PMID- 10151282 TI - Pharmacotherapy practice in a rehabilitation hospital. AB - A description of a pharmacotherapy practice in a rehabilitation hospital is presented. Patient pharmacotherapy assessments were classified using the pharmaceutical care model as a typology. Pharmacotherapy log-sheets for a 2-year period were reviewed and categorized. The most frequent type of observed medication related problem encountered in the practice was "drug induced medical problem," followed by "duration or dose of medication too great" and "indication without drug therapy." The most serious type was "duration or dose of medication too great." "Drug-food interactions" were not examined during the course of the practice. The particular medications found to be frequently associated with medical problems in the rehabilitation population were those affecting 1) bowel and bladder training, 2) cognitive retraining, and 3) gait and strengthening. Those in the "duration or dose of medication too great" category included ciprofloxacin, histamine-2-antagonists, phenytoin, and benzodiazepines. The report provides additional evidence of the practical use of the theoretical model of pharmaceutical care in the approach to pharmacotherapeutic management of patients. PMID- 10151283 TI - Clinical psychopharmacy consultations: acceptance of recommendations on an adult inpatient psychiatric unit. AB - A retrospective chart review of consultations performed by a clinical pharmacist practicing in an adult psychiatric hospital was conducted. Data during the first 12 months of the service were collected from consultation reports, progress notes, physician's orders, laboratory data, and discharge summaries. Twenty-nine consultations were performed, resulting in a total of 135 recommendations. Of those, 125 were assessed and categorized. Of the recommendations, 113 (90.4%) were medication related and 12 (9.6%) were non-medication related. From the 125 recommendations, 99 (79.2%) were implemented and 26 (20.8%) were not. Particular categories of recommendations were also analyzed and had individual implementation rates ranging from 33.3% to 100%. Clinical pharmacists have previously documented their positive impact on patient care in a variety of settings, including psychopharmacy. The majority of recommendations made in this study were medication related with an overall implementation rate of 79%. This report illustrates the influence the clinical pharmacist has on the drug therapy of the psychiatric patient. PMID- 10151284 TI - Legal issues in managed care for hospital pharmacists. PMID- 10151285 TI - Compensation for vaccine injury: balancing society's need and personal risk. PMID- 10151286 TI - Cervical cancer: new technologies target treatment strategies. PMID- 10151287 TI - Using lasers to treat enlarged prostates. PMID- 10151288 TI - A technology typology. PMID- 10151289 TI - Strategic planning for radiology: an approach and methodology. PMID- 10151290 TI - Combining aesthetics and practicality in health care architecture. AB - Architecture, like health care, is a service profession. It serves not only a functional purpose by providing designs for shelter, but also incorporates social purpose. It allows people to conduct business, congregate for amusement, express their faith, and educate themselves. It is also a collaborative art, creating an environment that influences its users by their interactions with it and how they use it. PMID- 10151291 TI - Creating a healing environment by design. AB - This article focuses on offering a methodology that goes beyond creating a noninstitutional environment to one intended to assist in the development of a healing environment, one that influences patients' responses to the environment, and one that offers patients opportunities to cope. This article does not advocate a formula for design that, by its nature, would be antihetical to the dynamic proposed. Instead, this article suggests a methodology that allows and recommends flexibility in design. While the article discusses design issues for outpatient oncological centers and offers specific examples as demonstrations of implementation, the methodology is not limited to outpatient cancer care centers. Ambulatory care centers in general would benefit from application of these principles. PMID- 10151292 TI - Is patient-focused outpatient cancer care on target? AB - Patient-focused care seeks to improve both patient and staff satisfaction while reducing the costs associated with health care services. Concepts borrowed from inpatient care settings are now being applied to outpatient facilities. Incorporating many of the Planetree principles in design ensures that patients' physical as well as emotional and psychological needs will be addressed. In addition, these same principles, while patient focused, serve the staff needs as well as by providing varied tasks, increasing levels of responsibility, and improving efficiencies in operations by improved design. PMID- 10151294 TI - SAFE (strategy, assessment, flexibility, and efficiency) for future use? Stages in master planning, programming, and architectural design. AB - Health care facility design must incorporate four key elements: Strategy, Assessment, Flexibility, and Efficiency. These SAFE elements will offer the organization the greatest return on investment, because they encompass both present needs and future demand. They respect the integrated nature of functional operations by clustering them in ways that permit growth or consolidation. In the rapidly changing health care environment, flexibility is fundamental to successful design. PMID- 10151293 TI - The difference in dollars and sense: effective facility management for the outpatient cancer care center. AB - This article discusses the process to manage a modern cancer center effectively. The process is a continuous management cycle that begins with planning, then moves to implementation, and ultimately returns to planning. Within this cycle, a variety of management decisions and tools is analyzed. PMID- 10151295 TI - Cue for quality. AB - Continuous improvement or CI is an approach to improving quality in an organization's processes on an ongoing basis. Three key components contribute to CI success: (1) draw on the knowledge and abilities of employees at all levels; (2) focus on customer needs; and (3) use data in a scientific approach to decision making. A long-term effort, not a short-term fix, the classic CI cycle is Plan, Do, Study, Act. Health care organizations are finding a good fit for CI in clinical applications. Improved patient care through efficient, consistent processes is one of the immediate, obvious benefits of CI. The data collected can also validate decisions from a financial standpoint and provide necessary information to regulatory agencies. Over the longer term, applying CI data and understanding customer needs can help to develop efficient, user-oriented facilities. The chief payback, however, is an organization that is flourishing because it meets the needs and expectations of customers--patients, physicians, employees, and the community. PMID- 10151296 TI - Graduate education in health policy and management: the University of Massachusetts experience, 1978-1990. AB - For students in undergraduate and graduate programs in health policy and management, particularly those who wish to be trained as public-health-oriented generalist health administrators, as well as those charged with the responsibility of being their teachers, it is important to consider the trajectory, tensions, and rewards of a career in health policy and management. This article begins by examining what we have learned from earlier research and writing on health policy and management careers and then moves on to analyzing the career history and professional development of 40 graduates of the generalist health policy and management program at the University of Massachusetts School of Public Health. Finally, the article reaches some conclusions about career paths for generalist health administrators trained in at least one school of public health. PMID- 10151297 TI - Accommodating modern cancer treatment procedures in an outpatient facility. AB - The aging of the American population, the recent increasing prevalence of smoking in females, and the decline in heart disease mortality are setting the stage for cancer to be the most common cause of death in the United States by the year 2000. The technology exists today to increase survival rates from 50% to 75%, but this continuing care will increase cancer-related expenditures to 20% of the nation's total health care expenditures. Many advances in cancer diagnosis and treatment offer promise for less invasive procedures, and some new interventions focus on prevention or early detection of limited disease in ambulatory patients. The likelihood and the length of hospital admissions are declining, and the proportion of care delivered in an inpatient setting is expected to represent less than 10% of total cancer patient care. While the delivery of care shifts to the outpatient setting, the need for a continuum of care, interdisciplinary collaboration, and access to regional centers for technology and research is likely to encourage the formation of systems that combine a tertiary care hub and a network of community-based ambulatory centers. PMID- 10151298 TI - Expanded-scope EMS education. A matter of degree? PMID- 10151299 TI - Find the value in people. PMID- 10151300 TI - How to influence purchasing decisions. PMID- 10151301 TI - Rwanda: an EMS journal. PMID- 10151303 TI - JEMS 1996 Buyers Guide. PMID- 10151302 TI - How much is your body worth? Hard bodies earn hard cash. PMID- 10151304 TI - The intellectual foundation of pastoral counseling: a perspective on the future of the profession. AB - Reflects on the intellectual nature of pastoral counseling, compares it with certain aspects of contemporary research in psychiatry and clinical psychology, and offers some observations regarding the uniqueness of pastoral counseling as a profession. Argues that pastoral counseling can offer a truly wholistic view of mental health if (1) its intellectual foundation is developed in theological perspective, (2) continues to integrate its theological dimension with clinical psychology and psychiatry, and (3) evaluates its applied research within the framework of the normative standards of mental health. PMID- 10151305 TI - Animal-assisted therapy with adolescents in a psychiatric facility. AB - Reports personal experiences and research findings which suggest that pets may serve various therapeutic functions in working with children and adolescents in a psychiatric environment. Outlines research data on animal-assisted therapy and urges caregivers to include it in their armamentarium of therapeutic aids. PMID- 10151306 TI - Selection of a hospital based director of pastoral care: process and stakeholders. AB - Details the steps which were taken in the process of hiring a Director of Pastoral Care for a 274-bed acute care regional referral center in southern Alberta, Canada. Stresses the importance of anchoring the hiring process steps within a relevant context. Offers recommendations for hospitals and clergy faced with a similar project. PMID- 10151307 TI - Universal precautions compliance and exposure frequency to patient body fluids in nurses employed by urban and rural health care agencies. AB - Previous studies have suggested that health care workers may differ with respect to universal precautions knowledge, compliance, practice setting barriers, or exposure to patient body fluids in rural and urban areas. The purpose of this study was to determine whether or not there are rural/urban differences in the degree of precaution taken by health care workers to prevent the spread of blood borne pathogens, specifically human immunodeficiency virus (HIV) and hepatitis B virus (HBV). A random sample of rural and urban registered and licensed practical nurses in Tennessee was surveyed. The respondents completed two instruments that assessed self-reported universal precautions knowledge, precautions, and practice barriers. No measurable differences in universal precautions knowledge, compliance, or barrier scores between the two groups were found; yet rural nurses were 2.7 times as likely to be exposed to patient body fluids than urban nurses (P < 0.005). The conclusion was that rural nurses were as experienced and as knowledgeable about universal precaution techniques as their urban peers, but their knowledge was not translated into practice to the same degree. Two possible explanations offered are (1) rural nurses are more likely to be acquainted with, and thus trusting of, their patients, and (2) the lower seroprevalence of human immunodefiency virus and hepatitis B virus in rural areas may lead to complacency. PMID- 10151308 TI - Changes in health insurance coverage within rural and urban environments--1977 to 1987. AB - This study examines changes in the health insurance coverage of the nonelderly population in rural and urban areas between 1977 and 1987, using data from the National Medical Care Expenditure Survey (NMCES) and the National Medical Expenditure Survey (NMES). It was designed to test the hypothesis that differences in the rates of health insurance coverage in rural and urban areas have diminished over time, and to explore the composition of changes in coverage within rural and urban environments. The data suggest that the proportions of the populations that are without health insurance in rural and urban areas have converged since 1977. Although both rural and urban settings witnessed increases in the proportion of their populations without health insurance from any source, urban regions experienced a greater increase than did rural areas. These changes occurred among most subgroups within the population. In no subgroup did the percentage of the population without insurance in urban areas exceed that found in rural areas in either 1977 or 1987. PMID- 10151309 TI - Inequities in health care and survival after injury among pedestrians: explaining the urban/rural differential. AB - This study investigated whether rural/urban differences in injury mortality and morbidity are primarily due to medical care maldistribution or to other factors such as sociodemographic or environmental characteristics that are highly correlated with location. To separate incidence from case-fatality rates, the study analyzed the determinants of survival rather than cause-specific mortality rates. Using information from Florida traffic crash reports for 1988 through 1990, the study focused on Florida pedestrians hit by motor vehicles. It explores the effect of individual-level demographic characteristics, crash-level indicators of impact severity, and county-level measures of socioeconomic and medical care resources, on the odds a pedestrian survived an injury. Logistic regression analyses reveal the importance of both road environment and percent of the county that is rural. However, these analyses are not able to isolate the influence of medical care from the level of urbanization. Although the percent rural was statistically significant, indicators of the mechanical energy involved in producing the injury, posted speed, and a dark road environment were substantively more important determinants of survival. PMID- 10151310 TI - Interactions with colleagues and their effects on the satisfaction of rural primary care physicians. AB - Physician work satisfaction is related to several aspects of practice organization, including work group or colleagues, job content, work hours, and future opportunities. Practice location is an important determinant of practice organization and personal life satisfaction. This study compared the professional satisfaction of physicians in rural and urban settings to determine how practice setting, practice type, work hours, and interactions with colleagues influenced satisfaction. Surveys focusing on professional satisfaction were mailed to community-based, primary care physicians in Kentucky. Overall, physicians were satisfied with their practices, with physicians in larger communities being more satisfied than those from smaller communities. Professional satisfaction was associated with practice location, practice type, number of years since graduation from medical school, number of colleagues identified, and the quality of professional interactions with colleagues. The study concluded that collegial support for physicians is important in creating work environments that promote professional satisfaction. PMID- 10151311 TI - Availability of rural Minnesota obstetric services: is it a problem? AB - In the late 1980s several published articles predicted a crisis in the availability of obstetric care due to declining numbers of rural obstetrical providers. Several state and national studies documented the adverse impact of malpractice and time demands on both urban and rural physicians. But only limited information is available to document current trends in rural obstetrical practice and assess whether or not the predicted crisis occurred. This study sought to provide that updated information for rural Minnesota. A telephone survey of all rural Minnesota obstetrical providers was used to document the number, location, and specialty of rural obstetrical providers, their practice limitations, and plans for future practice. This data was combined with state perinatal statistics for each county to further assess obstetrical care availability and perinatal outcomes. All rural Minnesota obstetricians and certified nurse midwives provide obstetrical care as did 69 percent of all rural family physicians. Only 27 percent of rural obstetrical providers put any type of restrictions on their obstetrical practices. During the past year, 67 currently practicing rural physicians have stopped providing obstetrical care while 55 new obstetrical providers have begun rural practice. Two to 3 percent of current rural providers plan to retire or discontinue obstetrical services during the next five years. The provider demographics from the survey identified eight counties with no prenatal providers, and 12 additional communities of decreased provider availability. However, only two of the counties with no prenatal providers and five of the counties with areas of limited providers had increased percentages of adverse prenatal outcomes such as low birthweight or late prenatal care. This study concluded that Minnesota does not have a serious statewide problem with availability of rural obstetrical providers. However, a few isolated regions of the state have limited provider availability, including limited availability of local high-risk services and consultants. PMID- 10151313 TI - Families and family life in rural areas. PMID- 10151312 TI - The effects of on- and off-reservation residence on in-home service use among Great Lakes American Indians. AB - Community-based, in-home services are a crucial component in the long-term care continuum. Research has shown rural populations to be less likely to use these services. American Indian elders are more likely than their non-American Indian counterparts to reside in non-metropolitan areas, yet little rural research has focused on this subpopulation. The purpose of this article is to explore differences in in-home service use among urban, rural off-reservation, and rural on-reservation older American Indians using data from a statewide needs assessment. The sample includes 206 Great Lakes American Indians aged 55 and older. Predictor variables include the residential classification variable (rural off-reservation, rural on-reservation, and urban) along with sociodemographic, social support, health and functional status, and general knowledge of services. Results of logistic regression analysis indicate that the odds are significantly greater for on-reservation rural American Indian elders use of home services, home health aides, and home visits, than for urban American Indian elders. The off-reservation rural American Indian elder is significantly less likely than the urban American Indian elder to use a home health aid. Health rating, activities of daily living/instrumental activities of daily living (ADL/IADL) impairments, and general knowledge of in-home service availability increase the odds for all groups use of home services and home health aides. PMID- 10151314 TI - The health care system of Japan. PMID- 10151315 TI - Proposition to healthcare in Japan towards 21st century. PMID- 10151316 TI - Dose new management strategy bring us a gift of cost reduction? First Report. A study on the effect of contract-out strategy in Japanese local government hospitals. PMID- 10151317 TI - The role of teaching hospital in Japanese health care system. PMID- 10151318 TI - Creative thinking-clinical problem solving resident physician training program at Kameda Medical Center. PMID- 10151319 TI - A nursing education experiment by a communications satellite. PMID- 10151320 TI - A study of information of emergency medical care centers. PMID- 10151321 TI - Is deinstitutionalization possible in the psychiatry department of the community general hospital? PMID- 10151322 TI - Measures adopted by the Japanese Red Cross Society on the occasion of the Great Hanshin Earthquake. PMID- 10151323 TI - Ten urgent issues related to the health care system of Japan. PMID- 10151324 TI - Prosecuting doctors for bad outcomes. PMID- 10151325 TI - The Republican Rx for Medicare. Interview by Michael Pretzer. PMID- 10151326 TI - Are you ready for the new grading system? PMID- 10151327 TI - Meningitis outbreak: Mother Nature sends a scary message. PMID- 10151328 TI - I don't go to work angry anymore. PMID- 10151329 TI - Integration: will it curb your product choices? PMID- 10151330 TI - Patient survey: bedside manner. What you're doing right--and what you're doing wrong. PMID- 10151331 TI - Patient survey: Medicare patients. Your biggest fans. PMID- 10151333 TI - Patient survey: physician extenders. Why patients love physician extenders. PMID- 10151332 TI - Patient survey: loyalty. Will patients leave you for cheaper care? PMID- 10151334 TI - Patient survey: convenience. Convenience: you still have a way to go. PMID- 10151335 TI - Patient survey: malpractice. Good news: malpractice is not on their minds. PMID- 10151336 TI - Who gets patients' wrath for short hospitals stays? PMID- 10151337 TI - Patient survey: public image. What's behind your profession's bad image? PMID- 10151338 TI - Who says you have to be in managed care? PMID- 10151339 TI - Super-PHOs: super path to a larger market share? PMID- 10151340 TI - When an insurer calls your treatment experimental. PMID- 10151341 TI - Doctors struggle to keep their earnings up. PMID- 10151342 TI - When a favor becomes a kickback. PMID- 10151343 TI - Were these doctors tricked into selling their IPA? PMID- 10151344 TI - Satellites: what groups have learned the hard way. PMID- 10151345 TI - Letting good care drive out the bad. Interview by Anita J. Slomski. PMID- 10151346 TI - Selling a practice? Good will may boost your take. PMID- 10151347 TI - Saving money and pleasing patients at the same time. PMID- 10151348 TI - Four myths about using med students. PMID- 10151349 TI - Will you wind up on the unemployment line? Part I: What jobs are out there now. PMID- 10151350 TI - Will you wind up on the unemployment line? Part II: Which jobs will be there tomorrow. PMID- 10151351 TI - Will you wind up on the unemployment line? Part III: Who can help you land a job. PMID- 10151352 TI - How physicians cope with violent patients. PMID- 10151353 TI - A new spurt of growth for HMOs. PMID- 10151354 TI - Three ways to make an IPA succeed. PMID- 10151355 TI - What to do when your earnings hit the skids. PMID- 10151356 TI - Doctors' misconceptions about hospice care. PMID- 10151357 TI - Anticipating state regulation of physician-hospital organizations. What the future may hold. AB - Faced with a regulatory void, state insurance officials are now considering whether and how physician-hospital organizations (PHOs) should be treated under state law. One main focus is the extent to which PHOs accept "risk" that health care services which the PHOs are contractually obligated to arrange may not be adequately funded from revenues received prior to actual delivery of patient care. From a regulatory perspective, the risk that consumers may not receive contracted services is arguably the proper function of insurance companies or other licensed entities. From the PHO viewpoint, however, the risk concerning a PHO's obligation to arrange for the delivery of services may only be a business risk which should not be burdened by costly insurance law requirements. Important factors in analyzing the question include the identity of the party contracting with a PHO and whether that party is itself a licensed insurer. In a rapidly changing regulatory environment, many states are likely to consider model legislation now being developed by the National Association of Insurance Commissioners, which imposes risk-based capital reserve and solvency requirements upon certain PHO arrangements to address these issues. PMID- 10151359 TI - Patients build your practice. AB - Most health care professionals want a business that is built primarily on their reputation. Even in mature managed care marketplaces, reputation and word of mouth are important components to successful marketing. We all talk, but some people talk and get listened to more than others. The challenge is in knowing who talks and what motivates them to talk about your practice to others. Social science research has uncovered several factors that help you identify the most likely talkers in your practice. While most talkers are socially outgoing, these identifying factors go much deeper than this one element. Specific tactics are illustrated that can be used with these talkers to inspire them to talk more. Low cost, appropriate means of showing appreciation for talkers will inspire even more talk. PMID- 10151358 TI - Nuts and bolts issues to consider when selling your practice. AB - Ten issues are provided that will help physicians and administrators through the process of selling a practice. Those issues include determining the buyers reasons for buying, determine your reason for selling, finding the right people, how the buyer is valuing your practice, how you value your practice, preparing the selling package, employment agreements and compensation packages, negotiating the operating contract, tax consequences and knowing when to walk away from the deal. PMID- 10151360 TI - Utilizing physician leadership to reduce length of stay. AB - With the proliferation of prospective payment, managed care and the concomitant shift in risk from payer to provider, hospitals are investing in utilization management programs to reduce cost per case while maintaining or improving clinical quality. This article discusses a major component of the utilization management program at the Cleveland Clinic Foundation: the use of physician champions. Overall, the length of stay reduction initiative resulted in a shorter average length of stay by 1.8 days (22 percent). PMID- 10151361 TI - Hospital affiliation: a two-year journey--the physician/administrator team at work. PMID- 10151362 TI - Increased physician disability claims causing 'crisis'. High utilization of disability insurance may leave physician groups fewer options in the future. AB - With physician claims on the rise, disability insurers are adjusting rates, provisions and benefit plans that are offered to those in the medical field. Physicians are being hit the hardest, experiencing premium increases, benefit reductions and stricter qualifications for coverage. There are only a few carriers who have not changed their rate structures and benefit plans. Now is the time to review the quality of your disability programs and establish how your carrier is reacting to this trend. PMID- 10151363 TI - The group dynamics of medical practices. AB - A medical group by definition is a group of physicians and their support staff who have joined together to practice medicine. However, a medical group is more than that. Medical groups are composed of many different types of subgroups and group dynamics that are in constant flux and which may serve the medical group well or inhibit it from achieving its best performance. Understanding group dynamics is, therefore, one of the paths toward achieving excellence in the practice of low cost but fulfilling medicine. This article describes three types of potentially unsatisfactory group dynamics--homogenized, institutionalized and autocratic. Homogenized dynamics occur when physicians act as though they must all participate in decision making. Managing the group can become deadlocked by one veto. Institutionalized group dynamics lead to an over reliance upon systems and procedures to control work. Flexibility, adaptability and creativity are often lost in the process. Autocratic group dynamics arise when a single individual assumes nearly absolute control of decision making. Each of these group dynamics contain positive and negative outcomes that must be considered when evaluating medical group performance. Case examples and exhibits are provided to operationalize the importance of understanding these potentially dysfunctional group dynamics. PMID- 10151364 TI - Health insurance coverage for families with children. PMID- 10151367 TI - Catholic system plans secular links. PMID- 10151366 TI - Merger set in St. Louis. PMID- 10151365 TI - Aetna retaliates in dispute. PMID- 10151368 TI - Two Fla. hospitals take lead in forming statewide network. PMID- 10151369 TI - Chicago networks adding partners. PMID- 10151370 TI - Suit says Wash. firm stole capitation data. PMID- 10151371 TI - GOP begins detailing Medicare plans. PMID- 10151372 TI - Tenet settles suit for $63.8 million. PMID- 10151373 TI - Wyo. unions work on plans for PPO. PMID- 10151374 TI - S&P, Moody's announce credit-rating updates. PMID- 10151375 TI - Six systems to lead Detroit market--S&P. PMID- 10151376 TI - Black-oriented firm offers HMO. PMID- 10151377 TI - Calif. union airs woes to Clinton. PMID- 10151378 TI - KU retains full accreditation. PMID- 10151379 TI - WellPoint-HSI deal gets final OK. PMID- 10151380 TI - GOP lays out red carpet again for Perot, this time on Medicare. PMID- 10151381 TI - The vanishing art of mentoring. AB - Behind every successful healthcare executive, there is likely to be a good mentor, or maybe two or three. Without structured programs, however, some fear the art of mentoring may be squeezed out of existence. Time, or the lack thereof, is taking its toll, and mentoring is in danger of becoming a casualty of the hectic world of healthcare. PMID- 10151382 TI - Academic centers get turnaround advice. PMID- 10151383 TI - Deals often require detective work. PMID- 10151384 TI - AmHS-Premier link may cause member losses. PMID- 10151385 TI - Fla. governor reveals plan to buffer cuts. PMID- 10151386 TI - Calif. plan to adopt bidding strategy. PMID- 10151387 TI - HCFA nursing home report revives debate on new rules. PMID- 10151388 TI - Budget cut forces La. system to drop group memberships. PMID- 10151390 TI - Competitor gets county hospital. PMID- 10151389 TI - Houston children's hospital plans for-profit pediatric HMO. PMID- 10151391 TI - GOP still split on Medicaid. PMID- 10151392 TI - VHA to offer its members committed buying program. PMID- 10151393 TI - IPO planned by COHR, which runs hospital purchasing group. PMID- 10151394 TI - Providers win device-payment fight. PMID- 10151395 TI - Antitrust rulings set PHO limits. PMID- 10151397 TI - Wis. hospital group makes deal with CHIN. PMID- 10151396 TI - Ky. hospital may delay decision on Columbia. PMID- 10151398 TI - Military managed care is under fire. PMID- 10151399 TI - Consultants must keep act clean. PMID- 10151400 TI - GOP plan sees 5% rise in Medicare hospital payments. PMID- 10151401 TI - ProPAC studies effects of Medicare HMO rate cuts. PMID- 10151402 TI - Up & comers 1995. AB - Modern Healthcare's Up & Comers are working to improve the quality of medical care, expand access to healthcare and formulate a cost-efficient delivery system best suited to the needs of the 21st century. These professionals, 40 or younger, are nominated by our staff and readers as examples of the best healthcare has to offer. PMID- 10151404 TI - Study shows value of Wis. CHIN. PMID- 10151403 TI - Senate panel aims to restore AHCPR funds, cut VA's. PMID- 10151405 TI - Companies find big dollars in data. PMID- 10151406 TI - Columbia bolsters California presence. PMID- 10151407 TI - Tulsa hospital chooses Columbia. PMID- 10151408 TI - Hillhaven nurses stage strike. PMID- 10151409 TI - Reform plans likely to change the rules of long-term care. PMID- 10151410 TI - Columbia bags a convert in S.C. PMID- 10151411 TI - JCAHO decides against survey fee hike. PMID- 10151412 TI - Hospital survey process to get community input. PMID- 10151413 TI - JCAHO value doesn't equal cost--poll. PMID- 10151414 TI - Financial reasons lead quest for JCAHO approval. PMID- 10151415 TI - Cost-cutting pays off at Bronx hospital. PMID- 10151416 TI - Hoechst plans divestitures to gain FTC nod. PMID- 10151417 TI - ANA fires back at Calif. secessionists. PMID- 10151418 TI - Study fuels charity debate. PMID- 10151419 TI - Deals may redefine Tenn. market. PMID- 10151420 TI - Opposition stalls N.H. HMO merger. PMID- 10151421 TI - Marshfield verdict partly overturned; panel orders retrial. PMID- 10151422 TI - GOP details Medicare plan. PMID- 10151423 TI - Timing of GOP plan may be everything. PMID- 10151424 TI - Lack of unity over reforms handcuffs public hospitals. PMID- 10151425 TI - Purchasing groups struggle to keep pace with members. AB - Hospital alliances and group purchasing organizations don't plan to stand still while mergers and acquisitions transform their traditional hospital members into integrated healthcare systems. Included are some survival strategies of the 10 largest groups responding to Modern Healthcare's 1995 group purchasing survey. PMID- 10151426 TI - Hospitals' fiscal health stable in '94. PMID- 10151427 TI - Dems, providers rip GOP Medicaid plan. PMID- 10151428 TI - HMOs mine workers' comp market. PMID- 10151430 TI - HealthOne hospital keeps HCFA accreditation. PMID- 10151431 TI - AmHS to negotiate drug-benefit alliance. PMID- 10151429 TI - As charity-care funds dry up, states scramble to find new sources. PMID- 10151432 TI - OrNda buys back Houston hospital. PMID- 10151433 TI - Mass. panel proposes steps to cut uninsured. PMID- 10151434 TI - U. of Minn. hospital weighs more mergers with rivals. PMID- 10151435 TI - Samaritan, HealthPartners to form largest Ariz. network. PMID- 10151436 TI - Dispute over ownership of Fla. hospital heats up. PMID- 10151437 TI - Union can't stop Vencor-Hillhaven deal. PMID- 10151438 TI - Provider networks gaining in Senate. PMID- 10151439 TI - Tenet: more expansion ahead. PMID- 10151440 TI - IRS addresses physician employment. PMID- 10151442 TI - Primary-care pay may be at peak--MGMA. PMID- 10151441 TI - Doc groups at odds over Medicare pay. PMID- 10151443 TI - Rising overhead costs spark doc practice mergers--study. PMID- 10151444 TI - Ga. hospitals duel over CON reform. PMID- 10151445 TI - Caremark to buy Cigna's system in Los Angeles. PMID- 10151446 TI - Fed reprieve gives L.A. time to bicker. PMID- 10151448 TI - NCQA report summarizes its decisions on health plans. PMID- 10151447 TI - Universal Health to buy Amarillo public hospital. PMID- 10151449 TI - Cancer center makes deal to expand in N.Y. PMID- 10151450 TI - Group urges supervision of for-profit deals. PMID- 10151452 TI - Senate raises VA budget for healthcare by 1.8%. PMID- 10151451 TI - Hospitals fight for federal discount law. PMID- 10151453 TI - Kaiser plans aggressive cost cutting. PMID- 10151454 TI - Congress tinkering with Medicare HMO formula. PMID- 10151455 TI - More med school grads choosing primary care. PMID- 10151456 TI - VHA to rate technology products. PMID- 10151457 TI - Sun, union trade punches in Conn. PMID- 10151458 TI - Underwriter hit with claim in Nevada hospital default. PMID- 10151459 TI - Univ. of Missouri to partner with Tenet. PMID- 10151460 TI - Venerable Texas hospital emerges from bankruptcy. PMID- 10151461 TI - 'Midas' tries touch on doc management IPO. PMID- 10151462 TI - Tenet execs see big pay increases. PMID- 10151463 TI - 3 companies file CON requests for Fla. long-term-care ventures. PMID- 10151465 TI - 3 outpatient-care firms file for initial offerings. PMID- 10151464 TI - Michigan Health Care debt rating lowered after interest default. PMID- 10151466 TI - Bon Secours cuts middleman. PMID- 10151467 TI - Mayo builds primary-care muscle. PMID- 10151468 TI - Providers look ahead with fear at Medicare 'look-back' provision. PMID- 10151469 TI - Healthcare philanthropy's big challenge. AB - Merger mania among hospitals and health systems can be troubling and costly for charitable foundations, as philanthropy experts such as George F. Maynard III and Mary K. Anstine will attest. Some development professionals fear that for-profit takeovers of not-for-profit hospitals are driving donors away from healthcare entirely. PMID- 10151470 TI - N.Y., Calif. win under Senate Medicaid plan. PMID- 10151471 TI - Wrestling with Medicare doc fee schedules. PMID- 10151473 TI - Move eases program's growing pains. PMID- 10151472 TI - Stay-an-extra-day programs prove popular. PMID- 10151474 TI - Basic services key to CHIN's quick start. PMID- 10151475 TI - OR managers' salaries hold up under pressure. PMID- 10151476 TI - ASC managers' salaries lower, raises smaller. PMID- 10151477 TI - Financial issues, staffing are top pressures. PMID- 10151478 TI - OR quality of patient care hasn't been affected ... yet! PMID- 10151480 TI - How to fire a physician. AB - How does one fire a physician? In a word, carefully! Most of the legal protections for other employees apply just as well to physicians. And physicians have access to an expanded realm of protections because of the nature of their profession and because of its role in the health care delivery system. The ordinary employee cannot raise antitrust; the fired physician may very well raise just that issue. And yet the need to terminate a physician will sometimes, even though rarely, occur. How can the organization be certain that it has treated the physician fairly, has documented any and all offenses in a defensible fashion, and has generally followed accepted practices in all aspects of dealing with the physician? The author provides some guidelines for dealing with the problem or the incompetent physician. PMID- 10151479 TI - Predictive dialing improves small-balance accounts collection. AB - Healthcare organizations can control collection costs and improve cash flow by initiating collection contacts sooner. The cost of collections generally is one of the largest expenses in a business office budget, so the financial benefits of contacting the accounts earlier may be significant. PMID- 10151481 TI - Corporate compliance programs: risk management for the future. AB - The Department of Justice has estimated that the government loses $100 billion annually in health care fraud. Consequently, the government's health care fraud enforcement activities with respect to all health care providers and suppliers continue to grow. Last year alone, the government collected more than $8 billion in settlements, fines, and penalties involving health care fraud. Recent settlements with the government have begun to include corporate compliance programs that require continued government oversight of the health care organization as an essential part of the settlement. The first section of this article describes the legal significance of health care companies' having corporate compliance programs. The second section provides a sample list of topics that should be included in any corporate compliance program. Finally, we describe various issues related to the creation and implementation of corporate compliance programs. PMID- 10151482 TI - New governance for a new era: issues and challenges for integrating systems. AB - In this second part of a two-part column, Dr. Ruffin provides greater detail on seven key factors that he believes will govern the operations of integrated systems. Successful systems, he says, will be those that attract and retain physicians, have disciplined governance, integrate care through sharing of information among system elements, conserve capital, ensure strategic growth, control costs, and are proficient at processing information. It is important to understand, he says, that, in the movement from a fee-for-service payment mechanism, in which the various elements of the health care field bill for their services independently and according to rules designed for their benefit, to an integrated system, in which such independence can only lead to chaos, very substantial changes will be required in the governance of our health care institutions and organizations. PMID- 10151483 TI - The mandate for investigational cancer therapies. AB - The heated national health care reform debate of the summer of 1993 has now simmered down, but pieces of the debate are still percolating along at the state level. Within the past year, numerous states have introduced bills that would mandate insurance coverage for investigational cancer therapies--in particular high-dose chemotherapy and bone marrow transplant for breast cancer. The problem with these initiatives, well-intended though they may be, is that they threaten to spread unproven technologies at a rapid rate and at the same time miss the opportunity to collect data that would prove the safety and effectiveness of the methods. The author explores these issues and suggests how managed care companies can play a more aggressive role in parrying the threat. PMID- 10151484 TI - Lourdes wins 1995 McGaw Prize. Camden, N.J., hospital receives coveted award for excellence in community service. AB - Once a year, the prestigious Foster G. McGaw Prize for Excellence in Community Service is presented to a hospital. This year's award, presented Aug. 21 at the American Hospital Association's 1995 convention in San Francisco, was awarded to Our Lady of Lourdes Medical Center in Camden, N.J. Camden, N.J., is a city awash in negative statistics. It is considered the most economically depressed city of its size in the United States. A Rand Corp. study considers it one of the three worst areas in the country (placed in the "disaster" class). Not surprisingly, the problems extend to healthcare indicators as well. In the middle of Camden and in the middle of the statistics in Our Lady of Lourdes Medical Center. Their efforts and their commitment to the community is driven by its mission and vision, which states that working collaboratively, Lourdes "...will be both a catalyst and major participant in the revitalization of the city...in community benefit programs and community activities that give meaning, dignity and hope to all." Our cover story this issue examines the many and varied programs that enabled Our Lady of Lourdes to win the coveted prize, awarded "to a healthcare organization that demonstrates commitment to community service through a range of innovative programs that expand access to healthcare." And if your healthcare organization plans to enter the competition next year, we've included a bonus: Some helpful hints from this year's winner on putting the application together. PMID- 10151485 TI - Breaking the borders. Hospitals nationwide are targeting foreign consumers. AB - While some healthcare marketing programs are geographically limited to a city, state or region, others are international in scope. Some U.S. hospitals are finding a receptive market in the Caribbean, South America, Central America and Mexico. PMID- 10151486 TI - Community planning effort about to shift to action plans. Laurens County Health Care System, Clinton, SC. AB - If you're planning a communitywide focus on healthcare, it's important to involve the entire community in the process. And that's exactly what Laurens County, S.C., did. Here's a detailed look at their blueprint. PMID- 10151487 TI - Capital Medical Center personalizes physicians through marketing. AB - Capital Medical Center in Olympia, Wash., renewed its emphasis on physicians, following the arrival of a new CEO. "If physicians are successful, the hospital will be successful" was the overriding philosophy. Newsletters and seminars, supported by advertising, are working together to enhance the image of both. PMID- 10151488 TI - Rancocas and Zurbrugg Hospitals introduce "News Hound" idea. AB - You may have more public relations ambassadors throughout your healthcare facility than you realized. They're called employees. Rancocas and Zurbrugg Hospitals in New Jersey mobilized them in an effort to spread the good news. Now they're News Hounds, and the results have been above expectations. PMID- 10151489 TI - Blue A.C.E. (active community enrichment) team members enrich local communities in three states. AB - Rocky Mountain Health Care Corp.'s 2,300 employees work in three states. About half of them contribute to various community causes as members of the company's Blue A.C.E. Team. The company comes out ahead, the employees feel good and recipients in three states benefit from focused efforts. It's rewarding for all. PMID- 10151490 TI - Memorial Medical Center: new hospital, new name. AB - Memorial Medical Center is a rarity these days--a new hospital opened when others are consolidating or closing. Handling the marketing, public relations and promotion (not to mention five open houses back-to-back) was a real challenge, successfully met. Here's the background on how it was accomplished. PMID- 10151491 TI - Rethinking refrigeration. PMID- 10151492 TI - AWOL on health tests. Fewer volunteers makes research tougher. PMID- 10151493 TI - Separating smoke and substance. PMID- 10151494 TI - The war over that other M program. PMID- 10151495 TI - Retirees thrive as volunteers. PMID- 10151496 TI - Hospitals, states set standards for benefiting communities. PMID- 10151497 TI - Citizens start clinic in Little Saigon. PMID- 10151498 TI - Rural PA harbors model for 21st century health care. PMID- 10151499 TI - Churches of all faiths help connect health and spirit. PMID- 10151500 TI - Coca-Cola helps value at-risk teens. PMID- 10151501 TI - Adding up the advantages of reusable textiles. PMID- 10151502 TI - The quality-service connection. PMID- 10151503 TI - Critical pathways to utilization review. PMID- 10151504 TI - A road map for managed care success. PMID- 10151505 TI - Medical imaging 2095. PMID- 10151506 TI - Rethinking the radiologists' role in breast centers. PMID- 10151507 TI - Exposing the "silent" PPO. PMID- 10151508 TI - Avoiding the legal pitfalls of outcomes measurement and management activities. PMID- 10151509 TI - CCQE (Center for Clinical Quality Evaluation) develops quality measures for AHCPR pain guideline. PMID- 10151510 TI - Measuring quality: report cards get low grades. PMID- 10151511 TI - Quality activities result in tangible benefits. A follow-up on the Clinical Resource Utilization Project (CRUP) at Bowman Gray/Baptist Hospital Medical Center. PMID- 10151512 TI - Use of benchmarking techniques to justify the evolution of antibiotic management programs in healthcare systems. AB - OBJECTIVE: To apply basic benchmarking techniques to hospital antibiotic expenditures and clinical pharmacy personnel and their duties, to identify cost savings strategies for clinical pharmacy services. DESIGN: Prospective survey of 18 hospitals ranging in size from 201 to 942 beds. Each was asked to provide antibiotic expenditures, an overview of their clinical pharmacy services, and to describe the duties of clinical pharmacists involved in antibiotic management activities. Specific information was sought on the use of pharmacokinetic dosing services, antibiotic streamlining, and oral switch in each of the hospitals. RESULTS: Most smaller hospitals (< 300 beds) did not employ clinical pharmacists with the specific duties of antibiotic management or streamlining. At these institutions, antibiotic management services consisted of formulary enforcement and aminoglycoside and/or vancomycin dosing services. The larger hospitals we surveyed employed clinical pharmacists designated as antibiotic management specialists, but their usual activities were aminoglycoside and/or vancomycin dosing services and formulary enforcement. In virtually all hospitals, the yearly expenses for antibiotics exceeded those of Millard Fillmore Hospitals by $2,000 3,000 per occupied bed. In a 500-bed hospital, this difference in expenditures would exceed $1.5 million yearly. Millard Fillmore Health System has similar types of patients, but employs clinical pharmacists to perform streamlining and/or switch functions at days 2-4, when cultures come back from the laboratory. CONCLUSIONS: The antibiotic streamlining and oral switch duties of clinical pharmacy specialists are associated with the majority of cost savings in hospital antibiotic management programs. The savings are considerable to the extent that most hospitals with 200-300 beds could readily cost-justify a full-time clinical pharmacist to perform these activities on a daily basis. Expenses of the program would be offset entirely by the reduction in the actual pharmacy expenditures on antibiotics. PMID- 10151513 TI - Perspectives. Size of hospital cuts soon to sink in back home. PMID- 10151514 TI - Perspectives. Nursing home standards: flashpoint for federalism. PMID- 10151515 TI - Perspectives. Autumn in New York: twilight time for traditional Medicaid. PMID- 10151516 TI - Perspectives. Capitation outlook: "There are no silver bullets". PMID- 10151517 TI - Lightning and the threat it poses. PMID- 10151518 TI - Refrigeration in the hospital. PMID- 10151519 TI - Advanced European technology at Queen Alexandra Hospital. PMID- 10151520 TI - An integrated approach to hospital security at the James Paget Hospital. PMID- 10151521 TI - Designing at speed--maintaining quality on a fast track programme. PMID- 10151522 TI - Engineering clinical systems. PMID- 10151523 TI - Responding to the reform--are we meeting the need? AB - Changes in postgraduate medical education funding have had a major impact on the management of NHS library services. This paper looks at the nature of these services, by reviewing the literature on the information-gathering needs and practices of different groups of health-care professionals, and by relating the findings to the types of information service currently available. It is concluded that library and information professionals need to develop services that are more accurately attuned to the needs of their users, and various ways of approaching this objective are suggested. PMID- 10151524 TI - Systems used to automate medical libraries--analysis by type of library. AB - Analysis of data recorded in 626 questionnaires on systems used to automate medical libraries by type of library showed that academic and industrial libraries automated all serial and book functions to a greater degree that the other types of medical libraries (hospital, governmental, institutional and medical centre). Almost 75% of the academic libraries had automated some or all serial functions; 80% had automated some or all book functions. Half of the hospital, institutional and medical centre libraries (50-51%) performed all serial functions manually; 29-40% performed all book functions manually. No software was used consistently by all types of libraries to process serials or books. Mainframe or minicomputers were used more by academic libraries to process serials and books than personal computers. PMID- 10151525 TI - Library audit: report of the process of undertaking the audit of library services of selected educational providers within the former Northern Region: July 1994. AB - With the current purchaser/provider split in the NHS the purchaser has a responsibility to evaluate the quality of services provided by the provider. In the past year the Northern and Yorkshire Regional Health Authority expressed an interest in auditing library services supplied from selected education providers. This article attempts to given an account of the experience and focuses on the background, the rationale, the process and the outcomes. PMID- 10151526 TI - A code of ethics for European health librarians: the points of departure. AB - Codes of ethics are a classic mark of a profession, and their preparation is an important part of the work expected of a professional organization. EAHIL has recently embarked on drafting a code for European health librarians. This paper explains the background to EAHIL's decision, and reviews existing codes of ethical practice in the fields of both medicine and library and information work. PMID- 10151527 TI - The therapeutic partnership: legal and ethical aspects of consumer health information. AB - Patients' rights to information in the UK are based on a mixture of statute (including legislation on access to medical records) and case law (principally revolving around the issue of informed consent). These rights are set out in the Patient's Charter, which is itself a mixture of rights based on legislation and those enforced by management practice. Failure to provide adequate information to a patient could expose a medical practitioner to action for negligence or battery. Negligent information-giving could also expose consumer health information services to damages, for which the best defence is a high standard of professional competence and adequate professional indemnity insurance. Sharing information about the risks and benefits of treatment to enable truly informed decision making and consent by the patient is a key element of an ethical relationship between care giver and consumer--the therapeutic partnership. PMID- 10151528 TI - The legal responsibilities of the health-care librarian. AB - This article discusses the legal responsibilities that information intermediaries have towards the users of their services. The areas of law that affect legal liability are contract law, tort and strict liability. The likelihood of health care librarians being held liable for the service they provide is assessed, and methods of reducing this risk are discussed. The key issues are: whether the recipient is relying on the information you provide and whether this reliance is reasonable; whether money changed hands; and whether the institution is under a statutory obligation to provide the information. All-embracing exclusion clauses are often used as an attempt to exclude liability, but their validity in law is doubtful, and they should be replaced by more reasonable ones. Adhering to good professional practice, and avoiding interpreting information for laymen are ways of minimizing liability. If court proceedings do take place, professional indemnity insurance can reduce financial loss. PMID- 10151529 TI - Don't live up to your potential: the Clean Air Act operating permit. PMID- 10151530 TI - Management services organizations (MSO). Fad or future? PMID- 10151531 TI - Optimizing resources and access improvement through balanced scheduling in a group practice setting. AB - The Division of Medicine was able to achieve its goals to improve patient access by increasing the available appointment slots, on average, by 15 percent, balancing schedules to improve resource utilization, ensuring access to all patients within two weeks of a request, and by maintaining cost per case by increasing appointment slots during a period of growth. The process is dynamic in nature and ongoing review by health care access managers is important to identify opportunities for further improvement. PMID- 10151532 TI - Emerging technologies: re-engineering ADT. PMID- 10151533 TI - An open letter regarding quality teams in admitting. PMID- 10151534 TI - Critical pathways and the health care access manager on the edge of technology. PMID- 10151535 TI - The politics of Medicare and Medicaid. PMID- 10151536 TI - To Russia with love. PMID- 10151537 TI - Influence of physicians' power on health care cost. PMID- 10151538 TI - Oregon's health care plan: one state's model. AB - The Oregon plan has had a significant impact in the U.S., sparking a public debate over issues such as cost-containment and access. This paper follows the Oregon health care plan from its beginnings in 1987 to the present, discussing the plan's pros and cons, the final outcome of the proposed legislation, and its relation to the national health care reform package proposed by President Clinton. Arguments for the plan have included: its innovativeness, its plans to expand accessibility and contain health care costs, and its encouragement of public involvement in health care issues. Arguments against the plan are: it provides no guarantee of a minimal level of services for medical recipients and it rations health care for the poor based on prioritization of condition treatment pairs. PMID- 10151539 TI - The costs and consequences of caring for boarder patients in an acute-care urban hospital. PMID- 10151541 TI - The role of health insurance in the use of health services among the non-elderly. AB - Ronald Andersen's behavioral model was used to develop and test predictive expectations about the role of health insurance in the use of hospital and physician services. Health insurance should be more predictive of the use of physician than hospital services and it should not be predictive of the use of health care for those in poorer health who are in greater need of care. As expected, health insurance status was a predictor of physician use and not of hospital use. However, contrary to expectation, health insurance was also a predictor of hospital and physician use for those in poorer health. The results underscore the national debate concerning the uninsured and their access to health care, particularly for those in poorer health. PMID- 10151540 TI - A programmatic approach to improving the health of poor children. AB - There is a consensus among policy makers, physicians, child health advocates, and the general public on the need for federal action to improve the health care delivery system for poor children. What should be done, how it will be done, and who will be responsible remains a controversy. This article addresses the problems and potential of the Early and Periodic Screening Diagnosis and Treatment (EPSDT) Program within the context of Medicaid, and proposes a programmatic strategy to make EPSDT more effective. PMID- 10151542 TI - Assuming and managing risk. PMID- 10151543 TI - Joint Commission medical record interview: one hospital's experience and guidelines for 1996. PMID- 10151544 TI - Recruitment: have we oversold the profession? Kansas--the Land of Ahs--looks for the answer. PMID- 10151545 TI - Debugging viruses. PMID- 10151546 TI - Managed care in the Twin Cities and its impact on health information management professionals. PMID- 10151547 TI - Preparing for managed care during a health information management system selection project. PMID- 10151548 TI - Managing rehabilitation hospital costs and services in a state regulated environment. PMID- 10151549 TI - Preparing the master patient index for an integrated delivery system. PMID- 10151550 TI - CHINs--a reality check. PMID- 10151551 TI - A case study in chart availability--University of Texas Medical Branch Hospitals and Clinics. PMID- 10151552 TI - AHIMA's volunteers lead the way. PMID- 10151553 TI - Managing care & managing change. PMID- 10151554 TI - Teaching and performing surgery in Africa. A volunteer's perspective. PMID- 10151555 TI - A look at the work of the RUC (AMA/Specialty Society RVS Update Committee). Interview by Patricia Parks. PMID- 10151556 TI - No good deed goes unpunished. PMID- 10151557 TI - ERISA--implications for state health systems reform efforts. PMID- 10151558 TI - Guidelines for the operation of burn centers. American Burn Association and American College of Surgeons. PMID- 10151560 TI - New directions in surgery: surgeons who have switched careers. PMID- 10151559 TI - Practice expense studies. PMID- 10151561 TI - Intellections on retirement, career change, and the end game of life. PMID- 10151562 TI - Hepatitis B virus, surgeons, and surgery. AB - Surgeons continue to be at high risk for occupationally acquired HBV infection. Immunization against HBV is safe and effectively prevents transmission of HBV from patients to surgeons. Such immunization is also the most effective way to reduce the risk of transmission of HBV from surgeons to patients. Postvaccination testing, although not required, should be strongly considered. Such testing will confirm the success of vaccination and can, in conjunction with testing for HBsAg, identify surgeons who are unknowingly carriers. State laws and guidelines regarding restrictions of HBeAg-positive surgeons vary and surgeons should be familiar with the laws and guidelines that apply in their state. Until all surgeons are successfully immunized, HBV is likely to remain a threat. PMID- 10151563 TI - Income-sharing with managed care. PMID- 10151564 TI - Review of a hospital preadmission program: applying the principles of continuous quality improvement. AB - The importance of hospital preadmission programs is increasing in light of the trend toward shorter lengths of stay. New processes are required to prepare patients for same-day admission, to initiate discharge planning at the earliest possible opportunity and to provide education to patients for which there is now less time during hospitalization. This article presents the process and outcomes of one hospital's review of its preadmission program. PMID- 10151565 TI - Benchmarking: breakthrough results through structured analysis. AB - Benchmarking is the continuous process of measuring processes, services and practices against the toughest competition, or against companies recognized as industry leaders, for the purpose of identifying and adopting best practices. To facilitate this process, the Hamilton Civic Hospitals has developed a series of benchmarking templates, loosely based on the "unified model" of quality. This article presents the templates and describes their application as part of a benchmarking feedback loop. PMID- 10151566 TI - Does two-tier medicine cost more? PMID- 10151567 TI - Measuring quality in long term care. PMID- 10151568 TI - Personal calm in a professional storm. PMID- 10151569 TI - Euthanasia: another choice in healthcare? PMID- 10151570 TI - Case studies. With emphasis on short stays and functional outcomes, subacute care finds strong niche in managed care. PMID- 10151571 TI - Optimizing the hospital's ECG cost-effectiveness. PMID- 10151572 TI - How the use of well-designed forms can improve patient care in the ambulatory setting. PMID- 10151573 TI - Eliminating serious risks in the outpatient clinic with an electronic medical record. PMID- 10151574 TI - Risk management issues for occupational health. PMID- 10151575 TI - Communication, breast cancer, and malpractice claims: a study. PMID- 10151577 TI - Management by report card: avoid suspension in a few easy lessons. PMID- 10151576 TI - ED risk management: a practical, comprehensive program for a high-risk area. PMID- 10151578 TI - Shared evaluations: are they the wave of the future? PMID- 10151579 TI - Not all roads lead to central service consolidation. PMID- 10151580 TI - Will history repeat itself at Tampa General? PMID- 10151581 TI - Well-centered: balancing materials and patient-focused care. PMID- 10151582 TI - What a deal: gas for less. PMID- 10151583 TI - Rags to riches: software helps clean up linen losses. PMID- 10151584 TI - Stats. Getting the word out on EDI. PMID- 10151585 TI - Mortal combat at the VA. PMID- 10151586 TI - Giving consumers the quality information they need. PMID- 10151587 TI - Measuring health plan performance: sample report formats. PMID- 10151588 TI - Are you providing the information purchasers and consumers need to make informed decisions? PMID- 10151589 TI - Member satisfaction surveys: the next frontier. AB - The content and applications of member satisfaction surveys in managed care have undergone a rapid series of transformations. In this article, the recent evolutions are reviewed and summarized in terms of emerging trends. Several of the operational issues related to the standardization of a core general member satisfaction survey are identified and explored. Standardization will require collaboration, and ongoing feedback, to refine the process of collecting the data and disseminating the results to various stakeholders and consumers. Member satisfaction survey standardization presents an excellent opportunity for the wide range of insurance products to be evaluated in a uniform manner. PMID- 10151590 TI - Toward the intelligent use of health care consumer surveys. AB - Consumer surveys are at a pivotal moment in health care. With demand for consumer supplied data escalating in every sector of the industry, current opportunities for consumer surveys to demonstrate unique value in the marketplace are unparalleled. These opportunities, however, carry considerable risks, particularly with respect to performance report cards for competing health plans and providers. As investigators multiply in an area notably lacking in standardization, the chances increase that surveys will arrive at conflicting assessments of plans and providers. To resolve these inconsistencies, users will need to sharpen their understanding of the role of consumer surveys, the business and operational needs they can address, and how their results can be affected by methodology. This article discusses each of these issues with an eye toward promoting intelligent use of consumer surveys in the health care marketplace. PMID- 10151591 TI - Using patient surveys to measure health plan performance and improve quality of care. AB - The market place is demanding more information about health plan performance. Employer efforts to restrain increasing premium costs have spawned numerous business coalition initiatives to obtain and analyze performance information. Employer and health plan cooperation on the development of the Health Plan Employer Data Information Set (HEDIS) represents progress toward standardizing data capture, but the complexity of the information does not lend itself to consumer use. This article explores the evolution of the demand for health care performance information and the role of member/employee satisfaction surveys as a tool to capture meaningful data to help measure performance and improve quality. PMID- 10151592 TI - How will consumers use report cards in selecting health plans? AB - There are many new tools, such as health plan report cards, to help consumers and employers to compare health plan options. However, their usefulness has been limited in several ways: the lack of outside verification, questions about comparability of data reported, and the focus on health plans, not individual providers, as the unit of analysis. Organizations like the National Committee for Quality Assurance are making important improvements in reporting methods and presentation. The next step is to assess the usefulness of current report cards and to make them more responsive to the specific needs of consumers. PMID- 10151593 TI - Member satisfaction information as competitive intelligence: a new tool for increasing market share and reducing costs. AB - MCOs have begun to realize the impact that consumer satisfaction has on enrollment and pricing. Taking a lesson from auto manufacturers, MCOs are now realizing the additional advantages of obtaining consumer satisfaction information about their competitors. Knowing competitors' members intentions to stay or leave their plans, pin-pointing competitors' strengths and weaknesses, and identifying unmet consumer needs, allow MCOs to more successfully develop tactics and strategies for sales, marketing, and planning. This article describes the use of member satisfaction information as competitive intelligence, what to look for in this information, and sources for obtaining reliable information. PMID- 10151594 TI - Custom versus standardized patient satisfaction surveys: a Pacific Telesis case study. AB - With the increased interest in and use of patient satisfaction surveys has come the search for the ideal survey that could be used as a definitive tool to measure satisfaction. This article overviews the advantages and disadvantages of custom versus standardized patient satisfaction surveys. A disenrollment survey conducted by Pacific Telesis in 1994 and 1995 serves as a case study of a useful custom survey. PMID- 10151595 TI - Using customer input to improve managed care performance. AB - How do you get the information you need to manage your company's health care plans effectively? Consider a "customer satisfaction survey" that gathers data from the people who use the plans every day: employees. Make the data work for you when you negotiate costs, communicate key plan features, and look for ways to improve health care quality and upgrade the service you and your employees get from your health plans. American Express and the Chicago Health Plan Value Project (a unique group of 14 companies and 7 health plans) tried this approach, and they now expect a "win-win-win" situation all around. PMID- 10151596 TI - Childhood immunization: one HMO's experience in benchmarking and improving plan performance. AB - In 1994, Health Net initiated a childhood immunization campaign and research project to improve health plan member immunization rates by motivating and educating parents of children 20-32 months old as to the importance of fully immunizing their child. The findings indicate that 88 percent of those parents with children who were not fully immunized believed their child had been fully immunized by age two. This lack of awareness may explain the unreliability of self-reported immunization status. Future immunization campaigns must include ongoing member reminder systems, educate members as to the immunization schedule, and must take into consideration the barriers, real and perceived, that block full immunization. PMID- 10151597 TI - Patient-based surveying: a cost-effective approach for reaching large markets. AB - Member-based surveying is an important tool for managed care companies to discern newer and better ways in which to keep their current members satisfied, develop products that will attract new members, and to gauge changes of course in health consumer opinion. This article discusses a consumer friendly and cost-effective method to survey members and the general public that has produced a very positive response for a modest investment. The response rate will likely improve over time as the method gains broader acceptance. PMID- 10151598 TI - Measuring to improve. AB - Rush Prudential Health Plans, a managed care company located in Chicago, Illinois, is implementing a service quality improvement process across the three products it markets in the Chicago area: The Anchor Plan (a primarily staff model HMO), The Affiliates Plan (a network model HMO), and The Plus Plan (a point of service plan). In 1994, the company instituted an annual member satisfaction research study, conducted across the three plans, and began building a link between external customer requirements and internal operations. The research process consisted of three stages: determining external customer requirements, translating these customer-defined "symptoms" into underlying root causes, and developing a service quality improvement action plan. Rush Prudential determined that traditional "report card" surveys would not meet their goals for the information measurement process. A detailed diagnostic telephone survey was used to provide a picture of the entire clinical encounter, from scheduling an appointment through the time a member left the physician's office. PMID- 10151599 TI - Outcomes assessment: at what cost? AB - Outcomes assessment has become a major focus for evaluating managed care, but little is known about the feasibility and costs of a comprehensive outcomes assessment program. In this pilot study, more than 200 patients who were scheduled for elective hospital admissions were assessed using the Short Form 36. This instrument was mailed to patients the week before admission and three months after discharge. Cost for each complete set of pre- and post surveys was more than $60. Data from the SF-36 suggests that diagnosis-specific instruments and survey timing are necessary, which would increase the cost of outcomes assessment. PMID- 10151600 TI - Improving the quality of care and reducing health care costs through a point-of service health care information system. AB - Health care information systems will become critical to the success of health care providers. These systems must make the process of health care delivery more effective and more efficient, assisting the provider in improving the quality of care while maximizing cost reduction through more appropriate care and reduction in administrative costs. The system must be able to capture accurate encounter data for outcomes analyses and capable of use by multiple health plans for their unique policies or programs such as disease management. The most effective means of achieving all of the above will be to re-empower the physicians through software placed in a mobile computing environment with full integration among all participants. PMID- 10151601 TI - The ups and downs for children with chronic illnesses. AB - Children with chronic illnesses have the same basic need for preventive care as their healthy peers. In Michigan a Medicaid Physician Sponsor Plan was established to provide that care for this special population. Incentives and barriers for both physicians and families were identified as well as the advantages to providing care in a managed care delivery system. PMID- 10151602 TI - Federal tax concerns in structuring integrated delivery systems. Part II: Systems with taxable and tax-exempt participants. AB - The concluding segment of this two-part article covers the tax rules for integrated delivery systems that incorporate both taxable and tax-exempt participants. The author also analyzes the different organizational forms such ventures may take. PMID- 10151603 TI - Future funding of entitlement programs: who will carry the burden? PMID- 10151604 TI - Life after PHOs: MSOs take center stage. PMID- 10151606 TI - Foundations of market restructuring: local hospital cluster and HMO infiltration. AB - Much has been said about the rapid penetration of HMOs. Yet, little attention has been given to another, equally important trend--the consolidation of hospitals into local systems and networks. The number of local hospital clusters has increased significantly in recent years. They are now taking the lead in the majority of markets across the country in forming integrated systems. PMID- 10151605 TI - The patient survey as data source for CQI and risk management. AB - Improving communication between patients and providers is important for several reasons. Survey tools provide a useful approach to enhancing patient-provider communication. Combined with clear and concise verbal communication, information obtained through the use of survey tools provides a comprehensive databank of individualized information for delivery of patient-centered care within efficient time parameters. PMID- 10151607 TI - Proving the link between outcomes and resource utilization. AB - Medical practice profiling is a popular way of helping to reduce variation in resource utilization among providers in managed care organizations. Usually, these programs take into account severity of illness, patient demographics, and so forth, but rarely are clinical practice patterns linked with outcome. The authors offer information about an information system-based program that attempts to do just that. PMID- 10151608 TI - Risk management and quality of care. PMID- 10151609 TI - Reducing risk in obstetrics. PMID- 10151610 TI - Clinical risk management in anaesthesia. PMID- 10151611 TI - Clinical risk management in psychiatry. PMID- 10151612 TI - Essentials of clinical risk management. PMID- 10151613 TI - Dealing with clinical complaints. PMID- 10151614 TI - Caring for patients harmed by treatment. PMID- 10151615 TI - Alternative dispute resolution and mediation. PMID- 10151616 TI - Clinical risk management: one piece of the quality jigsaw. PMID- 10151617 TI - Principles of risk management. PMID- 10151618 TI - Understanding adverse events: human factors. AB - (1) Human rather than technical failures now represent the greatest threat to complex and potentially hazardous systems. This includes healthcare systems. (2) Managing the human risks will never be 100% effective. Human fallibility can be moderated, but it cannot be eliminated. (3) Different error types have different underlying mechanisms, occur in different parts of the organisation, and require different methods of risk management. The basic distinctions are between: Slips, lapses, trips, and fumbles (execution failures) and mistakes (planning or problem solving failures). Mistakes are divided into rule based mistakes and knowledge based mistakes. Errors (information-handling problems) and violations (motivational problems) Active versus latent failures. Active failures are committed by those in direct contact with the patient, latent failures arise in organisational and managerial spheres and their adverse effects may take a long time to become evident. (4) Safety significant errors occur at all levels of the system, not just at the sharp end. Decisions made in the upper echelons of the organisation create the conditions in the workplace that subsequently promote individual errors and violations. Latent failures are present long before an accident and are hence prime candidates for principled risk management. (5) Measures that involve sanctions and exhortations (that is, moralistic measures directed to those at the sharp end) have only very limited effectiveness, especially so in the case of highly trained professionals. (6) Human factors problems are a product of a chain of causes in which the individual psychological factors (that is, momentary inattention, forgetting, etc) are the last and least manageable links. Attentional "capture" (preoccupation or distraction) is a necessary condition for the commission of slips and lapses. Yet, its occurrence is almost impossible to predict or control effectively. The same is true of the factors associated with forgetting. States of mind contributing to error are thus extremely difficult to manage; they can happen to the best of people at any time. (7) People do not act in isolation. Their behaviour is shaped by circumstances. The same is true for errors and violations. The likelihood of an unsafe act being committed is heavily influenced by the nature of the task and by the local workplace conditions. These, in turn, are the product of "upstream" organisational factors. Great gains in safety can ve achieved through relatively small modifications of equipment and workplaces. (8) Automation and increasing advanced equipment do not cure human factors problems, they merely relocate them. In contrast, training people to work effectively in teams costs little, but has achieved significant enhancements of human performance in aviation. (9) Effective risk management depends critically on a confidential and preferable anonymous incident monitoring system that records the individual, task, situational, and organisational factors associated with incidents and near misses. (10) Effective risk management means the simultaneous and targeted deployment of limited remedial resources at different levels of the system: the individual or team, the task, the situation, and the organisation as a whole. PMID- 10151619 TI - Clinical risk management: experiences from the United States. PMID- 10151620 TI - Tackling risk by changing behaviour. PMID- 10151621 TI - The measurement of physician performance. AB - There is growing interest in measuring the performance of physicians. At U.S. Healthcare (USHC), performance assessment is the responsibility of U.S. Quality Algorithms, one of its subsidiaries. This article discusses the development and application of certain measures employed to assess the performance of physicians and how compensation is linked to performance in USHC's quality-based compensation model. PMID- 10151623 TI - The toxicity of pay for performance. AB - Despite their superficial logic, systems of merit pay or pay for performance have features that are toxic to systemic improvement. Contingent rewards doled out by supervisors cause decreased focus on customer needs, loss of accurate information about defects and improvement opportunities, avoidance of stretch goals, and decreased innovation. They may also erode teamwork. Pay for performance may mark a naive understanding of the complexity of human motivation. PMID- 10151622 TI - Utilizing reward systems to mobilize change. AB - The pressures for change in health care organizations mean that people need to do things differently. Reward systems offer an opportunity to share in the success of the enterprise if they are designed and managed effectively. This article shows how and why they work. Case studies illustrate the key principles in action. PMID- 10151624 TI - Health care reform and managed care: challenges for nursing education. AB - The future of nursing education is inextricably linked to structural changes in the health care delivery system, changes brought about by health care reform, integrated health care delivery systems, and the use of "managed care." Multiple entry points to nursing education cause overlap in skills of graduates and result in rework. This article discusses this problem, the impact of the changing job market and case management on nursing education, and two new emerging advanced practice roles: the primary care nurse practitioner and the acute care nurse practitioner. PMID- 10151626 TI - Goal-publication, feedback, and communication processes: views of the Finnish health care work force. AB - This article describes a study that investigated several aspects of organizational behavior in Finnish hospitals and other areas of Finnish health care. It was hypothesized that health care providers often lack awareness of organizational goals, that feedback about how their performance contributes to achieving the goals is frequently inadequate, and that the knowledge available in organizations is commonly maldistributed because of ineffective communication. The findings of the questionnaire survey supported the hypotheses. PMID- 10151625 TI - Redesigning patient care roles: a case study. AB - Many hospitals and health care systems have reacted to changes in health care over the last 10 years through operational redesign. This article provides a graphic and detailed discussion of how one institution dealt with a core redesign issue--changing provider roles and how they affect service, quality, and cost. PMID- 10151627 TI - Tool use and team success in continuous quality improvement: are all tools created equal? AB - This article describes a study that used data from the Department of Veterans Affairs Health Services' Western Region TQI Registry to compare the relationship between theory tools, data tools, and perceived quality improvement. No significant bivariate relationship between the use of theory tools and perceived improvement was found, but there was a positive and significant relationship between the use of data tools and perceived improvement. The use of data management tools by all teams in the study was much lower than expected. PMID- 10151628 TI - Phase plane analysis: applying chaos theory in health care. AB - This article applies the new science of nonlinearity to administrative issues and accounts receivable management in health care, and it provides a new perspective on common operating and quality control measures. PMID- 10151629 TI - Patient reports about ambulatory care. AB - To improve, managers need information on the process of care and patient satisfaction. The study described in this article validates a survey for assessing the process of care and satisfaction with ambulatory care visits and illustrates how this information can be used to estimate the impact of different visit processes on patient satisfaction. PMID- 10151630 TI - Show data warehouse benefits to end users. PMID- 10151632 TI - I/S component crucial to diabetes management program. PMID- 10151631 TI - Let business goals drive your data warehouse effort. PMID- 10151633 TI - Case management software. PMID- 10151634 TI - Security is achievable even in today's complex networks. PMID- 10151635 TI - HotList. Tools for systems security. PMID- 10151636 TI - Success means having the right tools to make decisions. AB - Successful enterprises develop a strategy to effectively manage the health of a population. The proper information systems tools can help you do that. PMID- 10151637 TI - The mirage called choice. PMID- 10151638 TI - Why the NHS should abandon the search for the universal outcome measure. AB - This paper considers the use of outcome measures in the British National Health Service (NHS). Measuring outcomes is a major conceptual and practical problem. Many different measures are currently available yet no consensus has been reached on which should be preferred over others, or about which should take priority when they conflict. Some currently used measures are described, the relationship between these measures and the measured activities are discussed, and fundamental problems with both the measures and their use are revealed. It is shown that however assiduous the search, the 'perfect' outcome measure will always remain elusive. PMID- 10151639 TI - Involving consumers in health care decision making. AB - This paper considers ways of involving consumers in decisions regarding the allocation of scarce health service resources. Specifically, two levels of consumer participation are highlighted and discussed. These are: (1) at the level of deciding whether or not a particular service should be introduced or its scale changed; and (2) at the level of deciding how best to provide a service once it has been decided that the service will be provided. The limitations of the current methods of involving consumers are outlined and two alternative approaches discussed. These are willingness to pay and conjoint analysis. PMID- 10151640 TI - The way around health economics' dead end. AB - Many leading health economists hold misconceived ideas about central components of their work. In particular, they assume that their methods are in principle value-neutral. This belief is demonstrably false. Health economic investigations incorporate mainly unexpressed theories of health. Unless this fact is recognised health economics will shortly reach a conceptual and practical dead end. The way to avoid this dead end is to express implicit theories of health, and explicitly to base philosophically and economically justifiable policy proposals on them. PMID- 10151641 TI - Economics, QALYs and medical ethics--a health economist's perspective. PMID- 10151642 TI - QALYs: maximisation, distribution and consent. A response to Alan Williams. PMID- 10151643 TI - Economics, QALYs and medical ethics: a practical agenda? PMID- 10151644 TI - The danger of partial evaluation. PMID- 10151645 TI - New legal controls in psychiatric community care. PMID- 10151646 TI - Health care reform: a contrary opinion. PMID- 10151647 TI - Examining preferences for allocating health care gains. AB - This study is part of a programme to elicit and examine community preferences for health care in different contexts. Data were obtained from a group of predominantly Australian health care decision-makers. A short questionnaire contained six valuation questions and four demographic questions. The six valuation questions posed choices where equal health gains were to be allocated to different population groups based upon: age; sex; current health; socio economic status; across time; and across different numbers of individuals. The results provide some evidence that respondents were prepared to discriminate between health gains derived in different contexts especially where health gains were to be allocated between groups of different health status and over time. Further research is planned and the possible implications for health policy, and in particular for resource allocation in health care, are briefly discussed. PMID- 10151648 TI - Long-term care and the Navajo elder. PMID- 10151649 TI - Reaching financial viability in adult day care. PMID- 10151650 TI - Controversies in case management. AB - A myriad of controversies exists around the provision of case management services in the private, public, nonprofit or insurance sector. As our population ages, it will be important for all of us to confront these issues as our profession continues to grow and inevitably change. In addition, it will be increasingly important, given the limited resources which will be available, for all sectors to join and work together to ensure that the needs of our older clients are met with services of the highest quality. PMID- 10151651 TI - Home health care for cancer patients. Insights from the American Indian community. PMID- 10151652 TI - Case management: balancing cost containment and utilization controls with quality outcomes. PMID- 10151653 TI - Medicare program; standards for quality of water used in dialysis and revised guidelines on reuse of hemodialysis filters for end-stage renal disease (ESRD) patients--HCFA. Final rule. AB - This final rule revises the Medicare conditions for coverage of suppliers of end stage renal disease services. The revisions remove general language in the regulations regarding water quality; incorporate by reference standards for monitoring the quality of water used in dialysis as published by the Association for the Advancement of Medical Instrumentation (AAMI) in its document, "Hemodialysis Systems" (second edition); and update existing regulations to incorporate by reference the second edition of AAMI's voluntary guidelines on "Reuse of Hemodialyzers." PMID- 10151654 TI - Regional offices and Health Resources and Services Administration; statement of organization, functions and delegations of authority--PHS. PMID- 10151655 TI - Schedule for rating disabilities; hemic and lymphatic systems--VA. Final rule. AB - This document amends the Department of Veterans Affairs' (VA) Schedule for Rating Disabilities of the Hemic and Lymphatic Systems. The effect of this action is to update the hemic and lymphatic portion of the rating schedule to ensure that it uses current medical terminology and unambiguous criteria, and that it reflects medical advances that have occurred since the last review. PMID- 10151656 TI - Notice regarding the Federally Supported Health Centers Assistance Act of 1992- HRSA. Notice. AB - On May 8, 1995, the Secretary of Health and Human Services published a final rule implementing certain provisions of the Federally Supported Health Centers Assistance Act of 1992 (the Act). The Act provides for liability protection for certain grantees of the Public Health Service and for certain individuals associated with these grantees. The Health Resources and Services Administration is the agency within the Department responsible for administering certain aspects of the Act. This notice provides further guidance regarding the final rule. PMID- 10151657 TI - Medicare program; authority citations: technical amendments--HCFA. Final rule with comment period. AB - This technical regulation provides uniform simplified authority citations for most of the parts that pertain to the Medicare program, and revises the sections or paragraphs that explain the statutory basis for the substance of the rules. These changes are consistent with the use of authority citations and paragraphs identified as "statutory basis" in the regulations that pertain to the Medicaid program. They are intended to put an end to the continual changing of the current lengthy authority citations and, by clarifying and, where needed, expanding the "statutory basis" portions, ensure better understanding of that basis. PMID- 10151658 TI - Medicare and Medicaid programs; approved information collection requirements- HCFA. Technical final rule. AB - This technical final rule updates our display of approved control numbers for the collection of information that have been assigned to us by the Office of Management and Budget (OMB). OMB regulations require each agency to include the approval numbers in the agency's rules. PMID- 10151659 TI - Medicare program--providers and suppliers of specialized services: technical amendments--HCFA. Final rule with comment period. AB - This rule makes editorial and clarifying changes in the regulations that pertain to providers and suppliers of specialized services. It also adds a new subpart A to those that pertain to suppliers. These changes are purely technical and have no substantive effect on the Medicare program. PMID- 10151660 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); FY96 DRG updates--DoD. Notice of DRG revised rates. AB - This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1996 under the CHAMPUS DRG-based payment system. It also describes the changes made to the CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS). PMID- 10151661 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE program; uniform HMO benefit; special health care delivery programs--DoD. Final rule. AB - This final rule establishes requirements and procedures for implementation of the TRICARE Program, the purpose of which is to implement a comprehensive managed health care delivery system composed of military medical treatment facilities and CHAMPUS. Principal components of the final rule include: establishment of a comprehensive enrollment system; creation of a triple option benefit, including a Uniform HMO Benefit required by law; a series of initiatives to coordinate care between military and civilian delivery systems, including Resource Sharing Agreements, Health Care Finders, PRIMUS and NAVCARE Clinics, and new prescription pharmacy services; and a consolidated schedule of charges, incorporating steps to reduce differences in charges between military and civilian services. This final rule also includes provisions establishing a special civilian provider program authority for active duty family members overseas. The TRICARE Program is a major reform of the MHSS that will improve services to beneficiaries while helping to contain costs. PMID- 10151662 TI - Medical and dental reimbursement rates for fiscal year 1996--DoD. PMID- 10151663 TI - Waiver of two-year home-country physical presence requirement, foreign medical graduates, exchange visitor program--USIA. Final rule. AB - Section 220 of the Immigration and Nationality Technical Corrections Act of 1994 (Pub. L. 103-416) amended Section 212(e) of the Immigration and Nationality Act (8 U.S.C. 1182(e)) and added a new subsection (k) to section 214 of that Act (8 U.S.C. 1184) regarding waiver of the two-year foreign residence requirement as it applies to foreign medical graduates. An Interim Final Rule with request for comments was published in the Federal Register on April 3, 1995 (60 FR 16785). This final rulemaking amends the Exchange Visitor Program regulations to reflect those legislative changes. PMID- 10151664 TI - Medicare program; inpatient hospital deductible and hospital and extended care services coinsurance amounts for 1996--HCFA. Notice. AB - This notice announces the inpatient hospital deductible and the hospital and extended care services coinsurance amounts for services furnished in calendar year 1996 under Medicare's hospital insurance program (Medicare Part A). The Medicare statute specifies the formulae to be used to determine these amounts. The inpatient hospital deductible will be $736. The daily coinsurance amounts will be: (a) $184 for the 61st through 90th days of hospitalization in a benefit period; (b) $368 for lifetime reserve days; and (c) $92 for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period. PMID- 10151665 TI - Medicare program; monthly actuarial rates and monthly supplementary medical insurance premium rate beginning January 1, 1996--HCFA. Notice. AB - As required by section 1839 of the Social Security Act, this notice announces the monthly actuarial rates for aged (age 65 or over) and disabled (under age 65) enrollees in the Medicare Supplementary Medical Insurance (SMI) program for 1996. It also announces the monthly SMI premium rate to be paid by all enrollees during 1996. The monthly actuarial rates for 1996 are $84.90 for aged enrollees and $105.10 for disabled enrollees. The monthly SMI premium rate for 1996 is $42.50. PMID- 10151666 TI - Medicare program; Medicare secondary payer for individuals entitled to Medicare and also covered under group health plans; correction--HCFA. Final rule with comment period; correcting amendments. AB - This document makes corrections to the final rule with comment period entitled "medicare program; medicare secondary payer for individuals entitled to medicare and also covered under group health plans" that was published in the Federal Register on Thursday, August 31, 1995 (60 FR 45344). PMID- 10151667 TI - Medicare program: suppliers of specialized services; technical amendment--HCFA. Technical amendment. AB - A final rule with comment period, pertaining to providers and suppliers of specialized services, published on September 29, 1995 at 60 FR 50446, redesignated 42 CFR part 485, subpart D as 42 CFR part 486, subpart G, and corrected internal cross-references as required by the redesignation. This document corrects one cross-reference that we failed to identify in the final rule with comment period. PMID- 10151668 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); FY 96 updates--DoD. Amendment to notice. AB - On October 3, 1995, 60 FR 51779, the Department of Defense published the "Notice of DRG Revised Rates" without Tables 1 and 2. These tables provide the rates and weights to be used under the CHAMPUS DRG-based payment system during FY 1996. This amendment is to display the updated rates and weights for Tables 1 and 2. PMID- 10151670 TI - For Republicans, an urge to merge. PMID- 10151671 TI - Not your father's HMO. AB - It's new. It's improved. And it's coming to medicare beneficiaries everywhere. It's the next generation of managed care, and it will happen even if Congress does nothing to reshape the medicare program this year. PMID- 10151669 TI - Showdown time. AB - There may not be a train wreck this fall, but that doesn't mean that there won't be some close calls as the White House and Congress come to grips on such issues as spending and taxes, health care, welfare and the environment. PMID- 10151672 TI - Who pays the coal miner's daughter? PMID- 10151673 TI - How managed care is changing the recruitment of physicians. PMID- 10151674 TI - Learning to communicate with physicians ... a must for plan executives. PMID- 10151675 TI - What Congress has in store for Medicare--and physicians. PMID- 10151676 TI - Coping with managed care in fast-changing Atlanta. PMID- 10151677 TI - Who's the most cost-effective provider of skin care? PMID- 10151678 TI - Are primary care physicians well trained in dermatology? Yes. PMID- 10151679 TI - Are primary care physicians well trained in dermatology? No. PMID- 10151680 TI - California employers' group moves beyond cost-cutting. PMID- 10151681 TI - Medicare in managed care: seeing patients as 'losses'. PMID- 10151682 TI - That sigh of relief may be premature. PMID- 10151683 TI - Two views of managed care's quality. PMID- 10151684 TI - Reducing inventory at Summit Medical Center. AB - In its quest to reduce inventory and streamline operations, the Materials Management department at Summit Medical Center (Oakland, CA) has used information systems technology to become agents of change for the medical center. The use of a materials management information system (MMIS) played a pivotal role in allowing for the reorganization of their materials management department after a 1992 merger. Since then, the department has reduced inventory by 47% of total dollar volume, while at the same time giving its diverse group of internal customers the assurance that preferred products will be readily available. Equally important, Summit's information technology has allowed materials management staff to gain control of the larger logistical challenges of time and motion that are inherent to the department. As a result, FTEs have been streamlined by 50%. Additionally, software usage reports helped bring consensus to product review committees as they standardized product lines for greater savings. PMID- 10151685 TI - Meeting instrument needs of incoming surgeons. AB - Have you ever wondered what it would be like if you had the opportunity to be involved in surgeon recruitment? What kind of planning would be necessary? Who else would be involved? How many hours would it take? As director of central services, Oak Hill Hospital (Joplin, MO) for nine years, I had never before had an opportunity like this presented to me until recently. When asked to help prepare for the arrival of a new ear, nose, and throat (ENT) surgeon, I felt elated at the prospect of this challenge. This article reviews the steps we went through to prepare for the new physician with special emphasis on meeting his specific instrument needs. PMID- 10151686 TI - Technology: drug and device export reform. PMID- 10151687 TI - Conflicts of interest. PMID- 10151688 TI - Capital asset management: rhetoric to reality. PMID- 10151689 TI - Spotlight--clinician perspectives on redesign. Interview by Terry G. Williams. PMID- 10151690 TI - Glimpses. A real world vignette illustrating patient focused problem-solving. PMID- 10151691 TI - Master patient scheduling. Enhanced continuity as a strategic weapon. AB - Master patient scheduling can be a strategic weapon for your organization as it battles the pressures posed by a steadily more demanding marketplace. The enhanced continuity offered by master patient scheduling can unlock the power of self-directed teams and collaboration between your organization and physicians. This power, in turn, can help you continuously improve quality and service levels while keeping operating costs under control. Still, implementing master patient scheduling poses challenges. Those who take on these challenges are convinced that continuity is the secret to their future success. PMID- 10151692 TI - Healthcare combinations. Setting the stage for real innovation. PMID- 10151693 TI - The whole hospital model. Bristol Hospital's patient focused care redesign. PMID- 10151694 TI - Is your agency in a box? AB - As discussions and focus turn more and more to "systems thinking" and community integration, it is essential for a home health agency to see itself as an integral component of a seamless health care system. The agency must collaborate and cooperate with other members of the system and understand that while home care is an important part of the system, it is only one of the many pieces in a cooperative health care system. PMID- 10151695 TI - Is this legal? A non-profit primer on lobbying and political activities. AB - Lobbying by tax-exempt entities is permissible, but regulated by the Internal Revenue Code. Tax-exempt entities that lobby should not be confused with political activity by tax-exempt entities. Although a public charity may not involve itself in political campaign activities in any way, a public charity may engage in a certain level of lobbying activities. Consider three hypothetical situations involving CEOs of health care providers. PMID- 10151696 TI - The best laid plans ... can bring about amazing results. PMID- 10151697 TI - Finding a "healthy" medium. AB - Home health care is an integral part of the health care system. As home care grows--a natural outcome with a growing elderly population and earlier discharges from the hospital under DRGs--so do the many challenges. Proposed Medicare budget cuts, managed care and Medicaid block grants are just a few of the pressing issues faces by not only home care, but the entire health care industry. PMID- 10151698 TI - Future roles of management. PMID- 10151699 TI - A survey in action. The "next wave assessment" takes shape. AB - With the initiation of the Health Care 2000 vision project in 1988, the MHA established itself as one of the first state hospital associations to strategically assess important health care trends and craft a framework for the future of health care delivery and financing for its membership. The 1990s have brought much change and unprecedented challenge to the health care field. As MHA continues to transform to meet the needs of its members, the time has come to reassess our health care environment and critically examine our assumptions about the future. PMID- 10151700 TI - Knock! Knock! Who's there? PMID- 10151701 TI - Community service winners. Parish nurses--a bridge to community health care. PMID- 10151702 TI - Adding a personal touch. Nurse-midwives improve the quality of health care. AB - Nurse-midwifery practice has evolved to the independent management of women's health care, focusing mainly on pregnancy, childbirth, the postpartum period, care of newborn, family planning and the gynecological needs of women. PMID- 10151703 TI - Stark reality. How Stark I and II will impact physician relationships. AB - On August 14, 1995, the Health Care Financing Administration (HCFA) published a long-awaited final rule implementing the Ethics in Patient Referrals Act (Stark I). In conjunction with this final rule, HCFA intends to survey hospitals and physicians to obtain information necessary to evaluate compliance with the Omnibus Budget Reconciliation Act of 1993 amendments to the Stark Act (Stark II), most of which took effect on January 1, 1995. PMID- 10151704 TI - Wheeling and healing. AB - There's a new road company touring Southeast Michigan with a never-before-seen act! Their costumes are all in white, their set and props elaborate, and they actually perform inside a truck! Get this--they're not actors. They're doctors. And these doctors from Mount Clemens General Hospital have gotten their facts together and are taking their show on the road. PMID- 10151705 TI - Clinical pathways: too hard a course for complex patients? PMID- 10151706 TI - Federal regulations on patient transfers. PMID- 10151708 TI - Selecting a pharmacy computer system for the future. AB - Major advances are occurring in the field of computer science that have placed us at the threshold of a significant revolution in the management and application of clinical data. These advances will have a profound effect on the practice of pharmacy and are occurring at a time when many hospital pharmacies are deciding whether to enhance or replace their current systems. To best position your department for the future, it is essential that you are knowledgeable of the advances being made, have a vision for how they will affect your practice, and undergo a well-organized and thorough selection process. PMID- 10151707 TI - Paraprofessional training and support: the PATH (Patient Advocacy in the Home) example. PMID- 10151709 TI - A stepwise approach to the evaluation and selection of a hospital pharmacy information system. AB - The current demands for cost reduction, increased efficiency, and quality care placed upon hospital pharmacy departments underscores the need for an effective information system. In this article, we describe the stepwise approach we used to evaluate and select a new pharmacy information system. The importance of involving staff in the evaluation process is discussed, along with the mechanisms we used to learn as much as we could about the vendors before making our selection. PMID- 10151710 TI - Automation and the future practice of pharmacy--changing the focus of pharmacy. AB - Automation technology offers great potential in pharmacy practice. To realize the full benefits of the potential inherent in automation systems, it is necessary to understand basic concepts of automation and to realize that automation is simply a tool to help achieve the goals of practice. The goal of pharmacy practice is pharmaceutical care. Through using the techniques of reengineering, pharmacies can be redesigned with the help of automation to facilitate the accomplishment of that goal. Essential to achieving that goal is the necessity to change the focus of pharmacy from distribution to pharmaceutical care. Reengineering and automation are the tools to help make that change in focus. PMID- 10151711 TI - Computerized pharmacokinetics on an institutional clinical information system. AB - Computer-based hospital information systems (HISs) are an integral part of the current hospital environment. Traditionally, the HIS hospital information system has performed drug distribution-related activities for the pharmacy. Clinical applications have been limited to monitoring for drug interactions, duplication of therapy, drug allergies, and dosage range checking. Personal computers have been used for more clinical applications and individualized dosing. At Hamot Medical Center, the integration of the pharmacokinetics consultation service with the HIS has been accomplished. The pharmacokinetic equations were programmed into the HIS. Data needed for the equations were extracted from information in the database, thereby eliminating the need to enter the majority of the data. The program was designed to print the pharmacokinetic consultation for the chart. The integration of the pharmacokinetic consultation service with the HIS has saved time and increased efficiency. PMID- 10151712 TI - Multidimensional work sampling in an outpatient pharmacy. AB - Multidimensional work sampling was performed at a hospital-based outpatient pharmacy. Data were collected from nine full-time and five part-time pharmacists over a 45-day baseline period. Pharmacists wore silent, random-signal generators that permitted continuous work sampling. We introduced the concept of quick codes to allow pharmacists to record their work using a single letter for repetitive activities. Pharmacists recorded 4,687 observations, 90 percent using quick codes. The most common activity was checking prescriptions (36.2 percent). Detection and correction of prescribing errors was the most common reason for their work (39.4 percent). Most work-related activities were performed alone (80 percent) with little time in contact with patients or physicians. These baseline measures will be compared with future measures to assess the effect of the implementation of computerized prospective drug utilization review and clinical treatment guidelines on pharmacists' work. It is expected that these technologic and process changes will increase opportunities for pharmacists to educate patients and consult with physicians. PMID- 10151713 TI - Continuous quality improvement teams achieve elements of pharmaceutical care. PMID- 10151714 TI - Ethics of automated compounding and dispensing. PMID- 10151715 TI - Cost of asthma illnesses: emergency department visits without admission. PMID- 10151716 TI - Drug formulary commentary: an integrated health systems approach. AB - Integrated health systems create opportunities and challenges for pharmacists in developing approaches to provision of pharmaceutical care and services. A fundamental area for integration is drug formulary management. This commentary addresses the need for pharmacists in integrated systems to first create a vision of success. From there, pharmacists can capitalize on their expertise in drug formulary management to create and win in terms of quality and cost for the entire system. PMID- 10151717 TI - Integrated delivery networks. Organized delivery systems include physicians, hospitals, and HMOs. PMID- 10151718 TI - America needs a cooperative model of health care organization. PMID- 10151719 TI - Health Systems Integration Study offers lessons for IDNs. Findings from Northwestern University's four-year analysis. PMID- 10151720 TI - Managed medicine: HMOs and managed care put physician incomes under the knife. PMID- 10151721 TI - Physicians should take charge of "managed medicine". PMID- 10151722 TI - Capitation will drive physicians away from fee-for-service. PMID- 10151723 TI - Patient adherence to pharmacotherapy: the importance of effective communication. AB - Despite the potential of modern pharmacotherapy to control disease and enhance quality of life, two out of five patients fail to take their prescribed medication correctly. Research indicates that the two primary influencers of adherence are the patient's beliefs in the value of the regimen and the patient's ability to overcome practical barriers to adherence. The patient's perception of value--ie, the risks, benefits, and efficacy of therapy--influences his or her commitment to the medication regimen. Barriers to adherence include side effects, number and frequency of dosages, and cost. Communication between health care providers and patients is crucial to enhancing patient adherence to medication regimens. PMID- 10151724 TI - Pharmaceutical management strategies of industrialized countries. AB - Health care costs as a percentage of the gross national product have been increasing in most industrialized countries. As part of the trend, pharmaceutical expenditures also have been rising. In many countries, pharmaceutical costs are the largest single health care expenditure. In an effort to contain rising costs, governments are exploring a variety of pharmaceutical management strategies. These include price controls, restrictive formularies, budget caps, profit controls, and practitioner education. PMID- 10151725 TI - FDA puts forth proposal to mandate patient information. PMID- 10151726 TI - Physicians' perceptions and knowledge of drug costs: results of a survey. AB - The objective of this survey was to determine physicians' opinions of the importance of drug costs, sources of drug cost information used, preferences for mechanisms to lower drug costs, and to assess knowledge of the relative cost of common drugs. A questionnaire containing opinion statements and five categories of drugs to be ranked from least to most expensive was sent to 598 physicians at our tertiary-care, university-affiliated teaching hospital. In all, 398 (66.6%) surveys were completed. Survey results indicate that physicians are interested in lowering the cost of drug therapy, and that they are knowledgeable of relative drug costs but would like more cost information to make more informed prescribing decisions. Most believe that a readily available drug cost index is the most beneficial mechanism to decrease drug expenditures. PMID- 10151728 TI - Initiating a drug blood level monitoring program through CQI. AB - A blood level monitoring program was developed at St. James Hospital and Health Centers--a 472-bed community hospital located in Chicago Heights, IL. The primary goal of the program was to improve patient care by ensuring that drug levels were within their target range for the condition being treated. Additional benefits obtained from the program included meeting Joint Commission on Accreditation of Healthcare Organization's standards for medication monitoring and generating additional revenue for the institution from pharmacokinetic consults. Highlights of the service and its implementation are presented in this article. PMID- 10151727 TI - Evaluating the value, accuracy, and operational feasibility of DUE criteria. AB - The purpose of this investigation was to evaluate the value, accuracy, and operational feasibility of indicators/criteria in a drug use evaluation (DUE) examining IV histamine2-receptor antagonists (H2-RA). Pharmacists in 40 hospitals collected DUE data concurrent with hospital stays on a total of 1,200 patients. After completing the DUE, pharmacist data collectors were asked to evaluate each DUE criterion. Most reported that criteria relating to indications for use, therapeutic drug monitoring, and adverse drug reactions/drug interactions should be included in a DUE, but some criteria were not easy to collect or were inaccurate. The data suggest the need to carefully select DUE criteria that can be used for continuous improvements that meet JCAHO accreditation requirements. PMID- 10151729 TI - Medicaid, FDA reform key issues building steam in Congress. PMID- 10151730 TI - Pegaspargase versus asparaginase in adult ALL: a pharmacoeconomic assessment. AB - Asparaginase is an effective treatment for patients with acute lymphocytic leukemia (ALL). Unfortunately, asparaginase therapy is associated with a high incidence of hypersensitivity reactions (up to 73%), including life-threatening anaphylaxis, and its half-life of approximately 20 hours necessitates daily administration. Pegaspargase, a modification of L-asparaginase, has a longer half life (357 hours), a decreased incidence of hypersensitivity reactions, and when doses every 14 days, provides comparable efficacy to asparaginase; however, it is much more expensive per single-dose vial ($980.00 vs $52.38). To determine the pharmacoeconomic impact of the two agents, we conducted a cost-minimization analysis for three common adult ALL protocols. Results showed that pegaspargase was significantly less costly to payers on an inpatient or outpatient basis and warranted addition to our formulary. PMID- 10151731 TI - Use of decision analysis to evaluate the costs and benefits of filgrastim (G-CSF) therapy. AB - The FDA's approval of filgrastim (granulocyte colony-stimulating factor [G-CSF]) for accelerated recovery of neutrophil counts following chemotherapy has prompted discussions regarding the cost and benefits associated with such expensive new therapies. One method to evaluate the cost effectiveness of a therapy is decision analysis, which provides a quantitative method of cost analysis. Using the principles of decision analysis, we created a decision-analysis tree for evaluating the cost effectiveness of G-CSF therapy. Based on data gathered from a retrospective review of ambulatory oncology patients, we found that routine administration of G-CSF to all outpatients receiving chemotherapy is not cost effective, although it would be justifiable for some patients. PMID- 10151732 TI - FDA says 'Look at the facts' when judging its record on drug approvals. PMID- 10151733 TI - An ADR surveillance program: increasing quality, number of incidence reports. AB - An Adverse Drug Reaction Surveillance Program (ADRSP) was implemented by the pharmacy department of the University of Maryland Medical System to address the institution's underreporting of adverse drug reactions. The program aims were to increase the number and quality of significant adverse drug reaction (ADR) reports by facilitating and standardizing the reporting process, to more actively involve the pharmacy staff, and to create a comprehensive database, thus enabling the intervention of future untoward events. During the program's first 2 years, the number of ADR reports more than doubled, primarily due to increased pharmacists' participation. The ADRSP has facilitated the reporting process, enhanced the submission of ADR reports to the FDA, and helped prevent ADRs. PMID- 10151734 TI - Results of our national survey. Current formulary decision-making strategies and new factors influencing the process. AB - Formulary recently conducted a survey of 2,000 of its readers to uncover what forces are at play in their formulary decision-making processes. Topics included general philosophies toward formulary decision making, philosophies toward adding and deleting products, influences on the process, trends related to product reviews, formulary management strategies, drug information educational strategies, and new approaches to the formulary decision-making process. Some 295 surveys (14.75%) were returned. Highlights and analyses of the survey findings are presented for your review and comparison with your practice setting's approaches. PMID- 10151735 TI - Increased adverse drug reaction reporting through wall-mounted ADR reporting cards. AB - To increase adverse drug reaction reporting, the Pharmacy Department Quality Assessment and Improvement Committee at the University of Iowa Hospitals and Clinics created an abbreviated wall-mounted adverse drug reaction card on "tear off" pads. This report discusses strategies the Committee identified in order to attain its goal. PMID- 10151736 TI - Will politics sidetrack FDA reform? PMID- 10151737 TI - Developing guidelines for biotechnology drug use: experience with antithrombin III. AB - Development of institutional guidelines for use of high-cost biotechnology drugs, such as antithrombin III, is a valuable tool in formulary management. This article describes the process by which the University of California Davis Medical Center used an ad hoc committee to the P & T Committee to develop guidelines for antithrombin III use. Performing an objective analysis of available literature to address the appropriate role of a biotechnology agent is necessary to develop consensus guidelines. Approval of use guidelines by the P & T Committee provides the necessary structure for optimal use of biotechnology agents, such as antithrombin III. PMID- 10151738 TI - Medicaid, Medicare reform proposals stir debate over prescription benefits. PMID- 10151739 TI - Pharmacoeconomic issues in the treatment of depression. AB - The goal of pharmacoeconomics is to define the cost and value of different treatment strategies. The cost-effectiveness analysis, one model used in the study of pharmacoeconomics, considers not only the cost of the drug itself, but also the labor costs associated with physician and pharmacy visits, and expenses for laboratory testing. Drugs that require more intensive medical surveillance, either for dose adjustments or overall management of treatment-related side effects, can escalate costs. In the case of antidepressant drugs, various cost effectiveness analyses have shown that the total cost of disease management is similar for generic tricyclics and the more expensive selective serotonin reuptake inhibitors. This outcome is due to the higher labor costs associated with tricyclics that offset their acquisition cost advantage. The application of cost-effectiveness studies in formulary decision-making and clinical practice guidelines, will maximize the use of health care resources. PMID- 10151740 TI - Special report: how an HMO grades physicians. PMID- 10151741 TI - Health economics worldwide. PMID- 10151742 TI - The validity of the MIMIC (Multiple Indicators/MultIple Causes) health index- some empirical evidence. AB - This study evaluates the potential of econometric models with latent (unobservable) variables for measuring health or health impairment due to a specific disease. A MIMIC disability index is estimated for a sample of 145 adults with chronic bronchitis, expressing their self-reported disability caused by the disease on a one-dimensional scale. The index is determined up to a linear transformation. Disability is thus measured on an interval scale. The data were collected by interviews. The questionnaire used for this purpose is based on a number of in-depth interviews with selected bronchitis patients conducted beforehand. The study therefore focuses directly on the patients' perceptions of their disease. The validity of the index is evaluated in three different ways. First, construct validity is assessed performing groupwise analysis and testing for differences in the index values by subgroup. To a large extent, the index is consistent with a priori expectations. Therefore, we conclude that it has high construct validity. Second, validity of the index is assessed by comparing its results to a direct rating scale produced by 21 physicians with various medical backgrounds. The MIMIC index turns out to be related in a systematic, but nonlinear way to this direct rating scale. This can be interpreted in two different ways. If one accepts the preferences of health providers as the ultimate yardstick when it comes to ranking health or chronic states the result suggests that the MIMIC index estimated in this way is not a valid measure of treatment success. By contrast, if patients' preferences are considered to be decisive, it suggests that physician-based ratings should be substituted for or at least complemented with patient-based indices (such as the MIMIC disability index estimated here) when evaluating medical services in terms of cost effectiveness. Third we explore the extent to which the MIMIC index reflects utility associated with different states of disability, using a modified Torrance Standard Gamble approach. The above-mentioned physicians are used as experts in this procedure. The results indicate that the MIMIC index as estimated here is related in a systematic, but nonlinear way to the Standard Gamble risk index as well. The fact that this relationship is nonlinear indicates that the MIMIC index does not measure utility as derived from the experts' preferences directly. How this index would fare compared to a Standard Gamble risk index provided by patients (bronchitis subjects) is a question which remains open.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10151743 TI - Welfare economics and cost-utility analysis. PMID- 10151744 TI - Excess demand and patient selection for heart and liver transplantation. PMID- 10151745 TI - Non-price allocative procedures: Scottish solutions to a National Health Service problem. AB - Except for a few NHS services, the allocation of resources depends on administrative-cummedical decision-making. At one level the Scottish Home and Health Department allocates funds between the fifteen health boards, at another level clinicians allocate resources between patients. We examine experience at a level intermediate between these two, and focus on the provision of two services- diagnostic radiology and ECG--at health centres. A benefit: cost framework is used to test three hypotheses about how the two services have been allocated. The three hypotheses relate to the benefits from provision and are characterised as 'medical excellence', 'equity' and 'market' orientated. Data on health centre list size and distance to alternative provision are used to test the hypotheses. The conclusions are as follows. The equity and market models are equally valid descriptions for ECG, a service provided by general practitioners. A combination of the equity and/or market model with the medical model is a valid description for diagnostic radiology, a service provided by health boards and the Scottish Home and Health Department. PMID- 10151746 TI - Priorities among waiting list patients. PMID- 10151747 TI - Consumer information, price, and nonprice competition among hospitals. AB - The results of the empirical analysis in this paper indicate that broadly defined hospital quality declines in more concentrated markets. The direction of the effect of concentration on hospital charges is smaller and the direction is less clear. Prices are little, if any, lower in more concentrated markets. Hospital price-cost margins are higher in more concentrated markets. Higher concentration discourages price competition. The data do not support the increasing monopoly theory. Further, since hospital price-cost margins do not appear to remain constant, we must reject the redundant resources theory as well, though its stress on nonprice competition rings true. The empirical results are consistent with the traditional antitrust theory. In addition, consumer information plays a surprisingly important role. Consumer information is important in explaining hospital prices, and less important in hospital quality. Consumers are not passive; they do play a role in hospital choice. It is likely that more recent innovations in health insurance will increase consumer awareness. With an increase in consumer copayments, and more active insurer contracting, it is likely that future hospital competition is more likely to stress price, and future antitrust activity could lead to price reductions in addition to declining hospital price-cost margins. PMID- 10151748 TI - How can we prevent cream skimming in a competitive health insurance market? The great challenge for the 90's. PMID- 10151749 TI - Cost containment in health care: justification and consequences. PMID- 10151750 TI - Political economy of hospital financing. AB - In this paper we tried to explain the recent reform in the law of financing German hospitals. We first described five basic types of hospital payment systems which were available as alternatives to the decision on the reform in the early 1980s. In the next step we identified five concerned interest groups whose actions certainly had a great influence on the legislative process. We proposed a simple theoretical model to examine how these groups of actors evaluated the different payment systems. After deriving a preference ranking for each actor, we confronted these rankings with the respective revealed preferences, which could be inferred from their official statements towards the reform. It could also be shown that quite often the actual statements deviated strongly from the theoretically expected preferences because all groups were engaged in a highly interactive lobbying game. In the last step we compared these preferences to the actual outcome of the legislation and found that all groups have at least partly realized their targets. So in contrast to the typical results of interest group theory, the differences in bargaining power do to appear to have led to a solution which unambiguously benefits some groups of actors at the expense of others. It has to be repeated that the empirical analysis was limited to statements from the interest groups in the pre-legislative stage of the whole process. From this point the most promising procedure would appear to be the step by-step analysis of the statements of the groups during the legislative process as well. This would give the researcher a chance to evaluate whether or not the theoretical hypotheses can be confirmed, whether or not our simple theoretical model is an appropriate way to understand the behavior of the affected groups and what was finally responsible for the outcome of the legislation. Therefore this paper should be seen as a first attempt to apply the framework of public choice theory to the field of health care financing and to demonstrate that much more research is needed. PMID- 10151751 TI - Pricing and imperfections in the medical care marketplace. AB - To summarize: Some economic literature treats price determination in the medical marketplace as if it were similar to that of a standard marketplace. It seems more realistic to treat it as an outcome of one or more administered price systems. Such systems, may be formula-based, as is common in the United States (for example, the Prospective Payment System), or not (for example, a negotiated budget). In either case, however, the actual price is likely to deviate from the ideal price in part for lack of information. Plausible deviations can explain some observed phenomena. The inability to attain the ideal price, together with heterogeneity of patients, may also explain why in practice we observe several different bases of provider payment; for example, fee-for-service, capitation, and salary. All of these may be attempts to arrive at second best prices. Ignoring any welfare loss from raising revenue and assuming those with the largest marginal social valuation for the service are served first, errors in price setting lead to a welfare loss that is approximately proportional to the square of the deviation from the ideal price. If price setting is unbiased (i.e., errors have a mean of zero), the welfare loss is approximately proportional to the variance of the error in setting price. If price setting is biased, welfare loss is approximately proportional to the variance plus the square of the bias. Taking account of welfare loss from raising revenue may make monopsonistic pricing optimal. If one uses multiple bases of payment, for example both fee-for service and capitation, one can average the errors that arise in each basis. This creates a gain from using a mixed system, in addition to those gains cited by other analysts, who focus on the method of reimbursement assuming what, in the present context, could be termed error-free price effects. The gains from averaging errors would appear available in any administered price system and are compatible with a wide variety of models of provider behavior. PMID- 10151752 TI - Deaths from gastro-intestinal cancer in Mexico: probable cause for water sampling. PMID- 10151753 TI - The impact of utilization review on costs and utilization. AB - This paper examines the performance of a utilization review program using data from Aetna's utilization review (UR) customers compared to a representative sample of its customers which had no utilization review during the study period. Statistical adjustments were made for the utilization management status, employee demographics, plan benefits, group size, year effects and seasonality. The study period covered from the first quarter of 1987 through the last quarter of 1988. The data suggest that UR reduces overall medical expenses by 4.4 percent, and inpatient expenses by 8.1 percent after a year of experience, largely by reducing length of stay. PMID- 10151754 TI - The normative and positive economics of minimum health benefits. PMID- 10151755 TI - Cost-effectiveness analysis of strategies for screening prostatic cancer. PMID- 10151756 TI - Henry Ford Health's 'Saturn' system slashes waiting times. PMID- 10151757 TI - Educate trustees to keep health system plans on track. PMID- 10151758 TI - Half-evolved managed care markets may be worst kind, survey finds. PMID- 10151760 TI - Harris Methodist shifts thinking from hospital-centered to system-centered. PMID- 10151759 TI - Group asks who's watching when not-for-profit hospitals sell? PMID- 10151761 TI - Execs hit hardest in realignment lay-offs. PMID- 10151762 TI - Children's hospitals forming specialty networks for carve-outs. PMID- 10151763 TI - Alliance greets new member, snags contract with major HMO. PMID- 10151764 TI - Quarter of metro areas have HMO penetration above 25%, survey finds. PMID- 10151766 TI - Grantees to study uses of IDSs in treating under- and uninsured. PMID- 10151765 TI - Home care, rehab among hospitals' top ambulatory services plans. PMID- 10151767 TI - Columbia/HCA battles Neb. hospital to buy not-for-profit. PMID- 10151768 TI - Rural hospitals still spooked by costs of telemedicine, survey says. PMID- 10151769 TI - Omaha hospital systems moving past engagement to full integration. PMID- 10151770 TI - Physician practice purchases hurting Pa. hospital ratings, Moody's says. PMID- 10151771 TI - Unions target Kaiser, Philly hospital as bottom-line pressures build. PMID- 10151772 TI - Ind. hospital looks outward to find savings internally. PMID- 10151773 TI - Chicago hospitals poised to build ties electronically with info network. PMID- 10151774 TI - Minn. providers, Blues team to ready rural market for managed care. PMID- 10151775 TI - Inpatient hospital days ready to dive, but IDSs will prosper, study predicts. PMID- 10151776 TI - HFMA drafts standards to help IDSs track funds amidst deal-making. PMID- 10151777 TI - Tampa not-for-profit hospitals unite to compete with Columbia/HCA. PMID- 10151778 TI - TQM sparks Cincy health system's revitalization. PMID- 10151779 TI - Think twice about the 'facts' of capitation, expert warns. PMID- 10151780 TI - Some IDSs, PHOs should follow insurance regs, NAIC recommends. PMID- 10151781 TI - Columbia's plans for Va. hospital's psych facilities raise FTC red flags. PMID- 10151783 TI - Integrating? Most say yes, though payment methods slow to follow. PMID- 10151782 TI - Clinical integration essential to Minn. IDSs' acceptance of packaged prices. PMID- 10151784 TI - 'Champions' lead Mo. system's C-section reduction plans. PMID- 10151785 TI - N.J. hospitals team to build pathways database open to competitors. PMID- 10151786 TI - Peoria, Ill., hospitals align organizations with long-term goals. PMID- 10151787 TI - Partners in practice: riding the waves of change. PMID- 10151788 TI - Strategic planning: positioning occupational therapy to be proactive in the new health care paradigm. AB - Strategic planning can be a powerful tool for occupational therapists seeking to position themselves to be leaders in the rapidly changing health care environment. The philosophical base and values of occupational therapy are consistent with those embraced by the emerging health care paradigm. However, occupational therapy staff at Victoria Hospital, an acute care university affiliated health care institution, identified obstacles to seizing the opportunities offered by this shift in health care. In reviewing the literature, it was discovered that these obstacles were not unique to one particular facility, but were in fact common issues faced by the profession. The strategic planning process described in this paper provided a framework for addressing the identified barriers and positioning occupational therapists to play a proactive role in the evolving health care paradigm. PMID- 10151789 TI - Re-engineering of health care: opportunity or threat for occupational therapists? AB - The health care system is responding to a paradigm shift from the industrial era to the knowledge society. The rapidly changing administrative structures of some hospitals and increasing numbers of proposals for new models of care are disconcerting for therapists who are used to working in traditional organizational structures and models of care. However, with a broader understanding of the shift that is occurring, it becomes apparent that this paradigm shift is pushing the system toward care practices that are more consistent with occupational therapy practices than those of the traditional medical model. This paper describes the factors influencing the direction of the paradigm shift, the major emerging models of care and organizational structures associated with the paradigm shift, and then discusses the issue of whether the paradigm shift presents a threat or a challenge to occupational therapists. PMID- 10151790 TI - Staff rotation: implications for occupational therapy. AB - Occupational therapy departments of tertiary care hospitals can provide staff with opportunities to gain diverse clinical experience if they rotate through the various services such as surgery, medicine, geriatrics, plastic surgery and orthopaedics. The system of rotation offers both advantages and disadvantages for the staff and the institution. The Royal Victoria Hospital in Montreal, a large university teaching hospital, had traditionally offered staff the opportunity to rotate. Changes in staffing and their needs however, resulted in rotation becoming an important issue within the department. This article presents the pros and the cons of rotation and non-rotation systems as identified by therapists and administrators across Canada. Staff rotation was found to have an effect on job satisfaction and a therapist's career orientation. Given these findings, administrators may want to reconsider the role of the generalist and specialist in their facilities. PMID- 10151791 TI - Effecting change through programme evaluation. AB - This paper highlights a children's mental health facility's approach to growing waiting lists and constraints on staffing dollars. The process undertaken to streamline service, develop and market a new model of service delivery, and evaluate its effectiveness is presented. Results of the evaluation of the treatment specialty model were most supportive of its implementation. PMID- 10151792 TI - Do you know the codes? True or false. PMID- 10151793 TI - Extra, extra! How to avoid costly change orders. Interview by Yvonne Parsons. PMID- 10151794 TI - Assisted living preview. PMID- 10151795 TI - Building a design team. PMID- 10151796 TI - Leadership in the '90s--what does it take? AB - Leaders are those who have the ability to identify necessary steps and the right things to do, which will be crucial in the next several years of home care. These individuals possess special competencies that differ from the skills of good workers or managers. What skills are unique to leaders? PMID- 10151797 TI - Key strategies for risk management in acute home care. AB - Home care agencies face new challenges as more acute medical care shifts to the home setting. Successful risk management must address effective communication and documentation, as well as proper management of new medical technologies. PMID- 10151798 TI - Leadership trends--getting to the year 2000. AB - Leaders for tomorrow need two things: vision and the ability to inspire groups to reach that vision. They need to learn from leaders from the past, then turn their focus to the future to set a tone that will enable their teams to reach and surpass new boundaries. PMID- 10151800 TI - Profiles in leadership. PMID- 10151799 TI - Are you speaking French in Japan? Home care's 21st-century leadership model. AB - Home care leadership is headed for change in the 21st century in demographics as well as legislative issues. With the influx of men into a female-dominated industry, leadership in home care will need to integrate the language of traditional male and female culture into a workable management style. PMID- 10151801 TI - Leadership--a psychological trait perspective. AB - Research on leadership points to five psychological traits that leaders have in common. Organizations as well as individuals display leadership traits. This knowledge may help home care providers identify and select leaders who can take the industry through the next few turbulent years of managed care. PMID- 10151802 TI - Industry Leadership Forum recommends strategies for the future. AB - In June 1995 about 100 industry leaders gathered to assess the status of the home care and hospice industry. Recognizing that great changes will be taking place in the next few years, they identified assumptions under which providers should work and made related recommendations for providers that will help ensure the industry remains strong in the future. PMID- 10151803 TI - Home care executive certification: recognizing leaders and quality. AB - Leaders in any industry are recognized for what they have done and earned in their professional experience, but this recognition is not standard or formal. An executive certification program would formalize that recognition as well as provide a key to those outside the industry of the high standards the home care and hospice industry require of its members. PMID- 10151804 TI - Middle management training: investment in the future. AB - Most home care agencies are in desperate need of good middle-level managers. The solution seems to lie in recruiting or promoting people with potential, teaching them the necessary skills, and imparting to them the motivation they need to be successful. PMID- 10151805 TI - Business growth--a perspective on home health management companies. AB - Running a home care agency is a complicated business. Many agencies are now turning to home care management companies to help them start up a new agency or make an existing one more efficient. What should home care agencies look for in a management company? PMID- 10151806 TI - The endangered species. AB - To survive the changes sweeping over the home care industry, companies will look for innovative management concepts to help them meet challenges with positive action. The author details the success his organization has enjoyed since it incorporated Customer 1st, an application of Total Quality Entrepreneurship. PMID- 10151807 TI - What home care executives should know about managed care organizations: preliminary results from a national study. AB - An industry survey explored the growing relationship home care has with managed care by asking managed care organizations (MCOs) what they know about home care, what they want from home care, and what they expect from home care agencies. The preliminary results here should help home care providers develop a working partnership with MCOs that will be successful now and in the future. PMID- 10151808 TI - Developing a managed care mindset: getting staff on the managed care bandwagon. AB - A managed care mindset involves understanding how managed care works and what managed care organizations will expect when they work with home care providers. To gain that mindset, once managers understand the concept, they need to take steps to educate their staff members and bring about a new perspective. PMID- 10151809 TI - Managed care: are your middle managers ready? AB - In the midst of the trepidation surrounding the home care industry during this advent of managed care, one agency has developed a strategic plan to survive and improve under this new health care system. A crucial part of this plan is the careful encouragement and specialized training of middle managers. PMID- 10151810 TI - Killer heat. More than 500 residents die from Chicago's temperatures. PMID- 10151812 TI - Taking aim at EMS' future. PMID- 10151811 TI - Congress hears from Oklahoma City medics. PMID- 10151813 TI - Curing what ails us. PMID- 10151814 TI - Color bind. Some providers believe EMS and the fire service are still a "white man's club". PMID- 10151815 TI - Fair play. Are your feelings about coworkers and patients based on facts or perceptions? PMID- 10151816 TI - A class act. Recognize, accept, understand. PMID- 10151817 TI - Managing cultural diversity. A primer for EMS managers. PMID- 10151818 TI - Diagnosis: Babel. AT&T provides a way to cope with language barriers. PMID- 10151819 TI - Hispanics are the fastest-growing population--and patient--segment. Interview by Nancy Perry. PMID- 10151820 TI - Doing what comes naturally. PMID- 10151821 TI - My feet are killing me! PMID- 10151822 TI - 60 ways to contain hospital supply costs. PMID- 10151823 TI - Color affects how we feel. PMID- 10151824 TI - Quality environmental services: wearing multiple hats. Interview by Lisa M. Marinik. PMID- 10151825 TI - Making the best choice for medical waste management. On-site vs. off-site processing. PMID- 10151826 TI - Ways to save linen costs. PMID- 10151827 TI - Improving union relationships in a performance-based environment. PMID- 10151828 TI - Breaking down barriers at Franciscan Health Systems. PMID- 10151829 TI - Challenge: how to improve quality of life for seniors in a CCRC. PMID- 10151831 TI - The five fundamental fund-raising strategies. PMID- 10151830 TI - A balance of tastes. Chefs & dietitians roundtable discussion. AB - The demands from foodservice customers for healthier foods that also taste good have compelled chefs & dietitians to break off their traditional separation of powers & begin forming working partnerships. These new partnerships are producing menus that strike a balance just as new--a balance between the preferences & priorities of both professions. It means a combining of two different but not incompatible perspectives that magnifies both the pleasure & the benefit of the good food they serve. In recognition of these new partnerships, FM convened the first roundtable with chefs & dietitians, all of whom are on the leading edge of this emerging trend. Excerpts of their discussion reflect striking similarities in opinion--as well as differences still to be reconciled. PMID- 10151832 TI - Non-profits in cyberspace: the fund raiser's guide. PMID- 10151833 TI - The 1995 Non-profit Software Directory. PMID- 10151834 TI - Using online databases for prospect research. PMID- 10151835 TI - Listen to employees! PMID- 10151836 TI - Health care changes rock hospitals. PMID- 10151837 TI - Healthcare revolution forcing institutions to change to survive. PMID- 10151838 TI - Recalls. FDA, industry cooperate to protect consumers. AB - When a marketed product is found to violate the law, more often than not it's the company that removes it from the market--or recalls it in FDA lingo. This helps the companies, taxpayers and consumers. PMID- 10151839 TI - Getting SMART (submission management and review tracking) drug review in the computer age. AB - FDA is beginning to launch its drug review process into cyberspace. This electronic transformation is expected to speed review of new drug applications. PMID- 10151840 TI - Overview: health financing reforms in Africa. PMID- 10151841 TI - The impact of alternative cost recovery schemes on access and equity in Niger. AB - The authors examine accessibility and the sustainability of quality health care in a rural setting under two alternative cost recovery methods, a fee-for-service method and a type of social financing (risk-sharing) strategy based on an annual tax+fee-for-service. Both methods were accompanied by similar interventions aimed at improving the quality of primary health services. Based on pilot tests of cost recovery in the non-hospital sector in Niger, the article presents results from baseline and final survey data, as well as from facility utilization, cost, and revenue data collected in two test districts and a control district. Cost recovery accompanied by quality improvements increases equity and access to health care and the type of cost recovery method used can make a difference. In Niger, higher access for women, children, and the poor resulted from the tax+fee method, than from the pure fee-for-service method. Moreover, revenue generation per capita under the tax+fee method was two times higher than under the fee-for service method, suggesting that the prospects of sustainability were better under the social financing strategy. However, sustainability under cost recovery and improved quality depends as much on policy measures aimed at cost containment, particularly for drugs, as on specific cost recovery methods. PMID- 10151843 TI - Improving quality through cost recovery in Niger. AB - New evidence on the quality of health care from public services in Niger is discussed in terms of the relationships between quality, costs, cost effectiveness and financing. Although structural attributes of quality appeared to improve with the pilot project in Niger, significant gaps in the implementation of diagnostic and treatment protocols were observed, particularly in monitoring vital signs, diagnostic examination and provider-patient communications. Quality improvements required significant investments in both fixed and variable costs; however, many of these costs were basic input requirements for operation. It is likely that optimal cost-effectiveness of services was not achieved because of the noted deficiencies in quality. In the test district of Boboye, the revenues from the copayments alone covered about 34% of the costs of medicines or about 20% of costs of drugs and administration. In Say, user fees covered about 50-55% of the costs of medicines or 35-40% of the amount spent on medicines and cost-recovery administration. In Boboye, taxes plus the additional copayments covered 120-180% of the cost of medicines, or 75-105% of the cost of medicines plus administration of cost recovery. Decentralized management and legal conditions in the pilot districts appeared to provide the necessary structure to ensure that the revenues and taxes collected would be channelled to pay for quality improvements. PMID- 10151842 TI - Protecting the poor under cost recovery: the role of means testing. AB - In African health sectors, the importance of protecting the very poor has been underscored by increased reliance on user fees to help finance services. This paper presents a conceptual framework for understanding the role means testing can play in promoting equity under health care cost recovery. Means testing is placed in the broader context of targeting and contrasted with other mechanisms. Criteria for evaluating outcomes are established and used to analyze previous means testing experience in Africa. A survey of experience finds a general pattern of informal, low-accuracy, low-cost means testing in Africa. Detailed household data from a recent cost recovery experiment in Niger, West Africa, provides an unusual opportunity to observe outcomes of a characteristically informal means testing system. Findings from Niger suggest that achieving both the revenue raising and equity potential of cost recovery in sub-Saharan Africa will require finding ways to improve informal means testing processes. PMID- 10151844 TI - Efficiency and quality in the public and private sectors in Senegal. AB - It is often argued that the private sector is more efficient than the public sector in the production of health services, and that government reliance on private provision would help improve the efficiency and equity of public spending in health. A review of the literature, however, shows that there is little evidence to support these statements. A study of government and non-governmental facilities was undertaken in Senegal, taking into account case mix, input prices, and quality of care, to examine relative efficiency in the delivery of health services. The study revealed that private providers are highly heterogeneous, although they tend to offer better quality services. A specific and important group of providers--Catholic health posts--were shown to be significantly more efficient than public and other private facilities in the provision of curative and preventive ambulatory services at high levels of output. Policies to expand the role of the private sector need to take into account variations in types of providers, as well as evidence of both high and low quality among them. In terms of public sector efficiency, findings from the study affirm others that indicate drug policy reform to be one of the most important policy interventions that can simultaneously improve efficiency, quality and effectiveness of care. Relationships that this study identified between quality and efficiency suggest that strategies to improve quality can increase efficiency, raise demand for services, and thereby expand access. PMID- 10151845 TI - Increasing the utilization of cost-effective health services through changes in demand. AB - Attaining efficiency in a health care system with a budget constraint involves increasing the utilization of the most cost-effective services. This can be achieved by adjustments to prices, cost curves, or demand curves. In this paper, the potential for demand curve adjustments is examined by selecting two apparently cost-effective services (prenatal care and childhood immunization against tuberculosis), and analyzing the factors explaining their utilization. Data from recent household surveys in Burkina Faso and Niger are used. A multivariate analysis of utilization employs income, price, and taste variables. Utilization is highly sensitive to the distance which must be travelled to the health facility, a price, and taste variables. Utilization is highly sensitive to the distance which must be travelled to the health facility, a price variable. Members of certain ethnic groups tend to use the services less, other things being equal. The importance of demand-side factors like ethnicity points to certain kinds of policy interventions like information, education and communication activities which could increase the utilization of cost-effective services. PMID- 10151846 TI - Research note: does cost recovery for curative care affect preventive care utilization? PMID- 10151847 TI - Research note: price uncertainty and the demand for health care. PMID- 10151848 TI - Factors affecting acceptance of immunization among children in rural Bangladesh. AB - This paper uses the Bangladesh Fertility Survey 1989 data to identify the factors affecting acceptance of immunization among children in rural Bangladesh. Acceptance of DPT, measles and BCG vaccinations were the dependent variables. The independent variables included proximity to health facilities, frequency of visit by health worker, respondent's mobility, media exposure, education, age, economic status of household, region of residence, and gender of child. Logistic regression analysis was performed to assess the net effects of the variables in addition to univariate analysis. Among the independent variables, proximity to health facility, frequency of health worker's visit, mother's mobility, education, age, gender of child, ownership of radio, economic condition of household, and region of residence showed statistically significant association with acceptance of immunization. The effect of frequency of health worker's visit was dependent on region of residence, possession of radio, and mother's education. The effect of mother's ability to visit health centre alone was also dependent on ownership of radio, economic condition of household, and mother's education. PMID- 10151850 TI - User fees and drug pricing policies: a study at Harare Central Hospital, Zimbabwe. AB - In 1991, Zimbabwe introduced cost recovery measures as part of its programme of economic reforms, following a course taken by many developing countries. The system of user fees in public health care, aimed to 'protect and support the vulnerable groups' by exemption or incremental fees based on 4 income brackets. Drugs were charged at a percentage of the recommended retail price in the private sector. This study of 488 outpatients at a referral hospital in Harare examined how the new fee system functioned 6 months after its introduction. Patients were interviewed and their prescription records examined. Mean charges were determined for each fee category and revenue from drug charges was analyzed in relation to purchase cost to determine the gross profit. 31% of patients were exempted from all fees upon proof of monthly earnings of less than Z$150 (Z$5 = US$1). The remainder were classified into three fee-paying categories. The mean purchase cost for drug items was Z$3.89 per outpatient prescription. Outpatients paid a mean drug charge of Z$9.75 after exemption or discount. This was 2.5 times the cost price. The number of drug items obtained differed according to fee status: the fee-exempt category received a mean of 2.9 drug items compared with 1.9 drug items in the fee-paying categories. This difference originated at the point of prescribing. A number of practical problems in fee collection were noted. The drug pricing system generated high profit even after re-distribution to low income users. This was attributed to economical and rationalized public sector drug procurement. Observation indicated that a proportion of the vulnerable were not effectively protected due to stringent requirements for proof of income. Appraisal of the fee policy indicated the need for more effective cross-subsidy and better administrative procedures; fee revenue should be directed towards improvement in quality of service. PMID- 10151849 TI - Immunization determinants in the eastern region of Ghana. AB - A study of the immunization determinants of children aged 12 to 18 months was conducted in 1991 in the Eastern Region of Ghana, using structured interviews of mothers and fathers. The completion of immunization schedules by one year, among the 294 children, was positively associated (P < 0.005) with the town of residence of the child and mother, the ability of the mother to speak English, the target child having been treated for illness at the local hospital, the child's mother having given birth to less than 5 children, the possession of a sewing machine by the mother, and the birth of the child in the current town of residence. Significantly higher immunization coverage levels were achieved where the Under Fives' Clinic was an affordable and acceptable service, integrating preventive and curative care, and where measures were implemented by the community to increase attendance levels at the Clinic. This was achieved among a target group who were otherwise at a relatively high risk of failing to complete immunization schedules on-time. PMID- 10151851 TI - Demand management will be a necessity, a baked-in utility. PMID- 10151852 TI - Subacute utilization will double, revenues will triple over next five years. PMID- 10151853 TI - The Health Care Advisory Board provides research for health systems and hospitals. PMID- 10151854 TI - You'd better be providing capitated care today, or else. PMID- 10151855 TI - Defining characteristics of chronic disease. PMID- 10151856 TI - How to develop a primary care network. PMID- 10151857 TI - Survival demands embracing Medicare managed care. PMID- 10151858 TI - Limits placed on PHOs by antitrust rulings, transitional structure for integration. PMID- 10151859 TI - Provider-sponsored networks top priority. PMID- 10151860 TI - Geisinger Health System mines for Medicare population with its Health Plan Gold. PMID- 10151861 TI - HCIA (Health Care Investment Analysts) provides huge health care database, more detailed than competitors'. PMID- 10151862 TI - Senior nurse executives in transition: increased responsibilities and pay. PMID- 10151863 TI - Defining gatekeepers for Medicare managed care. PMID- 10151864 TI - Legal issues affecting IPA formation. AB - Independent practice associations (IPAs) and similar organizations are forming more rapidly as the healthcare industry evolves. The formation of IPAs, however, raises a number of legal issues that must be addressed and resolved, issues related to licensure and choice of entity, antitrust, self-referral, insurance regulations, and liability. PMID- 10151865 TI - IRS views on physician control of integrated networks. AB - Integrated delivery systems and their components are evolving rapidly, as are Internal Revenue Service (IRS) tax-exemption rulings and standards affecting these entities. A common concern addressed by two recent IRS tax-exemption rulings centered on the impact of physician involvement on a hospital's tax exempt status. PMID- 10151866 TI - Predicting financial risk under capitation. AB - As managed care proliferates, providers must understand the types of financial risks they face when providing care under capitation. There are two basic types of financial risk (which arises from uncertainties about revenues and costs): objective risk and subjective risk. Objective risk exists when financial managers can anticipate, with reasonable confidence, the expected range of revenue and cost variation. Subjective risk exists when financial managers cannot accurately predict the range of revenue and cost variation. Providers moving from a prospective payment system to a capitated system will find that objective financial risk potentially is reduced. However, subjective financial risk under capitation can be significant. To minimize subjective risk, healthcare executives must have access to data about the population covered by the capitation contract, must have sufficient numbers of covered lives, must reduce costs involved with providing healthcare services, and must reduce the volume of patients treated- for example, by implementing disease and injury prevention programs. PMID- 10151867 TI - Effective planning for managed care. AB - In response to the changing healthcare market, many providers are forming networks for managed care contracting. These networks may fail, however, if planning focuses on maintaining business practices of the past rather than responding to market forces of the future. Effective planning for managed care requires that network executives establish a vision of the future that is not shackled by experiences of the past, articulate a mission that outlines what the network's role will be in the future, and create strategies that will help the network fulfill its mission. Although financial data are necessary to measure a network's progress toward fulfilling its mission, data on past performance should not be used to shape a vision of the future. PMID- 10151868 TI - Obtaining low bond interest rates. AB - Healthcare executives whose organizations seek major capital financing through bond offerings typically focus their attention on obtaining the lowest possible bond placement fees for the services of underwriters, legal counsel, accounting firms, and other advisors. However, far greater savings can be achieved by employing a strategic approach to securing low bond interest rates. PMID- 10151869 TI - Cost-effective facility parking strategies. AB - For many healthcare facilities, increasing use of outpatient services has resulted in a greater demand for parking space. Consequently, parking structure costs have become a more important capital budget item than in previous years. Financial managers need to understand the parameters of parking costs for their facilities and their capital financing options, including off-balance sheet leaseback arrangements. PMID- 10151870 TI - EDI and reinsurance. PMID- 10151871 TI - Asset management: the next step. PMID- 10151872 TI - Protecting your career investment. PMID- 10151873 TI - Data trends. November 1995. PMID- 10151874 TI - Protecting patient confidentiality when the patient is 'superman'. PMID- 10151875 TI - Respiratory disease outbreaks affect patients, staff at two hospitals. PMID- 10151876 TI - Hospital officials report on results of cellular phone bans. PMID- 10151877 TI - Hospital program trains security officers in bicycle patrolling. PMID- 10151878 TI - The hidden costs of computerization. PMID- 10151879 TI - Training the trainer. PMID- 10151880 TI - Nutrient analysis of menus. PMID- 10151881 TI - Revisiting Walter Reed's clinical nutrition services. PMID- 10151882 TI - Issues in measuring and improving health care quality. AB - This issue of the Health Care Financing Review focuses on issues and advances in measuring and improving the quality of care, particularly for Medicare and Medicaid beneficiaries. Discussions of quality-related topics are especially timely, given the growing and widespread interest in improving quality in the organization, financing, and delivery of health care services. This article has several purposes. The first is to provide a brief description of some of the causes underlying the growth of the health care quality movement; the second is to provide a contextual framework for discussion of some of the overarching themes that emerge in this issue. These themes include examining conceptual issues, developing quality measures for specific sites and populations, and creating or adapting data sets for quality-measurement purposes. PMID- 10151883 TI - Development and testing of nursing home quality indicators. AB - In this article, the authors report on the development and testing of a set of indicators of quality of care in nursing homes, using resident-level assessment data. These quality indicators (QIs) have been developed to provide a foundation for both external and internal quality-assurance (QA) and quality-improvement activities. The authors describe the development of the QIs, discuss their nature and characteristics, address the development of a QI-based quality-monitoring system (QMS), report on a pilot test of the QIs and the system, comment on methodological and current QI validation efforts, and conclude by raising further research and development issues. PMID- 10151884 TI - A data-driven approach to improving the care of in-center hemodialysis patients. AB - Health care providers, patients, the end stage renal disease (ESRD) networks, and HCFA have developed the ESRD Health Care Quality Improvement Program (HCQIP) in an effort to assess and improve care provided to ESRD patients. Currently, the ESRD HCQIP focuses on collecting information on quality indicators (QIs) for treatment of anemia, delivery of adequate dialysis, nutritional status, and blood pressure control for adult in-center hemodialysis patients. QIs were measured in a national probability sample of ESRD patients, and interventions and evaluations of the interventions are beginning. The ESRD HCQIP illustrates a way to mobilize the strengths of the public and private sectors to achieve improved care for special populations. PMID- 10151885 TI - Florida's Medicaid AIDS waiver: an assessment of dimensions of quality. AB - Some State Medicaid agencies have implemented home and community-based waiver programs targeting acquired immunodeficiency syndrome (AIDS) patients. Under these initiatives, State Medicaid agencies can provide home and community-base services to persons with AIDS (PWA) as an alternative to more costly Medicaid covered institutional care. This article evaluates quality of care under the Florida Medicaid waiver for PWA along two dimensions: program effectiveness and client satisfaction. Clients are generally satisfied with their case managers and the range and availability of services. Case managers appear to be well trained. Moreover, the probability of turnover is quite low, despite heavy caseloads and high mortality. The major difficulty faced by clients adn case managers relates to the process of becoming Medicaid eligible. PMID- 10151886 TI - Health Care Quality Improvement Program: a new approach. AB - The Health Care Financing Administration (HCFA) has embarked on a new program to ensure the quality of care provided to Medicare and Medicaid beneficiaries. The approach, entitled the Health Care Quality Improvement Program (HCQIP), focuses on improving the outcomes of care, measuring improvement, and surveying for patient satisfaction. HCQIP, still in its infancy, is undertaken in collaboration with the providers of care. This article describes HCQIP. PMID- 10151887 TI - Surveying consumer satisfaction to assess managed-care quality: current practices. AB - Growing interest in using consumer satisfaction information to enhance quality of care and promote informed consumer choice has accompanied recent expansions in managed care. This article synthesizes information about consumer satisfaction surveys conducted by managed-care plans, government and other agencies, community groups, and purchasers of care. We discuss survey content, methods, and use of consumer survey information. Differences in the use of consumer surveys preclude one instrument or methodology from meeting all needs. The effectiveness of plan based surveys could be enhanced by increased information on alternative survey instruments and methods and new methodological studies, such as ones developing risk-adjustment methods. PMID- 10151888 TI - Agreement between physicians' office records and Medicare Part B claims data. AB - This article tests agreement between demographic, diagnostic, and procedural information from primary-care physicians' office records and Medicare Part B claims for Maryland Medicare beneficiaries. The extent of agreement depended on the category of information being compared. Demographics matched poorly, probably due to incomplete record samples. Important diagnoses were often missing from the medical record. When claims indicated presence of disease, the patient was likely to have the disease, but claims did not capture all people who have the disease. Additionally, many laboratory tests and procedures were missing from the primary care record. The appropriate use of either of these data sources depends on the specific research question that is being asked. PMID- 10151889 TI - Impacts of hospital budget limits in Rochester, New York. AB - During 1980-87, eight hospitals in the Rochester, New York area participated in an experimental program to limit total revenue. This article analyzes: increase of costs for Rochester hospitals; trends for inputs and compensation; and cash flow margins. Real expense per case grew annually by about 3 percent less in Rochester. However, after 1984, Medicare prospective payment had an effect of similar size outside Rochester. Some capital inputs to hospital care were restrained, as were wages and particularly benefits. The program did not generally raise or stabilize hospital revenue margins, while the ratio of cash flow to debt trended down. Financial stringency of this program relative to alternatives may have contributed to its end. PMID- 10151890 TI - National health expenditure projections, 1994-2005. AB - Using 1993 as a baseline and assuming that current laws and practices continue, the authors project U.S. health expenditures through the year 2005. Annual spending growth has declined since 1990, and, in the scenario reported here, that trend continues in 1994. Growth of health spending increases thereafter, but remains below the average experience of the past decade. Even so, health expenditures grow faster than the gross domestic product (GDP), and by 2005, account for 17.9 percent of the GDP. Unless the system changes, Medicare and Medicaid are projected to pay for an increasing share of total spending during the next decade. PMID- 10151891 TI - Health care indicators ... community hospital statistics; private sector employment, hours, earnings; prices; national economic indicators. PMID- 10151892 TI - Toward a 21st century quality-measurement system for managed-care organizations. AB - As the Nation's largest managed-care purchaser, the Health Care Financing Administration (HCFA) is working to develop a uniform data and performance measurement system for all enrollees in managed-care plans. This effort will ultimately hold managed-care plans accountable for continuous improvement in the quality of care they provide and will provide information to consumers and purchasers to make responsible managed-care choices. The effort entails overhauling peer review organization (PRO) conduct of health maintenance organization (HMO) quality review, pilot testing a new HMO performance measurement system, establishing criteria for Medicaid HMO quality-assurance (QA) programs, adapting employers' HMO performance reporting systems to the needs of Medicare and Medicaid, and participation in a new alliance between public and private sector managed-care purchasers to promote quality improvement and accountability for health plans. PMID- 10151893 TI - Report to Congress. Evaluation of the grant program for rural health care transition. PMID- 10151894 TI - Measuring quality of care under Medicare and Medicaid. AB - The Health Care Financing Administration's (HCFA) approach to measuring quality of care uses an accepted definition of quality, explicit domains of measurement, and a formal validation procedure that includes face validity, construct validity, reliability, clinical validation, and tests for usefulness. The indicators of quality for Medicare and Medicaid patients span the range of service types, medical conditions, and payment systems and rest on a variety of data systems. Some have already been incorporated into operational systems while others are scheduled for incorporation over the next 3 years. PMID- 10151896 TI - Reconciling practice and theory: challenges in monitoring Medicaid managed-care quality. AB - The massive shift to managed care in many State Medicaid programs heightens the importance of identifying effective approaches to promote and oversee quality in plans serving Medicaid enrollees. This article reviews operational issues and lessons from the ongoing evaluation of a three-State demonstration of the Health Care Financing Administration's (HCFA) Quality Assurance Reform Initiative (QARI) for Medicaid managed care. The QARI experience to date shows the potential utility of the system while drawing attention to the challenges involved in translating theory to practice. These challenges include data limitations and staffing constraints, diverse levels of sophistication among States and health plans, and the practical limitations of using quality indicators for a population that is often enrolled only on a discontinuous basis. To overcome these challenges, we suggest using realistically long timeframes for system implementation, with intermediate short-term strategies that could treat States and managed-care plans differently depending on their stage of development. PMID- 10151895 TI - Quality of care in teaching nursing homes: findings and implications. AB - This article explores policy implications and selected methodological topics relating to long-term care (LTC) quality. We first discuss the Teaching Nursing Home Program (TNHP), in which quality of care in teaching nursing homes (TNHs) was found to be superior to the quality of care in comparison nursing homes (CNHs). A combination of outcome and process/structural measures was used to evaluate the effects of care and underlying reasons for superior TNH outcomes. Second, we explore policy and analytic ramifications. Conceptual, methodological, and applied issues in measuring and improving the quality of LTC are discussed in the context of TNH research and related research in home care. PMID- 10151897 TI - Measuring outcomes in home care: current research and practice. PMID- 10151898 TI - Organizational and provider structural changes and resource utilization of services for the elderly in Norway. AB - This paper presents recent innovations in organizing provider work and changes in organizational structure that promote: (1) reduction in fragmentation of care (2) improved continuity and quality of care and (3) improved cost-containment efforts and (4) better decision making. Data is also given on resource utilization. It is anticipated that these models of care and services are prototypes of future models of care for the elderly as this population increases in number. Data is also presented that suggests that, eventually, increases in taxes and social security contributions and/or the rationing of health care may be necessary to meet pensioner health needs. PMID- 10151899 TI - Profit and non-profit home health care agency outcomes: a study of one state's experience. AB - The home health care industry, traditionally an industry of non-profit organizations, has increasingly become, as has the rest of the health care industry, invaded by for-profit organizations. The impetus for this invasion was the Omnibus Reconciliation Act (OBRA) of 1980 which encouraged previously restricted for-profit organizations to participate in the Medicare and Medicaid home health care program. Following enactment of OBRA, the number of for-profit organizations grew rapidly and the advantages and disadvantages of their presence in the market has been widely debated. The purpose of this study was to describe differences in behaviors and industry outcomes generated by non-profit and for profit organizations in Massachusetts. Data for the study was from the Massachusetts State Department of Public Health's Annual Reports of Home Health Agencies. Results suggest that while profit and non-profit agencies behave similarly in many areas, there are areas of difference, with significant differences found in the amount of service delivered and the rates charged. PMID- 10151900 TI - Home health care industry growth and change: a study of one state's experience. AB - Federal expenditures for home health care have been increasing at an annual rate of 30% per year since 1974, and are predicted to continue to increase more rapidly than expenditures for other health services in the future. This predication is based on: the aging population, increases in medical technology and the impact of government regulatory mechanisms which encourage growth and competition in the home health industry. In order to develop effective regulatory policies for the future it is necessary to understand the effect of past policies on home health care services. This is a descriptive study of one state's experience with a changing regulatory environment over a ten year period of time. Data from the Massachusetts Department of Public Health's Annual Reports for Home Health Agencies was used to describe industry growth and change and the effect these had on the accessibility, quality and efficiency of service delivery from 1980 to 1990. Results suggest dramatic changes in the industry, with strong evidence of agencies' competitive behaviors, improved patient access to most services, changes in staffing patterns and concerns for quality of care. PMID- 10151901 TI - The home health agency as a cost center. AB - Decisions involving the economics of home health care agencies require accurate and useful data on agency finances and cost-efficiency relationships, One step in the direction of improving economic management can be taken by defining the agency as a cost center, that is as an economic entity, with which specific resources, revenues and costs which can be expressly identified. This paper describes the economics and accounting frameworks within which resources and costs are classified and allocated into direct and indirect, and fixed and variable categories. PMID- 10151902 TI - Nutrition risk factors in a home health population. AB - This cross-sectional study focused on three related questions: (1) What is the prevalence of nutrition-related risk factors among home health care clients? (2) What is the relationship between nutrition-related risk factors and client demographic characteristics? (3) How does the assessment of nutritional status by home health nurses compare with a standardized screening method? One hundred twenty completed questionnaires, modified from the Nutrition Screening Initiative's "DETERMINE Your Nutritional Health" assessment form, were administered by home health nurses to their clients during a one-week period. Results indicated a high prevalence of nutritional risk factors including the need for meal preparation assistance (71%), shopping difficulties (66%), special diet (55%), and regular meals alone (39%). The number of medical diagnoses was associated with several risk factors. Nurses, when asked to assess their clients, were able to discern a client's nutritional risk relative to others but tended to underestimate the degree of risk. Routine nutrition screening, further training of home health providers and access to dietitians for consultation could minimize poor nutritional status as a complicating factor in the treatment of home care clients. PMID- 10151903 TI - Treatment center. Rivington House, New York City. PMID- 10151904 TI - Measuring patient satisfaction: how and why you should start now. PMID- 10151905 TI - An internist's view of Capitol Hill. Interview by C. Burns Roehrig. PMID- 10151906 TI - Reinventing Medicare: what does ASIM propose? PMID- 10151907 TI - Diagnosing quality in health plans. American Society of Internal Medicine. PMID- 10151908 TI - Quality drives physician assessment. PMID- 10151909 TI - Can physicians serve two masters and retain their mastery? PMID- 10151910 TI - Private payers should not mirror Medicare's use of the RBRVS. PMID- 10151911 TI - Calculating the RBRVS. PMID- 10151912 TI - The RBRVS: fixing the flaws. PMID- 10151913 TI - Developing measures to ensure quality health care. Interview by Laurie Hall. PMID- 10151914 TI - Reinventing government: promise--and Stark reality. PMID- 10151915 TI - Resident training and managed care: what's really going on? PMID- 10151916 TI - The Medicare fee schedule: has it worked? PMID- 10151917 TI - Third-party use of the RBRVS: is the glass half full or half empty? PMID- 10151918 TI - Accident and emergency. Counting the casualities. PMID- 10151919 TI - Service committees. Stage effects. PMID- 10151920 TI - Out-of-house care. Night & Dane. PMID- 10151921 TI - Career development. On the swap floor. PMID- 10151922 TI - ECRS (extra-contractual referrals). Mind the gaps. AB - METHOD. Buckinghamshire HA's ECR account budget sheet was reviewed for a five month period from April 1993, to identify adult mental health patients who were residents. Children under 16 and patients with physical disabilities were excluded from the study. All local consultant psychiatrists who either referred the patients or were responsible for their care were interviewed by a public health doctor, using a structured questionnaire. Basic demographic details, diagnoses, details of the ECR request, reasons for referral, current care needs and future patient plans were analysed for patients known by their consultants. RESULTS. Thirty-two patients were identified from the ECR account sheet. Twenty eight patients were known by a local consultant and included in the analysis. Of the outstanding four patients (14 per cent), one had returned to their local provider unit but was still being invoiced as an ECR patient, and three were long term chronically ill patients referred before ECRs were introduced. PMID- 10151923 TI - R&D. Marriage guidance. PMID- 10151924 TI - Locality commissioning. The persuaders. PMID- 10151925 TI - Community care. Consulting room. PMID- 10151926 TI - Data briefing. Nasty, brutish and short. PMID- 10151927 TI - Leadership. Does the NHS have any real leaders? PMID- 10151928 TI - Nurse leadership. Revival of the fittest. PMID- 10151929 TI - Transport policy. Life cycle. PMID- 10151930 TI - Public consultation. Public enemy. Why asking the people about acute services goes wrong. PMID- 10151931 TI - Public Consultation. Does public opinion matter? (Yes/no/don't know). PMID- 10151932 TI - Community nursing. Contact points. PMID- 10151933 TI - Careers profile. Finance: seeing both sides. PMID- 10151934 TI - Information management. Will the NHS get wired? PMID- 10151935 TI - Non-executives. Natural selection? PMID- 10151936 TI - Health Promotion. Candidates for promotion. PMID- 10151937 TI - User consultation. The listening blank. PMID- 10151938 TI - Chaplaincy. Holy natural. PMID- 10151939 TI - Bed use. In the realm of the census. PMID- 10151940 TI - Emergency admissions. Under observation. PMID- 10151941 TI - Data briefing. Managers: in the ascendancy? PMID- 10151942 TI - Should complaints be treasured? PMID- 10151943 TI - Complaints. Telling examples. PMID- 10151944 TI - Complaints. Fault lines. PMID- 10151945 TI - It's all at the co-op. PMID- 10151946 TI - Primary care. Three years after Tomlinson ... why millions are still unspent. PMID- 10151947 TI - User involvement. BUG-ging (Bromley user group) mental health services. PMID- 10151948 TI - Community care. Home base. PMID- 10151949 TI - Consulting users. When I'm calling you ... PMID- 10151950 TI - Data briefing. The heart of the matter. PMID- 10151951 TI - A multidisciplinary approach to enhance documentation of antibiotic serum sampling. AB - A procedure to improve interdepartmental communication and documentation of antibiotic serum sampling data for pharmacokinetic evaluation will be presented. A prospective audit by the Pharmacokinetic Service revealed that approximately 40% of all antibiotic serum levels were improperly drawn resulting in unsuitable specimens and erroneous serum concentrations or lacked sufficient data for pharmacokinetic analysis. A lack of communication and documentation between phlebotomy and nursing personnel was found to be the most significant source of potential error in serum sampling. Once the protocol for serum sampling was revised, less than 5% of antibiotic serum levels were found to be unsuitable for evaluation and interpretation. A continuous audit for procedural compliance identifies any source of potential sampling error and provides a means to improve the overall quality of a Pharmacokinetic Service. PMID- 10151952 TI - Evaluation of drug interaction microcomputer software: an updated comparison. AB - Nine drug interaction microcomputer software programs were evaluated and compared using clinical and general ease of use criteria. Descriptions of major changes or additions since the last review are detailed. The ability to screen for drug interactions was based on recent drug-drug and drug-food interactions. Recommended programs based on three price ranges are suggested. PMID- 10151953 TI - The changing temperament and retuning of practice for pharmacists. PMID- 10151954 TI - Learning from the ghost of healthcare past. PMID- 10151955 TI - Collaboration: the new leadership. Interview by Joe Flower. PMID- 10151956 TI - The collaborative competitors. PMID- 10151957 TI - 1995 Commitment to Quality Award. A system that tries harder. PMID- 10151958 TI - Follow the money. AB - Like a torrent cutting its way to the main riverbed, investor capital is moving relentlessly into the physician practice business. It rolls on without any concern for the traditions that created the deep revenue pools of hospitals, specialists, and insurance companies--except for an irrepressible need to drain them. PMID- 10151959 TI - Value-driven healthcare. PMID- 10151960 TI - Bringing an integrated system to market. The fundamental things apply. PMID- 10151961 TI - Technology, medicine & health, Part 8. A new generation of transplant therapies. PMID- 10151962 TI - Health care reforms: the unfinished agenda. AB - A number of similar trends emerge in the development of major reform programs in all Western societies: (1) convergence and divergence: whether intentionally or not, the reform programs follow the proposed general directions across countries. This convergence is challenged by an opposite trend towards divergence through regionalization; (2) politics: the interference of the political process and of government coalitions is manifest in health policy making; (3) competition: the movement away from the public integrated model towards the public contract model is occurring in National Health Service type systems as well as in Health Insurance Systems; (4) privatization: the increase of the private sector is encouraged in all European countries by a variety of mechanisms such as opting out and tax concessions; (5) inequity: gains in efficiency entail a decrease in availability and accessibility of high quality care among the different population groups; (6) management costs: cost-containment efforts lead to an increase in management costs especially of management information both in real money and human resources; (7) power shifts: there is a reorientation of the flux of money throughout the system with shifts in authority away from the traditional power groups; and (8) public deficits: concern about the reduction of public deficits prevails over cost-effectiveness, or macro-efficiency prevails over micro-efficiency. PMID- 10151963 TI - Evaluation and diffusion of excimer laser treatment of myopia in the United States and in The Netherlands. AB - Excimer laser photorefractive keratectomy (PRK) is an experimental treatment to correct myopia (short-sightedness) that is diffusing into use without convincing evidence of safety and efficacy. It has been claimed that PRK may render conventional methods of correcting myopia, such as wearing glasses or contact lenses, obsolete. Since about 25% of the world's population is myopic, the consequences of this technology in terms of benefits, risks, and costs could be truly enormous. The fee for the procedure in various countries such as the United States, the Netherlands, and Australia varies from about US $1500 to US $2250 per eye. In the United States, the Food and Drug Administration, acting as authorized in the Medical Devices Act of 1976, has limited the use of PRK to patients participating in clinical trials. In the Netherlands, in contrast, where medical equipment is not regulated, the method has diffused without controls, although it is not reimbursed by health insurance agencies. The procedure has become controversial in the Netherlands because it is provided privately and has been aggressively and inappropriately promoted. The case illustrates the limitations of health policy concerning technologies provided privately and raises a number of social and political questions. PMID- 10151964 TI - A cost-effectiveness analysis of cervical cancer screening: health policy implications. AB - This paper presents a framework for comparison of screening programme designs, based on efficiency and cost effectiveness criteria. The design parameters, such as choice of screening interval, which population segments to screen and expected participation rates in the selected population segments, are varied simultaneously. The costs and effects for a range of existing and hypothetical screening programmes against cervical cancer are estimated, using a mathematical simulation model. On the basis of these estimates average costs per life year and marginal costs per life year are calculated for a range of programmes. These calculations result in the definition of a range of inefficient programmes. Moreover, it is illustrated that the cost effectiveness of the efficient screening programmes decreases at an increasing rate as programmes are intensified either by way of shortening the screening interval or extending the target population segment to encompass the very young and/or the very old. The conclusion of this paper is that one should probably not extend screening programmes against cervical cancer beyond screening women in the age group 25-59 years every 4 years. In addition, increasing the participation rate of this group is a more cost effective way of increasing the number of life years gained, rather than extending the target group or decreasing the screening interval. PMID- 10151965 TI - Health services financing in Greece: a role for private health insurance. AB - Private health insurance can play a significant role in the financing and delivery of health services in relatively undeveloped health systems which suffer from limited public expenditures, resource shortages, and quality of care problems. Research results, however, indicate that private health insurance in Greece has not yet assumed that role. The rapid increase of private health insurance was the result of underfinancing by the public sector and restrictive policies for the private sector. The private sector, however, largely financed by private health insurance, found alternative investment and profit opportunities, which, unfortunately, did not improve health system microeconomic efficiency. In this paper we propose that a way of cooperation could exist between the public sector and private health insurance, which would improve public health services provision and the overall technical, allocative and dynamic efficiency of the health system. PMID- 10151966 TI - The evolution of heart, lung and liver transplantation services in Australia. AB - The introduction and operation of heart, lung and liver transplantation services in Australia have been assisted by a Nationally Funded Centres policy adopted by health ministers. Assessment for eligibility for support under the program has been undertaken by the Australian Health Technology Advisory Committee. Outcomes/survival rates at transplantation centres have compared favourably with results from other countries. As in other countries, shortage of donor organs has limited the number of procedures undertaken. Some concern remains regarding the viability of newer transplantation programs which are now being established in smaller centres of population. PMID- 10151967 TI - Measuring human betterment through avoidable mortality: a case for universal health care in the USA. AB - The USA system of health care has begun a monumental change that will affect everyone, irrespective of their socioeconomic status, professional status or pre existing health insurance status. Whatever type of plan is finally implemented through the legislative process, there will need to be a way to evaluate its success (or failure). One way to evaluate the plan's effectiveness is through its impact on human betterment as viewed by a reduction in 'avoidable mortality' for those most in need of health care; the poor and uninsured. For one USA minority population, universal health care has improved human betterment by reducing avoidable mortality, even in the face of a severe burden of poverty. PMID- 10151968 TI - Taking it to the streets: renovation creates a new community health center. PMID- 10151969 TI - Out of harm's way: curbing violence in the ED. PMID- 10151970 TI - What a deal: gas for cheap. PMID- 10151971 TI - Interior design. Mastering the master plan. AB - Reflecting on the results of the survey, this proposed interior design master planning process addresses the concerns and issues of both CEOs and facility managers in ways that focus on problem-solving strategies and methods. Use of the interior design master plan process further promotes the goals and outcomes expressed in the survey by both groups. These include enhanced facility image, the efficient selection of finishes and furnishings, continuity despite staff changes, and overall savings in both costs and time. The interior design master plan allows administrators and facility managers to anticipate changes resulting from the restructuring of health care delivery. The administrators and facility managers are then able to respond in ways that manage those changes in the flexible and cost-effective manner they are striving for. This framework permits staff members to concentrate their time and energy on the care of their patients- which is, after all, what it's all about. PMID- 10151972 TI - Who likes what in health care design? A survey of preferences. PMID- 10151973 TI - Fit to be cared for. PMID- 10151975 TI - 10 tips for construction cleanup before--and after. PMID- 10151974 TI - IPS (isolated power systems) still play an important role in safer patient care. PMID- 10151976 TI - The dirty dozen: those common mistakes made when managing. PMID- 10151977 TI - New design brings rays of light--and hope--to cancer patients. PMID- 10151978 TI - Future scope. Interview by Karen Sandrick. PMID- 10151979 TI - The top 10 trends in clinical engineering. PMID- 10151980 TI - Know how to manage your service contracts. PMID- 10151981 TI - Can purchasing alliances adapt? PMID- 10151983 TI - Interior design and artwork stimulate the five senses--sense-ability. PMID- 10151982 TI - The leaders of the new alliance created by the AmHS/Premier merger aim to capitalize on size and strengths. Interview by Mark Hagland. PMID- 10151984 TI - Beyond aesthetics--gearing artwork to patients. PMID- 10151985 TI - New OSHA rules allow more TB respirator choices. PMID- 10151986 TI - Floor bored: an old system may be right for your facility's floor. PMID- 10151987 TI - Empowering employees: 7 common mistakes. PMID- 10151988 TI - A growing credentialling burden. PMID- 10151989 TI - Enforcing noncompetition agreements after corporate reorganization. PMID- 10151990 TI - Hospitals frustrated by Owens' spotty distribution performance. PMID- 10151991 TI - Hip implant prices on way down. PMID- 10151992 TI - Consider costs vs. benefits before changing sterility policies. PMID- 10151993 TI - Hospitals feeling pinch of rising paper product prices. PMID- 10151994 TI - VHA establishes new committed purchasing program. PMID- 10151995 TI - New CLIA rule makes personnel and PPM changes. PMID- 10151996 TI - Clinical integration. PMID- 10151997 TI - Cancer care critical pathways: implementing a successful program. AB - Change in any form creates stress on systems, yet there is growing awareness within the health care field that change must come as cost-conscious insurers and employers refuse to pay for overextended processes that grew out of the charge based reimbursement era. Short-term solutions, such as discounted charges and staff cuts, are not the answer when the entire system needs an overhaul. The cost of care escalates and the quality of patient care suffers because the system lacks the appropriate mechanisms to reduce redundancy, eliminate waste, improve effectiveness, and provide the high-quality care that a community expects from its hospital. The outcomes-based critical pathway approach discussed here has been used with great success and differs from classic pathway writing in that only elements related to the specific outcome are allowed on the order set. The critical pathway process starts with a review of historical patient records, which yields information about both historical practice patterns and the provider team. Using this information, a work group is formed and patient goals or outcomes are established for the population in question. The entire system is informed and educated, with special attention given to the medical staff, clinical outcome and financial data are developed and provided to individuals in the process, and a feedback loop is established. Cancer care is an attractive target for critical pathways, because it is an area with high cost and expensive technology, and physician practice patterns and patient outcomes can vary widely. On the flip side, the historically multidisciplinary nature of cancer care offers a good starting point for the collaborative culture needed to successfully implement critical pathways. When done right, critical pathways can decrease morbidity and mortality, reduce redundancy and cost, increase patient satisfaction, and improve patient outcomes. Shifting practice and eliminating variation in practice patterns, without regard to best practices and outcomes, could leave an organization compromised by group norms. Few things will sustain the energy needed to keep the hospital culture moving forward. This is not to say that it cannot be done, because it can. The critical pathway process has noticeable energy cycle levels--periods of high energy and low energy. The two hospitals discussed here reveal their painstaking effort to maintain and invigorate a process that would rather wait another day. Carefully selected work group members, reminders to keep individuals from returning to old practice habits, and an established, firm connection between cost and quality will help carry an organization through periods of low energy.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10151998 TI - Up and down the decision tree. PMID- 10151999 TI - EMS equipment of the future. AB - Just Imagine ... NASA contracts you to design the next lunar module. Or General Motors solicits you to work on an entirely new approach to carrying luggage in cars that will come off the assembly line in the year 2020. You ask, what does this have to do with me? EMSAT, that's what. If you're involved in EMS, read on. It's your future. PMID- 10152000 TI - Shocking history: the first portable defibrillator. PMID- 10152001 TI - The streetcar of your dreams. PMID- 10152002 TI - 1995 Ambulance Manufacturers Directory. PMID- 10152003 TI - Health care reform the international way. PMID- 10152004 TI - Coordinated services for children's mental health: a process evaluation. AB - This article reports on a process evaluation of the Texas Children's Mental Health Plan, a statewide initiative to provide interagency coordinated mental health services to severely emotionally disturbed children and their families. Researchers followed the activities of the state management team and three local sites during the first year and a half of the project's implementation. This article delineates the major positive effects of the plan as well as the facilitating factors and barriers to the development of such an effort. PMID- 10152006 TI - Patients' rights advocacy: implications for program design and implementation. AB - Individuals held in mental health care facilities often have been deprived of their basic civil and legal rights. In Canada and the United States, legislation now exists to ensure the protection of these rights, and advocacy programs have been developed to apply and enforce this legislation. It is important for mental health professionals to be aware of the relevance and need for advocacy programs. Equally important is the appreciation of the structural issues involved in developing and administering advocacy programs. In examining a number of patients' rights advocacy programs, strengths, weaknesses, and general success factors are identified. Recommendations are then made for the development, implementation, and modification of advocacy programs. A review of this area indicates a need for empirical research in a number of areas, and directions for future research are discussed. PMID- 10152005 TI - A multivariate analysis of mental hospital recidivism. AB - This study identifies health problems, instrumental activities of daily living, employment status, and number of previous admissions as significant factors of recidivism to a mental health residential facility. The study, conducted over a 5 year period, includes measures on 32 predictor variables collected either on admission, on discharge, or 12-15 months following discharge or on readmission. The study's results are interpreted in light of current changes in the mental health service delivery system including the interactive role of physical and mental illnesses, expanding access to community-based generic services, focusing on functional skills and their development or remediation, and the changing criteria for measuring mental health effectiveness. PMID- 10152007 TI - Psychiatric hospital care and changes in insurance coverage strategies: a national study. AB - The 1975, 1980, and 1986 sample surveys from the National Institute of Mental Health were used to predict the type of inpatient psychiatric facility where people were admitted. Predictors used were demographics (age, gender, race, marital status, and education), psychiatric diagnosis, and insurance status (primary payment source). A discriminant analysis revealed that insurance status was the most important discriminator in predicting hospital type. State hospitals were more likely to care for patients with little or no resources, whereas private hospitals cared for patients with some form of insurance. The authors discuss the implications of insurance status and access to psychiatric treatment. PMID- 10152008 TI - Measures of impairment for children and adolescents. AB - Measuring the degree of impairment in children and adolescents due to emotional or behavioral disorders is a recent development that will become increasingly important to states and their mental health administrators. A survey of the 50 states was conducted to identify impairment measures that were used on a statewide basis. The results of the survey are presented; five measures were found to be used consistently. The three global measures and two multidimensional measures identified in the survey are reviewed here. Each measure is described and its pertinent psychometric data are presented. The implications for mental health administrators in terms of implementing statewide procedures to assess impairment are considered. PMID- 10152009 TI - Quality and customers: Type 2 change in mental health delivery within health care reform. AB - The traditional separation of mental health and medical programs is problematic because mental health issues are inseparable from the larger medical system. By contrast, a collaborative primary care model of mental health care, augmented and supported by secondary specialty mental health services, has the potential to optimize quality and cost goals while reinforcing health care reform principles. The flexibility of mental health treatment in this delivery structure provides opportunities to customize services according to patient and purchaser expectations. PMID- 10152011 TI - Maryland hospital uses team strategy to prepare for survey. PMID- 10152010 TI - Formula used to translate survey findings into performance report scores. PMID- 10152012 TI - The value of accreditation: on the other side of the ledger. PMID- 10152013 TI - Various sources for assessing competence exist. PMID- 10152014 TI - Comparative charts available to IMSystem participants. PMID- 10152015 TI - Teams formed in Accreditation Operations reorganization. PMID- 10152016 TI - External agencies playing role in primary source verification. PMID- 10152017 TI - Medical savings accounts: the antidote to managed care? PMID- 10152018 TI - We challenged a big insurer--and won. PMID- 10152019 TI - My "plain people" changed the way I practice. PMID- 10152020 TI - What you charge vs. what you're paid. PMID- 10152021 TI - Deselected doctors vs. the Blues: who really won? PMID- 10152022 TI - Is that difficult patient faking it? PMID- 10152023 TI - Hospitals downshift on doctor recruiting. PMID- 10152024 TI - Teaming up with employers against HMOs. PMID- 10152026 TI - What we do about unreasonable patients. PMID- 10152025 TI - What makes this practice everybody's darling? PMID- 10152027 TI - Are hospitals unreliable managed-care partners? PMID- 10152028 TI - Lawyers: the pain is just beginning. PMID- 10152029 TI - An HMO's happy surprise for its doctors. PMID- 10152030 TI - How big is doctors' prepaid income? PMID- 10152031 TI - When managed care takes over, watch out! PMID- 10152032 TI - Selling your practice? Avoid these tax traps. PMID- 10152033 TI - Does downsizing have to spell disaster? PMID- 10152034 TI - The commercialization of lab services ... or, make no mistake about it, lab testing is big business. PMID- 10152035 TI - Hemolysis meets QIP (quality improvement process). PMID- 10152036 TI - Managed care, Part 2. Dying for care: capitation and its discontents. PMID- 10152037 TI - A quality system for transfusion medicine ... and beyond. AB - When more than 500 serious blood banking problems arose in a recent 12-month period, the FDA and AABB knew it was time for a change. The quality system they developed can help the staff of any lab section stand up to the toughest inspection. PMID- 10152038 TI - Docs in late bid to avoid Medicare fee cutbacks. PMID- 10152039 TI - Wash. docs start statewide health plan. PMID- 10152040 TI - United, MetraHealth merger creates huge managed-care player. PMID- 10152041 TI - Ohio consolidation bridges Dayton-Cincinnati corridor. PMID- 10152042 TI - Tokos, Healthdyne agree to merge. PMID- 10152043 TI - Dems' Medicare plan resembles GOP's. PMID- 10152045 TI - New Chicago Catholic system makes leadership selections. PMID- 10152044 TI - GOP plans would boost for-profits' capital pay. PMID- 10152046 TI - Medicus product gets nod; company gets cold shoulder. PMID- 10152047 TI - Info groups question VHA plan to promote software. PMID- 10152048 TI - Feds fund new health technology. PMID- 10152049 TI - Tenet launches La. ad campaign. PMID- 10152050 TI - Groups in last-minute pitch for IDN legislation. PMID- 10152051 TI - Calif. jury hears latest assault on HMOs. PMID- 10152052 TI - Feds challenge Marshfield ruling. PMID- 10152053 TI - OrNda plans to sell 10 million shares. PMID- 10152054 TI - NCQA score system shows refinements. PMID- 10152055 TI - L.A. plan keeps clinics, health centers alive. PMID- 10152056 TI - Most Conn. insurers limit maternity stays to 24 hours. PMID- 10152058 TI - N.J. nurses unions team up to protect outpatient roles. PMID- 10152057 TI - Frustrated Calif. nurses leave ANA. PMID- 10152059 TI - Pennsylvania's war on property-tax exemptions escalates through suits. PMID- 10152060 TI - It's now or never for IRS to win new powers over not-for-profits. PMID- 10152061 TI - CEO profits as hospital changes status--again. PMID- 10152062 TI - AHA, MMI both win through sale. PMID- 10152063 TI - AHA's action limits members' access to financial information. PMID- 10152064 TI - Medicare supply fraud costing millions--GAO. PMID- 10152065 TI - REIT delays big investment in U.K. PMID- 10152066 TI - New Calif. health plan specializes in Medi-Cal. PMID- 10152067 TI - Providers say Senate's Medicaid plan will sting. PMID- 10152068 TI - PHOs fall short of expectations. Despite failings, networks may have role as a transition to vertical integration. AB - An estimated 3,000 physician-hospital organizations have formed since the early 1980s, most of them in the last two years. But their slow progress in managed care contracting has many wondering if they're anything more than an expensive fad. Proponents argue that despite their failings, PHOs may have a role as a transition to vertical integration. PMID- 10152069 TI - Columbia hospitals in Fla. want more. PMID- 10152070 TI - Columbia increases Chicago-area strength. PMID- 10152071 TI - Hospitals fear loss of drug discounts. PMID- 10152072 TI - Disaster drill becomes reality for Ga. hospital. PMID- 10152073 TI - Technology keeps food costs on diet. AB - In the past when a patient missed a meal at Good Samaritan Hospital in Cincinnati, nurses often had to interrupt their work and rush down to the kitchen for the tray. Now, the nurses can call the food service and request that SAM bring it up. Not quite R2D2, but versatile nonetheless, SAM is a cordless, programmable robotic courier that keeps going until its 24-volt batteries need recharging. PMID- 10152074 TI - A mixed diagnosis for California system. PMID- 10152075 TI - 'Flat tax' raises interesting questions. PMID- 10152076 TI - Most HMOs report modest earnings growth in 1994--study. PMID- 10152078 TI - HealthSouth to take lead in ambulatory sector. PMID- 10152077 TI - Patients over 50 often uninformed. PMID- 10152080 TI - Boston system links with 2 more doc groups. PMID- 10152079 TI - GOP picks up AMA support as Medicare plan advances. PMID- 10152081 TI - Former hospital execs indicted in Florida. PMID- 10152082 TI - Small firm stops three big contracts. PMID- 10152083 TI - Wisconsin printer, provider form unusual healthcare partnership. PMID- 10152084 TI - Full speed ahead with integration, for better or worse. PMID- 10152085 TI - AHA revenues down; profit, salaries up. PMID- 10152087 TI - Tenn. hospital settles patient 'dumping' case. PMID- 10152086 TI - Physician management firm in Fla. makes IPO. PMID- 10152088 TI - EFfort to drop Stark fraud, abuse rules makes Dems angry, providers happy. PMID- 10152089 TI - GOP governor opposition jeopardizes Senate plan. PMID- 10152090 TI - N.Y. court order bars Medicaid cost shifting. PMID- 10152091 TI - Tennessee system expands to compete with Columbia. PMID- 10152092 TI - Managed-care PACs follow voters' lead. PMID- 10152093 TI - Providers hope reforms fly by Byrd rule. PMID- 10152094 TI - Halfhearted fight could prove costly for hospitals. PMID- 10152095 TI - Labor looks to lead counter-revolution. AB - The withdrawal of the California Nurses Association from the American Nurses Association on Oct. 1 exposed the tensions in nursing. Should nurse organizations be primarily professional associations or collective-bargaining units? How should they address their employers and the public? Having reached different conclusions, the CNA and the ANA will go their separate ways. PMID- 10152096 TI - Alliance urges patient-oriented measures. PMID- 10152097 TI - Providers turning to taxable bonds. PMID- 10152099 TI - Hospital execs worried about future. PMID- 10152098 TI - Mont. hospitals pitch merger as a tax cut. PMID- 10152100 TI - Calif. hospital wins case against docs. PMID- 10152101 TI - Last-minute deals precede House passing Medicare bill. PMID- 10152102 TI - Hospital groups fight bad-debt reduction. PMID- 10152103 TI - GOP senators fight long-term-care plans. PMID- 10152104 TI - Court amends its opinion in Marshfield Clinic ruling. PMID- 10152105 TI - U. of Wis. drafting details of new authority. PMID- 10152106 TI - Ind. firm wins Peace Corps' first managed-care contract. PMID- 10152108 TI - Hospital mergers, acquisitions on rise. PMID- 10152107 TI - Kaiser puts technology project on hold. PMID- 10152109 TI - Partnership wins Univ. of Louisville Hospital contract. PMID- 10152110 TI - Hospital joins S.C. network after merger falls through. PMID- 10152111 TI - Columbia wades into Mass. conflict. PMID- 10152112 TI - L.A. County probes docs' moonlighting. PMID- 10152113 TI - Reforms spark debate over docs' power. PMID- 10152115 TI - Winning strategies in risk management. PMID- 10152114 TI - Not-for-profits stash the cash. AB - Like never before, not-for-profit hospitals are in the money. However, they expect their cash-rich positions will be battered by poorer government reimbursement, the demands of creating integrated systems, the growth of managed care and the Darwinian struggle for survival with investor-owned giants. PMID- 10152116 TI - HealthSouth makes another big deal. PMID- 10152117 TI - HMO acquisition in N.H. gets antitrust OK--with strings. PMID- 10152118 TI - Charter announces deal, name change. PMID- 10152120 TI - 2 AHA execs got full wages despite mid-year departures. PMID- 10152119 TI - HMO's lawsuit will test NCQA's growing clout. PMID- 10152121 TI - Data supports docs who gripe about pay squeeze. PMID- 10152122 TI - Milwaukee-based systems venturing farther from home. PMID- 10152123 TI - Senate makes concessions to win support for budget. PMID- 10152124 TI - AMA's Medicare deal with GOP may not be so sweet. PMID- 10152125 TI - CHS (Community Health Systems) earnings fall short of projections. PMID- 10152126 TI - Roanoke, Va., system to slash costs through big restructuring. PMID- 10152127 TI - Cerner stock split, earnings report cause slump in price. PMID- 10152128 TI - Colo. hospitals readying Medicaid HMO. PMID- 10152130 TI - Consumers rank good service first. PMID- 10152129 TI - Columbia expands its Fla. power base. PMID- 10152131 TI - Small for-profit chain seeks Catholic group's blessing. PMID- 10152132 TI - Catholic mergers affect women's services. PMID- 10152133 TI - Mo. settlement leaves rivals unconvinced. PMID- 10152134 TI - Senate votes against changes in standards for nursing homes. PMID- 10152135 TI - Hill-Rom won't face charges it blocked probe. PMID- 10152136 TI - New AFL-CIO chief targets healthcare. PMID- 10152137 TI - Unlicensed Md. doc under probe. PMID- 10152138 TI - HCFA makes concession on 'Stark I' exemptions. PMID- 10152139 TI - Judge sides with nurses in labor dispute. PMID- 10152140 TI - Calif. nurses lose court decision on hospital's gag rule. PMID- 10152141 TI - Doc/clown says laughter is best medicine. PMID- 10152142 TI - Blow of Medicaid cuts eased by late deals. PMID- 10152143 TI - Total Renal Care plans stock offering. PMID- 10152144 TI - Cleveland Clinic, drug company team up. PMID- 10152145 TI - Rise in expenses main factor in K.C.-area's profit decline. PMID- 10152146 TI - Wall Street questions new networks. PMID- 10152147 TI - HMOs move east. AB - California HMOs, experts in squeezing costs out of the healthcare system by slashing hospital utilization and placing more physicians at risk, are looking for new lands to conquer. Leading the trend are four big HMOs that have been on an expansion binge east of the Sierras in the past several years. Foundation Health Corp., FHP International Corp., PacifiCare Health Systems and Health Systems International have moved aggressively beyond California's borders, adding hundreds of thousands of new enrollees. PMID- 10152148 TI - Closed Fla. hospital in eye of the storm. PMID- 10152149 TI - Groups cope with addicted doc problem. PMID- 10152150 TI - Catholic systems opt to switch rather than fight. PMID- 10152151 TI - New types of fraud may be side effect of capitation. PMID- 10152152 TI - Credit card firms charge into healthcare. PMID- 10152153 TI - Two-hospital-town mergers win a round. PMID- 10152154 TI - 3-way, $4 billion Catholic merger moving forward. PMID- 10152155 TI - IRS ruling offers guidance on hospital cooperatives. PMID- 10152156 TI - N.Y. state hospitals going private. PMID- 10152157 TI - Allina enters another Mayo market. PMID- 10152158 TI - Georgia Blues plans to restructure into for-profit company. PMID- 10152159 TI - Providers push federal network rules. PMID- 10152160 TI - FEMA to let L.A. decide how to spend federal relief funds. PMID- 10152161 TI - Art sale may be next for CompCare. PMID- 10152162 TI - Meeting with AHA leaves N.Y. executives unhappy. PMID- 10152163 TI - Vatican allows Columbia, CSA to complete deal. PMID- 10152164 TI - VHA joins effort to aid for-profit conversions. PMID- 10152165 TI - Designs for age of cost control. This year's Design Awards Competition winners find that aesthetics can help the bottom line. AB - Should healthcare architecture emphasize aesthetics or solutions to problems? This question sums up the discussion of judges for Modern Healthcare's 10th annual Design Awards Competition. Judging by the award winners, cost pressures and increasing competition in the healthcare industry seem to be making both design aesthetics and functionality more important. PMID- 10152166 TI - AHA phasing out departments to fund membership initiative. PMID- 10152167 TI - FTC move gives CMA 'green light' for HMO. PMID- 10152168 TI - Joint marketing a solution for restructuring systems. PMID- 10152169 TI - Frail Pa. system fights to survive. PMID- 10152170 TI - VHA program lets members redeem equity for services. PMID- 10152171 TI - Mo. hospitals blend services after ruling. PMID- 10152172 TI - UniHealth execs outsource themselves. PMID- 10152173 TI - Red Cross touts its broad restructuring. PMID- 10152175 TI - Doc practice buys are risky--Moody's. PMID- 10152174 TI - Colo. hospital, clinic get OK to divvy patients. PMID- 10152176 TI - Hospital in Quorum deal. PMID- 10152177 TI - Columbia pulls ads from Fla. paper. PMID- 10152178 TI - Columbia's acquisition strategy on track. PMID- 10152179 TI - Health plan pay among key hurdles. PMID- 10152180 TI - Champion's earnings fall as it buys more hospitals. PMID- 10152181 TI - CPC psych chief quits; operations face revamp. PMID- 10152182 TI - J&J's purchase of Cordis to provide marketing edge. PMID- 10152183 TI - Sun subsidiary settles labor dispute in Conn. PMID- 10152184 TI - St. Luke's plans new K.C. hospital. PMID- 10152185 TI - Specialty hospitals' reliance on government funds disputed by study. PMID- 10152186 TI - Wary GOP legislators ready deal on provider-sponsored networks. PMID- 10152187 TI - Catholics urge hospitals to stay not-for-profit. PMID- 10152188 TI - IRS ruling a doc primer on networks. PMID- 10152189 TI - Report shows how far HHC has to go in restructuring. PMID- 10152190 TI - Texas tort reform to roll back premiums. PMID- 10152191 TI - Group pushes data reporting in Mich. PMID- 10152192 TI - Groups support PPS for skilled-nursing care. PMID- 10152193 TI - VHA restructures to boost integration. PMID- 10152194 TI - Harry and Louise would like GOP bill. PMID- 10152195 TI - Day of the per diem. AB - While the concept of capitation is getting a lot of press, it's the older and less-well-known term "per diem" tht's the order of the day for hospitals in managed care. The truth is that capitation is still a reimbursement myth for hospitals. Learning the ins and outs of per diems will be key for executives. PMID- 10152196 TI - Alliances begin replacing supplier bidding with more efficient systems. PMID- 10152198 TI - Doc groups differ on antitrust reforms. PMID- 10152197 TI - Charter Medical invests in managed-care strategy. PMID- 10152199 TI - Study highlights 'urgency' for change. PMID- 10152200 TI - Govs back current nursing home regs. PMID- 10152201 TI - Best practices for reducing accounts receivable days. AB - This survey suggests that healthcare organizations of any size, whether for profit or not-for-profit, can attain superior performance in their gross revenue holding in Medical Records. The directors who participated in the survey have demonstrated that they have overcome the performance barriers cited most often. If no standards currently exist regarding DNFB for the Medical Records departments, directors should establish aggressive standards that compare to those of better performers. Directors should have a standard of four to five days or fewer of gross revenue in AR holding in Medical Records. The standard for outpatient accounts should be to code all accounts within the bill hold timeframe. Every one-day reduction equates to a one-day improvement in the time that a bill can be billed and potentially collected. A healthcare organization's financial performance indicators, including days of revenue in accounts receivable and cash collected as a percentage of net revenue, will be improved as a result. PMID- 10152202 TI - The ascendancy of primary care: permanent or temporary? AB - The conventional wisdom strongly suggests a health care provider food chain for the future: Primary care physicians (PCPs), principally family practitioners, on the top playing the lead role, distantly followed by specialists, with hospitals and other ancillary services even further down the line. Is this a reasonable expectation? Will PCPs dominate the new systems? Or will they be but one of many equally necessary components of these developing integrated health care delivery organizations? Looking at the various models now developing, it would seem that future integrated delivery systems will utilize both PCPs and specialists, but with strong augmentation from a diverse assortment of other health care professionals, including nonphysician providers, educators, and administrators. To separate the illusion of primary care dominance of the coming health care system from the likely reality, we should first determine what is driving the apparent present demand for primary care physicians. Next, we will examine the possible and probable reactions to that demand from an economic standpoint and from the points of view of both health care professionals and the public. Finally, we must try to picture how health care provider organizations of the future are likely to look and how they will integrate their health care professionals. PMID- 10152203 TI - New market forces are special challenge to academic health centers. AB - New market forces--insurer integration into the provider business, "mega-mergers, price and premium reductions, a scramble to create specialty carve-out networks, and the like--have emerged that are placing significant pressure on academic medical centers. All of these forces are accelerating the pace of managed care market maturation. In order to effectively compete in this new marketplace, academic health centers have substantial barriers to overcome. To do so will require the creation of a system to manage the health care of populations while minimizing system costs and maximizing quality. This will require the establishment of a unified medical center approach to markets and value management. Academic health centers will by necessity develop strategies to include strong primary care-based network affiliations in order to accomplish these tasks. PMID- 10152204 TI - PAs/NPs: forging effective partnerships in managed care systems. AB - Three issues have dominated national health policy discussions over the past three decades--how to control health expenditures, how to improve access to care, and how to ensure delivery of high-quality health services. Cost remains the principal societal concern today. An important new dimension in this debate, however, is a critical examination of the impact of the structure of the nation's health workforce on health expenditures. Within this examination, policy makers are giving specific attention to the supply of health professionals, the role of primary care, and the identification of the most appropriate professionals to deliver primary care. In particular, a renewed interest is being shown in the potential of physician assistants (PAs) and nurse practitioners (NPs) to address all three issues. This article will examine the factors that prompted this focus on health workforce issues and the implications of the use of PAs and NPs for the structure and management of the health workforce in the future. PMID- 10152205 TI - Super doc and real health reform. AB - A large array of social, economic, and professional issues will have to be confronted and resolved before primary care physicians can take their logical place as leaders in the health care delivery system. Linkages will have to be forged between primary care physicians and specialists and between primary care physicians and nonphysician providers of primary care. Key to successful resolution of the current dilemma is ensuring that primary care physicians are compensated at a fair level for their skills. It is the disparity in physician incomes that lies at the heart of the problem, according to the author. PMID- 10152206 TI - Quantification of quality: a commentary. AB - The literature is replete with theoretical discussions of medical quality management, particularly of the measurement of quality in the health care setting. While there is a growing body of knowledge on both quality and its measurement, this author questions whether medical quality can ever be quantified. He says that the concept of quality is still a moving target, so that the value of attempts at quantification can only be short-lived. PMID- 10152207 TI - Cost-effective rehabilitation: Part 1--Basic principles. AB - Patients may be referred for rehabilitation services with a variety of diagnoses, including stroke, spinal cord injury, brain injury, multiple trauma, orthopedic disorders, arthritis, multiple medical problems, and chronic pain. The goals and endpoints for treatment of these conditions are often unclear. The principles that are described in this article provide a structure for creating efficient and effective rehabilitation treatment plans. These principles can also focus the utilization and peer review processes and can assist in determining medical necessity of rehabilitation services. Part one of this two-part article discusses general principles of cost-effective rehabilitation. Part two, in the December 1995 issue, will focus on individual patient management issues. PMID- 10152208 TI - The politics of mean. AB - Since mid-1990, there have been many signs that politics--especially relationships between middle management and the troops--have changed from annoying but rarely lethal to Mean, as in ornery, ugly, and sometimes downright grisly. Part of this has to be recession-related, but part comes from top management's attention having been diverted to survival issues. The loser has been the individual contributor in the organization. In laying out the reasons for this distressing turn of events, the author provides clear-cut advice on how to overcome it. PMID- 10152209 TI - Provider profiling: advancing to episodes of care. AB - Judging by the interest expressed by managed care organizations, provider profiling has arrived. Surveys indicate that most organizations have adopted, or plan to adopt in the near future, a means to describe provider practice patterns. A further vote of confidence came from providers: In 1994, the American College of Physicians, the largest national specialty organization, issued a position paper supporting provider profiling and questioning the value of other approaches to utilization management, such as preauthorization of individual services. Also, an article and an editorial in the New England Journal of Medicine cautiously supported the concept of profiling. Provider profiling has great promise as a means to promote cost-effective care without the limitations of case-by-case preauthorization. The combination of a sophisticated episode of care methodology and a set of validated practice benchmarks offers the opportunity to perform true clinical profiling and to supply providers with data to review and alter practice patterns. PMID- 10152210 TI - A rational approach to career change. AB - Recently, the number of physicians who have been interested in alternative careers has vastly increased. Many physicians express dissatisfaction with clinical practice, but they are uncertain about which nonclinical options are appropriate for them. Pursuing a different career after many years of studying and practicing medicine can seem like an overwhelming task. In this article, the author briefly outlines a decision-making process that can be used in analyzing career options and suggests some careers that have provided challenging opportunities for physicians. PMID- 10152211 TI - Physician profiling: trends and implications. AB - Every professional is subject to profiling, and most are profiled more rigorously, more thoroughly, and more dispassionately than are physicians. Profiling occurs when society has the technologies and the economic incentives to perform profiling. In the first of this two-part article, we will consider trends in profiling all professionals and those in profiling physicians. We conclude in the second part of the article with a discussion of the specific methodologies and vendors used in profiling the practice habits of physicians. PMID- 10152212 TI - Primary care: the driver in health care reform. AB - The changes occurring in the health care industry have resulted in a cost-quality competition that has not been present in the past. Because of this competition, managed care is a growing way of financing and providing health care to the people of the United States. Managed care depends heavily on competent primary care physicians. Because primary care physicians are in short supply, the status and financial rewards of primary care practice are increasing. The primary care physician will be the dominant force in medical practice in the immediate future. He or she is capable in a managed setting of resolving the perceived problems of the health care industry in responding to the drivers of health care reform. Costs are reduced while quality is maintained. Access to health care is improved, and fragmentation of health care is significantly lessened. PMID- 10152213 TI - From managing access to managing care: the impact of primary care on health care delivery organizations. AB - Professional "revenge of the nerds" is currently taking place, as managed care evolves generalist physicians into new professional prominence. Primary care physicians are finding themselves at the center of health care market reform as health plans, insurers, and other financing organizations turn to them as the key to cost control. In short supply, they are prospering financially from the demand. As the source of patients, they are gaining in prestige from specialists and hospitals who once demeaned them. But these newfound roles are only the initial steps in the transformation of the primary care practitioner. The change that the generalists are experiencing is essentially managing access to care, not truly managing care itself. There are large and crucial differences between managing access to care and actually managing care. These differences are, in many ways, a higher calling for primary care practitioners as they refocus attention on patient outcomes, which will in itself result in a lower resource utilization above and beyond the crude controlling of access. What those differences are, what new roles they require, and what impact they will have on organizations that either house or contract with primary care physicians will be the focus of this article. PMID- 10152214 TI - Caught in the middle of cultural diversity. PMID- 10152215 TI - Ethics cultivated, not legislated. PMID- 10152216 TI - Giving people a choice in dying. PMID- 10152217 TI - Physician agreements in long term care. PMID- 10152218 TI - Much ado about Medicare. PMID- 10152219 TI - Financing for senior housing improves. PMID- 10152220 TI - Subacute opens arms to home care. PMID- 10152221 TI - Aging in place fuels growth in assisted living. PMID- 10152222 TI - Coming home to assisted living. Desire for homelike care drives growth. PMID- 10152223 TI - Regulations in the assisted living community. States seem willing to adapt rules. PMID- 10152224 TI - The time is now. An assisted living primer for keeping a full house. PMID- 10152225 TI - Working out for assisted living. Cross training benefits smaller facilities. PMID- 10152226 TI - Scaling the quality heights. Portraits in total quality management. PMID- 10152227 TI - Problems persist with enforcement rule. Surveys find most facilities out of compliance as moratorium ends. PMID- 10152228 TI - Subacute's place in the capitated scene. PMID- 10152229 TI - Negotiated risk--an operational issue. PMID- 10152230 TI - Redesign emphasizes homelike environment. A new look for nursing facilities. PMID- 10152231 TI - Customer satisfaction--key to quality. Survey measures what's important to customers. PMID- 10152232 TI - 1995 Volunteer of the Year Awards. AHCA honors three. PMID- 10152233 TI - Guilt: a hidden problem in caregiving. PMID- 10152234 TI - Redefining quality in assisted living. PMID- 10152235 TI - Consensus Conference III: Assessing innovations in mechanical ventilatory support. Conference held January 13-15, 1995 in Ixtapa, Mexico. PMID- 10152237 TI - Mechanical ventilation innovations: the manufacturer's perspective. AB - Manufacturers develop products that fit the corporate vision and maximize their return on investment. The expense and time required by the FDA regulatory approval process have a negative impact on product innovation. I propose the following approach: Reduce the amount of documentation required for a PMA or 510(k). Reduce approval times through cooperative interaction among manufacturers, clinicians, and the FDA throughout the product-development process. Allow independent agencies to provide product approvals. Efficacy assessment guidelines should be a function of the level of risk and the claims made for the marked device. PMID- 10152236 TI - Current limitations of mechanical ventilation: what improvements should the clinician expect? PMID- 10152238 TI - Introducing new mechanical ventilation technology: the hospital perspective. AB - The introduction of innovative mechanical ventilation technology requires a careful assessment of the cost-benefit relationship of the new technology. Justification for purchase can be sometimes be made on the basis of improved patient safety and physiologic response. Improved patient outcome is much more difficult to demonstrate. It is clear in today's health-care environment that outcome-based research is needed before new technology is introduced to the marketplace, if that new technology is to become part of the average community hospital complement of mechanical ventilators. PMID- 10152239 TI - FDA: the regulatory process. PMID- 10152240 TI - Case studies on mechanical ventilator innovations: perspectives of two clinicians. PMID- 10152241 TI - Efficacy assessment criteria based on risk and cost. PMID- 10152242 TI - Using physiologic end points to assess innovations in mechanical ventilation. AB - It is our view that new ventilatory methods should be withheld from clinical practice until there has been adequate evaluation of their effect on physiologic variables and the link to long-term outcomes has been established. In the past, premature and over-enthusiastic acceptance of ventilatory strategies may have resulted in patient discomfort and even harm, and this can be minimized by a more careful evaluation of the physiologic effects of such innovations before their acceptance into clinical practice. PMID- 10152243 TI - Clinical outcome end points and assessment of mechanical ventilation innovations. PMID- 10152244 TI - Study design: statistical and methodologic considerations. PMID- 10152245 TI - Resources for assessing innovations in mechanical ventilatory support: the missing link. PMID- 10152246 TI - 1994 Certified First Assistant job analysis. PMID- 10152247 TI - Open minds resurrect closed hospital. PMID- 10152248 TI - They ride horses, don't they? A lesson in strategic choices. PMID- 10152249 TI - 20 questions. Interviewing your next CEO. PMID- 10152250 TI - If it ain't broke, don't fix it! PMID- 10152251 TI - A clean slate. Disney's celebration of a healthy community. PMID- 10152252 TI - Trustee Workbook 4. Board composition and trustee selection. PMID- 10152253 TI - Tension between trustees: can they build true system boards? PMID- 10152254 TI - Experts take the sting out of the CEO search. PMID- 10152255 TI - Why aren't CEO salaries going down? PMID- 10152256 TI - The best CEOs make their money the old-fashioned way. PMID- 10152257 TI - What to ask before a merger. PMID- 10152258 TI - A step ahead. Cleveland's Fairhill Center offers the elderly one-stop health services--and a new attitude toward aging. PMID- 10152259 TI - Tax exempt! Many nonprofits look and act like normal companies--running businesses,making money. So why aren't they paying Uncle Sam? PMID- 10152260 TI - An invaluable inventory control tool. Usage spreading for automated ID systems. PMID- 10152261 TI - Galactography--the under-utilized procedure. AB - The patient-centered breast center should be utilizing a team approach, with technologists, radiologists, surgeons, pathologists, oncologists, therapists, etc. all working together to provide accurate, efficient and compassionate service to the patient. Patient intake questionnaires should include appropriate questions regarding nipple discharge. Members of the team such as secretaries and technologists need to be attuned to the significance of the patients complaints. We must keep utmost in our minds the many concerns of the patient. The comprehensive breast center should be a place where the patient can get answers. The Radiologist Breast Professional should be willing and able to ensure that they are provided. Galactography is one of the many ways that role can be fulfilled. PMID- 10152262 TI - Rethinking breast care delivery. PMID- 10152263 TI - The radiologist as clinician. PMID- 10152264 TI - Oncology information management. PMID- 10152265 TI - The cancer carve-out. PMID- 10152266 TI - Patient centered care in radiation treatment. PMID- 10152267 TI - ICD-9 V codes. PMID- 10152268 TI - Measuring productivity in health care. PMID- 10152269 TI - Characteristics of women treated for cervical cancer at Westmead Hospital. Implications for hospital and community-based health services. AB - This study was conducted to assess the sociodemographic and histopathological characteristics of women presenting to Westmead Hospital with cervical cancer, and to assess the previous opportunities for Pap smear screening and prevention of this disease. This retrospective review of medical records was carried out in the Department of Gynaecological Oncology at Westmead Hospital, New South Wales, using the medical records of the first 33 women with cervical cancer referred to the newly enhanced Department of Gynaecological Oncology between March and June 1994. Twenty-three (70 per cent) presented with early-stage disease. Interpreters were required for five (16 per cent) patients. Only six women (18 per cent) had been screened for cervical cancer within the last two years and 14 (42 per cent) had never been screened. Many of these women had been attending general practitioners for the management of chronic medical conditions and two had undergone major cardiac surgery at Westmead within the previous two years. There are likely to be new and continuing demands for comprehensive health services for these women, including the use of medical facilities, interpreter services and complex psychosexual counselling. Further, lost opportunities to prevent cervical cancer warrant further study. PMID- 10152270 TI - Diagnosing idiopathic dystonia: must it take so long? AB - Idiopathic dystonia is a chronic, disabling movement disorder. This study attempted to verify anecdotal evidence that sufferers experience delay in achieving a correct diagnosis. A survey of 133 patients revealed that diagnosis after first seeking help required a mean of 3.8 years. Diagnostic latency varied considerably, with 22 per cent of respondents reporting a diagnostic latency of more than five years, while a further 22 per cent reported a latency of one month or less, with a sample median of 1.5 years. Respondents consulted a mean of 8.3 practitioners, including a mean of 2.1 general practitioners and 1.6 neurologists. Results were consistent with reports of lengthy diagnostic delays and inappropriate referrals. Greater awareness of dystonia and referral of suspected cases to a neurologist interested in movement disorders are recommended. PMID- 10152271 TI - Inequalities in the health of Australian children. PMID- 10152272 TI - Australia's mothers and babies. PMID- 10152273 TI - Designing a funding system for rehabilitation services. Part 1: Rationale and recent developments. AB - Part 1 of this paper presents a critical review of several aspects of risk sharing in rehabilitation that need to be taken into account in designing a funding system. It argues the case for the development of a new rehabilitation payment system separate from both the acute care casemix system and funding arrangements for long-term residential care. The paper then outlines a number of recent developments in the United States and in Australia that draw attention to the need for such a separate system, and details the current provisions for funding rehabilitation in Victoria. An analysis of existing rehabilitation classification systems is given to set the scene for proposing further developments, which are taken up in part 2 of the paper (to be published in the next issue of Australian Health Review). PMID- 10152275 TI - Values and value--a vision for the Australian health care system. AB - The Australian health care system is at a crossroads. Status quo is not a sustainable option for the future. Rising consumption, spiralling costs, the decline of private health insurance and a public sector 'bursting at the seams' threaten our traditional values of a universal, affordable, accessible, equitable, high-quality system. As a result, we believe that major reform of the health care system is both necessary and inevitable in order to ensure that the values of the system are maintained and to extract maximum value from limited health resources. In this article we lay out our vision for the Australian health care system. It is a vision characterised by transformational change--shifting of risk from patients and taxpayers to providers, downsizing of acute care capacity, integration of services across the system, rationalisation of State and Federal responsibilities and a 'shakeout' of providers and insurers resulting from intensified, but bounded, competition. We believe that the direction for health care players needs to be clarified so that, as a country, we can continue to have a best practice model of health care delivery. We present this vision as a 'stake in the ground' to set parameters around which this debate can emerge. It may be provocative and challenging, but it is our vision into the future. PMID- 10152274 TI - Tourist health services at tropical island resorts. AB - An unfamiliar holiday environment may give rise to a range of common and unique medical conditions and injuries. Based on a six-month retrospective analysis of clinic records, the present study reports a detailed profile of health services provided for guests at three tropical island tourist resorts. A total of 1183 clinic visits were analysed; 735 (62 per cent) concerned medical conditions, while 448 (38 per cent) were related to injuries. The most common medical conditions treated were respiratory, digestive, skin problems, eye disorders, and genito-urinary complaints. Injuries included lacerations, bites and stings, sprains and fractures. Health services consisted mainly of medication, specialist nursing care and first aid. Study findings highlight the advantages of using an internationally accepted classification system for primary health research, and the critical role of the nurse in tourist health services. PMID- 10152276 TI - Hospital characteristics associated with unplanned readmissions. AB - The rate of unplanned readmission of patients to hospitals has been introduced into the Australian Council on Healthcare Standards accreditation program as an internal flag of problems in patient management and outcome. An emphasis, in the indicator definition, is placed on the unexpected nature of the admissions to exclude those which are unplanned but simply due to progression of a disease, and are therefore not 'unexpected'. The association of hospital characteristics with unplanned readmissions was examined using logistic regression on the data collected from hospitals surveyed in 1993. The risk of unplanned readmission was significantly higher in public hospitals than in private hospitals. Hospital bed size also reflected differences in the risk of unplanned readmission, being significantly higher for hospitals with over 200 beds than for those with 1-100 beds. In rural areas, the risk of unplanned readmission was significantly lower in hospitals with 101-200 beds and over 200 beds compared to hospitals with 1-100 beds (p for trend = .004). However, in metropolitan areas, the risk of unplanned readmission increased with the size of the hospitals (p for trend < .0001). Monitoring of unplanned readmissions prompted internal clinical review and action in 31 per cent of hospitals, demonstrating the indicator's usefulness as an internal quality tool. However, the use of unplanned readmissions as an external performance measure must take into account a hospital's characteristics and will remain of limited value in the absence of clinical information about the expected or unexpected nature of the readmissions. PMID- 10152278 TI - Putting the horse before the cart. PMID- 10152277 TI - Effective hospital leadership for quality: theory and practice. AB - Hospitals need excellent leadership to be efficient in the use of scarce stakeholder resources and to be effective in the competitive provision of services to multiple customers. This study was conducted with the cooperation of the executive team at a large government-funded hospital in Brisbane. It focused on understanding the conceptual models of leadership held by members of the executive and comparing this model with an externally derived model of leadership. Performance on the local model was estimated by cross-linking performance assessment on the external model. Members of the executive espoused, and were also rated by others in the hospital as practising, to a moderate degree, a transformational style of leadership. An overall evaluation of quality practice in the hospital revealed the use of data, the understanding of processes and the formation of supplier partnerships as the areas of hospital activity most limiting the ability to improve. The implications of the conceptual model and performance levels are discussed in relation to the introduction of quality management practice in the hospital, and in terms of management development. A complementary paper focusing on quality implementation as perceived at different staff levels in the hospital is in preparation. PMID- 10152279 TI - Information security: how safe is your system? PMID- 10152280 TI - Looking it up in real time. PMID- 10152281 TI - "Best-of-breed" vs. monolithic solutions. Roundtable discussion. AB - The debate is hotter now than it was when we alluded to it in our June issue's "round table." CIOs and IS directors still wonder about the strategic advantages of single-vendor solutions vs. the best-of-breed approach. In June we noted that this dynamic has driven system acquisitions for several years. Since then we have witnessed what amounts to a feeding frenzy. We asked a few experts to discuss their perceptions of the controversy. Their comments follow. PMID- 10152282 TI - Integrated delivery systems: virtuality becomes reality. PMID- 10152283 TI - America's Best Networked Healthcare Organizations Hall of Fame. PMID- 10152284 TI - Client/server technology: the agony & the ecstasy. Who's serving whom? PMID- 10152285 TI - Client/server technology: the agony & the ecstasy. Lessons learned from a pioneer. PMID- 10152286 TI - Cabling into the future. PMID- 10152287 TI - The telemedicine revolution hits home. PMID- 10152288 TI - Wireless phones give nurses more time with patients. PMID- 10152289 TI - Thriving in today's healthcare environment. PMID- 10152290 TI - Connecting with the community. Implementing Senate Bill 697. PMID- 10152291 TI - Leveraging data to more effectively treat patients. PMID- 10152292 TI - PHOs undergo new level of antitrust scrutiny. PMID- 10152293 TI - Leaders rely on insight and values to survive changing health care environment. PMID- 10152294 TI - Handling of transplant cases criticized. AB - Two separate transplant programs came under fire in recent months--one for betraying the public's trust, the other for denying a transplant for a Downs syndrome patient, as the following articles describe. PMID- 10152295 TI - Managed care woes accumulate. AB - Pity the poor managed care organization. Try to help the country save a few bucks, while making a few for yourself, and the whole country--well, at least mothers, emergency room patients, and physician groups--turns against you as the following articles show. PMID- 10152296 TI - Social responsibility model proposed for organizational ethics. PMID- 10152297 TI - Ohio patients go public to raise funds for services. PMID- 10152298 TI - Debates over assisted dying continue to spread. PMID- 10152300 TI - Telemedicine and telecare: an assessment. PMID- 10152299 TI - HCFA issues final rule for PSDA (Patient Self-Determination Act of 1990). PMID- 10152301 TI - The role of the consultant in telemedicine. PMID- 10152302 TI - Nursing and telemedicine: merging the expertise into 'telenursing'. PMID- 10152303 TI - Defining a structure for delivery of telemedical services. PMID- 10152304 TI - Memo from the future: telemedicine in Iowa. PMID- 10152305 TI - Telemedicine and the law. PMID- 10152306 TI - Case study: telemedicine trial and applications development. PMID- 10152307 TI - Telecommunications in telemedicine. PMID- 10152308 TI - The new role for telecommunications: support of the institution's business strategy. PMID- 10152309 TI - Telecare as a vehicle on the information superhighway. PMID- 10152310 TI - Case study. Fresno's Community Hospitals of Central California lays off everybody but the CEO, rehires most in new jobs. PMID- 10152311 TI - Putting your money where your future is. PMID- 10152312 TI - The challenges posed by managed care. PMID- 10152313 TI - Developing an effective integrated delivery system requires more than collaboration. PMID- 10152314 TI - Developing and operating a self-funded provider network. PMID- 10152315 TI - Quality care ... good prices! Please define! PMID- 10152316 TI - Increasing the role of managed care in long-term care. PMID- 10152317 TI - Case management: today and the future. PMID- 10152318 TI - Sharing a vision for empowered patients and healthier communities. PMID- 10152319 TI - Is managed care synonymous with less care? PMID- 10152321 TI - Legal issues facing the managed care attorney. PMID- 10152320 TI - The first steps taken: awareness of the need and establishment of fellowships. PMID- 10152322 TI - Medicare home health agency trends: an opportunity for disease state management programs? PMID- 10152323 TI - The business case for quality improvement. PMID- 10152324 TI - A prescription for survival. PMID- 10152325 TI - Integrating disease state management and pharmaceutical care for cost-effective quality care. PMID- 10152326 TI - Considerations in a highly competitive environment. PMID- 10152327 TI - Benefits management in the 21st century. PMID- 10152328 TI - An industry in evolution. PMID- 10152329 TI - The state of the art in clinical quality management. PMID- 10152330 TI - The state of utilization management. PMID- 10152331 TI - Managed care and the information systems challenge. PMID- 10152332 TI - Medicare risk: what's around the corner? PMID- 10152333 TI - Medicaid managed care: an update. PMID- 10152334 TI - Provider-sponsored networks: another option for Medicare. PMID- 10152335 TI - Beware your HMO. PMID- 10152336 TI - Can HIV-negative plaintiffs recover emotional distress damages for their fear of AIDS? PMID- 10152337 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); expanded active duty dependents dental benefit plan--DoD. Final rule. AB - The rule establishes an expanded dental program for dependents of active duty members of the Uniformed Services. The amendment specifically describes: the legislative authority for expansion of dental benefits outside the United States; the continuation of dental benefits for active duty survivors; eligibility for pre-adoptive wards; the enhanced benefit structure; enrollment and eligibility requirements; premium cost-sharing; and benefit payment levels. The provisions of this rule will provide military families with the high quality of care they desire at an affordable price. PMID- 10152338 TI - Purchasing of services contracting: a symbiosis of voluntary organizations, government, and clients. AB - In the last twenty years, the phenomenon of government contracting with nonprofit human service organizations to deliver welfare services has intensified. This phenomenon, also known as privatization or purchase of services, is intriguing for welfare as well as nonprofit scholars. Using the functional-structuralist approach, the author explores analytically the mutual benefits as well as risks involved in contracting. He reviews four theoretical approaches regarding the evolution and function of voluntary organizations and how they and the public authorities divide the provision of welfare services. He discusses what each party gains, how each party takes advantage of this arrangement, and how these relationships affect services and clients. This article is based on personal experience in the U.S.A. and Israel as well as the literature from other countries including many European countries. Finally, he proposes that the framework presented in this article guide a cross-national, empirical analysis of the relationships between nonprofits and governments in welfare provision and its consequences. PMID- 10152339 TI - The evaluation of a burnout workshop for community nurses. AB - This study evaluates the effects of a burnout workshop that was conducted for community nurses (N = 64). The workshop included relaxation training, didactic and cognitive stress management, interpersonal skills training, and the enhancement of a more realistic professional role. The nurses' symptom levels (i.e., emotional exhaustion, tedium, psychological strain, and somatic complaints decreased significantly. However no significant changes were observed in the attitudinal component of burnout: the nurses' negative attitudes toward their recipients (depersonalization) and toward their performance on the job (reduced personal accomplishment) did not decrease. In addition, personality (i.e., the nurses' level of reactivity) played a moderating role: low reactive nurses who, by definition, are rather resistant to stress benefited more from the workshop than did high reactive nurses who are less resistant to stress. Since no control group was included, the results of this study are tentative and should be confirmed by future research. PMID- 10152340 TI - Burnout and health care utilization. AB - This study explores the relationship between burnout and health care utilization of 238 employed adults. Burnout was measured by the Maslach Burnout Inventory and health care utilization by insurance company records regarding these employees' health care costs and number of times they accessed health care services over a one year period. ANOVAs were conducted using Golembiewski and Munzenrider's approach to define the burnout phase. Significant differences in health care costs were found. PMID- 10152342 TI - House & Senate GOP proposals for restructuring Medicare. PMID- 10152341 TI - A comparative study of entrepreneurs and managers: stress, burnout, locus of control, and social support. AB - This study investigated the relationships of job stress to job burnout, of locus of control and social support to stress and burnout, and the moderating effects of locus of control and social support on the stress-burnout relationship. These relationships were tested with questionnaire data collected from a random sample of entrepreneurs (N = 238) and managers (N = 288). Results showed that entrepreneurs reported that they had higher internal locus of control, received less social support, and had less job burnout than managers. Hierarchical regression analyses found support for eight of the ten main effects and one of the four moderating effects. PMID- 10152344 TI - U.S. health care in transition: reforming America's health system. Analysis, reactions, alternatives. PMID- 10152343 TI - The Clinton health care reform proposal: efficiency, fairness, and the role of government. AB - In a detailed evaluation of the Clinton reform proposal, this article deals with the many thorny yet pragmatic problems concerning the proper role of government in reforming the health care system. Areas of focus include mandatory coverage, information networks, market failure, and the ability of government-controlled systems to produce efficiency and fairness for the health care consumer. It is the author's opinion that the plan needs to be resubmitted with substantial revisions. PMID- 10152345 TI - Commentary on the Clinton health care plan. AB - The best that can be said for the plan is that it provides a roadmap for dialogue, and the worst that can be said is that it is a prescription for disaster, states this article. The author's major concern is that the Clinton plan would take away from consumers choice and control over their own health care. He fears that patient health care decisions will be placed in the hands of government-appointed boards, employers, or regional health alliances. What we don't need, claims the author, is a plan that creates more bureaucracies, more paperwork, global budgets, and control over the use and development of drugs and technology. PMID- 10152346 TI - Quality assessment and health care reform: the view from the Joint Commission. AB - There has been considerable discussion on the best way not only to maintain current levels of quality but to improve them. The Joint Commission on Accreditation of Healthcare Organizations is uniquely qualified to speak on these issues, since it evaluates and accredits more than 9,000 health care organizations, including 80% of American hospitals. The author presents the criteria for measuring and monitoring health care standards and performance quality, and cautions that any meaningful evaluation process must not only address each facility, but must also evaluate it in the context of the national network as a whole. PMID- 10152347 TI - Core values in health care reform: a communitarian approach. AB - Controlling health care costs should allow the nation to provide more health services and higher quality care to more people. The authors are concerned, however, that many of the reform efforts will unwittingly undermine the culture of care in their pursuit of savings and access. This article is a plea to maintain the core moral values and the social and institutional commitments that are essential in the delivery of care, so that the health care community is not turned into a health industry. The authors' communitarian approach aims to preserve the balance between individual rights and social responsibilities, the moral integrity of a caring society, and the unique character of mutual trust between patients and health care personnel. They advocate an orientation toward preventing disease and promoting health, an imperative of reforming the violent, reckless, and costly aspects of American society, and a moral justification for cutting administrative waste, defensive medicine, and excessive profits rather than rationing beneficial and humane health services. PMID- 10152348 TI - The Health Security Act and academic medicine. AB - The mission of academic medicine is the production and dissemination of new and useful medical knowledge, and the education and training of practitioners. The authors' position is that the Clinton reform proposal is likely to interfere with the mission of academic medicine in ways that may lead to higher cost and lower quality of health care. It is the authors' opinion that the pressing moral problem of the uninsured and the undertreated can be solved without sacrificing the diversity, creativity, and excellence of American medicine. The most significant improvements in quality of care and reductions in costs of health care delivery arise from scientific discoveries and innovations in practice, and not from direct government control of prices or attempted regulation of quality. PMID- 10152350 TI - Health care reform and the urban crisis. AB - As designed, the Health Security Act will be dysfunctional to those in greatest need, as the majority of the population residing in the 20th Congressional District in Texas. These have limited education, work for low wages, and live in a general state of high poverty. The author identifies specific concerns regarding the adequacy of Clinton's proposal in meeting the needs of that population, and provides a supportive analysis for McDermott's "American Health Security Act," and the possible effect that its single-payer concept may have on the people in the border state of Texas. PMID- 10152349 TI - Refocusing health care management: education and training for national health reform. AB - Today's health care professionals must deal with problems of financial viability, competitiveness, quality control, and consumer focus. The major theme of this article is how appropriate is the education system that trains and prepares health care managers for these challenges. Because we are not in the health care business, but rather in the business of managing health care, the authors suggest that a new educational paradigm that incorporates indepth study of business disciplines be the health administration educational model for the 21st century. Whether or not the proposed model is alien to our basic traditional concepts of health care management, the viability of our institutions will be at stake if they do not implement a healthy business protocol to the services they provide. PMID- 10152351 TI - Implications of health reform for urban America: a case study approach. AB - The major components of the Clinton health plan need to be examined from the point of view of their effect on access and delivery of health care services for minorities in the urban environment. Through the case analysis method, the authors address the important question of whether any adopted health care reform would, over the long run, extend the length and quality of life of urban populations. Universal health coverage is not sufficient, argue the authors. Health issues related to violence in the urban environment, unemployment, educational deficits, and the availability of health professionals for underserved populations in urban areas must be given utmost priority. PMID- 10152352 TI - Managing rural health care reform. AB - Rural health care requires a response system that is unique and substantially different from other, more traditional systems of health care delivery. Any reform of the present rural health care system must offer services that include the public health sector as well as other aspects of the social "safety net." The authors present a vivid picture of the multiple realities operating in the rural environment, and they explore the opportunity for the creation of Accountable Health Plans suitable for the rural health care delivery mechanism. PMID- 10152353 TI - Health care reform and the pharmaceutical industry. AB - Consumer choice among competing private plans should be strengthened, rather than lending support to the mandate for a government single-payer plan. A major theme running through this position paper is that drugs are not only the most cost effective form of medical treatment, but they represent only a small share of the national health care expenditures. In this article, the author focuses on defending three guiding principles for reform: (1) all Americans should have prescription-drug coverage; (2) competition can and must be relied on to control costs; and (3) the discovery of new cures must be actively encouraged through adequate incentives for the pharmaceutical industry. PMID- 10152354 TI - Health care reform: the case for a primary care imperative. AB - One of the major goals of health reform is assuring financial access to a basic benefits package for all U.S. citizens, while maintaining better health at a contained rate of growth in costs. In questioning the ability of the Clinton Health Security Act to achieve this goal, the article presents a rationale for the consideration of those aspects of organizational reform that are necessary to achieve a primary care orientation that would meet such a goal. The author cautions that reform proposals that focus primarily on the financing of services are unlikely to influence the organizational reorientation from a specialty focus to a primary care imperative. PMID- 10152355 TI - President Clinton's Health Security Act: a financial perspective. AB - The loftiness of President Clinton's goals may not survive the devil in the details, suggests the author of this article, who identifies four fundamental flaws in the Health Security Act of 1993. First, the act does not link the benefit package of coverage offered to all Americans with the funding available from employers or government to pay for these benefits; second, the act does not provide incentives for consumers to use health resources wisely; third, the act relies too much on government regulation; and fourth, the act provides few incentives for medical research, new drugs, and improved technology. PMID- 10152356 TI - Choosing among health plans. AB - The health care reform system that is ultimately adopted, suggest the authors of this analysis, should rely on market forces, rather than government regulation, to reduce cost and improve quality in our health care delivery. A major portion of this paper compares the Health Security act (the Clinton proposal), the American Health Security Act (the McDermott bill), the Health Equity and Access Reform Today, HEART (the Chafee proposal), and the Managed Competition Act (the Cooper bill). The article focuses on the major areas of difference between these alternative proposals in the extent to which they would achieve true market-based reform, small group reform, universal coverage, and financing mechanisms. PMID- 10152357 TI - U.S. health care in transition: a response to the Health Security Act of 1993. AB - Although the President and Mrs. Clinton are to be commended for their courage and commitment in bringing the issue of health care reform to the forefront of national concern, their proposal has "too much regulation and too much government." The author fears that the plan will not work due to its emphasis on global budgeting, price controls, and the regulatory nature of the regional health alliances. He advocates a reform system based on the American values of innovation, entrepreneurship, and the spirit of free enterprise. PMID- 10152358 TI - Prescription for health care reform. AB - In a concise critical look at Clinton's proposal the author provides direction signs, caveats, and guiding principles for a durable reform. In opposing the Oregon health care system as discriminatory, the author cautions against rationing as a means of reducing health care costs. PMID- 10152359 TI - Hawaii's health care system: imparting ideas for reform. AB - The state of Hawaii has implemented a health care system that offers high quality, cost-effective care to all of its citizens. This article provides an analysis of each of the six basic principles of the Clinton Administration's proposals and how these principles are used in Hawaii's health care system. A key question posed by the authors is whether, and to what extent, Hawaii's success with its health care delivery model can be packaged and applied to other parts of the nation. PMID- 10152360 TI - Comprehensive health care reform: an imperative. AB - A public relations marketing strategy is essential to the consensus building for the enactment of health care reform legislation. As Governor of Kentucky, the author reflects on the complex legislative experience that he went through in his state, while attempting to enact a health care reform bill similar to President Clinton's proposal. This article draws the parallel in the politics of health reform between the political reality of an individual state, as compared to the one operating on the national scene. PMID- 10152361 TI - Key challenges posed by the Clinton health care reform proposal. AB - President Clinton's proposal assumes that the bureaucratic, regulatory, informational, and financial demands it places on the health care system may be feasibly met. The authors refute these assumptions and argue that the proposal restricts individual freedom while it requires less individual responsibility. They also challenge the lack of incentives for cost-conscious purchasing of health care and for taking greater responsibility for individual well-being and societal health. The article recommends that behavior that drives up the cost of health care for individuals and society should be strongly discouraged through disincentives. PMID- 10152362 TI - The Health Security Act and improving the quality of care: will the Clinton reforms help or hinder? AB - Maintaining and improving the quality of care is central to the Health Security Act, according to this in-depth analysis of the Act's intended quality reforms. The author reviews the proposal from several perspectives, including those of administrative law, hospital administration, health services research, and risk management. In the author's opinion, quality reforms involving the federal government as purchaser of medical care and as grader of the quality of its health care providers require close scrutiny. The establishment of a National Health Board and a National Quality Management Council further heightens concerns for quality standards and oversight. The article also evaluates the proposed health quality data super-highway, making several stops for contemplation and critical analysis. PMID- 10152363 TI - Fla.'s Morton Plant, Mease Health share services, savings. PMID- 10152364 TI - Employers find Minneapolis model could mean big savings for Baltimore. PMID- 10152365 TI - Decentralization, physician buy-in key to IDS success, expert says. PMID- 10152366 TI - IDSs asking suppliers to share financial risks, survey shows. PMID- 10152368 TI - Johns Hopkins teams with six Md. hospitals to form Baltimore system. PMID- 10152367 TI - Mass. AG to take sharp look at Columbia's MetroWest deal. PMID- 10152369 TI - Minn. hospital bets home care will cut outpatient surgery LOS. PMID- 10152370 TI - Bankers Trust to offer smaller providers receivables financing. PMID- 10152371 TI - FTC unveils plans for wider antitrust cooperation with state agencies. PMID- 10152372 TI - Virginia Mason, Group Health Cooperative talk total integration. PMID- 10152374 TI - Hospitals turning to primary care to spearhead ambulatory care push. PMID- 10152373 TI - Seattle system sells group practice to further integration. PMID- 10152375 TI - Hospitals admire one MCO type, contract with another, survey says. PMID- 10152376 TI - Study casts doubt on gains being made by restructuring systems. PMID- 10152377 TI - UCLA strengthens physician links to prepare for capitation. PMID- 10152378 TI - 'Messenger model' go-between too involved, FTC warns Nev. providers. PMID- 10152379 TI - DOJ's Medicare hospital billing crackdown moves into three states. PMID- 10152381 TI - Pa. Blue Cross links payer, delivery roles with care centers. PMID- 10152380 TI - Risk-sharing PHOs escaping state regulators' scrutiny, study says. PMID- 10152382 TI - Fla. facility uses telephone outreach to boost market share. PMID- 10152383 TI - AAMC center to give teaching hospitals managed care edge. PMID- 10152384 TI - Are IDSs paying too much for PCPs? Look again, expert survey says. PMID- 10152385 TI - Ohio Blues implements APG system for outpatient payment. PMID- 10152386 TI - 'Model' rural IDS suffers $49M legal hit in battle with Blues. PMID- 10152387 TI - Minn. state-sanctioned provider co-ops offer model for rural IDS. PMID- 10152388 TI - D.C. providers fear public hospital problems could speed consolidation. PMID- 10152390 TI - Physician network uses capitation, withholds to earn FTC okay. PMID- 10152389 TI - Teaching hospital demo moves away from resident-oriented care. PMID- 10152391 TI - Calif. hospital thrives in indigent area with community outreach program. PMID- 10152393 TI - Top health systems can't gauge how improvement efforts affect quality. PMID- 10152392 TI - AmeriCares links urban Conn. clinic for indigent to doctors, hospital. PMID- 10152394 TI - N.M. health system reworks guidelines to save millions. PMID- 10152395 TI - AmHs, Express Scripts plan partnership to build joint formularies. PMID- 10152396 TI - N.C. providers rush to hop on managed care bandwagon. PMID- 10152397 TI - Most PHOs still show low enrollment, too many physicians, survey finds. PMID- 10152398 TI - VHA group beats Columbia/HCA, Tenn. Blues to state network punch. PMID- 10152399 TI - Partnership can smooth hospitals' path to subacute care success. PMID- 10152400 TI - HCFA vows crackdown on hospital taxes inflating feds' Medicaid burden. PMID- 10152401 TI - Special report. Managers jumping into new healthcare models to survive hospital industry downsizing. AB - The rise of managed care and risk-sharing reimbursement have hospitals shedding personnel and banding together with other providers to protect margins in the face of plummeting occupancy rates. Those forces are taking their toll on the middle levels of hospitals' administrative structures. For many hospital managers, integration and reform promise uncertainty and unemployment. How can hospitals cushion the painful blow to mid-level management? And where do managers look when restructuring leaves them out of a job? Early communication and strong support structures are crucial to easing an organization through a difficult downsizing, one hospital found. For downsizing's management casualties, industry changes are creating opportunities outside the traditional hospital management structure, executive employment experts say. PMID- 10152402 TI - 'Academy' aligns training with hospital's restructuring goals. PMID- 10152403 TI - Old cost accounting systems won't survive capitation, experts warn. PMID- 10152404 TI - ER-coordinated home care can save hospitals expensive inpatient costs. PMID- 10152405 TI - MCOs tell Johns Hopkins to bundle prices or lose business. PMID- 10152406 TI - Not-for-profit hospitals unprepared for sharper tax scrutiny, study finds. PMID- 10152407 TI - Columbia/HCA, Medical University of S.C. happiest of odd couples. PMID- 10152408 TI - Tampa Bay hospitals keep healthcare local with managed care network. PMID- 10152410 TI - Calif. could be tough market nut to crack for Columbia/HCA. PMID- 10152409 TI - Re-engineering leaps beyond downsizing, TQM, expert says. PMID- 10152411 TI - Hospitals posting profits on Medicare, ProPAC tells Congress. PMID- 10152412 TI - Mayo Clinic contract could spur change in Phoenix provider market. PMID- 10152413 TI - Columbia/HCA dragged into fight over Orlando hospital ownership. PMID- 10152414 TI - Pa. employers building provider networks around state reports. PMID- 10152415 TI - Mo. network integrates structural, clinical systems. PMID- 10152416 TI - MSU program to train doctors, nurses in ways of managed care. PMID- 10152417 TI - Training hospital R.N.s in home care streamlines processes, ups income. PMID- 10152418 TI - Stockholder expectations should temper aggressive strategic planning. AB - Too often, healthcare organizations make strategic plans with performance targets that don't justify the company's stock price. The result: They never really know if those plans will create value--even if they are fully achieved. In the race to provide superior returns to shareholders, companies must instead keep one eye on the competitive marketplace and the other on equity market expectations. In this article, Wayne Lowell, CFO of PacifiCare Health System, explains how his organization learned to do just that. PMID- 10152419 TI - N.J. hospitals say state demands for 'efficiency' are unfair--and unreal. PMID- 10152420 TI - To remain players, teaching hospitals must sell vision, heed the market. PMID- 10152421 TI - IRS, in crackdown on physician recruiting, issues guidelines. PMID- 10152422 TI - Case study. Stanford restructures to beat the teaching hospital blues. PMID- 10152423 TI - Prospecting for primary-care docs? Foreign medical grads can ease the search. PMID- 10152424 TI - Factors to consider when scouting for IMGs (international medical graduates). PMID- 10152425 TI - Networks need not build a physician comp program entirely from scratch. PMID- 10152426 TI - Telemedicine begins to make its case. PMID- 10152427 TI - NLRB rule making. The impact of regulatory reform on hospital unionization. AB - Many hospital executives feared that the National Labor Relations Board's 1991 decision to recognize eight hospital employee bargaining units would lead to increased union activity. However, this study shows that union activity actually decreased after that decision. PMID- 10152428 TI - The hospital revolution. Community relations. AB - As hospitals try to make sense of the constant changes occurring around them, they often look to the past and discover strong roots in their communities. Rebuilding strong hospital-community ties may help hospitals maintain their tax exempt status, provide services to underserved community members, and lower community healthcare costs. PMID- 10152429 TI - Strategic planning/management by objectives. A boon for healthcare administrators. AB - The means of delivering effective, efficient healthcare are undergoing rapid change. Hospitals, clinics, and all organizations must react to change to meet the needs of their clientele and to survive. This article demonstrates how strategic planning can contribute to that end. PMID- 10152430 TI - Help wanted. Nurse or health educator? AB - Although health education may be considered a component of nursing, trained professionals exist whose sole focus is health education. For optimal results, these health education specialists, not nurses, are the ones hospitals and healthcare organizations should seek out when staffing their departments of health education. PMID- 10152431 TI - The Malcolm Baldrige National Quality Award for healthcare organizations. PMID- 10152432 TI - The death of line management in a self-complicating society. PMID- 10152433 TI - Medicare and Medicaid statistical supplement, 1995. U.S. Department of Health and Human Services, Health Care Financing Administration. PMID- 10152434 TI - What's your hospital's image? PMID- 10152435 TI - Texas physicians: THA report reveals information helpful to hospitals. PMID- 10152436 TI - Quality: national cooperative project focuses on cardiovascular care. PMID- 10152437 TI - Disease management. Panacea or placebo? PMID- 10152438 TI - Managed Care. Atlantic crossing. PMID- 10152439 TI - Evidence-based medicine. Facing the facts. PMID- 10152440 TI - Care pathways. On the right path. PMID- 10152441 TI - Pay. Join the club. PMID- 10152442 TI - Careers profile. Human resources expedient moves. PMID- 10152443 TI - Radiology & imaging technology: every challenge an opportunity. PMID- 10152444 TI - Factors affecting film-screen mammographic image quality. AB - This paper discusses the technical aspects of mammographic image quality and the factors that affect it. Emphasis is placed on the role of the service professional and the challenges he or she faces as a result of implementation of the Mammography Quality Standards Act of 1992 (MQSA). The passage of the MQSA represented the first attempt to legislate diagnostic image quality. Such legislation will only succeed, however, if all members of the mammographic imaging team fully understand the factors that affect image quality, the role that each member plays in assuring image quality, and the mandates of the MQSA. PMID- 10152445 TI - Focus on: ORBIS International Flying Eye Hospital, Department of Technical Services. AB - The ORBIS International Flying Eye Hospital is dedicated to restoring sight to the blind through medical education programs in developing countries. The modification of a DC-10 aircraft to house a teaching hospital for ophthalmic surgery involved a variety of engineering challenges to satisfy standards for both hospital and aircraft safety. The Technical Services Department maintains all medical equipment on the aircraft, encountering situations not found in traditional clinical engineering departments. Technical education is also an important part of the ORBIS biomedical engineering program. Future plans include expansion of existing technical training efforts, as well as using technology to improve the medical education program as a whole. PMID- 10152446 TI - Advancing biomedical engineering in developing nations: Project HOPE and the potential impact of nongovernmental organizations. AB - Nongovernmental organizations (NGOs) have played a major role in the diffusion of biomedical engineering training to developing nations. This paper reviews the roles and unique attributes of NGOs in biomedical engineering training programs. The activities of one leading NGO in this field, Project HOPE, are discussed with examples drawn from around the world. Future challenges to biomedical engineering in the developing world, and the potential of NGOs to provide a response to these needs, are considered. PMID- 10152448 TI - Developing technology planning teams. PMID- 10152449 TI - Variations in the treatment of heart attack. PMID- 10152447 TI - Airborne transmission of respiratory diseases. AB - In surveys during the past decade, CEs and BMETs have reported an increasing frequency of respiratory illnesses they believed to be acquired as a result of their occupation. These illnesses varied from mild to severe in terms of long term prognosis. With the increasing numbers of cases of drug-resistant organisms, respiratory infections are a growing concern for healthcare workers, employers, and government officials. Armed with a better knowledge base about symptoms, transmission and prevention, CEs and BMETs will be more aware of potential biohazardous situations and the necessary personal protective measures to be employed. Both the Occupational Safety and Health Administration (OSHA) and the Centers for Disease Control and Prevention (CDCP) have issued guidelines for preventing airborne transmission of infectious diseases. This paper addresses the respiratory illnesses reported by CEs and BMETs as occupational concerns, as well as briefly discussing potential epidemic pulmonary conditions. PMID- 10152450 TI - The strategic roles of technology. PMID- 10152451 TI - Pursuing payment under the Medicare as secondary payer statute. PMID- 10152452 TI - From hospital cafeteria to courtyard cafe ... Poudre Valley Hospital. PMID- 10152453 TI - AIDS, Judaism, and the limits of the secular society. PMID- 10152454 TI - Can a healer be too wounded to heal? PMID- 10152456 TI - A primer on capitation: another step in managed care. PMID- 10152455 TI - The reign of autonomy: is the end in sight? PMID- 10152457 TI - Sterilization or disinfection: that is the question. PMID- 10152458 TI - The GOP cause steps forward. Medicare cuts advance, but veto battles loom. PMID- 10152459 TI - Copper systems in health care premises. PMID- 10152461 TI - Continuing professional development and the Institute (Institute of Hospital Engineering). PMID- 10152460 TI - Alternative materials for domestic water services installations. PMID- 10152462 TI - The way forward in facilities management. PMID- 10152463 TI - Listening to latex. PMID- 10152464 TI - Your emergency. PMID- 10152465 TI - The rewards of risk. AB - The capitation contracting revolution isn't affecting only the provider-insurer relationship. Hospitals are now passing risk further down the purchasing chain to their suppliers of medical products. PMID- 10152466 TI - Orion--shaping a new accreditation process. AB - In January, the Joint Commission on Accreditation of Healthcare Organizations announced an Action Plan in response to criticisms leveled by the American Hospital Association. A key element of the plan is the Orion Project. Already in the planning stages, it was designed to test various accreditation process improvements. Here, two of JCAHO's leaders describe what Orion is and how it will work. PMID- 10152467 TI - Storm warning. Insurance regulation. AB - Pressure is mounting on state insurance commissioners to treat provider-run health networks like insurers. Like a distant tropical depression, this potential threat to collaborative networks hasn't shown up on the radar screens of most hospitals. But it will. Put on your galoshes. PMID- 10152469 TI - Health systems under the microscope. PMID- 10152468 TI - Thinking small. PMID- 10152470 TI - An outside job. AB - Would you turn the management of clinical assets over to an outside company? More and more hospitals are doing it. Here, two executives from a Bellevue WA hospital explain how "outsourcing" is working for them. PMID- 10152471 TI - You have not yet begun to integrate. PMID- 10152472 TI - Data. National health expenditure. PMID- 10152473 TI - Health care information services in Ireland. AB - Against a background of fundamental change in the Irish health care environment, a research project was commissioned to determine the information needs of all health care practitioners (including physicians, allied health professionals, managers, scientists, and technicians) as well as the public, patients, and their caregivers. The research, including a study of international best practice, revealed serious deficiencies in access, awareness, and availability of information for both staff and patients in Ireland. Recommendations include the establishment of a panel to develop a comprehensive national health information strategy and plan to coordinate the future development of health sciences information services. PMID- 10152474 TI - Information in general medical practice: a qualitative approach. AB - The aims of the study reported here were to describe the information-related behavior of general medical practitioners, to study information communication in general practices, and to establish guidelines for good practice. General practitioners (GPs) were interviewed, and information and communication audits also involving other staff at the practices were undertaken. The main reasons why GPs needed information were for patient care, managing the practice, legal and ethical matters, and teaching trainee GPs. Most practices had problems with internal and external communication and the storage and retrieval of information. The main conclusion is that practices need to have an information strategy that considers human, manual, and computer aspects of information handling. PMID- 10152475 TI - A new method for studying patient information needs and information-seeking patterns. AB - Studies on information needs and information-seeking patterns of patients focus on people who seek information and rarely attempt to explain the behavior of people who do not want information. Strategies for coping with stress may yield insight into information-seeking patterns. A study of information preferences of women with multiple sclerosis was based on a theory of information seeking that states that "monitors" cope by actively seeking information, whereas "blunters" reject information. Results revealed that both monitors and blunters wanted information but differed in what they wanted and when they wanted it. This study contributes to the development of a methodology for studying information-seeking patterns. PMID- 10152476 TI - Information requirements underlying medical decision making in the diagnosis and early management of spontaneous subarachnoid hemorrhage. AB - The research reported here investigated an area in which improved information would significantly enhance decision making focusing upon the diagnosis and management of spontaneous subarachnoid hemorrhage (SAH). The incidence of SAH is low, but morbidity and mortality are high. Furthermore, nonspecialists acting as gatekeepers to specialist care may not possess the required knowledge base and diagnostic skills to make reasonable decisions. The information used by experts was evaluated and an expert consensus established. An analysis of nonspecialist decision making was then completed, and finally the expert consensus was utilized to identify both the information deficits and the training requirements of nonspecialists. PMID- 10152477 TI - Modeling shared health and social care information. AB - The article describes an analysis of the detailed data used by different groups of health care professionals and their requirements to share data as part of an integrated information systems design project. This systematic recording of their data usage and sharing requirements led to the development of a novel analysis technique: the complex object grid. The use of the complex object grid facilitates the description of information usage and needs at several levels of detail. PMID- 10152478 TI - Management of information: analysis of the Joint Commission's standards for information management. AB - In the 1994 Accreditation Manual for Hospitals, the Joint Commission on Accreditation of Healthcare Organizations published ten standards relating to the management of information. Using Andrew Abbott's systems theory of professions, the article compares the views of information management that were prevalent in hospitals before the publication of the standards with the view of information management represented by the new standards. Five characteristics of the standards are discussed: conceptual view of information management, tension between the unity and diversity of information management activity, lack of specificity about who performs information management activities, separation of professional qualifications from functions, and privileging of information systems concepts and vocabulary. The unfamiliarity of the standards and their inherent ambiquities will give rise to many attempts to interpret their meaning and intent. Five interpretive themes that may arise from the characteristics of the standards are identified: unified diversity in information management, unity in information management, diversity in information management, monotheistic view of information, and information management czar. The future of information management in hospitals will be affected by the jockeying over the interpretation and implementation of the Joint Commission's standards. PMID- 10152479 TI - Education review: a computer-assisted instructional tool to assist students in developing an epidemiological research proposal. AB - The development of an epidemiological research proposal can be a difficult assignment for junior health information management students. The article demonstrates how a computer-assisted instructional (CAI) tool was developed to assist students in the development of an epidemiological research proposal. Surveys were conducted to determine where students were having the most problems, information about writing a research proposal was gathered and organized into an appropriate format, appropriate software (Hypercard) was chosen, the final CAI tool (the Research and Grant Writer) was developed, and positive feedback was obtained from junior health information management students using the CAI tool. PMID- 10152480 TI - Commentary: confidentiality of patient information--challenges and opportunities for physicians in using the computerized medical record. PMID- 10152481 TI - The new Stark regulations. PMID- 10152482 TI - Cost-containment in cardiovascular surgery through collaborative practice. AB - There is fierce competition in the healthcare setting to reduce costs and charges while maintaining a viable business. It is not unusual for many hospitals in the same city to offer cardiovascular surgery programs. In an effort to facilitate the achievement of cost-effective, quality outcomes, one hospital instituted a case-management model. PMID- 10152483 TI - Computerization helps healthcare industry increase efficiency. PMID- 10152484 TI - Primary-care doctors lured, and integrated delivery systems surge. AB - Respondents of this survey revealed that hospitals as critical pieces of IDSs have declined, while primary-care centers have skyrocketed. According to a spokesperson from the company that conducted the survey, "Healthcare organizations may be well on their way toward forming IDSs and turning family physicians into gatekeepers, but, in many ways, they're still novices when it comes to using capitation and compensation as tools to control costs." PMID- 10152485 TI - Elder care. Beyond retirement. PMID- 10152486 TI - 'Stakes are even higher'. AB - While Congress continues to debate how and where to slice more than $450 billion out of the future growth of the federal Medicare/Medicaid programs, the American Hospital Association is in the midst of an aggressive advocacy campaign intended to minimize the impact on America's hospitals and health systems. In an exclusive interview with the editors of Georgia Hospitals TODAY, American Hospital Association President Richard Davidson outlined AHA's efforts and goals during the legislative process and stressed the need for all hospitals to be involved in educating their legislative representatives. PMID- 10152487 TI - Health reform proposals: Stark's all-payer fraud bill. PMID- 10152488 TI - Creative chef brightens Arizona Care Center. PMID- 10152489 TI - Arizona hospital targets acute care geriatric population. PMID- 10152490 TI - Steel can recycling: how to cut costs and support the environment. AB - This is the first in a series of three articles regarding steel can recycling from foodservice operations of healthcare facilities. This article highlights the benefits of recycling and how steel is recycled across the country; the second will focus on the basic methods of recycling steel cans, and will include information on conducting a waste audit and negotiating with a hauler; the final article will convey a case history of actual foodservice recycling practice from a healthcare facility. PMID- 10152491 TI - Satelliting: one kitchen, less waste. PMID- 10152492 TI - Efficient kitchen design: the flexible cooking wall. PMID- 10152493 TI - Food safety. Overcoming HACCP (hazard analysis at critical control points) hassles. PMID- 10152494 TI - Praising Arizona. AB - Out west in the Grand Canyon State, Arizona has accomplished what many health care experts said was impossible. The state has slashed the costs of long-term care for the elderly and the disabled, the most expensive part of its medicaid program, and improved the quality of care. PMID- 10152495 TI - Case study. The little HMO that could: heart of America HMO in Rugby, North Dakota. AB - What does an HMO need to succeed in rural America? For this 3,000-member health plan, the key ingredients are enlightened self-interest by a committed medical group, support from local employers, low overhead, efficient practice styles, and luck in the form of benevolent state insurance rules. But a catastrophic illness almost doomed the plan in 1992 and convinced leaders of the need to grow. PMID- 10152496 TI - Can freestanding hospitals survive amidst market consolidation? Denver may tell. AB - Rapid growth of managed care in Denver has provoked equally rapid consolidation of hospitals into four large systems with 53 percent of the market. But two large hospitals hope to retain their autonomy through an alliance and physician ties. HSL analyzes the latest trends in the mile-high city. PMID- 10152497 TI - Rehabilitation services in an integrated delivery system. AB - For rehabilitation providers, managed care means cutting costs 20 percent to 40 percent and responding to a major shift from acute inpatient rehabilitation to subacute, outpatient, and home-based services. By becoming more efficient and joining integrated networks, rehabilitation providers can participate in the continuum of care and align their economic incentives with other providers and HMOs. But in this month's Director's Notebook, rehabilitation leaders also worry that the shorter lengths of stay they must impose could compromise patient recovery. PMID- 10152498 TI - Reengineering governance to make mergers work. AB - Mergers are designed to trim excess capacity, but they can't if powerful local boards thwart restructuring efforts. UniHealth discovered that the hard way when local trustees stalled efforts to close a hospital; investment bankers told the system to clean up its board act. HSL examines how UniHealth, BJC, Lifespan and others are reshaping governance to act in their system's best interests. PMID- 10152499 TI - Physician partners. AB - One plan's innovative approach to networks allows independent physicians to form their own practice partnerships--paying off in satisfaction and quality care. PMID- 10152500 TI - The ABCs of health awareness. PMID- 10152501 TI - Insurance market reform: what's ahead? PMID- 10152502 TI - Teaching the art of primary care. PMID- 10152503 TI - The best of both worlds. AB - Integrating the medical component of workers comp with group health benefits results in better medical outcomes and higher worker productivity. Here's how HMOs are leading the way in this emerging approach to occupational health care. PMID- 10152504 TI - Health care legislation: the outlook for 1995. AB - With Republicans now in charge of Congress, the federal health care debate is sure to shift focus. Here's a look at "incremental" proposals that could surface- and the potential impact on health plans' ability to provide high quality, cost effective care. PMID- 10152505 TI - HMOs: more to come. PMID- 10152506 TI - Measuring up to HEDIS. PMID- 10152508 TI - HMOs continue to change the health care marketplace. PMID- 10152507 TI - How patients judge physician quality. PMID- 10152509 TI - Meeting the needs of large employers. PMID- 10152510 TI - Michigan network beats the primary care odds with hustle and aggressive recruitment. PMID- 10152511 TI - PHOs of the future must evolve and diversify--or perish. PMID- 10152512 TI - Bridging the gullies on the road to full integration. PMID- 10152513 TI - Academic medical center sees strength in its array of relationships with MDs. PMID- 10152514 TI - Critical values and sound economics. PMID- 10152515 TI - Living the questions: our destiny today. PMID- 10152516 TI - The challenges of mission integration. PMID- 10152517 TI - Lessons from Europe on the funding of healthcare. PMID- 10152518 TI - The dilemma of managing value. AB - "Value" is an elusive term, but talk of how to manage value raises the specter of chaos. Value is defined as a working equation involving appropriateness of care, quality of outcomes and service, and cost. One hypothesis is that purchasers and providers will ultimately recognize that the value of health care services provided is critical because value, properly managed, directly addresses the volatile issue of containing health care costs. But to achieve success in managing value, providers must initiate new strategies and transform organizational and clinical priorities and practices. As the contest intensifies between society's infinite demand for health care services and finite resources, the need to truly subscribe to the management of value will become ever more important. Those providing care will learn to appreciate that long-term success will depend on much more than mere cost cutting. PMID- 10152519 TI - The threat of time. PMID- 10152520 TI - The transformation journey to value in health care. PMID- 10152521 TI - Value management: an incremental approach. PMID- 10152522 TI - MCOs appreciate hospitals that put a premium on credentialing. PMID- 10152523 TI - 9 techniques for better background checks. Investigate beyond the medical degree. PMID- 10152524 TI - Quality data give hospitals edge in MCO contracting. PMID- 10152525 TI - Performance measures required, but which ones? Joint Commission flexible on chosen measures. PMID- 10152526 TI - Using Quick Response to manage the material flow. AB - The long-awaited "paperless society" now truly appears to be within our grasp. Quick Response will reduce the mounds of paper on which we depend and minimise the time and expense needed to satisfy customers' demands/requirements. Quick Response will accomplish this while keeping inventory level at a minimum. Quick Response will significantly increase the bottom line. PMID- 10152527 TI - The road to business process improvement--can you get there from here? AB - Historically, "improvements" within the organization have been frequently attained through automation by building and installing computer systems. Material requirements planning (MRP), manufacturing resource planning II (MRP II), just-in time (JIT), computer aided design (CAD), computer aided manufacturing (CAM), electronic data interchange (EDI), and various other TLAs (three-letter acronyms) have been used as the methods to attain business objectives. But most companies have found that installing computer software, cleaning up their data, and providing every employee with training on how to best use the systems have not resulted in the level of business improvements needed. The software systems have simply made management around the problems easier but did little to solve the basic problems. The missing element in the efforts to improve the performance of the organization has been a shift in focus from individual department improvements to cross-organizational business process improvements. This article describes how the Electric Boat Division of General Dynamics Corporation, in conjunction with the Data Systems Division, moved its focus from one of vertical organizational processes to horizontal business processes. In other words, how we got rid of the dinosaurs. PMID- 10152528 TI - Cut supplier lead times by 50 percent--no mirrors, no kidding. AB - Every buying organization wants shorter supplier lead times--a lot shorter. In the past, we have expedited, negotiated supplier-held and consigned inventories, made deals with distributors to stock original equipment manufacturers (OEM) items, and pushed for supplier partnerships. In the end, the ebb and flow of the economy has had, perhaps, the greatest impact on supplier lead times--lower backlogs mean quicker deliveries. PMID- 10152529 TI - Without a vision, a business may perish. AB - The process described is not only viable for a company, but also can be used by any group that is gathered to perform any task. The process serves to explore strengths and weaknesses so the group can use one and shore up the other. It looks at the outside forces that may affect the work and allows the group to place its effort in the areas it can influence. By looking at what is or about to occur, the process may be able to create synergism or prevent disaster. A vision or direction statement that many if not all had some input into is easier to understand and support. Referral to these benchmarks or compass points makes the journey easier. PMID- 10152530 TI - Strategic planning to drive integrated continuous improvement. AB - This case study describes how one company involved multiple levels of all functions to develop a comprehensive strategic plan that drives the continuous improvement initiative. The process involves clearly defining a mission, assessing the current situation, developing goals designed to achieve a preferred future status, and establishing the specific tactics to move toward that preferred future. The plan then drives integrated efforts throughout the organization to help manage the business of providing the highest quality products and services to meet current and anticipated customer requirements. PMID- 10152531 TI - Reengineering: forty useful hints. AB - Business Process Reengineering (BPR) principles have been around for a long time, piecemeal and under other labels. In recent years they started coming together as a discipline, incorporating world class business principles and focusing on quantum improvements--not merely continuous gradual improvement. BPR is the complete or partial "reinventing" of how business processes are done to attain major performance improvement. It questions the underlying assumptions and principles, including what, why, by whom, and even if things should be done. This article will contribute by stating and helping to clarify a number of important principles, plus some useful insights, techniques, and hints--40 in all! PMID- 10152532 TI - Defining cost of quality in the materiel department. AB - The first step in reducing the cost of poor quality is to identify the defects controlled by materiel management. This article discusses the defects the authors have identified and measured in their efforts to reduce quality costs. PMID- 10152533 TI - Ten ways to create a motivating learning environment. AB - This article provides a wide variety of "how-tos" that can increase the results of a training session. It suggests that high-performance training goes far beyond presentation of the material. There are both general and specific behaviors that can be used to increase the learning outcomes. PMID- 10152534 TI - Developing performance measurement systems that support continuous improvement. AB - Many organizations are in a perpetual state of change. Changing markets, changing competition, changing organization structures, total quality initiatives, and reengineering are often the rule rather than the exception. Often these initiatives fail to yield the desired results or, in the extreme, fail entirely. The reasons for this failure, of course, can be many and multiple. However, one that often stands out is the lack of change in the performance measurement system as the needs for measurement change. PMID- 10152535 TI - Inventory management--a business issue. AB - Inventory management utilizes root cause analyses and requires cross-functional development of action plans and accountability. The inventory management process turns inventory control from a reactive to a proactive management tool that will have a favorable impact on business performance measurements and the bottom line. PMID- 10152536 TI - A physical examination of health care's readiness for a total quality management program: a case study. AB - Initiating a total quality management (TQM) effort can be a time-consuming and costly effort for a hospital. Perceptions of management and employees are important in initiating TQM because people function as if perceptions are fact. Assessing these perceptions and determining the levels of readiness or resistance to change are important steps in reducing costs, thus increasing organizational ability to address proactively challenges to the implementation and ultimate success of a TQM effort. Key assessment criteria are discussed including a comparison of management and employee perceptions in one hospital. PMID- 10152537 TI - Change--how to remove the fear, resentment, and resistance. AB - This article introduces active learning, which is an innovative education methodology for the workplace classroom. It is used to help people remove their fear, resentment, and resistance to the change process itself. Active learning makes education more effective compared with the predominantly used traditional lecture-type teaching methodology. PMID- 10152538 TI - High-performance cycle counting. AB - This article describes how to perform cycle counting to measure inventory record accuracy and to find errors in inventory records--and to fix the causes of those errors. Cycle counting is an efficient way of accomplishing these two objectives. The article describes various inventory counting methods and their advantages and disadvantages. PMID- 10152539 TI - Children's hospital ... dancing light makes healing magic in a child-friendly hospital tower. PMID- 10152540 TI - Alternative medicine: Feds give their blessing to the laying on of hands. PMID- 10152541 TI - Is the Stark law necessary? An interview with a health law expert. Interview by Joan Naper. PMID- 10152542 TI - AIDS in the 1990s: managing a decade-long disease. PMID- 10152543 TI - Technology planning: benefit analysis. PMID- 10152545 TI - Panel urges cutting number of doctors. PMID- 10152544 TI - Is it the data that's making patients sicker? PMID- 10152546 TI - VHA teams with financing firms. PMID- 10152548 TI - Drop in hospital cost shifting showing up on bottom line. PMID- 10152547 TI - Coram doubles 1994 loss in 3rd quarter. PMID- 10152549 TI - Moody's downgrades 4 New York hospitals. PMID- 10152550 TI - Mo. hospital officials defend Tenet deal. PMID- 10152551 TI - Columbia nears big Mich. deal. PMID- 10152552 TI - Hospital workers fear effects of Tenet's focus on bottom line. PMID- 10152553 TI - Allina in link with HealthEast. PMID- 10152554 TI - Chicago Catholic network launched. PMID- 10152555 TI - Physician's center treating very ill on outpatient basis. PMID- 10152556 TI - Hospital construction booming in Texas. PMID- 10152557 TI - Foiled on PSNs, hospitals oppose budget. PMID- 10152558 TI - HCFA's growing financial woes stall surveys. PMID- 10152559 TI - Groups oppose House plan's antitrust rules. PMID- 10152560 TI - 24-hour rule is OK if mom is a nurse. PMID- 10152561 TI - Tax-exempts feeling the heat. AB - Should government change decades-old tax codes to require that not-for-profit hospitals prove they deserve their tax exemptions? Healthcare Corp. has suggested that tax codes be re-examined because some not-for-profits provide less charity care than the value of their tax exemptions. PMID- 10152562 TI - JCAHO spent big on 1994 lobbying. PMID- 10152563 TI - Medicaid cuts jeopardize Ore. plan. PMID- 10152564 TI - Managed care making Medicare look generous. PMID- 10152565 TI - Medicaid managed-care plans face tough new rules in N.Y. PMID- 10152566 TI - Temple University files suit in dispute with Allegheny. PMID- 10152567 TI - Healthcare securities unhurt by budget battle. PMID- 10152568 TI - Hearts, minds and wallets. The showdown over the budget will define the Republican Party and change millions of lives. PMID- 10152569 TI - The laboratory restructuring challenge: the reengineering imperative. An introduction to the focus issue. AB - This article defines restructuring and describes how this strategy for organizational survival is affecting health care overall and clinical laboratories in particular. The author explains why laboratorians are uniquely positioned, in terms of both their skills and their knowledge base, to take leadership roles in restructuring initiatives within their own institutions. PMID- 10152570 TI - Preparing for the future: a case study of role changing and reengineering. Recognize and seize the new opportunities. AB - Today's laboratory managers are caught in the midst of a tumultuous environment as a result of managed care, mergers and acquisitions, and downsizing. We must prepare ourselves through continuous learning, recognize the marketable value of our skills outside of the laboratory, and seize opportunities to expand into new roles. At Arkansas Children's Hospital, the Chief Executive Officer selected the Administrative Director of Laboratories to reengineer the General Pediatric Center. Our goals were to improve quality of care, efficiency, teamwork, clinic visit times, and satisfaction of patients, staff, and physicians. We developed ideal objectives from surveys, brainstorming sessions, and interviews to serve as guidelines for reengineering teams. Teams met the goals and 12 of 15 ideal objectives. Patient flow redesign resulted in different processes for different patient populations and a 35% decrease in the average clinic visit time. Patient, staff, and physician satisfaction improved, as did the clinic's financial status. The project's success confirms that our leadership and analytical skills are transferable from the laboratory to carry us to new heights in other health-care arenas. PMID- 10152571 TI - Reengineering the laboratory: strategic process and systems innovation to improve performance. Recreating our role on the health-care team. AB - The author describes reengineering efforts in the laboratory of a 550-bed hospital. Key benefits include reduced costs, improved turnaround time, and redirection of staff into new roles in information management and outreach. PMID- 10152572 TI - Restructuring of laboratory services at the Detroit Medical Center. Process and outcomes. AB - Following an era of "do more, earn more," the health-care industry, including physicians and hospitals, has been faced with cost-containment measures. With this in mind, the Detroit Medical Center (DMC) embarked on a laboratory consolidation initiative to achieve this objective in 1985. The DMC entered into a partnership with Damon Clinical Laboratories, forming Damon Clinical Laboratories at the Detroit Medical Center. This partnership resulted in the consolidation of laboratory services within the DMC and the establishment of an outreach activity. In December 1992, it was decided that the partnership would be dissolved, with the DMC assuming full ownership and responsibility for the management of laboratory services. Thus, DMC University Laboratories was created and is currently in its third year of operation. This article presents how the decision to consolidate laboratory services within the DMC was made, along with the process and outcomes of consolidating the operations of seven hospital laboratories. PMID- 10152573 TI - An independent laboratory's experience with a hospital partnership. PMID- 10152574 TI - A model to begin reengineering the laboratory. How do you change an outmoded laboratory structure? AB - If a traditionally structured laboratory cannot incorporate new technologies efficiently and can no longer meet its changing service demands, it may require reengineering. A model is presented that can be followed by the laboratory director and a small group of planning colleagues to begin the process. The model was effectively used at British Columbia's Children's and Women's Hospitals (BCCH/WH) to review their laboratory structure and redraft it for the future. The model considers the external and internal pressures facing the laboratory. Technological trends, which have significant impact on laboratory service, are also incorporated into the model. The current list of services, staff expertise, and laboratory specialties is used as the base in the model to formulate the opportunities for improvements and identify the future direction of the laboratory. These opportunities are the context for the vision of the future laboratory. With this vision in mind and a creative planning approach, a new optimum laboratory structure can be outlined. This model begins the reengineering process and can be applied to any laboratory where there is the need for dramatic improvements to accommodate the changes in today's rapidly evolving health-care environment. PMID- 10152576 TI - Hospital laboratory consolidation. Reduce costs, improve service, enhance the workplace. AB - Laboratory management faces a challenge to improve service and become more cost effective. For some, the need is for dramatic change. Implementing change in a proactive manner allows laboratory management to improve while protecting the important aspects of a laboratory's contribution to a hospital's programs and services. In this article, we describe how reorganization and consolidation of hospital clinical laboratories had the effect of reducing costs, improving service, and enhancing the workplace. PMID- 10152575 TI - Strategies for a successful organizational transition. Identifying staff roles and fulfilling their needs during changing times. AB - For a successful reorganization of the laboratory, there is a role for each staff member to play during the transition. The role of those in laboratory administration is that of leading change agent. Corporate support staff, such as those in a human resources department, can advise the laboratory director in their areas of expertise. The role of the medical and technical supervisory staff is that of chief implementers of the plan. General laboratory staff has a confusing dual role--not only must they continue to provide laboratory services during the transition, but they also may have to change what they are doing and how they are doing it. Success also depends on meeting the individual personal needs of staff. Laboratory directors and administrators want to make a meaningful contribution to health care. Corporate support staff need to feel that they are a part of the change process. Supervisors' needs vary--coping with the loss of identity, position, or territory will be difficult for some; others will want to be involved in all stages of planning and implementation. The major need of the general laboratory staff is stability. Strategies are listed for each staff grouping to help the laboratory director coordinate staff roles and satisfy staff needs during the transition period. PMID- 10152577 TI - Laboratory restructuring: a move to self-directed teams. The experience at United Health Laboratories. PMID- 10152578 TI - Delayering and span of control: a model to assess appropriate management size during downsizing. A continuing process of organizational renewal. AB - Health-care organizations are continuing to seek effective methods of "downsizing" or "rightsizing" their workforce in response to economic pressures imposed by local and national health-care reform. Staff reductions often appear haphazard or reactionary and typically include an "across-the-board" methodology to achieve a predetermined financial goal. In contrast, review of the literature suggests that chances of success improve when the approach is more thoughtful and based on sound principles. A key component of all successful strategies is proper sizing and restructuring of the management staff. This article presents one possible model that allows an organization to rationally assess management structure and carry out an effective downsizing strategy. The process considers the number of management layers in the organization, the number of individuals a manager supervises (span of control), and the relative complexity of the work performed. Critical to success is an effective training component to educate "surviving" managers on techniques needed to "do more with less." PMID- 10152579 TI - Assessing the cost of cost reduction. PMID- 10152580 TI - The future of organ transplantation: from where will new donors come, to whom will their organs go? PMID- 10152581 TI - Challenging parental decisions to overtreat children. PMID- 10152582 TI - Covert video surveillance of Munchausen syndrome by proxy: the exigent circumstances exception. PMID- 10152583 TI - The legal, ethical, and medical objections to procuring organs from anencephalic infants. PMID- 10152584 TI - The role of clinical practice guidelines in health care reform. PMID- 10152585 TI - It takes two to tango: rethinking negligence liability for the sexual transmission of AIDS. PMID- 10152586 TI - Punitive policies: constitutional hazards of non-consensual testing of women for prenatal drug use. PMID- 10152587 TI - Case study. Medalia HealthCare, a primary-care network, is innovative and quality oriented joint venture. PMID- 10152589 TI - Knowing when to stop. PMID- 10152588 TI - Houston's St. Luke's Episcopal redesigns around TeamCare. PMID- 10152590 TI - Eastern CFO perceptions on integration. PMID- 10152591 TI - Surfing the healthcare Internet. PMID- 10152592 TI - Defining a quality strategy for learning disability services. Lifecare NHS Trust establishes its core values for care and quality. AB - Describes how Lifecare NHS Trust established core values and an ISO 9000 quality framework as the foundation for patient care quality improvement. Discusses a procedural approach to ensure that Lifecare defines clearly the requirements of the management of every aspect of its care system. Presents a framework for total quality management and process improvement of care delivery. PMID- 10152593 TI - Following pathways in pursuit of excellence. Discusses the patient-focused approach of Cheviot and Wandbeck NHS Trust. AB - Presents Cheviot and Wansbeck NHS Trust's strategy for quality improvement with a patient-focused approach. Describes the development and implementation of multidisciplinary pathways of care. Discusses the benefits of using the pathways. Proposes that multidisciplinary pathways of care are the ideal method of reviewing and coordinating the care process. PMID- 10152594 TI - Patient-focused care and its role in hospital process re-engineering. Describes a programme of change implemented at the Derbyshire Royal Infirmary. AB - Examines the concept of patient-focused care and how it fits into hospital process re-engineering. Describes the project undertaken at the Derbyshire Royal Infirmary, to implement patient-focused care and care pathway development in accident and emergency, and trauma and orthopaedics. Concludes with an insight into how care pathways have been used to improve hospital documentation, reduce duplication of information and provide a rich source of data for effective clinical audit. PMID- 10152595 TI - Developing standards for patient information. Highlights that effective communication can improve health care delivery. AB - Presents a review of the patient information literature used in the Taunton and Somerset NHS Trust. Describes the changes made to this literature in an attempt to improve the patient experience of the health care delivery. Highlights that appropriate, timely and effective communication with patients can improve the effectiveness of care and the efficiency with which it is delivered. PMID- 10152596 TI - Path.Finder: an interactive clinical information system. The day-to-day management of patients requires unified information sources. AB - Presents Path.Finder, a locally managed health care information system built in response to the need for better communication of current research evidence and clinical practice guidelines. Concludes that this system will improve patient care by providing up-to-date, clinically useful information which is relevant locally. The technology and the information management system have been developed in parallel. PMID- 10152597 TI - Towards improving care for children with diabetes in Kuwait. AB - Presents the results of a medical audit of the records of 199 children diagnosed as diabetic and admitted to Al-Amiri Hospital, Kuwait. Uses the measurement of glycosylated haemoglobin (HbA1) to indicate the levels of control achieved. Finds that the degree of glycaemic control compares favourably with studies done in other hospitals, but unfavourably with specialized diabetic clinics. Proposes that glycaemic control could be improved by provision of the services of specialized support staff such as dietitian, educator, psychologist and health visitor. PMID- 10152598 TI - Do or die. Presents an initiative for improving the quality of patient care. AB - Over the recent past, a number of different approaches to quality improvement have been introduced to the field of health-care delivery. Presents an overview of the approach developed at Brighton Health Care Trust. Outlines the strategic approach incorporating: the recognition of the need for staff education to enable them to participate fully in improving the quality of patient care; the identification of seven core components; the development of an educational package; and the development of a structure to support the implementation. PMID- 10152599 TI - In-home and community-based service utilization by three groups of elderly Hispanics: a national perspective. PMID- 10152600 TI - The effect of mental health practitioners' racial sensitivity on African Americans' perceptions of service. PMID- 10152601 TI - Tennessee's "TennCare" program approved, aims to restructure delivery of Medicaid services. PMID- 10152602 TI - Medicaid managed care. State presents details of Medicaid HMO. PMID- 10152603 TI - Minority initiative opens door to health management. PMID- 10152604 TI - Paying the price of cost containment. PMID- 10152605 TI - Health care programs: fraud and abuse; revisions to the civil money penalty provisions relating to the misuse of certain names, symbols and emblems--HHS. Final rule. AB - In accordance with amendments to section 1140 of the Social Security Act, resulting from the Social Security Independence and Program Improvements Act of 1994, this final rule makes a number of revisions to the civil money penalty authority regulations relating to the misuse of certain symbols, emblems and names. Among other revisions, this rule eliminates the annual cap on penalties, includes the words and letters of the Department and Medicaid under the prohibition, and redefines a violation with regard to mailings. In addition, this final rule serves to remove references to Social Security and the Social Security Administration (SSA) from the HHS/OIG penalty regulations. The penalty regulations addressing the misuse of certain words, letters, symbols and emblems for SSA and its programs are being set forth in a new part of the Code of Federal Regulations published elsewhere in this edition of the Federal Register. PMID- 10152606 TI - Medicaid program: nurse-midwife services--HCFA. Final rule. AB - In accordance with section 13605 of the Omnibus Budget Reconciliation Act of 1993, this final rule expands coverage of nurse-midwife services under the Medicaid program by including coverage for those services that nurse-midwives perform outside the maternity cycle as allowed by State law and regulation. In addition, this rule includes several clarifying revisions to the Medicaid regulations. PMID- 10152607 TI - Case study. Sentara Health System: in transition to a health management enterprise. PMID- 10152608 TI - Achieving cultural congruence in integrated health systems: lessons from two corporate change initiatives. PMID- 10152609 TI - The Mullikin/MedPartners merger: physician groups go national. PMID- 10152610 TI - Understanding capitation and risk sharing. PMID- 10152611 TI - Behavioral health management: carve-out, carve-in, and fully integrated models. PMID- 10152612 TI - Provider-sponsored networks. PMID- 10152613 TI - PSNs may be the "silver lining" of Republican health reform. PMID- 10152614 TI - Developing a plan that will help providers determine payer strategy. PMID- 10152615 TI - New methods for securing J-1 physicians. PMID- 10152617 TI - Whether negotiating with insurers or with colleagues, healthcare professionals are always cutting deals. PMID- 10152616 TI - Cost containment pressures force physicians to think in new ways. PMID- 10152618 TI - Competency profiles ... what do they mean to the profession? PMID- 10152619 TI - Preparing for the new salary equivalency rates. PMID- 10152621 TI - How do you deal with staffing night shifts? PMID- 10152620 TI - Administration ratchets up anti-fraud, abuse drive. PMID- 10152622 TI - Going against the grain. Who needs vertical and horizontal integration? Chris Brogdon's booming company is betting on assisted living. PMID- 10152623 TI - Mental health break throughs. PMID- 10152624 TI - Nighttime incontinence. Less intrusive approaches to care. PMID- 10152625 TI - How much is your facility worth? PMID- 10152626 TI - LTC giants questioned on disclosure in mergers. PMID- 10152627 TI - Outcome findings from a multidisciplinary clinic for children with epilepsy. AB - Children with chronic or intractable epilepsy are at higher risk for medical and social difficulties. A multidisciplinary clinic was established to improve medical management and address psychosocial issues. The purposes of the present study were to describe the multidisciplinary clinic, retrospectively examine the referral patterns for children served by the clinic, and analyze factors significantly predictive of parental satisfaction with the multidisciplinary approach. The Epilepsy Clinic Satisfaction Questionnaire was sent to all patients seen in the clinic over a 2-year period. Outcome findings were based on 136 respondents. A stepwise regression analysis indicated that the best predictor of parental rating of clinic quality was the amount of information given concerning the diagnosis and treatment of epilepsy. Staff attitude was also significantly related to parental satisfaction. PMID- 10152629 TI - Integrating floor care for cost-effectiveness. PMID- 10152628 TI - Look down. What you see is your customer's first impression! PMID- 10152630 TI - Increasing vacuuming productivity. PMID- 10152631 TI - 1995 salary data by N.E.H.A. District. PMID- 10152632 TI - Protecting yourself against slip and fall claims. PMID- 10152633 TI - Medicaid managed care: hospitals need a "safety net". PMID- 10152634 TI - Will new provider sponsored networks seek Medicare risk contracts? PMID- 10152635 TI - Public backlash creates higher data demands. PMID- 10152636 TI - Salaries for hospital-based specialties have either decreased or stabilized. PMID- 10152637 TI - Providers must adapt fast to risk contracting. PMID- 10152638 TI - Hospital analysis using comparative data. PMID- 10152639 TI - State legislative approaches to regulating the use of genetic information. AB - As genetic testing becomes more prevalent and the uses for genetic information multiply, we are likely to witness more demand for comprehensive state legislation on the order of the Oregon law regulating the procedures for obtaining and using genetic information. In addition, the United States Senate has expressed an interest in the subject. The Senate Labor and Human Resources Committee reportedly agreed on August 2, 1995 to include in a health insurance reform bill (S. 1028) language prohibiting health plans from using genetic information when determining eligibility, continuation, enrollment, or contribution requirements. 4 BNA's Health Law Rep. at 1218 (Aug. 10, 1995). Insurance companies continue to maintain that genetic test results are simply another factor that should rightfully be used during underwriting, much as age, medical history, and physical examinations are routinely used today. Right to privacy advocates argue that genetic testing provides employers and insurance companies with too much information and offers a great potential for discrimination. As more states wrestle with this issue, these competing interests are likely to be debated in public forums throughout the country. PMID- 10152640 TI - State Medicaid reform under Section 1115 demonstration authority. AB - Given the complexity of federal Medicaid law and the limitations it imposes on state flexibility, it is likely that states will continue to ask the Secretary to grant waivers under Section 1115 to allow them to pursue new approaches to health care reform. The results of currently operational Section 1115 projects involving statewide managed care systems will be useful in evaluating the Medicaid reform measures currently under discussion in other states and at the federal level. In particular, the ability of the states to control Medicaid and indigent care costs and to utilize federal dollars more efficiently should prove important in evaluating a block grant approach to federal Medicaid funding. Moreover, Section 1115 project results that bear on the sufficiency of various Medicaid capitation rate methodologies will also be of value as more states expand the use of managed care arrangements for their Medicaid populations. PMID- 10152641 TI - For sale: hospital-based nutrition counseling. PMID- 10152642 TI - Are your employees bored? PMID- 10152643 TI - Conducting hospital business. PMID- 10152644 TI - Controlling bulk nourishments costs. PMID- 10152645 TI - Revisiting Walter Reed's food services. PMID- 10152646 TI - Choosing high-volume, high-cost DRGs for pathways not always the best bet. PMID- 10152647 TI - Critical paths conflict with MDs' traditional ethics. PMID- 10152648 TI - Medicare pilot programs praised for innovation. PMID- 10152649 TI - Top spinal cord rehab facilities juggle lower LOS, quality. PMID- 10152650 TI - Identify ADRs early with risk assessment. PMID- 10152651 TI - Successful people selection in action. AB - As a people-intensive industry, the health care service should invest both time and resource in attracting, selecting and retaining its staff. Highlights the fact that the traditional interview is a poor selection tool. Outlines a systematic approach to hiring people and describes the structured behaviour interview tool. Explains the tool using a recent recruitment exercise in the health-care setting. Concludes that line management should play an active role in staff selection and organizations should look for better approach and tools to improve their hiring effectiveness. PMID- 10152652 TI - Career management support for nurses. AB - The downsizing of many areas of the NHS is now affecting nurse education as it moves into the Further/Higher Education sector. Many staff are terminating their employment relationship through early retirement. Describes a career management workshop run for such staff and makes reflections on careers, especially of the objective and subjective kind. PMID- 10152653 TI - Training needs analysis within the community. AB - A project was undertaken to provide a description of the training needs of agencies who are partners in the provision of care in the community. In developing the research strategy a service design approach was adopted which complied with the design control requirement of the Quality Standard EN ISO 9001: 1994. A questionnaire for self-completion was sent to 25 individuals involved in delivering community care. The findings enabled priorities of joint training to be identified. The findings also enabled training to be suggested for both manager and direct care staff. Demonstrates the need for skill acquisition in a variety of areas. Generally it was indicated by respondents that planning training arising from the project should be multidisciplinary. Enthusiasm for such training was also a feature of the respondents' responses. PMID- 10152654 TI - New developments in hospital management. AB - Changes in the health care environment over the past ten years have prompted changes in the way hospitals are being managed. The rising cost of health care has affected Medicare reimbursement, caused business to be a discerning selector of medical care, and given birth to alternative forms of health care delivery. All these conditions have resulted in decreased revenue and increased competition for hospitals. Focuses on what hospitals have done to adapt to these changing conditions: cost containment, marketing strategies, and human resource management, since these areas have undergone the most meaningful changes. PMID- 10152655 TI - The monitoring and improvement of productivity in health care. AB - Considers the monitoring of productivity in the health care environment. Examines especially the development of a labour standard and a volume indicator. Sees the whole as a management tool for controlling staffing requirements and costs. Investigates the question of methods improvement, involving all staff, should the standard fail to be met. Discusses increased training, procedure scheduling, investment in equipment, incentives, reduction of paper work, physician utilization. Cautions that the implementation of change must not be vitiated by internal politics and concludes that that which gets monitored gets controlled. PMID- 10152656 TI - Sickness absence and health at work in the NHS. AB - Presents summary results from two surveys which the Institute for Employment Studies conducted in 1994 for the Health Education Authority. The first of these surveys reports national benchmarking data on rates of sickness absence and accidents at work in NHS provider and purchaser organizations. The second survey concerns implementation of the Health at Work (HaW) in the NHS initiative in NHS hospital worksites. Discusses structures and processes of HaW implementation. PMID- 10152657 TI - IOL (intraocular lense) prices continue sliding in the face of competition, vendor consolidation. PMID- 10152658 TI - Economic activity in manufacturing is spiraling downward; Purchasing Managers' Index nosedives to 46.8% in October. PMID- 10152659 TI - Supply distribution systems: ATMs of health care. PMID- 10152660 TI - Hospital supply and pharmaceutical costs are tied to competition in marketplace. PMID- 10152661 TI - Remodeling 101. PMID- 10152662 TI - Red River Project. Expanded scope program for New Mexico medics. PMID- 10152663 TI - How I avoided life-threatening surgery. PMID- 10152664 TI - Looking for tranquillity? Don't move to the country. PMID- 10152665 TI - Seven ways to prepare for managed care. PMID- 10152666 TI - Taming the paperwork monster. PMID- 10152667 TI - Doctors chip away at practice costs. PMID- 10152668 TI - The debate over Medicare managed-care savings goes on. PMID- 10152669 TI - The HMO industry: the big keep getting bigger. PMID- 10152670 TI - State health reform changes character. PMID- 10152671 TI - When a plan drops you, don't let it take your patients. PMID- 10152672 TI - Doonesbury's right: we can stay on schedule. PMID- 10152674 TI - Fla. for-profits sue over clinics. PMID- 10152673 TI - Can you make a killing with your own practice? PMID- 10152675 TI - Joint provider budget protest fractured. PMID- 10152676 TI - Hospital in Columbia's Ohio deal pays big fine. PMID- 10152677 TI - AHA cuts more jobs in Chicago. PMID- 10152678 TI - SunHealth, AmHS/Premier to merge. AB - The executive committee of SunHealth Alliance has voted to merge with newly formed AmHS/Premier, a deal that would make the nation's largest alliance even bigger. The merged organization would have a membership of nearly 1,700 hospitals with 315,000 licensed beds. That represents about one-third of U.S. community hospitals. PMID- 10152679 TI - U. of Minn. hospital seeks shelter from managed care. PMID- 10152680 TI - N.J. toughens its HMO rules. PMID- 10152681 TI - WellPoint postpones closing of HSI merger. PMID- 10152682 TI - California investigating Medi-Cal enrollment practices at Universal. PMID- 10152683 TI - Healthcare workers' raises dwindling. PMID- 10152684 TI - Clinton, Congress set to begin budget negotiations. PMID- 10152685 TI - Miami hospital settles charges of patient 'dumping'. PMID- 10152686 TI - CHA proposes budget alternative. PMID- 10152687 TI - HCFA studies equipment fees. PMID- 10152688 TI - Program smooths other side of access. PMID- 10152689 TI - Used equipment's bright future. AB - In the past, used imaging equipment often was destined for sale at 10 cents per pound to scavengers seeking the gold and lead in components. Some machines were shipped to hospitals in Third World countries or the rural United States. But today the future of used imaging equipment is getting an upgrade. PMID- 10152691 TI - Are physicians ready for networks? PMID- 10152690 TI - Bells and whistles of technology are being replaced more slowly. PMID- 10152692 TI - 'Junk' adds to pile of bond issues. PMID- 10152693 TI - Providers post solid earnings growth. PMID- 10152694 TI - Columbia plans 3rd new Texas hospital. PMID- 10152695 TI - Revenue lost from equipment downtime is real money. PMID- 10152696 TI - Sea change in Minnesota. PMID- 10152697 TI - Influencing legislators on healthcare matters. PMID- 10152698 TI - Radiology report turnaround time: survey results and success stories. PMID- 10152699 TI - Gainsharing: providing incentives for process improvement. AB - Gainsharing links pay for performance with employee involvement in improving operations. As operational performance improves, employees share financially in the gain. A successful gainsharing program addresses two primary issues: employee involvement and the formula for bonus payout. The formula must be simple and understandable, and the employees must see clearly how they can influence the probability of a payout. In 1995 Boulder Community Hospital (BCH) instituted a gainsharing program called "Encore! Quality Share." A design team consisting of employees from all levels of the organization developed the plan. "Team norms" encourage group discussion without regard to the institutional power of team members and call for consensus when making decisions. Major components of the gainsharing plan include standardized cost measurement per patient discharge, quality control feedback through patient surveys and designated quality levels for adjusting the amount of payout. The plan was introduced through educational seminars for employees. Quality improvement training and new employee orientation now include presentations on Quality Share. Early indications show that BCH's gainsharing program is a success. Significant payouts were made to employees at the end of the first and second quarters. Because success in the first two quarters seemed relatively easy to attain, safeguards against complacency are now being discussed. PMID- 10152700 TI - Process redesign: making your film library work for you. AB - When Riverside Methodist Hospitals in Columbus, Ohio, experienced serious problems in its radiology film library, administrators recognized that poor processes were to blame and used quality management techniques to create a new system. A radiology information system was part of Riverside's long-range plan, but an effective manual process was implemented first. Riverside had decided that closing the library to referring physician access would result in more successful operations. An Operational Changes Planning Committee composed of file clerks, technologists, managers, radiologists and referring physicians planned the redesign. The committee identified four goals: Reduce unmet requests. Improve response time. Benchmark operations of comparable organizations. Implement an effective manual process prior to automation. Steps in the redesign process included identifying the problem, applying statistical tools to the situation and understanding customer requirements. Flow charts, benchmarking, data collection within the department and focus groups provided important quantitative information. Creating an improved process included the following actions: Work simplification. Work elimination (especially non-value-added work). Uncovering and removing causes of delay. Automation of repetitive tasks via the RIS. Reduction and elimination of any rework steps. One important change was to close the library to physician access. There were moderate gains in effectiveness as a result of redesign of the manual process. Results have continued to improve, and the redesign process provided greater commitment and cooperation for the more significant improvements that followed the RIS introduction. PMID- 10152701 TI - Continuing education at reasonable cost: a case study. AB - Since January 1, 1995, the American Registry of Radiologic Technologists (ARRT) has mandated that radiologic technologists earn 24 units of continuing education every 24 months. Enforcement will begin in 1997, but the credits must be earned in the two-year period preceding the technologist's birth-month in 1997. Those who have earned 24 credits between their birth-months in 1993 and 1995 will be recognized for voluntary compliance. This article describes how a local affiliate of the California Society of Radiologic Technologists and a hospital in-service program provide continuing education for technologists in a semi-rural area. In 1986 two technologists from Kaweah Delta Hospital organized the Sequoia District Study Group (now called Sequoia District Affiliate). In 1992 that group recognized the need to meet upcoming continuing education requirements and made plans to provide 12 continuing education units per year. The Kaweah Health Care District offers financial support of the group's program and pays an annual fee to the ASRT to receive designated providership of continuing education. Individuals who pay a small annual membership fee to the Sequoia District Affiliate attend meetings for free and receive a discount on registration for an annual seminar. Staff involvement in soliciting speakers generates greater interest and better attendance. Cooperation between staff and management can facilitate the implementation of a low-cost education program that meets ARRT requirements. PMID- 10152702 TI - Controlling technology costs as integrated networks expand. AB - The expansion of integrated healthcare networks is changing the way radiology technology should be acquired and maintained. Some significant effects are that utilization will decline with managed care; the radiology department is now a cost center, not a source of revenue; and integrated networks find themselves with redundant technology and excess radiology equipment. While hospitals shoulder additional financial risk associated with managed care, responsibility for finding solutions to new problems falls to the radiology administrator. Administrators can take the following steps to effectively reduce expense and risk: Understand current usage. Eliminate redundancies. Prioritize modalities. Find new financing opportunities. Lease equipment. Purchase reconditioned equipment. Redeploy assets instead of buying new. Radiology administrators who view these problems as a challenging puzzle will naturally explore creative options. They will provide the greatest flexibility and best position for their department's contributions to the hospital's overall strategic goals. PMID- 10152703 TI - Severity scores in respiratory intensive care: APACHE II predicted mortality better than SAPS II. AB - BACKGROUND: In recent years several scoring systems have been developed to describe the severity of illness, to establish the individual prognosis, and to group adult ICU patients by predicted risk of mortality. In addition, these scores can be used to measure and/or compare the quality of care in different ICUs. We compared the mortality predictions of the Acute Physiology and Chronic Health Evaluation (APACHE II) score and a new Simplified Acute Physiology Score (SAPS II) in patients with respiratory disease who require intensive care. PATIENTS & METHODS: We prospectively studied all 306 admissions from January 1, 1992 through December 31, 1994. McNemar and Hosmer-Lemeshow tests, and receiver operating characteristic (ROC) curves were used to describe and analyze our data. RESULTS: The average APACHE II score was 17.5 (SD 6.0), corresponding to a mean predicted death rate of 24.9% (SD 17.2%) as compared to an observed overall RICU mortality rate of 21.6%. The average SAPS II score was 39.1 (SD 11.1) corresponding to a mean predicted death rate of 26.0% (SD 18.4%). The ratio between the actual and predicted hospital mortality was 86% for APACHE II and 83% for SAPS II. Survivors had a significantly lower predicted risk of death than nonsurvivors (p < 0.0001) with both indices, and a higher Glasgow coma scale score (p < 0.0001). The ROC-curve analysis suggested the superior predictive ability of APACHE II in our patients. Area under the APACHE II ROC curve was 80.88% (standard error [SE] 2.89%), significantly larger (p < 0.01) than that found for SAPS II (73.52%, SE 3.61%). CONCLUSIONS: The APACHE II score was a good predictor of hospital outcome and better than SAPS II in our population. PMID- 10152704 TI - Respiratory care practitioners as primary providers of neonatal intubation in a community hospital: an analysis. AB - BACKGROUND: Respiratory care practitioners (RCPs) serve as the primary providers of neonatal endotracheal intubation (ETI) in our institution. ETIs are performed by registered respiratory therapists who have completed Pediatric Advanced Life Support and Neonatal Advanced Life Support training and have successfully completed 3 intubations under the direct supervision of a senior therapist. The purpose of this study was to (1) ascertain whether RCPs can successfully provide this type of service with acceptable complications rates and (2) survey the economic impact of this practice on patient charges in our hospital. EVALUATION METHODS: An analysis of each intubation event in which an RCP participated was collected and compiled over a 5-month period (9-94 to 2-95). Calculations were made of the success rate and complications. RESULTS: A total of 38 ETIs were performed by the RCPs. Of these, 37 (97.4%) were performed with < or = 3 attempts; (73.7% with 1 attempt, 15.8% with 2 attempts, and 7.9% with 3 attempts). In only 1 event were more than 3 attempts required. There were no complications observed. CONCLUSION: RCPs can successfully serve as primary providers of neonatal ETI at a Level-II nursery in a community hospital, and this practice may result in a cost reduction. PMID- 10152705 TI - Canaries in the mine shaft: frustrations and benefits of community members on ethics committees. PMID- 10152706 TI - The Denver Community Bioethics Committee: healthcare decisions in adult protection and long-term care settings. PMID- 10152707 TI - Ethical issues in home care. PMID- 10152708 TI - A corporate approach to healthcare ethics. PMID- 10152709 TI - "I don't speak principles only": the language of ethics committees and the language of communities. PMID- 10152710 TI - The meaning of futility through conversation. AB - Decisions about futility were described as a joint conversation that includes patients, caregivers, and the community at large. Guidelines developed by consortiums such as GUIDe were viewed as contributing positively to the conversation by involving the public voice--a public voice that should be included in conversations at the bedside. Concern that guidelines may insidiously become institutional policies or viewed as blanket rules for decisions was expressed. Several participants cautioned that GUIDe will have a positive influence as long as guidelines and/or standards of practice remain as only a part of the conversation and do not become the conversation. Further, limitations of statistics in individual cases must be recognized. Data from outcomes research was considered as only a component of the conversation because the primary focus of conversation should be on real people in real situations, not extrapolated data. As stated by one of the participants, the most important focus of GUIDe or other similar consortia, may be "on how you hold conversations with people." An interest was expressed in facilitating conversations that enhance both patients' and healthcare providers' particularity, freedom, and awareness and expression of their values and best interests. Such conversations demonstrate respect for each other's positions rather than a wish that the other's world view would just go away. PMID- 10152712 TI - Perspectives. Unions push quality issues as workers and consumers. PMID- 10152711 TI - Easing the burden of decisionmaking in futile situations. PMID- 10152713 TI - Perspectives. Telemedicine races against time to earn its keep. PMID- 10152714 TI - FDA regulation of clinical software: what does this mean for the industry? PMID- 10152715 TI - The five levels of the ultimate electronic health record. PMID- 10152716 TI - Conquering conversion chaos with optical systems. PMID- 10152717 TI - Choosing an RIS (radiology information system) the second time around. PMID- 10152718 TI - Sounding out leaders of the PACs. Roundtable discussion. AB - Disparate needs and discriminating buyers are prompting picture archiving and communication systems, or PACS, providers to take a closer look at what their potential customers really want. Major considerations include integration with legacy systems, cost justification, technical support, and meeting HL7 and DICOM standards. One PACS provider observes, "[PACS] no longer is a radiology product, but rather a piece of the total information management system." Read on for further insights from five leading providers of PACS. PMID- 10152719 TI - Attaining maximum payback with EDI. PMID- 10152720 TI - COLD (computer output to laser disk) and paperless in Pennsylvania. PMID- 10152721 TI - Technology watch: patient cards. PMID- 10152722 TI - Laying to rest an archiving nightmare. PMID- 10152723 TI - New TB respirator standards mean more choices at less cost. PMID- 10152724 TI - Man meets machine: buying right can reduce human error. PMID- 10152725 TI - Chain dance: supply-side partners anticipate next move. PMID- 10152727 TI - On-site instrument repair trims time, saves money. PMID- 10152728 TI - Survey wants to know: safety first? PMID- 10152726 TI - Future scope: what will it take to manage new technology?. Interview by Karen Sandrick. PMID- 10152729 TI - Empowering employees: here's how to do it right. PMID- 10152731 TI - A resource list of organizations that have developed clinical pathways and clinical guidelines. PMID- 10152730 TI - Back to the Dark Ages. PMID- 10152732 TI - Clinical practice guidelines: a tool for the defense?. Interview by Reggi Veatch. PMID- 10152733 TI - Ten strategies for making clinical guidelines and pathways work. PMID- 10152734 TI - Designing and implementing guidelines-based performance measures. Agency for Health Care Policy and Research. AB - The Quality Agenda, a regular feature of The Quality Letter, offers practical models and information that leaders of healthcare organizations can adapt and use. This month, we present a model for designing and implementing guidelines based performance measures developed by the Agency for Health Care Policy and Research. For a complete description of the model, readers will want to refer to Using Clinical Practice Guidelines to Evaluate Quality of Care, Volumes 1 and 2. AHCPR publication numbers 95-0045 (Volume 1) and 95-0046 (Volume 2), March 1995. To order a copy of the publications, call 800/358-9295. PMID- 10152735 TI - A magic bullet for managed care. PMID- 10152737 TI - Changing patterns in health finance. PMID- 10152736 TI - Did the media kill health-care reform? PMID- 10152738 TI - How a store owner became a savvy shopper. PMID- 10152739 TI - Picture alternative medicine in the mainstream. PMID- 10152740 TI - The lowdown on those plummeting workers' comp costs. PMID- 10152741 TI - Florida. Fresh thinking for a spending squeeze. PMID- 10152742 TI - Would you live better without your own employees? PMID- 10152743 TI - Disease management: continuous health-care improvement. PMID- 10152744 TI - Disease management: at these companies, the future is now. PMID- 10152745 TI - Washington's new guidelines guru. Interview by Geoffrey Leavenworth. PMID- 10152747 TI - Small businesses create Texas-size choices in health-care. PMID- 10152746 TI - The limits of insurance reform. PMID- 10152748 TI - Court to plan sponsors: make your documents clear. PMID- 10152749 TI - Life in the Portland fast lane. PMID- 10152750 TI - California & Columbia/HCA mega-deals. PMID- 10152751 TI - Portability of health insurance: COBRA expansions and small group market reform. AB - Proposals are currently being put forth to change the health care system incrementally. One area of proposed legislation addresses portability, which allows an individual to change insurers without being subjected to a new waiting period for preexisting conditions. These proposals, discussed in this Issue Brief, contain provisions to limit preexisting condition exclusions, guarantee access to health insurance, guarantee renewal of health insurance, allow individuals to contribute to medical savings accounts on a pretax basis, and change the current law under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). The proposals would affect insurers, employers, and insured individuals by potentially increasing the cost of providing and purchasing health insurance. Concern about the portability of health insurance primarily arises in situations where an individual is leaving, or would like to leave, a job. If health insurance is not offered by a prospective employer, if the worker must satisfy a waiting period before becoming eligible for coverage, if the benefits package offered through the prospective employer is less generous, or if the employee (or a dependent) has a medical condition that is considered a preexisting condition and would not be covered by the new plan, the employee may opt to remain with his or her current employer--a situation known as job lock. Expansions of COBRA may not have any effect on portability. Employers can charge up to 102 percent of the premium for COBRA coverage, making it unaffordable for many workers. Because cost is a major factor, if there is no reduction in cost (or health care cost inflation) there could be little or no increase in coverage. According to one survey, in 1994 average COBRA costs were $5,301 per COBRA covered worker, compared with $3,420 for active employees. Any expansion of COBRA would almost certainly increase employer cost for health insurance.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10152752 TI - ERISA and health plans. AB - This Issue Brief is designed to provide a basic understanding of the relationship of the Employee Retirement Income Security Act of 1974 (ERISA) to health plans. It is based, in part, on an Employee Benefit Research Institute-Education and Research Fund (EBRI-ERF) educational briefing held in March 1995. This report includes a section by Peter Schmidt of Arnold & Porter, a section about multiemployer plans written by Judy Mazo of The Segal Company; and a section about ERISA and state health reform written by Kala Ladenheim of the Intergovernmental Health Policy Project. Starting in the late 1980s, three trends converged to make ERISA a critical factor in state health reforms: increasingly comprehensive state health policy experimentation; changes in the makeup of the insurance market (including the rise in self-insurance and the growth of managed care); and increasingly expansive interpretations of ERISA by federal courts. The changing interpretations of ERISA's relationship to three categories of state health initiatives--insurance mandates, medical high risk pools, and uncompensated care pools--illustrate how these forces are playing out today. ERISA does have a very broad preemptive effect. Federal statutes do not need to say anything about preemption in order to preempt state law. For example, if there is a direct conflict, it would be quite clear under the Supremacy Clause [of the U.S. Constitution] that ERISA, or any federal statue, would preempt a directly conflicting state statute. States can indirectly regulate health care plans that provide benefits through insurance contracts by establishing the terms of the contract. And they also raise money by imposing premium taxes. But they cannot do the same with respect to self-funded plans. That is one of the factors that has caused a great rise in the number of self-funded plans. State regulation [of employee benefits] can create three kinds of problems: cost of taxes, fees, or other charges; cost of dealing with substantive, possibly inconsistent, benefit standards; and cost of identifying, understanding, and complying with the regulations themselves. PMID- 10152753 TI - Health Management Technology I/T Consultant Guide. PMID- 10152754 TI - Remote image access expands services. PMID- 10152755 TI - Decision-support software. PMID- 10152756 TI - Fastest is always best and other PACS fallacies. PMID- 10152758 TI - Boston hospital using seven telemedicine systems within facility. PMID- 10152757 TI - Hospital saves thousands using multimedia tutorial. PMID- 10152759 TI - Buy materials management systems, or pray you can swim. PMID- 10152760 TI - HotList. Materials management software. PMID- 10152761 TI - Medicaid managed care has unique I/S needs. PMID- 10152762 TI - Live organ donations between siblings and the best interest standard: time for stricter judicial intervention. PMID- 10152763 TI - Campaign encourages participation from entire hospital family. PMID- 10152764 TI - Focus: fraud & abuse under health care reform. PMID- 10152765 TI - Criminal behavior viewed as public health problem. PMID- 10152766 TI - Georgia hospitals respond to child abuse. PMID- 10152767 TI - New lessons in caring. PMID- 10152768 TI - A closer look at Stark legislation. PMID- 10152769 TI - Collaborative Quality Improvement Partnership: GA health organizations join forces for quality improvement. PMID- 10152770 TI - Most Favored Nation clauses require close scrutiny. PMID- 10152771 TI - Price fixing in provider networks: the evolution of the "messenger model". PMID- 10152772 TI - Cost of hospital and medical care and treatment furnished by the United States; certain rates regarding recovery from tortiously liable third persons--OMB. PMID- 10152773 TI - Working in Washington's hospital zone. Interview by Marilyn Werber Serafini. PMID- 10152774 TI - Disease state management: reality or mythology. PMID- 10152775 TI - What do payors & providers see as their most important I.S. requirements? PMID- 10152776 TI - CHIN overview: when you've seen one, you've seen one. PMID- 10152777 TI - What the future holds for managed care. From legacy to new generation. AB - Legacies used to be legends--each one a proud heritage admired, respected, held in awe. Today they are mainframe, claims-based information system workhorses that cannot keep up with the promise of managed care. But for now, they might just be the best interim solution. The promises of future technologies for the managed care information age are still just promises, according to the experts. If you're thinking of replacing your legacy system, the experts say wait while the healthcare and technology markets try to figure out each other. PMID- 10152778 TI - Do we understand our business? PMID- 10152779 TI - Consulting services for managed care: who can you turn to? PMID- 10152780 TI - Using technology to manage Medicare secondary payor claims. PMID- 10152781 TI - Turnovers & CIOs: is IT apples & oranges? PMID- 10152782 TI - Pharmacoeconomic comparison of sequential IV/oral ciprofloxacin versus ceftazidime in the treatment of nosocomial pneumonia. AB - A retrospective, cost-effectiveness analysis was performed on 106 clinically evaluable patients who participated in a multi-centre, randomized study of sequential IV/oral ciprofloxacin therapy versus ceftazidime for the treatment of nosocomial pneumonia. Although nearly half of the ciprofloxacin patients received sequential therapy, the majority were treated with a full IV regimen. Clinical success rates and antibiotic-related adverse events were similar for the ciprofloxacin and ceftazidime groups. Per patient and per day costs of antibiotic acquisition; preparation and administration; treatment of adverse events, and clinical failures were compared. Decision analysis revealed that ciprofloxacin therapy was cost-effective compared to ceftazidime 2 g q8h. Varying the probability of clinical success between 60-99% failed to change the economic decision; costs for ciprofloxacin were always lower than for ceftazidime. Further sensitivity analyses demonstrated that if the ceftazidime price was reduced by 50% (equivalent to 1 g q8h), treatment costs would be similar to ciprofloxacin therapy. Increasing the ciprofloxacin price by 50% (equivalent to a q8h frequency) produced per patient costs similar to ceftazidime, although ciprofloxacin therapy retained a lower cost per day (p < 0.0002). For the treatment of nosocomial pneumonia, ciprofloxacin therapy was cost-effective compared to ceftazidime. PMID- 10152783 TI - Economic impact and clinical benefits of pharmacist involvement on surgical wards. AB - A one-year pilot project was performed to assess the economic and clinical benefit of pharmacist involvement on the surgical wards of a 600-bed tertiary care, teaching hospital. A total of 405 recommendations were collected with a physician acceptance rate of 90%. From these recommendations, 1416 patient follow ups were performed to document outcome. The total documented cost avoidance of the pharmacists' activities was $33,265.58. The total annual drug expenditure for the department of surgery declined by $59,662 representing a 9% decrease over the previous year with the greatest decline involving antimicrobials which decreased by $52,587 compared with the previous year. Most of the cost-avoidance in this area was attributable to antimicrobial selection and dosing adjustment in renal impairment. Pharmacist-directed pharmacokinetic monitoring of aminoglycosides resulted in a clinical success rate of 93.8% for treatment regimens and a 6.2% incidence of nephrotoxicity. Housestaff education aimed at improving prescribing practices were identified and provided for select agents including midazolam, ketorolac, vancomycin and aminoglycosides. As well, select recommendations were documented which illustrated the benefit to patient care of pharmacist involvement. Pharmacist involvement on the surgery services produced both financial and clinical benefits. PMID- 10152784 TI - Pharmacy technician unit dose certification program. PMID- 10152785 TI - Implementation of once or twice daily dosing in a long-term care facility. PMID- 10152786 TI - Innovation, teamwork pay dividends. PMID- 10152787 TI - FDA's Rx for better medication information. AB - Under a newly proposed program, by the turn of the century at least 75 percent of patients getting new prescriptions would receive easily understandable written information. The public has until Nov. 22 to comment. PMID- 10152788 TI - Computerized maintenance management systems: how to match your department's needs with commercially available products. AB - Computerized maintenance management systems (CMMS) are used by clinical engineering departments to collect, store, analyze and report data on the repair and maintenance performed on medical devices and other equipment. Evaluation of commercial CMMS require a careful requirements analysis and then a comprehensive evaluation of the products available in the marketplace that can come the closest to meeting those requirements. This paper provides a comprehensive list of evaluation questions to use to determine the best software system for a clinical engineering department's needs. PMID- 10152789 TI - Sales is an investment, attrition an expense. PMID- 10152790 TI - Is managed care managing to kill us? 'Conspiracy of silence' is taking its toll on health care professionals. PMID- 10152791 TI - Patient expectations of dental services. Image affects expectations, and expectations affect perceived service quality. AB - The authors construct a theoretical model of the antecedents of expectations for dental services by analyzing survey responses from 240 dental patients. The patients' image of the dentist, tangible cues, situational factors, and patient satisfaction with prior service encounters have the greatest influence on expectations of service, whereas marketing variables, such as price and advertising, appear to have no effect. PMID- 10152792 TI - Perception is everything. Marketers should prepare now to address the tough managed care questions. PMID- 10152793 TI - Satisfaction with medical care. It's easier to please patients than their family members and friends. AB - The authors conducted a multi-site study to compare the level of satisfaction with medical care and services between patients and their family/friends. Hierarchical regression results controlling for patient age, gender, medical service performed, and other factors suggest that inpatients are more satisfied with the care rendered by physicians and nurses, as well as with their overall hospital stay, than are their family members and friends. The authors speculate about why this is so and what health care providers can do about it. PMID- 10152794 TI - Beyond patient satisfaction. Broaden the scope of quality measurement by integrating the marketing view with other perspectives. AB - The patient satisfaction perspective has dominated recent marketing efforts to measure and understand health care quality. The authors propose a broader health care quality model that includes medical outcomes, access to health care services, and personnel dimensions along with patient satisfaction concerns as the foci of quality measurement. The model also encompasses important contextual factors that clearly affect the level of health care quality. PMID- 10152795 TI - Word-of-mouth communication: causes and consequences. PMID- 10152796 TI - Case study. Turning media gatekeepers into advocates. PMID- 10152797 TI - Equal access will shift marketing focus to consumers. PMID- 10152799 TI - Using the future search process for senior volunteer service in long-term care. AB - This article describes the use of the well-tested Future Search approach to achieving a common goal through a peer-managed consensus model. The issues and planning strategies forged through the use of the Future Search process are relevant to both volunteerism in general and senior volunteerism in particular. With rapid changes in societal infrastructures, an unstable economy, and rising numbers of at-risk populations, the volunteer community has been and will continue to be called upon to respond. To provide the most effective volunteer service, organizations can employ consensus-building planning strategies such as the Future Search to reach mutually satisfactory conclusions about necessary directions for volunteerism. A specific example of utilization of the Future Search approach, in reviewing the inclusion of older volunteers in long-term care, is presented. PMID- 10152798 TI - Diversity in the pastoral relationship: an evaluation of the helping styles inventory. AB - Presents an ethnographic study of practitioners' experiences of the Helping Styles Inventory (HSI). Analyzes the data from twenty-one interviews, noting helpful and limiting aspects of the HSI. Discusses implications of the research for the HSI and for ministry in general. PMID- 10152800 TI - Employer-sponsored health insurance: what's offered; what's chosen? PMID- 10152801 TI - Put your laboratory on the World Wide Web. PMID- 10152802 TI - Young and in the lab. How to keep new hirees happy. PMID- 10152803 TI - Point-of-care testing in pediatric hospitals. PMID- 10152804 TI - How to teach. A phlebotomy primer. PMID- 10152805 TI - Selling physicians on innovative technology. PMID- 10152806 TI - Molecular infectious disease testing: the hype, the hope, and the hoopla. AB - To remain competitive in the next century, microbiologists and virologists must acquire molecular diagnostic skills or they will relinquish molecular infectious disease testing to labs with little experience in handling infectious agents. PMID- 10152807 TI - HMA backs out of Cape Coral purchase. PMID- 10152808 TI - Doc Medicare fees may fall if talks drag. PMID- 10152809 TI - FHP to sell hospital in restructuring. PMID- 10152810 TI - Baxter split gets mixed reviews. AB - Baxter International's decision to spin off its U.S. distribution and hospital supply businesses is both troublesome and promising for hospitals. The new company plans to fuel profitable ?cost-management? services by investing in information systems and acquisitions. But the units that will form its core are growing slowly and earning operating profit margins of 5% to 6%. PMID- 10152812 TI - Suit over Epic sale a test of how to value systems. PMID- 10152811 TI - WellPoint-HSI merger further unravels amid angry accusations. PMID- 10152813 TI - SunHealth decision creates a stir. PMID- 10152814 TI - VHA to go it alone with advocacy effort. PMID- 10152815 TI - Hospitals appeal JCAHO verdicts. PMID- 10152816 TI - A big teaching center cuts the red tape. PMID- 10152817 TI - Hospital profits climb slightly during first half. PMID- 10152818 TI - Community opposition killed Mo. deal. PMID- 10152819 TI - Daughters of Charity reveals strong profits. PMID- 10152820 TI - System to pay $2 million a year. PMID- 10152821 TI - Humana wins big defense managed-care contract. PMID- 10152823 TI - Healthmaster sale draws lofty price. PMID- 10152822 TI - Virginia physicians in managed-care first. PMID- 10152824 TI - Kapiolani, HMSA to form HMO in Hawaii. PMID- 10152825 TI - Legislators far from budget compromise. PMID- 10152826 TI - Group to monitor rules for savings accounts. PMID- 10152827 TI - Caremark moves into foreign markets. PMID- 10152828 TI - VA system begins its revolution. PMID- 10152829 TI - Famous patients present a challenge for hospitals. PMID- 10152830 TI - Top 100 hospitals: the best-run hospitals. For-profits spur efficiency. AB - For-profit hospital companies are spurring the industry's all-out drive toward efficiency. That's one of the principal findings of an analysis of 1994 Medicare cost and discharge data from 4,000 acute-care hospitals by HCIA and William M. Mercer. The analysis produced a list of ?100 Top Hospitals: Benchmarks for Success.? PMID- 10152831 TI - Budget plan may affect HMOs' strategy. PMID- 10152832 TI - Providers see rewards of superior service. PMID- 10152833 TI - Adult day care: the new piece in the puzzle. PMID- 10152835 TI - Healthcare deals up 39% in 3rd qtr. PMID- 10152834 TI - Fla. tax-exempts cling to solid ground. PMID- 10152836 TI - APIC guideline recommends shortened surgical scrub. PMID- 10152837 TI - What's out in cyberspace for OR managers? PMID- 10152838 TI - Outpatient mastectomy patients recover at home. PMID- 10152839 TI - Large databases compare hospital profiles. PMID- 10152840 TI - Improving receivables with an interdepartmental CQI team. PMID- 10152841 TI - Tampa General Hospital "blows the whistle on violence". AB - At Tampa General Hospital, the professionals in the marketing and media relations department know how to stage a press conference and to get the attention of the media. It goes to the adage when you're buying real estate: location, location, location. Once the journalists were assembled, Tampa General launched its campaign to fight street violence: "Blow the Whistle on Violence." Their timing was aided by the release of the FBI's annual Preliminary Crime Report citing Tampa as the second most dangerous city in which to live. Tampa General's news media specialist Stacey Winn reported that "the day went together just like a puzzle with all the pieces coming together." Those pieces and more are detailed in this issue's cover story on community involvement. Street crime and violence are not unique to Tampa, of course. But with so many victims ending up in Tampa General's emergency room, Winn noted that physicians and nurses felt personally responsible for contributing toward the prevention of cases ending up there. One important element in the hospital's press conference was an appearance by one of the victims of the violence they're striving to prevent. Her appearance and statement to the assembled media representatives significantly enhanced the presentation. "Blow the Whistle on Violence" was a low-cost program with a high return. The potential benefits are enormous. PMID- 10152842 TI - A shot in the arm. M.D. Health Plan launches an immunization program that especially benefits infants in the inner city. AB - When you marry a solid public relations campaign to a genuine commitment to wellness, any number of good things can result. In Connecticut the result was "Smart Start," a campaign by M.D. Health Plan and other participants to launch an infant immunization program. It's been a real shot in the, er...arm. PMID- 10152843 TI - "A century of caring". The Chambersburg Hospital celebrates its centennial; three years of planning ensure successful events. AB - If you're planning to celebrate a centennial, those who have "been there, done that" say plan ahead. Not months; years. The Chambersburg Hospital started three years ahead. The first thing you'll probably discover: Your archives and photo files are not in order. PMID- 10152844 TI - How to build a magnet. Jewish Hospital built a $45 million heart and lung center and the patients came. AB - You might never have wondered how to build a magnet--unless that was a new heart and lung center that would be a "virtual magnet for physicians and patients." That's been the experience of Jewish Hospital in Louisville, Ky., and their new 14-story Rudd Heart and Lung Center. By the end of the year, it may be one of the top 10 centers for open heart surgeries in the country. What's the attraction? PMID- 10152845 TI - Talkradio talks healthcare. CareAmerica's media joint venture works to promote healthier lifestyles throughout southern California. AB - "Partners in Caring" is a unique community awareness campaign to promote healthier lifestyles throughout southern California. The media joint venture links CareAmerica and KABC Talkradio in Los Angeles. The synergy works on several different levels. The combination might even work in your locale. PMID- 10152846 TI - Making direct mail direct. Indian River Memorial Hospital reaches newcomers with an improved direct mail campaign. AB - New residents moving into a community are prime targets for new physicians and new hospitals. It's the hospital's chance to make a great first impression and establish a long-term relationship. Indian River Memorial Hospital in Vero Beach, Fla., has some experience in that area. They share their direct-mail ideas with you. PMID- 10152847 TI - Deaconess Hospital sponsors ninth Children's Art Fair. Deaconess Hospital, Evansville, IN. AB - It's almost a ritual. On the third Saturday of each September, thousands of parents and their children head for the Children's Art Fair at Mesker Park Zoo in Evansville, Ind. For the past 27 years, it has been the largest hands-on participative event in a tri-state area. For the past nine years, the event has been sponsored by Deaconess Hospital. Color it successful. PMID- 10152848 TI - Mother's Day celebration achieves dual objectives. "Largest Mother's Day celebration in the world" draws big crowds to Jewish Home for the Aging of Los Angeles. AB - Moms are usually treated with the respect they deserve, and they're always given special treatment on Mother's Day. But leave it to the Jewish Home for the Aging of Los Angeles to stage "The Largest Mother's Day Celebration in the World." As the title implies, it was a huge event: well planned, well executed. PMID- 10152849 TI - Quiet--hospital zone: why we should reduce noise levels in the hospital. PMID- 10152850 TI - First, do no harm: balancing the risks and benefits of medical procedures. PMID- 10152851 TI - Octave waveband analysis to determine sound frequencies and intensities produced by nebulizers and humidifiers used with hoods. AB - BACKGROUND: health-care practitioners should be aware of how their equipment and practices can increase the patient's risk for noise-induced hearing loss. PURPOSE: We conducted this study to determine the type of noise produced by humidifiers and nebulizers used with hoods in the neonatal intensive care unit (NICU). We performed octave waveband analysis to determine sound intensities and frequencies because degree of hearing loss from noise exposure is related to the intensity of sound, frequency of sound and duration of exposure. METHODS: We studies 4 simple humidifiers, 3 heated humidifiers, and 4 nebulizers. Sound levels were measured at various frequencies, flows, and water levels using Peace and Shiley oxygen hoods. RESULTS: The findings show that sound levels were significantly louder (p.0.001) for nebulizers compared to humidifiers. Aquapak nebulizers pose the greatest risk for hearing loss because they produce sound at the highest frequencies and volumes. The peak sound levels of humidifiers not only were significantly lower but also occurred at the lowest sound frequencies, which are the least damaging to hearing. Sound levels were generally higher across sound frequencies at higher flows and with the Peace Hood. CONCLUSION: We conclude that heated humidifiers produce lowest sound intensities at the lowest sound frequencies and, consequently, are most appropriate for use in the NICU. PMID- 10152852 TI - The impact of a postoperative oxygen therapy protocol on use of pulse oximetry and oxygen therapy. AB - BACKGROUND: Recent evidence suggests that both pulse oximetry monitoring and oxygen (O2) therapy may be used inappropriately at times, implying the need for improved use of pulse oximetry by health-care providers. METHODS: We studied the clinical and financial impact of a postoperative O2-therapy protocol in 2 groups of patients. Group 1 (n = 20) was comprised of patients whose physicians made all O2 therapy management decisions. Group 2 (n = 20) was comprised of patients whose O2 therapy management was performed by respiratory therapists according to an algorithm with a stop criterion of SpO2 > or = 92%. The duration of postoperative O2 therapy, the frequency of unnecessary O2 therapy, and group totals of SpO2 measurements were compared between groups using the Mann-Whitney Rank Sum Test. RESULTS: O2 therapy was used on average (SD) 3.45 (1.28) days/patient in Group 1 and 2.1 (0.64) days/patient in Group 2 (p < 0.003). Sixteen Group-1 patients continued to receive O2 at least 24 hours after achieving a room-air SpO2 > or = 92%. Group 1 had 57 SpO2 measurements and Group 2 had 24 (p < 0.003). No adverse clinical events ascribed to hypoxemia were noted in either group. CONCLUSIONS: Our experience suggest that implementing a uniform, clinically appropriate 'stop criterion' for low-flow O2 therapy in nonthoracic postoperative patients can shorten the duration of O2 therapy and reduce the number of SpO2 measurements without incurring additional complications. PMID- 10152853 TI - Ventilator-associated pneumonia: an update for clinicians. AB - VAP is a common problem faced by clinicians caring for critically ill patients. Use of appropriate preventive, diagnostic, and therapeutic strategies should minimize morbidity resulting from this clinical problem. Future investigations need to better define the optimum diagnostic methods and the most appropriate use of antibiotics for patients with suspected VAP. Only by developing these strategies can we hope to avoid the complications associated with spiraling empiricism. These complications include numerous outbreaks of serious antibiotic resistant nosocomial infections due to the empiric over-administration of broad spectrum antimicrobial agents. Advances in both the clinical and basic medical sciences are likely to help further elucidate the epidemiology and pathogenesis of VAP and, thereby, improve the opportunities for future prevention of this disorder. PMID- 10152854 TI - Median nerve damage from brachial artery puncture: a case report. AB - This report describes a case in which puncture of the brachial artery to obtain a sample for blood-gas analysis resulted in damage to the median nerve with a persisting neuropathy and apparent loss of function. Errors in judgment and contributions to possible negligence included (1) inappropriate choice of sampling site; (2) lack of knowledge of precautions and possible complications; (3) incomplete/inadequate description of optimal procedure in departmental procedure manual; (4) arbitrary selection of the dominant hand. PMID- 10152855 TI - The lighting business. IALD (International Association of Lighting Designers) poll studies work trends. PMID- 10152856 TI - Data rich, information poor (DRIP) syndrome: is there a treatment? PMID- 10152857 TI - Assessing provider quality in the age of information. PMID- 10152858 TI - From paradigms lost to paradigms regained? The MILTON approach to health care reform. AB - Proposes the MILTON model of health care policy and management as a framework within which debates about the future reform of the UK National Health Service may be conducted. Reviews the economic, political, social and technological forces which have shaped health care policy and management. Suggests that, at the macrolevel, the paradigm has changed from one based on assessment of needs to one based on securing value for money. At the microlevel, there have been equally profound changes in the nature and availability of work. A theme common to both levels is that of rapid and continuous change. Claims the MILTON model offers a way for the protagonists in the health care debate to locate their arguments about policies of health care provision and the implications for the management of work in a changing world in four planes of the model. The benefits are that the differing positions may be seen more clearly and, arguably more important, that a wider range of options is appreciated when, all too often in the past, arguments have become polarized on a single plane. PMID- 10152859 TI - Narrative in research: the research and the researcher survey--women GPs and stress. AB - Activities and stresses are linked and can be viewed closely only as a sequence of actors and behaviors, or a narrative. Examines such narratives from the which the individualized stress emerges plainly. Emphasizes that the researcher is involved in a narrative of her own life and reactions to the research project. Portrays the interdependence of these narratives: those of the doctor or GP under survey and those of the researcher. PMID- 10152860 TI - The future direction of general practice. AB - Examines the present strengths and weaknesses of the general practice system. Proposes a different structure for the future which should provide benefits for both the purchasers and providers of health care, as well as for the patients themselves. PMID- 10152861 TI - The effect of dental insurance on the demand for dental services in the USA: a review. AB - Examines the primary studies which have contributed to dental care research. By reviewing background information, lays a foundation for the review of the current empirical evidence, which examines the effect of dental insurance coverage on the oral health of the American population, as well as the utilization and demand for dental services. Raises questions and implications for future research and practice. PMID- 10152862 TI - The impact of environmental turbulence on American hospital strategies. AB - It is clear that dramatic changes are taking place in the way health care organizations are being managed. Health care executives are having to make the transition from managing with a "pass the cost along to the consumer" perspective to one of extreme competitive pressure to reduce costs while maintaining appropriate levels of quality. Reports the results of a survey of 135 American hospitals' executives. Uses factor analysis to uncover four distinct strategies being operationalized. Classifies hospitals' strategies as: strategic analysers, externally focused and offensively proactive; quality providers, internally focused and defensive reactors; price negotiators, externally-focused and offensively reactive; or cost efficiency providers, internally focused and defensively proactive. PMID- 10152863 TI - Surveying the organizational culture in an NHS trust. AB - Describes the methodology used to survey the organizational culture in four strategic business units of an NHS trust. Data were collected from selected organizational members on 19 different dimensions of culture using both qualitative and quantitative methods. Reports the findings from the culture survey in one of the four directorates in detail to demonstrate the quality of data to be collected using this methodology. PMID- 10152864 TI - Seek alternatives via simulation software. PMID- 10152865 TI - Hospital information systems. PMID- 10152866 TI - Legal and policy issues challenge telemedicine. PMID- 10152867 TI - Newton supporters offer multiple healthcare apps. PMID- 10152868 TI - Select mobile computers tailored to healthcare environment. PMID- 10152870 TI - Health information networks help prepare for change. PMID- 10152869 TI - Mobile computers and applications. PMID- 10152871 TI - Medicare program; revisions to payment policies and adjustments to the relative value units under the physician fee schedule for calendar year 1996--HCFA. Final rule with comment period. AB - This final rule revises various policies affecting payment for physician services including Medicare payment for physician services in teaching settings, the relative value units (RVUs) for certain existing procedure codes, and establishes interim RVUs for new and revised procedure codes. The rule also includes the final revised 1996 geographic practice cost indices. The rule redesignates current regulations on teaching hospitals, on the services of physicians to providers, on the services of physicians in providers, and on the services of interns and residents. This redesignation consolidates related rules affecting a specific audience in a separate part and, thereby, makes them easier to use. PMID- 10152872 TI - Medicare program; physician fee schedule update for calendar year 1996 and physician volume performance standard rates of increase for federal fiscal year 1996--HCFA. Final notice. AB - This final notice announces the calendar year 1996 updates to the Medicare physician fee schedule and the Federal fiscal year 1996 volume performance standard rates of increase for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and (f), respectively, of the Social Security Act. The fee schedule update for calendar year 1996 is 3.8 percent for surgical services, -2.3 percent for primary care services, and 0.4 percent for other nonsurgical services. While it does not affect payment for any particular service, there was a 0.8 percent increase in the update for all physicians' services for 1996. The physician volume performance standard rates of increase for Federal fiscal year 1996 are 0.5 percent for surgical services, 9.3 percent for primary care services, 0.6 percent for other nonsurgical services, and a weighted average of 1.8 percent for all physicians' services. In our July 26, 1995 proposed rule concerning revisions to payment policies under the Medicare physician fee schedule for calendar year 1996, we proposed using category-specific volume and intensity growth allowances in calculating the default Medicare Volume Performance Standard (MVPS). We received 20 comments on this proposal. Since this proposal is related to the MVPS and this notice deals with MVPS issues, we are responding to those comments in this notice instead of in the final rule for the fee schedule entitled "Medicare Program; Revisions to Payment Policies and Adjustments to the Relative Value Units Under the Physician Fee Schedule for Calendar Year 1996" published elsewhere in this Federal Register issue. PMID- 10152873 TI - Adapting a commercially available software program to improve ADR reporting. AB - To facilitate the long-term storage, retrieval, and analysis of adverse drug reaction (ADR) data, the drug information service at the University of Texas Health Science Center at San Antonio selected a computer software program with the capability to compile sets of relational databases. Five subsets were created to form the ADR database--patient demographics, medications, American Hospital Formulary Service classifications, adverse reactions, and case reports. This computerized system allows for quick information retrieval as well as the generation of monthly ADR reports. With such information, trends in ADRs can be identified and targeted for intervention programs to improve patient care and to comply with JCAHO requirements. PMID- 10152874 TI - Increased contributions, decreased fees, managed care are key Medicare reform issues. PMID- 10152875 TI - North suburban Chicago facility determines managed care and integration strategies. PMID- 10152876 TI - Physicians are the popular choice to lead integrated systems. PMID- 10152877 TI - Primary care facility in Michigan changes strategies after 18 months of talks, decides to forge ahead with PC-focused network. PMID- 10152878 TI - Columbia/HCA launches corporate strategy to create physician and consumer connections via the Internet. PMID- 10152879 TI - Collaborating to create important strategic partnerships for occupational therapy. PMID- 10152880 TI - The clinical utility of the Canadian Occupational Performance Measure. AB - A qualitative research project was undertaken to investigate the clinical utility of the Canadian Occupational Performance Measure (COPM) among therapists from the Regional Municipality of Ottawa-Carleton's Home Care Programme. Nineteen occupational therapists participated in one of four focus groups and in a plenary session to elicit reasons why some therapists used the COPM to assess clients and why others did not. The participants presented a wide range of opinions on the same theme, often from two polarities. The five themes that emerged from the focus groups and which were validated during the plenary session were: Use, environment, administration, outcome and suggested changes. The results demonstrated that COPM utility depended upon the degree to which therapists had incorporated the client-centred approach in their practice, the degree to which management valued and supported the use of the COPM and the degree to which the COPM could be flexible to fit practice context. PMID- 10152881 TI - Client-centred practice: what does it mean and does it make a difference? AB - During the past 15 years, occupational therapists in Canada, through the Canadian Association of Occupational Therapists, have worked to develop and implement guidelines for practice of a client-centred approach to occupational therapy. One of the difficulties with the current Guidelines for the Client-Centred Practice of Occupational Therapy is the lack of a definition and discussion of the concepts and issues fundamental to client-centred practice. In this paper, key concepts of client-centred practice: individual autonomy and choice, partnership, therapist and client responsibility, enablement, contextual congruence, accessibility and respect for diversity are discussed. Two practice examples are used to illustrate these ideas and raise issues about obstacles to the practice of client-centred occupational therapy. Research evidence about the effectiveness of client-centred concepts in enhancing client satisfaction, functional outcomes and adherence to health service programmes is reviewed. PMID- 10152882 TI - Tackling evaluation: applying a programme logic model to community rehabilitation for adults with brain injury. AB - Programme evaluation has become an important component of many rehabilitation initiatives in both institutional and community environments. Of key importance is a need for information on developing an evaluation framework to determine and address programme processes and outcomes. This paper presents a programme logic model used to guide the evaluation of a community rehabilitation programme for adults with brain injury. Programme logic models are visual models that provide a framework to organize and integrate information about programme inputs, processes and outcomes. The model is also used in this programme to incorporate the client centred values of the programme. It was developed through the consensus of the entire team, and was used to plan implementation and outcome evaluations. A similar programme logic model will be useful to occupational therapists and other health care professionals planning programme evaluations of their services. PMID- 10152883 TI - Medicare headed for PPS, but with fewer dollars. PMID- 10152884 TI - Estimating the true costs of assisted living. PMID- 10152885 TI - Proposed Medicaid cuts linked to OBRA '87 debate. PMID- 10152886 TI - 1995 awards. Honoring long term care's elite. Order of Excellence. PMID- 10152887 TI - Chains jockey for position. PMID- 10152888 TI - When clinical guidelines turn into standards of care. PMID- 10152889 TI - What about me? PMID- 10152890 TI - How global pricing works. PMID- 10152891 TI - Physician relations. Managing the transition after acquisition. PMID- 10152892 TI - Conducting financial due diligence of medical practices. AB - Many healthcare organizations are acquiring medical practices in an effort to build more integrated systems of healthcare products and services. This acquisition activity must be approached cautiously to ensure that medical practices being acquired do not have deficiencies that would jeopardize integration efforts. Conducting a thorough due diligence analysis of medical practices before finalizing the transaction can limit the acquiring organizations' legal and financial exposure and is a necessary component to the acquisition process. The author discusses the components of a successful financial due diligence analysis and addresses some of the risk factors in a practice acquisition. PMID- 10152893 TI - Practice acquisition: a due diligence checklist. HFMA Principles and Practices Board. AB - As healthcare executives act to form integrated healthcare systems that encompass entities such as physician-hospital organizations and medical group practices, they often discover that practical guidance on acquiring physician practices is scarce. To address the need for authoritative guidance on practice acquisition, HFMA's Principles and Practices Board has developed a detailed analysis of physician practices acquisition issues, Issues Analysis 95-1: Acquisition of Physician Practices. This analysis includes a detailed due diligence checklist developed to assist both healthcare financial managers involved in acquiring physician practices and physician owners interested in selling their practices. PMID- 10152894 TI - Tying physician incentive pay to performance. AB - Physician compensation costs in healthcare organizations continue to increase as organizations hire physician employees or acquire them through mergers with group practices and pay them salaries plus substantial benefits. In an effort to obtain the greatest possible return on their investments in physician employees, many healthcare organizations are linking physician pay and benefits to improved performance, according to two recent benefit and compensation surveys. PMID- 10152895 TI - Paying physicians for charity care. AB - The Internal Revenue Service's (IRS's) Announcement 95-25 gives important new legal support to the practice of compensating physicians for providing charity care. The announcement describes a situation in which tax-exempt hospitals may compensate non-employee physicians who are members of their staffs for providing charity care--a practice that in the past has had only indirect legal support. Before creating arrangements to compensate physicians for charity care, however, healthcare executives first must establish guidelines that ensure the arrangements comply with IRS rules and Federal antikickback laws. Careful planning on the part of healthcare executives can ensure that an important community service is provided without jeopardizing the hospital's tax-exempt status or exposing it to monetary penalties. PMID- 10152896 TI - Structuring competitive physician compensation programs. AB - One of the most momentous recent changes in the healthcare marketplace is the movement of physicians from the private practice of medicine to full- or part time employment. As increasing numbers of physicians become employees of healthcare organizations, structuring competitive physician compensation programs to attract and retain physicians will become increasingly important for the financial well-being of healthcare organizations. Healthcare executives should use data from an adequate sample of competing physician employers in structuring physician compensation programs consistent with their organization's strategic goals and objectives. PMID- 10152897 TI - CEO/CFO responses to materials management survey. AB - A national survey of chief executive officers (CEOs) and chief financial officers (CFOs) reveals that while CEOs and CFOs are satisfied overall with materials management at their hospitals, a number of individual facets of materials management need improvement. The survey also shows that reducing supply expenses and better managing operating room (OR) inventories are two of the best ways that materials managers can help reduce hospitals' total annual operating expenses. PMID- 10152898 TI - Rethinking the eligibility inquiry process. PMID- 10152899 TI - Data trends. December 1995. PMID- 10152900 TI - UR managers must ensure all sides are heard in treatment decisions. PMID- 10152901 TI - How to develop guidelines that work. PMID- 10152902 TI - Does your data answer the 'So what' question? PMID- 10152903 TI - Multidisciplinary plan wows Joint Commission. PMID- 10152904 TI - Take those clinical guidelines off the shelf. PMID- 10152905 TI - Treating patients at nursing home cuts hospital stays by 58%. PMID- 10152906 TI - Military managed care. PMID- 10152907 TI - Culture and the cost of clinical care. PMID- 10152908 TI - Long-term care. Nothing ventured, nothing gained. PMID- 10152909 TI - Long-term care. Down payment on later life. PMID- 10152910 TI - Long-term care. Faith, home and charity. PMID- 10152911 TI - Art in healthcare. Does NHS art make you sick? PMID- 10152913 TI - Ambulance services. Countdown to Christmas. PMID- 10152912 TI - Community nursing. Home economics. PMID- 10152914 TI - Practice management. Sweetening the pill. PMID- 10152915 TI - A changing order for pharmacy. PMID- 10152916 TI - A practical approach to achieving a $950,000 cost savings from a joint anesthesia pharmacy program. AB - This report describes a joint anesthesia-pharmacy program to change prescribing and use of neuromuscular blocking agents and narcotic analgesics. The program uses pancuronium and fentanyl as "workhorse" agents with more expensive, shorter acting agents used for short-duration cases and for patients with characteristics such as renal and hepatic insufficiency that may affect the duration of action of other neuromuscular blocking agents. Cost-savings associated with changes in drug prescribing were tracked. Some savings were applied to the planning and implementation of a pharmacy operating room satellite. A cost-savings exceeding $950,000 during a 3-year period was achieved. PMID- 10152917 TI - Changes in 1994 drug cost for inpatient services. AB - The healthcare system is undergoing major changes in the manner in which healthcare is being delivered. These changes have affected individual institutions per se, as well as having an affect upon the cost of the drugs being administered. The comparative indices for the years 1993 and 1994 indicate that the utilization and classes of drugs being prescribed are undergoing change. Although drug cost has not increased to the same magnitude as in the past, it continues to show significant growth. Of continuing importance is the changes taking place in the classifications of drugs being used and the affect that these changes have on cost. PMID- 10152918 TI - An evaluation of postoperative pain management in pediatric patients at a university teaching hospital. AB - In recent years, pediatric pain management has begun to receive some much deserved attention. Many misconceptions regarding pediatric pain management have resulted in infants and children receiving inadequate pain control after surgical or invasive procedures. The purpose of this investigation was to evaluate appropriateness of pain management practices, emphasizing drug therapy, in children with acute pain after a surgical procedure. Analgesic use and pain assessment methods were evaluated for 30 pediatric patients undergoing an invasive medical procedure or surgery. Data were collected concurrently on the use of pain medications, potential for drug interactions/duplication of therapeutic classes, pain assessment, patient response to medication, and any adverse effects experienced by a child. Twenty patients (67%) had concurrent orders written for multiple analgesics on admission to the nursing unit. Only 6 of these 20 order sets (30%) designated specific indications for use. Ten of the 14 remaining order sets (those without specific directions for use) contained at least one medication that was inappropriate to treat the expected level of postoperative pain. Fifty-four percent of total physician orders fell outside study criteria for appropriate dosing and scheduling frequency. Patient records revealed that nursing administered the lowest ordered dose 47% of the time, and a failure to consistently conduct pain assessments or document patient response to medication. Eight patients (27%) experienced allergic-type reactions, whereas 7 patients (23%) experienced adverse drug reactions. Information gathered from this review will be used to determine if a need exists to develop hospital guidelines or adopt the Agency for Health Care Policy and Research guidelines for acute pain management in children. PMID- 10152919 TI - Something old, something new: facility expansion emphasizes holistic health. PMID- 10152920 TI - Learning the hard way: veterans of disaster tell why--and how--you should be prepared. PMID- 10152921 TI - Salaries go up. PMID- 10152922 TI - DOT finalizes hazardous materials rule, defines RMW (regulated medical waste). PMID- 10152923 TI - Laundry: the next frontier for the value-added trend. PMID- 10152924 TI - Risky business: job interview traps and how to avoid them. PMID- 10152925 TI - Proposed Medicaid cuts target the vulnerable. PMID- 10152926 TI - Catholic collaboration: a sign of hope. PMID- 10152927 TI - Identity and institutions. Catholic healthcare providers must refashion their identity as actors and advocates in the world. PMID- 10152928 TI - Issues at the end of life. The revised Ethical and Religious Directives discuss suicide, euthanasia, and end-of-life procedures. AB - Part 5 of the Ethical and Religious Directives for Catholic Health Care Services reminds us that death is necessary for the transition to eternal life. Thus, although Christians have a duty to preserve worldly life, a gift from God, that duty is not absolute. Suicide and euthanasia are never morally acceptable. On the other hand, life-prolonging therapy need not be used if it provides insufficient benefit or imposes an excessive burden. Directive 55 describes the comfort and care that should be given to dying patients. Directives 56 through 59 discuss the ethical norms for either using or forgoing procedures designed to prolong life. Directive 60 repeats the Church's teaching in regard to euthanasia and physician assisted suicide (PAS)--that is, whatever the intentions of those who employ them, euthanasia and PAS remain forms of murder. Directive 62 considers the methods used to determine that death has occurred. Directive 66 encourages patients to donate their organs and bodily tissue after death. However, the directive says, Catholic healthcare facilities should not make use of tissue obtained by direct abortions. PMID- 10152929 TI - Patient-centered process of work redesign. Arizona hospital reengineers with no outside help. AB - A few years ago, Carondelet St. Joseph's Hospital in Tucson, AZ, realized that care delivery reflected a mechanistic, boundary-filled system rather than a process centered around patient care. To change this, St. Joseph's planned a work redesign process that a multidisciplinary team (under the guidance of nursing leadership) implemented and evaluated. The Steering Committee for Patient Centered Care (an interdisciplinary group) established five teams to plan and implement the redesign effort. The teams were responsible for quantification, quality, public relations and communication, education and human resources, and the pilot project. Four key factors helped get the redesign effort up and running: Support from the top. The involvement of all key disciplines. The timely movement from envisioning to implementation. Communication of tangible measurements of the change process. Patient-centered care continues to be refined and improved at St. Joseph's. PMID- 10152930 TI - How to foster self-determination. Practical ways nursing home staff can empower residents. AB - How can a long-term care facility empower its residents and enable them to become involved in decisions that affect their lives? A number of programs offer traditional and more innovative ways to support nursing home resident independence: Resident council. Resident welcoming committee. Resident activities committee. Food committee. Resident newsletter. Opportunity to vote. Quality-of life survey. Dietary survey. New employee orientation program. Care planning process PMID- 10152931 TI - Teen pregnancy: prevention and support. PMID- 10152932 TI - When to excuse employees from work responsibilities. PMID- 10152933 TI - "Dr. Kildare" stereotype undermines physician recruitment. PMID- 10152934 TI - Psychological types of health administration students: suggestions for teaching, learning, and the future of the profession. AB - In this article, the configurations of psychological types that exist among a sample of 393 American graduate health administration students are analyzed. These data are compared to the psychological type characteristics of both university-level faculty and practicing health care administrators. Important insights can be derived from these comparisons in terms of teaching and learning in health administration programs, and they serve as a foundation for a coming transformation within the profession of health services administration. PMID- 10152935 TI - The Primary Care Policy Fellowship: an innovative model for interdisciplinary collaboration. AB - The U.S. Public Health Service Primary Care Policy Fellowship is an interdisciplinary program that was created in 1991 to increase the capabilities of mid-career primary care academicians, researchers, administrators, and practitioners to the dynamics of primary care policy development, the legislative process, resource identification, and leadership development. Interdisciplinary education and collaboration is the means by which this goal is being met, with fellow and faculty representation coming from medicine, nursing, public health, dentistry, health administration, and others. Described in this article are collaborative activities that have been specifically designed to increase contact and collaboration between the multiple disciplines that attend. One such important activity has become the Primary Care Fellowship Society (PCFS), an alumni association that has been formed by veteran fellows who believe in the importance of continuing an interdisciplinary agenda beyond the 3-week Fellowship program. An important outcome of both the Fellowship and its alumni association has been an increased understanding and respect for one another's discipline. PMID- 10152936 TI - In pursuit of computer literacy in health management education. AB - Computer literacy skills are essential tools students must possess to do well in computer-related and quantitative courses, and to be effective health managers. Many health management education programs are faced with the challenge of finding an ideal framework for teaching computer literacy courses. Recently, Austin and Malec (1990) proposed an instructional method for teaching computer literacy. This method was used for three consecutive semesters to teach the computer literacy course offered at Sangamon State University. A case analysis technique was utilized to assess of the effectiveness of this method. A pre-test and post test design was used in the study. Post-test scores were found to be significantly higher than pre-test scores. Improvements in students' attitudes toward computers were noticed in the areas pertaining to how they view their competency levels. Overall, the data for this study suggest that this instructional method is effective for teaching computer literacy to adult students who have had limited exposure to computers. PMID- 10152937 TI - Teaching about cultural diversity to health administration students: a teaching module. AB - This article presents a detailed description of a teaching module on cultural diversity for use in the college classroom. The module has been successfully incorporated into courses in a health administration curriculum and is suitable for inclusion in a wide variety of courses. The module includes a short theory lecture, student discussion groups organized around ways in which students have experienced discrimination, and student reports. PMID- 10152938 TI - Graduate health administration field experiences: a university and health service delivery systems partnership. AB - The importance of experiential components of education to professional preparation has been evidenced in the curricula of academic institutions in several disciplines. Graduate programs in health administration offer a variety of alternative residency, internship, and other field experiences for students to apply academic theory to practical phenomena. Using a case study approach, this article presents the advantages of field experience options to both students and health care delivery sites. Components of a model of experiential alternatives in a graduate health administration program are described. PMID- 10152939 TI - Education for health services management: a graduate student survey of an Australian program. AB - This article reports the results of a study which was designed to evaluate a revised Master's of Health Administration program in the School of Health Services Management at the University of New South Wales, Australia. The original program was established in 1956; during the 1970s, humanities-based subjects such as sociology and quality assurance were added to the traditional financial and management subjects. During 1987-88, health-oriented subjects such as public health and epidemiology were included as compulsory subjects. To assess the program, a cross-sectional study of 1990 to 1992 graduates was undertaken. The study revealed that students found that the traditional financial and management subjects and the health-related subjects were useful to their jobs. The study also demonstrated significant career advancement for a majority of graduates. Two thirds of the respondents stated that their initial objectives for enrolling in the course had been met. PMID- 10152940 TI - Graduate programs in health administration: faculty academic reputation and faculty research reputation by program location and program reputation. AB - This study used program location and program reputation to describe two important faculty characteristics: academic reputation and research reputation. The study involved 44 graduate programs in health administration representing four program locations: schools of public health, business, medicine/allied health, and graduate/independent. Fourteen programs were identified as ranked programs and the remaining 30 programs were identified as unranked programs. While the study identifies many differences, few are significant, thus adding credence to the argument for diversity in program location and diminishing credence in the argument for program reputation. PMID- 10152941 TI - How a ditchdigger made doctors of his daughters. PMID- 10152942 TI - How I made medicine fun again. PMID- 10152943 TI - Forecast for doctors: stronger winds of change. PMID- 10152944 TI - Practice changes. Should you merge or sell--or do nothing? PMID- 10152945 TI - For HMOs, "self interest" is now spelled G-O-P. PMID- 10152946 TI - We don't have to tell third parties everything. PMID- 10152947 TI - Should your group have its own HMO? PMID- 10152948 TI - When a 23-year-old asks to die. PMID- 10152949 TI - Honey, I shrunk the patient records. PMID- 10152950 TI - Are jurors competent enough to judge doctors? PMID- 10152951 TI - Economics 101: exploring the land of costs. AB - The word "cost" is a slippery, chameleon-like beast that changes its meaning to suit the occasion. The author's "economish" dictionary will help you survive the purchasing jungle. PMID- 10152952 TI - Steering your CQI team. A guide for group leaders. PMID- 10152953 TI - Here's how to keep your safety program on track. PMID- 10152954 TI - Providers applaud latest White House budget plan. PMID- 10152955 TI - Mo. system moves on as FTC dismisses suit. PMID- 10152956 TI - Comments on PHO antitrust case have poured in. PMID- 10152957 TI - AMA seeks 3-year Medicare fee transition. PMID- 10152958 TI - FTC weighs easing antitrust rules for provider networks. PMID- 10152959 TI - AMA names first woman chair of board of trustees. PMID- 10152960 TI - Medicaid block-grant plan under siege. PMID- 10152961 TI - Ariz. county board to name contract finalist. PMID- 10152962 TI - Iowa system to add fifth hospital. PMID- 10152963 TI - Some docs refusing CHAMPUS patients. PMID- 10152964 TI - Home equipment groups, HCFA fight over study. PMID- 10152965 TI - N.Y. to dump rate-setting system. PMID- 10152966 TI - Texas orders Charter to pay fine, offer free care to Medicaid kids [corrected]. PMID- 10152968 TI - Some upset as Ill. hospital's deal gets OK. PMID- 10152967 TI - Foes, friends address Mass. hospital deal. PMID- 10152969 TI - Higher pay now may mean more pain later. PMID- 10152970 TI - A single standard for measuring community benefit is needed. PMID- 10152971 TI - Tax-exempts haven't proved their case on community benefits. PMID- 10152972 TI - Morale hits new low. AB - If President Clinton thinks Americans are in a national funk, he should stay out of the hospital, where the atmosphere is positively morose. Poor morale is by far the worst human resources problem in the hospital industry, according to a survey of 681 hospitals conducted in October by Deloitte & Touche for Modern Healthcare. PMID- 10152973 TI - Columbia-Sharp deal faces scrutiny. PMID- 10152974 TI - Brim, Paracelsus call off deal. PMID- 10152975 TI - HMO groups plan counterpunch to media criticism. PMID- 10152976 TI - Hospitals post impressive numbers in '94. PMID- 10152977 TI - Premier closes its N.Y. regional office. PMID- 10152978 TI - Council sees dire impact of funding cuts on hospitals. PMID- 10152979 TI - Governor's panel OKs major Indianapolis deal. PMID- 10152980 TI - Aetna charges Paracelsus with fraud. PMID- 10152981 TI - U. of Pa. officials: doc fines won't affect hospital finances. PMID- 10152982 TI - Columbia to open 5 women's health centers in Tenn. malls. PMID- 10152983 TI - Medicare margins climb through cost cutting. PMID- 10152984 TI - Provider support Dems' budget plan. PMID- 10152985 TI - Texas, Okla. hospitals consider sales, mergers. PMID- 10152986 TI - Allina redraws operating divisions. PMID- 10152987 TI - Columbia move into Michigan draws fire. PMID- 10152988 TI - Firm to buy Cleveland system. PMID- 10152989 TI - Two northwest hospitals draw closer. PMID- 10152990 TI - Wis. hospitals to link despite differences. PMID- 10152991 TI - Merger creates big Colo. system. PMID- 10152992 TI - Wash. medical groups form company. PMID- 10152993 TI - Poll: for-profits, not-for-profits both have advantages. PMID- 10152994 TI - CHA urges Clinton to fight tax reimbursement. PMID- 10152995 TI - Providers rooting for Clinton Medicaid plan. PMID- 10152996 TI - Fla. nursing home group seeks independent study. PMID- 10152997 TI - Allegheny barred from severing pact. PMID- 10152998 TI - New Tenn. rural health firm to built outpatient center. PMID- 10152999 TI - More providers using care protocols, new study finds. PMID- 10153000 TI - Storing device saves space, money. PMID- 10153001 TI - Columbia, Pittsburgh hospital discussing some form of link. PMID- 10153002 TI - Mergers and acquisitions report. 1995: a record year for hospital deals. AB - Healthcare executives whose organizations didn't do anything this year are the odd men out in an industry that made big news almost daily in 1995. The year included not only the usual smattering of mega-mergers but also featured wrongly amputated limbs, more than the normal trade association positioning, and major Medicare and Medicaid reform proposals. PMID- 10153003 TI - WellPoint, HSI pull the plug on merger. PMID- 10153004 TI - NCQA assembles panel to refind HEDIS measures. PMID- 10153005 TI - Hospitals turn attention to assisted living. PMID- 10153006 TI - MedPartners/Mullikin adds Pacific Physician. PMID- 10153007 TI - How to keep the Joint Commission happy and plaintiff's attorneys frustrated. AB - With the first minimum standard by the American College of Surgeons in 1918, the credentialing of physicians became formalized Since those days, in which a physician was basically required to be licensed and of high professional, moral, and ethical character, many requirements have been added. All have been appended for the safety and quality of care of our patients. However, liability attorneys have discovered credentialing requirements and found them a veritable gold mine for litigation. As rapidly as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) offers another standard to help us protect not only our patients but also ourselves in this litigation-bent atmosphere, attorneys engineer a way to bring suit, using the standard as if it were a requirement for prevention of negligence rather than a self-imposed goal for attainment of quality. This article presents a method of credentialing medical staff members that neutralizes the threat of antitrust actions alleging the compromising of livelihood by the denial of membership or clinical privileges. Additionally, the methodology offers maximal protection and integrity of credentialing procedures while optimizing compliance with Joint Commission standards. PMID- 10153008 TI - A comparison of quality and utilization problems in large and small group practices. AB - Physicians practicing in large, multispecialty medical groups share an organizational culture that differs from that of physicians in small or independent practices. Since 1980, there has been a sharp increase in the size of multispecialty group practice organizations, in part because of increased efficiencies of large group practices. The greater number of physicians and support personnel in a large group practice also requires a relatively more sophisticated management structure. The efficiencies, conveniences, and management structure of a large group practice provide an optimal environment to practice medicine. However, a search of the literature found no data linking a large group practice environment to practice outcomes. The purpose of the study reported in this article was to determine if physicians in large practices have fewer quality and utilization problems than physicians in small or independent practices. PMID- 10153009 TI - Cost-effective rehabilitation: Part 2--Approaches to patient management problems. AB - Part one of this two-part series discussed general principles of cost-effective rehabilitation: Patients in rehabilitation programs should be working toward achievement of real-world functional goals. Goals should be realistic, and reachable in a reasonable amount of time. Rehabilitation services should be provided at the lowest safe and effective level of care appropriate to the patient's needs. Patients should be participating to their full potential in an active therapy program. Therapy intended to maintain a patient's current condition should be carried out by nonprofessionals who have had training sessions with rehabilitation professionals as needed. Discharge planning begins on the day of admission to the inpatient or outpatient rehabilitation program. This second of the two-part series will focus on individual patient management issues. It discusses circumstances in which the principles of cost-effective rehabilitation may need to be modified. It also discusses approaches to remedy patient management problems that may lead to excessive or ineffective utilization of rehabilitation services. PMID- 10153010 TI - Establishment of a community advisory committee at a major teaching hospital. AB - With the advent of continuous quality improvement and the '90s focus on patient or customer satisfaction, hospitals have started to try to identify what their patients or customers want. Hospitals serve communities of one sort or another, whether local communities or statewide communities for highly specialized procedures. They need to consult at least their local communities as part of a quality improvement process and also to help determine future directions. Austin Hospital in Australia decided to establish a formal advisory committee in order to accomplish this consultation. Although there have been minor deficiencies in the arrangement, the advisory committee has largely fulfilled the promise for which it was created more than seven years ago. PMID- 10153011 TI - Telemedicine: where is technology taking us? AB - Five years ago, a few zealots in Switzerland, at the CERN Laboratory, were contemplating using the Internet for hypertext and for transfer of still images, recorded sounds, and compressed video files. Five years later, the World Wide Web defines a set of standards for packaging and routing information over the Internet that involve millions of people and personal computers and that allowed a start-up Netscape to enjoy a capitalization of more than $2 billion when it sold stock to the public recently. Now, video-conferencing and multimedia electronic mail over the Internet are the fascinations of engineers at NASA, and the MBONE Information Web, the province of technophiles with UNIX workstations. Five years from now, you may be participating in telemedicine sessions frequently, from your workstation, and think nothing of it. PMID- 10153012 TI - Power and new economic relationships. AB - We are going through a transformation of our health services from a community and patient focus fueled by fee-for-service and cost-plus reimbursement. This transformation, called managed care, is shifting power away from professionals and communities into both new and old organizations financed by Wall Street. Even traditional community organizations are driven by Wall Street-dictated financial ratios that represent scoreboards to determine who gets capital for growth and development. Times are changing, organizations are changing, and still more change is ahead. PMID- 10153013 TI - Block grants set up funding tug-of-war. PMID- 10153014 TI - Looking abroad for business opportunities. PMID- 10153015 TI - Top training: a formula for success. PMID- 10153016 TI - Starting an adult daycare center. PMID- 10153017 TI - Guidelines: leading the way to best practices in long term care. PMID- 10153018 TI - Therapy providers await next move: rules on salary equivalencies expected soon. PMID- 10153019 TI - Securing a loan with government backing. PMID- 10153020 TI - Think productivity for oldest residents. PMID- 10153021 TI - '95 jobs. Think your salary's too low? Compare your career stats with peers' in R&I's 27th annual survey. PMID- 10153022 TI - Table toppers. PMID- 10153023 TI - Pew Commission releases recommendations. PMID- 10153025 TI - The meaning of certification--then and now. PMID- 10153024 TI - STs on international surgical teams: an unsurpassable experience. PMID- 10153026 TI - The hospital fraud inquiry that fizzled. PMID- 10153027 TI - Using process management to improve performance. The University of Maryland Medical System methodology. PMID- 10153028 TI - Getting the FAccts (Foundation for Accountability) straight. AB - Purchasers and consumers are taking the lead in monitoring health care quality through the new Foundation for Accountability. The aim is to consolidate, not proliferate, the quality criteria to which hospitals will have to respond in the future. PMID- 10153029 TI - Turmoil at the top. PMID- 10153030 TI - Risky business. PMID- 10153031 TI - The power circuit. Strategically integrated information systems could rescue hospitals from "servant" status. PMID- 10153032 TI - The Stark regulations: so much text; so little substance. AB - Regulations outlining providers' rights and responsibilities under the first Stark self-referral law are here at last. The authors argue they weren't worth the wait. PMID- 10153033 TI - Retreating and regrouping. The States wait and worry while Washington redesigns Medicaid. PMID- 10153034 TI - New York: a whole system in play. PMID- 10153035 TI - Texas: turmoil on the road to managed care. PMID- 10153036 TI - California: fishbowl of statutory and market hooks. PMID- 10153037 TI - 1995 State legislative survey. PMID- 10153038 TI - We're swimmin' in the same direction. PMID- 10153039 TI - Ethical dilemmas in managed care. PMID- 10153040 TI - Medical liability reform and the federal government. PMID- 10153041 TI - Designing healthcare regions: a Canadian approach. AB - Regionalizing healthcare delivery is a means to control rising costs and improve service delivery. The authors reviewed current and proposed healthcare regionalization models across Canada, and summarized their findings regarding several key factors. Their research on regionalization has led them to develop guidelines directed at those involved in planning and implementing healthcare regionalization. PMID- 10153042 TI - A model of mixed-market healthcare delivery: the British Columbia Transplant Society. AB - Driven by the twin imperatives of cost and quality, healthcare providers must innovate and adapt new management models which continuously improve performance. Focusing specifically on the British Columbia Transplant Society (BCTS), this article describes a successful mixed-market management model for delivering healthcare services to a relatively well-defined patient population which is suffering from chronic disease and has predictable healthcare needs. The BCTS is an example of a healthcare organization which combines the best aspects of both the Canadian and American healthcare systems. PMID- 10153043 TI - Taking care of healthcare a delicate balance. Interview by Aileen Leo. PMID- 10153044 TI - The relationship of hospitals and home care. PMID- 10153045 TI - Humour's potential as a management tool. PMID- 10153046 TI - Patients as professionals: enhancing inpatient care for psychiatric patients in Winnipeg. AB - Self-help in mental healthcare has made some profound strides over the last two decades. One area that has gone unnoticed is the greatly increased cooperation between self-help organizations and acute care psychiatric units. In this article, the author describes a program at Winnipeg's PsycHealth Centre that illustrates a new approach to combining self-help and the formal acute care system. It provides support, education, commonality and caring, and has produced remarkable reviews from patients, families and caregivers. PMID- 10153047 TI - Home care: the cornerstone of health renewal in Nova Scotia. AB - Until recently, home care services in Nova Scotia lacked uniformity and were difficult to access. This changed dramatically last June when the province launched Home Care Nova Scotia, the linchpin in the province's plan for health renewal. The program provides chronic and home hospital care to Nova Scotians of all ages, with five additional categories of care planned for the future. Like the 400 other coordinated home care programs in Canada, Home Care Nova Scotia is one alternative to the inappropriate use of acute and long term care facilities. It is also a valued service in its own right within the continuum of health services. PMID- 10153048 TI - TENS: the Canadian Physiotherapy Association sets the record straight. PMID- 10153049 TI - Managed care California style. California CEOs: aligned incentives a must in managed care environment. PMID- 10153050 TI - Q & A with Acting DMA Commissioner Marge Smith. PMID- 10153051 TI - Private/public sectors collaborate on health reform. PMID- 10153052 TI - Business still searching for common ground on reform. PMID- 10153053 TI - Health care reform presents substantial issues for employers. PMID- 10153054 TI - Perspectives on the public's health. PMID- 10153055 TI - "Any willing provider" issue adds fuel to reform debate. PMID- 10153056 TI - Health care by the numbers. New state information system focuses on healthier communities. PMID- 10153058 TI - Using information networks as a decision-making tool. AB - Reforms in healthcare have made the industry more competitive than ever. With budgets being cut all across the country, many healthcare managers are being asked to do more with less, and to do it more quickly. This combination of dynamics creates the need for tools that can help healthcare decision makers make good strategic decisions quickly and confidently. One such tool available to hospitals are information networks. A healthcare information network is an organization that streamlines and expedites decision-making processes by providing healthcare facilities with information that is either too time consuming or impossible for the facility to gather on its own. The information networks conduct research, analyze and condense the findings, and forward relevant data to the member facilities. By outsourcing the tedious research, analysis, synthesis, and presentation of key decision-making data to the information networks, member hospitals free their limited resources to concentrate on the details of the day-to-day operations. In most cases, hospitals that use information networks can also receive the information back more quickly than if they had done the research themselves. PMID- 10153057 TI - A cost benefit analysis of outsourced laboratory services. AB - As healthcare moves toward increased capitation, hospital administrators must be aware of all costs associated with patient services. This article describes the cost benefit analysis process used by northern Indiana hospital consumers during 1994-1995 to evaluate a local laboratory service outsource provider, South Bend Medical Foundation (SBMF). In an effort to meet the best interests of the community at large, three competing hospitals, medical leadership, and the local outsource provider joined forces to ensure that cost effective quality services would be provided. Laboratory utilization patterns for common DRGs were also analyzed. The team created a reconfiguration analysis to help develop benchmark figures for consideration in future contract negotiations. PMID- 10153060 TI - How to interpret vendor statements regarding ISO 9000 certification. PMID- 10153059 TI - Outsourcing: hospitals call for help. PMID- 10153061 TI - The good, the bad, and the ugly. PMID- 10153062 TI - Single source or low bidder? PMID- 10153063 TI - The outsource contract. AB - Outsourcing business functions has become part of the US corporate culture in the 1990s. The general concept of outsourcing is that a company, which historically has performed its own services in a given area using in-house employees, transfers these services to an outside vendor. Many companies in a variety of industries have found the economics and the flexibility that outsourcing can offer to be attractive; healthcare is no exception. Whether the entity that outsources an internal function is a hospital, health insurer, or another entity involved in the delivery of services, outsourcing is now a viable alternative in healthcare. This is particularly true with respect to hospital support services, such as accounts receivable collection and processing, medical records, laboratory testing, and dietary. While outsourcing can be highly beneficial, several issues exist that could create pitfalls for the uninitiated. Wary outsourcers should consider the following issues to reap maximum benefits from the outsourcing experience. PMID- 10153064 TI - Ethical dilemmas in the health care of older people. PMID- 10153065 TI - Nursing homes in the United States: an historical view and contemporary description of facilities and residents. PMID- 10153066 TI - Conceptions of long-term care risk, costs, and reimbursement among middle-aged and elderly people. PMID- 10153067 TI - Public versus private sector insurance for long-term care: issues and prospects. PMID- 10153068 TI - The utilization of social services by the elderly: are Area Agency on Aging services becoming biomedicalized? PMID- 10153069 TI - A model geriatric health care program for community/migrant health care centers. PMID- 10153070 TI - Home is not where the heart is: looming problems of the home care industry. AB - This analysis shows a definite trend of fiscal and social retrenchment policy by the government concerning in-home care service delivery (Tables 1 and 2). Ruggie (1990:164) notes that such shifts and changes in Medicare reimbursement patterns may be efforts of the government to realign itself to become the pivotal force in the provision or delivery of in-home care. Cost-containment pressures, although most needed in the health care industry, are the primary driving force behind retrenchment and the subsequent realignment of government. Such forces tend to impede the development of a comprehensive system for the provision of long-term care services. As noted, the movements and shifts in reimbursement patterns documented by this analysis can lead one to conclude that the same old features will continue to prevail instead of new and innovative delivery structures or public-private partnerships. In other words, the in-home care industry will become more like the nursing home industry--highly regulated and perpetually plagued by questions concerning quality of care. Although government is attempting to diminish its task as the prime provider of health services (i.e., through fiscal retrenchment) and the public's role as the dominant delivery system (i.e., social retrenchment), nevertheless the government has been unable to retrench politically in spite of its present direction of cost containment and fiscal restraint. Consequently, Ruggie (1990:147) notes that "the social welfare functions may continue to be performed" in spite of cost restraint policies. As a result, another "no care zone" is created and policy-makers will continue to develop "crisis policy" such as intense demands to hold unit costs low. The home care system has expanded many of the long-term care options and has emerged as a salient segment of our health and social service system (Applebaum and Phillips, 1990). Yet, policy-makers have not developed a comprehensive long-term care system, particularly one that defines a common policy for home care benefits and engenders the right kind of public-private partnership for the delivery of quality home care. PMID- 10153071 TI - Job satisfaction of public health nurses: is there a predictable decline? PMID- 10153072 TI - State regulation of hospitals: how does it affect nursing employment? PMID- 10153073 TI - Another look at work design in hospitals: redesigning the work roles of nurses. PMID- 10153074 TI - Volunteers in AIDS service organizations: motivations and values. PMID- 10153075 TI - Exploring the management development needs of health care managers: a case study. PMID- 10153076 TI - Barriers to women's career attainment. AB - Articles in the literature in the popular and professional journals and periodicals sustain the idea that significant barriers and a glass ceiling exist for women. While recognizing that overt and covert intentional discrimination may be a force in women's lack of career attainment, this work focuses on a network of semi-transparent societal and work world barriers which impede the career success of female healthcare managers. PMID- 10153077 TI - Employer coalitions flex their muscles. PMID- 10153078 TI - A whole new ballgame: employers focus on quality. PMID- 10153079 TI - Report cards: employers demand accountability. PMID- 10153080 TI - Rochester employers talk tough in face of rising costs. PMID- 10153081 TI - Employer health coalitions: activities and impact. PMID- 10153082 TI - Developing and implementing a statewide formulary system: one state's experience. AB - Prior to the Pennsylvania Department of Public Welfare (DPW) implementing a statewide formulary for its 21 mental health hospitals and mental retardation facilities, each facility had its own drug use policy. In many facilities, drugs were ordered with little or no cost-containment or drug-management consideration. To change drug purchasing and usage policies, a task force was created to develop a state formulary system. The task force appointed a formulary subcommittee to research and make recommendations on issues such as drug selections, formulary substitutions, and nonformulary drug use. The step-by-step process of developing and implementing the Pennsylvania DPW state formulary--including pitfalls and successes--is presented. PMID- 10153083 TI - FDA considers effects of managed care marketplace on drug promotional practices. PMID- 10153084 TI - Hospital cost analysis. PMID- 10153086 TI - Court stenographers deliver quick transcription. PMID- 10153085 TI - Innovative charting can slash costs, bolster efficiency, enhance quality. PMID- 10153087 TI - Train assistants to do the dictation for you. PMID- 10153088 TI - Pediatric hospitals use paramedics to free nurses. PMID- 10153089 TI - Portable fluoroscopy can speed patient care in EDs. PMID- 10153090 TI - Total computer management finding its way into progressive EDs. PMID- 10153091 TI - RFP: how to write one that works. Tips for purchasing an information system. PMID- 10153092 TI - Chicago ED turns patient complaints into praise. PMID- 10153093 TI - Flexible staffing programs help EDs expect the unexpected. PMID- 10153094 TI - Critical resource nurses solve staffing dilemmas. PMID- 10153095 TI - 1995 CPT documentation guidelines more stringent. Use checklists, templates to prevent oversights. PMID- 10153096 TI - Hand-held device provides lab results in 90 seconds. PMID- 10153097 TI - ED changes improve staff morale, patient care. PMID- 10153098 TI - Code response team organization can help save time and lives. PMID- 10153099 TI - Team mental health tied to training, evaluation. PMID- 10153100 TI - Improvement in coding sees million-dollar payoff. PMID- 10153101 TI - Diluting the skill mix: are nurses, patient care really threatened? PMID- 10153102 TI - Exercise care in using UAPs (unlicensed assistive personnel): a cautionary tale. PMID- 10153103 TI - Nurse clinicians are key to fast-track program. PMID- 10153104 TI - Pediatric hospitals offer services in adult EDs. PMID- 10153106 TI - FTC OKs merger; Columbia to sell seven hospitals. PMID- 10153105 TI - Ultrasound in the ED can mean faster diagnoses. PMID- 10153107 TI - Tie in physicians, grow IDSs slowly to win investors' favor, says Moody's. PMID- 10153108 TI - Pioneering not-for-profit IDS takes on major players in S. Florida market. PMID- 10153109 TI - Teaching hospital's redesign targets primary care, networks, IS. PMID- 10153110 TI - Integration begins moving through Pittsburgh provider, payer markets. PMID- 10153111 TI - Managed care, state cuts creating limits to charity care, study says. PMID- 10153112 TI - Laptops and health care: going mobile. AB - Kaiser Permanente's Northwest Region is using laptop computers for patient charting in its home care unit. THE RESULTS: improved quality and continuity of care, greater productivity, and reduced costs. PMID- 10153113 TI - Learning to drive on the information highway. PMID- 10153114 TI - What members want. AB - One large multi-market study recently confirmed that people are more satisfied in HMOs than they are in other types of health plans--and the results have nothing to do with health status. Here's a look at what drives HMO member satisfaction. PMID- 10153115 TI - Taking aim at childhood illnesses. PMID- 10153116 TI - A track record. When it comes to assuring quality and protecting consumers, HMOs have an established track record. PMID- 10153117 TI - Political action: beginning at the roots. AB - With a new round of health reform initiatives brewing in Congress and the states, the HMO community is making a priority of grassroots action. The message: HMOs are health reform that works--and a choice we need to keep. PMID- 10153118 TI - To carve out or not to carve out. Why HMOs need specialized partners for behavioral health care. PMID- 10153119 TI - Going to press with the HMO story. PMID- 10153120 TI - Rx and MD: cooperating for quality. AB - The University of Minnesota and a group of health plans are studying the clinical benefits of coordinated pharmaceutical care--demonstrating the value of doctor pharmacist teamwork in improving outcomes for patients. PMID- 10153121 TI - HMO strategies for improving childhood immunization rates. AB - Last fall, Group Health Association of America (GHAA) surveyed plans that are participating in the Childhood Immunization Program (see p. 29). The 121 HMOs that responded reported on a variety of immunization interventions. The survey is not representative of all HMOs because of the size of the response rate. Nevertheless, the survey provides an interesting snapshot of the immunization tactics that these HMOs are employing. PMID- 10153122 TI - On-line prescribing: keystrokes for quality. AB - HMOs and PBMs are implementing electronic prescription processing systems, linking doctors and pharmacies and moving the DUR process to the point of care. THE RESULTS: improved quality, efficiency, and patient satisfaction. PMID- 10153124 TI - New measures for chronic care. AB - Seven HMOs are collaborating with NCQA to ensure that members with asthma, diabetes, depression, and heart disease receive quality care through the course of their lives. PMID- 10153123 TI - A unique alliance for Medicare. PMID- 10153125 TI - Medicare. What does the future hold? AB - Congress is debating the future of the popular, but expensive, Medicare program. The HMO community wants lawmakers to expand the options available to seniors. PMID- 10153126 TI - Linking research to patient care. PMID- 10153127 TI - Keeping the promise. PMID- 10153128 TI - Going public. AB - The National Committee for Quality Assurance is developing new "accreditation summary reports"--to be released to employers and consumers. The goal is to help people evaluate HMOs. But will the information be useful to the general public? PMID- 10153129 TI - A new test for HMO solvency. AB - Risk-based capital: it's a complex formula that few people understand. But state regulators believe it's key to protecting consumers before a health plan becomes insolvent. PMID- 10153130 TI - Bidding for a Medicaid contract. PMID- 10153131 TI - Keeping at-risk members healthy. AB - HealthPartners' "Partners for Better Health" program brings physicians and other health care professionals, members, and the community together to prevent illness and improve health status. PMID- 10153132 TI - Medicaid block grants: there is a better way. PMID- 10153133 TI - HMOs reach out to Medicare beneficiaries. PMID- 10153134 TI - Indianapolis providers pilot variation on capitation and FFS payment methods. PMID- 10153135 TI - Empowering physicians to take charge of IDS requires business training. PMID- 10153136 TI - Primary care "councils" keep colleagues in line. PMID- 10153137 TI - Eccentric physicians translate into trouble as physician panels tighten up. PMID- 10153138 TI - Avoiding antitrust snags requires forethought and thorough market analysis. PMID- 10153139 TI - L.A.-area oncologists join the march to capitated healthcare. PMID- 10153140 TI - Winning the race for primary care physicians. PMID- 10153141 TI - Where the rubber meets the road: PHO capital, governance, and the feds. PMID- 10153142 TI - Managed care is forcing changes in physician compensation incentives. PMID- 10153143 TI - Assignable contracts warrant caution--and plenty of forethought. PMID- 10153144 TI - Colorado hospital stakes its integration bet on ambulatory services. PMID- 10153145 TI - Buying or creating a group practice calls for doctors who play by the rules of managed care. PMID- 10153146 TI - Why an assessment of 'community need' is more than a tax matter. PMID- 10153147 TI - Cultural differences can fray the knot after MDs, hospitals exchange vows. PMID- 10153148 TI - Applying several valuation methods eases practice acquisitions. PMID- 10153149 TI - Becoming a health plan is like learning to swim: enter the water with caution. PMID- 10153150 TI - Affiliations may pay the price of "bigger is better". PMID- 10153151 TI - The need to develop transfer pricing methods grows as systems become regional. PMID- 10153152 TI - Selecting primary care sites in a managed care market. PMID- 10153153 TI - Specialists watch on the sidelines as generalists are recruited relentlessly. PMID- 10153154 TI - Boston network prepares for capitation growth. PMID- 10153155 TI - Physician compensation strategy: creating an equity partnership practice. PMID- 10153156 TI - 'Quick and clean': authoritative health technology assessment for local health care contracting. AB - Commissioners of health care require rapid, accurate and usable information on health technology effectiveness to help them to decide on the content of contracts. Despite major strides in the national initiatives in health technology assessment, such information is still in short supply at the local level. In 1991 the former Wessex region (now in the new South and West Region) established a mechanism which continues to provide carefully established recommendations on new technologies. Its features include: identification of locally important topics for evaluation by the purchasers and the providers; an evaluation team, working to a well-defined format in a service-led academic institute; an arbitration committee to deliver recommendations to purchasers on the basis of both the cost utility of proposals and the quality of the evidence; and implicit obligations for purchasers to respond to strong recommendations. PMID- 10153157 TI - Care of the elderly patient following surgery for a fracture of the proximal femur. AB - A short postal questionnaire was sent to all practising orthopaedic surgeons in the United Kingdom, to determine the current pattern of post-operative care for patients with a fracture of the proximal femur, and to determine the current contribution to care being undertaken by geriatricians. This paper presents the responses of 616 orthopaedic surgeons who are actively involved in the care of patients with a fracture of the proximal femur. For the patient who had been partially dependent on family and social services before injury, and thus had most to benefit from an effective rehabilitation, there was a diversity of care on offer. Sixty-three per cent of surgeons stated that this category of patient was routinely cared for on an acute orthopaedic ward; 36% regularly transferred such patients to rehabilitation units, which were geriatric units in 18% of cases, 'second line' orthopaedic beds in 9% of cases and orthogeriatric units in a further 9% of cases. Surgeons who regularly transferred patients to designated rehabilitation units were more satisfied than those whose patient care took place in the environment of the acute orthopaedic ward. Eighty per cent of surgeons were satisfied with orthogeriatric units, and 62% were satisfied with transfer of patients to units supervised by geriatricians. By contrast, only 17% of surgeons were satisfied with a system of care in which geriatricians were available for consultation by written request only. The specialties of orthopaedic surgery and geriatric medicine have a vital role to play in the post-operative care of patients, and a combined effort to address this issue should be made. PMID- 10153158 TI - Responsibilities and resources of on-call public health doctors. AB - We investigated the resource available for public health doctors to carry out statutory responsibilities out-of-hours by a postal questionnaire survey of consultants in communicable disease control (CsCDC) in England and Wales. The questionnaire requested details of local District Health Authority (DHA) population profile, major incident and outbreak policies, the background of the CCDC, out-of-hours communication, access and resources, reference materials and medical equipment carried by the public health doctor on duty. The CsCDC from 96% (121/126) DHAs in England and Wales responded. Whilst 85% (101/119) of public health doctors carried policies on infectious disease when on duty, only 28% (32/116) carried policies on dealing with chemical incidents and 25% (28/111) carried the District policy to deal with radiation hazards. Twenty-six per cent (32/121) of public health physicians had no access to their District headquarters. There is a wide variation in the standard of resources available to on-call public health doctors in England and Wales; following Department of Health and Department of the Environment guidance, Health Authorities need to ensure that they have adequate arrangements in the event of any major incident or outbreak. PMID- 10153159 TI - The DH register of cost-effectiveness studies: content and quality. AB - The Department of Health has recently published a register of economic evaluations of health care treatments and programmes, to assist health care decision-makers to assess the value for money from alternative ways of allocating scarce resources. If the register is to be useful, it is important that decision makers have an appreciation of the methodological quality of the studies contained in the register, and hence the confidence that can be placed in the results. This paper outlines an approach for assessing the methodological quality of economic evaluations, and the result of its application to studies contained in the register. Comments are made about the interpretation of the existing register and the future reporting of economic evaluations. PMID- 10153160 TI - Gynaecology: the experience of patients referred to NHS and private clinics. AB - This cohort study compared the experience of patients seeking treatment for menorrhagia who were referred to National Health Service (NHS) or private clinics. Two-hundred and nine patients in 73 general practices in Berkshire, Buckinghamshire, Northamptonshire and Oxfordshire were recruited by their general practitioners and followed-up with questionnaires at nine months and 18 months after entry to the study. One hundred and fifty patients were referred to NHS clinics and 59 to private clinics; there were no significant differences between the two groups of patients in terms of symptom severity, reason for referral or treatment received. Patients who went to private clinics were more likely to report active participation in decisions about their care (p < 0.05 after adjustment for age and educational status), and were slightly more likely to be satisfied with the care they had received. The treatment decisions made in gynaecological clinics in the NHS and private sector were similar, but the decision-making styles appeared to be different. Private patients were more likely to participate in treatment decisions than NHS patients. PMID- 10153161 TI - Cost and utilisation of community services for people with HIV infection in London. AB - This study aimed to describe the use and costs of community services for HIV infected people by disease stage, sex and transmission category (homosexual, heterosexual, injecting drug use) by use of a prospective cohort study in which people were followed up for six months. There were two major components; gathering quantitative information on service utilisation from people with HIV infection using two interviewer-administered questionnaires and six self completed monthly diaries; and estimating the costs of the services provided. People were recruited from two London clinics: the Jefferiss Wing Genito-urinary Medicine (GUM) clinic at St. Mary's Hospital, Paddington, and the Patrick Clements GUM clinic at the Central Middlesex Hospital, Harlesden. Costing data was obtained from providers of community services throughout Greater London. The main outcome measures were contacts per person-year, and costs per person-year, for all community services stratified by service sector. The people studied each made, on average, 139 community service contacts per year at a cost of 2,806 pounds; there was little difference in average utilisation between the three transmission categories. There were differences in both the utilisation of services and costs within the formal and informal sectors for subjects from different disease stages. Although the average number of contacts per person-year were similar for women and men, the total cost of community services was higher for women than for men, reflecting the differences in types of services used. The results indicated a high proportion of total care costs for people with HIV and AIDS is incurred through community-based social care.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10153162 TI - Meta-analysis at 20: retrospect and prospect. AB - It has been 20 years since Gene Glass reinvigorated research integration through the formalization of meta-analysis. This article explores the nature of meta analysis by placing it within the context of research synthesis. The methods of meta-analysis are described briefly and compared and contrasted with other forms of research integration. In addition, the findings from several meta-analyses are provided to show the advantages of quantitative review methods. Finally, criticisms of meta-analyses are analyzed, as are several unanswered questions about the direction of meta-analysis. PMID- 10153163 TI - Use of meta-analysis for testing theory. AB - Within the context of the general superiority of meta-analytic reviews over qualitative reviews, we emphasize the fragility of meta-analytic outcomes, especially when the effects of moderator variables remain unexamined. We consider the contribution to increased theoretical understanding made by moderator analyses both of methodological and substantive variables in psychological, health, and medical research. The potential contribution of meta-analysis to understanding the process underlying established relationships and to assessment of the convergent and discriminative construct validity of previously used concepts is discussed. PMID- 10153164 TI - Interpreting and evaluating meta-analysis. AB - This article offers some guidelines for interpreting and evaluating meta-analytic reviews of research. The fundamental goals of meta-analysis are to combine results across studies to yield an overall estimate of effect and to compare effects between studies in order to understand moderating factors. Suggestions are made for what readers should look for in a meta-analysis, and a discussion is provided of several issues that are not often explicitly addressed: choice of unit of analysis, fixed versus random effects, the meaning of heterogeneity, determination of when contrasts are appropriate, and the choice of measure of central tendency. We recommend that readers adopt a skeptical attitude about the results of meta-analysis, particularly when only complex analyses are reported. PMID- 10153165 TI - The impact of data-analysis methods on cumulative research knowledge: statistical significance testing, confidence intervals, and meta-analysis. AB - The methods of data analysis used in research have a major effect on the development of cumulative knowledge. Traditional methods based on statistical significance testing have systematically retarded the growth of cumulative research by making it virtually impossible to discern the real meaning of research literatures. Meta-analysis makes it possible to demonstrate graphically the high price the research enterprise has paid for its reliance on significance testing. But in addition to these demonstrations, reform will require that researchers come to understand that the benefits they see as flowing from the use of significance tests are illusory. In research practice and in training of researchers, we must use and teach appropriate data analysis methods: point estimates of effect sizes and confidence intervals within individual studies, and meta-analysis in the integration of multiple studies to produce final conclusions. These reforms are essential to the progress of cumulative research knowledge. PMID- 10153166 TI - The Cochrane pregnancy and childbirth database. Implications for perinatal care policy and practice in the United States. AB - The Cochrane Pregnancy and Childbirth Database (CCPC) is the most sophisticated realization of the meta-analytic potential within the health fields. At the core of this ongoing collaborative international project are about 600 systematic reviews of the effectiveness of specific forms of perinatal care, which have been created from a registry of clinical trials. The scale and quality of information available through CCPC are unprecedented. An examination of implications of CCPC suggests that many far-reaching changes in perinatal policy and practice are indicated. CCPC has become a model for similar work that is being organized in many other clinical areas under the umbrella of the pan-clinical Cochrane Collaboration, and the experience and implications of CCPC will be of interest to many working in other areas. The implications of these ambitious meta-analytic projects are profound; the degree to which they will be realized is less certain. PMID- 10153167 TI - Rochester hospital overhauls foodservice. PMID- 10153169 TI - NSU hosts wellness fair. PMID- 10153168 TI - AAHSA (American Association of Homes and Services for the Aging), NANASP (National Association of Nutrition and Aging Services Programs) form alliance. PMID- 10153170 TI - Hospital's Chick-fil-A is full. PMID- 10153171 TI - Technomic: creating value is key for slow-growth 1996. PMID- 10153172 TI - Establishing & maintaining a cross-training program. PMID- 10153173 TI - Challenge: how to implement a successful HACCP (Hazard Analysis and Critical Control Points) program. PMID- 10153174 TI - Careers in hospital quality hinge on process management, ability to handle change. PMID- 10153175 TI - Setting priorities for improvement means finding most important projects. PMID- 10153176 TI - Know what to collect before setting out. PMID- 10153177 TI - Keep guideline implementation orderly. PMID- 10153178 TI - Cross-walk Baldrige-Joint Commission with care. PMID- 10153179 TI - Survey-weary hospitals drop JCAHO accreditation, others may follow. PMID- 10153180 TI - Hospitals question cost of Joint Commission surveys. PMID- 10153181 TI - Iowa PRO saves almost $4 million. PMID- 10153182 TI - Discrepancy triggers hospital's policy overhaul. PMID- 10153183 TI - Set priorities when planning QI projects. PMID- 10153184 TI - IMSystem set for overhaul that offers multiple options. PMID- 10153185 TI - Study: empowering nurses promotes quality care. Mortality rates 5% lower in 'magnet' hospitals. PMID- 10153186 TI - Magnet hospitals share their successes. PMID- 10153188 TI - Joint Commission tests waters to create user-friendly accreditation. PMID- 10153187 TI - Is your quality planning tied to your QI strategy? PMID- 10153189 TI - A new survey approach: continuous accreditation. PMID- 10153190 TI - Joint Commission trims staff, surveys itself. PMID- 10153192 TI - Therapeutic golf puts patients back in the swing. PMID- 10153191 TI - Discharge planning for elderly requires extra considerations. PMID- 10153194 TI - Rehab facilities offer breath of new life. 'Unweanable' ventilator patients respond. PMID- 10153193 TI - Discharge planning starts early for family physicians. PMID- 10153195 TI - UM (utilization management) newsletter eases physician buy-in. PMID- 10153196 TI - Re-engineering: a smart move or the downfall of quality care? PMID- 10153197 TI - Organized documents pave way for a smooth survey. PMID- 10153198 TI - Tracking immunization: new twist on old concept. PMID- 10153199 TI - Design new processes to meet JCAHO standards. PMID- 10153200 TI - Organizationwide plan of care: Joint Commission offers flexibility. PMID- 10153201 TI - Medicare APG (ambulatory patient grouping) system looms on the horizon. PMID- 10153202 TI - MCOs, Joint Commission eye nonadmitting doctors. PMID- 10153203 TI - About 75% of hospitals not reporting to data bank. PMID- 10153204 TI - Frail elderly patients avoid nursing home through PACE (Program of All-inclusive Care for the Elderly) PMID- 10153205 TI - PROs favor observation of some prostate patients. PMID- 10153206 TI - Avoid malpractice woes by shoring up credentialing. PMID- 10153207 TI - The secrets to surviving EC scrutiny: a good plan and even better training. PMID- 10153208 TI - HPR readers speak out on accreditation issues. PMID- 10153209 TI - Rise to the CC (continuum of care) challenge by stressing the total patient care experience. PMID- 10153210 TI - Neonatal ailments plunge in wake of prenatal plan. PMID- 10153211 TI - Know the game plan before entering risk contracts. PMID- 10153212 TI - How to manage your outcomes more effectively. PMID- 10153213 TI - Joint Commission frees hospitals from tight restraint rules. PMID- 10153214 TI - Avoid overdeveloping restraint policy. PMID- 10153215 TI - Be sure to monitor quality in your psychiatric unit. PMID- 10153216 TI - Tracking ADEs (adverse drug events) leads to root causes of errors. PMID- 10153218 TI - New diversity, emerging destiny. PMID- 10153217 TI - Setting sail before the winds of change. PMID- 10153219 TI - Medicare reform: will a compromise be found? PMID- 10153220 TI - Logos. Do the logomotion. PMID- 10153221 TI - Staff development. Personal effects. PMID- 10153222 TI - Physiotherapy services. Measure for leisure. PMID- 10153223 TI - Neonatal care. Birth rights. PMID- 10153224 TI - Change management. Face the music. PMID- 10153225 TI - Consultants. Is doctors' power shrinking? PMID- 10153226 TI - Local pay bargaining. Folk law. PMID- 10153227 TI - Primary care. A charter by any other name. PMID- 10153228 TI - Data briefing. Fairer primary care budgets. PMID- 10153229 TI - A participative approach to reprofiling--theory and practice. AB - Discusses the concept of reprofiling. After providing a working definition, a discussion of the theory that underpins the "participative" approach shows how it is linked to established change management ideas. Outlines how the approach is used in practice. PMID- 10153230 TI - Correlates of hospital leadership team effectiveness: results of a national survey of board chairmen. AB - To examine hospital leadership team effectiveness, analyses the responses of 540 randomly sampled board chairmen of US hospitals. Reports findings regarding board chairmen's evaluation of their hospitals' productive outputs and of the adequacy of their communications with the CEO and medical staff president (MSP) in their hospitals. Notes that over one-quarter of board chairmen found communications with the MSP to be only sometimes productive and notes means whereby positive communications are promoted. Offers suggestions for board chairmen recruitment. PMID- 10153231 TI - Evaluating self-managed learning--Part 3: Developing leaders in a US health system. AB - The last in a series which evaluates the use of self-managed learning in management development processes within health care settings. Analyses the evolution of the leadership development programme established by the Lutheran Health System in the mid-West USA. PMID- 10153232 TI - A step into the unknown? The new education and training contracting arrangements. AB - The next few years are likely to see the introduction of an educational contracting regime for professional education in the UK between the NHS and the higher and further education sectors. It will involve all employers of health care staff-the NHS, private and voluntary sectors, GP fundholders and local authorities. Outlines these changes and identifies some of the likely problem areas with the new arrangements. Seven key areas are explored--workforce planning, membership of the new consortia, the NHS Executive/regional office role, timescales, finance, the scope for innovation and the operation of the new system. PMID- 10153233 TI - A missing link? Workforce demand as the link between two health care related markets. AB - Examines the links between workforce demand and two health care related markets, the first being the internal market between purchasers and providers of health care, and the second the market for education expressed between colleges of education as providers and NHS Trusts as purchasers of the courses. Workforce demand has to take account of the numbers of people on courses, but also specialist skills required to enable NHS Trusts to deliver changing health care needs of the future. PMID- 10153234 TI - International trends in accreditation. AB - Accreditation of hospitals began in the early part of the twentieth century in the USA as a mechanism to ensure an appropriate environment in which clinicians could practise effectively. It was adopted in Canada and Australia, where it conformed to the early design of standards to control the hospital environment. In the past decade, these accreditation systems have been forced to change in response to the decline in the role of the hospital in health care delivery; the demands of governments and the public for greater information about quality of health care. They have also responded to pressure for greater knowledge of clinical effectiveness by introducing indicators of clinical performance. Within the past 5 years, accreditation has been adopted in a number of other countries where governments have extended their role into assuring the quality of health care. Accreditation, originally perceived as a vehicle to enable organizational development, is increasingly an agent of government regulation. PMID- 10153235 TI - An overview of hospital accreditation in Taiwan, Republic of China. AB - This paper examines the hospital accreditation system in Taiwan, Republic of China. The paper describes the historical evolution of accreditation; preliminary teaching hospital accreditation; hospital and teaching hospital accreditation; issues and problems; and perspectives and challenges. PMID- 10153236 TI - Accreditation trends in Spain. AB - The profound political changes that followed the Spanish Constitution of 1978 have had a major influence in the healthcare offered to the Spanish population. The healthcare provision once centred in a single government agency, the Instituto Nacional de la Salud (INSALUD), is now being decentralized to the 17 autonomous regions established by the Constitution. Existing Spanish legislation, traditional accountability and established professional roles are determinant factors in defining the boundaries amongst the main stakeholders in the healthcare accreditation issue. Hospital accreditation has been traditionally understood by the central government agency as a way to assure regulated standards for licensing the operations of healthcare facilities. However, recent public concern over the quality of healthcare, health departments' accountability and health professional technical knowledge are now creating the search for a common approach to accreditation in Spain. PMID- 10153237 TI - Hospital accreditation in Catalunya: an assessment of the performance in quality of hospitals. AB - Information about a hospital accreditation program generally goes unpublished, and when published, it is seldom used to analyse the quality performance in a group of hospitals. This article uses the information derived from the Accreditation Program of Hospitals in Catalunya to assess the quality of the performance of hospitals in this region. Catalunya's accreditation program is publicly administered, and the advantages and disadvantages of such a model in comparison to others will also be analysed. PMID- 10153238 TI - Client-centered accreditation. AB - The Canadian Council on Health Services Accreditation has restructured its approach to health services accreditation, moving from a focus on hospital departments to what is termed a client-centred approach. This was a response to the philosophy of Continuous Quality Improvement, which has caused a rethinking of the approach to accreditation. The process of change has required total revision of the standards used, moving the focus from individual hospital or health service departments, to standards which describe the main processes of patient care within the organization. This has resulted in the need for new survey techniques and award structures. PMID- 10153239 TI - Extending facility accreditation to the evaluation of care: the Australian experience. AB - The Australian Council on Healthcare Standards (ACHS) has introduced clinical performance measures--clinical indicators--into the accreditation process. The indicators are developed with the assistance of the various medical colleges (professional associations of specialists). Sixteen such bodies are now in the program, with 150 draft indicators covering 90 areas of hospital practice. The development of a set of indicators passes through a number of stages to ensure their validity, and a process is in place to assess their reliability, reproducibility and responsiveness. The qualitative information available indicates a willingness on the part of health care facilities to address the indicators, and alter the process of care. It is anticipated that the quantitative information being collected in aggregate form will subsequently demonstrate an improvement in the outcome of care. Hospital specific information currently remains confidential to the ACHS and the particular health care facility. The public release of such information and the value of doing so remains undetermined. PMID- 10153240 TI - Models for relating performance measurement and accreditation. AB - The Joint Commission on Accreditation of Healthcare Organizations has attempted to move away from simple measures of organizational process to measures of organizational performance. As no measures of organizational performance existed, the Joint Commission was forced to embark upon a lengthy search for methodologies and technologies to measure organizational performance. In addition, an approach to the use of performance measures, which would be acceptable to the health service community, and which was compatible with the process of accreditation, had to be found. PMID- 10153241 TI - How opinion surveys improve employee morale and resident satisfaction. PMID- 10153242 TI - Overcome imperfection with ten simple management axioms. PMID- 10153243 TI - Knowledge is key to improving motivation in the workplace. PMID- 10153244 TI - The disservice of rapid administrative turnover. PMID- 10153245 TI - Board members prepare for future challenges. PMID- 10153246 TI - Improve performance through upward and multi-rater feedback. PMID- 10153247 TI - Is your feedback system too formal to be effective? PMID- 10153248 TI - The effects of benefit design and managed care on health care costs. AB - Recently, the Department of Defense replaced its traditional fee-for-service insurance plan for military health care beneficiaries with an HMO/PPO hybrid. Using survey and claims data, we compare changes in costs over two years at sites that implemented this initiative (CRI) with changes at matched control sites. The results indicate that CRI substantially raised per beneficiary government costs for providing benefits (as compared to predicted costs in the absence of CRI). We attribute this difference to the higher overhead of managed care and the increased expenditures by HMO participants. PMID- 10153249 TI - Optimal medical treatment under asymmetric information. AB - A model is developed of patient-doctor interaction under asymmetric information. It examines how both the probability of consulting and initial health status are semi-endogenously determined by a potential patient determining a threshold health level, below which he demands a consultation. It is shown that the demand elasticity with respect to socio-economic variables is lower the more severe the illness. The paper also offers a model of the supply side. A distinction is established between uncertainty and asymmetric information between the patient and the doctor. After deriving the conditions for an equilibrium of the patient doctor interaction, payment systems for achieving medical 'adequacy' and Pareto efficiency are analysed. PMID- 10153250 TI - Monopsony power and relative wages in the labor market for nurses. AB - This paper examines the thesis that monopsony power is an important determinant of wages in nursing labor markets. Using data from the 1985-93 Current Population Surveys, measures of relative nurse/non-nurse wage rates for 252 labor markets are constructed. Contrary to predictions from the monopsony model, no positive relationship exists between relative nursing wages and hospital density or market size. Nor is support found for the presence of monopsony power based on evidence on union wage premiums, slopes of experience profiles, or the mix of RN to total hospital employment. PMID- 10153251 TI - Optimal times of transfer between therapies: a mathematical framework. AB - This paper develops a mathematical framework for identifying optimal transfer times from a low-intensity, watchful waiting therapy to direct intervention. It allows for the probability that patients discharged from watchful waiting will suffer disease recurrence. Two specific functional forms for the resolution of the relevant medical condition are modeled (modified exponential and logistic). Initially structured as an expected cost minimisation problem, the analysis is extended to include the possibilities of differential benefits of the therapies and discounted cost and benefit valuations. The framework demonstrates the existence of non-synchronous transfer optima. PMID- 10153252 TI - Labour supply and saving decisions with uncertainty over sickness. PMID- 10153253 TI - Clinical practice guidelines: why, whence, and whither? PMID- 10153254 TI - Guidelines: a call for local implementation and assessment of impact. PMID- 10153255 TI - AARC (American Association for Respiratory Care) clinical practice guideline. Assessing response to bronchodilator therapy at point of care. PMID- 10153256 TI - AARC (American Association for Respiratory Care) clinical practice guideline. Discharge planning for the respiratory care patient. PMID- 10153257 TI - AARC (American Association for Respiratory Care) clinical practice guideline. Long-term invasive mechanical ventilation in the home. PMID- 10153258 TI - AARC (American Association for Respiratory Care) clinical practice guidelines. Capnography/capnometry during mechanical ventilation. PMID- 10153259 TI - AARC (American Association of Respiratory Care) clinical practice guideline. Selection of an aerosal delivery device for neonatal and pediatric patients. PMID- 10153260 TI - AARC-APT (American Association of Respiratory Care-Association of Polysomnography Technologists) clinical practice guideline. Polysomnography. PMID- 10153261 TI - Day shift. Work patterns are changing. How will local employment trends affect your strategic plan? PMID- 10153262 TI - You gotta have trust. 9 rules for building it. PMID- 10153263 TI - More than just a money-lender. PMID- 10153265 TI - Columbus Regional Hospital, Columbus, Indiana. PMID- 10153264 TI - Conflict resolution. Can both sides of a dispute end up winners? PMID- 10153266 TI - Pacific Medical Center Tower, Seattle, Washington. PMID- 10153267 TI - Shiprock Comprehensive Care Facility, Shiprock, New Mexico. PMID- 10153268 TI - A shrinking federal pie costs courts and hospitals. PMID- 10153269 TI - Are big hospitals dinosaurs? PMID- 10153270 TI - Using comparative clinical and economic outcome information to profile physician performance. AB - This paper presents strategies and empirical examples of comparative physician profiling under conditions of limited patient sample sizes and varying patient severity. A method by which clinical and cost outcomes may be evaluated simultaneously is also presented. Physician economic and clinical performance are compared using data abstracted from nine hospitals into the MedisGroups clinical information management system for inpatients treated from July, 1990 through June, 1992. The main outcome measures are comparative total and ancillary adjusted charges, and morbidity status. Results suggest that objective comparative outcome data provide useful information to assist in evaluating physician performance. A simultaneous comparison of clinical outcomes and adjusted charges identifies physicians who experience favorable outcomes at lower charges, as well as those who have higher charges and/or poorer outcomes. Strategies outlined in this paper may be of value to clinicians, governing boards, and third party payors. These strategies may be used to assist with privileging and other peer review activities when pursued proactively within a Continuous Quality Improvement framework to improve care. PMID- 10153271 TI - Linking cost control measures to health care services by using activity-based information. AB - Canada's health care institutions are under pressure to limit expenditures, maintain or increase productivity, and assimilate new technology. Even though more than 75% of hospital operating expenditures are controllable, according to a study by the Economic Council of Canada, cost systems are needed to provided essential management information. The new Canadian Management Information System (MIS) Guidelines for health care are designed to provide accurate cost measurement of patient treatment and to help managers evaluate the impact of planned program changes on areas of operational responsibility. Other potential benefits of implementing the MIS guidelines include correcting dysfunctional funding of health care units with benchmarking and setting high reporting standards for resource use at the patient level (MIS, 1991). This paper focuses on one important aspect of bringing these costs under control by examining the relation between cost deviations (variances) and underlying cost drivers. Our discussion will lead to the conclusion that incompatibility of DRG methodology and traditional cost accounting models may be an important source of cost variability within diagnostically-related disease groupings. PMID- 10153272 TI - Does health information alone help in equitable distribution of essential drug kits between health units at district level? AB - In Tanzania, the essential drugs programme (EDP) faces acute shortage of drugs brought about by a deteriorating economy and an expanding primary health care system. Many health units complain of shortages of drugs but no increase in the district allocation of EDP kits is foreseen. In the light of the aforementioned problem, a study was carried out in the Kisarawe district of Tanzania to discover, on behalf of the District Health Management Team (DHMT), the extent of the maldistribution with a view to reallocate the EDP kits among the health units on the basis of workload and catchment population. The relative workload of each health unit was estimated from the number of outpatient attendants and the catchment population estimates are based on a 1988 national census. An equitable distribution of EDP kits for each indicator was then developed by ranking the health units in order of workload and catchment population and dividing up the available number of EDP kits proportionately. Health units were categorised as either 'over-allocated', 'appropriately-allocated' or 'under-allocated' with EDP kits by comparing their actual drug supply with the equitable supply. The findings were presented to a meeting of the DHMT attended by the Regional Medical Officer and Ministry of Health officials. Despite being presented evidence of astounding inequity in drug distribution, there was a marked reluctance on the part of the DHMT to decide upon actions to redress some of the imbalance. In this study, we demonstrated that although data from the routine information system on essential drugs at peripheral health units provided sufficient information for managerial purposes, decision-making was delayed and limited. Several possible reasons for this are discussed. PMID- 10153274 TI - Developing GP monitoring systems guided by a soft systems approach. AB - This paper describes a selected aspect of a research project concerned with 'contracts and competition' in the recently reformed National Health Service. The particular feature highlighted in this paper is the central role played by the general practitioners in the health service as principal sources of the demands made on provider units (particularly hospitals) and, hence, critical determinants of volumes and costs in contracting. A practical outcome of the research has been the development of GP monitoring systems to be used by provider units particularly in the context of marketing-led referral expectations. The approach used to highlight areas of potential GP contract management and monitoring improvements has been a development of soft systems methodology. PMID- 10153273 TI - An analysis of the adoption of managerial innovation: cost accounting systems in hospitals. AB - The adoption of new medical technologies has received significant attention in the hospital industry, in part, because of its observed relation to hospital cost increases. However, few comprehensive studies exist regarding the adoption of non medical technologies in the hospital setting. This paper develops and tests a model of the adoption of a managerial innovation, new to the hospital industry, that of cost accounting systems based upon standard costs. The conceptual model hypothesizes that four organizational context factors (size, complexity, ownership and slack resources) and two environmental factors (payor mix and interorganizational dependency) influence hospital adoption of cost accounting systems. Based on responses to a mail survey of hospitals in the Chicago area and AHA annual survey information for 1986, a sample of 92 hospitals was analyzed. Greater hospital size, complexity, slack resources, and interorganizational dependency all were associated with adoption. Payor mix had no significant influence and the hospital ownership variables had a mixed influence. The logistic regression model was significant overall and explained over 15% of the variance in the adoption decision. PMID- 10153275 TI - Importance-performance analysis as a guide for hospitals in improving their provision of services. AB - As a result of the 1990 National Health Services Act, hospitals now compete with one another to win service contracts. A high level of service quality represents an important ingredient of a successful competitive strategy, yet, in general, hospitals have little external information on which to base quality decisions. Specifically, in their efforts to win contracts from fundholding general practitioners, hospitals require information on that which these purchasers deem important with respect to quality, and on how these purchasers assess the quality of their current service performance. The problem is complicated by the fact that hospital service quality, in itself, is multi-dimensional. In other areas of economic activity, the information problem has been resolved by importance performance analysis and this paper reports the findings of such an analysis conducted for hosptials in the Trent region. The importance and performance service quality ratings of fundholders were obtained from a questionnaire survey and used in a particular variant of importance-performance analysis, which possesses certain advantages over more conventional approaches. In addition to providing empirical data on the determinants of service quality, as perceived by the purchasers of hospital services, this paper demonstrates how such information can be successfully employed in a quality enhancement strategy. PMID- 10153276 TI - Breaking down barriers to creativity. AB - The author describes six barriers to creativity in the workplace and explains how they can be avoided. He emphasizes the importance of creativity to meet the demands--especially the unforeseen demands--of today's chaotic health-care environment. PMID- 10153277 TI - Productive criticism. Part 1: Criticism that works. AB - Criticism affects almost all aspects of your job: the quality of work you do, how you feel about your performance, and your relationships with your boss, coworkers, and subordinates. Used productively, criticism is a powerful tool that helps you improve your work, enhance your working relationships, increase your job satisfaction, and achieve better overall results. Improperly used, it impedes performance, demoralizes you, discourages you from wanting to try again, and creates friction in the workplace. In short, the ability to give and take criticism significantly determines how well you do on the job. In Part I, we will examine the traditional negative approach to criticism and develop new management tools to turn criticism into an opportunity for growth and education. By explaining new evaluation and communication techniques, we will show the reader how to use productive criticism to increase job performance and satisfaction. PMID- 10153278 TI - Groups and decision making. AB - A hallmark of clinical service management in particular, and contemporary health care in general, is the team approach. Yet, many managers do not have appropriate background and skills for group leadership. This article reviews some essential characteristics of groups and suggests strategies for facilitating group decision making. PMID- 10153279 TI - Creating the environment for process improvement. AB - The incorporation of quality improvement methods into the practice of laboratory medicine has become widespread in recent years. However, a significant number of laboratory professionals feel that quality improvement efforts take an excessive amount of time to achieve results. Using quality improvement methods and tools will have limited success without first creating the proper environment. Steps that we have found to be beneficial in creating the environment for successful improvement activities using the FOCUS-PDSA model include having senior leaders perform specific activities, aiming the team, and strategic contracting. PMID- 10153281 TI - Clinical pathways: Part 2. PMID- 10153280 TI - When mistakes happen. PMID- 10153283 TI - Best Maintenance Practice Awards. PMID- 10153282 TI - The Environmental Protection Act 1990, Part I. PMID- 10153284 TI - Conciliation service for architects. PMID- 10153285 TI - Electrical installations in 'medical locations'. PMID- 10153286 TI - Hiring foreign nationals in the health care industry. PMID- 10153287 TI - Jackpot justice: tort reform revisited. PMID- 10153288 TI - The future of healthcare education. Panel discussion. PMID- 10153289 TI - Assuming and managing risk: Part II. AB - Last month HCMA began to address the issue of hospitals assuming risk as they become more and more involved in managed care situations. This article continues that discussion. The focus is on capitation contracting, physician-related issues, and a final assessment of the risk that hospitals should and will acquire as they move forward in a heavily managed care environment. PMID- 10153291 TI - Signs of an uprising. PMID- 10153290 TI - Hospital managed care diversification and reinsurance strategies. AB - As increasing numbers of patients enroll in managed care plans, health care providers are faced with new operational and financial challenges. This article, the fourth in a series on the financial perils of managed care contracting, addresses issues related to diversification of risk and reinsurance. PMID- 10153292 TI - Air medical transport for the trauma patient requiring cardiopulmonary resuscitation: a 10-year experience. AB - INTRODUCTION: Air medical response and transport for the injured patient in cardiopulmonary arrest remain controversial. This study is a large, single program experience. METHODS: A retrospective chart review and descriptive study of all injured patients requiring cardiopulmonary resuscitation (CPR) immediately before or during air medical transport. The crew functioned under advanced cardiac life support/advanced trauma life support protocols. SETTING: The patients, when transported, went to a variety of facilities, with the majority of patients transported to a level-I trauma center. The service area was primarily rural. RESULTS: During 1985 to 1994, inclusive, there were 12,518 completed missions. A total of 320 injured patients required CPR (284 with blunt injury and 36 with penetrating injury), six of the 320 patients (1.9%) survived. Survivors and nonsurvivors did not differ significantly in age, mechanism of injury, time from initiation of CPR to arrival in the emergency department (ED), year of injury or initial cardiac rhythm. All survivors did, however, present to the ED in normal sinus rhythm with a palpable blood pressure. CONCLUSION: Air medical transport for the injured patient without signs of life following prehospital intervention appears futile. PMID- 10153293 TI - Study of multiple rotor-wing flight programs on emergency medical services. AB - INTRODUCTION: Improvements in prehospital care, designation of trauma centers and expeditious transport have significantly reduced trauma deaths. In 1985 Pennsylvania formally introduced trauma-system implementation, including the integration of regional prehospital trauma guidelines. The purpose of this study is to examine the similarities and dissimilarities of advanced life support (ALS) trauma operations in eastern Pennsylvania and southern New Jersey, and the impact and integration of multiple flight programs on regional ALS systems. SETTING: Ground ALS (GALS) operations within Pennsylvania and New Jersey, and air medical operations in Pennsylvania. METHODS: Site visits and telephone interviews were used to characterize demographic, operational and clinical practice characteristics, including those flights where GALS was on location. Descriptive statistics were used to compare the various programs. RESULTS: Airway management differed greatly among the respondents. For example, of five air medical services, one did not carry paralytic agents, and one performed oral intubations only after the use of such agents. None of the GALS services used such agents. Procedures that required direct physician orders varied among the flight programs and the GALS services. Trauma triage guidelines following the American College of Surgeons recommendations were modified by all GALS services. CONCLUSIONS: Wide variation in the scope of practice exists among air medical services and GALS services within New Jersey and Pennsylvania. PMID- 10153295 TI - The effectiveness of esophageal stethoscopy in a simulated in-flight setting. AB - PURPOSE: Previous research has confirmed the inability of flight nurses in an airborne BO-105 helicopter to hear breath sounds using normal or amplified transthoracic stethoscopy. The purpose of this study was to determine whether esophageal stethoscopy enabled effective auscultation of breath sounds in a simulated in-flight environment. METHODS: The cabin-sound environment of an in flight BO-105 was recorded and recreated in an audiology laboratory, where five flight nurses were evaluated listening to taped breath sounds via an esophageal stethoscope. This audiotape model, validated in a previously published study, used a tape consisting of 24 20-second segments. Each segment, the beginning of which was marked with a beep signal, consisted of 20 seconds of silence or breath sounds. The distal (esophageal) end of the esophageal stethoscope was attached to the tape recorder; the intensity level of breath sounds heard at the stethoscope earpiece was calibrated to equate the sound level of actual esophageal breath sounds recorded on a volunteer. RESULTS: All nurses correctly identified the 24 taped segments as silent or including breath sounds 100% of the time. CONCLUSION: In the simulated environment tested, esophageal stethoscopy enabled 100% accuracy in identification of breath sounds, as compared with previously reported 0% efficacy for standard transthoracic auscultation. Study in the actual patient care environment is indicated to confirm the usefulness of esophageal stethoscopy in the in-flight setting. PMID- 10153294 TI - Characteristics of flight nursing practice. AB - INTRODUCTION: The purpose of this study was to describe the roles, levels of responsibility and backgrounds of flight nurses employed in flight programs across the country and to determine if the role of the flight nurse varied as a function of crew configuration or size of program. METHODS: In 1991, a retrospective statistical questionnaire was sent to 105 programs with 50 or more flights per month. RESULTS: This survey provides national data regarding description of programs, evidence of the critical-care environment, professional profiles of flight nurses and practice differences between nurse and paramedic personnel. A difference in the practice for nurses existed in the larger programs (> or = 1,100 flights) with nurse/paramedic flight configurations. Nurses more frequently performed interventions regarding initiating and discontinuing medications (p = 0.00023)--especially paralyzing agents (p = 0.012) and blood (p = 0.0016)--and recognizing by physical exam the need for interventions to decrease intracranial pressure (p = 0.0194). In the larger programs, nurses also were more responsible for decision making regarding titration of medications (p = 0.027). CONCLUSIONS: Flight nurses practice in advanced autonomous roles, performing duties and skills consistent with critical care and emergency medicine in air medical transport. PMID- 10153296 TI - Basics of research (Part 4): research study design (Part 2). PMID- 10153297 TI - What the fight's about. As Washington gets to work on the budget, who's winning- and losing? PMID- 10153298 TI - Terminal care: too painful, too prolonged. PMID- 10153299 TI - An SOS for AIDS. PMID- 10153300 TI - Shortage vs. glut. Are there too many doctors? PMID- 10153301 TI - Physicians, beware of the 'iceberg' exclusivity clause. PMID- 10153302 TI - Checking out the checkers that check out doctors. PMID- 10153303 TI - Why physicians should cooperate with consultants. PMID- 10153304 TI - A partnership can begin with identifying a mutual need. MidAtlantic Healthcare Purchasing Coalition. PMID- 10153305 TI - Anticipating managed care's effect on culturally diverse populations. PMID- 10153307 TI - Arriving: the age of the mixed-model HMO. PMID- 10153306 TI - The Feds are targeting your independent physician contracts. PMID- 10153308 TI - HIV/AIDS in the rural United States: epidemiology and health services delivery. AB - This integrated research review addresses the epidemiology of rural human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and the organization, financing, and delivery of health services for rural persons living with HIV or AIDS (PLWHIVs, PLWAs). Several abstracting services, indexing services, and bibliographies were searched. An annotation form served as the guideline for data extraction. Several conclusions emerged from this review. Epidemiological evidence indicates that there has been a dramatic increase in the relative proportion of rural HIV/AIDS incident cases over the past 5 years. Explanations for the rural increase focus on injection drug use, heterosexual behavior, and sexually transmitted disease levels. Dramatically elevated rates of infection in rural Black women are indicated. Rural areas experience important levels of in-migration of HIV/AIDS-infected individuals. The health services literature suggests that rural providers and institutions have limited resources and little experience with PLWHIVs or PLWAs. PMID- 10153309 TI - The use of hospital emergency departments for nonurgent health problems: a national perspective. AB - The use of the hospital emergency department (ED) for nonurgent health problems has been a subject of considerable controversy, in part because there is no widely accepted definition of "nonurgent." Elimination or substantial reduction in nonurgent ED use is frequently offered as a strategy for reducing health expenditures. Previous studies, often limited to individual hospitals or communities, have limited generalizability and do not permit examination of multiple factors likely to influence nonurgent ED utilization or examination of ED use for nonurgent problems in the context of overall outpatient utilization. This analysis of the 1987 National Medical Expenditure Survey (NMES) provides a nationally representative examination of nonurgent ED utilization that describes the frequency of ED use for nonurgent problems, characteristics of individuals that are associated with an increased likelihood of nonurgent ED use, the use of other outpatient physician services, and expenditures associated with nonurgent ED visits. PMID- 10153310 TI - Self-insuring employee health benefits. AB - Self-insurance is a popular way to fund employee health benefits, but it presents a potential barrier to state health insurance reform initiatives because self insured health plans are able to avoid state regulation. Thus it is important to understand why employers self-insure. This study tests an explanatory model of self-insurance, using data from the 1989 Survey of Health Insurance Plans. Models predicting self-insurance are estimated for private employers and for all health plan sponsors, including public employers, unions, and trade associations. The author found a threshold for self-insuring among private employers at about 100 employees and another at about 200 workers when all health plan sponsors were considered. Plans with union members are more likely to be self-insured. Self insurance is more likely in the presence of alcohol treatment mandates but less likely with mental health mandates. PMID- 10153311 TI - Intention of inactive registered nurses to return to nursing. AB - A mail survey of inactive registered nurses who indicated they were either not employed or employed in a nonnursing field was conducted in the state of Alabama. Results of a multiple regression prediction model indicate their intention to return to nursing is affected by career satisfaction/commitment, demographic, and work history variables. The primary reasons for leaving the nursing field were more personal (i.e., pregnancy/child rearing) than professional. However, professional factors predominated when all the reasons for leaving or returning to the field were identified. Implications for management and policy are discussed. PMID- 10153312 TI - Organizational characteristics, client characteristics, and the delivery of home care services. AB - This research examines the extent to which organizational professional orientation, client perceived needs, and client characteristics jointly determine long-term care service delivery to a frail elderly population. The study uses primary data collected from 16 community networks that were part of a national demonstration of the Living at Home Program, conducted from 1986 to 1989. Data include baseline assessments of individuals enrolled at each site, subsequent utilization data, and data on community network characteristics. Site professional orientation has a significant role in determining services provided to clients, with social service agencies more likely to provide nonmedical services and less likely to provide skilled-care services. Despite systematic site variation in the services provided to individuals, sites appear to reasonably allocate resources among individuals with differing levels of functional disability. PMID- 10153314 TI - Medication teaching guideline. PMID- 10153313 TI - Correlation of travel time on roads versus straight line distance. AB - Studies of hospital demand and choice of hospital have used straight line distance from a patient's home to hospitals as a measure of geographic access, but there is the potential for bias if straight line distance does not accurately reflect travel time. Travel times for unimpeded travel between major intersections in upstate New York were compared with distances between these points. The correlation between distance and travel time was 0.987 for all observations and 0.826 for distances less than 15 miles. These very high correlations indicate that straight line distance is a reasonable proxy for travel time in most hospital demand or choice models, especially those with large numbers of hospitals. The authors' outlier analyses show some exceptions, however, so this relationship may not hold for studies focusing on specific hospitals, very small numbers of hospitals, or studies in dense urban areas with high congestion and reliance on surface streets. PMID- 10153315 TI - Improve patient satisfaction and staff efficiency with ED patient representatives. PMID- 10153316 TI - New Joint Commission standards: look beyond ED. PMID- 10153317 TI - Nerve gas: contaminant in the Riverside case? PMID- 10153318 TI - Diagnostic interpretations: improving chances for being paid. PMID- 10153319 TI - Tuberculosis is going unrecognized, risks of infection are not controlled. PMID- 10153320 TI - Classifying patients can help you manage costs. PMID- 10153321 TI - Companies mandating drug testing need sites. PMID- 10153323 TI - Education of public critical to CPC (chest pain center) success. PMID- 10153322 TI - Chest pain centers: enhancing quality patient care in the ED. PMID- 10153324 TI - Aging populace intensifies focus on specialty units. PMID- 10153325 TI - Unnecessary admissions curtailed under program. Chest pain patients observed in ED first. PMID- 10153327 TI - Aid crime victims, families by preserving evidence. PMID- 10153326 TI - Staff collaboration leads to happier patients, fiscal health for EDs. PMID- 10153328 TI - Capable ED photography augments medical record. PMID- 10153329 TI - Center treats abused children sensitively. PMID- 10153330 TI - Fla. case could open antitrust door for public hospitals. PMID- 10153331 TI - Houston hospital targets new R.N. grads to end contract labor needs. PMID- 10153332 TI - Quality-of-care report could speed consolidation of Cleveland hospitals. PMID- 10153333 TI - TQM trips over glorified firefighting, poor communication, expert warns. PMID- 10153335 TI - Reduce staff education woes--target audience. PMID- 10153334 TI - Fine-tuning of critical pathways lies in auxiliary algorithms. PMID- 10153337 TI - RNs, social workers take team approach to CM. PMID- 10153336 TI - Network's pathway provides smoother neonatal transport. PMID- 10153339 TI - Disease management begins in community CM. PMID- 10153338 TI - Texas payers, providers team up to tackle Medicaid challenge. PMID- 10153340 TI - CMs take strong role in Medicare managed care. PMID- 10153342 TI - Make path development teams integral part of CM. PMID- 10153341 TI - Pathway for MI patients looks to discharge on day 1. PMID- 10153343 TI - Proven tips to keep path teams motivated. PMID- 10153344 TI - Indicator sheets streamline paths, improve variance tracking. PMID- 10153345 TI - How to market paths for successful staff buy-in. PMID- 10153347 TI - Path development takes on community approach. PMID- 10153346 TI - Medication profile key to surpassing LOS reduction goal. PMID- 10153348 TI - Case manager solves PACU (post-anesthesia care unit) mystery. PMID- 10153349 TI - View redesign as an opportunity, not roadblock, for staff development. PMID- 10153350 TI - Don't look over shoulder to measure productivity. PMID- 10153351 TI - Transferable pathway benefits hospital, hospice. PMID- 10153352 TI - Flow charts help hospital with perioperative paths. PMID- 10153353 TI - Universal demands don't hinder development of CM. PMID- 10153354 TI - Case manager functions evolve. PMID- 10153355 TI - Turbulent changes in CM provide for calmer waters after restructuring. PMID- 10153356 TI - Power of pathways now in staff hands. PMID- 10153357 TI - Hospitalwide guidelines get staff motivated. PMID- 10153358 TI - Physician-driven depression path standardizes care. PMID- 10153359 TI - To sample or not to sample? Cutting case reviews can save time. PMID- 10153360 TI - Keep program flexible for physician support. PMID- 10153361 TI - Local circumstances, not fashion, are key when a hospital and MDs weigh an affiliation. PMID- 10153362 TI - Rural clinics often are overlooked as a way to expand catchment area. PMID- 10153363 TI - Why Aetna wants a piece of the primary care action. PMID- 10153364 TI - Information systems are an often-neglected but vital integration building block. PMID- 10153365 TI - Physicians in a Chicago network learn how to take command on choppy healthcare seas. PMID- 10153366 TI - Fostering common vision among network players. AB - In summary, a common vision requires two elements: a similar view of the external environment and where it is headed, and agreement on how to position the organization--physicians, hospitals, and others--to be successful over the long haul. Developing and embracing a common vision is critically important in moving toward integration or committing to other strategies for surviving and prospering in the future. PMID- 10153367 TI - The hospital as provider and employer: the case of AIDS. PMID- 10153368 TI - Fear of HIV contagion as workplace stress: behavioral consequences and buffers. AB - This article conceptualizes employees' fears for their health on the job as a form of stress with a collective, detrimental impact on work behavior. It tests a job-control of stress reduction that focuses on reducing uncertainty. Results indicate that fear levels are lower in organizations that have policies providing employees with certain types of information about the stressor. Analysis reveals that mechanisms conveying explicit information, rather than information that is indirect or implied, have the strongest association with lower fear levels. Hypotheses are tested in the context of nursing staff fears of contagion from HIV infected patients, using data from 558 randomly selected hospitals nationwide. Implications for the policymaking dilemma of conflicting rights to privacy and disclosure are discussed. PMID- 10153369 TI - The consequences of disclosure: one hospital's response to the presence of an HIV positive physician. AB - Health care administrators are having to confront the many and complex problems associated with patient fears about the transmissibility of the HIV virus. Particularly acute are concerns that are raised when the physicians are HIV positive or have AIDS. This article presents a case history of how one hospital handled the problems created by the announcement by one of its emergency room physicians that he was HIV-positive. The hospital's response--which included disclosure to the community, the full cooperation of the physician, provision of free counseling, and HIV testing--and the aftermath of this AIDS-related event are described. This case is discussed in relationship to the ongoing debate about the ethics and consequences of disclosure of the HIV status of health care workers. PMID- 10153370 TI - Consequences of hospital financial distress. AB - This study identifies a group of financially distressed hospitals and tracks them over time to identify the consequences of their financial distress and the factors that may precipitate different events. Of 2,547 that supplied complete financial data to the American Hospital Association for the period 1983-1985, a total of 340 community hospitals met our definition for distress. The most striking finding is that 91.2 percent of hospitals that were distressed in 1983 1985 survived through the end of 1990. Distressed hospitals also had significantly higher rates of system acquisition and merger, as well as higher rates of system divesture. Growing competition in a market appeared to be a major factor in the closure of a distressed hospital. The results of this study suggest that financially distressed hospitals have a remarkable resiliency that allows them to continue operation without dramatic change. This may be good news to local community officials concerned about maintaining financially weakened hospitals. Alternatively, it may be bad news if poor financial performance is a signal of unneeded capacity. PMID- 10153371 TI - U.S. hospital workforce-to-population ratios by service area. AB - Traditionally, hospital productivity has been measured in terms of episodic patient services such as days or admissions. However, the delivery of health care is shifting toward a greater focus on the health of a covered population. Thus, population-based indicators of hospital productivity are needed. This work analyzes hospital FTEs per 10,000 served population across the United States as a function of regional demographic, socioeconomic, and geographic factors. For managers of integrated service networks, it provides benchmarks for hospital FTEs per service population for several personnel categories. Important findings for public policy include an 11 percent increase in FTEs per 1 percent increase in interns and residents and a 2 percent increase in FTEs per 1 percent increase in the elderly. PMID- 10153372 TI - Hospital staffing adjustments under global budgeting. AB - The U.S. Department of Veterans Affairs operates a hospital system that distributes a national global budget to 159 hospital units. Over recent years, cost containment and downward budgetary pressures have affected hospital performance and the quality of care delivered in unknown ways. This article examines hospital staffing levels as potential performance measures. We first develop a regression model to estimate the number and types of clinical staff required to meet current inpatient workloads at VA medical centers. We are able to improve on previous analyses by employing better data on physicians and by evaluating the behavior of hospitals in consecutive years. Our findings provide managers of hospital systems with promising new approaches for comparing hospital production processes and more information on the effects of global budgeting on individual hospital staffing within systems. PMID- 10153373 TI - Comparisons of medical technology in Canadian, German, and U.S. Hospitals. AB - One strategy proposed to constrain our health costs is to regulate the acquisition of and to centralize the availability of tertiary care services. American hospitals provide significantly more sophisticated equipment per million persons than is available either in Canada or Germany in six of seven expensive medical technologies studied (radiation therapy being the exception). The regionalization of tertiary care resources should be stimulated by the fiscal incentives inherent in managed care and capitated payment, additional shortfalls in Medicare and Medicaid reimbursement, and hospitals, physicians, and insurance companies' organizing health networks. These trends could eventually force an increasing number of community hospitals to eliminate their expensive sophisticated services. PMID- 10153374 TI - Service quality revisited: striving for a new orientation. AB - This article examines the concept of service orientation. A brief overview of what is known about the concept in general service and health care organizations is provided, as is consideration of measurement issues and directions for future research in this area. Unfortunately, despite the great need for information, very little is known about service orientation in health care. This state of affairs, however, affords abundant opportunities for relevant research. PMID- 10153375 TI - Review of the multi-hospital arrangements literature: benefits, disadvantages and lessons for implementation. AB - The multi-hospital arrangements literature is reviewed for Canada and the United States. There is a notable lack of evaluations on the outcomes of these arrangements, especially in the Canadian context. For evaluations that do make it to the literature, generalizability of conclusions is difficult because most is based on case studies and relates to "for-profit" U.S. hospitals. We are forced to conclude, however, that there is little definitive evidence that quality of care is improved by multi-hospital arrangements or to support or refute the claims of better human resources deployment. The most striking organizational benefit appears to be that institutions considering merger or other arrangements are forced into explicit considerations of their mission and goals. Many of the potential disadvantages of multi-hospital arrangements may be ameliorated with appropriate strategic planning and attention to detail during negotiation of the arrangement. As new multi-institutional arrangements may cause harm as well as reap benefits, careful evaluation is needed. PMID- 10153376 TI - Governance for quality: getting to the heart of it. AB - This article discusses the information a board needs to ensure that a systematic and strategic approach is taken to the management of quality throughout the organization; the outcomes of care/service meet professional standards, external requirements and key expectations of clients; and care/service is continually being improved. A practical framework for the reporting of quality management issues and their implications is provided, within the context of a chronic care/long-term care setting with multiple levels of care. The constraints presented by issue-based reporting are also addressed briefly. PMID- 10153377 TI - Manitoba's population-based databases and long-term planning: beyond the hospital databases. AB - The Manitoba Centre for Health Policy and Evaluation (MCHPE) conducts health services research focusing on Manitoba's administrative databases. Administrative databases contain information which is routinely and systematically collected for administrative purposes such as hospital and physician claims and funding requirements. This article describes the MCHPE's five major databases, their strengths and limitations, and the development of the Population Health Information System (PHIS). Four modules from PHIS illustrate how the data are used to provide useful information for health care planners, administrators and policy analysts. Finally, future projects and directions for using administrative databases are explored. PMID- 10153378 TI - Patient satisfaction: a customer service approach. AB - In health care, as in any service business, monitoring quality is an important component. Patient satisfaction, despite its measurement difficulties, is an excellent gauge of the institution's ability to delivery quality service. As part of quality improvement activities, the Division of Neurosciences at the Toronto Hospital measured patient satisfaction on various validated dimensions, then attempted to identify which components of service provision were key in determining patients' overall levels of perceived satisfaction with care. Results indicated that much of perceived quality and satisfaction was explained by the dimension of care which included prompt response to needs, organization, efficiency of care and communication. The authors recommend focusing improvement efforts on activities with the greatest potential to influence patient satisfaction. PMID- 10153379 TI - The medical information highway: where is the access ramp? AB - In this article, an analogy is drawn between a health care information system and a freeway transportation system. Unfinished access ramps and disconnected road sections are likened to unlinked computer information systems. It is not until there is "connectivity" between roadways that vehicles can take advantage of the efficiencies of a freeway system or until there are comprehensive, integrated information systems that quality health care can be provided. The Greater Victoria Hospital Society used quality improvement techniques to improve the medical information highway, and theories of change management to encourage physician leaders to "buy into" the information system to produce needed change in the organization and in patient care. PMID- 10153380 TI - The role of CRAHCA (Center for Research in Ambulatory Health Care Administration). PMID- 10153381 TI - Anatomy of an outpatient visit. An evaluation of clinic efficiency in general and subspecialty clinics. AB - The time spent in outpatient visits to a Veteran's Administration medical center was measured to determine clinic efficiency. Patient flow through the outpatient department of the medical center was studied to: 1) evaluate how time is spent in VA outpatient settings as compared to non-VA outpatient settings, including waiting time, checking of vital signs, seeing the doctor, etc., 2) develop a baseline to gauge the comparison of the effects of management changes; and 3) develop a mechanism for collecting clinic activity efficiency. PMID- 10153382 TI - Why do key integrated delivery stakeholders really matter? Assessing control, coalitions, resources and power. AB - This is the fourth in a series of articles describing and interpreting the results from the Facing the Uncertain Future (FUF) study. This article focuses on one vital aspect of strategic stakeholder management: assessment of key stakeholders. Specifically, the article uses Round Two data and presents an assessment of four key medical group practice stakeholders: integrated delivery systems/networks (IDS/Ns), managed care organizations (MCOs), physicians and hospitals. These key stakeholders were identified by medical group practice executives as some of the most important stakeholders in the year 2000. These four stakeholders are assessed on the criteria of organizational control, coalition formation, control of resources, and relative power. The FUF study was conducted jointly between the Center for Research in Ambulatory Health Care Administration (the research and development arm of MGMA), and The Institute for Management and Leadership Research (IMLR), College of Business Administration at Texas Tech University, Lubbock, Texas. MGMA's American College of Medical Practice Executives, faculty of Texas Tech University's Ph.D. and M.B.A. Programs in Health Organization Management (HOM), and faculty from the University of Alabama at Birmingham collaborated on the project. Abbott Laboratories, Abbott Park, Ill., provided funding for the FUF project. The administration of Round One was completed in the Fall of 1994. The administration of Round Two was completed in the summer of 1995. Selected Round One and Round Two results have previously been presented in educational programs and publications. PMID- 10153384 TI - Cost analysis for procedure comparisons. AB - Using the methodology of activity-based costing as a conceptual framework, the authors present the potential cost reduction of a new office routine and a medical procedure. The costs of a new instrument for colorectal cancer screening and a new surveying and follow-up of at-risk patients show that time and relevant costs in the G.I Clinic and G.I Endoscopy Lab were significantly reduced. PMID- 10153385 TI - The role of physician leaders in partnering to shape quality management. PMID- 10153383 TI - Information management for managed care. AB - A key concern for medical groups is how to manage information in a dual environment of capitation and fee for service. Information systems that work for one may not work for the other. Finding a system that works for both is critical. Some of the data that would be beneficial to collect for starting managing capitation contracts include: age/sex ratios of the practice patient population, average number of visits per patient per year, average number of visits by ICD-9 code for total population, average procedures per patient per year, and analysis of paverage payment per visit/procedure for commercial and Medicare patients. Some of the major concerns addressed include operational issues, financial viability and automated billing systems. PMID- 10153387 TI - Health Services Technology/Assessment Text (HSTAT). AB - Health Services Technology/Assessment Text (HSTAT), an online collection of documents pertaining to clinical practice guidelines, HIV/AIDS treatment information, and health care decision making, was recently introduced by the National Library of Medicine. Access to HSTAT is available through the NLM Full Text Retrieval System (FTRS), a document search and retrieval system developed by the Information Technology Branch of NLM. Internet FTP, Gopher, and World Wide Web clients may also be used to obtain documents from the HSTAT collection. PMID- 10153386 TI - RNdex Top 100: a quality-filtered database for nursing research. AB - RNdex Top 100, a value-added database providing citations and abstracts for more than 100 of the leading nursing journals, is one of the first products specifically developed for electronic searching published by SilverPlatter Information, Inc. To provide focused access to the literature, a new 9,000-term thesaurus reflecting the current terminology of the nursing profession is used. Abstracts for each record, new field descriptors, and rapid indexing are some of the features which make this database a viable alternative or supplement to CINAHL. PMID- 10153388 TI - Benchmarking reference services: an introduction. AB - Benchmarking is based on the common sense idea that someone else, either inside or outside of libraries, has found a better way of doing certain things and that your own library's performance can be improved by finding out how others do things and adopting the best practices you find. Benchmarking is one of the tools used for achieving continuous improvement in Total Quality Management (TQM) programs. Although benchmarking can be done on an informal basis, TQM puts considerable emphasis on formal data collection and performance measurement. Used to its full potential, benchmarking can provide a common measuring stick to evaluate process performance. This article introduces the general concept of benchmarking, linking it whenever possible to reference services in health sciences libraries. Data collection instruments that have potential application in benchmarking studies are discussed and the need to develop common measurement tools to facilitate benchmarking is emphasized. PMID- 10153389 TI - '96 Accreditation Manual shrinks; standards are less prescriptive. PMID- 10153390 TI - Rebuilding a unit for seamless surgical care. PMID- 10153391 TI - Getting ready for a new sterilization process. PMID- 10153392 TI - Advice to clear up disinfection controversies. PMID- 10153393 TI - Physical therapy: a profession prepared and poised. PMID- 10153394 TI - The lower extremity activity profile: a health status instrument for measuring lower extremity disability. AB - The Lower Extremity Activity Profile (LEAP) is a comprehensive measure of lower extremity function. It measures the client's perception of difficulty and satisfaction with performance in the following areas: self care, mobility, household activities, work, leisure activities, and social activities. The development and initial reliability and validity testing of LEAP was conducted with 32 osteoarthritis clients undergoing total knee replacement. Using a one group repeated measures design, the LEAP, knee range of motion and self-paced walk measures were administered pre-operatively and 3 months post-operatively. The internal consistency of the LEAP using Cronbach's Alpha was 0.73. All LEAP scores showed significant improvement (p<0.01) between the two administration times demonstrating responsiveness of the measure. Correlations of LEAP with the clinical measures were moderate. LEAP is recommended for use as an outcome measure in similar populations, if used in conjunction with clinical and physical performance measures. Further testing of the LEAP is warranted for use in evaluating outcomes of rehabilitation programs addressing lower extremity musculoskeletal impairment and disability. PMID- 10153395 TI - Analysis of outcome measures used in the study of patellofemoral pain syndrome. AB - Validation of evaluation methods is necessary in order to appropriately monitor Patellofemoral Pain Syndrome (PFPS) patients and to determine the effectiveness of treatment and prevention programs. The goal of this study was to investigate the psychometric properties of five evaluation methods: a functional index questionnaire (FIQ), visual analogue scales (VAS) for pain, a patellofemoral function scale (PFS), a step test and a subjective report of functional limitations. Measurements for each of the six components were taken on 56 PFPS patients participating in a randomized clinical trial, prior to and at one month following treatment. Modest test-retest reliability for the FIQ, VAS and step test were found. High internal consistency for the FIQ and modest internal consistency for the PFS were demonstrated. The VAS and FIQ were found to be good discriminators for measuring clinical change, while the step test was found to be reliable but poor at detecting clinical change. The PFS, which combines a number of evaluation areas into an index, demonstrated potential to detect clinical change, however, conclusions are limited as reliability testing was not performed. PMID- 10153396 TI - Individual rights and public health. Physician Assistant forum. PMID- 10153397 TI - Implementing a smoking cessation program for your patients. AB - PAs can improve the health of their patients by promoting healthy life-styles. By integrating a smoking cessation program into a surgical practice, the authors were able to achieve a cessation rate of 64% at 6 months and 1 year. The method, which includes screening, education, motivation, and follow-up, is applicable to any type of practice. PMID- 10153398 TI - Placing the right person in the right place at the right time. PMID- 10153399 TI - The byte stuff. Today's foodservice software can do almost everything except cook. Here's a look at some popular programs. PMID- 10153400 TI - The American way of dying. PMID- 10153401 TI - Healthcare reform 101. PMID- 10153402 TI - Central RHA uses geographic information system to visualise its data. PMID- 10153403 TI - Treating patients safely with electrical equipment. PMID- 10153404 TI - Telemedicine diagnosis launched at Health Waikato. PMID- 10153405 TI - Implementing case management and developing clinical pathways. AB - Efforts to implement case management and, subsequently, to develop critical paths at Birmingham Baptist Medical Center Montclair in Birmingham, AL, began in the late 1980s. Under the case management system, registered nurses using the CareMap system manage the care of 60-80% of the medical center's patients. Those patients whose care does not follow a map are managed by nurse case managers. The patients who do not meet the identified goals for care require a collaborative effort from all the healthcare professionals associated with their care. Since the inception of the case management program, Montclair has made significant strides in decreasing the cost per discharge, decreasing the variable cost per case, and, most importantly, improving quality outcomes for designated case types. PMID- 10153406 TI - Clinical pathways: improving patient education and influencing readmission rates. AB - Clinical pathways have long been used as a mechanism for implementing a managed care delivery system. They have been effective in highlighting lengths of stay, outcome variances, and systems problems. Clinical pathways play an important part in enhancing quality improvement activities, especially in accordance with the standards of the Joint Commission on Accreditation of Healthcare Organizations. This article addresses benefits of clinical pathways in general, and benefits at the authors' facility in particular, specifically, a clinical pathway's effectiveness in influencing readmissions of patients with atrial fibrillation. PMID- 10153407 TI - Path-based patient care should build quality into the process. AB - Clinical paths can help caregivers "do the right thing the first time" for the individual patient. They also can help to continually improve the system of providing care for future patients. By comparing what should be happening (according to the clinical path) with what actually is happening, the healthcare team can design an effective plan for patient care. By gathering data about the patient care experience, the healthcare team can redesign care for future patients. This article describes important concurrent and retrospective activities of path-based patient care and the ways in which healthcare providers are using clinical paths to improve patient outcomes. PMID- 10153408 TI - Collaborative development of a clinical pathway for congestive heart failure. AB - Bon Secours Hospital, a 304-bed community hospital in Grosse Pointe, MI, decided to target high-volume and high-cost DRGs for clinical process improvement. Working collaboratively with members of the medical staff, the cardiac team set out to improve outcomes by reducing the non-value-added costs and the variations in the treatment of patients with congestive heart failure (CHF). A comprehensive program of care for these patients, that included the full continuum of care, from prevention to maintenance, is being developed, using a clinical pathway to manage the acute phase of treatment. PMID- 10153409 TI - Developing a hospital policy for clinical pathways. AB - Clinical pathways are used for planning, coordinating and facilitating the continuum of patient care from before admission to after discharge. They rapidly are changing the provision of healthcare services through improved patient care and cost containment, but they also have raised questions about possible legal ramifications. If sound policies and procedures for clinical pathways are developed and consistently adhered to by healthcare facilities, the potential for liability may be minimized while patient care is improved. This article describes a multidisciplinary task force's work to develop such policies and procedures. PMID- 10153410 TI - Introduction to clinical pathways. AB - A clinical pathway is a comprehensive method of planning, delivering, and monitoring patient care. As efforts continue to streamline the delivery of services at all levels of care and settings, it is essential that quality management and utilization management professionals respond in a proactive manner to facilitate quality outcomes while decreasing cost and increasing efficiency. The use of clinical pathways, as one part of a facility's or an organization's total quality management program, may be the answer to this challenge. PMID- 10153411 TI - Benchmarking: go ahead, it's ok to copy. PMID- 10153412 TI - Pay increases for materials managers head slightly upward. PMID- 10153413 TI - Latex allergies: where the rubber glove meets the road. PMID- 10153415 TI - The lowdown on long-term care. PMID- 10153414 TI - It takes many hands to finally solve a glutaraldehyde safety problem. PMID- 10153416 TI - Your next move in managing drug costs. AB - Payers have squeezed short-term savings from the administration of pharmaceutical benefits. Now they need long-term control of expenditures for new products and increased usage. An industry veteran suggests how to make this happen. PMID- 10153417 TI - New ways to fight fraud. PMID- 10153418 TI - Maryland a trailblazer in top-down control. PMID- 10153419 TI - Big savings from tackling the basics. PMID- 10153420 TI - Block grants for sale. PMID- 10153421 TI - Who shall define accountability? PMID- 10153422 TI - Auditing the intangible. PMID- 10153423 TI - Community hospitals: a desirable option? PMID- 10153424 TI - Feasibility of monitoring patient based health outcomes in a routine hospital setting. AB - OBJECTIVE: To assess the feasibility of monitoring health outcomes in a routine hospital setting and the value of feedback of outcomes data to clinicians by using the SF 36 health survey questionnaire. DESIGN: Administration of the questionnaire at baseline and three months, with analysis and interpretation of health status data after adjustments for sociodemographic variables and in conjunction with clinical data. Exploration of usefulness of outcomes data to clinicians through feedback discussion sessions and by an evaluation questionnaire. SETTING: One gastroenterology outpatient department in Aberdeen Royal Hospitals Trust, Scotland. PATIENTS: All (573) patients attending the department during one month (April 1993). MAIN MEASURES: Ability to obtain patient based outcomes data and requisite clinical information and feed it back to the clinicians in a useful and accessible form. RESULTS: Questionnaires were completed by 542 (95%) patients at baseline and 450 (87%) patients at follow up. Baseline health status data and health outcomes data for the eight different aspects of health were analysed for individual patients, key groups of patients, and the total recruited patient population. Significant differences were shown between patients and the general population and between different groups of patients, and in health status over time. After adjustment for differences in sociodemography and main diagnosis patients with particularly poor scores were identified and discussed. Clinicians judged that this type of assessment could be useful for individual patients if the results were available at the time of consultation or for a well defined group of patients if used as part of a clinical trial. CONCLUSIONS: Monitoring routine outcomes is feasible and instruments to achieve this, such as the SF 36 questionnaire, have potential value in an outpatient setting. IMPLICATIONS: If data on outcomes are to provide a basis for clinical and managerial decision making, information systems will be required to collect, analyse, interpret, and feed it back regularly and in good time. PMID- 10153425 TI - How patients perceive the role of hospital chaplains: a preliminary exploration. AB - OBJECTIVE: An exploratory study of the attitudes of hospital patients to the service provided by hospital chaplains. DESIGN: Questionnaire study of hospital inpatients in December 1992. SETTING: One large teaching hospital in London. PATIENTS: 180 hospital inpatients in 14 different general wards, 168 (93%) of whom agreed to take part. MAIN MEASURES: Attitudes to chaplains and their role contained in 12 questions developed during a pilot study on hospital inpatients (16) and staff (14) and their relation to patients' age, sex, length of hospital stay, and religious beliefs, according to Kendall rank order correlations. RESULTS: Of 168(93%) respondents, 72(43%) were women; mean age of patients was 63.1 (SD 16.8) years. Forty five (27%) were inpatients of three days or less and 22(13%) for one month or more. 136(81%) were Christian; 17(10%) atheist, agnostic, or had no religion; and 15(9%) were of other religions. In general, patients showed positive attitudes towards the role of hospital chaplains and to the services they provided. The correlation analysis showed that there was a significant tendency for older patients, those who had been inpatients for longer, and those with religious beliefs to be more sympathetic to the role of hospital chaplains. CONCLUSIONS: Hospital chaplains provide a service which is appreciated by patients. This study provides a simple instrument for assessing patients' attitudes to chaplains. PMID- 10153426 TI - Audit activity and quality of completed audit projects in primary care in Staffordshire. AB - OBJECTIVES: To survey audit activity in primary care and determine which practice factors are associated with completed audit; to survey the quality of completed audit projects. DESIGN: From April 1992 to June 1993 a team from the medical audit advisory group visited all general practices; a research assistant visited each practice to study the best audit project. Data were collected in structured interviews. SETTING: Staffordshire, United Kingdom. SUBJECTS: All 189 general practices. MAIN MEASURES: Audit activity using Oxford classification system. Quality of best audit project by assessing choice of topic; participation of practice staff; setting of standards; methods of data collection and presentation of results; whether a plan to make changes resulted from the audit; and whether changes led to the set standards being achieved. RESULTS: Audit information was available from 169 practices (89%). 44(26%) practices had carried out at least one full audit; 40(24%) had not started audit. Mean scores with the Oxford classification system were significantly higher with the presence of a practice manager (2.7(95% confidence interval 2.4 to 2.9) v 1.2(0.7 to 1.8), p < 0.0001) and with computerisation (2.8(2.5 to 3.1) v 1.4 (0.9 to 2.0), p < 0.0001), organised notes (2.6(2.1 to 3.0) v 1.7(7.2 to 2.2), p = 0.03), being a training practice (3.5(3.2 to 3.8) v 2.1(1.8 to 2.4), p < 0.0001), and being a partnership (2.8(2.6 to 3.0) v 1.5(1.1 to 2.0), p < 0.0001). Standards had been set in 62 of the 71 projects reviewed. Data were collected prospectively in 36 projects and retrospectively in 35. 16 projects entailed taking samples from a study population and 55 from the whole population. 50 projects had a written summary. Performance was less than the standards set or expected in 56 projects. 62 practices made changes as a result of the audit. 35 of the 53 that had reviewed the changes found that the original standards had been reached. CONCLUSIONS: Evaluation of audit in primary care should include evaluation of the methods used, whether deficiencies were identified, and whether changes were implemented to resolve any problems found. PMID- 10153427 TI - Reliability of data of the Thames cancer registry on 673 cases of colorectal cancer: effect of the registration process. AB - OBJECTIVE: To measure the reliability of data collected by the Thames cancer registry and to identify factors in the registration process affecting reliability. DESIGN: A retrospective study of data from the registry, including death certificate only registrations, and hospital case notes on cases of colorectal cancer diagnosed in 1983 or 1988. SETTING: Four districts in South Thames region. SUBJECTS: 673 cases of colorectal cancer in resident patients. MAIN MEASURES: Dates of birth, diagnosis of cancer, and death; sex; tumour site; whether treatment was given; type of treatment; and district of residence. RESULTS: Among the 416 (62%) case notes retrieved, including 66 death certificate only registrations, full or high agreement between registry data and hospital notes was recorded for sex, district of residence, and dates of birth and death. Only 12% of cases had the same date of diagnosis, which may be due to failure of registry policy. Lower agreement rates occurred for tumour site (87%), whether treatment occurred (84%), and treatments administered (80%, 1983; 72%, 1988). 20% of surgical treatments and 37% of adjuvant therapy, radiotherapy, and chemotherapy were not recorded by the registry. Disagreements were common among death certificate only registrations. Such registrations accounted for 16(32%) disagreements over tumour site, 33(41%) major disagreements over date of diagnosis (difference > 30 days), and 47(44%) disagreements over treatment. In 65 cases the registry failed to capture all treatments carried out within the six month follow up period, 38(58%) of which were for death certificate only registrations. In 36% of death certificate only registrations the patients survived more than one year from diagnosis, indicating a failure of registry policy over retrospective follow up. CONCLUSIONS: Registry data on district of residence; sex; dates of birth, diagnosis, and death are highly reliable, but treatment and tumour site data are less so. Lack of follow up in death certificate only registrations and failure to monitor treatments during follow up period seemed to be associated with disagreements. PMID- 10153428 TI - Can admission notes be improved by using preprinted assessment sheets? AB - Inpatient medical notes often fail to record important details of patient history and findings on clinical examination. To overcome problems with content and legibility of notes we introduced preprinted notes for the admission of children to this hospital. The quality of the information recorded for 100 children whose admissions were clerked with the preprinted notes was compared with that recorded for 100 whose admissions were recorded with the traditional notes. All case notes were selected randomly and retrospectively from traditional notes written from April to October 1993 and from preprinted notes written from October 1993 to April 1994. The quality of information was assessed according to the presence or absence of 25 agreed core clinical details and the number of words per clerking. In admissions recorded with the preprinted notes the mean number of core clinical details present was significantly higher than those recorded with traditional notes (24.0 v 17.6, p < 0.00001). Admissions recorded with the preprinted notes were also significantly shorter (mean 144 words v 184 words, p < 0.0001). The authors conclude that information about children admitted to hospital is both more complete and more succinct when recorded using preprinted admission sheets. PMID- 10153429 TI - Implementing a policy for pneumococcal prophylaxis in a haematology unit after splenectomy. AB - People who have had a splenectomy for any reason are 40 times more likely to have an overwhelming infection, especially pneumococcal infection, and 17 times more likely to suffer fatal sepsis. The incidence of such life threatening infections is reduced by prophylactic immunisation with polyvalent pneumococcal vaccine and long term antibiotic prophylaxis or instituting prompt antibiotic treatment in the event of fever. This haematology unit agreed a policy of immunisation and antibiotic prophylaxis in June 1988 for all patients undergoing elective splenectomy. The success of this policy was audited in July 1993 by a retrospective analysis of patients' case notes. Seventy four patients were identified as having had a splenectomy, 54 (73%) before June 1988, of whom only 13 (24%) had received both pneumococcal immunisation and antibiotic prophylaxis before implementation of the agreed policy. At the time of audit, 46/74 (62%) patients were recorded as having received immunisation and 64/74 (86%) as receiving antibiotic prophylaxis or a supply of antibiotics to take in the event of a fever. All but one of the 20 patients who had a splenectomy after June 1988, since implementation of the agreed policy, received immunisation and antibiotic prophylaxis. The authors conclude that establishment of a formal agreed policy for pneumococcal prophylaxis for patients undergoing splenectomy has improved the quality of care. PMID- 10153430 TI - Never mind solutions: what are the issues? Lessons of industrial technology transfer for quality in health care. PMID- 10153431 TI - Protection of personal health information in The Netherlands: getting the balance right? PMID- 10153432 TI - Assessing the benefits of health care: how far should we go? PMID- 10153433 TI - Is there a demand among general practitioners for inner city community hospitals? PMID- 10153435 TI - Memorandum. Re: Autopsy report on health reform: future mistakes to avoid. PMID- 10153436 TI - Identifying the missing link in the audit cycle. PMID- 10153437 TI - Phone and fax. PMID- 10153438 TI - What to look for in benchmarking partners. PMID- 10153434 TI - Managing menorrhagia. PMID- 10153439 TI - Customer service-based performance evaluations. PMID- 10153440 TI - Bonus options in health insurance. PMID- 10153441 TI - HMOs and medical ethics. PMID- 10153442 TI - Maintaining morale in the midst of rapid change. AB - Change--even when it's change for the better--can strain the fabric of any organization. Here's how Healthsource Maine has been able to maintain employee commitment during five years of rapid growth. PMID- 10153443 TI - Member appeal. AB - To determine whether a particular HMO is right for them, consumers need to understand what an HMO is and how it works. Health plans use a variety of strategies for getting the word out to new and prospective members. PMID- 10153444 TI - Nutrition and the elderly. PMID- 10153446 TI - GHAA (Group Health Association of America) and AMCRA (American Managed Care and Review Association) merge. PMID- 10153445 TI - Strengthening the link between managed care and public health. PMID- 10153447 TI - A healthy start. PMID- 10153448 TI - No silver bullets. PMID- 10153449 TI - Credentialing HMO physicians. PMID- 10153450 TI - Community service: how HMOs target their efforts. PMID- 10153451 TI - Medicare risk contracts: the rules for the group market. AB - Different rules apply when Medicare risk HMOs serve groups of retirees, rather than individuals. Here's what plans can and cannot do in providing coverage to retiree groups. PMID- 10153452 TI - Getting to the core of marketplace issues. PMID- 10153453 TI - HMOs provide comprehensive care to mothers and newborns. PMID- 10153455 TI - Doctors may play a bigger leadership role in networks of the future. PMID- 10153454 TI - Medical group practices need more than luck in the provider-mix game. PMID- 10153456 TI - Expert says outlook for specialists isn't all gloom and doom. PMID- 10153457 TI - New Mexico network coddles MD partners by preserving some group independence. PMID- 10153458 TI - How to maximize doctors' productivity and profitability in the shift to capitation. PMID- 10153459 TI - When two hospitals team up: integrating security without merging forces. PMID- 10153460 TI - Course trains security officers in resolving violent situations. PMID- 10153461 TI - Expert tips on spotting troubled employees who may be prone to violence. PMID- 10153462 TI - Renovated hospital facilities include heavy investments in security. PMID- 10153463 TI - More on problems protecting celebrities: Mickey Mantle's stay at Baylor. PMID- 10153464 TI - Special report. Some new approaches to hospital parking security--Part II. AB - In Part I, in the October 1995 issue, we reported on some new developments that were already in use or had promising applications for hospital parking security. These included radio frequency access control systems and mounted horse patrols. In this part, we'll give you details on the use of bicycle patrols. We'll review some federal recommendations for parking security for buildings of all sizes that followed the Oklahoma City bombing. And we'll give details on how a leading parking management company that operates over 30 hospital parking facilities works together with hospital security to maximize both people and asset protection. PMID- 10153465 TI - Issues in rural health: access, hospitals, and reform. AB - This overview discusses articles published in this issue of the Health Care Financing Review, entitled "Access to Health Care Services in Rural Areas: Delivery and Financing Issues." These articles focus on the following topics: rural hospitals (including closures, the impact of Federal grants, network development, and costs), managed care in rural areas, telemedicine, and the delivery of mental health services to rural Medicaid beneficiaries. PMID- 10153467 TI - Access of rural AFDC Medicaid beneficiaries to mental health services. AB - This article examines geographic differences in the use of mental health services among Aid to Families with Dependent Children (AFDC)-eligible Medicaid beneficiaries in Maine. Findings indicate that rural AFDC beneficiaries have significantly lower utilization of mental health services than urban beneficiaries. Specialty mental health providers account for the majority of ambulatory visits for both rural and urban beneficiaries. However, rural beneficiaries rely more on primary-care providers than do urban beneficiaries. Differences in use are largely explained by variations in the supply of specialty mental health providers. This finding supports the long-held assumption that lower supply is a barrier to access to mental health services in rural areas. PMID- 10153466 TI - Effects and effectiveness of telemedicine. AB - The use of telemedicine has recently undergone rapid growth and proliferation. Although the feasibility of many applications has been tested for nearly 30 years, data concerning the costs, effects, and effectiveness of telemedicine are limited. Consequently, the development of a strategy for coverage, payment, and utilization policy has been hindered. Telemedicine continues to expand, and pressure for policy development increases in the context of Federal budget cuts and major changes in health service financing. This article reviews the literature on the effects and medical effectiveness of telemedicine. It concludes with several recommendations for research, followed by a discussion of several specific questions, the answers to which might have a bearing on policy development. PMID- 10153468 TI - Hospital department cost and employment increases: 1980-92. AB - Hospital costs have continued to rise at rates well in excess of inflation generally, even after the introduction of Medicare's per case prospective payment system (PPS). This article uses a hospital subscriber microcost reporting system to show trends in costs, wages, labor hours, and outputs for more than 50 individual departments from 1980-92. Descriptive results show dramatic growth in the operating room, catheter lab, and other technologically driven cost centers. Administrative costs also increased rapidly through 1988, but slowed thereafter. The paperwork billing and collection burden of hospitals is estimated to be $6 billion in 1992, or approximately 4 percent of total expenses. PMID- 10153469 TI - Access to care in rural America: impact of hospital closures. AB - This article employs a quasi-experimental, pre/post comparison group design to determine whether rural hospital closures (n = 11) have had a detrimental impact on access to inpatient and outpatient care for the Medicare population. Closure areas experienced a significant decrease in medical admissions, although admission rates remained higher than in comparison areas. Physician services were not found to substitute for inpatient services following a closure. No adverse impacts on mortality were observed. Patients in closure areas were more likely to be admitted to urban teaching hospitals following the closure of their local hospital. PMID- 10153470 TI - Medicaid fees and the Medicare fee schedule: an update. AB - This study analyzes changes in Medicaid physician fees from 1990 to 1993. Data were collected on maximum allowable Medicaid fees in 1993 and compared with similar 1990 Medicaid data as well as the fully phased-in Medicare Fee Schedule (MFS). The results suggest that, on average, Medicaid fees have grown roughly 14 percent, but considerable variation continues to exist in how well Medicaid programs pay across types of services, States, and census divisions. Medicaid fees remain considerably lower (27 percent for the average Medicaid enrollee) than fees under a fully phased-in MFS. Medicaid fees for primary-care services were, on average, 32 percent lower. PMID- 10153471 TI - Variations and trends in state nursing facility capacity: 1978-93. AB - The demand for nursing facility (NF) beds has been growing with the aging of the population and many other factors. As the need for nursing home care grows, the Nation's capacity to provide such care is the subject of increasing concern. This article examines licensed NFs and beds, presenting data on trends from 1978-93. Measures of the adequacy of NF beds in States are examined over time, including the ratio of beds per aged population, occupancy rates, and State official's opinions of the adequacy of supply. State and regional variations are shown over time, and we speculate on the factors which may be associated with the variation. PMID- 10153472 TI - State health expenditure accounts: building blocks for state health spending analysis. AB - The dynamics of financing health care among various levels of government and the private sector are rapidly changing; structural relationships among health care providers are also being altered. These changes are placing increased importance on State-level expenditure estimates that will be instrumental in measuring the differential impact of Federal policies and State-specific initiatives on individual States. This article presents personal health care expenditures (PHCE) for 1980-93. Statistics show wide variation in level and rate of growth of regional spending per person. These statistics also quantify differences in both the percent of health care costs in each State borne by Medicare and Medicaid and in the proportion of each State's economy devoted to the provision of health care. PMID- 10153473 TI - Ownership and average premiums for Medicare supplementary insurance policies. AB - This article describes private supplementary health insurance holdings and average premiums paid by Medicare enrollees. Data were collected as part of the 1992 Medicare Current Beneficiary Survey (MCBS). Data show the number of persons with insurance and average premiums paid by type of insurance held--individually purchased policies, employer-sponsored policies, or both. Distributions are shown for a variety of demographic, socioeconomic, and health status variables. Primary findings include: Seventy-eight percent of Medicare beneficiaries have private supplementary insurance; 25 percent of those with private insurance hold more than one policy. The average premium paid for private insurance in 1992 was $914. PMID- 10153474 TI - Do transition grants help rural hospitals? AB - Congress introduced the Rural Health Care Transition (RHCT) Grant Program in 1989 to assist financially troubled, small rural hospitals. This article discusses grant effects on the second cohort of hospitals to complete their 3-year grants. Although three-quarters of the grantees implemented all or most of their goals, 11 percent could not implement a viable project. Grantees added or upgraded 523 services with the help of their grants, especially outpatient and social services, most of them financially self-supporting. Except among the largest hospitals, there was no evidence that the grants improved grantee finances. Management appeared unaffected by the grants. PMID- 10153475 TI - Rural hospital networks: implications for rural health reform. AB - This article summarizes the perspectives gained in the course of evaluating a 4 year demonstration program that supported rural hospital networks as mechanisms for improving rural health care delivery. Findings include: (1) joining a network is a popular, low-cost strategic response for rural hospitals in an uncertain environment; (2) rural hospital network survival is enhanced by the mutual resource dependence of members and the presence of a formalized management structure; (3) rural hospitals join networks primarily to improve cost efficiency but, on average, hospitals do not appear to realize short-term economic benefit from network membership; and (4) some of the benefits of these networks may be realized outside of the communities in which rural hospitals are located. PMID- 10153476 TI - Variations in rural hospital costs: effects of market concentration and location. AB - This article explores two neglected questions: (1) Does the relationship between hospital concentration and costs vary between urban and rural markets? and (2) Do hospital costs in non-metropolitan areas vary with rurality? Covariance model results using 1992 data reveal that: (1) Although metropolitan and urban markets exhibit a negative relationship between hospital average costs and market concentration, non-metropolitan and rural markets fail to exhibit any relationship between costs and concentration; and (2) among non-metropolitan hospitals, only hospitals located in single-hospital communities have lower costs than their counterparts in multiple-hospital communities, once other factors are held constant. PMID- 10153477 TI - Why do so few HMOs offer Medicare risk plans in rural areas? AB - Only 17 of the 38 health maintenance organizations (HMOs) that have Medicare risk contracts and offer coverage to commercial clients in rural counties include the rural counties in their Medicare plan service areas. Rural counties in which HMOs offer Medicare coverage have higher average adjusted average per capita costs (AAPCCs), larger populations, and more physicians per capita than rural counties excluded by risk plans. Interviewed plans cite low and erratic AAPCCs, scarcity of potential enrollees, lack of negotiating power with physicians, and adverse selection as drawbacks in rural areas. Proposed changes to the payment methodology would probably lead HMOs to increase their Medicare offerings in urban fringe areas, but not in isolated rural areas. PMID- 10153478 TI - Patterns of health maintenance organization service areas in rural counties. AB - This study analyzes the 1993 National Directory of HMOs to determine the extent to which rural counties are included in health maintenance organization (HMO) service areas. Two specific questions are addressed: (1) How do the patterns of service areas differ across HMO model types? (2) What are the characteristics that distinguish rural counties served by HMOs from those that are not? Although a majority of rural counties are in HMO service areas, substantially fewer are served by non-individual practice association (non-IPA) models. Access to HMO services is found to decrease with county population density, and adjacency to metropolitan areas is an important predictor of inclusion in service areas. PMID- 10153480 TI - Healthy communities: beginning inspiration. PMID- 10153479 TI - Changes made in Federal advance directive law. PMID- 10153481 TI - Hospital payment arrangements to encourage efficiency: the case of Victoria, Australia. AB - The casemix funding arrangements introduced in Victoria on 1 July 1993 represent a significant departure from the previous approaches to public hospital funding in Australia. They are designed to change the economic incentives on hospitals by linking payment to the number and case complexity of patients treated. The new funding arrangements include a combination of fixed and variable payments to hospitals for inpatient services. Outpatient services remain funded on a historical basis. Special payments are made for teaching and research functions. Total payments to hospitals are capped through operation of an 'Additional Throughput Pool' which allows price to fluctuate inversely with volume to ensure an expenditure limit. Because of operations of specific conditions on the Additional Throughput Pool, hospitals were given an incentive to reduce waiting lists. Despite the success in reducing waiting lists and budgets, there are a number of problems with the casemix approach including both technical issues (how are payment rates to be updated?; the failure to address problems of capital) and ethical issues. These are discussed in the paper. PMID- 10153482 TI - Value for money? A contingent valuation study of the optimal size of the Swedish health care budget. AB - The contingent valuation method has been developed in the environmental field to measure the willingness to pay for environmental changes using survey methods. In this exploratory study the contingent valuation method was used to analyse how much individuals are willing to spend in total in the form of taxes for health care in Sweden, i.e. to analyse the optimal size of the 'health care budget' in Sweden. A binary contingent valuation question was included in a telephone survey of a random sample of 1260 households in Sweden. With a conservative interpretation of the data the result shows that 50% of the respondents would accept an increased tax payment to health care of about SEK 60 per month ($1 = SEK 8). It is concluded that the results indicate that the population overall thinks that the current spending on health care in Sweden is on a reasonable level. There seems to be a willingness to increase the tax payments somewhat, but major increases does not seem acceptable to a majority of the population. PMID- 10153483 TI - The efficacy and equity of retransplantation: an experimental survey of public attitudes. AB - PURPOSE: To measure the relative importance people place on prognosis and retransplantation status in allocating scarce transplantable livers. METHODS: 138 subjects were asked to distribute scarce livers amongst transplant candidates with either a 70% chance or a 30% chance of surviving if transplanted. In one group of subjects, the prognostic difference was based on the presence or absence of a 'blood marker.' In the other group, the prognostic difference was based on whether candidates had been previously transplanted or not, with retransplant candidates having a 30% chance of surviving if transplanted. RESULTS: Subjects answering the retransplantation survey gave a higher percentage of organs to the better prognostic group than subjects answering the blood marker survey, with a mean of 71.6% versus 65.0%, although this difference fell just short of statistical significance (P = 0.0581). Retransplantation survey respondents were significantly less likely to want to ignore prognostic information than were blood marker respondents (P = 0.026). Subjects in both survey groups were equally unwilling to abandon the poor prognostic group, with only 18% in each group choosing to give all the available organs to the better prognostic group. CONCLUSIONS: Respondents reacted more strongly to prognostic differences when they were due to retransplant status than to the results of a blood test. However, most people were not solely interested in the aggregate medical benefit brought by different allocation systems, but were also interested in the amount of benefit brought to the worst off. PMID- 10153485 TI - More effective and less expensive: lessons from five studies examining community approaches to care. AB - Does the nature of community health services used by chronically ill clients and their caregivers have an impact on utilization of services, expenditure and well being outcomes? A series of five studies, (four historic cohort and one randomized trial) examined clients suffering from a variety of chronic conditions in a number of community settings in different regions of Southern Ontario. Study sample composition and size varied. Each study was designed to quantify the well being outcomes, and expenditure associated with different community approaches is covered under a nation-wide system of health insurance plans. As a collective, these studies represent increasing methodological rigor. Multiple-perspective client well-being outcome measures were used. Caregiver burden was also analyzed. A common approach to quantification and evaluation of expenditure for service consumption was applied across all five studies. The nature of community health services (proactive versus reactive approaches to care) was found to have direct and measurable impact on total expenditure for health service utilization and client well-being outcomes. A recurring pattern of lower expenditure for community health service utilization and equal or better client outcomes was associated with well-integrated proactive services when compared with individual fragmented, reactive approaches to care. The main lesson emerging from examining the five studies on approaches to community care is that it is as, or more, effective and less expensive to offer complete proactive health care services to chronically ill people in the early stages of their illness than to provide services on demand in a piecemeal manner. PMID- 10153484 TI - Who cares about cost? Does economic analysis impose or reflect social values? AB - In a two-stage survey, a cross-section of Australians were questioned about the importance of costs in setting priorities in health care. Generally, respondents felt that it is unfair to discriminate against patients who happen to have a high cost illness and that costs should therefore not be a major factor in prioritising. The majority maintained this view even when confronted with its implications in terms of the total number of people who could be treated and their own chance of receiving treatment if they fall ill. Their position cannot be discarded as irrational, as it is consistent with a defensible view of utility. However, the results suggest that the concern with allocative efficiency, as usually envisaged by the economists, is not shared by the general public and that the cost-effectiveness approach to assigning priorities in health care may be imposing an excessively simple value system upon resource allocation decision-making. PMID- 10153486 TI - The mourning after. Grieving a medic's suicide. PMID- 10153487 TI - Medic suicide. What can be done? PMID- 10153488 TI - Awake and hassled. What stresses an EMT. PMID- 10153489 TI - Stress busters. Providers offer peer support in NYC*EMS. PMID- 10153490 TI - Hot dogs, houses, and hope. The 1995 JEMS salary survey. PMID- 10153491 TI - Perspectives. Even true believers hedge bets on nonprofit deal. PMID- 10153492 TI - Perspectives. Year in review: ghost of reform returns to haunt GOP. PMID- 10153493 TI - Perspectives. Medicine & Health at 50: wheels of policy grind slowly. PMID- 10153494 TI - Perspectives. Four futures: alternative scenarios for health care in the 21st century. PMID- 10153495 TI - Robots in the Rx: automating medication distribution. PMID- 10153496 TI - 1995 pharmacy review. Pharmacy systems: keeping pace. PMID- 10153497 TI - Hospitals on the highway. Alabama facilities make the most of information services. PMID- 10153498 TI - Taming risk under managed care. PMID- 10153499 TI - One observer takes his own look at capitation, which he calls ... the ultimate mind reversal. PMID- 10153500 TI - Are your organization's outsourced personnel employees or independent contractors? The wrong answer could cost money. PMID- 10153501 TI - Control systems for advertising spending. PMID- 10153502 TI - What is benchmarking? PMID- 10153503 TI - Simulation of a hospital's theatre suite. AB - Describes a study of sex operating theatres in a modern hospital where management was concerned about the throughput of the system. Senior medical staff were of the opinion that insufficient recovery spaces had been provided when the suite of theatres had been built which, if correct, was a physical constraint requiring considerable financial investment to remedy. They also thought that shortage of porters (?You can never find a porter when you need one!?) and recovery nurses were current operational problems. The relationship issues encountered when interfacing with the staff involved, the collection and analyses of relevant data and the building of a visual interactive simulation model are described. PMID- 10153504 TI - Managing capacity and demand in a resource constrained environment: lessons for the NHS? AB - The purchaser-provider split within the NHS which emerged out of the government's 1990 White Paper, Working for Patients, together with the introduction of the Patients Charter, has imposed new, tighter performance measures on provider units. The internal market has placed clear contractual guarantees on providers in terms of service/care provided. The Patients Charter has set, with little reference to local conditions, required timescales for treatment, i.e. waiting time guarantees for patients. The government is committed to reducing these guaranteed waiting times further. Both these factors have forced provider units to look far more closely at the way they operate, and the way they provide services. The impact of these performance measures has been magnified by the tight budgetary constraints within which provider units are currently expected to operate. Consequently the option of increasing service provision through expanding facilities and staff has effectively been precluded in the majority of instances. Thus provider units have been forced into reappraising the manner in which service provision is structured and the services delivered. While this restructuring of service provision has been most obvious in those services where the internal market has had the more immediate effect - for example, direct access services such as physiotherapy - increasingly, performance measure pressures have forced providers to examine the processes by which they deliver both in-patient and out-patient care. Analyses the difficulties encountered by an NHS Trust in Scotland in managing capacity and demand in a specialist out-patient clinic. PMID- 10153505 TI - Managerial objectives in the NHS. AB - Discusses managerial objectives in the National Health Service and compares service to patients with financial considerations. Reviews the growing influence of financial criteria and the manner in which financial objectives have been introduced. Asks if managers see their mission in terms of financial targets or patient service. Reports on the results of a questionnaire survey of all the managers in the provider units within two District Health Authorities. Managers were asked to rank a set of five statements in order of the extent to which they agree with them. Analysis of the overall results shows a large measure of agreement within the group of respondents that service to patients ranks first, with financial aspects coming last. The same outcome occurred when the results were disaggregated to NHS Trust/non-Trust level and between staff categories. PMID- 10153506 TI - Physician supply and distribution in the USA. AB - The rising cost of US health care has precipitated some close examination as to the supply, distribution, and specialty choice of the physician workforce. It is an issue of considerable concern as America struggles to control health-care expenditures by shifting resources away from specialty medicine. Central to this problem are the various programmes and incentives which have encouraged an excess number of residency positions and specialty training. Examines the consequences of an unregulated medical school structure and provides an overview of current policy alternatives designed to increase the number of primary care physicians, correct the problems of physician maldistribution, and limit the overall number of medical school graduates. PMID- 10153507 TI - An alternative method for the identification of potential habitual narcotic users from a managed care claims database. AB - The purpose of this study was to identify an alternative method of initial narcotic abuse screening to distinguish members who have a greater likelihood of being correctly classified as potential narcotic abusers. Members 10 years of age and older, who had one or more pharmacy claims for narcotics within a quarter were included in the analysis. Members were classified according to the number of narcotic prescriptions, unique pharmacies, and unique physicians in a quarter. Those with excluded medical conditions and abuse-related diagnoses were identified. A narcotic abuse decision tree was developed to identify population(s) with the highest likelihood for a potential abuse history. Using a combination of variables, especially age, strengthened the likelihood of identifying potential narcotic abusers. PMID- 10153508 TI - The voyage to total quality: time to course correct: Part I. AB - Quality management principles from the manufacturing industry have been transferred to the service industry with varying results. What have we learned from our experience in managed care? In a two-part article, the author describes some common problems, which when addressed, will help promote smooth sailing through the waters of total quality management. PMID- 10153509 TI - Distributing full-risk capitation revenues among providers. AB - What are the predominant types of vertical-integration models used to form health systems? The author describes these and the most common approaches employed by health systems to distribute full-risk capitation revenues between their primary care physicians, specialists, and hospitals. PMID- 10153510 TI - Is disease state management what customers really want? PMID- 10153512 TI - What is the Federal government's role in promulgating clinical practice guidelines? PMID- 10153511 TI - Medicare home health agency trends: an opportunity for disease state management programs? PMID- 10153513 TI - Career opportunities in managed care: what's hot and what's not? AB - Managed health care is poised for tremendous growth, particularly with the states' plans to increase Medicaid enrollment and the federal government's initiatives to jump-start Medicare enrollment. That means that employment opportunities should become widely available as managed care starts a new period of growth. What job opportunities are out there? What do they pay? What credentials are needed to take advantage of these openings? PMID- 10153514 TI - Gaining physician acceptance of information technology systems. AB - What are the keys to implementing a new information system within a physician environment? How can resistance to the technology be circumvented? Should physicians be brought in on the front end of system development, to help design information technology that can meet their needs? The authors give some timely advice for the information-driven industry. PMID- 10153515 TI - The value of goodwill in medical practice. AB - Accountants measure goodwill as the amount paid to acquire a medical practice over and above the current value of its net tangible assets. Patient lists, a well-respected practice, an ideal location, and other factors are expected to result in greater than normal earning power. In this article, the author discusses the hidden value of goodwill and its important in medical acquisitions and other business transactions. PMID- 10153516 TI - Information system solutions for pharmacy management. PMID- 10153517 TI - The effect of health risk on medical costs. PMID- 10153518 TI - Disease management in the treatment of cancer. PMID- 10153519 TI - The evolving health care market and emerging health information systems. PMID- 10153520 TI - Physicians under siege. PMID- 10153521 TI - Managed care organizations: the new research partners. AB - The current "accountability movement" in managed care demands many of the same components as good research methodology: both issues depend on comprehensive data sources, knowledgeable data manipulation, and credible reporting of the results. As a result, some plans that have earmarked resources and institutional support to good accounting practices are also forming centers of research. The following is an overview of these managed care organizations and their studies, which investigate questions most relevant to their populations and data sources. This article summarizes this expanding area of health services research and identifies the key institutional components of the plans that support this work. PMID- 10153522 TI - Wholesaling in the managed care market. PMID- 10153523 TI - The coming of Medicaid. PMID- 10153524 TI - Implementation of a pharmacy benefit to a managed Medicaid population. AB - This paper describes an evaluation of per member per month costs, preauthorization processes, drug utilization, and provider and member educational efforts after one year of managing the pharmaceutical benefit of a former Medicaid population. During TennCare's inaugural year, HMO per member per month pharmacy costs decreased, prior authorization request and call activity decreased, and drug marketshares aligned toward formulary agents. Provider and member acceptance of the restrictive formulary grew as consistent interaction with the HMO became patient-specific. PMID- 10153525 TI - The voyage to total quality: time to course correct: Part II. AB - Quality management principles used by the manufacturing industry have been transferred to the service industry with varying results. What have we learned from our experience in managed care? The author offers some common problems faced by companies, which, when addressed, will help promote smooth sailing through the waters of total quality management. PMID- 10153526 TI - 1995 in the states: refinement of reform. AB - With the exception of Kentucky, all state legislatures met in regular session in 1995. By mid-September, all but 10 had adjourned for the year. Not surprisingly, health care reform continued to be a priority for lawmakers. However, in sharp contrast with reform activity in past years, state lawmakers chose refinement over sweeping reform as their preferred approach to health care issues. The year was not without its significant legislative initiatives, including the roll-back of far-reaching reform plans in Minnesota and Washington. However, the fine tuning of insurance market reforms, Medicaid reform, continued growth of medical savings account (MSA) legislation, and making managed care more consumer-friendly were the mainstream activities of this legislative year. PMID- 10153527 TI - Calling the cadaver king. An autopsy chain? Isn't that a dying business? PMID- 10153528 TI - Yale-New Haven Hospital prepares clambake for 10,000 at Special Olympics World Games. PMID- 10153529 TI - Planning foodservice areas: practical guides to efficient design. PMID- 10153530 TI - Vegetarian offerings vary with clientele. PMID- 10153531 TI - How to beef up cafeteria business in the summer? Open an outdoor cafe. PMID- 10153532 TI - Building a central commissory. PMID- 10153533 TI - Temporary alien workers seeking H classification for the purpose of obtaining graduate medical education or training--INS. Final rule. AB - After consideration of comments filed and the relevant issues, the Immigration and Naturalization Service (Service) has decided not to implement one of the changes previously proposed, to preclude the use of the H-1B non-immigrant classification for graduates of foreign medical schools pursuing medical residencies in the United States. However, this rule amends the Service's regulations in other respects by modifying the filing procedures for certain H nonimmigrant petitions involving multiple beneficiaries. The rule allows a petitioner to file a single petition even when the beneficiaries listed on the petition will be applying for nonimmigrant visas at different consulates or for entry into the United States at different Ports-of-Entry, provided that the aliens will be performing the same service or receiving the same training, for the same period of time, and in the same location. This rule further amends the Service's regulations by clearly differentiating between an H-3 alien trainee and an H-3 special education trainee with respect to the time limitations on admission for these types of classifications. This rule will ease the burden on the public when filing H petitions involving multiple beneficiaries and will correct a regulatory inconsistency regarding the limitations on stay for H-3 nonimmigrant aliens. PMID- 10153534 TI - Medicare program; physician self-referral regulations: change in date for submission of group attestation statement--HCFA. Final rule--technical amendment. AB - This final rule changes (delays) the date by which a group of physicians that wishes to be identified as a group practice for purposes of the physician self referral regulations (42 CFR 411.350 through 411.361) must file a statement attesting that it meets certain specified conditions. PMID- 10153535 TI - Medicare program; additional supplier standards--HCFA. Final rule with comment. AB - This final rule with comment period conforms our regulations to changes made to section 1834 of the Social Security Act (the Act) by section 131 of the Social Security Act Amendments of 1994. Section 1834(j) of the Act requires that suppliers meet additional standards related to compliance with State and Federal licensure requirements, maintaining a physical facility on an appropriate site, and proof of appropriate liability insurance. This final rule retains existing regulatory standards and incorporates the three additional standards specifically cited from the statute. PMID- 10153536 TI - Domestic violence: how EDs can address the legacy of pain. PMID- 10153537 TI - Community approach helps sex-crime victims. PMID- 10153538 TI - Lawsuit prevention takes a good 20 minutes. PMID- 10153540 TI - 'Family room' offers place to grieve after ED death. PMID- 10153539 TI - Critical care time: not just bedside time. PMID- 10153541 TI - Includes forms and charts on: nontreatment release, managed care, patient financial responsibility, patient-focused care, staff performance appraisal. PMID- 10153542 TI - Managing managed care in the emergency department. PMID- 10153543 TI - Do your homework before negotiating with MCOs. PMID- 10153544 TI - Unique idea: provide after-hours care. PMID- 10153545 TI - Protect your ED's legal rights under managed care. PMID- 10153546 TI - Focus on patients empowers ED staff. PMID- 10153547 TI - Performance appraisals: let staff take charge. PMID- 10153548 TI - Staffing is top concern among ED managers. PMID- 10153549 TI - Public, private agencies aid disaster planning. The key: organize community in advance. PMID- 10153550 TI - When your hospital is the disaster site: how to cope. PMID- 10153551 TI - Rely on clinical judgment to avoid missed diagnoses. PMID- 10153552 TI - Planning, communication, staffing critical when disaster hits home. PMID- 10153553 TI - Vendors hot on the trail to capture pathway market. A resource guide to system vendors. PMID- 10153554 TI - PA hospital computerizes variance analysis system, aids pathway team. PMID- 10153555 TI - Variance program melds hospital's, vendor's ideas. PMID- 10153556 TI - Hospitals integrate MDs in variance tracking efforts. PMID- 10153557 TI - Take the next step in variance management. PMID- 10153558 TI - Clinical automation assists cardiac ICU. PMID- 10153560 TI - Hospital reduces practice pattern variation before starting pathways. PMID- 10153559 TI - Transitional pathway encompasses outpatient settings. PMID- 10153561 TI - Complex patients demand higher-level CMs. PMID- 10153562 TI - Don't cut LOS at expense of readmission rates. PMID- 10153563 TI - Higher admissions lead to new vaginal hysterectomy path. PMID- 10153564 TI - Breast centers rely on CMs to streamline care. PMID- 10153565 TI - Data collection efforts made easy. PMID- 10153566 TI - Pathways, patient education improve satisfaction rates. PMID- 10153567 TI - Critical path use doesn't have to be as traumatic as the condition. PMID- 10153568 TI - Hospital's stroke path proves myth wrong. PMID- 10153569 TI - Teaching path balances LOS, education needs for MI. PMID- 10153570 TI - Stroke path calls for care when evaluating variances. PMID- 10153571 TI - What redesign efforts mean to case managers. PMID- 10153572 TI - Map your course with pathway automation, new responsibilities. PMID- 10153573 TI - HIV pathway progress based on intervals instead of days. PMID- 10153574 TI - Don't automatically point fingers at doctors. PMID- 10153575 TI - Let pathways help solve the HIV puzzle. PMID- 10153576 TI - What's your role in raising patient satisfaction? PMID- 10153577 TI - Documentation, CM system praised by Joint Commission. PMID- 10153578 TI - Pneumonia pathway gets OK for further LOS reduction. PMID- 10153579 TI - Automated guidelines inching into CM. PMID- 10153580 TI - ANA's standards might solve automation hassles. PMID- 10153581 TI - Can you ever have too many pathways? PMID- 10153582 TI - Acute pain management pathway eliminates sore spot in pediatric unit. PMID- 10153584 TI - How to give physicians meaningful report cards. PMID- 10153583 TI - Comfort care path strengthens support for terminally ill. PMID- 10153585 TI - Hospital restructures CM, discharge planning. PMID- 10153586 TI - Small hospital reaps big rewards from CM approach. PMID- 10153587 TI - Medicare prepaid plans drive emergence of shared equity IDSs. PMID- 10153588 TI - Most medical staffs have an oversupply of specialists, but don't plan to take action to correct this. PMID- 10153589 TI - Compensation for specialists bounces back--a bit--after income declines in 1993. PMID- 10153590 TI - Wall Street funds MSO growth. PMID- 10153591 TI - IDS includes community in governing process; creates scores of opportunities for physician leadership. PMID- 10153592 TI - Recruiting on the Internet. PMID- 10153593 TI - Canadian physicians offer primary care alternative. PMID- 10153594 TI - The end may be in sight for Boren. PMID- 10153596 TI - Single-facility operators must rise to the challenge. PMID- 10153597 TI - A stumbling giant. Is Beverly Enterprises headed for a fall, or will CEO David Banks outfox Wall Street? PMID- 10153595 TI - Federal funding, OBRA on the chopping block. PMID- 10153598 TI - Managed care. Pennies from heaven? AB - Managed care now covers almost a quarter of all Medicaid participants, but only a handful of those receiving long term care. And no wonder: Where could the savings be found? A few model programs indicate how--and whether--Medicaid managed care for long term care can work. PMID- 10153599 TI - Food, water, and a patient's final days. PMID- 10153601 TI - Contemporary Long Term Care Products and Services Directory. PMID- 10153600 TI - Surviving the survey. New process turns up the heat on administrators. PMID- 10153602 TI - Community Health Purchasing Alliances (CHPAs): how Florida CHPAs are affecting employers. A case study. AB - Florida's health insurance reforms for small employers can be viewed as two distinct initiatives: insurance reform and the community health purchasing alliances (CHPAs). While small employer insurance reform legislation appears to have expanded access to coverage, the administrative structure of the CHPA still has a long way to go to capture the confidence of the marketplace. PMID- 10153603 TI - The impact of horizontal mergers and acquisitions on cost and quality in health care. AB - Mergers and acquisitions among HMOs, hospitals and other health care providers can be disconcerting to benefits staff and employees, but they can be successfully managed. They may offer an employer the opportunity to improve the quality of care provided and to do so at reduced costs. PMID- 10153604 TI - State health reform. AB - Health care reform has continued to proceed in a number of different directions at the state level. The likelihood of significant limits on future federal spending for Medicaid and Medicare points to continuing challenges for state health care policy makers. PMID- 10153606 TI - EMS Buyers' Guide--companies. PMID- 10153605 TI - Changing the way employee benefit communications are produced: outsourcing, a more efficient, less costly process. AB - Outsourcing may offer employers an efficient, cost-effective way to produce employee benefit communications. It offers a way to utilize the latest technology to produce personalized benefit statements or to target an announcement of benefit changes to a specific group of employees. PMID- 10153607 TI - Directory of EMS organizations. PMID- 10153608 TI - 19th Annual EMS State and Province survey. PMID- 10153609 TI - Tactics for the times. 1995 eldercare foodservice report. The maturing senior challenge. PMID- 10153610 TI - Celebrating anniversaries. PMID- 10153611 TI - Paving the way for life--one brick at a time. PMID- 10153612 TI - Spotlight on the future. PMID- 10153613 TI - Moving into the 21st century. PMID- 10153614 TI - $5 million endowment. PMID- 10153615 TI - Concern about AIDS in minority communities. PMID- 10153616 TI - Strategic planning and the health care supervisor. AB - This article explores strategic planning from the perspective of the health care supervisor. It analyzes the strategic environment of organizations, the planning process, how to evaluate the strategic plan, and the implementation phase. A strategic planning model is offered as well as a view of the future of strategic planning. The article articulates that strategic planning should emphasize flexibility. The plan needs to be custom designed for the particular organization. Strategic planning is a primary vehicle for health care supervisors to use work teams to further develop organizational effectiveness. Finally, strategic planning is linked to both research and systems theory. PMID- 10153617 TI - The CQI paradigm: a pathway to nurse empowerment in a community hospital. AB - Anderson Area Medical Center instituted continuous quality improvement (CQI) hospitalwide two years ago. Three teams were challenged with identifying and improving processes related to accounts receivable. X-ray report turn-around time, and emergency department patient satisfaction. Nursing participation was sought for all three teams. An eight-step CQI process was used to identify, analyze, and improve these three processes. Substantial nursing participation in these pilot CQI teams led to further participation in many other CQI teams optimizing clinical processes. Nursing personnel gained opportunities to make significant contributions to the enhancement of clinical and administrative processes in a large hospital. Nurses learned to work with other members of the health care team outside of their traditional domains, and this, combined with formalized training in the team process, is empowering. PMID- 10153618 TI - How developmental supervision and performance management improve effectiveness. AB - Health care supervisors play an important role in helping organizations achieve their goals by ensuring that employees perform their jobs as effectively and efficiently as possible. In most organizations, ill-defined and improperly designed systems exist for assessing and managing employee performance. Health care managers and supervisors can use knowledge of developmental supervision and performance management to increase employee job performance and satisfaction while providing useful information to human resource departments regarding training needs of employees. PMID- 10153619 TI - Cost-accounting techniques for health care providers. AB - The author reviews cost-accounting techniques and systems used by manufacturing companies. Some of the concepts and techniques used by for-profit companies can be implemented for health care institutions. Nurse executives can learn many lessons in product cost accounting from these for-profit companies. Understanding the various cost-accounting methodologies and techniques that are available can help nurse executives design, implement, and use a cost accounting system that will identify the costs associated with products and services provided. The author also reviews and explains standard costing systems. These systems can serve as valuable tools for budgeting, evaluating, and controlling departmental costs. When used in these instances, they can prove useful, and they furnish important information that is necessary for pricing products, determining alternatives or substitute services, and controlling costs. PMID- 10153620 TI - Telecommuting and health care: a potential for cost reductions and productivity gains. AB - Health care administrators are striving to maintain positive operating margins while remaining responsive to community needs. As they look for ways to reduce costs and improve productivity, they may consider the benefits associated with telecommuting. Telecommuting refers to the work performed by organizational employees who use computers and telecommunication equipment to work at home or at remote sites one or more days a week. Benefits to the health care industry include release of valuable hospital space, reduced employee turnover, and increased productivity. The time away from the institution may provide administrators with valuable planning time, free from interruptions. PMID- 10153622 TI - Enhancing peer review with communication skill building. AB - The purpose of this pilot was to improve the peer review process by enhancing the communication skills of staff nurses. Communication skill building was taught to staff members with practice time allotted. The paradigm shift occurred in teaching staff that communication is a learned skill built through practice and not solely a cognitive skill. The results of this pilot demonstrated improved verbal communication, increased comfort with peer review, improved ability to separate performance from individual style differences, and increased accuracy with which staff rate themselves on self evaluations. An indirect benefit has been improved teamwork from increased support among the staff. PMID- 10153621 TI - In search of optimal productivity and hospital size: a case study. AB - This study examines the relationship between optimal employee productivity and hospital size based on a sample from the state of Texas during 1982-91. Full-time equivalents (FTEs) per adjusted occupied bed is employed to represent productivity. The number of beds, total employees, and eight standard categories are used to measure hospital size. The impact of the diagnosis-related group implementation on productivity is also tested. Major findings suggest that productivity is found to be the highest for hospitals with 272 beds or 945 employees or in the category IV or V. The implementation of the DRG has not increased employee productivity. PMID- 10153623 TI - Hippocrates takes a blow: the Family and Medical Leave Act and health care administration. AB - This article examines the special legal and administrative issues for health care management that are posed by the recently enacted Family and Medical Leave Act (FMLA). Following a question-and-answer format, the article outlines the basic provisions of the law and answers what will likely be the most commonly faced administrative questions. It will be seen that FMLA issues and administration will be of significant concern to managers at all levels in health care organizations for some time to come. The conclusion of the article outlines a series of administrative steps that health care managers should undertake to proactively administer the federal leave law. PMID- 10153624 TI - "We missed you": the absence that fails to make the heart grow fonder. AB - Absenteeism is a problem that costs business in general billions of dollars each year. No industry is immune from its impact, least of all health care. The control of absenteeism rests largely in the hands of the first-line supervisor who must demonstrate visible concern for absenteeism and who must faithfully apply the organization's policies in the correction and control of absenteeism. The keys to absence control are visible concern, reliable documentation, consistent policy application across the work group, and constant attention to employee needs and concerns. PMID- 10153625 TI - The impact of the Ontario Consent to Treatment Act (Bill 109) on adolescent health care. PMID- 10153626 TI - The assessment of the intoxicated patient: medical-legal issues. PMID- 10153627 TI - Approaches to the assessment of mental competency. PMID- 10153628 TI - Consents for traditional practice: the changing roles of health care professionals. PMID- 10153629 TI - Pregnant women and consent to medical treatment. PMID- 10153630 TI - Clinical trials, consent and the doctor-patient contract. PMID- 10153631 TI - Dilemmas of the clinical researcher: a view from the inside. PMID- 10153632 TI - Recovery room rapes spur new Florida laws involving hospital security. PMID- 10153633 TI - Dennis Burns on installing cctv in cashier/attendants' booths. PMID- 10153634 TI - 'User-friendly,' low-cost incident reporting software available. PMID- 10153635 TI - Boston hospital ups security after abortion protests and violence. PMID- 10153636 TI - NYC-Cornell: security for an off-site health center in a high-crime area. PMID- 10153637 TI - Special report. Recent natural and man-made disasters: testing hospital disaster plans and security departments in real-life situations. AB - In 1995, hurricanes, windstroms, hailstroms, and record flooding challenged the disaster-coping capabilities of hospitals in the Florida Panhandle, New Orleans, and Texas. And, in Carrollton, GA, a severe test of a hospital's disaster plan literally dropped out of the sky. In this report, we'll present some firsthand accounts of what happened; how hospital security and emergency personnel responded; and what lessons all hospitals can learn from these unusual, but not unforeseen, occurrences. PMID- 10153638 TI - How two Wichita medical centers seek to curb ER violence, control gangs. PMID- 10153639 TI - The 1996 standards. Joint Commission refines its approach. PMID- 10153640 TI - Survey success: a case study in QI. PMID- 10153641 TI - Tips for streamlining tray assembly. PMID- 10153642 TI - Obtaining patients' heights and weights. PMID- 10153643 TI - Joint Commission rolls out 1995 standards, pares down paperwork. PMID- 10153644 TI - Narcotics are safe for acute and chronic pain. PMID- 10153645 TI - Changeover helps staff learn CQI by living it. PMID- 10153646 TI - HCFA grants 'deemed status' to accredited labs. PMID- 10153647 TI - Success under capitation hinges on 'big picture'. PMID- 10153648 TI - Hospital makes dramatic shift to QI in 12 weeks. PMID- 10153649 TI - Learn family background of children with brain injury. PMID- 10153650 TI - Private care. Gold rush. PMID- 10153651 TI - Private care. Putting on the Ritz. PMID- 10153652 TI - Palliative care. Hospices to fortune. PMID- 10153653 TI - Shared governance. Caring and sharing. PMID- 10153654 TI - Careers profile. Health promotion: promotional tactics. PMID- 10153655 TI - Impact of the development of a multidisciplinary adverse drug reaction committee. AB - A multidisciplinary Adverse Drug Reaction (ADR) committee consisting of pharmacists, nurses, and physician was formed. The committee developed an ADR Reporting Form and a 24-hour ADR Reporting Hotline to simplify ADR Reporting throughout the hospital. An ADR Newsletter and an extensive inservice education program was also implemented. Suspected ADRs are investigated by a pharmacist and presented to committee. A formal report is then forwarded to the Pharmacy and Therapeutics Committee, as well as the clinical departments within the hospital. The establishment of a formalized multidisciplinary ADR committee was successful in generating 2.1 ADR reports per 100 hospital admissions. These ADRs were reported from a variety of healthcare professionals. PMID- 10153656 TI - Control charts to monitor rates of adverse drug reactions. AB - We describe the use of control charts in monitoring rates of adverse drug reactions. Adverse drug reactions are recognized as important outcomes of patient care and are specifically associated with the process of medication use. The systematic monitoring of adverse drug reactions may allow one to identify opportunities to improve this process. Reported adverse drug reactions from 36 consecutive months at a university hospital were analyzed. The mean rate of adverse drug reaction reporting was 1.65% (denominator of patient admissions) and the 3 sigma upper and lower control limits were 3.22% and 0.08%, respectively. The mean rate of preventable adverse drug reactions was 21.25% (denominator of total reported adverse drug reactions) and the 3 sigma upper and lower control limits were 73.54% and < 0%, respectively. The experience described in this report suggests that monitoring adverse drug reactions using control charts, facilitates identification of trends in reporting and the actual incidence of adverse drug reactions, and allows identification of opportunities to improve the systems and processes of medication use. PMID- 10153657 TI - Documentation of the first steps of pediatric pharmaceutical care in a county hospital. AB - Pediatric pharmaceutical care is still a new concept in the pharmacy profession. In our county institution with 35% of the beds reserved for pediatric patients, there existed no formal process for providing specialized pediatric pharmacy services. In an effort to rectify this situation, a study was conducted to determine the benefits of providing pharmaceutical services by having a clinical pharmacist round with physicians on a daily basis for 3 hours. All services provided were documented for 6 months and direct cost-savings were calculated. Five hundred four different interventions and services were provided, with over $7000 in savings. Because of these findings, the pharmacy and hospital administration agreed to provide a staff pharmacist to round in pediatrics on a regular basis. This approach is considered to be more cost effective than using a clinical pharmacist for daily rounds. PMID- 10153658 TI - The development of a computerized LAN-based investigational drug information database. AB - A computerized LAN-based investigational drug information database, IRxBase, was developed at the University of Pittsburgh Medical Center to facilitate healthcare professionals' access to investigational drug information. Healthcare professionals at the medical center were surveyed to identify current problems in accessing investigational drug information. The survey reflected that before the implementation of the database, the medical center lacked a systematic approach to providing protocol-specific investigational drug information. Although investigational drug information software programs are commercially available, they provide limited information and few are protocol-specific. IRxBase offers an efficient means for the widespread provision of investigational drug information with advantages of accessibility, ongoing data entry, and preservation of confidentiality. PMID- 10153659 TI - Hospitals, managed care, and HEDIS. PMID- 10153661 TI - Building senior management teams. A critical process with critical differences. PMID- 10153660 TI - Choosing to change. Three healthcare executives discuss how and why they made the transition out of acute care settings. AB - It was the hot opportunity for professionals in healthcare administration. But hospital administration is no longer necessarily the most attractive career option for healthcare executives at any stage of their career. Many professionals who have built their careers in the once rock-solid field of hospital management are having to eye other healthcare management avenues, and most of them are finding that the field is wide open. Following are three profiles of former acute care executives who moved out of the acute care setting into areas where they never dreamed of working. While change is always a little threatening, all of them agree that the transition from the acute care world has not been overly traumatic. In fact, their experiences suggest that with the right skills and the right opportunities, transitioning out of acute care can be a positive experience. PMID- 10153662 TI - Acute to long-term care: bridging the gap. PMID- 10153663 TI - Career planning. PMID- 10153664 TI - Retirement planning essentials. PMID- 10153665 TI - Performing an ethics audit. PMID- 10153666 TI - Who will control the Medicare dollar? PMID- 10153667 TI - American College of Healthcare Executives Public Policy Statement. Enhancing minority opportunities in healthcare management. PMID- 10153668 TI - 1995 Directory of Executive Search Firms. PMID- 10153669 TI - Career derailment: are you at risk? Any of nine fatal flaws can derail even the most successful executive. PMID- 10153670 TI - Management teams for the 21st century. PMID- 10153671 TI - 20 strategies for marketing your managed care plan. AB - In today's fiercely competitive managed care marketplace, healthcare executives must find a way to set their plans apart from the competition and build a sufficient customer base. At the same time, they must confront a growing anti managed care backlash among a wary and confused public. Healthcare executive magazine talked with managed care experts to gather their views on key strategies to help executives meet both of these challenges. Here's what they suggest. PMID- 10153672 TI - Networking is tough: not working is tougher. PMID- 10153674 TI - Motivating physicians under capitation. PMID- 10153673 TI - Capitation is coming. PMID- 10153675 TI - Medicaid reform: states take control. PMID- 10153676 TI - The ethics of downsizing. PMID- 10153677 TI - American College of Healthcare Executives Ethical Policy Statement. Ethical issues related to downsizing. PMID- 10153678 TI - Clinical specialization programs for dietitians: a needs assessment. AB - This needs assessment was conducted to identify the perceived need for advancement and specialization through practicum programs in clinical dietetics. A questionnaire was developed and validated through a pilot study. It was mailed to a randomized sample of 950 dietitians (52%) registered with the ODA. Fifty two per cent responded, representing 27% of ODA members. Of those surveyed 89% were currently employed. The most current area of practice was clinical nutrition (55%) followed by foodservice (22%) and community nutrition (14%). Seventy two per cent of the respondents identified that they would consider enrolling in a specialized practicum. Most cited reasons for enrolling were increased knowledge/expertise (44%) and increased professional profile (25%). Areas of greatest interest were: nutrition assessment (9%), critical care/nutrition support (8%) and gerontology (7.5%). Sixty two per cent preferred the program to be offered part-time, 27% full-time and 9% were impartial. The most frequently cited length and cost per week for the program within specified part or full-time categories was: two weeks full-time (36.5%) at S200-299.00 (33%), four weeks full time (25%) at S100-199.00 (31%) and two weeks part or full-time (23.5%) at S200 299.00 (57%). Desired ODA regions for program availability were: Toronto (34%), Kitchener/Waterloo/Hamilton (17.5%) and London (14%). Lastly, 92% of the respondents felt the program should be CDA and ODA approved and continuing education points be provided. These results indicate that dietitians are interested in pursuing professional self-development through specialized practicums. PMID- 10153679 TI - The transformation of hospital laboratories: why regionalization, consolidation, and reengineering will lead laboratories into the 21st century. AB - In 1990 we predicted that the growth of prospective payment and fixed reimbursement plans would force hospitals to transform the hospital laboratory into a cost center. The need to create alternative modes of care would further lead hospitals to create regional laboratory consortia. This would include the "commercialization" of the laboratory so that it could become a regional resource and expand outreach activities. This report updates events since 1990. Indeed, the arrival of prospective payment and fixed reimbursement has caused a radical upheaval among health care providers in every part of the country. The transformation was more rapid than we expected, particularly in two areas. First, the commercial laboratory industry devoured itself. By 1995 the consolidation movement ended and three huge national laboratory chains now provide laboratory services throughout the United States. Second, not only did prospective payment arrive in the form of capitated contracts for laboratory services, but it arrived with remarkable speed. It was coupled with the absolute decline for three years in Medicare reimbursement for lab services. Such changes to reimbursement levels have seriously undercut the financial viability of the laboratory industry. Hospital-based laboratories are responding to these pressures with three strategies: reengineering, consolidation, and networking. Six identifiable trends will drive the transformation of laboratories into regional provider consortia between now and the year 2000. We predict that the speed of this transformation will be even faster than that experienced by the consolidation of commercial laboratories. This will occur because hospital labs are already a component within integrated delivery systems. As these systems transform and evolve, the laboratories must transform in concert. Our experience indicates that laboratory consolidation delivers economic benefits that are considerably greater than either networking or reengineering. Consolidation, accompanied by new testing technologies and tighter data links, will lead the transformation of today's hospital laboratory into a "virtual" laboratory. Such laboratories will be self sufficient, capable of performing all but esoteric tests in-house. It will be a "laboratory without walls," emphasizing testing performed at the point of care, be it bedside, physician's office, clinic, nursing home, ambulance, workplace, or patients' homes. A combination of economic and organizational pressures will cause hospital-based laboratories to adopt some form of regionalization within the next two to three years. PMID- 10153680 TI - Integrated delivery systems: strategic implications of levels of care. PMID- 10153681 TI - Employment trends and the traditional baccalaureate health administration student. AB - Baccalaureate programs in health administration serve both traditional undergraduates--usually age 18 to 22 with little experience--and older adult students with more experience. The former group of students, as well as some older students who are changing their fields, are sometimes not as well informed as graduate students and adult undergraduates with health care experience about the impact of changes in the health care sector on employment opportunities. Furthermore, career advisers in placement offices may not be able to keep pace with the rapid change in health care. This article examines past and future changes in employment opportunities for baccalaureate students, with a particular focus on the changes that are occurring in sector employment growth. The implications of the continued shrinking in the acute care sector, the growth of managed care, the increased complexity of physician group management, and the ongoing rise in long-term care for employment are too often missed by students with limited experience in health care. PMID- 10153682 TI - Expert systems in the health administration curriculum. AB - With the growing use of computers and on-line hospital information systems, a need exists for health care managers trained in computing and computer applications. This article reviews the advances in health care computing and reports on the design and implementation of a new course in a specific computer application, known as expert systems, in a health administration curriculum. The specific course framework is described and several student projects are presented and discussed. PMID- 10153683 TI - Health care executive education and training. AB - This paper examines the new situation of unprecedented change in the health care field--in which yet greater demands are in place for executive performance--and studies the educational and learning resources available to health care executives. The virtual transformation of the field requires new skill sets, competencies, and knowledge for high performing executives. How well is the field as a whole doing in providing appropriate learning opportunities? How well are health care organizations doing in effectively utilizing these resources of the field? What are the most crucial and immediately pertinent competencies needed; what are the topics of prime interest? And, are the overall learning efforts cost effective with efficacious means of evaluation? These are the questions addressed by this article ... with the answers drawn from health care executives themselves. PMID- 10153684 TI - The Andrew Pattullo lecture. Healthy populations or healthy institutions: the dilemma of health care management. PMID- 10153685 TI - Texas hospital chief executive officers evaluate content areas in health administration education. AB - Health care executives are confronted by a working environment that is increasingly difficult to manage. Skyrocketing health care costs, with shrinking reimbursement, threaten the existence of hospitals. A successful hospital chief executive officer (CEO) is one who can effectively manage his/her hospital in spite of industry challenges and problems. Graduate programs in health services administration must be designed to meet the needs of future health care executives. Many times, educators are criticized for not addressing "real world" issues within the curricular structure. The present study was conducted to gather information from executives who are the experts on what to expect in the health care industry regarding the appropriateness of curricular topics. Results indicate that practicing CEOs believe those curricular areas which focus on financial planning, budgeting, medical-legal issues, and strategic planning are more important than those that deal with international health care, epidemiology, or research methods. The information gathered in this study may be useful as a guide for educators, to evaluate and revise existing graduate programs in health care administration. Data presented here may also be used to assist in long-range planning for new health administration programs. PMID- 10153686 TI - Patterns and predictors of noninstitutional health care utilization by older adults in rural and urban America. AB - Noninstitutional long-term care is not often included in policy studies or recommendations in the United States even though there have been recent efforts to include this type of care in health reform proposals. This study was designed to provide insight into the patterns and predictors of noninstitutional medical, home-, and community-based services utilization by older adults in rural and urban America. The National Long Term Care Survey (NLTCS) was used to explore the relationship between residential setting and subsequent noninstitutional services utilization. Weighted logistic regression procedures for complex survey designs were used to guide the analysis. Living in the Northeast and residence in moderately densely populated areas (towns, small cities, and suburbs) were significant positive predictors of subsequent medical, home-, and community-based services utilization. Because some differentials were found in access to and use of services by regional and geographic setting, policy-makers need to develop alternative strategies to eliminate inequities in the distribution of noninstitutional long-term care services in more remote areas. PMID- 10153687 TI - Rural and urban differences in mortality among Americans 55 years and older: analysis of the National Longitudinal Mortality Study. AB - Previous research on rural and urban differences in risk of mortality has been inconclusive. This article used data from the National Longitudinal Mortality Study to establish whether all-cause mortality risk among persons 55 years and older varies by degree of urbanization, controlling for the potential sociodemographic confounders of age, gender, race/ethnicity, education, income, and marital status. Using the Cox Proportional Hazards Regression Procedure, the authors found that persons living in the most rural locales and those living in rural communities in standard metropolitan statistical areas (SMSAs) have the lowest risk of mortality, while those living in SMSA central cities had the highest risk of dying during the study period. The protective effect of rural residence declines in older age cohorts. PMID- 10153688 TI - Rural emergency medical services: patients, destinations, times, and services. AB - This study sought to describe the volume of use, mix of patients, origin and destination of runs, times and distances to care, and the volume of clinical services provided in a rural emergency medical services region. This study summarizes all 6,080 rural emergency ambulance trip reports filed from April through September 1991 from the 12 rural counties surrounding Augusta, GA. Rural ambulances are regularly used and are used extensively by elderly populations. The pattern of services provided suggests that while advanced care may or may not have been indicated, it was rarely provided and that rural emergency medical service programs should consider a greater reliance on basic life support teams. PMID- 10153689 TI - Agricultural work safety efforts by Wisconsin extension agricultural agents. AB - This study investigated the agricultural work-related safety and health programming of county-level cooperative extension agents who work through land grant universities to provide a range of educational programs to agricultural producers. A questionnaire was designed and administered to all 89 Wisconsin agriculture and agribusiness extension county faculty. The questionnaire obtained valid responses from 98.9 percent of the agents. Ninety percent of all agents conducted some occupational safety and health promotion programming in the last year. These activities occupied an average of 4.8 days per agent per year. Most of the reported activities were group programs for the agricultural labor force that involved other extension agents and included the use of videotapes. The greatest barrier to more programming was lack of time on the part of both the agricultural work force and the agents. Most extension agents placed greater emphasis on training in how to work safely around hazards than on how to recognize and permanently correct hazards. For future programs agents requested more short format materials to use in programming, such as fact sheets, videotapes, and farm hazard inspection checklists. Agents are important training delivery resources for controlling farm-related injury and disease. Agents could be more effective with more time, better materials, and with more emphasis on hazard correction in workplace safety programs. PMID- 10153690 TI - Oregon update: if this is rationing, what's the problem? PMID- 10153691 TI - Why it's dangerous to talk about a malpractice suit. PMID- 10153692 TI - Truly informed consent? Who are we kidding? PMID- 10153693 TI - Fiscal straitjacket: managed care comes to inpatient psychiatry. PMID- 10153694 TI - Don't let your deposition be used against you. PMID- 10153695 TI - Negotiating the best package when you sell to a hospital. PMID- 10153696 TI - Financial advisers. What to expect--and what not to. PMID- 10153697 TI - Retirement planning. Why your pension plan needs a checkup now. PMID- 10153698 TI - Will capitation unite or kill this IPA? PMID- 10153699 TI - Advice to new doctors: let Uncle Sam pay your school debt. PMID- 10153700 TI - Why doctors will take back health care. PMID- 10153701 TI - What you might earn in a new job. PMID- 10153702 TI - Doc income falls 3.6% in '94. PMID- 10153703 TI - Seattle HMO, system to strengthen alliance. PMID- 10153704 TI - Value of Wash. exemption law questioned. PMID- 10153705 TI - St. Louis hospitals agree to merge. PMID- 10153706 TI - AHA plans to buy several businesses. PMID- 10153707 TI - 3 not-for-profit S.C. hospitals propose merger. PMID- 10153708 TI - Accreditation gaining as quality-improvement tool. PMID- 10153709 TI - HealthSouth nets one last '95 deal. PMID- 10153710 TI - CPC spinoff sets hospitals free. PMID- 10153712 TI - HMOs plan campaign to fight bad image. PMID- 10153711 TI - Public hospital management, labor ally. PMID- 10153713 TI - Regulation of docs, nurses needs overhaul, panel says. PMID- 10153715 TI - Kaiser nurse pay may be tied to early patient discharges. PMID- 10153714 TI - 1996 outlook: systems, for-profit chains, medical groups, religious healthcare, managed care, post-acute care, finance, purchasing, info systems, labor, legal, construction. AB - It's put-up-or-shut-up time for healthcare providers in 1996. Two years ago, everyone talked about fixing the healthcare system. Not much happened. Last year, providers and politicians concentrated on squeezing medical costs. According to some of Modern Healthcare's key beat reports, this year it's back to the basics of running a business. PMID- 10153716 TI - Columbia is biggest on the Web, too. PMID- 10153717 TI - Mass. plan seeks to build regional link from the ground up. PMID- 10153718 TI - Failed mergers offer valuable lessons. PMID- 10153719 TI - Co-op testing healthcare credit card. PMID- 10153720 TI - N.C. hospitals' antitrust victory looks hollow. PMID- 10153721 TI - Wash. hospitals get advice on dealing with Columbia. PMID- 10153722 TI - 'Best performers' work to keep surgeons happy. PMID- 10153724 TI - Flexible staffing for OR's peaks and valleys. PMID- 10153723 TI - Prepare your OR now for a Stage 4 market. PMID- 10153725 TI - New cheaper TB respirators starting to enter the market. PMID- 10153726 TI - Licensing recommendations stir controversy. PMID- 10153727 TI - Preparing mind as well as body for surgery. PMID- 10153728 TI - Secrets of successful self-managing teams. PMID- 10153729 TI - Stimulating high performance in frontline staff. AB - When the author of this article found herself in need of emergency medical help, her role reversed from physician to patient. Unlike many patients who are traumatized by an emergency department visit, Dr. Blumberg was pleased with her treatment. However, in later reviewing the experience with her nonphysician husband, she was amazed to learn that he was left with negative feelings about how he was treated by the frontline staff and about the appearance of the facility. As a result, Dr. Blumberg wrote this article detailing the importance of frontline staff performance and exploring ways staff can be motivated to gain maximum job and patient satisfaction. PMID- 10153730 TI - Cost and quality outcomes of comprehensive epilepsy monitoring review of referrals in a managed Medicaid program. AB - The proceedings of the National Institute of Health's "Consensus Development Conference on Epilepsy Surgery" was published in March 1990. In it, the conclusion was made that, while surgery for intractable epilepsy can stop or decrease documented seizures, "effects in overall health status and quality of life have not been adequately studied." Recommendations for standardized data collection for surgery in qualified, technologically-equipped centers included the need for follow-up studies of outcomes for at least five years. The University of Arizona's Epilepsy Center was established in 1984, and the Arizona Comprehensive Epilepsy Monitoring Program started at the University of Arizona Health Sciences Center in 1990. Patients from various payer sources have been managed, and many surgeries have been performed. This report focuses on patients covered under the state's managed Medicaid program for patients under a full risk, capitated managed care contract with University Physicians. The Arizona Health Care Cost Containment System (AHCCCS) contracted with University Physicians, Inc., of the University of Arizona Health Sciences Center, for comprehensive health care services under a capitated payment mechanism from 1982 to 1992. Thereafter, University Physicians has provided services through subcontracts with other managed care organizations. This report focuses on this Medicaid population. PMID- 10153731 TI - Keeping the "care" in managed care: the importance of the therapeutic relationship and psychosocial factors in the managed care setting. AB - There is much truth in the adage that "the more things change, the more they stay the same." Nowhere does this seem more apparent than in health care where, amidst monumental reconfiguration, basic foundations of physician-patient relationships and attention to the impact of psychosocial factors on health and health care delivery remain as critical influences. While the importance of the therapeutic relationship and the influence of psychosocial factors in medical care has been clear in traditional systems of delivery, these factors may be even more critical in managed care systems. These emphases must be incorporated by design, however, and not left to default. PMID- 10153732 TI - The role of health care ADR (alternative dispute resolution) in reducing legal fees. AB - An increasingly complex health care system undergoing rapid changes is an ideal set-up for frequent conflicts among the numerous participants. While conflict is inevitable, the manner in which it is handled can markedly affect the outcome of the dispute and the future relationship of the parties, as well as the emotional and financial cost of the dispute. This article presents an overview of the principles and processes of alternative dispute resolution (ADR), and describes how these processes are currently being used to resolve health care disputes. PMID- 10153733 TI - Physician profiling: trends and implications. AB - In the October 1995 issue of Physician Executive, the author discussed the general notions of profiling of professionals, comparing the emerging methods of profiling of physicians to methods already in place for profiling professional athletes, investment bankers, and others. In this issue, the author provides details on specific methodologies in place for profiling physicians. While the science of profiling may be in its infancy, managed care organizations and third party payers are clearly demanding more precise and useful information on the practice patterns of the physicians they hire or contract with. PMID- 10153734 TI - The pitfalls of managing contingency workers. AB - Contingency workers have proven so cost effective that they may constitute half of the health care industry work force before the end of this century. However, because these workers don't have stakes in the companies and are bitter about losing their full-time jobs, they are often difficult to motivate and even more difficult to manage. In fact, their attitudes negatively affect the morale of their full-time coworkers and poison the overall work environment. The author offers some tips to make contingency workers feel more a part of organizations in hopes that their attitude and performance will improve. PMID- 10153735 TI - The medical device payment controversy rages on. AB - Who will pay for investigational research? This seemingly endless debate assumes different guises as different aspects of the health care industry come under scrutiny. The latest wrinkle in the debate involves reimbursement for devices that are not FDA approved. My September column discussed the issue of funding investigational cancer therapies, specifically high-dose therapy and bone marrow transplant, as treatments for various malignancies. That controversy was centered on the use of FDA-approved drugs in settings beyond the labeled indications. However, the issue with medical devices is different. It involves implantable devices that the FDA says have not proven to be safe and effective. PMID- 10153736 TI - HCFA issues final Stark I rules. AB - While final rules clarify many "gray" areas of statutory interpretation under Stark I, some questions of interpretation under this law will remain largely unanswered until further Stark II regulations are issued. Thus, the health care industry is without definitive guidance on many issues. It must continue to make "best guesses" in interpreting the intent of the statute. However, bad guesses could mean imposition of severe penalties, including recoupment and substantial civil money penalties for making prohibited referrals. Moreover, the regulations confirm the Department of Health and Human Services' position that no advisory opinions are available. Because the final regulations were not issued until after the effective dates of the Stark Law, yet another round of restructuring may be required to effect regulatory compliance and avoid imposition of penalties. "Health Law" is a regular feature of Physician Executive from the Washington, D.C., law firm Epstein Becker & Green. Mark Lutes of that law firm serves as editor of the column. PMID- 10153737 TI - Health care industry consolidation: implications for physician executive careers. AB - Corporate America is changing in ways never seen before. At the same time that stockholders are cheering the rise in many companies' profits, people within these organizations are struggling with new definitions of job and career. To satisfy Wall Street and presumably to be more successful, workers and managers are encouraged to become more entrepreneurial, more accountable, more efficient. If they are successful, they are told, they might get to keep their jobs, but there are no guarantees. Security, whether economic or emotional, is no longer part of the deal. PMID- 10153738 TI - Mirror, mirror on the wall: reflections from failure to establish a truly uniform national health care policy. AB - When the author gazed into the proverbial mirror and asked if the U.S. health care system was the fairest of them all, it shattered. In this article, Thompson tells why the system is broken and what failure to fix it means to physician executives. He suggests that we, as Americans, must reinvent ourselves by realigning our value systems and and stifling our obsession with profit before trying to reinvent health care. PMID- 10153739 TI - A survey of ethics committees in national medical organizations in the United States. PMID- 10153741 TI - Ethics committee networks: facing the future. PMID- 10153740 TI - A comparison of principle-based and case-based approaches to ethical analysis. AB - Illness is not just something that persons have or get--it is something that they experience. They live this experience fully with their entire being--emotionally, psychologically, spiritually, and physiologically. Any method of ethical analysis must take care to not simplify the process of dealing with morally troubling cases. The multidimensional nature of human life is so complex that the decisions made in these situations are seldom if ever strictly medical decisions--they are also social, emotional, religious, and moral ones. Ethical dilemmas present in today's health care settings compel members of HECs to engage in and contribute toward meaningful dialogue in ethics that is collaborative, multidisciplinary, and mutually respectful. The inevitability of change in the way in which the health needs of people are going to be handled in the future demands this proactive approach. Individuals who accept this responsibility must equip themselves for ethical analysis that deals effectively with the inevitably complex questions that will arise. PMID- 10153743 TI - Should religiously-oriented healthcare institutions have at least one HEC member with opposing views from the institution's "standard position"? No. PMID- 10153742 TI - Should religiously-oriented healthcare institutions have at least one HEC member with opposing views from the institution's "standard position"? Yes. PMID- 10153744 TI - Should healthcare institutions have at least one medically indigent member on the institution's HEC? Yes. PMID- 10153745 TI - Should healthcare institutions have at least one medically indigent member on the institution's HEC? No. PMID- 10153746 TI - The first Code of Medical Ethics in an independent nation. PMID- 10153747 TI - The computer-based record: a definitional perspective. PMID- 10153749 TI - Interface engines: starting up. PMID- 10153748 TI - IS outlook '96: predictions & predilections. Roundtable discussion. AB - Musings from some of the leading national and international HIT organizations make it clear that the need for a computer-based patient record is approaching the critical point. Half of our respondents identified the CPR as the single most important technology in 1996. One of our participants goes so far as to say that the era prior to the electronic medical record will one day be remembered as the "paper age." Progress in the development of standards--crucial to the CPR--could be dramatic this year, say experts from two of the major standards organizations. For a look at these issues and others, including key government policies to watch this year, read on. PMID- 10153750 TI - Zeroing in on the integration hub. PMID- 10153751 TI - Healthcare computing: achieving mobility. PMID- 10153752 TI - HL7 Forum. How long does it take to write a standard? PMID- 10153753 TI - Integrated information key to healthcare advantage. PMID- 10153755 TI - Energy management of industrial plant. PMID- 10153754 TI - Lighting quality considerations in health environments. PMID- 10153756 TI - Recycling of unwanted unbroken waste fluorescent tubes, the ecological and environmental implications of current schemes. What is to be done with all the other kinds of lamps? PMID- 10153757 TI - Application of fuel cell technology to health care institutions in rural and urban environments. PMID- 10153758 TI - The doctor-proxy relationship: the neglected connection. AB - Advance directives have been lauded by scholars and supported by professional organizations, Congress, and the United States Supreme Court. Despite this encouragement, only a small number of capable patients execute living wills or appoint health care agents. When patients do empower proxies, doctors may be uncertain about the scope of their duties and obligations to these persons who, in theory, stand in the shoes of the patient. This article argues for a conscious focus on the ethical duties, emotional supports, and guidance owed by physicians to health care agents. PMID- 10153759 TI - Beyond Pittsburgh: protocols for controlled non-heart-beating cadaver organ recovery. AB - Much of the ethical debate about controlled non-heart-beating cadaver (NHBC) organ recovery has focused on the University of Pittsburgh Medical Center (UPMC) protocol. Some commentators have voiced serious reservations about the ethical acceptability of that protocol; others have argued that the protocol contains sufficiently stringent ethical safeguards to warrant a limited and carefully monitored trial at UPMC. UPMC is not the only organization pursuing controlled NHBC organ procurement, however. The study of organ procurement organizations described in this article suggests that controlled NHBC organ procurement is a practice that, if not yet widespread, is certainly no longer isolated to a few organizations in which it is carefully monitored. Rather, it is being carried out under a variety of circumstances, many of which are less carefully constrained ethically than at the University of Pittsburgh Medical Center. The next stage of the ethical debate should focus on issues that are arising in a variety of settings as the practice spreads. PMID- 10153760 TI - Perish and publish: non-heart-beating organ donation and unduly iterative ethical review. AB - In the expanding repertoire of practices designed to increase the supply of organs for transplantation, non-heart-beating cadaver organ donation has generated an ongoing debate in the literature. The continuing stream of articles is disquieting in part because it documents a troubling "trial-and-error ethics" approach to the formulation of organ procurement policy, and because it raises serious questions about the reasons that the development of this policy is being mediated by published communication. In the light of concerns about the implicit support and credibility that professional publications give to organ procurement policies, restraint in publishing articles about non-heart-beating organ donation as well as in devising such policies is strongly advocated. PMID- 10153761 TI - Clinical bioethics at NIH: history and a new vision. PMID- 10153762 TI - Organ transplant allocation. PMID- 10153763 TI - Update on Waiving Informed Consent in Emergency Research. PMID- 10153765 TI - Description of the computer-based patient record and computer-based patient record system. CPRI Work Group on CPR Description. AB - Computer-based patient records and computer-based patient record systems support health care effectiveness and efficiency with appropriate safeguards for confidentiality. Achieving a health information infrastructure with computer based patient records supported by fully integrated computer-based patient record systems is obviously a process of incremental steps. However, CPRI believes significant benefits in health care delivery are certain to be realized over the full course of this process. PMID- 10153764 TI - Deception in psychological research. PMID- 10153766 TI - Safeguard your secrets from your nosy boss. PMID- 10153767 TI - Three hospitals' survey experiences. AB - The Joint Commission on Accreditation of Healthcare Organizations has made major alterations in its standards and survey process under the Agenda for Change, by emphasizing cross-functional healthcare. The Joint Commission published the changes in its 1994 Accreditation Manual for Hospitals, under which criteria these hospitals were surveyed. Surveyors concentrated on evaluating the following major issues: care of patients, particularly restraint policies and procedures; uniform performance of processes, particularly as related to conscious sedation; staff competency; and process improvement. The authors detail why a thorough, detailed preparation for the document review session is essential for a successful survey. PMID- 10153768 TI - Total quality improvement: an example of an effective team. AB - Total quality improvement (TQI) advocates that all staff members in an organization develop their own ideas on job improvement about their own specific jobs. This process helps to improve staff performance and to build continually on those improvements. This article will describe how the TQI process was used successfully by quality management staff members at a federal medical center to investigate a problem with linen. PMID- 10153769 TI - Benchmarking and networking through collaborative groups. AB - The search for better ways to deliver healthcare services at lower cost led a group of hospitals in the Carolinas, 2 years ago, to pioneer a new concept, the collaborative group. A collaborative group typically is composed of five or six similar (but not competing) hospitals that work together closely to help each other make the changes necessary to survive in an increasingly competitive marketplace. Hospital staff members at all levels are able to work together to discover improvement opportunities through benchmarking teams and networking efforts. This article describes their experiences, achievements, and lessons learned. PMID- 10153770 TI - HEDIS: implementation issues. AB - Historically, employers have asked health plans to measure performance in terms of quality, utilization, satisfaction, and cost. As organizations collected these data, employers realized that rarely were all the data comparable. Several employers, such as Xerox Corporation, Digital Equipment Corporation, and Bull HN Information Systems, Inc., agreed to work together to create reporting criteria that would standardize measurement. This collaboration resulted in the Health Plan Employer Data Information Set (HEDIS) criteria. This article reviews some of the implementation issues and decisions that a plan must resolve to gather accurate HEDIS data. PMID- 10153771 TI - Legislative forum: confidentiality. AB - In summary, there are no quick or easy guidelines for maintaining and protecting confidentiality and avoiding discovery. It appears that managers who are responsible for information that is at risk will have to make an extra effort to learn not only their own state laws, but also the laws of any other states their facility or corporation might do business in. Close contact with the organization's attorney certainly enhances the ability to stay on top of the issues as healthcare delivery systems change. PMID- 10153772 TI - Case management: a formula for resource conservation. AB - Case management as a concept of efficiency and effectiveness has demonstrated its applicability in acute care. This article addresses one model of case management that integrates the traditional structure of independently functioning, nonrevenue-producing activities of quality, risk, and utilization management under the comprehensive umbrella of quality resource management. The model transformed existing full-time equivalent services at an acute care hospital in Florida into value-added services on behalf of patients, physicians, the hospital, and payers and presented a practical approach to organizing a case management program. Issues in the transformation process also are addressed. PMID- 10153774 TI - Rethinking the patient care information system. PMID- 10153773 TI - Information technology implications of case management. AB - Information technology is a critical component to implementing a comprehensive and effective case management process. The vendor marketplace is aggressively working to address gaps in function and integration. In the meantime, organizations must begin now to plan their case management processes. This is no small task. Most organizations are struggling to develop the necessary manual systems through consensus building on a multidisciplinary basis. Success in developing and implementing a good manual system, although cumbersome, is an essential prerequisite to automation. Major organizational growth and restructuring is already under way in most settings to respond to the pressures of health care reform. Availability of a tight case management process with appropriate information technology support is the key to success. PMID- 10153775 TI - A study of users' perceptions on the benefits of information systems in hospitals. PMID- 10153776 TI - Nursing management system interfaces: what to watch out for! PMID- 10153777 TI - Reengineering and integration: six tales from the health care front. PMID- 10153778 TI - Health care data repositories: components and a model. PMID- 10153779 TI - Rethinking health care reform. PMID- 10153780 TI - Gagging the doctors. Critics charge that some HMOs require physicians to withhold vital information from their patients. PMID- 10153781 TI - Breakdown. How the budget talks fell apart. PMID- 10153782 TI - The soul of an HMO. PMID- 10153783 TI - Picking a health plan: a how-to guide. PMID- 10153784 TI - Antitrust developments: justice proposes consent decrees with PHOs. PMID- 10153785 TI - Integrated health systems: managing the transition to the new environment. PMID- 10153786 TI - The swing lab--a management adventure. PMID- 10153787 TI - Battlefield Florida. AB - What did we discover in our Florida review? We found that south Florida has the highest Medicare cost in the country fueled in part by an abundance of specialists, traditional emphasis on high-end tertiary care, and relatively minimal historic managed care. In retrospect the history of high costs created the high AAPC for this area. But, the high visibility of potential pay-offs hasn't been lost to the roving bands of national HMOs in search of new markets. For many reasons, Florida has become a magnet for out-of-state HMOs, hospital chains and practice management companies. With the influx of new players, the Florida battle zone will soon become a very interesting marketplace, if it isn't already. Maybe Darwin was right. In the evolution of healthcare in Florida it may be the "survival of the fittest." PMID- 10153788 TI - MedPartners/Mullikin buy Pacific Physicians. PMID- 10153790 TI - PPOs: rejuvenating Medicare. PMID- 10153789 TI - Pharmacoeconomic comparison of loop diuretics in the treatment of congestive heart failure. AB - As MCOs explore opportunities for delivering more cost-effective medical care, prioritization based on drug utilization reviews alone may not adequately highlight those disease states that consume a disproportionate share of overall resource cost; the daily cost of pharmacotherapy may not reflect the overall economic effect. As the elderly proportion of the population grows, the treatment of congestive heart failure may represent for MCOs an increasingly important opportunity to achieve acceptable or even improved outcomes while controlling the costs of hospitalization and other resources. The introduction of new pharmaceuticals presents an ongoing challenge for managed care to determine whether they offer a pharmacoeconomic advantage over current treatment regimens. This paper reports on an economic assessment made between a new and an existing loop diuretic in the treatment of congestive heart failure. PMID- 10153791 TI - Contracting for CHAMPUS. The marketplace at work? PMID- 10153792 TI - Marketing a managed care plan: achieving product differentiation. AB - The health care marketplace is changing dramatically, even without federal reform measures. This is a volatile, yet promising, time to market a managed care plan. Before marketing the product, it is critical that the competition is thoroughly evaluated and consumer and employer needs are researched. The final product should be distinguishable from the competition and address market needs. Promotion can then begin, utilizing a proactive public relations and advertising campaign in addition to traditional methods of marketing. PMID- 10153793 TI - Putting the management back in PBM (pharmacy benefit management). PMID- 10153794 TI - The HMO-PBM relationship: getting along in today's market. AB - With the many interesting trends apparent in today's pharmacy benefit management market, it becomes increasingly difficult to find a benefit manager who can meet an HMO's particular needs. What does the HMO need to do when seeking to establish a new relationship or renew an old partnership with the pharmacy benefit manager? PMID- 10153795 TI - Data integration: blue skies ahead for network management. AB - Managed care organizations with an eye on the future realize that they must make the transition from cost management to quality management. This process relies heavily on the integrity and immediacy of the data that are collected, collated, and interpreted. Physicians and other medical providers will now play key roles in this process because, to date, MCOs have proved more adept at collecting reams of data than at employing data to effectively improve quality and reduce costs. PMID- 10153796 TI - Educational reform in health administration. AB - The transformation of the health care marketplace now demands transformation of the academy. The stakeholders--students, industry leaders, business, government, consumers--are all demanding managed care education now for the students of health administration. The authors describe a graduate course on managed health organizations initially offered to students at a Southwestern university during 1994. PMID- 10153797 TI - Implications of managed care for hospice care. PMID- 10153798 TI - Geriatric medicine--maturation or senescence? AB - Geriatric medicine is at a crossroads. Much time and effort have been given to develop training programs that aim at making physicians better able to care for the multiple and interacting problems affecting the elderly. It appears, however, that the best option at this time is to focus efforts and limited resources on undergraduate- and resident-level training. Fellowship training, given the limited number of well-qualified candidates and limited interest at this time, should largely be aimed at developing a cadre of leaders and role models who in turn will perhaps be more successful than we have been to date in fostering careers in geriatric medicine. Perhaps the increase in numbers of elderly persons will at last become a mandate for action. Presently, most physicians and health care planners recognize that demographic changes will occur, but the reality has not yet hit. In the next few decades, when there are more persons over the age of 85 than in the 65-to-85-year old group, the message may be clearer. Geriatric physicians may be able to teach by example, become administrative leaders, researchers, and makers of public policy for today and years to come. Although one might argue that geriatric medicine has gone through a difficult transition, to maturation and now, in many persons' opinion, has entered senescence, like the elderly patient of today, even in old age, there is grace, room for growth, and yes, even time to learn new tricks. PMID- 10153799 TI - Application of current knowledge in lighting to the needs of the homebound aged. PMID- 10153800 TI - Positioning a long-term system for managed care: The Eddy. PMID- 10153801 TI - A centrist view of Medicare reform. PMID- 10153803 TI - GHA Web Site now available on Internet. PMID- 10153802 TI - Managed care: implications for caregiver staff. PMID- 10153804 TI - Health care programs: fraud and abuse; revisions to the PRO sanctions process- HHS. Final rule. AB - This final rule revises and updates the procedures governing the imposition and adjudication of program sanctions predicted on recommendations of State Utilization and Quality Control Peer Review Organizations (PROs). These changes are being made as a result of statutory revisions designed to address health care fraud and abuse issues and the OIG sanctions process. In addition, this final rule sets forth new appeal and reinstatement procedures for practitioners and other persons excluded by the OIG based on a PRO recommendation. PMID- 10153805 TI - New Stark regs threaten groups' ties to independent physicians. AB - Depending on what emerges from Congress, the Stark law limiting referrals by physicians to facilities with which they have a financial connection soon may be changed. Meanwhile, we continue our discussion of the new regulations implementing Stark. As we explained last month, these new rules could endanger a common contractual relationship among physicians. PMID- 10153806 TI - Patient-reported outcomes measures pay off for physicians and patients. PMID- 10153807 TI - The 'PPM' (physician practice management companies) boom could mean a new deal for you in '96. PMID- 10153808 TI - 'Give me back managed care.' Part 1. PMID- 10153809 TI - How physicians can work with managed mental health care. PMID- 10153810 TI - Five ways physicians can catch an HMO's eye. PMID- 10153811 TI - What you should know about the role of house physicians. PMID- 10153812 TI - Kodak develops a role in health cost containment. PMID- 10153813 TI - Modest HMO premium hikes foreseen for '96. PMID- 10153814 TI - Case study. Morton Plant Mease Health Care: how well is the non-merger working? PMID- 10153815 TI - Provider-sponsored networks: easing capital requirements doesn't guarantee success. PMID- 10153816 TI - Home care organizations and integrated delivery networks. PMID- 10153817 TI - Health manpower trends in a market-driven environment. AB - In the context of the American health system shifting to a more market-driven environment of networks and HMOs, this article focuses on the possible effects of these competitive strategies on the future demand for various categories of health manpower. The consolidation in healthcare resources by forming alliances and aligned HMOs, and the reduction in Medicare and Medicaid reimbursements have the impact of paying specialists less and generalists more. Some medical schools modified their curricula and encouraged more of their graduates to pursue family practice, general internal medicine, and pediatrics. Until recently, none of these efforts made a dent. Medical school graduates continue to find the specialties to be intellectually more rigorous, technologically more exciting, and know that they were still financially more rewarding than engaging in a primary care practice. And, the academic health centers continue to offer a large number of fellowships to supply the highly skilled, relatively inexpensive labor for delivering tertiary services. When completing their training programs, almost all subspecialists (anesthesiologists being among the exceptions) were still being recruited for positions that allowed them to make a comfortable living. PMID- 10153818 TI - Practice guidelines and the emperor's new clothes. AB - Clinical guidelines are problematic because it is difficult to get people to follow them, effective mechanisms are usually not in place to determine guideline compliance, and the belief that guideline compliance is associated with higher clinical quality or lower cost is usually based on faith rather than data. These issues can be addressed by combining practice guidelines with outcome research and clinical information system technology which can result in a method to track adherence to and variance from guidelines; determine the effectiveness of guidelines in improving quality and decreasing costs; and create a dynamic system for guidelines development and differentiation based on empirical results related to which guidelines and variations are most effective for different types of patients. PMID- 10153819 TI - Looking ahead: a matter of survival. PMID- 10153820 TI - The exercise of power. PMID- 10153821 TI - A Christmas Carol: a story of changing ethics. PMID- 10153822 TI - Corporate profile. AMSCO, International, Inc.; Devon Industries, Inc.; Kimberly Clark; Micro-Aseptic Products, Inc.; Nellcor Puritan Bennett; Paragon Medical, Inc. PMID- 10153823 TI - Managed care leadership. PMID- 10153824 TI - Materiel managers: survival under managed care. AB - Managed care by healthcare providers is becoming the method of choice for controlling costs. Insurance companies, employers, employees as well as healthcare providers are all doing what they can to understand and practice economical managed care. With financial systems that reimburse healthcare providers now moving to a capitated approach, providers need to get away from a cost-plus mentality. More than ever materiel managers need to realize that providers are moving from revenue to expense accounting. Under capitation many, if not all, of management philosophy must change to compete in the new healthcare delivery environment. PMID- 10153825 TI - Rx for the future. Telemedicine: tomorrow's technology is emerging today. PMID- 10153826 TI - Promises and pitfalls. The ins and outs of CHINs and RHINs. PMID- 10153827 TI - Minimizing technology's risks. How to manage risks and technology. PMID- 10153828 TI - Accessible accountability. A member perspective on public data release. PMID- 10153830 TI - High tech equipment. The latest and the greatest. PMID- 10153829 TI - Electronic patient records. Client server technology is making it happen. PMID- 10153831 TI - The changing face of hunger. McLaren Health Care Corporation feeds those in need. PMID- 10153832 TI - Lower than expected. Health care costs: a Michigan success story. PMID- 10153833 TI - All I ever needed to know ... I learned in the "real world". PMID- 10153834 TI - Technologically challenged. It doesn't have to be way of life. PMID- 10153835 TI - The truth about data. PMID- 10153836 TI - You oughta be in pictures. Enhancing quality of care through videoconferencing. PMID- 10153837 TI - Associations. Key groups involved in technology issues. PMID- 10153838 TI - Standard-setting groups. The major players. PMID- 10153839 TI - Health care automation companies. AB - Health care automation companies: card transaction processing/EFT/EDI-capable banks; claims auditing/analysis; claims processors/clearinghouses; coding products/services; computer hardware; computer networking/LAN/WAN; consultants; data processing/outsourcing; digital dictation/transcription; document imaging/optical disk storage; executive information systems; health information networks; hospital/health care information systems; interface engines; laboratory information systems; managed care information systems; patient identification/credit cards; pharmacy information systems; POS terminals; radiology information systems; software--claims related/computer-based patient records/home health care/materials management/supply ordering/physician practice management/translation/utilization review/outcomes; telecommunications products/services; telemedicine/teleradiology; value-added networks. PMID- 10153840 TI - Plotting a technology strategy. PMID- 10153841 TI - Pharmacy benefits management and ambulatory pharmacy services. AB - The business of pharmacy is changing dramatically as new components are added to our health care system and new terms developed to describe existing functions. For example, payment for pharmacy products and services are increasingly coming under control of Pharmacy Benefits Management (PBM) companies who are also racing to develop Disease State Management Programs. Additionally, health care purchasers have welcomed the development of HEDIS (Health Employer Data Information Set) as another tool to evaluate both the cost and quality of health care provided to their enrollees. All this means pharmacy will have to change its paradigm from dispensing to managing the medication consumption/compliance process in addition to traditional dispensing activities. PMID- 10153842 TI - Medication prescribing advice and drug utilization: a review from the United Kingdom. AB - General Medical Practitioners (GPs) in the United Kingdom are usually the first point of contact with the National Health Service (NHS) for patients. They provide the majority of ambulatory care for their practice population and act as 'gatekeepers' for referral onwards to other services. This article investigates the influence of the purchasing authority prescribing advisors (PAs), including pharmacists and GPs on the prescribing habits in Salford, England, an inner city area in the North of England, close to the city of Manchester. The PAs became known as the prescribing CIA, and used the strategy of Control, progressing to Influence and Autonomy, to develop a mature partnership between the GPs, PAs and other health care professionals. Information collated from prescribing (PACT) data, by the Prescription Pricing Authority, was used to make comparisons between different practices within an area. Savings made by making rational changes in prescribing, were used to enhance practice development for the benefit of patient care. PMID- 10153843 TI - The pharmacist's role in the optimal delivery of primary care in a managed care world. AB - For managed care to continue positive growth, pharmacists will have to offer support measures for primary care physicians, even as efforts are made to increase the supply of these physicians. The pharmacy practice at Medical University of South Carolina Family Medicine Center has gained national recognition for providing an expansive role model for pharmacists who are committed to providing pharmaceutical care and related services in primary care surroundings. This article discusses managed care in the primary care arena and pharmacists' role in providing pharmaceutical care and teaching future pharmacists their role in a managed primary care world. PMID- 10153844 TI - Evolution of ambulatory pharmacy services at a public health department. AB - This article is a narrative of the development of several key pharmacy services at a public health department in a metropolitan area fraught with many urban problems and obstacles for delivery of health services to the underserved. The pharmacy operation evolved from a traditional dispensing role to fully integrated clinical pharmacy services. PMID- 10153845 TI - Validating a clinical workload measurement instrument for documenting pharmaceutical care. AB - The purpose of this study was to develop and validate a workload documentation instrument to manually record clinically oriented pharmaceutical care activities. Previous research documents clinical workload by pharmacists; however, the tools employed have not been tested for validity. Reported information is difficult to interpret since individuals are unlikely to categorize activities in a consistent manner. PharmaTrend was used as a template for defining activity and problem categories that corresponded to various clinical activities performed by our clinical, faculty, and staff pharmacists. Because the institution was not completely computerized, the actual documentation tool was portable and manual. Testing of the original instrument was accomplished using a survey consisting of written scenarios. Two phases of testing were required to achieve an overall 80 percent accuracy rate. At least 60 percent of available pharmacists participated in both phases and completed 90 percent or more of the surveys. The investigators concluded that an instrument to record clinically oriented pharmaceutical care activities had been developed, tested, and validated. PMID- 10153846 TI - Strategic planning for applied pharmacoeconomics programs. AB - Escalating costs are changing the infrastructure in which health care is provided. Managed care programs are financing an ever-increasing share; rationing has already become reality in at least one state; and the federal government is once again examining the concept of a national health care plan. The primary goal of each of these initiatives is to control cost: the increasing cost of providing drug therapy is a major target. Increasing demands for shrinking resources will demand demonstration of value for money spent. Pharmacoeconomics provides a mechanism to establish the value of drug therapy. Using the strategic planning process, the Division of Pharmacy at M.D. Anderson Cancer Center and the Department of Pharmacy Services at Oregon Health Sciences University Hospital and Clinics have developed pharmacoeconomics programs to provide the focus for ensuring that every dollar spent on drug therapy and pharmaceutical services buys the best outcomes. These two case studies illustrate the processes for developing an applied pharmacoeconomics program and the activities such a program should embrace. PMID- 10153847 TI - High-touch human resource management: finding the needed time. PMID- 10153848 TI - Impact of pulmonary rehabilitation team effort for ambulatory patients with chronic lung disease. AB - The pulmonary rehabilitation program at the Veterans Affairs Medical Center in Memphis, Tennessee, is a program consisting of an interdisciplinary team effort that is coordinated by a clinical pharmacist and focuses intensively on educating patients with chronic lung disease about their disease, the basics of care, and life style changes that may prevent acute illnesses and help the patient remain as functional as possible. Implementation of this program, including information and data on proposal and development of this preventive care program are included. The success has been measured in the accomplishment of its goals of decreasing inpatient acute care needs through patient and family education, increasing functional status of patients handicapped with lung disease, and increasing patients' satisfaction with their care. PMID- 10153849 TI - The challenge for 1996: EDs must realign their priorities or perish. PMID- 10153850 TI - Revised policies to guide EDs in using NPs, PAs. American College of Emergency Physicians. PMID- 10153851 TI - Pa. hospital cuts time spent on joint replacement rehab. PMID- 10153852 TI - MSOs help cut costs, streamline operations and standardize MIS. PMID- 10153853 TI - Creating a successful culturally sensitive home care program. AB - Providing quality home care services to immigrants requires an integrated, holistic approach that genuinely addresses language and cultural differences. One home care agency in Massachusetts developed a team-oriented, culturally sensitive outreach program that ensures non-English-speaking patients the same level of service that the general population receives. PMID- 10153854 TI - Apples & oranges: a look at cultural diversity. AB - Both assimilating into another culture and developing an understanding of our own culture require a process of several stages. With the goal of assisting in the cultural awareness training of home care staff, the author offers some academic theories concerning cultural transitions. PMID- 10153855 TI - VNA of Boston addresses cultural barriers in home-based care. AB - Home care professionals know that communication is the key to successful treatment. But what if the patient speaks a different language? One home care agency addresses this problem with a culturally diverse staff and access to interpretation services. PMID- 10153856 TI - Cross-cultural caring. Positive outcomes in Hawaii. AB - Cultural diversity in Hawaii affects all aspects of health, illness, and death and dying. Effective home care requires sensitivity to each patient's culture and a knowledge of how cultural differences can affect client outcomes. PMID- 10153857 TI - Innovations in refugee health care. AB - As the face of immigration in the US changes, so must health care programs for these new Americans change. Two refugee programs in Maryland prove that adapting to the medical needs of the refugee community can benefit not only these immigrants but the US health care system as well. PMID- 10153858 TI - Weathering multicultural clashes: knowing hospice patient ethnicity. AB - Dealing with a death in the family is always difficult. Hospice professionals can ease some of the burden by learning about each family's particular religious and cultural beliefs, ensuring that everyone's emotional and cultural needs are addressed. PMID- 10153859 TI - Growing diversity in the aging population. PMID- 10153860 TI - Cultural diversity: the future, the market, and the rewards. PMID- 10153861 TI - Creating a culturally competent workforce. AB - Culturally sensitive health care professionals will have a distinct advantage in the 21st century. As the United States continues to grow as a multicultural society, practitioners will require access to cultural diversity training tailored to the needs of health care providers. The American Occupational Therapy Association offers an array of such educational resources through its Multicultural Affairs Program. PMID- 10153862 TI - Diversity for the duration. PMID- 10153863 TI - A wake-up call for cultural diversity. PMID- 10153864 TI - Nursing across cultures. PMID- 10153865 TI - A prospective survey of knowledge and perceptions of ondansetron: what do health care workers know about this drug? AB - Ondansetron is a relatively new drug whose optimal use is dependent on an understanding of its characteristics and role relative to traditional antiemetics. To assess perceptions and knowledge regarding ondansetron, we conducted a prospective written survey involving 56 physicians, pharmacists, and nurses at this hospital. Pharmacists claimed to be exposed to ondansetron promotion by industry more than the other groups. Apart from industry, pharmacists were considered to be the most common source of drug information. Nurses were less aware of dosage form equivalence than the other groups (p = 0.042). Physicians were more aware of twice daily dosing efficacy than other respondents (p = 0.0006). Nurses were able to better identify the relative duration of antiemetic benefit over metoclopramide (p = 0.008); however, most participants tended to be misinformed on this issue. Pharmacists were more familiar with the side effect profile while physicians were more cognizant of oral (p = 0.001) and parenteral (p = 0.018) drug costs than other groups. Overall, survey scores for physicians and pharmacists were higher than those for nurses (p = 0.007). There is an apparent difference across health care profession disciplines in the perceptions and knowledge about ondansetron. Specific misconceptions could lead to suboptimal drug use and warrant efforts to ensure a good understanding of the attributes and relative role of this agent. PMID- 10153866 TI - Sedation in the intensive care unit: an overview. AB - Sedation in the critically ill patient is essential to ensure maximal quality of life in the high-stress environment of the intensive care unit. The main goals of sedation include augmentation of pain control, management of agitation and psychological distress, and improvement of patient tolerance and acceptance of the endotracheal tube and ventilatory support. Ideally, the sedated patient should be asleep yet easily rousable. This is most commonly achieved in practice with a combination of morphine and benzodiazepines although a variety of combinations of drugs have been utilized. Other agents which have been employed include, other opiates such as fentanyl and sufentanil, butyrophenones such as haloperidol, and anesthetics such as propofol. These agents will be reviewed with respect to their role in sedating the critically ill patient. PMID- 10153867 TI - The geographic distribution of tuberculosis and pyridoxine supply in Ontario. AB - Acute poisoning with isoniazid causes generalized convulsions which should be treated with intravenous pyridoxine and a rapidly-acting anticonvulsant. The purpose of this study was to determine the correlation between the distribution of tuberculosis (as a proxy for isoniazid use) and acute care hospital supplies of intravenous pyridoxine (the antidote for isoniazid overdose). The distribution of tuberculosis was based on Ontario public health regions. The study was descriptive using simple linear regression to assess the degree of correlation. Only 15.6% of Ontario acute care hospitals have enough intravenous pyridoxine to treat an average isoniazid overdose. The distribution of tuberculosis and the number of hospitals in the region correlated best with hospital supplies of pyridoxine, although these variables explained only 22% and 23.7%, respectively, of the variation in supply. It does not appear that the distribution of tuberculosis is a major determinant of the availability of the isoniazid antidote, pyridoxine. Acute care hospitals in Ontario should re-evaluate their need for pyridoxine in light of the incidence of tuberculosis in their regions. Each hospital should stock at least 5 Gm of intravenous pyridoxine; additional amounts may be appropriate if there is an increased incidence in the area. PMID- 10153868 TI - Pharmaceutical care: a survey of Canadian hospitals. Pharmaceutical Care Advisory Committee, Canadian Society of Hospital Pharmacists. PMID- 10153869 TI - Cost effective and efficient delivery of medications through multi-dose i.v. pumps. PMID- 10153870 TI - Material safety data sheets. Ensuring understanding. PMID- 10153871 TI - Can you afford not to recycle? PMID- 10153872 TI - It's a new day. PMID- 10153873 TI - A rose is a rose. Quality environmental service blooms in Rochester. PMID- 10153874 TI - Hazardous spills. Reducing your risks. PMID- 10153875 TI - IT update. The future has finally arrived. PMID- 10153876 TI - IT update. Recorded delivery. PMID- 10153877 TI - IT update. Taking a leaf out of the airlines' book. PMID- 10153878 TI - IT update. An act of faith. PMID- 10153879 TI - Sponsorship. No such thing as a free lunch? PMID- 10153880 TI - Primary care. All aboard. PMID- 10153881 TI - Management development. The mirror group. PMID- 10153883 TI - Board development. Boarding school. PMID- 10153882 TI - Board development. Self-starters. PMID- 10153884 TI - Primary care. First things first. PMID- 10153885 TI - Measuring outcomes. Shooting straight from the hip. PMID- 10153886 TI - Treatment decisions. Every manager's nightmare. PMID- 10153887 TI - Consulting consumers. A manager's guide to consumers. PMID- 10153888 TI - Community care. Could do better. PMID- 10153889 TI - Clinical development. The burden of proof. PMID- 10153890 TI - Security. Secure units. PMID- 10153891 TI - Security. You've been framed. PMID- 10153892 TI - Security. Baby alarm. PMID- 10153894 TI - Health Management Awards. Excellence, ingenuity and commitment. PMID- 10153895 TI - Management development. Scaling the dizzy heights. PMID- 10153893 TI - Security. Back to the drawing board. PMID- 10153896 TI - Communication. Read my lips. PMID- 10153897 TI - Cancer services. This way, please. PMID- 10153898 TI - Evaluation of diffuse technologies: the case of digital imaging networks. AB - There have been significant developments in recent years in the methodologies and methods for the evaluation of a wide range of health technologies. There remain, though, many technologies which are difficult to evaluate. Often the difficulty stems from the complexity of the technologies themselves, which are in effect hybrids, comprising combinations of several distinct elements. In this paper these are termed 'diffuse' technologies, because the different elements exert different costs and effects, often across several different services. Computer networks are one, increasingly important, example of such technologies in health care. While it is possible to evaluate individual elements of such technologies, it is not clear how to evaluate the technology as a whole, where the whole may be greater (or less) than the sum of the parts. The paper outlines a seven-stage framework for the evaluation of diffuse technologies. The general principles of evaluation are illustrated using the example of picture archiving and communication systems (PACS), which are computer systems designed to capture, store and distribute electronic radiological images within a hospital. PMID- 10153899 TI - Dissemination of effectiveness and outcomes research. AB - Effectiveness and outcomes research seeks to improve patients' health outcomes by improving the quality of the health care they receive. Dissemination of the findings of such research is a necessary step in that process. This paper reviews what is known about designing and disseminating effective information packages aimed at health care providers (mainly physicians), where effectiveness means promoting behavior change on the part of practitioners that leads to better patient care. Practice-relevant research information is delivered to providers through publication of results from randomized clinical trials, dissemination of consensus recommendations, development and use of computer-based aids to clinical decision making, and provision of continuing medical education. Each of these areas offers numerous examples of the exceedingly modest behavioral response that can be expected from the mere provision of information. The literature also offers some principles that may improve the chances for success, including the desirability of techniques that involve face-to-face interaction, promoting the active involvement of the learner, repeating the message, making recommendations explicit and relevant to clinical practice, and making use of opinion leaders and peer influence. Little basic research has been done on providers' motivations and actual decision-making processes. Research aimed at furthering a behavioral science of providers could yield new insights on effective dissemination strategies as well. PMID- 10153900 TI - Accreditation: what can we learn from the Anglophone model? AB - There is growing interest in the development and application of standards for the health care to both promote quality assurance but also to improve the processes by which health services are held accountable to the public. This paper maps the development of organisational accreditation systems in the USA, Canada, Australia and the United Kingdom. In the USA, accreditation, which began as a means of ensuring the correct environment for clinical practice has developed into a form of public regulation. In the United Kingdom, many different approaches to the setting of standards and their assessment has created a variety of accreditation systems. The case studies demonstrate that as the concept of accreditation diffuses into the health care systems of different countries, it is being adapted to meet the wider policy needs of different national circumstances. PMID- 10153901 TI - Incentives and financing methods. AB - On an incentive theory background the different financing methods for health care are discussed. Three main categories of financing methods are presented: (1) global budget solutions (capitation and global budget based on historical costs), (2) per-case reimbursement (per-diem rates, fee-for-service, prospective reimbursement on the basis of product groups, episode of care-based reimbursement, result graded reimbursement with use of e.g. the Oregon model concept), (3) hybrid methods of financing. Financing methods can be used to obtain different goals. Organizations and individual physicians seem to respond generally in the same way to similar incentives. Also unwanted effects seem common. Shifts in financing methods over time may look natural to attack problems. Empirical research has demonstrated financing methods as important tools in the management of a health service. Knowledge of possible health effects for the patients as a consequence of financing methods seems limited. PMID- 10153902 TI - Beth Israel's Phillips Ambulatory Care Center: designing for the future. PMID- 10153903 TI - Making it disappear. How to reduce medical waste by giving your team the big picture. PMID- 10153904 TI - Responsive design in HIV/AIDS facilities. PMID- 10153905 TI - A brave new capitated world. Facilities managers face a challenging future. PMID- 10153906 TI - How to keep bad apples off the company payroll. PMID- 10153907 TI - EPA refrigerant recycling rule on leak repair goes into effect. PMID- 10153908 TI - Tips on how to be good to your commercial resilient floor. PMID- 10153909 TI - Defense department takes lead on bar coding initiative. PMID- 10153910 TI - Prices for heart valves show a big downward slide from last year's levels. PMID- 10153911 TI - Is outsourcing of the materials management function on the horizon at your hospital? PMID- 10153912 TI - Digital cardiac archive systems reduce costs, position Baptist Memorial Hospital (Miss.) for the future. PMID- 10153913 TI - Internal studies and self-assessment are better predictors of pressure sore product expenses than is patient acuity. PMID- 10153914 TI - GPOs and materials managers must adapt to integrated systems. PMID- 10153915 TI - The unintended effects of technology. PMID- 10153916 TI - Women's centers: serving more women with less confidence in the future. PMID- 10153917 TI - Patient care technology transformation. PMID- 10153918 TI - Should medics unionize? Yes! PMID- 10153919 TI - Should medics unionize? No! PMID- 10153920 TI - Hawaii medics find unified voice. PMID- 10153921 TI - Exploring the association option. PMID- 10153922 TI - Infection control in rural EMS. PMID- 10153923 TI - 1996 Almanac. Jems 200 City Survey. Budget tightening, technology affect EMS systems in 200 largest cities. PMID- 10153924 TI - 1996 Almanac. Information resources. PMID- 10153925 TI - Joint Commission on Accreditation of Healthcare Organizations. Standards for the use of restraint, 1995 Accreditation Manual for Home Care (AMHC). PMID- 10153926 TI - Orion-Arizona: up and running. PMID- 10153927 TI - Subacute care survey protocol receives favorable support in first year. PMID- 10153928 TI - Joint Commission, Westcott Communications announce satellite network agreement. PMID- 10153929 TI - Spohn Kleberg Memorial Hospital, Kingsville, Tex. Texas hospital collaborates for its Joint Commission survey. PMID- 10153930 TI - A "Secret Santa" came calling. PMID- 10153931 TI - Tips on compliance: top 10 problematic home care standards. PMID- 10153932 TI - How groups successfully manage pain patients. PMID- 10153933 TI - Business has a mixed message for doctors. PMID- 10153934 TI - Women doctors: narrowing the earnings gap. PMID- 10153935 TI - Is an all-female practice better for its doctors? PMID- 10153936 TI - A doctor-friendly alternative to managed-care plans. PMID- 10153937 TI - Four setups for embezzlement. PMID- 10153938 TI - Not knowing the Stark lab rules can cost you big. PMID- 10153939 TI - Coram tries stock option transfer. PMID- 10153940 TI - Dallas project measures quality of treatment, patient satisfaction. PMID- 10153941 TI - Staff moves complete GHAA-AMCRA merger. PMID- 10153942 TI - Unions fight to block Sutter lease in Calif. PMID- 10153943 TI - Partisan sniping blocks progress in budget battle. PMID- 10153944 TI - Medicare, VA funds still in jeopardy. PMID- 10153945 TI - Mass. maternity-stay law protects providers. PMID- 10153946 TI - Milwaukee data network poised to go statewide. PMID- 10153947 TI - Surveys mixed on cost-emphasis backlash. PMID- 10153948 TI - Lawsuit challenges Aetna Health of N.Y. capitation contracts. PMID- 10153949 TI - Panel: Medicare users could flood providers. PMID- 10153950 TI - Mega-merger, Baxter split stir up hospital-supply field. PMID- 10153951 TI - Owner groups square off in Tenn. PMID- 10153952 TI - Healthcare stocks soar on wings of restructuring. PMID- 10153953 TI - '96 may deal challenging hand. PMID- 10153954 TI - VA, Defense Dept. healthcare set to mirror private sector. PMID- 10153955 TI - Try a bond-based model to finance indigent care. PMID- 10153956 TI - Docs get their way. Under AMA attack, feds back off antitrust enforcement. AB - Although the American Medical Association didn't win antitrust relief for doctors through federal legislation, the mere threat of a new law that would reduce federal agencies' authority appears to have resulted in a host of favorable legal rulings for physicians and implied promise of lenient enforcement in the future. PMID- 10153957 TI - Groups battle to fund costly new AIDS drugs. PMID- 10153958 TI - HMOs, providers sharing data key to making capitation work. PMID- 10153959 TI - Not-for-profit system a model of fiscal fitness. PMID- 10153960 TI - Calif. teaching hospitals exploring collaboration. PMID- 10153961 TI - Mergers main cause of '95 closures in Okla., Texas. PMID- 10153962 TI - Small providers join Mo. antitrust case. PMID- 10153963 TI - National Blues pushes uniform medical policy. PMID- 10153964 TI - Blizzard mobilizes East Coast medics. PMID- 10153965 TI - Salick Health Care poised to buy California medical center. PMID- 10153966 TI - Advocate near deal with Ill. hospital. PMID- 10153968 TI - GNYHA awards first distribution pact. PMID- 10153967 TI - Delayed joint-venture, self-referral report slated for February release. PMID- 10153969 TI - Pa. system lures heart institute's faculty. PMID- 10153970 TI - Transplant surgeon to go on trial. PMID- 10153971 TI - Investors explore buying technology data. PMID- 10153972 TI - St. Paul raises premiums for docs in handful of states. PMID- 10153973 TI - Budget talks snagged on Medicare. PMID- 10153974 TI - Bioethics programs' future uncertain. PMID- 10153975 TI - L.A. County starts privatizing clinics to fight budget woes. PMID- 10153976 TI - Calif. insurer, hospital, IPA ally to serve Hispanic market. PMID- 10153977 TI - Hospitals seek extra Medicare payments. PMID- 10153978 TI - WellPoint to buy Mass. insurer. PMID- 10153979 TI - Columbia hires ad agency to put name on nation's lips. PMID- 10153980 TI - Boards often last to get the ax. PMID- 10153981 TI - Performance comparisons gaining. PMID- 10153982 TI - MGMA, AAMC to develop joint survey. PMID- 10153983 TI - Report profiles doc-run organizations. PMID- 10153984 TI - Bond market ends '95 on high note. PMID- 10153985 TI - Intermediaries to be paid 1995 rates for administrative costs. PMID- 10153986 TI - Fla. rejects Columbia's CON request. PMID- 10153987 TI - Docs fight to nullify noncompete clauses. PMID- 10153988 TI - The new indicators of accounts receivable excellence. AB - Calculation of AR days will continue to be a valuable internal measurement tool of accounts receivable excellence. As healthcare organizations move toward managed care through a mix of reimbursement systems--many with conflicting incentives--the director of patient accounting must approach each system separately and ensure that the hospital receives all of the reimbursement to which it is entitled. The director of patient accounting must understand the industry and recognize that healthcare reimbursement will almost certainly continue to become more complex rather than simpler. Creativity will be a necessity, and good luck will be an advantage. PMID- 10153989 TI - Managed geropsychiatric unit opens. Delaware Valley Medical Center repositions its services for older adults. AB - An analysis of the numbers showed Delaware Valley Medical Center that its existing adult psychiatric unit was no longer making a positive contribution to the hospital's long-term goals. At the same time, other statistics indicated a growing need--both nationally and locally--for geropsychiatric services fueled by the increased lifespan of Americans. Following a market analysis, the hospital set a long-term goal to increase its visibility and impact within the elder community of Lower Bucks County, Pa. It did so, in October 1994, by opening the Behavioral Health Center for Older Adults. Since its opening, the center has steadily increased inpatient admissions, operating at capacity several times during the fourth quarter of operation. By repositioning psychiatric services at Delaware Valley with the aid of a management company, the medical center is now seen as the county's premier provider of geropsychiatric services. PMID- 10153990 TI - Fighting domestic violence. Newton-Wellesley Hospital Hospital recognized as major advocate, role model for others. AB - Newton-Wellesley Hospital wanted to be a major advocate in its region in detecting and helping domestic violence victims. It did that and more. In the process, the hospital attained significant recognition as a leader in community benefits and advocacy for domestic violence survivors. PMID- 10153991 TI - How to market an affiliation. St. Elizabeth Hospital and Mercy Medical Center affiliate to create Affinity Health System. AB - When Wisconsin's St. Elizabeth Hospital and Mercy Medical Center affiliated to create Affinity Health System, Inc., strategic planning and a solid marketing plan carefully executed were instrumental in its success. A corporate identity campaign and product line identification were follow-up phases to the merger approval. PMID- 10153992 TI - Bridging the gap. A new study offers advice on marketing to Hispanics. AB - "A lot of people lose their Marketing 101 hats when marketing to Hispanics." That's Loretta Adams talking, president of Market Development, Inc. Their recent report, "Patient Care: Bridging the Gap with Hispanic Consumers," is designed to make things easier. PMID- 10153993 TI - Marketing wellness for private practice. Carolina Heart, Greenville, NC. AB - "Wellness," the marketing mantra of the '90s among managed care organizations and large hospitals, might well be expanded to private practices as well. Carolina Heart, a private cardiology practice in Greenville, N.C., is now the area resource for heart disease prevention. PMID- 10153994 TI - "Kid Kit" scores with parents. Community Hospital of Roanoke Valley, Roanoke, VA. AB - What started as a plan to speed up consent for treatment of children using the emergency room at Community Hospital of Roanoke Valley developed into a Kid Kit and Babysitter's Guide. When it was offered to the public, response was "overwhelming." PMID- 10153995 TI - Neighborhood Helper Program gets back to the basics. Chesapeake General Hospital, Chesapeake Health Department forge partnership to promote neighbors helping neighbors. AB - Chesapeake General Hospital and Chesapeake Health Department have formed an alliance that gets back to the basics. Trained volunteers serve as a healthcare resource for their neighbors. It's called the Neighborhood Helper Program, and it's expanding neighborhood by neighborhood in Chesapeake, Va. PMID- 10153996 TI - OSU Medical Center makes a large center feel small, friendly. A large academic medical center improves internal and external communications. AB - Size can be an asset; it can also cause problems. Often, it's communication that can be a problem with a large organization. Ohio State University Medical Center addressed the issue with a coordinated marketing campaign that's solving their problems. PMID- 10153997 TI - Creating that warm fuzzy feeling. PMID- 10153998 TI - Every business needs satisfied customers. PMID- 10153999 TI - The outlook for '96. Providers diversify to stay healthy. PMID- 10154000 TI - The top multifacilities of 1995. PMID- 10154001 TI - Congressional roundup. Looking at the legislative changes of 1995. PMID- 10154002 TI - How to manage the media effectively. PMID- 10154003 TI - Fraud and abuse enforcement revs up. PMID- 10154004 TI - It's time to enter the computer age. PMID- 10154005 TI - The lonely road. Primary care providers coping with AIDS. PMID- 10154006 TI - The emerging infectious diseases. AB - Emerging infectious diseases pose a significant but underappreciated threat to public health. In a world where international travellers, immigrants, and refugees can carry dangerous organisms almost anywhere, no region should be considered free from risk. Outbreaks of disease may be caused by newly recognized pathogens and drug-resistant organisms. These outbreaks demonstrate the need for improved worldwide surveillance and for improved compliance with guidelines for the use of antimicrobial agents. PMID- 10154007 TI - California's single-payer initiative: what went wrong? PMID- 10154008 TI - The future of hospitality and healthcare laundries. PMID- 10154009 TI - 1996 industry forecast. PMID- 10154010 TI - The strategy of casemix. AB - While the political debate rages over whether casemix brings economic benefits for Australian health care, managers are observing a pragmatic change to their business and some are using casemix to understand and manage their business better. Casemix is a useful tool in this environment of increasing management accountability and process re-engineering. This article reviews casemix from a process innovation perspective; comments on its real use for strategic health care management; and suggests a simple matrix used by St John of God hospitals throughout Australia to implement and measure progress towards quality casemix managed hospitals. The management motivation for this matrix was to promote hospital resourcing decisions supplemented by casemix information. PMID- 10154011 TI - A comparison of costs in Australian public teaching, public non-teaching and private hospitals. AB - This paper compares costs for caring for patients according to common diagnosis groups in Australian public teaching, public non-teaching and private hospitals. Generally, the costs for general surgical procedures are highest in public teaching hospitals, followed by public non-teaching hospitals, and are lowest in private hospitals. However, the private sector is more expensive than the public sector for obstetric activities. The reasons for the differences appear to be the much higher 'overheads' in the public sector than in the private sector, and the longer hospital stay for obstetric patients in private hospitals. Managers of individual hospitals should examine the data in detail to determine if alternative approaches are appropriate. PMID- 10154012 TI - Health spending proportion of GDP falls. PMID- 10154013 TI - Sectoral differentials in hospital services. PMID- 10154014 TI - Health services management education in South Australia. AB - In December 1994 the Australian College of Health Service Executives (SA Branch) sought 'a needs analysis for health management training programs within South Australia'. Although the college was interested in a range of matters, the central issue was whether the current Graduate Diploma in Health Administration (or a similar course) would continue to be provided in Adelaide. The college provided background material and discussions were held with students, the health industry, relevant professional associations and the universities. This commentary sets out some of the background factors and my conclusions, which have been accepted by the South Australian authorities. PMID- 10154015 TI - Community-based health care: a different approach to health outcomes. AB - Health sector organisations are undergoing a period of fundamental change. One set of changes is about increasing the capacity of the system to provide integrated client care. This paper discusses the practices that community health care workers have used to approach some basic issues of service integration. Although the discussion is about practices in community health, the issues are important for health care providers, managers and policy-makers throughout the health care system. PMID- 10154016 TI - The strategic planning of health management information systems. AB - This paper discusses the roles and functions of strategic planning of information systems in health services. It selects four specialised methodologies of strategic planning for analysis with respect to their applicability in the health field. It then examines the utilisation of information planning in case studies of three health organisations (two State departments of health and community services and one acute care institution). Issues arising from the analysis concern the planning process, the use to which plans are put, and implications for management. PMID- 10154017 TI - Information systems for community health: are we addressing the right strategy? AB - Computerised information systems for community health services have evolved with advances in information technology (IT) in Australia and overseas. However, there is evidence from other sectors for the need to distinguish between an information systems (IS) strategy and an IT strategy. This paper uses case studies of computerised information systems developed in New South Wales to identify issues that lead to success and failure. These issues show that many of the shortcomings can be attributed to a poor IS strategy. The paper discusses the shortcomings of an IT-driven strategy. It argues that an IS strategy needs to be congruent with the organisational strategy for community health and that the system design should satisfy the information needs of service personnel if the information is to be used. PMID- 10154018 TI - Designing a funding system for rehabilitation services. Part 2: Policy objectives and options for achieving efficiency and quality of care. AB - This paper examines the objectives of a funding policy for rehabilitation services. A casemix funding system comprises two sets of instruments: a classification system and a payment system. Attention is given to identifying which policy objectives are best pursued through each of these instruments. The paper then analyses the effect of various instruments on creating incentives for efficiency and quality, and assesses policy options with regard to their capacity for dealing with the heterogeneity of rehabilitation patients and controlling various forms of gaming. In conclusion, the paper canvasses four major areas warranting consideration in advancing policy: the use of a blended payment system; dealing with functional gain; the development of an information base; and the focus on designated rehabilitation units. PMID- 10154019 TI - Divisions of general practice: a status review. AB - This paper looks at the emergence of divisions of general practice in Australia. Divisions are local groups of general practitioners working to integrate general practice into the wider health system and to explore opportunities for improving service delivery, teaching and research. There are now 116 divisions of general practice, covering over 95 per cent of the Australian population. Projects and infrastructure funding was approximately $35 million in 1994-95. Divisions have enabled general practitioners to retain their autonomy while responding to a government health reform process which depends on their participation. They are a uniquely Australian solution to the problems confronting general practice in the 1990s, bridging the gap that previously existed between individual general practitioners and the health system as a whole. The Divisions and Projects program is being evaluated using a variety of methods which allow feedback into the program in a timely way. The program thus remains sensitive to new strategies and directions, either from the general practitioners themselves or from other stakeholders. PMID- 10154020 TI - As good as anyone: antenatal shared care at an inner Sydney hospital. AB - An exploratory survey design was used to assess satisfaction with antenatal care over a two-month period of women giving birth in an inner Sydney teaching hospital. Patients received obstetric services from private obstetricians, midwives, the hospital outpatient clinic, or 'shared care' between general practitioners and the outpatient clinic or birth centre. Insurance status and demographic information were collected across all groups. Shared care patients gave reasons why they chose that model of antenatal service. Ten per cent of women in the sample received shared care. Shared care patients were equally as satisfied as those in other modes of care in all but one factor--promptness of service (in which private obstetricians received higher ratings). They also judged shared care to have the advantages of being convenient, personal, and culturally appropriate. Significantly more patients in the shared care group were born overseas and they were less likely to hold private insurance. This paper discusses the results of the current study in the context of the Australian literature, explores some issues surrounding satisfaction research, and suggests further research arising from this work. PMID- 10154021 TI - Materials management is a major part of MidCentral Health's business. PMID- 10154022 TI - Air ambulance services. Aviation Industry Association of NZ (Inc). PMID- 10154024 TI - Women to benefit from investment in early detection of breast cancer. PMID- 10154023 TI - Changes in the long-term care of older people in Auckland between 1988 and 1993. PMID- 10154025 TI - Managed care in New Zealand: managed competition or managed collaboration? AB - Managed care is making major progress in New Zealand through independent practice associations (IPAs) now representing more than 50% of general practitioners. It is also being implemented by community groups, especially Maori, who see great potential in improving the health status of their people through this strategy. However, a significant conflict appears to be developing between achieving managed care through managed competition on the one hand and managed collaboration on the other. There appear to be fundamental flaws in the concept of managed competition. Evidence is emerging that managed collaboration is far more likely to be effective in achieving the Government's goals of improving health status and access and more cost-effective healthcare. PMID- 10154026 TI - New software promises benefits for healthcare system. PMID- 10154027 TI - Developing a case management program: the perspective of a small hospital. PMID- 10154028 TI - Health Outcomes Institute launches Outcomes Management System. PMID- 10154029 TI - Managed care--check your internal systems. PMID- 10154030 TI - POint-of-service collections: help or hindrance? PMID- 10154031 TI - Understanding and preparing for the transition to capitated access management. PMID- 10154032 TI - A proposal for a preregistration service bureau. PMID- 10154033 TI - Re-engineering for managed care: an integrated solution. PMID- 10154034 TI - The growing use of physician extenders: a concept whose time has come. PMID- 10154035 TI - Physician extenders: a wave of the future or a passing fad? PMID- 10154036 TI - Pilot study of automated insurance directory. PMID- 10154037 TI - The millennium: uncertainty in health care. PMID- 10154038 TI - Engineering access management processes around information technology. PMID- 10154039 TI - Front-end strategies for improving collections: a case study. PMID- 10154040 TI - Practice brief. Issue: Destruction of patient health information. American Health Information Management Association. PMID- 10154041 TI - Update on the Medical Records Confidentiality Act of 1995. PMID- 10154042 TI - Code assignments for bone marrow and stem cell transplants; liver cell transplants. PMID- 10154043 TI - AHIMA unveils strategic plan for coding. PMID- 10154044 TI - Accreditation of managed care organizations. PMID- 10154045 TI - The World Wide Web. PMID- 10154046 TI - Facing an EDI future. PMID- 10154047 TI - Introduction to managed care. Part 1. PMID- 10154048 TI - The technological reengineering of health information management departments: myth or reality? AB - Data from this study indicate that health information professionals are poised to take on greater responsibility in the design, evaluation, and application of information systems within healthcare. Whether or not health information management will move into these areas and begin to control future technological reengineering, however, remains unanswered from findings in this study. Future studies on healthcare administrator attitudes toward HIM professionals, curricular emphasis on information system design and analysis, and health information professionals in nonacute care settings are necessary to understand the direction of the HIM profession and its role in information systems. PMID- 10154049 TI - Developing a networking strategy for an integrated healthcare delivery system. AB - Dramatic changes in the healthcare industry are forcing organizations to find innovative ways to survive. The most critical component for organizational survival is the ability to communicate with and connect to internal and external information sources. It becomes imperative that organizations employ minimum standards and protocols in network design even as legacy systems remain in place as a part of their networks. PMID- 10154050 TI - Telemedicine system evaluation, transaction models, and multicentered research. PMID- 10154051 TI - CCS (Certified Coding Specialist) examination--1995 results. AB - After four years, the CCS credential has matured and stabilized both as a credential and as a testing experience. Early complaints about the length of the exam, the difficulty of the cases, the readability of the exam booklets, and adequate room in the testing centers have been addressed and rectified. A significant step in the quality of the examination has been achieved by the cooperative arrangement between the COC, the SCC, and the COCC (renamed the Coding Policy and Strategy Committee in 1996). Each year about 1000 individuals take the CCS examination, and most individuals who earn the credential maintain it. The profile of the CCS candidate is remarkably consistent over the four years, indicating that a coding specialty examination fulfills an important niche in the marketplace. Respect for the CCS credential is reinforced as an increasing number of medical facilities require the CCS credential for coding professionals. AHIMA strongly supports coding specialization and standards of excellence in all aspects of clinical data management. For this reason, the COC and the CCS Construction Committee will continue to analyze the CCS skill set and to consider appropriate modifications to the examination as healthcare migrates to outpatient and managed care settings. PMID- 10154052 TI - AHIMA Code of Ethics and Bylaws. Bylaws amended, October 1994; Code of Ethics amended, 1991. American Health Information Management Association. PMID- 10154053 TI - Reaffirmation of fealty--to serve all. PMID- 10154054 TI - Trends in specialty certification. AB - From 1980 to 1994, 283,024 certificates were issued by the 23 specialty boards. Of these certificates, 137,852 (48.7%) were issued in primary care specialties, 84,993 (30.0%) were certificates in the other medical specialties, and 60,179 (21.2%) were certificates in the surgical specialties. The figure on page 26 illustrates the changes that have occurred in the pool of board-certified physicians from 1980 to 1994. Since 1980, the number of certificates issued in the primary care specialties and the number of certificates issued in the other medical specialties has consistently exceeded those issued in the surgical specialties. In 1977, Mr. James Haug, Director, ACS Socioeconomic Affairs Department, correctly predicted that the pool of board-certified surgeons as a percentage of the total pool of board-certified physicians would decline. In 1980, the total number of certificates issued by the 23 specialty boards was 16,034. Surgical specialty certificates accounted for 23.8 percent of the total number of certificates issued by the 23 specialty boards in 1980. In 1994, the total number of certificates issued by the 23 specialty boards was 22,090. Surgical specialty certificates accounted for 19.8 percent of the total number of certificates issued by the 23 specialty boards in 1994. In 1980, 1984, 1986, and 1989 primary care specialty certificates accounted for greater than 50.0 percent of the total number of certificates issued by the 23 specialty boards in those years. Given the substantial growth in the number of certificates in the primary care and other medical specialties depicted in the figure, certificates in the surgical specialties as a percentage of the total number of certificates has remained stable. PMID- 10154055 TI - Physician self-referral laws. PMID- 10154056 TI - Strategic performance measurement systems: next step after dashboards. AB - This article has summarized work being done at the leading edge of strategic performance measurement. Initiatives that today seem ivory-towerish tomorrow may represent the mainstream. Compared with the organizations profiled here, other health systems may be smaller, be less automated, or lack expertise in statistics and graphic presentation. Such differences should not prevent any hospital, medical group, HMO, or integrated delivery system from embracing in its own way the essential aspects of strategic performance measurement: Developing--as the cornerstone for measurement--a clear mission, vision, and strategy based on the organization's core values, core competencies, and customer expectations. Developing high-level performance measures of the organization's current performance and progress toward its strategic vision. Cascading measures throughout the entire organization, from the governing board and senior management down to operating clinical and administrative units. Expanding measures beyond internal operations to include measures of community or population health, systemwide measures along the continuum of care, and environmental scanning of key external trends. Using measurement actively throughout the organization to drive strategic planning and continuous improvement. Such efforts are not an "add-on" to busy board and executive agendas; they are an integral part of them. When measures on performance reports are reflective of organizational reality--like the speed and compass gauges on a jetliner's instrument panel--knowledgeable leaders will use them with ease. Even such complex constructs as spider diagrams, says Dr. Berman, are putty in a board's hands when the measures are pertinent and directors are educated about them. "They're useful decision-making tools because they're easy for our board members and managers to understand," he sums up. "They provide a snapshot of our organization." PMID- 10154057 TI - The board perspective on instrument panels: an interview with five board members. Interview by Maggie Kennedy. PMID- 10154058 TI - One-way neonatal transports: a new approach to increase effective utilization of air medical resources. AB - INTRODUCTION: High-risk neonates often require significant stabilization and preparation time for transport. The purpose of this study was to determine whether the institution of a formal neonatal transport policy would increase the effective utilization of air medical resources and to determine whether such a policy would be useful to other air medical transport programs. METHODS: A descriptive review of flight data from time periods before and after the institution of the policy, combined with a telephone survey of 20 other rotor wing transport programs. RESULTS: After implementation of the policy, the total number of neonatal transports decreased (85 in 13 months vs 60 in 17 months) as did the number of two-way transports per month (4.6 vs 1.3). In addition, average mission time for all neonatal transports decreased. Fifteen of 20 transport programs in this Association of Air Medical Resources region perform neonatal transports. Only one of the 15 has a formal policy to determine the use of one way versus two-way neonatal transports. CONCLUSION: The neonatal team transport policy has increased the effective utilization of air medical resources in this program. This policy could have wider application for other programs as well. PMID- 10154059 TI - A comparison of pediatric and adult trauma patients transported by helicopter and ground EMS: managed-care considerations. AB - INTRODUCTION: There is a paucity of data comparing injured pediatric patients transported by helicopter emergency medical services (HEMS) with patients transported by ground ambulance. The purpose of this study was to compare HEMS pediatric trauma patients to: 1) pediatric patients transported by ground to an urban level-1 trauma center (TC), and; 2) a similar cohort of adult patients. The managed-care consequences of these comparisons are highlighted. METHODS: All trauma patients flown directly from the scene by HEMS from January 1, 1990, to April 30, 1993, were compared to a cohort of trauma patients arriving by ground advanced life support (ALS). All patients were transported to the same level-1 TC. The data collected included the mechanism of injury and the prehospital procedures performed, the injury severity score (ISS), and outcome. RESULTS: There was no difference in the ISS between the HEMS (n = 216) and ground ALS (n = 355) pediatric patients (16.8 vs 17.1; p = 0.55). Adult HEMS patients (n = 202) had significantly higher ISS than did injured adults (n = 1652) transported by ground (18.0 vs 13.6; p < 0.0001). Overall, trauma patients transported by air directly from the scene have a higher ISS than patients transported by ground (17.5 vs 13.6; p < 0.001). CONCLUSIONS: Pediatric patients transported by HEMS were as severely injured as those transported by ground, in contrast to adult patients. We conjecture that since trauma triage schemes classically focus on adults, ground personnel are more selective about which patients are flown to a TC, and less selective for pediatric patients. Trauma centers and HEMS programs should develop pediatric trauma triage protocols that do not overemphasize physiologic parameters. PMID- 10154060 TI - Survival from cardiac arrest during air medical transport. PMID- 10154061 TI - Basics of research (Part 5): Ethics and human rights. PMID- 10154063 TI - Success of Medicaid managed care using a public-private sector model. AB - This article provides an overview of Wisconsin's Mandated Medicaid Managed Care Initiative--the physician network--Wisconsin Independent Physicians Group (WIPG) that provides and manages the medical services for many of these Medicaid recipients and the public and private sector partnership that has helped to make this program successful. Special programs, such as the Prenatal Support Program, implemented by WIPG are described along with detail regarding the successful outcomes resulting from the programs. The article also includes the quality of care, improved outcomes and financial success of the Initiative when compared to the state's Medicaid fee-for-service program counterpart. Additional discussion includes capitation versus fee-for-services payments, mandated versus voluntary enrollment, and combining social services with medical services to improve health outcomes. PMID- 10154062 TI - Medicare managed care and the need for quality measurement. AB - With the increasing penetration of managed care as health insurance coverage for Medicare beneficiaries, accountability for quality of care is being demanded. While HEDIS 2.5 has become the standard for assessing the performance of health plans in caring for their commercial members, no such standard exists for Medicare enrollees. U.S. Quality Algorithms, the performance measurement subsidiary of U.S. Healthcare, has developed the Medicare Quality Report Card as a tool for performance assessment and quality improvement. This article describes how the measures of quality important to the Medicare population were chosen, how the measures were calculated, and how they have been used in programs designed to improve the quality of care for U.S. Healthcare Medicare members. PMID- 10154064 TI - Creating an integrated health care system: the health and human risk management model. AB - This article critiques the current health care system and presents a new conceptual model that offers the potential for an integrated health care system in the future. Health care currently consists of parallel care systems based on the competing conceptual frameworks of the medical model and the psychosocial model. It is argued that psychosocial factors must be included in an integrated system. Research literature is reviewed that documents the need for, the therapeutic effectiveness of, and the medical cost-offset benefits of mental and behavioral health interventions. The Health and Human Risk Management Model is described and illustrated with a case example as well as research outcomes from its implementation at United HealthCare Corporation. PMID- 10154065 TI - Diabetes and managed care: the Lovelace Health System's Episode of Care Program. AB - In order to efficiently manage the care of large populations, the health of that population must be evaluated. People identified with chronic medical disorders, such as diabetes mellitus, should have their disease managed proactively in the most cost-effective manner across the continuum of care. Lovelace Health System has established an Episode of Care disease management program based on the principles of clinical practice improvement. The diabetes program is described as an example of this approach to define and monitor best practice and to decrease variation among providers. This approach optimizes the use of health care resources and improves patient outcomes. PMID- 10154066 TI - Integrating chiropractic in managed care. AB - Alternatives to traditional health care are emerging as an important element in the mix of services offered by managed care plans. Integrating these nontraditional services, such as chiropractic, presents special challenges for plan managers. ChiroNet, an Oregon-based chiropractic specialty PPO network, has formed partnerships with a variety of managed care plans bringing managed chiropractic services to the PPO, EPO, and HMO environments. Practical experience with benefit design, access protocols, utilization management, quality assurance, provider credentialing, and administrative integration has been developed over the period of the network's cooperation with its managed care partners. Successful integration of these nontraditional provider groups depends on alignment of goals and incentives among all players in the system, including providers, their network, the patients, and the managed care plan. PMID- 10154067 TI - IBM's pursuit of quality and cost-effective health benefits. AB - With over 500,000 individuals receiving health benefits at a cost of over $900 million, the IBM Corporation has a keen interest in the future of the U.S. health care system, the employer's role in it, and the quality of medical care its employees and retirees receive. The U.S. health care system is in the midst of undergoing a dramatic transformation, and employers and their employees need to understand this change and know how to become informed purchasers of the medical care they need. PMID- 10154068 TI - Health care fraud: a critical challenge. AB - Fraud is defined as an international deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, the entity, or some other party. This article focuses on acts committed by health care providers but it is important to note that health care fraud also encompasses those fraudulent acts perpetrated by employer groups, members or insureds, and employees. PMID- 10154069 TI - Managed care under siege: how an effective compliance program can protect your company. AB - This article discusses the current enforcement emphasis on managed care fraud and examines how managed care organizations can utilize compliance programs, including legal audits, to protect against unwarranted investigations and liability. The article reviews the elements of an effective compliance program, how to conduct an internal audit, and the risks and benefits of a voluntary disclosure in the event fraudulent activity is discovered. PMID- 10154070 TI - Hospital blazes new trails with cross-continuum case management program. PMID- 10154071 TI - Daily schedule keeps CMs (case managers) working consistently. PMID- 10154072 TI - Variance tracking, analysis easier with guidelines. PMID- 10154073 TI - Cross the continuum divide with 'firm' footing. PMID- 10154074 TI - Hospital nixes pathways, keeps case management. PMID- 10154075 TI - Lumbar discectomy procedure cuts 5-day LOS to 1 day. PMID- 10154077 TI - Explosive growth in Medicare demands new demographic analysis, different marketing. PMID- 10154076 TI - Risk-shared outsourcing will soar as build-or-buy solution. PMID- 10154078 TI - Top hospitals named, new industry benchmarks released. PMID- 10154079 TI - CareData Reports provides information on consumer satisfaction with managed care. PMID- 10154080 TI - Large medical groups make integrated systems competitive. PMID- 10154081 TI - Provider sponsored organizations will be capitated, backed by rich companies. PMID- 10154082 TI - Publish capitation rates, HMO premiums. PMID- 10154083 TI - The revolt against the one-day stay. PMID- 10154084 TI - The MEDSTAT Group is a market leader in healthcare databases. PMID- 10154085 TI - New roles, new responsibilities for health. PMID- 10154086 TI - Look for more turmoil in health care markets. PMID- 10154087 TI - There's a big niche market for infertility care. AB - A lucrative niche remains in a market increasingly dominated by managed care and cost containment. Many infertile women are willing to pay just about any price for infertility products, usually not covered by their insurers, writes Pamela Moore, managing editor of Healthcare Advertising Review. PMID- 10154088 TI - Telephone-based demand management: what you need to know now. PMID- 10154089 TI - Integration inertia a problem at board level. PMID- 10154090 TI - Purchasing provider stop-loss reinsurance. PMID- 10154091 TI - Exploring practice management options. PMID- 10154092 TI - Information systems for integrated healthcare delivery. AB - Even without passage of Federal healthcare reform legislation, the healthcare market is responding to cost-control pressures by becoming more integrated and business-driven. As mergers and collaborations increase, automated system infrastructures must be developed to support the information needs of newly formed integrated healthcare delivery systems. Strategic plans must include provisions for creating new information systems or expanding existing systems so they can support seamless integration and access to patient data among varying providers. PMID- 10154093 TI - Accessing capital for integrated delivery systems. AB - As healthcare organizations integrate to better coordinate services and control costs, they often must turn to capital markets for financing. To successfully access capital for system development, however, healthcare executives first must understand how capital markets view the various entities of a healthcare system and must structure financing proposals in keeping with market expectations. Some relatively new financing strategies, such as taxable debt and equity financing, can help healthcare executives acquire the necessary capital for systems development. PMID- 10154094 TI - Reporting IDS home office costs for Medicare reimbursement. AB - Under Medicare, providers that are part of a chain can be reimbursed for an allocable portion of allowable home office costs. Before a provider can be reimbursed for these costs, however, a home office cost statement must be submitted to the providers' fiscal intermediary. The statement provides a means of allocating certain home office costs to the provider components of a system so that providers can be reimbursed directly for these costs. The home office cost statement also offers a useful financial overview of the home office's operations in relation to the system's overall operations. PMID- 10154095 TI - How should hospitals relate to Medicare HMOs? AB - With the increased emphasis on the development of Medicare managed care plans, healthcare organizations should explore Medicare managed care products and structures available in the marketplace and assess how they best fit with their overall strategy and strengths. An organization's Medicare strategy might involve protecting the organization's current Medicare population, increasing network linkages, and gaining experience with managed care and capitated payment contracting. Medicare, however, is only one of many potential payers for organizations. A strategy developed around Medicare, therefore, also must support the organization's overall managed care strategy. PMID- 10154096 TI - EDI helps PHOs meet information needs. AB - While the organizational structures of physician-hospital organizations (PHOs) may differ from region to region, financial management of all PHOs requires that comparable information about the type and volume of patient services provided under each contract must be available so that the profitability of different contracts can be analyzed. However, comparable information often is not readily available. Obtaining these data is a challenge facing all PHOs. One Midwest healthcare system has designed and implemented an inexpensive electronic network that connects most of the participants in its PHO. This network has enabled the PHO to obtain information about the care provided under its contracts, information that would not be available otherwise. PMID- 10154097 TI - Information technology financing options. AB - Healthcare executives facing the challenges of delivering quality care and controlling costs must consider the role information technology systems can play in meeting those challenges. To make the best use of information system expenditures, organizations must carefully plan how to finance system acquisitions. Some options that should be considered are paying cash, financing, financing "soft" costs, leasing, credit warehousing and early acceptance financing, and tax-exempt and conduit financing. PMID- 10154099 TI - A milestone for paperless claims processing. PMID- 10154098 TI - Exploring the benefits of full-service EDI networks. AB - The financial and administrative rewards of electronic claims transmission have been realized by the healthcare industry for more than a decade. However, some EDI administrators see a need for full-service EDI networks that can save providers thousands of dollars in transactions fees. By accessing a full-service EDI network, providers can send claims to any payer through one source. Providers sending claims electronically no longer need to sort claims for transmission or print to paper; they can submit all claims to one source. PMID- 10154100 TI - Medicare bad-debt litigation continues. PMID- 10154101 TI - Preparing for future roles as claims payers. PMID- 10154103 TI - Data trends. January 1996. PMID- 10154102 TI - Selecting an active portfolio manager. PMID- 10154104 TI - Best healthcare project. Spectrum Center for Integrated Care, Lake View, Illinois. PMID- 10154105 TI - Ladders in nursing careers. Project LINC. Helping hospitals polish their diamonds in the rough. PMID- 10154106 TI - Demand management. Toward appropriate use of medical care. PMID- 10154107 TI - Demand management. Predicting the demand for healthcare. PMID- 10154108 TI - Demand management. Electronic umbilical cords bring healthcare back home. PMID- 10154109 TI - Disease management. To partner or not to partner? PMID- 10154110 TI - Technology, medicine & health, Part 9. Multi-drug resistance and other "wildcard" diseases. PMID- 10154111 TI - Ownership--the longest lever. PMID- 10154112 TI - The coming dislocation in the health professions. PMID- 10154113 TI - A demanding issue. AB - The sudden condemnation of ?inappropriate patient demand? begins to ring a little hollow when one notices how closely it is tied to changes in financial incentives. PMID- 10154114 TI - Medicare changes you need to know about. PMID- 10154115 TI - Getting the best deal when you sell your practice. PMID- 10154116 TI - Two surefire remedies for growing pains. PMID- 10154117 TI - Has managed care made your shareholders' agreement obsolete? PMID- 10154118 TI - Allocating global package pricing. The example of bypass surgery. AB - When health care organizations announce a change in rates paid to physicians, determining how to equitably distribute the new allocation can be a problem. Package pricing requires practitioners to justify their fees or costs to their colleagues and negotiate for a "specific piece of the pie." While this approach has many models, there are few actual examples. When some successful ones are developed, they should include an economic model which allows a practice to make business decision about marginal production opportunities that are in the best interest of all parties involved. Steps include determining actual costs, historical charge patterns, historical payment patterns and Medicare payment rates. PMID- 10154119 TI - The promise of integrated health care. Simple strategies for transforming organizations. AB - To meet rapidly changing industry conditions, successful integrated health care systems must cease to rely on the traditional medical model. No longer can these enterprises reactively deliver care to the sick and injured, but will be forced to transform their model to deliver the value customers demand. This new strategy is based on managing health. In this article on the promise of integrated health care, the author details how the redefined managed care industry--team-based, entrepreneurial primary care offices supported by corporate facilities, specialists and managers--will assume responsibility to redefine the marketplace and manage the health of a population. Key to this evolution, according to Manley, will be organizational revolution of the team structure, information management technology and value-added services that create long-term customer relationships. PMID- 10154120 TI - Strategies for success when medical groups participate in CHINs. AB - A community health information network (CHIN) is a group of health care providers and others interested in health care in a community who share computerized patient information and medical records to provide comprehensive quality care at a lower cost. To protect confidential patient data, all CHIN members should sign a confidentiality agreement describing how and for what purposes health information may be used and incorporating adequate indemnification provisions for unauthorized disclosure. Further, CHIN members should implement practical security passwords which are periodically changed, and the rapid deactivation of the user identification of terminated employees. To ensure data integrity, clear policies should be established for recording, amending and destroying information stored in patient records. To preserve the availability of the network's essential software, CHIN members also should enter into software license agreements which will allow for uninterrupted use of the network software following the addition of a new member or the departure on an existing member. Medical groups participating in CHINs can utilize these strategies to minimize their liability exposure from patient data confidentiality lapses and to promote proper data management and software availability for the smooth functioning of the network. PMID- 10154121 TI - The 'Fulcrum for Quality'. The physics of provider reform: six key variables to achieve 'MEDQIC'. AB - As health care providers move from a fee-for-service, revenue-driven system to total capitation, the need to focus on achieving the most efficient delivery of quality integrated care will be paramount to survival. The energy to survive a totally capitated reimbursement system will depend on the degree that a provider is able to evolve from a revenue-driven to a quality-driven organizational culture. This evolution is going to be very difficult for many health care providers who are committed to a managing money mentality rather than a managing quality mentality to achieve the "bottom line" and regard human resources as expendable and quality as unmeasureable rhetoric. The "Fulcrum for Quality" demonstrates how six key variables change when moving from a fee-for-service to a capitated reimbursement system: reimbursement methodology, utilization, operational expenses, information systems, management and communication. In a fee for-service system, providers experience minimal restrictions on the revenue limits they could achieve. Consequently, inefficiencies and poor quality had little to do with a provider's ability to increase profits. Under a totally capitated system that limits revenue, providers will experience that quality and efficiencies directly affect profits. The "Fulcrum for Quality" discusses the transformation of the six key variables and the changes a medical practice manager will need to make in order to achieve the most efficient delivery of quality integrated care. PMID- 10154122 TI - Physician compensation in transition. The market-based alternative. AB - Current compensation systems are not working for the new and emerging models of health care systems. While there is not a perfect solution, there are alternatives that should be considered. The dynamics that are influencing compensation include: consolidation and integration are creating tighter group infrastructures than have previously existed--groups must place greater emphasis on the manner in which physicians function in support of common goals; the regulatory environment has increased due to the Stark legislation; the marketplace is a force in super-specialties and primary care physician compensation; and managed care is demanding new methods of compensation. Market based compensation is attracting interest because of the complexity of external pressures. It is defined as the relationship between productivity and compensation and utilizes external benchmarks. Future market-based compensation plans will have five main components: productivity, as measured by dollars or RVUs; resource utilization, as service becomes a cost that is debited against capitated revenue; outcomes will be fundamental; service ratings will be instrumental; and physician "citizenship" will garner a higher profile. PMID- 10154124 TI - Mass. healthcare reform bill revives employer mandate. PMID- 10154123 TI - Calif. group adopts policy on for-profit conversion. PMID- 10154125 TI - Quorum pays its employees big bucks for purchase tips. PMID- 10154126 TI - Saint Barnabas becomes N.J.'s largest system. PMID- 10154127 TI - Three Boston hospitals agree to combine cancer programs. PMID- 10154129 TI - Mental Health to sell 6 of its 7 hospitals. PMID- 10154128 TI - AmHS/Premier/SunHealth names preferred provider. PMID- 10154130 TI - Imnet snags HBO & Co. for marketing services. PMID- 10154131 TI - Devices at heart of civil fraud suit. PMID- 10154132 TI - AMA database approved for physician credentialing. PMID- 10154133 TI - Budgets ease move to one doc payment base. PMID- 10154134 TI - HMOs' question: to pay and deliver or just pay? PMID- 10154135 TI - What's new in subacute care? AB - What's new in subacute care? Despite growth, the industry has yet to prove it can deliver the cost savings it has promised, according to a recently released study. Moreover, after all these years much disagreement remains over just what is meant by the term ?subacute care.? PMID- 10154136 TI - Turf wars erupt over subacute-care rules. PMID- 10154137 TI - ProPAC seeks 1.4% update for 1997. PMID- 10154138 TI - IRS says not-for-profit systems' deal won't affect their tax status. PMID- 10154139 TI - AHA turns the page. PMID- 10154140 TI - Doc companies dominate top IPOs. PMID- 10154142 TI - Quorum confirms it's talking about a merger or sale. PMID- 10154141 TI - Study seeks change in nursing staff uses. PMID- 10154143 TI - Another week, another snag in budget talks. PMID- 10154144 TI - New action in Caremark cases. PMID- 10154145 TI - Pa. systems complete deal. PMID- 10154146 TI - Caremark records $52 million charge. PMID- 10154147 TI - Quorum merger still could be in works. PMID- 10154148 TI - Blues plans scramble to change lobbying law. PMID- 10154149 TI - Ill. hospitals sign pact to consider merger. PMID- 10154150 TI - Nurses to march on Capitol May 10. PMID- 10154151 TI - Teaching limbo for hospital, medical school. PMID- 10154152 TI - New GOP tack may limit Medicare cuts. PMID- 10154153 TI - FTC bids to block Mich. merger plan. PMID- 10154154 TI - Federation head serves as paid HMO director. PMID- 10154155 TI - Wilensky another example of D.C. revolving door. PMID- 10154156 TI - Boston hospital sells software unit. PMID- 10154158 TI - Wis. doc network challenging hospitals. PMID- 10154157 TI - JCAHO unveils guidelines for outcomes measures. PMID- 10154159 TI - Merger brings charity law to fore. PMID- 10154160 TI - VA health system hunts for bargains. PMID- 10154161 TI - ERs adapt to era of HMOs. PMID- 10154162 TI - HMOs taking time on link. PMID- 10154163 TI - IHC sets pace on quality improvement. PMID- 10154164 TI - Home health a key factor in systems' integration efforts. PMID- 10154165 TI - Controls sought on drug samples. PMID- 10154166 TI - Health systems planning to add to their paperwork. PMID- 10154167 TI - Claims handling centralized. PMID- 10154169 TI - AMA opposes HMO 'gag clauses'. PMID- 10154168 TI - SunHealth creates 'suballiances'. PMID- 10154170 TI - Texas probes HMO conversion. PMID- 10154171 TI - N.Y. legislators hit HMO 'gag rules'. PMID- 10154172 TI - Bill would give providers antitrust relief. PMID- 10154173 TI - AHA supports Medicare tax reimbursement. PMID- 10154174 TI - Study: higher Medicare spending doesn't guarantee better care. PMID- 10154175 TI - AHA will own library materials. PMID- 10154176 TI - Texas home health firms sue Columbia. PMID- 10154177 TI - HCFA to expand CABG project, add others. PMID- 10154178 TI - Home-care group devises compromise payment plan. PMID- 10154180 TI - House Republicans seek votes for Medicare reform package. PMID- 10154179 TI - Studies show HMO payoff. PMID- 10154181 TI - Debt ratings rebounded in 1995 at not-for-profits. PMID- 10154182 TI - Rollback of self-referral laws in doubt. PMID- 10154183 TI - The game of risk. AB - Fuming over HMOs' high margins and lower payments, providers are negotiating ?global? or full-risk contracts to get a bigger chunk of the capitation dollars employers pay HMOs. Providers also want more control over how care is delivered. PMID- 10154184 TI - Medicare tops all categories on inpatient revenue growth. PMID- 10154185 TI - Data sector has Wall Street's attention. PMID- 10154186 TI - Vertical integration up, horizontal flattens. PMID- 10154187 TI - Survey: PHOs a popular managed-care strategy. PMID- 10154189 TI - Baxter offers to buy NMC for $3.8 billion. PMID- 10154188 TI - Venture capital financing sets record pace in '95. PMID- 10154190 TI - New England HMO merger called off. PMID- 10154191 TI - Illinois, Texas Blues pursue merger. PMID- 10154192 TI - Breakup shakes Indianapolis market. PMID- 10154193 TI - Columbia signs with W.Va. Catholic facility. PMID- 10154195 TI - Changing the face of care delivery. Case study II: The Medical Center, Beaver, PA. Healing patients and delivery system. PMID- 10154194 TI - Lubbock, Texas, hospitals to merge. PMID- 10154196 TI - Boosting the bottom line. Florida Hospital, Orlando. PMID- 10154197 TI - Changing the face of care delivery. Case study I: Cooperative Care Center, Providence, RI. A built-in patient focus. PMID- 10154198 TI - Networking with doctors. Island Hospital, Anacortes, WA. PMID- 10154199 TI - Timing is everything. Los Angeles Jewish Home for the Aging, Reseda, CA. PMID- 10154201 TI - It's not about price, but quality. Boone Hospital Center, Columbia, MO. PMID- 10154200 TI - First time's a charm. Danbury Hospital, CT. PMID- 10154202 TI - Ordinary people's stories. The Menninger Clinic, Topeka, KS. PMID- 10154203 TI - Pieces of the puzzle fall into place. Lakeland Medical Center, Elkhorn, WI. PMID- 10154204 TI - The National Model Fire Prevention Code: who's going to write it? AB - The user-friendly and vastly improved NFPA 1, Fire Prevention Code, is the best fire prevention code out there. Here's how NFPA worked toward consensus on the document, and why it's getting rave reviews from fire marshals and inspectors nationwide. PMID- 10154205 TI - Developing performance-based documents one step at a time. PMID- 10154206 TI - Documenting disaster response. PMID- 10154207 TI - Report from California Task Force #2. PMID- 10154208 TI - Common products that cause uncommonly severe burn injuries. PMID- 10154209 TI - Practice brief. Issue: Data quality. American Health Information Management Association. PMID- 10154210 TI - A closer look at Ambulatory Patient Groups: APG Version 2.0 update. PMID- 10154211 TI - Systems analyst blends HIM background with technological expertise. Interview by Maggie Pelletier. PMID- 10154213 TI - Information-seeking strategies for locating management materials. PMID- 10154212 TI - Organization performance assessment: a multidisciplinary tool for improving institutional performance. PMID- 10154214 TI - How to use entity-relationship diagrams in developing personal database systems. PMID- 10154215 TI - Measurement systems beyond HEDIS: the evolution of healthcare data analysis in managed care. PMID- 10154216 TI - Success with less. PMID- 10154217 TI - A case study in outsourcing transcription. PMID- 10154218 TI - From controlled to committed. AB - Most of us agree that people are our most important resource. Yet we spend a minimal amount of time learning more about human behavior, communication, and how our attitudes and behavior impact employee performance. Instead we rely on traditional methods of negative reinforcement in an attempt to control our areas of responsibility. While these methods can render some short-term success, managers and organizations that succeed during these times of change and fierce competition will be those that take the time to understand and capture the power of a committed workforce. The committed workforce is energized, not simply compliant, as a result of having basic human needs for achievement satisfied, belonging to a group, and receiving recognition for its contributions. Committed workers typically describe the manager as one who has the ability to give them a great degree of control over their area of influence. We all know that we don't change our leadership style like we change clothes. Old habits die hard. it takes a personal commitment and lots of practice to rid outselves of habits and behavior that no longer serve our departments and facilities. This commitment, however, is crucial to survival. As managers, we must cope with increasing ambiguity and uncertainty in the workplace. To survive these challenges, we must improve our interpersonal skills and ability to successfully bring out the best in others. I believe that success will continue for managers who not only increase their knowledge and technical ability, but who also inspire their workers to move forward with a collective sense of enthusiasm and purpose. PMID- 10154219 TI - Accuracy of coding for cardiac catheterization and percutaneous transluminal coronary angioplasty at a Department of Veterans Affairs Medical Center. PMID- 10154220 TI - TENS: CCOHTA (Canadian Coordinating Office for Health Technology Assessment) responds. PMID- 10154221 TI - Who do you serve?: defining clients and stakeholders of long term and continuing care organizations. AB - Many different groups each have a particular stake in the success of a continuing care or long term care organization. Each of these groups, however, measures success according to its own priorities. Before it can truly measure its accomplishments, an organization must first recognize all of its interested groups and understand their perspectives. Only then will it have a meaningful yardstick with which to measure its success. PMID- 10154222 TI - Cluster budgeting: a continuous quality improvement approach. PMID- 10154223 TI - Health for All (?) by the year 2000: backward to the millennium. PMID- 10154224 TI - Six simple prescriptions for effective writing. PMID- 10154225 TI - The Health Action Lobby promotes a prescription for Medicare. PMID- 10154227 TI - The role of therapeutic services in long term care. Interview by Aileen Leo. PMID- 10154226 TI - A policy for allocating off-site continuing education funds. AB - Providing support for travel to conferences, workshops and other off-site continuing education activities is an expensive component of a professional development program. The authors describe a policy addressing this issue which was implemented within the multidisciplinary environment of a comprehensive cancer centre. The policy is open, easily adapted to changes in overall funding and can be used to reflect the organization's expectations regarding employee performance in service, academic, management and leadership roles. PMID- 10154228 TI - Legalizing active euthanasia a dangerous step. PMID- 10154229 TI - Preadmission strategies: reducing the length of preoperative stay. AB - Pursuing efficiency, the Ottawa Civic Hospital implemented a preadmission program which moved as much of the surgical admission procedure as possible to a single preadmission visit. The authors describe the process of researching, planning and implementing the program. They also report the savings it has represented for the hospital and the reaction from surgical patients. PMID- 10154230 TI - Case study. Nurse coordinators team with physicians for seamless care at Delano Regional Medical Center. PMID- 10154231 TI - Case management revamps ambulatory care. PMID- 10154232 TI - End of an era. The new debate over health care financing. PMID- 10154233 TI - Integrated healthcare information systems. AB - When it comes to electronic data processing in healthcare, we offer a guarded, but hopeful, prognosis. To be sure, the age of electronic information processing has hit healthcare. Employers, insurance companies, hospitals, physicians and a host of ancillary service providers are all being ushered into a world of high speed, high tech electronic information. Some are even predicting that the health information business will grow from $20 billion to over $100 billion in a decade. Yet, out industry lags behind other industries in its overall movement to the paperless world. Selecting and installing the most advanced integrated information system isn't a simple task, as we've seen. As in life, compromises can produce less than optimal results. Nevertheless, integrated healthcare systems simply won't achieve their goals without systems designed to support the operation of a continuum of services. That's the reality! It is difficult to read about the wonderful advances in other sectors, while realizing that many trees still fall each year in the name of the health care industry. Yes, there are some outstanding examples of organizations pushing the envelop in a variety of areas. Yet from a very practical standpoint, many (like our physician's office) are still struggling or are on the sidelines wondering what to do. Given the competitive marketplace, organizations without effective systems may not have long to wonder and wait. PMID- 10154234 TI - How are you going to pay for it? PMID- 10154235 TI - November quakes in Northern California. PMID- 10154236 TI - Vital parts. AB - As the demand for organ transplants has grown, a shortage of hearts, kidneys, lungs and other vital organs has developed. Government and health officials have been forced to ration these vital organs. But what's fair? Who should be helped first--the sickest or those who have waited longest for help? PMID- 10154237 TI - Caring about its image. PMID- 10154238 TI - A November to remember on Medicare? PMID- 10154239 TI - Friendship matters. PMID- 10154240 TI - A snag in Forbes's flat tax? PMID- 10154241 TI - Should primary care physicians be capitated? Yes. AB - Yes, argues medical group executive Phil Beauchene, because they're the ?natural coordinators? of the healthcare system and can encourage appropriate care and health promotion. But Lee Newcomer, MD, United Healthcare's medical directors, cautions that in some markets, capitating specialists may be preferable. Read why. PMID- 10154242 TI - Should primary care physicians be capitated? No. PMID- 10154243 TI - Case study. Columbia/HCA in Florida: a national strategy played out in a $47 billion market. AB - The world's largest health management company controls a fourth of Florida's hospital beds and is assembling a full-fledged integrated system, including physician investors. HSL looks at Columbia's key strategies, from geographic encirclement to overwhelming purchasing power. And we listen to critics who warn that Columbia "skims the cream" and abandons communities to maximize profits. PMID- 10154244 TI - TennCare: managed care or managed financing? AB - Tennessee's troubled experience in shifting 1.2 million Medicaid beneficiaries into managed care virtually overnight has important lessons for other state governments and health systems. PMID- 10154245 TI - Evolution of markets and integration mechanisms. AB - Start a PHO or MSO too early, or too late, and it could be a roadblock rather than a building block toward an integrated system. HSL explains how to time integration mechanisms to the evolution of managed care in the local market. PMID- 10154246 TI - Capitation revisited: integrated systems learn how to manage care and risk. AB - Caught in the middle of HMO price wars, integrated delivery systems are tightening their belts and demanding a greater share of what they save from delivering good outcomes more efficiently. Quality isn't endangered yet, leaders agree, but could be unless employers start to incorporate outcomes measures into their choice of health plans. PMID- 10154248 TI - GOP's proposed Medicare antitrust exemptions dangerous, feds warn. PMID- 10154247 TI - Execs say GOP behind the curve on system changes. PMID- 10154249 TI - Cost-related fears fill hospital execs' predictions for future, survey finds. PMID- 10154250 TI - Primary care networks lead hospitals' development plans. PMID- 10154251 TI - Hospitals paying what experts expect for physician practices. PMID- 10154253 TI - PHP's 'integrated system of care' shows costs savings in two demos. PMID- 10154252 TI - Telemed consultations teach GPs about specialties, network finds. PMID- 10154254 TI - Solo hospitals to be a thing of the past by end of decade, survey says. PMID- 10154255 TI - Duke plans for regional MCO with New York Life are a go. PMID- 10154256 TI - Hospitals' cost, quality data open to all with measurement software. PMID- 10154257 TI - Judge in Marshfield appeals case, clarifies views on MFNs, markets. PMID- 10154258 TI - East Texas sees Trinity Clinic, Mother Frances Hospital link. PMID- 10154259 TI - Control charts of the '20s can have relevance for '90s health systems. PMID- 10154260 TI - Project taps nurses, networks to preserve rural hospitals. PMID- 10154261 TI - Hospital network turns to '24-hour coverage' to eliminate comp waste. PMID- 10154262 TI - HMOs found to use few standards in contracts for tertiary care. PMID- 10154263 TI - Hospital employees, patients unhappy with restructuring. PMID- 10154264 TI - MSO growth, vertical vs. 'virtual' integration to top 1996 trends list. AB - After a whirlwind 1995, what's coming for healthcare systems in 1996? Not much time to rest, predicts Alan Zuckerman, executive vice president, Chi Systems Inc., Philadelphia. More intense competition between for-profit and not-for profit health systems, a rising debate over vertical vs. "virtual" integration and a wave of management services organizations could define 1996. PMID- 10154265 TI - Referrals between specialists in hospital outpatient departments. AB - There is little information on referrals between consultants (cross-referrals), and they are difficult to identify within current information systems which may affect the development of efficient services, and erode the traditional role of the general practitioner (GP) as the gatekeeper to secondary care. For one month in 1994, the source and outcome for all outpatient attendances was recorded in medical, paediatric and orthopaedic clinics in a teaching hospital and in a district general hospital. Detailed interviews were also held with consultants to increase understanding of reasons for cross-referral, and their appropriateness. Referrals from hospital doctors were more frequent in the teaching hospital and in the more specialised clinics. Cross-referral as an outcome of a clinic attendance was more common in the teaching hospital, and among patients seen in the general clinics. These findings support the view that cross-referrals are likely to increase as specialisation among consultants increases. Interviews with consultants showed that they did not believe that there was a need to reduce cross-referrals, which were regarded as an integral part of an effective service for patients. However, the development of GP fundholding may impose new constraints on specialists' ability to refer within the hospital system. PMID- 10154266 TI - The training of non-medical theatre personnel. AB - Highly trained, dedicated assistants with relevant occupational skills are essential for safe medical practice. A vocational qualification has been introduced as a potential common training for non-medical personnel wishing to pursue a career in operating department practice. Approval of extended role options gives an opportunity for specialist support, and may also be of use in relieving some of the problems associated with the reduction of the hours of trainee doctors. This paper briefly traces the evolution of theatre training and reviews current developments. PMID- 10154267 TI - Knowledge of junior doctors regarding the New Deal. AB - Junior doctors' knowledge of the content and local implementation of the New Deal for junior doctors was surveyed in one English region. Data were analysed from 254 replies (response rate 60%); a majority (86%) knew that the initiative was intended to reduce their working hours, but detailed knowledge was lacking. Less than half could identify the correct limits on contracted hours for full or partial shift working patterns, while 73% knew that they should not be contracted for more than 72 hours per week for an on-call pattern, the most common and traditional pattern worked. Only 20% knew that hours actually worked should not exceed 56 per week. Only 13 of 114 doctors who believed their posts conformed to the New Deal knew the correct hours limits. Only 11% knew any member of the hospital local implementation group for the New Deal. The results of the survey indicate that junior doctors are not well informed about the details of the New Deal, or its local implementation-four years into the New Deal, this situation needs to be improved, especially as junior doctors are now to be asked to validate the progress of the initiative. PMID- 10154268 TI - General practice health checks of elderly people: a county-wide survey. AB - All general practices in Nottinghamshire were sent a questionnaire to examine the organisation and structure of their annual health checks for elderly people. The results indicated that 99% of responding practices offered checks, yet nearly one quarter estimated that under 50% of their elderly population actually had a check. Many practices had no system for following up old people who did not respond to an invitation for a check. Practices with smaller numbers of elderly people were more likely to estimate high response rates to invitations for a check and more likely to follow-up those who did not respond. The findings are discussed in relation to the reasons why many elderly people do not receive their annual health check. PMID- 10154269 TI - Education and audit can improve the identification of excessive drinkers among medical inpatients. AB - This study investigated the effect of education and audit on the identification and management of medical inpatients with excessive alcohol consumptions by use of a cross-sectional survey of medical and nursing notes, compared with historical controls. We report the proportion of medical and nursing notes containing qualitative and quantitative drinking histories, the use of the CAGE questionnaire, and notification of alcohol consumption in discharge summaries. A total of 1,979 out of 2,680 (74%) notes of eligible patients were examined. The number of medical notes containing quantitative alcohol histories rose from 175/792 (22%) among historical controls, to 242/690 (35%) after training of junior medical and nursing staff, and to 241/497 (48%) after feedback of results in a clinical audit meeting. The number of medical notes with no recorded alcohol history changed from 309/792 (39%) to 287/690 (42%) to 152/497 (31%), respectively (chi 2 for trend = 97.2, p < 0.0001). The number of nursing notes containing quantified alcohol histories rose from 31/792 (4%) among historical controls, to 123/690 (18%) after training, and to 237/497 (48%) after feedback of results in a clinical audit meeting. The number of nursing notes with no recorded alcohol history fell from 309/792 (90%), to 512/690 (74%), to 205/497 (41%) respectively (chi 2 for trend = 353.7, p < 0.0001). The proportion of patients found to be drinking excessively rose from 40/792 (5.1%) to 57/690 (8.3%) to 45/497 (9.1%) (chi 2 for trend = 8.25, p = 0.004). There was little worthwhile improvement in use of the CAGE questionnaire and in discharge summaries. Education and audit are effective ways of improving the identification of excessive drinkers by both junior doctors and nurses alike. Other aspects of management are less responsive. PMID- 10154270 TI - Early post-tonsillectomy morbidity following hospital discharge: do patients and GPs know what to expect? AB - Tonsillectomy is a commonly performed operation; like many others there is increasing pressure for it to be performed as a day-case procedure, with no follow-up for the majority of patients. This paper presents the results of a prospective study of the incidence of post-tonsillectomy morbidity, the recognition of these symptoms by patients, and their management by general practitioners. The results indicate: a lack of awareness by patients of symptoms they might expect post-operatively, despite written and verbal information given; an over-prescription of antibiotics by general practitioners for normal post operative symptoms such as throat pain, temporary voice changes and referred otalgia; and a failure by patients to recognise the importance of the potentially life-threatening complication of secondary haemorrhage from the tonsillar bed. PMID- 10154271 TI - California's security law: impact greatest in ER, maternity units. PMID- 10154272 TI - How new employee ID/access control system ups safety and efficiency. PMID- 10154273 TI - Hospital installs wireless callboxes; reports faster response times. PMID- 10154274 TI - Special report. Hospitals that are becoming 'hotel friendly' to guests ... and the role played by security officers. AB - Faced with increasing competition, hospitals in New York City are developing programs to become more user friendly and, like hotels, to treat patients more as "guests" than as "customers." These programs, which have particular applications for security personnel, are also seeking to improve communications and relationships among the hospital's medical staff and other employees. In this report, we'll describe some of these efforts in which hospitals are turning to hoteliers, consultants, and others for advice in the area of customer service, and the role seen for hospital security. PMID- 10154275 TI - TEAM (Teamwork for Employees and Management) Act: boon to worker/management relations or threat to jobs? PMID- 10154276 TI - Maintaining patient satisfaction in a hospital reorganization. AB - A review of inpatient satisfaction data for MUSC provides both comfort and cause for additional study. Although overall satisfaction rates of 89 and 88 during the period of organizational change indicate stable patient perceptions, one must reflect upon these scores in greater detail. For example, although survey response rates in the 36 percent to 28 percent range appear customary for this type of survey, absolute numbers of discharge responses averaged 496 for the four quarters reported. Some confidence can be taken in the fact that overall survey scores were highly consistent in the 89 to 88 range for the entire reporting period. Moreover, the fact that workforce performance variables such as medication errors and patient occurrence reports did not change indicates that patient care did not deteriorate during this period. Although one could argue that in a time of workforce reduction, employees may work more diligently in order to ensure job security, and that work deterioration may be more apparent over a longer period of observation, this limited view suggests that, at least in the acute phase, work performance was maintained. Future studies should review the relative effectiveness of the specific strategies adopted by MUSC management to ensure high levels of patient care. For example, although MUSC adopted a fairly comprehensive communications effort, it is difficult to discern whether timeliness, variety, or repetition contributed more to the effectiveness of the communications program. Such information could help managers develop focused change implementation strategies. It appears from the inpatient survey data collected by UHC and from the two work performance monitors that MUSC's approach to change management has been able to preserve acceptable levels of patient satisfaction in the face of significant organizational change. Furthermore, these strategies may have been helpful in countering the turbulence caused by large scale change or, at the very least, insulating the care site from potentially negative effects. PMID- 10154278 TI - Conversion. A strategy for troubled hospitals. PMID- 10154277 TI - Hospital trustees: the new stewards of the public's health? PMID- 10154279 TI - The hospital volunteer. An important organizational resource during uncertain times. PMID- 10154280 TI - State health services commissions German style. AB - After the health networks tied to HMOs are organized into oligopolies, and eventually fail to provide adequate access, social equity, and cost containment, public pressures will demand that state health services commissions be established to regulate market share, the scope of health services, reimbursement rates, and allowable profits. The German health system is multipayer, multitier, decentralized, self-governing, and allows providers and insurers to negotiate reimbursement rates without direct government involvement. Such a model would offer more competition among providers and less government regulation. PMID- 10154281 TI - Alcohol consumption and healthcare worker's success and effectiveness. An alternative perspective. PMID- 10154282 TI - Considering a futile care policy. PMID- 10154283 TI - When N = 1: healthcare close up. PMID- 10154284 TI - Cyberhealth. A look back from 2019. PMID- 10154285 TI - The Synapse Project. Information technology meets clinical practice through the Internet. PMID- 10154286 TI - Consumer health informatics. PMID- 10154287 TI - The structure of organized change. Interview by Joe Flower. PMID- 10154288 TI - Technology, medicine & health, Part 3. Therapeutics for tomorrow. PMID- 10154289 TI - In the land of the giants, Part 2 of 2. Big--anything less than an optimal-size organization will suboptimize care. PMID- 10154290 TI - Integrating? Hang in there--the odds are in your favor. PMID- 10154291 TI - I've got a secret. PMID- 10154292 TI - AmeriNet rejects Owens & Minor's 1% price increase. PMID- 10154293 TI - "The juice isn't worth the squeeze;" syringe and needle prices hold steady. PMID- 10154294 TI - Provider criticism of medical-surgical supply distributors is based on incorrect perceptions and expectations. PMID- 10154295 TI - University of Texas Medical Branch pares $500,000 from its operating room materials and supplies budget. PMID- 10154297 TI - AMHS/Premier/SunHealth merger. When does big become too big? PMID- 10154296 TI - Large hospitals and integrated systems are asking: are group purchasing organizations really necessary? PMID- 10154298 TI - AmeriNet annual report shows significant gains for GPO, in spite of loss of members for Vector Healthsystems. PMID- 10154299 TI - Generic pharmaceutical prices continue their decline in prices from last year. PMID- 10154300 TI - Study examines costs of change to JIT or stockless. PMID- 10154301 TI - Community hospitals of California cuts 20% from its supply budget in the operating room with custom procedure trays. PMID- 10154302 TI - VHA says it's ahead of schedule in signing up members for its OPPORTUNITY committed purchasing program. PMID- 10154303 TI - Total joint replacement procedures present opportunities to drive out costs through standardization, demand matching. PMID- 10154304 TI - GPOs must redefine the term "benefit" to remain viable. PMID- 10154305 TI - Health care reform: informing difficult choices. AB - During the last decade, policy makers in a large number of countries have attempted various reforms of their health care systems. Health care reform has been described as a 'global epidemic' (Klein, 1993). All health care reforms consist of very complex policy choices, some of which are examined in this article. After an introductory exploration of ideological issues, the objectives of health care reformers are considered. Three major policy objectives of health care reform are examined: cost containment; efficiency; and, equity. Three types of reform which have been advocated are also considered: public planning; market regulation; and provider-advocated reforms such as a 'basic package' with copayments and alternative means of finance. Finally, appropriate features of efficient health care reform are suggested, addressing explicit policy goals. PMID- 10154306 TI - The financing and organization of health services in poor rural China: a case study in Donglan County. AB - The socio-economic reforms launched in China in the late 1970s led to rapid economic growth and, with it, health sector resources expanded rapidly. The rural health services have benefited from the policies of economic reform, but not in an optimal way, particularly in poor areas. This article uses a case study of a poor county--Donglan--to illustrate that the fiscal decentralization combined with the financial responsibility system have resulted in a weakening of financing and provision of rural health services in poor areas. The need for health facilities to generate revenue has had unfortunate consequences for the style of medical care, such as over-prescription. In addition, the collapse of the cooperative medical system and the weakening of the three-tier network of rural health care in Donglan have jeopardized preventive programs and threaten access to basic health care for the peasants, especially the poor. The study found evidence that preventive programs have deteriorated over the past years, the poor had financial difficulty in access to services, particularly hospital care, health facilities at township and village levels have been run down, and less training and supervision have been provided by upper-level health facilities. The article concludes with recommendations for a strategy for rebuilding and strengthening the three-tier network of rural health care, and for establishing a cooperative medical and health care scheme to ensure that the majority of peasants in Donglan can be guaranteed access to basic health services. Limited health resources will therefore be better used. PMID- 10154307 TI - Health reform in Greece: planning and implementation of a national health system. AB - The health system in Greece has for many years been in a state of continuous crisis. The basic aspects of this crisis involve: a fragmented administrative framework; low level of public expenditure; a significant private sector; inadequate hospitals; skewed manpower; and, a low level of primary care. In 1983, the National Health System (ESY) was established, as an effort to improve the above situation. This article presents the context of the ESY and the situation of the health system prior to and after the establishment of the ESY. The conclusion drawn is that many of the goals of the ESY have not been achieved or only partly achieved, and that a number of the above serious problems still persist. PMID- 10154308 TI - Shaping the health future in Turkey: a new role for human resource planning. AB - The expanding health needs and expectations of a growing and changing population in Turkey are placing new pressures on a health system that is increasingly financially constrained. These pressures are bringing into sharp focus the need to take radical approaches to the organization, planning and management of the health sector; and, in particular, in the planning and management of health human resources. Issues of effectiveness, efficiency and value for money are increasingly becoming the central issues for the 1990s and beyond. The article examines the development of the Turkish health system. Within a framework of health care reform proposals emerging from a major development project in the Ministry of Health itself, the text explores current initiatives and future needs in developing human resource planning if the health care reforms are to be successful in meeting the health needs of the population. PMID- 10154309 TI - Managing care: two views from Oregon. PMID- 10154310 TI - Implications of a children's mental health managed care demonstration evaluation. AB - This article summarizes the major findings of the Fort Bragg Evaluation and considers alternative explanations for the results. The evaluation found that the continuum of care provided a high-quality system of care but was more expensive and produced no better clinical outcomes than traditional services. The possibility of implementation failure at both the systems and services levels is considered and rejected as an explanation for the results. Support for the validity of the measurement, design, and the analysis is also presented. The implications for research and policy are described. PMID- 10154311 TI - Policy implications of the evaluation of the Fort Bragg Child and Adolescent Mental Health Demonstration Project. PMID- 10154312 TI - The Fort Bragg Demonstration Project: a look back. PMID- 10154313 TI - Comment on the final report of the Fort Bragg Evaluation Project. PMID- 10154314 TI - The evaluation of the Fort Bragg Demonstration Project: an alternative interpretation of the findings. PMID- 10154315 TI - Reinterpreting the Fort Bragg Evaluation findings: the message does not change. PMID- 10154316 TI - Implementing a system of care: findings from the Fort Bragg evaluation project. AB - The Implementation Study of the Fort Bragg Evaluation documented how the Demonstration was executed and whether it met the expectations of the continuum of care philosophy upon which it was based. Based on the theory-driven and component approaches to program evaluation, a case study methodology was employed. First, the theories and assumptions about the Demonstration were explicated to derive a program model. Next, the program-as-implemented was compared to the program-as-planned. Barriers responsible for diluting full-scale implementation were documented. This study provides a comprehensive description of how the Demonstration was put into place and the evidence necessary to conclude that the Demonstration was executed with high fidelity, despite barriers, to provide an excellent test of the program theory. PMID- 10154317 TI - The quality of services in a children's mental health managed care demonstration. AB - The Fort Bragg Demonstration and evaluation was designed to test the cost effectiveness of a continuum of care model of service delivery for children and adolescents. A crucial aspect of the evaluation was the measurement of the quality of services provided in the Demonstration. Two key service components were examined: intake assessment and case management. It was concluded that these key components of the continuum of care were implemented with sufficient quality to have the theoretically predicted effects on mental health. PMID- 10154318 TI - Methodological issues in evaluating mental health outcomes of a children's mental health managed care demonstration. AB - A key question of the Fort Bragg Evaluation was whether the continuum of care model implemented at the Demonstration produced better mental health outcomes for children and adolescents than a traditional system of care. This article describes a few of the key methodological issues that were addressed to help ensure that findings about mental health outcomes were valid. The research design was quasi-experimental and longitudinal. Nearly 1,000 families participated, and attrition was low throughout the study. Multiple informants responded to a comprehensive array of widely used instruments in the area of children's mental health and mental health services. Despite the absence of random assignment, sites were comparable upon entry to the study on numerous factors that might affect outcome. Further, data lost through the course of study did not vary appreciably across sites. Finally, some evidence suggests that the findings of the Outcome Study may generalize to other populations of low-middle to middle class youth in treatment. PMID- 10154320 TI - The Fort Bragg experiment. PMID- 10154319 TI - Clinical outcomes of a children's mental health managed care demonstration. AB - The Fort Bragg Evaluation Project hypothesized that the mental health of children treated in the Demonstration's continuum of care would improve more than that of children receiving traditional mental health services at a comparison site. Program theory further predicted site differences in outcome for certain subgroups of children, such as those with severe mental health problems. These hypotheses were tested at 6-month and 1-year follow-ups in several ways, but results showed only slightly more site differences than expected by chance. For the evaluation sample of N = 984 treated children aged 5-17, site differences favored the Comparison about as often as the Demonstration. Children at both sites improved, but there was no overall superiority in mental health outcomes at the Demonstration. PMID- 10154322 TI - The evaluation of a children's mental health managed care demonstration. AB - This article introduces the Fort Bragg managed care experiment. This study was a 5-year, $80 million effort to evaluate the cost-effectiveness of a full continuum of mental health services for children and adolescents. The article describes the development of the Demonstration, the program theory underlying intervention, and how this theory was tested. PMID- 10154321 TI - Parent satisfaction with children's mental health services in a children's mental health managed care demonstration. AB - This article presents findings from a quasi-experiment that included the use of satisfaction scales to compare parent's satisfaction with the services their children received through two different mental health care delivery systems. Satisfaction with the following three types of service were compared: (1) intake assessment during the admission process to any service setting, (2) outpatient services, and (3) residential treatment including inpatient hospitalization and residential treatment centers (RTCs). Additionally, satisfaction with several areas of care (e.g., access, treatment process, therapist relationship, parent and family services, discharge and transition planning), as well as global satisfaction, was assessed. In general, parents whose children received services through an innovative continuum of care system reported significantly higher satisfaction with intake assessment and outpatient services than did parents whose children received care in a traditional fee-for-service system. Fewer differences were found in satisfaction with residential services. PMID- 10154323 TI - Mental health services utilization in a children's mental health managed care demonstration. AB - Service delivery under two systems of care--a traditional Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) reimbursement system and an innovative continuum of care--was examined along six dimensions: access, type, mix, volume, timing, and continuity of services received by children and adolescents. It was found that the Demonstration served over three times as many children as the Comparison. In addition to serving more children, the Demonstration also provided more and different types of services to each child treated. Finally, the Demonstration appears to have delivered services in a more timely fashion and made a considerable effort to match children's and families' needs with services. PMID- 10154324 TI - The costs of mental health services under the Fort Bragg Demonstration. AB - This article examines the costs of treatment under the Fort Bragg Demonstration. It focuses on the direct costs of mental health services and suggests that expenditures on those services were much higher at the Demonstration. Increased access and greater "doses" of services provided at the Demonstration are identified as the proximal causes of the system-level cost difference. Consideration is given to whether these differences in costs and in service use can be attributed to the continuum of care per se or to differences in the financial arrangements under which care was provided. Supplemental analyses suggest that these expenditures were not offset by cost savings elsewhere. Implications for mental health policy are discussed. PMID- 10154325 TI - When the bear came out of hibernation. AB - For five years long term care companies outperformed the stock market. By the end of 1995, assisted living facilities still were going strong, but nursing facilities had taken a hit. PMID- 10154326 TI - Taking the managed care plunge. PMID- 10154327 TI - Assisted living providers: the top crop. PMID- 10154328 TI - Reversing the revolving door syndrome. How to find and keep quality care staff. PMID- 10154329 TI - Testing the subacute care market. PMID- 10154330 TI - Safely handling a harassment complaint. PMID- 10154331 TI - Using cost-volume-profit methods to purchase open MRI equipment. PMID- 10154332 TI - How secure is the Internet for healthcare applications? AB - The Internet has grown faster than any other communications medium or consumer electronics technology--including the fax machine and personal computer. It offers new possibilities for providing economical and good quality patient care, but how secure is it? Is it prudent to communicate patient information over the Internet? For confidential patient information to be transmitted appropriately on the Internet, the originator must be clearly identified without any chance of impersonation; the information must be transmitted without any possibility of corruption or alteration; and the process must be secure. Many experts recognize the need to secure privacy of information, and there are some standards for electronic signatures and data encryption. However, no one has yet come up with a plan that offers a comprehensive solution. Appropriate confidentiality and security legislation has not yet been passed by the U.S. Congress. The following security technologies are currently available and are described in this article: cryptography, authentication devices, electronic signature systems, firewalls, secure hypertext transfer protocol and secure sockets layer protocol. Until proper standards are developed and accepted, providers should use available technologies to protect both patient records and themselves. The legal consequences of mishandling confidential patient information can be disastrous. PMID- 10154334 TI - Benchmarking in healthcare: evaluating data and transforming it into action. AB - After the benchmarking team has accumulated data for the development of comparisons, it must be validated for completeness and consistency. Various factors can skew the analysis and should be watched: Subjective interpretations of survey questions. Lack of common definitions. Composition of input data. External factors and extraordinary events. After verifying consistency of data gathered from benchmarking partners, calculate appropriate statistics for the performance metric. Typical data tabulations are: mean, median, ratio, minimum and maximum value, normal operating range, standard deviation and correlation coefficient. Statistics derived from the data produce the benchmark against which you will measure your institution's performance. Gap analysis establishes the difference between your internal operation's performance and that of the benchmark. Information developed from properly collected data will help you determine reasons for the gap between your performance and the benchmark and project future trends. The next step is to develop an action plan based on what has been learned from benchmarking and targeted to improving performance in areas that further the strategic goals of the institution. In addition to determining performance goals, you must analyze the decision-making process involved in making changes that will move you toward those goals. Since the goal of benchmarking is to improve the organization, the team must present its analysis to those members of management who can approve an action plan. Changes resulting from benchmarking can range from incremental improvement of existing practices all the way to reenginering. Action plans are designed to effect change at levels that will vary according to the goals that have been set. The more incremental the change, the easier the implementation. The more radical the change, the greater the reward. PMID- 10154333 TI - Teleradiology: opportunities, problems, implementation. AB - With the introduction of computerized tomography and magnetic resonance imaging in the early 1970s, computers became integral to the imaging process. Shortly thereafter, scanners that create digitized images from film were introduced and teleradiology--images transmitted in real time--became possible. In the early 1980s, the idea of a picture archiving and communications system (PACS) began to develop. It promised to retrieve, connect and store every kind of image, from x ray to CT, and render film obsolete. However, inflated expectations and inadequate technology hindered PACS implementation. Digital imaging offers the following benefits over film-based systems: - Less space is needed to store imaging studies. - Digital imaging files can be faster and easier for referring physicians to retrieve than film and are not susceptible to loss and damage. - Digital images can be enhanced, contrasted, colored and otherwise manipulated to maximize available information. - There are no chemicals to dispose of. While telemedicine promises to increase the efficiency and effectiveness of medical professionals, wide-scale implementation faces the following obstacles: - It has been difficult to establish a uniform standard that allows file transfer among systems made by different vendors. - There are unresolved legal questions about "interstate" medical practice as it occurs in teleradiology and about standards of care and image quality. - Any system available on a network is vulnerable to unauthorized users who may invade the database or operation of the system, and it is very difficult to detect fraud--data that has been tampered with--in digital records. - Connections to remote locations depend on local telephone lines, which may be slow. Other options are available, but they may be too expensive for facilities in the rural areas that need them the most. - Digital imaging equipment is still very costly to acquire and install. The future of telemedicine rests now with those who implement it. Once instituted, it will surpass traditional medicine by reducing the expense of storage and misplaced information and allowing faster and more accurate diagnoses. PMID- 10154335 TI - AHRA survey. Trends in radiology 1994: Part II. PMID- 10154336 TI - The war on cancer. PMID- 10154337 TI - The most deadly cancers. PMID- 10154338 TI - The cancer wars at HMOs. PMID- 10154339 TI - A new age of healing hands. Cancer centers embrace alternative therapies as 'complementary care'. PMID- 10154340 TI - Underreporting of race in the National Hospital Discharge Survey. PMID- 10154341 TI - It's an on-line revolution: is the health care community ready? PMID- 10154342 TI - Transforming for the future: the California Healthcare Association is born. PMID- 10154343 TI - School-based health centers foster the well-being of children. PMID- 10154344 TI - New technology expands use of radiosurgery. PMID- 10154345 TI - Pilot project offers help to victims of domestic violence. PMID- 10154346 TI - Hospital recognized for its back-to-work program. PMID- 10154347 TI - Medical equipment electrical safety. PMID- 10154348 TI - JCAHO--preparing for 1996. PMID- 10154349 TI - At 940-bed Hartford Hospital, collaboration is key to quality and culture gains, plus $50 million in savings. PMID- 10154350 TI - What makes cross-functional teams work? PMID- 10154351 TI - The scientific method. PMID- 10154352 TI - Working for the common good. Interview by Bruce Bunschoten. PMID- 10154353 TI - Provider automation. Earning the public trust. PMID- 10154355 TI - "What role will speech recognition play in health care?". AB - Speech recognition technology holds great promise for simplifying the creation of an electronic record of care. Although some users say the software offers a practical solution today, skeptics argue that further refinements are needed before most clinicians will choose this emerging data entry option. PMID- 10154354 TI - Disease management. Putting the pieces together. AB - Many providers are launching disease management programs to improve the cost efficiency and quality of health care. The hot new buzzword encompasses many components, including utilization management, patient education and treatment protocols. Savvy health care organizations are devising ways to take full advantage of information technology when implementing disease management programs. PMID- 10154356 TI - 1995--a healthy year for electronic claims growth. AB - Electronic claims processing is coming of age. nearly half of the more than 3.6 billion claims providers submitted during 1995 were transmitted electronically. Providers submitted an estimated 47% of all claims electronically last year, compared to 41.5% in 1994. PMID- 10154357 TI - Facing the outpatient coding challenge. PMID- 10154358 TI - The role of private medical practitioners and their interactions with public health services in Asian countries. AB - This paper aims to review the role of private practitioners and their interactions with public health services in developing countries, focusing largely on the Asian region. Evidence on the distribution of health facilities, manpower, health expenditures and utilization rates shows that private practitioners are significant health care providers in many Asian countries. Limited information has been published on interactions between public and private providers despite their co-existence. Issues related to enforcement of regulations, human resources, patient referrals and disease notifications, are examined. PMID- 10154359 TI - User fees and patient behaviour: evidence from Niamey National Hospital. AB - Evidence is presented on the effects of price changes on the delay before seeking care and on referral status in a sample of hospital patients in Niger. Price changes are measured as differences across patients at one hospital in whether or not they pay for care, rather than as differences in prices across several hospitals. User fees are charged, but the fee system allows exemptions for some payor categories such as government employees, students, and indigent patients. Evidence is also presented on the effect of income on the delay before seeking care and referral status. The analysis demonstrates a technical point on whether household consumption or current income is a more appropriate measure of income. The analysis shows that user fees affect patient behaviour, but the effects are not the same for outpatients and inpatients. Outpatients who pay for care wait longer before seeking care, but inpatients do not. Inpatients who pay for care are more likely to be referred, but outpatients are not. Patients with more income wait less time to seek care and are less likely to be referred than other patients. Further, household consumption explains patient behaviour better than current income. PMID- 10154360 TI - Private payers of health care in Brazil: characteristics, costs and coverage. AB - The private sector is the predominant provider of health care in Brazil, particularly for inpatient services, and financing is a mix of public (through a prospective reimbursement system) and private. Roughly a quarter of the population has private insurance coverage, reflecting rapid growth in the past decade fuelled by the crisis in the public reimbursement system and the perceived deterioration of publicly provided care. Four major forms of insurance exist: (1) prepaid group practice; (2) medical cooperatives, physician owned and operated preferred provider organizations; (3) company health plans where employers ensure employee access to services under various types of arrangements from direct provision to purchasing of private services; and (4) health indemnity insurance. Each type of plan includes a wide variety of subplans from basic individual/family coverage to comprehensive executive coverage. The paper discusses the characteristics, costs and utilization patterns of all types of privately financed care, as well as the major problems associated with private financing: the limited package of benefits and low payout ceilings, inadequate consumer information and virtually no regulation. PMID- 10154361 TI - The determinants of infant and child mortality in Tanzania. AB - This paper investigates the determinants of infant and child mortality in Tanzania using the 1991/92 Tanzania Demographic and Health Survey. A hazards model is used to assess the relative effect of the variables hypothesized to influence under-five mortality. Short birth intervals, teenage pregnancies and previous child deaths are associated with increased risk of death. The Government of the United Republic of Tanzania should therefore maintain its commitment to encouraging women to space their births at least two years apart and delay childbearing beyond the teenage years. Further, this study shows that there is a remarkable lack of infant and child mortality differentials by socioeconomic subgroups of the population, which may reflect post-independence health policy and development strategies. Whilst lack of socioeconomic differentials can be considered an achievement of government policies, mortality remains high so there is still a long way to go before Tanzania achieves its stated goal of 'Health for All'. PMID- 10154362 TI - Knowledge, attitudes and practices during a community-level ivermectin distribution campaign in Guatemala. AB - Community acceptance and participation are essential for the success of mass ivermectin chemotherapy programmes for onchocerciasis (river blindness). To explore the local understanding of the purpose of ivermectin and willingness to continue taking the drug, we performed questionnaire surveys in four communities with hyperendemic onchocerciasis after each of three ivermectin treatment rounds. More than 100 respondents participated in each KAP survey, representing the heads of 30% of the households in each community. The respondents rarely stated that the goal of the ivermectin treatment programme was to prevent visual loss. Instead, they said they were taking the drug for their general well-being, to cure the onchocercal nodule (filaria), or to cure the microfilaria, a term newly introduced by agents of the treatment programme. The principal reason identified for refusal to take ivermectin was anxiety about drug-related adverse reactions, and there were marked differences between communities in acceptance of treatment. In one community over 50% of residents initially refused to take ivermectin, although participation rates improved somewhat after programmatic adjustments. We recommend that ivermectin distribution programmes establish surveillance activities to detect where acceptance is poor, so that timely and community specific adjustments may be devised to improve participation. PMID- 10154363 TI - Measuring time utilization in rural health centres. AB - OBJECTIVES: During the recent re-design of the primary health care system in Cameroon a time-motion study was undertaken to determine how health workers at rural health centres use their time before redefining their roles. METHODS: The study developed a simple, effective and inexpensive tool which uses the activity sampling technique, and was applied to 20 health centres with a total of 19,080 observations being made of 64 health workers who represented all grades of worker in the government health services. RESULTS: The study developed a clear picture of how health centre staff apportion their time, and how the division of labour and tasks is carried out in a rural health centre. It found that only 27% of health workers' time is currently being spent on productive, health-related activities, and of this time, the largest proportion is spent on curative, clinical work. Less than 1% of health workers' time is spent on preventive and outreach activities. DISCUSSION: This study has developed a simple and inexpensive tool which can be used in any health facility to determine how health related activities are carried out. This is an important step if changes in the delivery structure are to be made, because it establishes the discrepancy between expected and actual behaviour, and provides an important baseline for the evaluation of the effectiveness of any changes that are introduced within the system. PMID- 10154364 TI - The bed census survey: a tool for studying hospital inpatient services. PMID- 10154365 TI - Carrying out a bed census at a district hospital in Zambia. PMID- 10154366 TI - The effects of capitation payment on the organizational structure of medical group practices. AB - This study explores the effects of capitation payment on the structural elements used by medical group practices to control physician-directed use of resources and the quality of patient care. Forty-five medical groups located in the highly competitive Minneapolis/St. Paul metropolitan area were studied. The range of capitation payment in these medical group practices is from 2% to 87%. Although the practices vary considerably in the extent to which they have developed these control mechanisms, it does not appear that capitation payment is a major factor influencing that pattern. It appears that many of these medical group practices either use less formal mechanisms than those included in this study to control resource use and the quality of care or use none at all. In either event, the data suggest that the effects of capitation payment on the structure of medical practices may be overestimated. PMID- 10154367 TI - Evaluating the physician office visit: in pursuit of a valid and reliable measure of quality improvement efforts. AB - In an effort to develop a patient questionnaire with sufficient validity and reliability to be used to measure patient perceptions of quality, over 30,000 patients from 178 solo and group practices completed the Physician Office Quality of Care Monitor (QCM). The study found strong evidence of construct validity, predictive validity, and internal consistency for the questionnaire. Physician interactions were the most important aspect of office care while coordination of care over time was found to be the best issue to differentiate patients likely to recommend a practice from those less likely to recommend. An inverse relationship was found between practice size and patient satisfaction. Health maintenance organization (HMO) patients reported lower satisfaction, as did younger patients. PMID- 10154368 TI - Pneumocystis pneumonia in a prepaid care system caring for a Medicaid-covered population with AIDS. AB - Pneumocystis pneumonia (PCP) is the most common pneumonia in persons with acquired immunodeficiency syndrome (AIDS) and a frequent cause of hospitalization. The incidence of PCP in patients with AIDS can be substantially reduced when patients comply with standard prophylaxis protocols. However, achieving acceptable prophylaxis compliance in any patient population is difficult, particularly with intravenous drug users (IVDU), homeless, or medically disenfranchised patients. This study defines the rates and locations of treatment of PCP in a prepaid managed care program for a Medicaid-covered population with AIDS, with comparisons to PCP incidence rates in the same population receiving care in the fee-for-service system. PMID- 10154369 TI - Quality of life and quality of care data from a 7-year pilot project for home ventilator patients. AB - A research demonstration pilot project for hospitalized adult and pediatric long term ventilator-dependent patients was conducted by Kaiser Permanente Southern California Region from 1985 until 1992. The purpose of the pilot project was to investigate if home care was a realistic alternative to continued hospital care. Many aspects of home care as compared to hospital care were studied. The results of the quality of life and quality of care study in addition to cost data are presented in this paper. Standardized questionnaire tools were used to obtain patient data from the perspective of the patient, as well as others providing direct patient care. Respondents were asked to measure perceptions of quality of life and quality of care at home versus at the hospital in regard to health status, life satisfaction, emotional well-being, caregiver ability, and professional care and services. Quality of care was found to be similar to hospital care. Quality of life was judged to be better at home. PMID- 10154370 TI - Profiling primary care physician resource use: examining the application of case mix adjustment. AB - Growing emphasis on managed care has led to increased interest in physician practice profiling. Standardized techniques for conducting profiling are not yet well established. One particularly challenging methodologic issue, case mix adjustment, is explored here using actual cost profiles derived from primary care physicians at two independent practice association (IPA)-model health maintenance organizations (HMOs). Specifically, this article examines how the ambulatory care group case mix methodology can be applied to profiling and illustrates that it provides more depth of information with which to assess performance than does standard demographic adjustment alone. This analysis suggests both the potential and methodologic limitations of profiling at the individual physician level. PMID- 10154371 TI - Physician profiling: 12 critical points. AB - Physician profilers encompass an array of technological products that purport to evaluate individual clinician performance on utilization and other measures. Prior to installation, an organization should be familiar with a number of major concepts that encompass understanding of clinical practice processes, claims data limitations and idiosyncrasies, ethical issues, and mathematical principles. Twelve specific elements are described to assure that these concepts are addressed. PMID- 10154372 TI - Ambulatory care groups and the profiling of primary care physician resource use: examining the application of case mix adjustments. AB - A variety of profiling models and tools is utilized by payers, providers, and regulators to evaluate physician work, performance, and resource utilization. In physician profiling, the provider's pattern of practice is expressed as a rate of service or outcome. The article by Tucker, Weiner, Honigfeld, and Parton (this issue) compares the practice-based norms of primary care physicians by adjusting for case mix using ambulatory care groups (ACGs), a population-based classification method. Once the case mix is adjusted, the actual use of resources, as measured by overall charges, is compared with the expected value of resource use. In the Center for Research in Ambulatory Health Care Administration (CRAHCA) Physician Profiling Project, funded by The Robert Wood Johnson Foundation, physicians learn which services other physicians in their specialties perform. Physicians are able to compare their profiles with state and national level medians. The profiling project is one of the first demonstration projects in the field to profile ambulatory care practice patterns and collect patient demographics. An aspect of the project is to test the ACG classification system to data selected from 130 nonacademic practices representing over 5,000 physicians. PMID- 10154373 TI - Health information services technologies. AB - Increasing demands for provider profiling have led to the growth of health information services units within payers and health plans. An important decision faced by these groups is whether to buy or build the information infrastructure necessary to support the activities of the department. The article offers an overview of a system that was collaboratively designed and built by Blue Cross and Blue Shield of Iowa and the Dartmouth Medical School. A case study illustrating the flexibility of the information system in adapting ambulatory care groups to the fee-for-service payer industry is reviewed. PMID- 10154374 TI - The Iowa CHMIS (Community Health Management Information System): work in progress. AB - The Iowa Community Health Management Information System (CHMIS) is a legislatively authorized system that is designed to meet Iowa's shared information needs and reduce administrative costs. A public/private partnership has been planning this system for over three years, implementation is scheduled to begin in July 1996. At that time, certified transaction networks will route claims data between providers and payors, a subset of that data will be stored by a centralized data repository. As the system evolves, provider access will be expanded and additional data elements will be captured. PMID- 10154375 TI - The layoff. It's a business decision. PMID- 10154376 TI - Laboratory information systems, Part 2. How well does LIS reach all 4 corners of the lab? PMID- 10154377 TI - A lab's outreach for healthier school kids. PMID- 10154378 TI - The health-care manager's guide to managing change in challenging times. AB - Fifteen years ago, Bill Gates was a college dropout working for a four-member, fledgling company in New Mexico. Today, he is the richest man in America and the head of perhaps the most powerful company in recent corporate history. Ten years ago, managed health care was merely a concept discussed in academic and industry observer circles. Now it is a norm in almost every health-care organization nationally. Five years ago, health-care professionals in every discipline believed the maxim that, ?as long as people get sick, health-care professionals will have jobs.? In 1995, health-care executives have alternately referred to the widescale process of laying off employees as reengineering, rightsizing, downsizing, or RIF (reduction in force). With this massive amount of change, both societally and professionally, health-care managers have been contending with the change management process. Although a breadth of concepts borrowed from other industries and a plethora of conceptual practicums have entered the health-care educational realm, a straightforward, immediately useful approach to managing change is probably more beneficial, as the need to manage change quickly and effectively becomes the paramount criterion for health-care management success in the second half of this decade of change. In this article we will explore the four areas where mistakes are made most frequently by leaders in the change process, and we will provide specific strategies to not only avoid these mistakes but moreover reduce resistance to change, activate positive action, and ultimately improve performance through optimum staff contribution. The four critical areas we will explore are the reasons for resistance to change, the management of the proactive phase of change, creating staff interdependence, and key leadership roles for change management. PMID- 10154379 TI - Productive criticism, Part 2: A new environment for criticism. Performance appraisals and other real-life situations. AB - Criticism affects almost all aspects of your job: the quality of work you do, how you feel about it, and your relationships with your boss, coworkers, and subordinates. Used productively, criticism is a powerful tool that helps you improve your work, enhance your working relationships, increase your job satisfaction, and achieve better overall results. Improperly used, it impedes performance, demoralizes you, discourages you from wanting to try again, and creates friction in the workplace. In short, the ability to give and take criticism significantly determines how well you do on the job. In Part 1, we explained how to use productive criticism as an opportunity for the growth and education of subordinates. In Part 2, we will examine how you can productively criticize superiors and peers. We will also offer new performance appraisal technics and examine real-life criticism situations. PMID- 10154380 TI - How to improve your image with physicians. Differentiating your laboratory for a competitive advantage. AB - A collaborative partnership between physicians and the laboratory is more important than ever. This requires addressing the five major complaints that physicians have regarding the laboratory within the context of six key characteristics of doctors. The complaints concern: timeliness of information, completeness, accessibility, providing information in a suitable form, and making it understandable to time-pressed physicians. Working effectively with physicians to achieve an immaculate image means understanding why they tend toward control, have difficulty with conceptual presentations, and are quick to stereotype. It also means understanding how to capitalize on their tendency to respect expertise and reward it with loyalty. Establishing a favorable image requires creating a perception of cooperative proactivity based on sensitive performance. PMID- 10154381 TI - Reflections from a Quality Management Award winner. PMID- 10154382 TI - Laboratory manager's financial handbook. The laboratory's importance to the financial stability of a health-care organization. AB - From a financial standpoint, one of the most valuable assets in the survival of a health-care organization is the clinical laboratory. Laboratory directors, managers, and supervisors have indicated their overwhelming need to understand finance, especially cost management, to CLMA and to the author at national meetings and workshops, Tremendous financial pressures are being applied in health-care organizations across the country. Two strategic factors in their successful move into the 21st century are more appropriate test utilization and cost control in the laboratory. PMID- 10154383 TI - Cost accounting in the laboratory. Panel discussion. PMID- 10154384 TI - Perspectives. Geography is destiny in atlas of care variations. PMID- 10154385 TI - Nurses: the saga continues. AB - Some nurses are claiming that patient-focused work redesign models sacrifice quality of care for cost efficiency. While they have some valid concerns, others see legitimate reasons for using unlicensed assistive personnel at the bedside as the role of nursing changes within hospitals. PMID- 10154386 TI - An act of privacy. AB - Lawmakers in Washington have drafted a new bill to protect the privacy of medical records in the digital age. The author argues that the measure needs fine tuning, but that it's a good start. PMID- 10154387 TI - The tax code at the bedside. AB - Last June, Washington's Heritage Foundation sponsored a symposium called ?Restoring the Doctor-Patient Relationship: The Challenge of Third-Party Payment and Government Regulation.? This article, adapted from those proceedings, argues that tax fairness and choice are critical underpinnings of ethical medicine in the managed care era. PMID- 10154388 TI - The new rules of home health. AB - Home care is an ever more important component of a system's arsenal of care, but most hospital-based programs were set up for reasons that no longer apply in today's marketplace. The author offers a framework for thinking through a hospital home care program for the next decade. PMID- 10154389 TI - Certificate of Need: up for revision. AB - Three states scaled back their Certificate of Need programs during 1995. Intergovernmental Health Policy Project research scientist Helen Leeds examines the history of CON and discusses whether Ohio, Wisconsin, and North Dakota presage a trend. PMID- 10154390 TI - Anatomy of a roadblock. PMID- 10154391 TI - Seeking common ground. PMID- 10154392 TI - Recycling the hospital. PMID- 10154393 TI - Crying wolf in Washington? PMID- 10154394 TI - LA, NY: big city blues. Interview by Craig Havighurst. PMID- 10154395 TI - The prognosis for pathways: a study of clinical path trends in health care. AB - In the late spring of 1995, Charlotte NC-based Decision Support Systems and Andersen Consulting launched a survey designed to collect information on implementation of clinical pathways at hospitals around the United States. The purpose of the survey was to understand the prevalence of clinical paths, the process hospitals use to develop and implement paths, and the level of automation in place to support them. Of the 1,100 surveys distributed, approximately 17 percent were returned. Geographical distribution of survey respondents was coast to-coast, with the strongest responses from California and Florida. The results of the survey are reprinted here in their entirety. Additional commentary by Editor Craig Havighurst appears in the gray sidebar. PMID- 10154396 TI - Monitoring quality of medical care: how about a level playing field? PMID- 10154398 TI - The 1996 Medicare fee schedule. PMID- 10154397 TI - Federal antitrust reform: is relief for physicians on the way? PMID- 10154399 TI - Mission: possible. Forces rally behind universal numbering. PMID- 10154400 TI - Earwitness. Hearing isn't always believing. PMID- 10154401 TI - Let's make a deal: contract terms to bring up in negotiations. PMID- 10154402 TI - Five years later, DOT's hazardous materials rule is final. PMID- 10154403 TI - Surgical linens: buyers and sellers play on the same team. PMID- 10154404 TI - Head 'em up, move 'em out: taking OR case carts off-site. PMID- 10154405 TI - Health care programs: fraud and abuse; revisions to the PRO sanctions process HHS. Correction to final regulations. AB - This document corrects a technical error that appeared in 42 CFR part 1004 of the final rule published in the Federal Register on December 12, 1995 (60 FR 63634). The final rule was designed to revise and update the procedures governing the imposition and adjudication of program sanctions predicated on recommendations of State Utilization and Quality Control Peer Review Organizations. Specifically, this correction notice sets forth the corrected text for section 1004.110(f) which contained a typographical error in subparagraph (2). PMID- 10154406 TI - Cancer treatment clinical trials--DoD. Notice of demonstration project. AB - This notice is to advise interested parties of a demonstration project in which the DoD will expand a current demonstration for breast cancer treatment clinical trials to include all cancer treatment clinical trials under approved National Institutes of Health, National Cancer Institute (NCI) clinical trials. Participation in these clinical trials will improve accessing to promising cancer therapies for CHAMPUS eligible beneficiaries when their conditions meet protocol eligibility criteria. DoD financing of these procedures will assist in meeting clinical trial goals and arrival at conclusions regarding the safety and efficacy of emerging therapies in the treatment of cancer. This demonstration project is under the authority of 10 U.S.C. 1092. PMID- 10154407 TI - Indian Self-Determination and Education Assistance Act amendments--BIA, IHS. Notice of proposed rulemaking. AB - The Secretaries of the Department of Interior (DOI) and the Department of Health and Human Services (DHHS) propose a joint rule to implement section 107 of the Indian Self-Determination Act, as amended, including Title I, Public Law 103-413, the Indian Self-Determination Contract Reform Act of 1994. A joint rule, as required by section 107(a)(2)(A)(ii) of the Act, will permit the Departments to award contracts and grants to Indian tribes without the unnecessary burden or confusion associated with having two sets of rules for single program legislation. In section 107(a)(1) of the Act Congress delegated to the Departments limited legislative rulemaking authority in certain specified subject matter areas, and the joint rule addresses only those specific areas. As required by section 107(d) of the Act, the Departments have developed this proposed rule with active tribal participation, using the guidance of the Negotiated Rulemaking Act. PMID- 10154408 TI - Which kind of group is more lucrative? It depends on the primary care specialty. PMID- 10154409 TI - Big employers back new drive for comparable quality measures. PMID- 10154410 TI - Picking the right 'horse'. PMID- 10154411 TI - Satisfying managed care patients through ethics consultation. PMID- 10154412 TI - Health insurance premiums are no longer racing ahead of inflation. PMID- 10154413 TI - Now you can look it up. PMID- 10154414 TI - Provider automation. Lessons learned the hard way. AB - Sentara Health System is going back to the drawing board after determining through exhaustive research that it could not carry out its original enterprisewide network strategy. PMID- 10154415 TI - Will CHINs hit the jackpot or break the bank? AB - Before providers, payers and others sign up to share data through community health information networks, they're asking for proof that savings will far exceed the cost. The fate of the CHIN movement may hinge on the evidence. PMID- 10154416 TI - Some ups, downs for CHIN efforts. PMID- 10154417 TI - Electronic prescriptions: just what the doctor ordered. AB - Electronic prescription systems address many of the ills in the current paper based system of getting drug orders from physicians to pharmacies. This new automation application shows tremendous potential for saving time and money and reducing the chance for medication errors. But many hurdles must be overcome before electronic prescribing is widely used. PMID- 10154418 TI - HMOs rallying physicians to use electronic records. PMID- 10154419 TI - Technology. The need for speed. PMID- 10154420 TI - Meeting managed care's EDI needs. PMID- 10154421 TI - Health care 1996. Top 10 trends for the era of integrated delivery. PMID- 10154422 TI - Forming PSNs through strategic partnerships and joint ventures. PMID- 10154423 TI - Corporate soul. Seven pathways to organizational enlightenment for health care organizations. PMID- 10154424 TI - A conversation with Jerry Berkman. PMID- 10154425 TI - Will the cost cutting in health care kill you? PMID- 10154426 TI - Disease management can aid at-risk academic hospitals. PMID- 10154427 TI - Direct contracting demands of employers increase pressure on hospitals. PMID- 10154428 TI - Study shows Hispanics' experiences and expectations of nation's health care system. PMID- 10154429 TI - The survival of Catholic health care: geographically linked networks. PMID- 10154430 TI - Cost-effective choices for provider stop-loss reinsurance. PMID- 10154431 TI - Mix marriages: for-profit and nonprofit integration. PMID- 10154432 TI - Positioning hospital-based home care agencies for managed care. AB - Over the next several years, Medicare cost-cutting strategies and changing market forces will decrease home health visits and revenue per visit and will probably eliminate the Medicare overhead allocation for hospital-based home care agencies and freestanding home care facilities. Consequently, home care agency managers need to plan now to make their operations more efficient and more competitive in the future. Managers should improve their collection of data needed for cost reporting to optimize overhead reimbursement while it is still allowed and to begin lowering costs per visit. Chief financial officers have an important role to play in making hospital-based home care agencies financially successful. PMID- 10154433 TI - Strategic benefits of master facility plans. AB - In recent years, many healthcare executives have stopped developing master facility plans due to some basic misconceptions about them, namely that master facility plans are too rigid or require major capital commitment. By getting past these misconceptions, healthcare executives can help their organizations develop and implement master facility plans that serve as flexible, reliable blueprints in guiding the organizations toward achieving their strategic, operational, and financial goals. PMID- 10154434 TI - Restructuring public hospitals to meet marketplace demands. AB - Legal and political limitations often prevent public hospitals from offering the full range of services and programs that might best serve their communities and allow them to compete successfully with nongovernmental facilities. Faced with such limitations, a growing number of public hospitals are being restructured as nongovernmental entities. Rather than selling these facilities outright, some cities, counties, and hospital districts are "privatizing" their public hospitals, which enables both the municipality and the hospital to take advantage of potential benefits while ensuring community access to appropriate, high quality healthcare. PMID- 10154435 TI - Preparing for the new outpatient reimbursement system. AB - The Health Care Financing Administration is expected to soon introduce a prospective payment method for reimbursement of hospital-based outpatient services provided to Medicare recipients. This payment system most likely will make use of an outpatient classification system based on ambulatory patient groups (APGs). Although the details of the new ambulatory payment system have not yet been finalized, healthcare facilities should start planning for implementation. PMID- 10154436 TI - Developing an incentive system for PHO physicians. AB - To succeed in a capitated market, a physician-hospital organization (PHO) must deliver high-quality health care in the most cost-effective manner possible. Integral to the provision of cost-effective care for patients covered by capitated contracts is the development of a sound physician incentive program. Such a system is essential to align the incentives of all the key players and enable them to share in the rewards and risks associated with capitation. Following specific guidelines for establishing physician incentive programs in a PHO can ensure the success of such programs. PMID- 10154437 TI - Reassessing the number and mix of system physicians needed. AB - As the fee-for-service reimbursement environment gives way to managed care in many parts of the country, healthcare executives are facing the need to reassess the number and specialty mix of their systems' physician populations. By using two sets of guidelines--one developed for fee-for-service environments (the Graduate Medical Education National Advisory Committee guidelines) and the other developed for managed care environments (the Kaiser Permanente guidelines)- healthcare executives can calculate the appropriate number and specialty mix of physicians their systems need to serve their communities. PMID- 10154438 TI - Using derivatives to hedge against the unexpected. AB - Derivatives--financial instruments with a rate of return derived from an underlying asset--have been used as investment instruments for decades. Many derivative products originally were created explicitly for the purpose of reducing financial risks and have become more widely used and more complex in recent years. Healthcare financial managers should have a basic understanding of derivatives as well as the ability to apply general guidelines for their appropriate use in healthcare financial management. PMID- 10154439 TI - EDI and patient confidentiality. PMID- 10154440 TI - Long-term care insurance can reduce financial risk. PMID- 10154441 TI - Data trends--February 1996. PMID- 10154442 TI - Our health is our environment. Interview by C. Burns Roehrig. PMID- 10154444 TI - Where have all the uninsured gone? PMID- 10154443 TI - The Republican revolution: what does it all mean? PMID- 10154445 TI - How to use ASIM's worksheet for care plan oversight services. PMID- 10154446 TI - Tough choices for our economy. American Society of Internal Medicine. PMID- 10154447 TI - Organizing to succeed: managed care in California. PMID- 10154448 TI - Joining managed care instead of fighting it: one doctor's perspective. PMID- 10154449 TI - Is an integrated practice in your future? PMID- 10154450 TI - Professional licensure issues of the 1990s. PMID- 10154451 TI - Beyond the politics of Medicare reform. PMID- 10154452 TI - Insurance departments may regulate some managed care arrangements. PMID- 10154453 TI - New covenant process: progress toward collaboration. PMID- 10154454 TI - A moral quandary for sponsors. Like the family, and the state, sponsorship is an institution. AB - Nowadays many religious institutes are asking questions about sponsorship. The issue is usually phrased as the sponsoring of institutions. But it might be useful to ask about the institution of sponsorship instead. In The Good Society, Robert Bellah and his associates say that, on one hand, institutions are created by human beings; on the other hand, because we draw our sense of identity from them, institutions create us too. Bellah et al. also say that institutions, being human creations, are susceptible to corruption, especially when great wealth and power are involved. Since hospitals and healthcare systems obviously do involve wealth and power, we sponsors now have many questions, as well as some ambiguity about our sponsorship capability. One might even say that a moral debate is raging in our collective subconscious: Is loss of corporate influence something we would do something about if we could, or have we chosen some other value, such as ministerial diversity, instead? My institute, the Sisters of Mercy, has decided to continue our sponsorship of such organizations. As an institution, sponsorship is an essential bearer of our ideals and meanings. We need this institution to announce, to the world and to ourselves, that whatever power and wealth we possess are committed to mercy and justice. PMID- 10154455 TI - Catholic healthcare without sisters. PMID- 10154456 TI - Public juridic person ensures Catholic presence. How one Catholic healthcare system assumed a lay model of sponsorship. AB - To ensure that the Catholic healing presence remained in the communities it has served for many years, the United States St. Joseph Province of the Sisters of Charity of Montreal (Grey Nuns) is transferring its healthcare institutions to a lay model of sponsorship. The new arrangement makes Covenant Health Systems (CHS) a public juridic person of pontifical right sponsoring the U.S. Grey Nuns' healthcare organizations. In addition to extensive education and communication efforts aimed at all its constituencies, CHS needed to pass through several stages before it could become a public juridic person. Approval had to be obtained from the Grey Nuns Provincial Administration and General Administration (in Montreal). Proposed statutes and bylaws had to be drafted. The CHS Board of Directors had to sign a letter of intent, indicating its willingness to accept these responsibilities of sponsorship. The Congregation for the Institutes of Consecrated Life and Apostolic Societies approved the request for public juridic person status. CHS and the Grey Nuns will take a year to implement the transfer, which will be official on October 24, 1996. CHS will continue to operate in a manner consistent with the teachings of the Catholic Church by complying with the Ethical and Religious Directives and by maintaining contact with local ordinaries. PMID- 10154457 TI - A closer look at lay sponsorship. A CHA survey reveals some problems with two established models. AB - The private association of the Christian faithful (PACF) and private juridic person (PJP) are two lay sponsorship options for healthcare organizations that find traditional sponsorship unavailable. Today two questions relate to these models: Are the PACF and the PJP still realistic and attractive models of sponsorship? Can Catholic identity be maintained in them? Last summer CHA surveyed the seven member organizations that use either the PACF or the PJP as sponsorship models. In addition, CHA conducted four site visits, which corroborated the survey findings. Most respondents said their organizations had adopted the lay model as a means of remaining Catholic after their original sponsors withdrew. Most said they had a good relationship with the local diocese, although formal meetings with the diocesan leaders were infrequent. Each organization had a clearly articulated mission and reinforced their mission and values in various ways. Leadership development appeared somewhat weak. Some respondents spoke favorably of the PACF and PJP models of sponsorship, but others saw limitations, including isolation, lack of clarity in reporting mechanisms between the organization and the diocese, and lack of board education about the models. Even those who saw a future for lay sponsorship on the PACF and PJP models said that, although it is important for Catholic healthcare to develop lay leadership, these models are not promising steps in that direction. PMID- 10154458 TI - Public juridic person offers flexibility. Structuring and writing statutes for this model is simple in theory, complex in practice. AB - Public juridic person is an alternative sponsorship arrangement that allows various Church entities to share resources, thus strengthening their competitive position. Creating a public juridic person is simple in theory but can be complicated in practice. The 1983 Code of Canon Law states that public juridic persons are ?aggregates of persons or things? constituted by the ?competent ecclesiastical authority? to ?fulfill a proper function given them in view of the common good.? The canon law further indicates that public juridic persons require statutes. The code provides a list of items to be included in the statutes, such as a purpose, constitution, governance, operations, and conditions of membership. Writing these items can be complex, depending on the makeup of the public juridic person. After writing the statutes, the entities' leaders take them to the competent ecclesiastical authority, who approves them and thereby founds the public juridic person. But it is not always easy to determine who the competent authority is. Statutes can be tricky to formulate and therefore should contain provisions for modifications. They should be written as simply as possible. Bylaws should be used as much as possible for detailed provisions. Still, the most important safeguards of Catholic identity will be the makeup of the board, provisions for monitoring its activities, and the implementation of ethical directives issued by Church authority. PMID- 10154459 TI - Total transformation for the future. How the ASC Health System crafted strategic partnerships to better position its facilities. PMID- 10154460 TI - A journal of community. Catholic healthcare providers' presence is necessary to sustain a values-based system. AB - Catholic healthcare leaders must use all their will and creative imagination to find a way to maintain a significant Catholic presence in healthcare. Catholic healthcare leaders across the nation are acquiring, consolidating, and merging hospitals; forming alliances and networks of integrated services; and bringing together Catholic healthcare systems on a regional and local basis. The next few years are critical for Catholic sponsors of healthcare services. The unique challenge is to pursue the development of a Catholic network that would include a wide range of health, mental health, home care, long-term care, social, and housing services. The key ingredient to making networks happen will be leadership, and I think CHA and sponsors rightly emphasize the need for continuing leadership formation and development of trustees and executives in Catholic healthcare. A united effort by Catholic healthcare providers could have a penetrating influence on the overall development of healthcare in this nation. Now is the time to exercise imaginative leadership; to reach out to the existing Catholic and community-based providers of health and human services; and to create networks that can provide a continuum of accessible, high-quality, values based, and cost-efficient services. PMID- 10154461 TI - The application of faith-based principles. Mission leaders can facilitate an organization's cultural transformation. AB - Cultural factors account for a high percentage of the less-than-successful mergers, partnerships, and joint ventures that are taking place in today's healthcare marketplace. Culture is found wherever people live and work together in relative stability. Those in the Catholic healthcare ministry are in need of faith-based wisdom to deal with the challenges of cultural transformation. Five principles may be helpful: Take time as a team to return in a reflective way to the wellsprings of our ministry. Remember that this is a three-way undertaking- you, your co-workers, and God. Remember that to hear God speak to us, to recognize God's presence, we need to keep ourselves centered and deeply attentive. Help one another sort out motivations and maintain a clean heart. Appreciate the affective potential in the cultural elements of symbol, myth, and ritual. Using these principles, leaders can begin to focus on how they can positively affect culture change through the following conceptual model of culture: The symbolic dimension of symbols, myths, and rituals. The dimension of espoused beliefs, purpose, and values. The mini-expressive dimension of revealing everyday comments and behaviors. The hidden dimension of sentiments, convictions, and commitments. PMID- 10154462 TI - IRS proposes ruling on physician recruitment. How a hospital recruits physicians would affect its tax-exempt status. AB - On March 15, 1995, the Internal Revenue Service (IRS) announced a proposed revenue ruling stating how certain physician recruitment practices could be implemented without threatening hospitals' tax-exemption. As proposed, the IRS ruling would provide flexibility for recruitment incentives rather than a list of strict physician recruitment guidelines. The proposed ruling is not legally binding until issued in final form, and there is no deadline for finalizing it. In the meantime, however, the standards outlined in the proposed ruling reflect arrangements the IRS likely would approve, which should be an incentive for tax exempt hospitals to follow reasonable physician recruitment practices. Assuming a hospital complies with other legal requirements such as fraud and abuse laws, it must answer two key tax-exempt status questions for its recruitment or retention package: Will the incentives result in a disguised distribution of profits from the operation of the organization? Is the total incentive package reasonable under all the facts and circumstances, both in absolute total value for physician(s) recruited and in relation to services required by the hospital and the community? The proposed ruling also provides guidance on basic documentation requirements and a process for approving recruitment arrangements. PMID- 10154463 TI - School-based program promotes physical fitness. PMID- 10154464 TI - Subacute providers offer the flexibility managed care organizations seek. PMID- 10154465 TI - Pitfalls and problems in physician integration. PMID- 10154466 TI - New and emerging pathogens, Part 1. Threats from the water. PMID- 10154467 TI - Cross-training. Concepts, considerations, and challenges. PMID- 10154468 TI - Is POCT cost effective for coronary bypass patients in ICUs? PMID- 10154469 TI - Time to change medical technology education. PMID- 10154470 TI - Make high performance teams work for you. PMID- 10154471 TI - American Laundry Digest buyer's guide. PMID- 10154472 TI - Has support service management lost its luster? PMID- 10154473 TI - The evolutionary role of hospital leadership. PMID- 10154474 TI - Staffing analysis in a capitated environment: a case study. PMID- 10154475 TI - MSO's: a medical entity that endangers physicians and patients. PMID- 10154476 TI - 1995 buyer's guide. PMID- 10154477 TI - Florida's inpatient report card provides information to purchasers and consumers. PMID- 10154478 TI - Patient satisfaction surveys can improve your bottom line. PMID- 10154479 TI - Perspectives. Efficacy studies key to managed behavioral care. PMID- 10154480 TI - Perspectives. Road to integration leads to community health, too. PMID- 10154481 TI - Perspectives. Individual market: endangered habitat for indemnity insurance. PMID- 10154482 TI - Perspectives. Approval process a moving target in FDA reform hearings. PMID- 10154484 TI - Survival of the fittest: CIOs share their secrets. PMID- 10154485 TI - The CPR: an evaluative perspective. PMID- 10154483 TI - Perspectives. Ad hoc funding threatens rural health links. PMID- 10154486 TI - Cutting costs with automatic eligibility verification. PMID- 10154487 TI - 1996 EDI applications. Healthcare EDI & electronic commerce: just do it! PMID- 10154488 TI - Data repository: vision becomes reality. PMID- 10154489 TI - Hardware houses herald changes in '96. Roundtable discussion. PMID- 10154490 TI - America's most computer advanced healthcare facilities. PMID- 10154491 TI - Massachusetts General's amazing migration: mastering the maze. PMID- 10154492 TI - Defining levels of security. PMID- 10154493 TI - The Special Hospitals Service Authority. PMID- 10154494 TI - The cost of health and safety in the kitchen. PMID- 10154495 TI - CCTV: from patient treatment to patient protection. PMID- 10154496 TI - Risk management. PMID- 10154497 TI - Le nouveau respirators est arrivee! PMID- 10154498 TI - Laminar airflow hoods. PMID- 10154499 TI - Hospital telecommunications. PMID- 10154500 TI - Reengineering, rethinking, redesign: the three "R's" for Oregon Health Plan's success at Bay Area Hospital. PMID- 10154501 TI - Access managers--expand your thinking. PMID- 10154502 TI - Consumer education and industry marketing. Changes in the acute- and long-term settings. PMID- 10154503 TI - Win win win. Miscommunication miasma. PMID- 10154504 TI - Coaching maximizes reengineering success. PMID- 10154505 TI - Can hospitals thrive in the world of managed care? PMID- 10154506 TI - Healthcare reform--a world away. PMID- 10154507 TI - Accessing an understudied population in behavioral HIV/AIDS research: low income African American women. AB - Most HIV/AIDS behavior research involving African American women has focused on traditional high risk populations, such as those in drug treatment centers, STD clinics, and hospitals. Few studies have examined the health needs and behaviors of African American women in the general population (i.e., working mothers and homemakers). The Parent Health Project examined beliefs and concepts of illness, including AIDS, of low income African American mothers of young children. We used a variety of methods of community outreach and recruitment strategies to gain access and trust from these African American women, including (1) recruitment of women who had children in a related research project, (2) subject reimbursement, and (3) culturally sensitive community based outreach. Of approximately 200 women contacted, 147 (74%) agreed to participate in a two-hour face-to-face interview about concepts of health and illness. Through our efforts, we were able to gain access to a population generally not studies in HIV/AIDS research. We were also exposed to a number of issues, concerns and behaviors faced by women not classified as high risk, yet who are at risk as a result of their own and/or their sexual partner's(s) risk behaviors. PMID- 10154508 TI - American Indian uranium millworkers: a study of the perceived effects of occupational exposure. AB - A case study of 81 American Indian uranium millworkers who worked during the 1950s and 1960s was conducted to determine the perceived effects of occupational exposure from uranium mill processing. Many respondents reported health problems felt to be associated with the millwork. The most frequently identified physical problems were respiratory problems and rashes. Anxiety and depression were the most often identified emotional problems. Policy implications related to these findings are discussed. PMID- 10154509 TI - Nursing home waits for admission in an era of change. AB - Access by older persons to nursing home care is a major concern. Turmoil in the health care industry in the 1980s worsened access problems, including waits for admission, already severe at the start of the decade. This paper examines waits for nursing home admission, relating them to facility and market factors. PMID- 10154510 TI - Males' use of alcoholic beverages: a study of contexts. AB - This paper explores the efficacy of lifestyle and demographic profiles constructed from a large, national consumer database as explanatory variables for variations in alcoholic beverage consumption and related behavior by American males across three different usage contexts. The authors conclude that such predictors do serve to account for consumption variability, and that user profiles differ by consumption context. The findings may be useful to policymakers and others who wish to efficiently target their communications efforts. PMID- 10154511 TI - Effects of the mental illness label in 1993: acceptance and rejection in the community. AB - Effects of the mental illness label in obtaining community accommodation were examined, in a sample of 160 individuals advertising rooms or flats for rent in two Canadian cities, Windsor and London, Ontario, and in Detroit, Michigan. Telephone calls, for half the sample, made simple enquiries as to availability; for the other half, similar enquiries were made by an individual ostensibly receiving psychiatric treatment but soon to require accommodation. In the latter condition, rooms were significantly more likely to be described as unavailable. Comparisons are made to similar, previous research, and to current perspectives about community reactions to stigmatizing conditions. PMID- 10154512 TI - A comparison of concurrent general and HMO-affiliated medical practice experience. AB - This study was designed to differentiate the general practice perceptions of physicians who affiliate with an HMO and those not affiliated with an HMO as well as the "within physician" comparison of HMO practice experience relative to one's own general practice. A written survey was mailed to 1,000 members of the Florida Medical Association (FMA). A total of 372 physicians responded to the survey; 114 (31%) reported affiliation with an HMO. Based on a 5-point Likert-type scale, the rating of overall satisfaction with the general practice of medicine was good (mean=3.19). Perceptions of general practice did not differ substantially based on HMO-affiliation status. However, physicians reporting concurrent general and HMO-affiliated practice clearly distinguished these experiences. All aspects of medical practice, except paperwork, were rated consistently lower for HMO practice in comparison to general practice. PMID- 10154514 TI - Measuring the costs of quality. PMID- 10154513 TI - Principles of social systems structure and social interaction: an application to the health planning process. AB - The purpose of this article was to explore how applications of principles of social structure and social interaction may enhance health program planning. Theoretical aspects of social structure and social interaction and their relationships to planning were discussed. Potential problems in health planning as a result of not considering social system structure and interaction within a system were discussed. It was concluded that the health educator could benefit by applying principles of social structure and social interaction in health planning. Practical applications to the health planning process were postulated. PMID- 10154515 TI - Forecasting and its importance to health managers in the ever-changing health care industry. PMID- 10154516 TI - Robert Wood Johnson University Hospital makes a success of high-intensity care niche. PMID- 10154518 TI - Small steps. Health care reform is still possible. PMID- 10154517 TI - Managing survivor symptoms during and after layoffs, mergers, re-engineering initiatives. PMID- 10154519 TI - 48-days in northern California. PMID- 10154520 TI - Going to your doctor--at work. PMID- 10154521 TI - Medical records may become part of nationwide database. PMID- 10154522 TI - How voluntary benefits can enhance employee benefits. PMID- 10154523 TI - A report card for assessing corporate health. PMID- 10154524 TI - A behavior approach to benefits management. PMID- 10154526 TI - The energy behind voluntary purchasing alliances. PMID- 10154525 TI - The coming growth slowdown in the health care industry. PMID- 10154527 TI - Six keys to cost-effective health care. PMID- 10154528 TI - Have we really tried to solve the right problem? PMID- 10154529 TI - Transtelephonic cardiac monitoring. PMID- 10154530 TI - How managed care redefines quality in consumer terms. PMID- 10154531 TI - Measuring clinical performance to provide information for quality improvement. AB - Measures of clinical performance summarize quality of care given to groups of patients by a practice, provider network, or plan. Clinical managers can use these measures to drive and track internal quality improvements, and purchasers and accreditors can provide benchmarks based on comparisons of performance in order to stimulate internal improvements. This article explains desired properties of such clinical performance measures and the AHCPR Typology of Clinical Performance Measures Project. PMID- 10154532 TI - Forming a coronary services network on the basis of quality of care. AB - An Ohio insurance company's initiative to emphasize risk-adjusted clinical outcomes as criteria for selecting and reimbursing members of a network is stimulating a new emphasis on quality of care throughout the market area. Hospitals inside the network are cooperating to improve their collective results, while providers on the outside have launched major quality improvement programs in the effort to become measurably competitive with these centers of excellence. This case study in network selection demonstrates a new role for fiscal intermediaries in health care. PMID- 10154533 TI - Clinical decision support: managing quality in integrated delivery systems. AB - Delivery of health care services under financial risk requires clinical decision support to ensure good and improving quality at efficient costs. This article reports our first five years of experience in developing clinical decision support methods at the University of Pennsylvania and Care Management Science Corporation. PMID- 10154534 TI - The missing links in guideline implementation. AB - Practice guidelines or standards of quality are expected to be credible, valid, flexible, clear, and address the target population appropriately. Most, however, do not meet these criteria. Guidelines and standards of quality need to be written with indicators to measure compliance. If inadequate, compliance can be improved by devising implementation methods. PMID- 10154535 TI - Coordinating initiatives in critical pathways and information systems. AB - Health care providers have begun to use critical pathways and order sets to standardize clinical care in order to improve clinical resource management. This article describes ways that critical pathways and order sets can be developed and implemented in a coordinated manner. This approach allows for a process that facilitates automation of critical pathways variance analysis and continuous feedback to clinicians. PMID- 10154536 TI - The Quality Cup winner: Fletcher Allen Health Care's early extubation team. AB - Many organizations are looking for ways to reduce the cost and improve the quality of open-heart surgery. Fletcher Allen Health Care in Burlington, Vermont used a total quality management approach to do just that. The result was a dramatic improvement in outcomes. Fletcher Allen won the 1994 USA Today Quality Cup for its efforts. PMID- 10154537 TI - Using patient feedback for quality improvement. AB - This article describes the results of a study designed to understand h how health care organizations use patient feedback. The article examines the organizational factors and the barriers that influence patient feedback use and concludes with propositions that can serve to guide future action and research in this area. PMID- 10154538 TI - Transforming paradigms for provider information systems. AB - Developments in health care information systems are being driven by the changing health care market environment as well as the availability of enhanced communication and computer technologies. These developments represent basic shifts in traditional paradigms on which provider information systems are based. The ultimate success of providers will depend on their making fundamental changes in the use of information systems to support new and evolving incentive systems, organizational structures, and market expectations. PMID- 10154539 TI - Physician practice in a dynamic environment: implications for the health care system. PMID- 10154540 TI - Financing health care risk. PMID- 10154542 TI - 1996 annual market directory issue. PMID- 10154541 TI - The relationship between social support and health status of elderly people: does social support slow down physical and functional deterioration? PMID- 10154543 TI - The Emergency Medical Treatment and Active Labor Act of 1986: providing protection from discrimination in access to emergency medical care. PMID- 10154544 TI - Bureau of Program Operations, statement of organization, functions, and delegations of authority--HCFA. PMID- 10154545 TI - Collection from third party payers of reasonable costs of healthcare services- DoD. Final rule. AB - This final rule establishes a new rule under the Third Party Collection program for determining the reasonable costs of health care services provided by facilities of the uniformed services in cases in which care is provided under TRICARE Resource Sharing Agreements. For purposes of the Third Party Collection program such services will be treated the same as other services provided by facilities of the uniformed services. The final rule also lowers the high cost ancillary threshold value from $60 to $25 per 24-hour day for patients that come to the uniformed services facility for ancillary services requested by a source other than a uniformed services facility. The reasonable costs of such services will be accumulated on a daily basis. The Department of Defense is now implementing TRICARE, a major structural reform of the military health care system, featuring adoption of managed care practices in military hospitals and by special civilian contract provider networks. Consistent with TRICARE, as part of the Third Party Collection Program, DoD is transitioning to a billing and collection system in which all costs borne by DoD Medical Treatment Facilities (MTFs) will be billed by the MTF providing the care. Thus, all care performed within the facility, plus an added amount for supplemental care purchased by the facility, will be billed by the MTF. Conversely, care provided outside the MTF under other arrangements will be billed by the provider of that care. PMID- 10154546 TI - Newtral actions. PMID- 10154547 TI - Up against ERISA. AB - In the absence of national health care reform, many states are eager to press forward with their own reforms. But there's a stumbling block: the 1974 Employee Retirement Income Security Act, which bars states from taxing and regulating many health plans. And the business lobby promises to fight efforts to weaken the law. PMID- 10154548 TI - High-tech house calls. AB - Think of telemedicine as a stethoscope that electronically links doctors and patients. But before the long-distance diagnosis becomes reality, telemedicine must overcome legal, financing and regulatory obstacles. PMID- 10154549 TI - Managed care's driving force: demand management. PMID- 10154550 TI - What are the benefits & drawbacks to electronic eligibility verification? PMID- 10154551 TI - Managed care: where's the magic? PMID- 10154552 TI - Arkansas experience: between the government & the private sector. AB - Officials in many communities, states and regions are trying to establish networks to electronically exchange administrative and clinical data. Today, however, few examples of truly operational healthcare information networks (HINs) exist. Because of governance, control and cost, efforts toward integrating clinical information have not progressed. These issues are most apparent in the struggle to establish community health information networks (CHINs). PMID- 10154553 TI - Using electronic provider credentialing to address the quality revolution. AB - In recent years, provider credentialing has emerged as a quality initi ative for managed care organizations (MCOs). To satisfy the quality concerns of insurers, purchasers and patients, network officials are seeking industry accreditation, which requires credentialing. But while many organizations are conducting credentialing, it can be an underutilized and misunderstood resource. Credentialing is not an end in itself; it is the first step in building a quality management system. Used in this context, credentialing confers enormous advantages that go far beyond basic background checks. PMID- 10154554 TI - Information management & healthcare reform: the role of collaborative computing & videoconferencing. PMID- 10154555 TI - Compensation in a restructured environment. Part II: The past, present, and future of reward systems. AB - The participants in the HR Consortium walked away satisfied that they had left "no stones unturned" in their efforts to create new compensation approaches. The major takeaway was that there is no ready panacea. The creation of an effective compensation system will be the development of an approach that does not serve as an obstacle to staff and managers in their efforts to build a hospital system that services customers in a restructured setting; rather it shadows and supports these operational changes. PMID- 10154556 TI - Restructuring critical care services. Critical care--a patient-friendly place? PMID- 10154557 TI - Healthcare combinations. Part II: Consummating the merger. AB - As a starting point, the initiatives outlined above provide a combination strategy to build a solid operating platform for the combined entity. Every organization will take this list and define which areas it believes are critical to its merger success. That means boring deeply into some initiatives and lightly touching others. But, it will be a rare organization that does not need to pursue some of these items. These initiatives may prove to be the ante for healthcare in the years to come; the structural starting point on the path to the next round of healthcare breakthroughs. PMID- 10154558 TI - Restructuring in a unionized environment. Selecting the right approach for union involvement. AB - Restructuring in a unionized environment doesn't have to be a nightmare. You must assess your current environment to be able to make smart strategic choices. Your strategic choices will lead you to an appropriate union involvement approach and guide you through the dozens of detailed design and implementation issues. However, don't worry so much about them being smart choices that you make no choices. When it comes to restructuring with unions, no plan is the worst plan. PMID- 10154559 TI - Hospital choice models: a review and assessment of their utility for policy impact analysis. PMID- 10154560 TI - HMO use of diagnostic tests: a review of the evidence. PMID- 10154561 TI - Medical practice profiling: concepts and caveats. PMID- 10154562 TI - Geographic variations in physician service utilization. PMID- 10154563 TI - A descriptive economic analysis of HMO mergers and failures, 1985-1992. PMID- 10154565 TI - A guide to health data terms. PMID- 10154564 TI - Health care automation companies. PMID- 10154566 TI - Issuing CIOs a wake-up call. Interview by Howard J. Anderson. PMID- 10154567 TI - Provider automation. Making every dime count. PMID- 10154568 TI - Stanford's technology game plan. PMID- 10154569 TI - Managed care. Automation strategies for a new market. PMID- 10154570 TI - Employers' cost-cutting team spawns a network. PMID- 10154571 TI - Standards. Trading clinical data. PMID- 10154572 TI - Critical care pathways: the basics of development and implementation. PMID- 10154573 TI - From perils to partnerships: health care into the 21st century. PMID- 10154575 TI - Restructuring. Hospitals must track link between changes, outcomes. PMID- 10154574 TI - Discharge planning: Medicare conditions of participation. PMID- 10154576 TI - Hospital service areas don't conform to political boundaries. PMID- 10154577 TI - Paths provide a common ground for better practice--a team approach. PMID- 10154578 TI - Merger gives CMs righter focus, network resources--expands role beyond the hospital walls. PMID- 10154579 TI - CHF (congestive heart failure) path begins in ED, saves hospital $1,000 per patient. PMID- 10154580 TI - NJ hospital gives internal merger second chance. Case management functions streamlined. PMID- 10154581 TI - Rethinking an old notion. HMO restructures case management model. PMID- 10154582 TI - Specialty facilities face challenges. PMID- 10154583 TI - Communicating with physicians a priority at Nashville facility. PMID- 10154584 TI - St. Louis shares risk with the Blues. PMID- 10154585 TI - Jacksonville market on fire. PMID- 10154586 TI - Governance and resource allocation top the list of murky IDS planning issues. PMID- 10154587 TI - Recruiting physicians into a managed care environment. PMID- 10154588 TI - All the President's medics. A behind-the-scenes look at the White House Medical Unit. PMID- 10154589 TI - Tactical EMS. PMID- 10154590 TI - Sultans of SWAT. PMID- 10154591 TI - The Chinese challenge. PMID- 10154592 TI - Subway assault. PMID- 10154593 TI - With a new Congress, what's in store for health-care reform? PMID- 10154594 TI - Cutting hospital ES (environmental services) costs with standardization. PMID- 10154595 TI - Planning for safety and security in a healthcare facility. PMID- 10154596 TI - Tuberculosis--what can you do for protection? PMID- 10154597 TI - Candid talk about TB and infection control. PMID- 10154598 TI - Saint John's Hospital: a phoenix rises from the ashes. PMID- 10154599 TI - Case statement: sell the benefits. PMID- 10154600 TI - What you should know about executive search firms. PMID- 10154601 TI - The case statement: the first foot forward. PMID- 10154602 TI - Where companies rank in their own industries. PMID- 10154603 TI - Special report on corporate/finance. Effectively negotiating integrated information system contracts: common issues and practical approaches (Part I). PMID- 10154604 TI - New antitrust enforcement policy statements issued for health care providers. PMID- 10154605 TI - Recovering Medicaid/Medicare costs from tobacco companies. PMID- 10154607 TI - Using robots for security and safety patrolling: a progress report. PMID- 10154606 TI - The quality improvement customers didn't want. AB - Is investing in new technology always the right choice for a company and its customers? Allan Moulter, the CEO of Quality Care, isn't sure he wants to invest in the computerized reception system that consultant Jack Zadow has outlined for him. But in this HBR case study, the argument Zadow makes is impossible to ignore. Quality Care's rivals have invested in similar systems or are planning to do so. The new system promises to take care of routine busywork, freeing staff up for other interactions with patients. It seems as if the competition hasn't even cut staff and is counting on increased customer retention to pay for the investment. And yet, Quality Care's surveys of its own customers show that they prefer the human touch when checking in. How would customers feel if the first ?person? they met when they came in the door turned out to be a machine? Moulter prides himself on his responsiveness to customers. And with 86% of Quality Care's customers either satisfied or completely satisfied, aren't things fine as they are? Has Moulter considered all the facets of his predicament? How will Quality Care's staff be affected by a decision one way or another? What about the costs of upgrading the system? Can Quality Care maintain its standing without going high-tech? Would customers rebel when confronted with the proposed reception area or would they appreciate the increased efficiency? Six experts weigh the costs and benefits of technology in a service industry. PMID- 10154608 TI - New M.S. degree in protection management covers both fire and security. PMID- 10154609 TI - Screening hospital personnel for security. PMID- 10154610 TI - Hospital theft on a large scale: what can be done to spot problems before huge assets are put at risk. AB - When a hospital's top executives engage in fraud, theft, and embezzlement, it can be one of the most unobtrusive and damaging crimes a health care institution can face. While, in the past, even incidents involving millions of dollars were covered up and often went unprosecuted, today the U.S. Attorney General is pursuing such crimes more vigorously because of the federal funds that can be involved. In this report, those involved in investigating and prosecuting executive-level fraud cases offer advice on what to watch for and how to protect your facility against these financially damaging crimes. PMID- 10154611 TI - Cost-effective care. PMID- 10154612 TI - The year ahead ... and a happy new year. What do people in healthcare hope and fear 1996 will bring? PMID- 10154613 TI - Eastern Europe. A winter's tale. PMID- 10154614 TI - Job swap. Me and my shadow. PMID- 10154615 TI - National Sound Archive. Sound proof. PMID- 10154616 TI - Training and development. University challenge. PMID- 10154617 TI - Predicting the degree of rurality of physician assistant practice location. AB - This study used a block multiple regression analysis to examine the impacts of different factors on the degree of rurality of physician assistants' (PAs') practice location and compared the power of each block of factors in predicting rurality. Differences in the models for PAs in primary care specialties and for PAs as a whole were also explored. The findings suggest that policies should provide support to PA students in primary care specialties and to rural-oriented PA education/training programs. Efforts to facilitate PA recruitment and retention should include, among other things, increasing practice responsibility/autonomy, broadening acceptance of PA prescriptive authority, and providing equitable reimbursement for nonphysician care of Medicare and Medicaid beneficiaries. PMID- 10154618 TI - Contemporary models of change in the health professions. AB - This article reviews the special position that health professionals have occupied and the ways in which changes threaten the foundations of professional work. The application of modern management principles to health care runs the risk of overriding the "action orientation" that is a defining component of professional work. One goal of health workforce design should be the engineering of opportunities for the preservation of "professional voice" as a countervailing force to ensure high quality health care. Contemporary models of change applied to health care workforce include: (1) the system of professions models in which securing and maintaining jurisdiction are the mechanisms that professions employ to sustain their position, (2) a strategic adaptation model by which professions attempt to adjust to changing environments, (3) a model of redesigning patient care which applies Total Quality Management (TQM) and other "industrial techniques" to the health care workplace, and, (4) model of "consumer sovereignty" in which groups of citizens come together to determine the nature of care services and professional work, with the participation of the organizations and providers. PMID- 10154619 TI - Reengineering the work of caregivers: role redefinition, team structures, and organizational redesign. AB - Health care organizations are implementing new patient care delivery models with the expectation that operations reengineering will bring dramatic improvements in cost, quality, and patient satisfaction. Together with the fundamental redefinition of caregivers' work roles, the adoption of reengineering principles features the organization of work activities around team structures such that teams are considered the basic unit of work performance. This article draws from reengineering case studies to consider how hospitals are operationalizing team care concepts at the patient care unit level. Using a classification of caregiver work that distinguishes care production and care management tasks, evolving care team models are discussed through a conceptual framework that defines a continuum of team delivery strategies. The team models are illustrated by brief case examples. PMID- 10154620 TI - Business as usual? Changes in health care's workforce and organization of work. AB - Major changes are occurring in the health care workforce and organization of work. Such changes include, for example, a shift in workforce composition from specialists to generalists in medical care, as well as a shift from autonomous work performance to work performed in teams. This article provides a survey of such major changes. It identifies patterns of change and examines their causes. Further, we raise questions about the implications of these changes for practice and research in the health care field. PMID- 10154621 TI - The effects of treatment team diversity and size on assessments of team functioning. AB - Team-based health care assumes that groups representing multiple disciplines can work together to implement care plans that are comprehensive and integrated. It also assumes that professionals can function effectively in an interdependent relationship with members of other occupational groups. However, we know little about what makes effective team functioning. This article examines the factors related to health care team functioning, with specific emphasis on team demographic composition and size. Hierarchical linear modeling is used to analyze 106 Veterans Affairs (VA) hospitals. Results indicate that individuals who operate on more heterogenous and larger teams have lower perceptions of team functioning. PMID- 10154622 TI - The role and impact of multiskilled health practitioners in the health services industry. AB - The utilization of multiskilled health practitioners (MSHPs) is one method of enhancing employee productivity and cost effectiveness of health services delivery. This article reviews the trend toward increasing specialization of health personnel in this century as well as its limitations and the potential of the MSHP to enhance productivity. Then research on factors that inhibit or facilitate adoption of the concept, the effectiveness of the concept, and implementation strategies that impact effectiveness are presented. The article concludes with guidelines and future challenges for health care executives, public policymakers, and researchers as regards implementation of the multiskilled concept. PMID- 10154624 TI - Managing diversity: a senior management perspective. AB - Diversity and managing diverse workgroups have become strategic imperatives for many organizations. Corporations are developing programs and opportunities to increase the participation of their employees, especially those who have not been previously included in the mainstream of their organizations. Many health care institutions are also focusing on diversity management. This study was designed to examine the manner in which diversity management is perceived and implemented by hospital executives. To determine the perception of executives, a 16-item questionnaire was developed and distributed to hospital executives. The data showed that executives in urban teaching hospitals considered their workforce diverse, and many of these organizations had implemented diversity management programs in their facilities. Surprisingly, this study found that although most executives (68 percent) agreed they had a diverse workforce, less than one-third (30 percent) of these executives had specifically developed diversity management programs in their hospitals. PMID- 10154623 TI - Human resource departments and hospital labor strategies. AB - Recently hospitals have increased their use of external labor sources, contracting many traditional functions such as pharmacy and emergency to outside labor providers. Use of external labor sources often means that traditional human resource functions such as screening, hiring, and training are performed by the external labor provider, potentially reducing the value of the HR function. Using financial and staffing data gathered by the California Statewide Health Planning and Development Office during the period 1976 to 1989, this study explores the relationship between the size of HR functions and the utilization of contingent labor. PMID- 10154625 TI - Clinical engineering in South Africa. PMID- 10154626 TI - Problems, perils, precautions and rewards in overseas clinical engineering training. PMID- 10154627 TI - Use of an in-house-built ribavirin aerosol evacuation system to control incidental employee exposure to ribavirin aerosol. AB - Ongoing controversy regarding the hazards of exposure of healthcare workers to ribavirin aerosol led to the design and evaluation of a ribavirin aerosol evacuation system that scavenges the excess ribavirin. An oxyhood was placed within a croupette oxygen and cool mist tent. The tent was placed under negative pressure, using the hospital wall suction. Air samples were taken to determine ambient air concentrations and patient exposure concentrations and were compared to airborne ribavirin concentrations that occurred during administration of ribavirin without an evacuation system. The ribavirin evacuation system reduced ribavirin ambient air concentrations from 54 ug/m3 (mean) to 11 ug/m3 (mean) without reducing patient exposure concentrations. The results suggest that the system evaluated is an efficient and inexpensive means of reducing incidental employee exposure to ribavirin aerosol. PMID- 10154628 TI - Contract management using cause-effect clues in service worksheets. AB - Sophisticated equipment often needs intensive technical resources to maintain its system availability. Service contracts can be an easy channel to outside technical resources. Usually, a service contract purchaser only sees its cost instead of its maintenance quality. A system's needs, however, depend on the trade-off between the cost paid and the quality received. If a clinical engineer can actively interpret and integrate the cause-effect consequences on the compiled service worksheets, those clues can serve as a criterion to justify the quality and the cost-effectiveness of a service contract. Through the analysis of the service labor consumed, the justification of the parts replaced, and the assessment of the "fit" to system availability, this paper provides a cost effective tool for equipment management. PMID- 10154629 TI - Magnetic resonance imaging: a bright future despite health care's cost-conscious environment. PMID- 10154630 TI - Planning and partnering for healthier communities. PMID- 10154631 TI - Demarketing of health services. PMID- 10154632 TI - Inequality in health insurance reform: are the elderly more at risk? PMID- 10154633 TI - Implementing the patient circle. Call on patients to help improve perceptions of health care quality. AB - Adapting the quality-circle concept to a health care setting helped one hospital solve a problem and boosted its image among patients. The "patient circle" technique is one step health care providers can take toward delivering "total customer value," a quality perception that can mean the difference between surviving and thriving in the future. PMID- 10154634 TI - Auditing the health care enterprise. Evaluation research can improve strategic planning and implementation in hospitals. AB - Financial audits that focus on the recent past have been criticized for not answering questions concerning whether or not the enterprise will survive and thrive during the next few years. Strategic management/marketing audits (SMMAs) are designed to respond to these concerns. In conducting an SMMA for a long-term care hospital, the authors found critical differences in the beliefs held by key executives and staff members regarding the strategic goals, planning, and actions of the hospital. PMID- 10154635 TI - Root canals and retailing. When it comes to merchandising activities in a dental office, dentists are their own worst critics. AB - As professional service providers continue to face an increasingly competitive environment, marketing becomes a more attractive prospect. One marketing activity that has emerged in recent years is the retailing of products related to one's profession directly from the office. The authors explore the retailing phenomenon from the perspective of dentists and dental patients and find that patients are less critical of the practice than dentists are themselves. PMID- 10154636 TI - Relationship marketing in health care. AB - Building relationships with patients is critical to the success of many health care organizations. The authors profile the relationship marketing program for a hospital's cardiac center and discuss the key strategic aspects that account for its success: a focus on a specific hospital service, an integrated marketing communication strategy, a specially designed database, and the continuous tracking of results. PMID- 10154637 TI - Patient loyalty to physicians. PMID- 10154638 TI - Marketing on the Internet. Innovative providers educate, inform, and communicate through cyberspace. PMID- 10154639 TI - Mediators vs. moderators of patient satisfaction. PMID- 10154640 TI - Quality, sacrifice, and value in hospital choice. PMID- 10154641 TI - Should marketers care about satisfying Medicaid patients? PMID- 10154642 TI - Market orientation and performance in the hospital industry. PMID- 10154643 TI - Diagnosing perceived quality in the medical service channel. PMID- 10154644 TI - Cultivating loyal patients. PMID- 10154645 TI - Strategic marketing and communications audits. PMID- 10154646 TI - Remarketing, yes, remarketing health care. PMID- 10154647 TI - Can prevention be marketed profitably? PMID- 10154648 TI - Strategic planning. PMID- 10154649 TI - Lights, sirens and liability. PMID- 10154650 TI - Resuscitating CPR. Looking at the basics and adjuncts. PMID- 10154651 TI - Obtaining a valid AMA (Against Medical Advice). PMID- 10154652 TI - Lost without a trace? PMID- 10154653 TI - Patient positioning. Laying out the options. PMID- 10154654 TI - The demand for alcohol: the differential response to price. AB - Although several studies indicate that drinking is responsive to price, little work has focused on whether prices have a differential effect on light, moderate, or heavy drinking. This study examines the price responsiveness of the demand for alcohol: whether heavy drinkers are less sensitive to price than light or moderate drinkers. The study uses data on alcohol consumption on the 1983 National Health Interview Survey. The results indicate that both light and heavy drinkers are much less price elastic than moderate drinkers. Further, we cannot reject the hypothesis that the very heaviest drinkers have perfectly price inelastic demands. PMID- 10154655 TI - Consumer information surplus and adverse selection in competitive health insurance markets: an empirical study. AB - If premiums for health insurance are not risk related, there exists a consumer information surplus that may result in adverse selection. Our results indicate that insurers can greatly reduce this surplus by risk-adjusting the premium. We conclude that there need not be any substantial unavoidable consumer information surplus if consumers can choose whether to take a deductible for a one- or two year health insurance contract with otherwise identical benefits. Therefore, adverse selection need not be a problem in a competitive insurance market with risk-adjusted premiums or vouchers and with such a consumer choice of health plan. PMID- 10154656 TI - The friction cost method for measuring indirect costs of disease. AB - A new approach for estimating the indirect costs of disease, which explicitly considers economic circumstances that limit production losses due to disease, is presented (the friction cost method). For the Netherlands the short-term friction costs in 1990 amount to 1.5-2.5% of net national income (NNI), depending on the extent to which short-term absence from work induces production loss and costs. The medium-term macro-economic consequences of absence from work and disability reduce NNI by an additional 0.8%. These estimates are considerably lower than estimates based on the traditional human capital approach, but they better reflect the economic impact of illness. PMID- 10154657 TI - Choosing between public and private health-care: a case study of malaria treatment in Brazil. AB - Individuals infected with malaria may be treated either in the public sector in in a private clinic. Private treatment is better, but expensive. Using micro level data from a colonization project in Brazil, we estimate the factors that determine an individual's choice between the two sectors. Private treatment is (strongly) price sensitive and (weakly) wealth sensitive. Rural individuals are more likely to choose private treatment, but long distances to the treatment source deter private treatment. Individuals belonging to small, literate households are more likely to choose private treatment. Gender, age, and number of previous infections are unimportant. Policy implications are discussed. PMID- 10154658 TI - Supplier inducement in a public health care system. AB - The present paper examines whether supplier inducement exists for primary physicians' services in Norway. Our model assumes optimization behavior of the physician. The research design is adapted to the institutional setting of Norwegian primary physician services, where there is a fixed fee schedule. According to our model, the physician has three choices: to rational services, to supply an optimal amount of services, or to induce demand for services. The analyses revealed no indication of inducement with respect to physician-initiated visits. However, supplier inducement effects were found for provision of laboratory tests. PMID- 10154659 TI - A model of demand for effective care. PMID- 10154660 TI - A problem with consumer surplus measures of the cost of practice variations. AB - Estimates of the surplus loss due to physician practice variation measure the area under the 'shifted' demand curve. This method is valid only if the unshifted demand curve is derived form the distribution of true(ex post) values of care. If the unshifted demand curve does not reflect the true value of care, then the traditional methods of measuring surplus loss can be seriously biased. PMID- 10154661 TI - Welfare loss from variations: further considerations. PMID- 10154662 TI - Has there been a failure to prepare and support parish-based clergy in their role as frontline community mental health workers: a review. AB - Addresses the issue that parish-based clergy, functioning as frontline community mental health workers, often do so with inadequate training and limited support from the mental health community. Claims that although a clergyperson is as likely to have a severely mentally distressed person seek her or his assistance as is a mental health specialist, there is inadequate research on the function of clergy in the mental health network or the psychological dynamics of religion. Suggests that clergy can serve most effectively in the mental health network as skilled facilitators, identifying the needs of persons, and connecting them to a larger circle of specialized helpers. Argues that the mental health and religious communities share many common values and goals and need to work together more effectively for the best interest of those they are called to serve. PMID- 10154663 TI - New insights on the emotional response of cancer patients and their spouses: where do they find help? AB - Reports the results of a questionnaire survey designed to discover relationships of the emotional responses of cancer patients and their spouses to variables of age, gender, and church attendance. Claims that contemporary high-tech health care developments tend toward a process of despiritualization, and that one-on one spiritual relationships seldom occur with physicians, nurses, or pastors. Notes that pastors need to assume a greater role as spiritual leaders, encouraging all members of the health care team to contribute to healing the whole person. PMID- 10154664 TI - The quagmire of HIV/AIDS related issues which haunt the Church. AB - Identifies and explores the extreme difficulties of HIV/AIDS realities for the evangelical Christian churches and which tend to stymie effective ministry. Discusses the issues of morality, morbidity, mortality, reality, responsibility; and concludes that the church has fallen short in its mission to HIV/AIDS persons. Claims that this shortfall has created an integrity question in the minds of those whose lives have been touched by this contemporary health crisis. PMID- 10154665 TI - Variables that predict interest in and the completion of living wills. AB - Observes that although chaplains and congregational pastors frequently advocate the completion of advance directives, including living wills, the research reports that only 5 to 15% of the general population have completed the instrument. Asks, Why have so few completed it? Reports on research which suggests that age is the only statistical predictor of whether a person possesses a completed living will when measured against social and personality variables, including levels of social support, fear of dying, religiousity, self-esteem, and trust in physicians. Concludes that it is likely that age is a proxy variable which represents changes in attitudes, beliefs, and thoughts which tend to occur as persons grow older. PMID- 10154666 TI - Congress to the states: take Medicaid. Please! PMID- 10154667 TI - Can a patient have too many doctors? PMID- 10154668 TI - Hiring a billing service that won't be a headache. PMID- 10154670 TI - Turn patient complaints into patient pleasers. PMID- 10154669 TI - Malpractice lawyers' new target. PMID- 10154671 TI - How not to launch health reform. PMID- 10154672 TI - Selling your practice to a hospital? Watch out! PMID- 10154673 TI - Wake up, guys! Women doctors are here to stay. PMID- 10154674 TI - Have doctors lost their work ethic? PMID- 10154675 TI - Managed care needn't come between you and your patients. PMID- 10154676 TI - Why you get those UR denials. PMID- 10154677 TI - Where doctors get sued the most. PMID- 10154678 TI - The new quality standards: how well will you measure up? PMID- 10154679 TI - Now I know why some patients sue. PMID- 10154680 TI - Dr. Smith goes to sexual-rehab school. PMID- 10154681 TI - How PHOs pick their doctors. PMID- 10154682 TI - How I got Medicare to apologize. PMID- 10154683 TI - Malpractice. Doctors' six fatal mistakes. PMID- 10154684 TI - How one health plan gets doctors to improve. PMID- 10154685 TI - When you must give a baby's parents terrible news. PMID- 10154686 TI - Shun managed care? These doctors do. PMID- 10154687 TI - Employment contracts: look carefully before you leap. PMID- 10154688 TI - Where will the fight over Medicare lead? PMID- 10154689 TI - Specialists are getting a bum rap. PMID- 10154690 TI - Did an HMO doctor's greed kill Joyce Ching? PMID- 10154691 TI - How doing nothing got this doctor charged with a crime. PMID- 10154692 TI - Are you prepared for these new ethical dilemmas? PMID- 10154693 TI - Are more college graduates really taking 'high school' jobs? PMID- 10154694 TI - Earnings of college graduates, 1993. PMID- 10154695 TI - Trends in out-of-pocket spending on health care, 1980-92. PMID- 10154696 TI - Shaking the foundation. Accounting change could fatten hospital assets at the expense of their foundations. PMID- 10154697 TI - Tales of JCAHO reform from a converted critic. PMID- 10154698 TI - Big employers lean toward local HMOs. PMID- 10154699 TI - Payers start to worry about impact of HMOs' bad press. PMID- 10154700 TI - Chicago hospital invests in minorities. PMID- 10154701 TI - Hospital counts on specialist to control equipment costs. PMID- 10154702 TI - Info systems firms post revenue gains. PMID- 10154703 TI - Baxter reports 9% rise in '95 profits. PMID- 10154704 TI - Kaiser to restructure inpatient services in California regions. PMID- 10154705 TI - S&P reviews two Michigan hospitals. PMID- 10154706 TI - Two NLRB rulings define 'supervisor'. PMID- 10154707 TI - N.Y. governor proposes giving counties Medicaid block grants. PMID- 10154708 TI - Bill bases payment for ER care on symptoms. PMID- 10154709 TI - Texas hospital, docs end legal battle. PMID- 10154710 TI - Congressional leaders inch toward Medicare reform. PMID- 10154711 TI - Lawmakers show compromise is possible. Governors unanimously OK Medicaid reform policy. PMID- 10154712 TI - New network a first for Connecticut. PMID- 10154713 TI - Disagreement ends Peoria network. PMID- 10154714 TI - 29% of rural hospitals have telemedicine plans. PMID- 10154715 TI - Spurned La. bid is new sign some are wary of Columbia. PMID- 10154716 TI - Clinton urged to back Medicare MSA plans. PMID- 10154717 TI - Experts question impact of Grace spinoff. PMID- 10154718 TI - N.C. hospitals' link gets first state antitrust inoculation. PMID- 10154719 TI - U.S. Healthcare addresses 'gag' issue. PMID- 10154720 TI - Hasan: basic differences killed HSI-WellPoint deal. PMID- 10154721 TI - Wayne General in merger talks with large N.J. system. PMID- 10154722 TI - Ill. system, Blues sign deal to buy clinic. PMID- 10154723 TI - CHS exec launches hospital firm. PMID- 10154724 TI - Private med schools in Pa. to lose millions under governor's plan. PMID- 10154725 TI - IOM study shows jump in nurses' wages. PMID- 10154726 TI - Kaiser labor deal rewards nurses if plan meets goals. PMID- 10154727 TI - Maine hospitals' antitrust deal OKs joint contracting. PMID- 10154728 TI - CHA, VHA collaborate on software. PMID- 10154730 TI - Ohio program targets uninsured kids. PMID- 10154729 TI - Tenn. alliance seeks law requiring reports on community benefits. PMID- 10154731 TI - Columbia holds fire during talks in S.C. PMID- 10154732 TI - APS moves ahead on Express Scripts deal. PMID- 10154733 TI - Insurance reform plan no longer held hostage. PMID- 10154735 TI - CIOs ring in HIMSS with CHIME. PMID- 10154734 TI - Moody's: expect more downgrades. PMID- 10154736 TI - Boeing lands on Kan. hospital in bid to trim healthcare costs. PMID- 10154737 TI - Fla. hospital ownership fight set for trial. PMID- 10154738 TI - Md. plans to expand Medicaid managed care. PMID- 10154739 TI - Presidential hopefuls pump up flat-tax debate. PMID- 10154740 TI - FTC, Justice antitrust policies right on target. PMID- 10154741 TI - How much? Price is becoming a contentious issue in sales of not-for-profit hospitals, as communities seek fair value and challenge secrecy. AB - When a tax-exempt hospital is sold, board members may wax eloquently about the synergies, mission and vision of the deal. But how much the facility sells for is becoming the key issue in many communities where tax-exempts have been purchased by investor-owned companies. PMID- 10154742 TI - Docs question new Medicare billing rule. PMID- 10154743 TI - Kaiser ads: we're not like other HMOs. PMID- 10154744 TI - Kaiser physicians unhappy with changes, memo shows. PMID- 10154745 TI - Busted merger with WellPoint cost HSI $20.2 million. PMID- 10154746 TI - S.C. deal continues consolidation wave. PMID- 10154747 TI - Suit seeks to void Mayo hospital deal. PMID- 10154748 TI - Columbia's S.C. deal will cost it more than $1 billion. PMID- 10154749 TI - CON law sparks battle between institutions. PMID- 10154750 TI - Columbia's latest venture: teaming with insurance concerns. PMID- 10154751 TI - Federal antitrust probe targets Columbia-affiliated PHO. PMID- 10154752 TI - Minn. pilot program's goal to reform long-term care. PMID- 10154753 TI - Grant to fund NCQA study on chronic care. PMID- 10154755 TI - PROs aren't catching bad providers, audit says. PMID- 10154756 TI - The SEIU: a partner for change in U.S. healthcare. PMID- 10154754 TI - Governors' proposal urges coverage for poor elderly. PMID- 10154757 TI - Promises, promises. Hospitals are using price-control pledges to win antitrust clearance from states, but the feds are wary. AB - The wariness of the Federal Trade Commission hasn't stopped a number of hospitals from trying, particularly at the state level, to get antitrust clearance for their high-marketshare mergers. Pledges to freeze or limit prices have become the antitrust strategy du jour. PMID- 10154758 TI - Congressional hearing explores Medicare fraud. PMID- 10154759 TI - Chronic-care consortium develops 'living tool' to help integrate services. PMID- 10154760 TI - Survey: doc practice buys don't boost pay. PMID- 10154761 TI - 'Maturation' of senior housing boosts outlook for financing. PMID- 10154762 TI - 26 states seek antitrust ruling. PMID- 10154763 TI - Provider groups say governors' plan would trim payments. PMID- 10154764 TI - The Blue Dogs won't bite on reform plan. PMID- 10154765 TI - Tampa hospital discussing partnership with Columbia. PMID- 10154766 TI - FDA issues new rule on medical device reporting. PMID- 10154767 TI - High-tech design borrows from B-2 bomber. PMID- 10154768 TI - Pushing costs down with inventory control. PMID- 10154769 TI - For-profits make up third of new top 100 hospitals list. PMID- 10154770 TI - Searching for the data you need online. PMID- 10154771 TI - Survey tracks pathway use. PMID- 10154772 TI - Exploring patient account processing alternatives. PMID- 10154773 TI - Breaking away. AB - While life as hospital employees was comfortable, the lure of independence won out for these two emergency department physicians. Breaking away to develop a new company was not easy, but it's paid off for the entrepreneurs of the Capital Region Emergency Medicine, P.C. Developing an emergency medicine business meant learning all aspects of business: billing services, evaluating legal services, raising capital, and becoming employers. The advantage has been an ability to use profits to improve the moral of staff, an increase in salary, and an overall sense of satisfaction. PMID- 10154774 TI - The hidden competitive weapon supporting innovation in health care. AB - It is trite to say health care is experiencing an era of unprecedented change. However, with the preoccupation with reimbursement and economic reform, it is easy to focus on this single dimension and lose sight of the pervasiveness of the need for continuous change throughout the entire health care organization. Health care organizations that will emerge as leaders within the industry will have incorporated not only radical changes to deal with new patterns of reimbursement, but also simultaneous changes in core medical services--changes that not only incorporate new technology, but also push down costs. They will also have to cope with radical changes in information and quality systems. Physical facilities will look less like citadels, and new flexible architectures will emerge. Coping with transportation logistics and remote site service provision will be part of the new industry. Patients will become full partners in ?health,? requiring very different approaches to patient education and involvement in prevention, not simply treatment. Indeed, without belaboring the almost endless list, it is impossible to think of a single dimension of health care that will be untouched. PMID- 10154775 TI - Informatics for the transition from managed care to organized care. PMID- 10154776 TI - The basic rules of questions and answers. AB - Our world is full of basic rules. And life is loaded with questions. The physician executive's life is certainly governed by both items. With a mountain of information, separation of fact from nonfact involves methodical processing. The physician executive must spend vast amounts of time in the pursuit of factual, pertinent information. Equally time-consuming is the application and dissemination of this information. This article offers a physiologic model for understanding the acquisition and dissemination of information and applies the model to the specifics of handling questions from a broad range of people- subordinates, superiors, constituents, customers, etc. PMID- 10154777 TI - Important considerations in using indicators to profile providers. AB - The demand is accelerating for information about the clinical performance of providers. In the more competitive and value-sensitive marketplace that is already developing, purchasers (consumers, employers, and insurers) of health care services will require more information to better assess the relative value of providers' (professional and hospital) services. The cornerstone of a wise, value-based strategy in selecting health care services is careful assessment of each provider's performance based on detailed, quantitative data in the form of clinical indicators. The use of indicators to profile the comparative performances of providers allows purchasers to compare as well as to influence provider performance. PMID- 10154778 TI - The ups and downs of managing employed physicians. AB - The number of employed physicians is growing, posing new challenges to physician executives. Managing employed physicians begins during the hiring process. Once the new physician is on board, an organization should appoint a mentor to help the new employee adjust. Compensation remains a consistent challenge in most organizations with employed physicians. One of the most popular compensation models involves a market-based salary with the opportunity for a performance bonus. PMID- 10154779 TI - The old ways of doing medical business are passing. AB - Doctors must realize that the ?us and them? labels have to be discarded. No longer do physicians wield the ultimate power. We've lost our patients to insurance companies and part of our medical knowledge rests with nonphysicians. Likewise, physicians must accept the reality that all doctors aren't going to be in the same practice setting: some will work for hospitals, some for insurance companies, some for HMOs, some for themselves. But we're all members of a great profession that has proven its ability to give high-quality care to our patients, and now more than ever with more attention paid to costs. PMID- 10154780 TI - Win/win with an improved appeals process. AB - In the past, decisions on what services were appropriate and/or desirable were made between the patient and the physician. In most cases, the cost of services was ignored. Lately, concern for cost containment has introduced a new person into the health care decision-making process: the managed care monitor/planner. The appearance of this new person has produced ambivalent feelings among patients and physicians, from joyful approval for those concerned with rising costs to extreme anger for those whose services are denied, while perceived by them as absolutely necessary. Thus, appeal mechanisms have become a way of life. This article explores ways in which the appeals process may be used as a tool to improve satisfaction levels among providers and subscribers and still fulfill the cost containment and efficiency goals of case management. PMID- 10154781 TI - Event-related sterility assurance--an opportunity for continuous quality improvement. PMID- 10154782 TI - Anesthetic gas: danger in the OR. PMID- 10154783 TI - PACS: a phased implementation strategy. PMID- 10154784 TI - Thriving under capitation. PMID- 10154785 TI - Quality: the enemy is us. PMID- 10154786 TI - The wisdom of managed care delivery. PMID- 10154787 TI - Impact of the new ARRT (American Registry of Radiologic Technologists) guidelines on the radiology administrator. PMID- 10154788 TI - The importance of practice patterns. PMID- 10154789 TI - Ambulatory Patient Group System (APGS) impact in radiology. PMID- 10154790 TI - Open or closed staff? AB - A competent medical contract lawyer should always review any contract prior to your signing. Physicians often rush into a contract under the press of the moment and the good behavior of all parties during the initial courtship phase. Situations can become very nasty during the termination phases of a contract, and you should have researched potential termination scenarios long before they become a reality. Every contract should have a strong non-compete clause clearly written into it. If your potential partner refuses to sign a contract with a strong non-compete clause in it, you may rest assured that this individual may have already coveted your position in the center. As a radiation oncologist, your best protection is to have some type of equity ownership and therefore a voice in the administration and direction of a freestanding center. This will give you the greatest possible security in terms of control over staffing, billing and managerial matters. PMID- 10154791 TI - Perspectives. Seeking a cure for violence among America's youth. PMID- 10154792 TI - Perspectives. Ides of March a wary time for inner city hospitals. PMID- 10154794 TI - Perspectives. HCFA retooling to keep pace with booming Medicare HMO. PMID- 10154793 TI - Perspectives. Children, AIDS patients, and the future of the safety net. PMID- 10154795 TI - Perspectives. Embers flow through ashes of Washington State's reform. PMID- 10154796 TI - Platform for change: the Medical Library Association's response to the professional development challenge. PMID- 10154797 TI - In the right vein? How adequately are departments of information and library studies educating for health care information management and library services in a changing health service? PMID- 10154798 TI - Who's been using my CD-ROM? Results of a study on the value of CD-ROM searching to users in a teaching hospital library. PMID- 10154799 TI - Managing mercury. PMID- 10154800 TI - FDA issues final medical device reporting regulation. PMID- 10154801 TI - Level of stress among medical and nursing personnel working in the emergency department of a teaching hospital. PMID- 10154802 TI - Antibiotics--use and misuse. PMID- 10154803 TI - Utilisation of glass syringes in Institute of Medical Sciences Srinagar. PMID- 10154804 TI - Prevalence of psychiatric problems and neurosis among females in an out patient department of a general hospital. PMID- 10154805 TI - Hospital and institutional responsibilities in embalming. PMID- 10154806 TI - Nurses and medical records documentation (role and responsibility). PMID- 10154807 TI - Demographic consumer profile as a scientific planning tool in hospital scenario. PMID- 10154808 TI - Role of motivation for job satisfaction among faculty of NIMS. PMID- 10154809 TI - Planning and designing of operation theatre complex for district hospital (200 300 beds). PMID- 10154810 TI - "Organising the admission clinic in teaching hospitals". PMID- 10154811 TI - Customizable human resource software replaces incompatible systems at West Virginia University Hospitals. PMID- 10154812 TI - The Family and Medical Leave Act of 1993: final regulations change rules on employee benefits. PMID- 10154813 TI - Speech recognition in the age of CPR. PMID- 10154814 TI - Total hip replacement. Office of Medical Applications and Research, National Institutes of Health. PMID- 10154815 TI - 1995 AAMT Employer of the Year: Scott & White Hospital and Clinic. Interview by Pat Forbis. PMID- 10154816 TI - Hospital fund raising and its marketing by-product. PMID- 10154818 TI - Attracting and keeping volunteers using a volunteer qualification system. PMID- 10154817 TI - To grantwrite or not to grantwrite ... that is the question. PMID- 10154819 TI - Big lessons from big business. PMID- 10154820 TI - A bicycle for India. PMID- 10154821 TI - Why and how managed care is prompting reforms in your institution. PMID- 10154822 TI - Credentials--why bother? PMID- 10154823 TI - Two hands clapping: how to secure physician gifts. PMID- 10154824 TI - Nonprofit hospitals pick business partners' brains to reap savings through supply side economies. PMID- 10154825 TI - Why many quality methods don't work. PMID- 10154826 TI - Border bargains. PMID- 10154827 TI - Community-wide health improvement: lessons from the IHI-GOAL/QPC Learning Collaborative. PMID- 10154828 TI - Improving community health status: strategies for success. PMID- 10154829 TI - Grant development checklist. PMID- 10154830 TI - How MCOs manage MDs. PMID- 10154831 TI - Information technology--making data work for you. First in a two-part series. PMID- 10154832 TI - These employees light the way to lower costs. PMID- 10154833 TI - Detroit's new model for health care. PMID- 10154834 TI - Who should have access to your medical record? Good health care is built on good data. PMID- 10154835 TI - Who should have access to your medical record? Privacy protection or legalized prowling? PMID- 10154836 TI - Market dynamics 1995. AB - The healthcare industry last year saw a continuation of the market-based reform revolution. Competition and economic forces are squeezing dollars out of the system but at varying rates depending on where you are in the country. Health benefit and hospital cost variations appear to be directly related to managed care penetration. Treatment protocol variations may also be related to economic incentives. The question is, will the variations disappear over the coming years? PMID- 10154837 TI - Demographics of the Medicare end-stage renal disease population and populations receiving a functioning graft 1992. PMID- 10154838 TI - A conversation with Ernest L. Berger. PMID- 10154839 TI - Shopping the stop-loss insurance market. PMID- 10154840 TI - Prescriptive authority for pharmacists. PMID- 10154841 TI - Avoiding the legal pitfalls of unlimited agency provisions in health care network provider contracts. PMID- 10154842 TI - Cost and value key to choice of health plan. PMID- 10154843 TI - Going mainstream. PMID- 10154844 TI - Sources of health insurance and characteristics of the uninsured. Analysis of the March 1995 Current Population Survey. PMID- 10154845 TI - Office of Management and Budget control numbers under the Paperwork Reduction Act -OSHA. Final rule. AB - The Occupational Safety and Health Administration (OSHA) is adding new sections to its Safety and Health REgulations for General Industry, Construction and Shipyard Employment. These new sections will be used to consolidate and display all of the control numbers assigned by the Office of Management and Budget (OMB) for "approved" information collection requirements. OSHA is also identifying information collection requirements found in certain of its other regulations and displaying the OMB control number at the end of each section containing a collection of information. None of the requirements are new; they have been promulgated by OSHA at various times over the past 25 years. The display of OMB control numbers is required under the implementing rules and regulations of OMB and under the Paperwork Reduction Act of 1995. PMID- 10154846 TI - A Medicaid miracle? PMID- 10154847 TI - Health care's coming back, but slowly. Interview by Marilyn Werber Serafini. PMID- 10154848 TI - A bigger bank for the welfare buck? PMID- 10154849 TI - He's high on managed health care. Interview by Marilyn Werber Sarafini. PMID- 10154850 TI - Managed care digs out, maybe. PMID- 10154851 TI - Have you reached your peak earning years? PMID- 10154852 TI - Unlocking the secrets of restrictive formularies. PMID- 10154853 TI - 'I never thought I'd sell my practice'. PMID- 10154854 TI - Health reform prospects after the G.O.P. blowout. PMID- 10154855 TI - Managed care needs the credibility of professional moral standards. PMID- 10154857 TI - Which U.S. cities give a 'go' to managed care and its goals? PMID- 10154856 TI - Five key requirements for a compensation formula. PMID- 10154858 TI - Who should own America's healthcare systems? PMID- 10154859 TI - The "grand experiment": the Meridia Health System/Blue Cross joint venture. PMID- 10154860 TI - Should providers run their own HMOs? PMID- 10154861 TI - Technology availability and cost: a comparative analysis. PMID- 10154862 TI - Managing the product standardization process. PMID- 10154863 TI - Technology planning: benefit analysis. PMID- 10154864 TI - The blind hog and the acorn: Medicare coverage for investigational devices. PMID- 10154865 TI - Building on a vision of clinical networking. Interview by Bruce Bunschoten. PMID- 10154866 TI - A strategy to bring automation to rural America. PMID- 10154867 TI - How to assess the value of translation software. PMID- 10154868 TI - Translation trailblazers are proceeding with caution. PMID- 10154869 TI - A new age for outcomes research. PMID- 10154870 TI - Magnetic stripe ID cards ease eligibility inquiries. PMID- 10154871 TI - In search of new territory. PMID- 10154872 TI - Avoiding legal pitfalls in records automation. PMID- 10154873 TI - Health care architecture and design 2000. PMID- 10154875 TI - 21st century health care design. PMID- 10154874 TI - Let's build health facilities that put patients first. PMID- 10154876 TI - The managed care era: untangling preauthorization requirements in the ED. PMID- 10154877 TI - What exactly is a medical screening exam? PMID- 10154878 TI - Conquering COBRA. PMID- 10154879 TI - Sharp/Columbia deal offers lessons for other systems. PMID- 10154880 TI - New York may scrap controversial hospital rate-setting system. PMID- 10154881 TI - Denver market may signal fate of freestanding hospitals. PMID- 10154882 TI - Kaiser Northern California considering out-of-network contracts. PMID- 10154883 TI - Medicare risk point-of-service plans offer providers competitive opportunities. PMID- 10154884 TI - Medical staffs change stripes. PMID- 10154885 TI - Networks prepare to take on more risk: advice from some of the groundbreakers. PMID- 10154886 TI - Using locum tenens as a long-term staffing tool. PMID- 10154887 TI - Following the market for assisted living. PMID- 10154888 TI - Emotional pathways--ways to raise sinking staff morale. PMID- 10154889 TI - Pair power. Interview by Elise Nakhnikian. PMID- 10154890 TI - New guidelines surprise seasoned administrators. PMID- 10154891 TI - Surviving and keeping the heart in hospice--not mutually exclusive. PMID- 10154892 TI - Uniquely hospice: policies and procedures of terminal care at home. PMID- 10154893 TI - An evaluation of hospice care with terminally ill cancer patients. PMID- 10154894 TI - The hospice ethics committee. PMID- 10154895 TI - The hospice wage index: reslicing the reimbursement pie. PMID- 10154896 TI - Antitrust issues for hospice agencies. PMID- 10154897 TI - Hospices and networks. PMID- 10154898 TI - All about public relations: answers to commonly asked questions. PMID- 10154899 TI - Riverways Hospice delivers holiday cheer. PMID- 10154900 TI - The ordinary things of life: aides do what no one else can. PMID- 10154901 TI - The changing face of hospice. PMID- 10154902 TI - Better than chicken soup: encouraging older patients to receive influenza immunization. PMID- 10154903 TI - The spirit of hospice. PMID- 10154904 TI - Managed care's expectations: final results from a national study. PMID- 10154905 TI - Vertical mergers of for-profit home care providers. PMID- 10154906 TI - Building bridges to wellness: changing the Medicare system. PMID- 10154907 TI - National Association for Home Care 1995 award winners. PMID- 10154908 TI - Managing managed care--controlling our destiny. PMID- 10154909 TI - Are your donors in the "market" for planned gifts? PMID- 10154910 TI - The potential dilemma of contingent gifts. PMID- 10154911 TI - Grantseeking for the startup program: a strategic approach. PMID- 10154913 TI - Fund raising amidst health care reform. PMID- 10154912 TI - 10 keys to security a bequest. PMID- 10154914 TI - It's how you ask that counts. PMID- 10154915 TI - The managed care time clock: what's making it tick? AB - Continued and even accelerated growth in managed care is expected. Managed care organizations achieve their objectives through pricing practices, carefully defined provider networks, risk-sharing reimbursement, and medical care management. These organizations are succeeding in managing cost and at the same time are experiencing equal or better medical outcomes. This article will examine some of the elements necessary to provide a successful managed care organization. It will show how each facet of a managed care organization supports all other facets. PMID- 10154916 TI - The organization zoo: a fable. AB - In the parable that follows, we have exaggerated animal behavior to show the importance of ego niches that people make for themselves in organizations. The parable illustrates the difficulty supervisors have in juggling individual egos, organizational needs, and change. We are all familiar with the moral of this fable: ?The more things change, the more they stay the same.? PMID- 10154917 TI - Improving the accuracy of total quality management instruments. AB - Total quality management (TQM) instruments are essential tools in defining concepts identified in an Ishikawa or ?cause-and-effect? diagram. Collecting meaningful and accurate data using TQM instruments is imperative if productivity and quality of care are to be enhanced. This article provides managers with techniques and guidelines that will enhance the reliability and validity of TQM instruments, thereby promoting organization efficiency and customer satisfaction. PMID- 10154918 TI - Negotiating skill for health care professionals. AB - Health workers engage in negotiations at work and at home on a daily basis. The ability to negotiate is a vital part of interpersonal skill. The paradigm of negotiation strategy is undergoing a profound shift from power pressure to an egalitarian form of problem solving or value-added approach that is much more likely to result in win/win outcomes. The basic principle of this refreshing innovation is similar to what we learned about brainstorming and creative problem solving. PMID- 10154919 TI - The role of the human resources department in hospital reengineering. AB - The ?people part? of reengineering is the most difficult to implement or even predict. In this context, active involvement by the Human Resources (HR) Department is a necessity, not an option, for the success of reengineering initiatives. Reengineering requires a changed environment and methods that HR must facilitate; creates extraordinary demands for leadership and communication, which HR is uniquely qualified to support; and represents an extraordinary opportunity for HR to reinvent its own processes and create a sustained competitive advantage for the organization. Exploiting these opportunities will require HR to proactively engage the organization. PMID- 10154920 TI - "I didn't know if it would work, but I tried it anyway". AB - To be an excellent manager, daring, creative, and innovative solutions should be tried for management problems. A manager may feel he or she is treading on ground where no one walked before; however, the manager who takes no risk will never come up with the novel and original solutions. This article supplies guidelines for the evaluation of creative and innovative solutions. These guidelines are especially appropriate for the employee who needs a smooth transition into management. PMID- 10154921 TI - The effects of hospital downsizing on staffing and quality of care. AB - Hospital managers are making aggressive changes in their caregiver staffs to meet challenges such as reductions in utilization and capitated care. Managers are doing this to decrease the cost of care while maintaining or improving quality of care. However, the literature addressing the impact of hospital staffing practices on quality of care indicates that these changes may negatively influence quality. Department administrators must be cautious, yet proactive in their approach to patient care restructuring in order to ensure continued quality as well as cost-effectiveness. PMID- 10154922 TI - Physicians, nurses, and community hospitals: defining a niche for the 21st century. AB - The health care industry is currently the largest single employer monitored by the U.S. Department of Labor. Physicians, nurses, and community hospitals are challenged as never before to define their roles in this system. New competition has emerged as these traditional providers are suffering identity crises. Physicians have suffered a loss of control over the health care system, nurses have not achieved the rewards commensurate with their skills and training, and community hospitals, especially rural facilities, have suffered closures. In order to maintain the integrity of their profession, each must make a concerted effort to position themselves for the next century. PMID- 10154923 TI - The continuum of care protocol: a strategic response to Joint Commission change. AB - Changing mandates of the Joint Commission on Accreditation of Healthcare Organizations, including the 11 functional standards, the nine dimensions of performance, and the interdisciplinary approach, are reviewed. One hospital, City Hospital, strategically managed this change by marrying the principles of strategic management and continuous quality improvement. The end result of this pursuit was the production of a technology--a continuum grid--that helps to address accountability for hospitalwide functions, dimensions of performance, and interdisciplinary approaches while also addressing the need for a clinical pathway of care. The use of the continuum of care grid and steps to achieve a similar technology are identified. PMID- 10154924 TI - Establishing a cost-effective formulary. PMID- 10154925 TI - "Seamless" health care. PMID- 10154926 TI - Ishikawa diagrams help managers sort out facts, correct problems. PMID- 10154927 TI - California hospital alters doctors' habits with timely comparative data. PMID- 10154928 TI - HINN (hospital initiated notice of non-coverage): a powerful tool in Medicare discharges. PMID- 10154929 TI - Culture of quality captures award for TN hospital. PMID- 10154930 TI - Loose lips sink ships and hospital QA departments. PMID- 10154931 TI - A manufacturing excellence team-based learning process for our foundation workers. AB - Foundation workers, people who do the daily tasks to serve customers, have long been ignored and misused in the productivity equation. Every person in a company can and must contribute to improved performance. Equipping out foundation workforce with knowledge and skills via a team-based education and training process is prerequisite to their effective engagement in the business management process. PMID- 10154932 TI - The management of leadership. AB - Leaders are made, not born. Leadership is a science, a set of skills that can be taught, learned, and practiced. Today's business climate demands that managers be leaders and that they must be taught human and interpersonal skills along with their technical skills. The intuitive abilities of leaders are a set of behaviors that define leadership traits. PMID- 10154933 TI - Take two classes and call me in the morning: the case for training wellness. AB - The purpose of this article is to show how a well-conducted needs assessment coupled with a well-conceived training plan can improve training and, indeed, total organizational wellness. This is important on two fronts--organizational and individual. Conceptually, providing training is not much different than providing any other product or service. We often have no idea of how to get the ?right stuff to the right people at the right time under the right conditions.? Thus, this article will provide a framework for ?getting it right? (the first time)! The message? Make your training time and dollars count, no training simply for the sake of training; we must apply it to the training wellness equation. PMID- 10154934 TI - Attilla the Hun: leadership as a change agent. AB - This presentation will examine both ideas and successful examples of how some companies are inspiring and empowering their employees through the development of leadership skills within their management ranks. These skills can be learned and used to aid any organization in its goal of continuous improvement. Today's leadership establishes corporate directions while balancing individual and group achievement, both of which can improve the overall company. Power is shared, not used to control. After all, leadership is not about power. It is about setting directions for others, the clearing of obstacles, and then allowing others to believe the direction was their idea. Great leadership is based on the success of others. PMID- 10154935 TI - Time for a change! AB - Learn how one successful manufacturer uses in-house training to cut the time it takes to do things in all areas of the company. Learn basic principles that can be used by anyone to reduce time in their work, no matter what job they do. PMID- 10154936 TI - Work-team implementation. AB - The authors describe the implementation of the Work-Team Concept at the Frigidaire plans in Jefferson, Iowa. By forming teams, plant staff have made significant improvements in worker safety, product quality, customer service, cost-effectiveness, and overall employee well-being. PMID- 10154937 TI - Leadership and change management. AB - The purpose of this article is to understand that the reason so many programs fall short in addressing and improving competitiveness is that their single focus is on information technology, to instill in our minds that there are many other elements of change that need to be considered (behavior being one), and to present an overview of the motor, the motive, and the mirror that drive behavior and its characteristics. PMID- 10154938 TI - The realities of empowering teams: a case study. AB - This case describes the transition of a manufacturing unit from operating under a rigid hierarchical environment to being run by empowered process management teams. This article traces the evolution of the transformation from the early days of skepticism and nonparticipation to the present, where most of the teams function with a large degree of autonomy and have made significant improvements in quality, lead time, and cost. Elements that help the team process are described, and potential hazards are outlined. PMID- 10154939 TI - From zero to teamwork: a manufacturing journey. AB - This article is a case study of the implementation of employee-empowered problem solving teams. Topics include how projects were selected, how project teams were trained, and how obstacles were overcome. Ths article concludes with 10 recommendations for organizations that would like to initiate team-based activities. PMID- 10154940 TI - The dynamics of role interaction. AB - Success in our respective business environments is not totally dependent on technical expertise; we must be able to also effectively interact with people. The necessity of successful leadership is assumed; however, we often fail to recognize the value of strategically subordinating ourselves to others. Both roles must be emphasized with the knowledge that preferred individual styles are valid. PMID- 10154941 TI - Exploring patient role behaviors for health care services: the assertive, activated and passive patient. AB - Several conceptual models describing how patients ought to behave have been discussed in the literature. Less attention has been devoted to classifying and profiling the primary types of actual patient behavior. This study develops and tests a patient role behavior scale which is used to group patients into three behavioral categories: assertive, activated, and submissive. Patient groups were found to differ significantly with respect to the kind of interaction they received from their physician during their office visits. However, perceptions of the amount of time spent with their doctor were not significantly different. These findings suggest that patients differ with respect to how they view their role in health care service encounters and that physicians may be able to accommodate differing patient roles without unduly influencing productivity. PMID- 10154942 TI - UCHP: a case study of access for the medically uninsured. AB - Utah Community Health Plan (UCHP) is one of fifteen Robert Wood Johnson Foundation Programs for the uninsured. The experience of UCHP is similar to the other nine demonstration programs for the uninsured who have actually enrolled individuals: offering premium subsidies to uninsured small employers is an ineffective way to expand coverage among the working uninsured. PMID- 10154943 TI - Eldercare benefits offered by the best companies to work for in America. AB - The top 100 companies to work for in American were surveyed to determine what eldercare benefits they offer to employees and retirees. Benefits that allow employees flexibility (leave, time off, part time work, flextime, flexplace) were most frequently offered. Information and referral services (telephone, seminars, consultation) were less frequently available. Direct care services (home care, day care, case management) were seldom offered. The most frequently offered benefit for retirees was health insurance. PMID- 10154944 TI - Health marketing information: an assessment of past and future utilization patterns. AB - A sample of 108 members of the Academy of Health Services Marketing provided bibliographic citations of 629 sources of information which have been important to them in their jobs. The results indicate that the propensity to rely upon a source is dependent upon the topic of the information sought. The sources under scrutiny were consultants, books, journals, magazines, seminars, conferences, video tapes, and audio tapes. The topics considered included the variables of the marketing mix as well as market planning and marketing research. The discussion provides insight about where seekers of health care marketing knowledge go for specific kinds of information. It also suggests types of media that information providers should consider for dissemination of their material. PMID- 10154945 TI - A strategic approach to service quality: a field study in a rural health care setting. PMID- 10154946 TI - The challenge of marketing wellness programs to small versus large firm employees. AB - The authors extend prior research by examining employee attitudes towards wellness programs among thirty-eight large and small companies in five states. Program components that were considered to be most desirable by workers at different sized companies are identified in a series of regression models. The results indicate that different sized firms can emphasize general wellness and aerobic exercise programs during the design phase of employee wellness programs. However, employees at large companies were more interested in early detection programs than small firm employees. PMID- 10154948 TI - This little trust went to market. PMID- 10154947 TI - Equipment management. Loan rangers. PMID- 10154949 TI - Emergency admissions. True admissions. PMID- 10154950 TI - Mental health. An extra-special relationship. PMID- 10154951 TI - IT update. Numerical control. PMID- 10154952 TI - IT update. A sum of the whole. PMID- 10154953 TI - Complementary medicine. More than pin money. PMID- 10154954 TI - Complementary medicine. Complements slip. PMID- 10154956 TI - New Biomedical Research Center puts a square peg in a round hole. PMID- 10154955 TI - Fundholding. The best of both worlds. PMID- 10154957 TI - A framework for flexibility. PMID- 10154958 TI - All secure: protecting your facility from major threats. PMID- 10154959 TI - Redoing the laundry. PMID- 10154960 TI - OSHA's new asbestos rule: what you need to know. PMID- 10154961 TI - Create a more patient-focused environmental services dept. PMID- 10154962 TI - Health care field is eighth among 16 in severance pay. PMID- 10154963 TI - Linking technology with strategic and financial plans: a case study of Franciscan Health System. PMID- 10154964 TI - Shaping the future of EMS delivery. PMID- 10154965 TI - All patients are created equal. PMID- 10154966 TI - Stout's concepts in today's EMS. PMID- 10154967 TI - Tough stuff. Learning to seize the opportunities. PMID- 10154968 TI - Removing the mask of hero. PMID- 10154969 TI - The 15 most significant influences in EMS in the past 15 years. PMID- 10154970 TI - Partners. Part III: Rambo medics, trauma junkies and Barney Fifes. Roundtable discussion. PMID- 10154972 TI - 10th Anniversary Colloquium. Medicine, public health, and environment. PMID- 10154971 TI - Organ donations: the failure of altruism. PMID- 10154973 TI - Facing up to bioethical decisions. PMID- 10154974 TI - Software helps find critical pathways. PMID- 10154975 TI - Metro Chicago CHIN on new course. PMID- 10154976 TI - Kan. hospital groups to merge. PMID- 10154977 TI - Medicare/Medicaid reform dead--GOP. PMID- 10154978 TI - Medicare billing probe reaches national scale. PMID- 10154979 TI - Insurance reform earning nod from Congress. PMID- 10154980 TI - Wis. organizations link to take on Mayo system. PMID- 10154981 TI - Universal opens first chain of women's hospitals. PMID- 10154983 TI - Budget cuts hinder creation of quality award. PMID- 10154982 TI - Maryland lets hospital continue to offer new moms a free day. PMID- 10154984 TI - Feds challenge Dubuque decision ... while potential partners walk tightrope. PMID- 10154985 TI - New York's Empire Blues gets OK for for-profit status. PMID- 10154986 TI - Justice Dept. nixes N.J. doc network. PMID- 10154987 TI - Hospitals in Maine, Fla. seek states' aid with antitrust issues. PMID- 10154988 TI - Official drops legal challenge against Mayo. PMID- 10154989 TI - MedPartners/Mullikin gets license allowing full-risk contracting. PMID- 10154990 TI - Mont. merger receives conditional approval. PMID- 10154991 TI - VA disability rating schedule under study. PMID- 10154992 TI - Internet technology moves to patient-care front lines. AB - Hundreds of home pages--many of which amount to electronic marketing brochures- have marked healthcare's first tentative steps onto the World Wide Web. Now, a few innovators are taking Internet technology to the front lines of patient care. PMID- 10154993 TI - UCLA merger begins paying dividends. PMID- 10154994 TI - ER visits dropped 2.2% in 1994--AHA. PMID- 10154995 TI - Healthcare stocks stoke mutual funds. PMID- 10154996 TI - HBO & Co. moves to integration phase. PMID- 10154997 TI - Info execs vexed by lack of strategy. PMID- 10154998 TI - Justice Dept., FTC officials stay aggressive on antitrust. PMID- 10154999 TI - Voters to decide if Calif. hospital needs new wing. PMID- 10155000 TI - No deal on charity care in N.J. PMID- 10155001 TI - Study documents brisk merger-acquisition pace. PMID- 10155002 TI - Governors' plan for Medicaid reform hits snag. PMID- 10155004 TI - Archdiocese threatens hospital's Catholic status. PMID- 10155003 TI - Lawmakers gear up for Medicare trust testimony. PMID- 10155005 TI - Baxter withdraws bid for NMC. PMID- 10155006 TI - Fla. hospitals may face assessment. PMID- 10155007 TI - Wash. insurance chief supports state reforms. PMID- 10155008 TI - Mich. Blues, Big 3 reach compromise. PMID- 10155009 TI - Docs split on payment system change. PMID- 10155010 TI - Healthcare union rejoins AFL-CIO. PMID- 10155011 TI - Hospitals to pay for double-billing. PMID- 10155012 TI - Calif. Blue Cross reviewing controversial maternity rule. PMID- 10155013 TI - Two Fla. hospitals plan new company to battle Columbia. PMID- 10155014 TI - WellPoint announces recapitalization. PMID- 10155015 TI - CHW to launch L.A. system by acquiring two hospitals. PMID- 10155017 TI - HCFA to unveil Medicare bonus program. PMID- 10155016 TI - Fla. hospitals turn to commercial insurance. PMID- 10155018 TI - Retooling without layoffs. AB - Hospitals nationwide are looking for ways to cut expenses in hopes of attracting managed-care contracts and in preparation for expected restrictions in the growth of the Medicare and Medicaid programs. But they're learning that the pink slip usually isn't the best way to achieve those cost reductions. PMID- 10155020 TI - Rural hospital exec urges broader measure of value. PMID- 10155019 TI - Automated supply cabinets aren't a financial cure-all. PMID- 10155021 TI - Linda Krauss and the lap of God. A spiritual assessment case study. PMID- 10155022 TI - CEO evaluation and compensation. PMID- 10155023 TI - Finding the perfect system CEO. PMID- 10155024 TI - When you have to fire your CEO ... you haven't done your job. PMID- 10155026 TI - The changing face of governance. PMID- 10155025 TI - Those who know, teach. PMID- 10155027 TI - Staying up front in the primary care marathon. PMID- 10155028 TI - What is corporate culture? PMID- 10155029 TI - Jumping into the unknown. PMID- 10155030 TI - Balancing act. Working without a net, Allina boards pursue equilibrium. PMID- 10155031 TI - Smooth talk. PMID- 10155032 TI - Turning complaints into compliments. PMID- 10155034 TI - Who owns the hospital? PMID- 10155033 TI - Giving workers healthy incentives. PMID- 10155035 TI - Show and tell. Peer counselors teach young teens to say 'No' to sex. PMID- 10155036 TI - The baby chase. PMID- 10155038 TI - Helen B. Landgarten. Interview by Linda A. Warren. PMID- 10155037 TI - Check in, deliver, go home. PMID- 10155039 TI - The best investment is in education. PMID- 10155040 TI - Using quality improvement techniques to make informed decisions. PMID- 10155041 TI - Filmless automation: from vision to reality. PMID- 10155042 TI - Mentoring in the "man-age". PMID- 10155043 TI - Managed care consult: rounding up referrals. PMID- 10155044 TI - Telephony--the science of communication. PMID- 10155045 TI - Turning data into information: systems approach. PMID- 10155046 TI - The evolution of radiologic accreditation. PMID- 10155047 TI - Rethinking patient education and support. PMID- 10155048 TI - Educating doctors on educating patients. PMID- 10155049 TI - The importance of outcome. PMID- 10155050 TI - Retrospective study of bitolterol mesylate in the treatment of conditions associated with reversible bronchospasm. AB - Patients with reversible bronchospasm benefit from the use of inhaled beta adrenergic agents. In this retrospective study of 24 older patients with a variety of conditions associated with reversible bronchospasm--asthma, asthma with emphysema, chronic bronchitis, and asthmatic bronchitis--symptomatic improvement was noted after treatment with inhaled bitolterol mesylate. Symptoms resolved or improved after 1 month in 93.8% (15/16) of patients using a metered dose inhaler and in 75% (6/8) of those using a hand-held nebulizer. Sixteen additional patients were randomly selected to undergo pulmonary function tests after receiving two to three puffs of bitolterol from a metered-dose inhaler. FEV1 improved by 10.9%, FVC by 12.1%, and FEF25%-75% by 34.4% after administration of bitolterol. No adverse events were noted in any patients in either group. The results of this retrospective study suggest that bitolterol is an effective and safe treatment in patients with conditions associated with reversible bronchospasm. PMID- 10155051 TI - Efficacy of nebulized albuterol and cromolyn sulfate for acute wheezing and stridor in children: a prospective, randomized study. AB - A number of respiratory tract illnesses may produce acute wheezing and stridor in children, and treatment may vary, depending on the specific illness. These illnesses, however, may be difficult to differentiate solely on clinical grounds. A uniform therapeutic approach for children with acute wheezing or stridor independent of the specific etiology can be employed. In this prospective study, 246 children received aerosolized albuterol and cromolyn sulfate. Children who remain in distress after aerosolized medications should be admitted to the hospital. Those with partial improvement may be treated with home aerosol treatments after intramuscular injection of dexamethasone. PMID- 10155052 TI - Drug interference in amino acid analysis of urines: a graphic presentation on selected pediatric antibiotics. PMID- 10155053 TI - A new approach to anaerobic atmosphere generation. PMID- 10155054 TI - Optical disk technology application to laboratory records management. PMID- 10155055 TI - Blood gas/electrolyte analysis during patient evacuation and in the prehospital environment. PMID- 10155056 TI - Development of a method for the analysis of warfarin and metabolites in plasma and urine. PMID- 10155057 TI - A tracker for bar-coded samples. PMID- 10155058 TI - Rapid, precise immunophenotyping of T-lymphocyte subsets in monitoring HIV status. PMID- 10155059 TI - Endoscopic CO2 laser cricopharyngeal myotomy. AB - Cricopharyngeal dysfunction due to various causes can lead to severe upper pharyngeal dysphagia with or without laryngeal penetration. Resurgence of Dohlman's endoscopic diverticulotomy for Zenker's diverticulum has been brought about by the development of the diverticuloscope, improved intravenous analgesia, and the advent of the laser. Recent use of videofluoroscopy for swallowing documents a frame-by-frame picture of swallowing with special focus on the cricopharyngeal function and its stages of malfunction. The "cricopharyngeal crescent" (cricopharyngeal bar) as termed by Jackson is visible during endoscopy and can be incised in layers under the operating microscope with the CO2 or contact Nd:YAG laser. This paper introduces the staging of cricopharyngeal dysfunction regarding its initiation and progression in correlation with its symptoms and videofluoroscopic pictures. It also reports the application of endoscopic laser cricopharyngeal myotomy for 44 patients with cricopharyngeal dysfunction besides 4 with Zenker's diverticulum. This procedure is found to be effective, safe, brief, and prompt in restoring swallowing. PMID- 10155060 TI - Megasession hair transplantation with a CO2 laser flashscanner technology. PMID- 10155061 TI - The results of 1328 periodontal pockets treated with the argon laser: selective pocket thermolysis. AB - A study of 30 randomly selected cases of type II-IV periodontitis was done from a group of 130 patients who had been treated with argon laser pocket thermolysis and root planing between January 1993 and April 1994. The group consisted of 12 males and 18 females with a mean age of 47. No antibiotics were taken 6 months prior or during the treatment. A pocket charting and bleeding index was done at a mean of 4.6 months after treatment. A total of 1328 pockets were treated using a 300-microns fiber in contact at 0.4 W for 20-30 sec per pocket with coaxial irrigation. The 4-5 mm pockets were reduced by 1.62 mm, 6-7 mm pockets by 2.85 mm, and 8-9 mm by 3.30 mm. The bleeding of probing was reduced by 75%. The mean postoperative pain medication was 400 mg/day of ibuprofen for 1-2 days. Laser pocket thermolysis with subgingival thermodynamic debridement may eliminate or greatly reduce the need for additional treatment. There is a great need for further investigation. PMID- 10155062 TI - Experimental studies of the applications of the holmium laser in dentistry. AB - The purpose of this study is to evaluate the possibility of using a pulsed Ho:YLF laser for endodontic surgery access, preparation of cavities, etching of dental enamel, and treatment of dental caries. Specimens were irradiated with a prototype of pulsed Ho:YLF laser (2,065 microns). Laser energies in the range of 120-750 mJ per pulse were used. The study of morphological changes on enamel and dentine was conducted on light and scanning electron microscopes. Perforation of approximately 4 mm depth with homogeneous and smooth aspect of its wall surfaces was obtained. There was no carbonization. Irradiation with low energy results in melted and recrystalized surface with small and shallow pits. In accordance with our results the Ho:YLF laser produces surfaces that are white in appearance in contrast to the Nd:YAG modified enamel and dentine surfaces, that were darkened. These are indications that the holmium laser may be useful for dentistry in the future. PMID- 10155063 TI - The fracture, dislodgement and retrieval of a probe III balloon-on-a-wire catheter. AB - The fracture and dislodgement of an angioplasty device within the coronary arteries is a rare but increasingly noted complication. If the fragment of angioplasty balloon or guidewire is dislodged in a proximal and patent coronary artery, the likelihood of acute embolization which could lead to an acute coronary thrombus and/or myocardial infarction exists. Therefore, the immediate removal of the broken piece of the angioplasty catheter is imperative. A case of unusual fracture and dislodgement of a Probe III Balloon-on-A-Wire catheter and retrieval of the broken piece is reported. PMID- 10155064 TI - Pseudoaneurysm following successful excimer laser coronary angioplasty of a restenotic left internal mammary artery graft ostial lesion. AB - Although significant left internal mammary artery graft ostial stenosis is extremely rare, the clinical importance can be profound. In this report we describe a case in which a restenotic left internal mammary artery graft ostial lesion was successfully opened with excimer laser coronary angioplasty. A resulting pseudoaneurysm spontaneously closed after conservative therapy. PMID- 10155065 TI - Luminal narrowing after percutaneous transluminal coronary angioplasty. A multivariate analysis of clinical, procedural and lesion related factors affecting long-term angiographic outcome in the PARK study. Post-Angioplasty Restenosis Ketanserin. AB - BACKGROUND: Long term luminal renarrowing after successful coronary balloon angioplasty is a major limitation of the technique. Knowledge of factors which influence long term luminal re-narrowing could be very valuable in selecting appropriate patients or lesions for the procedure and may therefore improve the medium term prognosis after angioplasty. Furthermore, modification or control of the identified risk factors could reduce overall restenosis. Additionally, identification of such factors would assist in the selection of high risk patients, who could then constitute the target population for pharmacological intervention studies. Thus the aims of the present study were to find independent patient, lesion and procedural related risk factors for the restenosis process. METHODS AND RESULTS: Quantitative angiography was performed on 742 successfully dilated lesions at angioplasty and 6 months follow-up. Long-term luminal re narrowing was defined as the absolute change in minimal luminal diameter (MLD) from post PTCA to follow up. Univariate and multiple linear regression analysis of all available clinical, lesion and procedural variables was performed to identify variables with a significant contribution to the prediction of change in MLD. Gain in MLD at angioplasty, pre PTCA MLD, total inflation time and male sex were positively related to change in MLD while a positive smoking history, vessel and maximum balloon size were negatively related. The overall prediction of the model was poor (R2-0.14) suggesting that many factors influencing the process are still outside our understanding. CONCLUSIONS: These results indicate that re narrowing after successful PTCA is a process which can be influenced by a number of clinical, angiographic and procedural characteristics but cannot yet be accurately predicted by these. PMID- 10155066 TI - Chronic ulcerated plaques: new insights into the pathogenesis of acute coronary disease. AB - Ulcerated atherosclerotic plaques form the substrate for the vast majority of coronary thrombi, but this association does not prove that either one or both of these lesions represents a recent development. Recent reports suggest ulcerated plaques may exist for weeks, months, and possibly years without resolving and reestablishing endothelial integrity. The coronary arteries of 83 patients dying of acute coronary disease were extensively examined, histologically, to determine the pathologic features associated with ulcerated plaques but not associated with an intraluminal thrombus. These findings were then correlated with the degree of luminal stenosis, the presence of inflammatory cell infiltrates, calcification, and necrotic atherosclerotic plaques. The results show ulcerated plaques without thrombosis are ubiquitous, multiple, are unrelated to the degree of luminal stenosis, and are consistently associated with inflammatory cell infiltrates, calcification, and necrotic plaques. Our observations suggest acute coronary disease may result from thrombosis and possibly other biochemical reactions, superimposed on chronic, rather than on recent, ulcerated plaques that have been present for an indeterminate length of time before the onset of acute symptoms. These observations form the basis for an alternative approach to the understanding of the pathogenesis of acute coronary disease and have implications for the prevention of thrombosis. PMID- 10155067 TI - A randomized study of sheaths versus guidewires for arterial access during elective cardiac catheterization. AB - PURPOSE: The aim of this study was to compare the ease and safety of intravascular sheaths versus guidewires for maintaining arterial access during cardiac catheterization. METHODS: Two hundred patients with normal coagulation status undergoing routine diagnostic cardiac catheterization were randomized to intravascular sheath access versus guidewire access groups. Procedure times and difficulties were recorded during the procedure. Patients were asked to evaluate groin discomfort immediately after the procedure and two weeks later. Complications including groin hematoma, vascular damage, and stroke were assessed at the end of the procedure and the following morning. RESULTS: There were no differences between the sheath and guidewire groups in patient discomfort, procedural time or difficulty, or total complications. Hematomas occurred in 18% of patients (sheath 16% vs. guidewire 20%, p = NS) and were more often large in the guidewire group (5% vs. 0%, p = .05). None required vascular repair. Oozing around the catheter was more frequent in the guidewire group (6% vs. 0%, p = .03) but did not lead to any significant complications. CONCLUSIONS: We conclude that using guidewires for arterial access during cardiac catheterization leads to more large hematomas and more access site oozing during the procedure. However, there were no differences in patient comfort, overall procedural difficulty, or total complications between sheath and guidewire techniques. PMID- 10155068 TI - Directional coronary atherectomy and its use in treating occluded left main arteries in cardiogenic shock patients: a case study. AB - This article presents a case where directional coronary atherectomy was successfully performed on an occluded left main coronary artery in a cardiogenic shock patient in an emergency setting where thrombolytic agents were contraindicated. Further investigation is suggested and warranted and use of DCA may aid in management of cardiogenic shock patients. PMID- 10155069 TI - A lesion marker to facilitate placement of the Simpson's atherocath device during directional atherectomy of left anterior descending coronary artery stenoses. AB - Placement of the directional coronary atherectomy cutter requires frequent angiographic contrast injections to aid in the precise location of the device in relation to the target stenosis. A method is described to enable rapid positioning of this device across stenotic lesions occurring in the left anterior descending coronary artery, with the use of a simple lesion marker. Two short lines demarcating the limits of the stenotic lesion are drawn onto a transparent one-sided adhesive plastic sheet that has been pasted beforehand onto the active monitor screen. Using this reference marker, the atherectomy device can be reliably positioned across the stenotic lesion. PMID- 10155070 TI - Coronary angioplasty in the young: procedural results and late outcome. AB - Procedural outcome of coronary angioplasty in 89 patients < or = 40 years was compared to an older group of 1,916 patients > 40 years. Young patients were more often male (98% vs. 81%), smokers (89% vs. 70%), and more stressed (subjectively) (29% vs. 15%) compared to the older group. Other coronary risk factors were less common in the younger group: diabetes (5% vs. 13%), and hypertension (19% vs. 40%). Left ventricular function, number of diseased vessels, and the number and location of sites dilated were similar in the two groups. Procedural success rates were similar in the two groups (90% in young, 86% in old; p = NS). Younger patients suffered no major complications of the procedure, in contrast to a myocardial infarction rate of 5%, and urgent bypass surgery and mortality rates of 1% each in the older group. Young patients were followed up for a mean of 30 +/- 26 months after the procedure, with an actuarial 5-year survival of 100%. Four patients (5%) required elective coronary bypass surgery: two due to a failed angioplasty attempt (failure to cross), the other two for progressive multivessel disease. A total of 28 patients (34%) required re-angioplasty (restenosis: 13%, progression elsewhere: 12%, both: 9%). All re-angioplasty procedures were angiographically and clinically successful, with no major complications. For young patients, coronary angioplasty is a safe and effective procedure. If technically feasible, angioplasty should be considered the initial therapeutic option without neglecting risk factor modification. PMID- 10155071 TI - A new low profile balloon atrial septostomy catheter: initial animal and clinical experience. AB - OBJECTIVE: To evaluate the safety and efficacy of a new low profile balloon septostomy catheter in neonatal animals as well as in one newborn infant. BACKGROUND: Balloon atrial septostomy remains one of the most commonly performed palliative procedures in pediatric cardiology. The currently available septostomy catheter requires a large introducer sheath (6 or 7F), does not have an end hole for confirmation of position or pressure measurement and is limited in patients with a small left atrium due to its large balloon inflated diameter. METHODS: Four neonatal piglets (average weight 3.9 kg) underwent percutaneous balloon atrial septostomy using the new balloon catheter inflated to 1 cc via a 5F sheath in the femoral vein. Two other piglets (average weight 4.9 kg) underwent septostomy with the conventional catheter inflated to 3.5 cc via a 6 or 7F sheath in the femoral vein. All animals underwent transthoracic echocardiography pre and post septostomy. All animals were sacrificed after the procedure and the size of the atrial defect created was measured. One neonate with Taussig-Bing anomaly underwent septostomy with the new balloon catheter. RESULTS: The left atrium was entered in all piglets. It was easier to enter the left atrium with an end hole catheter which was exchanged over a wire with the septostomy catheter. Septostomy was performed with the new or conventional catheters without complications. Echocardiography demonstrated a very small patent foramen ovale prior to the procedure and a large atrial defect after septostomy. The average size of the defect created by the new catheter was 11.3 x 10 mm in diameter and 11 x 10 mm using the conventional catheter. A 10 x 10 mm atrial communication was created in the neonate. CONCLUSIONS: This study demonstrates the safety and efficacy of this new catheter. This catheter will be of potential importance in patients with a small left atrium and in small neonates with congenital heart disease requiring septostomy. PMID- 10155072 TI - Electron beam computed tomographic imaging of aortic aneurysms and dissections. AB - Electron Beam Computed Tomography (EBCT), like conventional CT has the capability to acquire high resolution images of the aorta. The millisecond image acquisition time characteristic of EBCT makes it an ideal modality to evaluate patients with suspected aneurysms or dissections of the aorta. Unlike conventional CT, electron beam technology produces images with excellent resolution, minimal respiratory artifact, and superior vascular enhancement. Compared with alternative modalities, EBCT probably represents a superior tool in the workup of aortic pathology. Whether in the acute or chronic setting, the reliability, speed, ease, and reproducibility of EBCT makes it truly superior in the diagnosis and follow up of aortic aneurysms and dissections. PMID- 10155073 TI - Voda guiding catheter is superior to amplatz guiding catheter for performing left circumflex PTCA. AB - Amplatz guiding catheters have traditionally been recommended for performing Left Circumflex PTCA because of their enhanced support. The Voda (Scimed Inc.) design guiding catheter may provide similar support for the left coronary artery, particularly the left circumflex, with less catheter manipulation. We prospectively randomized 40 patients to either Amplatz or Voda guiding catheters to compare ease of use and observed that a Voda design guiding catheter has more favorable characteristics for use without sacrificing support. PMID- 10155074 TI - The impact of autoperfusion on quantitative electrocardiographic parameters of ischemia severity, extent, and "burden" during salvage of elective coronary angioplasty. AB - Long angioplasty inflations have been reported using an autoperfusion system that delivers oxygenated blood distal to the balloon segment. The safety and efficacy of this system has been demonstrated in anatomically selected patients. The clinical use, however, is frequently to stabilize intimal dissection in unselected patients. We reviewed 12-lead continuous electrocardiographic (ECG) recordings in 40 patients in whom prolonged salvage with autoperfusion was attempted. Sub-optimal results were stabilized in 36 of 40, while 4 patients had urgent bypass. The presence of ischemia, as > or = 100 uV ST elevation over the 12 lead ECG, and the total ST deviation over all leads over the entire inflation period (total ischemic "burden") were compared within each patient between the longest standard balloon and autoperfusion inflations. Median duration of inflation was 3.03 min. with balloon vs. 15.6 min. with autoperfusion (p < 0.00002). Of the 40 patients, 35 (87%) had ECG ischemia with balloon vs. 18 (45%) with autoperfusion (p < .00002). Median severity of peak ST deviation was 321 uV with balloon vs. 132 uV with autoperfusion (p = 0.0001). Median extent of ST elevation was 3 leads with balloon vs. 0 leads with autoperfusion (p = 0.0001). Median total ischemic burden was similar with balloon (1173 uVmin) and autoperfusion (1083 uVmin, NS) despite the fivefold longer inflation duration with autoperfusion. Thus, in patients selected by clinical necessity rather than optimal anatomy, severity and extent of ST elevation were significantly reduced, although not entirely eliminated, by autoperfusion. PMID- 10155075 TI - Resuscitation from cardiogenic shock by direct angioplasty and 23-hour balloon inflation using a coronary perfusion balloon. AB - Direct angioplasty is an accepted treatment for acute myocardial infarction and has resulted in stabilization and improvement in the clinical, electrocardiographic, and hemodynamic consequences of acute myocardial infarction. This case demonstrates the effectiveness of coronary perfusion as a method of resuscitation during cardiogenic shock and asystole in a patient with massive acute diaphragmatic and right ventricular infarction. Utilization of prolonged balloon inflation in this case obviated the need for emergency coronary bypass surgery and provided the patient with remarkable and almost complete recovery of left and right ventricular function. PMID- 10155076 TI - A new approach: a single triple electrode lead system interfaced with a third generation defibrillator. AB - The efficacy of implantable third generation cardioverter defibrillators has been well established for the treatment of patients with malignant ventricular arrhythmias and survivors of cardiac arrest. However, many patients have been reluctant or unwilling to endure the discomfort of an open chest procedure, despite their need for the device. Furthermore, morbidity (pneumothorax, pneumonia, sepsis, pleural effusion, hemorrhage, pericarditis, etc.) and mortality associated with the application of epicardial lead systems is of concern. Finally, the mean overall expense of $80,433 for the epicardial method of defibrillator implantation is a consideration in an era of increasing cost awareness in health care. Fortunately, the recent market-release of a single lead transvenous defibrillation system [Endotak, Cardiac Pacemakers, Inc. (CPI), St. Paul, Minnesota] may address these pressing issues. The specific purpose of this report is to demonstrate the patient benefit derived from interfacing a single endocardial lead system with a biphasic third generation defibrillator. PMID- 10155077 TI - Technique of apical left ventricular puncture revisited: a case report of double valve prosthesis evaluation. AB - The presence of both mitral and aortic mechanical prostheses often make access to the left ventricle difficult for hemodynamic evaluation of valve gradients and for performing angiography. We present a case where both the transseptal and direct apical ventricular puncture techniques are utilized for assessing prosthetic valve function. The use of a new over the wire technique for left ventricular access using a flexible 4 French pediatric multipurpose catheter is described. PMID- 10155078 TI - Long-term patency of a Cook stent without anticoagulation. AB - In recent years intracoronary stenting has been proven to be an effective bail out for acute and threatened closure during and after coronary angioplasty. Initial enthusiasm has been hampered by significant anticoagulation related vascular and bleeding problems. We report a patient with intracoronary stent whose stent remained patent despite lack of any anticoagulation. PMID- 10155079 TI - Intravascular ultrasound imaging of a patent ductus arteriosus in an adult. AB - A small patent ductus arteriosus (PDA) is compatible with a normal life span. A non-restrictive PDA may present with signs of heart failure, supraventricular arrhythmia's, bacterial endocarditis or endarteritis later in life. Fewer than 50% of patients, including those with small shunts, are symptomatic by the age of 50. Considering that 40% of patients with PDA's will die before the age of 45 as a result of bacterial endocarditis or heart failure, closure of the PDA is recommended. Exceptions are patients with a nondilated heart, a right-to-left shunt, or age greater than 60 years old. Because of the wider use of echocardiography, especially transesophageal echocardiography, many PDA's are now detected incidentally in patients without symptoms. PMID- 10155080 TI - Marked ST elevation after successful PTCA for acute myocardial infarction. AB - Prompt reperfusion of acutely ischemic myocardium appears to be the rational way of reversing ischemic injury and limiting the extent of eventual necrosis. Recent advances in emergency coronary bypass surgery, percutaneous transluminal coronary angioplasty (PTCA) and thrombolytic therapy have provided methods for effective treatment of acute myocardial infarction. However, several observations indicate this issue is more complex. Although blood flow must be restored to ischemic myocardium if it is to survive, animal experiments suggest potential deleterious effects associated with this reperfusion. These deleterious effects may be associated with unstable ST segments reported early after acute infarct thrombolysis. Though recurrent coronary occlusion cannot be excluded, reperfusion injury in this setting of coronary artery patency must be considered. This case illustrates this proposed reperfusion injury reflected as "tombstone" ST segment elevation in a patient following successful acute infarct PTCA. PMID- 10155082 TI - Puncture site hemostasis. AB - The Angio-Seal hemostatic puncture closure device was designed to provide diagnostic as well as post-complex angioplasty hemostasis in coronary and peripheral procedures without compromising blood flow to the distal extremity: 1) by allowing immediate removal of the introducer sheath, and 2) by providing puncture hemostasis without the need for manual pressure. The Angio-Seal is currently in clinical trials and is being evaluated by the FDA. We are hopeful that its future use will reduce the cost of medicine while greatly enhancing the quality of patient care as initial clinical trial results indicate. PMID- 10155081 TI - Lack of predictors of left ventricular functional improvement following coronary angioplasty. AB - Coronary angioplasty is frequently performed in a vessel with corresponding regional wall motion abnormalities. However, late improvement of left ventricular function remains questionable in many cases and is difficult to predict. A retrospective analysis of 115 patients with single vessel disease and corresponding abnormal regional left ventricular function at the time of coronary angioplasty was performed. All patients had control coronary angiography and a new contrast ventriculography 5.6 +/- 3.1 months later (range 0.8-11.8 months). Among those patients, 61 (53%) showed improvement of regional left ventricular function, which was not seen in the 54 (47%) others. Global ejection fraction increased significantly in the former group, whereas it remained unchanged in the later group. Before angioplasty, patients with and without improvement of systolic left ventricular function were indistinguishable in terms of history, medication, rest and stress electrocardiogram, and angiographic characteristics. During angioplasty, angina was more frequent (65% vs. 44%, p < 0.02) in patients with subsequent left ventricular functional improvement. At follow-up study, significant angiographic restenosis was more frequently encountered (68% vs. 43%, p < 0.05) in patients with no evidence of functional improvement. Thus, coronary angioplasty in a vessel responsible for left ventricular systolic dysfunction is followed in only half the cases by improvement of this parameter. No predictor of the functional outcome of the myocardium can be pointed out before the procedure is performed. PMID- 10155083 TI - Current concepts of thrombosis. PMID- 10155084 TI - A new method for brachial artery hemostasis following percutaneous coronary angiography. PMID- 10155085 TI - Radiofrequency catheter ablation as primary therapy for symptomatic ventricular tachycardia. AB - Most applications of radiofrequency (RF) catheter ablation for treatment of ventricular tachycardia (VT) have been as a treatment of last resort. The purpose of this study was to determine the efficacy and safety of RF catheter ablation as the primary treatment for symptomatic single morphology VT. Eleven of 81 patients (14%) with inducible sustained monomorphic VT underwent RF ablation as the primary treatment. One of these 11 patients had successful RF ablation of bundle branch reentry VT and was excluded from this series. The remaining 10 patients had a mean age of 58 +/- 19 years (range 20 to 73 years), were mostly men (7 of 10 patients), and all presented with documented evidence of symptomatic sustained monomorphic VT, at a mean cycle length of 340 +/- 60 milliseconds (ms) (range 250 to 430 ms). Six patients had coronary artery disease (CAD), one had surgical repair for tetralogy of Fallot, one had surgical repair of a ventricular septal defect, and two had a normal cardiac substrate. The VT origin was mapped using a combination of activation mapping, mid-diastolic potentials, pace mapping, and concealed entrainment. A mean of 5 +/- 3 (range 2 to 11) RF applications were administered to the putative VT foci. Eight of 10 (80%) clinical VTs were successfully ablated. There were no serious complications. Patients with VT originating from the left ventricle were offered implantable cardioverter defibrillator back-up; however, only one patient accepted this option. At a mean follow-up of 12 +/- 7 months, only one patient had a possible arrhythmia recurrence. PMID- 10155086 TI - Pseudo-dissection in percutaneous transluminal coronary angioplasty. AB - Percutaneous transluminal coronary angioplasty (PTCA) is a well-established and effective treatment modality for significant coronary artery disease. Because it enlarges the arterial lumen by plaque disruption, minor wall dissection is not infrequent. Complex dissections are, however, uncommon but may lead to acute vessel closure with its attendant major clinical morbidity and mortality. We describe here a case of pseudo-dissection and its potential for misinterpretation and subsequent inappropriate management. PMID- 10155087 TI - Complications of cardiac catheterization, coronary angiography, and coronary interventions. AB - Cardiac catheterization and coronary angiography have evolved, especially after the advent of percutaneous coronary interventions. Although older patients with more advanced disease are being studied, the overall rate of complications has not dramatically increased and the spectrum of complications has somewhat changed to select the more acute nature of the procedures performed. Careful prophylactic measures such as anticoagulation, ischemia prevention, blood pressure control, hydration as well as the availability of defibrillation and pharmacologic and mechanical means of circulatory support have helped minimize these complications and improve outcome. PMID- 10155089 TI - Patients at high risk for ischemic complications. AB - The identification of the factors which predict increased risk for procedural complications in patients undergoing percutaneous revascularization allows a prospective stratification and evaluation of the risk benefit ratio in the individual patient. Such stratification may allow choice of other management options, such as medical therapy or bypass surgery, but probably more importantly allows the selective application of adjunctive pharmacotherapy or mechanical support techniques. It is important to recognize the limitations of all pre procedural risk assessment however in that overall these criteria still have relatively low predictive value and to a great extent closure remains unforeseeable. Additionally, high risk characteristics are frequently encountered in clinical practice, and for many high risk patients the best option for revascularization may still be the percutaneous one. PMID- 10155088 TI - Abrupt vascular closure. PMID- 10155090 TI - Early and late clinical outcome following coronary angioplasty performed with platelet glycoprotein IIb/IIIa receptor inhibition: the EPIC Trial results. AB - Ischemic complications complicate coronary angioplasty in 10-20% of patients. Antithrombotic agents, such as aspirin and heparin, reduce the frequency of peri procedural complications, but their effect is incomplete. A chimeric (mouse and human) monoclonal antibody (c7E3 Fab) has been developed, which is a specific inhibitor of the platelet glycoprotein IIb/IIIa receptor and prevents platelet-to platelet aggregation. A randomized study of 2099 patients at "high-risk" for complications after coronary angioplasty has demonstrated a 35% reduction in 30 day ischemic complications resulting from bolus (0.25 mg/kg) and 12-hour infusion (10 micrograms/min) of c7E3 Fab (8.3% in c7E3 Fab-treated patients versus 12.8% in placebo-treated patients; p = 0.008). The highest reduction in ischemic complications was noted in patients presenting with acute myocardial infarction or unstable angina (hazard ratio = 0.5; 95% confidence intervals [CI]: 0.3-0.9) compared with those patients with high-risk anatomy alone (hazard ratio = 0.7; 95% CI: 0.5-1.1). Late (6-month) clinical events were also lower in patients undergoing successful coronary angioplasty (event-free at 48 hours) who treated with bolus and infusion c7E3 Fab (19.2% versus 25.4% in placebo-treated patients; p = 0.007). The beneficial effect of c7E3 Fab on reducing ischemic complications after coronary angioplasty was balanced by a doubling of major bleeding complications in c7E3 Fab-treated patients (14% versus 7% in placebo-treated patients; p = 0.001). Bleeding complications appear to be related to the intensity of peri-procedural anticoagulation using nonweight adjusted heparin. These results suggest that bolus and 12-hour infusion of c7E3 Fab is a valuable pharmacologic adjunct to reduce peri-procedural complications in "high-risk" patients undergoing coronary angioplasty, particularly in those patients with myocardial infarction or unstable angina. Further studies are underway to develop alternative heparin dosing strategies in an effort to reduce the occurrence of bleeding complications associated with c7E3 Fab administration and to assess the benefit of c7E3 Fab-mediated platelet inhibition in lower risk patient subgroups. PMID- 10155091 TI - Dosing and administration of ReoPro (c7E3 Fab). PMID- 10155092 TI - Early and late ischemic complications of PTCA. PMID- 10155093 TI - Post-procedural patient management: prevention and management of bleeding complications. PMID- 10155094 TI - Care of the patient receiving ReoPro following angioplasty. PMID- 10155095 TI - A new platinum balloon-expandable stent (Angiostent) mounted on a high pressure balloon: acute and late results in an atherogenic swine model. AB - BACKGROUND: Randomized studies have proven the efficacy and safety of stent placement to treat de novo coronary stenosis. However, the poor radio-opacity and the use of an additional high-pressure balloon to fully expand the stent are the major limitations of the currently clinically-approved stents. OBJECTIVE: We evaluated the safety, efficacy, angiographic and histologic effect of a new platinum balloon expandable stent mounted on a high-pressure balloon in Yucatan miniature swine fed high cholesterol diet. METHODS: Fifteen Angiostents (NuMED, Inc., Hopkinton, NY and Angiodynamics, Glens Falls, NY) (coronary stent was 3, 3.5, or 4 mm in diameter and 12 mm long; renal and carotid stents were 5 mm in diameter and 13 mm long) mounted on a high-pressure balloon were placed percutaneously in blood vessels of 10 pigs [5 in circumflex (CX), 2 in left anterior descending (LAD), 5 in renal and 3 in carotid arteries]. The stent was 10-20% larger than the native vessel diameter. All animals received 5000 I.U. of heparin during the procedure and were maintained on 325 mg aspirin daily. Follow up angiography and histology in the animals was performed at 2, 4, 12, 20, 26 and 52 weeks. RESULTS: The stents were easily visualized with fluoroscopy and placed in all animals without episodes of balloon rupture or embolization. There was no episode of acute thrombosis. Follow-up angiography in the animals revealed patency of all renal and carotid stents, however, 2/7 coronary stents in the animals revealed angiographic lumen narrowing (> 20%) at 20 and 52 weeks. Histologic examination revealed neointimal formation at the stent site with an average neointimal thickness ranging from 325-650 microns. CONCLUSION: This stent was safe in this animal model, easily deployed, had excellent radio-opacity and with good short-term patency without anticoagulation. Clinical trials and experience is underway. PMID- 10155096 TI - Results of a national survey on anticoagulation for PTCA. AB - In order to assess the current practice patterns in the United States for anticoagulation during PTCA, a survey was sent to the ACC membership. A total of 377 surveys from physicians performing PTCA were tabulated; 5 (1.3%) respondents performed < 20 PTCAs/year, 128 (34.0%) performed 20-75 PTCAs/year, 141 (37.4%) performed 75-150 PTCAs/year, 98 (26.0%) performed > 150 PTCAs/year and 5 (1.3%) did not report their volume. Seventy-eight (20.7%) were at university hospitals 153 (40.6%) were at other teaching hospitals, 142 (37.7%) were at non-teaching hospitals and 4 (1.1%) did not report their institutional affiliation. A total of 76.8% of respondents routinely started with a 10,000 U bolus of heparin, while only 3.2% of respondents used only a weight-adjusted heparin bolus. Fifty-nine percent of respondents routinely used intra-procedure heparin infusions, usually 1000 U/hr. Anticoagulation monitoring was used by 92.6% of respondents during PTCA, almost always activated clotting times (ACTs). Of the 335 physicians who used ACTs to guide heparin therapy during PTCA, 59.1% used the Hemochron device, 16.7% used the HemoTec device, and 24.2% did not know which machine they used. Lower volume operators and operators at non-teaching hospitals were more likely not to know the type of ACT machine used. Post-procedure heparin infusions (usually titrated to an aPTT > 2 x control) were used by 70.3% of respondents. Lower volume operators were more likely to use post-procedure heparin infusions. Thus, heparin therapy for PTCA continues to be largely empiric, although the vast majority of cardiologists surveyed use ACT-guided heparin therapy for the procedure.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155097 TI - PTCA using the right radial artery access site. AB - In order to evaluate the right radial artery approach (RRA) in PTCA, our first 50 patients (pts) who had undergone PTCA from this access site were evaluated. Seventy-eight percent of pts were male, 68% had unstable angina or recent MI. Seventy-seven lesions were dilated (31 type A, 32 type B, 13 type C). Access time was 4.3 +/- 2.4 minutes (min). Six French Voda and multipurpose guide catheters were primarily utilized (mean 1.2 guides/case). Several different balloon types were used satisfactorily (mean 1.5 balloons/case). Sheaths were pulled 3.4 +/- 1.2 hours post-procedure when ACT was less than 200 seconds. Compression time was 24.8 +/- 11 and heparin was immediately resumed. No access site complications occurred. Results were compared to a cohort of 100 pts who had undergone PTCA from the right femoral artery approach (RFA). PTCA time, fluoroscopy time, contrast utilized, primary success rate, emergency bypass and cath lab charges were the same in both groups. Access site complications were significantly less in the right radial group (0 RRA vs. 4 RFA, p < .02). Post PTCA length of stay (1.9 +/- 0.3 vs. 3.4 +/- 0.6, p < .05) and total hospital length of stay (3.7 +/- 0.5 vs. 5.2 +/- 0.6, p < .05) were significantly less in the radial group. As a result of the shorter hospital stay, total hospital charge was less in the radial group (14,730 +/- 882 vs. 17,461 +/- 908, p < .05). CONCLUSION: Results of PTCA performed from RRA are similar to those from RFA with a significant reduction in access site complications.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155098 TI - Difficult mitral valvuloplasty: an "over the wire" modification of Inoue technique. AB - Failure to cross the mitral valve remains an important cause of the technical failure in performing mitral valvuloplasty with the Inoue technique, especially during initial experience of the operator. We report two such cases where conventional methods failed and an "over the wire" modification of the Inoue technique had to be utilized. This particular modification can be beneficial in the rare cases where negotiating the Inoue balloon across the mitral valve is particularly difficult. PMID- 10155099 TI - Asystole associated with herpes simplex encephalitis. PMID- 10155100 TI - Comparison of clinical outcome after elective and "bail out" coronary stent insertion. AB - BACKGROUND: Coronary stents may be used electively during percutaneous transluminal coronary angioplasty (PTCA) or as a "bail-out" device to treat abrupt or threatened vessel closure following PTCA. OBJECTIVE: To compare the clinical outcome of elective and "bail-out" coronary stent insertion. DESIGN: A retrospective analysis of all patients receiving coronary stents. SETTING: Tertiary referral center performing over 400 PTCA procedures a year. PATIENTS: Fifty-six patients (42 male), mean age 57 (range = 32 to 78) years received 67 Palmaz-Schatz coronary stents. Forty-nine stents were deployed as "bail-out" in 41 patients (abrupt vessel closure in 15 and threatened vessel closure in 26) and 18 stents were deployed electively in 15 patients. MAIN OUTCOME MEASURES: Myocardial infarction, repeat angiography, coronary artery bypass graft surgery and death. RESULTS: Stents were successfully deployed in 56/62 (90.3%) patients. In-hospital events were significantly more common in the "bail-out" group compared to the elective group. The in-hospital events, comparing the "bail-out" group versus the elective group, were as follows: Death 2/41 (4.9%) vs 0/15 (0%), coronary artery bypass graft surgery (CABG) 8/41 (19.5%) vs 0/15 (0%), stent thrombosis 3/41 (7.3%) vs 0/15 (0%), and myocardial infarction 6/41 (14.6%) vs 1/15 (6.7%) respectively. After discharge no patient died or had CABG. One patient in the "bail-out" group had a myocardial infarct (late stent thrombosis). Two patients from each group had repeat angiography because of recurrent angina in the 6 month follow up period. CONCLUSION: "Bail-out" stenting has an increased incidence of in-hospital complications compared to elective procedures. If these short-term problems can be overcome however, the clinical events in the first 6 months after leaving hospital are low and similar to patients under-going elective procedures. PMID- 10155101 TI - Elastic recoil following percutaneous transluminal coronary angioplasty and Palmaz-Schatz stent implantation. AB - The post-procedural elastic recoil in 133 lesions treated with the Palmaz-Schatz stent was compared to 133 matched lesions treated with balloon angioplasty to determine the role of prevention of elastic recoil in the creation of a larger initial luminal diameter. Elastic recoil was defined as the difference between the maximal diameter of the inflated balloon and the minimal luminal diameter of the dilated segment immediately after the procedure and was evaluated by quantitative coronary angiography. Overdilatation was defined as a dilatation induced by a balloon with a maximal diameter larger than the pre-procedure reference diameter. The percent diameter stenosis was reduced from 73% to 31% in the balloon angioplasty group and from 72% to -4% in the stent group (31% vs. 4%, p < 0.01). Elastic recoil was significantly larger in the balloon angioplasty group than in the stent group (0.94 +/- 0.29 mm vs. 0.09 +/- 0.09 mm, p < 0.01). Overdilatation and lesion morphology had no significant effects on elastic recoil in the stent group. In the balloon angioplasty group, overdilatation, noncalcified lesions and eccentric lesions were associated with increased elastic recoil. These results indicated that the larger post-procedural luminal diameter associated with the Palmaz-Schatz stent was primarily the result of prevention of elastic recoil, which was not influenced by the degree of overdilatation or lesion morphology. PMID- 10155102 TI - Restenosis following placement of an intracoronary heparin treated tantulum stent in the hyperlipidemic miniature swine model. AB - Restenosis persists as an important factor limiting a favorable long term outcome following mechanical revascularization. The objective of the present study was to compare the effects of an intracoronary heparin treated tantalum prototype stent and balloon angioplasty on intimal hyperplasia, luminal diameter, and thrombosis in a porcine restenosis model. Male miniswine maintained on a high cholesterol diet and 325 mg aspirin per day underwent cardiac catheterization and oversized balloon injury to the right and left circumflex coronary arteries. Two weeks later one artery was either balloon injured again or implanted with a stent. No additional anticoagulation following stent placement was given, however aspirin was continued throughout the study. At four weeks, the coronary arteries were harvested and prepared for histologic examination and blinded quantitative morphometric analysis. The prototype stent was successfully deployed in 10 coronary arteries. Histological examination at explant revealed no evidence for thrombus or platelet aggregation. The angiographic luminal diameter of stented vessels was not significantly different from the diameter measured prior to implantation. In contrast, the angiographic diameter of balloon injured vessels was significantly decreased (4.4 +/- 0.4 mm2, balloon injured, vs. 5.8 +/- 3.3 mm2, control; p < 0.05). Stented arteries showed significantly more intimal hyperplasia, compared to balloon injured vessels (2.99 +/- 0.58 mm2 intimal area, stented arteries vs. 0.38 +/- 0.15 mm2 intimal area, control arteries; p < 0.05). In conclusion, heparin treated tantalum wire prototype intracoronary stents were successfully deployed in swine coronary arteries with no evidence for thrombus formation. Despite a significant intimal response, luminal diameter was preserved in stented vessels. The data suggest that a heparin treated tantalum wire prototype intracoronary stent may be an effective method of coronary revascularization that results in the preservation of luminal diameter without thrombotic occlusion. PMID- 10155104 TI - Can electrophysiology deliver a knock-out punch for atrial fibrillation and ventricular tachycardia? A ringside view. PMID- 10155103 TI - Iatrogenic left main coronary artery stenosis. AB - Iatrogenic left main coronary artery stenosis is a potentially life-threatening complication of cardiac valve replacement surgery due to injury by perfusion cannulas. This requires prompt clinical recognition and diagnosis by repeat coronary angiography, and treatment by early coronary artery bypass grafting. We present 3 patients who had normal coronary arteries prior to valve replacement surgery, and who developed severe left main coronary artery stenosis after surgery. Accelerating angina and refractory ventricular arrhythmia were presenting clinical manifestations. Coronary artery bypass grafting was successfully performed in all 3 patients. PMID- 10155105 TI - Six month outcome and determinants of adverse clinical events after successful excimer laser coronary angioplasty. ELCA A.I.S. Multicenter Registry. AB - OBJECTIVE: To describe the six month outcome and predictors of adverse clinical events following successful excimer laser coronary angioplasty (ELCA). DESIGN: Retrospective analysis of comprehensive data collected at time of initial procedure and during planned follow-up intervals. SETTING: There were 35 participating institutions throughout the United States. PATIENTS: The study population was comprised of 3,069 patients who had successful ELCA and completed follow-up at 6 months, representing 91% of eligible cases. Forty percent had prior balloon angioplasty and 34% had prior bypass surgery. MEASUREMENTS: Patient symptomatology was assessed by Canadian Cardiovascular Society functional (CCSF) class. Interim adverse clinical events [death, Q wave myocardial infarction (QMI), repeat intervention, bypass surgery, and a composite end-point] were tracked. Twenty-six pre-ELCA clinical, angiographic and procedural variables were evaluated to assess their ability to predict outcome. RESULTS: At 6 months, there was 2.8% mortality, 2.5% incidence of QMI, and 28.7% required either repeat intervention or bypass surgery. Overall, 69.2% of patients had no adverse event. In this cohort, the pre-ELCA CCSF class grade was 2.7 +/- 1.2, but at 6 months, it was 0.7 +/- 1.1 (p < 0.001). The multivariate predictors of the composite end point were gender, stenosis location, and rest and unstable angina. CONCLUSIONS: There is an excellent 6 month outcome after successful ELCA in this selected population with complex coronary artery disease. The majority of patients without interim events enjoy significant alleviation of symptoms. The predictors of adverse events are clinical rather than angiographic. PMID- 10155106 TI - The effects of intravascular stents on vasomotion in porcine coronary arteries. AB - Intravascular stents are being increasingly utilized in the treatment of atherosclerotic coronary artery disease, however little is known about the effects of stents on coronary vasomotion. The purpose of the present study was to compare the effects of a heparin treated tantalum stent and balloon injury on coronary artery vasorelaxation and vasoconstriction. Male miniswine underwent cardiac catheterization and oversized balloon injury to the right and left circumflex coronary arteries. After two weeks, one artery was either balloon injured again, or underwent implantation of a stent. Four weeks later, the coronary arteries were prepared for in vitro isometric ring studies. Vasodilator responses to bradykinin and A23187 calcium ionophore were significantly impaired in balloon-injured vessels. The bradykinin and A23187 responses in stented vessels showed significantly less vasorelaxation, compared to both balloon injured and normal vessels. There were no significant differences between any of the groups in their vasodilator response to nitroprusside. Vasoconstrictor responses to acetylcholine were significantly greater in balloon-injured vessels, compared to normal vessels. Stented vessels, however, showed markedly less vasoconstriction to acetylcholine compared to both balloon-injured and normal vessels. The maximal KCI vasoconstrictor responses in balloon injured vessels and normal controls were not significantly different. However, the maximal KCI responses in stented vessels showed significantly less constriction compared to both balloon injured and normal vessels. In conclusion, the data demonstrated that coronary arteries implanted with a heparin treated tantalum stent were capable of vasomotor activity. Both conventional balloon angioplasty and stents resulted in impaired endothelium-dependent vasorelaxation. Endothelium independent vasorelaxation, however, was not impaired.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155107 TI - Treatment of refractory recurrent multifocal atrial tachycardia with atrioventricular junction ablation and permanent pacing. AB - Multifocal atrial tachycardia is a difficult clinical problem generally associated with acute cardiorespiratory illness. The purpose of this study was to assess the feasibility and clinical utility of atrioventricular junction ablation plus permanent transvenous pacemaker implantation as therapy for uncontrolled refractory multifocal atrial tachycardia. Three patients with uncontrolled refractory multifocal atrial tachycardia underwent atrioventricular junction ablation plus permanent transvenous pacemaker implantation. Complications and outcome of each procedure was monitored and both objective and subjective assessment of physical functional capacity was assessed by a semiquantitative examination. Ablation procedures controlled the ventricular response in all patients. There were no complications related to the ablation procedure or implantation of permanent transvenous pacing system. All patients demonstrated subjective improvement in symptoms. Palpitations were virtually eradicated in these patients and all enjoyed significant improvements in rest and effort dyspnea, exercise tolerance and asthenia. Objective assessment of functional class also demonstrated significant improvements. Atrioventricular ablation plus permanent transvenous pacing offers a safe and effective therapy for uncontrolled refractory multifocal atrial tachycardia. PMID- 10155108 TI - Skinning an old ailment (multifocal atrial tachycardia) with a new treatment (radiofrequency catheter ablation) PMID- 10155109 TI - A technique for difficult-to-cross ostial side-branch lesions. PMID- 10155110 TI - Antegrade filling of an occluded right coronary artery via collaterals from a separate conus artery, a previously undescribed collateral pathway. AB - The conus artery is known to be a frequent supplier of collaterals to the LAD and distal marginal branches of the RCA. In this report we describe a patient with an ostial RCA occlusion who was found to have, during selective conus artery injection, excellent collaterals directly to the proximal RCA. This anatomy was initially mistaken for diffuse disease of the ostium and proximal portion of the RCA. PMID- 10155111 TI - Clinical and angiographic outcome after Palmaz-Schatz stent implantation guided by intravascular ultrasound. AB - Intracoronary stents can be implanted with a low incidence of stent thrombosis (< 1%) when the stent procedure is guided by intravascular ultrasound. The long-term clinical and angiographic effects, however, have not been reported. This study assesses the 6 month clinical and angiographic results of a consecutive series of patients with intravascular ultrasound guided Palmaz-Schatz stent deployment that were not treated with subsequent anticoagulation after a successful stent implantation procedure. From March, 1993 to April 1994, 411 patients underwent Palmaz-Schatz stent implantation. There were 26 patients that had uncomplicated Palmaz-Schatz stent implantation that were treated with a standard anticoagulation regimen that are not evaluated in this study. Thus, this study includes an assessment of 385 patients that had either a successful intravascular ultrasound guided stent implantation procedure and did not receive post procedure anticoagulation or had a procedural complication. Procedural success was achieved in 369 patients (96%). Clinical success (procedure success without early post procedure event) was achieved in 363 patients (94%). There were 2 acute stent thrombosis events (0.5%) and 1 subacute stent thrombosis (0.3%) in the group of 369 patients with 454 lesions treated without anticoagulation. At 6 month clinical follow-up the incidence of myocardial infarction was 4.9% and the rate of coronary bypass surgery was 6.2%. There was a 2.1% incidence of death. Emergency intervention (emergency angioplasty or bailout stent implantation was necessary in 3 patients (0.8%). The total incidence of repeat percutaneous intervention was 11.4%. By 6 months clinical follow-up, major events had occurred in 19.2% of patients. The angiographic lesion restenosis rate, according to 50% diameter stenosis criteria, was 19%. The incidence of restenosis per patient was 22%. In conclusion, intravascular ultrasound guided Palmaz-Schatz can be performed without subsequent anticoagulation with a low incidence of stent thrombosis and acceptable clinical and angiographic outcome at 6 month clinical follow-up. PMID- 10155112 TI - Palmaz-Schatz stent implantation in the treatment of saphenous vein graft lesions. PMID- 10155113 TI - New coronary stenting management. PMID- 10155114 TI - Advances in post stenting medication protocol. PMID- 10155115 TI - Coronary stenting: costly or cost-effective? AB - In today's health care climate, decisions about new technologies need to reflect measures of cost as well as clinical benefit. By estimating the cost effectiveness ratio for a new treatment compared to a current standard (e.g., stenting as compared to conventional PTCA), it is possible to decide whether the new treatment represents an efficient use of limited health care resources. In this analysis, stenting carried a $2500 greater in-hospital cost, which was partially defrayed by a $1900 savings in follow-up costs due to reductions in abrupt closure and restenosis. The net $600 increase in cumulative costs for stenting "bought" additional quality-adjusted life expectancy at a cost effectiveness ratio of $33,700/QALY over conventional angioplasty, giving stenting a cost-effectiveness comparable to many other accepted medical therapies. Any future reduction in stent costs (e.g., by reducing length of stay or vascular complications) would improve this estimate of relative cost effectiveness. PMID- 10155116 TI - New challenges in coronary stenting. AB - Coronary stenting with the Palmaz-Schatz coronary stent has evolved into an exciting discipline which has undergone radical change through the years. Custom length stents which are heparin-coated and more radiopaque promise to enhance both the safety and efficacy of the procedure in the future. It is hopeful that with elimination of subacute stent thrombosis, vascular bleeding, and lower restenosis rates with the heparin coating, the Palmaz-Schatz coronary stent will be the most cost-effective therapy in the majority of patients with disease of both native coronary arteries and saphenous vein bypass grafts. PMID- 10155117 TI - Transradial Palmaz-Schatz coronary stenting on an outpatient basis: results of a prospective pilot study. AB - BACKGROUND: The applicability of Palmaz Schatz coronary stent implantation is limited by bleeding complications and prolonged hospitalization. Coronary stenting on an outpatient basis, may be the ultimate means to reduce costs of this treatment. Since bleeding and stent occlusion were infrequent complications in a group of 100 ambulatory patients who underwent stent implantation via the radial artery in our department, we performed a pilot study to determine the feasibility of using coronary stenting on an outpatient basis. METHODS: Patients selected for Palmaz Schatz stent implantation, were adequately adjusted on coumadin. At an INR > 2.5, stenting was performed via the radial approach. Based on pre-, post- and procedural criteria, considering clinical status, procedural course and outcome, absence of predictors for stent occlusion and of events during 4 to 6 hours observation, patients were considered candidates for same-day discharge. Heparin was administered only during the procedure. Immediately after the procedure, the arterial sheath was removed. Patients were mobilized and were discharged with a pressure dressing over the puncture site. Follow-up was performed on the next day, at 2 weeks and at one month. RESULTS: Between May and September 1994, 47 patients underwent Palmaz Schatz stent implantation via the radial artery. Of these, 27 remained hospitalized for reasons, considered to be incompatible with outpatient treatment. Twenty patients (CCS-class III and IV; n = 17 (85%)) received 29 stents for 23 lesions, distributed in 21 vessels and were discharged the day of treatment. No cardiac or bleeding events were encountered within 24 hours. At 2 weeks follow-up, one patient was readmitted (day 4) because of a bleeding abdominal aortic aneurysm, requiring surgery. At 1 month follow-up, no bleeding, entry-site and cardiac complications were noted. CONCLUSION: Since no complications were encountered (95% confidence interval; 0-17%) in the first 24 hours after optimal coronary stent implantation in patients with an adequate preprocedural level of anticoagulation, a larger feasibility study of outpatient coronary stenting will be undertaken. PMID- 10155118 TI - Evolving balloon inflation strategies: analysis of patterns over 15 years and relationship to lesion morphology. PMID- 10155119 TI - Use of the perfusion balloon as a primary dilation device. AB - The development of more user-friendly and versatile perfusion balloon catheters has increased the use of prolonged dilations as a primary catheter treatment for coronary artery disease. In a multicenter randomized trial, the use of these devices to prolong initial inflation durations resulted in improved angiographic outcomes when compared with conventional short dilations. This benefit was most apparent in stenoses with complex morphology. Use of the perfusion balloon as a primary device is also appealing because of its ability to reduce anginal pain and hemodynamic changes during balloon inflation. Clinical experience suggests that primary use of the perfusion balloon may improve patient stability during procedures in which the treated segment jeopardizes a large percentage of the functional myocardium. An observational series has demonstrated the excellent outcomes which can be achieved in selected patients using a strategy of primary perfusion angioplasty with stent bailout when needed. Selection of a perfusion balloon rather than a conventional balloon as a primary device has the potential to decrease overall balloon usage approximately 25%, but the economic benefit of this strategy will depend on the cost of the perfusion balloon relative to a conventional balloon. Retrospective analyses suggest that perfusion angioplasty as a primary treatment strategy compares favorably with directional atherectomy for left anterior descending lesions. The use of coronary stents has not been directly compared to perfusion angioplasty as a primary treatment for coronary lesions, but use of a perfusion balloon as an initial device may have broader applicability, lower cost and less technical demands on the operator compared to stent deployment. In conclusion, when overall applicability, clinical outcome and cost are considered, the primary strategy of prolonged dilation with a perfusion balloon should have an important role in coronary intervention. PMID- 10155120 TI - Preliminary report of the International Primary Perfusion Registry. New Mexico Heart Institute. PMID- 10155121 TI - Bail-out coronary angioplasty. PMID- 10155122 TI - Clinical experience with the ACS RX Lifestream coronary dilatation catheter: a new low profile perfusion balloon catheter. AB - BACKGROUND: Although the use of the perfusion balloon catheter (PBC) has been widely accepted, there are some indicational limitations in percutaneous transluminal coronary angioplasty (PTCA). A new low profile perfusion balloon catheter, the ACS RX Lifestream Coronary Dilatation Catheter, was developed by Advanced Cardiovascular Systems, Inc. in which material and structures were improved to reduce previous limitations. PURPOSE AND STUDY DESIGN: In order to evaluate the ACS RX Lifestream Catheter's performance not only in PTCA but also in stent implantation, we used the catheter in 45 consecutive patients (male = 35, mean age 66 years) with combined use of 6F guiding catheter. Exclusions included total occlusions, long diffuse and acute MI lesions. There were 4 with Left Main Trunk Disease (LMTD), 15 with single vessel disease, 26 with multi vessel disease, 20 with prior MI, 4 with prior CABG, and 10 with unstable angina. In bare stent procedures, a Johnson & Johnson metal stent was mounted on an ACS RX Lifestream Catheter previously used for predilation. Stent delivery and post dilatation were performed using the same balloon. RESULTS: Forty-nine lesions in 45 cases (de novo lesion-31) including 7 of Type A, 15 of Type B1, 19 of Type B2, and 8 of Type C lesions were successfully dilated without any complications. Primary guiding catheter use was 6F in 40, 7F in 2 and 8F in 3 cases. The perfusion balloon was used alone in 30 cases and combined with stent placement in 15 cases. In 40 cases of 6F use, the ACS RX Lifestream Catheter could not cross the lesion in 3 cases at first attempt, of which 2 cases were successfully dilated with the balloon after predilatation with standard low-profile balloon catheters. Two cases with 7F use were bail-out cases after PTCA for long diffuse lesions. In one case of 8F guide use, flow patterns of ACS RX Lifestream Catheters and ACS RX Flowtrack Coronary Dilatation Catheters were examined with a flow-wire in the same lesion for comparison. All 15 stent cases performed using bare technique (10 with 6F, 2 with 7F and 3 with 8F guiding catheters) including 7 primary and 8 secondary use, were successful. Percent diameter stenosis pre dilatation was 81% and 12.8% post-procedure. CONCLUSION: ACS RX Lifestream Catheter is a useful device in both PTCA and bare stent procedures. Consequently, it is possible to expand its indications to more difficult types of lesions. PMID- 10155123 TI - Perfusion balloon angioplasty in patients with complex coronary lesion morphology. PMID- 10155124 TI - Active perfusion: current status. PMID- 10155125 TI - TEC before stent implantation. PMID- 10155126 TI - Optimal therapy for degenerated saphenous vein graft disease. PMID- 10155127 TI - TEC for old grafts, TEC for new clots: if you don't like it, you're not using it right. PMID- 10155128 TI - TEC in acute ischemic syndromes. PMID- 10155129 TI - Photodynamic therapy. AB - Photodynamic therapy (PDT) is a new treatment for solid tumors utilizing the combined action of light and a photosensitizing drug. Laser-fiber optic delivery systems make it practical to treat superficial and interstitial cancers, including malignancies of the skin, head and neck, esophagus, endobronchial tract, stomach, urinary bladder, female genital tract, and other sites. The putative action mechanism in PDT involves photochemical destruction of tumor tissue membranes mediated by singlet molecular oxygen. Light dosimetry modeling based on tissue optics is applicable for treatment planning. Related research areas include non-invasive optical diagnosis and imaging, development of new PDT drugs and light sources, and the extension of PDT methods to treatment of atherosclerotic vascular disease and blood detoxification. PMID- 10155130 TI - Concepts of laser applications in medicine and surgery. PMID- 10155131 TI - Laser operator training and competency assessment in the community hospital setting. AB - At the 279 bed Marymount community hospital, Cleveland, Ohio, the importance of providing a safe laser environment for patients as well as staff was identified. The decision was made to cross-train all full-time RNs, LPNs, and SAs to allow flexibility in staffing all laser procedures with a qualified operator. A competency based training program was implemented, utilizing a combination of techniques to assist the adult learner. Selected video tapes were used to teach laser physics and applications. Comprehension was assessed through written and oral quizzing. Individual time was spent familiarizing trainees with the equipment and accessories. Practice setups were performed until that individual reached a comfort level satisfactory to him/her and the laser coordinator. Actual experience in the various surgical specialties was dependent upon our case load. Initially very close supervision was provided. Each trainee was gradually given more autonomy as his/her skills improved and permitted to operate the laser independently after passing our competency assessment. During the first year, each operator was given competency assessment reviews at regular intervals. This approach was found to have both strengths and weaknesses and the program was modified accordingly. PMID- 10155132 TI - Scientific assay methods as the basis for glove selection. AB - Allergies to latex proteins and glove chemicals are increasing in the clinical practice setting. Inasmuch as latex is ubiquitous in the health environment, individuals may be exposed to latex antigens by a number of different routes, including compromised skin, mucous membranes of the respiratory and urogenital tracts, and internally during surgery. As demonstrated by numerous research articles, the key factors that appear to play a role in acquired latex hypersensitivity are chemicals used in the manufacture of products; the level of residual latex proteins, and the presence of glove powder, which binds latex protein. Currently, devices and materials containing latex are not labeled, although this may be rectified by the FDA in the near future. Until products are labeled, it is important for physicians to familiarize themselves with the routes of sensitization, variations in assay methods, and the type and amount of allergen in products in order to select the safest product for patient use and personal protection. PMID- 10155133 TI - Negative effects of powdered latex gloves in clinical dentistry. AB - With the advent of CDCs "universal precautions" and OSHA's bloodborne pathogen standard, the number of health-care workers wearing latex gloves has increased dramatically in the law few years. Reports of irritation, contact, and allergic reactions to powdered latex gloves in both medicine and dentistry are on the rise as well. However, other problems related to powdered gloves and their effect on clinical dentistry are just beginning to be addressed. One recent study demonstrated that the starch used as a lubricant on latex rubber gloves significantly reduced the shear bond gloves significantly reduced the shear bond strength of etched porcelain to etched enamel with a resin adhesive system by nearly 40%. Question also arise as to the proper handling of dental implants and the effect that powdered gloves may have on their success based on the negative effects of post-surgical foreign body granulomas reported in the medical community. PMID- 10155134 TI - Barrier breach of surgical gloves. AB - The barrier properties of natural rubber latex gloves have been of clinical interest since the concept of using an integrity monitor was introduced by me over 30 years ago. Although surgeons expect their gloves to serve as an effective barrier during use, products can and do fail. Failure is often unrecognized, resulting in the wearer's exposure to potential pathogens and the patient to microorganisms shed by surgical team members. Although a variety of solutions have been suggested (double gloving, cut-resistant gloves), these remedies do not alert the surgeon to a breach of barrier, the cost and consequences of which are astronomical to the health system. As a result, some form of breach detection device is now recommended to minimize the likelihood of exposure, infection, and/or allergy. PMID- 10155135 TI - Biomechanics of surgical glove expansion. AB - The purpose of this study was to correlate the latex gloves' susceptibility to hydration to its development of glove expansion or irreversible elongation of the latex glove. During hydration, the Micro-Touch glove exhibited significantly more creep strain than did the Biogel gloves. Similarly, the Micro-Touch glove exhibited glove growth, while the Biogel glove maintained a uniform fit during hydration. PMID- 10155136 TI - Risk analysis as the basis for surgical glove selection. AB - The growing use of outcomes research will have a significant effect on the way surgeons make decisions concerning glove product selection. These effects will be both direct and indirect, as payers begin to use outcome data to develop practice guidelines. to reduce morbidity and mortality rates, and to alleviate long-term cost and consequences of acquired latex allergy or powder-related postoperative complications in patients. This article reviews elements of risk associated with surgical gloves. PMID- 10155137 TI - Latex allergy--a clinical perspective. AB - Latex allergy has been increasingly recognized in the past 6 years. Defined risk groups are health-care workers, spina bifida children, and possibly food allergy patients. Powdered latex gloves and latex barium enema tips are products most commonly associated with allergy. Clinically, patients present with contact urticaria, allergic rhinoconjunctivitis, asthma, and anaphylaxis. At least 15 deaths are reported to have occurred because of latex allergic reactions. Severe occupational latex allergy can result in removal of the affected individual from the workplace. This will have important cost implications. The only presently available treatment of latex allergy is avoidance. PMID- 10155138 TI - Long-term performance and wear of ultrahigh-molecular-weight polyethylene in total joint replacement prostheses: a brief overview and perspective. AB - Ultrahigh-molecular-weight polyethylene (UHMWPE) is used extensively in total joint replacements, particularly in hip and knee joints. At present, there is extensive concern with the long-term consequences of wear of this material, specifically osteolytic reactions to wear debris. The relationship of wear behavior to polymer morphology is almost completely unknown. Information on the effects of radiation sterilization on crystallinity is available, but gross conflicts exist. A central problem is the release, over long time periods, of huge numbers of submicron particles by wear. It has not been generally recognized that short-term, severe wear and long-term wear of UHMWPE in total joint replacements are very different in character and results. When the long-term wear regime is correctly defined, it is clear that knowledge of the influence of structure and properties on this specific phenomenon is almost completely absent. PMID- 10155139 TI - Clinical and laboratory investigations of fretting and corrosion of a three component modular femoral stem design. AB - A retrieval analysis of three modular femoral stems in vivo up to 25 months were examined using laboratory-based comparisons of similar devices as controls. The internal taper connection of each retrieved femoral component, and the laboratory controls were evaluated using SEM, EDAX, and epoxy vacuum infiltration. No corrosion of the substrate was detected for any of the retrievals. Fretting was mild on one retrieval and the in vitro-fatigued component, whereas minor fretting was observed for the other retrievals. Particulate debris was not evident as revealed by the epoxy infiltrate of the modular junction. PMID- 10155140 TI - The hydration phenomenon in natural rubber latex gloves and its effect on electronic glove monitors. AB - A physical model is presented to explain the phenomenon of hydration in natural rubber latex (NRL) gloves and to account for the observed decrease in electrical resistance of these gloves when exposed to normal saline solution. Microporosity in the rubber is attributed to failure of all latex particles making up a typical glove to completely coalesce with each other and form a continuous film free of interstitial voids. Native proteins and chemicals used in the manufacturing process are suspected of inhibiting coalescence and causing allergic reactions to some wearers after repeated uses. The effect of hydration on the performance of electronic glove monitors is discussed. Glove monitors that can distinguish between hydration and holes are considered to be the most reliable. PMID- 10155141 TI - Measurements of long-term periprosthetic bone changes around a unique composite implant. AB - Periprosthetic bone changes around a non-bonded composite implant were measured after 6.5 years of implantation. The implanted and unimplanted femora of three canines were cut simultaneously at 3-mm increments. Cortical bone changes at all levels were determined from contact radiographs of the sections using an image analysis system. Alternating sections were cut into 3-mm cubes. The elastic properties of the cancellous bone cubes were determined using ultrasonic techniques. The method of directed secants was used to determine the cancellous bone orientation. The proximal cortical wall thickness on the implanted side increases by an average of 30%. The cancellous bone directly adjacent to the implant was an almost continuous shell encircling the prosthesis. The periprosthetic orientation was circumferential around the implant. The elastic and shear moduli of the cancellous bone increased on the implanted side. The bone changes are currently being correlated with results from finite element calculations. PMID- 10155142 TI - Recommendations on whole blood sampling, transport, and storage for simultaneous determination of pH, blood gases, and electrolytes. International Federation of Clinical Chemistry Scientific Division. AB - Pre-analytical variables, e.g., specimen collection, transport, and storage, can contribute significantly to inaccurate pH, blood gas, and electrolyte values. The International Federation of Clinical Chemistry (IFCC), through its Committee on pH, Blood Gases and Electrolytes, has developed specific recommendations to minimize the undesirable effects of pre-analytical variables. The Committee has drawn upon the experiences of its own members as well as published data by others. Specifically, the Committee has included pertinent guidelines and suggestions by the IFCC Working Group on Selective Electrodes (WGSE), the National Committee on Clinical Laboratory Standards (NCCLS), and the Electrolyte/Blood Gas Division of the American Association for Clinical Chemistry (AACC). This paper will familiarize the reader with the effect of different types of specimen containers and anticoagulants. It discusses important aspects of specimen collection procedures including patient status and special precautions during specimen collection from indwelling catheters or cannulae. The paper also identifies different requirements in storage and transport of specimens for blood gas and electrolyte analysis. PMID- 10155143 TI - Laboratory tests in rheumatology. AB - The most commonly used laboratory tests in the diagnosis and monitoring of rheumatic diseases are reviewed. Particular emphasis is placed on antinuclear antibodies as markers of specific rheumatic disorders and disease subsets. The use of synovial fluid tests to differentiate between inflammatory and noninflammatory rheumatic disorders is described as well as the use of common hematological tests. PMID- 10155144 TI - Transfusion-transmitted diseases. Current status and future directions. AB - Blood transfusion is associated with a number of potential risks, including the transmission of infectious diseases. Although a zero-risk blood supply may never be attainable, much effort is directed toward the identification of blood donors with evidence of transmissible infectious agents. This article summarizes the current knowledge of transfusion-transmitted diseases. In addition, possible future directions in decreasing the incidence of such diseases are discussed. PMID- 10155145 TI - Clinical use of laboratory thyroid tests and investigations. AB - Laboratory thyroid testing involves in vitro tests for autoimmune thyroid disease, thyroid dysfunction and neoplasia, in vivo investigations of thyroid function, and investigations of thyroid morphology. The authors describe, in tabular form, the diagnostic information carried by the tests and their clinical utility as well as clinically relevant interferences. PMID- 10155146 TI - The investigation of adrenocortical disorders. AB - This article reviews effective approaches to the investigation of cortisol hypersecretion (Cushing's syndrome), adrenal failure, and congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency. These conditions generate most of the investigations of adrenocortical function in the clinical chemistry laboratory. PMID- 10155147 TI - The endocrine investigation of disorders of sodium and water homeostasis. AB - This article reviews critically the investigation of polyuric states, hyponatremia with particular emphasis on the syndrome of inappropriate antidiuretic hormone secretion, and primary hyperaldosteronism. Details of some essential tests are given with comments on interpretation of results. PMID- 10155148 TI - The diagnostic application of serum growth hormone, insulin-like growth factor (IGF), and IGF binding protein measurements. AB - Selected combinations of tests for growth hormone and the growth mediating peptides, insulin-like growth factors, and their binding proteins have improved the diagnostic reliability of the procedures used in the investigation of growth abnormalities (GH deficiency, GH and IGF receptor deficiencies, GH excess, diabetes, or undernutrition) and in malignancies associated with hypoglycemia. PMID- 10155149 TI - Endocrine investigation of gonadal dysfunction. AB - This article reviews the hormone assays available for the assessment of gonadal function and some pitfalls in their interpretation. Simple strategies are suggested for the investigation of disorders of gonadal function in males and females. Emphasis is placed on relating the indications for hormone assays to the appropriate clinical context. PMID- 10155150 TI - Investigation of calcium disorders. AB - The advent of new two-site immunometric assays for intact parathyroid hormone (PTH) measurement has enhanced the interpretation of results in many patients under investigation for hypercalcemia. The aim of this article is to give practical advice on the use of the new intact PTH methods and other tests for the investigation of the more common disorders of calcium metabolism. PMID- 10155151 TI - The investigation of thyroid function. AB - The measurement of thyrotropin (TSH) by a third-generation assay (functional sensitivity 0.01-0.02 mU/L) offers the single best test of assessing thyroid status and is more cost effective than measurement of thyroxine (T4) as a first line test. However, in certain situations, e.g., nonthyroidal illness (NTI), secondary thyroid disease, early treatment of hyperthyroidism, early pregnancy, and heterophilic antibody interference, TSH alone may be misleading, and thyroid hormone measurements are also required. The author's laboratory has found that the measurement of TSH together with free thyroxine (by a nonanalogue method) offers the most speedy and effective first-line strategy for thyroid function testing. Abnormalities in thyroid function tests in euthyroid patients are most likely found in NTI and the elderly. For this reason, thyroid function tests (TFTs) should not be requested in elderly or hospitalized patients unless the presenting complaint is considered to be because of a thyroid problem. PMID- 10155152 TI - Microbiology of the infected total joint arthroplasty. AB - Infection associated with arthroplasty is a relatively rare event, but when it does occur, it is of major consequence for the patient. Many organisms can cause these infections, but most are the results of gram-positive bacteria, with the genus Staphylococcus accounting for at least 50%. Streptococcus and aerobic gram negative bacilli are responsible for another significant percentage. The ability of the organism to produce a slime or glycocalix extracellular layer seems to be a contributing virulence factor for prosthesis-associated infections. Growth, identification, and susceptibility testing of the etiologic agent are performed by the microbiology laboratory, but antimicrobial treatment is usually only successful after removal of the prosthesis. PMID- 10155153 TI - Prevention of deep wound infection after total hip arthroplasty: the role of prophylactic antibiotics and clean air technology. AB - The role of antimicrobial prophylaxis has been established to be the single most significant factor in the prevention of deep wound infection following total hip arthroplasty. The proper dose, duration of treatment, and type of antibiotic have not been definitively established. The effect of clean air technology techniques has not been universally proven in the clinical setting to provide a reduction in the incidence of infection following total hip arthroplasty. The role of these two methods to prevent deep infection following total hip arthroplasty requires further study. PMID- 10155154 TI - Two-stage exchange arthroplasty using a functional antibiotic-loaded spacer in the treatment of the infected knee replacement: the Vancouver experience. AB - Two-stage exchange arthroplasty is currently the method of choice in the treatment of the infected knee replacement. The prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) is a temporary, antibiotic-loaded functional prosthesis that is used as an interim spacer in two-stage exchange arthroplasty. In this prospective series, we report on the early results of the use of the PROSTALAC knee spacer in two-stage exchange arthroplasty of infected knees. A total of 24 knees were treated with this prosthesis, and were reviewed at a mean follow-up time of 2.2 years. Infection was controlled in all but 2 knees, for an infection cure rate of 91.7%. The patients' function was improved between stages, and motion was maintained in the majority of cases. The significant complications with the PROSTALAC implant in place were tibio-femoral instability, which was corrected with a design modification, and patellar instability, which continues to be a problem. These complications were transient and were not of any significance after the second stage. PMID- 10155155 TI - One-stage exchange in the treatment of the infected total hip arthroplasty. AB - One-stage exchange for deep infection of a joint arthroplasty has a valuable place in our range of techniques but should be utilized with great care. Bacteriological facilities must be of an especially high quality. If the operator lacks experience, it is wise to revert to a more conventional two-stage procedure. I believe that for one-stage exchange, heavily antibiotic-loaded acrylic cement should be used. In this account, results from my hospital show that useful survival can be achieved as well as an acceptable rate of control of the infection. PMID- 10155156 TI - Two-stage reimplantation of the infected hip. AB - To determine the diagnosis of patients with infection after total hip replacement may be very difficult, and successful reimplantation is even more challenging. Surgical debridement, removal of all foreign material, and the prosthesis followed by antibiotic therapy are essential for successful eradication of the infection. Reimplantation of the hip allows for functional recovery of the patient. The optimal time for reimplantation of the prosthesis and the role of antibiotic impregnated cement is less clear. A review of the literature strongly favors a two-stage reimplantation with local antibiotic delivery with successful results of approximately 93%. PMID- 10155157 TI - Nuclear imaging in the diagnosis of the infected total joint arthroplasty. AB - Nuclear medicine can be of great value in diagnosing infected total joint arthroplasties. Bone scintigraphy is very sensitive for the diagnosis of prosthetic infection but is nonspecific. Gallium scintigraphy has been used in conjunction with bone scintigraphy, but this approach has not proven to be as valuable as originally anticipated. Indium leukocyte scintigraphy, especially when correlated with a bone scan and, at times, a bone marrow scan, is now the preferred scintigraphic approach for identifying the infected prosthesis. Newer imaging agents such as technetium leukocytes and radiolabeled antibodies are now being studied to determine their role in the management of prosthetic infection. PMID- 10155158 TI - The incidence of sepsis after total hip replacement arthroplasty. AB - The incidence of surgically acquired infection during the first 2 years after total hip arthroplasty has decreased more than 10-fold since the introduction of the procedure. Advances in surgical procedures, sterile technique, and antibiotic prophylaxis have contributed to the current incidence of less than 0.5% in most major centers. At the present time, the majority of cases are not related to intra-operative contamination, but to late seeding of the joint from bacterial sources elsewhere in the body. Unfortunately, the overall infection rate (when late sepsis is included) remains at over 1%, and will likely increase as the life expectancy of implants is increased and patients are followed up longer. Given that late sepsis is now the most common type of infection involving total hip replacements, attempts to reduce the infection rate must be directed toward this patient population. Methods must include patient education to prevent sepsis, as well as to identify potentially dangerous infections early so they can be treated expeditiously. The development of a sound basis for antibiotic prophylaxis in cooperation with our medical and dental colleagues in this regard will be welcome. The prompt treatment of infections before they can spread to the prosthetic joint is essential for the continued well-being of the total hip arthroplasty patient. PMID- 10155159 TI - The glycocalyx, biofilm, microbes, and resistant infection. AB - Biomaterial implants, traumatized tissues and bone are susceptible to immediate and delayed infections because microbes preferentially adhere to "inert biomaterials" or to damaged tissue surfaces. This type of infection is resistant to antibiotic therapy and most often requires removal of the prosthesis or infected tissue. This article discusses glycocalyx, biofilm, microbes, and resistant infection in prosthesis or infected tissue. PMID- 10155160 TI - Temporary antibiotic loaded acrylic hip replacement: a novel method for management of the infected THA. AB - Postoperative infection after hip joint replacement is an uncommon but potentially devastating complication in contemporary orthopaedics. Management in two stages is the more favored approach in North America. This introduces difficulty with patient management in the interval between stages, delays rehabilitation, and introduces technical difficulty during the second stage. A method has been developed whereby a temporary antibiotic-loaded facsimile of the hip is introduced at the first stage, designed to maintain stability of the joint, length of the limb, and mobility of the patient. It has been used in a total of 86 cases to date. The results in 46 cases with a minimum follow-up of 2 years are reviewed in this article. The infection was controlled in 93.5% of cases. PMID- 10155161 TI - Evaluation and management of infected total knee arthroplasty. AB - Infection after total knee arthroplasty is an infrequent but devastating complication. An understanding of the cause of infection, its diagnosis, and potential treatment options is essential to achieve a satisfactory result. The most successful treatment option is reimplantation with an 89% success rate of elimination of infection. However, some individuals require alternative salvage techniques. PMID- 10155162 TI - Septic total hip arthroplasty patient care management. PMID- 10155163 TI - Surgical nuances of living-donor nephrectomy. PMID- 10155164 TI - Treating male-factor infertility with ICSI. PMID- 10155165 TI - Choosing a revascularization strategy for your patient with CAD. Consider both the clinical presentation and the urgency of the situation. AB - For patients with less severe coronary artery disease, particularly one- or two vessel disease, initial therapy may be with either thrombolytics or angioplasty. In those with more extensive disease (three-vessel or left main artery disease or proximal left anterior descending artery stenosis), bypass grafting can significantly reduce mortality. However, a patient's risk profile markedly influences outcome regardless of the procedure performed. Because angioplasty achieves incomplete revascularization, patients may need repeated angiography or revascularization, or they may have recurrent angina. If bypass graft disease is prevented, surgery may be effective for up to 20 years. PMID- 10155166 TI - Hypothermia: a critical problem in the intensive care unit. PMID- 10155167 TI - Trauma radiology: Part V. Imaging of acute cervical spine trauma. AB - Cervical spine injury constitutes a major cause of morbidity resulting from trauma. The consequences of a missed "significant" injury can be devastating for the patient and can create potential medical legal consequences for involved physicians. Multiple imaging modalities can be applied to imaging of the cervical spine after trauma, including radiography, computed tomography (CT), myelography, CT myelography and magnetic resonance imaging (MRI). Controversy exists concerning the appropriate number of radiographic views required for the screening assessment of cervical spine injuries. CT clarifies uncertain radiological findings, identifies subtle fractures in patients with neck pain or with neurological deficits but with normal radiographs, determines details of injury, and assists in operative planning. MRI has virtually replaced myelography and CT myelography in evaluating the traumatized cervical spine. MRI is more accurate than CT with intrathecal contrast in delineating epidural pathology, ligament injury, soft-tissue edema, and cord parenchymal injury. Information derived from MRI guides appropriate management and has value in predicting injury outcome. We consider indications for and relative merits of these various diagnostic modalities, and we describe imaging features of major patterns of cervical spine injury. PMID- 10155168 TI - Invasive aspergillosis in a patient with bronchocentric granulomatosis. PMID- 10155169 TI - Gastric tonometry: a new monitoring modality in the intensive care unit. AB - In many critically ill patients, systemic measures of hemodynamic and O2 transport variables may not be sufficiently sensitive to portray the complex interaction between energy requirements and energy supply in all tissues. Gastric or intestinal tonometry has been proposed as a relative noninvasive index of the adequacy of aerobic metabolism in the gut mucosa, a tissue that is particularly vulnerable to alterations in perfusion and oxygenation. The gut mucosa lacks some of the microvascular control mechanisms that allow other tissues, such as the heart, skeletal muscle, and the brain, to increase tissue perfusion during times of stress, and, just like the canary, it will display metabolic changes indicative of dysoxia earlier than those more "vital" tissues. The tonometric measurement of mucosal PCO2 rests on the premise that equilibrium exists between mucosal and luminal PCO2. Increases in mucosal PCO2, or conversely, decreases in mucosal pH (pHi), are associated with the development of intestinal mucosa ischemia. The clinical utility of pHi to detect intestinal mucosal ischemia has been demonstrated in patients undergoing abdominal aortic surgery. Further, a low gastric mucosal pHi on admission to the ICU appears to be predictive of mortality and pHi-guided resuscitation may improve outcome in a subpopulation of patients admitted to the ICU with normal pHi, perhaps by preventing splanchnic ischemia and the development of a systemic oxygen deficit. PMID- 10155170 TI - Spinal aspergillus abscess in a patient with bronchocentric granulomatosis. AB - Aspergillus fumigatus hyphae is often found in the lung tissue of patients with bronchocentric granulomatosis (BCG). This organism is believed to be one agent responsible for inciting the hypersensitivity response and subsequent development of the characteristic pathology that defines BCG. The definitive etiology of this disease, however, remains conjectural. Corticosteroids represent the mainstay of therapy. The fungi recovered from patients with BCG are considered noninvasive; thus, the risk of fungal invasion secondary to steroid-induced immunosuppression is believed to be negligible. However, we report a case of spinal aspergillus abscess that developed in a patient with BCG subsequent to steroid therapy. This case also highlights the necessity for aggressive medical and neurosurgical intervention to avert the development of neurological sequelae. PMID- 10155171 TI - Treatment of hypothermia in trauma victims: thermodynamic considerations. AB - The relatively high specific heat of the human body makes hypothermia very difficult to treat. Although there are many treatment methods available, most evaluations of rewarming techniques are based on clinically observed rewarming rates, and they do not take into account initial core temperature, ambient temperature, the patient's own heat production, the effects of anesthesia, paralytic agents, and other variables. A heat transfer model is proposed that simulates the flow of heat through the body of a hypothermic patient. The model uses first principles involved in heat transfer and thermodynamics to describe the effects of currently available rewarming techniques. A commercially available routine is used to solve the equations, which also include any heat exchange between the patient's body and the environment, as well as metabolic heat generation as a function of time and core temperature. This thermodynamic analysis of rewarming, based on computer modeling of heat transfer, provides a scientific basis on which to establish guidelines for appropriate selection of treatment strategies for hypothermia, and it indicates that direct blood warming or infusion of warm intravenous fluids are the most effective rewarming techniques. PMID- 10155172 TI - Role of nephrologists in the intensive care unit. PMID- 10155173 TI - Tracheoarterial fistula: an unusual complication of tracheostomy. AB - The tracheoarterial fistula is an unusual but devastating complication of tracheostomy. It occurs with a frequency of approximately 0.7%, and it is uniformly fatal if not recognized and surgically corrected. Mucosal damage from the tracheal cannula, pressure necrosis from high cuff pressure, or mucosal trauma from an improperly positioned cannula tip results in erosion through the tracheal wall into the vascular structures that lie in the pretracheal space. Bleeding from this complication almost always occurs late (> 48 hours postprocedure). It is often preceded by sentinel hemoptysis. A paucity of signs and symptoms that precede or are associated with this complication require a high index of clinical suspicion to make the diagnosis. In addition to bleeding, other potential clues include a low-lying tracheostomy tube, pulsation of the tracheostomy tube, and the presence of infection, hypotension, malnutrition, and corticosteroid use. Unfortunately, there are no consistently useful diagnostic tools for tracheoarterial fistula. Fiberoptic bronchoscopy and angiography have been performed with mixed results. Should no other cause be found to explain the hemorrhage from or around the tracheostomy, or from disease distal to the primary carina, the patient must be taken to the operating room for a more definitive examination and possible vascular repair. Management is divided into acute stabilization and support, with protection of the airway and restoration of circulating blood volume, followed by definitive repair should the patient survive. Measures to prevent tracheal damage by the tracheostomy tube, such as proper surgical technique and proper inflation of the tracheostomy tube cuff, may go a long way to avoid this potentially lethal complication. Early consideration of this entity may be what saves the life of its victim. PMID- 10155174 TI - Current concepts in splenic trauma. AB - Despite its protected location inside the rib cage, the spleen remains the most commonly injured organ after blunt abdominal trauma. The clinical decision-making process of splenic injury management continues to evolve due to improvements in surgical technique and noninvasive assessment. Splenic preservation techniques and splenic injury grading systems using computerized tomography were developed due to an increased understanding of the spleen's importance in the body's immunological defense system and awareness of the spleen's resiliency after injury. The concept of splenic salvage using splenorrhaphy and nonoperative management was initially applied to the pediatric population during the 1970s, with great success. Application of splenic salvage to hemodynamically stable adult patients with known or unknown splenic injury has demonstrated that adults can be less predictable in their clinical course. Despite the rigorous attention splenic trauma has received, it remains a controversial subject in the surgical and the radiological literature. PMID- 10155175 TI - Nonconventional therapy for asthma in the intensive care unit. PMID- 10155176 TI - Medical therapy of acute myocardial infarction: Part II. The role of adjunctive medical therapy. AB - The second part of this review summarizes the role of other classes of pharmacological therapy in treatment of acute myocardial infarction (MI). The goals of pharmacological therapy are to alleviate symptoms, to stabilize hemodynamic status, and to prevent arrhythmias. These agents have been utilized primarily because of their ability to limit infarct size. Other beneficial properties may include their effects on neurohormonal activation, hemodynamics, and arrhythmias. In an individual patient, age, associated medical conditions, and hemodynamic status are important considerations in choosing a specific class of drug therapy. The beta-adrenergic blocking agents have modest effects on mortality, and they are useful when used alone and in combination with thrombolytic agents. Calcium antagonists have a limited role in acute MI. Diltiazem reduces the incidence of reinfarction in patients with non-Q MI. Oral nitrate therapy has not been shown to reduce mortality. Data from recent trials suggest that prophylactic administration of antiarrhthymic therapy is also not useful in acute MI. The role of angiotensin-converting enzyme inhibitors when administered in the acute phase of MI needs to be evaluated further. These agents are safe and well tolerated, and they offer greatest benefit when given in patients with left ventricular dysfunction. PMID- 10155177 TI - Diagnosis and treatment of smoke inhalation. AB - Inhalation remains the most frequent and serious comorbid event that occurs in thermally injured patients. A thorough understanding of the pathophysiology enables individualization of therapy and appropriate triage of patients. We summarize our current knowledge of the pathophysiology, diagnosis, and treatment of inhalation injury, with a focus on newer treatment strategies that are evolving secondary to laboratory research. PMID- 10155178 TI - Hyperviscosity syndrome. AB - Hyperviscosity syndrome is clinically manifested by oronasal bleeding, retinal hemorrhages, and variable neurological symptoms. It occurs when resistance to flow of blood increases sharply, resulting in impaired transit through the microcirculatory system. The most common cause of hyperviscosity is increased concentrations of gamma globulins, either monoclonal in malignant disease or polyclonal, usually seen with rheumatic disorders. Increased numbers of red blood cells, as in polycythemia vera, can result in viscous blood. Extreme increases in concentrations of mature and immature white blood cells can also produce hyperviscosity. Treatment with plasma exchange is required when the clinical syndrome is symptomatic. Although plasma exchange is not a completely benign procedure, it represents the most effective method of controlling hyperviscosity. PMID- 10155179 TI - Trauma, sepsis, and disseminated intravascular coagulation. AB - Disseminated intravascular coagulation (DIC) was first observed clinically in a case of sepsis following severe trauma. It was postulated that the observed clotting defect and bleeding were due to the using up of clotting factors in an episode of intravascular clotting. It was also postulated that the multiple organ failure observed was due to obstruction of the microcirculation of the organs by microclots. Evidence for this process was worked out in many animal studies. It was then postulated that if these microclots could be lysed before organ necrosis was produced, organ failure could be prevented. This prevention was shown to be possible in animals. It was then tried in humans using plasminogen activators, and the approach was found to be effective. Using a low dose of plasminogen activator over a 24-hour period caused no changes in the coagulation profile or bleeding. PMID- 10155180 TI - The role of angioplasty in acute myocardial infarction. AB - The role of percutaneous transluminal coronary angioplasty (PTCA) in the management of acute myocardial infarction (AMI) has not yet been precisely defined. The longest experience with PTCA in this setting has been in patients who are not candidates for thrombolytic therapy and in patients in whom thrombolysis has failed. Clinical interest has recently focused on direct use of PTCA (instead of thrombolysis) as the initial approach to reperfusion in AMI. We review the conceptual bases for both thrombolytic therapy and PTCA in AMI, and we then detail the clinical experience with PTCA in a variety of patient populations with AMI to guide use of both therapies in this setting. PMID- 10155181 TI - Bone marrow necrosis. AB - Bone marrow necrosis is regarded as an uncommon entity that is associated with a poor prognosis. However, organized studies using either bone marrow biopsy specimens or autopsy material showed that bone marrow necrosis can be demonstrated in approximately one third of specimens. It is found in a large number of both malignant and nonmalignant disorders, in addition to occurring following large exposures to radiation or high dose cancer chemotherapy. In the absence of radiation or cancer chemotherapy, it probably eventuates from either vascular occlusion or blood stasis in small blood vessels. When bone marrow necrosis is prolonged, it may be associated with the development of bone marrow fibrosis, and it may serve as a predisposing etiology for idiopathic myelofibrosis. Most patients discovered with bone marrow necrosis have few symptoms, and they are eventually lost to follow-up without evident progression or development of a clinical illness. In acute disorders and in those who undergo effective therapy, recovery appears to occur without complications. This frequently overlooked finding is the subject of many case reports in the medical literature, but it has only been rarely systematically investigated. The latter is probably warranted because of the potential role of bone marrow necrosis in the pathophysiology of a number of disorders and the paucity of information for treatment of this pathological finding. PMID- 10155182 TI - Long-term enteral access in aspiration-prone patients. AB - Aspiration pneumonia is a serious complication of enteral feeding. Many critically ill patients are particularly at risk for aspiration. Few studies have rigorously compared various access devices. Risk factors for aspiration and studies examining aspiration associated with enteral feeding devices are reviewed. We recommend a surgical jejunostomy for all patients at high risk for aspiration who require more than 3 weeks of enteral nutrition support. PMID- 10155183 TI - A prospective study of continuous venovenous hemodiafiltration in critically ill patients with acute renal failure. AB - We studied the biochemical and the clinical consequences of the application of continuous venovenous hemodiafiltration to the management of acute renal failure in critically ill patients. One hundred consecutive surgical and medical ICU patients with acute renal failure were entered into a prospective clinical study at an intensive care unit of tertiary institution. INTERVENTION: included assessment of illness severity by APACHE II score on admission and by organ failure score prior to initiation of renal replacement therapy; treatment of patients with continuous venovenous hemodiafiltration; and measurement of biochemical variables prior to and after therapy. Outcome assessment included incidence of complications, duration of oliguria, duration of intensive care and hospital stays, and survival to hospital discharge. MEASUREMENTS AND MAIN RESULTS: included the following: mean patient age was 60.9 years (range 21-81 yr); mean APACHE II score, 28.6 (95% confidence interval; 27.4-29.8); and number of failing organs, mean, 4.1 (95% confidence interval; 3.8-4.4). At commencement of continuous venovenous hemofiltration with dialysis, 79% of patients were receiving inotropic drugs and 72% were septic, and, in 35%, bacteremia or fungemia was demonstrated. Renal replacement therapy was applied for a mean duration of 186.2 hours (95% confidence interval; 149.2-223.7), with a mean hourly net ultrafiltrate production of 621 mL (95% confidence interval; 594-648) and a mean urea clearance of 28.1 mL/min (95% confidence interval; 26.7-29.5). Azotemia was controlled in all patients (plasma urea < 30 mmol/L). During the more than 18,000 hours of treatment, there was no therapy-associated hemodynamic instability. Complications were rare. They included two cases of hemofilter rupture with minor blood loss and a single case of bleeding at the site of the vascular-access catheter. Forty-three patients survived to ICU discharge, and 40 survived to hospital discharge. Continuous venovenous hemodiafiltration is a safe and an effective form of renal replacement therapy in critically ill patients. In such patients, who have a high predicted mortality rate, it was associated with a 40% survival rate. These findings suggests that continuous venovenous hemodiafiltration may be ideally suited to patients with multisystem organ failure with acute renal failure. PMID- 10155184 TI - A critique of the ACCP consensus conference on mechanical ventilation. American College of Chest Physicians. AB - The American College of Chest Physicians recently published a statement summarizing the results of the Consensus Conference on Mechanical Ventilation (Chest 1993; 104:1833-1859). In this statement, the physiology of mechanical ventilation was extensively reviewed, and 5 principles and 38 guidelines or recommendations on which consensus was reached were presented. The following critique (1) summarizes the findings of the conference; (2) comments on selected principles, recommendations, and physiological concepts presented in the statement; and (3) discusses the strengths and the limitations of the consensus conference format, as well as the errors and biases inherent in the policy-making process. The Consensus Conference statement is one of the clearest, most complete reviews of physiology and techniques of mechanical ventilation I have yet encountered. The suggested guidelines and recommendations clearly follow from the physiological principles discussed. Unfortunately, numerous problems with the consensus conference format and the almost total lack of controlled randomized studies limit the confidence with which these suggestions can be accepted. Our experts in respiratory care are remiss for not providing outcome-based or preference-based data, and the pulmonary and critical care community is remiss for not demanding that they do so before changing our approaches on the basis of their suggestions. PMID- 10155185 TI - Renal replacement therapy in the intensive care unit. PMID- 10155186 TI - Continuous renal replacement therapy for critically ill patients: an update. AB - Despite continuous progress in intensive care during the last decades, the outcome of critically ill patients in whom acute renal failure (ARF) develops is still poor. This outcome may be explained partially by the frequent occurrence of ARF as part of multiple organ systems failure (MOSF). In this complex and unstable patient population, the provision of adequate renal support with either intermittent hemodialysis or peritoneal dialysis may pose major problems. Continuous renal replacement therapy (CRRT) is now increasingly accepted as the preferred treatment modality in the management of ARF in these patients. The technique offers adequate control of biochemistry and fluid balance in hemodynamically unstable patients, thereby enabling aggressive nutritional and inotropic support without the risk of exacerbating azotemia or fluid overload. In addition, experimental and clinical data suggest that CRRT may have a beneficial influence on hemodynamics and gas exchange in patients with septic shock and (nonrenal) MOSF, independent of an impact on fluid balance. We review both technical and clinical aspects of various continuous therapies, including their impact on serum drug levels and nutrient balance. In addition, an attempt is made to clarify the possible beneficial role of CRRT in reducing patient morbidity and mortality in the ICU. PMID- 10155187 TI - Pancreas-kidney transplantation for intensivists: perioperative care and complications. AB - Simultaneous pancreas-kidney transplantation is a therapeutic option for type I diabetics with end-stage renal disease. It aims to correct the uremic state, to normalize glucose hemeostasis, and to ameliorate diabetic complications. Careful donor-recipient selection and meticulous intra-operative and postoperative care will substantially impact recipient morbidity. An understanding of the technical aspects of the surgical procedure and its metabolic and immunological consequences is necessary to successfully manage a pancreas-kidney transplant recipient, many of whom are nursed in intensive care units. A successful outcome is predicted in early recognition of technical complications and aggressive management of rejection to achieve the current 1-year graft survival rates of 75% for pancreas transplants and 84% for kidney transplants. PMID- 10155188 TI - Trauma radiology: Part IV. Imaging of acute craniocerebral trauma. AB - Diagnostic imaging has a key role in diagnosis and management of patients sustaining craniocerebral injuries from trauma. We review the current role of skull radiography, computed tomography (CT), and magnetic resonance (MR) in imaging patients sustaining craniocerebral trauma, and we describe the appearance of major forms of pathology as depicted by each modality. CT scan is used to assess quickly the extent of injury and to triage patients to observation, medical, or neurosurgical management. CT findings can be divided into primary craniocerebral injuries, including skull fractures; extraaxial hematomas (subdural and epidural); intraparenchymal injury, such as hematoma, contusion, and diffuse axonal shearing; and intraventricular or subarachnoid hemorrhage. Secondary manifestations of injury, such as cerebral edema and herniation, are also identified, and their course can be followed by serial CT. CT is crucial in assessing the outcome of surgical intervention and in identifying potential delayed complications of either head trauma or surgical intervention, including infection, delayed hemorrhage, cerebral infarction, and tension pneumocephalus. In recent years, MRI has been shown to be valuable in diagnosing cerebral injury. MRI has generally been shown to have greater overall accuracy than CT in identifying and characterizing most forms of traumatic cerebral pathology, but it is less accurate at demonstrating subarachnoid hemorrhage acutely, pneumocephalus, and calvarial fractures, particularly those involving the skull base. Moreover, MRI is still more difficult to perform than CT in critically ill patients, and it is generally far more time-consuming. However, MRI is unequivocally more accurate than CT at revealing certain lesions, particularly brainstem contusion, diffuse axonal shearing, predominantly nonhemorrhagic contusions, and thin collections of blood adjacent to bone, and it should be used selectively when these injuries are suspected. PMID- 10155189 TI - The value of transesophageal echocardiography in predicting immediate and long term outcome of balloon mitral valvuloplasty: comparison with transthoracic echocardiography. AB - The purpose of this study was to assess the role of transesophageal echocardiography in predicting the immediate and long-term outcome of balloon mitral valvuloplasty, and compare the results to transthoracic echocardiography. BACKGROUND: Transesophageal echocardiography accurately detects left atrial thrombi and allows better visualization of mitral valve morphology; however, its value in predicting the immediate and long-term outcome of balloon mitral valvuloplasty had not been assessed as adequately as for transthoracic echocardiography. METHODS: In 56 patients referred for balloon mitral valvuloplasty, both transesophageal and transthoracic echocardiography were performed (Group A). An echo score for both techniques was used to reflect mitral valve morphology, and its predictive value for immediate and long-term outcome of the valvuloplasty was assessed. The impact of transesophageal echocardiography in preventing procedural embolic events in those 56 patients was assessed by comparison to another group of 41 patients, who were examined only by transthoracic echocardiography prior to balloon mitral valvuloplasty (Group B). RESULTS: In Group A, transesophageal echocardiography detected left atrial thrombus in seven, while transthoracic echocardiography detected left atrial thrombus in two patients. After 2 months of warfarin therapy, a repeat transesophageal echo examination in four patients showed resolution of thrombus in three who went on to have balloon mitral valvuloplasty. Among the 52 patients who eventually had the procedure after thrombus was excluded by transesophageal echocardiography, there were no embolic events, compared to three embolic events among the 41 patients in Group B (P = 0.08). The transthoracic echocardiography scores, while slightly higher, correlated well with transesophageal echocardiography scores (r = 0.51, P < 0.001). The increase in mitral valve area did not correlate well to total transthoracic or transesophageal echocardiography scores, while it correlated negatively to valve calcification by transthoracic (r = -0.29, P < 0.05) and mobility by transesophageal echocardiography (r = -0.59, P < 0.02). At follow-up (7 +/- 4 months) nonsurvivors (7/56) had higher total scores by either transthoracic (P < 0.01) or transesophageal echocardiography (P < 0.05) compared to survivors. The percent reduction in mitral valve area was greater with age (r = 0.5, P < 0.02), time to follow-up (r = 0.67, P < 0.002), valve mobility by transthoracic echocardiography (r = 0.59, P < 0.01), and valve calcification by transthoracic echocardiography (r = 0.37, P = 0.09) and transesophageal echocardiography (r = 0.4, P = 0.07). CONCLUSIONS: Transesophageal echocardiography is superior to transthoracic echocardiography in detecting left atrial thrombi, and it may reduce the risk of embolic events following balloon mitral valvuloplasty. Assessment of mitral valve morphology by transesophageal echocardiography is complementary and not superior to assessment by transthoracic echocardiography. Mitral valve calcification and mobility appear to be the best morphological predictors of immediate and long-term outcome following balloon mitral valvuloplasty. PMID- 10155190 TI - Antithrombin and thrombolytic effects of a new antithrombin agent: angioscopic and angiographic comparison with heparin or batroxobin. AB - The antithrombotic effect of three different types of antithrombotic agents (antithrombin:argatroban, heparin, defibrinogenating agent:batroxobin) were evaluated in canine coronary and iliac arteries. An occlusive thrombus was produced by balloon injury. One of the three agents was infused intravenously at 1 hour after thrombus formation (heparin 250 U/kg, argatroban 0.5 mg/kg, batroxobin 0.5 U/kg) and the effect of thrombus size reduction was evaluated. On the contralateral side of the iliac artery, the preventive effect of these agents on thrombus formation was evaluated after balloon injury. In the iliac artery, angioscopic percent area obstruction by the thrombus before and 60 minutes after treatment reduced from 69% to 32% in the argatroban group, and from 64% to 51% in the batroxobin group (P < 0.0001 and P < 0.05, respectively). No significant change was observed in the heparin group. Angiography demonstrated the same trend. The percent area stenosis with thrombus at 60 minutes following balloon injury was 0.75% in the argatroban group, 18.9% in the heparin group (P < 0.05 vs argatroban), and 12.9% in the batroxobin group. Thrombus size at the treated site was smaller than that at the control site in all three groups (P < 0.05 vs control). In the coronary artery, angioscopic percent area obstruction by the thrombus before and 60 minutes after treatment reduced from 84% to 53% in the argatroban group, and from 86% to 68% in the batroxobin group (P < 0.0001 and P < 0.05, respectively). No significant change was observed in the heparin group. Angiography also demonstrated the same trend. The activated partial thromboplastin time (APTT) was prolonged to 189% of the control value with argatroban and to 1253% of the value with heparin (P < 0.0001). Fibrinogen was markedly reduced with batroxobin. These results showed that both the antithrombin agent and the defibrinogenating agent have a preventive effect on thrombus formation and the effect on thrombus size reduction, without marked prolongation of the APTT. PMID- 10155191 TI - Spontaneous coronary arterial dissection causing acute myocardial infarction. AB - We report the case of a middle-aged female who presented with an acute inferior myocardial infarction treated with intravenous thrombolytics. Immediate coronary angiography demonstrated the presence of a spiral dissection and a large thrombus. After 1 week of anticoagulation the thrombus had resolved, but a large spiral dissection persisted. This was confirmed by intracoronary ultrasound. We then review the literature on spontaneous coronary arterial dissection. PMID- 10155192 TI - Third- and fourth-generation implantable cardioverter defibrillators: current status and future development. AB - Implantable cardioverter defibrillator (ICD) therapy has become the mainstay of therapy for patients with a history of sudden cardiac death or life-threatening ventricular arrhythmias. The current generation of ICDs used for secondary prevention combines features for tachycardia reversion with demand ventricular pacing, antitachycardia pacing, programmable shock therapy, and tachycardia events memory. Although demand pacing and defibrillation is indicated for primary prevention usage of ICDs, the application of antitachycardia pacing modes is more controversial. High energy cardioversion and defibrillation shocks remaining the mainstay of sudden death prevention will be redefined as more effective defibrillation shock modes and lead systems are developed. Fourth-generation ICD systems accomplished a significant reduction of device size and almost universal success using an endocardial lead configuration and pectoral implant. A variety of new directions of ICD therapy in clinical practice such as primary prevention applications and the adjunctive role of antiarrhythmic drug therapy are currently being examined in clinical trials. The concepts underlying initiation of tachyarrhythmias are being studied to develop new approaches to tachycardia prevention. These include rate support, subthreshold stimulation, and multiple site pacing. The current developments of ICD therapy promise continued growth of this technology. PMID- 10155193 TI - Hybrid ICDs: issues and applications. PMID- 10155194 TI - Advances in ICD lead systems. AB - We have presented both technical and clinical data indicating that transvenous lead systems are comparable to standard epicardial ICD systems with respect to efficacy. In addition there may be a reduction in morbidity when compared with the standard epicardial implant. We have shown for the Endotak and Transvene systems that each has its own idiosyncrasies, advantages, and disadvantages. Other lead systems are too early in their clinical evaluations for such definitive statements to be made. Regarding long-term reliability, the issues of mechanical integrity of the insulation and conductor materials, as well as the stability (or otherwise) of sensing and defibrillating characteristics remains to be determined for all lead systems. Similarly, compatibility between lead systems and pulse generators made by different manufacturers cannot be assumed, but needs to be prospectively examined in rigorous clinical trials. PMID- 10155195 TI - Tachycardia detection by antitachycardia devices: present limitations and future strategies. AB - Early experience with three generations of implantable devices has demonstrated the need to further refine the accuracy of automated rhythm analysis. Although initial experience with commercially utilized morphological waveform analysis has been disappointing, other time and frequency domain electrogram features have been developed and show potential promise for future devices. While single chamber algorithms for rate and rate variations have theoretical appeal because of their limited power demands, practical experience has demonstrated that inaccurate arrhythmia diagnosis continues to occur by antitachycardia devices that utilize them. Technological advancement in hardware manufacturing and the design of increasingly more efficient software algorithms for tachycardia detection will continue to yield lower power digital circuitry, to increase device battery power and life, and to permit more and more accurate automated arrhythmia diagnosis and treatment by antitachycardia devices. Two chamber sensing has been available for decades in dual chamber antibradycardia pacemakers. The introduction of this technology into antitachycardia devices is not only inevitable but should dramatically improve the precision of diagnosis in future generation devices. PMID- 10155196 TI - Troubleshooting new ICD systems. AB - Advances in ICD technology have improved arrhythmia detection and termination, and the development of nonthoracotomy lead systems has reduced operative mortality and morbidity. Despite these important developments, patients with ICDs continue to experience untoward events that are usually attributable to lead failures, the effects of antiarrhythmic drugs, problems related to signal processing, or the need to modify the ICD program. It is incumbent on physicians who implant ICDs and monitor long-term therapy to appreciate the mechanisms by which these events occur, approaches needed to establish a diagnosis, and therapeutic interventions that can resolve problems associated with ICDs. PMID- 10155197 TI - Sudden death in recipients of first-generation implantable cardioverter defibrillators: analysis of terminal events. Participating investigators. AB - Clinical factors and terminal events associated with sudden death in 51 patients were analyzed from among a multicenter experience of 864 recipients of first generation automatic implantable cardioverter defibrillator (AICD) devices (single zone, committed, monophasic pulse with > or = 1 epicardial patch electrode) during the period May 1982-February 1988. For these 51 patients, mean age was 58 years and atherosclerotic heart disease was present in 84%, with a history of ventricular fibrillation (VF) in 61%, and inducible sustained ventricular tachycardia (VT) in 84%; mean left ventricular ejection fraction was 0.26. Nearly 80% experienced one or more appropriate AICD shocks during the median 9 month (range 0-46 months) period prior to death. Of 30 monitored deaths, the first documented terminal rhythm was VF in 12 (40%), VT in 8 (27%), and asystole or electromechanical dissociation in the remaining 10 (33%). Shocks were documented during terminal events in 21 (66%) of 32 witnessed cases of sudden death with activated devices. The proportion of monitored or witnessed sudden deaths that were known or presumed to be tachyarrhythmic (based on terminal VT, VF, or shocks) ranged from 69% (11/16 cases with activated/nondepleted devices and a defibrillation threshold [DFT] < or = 20 J) to 81% (29/36 cases on intention-to-treat basis). Of 27 patients with known or presumed sudden tachyarrhythmic death, the AICD had been deactivated prior to death in 4 (15%); activated, but depleted in 4 (15%); activated/nondepleted, but with DFT of 25 J in 4 (15%); and activated/nondepleted, but without DFT testing in 4 (15%). The remaining 11 (41%) known or presumed sudden tachyarrhythmic deaths occurred in patients with activated/nondepleted devices and DFT < or = 20 J; however, definite or suspected contributory factors (e.g., hematoma under epicardial patch, generator component failure, or drug-induced DFT rise) could be identified in 6 (55%) of 11 cases. Thus, in this first-generation AICD experience: 1) most sudden deaths occurred on the basis of a known or presumed tachyarrhythmia; and 2) an understanding of apparent "failure" of ICD therapy could often be gained through an integrated analysis of associated clinical factors and management practices, as well as device "hardware" function. These observations are likely to remain relevant, even with respect to newer generation ICDs. PMID- 10155198 TI - Results of recent trials on the progression of coronary artery disease and recurrent ischemic events: implications for interventional cardiology. PMID- 10155199 TI - Preliminary experience using directional coronary atherectomy for the treatment of acute myocardial infarction. AB - Directional coronary atherectomy (DCA) has proven to be an effective treatment for coronary artery disease, both in multiple anatomical locations and in various clinical settings. Little has been published, however, regarding efficacy of DCA for treatment of acute myocardial infarction (MI). This brief report reviews our early experience with DCA in this new role. Twelve patients presenting from April 1993 through February 1994 were identified by review of the DCA Registry at Hamot Medical Center. The group comprised six men and six women mean age 60 years (range 39-81 years). Patients were administered oral aspirin and intravenous nitroglycerin Heparin dose was titrated to maintain ACTs > 300 seconds. DCA was performed using 9.5-, 10-, and 11Fr guiding catheters. Seven Fr EX, 7Fr graft, 7Fr surlyn, and 6Fr EX devices were used. Predilation and/or postdilation with balloon angioplasty was performed when clinically indicated. Postprocedure stenoses were determined using comparable orthogonal angiographic views. Lesions were measured by manual caliper assessment and tissue weights were obtained from all specimens. The procedural success rate was 92% (11/12) and the mean postprocedural diameter stenosis was 15% (range -20% to 52%). The mean tissue weight from atherectomy specimens was 16 mg (range 7.6-35 mg). The mean time from onset of pain to reperfusion was 2.8 hours (range 40 min to 5.5 hours). Clinical success was achieved in 83% (10/12) of patients. Two deaths occurred in patients presenting with cardiogenic shock. Ten patients experienced no ischemic events, heart failure, or arryhthmias following their interventional procedure.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155200 TI - Laser thrombolysis in acute myocardial infarction: results of a clinical feasibility study. AB - Laser thrombolysis is a new, experimental, catheter based intervention aimed at selectively removing intracoronary thrombus. This first clinical study was performed to assess the feasibility and safety of laser thrombolysis, as well as its potential therapeutic place in acute myocardial infarction. Eighteen patients with acute myocardial infarction, who were either noncandidates for, or failures on, intravenous fibrinolytic therapy were included for treatment with laser thrombolysis followed by balloon angioplasty. As a result of catheter and technical failures, the laser was actually fired in only 12 patients. Improvement in TIMI flow from grade 0-1 to grade 2-3 was observed in 10 of these 12 patients after laser application. The overall results of 18 patients were: increase in TIMI grade flow from 0.33 +/- 0.49 after wire passage to 1.28 +/- 1.23 (P = 0.0051) after attempted laser application, and to 2.67 +/- 0.97 after PTCA (P = 0.0004). Two patients with previous infarctions died from left ventricular failure despite successful laser thrombolysis. One patient died during emergency bypass surgery after a failed recanalization attempt. Perforation or laser related dissection did not occur. The concept of selective laser thrombus ablation seems to be safe and feasible, but substantial improvements of the laser delivery catheters are needed. Laser thrombolysis is not an effective stand-alone therapy in acute myocardial infarction, but other possible applications warrant further research and development efforts for this potentially useful interventional tool. PMID- 10155201 TI - Mitral valve prosthesis disk embolization during transeptal atrioventricular junction ablation. AB - We report a case of disk embolization from a Bjork-Shiley mitral valve prosthesis (Shiley Inc., Irvine, CA, USA) which occurred during transeptal atrioventricular (RV) junction ablation. The disk lodged in the lower thoracic aorta. The patient was treated successfully by emergency valve replacement, and the escaped disk has been left in situ with no complications. PMID- 10155202 TI - Randomized trial comparing two devices: the Palmaz-Schatz stent and the Strecker stent in bail-out situations. AB - To assess whether differences in design (geometry, flexibility) and material (electrostatic behavior) may influence the acute and late outcome following intracoronary stent implantation in the treatment of acute or threatened closure after prolonged balloon inflations, 50 patients were randomized to receive either a Palmaz-Schatz stent (n = 25) or a Strecker stent (n = 25). RESULTS: [table: see text] CONCLUSION: Both Palmaz-Schatz and Strecker stents are equally effective in restoring vessel patency in bail-out situations. The incidence of complications is high and similar for both stents if they were used after failed prolonged balloon inflations. Differences in design and material do not seem to influence the results. PMID- 10155203 TI - Bail-out stenting with Medtronic Wiktor: results from the European Stent Study Group. PMID- 10155204 TI - Clinical and angiographic outcome following implantation of the new Less Shortening Wallstent in aortocoronary vein grafts: introduction of a second generation stent in the clinical arena. AB - One of the factors felt to have contributed to the high rate of stent occlusion in the European registry of the coronary Wallstent in the 1980s was the frequent deployment of more than one stent to cover the target lesion. This resulted from a high degree of shortening of the Wallstent upon expansion. To overcome this limitation the design of the Wallstent was modified to reduce the degree of shortening. We report the results of a study of the first patients to undergo implantation of the new Less Shortening Wallstent. Thirty-five Wallstents were electively deployed in aortocoronary vein grafts in 29 patients. Stent deployment was successful in 35 of 36 attempts in 30 lesions. In five of the 30 lesions, a second stent was required to cover the proximal portion of the lesion. Angiographic success (< 50% residual diameter stenosis as determined by off-line quantitative coronary angiography) was achieved in all 29 patients. During the in hospital phase, no major adverse cardiac event occurred (reintervention, re-CABG, myocardial infarction, or death) and five patients had hemorrhagic complications. Following hospital discharge, one patient had a subacute stent occlusion associated with symptoms and elevated cardiac enzymes at 11 days, another patient had symptoms and elevated cardiac enzymes (CK 300 U/I) at 22 days with a patent stent, five patients required balloon angioplasty within the 6 month follow-up period (four for restenosis and one for stent occlusion), one patient underwent re-CABG for a native artery stenosis distal to the anastomosis of the patent stented vein graft.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155205 TI - Clinical experience with stent implantation in the treatment of saphenous vein graft lesions. PMID- 10155206 TI - Insights from the STRESS trial. STent REStenosis Study. PMID- 10155207 TI - Designing of trials: power calculations based on matching as a surrogate for randomization. AB - In the design of clinical trials we strive to extract the maximum amount of information from a minimum number of patients and yet retain statistical validity. Matching has become acknowledged as a useful and valid surrogate for the randomized trial. By using data from matched trials along with power calculations we can accurately predict the number of patients required to achieve statistical significance in a related randomized trial. PMID- 10155209 TI - Interventional cardiology worldwide. PMID- 10155210 TI - Interventional cardiology in Ireland. PMID- 10155208 TI - Benestent II: back to the future. AB - It has been shown repeatedly in animal and clinical studies that heparin coating reduces thrombotic complications of several surfaces in contact with flowing blood. The demonstration that implantation of heparin-coated coronary stents is also effective in prevention of subacute thrombotic occlusion in a pig model offers the perspective of a clinical role of this treatment too. In order to put this to the test, the Benestent II pilot trial has been designed. This study will be conducted in a stepwise fashion in order to explore the feasibility of delaying deep anticoagulation as much as possible. Therefore, the primary goal is to minimize or exclude the need for heparin treatment following stent implantation. In addition, the effects on the need for revascularization procedures during follow-up will be recorded as well as the late morphological consequences as measured with quantitative coronary angiography. PMID- 10155211 TI - Interventional cardiology in Mexico: a perspective from the Instituto Nacional de Cardiologia Ignacio Chavez. PMID- 10155212 TI - Interventional cardiology in Chile. AB - In Chile the first experiences with cardiac catheterization began very shortly after Forssmann's first studies. Percutaneous coronary balloon angioplasty (PTCA) was first performed in 1982. Despite a progressively great interest and training of physicians in invasive cardiology there are still restrictions in its development. Most private institutions have modern facilities but their caseloads, ever increasing, are still limited because they take care of only 35% of the population. Public institutions are limited because of funding, and some are just developing PTCA. The situation has improved recently because of deals between the private and public systems. Experience with newer devices is even more limited. PMID- 10155213 TI - Transcatheter ablation of incessant ectopic left atrial tachycardia using radiofrequency current. AB - Catheter ablation of ectopic atrial tachycardia has been previously reported in a small number of patients in whom the ectopic focus was predominantly located in the right atrium. We report on a 51-year-old patient with atrial automatic tachycardia originating in the left atrium, in whom successful radiofrequency catheter ablation was performed via a transseptal puncture. The patient had suffered incessant atrial tachycardia for several years, refractory to antiarrhythmic drug treatment and DC-cardioversion. Radiofrequency ablation terminated left ectopic atrial tachycardia and, therefore, should have been attempted before resorting to open heart surgical ablation. PMID- 10155214 TI - Interventional cardiology in New Zealand. AB - Death rates from coronary heart disease in New Zealand are among the highest in the world although they have steadily fallen since a peak in 1968. The health care system is largely publicly funded with most cardiologists being salaried, although there has been a growth in fee-for-service private practice. Waiting times in public hospitals for bypass surgery can be years for chronic stable angina. The publicly funded health care system is being reformed. In 1993 there were in New Zealand, for a population of just less than 3.5 million: 6,227 coronary angiograms; 1,365 percutaneous interventions; and 1,513 coronary artery bypass only operations. The percutaneous intervention rate was 391 per million. There has been an increase in new device use so that in Auckland 11% of percutaneous interventions involved new devices. PMID- 10155215 TI - Interventional cardiology in Switzerland. PMID- 10155216 TI - Interventional cardiology in South Africa. AB - South Africa is a country in political and cultural flux. Because of the iniquitous system of apartheid, inequalities have been perpetuated at all levels including health care. Due to the high prevalence of ischemic heart disease and rheumatic heart disease, coronary angiography, PTCA, intracoronary stenting, and balloon valvuloplasty have become established cardiological procedures in South Africa. However, a new political dispensation promises changes to health care, which will impact on interventional cardiology. With a proposed emphasis on primary health care, resources for tertiary health care will probably be curtailed. Thus consideration will have to be given to reducing expenditure by careful review of indications for expensive interventional procedures and developing new ideas to contain costs. This will be the challenge facing cardiologists in a "New South Africa". PMID- 10155217 TI - Catheter ablation in supraventricular tachyarrhythmias. PMID- 10155218 TI - Radiofrequency catheter ablation of septal accessory pathways. AB - Catheter ablation of septal accessory pathways in preexcitation syndrome is associated with special problems because of the risk of impairment of atrioventricular nodal conduction during ablation of anteroseptal and midseptal pathways. The complex morphology of the posteroseptal space has special problems for ablation with unclear location of the ablation catheter in the left or right atrial or ventricular cavum, in the coronary sinus, ventricular veins, or the neck of a coronary sinus diverticulum. Therefore, the visualization of the pyramidal space using echocardiographic investigations before the ablation procedure and retrograde coronary sinus phlebography during the ablation session has proven to be very helpful in placement of the electrode to the successful position. Reported herein are the techniques, results, and problems of radiofrequency ablation of 30 patients with septal accessory pathways compared to published data. PMID- 10155219 TI - Radiofrequency catheter ablation of left-sided accessory pathways: clinical and regulatory issues in the return to the coronary venous system. PMID- 10155220 TI - Surgery for cardiac arrhythmias. PMID- 10155221 TI - Posteroseptal accessory pathways: an overview of anatomical characteristics, electrocardiographic patterns, electrophysiological features, and ablative therapy. AB - First, the posteroseptal region of the heart is probably the most complex area among those that harbor AV accessory fibers and a firm grasp of the anatomical characteristics of this region may facilitate achieving a successful AP ablation. Second, there is no sharp demarcation between the posteroseptal area and its surrounding regions including mid-septal, left posterior paraseptal, and right posterior paraseptal locations. Therefore, there are some inevitable overlaps between the electrocardiographic and electrophysiological features of APs located in the posteroseptal region and those areas immediately adjacent to it. Third, in the vast majority of cases, successful ablation can be achieved using a right atrial approach. Therefore, dividing posteroseptal APs into right- or left-sided pathways may only be useful for describing their ECG or electrophysiological characteristics with little or no value in predicting the site of successful ablation. Fourth, it seems advisable to attempt efforts to induce functional bundle branch block during orthodromic tachycardia and assess its effect on the VA interval. Ventriculoatrial interval prolongation due to right bundle branch block strongly favors a right free-wall or anteroseptal AP location. Prolongation of the VA interval by 30 msec or less in response to left bundle branch block is compatible with a posteroseptal location. In this situation, the mapping and ablative efforts should primarily be focused on the right atrial approach, including the terminal coronary sinus. If left bundle branch block causes VA interval lengthening of 30 msec or greater, the AP is most likely in the left free-wall region, including the posterior paraseptal area. Finally, the presence of APs having an intimate relationship with the middle cardiac (posterior interventricular) vein or the coronary sinus pouch, although exceedingly uncommon, should be considered in difficult cases in which radiofrequency applications to the conventional posteroseptal locations are unsuccessful. Such cases may require coronary sinus venography for better visualization and precise mapping of the terminal sinus complex. PMID- 10155222 TI - Sudden cardiac death prevention: antiarrhythmic drugs and the implantable cardioverter-defibrillator. PMID- 10155223 TI - Health care reform: impact on referral, nonuniversity hospitals and practices. PMID- 10155224 TI - The Thrombolysis in Myocardial Infarction (TIMI) trials: the first decade. PMID- 10155225 TI - Elastic recoil and intimal thickening after coronary stenting. AB - In this study, the long-term elastic recoil of the stents and the intimal thickening over the stents were evaluated separately. Twenty-nine patients who received a Wiktor coronary stent were angiographically followed-up at 2 weeks, 3 months, and 6 months. The elastic recoil of the stent was evaluated by the changes in minimum stent diameter. The intimal thickness was evaluated by the difference between minimum stent diameter and minimum lumen diameter. Minimum stent diameter showed no significant change up to 6 months. The significant increase (P < 0.05) of the intimal thickness was detected only between 2 weeks and 3 months. In conclusion, the Wiktor stent prevented the elastic recoil up to 6 months, and was covered by the neointima which increased its thickness mainly between 2 weeks and 3 months after stenting. It was suggested that stent restenosis was not caused by the elastic recoil, but by the intimal thickening. PMID- 10155226 TI - Lesion specific approach to coronary intervention. PMID- 10155227 TI - Mechanical assistance and the cardiac catheterization laboratory. PMID- 10155228 TI - The use of intraaortic balloon counterpulsation in acute myocardial infarction and high risk coronary angioplasty. AB - Patients with complex coronary arterial stenoses, decreased ejection fraction, or acute myocardial infarction are at increased risk during percutaneous coronary interventions. Intraaortic balloon counterpulsation (IABP) can provide benefit in such cases by several mechanisms. Myocardial perfusion is improved and left ventricular afterload is reduced by balloon counterpulsation. Patients with cardiogenic shock clearly benefit from balloon counterpulsation until revascularization can be performed. Recent studies have documented the utility of balloon counterpulsation in patients undergoing angioplasty as treatment for an acute myocardial infarction. Balloon counterpulsation is also an effective means to reduce ischemia and provide hemodynamic support during complex percutaneous coronary interventions. This review will summarize the benefits, indications, and complications of balloon counterpulsation during acute myocardial infarction and high-risk coronary angioplasty. PMID- 10155229 TI - Cardiopulmonary bypass support of high risk coronary angioplasty patients: registry results. AB - Coronary angioplasty has been increasingly utilized in patients with extensive coronary disease, severe and acute chest pain syndromes, and poor ventricular function. This process has been facilitated in part by use of circulatory support, including perfusion balloons, intraaortic balloon pumps and cardiopulmonary bypass support systems. Percutaneous cannulation has facilitated elective and emergency application of cardiopulmonary bypass support in patients undergoing high risk coronary angioplasty. A National Registry of 25 centers has accumulated data on 801 elective and 210 emergency support angioplasty patients. Standby cardiopulmonary bypass support of elective high risk patients was associated with fewer complications and less in-hospital mortality in patients other than those with left ventricular ejection fraction < or = 20% and possibly older high risk patients. In elective cases, circulatory support was required in only approximately 7% of high risk patients, although need appeared to be unpredictable. Emergency use of cardiopulmonary bypass support, initiated < 20 minutes from the time of circulatory collapse, was associated with improved patient prognosis. Overall, patients undergoing circulatory cardiopulmonary bypass supported angioplasty had a marked reduction in anginal status, improvement in left ventricular ejection fraction and good (80%) 2-year survival. Although used only occasionally, circulatory support remains an important prophylactic interventional tool for the extremely high risk patient (left ventricular ejection fraction < or = 20%) and a lifesaving emergency technique for the occasional patient with circulatory collapse. PMID- 10155230 TI - Coronary angioplasty in high risk patients: comparison of elective intraaortic balloon pump and percutaneous cardiopulmonary bypass support--a randomized study. AB - Forty patients undergoing percutaneous transluminal coronary angioplasty (PTCA) with severely impaired left ventricular ejection fraction (LVEF) < 30% were randomized between prophylactic intraaortic balloon pump (IABP) support (N = 20) and percutaneous cardiopulmonary bypass (PCPB) support (N = 20). The indications for both groups were left ventricular (LV) dysfunction and a large area of myocardium (> 50%) being perfused by the target vessel. The IABP and PCPB supported groups were comparable in LVEF (20% +/- 6.4% vs 22.8% +/- 8.1%), mean pulmonary artery pressure (46.5 +/- 10.5 mmHg vs 42.6 +/- 12.6 mmHg), average number of vessels dilated (1.4 vs 1.3), mean inflation time (2.8 +/- 0.3 min vs 3.1 +/- 0.5 min), and hospital stay after PTCA (5.6 +/- 1.2 days vs 5.2 +/- 1.4 days). The primary success rate (95% vs 95%) and hospital mortality (5% vs 5%) were also similar in the two groups. Two patients required surgical exploration of the femoral artery and eight patients required blood transfusion in the PCPB group. IABP patients had no vascular complications and did not require blood transfusion. High risk PTCA is equally effective whether using prophylactic IABP or PCPB support. PCPB support, however, has a higher rate of vascular complications and need for blood transfusions. IABP has the additional advantage of ease of insertion and the support can be used for a longer period after PTCA, if required. PMID- 10155231 TI - Intraluminal Palmaz stent implantation for treatment of recurrent carotid artery occlusive disease: a plan for the future. AB - While carotid endarterectomy (CEA) has been used commonly and with great effectiveness for de novo carotid occlusive lesions, its success in cases of recurrent disease has been attenuated by a higher incidence of complications and lower durability. Although interventional techniques have been introduced cautiously into the cerebrovascular system, balloon dilation for both primary and recurrent carotid atherosclerotic disease has been successful in establishing an adequate lumen without an increase in embolic complications over surgery. Because the likelihood exists that postdilation restenosis may be as common in the carotid arteries as it is in other vascular segments, the use of intraluminal stenting may mitigate this long-term complication, a benefit that has been demonstrated in other high flow vessels such as the aorta and iliac arteries. To begin an investigation of this hypothesis, we treated a 69-year-old symptomatic man who required a third intervention for recurrent carotid disease. A > 90% stenosis of the distal third of his right common carotid artery was successfully dilated, and a Palmaz stent was deployed without incident. The patient experienced no complications to the percutaneous procedure, and at 15 months posttreatment, he is well and asymptomatic. Although greater clinical experience must be accumulated with this new approach, intraluminal stenting following balloon dilation for recurrent carotid disease may surpass redo CEA in long-term patency and may entail fewer procedural complications. PMID- 10155232 TI - Implantation and follow-up of a third-generation cardioverter defibrillator: comparison of epicardial and nonthoracotomy defibrillation lead system. AB - OBJECTIVE: The intraoperative and follow-up results were compared in 67 patients with ventricular tachyarrhythmias who underwent implantation of the Ventritex Cadence defibrillator with either epicardial patch (EPI, 25 patients) or nonthoracotomy CPI Endotak (ENDO, 42 patients) defibrillation lead systems. RESULTS: There was no significant difference between groups in age, sex, structural heart disease, ejection fraction, arrhythmia history, or drug therapy. Successful implantation was accomplished in all patients using either lead system. In the ENDO group, 35 patients (83%) had a defibrillation threshold < or = 550 V and did not require a subcutaneous patch. Intraoperatively, the defibrillation threshold was 453 +/- 139 V (13 +/- 9 J) for EPI and 490 +/- 113 V (15 +/- 8 J) for ENDO (P = NS). There were no perioperative deaths in either group. At predischarge testing, the defibrillation threshold was 445 +/- 183 V (14 +/- 12 J) for EPI and 439 +/- 133 V (13 +/- 7 J) for ENDO (P = NS). During a mean follow-up of 16 +/- 8 months, there were no sudden deaths, and four patients died from congestive heart failure (3 EPI, 1 ENDO). During follow-up, 916 spontaneous arrhythmia episodes occurred in 16 of 25 EPI patients (64%) and 967 episodes occurred in 31 of 42 ENDO patients (74%) (P = NS). The number of episodes detected as ventricular fibrillation were 192 for EPI (21%) and 232 for ENDO (24%), with first shock success in 76% and 75%, respectively; all episodes were successfully terminated by the device. In the remaining episodes detected as ventricular tachycardia, antitachycardia pacing was attempted and was successful in 672 of 724 episodes (93%) with EPI and 666 of 735 episodes (91%) with ENDO lead systems (P = NS). Acceleration of ventricular tachycardia with antitachycardia pacing occurred in 21 episodes (3%) with EPI and in 37 episodes (5%) with ENDO leads (P = NS). CONCLUSIONS: A nonthoracotomy approach using the third generation cardioverter defibrillator Cadence V-100 is safe and effective and has clinical results that are not significantly different from epicardial defibrillation lead systems. PMID- 10155233 TI - Percutaneous transluminal coronary angioplasty as alternative treatment to coronary artery bypass surgery in iatrogenic stenosis of the left main coronary artery. AB - The present report describes three patients with iatrogenic left main coronary artery after aortic valve replacement. All three patients were successfully treated by percutaneous transluminal coronary angioplasty. No clinical or angiographic signs of restenosis were seen during the long-term follow-up (4, 6, and 11 years). These patients show the feasibility of percutaneous transluminal coronary angioplasty in iatrogenic left main coronary artery stenosis as alternative of coronary artery bypass surgery. However, it should be only considered in patients who would otherwise be deemed inoperable, refused reoperation, and are willing to take the risk involved. PMID- 10155234 TI - Initial experience with the "Big-Skinny" angioplasty catheter. AB - We describe our initial experience with the "Big Skinny" angioplasty catheter, currently only available as an investigational device and in sizes of 4.5, 5, and 6 mm. Six patients with severe angina pectoris were successfully dilated with this angioplasty catheter and have remained asymptomatic up until a mean follow up period of 6 months. However, because of the large profile of the catheter, sufficient back-up with an adequate guiding catheter should be obtained and predilation with a smaller angioplasty catheter should be performed. The use of this catheter may be a more simple alternative for the treatment of oversized vessel stenosis than the "hugging balloon" technique or directional atherectomy. Otherwise, it may be considered as an adjunct technique in order to optimize the angiographic result after stenting or directional arthrectomy in this particular indication. PMID- 10155235 TI - Emergency use of cardiopulmonary bypass. AB - Emergency cardiopulmonary support has been used in the United States since 1986. Physicians at participating centers for the National Registry of Elective Supported Angioplasty have contributed data on emergent cardiopulmonary support from their institutions. Results were analyzed to assess the benefits of cardiopulmonary support in patients with hemodynamic collapse. Patients with either cardiac arrest or hemodynamic collapse with cardiogenic shock unresponsive to pressor agents were placed emergently on cardiopulmonary support. Subsequent treatment comprised either angioplasty or surgical revascularization. Patients placed on cardiopulmonary support in < 20 minutes experienced a 41% survival rate across the entire registry of the participating centers of the National Cardiopulmonary Bypass Registry. Two centers with considerable experience demonstrated a 69% survival rate. Patients treated with emergency cardiopulmonary support because of hemodynamic collapse showed improved survival over any other hemodynamic support system. Results have improved for survival with increased operator experience, particularly in the early application group. PMID- 10155236 TI - Cardiopulmonary support for complex angioplasty. AB - The role of cardiopulmonary support (CPS) in interventional procedures is currently in evolution. The authors review the clinical applications and technical considerations involved in CPS including discussion of indications, hemodynamic effects, complications, and prophylactic versus stand-by techniques. Use of the technique in high risk percutaneous transluminal coronary angioplasty patients is discussed. PMID- 10155237 TI - Regional flow adjusted hemoperfusion during coronary angioplasty: circulatory support/myocardial protection. AB - Routine percutaneous transluminal coronary angioplasty catheters are adequate and demonstrate high success rates in balloon angioplasty with stable patients. Active hemoperfusion seems to offer an advantage in patients with hemodynamic instability. Active hemoperfusion provides myocardial protection during coronary interventions and can be applied in conjunction with routine angioplasty equipment. When compared with other devices demonstrating clinical utility in a supported angioplasty setting, this flow adjustable active antegrade hemoperfusion pump appears reliable, simple to use, cost-effective, and requires much less instrumentation than the more bulky CPS systems. PMID- 10155238 TI - Transvalvular left ventricular assistance in acute myocardial infarction with cardiogenic shock and high risk angioplasty: experimental and clinical results with the Hemopump. AB - The Hemopump has been shown to be an effective left ventricular assist device. It is capable of supporting the circulation in patients with profound left ventricular dysfunction in the setting of cardiogenic shock. In experimental animals it seems possible that supporting the circulation immediately prior to reperfusion will produce a significant decrease in infarct size, which has important clinical ramifications, particularly in the setting of patients with large anterior myocardial infarction. The mechanism for this infarct salvage is unclear at the present time and requires further investigation, at a more basic level. The current tools available to the cardiologist include the intraaortic balloon pump and the cardiopulmonary support system (CPS), (PCs, BARD, Inc.). The Hemopump is available in Europe, but not in the United States at the present time. Clearly, the CPS system is the most powerful of the devices available, producing up to 61/m of flow. Unfortunately, there are a number of drawbacks with the CPS system, including its need for an oxygenator, which limits its useful period of support to approximately 8 hours. Additionally, support with the PCS system may be associated with adverse physiological events. The intraaortic balloon pump requires synchronization with the cardiac cycle, and hence, is not suitable for patients with significant tachyarrhythmias. Patients with overt cardiac arrest, similarly, cannot be supported with the intraaortic balloon pump. Nonetheless, the balloon pump has been associated with improved infarct salvage in an experimental animal model. On the other hand, the Hemopump, in its first version, required a surgical incision and placement of a graft onto the femoral artery.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155239 TI - Diagnosis and treatment of complications in patients implanted with a TCI left ventricular assist device. AB - Currently used left ventricular assist devices allow chronic mechanical cardiac support in the patient with end-stage heart failure. Recognition and treatment of problems uniquely associated with this device may be increasingly important for the invasive cardiologist as application of this technology becomes more prevalent. PMID- 10155240 TI - Coronary artery perfusion during angioplasty: a 10-year milestone. PMID- 10155241 TI - Basic view on the pathobiology of myocardial ischemia during coronary angioplasty: implications for cardiac protection. AB - PTCA is not only an effective therapeutic tool but a unique opportunity to study the pathobiology of the human myocardium during ischemia and reperfusion. In addition, it is a good model to assess potential therapeutic interventions. Studies performed during PTCA contributed significantly to the understanding of the metabolic, electrophysiologic, hemodynamic, and coronary perfusion changes in the human heart following coronary occlusion. Combining the data from experimental models and human patients may lead to better techniques for myocardial protection during PTCA and consequently reduce the risk of patients undergoing mechanical revascularization. PMID- 10155242 TI - Use of active hemoperfusion during percutaneous transluminal coronary angioplasty. PMID- 10155243 TI - The role of the perfusion balloon catheter after an initially unsuccessful coronary intervention. AB - Major dissection and acute closure following conventional percutaneous transluminal coronary angioplasty (PTCA) occur in 5%-10% of cases and lead to significant morbidity. Newer percutaneous modalities such as directional coronary atherectomy (DCA), excimer laser coronary angioplasty (ELCA), rotational ablation, and transluminal extraction atherectomy (TEC) can also be complicated by dissection and acute closure. Redilatation with conventional balloon catheters can reestablish patency of the artery or improve flow in a minority of cases. The perfusion balloon catheter (PBC) has several advantages over conventional balloon angioplasty in this situation. In approximately 70% of these cases, subsequent use of a PBC yields an acceptable clinical and angiographic result. The PBC permits rapid resolution of ischemia caused by acute closure or a flow-limiting dissection. New modifications of the PBC make it possible to position the catheter in nearly all segments of the coronary arterial tree including locations not accessible to other modalities, such as coronary stents or DCA, that are also used for salvage after a failed coronary intervention. Even if the PBC does not yield a definitive result, it allows rapid restoration of antegrade flow prior to coronary artery bypass grafting or coronary stent placement. Because of its ease of use, wide applicability, and efficacy, the PBC should be considered as the initial means of treatment in cases of major dissection or acute closure following any modality of percutaneous coronary revascularization. PMID- 10155244 TI - Perfusion therapy to reduce myocardial ischemia en route to emergency coronary artery bypass grafting for failed percutaneous transluminal coronary angioplasty. AB - Despite improvements in operator technique, catheter technology, and the development of new devices, emergency coronary artery bypass grafting (CABG) is still required in 1%-4% of attempted catheter based revascularization procedures. Patients who require such emergency CABG after failed percutaneous transluminal coronary angioplasty (PTCA) have worse acute outcomes than those undergoing elective CABG, with a higher incidence of Q wave myocardial infarction (MI) and a higher operative mortality. In patients with otherwise refractory abrupt closure, maintenance of antegrade coronary blood flow using perfusion catheters lessens the incidence of Q wave MI and lowers peak creatinine phosphokinase. Direct maintenance of coronary flow thus appears to provide more definitive control of myocardial ischemia than purely adjunctive measures, such as intra-aortic balloon pumping, cardiopulmonary support, or coronary sinus retroperfusion. Although the recent introduction of coronary stents holds great promise for definitive percutaneous reversal of abrupt closure and a dramatic decrease in the incidence of emergency CABG for failed PTCA, maintenance of antegrade flow via perfusion technology remains the cornerstone of management in reducing the perioperative mortality and morbidity of patients who still require emergency bypass surgery after failed PTCA. PMID- 10155245 TI - Certification in interventional cardiology: how far have we come? What remains to be done? PMID- 10155246 TI - The systems, the operators, the patients: the impact of PTCA equipment on health care cost. PMID- 10155247 TI - A prospective randomized trial comparing the benefits and limitations of 6Fr and 8Fr guiding catheters in elective coronary angioplasty: clinical, procedural, angiographic, and economic end points. AB - OBJECTIVES: To determine the relation between guiding catheter size, procedural and angiographic details, and cost of coronary angioplasty. BACKGROUND: Miniaturized angiographic equipment used during coronary angioplasty is proposed as a method to decrease the duration of supine bed rest, length of hospital stay, and cost of expensive inpatient hospitalization. METHODS: One hundred and sixty patients were randomized to undergo elective coronary angioplasty with a 6Fr (external diameter, 0.079-in; internal diameter 0.062-in) or 8Fr (external diameter, 0.105-in internal diameter, 0.078-0.079-in) guiding catheter. Standard balloon dilatation catheters were used. END POINTS: 1 degree peripheral vascular complications, 2 degree technical and procedural outcomes; quantitative and qualitative quality of the coronary angiograms; and the in-hospital ("bottom up" cost accounting of equipment, supplies, support personnel, postcoronary angioplasty room), and physician cost (using Resource Based Relative Value Scale). RESULTS: There was no difference in peripheral vascular complications between the two groups (6Fr, 21%; 8Fr, 30%; P = NS). Less contrast medium was used with the 6Fr guiding catheters (6Fr, 178 +/- 102 mL; 8Fr, 257 +/- 147 mL; P = 0.0001). The qualitative quality of the angiograms was better with 8Fr than with 6Fr guiding catheters. For the entire population, the total cost of coronary angioplasty was less with 6Fr guiding catheters ($3,956 +/- $2,415) than with 8F guiding catheters ($5,073 +/- $3,985, P = 0.03). Excluding patients with either a coronary or peripheral vascular complication, there was less cost savings (6F, $3,720 +/- $1,338; 8F, $4,376 +/- 2,699, P = 0.05). Independent variables associated with increased cost included: large body mass index; hypercholesterolemia; nonionic contrast media; 8F guiding catheter; complex lesions; and duration of procedure. CONCLUSIONS: The use of smaller guiding catheters led to use of less contrast medium with a modest decrease in angiographic visualization. The cost savings seen with 6F guiding catheters is multifactorial due to smaller arteriotomy accompanying sheath insertion and reduced rate of clinically significant coronary and peripheral vascular complications. PMID- 10155248 TI - Multivessel coronary angioplasty with anomalous origin of the left main coronary artery. AB - We report a case of coronary angioplasty to the right coronary artery, the circumflex, and the left anterior descending artery in a patient with anomalous left main coronary artery arising from the right aortic sinus of Valsalva. At angiographically documented follow-up of more than 2 years, the patient remains well without restenosis. This case represents the only such report in the literature. Angioplasty hardware was an important factor in successful crossing and dilatation of multiple severe and distal stenoses in the anomalous left system; appropriate technical details are discussed. PMID- 10155249 TI - Cardiovascular molecular biology: if not now, when? If not us, who? PMID- 10155250 TI - Vascular applications of human gene therapy. PMID- 10155251 TI - Potential for transcatheter application of antisense oligonucleotides for the treatment of vascular diseases. PMID- 10155252 TI - Seeding of intracoronary stents with endothelial cells: current status and future prospects. PMID- 10155253 TI - Strategies for myocardial repair. AB - The therapeutic recourse for end-stage heart disease is currently limited to cardiac transplantation. The ability to augment cardiomyocyte number in an end stage heart might facilitate myocardial function. Augmentation of cardiomyocyte number may be achievable by the targeted expression of cell cycle regulatory genes to the myocardium. Alternatively, intracardiac grafting of exogenous cardiomyocytes might also provide a viable approach to augment cardiomyocyte number. Potential strategies for heart muscle regeneration via gene therapy and cellular transplantation are discussed. PMID- 10155254 TI - Biodegradable stents: the future of interventional cardiology? PMID- 10155255 TI - Current status and potential applications of drug delivery balloon catheters. PMID- 10155256 TI - Potential applications of iontophoresis for local drug delivery of vascular diseases. PMID- 10155257 TI - New antithrombotic drugs for systemic and local delivery for coronary artery disease. PMID- 10155258 TI - Ethical and legal issues in conducting research involving elderly subjects. AB - Older people are increasingly the focus of biomedical and behavioral research not only because the elderly constitute the fastest growing segment of our population but because there is a societal concern to improve the elderly's quality of life. The profound need to advance that research carries with it an equally profound obligation to protect the rights and welfare of elderly research subjects, and thus raises difficult ethical and legal issues. Against a background of foundational principles for the protection of human subjects, we discuss whether older subjects should be treated as a special class, the ethical and legal issues over informed consent, capacities for consent, and special problems related to cognitive impairment. We discuss surrogate/proxy consent procedures in research, recruitment of elderly subjects, conflicts of interest, special problems regarding institutional research, and risk/benefit analyses. We offer recommendations and practical guidelines for conducting current and future research involving elderly participants. PMID- 10155259 TI - Decision-making incapacity among nursing home residents: results from the 1987 NMES survey. National Medical Expenditure Survey. AB - Recent legislative and regulatory developments have focused attention on older adults' capacity for involvement in health care decision-making. The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) focused attention on the rights of nursing home residents to be involved in health care decision-making to the fullest extent possible. This article uses data from the 1987 National Medical Expenditure Survey (NMES) to examine rates of incapacity for health care decision making among nursing home residents. Elements of the Oklahoma statute were used to operationalize decision-making incapacity: disability or disorder, difficulty in decision-making or communicating decisions, and functional disability. Fifty three percent of nursing home residents had a combination of either physical or mental impairment and an impairment in either self-care or money management. The discussion focuses on the policy and practice implications of significant rates of incapacity among nursing home residents. PMID- 10155260 TI - Autonomy for nursing home residents: the role of regulations. AB - The importance of autonomy and choice to nursing home residents' well-being has been well established. This paper examines the complex role of regulation as it affects the autonomy of nursing home residents. Nonstandardized interviews with residents, family members, nursing staff members, and administrators were conducted at three nursing homes in suburban Maryland. These anecdotal interviews identified the most problematic areas where regulations enforce barriers to autonomy and control. These areas include: scheduling of activities of daily living, food portions, physical environment, and documentation. Suggestions for possible improvements are discussed. PMID- 10155261 TI - Copayments for medicines. How much should patients pay? PMID- 10155262 TI - Applying the Australian guidelines for the reimbursement of pharmaceuticals. PMID- 10155264 TI - The burden of migraine. A review of cost to society. AB - Migraine is a common episodic disorder with considerable impact on individuals and society. Migraine occurs with the highest prevalence between the ages of 25 and 55 years, potentially the most productive period of life. Severe migraine can lead to disruption of work, family and social life, the long term consequences of which may affect quality of life. The direct costs of migraine (due to medical care) are small compared with the indirect costs caused by absence from work and reduced productivity. Population-based studies are required to assess incidence, prevalence and distribution of the disease. These studies also reveal that migraine is currently underdiagnosed and undertreated. The cumulative impact of migraine on individuals produces the burden of illness on society. Measuring the severity of migraine is important in understanding the extent of the burden of migraine on the individual and on society. Measures of severity may be useful as predictors of disability and healthcare use. These measures may also be useful in assessing the need for patient care and treatment and help target those more disabled by migraine. Identifying and treating appropriate patients should reduce the impact of migraine on the individual and the burden of migraine on society. PMID- 10155263 TI - Therapy of acute otitis media. Clinical and economic aspects. AB - Acute otitis media is a common health problem worldwide that accounts for significant morbidity, primarily among pre-school-age children, for which antimicrobial therapy is currently the treatment of choice. Approximately 25% of all prescriptions written in the US for children under the age of 10 years are for children diagnosed as having acute otitis media. Until adequately designed studies with appropriate patient populations are conducted, clinicians must base their decisions to treat acute otitis media with antimicrobial therapy, and their choice of drug, on local susceptibility patterns (if known), in vitro and in vivo studies, adverse effect profiles, tolerability, and affordability. Such studies will hopefully answer questions about selecting an antimicrobial for acute otitis media and address the comprehensive cost of using various antimicrobials for the condition. Because of the human and economic costs associated with acute otitis media, healthcare practitioners should also be aware of the epidemiology, pathophysiology and various treatment options for children with acute otitis media. PMID- 10155266 TI - The costs of treating febrile neutropenia in patients with malignant blood disorders. AB - Retrospective data were collected over a 1-year period from the medical records of patients admitted to a district general hospital, either with febrile neutropenia or who developed this complication whilst receiving inpatient chemotherapy. Costs were calculated for inpatient stay, drug treatment and diagnostic tests. The median total costs for 46 episodes of febrile neutropenia were 2068.35 pounds and the median total cost per day was 139.41 pounds. Inpatient bed-days accounted for 57.8% of total costs, followed by drug treatment at 25.8% and diagnostic tests at 16.4%. The costs of blood products were excluded since they are frequently administered irrespective of the neutropenia. This study serves as a useful pointer to the expenditure in measurable antibiotic costs and investigations in patients with malignant blood disorders who develop febrile neutropenia. PMID- 10155265 TI - Economic incentives and disincentives for efficient prescribing. AB - Efficient prescribing is a controversial concept when defined in economic terms. Such terms imply that neither the best nor the cheapest drug may be efficient. Efficiency depends on patient evaluations of outcomes--an essential, yet still underdeveloped, field of inquiry. Encouraging prescribing efficiency (once it is clear what efficient treatments are) may require the use of incentives, (economic and otherwise). Although physicians do react to economic incentives, encouraging them to also act as good economists rather than only as good healthcare providers may be difficult since economic efficiency goals may conflict with pure medical goals. While it is conceptually reasonable to assume that economic incentives will accomplish behavioural change, other (noneconomic) incentive mechanisms may appear less controversial. Since it is the result, not the process, that is important, a mix of incentives to achieve efficient solutions is suggested. However, further investigation into both health and economic outcomes research and debate on proper efficiency goals should precede the discussion of optimal incentives. PMID- 10155267 TI - Identifying costs of intravenous solution wastage. AB - A monitoring programme to systematically evaluate and decrease wastage of intravenous (i.v.) solutions was developed. Documentation of type and quantity of wasted solutions can help identify potential causes of waste. Subsequent systems changes intended to decrease waste can then be evaluated. Pharmacy technicians daily recorded the number, identity and locations of discarded i.v. solutions. A computer spreadsheet application was developed and used to produce a monthly summary identifying the number, drug cost and solutions wasted by hospital unit, thus establishing specific areas to target for i.v. wastage control. Investigators conducted a 12-month retrospective evaluation of i.v. wastage, revealing that over 14,000 i.v. preparations were destroyed at an estimated $US90,000 in drug costs. This equates to 2.5% of total drug costs wasted in small volume parenterals. Target programmes were implemented for drugs that were frequently wasted and systems changes implemented that decreased overall wastage of i.v. solutions. PMID- 10155269 TI - Issues in the conduct of economic evaluations of pharmaceutical products. PMID- 10155268 TI - Ceftriaxone. A pharmacoeconomic evaluation of its use in the treatment of serious infections. AB - Ceftriaxone possesses a broad spectrum of antimicrobial activity that includes the Gram-positive and Gram-negative aerobes commonly associated with serious infections. Its therapeutic efficacy is comparable to that of other third generation cephalosporins and aminoglycoside-combination regimens. The most commonly reported adverse events with ceftriaxone are similar in incidence and severity to those reported with other third-generation cephalosporins. Notably, the drug has a favourable pharmacokinetic profile which allows once-daily administration. In comparative studies with other parenteral regimens requiring 3 to 6 daily doses, treatment with once-daily ceftriaxone reduced total antimicrobial drug costs (i.e. acquisition, preparation and administration costs) by 17 to 52%. Ceftriaxone was also more cost effective than ceftazidime and a variety of other antimicrobial treatment regimens (penicillins, cephalosporins, combination regimens) in the treatment of patients with community-acquired pneumonia or bronchopneumonia. This reflected lower drug and hospitalisation costs associated with a reduced length of hospital stay in ceftriaxone recipients. In noncomparative studies, ceftriaxone achieved considerable hospitalisation cost savings in patients with serious infections (mostly bone, joint, skin/skin structure infections), who were able to receive all or part of their antimicrobial therapy as outpatients. In one analysis which evaluated all direct and indirect costs (such as training programmes, transportation, time for visits and supplies) and benefits (such as hospitalisation cost savings, return to work or school, increased productivity) of outpatient ceftriaxone therapy, the overall benefit-cost ratio was approximately 5:1. The studies to date confirm that ceftriaxone is effective, well tolerated, convenient to administer and, when utilised appropriately, offers the potential for cost avoidance in patients with serious infections. Although additional well designed pharmacoeconomic analyses are needed to further evaluate its cost effectiveness, ceftriaxone should be considered an essential third-generation cephalosporin formulatory representative in most clinical settings. PMID- 10155270 TI - Implementing pharmacoeconomic outcomes management. PMID- 10155271 TI - Pharmaceutical prices, quantities and innovation. Comparing Japan with the US. AB - Per capita expenditure on pharmaceuticals is higher in Japan than in the US, despite a series of drug price reductions instigated by the Japanese Ministry of Health and Welfare that began in 1981. For some individual products, these price reductions cumulatively totalled more than 50%. This article argues that although the price of individual drugs is lower in Japan than in the US, aggregate expenditure is higher because of the greater use of newly-introduced original drugs and lower use of generics. Providers and consumers also tend to use drugs in larger quantities in Japan, because of polypharmacy and greater use of vitamins and nutrients, antihypertensives, cerebral metabolic activators (e.g. idebenone) and milder-acting drugs (i.e. drugs with low toxicity but unproven clinical efficacy). The level of expenditure is unlikely to decline, despite changes to pricing policy and ongoing efforts to improve the pharmaceutical distribution system and to discourage physician dispensing activities. PMID- 10155272 TI - Quality-of-life assessment of adults with growth hormone deficiency. Implications for drug therapy. AB - Growth hormone (GH) deficiency in adults affects many physiological functions. It may result in reduced muscle volume and strength, changes in body mass, lowered metabolic rate, low energy and sexual drive and impaired cognitive function. GH deficiency may also lead to an increase in mortality due to vascular disorders. However, the benefits of GH replacement are still controversial. Recently, investigators have looked at the effects of GH replacement therapy on the well being of patients. However, the studies which have been published generally have small sample sizes, use inadequate methodology and employ health status measures that lack the necessary sensitivity. Despite these weaknesses, results suggest that replacement GH does have a positive effect on well-being. A GH-specific quality-of-life measure has now been produced, which will provide a clearer view of the benefits of replacement therapy for patients. The use of this measure should help guide decisions about the necessity of providing replacement therapy for GH-deficient patients. PMID- 10155273 TI - Chemonucleolysis versus surgical discectomy for sciatica secondary to lumbar disc herniation. A cost and quality-of-life evaluation. AB - The objective of this study was to evaluate and compare the cost and effects on quality of life [using quality-adjusted life years (QALYs)] of 2 treatments for sciatica secondary to lumbar disc herniation: chemonucleolysis and surgical discectomy. The design involved a combination of decision analysis and Rosser index, with assessment of probabilities from long term clinical series. Utility was based on patients' subjective assessment using a simplified self-administered Health Measurement Questionnaire (HMQ). 146 patients from 7 hospitals were enrolled, 2 to 3 months after chemonucleolysis or surgery. The end-points used were cost and QALYs for each intervention, every year for years 1 to 7. At the time of analysis (1990), the total cost of surgical discectomy was FF15,400, compared with FF8000 for chemonucleolysis. After 1 year, and including the costs of reoperation for failure and relapse and long term medical costs for the non reoperated unsatisfactory results, discectomy costs were almost 40% higher than those of chemonucleolysis. Ratios remain unchanged after 7 years. QALY results reveal an additional benefit of 52 days of good health associated with chemonucleolysis. PMID- 10155274 TI - Economic evaluation of immunoprophylaxis in children with recurrent ear, nose and throat infections. AB - This study compares the costs of immunoprophylaxis versus no immunoprophylaxis in children with recurrent ear, nose and throat (ENT) infections (otitis media and rhinopharyngitis) using ribosomal immunotherapy ('Ribomunyl'). The per-patient cost of ribosomal immunotherapy (FF297) is offset by direct savings garnered through the prevention of many acute infectious episodes. The net 6-month per patient savings associated with immunoprophylaxis range from FF272 to FF1704, depending on the indication and the type of treatment-cost estimate. Saved healthcare resources include physician consultations and visits, laboratory tests, medicotechnical services (audiometric tests) and antibiotic therapy. Sensitivity analysis of efficacy and treatment-cost estimates enabled threshold ranges of incremental efficacy to be identified. Cost-equivalence between the 2 treatment options was found to exist when the incremental efficacy of immunoprophylaxis lay between 7.4 and 17.5% (recurrent otitis media), and between 8.9 and 26.1% (recurrent rhinopharyngitis). Thus, even when clearly lower incremental efficacy rates than those reported in controlled clinical trials (approximately 40 to 60%) are assumed, ribosomal immunotherapy can still be expected to be cost effective. An analysis of the perspectives of the various payers in the French healthcare system demonstrated that net savings occurred for all payers involved. However, social security insurance would gain most from an immunoprophylaxis programme. Based on the evidence presented here for France, physicians and payers should give increased attention to this treatment option. PMID- 10155275 TI - Expert systems. Assisting formulary decision making in the ambulatory setting. AB - In this article, the author reviews the application of a computer-assisted decision support system to their formulary decision-making process. Basic information is presented describing expert systems, which are a type of computer assisted decision support system, and their advantages and disadvantages. A specific example of an expert system, 'RXPERT', is described. 'RXPERT' is a prototype expert system that models the decision-making process for an ambulatory (nonhospital) formulary. This formulary is the underpinning of the prescription drug benefit programme for the nearly 1 million residents of Saskatchewan, Canada. In the current formulary decision process, each drug product is evaluated by 2 separate committees, with the third and final decision resting with the Ministry of Health. The first committee, the Drug Quality Assessment Committee (DQAC), comprises members with expertise in medicine, pharmacology, clinical pharmacy, pharmaceutics, statistics, and regulatory processes. The DQAC evaluates information from the drug manufacturer and other independent sources, and makes an initial assessment with respect to clinical aspects of alternative therapies and generic interchangeability. The committee then makes its recommendation to the Saskatchewan Formulary Committee (SFC). The SFC reviews the recommendation of the DQAC and considers the administrative and economic implications of accepting the product for the patient, the programme, and healthcare professionals' practice. The SFC either reaffirms the recommendation of the DQAC or modifies it based on further review, and forwards its recommendation to the Ministry of Health. Finally, the Ministry of Health reviews the evaluation and determines the drug's formulary status.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155277 TI - Infection after surgery for gastrointestinal cancer. Assessing the costs. AB - This study was a retrospective analysis of 85 patients who underwent major abdominal surgery for gastrointestinal malignancies between September 1988 and August 1990. The aim of the study was to evaluate the effects of diagnosed infections, both surgical and nonsurgical, and postoperative fever on the costs and charges for hospitalisation. Patients with preoperative infections or immunosuppression were excluded from the study. 21 (25%) of the patients were diagnosed as having infections and, of those, 13 had major systemic infections and 8 had minor infections (urinary tract or wound infections). Of the 64 noninfected patients, 13 (20%) were febrile. Infection rates were highest in patients with oesophageal, gastric or pancreatic cancer (31, 29 and 24%, respectively). The mean costs for patients with major infections, those with minor infections, febrile patients with no identified infection and afebrile patients with no signs of infection were $US58,067, $US16,726, $US30,236 and $US14,961, respectively. The corresponding charges were $US151,259, $US41,721, $US75,094 and $US37,512, respectively. Major infections and postoperative febrility both significantly increased costs and charges while minor infections only marginally affected these parameters. Comparing patients with and without diagnosed infections, the increases in costs were 402% for microbiological tests ($US497 vs $US99), 144% for other laboratory tests ($US9247 vs $US3790), 167% for radiological examinations ($US3996 vs $US1496), 152% for pharmacy costs ($US2903 vs $US1153), 97% for room costs ($US15,757 vs $US8014), 189% for other items ($US10,151 vs $US3512) and 136% for the total costs ($US42,551 vs $US18,064).(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155276 TI - Generic competition in Canada. AB - This study was designed to assess the potential impact of generic drug competition on prescription prices in Ontario, Canada, and the costs and benefits of the passage of Bill C-22 by the Canadian federal government. Bill C-22, passed in 1987, extended the period during which a patented drug is exempt from compulsory licensing by a generic drug manufacturer, and created the Patented Medicine Prices Review Board (PMPRB). The purpose of the PMPRB is to 'ensure that the prices of patented medicines charged by patentees are not excessive' and to 'report annually on the ratios of research-and-development expenditures to sales for individual patentees and for the patented pharmaceutical industry as a whole'. Lexchin analysed prices in the 1991 Drug Benefit Formulary of Ontario for interchangeable products which were manufactured by more than one company. He also noted the best available price for the highest and lowest priced versions, and the number of manufacturers of that product. Products were then grouped according to the number of manufacturers, and the price of the least expensive version of each product was expressed as a percentage of that of the most expensive version (i.e. the proportional cost). For products marketed by 2 to 6 companies, the data were further subdivided into 4 categories representing 0%, non-maximal, maximal and 100% generic competition.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155278 TI - Guidelines for pharmacoeconomic studies. The ways forward. PMID- 10155279 TI - Therapeutic dilemmas. An approach to the management of expensive pharmaceutical advances. PMID- 10155280 TI - Effects of capitation on health of the chronically ill. Implications for antipsychotic drug therapy. PMID- 10155281 TI - The costs of rheumatoid arthritis. AB - The economic costs associated with rheumatoid arthritis (RA), a chronic, systemic, inflammatory disorder that affects many joints, are high, approximating those of coronary heart disease. The estimated prevalence of RA in the US is 0.9%. Incidence increases with age, and is highest among women in the fourth to sixth decades of life. The primary impact of RA is due to the significant morbidity associated with this disease. Mortality is increased among a poorly defined subgroup of RA patients. The average level of disability among RA patients is moderate, but 6.5 to 12% of patients are severely disabled. Between one- and two-thirds of previously employed patients have a reduced work capacity. Treatment primarily involves the use of nonsteroidal anti-inflammatory drugs and disease modifying antirheumatic drugs. Rehabilitation measures and orthopaedic surgery are also used. Total annual direct costs of RA (total charges) have been calculated to be $US5275 and $US6099 (1991 dollars) per patient. Lifetime medical care charges were estimated at $US12,578 per patient (1991 dollars). The direct costs of RA are substantial, but indirect costs have been calculated to be much higher because of extensive morbidity. The difference between the direct and indirect costs of RA is decreasing because salary increases have not kept pace with rising healthcare costs. The latter are increasing rapidly in RA because of the use of new technology, surgical procedures, and the greater use of drugs with frequent monitoring requirements and significant toxicity. Because intangible costs such as pain form a substantial part of the overall costs of RA but are difficult to evaluate, cost estimates inevitably underestimate the impact of the disease on individuals and society. PMID- 10155282 TI - Quality-of-life instruments in hypertension. AB - This review considers the choice of dimensions to be assessed and the practical problems of measuring quality of life in hypertensive patients. The dimensions of symptomatic well-being, psychological well-being, sleep, sexual function and cognitive function should be assessed. Symptomatic well-being may be measured by many different instruments, and that devised by the authors has been used extensively. The results in different trials may therefore be examined for consistency and sensitivity. Psychological well-being has been assessed by the Psychological General Well-Being Index, the Symptom Rating Test and the Profile of Mood States. The response of these instruments is discussed. The assessment of sleep, sexual function and cognitive function is also described. It is recommended that quality-of-life instruments to be employed in trials of antihypertensive drugs are known to be sensitive to the effects of such drugs. PMID- 10155283 TI - Costs of illness in cost-effectiveness analysis. A review of the methodology. AB - Costs of illness are an important input in cost-effectiveness analysis (CEA). Reviews of the literature have found that many CEAs are of low technical quality and fail to take account of costs of illness appropriately. The costs of illness and disease averted by an intervention, indirect costs, and medical care costs in added years of life are topics that present methodological issues and are not handled consistently in CEAs. Costs of illness and disease averted may be estimated by prevalence- or incidence-based methods; the correct conceptual paradigm depends on the nature of the disease. Incidence costs may be estimated by modelling the disease process, or directly from prevalence costs, the choice being determined by the extent and quality of data available. Regardless of the method, in forward-looking CEAs potential technological change must be taken into account so that incidence-based lifetime costs estimated from current treatment practices will not be biased. Whether to include indirect costs is an important issue, because indirect costs may be large and have a significant impact on the cost-effectiveness ratio. In the pure CEA model, indirect costs are excluded on ethical grounds and to prevent incursion of elements of cost-benefit analysis into CEA. The modified CEA model accepts enhanced productivity as an economic benefit made possible by, but distinct from, the health effect of an intervention. Indirect costs are included when appropriate, depending on the perspective of the analysis, the measure of effectiveness, and who bears the costs. When medical care extends life, expenditures will be incurred in the added years for illness and disease unrelated to the intervention. As with indirect costs, the pure CEA considers unrelated 'downstream' costs an indirect consequence of the health benefit of the intervention and excludes them from CEAs with the societal perspective. The modified CEA treats unrelated downstream costs as an economic effect of the change in health due to the intervention and includes them in order to have a more complete accounting of the cost of the intervention. PMID- 10155284 TI - Cost effectiveness of antiviral treatment with zalcitabine plus zidovudine for AIDS patients with CD4+ counts less than 300/microliters in 5 European countries. AB - A cost-effectiveness model was developed on the basis of early clinical trial results from the US reporting sustained CD4+ cell response in patients receiving zalcitabine in addition to zidovudine. This model was then adapted and applied to 5 European countries to assess the comparative cost effectiveness of adding zalcitabine to antiviral treatment for AIDS patients. The countries included in the modelling effort were Switzerland, France, Italy, Germany and the UK. The model used a Markov state-transition process to estimate the rate of acute opportunistic disease episodes, lifetime medical treatment costs, and survival for populations of AIDS patients with baseline CD4+ counts of less than 300/microliters. Physician panels in each country developed standard treatment algorithms and adjusted the epidemiological data to reflect the AIDS profile of each country. Economic consultants provided cost data. Results from this exploratory data analysis show that if CD4+ counts correlate with the incidence of opportunistic disease episodes as expected, the combined use of zalcitabine and zidovudine for a 1-year period should be cost effective. PMID- 10155286 TI - Measuring quality of life in inflammatory bowel disease. AB - In this study, the authors developed a disease-specific health related quality-of life (HRQOL) measure that differentiated patients with ulcerative colitis (with and without surgery) from patients with Crohn's disease (with and without surgery). The purpose of the measure, which was facilitated by a questionnaire, was to produce a patient-orientated HRQOL index applicable to physicians' day-to day management, and to provide a quality assurance mechanism to assess outcomes for these chronic diseases. The interview-directed questionnaire contained 47 items covering the following 4 domains: functional/economic, social/recreational, affect/life, and medical/symptoms. The items were selected by the authors from clinical experience and literature review, and showed good test-retest reliability over a 2-week period. The questionnaire had construct validity based on those items that correlated with the Sickness Impact Profile (SIP), a standardised generic health profile measure. From the 47 questions, a quality-of life index was constructed by condensing the questionnaire to include only those 18 items that significantly differentiated between the 4 patient groups. Using this questionnaire, the authors studied 164 ambulatory patients (94 with ulcerative colitis, 70 with Crohn's disease) from a registry developed at the Cleveland Clinic. All patients had had their illness for at least 10 years, and 62% had undergone surgery because of it. When comparing the groups, the authors found that patients with ulcerative colitis had a better quality of life than those with Crohn's disease. In addition, patients who had not had surgery for their disease had a better quality of life than those who had.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155285 TI - Colfosceril palmitate. A pharmacoeconomic evaluation of a synthetic surfactant preparation (Exosurf Neonatal) in infants with respiratory distress syndrome. AB - Comprehensive clinical data provide strong evidence of the efficacy of the synthetic lung surfactant colfosceril palmitate (Exosurf Neonatal) administered as prophylaxis or rescue therapy in infants with respiratory distress syndrome (RDS). The use of rescue therapy with colfosceril palmitate is further supported by cost-effectiveness analyses which report a 9 to 48% reduction in the cost per survivor compared with placebo or historical controls, despite divergent study methodology and location. Importantly, the savings were evident in both larger (> or = 1250g) and smaller (700 to 1350g) infants. All studies considered costs or charges accrued during initial hospitalisation through to 1 year; measurement of long term resource use data and all resulting costs are required for a more complete pharmacoeconomic evaluation. The optimal timing of surfactant administration is likely to be an important economic issue given that efficacy data from a large international trial support earlier administration of colfosceril palmitate versus delayed therapy in high risk patients. Further economic benefits may be realised by the sequential use of antenatal corticosteroids and surfactant therapy, although this has yet to be prospectively investigated. In conclusion, clinical and pharmacoeconomic data strongly support the use of rescue therapy with colfosceril palmitate. Additionally, recent clinical data indicating that even better results may be achieved with earlier administration and/or combined use with antenatal corticosteroids should be assessed from an economic standpoint to determine the optimal prescribing strategy for this agent. PMID- 10155287 TI - Is ondansetron cost effective? AB - 5-Hydroxytryptamine3 (5-HT3) receptor antagonists are a major breakthrough in the prevention of nausea and vomiting induced by cancer chemotherapy. The acquisition cost of these drugs is considerably higher than for more conventional antiemetics. In this study, the authors reported on the economic consequences of giving ondansetron in Thomas Jefferson University Hospital, Philadelphia, USA. The study was divided into 3 parts. The first part was retrospective, and had the primary aim of comparing lengths of hospital stay and overall hospital costs for patients who had received intravenous ondansetron or standard antiemetic therapy. The purpose of the second part, which was prospective, was to determine the cost of emesis. In the third part, quality of life was studied; however, the results of this part were difficult to interpret because only 27 of the 52 selected patients completed the questionnaire, and only 4 of these patients received standard antiemetic therapy. In the retrospective study, costs were evaluated for patients who never received ondansetron, those who always received it, and those who received ondansetron during at least 1 hospital stay. In the prospective study, the costs associated with vomiting were nursing time, time required to obtain antiemetic therapy from the pharmacy, telephone calls to contact physicians, additional use of ancillary services, and laundry costs for soiled items. In the retrospective analysis, it was found that the average length of hospital stay for patients who were always given ondansetron was significantly shorter than for those who never received it.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155288 TI - How much faith can we have in pharmacoeconomic analyses? PMID- 10155289 TI - A proposal for Italian guidelines in pharmacoeconomics The Mario Negri Institute Centre for Health Economics. PMID- 10155290 TI - Economic aspects of pharmacotherapy for chronic constipation. AB - Constipation is one of the most common digestive complaints. It is a symptom, not a disease. The subjectivity that this involves means that assessments of clinical epidemiology, socioeconomic costs and pharmacotherapy are difficult, since there is no definition of 'normal' bowel habit. Although constipation can affect all ages, the problem increases with age, and is of particular concern for those who are frail and in long term care. Cultural influences may affect the prevalence in older people. Drug therapy of constipation cannot be considered in isolation, since there are issues in the prevention of constipation and the principles of good management that also apply. Furthermore, some consideration of the pathophysiology and diagnosis is important. This is because a number of remediable causes can be identified, and the diagnostic process involves patient education, which in turn may be effective in reducing costs. It is the complaint of constipation which leads either to self-medication or to consultation with the medical profession. Both of these courses of action have a significant influence on utilisation of laxatives (cathartics), obtained both over-the-counter and by prescription. Although there are a large number of laxative preparations available, therapy has changed little in half a century. Costs may vary considerably, and with such a significant problem there is a need for comparative studies. However, study methodologies are difficult, and a significant placebo response may be found. Education and preventive measures have been shown to reduce laxative use and costs in institutions. Unfortunately, there are few comparative studies of individual laxatives and even fewer cost-effectiveness studies. Those that there are have been based in institutions, and so extrapolation to other situations may be difficult. In general, little attention is given to constipation. It is, however, an area with significant resource implications in which education and preventive measures have been shown to be beneficial. Even so, there is still a need for good comparative studies, particularly where cost effectiveness is concerned. PMID- 10155292 TI - Operational aspects of Quality-of-Life Assessment. Choosing the right instrument. AB - In assessing quality of life, the most important goal is to develop a strategy that produces useable and useful information for decision making. Assessment design is complex, and whether an assessment is developed from scratch, or 1 or more portions of existing instruments are adapted, the focus must be on the quality of the theoretical and operational elements of the particular line of inquiry and its environment. The necessary and most often discussed focus on the theoretical dimensions of validity, reliability and responsiveness is not sufficient to insure that the data are of the requisite high quality. There is also a need, almost universally given little attention in the literature, to look at operational aspects, such as design, format, flow, appearance, and response stimulus, of each assessment instrument. Searching for guidance in the quality-of life (QOL) literature remains a challenge even with computers, modems, keywords, static guidebooks and bibliographic systems. The On-Line Guide to Quality-of-Life Assessments (OLGA) is presented as a personal computer-based system that is updated 3 times a year to provide QOL researchers and assessment developers with 2 databases: assessments providing full descriptions and contact information; and references providing fully keyed citations to the assessment use literature. These databases are made more useful by decision-logical programs that identify relevant assessments and supporting research literature. OLGA can thus save time and other resources by helping investigators concentrate on the most relevant elements of the existing literature. This focus will assist them in avoiding the problems of ending up with the right answers to the wrong questions. PMID- 10155291 TI - Criteria for drug usage review of thrombolytics in acute myocardial infarction. AB - Thrombolytic drugs are now the mainstay of the management of acute myocardial infarction (AMI). Although their use is associated with reduced mortality, significant adverse effects can occur, especially if they are used inappropriately. Drug usage review of this group of drugs provides a measure of the appropriateness of their use. The development of criteria against which the use of these drugs can be compared allows the collection of qualitative and quantitative data on their use. Those criteria identified during this process include: evidence for, and accuracy of, diagnosis of AMI; when, where and how to administer the drug; what drug to use, and at what dose. Identification of potential adverse effects, measures of treatment success and the role of adjunctive therapy may also be included as part of a drug usage evaluation process. PMID- 10155293 TI - Pharmacoeconomic analysis of empirical therapy with ceftazidime alone or combination antibiotics for febrile neutropenia in cancer patients. AB - There is evidence to suggest that single-agent broad spectrum antibacterials may be cost-effective alternatives to combination antibiotics for the empirical management of febrile neutropenia in cancer patients. The objectives of the present study were 2-fold. The first objective was to compare the clinical effectiveness of ceftazidime monotherapy with that of 2 combination antibiotic regimens in cancer patients with febrile neutropenia. The 2 comparator regimens consisted of tobramycin plus piperacillin, either with (regimen 'CAP') or without (regimen 'AP') cefazolin. The second objective was to perform a cost effectiveness analysis of the 3 regimens. Meta-analysis of randomised comparative trials between the 3 therapy groups was performed to determine the average overall response rate after 3 to 5 days of treatment. Seven clinical studies were selected for analysis. The overall incidence of adverse drug reactions (ADRs) was determined using the results of comparative and noncomparative studies. A comparative cost-analytic model was applied from a hospital perspective. The costs of primary therapy, hospitalisation, laboratory tests, routine patient care and treating ADRs were calculated, as were future costs. Monotherapy with ceftazidime was associated with an overall response rate of 63.5% and mean per patient costs of $Can12,000 to $Can14,000. In comparison, regimen AP was associated with an overall response rate of 58.8% and mean costs of $Can13,000 to $Can16,000 per patient. The overall response rate in patients receiving CAP was 75.3%, and the mean cost per patient was $Can11,000 to $Can12,000. Thus, regimen CAP was the most cost-effective therapy from a hospital perspective. PMID- 10155295 TI - Necessity of using intermediate outcome to proxy long term effects. The example of thrombolytics. PMID- 10155296 TI - Hospital administrative costs in the US. AB - In a study of administrative costs in US hospitals, Woolhandler et al. reviewed 1990 Medicare cost reports from 6400 hospitals. The intent of this study was to determine the validity of previous administrative cost estimate studies in Californian hospitals, which were extrapolated nationwide. The study found that hospital administrative costs ranged from 20.5 (in Minnesota) to 30.6% (in Hawaii) of each hospital's spending. Furthermore, the investigators found that these administrative costs did not vary according to the level of managed care penetration in a particular US state. Using a health maintenance organisation (HMO) enrolment rate of 20% as the median, the study found hospital administrative costs to be similar to states with an HMO enrolment rate of < 20%. The authors concluded that reducing hospital administrative costs to the Canadian level (9 to 11% of total hospital spending) would result in annual savings of $US50 billion. Thus, the authors suggest that if administrative costs are high, US healthcare reform should follow a system similar to that used in Canada. PMID- 10155294 TI - Alglucerase. A pharmacoeconomic appraisal of its use in the treatment of Gaucher's disease. AB - Alglucerase is a modified form of human placental glucocerebrosidase used as enzyme replacement therapy for patients with Gaucher's disease, in whom functional glucocerebrosidase is deficient. Alglucerase has provided a breakthrough in treatment for patients with this relatively rare disease. With alglucerase infusions typical disease manifestations are ameliorated or normalised: hepatosplenomegaly is reduced, haematological parameters improve, and patients experience an increased quality of life usually within 4 to 6 months of treatment. Parameters of bone disease also respond, but generally over a longer period of treatment. Alglucerase is well tolerated by children and adults, with few adverse effects reported. Seroconversion occurs in approximately 15% of patients on high-dose therapy, but does not appear to affect the efficacy of treatment. Several dosage regimens have been used to deliver alglucerase, and the comparative benefits of these remain controversial. High-dose regimens of 60 IU/kg bodyweight administered every 2 weeks are clearly effective; however, smaller dosages given more frequently are also effective and incur a greatly reduced acquisition cost. Patient responses are variable, and the dosage regimen should be tailored to individual needs. Dosage regimens may be considerably reduced for the maintenance phase of treatment, but clinical experience is as yet insufficient to establish the minimum dosages required in the long term. Acquisition cost of alglucerase is $US3.70 per unit (1994 US dollars); thus, a dosage regimen of 60 IU/kg bodyweight administered every 2 weeks for a patient weighing 70kg costs $US404,040 per year. The minimal costs per quality-adjusted life year saved (QALY) have been estimated for 3 dosage regimens over a 10-year period. Cost per QALY was $US147,000 for 60 IU/kg bodyweight administered every 2 weeks, $US75,000 for 30 IU/kg every 2 weeks, and $US49,000 for 2.3 IU/kg administered 3 times per week. These costs were calculated assuming immediate death with no treatment, which suggests that the actual costs per QALY for most patients with type 1 or 3 disease are likely to be much higher. Drug administration costs may become a significant part of the cost during maintenance therapy; in addition, possible cost savings due to increased patient productivity and reduced palliative treatments remain unresolved. Although some patients may obtain increased benefit from high-dosage regimens, the very high cost may preclude general use of these regimens. Healthcare resources consumed by alglucerase therapy represent a large opportunity cost for other therapeutic areas.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10155297 TI - Cost effectiveness of roxithromycin versus cefaclor in Australia. PMID- 10155298 TI - The economics of mail service pharmacy. PMID- 10155299 TI - Clinical and economic factors in the treatment of congestive heart failure. AB - Congestive heart failure (CHF) is a disease of massive clinical and economic importance throughout the developed world. Approximately 1% of the population are affected, with incidence and prevalence of CHF increasing with age. The major aetiological factor is ischaemic heart disease and, despite advances in treatment, mortality from CHF remains appallingly high, and comparable to that of many malignancies. The majority of patients with CHF require treatment with a diuretic, though there is now clear evidence that the addition of an angiotensin converting enzyme (ACE) inhibitor will not only improve symptoms but also reduce mortality and delay the progression of the disease. The vast economic impact of CHF is now becoming fully appreciated, with the majority of expenditure on hospital admissions. The earlier and more widespread use of ACE inhibitors in the treatment of CHF would be highly cost effective, with substantial savings in hospitalisation costs, though new and effective treatments are still urgently required. PMID- 10155301 TI - Quality-of-Life measurements for patients taking which drugs? The clinical PCASEE perspective. AB - Of the many publications on quality of life in medicine over the last 2 decades, only a minor fraction have been devoted to drug trials. The most frequently investigated are classes of drugs within cancer disorders, hypertension and depressive illness. Health-related quality-of-life (QOL) measurements are typically applied in chronic or subchronic disorders where the balance between effectiveness (disease-modifying drug effects) and safety (adverse drug reactions) are assessed by patients in terms of subjective well-being. In this context, quality of life is an attempt to help the doctor to listen to his or her patient. The components of QOL measurements are to be found within the PCASEE model where: P = physical indicators; C = cognitive indicators; A = affective indicators; S = social indicators; E = economic-social stressors or negative life events; and E = ego function or personality problems. Most variance in QOL measurements arises through operating in the cognitive (e.g. lack of control, concentration difficulties) or affective (e.g. depressed mood or anxiety) components. The most specific component is, of course, adverse drug reactions, which are typically gastrointestinal symptoms in cancer therapies, and circulatory symptoms and sexual function with antihypertensive drugs. However, the affective and cognitive components also have different weights within subclasses of drugs, such as antihypertensive agents. Thus, angiotensin converting enzyme inhibitors act on the affective component (depression and anxiety) and calcium channel blockers on the cognitive component (neurasthenia). In general, patients with cancer or hypertension give more reliable assessments of their cognitive and affective symptoms than their doctors do, while patients with primary depression are less reliable than their doctors or relatives in measuring changes in the affective components of their illness when they are ill. Health-related QOL measurements have not only an impact on the doctor-patient relationship but also involve a holistic approach to drug treatment, by checking all the PCASEE components. PMID- 10155302 TI - Research and development costs for new drugs by therapeutic category. A study of the US pharmaceutical industry. AB - The clinical period (i.e. clinical trial and long term animal testing) development costs of a random sample of new chemical entities (NCEs) were examined for differences in average cost. All of the NCEs studied were first tested in humans between 1970 and 1982, and were classified for the purposes of the study by therapeutic class. The costs of unsuccessful projects were included with those of projects that resulted in US marketing approval. Including income forgone from expending funds before returns are earned ('time costs'), the capitalised (i.e. out-of-pocket plus time) clinical period costs per approved NCE were $US70, $US98, $US103 and $US163 million (1993 dollars) for anti-infective, cardiovascular, neuropharmacological and nonsteroidal anti-inflammatory drugs, respectively. Combining the data for all therapeutic categories, the mean clinical period cost per approved NCE was $US93 million. Omitting costs associated with unsuccessful projects, the mean capitalised clinical period costs for approved NCEs ranged from $US7.1 million (for topical steroids) to $US66.7 million (for cardiovascular agents) [1993 dollars]. The estimates of total clinical period costs per approved NCE depend on average out-of-pocket clinical phase costs, attrition rates across phases (i.e. the rates at which compounds drop out of active testing), the probability of marketing approval, and development and regulatory review times. Phase attrition and approval rates are the most important sources of variability in total clinical period costs between therapeutic categories. Development cost estimates by therapeutic category did not correlate strongly with US sales in the fifth year of marketing. Cardiovascular NCEs had much higher than average sales revenues, but clinical development costs for these drugs were only slightly above average. Conversely, nonsteroidal anti-inflammatory drugs attained average sales revenues, but had much higher than average development costs. PMID- 10155300 TI - Epidemiology, therapy and costs of nosocomial infection. AB - In the current climate of cost containment and quality control, nosocomial infection is a worrisome adverse event in hospital care. Hospitalised patients require care for increasingly severe illnesses, and are therefore more susceptible to infection, especially by opportunistic micro-organisms. It is thus necessary to accurately assess and adjust for the severity of the underlying illness in studies of risk factors involved in nosocomial infections. The appearance of new diagnostic and therapeutic techniques provides novel opportunities for infection control and represents a constant challenge to hospital systems. The continuous selection of resistant flora, together with the identification of new pathogens, calls for a reconsideration of hospital policies regarding the dispensation of antibiotics. Epidemiological surveillance continues to be the most important aspect of attempts to monitor infection control programmes, and to identify changes in risk factors that may increase the infection rate. Among the major challenges now facing the infection control practitioner is the use of nosocomial infection rates as an indicator of quality of care. Awareness of infection statistics would serve as a stimulus to the prevention and control of infection, but would be useless if not accompanied by adequate systems to guarantee the comparability of data from different studies and centres. Suitably sensitive and specific surveillance systems should be developed, and the use of site-specific and procedure-specific infection rates adjusted for the patient's intrinsic risk should be encouraged. PMID- 10155303 TI - Societal perspective on the burden of migraine in The Netherlands. AB - This study presents a comprehensive overview of the societal burden of migraine in The Netherlands. We assessed the direct and indirect costs of this disease, and the health status of patients with migraine. We developed the 'illness and labour' (I&L) questionnaire to collect data on the effect of illness on labour performance. 846 migraine patients and 834 controls were selected from the general population. Participants completed an I&L questionnaire as well as generic health status questionnaires. The direct costs of migraine amounted to 134 million Netherlands guilders (NLG) [$US1 = NLG1.68, October 1994]. Conservative calculations of the costs of absence from work and reduced productivity at work were NLG264 and NLG277 million per year, respectively. Our study did not indicate that migraine caused household productivity losses. The baseline estimate of the total societal costs of migraine in The Netherlands was NLG675 million per year. The assessment of health status showed considerable impairment of psychological and social functioning in migraine patients. PMID- 10155304 TI - The system of objective judgement analysis method: less objectivity than pretended? PMID- 10155305 TI - Clinical and economic aspects of prophylaxis and treatment of Pneumocystis carinii pneumonia. PMID- 10155306 TI - Preventing NSAID-induced gastrointestinal toxicity. Economic considerations, methodological problems and results. PMID- 10155307 TI - Physician rewards for postmarketing surveillance (seeding studies) in the US. PMID- 10155308 TI - Minimising the cost of urinary incontinence in nursing homes. PMID- 10155309 TI - Economic decision making in healthcare. A standard approach to discounting health outcomes. PMID- 10155310 TI - Relationships between sponsors and investigators in pharmacoeconomic and clinical research. AB - Potential conflict between the goals of the investigators and the sponsors of pharmacoeconomic and clinical research has been well documented. Although there have been efforts to formalise relationships between sponsors and investigators in some areas of clinical research, no set of guidelines or standardised contract to govern pharmacoeconomic research relationships is currently in use. In this paper, we discuss a number of provisions that should be included in a sponsored research agreement to define the responsibilities and clarify the rights of the parties in the collaborative research relationship. We also present an example of a sponsored research agreement that we have designed as a model formal contract between sponsors and investigators. The most salient areas in the research agreement include: publication, specification of analysis, data access/ownership, confidentiality, termination and payment to investigators. While this paper focuses on pharmacoeconomic research, many of the principles have relevance to a broader range of research relationships and to other clinical economics and clinical trials research. PMID- 10155311 TI - Defining the patient group for cost-effective withdrawal of antihypertensive therapy. AB - Many people receiving drug treatment for hypertension have had good control of their blood pressure for several years. It is feasible, and might be desirable, to discontinue drug treatment in selected groups of these patients if their long term outcome was not adversely affected. A few small series and 2 larger trials indicate that withdrawal of antihypertensive medication can be followed by 1 to 4 years of normal blood pressure, especially for those with mild hypertension (pretreatment diastolic blood pressure < 100mm Hg) and who have no evidence of target organ damage. In the 2 randomised trials of withdrawing medication emerging from the High Blood Pressure Detection and Follow-up Program, the addition of nutritional interventions (bodyweight reduction and/or dietary salt restriction) was shown to enhance the likelihood that antihypertensive drugs could be deferred for long intervals. Sustained bodyweight reduction for overweight patients with mild hypertension was the most successful approach. Short term nonpharmacological programmes have been evaluated for their economic effects on this process through cost-effectiveness and cost-benefit analyses. The available studies imply that reduced costs and decreased adverse effects associated with withdrawal of antihypertensive medication are offset by cost of the nonpharmacological interventions needed to maximise continued blood pressure control. Other influences, such as willingness to pay for nonpharmacological management or change in sense of well-being when on or off medication, need consideration for comprehensive cost-effectiveness analyses.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155312 TI - Quality-of-life instruments for severe chronic mental illness. Implications for pharmacotherapy. AB - The care of persons with severe chronic mental illness is one of the most pervasive and neglected public health problems in the US. Increasingly, researchers are focusing on the effectiveness of care and quality of life in these patients. This article reviews the status of quality-of-life (QOL) research in mental health published until 1993. It describes conceptual and methodological approaches, reviews QOL instruments developed for persons with severe chronic mental illness, and discusses the implications for pharmacotherapy. Consistent methods, definitions and models must be developed to make QOL research more applicable to the evaluation of pharmaceuticals. Standardisation of approach is necessary to facilitate meta-analyses and to increase our understanding of how pharmacotherapy can improve quality of life for persons with severe chronic mental illness. QOL data cannot stand alone. Its use is limited by the reality that psychopathology affects quality of life, and quality of life affects psychopathology. For the foreseeable future, evaluation of pharmacotherapy in severe chronic mental illness will require combined measurement of quality of life and psychopathological symptoms. PMID- 10155313 TI - Effect of lenograstim on the cost of autologous bone marrow transplantation. A preliminary communication. AB - High dose chemotherapy and autologous bone marrow transplantation (BMT) can produce prolonged remission in patients with malignant lymphoma or solid tumours. However, neutropenia is a serious complication of treatment in patients with these diseases. In this study, we investigated the costs and effects of using lenograstim, a recombinant human granulocyte colony-stimulating factor, to treat neutropenia in 16 patients with lymphoma or solid tumours. The cost of lenograstim was not included in the calculations. The duration of neutropenia and hospitalisation were both lower in patients who received lenograstim compared with no treatment. The mean cost of autologous BMT was FF142,000 in patients who received lenograstim, compared with FF166,000 in patients who did not. Savings were largely attributable to decreased expenditure on hospitalisation in the lenograstim-treated group. The cost of 14 days' treatment with lenograstim was estimated at FF10,500, based on a daily dosage of 150 micrograms/m2/day. PMID- 10155314 TI - The cost effectiveness of hypertension treatment in Sweden. AB - The aim of this study was to carry out an analysis of the cost effectiveness of antihypertensive drug treatment in different patient groups in Sweden. The cost effectiveness ratios were estimated as net costs (treatment costs minus reduced costs of cardiovascular morbidity) divided by the number of life-years gained (the increase in life expectancy). The analysis was based on the reduction of coronary heart disease and stroke in the most recent meta-analysis of antihypertensive treatment, to which Swedish cost data were applied. We found that the cost per life-year gained decreases with age for both men and women, and is relatively low for middle-aged and older patients, even when the diastolic blood pressure (DBP) range is 90 to 94mm Hg. In conclusion, the results indicate that, in Sweden, antihypertensive treatment is generally cost effective in middle aged and older patients with a DBP of > or = 90 mm Hg. However, it is questionable whether it is generally cost effective to treat younger patients with mild hypertension. PMID- 10155316 TI - Alglucerase: the debate continues. PMID- 10155315 TI - Pharmacoeconomic analysis of topical treatments for tinea infections. AB - The purpose of this study was to perform a government-perspective economic analysis of the most widely used topical creams [namely, ciclopirox (CIC), clotrimazole (CLO), ketoconazole (KET), miconazole (MIC), and terbinafine (TER)], for the treatment of 2 types of dermatophyte skin infections: dermatophytosis major (excluding onychomycosis) and dermatophytosis minor. A 3-phase approach was used. In phase I, experts were assembled to identify the standard approach for management of fungal infections and a decision tree was constructed to model the process; in phase II, meta-analysis was used to determine success, failure, and relapse rates; and in phase III, economic analyses were performed including cost of regimen, total expected cost and cost-effectiveness analysis. Sensitivity analyses (robustness analyses) were also performed in phase III. It was found that while TER was successful following 1 week of administration for minor infections and after 2 weeks for major infections, duration of drug treatment was usually twice that time. Other comparators (CIC, CLO, KET and MIC) took 4 weeks to achieve a successful outcome. In addition, an extra 2 weeks were often needed to clear both types of infections because the comparators are fungistatic, whereas TER is fungicidal. In the total expected cost analysis, TER had the lowest overall cost of treating patients for both infection categories. It was also responsible for the highest number of disease-free days and, consequently, the lowest cost per disease-free day. Sensitivity analyses confirmed that TER was the most cost-effective topical agent for treating dermatophytosis major (excluding onychomycosis) and dermatophytosis minor. PMID- 10155317 TI - The defined daily dose as a tool in pharmacoeconomics. Advantages and limitations. PMID- 10155318 TI - The added costs of depression to medical care. PMID- 10155319 TI - Diabetes mellitus and the St Vincent Declaration. The economic implications. AB - Diabetes mellitus imposes significant costs both on individuals and on healthcare delivery systems. Chronic diseases such as diabetes mellitus have lifetime costs, and so resources spent on interventions now may not bring benefits, in terms of reduced complications, for many years. In Europe, the St Vincent Declaration, which includes targets for the reduction of diabetes mellitus-related complications, is an important initiative set up to address quality and education issues relevant to people with diabetes mellitus. The Declaration is to be welcomed as focusing attention on diabetes mellitus, and its implementation may lead to a reduction in healthcare expenditure on complications in future years. The aims of the St Vincent Declaration are to set goals and 5-year targets to improve quality of life and life expectancy for people with diabetes mellitus and to reduce the serious complications associated with the disease. Achievement of these targets will depend on good organisation and management of services to people with diabetes mellitus, but the aims are a clear signal that the importance of prevention and education have been recognised. A major barrier to the implementation of the Declaration is financial. If more people are diagnosed and treated, more services will be required. This will incur costs, although future benefits will be gained in terms of a reduction in complications. PMID- 10155320 TI - Measuring the effect of cancer on health-related quality of life. AB - Measuring health-related quality of life in patients with cancer has focused primarily on the development of reliable and valid instruments (questionnaires), and on the effect of chemotherapy in phase III clinical trials. From this research several important lessons have emerged, such as: (i) the need to measure multiple domains; (ii) the importance of self-rating; (iii) the reports of counter-intuitive results; (iv) the ability to quantify the effects of symptoms on health-related quality of life; and (v) the prognostic value of health-related quality of life measurement for survival. Many challenges lie ahead. Among these are the difficulties encountered by medical clinicians in choosing appropriate instruments to measure health-related quality of life, the dilemma of choosing between aggregate scores and domain scores, questions surrounding the significance of results, and whether measurement of health-related quality of life is now at a point where it can be used in routine practice outside of the clinical trials setting. Although further research is required in all of these and other areas, the future for health-related quality-of-life measurement in oncology is promising. PMID- 10155321 TI - Current prescribing in primary care in the UK. Effects of the indicative prescribing scheme and GP fundholding. AB - The costs of drugs prescribed in primary care in the UK continue to rise despite a variety of government initiatives. Two of the major initiatives are considered here in detail: the Indicative Prescribing Scheme (IPS), and general practitioner (GP) fundholding, both of which began in 1991. Other more recent initiatives are also described, including the selected list, the Pharmaceutical Pricing Regulatory Scheme and the move to relicense drugs for nonprescription sale. The IPS has generally failed to control the rise in drug costs because of unrealistic targets, organisational difficulties (including the lack of adequate data to set budgets properly) and because there was neither incentive nor penalty to encourage compliance on the part of the GP. The IPS stresses cost containment, and makes little allowance for the consideration of quality of appropriateness of prescribing. Despite this disappointment, the IPS is continuing, and the future of the scheme is discussed here. GP fundholding, in contrast, has reduced the rate of rise of drug costs in participating GP practices, although it has not actually reduced drug costs. There have been a number of studies of this model, which are discussed here. The clear financial incentive to fundholders encourages them to restrain drug costs. Attempts to extend similar incentives to nonfundholding GPs are also described. Although there is a commitment on the part of the government to encourage and make use of data about economic evaluations of drug therapy and other medical interventions, so far the emphasis has been exclusively on cost containment. In this paper, we consider possible mechanisms by which this might be improved. PMID- 10155322 TI - Profile of drug use in urban and rural India. AB - Information on pharmacoepidemiology is particularly important in developing countries where a rational drug policy has not been adopted. In the present study, a profile of 1769 doctors' prescriptions and 763 self-orders were monitored at pharmacy outlets in the twin cities of Hyderabad and Secunderabad and 4 rural areas of Andhra Pradesh with the aim of identifying urban and rural differences, if any, in the self-medication rate, prescription costs, types of drugs purchased and factors influencing self-medication. Self-medication, expressed as the percentage of the total population that self-medicates, was found to be high in urban areas (37%) compared with rural areas (17%), and the majority of the over-the-counter sales were for prescription-only drugs. The majority of physicians' prescriptions were incomplete with respect to diagnosis and dosage regimen. The mean cost of the drugs purchased on doctors' prescriptions was 2-fold higher than the cost of drugs sold over the counter. A higher proportion of patients from rural areas (80%) purchased all the prescribed drugs compared with those from urban areas (54%). Financial constraints in urban areas were a major determinant in the partial purchase of prescribed drugs. In addition, the urban elite (i.e. professional people with high incomes, who comprise 18% of the total population) considered that all of the prescribed drugs were not necessary for their present disease. Nutritional products, potent compounds with analgesic, antipyretic and anti-inflammatory effects, and broad spectrum antibiotics constituted a high proportion of prescriptions in both urban and rural areas. The consumption of food supplements was higher in rural areas than in urban areas. Based on WHO criteria, most of the drugs (60%) prescribed in rural areas were nonessential, compared with 47% in urban areas. The results of this study emphasise the need for comprehensive measures, including information, training, legislation and education at all levels of the drug delivery system, to rationalise drug therapy by improving prescribing patterns and influencing self medication. PMID- 10155324 TI - Generic medicines. Reducing cost at the expense of quality? PMID- 10155325 TI - Therapeutic conservatism: more costly in the long term? A UK perspective. PMID- 10155326 TI - The use of pharmaceuticals in critical care. The importance of outcome prediction models. PMID- 10155323 TI - Teicoplanin. A pharmacoeconomic evaluation of its use in the treatment of gram positive infections. AB - Teicoplanin, a glycopeptide antibiotic, is active against Gram-positive organisms, including methicillin-resistant staphylococci. It has demonstrated similar efficacy to vancomycin in the treatment of Gram-positive infections in febrile patients with neutropenia; fewer comparative data are available in patients with other infection types. Compared with vancomycin, teicoplanin is associated with less nephrotoxicity, appears to cause fewer anaphylactoid reactions, requires less monitoring and is more convenient to administer (once daily by intravenous bolus or intramuscular injection vs 2 to 4 times daily by intravenous infusion). Two European cost-minimisation studies have demonstrated that while the acquisition cost per dose of teicoplanin was approximately twice that of vancomycin, the cost of 2 weeks' therapy with either agent was similar (difference of 1 to 2%). However, in order to fully explore potential differences between these agents, a full economic analysis which considers all treatment related costs is needed. Home therapy of Gram-positive infections, a setting in which teicoplanin may be preferred over vancomycin because of its tolerability profile and ease of administration, is particularly worthy of future economic study. Thus, there are a number of areas needing further study before the optimum formulary positioning of teicoplanin can be definitely stated. Nevertheless, present evidence suggests that teicoplanin is likely to have pharmacoeconomic advantages over vancomycin in at least some situations. PMID- 10155327 TI - Once-daily aminoglycoside administration in gram-negative sepsis. Economic and practical aspects. AB - A fuller understanding of the pharmacodynamics of aminoglycoside antibiotics now exists compared with when they were introduced. Recent findings have shown that once-daily dosage regimens of aminoglycosides are as effective as bd or tid regimens in the treatment of Gram-negative sepsis. However, radical changes in dosage frequency based on this knowledge are resisted by some physicians because of fears about the peak concentration toxicity of aminoglycosides. These fears have been shown to be misplaced. The delay in the translation of research findings into practice may be attributable to the sheer quantity of medical literature and the limited time that clinicians have available to read it. Because healthcare resources are finite, physicians are increasingly becoming aware of the need to use drug therapy in the most cost-effective way. An important component of aminoglycoside therapy that may persuade clinicians to change their practice is the organised consideration of the various costs associated with different administration regimens. This review examines the source of those costs, and endorses once-daily dosage of aminoglycosides from both an economic and practical viewpoint. PMID- 10155328 TI - The Short-Form 36 (SF-36) Health Survey and its use in pharmacoeconomic evaluation. AB - The Short-Form 36 (SF-36) Health Survey is a brief self-administered questionnaire that generates scores across 8 dimensions of health. It has been found to be reliable, and valid in terms of criteria such as agreement with clinical diagnosis and disease severity, but its underlying values have not been tested against patient preferences. The SF-36 was not devised for use in economic evaluation. The SF-36 may be used in cost-minimisation analyses, where the dimension scores can be shown to reflect people's values for health at an ordinal level, but it cannot be used in either cost-effectiveness or cost-utility analyses. The dimensions scores of zero to 100 do not provide a common currency and, where there is conflict between the dimension scores, there is no basis for establishing an overall health benefit. Furthermore, in clinical trials, the usual comparison is between mean or median scores, which assumes risk neutrality and does not take adequate account of the relationship between the value of health and time. Although they are under pressure to assess the cost effectiveness of healthcare interventions, researchers and policy analysts must resist short-cut methods of deriving a single index from the SF-36 that are based on arbitrary aggregation schemes, because these ignore people's preferences and the crucial quantity/quality trade-off, and therefore cannot be used in economic evaluations. However, the rich descriptive material and multidimensionality of the SF-36 may have potential for use in economic evaluation. Multi-attribute utility theory provides a way of deriving a single index based on elicited values, but it requires a major restructuring of the scales of the SF-36. Alternatively, SF-36 responses may provide material for constructing health scenarios that could then be valued on a holistic basis. PMID- 10155329 TI - Clinical and economic considerations in the use of third-generation oral cephalosporins. AB - A number of oral third-generation cephalosporins (cefixime, cefetamet pivoxil, ceftibuten and cefpodoxime proxetil) have been widely trialled and are becoming available. In addition, cefdinir may also be marketed. Compared with first- and second-generation agents, the oral third-generation cephalosporins have an improved antibacterial spectrum and reduced minimum inhibitory concentrations against common Gram-negative pathogens. In contrast, with the exception of cefdinir, they are less active against Staphylococcus aureus. They have favourable pharmacokinetic profiles and are generally administered in once- or twice-daily regimens. They are well tolerated, but cefixime has been associated with a particularly high rate of diarrhoea. Possible clinical indications for the use of oral third-generation cephalosporins include upper and lower respiratory, genitourinary and soft-tissue infections and follow-on treatment of severe infections requiring hospitalisation. At present, these drugs offer no particular clinical advantages over standard therapy in most circumstances. However, they may be considered where there is hypersensitivity to penicillins, a high incidence of resistance to first-line therapy in the community, or failure of standard therapy. Further studies are needed to define the efficacy of oral third generation agents in the prevention of rheumatic fever and as follow-on therapy for severe infections. The oral third-generation cephalosporins are generally more expensive than standard agents, but detailed studies that include extended costs (e.g. treatment of adverse effects, treatment of clinical failure, return visits to physicians) have yet to be reported. PMID- 10155330 TI - Cost-effectiveness analysis of hepatitis B vaccination strategies in Catalonia, Spain. AB - Hepatitis B virus (HBV) infection is an important public health problem all over the world. Vaccination is one way to prevent it, and several strategies can be used depending on endemicity, the main pattern of HBV transmission and the demographic structure of the population. In this study, an economic comparison of 3 vaccination strategies (mass adolescent vaccination, mass infant vaccination and mass combined vaccination) was performed in Catalonia, Spain. Screening pregnant women for HBV infection in combination with these strategies was also evaluated. Epidemiological models to analyse patterns of HBV infection with and without vaccination and to calculate HBV-associated costs were designed. Comparison between strategies was done using cost-effectiveness analysis from the perspective of the healthcare system. Epidemiological model results indicate that implementation of HBV vaccination could prevent as many as 104,778 new acute infections, and avoid up to 5239 chronic infections, 2096 cases of cirrhosis and 419 cases of hepatocarcinoma over a 20-year period in Catalonia. Cost effectiveness analysis shows that mass adolescent vaccination is the most efficient strategy, with lower costs per avoided case than the other 2 strategies. When any of these strategies is complemented by screening for HBV in pregnant women, the number of avoided cases is always higher and the cost per avoided case decreases or remains unchanged. PMID- 10155332 TI - A UK national prescribing list? PMID- 10155331 TI - A decision analysis comparing three dosage regimens of subcutaneous epoetin in continuous ambulatory peritoneal dialysis. AB - Epoetin (recombinant human erythropoietin; EPO) therapy adds a significant cost to the management of end-stage renal disease, the majority of the extra expense being attributable to its acquisition cost. In a Japanese multicentre, randomised, prospective study, a significant dose-dependent response was documented with epoetin given subcutaneously (SC) once a week or once every 2 weeks to patients receiving continuous ambulatory peritoneal dialysis. Three different dosages were studied over 5 months in patients with a haematocrit (Hct) of 0.28 or less, namely 6000U (107 U/kg), 9000U (167 U/kg) and 12,000U (211 U/kg). Epoetin was given weekly for the first 2 months until the target Hct value of 0.33 was reached. The rates of response were 81, 85 and 100% with the 6000U, 9000U and 12,000U regimens, respectively. Subsequently, responders were maintained at the target Hct for an additional 3 months, with the administration frequency eventually being reduced to fortnightly or 4-weekly. Patients in the epoetin 6000U and 9000U groups who did not respond after 2 months' treatment underwent induction and maintenance with the 12,000U regimen. During the maintenance phase, patients receiving the epoetin 6000U and 9000U dosages required weekly (54 and 64%, respectively) or fortnightly (46 and 36%, respectively) injections. Patients receiving the 12,000U regimen were found to require weekly (9%), fortnightly (73%) or 4-weekly (18%) injections. Using these data, we performed a decision analysis that quantitatively incorporated the probability of attaining and maintaining target Hct levels in all patients (i.e. the effectiveness of epoetin), and direct costs as a function of both cumulative doses and injections required in all 3 strategies over 5 months. Decision analysis indicated that the most cost-effective SC epoetin strategy in patients undergoing peritoneal dialysis is epoetin 6000U weekly for 2 months, followed by maintaining the target Hct with weekly or 2-weekly epoetin 6000U for the next 3 months. Nonresponders should restart epoetin therapy using the 12,000U strategy. The 9000U and 12,000U strategies were associated with similar costs, because the economic advantages associated with the lower administration frequency of the 9000U regimen compared with the 6000U regimen were offset by its higher cumulative acquisition cost. In other words, decision analysis indicated that the most cost-effective strategy was to use the lowest effective dose, reserving the highest dosage for patients who do not respond after 2 months. The superiority of this strategy was confirmed by a sensitivity analysis performed on the cost of drug administration, which was varied from zero to $US60 per dose.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10155333 TI - The role of pharmacoeconomics in health policy and management in Norway. PMID- 10155334 TI - The economic burden of glaucoma in the UK. The need for a far-sighted policy. PMID- 10155335 TI - Multi-attribute health status classification systems. Health Utilities Index. AB - In this article, multi-attribute approaches to the assessment of health status are reviewed with a special focus on 2 recently developed systems, the Health Utilities Index (HUI) Mark II and Mark III systems. The Mark II system consists of 7 attributes: sensation, mobility, emotion, cognition, self-care, pain and fertility. The Mark III system contains 8 attributes: vision, hearing, speech, ambulation, dexterity, emotion, cognition and pain. Each attribute consists of multiple levels of functioning. A combination of levels across the attributes constitutes a health state. The HUI systems are deliberately focused on the fundamental core attributes of health status, and on the capacity of individuals to function with respect to these attributes. Thus, the measure obtained constitutes a pure description of health status, uncontaminated by differential opportunity or preference. Multi-attribute systems provide a compact but comprehensive framework for describing health status for use in population health and programme evaluation studies. An important advantage of such systems is their ability to simultaneously provide detail on an attribute-by-attribute basis and to capture combinations of deficits among attributes. An additional advantage is their compatibility with multi-attribute preference functions, which provide a method for computing a summary health-related quality-of-life score for each health state. PMID- 10155336 TI - Multi-attribute preference functions. Health Utilities Index. AB - Multi-attribute utility theory, an extension of conventional utility theory, can be applied to model preference scores for health states defined by multi attribute health status classification systems. The type of preference independence among the attributes determines the type of preference function required: additive, multiplicative or multilinear. In addition, the type of measurement instrument used determines the type of preference score obtained: value or utility. Multi-attribute utility theory has been applied to 2 recently developed multi-attribute health status classification systems, the Health Utilities Index (HUI) Mark II and Mark III systems. Results are presented for the Mark II system, and ongoing research is described for the Mark III system. The theory is also discussed in the context of other well known multi-attribute systems. The HUI system is an efficient method of determining a general public based utility score for a specified health outcome or for the health status of an individual. In clinical populations, the scores can be used to provide a single summary measure of health-related quality of life. In cost-utility analyses, the scores can be used as quality weights for calculating quality-adjusted life years. In general populations, the measure can be used as quality weights for determining population health expectancy. PMID- 10155337 TI - Prescribing trends and pharmacoeconomic considerations in the treatment of arrhythmias. Focus on atrial fibrillation and flutter. AB - Considerable progress has been made regarding the treatment of atrial fibrillation and atrial flutter. However, controversies still exist with respect to the therapy of choice for ventricular rate control, requirements for long term preventive therapy, and the place of surgical and ablation alternatives. Surrounding these controversies also lies a paucity of pharmacoeconomic studies, which limits delineation of the most cost-effective therapy for patients with atrial fibrillation and atrial flutter. This article reviews prescribing trends in the US for antiarrhythmic agents, and the available pharmacoeconomic studies that have specifically addressed the treatment of atrial fibrillation and atrial flutter. PMID- 10155338 TI - Drug expenditures in a balanced strategy for healthcare policy. AB - The US, like many countries, has turned its public focus onto its healthcare system, with drug prices drawing particular attention. Expenditure trends indicate that drugs do not represent a large portion of the overall healthcare picture; the typical US consumer, however, feels these costs more personally because large portions of outpatient drugs in the US are purchased with out-of pocket funds. Using data trends for US expenditures, we contrasted projections in the year 2000 under the current US system relative to a strategic policy with full coverage of prescription drugs. Under this proposed scenario, drugs still captured just a small portion of overall healthcare expenditures, but with major shifting to private insurance and government programmes. Thus, as society increasingly views some level of healthcare as a basic human right, effective policies for the healthcare system--including the drug sector--must balance competing regulatory and market pressures. PMID- 10155339 TI - The use of first- and second-line outpatient antibiotics under the Saskatchewan Drug Plan. AB - The Saskatchewan Drug Plan proposed de-listing several second-line antibiotics from its formulary for reasons of potential overuse and expense. This study evaluated the use of second-line antibiotics as initial and secondary courses of therapy depending on the patient's prior use of other antibiotics and other factors. A total of 637,607 courses of therapy dispensed to Plan members for selected antibiotics between July 1989 and June 1990 were evaluated. Second-line antibiotics were used in 5.0% of all initial courses of therapy. This use was correlated with patient characteristics that may warrant use of second-line antibiotics as initial therapy: age, rural residence, the use of bronchodilators or inhaled steroids, and the number of prior courses of antibiotic therapy. The potential savings from de-listing second-line antibiotics from the formulary are limited because of their use in only 5% of all initial courses of therapy. Savings would be further reduced by administrative costs and physician time required to process prior authorisation requests, and the costs of treating any additional antibiotic treatment failures that may result from reduced access. PMID- 10155340 TI - The Nelson Prescribing Project. A programmed intervention in general practice in New Zealand. AB - We have defined the effect and acceptability of a locally developed general practice programme for the modification of prescribing. This voluntary programme consisted of prescription analysis and feedback, followed by visits from a pharmacist, a therapeutic bulletin on benzodiazepine prescribing, and use of a locally compiled preferred medicines list. A 3-month prescription sample from 26 general practitioners (GPs) fulfilling a stable practice definition was used to compare prescribing pre-project and mid-project. For 20 out of 26 GPs, prescribing of medicines on the preferred medicines list had increased significantly 8 months after the intervention programme had been introduced. Total prescription numbers and total medicines expenditure decreased by 8.3 and 4.9%, respectively, from 1988 to 1989. The decrease in benzodiazepine prescribing was marked (mean -22.2%, range -50.3 to +4%). The cooperative multimodel approach was highly successful in modifying prescribing in general practice. PMID- 10155342 TI - Indications for bilateral total knee replacement. AB - A total of 64 patients with clinical and radiographic signs of bilateral knee arthritis were evaluated based on multiple associated variables including complications, community ambulatory levels, and timing of staged knee replacement. A pain/dysfunction categorization based on initial presentation was established so that temporal progression of symptoms could be documented. Two surgical groups were represented: simultaneous bilateral total knee replacement and staged bilateral knee replacement. The findings in this study indicate that a patient with equally painful knees should undergo simultaneous bilateral total knee arthroplasty. If a patient has bilateral disease but only one knee is symptomatic, surgery should be performed on only the painful knee. If both knees are symptomatic, but one knee is much more painful than the other, the choice of treatment must be individualized based on the patient's medical health, symptoms, type of fixation used, and Charnley activity classification. PMID- 10155341 TI - Salmeterol. An appraisal of its quality-of-life benefits and potential pharmacoeconomic positioning in asthma. AB - Salmeterol is a selective beta 2-receptor agonist with a long duration of action that permits twice daily administration. It is effective in the prophylaxis of asthma symptoms, including nocturnal and exercise-induced asthma, and it has shown clinical benefits in both adults and children. Because of its slow onset of action, salmeterol is not intended for relief of acute symptoms. The addition of salmeterol 50 micrograms twice daily to existing asthma therapy has a positive effect on patient quality of life in the short term (up to 3 months), as assessed by the Living With Asthma Questionnaire and Asthma Quality of Life Questionnaire. This improvement in well-being appears to be greater than that associated with salbutamol (albuterol). Furthermore, in patients with asthma symptoms despite inhaled corticosteroid therapy, a reduced dose of corticosteroid plus salmeterol produced a greater improvement in quality of life as assessed by a daily symptom diary (but not by the Living With Asthma Questionnaire), and was more clinically effective than a higher dose of corticosteroid alone. Evaluation of the effects of salmeterol on quality of life compared with other standard therapies, and extension of these results into the long term are required to consolidate these conclusions. Salmeterol 50 micrograms twice daily was associated with an estimated incremental cost of 736 pounds per symptom-free patient in the final week of 7.5 months' therapy, 648 pounds per patient with improved morning (am) peak expiratory flow rate (PEFR) and 1013 pounds per patient with improved evening (pm) PEFR compared with salbutamol (400 micrograms twice daily) in a cost effectiveness analysis. However, these results should be tested by sensitivity analyses and compared with the incremental costs of other asthma interventions more applicable to recommended clinical practice. The cost effectiveness of salmeterol relative to other asthma therapies, and the effect of salmeterol on patient quality of life in the long term require further investigation. However, when added to existing asthma therapy, salmeterol improves patient quality of life in the short term (up to 3 months). It may also have some beneficial effects on patient well-being when used to provide a steroid-sparing effect. PMID- 10155343 TI - Symposium: the national hip registry: a new resource for measuring and improving the quality of health care. PMID- 10155344 TI - Practice parameters/clinical policies: the new approach to the practice of medicine. AB - Practice parameters or clinical policies and the future practice of medicine are covered in a series of three articles. In Part I, the term practice parameters is defined, and the background of practice parameters at the federal, AMA, and specialty society level is discussed. In Part II, the development, application, dissemination, and monitoring of practice parameters, including the clinical usage and impact, will be discussed. In Part III, the advantages, disadvantages, and legal implications of practice parameters will be reviewed. PMID- 10155345 TI - Pyogenic vertebral osteomyelitis: report of a series of 23 patients. AB - Vertebral osteomyelitis, an infectious disease with vague manifestations, can be difficult to diagnose. Although vertebral osteomyelitis represents only 2-4% of bone infections, the consequences are often grave and disabling, even fatal, when untreated. A series of 23 cases is reported in which patient records were reviewed to determine the etiology and appropriateness of diagnosis and management. Information on treatment and follow-up after discharge was obtained from outpatient progress notes, records from subsequent hospital admissions, and telephone interviews of patients. Pyogenic vertebral osteomyelitis was diagnosed by positive needle or open biopsy tissue cultures, positive blood cultures in the appropriate clinical setting, or diagnostic histopathology. Staphylococcus aureus was grown from 75% (15/20) of patient cultures, Escherichia coli from 15%, and Staphylococcus epidermidis from 10%. Overall, 87% (20/23) of these patients were disease-free at follow-up. The experience with this series of patients demonstrates that early diagnosis aided by MRI ensures a high cure rate and low complication rate. PMID- 10155346 TI - Difficulty in removal of the distal locking device of the Brooker-Wills tibial nail. AB - Complications in removal of the Brooker-Wills tibial nail were encountered in eight patients, and breakage of the distal fins occurred in four of these patients. Although none of the patients experienced residual effects related to removal of the tibial nail, the procedure is associated with potential risks such as infection or nonunion. Three methods of nail removal are described. PMID- 10155347 TI - Symposium: management of infections in total joint replacements. PMID- 10155348 TI - Cost considerations in oral antibiotic therapy. AB - The total cost of antibiotic treatment may be computed from basic treatment and indirect costs. Basic treatment costs represent the product of the per-dose acquisition cost and the number of doses. Agents with a high per-dose acquisition cost and an infrequent (eg, once daily), short duration of therapy may have lower total costs than agents with a low per-dose acquisition cost and a high-frequency (eg, four times daily), long-duration regimen. Indirect cost reflects expenditures associated with noncompliance, treatment failure, adverse events, and drug interactions. These costs result, in turn, from additional office visits, treatment with alternative or additional medications, hospitalization, and lost productivity. Older agents, though likely to have lower acquisition costs, may have reduced efficacy against clinically important pathogens, side effects, drug interactions, and the requirement for multiple daily doses and long dosage regimens--factors that may increase the probability of poor outcome and the overall treatment cost. Newer broad-spectrum agents are effective and generally well tolerated and may have fewer drug interactions; however, most require long and relatively complex dosage regimens. These limitations increase the basic treatment cost and influence indirect costs through negative effects on patient compliance. Broad-spectrum antibiotics with low acquisition costs, simple dosing regimens, and relatively favorable safety and tolerability profiles may provide benefits in the treatment of common infections. PMID- 10155349 TI - Efficacy of carvedilol in mild to moderate essential hypertension and effects on microalbuminuria: a multicenter, randomized, open-label, controlled study versus atenolol. AB - In this randomized, open-label, multicenter comparison, 140 adults with mild to moderate essential hypertension were treated with the nonselective beta blocker carvedilol (25 mg once daily) or the selective beta 1 blocker atenolol (100 mg once daily) orally for 2 months. Systolic and diastolic blood pressure and heart rate were measured monthly in the supine and standing positions. Urinary albumin levels and blood lipid profile were determined at baseline and at study end. The occurrence of cold extremities was monitored throughout the study. Both treatments significantly decreased systolic and diastolic blood pressure at a comparable level. At the final assessment, 88% of the carvedilol group achieved a supine diastolic blood pressure of 90 mm Hg or lower, compared with 82% of the atenolol group. Atenolol produced the greater decrease in heart rate, but between group differences were significant only for standing measurements. With carvedilol, urinary albumin decreased in 25% of patients and increased in 2%; corresponding figures with atenolol were 13% and 12%. At study end, 10% of the carvedilol group and 37% of the atenolol group complained of cold extremities. No major between-group differences were observed in the percentage of patients with an increase in high-density lipoprotein or a decrease in low-density lipoprotein cholesterol. Triglycerides and total cholesterol tended to decrease in a greater percentage of patients taking carvedilol than atenolol. PMID- 10155350 TI - Cost-effective management of complicated urinary tract infections. AB - Complicated urinary tract infection (UTI), which often requires hospitalization or prolongs a hospital stay, presents numerous diagnostic and therapeutic challenges. Implementation of effective antimicrobial treatment is vital because of the risk of adverse sequelae due to persistence of infection, relapse, or reinfection. Further, the increasing resistance of common uropathogens, such as Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter species, can complicate the therapeutic outcome. Economic factors also mandate cost-effective therapy. The costs of managing adverse sequelae have placed a significant liability on an already overburdened health care system. Estimates for prolonged hospitalization due to nosocomial UTI are reported as high as $2 billion a year in the United States. When parenteral rather than oral antimicrobial therapy is used, additional health care costs approximate $1000 per day per patient. Given the resistance to commonly used medications and the risk of serious adverse sequelae, clinicians are seeking more appropriate therapy. New oral antimicrobial agents now permit outpatient management of complicated UTIs that formerly required hospitalization for prolonged treatment. Currently, quinolones are recommended as first-line agents for complicated UTI. Reviews of pharmacokinetics, antimicrobial activity, efficacy, and safety of these drugs have noted equipotence or superiority to other antimicrobials, including trimethoprim/sulfamethoxazole. When used appropriately, quinolones provide effective and safe therapy for complicated UTI and offer in vitro efficacy against a broad range of pathogens. PMID- 10155351 TI - Measuring alveolar dimensions at total lung capacity by aerosol-derived airway morphometry. AB - A technique based on particle sedimentation, aerosol-derived airway morphometry (ADAM), was modified to investigate the morphometry of human lung airspaces at full inflation in 54 subjects with normal lung function, ages 18 to 69 years. The technique compares the recovered concentrations of monodisperse aerosol particles after gravitational settling during breath holds to determine effective airspace diameters (EADs) as a function of volumetric lung depth. The method is simple and non-invasive, requiring only several inhalations of aerosol to total lung capacity, breath holds at end inhalation and exhalation to residual volume (RV). The method is sensitive enough to detect differences in the smallest observed airspaces (EADmin) due to normal aging of healthy lungs when older subjects are compared to younger subjects. The average EADmin was larger (p = 0.009) for the oldest adults (293 +/- 54 um, s.d., 50-70 years, n = 13) at the deepest volumetric lung depth (near 40% of TLC into the lung) when compared to the youngest adults (250 +/- 38 um, s.d., 18-40 years, n = 22). The two groups had similar EADs at a depth of 5% of TLC. No gender difference in EADmin was found when comparing all males and females. No correlation was found between EADs and TLC implying number of alveolar airspaces rather than airspace size determines lung volume. The effects of changing the aerosol inhalation volume to TLC ratio was also investigated. Compared to the dichotomous Weibel morphometric model, the average EADs of 22 18-40 year old subjects were found to be equivalent near 1% TLC and 40% TLC, but were larger in size than the model between those extremes with a maximum difference occurring at approximately 3% TLC. This method appears to be extremely sensitive to in vivo changes in airspace dimensions and may prove useful in determining changes in these dimensions associated with normal lung development and early disease states. PMID- 10155352 TI - Technique for measurement of oropharyngeal clearance in the elderly. AB - In elderly patients, gram negative bacterial colonization often preceeds nosocomial pneumonia. As we propose that a critical factor influencing this change from normal to gram negative predominance is an alteration in oral clearance, we designed this study to validate a technique for measurement of oropharyngeal clearance in a large number of nursing home residents. We modified a protocol of La Force et al who utilized an atomizer to radiolabel oropharyngeal secretions. We determined the output per spray of a DeVILBISS model 152 atomizer and found that 3 sprays of 5 mCi of 99mTc-HSA in 4 ml saline delivered 263 microCi in 0.21 ml. To measure clearance, we designed a portable, collimated ratemeter. It has a lead lined tapered aluminium frame 15 cm high, originating from a 7.5 cm rectangular base which is fitted to the scintillator. On the bench we demonstrated that this collimator, used to confine detection to the face, did not alter sensitivity and linearity of the ratemeter in our specific experimental conditions. When the ratemeter was collimated and its window off, its sensitivity was 5 times greater than the gamma camera with no loss of linearity. However, distance had a significant effect on the ratemeter's sensitivity whereas it had little effect on the gamma camera. Finally, in thirteen patients we assessed the ratemeter's accuracy in measurement of oropharyngeal clearance by comparing curves obtained simultaneously from the ratemeter and gamma camera. While each curve had its own characteristics, both devices provided remarkably similar data and there were no significant differences (r = 0.967, p < 0.0001). We conclude that oropharyngeal clearance can be conveniently and accurately studied in elderly patients at the bedside with a collimated ratemeter. The high sensitivity provides a measure of clearance with low levels of radioactivity exposure, allowing repeated studies over time. PMID- 10155353 TI - A novel breath actuated device (Autohaler) consistently actuates during the early phase of inspiration. AB - OBJECTIVE: To establish and quantify the point during inspiration that the Autohaler (AH) inhalation system releases a metered dose of aerosol (placebo). The second objective was to determine if the Autohaler system actuates consistently, regardless of the canister life. DESIGN: Double-blind, randomized, two-period crossover, one-day trial. SETTING: Community based allergy and asthma clinic. PARTICIPANTS: Twelve patients with mild to moderate asthma. RESULTS: Mean verbal training time for the AH which included the patient demonstrating their ability to correctly use the AH was approximately 6 minutes. The mean time for actuation for the AH early in its canister life ("new canister") was 195 msec compared to 205 msec for the AH late in its canister life ("old canister") (p = 0.589). This represented the early part of inspiration as patients had a mean inspiratory duration of 2231 msec for the "new" AH and 2343 msec for the "old" AH. The mean percentage of inspiration time required to actuate the "new" AH was 8.92% compared to 8.82% for the "old" AH. Patients rated the system as easier to much easier to use compared with their current standard press and breathe inhaler. CONCLUSIONS: The AH consistently actuates early during inspiration, which is considered the optimal time for drug delivery, regardless of the canister life. PMID- 10155354 TI - The Diskus: a new multi-dose powder device--efficacy and comparison with Turbuhaler. AB - The Diskus is a novel multi-dose powder inhaler for the treatment of asthma, delivering precise individual doses of drug to allow the 'average' patient a month's therapy. It was designed to be simple to operate and contains a dose counter. The performance of the Diskus has been compared with that of a well established reservoir powder inhaler. The pharmaceutical assessment of the Diskus has shown that the delivered dose of salmeterol and fluticasone propionate (FP) remains at approximately 90% of the labelled claim at a range of flow rates of 30 90L/min. This contrasts with data for the reservoir powder inhaler which show that the delivered dose as a percentage of the labelled claim is both lower and more variable, particularly at flow rates between 30 and 60L/min. The mass of drug substance (mass median aerodynamic diameter (MMAD)), < 6 microns) delivered from the Diskus also remains relatively constant at different flow rates, unlike the reservoir powder inhaler, in which the fine particle mass is more dependent on flow rate. The doses of drug in the Diskus are protected from moisture; the fine particle mass of salmeterol delivered from the Diskus is unaffected by humid conditions (30 degrees C/75% relative humidity) as opposed to the reservoir powder inhaler in which the ingress of moisture is associated with a decrease in particles of MMAD < 6 microns. In clinical studies, salmeterol, 50 micrograms twice daily, and FP, 50-500 micrograms twice daily, have been shown to be equally effective and well tolerated when delivered by Diskus as compared with Diskhaler.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155355 TI - Babyhaler--a new paediatric aerosol device. AB - Nebulizers have, until recently, been the mainstay of drug delivery by inhalation in babies and young children. The willingness of a young child to cooperate, however, is limited and the 10-12 mins needed to deliver drug using a nebulizer often limits the compliance with this mode of administration in infants. Therefore, drug delivery systems using the metered-dose inhaler (MDI) as the aerosol generator attached to valved holding chambers were developed. The breathing pattern of a baby with lung disease is quite different from that of older children and adults, for whom most large-volume devices were developed. Infants have a high respiratory frequency, small tidal volume, and low inspiratory airflow rate. Therefore, specific conditions for optimal drug use in this particular group of patients have to be met. Efficacy of topical drug delivery depends on the generation of aerosol particles with an adequate size distribution (technical prerequisites), the breathing pattern of the child (physiological requirements), and the willingness of a young child to cooperate with parental drug administration (practicality and compliance). Infants with lung disease have a tidal volume of 8-10ml/kg body weight. The volume of a spacer device must be such that about 5-10 breaths would be needed to provide an adequate dose. In addition, the dimensions of a spacer device must be such that sufficient drug particles of optimal size will be generated to minimize impaction and deposition within the device. The Babyhaler consists of a tubular chamber 230mm long, with a volume of 350ml and low-resistance inspiratory and expiratory valves.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155356 TI - The choice of inhalers in adults and children over six. AB - Available delivery systems for ambulatory use include the conventional suspension pressurized metered dose inhaler (MDI), the conventional MDI with add-on devices such as spacing chambers and several powder delivery systems. Gas-driven or ultrasonic nebulizers are also available but are generally reserved for in hospital use or for the treatment of the most severely obstructed patients. It is difficult to select one best system for use in older children, adolescents and adults; all available systems have their deficiencies and these are outlined here. The most widely prescribed device, the MDI, is misused by some patients with claims of up to one-third of clinic patients showing inadequate inhaler technique. In the 1990s, the MDI has also been criticized for liberating chlorofluorocarbons (CFCs). On occasion, the adjuvants are said to precipitate cough. In some countries, the production of generic or second entry inhalers has been accompanied by vexing concerns over the bioequivalence of therapeutic aerosols. The problem of patient coordination with the inhaler is meant to be dealt with by a variety of add-on devices. Spacing chambers and reservoir systems improve drug delivery and treatment efficacy for some patients. Unfortunately, there are relatively few data on patient spacer technique or optimal teaching methods. There is considerable potential for patient misuse of these superficially simple devices. One common problem is that the devices become dirty and worn but are seldom replaced by patients. A more subtle problem is electrostatic drug adherence to the spacing chamber thereby reducing drug delivery.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155357 TI - Continuing patient care with metered-dose inhalers. AB - International guidelines recommend inhaled therapy over oral therapy for asthma because of greater efficacy and safety. Metered-dose inhalers (MDIs) are the delivery system of choice for the majority of patients with asthma. They have been well tried and tested and proven to be safe, reliably delivering a reproducible and precise dose, and account for 85% of the 400 million inhalers currently sold worldwide. Current products using chlorofluorocarbon (CFC) 11/12 as the propellant are being reformulated. Under the Montreal Protocol, CFCs are to be phased out worldwide, though MDIs have been granted temporary exemption, thus far until 1997. Two propellants, hydrofluoroalkane (HFA) 134a and 227, have been identified by the pharmaceutical industry to replace CFCs. However, they have different properties and reformulation has been difficult in relation to surfactants, valves and elastomeric seals. The manufacturing process has been re engineered to take place at high pressure, because at normal pressure HFA134a is a gas, in contrast with CFC 11 which is a liquid at room temperature. Glaxo has carried out an extensive toxicological assessment of HFA134a and thorough clinical testing has shown it to be well tolerated. To date they have carried out safety and efficacy testing on reformulations of salbutamol, salmeterol and fluticasone propionate (FP). Single-dose studies of salbutamol, 200 micrograms, with HFA134a have been shown to provide equivalent protection against bronchial provocation by histamine in both adults and children with asthma when compared with the currently available CFC preparations. In a subsequent 4-week study, both formulations had similar effects on morning peak flow and the patients believed that the two preparations were equivalent. PMID- 10155358 TI - Coagulation monitoring during extracorporeal membrane oxygenation: the role of thrombelastography. AB - Patients undergoing extracorporeal membrane oxygenation (ECMO) are at an increased risk for developing coagulopathies due to the adverse effects of extracorporeal circulation on the hemostatic mechanism. Methods of determining causative factors of bleeding diathesis are often inconsistent and non-specific. ECMO patients require aggressive transfusion therapy with autogenic blood products to stabilize and maintain hemostasis. The present study evaluated the coagulation status of newborn patients undergoing ECMO therapy, using a viscoelastic monitor (Thrombelastograph -TEG) that measures functional aspects of clot development and stabilization. Seventeen neonatal patients undergoing ECMO for severe respiratory dysfunction were entered into this study. Serial blood samples were obtained and routine coagulation assessment including fibrinogen concentration, platelet count and ionized calcium was performed. In addition, fibrin(ogen) degradation products (FDP), d-Dimers, antithrombin III and plasma free hemoglobin were measured. Transfusion indicators were established and total transfusion requirements recorded. TEG profiles were determined with the use of heparinase, an enzyme that degrades heparin but has little effect on other coagulation factors. The most commonly encountered complication was hemorrhaging which was diagnosed by laboratory and clinical assessment in 11 of 17 patients. Transfusion requirements (measured in ml/kg/ECMO hour) were the following: packed red blood cells--1.34 +/- 0.5; platelets--0.71 +/- 0.57; fresh frozen plasma- 0.09 +/- 0.12; cryoprecipitate 0.05 +/- 0.05. Thrombelastograph profiles reflected hemostatic conditions that ranged from severe coagulopathies (DIC) to hypercoagulability. Interpretation of TEG profiles identified hemostatic abnormalities in 57 of 101 profiles (46.5%), with the most common etiology related to platelet dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155359 TI - Proinflammatory mediator response in coronary bypass surgery using a centrifugal or a roller pump. AB - Major surgery, trauma, and infection induce a proinflammatory mediator response which, if excessive, may cause tissue injury. The response was measured during elective coronary bypass surgery when a centrifugal pump or a roller pump, differing in their basic working principles, was used for extracorporeal circulation (ECC). Eight patients were perfused with a centrifugal pump and eight patients with a roller pump during ECC. Plasma interleukin-1 beta (IL-1 beta), IL 2, IL-6, tumor necrosis factor alpha (TNF alpha), group II phospholipase A2, (PLA2), endotoxin, fibronectin and serum C-reactive protein (CRP) concentrations were measured. The operation increased plasma IL-6, group II PLA2, and serum CRP concentration and decreased plasma fibronectin concentrations. IL-1 beta and TNF alpha concentrations did not change. IL-2 occurred only occasionally, and endotoxin did not occur in any patient. No differences were seen between the group using a centrifugal pump and the group using the roller pump. Cardiac surgery with a perfusion time of less than two hours thus caused a proinflammatory mediator response which was similar whether a centrifugal or a roller pump was used for ECC. PMID- 10155360 TI - A clinical evaluation of the Terumo Capiox SX18R hollow fiber oxygenator. AB - The Terumo Capiox SX18R is a commercially available, low prime, reverse phase, hollow fiber membrane oxygenator. The oxygenator consists of a 1.8 m2 microporous polypropylene hollow fiber bundle, a 2200 cm2 tubular stainless steel heat exchanger, and an open hard shell venous reservoir with integral cardiotomy filter. The Terumo Capiox SX18R oxygenator was evaluated to determine its clinical oxygenating performance. Blood samples were drawn from 25 patients yielding 114 data points. The following parameters were recorded: blood flow, cardiac index, gas flow, gas to blood flow ratio, and oxygen fraction. Samples were assayed for hematocrit, hemoglobin, arterial and venous blood gas values, and venous oxygen saturation. The data and assay results were used to calculate arterial, venous, and membrane gas oxygen content, oxygen transfer, shunt fraction, and oxygen diffusion capacity. The Terumo Capiox SX18R oxygenator performed adequately with sufficient oxygen transfer reserve and carbon dioxide clearance under a variety of clinical conditions for the tested population. PMID- 10155361 TI - Hemofiltration: determinants of drug loss and concentration. AB - Ultrafiltration has proven to be an effective method of reducing post cardiopulmonary bypass edema and the inflammatory response associated with activation of the complement cascade. Recently, a modified ultrafiltration process has been developed which allows further hemoconcentration after weaning from bypass. Both of these procedures can have an effect upon the concentrations of many of the pharmaceutical agents being used either pre- or perioperatively. Based upon work done by other investigators in the field of dialysis, we have developed sieving coefficients for many cardiovascular drugs in order to provide an estimation of their loss during extended periods of hemofiltration. Our study utilized the pharmacological and physical characteristics for volume of distribution and protein binding to determine the movement of drugs through a hemofilter. Our results demonstrated that concentrations of certain drugs used during open heart surgery may be significantly increased or decreased with the use of hemofiltration techniques. PMID- 10155362 TI - The buffering ability of commonly employed cardiopulmonary bypass solutions and alkalizing agents. AB - This experiment evaluated the hydrogen ion (H+) buffering capacity (BC) of solutions and alkalizing agents employed during cardiopulmonary bypass (CPB). A solution's BC can be determined when a known quantity of H+ is titrated into the solution and the change () in pH (-log of the hydrogen ion activity ([H+]a)) is measured ([H+]a/mmole H+). Eleven solutions were studied:Lactated Ringers (LR), 0.9% NaCl (NS), Plasma-Lyte A, Hespan (6% hetastarch), banked donor blood with citrate phosphate dextrose adenine (CPDA-1), fresh donor blood, THAM, sodium bicarbonate (NaHCO3; 1 mEq/ml), high potassium crystalloid cardioplegic solution (HKCCPS), oxygenated crystalloid cardioplegic solution (OCCPS), and adult crystalloid priming solution (AP) per institutional protocol. The solutions were studied at three temperatures: 37 degrees C, 28 degrees C, and 18 degrees C. The null hypothesis stated there was no difference in the BC of the solutions studied. The solutions were first titrated to the same starting pH of 8.0. The solutions were then titrated with a predetermined concentration of hydrochloric acid (HCl) to a pH of 7.0. A higher quantity of H+ added to a solution indicated a greater ability of that solution to buffer H+ within pH limits of 8.0 to 7.0. The data was analyzed with a two way ANOVA and Bonferonni method. A p value < 0.05 was considered to be statistically significant. The significant results of our study indicated that THAM demonstrated the best BC, followed in decreasing order by NaHCO3, banked blood, fresh blood, HKCCPS, AP, OCCPS, Plasmalyte, LR, Hespan, and NS. PMID- 10155363 TI - A technique for separation of perfluorocarbons from blood used in cardiopulmonary bypass laboratory procedures. AB - Eliminating from physiologic circulation a significant amount of unnecessary perfluorocarbons (PFC) is advantageous since little is known about long-term effects of PFC in the circulatory system. The basic circuitry, cell-washer, mechanical manipulations, and overall concept revealed that a significant amount of PFC can be retrieved and estimated in volume and compared to initial volumes. A method of separating a certain PFC blood substitute from blood following laboratory cardiopulmonary bypass is described. PMID- 10155364 TI - Directional coronary atherectomy: experience in 310 patients. AB - This article describes the acute and long-term clinical outcomes of 310 consecutive patients who underwent directional coronary atherectomy (DCA) for treatment of coronary artery disease. An overall procedural success rate of 95% was noted with a total major complication rate of 5%. Analyses of minimal luminal diameter (MLD) were performed pre- and post-procedure for 160 patients. Clinical follow-up including treadmill testing and/or clinical symptoms was obtained on 293 patients. Results of angiographic analyses corresponded with the Kuntz model suggesting that larger MLDs are associated with lower restenosis rates. The overall target vessel revascularization rate was 27.6%, with a mean post procedure percent diameter stenosis of 16%. These results indicate that DCA is associated with acceptable clinical restenosis rates, complications and long-term outcome. PMID- 10155365 TI - The use of the Tracker catheter as a guidewire support device in angioplasty of angulated and tortuous circumflex coronary arteries. AB - Marked angulation and tortuosity of the coronary arteries, particularly the circumflex, can limit coronary angioplasty. Despite the use of adequate guide catheter support and high performance guidewires, it is often difficult or even impossible to reach the distal segment of the target vessel with the guidewire. We describe three cases of successful complex circumflex coronary artery angioplasty where guidewire advancement through proximal angulated and tortuous anatomy was facilitated by the Tracker-18 Hi-Flow catheter after failure of conventional angioplasty hardware. PMID- 10155366 TI - Clinical experience with transvenous implantable cardioverter-defibrillators for treatment of malignant ventricular arrhythmias. AB - The need for thoracotomy has previously limited the use of the implantable cardioverter-defibrillator. Prior investigators have shown the efficacy and reduced risk of the transvenous implantable cardioverter-defibrillator. In this study, we report our experience with the transvenous implantable cardioverter defibrillator as a first-line system. Thirty-four patients with mean age 63.2 +/- 10.3 years and mean ejection fraction 32.6 +/- 11.4% underwent implantation of a transvenous cardioverter-defibrillator using an Endotak lead with or without a subcutaneous patch. Twenty-one patients received a biphasic device and the remainder a monophasic device. Thirty-three of 34 patients (97%) were successfully implanted. The mean defibrillation threshold was than < or = 15.3 +/ 3.6J. Overall, 25 of 34 (74%) patients were implanted with a single endocardial lead alone. In the group receiving a biphasic device 19 of 21 (90%) were successfully implanted with a single endocardial lead alone whereas in the group receiving a monophasic device only 6 of 12 (50%) were successfully implanted with single endocardial lead alone (p < 0.05). There were no serious complications. One postoperative death was a result of end-staged congestive heart failure. We conclude that the transvenous implantable cardioverter-defibrillator is safe and efficacious and that incorporation of biphasic waveform may lead to higher rates of implantation of single transvenous lead alone without the need for subcutaneous patch. PMID- 10155367 TI - Successful coronary angioplasty in a pregnant woman at term: a case report. PMID- 10155368 TI - Current status of percutaneous vascular procedures. AB - The current nonsurgical therapeutic options for patients with peripheral vascular disease are rapidly expanding. No longer is conservative management the only alternative for patients with significantly symptomatic but noncritical limb ischemia. Certainly for vascular disease above the inguinal ligament interventional procedures especially with adjunctive stent placement have excellent success and long term patency. Femoropopliteal vascular disease of relatively limited nature also is well-treated with interventional procedures. Infrapopliteal vascular disease treated with a surgical venous bypass appears to have superior results than intervention. However, for poor surgical risk patients or in patients without the necessary venous conduit, limb salvage is still good with a percutaneous approach. Renal artery stenosis appears now to be well treated with interventional techniques. Early data with up to one year follow-up shows that even ostial stenoses respond well when vascular stents are utilized. Extending the life of failing hemodialysis grafts is another area where interventional techniques are of benefit. In the future, more extensive vascular disease and other vascular disease entities such as cerebrovascular disease and abdominal aortic aneurysm may be successfully treated by a percutaneous approach. PMID- 10155369 TI - A new year's revelation: the boss needs training too. AB - The managing director of a medical device company has been heard to refer to his manager's efforts to implement a quality system as his quality "sideline." Another device company that lacks a quality system could lose a significant percentage of its turnover because its major clients require their suppliers to operate under a documented quality system. The top executives of too many medical device companies lack the information they need to make informed quality-related decisions. This article will discuss the types of information a top executive needs to make informed decisions concerning the quality status of his/her company. PMID- 10155370 TI - Material selection. AB - Correct and well-informed material selection is crucial to the manufacture of safe and successful medical devices. However, the vast array of materials and processing methods and the innovation going on in this area can make the task difficult. This article offers advice on the best approach to material selection and sourcing information on new developments. PMID- 10155371 TI - Designing for the user. AB - During the development of medical products, attention mainly focuses on technical specifications. But however well thought out they are, technical features do not guarantee that a product will be easy and safe to use. The strengths and weaknesses of human beings and the needs and habits of end users also need to be taken into account. This article sets out essential guidelines and criteria for optimizing the interface between man and machine and presents a case study to demonstrate the practical benefits of this approach. PMID- 10155372 TI - Wound dressings. Past, present, and future. AB - The discovery that "moist" dressings can promote faster healing has led to a number of innovations in wound care. Modern dressings are playing an active part in the healing process and, in the future, will be condition-specific rather than offering off-the-shelf solutions. Focusing on hydrocolloids and alginates, which are used in bioactive dressings, this article reviews the developments that have been made to date, and includes discussion of the demands being made on the manufacturing process. PMID- 10155373 TI - Biomimetic surfaces: how man-made becomes man-like. AB - Biomaterials are usually synthetic or man-made substances that possess one or more properties that are suitable for use in devices that come into contact with living tissues. Living tissues are most content to be in contact with other tissues, especially those of their own kind. Biomimicry takes this observation and turns it into a practical solution to some problems of biocompatibility. It involves transforming traditional materials into tissue-like materials so that they may then be able to convince their host that it is in contact with one of its kind. PMID- 10155374 TI - A logical approach to process validation. AB - KISS stands for "Keep it simple, stupid!" Sometimes those of us who cringe at the inelegance of this adage, nevertheless resort to it to point out that quality system policies, procedures, and work instructions should be described in clear and simple terms. This should also apply to process validation. This article will describe a logical approach to certain key elements of process validation that should help in meeting that objective. PMID- 10155375 TI - Surface modification with functionally active heparin. AB - Efforts to improve the blood compatibility of artificial materials have involved coating the surfaces with heparin. However, the anticoagulation activity of heparin is based on its binding to antithrombin, and if the specific structure involved in this interaction is compromised by the coating procedure, then the activity is lost. Surface modification with end-point-immobilized heparin has been found to be successful in inhibiting coagulation factors and minimizing complement activation. PMID- 10155376 TI - Notified bodies. Questions and answers. AB - Under the new system of regulation, many companies will need to develop working relationships with Notified Bodies to achieve approval to affix the CE mark to their products. This article answers some pertinent questions relating to Notified Bodies in general, and describes the situation in the United Kingdom. PMID- 10155377 TI - Medical equipment leasing. Benefits and opportunities. AB - Medical equipment manufacturers throughout Europe now have the opportunity to take advantage of changes in the United Kingdom Treasury rules, which introduce flexibility into hospital financing. This could result in more equipment sales for manufacturers and better equipped hospitals. PMID- 10155378 TI - Below the belt: the technology of incontinence. AB - At a time when advances in so many areas of medicine and surgery mean that hitherto catastrophic diseases can be prevented, diagnosed, or treated with amazing precision and efficiency, the urinary track remains relatively ignored by molecular biology and medical technology. This article addresses some of the reasons underlying this phenomenon and points to major technical and commercial opportunities in this neglected area. PMID- 10155379 TI - Computer vision for quality control and inspection. AB - Ever-increasing requirements for documentation and productivity necessitate in line quality inspection and control. Computer vision technology can be a useful tool in this context. This article describes how the process operates and offers an application case study. PMID- 10155380 TI - Implementing a QA system in a small company. AB - Establishing a quality assurance system is a costly undertaking that holds particular problems for small companies, which typically have fewer resources. This article reports on one manufacturer's experience of the potential problem areas in implementing ISO 9002 and discusses the cost implications. PMID- 10155381 TI - Polyurethane paranoia flexible friend or deadly foe? AB - One of the most versatile of all materials used in medical devices has been under a cloud of suspicion for a few years, because of concerns about degradability and carcinogenicity. There is considerable confusion about the exact nature of polyurethanes and the extent of the problem. This article attempts to explain the essentials of polyurethane chemistry and put these concerns into perspective. PMID- 10155382 TI - Risk analysis: a standard approach? (Part II). AB - Part I of this article noted that the European Medical Device Directive requires risk analysis to be conducted for all classes of devices. The article also pointed out that a risk analysis standard is being developed to assist companies in complying with this requirement. Part II will discuss the contents of the draft standard, some issues that should be considered in meeting the standard, and the usefulness of failure analysis techniques. PMID- 10155383 TI - Package seals. Causes and avoidance of defects. AB - Defective heat sealing can result in leakage, packs that are difficult to open, or contamination of the contents. This article comments on materials, machinery, and maintenance to provide an understanding of the causes of sealing problems. PMID- 10155384 TI - Packaging legislation. Objectives and consequences. AB - The recently published Directive on packaging and packaging waste makes new demands on the industry. This article highlights the key areas and raises some of the issues that must be confronted in the future. PMID- 10155385 TI - A packaging update. Recycling, testing, and pricing. AB - Europe has taken legislative measures to improve the management of packaging and packaging waste. This article outlines the arguments for excluding medical device packaging from the provisions of the recently published European Directive on packaging and packaging waste. Developments in a new barrier test method and further increases in the price of raw materials are also discussed. PMID- 10155386 TI - Market report. Packaging. AB - Medical Device Technology's second annual packaging study looks at the materials and methods used by its readers throughout Europe. Rises in the level of use of some materials and certain packaging requirements are indicated and subcontracting shows increased demand. PMID- 10155387 TI - Beyond the barrier: devices inside the brain. AB - The brain is usually thought of as an extremely sensitive part of the body, which should be entered only with great caution. However, it does appear to be amenable to intervention with treatment involving devices in a number of circumstances. This article describes one such application. PMID- 10155388 TI - Management responsibility. AB - The role and responsibility of management in implementing and maintaining a quality system is one of the most important elements of EN ISO 9001 and EN ISO 9002. Unless top management recognizes its quality-related responsibilities, it is virtually impossible for all levels of a company to implement and maintain a successful quality system. This article will discuss the management responsibility provisions of the 1994 quality system standards and point out the modifications that were made to the previous version of the standard. PMID- 10155389 TI - The economics of sterilization. AB - In this approach to selecting the most appropriate sterilization method, comparisons are made of the initial and ongoing costs for sterilization by ethylene oxide, gamma radiation, and electron radiation. Considerations that have an impact on cost include the monetary value of the time that elapses between sending a product for processing and its release for sale, anticipated growth in the level of product to be sterilized, labour, electricity and utilities, and the price of the sterilant. PMID- 10155390 TI - Ethylene oxide sterilization update. AB - Ethylene oxide (EtO) sterilization technology faced an uncertain future a few years ago, but this situation has now changed. The factors involved and the advantages offered by the latest technically sophisticated EtO technology are reviewed in this article. PMID- 10155391 TI - Sterilization update. AB - After publication of the sterilization standards, it is the related issues that are being debated. This article reviews some of the issues posed by the published standards and the new areas that are under consideration, which include bioburden determination and ethylene oxide residual levels. PMID- 10155392 TI - Clinical investigation of medical devices. AB - Clinical investigations are required for implantable and invasive devices in Class IIa or IIb, and all Class III devices. This article describes how to successfully perform a clinical trial according to the standards set in EN 540, Clinical Investigation of Medical Devices for Human Subjects. PMID- 10155393 TI - Tiredness can kill. The real story of fatigue. AB - Medical devices are often subjected to repetitive stresses, the magnitude and frequency of which means that they are susceptible to fatigue. This article discusses some of the implications of fatigue and methods for its avoidance. PMID- 10155394 TI - The proposed in vitro diagnostic directive. AB - After a long delay, the official proposal for the In Vitro Diagnostic (IVD) Directive has been published. Some changes could be made during the process of publishing a final Directive, however, it is unlikely that they will be extensive. Therefore, IVD manufacturers should be aware of the proposed requirements. This article will discuss the scope and conformity assessment procedures of the official proposal and point out some of the major modifications that were made to the preceding draft proposal, which was discussed in a previous article. PMID- 10155395 TI - Making PVC more biocompatible. AB - Poly(vinyl chloride) (PVC) is used extensively for disposable medical devices. However, it produces adverse reactions when in contact with body tissues and fluids, and can lead to thrombus formation. This article proposes coating material surfaces with synthetic phosphorylcholine-containing polymers to mimic the outer surface of the natural cell membrane. Experimental evidence is provided to support the use of this approach to enhancing the biocompatibility of PVC and other materials. PMID- 10155396 TI - Implementing standards for radiation sterilization. The challenges. AB - This article discusses the limitations of the methods offered in the radiation standards for selecting radiation dose. It highlights the difficulty of using these methods for product-specific dose-setting and, in particular, their inability to determine this for products with low bioburdens. Issues relating to the appropriateness of 25 kGy are also discussed. PMID- 10155397 TI - The 1995 Medical Device Technology raw materials survey. AB - Using information supplied by manufacturers, this article reports on the use of raw materials and compounding and conversion practices in the European medical device manufacturing industry. The findings of the survey provide an indication of which materials are being used and how frequently, and the process of selecting suppliers. PMID- 10155398 TI - Hydrogels: are they keeping their heads above water? AB - For as long as biomaterials have been designed, there has been a strong interest in certain water-containing substances known as hydrogels. These have been assumed to be "biocompatible" because of certain similarities they have with tissues of the body, but they also offer a variety of other desirable characteristics. For several reasons, however, hydrogels have not fully realized their potential. This article addresses some of the issues involved. PMID- 10155399 TI - Out-of-hospital deliveries: a five-year experience. AB - INTRODUCTION: Prehospital providers regularly encounter patients with obstetrical emergencies. This study determined the frequency and outcome of out-of-hospital deliveries in an urban, all advanced life support (ALS) emergency medical services (EMS) system. METHODS: Retrospective review of all out-of-hospital records that involved women delivering babies in the care of prehospital providers from 1984-1988. The EMS system answered an average of 62,000 calls during the study period. The records of these patients were identified through a computer database. RESULTS: A total of 81 out-of-hospital deliveries (1.4/month) occurred during the study years. The average age of the mothers was 24 years, and the average gestation period was 30 weeks. The women had an average of three previous pregnancies and two previous deliveries, and 10 were primagravida. Seventy-two (89%) of the deliveries occurred in the home. The paramedics encountered a variety of obstetrical and neonatal complications in 34% of the patient encounters. Nine neonates were delivered prior to the arrival of the paramedic team. Twenty-four neonates had Apgar scores calculated, and the one- and five-minute scores averaged eight and nine respectively. Five of the mothers had no prenatal care. Maternal complications included four patients noted to be hypertensive with the delivery, nine patients had some degree of vaginal bleeding, and in 33 patients, the prehospital providers did not deliver the placenta in the field. An EMS physician was in attendance for only two of the out of-hospital deliveries. DISCUSSION: In this urban EMS system, out-of-hospital deliveries, especially pre-term deliveries, are a common event. There appears to be a significant number of neonatal complications that confront paramedics. Generally, the paramedics were deficient in their documentation of the neonatal assessment. Continuing educational programs for paramedics should include reviewing normal and complicated vaginal deliveries as well as ALS measures for neonates. Protocols for obstetrical emergencies need to be developed and subjected to quality improvement measures. CONCLUSIONS: Paramedics, especially those in urban settings, are likely to encounter obstetrical and neonatal emergencies and a significant number of associated complications. Emergency medical services systems and medical directors should have in place continuing educational programs, patient-care protocols, and continuous quality improvement measures to evaluate the care rendered to patients having out-of-hospital deliveries. PMID- 10155400 TI - Review of accidents/injuries among emergency medical services workers in Baltimore, Maryland. AB - OBJECTIVES: To characterize the types of occupational exposures and injuries reported by emergency medical service (EMS) workers. METHODS: A blinded review of accidents/exposures among EMS workers employed by a Baltimore County fire department was conducted. Medical records for 1992 were reviewed. RESULTS: Two hundred and twenty-six reports were filed by EMS workers (n = 197) employed by a large, urban fire department in 1992. The most commonly reported injuries were sprains (23%), strains (20%), and exposure to blood and body fluids (15%). The body site most commonly injured was the back (20%) followed by the respiratory system (10%). Most incidents were treated at the employee health clinic, and 13% of the incidents resulted in a hospital visit. Fifteen percent of the injuries resulted in more than seven lost work days. Most incidents were caused by stretcher mishaps, especially during transport of heavy patients. Walkway impediments (e.g., icy steps, wet leaves, broken and uneven pathways) also played an important role in creating slipping and tripping hazards. CONCLUSION: These results suggest a variety of prevention strategies aimed at reducing accidents and exposures among EMS workers. PMID- 10155401 TI - Outcome in an urban pediatric trauma system with unified prehospital emergency medical services care. AB - HYPOTHESIS: Pediatric mortality is predicted by age, presence of head trauma, head trauma with a low Glasgow Coma Scale (GCS) score, a low Pediatric Trauma Score (PTS), and transport directly to a pediatric trauma center. POPULATION: Studied were 1,429 patients younger than 16 years old admitted to or declared dead on arrival (DOA) in a pediatric trauma center from January through October, 1988. The trauma system, which served 3-million persons, included six pediatric trauma centers. METHODS: Data were obtained by a retrospective review of summary statistics provided to the Chicago Department of Health by the pediatric trauma centers. RESULTS: Overall mortality was 4.8% (68 of 1429); 32 of the patients who died (47.1%) were DOA. The in-hospital mortality rate was 2.6%. Head injury was the principal diagnosis in 46.2% of admissions and was a factor in 72.2% of hospital deaths. The mortality rate was 20.3% in children with a GCS < or = 10 and 0.4% when the GCS was > 10 (odds ratio [OR] = 67.0, 95% CI = 15.0-417.4). When the PTS was < or = 5, mortality was 25.6%; with a PTS > 5, the mortality was 0.2% (OR = 420.7, 95% CI = 99.3-2,520). Although transfers to a pediatric trauma center accounted for 73.6% of admissions, direct field triage to a pediatric trauma center was associated with a 3.2 times greater mortality risk (95% CI = 1.58-6.59). Mortality rates were equal for all age groups. Pediatric trauma center volume did not influence mortality rates. CONCLUSIONS: Head injury and death occur in all age groups, suggesting the need for broad prevention strategies. Specific GCS and PTS values that predict mortality can be used in emergency medical services (EMS) triage protocols. Although the high proportion of transfers mandates systemwide transfer protocols, the lower mortality in these patients suggests appropriate EMS field triage. These factors should be considered as states develop pediatric trauma systems. PMID- 10155402 TI - The effect of prehospital transport time on the mortality from traumatic injury. AB - OBJECTIVE: To test the hypothesis that a prehospital time threshold (PhTT) exists that when exceeded, significantly increases the mortality of trauma patients transported directly from the scene of injury to a trauma center rather than to the closest hospital. DESIGN: Review of data contained within the Illinois Trauma Registry encompassing the period from fall 1989 through spring 1991. PARTICIPANTS: A total of 5,215 injured persons with an Injury Severity Score (ISS) > 10, cared for in an Illinois level-I or -II trauma center outside of the city of Chicago. MEASUREMENTS: Injury severity expressed as ISS, scene time (ST), transport time (TrT), total emergency medical services time (TEMST), and outcome were determined for each patient. Patients were stratified into groups on the basis of ISS. RESULTS: Patient outcomes were significantly different statistically between ISS groups (p < 0.001, chi 2). Mean ST and TEMST, but not TrT, were significantly different statistically between ISS groups (p < 0.001, analysis of variance). Lower ISS was associated with longer times. Mean ST, TrT, and TEMST were significantly different statistically between survivors and nonsurvivors (p < 0.001, two-sample t-tests). Survival was associated with longer times. Each of the mean times remained significantly different between survivors and nonsurvivors after controlling for severity of injury (p < 0.001, two-way analysis of variance). CONCLUSION: No PhTT beyond which time patient transport to the closest hospital would have decreased mortality was identifiable, because no prehospital time < 90 minutes exerted a significant adverse effect upon survival. PMID- 10155403 TI - Patient-initiated refusals of prehospital care: ambulance call report documentation, patient outcome, and on-line medical command. AB - INTRODUCTION: There is a growing interest in cases in which emergency medical services (EMS) providers evaluate a patient, but do not transport the patient to a hospital. A subset of these cases, the patient-initiated refusal (PIR) in which the patient refused care and transport, was studied and evaluated. The objectives of the study were to examine the adequacy of ambulance call report documentation in PIR, to examine the clinical outcome of these patients in one hospital-based, suburban EMS system, and to assess the potential impact of on-line medical command (OLMC) on cases of PIR. METHODS: The system studied is a hospital-based, transport-capable, advanced life support service in a suburban EMS system, with an annual call volume of 4,200 runs. During the 6-month study period, all ambulance call reports completed by the paramedics and medical command control forms completed by medical command physicians were examined, and cases of PIR collected. Each ambulance call report was examined for adequacy of documentation. Patient outcome was determined from emergency department records and telephone follow-up. RESULTS: Eighty-five PIRs were documented during the study period. Four cases were excluded because of a missing ambulance call reports and/or medical command control forms, leaving 81 PIRs for analysis. Despite policy requiring OLMC in cases of PIR, OLMC was established in only 23 PIRs (28%). Of these, two (9%) had inadequate ambulance call report documentation. Of the 58 PIR in which OLMC was not established, 25 (43%) had inadequate ambulance call report documentation (p < 0.001, Fisher's exact test). Follow-up was obtained for 54 (67%) PIR. Of these, 37 (68%) did not subsequently see a physician, and all needed no further medical care. Seven (13%) saw their own physicians within a few days of the initial refusal of prehospital care, and had no further problems. Ten patients were seen in an emergency department within a few days. Three (6%) were discharged, and did well. Seven (13%) were admitted to the hospital, with four (7%) admitted to monitored beds, and three (6%) to unmonitored beds. There were no deaths. CONCLUSIONS: Ambulance call report documentation is better with OLMC than without. Patients who initially refuse care may be ill, and some ultimately will be hospitalized. Further research may elucidate a role for OLMC in preventing refusals by incompetent patients, convincing patients who are competent but appear ill to accept transport, and assisting paramedics with other difficult or unusual circumstances. PMID- 10155404 TI - Pedestrian intoxication and fatal traffic accident injury patterns. AB - INTRODUCTION: Sixteen percent of all motor-vehicle fatalities are pedestrian, and accidents involving pedestrians are associated with the highest morbidity and mortality rates. Classic pedestrian injury patterns have been described. However, it has been suggested that the pattern may differ if the pedestrian is intoxicated. The role of pedestrian intoxication on motor-vehicle accident injury patterns has not been well-delineated. HYPOTHESIS: Intoxicated pedestrian traffic victims have an injury pattern that is more serious and more rapidly fatal than is the pattern for nondrinking victims. METHODS: Autopsies of 223 consecutive pedestrian victims were reviewed and grouped according to the presence of alcohol in the blood: Group I, Negative (n = 165); Group II, Positive (n = 58). Gender, age, anatomic injuries, survival time, time of day, and year also were examined. RESULTS: Results indicated that there were more males in Group II (79%) than in Group I (64%); younger victims, younger than 40 years old, in Group II (70%) than in Group I (34%); fewer victims older than 60 years old in Group II (8%) than in Group I (38%). Group II sustained more frequent and more severe injuries--two times the frequency of the cervical spine, liver, upper and lower extremity, pelvic and rib fractures and thoracolumbar spine injuries; three times more aortic injuries; five times more heart injuries. Death occurred within 24 hours in 95% of those in Group II and in 67% of those in Group I. Accidents occurred from 1500h to 2300h in 67% of Group II and in 53% of Group I victims. CONCLUSION: Intoxicated pedestrian accident victims are predominantly young men, struck between 1500h and 0700h; they have an injury pattern that is two to five times more serious than is the pattern for the sober victims. PMID- 10155405 TI - Complex, humanitarian emergencies: I. Concept and participants. AB - Complex, humanitarian emergencies, the result of civil strife and armed conflict affecting large populations at the brink of extinction, represent the most compelling of disaster relief challenges. They require the coordination of the United Nations agencies, the International Committee of the Red Cross, international nongovernmental relief organizations, and military forces. An increasing number of civilian and military health-care providers find themselves involved in the planning, coordination, and direct patient-care aspects of these emergencies, often without proper initiation and understanding of the unique nature of these disasters. This article provides a primer on the concept of complex, humanitarian emergencies and the contributions, characteristics, capabilities, and limitations of each major participant. PMID- 10155406 TI - Complex, humanitarian emergencies: II. Medical liaison and training. AB - In complex, humanitarian emergencies, professional liaison roles are just one of many that evolve from the coordination of United Nations agencies, the International Committee of the Red Cross, international and national non governmental relief organizations, and coalition military forces. Liaison is crucial to the humanitarian relief process. Decision makers benefit from liaisons' professional experience, their knowledge of the characteristics, missions, and capabilities of each major participant in the relief process, and in their ability to coordinate and clarify professional issues in meeting the goals of a mission. Medical liaison roles develop from the awareness that complex emergencies primarily are catastrophic public-health emergencies. Unfortunately, education and training of the medical liaison currently are ill-defined. However, limited experience suggests that skills should be broadly based in principles of disaster epidemiology, assessment and management, knowledge of contributing relief resources, agencies and the military, and international humanitarian law and the Geneva Conventions. PMID- 10155407 TI - Complex, humanitarian emergencies: III. Measures of effectiveness. AB - Complex humanitarian emergencies lack a mechanism to coordinate, communicate, assess, and evaluate response and outcome for the major participants (United Nations, International Committee of the Red Cross, non-governmental organizations and military forces). Success in these emergencies will depend on the ability to accomplish agreed upon measures of effectiveness (MOEs). A recent civil-military humanitarian exercise demonstrated the ability of participants to develop consensus-driven MOEs. These MOEs combined security measures utilized by the military with humanitarian indicators recognized by relief organizations. Measures of effectiveness have the potential to be a unifying disaster management tool and a partial solution to the communication and coordination problems inherent in these complex emergencies. PMID- 10155408 TI - The use of intraperitoneal infusion for the outpatient treatment of hypovolemia in Somalia. AB - INTRODUCTION: The civil war in Somalia has destroyed the medical system and left hundreds of thousands of people without access to medical care. Samaritan's Purse and World Medical Missions, two relief organizations, developed mobile medical teams to provide health care to urban and rural Somalia. Gastroenteritis with severe dehydration was encountered frequently, and difficult intravenous (i.v.) access presented a challenging dilemma for patients who were unable to tolerate oral or nasogastric fluid administration. HYPOTHESIS: Intraperitoneal (i.p.) fluid infusion may be used to treat dehydration in patients with poor venous access and ongoing fluid losses. METHODS: Two mobile medical teams treated patients from 1 January to 1 April 1993. Intraperitoneal fluid infusions were given to 16 patients with severe dehydration in whom i.v. access was unobtainable. Children received approximately 80 ml/kg of 0.45% normal saline, and adults received 40 ml/kg of 0.9% normal saline. Patients were reexamined at one and seven days. RESULTS: A total of 25,659 patients were seen in the mobile medical clinics during a 3-month period. Dehydration was diagnosed in 1,833 (7.1%) patients, and 1,203 (4.7%) patients were found to be malnourished. Sixteen patients were treated with i.p. fluid infusions, 14 patients (87.5%) survived, and two patients (12.5%) died, both within 24 hours. In one patient (6.3%), subcutaneous infiltration occurred without subsequent adverse effects. CONCLUSION: This case series found that in the mobile clinic setting in Somalia, i.p. fluid administration improved the hydration status in patients with significant dehydration. Although i.v. infusion remains the treatment of choice when oral or nasogastric fluid administration is not possible, i.p. infusion is easily performed and may be an important alternative in disaster settings. PMID- 10155409 TI - Successful resuscitation of a child with severe hypothermia after cardiac arrest of 88 minutes. AB - A 4-year-old boy broke through the ice of a frozen lake and drowned. The boy was extricated from the icy water by a rescue helicopter that was dispatched shortly after the incident. Although the boy was severely hypothermic, no cardiac response could be induced with field resuscitation measures, including intubation, ventilation, suction, and cardiopulmonary resuscitation. On admission, the primary findings included fixed, nonreacting pupils and asystole. The first core temperature measured was 19.8 degrees C (67.6 degrees F). During active, external warming, the first ventricular beats were observed 20 minutes after admission, and changed 10 minutes later to a sinus rhythm. Continuous monitoring included repeated arterial blood gas and electrolyte tests; prophylaxis for cerebral edema was performed with hyperventilation and administration of sodium Brevimytal and dexamethasone. Seventy minutes after admission, hemodynamics stabilized and the boy was transferred to the pediatric intensive care unit (PICU), where active external warming was continued to raise the core temperature at a rate of 1 degree C/hour. Adult respiratory distress syndrome developed, and the boy had to be ventilated in the PICU for 10 days. He was discharged home after another two weeks. He recovered fully. The rapid heat loss with the induction of severe hypothermia (< 20 degrees C; 68 degrees F) was the main reason for survival in this rare event of a patient with cardiac arrest lasting 88 minutes after accidental hypothermia. PMID- 10155410 TI - Natural hazards: causes and effects. Lesson 3--tsunamis. PMID- 10155411 TI - Assessment of pulmonary mechanics and gastric inflation pressure during mask ventilation. AB - INTRODUCTION: Mask ventilation is a procedure routinely used in emergency medicine. Potential hazards are inadequate alveolar ventilation and inflation of the stomach with air, leading to subsequent regurgitation and aspiration. The aim of this study was to measure lung function and gastric inflation pressures during mask ventilation. METHODS: For this purpose, 31 patients scheduled for routine urological procedures were studied during induction of anesthesia. Lung function was assessed by recording respiratory flow and pressure directly at the face mask. Gastric inflation was observed with a microphone taped to the epigastric area. RESULTS: Gastric inflation occurred in 22 of the 31 patients. Mean gastric inflation pressure was 27.5 +/- 6.55 cm H2O, mean compliance was 67 +/- 24.1 ml/cm H2O, mean resistance was 17.4 +/- 6.41 cm H2O/L/sec, and the mean respiratory time constant was 1.1 +/- 0.26 seconds. CONCLUSIONS: These data suggest that inspiratory pressure be limited to 20 cm H2O, and that an inspiratory time of at least four times the respiratory time constant be allowed. Monitoring airway pressure and gastric inflation is a simple technique that may improve the safe-ty of patients during mask ventilation. PMID- 10155412 TI - Paramedic field instructors: an approach to training the newest paramedics while maintaining the interest of the most successful senior paramedics. AB - A unique approach to providing orientation and supervised field experience for newly graduated paramedics and for the continuing education and recognition of experienced, skilled, operational paramedics is described. A group of 30 paramedic field instructors (PFI) was selected following application, development of criteria for selection, and interviews. This program had a positive effect in both realms during its first year of operation in the emergency medical services system in which it was implemented. PMID- 10155413 TI - Emergency medical care in the athletes' village: World University Games 1993. AB - OBJECTIVE: Little information exists concerning special medical needs at the athletes' residence (as distinct from the sport venues) at major international sporting events. During the summer of 1993, Buffalo, New York became the first city in the United States to host the World University Games. Approximately 6,000 athletes and accompanying staff from 118 countries attended. This report seeks to characterize emergency medical care use and the degree of language difficulty encountered at the athletes' village medical center (AVMC) set up at the athletes' residence for this event. METHODS: Demographic data were collected prospectively for each athlete or staff member housed in the athletes' village who presented to AVMC for medical evaluation rather than being cared for by a team physician or at one of the venues. Difficulty in medical treatment secondary to language differences was assessed by the treating physician on a scale of 0-3. RESULTS: Over the 14 days that the AVMC was in operation, for 24 hours a day, a total of 362 athletes (mean age: 22.9 +/- 2.9 years, 257 males, 105 females) and 149 accompanying staff (mean age: 39.8 +/- 11.6 years, 110 males, 39 females) were treated. More than 90% of the patients were seen between the hours of 0800 and 2400. A broad spectrum of minor medical problems occurred, with musculoskeletal injuries accounting for most of the visits for both athletes (54%) and staff (27%). Nonsteroidal anti-inflammatory agents and oral antibiotics were the most commonly prescribed medications. On-site radiographic facilities were used for 22% of the athletes and 11% of the staff treated. The majority of patients (92% of athletes, 91% of staff) were discharged from the AVMC. Four of the 12 patients that were transferred to a hospital-based emergency department were admitted to the hospital. Language problems, as assessed by the treating physician, were mostly minor; 25% of the patients had accompanying interpreters. One volunteer physician, and two to three nurses adequately staffed each shift. CONCLUSION: The AVMC provided medical care for a large variety of medical problems that could be treated on-site without transfer to a higher-level facility, thereby providing directed medical care for this special population in a secure environment. Language differences were perceived as a minor problem. This report should be valuable in the planning of medical care at the athletes' residences for similarly large sporting events. PMID- 10155414 TI - Mobile medical relief and military assistance in Somalia. AB - INTRODUCTION: Mobile medical clinics were established by an international medical relief organization to provide health care to victims of the war in Somalia. The study's purpose was to examine the prevalence of diseases seen and the effectiveness of mobile medical clinics, and to evaluate military support in security and care provisions. METHODS: This is a descriptive case series conducted over a 6-month period. Physicians determined clinical diagnoses, and clinic personnel assigned security scores (one to five) based on: 1) crowd control; 2) the incidence of looting; and 3) threats of violence by individuals demanding treatment. SETTING: Mobile medical teams that provided health care to regions in urban and rural Somalia assisted by United States and Italian military forces. PARTICIPANTS: At 149 mobile clinics, 25,265 patients were treated. INTERVENTIONS: Medical treatment included dispensing medications, intravenous rehydration, and minor surgical procedures. The effectiveness of security measures was scored based on: 1) effective crowd control; 2) the lack of theft or threats of violence; and 3) the unimpaired operation of the clinic. RESULTS: Medical teams treated 25,265 patients. The most common medical problems encountered were skin infections (19.5%), upper and lower respiratory tract infections (16.1%), and gastroenteritis with dehydration (7.1%). Malnutrition was seen in 4.7% of cases, and trauma accounted for only 0.7% of complaints. When military escorts were provided, the mean security score was 43% higher (4.85 +/- 0.46) as compared to the absence of a military escort (3.40 +/- 0.60) (p < 0.001). CONCLUSIONS: Mobile medical clinics were found to be effective in this setting despite difficult conditions, limited therapeutic modalities, and few in patient facilities. Infectious diseases were most common, while malnutrition and trauma were less commonly seen. The cooperation of United States and Italian military forces facilitated relief efforts by maintaining security, particularly in unstable areas. PMID- 10155415 TI - Can correct closed-chest compressions be performed during prehospital transport? AB - INTRODUCTION: The resuscitation rate from out-of-hospital cardiac arrest is low. There are many factors to be considered as contributing to this phenomenon. One factor not previously considered is the impact of a moving ambulance environment on the ability to perform closed-chest compressions. HYPOTHESIS: Proper closed chest compressions can be performed in a moving ambulance. METHODS: A cardiopulmonary resuscitation (CPR) training mannequin with an attached skill meter (Skillmeter ResusciAnnie, Laerdal, Armonk, N.Y., USA) that measures each chest compression for proper depth and hand placement was used. Ten emergency medical technician-basic (EMT-B) certified prehospital providers were assigned into one of five teams. Each team performed a total of four sessions of five minutes of continuous closed-chest compressions on the mannequin. Two sessions were done by each team: one in the control environment with the mannequin placed on the floor, and the other in the experimental environment with the mannequin placed in the back of a moving ambulance. The ambulance was operated without warning lights and siren, and all traffic rules were obeyed. The percentage of correct closed-chest compressions was recorded for each session, and the mean values were compared using Student's t-test with alpha set at 0.01 for statistical significance. RESULTS: Ten sessions of compressions were done in both environments. The mean percentage of correct compressions was 77.6 +/- 15.6 for the control group and 45.6 +/- 18.3 for the ambulance group (p = 0.0005). CONCLUSION: A moving ambulance environment appears to impair the ability to perform closed-chest compressions. PMID- 10155416 TI - Natural hazards: causes and effects. Lesson 4--Volcanoes. PMID- 10155417 TI - Cardiopulmonary resuscitation. PMID- 10155418 TI - Putting it together: a model for integrating injury control system elements. PMID- 10155419 TI - Liability immunity as a legal defense for recent emergency medical services system litigation. AB - BACKGROUND: Although many emergency medical services (EMS) providers are concerned about liability litigation, no comprehensive, national studies of EMS appelate cases have been published. Information about these cases and the use of liability immunity (sovereign immunity, emergency medical care immunity, or Good Samaritan immunity) as a defense could be used for EMS risk management and better patient care. OBJECTIVE: To review recent EMS system civil litigation cases to determine their common characteristics and the number that used liability immunity as a legal defense. METHODS: An observational study of the WESTLAW computerized database of legal cases from all state and federal appellate courts. All legal cases that named a member of the EMS system as a defendant, involved either a patient-care incident or ambulance collision, and received an appellate court opinion from 1987 through 1992, were studied. RESULTS: Eighty-six cases were identified and analyzed. Most cases (85%) were related to a patient-care incident, and 71% of the cases involved a death or significant physical injury. More than 49% of the patient cases alleged inadequate assessment or treatment, and 27% alleged delay in ambulance arrival or no ambulance arrival. There were 11 cases (15%) that alleged no transport of the patient to the hospital. Liability immunity was used as a defense in 53% of the cases. The appellate courts ruled in favor of 68% of the defendants that did not use an immunity defense and in favor of 72% of those that did use liability immunity. CONCLUSION: There have been a large number of recent appellate cases involving EMS systems. The common characteristics of many of these cases demonstrate the need for providing rapid ambulance arrival, proper assessment and treatment, and rapid patient transportation to a hospital. Although liability immunity was used as a legal defense by most EMS system defendants, the appellate court outcome was similar regardless of its use. PMID- 10155420 TI - Sources of disagreement among public and private agency paramedics. AB - INTRODUCTION: The purpose of the study was to document the occurrence and causes of disagreements between paramedics in a tiered-response emergency medical services (EMS) system. METHODS. This cohort analysis of disagreements between paramedics sampled 63 male public agency, 90 male private agency, and 41 female private agency paramedics. Paramedics responded to Likert-type items and one open ended item concerning the occurrence of conflict between paramedics. RESULTS: On scene conflict between EMS personnel from public and private agencies was reported by 70% of the respondents. Conflicts that interfered with patient care were reported to occur more frequently between paramedics from different types of agencies. The most commonly mentioned subject of disagreement was patient treatment, followed by patient transport, interpersonal and interagency conflicts, and patient assessment. CONCLUSION: A majority of paramedics have experienced on-scene disagreements with other paramedics. Disagreements occur more frequently between paramedics from different agencies and encompass a wide range of issues concerning patient care and interpersonal relationships. PMID- 10155421 TI - To report or not to report: emergency services response to elder abuse. AB - PURPOSE: Prehospital emergency medical services (EMS) personnel, as initial responders to calls for assistance, are in an ideal position to identify abused or neglected elderly. A survey of prehospital personnel in Michigan was conducted to determine the scope of this problem, levels of awareness, and willingness to report cases of elder abuse. METHODS: The study population was a random sample of 500 prehospital personnel throughout one state. A blinded, self-administered survey was completed by emergency medical technicians (EMTs) and paramedics outlining their practice characteristics, prevalence of abuse in their community, and training available specific to elder abuse. Attitudes concerning the understanding and reporting of geriatric abuse were measured using a Likert-type scale. RESULTS: A total of 156 surveys (31%) was completed; 68% of the respondents were paramedics. Respondents had an average of 8.7 years (range: 9 months-30 years) of prehospital emergency-care experience, and evaluated an average of 11 patients (range: 1-59) older than 65 years of age each week. Seventy-eight percent had seen a suspected case of elder abuse or negligence during their careers; 68% had seen a case during the past 12 months (mean: 2.3 cases/yr; range: 0-24 cases/yr). However, surveyed personnel reported only 27% of suspected cases to authorities last year (mean: 0.62 cases/yr). Reasons for not reporting included 1) unsure which authorities take reports; 2) unclear definitions; 3) unaware of mandatory reporting laws; and 4) lack of anonymity. Ninety-five percent of respondents stated that training related to elder abuse was not available through their EMS agency. CONCLUSION: Paramedics and EMTs lack complete understanding of their role in the identification and reporting of elder abuse. This information should be emphasized during EMS training and reinforced through continuing education. PMID- 10155422 TI - A comparative analysis of the emergency medical services and rescue responses to eight airliner crashes in the United States, 1987-1991. AB - INTRODUCTION: Crashes involving commercial airliners stress emergency medical services (EMS) and rescue operations to performance far in excess of everyday activities, and special adaptations of everyday responses need to be implemented. Fortunately, these events are infrequent and usually do not occur more than once in any location. The responses that occur must be highly coordinated and efficient. Little is known about the responses to such events. This study examines the EMS and rescue responses associated with eight recent crashes involving commercial airliners in the United States. OBJECTIVE: To identify common factors for which alterations in responses may enhance the survival and decrease the morbidity to victims involved in commercial aviation crashes. STUDY POPULATION: Eight commercial airliner crashes in the United States from 1987 through 1991. METHODS: Case review using: 1) press and media accounts; 2) U.S. National Transportation and Safety Board testimony and reports; and 3) structured interviews with airport, fire, EMS, and hospital personnel. Data were collated and common factors identified for the cases. Findings are classified into: 1) conditions at the crash sites; 2) initial responses; 3) scene management; 4) scene status; 5) patient transport; 6) hospital responses; and 7) preplanning exercises. RESULTS: Common factors that impaired responses for which some remediation is possible include: 1) new methods for training including computerized simulations; 2) improvements in rescue-extrication equipment and supplies; 3) stored caches of EMS equipment and supplies at airports; 4) ambulance transport capabilities; and 5) augmentation of patient transport capabilities. CONCLUSIONS: Many lessons can be learned through structured studies of commercial aircraft crashes. These findings suggest that simple and relatively inexpensive modifications may enhance all levels of emergency responses to such events. PMID- 10155423 TI - Post-disaster malaria in Costa Rica. AB - INTRODUCTION: In recent years, controversy has surrounded the issue of whether infectious disease should be considered a serious potential consequence of natural disasters. This article contributes to this debate with evidence of a significant outbreak of malaria in Costa Rica's Atlantic region after the 1991 earthquake and subsequent floods. METHODS: This study is an epidemiologic investigation of the incidence of malaria for the periods of 22 months before the April 1991 Limon earthquake and for 13 months afterward. Data were obtained from the Costa Rican Ministry of Health's malaria control program. RESULTS: Some of the cantons in the region experienced increases in the incidence of malaria as high as 1,600% and 4,700% above the average monthly rate for the preearthquake period (p < or = 0.01). Causal mechanisms are postulated as relating to changes in human behavior (increased exposure to mosquitoes while sleeping outside, and a temporary pause in malaria control activities), changes in the habitat that were beneficial to mosquito breeding (landslide deforestation, river damming, and rerouting), and the floods of August 1991. CONCLUSIONS: It is recommended that there be enhanced awareness of the potential consequences of disaster-wrought environmental changes. Date of Event: 22 April 1991; Type: Earthquake, 7.4 Richter scale; LOCATION: Costa Rica; Number of deaths and casualties: 54 deaths and 505 moderate to severe injuries. PMID- 10155424 TI - The impact of variation in trauma care times: urban versus rural. AB - STUDY OBJECTIVES: To document the existence and nature of variation in times to trauma care between urban and rural locations; to assess the impact of identified variations on outcome. DESIGN: Retrospective case review. SETTING: Washington state, 1986. PARTICIPANTS: Motor-vehicle-collision fatalities. METHODS: Previously unreported definitions of urban and rural location and possibly preventable death were used to conduct a comparative analysis of urban and rural fatalities. Trauma care times in the prehospital and the emergency department (ED) phases of care were abstracted. Their relationships to corresponding crude death rates and possibly preventable death rates also were examined. RESULTS: Prehospital times averaged two times longer in rural locations than in urban areas. Fist-physician contact in the ED averaged six times longer in rural locations than in urban settings. Concomitantly, the crude death rate in rural settings was three times that of the urban areas. The overall possibly preventable death rate was double the urban rates in rural incidents. When stratified by phase of care, rate of possibly preventable death showed no urban/rural variation for the prehospital phase, but was three times greater for the ED phase in rural areas than in urban ones. CONCLUSIONS: Trauma care times and adverse outcome appear to be associated. Allocation of resources to decrease length of and geographic variation in time to definitive care, particularly in the ED phase, seems appropriate. PMID- 10155425 TI - Spirituality of EMTs: a study of the spiritual nature of EMS workers and its effects on perceived happiness and prayers for patients. AB - INTRODUCTION: There is reason to believe that traumatic events experienced on the job make emergency medical services (EMS) workers more skeptical about their spiritual beliefs. Little is known about the spiritual lives and experiences of emergency medical technicians (EMTs). No studies have measured the responses of EMTs to the spiritual needs of their patients. PURPOSE: This study investigates whether EMS workers are less spiritual than the average U.S. citizen, and what effect this has on prayer for patients and perceived happiness. METHODS: Data were collected in a major metropolitan EMS system from 125 EMTs and paramedics through a questionnaire about their beliefs and behaviors regarding their spirituality. Pearson product-moment correlation coefficients (r) were used to analyze variables. The religious attitudes of EMTs were compared with those of the general population as defined in the Gallup studies. RESULTS: Ninety-one percent of the EMS workers interviewed and 94% of Gallup's sample of the general population said they believe in God. The findings on other measures in the EMT sample also were very similar to those defined in the general population. Of the EMTs, 60% said they never have doubted the existence of God. Eighty-four percent believe God still works miracles, and 80% of the EMTs believe in life after death. Eighty-seven percent of EMS workers pray; 62% pray for their patients, and 54% pray for their coworkers. Frequency of church or synagogue attendance is positively and significantly correlated with the degree of perceived life happiness (r = 0.226, p < 0.025 > 0.005). Frequency of prayer also is correlated positively to perceived life happiness (r = 0.182, p < 0.025 > 0.005). CONCLUSION: Emergency medical services workers are interested and willing to talk about their spiritual lives. They do have more doubts about the existence of God than does the average civilian, but are just as spiritual. Those EMTs with more active spiritual lives perceive themselves as happier. The majority of EMS workers pray for their patients. PMID- 10155426 TI - On-line medical direction: a prospective study. AB - OBJECTIVES: To determine the frequency with which physician, on-line medical direction (OLMD) [direct medical control] of prehospital care results in orders, to describe the nature of these orders, and to measure OLMD time intervals. METHODS: Blinded, prospective study. SETTING: A university hospital base-station resource center. PARTICIPANTS: Ten emergency physicians, 50 advanced life support providers. INTERVENTIONS: Prehospital treatment was directed by both standing orders and OLMD physician orders. Independent observers recorded event times and the characteristics of OLMD. RESULTS: Physician orders were given in 47 (19%) of the 245 study cases, and covered a variety of interventions, including many already authorized by standing orders. Mean OLMD radio time was four minutes (245 +/- 216 seconds [sec]), and time from beginning of OLMD to hospital arrival averaged 12 minutes (718 +/- 439 sec). Mean transport time in this system was 13 minutes. CONCLUSION: Despite detailed standing orders, OLMD results in orders for clinical interventions in 19% of cases. On-line medical direction requires about four minutes of physician time per call. This constituted about one-third of the potential field treatment time interval in this system. Thus, OLMD appears to play an important role in providing quality prehospital care. PMID- 10155427 TI - Patient-data collection system used during medical operations after the 1994 San Fernando Valley-Northridge earthquake. AB - INTRODUCTION: In large disasters, such as earthquakes and hurricanes, rapid, adequate, and documented medical care and distribution of patients are essential. METHODS: After a major (magnitude 6.7 Richter scale) earthquake occurred in Southern California, nine disaster medical assistance teams and two Veterans Administration (VA) buses with VA personnel responded to staff four medical stations, 19 disaster-assistance centers, and two mobile vans. All were under the supervision of the medical support unit (MSU) and its supervising officer. This article describes the patient-data collection system used. All facilities used the same patient-encounter forms, log sheets, and medical treatment forms. Copies of these records accompanied the patients during every transfer. Centers for Disease Control and Prevention data classifications were used routinely. The MSU collected these forms twice each day so that all facilities had access to updated patient flow information. RESULTS: Through the use of these methods, more than 11,000 victims were treated, transferred, and their cases tracked during a 12-day period. CONCLUSIONS: Use of this system by all federal responders to a major disaster area led to organized care for a large number of victims. Factors enhancing this care were the simplicity of the forms, the use of the forms by all federal responders, a central data collection point, and accessibility of the data at a known site available to all agencies every 12 hours. PMID- 10155428 TI - Hospital application of the incident management system. AB - The organization of hospitals during an external or internal disaster frequently is defined in the required disaster plan. However, the organizational structure is not uniform. This article describes the incident management system (IMS) established for the organization of out-of-hospital disaster responses and suggests a similar system for use in disaster management within hospitals. Adoption of the Hospital Incident Management System (HIMS) not only would provide a powerful framework for all hospital emergency responses, but it also would provide a necessary link to outside agencies. PMID- 10155429 TI - Mistaken identity: the effect of badges on EMT recognition. AB - INTRODUCTION: Many emergency medical services (EMS) providers wear badges with their uniforms. This study was undertaken to determine whether emergency medical technicians (EMTs) who wear badges with their uniforms are more likely to be mistaken for law enforcement personnel than are those who do not wear badges. HYPOTHESIS: Emergency medical services providers who wear badges are more likely to be mistaken for law enforcement personnel than are those who do not wear badges. METHODS: High school students, college students, civic organizations, and church groups were shown slides of different uniforms and badges/insignia and asked to identify the person portrayed. Responses were categorized as "EMS," "law enforcement," or "other." Frequency of responses for each uniform and insignia were compared with chi-square analysis. RESULTS: Fifty-nine percent of the uniforms with badges were identified as law enforcement personnel. Only 5.5% of the uniforms with badges were identified as "EMS," compared with 74% of the uniforms with a Star of Life (p < 0.001). CONCLUSION: Individuals wearing uniforms with badges are more likely to be identified as law enforcement personnel than are EMS personnel. Emergency medical services providers who do not wish to be mistaken for law enforcement personnel should wear the Star of Life, not a badge, with their uniform. PMID- 10155430 TI - Isolated intrathoracic injury with air bag use. AB - The restrained (air bag and seatbelt) driver of a vehicle involved in a high speed motor-vehicle accident sustained a tear of the thoracic aorta with no signs of external injury. Air bag deployment may mask significant internal injury, and a high index of suspicion is warranted in such situations. PMID- 10155431 TI - Natural hazards: causes and effects. Lesson 5--Tropical cyclones (hurricanes, typhoons, baguios, cordonazos, tainos). AB - The many conclusions drawn and lessons learned from past cyclones can be used to mitigate and better respond to future occurrences. Some of the most helpful are listed below: 1) Outbreaks of cholera do not follow cyclones. Cholera must be endemic previously to a community; 2) Waterborne diseases do not increase as a result of cyclones; 3) Massive food aid rarely is required after a cyclone; 4) Used clothing almost never is needed. It usually is culturally inappropriate. Though accepted by disaster victims, it almost never is worn; 5) Blankets can be useful, but if they are needed, they usually can be found locally and do not need to be imported; 6) Assistance by outsiders is most effective in the reconstruction period, not the emergency phase; 7) Most needs are met by the victims themselves or their local governments; 8) In general, victims do not respond to disasters with abnormal behavior. Cyclones do not incite panic, hysteria, or rioting; 9) Cyclone relief and reconstruction programs should be integrated with long-term development programs; 10) When properly executed, reconstruction assistance can provide a strong stimulus to recovery and a base for future development work; 11) Reconstruction programs should seek to reduce vulnerability to future disaster; 12) Re-establishment of the local economy, income security, and agriculture usually are more important to cyclone victims than is material assistance; and 13) Churches, schools, and other large buildings that often are designated as cyclone shelters usually are not safe. The number of deaths attributed to destroyed or flooded shelters is alarming. Most experts agree that the best alternative is adequate warning and evacuation of the threatened areas. PMID- 10155432 TI - On-site physicians and scene time. PMID- 10155433 TI - The good, the great, and the exciting. PMID- 10155434 TI - Disaster preparedness and response as primary health care. PMID- 10155435 TI - Comparison of prehospital cervical immobilization devices using video and electromyography. AB - INTRODUCTION: Previous evaluations of prehospital devices intended for spinal immobilization have focused on the device's ability to restrict motion only. This study defines six relevant criteria for evaluation of cervical immobilization device (CID) performance. OBJECTIVES: To suggest relevant criteria for evaluation and use available technology to improve measurements for performance testing of prehospital-care devices. METHODS: Six parameters (motion restriction, access, ease of application, environmental performance, radiolucency, and storage size) were used to evaluate three types of CIDs: Device A--a single-use corrugated board; Device B--a reusable foam-block CID; and Device C--hospital towels and adhesive tape. To test motion restriction, the most frequently compared parameters for immobilization devices, 20 volunteers were asked to move their heads and necks through a series of motions (flexion, extension, lateral bending, and rotation). Their movements were videotaped, still images of each movement were generated, and the degrees of deflection recorded from these still images. To ensure a consistent level of force, electromyography (EMG) of the sternoclydomastoid and extensor muscles was employed. RESULTS: Data were produced for each parameter and presented for comparison. The use of video to determine deflection proved to be a useful and highly accurate (+/- 1o) method for measurement. The use of EMG technology enabled force to be controlled indirectly when the subjects used moderate levels of exertion. Overall, Devices A and C restricted motion better than Device B. Although Device C required the shortest time for application, it took the longest to prepare for application. The total time required for preparation and application of A and B essentially were equivalent, with A requiring no preparation time but taking the longest for application, and B having an intermediate interval for application. Device A allowed for the best examination of the head and neck. No differences were detected in performance in extreme environmental conditions or in radiolucency for cervical spine X-ray examinations. Device A consumed the smallest storage volume, B the greatest storage volume, and C an intermediate volume substantially greater than that required for A. CONCLUSION: Device evaluation should include examination of all relevant performance parameters using the most accurate and meaningful methods possible. PMID- 10155436 TI - Paramedic diagnostic accuracy for patients complaining of chest pain or shortness of breath. AB - INTRODUCTION: A multitude of life-threatening and nonlife-threatening processes cause chest pain and shortness of breath. Prehospital therapy for these patients may be lifesaving and includes pharmacologic interventions, as well as invasive procedures. Appropriate therapy depends on the diagnostic skills of the paramedic. OBJECTIVE: This study was undertaken to determine the accuracy of the paramedic diagnosis in patients transported with a chief complaint of pain or shortness of breath. SETTING: Multihospital, one large municipal hospital, one community hospital. DESIGN: Prospective, cross-sectional study. Paramedics evaluated the patient and then completed a standard form indicating the diagnosis. The paramedic's and final emergency physician's diagnoses were compared to assess the accuracy of the paramedic diagnosis. POPULATION: All patients who complained of chest pain or shortness of breath, transported to the study centers by the city of Denver paramedics, were eligible for the study. Ninety-nine of the 102 patients enrolled had complete records for analysis and were entered into the study. RESULTS: Diagnostic concordance data were analyzed by organ system (e.g., cardiac, pulmonary, etc.) and for specific diagnoses using the kappa statistic and McNemar's chi-square analysis for discordant pairs. Using the kappa statistic, there was statistically significant concordance between the paramedic and emergency-physician diagnosis for cardiac (p = 0.0001; kappa value = 0.54) and pulmonary organ systems (p = 0.0001; kappa value = 0.61). Overall, for organ system diagnosis, the paramedics had an 82% accuracy (p = 0.05) rating. For specific cardiac and pulmonary diagnosis, paramedics had good concordance with emergency physicians. CONCLUSIONS: Overall, paramedics have excellent diagnostic agreement with emergency-physician diagnosis by organ system. They retained good agreement on specific cardiac diagnoses and pulmonary diagnosis. PMID- 10155437 TI - Using interactive videodisc to test advanced airway management skills. AB - PURPOSE: To evaluate the effectiveness of the Actronics Interactive Learning System to teach the psychomotor skills of advanced airway management compared to the traditional method of lecture/demonstration. METHODS: The study was a nonrandomized, nonequivalent comparison group design of a convenience sample of 86 American Heart Association (AHA), advanced cardiac life support (ACLS) students, who obtained instruction in airway management by the interactive videodisc (IVD) learning system (n = 41), or by the traditional method of demonstration/return demonstration (n = 45). The evaluation criteria for the students were based on the number of attempts required to perform successfully endotracheal (ET) intubation and esophageal obturator airway (EOA) insertion. RESULTS: No statistically significant differences in the performance of ET insertion between the IVD and the traditional method of instruction could be demonstrated. However, initial certifiers for ACLS learning EOA insertion by the IVD method had a treatment effect (p = 0.004) compared to ACLS students learning by the traditional method. This treatment effect was not noted with ET intubation and EOA insertion for students seeking recertification. In a post-test satisfaction questionnaire, 34 IVD students reported satisfaction with learning airway management using this instructional method, but also expressed a preference to have an ACLS instructor available. CONCLUSION: This study highlights the role of IVD in teaching the complex skills of advanced airway management. PMID- 10155438 TI - Factors influencing successful intubation in the prehospital setting. AB - OBJECTIVE: To explore the determinants influencing oral/nasal endotracheal intubation (OETI/NETI) and determine which cognitive, therapeutic, and technical interventions may assist prehospital airway management. DESIGN, SETTING, AND PARTICIPANTS: Prospective review of run reports and structured interviews of paramedics involved in OETI/NETI attempts were conducted in a high-volume, inner city, advanced life support (ALS) system during an eight-month period (July 1991 to February 1992). Data were abstracted from run reports, and paramedics were asked in structured interviews to describe difficulties in OETI/NETI attempts. RESULTS: Of 236 patients studied, 88% (208) were intubated successfully. Success/failure rate was not related statistically to patients' ages (p = 0.78), medical or trauma complaint (89% vs 85%, p = 0.35), oral versus nasal route (88% vs 85%, p = 0.38), care time (scene+transport times: success, 18 minutes; failure, 20 minutes, p = 0.30), paramedic seniority (p = 0.13), or number of attempts per paramedic (p > 0.05). Increased level of consciousness (LOC) was associated with decreased success rate (p = 0.04). Paramedics reported difficulties in endotracheal intubation (ETI) attempts in 110 (46.6%) of patients. Factors reported to increase ETI difficulty were: 1) technical problems (35.6%); 2) mechanical problems (15.6%); and 3) combative patients (12.7%). CONCLUSIONS: Oral endotracheal intubation and NETI success rates identified in this study are similar to those described in the literature, although innovative strategies could be used to facilitate prehospital airway management. Many of the factors found to increase ETI difficulty could be ameliorated by the administration of paralytic agents, that is, for combative patients. Focused training in cadaver and animal labs coupled with recurrence training in the operating suites should be used on a regular basis to decrease difficulties in visualization. Interventions directed at alleviating mechanical difficulties that should be explored include new-to-the-field techniques, such as retrograde intubation, fiber-optic technology, and surgical tracheal access. PMID- 10155439 TI - Hand injuries from snow blowers: a report of an epidemic. AB - During a record snowfall in Worcester, Massachusetts, 11-13 December 1992, 37 male patients with hand injuries suffered during snow blower operation were seen at three area hospitals. Two previous reports describe 13 patients seen over a 3 year period and 28 patients over a 12-year period. This report describes the largest number of hand injuries from snow blowers that have occurred over a 48 hour period. The snow was unusual because of the high water density in the initial 9 inches (23 cm) that fell at an average temperature of 33 degrees F (0.6 degree C) with the final depth of 30 inches (76 cm), causing the machines to become clogged. Patients admitted to reaching into a running machine in 35/37 (95%) cases, 11/37 (30%) claimed the auger and impeller blades were disengaged, and 2/37 (5%) patients claimed their injuries occurred with the engines turned off. All injuries occurred when the patients placed their hands down the chute, contacting the impeller blades. Injuries involved 32 long, 15 ring, 13 index, and five small fingers and ranged from simple lacerations to partial phalangeal amputations. The majority, 27/37 (73%), were managed in emergency departments without interventions in the operating suites. Infection occurred in one patient who had the lesion repaired in the operating suite. As in previous studies, no differences were found for the variables of snow-blower age, type, or horsepower, or on experience level or age of the operators.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155440 TI - Survey of medical services at major league baseball stadiums. AB - OBJECTIVE: To analyze the availability and level of medical services for fans at major league baseball games in the United States. METHODS: A 10-item questionnaire was sent to the operations managers of each of 28 major league baseball stadiums. The survey was distributed in cooperation with a major league baseball club. Telephone follow-up was used to complete missing responses. The survey addressed five areas of fan medical services: 1) health-care provider availability and compensation; 2) advanced cardiac life support (ACLS) capabilities, including equipment; 3) presence of on-site ambulance(s); 4) fan fatalities; and 5) alcohol consumption limitations. RESULTS: Survey response was 100%. Healthcare providers are on-site at all stadiums: nurses (86%), physicians (75%), emergency medical technicians (EMTs, [68%]), and paramedics (50%). Ninety six percent use a combination of health-care providers. The most common medical teams are nurse+EMT+physician (25%) and nurse+EMT+paramedic+physician (18%). All health-care providers receive some form of compensation. All stadiums have at least one ACLS-certified provider; 96% have ACLS equipment. Ambulances are on site 75% of the time. Sixty-eight percent of the clubs reported at least one fan fatality through the 1992 and 1993 seasons (mean 1.1, range 0-4). All clubs limit alcohol consumption; 96% use multiple approaches. The various approaches include: 1) specific inning discontinuation (86%); 2) maximum purchase (68%); 3) restricted sale locations (64%); and 4) crowd conduct (57%). Advertisement for responsible alcohol consumption is displayed at 75% of the stadiums; designated driver programs exist at 46%. CONCLUSIONS: All major league baseball clubs provide medical services for fans. Furthermore, almost all stadiums have ACLS capabilities. Responsible alcohol consumption also is a recognized priority for fan safety. PMID- 10155441 TI - Medical care at mass gatherings: considerations for physician involvement. AB - Although many authorities define a "mass gathering" as a group exceeding 1,000 persons, several times that number likely are to be present. The event for which the group will gather may be anything from a rock concert to an Olympic competition. Preparations for the event can be minor or major. This article reviews the issues that a physician should consider if he or she chooses to become involved in the delivery of medical care to such populations, as well as the evidence suggesting that a physician should be involved in most such gatherings. Emergency medical care at public gatherings is haphazard at best and dangerous at worst. There are surprisingly few data from which to plan the emergency medical needs for public events and no recognized standards or guidelines for providing emergency medical services at mass public gatherings. PMID- 10155443 TI - Paramedic field instructors: an approach to training the newest paramedics while maintaining the interest of the most successful senior paramedics. PMID- 10155442 TI - Low-level carbon-monoxide poisoning: inability of neuropsychological testing to identify patients who benefit from hyperbaric oxygen therapy. AB - INTRODUCTION: Although major sequelae of carbon-monoxide (CO) poisoning and its treatment with hyperbaric oxygen (HBO) are well-documented, a syndrome of low level CO poisoning has received relatively little attention. Subtle symptoms of poor concentration, language difficulty, problems with calculations, and memory loss were noted after an acute exposure of 131 dormitory residents to low levels of CO. The CO Neuropsychological Screening Battery (CONSB), a series of tests reported by others as useful to identify victims of CO poisoning, was performed on a subset of 46 victims. It was hypothesized that their test scores would improve after treatment with HBO. METHODS: Testing was performed both before and after HBO on 35 CO-exposed victims. A control group of 20 students residing on the same college campus, but not involved with the CO incident, also were tested on two separate occasions to assess the ability of the test to identify selectively victims of low-level CO poisoning, as well as to evaluate its validity when administered serially. RESULTS: Both CO-exposed and control subjects demonstrated significant performance improvement when completing the testing for the second time. In addition, the baseline test scores were not significantly different for either the CO-exposed or the control groups. Nonetheless, all CO-exposed victims reported immediate subjective improvement of their symptoms after HBO therapy. CONCLUSION: These observations and a review of the literature suggest that there might exist a syndrome of subtle neurological disturbances in victims of low-level CO poisoning. Whether this is permanent or might regress spontaneously over time is unknown. As a diagnostic adjunct, the CONSB does not appear to be as useful in low-level CO poisoning. PMID- 10155444 TI - Successful resuscitation of a child with severe hypothermia after cardiac arrest. PMID- 10155445 TI - Performance of chest compressions during prehospital transport. PMID- 10155446 TI - Assessment of pulmonary mechanics and gastric inflation pressure during mask ventilation. PMID- 10155447 TI - Philosophy of prehospital advanced trauma life support by well-trained emergency physicians is preferred. PMID- 10155448 TI - Natural hazards: causes and effects. Lesson 6--Floods. PMID- 10155449 TI - Utstein, Kaiser, and Scrooge. PMID- 10155450 TI - Guidelines for the use of guidelines. PMID- 10155451 TI - The prehospital use of nitroglycerin according to standing medical orders in an urban EMS system. AB - PURPOSE: The purposes of this study are to quantify the use of nitroglycerin (NTG) in prehospital care, to detect deviations from the Standing Medical Orders (SMO), to determine the effectiveness of its administration, and the incidence of clinically significant adverse reactions (hypotension, bradycardia). METHOD: Retrospective review of 7683 Advanced Life Support (ALS) telemetry, base-station contacts over a three month period (June, July, August 1990) to identify all prehospital patient contacts in which NTG was utilized. SETTING: The Resource Hospital/Telemetry Base-Station and two community hospitals/Telemetry Base Stations for the Chicago North EMS System. RESULTS: There were 445 runs in which NTG was indicated as per SMO. Two hundred eighty-eight patients (64.7%) received NTG for appropriate indications as per SMO, 203 for ischemic chest pain (45.6%), 79 for pulmonary edema (17.7%), and six for both (1.3%). There were 157 (35.5%) runs in which NTG was indicated, but not administered. There were 22 patients who received NTG for indications that deviated from the SMO. Reassessment data concerning the subjective symptom was completed on 118 patients (40.9%), 92 (45.3%) patients with chest pain and 26 with dyspnea (32.9%). Following the administration of NTG, 21 patients (10.1%) with chest pain were unchanged, while 13 with dyspnea (15.3%) improved, 13 patients (15.3%) were unchanged, and none worsened. In 121 patients, the systolic blood pressure (SBP) decreased, while 24 were unchanged (5.4%), and 28 had an increase (6.3%). The mean initial value SBP was 176 +/- 44 mmHg and the repeat mean SBP was 164 +/- 41 mmHg with a mean decrease of 12 +/- 22 mmHg. The diastolic blood pressure (DBP) decreased in 87 patients, was unchanged in 53 (11.9%), and increased in 33 (7.4%). The initial mean DBP was 97 +/- 24 mmHg, the repeat mean DBP was 92 +/- 23 mmHg, a mean decrease of 5 +/- 15 mmHg. Only one patient became hypotensive with the administration of NTG and was successfully resuscitated with a fluid bolus of 300 ml normal saline. CONCLUSIONS: In this EMS system, NTG is under-utilized based on the indications delineated by this system's SMOs. Reassessment is documented infrequently, but when completed, clinically significant adverse reactions are rare. Since the incidence of hypotension and bradycardia are rare, the inability to establish an IV line should not preclude the administration of NTG. PMID- 10155452 TI - The non-use of 9-1-1. Private transport of trauma patients to a trauma center. AB - HYPOTHESIS: Privately transported, major trauma patients made up approximately 4% of the total trauma patients population at a major, regional trauma center which treats over 90% of all major trauma victims in the geographic area. This study was undertaken to evaluate the patient profile of those individuals who did not access 9-1-1 for transport to a trauma center, including their reasons for such non-use. METHODS: Data on all major trauma occurring within Dade County, Florida, were collected by the county trauma registry. RESULTS: In the last six months of 1989, 1,672 patients were entered into the trauma registry. One-thousand-six hundred-thirteen (1,613) were transported by professional ground or air services, 59 by private vehicle. For those patients transported directly from the Emergency Department to the Operating Room, only 35% of private vehicle patients entered surgery within 90 minutes of presentation compared to 57% of those who gained access to the 9-1-1 system and used emergency medical services (EMS). One-half of those patients who did not use 9-1-1 did not have telephone access. Patient acuity was similar for those transported by private vehicle compared to those transported by basic or advanced life support units. Private vehicle transport often delayed patient triage and assessment. Thus, for a number of lower income patients, 9-1-1 access was difficult. CONCLUSION: Underestimation of the severity of the injury or fear of delay in rescue response were prominent reasons for non use of 9-1-1. While educational efforts should concentrate on decreasing inappropriate 9-1-1 use for non-emergencies, the causes of underutilization should not be ignored. PMID- 10155453 TI - The prevalence of occupational injuries in EMTs in New England. AB - OBJECTIVE: To characterize the prevalence and morbidity of injuries to emergency medical technicians EMTs) in New England [United States]. DESIGN: A survey was mailed to a 2% random sample of all registered EMTs in the six New England States. The identity of the EMTs remained anonymous, and a second mailing was used to improve return rate. The EMTs were requested to recall events that occurred during the previous six months. RESULTS: A total of 439 of the 786 (56%) surveys were returned representing 13,875 hours of duty time in the six-month period. Seventy-one percent of the EMTs were male with a mean age of 35 years. Sixty-six percent were basic-EMTs. Injury attack rates (number of injuries/100 EMTs/6 months) were: stress, 11.2; back, 10.5; extremity, 9.8; assault, 8.4; ambulance collision, 4.1; hearing loss, 2.5; and eye injury, 1.4. Twelve percent of the EMTs were injured more than once in the six-month period. The paramedics more frequently were involved in ambulance collisions, suffered from stress, and were less likely to injure their back. There were minor interstate differences. Disability due to back injury affected 2.5% of those surveyed, four EMTs lost duty time secondary to an assault, and 0.5% of the EMTs were out of work due to stress. CONCLUSIONS: This survey begins to characterize the occupational risks of EMTs. The prevalence of back injuries, assault, stress, and extremity injuries seems to be too high. Educational programs and preventive interventions should be designed to minimize back injuries, stress, and assault. There is a need for more research nationwide in order to better characterize these injuries. PMID- 10155454 TI - Do-not-resuscitate orders. Where are they in the prehospital setting? AB - Without a well-functioning, prehospital, do-not-resuscitate (DNR) system in place, emergency medical service (EMS) providers must resuscitate all patients who access the system, regardless of the patients' wishes and regardless of what makes ethical or economic sense. In lieu of valid documentation, it is not appropriate to withhold resuscitative measures in this critical, time-dependent situation. In order to help EMS systems implement functional prehospital DNR protocols, this paper reviews the state-of-the-art of prehospital DNR including the issues to consider when designing such a system and a discussion of the features of some of the existing systems. This review includes: 1) the basis and requirements of a DNR system; 2) legal and physical forms for DNR orders; 3) eligibility for DNR status; 4) reversal of DNR orders; and 5) inappropriate use of EMS systems for DNR patients. Finally, a more general discussion of overall resource utilization in prehospital resuscitations is presented to emphasize that implementing prehospital DNR systems is only one piece of a larger issue. PMID- 10155455 TI - Reporting of child abuse by prehospital personnel. AB - INTRODUCTION: Prehospital (EMS) personnel routinely enter patient's homes and often are the first trained persons to evaluate an ill or injured child. Therefore, it is vital for these individuals to recognize child abuse (CA), and to understand the proper procedures for reporting suspected cases. METHODS: A questionnaire was administered to prehospital care-givers participating in a seminar on pediatric emergencies. Questions were designed to test factual knowledge of CA and the correct reporting procedures, as well as to evaluate attitudes toward CA. RESULTS: There were 48 responses to the questionnaire; 34 (71%) were paramedics, the remainder were emergency medical technicians (EMTs) and/or registered nurses (RNs). Thirty-three (69%) practiced either in a rural or suburban setting. Subjects had an average of 10.8 years of prehospital emergency care experience. Twenty-eight (58%) reported no previous training in CA. All participants understood the nature of CA, were able to identify the various forms of CA, and believed CA to be a significant problem. However, 33 (69%) did not understand the legislation that mandates reporter status, and while 27 (56%) claimed to have reported CA, only 16 (33%) had made a report either to police or to children's services workers. Of the 21 who never had reported a case of CA, 14 (67%) believed that they never had encountered an abused child. The remainder were not certain, and therefore, did not report, or thought that the hospital staff would report. CONCLUSIONS: While this subject deserves further study, it seems that many EMTs and paramedics lack a complete understanding of their role in the identification and reporting of CA. This information should be emphasized further in EMT and paramedic education, and should be reinforced through continuing education. PMID- 10155456 TI - Pregraduate training in emergency medicine. AB - A panel session on undergraduate education in Emergency Medicine from a worldwide perspective was conducted at the Seventh World Congress of Emergency and Disaster Medicine in Montreal, in May, 1991. Desmond Colohan MD, of the University of Toronto (Canada) was the panel moderator. Panel speakers were: Louis Binder MD, Texas Tech University Health Services Center (USA); Wolfgang Dick MD, University of Mainz (Germany); Bernard Nemitz MD, Faculty de Medicine d'Ameins (France); Yoel Donchin MD, Hadassa Medical Organization (Israel); and Noriyoshi Ohashi MD, Tsukuba Medical Center (Japan). PMID- 10155457 TI - Use of selective decontamination in the prevention of infection after accidental irradiation. A review. AB - Exposure to radiation induces a reduction in the number of gastrointestinal, anaerobic bacterial flora, and an increase in the number of Enterobacteriaceae that are associated with sepsis and mortality. Antimicrobials that suppress anaerobic flora have a deleterious effect on survival by promoting earlier enterobacterial sepsis. In contrast, in studies of animals and immunosuppressed patients, antimicrobials that inhibit gram-negative enteric bacteria and preserve the anaerobic flora have shown a beneficial effect by preventing bacterial translocation and fatal sepsis. The quinolone antimicrobials hold potential for therapy of endogenous and exogenous infection after irradiation. PMID- 10155458 TI - Sources of occupational stress among firefighter/EMTs and firefighter/paramedics and correlations with job-related outcomes. AB - INTRODUCTION/OBJECTIVE: This paper reports the results of an initial effort to develop and test a measure of the various sources of job-related stress in firefighter and paramedic emergency service workers. METHODS: A 57-item paper and pencil measure of occupational stressors in firefighter/Emergency Medical Technicians (EMTs) and firefighter/paramedics was developed and administered by anonymous mail survey. RESULTS: More than 2,000 (50% rate of return) emergency service workers completed and returned the surveys. The responses of 1,730 firefighter/EMTs and 253 firefighter/paramedics were very similar in terms of the degree to which job stressors were bothersome. A factor analysis of replies yielded 14 statistically independent "Occupational Stressor" factors which together accounted for 66.3% of the instrument's variance. These Sources of Occupational Stress (SOOS) factor scale scores essentially did not correlate with a measure of the social desirability test-taking bias. Finally, SOOS factors were identified that correlated with job satisfaction and work-related morale of the respondents. Conflict with administration was the job stressor factor that most strongly correlated with reports of low job satisfaction and poor work morale in both study groups. CONCLUSION: The findings suggest that firefighter and paramedic job stress is very complicated and multi-faceted. Based on this preliminary investigation, the SOOS instrument appears to have adequate reliability and concurrent validity. PMID- 10155459 TI - Guidelines for rescue training of the lay public. AB - The fundamental goal of emergency medical response in disaster is to save lives and reduce injury and permanent disability. It has been observed that urgent emergency medical care of seriously injured earthquake casualties trapped under building rubble, cannot be provided unless the victims have been extricated and transported to medical facilities by friends or relatives, or are accessible to field rescue and medical teams. Equally important is the fact that extrication of seriously injured, trapped victims by laypersons is hazardous, unless the following conditions are met: 1) the rescuer has basic knowledge of extrication, and; 2) there is early application of effective life-supporting first-aid (LSFA) and/or advanced trauma life support (ATLS) at the scene. Time is the critical factor in such an effort. In previous studies of death and dying in earthquakes, it was noted that extrication of trapped victims will be attempted by survivors. Therefore, it is suggested that citizens living in regions of high seismic risk and trained in basic search and rescue and in LSFA are the most immediate resource for early response after an earthquake. An accompanying paper addresses the issue of citizen LSFA training. This paper focuses on the basic concepts of search and rescue training for the lay public. PMID- 10155460 TI - Recommendations for Life-Supporting First-Aid training of the lay public for disaster preparedness. AB - In catastrophic disasters such as major earthquakes in densely populated regions, effective Life-Supporting First-Aid (LSFA) and basic rescue can be administered to the injured by previously trained, uninjured survivors (co-victims). Administration of LSFA immediately after disaster strikes can add to the overall medical response and help to diminish the morbidity and mortality that result from these events. Widespread training of the lay public also may improve bystander responses in everyday emergencies. However, for this scheme to be effective, a significant percentage of the lay population must learn in eight basic steps of LSFA. These have been developed by the International Resuscitation Research Center in collaboration with the World Association for Emergency and Disaster Medicine, the City of Pittsburgh Department of Public Safety, and the American Red Cross (Pennsylvania chapter). They include: 1) scene survey; 2) airway control; 3) rescue breathing (mouth-to-mouth); 4) circulation (chest compressions; may be omitted for disasters, but should be retained for everyday bystander response); 5) abdominal thrusts for choking (may be omitted for disasters, but retained for everyday bystander response); 6) control of external bleeding; 7) positioning for shock; and 8) call for help. PMID- 10155461 TI - Therapeutic agents utilized in urban/rural prehospital care. AB - INTRODUCTION: Objectives of this study were to determine the number of prehospital emergency patients who were given advanced life support (ALS) drugs and to compare utilization rates for ALS drugs in urban and rural environments. Certified ALS emergency medical technicians (Arizona) have 29 therapeutic agents authorized for prehospital administration. These agents may be administered only under direction of a medical control authority or by following standing orders. METHODS: A retrospective review was made of prehospital emergency encounter records. They were acquired by the Arizona Office of Emergency Medical Services (OEMS) from rural EMS providers who used optically scannable forms and from a metropolitan fire department's medical emergency response records. RESULTS: In 1989 and 1990, 273,611 emergency patient encounter records were entered into the EMS database; 197,260 were urban responses and 76,351 were rural responses. Drugs (ALS) were administered to 16,730 (8.5%) urban emergency patients and to 5,359 (7%) rural emergency patients at the incident site or during transport to a medical care facility. Nitrostat, 0.4 mg sublingual tablet, was the drug most frequently administered to emergency patients in the prehospital setting. Utilization rates found in the urban and the rural data sets were consistent for the individual agents. Variations in use frequency between urban and rural setting were noted for some drugs. Of the 29 approved ALS drugs, seven (24%) were administered to 10% or more urban patients who received drugs. In the rural areas, eight (27.6%) were administered to 10% or more patients who received drugs. There were nine (31%) agents administered to less than 1% of all patients who received drugs. A majority of the approved drugs, 17 (59%) were administered at a rate below 5% of all patients receiving medications. CONCLUSION: Severity of illness or injury prompted administration of ALS drugs to 8.1% of patients receiving prehospital emergency care. The most frequently utilized medication in the urban/rural areas was for treatment of cardiac symptoms. Variations between urban/rural drug utilization reflected the drugs of choice which are compatible with long transport times to a medical facility. PMID- 10155462 TI - Physician integration into mass gathering medical care. The United States Air Show. AB - INTRODUCTION: Limited information exists concerning physician staffing at mass gathering events. METHODS: A retrospective review of the preparation, planning, and provision of medical care for the United States Air Show was performed. Patient encounters from the air show for the years 1981-1991 also were evaluated. RESULTS: The frequency rate of overall encounters was 8.45 patients/10,000 spectators and hospital transport rate was 0.6/10,000 spectators. The majority of complaints were related to heat or minor injuries. During this period, emergency physicians played a vital role in both medical planning and on-site staffing. Emergency medicine residents also participated. A small patient population received direct benefit from on-site physician intervention. CONCLUSION: The on site emergency physician is of benefit in event preplanning and reducing the burden on the EMS system during mass gathering events. PMID- 10155463 TI - After Hurricane Andrew. An EMS perspective. PMID- 10155464 TI - The role of health sectors in disaster preparedness. Floods in southeastern China, 1991. AB - Disasters, whether natural or man-made, usually are unpredictable. Efforts to reduce morbidity and mortality from a disaster should be put forth before it occurs. A brief survey is presented of the worst flood to occur in a hundred years that affected eight provinces in Southeast China. The disaster preparedness and response for Anhui Province, the hardest hit area, is summarized. The disaster preparedness was comprehensive, and cooperation was achieved among various specialties: military forces; firefighters; civil engineers; mechanics; police; provincial governors; the medical sectors; and so forth. Among these groups, the role of medical sectors was of great importance in reducing disease that would have resulted from such a disaster. The measures undertaken by the medical sectors included development of an organization to reduce the impact of disaster; training of medical personnel in techniques of rescue and in treatment of victims in disaster areas; development of a plan to assist the leadership in decision-making and establishing support for disaster preparedness; and maintaining sufficient capacity in general hospitals for the admission of victims from disaster areas. PMID- 10155465 TI - Clinical guidelines for delayed or prolonged transport. III. Spine injury. Rural Affairs Committee, National Association of Emergency Medical Services Physicians. PMID- 10155466 TI - Ethical challenges in emergency medical services. A special contribution of the Ethics Committee, National Association of Emergency Medical Services Physicians. AB - Patient autonomy, beneficence, and justice are the fundamental ethical principles of an emergency medical service. Ethical conflicts are present in the daily practice of prehospital care. These conflicts surround issues of resuscitation, futile therapy, consent, and refusal of care, duty, and confidentiality. Emergency medical services must remain fair and equitable, equally available to those it is designed to serve, regardless of the patient's social or economic status. Establishing priorities for patient care is dictated by medical and operational concerns. Education and information regarding ethical issues are important for the providers of prehospital medical care as well as the medical director. Policies and protocols must continue to be developed to address requests to limit resuscitation, such as refusal of care and patient confidentiality. Policies should be developed in conjunction with experienced legal advice. Current training does not equip even the most advanced prehospital care provider to deal easily with every potential situation. Many learn by experience, some are guided by clear policy. Ideally, medical control personnel will be educated, interested, and available to address dilemmas which arise. Where possible, policies and procedures should be developed to address ethical issues which are likely to be faced by EMS personnel. PMID- 10155467 TI - Flight physician training program. Core content. A special contribution of the Air Medical Services Committee, National Association of EMS Physicians. PMID- 10155468 TI - Prehospital care of agricultural injuries. AB - In the United States, farming has become one of the most dangerous occupations. There are unique challenges for the providers of prehospital care to victims of agricultural trauma. The machinery and the work environment associated with agricultural trauma are different from those encountered in other occupations. The unique features of the machinery and risks are discussed. In addition, solutions unique to the problems of agricultural prehospital care are discussed. Effective care of the victims of agricultural trauma has a potential to reduce morbidity. PMID- 10155469 TI - Joint position statement on emergency medical services and emergency medical services systems. National Association of State EMS Directors and National Association of EMS Physicians. PMID- 10155470 TI - The 1989 Loma Prieta earthquake: issues in medical control. AB - INTRODUCTION: The role of the base-hospital and on-line medical control in a disaster has not been investigated previously. This study assesses the roles of base-hospitals and the value and feasibility of on-line medical control during the 1989 Loma Prieta earthquake. METHODS: The researchers studied five Bay Area counties most affected by the earthquake: San Francisco, Alameda, San Mateo, Santa Clara, and Santa Cruz. Researchers sent questionnaires to all 1,498 registered EMTs and paramedics in these counties; 620 were returned (41.4%). Respondents answered questions about activities performed, contacts with base hospitals and other agencies, and problems encountered the night of the earthquake. Researchers selected 63 paramedics for in-depth interviews based on their performance of significant advanced life support (ALS) activities performed during the disaster. The coordinators of the 13 base-hospitals (BHCs) in the region also received and returned questionnaires about medical control, base hospital roles during the disaster, and problems encountered. Researchers interviewed all five county emergency medical services (EMS) agency directors. RESULTS: The surveys of EMS directors, base-hospital coordinators, and paramedics indicate that confusion existed over the status of medical control after the earthquake. There was general agreement among base-hospital coordinators (BHCs) that suspension of medical control is appropriate in a major disaster. Three bases had appropriate equipment to function as back-up dispatch centers. Eight bases had adequate personnel, but only one BHC felt his personnel had adequate training to function in a dispatch capacity. Nine paramedics did not start or continue resuscitation on patients whom they ordinarily would have begun resuscitation. CONCLUSION: Emergency medical services should suspend medical control immediately following a major disaster and ensure that all prehospital and base personnel are notified. Disrupted communications protocols for prehospital personnel should reflect the skill and knowledge level of paramedics and the need for rapid, advanced practice in a disaster. Disaster planners should consider other roles for base hospitals in major disasters. PMID- 10155471 TI - Physician in-field observation of prehospital advanced life support personnel: a statewide evaluation. AB - STUDY HYPOTHESIS: Direct physician observation of advanced life support (ALS) personnel is rare in a demographically diverse state. STUDY POPULATION: Twenty ALS agencies from throughout Arizona. METHODS: A board-certified emergency physician performed on-site interviews with the emergency medical services (EMS) supervisor of each agency to approximate the number of days per year that physicians observe ALS personnel in the field. RESULTS: Only 11 agencies (55%) reported that physicians ever observed ALS personnel. Among all agencies, an estimated total of 84 observer-days occurred per year. The agencies staffed a total of 86 ALS units, resulting in an estimated 0.98 observer-days/unit/year (84/86). On the average, it took 3.4 ALS personnel to staff a given unit over time and the probability that an ALS provider would be on a unit on any given day was 0.29 (1/3.4). The probability of a given provider being observed during one year was approximately 0.29 (0.98 x 0.29). Thus, on the average, an ALS provider would be observed by a physician approximately once every 3.5 years (1/0.29). Among urban agencies, the "average" ALS provider would be observed once every 2.9 years. This compared to a likelihood of in-field observation of only once every 6.7 years for non-urban providers (p = .036). CONCLUSIONS: The skills of ALS providers in Arizona are observed by a physician in the field very infrequently. Although an uncommon occurrence in urban agencies, observation of non-urban ALS personnel occurs even less frequently. In addition, nearly one-half of the agencies surveyed never had a physician-observer. Although a variety of skills evaluation methods exist, it remains unclear whether any method is as useful as direct observation. Future investigations are needed to evaluate whether in-field physician observation impacts skills, patient care, or outcome in EMS systems. PMID- 10155472 TI - Comparison of two systems for quality assurance of prehospital advanced life support services. AB - INTRODUCTION: The need for quality assurance (QA) systems for review of prehospital advanced life support (ALS) care has long been recognized. However, there only have been limited published studies on the operation and cost of QA systems for prehospital care. A number of different systems currently are in use, and the relative effectiveness of different QA systems has not been well determined. OBJECTIVE: The aim of this study was to compare the personnel work time and costs of two different systems of QA for prehospital ALS services, and thereby determine which type of system was more cost-effective in the generation of QA reports. METHODS: The quality assurance program (System 1) for three independent ALS services in a rural/suburban area and the QA program (System 2) for a nearby urban ALS service were compared. Data recorded included the training level and number of hours per year devoted exclusively to QA activities by different personnel. The annual costs for other aspects of the QA systems and apportioned salary costs for time spent on QA work were recorded. RESULTS: System 1, a computer-based system, utilized 1,116 hours per year of personnel time and required [US]$17,662 in total costs per year (average cost per run reviewed of $4.38). System 2 (a manual system) utilized 569 hours per year of personnel time and had an annual cost of [US]$8,361 (or $2.15 per run reviewed). System 1 generated 852 reports per year (21% of runs) about non-compliance with protocols or charting deficiencies. System 2 generated 284 reports per year (7.3% of runs) for similar events. CONCLUSIONS: Either a computer-based or "manual" system for QA of prehospital ALS services can be utilized. A computer-based system requires more personnel time and is more expensive, but generates more reports per year than does the manual system. A computer-based system more readily can retrieve run report data for further review. PMID- 10155473 TI - Prehospital do-not-resuscitate orders: a survey of state policies in the United States. AB - INTRODUCTION: Many states in the United States have developed policies that enable prehospital emergency medical services (EMS) providers to withhold cardiopulmonary resuscitation (CPR) in the terminally ill. Several states also have policies that enable the implementation of do-not-resuscitate (DNR) orders. OBJECTIVES: 1) assess which states have statutes governing DNR orders for the prehospital setting; 2) determine which states authorize DNR orders in ways other than by specific state statue; and 3) define those states that had regional protocols which address prehospital DNR orders. METHODS: Survey of the state EMS directors in each of the 50 U.S. states, the District of Columbia, and Puerto Rico. RESULTS: As of 1992, specific legislation authorizing the implementation of DNR orders was in place in 11 states. In addition, six others have a legal opinion or policy allowing the implementation of DNR orders. Fourteen additional states have either working groups or legislation pending that address prehospital DNR orders. In only five were there no existing regional protocols for implementation of DNR orders in the prehospital setting. CONCLUSIONS: There exists great variation in legal authorization by states for implementation of DNR orders in the prehospital setting. Despite the existence of enabling legislation, many state, regional, or local EMS systems have implemented policies dealing with DNR orders. PMID- 10155474 TI - Medical control of mass gatherings: can paramedics perform without physicians on site? AB - OBJECTIVE: Evaluate the experience of paramedic personnel at mass gatherings in the absence of on-site physicians. DESIGN: Retrospective review of patients evaluated by paramedics with emergency medical services (EMS) medical control. SETTING: First-aid facility operated by paramedics at an outdoor amphitheater involving 32 (predominantly rock music) concerts in accordance with the Chicago EMS System, June through September 1990. PARTICIPANTS: A total of 438 patients (< or = 0.1% on-site population) were evaluated. INTERVENTIONS: Presentations to the first-aid facility were viewed as if the patient was presenting to an ambulance. Transportation to an emergency department was strongly recommended for all encounters. Time from presentation to the first-aid facility until disposition was limited to 30 minutes in the absence of on-line [direct] medical control. Refusal of care was accepted. On-line [direct] medical control with the EMS resource hospital was initiated as needed. Off-line [indirect] medical control consisted of weekly reviews of all patients records and periodic site visits. RESULTS: Of the 438 patients, 366 (84%) refused further care, including 31 patients (7%) who refused advanced life support (ALS) level care. Seventy-two patients (16%) were transported; 37 by ALS and 35 by basic life support (BLS) units. On-line [direct] medical control was initiated in all ALS patients that were transported as well as for those who refused care. No known deaths or adverse outcomes occurred, based on lack of inquiries or complaints from the local EMS system, emergency departments receiving transported patients, law enforcement agencies, 9-1-1 emergency response providers, venue management, or security. No request for medical records from law firms have occurred. Problems noted initially were poor documentation and a tendency not to document all encounters (e.g., dispensing band-aids, tampons, earplugs, etc.). Concerns noted included: initial and subsequent vital signs, times of arrival, interventions, dispositions, and patient conditions of refusal. Specific problems with documentation of refusals at disposition included: appropriate mental status, speech, and gait; release with an accompanying family member or friend; and parental notification and approval of care for minors. There also was an initial tendency not to establish on-line [direct] medical control for ALS refusal or BLS medicolegal issues. CONCLUSIONS: The medical system configuration modeled after practices of prehospital care, demonstrates physicians did not need to be on-site when adequate EMS medical control existed with less than 30 minutes on-scene time. PMID- 10155476 TI - A hospital-based, hazardous materials decontamination and treatment unit: utilization patterns over a nine-month period. AB - Federal [U.S.] law and the Joint Commission on the Accreditation of Healthcare Organizations mandate plans and mechanisms for response by hospitals to hazardous material incidents/accidents be developed and implemented. This paper describes the response of the University Hospitals of Cleveland to these regulations and to the anticipated needs of the community and local industry. The physical plant constructed and its relationship to the emergency department personnel for staffing this unit are described. Utilization patterns since implementation of this program are presented. PMID- 10155475 TI - Mouth-to-mouth ventilation of cardiac arrested humans using a barrier mask. AB - INTRODUCTION: Concern for possible disease transmission during mouth-to-mouth resuscitation has decreased the incidence of bystander cardiopulmonary resuscitation (CPR). Barrier masks have become available that may be effective in CPR as well as protective against cross-contamination. HYPOTHESIS: A silicone rubber barrier mask incorporating a one-way-valved airway (Kiss of Life [KOL]) designed to prevent contamination of the rescuer, permits satisfactory mouth-to mouth ventilation of victims of cardiopulmonary arrest. METHODS: Ten adult patients who did not survive non-traumatic cardiac arrest were ventilated with exhaled room air using a KOL barrier mask while external cardiac massage continued. Arterial blood gases were obtained every two minutes for a maximum of 10 minutes. The operator was blinded to the results of these blood tests. RESULTS: Eight men and two women with ages from 55 to 99 years were studied. Four patients were edentulous and two of these had marked mandibular atrophy. The two patients with mandibular atrophy were poorly ventilated with the barrier mask. One other patient was not ventilated successfully. This patient had undergone multiple attempts at endotracheal intubation and had transtracheal needle ventilation performed prior to use of the barrier mask. One patient had elevated PaCO2 despite being well-ventilated clinically. Six patients were ventilated well clinically and had satisfactory PaCO2 and PaO2 values. CONCLUSION: The barrier mask studied appears to be an effective aid to ventilation in CPR. Patients without facial support, as in edentulous patients with mandibular atrophy, are not ventilated well with this device. PMID- 10155477 TI - Intermediate ALS providers' level of interest in paramedic education. AB - OBJECTIVE: To examine the level of interest in paramedic upgrade education among a sample of intermediate-level emergency medical technicians, referred to as cardiac rescue technicians (CRT), to obtain education to upgrade to the paramedic level. METHOD: The design of this study was a descriptive, cross-sectional study utilizing a mailed survey instrument. RESULTS: Most of the CRTs reported interest in advancement to the paramedic level with the most active CRTs significantly more interested in upgrading than were those with lower grade of activity. Preference was for the upgrade training to be offered as a single course, two nights per week. Respondents also indicated an interest in receiving college credits for the course. CONCLUSION: Active volunteer, intermediate-level emergency medical technicians (EMTs) in Maryland are interested in participating in the education necessary to advance them to the paramedic level. PMID- 10155478 TI - Emergency medical training in the 82d Airborne Division. The Gulf War experience. AB - The 82d Airborne Division, as the Army's worldwide contingency division, places unique demands on its medical personnel. This was true particularly during Operations Desert Shield and Desert Storm in 1990-1991. An unprecedented emergency medical training program was carried out in preparation for the Gulf War. All levels of expertise were involved: non-medical Combat Lifesavers, medics, physician assistants, and physicians. Courses provided included Combat Lifesaver provider and refresher training, Basic Trauma Life Support (BTLS) provider and instructor training, Chemical Casualty courses, and a Combat Surgical Skills course. Approximately 736 personnel, including 80 Saudi and allied physicians and medics, participated in these courses. Confidence and competence in handling war casualties at all levels was enhanced greatly. Prepackaged courses such as BTLS enabled the rapid training of large numbers of medical personnel under challenging conditions. PMID- 10155479 TI - Urban search and rescue medical teams: FEMA Task Force System. AB - Recent national and international disasters involving collapsed structures and trapped casualties (Mexico City; Armenia; Iran; Philippines; Charleston, South Carolina; Loma Prieta, California; and others) have provoked a heightened national concern for the development of an adequate capability to respond quickly and effectively to this type of calamity. The Federal Emergency Management Agency (FEMA) has responded to this need by developing an Urban Search and Rescue (US&R) Response System, a national system of multi-disciplinary task forces for rapid deployment to the site of a collapsed structure incident. Each 56-person task force includes a medical team capable of providing advanced emergency medical care both for task force members and for victims located and reached by the sophisticated search, rescue, and technical components of the task force. This paper reviews the background and development of urban search and rescue, and describes the make-up and function of the Federal Emergency Management Agency (FEMA) Task Force medical teams. PMID- 10155480 TI - Use of BAAM with a digital intubation technique in a trauma patient. PMID- 10155481 TI - The emergency medical response to the Cantara hazardous materials incident. AB - On 14 July 1991, at 2150 h, a train derailment occurred near the Cantara rail curve about six miles above Dunsmuir in Northern California. The derailment spilled approximately 19,000 gallons of metam-sodium into the Sacramento River. When mixed with water, metam-sodium degrades to methylisothiocyanate (MITC) and other gases. The contaminated river water passed the town of Dunsmuir and other occupied areas exposing residents to MITC gas. From 15 July to 20 July (five days), a total of 360 people underwent triage. The majority of patients displayed minor exposure symptoms that did not require hospital care. Mercy Mt. Shasta Hospital, a small rural hospital close to Dunsmuir, received the majority of patients. As of 29 July, 15 days after the incident, Mercy Mt. Shasta Hospital had seen 244 exposed patients in its emergency department, and had admitted five. Three had symptoms that could have been spill-related. Three Regional Poison Control Centers provided medical toxicology advice. Medical management of the emergency medical services (EMS) response to the event was piecemeal and weak. There did not appear to be a medical operations component at local Emergency Operations Centers (EOC). Most health care personnel interviewed complained about inadequate information about the substance and the situation. Local fire service mutual-aid agreements to obtain additional fire service and ambulance personnel worked well. It is important to emphasize that everyone who believed they had been exposed to the chemical underwent triage and received appropriate acute medical care. PMID- 10155482 TI - The humanitarian postulate in international disaster relief. PMID- 10155483 TI - Motor vehicle safety, health care, and taxes. National Highway Traffic Safety Administration, U.S. Department of Transportation. AB - INTRODUCTION: Motor vehicle injuries are a major public health problem. They are a primary cause of: 1) death and injury in the United States; and 2) result in a substantial loss of productive life. These injuries and fatalities have serious social and economic consequences for the injured individual, their families, and society. This report focuses on the portion of health care expense borne by the public and the tax revenue implications of these injuries and fatalities. METHODS: The relationship between motor vehicle injuries and fatalities, health care costs, and income taxes was analyzed for four situations: 1) 1990 baseline; 2) achievement of modest goals for safety improvements; 3) population growth with constant injury and fatality rates; and 4) the effect of higher injury and fatality rates. Total health care costs, publicly funded health care costs, lost income tax revenue, and increased public assistance were estimated at the [U.S.] federal level, and at the state and local level. RESULTS: Study of these relationships indicate that: 1) the lifetime economic cost of motor vehicle injuries, fatalities, and property damage that occurred in 1990 is $137.5 billion. American taxpayers will pay $11.4 billion of that total to cover publicly funded health care ($3.7 billion), reduced income tax revenue ($6.1 billion), and increased public assistance expenses ($1.6 billion); 2) the lifetime economic cost of alcohol-related, motor vehicle injuries, fatalities, and property damage that occurred in 1990 was $46.1 billion. Of this, the American taxpayer will pay $1.4 billion to cover publicly funded health care and $3.8 billion to cover reduced income tax revenue and increased public assistance; 3) reducing the percentage of the alcohol-related portion of these fatalities from 45% to 43% (1,200 lives saved), and alcohol-related injuries by a proportionate amount, would save American taxpayers $73 million in publicly funded health care and $208 million in income taxes and public assistance; 4) by increasing observed safety-belt usage in passenger cars from 62% to 75%, (1,700 lives saved plus a proportionate reduction in injuries), publicly funded health care costs would be reduced by $180 million, and $328 million would be saved in the combination of increased income tax revenues and reduced public assistance; 5) Further reductions in publicly funded health care, increases in income tax revenues, and reductions in public assistance are possible as a result of reasonable gains in other areas, such as increased safety-belt usage in light trucks, increased usage of motorcycle helmets, increased correct usage of child safety seats, and reducing the number of speeding drivers; 6) if injury and fatality rates remain at the 1992 level, population increases alone would result in 3,300 more fatalities in the year 2000. Economic costs from these fatalities and a proportionate increase in injuries would increase by an estimated $7.4 billion, including a $277 million increase in publicly funded health care costs, and $573 million in reduced income tax revenue and increased public assistance; and 7) if injury and fatality rates increase from the 1992 level, injuries, fatalities, and costs will increase. In one scenario, with 5,800 more fatalities than the population growth scenario, economic costs would increase by $13 billion, including a $350 million increase in publicly funded health care, and an additional $1 billion in taxes to cover lost income tax revenue and increased public assistance. CONCLUSIONS: It is obvious that inaction is a costly alternative and that anticipated population gains will require further reductions in injury and fatality rates just to maintain current injury and fatality rates. Fortunately, countermeasures are to be available that can accomplish this. Lack of vigilance that would result in deterioration of safety levels would be even more costly. PMID- 10155485 TI - Hospital disaster preparedness in Osaka, Japan. AB - PURPOSE: To investigate the adequacy of hospital disaster preparedness in the Osaka, Japan area. METHODS: Questionnaires were constructed to elicit information from hospital administrators, pharmacists, and safety personnel about self sufficiency in electrical, gas, water, food, and medical supplies in the event of a disaster. Questionnaires were mailed to 553 hospitals. RESULTS: A total of 265 were completed and returned (Recovery rate; 48%). Of the respondents, 16% of hospitals that returned the completed surveys had an external disaster plan, 93% did not have back-up plans to accept casualties during a disaster if all beds were occupied, 8% had drugs and 6% had medical supplies stockpiled for disasters. In 78% of hospitals, independent electric power generating plants had been installed. However, despite a high proportion of power-plant equipment available, 57% of hospitals responding estimated that emergency power generation would not exceed six hours due to a shortage of reserve fuel. Of the hospitals responding, 71% had reserve water supply, 15% of hospitals responding had stockpiles of food for emergency use, and 83% reported that it would be impossible to provide meals for patients and staff with no main gas supply. CONCLUSIONS: No hospitals fulfilled the criteria for adequate disaster preparedness based on the categories queried. Areas of greatest concern requiring improvement were: 1) lack of an external disaster plan; and 2) self-sufficiency in back-up energy, water, and food supply. It is recommended that hospitals in Japan be required to develop plans for emergency operations in case of an external disaster. This should be linked with hospital accreditation as is done for internal disaster plans. PMID- 10155486 TI - The effect of a quality improvement feedback loop on paramedic skills, charting, and behavior. AB - OBJECTIVE: A mechanism was initiated for conveying quality improvement (QI) results to paramedics as a means of improving chart documentation in difficult-to correct areas. This study examines the impact of this QI feedback loop on charting, resuscitation rates from cardiac arrest, endotracheal intubation (ETI) success rates, and trauma scene times. DESIGN: Paramedic trip sheets were reviewed before and after the institution of the QI feedback loop in this interrupted time series design. SETTING: The New Castle County, Delaware, Paramedic Program. PARTICIPANTS: All New Castle County paramedics participated in the study. INTERVENTIONS: In January 1990, the medical director began to circulate a QI summary among the paramedics in an effort to improve performance and chart documentation. The summary focused on the management of respiratory distress or arrest, cardiac arrest, and major trauma. The success rate for ETI was compared with the rate of field resuscitation from cardiac arrest, the percentage of unjustified prolonged trauma scene times (longer than 10 minutes), and the percent compliance with minimum endotracheal intubation documentation (ETID) requirements from a six-month period before institution of the QI feedback mechanism with data obtained from a six-month period after the program had been operational for one year. RESULTS: Comparing results from before with after the initiation of the QI program, the ETI success rate was 273 of 295 (92.5%) before and 300 of 340 (88.2%) after (chi 2 = 3.04, p < .1, ns); field resuscitations totaled 26 of 187 (13.9%) before and 44 of 237 (18.6) after (chi 2 = 1.40, p < .25, ns); ETID rate was 249 of 295 (84.4%) before and 336 of 340 (98.8%) after (chi 2 = 44.24, p < .001), and unjustified prolonged trauma scene times were 69 of 278 (24.8%) before and seven of 501 (1.4%) after (chi 2 = 320.5, p < .001). CONCLUSION: The use of QI feedback had little effect on psychomotor skills as the ETI success rate or resuscitation rate, but had a dramatic effect on chart documentation, as evidenced by ETID rate, and behavior, as evidenced by the reduction in prolonged trauma scene times. The use of QI feedback is recommended as a means of correcting charting deficiencies or modifying behavior. PMID- 10155487 TI - Ethics in disaster medicine. PMID- 10155488 TI - Paramedic documentation of indicators for cervical spine injury. AB - INTRODUCTION: Current paramedic training mandates complete immobilization of all patients, symptomatic or not, whose mechanism of injury typically is viewed as conducive to spinal trauma. It is common to observe confrontations between paramedics and walking, asymptomatic accident victims who fail to understand why they should "wear that collar and be strapped to that board." Immobilized, frustrated patients then may wait for hours in a busy emergency department until a physician declares them to be without spinal injury. Patients frequently refuse treatment and transport. HYPOTHESIS: Algorithms exist for physicians to "clear" the cervical spine (C-spine) without radiography. It was hypothesized that paramedics routinely assess and document these indicators in their patient evaluations. METHODS: A retrospective chart review was conducted on 161 patients (Group 1) admitted to a regional medical center with a diagnosis of C-spine injury over a 52-month period. The charts of 225 motor vehicle accident (MVA) victims (Group 2) transported by ambulance to the emergency department over a five-month period then were studied. Indicators for C-spine injury documented by emergency medical service (EMS) personnel were abstracted. RESULTS: All patients underwent mental status assessment and full spinal immobilization (neck and back) by EMS crews prior to transport to the hospital. Two or more indicators of possible C-spine injury were documented on each prehospital care report (PCR). CONCLUSION: Paramedics already assess most, if not all, of the criteria standard to C-spine clearance algorithms, but are inconsistent in their documentation of the presence or absence of all of the relevant findings. PMID- 10155489 TI - Airway control in trauma patients with cervical spine fractures. AB - INTRODUCTION: Proper airway control in trauma patients who have sustained cervical spine fracture remains controversial. PURPOSE: This study was undertaken to survey the preferred methods of airway management in cervical spine fracture (CSF) patients, to evaluate the experience of handling such patients at a level-I trauma center, and to contrast the findings with recommendations of the American College of Surgeons Committee on Trauma. HYPOTHESIS: The methods used for control of the airway in patients with fractures of their cervical spine support the recommendation of the American College of Surgeons (ACS) Committee on Trauma. METHODS: The study consisted of two parts: 1) a survey; and 2) a retrospective study. Survey questionnaires were sent to 199 members of the Eastern Association for the Surgery of Trauma and to 161 anesthesiology training programs throughout the United States. Three resuscitation scenarios were posed: 1) Elective airway- CSF--breathing spontaneously, stable vital signs; 2) Urgent airway--CSF- breathing spontaneously, unstable vital signs; and 3) Emergent airway--CSF- apneic, unstable. In addition, a three-year retrospective study was conducted at a level-I trauma center to determine the method of airway control in patients with cervical spine fractures. RESULTS: Responses to the questionnaires were received from 101 trauma surgeons (TS) and 58 anesthesiologists (ANESTH). Respondents indicated their preference of airway methods: Elective airway: Nasotracheal intubation: TS 69%, ANESTH 53%. Orotracheal intubation: TS and ANESTH 27%. Surgical airway: TS 4%. Intubation with fiberoptic bronchoscope (FOB): ANESTH 20%. Urgent airway: Nasotracheal intubation: TS 48%, ANESTH 38%. Orotracheal intubation: TS 47%, ANESTH 45%. Surgical airway: TS 4%. FOB: ANESTH 16%. Emergent airway: Orotracheal intubation: TS 81%, ANESTH 78%. Surgical Airway: TS 19%, ANESTH 7%. FOB: ANESTH 15%. The retrospective review at the trauma center indicated that 102 patients with CSF were admitted; 62 required intubation: four (6%) on the scene, seven (11%) en route, five (8%) in the emergency department, 42 (67%) in the operating room, and four (6%) on the general surgery floor. Airway control methods used were nasotracheal: 14 (22%); orotracheal: 27 (43%); FOB: 17 (27%); tracheostomy: one (2%); unknown: three (4%). No progression of the neurological status resulted from intubation. CONCLUSION: The choice of airway control in the trauma patient with CSF differs between anesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The recommendations of the American College of Surgeons Committee on Trauma for airway control with suspected cervical spine injury are useful. The technique utilized is dependent upon the judgment and experience of the intubator. PMID- 10155490 TI - Adverse events during interfacility transfers by ground advanced life support services. AB - OBJECTIVE: To identify risk factors for adverse events that occur during interfacility transfers by advanced life support (ALS). DESIGN: A four-year, retrospective, case series. SETTING: Three ALS units in a rural/suburban emergency medical services (EMS) system. PARTICIPANTS: 351 transports to or from twelve acute care facilities; two patients records could not be located. INTERVENTIONS: Patients were classified by illness/injury, transporting staff, and ongoing therapy; these were correlated with frequency of ALS intervention and patient deterioration. RESULTS: During the study period, the number of transfers as a percentage of total calls (1.1%-5.2%) rose consistently. There were 11 illness/injury categories; the largest was cardiac (44%, 154 patients). Hospital staff accompanied the patient in 15% (52). Advanced life support (ALS) therapy was required in 4.9% (17): one monitored cardiac arrest was defibrillated successfully, 13 patients required unanticipated medication therapy, and three were noted to have clinical deterioration en route. The upper 95% confidence limit for cardiac arrest is 12.9/1,000 transfers or 20.8/1,000 hours. Patient deterioration and the need for ALS intervention were associated with the presence of medication infusions (p < .05), but not with hospital staff (p > .40). CONCLUSIONS: Interfacility transfers of a heterogeneous group of patients in this series involve a low risk of cardiac arrest. Patients with medication infusions are at higher risk of deterioration and more frequently require ALS intervention en route. The presence of hospital staff had no measurable effect. These findings have implications for the development of ALS transfer protocols. PMID- 10155491 TI - Agreement between paramedic-estimated weights and subsequent hospital measurements in adults with out-of-hospital cardiac arrest. AB - OBJECTIVE: To assess the accuracy of paramedic estimates of adult body weights in cardiac arrest cases. HYPOTHESIS: Paramedics could accurately estimate the weights of out-of-hospital cardiac arrest patients. DESIGN: Retrospective data analysis of a 15-month, multicenter study involving nontraumatic out-of-hospital cardiac arrest patients. Paramedic estimates of body weights were compared to weights measured in the hospital. Patients were included in the analysis only if both a paramedic weight and a measured in-hospital weight were recorded. SETTING: Six urban emergency medical services systems. PARTICIPANTS: The study population included adults with return of spontaneous circulation who subsequently were admitted to the hospital. MEASUREMENTS: Pearson correlation analysis of paramedic estimated weights and measured weights. RESULTS: Among the 133 study patients, the correlation coefficient (R) for paramedic estimates and the actual measured weight was 0.93. Paramedic estimates of weight were within 10% of the measured weights in 74% of the patients, and within 20% of measured weights in 93% of the patients. CONCLUSION: Paramedic weight estimates correlated well with measured weights. PMID- 10155492 TI - In the shadow of El Chichon: an overview of the medical impact of the 28 March to 4 April 1982 eruptions of the Mexican volcano. PMID- 10155493 TI - Risk and risk evaluation. PMID- 10155495 TI - Pediatric casualties during the civil conflict in the Republic of Georgia 22 November-5 December 1991. PMID- 10155496 TI - Prototype curriculum for a fellowship in emergency medical services. PMID- 10155497 TI - Natural hazards: causes and effects. Lesson 1--introduction to natural disasters. PMID- 10155498 TI - The importance of proper organization of responding emergency services. PMID- 10155499 TI - To intubate or not to intubate: that is the question. PMID- 10155500 TI - An analysis of prehospital mortality in an earthquake. Disaster Reanimatology Study Group. AB - INTRODUCTION: Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy. METHODS: A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991. RESULTS: Fifty-four deaths occurred prior to hospitalization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p < .01) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death. CONCLUSIONS: A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life-saving potential in these events. PMID- 10155501 TI - Ambulance collisions in an urban environment. AB - INTRODUCTION: Decisions to send an ambulance with or without lights and siren are made every day. While travel with lights and siren is presumed to have relatively more risk associated with it than travel without, little epidemiologic analysis has been conducted to compare the two modes of travel or to characterize collisions in general. OBJECTIVE: To characterize ambulance collisions and assess the risk of traveling with lights and siren in an urban 9-1-1 environment. METHODS: Retrospective analysis of all consecutive ambulance collisions of the Paramedic Division of the San Francisco Department of Public Health during a 27 month period. RESULTS: The overall collision rate for lights and siren (LS) travel was higher than that for non-lights and siren travel, although the difference was not statistically significant (45.9 collisions per 100,000 LS patient travels, 95% confidence limits 29.7, 62.1, versus 27.0/100,000 for non-LS travel, 95% confidence limits 18.3, 35.7). However, the rates of resulting injuries displayed a statistically significant difference (22.2 injuries per 100,000 LS patient travel, 95% confidence limits 11.0, 33.5, versus 1.5/100,000 for non-LS travel, 95% confidence limits -0.6, 3.5). While the majority of collisions (60.0%) occurred during patient-related travel, 35.6% occurred while the ambulance was available awaiting assignment, and 4.4% in a hospital parking lot. The majority of collisions were due to inattention, failure of on-coming traffic to yield, or unsafe parking; unsafe speed was an infrequent cause. Most crashes occurred during daylight, in dry weather, and involved another vehicle. CONCLUSION: There is some elevated risk for collision and added injury during lights and siren travel compared to travel without LS. The causes for these collisions suggest that interventions designed to improve driver skills and increase citizen awareness of an approaching ambulance could help reduce the number of collisions. PMID- 10155502 TI - Characteristics of fatal ambulance crashes during emergency and non-emergency operation. AB - OBJECTIVE: To analyze the characteristics of fatal ambulance crashes to assist emergency medical services (EMS) directors in objectively developing their EMS system's policy governing ambulance operations. HYPOTHESIS: No difference exists between the characteristics of fatal ambulance crashes during emergency and nonemergency use. DESIGN: Retrospective, cross-sectional, comparative analysis of ambulance crashes resulting in fatalities reported to the Fatal Accident Reporting System (FARS) from 1987 to 1990. METHODS: Twenty variables, representing characteristics of fatal ambulance crashes, were selected from the National Highway Traffic Administration FARS Codebook and were evaluated using tests of significance for categorical data grouped by emergency use and nonemergency use. Crash variable categories examined included demographics, accident configuration, accident severity, vehicle description, and ambulance operator action. RESULTS: During the four-year study period, 109 fatal ambulance crashes occurred producing 126 deaths. Four states, New York, Michigan, California, and North Carolina, accounted for 37.5% of all fatal crashes. Seventy five fatal crashes (69%) occurred during emergency use (EU) and 34 fatal crashes (31%) occurred during nonemergency use (NEU). The total number of fatal crashes varied in a downward trend (1987:32; 1988:24; 1989:28; 1990:25). The number of fatal EU crashes also varied in a downward trend (1987:28; 1988:16; 1989:19; 1990:12), while the number of fatal NEU crashes increased each year [1987:4; 1988:8; 1989:9; 1990:13](p = .016). Most EU fatal crashes occurred between 1200 h and 1800 h (p = .009). Most NEU fatal crashes occurred during times when light conditions were poor (p = .003). When a violation was charged to the ambulance driver (17 cited), the vehicle was more likely to be in EU (p = .056). No statistically significant differences between EU and NEU were identified by: 1) day of week; 2) season; 3) atmospheric conditions; 4) roadway surface type; 5) roadway surface condition; 6) speed limit; 7) roadway alignment; 8) relationship to junction; 9) manner of collision; 10) year manufactured; 11) vehicle role; 12) vehicle maneuver; 13) manner leaving scene; 14) extent of deformation; 15) violations charged; or 16) number of persons killed in accident. CONCLUSION: Few characteristics differentiate between fatal ambulance crashes during EU and NEU. The difference between EU and NEU were statistically significant in only three out of the 20 variables examined: 1) year occurred; 2) time of day; and 3) light condition. These data provide few objective measures that may be used to develop ambulance operation policies to decrease fatal ambulance crashes. PMID- 10155503 TI - Use of warning lights and siren in emergency medical vehicle response and patient transport. National Association of Emergency Medical Services Physicians (NAEMSP) and the National Association of State EMS Directors (NASEMSD). PMID- 10155505 TI - Criteria for prehospital air medical transport: non-trauma and pediatric considerations. Air Medical Services Committee of the National Association of EMS Physicians. PMID- 10155504 TI - National guidelines for statewide implementation of EMS "do not resuscitate" (DNR) programs. National Association of State Emergency Medical Services Directors (NASEMSD) and the National Association of Emergency Medical Services Physicians (NAEMSP). PMID- 10155506 TI - Action resolutions. The National Association of State EMS Directors. PMID- 10155507 TI - Disaster medicine and wartorn former Yugoslavia. PMID- 10155508 TI - Hospital disaster preparedness in Osaka, Japan. PMID- 10155509 TI - Post-preparedness medical disaster response in Costa Rica. AB - INTRODUCTION: The 1991 earthquake in the Limon area of Costa Rica presented the opportunity to examine the effectiveness of a decade of disaster preparedness. HYPOTHESIS: Costa Rica's concentrated work in disaster preparedness would result in significantly better management of the disaster response than was evident in earlier disasters in Guatemala and Nicaragua, where disaster preparedness largely was absent. METHODS: Structured interviews with disaster responders in and outside of government, and with victims and victims' neighbors. Clinical and epidemiologic data were collected through provider agencies and the coroner's office. RESULTS: Medical aspects of the disaster response were effective and well managed through a network of clinic-based radio communications. Nonmedical aspects showed confusion resulting from: 1) poor government understanding of the roles and responsibilities of the central disaster coordinating agency; and 2) poor extension of disaster preparedness activities to the rural area that was affected by the earthquake. CONCLUSION: To be effective, disaster preparedness activities need to include all levels of government and rural, as well as urban, populations. PMID- 10155510 TI - Mission to Sarajevo. PMID- 10155511 TI - A short look at the history of the State Hospital of Sarajevo. PMID- 10155512 TI - Transfusion therapy during war and peace in Sarajevo. AB - OBJECTIVE: To investigate surgical blood usage during the siege of Sarajevo. METHODS: Data on blood usage and pre-transfusion hematocrit (Hct) values from blood transfusion request forms in 250 wartime emergency surgical procedures during August through October 1992 (experimental group), and in 146 peacetime elective surgical procedures (control group) during April through June 1991 at the State Hospital of Sarajevo, were reviewed. RESULTS: The mean number of blood units transfused per patient (blood usage rate) was 1.13 in the experimental group versus 2.56 in the control group (p < 0.001). During the war, for blood conservation, normovolemic hemodilution was practiced widely. A significantly lower mean pre-transfusion Hct value of 0.21 was observed in the experimental group versus 0.27 in the control group (p < 0.001). CONCLUSION: Blood-usage rate was lower during emergency surgical procedures in war than during elective surgical procedures in peacetime without apparent adverse patient outcome. This decrease in blood-usage rate in the face of increased numbers of trauma victims was the result of a planned blood-conservation program which included: stringent blood-usage criteria, and widespread implementation of casualty resuscitation using normovolemic hemodilution with colloid and crystalloid plasma substitutes. PMID- 10155513 TI - Blood transfusion requirements among war casualties in Sarajevo. AB - INTRODUCTION: The safe and timely provision of blood is of crucial importance in the prevention and mitigation of morbidity and mortality due to trauma. The use of blood in the treatment of war casualties, soldiers as well as civilians, was analyzed retrospectively and the impact of massive blood transfusion on blood banking services and reserves of blood during the war in Sarajevo was assessed. METHODS: A retrospective analysis of 3,215 war casualties (1,815 civilians plus 1,400 military) who arrived to the casualty reception center of the State Hospital of Sarajevo during the period 11 May through 31 October 1992 was performed. Blood usage was reviewed in three stages: within 24 hours (h) of admission, after seven days of hospitalization, and after 30 days of hospitalization. The types of injury, survival rate, and blood-usage rate in a sample of 37 war casualties who required massive blood transfusions (MBT) during the period 11 May through 31 December 1992 was examined. RESULTS: The civilian casualty rate in this series of patients was 56.5%. A total of 1,217/3,215 (37.9%) casualties were hospitalized. In this study, 16% (504/3,215) of total number of persons wounded received blood transfusion. Of these patients, 504/1,217 (41.4%) were transfused. A total of 971.1 liters of blood were transfused through 31 October 1992; 68% within 24 h of admission, 91% within the first seven days, and 100% within the first 30 days. From a total of 37 MBT recipients, 36 (97%) were injured by firearms. Survival rate among MBT patients was 30%. The MBT recipients comprised 2% of total hospitalized patients and 6% of total number of patients transfused. The amount of blood needed during episodes of MBT was 15% of total blood used through 31 December 1992. CONCLUSIONS: Based on these data, prospective requirements for blood usage should take into account casualty triage, as follows: for each casualty transported to the hospital, hospitalized, or transfused, 0.302, 0.796, and 1.912 liters of blood respectively, will be needed for the first 30 days of treatment. Recipients of massive blood transfusions are a significant drain on blood reserves in war. This experience can be utilized in the development of revised guidelines for blood usage for an entire population affected by war. PMID- 10155514 TI - Improvised purification methods for obtaining individual drinking water supply under war and extreme shortage conditions. AB - BACKGROUND: Supplying an adequate amount of drinking water to a population is a complex problem that becomes an extremely difficult task in war conditions. In this paper, several simple methods for obtaining individual supplies of drinking water by filtration of atmospheric water with common household items are reported. METHODS: Samples of atmospheric water (rain and snow) were collected, filtered, and analyzed for bacteriological and chemical content. The ability of commonly available household materials (newspaper, filter paper, gauze, cotton, and white cotton cloth) to filter water from the environmental sources was compared. RESULTS: According to chemical and biological analysis, the best results were obtained by filtering melted snow from the ground through white cotton cloth. CONCLUSIONS: Atmospheric water collected during war or in extreme shortage conditions can be purified with simple improvised filtering techniques and, if chlorinated, used as an emergency potable water source. PMID- 10155515 TI - Epidemiology and surgical management of abdominal war injuries in Sarajevo: State Hospital of Sarajevo experience. AB - BACKGROUND: In war, abdominal injuries constitute a significant proportion of the total injuries. These injuries are associated with high mortality and their treatment poses diagnostic, surgical, and therapeutic dilemmas. This article presents the epidemiology of abdominal war injuries during the siege of Sarajevo, and briefly describes the surgical techniques and therapeutic practices used in their treatment. METHODS: A retrospective medical record review was performed of 273 war casualties with trauma to visceral and vascular structures in the abdomen inflicted during a 7.5 month period in 1992. RESULTS: Most patients underwent exploratory laparotomy. Six percent had negative laparotomies, and there were no deaths in this group. In 18.3%, injuries were limited to one organ system, while 81.7% sustained combined injuries to multiple-organ systems. The crude mortality rate was 26.0%. Mortality rate excluding deaths within 24 hours of injury was 10.3%. Injuries were caused by metal fragments from artillery shrapnel, mortar and contact mines, or hand grenades. Because of a shortage of colostomy bags, resections of the colon with primary end-to-end anastomoses rather than colostomy were performed in 72% of the cases. CONCLUSIONS: Mortality was highest in those victims with four or more injured organ systems (81.3%) or with major vascular injuries (64.7%). The primary cause of death within the first 24 hours was prolonged hemorrhagic shock. PMID- 10155516 TI - Epidemic of surgical wound infections in wartime Sarajevo. AB - BACKGROUND: An epidemic of surgical wound infections observed at the State Hospital of Sarajevo during June-September 1992 is reported. METHODS: A cross sectional survey of 138 surgical patients with wound infection treated by the Department of Surgery of the State Hospital of Sarajevo was performed in mid September and again in mid-November 1992. A preliminary evaluation of the bactericidal effectiveness of a new antiseptic preparation called DI-ASEPT also was done. RESULTS: The frequency of wound infections was 24.4% in September and 19.2% in November. Pseudomonas species was the primary etiologic agent in this epidemic. DI-ASEPT was as effective as povidone-iodine in producing wound asepsis. CONCLUSIONS: Because of limited resources, large numbers of casualties, and an extremely adverse environment as a result of war that has affected hygienic conditions at the State Hospital of Sarajevo, a high frequency of contaminated or dirty operations were performed. This was the primary reason for the observed increase in wound infections. After hygienic conditions were restored, the epidemic of wound infections was terminated. PMID- 10155517 TI - Emergency medical services during the siege of Sarajevo, Bosnia and Herzegovina: a preliminary report. AB - BACKGROUND: The siege of Sarajevo is a long-term, human-made, medical disaster of international significance. The delivery of emergency health care provided to the large civilian population held captive in that war zone for an extended time was studied. METHODS: In May 1993, a humanitarian and fact-finding visit to Sarajevo was conducted. Physicians, administrators, and public health officials were interviewed; epidemiological data were acquired--the resuscitation of war casualties at the two largest hospitals were observed; and local published reports and videotaped footage on the organization and delivery of prehospital and hospital care were reviewed. The videotapes also served to document war crimes. RESULTS: Daily bombardment and sniper fire directed at civilians have caused a steady stream of casualties (64,130, or an average of 119 killed or injured per day in 18 months). Eighty percent of the victims were civilian. Despite hazardous conditions from direct shelling, disruption of vital lifelines, and shortage of supplies, medicines, oxygen, and anesthetics, the physicians continue to provide at least a minimum standard of resuscitative care. Seventy percent of all war victims were transported to hospitals in private vehicles. Most casualties (93%) received some form of prehospital, basic first-aid from lay bystanders or first responders. From November 1992 to February 1993, 27,733 patients were treated in hospitals, resulting in 2,139 major surgical procedures. The primary cause of death in 71 of 273 victims was prolonged hemorrhagic, hypovolemic shock. Sixty-one percent of these victims died within 24 hours of injury. CONCLUSIONS: Continuous needs assessment of a civilian population in a war zone should be accompanied by rapid delivery of outside aid. International "peacekeeping" forces should protect hospitals and their staffs, and ensure the entry of supplies and evacuation of some patients. A public trained in life supporting first-aid, and physicians and paramedics with experience in advanced life support may have enhanced lifesaving efforts in Sarajevo. PMID- 10155518 TI - Humanitarian, noncombat role for the military. PMID- 10155519 TI - Experiences from the World Health Organization Missions in Sarajevo, 1992-1993. PMID- 10155520 TI - Only an ounce. PMID- 10155521 TI - Hospital disaster operations during the 1989 Loma Prieta earthquake. AB - OBJECTIVE: To study hospital disaster operations following a major United States disaster. DESIGN: Researchers interviewed all 51 hospital administrators and 49 of 51 emergency department (ED) charge nurses and emergency physicians who were on duty at the study hospitals during the 13-hour period immediately following the 1989 Loma Prieta earthquake. SETTING: The 51 acute-care hospitals in the six northern California counties most affected by the Loma Prieta earthquake. MEASUREMENTS: Questionnaires and in-person interviews. RESULTS: The most frequently noted problem was lack of communications within and among organizations. Hospitals received inadequate information about the disaster from local governmental agencies. Forty-three percent of hospitals had inadequate back up power configurations, and five hospitals sustained total back-up generator failures. Twenty hospitals performed partial evacuations. CONCLUSIONS: The Loma Prieta earthquake did not cause total disruption of hospital services. Hospitals need to work with local governmental agencies and internal hospital departments to improve disaster communications. PMID- 10155522 TI - Effects of EMS transportation on time to diagnosis and treatment of acute myocardial infarction in the emergency department. AB - INTRODUCTION: Recent studies have documented decreased time to emergency department (ED) thrombolytic therapy with the use of prehospital electrocardiography. PURPOSE: Is the time to ED diagnosis and treatment of acute myocardial infarction (AMI) patients with thrombolytic agents decreased by emergency medical services (EMS) transport when compared with those transported by other means (non-EMS)? DESIGN: Retrospective, case-control study. POPULATION: The AMI patients treated with thrombolytic agents at a 34,000-visit, community hospital ED during 1992. METHODS: Review of records of patients who received thrombolytic therapy for AMI. Statistical analysis was performed using "Student's" t-test and Yates corrected Chi-square (chi 2). RESULTS: Eighty-seven patients received thrombolytic agents for AMI during 1992; 33 arrived by ambulance, 54 arrived by other methods. There were no differences in age, gender, or time of ED arrival among these groups. Ambulance patients received standard advanced life support (ALS) care, but not a 12-lead electrocardiogram (ECG) or thrombolytic agents. Ambulance patients experienced a significantly shorter time to first ECG (12.9 +/- 9.1 min. versus 20.8 +/- 25.3 min.; p = .028) and received thrombolytic therapy sooner than did controls (56.0 +/- 31.5 min. versus 78.0 +/- 63.4 min.; p = .018). There was no difference in time from diagnosis to treatment between these groups. CONCLUSION: Emergency medical services transport of AMI patients in this study decreased time to diagnosis and treatment and may be a confounder in studies that assess the value of field EMS interventions. Non-EMS AMI patients did not receive as rapid diagnosis and treatment, and emergency physicians should evaluate and address this issue in their departments. PMID- 10155523 TI - Effectiveness of interactive videodisc instruction for the continuing education of paramedics. AB - OBJECTIVES: To evaluate the effectiveness of interactive videodisc (IVD) instruction of paramedics through the use of computer analysis of trip sheets. DESIGN/SETTING: Prospective, controlled, in an urban 9-1-1, paramedic, emergency medical services (EMS) system with total call volume of 62,000/year; 15,000 advanced life support (ALS). INTERVENTIONS: All 150 paramedics in the system received eight hours of IVD instruction covering five subject areas: 1) airway; 2) head/cervical trauma; 3) chest; 4) shock; and 5) cardiac arrest. Trip sheets from 9,943 runs in the pre-IVD period were subjected to computer analysis, and a compliance score was generated using previously developed algorithms that assigned a weight to each omission and commission. After a nine-month IVD training period, 4,303 cases were collected and analyzed in the post-IVD period. Statistical analyses were made using "Student's" t-test and Chi-square with alpha set at 0.05. EXCLUSIONS: Only those records of adult patients who fit one of the five protocols were eligible for computer analysis. Of the 9,943 cases in the pre IVD group, 480 (4.8%) were excluded, all due to inadequate data recording by the paramedics. A statistically similar portion, 233 (5.4%) of the 4,303 post-IVD instruction cases were excluded (p = .15). RESULTS: Overall the mean compliance score of the pre-IVD group was 0.65 +/- 0.19 (+/- SD). The post-IVD group score was 0.65 +/- 0.19 (p = 0.99). Analysis of scores for each algorithm also showed no significant differences. This study had an observed power of .94 to detect a difference in compliance as small as 0.030. CONCLUSION: Eight hours of IVD instruction did not result in improved paramedic performance as judged by computer analysis of trip sheets. PMID- 10155524 TI - The effect of hospital resource unavailability and ambulance diversions on the EMS system. AB - HYPOTHESES: 1) There is no increase in transport or scene time of diverted patients and no increase in distances traveled; 2) hospital resource shortages bear no relationship to the number of patients diverted; and 3) paramedics are able to match their patient correctly with the resources available at a given hospital. METHODS: This was a five-month, prospective, observational study in an urban area with a population of 600,000 comparing all 9-1-1 ambulance diversions against a randomly selected sample of 5% of all other 9-1-1 originated patients. All patient diversions that originated from the 9-1-1 center are included in the study. RESULTS: Hospitals identify their diversion status on a community-wide computer system monitored at the 9-1-1 center and base station. Accepted categories include: 1) diversion of all patients through the 9-1-1 center from the emergency department (ED); 2) trauma system patients (T); 3) psychiatric secure beds (PSB); 4) general acute ward beds (AW); 5) critical care (CC); 6) computed tomography scan (CT); 7) labor and delivery (LD); and 8) pediatric beds (PEDS). Data were abstracted from 481 patients' records. A total of 111 were diverted from their intended destination. Transport times were longer and diverted patients traveled further (p < .002). Hospitals showing ED and LD diversion categories were more likely to have patients diverted away (r2 = .895, multilinear regression, p < .001). Of the 111 patients, 21 (19%) were diverted because of CC unavailability. Six of these (28%) were inappropriate because they did not fit the CC definition. CONCLUSIONS: In this system, hospital diversions increase transport times and distances traveled. Diversion of patients correlated strongly to unavailability of specific categories. Paramedics make errors in determining appropriate CC diversions. Systems reviewing their diversion problems need to assess the impact of longer out-of-hospital times and of certain diversion categories, and to clarify definitions. PMID- 10155525 TI - Determinants of on-scene time in injured patients treated by physicians at the site. AB - INTRODUCTION: The controversy surrounding the use of advanced life support (ALS) for the pre-hospital management of trauma pivots on the fact that these procedures could cause significant and life-threatening delays to definitive in hospital care. In Montreal, Quebec, on-site ALS to injured patients is provided by physicians only. The purpose of this study was to identify parameters associated with the duration of scene time for patients with moderate to severe injuries treated by physicians at the scene. HYPOTHESIS: The use of on-site ALS by physicians is associated with a significant increase in scene time. METHODS: A total of 576 patients with moderate to severe injuries are included in the analysis. This group was part of a larger cohort used in the prospective evaluation of trauma care in Montreal. Descriptive statistics, analysis of variance, multiple linear regression, and multiple logistic regression techniques were used to analyze the data. RESULTS: Use of ALS in general was associated with a statistically significant increase in the mean scene time of 6.5 min. (p = .0001). Significant increases in mean scene time were observed for initiation of an intravenous route (mean = 6.6 min., p = .0001), medication administration (mean = 5.7 min., p = .0001), and pneumatic antishock garment (PASG) application (mean = 9.3 min., p = .03). Similar differences were observed for total prehospital time. A significant increase in the relative odds for having long scene times (> 20 min.) also was associated with the use of ALS. This level of scene time was associated with a significant increase in the odds of dying (OR = 2.6, p = .009). CONCLUSION: This study shows that physician-provided, on-site ALS causes significant increase in scene time and total prehospital time. These delays are associated with an increase in the risk for death in patients with severe injuries. PMID- 10155526 TI - Saline locks in prehospital care. AB - OBJECTIVES: 1) To determine if paramedics could select appropriate patients for use of the saline lock; 2) to evaluate saline-lock patency upon arrival at the emergency department (ED); and 3) to define any cost-savings associated with the use of the saline lock. POPULATION: Patients in the prehospital setting who required intravenous (IV) access, but did not require fluid resuscitation. Patients with hypotension or multiple traumatic injuries were excluded. METHODS: Paramedics were given the option for the use of either the saline lock or a routine IV set-up. Initially, the reservoir was flushed with 1 ml 0.9 N saline solution and the flush was repeated only if medications subsequently were completed for each patient. Information collected included: 1) demographics; 2) reason for selection; 3) need for fluid infusion; 4) conversion of the lock to a routine IV set-up; and 5) administration of medications through the lock. Failures included inability to flush after arrival to the ED, or local infiltration detected on flush while in the ED. Costs associated with the use of the saline locks were compared with those associated with the use of traditional IV set-ups. Cost-savings were calculated as the cost of a traditional IV set-up minus costs of the lock set-up. RESULTS: A total of 58 male and 42 female patients was enrolled. All patients were assigned appropriately. The most commonly used indications included chest pain, possible stroke, and shortness of breath. Two locks were occluded, and two had infiltrated when flushed following arrival of the patient to the ED. Five patients had IV fluid loads initiated through the locks. Cumulative cost-saving were [U.S.]$130 to the hospitals and $1,710 to the patients or their carriers. Most paramedics were pleased with the performance and utility of the locks. CONCLUSIONS: The use of saline locks is an alternative to the use of traditional IVs in certain patients in the prehospital setting. PMID- 10155527 TI - Evolution of rescue systems: a comparison between Cologne and Cleveland. AB - INTRODUCTION: Comparisons of different emergency medical services (EMS) systems often are reduced to simple comparisons between distinct facilities or strategies (e.g., prehospital physician versus paramedic, "scoop and run" versus "stay and play"). METHODS: The EMS systems of similar cities (Cologne and Cleveland) in two different countries (Germany and the United States) are compared. The comparison is seen from the perspective of an evolutionary standpoint that reflects the development of the EMS system in connection with the special environments. Data on rescue times, facilities, and (trauma) outcomes are compared. RESULTS: No statistically significant differences in outcome between the systems were detected. CONCLUSION: Both systems are developed in special environments and are optimized over decades, which explains the similarities in outcome. PMID- 10155528 TI - National Association of Emergency Medical Services Physicians (NAEMSP) PMID- 10155529 TI - Comparison of interventions in prehospital care by standing orders versus interventions ordered by direct [on-line] medical command. AB - OBJECTIVE: The aim of this study was to compare the patient care measures provided by paramedics according to standing orders versus measures ordered by direct [on-line] medical command in order to determine the types and frequency of medical command orders. DESIGN: Prospective identification of patient care measures done as part of a prehospital quality assurance program. SETTING: An urban paramedic service in the northeast United States with direct medical command from three local hospitals. PARTICIPANTS: One thousand eight paramedic reports from October 1992 through March 1993. INTERVENTIONS: All patient care interventions recorded as done by standing orders or by direct medical command orders. Errors in patient care were determined by the same criteria as in the prior two studies of the same system. RESULTS: Direct medical command gave orders in 143/1,008 (14.2%) cases. Paramedics performed 2,453/2,624 (93.5%) of the total patient care interventions using standing orders. In 61 cases (6.1%), medical command ordered a potentially beneficial intervention not specified by standing orders or not done by the paramedic. 21/171 (12.3%) command orders were for additional doses of epinephrine or atropine in cardiac arrest cases (where the initial doses had been given under standing orders), and 59/171 (34.5%) were for interventions already mandated or permitted by standing orders. The paramedic error rate was 0.6%, and the medical command error rate was 1.8% (unchanged form the prior study of the same standing-orders system). CONCLUSION: Direct medical command gave orders in 14% of cases in this standing-orders system, but 35% of command orders only reiterated the standing orders. More selective and reduced uses of on-line command could be done in this system with no change in the types or numbers of patient care interventions performed. PMID- 10155530 TI - Emergency medical services liability litigation in the United States: 1987 to 1992. AB - INTRODUCTION: Although emergency medical services (EMS) liability litigation is a concern of many prehospital health care providers, there have been no studies of these legal cases nationwide and no local case studies since 1987. METHODS: A retrospective case series was obtained from a computerized database of trial court cases filed against EMS agencies nationwide. All legal cases that met the inclusion criteria were included in the study sample. These cases must have involved either ambulance collisions (AC) or patient care (PC) incidents, and they must have been closed between 1987 and 1992. RESULTS: There were 76 cases that met the inclusion criteria. Half of these cases involved an AC, and the other cases alleged negligence of a PC encounter. Thirty (78.9%) of the plaintiffs in the AC cases were other motorists, and 35 (92.1%) of the plaintiffs in the PC cases were EMS patients. Almost half of the cases named an individual (usually an emergency medical technician or paramedic) as a codefendant. Thirty one (40.8%) of the cases were closed without any payment to the plaintiff. There were five cases with plaintiffs' awards or settlements greater than [US] $1 million. Most (71.0%) of the ACs occurred in an intersection or when one vehicle rear-ended another vehicle. The most common negligence allegations in the PC cases were arrival delay, inadequate assessment, inadequate treatment, patient transport delay, and no patient transport. CONCLUSION: Risk management for EMS requires specific knowledge of the common sources of EMS liability litigation. This sample of recent legal cases provides the common allegations of negligence. REcommendations to decrease the legal risk of EMS agencies and prehospital providers are suggested. PMID- 10155531 TI - Emergencies in the school setting: are public school teachers adequately trained to respond? AB - INTRODUCTION: This study attempted to determine the extent of training and emergency care knowledge of public school teachers in midwestern states. A secondary purpose was to assess the frequency of injury and illness in the school setting requiring the teacher to first-respond. METHOD: A questionnaire and 14 item, scenario-based, emergency medical care test was developed and pretested. A discrimination index was used for validation of the instrument and a reliability coefficient of .82 was computed using the Kuder-Richardson Formula 20. A randomly recruited group of public school nurses from Arkansas, Kansas, and Missouri administered the instrument to 334 teachers who had no prior knowledge of the test. A random telephone survey of local school patrons also was completed to determine parental assumptions and expectations for emergency care and cardiopulmonary resuscitation (CPR) training in teachers. RESULTS: One-third (112 teachers) had no specific training in first-aid and 40% never had been trained in CPR. However, most (87%) of the respondents strongly agreed that emergency care training should be required in teacher preparation programs. Eighteen percent of the teachers responded to more than 20 injured or ill students annually, and 17% reported that they had encountered at least one life-threatening emergency in a student during their career. The average score for all respondents on the emergency care test was 58% (chi 2 = 8.12 +/- 2.42). Those with prior first-aid training averaged 60.5% (chi 2 = 8.47 +/- 2.32). Significant deficiencies were noted for recognition and appropriate treatment of student emergencies involving basic life support (BLS) and airway interventions, diabetic emergencies, and treatment of profuse bleeding. Forty of the 50 (80%) parents surveyed assumed that all teachers were adequately trained in first-aid and CPR. CONCLUSION: Public school teachers represent a potentially effective first-response component during disasters and isolated emergencies in the school environment. Overall, most of public school teachers in this study were deficient in both training and knowledge of emergency care and BLS modalities. Lack of effective, formal emergency care training in teacher preparation programs coupled with no continuing education requirement is a possible explanation of these results. Emergency medical services providers should seek opportunities to help with first responder training and continuing education in their schools. PMID- 10155532 TI - Patient outcome using medical protocol to limit "lights and siren" transport. AB - INTRODUCTION: Emergency medical services vehicle collisions (EMVCs) associated with the use of warning "lights and siren" (L&S) are responsible for injuries and death to emergency medical services (EMS) personnel and patients. This study examines patient outcome when medical protocol directs L&S transport. DESIGN: During four months, all EMS calls initiated as an emergency request for service and culminating in transport to an emergency department (ED) were included. Medical criteria determined emergent (L&S) versus non-emergent transport. Patients with worsened conditions, as reported by EMS providers, were reviewed. SETTING: Countywide suburban/rural EMS system. RESULTS: Ninety-two percent (1,495 of 1,625) of patients were transported nonemergently. Thirteen (1%) of these were reported to have worsened during transport, and none of them suffered any worsened outcome related to the non-L&S transport. CONCLUSION: This medical protocol directing the use of warning L&S during patient transport results in infrequent L&S transport. In this study, no adverse outcomes were found related to non-L&S transports. PMID- 10155533 TI - System implications of the ambulance arrival-to-patient contact interval on response interval compliance. AB - BACKGROUND: In some emergency medical services (EMS) system designs, response time intervals are mandated with monetary penalties for noncompliance. These times are set with the goal of providing rapid, definitive patient care. The time interval of vehicle at scene-to-patient access (VSPA) has been measured, but its effect on response time interval compliance has not been determined. PURPOSE: To determine the effect of the VSPA interval on the mandated code 1 (< 9 min) and code 2 (< 13 min) response time interval compliance in an urban, public-utility model system. METHODS: A prospective, observational study used independent third party riders to collect the VSPA interval for emergency life-threatening (code 1) and emergency nonlife-threatening (code 2) calls. The VSPA interval was added to the 9-1-1 call-to-dispatch and vehicle dispatch-to-scene intervals to determine the total time interval from call received until paramedic access to the patient (9-1-1 call-to-patient access). Compliance with the mandated response time intervals was determined using the traditional time intervals (9-1-1 call-to scene) plus the VSPA time intervals (9-1-1 call-to-patient access). Chi-square was used to determine statistical significance. RESULTS: Of the 216 observed calls, 198 were matched to the traditional time intervals. Sixty-three were code 1, and 135 were code 2. Of the code 1 calls, 90.5% were compliant using 9-1-1 call-to-scene intervals dropping to 63.5% using 9-1-1 call-to-patient access intervals (p < 0.0005). Of the code 2 calls, 94.1% were compliant using 9-1-1 call-to-scene intervals. Compliance decreased to 83.7% using 9-1-1 call-to patient access intervals (p = 0.012). CONCLUSION: The addition of the VSPA interval to the traditional time intervals impacts system response time compliance. Using 9-1-1 call-to-scene compliance as a basis for measuring system performance underestimates the time for the delivery of definitive care. This must be considered when response time interval compliances are defined. PMID- 10155534 TI - Teaching basic EMTs endotracheal intubation: can basic EMTs discriminate between endotracheal and esophageal intubation? AB - HYPOTHESIS: Advanced airway intervention techniques are being considered for use by basic emergency medical technicians (EMTs). It was hypothesized that basic EMTs would be able to discriminate reliably between intratracheal and esophageal endotracheal tube placement in a mannequin model. DESIGN: An airway mannequin with a closed chest cavity was intubated randomly either esophageally or tracheally, and the cuff was inflated. A stethoscope, bag ventilator, and laryngoscope were available next to the mannequin. Placement was assessed by auscultation or direct visualization at the discretion of the EMT. A blinded investigator graded the student. SETTING: A classroom in a large, urban medical center. PARTICIPANTS: Subjects were basic EMTs who volunteered to take part after the conclusion of a six-hour endotracheal intubation training course. RESULTS: Thirty-three subjects were tested. Seventeen of 18 (94%) tracheal intubations and 11 of 15 (73%) esophageal intubations were identified correctly. Only 72% of the students listened to the epigastrium, 81% listened to the lungs, and 85% attempted ventilation. The 10 students who visualized the cords discovered all five esophageal intubations. The 23 students who did not visualize the cords missed four and found six esophageal intubations. CONCLUSION: Basic EMTs had difficulty assessing endotracheal tube placement in a mannequin model. The 27% miss rate for identifying esophageal intubations suggests that basic EMTs will require additional training for safe field use of any airway that requires assessment of tube placement. PMID- 10155535 TI - Critical thinking: incorporation into the paramedic curriculum. AB - The purpose of this paper is to present approaches to foster critical thinking skills within the context of the current paramedic curriculum. It reviews some of the definitions and concepts of critical thinking from selected adult education and nursing literature in an attempt to formulate a workable definition as it applies to paramedics. From that definition, elements are identified and incorporated to form a teaching model for use in presenting the curriculum content. Some sample teaching strategies based on revised objectives of the airway/ventilation section also are included. PMID- 10155536 TI - Emergency medical services systems in the United States and China: a developmental comparison. AB - International emergency medical services (EMS) consultation requires many sensitivities to cross-cultural issues. Contemporary EMS models in developed countries have, by necessity, a systems framework. This study compares evolving EMS systems in the United States and China. It is concluded, that, no matter what the potential and cultural differences might be, a systems framework inherently will emerge in EMS development. As such, the EMS components recognized often will expose an evolving systems approach with more similarities than differences and can reveal strategies for improvement. Providing a developmental comparison process is a necessary first phase in analysis of a country's systems development or restructuring. PMID- 10155537 TI - Outcome of patients after air medical transport for management of nontraumatic acute intracranial bleeding. AB - INTRODUCTION: Patients with acute, intracranial bleeding (ICB), particularly from intracranial aneurysms, are believed to be at high risk for rebleeding or neurologic deterioration if subjected to noise, motion, or stress, but are transported by helicopter with increasing frequency. This study was undertaken to examine the characteristics, safety, and outcomes of air transport for patients with acute subarachnoid hemorrhage (SAH) or other forms of acute ICB in an air medical system. METHODS: Charts of all patients with spontaneous, acute ICB who were transported by air from 1986 through 1989 were reviewed. Age, gender, time of transport, transport management measures, pre- and post-transport Glasgow Coma Scale (GCS) score, intensive care unit (ICU) and hospital days, operations, and mortality were compiled for all patients and analyzed. RESULTS: Eighty-seven patients ranging in age from 2 to 83 years (mean: 47.5 +/- 18.5 years) met entry criteria. The source of bleeding was cerebral aneurysm in 37 patients; intraparenchymal hemorrhage in 29; an unidentified vascular source in 11; and arteriovenous malformation (AVM) in 10. Mean GCS score measured in 69 patients before and after transport was 10.5 +/- 4.5 Glasgow Coma Scale score did not change during transport in 61 patients (88%), improved in three (4%), and deteriorated in five (7%). Fifty-nine patients (69%) underwent operations, 36 (41%) within 24 hours of arrival. Mean ICU stay was 14 days (95% CI: 12-15); mean hospital stay was 36 days (95% CI: 27-45 days). Overall mortality was 25% (95% CI: 16-34 days). A GCS score of 3 to 8 at time of transport was associated with both increased hospital length of stay and higher mortality. Patients transported within eight hours of symptom onset had lower GCS scores, but outcome measures were not significantly different from those transported later. CONCLUSIONS: Emergency air medical transfer of patients with acute ICB for definitive neurosurgical care appears to be both safe and effective, and facilitates early definitive diagnosis and operative intervention. PMID- 10155538 TI - Public perceptions of a rural emergency medical services system. AB - INTRODUCTION: To determine the awareness of citizens and physicians concerning the capabilities of a rural emergency medical services (EMS) system. HYPOTHESIS: Citizens and physicians are unaware of the capabilities of the EMS system. METHODS: Residents were selected randomly from the local telephone directory and asked a series of structured questions about their EMS agency. A written survey was distributed to area physicians. Chi-square analysis was used to compare the proportion of respondents who knew the available interventions in their community with the proportion of those who did not. Statistical significance was inferred at p < 0.01. RESULTS: A total of 49% of the citizens were able to identify available skills, and 41.4% of the physicians were able to identify available skills. Physicians were less likely than were the citizens to be able to identify the skills performed by each provider (p < 0.001). CONCLUSION: This study indicates that both physicians and the lay public have little understanding of the capabilities of their EMS system. PMID- 10155539 TI - Natural hazards: causes and effects. Lesson 2--earthquakes. PMID- 10155540 TI - The role of alloreactive cytotoxic and lymphokine-secreting T lymphocytes in the development of acute graft-versus-host disease. AB - The development of acute graft-versus-host disease (GVHD) after allogeneic bone marrow transplantation is mediated by alloreactive donor T cells infused with the bone marrow inoculum. This review discusses the role and significance of host specific cytotoxic and lymphokine-secreting donor T cells for the prediction and generation of acute GVHD. PMID- 10155541 TI - Cellular and molecular mechanisms of graft-versus-host disease. PMID- 10155542 TI - Molecular and biological actions of cyclosporin A and FK506 on T cell development and function. AB - The microbial products cyclosporin A (CsA) and FK506 are potent immunosuppressive agents in experimental and clinical transplantation. Binding of both drugs to intracellular immunophilins results in the inhibition of calcineurin activity and the prevention of interleukin-2 gene transcription and, thus, in the inhibition of T cell receptor-dependent T cell activation. CsA and FK506 also have a profound effect on the structure and function of the thymus with disruption of positive and negative selection of T cells. These influences on thymic microenvironment and T cell ontogeny disrupt the induction or maintenance of self tolerance (or both) and are thus of relevance to clinical transplantation immunology. PMID- 10155543 TI - Effect of HLA incompatibility in marrow transplantation from unrelated and HLA mismatched related donors. AB - Transplants from related donors who share one HLA haplotype and are variably matched with the recipient for HLA-A, B, or DRB1 loci on the unshared haplotype are associated with increased risks of graft failure and graft-versus-host disease (GVHD) that correlate with the degree of HLA mismatch. Survival, however, is not necessarily inferior if recipient incompatibility is limited to one HLA locus. Available methods for post-transplant immunosuppression have not allowed similar success with transplants incompatible for two or three HLA loci. GVHD incidence and severity can be decreased by depletion of donor T cells from the marrow inoculum. However, the potential benefit is offset by increased graft failure and leukemia relapse with no improvement in survival. Since fewer than 30% of the patients in North America or Europe have an HLA-matched sibling and less than 5% have a one HLA-locus mismatched relative, most candidates for an allogeneic marrow transplant are in need of an unrelated donor. As of October 1993, the National Marrow Donor Program (NMDP) has accrued more than 1 million volunteers typed for HLA-A and B, including 200,000 typed for HLA-DR, and has provided donors for more than 2000 transplants. The probability of finding an HLA A, B, DR match at the initial search has increased from 10-15% in 1987, to 50-55% in 1992. An additional 12% of patients will find a match when available HLA-A and B matched donors are typed for DR, and 20% of patients have a one HLA-locus incompatible unrelated donor. Through an international network of regional registries a search for an unrelated donor can now be conducted among 1.7 million volunteers worldwide. Unrelated donor transplants have allowed long-term disease free survival of patients with a variety of hematological disorders. When compared to HLA-matched sibling transplants, unrelated donor transplants are associated with an increase in the incidence of graft failure and GVHD. Such an increase may be due to undetected HLA disparities or to non-HLA-linked histocompatibility genes. At our center patients with CML in chronic phase, the most common indication for unrelated donor transplantation, have a 50-55% probability of survival 2-6 years after an unrelated donor transplant, whereas patients with aplastic or refractory anemia have a 25-35% probability of survival.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10155544 TI - Management of graft-versus-host disease. PMID- 10155545 TI - Graft-versus-host disease and the development of late complications. AB - Graft-versus-host disease (GVHD) in both its acute and chronic forms is a severe complication after allogeneic marrow transplantation. GVHD is associated with structural and functional defects in many organs and tissues. Severe immunoincompetence may result in frequent, often severe and at times fatal infections caused by various organisms. Prolonged antibiotic prophylaxis, and possibly immunoglobulin administration are beneficial. Ocular complications, airway and pulmonary damage, and oral or dental problems may cause severe morbidity. Despite aggressive management, a proportion of patients will succumb to these complications. Severe skin disease and joint contractures are currently seen less frequently, mostly due to early treatment of the disease. Psychosocial rehabilitation of patients with chronic GVHD is a demanding and protracted challenge and should be approached by a multidisciplinary team. PMID- 10155546 TI - Recovery of both acute massive pulmonary hemorrhage and acute renal failure in a systemic lupus erythematosus patient with lupus anticoagulant by the combined therapy of plasmapheresis plus cyclophosphamide. AB - Acute massive pulmonary hemorrhage (AMPH) is a rare and highly fatal complication in systemic lupus erythematosus (SLE). We report here survival in a case of AMPH in a SLE patient with both rapidly progressive glomerulonephritis and lupus anticoagulant. The AMPH occurred while the nephritis was refractory to 2 courses of pulse methylprednisolone therapy. After combined therapy with plasmapheresis plus cyclophosphamide, circulating immune complex levels declined, AMPH recovered, and serum creatinine levels returned to normal. In conclusion, the combined therapy of plasmapheresis plus cyclophosphamide should be considered for treating AMPH especially in those SLE patients with rapidly progressive glomerulonephritis. PMID- 10155547 TI - Composition and immunoreactivity of serum low density lipoproteins (LDL) before and after LDL-apheresis on dextran sulfate-cellulose columns. AB - The changes in low density lipoprotein (LDL) composition and immunoreactivity occurring after LDL-apheresis on dextran sulfate-cellulose columns (DSC) were investigated in 4 hypercholesterolemic patients. After apheretic treatment, serum levels of total cholesterol, triglycerides and apolipoprotein B (apo B) were decreased by 63, 80 and 65%, respectively, whereas the high density lipoprotein (HDL)-cholesterol remained unchanged. At the end of apheresis, LDL contained less triglycerides, more phospholipids and apo E and the ratio of LDL core lipid components, cholesteryl esters and triglycerides, to LDL surface lipid components, unesterified cholesterol and phospholipids was significantly lower. The post-apheretic LDL were characterized by the presence of subfractions slightly larger than those observed in the pre-apheretic LDL. The modifications of the composition and size of LDL after apheresis were accompanied by a relative increase in the immunoreactivity of 4G3 epitope, an apo B epitope located near the LDL-receptor binding site, with no change in the affinity of 1D1, an apo B epitope located in the amino-terminal region of the molecule. The changes in LDL composition, size and immunoreactivity following apheresis, suggest that postapheresis LDL could contain newly synthesized LDL, different from mature LDL. Thus, LDL-apheresis treatment could provide the opportunity to study the structural change of LDL during intravascular metabolism. PMID- 10155548 TI - Results with new software for plateletpheresis systems. AB - New software for the cell separators A 201 and CS 3000 Plus have been developed by Baxter. Fresenius recently offered a single needle option for the AS 104 device. The results of separation are described with respect to total platelet yield, efficiency and cell contamination of the platelet concentrate (PC). Two software programs were evaluated in both the A 201 (version 5.12 and 5.13) and AS 104 cell separators (version 4560 with different separation parameters according to protocol IV and V). With software version 5.12, the A 201 collected 2.0 +/- 0.9 x 10(11) platelets in 200 mL plasma whereas 2.3 +/- 0.7 x 10(11) platelets could be harvested with version 5.13. The separation efficiencies were 32.1 +/- 11.6 and 34.7 +/- 10.7%, respectively. The leucocyte contamination was 5.6 +/- 4.6 x 10(8) with software version 5.12 and 4.9 +/- 7.6 x 10(8) with the 5.13 version. With the CS 3000 Plus cell separator, 2.9 +/- 0.8 x 10(11) platelets (efficiency 38.4 +/- 8.2%) could be harvested in 208 +/- 2 mL plasma. The white blood cell contamination was extremely low (1.4 +/- 3.2 x 10(6). There was a high separation efficacy with the Fresenius single needle procedure of 59.1 +/- 10.6% (protocol IV) and 58.7 +/- 7.3% (protocol V), respectively. The total number of platelets sampled in 338 +/- 21 mL plasma was 3.1 +/- 0.8 x 10(11) in protocol IV.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155549 TI - Regulatory review of cellular and gene therapies: an overview of the process. AB - Cell and gene therapies, using several different approaches, have been proposed for a variety of genetic diseases, cancer and AIDS. The major regulatory review process in the US consists of an institutional review board, the recombinant DNA advisory committee (RAC) and the Food and Drug Administration (FDA). Within the Center for Biologics Evaluation and Research, the Division of Cellular and Gene Therapies has been formed to primarily review investigational new drug applications (INDs) for cellular and gene therapies. Several appropriate "points to consider" documents have been prepared and the RAC has approved over 40 clinical protocols. Advances in biotechnology and the scientific basis for these advances are changing rapidly. Although a flexible, case-by-case approach is necessitated by these rapid changes, regulatory concerns common to all biologicals administered to human subjects remain unchanged. These include safety, efficacy, purity, potency, quality control and assessment, and reproducibility of individual lots. The goal of the review process is a prompt, complete and meticulous review. The emphasis of a pre-IND meeting is toward a working relationship between the sponsor and the FDA prior to the phase I, II and III clinical trials. A timely and ongoing evaluation of pre-clinical testing cannot be overemphasized in this rapidly growing and changing field. The development of a working relationship at this stage will ensure a seamless integration of the IND process with the product and establishment license applications. Because replication-competent retrovirus (RCR) represents a potential for pathogenicity, the FDA is recommending a conservative approach to RCR testing. PMID- 10155550 TI - Peripheral blood stem cell transplants in lymphoma. PMID- 10155551 TI - Stem cell procurement and transplantation in paediatric patients. AB - Harvesting of peripheral blood stem cells (PBSC) with cell separators has become a safe procedure used in many centers. However, when PBSC harvesting in small children is considered, problems due to the small volume, loss of protein and red cell trapping arise. Priming the tubing of the cell separator with either albumin or red cells is necessary in children with a blood volume of less than 1500 mL. Ten children aged from 0.8 to 5 years underwent PBSC-apheresis without major problems despite low blood volume. Forty-one children with various malignancies had a total of 189 PBSC-aphereses with a median of 5 phereses for an individual patient. Harvesting of PBSC was started after recovering from neutropenia following scheduled chemotherapy. An average of 3.7 x 10(4)/kg CFU-GM per child was harvested. Sustained engraftment after myeloablative chemotherapy could be achieved when the dose of the retransfused PBSCs was greater than 3 x 10(4)/kg. Long-lasting complete remission was observed in 5 out of 25 patients. PMID- 10155552 TI - Quality of plasma for fractionation--does it matter? AB - Many plasmapheresis techniques cause greater activation of platelets, complement and coagulation than does simple whole blood collection. Activation of the coagulation cascade has been particularly evident in tests for potential thrombogenicity in prothrombin complex concentrates made from apheresed plasma. Attempts to improve the factor VIII content and fractionation yield of source plasma have centred on rapid freezing, increased concentration of anticoagulants and the exploitation of anticoagulants optimal for the preservation of coagulant, rather than cellular, activities. The cumulative advantage is of the order of 10% over recovered plasma. There are potential pitfalls in applying low-citrate anticoagulation strategies to plasmapheresis. Recalcification of citrated plasma, under cover of an optimal concentration of heparin, might be explored more vigorously. PMID- 10155553 TI - Aspects of platelet storage. AB - The proper storage of platelets requires sufficient knowledge of the behaviour of these cells, made by nature to react instantly. It is important not to activate them during preparation and storage and to maintain oxidative metabolism at the highest possible degree. Optimally, the citrate concentration in the storage medium should be 8-10 mmol/L. The addition of acetate either to the anticoagulant or to a platelet additive solution gives the potential for improved platelet storage. In order to evaluate the clinical efficiency of platelet concentrates (PCs), corrected count increment is to be recommended for frequent use. The in vitro bleeding time seems to be a valuable supplement, both for research and clinical purposes. Bacterial contamination is a threat which can be diminished by using an appropriate technique for preparation and storage. Rapid automated bacterial culture makes it possible to detect contamination which may be particularly important if the shelf life of PCs is being extended beyond the present 5 days. PMID- 10155554 TI - Leucocyte contamination of platelet products. PMID- 10155555 TI - A contribution to the indications for platelet transfusion and determination of its therapeutic efficacy. AB - The platelet count does not really reflect the true bleeding risk in chronically thrombocytopenic patients. Recently, we reported on two modifications of an in vitro bleeding test (IVBT) which appeared to be suitable for the evaluation of primary non-vascular hemostatis in thrombocytopenic and anemic patients (platelets 10-50,000/microL, hct 16-30 L/L). We report on the clinical study conducted with the IVBT modification which proved to be superior. Fifty thrombocytopenic patients, 42 with bone marrow hypoplasia and 8 with autoimmune thrombocytopenia, were followed up for a total of 686 days and received 161 platelet transfusions (mainly from cell separator). The IVBT was carried out with the Thrombostat 4000 in triplicate using 120 microns filters and evaluating the occlusion time (OT). Additionally, cell count, hematocrit, body temperature, platelet volume, platelet distribution width, Simplate time and a detailed analysis of bleeding signs for the calculation of a bleeding score were performed. The IVBT modification used allowed the determination of platelet related bleeding risk in thrombocytopenic patients. With the IVBT, significant differences in platelet function in different patients could be demonstrated which primarily reflected the underlying disease. In addition, bone marrow regeneration correlated with platelet function. From the findings of this study, the authors formulate criteria for the indication of platelet transfusion which includes platelet function as well as the platelet count. Increased individual bleeding risk factors have to be considered too. But before generalization these criteria have to be verified by a controlled prospective study.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10155557 TI - Immune modulating effects of intravenous immunoglobulin (IVIg) in autoimmune diseases. AB - Administration of intravenous immunoglobulins (IVIg) have now been reported to be beneficial in a large number of autoimmune diseases, whether mediated by autoantibodies or by T cells. We have proposed that the immunoregulatory effect of IVIg in autoimmune diseases is dependent on the selection of recipient's immune repertoires by variable (V) regions of infused immunoglobulins. Thus: (a) IVIg contains antibodies reactive with idiotypes of natural and disease-related autoantibodies and surface immunoglobulins of B cells; IVIg also contains antibodies reactive with idiotype, framework and constant regions of the beta chain of the alpha beta T cell receptor; (b) infusion of IVIg results in transient or long-lasting suppression of specific autoantibody clones in vivo and in stimulation of a distinct subset of B cells reactive with F(ab')2 fragments of IVIg; (c) infusion of IVIg alters the general "architecture" of the network as assessed by studying the kinetic patterns of spontaneous fluctuations of natural autoantibodies in serum; (d) infusion of normal mouse Ig in healthy adult mice selects expressed immune repertoire by removing late pre-B and B cells in the bone marrow, mostly those expressing D proximal VH genes, and by activating distinct subsets of B cells and CD4+ T cells in the spleen; and (e) infusion of IVIg results in a modulation of synthesis and release of cytokines. Although dependent on the V-region reactivities (composition) or injected preparations, these effects probably also require that the infused immunoglobulin contains an intact Fc moiety. This review focuses on autoimmune and inflammatory diseases in which IVIg therapy has been beneficial. Recent recommendations from a committee of experts for IVIg therapy have been pointed out. PMID- 10155556 TI - Treatment of polyarteritis nodosa and Churg-Strauss syndrome: indications of plasma exchanges. AB - To define the most effective treatment for polyarteritis nodosa (PAN) and Churg Strauss syndrome (CSS), we undertook 4 consecutive prospective therapeutic trials including 236 patients and tried to answer several important questions: Should cyclophosphamide (CYC) be given as the first-line treatment? What is the place of plasma exchanges (PE) in the treatment of systemic vasculitis? and does hepatitis B virus (HBV) related PAN require treatment? Our first randomized trial in 71 patients (1981-1983) compared the association of CYC with corticosteroids (CS) and PE to CS and PE, in order to evaluate the efficacy of CYC given as the first line treatment to control disease activity and subsequent survival of PAN and CSS patients. Between December 1983 and December 1988, we conducted two trials simultaneously: one aimed at patients without HBV markers and the second at patients with HBV markers. In 78 patients without HBV markers, we compared prednisone and PE to prednisone alone as the initial therapeutic regimen. In 33 patients with PAN related to HBV, a new therapeutic strategy was applied as an alternative to long-term steroid and immunosuppressive therapy: short-term steroid therapy and PE were used to control the evolution of PAN and anti-viral therapy was administered to suppress the etiological agent of the vasculitis. In the last protocol including 56 patients and addressed to severe PAN without HBV markers or CSS we have shown that PE did not improve the prognosis and control of the disease. Twelve years after the beginning of the trials on PAN and CSS patients, we think that the therapeutic strategy should be as follows: In PAN without HBV and CSS: prednisone in association with CYC improves the control of the disease despite infectious side effects which may be reduced by better CYC dose adaptation. In PAN related to HBV: The first-line treatment should be the association of anti-viral agents and PE. This treatment was effective and cured a majority of patients within 2 to 3 months; half of them seroconverted. The length of HBV infection before its diagnosis, delay before initiation of treatment and previous immunosuppressive therapy led to a poor seroconversion rate. The role of PE in the treatment of systemic necrotizing vasculitis: PE are obviously useful in PAN related to HBV where immune complex deposition has been demonstrated. When PAN is not related to HBV and in CSS, even in severe cases, there is presently no argument supporting systematic administration of PE at the time of diagnosis. PMID- 10155558 TI - Treatment of autoimmune disease by immunomodulation through extracorporeal elimination and intravenous immunoglobulin. AB - If customary drug mediated immunosuppressive therapy leads to intolerable side effects or is inefficient, extracorporeal elimination and untargeted or targeted immunoglobin therapy modulating the immune response are taken into consideration for the treatment of patients with autoimmune diseases. Both elimination and immunoglobulin therapy, are not alternatives but appear to act complementary, if sequentially applied. Selective immunoadsorption is increasingly applied for extracorporeal elimination and is able to replace plasma exchange therapy. Both, hydrophobic interaction chromatography and affinity chromatography are effective in given clinical conditions. Therapeutic affinity chromatography appears to be superior to hydrophobic interaction chromatography, if an effective, rapid elimination of the disease promoting agent is desired. Experience with therapeutic chromatography collected in the past, indicates that a rapid elimination of immunoglobulins and the subsequent intravenous infusion of 7S immunoglobulin is superior to elimination or untargeted immunomodulation alone. These experimental approaches lead to an extension of the available treatment modalities. However, controlled trials rather than anecdotal reports are needed, to provide substantial information. PMID- 10155559 TI - Technical and clinical experience with protein A immunoadsorption columns. AB - Protein A adsorption (Immunosorba, Excorim, Sweden) is a potent tool for the rapid removal of antibodies from the circulation. In comparison to conventional plasma exchange therapy, Protein A adsorption offers the advantage of processing large amounts of plasma, removing up to 87% of the initial level of IgG in one session without a clinically significant loss of fibrinogen. So far 61 treatments have been carried out in our department without serious side effects. PMID- 10155560 TI - Clinical applications of protein A immunoadsorption in thrombocytopenic disorders. PMID- 10155561 TI - Extracorporeal photochemotherapy: a scientific overview. AB - Extracorporeal photochemotherapy was developed for treatment of cutaneous T-cell lymphoma (CTCL). Several independent and multicenter trials using lymphapheresis with 8-methoxypsoralen (8-MOP) activated by shortwave ultraviolet light have demonstrated the clinical benefit of this modality for treatment of advanced CTCL. Recently, trials using the combination of photochemotherapy and recombinant interferons or photochemotherapy and low doses of methotrexate have been initiated to enhance the response to photopheresis. Also, a multicenter study evaluating a new 8-MOP formulation that could be added into the leukocyte/plasma fractions prior to ultraviolet exposure is in progress in CTCL patients. The applications of photochemotherapy in the treatment of other disorders of T-cells are being examined in ongoing clinical trials. Pilot studies have been completed and controlled trials are under way in patients with autoimmune diseases. Important information has emerged regarding the potential use of photopheresis for prevention of solid organ allograft rejection. Several investigators have undertaken pilot studies comparing the efficacy of photochemotherapy with the conventional immunosuppressive therapy for treatment of cardiac transplant rejection. It is hoped that photochemotherapy can induce an immune tolerance in the allograft setting and therefore eliminate or reduce the use of cyclosporin. Other considerations have led to the use of photochemotherapy in the prevention and treatment of graft-versus-host disease after alloeneic and unrelated donor marrow transplantation. Randomized studies are required to evaluate the impact of photochemotherapy on the course of graft-versus-host disease and overall survival. PMID- 10155562 TI - Treatment of Sezary syndrome with extracorporeal photochemotherapy. PMID- 10155563 TI - Extracorporeal photochemotherapy: evaluation of two techniques and use in connective tissue disorders. AB - Extracorporeal photochemotherapy (ECP) consists of collection of mononuclear cells, their irradiation with UV-A light in the presence of a photoactivable molecule--8-methoxy-psoralen (8-MOP) being the most widely used--and their reinjection into a patient. Two technical approaches have been developed. The photopheresis procedure involves four steps: (i) 8-MOP is given to the patient orally, 2 h before collection of white blood cells; (ii) a discontinuous flow cell separator (UVAR, Therakos, West Chester, PA, U.S.A.) is used for cell collection. The final product (740 mL) has a hematocrit of 4.5 +/- 1.7%); (iii) irradiation, performed with the same UVAR apparatus, begins before all the cells are collected, and lasts for 180 min after collection; and (iv) after irradiation, the buffy-coat is reinjected into the patient. We developed a technique summarized as follows: (i) mononuclear cell collection is performed using the Spectra (Cobe, Denver, CO, U.S.A.) cell separator, which provides a highly enriched mononuclear cell concentrate (always > 90% purity), in a small volume < 150 mL, subsequently adjusted to 300 mL for irradiation. Hematocrit of the final product is always < 2%. (ii) Soluble 8-MOP is added to the mononuclear cell concentrate at a final concentration of 200 ng/mL. (iii) Mononuclear cell concentrate is transferred in an EVA plastic bag (Macopharma, Tourcoing, France) to ensure an efficient irradiation with a UV irradiator (Vilber Lourmat, Marne-la Vallee, France). (iv) After irradiation at 2 J/cm2 (time < 20 min), the cells are reinfused into the patient. Experimental and clinical data suggest that ECP has potential applications in the treatment of connective tissue disorders, such as systemic sclerosis and rheumatoid arthritis. Although encouraging data have been obtained, further clinical trials are warranted to establish the role of this therapy in these indications. PMID- 10155564 TI - Intraoperative red cell retrieval in a multiple theatre programme. PMID- 10155565 TI - Autologous blood pre-deposit and cell salvage in orthopedic surgery. AB - A successful autologous blood program should enrol all appropriate patients, conserve homologous blood and minimize the exposure to the risks of donor blood. A program of autotransfusion and proper use of blood has been implemented since 1980 with the objectives of including all eligible patients and to transfuse autologous blood only. The following strategies were adopted: critical review of transfusion indications; control of over-transfusion; avoidance of waste; systematic and integrated use of all autotransfusion techniques currently available. Results in 1992 in elective surgery: 98% enrolment, 75% blood conservation. Exposure to homologous blood was completely avoided in 53% of the cases. PMID- 10155566 TI - The Allen Latham Award Lecture: specific immunotherapy for autoimmune disease. PMID- 10155567 TI - Application of therapeutic plasma exchange in hematology. AB - Therapeutic plasma exchange (TPE) was used in 146 patients with hematologic disorders: hyperviscosity syndrome, 74; cryoglobulinemia, 53; porphyria, 9; immune complex disease, 3; cold agglutinin disease, 1; hemolytic uremic syndrome, 1; autoimmune hemolytic anemia, 1; autoimmune thrombocytopenia, 1; autoimmune neutropenia, 1; Clq deficiency, 1; and secondary immunodeficiency, 1. It was shown that TPE applied in patients with hyperviscosity syndrome resulted in rapid reduction of paraprotein concentrations, and normalization or significant decrease of serum viscosity associated with marked clinical improvement (regression of neurologic, renal, hematologic, visual and other disturbances). Application of TPE in patients with cryoglobulinemia resulted in plasma cryoglobulin reduction and clear clinical effects (blood flow improvement, skin ulcer healing, reversal of impaired renal function and disappearance of purpura and other abnormalities). Very good results were obtained in patients with porphyria (decreased sensitivity to sunlight) and also in patients with Clq deficiency. Satisfactory clinical improvement and better laboratory findings were also seen in patients with immune complex disease, autoimmune hemolytic anemia, autoimmune thrombocytopenia and hemolytic uremic syndrome. PMID- 10155568 TI - Hemapheresis versus intravenous IgG: a debate for the 21st century. PMID- 10155569 TI - Treatment of Guillain-Barre syndrome: listening carefully to the music before jumping on the bandwagon. PMID- 10155570 TI - Measuring up. A critique of program evaluation and outcomes studies in industrial rehabilitation. PMID- 10155571 TI - Functional capacity assessment. The new health care system will demand documentation that is objective, reliable, and thorough. PMID- 10155572 TI - Patient-centered care. Designing and delivering quality rehab services means placing patient needs over those of providers. PMID- 10155573 TI - One-stop shopping. Developing an industrial rehabilitation service to meet consumer demand and competition. PMID- 10155574 TI - Stepping beyond traditional roles. Expanding opportunities for PTs and OTs in worker health have led to new questions about potential liability exposure. PMID- 10155575 TI - When S pneumoniae is penicillin-resistant. PMID- 10155576 TI - Acellular pertussis vaccines: what lies ahead? AB - A safe acellular pertussis vaccine may be in your patients' future. Here's the latest on how this vaccine's effectiveness and side effects compare with those of its whole cell counterpart. PMID- 10155577 TI - The use--and misuse--of growth hormone. AB - Recombinant growth hormone is an effective treatment for many children with short stature, but certainly not for all of them. The approach outlined here will help you make the right choices. PMID- 10155578 TI - Children with chronic conditions need your help at school. AB - As they try to make the most of their opportunities at school, children with chronic conditions need a pediatrician's advocacy. Use your knowledge of the illness, the law, and the resources in your community to play an active role. PMID- 10155579 TI - What's new in interventional radiology. AB - New applications of interventional radiology can remove foreign bodies from the esophagus, treat vascular malformations, and more. These relatively noninvasive and inexpensive alternatives to conventional surgery deserve a place on your list of management options. PMID- 10155580 TI - The National Health Service pharmaceuticals market. Recent and prospective reforms. PMID- 10155581 TI - Recent public policies in The Netherlands to control pharmaceutical pricing and reimbursement. AB - In The Netherlands, the rate of consumption of medicine is low compared with that in other member states of the European Community. Nevertheless, expenditure on medicines is high in this country, because of a high price level. In the past decade, the cost of medicines has been growing more rapidly than the total expenditure on healthcare in The Netherlands. This prompted The Netherlands government to take action against the rise in the cost of medicines. Some policies were directed at the volume of consumption, but most focused on price. All had in common that they failed to produce lasting cost containment or did not stand up in court or to political debate. As a result, the measures proposed and implemented by the government have become increasingly harsh, departing from the Dutch tradition of harmonious policy-making carried out jointly by government and societal groups. The latest step has been the introduction (as of July 1, 1993) of a new version of a price reference system, which discourages the prescription of innovative but expensive drugs. It is too early to tell whether this policy will have a more enduring effect on cost than the previous measures. PMID- 10155582 TI - The impact of recent legislative change in Germany. AB - Cost-containment policies introduced in Germany under the 'Health Structure Act' at the beginning of 1993 marked a dramatic turnaround in German healthcare policy. The traditional arms-length approach of government policy makers, under which responsibility for implementation of the measures specified in national legislation was devolved upon the representatives of healthcare providers and statutory health insurance funds, was replaced by government mandates at the national level. These mandates-including price controls, a national pharmaceuticals budget and copayment changes-had a dramatic impact on the German healthcare system and on the German pharmaceutical market in particular. Eventually, these national controls are to be phased out as the associations of healthcare providers and health insurance funds negotiate the terms for implementation of further measures specified in the 'Health Structure Act': regional budgets, prescription guidelines, stricter controls of prescribing behaviour and a positive list. Despite this gradual return to the federalistic principles of the German healthcare system, the German pharmaceutical market will never be the same. PMID- 10155583 TI - New developments in pricing and drug reimbursement in France. AB - In this article, we review the current French price reimbursement scheme and how this scheme is affected by a new decree published in 1993, or will be affected by this decision already announced but not yet implemented. France has been perceived as a pioneering country regarding the attitude of the Health Authority towards pharmacoeconomics. Here, we describe the present status afforded such studies in the price reimbursement scheme. Finally, we discuss the possible impact of the national agreement between physicians and statutory Health Funds on the pharmaceutical industry in France. PMID- 10155584 TI - The pricing and reimbursement of pharmaceuticals. AB - This paper identifies common research themes arising from the papers on the pricing and reimbursement of pharmaceuticals presented elsewhere in this supplement. These include the following: How effective has cost containment been? What is the base case against which this is measured? Is there any evidence that research and development is changing in value or character as a result? How can the implied contract between government and industry be made more explicit to avoid opportunistic behaviour? PMID- 10155585 TI - The economics of health reform. A prototype. PMID- 10155586 TI - The emerging government requirement for economic evaluation of pharmaceuticals. AB - With the advent of government guidelines for the provision of cost-effectiveness data, economic evidence has been elevated to a status similar to that of evidence of efficacy and safety, which is required before licensing of pharmaceutical products. Whilst the precise nature of government requirements is likely to vary from place to place, they pose a number of practical problems for pharmaceutical companies, in the funding of studies and in the need to modify the clinical trials programme to facilitate economic data collection. Economic evaluation requirements have been viewed by various parties as a basis for pricing and reimbursement, as a form of cost containment and as a way of securing more value for money in the healthcare system. It is unlikely that economic evidence could ever form the sole basis for setting price, since both industry and government often seek to introduce other factors into the price negotiations. Requirements for economic evidence may also be an inefficient form of cost containment, compared with other methods such as budgetary caps. These offer some potential as a way of securing more value for money, but they should be applied equally across all health technologies. In the future there needs to be much more clarity of purpose in government guidelines, and methodological standards for economic analysis need to be refined. PMID- 10155587 TI - The future research agenda. A view from the pharmaceutical industry. AB - As a responsible partner in healthcare systems, the pharmaceutical industry hopes to see a research agenda on pharmaceutical issues that will provide more information on trends in healthcare reform affecting medicines. Urgent questions include whether some forms of cost containment are harming innovation and the quality of care, and what constructive alternatives to policies such as reference pricing can the industry offer? PMID- 10155588 TI - Pricing, regulation, and competitiveness. Lessons for the US from the Japanese pharmaceutical industry. AB - This paper examines the nature of Japanese government regulation of pharmaceutical prices, and the impact of that regulation on the competitive performance of the Japanese industry. Possible implications for the reintroduction of pharmaceutical price controls in the US are also considered. PMID- 10155589 TI - The Canadian Patented Medicine Prices Review Board. New rules and new status. AB - The influence of the Patented Medicine Prices Review Board in restraining the prices of patented drugs has been established over the past 6 years. Recent legislative and policy changes now in place may result in the Board assuming a more influential, public, and activist posture. This article reviews the way in which the Board carries out its mandate to ensure that patented medicines sold in Canada are not 'excessive'. The Board represents one segment of Canada's ongoing effort to balance what often appear to be irreconcilable tasks-the promotion of an increased domestic research and development investment by the pharmaceutical industry, and the control of expenditures for pharmaceuticals in response to the escalating concerns of the provincial health authorities and consumers. PMID- 10155590 TI - The changing environment for US pharmaceuticals. AB - Health reform is currently the predominant health policy issue in the US. It carries profound implications for the pharmaceutical field, including the possibility of price controls that could stifle pharmaceutical research. While policy makers are contemplating alternative approaches to reform, the marketplace for pharmaceuticals has changed dramatically. For example, price increases have lessened, price discounting has increased, and new drugs are typically launched at prices lower than those of the leading product in the therapeutic class. These changes are driven in part by the growth of managed care. Further evidence of change in the industry is the number of job reductions announced and the decline in market valuation of pharmaceutical companies. Policy makers need to take the changed marketplace into consideration as they proceed with health reform, to avoid layering additional policy impediments on top of an increasingly harsh and unforgiving market. Such an approach could seriously compromise incentives for pharmaceutical research. PMID- 10155591 TI - Colony-stimulating factors. Present status and future potential. AB - Granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage colony stimulating factor (GM-CSF) have been used successfully to enhance neutrophil recovery in patients with various malignancies undergoing standard or high dose chemotherapy, with or without autologous or allogeneic bone marrow transplantation support, and offer potential advantages in these settings in terms of reducing the total costs of healthcare and/or improving therapeutic outcomes. Clinical trials are now aimed at identifying which patients and which nonhaematological malignancies will respond best to colony-stimulating factor (CSF) support, and which of the 2 factors is the most appropriate in each setting. Two areas of considerable interest at present are the potential for chemotherapy dose optimisation and intensification with CSF therapy, and the use of CSFs to permit the harvest and reinfusion of peripheral blood progenitor cells as an alternative to autologous or allogeneic bone marrow transplantation. In the case of dose-intensified chemotherapy, costs of treatment increase but the gain may be an increase in survival rates or disease-free intervals. The potential of G-CSF and GM-CSF therapy in other conditions, notably haematological malignancies such as myelodysplasia and myeloid leukaemias, and AIDS, means that these agents are likely to make a significant impact on the treatment of a wide range of debilitating conditions in the future. PMID- 10155592 TI - Methodological issues in economic assessments of new therapies. The case of colony-stimulating factors. AB - Pharmacoeconomic evaluations estimate the value of medical interventions by comparing their clinical consequences and costs. Economic analyses, based on resource use data collected during 3 clinical trials of lenograstim, were performed as part of a lenograstim economic evaluation programme. Undertaking economic evaluations alongside clinical trials presents a number of methodological challenges, since the trials may be performed in atypical settings, have inappropriate follow-up, or use end-points that are not useful for economic evaluation. This paper reports on how these challenges were met in the lenograstim economic evaluation programme. In particular, it was decided that the evaluations would be based on an intent-to-treat perspective, with the same period of follow-up (for costs) for both lenograstim and vehicle groups. PMID- 10155593 TI - Economic evaluation of lenograstim (glycosylated rHuG-CSF) in the treatment of inflammatory breast cancer for Germany and Italy. AB - Data from a French placebo-controlled double-blind trial in 120 female patients treated with high dose fluorouracil, epirubicin and cyclophosphamide (HD-FEC) chemotherapy for inflammatory breast cancer were used to assess the economic impact of adjunctive lenograstim therapy. The analysis compared direct costs of treatment, with or without lenograstim, with reference to the Social Security (Germany) or to the National Health Service (Italy). Resource utilisation differed between the 2 treatment groups. The lenograstim group reported 32% fewer antibiotic therapy days (9.8 days vs 14.6; p = 0.01) and 24% fewer inpatient days for any reason other than chemotherapy (7.4 'excess' days vs 9.8). By reducing infection-related morbidity associated with a high dose chemotherapy regimen, lenograstim decreased treatment costs by DM 1794 and ItL 1.2 million, excluding the cost of lenograstim itself. Since lenograstim patients reported fewer chemotherapy delays (16.4 vs 30.5%) and, hence, benefited from 1.2 (p = 0.04) more chemotherapy days, the related cost was DM 1519 and ItL 0.9 million higher than for the placebo group. This cost difference would be expected to be smaller if the placebo group patients had been followed until completion of their full chemotherapy regimen. Assuming that the costs of chemotherapy were the same for both groups, the direct cost saving for the lenograstim group would be 30% in Germany and 34% in Italy. PMID- 10155594 TI - Economic evaluation of lenograstim for prophylaxis of chemotherapy-induced neutropenia in patients with small cell lung cancer. AB - The impact of lenograstim, recombinant human granulocyte colony-stimulating factor, on healthcare costs was evaluated on the basis of the results of a clinical trial of the drug in patients receiving VICE (vincristine, ifosfamide, carboplatin and etoposide) chemotherapy for small cell lung cancer (SCLC). The use of lenograstim resulted in a significant (p < 0.03) increase in the cumulative chemotherapy dose intensity (125% with lenograstim vs 118% without). Lenograstim was found to have no significant impact on the use of healthcare resources for administration of chemotherapy, chemotherapy-induced neutropenia, and associated infections. The cost of healthcare for the lenograstim group (excluding lenograstim acquisition costs) was 700 pounds higher per patient than that for the group not treated with lenograstim (95% CI -930 pounds to 2300 pounds). The use of lenograstim to intensify the chemotherapy dose is likely to increase the costs of treatment for SCLC. However, any increased costs need to be balanced against the potential cost savings associated with the possible long term benefits resulting from chemotherapy dose intensification. PMID- 10155595 TI - Pharmacoeconomic evaluation of lenograstim. Conclusions and future directions. AB - To evaluate the safety and efficacy of lenograstim, a new recombinant human granulocyte colony-stimulating factor (rHuG-CSF), as an adjunct to cancer chemotherapy, 3 phase III randomised clinical trials were recently conducted in Europe in patients with inflammatory breast cancer, non-Hodgkin's lymphoma, and small cell lung cancer. To explore the economic implications of lenograstim therapy, a multinational pharmacoeconomics programme was undertaken using data collected during these clinical trials. This programme consisted of concurrent prospective economic evaluations undertaken by study teams in France (non Hodgkin's lymphoma), Germany and Italy (a combined evaluation in inflammatory breast cancer) and the UK (small cell lung cancer). In these studies, attention was focused on the direct costs of medical care-principally the costs of cancer chemotherapy as well as its associated morbidity. In 2 of the pharmacoeconomic evaluations (i.e. the French, German/Italian), lenograstim was found to generate cost savings as a result of reductions in morbidity associated with chemotherapy. However, the cost of lenograstim therapy would be likely to exceed these savings, leading to an overall increase in the costs of cancer treatment. Whether the use of lenograstim is cost-effective will therefore largely depend on its impact on patient survival and quality of life, and current practical use. These issues are the focus of additional clinical studies currently underway. In addition, new research is focusing on the clinical benefits of lenograstim in other areas of oncology and haematology. Further pharmacoeconomic studies in these areas are also warranted. PMID- 10155596 TI - Overview of the lenograstim pharmacoeconomics programme. AB - Lenograstim is a recombinant colony-stimulating factor that has been shown to be a useful adjunctive agent in cancer chemotherapy. Clinical trials have demonstrated the efficacy of lenograstim in correcting chemotherapy-induced neutropenia and associated complications in inflammatory breast cancer and non Hodgkin's lymphoma, and in facilitating dose intensification of chemotherapy in small cell lung cancer. To meet increasing demands for economic data on new drug entities, a lenograstim pharmacoeconomics programme was established. This programme involved prospective economic evaluations of lenograstim that were undertaken as part of phase III randomised clinical trials by a combined German/Italian health-economics team (inflammatory breast cancer), a French team (non-Hodgkin's lymphoma), and a team from the UK (small cell lung cancer). PMID- 10155597 TI - Paclitaxel and docetaxel. Innovation, but at what cost? PMID- 10155598 TI - The cost effectiveness of mass drug therapy for intestinal helminths. AB - This article reviews the principles involved in establishing the cost effectiveness of mass drug therapy for the major intestinal nematodes and the intestinal form of schistosomiasis, as well as the extent to which the available studies have provided definitive answers. For governments or agencies that have decided to introduce a control programme, there is considerable evidence about the comparative cost effectiveness of different types of delivery strategies. For example, mass treatment is more cost effective than selective treatment (treatment after individual screening) in high prevalence areas and at observed prices. Mass treatment targeted at known high risk groups, such as schoolchildren, for the major intestinal helminths (apart from hookworm) can be more cost effective than population-based mass treatment. However, this raises the question whether any form of mass anthelmintic chemotherapy is an efficient use of scare health resources in view of the competing demands for scarce public funds, and for the scarce resources of other funders of healthcare including donors, nongovernmental organisations and missions. Some evidence that it is an efficient use of resources is available; this article concludes by outlining the type of information that is required to strengthen the argument for mass therapy. PMID- 10155599 TI - Quality of life in cystic fibrosis. AB - Cystic fibrosis is a chronic, multisystem genetic disease with a wide variability in clinical severity. In recent years, advances in therapy have led to improved patient survival into adulthood. New treatments are rapidly being developed and require evaluation to determine their efficacy. The measurement of health-related quality of life in cystic fibrosis provides additional information about the impact of this disease that cannot be obtained by physiological tests such as pulmonary function. An instrument to measure health-related quality of life is especially useful as an outcome measure for clinical trials. To date, only a few general quality-of-life (QOL) measures have been used in people with cystic fibrosis. There has been some demonstration of validity in 2 measures (the Quality of Well-Being Scale and the Functional Status Index) but the responsiveness of these instruments in this population has not been established. A cystic fibrosis-specific QOL instrument would be valuable as an outcome measure because of its potential for increased responsiveness, but no published measures exist as yet. PMID- 10155600 TI - Assessing the economic value of a new antidepressant. A willingness-to-pay approach. AB - Using the method of willingness to pay (WTP), this study assesses the value of a new antidepressant, moclobemide, relative to that of tricyclic antidepressants (TCAs), which have equivalent efficacy but less favourable adverse effect profiles. From a published meta-analysis of controlled clinical trials, we identified 7 adverse effects, the risk of which differed significantly between moclobemide and TCAs. We obtained risk reduction data and descriptions of adverse effects from interviews with 95 individuals who had mild to moderate depression and who had been taking one or more TCAs in the previous year. Using a visual analogue scale, respondents ranked and rated each adverse effect. Participants were then asked (using the scenario of additional out-of-pocket drug payment) to quantify the maximum amount that they would pay for a new drug that reduced each adverse effect by the specified probability. Blurred vision and tremor were ranked and rated as the most bothersome adverse effects, with dry mouth being the least bothersome. On average, respondents were willing to pay an additional $Can22 per month [95% confidence interval (CI) 16-28] to reduce the risk of blurred vision from 10 to 5%. The lowest WTP value was for reducing the risk of dry mouth from 40 to 15%, at $Can11 per month (95% CI 8-15). Although not measured directly, we derived 2 estimates of WTP for multiple (i.e. all 7) risk reductions. We obtained upper and lower WTP limits of $Can118 and $Can36 per month, respectively, depending upon aggregation assumptions. Compared with the TCAs amitriptyline and imipramine, the net cost of moclobemide is greater, but the overall net benefit (WTP minus cost) is ambiguous given uncertainty about WTP aggregation over adverse effects. However, compared with the TCAs desipramine and clomipramine, the net benefit of moclobemide is unambiguously positive. We conclude that the WTP approach is a potentially valuable tool that requires more development for use in healthcare economic evaluation. PMID- 10155601 TI - Cost effectiveness of hepatitis A prevention in France. AB - A spreadsheet simulation model of hepatitis A disease was developed to evaluate the cost effectiveness of an inactivated [corrected] hepatitis A vaccine ('Havrix', SmithKline Beecham) in high risk groups in France. Gammaglobulin prophylaxis, systematic vaccination without screening and vaccination of nonimmune persons after systematic screening were compared with the reference situation of no prevention over a 10-year period. It was found that both vaccination strategies would prevent 98% of new cases of hepatitis A, and would generate savings of FF4.2 to FF4.7 million ($US1 = FF5, 1995) in alternative service volunteers [initial seroprevalence (IS) 26%] stationed in countries with high hepatitis A endemicity. The cost per symptomatic case avoided [i.e. the cost effectiveness ratio (CER)] was found to vary from FF177,612 with screening to FF281,463 without screening in adult tourists (IS 77%). In hospital workers, screening before vaccination (CER = FF65,108) would be about half as costly as systematic vaccination (IS 55 to 79%). Recommendations for vaccination should take into account the specific collective or individual risk, age, seroprevalence and probability of compliance with the prevention protocol. PMID- 10155602 TI - Cost effectiveness of alternative hepatitis A immunisation strategies. PMID- 10155604 TI - Cost-effectiveness controversy. PMID- 10155603 TI - Paroxetine. A pharmacoeconomic evaluation of its use in depression. AB - There has been intense debate about whether the use of paroxetine or other selective serotonin reuptake inhibitors (SSRIs) as alternatives to tricyclic antidepressants for first-line treatment of depression can be justified, considering their higher acquisition costs. The rationale for using paroxetine in the treatment of depression lies in its more favourable tolerability profile than tricyclic antidepressants and its lower risk of death on overdosage. Depression is one of the most common psychiatric disorders and is associated with substantial direct, indirect and intangible costs. Indirect costs account for the majority of costs associated with depression, while drug costs account for only 9 to 25% of direct costs. Therefore, increased recognition and treatment of depression has the potential to greatly reduce the overall cost of this disease. Pharmacoeconomic data on paroxetine and other SSRIs in the treatment of depression are scarce. Available studies are limited to considerations of direct costs alone and are primarily based on retrospective data from clinical trials. Nevertheless, in terms of costs per successfully-treated patient, available data suggest that the treatment costs associated with paroxetine are similar to those of amitriptyline and possibly less than those of imipramine. Paroxetine treatment costs also appear to be similar to those of amitriptyline and imipramine in terms of expected costs per patient. While one group of investigators suggested that the overall cost of administering paroxetine may also be less than that for fluoxetine and sertraline when drug costs and labour costs associated with dosage adjustment are taken into account, more data are required before conclusions on the relative pharmacoeconomic merits of SSRIs can be made. Despite the lower risk of death from overdosage with SSRIs, switching from an established tricyclic antidepressant to a newer tricyclic or related antidepressant in an attempt to avoid suicide appears to be more cost effective than switching to an SSRI. Thus, evidence available to date indicate that despite higher acquisition costs paroxetine and other SSRIs are no more costly than tricyclic antidepressants when total costs per successfully treated patient or expected costs per patient are considered. With its favourable tolerability profile and low risk of death on overdosage, paroxetine should therefore be considered as an effective alternative to tricyclic antidepressant agents as a first-line treatment of depression.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10155605 TI - Rational prescribing for acute bronchiolitis. AB - Acute bronchiolitis is the commonest lower respiratory illness of infancy and early childhood, and it is usually associated with respiratory syncytial virus infection. In the majority of infants, the illness is self-limiting and hence management is directed at maintaining fluid intake, minimal handling and close observation. Children who develop apnoea, fatigue and/or feeding difficulties as well as progressive respiratory distress require hospital admission. Oxygen, intravenous fluids and minimal handling are the pillars of hospital management, and less than 1% of hospitalised infants require additional assisted ventilation. Pharmacological therapy of acute bronchiolitis is contentious. Sympathomimetics are the drugs most frequently used. Inhaled salbutamol (albuterol) has been associated with both positive and negative outcomes. Recent work suggests that nebulised racemic adrenaline (epinephrine) may be helpful in reducing respiratory distress, but further work is needed to confirm this finding. The use of the antiviral drug ribavirin (tribavirin) in acute bronchiolitis remains very contentious. The overwhelming majority of infants do not require the drug and debate remains as to its true effectiveness. The literature tends to support its use in patients with underlying heart or lung disease, but the drug may not be cost effective in this setting. However, the costs of ribavirin therapy could be reduced by the implementation of more rigid treatment guidelines. A reduction in the use of bronchodilators, antibiotics and corticosteroids would help to reduce the overall costs of management. To date, acute bronchiolitis has not lent itself to pharmacological treatment and prescribing should therefore be very strictly audited by clinicians. PMID- 10155607 TI - Quality-of-life considerations in the treatment of asthma. AB - There is a growing body of evidence showing that the conventional clinical indices of asthma severity (airway calibre, symptoms, airway responsiveness, etc.) correlate only weakly with how patients are actually feeling and how they are able to function in their daily lives because of their asthma. When assessing and treating asthma, it is certainly important to evaluate the airways. However, it is equally important to evaluate the impact of the condition on the patients themselves. There are now a number of health-related quality-of-life instruments, with strong measurement properties, that may be used in both clinical studies and practice. They provide scientifically sound and valid information about patients' experience that complements conventional clinical measures. PMID- 10155606 TI - Cephalosporin utilisation review and evaluation. AB - The clinical misuse of drugs may result in preventable patient morbidity and mortality, costly remedial care, additional costs for diagnosis and management of iatrogenic disease and unnecessary wastage of healthcare resources. In recognition of this problem, drug utilisation evaluation (DUE) has been recommended as a method for identifying inappropriate or unnecessary drug use and for promoting rational therapy. Growing concern over the widespread misuse of antibiotics, together with the emergence of antimicrobial resistance and escalating expenditures, has resulted in antibiotics being the drugs most frequently chosen for DUE projects. Cephalosporin DUE is well documented as being successful for modifying cephalosporin use and for containing drug expenditure. Studies range from isolated projects to ongoing programmes that comprehensively evaluate cephalosporin use and the impact of corrective strategies. Sensible use of antibiotics requires a clear understanding of the infectious process, the clinical pharmacology of anti-infective agents and an appreciation of clinical and microbiological monitoring and assessment. Audit criteria that incorporate the above principles, and which are described in the studies reviewed in this article, will be useful for other investigators. Through its DUE programme, the Royal Adelaide Hospital has investigated the use of cephalosporins, including ceftriaxone, ceftazidime and cefoxitin. These reviews have resulted in improvements in cephalosporin use and significant cost savings. Alterations to cephalosporin use that were recommended following these reviews have not resulted in adverse changes to post-operative infection rates, clinical outcomes or adverse drug reactions. This experience, combined with that of other investigators, serves as a useful model for the promotion of rational and economical therapy with cephalosporins and other drug groups. PMID- 10155608 TI - Cost and quality effects of treating erosive oesophagitis. A re-evaluation. AB - The objective of this study was to re-evaluate the clinical and economic effects of common therapies for erosive oesophagitis in the light of a newly approved treatment regimen. A previously constructed 7-month community practice decision analytical model was revised to include the latest published data on efficacy and symptomatic outcomes. The original results of phase I therapy (antacids plus dietary, sleeping and lifestyle changes) alone or combined with ranitidine 150mg bid or omeprazole 20mg od were reassessed by adding new clinical data on the efficacy of and symptomatic response to ranitidine 150mg qid. The same payment data used in the first analysis were applied here as well, with the addition of the US price of ranitidine 150mg qid. The study perspective was that of the payer or insurer. Omeprazole-based therapy remained a dominant strategy for symptomatic care during the 7-month model. It was 14% less costly per patient, led to 23% fewer symptomatic months, and had 21% lower cost per symptom-free month than ranitidine 150mg qid, the next best alternative. Evolving treatment strategies necessitate rapid assessment and reassessment so that clinical practice can remain current, patients can be assured of the best quality, and insurers can be aware of treatment cost and budgetary impact given limited resources in all countries. Only by consistent and continuous re-evaluation of new or changing medical interventions can clinicians and insurers adapt patient management to new scientifically derived results. This is the best manner by which to meet patients' care needs and the clinical needs of practitioners, as well as the financial needs of payers. PMID- 10155609 TI - Eliciting EuroQol descriptive data and utility scale values from inpatients. A feasibility study. AB - We conducted a microstudy to elicit health state descriptions and utility values, using the EuroQol instrument, from a sample of acutely ill inpatients on 5 wards at University College London Medical School. Most current work to date has elicited such descriptive and valuation data from random surveys of the general population. One problem with this is that most responders from the general population have not actually experienced the states being valued. Our goal was to ascertain whether there were any differences between the values given by inpatients and those of the general population. However, the small sample size of patients included in our feasibility study means our conclusions must remain tentative. Nevertheless, the results suggest that patients give higher values than the general population. We suggest that more research needs to be done eliciting values from patients. PMID- 10155611 TI - Methodological and conduct principles for pharmacoeconomic research. Pharmaceutical Research and Manufacturers of America. AB - In January 1995, the Pharmaceutical Research and Manufacturers of America (PhRMA) adopted a voluntary set of principles to provide guidance for its member companies on the conduct and evaluation of pharmacoeconomic research. The principles were prepared by a working group of pharmacoeconomic scientists from the PhRMA Task Force on the Economic Evaluation of Pharmaceuticals. The principles were reviewed by a panel of academic experts and outside reviewers at each stage of their development. The PhRMA document consists of a set of broad principles that will foster high quality pharmacoeconomic research without impeding further methodological development of the field. Specific recommendations are offered in those methodological areas for which general agreement exists. However, no attempt was made to force a consensus for those methodological issues which have yet to be resolved. The principles address methodology and reporting of research rather than sponsor-investigator relationships or conflict of interest issues, which have been addressed elsewhere. This approach is based on the belief that the scientific integrity of pharmacoeconomic research is best ensured through the soundness of the research methods used and the full disclosure and transparency of all methods, analyses and results. PMID- 10155610 TI - A Markov process analysis comparing the cost effectiveness of maintenance therapy with citalopram versus standard therapy in major depression. AB - The objective of this study was to demonstrate the cost effectiveness of long term maintenance treatment with citalopram versus standard therapy (defined as short term antidepressant treatment) in patients with major depression in Germany. We chose doxepin, amitriptyline and trimipramine as standard therapy because these drugs are the leading antidepressants in that country. A Markov process analysis was used to model health status and economic outcomes as they accrued over a 1-year follow-up period. The main outcome measures were time without depression, direct costs and indirect costs (work days lost). All costs were in 1993 Deutsche marks. The clinical data were obtained from the published literature and US clinical practice guidelines; the associated unit costs of the medical resources used were derived from official German tariff lists. The results show that, compared with standard therapy, long-term maintenance treatment with citalopram is associated with a mean increase in time without depression of 7.9% (8.2 vs 7.6 months). The total costs of maintenance treatment with citalopram were substantially lower than with standard therapy (DM7985 vs DM11,948 per patient per year. In addition, both the direct and indirect costs of maintenance treatment with citalopram (DM3764 vs DM4221 per patient, respectively) were lower than with standard therapy (DM4577 vs DM7371 per patient, respectively). In conclusion, the study demonstrates that one year's maintenance treatment with citalopram is both more effective and less costly than standard therapy in the treatment of patients with major depression. PMID- 10155612 TI - Should the philosophy of postmarketing surveillance in the US be redefined? PMID- 10155613 TI - Cost-containment measures in the Italian healthcare system. PMID- 10155614 TI - Low molecular weight versus unfractionated heparin. A clinical and economic appraisal. AB - Unfractionated heparin (UFH) has been in clinical use for over 50 years and extensive clinical trials have demonstrated its effectiveness in the prevention and treatment of thrombotic disease. In the last 2 decades, low molecular weight heparins (LMWHs) have been developed and subjected to extensive laboratory and clinical studies. In clinical comparison with UFH in the treatment of venous thromboembolism, LMWHs appear to offer a superior benefit-risk profile. In addition, the ease of drug administration and lack of drug monitoring associated with LMWHs are attractive clinical features. We calculated the overall costs of UFH and LMWH therapy using recently published clinical data and local cost information. Although the acquisition costs of LMWHs are higher than for UFH, LMWHs are more cost effective in surgical prophylaxis of deep venous thrombosis (DVT) if the costs of failed prophylaxis are considered. The costs of using subcutaneous (SC) LMWH as therapy for established DVT are lower than those of UFH administered by intravenous infusion. The financial benefit of using LMWH treatment becomes more pronounced when the rates of antithrombotic failure and bleeding complications are incorporated. If UFH is given by SC injection, however, the cost differential favouring LMWH for the treatment of DVT is not so great. If current trials demonstrate that LMWH treatment can be given on an ambulatory outpatient basis, the economic advantages of LMWH will be considerable. However, the extent of this will vary from place to place depending on local funding arrangements. PMID- 10155615 TI - The human and economic cost of paracetamol (acetaminophen) overdose. PMID- 10155616 TI - A comparative review of pharmacoeconomic guidelines. AB - We have reviewed 4 international sets of guidelines for the economic evaluation of pharmaceutical products-those of the Australian Pharmaceutical Benefits Advisory Committee, the Canadian Coordinating Office for Health Technology Assessment, the Ontario Ministry of Health, and the England and Wales Department of Health. Comparison of these guidelines reveals that there are a number of differences between them, including disparities in outcome selection, costs and perspectives. These observations were attributed to differences in study purpose, conceptual approach, measurement techniques and value judgements. Uniformity can be achieved only in conceptual approach and measurement technique. Guidelines should be flexible to accommodate differences in the study purposes and value judgements of the analysts. PMID- 10155618 TI - Cost analysis of paroxetine versus imipramine in major depression. AB - A simulation decision analytical model was used to compare the annual direct medical costs of treating patients with major depression using the selective serotonin reuptake inhibitor (SSRI) paroxetine or the tricyclic antidepressant (TCA) imipramine. Medical treatment patterns were determined from focus groups of general and family practitioners and psychiatrists in Boston, Dallas and Chicago, US. Direct medical costs included the wholesale drug acquisition costs (based on a 6-month course of drug therapy), psychiatrist and/or general practitioner visits, hospital outpatient visits, hospitalisation and electroconvulsive therapy. Acute phase treatment failure rates were derived from an intention-to treat analysis of a previously published trial of paroxetine, imipramine and placebo in patients with major depression. Maintenance phase relapse rates were obtained from a 12-month trial of paroxetine, supplemented from the medical literature. The relapse rates for the final 6 months of the year were obtained from medical literature and expert opinion. Direct medical costs were estimated from a health insurance claims database. The estimated total direct medical cost per patient was slightly lower using paroxetine ($US2348) than generic imipramine ($US2448) as first-line therapy. This result was sensitive to short term dropout rates but robust to changes in other major parameters, including hospitalisation costs and relapse rates. The financial benefit of paroxetine, despite its 15-fold higher acquisition cost compared with imipramine, is attributable to a higher rate of completion of the initial course of therapy and consequent reduced hospitalisation rates. PMID- 10155619 TI - The cost of angina pectoris in Sweden. AB - A survey of 402 Swedish patients with angina pectoris was performed to estimate the annual direct medical costs, and nonmedical costs, of a typical Swedish angina pectoris patient, and to identify those variables having the greatest impact on the direct medical costs. Data regarding the consumption of healthcare services over a 3-month period were collected through telephone interviews conducted by trained nurses at a medical marketing agency. The data were multiplied by 4 to obtain an estimate of the annual resource consumption. The annual direct medical cost of angina pectoris was estimated at 40,052 Swedish krona (SEK; $US1 approximately SEK7.20, March 1995) per patient, comparable with the cost of a myocardial infarction. As expected, however, the severity of angina pectoris was important in determining the direct medical cost. The significant variables explaining variations in direct costs were (in order of importance): (i) whether the patient had undergone cardiovascular surgery; (ii) whether the patient was treated by a general practitioner or an internist; (iii) the number of years since first diagnosis of angina pectoris; and (iv) whether the patient's angina pectoris was characterised as stable or unstable. The annual nonmedical cost of angina pectoris per patient was estimated at SEK38,225. The relatively high costs of angina pectoris underline the importance of health economic evaluations of various diseases and medical interventions. PMID- 10155617 TI - Measuring the costs of schizophrenia. Implications for the post-institutional era in the US. AB - Schizophrenia is a stress-related biomedical condition of the brain, characterised by unusual internal experiences, severe and often persistent functional disability and socially inappropriate behaviour. It is estimated that schizophrenia affects approximately 1% of all adults worldwide. Young adults are especially vulnerable. It is an illness with profound economic impact on patients, their families and society at large. Before the 1950s, most patients with schizophrenia were admitted to hospital for long inpatient stays. Keeping the patient in an institutional setting was all that psychiatry could offer, because there was little active treatment available. After World War II, and especially following the introduction of chlorpromazine in 1954, treatment was offered increasingly in outpatient settings. At present, more than 90% of individuals with schizophrenia will receive most healthcare services in outpatient facilities, supplemented by brief hospital treatment. The trend toward community-based care continues into the 1990s, supported in part by recent pharmacotherapeutic developments that are making a new generation of drug treatment options available. Clozapine, the most widely used of these new drugs, has been the subject of several studies that compared its costs with those of conventional drug treatments. These early studies suggest that further reductions in the cost of hospital treatment are possible in the near future. At the same time, despite the increasing availability of effective treatment in outpatient settings, the shift of resources from institutional to community care will not occur as quickly as some might wish. Delays in the transformation of care systems are caused by political interest groups and the sheer inertia of the infrastructure left over from the era of institutional care. These factors must be taken into account in estimating the cost of schizophrenia care during the next decade. The aim of this review is to provide a clinical picture of schizophrenia, emphasising features that contribute most to the cost of illness. We define and quantify the direct and indirect costs of the illness, discuss the cost implications of new pharmacotherapeutic and psychosocial treatments, and critique strategies for measuring the economic efficacy of these new treatments. The difficulties in measuring the costs of schizophrenia that are related to the transition from institutional to community-based systems of care in the US are also reviewed. PMID- 10155620 TI - Economic analysis of health technologies and programmes. A Spanish proposal for methodological standardisation. PMID- 10155622 TI - Intraoperative imaging revolutionizes therapy. PMID- 10155621 TI - Terbinafine. A pharmacoeconomic evaluation of its use in superficial fungal infections. AB - Terbinafine is an orally and topically active allylamine antifungal drug which is an effective and well tolerated therapy for a wide range of superficial dermatophyte infections. In contrast to most other commonly prescribed antifungal agents, terbinafine is fungicidal in vitro and possesses improved pharmacokinetic properties with respect to drug penetration into nail tissue following oral administration. These properties enable terbinafine to achieve high success rates with shortened therapy regimens in the treatment of dermatophyte skin infections and onychomycosis. Pharmacoeconomic analyses have shown that oral terbinafine, with its higher rates of clinical efficacy and lower rates of relapse/reinfection, is less costly and more cost effective than oral griseofulvin, ketoconazole and itraconazole when used as initial therapy in the treatment of onychomycosis. However, some points regarding the clinical efficacy of itraconazole relative to terbinafine and the drug treatment regimens used in these studies need further clarification. In the management of tinea pedis, a cost analysis suggested that initial therapy with terbinafine 1% cream was more costly than initial therapy with miconazole, oxiconazole or clotrimazole. However, in cost-effectiveness studies, terbinafine had a lower cost per disease free day than ciclopirox, clotrimazole, ketoconazole and miconazole in the treatment of dermatophyte skin infections. In conclusion, available clinical and pharmacoeconomic data support the use of topical terbinafine as first-line treatment of dermatophyte skin infections unless the acquisition cost of terbinafine is markedly greater than that of alternative topical antifungal agents. Oral terbinafine can be recommended as a cost-effective first-line treatment, preferable to oral griseofulvin, ketoconazole and itraconazole, in patients with dermatophyte onychomycosis. PMID- 10155623 TI - Tech assessment adapts to image communication. PMID- 10155624 TI - Anterior segment manifestations of acquired immunodeficiency syndrome. PMID- 10155625 TI - An algorithmic approach to treatment of cytomegalovirus retinitis. PMID- 10155626 TI - Noncytomegalovirus-related chorio-retinal manifestations of the acquired immunodeficiency syndrome. AB - The diagnosis of the ocular manifestations of AIDS is based initially on the clinical appearance of the lesions. However, retinal and choroidal lesions in AIDS patients are frequently the manifestation of disseminated disease. In one autopsy series, 15 of 18 patients with infectious choroiditis died of systemic infection by the same organism causing the choroiditis. Despite the fact that more than 90% of posterior segment infections in AIDS patients are caused by CMV, careful examination with appropriate consideration of differential diagnosis is necessary in all cases in which a classic pattern of CMV retinitis is not seen. Extensive history taking, discussion with the primary care physician, and the appropriate systemic work-up can greatly facilitate the diagnosis of the most likely cause of the apparent opportunistic infection. It is important to remember that noninfectious causes of HIV-related retinal disease can have a similar clinical pattern as infectious causes. In particular, physicians must be careful not to confuse early CMV retinitis with HIV-related noninfectious retinal vasculopathy, the most common retinal finding in patients with HIV disease. In a patient with multifocal superficial lesions in the posterior pole, particularly if the CD4+ count is more than 100 cells/microL, reevaluation rather than immediately initiating therapy may prevent the inadvertent commitment to chronic therapy implicit in a diagnosis of CMV retinitis. PMID- 10155628 TI - Local treatment of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome. PMID- 10155627 TI - Clinically resistant cytomegalovirus retinitis. PMID- 10155629 TI - Pitfalls and unusual manifestations of acquired immunodeficiency syndrome in the retina. PMID- 10155630 TI - Ocular pathological changes in acquired immunodeficiency syndrome. PMID- 10155631 TI - Neuropathology of the retina in acquired immunodeficiency syndrome. AB - The pathogenesis of HIV-mediated neurodegeneration is unknown. Presently, work is focused on two main hypotheses: direct (caused by HIV or component proteins) versus indirect (monocyte-mediated) neurotoxicity. In HIV-induced retinal disease, the high incidence of opportunistic infections and the low HIV viral burden found in most clinical specimens present challenges in defining the roles played by potential factors. Future studies will see the resolution of these controversies by showing the mechanism of HIV-induced neuronal damage and its relationship to retinal disease. PMID- 10155632 TI - Rhegmatogenous retinal detachments in patients with acquired immunodeficiency syndrome. PMID- 10155633 TI - Medical and virological aspects of ocular human immunodeficiency virus infection for the ophthalmologist. PMID- 10155634 TI - Management of traumatic eyelid lacerations. PMID- 10155635 TI - Management of periorbital burns. PMID- 10155636 TI - The repair of corneal and scleral lacerations. PMID- 10155637 TI - Sympathetic ophthalmia. PMID- 10155638 TI - Imaging in orbital trauma. PMID- 10155639 TI - Intraorbital foreign bodies. AB - A high index of suspicion is important in evaluating any penetrating orbital injury. Likewise, any chronically infected orbit must be suspected of harboring an IOrbFB. Careful history and examination are mandatory for both clinical and medicolegal purposes. Appropriate imaging studies, usually including CT scanning, must be employed. Antibiotic therapy may be crucial in preventing infectious complications, including those involving the central nervous system. The decision regarding surgery must be individualized and should consider visual status, form and composition, and localization of an IOrbFB. The possibility of orbitocranial extension should always be considered and ruled out. Following these general rules, an injury with a small but real potential for clinical disaster may be mitigated, and visual and neurological outcome may be optimized. PMID- 10155640 TI - Traumatic optic neuropathy. PMID- 10155641 TI - Complex facial fractures in the periorbital region. AB - Recognition of periorbital facial fractures with appropriate clinical and diagnostic evaluation is essential for surgical decision making. Treatment planning should be directed at correcting any demonstrable functional problem or cosmetic deformity. The radiographic presence of a fracture line should not be the sole criterion for surgery. When surgical intervention is indicated, early repair will usually provide a more favorable result. PMID- 10155642 TI - Viscoelastic-related glaucomas. AB - The routine surgical use of viscoelastic substances has revolutionized many anterior segment procedures. All of the currently available agents may be responsible for causing or exacerbating a transient, but occasionally significant, postoperative IOP elevation. In spite of differences in physical properties such as molecular weight, concentration, and viscosity, none of the various viscoelastics has consistently shown a decreased likelihood of producing ocular hypertension. Moreover, any newly introduced product must be evaluated carefully for this potential complication. Lavage of viscomaterial from the anterior chamber and administration of ocular antihypertensives may be helpful in averting or controlling the increased IOP. The surgeon should be cognizant of any pre-existing optic nerve damage and adjust the aggressiveness of postoperative glaucoma therapy accordingly. In the future, the development of new substances or simultaneous use of degrading enzymes may reduce or eliminate the incidence of viscoelastic-induced ocular hypertension. PMID- 10155643 TI - Increased intraocular pressure after cataract surgery. PMID- 10155644 TI - Malignant glaucoma: theory and therapy, from past to present. PMID- 10155645 TI - Glaucoma secondary to epithelial and fibrous downgrowth. PMID- 10155646 TI - Glaucoma after penetrating keratoplasty. AB - Glaucoma after penetrating keratoplasty remains a management problem. The incidence is significant because of the status of those eyes undergoing PKP. Many have had multiple previous surgeries, and aqueous outflow may be compromised before the PKP. The surgery itself causes additional damage to the angle, often inducing peripheral anterior synechiae formation, with further impediment to aqueous outflow. Control of postkeratoplasty glaucoma is complicated by the need to preserve graft clarity for visual function. Medical treatment with aqueous suppressants is the first line of care. Since the introduction of apraclonidine 0.5%, and with topical carbonic anhydrase inhibitors soon to be introduced, perhaps medical management will become easier. When medical management fails, if the angle is open and viable, argon laser trabeculoplasty may be an option. If further intervention is indicated, the authors recommend a drainage seton (double plate Molteno, or Baerveldt tube) in those eyes with good visual potential. For those eyes with poor visual potential (or those patients who cannot undergo surgery), we recommend contact Nd: YAG CPC. PMID- 10155647 TI - Glaucoma after surgery on the retina and vitreous. AB - Increased intraocular pressure after retinal detachment or its surgery may be addressed in an effective manner, because the clinical setting invariably suggests an ascertainable etiologic mechanism. Directed, stepwise therapy may then be instituted promptly to minimize lasting or functional impairment from long-standing increased intraocular pressure. PMID- 10155648 TI - The glaucomas in aphakia. PMID- 10155649 TI - A non-traditional approach to risk assessment of respiratory exposure to outdoor air pollutants. AB - The aim of this study was to verify a non-traditional assessment of respiratory exposure to outdoor air pollutants in industrial areas. The technique involved environmental biological monitoring' using domestic rabbits in the neighborhood of a mercury-producing plant. Rabbits were exposed whole-body to mercury emissions for 6 months in special cages near the plant. Control rabbits were kept using the same schedule outside the polluted area. Potential toxicity was assessed by: (a) measurement of Hg-accumulation in lungs and other body tissues by atomic absorption spectroscopy (AAS); (b) scanning electron microscopy (SEM) of the tracheal surface; and (c) measurement of toxic effects on pulmonary alveolar macrophages (PAM) by a rossette assay (Fc immunoglobulin binding). We found increased Hg concentrations in the lungs, kidneys, liver, heart, brain and bone; changes in the mucosal relief of the trachea, and depression of PAM Fc receptor (FcR) activity to IgG. A 6-month chamber exposure of Wistar rats to the aerosol created from solid particles of the mercury-producing plant revealed the increase of Hg-content in the same body tissues except the brain, and, less intense morphologic changes on the tracheal relief. Biomonitoring using environmental exposure of domestic rabbits might be useful in screening for possible health hazards to the respiratory system from complex outdoor aerosols. PMID- 10155650 TI - Delivery and retention of an insulin aerosol produced by a new jet nebulizer. AB - This study describes the delivery and distribution of an aerosol generated by a jet nebulizer (MAXIN) in an experimental animal model. Anesthetised, intubated and ventilated piglets inhaled radiolabeled technetium diethylene-triamine-penta acetic acid (99mTc-DTPA) through the endotracheal tube. The lungs were excised en bloc and scintigraphed, using a computerized gamma camera to evaluate the pattern of distribution. By nebulizing radiolabeled 125I-insulin and comparing the activity deposited on inspiratory and expiratory electrostatic filters, delivery and retention of nebulized insulin was assessed. The distribution of aerosol in the lungs was very even and reached the most peripheral parts. The delivery of nebulized insulin was calculated to be 88.9 +/- 5.3% and 36.1 +/- 8.8% of the insulin delivered to the respiratory tract was retained. The immediate local effects of insulin aerosol administration on the lungs were evaluated using light microscopy. No adverse effects were observed at histopathologic examination of the lung tissue. CONCLUSION: This study shows a high penetration of aerosol to the peripheral parts of the lung and efficient delivery of nebulized insulin when using the MAXIN-nebulizer. PMID- 10155651 TI - Physical properties of aerosolized immunoglobulin for inhalation therapy. AB - Animal studies suggest that passive immunization by intratracheal application of gammaglobulins may succeed in treating small children and infants with severe lower respiratory tract infection caused by respiratory syncytial virus (RSV). Since proteins foam easily when stirred up or used with compressed air, the feasibility of nebulization of the immunoglobulin solution (IVIG, Sandoglobulin) had to be tested. The therapeutic effect of a drug delivered via inhalation is proportional to the mass of aerosol deposited in the lungs. For a fixed breathing pattern, the amount deposited per unit of time in the thoracic region depends on mass flow rate and distribution of aerosol mass by droplet size. Both these variables were determined in relation to the weight concentration (osmolality), viscosity, and surface tension of the IVIG solution for four compressed air nebulizers. The mass flow rate of the spray decreases as the weight concentration of the solution increases, but droplet size distribution does not change. If the IVIG solution does not exceed 5% and the airflow rate is 6 L/min, a mass flow of about 150 mg to 250 mg (7.5 to 12.5 mg IVIG) per minute is obtained, depending on the physical characteristics of the nebulizer used. Low mass median diameter of about 2 microns and a mass distribution with a high percentage of the droplets below 6 microns will allow optimum intrapulmonary deposition in infants. PMID- 10155652 TI - Quantitative left ventriculography: methods of assessment of the regional contractility. AB - To compare different approaches to the quantitative analysis of regional left ventricular (LV) function, six different protocols with various long axis definitions, with or without alignment, with radial or hemiaxial segmental definitions were used. Study group consisted of 20 patients with single vessel coronary artery disease after Q-wave anterior myocardial infarction (MI) and 20 patients after Q-wave diaphragmatic MI. Control group consisted of 100 patients. Analytic protocol with the long axis drawn between the apex of the LV and the center of aortic valve plane, radial coordinate system originating from the midpoint of the long axis and alignment of the long axes in systole and diastole, was found to be most sensitive and specific for detection of both anterior and diaphragmatic contraction abnormalities. Original method to measure both severity and length of the regional contraction abnormality is suggested. PMID- 10155653 TI - The relation of clinical outcome to dissection and thrombus formation during coronary angioplasty. Heparin Registry Investigators. AB - BACKGROUND: Although the development of thrombus or dissection during percutaneous transluminal coronary angioplasty (PTCA) increases the risk of abrupt vessel closure, the magnitude of the effect is difficult to define. OBJECTIVE: The aim of the study was to determine prospectively the effect of the development of thrombus or dissection on PTCA procedural outcome. METHODS: Data from 591 consecutive angioplasty procedures involving 756 lesions at 9 clinical centers were included in a prospective registry with a core angiographic laboratory. RESULTS: Clinical success (defined as < 50% stenosis of all target lesions assessed in a core angiographic laboratory, with no major complications of death, Q wave or non-Q wave myocardial infarction or emergency CABG) was achieved in 497 patients (84%). Major complications occurred in 45 (7.6%). Abrupt vessel closure, including both established closure (TIMI grade 0 or I flow) and impending closure (> 50% stenosis, TIMI grade 0-2 flow, plus use of additional interventions) occurred in 65 patients (11%). Angiographically visible dissections developed in 40% of lesions; more severe grades of dissection were associated with reduced success rates, and increased incidence of and abrupt vessel closure and major complication. Angiographic evidence of thrombus (filling defects) developed in 12.3% of lesions; the presence of thrombus was associated with significantly lower procedural success (61% vs. 86%) and significantly higher rates of abrupt vessel closure (28% vs 7%) and major complications (24% vs. 6%). With multivariable analysis, thrombus was identified as an independent predictor of procedural success, abrupt vessel closure, and major complications. CONCLUSIONS: The development of severe dissections or thrombus following PTCA is associated with significantly lower procedural success rates and higher rates of abrupt vessel closure and major complications. Patients who develop severe dissection or thrombus may be appropriate candidates for more aggressive forms of therapy. PMID- 10155654 TI - Comparison of total cholesterol measurement using reflotron capillary analysis and laboratory venous blood analysis. PMID- 10155655 TI - Sedentary lifestyle as a risk factor for self-reported poor physical and mental health. PMID- 10155656 TI - Risky sexual behavior and alcohol use among young adults: results from a national survey. AB - PURPOSE: To examine the relationship between alcohol use and sexual activity in a sample of young adults. DESIGN: Data were collected as part of a 1990 survey of a multistage area household probability sample. SETTING: In-home interviews were conducted by experienced interviewers. SUBJECTS: In total, 1006 persons from 18 to 30 years of age living in the contiguous United States were contacted. MEASURES: Detailed information was collected on alcohol use and sexual behavior. To minimize the reluctance of respondents to answer queries on sexual behavior, those questions were contained in a self-administered questionnaire. RESULTS: At the population level, having had multiple sexual partners in the past year was more likely among men who consumed five or more drinks per sitting. Condom use was less likely among respondents who had consumed five or more drinks on at least one occasion in the past year. In multivariate analyses, the amount of alcohol consumed at the new partner event was not associated with condom use with a new partner. When the effects of other demographic and psychosocial factors were removed, the number of drinks consumed during the heaviest drinking event was a significant predictor of engaging in sex for women but not for men. CONCLUSION: In young adults, alcohol use with sex does not necessarily lead directly to lapses in judgment about safe sexual practices. Alcohol is but one of a number of factors that play an important role in determining the riskiness of a particular sexual encounter. PMID- 10155657 TI - Organizational development of a university-based interdisciplinary health promotion project. AB - PURPOSE: To analyze the organizational development and implementation of an interdisciplinary health promotion project at the University of New Mexico. The effort involved three academic units in a 3-year externally funded project to institutionalize health promotion curricula in the respective schools and to develop a wellness-oriented service for students, faculty, and staff. METHODS: The open systems theory was used as a framework to analyze the organizational and role issues that emerged from the data collected through interviews, staff surveys, and document review. The analysis is summarized by five thematic questions: (1) How did the project's vision affect its development? (2) How was leadership enacted, and with what effect? (3) What were the organizational issues for the staff? (4) What were the interdisciplinary dilemmas? (5) What was instituted or changed as a result of the project? RESULTS: The analysis uncovered a series of interpersonal and organizational dilemmas involving the nature of the organizational environment, the character of interdisciplinary work, leadership, boundaries of group membership, and the structuring of a unified vision. CONCLUSIONS: Future projects should consider the strength and stability of the boundary spanners, the resource context, and the role of a unified vision for new and organizationally linked units as key issues in facilitating and sustaining change. PMID- 10155658 TI - Use of medical care after a community-based health promotion program: a quasi experimental study. AB - PURPOSE: To assess the effects of health promotion on the use of medical care services in a community setting. DESIGN: Quasi-experimental, multiple time points, case-comparison group. SETTING: Community health center in Ottawa, Canada. SAMPLE: 520 volunteer participants in a health promotion program and 932 matched comparison subjects. INTERVENTION: The health promotion program consisted of a weekend workshop on health behaviors, lifestyle assessment, and identification of weekly goals for change. This was followed by 18 months of support (5 group sessions, weekly telephone calls, and optional individual sessions). MEASUREMENT: Computerized data on health care use 6 months before, 18 months during, and 6 months after the program were obtained from Ontario's universal Health Insurance Plan (OHIP). These data were used to determine the number and system costs of visits made by participants and comparisons. RESULTS: When controlling for baseline differences through analysis of covariance, program participants were found to have higher costs and more visits for ambulatory care during the first year (p < .01) and second year (p < .05) of follow-up. Participants used significantly more diagnostic services than comparisons during both years of follow-up. Participants were also more likely to use more counseling and psychotherapy services in year 1 (relative risk, 1.53; 95% confidence interval, 1.28, 1.81) and year 2 (relative risk, 1.57; 95% confidence interval, 1.31, 1.89). No differences were found between participant and comparison groups in visits for medical consultations and assessments or preventive services. CONCLUSION: No evidence shows that this health promotion program reduced use in this population over the 2-year follow-up period. PMID- 10155660 TI - Freedom and health promotion. PMID- 10155659 TI - A model for worksite cancer prevention: integration of health protection and health promotion in the WellWorks Project. AB - OBJECTIVES: To describe a theoretic approach and rationale for the integration of health protection and health promotion in worksite cancer prevention programs and to describe an intervention study designed to implement this integration. METHODS: Twenty-four worksites were recruited to participate in this randomized, controlled study. The theoretically based intervention model integrates health promotion and health protection through (1) joint worker-management participation in program planning and implementation, (2) consultation on worksite changes, and (3) educational programs targeting health behavior change. RESULTS: Although the primary purpose of this paper is to describe a theoretic approach to the integration of health promotion and health protection, preliminary results are also noted. In these predominantly manufacturing worksites, many workers faced the double jeopardy of exposures to occupational carcinogens and personal risks such as smoking or poor dietary habits. Production workers' job responsibilities frequently limited their full participation. Barriers to participation were identified early in the project, and strategies were developed to facilitate maximal worker involvement and worksite changes. CONCLUSIONS: Lifestyle changes such as smoking cessation or dietary changes may be more effectively promoted among blue collar audiences when programs also encourage management actions to reduce occupational exposures. Public health professionals trained in health promotion and health protection must work together to effectively address the health concerns of this population. PMID- 10155661 TI - A statewide public service smoking cessation clinic. PMID- 10155662 TI - Looking for CLIA answers for low-volume laboratories. PMID- 10155663 TI - Health care adjusts to the squeeze: networks, outsourcing, and downsizing arrive. AB - The 1990s has become a time when fewer employees are producing more work than ever for increasingly consolidated industries. Here's what that means in the american health care system: hospital networks, sharing laboratory services, contracting for outside services, and restructuring staffs. PMID- 10155664 TI - Education and training for physician office laboratory personnel. PMID- 10155665 TI - Legal aspects associated with dismissal from clinical laboratory education programs. AB - OBJECTIVE: To review academic dismissals, students' rights in dismissal cases, and several key cases involving academic and disciplinary dismissals. DATA SOURCES: Recent academic literature and legal precedents. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Students involved in dismissals are protected under the principles of constitutional law and/or contract law, depending on whether the institution is public or private. The basis for dismissal from educational programs is either academic or disciplinary in nature. In academic dismissals, a student has failed to meet either the cognitive or the noncognitive academic standards of the program. In disciplinary dismissals, a student has violated the institutional rules governing conduct. Policies that affect progress in the program and the dismissal process should be published and distributed to students, as well as reviewed for consistency with institutional policies. CONCLUSION: The amount of documentation needed in the defense of a dismissal decision has not been specified, but, in general, more is better. Procedures are suggested as a guide to dismissals in clinical laboratory programs. PMID- 10155666 TI - Selected options supporting use of the group embedded figures test in modeling achievement in clinical laboratory science programs. AB - OBJECTIVE: To identify, in light of predicted future shortages of allied-health personnel, student and curricular characteristics of clinical laboratory science (CLS) programs relevant to recruitment and retention at the baccalaureate level. SETTING: Not applicable. PRACTICE DESCRIPTION: Not applicable. PRACTICE INNOVATION: Options for modeling achievement in CLS programs are developed, and designs and procedures for clarifying procedural questions are considered in a context of delivery of instruction for specialized curricula and skill development. Considerable attention is given to the potential for using the Group Embedded Figures Test (GEFT) in modeling, advising, designing curricula, and monitoring quality improvement of programs and graduates. MAIN OUTCOME MEASUREMENT: Not applicable. RESULTS: Supporting evidence is supplied from the literature for options in developing an appropriate model for examining those salient variables known to have linkages to achievement. CONCLUSION: An argument is presented for better understanding of antecedent variables affecting achievement and retention of CLS students. In addition, a case is made for development of an appropriate model examining variables identified in the literature as being linked to achievement. Dynamic models based on these considerations should be developed chronologically from entry through graduation with emphasis on growth at year-end milestones. PMID- 10155667 TI - Standards of practice for discharge planning. PMID- 10155668 TI - Nurse prescribing. Advantages, disadvantages and future implications. PMID- 10155669 TI - Pharmacoeconomic aspects in the treatment of curable and incurable cancer. AB - Assessments of the direct and indirect costs of cancer treatment have demonstrated the extreme complexity of these costs. Expenditure on cancer treatment is high, often reaching 3 to 6% of the gross national product in industrialised countries. In this article, we propose that the health outcomes associated with this high expenditure should be analysed in relation to concepts such as total cytoreduction (leading to disease-free survival and cure) and cytostabilisation with acceptable quality of life (in incurable cancer patients). Outcomes appear to be more variable among incurable compared with curable patients, so that cure and survival (which apply to only about 50% of all patients) are not the sole outcome parameters. For the 50% of patients in industrialised countries in whom cure is not possible, outcomes (in the form of cytostabilisation and an ongoing obligation to seek curative cytoreduction) will require further pharmacoeconomic assessment. PMID- 10155670 TI - Do physicians take cost into account when making prescribing decisions? PMID- 10155671 TI - Health-related quality-of-life evaluation in HIV-infected patients. A review of the literature. AB - This article presents a review of the literature on health-related quality-of life (HRQOL) measurements in HIV-infected patients by means of multidimensional self-report questionnaires. Since 1989, 11 HRQOL instruments have been used, the most frequently employed scales and items being derived from the Medical Outcomes Study. The 9 instruments that were evaluated for their internal consistency reliability and validity generally met the conventional levels of psychometric performance. Descriptive longitudinal and psychometric studies that examined the ability of HRQOL instruments to distinguish between diagnostic groups consistently showed that, over time, patients developed more symptoms and reported poorer physical, role and sexual functioning. Patients' psychological functioning improved or remained at approximately the same level. Despite some methodological limitations, the 4 HRQOL studies performed as part of clinical trials provided valuable information for both patients and doctors about the impact of treatment with zidovudine, interferon-alpha or epoetin (recombinant human erythropoietin) on patients' HRQOL. Future studies are needed that provide more information on the feasibility, stability and responsiveness of existing HRQOL instruments. In addition, future studies should focus on the natural history of HRQOL in HIV-infected patients, and on the impact of commonly prescribed prophylactic and antiretroviral drugs on patients' HRQOL. There is an urgent need for translations and cultural adaptations of HRQOL instruments for use in different HIV-infected populations, including women, children, intravenous drug users and patients from African and other developing countries. PMID- 10155673 TI - Cost utility of chemotherapy and best supportive care in non-small cell lung cancer. AB - Polychemotherapy is the therapeutic option recommended for nonresectable, non small cell lung cancer (NSCLC). However, the modest gains in survival, and the frequent and often serious adverse effects, associated with chemotherapy should also be considered when deciding on therapy. We therefore performed a cost utility analysis of chemotherapy and best supportive care in NSCLC. Effectiveness and costs were analysed on 70 patients who were randomised to receive one of 3 treatments: VP (vindesine and cisplatin), CAP (cyclophosphamide, doxorubicin and cisplatin), or best supportive care. Subsequently, an assessment of the value of polychemotherapy and best supportive care was performed by oncology personnel using the time trade-off technique. Polychemotherapy was found to be more effective than best supportive care, but was also more costly and had a lower value score. Because of its cost utility and its higher value, best supportive care should not be discarded as an alternative for the treatment of NSCLC. PMID- 10155672 TI - Measuring quality of life in patients with depression or anxiety. AB - One-fifth of all disability is caused by psychiatric morbidity, with depression and anxiety the most common conditions. Despite this, and the wide range of pharmaceutical treatments available, few quality-of-life studies have been conducted with depressed or anxious patients. Most studies focus on symptoms and adverse effects, rather than on the impact of these on the patient. Where health status is assessed, inappropriate generic measures have been used. Recently, a depression-specific measure of quality of life, the Quality of Life in Depression Scale, has been developed and is starting to be used in clinical trials. No equivalent measure for anxiety is available. Given the range and rapid increase in the number of treatments available for depression and anxiety, and issues of compliance and individual response to treatment, much more attention must be given to quality of life in these conditions. PMID- 10155674 TI - Theoretical changes in neonatal hospitalisation costs after the introduction of porcine-derived lung surfactant ('Curosurf'). AB - The aims of this study were to determine the effects of porcine-derived lung surfactant (PLS; 'Curosurf') therapy on mortality, periods of care and hospitalisation costs in a model cohort of 1000 premature neonates. In this cohort, 55% of the neonates would develop respiratory distress syndrome (RDS) and this would result in a mortality rate of 35%. The mortality rate among infants without RDS is 19%. Five modes of surfactant therapy were studied: (i) late rescue; (ii) early treatment; (iii) prophylaxis; (iv) multiple-dose treatment; and (v) high multiple-dose treatment. At a 55% incidence of RDS, we found that late rescue and single-dose treatment of severely ill neonates resulted in between 4 and 51 extra survivors, and that multiple-dose treatments increased the number of extra survivors by between 17 and 101. Early treatment and prophylaxis were found to be the most effective strategies, resulting in between 38 and 111 extra survivors. These 2 modes of surfactant therapy were also more effective than the other types of intervention at other incidences of RDS. The introduction of PLS therapy increased the total hospitalisation costs of the cohort of 1000 neonates [71 million Netherlands guilders (NLG) if no patients received surfactant] by 0.8 to 16.0% because of increased survival. Improved survival increased the mean period of intensive care by 0.5 to 12.6% and of nonintensive care by 0.6 to 16.0%, thereby increasing the need for more beds. Costs for PLS ranged from 0.3 to 1.2% of the total hospital costs. The additional costs of PLS therapy per additional survivor, compared with the 'do nothing' option, ranged from NLG68 034 to NLG136 233, and were lowest with prophylaxis and highest with high multiple-dose treatment. Savings in costs per survivor (0.2 to 4.1%) and nonsurvivor (5.1 to 23.1%) were highest with prophylaxis and early treatment, which were found to be the most cost effective of the strategies studied. PMID- 10155675 TI - Omeprazole or ranitidine plus metoclopramide for patients with severe erosive oesophagitis. A cost-effectiveness analysis. AB - The objective of this study was to evaluate the clinical and economic effects of 2 clinical strategies for treating severe (grade II and above) erosive oesophagitis or poorly responsive gastro-oesophageal reflux disease. A single blind, randomised controlled trial of up to 8 weeks' duration was undertaken comparing omeprazole with ranitidine plus metoclopramide in patients with severe and symptomatic erosive oesophagitis (endoscopic grade II and above). Two cost effectiveness ratios were calculated: cost per healed patient and cost per symptom-free day. The study perspective was that of the payer or insurer of medical care. Healing rates were significantly higher among omeprazole-treated patients than among those who received ranitidine/metoclopramide at 4 weeks (68.5% vs 30.4%; p < 0.01) and overall (81.5% vs 45.7%; p < 0.01). Overall, mean gastrointestinal-related direct medical costs per healed patient were lower for the omeprazole group ($US189.60) than for the ranitidine/metoclopramide group ($US319.28). The incremental cost of an additional cure with omeprazole compared with ranitidine/metoclopramide was $US24.05. The overall average cost per symptom free day was lower in the omeprazole group ($US7.88) than in the ranitidine/metoclopramide group ($US10.81). The incremental cost to obtain an additional symptom-free day with omeprazole, compared with ranitidine/metoclopramide, was $US1.41. In conclusion, superior efficacy at comparable cost is achieved by omeprazole compared with ranitidine/metoclopramide in the treatment of patients with severe erosive oesophagitis. PMID- 10155676 TI - Costs of antifungal prophylaxis after bone marrow transplantation. A model comparing oral fluconazole, liposomal amphotericin and oral polyenes as prophylaxis against oropharyngeal infections. AB - We used a costs model to compare alternative modes of prophylaxis against oropharyngeal fungal infections in patients with leukaemia or myeloma who had undergone bone marrow transplantation (BMT). We compared 2 innovative pharmaceutical options (oral fluconazole and intravenous liposomal amphotericin) with existing standard practice (oral polyenes). Costs were measured over a 12 week treatment period, and were compared with the 2 effectiveness measures: (i) the avoidance of colonisation or infection; and (ii) the patients' ability to continue with prophylaxis in an uninfected state. The costs and effectiveness of BMT itself were not considered in this evaluation. The costs per successfully treated patient over a 12-week period were 28,956 pounds (1 pound = $US1.60, June 1995) for oral fluconazole, 53,225 pounds for liposomal amphotericin and 32,768 pounds for oral polyenes. Sensitivity analysis showed that the costs of liposomal amphotericin always exceeded those of the oral comparators, reflecting its high acquisition, preparation and administration costs. PMID- 10155677 TI - Anesthetic and ferric-magnesium ion combinations as calcium antagonists for glutaraldehyde-treated pericardial tissues. AB - The principal cause of the clinical failure of bioprosthetic heart valves fabricated from glutaraldehyde-pretreated bovine pericardial valves is calcification. The present investigation describes the mineralization of glutaraldehyde-treated bovine pericardium (GBP), in an extra-circulatory environment and the possible methods of prevention via metal ions. Calcification was examined on GBP incubated in metastable solutions of calcium phosphate and the role of certain anesthetic drugs, ferric ions and magnesium ions in the media was evaluated. It seems that the addition of ethyl alcohol, pentothal and xylocaine in the calcium phosphate solutions, variably inhibited the GBP calcification. The metals like Fe3+ ions and Mg2+ ions and their combinations also substantially reduced the GBP mineralization. It is assumed that ferric ions may slow down or retard the calcification process by delaying the proper formation of hydroxyapatite while magnesium ions disrupt the growth of these crystals by replacing Ca2+. Hence, it is conceivable that a combination therapy- via local delivery of low levels of ferric ions and magnesium ions--may prevent the GBP-associated calcification. Further, a very low daily intake of alcohol appears to be beneficial to reduce the profile of calcium deposition at tissue interfaces. PMID- 10155678 TI - Treatment of osteomyelitis by antibiotic impregnated porous hydroxyapatite block. AB - A novel drug delivery system was developed for osteomyelitis using porous hydroxyapatite blocks (HA-b) that were impregnated with antibiotics by a centrifuge method. For the experimental study, a 10 mm3 HA-b was placed in a container, mixed with an antibiotic solution and centrifuged at 1500 rpm for 15 min for the purpose of impregnating antibiotics into the pores. The slow release activity of antibiotic (Arbekacin sulfate [1-N-(S)-4 amino-2-hydroxybutyryl dibekacin]) from the HA-b was tested. An evaluation was made of the slow releasing capabilities of the ABK from HA-b which was still maintained at 0.5 microgram/ml within 21 exchanges of PBS after 42 days. Consequently, seven patients with osteomyelitis, including one with tuberculosis and two with infected hip arthroplasty, have been treated. On a follow-up study, all of the foci had completely healed by the end of the follow-up period without complications. This new method is simple and can be performed safety as a one stage operation. PMID- 10155679 TI - Bone defect healing in the absence and presence of a plastic catheter: an experimental study in the rabbit. AB - The healing pattern of small, round, cortical defects, drilled in the upper tibial diaphysis of rabbits, was studied histologically and histomorphometrically. Group I rabbits were not further handled. In groups II and III animals, a polyethylene catheter was introduced into the medullary cavity by way of a second cortical hole and driven forward until its tip was close to the first cortical defect. Group II rabbits were not further handled. The cortical defect of group III animals was irradiated from a diode source via a fiber optic cable in the catheter. Assessment of the osseous healing of the cortical defects revealed neither qualitatively nor quantitatively significant differences among the three groups. The morphological catheter, which abuts on a cortical defect, does not hinder the normal progression of osseous bridging of the gap. PMID- 10155680 TI - Properties of titanium dental implants produced by electro-discharge compaction. AB - Highly porous dental implants of a cylindrical shape were fabricated from commercial grade titanium REP-atomized powders by EDC. They were intended to have the maximum porosity for maximum osseointegration, but to maintain the minimum mechanical properties functionally required. Two level full factorial experiments were conducted with respect to the sample weight, capacitance, input energy and electrode configuration. All samples were X-rayed prior to tests to ascertain the presence, extent and distribution of internal macroscopic voids. Torque and compression tests were conducted to evaluate the yield or ultimate strengths (34 90 cm N and 205-502 MPa, respectively). These results indicate that macroscopic void-free, highly porous implants can be fabricated. PMID- 10155681 TI - Quantification of anatomic, geometric, and load transfer characteristics of the wrist joint. AB - The work reported here is an assimilation of 8 years of research, the purpose of which was to gain a better understanding of the normal and abnormal workings of the wrist joint. The results are summarized in three major areas of concentration: descriptive anatomic studies, which include direct measurements of cadaver specimens, biomechanical loading studies to define load distribution through normal and abnormal wrists, and three-dimensional (3D) anatomy studies using solid models derived from computed tomographic (CT) images of in vivo and cadaver wrists. The descriptive anatomic studies used 393 cadaver wrists to evaluate the incidence and distribution of anatomic features, arthroses, chondromalacia, and soft-tissue lesions. The data were analyzed for any statistically significant associations among different variables. The biomechanical studies characterized the biomechanics of the human wrist in a variety of normal, simulated traumatic, and surgically treated conditions. The results of the load studies have provided clinically relevant information on the normal anatomy and functional mechanics of the wrist as well as guidelines for the treatment of a number of different fractures and ligament injuries. The 3D anatomic studies use quantitative analysis of 3D reconstructions of CT scan data to build a normative database of carpal bone morphology. Thirty-five wrists were imaged in a CT scanner. Quantitative measurements of volume, surface area, maximum length, and intercarpal distances were than assessed. A reliable 3D carpal height ratio (3DCHR) was calculated by dividing the capitate maximum length by the carpal height, which is the minimum distance between the fourth metacarpal and the radius. PMID- 10155682 TI - Finite element stress analysis of the wrist joint without and with an endoprosthesis. AB - The finite element analysis method was used to obtain the lateral deformation profile and values of the von Mises stress in the cortical and cancellous regions of the various bones in models of a selected space in the coronal plane of a human wrist joint, without and with a prosthesis. The prosthesis was the metacarpal component of the Trispherical design of the total wrist joint arthroplasty. The models included all the bones, the associated network of ligaments, and the intervening soft muscle tissue. Each type of model was completely constrained along its entire proximal surface and subjected to either a static point force (in the axial compressive or anteroposterior tensile direction) acting at the center of the distal tip of the third metacarpal cortical bone. For the models containing the prosthesis, a parametric study was conducted involving the method of anchorage of the prosthesis to the contiguous bones and the material of fabrication of the prosthesis. It was found that: (1) the axial force produces lower stresses in the bones compared with the anteroposterior one; (2) no clear-cut case can be advanced, from the stress viewpoint, for press-fitting the prosthesis to the contiguous bones rather than using bone cement for such anchorage; and (3) any alloy with modulus of elasticity in the 79 to 196 GPa range and Poisson's ratio of about 0.3 may be used to fabricate the prosthesis. The approximations used and the associated limitations of the work are fully discussed, as are the design implications and clinical significance of the results. PMID- 10155683 TI - The total wrist joint arthroplasty: biomechanical considerations and research directions. AB - A review of the state-of-the-art knowledge base on the biomechanics of the wrist joint, with emphasis on total wrist joint arthroplasty, is presented. The reasons for the reported high rate of aseptic loosening of the metacarpal component of such an implant are unknown at this time. It is suggested that detailed stress analyses of models of the joint, without and with the aforementioned implant, will yield results that will increase understanding of this problem and improve implant design, resulting in enhanced clinical performance of these replacements. For this purpose, it is recommended that the finite element analysis method be used. PMID- 10155684 TI - A contact-coupled finite element analysis of the radiocarpal joint. AB - A plane-strain finite element contact model of the radiocarpal joint has been developed to investigate the mechanical relationship between initial intra articular fracture of the distal radius, subsequent imprecise reduction of articular incongruency, and final onset of osteoarthrosis. The model includes the radius, two carpal bones (the lunate and the scaphoid), and the articulations and ligamentous connections between the bones. The model has been validated through comparisons with previous experimental and computational models of the wrist. The relationship between malreduced intra-articular fracture of the distal radius and the subsequent onset of posttraumatic radiocarpal osteoarthrosis is clinically important but poorly understood. The broad objective of the current research is the development of a well-verified computational model of the radiocarpal joint, which in concert with previously developed experimental models, will be capable of providing guidance toward rigorously grounded improvements in distal radius intra-articular fracture management techniques. This model represents a first step toward this objective as well as a new level of computational simulation of wrist mechanics. PMID- 10155685 TI - Wrist arthroplasty with the trispherical total wrist prosthesis. AB - The clinical results and long-term implant survival of wrist arthroplasty with the Trispherical total wrist prosthesis was evaluated in patients with inflammatory arthritis. Using the Hospital for Special Surgery wrist scoring system, the clinical evaluation of 35 Trispherical total wrist arthroplasties showed an excellent result in 20, good result in 8, fair result in 3, poor result in 2, and failed result requiring revision in 2 wrists at an average follow-up of 9 years. Cumulative implant survival in 67 consecutive Trispherical total wrist arthroplasties was 97% at 5 years and 93% at 10 and 12 years postoperatively. Patient satisfaction with wrist arthroplasty using the Trispherical prosthesis was excellent. We attribute the favorable long-term results obtained with the use of this prosthesis to its inherent design that allows for accurate restoration of the center of rotation of the wrist. PMID- 10155686 TI - The use of a high-hip center in revision total hip arthroplasty. AB - In certain cases, primary and revision total hip arthroplasty is complicated by insufficient bone stock and distorted acetabular anatomy such that the craniocaudal dimension of the acetabular recess is greater than the anteroposterior dimension. Acetabular reconstruction in such cases can be carried out by placing the acetabular component more proximally than normal (high-hip center). Recent biomechanical and clinical data suggest that placement of the acetabular component at a higher than normal hip center does not adversely effect the longevity of the component fixation. Proximal placement of the hip center also facilitates the contact between the host bone and the porous coating when uncemented porous coated components are used, and minimizes the need for structural bone grafts. However, femoral components with longer neck lengths and removal of impinging bone are needed when the acetabular components are placed more proximally in order to restore the limb lengths and minimize the chances for dislocation. PMID- 10155687 TI - Revision total hip arthroplasty using a cementless acetabular component: technique and results. AB - One hundred thirty-eight acetabular revisions for aseptic loosening were performed in 132 patients using a cementless hemispherical component coated with titanium mesh and inserted with supplemental screw fixation. Twelve patients died, 9 were lost to follow-up and 6 could not return, leaving 111 patients (115 hips) at mean 100 months follow-up. Thirteen hips required revision (11%); 4 for recurrent dislocations, 6 for sepsis, and 3 stable cups were revised (at the time of stem revision). No cup was revised for aseptic loosening. Radiographic review was available for 105 patients (109 hips) at mean 98 month follow-up (78 to 135 months). One hundred cups (91%) were considered stable. Seven cups were possibly unstable (7%), one cup was probably unstable (1%), and one septic hip had an unstable cup (1%). Four percent of the cups showed a complete radiolucency. A partial progressive radiolucency was seen in 3%, a partial nonprogressive radiolucency in 54%, and no radiolucency was present in 39%. A screw radiolucency was seen in 2%, and osteolysis at the cup margin in 4%. Revision of the acetabulum with a cementless porous-coated hemispherical fiber-metal component seems to be superior to the results reported for acetabular revisions with cement at similar follow-up. PMID- 10155688 TI - Acetabular reconstruction using structural grafts in total hip replacement: a 12 1/2 year follow-up. AB - We reviewed 34 patients who had structural acetabular grafts used in conjunction with total hip replacement. Two patients died and eight were lost to follow-up, leaving 24 patients with 24 grafts who were followed-up for a minimum of 10 years and an average of 12 1/2 years. There were 8 primary hips and 16 revisions. Twenty-two (92%) of the grafts united. The two non-unions were in patients with sepsis. Six grafts (26%) failed. Two failed because of sepsis and four were aseptic failures. All the aseptic failures were the results of technical errors. Two grafts were of poor quality and all of the aseptic failures had transverse trabeculae and transverse screws. There were 10 (41%) loose acetabular components. Two were loose because of sepsis. Of the eight aseptic failures, four were caused by failure of the graft and in the other four, the graft remained intact but the cemented acetabular components loosened. There was no correlation between the percentage of component coverage by the graft and component failure. The average preoperative Harris rating was 43 and the postoperative rating was 81, including the failures. If the failures were eliminated, the rating of the remaining patients was 93. Structural acetabular grafts are rarely necessary. However, they do work and their success is clearly related to technique. Important technical factors include: the graft must be of good quality, the trabecula must be oriented in the line of weight-bearing forces, the graft must accurately fit the defect, the graft must be supported by a host buttress, and the graft should be fixed with lag screws that are oriented in a line of weight bearing. If these criteria are met, early weight-bearing is important to stimulate graft healing and remodeling. PMID- 10155689 TI - Acetabular reconstruction in revision total hip arthroplasty. AB - Acetabular revision surgery is always associated with some degree of bone loss. Where an intact peripheral rim is present it can be used to achieve ingrowth and cementless prosthetic fixation. Where major segmental defects are present and prosthetic stability is not possible in host bone, structural allografts may be necessary to satisfy the principles of acetabular reconstruction. Using quality bone, proper fixation, and buttressing of structural allografts against host bone, a high degree of success can be expected. The majority of acetabular revisions can be reconstructed with large hemispherical sockets and adjuvant screw fixation and the use of bulk allografts should be reserved for those reconstructions where no good alternative exists. PMID- 10155690 TI - Extensile anterior column acetabular reconstruction in revision total hip arthroplasty. AB - The extensile triradiate approach, with anterior-column plate reconstruction using structural allografts, was used in 12 cases. Pelvic discontinuity requiring posterior-plate application was present in eight of these cases. Allograft reconstructions seemed to be radiographically incorporated by approximately 8 months postoperatively and all discontinuities united. The results were excellent in four cases, good in two cases, fair in three cases, and poor in three cases. Two cups were revised for loosening. Deep sepsis resulted in graft and component removal in two cases. At reexploration, discontinuity and allografts were noted to be healed in these cases. PMID- 10155692 TI - Acetabular defect classification: a detailed radiographic approach. AB - This classification system was developed based on clinically significant recurrent patterns of acetabular bone loss. The classification has now been refined with four specific radiographic parameters that provide specific criteria to classify each defect accurately. This detailed radiographic analysis is based on findings on the plain anterior-posterior pelvis radiograph and eliminates the need for costly computed tomography scans. Each defect classification type also has a clinically proven reconstruction method available. The failed acetabulum can be assessed accurately and easily with this method. PMID- 10155691 TI - Acetabular anti-protrusio rings and cages in revision total hip arthroplasty. AB - Uncemented hemispherical porous-coated acetabular components work well for the great majority of acetabular component revisions. Unfortunately, when bone loss is so severe that little contact between a porous-coated socket and native bone can be achieved, high rates of failure of uncemented porous-coated sockets have been reported. When circumstances are encountered in which porous-coated hemispherical sockets are unlikely to succeed, acetabular reinforcement devices have advantages over cemented polyethylene sockets alone. The ability of antiprotrusio rings and cages, now used to augment socket fixation to the pelvis, facilitate extensive pelvic bone grafting, and prevent early socket migration, have led to renewed interest in these devices as useful tools in the orthopedic surgeon's armamentarium to manage some of the most challenging acetabular reconstruction problems. This article discusses the rationale for selected use of acetabular reinforcement devices, the reported results of using acetabular reinforcement rings and cages in revision total hip arthroplasty, and the circumstances in which these devices may be considered for acetabular reconstruction at the present time. PMID- 10155693 TI - Total acetabular transplant allograft reconstruction of the severely deficient acetabulum. PMID- 10155694 TI - Dealing with the deficient acetabulum in revision hip arthroplasty. AB - Variable bone loss is the defining feature of the failed acetabulum. Preoperative planning must include an assessment of the extent of bone deficiency. When bone loss precludes a routine revision there are three reconstructive options, a small cup in the false acetabulum, reconstruction of the lost bone with an allograft, and a jumbo cup filling the expanded acetabulum. The investigators have found that the latter technique can often be used in the setting of the difficult acetabulum with improvement in hip mechanics and avoiding a structural bone graft. When a graft is necessary, the best technique is a small graft and large fixed cup, with support of both the cup and graft on as much host bone as possible. A posterior buttressing plate should be considered for any graft providing substantial posterior support of the acetabular component. PMID- 10155695 TI - Retinal detachments associated with blunt trauma. PMID- 10155696 TI - Pneumatic retinopexy and balloon buckles as alternatives to conventional scleral buckling surgery. PMID- 10155697 TI - Diagnosis and management of viral retinitis in the acute retinal necrosis syndrome. PMID- 10155698 TI - Current management of proliferative vitreoretinopathy. AB - The recognition of APVR and its dissection, along with the use of perfluorocarbon liquids, has greatly improved the success rate in surgery for severe PVR. In reviewing our first 71 cases using these techniques, 75% were attached with one operation and 90% were attached with one or more operations. These techniques have greatly improved our operative results and have obviated the use of retinal tacks and suturing, retinotomy (in most cases), and the need for very high scleral buckles. (We rarely alter an in-place scleral buckle.) PMID- 10155699 TI - Strabismus after retinal detachment surgery: etiology, diagnosis, and treatment. AB - Between 5% and 25% of patients may experience persistent diplopia after surgery for retinal detachment. The complexity of the presentation poses a distinct challenge to both the retinal and the strabismus surgeon. Careful evaluation to determine factors contributing to the strabismus and assessment of fusional capabilities are essential before treatment. A combination of the appropriate surgical approach with nonsurgical adjuncts such as prisms or botulinum toxin is often successful in relieving symptoms. PMID- 10155700 TI - The role of intraocular gases and air in scleral buckling surgery. PMID- 10155701 TI - Prophylaxis of retinal detachment. AB - Prophylactic treatment of retinal breaks can only be justified if the risk of complications from treatment is lower than the risk of breaks leading to clinical retinal detachment. Recommendations for prophylaxis should be based on results from valid controlled studies and not merely on traditional high-risk associations between certain risk factors and clinical retinal detachment. Present evidence supports prophylactic treatment of all symptomatic tractional tears; and is suggestive for the treatment of large, symptomatic operculated tears, high-risk fellow eyes of nontraumatic giant retinal breaks, retinal breaks with subclinical retinal detachments threatening progression, and retinal breaks before cataract surgery. Support for prophylactic treatment of asymptomatic retinal breaks in aphakic and pseudophakic eyes with or without an intact posterior capsule is at best, equivocal. Asymptomatic retinal breaks in phakic eyes with lattice degeneration, high myopia, and fellow eye detachments show no significant benefit from prophylaxis and should be followed without treatment. PMID- 10155702 TI - The role of vitrectomy in rhegmatogenous retinal detachment. AB - Several conditions, such as detachment from posterior breaks or detachment with significant media opacities, may warrant vitrectomy as the primary procedure. In cases in which the preoperative retinal view is clear and a posterior break is definitively excluded, vitrectomy does not appear to offer significant advantage over scleral buckling other than a theoretically improved ability to examine the retina microscopically with scleral depression. Performing a vitrectomy for an uncomplicated retinal detachment from a small peripheral break in which scleral buckling would be the usual procedure of choice remains controversial. Although it may avoid the complications of scleral buckling, vitrectomy does have its own potential complications. The status of the lens, cornea, and configuration of the retinal tears and detachment should carefully be considered before vitrectomy. Proper patient selection and appropriate education are important factors in a successful outcome. Finally, from an economic viewpoint, the likelihood of success with vitrectomy in one procedure compared with other less expensive procedures should be considered. PMID- 10155703 TI - Perfluorochemical-based artificial oxygen carrying red cell substitutes. AB - There has been rapid progress in research on artificial oxygen-carrying red blood cell substitutes composed of perfluorochemical emulsions (PFE). PFE are capable of delivering significant amounts of oxygen to tissues, but FDA approval is given for routine human use they must first overcome concerns regarding adverse effects and then clearly demonstrate efficacy in human trials. Infusion of the first commercial product used in humans, Fluosol-DATM, which contained a relatively low concentration of perfluorochemical, was associated with immediate adverse effects in some individuals and failed to demonstrate efficacy in a prospective clinical trial. A second generation PFE artificial oxygen carrier, Oxygent-HTTM, should be more effective since it carries five-fold more oxygen than Fluosol, does not require mixing, and is more stable. Initial clinical trials of this and other second generation PFE were accompanied by mild, transient flu-like side effects. PFE are also being investigated for regional organ perfusion, tumor oxygenation prior to radiotherapy, contrast imaging, and for liquid ventilation of infants with respiratory distress syndrome. The development of a safe, effective, artificial oxygen carrier at reasonable cost will have a major effect on transition practice. Since PFE have a brief intravascular survival they are unlikely to supplant the use of red blood cells in treatment of anemia. PMID- 10155704 TI - Recombinant growth factors. AB - Recombinant human growth factors are expected to have a significant impact on the use of allogeneic blood components. For example, subsequent to the approval of recombinant human erythropoietin, blood transfusions in renal dialysis patients declined substantially. Likewise, myeloid growth factors have reduced infections and hospital stay by promoting hematologic recovery after high dose ablative chemotherapy. The high costs of these agents mandate that their use be limited to settings where they are clinically indicated. The use of growth factors may be monitored at medical centers by hospital transfusion committees. This chapter reviews the emerging clinical guidelines for the use of hematopoietic growth factors. PMID- 10155705 TI - The development of hemoglobin solutions as red cell substitutes: hemoglobin solutions. AB - Although the efficacy of hemoglobin-based oxygen carriers was established more than 60 years ago, all prior clinical trials have demonstrated significant toxicity characterized by renal dysfunction, gastrointestinal distress, and systemic vasoconstriction. The mechanisms of these toxicities now appear to be understood. Tetrameric forms of the hemoglobin molecule extravasate from the circulation and interact with endothelial derived relaxing factor, leading to unopposed vasoconstriction. Although numerous efforts are underway to chemically modify the native tetramer, it is likely that all tetrameric forms of the hemoglobin molecule will continue to extravasate. We have focused on developing a polymerized form of hemoglobin that is virtually free of unreacted tetramer. The development and characterization of this polymerized pyridoxylated hemoglobin solution (Poly SFH-P) is described. Clinical trials have been completed successfully in volunteers, and are now underway to assess the safety and efficacy of Poly SFH-P as a clinically useful red cell substitute in the treatment of acute blood loss in the setting of trauma and surgery. PMID- 10155706 TI - Impact of autologous blood transfusion on blood support in general thoracic surgery: analysis of 969 patients over a 5-year period. AB - Autologous blood transfusion (ABT) is increasingly used in order to avoid transfusion-related risks. The effectiveness of this simple and feasible procedure depends on several factors, such as the timing of surgery, the patient's overall condition and, last but not least, the pre-disposition of the medical team towards the routine use of ABT. We report our experience in blood support with ABT for general thoracic surgical patients, indicating an overall partially satisfactory outcome due to a limited use of the procedure. In 1992, 61 patients (38%) received autologous blood only, as compared to 9 patients (6%) who had received ABT in 1989. The average pre-deposit per patient ratio in 1992 was 1.2 units, which provided insufficient autologous blood support. In the same period, only 23 patients were subjected to acute normovolemic hemodilution (ANH). However, we noted a reduction of homologous transfusions from 2.9 +/- < 2.1 in 1989 to 2.0 +/- < 1.5 in 1992 (P < 0.01). In addition, we observed that a single pre-deposit was not enough to enhance erythropoiesis and to improve post operative red blood cell rescue when performed in patients with Hb > 11 g%. Based on our data, we emphasize a more extensive move to ANH, along with pre-deposit, in order to avoid unnecessary homologous blood transfusions. PMID- 10155707 TI - A comparison of peripheral blood stem cell apheresis using the Fenwal CS3000 Plus and COBE Spectra. AB - We have compared the leukapheresis products collected on the Fenwal CS3000 Plus and COBE Spectra in a well-controlled patient population. While statistically significant differences were found, i.e. in product hematocrit, volume, number of granulocytes and platelets collected, these are not felt to be physiologically important. Similar efficiency in collecting mononuclear cells and colony forming unit assay results indicate that each instrument is capable of harvesting hematopoietic progenitor cells from peripheral blood. PMID- 10155708 TI - Double-lumen inferior vena cava catheters for peripheral stem cell apheresis and transplantations. AB - No previously published studies have described double-lumen hemodialysis/apheresis catheters for use with continuous-flow apheresis collection of peripheral stem cell (PSC). We prospectively evaluated experiences with these catheters during both PSC collection and transplantation. Because of previously-described successful experiences with single-lumen apheresis catheters placed in the inferior vena cava, all catheters evaluated in this study were placed in this anatomic location. Our experience demonstrated high rates of thrombotic occlusion (65%) and catheter-related infections (15%). This method of access should not be considered optimal in its present state of use. Further investigation into preferred catheter design, anatomic location, and thrombosis prophylaxis during continuous-flow apheresis is warranted. PMID- 10155709 TI - Evidence for proteolytic cleavage of covalently bound protein A from a silica based extracorporeal immunoadsorbent and lack of relationship to treatment effects. AB - Studies were conducted to evaluate the potential cause for release of covalently bound Staphylococcal protein A (SpA) from a silica based extracorporeal immunoadsorbent matrix. In vitro tests revealed that SpA could be detected in human plasma, human serum, and chicken serum upon exposure to the immunoadsorbent matrix which had been treated to remove non-covalently bound SpA. In contrast, only minute quantities of SpA were detected after exposure of a physiologic mixture of purified albumin and immunoglobulin G (IgG) to the immunoadsorbent matrix. Additional tests, employing a cocktail of protease inhibitors and formalin as a general stabilizer and protease inhibitor, revealed significant inhibition of endogenous proteolytic activity present in plasma and serum. Prevention of this proteolytic activity also significantly inhibited the release of covalently bound SpA from the immunoadsorbent matrix upon contact with plasma or serum samples. Further analyses of serum samples from patients with immune thrombocytopenia, chemotherapy associated thrombotic thrombocytopenic purpura hemolytic uremic syndrome, and breast cancer revealed a lack of association between the quantity of SpA proteolytically released and observed clinical responses or adverse effects experienced during immunoadsorption treatments. These studies indicate that SpA detected in plasma or serum after exposure to the immunoadsorbent is due to inherent endogenous proteolytic activity which cleaves protein fragments from the matrix and that these cleaved SpA fragments do not appear to contribute to the observed clinical responses or adverse effects in treated patients. PMID- 10155710 TI - Predictors of successful PTCA using coronary perfusion balloon catheters. AB - The purpose of this retrospective study was to define clinical, angiographic and procedural predictors of successful PTCA using perfusion balloon catheters (PBC). Age, gender, diabetes, clinical state (stable or unstable angina), coronary vessel, AHA/ACC lesion type, lesion contour, pre-procedural thrombus, percent stenosis, lesion length, balloon size, maximum PBC pressure, and maximum inflation time were analyzed for 207 lesions in 193 successive patients. Unsuccessful results occurred more frequently in patients with unstable angina, pre-PTCA thrombus, and those treated with smaller balloon catheter diameter. Logistical regression analysis identified larger balloon size (odds ratio [OR] = 0.447 [95% confidence interval 0.203, 0.986], p < .05); and absence of thrombus (OR = 2.217 [95% confidence interval 1.066, 4.610], p < .05) as predictors of success. This study suggests that small vessel size, approximated by balloon size selection, and the presence of pre-PTCA thrombus reduces the likelihood of success, especially in the setting of unstable angina. In these cases other percutaneous interventions may be warranted. PMID- 10155711 TI - Implanted devices and electromagnetic interference: case presentations and review. AB - Electromagnetic interference can cause implanted devices (pacemakers and defibrillators) to malfunction. This article reviews four cases of device interference and provides a review of the literature, and our recommendations for managing these problems. PMID- 10155712 TI - Dyslipoproteinemias in atherosclerosis, thrombosis and restenosis after coronary angioplasty. AB - Lipids play a vital role in normal metabolic function in mammals. However, dyslipoproteinemias have been implicated in the pathophysiologic process of atherogenesis, thrombogenesis and restenosis after interventional procedures. Lipoproteins provide important chemical linkages among these three complex phenomena. Lipoproteins participate in atherogenesis and play a major role in plaque fissuring, the pathophysiologic common denominator of acute ischemic syndromes. Thrombogenesis is majoraly affected by the action of lipids on platelets, coagulation and fibrinolysis. LDL tend to destabilize platelet membrane activity, macrophages, endothelial and smooth muscle cell function; HDL tend to reverse these abnormalities. The metabolism of arachidonic acid, a metabolite of the essential polyunsaturated lipoprotein, linoleic acid, is integral to platelet and endothelial cell membrane formation, via the cyclooxygenase-prostanoid pathway. Arachidonic acid also is metabolized by the lipoxygenase-leukotreine pathway in neutrophils and monocytes. The relationship of dyslipoproteinemias (increased LDL and Lp(a); decreased HDL) to restenosis after angioplasty has been reported, though there is not universal agreement about causality. Lipid lowering regimens and other pharmacotherapy have had favorable effect slowing the rate of atherogenesis, decreasing the frequency of cardiac events (perhaps by "stabilizing" vulnerable plaques) and causing regression in some atheromata. The salutary effect of lipid-lowering agents upon the incidence of restenosis after angioplasty is problematic. Some investigators have found a statistically significant correlation, while others have not; but studies have not been standardized. In conclusion, the study of lipid metabolism across a wide range of physiochemical activities and the interaction of these phenomena describe complex, genetically determined linkages which instruct (and often humble) investigators in their study of lipids in health and disease. PMID- 10155713 TI - Cardiogenic shock due to anterior myocardial infarction with right ventricular dysfunction. PMID- 10155714 TI - Management of ventricular tachycardia with ablation therapy in a patient with a previously implanted cardioverter defibrillator. PMID- 10155715 TI - Laboratory measurement of human cytokines. AB - Cytokines mediate and modulate different physiological systems. Accurate and sensitive methods for their measurement are being developed using bioassays, immunoassays, measurement of their mRNA, receptor binding assays, and immunochemical procedures. The most clinically significant cytokines and their assay methods are briefly reviewed. The need for standardization of assays is stressed. PMID- 10155716 TI - Biochemical markers of bone metabolism in the assessment of osteoporosis. AB - Several biochemical markers are available for the study of bone metabolism. The characteristics of these markers are reviewed and their potential application in osteoporosis is examined. It is concluded that biochemical markers are potentially useful in identifying those at risk of developing osteoporosis, selecting appropriate treatment, monitoring therapy, and studying the pathogenesis of osteoporosis. PMID- 10155717 TI - Biological variability in the concentration of serum lipids: sources, meta analysis, estimation, and minimization by relative range measurements. PMID- 10155718 TI - Impact of the clinical laboratory on health-care expenditures in Argentina. AB - This article describes how the Argentinian health-care system is organized and funded, and how it has developed. The provision of laboratory services in Argentina is the result of a unique approach involving negotiations between health-care organizations and professional associations. As a result, the professional associations, such as the Buenos Aires Province biochemists' federation, wield considerable economic power. This paper describes the roles played by biochemists and physicians, and how these and other professionals are remunerated. The attempts of the government to legislate the health-care system are discussed. PMID- 10155719 TI - The OpenLabs project. A suggested approach for more effective use of information technology in clinical laboratories. AB - The OpenLabs project is a major European initiative in laboratory medicine with a global audience in mind. OpenLabs aims to improve the efficiency and effectiveness of clinical laboratory services by integrating knowledge-based systems (using OpenLabs modules) with laboratory information systems and equipment. Standards for electronic data interchange between laboratories and other medical systems using the OpenLabs coding system and an open architecture for clinical laboratory information systems are being specified. PMID- 10155720 TI - Prenatal diagnosis of hemoglobinopathies. AB - Hemoglobinopathies are the most frequent and severe inherited diseases worldwide. Prenatal diagnosis is an effective way of controlling severe hemoglobin disorders for which effective treatments are not yet available everywhere. It is a multidisciplinary process requiring knowledge of the spectrum of molecular defects and involving laboratory investigations and genetic counseling. Hematological screening for these disorders is simple, rapid, and reliable. Carrier screening in populations at risk and genetic counseling are part of a number of European health programs, offering many couples at risk the chance of having a healthy child. This article describes the current molecular biology techniques for prenatal diagnosis of hemoglobinopathies. PMID- 10155721 TI - Laboratory tests for human immunodeficiency viruses. AB - Two types of human immunodeficiency viruses are known. Both type 1 (HIV-1) and type 2 (HIV-2) can lead to AIDS. This article describes laboratory tests that are used for diagnosis of HIV infection and for monitoring disease progression or the effects of therapy. These tests are based on detection of host antibodies, viral antigens, viral nucleotide sequences, or cultivation of the virus in vitro. The principles underlying test methods for differentiation between HIV-1 and HIV-2 are described. PMID- 10155722 TI - Specimen storage and the use of a relational database. AB - Advances in genetic research make laboratory specimens a valuable source of DNA. Regulations call for quick turnaround time in locating stored specimens. Personal computers and database software make it possible to store, locate, and inventory samples efficiently and assist in research work and cooperation between laboratory sites. PMID- 10155723 TI - Microchimerism after transfusion: the spectrum from GVHD to alloimmunization. PMID- 10155724 TI - Transfusion-associated graft-versus-host disease (TA-GVHD): cellular mechanisms and their possible modulation by ultraviolet radiation. PMID- 10155725 TI - Clinical and laboratory aspects of TA-GVHD with reference to perinatal patients and gamma-irradiated red cell components. PMID- 10155726 TI - Blood component irradiation and prevention of graft-versus-host disease. PMID- 10155727 TI - Effect of 25 Gy gamma irradiation on storage stability of three types of platelet concentrates: a comparative analysis with paired controls and random preparations. PMID- 10155728 TI - A comparison of in vitro storage markers between gamma-irradiated and non irradiated apheresis platelet concentrates (APC). PMID- 10155729 TI - U.K. guidelines for the irradiation of blood components. PMID- 10155730 TI - Pilot study of a new treatment concept for acute Guillain-Barre syndrome. AB - The pathogenesis of acute Guillain-Barre syndrome (GBS) is unknown as yet. Numerous clinical and experimental data suggest an autoimmune disorder. Controlled multicenter trials have demonstrated the efficacy of plasma exchange and intravenous immunoglobulin (IgG). A combination of these treatments appears to be a promising concept. We assume that initial selective adsorption treatment eliminates the postulated circulating pathogenetic agent and thereby allows for a more effective immunomodulation by the subsequent administration of i.v. IgG. In a pilot study of 30 patients (11 plasma exchange, 7 selective adsorption, and 12 patients treated with selective adsorption and subsequent administration of i.v. IgG) we found no significant differences for the variables including disability on admission, maximal disability, change of disability during treatment, and disability on discharge. Moreover, we found no apparent differences with respect to tolerance of the procedures or procedural side-effects. We conclude from these preliminary findings that these treatment regimens are viable and safe procedures and result in similar clinical improvement. Statistical evaluation of the efficacy of this treatment concept can only be done after a multicenter study of a large patient group. PMID- 10155731 TI - Hematopoietic engraftment from a minimal number of apheresis procedures after mobilization of peripheral blood stem cells with chemotherapy and rhG-CSF. AB - In a cohort of 13 patients, peripheral blood stem cells (PBSC) were harvested by apheresis after mobilization with chemotherapy and rhG-CSF. Nine patients who had excellent mobilization were transplanted with PBSC concentrates from a minimal number of apheresis procedures (mean of 1.5, range = 1-3). During collection, the number of circulating progenitors was on average 50 times higher than those observed at the steady state in the peripheral blood of healthy unstimulated individuals. The mean number of CFU-GM/kg reinfused per patient was 28.1 x 10(4) (range = 18.0-50 x 10(4)). The use of rhG-CSF, at either 1 or 5 micrograms/kg/day, resulted in a significantly greater yield of CFU-GM per mononuclear cells than that observed previously in a comparable group of patients receiving chemotherapy alone. Prompt and durable engraftment occurred after myeloablative chemotherapy. The average duration of absolute neutropenia was 9 days. Transfusion requirements were low with an average of four packed red cell units and two platelet transfusions per patient. The shortest follow-up is 5 months and the longest is 20+ months. The convenience of this new approach to support myeloablative therapy offers new possibilities for the administration of a higher dose-intensity of chemotherapeutic agents. A limited number of apheresis procedures timely harvested will improve the cost effectiveness of transplant programs. PMID- 10155732 TI - Studies on IgA class circulatory red cell antibodies--I. Preparation and identification of IgA class anti-A,anti-B. AB - To elucidate the role of IgA class alloantibodies in transfusion practice, anti A,anti-B was prepared using pooled serum from healthy group O donors. IgG was removed by protein A and protein G, whilst IgM was extracted by concanavalin A and anti-human mu chain. The final preparation contained both IgA1 and IgA2; it had an IgA concentration similar to the original serum pool and an environment as near to normal as possible; the absence of IgG and IgM was confirmed by sensitive enzyme-linked antiglobulin tests, and extensive haemagglutination studies showed that anti-A,anti-B was the only red cell antibody present. PMID- 10155733 TI - Studies on IgA class circulatory red cell antibodies--II. Properties of IgA class anti-A,anti-B. AB - The properties of IgA class red cell alloantibodies were determined using an anti A,anti-B preparation confirmed to be free from IgG and IgM. The following characteristics were found: a thermal optimum of 37 degrees C; saline agglutination enhanced by anti-human IgA; activity substantially unchanged after 1 year's storage at 4 degrees C, but reduced by papain and destroyed by pepsin and by reduction and alkylation; neutralization by AB blood group substance; an inability to activate complement; and a distinctive pattern of apparent molecular sizes (reflecting dimeric and monomeric forms and complexes with serum proteins) which was significantly altered by the action of enzymes and by reduction and alkylation. PMID- 10155734 TI - The use of therapeutic plasma exchange for treatment of acute polyradiculoneuropathy. AB - The rationale for therapeutic plasma exchange (TPE) in acute polyradiculoneuropathy (APRN) is based on the presence of circulating antibodies which cause demyelination of the peripheral nerves. This study included 24 patients, most having a neurological defect of grade 4, classified into groups A and B. Group A was treated with immunosuppressive drugs only, while group B was treated by a combination of immunosuppressive drugs and TPE. The average volume of plasma removed during a single TPE procedure was 2.95 L, and totalled 21 L overall. The efficacy of the TPE treatment was assessed on the basis of changes in the neurological deficit grade, and in electrophysiological parameters. It was shown that improvements were significantly better and faster in patients treated by a combination of immunosuppressive drugs and TPE, and when TPE was started within the first 7 days after the onset of the disease. PMID- 10155735 TI - Exploiting temperature dependence to improve selectivity in membrane-based plasmapheresis. AB - Temperature effects on cross-flow membrane plasmapheresis have been investigated with the help of hydrophillic polyvinylidene fluoride (PVDF) Durapore membranes of pore size 0.65 micron and an effective filtration area 30 cm2, using a thin channel device (Minitan-S, Millipore Inc., U.S.A.) and goat's blood as the working fluid. The filtration and sieving properties have been characterized by evaluating normal saline (0.9 g%) flux and the sieving coefficients of albumin, immunoglobulins, and fibrinogen respectively. Runs were performed at 10 +/- 1, 20 +/- 1, 30 +/- 1 and 40 +/- 1 degree C, the various filtration parameters were measured and samples of the feed and permeate were collected during steady state. It is seen that the "effective" pore size increases with temperature increase thereby increasing flux, sieving and fouling. Exploiting temperature effects can possibly help modify the sieving spectrum in membrane-based plasmapheresis. PMID- 10155736 TI - Cytokines in platelet concentrates. PMID- 10155737 TI - Preclinical testing of lyophilized platelets as a product for transfusion medicine. PMID- 10155738 TI - A clinical and laboratory study of platelet concentrates produced by pooled buffy coat and single donor apheresis technologies. PMID- 10155739 TI - Quality of leukodepleted blood products. PMID- 10155740 TI - Shall red cell units stand upright, lie flat or be mixed during storage? In vitro studies of red cells collected in 0.5 CPD and stored in RAS2 (Erythrosol). AB - Red cells were prepared using a new anticoagulant with half the normal amount of citrate and a new additive solution (RAS2, Erythrosol) previously shown to give improved storage conditions, and stored in a highly gas permeable plastic container (PL 2209). Mixing daily and weekly resulted in lower PCO2, higher PO2 and more rapid oxygen saturation of the haemoglobin than storage unmixed in an upright position. Storage horizontally in a lying position unmixed resulted in similar blood gas values as with mixing. The haemolysis was lowest in units mixed once weekly: 0.21 +/- 0.09% after 28 days and 0.26 +/- 0.06% after 56 days. The morphology was better maintained in mixed than in unmixed units. Horizontal storage and mixing once per week seem to be optimal as judged from these in vitro studies. PMID- 10155741 TI - Transfusion-associated graft-versus-host disease: current concepts and future trends. AB - Since the initial reports, in the early 1960s, of Transfusion-Associated Graft versus-Host Disease (TA-GVHD) in infants with congenital immunodeficiency and individuals with various haematological malignancies, our knowledge of this rare but uniformly fatal consequence of transfusion has improved. Today, it is possible to define with greater certainty patients who are most at risk; the blood components capable of causing TA-GVHD; and the methods for preventing TA GVHD. In the absence of effective treatment for TA-GVHD, attention is currently focused on potential preventative measures, in particular using u.v.- or gamma irradiated blood components. This overview deals with some general aspects of the current concepts and future trends in treatment of TA-GVHD. PMID- 10155742 TI - How to determine brain death in adults: new guidelines. PMID- 10155743 TI - How--and when--to obtain consent for do-not-resuscitate orders. Clinical guidelines and strategies for resolving conflicts. AB - Consider a do-not-resuscitate (DNR) order when a patient's presumed consent for cardiopulmonary resuscitation (CPR) is in question, the patient has an illness that is terminal or severe and irreversible, or he or she is permanently unconscious or likely to have cardiac or respiratory arrest. The patient with decisional capacity has the right to give or withhold consent for a DNR order. State law may limit a surrogate's authority to request that CPR be withheld. Remember, a DNR order does not restrict a patient's access to intensive care. Nurses, patient advocates, social workers, and clergy members may help mediate disputes. If necessary, seek advice from an ethics committee on how to resolve the conflict. PMID- 10155744 TI - Circadian variations in cardiac disease: clinical implications. Current strategies for preventing MI, dysrhythmias, sudden death. AB - Myocardial infarction (MI), myocardial ischemia, ventricular dysrhythmias, and sudden cardiac death (SCD) occur most frequently in the morning, especially in the first few hours after awakening. Among individual patients, however, this pattern may vary widely. Peaks in heart rate, blood pressure, and platelet aggregability and a trough in fibrinolytic activity are thought to influence the morning onset of events. beta-Blockers may blunt the peak occurrence of MI, SCD, and ischemia. Some calcium channel blockers may modify the pattern of ischemia. Alternate-day therapy with 325 mg of aspirin has been shown to blunt the morning onset of MI. The efficacy of thrombolytics may be affected by daily fluctuations in fibrinolytic activity. PMID- 10155745 TI - The technique of weaning from tracheostomy. Criteria for weaning; practical measures to prevent failure. AB - Use the following organized approach to determine whether a patient can be weaned from tracheostomy. Consider airway decannulation only if the original upper airway obstruction has resolved, if mechanical ventilation is no longer needed, and if airway secretions are controlled. Regard the presence of a vigorous cough and the absence of aspiration as additional portents of success. Most critically ill patients benefit from a well-planned, progressive weaning protocol. The tracheostomy button is an ideal weaning device; it maintains the stoma tract and allows the patient to breathe and clear secretions through the upper airway. Monitor the patient for up to 48 hours to ensure tolerance to decannulation. PMID- 10155746 TI - Maximizing oxygen delivery when resuscitating patients from shock. Clinical guidelines as well as some practical pointers. AB - In patients with shock and evidence of hypoperfusion, target therapy at increasing oxygen delivery and decreasing oxygen consumption. To augment delivery, increase arterial oxygenation (with mechanical ventilation and high levels of inspired oxygen), hemoglobin level to at least 10 g/dL (with transfusions of red blood cells), and cardiac output (with hydration and inotropic support). Avoid vasopressors because they increase afterload and thereby decrease cardiac output and oxygen delivery. To reduce oxygen consumption, consider antipyretics (to lower metabolic demand) and mechanical ventilation plus sedatives or paralytics (to decrease the work of breathing). Continue therapy until oxygen consumption is no longer coupled to delivery. PMID- 10155747 TI - Acute renal failure in the elderly: strategies for prevention. How the physiologic effects of aging increase nephrotoxic risk. AB - Elderly patients are susceptible to acute renal failure largely because of functional impairment of the kidneys secondary to diseases such as arteriosclerosis, hypertension, and heart failure. Successful prevention of renal failure in the elderly hinges on understanding the age-associated changes in renal anatomy and physiology. To prevent renal failure, rehydrate elderly patients who suffer significant fluid loss to avoid volume depletion. In addition, maintain adequate blood pressure in these patients, consider glomerular filtration rate when determining the dosage of nephrotoxic antibiotics, and administer saline preparation before injecting radiocontrast dyes. PMID- 10155748 TI - Treating intracerebral hemorrhage effectively in the ICU. The key steps: provide supportive care and determine the cause. AB - Consider intensive care for any patient with an intracerebral hemorrhage (ICH) and coma, cardiac ischemia, rhythm disturbances, severe respiratory distress, labile hypertension, or progressive neurologic deficits. Begin treatment with diuretics and prophylaxis of deep venous thrombosis; some patients may also require fluid restriction, hyperventilation, antiepileptic drugs, intracerebral drainage, or surgical evacuation. Common causes of ICH include hypertension; vascular malformations; hemorrhagic infarction; and administration of sympathomimetics, anticoagulants, or fibrinolytics. To predict outcome, consider both the clinical features and radiologic findings at presentation. PMID- 10155749 TI - The technique of pericardiocentesis. When to perform it and how to minimize complications. AB - Pericardiocentesis is primarily indicated for the management of emergent cardiac tamponade. Insert the needle into the left xiphocostal angle perpendicular to the skin and 3 to 4 mm below the left costal margin (the preferred approach); advance it 5 to 10 mm (or more if necessary) until it reaches the pericardial fluid. A "giving" sensation indicates penetration of the parietal pericardium; a "ticking" one, needle contact with the heart. The needle's position may be confirmed with two-dimensional echocardiography or fluoroscopy. Use the Seldinger technique to insert a catheter for fluid drainage. Monitor the patient continuously for recurrent tamponade, which may result from catheter blockage or fluid reaccumulation. PMID- 10155750 TI - The technique of administering enteral nutrition. Practical pointers for ensuring correct placement, avoiding complications. AB - Many critically ill patients require nutritional support to avoid protein-calorie malnutrition. Enteral administration is preferred because it is less expensive than parenteral nutrition and is associated with fewer complications. Nasogastric insertion is the route most often used; however, oral insertion is required for intubated patients. Administration of a promotility agent increases the chances that the feeding tube will migrate transpylorically; it also improves gastric emptying. To lower the risk of aspiration, check the level of gastric residuum before initiating, or increasing the level of, nutritional support. Diarrhea is not an indication for stopping enteral nutrition. PMID- 10155751 TI - Choosing the right dialysis option for your critically ill patient. What's right for a hyperkalemic patient may be wrong for one with shock. AB - Critically ill patients frequently require dialysis. Options include intermittent hemodialysis, peritoneal dialysis, and various forms of continuous extracorporeal therapy. Intermittent hemodialysis is useful for hemodynamically stable patients who can tolerate rapid solute and fluid removal. Peritoneal dialysis, which is underused in the ICU, offers two distinct advantages: It does not require vascular access and systemic anticoagulation is not necessary. Continuous extracorporeal therapies are better tolerated by hemodynamically unstable patients, since these techniques can remove large amounts of fluid over an extended period. Base your choice of therapy on the patient's condition and needs, the options available at your institution, and the experience of you and your staff. PMID- 10155752 TI - Clinical outcomes and cost of laser prostatectomy. PMID- 10155753 TI - Are HMO members willing to engage in two-way communication to improve health? PMID- 10155754 TI - Hospice, bereavement intervention and use of health care services by surviving spouses. PMID- 10155755 TI - Using guidelines to change clinical practice: three case studies. PMID- 10155756 TI - An internist in the emergency department: the IM facilitator program. PMID- 10155757 TI - Decreasing the number of recheck appointments for an urgent care clinic by using telephoned follow-up care by nurses. PMID- 10155758 TI - Restructuring health care. PMID- 10155759 TI - How to involve physicians in quality improvement initiatives. PMID- 10155760 TI - Overcoming the obstacles to developing a report card system. PMID- 10155761 TI - Redesigning care in a cardiac catheterization lab. PMID- 10155762 TI - Anatomy of a multi-site LIS. PMID- 10155763 TI - America's 10 most computer advanced laboratories. PMID- 10155765 TI - The stuff & strife of standards. PMID- 10155764 TI - Advances in telemedicine: has its day dawned? PMID- 10155766 TI - Swinging to digital with document imaging. PMID- 10155767 TI - 1996 document imaging systems. PMID- 10155768 TI - Database targets integrated delivery systems. PMID- 10155769 TI - Document imaging: defining its role. PMID- 10155770 TI - The CPR: a patient perspective. PMID- 10155771 TI - New FDA reporting rule means new concerns. PMID- 10155772 TI - Zone maintenance at Moore University Medical Center. PMID- 10155773 TI - Practice brief. Issue: Disaster planning for health information. American Health Information Management Association. PMID- 10155774 TI - Laser prostatectomy; ICD-10 Procedure Coding System. PMID- 10155777 TI - Disaster plans: lessons learned. PMID- 10155775 TI - Challenges keep HIM professional flying high. PMID- 10155776 TI - Security and safeguarding of health and hospital information. PMID- 10155778 TI - Quality quest--or questions? How to figure out what to do with those figures. PMID- 10155779 TI - A telemedicine trial. PMID- 10155780 TI - Disease management: the next step in managed care depends on information sharing. PMID- 10155781 TI - Health information managers and clinical data repositories: a natural fit. PMID- 10155782 TI - Databases--their use in developing clinical practice guidelines and estimating the cost impact of guideline implementation. PMID- 10155783 TI - Community health information networks: paving the country roads. PMID- 10155784 TI - Addressing the need for change: the development of a graduate program in health information administration. PMID- 10155785 TI - Comparing physician outcomes and influencing change. AB - An urban medical center uses outcomes data so that physicians can comp are their performance with that of their peers. Physician demand for this data is present, and the benefits of constructive use appear to justify the effort. PMID- 10155786 TI - Using severity-adjusted data to impact clinical pathways. AB - Feeling the weight of managed care, doctors and nurses at a Midwestern health system have joined forces to reduce costs and average lengths of stay (LOS) in a key practice area--orthopedics. The result has been a 40 percent decrease in average length of stay over a three-year period. PMID- 10155787 TI - Using data to measure outcomes. AB - The health care marketplace is beginning to demand that providers develop and provide outcomes data. But implementing a process of collecting outcomes data can be very labor intensive. Planning must include defining outcomes, understanding how outcomes are used in analysis and decision-making activities, identifying data sources, and identifying the users. PMID- 10155788 TI - Care mapping: measuring clinical and financial outcomes. AB - A medical center's nursing units were asked to develop care maps for s elected DRGs, with the goal of improving the level of patient care, reducing cost, and curtailing length of stay. However, none of the efforts provided a tangible way to measure the results. After a comprehensive study effort, the medical team decided that the missing element was better management of the emotional aspects of care. PMID- 10155789 TI - Information systems for the outcomes movement. AB - Outcomes research, measurement, and management have become hot topics well beyond the realm of the academic medical research community that first popularized the concept. While the ultimate outcomes information system will be some time in coming, it is nevertheless possible to foresee the day when patients, providers, and payers can finally answer the questions, What are our health care options? What are results of those practices? and how can we do better. PMID- 10155790 TI - Leveraging information technology for quality improvement. AB - The information technology that is absolutely essential to gather, analyze, manipulate, and report on treatment approaches, practice patterns, and clinical outcomes remains in the background, but it is absolutely key to success in virtually every effort at health care quality improvement. PMID- 10155791 TI - Achieving measurable CQI results. AB - A West Coast institution realized that patients receiving blood transfusions did not always have their data documented in accordance with hospital policy. By measuring compliance and communicating the results back to staff, the expected outcome was that compliance with the policy would increase. In addition, this study expected to determine whether the existing policy was effective in detecting transfusion reactions. PMID- 10155793 TI - One hospital's experience with the JCAHO'S IMSystem. PMID- 10155792 TI - Improving outcomes while reducing utilization: an ICU case study. AB - New computerized severity scoring and outcomes measurement systems promise to help clinicians reduce the costs of critical care without affecting clinical quality. Using these tools, a growing number of hospitals are achieving dramatic results. PMID- 10155794 TI - Towards an outcomes management informational processing architecture. AB - Health care's imperative to do it right the first time--every time--mu st be incorporated into building an information system to support outcomes management. An informational processing architecture proposed here defines key subcomponents necessary to support analysis of essential enterprise data. PMID- 10155795 TI - Profile of a chief information officer in today's integrated health network. PMID- 10155797 TI - Redefining the information technology governance model for an integrated delivery system. PMID- 10155796 TI - Information systems in an integrated delivery systems environment. PMID- 10155798 TI - How to strategically align information resources with the goals of an integrated delivery system. PMID- 10155799 TI - Forum. Translating the promise of integrated regional delivery systems into performance. PMID- 10155800 TI - 'Focusing' patient-focused restructuring for a health care system. PMID- 10155801 TI - Managing data sharing in the world of managed care. PMID- 10155802 TI - Managed care system requirements of integrated delivery systems. PMID- 10155803 TI - Integration comes to the Northland. PMID- 10155804 TI - An integrated patient information system for a primary care clinic network. PMID- 10155805 TI - Conservative care, "consumer government," and low premiums mean high-value at Group Health Cooperative. PMID- 10155806 TI - Questioning cost/benefit value of "pure" TQM in healthcare organizations. PMID- 10155807 TI - The disruptive physician: the risk manager's role. PMID- 10155808 TI - Integrated delivery systems: risk management programs in the private medical office. PMID- 10155809 TI - How do risk managers really learn about potential claims? PMID- 10155811 TI - Sexual harassment: what employers and risk managers need to know. PMID- 10155810 TI - Biomedical equipment maintenance liability: contractors and other issues. PMID- 10155812 TI - Confidentiality of health care information in the computer age: a litigator's perspective. PMID- 10155813 TI - Risk management and the media. PMID- 10155814 TI - Managing your telephone liability risks. PMID- 10155815 TI - Practice policies: potential implications for malpractice litigation. PMID- 10155817 TI - Liability of utilization review decision-making: overutilized, overexposed. PMID- 10155816 TI - Sexual exploitation by health care professionals: guidelines for risk managers. PMID- 10155818 TI - COBRA's caveats. PMID- 10155819 TI - Marketing cardiovascular services: the new paradigms--Part 3. PMID- 10155820 TI - Effective emotional management: keys to the balancing act facing contemporary administrators. PMID- 10155821 TI - Purchasing new equipment? Be informed. PMID- 10155822 TI - Results of the 1995 cardiac cath lab survey. PMID- 10155824 TI - Common pitfalls in scanning electronic patient records and how you can avoid them. AB - It is critical that new implementations of electronic patient record systems learn from the early products and implementations that blazed the trail in scanning medical records. With proper planning, scanning can be a major advance over maintaining paper records. PMID- 10155823 TI - Is "value" the new frontier? PMID- 10155825 TI - Who cares? PMID- 10155826 TI - Medicare and state health care programs: fraud and abuse; safe harbors for protecting health plans--Office of Inspector General, HHS. Final rule. AB - In accordance with section 14 of the Medicare and Medicaid Patient and Program Protection Act of 1987, this final rule sets forth various standards and guidelines for safe harbor provisions designed to protect certain health care plans, such as health maintenance organizations and preferred provider organizations, under the Medicare and State health care programs' anti-kickback statute. These safe harbor provisions were originally published in the Federal Register on November 5, 1992 in interim final form. In response to the various public comments received, this final rule revises and clarifies various aspects of that earlier rulemaking. PMID- 10155827 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1996 rates; corrections--HCFA. Correction to final rule. AB - In the September 1, 1995, issue of the Federal Register (60 FR 45778), we published a final rule with comment period revising the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes arising from our continuing experience with the system. In the addendum to that final rule with comment period, we announced the prospective payment rates for Medicare hospital inpatient services for operating costs and capital-related costs applicable to discharges occurring on or after October 1, 1995, and set forth update factors for the rate-of-increase limits for hospitals and hospital units excluded from the prospective payment systems. This document corrects errors made in that document. PMID- 10155828 TI - Records and reports regulations for radiation emitting electronic products; correction--FDA. Final rule; correction. PMID- 10155829 TI - Medicaid and Medicaid programs: requirements for physician incentive plans in prepaid health care organizations--HCFA. Final rule with comment period. PMID- 10155830 TI - Dear Washington: We want more, please. PMID- 10155831 TI - Research for hire. PMID- 10155832 TI - Outlining a new path for research. PMID- 10155833 TI - Primary care physicians hold their own as overall physician income takes its first dip. PMID- 10155834 TI - Why direct contracting won't put doctors back in the saddle. PMID- 10155835 TI - Finding happiness as a managed care physician. Second of a two-part series. PMID- 10155836 TI - How the little things can kill a practice merger. PMID- 10155837 TI - 25 large employers in Des Moines form direct-contracting corporation. PMID- 10155838 TI - Does the doctor-patient relationship mean more to doctors than patients? PMID- 10155839 TI - What's in store for physicians when a market enters Phase III. PMID- 10155840 TI - The point-of-service paradox: freedom vs. happiness. PMID- 10155841 TI - Marketing the full service library. PMID- 10155842 TI - Health administration resources and health statistics on the Web. PMID- 10155843 TI - A recent letter from MLA to JCAHO. PMID- 10155844 TI - Identifying potential benchmarking partners. PMID- 10155845 TI - Teaching the Internet--the Massachusetts General Hospital experience. PMID- 10155846 TI - The performance evaluation: opportunities for hospital librarians. PMID- 10155847 TI - The NLM/AHCPR large-scale vocabulary test. PMID- 10155848 TI - BJC Health System: the perils of a proactive strategy. PMID- 10155849 TI - Integrating clinical service lines. PMID- 10155850 TI - Designing support and administrative roles. Opportunities for changing non clinical services. PMID- 10155851 TI - Restructuring critical care services. Part II: A proven assessment and redesign process. PMID- 10155852 TI - Transfer pricing. Part II: Vignettes from the front lines. PMID- 10155853 TI - Leadership spotlight. "A tough, but worthwhile delivery". PMID- 10155854 TI - Critical paths for critical functions? An evolving discharge planning pathway. PMID- 10155855 TI - An interdisciplinary approach to inpatient palliative care. PMID- 10155856 TI - Converting acute beds to SNF: great expectations. PMID- 10155857 TI - Cystic fibrosis and the emerging adult: managing the continuum. PMID- 10155858 TI - Electronic medical records: honing the competitive edge. PMID- 10155859 TI - Patient service tips the scales. PMID- 10155860 TI - Building teams with staying power. PMID- 10155861 TI - Creative rural care. PMID- 10155863 TI - Let's get into the insurance business! PMID- 10155862 TI - Are we waiting for Godot? PMID- 10155864 TI - The power of straightforward selling. PMID- 10155866 TI - Software buyer's guide. MDS and beyond. PMID- 10155865 TI - Net results. PMID- 10155867 TI - The future of OSHA's ergonomics enforcement. PMID- 10155868 TI - The changing face of the assisted living market. PMID- 10155869 TI - A new way to classify occupations by education and training. PMID- 10155870 TI - Perspective on cleaning to combat TB. PMID- 10155871 TI - Team management and leadership development: an impossible mission? PMID- 10155872 TI - Service delivery for the 90s and beyond: keys are morale, flexibility, involvement. PMID- 10155873 TI - Achieving employee training--understanding and retention. PMID- 10155874 TI - Rethinking prime vendor contracts. PMID- 10155875 TI - Is antenatal care effective in reducing maternal morbidity and mortality? AB - Women in developing countries are dying from simple preventable conditions but what impact can the procedures collectively called antenatal care having in reducing maternal mortality and morbidity? More importantly what is antenatal care? This review found that questions have been raised about the impact of antenatal care (specifically on maternal mortality) since its inception in developed countries, and that although the questions continue to be asked there is very little research trying to find answers. Many antenatal procedures are essentially screening tests yet it was found that there were very few results showing sensitivity and specificity, and that they rarely complied with the established criteria for the effectiveness of a screening test. The acknowledged gold standard measurement of effectiveness is the randomized controlled trial, yet the only results available referred to nutritional supplementation. This service of flawed methodology has been exported to developing countries and is being promoted by WHO and other agencies. This paper argues that there is insufficient evidence to reach a firm decision about the effectiveness of antenatal care, yet there is sufficient evidence to cast doubt on the possible effect of antenatal care. Research is urgently required in order to identify those procedures which ought to be included in the antenatal process. In the final analysis the greatest impact will be achieved by developing a domiciliary midwifery service supported by appropriate local efficient obstetric services. That this domiciliary service should provide care for women in pregnancy is not disputed but the specific nature of this care needs considerable clarification. PMID- 10155876 TI - Computer analysis of qualitative data: the use of ethnograph. AB - Ethnograph, a code and retrieve software program for computer analysis of qualitative data, was utilized to assist in analyzing the content of in-depth interviews and focus group data. This program requires basic computer hardware and is fairly easy to use. The main advantage of the program is easy access to data dealing with a particular issue and easy retrieval of text for analysis and illustration. However, to get the maximum benefit from this program, documents need to be structured In the format suitable for the software. Among the difficulties encountered were the absence of on-line documents dummy coding, lack of options in printing facility and the tendency for the program to hang whenever there was a printing error. PMID- 10155877 TI - Demonstrating programme impact on maternal mortality. AB - Reducing maternal mortality if one of the primary goals of safe mother hood programmes in developing countries. Maternal mortality is not, however, a feasible outcome indicator with which to judge the success of these programmes. This is due to an unfortunate combination of obstacles to measurement--some general to assessing the mortality impact of health programmes and some peculiar to estimating maternal mortality. There is a need to promote alternative views and measures of programme success, and alternative uses for information on maternal deaths. PMID- 10155878 TI - The fall and rise of cost sharing in Kenya: the impact of phased implementation. AB - The combined effects of increasing demand for health services and declining real public resources have recently led many governments in the developing world to explore various health financing alternatives. Faced with a significant decline during the 1980s in its real per capita expenditures, the Kenya Ministry of Health (MOH) introduced a new cost sharing programme in December 1989. The programme was part of a comprehensive health financing strategy which also included social insurance, efficiency measures, and private sector development. Early implementation problems led to the suspension in September 1990 of the outpatient registration fee, the major revenue source at the time. In 1991, the Ministry initiated a programme of management improvement and gradual re introduction of an outpatient fee, but this time as a treatment fee. The new programme was carried out in phases, beginning at the national and provincial levels and proceeding to the local level. The impact of these changes was assessed with national revenue collection reports, quality of care surveys in 6 purposively selected indicator districts, and time series analysis of monthly utilization in these same districts. In contrast to the significant fall in revenue experienced over the period of the initial programme, the later management improvements and fee adjustments resulted in steady increases in revenue. As a percentage of total non-staff expenditures, fiscal year 1993-1994 revenue is estimated to have been 37% at provincial general hospitals, 20% at smaller hospitals, and 21% at health centres. Roughly one third of total revenue is derived from national insurance claims. Quality of care measures, though in some respects improved with cost sharing, were in general somewhat mixed and inconsistent. The 1989 outpatient registration fee led to an average reduction in utilization of 27% at provincial hospitals, 45% at district hospitals, and 33% at health centres. In contrast, phased introduction of the outpatient treatment fee beginning in 1992, combined with somewhat broader exemptions, was associated with much smaller decreases in outpatient utilization. It is suggested that implementing user fees in phases by level of health facility is important to gain patient acceptance, to develop the requisite management systems, and to orient ministry staff to the new systems. PMID- 10155879 TI - Strengthening health management: experience of district teams in The Gambia. AB - The lack of basic management skills of district-level health teams is often described as a major constraint to implementation of primary health care in developing countries. To improve district-level management in The Gambia, a 'management strengthening' project was implemented in two out of the three health regions. Against a background of health sector decentralization policy the project had two main objectives: to improve health team management skills and to improve resources management under specially-trained administrators. The project used a problem-solving and participatory strategy for planning and implementing activities. The project resulted in some improvements in the management of district-level health services, particularly in the quality of team planning and coordination, and the management of the limited available resources. However, the project demonstrated that though health teams had better management skills and systems, their effectiveness was often limited by the policy and practice of the national level government and donor agencies. In particular, they were limited by the degree to which decision making was centralized on issues of staffing, budgeting, and planning, and by the extent to which national level managers have lacked skills and motivation for management change. They were also limited by the extent to which donor-supported programmes were still based on standardized models which did not allow for varying and complex environments at district level. These are common problems despite growing advocacy for more devolution of decision making to the local level. PMID- 10155880 TI - Reproductive health and AIDS prevention in sub-Saharan Africa: the case for increased male participation. AB - Reproduction is a dual commitment, but so often in much of the world, it is seen as wholly the woman's responsibility. She bears the burden not only of pregnancy and childbirth but also the threats from excessive child bearing, some responsibility for contraception, infertility investigation and often undiagnosed sexually transmitted diseases (STDs) including AIDS. Failure to target men in reproductive health interventions has weakened the impact of reproductive health care programmes. The paper proposes that sophisticated and dynamic strategies in Africa and elsewhere which target women's reproductive health and research (such as control of STDs including AIDS, family planning, infertility investigation) require complementary linkage to the study and education of men. Men's perceptions, as well as determinants of sexual behavioural change and the socioeconomic context in which STDs, including AIDS, become rife, should be reviewed. There is a need to study and foster change to reduce or prevent poor reproductive health outcomes; to identify behaviours which could be adversely affecting women's reproductive health. Issues of gender, identity and tolerance as expressed through sexuality and procreation need to be amplified in the context of present risks in reproductive health. Researchers and providers often ignore the social significance of men. This paper reviews the impact of male dominance, as manifested through reproductive health and sexual decisions, against the background of present reproductive health problems. A research agenda should define factors at both macro and micro levels that interact to adversely impinge on reproductive health outcomes. This should be followed up by well developed causal models of the determinants of positive reproductive health promoting behaviours. Behaviour specific influences in sexual partnership include the degree of interpersonal support towards prevention, for example, of STDs, unwanted pregnancy or maternal deaths. Perceived efficacy and situational variables influencing male compliance in, say, condom use, form part of the wider study that addresses men. Thus preventive reproductive health initiatives and information should move from the female alone to both sexes. Women need men as partners in reproductive health who understand the risks they might be exposed to and strategies for their prevention. PMID- 10155882 TI - Making physician networks work: why it's important to educate physicians about managed care. PMID- 10155881 TI - Primary health care, community participation and community-financing: experiences of two middle hill villages in Nepal. AB - Although community involvement in health related activities is generally acknowledged by international and national health planners to be the key to the successful organization of primary health care, comparatively little is known about its potential and limitations. Drawing on the experiences of two middle hill villages in Nepal, this paper reports on research undertaken to compare and contrast the scope and extent of community participation in the delivery of primary health care in a community run and financed health post and a state run and financed health post. Unlike many other health posts in Nepal these facilities do provide effective curative services, and neither of them suffer from chronic shortage of drugs. However, community-financing did not appear to widen the scope and the extent of participation. Villagers in both communities relied on the health post for the treatment of less than one-third of symptoms, and despite the planners' intentions, community involvement outside participation in benefits was found to be very limited. PMID- 10155883 TI - Three VHA institutions find community assessment strategy facilitates integration. PMID- 10155884 TI - Aging boomers offer special opportunities. PMID- 10155885 TI - How to integrate a hospice into your system. PMID- 10155886 TI - Physician alignment tough for integrators. PMID- 10155887 TI - Hospital hiring experienced healthcare officers for Olympics' security. PMID- 10155888 TI - Title VII, whistleblower statues being used in sexual harassment suits. PMID- 10155889 TI - An interview with: Dr. John S. Anshus on getting medical staff and other personnel to work with security. PMID- 10155890 TI - Surveys: 13% of US crimes, 18% of hospital crimes occur in parking areas. PMID- 10155892 TI - The power of partnership. PMID- 10155891 TI - Surviving today's challenges to hospital security: some tips from experts. AB - Downsizing, re-engineering, consolidations, limited resources, managed care, the growth of technology, and rising crime within the hospital itself are being listed by healthcare officials as among the chief issues and concerns facing hospitals and today's hospital security director. In this report, we'll present four views by leading security directors and healthcare consultants on how those involved in hospital security can face these challenges, survive, and, hopefully, also prosper. PMID- 10155893 TI - Effective planning streamlines work processes. PMID- 10155894 TI - Wanted: QI professionals to improve community health status. PMID- 10155895 TI - Merger presents JCAHO survey opportunities. PMID- 10155896 TI - St. Luke's makes pain the fifth vital sign, cuts costs. PMID- 10155897 TI - The wave of the future: computer-based patient education. PMID- 10155898 TI - Set collection priorities, manage data requests. PMID- 10155899 TI - New supply chain management operation announced for VHA. PMID- 10155900 TI - Glove prices and usage more or less held steady last year, but that could change. PMID- 10155901 TI - Every birth is unique for the mother, but for the hospital is it worth the price to use custom packs instead of basic packs? PMID- 10155902 TI - Why bad things happen to good clinical engineers. PMID- 10155903 TI - Quality in management of biomedical equipment. AB - The project described in this paper concerns the assurance of quality in biomedical equipment management. The project commenced in 1988 with the establishment of the Clinical Engineering Department at the General Hospital of Bolzano, which was entrusted with the task of managing all biomedical equipment installed within its health institutions. To ensure the systematic and organic management of biomedical technology, new technical and administrative procedures were introduced. The results achieved have been validated both through a detailed analysis of staff replies to a specific questionnaire and on the basis of several objective indicators, such as maintenance costs and equipment breakdown times. PMID- 10155904 TI - SMDA '90 (Safe Medical Devices Act of 1990): user facility requirements of the final medical device reporting regulation. PMID- 10155905 TI - Electrosurgery smoke: hazards and protection. AB - Early discussion regarding smoke produced by both surgical lasers and electrosurgical machines concluded that the smoke produced by these instruments was little more than a malodorous nuisance. Animal and human studies to date, however, have suggested that this smoke is, indeed, dangerous. This smoke has been shown to be mutagenic and can contain bacteria and viruses, the HIV virus being the most notable. Furthermore, these particles are small enough to penetrate deep within the respiratory tract. In response to the concerns raised by these hazards, commercial smoke evacuation systems have been designed to greatly reduce the number of hazardous particles, as well as the noxious odor produced by electrosurgery and laser surgery. The efficacy of these systems, however, is dependent o n usage and placement close to the surgical site. This review paper presents the potential hazards of electrosurgical smoke, along with some guidelines on how to properly protect hospital staff and patients from these hazards. PMID- 10155906 TI - Community benefits of PHO and MSO participation. PMID- 10155907 TI - Insights for hospitals: the 1994 health care antitrust enforcement policy statements. PMID- 10155908 TI - The "special relationship" exception imposing a duty upon medical professionals to protect non-patient, third-parties. PMID- 10155909 TI - Recent developments in "loss of chance". PMID- 10155911 TI - Wrong way. PMID- 10155910 TI - Good faith immunity available to organ procurers. PMID- 10155912 TI - The U.S. EMS market report. PMID- 10155914 TI - Providers' primer on managed care. PMID- 10155913 TI - Are paramedics an endangered species? Five industry visionaries offer their perspectives. PMID- 10155915 TI - AMR Northwest helps Kaiser manage EMS care. PMID- 10155916 TI - Conflict management. PMID- 10155917 TI - CO2 monitoring--the quest to verify ETT placement. PMID- 10155918 TI - Chaplaincy: the greatest story never told. PMID- 10155919 TI - The request of the dying and pastoral care. PMID- 10155920 TI - Thinking about AIDS. PMID- 10155921 TI - Prayer reveals belief: images of God from hospital prayers. PMID- 10155922 TI - When dying is living: hospice pastoral care and education. PMID- 10155923 TI - What pastoral psychotherapists need to know about lesbians and gay men in the 1990s. PMID- 10155924 TI - Caregiving and spiritual direction with lesbian and gay persons: common themes and sharp divergencies. PMID- 10155925 TI - Forget everything you thought you knew about the Blues. PMID- 10155926 TI - Why some doctors make a lot, and some make little. PMID- 10155927 TI - What you can earn in a large group. PMID- 10155928 TI - Make sure you won't lose big with capitation. PMID- 10155929 TI - Outcomes: some practical considerations. PMID- 10155930 TI - Strategic stakeholder management. First round results from 'Facing the Uncertain Future'. AB - Authors summarize preliminary results from the first round of a two-round modified Delphi study called "Facing the Uncertain Future." Health care experts were asked to comment on the status of the health care industry in 1994 when the study began and their predictions for change by 1999. Major findings based on the 580 responses received include: (1) the continued movement of the U.S. health care industry from a primarily private insurance industry to one in which medical groups and hospitals will be members of integrated delivery systems/networks (IDS/N); (2) the increasing dominance of the components of IDS/Ns in 1999 (components are defined as: medical practices, system hospitals, managed care organizations and IDS/Ns); and (3) the potential effects of IDS/Ns on the health care industry, including: increases in cost effectiveness, quality of administrative management and the quality of physician leadership, as well as decreases in availability of advanced medical technology and the duplication of ancillary services, facilities and equipment. The study is being conducted jointly by the Medical Group Management Association and Texas Tech University with funding from Abbott Laboratories. PMID- 10155931 TI - Using cost accounting in a medical group practice. An application using the resource-based relative value scale. AB - With the presence of managed care increasing in our health care environment, today's practice administrator needs a method to determine whether the negotiated fee schedule, capitation rate, etc., is adequate. The only true method to make this determination is to undertake a cost study of physician activity. However, this approach could be tedious, cumbersome and beyond the resources of the practice. The author demonstrates a method to approximate the cost of a physician's activity by identifying the cost of a relative value. The relative value scale used is the resource-based relative value scale (RBRVS). The article also proposes other applications: comparative analysis, allocation of capitation payments and fee schedule development. PMID- 10155932 TI - Costing medical practice services: cost per RVU/procedure. PMID- 10155933 TI - Evaluating a practice opportunity. Asking the right questions. AB - As a candidate for a position, your job is to identify the expectations of physicians, why previous administrators have failed to meet these expectations and the limits within which a new administrator can operate. Most groups that approach experienced administrators with the prospect of future employment have already lost their administrator, either through a forced termination or the administrator's voluntary move. Administrators who do not adequately evaluate the opportunity usually receive their walking papers in a relatively short time, or depart on their own with a blustery "let-me-out-of-here" attitude. The key to success is knowledge. You must ferret out the fine points, understand the political climate the group's past financial performance, determine if there is a strategic plan and if it is taken seriously, and most of all, push to gain an understanding of what the key objectives are for the administrator in the first year. Then, you must determine the board's willingness to extend authority. Remember, the next position you accept will profoundly influence every corner of your life: finances, career, lifestyle, marriage and family. PMID- 10155934 TI - Subcapitation arrangements for specialists. AB - As group practices begin to change from fee-for-service to managed care/capitated contracts, one of the major issues they will face is how to divide up the revenue from capitated contracts. Single specialty primary care groups traditionally have utilized a method that takes into account the panel size of covered lives for revenue distribution. Multispecialty group practices have different and more complicated issues that need to be dealt with. It is important that medical groups understand the implications of capitated contracting. Not only will compensation formulas need to be revised, but utilization management, management information and referrals systems will all need to be reviewed in light of changing payment methodologies. This article will review some of the decisions that need to be carefully considered before a multi-specialty medical group should sign a capitated contract. PMID- 10155935 TI - Audit. Operations in an academic setting. AB - A-U-D-I-T...the very word instills fear in the hearts of many. We recently received a letter from the director of the University of Rochester's Internal Audit Department, notifying us that they had scheduled a routine operational audit of our department. What is an "operational audit"? What is meant by "routine"? Who are these internal auditors and what do they want from us? This article illustrates two actual experiences: an operational audit and the process used to develop and implement standards and practices consistent with an auditor's recommendations. Additionally, it provides information on what an auditor looks for during an audit, and lastly, provides tips on how to prepare for a "painless" audit. PMID- 10155936 TI - Developing a strategy for managed care. PMID- 10155937 TI - Beware: hospital control or ownership of medical groups. AB - The rapidly changing, unsettled economic and political health care environment is cause for great anxieties for physicians and hospitals alike. Most physicians have joined IPAs or medical groups in order to obtain continued access to patients who are rapidly shifting from indemnity to cost saving HMOs and PPOs. Many hospitals are seeking to increase their primary care provider base by obtaining control of physicians which may increase their opportunity for institutional success. In many cases, hospitals are providing substantial subsidies or buying physician practices, sometimes in apparent violation of anti trust law. Physicians ostensibly receive good management advice and infrastructure support from hospital business officers or hospital controlled MSOs. However, when the hospital controls individual physicians or medical groups, there is an inherent conflict of interest because of very different strategic needs. It is not in the physicians' best interests to succumb to the siren songs which hospitals are playing. Providing the highest level of care possible for patients requires that physicians maintain professional independence and autonomy now and in the foreseeable future. Equitable negotiation and collaboration between medical groups and hospitals can only be obtained when there is a lawful and level playing field. PMID- 10155938 TI - Systems of the future needed today. AB - Finding the right software for groups requires investigating a practice's quantifiable and qualitative needs, determining goals and translating the needs into system requirements. Software packages don't generally fill all the needs of a practice, therefore it is important to identify vendors who know about health care management and are willing to work with the practice to maintain an edge in business. Look for vendors who continually upgrade their products, service the practice's needs and anticipate future requirements. Quantifiable needs may include tracking patients and patient visits, referring physicians and payers, as well as billing. Qualitative needs include lifestyle (how many hours or days the practice will be open, covering physicians access) and computer usage patterns. Translating the needs into system requirements involves close work with the vendor to customize the software in order to fulfill practice information demands. PMID- 10155939 TI - Improving productivity in academic group practice. AB - The purposes of this article are to identify all the variables that impact productivity in a group practice, contrast the administrator's and physician's definitions of productivity, discuss current measurement tools and outline the steps in a traditional productivity project. The article identifies key variables that management must address: physician education, goals, feedback and rewards that are critical to the success of any productivity undertaking. Upon completion of this article, the reader will be able to understand the differences in the way administrators and physicians view productivity and be able to identify the vital areas that must be addressed in any effort to increase productivity. While the article focuses on the academic setting, the principles are applicable in any group practice. PMID- 10155940 TI - Keys to success for an optimally managed IDS. PMID- 10155941 TI - Prepare for managed care evaluation of physicians. PMID- 10155942 TI - Leading physicians to the head of the class in managed care. PMID- 10155943 TI - Nurse phone care--a new way of thinking (Part 1). PMID- 10155944 TI - Buy/sell agreements for medical practices. PMID- 10155945 TI - Diagnosing the stakeholder bottom line for medical group practices. Key stakeholders' potential to threaten and/or cooperate. PMID- 10155946 TI - Oligopsony, health insurance and antitrust. PMID- 10155947 TI - Medicare risk--is it right for your group? PMID- 10155948 TI - Employee assistance programs. Should practice plan corporations accept responsibility for their employees' health? PMID- 10155949 TI - Bargaining outlook for 1996. PMID- 10155950 TI - Early results encouraging in the Duke risk-sharing deal. PMID- 10155951 TI - OR, materials management communication is improving. PMID- 10155952 TI - Former Boston rivals join in the purchasing of supplies. PMID- 10155953 TI - New flash guideline focuses not on if you do it, but how. PMID- 10155954 TI - Planning yields efficiency for total hip cases. PMID- 10155955 TI - Cruising the Net can be fun and informative. PMID- 10155956 TI - Fast tracking an OR's cost reduction efforts. PMID- 10155957 TI - The art of managing diversity is connecting and directing. PMID- 10155958 TI - New skills are needed as purchasing shifts. PMID- 10155959 TI - Health care in the 21st Century. AB - Our primary agenda for the 21st Century is the reinvention of America. We must reinvent democracy, capitalism, entrepreneurism, and community. Indeed, we must recreate all of our major social institutions. This includes health care. A design for a new society requires a new design for health care. In fact, health care enjoys a special privilege in this regard. It is the gateway to total societal redesign. Health is the common denominator in any society. If you loose your health you cannot work, you cannot play, you cannot study; and, if you lose it sufficiently, you cannot even pray. Health and well-being create the foundation for all other constructive human endeavors. Therefore, the design of healthy communities is the necessary first step in the redesign of total human habitats. This massive redesign effort will take a century. However, it will be launched in the next few years. PMID- 10155960 TI - The American health system: a contentious environment in the 21st Century. AB - In the 21st Century, the American public and its elected officials will be unable to reach any overall consensus on our nation's health policies and priorities. With greater demands for health services and fewer fiscal resources, a more contentious environment in the health industry will ensue. As the American health system in the next 100 years continues to behave with an amalgam of competitive and regulatory approaches, it will be difficult to ensure that all Americans will receive universal access, equity, comprehensive benefits, and a high quality of care. For these reasons, the health system is predicted later on to swing away from market-driven to more state-oriented regulatory strategies as the United States attempts to blend such concepts as pluralism, regionalization of resources, and enforcing cost containment. PMID- 10155961 TI - The future of medical practice. AB - Managed care of some kind will dominate the future of health care, but the unresolved crucial question concerns ownership of the managed care plans. An investor-owned managed care industry now holds sway, but I do not expect it to last very long. In the long run, physicians must be in charge of medical care, but they must live within budgets and be accountable to payers and to their patients. The only solution that makes sense to me is one based on multiple local physician networks, organized on a not-for-profit basis. I predict that staff and group-model HMOs will be the mainstay of the medical care delivery system within a few decades. PMID- 10155962 TI - The great health policy debate of 2010. AB - Moderator: Good evening. Tonight I will be moderating a debate on the Health Care System Salvage and Coverage Overhaul Act of 2010 (Senate Bill 1, with companion legislation in the House). The bill is awaiting final congressional action, and the issue is considered so important that all 14 major television networks are carrying this debate live, along with many radio networks and at least 1,873 Internet/World Wide Web sites. As you know, S.B. 1 would provide immediate federal aid to the 1,000 hospitals and health care systems that are currently in bankruptcy; extend government-subsidized coverage to the estimated 90 million Americans who lack it; return to the federal government a wide range of health care regulatory and payment activities that had been transferred to the states; and prohibit certain types of health care enterprises and services, chiefly proprietary delivery and managed care systems. At the moment, the chances of its passage are too close to call. Arguments in support of S.B. 1 will be presented tonight by Sen. Joseph P. Kennedy II, Democrat of Massachusetts; arguments in opposition to the bill will be presented by Sen. George W. Bush, Republican of Texas; and the view of the Independent Party will be presented by former Kansas Senator Nancy Kassebaum, who also speaks as chairman of the National Nonpartisan Commission to Save American Health Care. Senator Kennedy will begin. PMID- 10155963 TI - The Clinton health care proposal: reform squandered again! AB - Unlike the other articles in this series on efforts to reform the American health care system, this article is necessarily somewhat personal. I lived through it- not as a participant in the process but as a very interested bystander. To President Clinton's credit, his proposal was the first comprehensive proposal from a President since at least President Nixon and strictly speaking since President Truman. Yet, in the final analysis, the results were extremely depressing, not merely because of the obvious failure of the effort, but, even more important, because of the impact it has had on Americans' belief in the possibility for significant government role/responsibility in health care or, for that matter, in any significant domestic initiative. This article will trace portions of the failed Clinton health care initiative proposal--not the myriad other proposals that percolated through Congress. Realistically, only a proposal that had the support of the President had any chance of legislative success. This article will trace the development of the proposal and, while focusing on the universal coverage aspect, point to critical decisions that led to its legislative demise. PMID- 10155964 TI - Computerization: reengineering the lawyering process for the 21st century. AB - Alvin and Heidi Toffler, describe the benefits of "informationware" and how one of the most tradition-bound organizations, the armed forces, has substantially changed its operations. According to the authors, mere knowledge is not sufficient to prevail; how one manages or uses knowledge separates winners from losers. Further, the authors say "...basically add new elements or create new combinations of old elements within an existing 'game.' A true revolution goes beyond that to change the game itself, including its rules, its equipment, the size and organization of the 'teams,' their training, doctrine, tactics, and just about everything else. Even more important, it changes the relationship of the game to society itself." Application of this theory to today's litigation is obvious and compelling. The ways in which clients and defense counsel obtain, analyze, and strategically apply evidence and legal principles must change to incorporate the informationware this society uses in other lines of business. This means more extensive and appropriate usage of computer hardware in a software environment that fully supports emerging client and defense counsel needs. The computer system must provide case direction, helpful suggestions, and direct, rapid access to data bases containing information presently available only through person-to-person networking. PMID- 10155965 TI - Awards recognizing quality in health care. AB - A variety of awards have been recognizing business, public, and educational sectors for their quality efforts. As of 1995, 10 states include the health care sector in their programs. The national Malcolm Baldrige Award now accepts volunteer applications from the health care sector as a prelude to their inclusion in 1996 in the regular award program. An evaluation model is common to the several award programs that describes how quality is enabled, the systems that make it work, and the desired goals in seven categories. Each category has criteria that allow the flexibility desired by individual programs. The important features are the self-examination required of the organization in preparing the application and the feedback reports to all applicants that note the strengths of applicant and the areas for improvement by the applicant. Health care organizations are encouraged to participate in these award programs as part of their individual improvements efforts. PMID- 10155966 TI - Health care 2015: flight of the butterfly. AB - Projecting out to the year 2015 sounds presumptuous. Who can predict that far ahead? Perhaps no one can. Social and organizational arrangements come slowly. It takes five years or so to implement simple concepts, sometimes decades for more radical changes. Once you have the ideas in tangible form, it can take another five years to get it working right. Early adopters bring others into the movement and, over 15-25 years, new directions dominate. It takes at least a generation of new practitioners to take on the new values and methods so what is likely to dominate in 2015 is beginning to be taken somewhat seriously as the successor movement to our current fad with externally imposed managed care. Put another way, entire generations of people will resist new ideas, making implementation unlikely until their control fades and a new generation takes the helm. The exciting challenge for the observer is to address the issue of where health is and should be going. Both are difficult challenges. Agreeing on what is important and what is not represents a competitive challenge. How do we perceive the world? Surely our value sets will color what we see. Who is not predisposed to select a future where they fit and their pet theories are likely to become reality. For these and other reasons, it is probably easier to agree on what we would like to see happen in the future than on what is happening. Unfortunately, unless we see the world as it is, we are less likely to be able to shift it in a direction we would like to see. PMID- 10155967 TI - New medical technology diffusion key element in health cost increases. PMID- 10155968 TI - Using a benchmarking system to improve patient care and assist in technology assessment. AB - Clinical benchmarking is a tool of CQI that can be used to improve outcomes in areas of strategic importance. While it is a simple tool, benchmarking requires a long-term commitment from the entire organization involved in its use to be successful. Benchmarking is a means of setting goals or targets. As a tool used for continuous quality management, benchmarking is an ongoing activity of comparing an organization's service, product, or process with similar ones outside the organization that are known to be the best. In attempting to emulate or surpass "best practice," an organization must set challenging but attainable goals and reach them with a plan of realistic and efficient actions. PMID- 10155969 TI - Physician career development: toward building a model. AB - Virtually no managed care organization provides a comprehensive and integrated program for physician career development. That's the principal finding of a survey we carried out in Spring 1994 in which we interviewed several individuals who have proven instrumental in the creation of career development programs at their managed care organizations. We started our research with the hypothesis that career development programs for physicians--frequently the most highly paid category of employees and the ones often most directly involved in the delivery of health care--should parallel the mission of the organization. In many of the organizations we surveyed, the mission included clinical excellence, managerial competence, research, teaching, community service, and building shareholder equity. While each organization offered some component of career development- usually clinical improvement and management development--very few offered programs that fostered the continued professional development of physicians in other aspects of their missions. In most cases, even in organizations with stronger career development agendas, the programs were passive and were rarely linked to the overall "corporate" goal of the managed care institution. This critical disconnect makes it extremely difficult for health care organizations to develop a workable system of accountability for their career development programs. PMID- 10155970 TI - Doing physician terminations right. AB - Few managers have the training or the expertise to terminate a physician. Some managers are uncomfortable with this process and may even subvert, delegate, or fumble the process. A properly performed termination will leave the physician with understanding of the termination and may assist in his or her development. A poor termination can cause ill effects not only with the involved physician, but also with the organization terminating the physician. Many physicians are leery of working for an organization that has the reputation of unfairly terminating physicians. They are also concerned with their job security. Potential legal ramifications make the process even more difficult. PMID- 10155971 TI - Practicing managed care in the academic medical center. AB - The purpose of this article is to outline the contrasts between the traditional AMC and an organization oriented toward the delivery of population-based managed care. Academic medical centers differ from one another considerably in the extent to which they serve as quaternary care community resources, the degree to which they emphasize primary care in training and care delivery, and the amount of research undertaken. Nor is there a single organizational structure for managed care; successful managed care is practices in IPAs, multispecialty groups, PHOs, and staff-model HMOs. Nonetheless, the contrasts outlined here between AMCs and managed care organizations (MCOs) are valid in most cases. PMID- 10155972 TI - Suggestions for management training of residents. AB - In addition to having medical expertise, physicians must possess managerial skills to deal with the ever-changing business environment of the practice of medicine. This article addresses the need for management training of physicians and calls for management training during residency and medical school. It also describes one residency program's efforts to provide comprehensive management training to its residents in pathology. PMID- 10155973 TI - Hungary: a health system in transition. AB - Hungary has an area of 93,030 square kilometers (35,900 square miles), the size of the state of Indiana in the United States. It is landlocked by the Czech Republic and the Slovak Republic to the north, Austria to the west, Yugoslavia to the south, and Romania and the Soviet Union to the east. Although the health care system is based on the Soviet system, there have been dramatic changes since 1991, when the soviet Union and its Eastern European partners discarded their communist structures and the Soviet empire was disbanded. In this report, the current Hungarian health care system and the political structure in which it is housed will be described in terms of a key set of characteristics and their subparts. The purpose of this approach is to facilitate comparison of the Hungarian system with other national health care systems. An expanded version of this article will appear in an upcoming second edition of the College's book, International Health Care: A Framework for Comparing National Health Care Systems, by Drs. Mendoza and Henderson. PMID- 10155974 TI - Outcome first target of technology assessment. PMID- 10155975 TI - The World Wide Web is coming soon to an organization near you. PMID- 10155976 TI - The medical practice as business organization. AB - Medical practices historically have not been examined in terms of their organizational structures and of the appropriateness of their structures for survival as business entities. In this paper, we propose a model for the typical medical practice and discuss its fit with current organizational theory. It is apparent that the medical practice organization does not fit with the demands of a rapidly changing and complex environment. To survive and grow, the medical practice organization must align itself with others that have an interest and stake in the health care system, develop teamwork among physicians, bridge the gap between physicians and others in the organization, and recognize that the work done in the organization depends on other components of the organization. PMID- 10155977 TI - Kids say yes to Y.E.A.H. (Youth Education Alliance for Health). PMID- 10155978 TI - All in a day's (school) work. PMID- 10155979 TI - Trustee education: how to curb the dropout rate. PMID- 10155980 TI - Opting for managed care. PMID- 10155981 TI - Urge to merge? Some thoughts on joining a regional network. PMID- 10155982 TI - Making a case for change. PMID- 10155983 TI - American Laundry Digest distributors directory. PMID- 10155984 TI - Veterans Administration launches external peer review program. PMID- 10155985 TI - UTMB's clinical resource management initiative helps to analyze physician practice patterns. PMID- 10155986 TI - Surgical technologists: what is their proper role? PMID- 10155987 TI - Electromagnetic interference and medical devices. PMID- 10155988 TI - Using technology to increase effectiveness in the work place. PMID- 10155990 TI - Cancellations and no-shows: an examination of influences and solutions. PMID- 10155989 TI - Nurse triage telephone centers: key to demand-management strategy. PMID- 10155991 TI - ORION--shaping a new accreditation process. PMID- 10155992 TI - Access management under managed care--methodology for identification. PMID- 10155993 TI - The health access manager's role in performance measurement systems: impact and opportunity. PMID- 10155994 TI - Preparing for JCAHO. PMID- 10155995 TI - The patient ID card: magnetic strip, smart card or bar code? PMID- 10155996 TI - Expanding the nurse practitioner's role in today's healthcare delivery. PMID- 10155997 TI - Hospital cuts material transport costs by using robot. PMID- 10155998 TI - Gazing into the crystal ball--AlaHA looks at its future. PMID- 10155999 TI - Walking the walk. Hospitals tie evaluations, compensation to organizational ideals. PMID- 10156000 TI - Zero-based budgeting for a radiology service: a case study in outsourcing. PMID- 10156001 TI - The tripartite regulation of America's health services. AB - The Republican takeover of Congress suggests that the payer-driven forces of managed care, capitated payment, and the regional networks (alliances) will serve as centerpieces to improve the organization, financing, and delivery of our nation's health services. These "voluntary" alliances, frequently as an amalgamation of health providers and health insurance underwriters, often foreshadow the powerful, geographically linked regional health networks that are evolving into oligopolies. The authors anticipate, as a result, the formation of state health services commissions that will regulate market share, the scope of health services, reimbursement rates and allowable profits. State departments of public health and insurance will have their own regulatory duties. Complex relationships will result as these groups will often have conflicting, politically-charged goals. PMID- 10156002 TI - Setting limits through global budgeting: hospital cost containment in Rhode Island. AB - In 1974, hospitals in Rhode Island have participated in annual negotiations with state officials and representatives from Blue Cross to determine the allowed increase in statewide hospital costs (the "Maxicap") for the next fiscal year, based on projected increases in hospitals' revenues, changes in patient volume and operating expenses. Individual hospital budgets may be above or below the Maxicap as long as the total increase in hospital costs for all hospitals in the state does not exceed the negotiated amount. At a time when regulatory solutions are increasingly under fire, continued support for Rhode Island's approach to hospital cost containment from third party payers, providers and public officials stands in stark contrast to other states where rate setting was either dismantled or discredited as a cost control strategy. A negotiated global cap on hospital expenditures offers an alternative to formula-based state rate-setting methodologies which could be incorporated as part of an all-payer reimbursement methodology or as an incremental step towards more comprehensive reform. PMID- 10156003 TI - 1996 OR survey results. Lean times and lead times. PMID- 10156004 TI - Do off-site consolidated warehouses make sense? PMID- 10156005 TI - Employee evaluation balancing act: avoid these 6 pitfalls. PMID- 10156006 TI - No meetings required: evaluation process elicits vital product info. PMID- 10156007 TI - Fast 'FADE' (focus, analyze, develop, execute) quickly heals OR's financial woes. PMID- 10156008 TI - Sterility assurance: who's responsible? PMID- 10156009 TI - Overcapacity update: markets still have too many beds. PMID- 10156011 TI - First and last, do no harm. PMID- 10156010 TI - A healthy merger? A big deal makes Aetna the country's largest health-care company. PMID- 10156012 TI - Sources and uses of capital. PMID- 10156013 TI - Professional peer review and the National Practitioner Data Bank. PMID- 10156014 TI - Depreciation in health care. PMID- 10156015 TI - A primer on quality-of-life instruments used in the health care setting. PMID- 10156016 TI - Shortening the time between availability of new medical information and its adoption in general practice. PMID- 10156017 TI - User applications of health economics data. PMID- 10156018 TI - The importance of direct physician connectivity in managing health care. PMID- 10156020 TI - Projected occupational employment and health care employment, 1994-2005. PMID- 10156019 TI - Episode treatment groups: an illness classification and episode building system- Part II. AB - The episode treatment group (ETG) methodology is a case-mix adjustment and episode-building system that uses routinely collected claims data. The resulting 558 clinically homogeneous groups adjust for severity by the presence of complicating conditions, comorbidities, and other characteristics of a patient's condition that affect resource utilization. The groups identify both complete and incomplete episodes in addition to those episodes which, from a cost perspective, are either low or high outliers. As a grouping ?engine,? the user controls the amount and format of the claims data as input, providing essentially unlimited provider profiling, demand analysis, disease management, and capitation and predictive modeling possibilities. PMID- 10156021 TI - The challenge for managed care is demand management. PMID- 10156022 TI - Does management expect too much from its employed physician group? PMID- 10156023 TI - Private medical insurance in the United Kingdom. PMID- 10156024 TI - Co-opetition, hypercompetition, and managed behavioral health care. PMID- 10156025 TI - Use of pharmacoeconomic research for benefit design decision support. PMID- 10156026 TI - Defining actional markets for disease state management. PMID- 10156027 TI - Management of rare chronic disease: a challenge to HMOs. PMID- 10156028 TI - An HMO's guide to subacute care savings. PMID- 10156029 TI - Managing hospital electrical systems shutdowns. AB - Hospital electrical systems shutdowns are an important component to both internal and external disaster planning. An organized, thorough and well-communicated plan can make this important process run smoothly. This document examines the necessary steps in developing and implementing such a shutdown. PMID- 10156030 TI - Final regulations address safe harbors for managed care plans. PMID- 10156031 TI - Insurance reform infighting. PMID- 10156032 TI - Moving records on the Internet. PMID- 10156033 TI - Focusing on the patient. Interview by Bruce Bunschoten. PMID- 10156034 TI - Taking medicine on the road. PMID- 10156035 TI - Going with the flow. PMID- 10156036 TI - Artificial intelligence: a new generation of health care applications. PMID- 10156037 TI - Implementing client/server: the long and winding road. PMID- 10156038 TI - State networks move ahead, learning from pioneers' travails. PMID- 10156039 TI - Analyzing the market for practice management software. PMID- 10156040 TI - Infrastructure upgrades a top priority, conference survey shows. PMID- 10156041 TI - Advanced capitation strategies. Providers "become the insurance company" in at risk arrangements. PMID- 10156042 TI - Economics vs. ethics. Will providers have more "soul" than HMOs? PMID- 10156043 TI - Managing 11 types of capitation risk. PMID- 10156044 TI - A short history of capitation. PMID- 10156046 TI - Four Michigan hospitals make community health their business. PMID- 10156045 TI - The key to major gifts: cooperative relationships. PMID- 10156047 TI - Success in project comes from commitment at top. PMID- 10156049 TI - From storybooks to fairs, hospital rewards CQI effort. PMID- 10156048 TI - Integration forces QI staff to expand scope. PMID- 10156050 TI - Small Nevada hospital overcomes CQI hurdles. PMID- 10156051 TI - Building stable customer relationships that stand the test of time. AB - This article shows how Baldor Electric Company is using training to build a foundation for improving service in all areas of the business. It covers the background that led to Baldor Electric's decision to develop service training in house, the steps that Baldor took in putting the course together, and the actual principles taught in the Baldor service course. The Baldor service course teaches basic principles that can be used by all employees to improve customer service, no matter what job they do. PMID- 10156052 TI - Supplier scheduling in a quick response environment. AB - Achieving the goal of reduced cycle time requires new techniques and new management approaches within a company and between customer and supplier. This article will cover the underlying technology and management orientation required for quick response (QR). Decision criteria for using customer-managed or supplier managed QR will be discussed. Methods to benchmark and attain QR benefits will be reviewed. PMID- 10156053 TI - Eliminating the "I hate you" in the supplier-purchasing relationship. AB - Throughout time there has always been a supplier of some service or goods, and there has always been a purchaser of that service or goods. The one thing that has remained constant throughout that time is that they have an agreement not to like each other. This article will approach the subject in the "today" sense using current practical approaches that are used in all industries and will not deal with the relationships of the future. To cover this complex arena, the article will deal with four areas: (1) where we are now, (2) supplier-based concentration, (3) single sourcing, and (4) transportation techniques. PMID- 10156054 TI - Supplier involvement through certification: a case study. AB - The Clarkson Company is located in the Reno-Sparks area of Nevada. We are a manufacturer of slurry valves for mining, pulp and paper, power generation, and various other industries. Because of the diverse nature of the applications for which the valves are used, the product can be configured a vast number of ways. Therefore, we use the assemble-to-order methodology for our master production scheduling. It became apparent over a decade ago that the use of materiel requirements planning (MRP) would aid us in controlling our low volume, high option mix environment. That journey led to The Clarkson Company becoming a Class A user of MRPII in June of 1990. PMID- 10156055 TI - Making a win-win partnership. AB - With increased global competition, it has become necessary for customers and suppliers to partner for common benefits. Xerox and Avery Dennison have developed new concepts to effectively deliver products to the end customer, taking the cost out of the entire supply chain. The mutual benefits of this partnership are shorter lead times, lower overall inventory, and increased profitability. In order to attain these benefits, certain business paradigms had to be changed, that is, walls had to be broken down. This article gives a hands-on explanation of how to establish a working partnership between two companies. PMID- 10156056 TI - Supplier-managed inventory: schedule sharing. AB - Supplier-managed inventory (SMI) is a methodology that provides a true win-win partnership between customers and suppliers. SMI supports flexibility for the customer to change schedules and flexibility to the supplier to decide when and how much to ship. All this is accomplished via electronic data interchange (EDI), which communicates the customer's gross requirements, inventory, and desired minimum/maximum inventory levels. PMID- 10156057 TI - Six ways to reduce inventory. AB - The purpose of this presentation is to help you reduce the inventory in your operation. We will accomplish that task by discussing six specific methods that companies have used successfully to reduce their inventory. One common attribute of these successes is that they also build teamwork among the people. Every business operation today is concerned with methods to improve customer service. The real trick is to accomplish that task without increasing inventory. We are all concerned with improving our skills at keeping inventory low. PMID- 10156058 TI - Slashing cycle time in all we do: techniques for success. AB - Cycle time improvement programs must start with the establishment of standard definitions, agreed-on methods of calculation, and publicized goals. To reduce cycle time, all processes must evolve from batch to flow by using "pull' systems. Effort must concentrate on improving efficiency at the bottleneck operations. Cycle time projects must be carefully chosen to produce visible success, thus ensuring continued funding. PMID- 10156059 TI - Nursery. PMID- 10156060 TI - New bed study demonstrates significant opportunities for risk managers. PMID- 10156061 TI - Private finance initiative. Capital games. PMID- 10156062 TI - Private finance initiative. Rough ride. PMID- 10156063 TI - Private finance initiative. Some taxing issues. PMID- 10156064 TI - Private finance initiative. Risky business. PMID- 10156065 TI - Private finance initiative. Case study: in search of the holy grail. PMID- 10156066 TI - Managerial careers. Get a move on. PMID- 10156067 TI - Hospital admissions. Bed spread. PMID- 10156069 TI - Community care. DISHing (Dispersed Intensively Supported Housing) it up. PMID- 10156068 TI - Meetings. Table manners. PMID- 10156070 TI - Careers profile. Facilities management--tuning into FM. PMID- 10156071 TI - Masquerade: tracking the bogus doctors. PMID- 10156072 TI - Primary care. Fair ground reaction. PMID- 10156073 TI - Mental health. Hot seat. PMID- 10156074 TI - Equality on boards. Room at the top. PMID- 10156076 TI - Race and health. Race against time. PMID- 10156075 TI - In the black. PMID- 10156077 TI - Evidence-based care. Prove it. PMID- 10156078 TI - NHS reforms. And how are we feeling today? PMID- 10156079 TI - Medical assistants. Navy train. PMID- 10156080 TI - Careers profile. Finance: life at the sharp end. PMID- 10156082 TI - The pain of the gentle touch. PMID- 10156081 TI - Children's services. What about me? PMID- 10156083 TI - So what do community nurses do? PMID- 10156084 TI - Health visiting. Visiting time. PMID- 10156085 TI - Managing volunteers. Free-for-all. PMID- 10156086 TI - Data briefing. Migraine. PMID- 10156087 TI - Sister act. PMID- 10156088 TI - General practice. Weight watchers. PMID- 10156089 TI - Service planning. Whose shout? PMID- 10156090 TI - Research-based practice. Show a leg. PMID- 10156091 TI - Baylor/TOPA oncology center brings new life to old facilities. PMID- 10156092 TI - Robot for hire. PMID- 10156093 TI - Baltimore hospital cashes in its 'Chip' for big savings. PMID- 10156094 TI - True or false? High-tech smoke detectors tackle false alarms. PMID- 10156095 TI - The magic of carpet. PMID- 10156096 TI - Safe Medical Devices Act: reporting rules face hurdle. PMID- 10156098 TI - Take steps to avoid the tax penalties of outsourcing. PMID- 10156097 TI - Code red! Some tips on fighting fire in the ICU. PMID- 10156099 TI - Not all cents are common. PMID- 10156100 TI - Is there a silver lining to managed care? PMID- 10156101 TI - The National Registry: is it finally going national? PMID- 10156102 TI - Reciprocity nightmares. PMID- 10156104 TI - Air National Guard promotes EMS training. PMID- 10156103 TI - Military medic: the original expanded-scope EMS provider. PMID- 10156105 TI - Latex allergy: the dark side of infection protection. PMID- 10156106 TI - Career development--Part 1. Careers in the lab: an open door or a shut case? PMID- 10156107 TI - New and emerging pathogens, Part 3. Threats from the food we eat. PMID- 10156108 TI - A redesign of RBC morphology reporting. PMID- 10156109 TI - Unsize yourself, Part 1. Upsize yourself in a downsizing climate. PMID- 10156110 TI - HMO execs team up for public image forum. PMID- 10156111 TI - Giant HMOs struggle with risk contracts. PMID- 10156112 TI - Manor Care to split lodging, healthcare units. PMID- 10156113 TI - Columbia closes former CHS hospitals. PMID- 10156114 TI - Long-term Medicare, Medicaid cuts in proposed 1997 budget. PMID- 10156116 TI - U.S. approves Mass. allergist network. PMID- 10156115 TI - Reform-driven efficiencies power record '94 profits. PMID- 10156117 TI - Hospital mortgage program at risk--GAO. PMID- 10156118 TI - Nashville's Baptist weighs for-profit status. PMID- 10156119 TI - Ore. court ruling threatens not-for-profits' exemptions. PMID- 10156120 TI - Pataki plan would end rate setting. PMID- 10156121 TI - Compromise trims N.J. charity-care support. PMID- 10156122 TI - Health workers highly vulnerable to violence. PMID- 10156123 TI - Caremark agrees to new settlement. PMID- 10156124 TI - Dallas hospitals ask consulting firm to aid affiliation. PMID- 10156125 TI - Minn. reform repeals may accelerate. PMID- 10156126 TI - VA medical center dedicated in Detroit. PMID- 10156127 TI - Va. hospital courted by 4 systems. PMID- 10156128 TI - Med school grads show little interest in specialist fields. PMID- 10156129 TI - S.C. hospital pulls out of partnership. PMID- 10156130 TI - Sweeney launches blitz on Kaiser's labor cuts. PMID- 10156131 TI - NCQA database to allow quick HMO comparisons. PMID- 10156132 TI - Alliance prepares to roll out proposed performance measures. PMID- 10156133 TI - Dallas groups invest in primary-care docs. PMID- 10156134 TI - Omnia forms OB/GYN network in Chicago. PMID- 10156135 TI - High court's snub brings Wis. antitrust case to close. PMID- 10156136 TI - Hospitals fined for 'dumping' patients. PMID- 10156137 TI - Ind. hospital plans changes in board. PMID- 10156138 TI - Baptists, Methodists spar in Tenn. arena. PMID- 10156139 TI - Job cuts ahead for heartland hospitals. PMID- 10156140 TI - Ga. not-for-profits win CON battle. PMID- 10156141 TI - Va. hospital bond ratings buck trends. PMID- 10156142 TI - GOP, Democratic governors clash over Medicaid reform. PMID- 10156143 TI - House to vote on insurance reform bill. PMID- 10156144 TI - Tug of war. Investor-owned hospital chains aim to lasso doc's loyalties. AB - When investor-owned hospital chains try to secure physicians' loyalties, it can be a lose-lose situation. However, pressure to grow is forcing these companies to unfold an extensive range or organizations linking them to doctors. You name it, for-profit chains are doing it. But how well? PMID- 10156145 TI - Managed care will end era of provider networks. PMID- 10156146 TI - NAHC (National Association for Home Care) allays members' concerns over spinoff. PMID- 10156147 TI - Defense Dept. pressure speeds move to UPNs (universal product numbers). PMID- 10156148 TI - System reform in integrated health systems. AB - As the debate progresses on health care reform and the ultimate form of the U.S. system, important lessons can be drawn from examinations of other health care systems. From the U.S. perspective, European health systems appear to have a certain homogeneity about them. Americans tend to look at all European arrangements as single-source financing systems. Because these systems all provide universal coverage, the assumption is that there must be a strong cohesion and similarity among them. Viewed from the European perspective, the reality appears to be rather different. In this article, the health cae systems of Nordic countries are analyzed in terms of their differences both from other European systems and from the United States approach. PMID- 10156149 TI - A survey of marketing practices by family practice residency programs. AB - The purpose of the study reported in this article was to identify marketing practices that are being utilized by family practice residencies in the United States and to differentiate which strategies were felt to be most useful. A survey questionnaire on marketing strategies was mailed to 361 civilian family practice residencies listed in the 1992 Director of Family Practice Residency Programs. A total of 151 questionnaires were returned for a total response rate of 42.1 percent. The results were summarized using descriptive statistics and Chi square analysis. Family practice residency programs use a number of different strategies to attract patients. The effectiveness of a given program is dependent on local factors, program strengths and the target population desired. The three most useful marketing strategies reported in the survey were HMO listings, emergency department referrals, and patient referrals. The three least effective strategies were health fairs, sports physicals, and school presentations. PMID- 10156150 TI - Strategic issues requiring public accountability: food for thought. AB - Although the exact outline of U.S. health reform has become fuzzy because of political events, it seems clear that major changes in the manner in which health care is delivered and financed are under way. The initiative for the most part has been assumed by state government and by the health care field itself, as managed care becomes ever more entrenched and the health care system becomes ever more integrated. An expected outcome of these changes will be demands for greater public accountability on the part of health care providers and organizations. In this article, the author discusses some of the issues--professional compensation, documenting community service, ensuring public input into planning efforts, economic credentialing and quality of care, and managing ethics under managed competition--that will have to be addressed at the local level as these shifts take place. PMID- 10156151 TI - Management's latest worry: nonsexual harassment. PMID- 10156152 TI - A conversation on the future of health care. AB - An extensive amount has been written, reported, and spoken on health care reform. It is a time of turmoil and uncertainty in the health care field. There is a great deal of talk at the federal level on reform, but efforts there seem to be at least temporarily stymied. Much is happening at the local and regional level, however, as the health care field itself wrestles with the changes that have already occurred and with the promise of changes that lie ahead. In the following conversation between two fictional physician executives, one with many years experience, the other his junior, some of the issues surrounding health care reform are discussed. Although the specific environment for the conversation is managed care, most physician executives will find themselves somewhere in the conversation. let's eavesdrop as they speak, in the late summer of 1994. PMID- 10156153 TI - Perspectives. Health insurance tax break: sacred cow on chopping block? PMID- 10156154 TI - Perspectives. Compromise averts repeal of ambitious Kentucky reform. PMID- 10156155 TI - Perspectives. States and Feds struggle to mesh care for dual eligibles. PMID- 10156156 TI - Perspectives. Shrinking private system maroons the uninsured. PMID- 10156158 TI - Perspectives. Cops or colleagues? Fuzzy standards for judging PROs. PMID- 10156157 TI - Perspectives. Federal dollars boost drive to stop violence against women. PMID- 10156159 TI - Where we spend health care dollars. PMID- 10156160 TI - Special report: Putting outcomes management to the test--from theory to practice. PMID- 10156161 TI - 1996 CPT revisions will affect the ED; prepare now. PMID- 10156162 TI - Computerized system allows lab orders at triage. PMID- 10156163 TI - Examine benefits of managed care contracting. PMID- 10156164 TI - Integrating managed care systems--a cooperative venture. PMID- 10156165 TI - Techniques for optimizing MRI relaxation and visualization. PMID- 10156166 TI - Competitive strategies for physician practices. PMID- 10156167 TI - Headaches, backaches--healthcare's industrial revolution. PMID- 10156168 TI - Managed care contracts and risk assessment. PMID- 10156169 TI - Magnetic resonance--the upgrade/purchase decision. PMID- 10156170 TI - Metastron (strontium-89 chloride) injections reimbursement issues. PMID- 10156171 TI - Capital improvement vs. managed care. PMID- 10156172 TI - Managing the transition to integrated health care organizations. AB - Today's successful community hospitals should and will evolve into integrated health care organizations (IHCOs) that will share several common characteristics. IHCOs will have a community--not a membership--orientation, and this will be a distinguishing characteristic and a source of market appeal. The transition to IHCO will be a slow one, and to prosper, the IHCO will have to accommodate both price-oriented markets and traditional ones. Successful IHCOs will expand technical skills and capabilities to control costs and quality. New strategic competencies will have to be developed, and to do this, emerging IHCOs will improve the ability of managers to support decisions and sell them both to the buyers and the public at large. Excellent patient care will rest upon better trained, advised, and informed management teams. Making the change to an IHCO will take time and money, but organizations that make steady progress are likely to succeed. PMID- 10156173 TI - Key factors in the transition to IHCOs. PMID- 10156174 TI - The "community-oriented" IHCO: how viable? PMID- 10156175 TI - The case for regionals: a not-for-profit perspective. PMID- 10156176 TI - Recruiting physicians to rural areas. PMID- 10156177 TI - Building a rapport with legislators. PMID- 10156178 TI - A closer look at physician management companies. Why they're strong and getting stronger. PMID- 10156179 TI - Physical restraints in long-term care: complexity and contradiction. PMID- 10156180 TI - What marketing professionals want to know about middle adulthood. PMID- 10156181 TI - An empirical examination of shift strategies in the service industry: how hospitals adapt to industry change. AB - Research on the ability of firms to select different strategies in an effort to shift their strategic position has focused almost entirely on the mature manufacturing industries. In this paper, we propose that the relationship of strategy selection in manufacturing extends to the service industry, and test this proposition in one very visible faction of the service industry, health care. The results of this study show that health care organizations use both operational and strategic shift strategies to adjust to new environmental conditions. PMID- 10156182 TI - Marketing implications of the shift in power of the hospital. AB - With the introduction of the Prospective Payment System, hospital accountants' role changed from reimbursement maximizers to an important role in decision making. Faced with increased competition, hospitals are installing financial controls. Hospital marketers are also engaging in external promotional and health awareness campaigns and expanding their services to stabilize income and reduce the effects of a changing environment. Thus, hospitals operate in a more competitive environment with increasing uncertainty. When faced with uncertainty, organizations often believe that they must convince society that their existence is legitimate. Increasing specialization and organizational complexity in health care professions have made the expert important. Experts, such as the role assumed by hospital accountants and physicians, maintain power because the organization depends on them for their special skills and information. Marketing should also develop an internal marketing program to reach these power influencers. Scarce resource coupled with uncertainty move hospital accountants as experts into the power equation in the changing control of the U.S. healthcare system. Previously, the physician was the major source of hospital power. Since accountants often serve as monitors of scarce resources, information about the resource allocation directly affects the distribution of power. Marketers should acknowledge that this places hospital accountants in a critical role of assisting their institutions in adapting to a new environment. PMID- 10156183 TI - An analysis of the hospital-patient marketing relationship in the health care industry. AB - For many years hospitals have viewed patients paternalistically and failed to address many customers' needs and wants in the health care market. Early attempts at marketing by hospitals were haphazard and focused primarily upon advertising and public relations. Through a review and discussion of documented hospital marketing practices, the hospital-patient marketing relationship is examined. Conclusions about hospital marketing practices and suggestions for future research are also provided. PMID- 10156184 TI - Patient loyalty to physicians: attitudes and behavior. PMID- 10156185 TI - Marketing hospital wellness products to service companies. AB - The authors examine service firm employee attitudes towards wellness programs among twenty-three service companies in three states. Program components that were considered to be most desirable by service industry workers are identified in a regression model. The results indicate that hospital administrators need to adopt a marketing approach during the design phase of employee wellness programs. PMID- 10156186 TI - Ethical issues in purchasing: a field study of Midwest hospitals. AB - A large sum of money is spent annually by salespeople on gifts and favors for purchasing executives. The provision of gifts and favors to buyers remains a common practice despite the fact that it often leads to ethical conflicts for purchasing executives, sales managers, and salespeople. This paper investigates the perceptions of 51 purchasing executives of midwest hospitals regarding their behavior towards certain buying practices, the favors offered by vendors, favors actually accepted, as well as purchasers' discomfort and repayment levels regarding indebtedness. Based on the data analysis, this paper provides conclusions and directions for future research. PMID- 10156187 TI - Hospital portrayal of seniors in newspaper advertisements: a content analysis. AB - The purpose of this inquiry was to analyze: (a) the extent to which hospitals employed senior citizens as models in their advertisements, (b) the roles of these models and their active-passive status, and (c) the degree to which the advertisements portrayed seniors in a positive or negative status. Content analysis was employed to assess these issues. Hypotheses about the portrayal of senior citizens by hospitals were tested by examining advertisements in newspapers. The analysis provided some findings which should be of value to researchers and practitioners in the health care industry. PMID- 10156188 TI - Socio-economic correlates of outpatient care in a factor analytic framework. PMID- 10156189 TI - Prediction of medical student achievement by the utilization of personality characteristics and personal values. PMID- 10156191 TI - Interventions and policies to serve homeless people infected by HIV and AIDS. PMID- 10156190 TI - Advance care planning among nursing home residents prior to the Patient Self Determination Act. PMID- 10156192 TI - Health care in the United States: the battle of reform. PMID- 10156193 TI - An exploration of factors associated with clients prematurely exiting psychiatric treatment: implications for the Community Mental Health Centers Act. PMID- 10156194 TI - Unique characteristics of the physicians' market: inducement of demand and barriers to entry. PMID- 10156195 TI - Achieving excellence in health information management. PMID- 10156196 TI - Health information management department: reengineering file management. PMID- 10156197 TI - Health information management department: reeingineering accounts receivable and documentation. PMID- 10156198 TI - Transitioning to self-directed work teams: a health information services experience. PMID- 10156199 TI - Information management plan and the role of the health information management professional. PMID- 10156200 TI - Assessment of current compliance with the Joint Commission information management standards. PMID- 10156201 TI - Primary and secondary record management in electronic patient record systems. PMID- 10156202 TI - Case management: a quality process. PMID- 10156203 TI - Evaluating a telemedicine delivery system. PMID- 10156204 TI - Research review: reimbursement optimization and the quality of multihospital discharge databases. PMID- 10156205 TI - Total quality implies total democracy. PMID- 10156206 TI - Processes of persuasion: social interests and total quality in a UK hospital trust. AB - This paper examines some of the processes which have contributed to the development of a 'total quality' (TQ) approach within British health care. The paper challenges the idea that TQ is part of a redistribution of power within the NHS. Rather it is argued that through the elaboration of consumer-led market identities TQ misrepresents the interests of management and constructs a version of the self which obscures new forms of managerial control. TQ constrains alternative forms of social organisation, local knowledge and the social interests invested in them. An example of a competing set of assumptions is discussed. It is suggested that clinical groups--who are primarily motivated by the principles of professional, collegiate control--seek to free themselves from the constraints of TQ. Thus clinical discourse appropriates a professionally led version of the market and protects the traditional autonomy of professionals whilst seeming to render their interests synergistic with those of management. This casts 'quality', and perhaps even the 'market', as conceptual sites upon which different groups strive to construct and legitimate their own interests. It is concluded that the changes explicitly associated with TQ are not as fundamental as they seem. PMID- 10156207 TI - On chronic illness and quality of life: a conceptual framework. AB - In this paper I focus on the topic of chronic illness in the context of quality of life. I offer a conceptual explanation of these notions and then try to systematise the various species of suffering connected with chronic illness. Suffering in illness rarely attracts systematic analysis. Part of the reason for this is that the topic is in a way an aspect of common sense. It has an air of self-evidence and seems not to require analysis. However, it is my contention that the nature of human suffering is not at all self-evident. In many ways we know very little about the content and extent of suffering. And, although it may not be sensible to borrow traditional scientific techniques for the study of suffering, we need as much intellectual penetration and rigorous analysis in order to clarify the nature of suffering as for any other scientific investigation. Moreover, there are good reasons for saying that we ought to direct much more of our attention to this humanistic aspect of medicine. We ought to remember that the existence of suffering is one of the main motives, if indeed not the most important motive, for undertaking the medical enterprise. PMID- 10156208 TI - Rationing health care: from needs to markets? The politics of destruction: rationing in the UK health care market. AB - Rationing health care is not new. As governments world wide struggle to contain the costs of health care, health policy analysts debate how rationing should be done. However, they too often neglect how the mechanisms for funding and allocating health care resources are themselves vehicles for rationing treatment. In the UK, where health care rationing debates currently abound, there has been no formal evaluation of the role of the market in allocating scarce health care resources. The market in health care has increased administration, fragmented services, eroded local accountability, and decreased choice. This fragmentation, and the associated competition between purchasers and providers, means that resource allocation can no longer be monitored and evaluated in a national context. The loss of a population focus has left a vacuum in planning. Services cannot be planned rationally, and so are not able consistently to avoid duplication or to respond cogently to estimates of need. The loss of accountability means that decisions about the allocation of health care resources are no longer open to scrutiny by local people. Increasingly, especially in social and long term care the cost of care is being transferred to the individual. The new mechanisms for resource allocation are distributing resources unfairly: away from the poor, the sick and the elderly. The great myth of the market is that it has enabled decision-making to become explicit. This is not the case. To make health care resource allocation appear rational and acceptable to the public, health authorities have resorted to exercises in consumer consultation, and value laden guidelines where clinical cloaks are used to disguise political decisions on funding. In the UK, until the true role of the internal market is acknowledged, myths and subterfuge will conceal the winners and losers in the new system of rationing health care. PMID- 10156209 TI - Healthy cities: controlling the costs of health care. PMID- 10156210 TI - Managing (in)differently: the management and delivery of Australian nursing care under the economic rationalists. PMID- 10156211 TI - Patient autonomy as the prerequisite for care: opioids for chronic pain of non malignant origin. PMID- 10156212 TI - To those Diet members responsible for legislating on Japanese organ transplantation. PMID- 10156213 TI - A comparative health policy travelling seminar. PMID- 10156214 TI - Contract management: trying something new? PMID- 10156215 TI - Workers' compensation: the risk management balancing act. PMID- 10156216 TI - Remedy register: risk management systems review. PMID- 10156217 TI - How useful is the Internet for facilitating the delivery of care under capitation? PMID- 10156219 TI - Taking a gamble: how the Nevada CHIN hit the ground running. PMID- 10156218 TI - Managing outcomes & utilization in the home. PMID- 10156220 TI - How one rural hospital uses technology to manage care. PMID- 10156221 TI - The emerging global market for American managed behavioral healthcare. PMID- 10156222 TI - Behavior risk management--the preventive approach to reducing workplace problems. PMID- 10156223 TI - Health reform in the private sector: initiatives of the American Managed Behavioral Healthcare Association. PMID- 10156224 TI - Dialogue. How can privatized plans and delivery systems preserve the spirit of community? PMID- 10156225 TI - Partnership for provider network education: the Consortium for Clinical Excellence comes of age. PMID- 10156226 TI - CBGP position statement. Principles and priorities: standardization of operations, measurement and communication in behavioral healthcare. Council of Beahvioral Group Practices. PMID- 10156228 TI - Managed care: customizing networks through provider profiling. PMID- 10156227 TI - Going electronic. PMID- 10156229 TI - Public mental health systems, Medicaid re-structuring and managed behavioral healthcare. American Managed Behavioral Healthcare Association and National Association of State Mental Health Program Directors. PMID- 10156230 TI - Timing is everything: pre-post versus concurrent measurement. PMID- 10156231 TI - Quality and accountability as imperatives in managed behavioral healthcare. PMID- 10156232 TI - Real-time cardiac archive system productivity breakthrough. PMID- 10156233 TI - Using data to improve clinical effectiveness: an orthopedic case study. PMID- 10156234 TI - Medical technology: privacy on the information track. PMID- 10156235 TI - The entitlement ethic. PMID- 10156236 TI - Seeing around corners: planning for the next technological innovations. PMID- 10156237 TI - Keeping records private. PMID- 10156238 TI - California's CHIN team builder. Interview by Sharon Watson. PMID- 10156239 TI - Slicing costs in the OR. PMID- 10156240 TI - Automation strategies at smaller clinics and hospitals. AB - When it comes to applying the latest technology, giant academic medical centers and multi-specialty clinics grab most of the headlines. But throughout the country, smaller provider organizations with modest budgets and limited staffs are showing ingenuity in devising strategies for applying clinical information technology. This package of articles offers an overview of key clinical automation trends at smaller facilities, plus case studies of two clinics and two hospitals. PMID- 10156241 TI - Repositories promise to quench growing thirst for health data. AB - Consolidation among providers and the growth of managed care are fueling the development of clinical data repositories. Repositories may be a key to integrated delivery systems' efforts to conduct research to boost outcomes and cut costs. PMID- 10156242 TI - Group practice managers using technology to build virtual delivery systems. PMID- 10156243 TI - The dawn of computer age for home health care. PMID- 10156244 TI - Building an empire. PMID- 10156245 TI - Effective strategies for auditioning a consultant. PMID- 10156246 TI - Electronic records pay off twice. PMID- 10156247 TI - Cutting the cord. PMID- 10156248 TI - Average CIO salary is approaching $100,000. PMID- 10156249 TI - Ahead of his time. Interview by Bill Siwicki. PMID- 10156250 TI - Integrated delivery systems--the journey toward enterprisewide networks. PMID- 10156251 TI - Special report: health care and the Internet. PMID- 10156252 TI - Pushing physicians to give data entry a spin. PMID- 10156253 TI - Will real-time EDI take off in managed care? PMID- 10156254 TI - RFP--simplifying the task of selecting a system. PMID- 10156256 TI - Investigation leads to new assessment, critical path. PMID- 10156255 TI - Don't let wound care scar your case management program. PMID- 10156257 TI - Making a case for better management of back pain. PMID- 10156258 TI - Hospital redesign complements new PTCA pathway. PMID- 10156259 TI - Long term care on trial. PMID- 10156260 TI - Decoding the codes. PMID- 10156261 TI - FDA spells out new reporting requirements. PMID- 10156262 TI - Crime in hospitals 1994--the latest IAHSS survey. PMID- 10156263 TI - Using K-9s for healthcare security. PMID- 10156264 TI - Preparing for a hazardous materials accident. PMID- 10156265 TI - A guide for selecting the healthcare safety officer. PMID- 10156266 TI - Doing more with less = working smarter, not harder. PMID- 10156267 TI - Continuous quality improvement to manage emergency department violence and security-related incidents. PMID- 10156268 TI - An emergency department security plan. PMID- 10156269 TI - Protecting hospitals against infant abductions. PMID- 10156270 TI - The bomb and the Oklahoma standard--or, it couldn't happen in Oklahoma City. PMID- 10156271 TI - Recognizing and dealing with violence as a healthcare occupational hazard. PMID- 10156272 TI - Violent persons in the workplace: implications for hospital security. PMID- 10156273 TI - Evidence-based decision making. PMID- 10156274 TI - Fighting the bully. PMID- 10156275 TI - Consulting consumers. Fertile ground. PMID- 10156276 TI - Complaints. Diplomatic service. PMID- 10156277 TI - Consulting consumers. Back to basics. PMID- 10156278 TI - Organisational audit. A plaudit for audit. PMID- 10156279 TI - New health authorities. Learning curve. PMID- 10156280 TI - Capitation funding. Is it worth the weight? PMID- 10156281 TI - Mental health. Home help. PMID- 10156282 TI - Primary care. Practice makes perfect. PMID- 10156283 TI - Temperature rises for paediatrics. PMID- 10156284 TI - Mental health services. The cost of living. PMID- 10156285 TI - Information for purchasing. The informers. PMID- 10156286 TI - Consulting consumers. Only human. PMID- 10156287 TI - In a job, out of work. PMID- 10156288 TI - Protecting patient confidentiality. PMID- 10156289 TI - Rethinking the link: information systems improvements and reengineering. PMID- 10156290 TI - Ethical policy statement. Creating an ethical environment for employees--August 1995 (revised). American College of Healthcare Executives. PMID- 10156291 TI - Your CIO is talking: are you listening? PMID- 10156292 TI - The Health Care Quality Improvement Act in the courts: fast-acting cure for physician peer review headaches? PMID- 10156293 TI - When staff object to participating in care. PMID- 10156294 TI - Home health care nursing: liability and risk management for "informed consent" and "The Safe Medical Devices Act" duties. PMID- 10156295 TI - Unlicensed hospital assistive personnel: efficiency or liability? PMID- 10156296 TI - Venturing into the Labyrinth of Stark: impact of Stark Law and Stark I regulations on integrated delivery systems. PMID- 10156297 TI - Doing "big deals" and the board's duty of care. PMID- 10156298 TI - Labor and employment law issues in hospital closures and downsizing. PMID- 10156299 TI - Managed mental health care: changing the future of mental health treatment. PMID- 10156300 TI - COBRA continuation coverage: does coverage under a spouse's preexisting group plan terminate eligibility? PMID- 10156301 TI - The impact of volunteer coordinators on volunteer programs: an evaluation of Volunteer Maryland! PMID- 10156302 TI - Direct care and nondirect care hospice volunteers: motivations, acceptance, satisfaction and length of service. PMID- 10156303 TI - The new AVA statement of professional ethics in volunteer administration. Association for Volunteer Administration. PMID- 10156304 TI - Productive retirement: stimulating greater volunteer efforts to meet national needs. PMID- 10156305 TI - Assessing the quality of management decisions. PMID- 10156306 TI - When to change, bend, or modify the rules. PMID- 10156307 TI - A step-by-step approach to implementing change. PMID- 10156308 TI - Clearing up the mystery surrounding JCAHO's affiliation with POLs (physicians' office laboratories). PMID- 10156309 TI - Risk management in transfusion medicine. The AIDS era underscores the need for a unified, comprehensive risk management program for all aspects of transfusion- from donor selection to post-transfusion outcomes. PMID- 10156310 TI - (Relatively) painless downsizing. PMID- 10156311 TI - Confront TQM resisters head-on. PMID- 10156312 TI - A broader vision. CIOs shift strategy to look beyond the hospital. PMID- 10156313 TI - Clinical systems add market momentum. PMID- 10156314 TI - Chicago CHIN moves to next phase. PMID- 10156315 TI - OrNda to spend $300 million to enter second-largest Mass. market. PMID- 10156316 TI - CIO pay averages $110,000 a year. PMID- 10156317 TI - Privatized Medicaid ventures find success. PMID- 10156318 TI - Rehab providers fight HCFA data. PMID- 10156319 TI - N.C. hospital partnership sets precedent. PMID- 10156321 TI - New healthcare stock indexes add to investment options. PMID- 10156320 TI - Providers should look before leaping into laser eye surgery. PMID- 10156322 TI - AmHS-Premier-SunHealth mega-merger stirs market. PMID- 10156323 TI - VHA studies Columbia's doc investment strategy. PMID- 10156324 TI - Advocates welcome Clinton shift on PSNs. PMID- 10156326 TI - GOP to pitch insurance reform. PMID- 10156325 TI - Ranks of physicians continue to swell--study. PMID- 10156327 TI - Data companies, St. Anthony, CHIPS to merge. PMID- 10156328 TI - Houston hospital council disbands. PMID- 10156329 TI - Texas hospital closes, but its mission lives on. PMID- 10156330 TI - Blues panel: marrow transplants effective in advanced breast cancer. PMID- 10156331 TI - Minn. group asks providers' help in bid to keep local control of hospital. PMID- 10156332 TI - 15 hospitals in Ind., Ill. form alliance. PMID- 10156333 TI - Failed merger cost WellPoint in 4th quarter. PMID- 10156334 TI - Mo. system to consolidate services. PMID- 10156335 TI - Clinical integration may not be needed for system growth--study. PMID- 10156336 TI - Alaska partnership links delivery systems. PMID- 10156337 TI - Software lets systems test strategies. PMID- 10156338 TI - Congressmen propose law barring HMO doc 'gag rules'. PMID- 10156339 TI - Connecticut's oldest HMO plan to dissolve. PMID- 10156340 TI - Empire Blues reports it is 'on the road to recovery'. PMID- 10156341 TI - FTC opposes bill aimed at loosening provider rules. PMID- 10156342 TI - Hospitals shifted fewer costs in '94. PMID- 10156343 TI - HSI launches electronic info link in Pa. PMID- 10156344 TI - NMA celebrates 100 years of activism. PMID- 10156345 TI - IHS reports fourth-quarter shortfall. PMID- 10156346 TI - Pa. hospital settlements average just $21,000. PMID- 10156347 TI - Chinatown Clinic feeling pinch of competition. PMID- 10156348 TI - White House won't support governors' plan. PMID- 10156349 TI - Florida 2nd state to issue 'report cards'. PMID- 10156350 TI - Maternity-stay rule sparks backlash. PMID- 10156351 TI - California hospital to settle patient 'dumping' charges. PMID- 10156352 TI - Columbia reorganizes in Kan., Mo. PMID- 10156353 TI - Accountant sues five Minn. hospitals. PMID- 10156355 TI - Task force seeks changes in workers' comp system. PMID- 10156354 TI - Policymakers debate future of MSAs. PMID- 10156356 TI - Full speed ahead. CIO survey reveals push to build computer links in integrated healthcare delivery networks. AB - The ruminating is over. Projections of fundamental, and expensive, information system changes have turned into projects. And the electronic integration of diverse healthcare delivery networks is moving ahead with stunning speed, according to Modern Healthcare's sixth annual survey of information system trends. PMID- 10156357 TI - Is ethics consultation an elegant distraction? PMID- 10156358 TI - Dialogue to Action: including public expectations in healthcare ethics. PMID- 10156359 TI - The evolution of a long-term care ethics committee. PMID- 10156360 TI - Responsibility of healthcare ethics committees toward nurses. PMID- 10156361 TI - Case Series: No. 4. The healthcare team's responsibility to the non-English speaking patient: coping with cultural values and alleged spouse abuse. PMID- 10156363 TI - NIH's newest experiment. PMID- 10156362 TI - The woman who wasn't herself: moral response to medical insurance fraud. PMID- 10156364 TI - Quality--what is it and who cares? PMID- 10156365 TI - Drug utilization review. PMID- 10156366 TI - AAMT guidelines on confidentiality, privacy, and security of patient care documentation through the process of medical dictation and transcription. American Association of Medical Transcription. PMID- 10156367 TI - Fit to be tied? How to know when a deal violates antitrust laws. PMID- 10156368 TI - Group hysteria! Defining GPOs in the 1990s. PMID- 10156369 TI - Start the new year right: reevaluate supply prices. PMID- 10156370 TI - Mastering red tape: fighting for the use of safer products. PMID- 10156371 TI - Bloom where you are planted: CS can flower in a rocky setting. PMID- 10156372 TI - Instrument standardization saves money and time. PMID- 10156373 TI - My days with Uncle Dupie: a look back at the 'personal sell'. PMID- 10156374 TI - Double jeopardy: answers to wound care cost questions. PMID- 10156376 TI - Credentialing and peer review foul-ups remind hospitals of need for vigilance and accountability. PMID- 10156375 TI - Partnering with disease state management vendors: is it risky business? PMID- 10156378 TI - A directory of organizations offering disease state management services. PMID- 10156377 TI - Using disease state management to coordinate care across the continuum. PMID- 10156379 TI - Predicting progress and pitfalls in 1996. Discussion. PMID- 10156380 TI - The budget battle. What's at stake for employers, what's likely to emerge. AB - At B&H press time, Republicans and the White House had finally agreed to sit down for serious talks. Numbers and details of the proposals were highly fluid but core positions remained consistent. What follows is a comparison of the key health-care and health benefits-related measures contained in the Balanced Budget Act of 1995-the massive seven-year GOP budget-balancing plan--with those in the Clinton Administration's revised seven-year budget plan released on December 7. President Clinton vetoed the Balanced Budget Act on December 6. All numbers and positions are as of December 20 and are based on the differing "baseline" economic and fiscal assumptions both sides were using as of that date. PMID- 10156381 TI - Is it risky to ride with a drug company? PMID- 10156382 TI - Here's looking at vision care. PMID- 10156384 TI - When employers get tough about unhealthy habits. PMID- 10156383 TI - Data watch. HMOs make a move on workers' comp. Retiree health benefits wane. PMID- 10156385 TI - Case management: communicating real savings. PMID- 10156386 TI - When not-for-profits decide to make a buck. PMID- 10156387 TI - Health costs: why employers won another round. PMID- 10156388 TI - PBMs (pharmacy benefit managers): why this exponential growth? PMID- 10156389 TI - Opportunities for improving the practice of clinical audit. PMID- 10156390 TI - Nursing research: a key to quality care. PMID- 10156391 TI - Assessing the work of medical audit advisory groups in promoting audit in general practice. AB - Objectives--To determine the role of medical audit advisory groups in audit activities in general practice. Design--Postal questionnaire survey. Subjects- All 104 advisory groups in England and Wales in 1994. Main measures--Monitoring audit: the methods used to classify audits, the methods used by the advisory group to collect data on audits from general practices, the proportion of practices undertaking audit. Directing and coordinating audits: topics and number of practices participating in multipractice audits. Results--The response rate was 86-5%. In 1993-4, 54% of the advisory groups used the Oxfordshire or Kirklees methods for classifying audits, or modifications of them. 99% of the advisory groups collected data on audit activities at least once between 1991-2 and 1993 4. Visits, questionnaires, and other methods were used to collect information from all or samples of practices in each of the advisory group's areas. Some advisory groups used different methods in different years. In 1991-2, 57% of all practices participated in some audit, in 1992-3, 78%, and in 1993-4, 86%. 428 multipractice audits were identified. The most popular topic was diabetes. Conclusions--Advisory groups have been active in monitoring audit in general practice. However, the methods used to classify and collect information about audits in general practices varied widely. The number of practices undertaking audit increased between 1991-2 and 1993 1. The large number of multipractice audits supports the view that the advisory groups have directed and coordinated audit activities. This example of a national audit programme for general practice may be helpful in other countries in which the introduction of quality assurance is being considered. PMID- 10156392 TI - Medication errors during hospital drug rounds. AB - Objective--To determine the nature and rate of drug administration errors in one National Health Service hospital. Design--Covert observational survey be tween January and April 1993 of drug rounds with intervention to stop drug administration errors reaching the patient. Setting--Two medical, two surgical, and two medicine for the elderly wards in a former district general hospital, now a NHS trust hospital. Subjects--37 Nurses performing routine single nurse drug rounds. Main measures--Drug administration errors recorded by trained observers. Results--Seventy four drug rounds were observed in which 115 errors occurred during 3312 drug administrations. The overall error rate was 3.5% (95% confidence interval 2.9% to 4.1%). Errors owing to omissions, because the drug had not been supplied or located or the prescription had not been seen, accounted for most (68%, 78) of the errors. Wrong doses accounted for 15% (17) errors, four of which were greater than the prescribed dose. The dose was given within two hours of the time indicated by the prescriber in 98.2% of cases. Conclusion--The observed rate of drug administration errors is too high. It might be reduced by a multidisciplinary review of practices in prescribing, supply, and administration of drugs. PMID- 10156393 TI - Predictors for waiting time for coronary angioplasty in a high risk population. AB - Objective--To describe the clinical and non-clinical factors which influence the waiting time from initial angiography to angioplasty. Design--Follow up of a random sample of 106 patients undergoing their first coronary angiography for whom a decision to revascularise by percutaneous transluminal angioplasty was made in 1991. The period between the date of angiography and the date of angioplasty and various clinical characteristics of patients were retrieved from medical notes in mid 1993. Patients were sampled from those investigated in the two Northern Ireland catheterisation laboratories in Belfast, which provide services for the whole of the province (population 1.5 million). Main measures- The dependent variable was the period between initial angiography and angioplasty, and the independent variables included age, sex, distance from cardiac catheterisation centre, referral source, characteristics of the clinical history, severity of angina, and anatomical extent of disease. Cox's proportional hazards analysis was used to derive a relative hazard, expressing the relative chances of revascularisation occurring at any time during follow up. Results--Of the 106 patients studied, 93 had had percutaneous transluminal angioplasty at follow up. The most important predictors of waiting time were the presence of severe angina (relative hazards 3.1(95 % confidence interval (95% CI) 1.4-6.8) and 2.7(1.2-6.2) for Canadian Cardiovascular grades III and IV v angina grade I angina), a recent history of myocardial infarction (relative hazard, 2.5(1.3 4.8), and whether or not the patient was economically active (relative hazard 0.6(0.4-1.0) for economically inactive v active patients). Although there was also an association with the relative deprivation of the area of residence of the patient it had no clear linear trend. Conclusions--Although waiting time for percutaneous transluminal angioplasty was predictably related to the patient's clinical presentation, demographic factors may also be important in determining access to intervention. These factors clearly merit further study; ultimately, the evaluation of equity in a waiting time distribution may more properly be a societal rather than a clinical judgment. PMID- 10156394 TI - Attitudes and behaviors towards clinical guidelines: the clinicians' perspective. AB - Objectives--To find out what attitudes hospital doctors have towards the culture of clinical guidelines; to ascertain perceived knowledge and use of clinical guidelines; and to investigate why hospital doctors think that clinical guidelines may not be used and how they think that the use of guidelines can be encouraged. Design--Postal questionnaire survey be tween October 1993 and January 1994. Setting--Hospitals within Oxford region. Subjects--409 doctors of all grades working in one of six specialties (anaesthetics, paediatrics, general surgery, general medicine, obstetrics and gynaecology and accident and emergency medicine). 47 were randomly picked as part of the pilot study, 362 were extracted from hospital staffing lists. Results--268 clinicians (66%) responded to the questionnaire. Most respondents (77%, 208) expressed welcoming attitudes towards guidelines but 51%(136) perceived the attitudes of their colleagues as being less favourable. Over three quarters of respondents claimed to use guidelines at least once a month. Most respondents learnt about guidelines from discussions with their peers (50%, 134 respondents) or senior doctors 37%, 99) or from journals (39%, 105). Reasons why guidelines may not be used included being unaware of particular guidelines (80%, 213 respondents) and the fact that guidelines had been poorly developed (64%, 171) or were impractical (49%, 132). The best ways to encourage the use of guidelines were thought to be encouragement from senior doctors (72%, 193 respondents) and peers (59%, 157) and by monitoring behaviour and providing feedback (68%, 181). Conclusion--The decision to use a guide line was based on the perceived value of each guideline and was influenced by other clinicians' behaviour. The results provide an insight into aspects of dissemination and implementation which are perceived as influential by the recipients of guidelines. PMID- 10156395 TI - The feasibility and cost of a large multicentre audit of process and outcome of prostatectomy. AB - Objective--To determine the feasibility of performing multicentre process and outcome audits of common interventions taking prostatic procedures as an example. Design--Prospective, cohort study. Setting--All National Health Service and independent hospitals in Northern, Wessex, Mersey, and South West Thames health regions. Patients--5361 men undergoing prostatectomy identified by 103 of the 107 urologists and general surgeons performing prostatectomy in the study regions. Main measures-- Rates of participation by surgeons and patients; completeness of clinical data provided by surgeons; patient response rate and completeness of patient derived data; and cost. Results--Most surgeons (103,96%) agreed to participate. Overall, the proportion of eligible patients invited to take part was high (89%), although this was only measured in South West Thames, where dedicated data collectors were employed. Few men (80, 1.5%) declined to participate. Of those surviving for three months after surgery, 82.4% (4226) completed and returned the postal questionnaire. The response rate was higher in South West Thames (86.7%) than in the other regions (80.6%-80.8%). The audit was well received: 91% of patients found the questionnaire easy to complete and only 2.3% of them disapproved. Completeness of data was high with both the hospital and patient questionnaires. Missing data occurred in less than 5% of responses to most questions. The attributable cost was 34.50 pounds per patient identified or 44 pounds for patients in whom either the treatment outcome or vital status was known three months after their prostatectomy. Conclusions--This multicentre audit of process and outcome of prostatectomy proved feasible in terms of surgeon participation, patient identification, and the quantity and quality of data collection. Whether the cost was warranted will depend on how surgeons use the audit data to modify their practice. PMID- 10156396 TI - Management of primary antibody deficiency by consultant immunologists in the United Kingdom: a paradigm for other rare diseases. AB - Variation in clinical practice and its effect on outcome is little known for rare diseases such as primary antibody deficiency. As part of a national audit a survey of all 30 consultant immunologists in the United Kingdom dealing with primary antibody deficiency syndromes in adults and children was carried out in 1993 to ascertain their practices in diagnosis and management. Consensus guidelines were published after the survey was completed. Comparison of the survey results of clinical practice at the time the guidelines were published with the standards identified highlighted that the practice of a minority of specialists was at variance with their peers and with the consensus document, particularly in the use of intramuscular immunoglobulin, the dose and frequency of intravenous immunoglobulin, and target trough immunoglobulin G concentration, which has implications for the quality of patient care. However, much closer agreement existed in the key areas of management, such as diagnosis and selection of intravenous immunoglobulin. The approach and the problems identified are relevant to the management of other rare diseases, in which diagnosis and management is complex and there are few specialists with the necessary knowledge to undertake such care. This survey, the first attempted audit of practice, shows that within a motivated group of specialists highly significant differences in practice may exist and the authors emphasise the importance of setting clear guidelines against which care can be assessed. PMID- 10156397 TI - Managing meningitis in children: audit of notifications, rifampicin chemoprophylaxis, and audiological referrals. AB - Important aspects of the management of meningitis in children include notification to local officers for control of communicable diseases; chemoprophylaxis for index cases and close contacts in cases of meningococcal or Haemophilus influenzae meningitis; and a formal hearing assessment for all survivors. A retrospective audit of these aspects of management was carried out for children admitted with meningitis in 12 months from 1 September 1990 to 31 August 1991 at the Royal Belfast Hospital for Sick Children. Only 20 of 36(56%) cases were notified by medical staff. Chemoprophylaxis was arranged for all close family contacts but to only five of the 23(22%) index cases for whom it was indicated. Appointments for audiological testing were arranged for only 19 of the 32(59%) survivors. Subsequently all doctors, including each intake of junior doctors, were given written information on the importance of notification and locally agreed guidelines for chemoprophylaxis and hearing assessments for survivors before discharge. Guidelines were also displayed prominently in each ward. A repeat audit from January 1992 to December 1992 showed significant improvement in these aspects of care. Twenty eight of 32 cases (88%) were notified, chemoprophylaxis was given to 20 of 22(91%) index cases for whom it was indicated, and 25 of 29(86%) survivors had hearing assessments arranged before discharge. Correct management of some aspects of care cannot be assumed, even if statutory (notification), nationally agreed (chemoprophylaxis), or generally agreed good practice (hearing assessments). These aspects of care improved after the first audit but the authors conclude that the notification rate remains below 100% and a repeat audit is necessary. PMID- 10156398 TI - Needs, rights, and equity: more quality in healthcare rationing. PMID- 10156399 TI - Rehabilitation for people with chronic lung disease. PMID- 10156401 TI - Medical Records Institute releases results of document imaging survey. PMID- 10156400 TI - Preventing and treating pressure sores. PMID- 10156402 TI - Columbia region defining PHO I/S needs. PMID- 10156403 TI - Andersen creates disease management network. Interview by Lois Drapin. PMID- 10156404 TI - Electronic data interchange. PMID- 10156405 TI - Stage is set for rapid CPR adoption. PMID- 10156406 TI - Start taking advantage of Internet resources. PMID- 10156407 TI - How to determine your case-management needs. PMID- 10156408 TI - HotList. Case-management software. PMID- 10156409 TI - Myths in the land of integrated delivery systems. PMID- 10156410 TI - Methodist Hospital's wireless network strategy. PMID- 10156411 TI - Document imaging systems. PMID- 10156412 TI - New HIMSS president creating Healthcare Alliance. PMID- 10156413 TI - Physicians drive profiling system at Family Health. PMID- 10156414 TI - Object technology cuts development time. PMID- 10156415 TI - CHINs, IHD systems remain in evolutionary state. PMID- 10156416 TI - Strategic I/T planning: a four-pronged approach. PMID- 10156417 TI - When will complete medical record systems exist? PMID- 10156418 TI - Ten things to look for in a systems integrator. PMID- 10156419 TI - HotList. Systems integrators. PMID- 10156420 TI - Patient identification: the Achilles heel of computerized health information. PMID- 10156421 TI - Deterring inefficient pharmaceutical litigation: an economic rationale for the FDA regulatory compliance defense. PMID- 10156422 TI - The tuberculosis emergency in Africa: opportunities and strategies for action. AB - Tuberculosis rates are increasing dramatically in many regions of the world due to poverty, rapid population growth, ineffective Tb programmes and the HIV pandemic. Innovative approaches of treatment supervision are required to increase cure rates and hence reduce transmission. National tuberculosis programmes need to be strengthened, co-ordinated with AIDS programmes and supported by national advocacy groups. PMID- 10156423 TI - Developing management capacity through training: the Mulago Hospital experience. AB - As part of its rehabilitation, Mulago Hospital, Uganda's national referral, teaching and research hospital, is undertaking a training programme for its staff both in-country and overseas. The focus of the in-country programme has been to develop the hospital's management capacity to cope with increasing responsibilities as a self-accounting unity due to develop its autonomy. Hitherto, the majority of the hospital's senior and middle-level managers are health professionals who have to carry out management functions without relevant training. The programme is managed by a hospital committee and training is conducted by staff who have themselves undergone training overseas or locally. The training programme has resulted in a number of positive changes such as improved teamwork and organizational cohesion. However, as the training is mainly donor funded, its sustainability is not assured. PMID- 10156424 TI - Don't shoot the messenter: master facilities planning for the hospital. AB - The acute care medical/surgical (somatic) hospital is among the most politicized, scrutinized, technically complex and increasingly expensive of building types within the infrastructure of civilized live. Unless well prepared, hospitals will generally continue to evolve haphazardly and expensively to become accretions of macro and micro renovations and additions. companion and servant to a hospital's overall Strategic Plan, a Master Facilities Plan should be an eminently accessible ongoing document for charging a hospital's facilities policy. It should be designed to assure continuity so that facilities responses to short term and term goals will remain compatible, complimentary and inherently flexible over time. The techniques employed in master planning for hospitals will vary with the planners, the clients and the agendas of governmental regulators. Although some unfavourable information concerning the condition of existing facilities is surely to be anticipated, especially for older buildings, how clearly that information is presented and then creatively resolved is often at the core of fine Master Facilities Planning. PMID- 10156425 TI - Healthcare financing in the Kingdom of Saudi Arabia: a review of the options. AB - Healthcare financing in the Kingdom of Saudi Arabia is overwhelmingly public and services provided in government facilities are free. However, even through the proportion of government outlays allocated to health care has been increasing, the actual amount per capita has been decreasing; a result of the double effects of a fast-growing population and a declining government revenue. Duplication of services and frivolous demands are identified sources of waste. This paper gives a brief description of current sources of financing, reviews the options for the future, argues for measures to raise cost consciousness and assesses the impact of user charges on the low income. Closer integration and co-ordination of the government agencies and introduction of user charges as a first step toward eventual adoption of a national health insurance are the measures recommended to increase efficiency and cost-awareness as well as to raise revenue. PMID- 10156426 TI - The Rene Sand Lecture--Rationing, rights and responsibilities in health care. PMID- 10156427 TI - Clean room approach to OR supply management. PMID- 10156428 TI - Let data drive your decision toward capitation. PMID- 10156429 TI - Reimbursement issues: 4 steps to managed care. PMID- 10156430 TI - No money, no mission: where to draw the line. PMID- 10156431 TI - Managed care--no magic bullet. PMID- 10156432 TI - Preparing for capitation. PMID- 10156433 TI - What type of quality information do consumers want in a health care report card? PMID- 10156434 TI - Patients' expectations for medical care: an expanded formulation based on review of the literature. PMID- 10156435 TI - An empirical assessment of health care management journals: a business perspective. PMID- 10156436 TI - Organizational approaches to integrated health care delivery: a taxonomic analysis of physician-organization arrangements. PMID- 10156437 TI - Interorganizational cooperation in community mental health: a resource-based explanation of referrals and case coordination. PMID- 10156438 TI - DOJ gives seal of approval to three provider networks. PMID- 10156439 TI - Johns Hopkins, Humana team to build Md. MCO network. PMID- 10156440 TI - Md.'s maternity LOS law isn't boosting hospital stays, some say. PMID- 10156441 TI - Expect more competition, capitation, consolidation in 1996, expert says. PMID- 10156442 TI - Medical groups will change drastically by 1999. PMID- 10156443 TI - St. Paul PO evolves to meet business coalition's market demands. PMID- 10156444 TI - Guthrie Clinic shares integration lessons it learned the hard way. PMID- 10156445 TI - Designing a capitated physician compensation plan. PMID- 10156446 TI - Long-term care: an innovative cross-functional model. PMID- 10156447 TI - What it is like to be a Catholic on a regional health authority. PMID- 10156448 TI - An ethics centre is reborn. PMID- 10156449 TI - Nutritional radar. You're in an ideal position to determine if your geriatric patients are malnourished. PMID- 10156450 TI - EMS experts support antiterrorism bill. PMID- 10156451 TI - Readin', writin', resuscitatin'. PMID- 10156452 TI - Nursing home transports. Rediscovering decency and respect. PMID- 10156453 TI - Geriatric injury prevention. A new role for EMS personnel? PMID- 10156454 TI - Looking out for older Americans. Interview by Barbara Feiner. PMID- 10156455 TI - Dignified death or disgraceful dishonor? PMID- 10156456 TI - New FCC rules affect EMS radio frequencies. PMID- 10156457 TI - "What we have here is a failure to communicate...". PMID- 10156458 TI - Terror on the tracks. PMID- 10156459 TI - Defending your life. How far can you go when protecting yourself against patients who physically attack you? PMID- 10156460 TI - Assault & pepper. PMID- 10156461 TI - Explosive emergencies. Bombings--and injuries--are on the rise. PMID- 10156462 TI - Support your local bomb squad. PMID- 10156463 TI - Invest in direct contracting, ties with employer-payers. PMID- 10156464 TI - Hospitals in strong managed care markets report lower costs and mortality rates. PMID- 10156465 TI - Kaiser Permanente targets internal services for strategic restructuring effort. PMID- 10156466 TI - The use of psychological screeners for containing costs and improving outcomes. PMID- 10156467 TI - Multi-hospital systems are adding complexity, not needed operational changes. PMID- 10156468 TI - Managing professional intellect: making the most of the best. PMID- 10156469 TI - Can public trust in nonprofits and governments be restored? PMID- 10156470 TI - Realizing the benefits of student involvement. PMID- 10156471 TI - Benchmarking food costs. PMID- 10156472 TI - Is your staff competent? PMID- 10156474 TI - How to understand your customers--be one. PMID- 10156473 TI - Interactive patient education. PMID- 10156475 TI - Ask not what your board can do for you--what can you do for your board? PMID- 10156476 TI - Take the lead out of quality improvement projects. PMID- 10156477 TI - Don't be afraid of the C-word in the age of managed care. PMID- 10156478 TI - Tomorrow's challenge: bridging the information gap. PMID- 10156479 TI - The evolution of the health care quality professional. PMID- 10156480 TI - Turn 'So what?' into 'Oh, really!'. PMID- 10156481 TI - Hospital. PMID- 10156482 TI - Comprehensive approach to utilization review based on patient-specific costing data. AB - The Ottawa General Hospital (OGH) is one of a growing number of institutions that has implemented a cost accounting system. The ability to track costs on a patient specific basis provides an exciting avenue for reviewing the use of resources. With the accumulation of a complete fiscal year of data, the hospital recently embarked on a review process to identify opportunities for more detailed review with practitioners. This will support the OGH's surgical approach of targeting cuts, rather than making across-the-board reductions. The objective is to allow the hospital to maintain the highest levels of quality and service as the eroding funding situation allows. This paper describes the comprehensive approach taken by the review team to identify populations of patients that were relatively homogeneous and yet showed the greatest practice pattern variances between physicians. The method described provides a template for others to summarize large amounts of data and stratify patient groups for more detailed analysis of the patient care delivery process. PMID- 10156483 TI - Reducing surgical length of stay: quantifying the impact. AB - Length-of-stay (LOS) reduction is a strategy encouraged at all levels of health care to manage within a resource limited environment. However, few organizations have attempted to quantitatively understand the impact of reducing LOS. This study examines the relationship between reducing LOS and cost through a retrospective, medical records analysis of three surgical procedures (appendectomy, cholecystectomy and caesarean section) at an Ontario community hospital Department of Surgery. Hypotheses are presented and a methodology is described. The results are discussed with a focus on the factors that hospitals, administrators and physicians might consider in a LOS reduction program. PMID- 10156484 TI - Estimating the cost of outpatient hospital care. AB - Hospital services can be divided into inpatient, outpatient and non-patient areas; outpatient care can be further subdivided into emergency room care, general and special clinic care, day procedures and non-admitted day/night care. Using 1992-93 Statistics Canada data on expenditures and outpatient activity from the Part One form for 29 Alberta hospitals, we estimated the average cost of each of the four outpatient areas. The estimated cost per visit was $183 for clinic visits, $166 for day/night care, $69 per emergency visit and $627 per day procedure. These estimates can be used in cost-effectiveness studies and, if supplemented with outpatient case weights and volumes, in provincial funding systems. PMID- 10156485 TI - Quality and governance in hospitals. AB - What is the role of the board in quality initiatives in an organization? How can the board improve its own processes through quality initiatives? What are the quality attributes that a board should monitor? The board at St. Mary's Hospital in Kitchener addressed these questions, resulting in a rethinking of the board's role and its relationship to the operation of the hospital. This article discusses how the board has been restructured, and how it has shifted over the past few years to a CQI focus. PMID- 10156486 TI - Redesign of a health science centre: reflections on co-leadership. AB - Since 1988, the Sunnybrook Health Science Centre has been proactive in re designing its system toward decentralized management, the purpose being to further enhance patient care. This process has involved numerous changes, among which were the establishment of three large clinical units. These clinical units are not defined following the historic medical model, but group patients with similar service and care needs. Subsequently, each of the clinical units defined Patient Service Units (PSUs). The hospital has chosen a co-leadership model for the lead management at each of the unit levels. This paper describes the model for clinical units. PMID- 10156488 TI - Rush-Copley: a modular hospital campus for the 21st century. PMID- 10156487 TI - A balanced scorecard for Canadian hospitals. AB - Managing a health care organization on the basis of one set of information alone (e.g., financial information) does not give a full view of the impact of changes on the organization. A balanced scorecard approach can provide management with a comprehensive framework that turns an organization's strategic objectives into a coherent set of performance measures. This approach has been used extensively in industry, but seldom in health care organizations. By developing a scorecard approach, these organizations could obtain feedback providing a balanced view of organizational performance, letting them see if improvements in one area may have been achieved at the expense of another. It also demands that managers translate their general mission statement on customer service into specific measures that reflect the factors that really matter to customers. PMID- 10156489 TI - 1995 Vista Awards. Celebrating teamwork and excellence in health facility design and construction. PMID- 10156490 TI - Constructing the future: a roundtable. PMID- 10156491 TI - Renovating as a team. PMID- 10156492 TI - Ready for the Title V tidal wave? How to stay afloat. PMID- 10156495 TI - Health care construction grows, say new reports. PMID- 10156494 TI - Training that will stick with your facility cleaning staff. PMID- 10156493 TI - Ways to find out how your customers define quality. PMID- 10156496 TI - Surgery pack ups and more ups: Baxter's prices up slightly, J&J's take big jump. PMID- 10156497 TI - Med-surg prices are predicted to be up only modestly in 1996. PMID- 10156498 TI - For group purchasing organizations, a hard strategic look at the future of health care is essential to continued survival. PMID- 10156499 TI - Trend is still down in cost per case in the operating room, but there is still room for driving out more cost; here's how. PMID- 10156500 TI - Medical costs in workers' compensation insurance. AB - We examine whether patients covered by workers' compensation insurance, which covers the cost of medical care for injured workers without cost sharing and with relatively little oversight, are charged more for treatment or receive more services than patients covered by traditional insurance. Our findings indicate that workers compensation recipients are charged more for treatment. This difference persists in individual services--workers' compensation recipients are charged more per X-ray and per examination than our patients. We consider different explanations and argue that price discrimination probably plays a role. PMID- 10156501 TI - Price regulation in the pharmaceutical industry: prescription or placebo? AB - President Clinton and several Legislators have proposed restrictions on price increases in the pharmaceutical industry similar to those on some public utilities. Studies, however, suggest that under conditions of rapidly changing demand (as found in pharmaceuticals), price-caps could be manipulated. Using simulations, we show that in reaction to regulation, pharmaceutical firms would optimally set launch prices 50 percent higher than in an unregulated market. Although initially hurt, after seven years consumers benefit as the unregulated price rises above the price-cap. Thus, before enacting legislation, Congress should assess America's willingness to pay more now for lower prices in the future. PMID- 10156502 TI - Nurses' labor supply: participation, hours of work, and discontinuities in the supply function. AB - This paper presents the results of a formal labor supply model for nurses in Great Britain. It corrects for misspecification and sample selection bias which affected earlier research on women's labor supply generally in the United Kingdom and tests for the existence of discontinuities in the supply curve of nurses. Estimates of labor market participation elasticities with respect to the wage rate, non-labor income, and to the costs incurred through work are reported for nurses, qualified and unqualified. Participation is found to be highly responsive to wage changes and some discontinuity is found in the supply function. PMID- 10156503 TI - Economic conditions and alcohol problems. AB - This study investigates the relationship between macroeconomic conditions and two alcohol-related outcomes--liquor consumption and highway vehicle fatalities. Fixed-effect models are estimated for the 48 contiguous states over the 1975-1988 time period. Alcohol consumption and traffic deaths vary procyclically, with a major portion of the effect of economic downturns attributed to reductions in incomes, rather than employment. The intake of hard liquor is the most sensitive to the state of the macroeconomy. There is no evidence, however, that fluctuations in economic conditions have a disproportionate impact on the drunk driving of young adults. PMID- 10156504 TI - Hartford system builds facilities, funds and community support. Saint Francis/Mount Sinai, Hartford, CT. PMID- 10156505 TI - Changing seniors opinions about changing health benefits. FHP Health Care, Englewood, CO. PMID- 10156506 TI - Ochsner/Sisters of Charity launches Total Health 65. Ochsner-Sisters of Charity Health Plan, Metairie, LA. PMID- 10156507 TI - The simple things. Saint Joseph Hospital, Omaha, NE. PMID- 10156508 TI - Launching a new resource center. Encino-Tarzana Regional Medical Center, Tarzana, CA. PMID- 10156509 TI - Tampa General Hospital offers mothers two free days. PMID- 10156510 TI - Professionals feel the heat. PMID- 10156511 TI - An evaluation of mobile HEPA (high-efficiency particulate-air) cleaners. PMID- 10156512 TI - Illiteracy in patients and HCWs means safety concerns. PMID- 10156513 TI - Nursing homes in transition. PMID- 10156514 TI - The other side of group purchasing: the employer's perspective. PMID- 10156515 TI - Keeping them well. PMID- 10156516 TI - A new kind of pressure: getting ready for capitation. PMID- 10156517 TI - The new world order: the market in the post-health reform era. PMID- 10156519 TI - The future of group purchasing: who survives and why? PMID- 10156518 TI - Antitrust law in 1995: mixed messages for providers. PMID- 10156520 TI - Bulk buyer. PMID- 10156521 TI - Emergency care under managed care: a fatal distraction? PMID- 10156523 TI - NFPA Journal buyers guide, 1996. PMID- 10156522 TI - Data ... nursing occupations. Institute of Medicine. PMID- 10156524 TI - Practice Brief. Issue: Electronic signatures. American Health Information Management Association. PMID- 10156525 TI - Another tool for information management--conducting a baseline survey. PMID- 10156527 TI - Thinking for us. PMID- 10156526 TI - Healthcare information system trends: the case for strategic planning. PMID- 10156528 TI - Long term care expands its realm within the continuum of care. PMID- 10156529 TI - Healthcare trends. PMID- 10156530 TI - Considerations for integrated case management models. PMID- 10156531 TI - Severity-adjusted case mix: the last frontier. PMID- 10156532 TI - Ambulatory patient groups--an outpatient data management tool. PMID- 10156533 TI - What does your future hold: capitation or decapitation? PMID- 10156534 TI - A practical approach to futile care. PMID- 10156535 TI - The ICU's financial future. PMID- 10156536 TI - Statement on indications for the use of permanently implanted cardiac pacemakers. American College of Surgeons. PMID- 10156537 TI - Health care quality in NHS hospitals. AB - Hospitals provide the same type of service, but they do not all provide the same quality of service. No one knows this better than patients. Reports the results of a market research exercise initiated to ascertain the different factors which patients of health care identify as being necessary to provide error-free service quality in the NHS hospitals. To measure patients' satisfaction with NHS hospitals, the internationally-used market research technique called SERVQUAL was used in order to measure patients' expectations before admission, record their perceptions after discharge from the hospital, and then to close the gap between them. This technique compares expectations with perceptions of service received across five broad dimensions of service quality, namely: tangibility; reliability; responsiveness; assurance; and empathy. This analysis covered 174 patients who had completed the SERVQUAL questionnaire, including patients who had had treatment in surgical, orthopaedic, spinal injury, medicinal, dental and other specialties in the West Midlands region. Recorded the average weighted NHS service quality score overall for the five dimensions as significantly negative. PMID- 10156538 TI - Using consumer feedback to improve services. AB - Describes how a consumer satisfaction survey was carried out at a community mental health centre and the improvements that occurred as a result. A questionnaire was designed to be delivered as a semi-structured interview to elicit the views and opinions of the clients. Their responses highlighted a number of positive areas about the centre, especially in terms of the staff and the therapeutic support they provide. The feedback also revealed a number of areas where improvements were needed. Reports on six recommendations which were made in terms of medication, activities, privacy, reviews, social service issues and complaints. The staff worked hard to implement a number of changes to improve the quality of the service they provide. The end result is that users' views and opinions have been integrated with the service design and delivery, making the centre a more user-friendly place. PMID- 10156539 TI - Continuity of care on admission to hospital: an audit of Airedale NHS Trust's transfer policy. AB - Describes an audit of interprofession communications among hospital, community health and social services concerning hospital admission. Information from 150 patient admissions (50 from each of three general practices after a target date) was gathered from both community and hospital sources. The results were used to audit the transfer policy operated by Airedale NHS Trust. The audit design incorporated an element of research, the results of which were used to inform the interpretation of the audit results and to suggest appropriate recommendations for change. Recommendations included the introduction of a pre-admissions checklist, specific changes to the nursing documentation, measures to improve the speed of information transfer, and the clarification of responsibilities for initiating contact across the hospital-community interface when patients with existing contacts in community services are admitted to hospital. Concludes that the introduction of supplementary research to an otherwise traditional audit cycle strengthened the resulting recommendations. PMID- 10156540 TI - Assessment of medical technology and the challenge for health reform in Africa. AB - Introduces an African perspective to existing research and scholarship on the relationship between western medical technology and health care planning in Africa. Examining the broader issues of development and underdevelopment, contends that the present health care system, fashioned after western medical systems (focusing on hospital and curative care), has failed to make significant impact by reducing mortality rates in Africa. Describes the already precarious health conditions in Africa and argues that, while Africa can benefit from the application of western medical technology, the irrelevance of current strategies to people's needs and the widespread abuse of medical resources have rendered western technology ineffective in Africa. Concludes by calling for the creation of a council of technological assessment in Africa to review requirements and recommend to African governments appropriate and efficient medical technologies to meet the health needs of Africans. PMID- 10156541 TI - Problem-based medical education in general practice and health care quality assurance. AB - States that health systems globally are in transition, for which also a correspondingly reformed education is required, involving new--and renewed--basic sciences, principles, skills and methods. To that end, demonstrates how problem based learning in general practice is almost ideal, although still sparsely implemented, and has much in common with health care quality assurance. Contends that primary care in many ways comprises the most important platform and vehicle of modern health services and their interaction with the population. Uses the example of the Faculty of Health Sciences in Linkoping, where all curricula are integrated, community-oriented, problem-based and have a focus on primary care and general practice. Represents a useful and hitherto insufficiently recognized widening of the overall field of health care quality assurance, and summarizes some of the experiences therein. Also provides a brief overview of the literature. PMID- 10156542 TI - Quality assessment and patient participation in care by means of a touch-screen computer. AB - Hospital characteristics vary greatly across a geographic area such as a state. Hospital peer groups internally exhibit similar characteristics and can be used as a basis for the analysis of data, the dissemination of information, and the adoption of continuous quality improvement project results. This paper reflects the efforts made toward the identification of hospital peer groups within the state of Michigan. Hospital characteristics data for fiscal year 1992 were obtained from the American Hospital Association's Annual Survey of Hospitals and the Health Care Financing Administration's MEDPRO database. Thirteen peer group clusters have been identified, reviewed, and commented on by the state's hospital association and have met general approval by hospital administrators across the state. The established peer groups are being used to identify the differences in patterns of care among hospitals in the state. The peer groups also are being used for the feedback of comparable data and the identification of hospitals for participation in continuous quality improvement projects. The next research objective is to experiment with other clustering techniques and other inpatient populations. The consistency of the peer groupings across all clustering techniques and across both Medicare and total inpatient populations will be studied. PMID- 10156543 TI - Inpatient treatment patterns of human immunodeficiency virus-associated Pneumocystis carinii pneumonia in New York State Medicare patients. AB - Hospital charts were reviewed to ascertain the frequency with which patients with human immunodeficiency virus (HIV)-associated Pneumocystis carinii pneumonia (PCP) were being managed in accordance with current guidelines or recommendations in New York State for the calendar year 1993. Comparisons were made between hospitals that are designated by the New York State Department of Health as comprehensive treatment centers--designated acquired immunodeficiency syndrome (AIDS) centers--and all other hospitals. For patients who had been on PCP prophylaxis before admission, 34% had documentation of positive histologic evidence for PCP infection during the studied hospitalization period. Of all patients not on PCP prophylaxis at the time of admission, 94% had at least one of the diagnostic tests for PCP done during the PCP hospitalization. Eighty-one percent of all patients had either pulse oximetry or an arterial blood gas determination. Seventy-seven percent of all patients with a PO2 equal to or less than 70 mm Hg received steroids. All eligible patients received one of nine possible treatment combinations, which included either single drug therapy, multiple drug therapy, or participation in a clinical trial. Sixteen percent of eligible patients had no documentation of receiving PCP medication at discharge. Proportions receiving diagnostic or treatment interventions were usually higher in designated AIDS centers than in non-designated AIDS centers. PMID- 10156544 TI - Assessing the quality of project data by means of a data sufficiency categorization scheme. AB - Improving the quality of gathered or abstracted data is often an important part of a quality improvement project's early stages. This is especially so if indicators will be compared across providers or if various data elements will be used for severity adjustment. One common data problem is missing data. This paper describes a flowchart-based approach for assessing the magnitude of missing data problems. The approach is demonstrated by means of two indicators currently used in multihospital cooperative improvement projects. The approach results in assigning each observation (e.g., patient record) in a sample into one of five data categories. These categories follow standard definitions advanced by the Joint Commission on Accreditation of Healthcare Organizations. Two of the categories tally observations with missing data problems. Assessment of missing data can be viewed as one component of reliability assessment, and its relationship to other forms of reliability assessment is discussed, with emphasis on the relationship to interrater agreement. PMID- 10156545 TI - Characteristics of hospitals providing preventive services: does delivery system integration make a difference? AB - OBJECTIVE: As health care organizations consolidate into integrated delivery systems, increased delivery of preventive services is expected. The study objective was to evaluate the impact of hospitals' participation in multiorganizational arrangements and managed care on their delivery of preventive services. METHOD: The study is a secondary data analysis of data in the American Hospital Association 1993 Annual Survey of Hospitals Data Base. Two primary prevention variables (health promotion services to patients and to community members), and one secondary prevention variable (screening mammography) were included. Hospital characteristics included ownership, bed-size, and integration participation in a multiorganizational arrangement and having managed care (HMO and PPO) contracts. RESULT: The 5,387 general medical and surgical hospitals responding to the 1993 survey were included in the analysis. Proportions of hospitals reporting delivery of health promotion services to patients, and to community members, and screening mammography services were respectively 90%, 83%, and 88%. Hospitals reporting participation in multiorganizational arrangements were more likely to report delivery of preventive services after adjusting for bed-size. The bed-adjusted odds ratios for providing health promotion services to inpatients, and to members of the community, and screening mammography services in hospitals with managed care contracts versus those without managed care contracts were respectively: 2.72 (95% CI: 1.65, 2.50), 2.03 (1.63, 2.53), and 1.51 (1.26, 1.81). CONCLUSION: Preliminary findings from this secondary data analysis support the expectation that current changes in the health care delivery system may expand the delivery of preventive services. PMID- 10156546 TI - Hospital responses to a data-driven statewide quality improvement project. AB - BACKGROUND: The overall success of any continuous quality improvement (CQI) project lies in the ability to measure changes resulting from the project and to show that changes have resulted n improved care. METHOD: A software tool was developed to categorize hospital responses and activities implemented by hospitals as a result of the Cooperative Cardiovascular Project CCP). Information was captured regarding the hospital's acceptance of data and the educational/interventional strategies implemented. Hospital size, number of acute myocardial infarction patients treated, indicator performances, and type of presentation given (on-site versus regional visit) was entered to allow analysis of factors affecting the response. RESULT: sixty-one of 107 hospitals responded to the peer review organization. Of those, 49% planned further educational activities and 75% planned to implement some form of CQI activity. Comparison of responses in relation to the type of presentation received suggested that on-site presentations are associated with higher response rates and more intense quality improvement efforts. This also could be attributed to other factors such as hospital size, teaching environment, or number of acute myocardial infarction patients treated. CONCLUSION: The system developed allowed us to collate hospital improvement efforts as a result of CCP. The system is limited in its ability to identify those activities taking place before CCP. Further development and refinement of the tool is warranted to document quality improvement efforts and determine best strategies for peer review organization intervention. PMID- 10156547 TI - In search of psychiatric performance measures. AB - The purpose of this article is to relate the experiences of a panel of industry experts and Maryland Hospital Association (MHA) staff who worked together to develop and pilot test a set of comparative performance indicators for psychiatric care. MHA's experiences with the Quality Indicator Project served to provide a sound structure for indicator development and testing. This paper explores the premise on which the indicator set was developed, the work of the expert panel, and the participation and contribution of the pilot sites. PMID- 10156548 TI - Opportunities for improving the care of patients with community-acquired pneumonia. AB - In Missouri, community-acquired pneumonia is the second leading cause of hospital admission in the Medicare population. Analysis of 1993 discharges revealed that more than 18,000 Medicare patients were admitted to acute care hospitals with a principal diagnosis of pneumonia. Statewide, the case fatality rate for these admissions was 9.6%, with an average length of stay of 8.2 days. Under the auspices of Medicare's Health Care Quality Improvement Program, the Missouri Patient Care Review Foundation (MPCRF) collaborated with five hospitals in the state on a project to enhance the outcomes and quality of care for patients admitted with community-acquired pneumonia. Narrowing the focus to bacterial community-acquired pneumonia, the five hospitals agreed to collect data, for a specified period, on each Medicare patient admitted with this diagnosis. The hospitals were encouraged to implement recommended critical pathways and guidelines for the initial management and treatment of community-acquired pneumonia. MPCRF assumed responsibility for data management activities for the project as well as production of feedback reports that were shared routinely with the hospitals. Although evaluation of the project continues, preliminary analysis of claims data for admissions occurring after process changes were implemented indicates that there has been improvement in the two outcome measures, patient mortality and length of stay. These results suggest that monitoring of key process indicators, coupled with ongoing analysis and feedback, has potential for facilitating positive change in the quality of care for patients with community acquired pneumonia. PMID- 10156549 TI - Developing quality of acute care indicators through claims data augmentation. AB - OBJECTIVE: To demonstrate the use of quality indicators developed through claims data augmentation. METHOD: A retrospective examination of field-tested acute care quality indicators and methods used in developing them to identify opportunities for quality improvement was used. The settings were 46 acute care hospitals and physician staffs serving Medicare beneficiaries in Vermont and New Hampshire, with more than 60,000 Medicare inpatient admissions per year. The objective was to measure hospital and provider initiatives in quality improvement projects. RESULT: More than 100 projects have been developed from hospital-specific comparative analyses and presentations about peer group profiles on indicator and outcome variables. Successfully completed projects have resulted in significant improvements in patient out comes, including reduced acute myocardial infarction mortality, reduced rates of discharges against medical advice, and increased use of pressure sore prevention and prophylactic antibiotics guidelines. CONCLUSION: Certain essential enabling data elements permit construction of a credible claims based acute care quality indicator dataset. Unique individual patient identifiers and validated deaths are essential for conducting readmission and mortality analyses, respectively. Risk adjustment is necessary for making provider comparisons on indicators influenced by patient severity of illness. Cross validation of outcome patterns with multiple indicators, and project successes have built provider interest and confidence in the use of such a data base. PMID- 10156550 TI - Creation of hospital peer groups. AB - Hospital characteristics vary greatly across a geographic area such as a state. Hospital peer groups internally exhibit similar characteristics and can be used as a basis for the analysis of data, the dissemination of information, and the adoption of continuous quality improvement project results. This paper reflects the efforts made toward the identification of hospital peer groups within the state of Michigan. Hospital characteristics data for fiscal year 1992 were obtained from the American Hospital Association's Annual Survey of Hospitals and the Health Care Financing Administration's MEDPRO database. Thirteen peer group clusters have been identified, reviewed, and commented on by the state's hospital association and have met general approval by hospital administrators across the state. The established peer groups are being used to identify the differences in patterns of care among hospitals in the state. The peer groups also are being used for the feedback of comparable data and the identification of hospitals for participation in continuous quality improvement projects. The next research objective is to experiment with other clustering techniques and other inpatient populations. The consistency of the peer groupings across all clustering techniques and across both Medicare and total inpatient populations will be studied. PMID- 10156551 TI - Linking mortality data with hospital morbidity data--a pilot study. AB - Record linkage is becoming an increasingly important technique in moni toring health outcomes. In this study we wought to examine the feasibility of linking mortality data held by the Registry of Birth, Deaths and Marriages with the Patient Master Index (PMI) at St. Vincent's Hospital, Melbourne, in order to document deaths soon after hospital discharge. Linkage was carried out using demographic details. Registry data required extensive editing and formatting prior to being matched with the PMI. 86.2% of cases identified by the computer algorithm were actual cases. Mortality data are an important source of information on health outcome but a process is needed to make them more usable. We have described one such method and suggested where the process could have been streamlined. The use of unique identifiers would have facilitated the matching process, curtailing several processing steps. PMID- 10156552 TI - Another day, another hospital, another town--a postcard from a health information manager in a small district hospital. PMID- 10156553 TI - Privacy and data collection: striking the balance. PMID- 10156555 TI - Revision of airman medical standards and certification procedures and duration of medical certificates--FAA. Final rule. PMID- 10156554 TI - Putting the 'status' back into health measurement. PMID- 10156556 TI - Friendly fire over health insurance. PMID- 10156557 TI - Expanding Medicare managed care. PMID- 10156558 TI - The new medical record and tools for its optimization. PMID- 10156559 TI - Assuring quality in managed care. PMID- 10156560 TI - Hospital technology assessment: Part I. PMID- 10156561 TI - Information technology must lead the way. PMID- 10156562 TI - Rural hospitals prepare for impending managed care. PMID- 10156563 TI - The bottom line: a look at one nonprofit's donations to the community. PMID- 10156564 TI - Immunize by two in Kalamazoo. PMID- 10156565 TI - Working across barriers. Facilitating the development of healthy communities. PMID- 10156566 TI - An eye toward the future. PMID- 10156567 TI - Serving populations in need ... without reinventing the wheel. PMID- 10156568 TI - Community benefits. Discussion. PMID- 10156569 TI - Taking care of the caretaker. PMID- 10156570 TI - Knowing is half the battle. PMID- 10156571 TI - A commitment to learn. PMID- 10156572 TI - The "new" choice: profit or tax-exempt nonprofit organization? PMID- 10156573 TI - Managing violence in the ED crucial to providing top-notch patient care. PMID- 10156574 TI - HCFA final rule: ED physicians can be paid for reading X-rays, EKGs. PMID- 10156575 TI - Beyond prescription benefits management: the systems approach to patient and pharmaceutical care. PMID- 10156576 TI - Coordination-of-leave benefits: an important component of preventing employee abuse of the Family and Medical Leave Act. PMID- 10156577 TI - Marketplace morality and managed care--will the "cure" prove worse than the "disease"? PMID- 10156578 TI - A total quality management approach to infection control. PMID- 10156579 TI - Using operational benchmark data for strategic cost management. PMID- 10156580 TI - Developing a managed care marketing plan. PMID- 10156581 TI - Operational assessments: a must for gauging practice efficiency. PMID- 10156582 TI - Finding relief from TEFRA cost limits. AB - The Tax Equity and Fiscal Responsibility Act (TEFRA) limits cost-per-case rate increases for inpatient care delivered by healthcare providers excluded from Medicare's prospective payment system. Costs beyond these limits normally are not reimbursed. Under certain circumstances, however, healthcare providers can receive reimbursement beyond TEFRA limits by petitioning for an adjustment from their fiscal intermediaries and the Health Care Financing Administration. Although the request process often is lengthy, providers who can thoroughly document substantial increases in the cost of delivering care due to extraordinary circumstances, significant wage, increases, or noncompatibility of cost-reporting periods may be granted relief in the form of a rate adjustment and, in rare cases, the assignment of a new base year. PMID- 10156583 TI - Refinancing Medicaid: one state's approach. AB - In recent years, The Colorado Medicaid Program has initiated a number of new and innovative disproportionate share payment plans for hospitals. These initiatives are designed to increase access to hospital care for Colorado citizens, to ensure the future financial viability of key safety net hospitals, and to partially offset the state of Colorado's cost of funding the Medicaid program. Between 1991 and 1994, a net of $174 million in disproportionate share hospital payments was distributed to Colorado hospitals. A combination of hospital donations, voluntary contributions, intergovernmental agency transfers, and provider taxes raised a total of $579 million. The state of Colorado received $128 million through these special refinancing efforts. These payment efforts have had a major financial impact, and despite recent changes in Federal limitations on payments, other states may find a theoretical template for refinancing efforts in the Colorado model. PMID- 10156584 TI - How to obtain a Medicare risk contract. AB - About 3.6 million Medicare beneficiaries--10 percent of the Medicare population- receive Part A and Part B benefits through health maintenance organizations (HMOs). Beneficiaries are spread unevenly among one-third of the nation's 575 HMOs, with four California HMOs accounting for almost 30 percent of all Medicare enrollees. HMO involvement in Medicare has increased steadily since 1993 and may continue to do so over the next few years for two main reasons. First, the HMO industry is committed to increasing its penetration of the Medicare market. Second, enactment of legislation now before Congress would modify payment formulas and regulatory requirements that prevent many HMOs from applying for Medicare contracts. Enactment also would permit a wider array of health plans to contract with Medicare. HMOs must meet Federal requirements and undergo a contracting process to obtain Medicare risk contracts. Proposed Federal legislation suggests tht most of the existing requirements will apply to the revised and expanded Medicare contracting opportunities. The accompanying recommendations should help HMOs expedite the application and approval process. PMID- 10156585 TI - HMO strategies for managing workers' compensation claims. AB - Health maintenance organizations (HMOs) have become very active in managing workers' compensation medical expense benefits. A survey of 316 HMOs shows that this activity takes the form of various network models and a range of services- such as utilization review and case management--that may not be linked to a provider network. Of the HMOs surveyed, 78 reported that, by using managed care services and provider discounts, they were able to save from 20 percent to 30 percent on occupational health claim costs. PMID- 10156586 TI - Implications of the SEC's final continuing disclosure rule. AB - The Securities and Exchange Commission's (SEC's) final disclosure rule affects healthcare providers who have $10 million or more in bonds outstanding and providers that plan to be active in the bond market in the future. As managed care providers, HMOs come under the jurisdiction of the rule and are required to expand their reporting of financial information and operational data to include secondary market bond purchasers. The SEC's broadened disclosure rule significantly affects the financial reporting practices of healthcare providers involved in capitated contracting--especially the areas of contract reporting, confidentiality of information, and catastrophic case loss reporting. PMID- 10156587 TI - What providers need to know bout the False Claims Act. AB - In the 1990s, the Federal government's antifraud efforts increasingly have focused on the healthcare industry, and the False Claims Act, a powerful law designed to curb fraud against the Federal Treasury, has been one of the government's most potent weapons. One reason for the act's potency is its qui tam provision, which encourages whistleblowers to expose fraud in return for a substantial percentage of money the government recovers. The False Claims Act has been used against healthcare providers in the following areas: billing for services or supplies not actually provided, billing for nonreimbursable services, using false diagnoses to justify claims, and cheating in government performance evaluations. PMID- 10156588 TI - Using MVA and EVA to measure financial performance. AB - Two measures of financial performance that are being applied increasingly in investor-owned and not-for-profit healthcare organizations are market value added (MVA) and economic value added (EVA). Unlike traditional profitability measures, both MVA and EVA measures take into account the cost of equity capital. MVA is most appropriate for investor-owned healthcare organizations and EVA is the best measure for not-for-profit organizations. As healthcare financial managers become more familiar with MVA and EVA and understand their potential, these two measures may become more widely accepted accounting tools for assessing the financial performance of investor-owned and not-for-profit healthcare organizations. PMID- 10156589 TI - First steps in managed care EDI. PMID- 10156590 TI - Job search 2000: dramatic changes are ahead. PMID- 10156591 TI - Data trends: March 1996. PMID- 10156592 TI - Recent court decisions expand merger possibilities. PMID- 10156593 TI - Establishing risk-sharing mechanisms. PMID- 10156594 TI - Assessing the financial feasibility of outsourcing. AB - Healthcare organizations frequently outsource support services--such as housekeeping, laundry, and collections--to manage costs while maintaining or improving quality. When evaluating the financial feasibility of outsourcing, financial models can be helpful in measuring the cost to the organization of the service being targeted for outsourcing. The financial model described in this article incorporates the direct costs of the targeted service and the hidden costs incurred by other departments that contribute to the service's operations. It thus provides comprehensive financial information that can be used reach more informed outsourcing decisions. PMID- 10156595 TI - Can MSAs help reduce healthcare costs? AB - Medical savings accounts (MSAs) have been proposed as one possible solution to the problem of escalating healthcare costs. Because MSAs allow consumers to shop for healthcare services and negotiate the cost, MSAs have the potential to restrain the rise in medical costs. This article compares MSAs to traditional insurance plans, highlighting the advantages and disadvantages of MSA. PMID- 10156597 TI - Keys to career success in managed care. AB - Given the prominence that managed care will have in the future U.S. healthcare system, financial managers who want to advance their careers must take steps to hone their managed care knowledge and skills, become accomplished managed care strategists, and identify opportunities to gain expertise in the managed care field. Healthcare Financial Management interviewed a number of managed care experts to obtain their views on how healthcare financial managers can prepare for a career in managed care organizations. The experts agree that one of the keys to future success lies in financial managers' willingness to assume more and different types of responsibility than before as the shift to managed care continues. PMID- 10156596 TI - Providing cost data to physicians helps contain costs. AB - Findings of a survey of 1,200 physicians suggest that healthcare organizations that provide physicians with pricing information can reduce resource utilization and control costs more effectively than organizations that do not provide such information. These findings also suggest that healthcare financial managers who are aware of physicians' responses to cost information--and who furnish them with effective cost information--may gain a timely competitive advantage. PMID- 10156598 TI - IDS technology management strategies. AB - The formation of integrated delivery systems has created new challenges for healthcare financial managers. Among these challenges is the need to respond to cost-cutting pressures related to technology acquisition, financing, and management. A well-developed technology management strategy can reduce technology costs and risks, free up capital for other strategic uses, and maintain the system's ability to adapt to change. PMID- 10156599 TI - Overcoming challenges to tax-exempt status. AB - The tax-exempt status of not-for-profit healthcare organizations increasingly is being challenged by private, for-profit, investor-owned organizations. Often, the business practices of not-for-profit organizations are virtually indistinguishable from those of for-profit organizations, and not-for-profit organizations sometimes provide less charity and unfunded care than their for profit competitors. Moreover, the tax subsidies not-for-profit organizations sometimes are used to support activities that compete with those of for-profit organizations. To withstand challenges to their tax status, financial managers in not-for-profit organizations should assume an active role in developing clearly articulated, empirically based information about the extent of community benefit their organizations provide and its value. PMID- 10156600 TI - How will AICPA proposed guides affect providers? AB - Two newly proposed American Institute of Certified Public Accountants audit guides--one for healthcare organizations and one for not-for-profit organizations -will require changes in accounting and financial reporting. The proposed guides cover topics such as flexibility in format and terms, functional and natural classification of expenses, differentiating revenue from gains, and rules relating to long-lived assets. PMID- 10156601 TI - The "other" payment standard. PMID- 10156602 TI - Caution: downsizing ahead. PMID- 10156603 TI - Data trends. April 1996. PMID- 10156604 TI - Physician employment experiences in health maintenance organizations: analysis of an urban HMO. PMID- 10156605 TI - How consumers view chiropractic advertising. AB - Chiropractic, as a medical profession, is finally receiving acceptance from the American Medical Association (AMA) and other medical groups. However, what do consumers think about chiropractors and how do they respond to the advertising efforts of chiropractors? This paper presents the findings of a survey concerning consumers' opinions of advertising by chiropractors. Although the opinions of the respondents were mixed, an analysis of the results of the survey suggests important implications for chiropractors and other medical practitioners who wish to use advertising media in marketing their services. PMID- 10156606 TI - Managed care positives and negatives for health care marketing. PMID- 10156607 TI - Providing services to obstetrical patients: an overview and implications. AB - Obstetrics is one of the few hospital services with the potential for developing favorable client relationships resulting in increased market share, repeat purchase behavior, and referral of other patients in a direct marketing environment. To determine what qualities women find appealing in an obstetrics service and if women's preferences for a specific type of birthing arrangement had been examined and reported, a review of the literature was carried out. After reviewing the extant literature, the article provides strategic implications for health care marketers. PMID- 10156608 TI - A comparison of hospice gatekeepers: do they have the necessary information to refer? PMID- 10156610 TI - Supermodels: the vital statistics. PMID- 10156609 TI - Consumer product branding strategy and the marketing of physicians' services. AB - Hospitals have traditionally maintained physician referral programs as a means of attracting physicians to their network of affiliated providers. The advent of managed care and impending healthcare reform has altered the relationship of hospitals and physicians. An exploratory study of marketing approaches used by twelve healthcare organizations representing twenty-five hospitals in a large city was conducted. Strategies encountered in the study ranged from practice acquisition to practice promotion. This study suggests that healthcare providers might adopt consumer product branding strategies to secure market-share, build brand equity, and improve profitability. PMID- 10156611 TI - Freemasonry. Hear, see, be silent. PMID- 10156612 TI - Emergency admissions. In the bleak mid-winter. PMID- 10156613 TI - Psychiatric care. Moving house. PMID- 10156614 TI - Elderly care. Step forward. PMID- 10156615 TI - Service development. Take it from the top. PMID- 10156616 TI - MBAs: are they worth the paper they're printed on? Open learning. Open all hours. PMID- 10156617 TI - MBAs: are they worth the paper they're printed on? Training for doctors. Method in the madness. PMID- 10156618 TI - MBAs: are they worth the paper they're printed on? Primary care. Primary education crisis. PMID- 10156619 TI - MBAs: are they worth the paper they're printed on? Career management. Circle of friends. PMID- 10156620 TI - MBAs: are they worth the paper they're printed on? A qualified success? PMID- 10156621 TI - French healthcare. Les miserables: what drove French doctors onto the streets? PMID- 10156622 TI - Psychiatric services. About FACE. PMID- 10156623 TI - First person. Personal effects. PMID- 10156624 TI - Too much of a bad thing. PMID- 10156625 TI - Burning the seed corn. PMID- 10156626 TI - Pride and prejudice. PMID- 10156627 TI - Competitive strategies for the next generation of managed care. PMID- 10156628 TI - Life-enhancing design. PMID- 10156629 TI - Meeting the value test. PMID- 10156630 TI - The view from bed number ten. PMID- 10156631 TI - Hearing the tidal wave. PMID- 10156632 TI - Cost-effectiveness and the socialization of health care. AB - The more health care is socialized, the more cost-effectiveness is an appropriate criterion for expenditure. Utility-maximizing individuals, facing divisibility of health care purchases and declining marginal health gains, and complete information about probable health improvements, should buy health care according to its cost-effectiveness. Absent these features, individual health spending will not be cost-effective; and in any case, differences in personal utilities and risk aversion will not lead to the same ranking of health care interventions for everyone. Private insurance frees consumers from concern for cost, which undermines cost-effectiveness, but lets them emphasize effectiveness, which favors value for money. This is most important for costly and cost-effective interventions, especially for poor people. Cost-effectiveness is more appropriate and easier to achieve under second-party insurance. More complete socialization of health care, via public finance, can yield greater efficiency by making insurance compulsory. Cost-effectiveness is also more attractive when taxpayers subsidize others' care: needs (effectiveness) take precedence over wants (utility). The gain in effectiveness may be greater, and the welfare loss from Pareto non-optimality smaller, in poor countries than in rich ones. PMID- 10156633 TI - Abnormal economics in the health sector. AB - The implosion of centrally-planned economies has led to a widespread and uncritical belief that a free market is the best mechanism for structuring the economic and social sectors. Many international agencies have pushed this belief on the developing nations. This paper offers a critical analysis of the effectiveness of using free market principles to structure the health sector. We try to answer two questions: in what spheres can the market operate freely? In what spheres is government action required? According to economic theory, the market is only appropriate for producing and distributing private goods. This study analyzed health care and subdivides it into three categories (public, merit, and private goods) to clarify where the market has a legitimate role. Next, we analyze two of the five markets in the health sector--financing and delivery--and assess the respective roles of the market and government Competitive markets have certain prerequisites. We identify the major market failures by evaluating where these conditions are not satisfied. Next, we draw on international experience to ascertain the seriousness of those failures and the capacity of government action to correct them. Lessons are drawn for developing nations about the appropriateness of market strategies to finance and deliver health care. PMID- 10156634 TI - Health sector reform: making health development sustainable. AB - Health sector reform is underway or under consideration.in countries throughout the world and at all levels of income. This paper presents an overview of key concepts and approaches to health sector reform in developing countries. Reform implies sustained, purposeful, and fundamental changes in the health sector. While it is difficult to define precisely what constitutes a true reform, there is widespread consensus that reform is a process of change involving the what, who, and how of health sector action. Health is increasingly included as an important goal of national development. It can make development more sustainable. The paper outlines some general and specific health sector reform strategies that can contribute to sustainable development for countries at all levels of income, although the strategies will differ in content and emphasis. Health sector reform should be based on an holistic view of the health sector. The paper presents two frameworks to aid in reform design: one highlighting the linkages between different institutional actors in the health sector; the second addressing linkages across different functional areas of reform action. In order to develop and carry out reform, information and analysis is needed. A variety of practical tools now available for this purpose are discussed, encompassing all the different areas of action. While tool development should continue, reform proponents already have much to work with. Given global interest, the importance of health sector reform in development strategies, and significant existing knowledge and experience, country level analysis and action should proceed vigorously. PMID- 10156635 TI - Market reforms in health care and sustainability of the welfare state: lessons from Sweden. AB - Reforming health care systems which are predominantly publicly provided and financed has usually been motivated as a way of increasing efficiency even if it seldom is explicit whether it is in the official sense related to individual utility or in the unofficial sense related to health outcomes. In the case of Sweden the welfare state has been made politically sustainable through a construction where cash benefits and service provision are tailored to satisfy not only the basic needs but even the more discriminating needs of the middle classes. Their loyalty with the taxes is politically crucial and therefore their evaluation of the services in the welfarist sense equally important. That loyalty was however threatened in a situation where cost-containment policies were applied while equity principles were still a strong priority. Health care utilization was increasing among the very old and chronically ill while it was decreasing for other groups. The reforms introduced in some counties during the 1990s have been focussing on a purchaser-provider split and fee-for-service payment of providers. They have increased productivity sharply, increased utilization even among the groups that previously were 'pressed out' and reduced waiting lists. Increased efficiency however, threatens equity in some specific aspects. Fee-for-service payment means increased production and so far even increased costs. If they are to be met with increased private financing, rather than with present tax financing, it will bring the risk of inequities. Payment of hospitals through DRG systems means payment to providers for medical interventions with no incentives to deal with social consequences of illness. Inequities in health care can be related to the way health care deals with inequalities in health due to inequalities in living conditions or inequalities in living conditions due to ill health. In the short perspective the reforms may threaten equity in the second aspect, in the longer perspective the problems of cost control and the pressure it raises for alternative financial sources may be a more serious risk even for the former. PMID- 10156636 TI - Chile's health sector reform: lessons from four reform periods. AB - This paper applies an interdisciplinary approach to analyze the process of health reform in four significant periods in Chilean history: (1) the consolidation of state responsibility for public health in the 1920s, (2) the creation of the state-run National Health Service in the 1950s, (3) the decentralization of primary care and privatization of health insurance in the 1980s, and (4) the strengthening of the mixed public-private market in the 1990s. Building on the authors' separate disciplines, the paper examines the epidemiological, political and economic contexts of these reforms to test simple hypotheses about how these factors shape reform adoption and implementation. The analysis underlines: (1) the importance of epidemiological data as an impetus to public policy; (2) the inhibiting role of economic recession in adoption and implementation of reforms: and (3) the importance of the congruence of reforms with underlying political ideology in civil society. The paper also tests several hypotheses about the reform processes themselves, exploring the role of antecedents, interest groups, and consensus-building in the policy process. It found that incremental processes building on antecedent trends characterize most reform efforts. However, interest group politics and consensus building were found to be complex processes that are not easily captured by the simple hypotheses that were tested. The interdisciplinary approach is found to be a promising form of analysis and suggests further theoretical and empirical issues to be explored. PMID- 10156637 TI - New methods of financing and managing health care in the Russian Federation. AB - Poor outcomes in Russian Federation health care performance have led to greater efforts being devoted to the search for new methods of finance and management. The new financial and managerial scheme was designed to introduce elements of market relations into a highly bureaucratic system. Strengthening the primary care sector and granting providers more economic freedom were intended to increase the quantity and quality of medical care, and make it more accessible to the population. In the late 1980s, economic experiments started in several regions of the country. This paper highlights the new methods of management, payment of providers, and quality assurance that were the focuses of the experiments. The impact of the experiments will be discussed. PMID- 10156638 TI - Reform of the Chinese health care financing system. AB - The radical changes which have been taken place in the Chinese economy since the late 1970s have influenced the health sector and the health care financing system. A rapid increase in medical care costs in the last decade has placed a heavy financial burden on the government and enterprises and a vast majority of the rural population. The public service medical scheme for government employees and labor insurance for enterprise workers are facing a great challenge of cost containment through a series of reforms in the mechanisms of fund collection and management. In the meanwhile, the collapse of the cooperative medical care scheme in most rural areas has raised the issue of gaining access to basic health care for the rural population and in particular the poor. This paper provides a description, with some explanation, of how and why the health care financing system had been changed and experienced such a sharp increase in expenditure. In conclusion, how to develop and improve a financing system appropriate to the level of socio-economic development in China is addressed. PMID- 10156639 TI - Have structural adjustments led to health sector reform in Africa? AB - This paper explores the issue of whether and how structural adjustment in Sub Saharan Africa has altered the level and nature of state involvement in the health care system. Stabilization and structural adjustment generally entail a reduction in aggregate demand, especially government spending, and a reduced role for the state in the provision of many goods and services. Consequently, there is an a priori concern that stabilization and adjustment in Africa may have resulted in lower health expenditures with deleterious effects on the health status of the population, particularly the poor. This paper concludes that structural adjustment programs in Africa did not reduce public health expenditures. In fact, many countries experienced higher real expenditures after adjustment. The fact that many indicators of health status deteriorated during the 1980s, however, presents somewhat of a paradox given the patterns of health expenditures. This paradox is resolved, by an investigation of the intrasectoral allocation of health expenditures which reveals that there are systematic biases in public expenditures towards tertiary and curative care, and a general weakness in the public sector's capacity to deliver adequate health care services even with higher real health sector budgets. In many countries, these biases have persisted despite government and donor intentions to promote health care reform. Finally, the paper reviews a set of policy and institutional issues which hinder the efficient use of budget resources, including overcentralization of health care administration, inappropriate drug and supply procurement practices, the lack of mechanisms for cost recovery, and poor organization, financial and personnel management. At each level of analysis, the paper catalogs those instances where progress is being made towards effective health care reform, including intrasectoral budget rationalization, administrative decentralization, the adoption of user fees for cost recovery, privatization in service delivery, particularly through non-governmental organizations, and organizational and management reform. PMID- 10156640 TI - Health sector reforms in sub-Saharan Africa: lessons of the last 10 years. AB - Over the past 10 years the poorest countries, especially in Africa, have struggled with worsening economic conditions and reduced public finance for health services. Some governments have responded in a piecemeal fashion, reacting to internal and external pressures. Others have embarked on major reforms of various aspects of their health systems. This paper reviews two specific types of strategy that have been initiated by governments: reform of financing strategies, and reform of public sector organization and procedures. Particular attention is paid to the experience of introducing user fees, community financing and decentralization since these have been some of the most popular strategies. The paper describes the nature, objectives and extent of reforms. It then presents an evaluation framework related to the criteria of efficiency and equity, and evaluates current reform experience using this framework. It concludes that assessment of the potential impact of reforms on efficiency and equity is undermined by the limited duration of many reforms and the limited nature of existing evaluations. It is clear, however, that a policy package is required rather than implementation of isolated reform strategies, and that in order to design an effective policy package, more needs to be known about the implementation and operation of reforms--particularly with respect to the influence of context, actors and processes. PMID- 10156641 TI - Health care reform in Kenya: a review of the process. AB - The paper looks at the process of health care reform in Kenya during the past 30 years, with a focus on implementation strategies. The data are from official documents of the government. The main finding is that development plans served as the medium through which the government announced its intentions as well as its decisions to implement reforms. A decision to implement a reform was normally accompanied by an implementation budget, whereas an announcement of an intention typically lacked such support. Some of the reforms were implemented speedily and firmly, whereas others suffered delays and reversals. Reforms were implemented with speed and firmness when research provided clear guidance on key policy issues or when political will and skill existed. Donor influence on the timing of reforms might have been excessive. Policy lessons from the process are indicated. PMID- 10156642 TI - Comprehensive policy analysis for health system reform. AB - This article presents the results of a comprehensive approach to policy analysis that may serve as an input for health system reform. The comprehensive character of this effort stems from the attempt to combine, in a coherent framework, various analytical tools that have been developed recently, such as measurement of the burden of disease, cost-effectiveness analysis to integrate packages of essential interventions, national health accounts, assessment of system performance, consumer surveys, and political mapping. These tools were all applied in a study that was carried out in Mexico from August 1993 through September 1994. After explaining the logic of the study, the paper summarizes the findings and recommendations under five headings that shape the form of reform: the problems, the principles, the purposes, the proposals, and the protagonists. Rather than describing these various elements in detail, the paper focuses on the strategic aspects, which are most relevant to other countries currently planning or implementing reform initiatives. The article concludes that, under the current wave of international interest in health system reform, it is necessary to establish a mechanism for shared learning at the global level. Only in this way will it be possible to reproduce the analytical skills and accumulate the body of evidence that health systems require for their sustained improvement. PMID- 10156643 TI - Preconditions for health reform: experiences from the OECD countries. AB - This paper discusses the basic conditions necessary for the successful implementation of health sector reforms. Lessons from health sector reforms in the 24 western industrialized member countries of the Organization for Economic Cooperation and Development (OECD) are discussed and applied in the context of reform efforts in developing countries. Reform areas addressed include: public and private institutional infrastructure development, financing arrangements, benefit design, eligibility determination, reimbursement and cost control methods, and service delivery system configurations. PMID- 10156644 TI - Ends and means in public health policy in developing countries. AB - International discussions of public health policy strategies in developing countries have been characterized by strong and conflicting positions. Differences regarding the means of health sector improvement can often be traced to differences about the ends, that is, the goals of the health sector. Three types of health sector goals are reviewed: health status improvement, equity and poverty alleviation, and individual welfare (utility) improvement. The paper argues that all three must be considered in developing health sector reform strategies in all countries. Highly normative policy positions often can be attributed a unidimensional affiliation with one health sector goal and denial of the relevance of the others. The current global interest in using cost effectiveness analysis to set national health priorities is assessed in light of this eclectic approach. Examples are provided of how a health sector strategy based on cost-effectiveness would give sub-optimal solutions. These examples include situations where a private health care sector exists and provides some degree of substitution for publicly provided services; significantly high income elasticities exist for health care such that higher income beneficiaries may differentially capture public subsidies; and market failures exist in insurance. It is argued that these conditions are virtually universal in developing countries. Thus, rational policy development should explicitly consider multiple goals for the health sector. PMID- 10156645 TI - Data analysis needs for health sector reform. AB - This paper addresses the role of information in health policy reform. It recognizes that reform can be based on data, but that there are other influences on health policy. The steps involved in making policy, including problem identification, comparison of solutions, policy adoption, implementation, and amendment, all require information. When information is unavailable for any of these steps, the policy process sometimes proceeds without it. The policy makers must make difficult choices regarding the potential benefit of comprehensive information to the policy outcome versus the potential drawbacks, in terms of time and cost, of seeking the missing information. Different areas where data are needed within health policy are enumerated, as are sources of health policy data, and examples of strategies are given. Finally, three case studies are presented, highlighting the use of information in policy making. The National Epidemiology Board in Thailand commissioned studies by experts on relevant policy topics. It had a substantial impact on changing policies in the areas of AIDS control, iodine deficiency, essential drugs and vaccination. The attempt at decentralizing health administration to the province level in Papua New Guinea is the second example presented. At the time of the evaluation, this effort had not yet attained its objectives of improving the health of the people, nor had it reduced costs or lessened inequity among regions. If this reform had been tested in a pilot project, its problems may have been discovered at an earlier stage of implementation when they would have been easier to correct. The final case concerns the UNICEF child survival interventions during the 1980s. These interventions were chosen based on cost-effectiveness analysis and were successfully implemented. The use of cost-effectiveness analysis in prioritizing interventions is one example of the way in which information can improve policy and health outcomes. PMID- 10156646 TI - Special issue: Health sector reform in developing countries: making health development sustainable. PMID- 10156647 TI - What can developing economies learn from health system reforms of developed countries? AB - This paper outlines some general lessons developing nations can draw from the health system reform experiences of developed nations. Using the experiences of developed countries, developing countries should be better able to anticipate socio-economic changes and choose an optimal path for their health systems development to accompany those changes. Most developed countries have adopted rather common objectives and principles in their health systems because of market failure in health care; developing countries may start adopting those principles because they do not have market conditions in the first place. It is suggested that developing countries strengthen what is probably the most fundamental initial systemic asset they have: public finance. They should do so by attracting democratically, possibly through earmarked taxes, resources otherwise channelled through the private sector, competing with public finance for limited real resources. This effort can be promoted by giving consumers, mainly of high income groups and in urban areas, more say (through institutions performing the OMCC function) in the nature of care these groups have access to under auspices of public finance. Where feasible, private insurance as a major source of finance should be seen as a transitional phenomenon, giving way to the emergence of OMCC institutions which require similar financial and managerial market infrastructure. Private and competitive provision of care may be unrealistic in many developing areas because of both scarcity of real resources, mainly manpower, and health needs. The challenge of government is, as resources grow, to divest itself from the provision of care and stay involved in activities and facilities that are of 'public nature'--under specific circumstances--that foster private competitive provision. In general, the government should play an enabling role also by investing in health promotions and management skills for health systems. PMID- 10156648 TI - Toward an analytical approach to health sector reform. AB - An analytical approach to health sector reform requires definition of the objectives of the health sector. Although a multiplicity of objectives may be appealing, there are compelling analytical reasons for simplicity. It is argued that a health status maximization objective is a widely acceptable choice, which captures most of the important aspects of utility maximization of relevance for health sector reform. Equity can be addressed in the process of aggregating individual outcomes. The widely recognized need for health sector reform in developing countries constitutes, in itself, evidence of the market failures in the health sector. If the market worked, why would we need reform? Given an objective and a justification for reform, analysis should proceed to address measurement questions and intervention strategies. The disability-adjusted life year lost is proposed as a consistent and feasible measure of health. Based on an optimization model of health sector performance in Africa, the paper discusses interventions to improve allocative and technical efficiency. These are broadly characterized as interventions dealing with lack of knowledge and interventions dealing with institutional shortcomings. They lead to different approaches to health sector reform. The paper concludes that we now have a systematic analytical approach to reform, in which tools and methods for addressing information gaps are well developed and need to be more widely applied, while those addressing institutional failures still need further development and application. PMID- 10156649 TI - Translating clinical practice into health policy: an example from China. AB - Understanding a health problem and even having the technological capability to solve it are often not enough to lead to changes in health policy. To help accomplish such policy changes, we propose a five-step approach that involves (1) specifying the disciplines; (2) developing multidisciplinary hypotheses; (3) investigating the hypotheses; (4) developing a policy 'story'; and (5) advocating these solutions to policy makers. We use the example of neonatal hypothermia in Eastern China to illustrate this approach. We found that the approach both better informed policy and better motivated policy change. Using the approach extended our involvement from the hospital to a wider population; in addition our initial solutions expanded from clinical interventions to broader public health approaches that proved to be quite different from our original recommendations. PMID- 10156650 TI - Costs, effects and cost-effectiveness analysis of a mobile maternal health care service in West Kiang, The Gambia. AB - The costs, effects and cost-effectiveness of a new mobile maternal care service offered in The Gambia at a government-run health centre in Karantaba were compared with the usual pattern of maternal care offered (at Ngayen Sanjal). Routinely collected data were supplemented by research on time allocation of staff by activity, use of drugs, medical consumables and vehicles, out-of-pocket payments by patients and a range of effectiveness indicators. To account for a differential effect on hospital referrals, maternity care at the main referral hospital was assessed. In 1991, the annual total cost of maternity care at Karantaba was US$64 800 compared with US$25 300 at Ngayen Sanjal. The largest proportion of this difference was attributed to training. Whilst average cost/attendance was higher at Karantaba, the marginal cost of expanding the service to other villages was lower than the marginal cost at Ngayen Sanjal. Incremental cost-effectiveness of the mobile service at Karantaba was calculated according to best and worst case scenarios which showed that the extra cost/extra death averted per year ranged between US$459 and US$2134. Using discounted life years gained reduced the figures to US$42.9 and US$206.3. Various suggestions are offered for reducing the cost of the new service, and a number of methodological points are raised for discussion. PMID- 10156651 TI - The cost of cataract surgery in a public health eye care program in Nepal. AB - Using data from the Lumbini Zonal Eye Care Program in Nepal, the authors estimated marginal costs, capital costs, and average recurring costs for a public health cataract program with and without donor agency overhead expenditures. Each estimate is useful for guiding decisions under certain conditions. Marginal costs are appropriate for short-term planning. Average in-country recurring cost figures are needed to project budgets for longer term program costs or major program expansion. A portion of donor agency overhead costs should be included if expansion requires more donor agency contributions. Marginal costs are estimated at US$3.01 per case. In country recurring costs are about $13.91. Capital costs excluding hospital construction are an additional $2.42. Seva's USA administrative expenditures in support of the cataract component of the program add about another $5.38. Total costs were about $21.71 per case. PMID- 10156652 TI - Public autonomous hospitals in sub-Saharan Africa: trends and issues. AB - Since the late 1980s, many countries in Africa have been granting increased autonomy to their main teaching hospitals. This policy has significant international support but has been evaluated little from either theoretical or empirical perspectives. This paper attempts to fill this gap by assembling evidence from policy documents, theoretical debates and empirical evidence of related policy changes in other contexts such as the development of trust hospitals in the UK NHS. The paper attempts to locate the policy in the broader context of the package of health sector reform measures proposed at international level, and to identify the role it is intended to play in the achievement of the implicit objectives of that package. The objectives identified are improvements in allocative efficiency and equity, improvements in internal efficiency and improvements in responsiveness, accountability and choice. Each of these objectives presents difficulties which suggest that only modest short-term expectations of the policy can be justified. Given the lack of evidence from existing experience, a research agenda is suggested, which aims to provide information to guide further implementation of the policy. PMID- 10156653 TI - Physician volume response to price controls. AB - The need to contain escalating health care costs is one of the major challenges facing health care systems today. It is often argued that price control is an effective tool for reducing both the level and the rate of growth in health spending. However, experience suggests that these savings may be partially offset by volume increases. These are initiated by providers, particularly physicians, who attempt to provide more health care goods and services in order to recapture lost revenues. This phenomenon is called the behavioral offset or volume response. This paper examines the physician behavioral response to the fee reductions at the practice level using the data from the U.S. Medicare program in 1989 and 1990. This is the most recent data currently available at the practice level for the Medicare program at this writing. This period of time corresponds to the fee reductions mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA89). The results show that the volume of services whose fees were cut by OBRA89 increased by 3.7% for every 10% fee reduction. This means that, for every dollar cut in their fees, physicians would recoup 37 cents by increasing volume. The presence of a volume response suggests that price control alone is not sufficient to cap rising health care costs. This indicates that additional or other tools must be considered if cost containment is to be attained. PMID- 10156654 TI - Bill squeaks by House ... Health Care Benefits Preservation Act of 1996. PMID- 10156655 TI - The use of multimedia computer-based patient records in ambulatory care. AB - The use of a multimedia computer-based patient record (CPR) within ambulatory care is a topic that has not achieved widespread understanding or acceptance. However, if the topic is divided into its parts, multimedia and computer-based patient record, it reflects both highly recognizable and desirable goals that most health care organizations are undertaking. Multimedia technology is quickly maturing. In addition, the goal of attaining a CPR is of primary interest to most health care organizations. It is inevitable that these two technologies will eventually become synergistic. This article presents the case for a multimedia ambulatory CPR and describes one example of this happy marriage. PMID- 10156657 TI - The objectives of paying doctors: views from Saskatchewan. AB - Physicians in Saskatchewan still favor the fee-for-service method of payment over salaries, capitation, and sessional contract. However, there appear to be two camps. Fee-for-service adherents felt that this method best ensured clinical autonomy, practice location, control over work schedule, and adequate income. Proponents of salaries felt that such methods best ensured adequate time with patients, clinical teamwork, preventive activities, teaching and research, continuing medical education, and administrative simplicity. PMID- 10156656 TI - ABC estimation of unit costs for emergency department services. AB - Rapid evolution of the health care industry forces managers to make cost effective decisions. Typical hospital cost accounting systems do not provide emergency department managers with the information needed, but emergency department settings are so complex and dynamic as to make the more accurate activity-based costing (ABC) system prohibitively expensive. Through judicious use of the available traditional cost accounting information and simple computer spreadsheets. managers may approximate the decision-guiding information that would result from the much more costly and time-consuming implementation of ABC. PMID- 10156658 TI - Applications of physician profiling in the management of primary care panels. AB - A primary care panel is a conceptual and institutional unit, in managed care organizations, that holds an individual primary care physician or a team of primary care physicians accountable for the care of a defined population of enrollees. A persistent question in ambulatory care management is how to align, across a set of primary care panels, the distribution of demand for primary care physician time with the distribution of supply of primary care physician time. Part of the solution to this resource allocation decision requires measurement of primary care panel case mix (a principal influence on demand); and, part of the solution requires measurement of physician practice (an influence on both demand and supply). The goals of this article are several, among them, to outline the reasons research and development in this area are important for the successful functioning of a primary care panel system, and to illustrate how methods of physician profiling may be usefully applied toward evaluating and implementing solutions to the alignment of demand for, and supply of, primary care physician time. PMID- 10156659 TI - General practitioner fundholding in the reformed National Health Service: a descriptive analysis. AB - Since 1991, general practitioners in Britain have been able to apply for fundholding status. This provides them with a budget allocation with which to purchase specialized care for their patients rather than using arrangements established by the District Health Authority. The article describes fundholding, and the arguments that support and oppose the initiative are rehearsed. These are then investigated in the context of treatment data. The article suggests that while some real benefits to patients have probably resulted from fundholding, these are limited due to the nature of the scheme and its domination by enthusiasts. PMID- 10156660 TI - Preventable hospitalizations: a tool for planning and marketing ambulatory health care services. AB - As the health care system evolves towards increased levels of managed care, planners and managers will need to understand how the utilization of ambulatory care services influences the use of more expensive hospital care. Preventable hospitalization, an index based on Ambulatory Care Sensitive (ACS) conditions, is proposed as an indicator for identifying communities with significant ambulatory care needs. The design and marketing of ambulatory health care services functionally adapted to meet the challenges of managed care will require new forms of health care information to plan, market, monitor, and evaluate the outcomes of health care policies and programs. An example is presented of the use of preventable hospitalizations as indicators of ambulatory care needs in 48 communities in Massachusetts. PMID- 10156661 TI - Emergency room encounters of pediatric patients with asthma: cost comparisons with other treatment settings. AB - More than 67,000 claims from a national database were analyzed to determine the relative costs of treating pediatric patients with asthma in physicians' offices, hospital outpatient departments, or emergency rooms. Billed charges and paid claims for these cases in emergency rooms average more than 5 times higher than in physician offices. Emergency treatment generally results from a failure of proper management and education in the primary care setting. Educational programs for pediatric patients with asthma and their families could save resources as well as reduce the trauma often associated with visits to the emergency room. PMID- 10156662 TI - Preparation for guardianship cases poses a constant challenge. PMID- 10156663 TI - Examining MDS (Minimum Data Set) resident assessments for the impact on public policy. PMID- 10156664 TI - How to manage changes in the health care workforce. PMID- 10156665 TI - Skilled nursing facilities battle ethical dilemmas. PMID- 10156666 TI - Long-term care in Finland offers refreshing differences. PMID- 10156667 TI - Certified recreation specialists carve a niche in geriatric rehabilitation. PMID- 10156668 TI - Learn to manage the gorilla. PMID- 10156669 TI - Luncheons to Grow keep staff involved. PMID- 10156670 TI - Managed care contracts require thoughtful planning. PMID- 10156677 TI - The ethics of excess. PMID- 10156678 TI - Beyond health care reform: assessing future challenges of education and training. PMID- 10156679 TI - Then and now ... human resources management. PMID- 10156680 TI - Why I went full tilt at an insurer over $267. PMID- 10156681 TI - A simple way to monitor your practice's vital signs. PMID- 10156683 TI - Is health reform a threat to doctor-patient rapport? PMID- 10156682 TI - My practice almost destroyed me. PMID- 10156684 TI - I lost a malpractice case--without knowing I'd been sued. PMID- 10156685 TI - Medicare capitation: how much risk should you take? PMID- 10156686 TI - Mutual fund Q&A. Health care: the sector that just keeps on booming. PMID- 10156687 TI - Preparing for disability: it takes more than insurance. PMID- 10156689 TI - AGPA, UMGA near agreement on merger. PMID- 10156688 TI - Keeping your staff happy when you can't afford raises. PMID- 10156690 TI - AMA program spawns first health plan. PMID- 10156691 TI - HCFA plans huge Medicare patient survey. PMID- 10156692 TI - Iowa PSN (provider-sponsored network) may get Medicare deal. PMID- 10156693 TI - House panel gives nod to antitrust bill. PMID- 10156694 TI - Expert spells doom for healthcare reform. PMID- 10156695 TI - IOM urges steps to boost primary care. PMID- 10156696 TI - 2nd Columbia facility in Fla. to pay 'dumping' settlement. PMID- 10156697 TI - Cancer treatment centers, hospitals settle with FTC. PMID- 10156698 TI - Medicare fee plan could save VA $33 million per year. PMID- 10156699 TI - Tax-exempt hospitals create lobby group. PMID- 10156700 TI - HCFA drafts new teaching doc rules. PMID- 10156701 TI - Double-digit growth continues. PMID- 10156702 TI - A closer look at salaries shows RNs are best value in healthcare. PMID- 10156703 TI - Virtual healthcare--linking firms to form all-star teams. AB - A new, cyber-sounding word is creeping into the healthcare lexicon. The term "virtual" is being used to describe integration initiatives that don't require a merger of assets. A main attraction of virtual integration is that a healthcare delivery system can be created without investing huge amounts of capital to acquire the pieces. PMID- 10156704 TI - Medicaid denials put Ohio clinic in legal fight. PMID- 10156705 TI - Quality project expands to psych care. PMID- 10156707 TI - Premier. Giant alliance shares new name, bold plans with hospital members. PMID- 10156706 TI - House panel supports expanded job-change insurance coverage. PMID- 10156708 TI - Mont. antitrust trade-off to hospital merger. PMID- 10156709 TI - Assistance programs bank on volunteers. PMID- 10156710 TI - Governors revamp Medicaid proposal. PMID- 10156711 TI - Bond ratings will stay high for children's hospitals--Moody's. PMID- 10156712 TI - Cookeville hospital on block despite city charter change. PMID- 10156713 TI - Organizing and managing an integrated delivery and financing system. PMID- 10156714 TI - Organizational and management challenges. General discussion. PMID- 10156715 TI - Organizational forms. The contractual approach. PMID- 10156716 TI - Organizational forms. The consortium. PMID- 10156717 TI - Organizational forms. The joint venture. PMID- 10156718 TI - Organizational forms. The consolidated and integrated system. PMID- 10156719 TI - The clinical side: the roles of physicians. Care of individual patients. PMID- 10156720 TI - The clinical side: the roles of physicians. Care of groups of patients. PMID- 10156721 TI - Goal setting increases motivation, enhances job performance. PMID- 10156722 TI - Outpatient critical pathways: five advantages for physicians who act now. PMID- 10156723 TI - Systematic approach reduces patient waiting times. PMID- 10156724 TI - March to national health reform continues, but slowly. PMID- 10156725 TI - From the factory floor to the doctor's office. PMID- 10156726 TI - Modification of physician behavior by performance feedback. PMID- 10156728 TI - The politics of informatics. PMID- 10156727 TI - Physician computer order entry in a hospital setting. PMID- 10156729 TI - When to counter and when not. PMID- 10156730 TI - Technology assessment at work: Part I--Principles and a case study. PMID- 10156731 TI - Budget balancing acts juggle provider rates. PMID- 10156732 TI - Food can make the resident feel at home. PMID- 10156733 TI - Physician standards set for subacute care. PMID- 10156734 TI - Linking data and quality in the age of computers. PMID- 10156735 TI - Sixth annual Provider software buyer's guide. PMID- 10156736 TI - Fraud and abuse law changes in store. PMID- 10156737 TI - Making a respite stay comfortable. PMID- 10156738 TI - Surfing the Internet for success. PMID- 10156739 TI - Find creative ways to market hospitality. PMID- 10156740 TI - Contracting strategies for independents. PMID- 10156741 TI - The emerging dimensions of long term care. Spoke services expand the field. PMID- 10156742 TI - Questions are key to quality rehabilitation. PMID- 10156743 TI - How to avoid fraud and abuse violations. PMID- 10156744 TI - Hotbed of innovation--the University of New Mexico is ahead of the pack. PMID- 10156745 TI - The top 25 medical schools. PMID- 10156746 TI - Uninformed consent: biased decisionmaking following spinal cord injury. PMID- 10156747 TI - The problem of (non-)compliance: is it patients or patience? PMID- 10156749 TI - Readings in rehabilitation ethics. PMID- 10156748 TI - Ethical considerations in brain injury rehabilitation: applications to mild traumatic brain injury. PMID- 10156750 TI - Death can be proud. PMID- 10156751 TI - The case of Mr. Sims. PMID- 10156752 TI - Windows systems overview: the windowful world of healthcare. PMID- 10156753 TI - Going wireless at the point of care. PMID- 10156754 TI - Calling all nurses: report to Jericho stat. PMID- 10156755 TI - 1996 nursing systems. PMID- 10156756 TI - Case management: a key to quality. PMID- 10156757 TI - Scheduling effectively and efficiently. PMID- 10156758 TI - Antitrust law: a remedy for poor peer review. PMID- 10156759 TI - Health systems reform: 1995 state legislative wrap-up. PMID- 10156760 TI - The gift of life: ethical issues in organ transplantation. PMID- 10156761 TI - The NPDB (National Practitioner Data Bank) and surgical residents. PMID- 10156762 TI - Columbia/HCA: transforming the health care marketplace. PMID- 10156763 TI - Exploring snares in indemnity contracts. PMID- 10156764 TI - Workforce issues in pediatric surgery. PMID- 10156765 TI - Can surgical innovation survive? Panel presentations. PMID- 10156766 TI - Scudder Oration on trauma: verification: the pursuit of optimal trauma care. PMID- 10156767 TI - Legal tips for the managed care age. PMID- 10156768 TI - Let common sense prevail. PMID- 10156769 TI - Understanding stop-loss coverage in managed care plans. PMID- 10156770 TI - Work and service in Bangladesh--the medical needs are manifold and profound. PMID- 10156771 TI - Advance directives: theory and reality. PMID- 10156772 TI - Are Canadian hospitals providing family-centered maternity and newborn care? AB - A philosophy of family-centered maternity and newborn care requires that there be open communication between a woman, her family and health professionals; that the woman be able to choose people to support her, and have those people present during labour and birth; and that the mother and infant remain in close contact whenever possible following birth. Using data from a 1993 survey, the authors conclude that Canadian hospitals still have a long way to go before putting these ideals into practice. PMID- 10156773 TI - Strategic alliances: a competitive strategy. PMID- 10156774 TI - A challenge postponed. Interview by Aileen Leo. PMID- 10156775 TI - Re-engineering: managing radical change. AB - Faced with both a move to a new facility and the need for radical, cost-saving organizational change, the Ontario Cancer Institute/Princess Margaret Hospital turned to the principles of re-engineering. With the help of a consulting firm, the organization overhauled sufficiently to save $7.5 million, enough to finance the move, the transition and even the expansion of some services. PMID- 10156776 TI - Managing diversity: a necessary skill. PMID- 10156777 TI - Outsourcing for food service: two scenarios. PMID- 10156778 TI - Elected or appointed? The case for healthcare trustees. AB - Although most trustees in Canada are appointed, there is a growing trend to publicly elect them instead. Though motivated by a desire to make healthcare boards more accountable to the public, there is no evidence that public elections will accomplish this. There are a number of mechanisms already in place to ensure accountability, and appointing trustees makes it more likely that only properly qualified trustees will hold board positions. That control is vital to ensure that trustees have the strategic business thinking necessary to ensure the future of hospital corporations. PMID- 10156779 TI - Creating tax-exempt medical practices in integrated delivery systems: physician contributions create a win/win situation. PMID- 10156780 TI - Marketing cardiovascular services: the new paradigms--Part 2. PMID- 10156781 TI - Is it a wonderful life? PMID- 10156782 TI - Pharmacist fills order to cut supply costs with I/T. PMID- 10156783 TI - Focus survey. Local area networks. PMID- 10156784 TI - Physician training key to successful implementation. PMID- 10156785 TI - EDI paves way for automating business office processes. PMID- 10156786 TI - Online documentation: making it work with POC technology. PMID- 10156787 TI - Companies define managed-care software. PMID- 10156788 TI - HotList: managed-care software. PMID- 10156789 TI - First impressions as a patient can last a lifetime. PMID- 10156790 TI - Introduction to statistical process control. AB - The Joint Commission on Accreditation of Healthcare Organizations is applying statistical process control techniques to monitor processes and measure the results of efforts to improve a process. Statistical process control techniques have been used for decades by the manufacturing industries and have translated well into the service industries. This article describes the successful use of control charts in improving processes within an engineering department. PMID- 10156791 TI - How to cut costs in your solid waste management program. AB - In the past 10 years, waste management has become a significant budget item. Previously, it was a tertiary function, coming after clinical and other facility support functions. But now that environmental concerns have spread and environmental responsibility becomes an accepted part of facility management, waste management is now a central issue. This document examines several ways to cut costs in a waste management program, primarily in the area of solid waste. PMID- 10156792 TI - The vagaries of home health care: a critical review of the literature. PMID- 10156793 TI - The Nursing Home Without Walls: New York State's long-term home health care program. PMID- 10156794 TI - Long-term home health care: what are the costs of care and costs of failure to give care? PMID- 10156795 TI - The seven sins of long-term-care insurance. PMID- 10156796 TI - The role of the religious community in shaping community partnerships for health care. PMID- 10156797 TI - A cross-cultural study of beliefs, attitudes and values in Chinese-born American and non-Chinese frail homebound elderly. PMID- 10156798 TI - A provider to managed care. PMID- 10156799 TI - Coordination of services for Medicaid populations. PMID- 10156800 TI - Listening to the knock on the door. Provider strategies for managed care initiatives under Medicaid and other programs. PMID- 10156801 TI - Case management in the managed care environment: keystone to integrated service delivery. PMID- 10156802 TI - Dialogue. Should public sector mental health and substance abuse funding be merged? PMID- 10156804 TI - Computerization in managed behavioral healthcare: a national survey. Work Group for the Computerization of Behavioral Health and Human Services Records. PMID- 10156803 TI - 1995 update: state healthcare reform and behavior benefits. PMID- 10156805 TI - Using outcomes data and clinical process redesign: improving clinical services. PMID- 10156806 TI - Behavioral healthcare benefit strategies of self-insured employers. PMID- 10156807 TI - How to link behavioral group practices with primary care physicians. PMID- 10156808 TI - Outpatient civil commitment and managed care: issues for providers. PMID- 10156809 TI - Study finds "widespread" supplier Medicare fraud. PMID- 10156810 TI - Minimizing monthly service fees in assisted living. PMID- 10156811 TI - From Albany to Tallahassee--the future of long term care is being decided in state capitals nationwide. PMID- 10156812 TI - Fall programs that work. PMID- 10156814 TI - Food and nutrition department costs--a smaller slice of the pie. PMID- 10156813 TI - Beware of pitfalls when drafting supplier contracts. PMID- 10156815 TI - Understanding trends in health care spending. PMID- 10156816 TI - Developing staff competencies. PMID- 10156817 TI - "Hotel-style" tips to improve patient satisfaction. PMID- 10156818 TI - How restructuring affects span of control. PMID- 10156819 TI - A strategic human resource management model for restructuring in healthcare organizations. PMID- 10156820 TI - Facilities design in a managed care environment. Healthcare market demands emphasis on master planning and creative use of space. PMID- 10156821 TI - Benefits and disadvantages of corporate restructuring--the hospital view. AB - Many hospitals have adopted a corporate structure to improve management and gain economic benefits. Our study of Massachusetts hospitals found that for only a few had these anticipated advantages materialized, while many found that the new structure entailed added bureaucracy and other disadvantages. The findings suggest that hospitals adopt or keep the structure not only for possible economic reasons but also to sustain their legitimacy in the eyes of important stakeholders. PMID- 10156822 TI - Executives' perceptions of total quality improvement. PMID- 10156824 TI - Limits of loyalty. PMID- 10156823 TI - The quality coach--the facilitators' perspective. PMID- 10156825 TI - Capitation: breaking rice bowls. How will capitation affect hospital department managers? PMID- 10156826 TI - Staff accommodation. Room service. PMID- 10156827 TI - First person. The Cinderella syndrome. PMID- 10156829 TI - Waiting lists. Bypassing the time. PMID- 10156828 TI - Managerial loyalties. Divided loyalties. PMID- 10156830 TI - Investing in people: a management responsibility and a social obligation? AB - Analyses the proposition in this title by reference to experience and reflective consideration, both of the motivation of organizations which are embracing the TQM philosophy and of the essential requirements to understand and interpret social and industrial contexts. PMID- 10156831 TI - Making staff aware of risks. AB - Outlines the essential steps in establishing risk management as an effective process in any organization and relates to management claims, complaints and adverse incidents. Discusses the way to elicit and use information from patients and staff. Emphasizes the need to learn from all those involved in delivery and receipt of care. PMID- 10156832 TI - Empowering staff through audit. AB - Describes the use of multidisciplinary project teams in audit planning, process and outcome. Discusses the motivation and need for reward in personal/professional settings and patient satisfaction surveys in the contractual arena into which they have been drawn. PMID- 10156833 TI - A multidisciplinary team approach to day hospital patient care. AB - A review of practice in a mental health day hospital led to a multidisciplinary quality group being established. Outlines changes implemented leading to service improvements and increases in patient and staff satisfaction. PMID- 10156834 TI - Motivating staff through teamwork: process review and data display. AB - Outlines four interconnecting factors which are essential to motivating staff: an understanding of the "psychology of excellence in teams"; establishing cross functional quality improvement teams; understanding and reviewing processes of care and service; and the use of data display. PMID- 10156835 TI - Generating a culture focused on continuous improvement. AB - Describes the principles and values on which the North Ayrshire & Arran NHS Trust was established. Presents the reasons for choosing a culture focused on quality together with the clinical and service development generated by continuous improvement. PMID- 10156836 TI - Accreditation for quality in health administration education. PMID- 10156837 TI - Trends, issues, and models in health services and health policy programs in business school settings. AB - This article briefly examines the evolution and convergence of graduate programs in health services administration in business school environments. Some of the problems along the way are identified through the discussion of the different tasks of professional as compared to academic knowledge. The underlying point is the degree to which the professions should be able to draw on academic knowledge from the disciplines to frame and analyze future problems and situations. Alternative models are present which build on the generic M.B.A. curriculum. PMID- 10156838 TI - New curriculum challenges in health administration education. AB - Tradition curriculum content and structure in health administration education programs have focused on the managing of individual institutions, the business function, and the hospital as the center of the health system. These assumptions are challenged by managed care, with its orientation on integrating the business and clinical functions; prevention and primary care; and the provision of services through integrated service networks. The design and process of curriculum change in response to new organization structures and management challenges are explored. PMID- 10156839 TI - The evolution of health administration education for public health: responding to a changing environment. AB - Health administration education in schools of public health has undergone a steady but remarkable evolution over the last five decades. What was once taught was simply an enumeration of statutory requirements and programs managed by public health agencies. This changed dramatically in the 1960s with the incorporation of both theoretical concepts and skills from the fields of public administration and business administration. In the 1990s, the differentiation between training required for public health administration and for health services administration has become increasingly blurred as institutional responsibility for the health of defined populations has necessitated the adoption of the community epidemiology perspective, long the centerpiece of public health programs, by all health services administration programs. The future challenge for programs located in schools of public health is to identify the unique characteristics of public health practice and to prepare graduates to assure that core public health functions are met adequately in the communities in which they will serve. PMID- 10156841 TI - The role of the educator in state, provincial, and federal health policy. AB - Many faculty members of programs in health administration participate in the policy-setting process. It is critical at the present time of health care reform that faculty members play an active role in influencing health policy. Educators may become involved in this activity in a number of ways. First, there may be opportunities as researchers to conduct short-term or long-term projects which promote a policy agenda. Faculty members can bring a range of analytical skills and knowledge and may bring in multi-disciplinary perspectives on substantive policy issues. Second, educators need to re-examine curriculum content of university programs in health administration to assure appropriate policy content and to seek out opportunities for graduates in policy analysis positions. Third, through community services, educators may take on advocacy roles for the promotion of particular perspectives or the support of special interest groups. It is clear that there are going to be growing opportunities for faculty members to work with practitioners to substantially influence health policy. PMID- 10156840 TI - Competencies for health management practice: a practitioner's perspective. AB - The current health care environment will require executive leadership with a new set of management competencies to effectively lead and manage the various components of a restructured health care delivery system. The traditional management skills of planning, organizing, directing, controlling, and staffing resources will remain relevant, but the true measure of professional success will be the development of conceptual skills. This means the ability to look at the health care enterprise as a whole, and recognize how changes in the environment shape your strategic mission, goals, and objectives. The successful health care leader will have a demonstrated ability to apply these conceptual skills to the development of information systems and integrated networks that position their organization to accept capitated risks. This paper examines the United States and Canadian health care systems from the perspective of both the more traditional hospital and the emerging medical care organizations. New importance of the team approach to leadership and management and all that entails is stressed. PMID- 10156842 TI - Your most crucial decision: who to team up with. PMID- 10156843 TI - Surprise! Capitation can be a boon. PMID- 10156844 TI - Getting the most out of your PPO contracts. PMID- 10156845 TI - How to avoid deselection. PMID- 10156846 TI - Here come big changes in your patients' insurance. PMID- 10156847 TI - Leading a physician network: forget democracy. PMID- 10156848 TI - Malpractice: the damning evidence is under your nose. PMID- 10156849 TI - The managed-care juggernaut: explosive growth nationwide. PMID- 10156850 TI - How are doctors adjusting? Very well, thank you. PMID- 10156851 TI - Your office: a lot of things will have to change. PMID- 10156852 TI - Aetna deal signals provider squeeze. PMID- 10156853 TI - Ga. hospitals mull restructuring to guard records. PMID- 10156854 TI - Cape Coral saga may end as it started. PMID- 10156855 TI - Groups rally support for measure making long-term care and insurance deductible. PMID- 10156856 TI - Medi-Cal contracts awarded to HMOs. PMID- 10156857 TI - Minn. deal satisfies union, hospitals. PMID- 10156858 TI - Coram reports 4th-quarter loss. PMID- 10156859 TI - Columbia execs Scott, McWhorter get big pay hikes. PMID- 10156860 TI - Docs criticize changes in clinic survey rules. PMID- 10156861 TI - Appellate court lifts N.Y. ban on doctor-assisted suicide. PMID- 10156862 TI - Congress nixes foreign nurse program. PMID- 10156863 TI - Fading psych business hurts CPC earnings. PMID- 10156865 TI - Sanctions on docs up 6.7% last year. PMID- 10156864 TI - OrNda hospital settles 'dumping' case. PMID- 10156866 TI - Columbia wins OK for Mass. deal. PMID- 10156867 TI - Mass. legislature mulls bills limiting for-profits. PMID- 10156868 TI - Rural firms set to acquire hospitals. PMID- 10156869 TI - Turnover of hospital CEOs reached 5-year high in 1995. PMID- 10156870 TI - Acquisition bids spark Neb. mergers. PMID- 10156871 TI - Sowing the seeds of partnership between providers, managed care. Columbia, Ohio Blues forge promising deal. PMID- 10156872 TI - VA journey to capitation picks up speed. PMID- 10156873 TI - Motives of reform players in question. PMID- 10156874 TI - Focus on fitness. Hospitals promote their health clubs as another service in care continuum. AB - Hospitals and systems are responding to demands by managed-care plans and large employers for wellness programs and other preventive health strategies by building their own multimillion-dollar health clubs, complete with exercise equipment to rival the local gym's. PMID- 10156875 TI - Federal judge rejects settlement between drugstores, drugmakers. PMID- 10156876 TI - HMOs battling horror stories, lawmakers. PMID- 10156877 TI - United blazes a trail in managed care. PMID- 10156878 TI - Patients bypass hospital with device. PMID- 10156879 TI - New disclosure rules boost some bonds. PMID- 10156880 TI - Hospitals in probe must turn in docs to cut losses. PMID- 10156881 TI - Medicare trust fund loses $3 billion. PMID- 10156882 TI - HCFA seen enacting disputed rule on interest. PMID- 10156883 TI - Cleveland's UH system discussing expansion. PMID- 10156884 TI - Ind. system, hospital sign letter of intent to merge. PMID- 10156885 TI - N.J.'s GOP leadership to sue tobacco industry. PMID- 10156886 TI - Kansas City-area hospitals in link. PMID- 10156887 TI - Physicians in K.C. suburb ready to take on new risk contracts. PMID- 10156888 TI - Agency hits Columbia for misleading ad campaign. PMID- 10156889 TI - Ala. system, hospital to ally. PMID- 10156890 TI - Conn. providers agree to link. PMID- 10156891 TI - CCA (Community Care of America) offering is postponed by Iowa probe. PMID- 10156892 TI - GAO traces high home-care costs to lack of government controls. PMID- 10156893 TI - NCQA releases draft standards. PMID- 10156894 TI - Suit signals cancer services fight. PMID- 10156895 TI - Calif. Blues drop maternity exclusion. PMID- 10156896 TI - Ohio weighs rules for risk bearers. PMID- 10156897 TI - HMO execs bring in big pay--studies. PMID- 10156898 TI - Public benefit rules cause Mo. stir. PMID- 10156899 TI - FBI widens Chicago hospital probe. PMID- 10156900 TI - Medicare capitation overhaul prospects dim. PMID- 10156901 TI - AHA backs reform bill through ad campaign. PMID- 10156902 TI - Redesigned IRS audits a success. PMID- 10156903 TI - Providers push for remedies to costly drug noncompliance. AB - About half of patients taking any drug don't follow instructions. It's a problem that costs billions of dollars annually. Health plans are working harder to improve compliance because of the high toll it exacts on patient health and their own pocketbooks. PMID- 10156904 TI - Accreditation agency for capitated groups looks for bigger role. PMID- 10156905 TI - Physical therapy group studying fruits of labor. PMID- 10156906 TI - Healthtrust vets spur Nashville start-up boom. PMID- 10156907 TI - Columbia closing in on deals with 2 Chicago-area hospitals. PMID- 10156908 TI - Columbia starts quality comparisons. PMID- 10156909 TI - Series billing requires innovative approaches. PMID- 10156910 TI - Hospitals adapting to competition, ProPAC data suggest. PMID- 10156911 TI - The corporatization of health care: an evaluation and an alternative. AB - The corporatization of health care organizations has become a significant international trend. This paper examines that trend, comparing the development of corporate health care in the USA with the impact of the New Zealand health reforms. The paper traces the evolution of the organizations of health care systems and explains the emergence of the corporate form. We argue that the corporate model of work organization is unsuited to the complex and ambiguous nature of the medical task as it ignores inherent interdependencies. An alternative is needed which addresses work practices rather than just participation in decision making and is based on a concept of mutual interdependence and support in the execution of work. PMID- 10156912 TI - Clinical audit: integrating the management of quality. AB - The recent implementation of clinical audit by the Department of Health seeks to both integrate existing professional audit activities, and to integrate the resulting multi-professional audit more closely with other quality-assurance activities developed by corporate management and purchasers. This paper, which is based on studies of medical and clinical audit undertaken over the past 3 years, examines the potential for integration in the light of, first, the history and characteristics of the different forms of quality assurance initiative and, second, a comparison of their different properties. In many ways clinical audit appears to stand between domination by both professional and managerial influences, which may enhance its potential for integrating different approaches. If, however, clinical audit is to succeed it is suggested that it requires a strong managerial infrastructure; with clearly delineated responsibilities related to the different modes of quality assurance. PMID- 10156913 TI - Communication audits and the management of change: a case study from an NHS unit of management. AB - This article explores the importance of high quality communication between managers and staff for the effective management of change within the National Health Service (NHS). In particular, a methodology termed communication audit is outlined. Such audits enable managers to gather accurate information about communication practices within organizations and allows them to assess the nature, quantity and quality of internal communications. This, in turn, facilitates the identification and resolution of potential problems and helps to provide a clearly focused agenda for action and change. A case study is offered which illustrates how such an audit was applied to a Unit of Management within the NHS. The implications for managers throughout the organization are then considered. PMID- 10156914 TI - Top management culture and performance in Canadian, UK and US hospitals. AB - This study examines the role of top management team culture in hospitals located in Canada, the UK and the USA. Clan, developmental, empirical, and rational cultures were identified using the competing values framework. This study was organized around three basic questions. The first question asked whether hospital management teams in the USA, Canada and the UK have different management cultures given the differences in their political economies. The second question asked whether management culture was associated with differences in performance? The third question addressed the issue of the legitimacy of culture type as an independent variable. If culture type has legitimacy, other organizational variables such as structure, conflict resolution style, market strategy, and stakeholder priorities should be manifested differently in each culture type. The findings support the legitimacy of the culture variable and the premise that the political economy influences the distribution of culture types. The dominant cultures of the hospital management teams studied were positively and significantly related to organizational performance for clan, rational, and developmental cultures. The implications for management theory, professional practice and public policy are discussed. PMID- 10156915 TI - Health services management manpower and educational needs with American health reform. AB - This paper argues that our previous health services management (HSM) manpower projections may be overly optimistic as the health networks, managed care, capitated payment, and eventually global budgetary targets become the dominant themes to implement cost restraints, universal access, and social equity. HSM programs should, therefore, focus more on their educational pursuits to produce leaders for clinical management teams, who are able to allocate scarce clinical resources. A sensible strategy for HSM programs is to develop closer ties with the schools of medicine, public health, nursing, or allied health. These cooperative efforts would be particularly beneficial in teaching 'clinical-fiscal performance methodologies' to familiarize students with such concepts as clinical benchmarking, managing quality, resource management, and continuous quality improvement (CQI). PMID- 10156916 TI - Targeting the mature consumer market. AB - The aging population in the USA makes skill in marketing to the mature consumer increasingly important. The biophysical and psychosocial aging process create a need for specific strategies to address the changes brought on by age. This study attempts to ascertain the degree to which the health service providers recognize some of the needs of the elderly market and the degree to which marketing programs are addressing these needs. A comparison with other industries is also provided. The results indicate that 4 out of 16 strategies directed at the mature market have been used by more than 80% of health care respondents. In addition, there are significant differences between the health care industry and other industries for five of the strategies. All but two of the strategies are thought to be important by more than half of the survey respondents. PMID- 10156917 TI - Human resource management in NHS trusts. PMID- 10156918 TI - Practice brief. Issue: Recommended regulation and standard acquisition for specific healthcare settings. American Health Information Management Association. PMID- 10156919 TI - Disorders of the breast. PMID- 10156920 TI - Speaking ahead. PMID- 10156921 TI - Have we entered the post-antibiotic era? PMID- 10156922 TI - Process improvement challenges in a decentralized environment--a view from the field. PMID- 10156923 TI - Strategies to improve patients' satisfaction with discharge planning--an interdisciplinary effort. PMID- 10156924 TI - Building customer-supplier relationships for performance measurement and quality improvement: hospital and health plan partnerships. PMID- 10156925 TI - Reengineering the HIM profession. PMID- 10156926 TI - HIM issues: a survey of professionals, Part I. PMID- 10156927 TI - A little more peace of mind. PMID- 10156928 TI - Health care Profit motive. PMID- 10156929 TI - Burning the midnight oil. PMID- 10156930 TI - Special report. Hospital maintenance staffing study: history and process. AB - This special report provides an overview of the ASHE Hospital Maintenance Staffing Study, which was conducted by the society in 1994-95 through the efforts of the ASHE Facilities Management Committee. The intent of the study was to develop a standard staffing equation to assist hospitals in determining appropriate maintenance staffing levels based on current practices of American Hospital Association member hospitals. Throughout the study, extensive survey data were collected and over 200 variables were considered. Statistical analyses were performed to determine which factors were most closely related to variations in staffing patterns, and whether staffing could be reliably predicted by a standard staffing equation. As with any benchmarking or other similar efforts, the results of this study should be approached with caution. There is variability in the data and the variability may change over time. However, the study has shown that high-quality predictability is possible Health care facilities will be able to use the resulting model to determine whether their staffing levels are significantly out of line and may help point to contributing factors. PMID- 10156931 TI - Harmonic interactions in health care facilities, Part II: Practical handling of harmonic interactions. AB - This is part two in a two-part series aimed at helping the reader understand and prepare for a world of electrical peculiarities. Part one offered an introduction to harmonics. This document covers practical issues involving the handling and mitigation of harmonic distortion. PMID- 10156932 TI - Service contract management and negotiation. AB - Service contract management can have a profound impact on the life cycle cost and general performance of serviced equipment. Negotiating service contracts from the client's perspective can help to ensure that the facility is receiving the best possible service and terms during the contract period. This document shows examples of contract considerations. PMID- 10156933 TI - Summary of major changes: 1992-93 Guidelines for Construction and Equipment of Hospital and Medical Facilities. AB - This document summarizes the changes that have been made to the 1992/93 edition of Guidelines for Construction and Equipment of Hospital and Medical Facilities in producing the 1993 edition. The general format and technical content follow the 1987 edition. Other changes not mentioned here were made to correct errors, clarify intent, and generally update the standards in conformance with current minimum needs and state-of-the-art medical and design procedures. The document is divided into two parts: Part One covers architectural considerations; Part Two deals with engineering criteria. PMID- 10156934 TI - A prescription for hospital safety: treating workplace violence. AB - Workplace violence is on the rise. The spillover effect includes psychological threats and a plethora of lingering mental health problems. The violent workplace mirrors an increasingly violent society. The increase in violence at work is directly proportional to the increase in violent crimes in our general population. This document examines the growing problem of workplace violence nd ways that can curtail potential incidences. PMID- 10156935 TI - A brief educational intervention for patients with rheumatic disease chosen to be presented in a clinic conference. AB - Being presented in a case conference can be anxiety-provoking and intimidating for the patient. We observed that patients, at times, would show signs of apparent discomfort. A structured interview of the patient was designed to assess, address, and clarify concerns the patient might have beforehand. The patients' concerns were communicated to the staff. The structured interview was given to 31 patients before they were presented. An additional 14 patients were interviewed after the conference about their experience without the prior interview. One year later, we followed up by interviewing another 15 patients who had been selected for clinic conference cases. The structured interview revealed confusion on the patient's part about the purpose of the conference, and a desire for information about the physical setting and who would be there. Patients wanted to be introduced formally when entering the room and to be thanked when leaving, and preferred to be questioned directly about their symptoms. Of the 31 patients interviewed before the conference, 23 (74%) reported that the conference was a positive experience when questioned afterward, compared with only 9 of 14 (64%) of those who were not interviewed before the conference. The results of this study were presented to the clinic staff, and education of the patients was stressed as a primary responsibility. At the follow up, 12 of the 15 patients reported real understanding of the clinic conference purpose. The only patient who reported being uncomfortable with the clinic conference and unwilling to attend another was the only patient who reported not being informed about what the conference entailed. It can be too easy for medical staff to forget that what is routine to them is very unusual and can be very stressful to the patient. PMID- 10156936 TI - A clinical pathway for pelvic inflammatory disease for use on an inpatient service. AB - OBJECTIVE: (1) To create a guideline to improve care of adolescent patients diagnosed with pelvic inflammatory disease (PID); (2) to promote cost-effective, consistent care while minimizing delays and ensuring timely and appropriate use of laboratory tests and other interventions; and (3) to describe the process of the development and the implementation of a clinical pathway for PID. METHODS: The study involved the creation and piloting of a multidisciplinary, collaborative clinical pathway for uncomplicated PID on an inpatient service, and the development of a standardized form for analysis of demographics and variances from the pathway. The setting was an inpatient adolescent service at a children's hospital in an urban setting. All patients admitted with a clinical diagnosis of PID from April 1, 1993, to November 30, 1993, were followed up by means of the clinical pathway. All patients discharged with a diagnosis of uncomplicated PID in fiscal year 1992 (FY92: October 1, 1991, to September 30, 1992) were used as a comparison population. The main outcome measures included length of stay, charges per patient, timing of antibiotic administration, use of laboratory tests at admission and at 48 to 72 hours, and documentation of pathway variances. RESULTS: A clinical pathway was created by consensus during a period of several months. During implementation, 28 of 34 (82%) patients admitted by use of the pathway had a final diagnosis of PID; 23 of the 28 (82%) had uncomplicated PID. Variances from the pathway included missed rapid plasma reagins (RPRs) and laboratory tests that were not indicated. For uncomplicated PID, length of stay was reduced (p=.08) from a median of 4 days in FY92 (mean, 5.0 1 3.1 days; range, 2-15 days) to a median of 3 days in the study group (mean, 3.5 + 1.0 days; range, 2-4 days), with differences not reaching the level of significance. There were significantly more patients staying 5 days or longer in FY92 than in the study group (p<.03). Average charges per patient also decreased by 10% (median, $5,275 in FY92 to $4,919), although these results were not statistically significant. CONCLUSION: A clinical pathway for uncomplicated PID can be developed and implemented through a multidisciplinary, collaborative process, with ongoing use as a means of quality improvement and continuing education. Variances from the pathway highlight the need for ongoing education for health care providers. Downward trends in charges per patient and length of stay, although not significant, are encouraging; but they require longitudinal follow up with larger numbers of patients and analysis of outcomes. PMID- 10156937 TI - Patient judgment of the quality of ambulatory care in a Japanese setting. AB - OBJECTIVE: To assess patient satisfaction with a hospital-based ambulatory service in Japan and define the determinants of satisfaction and the patient's intention to return to the service. DESIGN: A questionnaire was developed to measure overall satisfaction, intention to return to the service, patient judgment about the structure/process of the service, patient perception about the global reputation of the service, and other health-related items. The questionnaire was mailed to patients attending the ambulatory service. SETTING AND PATIENTS: All non-psychiatric patients who used the ambulatory service of a 350-bed general hospital in Tokyo in the sampling days were asked to participate. The response rate was 77.2% (1,307 responses). Of these, 1,074 non-proxy and non pediatric responses were used for the main analysis. RESULTS: Based on content analysis and factor analysis, scores for the service components were constructed and found to have high internal consistency and reliability. The results indicated several important points regarding the use of patients' evaluation of ambulatory services as a quality monitoring tool. It was shown that patients' overall satisfaction and intention to return to the same physician were determined primarily by their evaluation of their doctor's conduct and their perceived health outcome. The perceived reputation of the service also was a significant determinant of patient satisfaction and intention to return. Patient satisfaction and intention to return to the hospital were influenced also by non physician factors such as nurses, clerks, and environmental comforts. Notably, patient intention to return was linked with patient perceived need of care and regularity of care. In multiple-regression results, patient satisfaction with the doctor and with the hospital had different determinants. PMID- 10156938 TI - A gender-specific hazard-based clinical and noninvasive coronary risk scoring system for patients with suspected coronary artery disease. AB - OBJECTIVE: An outpatient-based scoring system was developed for at-risk patients with coronary artery disease based on data derived from the clinical history and noninvasive testing results for the prediction of an adverse event, the development of risk subsets, and the evaluation of the appropriateness of utilization patterns in an ambulatory care patient population. METHOD: This was a hospital-based cohort study. From a population of 3,795 consecutively tested patients, 872 with suspected coronary artery disease were enrolled from a midwestern university tertiary medical center from 1988 to 1989. RESULTS: Multivariable Cox modeling was used to develop scoring weights with scores ranging from -1.6 to 8.5 points. Significant multivariable disease predictors of cardiac death or myocardial infarction were use of nitroglycerin or insulin, ST-T wave changes, female gender, left ventricular hypertrophy, and a reversible thallium 201 defect. Receiver operating characteristics curves by use of the hazard score were comparable by gender. A probability threshold of .30 for cardiac death or myocardial infarction yielded a cut point of acceptable sensitivity and specificity for prompting medical management decisions. Below this threshold, the rate of follow-up diagnostic testing was 16.9% for women and 57.8% for men (p=.00001). Above this threshold, the rate of follow-up diagnostic testing was 40.6% for women and 64.3% for men (p= .04). CONCLUSION: Use of cardiac diagnostic services and cardiac event-free survival varies by gender in patients screened by noninvasive testing. For men at low risk of cardiac death or myocardial infarction, a statistically greater use of follow-up diagnostic testing was reported, thus reflecting more aggressive treatment and overuse of services for men as compared with women. PMID- 10156939 TI - Teamwork and technology. PMID- 10156940 TI - Diabetes education project: community networking in rural Utah. AB - People in rural areas often lack the financial resources, workforce, and professional network needed to sustain a diabetes education pro gram in their own community. HealthInsight, a nonprofit organization that works to improve the quality of health care in its community, developed a 2-day seminar in an effort to facilitate the networking of rural health professionals who educate patients with diabetes and to help those educators better learn how to use existing resources. Participants included nurses, dietitians, diabetes educators, quality managers, and education directors from hospitals and home health agencies in both rural and metropolitan areas. Speakers presented information on a variety of topics related to program development, and a resource manual containing numerous materials was given to each participant. At the end of the seminar, the group turned in goals for their own programs. Too often, providers of health care compete rather than collaborate with one another. There is a great need for such networking opportunities among health care professionals working on common goals- especially in rural areas. PMID- 10156941 TI - Cyberspace Hospital: growing from a simple idea to a global health information resource. PMID- 10156942 TI - Clinical research: outlook from industry. PMID- 10156943 TI - Total quality management: an epidemiologist's frank perspective. PMID- 10156944 TI - Dreaming of the future: bar codes and quality improvement. PMID- 10156945 TI - Systems and teamwork. PMID- 10156946 TI - Access to and participation in breast cancer screening: a review of recent literature. AB - Recently, attention has been focused on the incentives for access to and participation in breast cancer screening programs. The Healthy People 2000 health goals for the nation calls for 60% of women aged 50 years and older to have had mammograms and clinical breast exams within the preceding 2 years. To achieve this objective, the incentives for access to and participation in breast cancer screening programs must be identified. The present review examines incentive based hypotheses dealing with lower socioeconomic status, lack of insurance coverage, physician referral, and self-referral. Policy-oriented solutions that have attempted to correct the disincentives associated with low access and participation were analyzed. The sophistication of screening technology is of primary importance; however, this review provides additional information that can be used to ensure the implementation of quality mammography screening programs. PMID- 10156947 TI - The impact of different data feedback methods on provider response to the Cooperative Cardiovascular Project. AB - OBJECTIVE: To compare the effects of feedback methods on the type and frequency of responses received after dissemination of Cooperative Cardiovascular Project data. METHODS: Feedback visits were conducted throughout Iowa by means of two approaches; in-person (on-site) visits and telephone conference calls. The content of the presentations was the same for both approaches. This study examined the efficacy of the feedback methods used as determined by the response rates of facilities. A standardized questionnaire was requested from each facility to document the types of action taken by the facilities as a result of the presentations. The Cooperative Cardiovascular Project data were presented to 106 Iowa facilities. On-site presentations were held at 56 facilities; telephone conferences were held with 50 facilities. RESULTS: Facilities that were visited on-site responded with definite quality improvement plans more frequently than did facilities that participated in telephone conferences. Improvement plans were received from 36 of the 56 facilities (64%) visited on-site and from 20 of the 50 facilities (40%) participating in telephone conferences. CONCLUSIONS: On-site visits appeared to be more effective than telephone conferences in promoting quality improvement efforts through facility-specific feedback presentations. PMID- 10156948 TI - Musculoskeletal disease in very elderly nursing home patients: does under reporting exist? AB - To determine the extent of under-reporting of musculoskeletal disease among very elderly nursing home patients, 50 Veterans Affairs Nursing Home patients were evaluated by means of retrospective medical chart review. The primary caregivers' charted musculoskeletal examinations were scored objectively; then the patients completed an arthritis questionnaire, a short-form Geriatric Depression Scale assessment, and the Katz Activities of Daily Living Scale assessment. Finally, each patient underwent an objectively scored musculoskeletal examination by a rheumatologist. The results indicated that musculoskeletal disease in the very elderly nursing home patient is more prevalent than self-report or examination by the primary caregiver suggested. Brief but directed arthritis symptom questioning followed by a specialized examination were necessary to diagnose treatable musculoskeletal disease in this population. PMID- 10156950 TI - Trinity Mother Frances Health System: trust is the foundation of this eastern Texas physician-led system. PMID- 10156949 TI - Predicting survival of patients with sepsis by use of regression and neural network models. AB - OBJECTIVES: (1) To predict at the time of diagnosis of sepsis the subsequent occurrence of multiple organ failure and patient death; and (2) to compare the prediction accuracies of standard multiple logistic regression (MLR) and neural network (NN) models. METHODS: The data were collected during a 5-year period for all patients (n=173) who met prospectively determined criteria for sepsis and had positive blood culture results while admitted in the surgical intensive care unit at the University Hospital of Geneva, Switzerland. These data formed the basis for a retrospective cohort study described elsewhere. The MLR model was adapted from existing data. An NN model of the feed-forward, back-propagation type was constructed for predicting the outcome of sepsis with bloodstream infection. Both models were constructed from randomly chosen subsets of patients and subsequently were evaluated on the remaining (independent) patients. RESULTS: Survival after sepsis was predicted with an accuracy of 80% by the NN model, which used only information collected at the time of the diagnosis of sepsis. The development of multiple organ failure after the diagnosis of sepsis was predicted accurately (81.5%) with either the MLR or the NN model. Both the MLR and the NN methods depended on the interpretation of a likelihood quantity, requiring the choice of a threshold to make a survival prediction. The accuracy of the MLR models was very sensitive to the threshold value. The accuracy of the NN models was not sensitive to the choice of threshold, because they generated likelihood predictions that were distributed far from the middle range where the threshold was placed. CONCLUSION: Compared with MLR models, the NN models were slightly more accurate and much less sensitive to the arbitrary threshold parameter. PMID- 10156951 TI - Joint ventures between for-profits and not-for-profits: do they work and how? PMID- 10156952 TI - To outsource or not to outsource. AB - Outsourcing work can be a positive intervention if the environment and strategies are properly coordinated, but there is no guarantee of success. Today, more than ever before, hospitals are suffering from two pressures: economic constraints and the migration of managerial talent out of the field to other sectors of the economy. With these two pressures, hospitals are searching for ways to reduce costs and find skilled personnel. A common strategy is to seek support from the open market and outsource. This article looks at tools for making the outsourcing decision, such as risk and force field analysis. PMID- 10156953 TI - Getting the most from outsourcing. AB - Outsourcing is common in the business world for its cost saving benefits. This article examines outsourcing as it is used in the Hong Kong healthcare setting for security services and assesses its outcomes in terms of cost, quality, performance, and control. The author reports on several management problems, and makes suggestions for effective outsourcing practices. Hospitals are advised to prepare and manage their contracts as if they were run in-house. Administrators who manage hospitals must examine their operations and try to add value to services where applicable, including outsourced services. PMID- 10156955 TI - What is a "good" person? PMID- 10156954 TI - Curing Medicare's outpatient payment pains. PMID- 10156956 TI - The case for outsourcing core services. PMID- 10156957 TI - Managing expenses rather than materials. PMID- 10156959 TI - Benchmarking the discharge planning process: reflections and findings. PMID- 10156958 TI - A rural hospital's zero-based redesign of discharge planning. PMID- 10156960 TI - Hospitals, nursing homes design uniform patient transfer. PMID- 10156961 TI - Strategic business alliances. Developing partnerships, joint ventures, and collaborative relationships. PMID- 10156962 TI - Use guidelines as navigation tools, but don't let them steer your ED. PMID- 10156963 TI - Telephone advice lines: worth the risk? PMID- 10156964 TI - Activity-based cost system eliminates the money guessing game. PMID- 10156965 TI - Make your paths more cost efficient. PMID- 10156966 TI - Collaboration fills missing piece of CM puzzle. PMID- 10156967 TI - Preadmission testing, assessment reduce cesarean LOS. PMID- 10156968 TI - Freedom keeps CMs happy in job. PMID- 10156969 TI - Simple variance tracking programs yield better data and MD relations. PMID- 10156970 TI - Judging computer systems for case management. PMID- 10156971 TI - How to measure case management's success. PMID- 10156973 TI - Set internal goals before measuring outcomes. PMID- 10156972 TI - Asthma pathway slashes LOS in half, saves $2,300. PMID- 10156974 TI - Risk identification doesn't have to be problematic. PMID- 10156975 TI - Overcome the hurdles in cross-continuum projects. PMID- 10156976 TI - Merging corporate cultures in integrated systems. PMID- 10156977 TI - Customize physician incentive programs to fit the individual doctor's needs. PMID- 10156978 TI - Solo hospitals: sustainable strategy or passing phase? PMID- 10156979 TI - Fruad and abuse: the hospice perspective. PMID- 10156980 TI - Can Congress will the battle over fraud and abuse? PMID- 10156981 TI - Preventing fraud and abuse: the consumer's role. PMID- 10156982 TI - Passing the hot potato--voluntary disclosure and Operation Restore Trust. PMID- 10156983 TI - Why every agency needs a fraud and abuse compliance program. PMID- 10156984 TI - Establishing a corporate compliance program to combat fraud. PMID- 10156985 TI - Background checks prevent abuse. PMID- 10156986 TI - False accusations: the human side of an FBI investigation. PMID- 10156987 TI - Dietary considerations for hospice clients. PMID- 10156988 TI - Helping families with long-term care decisions. PMID- 10156989 TI - Current fraud and abuse issues for home care agencies. PMID- 10156990 TI - Medicare reimbursement for home care: past & future. PMID- 10156991 TI - Medicaid in 1996: opportunities & challenges. PMID- 10156992 TI - Restoring the Medicaid hospice benefit in Illinois. PMID- 10156993 TI - PPS: 1995 in review and prospects for the future. PMID- 10156994 TI - The effect of medication on older adults. PMID- 10156995 TI - Fighting to protect the individual. National Association for Home Care. PMID- 10156996 TI - Tuberculosis update. New regulations offer flexibility in respirator choices. PMID- 10156997 TI - Rings & things. Do pierced patients pose problems? PMID- 10156998 TI - School-age mothers: a forgotten risk. A successful fire-department program targets pregnant teens. PMID- 10156999 TI - When do you refuse ambulance transport?. Interview by Nancy Perry. PMID- 10157000 TI - The new customer. PMID- 10157001 TI - Feeding the hands that serve you. PMID- 10157002 TI - After reduction in force: reinvigorating the survivors. AB - In these days of reengineering health care and downsizing many health organizations, a great deal of attention is given to means of reducing the work force. Not nearly as much attention is paid to the survivors of a staff reduction and the problems that arise in the wake of a generally demotivating activity. However, it is the survivors--those who remain after downsizing--that will have the greatest influence on the organization's future performance. Therefore, the survivors must be remotivated and reinvigorated. Such is the task of surviving supervisors and middle managers, and their primary tools are communication, education, and people-centered management. PMID- 10157003 TI - Creating an organizational climate for multiculturalism. AB - Multiculturism is an ideal goal for our society, its organizations, and its institutions, involving a continuous process of education and change within organizations. Multiculturalism begins with diversity and requires various steps to achieve changes in attitudes, behaviors, and values. The leadership of organizations must not only commit to diversification, but they must participate in it and reward its efforts. Diversification should be managed by creating a climate of open participation, feedback, and control at the lower organizational levels. To micromanage the process of becoming diverse increases resistance and paranoia and counters educational efforts. PMID- 10157004 TI - Surviving organizational change. AB - Modern health care organizations are constantly undergoing change to keep up with technology, new federal regulations, new information, changes in personnel, budgetary problems, and a myriad of other factors. People are spending fewer days in the hospital than ever before. Businesses are taking a more active role in the health care their employees receive. Sage, chief executive officer (CEO) of Memorial Health Care System in South Bend, Indiana, states, ?Health care reform is here. And it's going to continue regardless of what happens in Washington.? PMID- 10157005 TI - Management by intimidation: "cooling out" perceived competitors. AB - Management by intimidation is not healthy, either for its victims or an organization. Intimidation is the style some managers use to keep potential competitors at bay, reminding them who holds the power. Intimidation creates fear within an organization and arouses a need for self-protection among its employees. Unfortunately, management styles often are not known or explored prior to hiring a chief executive officer (CEO). Since employees must adapt to a leader's style, this may mean that some have to leave the organization. PMID- 10157006 TI - Improving the political skills of health care supervisors. AB - The health care industry in the United States has been in a state of social, economic, and political flux for several years. This transition has put a great deal of pressure on supervisors, managers, and professionals in the health care field to adapt by acquiring new skills. Much of the emphasis has been on improving technical, managerial, and people know-how. An equally important area of expertise--political skills--has been virtually ignored. This may be due to the negative connotations associated with politics. Ways to enhance political skills are examined. PMID- 10157007 TI - When you lose your job in health care management. AB - In the present age of downsizing in health care, many health care professionals are losing their jobs. This significantly affects both the physical and psychological health of the person who has lost the job. Additionally, those left on the job are likely to feel insecure and fearful that their job may also be threatened. This article presents guidelines for coping with the loss of a job and how to aggressively seek a new one. PMID- 10157008 TI - Competency: a basis for the selection of staff nurses. AB - This article describes a process for competency interviewing of staff nurse applicants based on an evaluation of their knowledge, skills, and abilities. Planning an interview with consideration of job requirements and organizational expectations is essential. Guidelines for developing interview tools, conducting the interview, and rating applicants are included. PMID- 10157009 TI - Gender differences in managerial characteristics in a female-dominated health profession. AB - This study examines gender differences in characteristics of managers in terms of leadership roles, use of power, type of supervisory style preferred, career commitment, and work/family conflict for the female profession of physical therapy. A questionnaire sent to all members of the Private Practice and Administration Sections of the American Physical Therapy Association yielded 545 managers, 58 percent of whom were female. Females preferred to use a transformational supervisory style more than the men did but males used more masculine leadership traits. Females were as committed to their careers as males and reported the same work/family conflict as the men. These results raise questions as to why proportionately more males are managers in a female-dominated profession. Have health care executives promoted men over women even when the occupation is mainly female? PMID- 10157010 TI - Evaluating health care team performance: assessment of joint problem-solving action. AB - A method for evaluating health care team performance from a problem-solving perspective is described. The effectiveness of team collaboration is measured by the extent to which teams resolve or improve problems in interdisciplinary processes. A summary indicator of team performance is illustrated, and application of the approach to other health and human service problems is discussed. PMID- 10157011 TI - Measuring management potential. AB - This article provides a brief introduction to instruments that may be used to measure management potential in persons being considered for administrative positions. Instruments that measure aspects of leadership, power, personality, conflict, and organizational climate are discussed. An overview of each instrument is provided as well as data on the type of test, time to complete, cost, and purchasing information. While objective tests such as these are useful in assessing individual suitability for management positions, we advise that they be used prudently and judiciously. PMID- 10157012 TI - Using purchaser market research data in strategic planning. PMID- 10157013 TI - Walton spearheads development of Medicare transaction system. PMID- 10157014 TI - Capitated contracting for emergency services. AB - As a way of gaining further control over the cost of healthcare delivery, more managed care organizations are seeking to negotiate capitated contracts for emergency department services. In many instances, these contracts do not include disincentives that would discourage primary care physicians from sending patients who require nonurgent care to emergency departments for treatment. Without such disincentives, emergency departments may have to bear a considerable financial burden for providing additional services. Prior to negotiating the terms of capitated contracts for emergency services, managers should analyze carefully how patients use emergency department resources. By negotiating with managed care organizations to include volume stop-loss provisions and other financial disincentives to curb overutilization by physicians, financial managers can help protect their organizations from the costs of overutilization. PMID- 10157015 TI - Government launches major antifraud initiative. AB - Operation Restore Trust, a two-year intergovernmental demonstration project, was enacted in 1995 as an effort to curb Medicare/Medicaid fraud and abuse violations. This initiative targets five states with the most Medicare beneficiaries. If successful, Operation Restore Trust probably will be expanded to other states. PMID- 10157016 TI - Using cost accounting data to improve clinical value. AB - Value in health care can be defined as the provision of appropriate care at appropriate cost. While appropriate care is the province of clinical providers, cost data usually is maintained by financial managers. Collaboration between clinical providers and financial managers therefore is essential if optimum value is to be created. To this end, cost data are frequently given to providers for use in clinical care improvement projects. One such project has been implemented successfully at Virginia Mason Medical Center, Seattle, Washington. PMID- 10157017 TI - Avoiding potential problems when selling accounts receivable. AB - Accounts receivable financing is a potential tool for managing a provider organization's working capital needs. But before entering into a financing agreement, organizations need to consider and take steps to avoid serious problems that can arise from participation in an accounts receivable financing program. For example, the purchaser may cease purchasing the receivables, leaving the organization without funding needed for operations. Or, the financing program may be inordinately complex and unnecessarily costly to the organization. Sometimes the organization itself may fail to comply with the terms of the agreement under which the accounts receivable were sold, thus necessitating that restitution be made to the purchaser or provoking charges of fraud. These potential problems should be addressed as early as possible--before an organization enters into an accounts receivable financing program--in order to minimize time, effort, and expanse and maximize the benefits of the financing agreement. PMID- 10157018 TI - Business office customer service units pay dividends. AB - Business office managers, pressured to meet cash collection goals, sometimes fail to plan and implement restructuring and training initiatives that would improve customer relations. Even when customers complain about poor service, little may be done to address those concerns. But savvy business office managers are realizing that the potential benefits of forming a dedicated customer service unit within the business office include a well-run, customer-focused operation and improved customer satisfaction. PMID- 10157019 TI - A new standard for provider information and credentialing. PMID- 10157020 TI - Top 10 variables that affect job search success. PMID- 10157021 TI - Managing short-term investing. PMID- 10157022 TI - Data trends. May 1996. PMID- 10157024 TI - Michael Jackson at Beth Israel: handling press, fans, gawking employees. PMID- 10157023 TI - New OSHA guidelines target violence directed at health care employees. PMID- 10157025 TI - Paul M. Sarnese on using CQI to cut costs and improve security. PMID- 10157026 TI - University upgrades security after med center parking lot robberies. PMID- 10157027 TI - Security alert van escort program ups safety at Duke U., Med Center. PMID- 10157028 TI - Hospital safety and infection control: an update on new dangers and liability trends. AB - Patient and employee safety remains high on the list of hospital problems, with a number of new challenges facing safety officials. Lawsuits for negligent safety, the leading source of litigation against health care facilities, continue to produce costly judgments. In this update, we'll present a number of problems to watch out for and review some recent slip and fall and injury cases. PMID- 10157029 TI - IT update/case study. Law enforcement. PMID- 10157030 TI - IT update/PFI. From high and dry to PFI (private finance initiative). PMID- 10157031 TI - IT update/feature. Techno manager. PMID- 10157032 TI - IT update/case study. Live wire. PMID- 10157033 TI - IT update/PFI (private finance initiative). Shake-out. PMID- 10157034 TI - Assessing services. Knowing the score. PMID- 10157035 TI - Mental health. Everybody needs good neighbours. PMID- 10157036 TI - And the winner is .... PMID- 10157037 TI - Marketing. Kwik off the mark. PMID- 10157038 TI - Community care. Local heroes. PMID- 10157039 TI - Data briefing. Back pain. PMID- 10157040 TI - Lifetime hospitalization profiles for symptomatic, HIV-infected persons. AB - We explored the relationship between the incidence of hospitalization and disease progression in a group of 140 symptomatic, HIV infected patients by linking hospitalizations to the time of diagnosis, the time of death, or both. The relationship could best be described by positively skewed U-patterns or (weak) J patterns with a high use of resources immediately following diagnosis and preceding death. The lifetime hospitalization profiles differed according to the type of insurance, age, the initial diagnosis in the CDC-IV stage and the length of survival. The results not only confirm general hypotheses posed by other research groups, but also demonstrate the existence of variations among subgroups of patients. The results can be used to improve economic assessments of the impact of AIDS in The Netherlands and the European Union. The method used has the advantage of being based on a bottom-up approach to resource utilization, involving the use pf prospective data for the patients' full lifespans, and can easily be applied to other areas of health services research. PMID- 10157041 TI - Complex decisions about an uncomplicated therapy: reimbursement for long-term oxygen therapy in Catalonia (Spain). AB - Therapies used in the management of chronic diseases cause specific problems regarding reimbursement policy. Oxygen therapy is an example of such treatments that receive little attention from health care policy makers, due to their low cost to the health care budget and to their little importance from a social point of view. In this paper, we analyze the problems posed by this therapy in the Catalan health care system, as an example of the several aspects implied in the reimbursement of such kind of therapies. A technology assessment of this therapy was carried out showing that a change in the reimbursement of long-term home oxygen therapy (LTOT) was needed. Slow diffusion of new oxygen delivery modalities and over-prescription of LTOT were among the problems observed. The new system proposed is presented, and some preliminary results and consequences of the role of technology assessment in health care policy-making are discussed. PMID- 10157042 TI - Costs of mental illness in Britain. AB - Cost of illness studies are a growing area of literature without a common methodology and their usefulness has been debated over the years. A short review carried out of the British studies on mental health revealed differences which originate from three main areas: the epidemiological evidence on prevalence, service contact data and the unit costs employed. This paper outlines the differences found in a number of these studies and we develop a worked example using information from the studies to illustrate the issues of concern. We conclude that the area is problematic in two fashions. Firstly, the results are highly sensitive to epidemiological data and assumptions on costs. Secondly, the assumptions on costs and use of services must always be made explicit. PMID- 10157043 TI - Beyond the public-private debate: the mixed economy of health. AB - Can or should private organisations provide public healthcare services? What is the scope for private finance in public healthcare services? This paper reviews some of the arguments for and against public or private ownership management and financing of public healthcare services. It concentrates on health services, where non-economic values and ethical questions are as important as the efficiency considerations, and on health purchasing or funding organisations. The paper describes the increasingly complex interrelationship and forms of competition between public and private providers, purchasers and financiers in the UK health sector. It argues that the simple private/public distinction never did describe well the many different forms of financing ownership and operation of health services in any country and is now a handicap to both scientific and lay policy debate about future options. It proposes a framework for describing the main forms of ownership and operations of health services and considers the future for health service purchasing and funding. PMID- 10157044 TI - Assessing health service needs: tools for health planning. AB - As fiscal pressures mount, health-planning and decision-making at smaller geographics scales must be more effective. Involving local constituents in needs assessments, it is believed, would lead to better identification and serving of regional demands and needs for health services. This article examines needs assessment as a tool to determine a community's service needs and establish priorities for the creation of programs. Various approaches used in needs assessments are described, including survey methods, structured groups and geographic information systems. PMID- 10157045 TI - Toward a framework for health service research. AB - Fiscal concerns have provided the impetus for wide-ranging attempts to reform the delivery of health care in Canada. Health reform has in turn stimulated great interest and activity in health service research. For health service research to be of maximum use in addressing current and future challenges to the health care system, closer liaison is needed between researchers and decision makers--the users of research. The purpose of this paper is to promote greater interaction between decision makers and researchers by proposing a framework for health predicated on types of information needed for decision-making rather than on study methodologies. We distinguish between decision makers at the societal, health system, program and service levels. Types of studies are classified by their purpose and by the phase of the management cycle for which they provide information for decision-making. PMID- 10157046 TI - A decision-making aid for long-term care waiting list policies: modelling first come, first-served vs. needs-based criteria. AB - A chronic care hospital in London, Ontario, was faced with the question of whether to continue to admit applicants on a first-come, first-served basis, or to implement a needs-based admission criterion To provide information relevant to this decision, a simple computer modelling technique was used to model the waiting list under both policies. Analysis of the results indicated substantial variability in the need for care demonstrated by waiting list applicants, and individual placement priority under the two schemes. Descriptions of individuals affected by the proposed change in policy provided additional information. The information provided by the waiting list analysis contributed to the decision making process about waiting list policy. The method used is applicable to waiting list management decisions in other institutions. PMID- 10157047 TI - Identifying an appropriate case mix measure for chronic care: evidence from an Ontario pilot study. AB - With the move toward rate-based funding for chronic care hospitals, a case mix measure that describes chronic care patients in a valid and reliable manner is needed. A pilot study was done in Ontario to evaluate the effectiveness of three classification systems that have been implemented elsewhere. It was recommended that work continue on the basis that Ontario will implement the Resource Utilization Groups (RUG-III) system for activity measurement and funding of chronic care patients. PMID- 10157048 TI - On leaving Canada--reminiscences, remonstrations and recommendations. PMID- 10157050 TI - System integration: the view from the front. PMID- 10157049 TI - Selecting clinical outcome indicators for monitoring quality of care. AB - Clinical outcome indicators are used to identify opportunities for improvement in patient care processes. This paper focuses on issues specific to the selection of clinical outcome indicators for use in assessing performance within and between hospitals. The issues and examples are based on the experiences of a university research team that worked in collaboration with a group of teaching hospitals to develop and monitor clinical outcome indicators. Four sets of issues are discussed: the intended use, and end users of indicator information; aspects of indicator validity; data quality; and dissemination and use of indicator information. Recommendations are made that apply to individual hospitals, groups of hospitals and health care systems. PMID- 10157051 TI - IRS guidelines for purchasing medical practices. PMID- 10157052 TI - The ministry change imperative. Catholic healthcare providers must translate their assets into action. PMID- 10157053 TI - Care of the abused woman. A hospital's educational program assesses values and beliefs. AB - To answer questions about staff's ability to identify, assess, and support victims of woman abuse, St. Joseph's Hospital, Hamilton, Ontario, Canada, organized a task group that included a cross section of staff and representatives of a local women's shelter. A comprehensive literature review strongly confirmed the need for a program that would provide staff with relevant information about abused women and challenge them to examine their values and beliefs. The task group constructed a questionnaire that included six different scales measuring various aspects of respondents' beliefs and attitudes about woman assault. The educational program for the pilot units included a training video, in-service workshops, a resource training manual, and an assessment tool to assist staff in screening female patients. The survey identified some key areas of concern, including some widely held misconceptions about the causes of abuse. After the educational program, test scores showed significant changes, particularly on scales that measured belief in popular myths and the degree to which respondents held perpetrators responsible for their actions. Overall, the project demonstrated that values and beliefs related to woman assault can be significantly affected by an educational approach that combines information sharing with the opportunity for dialogue and questions. PMID- 10157054 TI - Fighting the "silent epidemic". Hospital launches comprehensive program against domestic violence. AB - In 1991, when Sacred Heart Medical Center, Spokane, WA, launched its Domestic Violence Task Force, the group's members soon discovered that few U.S. hospitals had policies on domestic violence. So they created one. They decided to address three interrelated areas: public education, professional education, and the care of patients who are domestic violence victims. First, the group wrote a booklet introducing the public to the battering phenomenon. Second, to show medical professionals how to identify battering victims and intervene on their behalf, the group produced a video and organized conferences and training sessions. Third, the task force rewrote hospital policy to ensure appropriate treatment for patients who are victims of domestic violence. Other organizations, including the U.S. Air Force, are using the task force's video. Sacred Heart has been given several awards for its work against battering. The task force is currently developing guidelines on domestic violence in the workplace. PMID- 10157055 TI - Teaching nonviolence in the inner city. A St. Louis hospital works with children and victims. PMID- 10157056 TI - An education in violence. Staged "trauma care" shows teenagers some harsh realities. PMID- 10157057 TI - Partners against violence. Two Minnesota hospitals join community-wide effort. AB - Mercy/Unity Hospitals, in the Minneapolis-St. Paul suburbs, have joined other local organizations in an attempt to respond to increasing reports of domestic violence in the community. Their effort has focused primarily on three fronts. In 1991 the hospitals began screening their emergency department patients for signs of domestic violence. Volunteers from a local women's shelter originally provided all advocacy services for battered Mercy/Unity patients, but in 1995 the hospitals set up their own advocacy office. More recently, the hospitals have created steering committees to guide the screening and treatment of battering victims and to educate employees and patients about domestic violence. In 1992, under the leadership of the county health department, Mercy/Unity and other local groups launched a study of violence against pregnant women in the community. Two hundred women volunteered for the study. The study indicated that healthcare professionals are sometimes slow to recognize signs of domestic violence. In 1993 each judicial district in Minnesota was told to create an organization to educate the community about child abuse and domestic violence. Mercy/Unity Hospitals are represented on their county's Domestic Violence Council. PMID- 10157058 TI - CHA survey report. Members' involvement in health and well-being activities. Catholic Health Association. PMID- 10157060 TI - Nursing home plans big party for its resident mothers. PMID- 10157059 TI - Danger signs. Coalition points to causes and consequences of inadequate care of the dying. AB - Dying patients and their families repeatedly express their need for supports based on compassion and caring, yet healthcare efforts focus on often ineffective technological interventions and procedures. Professional healthcare schools provide little or no formal training in pain and palliative symptom management or in the multidimensional approach to care of the dying. And the pace of change in healthcare leaves little time for communication between the patient, family, and caring team. Physician denial of death and dying has a significant impact on clinical decision making and misleads healthcare administrators about priorities. Even when clinicians want to practice holistic supportive care, they are often unable to because of competing productivity demands and lack of reimbursement. Inappropriate therapies may be initiated to justify continued care in acute and skilled nursing environments. Because healthcare professionals may not inform families about what can be done in the way of supportive care, they may choose to ?do everything,? which often means using inappropriate treatments. Supportive Care of the Dying: A Coalition for Compassionate Care is a unique collaborative effort to help change the culture of dying in healthcare and to help Catholic and other organizations offer appropriate care based on respect for the sanctity of life, regard for human dignity, and a commitment to stewardship. The coalition intends to develop a comprehensive supportive care model built on Catholic values and tradition. PMID- 10157061 TI - Community assessment or action? From conflict to synergy. PMID- 10157062 TI - Non-governmental organizations in international health: past successes, future challenges. AB - Non-governmental organizations, or NGOs, are increasingly instrumental to the implementation of international health programs. Following an overview of current conditions in global health and the problems that could be targeted by NGOs, this article describes the activities and philosophies of several representative approaches in this sector. The attributes of NGOs that increase their potential effectiveness are discussed, including ability to reach areas of severe need, promotion of local involvement, low cost of operations, adaptiveness and innovation, independence, and sustainability. A summary is provided of major future challenges in international health that may be addressed by NGOs, with particular emphasis on tobacco-related disease, communicable diseases and the AIDS epidemic, maternal mortality and women's health, injury prevention and control, and the need to secure durable financial support. PMID- 10157063 TI - The regulation of general practice in the UK. AB - When health professionals offer primary health services on a private market a number of problems can arise to do with choice, quality and supplier-induced demand. Professional self-regulation through qualification requirements and licensing procedures may offset some of the worst problems. However, in the UK, the primary health care sector is also subject to additional regulatory controls set within the context of the NHS. Private practitioners within the NHS function in a quasi-market setting, in which they are funded by public health authorities to provide services free at the point of delivery to their patients. Within this context there is regulation of quality, entry, prices and profits. This system can be contrasted with the much less extensive set of regulations applied to more market-based systems operating in countries such as the USA. Recent reforms in the UK have, however, initiated a movement towards a market-led system, extended the autonomy of health care practitioners, and increased the scope of financial incentives as a mechanism to promote professional quality and innovation. This article draws on the insights developed in Propper (1993) in her study of regulation and quasi-markets in secondary health care, education and community care. Its focus is on the extent of regulation in primary health care services; the effects of increased financial incentives on professional performance brought about by the NHS reforms; and, the scope for further deregulation of professional services in primary care. PMID- 10157064 TI - Experiences in paying for health care in India's voluntary sector. AB - This article summarizes the results of four in-depth case studies on the financing and costs of the health care programmes of well-known non-government organizations (NGOs) in India. These organizations have shown a high degree of creativity and innovation in developing varied sources of financing to reduce dependency and enable them to sustain their programmes. Government funds play a major role in supporting these voluntary health activities, with less significant roles played by foreign donations, user charges, pre-paid memberships, and public fund raising. Some effective methods of assuring access for poor clients while developing self financing are described. Cost studies of the NGOs' health schemes indicate that they operate at least as efficiently as public services and primarily supplement rather than substitute for such services. Suggestions for further development of voluntary sector financing are put forward. PMID- 10157065 TI - Health care provider choice: the North West Province of Cameroon. AB - Health care is provided in many developing countries free of any charge at the point of delivery. This is attributed to the fact that health care is one of the basic human rights. While modern health care in public health units is free, patients in rural areas continue to use either self-care, traditional healers or both. In Cameroon, the idea of integrating traditional and modern medical practices is discussed by both traditional and medical practitioners. However, it is not very clear what influences the household's choice of one or the other. Within a health district, where there are many providers, the question as to whether or not there is a possibility of choice open to all is posed. This article reports on a study undertaken in a rural health district that shows that there are many factors that influence the choice of health care. Among these factors is quality of care which is the most important factor influencing the choice of health care provider. As quality of care increases in governmental health centres, their choice probability also increases. Other factors include: the time spent seeking treatment; household income and size; distance; and, cost of health care. Those with higher incomes tend to choose private health units and those with larger families tend to choose government health units. Other socio cultural factors, difficult to model, appear to also influence the choice of providers. It is concluded that since household income influences the choice of private health units, policies targeting poverty alleviation should be instituted in the rural areas to provide households with income. This will enable them widened access to private health care and enable government to redeploy its scarce resources to maintain and extend services to needy areas. PMID- 10157066 TI - Access and payment for health care: the poor of Northern Vietnam. AB - In common with many developing countries, Vietnam has begun to introduce user fees at community and district level. This is part response to the transformation of the economy, economic recession, and the growing acceptability of alternative forms of health finance. This article examines the impact of these charges on the rural poor. Results from a 1995 survey in North Vietnam suggest that the poor generally delay treatment, make less use of government health facilities, and pay more for each episode of illness than the rich. There is evidence that the poor are forced to reduce consumption of essential goods or to borrow to meet these charges. A significant minority are deterred from using facilities. The current system of exemptions fails to provide adequate protection to the poor and a completely new system is required. The results suggest that it is the poor in poorer communes that are most affected by high user fees and it is to these areas that any assistance from government or donors should be targeted. PMID- 10157067 TI - Through traffic keep right. PMID- 10157068 TI - Managing crisis. PMID- 10157069 TI - Prehospital cardiac care. Interview by William J. Koenig and Lauren Simon Ostrow. PMID- 10157070 TI - Utstein applied. Fremont measures firefighter ALS response to cardiac arrests. PMID- 10157071 TI - Racing the clock. The emerging role of 12-lead ECGs. PMID- 10157072 TI - South Florida medics take training to heart. PMID- 10157073 TI - The EMD (emergency medical dispatcher) as a medical professional. PMID- 10157074 TI - The drawbacks of TQM programs in long-term care. PMID- 10157075 TI - Long-term care should attempt to embrace total quality management. PMID- 10157076 TI - Does TQM apply to long-term care? PMID- 10157077 TI - Create employee assistance programs to reinforce your progressive management style. PMID- 10157078 TI - Is total quality management a savvy trend or managerial trap? PMID- 10157079 TI - Total quality management benefits nursing homes. PMID- 10157080 TI - Residential differences in the use of pharmacies by older adults and their communication experiences with pharmacists. AB - This investigation compares adults (65 and older) living in two different types of communities on the characteristics of the pharmacies they use and their patterns of communicating with pharmacists. Telephone interviews were conducted with a random sample (N=400) of respondents, half residing in six nonmetropolitan counties (containing no towns of more than 4,000) and the other half in a single city (population approximately 130,000) located within a metropolitan county. Elders living in the sparsely populated nonmetropolitan areas were more apt to purchase their medications from an independent neighborhood pharmacy than their counterparts who lived in the large city. These pharmacies, however, were more likely to be located in another town. Differences between residential groups were also observed in the communication patterns that older patients had with their pharmacists. Elders residing in sparsely populated areas reported more frequent conversation with their pharmacists about general topics, although not about medicines or other health-related topics. The elders living in small and remote places also reported that they talked with their pharmacists longer, that communication about medications were more often initiated by the pharmacist, and that they were more likely to talk about their medications directly with their pharmacist rather than a non-pharmacist employee. The overall greater frequency of contact and communication between nonmetropolitan elders and their pharmacists would seem to be precursors to establishing a positive provider-client relationship and may increase the probability of more personal, medication related discussions. Further research is needed, however, to determine if these potentials are transformed into realities and if they lead to more positive medical outcomes for older persons. PMID- 10157081 TI - Prevalence of abnormal Pap smears in rural family practice. AB - The purpose of this study was to examine the prevalence of abnormal Pap smears in rural family practice, to compare this to the published literature, and to determine if the prevalence of abnormalities is higher in the younger age group (<=35 years of age). A retrospective chart audit was performed on all Pap smears from four rural family practice sites during a 12-month period. Data collected were Pap smear result, patient's age, and interval since previous Pap smear. Statistical analysis was used to determine if the prevalence of abnormal Pap smears was consistent among the practices as well as similar to the three larger published studies. Also, chi-square analysis was used to compare the prevalence of abnormal Pap smears in the younger (<=35 years of age) versus the older (>35 years of age) age groups. There were 2,891 Pap smears reviewed, with 782 (27%) recorded as abnormal. The prevalence of cervical intraepithelial neoplasia (CIN) (76 or 2.6%) was compared to the published literature and was found to be statistically significantly higher (chi square=772.194, P=0.000). The prevalence of abnormal Pap smears was higher in the younger than age 35 group when compared to the older than age 35 age group (chi square=20.953, P=0.000). Pap smear interval and age varied between the four practice sites, but the prevalence of CIN was not statistically different (chi square=3.154, P=0.368). The results of this study suggest that rural family physicians may encounter abnormal Pap smears at rates similar to those reported in the literature. This study also suggests that the prevalence of abnormal Pap smears may be higher in the younger groups in this population. PMID- 10157082 TI - Adjusting measures of physician availability to reflect importation of physician services into rural areas. AB - Recent changes in the organization and delivery of physician services in rural areas suggest the need to update how physician availability is viewed and measured. The objective of this study was to empirically examine the effect of rural hospitals contracting with outside physicians for part or all of their emergency room coverage, and the use of urban specialists to staff outpatient clinics, on measures used to assess physician availability. Based on data from one rural state, the findings demonstrate the importance of adjusting for the importation of physician services into rural areas. PMID- 10157083 TI - Implementation of an inpatient case management program in rural hospitals. AB - The objective of the study was to identify factors that affected the implementation of an inpatient case management program in rural hospitals. The hospitals studied were from the Western New York Rural Health Care Cooperative. Five of the hospitals implemented the program in 1992. A qualitative evaluation was conducted by analyzing tape-recorded interviews with nurses and chief executive officers to identify obstacles to and facilitators of program implementation. Many obstacles to implementation could be traced to workload and time constraints, physician autonomy concerns, and limited nursing staff and physician participation. Implementation was facilitated foremost by the effort and supportive attitudes of nursing leaders and hospital chief executive officers. This study concluded that it should be possible to successfully implement conceptually sound managed care and case management programs in rural hospitals, but it will require a relatively long period of support, especially from hospital administration and nursing leaders. PMID- 10157084 TI - The interactive effects of race and ethnicity and mother's residence on the adequacy of prenatal care. AB - Adequate prenatal care is known to reduce the risks of low birth weight and neonatal death, yet nearly one quarter of all women giving birth in the United States receive delayed, inadequate or no prenatal care. This suboptimal use of prenatal care has contributed to rates of low birth weight and neonatal mortality higher than those in most other industrialized nations. This paper examines the relationships among race/ethnicity, residence, maternal sociodemographic and medical risk characteristics, and use of prenatal care in the United States. Using data from the National Maternal and Infant Health Survey, this study found important differences in prenatal care use by race/ethnicity and residence, as well as interactive effects of these variables. Single marital status, nonmetropolitan residence, poverty, low level of education, and no insurance were more strongly associated with inadequate prenatal care for whites and Hispanics than for blacks. Nonmetropolitan residents were more likely to receive inadequate care, regardless of race/ethnicity or sociodemographic characteristics. Predicted probabilities of prenatal care use by race/ethnicity and residence showed that, regardless of risk, nonmetropolitan Hispanic women had the highest probability of obtaining inadequate prenatal care. Results highlight the continued importance of race/ethnicity and rural residence in determining prenatal care use and the need to design interventions targeted to these populations. PMID- 10157085 TI - Telecommunications and rural health care. PMID- 10157086 TI - Peer survey of physicians. PMID- 10157087 TI - Managing the managed care market competition. AB - Market competition among rival managed care plans has been rapidly changing the health care delivery of individual provider organizations, Local health care markets, and the American health care system. Yet, there are critical unanswered questions about managed care, and there are economic and structural problems inherent in health care markets. Thus, managed care market competition alone might not be sufficient to solve some important problems and meet the important goals of our health care system and society. Market competition, combined with some regulation to managed the competition, is more likely to achieve those goals. Market competition among managed care plans is described, and problems of this type of competition are explained in this article. One approach to managing the managed care market competition, which blends market competition with government regulation, is also presented. PMID- 10157088 TI - Making integrated health care work. AB - The primary purpose of forming integrated health care systems should be to increase value added for payers and patients. Without this kind of focus on customer needs, integration efforts are likely to fail. The authors identify seven factors that make up the value-added continuum for health care purchasers and providers. The article assesses several of the major strategies pursued by integrating systems (e.g., primary care network development, health plan partnership arrangements) against value-added criteria. The major finding: integrated health care has the potential to bring substantial added value to customers. PMID- 10157089 TI - The accountability continuum--employers and the community. PMID- 10157090 TI - Strategic choices for medical group practices. AB - This is the sixth in a series of articles (1) describing how to identify, assess, diagnose and strategically manage key medical group practice (MGP) stakeholders and (2) interpreting the results from the Facing the Uncertain Future (FUF) study. This article continues (from the previous article in this series) the discussion of the vital strategic stakeholder management process of choosing the most effective strategies for key stake holders based on two strategic priorities: reducing stakeholders potential for threat and enhancing their potential for cooperation. From this critical strategic priority-setting process. strategies are classified as either involving, collaborating, defending, or monitoring. Using data from the FUF project, four medical group practice (MCP) stakeholders are analyzed. These are the integrated delivery system/network (lDS/N) itself as well as its components: physicians, hospitals and managed care organizations (MCOs). The FUF project's MGP executive respondents believe these four stakeholders will be some of the most important MGP stakeholders in the year 2000. The FUF study was conducted jointly between the Center for Research in Ambulatory Health Care Administration (CRAHCA), the research and development arm of the Medical Group Management Association (MGMA), Englewood. Colo., and The Institute for Management and Leadership Research (IMLR). College of Business Administration at Texas Tech University, Lubbock, Texas. MGMA s American College of Medical Practice Executives (ACMPE), faculty of Texas Tech University's Ph.D. and M.BA programs in Health Organization Management (HOM), and faculty from the University of Alabama at Birmingham collaborated on the project. Abbott Laboratories. Abbott Park. Ill., provided funding for the FUF project The administration of Round One was completed in the fall of 1994. The administration of Round Two was completed in the summer of 1995. Selected Round One (i.e.. health care experts) and Round Two (i.e., MGP executives) results have previously been presented in educational programs and publications. PMID- 10157091 TI - Electronic medical records in the outpatient setting (Part 1). AB - Electronic medical records (EMR) are on the verge of becoming the standard within ambulatory practice. The costs and benefits of developing the use of EMR are summarized in this article. Some sample savings are included. Part 2, appearing in the next issue, will include a financial model that medical practices can use to begin developing their own cost-benefit scenarios. PMID- 10157092 TI - Nurse phone care--a new way of thinking (Part 2). AB - This article describes the development and design of a nurse phone care system that is integrated into the patient's total care within a multispecialty group practice and is reimbursable. The marketplace made clear to Park Nicollet, a Minneapolis multispecialty group practice of 375 physicians, that its access problem dissatisfied current patients and limited its market attractiveness. At first, Park Nicollet tinkered with its access problem in the tradition of Mobil Oil's ad: ?For every problem there is a solution: simple, neat and wrong.? Thus, an access task force was commissioned. Data was systematically gathered, the root causes were identified, and a nurse phone care system was designed. Some characteristics of the system are: the nurse is a provider of care, using approved guidelines; the service is designed to be reimbursed by third party payers; the patient decides whether he or she is comfortable managing the condition or needs an appointment; documentation of care goes to the medical record and the patient's regular physician; a follow-up call occurs whenever a patient accepts phone care; and it is available 24 hours a day and 365 days a year. PMID- 10157093 TI - What's up with managed workers' compensation? PMID- 10157094 TI - Due diligence helps you understand benefits and burdens. PMID- 10157095 TI - Empire Blues draws fire over for-profit ventures. PMID- 10157096 TI - HCFA ruling requires physician disclosure. PMID- 10157097 TI - Tricare shrinking military health budget. PMID- 10157098 TI - Watchdog group releases latest roster of 'questionable' doctors. PMID- 10157099 TI - White House details plan for Medicare. PMID- 10157100 TI - Insurance reform imperiled by add-ons. PMID- 10157101 TI - Fla. hospital ratings cause uproar. PMID- 10157102 TI - Healthcare Web surfers get guides. PMID- 10157103 TI - Georgia hospitals to launch 2 networks. PMID- 10157104 TI - 4th Colo. hospital network formed. PMID- 10157105 TI - N.J. hospital group wins OK to sue state. PMID- 10157106 TI - Study of U.S. system to focus on 12 sites. PMID- 10157107 TI - Effectiveness of provider networks, PHOs under study. PMID- 10157108 TI - Panel OKs new IRS penalties on tax-exempts. PMID- 10157109 TI - OrNda to study impact of hospital vendor contracts. PMID- 10157110 TI - 1996 construction & design survey. AB - Healthcare providers may not be investing as much capital in design and construction as they used to, but there's still plenty of activity in the facility management departments. Projects are smaller, and tight budgets are forcing facilities to spend less on more projects. PMID- 10157112 TI - How telemedicine eased ER's burden. PMID- 10157113 TI - Marketers gear up for quality ratings. PMID- 10157111 TI - Calif. county voters block construction of hospital addition. PMID- 10157114 TI - Former Mediplex execs in sibling rivalry of sorts. PMID- 10157115 TI - Colo. doc practice queried by FTC; reason unknown. PMID- 10157116 TI - Long controversy sinks Clarkson deal. PMID- 10157117 TI - Ousted ProPAC chairman 'not Republican enough'. PMID- 10157118 TI - Tenet admissions up 13% in 3rd qtr. PMID- 10157119 TI - 3 physician companies offer stock. PMID- 10157120 TI - Columbia to buy Ohio Blues for $299.5 million. PMID- 10157121 TI - Merger would form Utah powerhouse. PMID- 10157122 TI - N.J. group sues over payments. PMID- 10157123 TI - GOP plan separates budget bills. PMID- 10157124 TI - Not-for-profits: Columbia killed Tenn. bill requiring benefit reports. PMID- 10157125 TI - Agency probes Chicago clinic's referrals. PMID- 10157126 TI - AHA data: hospital closures drop to record low in 1994. PMID- 10157127 TI - Lower '94 spending on poor fuels record bottom line. PMID- 10157129 TI - Advocate system to sell health plan. PMID- 10157128 TI - Hospitals gain ground in Medicare device flap. PMID- 10157130 TI - Drug research firm acquires Lewin-VHI. PMID- 10157131 TI - Friendly Hills seeks Knox-Keene license. PMID- 10157132 TI - FTC goes to court to halt Mich. merger. PMID- 10157133 TI - Mont. hospitals seek clarification of pact. PMID- 10157135 TI - N.Y.C. hospital, Salick to establish cancer center. PMID- 10157134 TI - Eight New Orleans hospitals team up against for-profits. PMID- 10157136 TI - AHP moving into merchant banking. PMID- 10157137 TI - HCFA picks plans for Medicare program. PMID- 10157138 TI - The father of the HMO mulls quality measures. Interview by J. Duncan Moore Jr.. PMID- 10157139 TI - No prisoners. For-profit vs. not-for-profit hospital skirmishes intensify. AB - Intense competition has manifested itself in a number of Southern markets where historic Civil War battles took place. Like Union and Confederate regiments lining up against each other, once-competing hospitals have fallen in along ownership lines to form two competing systems: one for-profit, the other not-for profit. PMID- 10157140 TI - Senate near passage of insurance reform. PMID- 10157141 TI - Retailers make home-care shopping more convenient. PMID- 10157142 TI - Limiting waste in the supply chain. PMID- 10157143 TI - Opponents question Ohio Blues deal. PMID- 10157144 TI - Columbia aims to block Fla. tax. PMID- 10157145 TI - Common-sense ways to cut risk of violence. PMID- 10157146 TI - Patient is king. Studies define customers' satisfaction and the means to improve it. AB - It's being called a new age of healthcare consumerism. Researchers are compiling hard data on outcomes as well as launching sweeping surveys in the less tangible area of consumer satisfaction. The focus of all this activity is the patient. PMID- 10157147 TI - VA clinic plan could hit budget, watchdog warns. PMID- 10157148 TI - In the name of greed. In healthcare crime cases, execs risk six-figure incomes to steal the equivalent of several years' pay. PMID- 10157149 TI - Teamwork is the key to cutting costs. PMID- 10157150 TI - Late managed-care push fuels Pittsburgh networks. PMID- 10157151 TI - AARP adding HMOs to insurance plans. PMID- 10157152 TI - Miss. system focuses on prevention. PMID- 10157153 TI - Hospital sale is the talk of Texas town. PMID- 10157154 TI - Columbia eyes St. Luke's in Texas. PMID- 10157155 TI - D.C.-area cancer network planned. PMID- 10157156 TI - PHS takes on Columbia to gain ground in Ohio. PMID- 10157157 TI - N.J. system thrives despite stormy times. PMID- 10157158 TI - Wis. hospital deal scrutinized. PMID- 10157159 TI - La. hospital to restructure for antitrust compliance. PMID- 10157160 TI - Hospitals fear effects of disclosure laws. PMID- 10157161 TI - Attorney warns new rules may handcuff providers. PMID- 10157162 TI - 'De-selected' physicians dealt legal setback. PMID- 10157163 TI - Patient advocacy measures headed for California ballot. PMID- 10157165 TI - Medicare HMOs setting up shop in Michigan. PMID- 10157164 TI - Teaching hospitals in Boston to merge. PMID- 10157166 TI - Minn. HMO enrollment jumps 23%. PMID- 10157167 TI - Fla. HMO revamps hospital network. PMID- 10157168 TI - Premier funds biotechnology. PMID- 10157169 TI - Mass. Blues, hospitals at odds over indigent care. PMID- 10157170 TI - Pa. hospitals say charity-care data skewed. PMID- 10157171 TI - More budget cuts ahead at hospitals--survey. PMID- 10157172 TI - Medicare quality plan headed to overhaul. PMID- 10157173 TI - N.H. hospitals to study impact of medical care. PMID- 10157174 TI - AGPA creates satisfaction standards. PMID- 10157175 TI - Providers question bill's fraud language. PMID- 10157176 TI - Hope springs eternal in reports. PMID- 10157177 TI - HCFA revives proposal for cost-effectiveness rule. PMID- 10157178 TI - Alta Bates workers ignore union stand, OK pact. PMID- 10157179 TI - College gives antitrust intensive study. PMID- 10157180 TI - Three La. hospitals buy rural stake. PMID- 10157181 TI - Proprietary hospitals shifted more '94 cost. PMID- 10157182 TI - Smaller firms' struggle to grow continues. PMID- 10157183 TI - State-by-state hospital revenues and profits ranked by profit margin. PMID- 10157185 TI - Calif. foundation to assume programs' funding. PMID- 10157184 TI - New Cook County hospital postponed. PMID- 10157186 TI - Calif. doc aims to take firm nationwide. PMID- 10157187 TI - Providers smoke out tobacco tax. PMID- 10157188 TI - Insurance reform accord in negotiators' court. PMID- 10157189 TI - Medicaid funds help fill low income gap. PMID- 10157190 TI - Subacute providers measure success. PMID- 10157191 TI - Special section: assisted living. Going public--assisted living takes a walk down Wall Street. PMID- 10157192 TI - Special section: assisted living. Examining pharmacy needs: the search for medication management solutions. PMID- 10157193 TI - Special section: assisted living. Meeting needs through care planning. Process and form vary by state. PMID- 10157194 TI - Special section: assisted living. Preventing workplace violence: agency issues guidelines for providers. PMID- 10157195 TI - Getting a read on company publications. PMID- 10157196 TI - Feds chart new fraud and abuse territory. United States of America vs GMS Management Inc.; Tucker House II Inc. PMID- 10157197 TI - Provider 1996 corporate profiles. PMID- 10157198 TI - Managing multiple departments: isn't more really the same? PMID- 10157199 TI - Ethics, ethos, nonthinking and doing the right thing. PMID- 10157200 TI - Flattening the organization: implementing self-directed work groups. AB - In response to tremendous growth of managed care and threats to financial stability and job security, the Greater Baltimore Medical Center (GBMC) restructured itself into independent business units. The radiology department at GBMC resolved to reduce cost per unit-of-service, improve service, determine optimal staffing levels and reduce the number of layers of organization. It was decided to achieve those goals by implementing self-directed work groups. Staff buy-in was critical to success of the project. To begin, the staff was educated intensively about current trends in healthcare, managed care and potential changes in the job market. The radiology department was allowed to reduce the size of its staff through attrition and worked hard to focus staff concern on the impact each individual could have on the bottom line and the resultant effect on job security. Self-directed work groups were designed on a matrix that used small "service teams" in combinations to form larger "work groups." Actual work and daily activities occur at the service team level; information exchange and major decisions occue at the work group level. Seventeen months after beginning the project and 10 months after implementation, the organization has flattened, staff members have adjusted well to new roles, there have been no lay-offs, and the matrix system of small and large groups have proved particularly valuable. PMID- 10157201 TI - Preparing for change: strategic foresight scenarios. AB - Most people need stimulus to move from worrying about current problems to planning for the future. A carefully crafted strategic foresight scenario (SFS) can provide that stimulus. Recently, Allen Memorial Hospital, a 240-bed facility in Waterloo, Iowa, set up a management development team to help prepare hospital staff for changes that were expected to result from a reengineering study. One of the techniques they chose was to create an SFS. Strategic foresight exercises are often used at the highest management levels of corporations to prepare for strategic planning. At Allen, the exercise was prepared for use at all levels of staff to prepare for imminent change. A good scenario can stimulate foresight; it can show how relevant driving forces may affect not only the industry but also your individual health system. It identifies specific forces affecting healthcare delivery systems, tests assumptions for the future, assesses alternative and plausible futures and can form a springboard for future planning. A group of six employees considered factors that would affect healthcare delivery in 2005, drew on their creative energies and wrote a scenario (which is included in the article). The scenario is carefully written and follows a story line that is personal and specific to Allen. When presented to a group of senior managers, it was received with great interest and prompted discussion that ran beyond the designated meeting time. The SFS exercise successfully prepared staff at Allen for change, not by predicting the future but by modeling and inspiring an open mindedness and active approach to the future. PMID- 10157202 TI - Using breakeven analysis to examine price sensitivity. AB - Increased competition and managed care have brought about a need to reexamine how operating expenses are portrayed. Distinguishing between fixed and variable costs and using breakeven analysis can determine the implications of price concessions that may be requested by insurance companies. This technique also identifies areas of operating that hurt profitability of a specific imaging site or a modality within a single site. Breakeven analysis can also be used to investigate the effect of capitation and to strategize in an environment where commercial insurers sometimes establish fees that are so low, providers would prefer capitated contracts. In that situation the only option may be to manage utilization to enhance profit. This article includes financial models that can be used to simulate the implications of changes in the average income per scan (Table 1) and to examine the profitability of each segment of service within an imaging center (Table 2). Table 2 allows management to trendline each modality and examine cost chracteristics. That enables those responsible for overseeing operations to isolate and understand problem areas. PMID- 10157203 TI - Strategic repositioning: a practical approach to reducing costs and enhancing quality. AB - Sharply increased competition threatens the status quo in most healthcare organizations, which must now decrease costs while improving service. Those organizations can use strategic repositioning to evaluate their business practices and insure that they are performing at peak efficiency. Strategic repositioning (SR) is a process that changes functions within an institution--not just how people do the jobs they have done, but what they do. Meaningful cost savings come from changing the way services are delivered rather than from simple belt-tightening. This article discusses initiatives that resulted from an SR process at the University of Pittsburgh Medical Center. The radiology department was one of the first departments to participate in the process and successfully reached its goal: to reduce its operating budget by 22% over three years while increasing service quality. Generally, SR includes the following steps: assessing the status quo, project organization, benchmarking and evaluating results. Some of the changes proposed by the radiology department were: closing outpatient radiology services at an adjacent clinic, decommissioning the CT scanner in the OR, PACS implementation, consolidating ultrasound with the peripheral vascular lab, decreasing the use of non-ionic contrast media, decommissioning underutilized equipment, and consolidating services such as transcription and scheduling. As changes are suggested with an SR process, executives must make difficult decisions, such as whether a program survives or is discontinued. Radiology cannot do this alone! Establishing ambitious improvement goals at the beginning will set the stage for the program. Stretch beyond the limit. If the expectation is to decrease 15%, try to decrease 20% and in many cases quality will still be enhanced. It can be done. PMID- 10157204 TI - There they go again. This year's battle over health care reform is a political barometer. PMID- 10157205 TI - Fast, sensitive, painless, but a new imaging device may not be the best screen for heart disease. PMID- 10157206 TI - Inside the world of managed care. PMID- 10157207 TI - Expanding a right to die. Will new court decisions help or harm the terminally ill? PMID- 10157208 TI - Upset? Try cybertherapy. PMID- 10157209 TI - Older volunteers help themselves to better health. PMID- 10157210 TI - Marketing your gift shop to hospital employees. PMID- 10157211 TI - A village to tame the city of Detroit's mean streets. PMID- 10157212 TI - Community members introduce medical students to the real world. PMID- 10157213 TI - School-to-work programs turn students on to hospitals. PMID- 10157215 TI - Short stays for new moms create new challenges. PMID- 10157214 TI - Creating a true health care system. PMID- 10157216 TI - Caring volunteers boost patient pride. PMID- 10157217 TI - We get letters ... on "Healthcare Reform 101". PMID- 10157218 TI - Comparative attributes of effective health services managers and definitions of organizational effectiveness in Australia, the UK and the USA. AB - This paper explores and contrasts the perceptions of 855, mainly health services managers and 1452 students from three major English-speaking countries regarding the attributes needed for becoming effective managers in their country. Also addressed are country differences and similarities in the perceived relevance of particular indicators of organizational effectiveness. Despite Australia's British heritage, respondents from this country were found to be more similar to those from the USA, than those from the UK, in their views regarding the attributes of effective managers. Australian and American respondents rated 'nurturing' personality skills relatively highly, as they did 'classical' management skills. UK respondents rated 'classical' management skills as more important than 'political' skills. PMID- 10157219 TI - Design of effective health decision support systems: towards automating the health administrators's decision processes. AB - There has been very little evidence to suggest the effective use of, and demand for, computer-based systems by health care administrators to support their increasingly complex decision-making activities. This is so, despite a considerable amount of research attention paid to examining the efficiency and power of mathematical models, and the application of increasingly sophisticated Management Science Techniques to problems encountered within the health care system over the last several years. In recent times, advancing computer technology: 1) promises to close the gap between theory and practice, 2) creates a new perspective for computerized decision support in health care organisations, and 3) points to the need for new directions in research. This paper highlights the factors that are critical to the success of interfacing between health managerial decision-makers and effective computerized decision aids. PMID- 10157220 TI - A cost-constrained model of strategic service quality emphasis in nursing homes. AB - This study employed structural equation modeling to test the relationship between three aspects of the environmental context of nursing homes; Medicaid dependence, ownership status, and market demand, and two basic strategic orientations: low cost and differentiation based on service quality emphasis. Hypotheses were proposed and tested against data collected from a sample of nursing homes operating in a single state. Because of the overwhelming importance of cost control in the nursing home industry, a cost constrained strategy perspective was supported. Specifically, while the three contextual variables had no direct effect on service quality emphasis, the entire model was supported when cost control orientation was introduced as a mediating variable. PMID- 10157221 TI - Occurrence of validating clinical findings in the hospital record for appendectomy, cholecystectomy and intervertebral disc excision patients: comparisons among hospitals and among surgeons. AB - This study examines the variation among 36 Pennsylvania hospitals, and the individual surgeons practicing in them, in the proportion of appendectomy, cholecystectomy and intervertebral disc excision patients with clinical findings in the hospital record that validate the need for surgery. Using admissions from January 1990 through June 1991, we performed logistic regressions on the probability of validating clinical findings controlling for patient age, sex, admission severity of illness, and Medicaid and Health Maintenance Organization membership. Our results show that hospitals, and surgeons, vary significantly in their validation rates for cholecystectomy and disc surgery and, to a lesser extent, appendectomy. We also found that increased procedure-specific volume at both the hospital and surgeon levels is not related to the odds of validating clinical findings. We define a future research agenda to investigate the reasons for the observed differences among hospitals and among surgeons. PMID- 10157222 TI - Determinants of maternal mortality in rural China. AB - A case-control study of maternal mortality was conducted in selected rural areas of two provinces in China: Henan province, which has a relatively lower socio economic status and higher maternal mortality rates, and Jiangsu province with higher socio-economic status and lower maternal mortality rates. The major cause of maternal mortality in the two provinces was postpartum hemorrhage and the largest proportion of deaths occurred on the road between the women's home and the health care facility. Results indicate that the expectant mother's socio economic status, knowledge of maternal care, and the nature and level of maternal care provided all influence rural maternal death rates. However, socio-economic factors were only significant predictors of mortality in the poorer province. Implications for health policy and future research are discussed. PMID- 10157223 TI - Demographic and epidemiological aspects of plastic surgery: profile of a supradistrict specialty. AB - The workload of plastic surgery is often poorly understood by the public and those responsible for financing health care. The authors have used linked statistical data to analyse demographic and epidemiological profiles of workload in plastic surgery in Oxfordshire. The analyses were constructed for residents of the district and for patients treated from other districts. The former provides a profile of workload generated for plastic surgery from a geographically-defined population. The latter complements this by adding information about 'imported' workload. Admission rates for plastic surgery were higher for children and elderly people than for other age groups; higher for males than females; and they increased during the 11 years of the study. Most of the increase represented an increase in people treated by the service, rather than an increase in readmissions, although there was a modest increase in the latter too. Lengths of stay per admission and total time spent in hospital per person declined considerably. The bulk of the workload in plastic surgery is concerned with the treatment of trauma (including burns), cancer and congenital malformations. The main clinical conditions treated by the specialty are documented distinguishing, for each condition, the extent to which the patients came from outside the authority in which the provider unit is cited. PMID- 10157224 TI - Multi-phased bed modelling. PMID- 10157225 TI - Decrease in the rate of ruptured ectopic pregnancies: a successful team approach. AB - Noting the increasing frequency of ectopic pregnancy and desiring to reduce both morbidity and mortality, OB/GYN physicians at a large midwestern HMO systematically monitored all ectopic pregnancies in their clinical practice as the first step in a quality improvement project. Data were collected on several components of care including access, risk assessment, diagnosis of ectopic pregnancy, and intervention. To ensure the system was able to coordinate new diagnostic and therapeutic modalities, several key initiatives were instituted to improve patient outcomes. These included application of comprehensive guidelines, increased ultrasound availability, and increased staff and patient awareness. Following the implementation of the initiatives, there was a decrease in rupture rates from 32% in 1988 to 5% in 1992. This paper discusses the development and integration of the initiatives into the staff model HMO. PMID- 10157226 TI - Case management in a vertically integrated health care system. AB - A comprehensive case management system has been developed at Fallon Healthcare System, with overall aims of improving medical, social and financial outcomes for health plan members who need complex patient care management. A definition of case management is offered, goals of case management services are specified, criteria for appropriate referrals are outlined, and the process of implementing services is described. Formal evaluation of the program is being planned. PMID- 10157227 TI - A "high-tech," "soft-touch" immunization program for members of a Medicaid managed care organization. AB - Immunization rates among the very poor are critically low. The solution to improving rates requires technological tracking of immunizations linked to extensive home visiting outreach services as well as physician and member support services to increase compliance with recommended immunization schedules. This paper describes the development and implementation of a comprehensive immunization program which incorporates these strategies for members of a Medicaid managed care organization. Analysis of preliminary data provides some indication of the value of the tracking system and the effectiveness of incentives and home visiting on member compliance with immunizations. PMID- 10157228 TI - Promoting HMO values and the culture of quality: "Doing the right thing" in an HMO mental health department. AB - Innovation, collaboration, and efficiency are the hallmarks of good HMO therapy. The essential characteristics of effective therapy in managed care settings are described. A series of guidelines is presented for promoting clinician identification with HMO values. Emphasis is placed on the importance of a total quality management approach that enhances the development of a cooperative, competency-based culture. Selecting, educating, and rewarding clinicians for ?doing the right thing? is vital if we are to meet the challenge and mandate of providing high-quality, professional mental health services. PMID- 10157229 TI - The HMO Group's health policy position. PMID- 10157230 TI - A managed care education program for residents. PMID- 10157231 TI - Curbside consultations: a novel vehicle for physician education. PMID- 10157232 TI - A new audience: health promotion and SeniorCare. PMID- 10157233 TI - A learning disability clinic within the HMO setting. PMID- 10157234 TI - Capital Coast Health's investment plans. PMID- 10157235 TI - Well-managed deinstitutionalisation results in improved care. PMID- 10157236 TI - Radiotherapy services. Ministry of Health, New Zealand. PMID- 10157237 TI - Ethical issues surrounding access to health services. PMID- 10157238 TI - Local agencies cooperate on quality improvement project. Hip replacement variances examined. PMID- 10157239 TI - Hypoxemia on the general care floor: an emerging concern for risk managers. PMID- 10157240 TI - New York State aims to improve child health. PMID- 10157241 TI - Perspectives. Genetic discrimination issues emerges on uncertain terms. PMID- 10157242 TI - Perspectives. Twin studies analyze tactics for implementing guidelines. PMID- 10157243 TI - Perspectives. Backlash: how worried should health plans be? PMID- 10157244 TI - EPA's proposed medical waste incinerator regulations. PMID- 10157246 TI - Flexible budgeting allows for better management of resources as needs change. PMID- 10157245 TI - Industry's response to EPA's dioxin report. PMID- 10157247 TI - Continuous budgeting: a chance to catch up with change. PMID- 10157248 TI - Customer satisfaction: a practical approach for hospitals. AB - A California hospital developed a program to better serve and satisfy its customers. This article details the hospital's plan to implement the program with the collection and use of data to measure success, promote staff accountability, and, ultimately, demonstrate improved customer satisfaction as measured by fewer complaints. The various activities initiated to promote staff education and recognize employees also are briefly addressed. PMID- 10157249 TI - Interdisciplinary patient and family education. AB - The education of patients and their families can support positive patient healthcare outcomes. Patient and family education is an essential component of the healthcare delivery process, but it often is fragmented, with individual disciplines providing information without coordination. At the Carl T. Hayden VA Medical Center in Phoenix, AZ, a team reviewed the facility's process for providing patient education. As a result of this review, interdisciplinary process and documentation forms that improved both the quality of education provided and the documentation of that education in the medical record were developed. PMID- 10157250 TI - A theoretical model for coordinating and documenting patient education. AB - The Joint Commission on Accreditation of Healthcare Organizations' patient and family education standards pose a challenge to large medical centers. Prior to 1994, Joint Commission standards required all healthcare disciplines to instruct their patients about issues relevant to their health. There was no requirement that the information that was given to patients by providers in various disciplines, units, or clinics be coordinated. Now that education is a functional chapter in the Joint Commission's Accreditation Manual for Hospitals, an integrated approach to providing such education is necessary. This article proposes a theoretical model intended to help medical centers meet the new standards, improve patient education, and improve communication among healthcare providers. PMID- 10157251 TI - The Joint Commission survey can be a "SNAP" (Standards for Nursing Awareness Program). AB - Healthcare facilities' integration of the standards and changes in current Joint Commission survey process means that staff members at all levels must participate and interact with surveyors more than ever before. It no longer is sufficient just to meet the standards; staff members must under stand and invest in the standards' intent. One way to accomplish this is to increase staff members' awareness of the various survey processes. It is not necessary to ?teach? the standards, but rather to relate them to what already is known and understood. Empowering the nursing staff by relating their practices to the Joint Commission standards, from their perspective and within a familiar context, can contribute significantly to a successful survey. PMID- 10157252 TI - Integrated monitoring and evaluation in the ambulatory care setting. AB - The ambulatory care area has been slower to develop integrated monitor ing tools than have hospital-based systems. This article outlines some reasons for this slowness, elaborates on the need for further developments in this field, and describes one multispeciality clinic's process to meet this goal. PMID- 10157253 TI - Achieving patient satisfaction: the relationship between human motivation and outcome optimization. AB - With the advent of quality improvement and outcome measurement imperatives, providers of healthcare services must fully understand the importance of the human and clinical processes that lead to positive patient encounters. To that end, this article proposes that parallel qualities exist between behavioral need theory and the clinical hierarchy of patient outcomes. A conceptual framework, or construct, is developed and presented that illustrates the importance of this parallel relationship in improving and optimizing patient satisfaction. The article concludes with a discussion of these similarities and implications for the future. PMID- 10157254 TI - The sexual division of leadership in volunteer emergency medical service squads. AB - This article reports on theoretical and empirical research that explored the hypothesis that there is a sexual division of leadership in volunteer emergency medical service (EMS) squads. This hypothesis was tested against survey data obtained from 216 current members of nine upstate New York volunteer EMS squads. Despite several mitigating characteristics of these organizations, and despite the lack of supporting statistical evidence at the aggregate level of officership, the research found statistically significant confirmation of sex bias in officer selection when leadership was disaggregated into line and staff officer positions. Medical qualifications and length of EMS squad membership were also included in the model as determinants of leadership experience. These results are discussed relative to the question of the sexual division of leadership in the overarching nonprofit and voluntary sector of the U.S. economy. PMID- 10157255 TI - Case study. Aggressive physician-led clinical reengineering helps University of California-San Francisco Medical Center stay competitive. PMID- 10157256 TI - Clinical path study. PMID- 10157257 TI - Who's looking at your files? Prying eyes find computerized health records an increasingly tempting target. PMID- 10157258 TI - Managed care and chronic illness: an overview. AB - The growth in managed care raises a number of issues with respect to people with chronic illness. One issue is whether HMOs enroll their fair share of people with chronic illness. Another issue is how to address the fears among people with chronic illness or disabilities who are faced with requirements to join managed care plans. PMID- 10157259 TI - Improving outcomes in chronic illness. AB - Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of a protocol, reorganization of practice systems and provider roles, improved patient education, increased access to expertise, and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. PMID- 10157260 TI - Components of a successful case management program. AB - Many critical factors, including operational and organizational resources, must be considered and addressed to implement a successful case management program. This article provides a blueprint for establishing a program that is compatible with an organization's objectives. The authors provide a step-by-step process, from defining case management to organizing and assessing staff and data capabilities, for helping health plans develop processes to provide quality patient care. PMID- 10157261 TI - Case management: meeting the needs of chronically ill patients in an HMO. AB - Primary care staff education plays a critical role in a health plan making a transition from a case management model to a model that emphasizes close care coordination for chronically ill patients with multiple care needs. Multidisciplinary teams can help refine the system to have a positive impact on care across diverse settings: Health Plan of Nevada found that such training aids staff in identifying at-risk individuals and in developing plans for preventive health screening activities, medication compliance, and needs assessment. PMID- 10157262 TI - Managed care and chronic care: challenges and opportunities. AB - As managed care enrolls an increasing proportion of the population, increased attention needs to be paid to the care of persons with chronic conditions. This trend is occurring in the context of medical care in the United States that is deeply rooted in the acute care model of illness. The distinctive character of chronic conditions requires a reorientation of clinical practice and the way in which medical and nonmedical services are organized. Optimal chronic care systems are characterized by the integration of primary and specialty care, integration of medical and nonmedical services, and emphasis on functional status and quality of life. Analyzing enrollment data, beginning chronic disease care improvement efforts, and redesigning key support systems are all targets for HMO action. PMID- 10157263 TI - USQA Health Profile Database as a tool for health plan quality improvement. AB - Managed care organizations are in a unique position to evaluate and improve the quality of care delivered to their defined memberships. Traditionally, health services delivery has been claims-focused. We describe a potentially richer, patient-centered approach, whereby patients with certain chronic diseases are first identified and then used as the unit of analysis. U.S. Quality Algorithms (USQA), a subsidiary of U.S. Healthcare (USHC) based in Blue Bell, Pennsylvania, has developed selection criteria for 36 different chronic diseases and a new database, the USQA Health Profile Database (HPD), to identify and archive patients with those diseases. Examples of how this approach and database can be used as a quality tool are demonstrated. PMID- 10157264 TI - Physician attitudes toward computerized practice guidelines. AB - Computerized information systems are gaining ground in quality improvement, and will become even more important as health plans implement, evaluate, and maintain clinical guidelines. PacifiCare of California explored physicians' attitudes toward applying computerized technologies to direct clinical guidelines. The results indicate not only physician acceptance factors, but illustrate the issues, such as information for medical decision making, that health plans must consider in developing computerized case management systems to manage the care of the chronically ill. PMID- 10157265 TI - The treatment of chronic benign pain syndrome in capitated health care. AB - Developing specialized services for the management of chronic benign pain syndrome offers enhanced patient care and reduced costs. The evolution of a behavioral medicine/health psychology department to provide these services in a large HMO is described. Operational aspects and implementation challenges are discussed. PMID- 10157266 TI - Quality improvement: an international commodity? PMID- 10157267 TI - Investigation into the attitudes of general practitioners in Staffordshire to medical audit. AB - OBJECTIVES: To investigate the attitudes of general practitioners to medical audit, and any associations between their attitudes and their personal characteristics. DESIGN: Postal questionnaire survey. SETTING --Staffordshire, United Kingdom. SUBJECTS: 870 Staffordshire general practitioners. MAIN MEASURES: Agreement or disagreement and associations between the attitudes to 16 statements about audit and the doctors' personal or practice characteristics--namely, sex, number of years since qualification, practice list size, number of partners, and the practices' experience of audit. RESULTS: 601 Staffordshire general practitioners (69%) responded. There was most agreement with the statements that audit is time consuming (86%), that ongoing training and education is needed (71%), that there is a compulsion applied on doctors to audit (68%), and that extra resources for audit should be provided by the medical audit advisory group (65%). There was considerable disagreement (53% of general practitioners) with the statement that ?government policy to expect general practitioners to do audit will enhance the population's health.? The median response by the 601 general practitioners was four positive responses out of 14 statements about audit (two of the 16 statements could not be graded positive or negative to audit). Women doctors generally had more positive attitudes towards audit, and so had those working with smaller mean list sizes, those in larger partnerships, and those in practices that had carried out audit for a longer time. CONCLUSIONS: There was a generally negative attitude to medical audit, but it was encouraging that those doctors with the most experience of audit obtained the most job satisfaction from it. IMPLICATIONS: More effort is needed to convince general practitioners of the value of audit. Without this, attempts to involve other members of the primary care team in multidisciplinary clinical audit are unlikely to be effective. Successful audits that are shown to be cost effective as well as leading to improvements in patient care should be publicised and replicated. A higher proportion of resources should be devoted to audit. PMID- 10157268 TI - Primary hip and knee replacement surgery: Ontario criteria for case selection and surgical priority. AB - OBJECTIVES: To develop, from simple clinical factors, criteria to identify appropriate patients for referral to a surgeon for consideration for arthroplasty, and to rank them in the queue once surgery is agreed. DESIGN: Delphi process, with a panel including orthopaedic surgeons, rheumatologists, general practitioners, epidemiologists, and physiotherapists, who rated 120 case scenarios for appropriateness and 42 for waiting list priority. Scenarios incorporated combinations of relevant clinical factors. It was assumed that queues should be organised not simply by chronology but by clinical and social impact of delayed surgery. The panel focused on information obtained from clinical histories, to ensure the utility of the guidelines in practice. Relevant high quality research evidence was limited. SETTING: Ontario, Canada. MAIN MEASURES: Appropriateness ratings on a 7-point scale, and urgency rankings on a 4 point scale keyed to specific waiting times. RESULTS: Despite incomplete evidence panellists agreed on ratings in 92.5% of appropriateness and 73.8% of urgency scenarios versus 15% and 18% agreement expected by chance, respectively. Statistically validated algorithms in decision tree form, which should permit rapid estimation of urgency or appropriateness in practice, were compiled by recursive partitioning. Rating patterns and algorithms were also used to make brief written guidelines on how clinical factors affect appropriateness and urgency of surgery. A summary score was provided for each case scenario; scenarios could then be matched to chart audit results, with scoring for quality management. CONCLUSIONS: These algorithms and criteria can be used by managers or practitioners to assess appropriateness of referral for hip or knee replacement and relative rankings of patients in the queue for surgery. PMID- 10157269 TI - Policy priorities in diabetes care: a Delphi study. AB - OBJECTIVES: To produce policy priorities for improving care of diabetes based on the findings of original research into patient and professional opinions of diabetes care in South Tyneside. To judge the feasibility of implementing these priorities as policy. DESIGN: A two round Delphi survey with a panel of 28 ?experts.? In the first round each respondent produced a list of recommendations based on the findings of a report of patients' and professionals' opinions of diabetes care. 20 respondents produced a total of 180 recommendations, reviewed by a monitoring panel to produce a summary list of 28 recommendations. In the second round respondents rated each recommendation on two 5 point Likert scales. SETTING: Mainly Tyneside but also other parts of England. SUBJECTS: 28 healthcare professionals, including patients and patients' representatives. MAIN MEASURES: Voting by experts on how important each recommendation was to improving diabetes care service, and how likely the recommendation was to be implemented in the next five years. RESULTS: There was a high degree of consensus among respondents about recommendations considered important and likely to be implemented--namely, those concerned with improving communications between doctors in hospital and in general practice, and improving communications with patients. Respondents were more pessimistic about the prospects of implementing the recommendations than about their importance. Respondents thought that standards were important for improving care, and half would stop payments to general practice diabetic clinics that did not keep to district standards for diabetes care. For two recommendations a mismatch occurred between the importance of the recommendations and likelihood of implementation. This may reflect the practical problems of implementing recommendations. 18 of the 22 respondents thought that the study was useful in generating recommendations. CONCLUSIONS: The Delphi technique is a useful method for determining priorities for diabetes care and in assessing the feasibility of implementing recommendations. PMID- 10157270 TI - Assessing general practitioners' care of adult patients with learning disability: case-control study. AB - OBJECTIVE: To compare general practitioners' care of adult patients with learning disability with that of control patients in the same practice. DESIGN: Case control study of patients and controls by a structured interview study of general practitioners. SETTING: Avon. PATIENTS: 78 adult patients with learning disability and 78 age and sex matched controls--cared for by 62 general practitioners. MAIN MEASURES: Number and content of consultations and opinions of the general practitioners. RESULTS: There were more consultations for diseases of the central nervous system and of the skin among the patients than the controls (15 v 3 for central nervous system disease and 15 v 4 skin disease). There were also significantly fewer recordings of blood pressure and cervical cytology tests (34 v 51 for blood pressure and 2 v 18 for cytology). Although more patients were taking drugs affecting the central nervous system (33 v 6), more controls were taking drugs for musculoskeletal complaints (17 v 7). CONCLUSION: Although adult patients with learning disability consult with their general practitioners at equivalent rates to other patients, they get less preventive care and consult for different types of problems than do other patients. The reasons for these differences in preventive care are not clear. Carers and general practitioners should be informed of these differences to ensure that appropriate care is given. PMID- 10157271 TI - Bone densitometry at a district general hospital: evaluation of service by doctors and patients. AB - OBJECTIVE: To assess doctors' and patients' views about a district general hospital bone densitometry service and to examine existing practice to influence future provision. DESIGN: Three postal surveys: (a) of doctors potentially using the service, (b) of patients undergoing a bone densitometry test during a six month period, and (c) of the referring doctors of the patients undergoing the test. SETTING: Bone densitometry service at South Cleveland Hospital, Middlesbrough and two district health authorities: South Tees and Northallerton. SUBJECTS: All general practitioners (n=201) and hospital consultants in general medicine, rheumatology, obstetrics and gynaecology, orthopaedics, radio therapy and oncology, haematology, and radiology (n=61); all patients undergoing an initial bone densitometry test (n=309) during a six month period; and their referring doctors. MAIN MEASURES: Service awareness and use, knowledge of clinical indications, test results, influence of test results on patient management, satisfaction with the service and its future provision. RESULTS: The overall response rates for the three surveys were 87%, 70%, and 61%. There was a high awareness of the service among doctors and patients; 219(84%) doctors were aware and 155 of them (71%) had used it, and patients often (40%) suggested the test to their doctor. The test was used for a range of reasons including screening although the general use was consistent with current guidelines. Two hundred (65%) bone densitometry measurements were normal, 71(23%) were low normal, and 38(12%) were low. Although doctors reported that management of patients had been influenced by the test results, the algorithm for decision making was unclear. Patients and doctors were satisfied with the service and most (n=146, 68%) doctors wanted referral guidelines for the service. CONCLUSIONS: There was a high awareness of, use of, and satisfaction with the service. Patients were being referred for a range of reasons and a few of these could not be justified, many tests were normal, and clinical decision making was not always influenced by the test result. It is concluded that bone densitometry services should be provided but only for patients whose management will be influenced by test results and subject to guidelines to ensure appropriate use of the technology. PMID- 10157272 TI - Developing valid guidelines: methodological and procedural issues from the North of England Evidence Based Guideline Development Project. PMID- 10157273 TI - Changing the clinical behavior of doctors: a psychological framework. PMID- 10157274 TI - Looking at effectiveness: ideas from the couch. PMID- 10157275 TI - View from Ireland ... "Shaping a healthier future: a strategy for effective healthcare in the 1990s.". PMID- 10157277 TI - Follow the money. How more mental-health insurance can lead to even less care. PMID- 10157276 TI - Making sense of ambiguity: evaluation in internal reliability and face validity of the SF 36 questionnaire in women presenting with menorrhagia. AB - OBJECTIVE: To determine the face validity and internal reliability of the short form 36 (SF 36) health survey questionnaire in women presenting with menorrhagia. DESIGN: Postal survey of women recruited by their general practitioners followed by interviews of a selected subsample. PATIENTS: 348 women who had consulted their general practitioner with excessive menstrual bleeding and completed questionnaires after treatment. 49 women selected from this group were interviewed in depth about their health status, and requested to complete the SF 36 questionnaire. MAIN MEASURES: Subjective accounts of functioning and wellbeing as measured by the eight scales of the SF 36 questionnaire. RESULTS: Data from the postal survey indicated that the ?general health perceptions? and ?mental health? scales of the SF 36 questionnaire had lower internal reliability coefficients than documented elsewhere. In the follow up interviews several questions on the SF 36 questionnaire were commented on as inappropriate or difficult to answer for patients with heavy menstrual bleeding. CONCLUSIONS: Some questions on the SF 36 questionnaire were difficult to answer for this group of patients. Such problems can adversely effect the validity of the measure. It is suggested that comments of patients upon measures such as the SF 36 questionnaire could both determine the appropriateness of such measures for given studies and influence questionnaire design. PMID- 10157278 TI - System purchases support vendors' visions. Interview by Damon Braly. PMID- 10157279 TI - Sybase Healthcare Partners. Strong support offered by Sybase users, developers. PMID- 10157280 TI - PACS prices, performance showing improvement. PMID- 10157281 TI - When the playing field changes, rethink the rules. PMID- 10157282 TI - Telecommunications network services. AB - HMT's February Focus Survey deviates from the customary format to present the first segment of a multipart survey that was conducted by William Halverson, principal of Network Associates and a technical director for Pacific Bell's Healthcare Marketing Group. This first survey segment is designed to educate wide area network users about the multiple services that are offered within the U.S. market. General service availability and prices, as well as service descriptions and required equipment are covered in this segment of the survey. The remainder of Halverson's work will be published in the June issue of Health management Technology, and will detail service availability and prices for individual companies. PMID- 10157283 TI - Keep your options open with ambulatory systems. PMID- 10157284 TI - HotList. Ambulatory information systems. PMID- 10157285 TI - Network infrastructure is the key to your competitive advantage. PMID- 10157286 TI - Top executives share I/S strategies ... Anderson Consulting Health Management Conference. PMID- 10157287 TI - Mapping software/geographic information systems. PMID- 10157288 TI - PACS investment gains you a foothold on competition. PMID- 10157289 TI - Pick the right input device for your POC (point-of-care) systems. PMID- 10157290 TI - Enterprisewide scheduling: do you need it? PMID- 10157291 TI - Hotlist. Resource and staff scheduling/time and attendance software. PMID- 10157292 TI - CDC Wonder puts demographic data on Web. PMID- 10157293 TI - NIIT (National Information Infrastructure Testbed) update: Denver Health and Hospitals links rural areas. PMID- 10157294 TI - Decades of technology investment have halted healthcare inflation rate. PMID- 10157295 TI - National health care: will big brother's doctor be watching us? PMID- 10157297 TI - 1996 GHA legislative initiatives. PMID- 10157296 TI - Fraud and abuse crackdown: do corporate compliance programs make a difference? PMID- 10157298 TI - Electronic referrals: increasing satisfaction, reducing costs. PMID- 10157299 TI - Mapping: the road to health, wealth & happiness. PMID- 10157300 TI - Southwest Texas: finding the right mix. PMID- 10157301 TI - America's most computer advanced HMOs--1996. PMID- 10157302 TI - Medical records networking: banking on security. PMID- 10157303 TI - How is HEDIS affecting the information systems industry? PMID- 10157304 TI - Credentialing for practice privileges. PMID- 10157305 TI - Managed care and revenue in single-specialty groups. PMID- 10157306 TI - Time to revamp the gatekeeper system? PMID- 10157307 TI - 'Make gatekeepers true integrators of patient care'. PMID- 10157308 TI - Five lawyers recall 'The craziest HMO contract clause I've seen.'. PMID- 10157309 TI - 'Any willing provider': a toothless tiger? PMID- 10157310 TI - Should capitation's financial incentives be part of informed consent to treatment? PMID- 10157311 TI - When structuring contracts, don't forget about state laws. PMID- 10157312 TI - IPA models predominate among newer HMOs. PMID- 10157313 TI - Allina Health System revisited. Integration works, but not without major changes in operations, care delivery and governance. PMID- 10157314 TI - Columbia/HCA and Ohio Blue Cross: does the deal make strategic sense? PMID- 10157315 TI - Turning around ailing physician enterprises. PMID- 10157316 TI - Nursing homes in an era of health reform: implications for the future. PMID- 10157317 TI - Urban public hospitals: evolution, challenges, and opportunities in an era of health reform. PMID- 10157318 TI - Sexual harassment among nursing professionals: evidence and prescriptions for administrators. AB - The results of this study indicate that the experience of sexual harassment among nursing professionals may be more widespread than previously reported. With only one percent of respondents reporting ?quid pro quo? harassment, the vast majority of harassment fell into the ?hostile environment? category where the victim's perceptions are all important. Health care administrators should be cautioned that harassment and discrimination are evolving and expanding areas of the law, necessitating current knowledge of the standards for actionable conduct. To lower the risk of liability from claims of both victims and the accused, harassment and discrimination policies should be aggressive, proactive, fair, and thorough. PMID- 10157319 TI - Perceptions of management development in selected hospitals. AB - Today health care executives are managing organizations that are complex and require a higher degree of financial management, medical knowledge, and general business skills. The skills and academic background required to manage health care facilities have been debated by practitioners and academicians over the years. This study will examine executives' perceptions of management development activities in their organizations. To assess these perceptions, an eight-item questionnaire was mailed to 587 executives. Forty-two percent were returned. The data showed that a majority of the respondents indicated that the management development programs in their organizations were well received and that the morale of managers had improved. The pressures and challenges facing health care organizations will require managers and executives to make use of a wide range of skills if they are to be successful. PMID- 10157320 TI - Staffing in AIDS service organizations: the volunteer contribution. AB - This article reports results from a survey of AIDS service organizations (ASOs) that provide medical and social services to people with AIDS in the Oakland, California, area. The survey was designed to assess organizational and staffing characteristics of ASOs. Forty two of sixty-seven (62.7% response rate) ASOs responded, providing detailed data on their staffing patterns. ASOs that provided social services reported 48.5 percent of their total full-time equivalents (FTEs) as volunteers while medical organizations reported only 9.5 percent of their total FTEs as volunteers. Among the social service providers, ASOs that self identified as private, non-profit community-based organizations (CBOs) reported greater than half (50.8 percent) of their total FTEs as volunteer staff. All CBOs that reported utilizing more than five volunteer FTEs were AIDS-specific providers and had designated a full-time, paid staff position as volunteer coordinator/director. PMID- 10157321 TI - Ideological influence in U.S. health policy: catalysts or impediments? AB - Although pronouncements of the ?health care crisis? have been made for thirty years, in many ways the fundamental underpinnings of the U.S. health care system have changed very little. However, calls for health care reform have progressed through four distinct phases. From before the 1965 passage of the Medicare and Medicaid programs until about 1972, the primary issue was expanding access to care. From 1972 through 1976, health care reform proposals experienced a transition period. From 1976 until about 1992, cost containment became the dominant theme. Since 1992 there has been a renewed emphasis on improving access to care. But Americans have mixed feelings about health care reform. On the one hand, Americans want improved access to care, increased efficiency, and high quality care. On the other hand, Americans are leery of higher taxes and expanding the government's role in health care decision-making. In the final analysis, it is ultimately politics which governs the form of health care reform by effecting compromises between what is ideologically desirable and what is economically plausible. PMID- 10157322 TI - Psychometric properties and applications of the occupational needs questionnaire. PMID- 10157323 TI - The ins and outs of Internet outsourcing. PMID- 10157324 TI - CFO sees technology as a vital strategic weapon. Interview by MargaretAnn Cross. PMID- 10157325 TI - Military gunning for electronic records. PMID- 10157326 TI - From the back room to the board room. AB - CIOs are gaining new responsibilities as health care organizations turn to their information systems departments for help in achieving strategic objectives. CIOs are moving up the corporate ladder, participating in top-level decisionmaking and devising new ways to use information technology to solve business problems. They're discovering that an understanding of managed care and other industry trends is more important than technical knowledge of computers. PMID- 10157327 TI - How interface technologies bridge communication gaps. AB - Interface engines and translation software perform very similar, perhaps interchangeable, tasks. This special report offers an in-depth analysis of whether the lines between these two technologies will blur over time. PMID- 10157328 TI - Accreditation creates another incentive to automate. PMID- 10157329 TI - A tool for patient education. PMID- 10157330 TI - Sizing up the market for records software. PMID- 10157331 TI - Curing a credentials headache. PMID- 10157332 TI - Controlling payroll expenses. PMID- 10157333 TI - HCFA takes the lead on electronic attachments. PMID- 10157335 TI - Leading a PPO's push to empower physicians. Interview by Sharon Watson. PMID- 10157334 TI - The Web as an HMO marketing tool. PMID- 10157336 TI - Network meets rural needs. PMID- 10157337 TI - Taking on risk. PMID- 10157338 TI - The home care market offers telemedicine opportunities. PMID- 10157339 TI - Exploring the possibilities for applying teleradiology. PMID- 10157340 TI - An alternative approach to psychiatric consultations. PMID- 10157341 TI - Striking a balance between access and security. PMID- 10157342 TI - Managed care changes the clearinghouse market. PMID- 10157343 TI - ANSI X12 runs standards up the flagpole, but few salute. PMID- 10157344 TI - The difficult job of picking a standard. PMID- 10157345 TI - Clinical standards development shows signs of progress. PMID- 10157346 TI - Getting the codes right. PMID- 10157347 TI - The future lies in rehabilitation services. PMID- 10157348 TI - Fresh marketing ideas get results. PMID- 10157349 TI - How can facilities minimize staff turnover? PMID- 10157350 TI - Order of Excellence Awards. Honoring longterm care's elite. PMID- 10157351 TI - Changin' times. Administrators face many of the same problems, but their jobs are less secure. PMID- 10157352 TI - Creating prescription diets. PMID- 10157353 TI - As the staff turns. PMID- 10157354 TI - Legal traps face TB care providers. PMID- 10157355 TI - Poor dental care poses risks for elderly. PMID- 10157356 TI - Ballard opens rehabilitation center. PMID- 10157357 TI - Medical waste: new rules, requirements, and technologies. PMID- 10157358 TI - Resisting the effects of antibiotic resistance. PMID- 10157359 TI - Front line readiness in environmental service. PMID- 10157360 TI - Health systems ownership: can regulation preserve community benefits? AB - This article addresses two questions. What determines the amount of community benefit a nonprofit firm will provide? What would be the expected effect of legal rules requiring nonprofit firms to provide more community benefit than they would otherwise have chosen? The amount of community benefit provided, it is argued, depends on the desires of the donors who endow the nonprofit firm with its equity capital and control its corporate board. The effect of a law requiring the provision of community benefit depends on the degree of competition in the local market. In competitive markets, such a rule is like a hidden tax. In markets in which nonprofit firms have market power, it may divert resources from types of benefit valued highly by the board toward activities valued highly by the political process. The definition of community benefit and the future of nonprofit hospitals are also discussed. PMID- 10157361 TI - Tax exemptions as health policy. PMID- 10157362 TI - Adam Smith, George Orwell, and the contemporary hospital. PMID- 10157364 TI - Increased use of pepper sprays by hospital security reported. PMID- 10157363 TI - Why we need not-for-profit health care. PMID- 10157365 TI - Staffing and equipping security for two new 100-bed hospitals. PMID- 10157366 TI - Telephone towers provide emergency assistance at Denver hospitals. PMID- 10157367 TI - Security upgrading part of Children's Hospital's renovation, expansion. PMID- 10157368 TI - Hospital's 'too real' hostage drill results in staff complaints. PMID- 10157370 TI - Access to health services for vulnerable populations. PMID- 10157369 TI - The restructuring of hospital security and security management: how to go about it ... what can it accomplish. AB - We have written a number of articles and reports in the past year on the threat to hospital security operations posed by such concepts and buzzwords as re engineering, restructuring, downsizing, teams, and managed care--to name a few. Whatever doubts you may have about motivation behind these terminologies, and whatever skepticism you may have about the results that will be obtained when they are implemented, they remain, for the next few years at any rate, the facts of life for every security executive. For an increasing number of security professionals, this new ballgame represents an opportunity as well as a threat- an opportunity to enhance security's role in the new scheme of things and for security to become, as it has never been in the past, a more integral part of hospital management. In this report, we'll add three more phrases to your lexicon -value-added security, integrated security control, and self-directed work teams. And we'll give you details on how two hospital security directors are using the concepts they represent to their own and their hospital's advantage. PMID- 10157371 TI - Provision of home dialysis by freestanding renal dialysis facilities. AB - This article explores home dialysis provision among freestanding renal facilities by examining whether they provide continuous ambulatory peritoneal dialysis (CAPD), continuous cycling peritoneal dialysis (CCPD), and home hemodialysis. These modalities require fewer visits to a dialysis center, which may be beneficial for patients living long distances from facilities. A negative association was found between the number of facilities per square mile and the probability of provision of the home modalities. Secondly, facilities with a higher percent of black patients were less likely to provide the home modalities. Thirdly, facilities with larger numbers of patients were more likely to provide the home modalities. PMID- 10157372 TI - Excluded from universal coverage: ESRD patients not covered by Medicare. AB - Medicaid is believed to serve as the major insurer for end stage renal disease (ESRD) patients who are ineligible for Medicare coverage. Demographics, receipt of dialysis services, and costs of Medicaid-only populations were compared with Medicare ESRD populations in California, Georgia, and Michigan. Notable differences in patient demographics, dialysis practice patterns, and inpatient health resource utilization between the Medicaid and Medicare ESRD populations were observed. Medicaid expenditures for Medicare-ineligible ESRD patients were considerable: in 1991, California spent $46.4 million for 1,239 ESRD patients; Georgia and Michigan each spent nearly $5 million for approximately 140 ESRD patients. PMID- 10157373 TI - Participation in the Qualified Medical Beneficiary Program. AB - This article has three objectives: to estimate how many eligible elderly beneficiaries are participating in the Qualified Medicare Beneficiary (QMB) program; to determine the characteristics of participating and non participating eligibles; and to identify the most significant barriers to program participation. We used data from the Medicare Current Beneficiary Survey (MCBS) and the Medicare Buy-In file. We found that 41 percent of QMB eligibles are enrolled in the program; participation is higher for poor and less educated beneficiaries, those in poorer health, rural residents, African Americans, and Hispanics. Finally, we found that, in general, eligible beneficiaries are ill informed about the program. PMID- 10157374 TI - Medicare physician payment reform: its effect on access to care. AB - This study analyzed a specific indicator condition, congestive heart failure (CHF), to see if there is evidence that physician payment reform (PPR) has had an effect on access to care for Medicare beneficiaries. If there was a decrease in access to ambulatory care services associated with PPR, one would expect to see an increase in hospitalizations for CHF in the period after PPR was implemented This analysis examined the trend in rates of hospitalization for CHF for the overall Medicare population and for selected vulnerable subgroups. No significant discontinuity was found in hospitalizations for CHF with the implementation of PPR. PMID- 10157375 TI - Medicare spending by state: the border-crossing adjustment. AB - As the first step in a pioneering effort by the Health Care Financing Administration (HCFA) to measure interstate border crossing for services used by both Medicare and non-Medicare beneficiaries, the authors study the spending behavior of Medicare beneficiaries for 10 Medicare-covered services. Based on interstate flow-of-expenditure data developed for calendar year 1991, the authors analyze the spending patterns of State residents by studying the inflow and outflow rates and the netflow ratios of expenditures incurred by Medicare patients. The report also provides per capita expenditure estimates with residence-based adjustments and evaluates the impact of the border-crossing adjustment for individual services and States. PMID- 10157376 TI - Access to physicians. PMID- 10157378 TI - Variations in Medicare access and satisfaction by health status: 1991-93. AB - This article examines Medicare access, use, and satisfaction before and after implementation of the Medicare Fee Schedule (MFS), based on 3 years of data from the Medicare Current Beneficiary Survey (MCBS). Descriptive and multivariate analysis revealed that access has not deteriorated from 1991 to 1993; Medicare beneficiaries are reporting increased satisfaction--especially with the costs of care as well as reporting fewer barriers to care. Moreover, the gaps in levels of satisfaction and frequency of perceived barriers have narrowed among those in better and poorer health, suggesting that the program has become more equitable over time. PMID- 10157377 TI - Health care indicators. Hospital, employment, and price indicators for the health care industry: second quarter 1995. PMID- 10157379 TI - An analysis of utilization and access from the NHIS: 1984-92. AB - While the aged as a group have better access to health care since the inception of Medicare, there are subsets of the population that are still vulnerable to large out-of-pocket expenses. The focus of this analysis is on those segments of the Medicare population which are particularly vulnerable to access problems due to their personal characteristics. In particular, using data from the National Health Interview Survey (NHIS), this article will focus on the simultaneous influence of personal characteristics, such as insurance status, income, health status, and race on the use of physician services by the elderly population. PMID- 10157380 TI - Black-white treatment differences in acute myocardial infarction. AB - Previous research has documented that black patients with acute myocardial infarction (AMI) are significantly less likely than white patients to receive cardiac procedures. This article seeks to expand this research by: controlling for the limited ability of low income elderly to pay for care; and adjusting for the impact of differential mortality. We selected a sample of 18,202 Medicare beneficiaries admitted during 1992 with AMI, and followed them for 90 days. Even after adjusting for other factors, black patients with AMI were less likely to undergo cardiac catheterization, and if catheterized, less likely to receive a revascularization procedure. PMID- 10157381 TI - Medicaid and pregnant women: who is being enrolled and when. AB - Medicaid eligibility expansions and improved enrollment procedures for pregnant women during the late 1980s are examined in this article. Results show that the number of births financed by Medicaid has increased dramatically, and that women are enrolling earlier in the course of pregnancy. Nevertheless, problems continue to exist. If substantial numbers of women continue to enroll late in pregnancy, the expansions may not promote significantly earlier use of prenatal care. PMID- 10157382 TI - Health care use by Hispanic adults: financial vs. non-financial determinants. AB - The purpose of this article is to assess the relative effects of financial and cultural factors, namely language spoken, on health care use by Hispanic adults. Using a national sample, we examine the determinants of having a usual source of care (USOC), use of physician visits, and likelihood of having blood pressure checked. Multivariate analysis reveals the following: Monolingual Spanish speakers were not significantly different from English speakers for the three dependent variables; having private insurance or Medicaid was positively related to all three dependent variables. We conclude that financial factors--primarily insurance--remain as the paramount barriers to care. PMID- 10157384 TI - Hospital expansion. Harrison Memorial Hospital, Bremerton, Washington. PMID- 10157383 TI - Racial differences in access to kidney transplantation. AB - Previous work has documented large differences between black and white populations in overall kidney transplantation rates and in transplantation waiting times. This article examines access to transplantation using three measures: time from renal failure to transplant; time from renal failure to wait listing; and time from wait listing to transplantation. This study concludes the following First, no matter what measure of transplant access is used, black end stage renal disease (ESRD) beneficiaries fare worse than white, Asian-American, or Native American ESRD beneficiaries. Second, because the rate of renal failure exceeds the number of cadaver organs, access to kidney transplantation will deteriorate in future years for all races. PMID- 10157385 TI - Model housing. Rockwell Street House, Dorchester, Massachusetts. PMID- 10157386 TI - Take a walk. PMID- 10157387 TI - Rules for a bumpy road. PMID- 10157388 TI - Toward an ecology of health. Metaphorically speaking. PMID- 10157389 TI - Toward an ecology of health. Beyond the military and market metaphors. PMID- 10157390 TI - Toward an ecology of health. An ecological fairy tale. PMID- 10157391 TI - Beyond prevention: healing the "sociomas". PMID- 10157392 TI - Creating healthier communities. PMID- 10157393 TI - Technology, medicine & health, Part 10. Ecological medicine: the patient as planet. PMID- 10157394 TI - What if you could build it? PMID- 10157395 TI - Steering toward the endgame. Interview by Russell C. Coile Jr.. PMID- 10157396 TI - Realignments, realpolitik, religion, and reproductive health. PMID- 10157397 TI - The most important day. PMID- 10157398 TI - An epidemiological approach towards measuring the trade-off between equity and efficiency in health policy. AB - The concept of social welfare functions has been discussed in health economic literature, as it provides a way of examining the extent to which society is prepared to accept a trade-off between efficiency and equity. In this paper requirements for meaningful empirical estimates of the willingness to accept lower per capita health status in order to achieve greater equity are examined. Results from a pilot study aimed at testing the proposed measurement procedure are reported. They show that at least two thirds of the politicians who participated are prepared to accept a lower growth in per capita health in exchange for increased equity. Accordingly, we found a weak empirical support for the common health economic assumption that only total health benefit should guide the use of resources. PMID- 10157400 TI - Financing the World Health Organisation: global importance of extrabudgetary funds. AB - From 1948, when WHO was established, the Organisation has relied on the assessed contributions of its member states for its regular budget. However, since the early 1980s the WHO World Health Assembly has had a policy of zero real growth for the regular budget and has had to rely increasingly, therefore, on attracting additional voluntary contributions, called extrabudgetary funds (EBFs). Between 1984-85 and 1992-93 the real value of the EBFs apparently increased by more than 60% and in the 1990-91 biennium expenditure of extrabudgetary funds exceeded the regular budget for the first time. All WHO programmes, except the Assembly and the Executive Board, receive some EBFs. However, three cosponsored and six large regular programmes account for about 70% of these EBFs, mainly for vertically managed programmes in the areas of disease control, health promotion and human reproduction. Eighty percent of all EBFs received by WHO for assisted activities have been contributed by donor governments, with the top 10 countries (in Europe, North America and Japan) contributing about 90% of this total, whereas the UN funds and the World Bank have donated only about 6% of the total to date. By contrast, about 70% of the regular budget expenditure has been for organisational expenses and for the support of programmes in the area of health systems. Despite the fact that the more successful programmes are heavily reliant on EBFs, there are strong indications that donors, particularly donor governments, are reluctant to maintain the current level of funding without major reforms in the leadership and management of the Organisation. This has major implications for WHO's international role as the leading UN specialised agency for health. PMID- 10157399 TI - Health policy on bone density measurement technology in Sweden and Australia. AB - The possible adverse consequences of osteoporosis, particularly hip fractures, are a considerable health concern that is particularly relevant for elderly women. Bone density measurement is a method to assess bone mineral that has grown rapidly in recent years in both Sweden and Australia. The types of technologies adopted, their location and their level of use reflect the characteristics of the different health care systems, health technology assessments and policies adopted by health authorities. The health policy issues related to use of these technologies are complex and include consideration of who should be examined and treated, potential risks and benefits, machine performance, patient compliance and evidence of benefit. PMID- 10157401 TI - The ambiguous relationship between practice variation and appropriateness of care: an agenda for further research. AB - The analysis of variation in the use of health care services, and particularly of practice variation, has been the subject of renewed interest because of the view that the inappropriate use of procedures could be a major cause of these differences. In this article, recent literature is reviewed and the results of personal research are described on both the variation in care provision and on appropriateness assessment. In the few studies which have focussed on both subjects no evidence has yet been found to suggest that practice variation is to be explained by differences in appropriateness rates. However, there are still many methodological pitfalls in both variation analyses (statistical problems) and appropriateness assessment (reliability of the judgement), implying that this conclusion is far from definitive. More research should therefore be conducted on methodological questions of variation analysis and appropriateness assessment. Furthermore in variation analysis the relative contribution of all potential determinants has to be studied on the various levels of care provision. Finally, to study the relationship between practice variation and appropriateness of care, the clinical problem and not the procedure should be the starting point. PMID- 10157402 TI - An assessment of intraoperative radiotherapy. AB - An assessment of intraoperative radiotherapy (IORT) was undertaken to inform a decision on whether this technology should be introduced into the state of New South Wales. On the basis of a literature review, IORT appeared to be essentially an experimental technology, with limited data to demonstrate its comparative advantage over other treatments. Introduction of a dedicated IORT facility was technically feasible, but there appeared to be major uncertainties regarding selection and referral of suitable patients on a state-wide basis. The results of the assessment suggested that introduction of an IORT facility might have limited advantage for routine health services. A decision was subsequently taken not to support the introduction of this technology. PMID- 10157403 TI - Managed markets in health care: the UK experiment. AB - The reforms to the United Kingdom national health service initiated in 1989 have unlocked established relationships. Health care providers have come under challenge from an alliance of purchasers and general practitioners. This is resulting in a major rationalisation of acute hospital services in cities such as London. The general practitioner fundholding scheme appears to have produced benefits for patients, although its impact in the longer term remains uncertain. The combination of population based and patient focused models of purchasing within the reforms has created competition between purchasers as well as providers. This has served as a stimulus to purchasers to act as effective agents for patients but it also creates a risk of fragmentation. This paper analyses these developments and draws out their implications for the future of the National Health Service. PMID- 10157404 TI - Parents' perspectives on quality in family support programs. AB - Support services for families who have a member with developmental disabilities are a growing component of many state mental health systems. Family empowerment is a key principle of these programs, but parents and the staff who work with them are often challenged in their efforts to have parents participate in policy development, program management, and evaluation of programs. The use of nominal group techniques is described as a means of identifying factors parents believe characterize quality family support programs. Parents' identified factors are then compared with factors from a theoretical framework for quality. Parents stressed access to information, adherence to empowerment philosophy, and the importance of interpersonal relationships with staff. Parents placed less emphasis on factors generally found in accreditation criteria. PMID- 10157405 TI - The political development of "Program Realignment": California's 1991 mental health care reform. AB - This article reviews the legislative process that resulted in the most significant reform of California's public mental health system in nearly 25 years. The reform, termed "Program Realignment," decentralized administrative and fiscal control of the mental health system from the state to the county level. The system prior to Program Realignment is discussed here to reveal an already diverse and decentralized county mental health system, fiscal distress, and general dissatisfaction with the system. From these conditions, the objectives of the relevant political actors arose. By tracing the policy development process of Program Realignment, several independent variables are revealed that help explain how and why this legislation came into being and allow generalization of this case to other states' experiences. These independent variables are an urgent need for action within a limited timeframe, a preexisting knowledge base and well developed policy networks, a spirit of bipartisan cooperation, and the presence of strong leadership. Preliminary evidence suggests that consolidation of fiscal and programmatic authority at the local level has reduced fragmentation of services and increased fiscal flexibility. However, there is concern that the quality of care offered by the state's 59 local mental health programs will become increasingly disparate and that increased financial flexibility may not be used to improve services for clients but to save money for local governments. Lessons from California's experience can alert other states to the pros and cons of this policy approach to providing mental health services and inform policymakers in other states of the steps involved in bringing about such a policy change. PMID- 10157406 TI - Assessing client satisfaction in a psychology training clinic. AB - Client satisfaction with services obtained at a clinical psychology training center was assessed. A modified version of the Client Satisfaction Questionnaire was developed to obtain information about levels of satisfaction in such a setting and to evaluate training clinic-specific questions of interest, such as the impact of therapists' experience on satisfaction. Results indicated that client satisfaction is multidimensional. Consistent with other studies, satisfaction was greater among clients who were in therapy for longer periods of time, who completed treatment, and who sought therapy rather than an evaluation. Reasons for dissatisfaction included a wish for more directiveness or advice in therapy and concerns over videotaping procedures. Implications of these results for clinic administrators are discussed. PMID- 10157407 TI - Methodological advances in the use of recidivism rates to assess mental health treatment programs. AB - This study of recidivism rates within a state psychiatric system identifies and controls for a number of flaws in other recidivism studies and provides one of the few direct comparisons between different mental health programs using recidivism rates as a dependent variable. It is not an attempt to predict the likelihood of an individual patient's recidivism or to improve the treatment provided the individual patient. Instead, it is an endeavor to address the issue of using recidivism rates to assess a treatment program's effectiveness and to examine such treatment at the macro- or system wide level. PMID- 10157408 TI - AB 3632 mental health entitlement for special education students in California: aspects of the Los Angeles experience. AB - California Assembly Bill (AB) 3632, passed in 1984, ushered in an era of entitlement to mental health services for schoolchildren with serious emotional disturbances. This article examines the development of the law, the children's public mental health context in Los Angeles County, and the significant impact of the legislation on distribution of mental health services in Los Angeles County and in one Los Angeles area community mental health center. Countywide and agency data are presented that document AB 3632 and regular mental health service provision differences in gender, age, ethnic, income, and language domains and, at the agency level, an increasing proportion of AB 3632 clients. Implications of AB 3632 service provision in relation to provision of mental health services to children in general are reviewed. PMID- 10157409 TI - The mental health care reform debate: a content analysis of position papers. AB - Traditional and ethnographic content analyses of 23 position papers on mental health care reform issued during 1993 yield a comprehensive overview of the specific subjects and broad policy issues that were of concern at that time. Five concrete aspects of mental health service delivery systems and eight policy issues were identified as most important in position papers by service provider organizations and advocacy groups. These analyses identified overall similarities in the content of the position papers, although interesting differences among organizations emerged. The analyses also identified a measure of the quality of policy discussions that is derived from comparing the frequency of concrete references to aspects of mental health care with references to broader policy issues. PMID- 10157411 TI - Standards for restraint and seclusion. Joint Commission on Accreditation of Healthcare Organizations. PMID- 10157410 TI - Psychometric properties of a decision-support tool for the era of managed care. AB - This article reports psychometric properties of a decision-support scale designed to quantify the decision-making process for allocating psychiatric care. The authors developed a scale to evaluate the level of care needed for patients requiring psychiatric treatment in a health maintenance organization (HMO) setting. This study examines the reliability and validity of that scale by measuring interrater agreement among utilization reviewers from the HMO and between those reviewers and the clinicians who evaluated the patients directly. Agreement (kappa) among the five clinical raters acting in a utilization review capacity on dimensions of the scale ranged from .71 to .98. Kappas for agreement between the treatment intensity proposed by the reviewer/rater and used by the treating clinician were .41, .38, .40, .35, .36, and .39, respectively. The scale is reliable in the hands of trained personnel. Although there were important differences between clinicians' ratings and those of utilization review raters, these differences do not suggest that use of the scale would limit patient access to care. PMID- 10157412 TI - 1996 hospital survey process: what to expect. PMID- 10157413 TI - Top 10 most problematic hospital standards: how to comply. PMID- 10157414 TI - Joint Commission issues principles for evaluating credentials services: AMA Physician Masterfile qualifies. PMID- 10157415 TI - Home care standards and written policies and procedures. PMID- 10157416 TI - Quality drivers for the millennium. PMID- 10157417 TI - Circulating assignment in operating room clarified. PMID- 10157418 TI - Special report: restraint and seclusion standards. Restraint and seclusion standards for ambulatory care, hospital, and behavioral health care approved. PMID- 10157420 TI - Policy for evaluating occurrence of 'sentinel events' established. PMID- 10157419 TI - Accreditation process revised for adverse decisions. Decision appeal process and conditional accreditation affected. PMID- 10157421 TI - Revision calls for use of pulse oximetry equipment. PMID- 10157422 TI - Surveyors transmit first computerized preliminary report to Massachusetts hospital. PMID- 10157423 TI - Payment source and the cost of hospital care: evidence from a multiproduct cost function with multiple payers. AB - This study investigates the capacity of hospitals to vary the intensity of their services based on patients' expected sources of payment. While the concept of price discrimination by hospitals based on payer generosity ("cost-shifting") has been discussed extensively, the notion that hospitals can adjust payer-specific marginal costs to reflect differences in reimbursement policies has not been studied in depth. To examine this issue. this analysis employs a multiproduct cost function with hospital outputs defined as admissions by payment source, controlling for the distribution and severity of illness ("casemix") for each payer. Marginal costs of casemix-adjusted discharges are obtained and compared for Medicare, Medicaid, Private Payers, and a residual category that includes uncompensated care. We find that indeed, payer-specific marginal costs generally reflect payer generosity. PMID- 10157424 TI - On the value of changes in life expectancy. PMID- 10157425 TI - Modelling programme costs in economic evaluation. PMID- 10157426 TI - The determinants of health care expenditure: a cointegration approach. PMID- 10157427 TI - The effect of Medicaid reimbursement on quality of care in nursing homes. AB - This study uses a nationally representative sample of nursing homes and nursing home residents to examine the effect of Medicaid reimbursement on quality of care. The analysis shows that both reimbursement approach and level affect nursing home quality, as measured by case-mix adjusted staff to resident ratios. The analysis also shows that staffing ratios have a significant impact on resident outcomes, and these impacts vary by professional category of staff. Reimbursement does not have a significant impact on outcomes, however. PMID- 10157428 TI - Time preference, the discounted utility model and health. AB - The constant rate discounted utility model is commonly used to represent intertemporal preferences in health care program evaluations. This paper examines the appropriateness of this model, and argues that the model fails both normatively and descriptively as a representation of individual intertemporal preferences for health outcomes. Variable rate discounted utility models are more flexible, but still require restrictive assumptions and may lead to dynamically inconsistent behaviour. The paper concludes by considering two ways of incorporating individual intertemporal preferences in health care program evaluations that allow for complementarity of health outcomes in different time periods. PMID- 10157429 TI - New evidence on the relationship between income and health. AB - Using data from the National Survey of Families and Households, the Survey of Income and Program Participation, and the National Health Interview Survey, I estimate the structural impact of income on the following measures of health: self-assessed health status, work and functional limitations, bed days, average daily consumption of alcohol, and scales of depressive symptoms and alcoholic behavior. Both ordinary and IV estimates indicate that increases in income significantly improve mental and physical health but increase the prevalence of alcohol consumption. Cost-benefit analyses of government policies that may reduce disposable income should take into account potential effects on morbidity. PMID- 10157430 TI - Smoking, health knowledge, and anti-smoking campaigns: an empirical study in Taiwan. AB - This paper uses a measure of health knowledge of smoking hazards to investigate the determinants of health knowledge and its effect on smoking behavior. In our analysis, two equations are estimated: smoking participation and health knowledge. The simultaneity problem in estimating smoking behavior and health knowledge is also considered. Overall, the estimated results suggest that anti smoking campaigns have a significantly positive effect on the public's health knowledge, and this health knowledge in turn, has a significantly negative effect on smoking participation. The health knowledge elasticities of smoking participation are -0.48 and -0.56 for all adults and adult males, respectively. PMID- 10157431 TI - How can you survive continuous change. PMID- 10157432 TI - Why second opinions don't rankle me anymore. PMID- 10157434 TI - HMO growth shows no signs of slowing. PMID- 10157433 TI - Striking back at a bulldog attorney. PMID- 10157435 TI - We can win back our primacy over insurers. PMID- 10157436 TI - Here they come: price-conscious patients. PMID- 10157437 TI - What you must do to make a group practice work. PMID- 10157438 TI - Is "junk science" finally on the way out? PMID- 10157439 TI - How to give patients bad news. PMID- 10157440 TI - Why Columbia will be part of your life. PMID- 10157441 TI - Why I came back to medicine. PMID- 10157442 TI - Here's help for doctors battling a hospital. PMID- 10157443 TI - How doctors can regain control of health care. Interview by Stephen Murata. PMID- 10157444 TI - Readers talk back ... "Why doctors will take back health care". PMID- 10157445 TI - Practice sales. More and more doctors are hanging out "For Sale" signs. PMID- 10157446 TI - For these doctors, one audit fits all health plans. PMID- 10157447 TI - Here comes managed-care Medicaid. Should you hop aboard? PMID- 10157448 TI - "Doctoring" a chart cost this M.D. $1 million. PMID- 10157449 TI - N.Y. Blues to offer statewide HMO. PMID- 10157450 TI - Vatican to benefit from hospital sale. PMID- 10157451 TI - Cincinnati hospital considers conversion. PMID- 10157452 TI - Columbia dealt legal blow in Fla. PMID- 10157453 TI - Texas providers consider Medicaid lawsuit. PMID- 10157454 TI - Columbia wraps up Mass. venture. PMID- 10157455 TI - Minn. county faced with tough choice. PMID- 10157456 TI - VHA reaches marketing accord on pathways software. PMID- 10157457 TI - Insurance checks via CHIN offer savings. PMID- 10157459 TI - JCAHO hit with 5 years' back taxes. PMID- 10157458 TI - Charity care in Texas: numbers don't tell the story. PMID- 10157460 TI - Pilot program focuses on mental health for kids. PMID- 10157461 TI - Panels seek funds for military, VA healthcare. PMID- 10157462 TI - Alternative medicine not so unconventional. PMID- 10157463 TI - The perfect fit. Computerized patient scheduling requires the right mix of software, hardware, and human components. AB - As the arena of care widens beyond the hospital and begins to rely on moving patients around a scattered and diverse healthcare system, managers and clinicians will need a well-orchestrated method of keeping track of it all. For providers such as Lahey Clinical Medical Center, computerized patient scheduling is the key to a seamless system. PMID- 10157464 TI - Mo. antitrust probe focuses on PHO ... while market share is issue in N.H. case. PMID- 10157465 TI - Trading price controls for merger often pays. PMID- 10157466 TI - Trust fund report turns up pressure. PMID- 10157467 TI - Medical data accessible on Internet. PMID- 10157468 TI - AHA seeks to link PR, planning groups. PMID- 10157469 TI - CFO put through paces at Harvard. PMID- 10157470 TI - Mont. deal may be antitrust test case. PMID- 10157471 TI - AHA refuels search for firms to acquire. PMID- 10157472 TI - AHA to poll members on governance trends. PMID- 10157473 TI - Groups question impact of settlement. PMID- 10157474 TI - WellPoint gains East Coast ground. PMID- 10157475 TI - Demand sparks 1st-qtr. earnings rise. PMID- 10157476 TI - Feds project bleak Medicare payments to docs. PMID- 10157477 TI - Profits, investor angst climb during Columbia's 1st quarter. PMID- 10157478 TI - For Indians, a winning gamble. AB - For years, many of the nation's Indian tribes struggled to provide high-quality healthcare for their members. But that's all changing as the tribes parlay gambling revenues into new clinics, nursing homes and a variety of health programs. PMID- 10157479 TI - Nothing can stent device's growth. PMID- 10157480 TI - Specialists taking 'gatekeeper' role. PMID- 10157481 TI - Hospital attracts parade of bidders. PMID- 10157482 TI - GOP offers new plan for Medicare, Medicaid. PMID- 10157483 TI - AHA finds more satisfaction with accreditation process. PMID- 10157484 TI - HMOs scale back ownership of doc groups. PMID- 10157485 TI - Venture capitalists letting bets ride on healthcare firms. PMID- 10157486 TI - Data signal managed-care suits on rise. PMID- 10157487 TI - MedPartners: doc management's new goliath. PMID- 10157488 TI - Mo. Blues sues state on assets. PMID- 10157490 TI - AHA paints gloomier portrait of 1995's hospital performance. PMID- 10157489 TI - First Premier contracts put alliance to the test. PMID- 10157491 TI - La. wins two-year break on its Medicaid match. PMID- 10157492 TI - Efforts to mandate N.Y. plan stymied. PMID- 10157493 TI - Deal moves HBO & Co. into doc practice frontier. PMID- 10157494 TI - HCFA to respond to home-care fraud. PMID- 10157495 TI - Neb. wages war on hospital takeovers. PMID- 10157496 TI - Public hospital rebuilds to compete. PMID- 10157497 TI - Primary-care doc group joins Boston fray. PMID- 10157498 TI - Feds' scrutiny refocuses AHCPR mission. PMID- 10157499 TI - Providers must retake control of care decisions. PMID- 10157500 TI - Public firms report robust 1st quarter. PMID- 10157501 TI - Multi-unit providers survey. A tale of two ownership sectors. AB - In 1995 investor-owned systems balanced cutbacks and profits, while not-for profits suffered at the bottom line. Psychiatric hospital systems saw more upheaval, and outpatient and post-acute care grew at a steady pace. And in the senior-living business, the smart money was on assisted living. PMID- 10157502 TI - Multi-unit providers survey. More upheaval at psych systems. PMID- 10157503 TI - Multi-unit providers survey. Outpatient, post-acute care grows. PMID- 10157504 TI - Multi-unit providers survey. Assisted living leads growth. PMID- 10157505 TI - Dems, providers criticize GOP Medicaid proposal. PMID- 10157506 TI - AHA and AMA join forces to meet lobbying, education goals. PMID- 10157507 TI - Merger, acquisition activity hits record in 1st quarter, report says. PMID- 10157509 TI - Healthcare exec goes for the gold. Interview by Clark W. Bell. PMID- 10157508 TI - Mich. association reports on hospital performance. PMID- 10157510 TI - Blood from a stone. AB - Whether due to the federal government's generosity in handing out waivers or the creativity of healthcare visionaries across the United States, Medicaid is assuming a variety of shapes, colors and sizes. One of the largest experiments is in California. PMID- 10157511 TI - Industry takes steps to define itself. PMID- 10157513 TI - Squeezed distributors try new methods. PMID- 10157512 TI - Risk management efforts pay off--study. PMID- 10157514 TI - Ambulance companies adapt to market. PMID- 10157515 TI - 83 Mass. hospitals make feds' list. PMID- 10157516 TI - ORs try to overcome 'islands of automation'. PMID- 10157517 TI - Some ORs advanced, others lag in automation. PMID- 10157518 TI - Dartmouth, a pioneer in computerizing the OR. PMID- 10157519 TI - Patient survey opens door to improvement. PMID- 10157520 TI - Dolphins, not sharks, needed for leadership. PMID- 10157521 TI - What OSHA will look for in the event of a TB inspection. PMID- 10157522 TI - Trustee workbook. Board oversight of quality. PMID- 10157523 TI - Credentialing: a fresh start in a new world. PMID- 10157525 TI - What role does the board play in the medical credentialing process? PMID- 10157524 TI - If you knew what I know. Do you really want to communicate better with doctors? Try standing in their shoes for a day. PMID- 10157526 TI - Join the evolution! An IDN may be the answer to survival. PMID- 10157527 TI - Opportunity knocks for kids at risk. PMID- 10157528 TI - All work and no pay ... should board members be paid? The pros and cons. PMID- 10157529 TI - A last try at health reform. PMID- 10157530 TI - Shedding light on managed care. PMID- 10157531 TI - Lighting business sparkles in '96. PMID- 10157532 TI - Creation of an academic medical centre: management and service delivery at the Canberra Clinical School. AB - The Canberra Clinical School is attached to Woden Valley Hospital, the principal hospital in the Australian Capital Territory. The clinical school arose out of a memorandum of understanding signed between the University of Sydney and the ACT Department of Health (as it then was) in March 1993. One of the aspirations of those who negotiated the memorandum of understanding was that the creation of the clinical school would lead to a cultural shift in attitudes towards change within the health care system. This paper looks at the management structure of Woden Valley Hospital and at what the development of a clinical school in Canberra can achieve, particularly in relation to hospital and health service management. PMID- 10157533 TI - The Industry Commission inquiry into charitable organisations. AB - The Industry Commission has carried out Australia's largest inquiry into charities. It was, from the point of view of charities, an unsatisfactory operation, all the more so since it was not clear why the task had been given to the commission. This article examines the commission's work in three ways: the overall relationship between government and charities; the commission's proposed major reforms; and the minor reforms. PMID- 10157534 TI - Health service structures, management and professional practice: beyond clinical management. AB - At the heart of the operation of the health system is the relationship between managers and the various professionals who provide clinical services. While there is an inherent conflict between these two groups, this conflict has been avoided in the past by the managers playing a supporting rather than a controlling role. However, the current demands of cost-control are placing managers and professionals into direct conflict; a situation that many organisations are addressing by putting clinicians into management roles. This measure has had initial success in some situations, but it is argued that this success will be limited because clinical departments are not able to address many of the broader issues that affect the performance of health services. This paper proposes an alternative approach that will enable these broader issues to be effectively addressed, and also reduce the structural conflict. PMID- 10157535 TI - A proposal for managed care payment options for patients with chronic conditions. AB - This paper proposes an episode of care payment system for patients with chronic illnesses, extending earlier published work on this model of ambulatory care (Duckett and Jackson 1993). The payment system relies on annual voluntary enrollment and some marginal broadening of Medicare coverage in exchange for patients' willingness to participate in an ambulatory managed care arrangement. In the context of Australian health ministers' enthusiasm for managed care, the proposal embodies an intermediate policy approach which supports greater health care efficiency while minimising the prospect for reductions in patient autonomy or serious distortions in patterns of care. The policy is not designed to be applied population-wide, but to address the issues involved with a resource intensive patient group, those requiring ongoing management of chronic conditions. PMID- 10157536 TI - Total quality management practices in the NSW hospital system--an overview. AB - A two-phase descriptive study involving a questionnaire survey was undertaken during 1994 and 1995 to evaluate the extent of implementation of total quality management practices in New South Wales hospitals accredited by the Australian Council on Healthcare Standards. A survey response rate of 72 per cent was attained. Results indicated that most hospitals were aware of and consciously implemented aspects of the total quality management philosophy in some way. There is little evidence that whole systems have embraced the total quality management approach as a fully integrated endeavour. PMID- 10157537 TI - The annual variation in activity and funding for acute public hospitals in NSW, 1988-89 to 1992-93. AB - Casemix-based funding was introduced into the Victorian health system without an assessment of the annual variation in inpatient activity. Before undertaking such a funding reform, it would be appropriate to determine the level of annual variation in inpatient activity for individual hospitals that could be attributable to chance or random variation. If the annual random variation is not accounted for, then casemix-based funding may actually lead to inefficiencies. For this study, hospital inpatient activity and funding data for 120 acute public hospitals from New South Wales for the years 1988-89 to 1992-93 were used to estimate the standard deviation of the annual random variation in activity and gross operating payment. Through linear regression, estimates of the standard deviation of random variation about the underlying trend were obtained for each hospital. The results showed that, depending on the size of the hospital, total diagnosis related group cost weights have a standard deviation in the range of 2 to 16 per cent of total activity, whilst gross operating payment has an equivalent standard deviation that ranges from 1 to 10 per cent annually. The magnitude of the variation would suggest that funding of hospitals should either be based on average activity over several years or based on bands of activity in order to reduce the potential random variation in funding levels. PMID- 10157538 TI - Issues affecting refurbishment and re-use of pacemakers. AB - This paper discusses the problems associated with the refurbishing and re-use of medical devices which are sold by manufacturers as 'single use items' by focusing in particular on the re-use of pacemakers. Re-use of single-use devices such as pacemakers does occur in Australia, and in many other parts of the world, but there has been little public awareness of this fact. The paper explains and discloses medical, legal and ethical issues which arise through the re-use of pacemakers. It also discusses the recommendations of the 1995 'Draft report of the NHMRC Expert Panel on Re-Use of Medical Devices Labelled as Single Use'. PMID- 10157539 TI - Australia's 'free-ride' in pharmaceuticals: can it last? AB - The pharmaceutical subsidy scheme in Australia works in the public interest by keeping prices low while assuring access to drugs across most of the drug classes. By separating the approval to market drugs from the decision to subsidise them, the Commonwealth is able to take advantage of its position--to 'free-ride' on research and development expenditure in other countries. The first part of this paper examines the factors which allow Australia to free-ride. The second part explores some international and domestic factors which may influence the sustainability of the free-riding strategy. PMID- 10157540 TI - Clinical database repository--a solution for outcomes assessment. AB - This paper describes how implementation of a Clinical Database Repository (CDR) presents health care organizations with a tool to respond actively to quality and cost demands of the current delivery setting. The CDR is an innovative technological solution to integrate unlimited laboratory data with data from other systems, thereby expanding the contribution of routinely collected laboratory data to broader outcomes assessment goals of an organization. The technical components of a CDR, implementation methods, and deployment benefits to an organization are discussed. The resulting outcomes assessment from this tool will enable an organization to positively and cost-effectively influence how care is provided through system rules validation, measuring benefits of new technology, reducing unwarranted practice pattern variation, and validating practice guidelines. Although the value of systems such as CDR has been documented, their full potential for outcomes assessment has yet to be explored. PMID- 10157541 TI - A method for developing outcome measures in the clinical laboratory. AB - Measuring and reporting outcomes in health care is becoming more important for quality assessment, utilization assessment, accreditation standards, and negotiating contracts in managed care. How does one develop an outcome measure for the laboratory to assess the value of the services? A method is described which outlines seven steps in developing outcome measures for a laboratory service or process. These steps include the following: 1. Identify the process or service to be monitored for performance and outcome assessment. 2. If necessary, form an multidisciplinary team of laboratory staff, other department staff, physicians, and pathologists. 3. State the purpose of the test or service including a review of published data for the clinical pathological correlation. 4. Prepare a process cause and effect diagram including steps critical to the outcome. 5. Identify key process variables that contribute to positive or negative outcomes. 6. Identify outcome measures that are not process measures. 7. Develop an operational definition, identify data sources, and collect data. Examples, including a process cause and effect diagram, process variables, and outcome measures, are given using the Therapeutic Drug Monitoring service (TDM). A summary of conclusions and precautions for outcome measurement is then provided. PMID- 10157542 TI - Automating clinical practice guidelines: a corporate-academic partnership. AB - Implementation of guidelines offers one of the largest opportunities for quality improvement, utilization review, and cost control for the health-care enterprise. If guidelines could be implemented on a large scale, their adoption could result in $100 billion in annual savings as well as improve the quality of patient care. However, infrastructural barriers impede progress. Collaboration between the Laboratory Medicine Health Services Program at the University of Alabama at Birmingham, Columbia-Presbyterian Medical Center, and the Cerner Corporation, funded by the National Institute of Standards and Technology as part of the Advanced Technology Program involving ?Information Infrastructure for Healthcare,? is focused on developing and delivering: 1) methods for creating operational forms of guidelines; 2) an effective computer-based architecture for implementing guidelines in clinical practice; 3) methods for packaging guidelines for wide distribution; 4) methods for testing the efficacy, safety, and acceptability of guidelines; and 5) a model for collecting, aggregating, and normalizing data from disparate systems. This hypothesis-driven research program is focused on laboratory medicine-based guidelines as a tool for developing, testing, and evaluating methods that can be implemented widely. PMID- 10157543 TI - Utilization management in hospital clinical laboratories: a local analysis. AB - As hospital clinical laboratories position themselves for increasing involvement in managed care plans and for dealing with increasing cost containment, laboratory managers need to produce and assess data on the use of their testing services. The purpose of this study was to answer questions about the relationship between several dependent variables and the laboratory utilization management (UM) processes currently in place. An investigator-designed questionnaire was used to gather data on hospital bed size, availability of pathologists, involvement in managed care plans, and the types of laboratory information systems in use. The questionnaire was sent to the managers of all acute care hospital laboratories in the greater Houston metropolitan area. Although the total number of responses was small, the results showed that there is very little UM activity in Houston acute care hospital laboratories. This lack of sophisticated UM procedures may be consistent with the immature and evolving managed care environment in Houston. PMID- 10157544 TI - Improved Coumadin therapy using a continuous quality improvement process. AB - Through the Continuous Quality Improvement process, we determined that a significant number of patients were receiving too much Coumadin and having potentially serious side effects. The number of patients studied is limited, and there are only two time intervals reported postintervention. This makes it difficult to draw a definite relationship between the observed rates of Coumadin overdosing and the selected intervention. By educating the physicians on proper Coumadin dosing, we were able to reduce the number of patients experiencing hemorrhage or other complications. Our follow-up data review 1 year later showed that the gain had not been maintained as well as we would have hoped. This demonstrates that active review by Pharmacy and Laboratory on a regular basis and additional physician education would be beneficial. Through this process we gained valuable experience using the FOCUS PDCA method of continuous quality improvement. PMID- 10157545 TI - Managing technology. PMID- 10157546 TI - Apparent hemolysis in an AIDS patient receiving trimethoprim/sulfamethoxazole: case report and literature review. AB - OBJECTIVE: To describe a case of acute hemolysis associated temporally with administration of trimethoprim/sulfamethoxazole (TMP/SMX) in a patient with AIDS, review the available literature on TMP/SMX-induced hemolytic anemia, and discuss possible drug- and disease-related factors that may have contributed to the episode of hemolysis. CASE SUMMARY: A precipitous decrease in red blood cell count, hemoglobin, and hematocrit occurred shortly after a black woman with AIDS received a single intravenous dose of TMP/SMX for Pneumocystis carinii pneumonia. Following drug discontinuation and repeated transfusions, the patient's hematologic indices returned to baseline. LITERATURE SOURCES: References were obtained using MEDLINE searches, the bibliographies of articles identified during the searches, review articles, and standard textbooks. DATA SYNTHESIS: Of the two different mechanisms of TMP/SMX-induced hemolytic anemia, the reaction is most likely to occur via dose-related oxidative disruption of the erythrocyte membrane in subpopulations deficient in glucose-6-phosphate dehydrogenase (G6PD) activity. In the US, G6PD deficiency most frequently is encountered among blacks. The potential for hemolysis may be further increased in G6PD-deficient AIDS patients, who also appear to lack adequate intracellular glutathione, which is essential for protecting the erythrocyte membrane from oxidative damage. Although an assay for G6PD activity was not conducted, the case circumstances were consistent with TMP/SMX-induced hemolysis in a G6PD-deficient patient. CONCLUSIONS: Black patients with AIDS who are receiving relatively high (greater than or equal to 50 mg/kg/d) dosages of TMP/SMX should be monitored closely for signs and symptoms of hemolytic anemia. PMID- 10157547 TI - Directory of pharmacist-operated drug information centers in the US. PMID- 10157548 TI - Why a feminist approach to bioethics? AB - Many have asked how and why feminist theory makes a distinctive contribution to bioethics. In this essay, I outline two ways in which feminist reflection can enrich bioethical studies. First, feminist theory may expose certain themes of androcentric reasoning that can affect, in sometimes crude but often subtle ways, the substantive analysis of topics in bioethics; second, it can unearth the gendered nature of certain basic philosohical concepts that form the working tools of ethical theory. PMID- 10157549 TI - Rehabilitating care. AB - The feminist ethic of care has often been criticized for its inability to address four problems--the problem of exploitation as it threatens care givers, the problem of sustaining care-giver integrity, the dangers of conceiving the mother child dyad normatively as a paradigm for human relationships, and the problem of security social justice on a broad scale among relative strangers. We argue that there are resources within the ethic of care for addressing each of these problems, and we sketch strategies for developing the ethic more fully. PMID- 10157550 TI - Measured fairness, situated justice: feminist reflections on health care rationing. AB - Bioethical discussion of justice in health care has been much enlivened in recent years by new developments in the theory of rationing and by the emergence of a strong communitarian voice. Unfortunately, these developments have not enjoyed much in the way of close engagement with feminist-inspired reflections on power, privilege, and justice. I hope here to promote interchange between "mainstream" treatments of justice in health care and feminist thought. PMID- 10157551 TI - Feminism, law, and bioethics. AB - Feminist legal theory provides a healthy skepticism toward legal doctrine and insists that we reexamine even formally gender-neutral rules to uncover problematic assumptions behind them. The article first outlines feminist legal theory from the perspectives of liberal, cultural, and radical feminism. Examples of how each theory influences legal practice, case law, and legislation are highlighted. Each perspective is then applied to a contemporary bioethical issue, egg donation. Following a brief discussion of the common themes shared by feminist jurisprudence, the article incorporates a narrative reflecting on the integration of the common feminist themes in the context of the passage of the Maryland Health Care Decisions Act. The article concludes that gender does matter and that an understanding of feminist legal theory and practice will enrich the analysis of contemporary bioethical issues. PMID- 10157552 TI - Scope Note 30. Feminist perspectives on bioethics. PMID- 10157553 TI - Do-it-yourself case costing. PMID- 10157554 TI - Get the lowdown on orthopedic implants. PMID- 10157555 TI - 15 ways to discover hidden savings in freight. PMID- 10157556 TI - Germ busters. Experts tell how to choose--and use--the best antimicrobials. PMID- 10157557 TI - Don't just take the money and run: review your separation package. PMID- 10157558 TI - OR inventory systems: who's doing what--and why? PMID- 10157559 TI - Caught in the sterilization gap: which method works for you? PMID- 10157560 TI - Health service delivery to outback South Australia: a story of organizational change. AB - Discusses attempts to meet in an accessible, equitable and high-quality way, the health needs of 35,000 South Australians in 1.68 million square kilometres. Illustrates innovative work practices, developing teams and responses to regionalization. PMID- 10157561 TI - Improving the quality of NHS out-patient clinics: the applications and misapplications of TQM. AB - Presents and discusses the results of a monitoring programme instituted to comply with the objectives laid down in The Patient's Charter. Explores the dangers inherent in attempting to assess the quality of out-patient clinics by the use of single, simplistic indicators such as a waiting time. Examines the ways in which total quality management has been deployed in a health-service context and pays particular attention to the way in which the concept of ?the customer? may need considerable refinement. Suggests incorporating more user-centered approaches into evaluations of quality in the National Health Service, such as the patient satisfaction survey and the application of the SERVQUAL model of consumer satisfaction. Refines the concept of ?ecological validity? in an attempt to capture the perceptions and world views of all of the participants in episodes of out-patient care in order to derive more complete measures of quality. PMID- 10157562 TI - Implementation of ISO 9002 in cancer care. AB - Implementation and maintenance of a quality system in radiotherapy organization is discussed in the context of the Wessex Radiotherapy Centre, Southampton (UK). Examines the various development stages, staff attitudes, financial implications and identifies the positive and negative benefits. PMID- 10157563 TI - Drastically improving health care with focus on managing the patient with a disease: the macro and micro perspective. AB - The disease management approach to improving health care, at the systems as well as the hospital level, has proved to be very powerful, producing unprecedented results in reducing costs while improving quality of care and patient satisfaction. The Boston Consulting Group (BCG), working with a variety of leading managed care providers and pharmaceutical clients, has pioneered the development and dissemination of the disease management concept. Describes the disease management approach at the system level and shows results achieved so far. Shows also how the application of the logic of disease management within the boundaries of a single hospital leads to fundamental changes and quantum-leap results. In outlining the key success factors for a change process following the disease management approach, focusing on the patient with a disease, shows how the approach differs from traditional hospital re-engineering. PMID- 10157564 TI - Benchmarking in the UK National Health Service. AB - Traces the development of benchmarking in a number of UK National Health Service trusts, highlighting practical processes and the benefits of benchmarking but also identifying common pitfalls and ways of handling them when they arise or, better still, anticipating them. Several examples of successful benchmarking initiatives are given, emphasizing the advantages of using a systematic benchmarking approach, using benchmarking clubs and the need to develop ad hoc performance measures. Concludes by emphasizing the need for a new commitment to continuous improvement by senior managers to avoid the failures of previous drives for improvement. PMID- 10157565 TI - Life expectancy projection benchmarks: a how-to guide for medical equipment replacement programs. AB - This document provides clinical engineers, facility managers and hospital administrators a how-to guide for establishing a medical equipment replacement program based on the equipment's projected useful life after procurement and installation. This will allow managers a benchmark for establishing realistic budgets and plans for the phase-in of replacement medical equipment. PMID- 10157566 TI - Food contamination--reducing the risk. PMID- 10157567 TI - Overcoming obstacles in Minnesota's Roseau County. PMID- 10157568 TI - Hepatitis A increase warrants foodservice's attention. PMID- 10157570 TI - Centralized rethermalization helps the University Medical Center adapt to patient focused care. PMID- 10157569 TI - Recycling steel. Conducting a waste audit. AB - This is the second in a series of three articles regarding steel can recycling from foodservice operations of healthcare facilities. This article highlights the basic methods of recycling steel cans, and includes information on conducting a waste audit and negotiating with a hauler regarding the benefits of recycling. The previous article discussed how steel is recycled across the country. The next article will convey a case history of actual foodservice recycling practice from a healthcare facility. PMID- 10157571 TI - Public-private partnerships: what's in the public interest? PMID- 10157572 TI - An advocacy perspective on the AMBHA/NASMHPD White Paper. PMID- 10157573 TI - Integrating the delivery of privately and publicly funded substance abuse services. PMID- 10157574 TI - Platform for action. Consumer Managed Care Network. PMID- 10157575 TI - Refining the concept of public/private partnerships. PMID- 10157576 TI - Getting to cultural competence: guidelines and resources. PMID- 10157577 TI - Treatment readiness: a missing link in behavioral healthcare outcomes measurement. PMID- 10157578 TI - Managed care case management for people with serious mental illness. PMID- 10157579 TI - Managed care in the public sector: the federal role. PMID- 10157580 TI - Public purchasers, private delivery systems and incremental change. PMID- 10157581 TI - Personal protective equipment prices, under competitive pressure, still falling. PMID- 10157582 TI - Who will be the winner in this high-stakes fight for members? PMID- 10157583 TI - Laparoscopic cholecystectomy lends itself well to another look at reusable vs. disposable instrument packs. PMID- 10157584 TI - Developing health administration education leaders: the ACEHSA Fellowship experience. AB - The ACEHSA Fellowship was initially established as a professional and leadership development activity for individuals from academic and professional backgrounds. The Fellow plays an integral and critical role in the accreditation process. This key role of the Fellow is presented from former and current perspectives. Also, this discussion revisits the analysis of the Fellowship experience from the original study conducted by Fine (1984) and draws comparisons with data from a current study. The results demonstrate similarities in the role over time. The Fellowship experience appears to have a direct and positive impact on the ability of individuals to personally network with other professionals, which facilitates the opportunity to acquire future leadership roles. The authors of this study served as Fellows from 1993-1994. During that time, Dr. Sobczak was honored as Senior Fellow for his contributions to the Commission. PMID- 10157585 TI - Is accreditation in the public interest? AB - The relationship of accreditation to the public interest has been a topic of discussion in the media as well as in higher education circles as the topic has been politicized. This article examines the historical evolution of public involvement in the accreditation process as well as the reasons for public representation on accreditation bodies and in decision making. The links between accreditation and quality control are discussed and assessed. PMID- 10157586 TI - The role of research and scholarship in health administration programs. PMID- 10157588 TI - The value and promise of accreditation to the world of practice. PMID- 10157587 TI - The challenges facing American higher education. PMID- 10157589 TI - Evaluating health care management programs and schools of public health: some experiences in Europe. AB - The European Healthcare Management Association (EHMA) has built upon the ACEHSA model of accreditation to develop a European version-- program review--which takes account of the variety of health systems, cultures, and languages in Europe. This article describes the manner in which EHMA's ?program review? evolved, and the distinctive features of the process. It then analyzes some of the lessons that have emerged from the twenty-two evaluations completed in nine countries, distinguishing between issues of effectiveness (needs, objectives, and outcomes) and efficiency (inputs, processes, and outputs). It concludes by reviewing the efficacy of the methodology. PMID- 10157590 TI - The globalization of accreditation in the professions. AB - The direct relationship between educational quality and a successful economy, the proliferation of regional and global trade agreements which encourage professional mobility, and the growing international recognition of academic degrees are contributing factors to the globalization of quality assurance in higher education, including accreditation. On every continent, attention is being paid to developing professional educational standards within an international context, assuring that ?world class? professionals are produced for international as well as national practice. PMID- 10157591 TI - The Andrew Pattullo Lecture. In our new competitive world, is the health field headed for investor-owned takeover? Is it for better or worse? PMID- 10157592 TI - Slower economic growth affects the 1995 labor market. AB - As the pace of economic activity moderated in 1995, job growth slowed. Nonetheless, it was enough to absorb the small increase in the supply of labor, with the result that the unemployment rate remained at about the same level it had reached at the end of 1994. In the first quarter of 1995, employment grew at a brisk pace but, as the economy began to slow, job gains fell sharply. Employment growth continued at a much more moderate pace for the balance of the year, so that, by the fourth quarter, nearly 1.9 million jobs had been added to the Nation's payrolls. By comparison, in the fourth quarter of 1994 alone, payroll employment had grown by 1.1 million. Most of the job gains in 1995 were in the services industry group. Manufacturing employment, which had been rising since the fall of 1993, began to decline in the spring, and by the end of 1995, that industry group had lost nearly a quarter of a million jobs. Employment increased in most of the other major industry groups, even though declines in some of their component industries partly offset gains in others. PMID- 10157593 TI - Employers confront violence in the workplace of the '90s. PMID- 10157594 TI - New and emerging pathogens, Part 4. New and emerging viral diseases--the ultimate parasites. PMID- 10157595 TI - Improve microbiology procedures and utilization--while saving money. PMID- 10157596 TI - Questions mount on Ohio Blues deal. PMID- 10157597 TI - Rural providers voice concern over cuts. PMID- 10157598 TI - Coalition fights to block S.C. deal. PMID- 10157600 TI - Mo. to cut back most of its CON law. PMID- 10157599 TI - Proposed Mo. settlement upheld. PMID- 10157601 TI - Proposed merger of N.J. Blues, Anthem draws immediate fire. PMID- 10157602 TI - Providers dispute patient privacy bill. PMID- 10157603 TI - Community-benefit laws must be crafted with care. PMID- 10157604 TI - Buying doc practices often leads to red ink. AB - Like impulsive shoppers, hospitals can't seem to buy enough doctors. However, hospital-based systems aren't prepared for the management challenges of running medical groups. Many have been plagued by productivity slumps and high operating costs. PMID- 10157605 TI - Comdex operator plans healthcare conference. PMID- 10157607 TI - Hospitals concentrate on asset management. PMID- 10157606 TI - Hospitals expand via mall centers. PMID- 10157608 TI - Tech jobs grow, but distribution is uneven. PMID- 10157609 TI - OR managers squeeze out costs in Florida. PMID- 10157610 TI - Hepatitis C: increasing danger to workers. PMID- 10157612 TI - 'Dashboard' steers team through change. PMID- 10157611 TI - Health care 'report cards' go on sale at newsstands. PMID- 10157613 TI - Making the most of washer-decontaminators. PMID- 10157614 TI - New Jersey on a 'roller coaster' of change. PMID- 10157615 TI - National panel urges better RN, staff training. PMID- 10157616 TI - An information strategy to improve and measure quality. PMID- 10157617 TI - Applying QM concepts to futile care. PMID- 10157619 TI - CHINs: vapor-networks or reality? PMID- 10157618 TI - Managed care spices up the 1996 HIMSS/HP leadership survey. PMID- 10157620 TI - The smart card: wising up on plastic memory. PMID- 10157621 TI - Consult an expert: your computer. PMID- 10157622 TI - CPR by the year 2000--a myth? PMID- 10157623 TI - On the road to the CPR: where are we now? PMID- 10157624 TI - Guidelines for insurance for approved inspectors. PMID- 10157625 TI - A brief history and forward look into the materials used in plumbing. PMID- 10157626 TI - Estates management--the increasing trend for contracting-out. PMID- 10157627 TI - Is there a future for the general hospital? PMID- 10157628 TI - Rampton Hospital install largest patient call system in Europe. PMID- 10157629 TI - Rampton Special Hospital: rational approach. PMID- 10157630 TI - Constructive partnership for the health sector. PMID- 10157631 TI - 1996 Progressive Architecture awards. Citation: Head Start Child-Care Facilities, Hightstown, New Jersey. PMID- 10157632 TI - 1996 AIA honor awards. Joslin Diabetes Center, Boston, Massachusetts. PMID- 10157633 TI - New software saves BTUs. Computerized tools help architects improve energy efficiency during design development. PMID- 10157635 TI - The joy of x's. PMID- 10157634 TI - Surgical helmet systems and protection of staff and patients. PMID- 10157636 TI - The E&O decision. Is errors and omissions insurance necessary for medical transcriptionists? PMID- 10157637 TI - Variation in the process of pediatric asthma care. AB - In May 1994, the continuous quality improvement team at Hermann Children's Hospital in Houston, TX, began to study the structure, process, and outcome of asthma care for pediatric patients. The team's immediate goals were to identify variation in the treatment of pediatric asthma and to determine the most cost effective interventions. This article details the team's development of a clinical pathway to reduce variation in patient care; use of the pathway led to a reduction in length of stay and a corresponding reduction in costs. PMID- 10157638 TI - Using a multidisciplinary CQI approach to reduce ER-to-floor admission time. AB - A 110-bed community hospital used a multidisciplinary continuous quality improvement process to decrease the time needed to admit a non-critical care patient to the hospital from the emergency department (ER). The specific objective was to reduce the total amount of time needed for a patient who has entered the ER to be assigned to a bed on a designated medical/surgical unit, while at the same time maintaining quality of care and providing the patient with a pleasant atmosphere. PMID- 10157639 TI - Using the Internet for professional development. AB - This article relates how having access to and learning to use the Internet can benefit the careers of quality management professionals. Some ways to use the Internet for career enhancement are addressed, and some basic terms are explained. PMID- 10157640 TI - Perspective: time-limited mental health therapy as a form of quality improvement. AB - This article outlines a few significant similarities between a form of time limited therapy developed by the author and his colleagues and the principles of quality improvement and quality management. A few of the most pertinent components of their approach to providing more effective care are described. PMID- 10157641 TI - Illustrations that illuminate CQI. AB - Quality improvement professionals provide training in basic continuous quality improvement (CQI) concepts. In planning a training program, it is worthwhile to consider how material can be presented so that it will be remembered. Activities that allow adult learners to participate will increase their understanding and retention. Simple, effective illustrations can be used to promote interest, focus attention on the material, and make it more memorable. PMID- 10157643 TI - Integrating home health care into health care delivery. PMID- 10157642 TI - A model for a comprehensive infection control program in home healthcare. AB - A comprehensive infection control program in home healthcare consists of activities related to direct patient care as well as activities that support the provision of such care. All these activities are designed so as to reduce the transmission of infections among a facility's patients and staff members. This article relates how the cause-and-effect diagram becomes an effective tool to systematically delineate the key elements required to accomplish this goal. PMID- 10157644 TI - The context of home health care data collection and analysis. PMID- 10157645 TI - Automating the home health process. PMID- 10157646 TI - Medicare's Outcome and Assessment Information Set: an opportunity for home health automation. PMID- 10157647 TI - Enabling information technologies for home care. PMID- 10157648 TI - A new era of at-home health care services for private people with developmental disabilities. PMID- 10157649 TI - Home health care, managed care, and capitation. PMID- 10157650 TI - Transforming a home health care program through computerized charting. PMID- 10157651 TI - Integrating information systems between an acute care setting and a home care setting. PMID- 10157652 TI - How necessity produced a phone-based system. PMID- 10157653 TI - Educating for community nursing practice: point of care technology. PMID- 10157654 TI - Outcomes and home health care. PMID- 10157655 TI - Protecting individual privacy: a pothole on the information superhighway? AB - Ensuring that our society continues to protect both patient privacy and individual rights in the pursuit of the computer-based patient record requires that we also recognize the potential threats of the emerging systems and technology. Simultaneous parallel trends and advances in high technology could jeopardize underlying democratic principles if they converge without adequate protections in place. PMID- 10157656 TI - Privacy in the electronic age. PMID- 10157657 TI - The impact of technology on the confidentiality of health information. AB - The article discusses the changes in health care delivery and the advances in computer technology that have resulted in benefits to patient care but also have raised concerns for protecting the confidentiality of health information. Numerous techniques for safeguarding computer information are also presented. PMID- 10157658 TI - Privacy protections afforded by computer-based patient record systems. AB - Computer-based patient record (CPR) systems can afford greater protection of private health information. Key factors that enhance security of CPR systems include the capability to identify the user, verify authorization, determine legitimacy of use, restrict retrieval to only specific "need-to-know" information, encrypt access mechanisms and content, and track all access. The public demands greater protections for computer systems than for paper-based systems. Coupled with appropriate internal management controls and federal preemptive privacy law, breaches of confidentiality from CPRs would occur virtually through the only means that cannot be safeguarded: human communication. PMID- 10157659 TI - Implementation of information security and confidentiality policies, procedures, and standards. AB - The article describes one approach to developing and implementing a security program in response to the birth and growth of a computer-based patient record in a large teaching hospital. The discussion emphasizes the importance of the collaborative effort between the hospital and school of medicine in establishing one policy and set of standards because information is shared and electronically transferred between both institutions. The hospital's approach is summarized in five major steps: survey and literature search, development of key components or recommendations, institutional approval of the recommendations, feasibility analysis and projected time frame for implementation, and implementation of the recommendations with resolution of impediments to implementation. PMID- 10157660 TI - Standards for confidentiality, privacy, access, and data security. AB - The American Society for Testing and Materials (ASTM), an accredited standards development organization with a focus on health care informatics, has recently produced a standards document on the principles of confidentiality, privacy, access, and data security. The ASTM subcommittee responsible for this work is ASTM 31.17. The article discusses the link between voluntary health informatics standards and issues such as confidentiality and data security in computerized health information systems. PMID- 10157661 TI - Protection of privacy of personal health information: the Australian standard approach. AB - Effective privacy protection is a difficult problem, but it must be solved if we are to realize the benefits of electronic health information. The Australian Standard Personal Privacy Protection in Health Care Information Systems and its underpinning conceptual model address both the human and the technological parts of a pragmatic solution to privacy based on internationally accepted principles. This standard may offer useful guidance in an international context. PMID- 10157662 TI - Preserving confidentiality and security of patient health care information. AB - The lack of a uniform legal or regulatory scheme that applies to the protection of privacy in health care information and marketplace pressures placed on health care providers for access to patient data require physicians, hospitals, and other health care providers to establish and maintain security measures to protect against unauthorized access to patient records and vigilantly safeguard against improper disclosure. PMID- 10157663 TI - Legal challenges created by computerized medical records. AB - The article discusses protection of a patient's right of confidentiality, addresses some of the legal issues raised by computerized medical records, and provides some suggestions for securing the confidentiality and integrity of such records. Methods to ensure the admissibility of computerized medical records are suggested. PMID- 10157664 TI - Commentary: managing social, legal, and ethical issues of personal information systems. AB - This article is the transcript of a presentation at the conference "Privacy, the National Information Infrastructure, and Healthcare Reform" for the Center for Advanced Study in Telecommunications (CAST), Ohio State University, Columbus, Ohio, 27 January 1995. PMID- 10157665 TI - Mighty morphin' manufacturer: how Baxter's change affects you. PMID- 10157666 TI - CS fills its JCAHO dance card. PMID- 10157667 TI - U.S. turns to Japan for sourcing strategies. PMID- 10157668 TI - The taxman cometh. Are you at risk of outsourcing penalties? PMID- 10157670 TI - Chameleons. Three materials managers "changed colors" and adapted to a new industry. Here's how. PMID- 10157669 TI - Make education fun and build teams with Mat Man Ed. PMID- 10157671 TI - Could there be savings in gravity drip infusion? It's a heavy topic. PMID- 10157672 TI - Closing the clinical gap. PMID- 10157673 TI - When work becomes toxic, CS rides to the rescue. PMID- 10157674 TI - AmeriNet taps experts to predict pricing trends. PMID- 10157675 TI - Replicating knowledge across an organization: lessons from industry. PMID- 10157676 TI - Using accelerated replication to foster intraorganizational change. PMID- 10157677 TI - How to accelerate and replicate improvement. PMID- 10157678 TI - Is it time for 24-hour coverage? PMID- 10157679 TI - Health care's search for an information injection. PMID- 10157680 TI - Genetic testing: should you pay? PMID- 10157681 TI - Life in the health reform fast lane. PMID- 10157682 TI - Management of high blood cholesterol. PMID- 10157683 TI - Is self-insurance turning into a scam? Let's put an end to false self-funding. PMID- 10157684 TI - Is self-insurance turning into a scam? The self-insurance system ain't broke. PMID- 10157685 TI - Recent regulations clarify the application of Medicare fraud and abuse legislation to managed care relationships. PMID- 10157686 TI - Sickness and eligibility levels as factors in health care cost curve. PMID- 10157687 TI - Landing a government contract. PMID- 10157688 TI - Hospital discharge costs in competitive and regulatory environments. AB - To study the efficacy of America's current market-driven approaches to constrain health care expenditures, an analysis was undertaken of 1993 hospital discharge costs and related data of the 15 states in the United States with the highest percent of HMO market penetration. What is proposed herein to enhance hospital cost containment efforts is for a state to almost simultaneously use both market driven and regulatory strategies similar to what was implemented in California over the last three decades and in Germany for the last 100 years. PMID- 10157689 TI - Detecting and preventing adverse drug reactions in managed care. PMID- 10157690 TI - Improving adverse drug reaction reporting in the community setting. AB - Adverse drug reactions (ADRs) occur on a daily basis and result in much patient suffering as well as increased health care expenditures. Most ADR reports received by the Food and Drug Administration are from hospital-based health care professionals and pharmaceutical manufacturers. Community-based ADR reporting is currently not mandated by any regulatory authority and is an area in need of much attention. Pharmacists working in the community are in a unique position to become involved in ADR monitoring and reporting. PMID- 10157691 TI - The role of data in disease state management. PMID- 10157692 TI - Health care informatics: the key to successful disease management. AB - Health services integration and disease state management (DSM) require improved health care informatics systems. Accurate, comprehensive patient information and an integrated data infrastructure are needed for all stages of DSM, from development and implementation of programs to evaluation and continuous program improvement. The lack of an integrated information infrastructure is one of the leading obstacles to achieving a comprehensive electronic patient data system. This article examines initiatives underway to make the computer-based patient record a reality. PMID- 10157693 TI - Health insurance portability: access and affordability. PMID- 10157694 TI - The impact of Title V regulations on hospitals and health care facilities. AB - The Clean Air Act, enacted in 1970, failed to provide for an enforceable regulatory scheme at any level of government. In late 1990, Congress passed the Clean Air Act Amendments, of which Title V is the focal point. This amendment includes the Operating Permit Program, which states that all "major sources" are required to obtain Title V operating permits on or before November 15, 1995. Under Title V, the burden of demonstrating compliance will now fall directly to the facility itself. This document both summarizes and highlights the requirements of the Operating Permit Program and presents guidelines for preparing to file a Title V Operator Permit application. PMID- 10157695 TI - Dartmouth Atlas of Health Care: study of nation's health system uncovers large disparities. PMID- 10157696 TI - 1996 Georgia General Assembly: a successful, defensive session. PMID- 10157697 TI - Health reform in South Africa: challenges for the hospitals. PMID- 10157698 TI - Management training for restructuring of the health sector in South Africa. PMID- 10157699 TI - Designing for patients--redeveloping De Bijtjes Hospital. AB - 'De Bijtjes' is a hospital for treatment and care of patients with locomotive and neurological disorders, comprising an advanced rehabilitation centre. The existing buildings and the surrounding landscape were integrated in the design, which is a unique combination of a high-specialized hospital and a home-like environment. The surrounding gardens play an important therapeutic and recreative role in the healing and rehabilitation process. The different nursing units, each with their own architectural design, form separate villas around a central court, focusing on creating a small-scale atmosphere. The two nursing villas have a clove-leaf shape with each lobe forming a living unit for ten patients. The motored wheelchair was the scale-forming element for the design of the different utilities. PMID- 10157700 TI - Health development in South-East Asia and challenges to professional associations. PMID- 10157701 TI - The health insurance system in Korea and its implications. AB - The national health insurance system was introduced in Korea in 1977 and achieved universal coverage in July 1989. This article briefly describes the general features of the insurance scheme: coverage, management, benefit package, financing provision of medical services and method of reimbursement. Generally speaking, the system mirrors that of the German and Japanese experiences. Although the Korean health insurance system achieved universal coverage during a remarkably short time-span, there is much room for improvement. In this regard, the article also highlights the problems related to Korea's health insurance system and the attempts to improve equity and efficiency in both financing and provision of services. PMID- 10157702 TI - Indian Health Service. Reimbursement rates for calendar year 1996. PMID- 10157703 TI - Medicare program; payment for federally qualified health center services--HCFA. Final rule. PMID- 10157704 TI - Medical devices; medical device user facility and manufacturer reporting, certification and registration; Office of Management and Budget approval; extension of effective date--FDA. Final rule; notification of approval of information collection requirements. PMID- 10157705 TI - National Center for Health Statistics; ICD-9-CM E-Code revisions--NCHS. Notice. PMID- 10157706 TI - Medical; nonsubstantive miscellaneous changes--VA. Final rule. AB - This document amends the Department of Veterans Affairs medical regulations in 38 CFR Part 17 by making a number of nonsubstantive changes. More specifically, section numbers are redesignated, redundant material is removed, restatements of statutory material are removed, certain position titles and organizational titles are changed to reflect current titles, authority citations are added, obsolete material is removed, and material inadvertently deleted is restored. These changes are made for clarity and accuracy. PMID- 10157707 TI - Medicare and Medicaid program; criteria for a rural hospital to be designated as an essential access community hospital (EACH)--HCFA. Final rule with comment period. AB - This final rule revises the criteria that a rural hospital must meet to be designated as an Essential Access Community Hospital (EACH). The revised criteria permit HCFA to designate a hospital as an EACH if the hospital cannot be designated as an EACH by the State only because it has fewer than 75 beds and is located 35 miles or less from another hospital. Hospitals in rural areas that are designated as EACHs by HCFA are treated, for payment purposes, as sole community hospitals. The revised criteria are designed to facilitate development of network affiliations between rural EACHs and small rural facilities, known as Rural Primary Care Hospitals (RPCHs). The revisions would affect only hospitals located in rural areas of the States of California, Colorado, Kansas, South Dakota, New York, West Virginia, and North Carolina, or in an adjacent State. PMID- 10157708 TI - Hospitalization of nursing home residents: a review of the literature, 1980-1995. PMID- 10157709 TI - Structure of financial incentive systems for providers in managed care plans. PMID- 10157710 TI - Is there a U.S. drug lag? The timing of new pharmaceutical approvals in the G-7 countries and Switzerland. PMID- 10157711 TI - Changing patterns of physician services utilization in Ontario, Canada, and their relation to physician, practice, and market-area characteristics. PMID- 10157712 TI - The impact of residency training on physicians' outlook on AIDS: a cohort analysis. PMID- 10157713 TI - Involuntary health plan switching: case study of a corporate health benefits program. PMID- 10157714 TI - Health services research at U.S. Quality Algorithms, Inc. PMID- 10157715 TI - Producing research on health management and managed care: market failure or market success? PMID- 10157716 TI - Bridging the gap: what can health services researchers and HMOs do for one another? PMID- 10157717 TI - Conducting and writing research reviews. PMID- 10157718 TI - HMOs and health services research: the penalty of taking the lead. PMID- 10157719 TI - The internal economics of HMOs: a research agenda. PMID- 10157720 TI - Health services research at United HealthCare Corporation: the role of the Center for Health Care Policy and Evaluation. PMID- 10157721 TI - Health services research at Aetna Health Plans. PMID- 10157722 TI - Health services research in the Prudential Health Care System. PMID- 10157723 TI - Research at Fallon Community Health Plan. PMID- 10157724 TI - Executive overview of Michigan HMO trends. Michigan Health & Hospital Association. PMID- 10157725 TI - Capitation risk financing: two options for providers to consider. PMID- 10157726 TI - R2D2 joins the labor force. Outfitting providers for the new wave of robots. PMID- 10157727 TI - Common sense health care ... from the inside-out. PMID- 10157728 TI - Formula for the future: the elements of successful case management. PMID- 10157729 TI - Benefits under managed care--discussion. PMID- 10157730 TI - A partnership that works. PMID- 10157731 TI - Managed care accelerates. PMID- 10157733 TI - The kick from a mule. Learning from experience: managing employee turnover. PMID- 10157732 TI - Caring requires risk. Managed care organizations face challenges. PMID- 10157734 TI - Measuring managed care in meters or feet? PMID- 10157735 TI - How Michigan is managing. PMID- 10157736 TI - Medication use review process and information systems utilized for oncology chemotherapy quality improvement. AB - Fatal chemotherapy overdoses at prestigious institutions have prompted extensive reviews of policies and procedures in medical centers throughout the country. Improving medication use systems for chemotherapy requires a comprehensive multidisciplinary approach. A process to develop a medical center policy on chemotherapy based on the medication use model adopted by the Joint Commission on Accreditation of Healthcare Organizations will be discussed. This will include the prescribing, preparing, dispensing, administering, and monitoring process as well as quality improvement systems. Pharmacy information systems enhancements that safeguard patients are also discussed including maximum dose checks and specific dosing algorithms for bone marrow transplant patients. PMID- 10157737 TI - Service plans and clinical interventions targeted by the oncology pharmacist. AB - Pharmacists are faced with a changing health care environment where they are being asked to demonstrate "value-added" to patient care. Because of the toxicity, complexity, intensity, and cost of cancer treatment, oncology pharmacists have opportunities to prevent adverse drug reactions, reduce costs, optimize drug regimens, and improve patient outcomes. Programs implemented by pharmacists practicing on a 40-bed adult inpatient oncology unit are described, including (1) chemotherapy quality improvement, (2) treatment of febrile neutropenia, and (3) management of peripheral blood cell transplant patients. PMID- 10157738 TI - The American Society of Clinical Oncology guideline program. PMID- 10157739 TI - Oncology Nursing Society: development and implementation of practice guidelines. AB - With more than 25,000 professional nurse members, the Oncology Nursing Society (ONS) is the largest oncology membership organization in the world. Now in its 20th year, one way that ONS supports its mission of promoting excellence in oncology nursing is through the development and dissemination of patient care standards and guidelines. The first guidelines to be developed by ONS were the Cancer Chemotherapy Guidelines. Now in their third edition, the historical development and revision of these guidelines is detailed in this article, along with the evaluation and refinement of the process utilized by ONS. PMID- 10157740 TI - If there are expert systems and dose checks, why do we still need the clinical pharmacist? AB - Trends in patient care, along with escalating health care costs, and the demand for medication safety may provide a breadth of opportunities for clinical pharmacists. Service and drug use guidelines development, medication error prevention, quality assurance, and pharmacoeconomic assessment are areas in which skills of the oncology pharmacist may be used. Although expert systems may aid the pharmacist in these areas, such systems cannot replace the professional. PMID- 10157741 TI - Impact of an oncology pharmacy residency training program on quality improvement initiatives in an oncology center. AB - The concept of quality care is something every patient expects, regardless of how they enter the health care system. The specialty-trained oncology pharmacy practitioner possesses many skills to offer the patient and other health care practitioners. Oncology pharmacy residency training involves specific types of learning situations and experiences, which will be critical for future roles the specialty resident may assume. Oncology practice is an area requiring a high level of care for patients, and highly skilled pharmacy practitioners are crucial for the care of these patients. PMID- 10157742 TI - Reality check: the patient perspective. AB - No discussion of the topic of oncology chemotherapy quality improvement is complete without the patient as the focus of health care provider efforts. To explore the patients' perspective in their wellness quest, we present an interview with a patient who was diagnosed with lymphoma and received autologous stem cell and allogenic bone marrow transplants. As health care providers, let us never forget that advances in the science of medicine will ultimately be judged by their lasting effects, either positive or negative, on real people. PMID- 10157743 TI - Cross training of hospital pharmacy technicians. AB - Cross training is a job design method that can increase the efficiency and effectiveness of a hospital pharmacy department. Although employee satisfaction is often improved, some employees may fear that cross training makes them expendable. Good communication and employee participation are keys to successful implementation of a cross-training program. Methods of implementing cross training programs and avoiding potential pitfalls are also described. PMID- 10157747 TI - HHS' Stone urges subacute facilities to prove their value. PMID- 10157745 TI - Human resource management: coping with change. PMID- 10157746 TI - HHS study calls subacute care "old wine in new bottles". PMID- 10157748 TI - Five ideas on passing HCFA's new enforcement survey. PMID- 10157749 TI - Vladeck redefines Medicare reinbursement for subacute care. PMID- 10157744 TI - A proposed model for conducting institutional-specific cost-effectiveness analysis: a case study of lipid-lowering agents. PMID- 10157751 TI - Home health care providers may compete for subacute patients. PMID- 10157750 TI - AHCA study details charge/LOS data for subacute programs. PMID- 10157752 TI - Physician commitment a key to aggressive specialized program. PMID- 10157753 TI - How do real-world subacute facilities compare to the HHS "ideal"? PMID- 10157754 TI - Know actual costs in detail to price services for managed care. PMID- 10157756 TI - Why the enthusiasm for accreditation? Providers say, "Credibility.". PMID- 10157755 TI - Subacute experts disagree with IOM nursing proposals. PMID- 10157757 TI - New AHCA study bolsters claim subacute rehab is cost effective. PMID- 10157758 TI - Moratorium forces Wisconsin SNFs and hospitals into partnerships. PMID- 10157759 TI - New SNF owners face Medicare payment dilemma. PMID- 10157760 TI - Subacute network builds managed care business development model. PMID- 10157761 TI - HCFA overhauls negative enforcement survey policies. PMID- 10157762 TI - HCFA enforcement changes irk providers and consumers alike. PMID- 10157763 TI - Subacute admission, discharge criteria add to case manager tools. PMID- 10157764 TI - Subacute care isn't always ideal. PMID- 10157765 TI - Managing managed care payments. PMID- 10157766 TI - Transforming data into MIS. PMID- 10157767 TI - Opening the door to managed care. PMID- 10157768 TI - Rethinking rehabilitation. PPS means big changes for providers and rehabilitation companies. PMID- 10157769 TI - Subacute success story. De Witt Subacute Center. PMID- 10157771 TI - Patient focused breast care. PMID- 10157770 TI - Breast cancer epidemiology. PMID- 10157772 TI - National Breast Databank. PMID- 10157773 TI - Integrated healthcare delivery. PMID- 10157774 TI - AR's 96 guide to image management & teleradiology companies. PMID- 10157775 TI - The transmutation of medical informatics. PMID- 10157776 TI - Big opportunities in small communities. PMID- 10157777 TI - The power of faith. Spirituality plays a key role in residents' lives. PMID- 10157778 TI - The wages of nursing. Facility location and size drive wages, as our 1996 Nursing Staff Salary Survey shows. PMID- 10157779 TI - Assisted living sails uncharted waters. What legal obligations do operators have to their elderly residents? PMID- 10157780 TI - Subacute strategies. Partnerships are crucial for small providers. PMID- 10157781 TI - New survey process rocks Michigan facility. PMID- 10157782 TI - Feeding tube may not foster quality of life. PMID- 10157783 TI - Employment outlook: put on your sunglasses. PMID- 10157784 TI - Safeguarding your home care business: the latest employment law challenges. PMID- 10157785 TI - Common mistakes in personnel policies. PMID- 10157786 TI - Home care nursing: redefining roles and responsibilities. PMID- 10157787 TI - Making the transition into home care: a model orientation program. PMID- 10157788 TI - Designing training programs for specialty services. PMID- 10157789 TI - A home care career ladder: designing a multidisciplinary professional advancement program. PMID- 10157790 TI - Performance architecture for home care agencies. PMID- 10157791 TI - Time management training for home care workers. PMID- 10157792 TI - Expanding roles: delegating tasks to home care aides. PMID- 10157793 TI - The stay or stray phenomena. PMID- 10157794 TI - Standardize qualifications and training. PMID- 10157795 TI - Improving retention by implementing a home care aide preceptor program. PMID- 10157796 TI - The game of education. PMID- 10157797 TI - "Can't you take a joke?" Sexual harassment in health care. PMID- 10157798 TI - 24-hour care programs. AB - Twenty-four-hour care programs, which combine group health programs with workers' compensation and disability benefits, hold considerable potential for cost savings and greater efficiency. This article explains these programs and uses a care history to show the savings they can achieve. PMID- 10157799 TI - Why managed care has gone too far. AB - Managed care has not solved employers' problems with rising health care costs; instead, it has created another set of problems, this author maintains. She suggests steps that employers can take to enhance the quality of health care for their employees and prevent further damage from the excesses of managed care. PMID- 10157800 TI - Using health benefits as an incentive to change employee health risks: preliminary program results. PMID- 10157801 TI - Coming together over food at Tennessee cook-chill production center. PMID- 10157802 TI - Challenge: how to feed the elderly in a rural setting. PMID- 10157803 TI - Traffic stoppers. Intercept marketing via carts. PMID- 10157804 TI - Challenge: how to increase awareness of gourmet services and boost catering business. PMID- 10157805 TI - Travel as part of your job: a road map for success. PMID- 10157806 TI - Medicare's bad prognosis. PMID- 10157807 TI - Package pricing roils cardiac, orthopedic services. PMID- 10157808 TI - FPA is bridging the gap between primary care physicians and managed care payers. PMID- 10157810 TI - New AHCPR guideline targets and cost of smoking cessation programs. PMID- 10157809 TI - Fear of mergers and acquisitions has more hospitals pursuing managed care affiliations. PMID- 10157811 TI - The disease management dilemma. PMID- 10157812 TI - Organized health care is real wave of future. PMID- 10157813 TI - Innovative ways of responding to change. PMID- 10157814 TI - Developing effective clinical pathways for nutrition. PMID- 10157815 TI - An easy way to communicate pathways to patients. PMID- 10157816 TI - Proper handwashing--the key to infection control. PMID- 10157817 TI - Using the DETERMINE checklist in ambulatory care. PMID- 10157818 TI - Are waiting lists inevitable? AB - Waiting lists are a common phenomenon in markets in which non-price allocation of goods and services occurs. To the extent that waiting lists for in-patient health services are perceived to ration imperfectly, many propose policies which focus on reducing demand or increasing supply. Strategies aimed at increasing supply often create perverse incentives in that they reward hospitals with long waiting lists through the provision of additional resources. This paper describes how supply has been addressed in Victoria by changing the financial incentives relating to waiting lists. The success of this payment policy in reducing waiting lists to public hospitals is reported. PMID- 10157819 TI - Home care policy in the Netherlands. Reforming legislation to facilitate the provision of multi-disciplinary home care. AB - In the Netherlands, it is considered necessary to provide multidisciplinary home care to meet the demands of a growing number of patients. Existing legislation must be changed to facilitate the provision of such care. Although this has been an important government policy goal for several years, it has been extremely difficult to fundamentally change legislation. This article presents an analysis of the Dutch system of decision-making on government policy, to explain why this is the case. Using theoretical concepts such as 'interdependence' and 'steering', the authors studied empirical data published by the Willems Subcommittee, a governmental advisory body. PMID- 10157820 TI - A critical review of the remuneration systems for pharmacists. AB - This paper provides a critical review of different systems of remunerations of pharmacists which exist in various countries: the percentage mark-up, the graduated mark-up, the capitation system, the fee for service system and mixed system. In these different systems, we refer to the various ways the provisions of pharmaceutical services are paid and reimbursed rather than how persons who physically deliver the services are paid. Therefore, the differences among various types of remuneration may not impact directly the level of responsibility and motivations of the various employees or owners in contact with the patient. The dispensing service remains the essential service of the pharmacist in all systems. However, according to the types of remuneration, the revenue of the pharmacist can be more or less linked to the volume and the price of drugs. Capitation systems, professional allowance and fees in particular can be used to shift the objective of the pharmacist towards increased professionalism. In each system, policy makers, when they can negotiate with the whole national profession, can use the remuneration system to achieve public policy objectives such as cost containment, better drug use, or provisions of large packages of services. This paper discusses to what extent each system can contribute to such objectives. In order to achieve public policy objectives, it may be time to shift the valuation of pharmaceutical services towards more safe and effective therapy instead of safe and effective drugs. PMID- 10157821 TI - Appropriateness versus efficiency: the economics of utilisation review. AB - The aim of routine utilisation review is to identify patients who are inappropriately placed in an acute unit and who could be alternatively treated in a lower technology facility. Utilisation review was designed as a means of cost control in the USA. but problems with rising emergency admissions and consequent acute bed shortages in the UK have led to a substantial and growing interest in the concept of appropriateness and in the development of utilisation review instruments. Appropriate care is not necessarily the same as efficient care, however, and inappropriate care could potentially be more cost-effective than the alternative. This will depend on, first, whether the design of utilisation review instruments is such that they will encourage efficiency, and second. whether efficiency objectives would be met by the application of utilisation review in the context of the UK health care system. The first issue is discussed in relation to the effectiveness of alternative forms of care. The second is discussed in relation to the potential for reductions in cost, the issue of institutional resistance in the UK, and the validity of utilisation review instruments. The paper concludes that the potential impact of utilisation review on technical efficiency in the UK is ambiguous and questions its purpose in the National Health Service. PMID- 10157822 TI - Predictors of professional and non-professional community care for care-dependent adults. AB - The increasing number of elderly people in most industrialized countries makes reforms in health care necessary. However, knowledge of factors that determine the use of care is scarce. The study described in this article focuses on predictors of the diversity of professional and non-professional care used by care-dependent adults who live in the community. A group of 177 care-dependent adults was identified by means of a large scale telephone survey in the Dutch community of Tegelen. Potential predictors of the diversity of professional and non-professional care were derived from Andersen's Behavioral Model of Health Services [4,5] and Litwak's Task Specifity Model [12]. Both models proved to be valuable for the explanation of variance in the diversity of care. Potential predictors derived from the two models could account for 21% of the variance for total care, 25% of the variance for professional care, and 34% of the variance for non-professional care. PMID- 10157824 TI - Medical center finds new dimensions in patient-centered care. Crozer Chester Medical Center, Upland, Pa. PMID- 10157823 TI - Health facilities seek service over price in buying energy. PMID- 10157825 TI - Reinventing the wheels. Planning some remodeling? Then it's time to rethink your facility's transportation system. PMID- 10157826 TI - Color. It's the right Rx for health facilities. PMID- 10157827 TI - Fixing a hole. Don't let a leaky roof rain on your parade. PMID- 10157828 TI - State-of-the-art sterilization. New technologies for the '90s and beyond. PMID- 10157829 TI - Reengineering or rebirth? Risky, innovative models that have worked. PMID- 10157830 TI - Disinfection standards: whose should you follow? PMID- 10157831 TI - Needlesticks: the health care hazard that will never go away. PMID- 10157832 TI - Is it time to jump start your culture engine? PMID- 10157833 TI - A journey from bureaucracy to enterprise. AB - Uses the Business Development Consultancy as a case study to demonstrate how a training and development function responded to the working for patient reforms in the NHS. Offers an example of how change can be managed effectively when moving from a bureaucratic to enterprise culture. Emphasizes dealing with the human side (including the casualties of the change) and obtaining ownership of the change and focuses on how the mind set needs to shift. Highlights that change is more than implementation of a new organizational structure or set of rules. Reinforces that change is continuous and requires continual monitoring and review. Ends by stating that change from bureaucracy to enterprise may be difficult but can be achieved successfully. PMID- 10157834 TI - Ambulatory patient groups and redefining the roles of health care providers' delivery services in the USA. AB - Provides a review and analysis of the ambulatory patient groups classification system. Discusses a review of the history, development and implementation process. Concludes that in the ongoing efforts to move towards full-managed care in the not-so-distant future, ambulatory patients groups are another potential cost-cutting remedy for current health care providers and that future research into this issue is a must for public policy makers. PMID- 10157835 TI - The context of ethics in the health care industry. AB - Examines ethics in the health care industry from the perspectives of investors, employees, patients, competitors and the environment. Ethical behaviour in the health care industry is essential and desirable; however, determining which behavioural actions are ethical and which are unethical is difficult. Although never will everyone agree on specific ethical standards, everyone should agree that setting ethical standards is vital. Therefore, administrators of health care institutions and health care providers should work together to establish codes of ethics which define boundaries for ethical behaviours in the health care industry. PMID- 10157836 TI - Lies, damned lies and absence statistics. AB - Examines the extent of absenteeism and the associated costs. Considers recent guidance on indicators of absence rates and notes the difficulties in reaching a common interpretation of the advice given. Outlines the challenge in devising feedback to local managers which enables local interpretation. Recommends training for first-line managers. PMID- 10157837 TI - Leadership and vision in the NHS: how do we create the "vision thing"? AB - The development of NHS trusts has been a major part of the NHS reforms in the United Kingdom. The creation of trust boards has coincided with significant pressures from the combined forces for change and consolidation within publicly financed health care in the UK. The development of a long term strategic vision for trusts to ensure long-term survival is imperative. Considers evidence from international researchers and translates this into the context of NHS trusts. Discusses how they define and identify vision and ensure that vision building can be communicated and understood by key stakeholders within and outside the organization. Offers several practical suggestions on how their vision can be monitored and evaluated within the organization. PMID- 10157838 TI - Testing for EMC (electromagnetic compatibility) in the clinical environment. AB - Testing for electromagnetic compatibility (EMC) in the clinical environment introduces a host of complex conditions not normally encountered under laboratory conditions. In the clinical environment, various radio-frequency (RF) sources of electromagnetic interference (EMI) may be present throughout the entire spectrum of interest. Isolating and analyzing the impact from the sources of interference to medical devices involves a multidisciplinary approach based on training in, and knowledge of, the following: operation of medical devices and their susceptibility to EMI; RF propagation modalities and interaction theory; spectrum analysis systems and techniques (preferably with signature analysis capabilities) and calibrated antennas; the investigation methodology of suspected EMC problems, and testing protocols and standards. Using combinations of standard test procedures adapted for the clinical environment with personnel that have an understanding of radio-frequency behavior increases the probability of controlling, proactively, EMI in the clinical environment, thus providing for a safe and more effective patient care environment. PMID- 10157839 TI - Examination of several instruments for the electrical detection of holes in latex gloves during use. AB - The initial purpose of this research was to investigate the use of electrical conductivity for detecting holes in latex gloves, while they are being worn, using both recently developed devices and laboratory equipment. The individual devices were not evaluated or critically compared. The use of this technique as a quality assurance procedure, and to determine the degradation of latex gloves due to storage and exposure to disinfectants, was also investigated. The following conclusions were reached: (1) These devices alarm if the latex is breached by an object of at least 300 um-diameter and both the inside and outside of the glove are wet with a conductive fluid. False alarms from latex hydration is the primary disadvantage. (2) This technique is a sensitive QA procedure if any hole to be detected is wet with a conductive liquid. (3) Sealed, sterile latex gloves may degrade over many months. (4) There was no obvious degradation of latex gloves after two hours' exposure to three commonly used disinfectants. PMID- 10157840 TI - Development of a clinical internship program. PMID- 10157841 TI - Domestic violence. PMID- 10157842 TI - The organization as social technology. PMID- 10157843 TI - Benchmarking reference services: step by step. AB - This article is a companion to an introductory article on benchmarking published in an earlier issue of Medical Reference Services Quarterly. Librarians interested in benchmarking often ask the following questions: How do I determine what to benchmark; how do I form a benchmarking team; how do I identify benchmarking partners; what's the best way to collect and analyze benchmarking information; and what will I do with the data? Careful planning is a critical success factor of any benchmarking project, and these questions must be answered before embarking on a benchmarking study. This article summarizes the steps necessary to conduct benchmarking research. Relevant examples of each benchmarking step are provided. PMID- 10157844 TI - Benchmarking in health care: using the Internet to identify resources. AB - Benchmarking is a quality improvement tool that is increasingly being applied to the health care field and to the libraries within that field. Using mostly resources assessible at no charge through the Internet, a collection of information was compiled on benchmarking and its applications. Sources could be identified in several formats including books, journals and articles, multi-media materials, and organizations. PMID- 10157845 TI - NLM's new proximity searching. PMID- 10157846 TI - Internet access and connectivity: an explanation. PMID- 10157847 TI - Pharmaceutical published literature databases: a survey. AB - Pharmaceutical companies often maintain a bibliographic database of published articles on their products. Although such databases share the common purpose of providing the company with a centralized source of published information, the databases themselves vary in scope, uses, and technologies. In order to explore the current status of these databases, a survey was conducted in early 1995. This article provides an overview of pharmaceutical product literature databases and the results from that survey. PMID- 10157848 TI - Producing training videos for end-user training. PMID- 10157849 TI - Reuse of disposables. Reprocessing issues taking users down 'slippery slope'. PMID- 10157850 TI - Reuse of disposables. Investigate outsourcing companies with care. PMID- 10157851 TI - Examining liability risks in disposable reuse. PMID- 10157852 TI - Glutaraldehyde. FDA holds firm on need for 45-minute soak. PMID- 10157853 TI - New questions on low-temperature sterilization. PMID- 10157854 TI - Outsourcing reusables. Moving device sterilization outside the walls. PMID- 10157855 TI - CDC issues isolation standards. PMID- 10157856 TI - E-mail takes you around the world in a flash. PMID- 10157857 TI - Quality improvement. Reducing cystoscopy delays with a checklist. PMID- 10157858 TI - Choice to reuse disposables requires factual assessment. PMID- 10157859 TI - Using software tools to monitor receivables. PMID- 10157860 TI - The shift from vertical to networked integration, Part 1. AB - Lessons, dangers, and difficulties for health care integrators from the world of mergers, acquisitions, and alliances. The authors examine why there needs to be a shift from vertical integration, with its command and control hierarchical structure, to the more fluid and flexible networked enterprise in health care. By sharing the integration experiences of other industries, the authors make a compelling case for rethinking the integrated delivery system that so many have embraced and explain why the emergence of the extended health care enterprise will be the next stage in the progression. Making the journey into networked enterprises--how to start, what to do, and case studies from St. Vincent's, Cascade Healthcare Alliance, and Mullikin Medical Centers--will be presented in the second article in the June 1996 issue of Physician Executive. PMID- 10157861 TI - The rural health care enterprise: keeping up with the city slickers. AB - As the managed care juggernaut rolls into rural America, numerous communities appear to be following the strategies adopted by their urban counterparts. But rural areas are different. There are several key dynamics that must be considered for rural communities to be successful in responding to the considerable challenges of the brutal market forces of managed care. The author presents practical suggestions for success in rural health care systems. PMID- 10157862 TI - Making integrated health care work. AB - This article summarizes the authors' thinking on value added in health care, and offers examples of the major strategies being implemented by integrated systems across the United States to increase their value and improve their competitive positioning. The research results are based on a review of published literature on 150 health care organizations in various stages of integration, and 20 in depth case studies of integrating systems. PMID- 10157863 TI - Primary care networks: choose your physicians wisely. AB - As hospitals and health care systems maneuver for a position in the integrated health care delivery system, no initiative is more important than building an effective and competitive primary care network. Yet this critical initiative is fraught with potential pitfalls. In their haste to develop primary care networks, hospitals and health care systems may fail to thoroughly evaluate network participants and in turn create large, inclusive, and inefficient primary care networks that don't come close to breaking even, much less repay practice acquisition costs. In an effort to become more efficient, practitioners often find themselves in the unenviable position of "de-selecting" peers retrospectively. The author presents criteria for evaluating and selecting network physicians. PMID- 10157864 TI - Modern health care depends on technology, Part 2. AB - The first article in this series presented the principles and vocabulary of technology assessment and described the process used at St. Luke's, a tertiary care hospital in Bethlehem, Pennsylvania. This second article will describe the resources needed to support a technology assessment program. Technology planning, acquisition, and management will also be discussed. Historically, the health care marketplace has welcomed new technologies. In a future in which providers will be accountable for the outcomes of the care they provide, the ability to evaluate new and existing technologies will be essential for success. PMID- 10157865 TI - Knives in the water: politics '90s style. PMID- 10157866 TI - Can the patient be the focus of managed care? AB - If the question were simply put: "What is it that succeeds or fails to meet patients' needs in managed care?" Dr. John M Ludden would have a short answer. "It depends. Success depends on whether you are talking about individuals or about populations of patients. And it depends on whether you are talking about meeting patients' needs or their desires. It depends on whether you're talking about well patients or sick patients, young patients or older patients, new patients or established patients, rich patients or poor patients. And it depends on your ability to balance each of these qualities." This article explores how to translate high-quality care for a population to high-quality care for individuals. PMID- 10157867 TI - Launching today, defending tomorrow. In Atlanta, PROMINA tries to introduce, win and hold on to a new market idea. PMID- 10157868 TI - Combining fund-raising and recruiting. Hays Medical Center, KS. PMID- 10157869 TI - Stanford turns to public service announcements to promote a kids' hotline. Lucile Salter Packard Children's Hospital, Palo Alto, CA. PMID- 10157870 TI - Adapting to managed care, Children's Hospital turns to keeping seniors well. Children's Hospital, Baltimore, MD. PMID- 10157871 TI - These days, the most important hospital marketing may be internal marketing. PMID- 10157873 TI - Fighting words: providers take contract disputes public, capitalize on managed care backlash. Morris-Somerset IPA, Morristown, NJ. PMID- 10157872 TI - Reaching unreachable markets by "doing good". Harborview Medical Center, Seattle, WA. PMID- 10157874 TI - An Indiana hospital recruits doctors via Internet. Ball Memorial Hospital, Muncie, IN. PMID- 10157875 TI - Cries and whispers. AB - For abused women who see only darkness ahead, WomanKind, a hospital-based program, is a shining beacon--and a national model. Every woman entering a Fairview Health System hospital is routinely asked about abuse, and system hospitals address the problem throughout every department, not just in the emergency department. WomanKind than serves as a "bridge" to appropriate services in the community. PMID- 10157876 TI - The road to Wellville. AB - As the model of health care shifts to community wellness, hospitals and public health departments are finding common ground. And when an Idaho trustee planted the seeds for collaboration in the medical center's boardroom, community health blossomed. PMID- 10157877 TI - What'ya know? Good intentions won't get you through a merger. You need to know your partners and be clear about what you'll get and what you'll give. PMID- 10157878 TI - It's worth it to be green. PMID- 10157879 TI - What's all this talk of community? PMID- 10157880 TI - National Hospital Ambulatory Medical Care Survey: 1993 outpatient department summary. PMID- 10157881 TI - Characteristics of prepaid plan visits to office-based physicians: United States, 1991. PMID- 10157882 TI - National Ambulatory Medical Care Survey: 1993 summary. PMID- 10157883 TI - National Ambulatory Medical Care Survey: 1994 summary. PMID- 10157884 TI - An overview of home health and hospice care patients: 1994 National Home and Hospice Care Survey. PMID- 10157885 TI - Third generation information systems: integrating costs and outcomes. Tools for professional development and program evaluation. AB - The authors present specific procedures for obtaining cost per closed case and a case outcome rating for each closed case, computer generated, yielding a cost outcome report for single cases and aggregated cases. The procedures are illustrated with field data from an alcohol and drug addiction service. Cost per closed case is seen as the new unit cost datum. Combined with case outcome information, the cost-outcome report is seen as a promising new measure of efficiency. The potential of the cost-outcome report as a new basis for professional self-development, increased treatment effectiveness, and program evaluation is discussed. PMID- 10157886 TI - Do management tasks differ by field of practice? AB - The authors examine the question: Do management tasks differ by field of practice? Many social work Master's programs are organized on the principle of specialization by field of practice for both micro- and macro-practice students. Secondary analysis of task data suggests that managers and supervisors with MSW degrees perform the same task regardless of the field of practice. The study suggests a need to examine assumptions of current MSW curriculum organization. PMID- 10157887 TI - Downsizing of the nation's labor force and a needed social work response. AB - While employers recognize that downsizings are not cyclical but rather strategic business decisions, there is not sufficient recognition of the importance of these human resources in the profitability and service quality in their organizations. The author highlights the challenge to the social work profession to sensitize management to the needs of their employees, both the released workers and the survivors. The author recommends strategies to sensitize employers to implement processes to humanize the consolidations occurring increasingly in the workforce. An emphasis is placed on the challenges to the social work profession in providing programs and services to America's businesses and employees. PMID- 10157888 TI - Managerial manners--notably lacking in personnel recruiting. PMID- 10157889 TI - Stress in the workplace: looking bad, telling lies, and burning out. PMID- 10157890 TI - On the mend. Morphosis updates an early 1960s office building. PMID- 10157891 TI - The aetiology, consequences and prevention of barotrauma: a critical review of the literature. AB - PURPOSE: To review critically the literature on pulmonary barotrauma in mechanically ventilated patients. METHODS: Data sources included MEDLINE and citation lists of relevant articles. Articles investigating the aetiology or prevention of pulmonary barotrauma were critically evaluated according to published guidelines. RESULTS: Experimental animal studies and observational clinical studies consistently demonstrate that the high airway pressures and large tidal volumes associated with conventional modes of mechanical ventilation are major contributors to lung injury. Animal studies establish the correct temporal relationship and demonstrate a biological gradient. Observational clinical studies demonstrate an increased risk of barotrauma in the setting of acute lung injury. The results of three case series and two small randomised clinical trials indicate that a pressure-limited ventilation strategy aimed to reduce barotrauma may improve outcomes in patients with acute lung injury. CONCLUSIONS: Pulmonary barotrauma is a clinically important phenomenon that may delay the healing of injured lungs and lead to the development, or the exacerbation, of ARDS. Risk factors for barotrauma include high peak airway pressures, large tidal volumes and acute lung injury. Resolution of the role for pressure-limited ventilation in ARDS prevention and treatment requires a large scale randomised clinical trial. PMID- 10157892 TI - The role of the gastric reservoir in ventilator-associated pneumonia. AB - Ventilator-associated pneumonia (VAP) is a common complication of mechanical ventilation with an incidence ranging from 9-70% and averaging around 25%. The pathogenesis of VAP requires abnormal oropharyngeal and gastric colonisation and then aspiration of these contents into the lower airways. Another co-existing mechanism could be direct oropharyngeal or lower airways inoculation of microorganisms through contaminated respiratory therapy equipment. Ventilator associated pneumonia develops easily if aspiration or inoculation of microorganisms occur in patients with artificial airways and in whom mechanical, cellular and/or humoral defences are altered. Both host factors and treatments may alter pulmonary defence mechanisms; these too may contribute to the development of VAP. An alternative mechanism to explain VAP is bacterial translocation, although this mechanism is still under investigation. Figure 1 illustrates a schema of the pathogenesis of VAP. In this paper we review the possible role of the gastric reservoir in the aetiology of VAP, emphasising the following issues: 1. Risk factors for gastric colonisation 2. Clinical evidence of gastric aspiration to the lower airways in mechanically ventilated patients 3. Clinical evidence and controversies surrounding the role of the gastric reservoir in ventilator-associated pneumonia 4. The role of bacterial translocation as a mechanism for the development of VAP 5. A summary of prophylactic measures. PMID- 10157893 TI - Automated noninvasive blood pressure measurement. AB - Noninvasive blood pressure (NIBP) is one of the most common vital signs monitored by today's bedside and transport monitors. A variety of NIBP measurement methods has been used in these monitors. Some of the methods provide intermittent measurements over a period of time, while others provide continuous measurement on a beat-to-beat basis. Most of the monitors provide for on-demand measurement as well as automatic measurement at user-selected intervals. The measurement accuracy of an NIBP monitor is typically established by clinical evaluation. Generally safe and easy to use, NIBP monitors play a very important role in patient care. PMID- 10157894 TI - Development and evaluation of a pulsed nebulizer with predictable dosing characteristics. AB - A metered dose nebulizer assembly with the capability for repeatable doses is described, comprising a commercial disposable nebulizer and a timing circuit to control the duration of air supply. Data on performance of the nebulizer apparatus under typical operating conditions are presented, using cromolyn sodium as a model compound. Repeat doses from the apparatus typically show less than 10% relative standard deviation. PMID- 10157895 TI - A comparison of lung deposition patterns between different asthma inhalers. AB - Drugs for the treatment and prophylaxis of asthma are delivered to the lungs by inhalation and this is facilitated by the use of pressurized metered dose inhalers (pMDIs), pMDIs with spacer devices and dry powder inhalers (DPIs). Lung deposition of drugs from pMDIs depends upon both the physicochemical nature of the aerosol formulation and the patient's inhalation technique, however, the majority of the dose from a pMDI is deposited in the oropharynx. Large volume spacer devices can reduce oropharyngeal deposition; however, lung deposition may be increased or decreased with a spacer in comparison with a pMDI, according to the design of the spacer, the aerosol formulation, the patient's inhalation technique and the extent to which the electrostatic charge on the spacer is controlled. Lung deposition of drug from DPIs also varies according to the design of the device. One DPI, Turbuhaler, deposits twice as much drug in the lungs as a pMDI, has a lower intersubject variability of lung deposition and results in lower oropharyngeal deposition. PMID- 10157896 TI - Influence of inhaler systems on systemic availability, with focus on inhaled corticosteroids. AB - Local treatment of obstructive pulmonary diseases, such as asthma, is achieved by oral inhalation of the active substance. Drug deposited in the lung may then exert its effects locally before it is absorbed into the systemic circulation. The systemic availability of a drug is made up of the fraction deposited in the lung and the fraction deposited in the oropharynx, which is swallowed and absorbed from the gastrointestinal (GI) tract. For many drugs, the fraction absorbed from the GI-tract is subject to hepatic first-pass metabolism before reaching the systemic circulation, and for the corticosteroid budesonide, hepatic first-pass metabolism is substantial. Since metabolic inactivation of inhaled corticosteroids in the lung has not been demonstrated, the systemic absorption of the fraction deposited in the lower respiratory tract can be assumed to be proportional to lung deposition. The local versus total systemic availability (L/T-ratio) can be used to express the effectiveness of the inhaled formulation. For budesonide inhaled via a pMDI and the dry-powder inhaler, Turbuhaler, the L/T ratio was 0.59 and 0.84, respectively. The ideal L/T-ratio is 1.0. Thus, for inhaled budesonide it is an advantage for patients to change from budesonide pMDI to budesonide Turbuhaler with respect to the balance between desired and undesired effects. PMID- 10157897 TI - In vitro properties of pressurized metered dose inhalers with and without spacer devices. AB - Pressurized metered dose inhalers (pMDIs) have been used for the administration of drugs to patients with asthma since the late 1950s. However, it is only during the last few years that attention has been paid to how they work in detail. Studies have shown that the first dose, after the inhaler has been at rest for some hours, can be very variable. For suspension formulations, shaking the inhaler before actuation is important, since omitting shaking will affect the dose uniformity. The addition of a spacer device may increase the variability of the available dose. Factors affecting the available dose are, the electrostatic charge on the walls of the spacer device, the volume of the spacer device and the choice of material for the spacer device. Moreover, the fine particle dose, a measure of the effective deposition of inhaled drug in the airways, has been shown to be greater with a pMDI and a spacer device in comparison with a pMDI alone and is dependent on the choice of impactor inlet. PMID- 10157898 TI - Clinical comparisons of inhaler systems: what are the important aspects? AB - Inhaled medications are the mainstay of asthma treatment. This not only provides the greatest clinical effect in asthmatic patients, but does so with the least systemic side effects. A wide variety of inhaler systems exist, each of which has inherent advantages and disadvantages. These have to be considered when making a choice of inhaler system for a specific clinical circumstance, as no currently available system is ideal in every clinical situation. Three main types of inhaler systems currently exist and, of these, the pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) are most frequently used. The advantages of pMDIs are their portability, ease of use (in a properly instructed and adequately co-ordinated patient), cheap cost of manufacture, and low inspiratory flow rates needed to achieve adequate drug deposition in the lung. The main disadvantages of pMDIs, such as oropharyngeal deposition of drug and improper use (in an uncoordinated patient), can be minimized by the use of a spacer device. In contrast, DPIs are easy to use (no co-ordination between actuation and inhalation is required by the patient) and portable, and for the DPI, Turbuhaler, are multiple dose and deposit twice the dose of drug in the lung in comparison with pMDIs. Moreover, the side effects, namely bronchoconstriction and cough, associated with the use of pMDIs are minimized or eliminated with the use of Turbuhaler. A potential disadvantage of DPI systems is that patients need to generate inspiratory flow rates of at least 30 L/min to obtain optimal drug delivery. This is, however, feasible in almost all patients, even in those patients with very severe airflow obstruction. PMID- 10157899 TI - The impact of expertise and sufficient information on psychologists' ability to detect malingering. AB - Twenty-two forensic diplomates and 22 general clinical psychologists were asked to review a variety of psychological data from one of four cases (two cases of malingering and two cases of legal insanity) to determine whether data suggested malingering or insanity. Of the 44 psychologists who reviewed cases, 86.4% accurately determined whether their protocol was from a malingerer or an insane person. Forensic diplomates and clinical psychologists were equally accurate in their determinations; only three subjects from each group misidentified their case. In spite of their success, confidence levels for both groups were reported as moderate. These results contradict previous studies that have found psychologists to not only be poor detectors of malingering, but also overconfident in their ability to detect it. It is believed that the success of psychologists in this study compared to previous studies was due to improved methodology. PMID- 10157900 TI - Perspectives. Consumers gaining leverage in quality assessment arena. PMID- 10157902 TI - Practice brief. Issue: Information security--an overview. American Health Information Management Association. PMID- 10157901 TI - Perspectives. Easy money soon to fade for post-acute providers. PMID- 10157903 TI - V codes: supplementary classification of factors influencing health status and contact with health services. PMID- 10157904 TI - Documentation expert reaps rewards of risk taking. PMID- 10157905 TI - Creating a process-focused environment. PMID- 10157906 TI - Audit logs--a security tool for CPRs. PMID- 10157907 TI - VHA (Veterans Health Administration) looks at clinical practice guidelines, pathways, and algorithms. PMID- 10157908 TI - The Internet: what does it mean for healthcare provider organizations? PMID- 10157909 TI - The quest for the Holy Grail of systems. AB - Software agents like Edify can be used to retrieve (and store) information from most online systems, without having to access each system's database. These techniques allow information integration (display) into Windows applications or in new reference and information retrieval applications or Web pages. These techniques can be used to bridge the gap until the Holy Grail of systems is built (and works). PMID- 10157910 TI - Why don't we have computer-based patient records? PMID- 10157911 TI - Productivity standards: a survey of HIM professionals, Part II. PMID- 10157912 TI - Occupation of cancer patients: a challenge to healthcare facilities. PMID- 10157913 TI - Telemedical records: the weak link in telemedicine. PMID- 10157914 TI - Who should be managing your managed care plans? PMID- 10157915 TI - Indemnity insurance: down but not out. PMID- 10157916 TI - Measuring progress toward practice guidelines. PMID- 10157917 TI - Alternative medicine: where east meets west. PMID- 10157918 TI - More bang for the buck in managing high blood pressure. PMID- 10157919 TI - Lawmakers embrace managed care regulations. PMID- 10157920 TI - If you build it, we will come. PMID- 10157921 TI - Shopping for coverage: is cost everything? PMID- 10157922 TI - Should health plans offer an OTC drug benefit? PMID- 10157923 TI - Promotion of OTC products within a network-model HMO. AB - The drug benefits of most health plans do not include reimbursement for over-the counter (OTC) drugs. However, one PMB found that significant savings could be obtained if the OTC option was encouraged. PMID- 10157925 TI - Developing an effective business plan. AB - At some time, virtually all managed care executives, and most physician executives, will be asked to develop business plans. Business plans are thoughtful, comprehensive, and realistic descriptions of the many aspects of the formulation of a new business product or line for market. The author describes what goes into the writing of a business plan and how the physician executive should approach this task. PMID- 10157924 TI - Evaluating disease state management interventions. PMID- 10157926 TI - The cost of health care fraud and abuse. PMID- 10157927 TI - Aligning incentives to achieve real health care reform. PMID- 10157928 TI - The rise of physician-sponsored health plans: can they put doctors back in charge? AB - Congress is currently considering the American Medical Association and the American Hospital Association's proposed provider-sponsored organizations, which would possibly compete with MCOs. There are many reasons these plans have rapidly proceeded to the forefront of health plan innovation. PMID- 10157929 TI - Integrated delivery systems: the Edsel of health care. AB - Integrated delivery systems (IDSs) describe the various pieces of the provider world that have been pulled together contractually under one corporate roof, forming a single, relatively complete local delivery system to assume risk. Technically, the earliest examples of an IDS are HMOs themselves, be they IPA, staff, or group models. However, an HMO was not called an IDS then, because it was the risk-bearing entity. Integrated delivery systems really emerged over the last few years as HMOs changed from being the risk-bearing entity, to contracting with separate risk-bearing entities. PMID- 10157930 TI - Tricare: the military's version of managed care. AB - The Tricare program is a triple-option health delivery model that integrates health services for the nation's military. The author reviews the newest incarnation of the Department of Defense's attempts at providing managed care to CHAMPUS beneficiaries. PMID- 10157931 TI - Acting to end alleged "gag" clauses in participating provider contracts. AB - In light of calls from various provider and consumer groups, including the American Medical Association, state and federal legislators have recently proposed legislation to eliminate the use of alleged "gag" clauses found in some managed care contracts that prohibit physicians from discussing certain matters with their patients, including treatment options not covered by the MCO and financial arrangements between physician and MCOs. PMID- 10157932 TI - Introduction to property management. AB - This document provides an overview of professional real estate management techniques that can be applied to the operations of a health care organization's ancillary outpatient facilities, including medical office buildings. These techniques consolidate and focus real estate operations into a cohesive management structure, permitting the organization to identify areas of cost savings and cost control, identify opportunities for revenue enhancement and providing a higher level of service to physicians and other tenants. The concepts, principles, and techniques presented here can be applied to small, stand-alone hospitals, hospitals that are merging, as well as large multihospital organizations and integrated systems. PMID- 10157934 TI - National Practitioner Data Bank: availability of and cost options for copies of public use data file--HRSA. PMID- 10157933 TI - Health care system changes and their effect on design and construction. AB - In the rapidly changing health care delivery system, architects, engineers and health professionals must change their thinking of the design and construction of health care facilities. There are many influences affecting the health care environment design process. This technical document examines those influences and the key role that those involved in design and construction have in changing the way people view the health care environment. PMID- 10157935 TI - A health care lobbyist to the bone. Interview by Marilyn Werber Serafini. PMID- 10157936 TI - Take a snapshot of case management's results with internal report cards. PMID- 10157937 TI - Survey survival secrets lie in paths, documentation. PMID- 10157938 TI - Coordinated care guides detail arteriogram outcomes. PMID- 10157940 TI - Scaled-down ICU saves $5,000 per patient. PMID- 10157941 TI - Rx for hospital foodservice. Rightsizing for survival. PMID- 10157939 TI - Find your program improvement opportunities. PMID- 10157942 TI - QM reports to the board--it's just good business. PMID- 10157943 TI - Medication error tracking program cuts risk, impresses Joint Commission. PMID- 10157944 TI - Statistics let a hospital's star quality shine. PMID- 10157945 TI - Medicare conditions of participation require discharge pros. PMID- 10157946 TI - In sickness and in health. PMID- 10157947 TI - The final betrayal. PMID- 10157948 TI - Environment. What happened to the greening of the NHS? PMID- 10157949 TI - Waste disposal. Waste not, want not. PMID- 10157950 TI - Mental health. Private investigation. PMID- 10157951 TI - Staff development. CV times. PMID- 10157952 TI - Community care. Stuff as dreams are made on. PMID- 10157953 TI - The asylum of the 21st century. Home truths. PMID- 10157954 TI - Facilities management. Waste management--sorted. PMID- 10157955 TI - Facilities management. Outsourcing--open house. PMID- 10157956 TI - Facilities management. Value judgements. PMID- 10157957 TI - Joint commissioning. Jointly or severally? PMID- 10157958 TI - Fundholding. Mean feats. PMID- 10157959 TI - Mental health. Rapid reaction, speedy recovery. PMID- 10157960 TI - Implementation of total quality management: conventional wisdom versus reality. AB - Hospitals nationwide are beginning to implement continuous quality improvement (CQI) (Barsness et al. 1993; Kosta 1992). In large part this is due to the belief that the implementation of CQI will lead to higher quality patient care, improved patient satisfaction, better employee morale, and lower cost service delivery. However, to date there have been few empirical studies of CQI implementation efforts in healthcare (Shortell et al. 1994). PMID- 10157962 TI - Views of implementation approaches by top managers in health service organizations. AB - This study examined how top managers view the prospects of success and resistance when using four implementation approaches in participative and control cultures that foster climates more or less conducive to change. An accommodation approach was viewed as having the best prospect of success and of lowering resistance in a participative culture. Bargaining and incentive approaches were thought to have successful and low resistance outcomes, which were just below those of accommodation, in a control type of culture. A persuasion approach was thought to be the least effective implementation approach in a control-oriented culture. These preferences differ from prescriptions found in the implementation literature. Assuming that preferences influence behavior, implementation success could be improved if managers selected an implementation approach according to the demands of the situation. More research is needed to appreciate fully the rationale that lies behind the preferences uncovered in this research. PMID- 10157961 TI - Increasing employee productivity, job satisfaction, and organizational commitment. AB - Healthcare administrators endeavor to maximize the productivity of employees in an era of chaotic change and financial pressure. This study examines five leadership behaviors that were identified through the research of James Kouzes and Barry Posner and measures the use of these behaviors by hospital managers. It then identifies the relationships (both correlational and predictive) between the use of these behaviors and employee productivity, job satisfaction, and organizational commitment. The findings of this study have implications for health care managers and executives in identifying critical skills needed by leaders. PMID- 10157963 TI - The effects of hospital executives' personality traits on their perceptions and trust. AB - This field study examines the relationship between hospital executives' personality traits and both their perceptions of their subordinates' levels of skills and their level of trust in those subordinates. CEOs or senior executives of 37 acute care hospitals with at least 200 beds were surveyed. The high Nurturant manager did not perceive greater trust or skills than the low Nurturant manager. However, there was a significant and negative correlation between Person Dominant managers and trust scores. Furthermore, the high Goal-Dominant managers varied significantly less than the low Goal-Dominant managers in their perceptions of their subordinates' skill. The study calls for a reexamination of the influence of personality traits on hospital executives' perceptions and trust. Power in the hands of certain managers may lead to the devaluation of the abilities and motivations of subordinates, and even the devaluation of their subordinates themselves. PMID- 10157964 TI - Hospital middle managers' perceptions of their work and competence. AB - Middle managers in acute care hospitals in New England rated the importance of most work roles and skills higher than their competence to perform them. Being male, having a bachelor's or graduate degree, and reporting to a vice president were related to higher competence ratings for some roles and skills while having held a clinical position in the same organization was related to lower ratings. Middle managers rated skills and roles focused on their individual work units as more important than those associated with their organizations or external environments. This framework for categorizing work may be useful in identifying education, institutional support, or work redesign that would assist middle managers in being more effective. PMID- 10157965 TI - Linkage strategies of rural hospitals--independent hospital, local health system, and/or externally linked facility. AB - Strategies associated with ownership or management of a range of health service facilities, service sharing, and other coordination activities are important to the viability of many rural hospitals. This article articulates a set of linkage strategies employed by rural hospitals. Such strategies and their environmental and organizational correlates are assessed in a sample of 46 rural Pennsylvania hospitals. PMID- 10157966 TI - Considerations in establishing visiting consultant clinics in rural hospital communities. AB - Establishing specialty clinics staffed by visiting medical consultants is one way that rural hospitals can increase local access to specialty care. This example of private sector-driven regionalization of health care services typically involves an agreement among urban specialists, rural hospitals, and local primary care physicians. The urban-based physicians provide limited on-site specialty services in the rural community for patients who are referred by local physicians or self refer to the specialty clinics. The trend toward formalization of regional relationships across large geographic areas prompts both opportunity and need for careful consideration of visiting specialty clinic arrangements in rural hospital communities. This article delineates advantages and disadvantages associated with the development of Visiting Consulting Clinics (VCC) along with some ?ground rules? to consider when establishing this type of service. PMID- 10157967 TI - How health networks and HMOs could result in public utility regulation. AB - Health networks and HMOs--as strategies to reform the American health system--are considered by many elected officials and providers to be the most effective way to improve the delivery of medical care at a reduced cost. Strongly swaying these proposals are the fiscal pressures that now require us to harness such entitlements as Medicare and Medicaid. As these health networks and capitated payment approaches are being aggressively forged by hospitals, physicians, and insurers, the probable consequences are that one alliance will eventually dominate most geographic regions (except for our nation's largest metropolitan areas) and these oligopolies will tend to behave as a monopoly. More simply stated, this article argues that many healthcare markets will either evolve into monopolies or, at best, oligopolies. PMID- 10157968 TI - 'Drive-by deliveries'. PMID- 10157969 TI - Artificial neural networks boost physicians' own brain power. PMID- 10157970 TI - Anticipating the future using life-cycle analysis. PMID- 10157971 TI - Marketing-driven change management. PMID- 10157972 TI - Mega-niching: retail lessons for health care. PMID- 10157973 TI - The 'superior' product that failed in Hong Kong. PMID- 10157974 TI - Satisfaction with HMOs. Accessibility issues top the list for patients in commercial groups. AB - Most complaints about HMOs fall into three broad categories: quality of care, provider attitude, and accessibility to care. Of these, marketers should focus their efforts on the latter. Ensuring that subscribers understand their benefits can help reduce expectations and, therefore, dissatisfaction. Even though accessibility to care (as covered benefits) was very important in contributing to survey respondents' satisfaction with their health care, overall satisfaction did not affect a patient's decision to change physicians and only marginally affected the decision to change HMOs. In the member/provider relationship, the primary care physician may represent a barrier to benefits because he or she has the power to control access under the HMO structure. PMID- 10157975 TI - Legislation undermines us all. PMID- 10157976 TI - Integrating multiple publics into the strategic plan. The best plans can be derailed without comprehensive up-front research. AB - The mission of a health care organization represents its vision for the future. The authors present an approach used to develop an organizational mission for a large multispecialty physician clinic. In implementing the strategic planning process, research objectives must be clearly stated that identify in advance how the data will be used. Failure to integrate strategic data from all relevant publics will likely result in a mission statement that misses the significant interests of one or more stakeholders and reduces the effectiveness of the strategic planning process. Although costly, comprehensive research can uncover some surprising differences in perception that, if ignored, might complete defeat strategic planning efforts. PMID- 10157977 TI - Identifying new patient prospects: efficacy of usage segmentation. For some health care services, usage-based segmentation schemes can be wasteful and ineffective. AB - Even though there is intuitive appeal in identifying the user profile for a given service and then targeting similar nonusers, this approach can be very misleading when marketing health care services with low market penetration. If usage segmentation is employed without checking other indicators of latent demand and perceived barriers to use, significant misallocation of marketing resources is likely to occur. Confidentiality and embarrassment can be significant barriers to use by segments that are excellent patient prospects. In this study of mental and behavioral care, females and non-whites were found to be more concerned with confidentiality than were members of the user group. Lack of awareness can be a much bigger impediment to adoption than negative attitudes. Health care marketers need to design communications that not only increase awareness and familiarity for services with low market penetration, but also address other issues of concern to highly receptive segments. PMID- 10157978 TI - Yellow pages advertising by physicians. Are doctors providing the information consumers want most? AB - Yellow pages listing are the most widely used form of physician advertising. Every month, approximately 21.6 million adults in the United States refer to the yellow pages before obtaining medical care. Mobile consumers--approximately 17% of the U.S. population who move each year--are heavy users of yellow pages. Consumers desire information on a physician's experience, but it is included in less than 1% of all physician display ads. PMID- 10157979 TI - Internal marketing builds service quality. PMID- 10157980 TI - Ethical issues in marketing managed care. PMID- 10157981 TI - Fetal tissue transplants: a primer with a look forward. PMID- 10157982 TI - Harvesting organs from anencephalic infants for transplantation, are these donors dead or alive? PMID- 10157984 TI - Outlook gloomy for reform of failing Medicare trust fund. PMID- 10157983 TI - Va. makes compromise on financial data mandate. PMID- 10157985 TI - Survey tracks managed-care worries. PMID- 10157986 TI - Let the Medicare demagoguery season begin. PMID- 10157987 TI - Treating medical malpractice. AB - The tort reform issue is gathering steam again, despite national statistics indicating claims and payments in malpractice lawsuits are decreasing. Although federal and state governments are debating the issue, major tort reform hasn't occurred. PMID- 10157988 TI - Legislators near pact on insurance reform. PMID- 10157989 TI - Fla. lawsuits down, but payments up. PMID- 10157990 TI - Indicators point up for hospitals' cash flow, profits. PMID- 10157991 TI - Trial under way in suit against Epic. PMID- 10157992 TI - Mo. hospital offer causing concerns. PMID- 10157993 TI - Effort to save Conn. hospital has board, community at odds. PMID- 10157994 TI - Calif. report card uses uniform data. PMID- 10157995 TI - Groups: Ohio Blues misrepresenting deal. PMID- 10157996 TI - Leader's dilemma prompted Community sale. PMID- 10157997 TI - FTC won't challenge Mont. hospital merger. PMID- 10157998 TI - S.D. nursing homes in outcomes project. PMID- 10157999 TI - Group drops guidelines under Justice Dept. scrutiny. PMID- 10158000 TI - Mass. House votes to expand Medicaid. PMID- 10158002 TI - Baystate to acquire majority stake in HMO. PMID- 10158001 TI - Embattled Cape Coral ducks legal duel. PMID- 10158003 TI - Mass. systems keep merger local. PMID- 10158004 TI - Va. hospital breaks with university. PMID- 10158005 TI - Nurses' patient-care outlook grim. PMID- 10158006 TI - Fear of suit halts law to save small-town hospital. PMID- 10158007 TI - Experimental treatment being covered. PMID- 10158008 TI - Living wills present new challenges. PMID- 10158009 TI - Vigilance is needed to protect charitable assets. PMID- 10158010 TI - Systems begin pruning HMOs from holdings. HMO/PPO survey data indicate more health plans may go on selling block. AB - The conflicting pressures of owning provider networks and an HMO are pushing some multihospital systems into selling off their HMOs to focus on care delivery, data from Modern Healthcare's 1996 survey of HMOs and PPOs reveals. PMID- 10158011 TI - Healthcare executives find rewards of giving. Volunteer groups make a difference locally and globally. PMID- 10158012 TI - Antibiotic precision pays off for hospital. PMID- 10158013 TI - Surgical supply system slices costs. PMID- 10158014 TI - 1995 HAVE (Hospital Awards for Volunteer Excellence) winners announced. PMID- 10158015 TI - Family resource centers treat parents with TLC. PMID- 10158016 TI - A lesson in strategic choices. PMID- 10158017 TI - Making waves in a sea of problems. PMID- 10158018 TI - Open minds resurrect closed hospital. PMID- 10158019 TI - Architecture market outlook. Two crystal balls. PMID- 10158020 TI - Health-care prognosis: change. PMID- 10158021 TI - Software for the gravimetric calibration testing of pipets. PMID- 10158022 TI - DNA probe assays for the detection of sexually transmitted diseases. PMID- 10158023 TI - Prostate cancer: to screen or not to screen? PMID- 10158024 TI - Redefining the laboratory in an era of cost constraints. PMID- 10158025 TI - Diagnosing testicular torsion with Doppler US. PMID- 10158026 TI - Diffusion of an effective tobacco prevention program. Part I: Evaluation of the dissemination phase. AB - As health promotion methods are proven effective, the diffusion and widespread implementation of successful programs can significantly reduce behaviors that pose risks to health within a targeted population. The Smart Choices Diffusion Project developed and evaluated a dissemination intervention program that targeted 128 school districts in east Texas. The project employed a theory-based model to disseminate information about a proven tobacco prevention program to opinion leaders in each district. These opinion leaders were asked to personally communicate the program information within their district using a videotape and printed materials, and advocate for program adoption. In addition to personal communication, a newsletter linked school districts. Opinion leaders in 52% of the districts showed the videotape, which modeled program adoption. A quasi experimental design was used to evaluate the impact of the dissemination phase on teachers' and administrators' readiness to adopt a tobacco prevention program. Evaluation of the dissemination phase revealed no differences between the intervention and comparison districts in a district's readiness to adopt a tobacco prevention program. However, in intervention districts where school administrators viewed the videotape, the administrators were more likely to perceive the innovative program as having a relative advantage and to perceive their district's organizational and social environment as supportive of adopting the program. PMID- 10158027 TI - Diffusion of an effective tobacco prevention program. Part II: Evaluation of the adoption phase. AB - This paper presents the results of theory-based intervention strategies to increase the adoption of a tobacco prevention program. The adoption intervention followed a series of dissemination intervention strategies targeted at 128 school districts in Texas. Informed by Social Cognitive Theory, the intervention provided opportunities for districts to learn about and model themselves after 'successful' school districts that had adopted the program, and to see the potential for social reinforcement through the knowledge that the program had the potential to have an important influence on students' lives. The proportion of districts in the Intervention condition that adopted the program was significantly greater than in the Comparison condition (P < 0.001). Stepwise logistic regression indicated that the variables most closely related to adoption among intervention districts were teacher attitudes toward the innovation and organizational considerations of administrators. Recommendations for the development of effective strategies for the diffusion of innovations are presented. PMID- 10158028 TI - Personal incentives as determinants of adolescent health behavior: the meaning of behavior. AB - It has been suggested that prevailing theories do not fully incorporate the less rational, more emotional elements of adolescent health and risk behavior. To address this limitation, the perceived incentives construct from Tappe's Model of Personal Investment is split into intrinsic and extrinsic incentives, with the intrinsic incentives representing personal meanings of adolescent health and risk behaviors. Intrinsic incentives were operationalized using transcripts from focus group interviews for three behavioral domains: sleeping habits, eating habits at lunch and eating habits after school. The ensuing questionnaire was completed by 416 Dutch secondary school students with a mean age of 14 years. Intrinsic incentives, or the personal meaning with which behavior is imbued, predicted health and risk behaviors well in all three behavioral domains. The implications of these results for further research and for the development of health education programs are discussed. PMID- 10158029 TI - Evidence for the validity and utility of the Stages of Exercise Behaviour Change scale in young adults. AB - This study examined the validity and utility of the Stages of Exercise Behaviour Change (SEBC) scale in 244 young British adults. One-way ANOVA revealed significant differences (F > 7.34, P < 0.01) between the Exercise Behaviour Change Categories of Precontemplation/Contemplation (n = 49), Preparation (n = 87) and Action/Maintenance (n = 108) in self-report levels of exercise behaviour. Significant differences (F > 3.14, P < 0.05) were also revealed in exercise self efficacy, physical self-perception sub-domains and global self-esteem scores. Subsequent step-wise discriminant analyses revealed that discrimination between the Categories of Exercise Behaviour Change was possible on the basis of selected behavioural and psychological parameters (Canonical r = 0.76-0.82, Wilks' lambda = 0.30-0.33, chi 2 = 60.3-94.6, d.f. = 14, P < 0.0001). In both males and females, the most dominant discriminatory variables in the first Function were revealed to be perceived physical conditioning and 'strenuous' exercise behaviour. For males, the second Function comprised exercise self-efficacy and perceived bodily attractiveness, whilst for females it comprised perceived bodily attractiveness, perceived sports competence and perceived physical strength. Subsequent cross-validation analysis, using a randomly selected 40% sub-sample, revealed that 67.8-70.7% of subjects were assigned to the correct Category. These results appear to confirm the concurrent validity of the SEBC scale in terms of self-report of exercise behaviour. Furthermore, the utility of the SEBC scale was demonstrated via the ability to predict membership of specific Categories of Exercise Behaviour Change using a selection of behavioural and psychological parameters. PMID- 10158030 TI - Pain relief, acceleration of death, and criminal law. AB - This paper considers whether a physician is criminally liable for administering a dose of painkillers that hastens a patient's death. The common wisdom is that a version of the doctrine of double effect legally protects the physician. That is, a physician is supposedly acting lawfully so long as the physician's primary purpose is to relieve suffering. This paper suggests that the criminal liability issue is more complex than that. Physician culpability can be based on recklessness, and recklessness hinges on whether a physician has taken an unjustifiable risk of hastening death. The authors identify three conditions of justifiability. Their analysis helps to explain the distinction between euthanasia, which is legally banned, and the use of risky analgesics, which is permitted in limited circumstances. PMID- 10158031 TI - Why the United States should adopt a single-payer system of health care finance. AB - Although nothing could be less fashionable today than talk of comprehensive health care reform, the major problems of American health care have not gone away. Only a radical change in the way the U.S. finances health care- specifically, a single-payer system--will permit the achievement of universal coverage while keeping costs reasonably under control. Evidence from other countries, especially Canada, suggests the promise of this approach. In defending the single-payer approach, the author identifies several political and cultural factors that make it difficult for Americans to obtain a clear view of this option. Finally, the author argues that much discussion of rationing is vitiated by bracketing more systemic questions to which the issue of rationing is inextricably linked. PMID- 10158032 TI - Routine HIV testing of hospital patients and pregnant women: informed consent in the real world. AB - The Centers for Disease Control and Prevention (CDC) has recommended that HIV testing be routinely offered to certain patients in hospitals with a high prevalence of HIV infection and on all pregnant women. The CDC does not, however, offer implementation level guidelines for obtaining informed consent. We provide a moral justification for requiring informed consent for HIV testing and propose guidelines for securing such consent. In particular we argue that genuine informed consent can be secured without elaborate counseling, such as that currently used at Counseling and Testing Sites, provided that sufficient written notice is given to the patients before testing and that they are specifically asked for permission. PMID- 10158033 TI - A new look at animal-to-human organ transplantation. PMID- 10158034 TI - Scope Note 31. Managed health care: new ethical issues for all. PMID- 10158035 TI - Indoor air quality: a guide for facility managers. AB - With the marked increase in the awareness of indoor air quality (IAQ) issues, facility managers are under more pressure than ever to recognize and resolve IAQ problems. They must understand both the sources of these problems as well as the various methods for handling them. This document has been developed to help facility managers improve their understanding of IAQ issues and provide guidance for solving the problem of poor indoor air quality. PMID- 10158036 TI - T.E.A.M. maintenance: success for the nineties and beyond. AB - As hospital engineering departments are being asked to do more with less, they examine their current structure to see how they can become more cost-effective and efficient. This document examines one such department and the steps it took to reengineer and to evaluate both before and after the process. PMID- 10158037 TI - Preparing for a JCAHO survey. AB - With the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) new Environment of Care (EC) standards now in place, many facilities are struggling to reorganize their programs to meet JCAHO requirements. This document provides practical advice on how to approach a JCAHO survey and what a facilities manager can do to be as fully prepared as possible. PMID- 10158038 TI - Health maintenance organizations: employer contribution to HMOs--HCFA. Final rule. PMID- 10158039 TI - The Outcomes Roundtable. Developing, evaluating, and disseminating outcomes monitoring technology. PMID- 10158040 TI - Overcoming barriers to comprehensive quality improvement. PMID- 10158041 TI - Talking the talk, walking the walk. Implementing an outcomes information system. PMID- 10158042 TI - Dialogue. Aiming at the moving target: how much outpatient psychotherapy is enough? PMID- 10158043 TI - Performance measures for managed behavioral healthcare programs. PMID- 10158044 TI - Report cards accelerate quality and accountability. PMID- 10158045 TI - Implementing a practice-based outcomes program. PMID- 10158046 TI - Computer assisted patient evaluation systems: advice from the trenches. PMID- 10158047 TI - Patient-based assessment: tools for monitoring and improving healthcare outcomes. PMID- 10158048 TI - Disease prevention on the Web. PMID- 10158049 TI - Climbing the ladder, quickly. Interview by Bill Siwicki. PMID- 10158050 TI - A rural managed care strategy. PMID- 10158051 TI - Measuring outcomes. PMID- 10158052 TI - EDI enables hospitals to trim inventories. PMID- 10158053 TI - HMOs & CPRs. HMOs clarifying electronic records strategies. PMID- 10158054 TI - Malpractice insurers endorse electronic records as a way to reduce risk. PMID- 10158055 TI - Telemedicine. Choosing the right technology. PMID- 10158056 TI - Solving the cash crunch. PMID- 10158057 TI - What skills and talents make a good subacute nurse? PMID- 10158058 TI - Kaiser offers tips on how to win managed care contracts. PMID- 10158059 TI - New Chicago subacute network shapes itself for managed care. PMID- 10158060 TI - Ways to protect your facility against medical malpractice lawsuits. PMID- 10158062 TI - HCFA quality indicators may produce focus in survey process. PMID- 10158061 TI - How to assess market, operating needs to expand subacute rehab. PMID- 10158063 TI - Industry leaders agree: HHS study validates subacute care concept. PMID- 10158064 TI - HCFA test to adjust payment for severity moves to phase II. PMID- 10158065 TI - Three more insights on coping with HCFA's new enforcement survey. PMID- 10158066 TI - HCFA's Hoyer considers episodic prospective payment system. PMID- 10158067 TI - In Arizona, case management fights the heat of capitation. PMID- 10158070 TI - ProPAC endorses PPS, avoids saying who gets the money. PMID- 10158068 TI - Provisions in Medicare budget plans differ for SNFs. PMID- 10158069 TI - GAO says nursing facilities could help curb Medicare fraud. PMID- 10158071 TI - How more real-world subacute sites compare to HHS "ideal". PMID- 10158072 TI - ProPAC chairman expands ideas to combine Medicare payments. PMID- 10158073 TI - New Jersey SNFs oppose legislation favoring hospitals. PMID- 10158074 TI - Never say die. Allerton First Responders capture EMS Magazine's Gold Award. PMID- 10158075 TI - Mind your manners. Are you committing EMT etiquette sins? PMID- 10158076 TI - Trauma in the stands. Fan violence scars spectator events. PMID- 10158077 TI - Meet the stethoscope behind ER. Interview by Brian Johnston. PMID- 10158078 TI - I.V. solution prices are holding steady; little price change, up or down, expected. PMID- 10158079 TI - Prices for the anesthesia gas isoflurane falling through floor. PMID- 10158080 TI - Chemical costs are not insignificant part of the supply budget. PMID- 10158081 TI - Market transformation: will not-for-profit providers survive? PMID- 10158082 TI - Theology and ethics: keys to continuing Catholic healthcare. PMID- 10158083 TI - What is spirituality? PMID- 10158084 TI - Legal implications of computerized medical records. PMID- 10158085 TI - Certain service in an era of uncertain employment. Interview by Francis J. Wiesner. PMID- 10158087 TI - Sponsors lead ministry transformation. Interview by Judy Cassidy. PMID- 10158086 TI - A matter of value. Profits and losses in healthcare. AB - In the growing debate over for profit enterprise in healthcare, the real issues are ownership, conflicts of interest, profit margins, and what is done with those profits--not tax status or the presence or lack of a profit. Every healthcare sector--except hospitals--is now dominated by proprietary enterprise, and current attention is focusing on three types of entities: megasystems, systems and group practices, and for-profit HMOs. The question is, Do we indeed have a problem with the profit-related issues I have mentioned? A great deal of fog surrounds the discussion. Both the public and many healthcare people feel discomfort with the idea that healthcare is a commercial commodity. But there seems to be a certain amount of hypocrisy in how the argument has been framed; only certain for-profits are characterized as posing a threat. What we are really dealing with is a massive shift of power from one interest to another. Some not-for-profit providers' loss of money and power, however, does not mean that for-profits that gain money and power are scurrilous. Thus the debate over proprietary enterprise has been colored by extraneous concerns and hidden agendas. Nonetheless, three serious issues merit closer inspection: 1. Is the for-profit model flawed? Indeed, moral hazards certainly seem to be involved in stock holder-held entities that provide direct services to patients. 2. Is the problem making a profit or profiteering? Even if nonprofits are sometimes profiteers, the for-profits are hardly innocent. In addition to the huge sums being provided to stockholders, executives of proprietary firms often do very well indeed. 3. Do new models such as systems and HMOs pose any special problems when they are proprietary? In terms of systems, the jury is still out. Despite evidence that proprietary systems are forcing everyone to be more efficient, the question remains of who will subsidize unprofitable services like burn units and true indigent care if the system's hospitals and clinics do not provide it. When it comes to managed care, the tempting incentives to constrain access and skimp on services, combined with the requirements of for-profit enterprise, simply produce too dangerous a situation. PMID- 10158088 TI - Holistic center stresses spiritual healing. A team approach to therapy helps clients tap their inner healing powers. PMID- 10158089 TI - Healthy Communities. The National Civic League's model for collaborating to improve community health. PMID- 10158090 TI - Integrating complementary and traditional medicine. Healing Arts Center connects body, mind, spirit. PMID- 10158091 TI - A system for employee fitness. Sisters of Charity of Nazareth Health System makes wellness a top priority. PMID- 10158092 TI - Therapeutic touch: a healing intervention. Hospital uses complementary therapy to aid healing, relieve pain. PMID- 10158093 TI - The cultural basis of inadequate care. To provide supportive care of the dying, our society must learn to live with our mortality. PMID- 10158094 TI - Healthcare reform's moral, spiritual issues. The problems are not just political. AB - Although President Clinton's proposals were defeated in 1994, healthcare reform is an issue that will not go away. But it is an especially complex issue because it is moral and spiritual as well as political. Catholic social teaching could help free us Americans from our confusion on the topic. For example, the Catholic ideas of justice, subsidiarity, and the common good could help us address the crux of the healthcare reform debate, which questions the fairness of forcing more fortunate people to provide healthcare for those who are sick and poor. Catholic social teaching tells us that our healthcare decisions must be made not only on the basis of what is good for me but what is good for us as a community. By the same token, we might find that several specifically spiritual ideas are helpful. Christianity says, for example, that sickness can be a gift because it is a window on immortality for us; that we should not prize life above all other values; and that friendship--including the civic friendship involved in healthcare--is a way we can enter full friendship with God. These moral and spiritual ideas lead us to certain political conclusions: Healthcare reform should be politically realistic, relatively simple. and inclusive. Because healthcare is a good like no other, it can be a powerful occasion for realizing God's own compassion, healing, and justice. PMID- 10158095 TI - Communicating with lawmakers is citizen's responsibility now. PMID- 10158097 TI - Can pastoral counseling flourish in a world of managed care? PMID- 10158096 TI - Personal commitments needed to reduce violence. PMID- 10158098 TI - Pediatric pastoral care: a case study. PMID- 10158099 TI - An empirical investigation of the relationship between spirituality, coping, and emotional distress in people living with HIV infection and AIDS. AB - Evaluates levels of psychological distress, coping mechanisms, and their relationship with the religious beliefs and spiritual practices of people (N=65) living with HIV and AIDS. Results of the research indicate a strong relationship for spiritual dimensions with mental health, psychological adjustment, and coping. Concludes that a blending of spiritual traditions and mental health approaches are needed to facilitate the coping of people living with HIV and AIDS. PMID- 10158100 TI - The assessment of left ventricular filling dynamics using an online automatic border detection algorithm: comparison with cineventriculography. AB - An echocardiographic system has been developed that performs automatic endocardial border detection and instantaneously calculates and displays a waveform of left ventricular cavity area versus time. The purpose of this study was to compare measurements of left ventricular filling dynamics from automatic border detection echocardiography with similar measurements from cineventriculography. Thirty-three patients undergoing cardiac catheterization had automatic border detection echocardiography performed within 45 minutes of cineventriculography. Ten patients had normal catheterization findings and 23 had cardiac disease. The automatic border detection waveforms generated from two echocardiographic views were measured to determine the fraction of filling occurring during the early diastolic rapid filling phase and during the filling phase resulting from atrial contraction. Similar fractions were derived from curves generated from frame-by-frame measurements of cineangiographic volumes. Results were analyzed by correlating echocardiographic and cineventriculographic results, and by a limits of agreement analysis (limits of agreement were +/- 2 standard deviations of the mean difference between echocardiography and cineventriculography). There were significant correlations between echocardiography and cineventriculography for each of the parameters studied. The best results were obtained for the apical four-chamber view (rapid filling fraction r = 0.72, P < 0.0001, atrial filling fraction r = 0.56, P < 0.001). Differences in filling patterns between normal and abnormal patient groups detected by cineventriculography were also detected by automatic border detection echocardiography. However, broad limits of agreement were observed, that may limit the ability of the automatic border detection system to reliably predict cineventriculographic results in an individual patient. Automatic border detection echocardiography can provide information about left ventricular filling dynamics that is similar to that obtained from frame-by-frame analysis of cineventriculograms. However, the variability in the results may limit the application of the technique in individual patients. PMID- 10158101 TI - Has transesophageal echocardiography changed the approach to patients with suspected or known infective endocarditis? AB - Infective endocarditis is still a great clinical challenge. Its diagnosis is difficult to establish, and mortality has remained around 30%. Early diagnosis and optimal treatment are crucial fo prognosis improvement. Echocardiography plays an indispensable role in the management of this disease, especially with the recently introduced approach, transesophageal echocardiography (TEE). TEE can overcome the limitations of transthoracic echocardiography (TTE) and is superior to TTE in almost every way in providing earlier and more information for the diagnosis and treatment of infective endocarditis. TEE detects valve vegetations with much higher sensitivity and specificity than TTE. It can demonstrate smaller vegetations in the early stage of the disease and vegetations on atypical locations (e.g., mitral valve annulus), and provides detailed characterization of vegetations (e.g., location, size, mobility, and changes during treatment). Such information is of great prognostic value and may help in selecting proper treatment. TEE is more sensitive for detecting complications, such as mitral valve perforation, abscess, and subaortic complications, which respond poorly to medicine and for which timely surgery may be the best treatment. For those with prosthetic valve endocarditis, TEE is especially useful because TTE is greatly limited by the acoustic shadow of prostheses. Both positive and negative results of TEE examination are valuable for confirming or excluding infective endocarditis. TEE also plays a unique role in intraoperative monitoring and can assess surgical results before the chest is closed. TEE has become an invaluable tool for the diagnosis and management of patients with suspected or known infective endocarditis. PMID- 10158102 TI - Echocardiographic assessment of vegetations in patients with infective endocarditis: prognostic implications. AB - Today, echocardiography is the most important technique next to clinical findings and blood cultures in the diagnosis of infective endocarditis. The sensitivity of echocardiography, particularly the transesophageal approach, for detection of vegetations and endocarditis related valvular destructions is high. In addition, echocardiographic findings may have some prognostic implications. The size and mobility of vegetations stratifies endocarditis patients into a high risk group for arterial embolism. In particular, mobile vegetations attached to the mitral valve with a maximal diameter > 10 mm may be prone to embolic events. Furthermore, increase in size of vegetations during antimicrobial treatment may identify patients with no, or at least a prolonged, healing process. Also, a lack of increase in the echo density of vegetations under adequate antibiotic treatment may indicate a poor healing process and may necessitate more aggressive management. The demonstration of paravalvular abscesses by echocardiography, particularly by transesophageal echocardiography, identifies a subgroup of patients who will need urgent cardiac surgery before widespread tissue destruction has occurred. PMID- 10158103 TI - Criteria for the diagnosis of endocarditis and the role of echocardiography. AB - When infective endocarditis is a diagnostic possibility, echocardiography permits noninvasive imaging of cardiac structures. As involvement of the endocardium is a sine qua non of endocarditis, echocardiography may assist in its diagnosis by demonstrating such involvement. The ability of echocardiography to detect the intracardiac manifestations of infective endocarditis has continued to improve, especially with the introduction of transesophageal imaging. This article will discuss some of the echocardiographic findings in endocarditis and elucidate the incorporation of these findings in the new Duke criteria for the diagnosis of endocarditis. PMID- 10158104 TI - Role of transesophageal echocardiography in right-sided endocarditis. AB - Investigations performed over the last few years support the invaluable usefulness of transesophageal echocardiography in the diagnosis of left-sided endocarditis. Whether this can be applied to right-sided endocarditis remains speculative. Patients at risk of having right-sided endocarditis can be classified into three different and well-defined groups: (1) intravenous drug abusers; (2) patients with pacemakers; and (3) patients with congenital heart diseases. In this article, we review the different value of transesophageal echocardiography in right-sided endocarditis depending on the subset of patients considered. PMID- 10158105 TI - Complementary role of MRI in infectious endocarditis. AB - The usefulness of magnetic resonance for imaging of cardiac structures is well established. In this study, we evaluated the role of this technique in the diagnosis of perivalvular extension of infectious endocarditis. Our initial experience and the few case reports in the literature show that magnetic resonance imaging can complement echocardiography in the assessment of periannular extension of infectious endocarditis. PMID- 10158106 TI - Radiofrequency catheter ablation as primary therapy for supraventricular tachycardia. AB - BACKGROUND: Initial management of patients with supraventricular tachycardias has traditionally been with medications. More recently, radiofrequency catheter ablation offers curative therapy thus obviating the need for medications with potential side effects. The purpose of this study was to evaluate radiofrequency catheter ablation as an initial strategy to cure supraventricular tachycardias. METHODS: Radiofrequency catheter ablation was attempted as the initial therapy in 49 patients with supraventricular tachycardia, 25 with atrioventricular nodal reentrant tachycardia, 20 with atrioventricular reentrant tachycardia, two with both atrioventricular nodal reentrant tachycardia and atrioventricular reentrant tachycardia, and two with atrial tachycardia. RESULTS: Supraventricular tachycardia was rendered non-inducible in 48 of 49 (98%) patients undergoing radiofrequency catheter ablation. Thirteen of 14 patients returning for follow-up electrophysiologic study at 4.9 +/- 2.2 months had no evidence of recurrence. Three patients experienced documented recurrences of supraventricular tachycardia. One of these three patient's supraventricular tachycardia was rendered non-inducible after a final ablation session, and has had no recurrence after 24 months. The other two patients await repeat ablation. Two patients required treatment for atrial fibrillation which was documented prior to ablation. There were no complications or mortality from the procedure. CONCLUSIONS: Radiofrequency catheter ablation should be considered as first line therapy for symptomatic supraventricular tachycardia. PMID- 10158107 TI - Left ventricular pseudoaneurysm: a patient report and discussion. PMID- 10158108 TI - Prognostic significance of left main coronary artery disease detected by intravascular ultrasound. PMID- 10158110 TI - Treatment alternatives for chronically occluded saphenous vein grafts. PMID- 10158109 TI - Conus medullaris syndrome: a complication following insertion of an intraaortic balloon pump. PMID- 10158111 TI - Recanalization of coronary occlusions using the Magnarail system: technique and procedural outcome. AB - Angioplasty for occluded coronary arteries is less successful than for sub-total stenoses. The Magnarail system (Schneider) has been designed to improve success rates. We used the system in 112 patients with coronary occlusions (TIMI flow < or = 1) which the operator felt suitable for angioplasty. It was successful (defined as < 50% stenosis) in 75.9% overall, 65.9% in occlusions > 3 months and 83.3% < 3 months. Intimal dissection occurred in 26 instances, more commonly after right coronary angioplasties. One patient died and one procedure was complicated by coronary perforation treated surgically. The procedure was less successful in the right coronary artery (p = 0.02). Coronary calcification (p = 0.03), the absence of a tapered occlusion (p = 0.04) and the absence of collaterals from another vascular territory (p = 0.04) were all associated with angiographic failure. The mean fluoroscopy time for the procedures was 22.8 +/- 16.9 minutes. The Magnarail system seems highly effective in recanalization of coronary occlusions. PMID- 10158112 TI - Major dissection during coronary angioplasty: outcome using prolonged balloon inflation versus coronary stenting. AB - BACKGROUND: Abrupt or threatened closure is the major acute complication following conventional coronary angioplasty with a persistent incidence of 2% to 10%. OBJECTIVES: In order to evaluate the safety and efficacy of endoluminal stenting and autoperfusion balloon angioplasty in the setting of abrupt or threatened closure following coronary angioplasty, the short- and long-term clinical and angiographic follow-up of respectively 45 and 51 patients treated by either method were compared. METHODS: From August 1986 through August 1992, consecutive patients treated by either endoluminal stenting or autoperfusion balloon angioplasty for abrupt closure following coronary angioplasty, were entered into an observational trial that requested clinical follow-up and repeat angiography at 6 months. RESULTS: Except for vessel localization, baseline clinical, angiographic and procedural characteristics were comparable. The in hospital clinical and angiographic outcome was similar (p = 0.85) with 69% event free patients in both treatment groups. The postprocedural minimal luminal diameter was larger following stenting: 2.67 +/- 0.76mm versus 2.07 +/- 0.70mm (autoperfusion balloon) (p = 0.0002). At follow-up, there were less events in the stent group: 11% versus 34% for the autoperfusion balloon angioplasty group, (p = 0.03). Restenosis rates were 5% (2/37 patients, stent) versus 27% (11/41 patients, autoperfusion balloon) (p = 0.02). CONCLUSIONS: Autoperfusion balloon angioplasty and endoluminal stenting are effective and safe therapeutic options for abrupt or threatened closure following coronary angioplasty with a comparable short-term clinical and angiographic outcome. However, during follow-up, more complications occur following autoperfusion balloon angioplasty. This is explained by a higher restenosis rate in this treatment group. PMID- 10158113 TI - Efficacy of preconditioning with intracoronary diltiazem in preventing laser induced spasm. AB - Laser energy produces a multitude of effects, resulting both in therapeutic tissue ablation and complications such as laser-induced spasm (LIS). LIS can occur during lasing itself or during subsequent adjunctive angioplasty. Intracoronary diltiazem (ICD) can partially reverse LIS after it occurs. To determine whether pre-treatment with ICD might prevent LIS during laser interventions, 3 groups of 50 lesions each were studied. Group 1 served as controls receiving no ICD during the procedure. Group 2 received 2.5 mg ICD before lasing. Group 3 received ICD before lasing and then a second infusion of 2.5 mg ICD after lasing but before adjunctive therapy. There were no differences in clinical characteristics of the 3 groups. Over 75% of lesions in each group were complex (B2 or C) lesions, and average lesion length was 15 mm in all 3 groups. Procedural success was > or = 94% in all groups. There was no significant difference among groups in pre-procedure artery stenosis, post-procedure stenosis, laser power used or number of laser pulses delivered. Pretreatment with ICD produced vasodilation of the minimum lumen diameter from 0.86 +/- 0.1 to 1.0 +/- 0.1 mm (p < 0.01) and was well tolerated. Control patients exhibited a 12% incidence of LIS. Group 2 had an 80% reduction of LIS during lasing (p < 0.01) but had increased LIS during adjunctive therapy with the same 12% incidence of LIS overall. Group 3 had only a 2% incidence of LIS (p < 0.01). We concluded that pretreatment with ICD significantly reduces LIS. Multiple infusions of ICD are necessary to sustain this protective effect. PMID- 10158114 TI - Coronary artery stenting in active duty soldiers. AB - The treatment of coronary artery disease in young patients must take into account the long-term success of the treatment modality and the possibility of repeat interventions. Elective placement of Palmaz-Schatz coronary stents have been shown to reduce six month restenosis rates in discrete, de novo lesions in native coronary arteries albeit at a significant risk of bleeding and vascular complications. The present study was undertaken to evaluate the role of intracoronary stenting in young active duty soldiers. Between March 1988 and December 1994, fifteen active duty soldiers (age 37 to 53 years) underwent elective placement of one or more Palmaz-Schatz coronary stents at our institution. Angiographic success was 100% with no complications (acute/subacute closure, bleeding requiring transfusion, vascular repair, myocardial infarction, death, or in-hospital coronary artery bypass grafting). Six month angiographic follow-up is available in 13 patients (87%) with angiographic restenosis in one patient (8%) and no target vessel revascularization at six months. Clinical follow-up is available on all patients at a mean of 33 months (range 6-65) after the procedure. There was one death (7%) attributed to progression of coronary disease in another vessel and one patient (7%) who underwent target vessel revascularization for silent ischemia at 24 months after the procedure. These preliminary encouraging results suggest there may be a significant role for intracoronary stenting in active duty soldiers with coronary artery disease. PMID- 10158116 TI - Long-term successful coronary artery angioplasty in polycythemia vera. AB - In a 65-year-old man with Polycythemia Vera, invalidating angina pectoris was associated with severe narrowing of the right coronary artery. After percutaneous coronary angioplasty (PTCA) the patient became symptom free and remained so for 12 months, while receiving an antiplatelet agent, a calcium antagonist and nitrate. Coronary angiography repeated after a year, because of reappearance of angina, documented good patency of the treated artery and some progression of a narrowing involving another coronary vessel. This is the first reported case of long-term success of PTCA in Polycythemia Vera, a disease exposed to a high risk of thrombosis and, possibly, of restenosis. It is undefined whether medical treatment contributed to the anatomical and clinical results. As far as a single case can say, Polycythemia Vera might not represent a prohibitive background for coronary PTCA. PMID- 10158115 TI - Early repolarization: normalization of the electrocardiogram with exercise as a clinically useful diagnostic feature. AB - BACKGROUND: Early repolarization is a normal ECG variant which may resemble various pathologic conditions including acute myocardial infarction/injury and pericarditis. Some electrocardiographers believe early repolarization resolves with exercise-induced increases in heart rate. The purpose of this study was to evaluate qualitatively and quantitatively this phenomenon. METHODS: From among 3,000 consecutive patients referred for evaluation of ischemic heart disease by exercise treadmill testing, 25 patients with early repolarization and no risk factors for cardiovascular disease (Group I), 28 patients with early repolarization and risk factors for cardiovascular disease (Group IIA), and 28 matched control patients (Group IIB) were identified and evaluated retrospectively. Group II patients also underwent radionuclide stress imaging. All study patients had otherwise normal ECGs and a negative history of cardiovascular disease. RESULTS: In patients with early repolarization, diagnostic ST elevation was most frequently evident in ECG lead V4. We found that the ECG normalized progressively, beginning almost immediately with the onset of exercise, and typically returned completely to the isoelectric baseline at an average heart rate of approximately 106 beats per minute. In patients with otherwise normal ECGs and no history of cardiovascular disease, early repolarization was a strong predictor of a negative exercise treadmill test and only infrequently was associated with a positive radionuclide imaging study. Early repolarization was found in virtually all demographic groups with respect to age, race, and gender except for a disproportionate infrequency in white females. CONCLUSION: A progressive decrease in ST segment elevation and normalization of the ECG with mild exercise was a predictable response in patients who have early repolarization with otherwise normal ECGs and no history of cardiovascular disease. This phenomenon may be clinically useful as a bedside diagnostic tool in evaluating patients who present with early repolarization, otherwise normal ECGs, and negative cardiac history, in which the diagnosis of acute myocardial infarction/injury or pericarditis is being considered. These findings warrant formal evaluation in a prospective clinical trial. PMID- 10158117 TI - Intracoronary stent placement in thrombus containing vein graft lesions. AB - Intracoronary stents are traditionally considered to be contraindicated in presence of thrombus. However recent advances in stent deployment technique have reduced the risk of stent thrombosis. We report the placement of a stent in a thrombus laden saphenous vein graft to the posterior descending artery. Three months later the stent site was patent with severe stenosis with thrombus in another graft which was also stented. Intracoronary stents should be considered in patients with complex lesion even in presence of intraluminal thrombus. PMID- 10158118 TI - Taking control: the Validation Master Plan. AB - Companies preparing for compliance with the European quality system standards and US Good Manufacturing Practice regulations must comply with the process validation requirements that apply to their manufacturing processes. Effective planning for compliance is fundamental for companies with processes that must be validated, monitored, and controlled. This article discusses the basic elements of a Validation Master Plan, which can greatly facilitate this planning process. PMID- 10158119 TI - The future with SEBS-based compounds. AB - Styrene-ethylene/butylene-styrene (SEBS) block copolymers are thermoplastic elastomers that combine the properties of thermoplastics and rubbers in one polymer. After compounding with other materials to make them suitable for processing, new product opportunities are available including substitute materials for plasticized PVC. This article reviews the development and applications of these compounds. PMID- 10158120 TI - Fuzzy logic in drug delivery. AB - The first article in this series concentrated on the definition of terms and the methods that are applied in fuzzy logic. This article discusses the advantages of fuzzy logic in drug-delivery applications. The derivation of membership functions, linguistic variables, and drug-delivery control rules are shown for various delivery devices. A specific solution is discussed, which uses fuzzy logic decision-support methods for optimized treatment through respiratory drug delivery. PMID- 10158121 TI - Safety by design in electromedical equipment, Part II. AB - Part I of this article provided advice on how to minimize the safety risks when using electromedical equipment and safety features to incorporate into its design. Part II will provide further hints for safe design and compliance with safety legislation, in particular, concerning colours for indicator lights and wiring, power-supply cord sets, power inlets, connectors, and internal-powered devices. PMID- 10158122 TI - Market report. Poland. AB - From a supplier's point of view, the medical equipment market in Poland is an interesting market. This article outlines the funding and purchasing procedures that operate there. It is the author's view that the market is on the upturn and that the current difficulties as a result of lack of budgeted funds can be resolved by active salesmanship. PMID- 10158123 TI - The thin line: gas-phase polymeric coatings. AB - Medical devices often need some form of protection from their immediate environment. However, with small, complex, and sensitive components, the application of a protective coating is not a trivial matter. This article discusses the problem and describes a solution. PMID- 10158124 TI - Biological variability and predictability: an exercise in plausibility. AB - The inherent variability in the responses of the human body to stimuli means that it is often necessary to utilize statistical methods to evaluate causal relationships in clinical research. It is necessary, however, to be cautious with statistical methods and it is imperative that scientific plausibility is included in the analysis. This article addresses some of these issues in relation to the assessment of so-called adverse effects associated with medical devices. PMID- 10158125 TI - Working draft of the FDA GMP final rule (Part I). AB - On 24 July 1995, the US Food and Drug Administration (FDA) published a notice of availability of a working draft of a final rule for new good manufacturing practice (GMP) regulations for medical devices. The new regulations could be in force by late 1996. This is the first of a two-part series of articles discussing key provisions of the working draft and their importance to companies marketing or planning to market devices in the US. PMID- 10158126 TI - Surface analysis of biomedical devices. AB - Modern surface analysis methods are highly effective tools in the development and manufacture of biomedical devices. Improvements in the performance of surface analysis techniques and sample handling are shown to have extended their value throughout device development. The application of these techniques and key improvements in their capabilities are discussed in the light of possible future regulatory requirements, which could include auditing of the surface chemistry of devices during manufacture, packaging, and storage. PMID- 10158127 TI - Fuzzy logic and medical device technology. AB - This article introduces the concept of fuzzy logic and discusses its application in analytical processes. Terms such as fuzzy sets and membership functions, which can be used to describe the process states and conditions of a system, are defined. An example is given of how this reasoning technique could be applied to an actual device. PMID- 10158128 TI - Economics of electron beam accelerators. AB - Capital and operating costs for high-energy and high-power 10-MeV electron linear accelerators are presented in this article. These are compared with those for gamma-irradiation sterilization using cobalt 60. Medical sterilization processing costs for electron-beam and gamma-irradiation methods are derived as a function of plant utilization and capacity. PMID- 10158129 TI - Safety by design in electromedical equipment: Part I. AB - The increase in quantity and complexity of electromedical equipment can also mean an increase in the potential hazards. This article provides advice on how to minimize the safety risks when using the equipment and safety features to incorporate into its design. The sources of those hazards and safety-compliance criteria are also discussed. PMID- 10158130 TI - Managing the medical device directive. A practical case study. AB - Through a case study of a fictional company, this article provides a guide on how to implement CE-marking procedures, as detailed in the Medical Device Directive. The overlap in transitional periods between the Medical Device and Electromagnetic Compatibility Directives is discussed, together with issues such as selection of conformity assessment routes. PMID- 10158131 TI - Working draft of the FDA GMP final rule (Part II). AB - Part I of this two-part series provided information on the proposed design control provisions of the US Food and Drug Administration's (FDA) working draft of the final rule for new good manufacturing practice regulations for medical devices. The final rule could be published in April or May 1996. It would be in force 180 days after the date of publication. Design control requirements may become effective some months later. This article describes recommended modifications of three provisions that have been intensely discussed during recent FDA-sponsored public meetings. PMID- 10158132 TI - Without the denominator where is the quality improvement paradigm in the nation's health care reform? AB - This paper will argue that there is room for improvement in the quality of health care delivered in the United States. A quality improvement paradigm requires an assessment, inventory and prioritization of areas for improvement. It further nurtures the imperative of process improvement for the achievement of a targeted outcome. The dual obligations of reduction in outcome variability, and resource management, provide an exciting milieu for the integration of clinical practice, the numerator, with population based medicine, the denominator. PMID- 10158133 TI - Scuba diving: how high the risk? AB - The host factors that represent the most risk for scuba-diving safety are poor fitness, overweight, chronic diseases, structural abnormalities of the heart and lungs, and multiple risk factors for CAD. Any of these factors, plus inexperience, a history of irresponsible behavior, or participation in technical diving should alert medical underwriting that a scuba diver has excess risk for fatal accidents. PMID- 10158134 TI - Mortality from cerebrovascular disease. A study based on data from hospitalization benefits. PMID- 10158136 TI - Genetic information and life insurance; key issues regarding use of genetic information (2). PMID- 10158135 TI - Primary hyperparathyroidism, an overview for insurance medicine. PMID- 10158137 TI - Health care alliances provide market-based solutions for small business. PMID- 10158138 TI - How to implement a managed care information system. A primer. PMID- 10158139 TI - Specialized managed care contracting: the City of Hope tertiary care perspective. PMID- 10158140 TI - Position of the American Medical Association on silent PPOs. PMID- 10158141 TI - Development of provider networks for specific diseases. PMID- 10158142 TI - Making sense of managing professionals. PMID- 10158143 TI - Evaluating the economics of leasing hospital assets. PMID- 10158144 TI - Revamping health-care benefits to reduce costs and improve competitiveness at DuPont. PMID- 10158145 TI - Miracles or limits: what message from the medical marketplace? PMID- 10158146 TI - Managed care: the principles approach. PMID- 10158147 TI - Accepting death! PMID- 10158148 TI - Resolving moral dilemmas: a case-based method. PMID- 10158149 TI - Perspectives. New ideas for Medicare risk, but Baltimore demo stumbles. PMID- 10158150 TI - Perspectives. Kids' coverage crisis: next target for 'consensus' reform? PMID- 10158151 TI - The Dementia Education and Training Program. PMID- 10158152 TI - Following the road map. Strategic planning a must for facing change. PMID- 10158153 TI - Health care myths at the end of life. PMID- 10158154 TI - New AMA chief calls for a united front: "We physicians are all bound together". Interview by Dennis L. Breo. PMID- 10158155 TI - An old surgeon finds new work, Part I. PMID- 10158156 TI - Trends in federal health legislation. PMID- 10158157 TI - Workforce issues in otorhinolaryngology for 2010. PMID- 10158158 TI - New Medicare teaching regulations. PMID- 10158159 TI - Case studies. Six routes to exceptional cost performance, with same or superior quality, at widely disparate nonprofits. PMID- 10158161 TI - Integrating emergency medicine residents into a well-established helicopter program. AB - INTRODUCTION: The institution of an emergency medicine residency in a university affiliated Level 1 trauma center in July 1993 provided a challenge to develop a curriculum and on-line learning experience for emergency medicine residents in a well-established helicopter program. The purpose of this study was to survey flight crew members, emergency medicine at tending physicians, and emergency medicine residents on the anticipated roles and educational experience of integrating the emergency medicine residents from a new emergency medicine residency into the flight crew of a well-established helicopter program. METHODS: A survey consisting of multiple choice, Likert scale, and open-ended questions was distributed to flight crew members (RN, RT, pilots, communication specialists, EM attendings, and EM residents [n=72]). RESULTS: 92% of surveys were returned. These surveys identified specific issues of concern and those areas believed to be of academic importance for the emergency medicine residents. CONCLUSIONS: The results of this study allowed for the creation and implementation of a progressive flight experience for EM residents that incorporates increasing responsibility on the flight crew as experience is gained. PMID- 10158160 TI - Work redesign. Minimizing the risk of sabotage. PMID- 10158162 TI - Cabin configuration and prolonged oral endotracheal intubation in the AS365N2 Dauphin EMS helicopter. AB - INTRODUCTION: Most patients transported by air who require endotracheal intubation undergo endotracheal intubation before transport. However, in-flight endotracheal intubation may be indicated in the setting of certain scene conditions, in-flight patient deterioration, or endotracheal tube dislodgement. A previous report of high endotracheal intubation efficacy in the BK-117 in-flight recommended that flight programs review endotracheal intubation capabilities in their own aircraft. This study was conducted to determine whether in-aircraft endotracheal intubation times in the AS365N2 Dauphin were comparable to those previously reported for the BK-117. SETTING: AS365N2 and BK-117 helicopters stationary on a helipad. METHODS: Eight flight team members per formed three mannequin endotracheal intubations in each aircraft. Three time intervals were assessed: Setup, time required for equipping and positioning for endotracheal intubation; placement, time from laryngoscopy to endotracheal intubation; and total (Setup + Placement). Mean times for the BK-117 and AS365N2 were compared using the t test (a=0.05). RESULTS: All endotracheal intubation attempts were successful, but setup (p=0.0001), placement (p=0.0271), and total (p=0.0011) times were longer in the Dauphin. Crew members unanimously expressed endotracheal intubation difficulty caused by positioning problems in the Dauphin. CONCLUSION: In-aircraft intubation is significantly more time-consuming in the Dauphin than in the BK-117. This prolongation of intubation appears to be due to problems with positioning of the air medical crew and patient. PMID- 10158163 TI - Potentially fatal hemolysis of cross-matched blood during interfacility transport: standards of practice for safe transport of stored blood products. PMID- 10158165 TI - The Business Coalition charter. PMID- 10158164 TI - Basics of research (Part 6): Quantitative data analysis. PMID- 10158166 TI - The new accountability in managed care. PMID- 10158167 TI - Patients' rights and responsibilities: historical perspectives. PMID- 10158169 TI - The doctor is on. PMID- 10158170 TI - Facility planning for small and rural hospitals. AB - As changes in health care delivery move faster than ever, small or rural hospitals are struggling in a catch-up mode. In order to reverse this trend, these facilities need to reassess their position in the marketplace and develop a flexible plan for responding to the needs. This document provides a model to help achieve the vision of the physical plant in its supporting role to the strategic vision for the hospital, as well as options in the business of caring in a variety of alternative caregiving and treatment environments. PMID- 10158168 TI - Testing yourself for HIV. PMID- 10158171 TI - Harmonic interactions in health care facilities. AB - This document is the beginning of a two-part series that will help the reader understand and prepare for a world of electrical peculiarities. Part I offers an introduction to the problematic world of harmonics and their effects on medical equipment. Part II will take the subject a step further to cover the practical issues involving the handling and mitigation of harmonic distortion. PMID- 10158172 TI - Creating healthy communities: health care futurist paints system of the next millennium. PMID- 10158173 TI - Independent contractor or employee--worker classification update. PMID- 10158174 TI - Compensation for disability resulting from hospitalization, treatment, examination, or vocational rehabilitation--VA. Final rule. PMID- 10158175 TI - Personal protective equipment for general industry--OSHA. Final rule; technical amendment. PMID- 10158176 TI - Medicare and Medicaid programs; conditions of coverage for organ procurement organizations (OPOs)--HCFA. Final rule with comment period. PMID- 10158177 TI - Medicaid program; limitations on aggregate payments to disproportionate share hospitals: federal fiscal year 1996--HCFA. Notice. PMID- 10158178 TI - Medical news sites on the World Wide Web. PMID- 10158179 TI - After the Northridge quake--a long road to recovery. PMID- 10158180 TI - Creating a family library using the PDCA (plan-do-check-act) model for improving organizational performance. PMID- 10158181 TI - Evaluating scientific resources on the Web. PMID- 10158182 TI - The private sector and healthcare access: the good, the bad and the ugly. PMID- 10158183 TI - Case study. Group Health Cooperative/Virginia Mason: forging ahead with joint initiatives. PMID- 10158184 TI - Creating a new postmerger culture. PMID- 10158185 TI - The integrated supplier: key to cost management and multi-franchise capitation contracting. AB - Capitation...most healthcare providers do not work under it, comprehend it, or even want it, yet supply capitation contracting seminars are popping up everywhere creating the feeling that the bandwagon is leaving, and it might be time to get on board. Not true. Supply capitation is not for all organizations. Capitation contracting is not easy and there are not many successful models to help the uninitiated. If a panacea is sought for reducing supply costs, capitation is only one component of a systematic strategy to reduce materiel costs. This article suggests a direction using the Group Health Materiel Management (Group Health Cooperative of Puget Sound, WA) experience as a point of reference. It advocates a systematic approach that focuses on expense reduction in: cost of goods, holding cost of inventory, labor cost associated with all materiel processes, distribution cost (transportation and par stock pick, pack, and replenishment), product utilization, variation in product standards, and waste stream byproducts. At Group Health (GH) these issues are primarily addressed through the use of: information systems, supplier certification/selection processes, group purchasing compliance, supply channel management, supply capitation contracting programs, standardization, and utilization management. Because of managed care organizational structure, Group Health Cooperative supply capitation contracting, as performed at GH, is discussed not as a quick fix solution but in the spirit of sharing our experience with others who may be considering it as a cost savings tactic in the context of a broad-based materiel management strategy. This article highlights the experiences of GH beginning with materiel management's business process assumptions toward multiple-franchise supply capitation. PMID- 10158186 TI - Capitation and orthopedic services. AB - One method of regulating healthcare costs is through capitaiton--a per-member per month reimbursement to the provider of services. While there are many different entities affected by the capitation process, this article focuses predominantly on the hospital side of the equation as it relates to the delivery of orthopedic services. PMID- 10158187 TI - Health reform III: the hero or the goat? PMID- 10158188 TI - Data quality under capitation in managed care. PMID- 10158189 TI - Hospital technology assessment: Part II. PMID- 10158190 TI - Responsible managed care. PMID- 10158191 TI - PHOs--the next generation. Tens strategies for engineering sustainable physician hospital relationships. PMID- 10158192 TI - Will PHOs join the "alphabet graveyard" of management fads? PMID- 10158193 TI - Re-engineering PHOs. Ten strategies for sustaining physician-hospital relationships. PMID- 10158194 TI - Redesigning for better trauma care: innovation is key; retain essentials. PMID- 10158195 TI - Redesign triage areas for optimum efficiency. PMID- 10158196 TI - Keep COBRA, MCOs from slowing triage. PMID- 10158197 TI - How to come out a winner with capitation. PMID- 10158199 TI - Where to get a job: top 10 employment markets for physicians. PMID- 10158198 TI - Striving to reach a higher level of managed care. PMID- 10158200 TI - The future of care delivery: lower cost systems a must. PMID- 10158201 TI - Avoiding risk in capitated contracts. PMID- 10158202 TI - How to smooth potential bumps along the road to accreditation. PMID- 10158203 TI - To find good case managers probe personal traits, health care insight. PMID- 10158204 TI - Managed care leads Texas subacute facility to certification as a hospital. PMID- 10158205 TI - To know or not to know: a perilous conundrum for health care providers. PMID- 10158206 TI - The growth of enterprise liability in the managed care arena. PMID- 10158207 TI - Health care profession beware! The securities laws may bite you. PMID- 10158209 TI - Antitrust developments in healthcare: emphasis on net effects rather than structural presumptions. PMID- 10158208 TI - Avoiding the pitfalls of capitation and other HMO-physician provider agreements. PMID- 10158210 TI - Special report: Antitrust and health care. Anticipating antitrust pitfalls in new health care ventures. PMID- 10158211 TI - Assisted living cost creep can be a fatal disease. PMID- 10158212 TI - Downloading data puts patient privacy at risk. PMID- 10158213 TI - Physician reimbursement by the (Medicare) book. PMID- 10158214 TI - Separate and unequal. Long term care is failing to meet the needs of many black elderly. PMID- 10158215 TI - The right stuff. The emerging field of assisted living calls for a whole new crop of leaders. PMID- 10158216 TI - The many shades of Medicare fraud and abuse. PMID- 10158217 TI - A measure of risk. Why assessment tools are effective in preventing pressure ulcers. PMID- 10158218 TI - What the doctor has to say: the physician's perspective on home care. PMID- 10158219 TI - Home care and hospice residencies: enhancing care and exchanging knowledge. PMID- 10158220 TI - Taking physicians out of the hospital. PMID- 10158221 TI - Physician reimbursement: a practicing physician's perspective. PMID- 10158222 TI - A physician's view of care plan oversight. PMID- 10158224 TI - Putting care back into caring. PMID- 10158223 TI - Physician satisfaction: bringing it home. PMID- 10158225 TI - Why physicians are rediscovering home care. PMID- 10158226 TI - Managing clinical outcomes to produce income. PMID- 10158227 TI - Order in a new era: outcome documentation. PMID- 10158228 TI - The quest for accountability: patient costs & outcomes. PMID- 10158230 TI - Meeting the outcome challenge of psychiatric home care. PMID- 10158229 TI - Outcome-based critical pathways: quality management. PMID- 10158231 TI - Are you measuring ICD-9 codes or human beings? PMID- 10158232 TI - Rehab resource. Home care aides improve costs, outcomes, and satisfaction. PMID- 10158233 TI - Safety at home: a practical home-injury control program for independent seniors. PMID- 10158234 TI - Outcome-based quality improvement demonstration. PMID- 10158235 TI - Outcome-driven home care: quality, savings, and results. PMID- 10158236 TI - Data trends. June 1996. PMID- 10158237 TI - The fundamentals of contract negotiations. PMID- 10158238 TI - HFMA must reflect the industry and the needs of members. PMID- 10158239 TI - Selecting managed care information systems. AB - A decade ago, a handful of managed care information systems occupied a relatively minor niche in the healthcare information system industry. Today, dozens of small software development firms are experiencing explosive expansion and are being courted by larger vendors for partnership or acquisition. When selecting an information system capable of meeting the demands of managed care providers, financial managers should consider carefully the types of systems that are available, their price ranges, their modules, and the type of vendor selling the systems. PMID- 10158240 TI - Developing information systems for integrated systems. AB - As the structure of healthcare delivery systems changes, an increasing number of healthcare executives are rethinking their organizations' approaches to the delivery of care. At the same time, many executives are re-engineering their organizations' information systems to provide the infrastructure necessary to support changing requirements. Healthcare executives can take a number of steps to ensure that their organizations' information systems help reduce costs and improve quality of patient care. PMID- 10158241 TI - EDI helps group practices manage costs. AB - Electronic data interchange (EDI) experts in the healthcare industry are advising physicians and physician groups to increase their use of EDI for claims processing, eligibility verification, and remittance advice. Studies have shown that using EDI can, in fact, cut the number of errors on claims, and improve productivity. PMID- 10158242 TI - Healthcare cost of risk initiative: preliminary findings. AB - The Cost of Risk Initiative, jointly sponsored by HFMA and MMI Companies, Inc., is designed to identify the cost of risk in health care organizations and to gather case study examples of best practices in the management of the cost of risk. The first phase of the ongoing initiative, a pilot study, was completed in 1995. Although response to the pilot study was low, and the findings therefore are not statistically significant, the study provides initial insight into the cost of risk and the extent to which the cost of each component of risk contributes to the total cost of risk in various types of healthcare organizations. The total cost of risk ranged from 1 percent to 12.5 percent of net patient revenues among study participants. The organizations with the greatest average cost of risk were medical group practices. Costs for employee benefits, professional and general liability, workers' compensation, and risk management administration contributed the most to the total cost of risk. Baseline studies that will be conducted later this year and longitudinal data to be collected over the next five years will provide more reliable data that healthcare financial managers can use to assess and improve risk management in their organizations. PMID- 10158243 TI - Using an affordability analysis to budget capital expenditures. AB - A healthcare organization or system often needs to make capital expenditures to expand or renovate its facilities or to finance other important projects. It may be difficult, however, for an organization to gauge how much of its resources it can afford to commit to capital projects. To help the organization evaluate the feasibility of a capital expenditure, an analysis of financial resources should first be conducted. Using an actual healthcare system whose name has been changed to protect its identity, this article outlines how healthcare financial managers can perform an affordability analysis, based on the debt-to-capital ratio or debt service coverage, to determine the amount of resources to allocate for future capital expenditures. PMID- 10158244 TI - Identifying best practices for audit committees. AB - Most healthcare organizations have an audit committee of the governing board, or a finance committee, that fulfills the audit oversight function. Financial managers play a key role in shaping the content, agency, and operation of the audit committee. The findings of a recent research study conducted by Arthur Anderson & Co., SC, into the best practices of audit committees have implications for healthcare organizations. PMID- 10158245 TI - Healthcare Financial Management Association, Principles and Practices Board. Statement No. 19: Transactions among affiliated entities comprising an integrated delivery system. PMID- 10158247 TI - Court rejects agency's investigational device payment policy. Cedars-Sinai Medical Center v. Shalala. PMID- 10158246 TI - EDIBANX: a new EDI payment resource. PMID- 10158248 TI - Assessing your skills. How to become a more effective leader. PMID- 10158249 TI - Alternative employee scheduling. Meet your staff's changing needs. PMID- 10158250 TI - Tips for developing a workable drug policy. PMID- 10158251 TI - Battling burnout. PMID- 10158253 TI - CAD (computer-aided design) system impresses Joint Commission. PMID- 10158252 TI - Reverse high cesarean rates with hard-and-fast data and new policies. PMID- 10158254 TI - Database offers one-stop shopping for measures. PMID- 10158255 TI - Are clinic care providers doing the right thing? Appropriate reviews have the answer. PMID- 10158256 TI - Community care. A long way from home. PMID- 10158257 TI - Patients' views. On the right track. PMID- 10158258 TI - Locality information. Kind Herts and coronaries. PMID- 10158259 TI - Hospital at home. Your place or mine. PMID- 10158260 TI - Careers profile. Survey: tales by the nurses grim. PMID- 10158261 TI - Market testing. Tender mercies. PMID- 10158262 TI - Primary care. Power points. PMID- 10158263 TI - Community nursing. Self-fulfilling prophecies. PMID- 10158264 TI - Hospital activity. Unfinished business. PMID- 10158265 TI - Mental health. Reasoning the needs. PMID- 10158266 TI - Care documentation. Clear winners. PMID- 10158267 TI - Economic evaluation and health care decision-making. AB - The current role of economic appraisal in health policy and medical practice is outlined, emphasizing the pharmaceutical sector where developments are most marked. General health policy in the Netherlands and pharmaceutical policy in Australia are presented as examples of how economic appraisal may diffuse further as a decision-support tool for health authorities. This can be promoted by studying how policy-makers interpret and use results of economic evaluation studies and how the international transferability of information on the cost effectiveness profiles of health technologies can be enhanced. To be relevant for health policy, results from economic appraisal studies must be valid and reliable, relevant to the policy context and communicated to the proper decision makers. A number of recommendations are provided for economic appraisals to meet such requirements. PMID- 10158268 TI - The willingness to pay for health changes, the human-capital approach and the external costs. AB - In this paper, the relationship between willingness to pay for health changes, the human-capital approach, and the costs that should be included in a cost benefit analysis of a health care programme are analysed. The costs that should be included are defined as the change in consumption minus the change in production of the individual that receives a health care programme. The size of these external costs differs depending on the institutional arrangements in society. It is shown that the net production version of the human-capital approach is an estimation of the external costs. The human-capital approach can thus be given a theoretical foundation in cost-benefit analysis if it is used to estimate the external costs. PMID- 10158269 TI - Labour turnover in the British National Health Service: a local labour market analysis. AB - This study uses regression analyses to examine the relationship between staff turnover in the British National Health Service (NHS) and a range of labour market, job and worker characteristics. Data relating to nine staff groups in up to 103 District Health Authority areas, and covering over 300,000 employees, form the basis for the analysis. In the regression analysis, two variables consistently emerge as significantly related to turnover across a range of staff groups: the size of the private nursing homes, and the pay of the staff group relative to the local average for comparable workers. The results suggest that staff groups of different skill levels each have distinct labour markets, and this needs to be recognised in the future design of human resources management policies. PMID- 10158270 TI - Drake Center softens its edges for long-term care patients. PMID- 10158271 TI - Flower power. The proper garden can cultivate a wealth of hospital benefits. PMID- 10158272 TI - Getting the bugs out. PMID- 10158273 TI - Space odyssey. Parking experts are driving health facilities into the next century. PMID- 10158274 TI - Down the drain. AB - What do you do when you have a drainage problem that none of the plumbers you've contacted can solve as efficiently as you'd like? Instead of sweating through any of the lengthy solutions proposed by these customary service suppliers, a 56-bed Alabama hospital had its totally clogged food service sewer system restored to full flow in 2 1/2 days instead of the estimated 2 1/2 to 3 1/2 weeks. PMID- 10158275 TI - OSHA draws up interim enforcement policy for TB. PMID- 10158276 TI - Are you risking environmental impairment liabilities? PMID- 10158277 TI - A new model emerges for health facility parking lots. PMID- 10158278 TI - Service options under managed care: how to reap savings. PMID- 10158279 TI - Gene therapy: promising but not convincing. PMID- 10158280 TI - Bugs and drugs: hospitals running out of antimicrobials to fight common infections. PMID- 10158281 TI - Neurology group rates brain SPECT. PMID- 10158282 TI - Outsourcing technology. PMID- 10158283 TI - Medical peripheral devices for video telemedicine systems: products, vendors, and evaluation criteria. PMID- 10158284 TI - The ED: real savings questioned. PMID- 10158285 TI - Stents: strengthening the chief weapon against restenosis. PMID- 10158286 TI - Some facts about women and managed care. PMID- 10158287 TI - Cut down on hospital stays, heparin use: treating AMI in the thrombolytic era. PMID- 10158288 TI - The technology of teams. PMID- 10158289 TI - Give yourself a gift by giving away that white elephant. PMID- 10158290 TI - Is this how doctors will regain control of health care? PMID- 10158291 TI - The tough new realities of disability insurance. PMID- 10158292 TI - Electronic records solved this practice's problems. PMID- 10158293 TI - Should you charge for telephone medicine? PMID- 10158294 TI - Catching a malpractice plaintiff in a lie. PMID- 10158295 TI - Doctors are slow to adopt electronic patient records. PMID- 10158296 TI - Drowning in paper? You can toss more than you think. PMID- 10158297 TI - The IRS--when a doctor's nightmare becomes reality. PMID- 10158298 TI - Sometimes the good guy wins. PMID- 10158299 TI - An easy way you can help Third-World doctors. PMID- 10158300 TI - Managed care isn't hurting these specialists. PMID- 10158301 TI - Clinical pathways. Most hospitals are developing them. PMID- 10158302 TI - Are doctors evading the malpractice data bank? PMID- 10158304 TI - Leave a group to fly solo? These doctors did. PMID- 10158303 TI - "For the first time, I have a stress-free job". PMID- 10158305 TI - Putting your practice on a budget. PMID- 10158306 TI - What it will take to save Medicare. Interview by Michael Pretzer. PMID- 10158307 TI - How did I ever survive without automation? PMID- 10158308 TI - Easy ways to save on supplies. PMID- 10158309 TI - Malpractice. Awards bounce upward again. PMID- 10158310 TI - "We want you to pull the plug". PMID- 10158311 TI - House calls: better pay may bring them back. PMID- 10158312 TI - This doctor ignored his Yale professors. He's glad he did. PMID- 10158313 TI - Pleasing patients: it's the little things that count. PMID- 10158314 TI - Employers. They're worried about health-care quality, too. PMID- 10158315 TI - Should you fire some specialists? PMID- 10158316 TI - Patient phone calls driving you crazy? Here's relief. PMID- 10158317 TI - Disclosure can be key to credibility. PMID- 10158318 TI - Silver lining. AB - Despite a weighty debt load, healthcare's fiscal forecast remains upbeat, thanks to healthy industry trends. Some weaker providers are likely to succumb to the storm of managed care. But there are enough happy endings to sustain industry optimism. PMID- 10158319 TI - Managed care wreaking havoc at some hospitals. PMID- 10158320 TI - Forecast for 1996 finances: generally fair. PMID- 10158321 TI - NCI seeks partnership with HMOs. PMID- 10158322 TI - A question of care. HMO officials and AIDS activists are divided over the quality of AIDS care. PMID- 10158323 TI - U.S. HMOs aim to go global via overseas deals. PMID- 10158324 TI - Investor passion for doc management firms fades. PMID- 10158325 TI - Materials management. Premier seeking pledge of members' allegiance; COHR has master plan for acquisition spree. PMID- 10158326 TI - Providers find outreach is elementary. PMID- 10158327 TI - To play system game, you need more than the pieces. PMID- 10158328 TI - Multiple-partner deals let players hedge their bets. PMID- 10158329 TI - AHA tightens grip on into offered to public. PMID- 10158330 TI - Mich. suit blocks for-profit hospital deal. PMID- 10158332 TI - NYU, Mount Sinai agree to hospital mega-merger. PMID- 10158331 TI - HMO demonstration project may face delay. PMID- 10158333 TI - Boston hospital merger snags on talks with union. PMID- 10158334 TI - Deloitte survey identifies service consolidation as key to efficiency. PMID- 10158335 TI - Managed-care growth sparks activity in Virginia. PMID- 10158336 TI - AGPA, UMGA members ratify merger. PMID- 10158337 TI - AMA's finances improving, report says. PMID- 10158338 TI - Health researchers collect spoils amid TennCare turmoil. PMID- 10158339 TI - HMO, PPO enrollment growth solid. PMID- 10158340 TI - Cost-efficiency study: HMOs beat indemnity plans by 18% in U.S. PMID- 10158341 TI - Minn. free clinic off to solid start. PMID- 10158342 TI - Meridia a key player in Columbia/Ohio Blues deal. PMID- 10158343 TI - Ga. report stirs the pot on charity-care debate. PMID- 10158344 TI - Boston's Partners plans to replicate admired system. PMID- 10158345 TI - FTC previews doc network antitrust rules. PMID- 10158346 TI - Small Georgia hospitals fear competitors' expanding reach. PMID- 10158347 TI - CHA reorganizes for lobbying effort. PMID- 10158348 TI - Quality focus retools peer review panels. PMID- 10158349 TI - Providers hope Medicaid provision passes Senate. PMID- 10158350 TI - AIDS reporting softer, study shows. PMID- 10158351 TI - Boise hospital to take over and replace rural facilities. PMID- 10158352 TI - Calif. report card finds HMOs just average. PMID- 10158353 TI - At 50, HFMA looks to broaden its membership. PMID- 10158354 TI - Ancilla saves big via satisfaction data. PMID- 10158355 TI - Center polishes healthcare crystal ball. PMID- 10158356 TI - Two bills, same fear: more uninsured patients. PMID- 10158358 TI - Investor-owned chains seek rich rural harvest. AB - Rural and other nonurban hospitals have become hot acquisition targets for investor-owned healthcare companies. And when it comes to this turf, no company has been as successful as Naples, Fla.-based Health Management Associates, which is lead by William Schoen. PMID- 10158357 TI - Legal colloquium defines standards for tax-exempts. PMID- 10158359 TI - Cost benefit of data integration hard to prove. PMID- 10158360 TI - Convenience is key to firm's success. PMID- 10158362 TI - Fla. creates antitrust advisory system. PMID- 10158361 TI - Systems seek credit for 'hidden value'. PMID- 10158363 TI - Deal melds Ohio county's hospital, doc services. PMID- 10158364 TI - Hospitals and healthcare systems should take note of software copyright laws. PMID- 10158365 TI - OSHA issues guidelines to protect healthcare workers from violence. PMID- 10158366 TI - Options, influence and outcomes. PMID- 10158367 TI - Image and report distribution on the Internet. AB - The Internet links together millions of computers to share a wide variety of information--words, sounds and images--which makes it ideally suited for applications in diagnostic imaging departments. Timely availability of patient information is critical to patient care. In the form of a report, image or both, information is the final product of every imaging department. Internet applications can allow physicians easy access to and review of patient information. Many imaging departments already have the basic components of Internet technology in place, which may include an existing image distribution network. At the University of Kansas Medical Center (UKMC), we had a good network base and digital digitation and distribution system, but had not found an appropriate PACS for image distribution and display. When a home page was designed for the radiology department at UKMC, it was intended for report distribution. However, we quickly discovered that it could also function as a low cost/low-resolution image distribution system. Before making confidential patient information accessible on the Internet, appropriate information security requirements must be in place. At UKMC, access is strictly controlled through the medical records department. Programmers in the radiology department at UKMC are also using the Internet to develop applications for on-line review, editing and electronic signature. Early experience with the Internet as a basis for radiology image and report distribution has been extremely successful and popular with referring physicians at UKMC. PMID- 10158368 TI - Age-specific standards in radiology. AB - This article describes a plan developed by the radiology department at Sibley Memorial Hospital to meet JCAHO standards for age-specific care. The goal of the program was to improve patient care and document outcomes while complying with the standards. There are numerous references in the JCAHO standards that require recognizing physical motor/sensory, cognitive and psychosocial differences among the age groups served by an institution. One of the challenges of meeting age specific requirements is applying them to all aspects of care that are affected. The most important part of Sibley's age-specific program is a tool called the ?quick reference guide? (QRG). It was designed by the radiology department to provide detailed, comprehensive information to all staff members in an easy-to use format. The QRG is posted prominently throughout the department. The QRG includes age-specific information for the following patient care areas in radiology: radiation protection, exposure factors, immobilization, venipuncture, medication/contrast dose, skin care, communication, patient/family education and patient safety. The JCAHO is more interested in having staff members know where to obtain information about age-specific care than in having them memorize ?answers.? Having a clear and complete QRG available at all times fulfills that requirement. PMID- 10158369 TI - Healthcare on the horizon: getting ready for a preferred future. AB - The untenable cost of health service entitlements and the indefensible per-unit cost of service have provided the impetus for radical changes in healthcare service provision, including managed care. In a managed care environment, focusing solely on sickness care threatens the viability of the organization. Careful assessment of service structures should occur, a shift in the strategic efforts of the system is defined and a refocusing of the design of service is a central component of the organizations work. A more integrated organizational model and a broader understanding of health care service are the keys to survival. Changes we have seen so far lay the groundwork for a large-scale evolution that will take place over the next two decades. Developments that remain ahead include increased emphasis on health maintenance and growing effort to bring health services into the community itself. Wise health professionals will be thinking in terms of a career rather than a job. Education, breadth of talents, portability of skills and mobility of role become central to the ability to thrive in the new decade. Today's unpredictable atmosphere demands insight, fluidity and willingness to change and grow. PMID- 10158370 TI - Data rich, information poor (DRIP) syndrome: is there a treatment? AB - DRIP (data rich, information poor) syndrome is paralyzing the performance improvement efforts of many healthcare organizations. Symptoms of DRIP syndrome include the use of an abundance of indicators and the predominant use of a retrospective medical record review to collect data. Often, too many indicators are used because the organization is still subscribing to a traditional quality assurance methodology for performance improvement. In these cases, quality assurance programs monitor multiple areas of performance assuming that, except for occasional outliers, the results will be acceptable. Another cause of an unmanageable number of indicators may be a lack of understanding of JCAHO measurement requirements. The ?prescription? includes changing to a continuous quality improvement culture, learning measurement requirements, inventorying current data collection to identify and eliminate useless data and aligning data collection with the goals and objectives of the organization. An organization should collect only data that is required to improve performance and meet accreditation and regulatory requirements. Data collection should be automated and built into work processes as much as possible. Ideally, a well-integrated computer system offers access to real-time information and permits timely or even proactive performance. PMID- 10158371 TI - Managers' perceptions of radiographers' skills: current and future needs. AB - As the healthcare delivery system changes, it is imperative to assess the skills of practitioners to ensure consistency between educational preparation and work place needs. The purpose of this study was to examine radiology managers' perception of selected workplace skills and new radiography graduates' ability to perform them. A random sample of 1,932 members of the American Healthcare Radiology Administrators (AHRA) received a questionnaire containing 35 skills categorized as basic, intermediate or advanced. Skills were ranked by the magnitude of the difference between managers' rating of importance of each skill and their rating of graduates' ability to perform that skill satisfactorily. In the basic skill area, the four top-ranked skills represented problem-solving ability or critical thinking. Of the five highest-ranked intermediate skills, the top three were patient care skills: venipuncture, taking vital signs and monitoring patient equipment. In the advanced skill area, six skills exhibited high values for the difference between importance and ability. Two of those related to patient care, three were non-technical and the sixth was the ability to perform CT in addition to basic radiography. Employers and educators should work together to seek educational methods that produce radiographers who are better prepared for the fast-changing workplace. PMID- 10158372 TI - A systems approach to PACS: the key to realizing strategic benefits. PMID- 10158373 TI - Urban and rural classification of National Health Provider Inventory providers: United States, 1991. PMID- 10158374 TI - Office visits to neurologists: United States, 1991-92. PMID- 10158375 TI - National Hospital Ambulatory Medical Care Survey: 1993 emergency department summary. PMID- 10158376 TI - Characteristics of elderly home health care users. Data from the 1993 National Home and Hospice Care Survey. PMID- 10158377 TI - Assessment of outcome of bifurcation lesions and non-bifurcation lesions treated in the CAVEAT trial. CAVEAT investigator group. AB - Registry data suggests that bifurcation lesions are associated with reduced success during percutaneous revascularization. We studied 1012 CAVEAT patients to compare procedural outcomes in patients with and without bifurcation lesions whose target vessel was treated with either atherectomy or angioplasty. Bifurcation lesions have increased angiographic complexity and interventions on them are associated with lower acute procedural success rates compared to non bifurcation lesions. Subgroup analysis suggests that atherectomy treatment of bifurcation lesions improves acute procedural success rates and lowers restenosis rates compared to angioplasty treatment of bifurcation lesions but atherectomy of bifurcation lesions is associated with higher acute complication rates than angioplasty of bifurcation lesions. PMID- 10158378 TI - The Magnum wire for percutaneous coronary balloon angioplasty in 723 patients. AB - The experience of the use of the Magnum wire in a single center is reported. Percutaneous balloon coronary angioplasty, using the Magnum 0.021 inch wire, was attempted in 723 patients with 850 lesions; of these, 453 (53%) were chronic total occlusions and 50 (7%) recent occlusions of less than 24 hours (patients presenting with acute myocardial infarction). The overall technical success rate per lesion was 655/850 (77%). It was 255/280 (91%) for non-total lesions, 311/453 (69%) for chronic total occlusions, 53/67 (79%) for functional (TIMI grade I) occlusions, and 36/50 (72%) for recent occlusions. Clinical success was achieved in 196/232 patients (84%) with non-total lesions, in 292/436 (67%) with total chronic occlusions, in 49/65 (75%) with functional occlusions, and in 34/50 (68%) with recent occlusions. Complications (significant creatine kinase rise, new Q wave infarction, need for coronary bypass surgery or in-hospital death) occurred in 7% (3% if patients presenting with unstable ischemic syndromes were excluded from the analysis). These data confirm that the use of the Magnum wire has success rates competitive with other systems both in setting of chronic total occlusion and in that of routine percutaneous transluminal coronary angioplasty. PMID- 10158379 TI - Current clinical utility of body surface mapping. PMID- 10158380 TI - Will the body surface map replace the signal averaged electrocardiogram and other computerized techniques for the diagnosis and treatment of arrhythmias? PMID- 10158381 TI - Acute embolic carotid occlusion after cardiac catheterization: effect of local intra-arterial urokinase thrombolysis. AB - A 64-year-old woman developed a severe embolic cerebral attack with total left hemiplegia approximately 30 hours after cardiac catheterization for mitral stenosis. She underwent intra-arterial thrombolysis of the right internal carotid artery four and one-half hours after the onset of neurologic deficit with subsequent recanalization of the occluded vessel and near complete neurologic recovery. PMID- 10158382 TI - Multiple stenting in acute myocardial infarction with double vessel occlusion, complicated with cardiogenic shock. AB - Stenting of the infarct-related artery during the acute phase of myocardial infarction is a controversial issue. We report a case of primary multiple stent implantation in 2 vessels in a patient with AMI, double vessel total occlusion and cardiogenic shock. No intracoronary thrombotic therapy was given. Stenting provides an optimal angiographic result which may decrease the need for repeat interventions. Primary stenting in AMI deserves further investigation. PMID- 10158383 TI - Prophylactic thrombolysis during coronary intervention in unstable angina- results of the TAUSA trial. Thrombolysis and Angioplasty in Unstable Angina Trial. PMID- 10158384 TI - Recanalization of chronically occluded aorto-coronary vein grafts. AB - The problem of aorto-coronary vein graft occlusion remains a major clinical challenge. The approach described above offers one method of preserving the life of some occluded vein grafts. This study was done before the release of the coronary stent. This procedure will presumably permit patients to become candidates for this new technology and thereby improve the long-term patency. PMID- 10158385 TI - Overview of intracoronary thrombolysis. AB - Despite these negative results, the theoretical benefit of lysing clot in acute coronary syndromes remains appealing. Whether the use of more potent antiplatelet agents or antithrombin agents might improve the results of thrombolytics in unstable angina and acute myocardial infarction without an unacceptable bleeding risk remains speculative. Site-specific lysis with a high local concentration of thrombolytic without systemic fibrinolysis has the appeal of potentially fewer bleeding complications, but the safety and efficacy of site-specific thrombolysis remains unclear. Early results with coronary stenting to maintain the largest lumen possible in combination with lytic agents in acute infarction appears favorable in a preliminary report. It is possible that reocclusion mediated by coronary obstruction with static flow cannot be salvaged with lytics alone, but the adjunctive use of stents or other interventions to decrease mechanical atherosclerotic obstruction may be beneficial in the future. However, planned and ongoing trials will be required before a beneficial role for adjunctive thrombolysis with angioplasty in acute ischemic syndromes can be established. PMID- 10158386 TI - A prolonged intracoronary infusion of urokinase for chronic total occlusions: case reviews. PMID- 10158387 TI - Urokinase infusion and stenting of older saphenous vein grafts. PMID- 10158388 TI - Site-specific, catheter-based thrombolysis: a new technique for treating intracoronary thrombus and thrombus-containing stenosis. AB - Site-specific thrombolysis is a new technique for treating intracoronary thrombus and thrombus-containing stenoses that is currently under active investigation and that involves the local delivery of thrombolytic agents directly to intraluminal clot using catheter-based technology. The theoretic mechanisms of thrombolysis underlying this approach involves the "trapping" of thrombus in an environment of high thrombolytic drug concentration, mechanical disruption of intraluminal clot by the drug delivery catheter itself, and intramural deposition of lytic agents with the creation of a drug reservoir that may provide for prolonged local thrombolysis. To date, preliminary studies have documented enhanced local thrombolysis with urokinase using two new drug delivery systems--the Dispatch catheter and the hydrogel-coated balloon. In 68 patients that have been reported to date, use of these two new systems has resulted in enhanced intracoronary thrombolysis using much less urokinase than involved in standard infusion protocols, and with low complication rates. These preliminary observations will be further studied in two multicenter randomized protocols comparing local drug delivery with standard techniques for treating intracoronary thrombus. PMID- 10158389 TI - Primary PTCA in high risk patients with acute myocardial infarction. PMID- 10158390 TI - The evolution of primary PTCA therapy of acute myocardial infarction: a personal perspective. PMID- 10158391 TI - Early hospital discharge after acute myocardial infarction. PMID- 10158392 TI - Technical aspects in the performance of primary PTCA. AB - More than 2,000 angioplasties have been performed in our institutions either during or surrounding acute myocardial infarction. We will review the practical aspects of the performance of primary percutaneous transluminal coronary angioplasty with outlines for implementation of the angiogram, conducting angioplasty, giving adjunctive therapies, care of the patient after the intervention and the potential need for subsequent coronary bypass surgery. The rationale for risk stratification with angiography, order and technical aspects of the performance of percutaneous transluminal coronary angioplasty, need for adjunctive medical therapy and details of after care will be fundamentally outlined. PMID- 10158393 TI - Primary coronary angioplasty in hospitals with and without surgery backup. MITI project investigators. AB - In the Myocardial Infarction Triage and Intervention (MITI) project, a registry of acute myocardial infarction, 1,062 patients were treated for acute myocardial infarction using primary coronary angioplasty. Of those, 470 (44%) received the procedure in hospitals without coronary surgery capability on-site. These patients were compared to 592 (56%) other patients treated in hospitals with on site surgery. Most baseline characteristics of patients treated by primary angioplasty were similar in the two types of centers. ST segment elevation was present in 76% of patients; time from admission to angiography averaged 100 +/- 71 minutes (median 77 minutes). There was no difference in procedural success rate nor initial and long-term mortality rates in patients treated by primary angioplasty in the two types of hospitals. The mortality rate at discharge for patients treated by primary coronary angioplasty was 7% in both types of hospitals. In the subset of patients with ST segment elevation and no evidence of shock and no prior bypass surgery, 30 day mortality rates were 7% and 8% (p = 0.46), respectively. In a multivariable analysis of those factors influencing survival, age, a history of prior myocardial infarction, and anterior ST elevation but not the availability of on-site surgical backup, was associated with outcome. In summary, this observational study suggests that with appropriate patient selection, trained operators, and a provision for hospital transfer, primary coronary angioplasty can be accomplished in centers without on-site surgery with acceptable outcomes. PMID- 10158394 TI - Coronary angioplasty for acute myocardial infarction in hospitals without cardiac surgery. PMID- 10158395 TI - Primary angioplasty for myocardial infarction. PMID- 10158396 TI - Initiation and operation of a primary PTCA program. AB - Since beginning primary angioplasty in the early eighties we have used angioplasty in or related to acute myocardial infarction in over 2,300 patients. We will review here the use of direct, immediate, rescue and deferred or elective angioplasty in acute myocardial infarction. Organization of the cardiac catheterization laboratory staff, transport programs, and planning for surgical stand-by have all contributed to patient benefit in our program and will be outlined. Our acute MI approach both for angioplasty and for follow-up surgery will be reviewed. PMID- 10158397 TI - New products for pediatrics: 1995. PMID- 10158398 TI - Specimen processing: centralized or decentralized? AB - Specimen processing for the clinical laboratories of a large pediatric teaching hospital laboratory was centralized in 1991. A highly efficient service area evolved through reengineering and renovations and effected a 20% reduction in operating costs. Work flow analysis identified areas for improvements, renovations created a more efficient use of space, and staffing decreased from 18.4 to 8.5 FTEs without compromising service. PMID- 10158399 TI - Seeking improvements through laboratory benchmarking. The Western North Carolina Collaborative Group. AB - The laboratory departments at six North Carolina hospitals have formed an ongoing benchmarking team that has been meeting on a regular basis for more than 2 years. This article describes how the laboratory managers on this multihospital team have learned the benchmarking process, standardized procedural cost accounting in the group, compared and reduced costs, improved quality and efficiency, and created networking channels with other health-care professionals. The team members have quantified and reported significant savings and increased revenue for their laboratories as a direct result of their participation in this project. PMID- 10158400 TI - Case studies in ethics. Reporting test results. PMID- 10158401 TI - AP Easy: information management software for anatomic pathology. PMID- 10158402 TI - Our role in the future ... what laboratory professionals think the future holds for them. PMID- 10158403 TI - Walk-in clinics. PMID- 10158404 TI - Federal/provincial financial arrangements: the poverty of economic advice. AB - The Canada Health and Social Transfer was finally given shape in the 1996 federal budget. Like most contemporary fiscal policy, the budget's measures are designed to control federal spending on social programs, including healthcare, with an eye toward controlling the federal deficit. Yet cutbacks like these may be misguided. Research suggests that real healthcare expenditures have not increased unduly; rather it is the faltering Canadian economy and the resulting drop in tax revenues which contribute most of the deficit. Promoting a stronger economy by fostering the growth of jobs would reduce the demand for social programs while providing greater tax revenue with which to fund such programs. Surely this is a sounder course of action for Canada. PMID- 10158405 TI - Executive staff reductions. PMID- 10158406 TI - Strategic alliances: a partnership in action. PMID- 10158408 TI - Health: a community challenge for the 1990s. PMID- 10158407 TI - Thunder Bay Regional Hospital: an amalgamation. AB - Two acute care hospitals in Thunder Bay recently amalgamated into a single hospital. Acute care delivery in the region promises to be more efficient and less expensive, and the process has resulted in a hospital better able to absorb the 18 percent provincial funding cut announced last fall. This is an important step in developing a truly efficient and effective continuum of care in Thunder Bay, and an example of successfully meeting the challenges of delivering quality service on a tighter budget. PMID- 10158409 TI - Capturing discovery. AB - The Canadian Medical Discoveries Fund offers Canadian researchers the capital and business expertise to protect and market new medical discoveries. The fund allows Canadians to capitalize upon their public investment in research by creating jobs and wealth. This generates confidence and investment in Canadian research and development, which will help to protect our healthcare system as a whole by demonstrating its value as a financial asset. PMID- 10158410 TI - A circle of healing, a circle of hope: healthcare reform the Northwest Territories way. Interview by Aileen Leo. PMID- 10158411 TI - Evidence based health informatics: an overview of the Health Information Research Unit at McMaster University. PMID- 10158412 TI - Effects of health system restructuring on how quality is addressed at a governance level. PMID- 10158413 TI - Performance indicators for achieving goals at Allina. PMID- 10158414 TI - Survey: effect of health system restructuring on how quality is addressed at a governance level. PMID- 10158415 TI - Patients rate quality on a different scale from providers, survey shows. PMID- 10158416 TI - Effect of system restructuring on quality leadership. AB - As fully integrated systems are formed, leaders must develop new ways to manage quality. In interviews with leaders of four integrated health systems, we address the questions: How can formerly separate entities with different histories and cultures be united into a collaborative system? What is an appropriate role for a systemwide QI department? How should responsibility and authority be divided between the system board and subsidiary hospital or corporate boards? They gave no single answer to these questions. Each system is developing its own strategy for quality leadership in a restructured health system. First of two parts. PMID- 10158417 TI - A critical review of derived 12-lead electrocardiography. PMID- 10158418 TI - The specification and evaluation of digital cardiac archive and review systems. PMID- 10158419 TI - Middle management survival guide. PMID- 10158420 TI - Saving money on equipment service. PMID- 10158421 TI - The evolution of quality in the US health care industry: an old wine in a new bottle. AB - Explores the evolution of the quality issue within the health-care industry and also the significance of quality in the health industry along with the historical origins of quality management. Reviews applications of total quality management in the health care industry along with implementation issues. Concludes that a fundamental understanding of the process of total quality management is an absolute requirement. PMID- 10158422 TI - Evaluating intervention programmes for quality assurance in hospitals. AB - Describes a methodological framework for evaluating intervention programmes to establish and develop quality assurance systems in general hospitals, based on the authors' experience in participating in a specific intervention programme in quality assurance. Both the approach and the design of the evaluation programme were shaped by the unique characteristics of this intervention programme. The evaluation programme was based on a model of organizational behaviour and change developed especially for the introduction of quality assurance systems into hospitals. With modification. the programme can also be used to evaluate other intervention programmes. PMID- 10158423 TI - Handling complaints successfully. PMID- 10158424 TI - Achieving effective service-contracting results: the process is the key to success. AB - Focuses on the contract process as a source of information for managers seeking to contract more effectively. Draws on the findings of a multiple-case comparative study undertaken to understand service-contracting processes and the factors that influence them. Offers specific ideas for ways to manage contracting processes more effectively. Includes case examples to clarify the points raised. PMID- 10158425 TI - Service quality: a satisfaction survey of the elderly. AB - Locality management devolves the responsibility for the delivery of community health and social services to ?localities? of some 25,000-30,000 people. States that unit general managers wanted to measure the clients' perception of the quality of the service provided. Research resource constraints limited the study to the elderly in receipt of at least one statutory service and the carers. Describes how a survey of 410 elderly people was carried out by interview in their place of residence and a postal survey of carers based on the same criteria was conducted which yielded 221 usable responses. Analyses show considerable variability within the two groups across the criteria with informational needs scoring least well by a considerable margin in both. Comparing scores between the two groups shows that carers were much less satisfied than the elderly clients with scores in general being about 30 points lower for all criteria. PMID- 10158426 TI - Quality function deployment: application to rehabilitation services. AB - Describes how the challenge of providing rehabilitative services at reasonable costs is beginning to mount. The management of quality in rehabilitative services is therefore gaining increasing attention in the health care arena. States that if a link is implied between the above stated goal and customer satisfaction, it is imperative to evaluate quality or customer satisfaction in the context of the patient's experience. Describes the quality function deployment (QFD) system and how it leads to a better understanding of the customer's needs and wants. Explores the process of applying the concept of QFD to physical therapy. PMID- 10158427 TI - Northern California rates a "TENN" (Telemedical Emergency Neurosurgical Network). PMID- 10158428 TI - Master patient indexes. PMID- 10158429 TI - Staffing, training key to network success. PMID- 10158430 TI - Practice-management market to reach $1 billion by 1999. PMID- 10158431 TI - Hotlist. Clinical and financial decision-support software. Decision-support software clarifies cost, revenue division. PMID- 10158432 TI - Information is the glue holding together managed-care organizations. PMID- 10158433 TI - Incompetents and the right to die: in search of consistent meaningful standards. PMID- 10158434 TI - What does social meaning mean? PMID- 10158435 TI - Fair and effective resource allocation in cancer care: uncharted territory? PMID- 10158436 TI - Medical accountability and the criminal law: New Zealand vs the world. PMID- 10158437 TI - The research-practice gap and the role of decision analysis in closing it. AB - Current hypotheses for the existence of the 'research-practice gap' focus on weaknesses in research dissemination on the one hand and practitioner attitudes and motivations on the other. It is suggested that the gap has more fundamental origins in the cognitive and value mismatch between researchers and practitioners. To narrow the gap both cultures need to use a common framework (map and language) that is located at a level of analysis between their typical modes and makes explicit provision for the consideration of values. The decision analytic framework fulfills these requirements and it is therefore argued that all reports of research should include a decision analytic representations of the findings. PMID- 10158438 TI - Medical manslaughter law reform: a mistaken diagnosis. PMID- 10158439 TI - Fracturing the criminal law: disease control and the limits of law-making. PMID- 10158440 TI - Difficulties in obtaining informed consent by psychiatrists, surgeons and obstetricians/gynaecologists. PMID- 10158441 TI - Learning the law. PMID- 10158442 TI - Don't 'consent' patients, help them to decide. PMID- 10158443 TI - Informed consent for clinical treatment: a psychologist speaks for patients. PMID- 10158444 TI - Decision support for patient care: computerized rating scales. AB - Cost-effective patient assessment instruments continue to be developed and improved. Computer technology advances enable these instruments to be administered more efficiently, with more rapid feedback to clinical decision makers and patients. This article describes several of these instruments and how they are used in primary care and behavioral healthcare settings for treatment planning and disease management. The authors are eminent research pioneers and leaders in this field. PMID- 10158445 TI - Expert systems restructure managed care practice: implementation and ethics. AB - The development of computerized decision support technologies is having a profound impact on the management of patient care. This article describes different types of clinical decision support software, examines appropriate usage and current examples of implementation, and reviews a range of ethical considerations. The authors are in the midst of implementing a computerized decision support system for care management in their managed care organization. PMID- 10158446 TI - Dialogue. Privacy protection: paper or computer records? Computerization with increased privacy protection. PMID- 10158447 TI - Dialogue. Privacy protection: paper or computer records? Confidentiality of healthcare records. AB - In summary, security concerns surrounding health data are justified, but solutions are surmountable with currently available technologies. Whether systems are paper or electronic, human factors such as errors, negligence and unethical activities can result in breaches of confidentiality, despite optimal implementations. Neither automated teller machines (ATMs) nor EMRs are free from instances of abuse, but policies and protocols for electronic systems can be implemented that may provide better security than analogous paper record systems. PMID- 10158448 TI - Dialogue. Privacy protection: paper or computer records? Best strategies for clinical delivery systems. PMID- 10158449 TI - Legal requirements for computer security: electronic medical records and data interchange. PMID- 10158450 TI - Disease management strategy: initiative links pharmaceutical and mental health data. AB - The emphasis in healthcare is shifting to practical applications of medical knowledge for the provision of more cost-effective care. This requires greater linkages among clinical information systems across multiple organizations. This article describes new initiatives in disease management to link the traditionally separate data systems fo pharmaceutical, behavioral and general medical care. The potential for improved patient care is highlighted. The author is an expert consultant for a large pharmaceutical manufacturer's disease state management initiative, and has an extensive leadership background in many segments of the behavioral healthcare industry. PMID- 10158451 TI - How psychological testing can reinstate its value in an era of cost containment. AB - Managed care methods, and the cost containment concerns from which they arose, have dramatically reduced the use of psychological testing dramatically. This article critiques that trend, and proposes how selected tests can be used cost effectively in specific situations. The author has conducted research and written extensively on this subject, including a chapter in "The Computerization of Behavioral Healthcare: How to Enhance Clinical Practice, Management and Communications." PMID- 10158452 TI - Clinical practices use the Internet to enhance administrative operations. PMID- 10158453 TI - How information systems are opening the way for integrated healthcare. AB - Group practices, hospitals, managed care and insurance companies are integrated through mergers, acquisitions, joint ventures and other means. In this process, traditionally separate information system functions are also integrating. These trends present tremendous challenges as they impact the entire behavioral healthcare industry. The author reviews recent developments and takes the reader into his vision of standard integrated delivery system requirements for the near future. PMID- 10158455 TI - Falling diarrhoea mortality in Northeastern Brazil: did ORT play a role? AB - The impact of oral rehydration therapy (ORT) on the recent decline in diarrhoea mortality in the northeast of Brazil was studied. Proportionate infant mortality fell from 32% in 1980 to 17% in 1989 and infant deaths attributed to diarrhoea dropped from 41% to 25%, resulting in an overall reduction of 57%. Similar decreases were observed for children aged 1-4 years. Diarrhoea admissions also fell from 57% of infant hospitalizations in 1980 to 30% in 1990. None of the other major causes of death or admissions showed such decline. ORT was introduced in the early 1980s, being used in 35% of all episodes in 1991 and in 62% of those regarded as severe by the mother. Other changes included a worsening of socioeconomic conditions and increases in water supply, vaccine coverage, breastfeeding duration and nutritional status. A simulation model estimated that changes in factors other than ORT would lead to a 21% reduction in infant diarrhoea mortality, or about one-third of the actual decline. Finally, an ecological analysis showed that ORT use rates were inversely correlated to infant diarrhoea mortality (r=-0.61; p=0.04). Despite the shortcomings of the available data, these findings suggest an important impact of ORT on diarrhoea mortality. PMID- 10158454 TI - Complications of unsafe abortion in sub-Saharan Africa: a review. AB - The Commonwealth Regional Health Community Secretariat undertook a study in 1994 to document the magnitude of abortion complications in Commonwealth member countries. The results of the literature review component of that study, and research gaps identified as a result of the review, are presented in this article. The literature review findings indicate a significant public health problem in the region, as measured by a high proportion of incomplete abortion patients among all hospital gynaecology admissions. The most common complications of unsafe abortion seen at health facilities were haemorrhage and sepsis. Studies on the use of manual vacuum aspiration for treating abortion complications found shorter lengths of hospital stay (and thus, lower resource costs) and a reduced need for a repeat evacuation. Very few articles focused exclusively on the cost of treating abortion complications, but authors agreed that it consumes a disproportionate amount of hospital resources. Studies on the role of men in supporting a woman's decision to abort or use contraception were similarly lacking. Articles on contraceptive behaviour and abortion reported that almost all patients suffering from abortion complications had not used an effective, or any, method of contraception prior to becoming pregnant, especially among the adolescent population; studies on post-abortion contraception are virtually nonexistent. Almost all articles on the legal aspect of abortion recommended law reform to reflect a public health, rather than a criminal, orientation. Research needs that were identified include: community-based epidemiological studies; operations research on decentralization of post-abortion care and integration of treatment with post-abortion family planning services; studies on system-wide resource use for treatment of incomplete abortion; qualitative research on the role of males in the decision to terminate pregnancy and use contraception; clinical studies on pain control medications and procedures; and case studies on the provision of safe abortion services where legally allowed. PMID- 10158456 TI - The role of private providers in maternal and child health and family planning services in developing countries. AB - This paper uses data from the Demographic and Health Surveys program (DHS) in 11 countries in Asia, Africa, and Latin America to explore the contribution of private health care providers to population coverage with a variety of maternal and child health and family planning services. The choice of countries and services assessed was mainly determined by the availability of data in the different surveys. Private providers contribute significantly to family planning services and treatment of children's infectious diseases in a number of the countries studied. This is as expected from the predictions of economic theory, since these goods are less subject to market failures. For the more 'public goods' type services, such as immunization and ante-natal care, their role is much more circumscribed. Two groups of countries were identified: those with a higher private provision role across many different types of services and those where private provision was limited to only one or two types of the services studied. The analysis identified the lack of consistent or systematic definitions of private providers across countries as well as the absence of data on many key services in most of the DHS surveys. Given the significance of private provision of public health goods in many countries, the authors propose much more systematic efforts to measure these variables in the future. This could be included in future DHS surveys without too much difficulty. PMID- 10158458 TI - Childcare needs of female street vendors in Mexico City. AB - This article reports on strategies developed by female street vendors (vendedoras ambulantes) in Mexico City to ensure the care of their young children in the absence of a specific and operational government policy to fulfil this need. The information concerning child care and health was gathered by a survey of 426 street traders selected by multi-stage random cluster sampling in four of the administrative districts (delegaciones politicas) of Mexico City during 1990. It was found that, as mothers of young children, street vendors most frequently looked after their children personally on the street or left them with other members of the family. Related factors were availability of alternative child care providers in the family, the age of the children and working conditions of the mother. Children who remained on the streets with their mothers suffered more frequently from gastro-intestinal diseases and accidents than the national average. The incidence of acute respiratory diseases, however, was similar in the cases of maternal care in the street and care by family members in another environment. Existing public health measures show a greater concern for the health of food consumers than that of workers in this area. Current public policy seeks to regulate street vending activities and to concentrate traders in ad hoc areas and facilities. Our research results document the need for actions that can contribute to an improvement in the care and health conditions of these young children. PMID- 10158459 TI - AIDS-related policies, legislation and programme implementation in India. AB - This paper traces the evolution of AIDS-related policy and legislation in India from an initial response characterized by conservatism and discrimination to the development of a coherent national programme which aims to prevent the transmission of HIV and to develop support structures for people with HIV and AIDS. Examining the strategies, achievements and problems of specific components of the National AIDS Control Programme (NACP), the paper finds that the very progressive approach of national-level policy makers has been countered by conservative forces at the state and local levels. Little progress has been made, moreover, in incorporating HIV/AIDS prevention efforts into broader development and empowerment strategies. The paper concludes by considering the wider social context of AIDS in India and the role of more far-reaching policy measures. PMID- 10158457 TI - Breastfeeding promotion and priority setting in health. AB - An increase in exclusive breastfeeding prevalence can substantially reduce mortality and morbidity among infants. In this paper, estimates of the costs and impacts of three breastfeeding promotion programmes, implemented through maternity services in Brazil, Honduras and Mexico, are used to develop cost effectiveness measures and these are compared with other health interventions. The results show that breastfeeding promotion can be one of the most cost effective health interventions for preventing cases of diarrhoea, preventing deaths from diarrhoea, and gaining disability-adjusted life years (DALYs). The benefits are substantial over a broad range of programme types. Programmes starting with the removal of formula and medications during delivery are likely to derive a high level of impact per unit of net incremental cost. Cost effectiveness is lower (but still attractive relative to other interventions) if hospitals already have rooming-in and no bottle-feeds; and the cost-effectiveness improves as programmes become well-established. At an annual cost of about 30 to 40 US cents per birth, programmes starting with formula feeding in nurseries and maternity wards can reduce diarrhoea cases for approximately $0.65 to $1.10 per case prevented, diarrhoea deaths for $100 to $200 per death averted, and reduce the burden of disease for approximately $2 to $4 per DALY. Maternity services that have already eliminated formula can, by investing from $2 to $3 per birth, prevent diarrhoea cases and deaths for $3.50 to $6.75 per case, and $550 to $800 per death respectively, with DALYs gained at $12 to $19 each. PMID- 10158460 TI - Potential savings from generic prescribing and generic substitution in South Africa. AB - Generic prescribing and generic substitution are mechanisms for reducing the cost of drugs. The purpose of this study was to assess the extent to which generic prescribing by private medical practitioners and generic substitution by private pharmacists is practised in South Africa and to estimate the potential savings from these two practices. Prescriptions from 10 pharmacists were collected on four randomly selected days. Computer printouts of all the prescriptions dispensed on these four days together with the original doctor's prescription were priced using a commercially available pharmacy dispensing computer package. A total of 1570 prescriptions with a total number of 4086 items were reviewed. Of the total prescriptions, 45.7% had at least one item for which there was a generic equivalent. Of the 961 drugs which had generic equivalents, 202 (21 %) were prescribed using the generic name of the drug. Only 0.3% of prescribers prohibited generic substitution. The cost of the prescription as dispensed was 1.4% (mean cost: R116.19 vs R117.84) below that of the original doctor's prescriptions, indicating the marginal benefit from the current low substitution rate of 13.9% by pharmacists. About 6.8% of the cost of the original doctor's prescriptions (mean cost: R117.84) could have been saved if total generic substitution (mean cost: R109.65) was practised. The cost of the prescriptions with only brand name items (mean cost: R120.49) would have been 9.9% higher than if generic drugs were used. Current restrictive prescribing and dispensing practices result in marginal cost savings from generic prescribing and generic substitution. Both these practices have a potential to reduce drug costs, if actively encouraged and practised to maximum capacity. It is noteworthy, however, that the potential savings from generic prescribing and substitution are at most 9.9% in the absence of any changes in types of drugs prescribed. PMID- 10158461 TI - Sales practices of patent medicine sellers in Nigeria. AB - A survey was carried out among patent medicine dealers to evaluate their practices that militate against laws governing prescriptions-only medicines in Nigeria. Questionnaires were distributed to 46 patent medicine dealers and later collected from them on appointment. Analysis of the results showed that all the patent medicine dealers were aware of the law governing the sale of prescription drugs in Nigeria. Seventy-five per cent of them stock such drugs. Patent medicine dealers obtain their drugs largely from sales representative of pharmaceutical companies as well as from industries. Inappropriate use of sales boys and girls in patent medicine stores and defective government policies were all investigated. PMID- 10158462 TI - Using a longitudinal illness record to study household health care decision making in rural communes of Viet Nam. PMID- 10158463 TI - Medicare risk contracting is a risky yet potentially profitable game. PMID- 10158464 TI - MedSpan Inc. sets itself up to compete for Medicare managed care contracts. PMID- 10158465 TI - Integrated health systems' missing links. PMID- 10158466 TI - Making the best of a good situation: Rapid City Regional Hospital's continued success. PMID- 10158467 TI - Houston's Methodist Hospital adds the backbone to its product line. Institute for Spinal Disorders. PMID- 10158468 TI - Hospitals are using fitness centers to improve health status and lower costs. PMID- 10158469 TI - Parents are important markets for hospitals. PMID- 10158470 TI - Uncle Sam doesn't overcompensate Medicare risk HMOs, survey says. PMID- 10158471 TI - Average salaries for top hospital and integrated system execs top $200K. PMID- 10158472 TI - Increasing returns and the new world of business. AB - Our understanding of how markets and businesses operate was passed down to us more than a century ago by English economist Alfred Marshall. It is based on the assumption of diminishing returns: products or companies that get ahead in a market eventually run into limitations so that a predictable equilibrium of prices and market shares is reached. The theory was valid for the bulk processing, smokestack economy of Marshall's day. But in this century, Western economies have gone from processing resources to processing information, from the application of raw energy to the application of ideas. The mechanisms that determine economic behavior have also shifted--from diminishing returns to increasing returns. Increasing returns are the tendency for that which is ahead to get further ahead and for that which is losing advantage to lose further advantage. If a product gets ahead, increasing returns can magnify the advantage, and the product can go on to lock in the market. Mechanisms of increasing returns exist alongside those of diminishing returns in all industries. But, in general, diminishing returns hold sway in the traditional, resource-processing industries. Increasing returns reign in the newer, knowledge-based industries. Modern economies have split into two interrelated worlds of business corresponding to the two types of returns. The two worlds have different economics. They differ in behavior, style, and culture. They call for different management techniques, strategies, and codes of government regulation. The author illuminates those differences by explaining how increasing returns operate in high tech and in service industries. He also offers advice to managers in knowledge-based markets. PMID- 10158473 TI - Manage marketing by the customer equity test. AB - Managers have recently begun to think of good marketing as good conversation, as a process of drawing customers into progressively more satisfying relationships with a company. And just as the art of conversation follows two steps--first striking up a conversation with a likely partner and then maintaining the flow- so the new marketing naturally divides itself into the work of customer acquisition and the work of customer retention. But how can managers determine the optimal balance between spending on acquisition and spending on retention? Robert Blattberg and John Deighton use decision calculus to help managers answer that question. That is, they ask managers to approach the large, complex problem through several smaller, more manageable questions on the same topic. Then they use a formal model to turn those smaller judgments into an answer to the larger question. The ultimate goal, the authors say, is to grow the company's customer equity the sum of all the conversations-to its fullest potential. Recognizing that managers must constantly reassess the spending points determined by the decision-calculus model, the authors also provide a series of guidelines and suggestions to help frame the issues that affect acquisition, retention, and customer equity. When managers strive to grow customer equity rather than a brand's sales or profits, they put a primary indicator of the health of the business at the fore front of their strategic thinking: the quality of customer relationships. PMID- 10158474 TI - Musings on management. Ten ideas designed to rile everyone who cares about management. AB - Henry Mintzberg, a professor of management at McGill University in Canada and at INSEAD in France, takes aim at the hype surrounding management fads and gurus and dares to suggest that the emperor has no clothes. In order to rile all who care about management and get them thinking creatively, he presents ten contrarian observations on such topics as the meanness of leanness, the folly of CEOs who fancy themselves strategists, the disempowering that so-called empowerment creates, the myopia of purely financial measures, and the inadequacy of M.B.A. programs. Mintzberg maintains, for example, that it is time to delayer the delayerers. He argues that delayering has created more problems than it has solved be cause it is, in essence, a process by which people who barely know what's going on get rid of those who do--a process ensuring that the real database of the organization, the key to what was its future, lines up at the unemployment office. Too many managers, he says, dream of becoming the next turnaround doctor. They fail to understand that great organizations, once created, don't need great leaders: if a company can't function on its own, a hero won't help. A leader who draws out the knowledge embedded in all parts of an organization is a leader who can help a company function alone--without heroes. Such leaders often practice what Mintzberg calls the craft style of management (as opposed to the professional style or the boss style). It is about inspiring, not empowering. It is based on mutual respect rooted in common experience and offers hope for improving what is now wrong with management. PMID- 10158475 TI - Strategy as revolution. AB - How often does the strategic-planning process start with senior executives asking what the rest of the organization can teach them about the future? Not often enough, argues Gary Hamel. In many companies, strategy making is an elitist procedure and ?strategy? consists of nothing more than following the industry's rules. But more and more companies, intent on overturning the industrial order, are rewriting those rules. What can industry incumbents do? Either surrender the future to revolutionary challengers or revolutionize the way their companies create strategy. What is needed is not a tweak to the traditional strategic planning process, Hamel says, but a new philosophical foundation: strategy is revolution. Hamel offers ten principles to help a company think about the challenge of creating truly revolutionary strategies. Perhaps the most fundamental principle is that so-called strategic planning doesn't produce true strategic innovation. The traditional planning process is little more than a rote procedure in which deeply held assumptions and industry conventions are reinforced rather than challenged. Such a process harnesses only a tiny proportion of an organization's creative potential. If there is to be any hope of industry revolution, senior managers must give up their monopoly on the creation of strategy. They must embrace a truly democratic process that can give voice to the revolutionaries that exist in every company. If senior managers are unwilling to do this, employees must become strategy activists. The opportunities for industry revolution are mostly unexplored. One thing is certain: if you don't let the revolutionaries challenge you from within, they will eventually challenge you from without--in the marketplace. PMID- 10158476 TI - Strategic renewal for business units. AB - Over the past decade, business units have increasingly taken the role of strategy formulation away from corporate headquarters. The change makes sense: business units are closer to customers, competitors, and costs. Nevertheless, business units can fail, just as headquarters once did, by losing their focus on the organization's priorities and capabilities. John Whitney--turnaround expert and professor of management at Columbia University--offers a method for refocusing companies that he calls the strategic-renewal process. The principles behind the process are straightforward, but its execution demands extensive data, rigorous analysis, and the judgment of key decision makers. However, when applied with diligence, it can produce a strategy that yields both growth and profit. To carry out the process, managers must analyze, one by one or in logical groupings, the company's customers, the products it sells, and the services it offers in light of three criteria: strategic importance, significance, and profitability. Does a given customer, product, or service mesh with the organization's goals? Is it significant in terms of current and future revenues? And is it truly profitable when all costs are care fully considered? Customers, products, and services that do not measure up, says the author, must be weeded out relentlessly. Although the process is a painstaking one, the article offers clear thinking on why-and how-to go about it. A series of exhibits takes managers through the questions they need to raise, and two matrices offer Whitney's concentrated wisdom on when to cultivate--and when to prune. PMID- 10158477 TI - Visible security credited with changing med center's negative image. PMID- 10158478 TI - Florida company offers software program for obtaining background checks. PMID- 10158479 TI - An interview with: Harry J Azano on security's growing role in fire prevention. PMID- 10158480 TI - Small security force adjusts to major expansion of 134-bed med center. PMID- 10158482 TI - How a multi-department team eliminated duplication and improved service. PMID- 10158481 TI - Train crash disasters and emergency plans of suburban hospitals in the New York City and Washington, DC areas: what went right; what could have been improved. AB - Two major train crashes in February--one in Northern New Jersey and the other in Silver Spring, MD, near Washington, DC--posed severe challenges to the disaster plans of area hospitals. The first crash involving two commuter trains near Secaucus, NJ, tested the effectiveness of emergency plans at the Jersey City Medical Center, Jersey City, NJ, and the Meadowlands Hospital Medical Center, Secaucus. The incident occurred at approximately 8:40 a.m. and resulted in three deaths and 162 injuries. The Silver Spring crash, which took place a week after the one in New Jersey, occurred in early evening and involved an Amtrak and a commuter train. It resulted in 11 deaths and 26 injuries. Holy Cross Hospital, Silver Spring, was the primary caregiver. In this report, we'll provide details on how the incidents impacted on nearby hospitals and their security staffs; how challenges, anticipated and unanticipated, were met; and what conclusions were reached in follow-up critiques. PMID- 10158483 TI - Managing aggressive behavior: course offered for hospital personnel. PMID- 10158484 TI - Survey of pharmacists: impact of the generic drug scandal and implications for marketing generic drugs. AB - The generic drug scandal that made headlines in 1989 shocked consumers, prescribers, pharmacists, insurers, the pharmaceutical industry, the FDA and Congress. Using data collected after the scandal was reported, this study investigates the impact of scandal on pharmacists' confidence in generics, and their attitudes, opinions and behavior toward generics. Based upon the findings, the author provides a set of recommendations for marketing generic drugs. PMID- 10158485 TI - The health belief model and consumer information searches: toward an integrated model. AB - Some health data organizations (HDOs) are producing consumer-level health services information. National reform proposals would suggest that competition between health plans will be developed through the use of outcome information. Policy makers have paid little attention to how consumers might use that information or how that information might be most effectively packaged for consumer use. This paper argues that marketing literature developed over the last ten to fifteen years could prove to be an informative resource for policy makers and the health services provider community alike. This paper suggests that combining a consumer decision model (CDM) with the health belief model (HBM) will provide an important step toward an increased understanding of consumer information search behavior. This integrated model could form the basis of future research in this important area. PMID- 10158486 TI - Patterns of targeting and encouraging participation of elder consumers in human services marketing. AB - Competition within the older adult services sector is fueling the widespread adoption of an organizational marketing mentality. Yet little is known of the degree of variation in marketing technology and commitment to elder consumer subgroups in different health and social service settings or the extent to which elders are involved actively in the marketing process. This paper addresses these issues drawing on study data collected from 274 elder service programs in six major U.S. metropolitan areas. Findings confirm that providers frequently co market their services with other organizations and target multiple constituencies, but do not distinguish as well among specialized segments of the elder population varying in terms of gender, physical and mental capacity, age, financial status, or race. Significant predictors (p<.05) of increased levels of elder participation in the agency marketing pro cess include length of time marketing, specialized training in marketing, and nonsectarian auspice (R2=.22). Results lead to recommendations for mounting more cohort-sensitive marketing initiatives in human service agencies serving older adults. PMID- 10158487 TI - Current trends and challenges in marketing an executive candidate. PMID- 10158488 TI - A consumer evaluation of health warning labels on cigarette packages in Canada. AB - This paper reports on results of a study that examined consumers' evaluation of health warning labels on cigarette packages in Canada. Some health warning labels were rated, overall, as more effective as well as more believable, convincing and reasonable than others. Analysis of the differences in responses by smokers and non-smokers is also presented. PMID- 10158489 TI - Employer purchasing of health care benefits: marketing implications of an organizational buying perspective. AB - While health care providers recognize employers as key purchasers of health benefits, there is little understanding of how employers make these important buys. We propose a model of health benefits acquisition using an organizational buying perspective, and discuss findings from a study of employee benefits managers. Critical marketing implications are presented. PMID- 10158490 TI - Reforming the health care system: implications for health care marketers. AB - Health care reform has become the dominant domestic policy issue in the United States. President Clinton, and the Democratic leaders in the House and Senate have all proposed legislation to reform the system. Regardless of the plan which is ultimately enacted, health care delivery will be radically changed. Health care marketers, given their perspective, have a unique opportunity to ensure their own institutions' success. Organizational, managerial, and marketing strategies can be employed to deal with the changes which will occur. Marketers can utilize personal strategies to remain proactive and successful during an era of health care reform. As outlined in this article, responding to the health care reform changes requires strategic urgency and action. However, the strategies proposed are practical regardless of the version of health care reform legislation which is ultimately enacted. PMID- 10158492 TI - HMO facility. Kaiser Permanente TownPark, Cobb County, Georgia. PMID- 10158491 TI - AIDS knowledge, attitudes and beliefs among Chinese college students: implications for PSA development. AB - With growing numbers of reported HIV cases in The People's Republic of China, PRC health officials face the same information dissemination problems that have plagued other nations for a decade. The purpose of this study was to begin to understand Chinese college students' knowledge, attitudes and beliefs about HIV/AIDS as well as the cultural barriers which may prevent the acceptance of AIDS public service efforts. Focus group interviews were conducted with 76 college students at Xiamen University, PRC. Interviews revealed that many inaccurate beliefs exist regarding the AIDS disease and its modes of transmission. While many of the respondents reported that fate was the determining factor in trans mission of HIV, most felt distanced--physically, morally and culturally--from those at risk. PMID- 10158493 TI - New Zealand chops. PMID- 10158494 TI - Mental health. Crisis de coeur. PMID- 10158495 TI - Stroke care. Different strokes. PMID- 10158496 TI - Outreach clinics. Practice does not make perfect. PMID- 10158497 TI - Data briefing. Cancer. PMID- 10158498 TI - Woolf in sheep's clothing? New moves in clinical negligence. Peace deals. PMID- 10158499 TI - Whistleblowing. Worth the whistle. PMID- 10158500 TI - Nurse prescribing. In on the act. PMID- 10158501 TI - Self-development. Better than sex and the lottery. PMID- 10158503 TI - Human resources. Do as you would be done by? PMID- 10158502 TI - Primary care. Take five. PMID- 10158504 TI - Successful procurement. Inside edge. PMID- 10158505 TI - Successful procurement. Legal services: the law is an asset. PMID- 10158506 TI - Successful procurement. Supplies: coming up with the goods? PMID- 10158507 TI - Successful procurement. Utilities: cheaper by the meter. PMID- 10158508 TI - Meeting users. Up in alms. PMID- 10158509 TI - Non-attendance. A turn up for the books. PMID- 10158510 TI - Creating community health partnerships. PMID- 10158511 TI - 25 innovations in community collaboration. PMID- 10158513 TI - Working with a search firm. PMID- 10158512 TI - Collaboration: walking the talk. PMID- 10158514 TI - Respecting proprietary information. PMID- 10158515 TI - Health insurance bill sparks debate. PMID- 10158516 TI - American College of Healthcare Executives. Public policy statement. Age discrimination and the healthcare executive. May 1995 (revised). PMID- 10158517 TI - Competitors as collaborators. PMID- 10158518 TI - Managed care drives health care automation. PMID- 10158520 TI - Toward a technology of meaning. PMID- 10158519 TI - Medical necessity: trying to reach consensus. PMID- 10158521 TI - Don't gamble with medical record numbers. PMID- 10158522 TI - What makes an effective leader? PMID- 10158523 TI - Career development. Part 2. Is the door half open or half closed on the laboratory's future? PMID- 10158524 TI - Building a staffing plan based on OR's needs. PMID- 10158525 TI - Who assists circulator on a surgical case? PMID- 10158526 TI - 'Mad cow' particle challenges infection control. PMID- 10158527 TI - The need for a new model of care: revisiting the archetype. AB - Managed care organizations are refusing to accept the traditional academic health center's uncoordinated teaching model for their patients. They know that successful capitation can only be achieved when care is viewed from a population perspective, managed along a continuum, and coordinated at every point. Of the many changes that must occur, the care delivery paradigm, is a major area that needs to be redesigned. PMID- 10158528 TI - Making the journey into the networked enterprise, Part 2. AB - In the May issue of Physician Executive, the authors described the difficulties other industries have had with vertical integration and why so many corporations have abandoned it for other organizational structures. In this second part of the series, they explore the ways health care organizations can make the shift into integrated delivery systems, avoiding the trap of the hierarchical, vertically integrated monolithic structures that will become the dinosaurs of the future. PMID- 10158529 TI - The healing community. AB - As health care becomes more industrialized, more influenced by Wall Street, and more driven by internal needs instead of being patient-focused, patients and society lose faith, confidence, and trust in physicians and hospitals. In this paper, a new model of a health care system as a healing community--one that services a community--is presented. The proposed structure will foster service and support. PMID- 10158530 TI - A protocol for mutual respect and communication. AB - Physicians relating to each other, discussing a patient's problem, needs, and care plans, should be the easiest part of medical practice. Unfortunately, exchanging meaningful information between physicians and their offices is, at times, formidable. This article describes the guiding principles for physician referrals at Hamot Medical Center that were developed to enhance communication between physicians and increase patient care. PMID- 10158531 TI - Intranets advance medical care. PMID- 10158532 TI - Who should be responsible? PMID- 10158533 TI - Stabilizing the destabilized work force. PMID- 10158534 TI - Battle against bacteria shifts focus. Interview by William A. Check. PMID- 10158536 TI - Better maps put genome researchers at the wheel. Interview by Karen Titus. PMID- 10158535 TI - Virologic testing for HIV. Interview by Barbara Chapman. PMID- 10158538 TI - Jumping the hurdles to bar coded wristbands. PMID- 10158537 TI - For better cause-of-death statements, consistency's key. PMID- 10158539 TI - Heartier diagnoses with new cardiac assays. PMID- 10158540 TI - Lp(a): how useful a yardstick? PMID- 10158541 TI - Managed genetic care in a large HMO. AB - Comprehensive clinical genetic services are offered to 2.4 million members by the Kaiser Permanente Medical Care Program (KP), a not-for-profit HMO, in its Northern California region. Four genetics centers are staffed by clinical geneticists, genetic counselors, nurses, and laboratory technologists, who together provide patient and physician education, genetic screening, and prenatal, infant, and adult evaluation. Besides offering lectures and teleconferences, the geneticists publish a newsletter on how to use the genetic services for approximately 1200 pediatricians, obstetricians, and other relevant specialists. Clinical services offered to members include individual, group, and telephone consultations, and easy access to geneticists is provided for primary care providers with genetic care questions. In-house laboratory services include blood and tissue cytogenetic analysis, DNA testing, and prenatal blood and amniotic fluid testing. A large database and a comprehensive and cost-effective program of genetic services have been developed. An interregional genetics data system is being established to link Northern and Southern California and the Northwest (Portland and Hawaii regions). Steps are also underway to include other regions in the database and to encourage utilization of regionalized KP genetic laboratories by smaller regions. PMID- 10158542 TI - A cohort analysis of pre-menopausal women with dysfunctional uterine bleeding. AB - OBJECTIVE: To examine the clinical and cost outcomes of patients with dysfunctional uterine bleeding (DUB) who are treated with hysterectomy or not. DESIGN: A retrospective analysis of DUB patients over 30 months of treatment after initial diagnosis. SETTING: Patients with DUB from an HMO with over 200,000 enrollees. PARTICIPANTS: Study patients, all women with an initial diagnosis of DUB, were divided into two cohorts. Cohort 1 was women who had a hysterectomy (not for cancer); Cohort 2 was women who did not have a hysterectomy. MAIN OUTCOME MEASURES: Visit counts and costs, prescription counts and costs, hospital costs, and procedure counts. RESULTS: Hysterectomy patients in our dataset tend to have more prescriptions, higher prescription costs, more visits overall, higher visit costs, higher hospitalization costs, and higher total costs per member per month (PMPM) than non-hysterectomy patients. After surgery, the hysterectomy patients' costs and utilization PMPM are higher than those for the non-hysterectomy patients. CONCLUSIONS: There is wide variation in the treatment of patients with DUB. Clinical practice improvement studies are needed to determine the appropriate treatments based on patient characteristics to achieve better outcomes for lower costs. PMID- 10158543 TI - The place of hysterectomy in the management of benign uterine disease. AB - The wide variation in hysterectomy rates may reflect professional uncertainty as to the appropriateness of the procedure for managing benign uterine disease. This is thought to be due to diagnostic difficulties and especially to a lack of outcomes data. Many patients experience symptomatic relief after hysterectomy, but the long-term costs and benefits remain uncertain. Alternative treatments are available that spare the uterus and/or ovaries and appear to be as effective as hysterectomy. Vaginal hysterectomy is also associated with significantly reduced hospitalization and convalescent time and a lower rate of post-operative complications compared to abdominal hysterectomy, yet most hysterectomies continue to be performed abdominally. Based on the review, a number of steps are proposed for dealing with the problem of excess hysterectomy rates within a managed care setting. PMID- 10158544 TI - Assessing the costs of HMO services: a preterm birth prevention program. AB - The prevention of preterm birth has been widely recognized as a means of improving health outcomes as well as reducing medical care costs. Group Health, Inc. (now HealthPartners), a large HMO in Minneapolis/St. Paul, Minn, developed a comprehensive preterm birth prevention program. The cost savings of the program were estimated through retrospective review of medical records. The impact of the program on birth outcomes was used to project the estimated reduction in expenses. The results suggest a probable savings of $615,000 for the 33 babies born full-term, who might otherwise have been preterm. There is a significant need for improved methods to assure that this kind of cost estimate is valid. PMID- 10158545 TI - HMO physicians and the media. PMID- 10158546 TI - A modified health risk appraisal as a component of a senior health promotion program. AB - Because of their comprehensive service capabilities and traditional focus on prevention, HMOs have an outstanding potential for contributing to health promotion and disease prevention among special populations. But HMOs must acknowledge the special needs of key groups and modify traditional offerings accordingly. This article describes the use of the health risk appraisal (HRA) in a program, A Healthy Future, aimed at promoting health and preventing disease among elders. Unlike ?standard? HRAs, this program developed questions of special pertinence to elders and used face-to-face, human contact for communicating results. Most important, the program linked the HRA to primary care and to interventions particularly useful and acceptable to elders. PMID- 10158547 TI - Subacute care offers opportunities to reduce costs, maintain quality. PMID- 10158548 TI - Pathway automation: establishing a framework. PMID- 10158549 TI - Evaluation of self-reported quality indicators provides useful feedback for New York MCOs. PMID- 10158550 TI - Full disclosure. AB - The new regulations governing physician incentives in managed care organizations are out, and while they might prove to be another pit of paperwork, they might also make managed care easier to swallow for consumers. PMID- 10158551 TI - Information technology: the new edge in recruiting. PMID- 10158552 TI - A fresh start for health reform? AB - Health reform isn't a popular subject in Washington these days, but problems of cost and access persist. The author, a senior health policy analyst for the Progressive Policy Institute, argues that in next year's debate of tax reform, a few modest changes could lead to a more effective and universal market for health care. PMID- 10158554 TI - An academic marriage. PMID- 10158553 TI - Preserving the mission. AB - Teaching hospitals and medical schools are changing with the times, but the authors argue that other players in the delivery system--government, insurers, hospitals, and health systems--must share in the effort to preserve the nation's medical education and research infrastructure. PMID- 10158555 TI - Hospitals, doctors and the right to die. PMID- 10158556 TI - Strangers in a strange land. PMID- 10158557 TI - Physicians and hospitals: new partnerships. PMID- 10158558 TI - Optimizing primary care services. PMID- 10158559 TI - The Dartmouth Atlas of Health Care: what is it telling us? PMID- 10158560 TI - Data ... physician practice acquisition. PMID- 10158561 TI - Medicaid: perspectives from the states. PMID- 10158562 TI - Health planning and health care for the poor: the internal ethic of public health. AB - Health planning involves assessing health care needs of a defined population, setting priorities, then developing, implementing,m and evaluating programs that address priority needs. The concepts of health planning are central to the 1988 report of the Institute of Medicine on the Future of Public Health, which defined the three core functions of public health as assessment, policy development, and assurance. Generally, when health planning is instituted, poor people are identified as having the poorest health status and the greatest need. An internal ethic is therefore created for public health to focus on the health care needs of those in poverty. This internal ethic of public health health can become the driving force for reforming the present U.S. health care system. A reformed health care system would be guided by the principle of care according to need, which not only has a basis in health planning, but in social justice as well. PMID- 10158563 TI - Social and public policy analysis: a niche for social work practice. AB - This article provides front line social work practitioners with a mechanism for becoming more meaningfully involved in social and public policy analysis. It suggests that a new entry point for shaping policy formulation should occur earlier on in the problem identification stage of the rational policymaking process. The article offers a series of process questions to guide this approach and contends that practitioners have the necessary knowledge and skills to effect the various role expectations required of them in this regard. PMID- 10158564 TI - 1995 firefighter fatalities. PMID- 10158565 TI - The latest toll from the private use of fireworks. PMID- 10158566 TI - Inventory management system reaps savings for department. Case study: devising a system to order, track, and stock intraocular lenses. PMID- 10158567 TI - Outcome budgeting shifts focus to meeting objectives. PMID- 10158568 TI - Practice brief. Issue: Facsimile transmission of health information. American Health Information Management Association. PMID- 10158569 TI - Myocardial infarctions; frequently asked questions. PMID- 10158570 TI - Management materials II: career management in a changing world. PMID- 10158571 TI - Information superhighway or superHYPEway? PMID- 10158572 TI - Trends in managed care legislation. PMID- 10158573 TI - Career management--by choice, by chance, or by crisis. PMID- 10158574 TI - Lifelong learning and the nontraditional health information management career. PMID- 10158575 TI - HIM finds itself in a multiskilled workplace. PMID- 10158576 TI - Medical staff services: another career option for HIM professionals. PMID- 10158577 TI - Career paths, mobility, and advancement for health information managers. PMID- 10158578 TI - In pursuit of a graduate degree: follow the Yellow Brick Road. PMID- 10158579 TI - An old surgeon finds new work. Part II. PMID- 10158580 TI - Practice expense studies. An update. PMID- 10158581 TI - Lovelace Health Systems boosts quality, cost-effectiveness by managing comprehensive "episodes of care". PMID- 10158582 TI - Express admission: a model for front-end redesign. PMID- 10158583 TI - Scrap those old habits and watch OR linen costs drop. PMID- 10158584 TI - In or out? Materials managers work the outsourcing puzzle--and develop a whole new perspective. PMID- 10158585 TI - Automated supply stations take punches but still stand. PMID- 10158586 TI - Give and you shall receive: supply donation program proves it. PMID- 10158587 TI - Times and temperatures. Sorting out conflicting advice on disinfection procedures. PMID- 10158588 TI - Business approaches to quality improvement: why they are hard for the NHS to swallow. PMID- 10158589 TI - Benign prostatic hyperplasia. PMID- 10158590 TI - The reliability of cancer registry records. PMID- 10158591 TI - Medication errors during hospital drug rounds. PMID- 10158593 TI - Quality improvement: a multiprofessional commodity? PMID- 10158592 TI - Preprinted assessment sheet. PMID- 10158594 TI - Newcastle satisfaction with nursing scales: an instrument for quality assessments of nursing care. AB - OBJECTIVES: To test the validity and reliability of scales for measuring patients' experiences of and satisfaction with nursing care; to test the ability of the scales to detect differences between hospitals and wards; and to investigate whether place of completion, hospital, or home influences response. DESIGN: Sample survey. SETTING: 20 wards in five hospitals in the north east of England. PATIENTS: 2078 patients in general medical and surgical wards. MAIN MEASURES: Experiences of and satisfaction with nursing care. RESULTS: 75% of patients approached to complete the questionnaires did so. Construct validity and internal consistency were both satisfactory. Both the experience and satisfaction scales were found to detect differences between randomly selected wards and hospitals. A sample of patients (102) were sent a further questionnaire to complete at home. 73% returned this; no significant differences were found in either experience or satisfaction scores between questionnaires given in hospital or at home. CONCLUSION: Scales to measure patients' experiences of and satisfaction with nursing in acute care have been developed and found to be valid, reliable, and able to detect differences between hospitals and wards. Questionnaires can be given before patients leave hospital or at home without affecting scores, but those given at home have a lower response rate. PMID- 10158595 TI - Indicators of the quality of general practice care of patients with chronic illness: a step towards the real involvement of patients in the assessment of the quality of care. AB - OBJECTIVE: To develop a list of indicators of the general practice care of people with chronic illnesses considered important by both patients and practitioners and to identify the indicators that are considered relevant for patient assessment of health care quality. DESIGN: Qualitative study with focus group interviews and a written consensus procedure. SETTING: General practice in the Netherlands in 1993. SUBJECTS: 34 patients with chronic illness, mostly members of patient organisations, and 19 general practitioners with expertise in either chronic disease management or experience with patient surveys. MAIN MEASURES: Aspects of general practice care considered important for the delivery of good quality care that emerged from focus group interviews; the relevance of evaluations of 41 aspects of care for patients explored through the written consensus procedure. Those aspects of general practice care agreed to be both important and relevant by patients and general practitioners were considered to be suitable indicators for patient assessment of the quality of care. RESULTS: Patients and general practitioners differed to some extent in their assessment of the aspects of care that they considered important for quality. They agreed that most indicators of care that related to the ?doctor-patient relation? and to ?information and support? were relevant and therefore suitable as indicators for patient assessment of health care quality. There was less agreement about the relevance of indicators of ?medical and technical care,? ?availability and accessibility,? and ?organisation of services.? CONCLUSIONS: Several indicators of the quality of general practice care of patients with chronic illness were thought to be suitable for the patient assessment of healthcare quality, but other indicators were not, mainly because of reservations by general practitioners. IMPLICATIONS: Qualitative methods can contribute to the selection of indicators for assessment of the quality of health care in areas where scientific evidence is limited or where patients' and providers' preferences are particularly important. PMID- 10158596 TI - Comparison of measures to assess outcomes in total hip replacement surgery. AB - OBJECTIVES: To compare the performance of a disease specific and a general health questionnaire in assessing changes resulting from total hip replacement. DESIGN: Two stage prospective study of patients undergoing total hip replacement surgery involving an assessment at a clinic before and six months after surgery. 60(32%) patients were followed up by post. SETTING: Outpatient departments at a specialist orthopaedic hospital and peripheral clinics within Oxfordshire. PATIENTS: 188 patients admitted for unilateral total hip replacement between February and mid-August 1994. MAIN MEASURES: Patients' self assessed scores with the 12 item Oxford hip score and SF-36 general health questionnaire together with surgeons' assessment with Charnley hip score obtained before and again at six months after surgery. RESULTS: 186 patients were followed up six months after total hip replacement; a subsample (n=60) by post. Of the 60 postal patients, 59(98.3%) fully completed the Oxford hip score compared with 44(73.3%) who fully completed the SF-36. For the followup sample as a whole, post operative changes in scores produced a large effect size of 2.75 on the Oxford hip score, compared with -1.89 physical function (SF-36), -2.13 pain (SF-36). With the exception of physical function and role (physical), postoperative SF-36 scores were shown to be similar to or better than those found by two population surveys on patients of comparable age. The responsiveness of a disease specific questionnaire, the Oxford hip score, and relevant sections of a general questionnaire, SF-36, were found to be similar as assessed by three different criteria. CONCLUSIONS: A disease specific questionnaire, the Oxford hip score, and a general state of health questionnaire, SF-36, performed similarly in assessing outcomes of total hip replacement except that the disease specific questionnaire resulted in a higher completion rate and greater responsiveness in some sections. On the other hand the general health questionnaire drew attention to broader problems of physical function not considered by the Oxford hip score. The health questionnaires examined here offer a valid and practical means of monitoring outcomes of hip replacement surgery. PMID- 10158597 TI - Does a dedicated discharge coordinator improve the quality of hospital discharge? AB - OBJECTIVE: To evaluate the effectiveness of the role of a discharge coordinator whose sole responsibility was to plan and coordinate the discharge of patients from medical wards. DESIGN: An intervention study in which the quality of discharge planning was assessed before and after the introduction of a discharge coordinator. Patients were interviewed on the ward before discharge and seven to 10 days after being discharged home. SETTING: The three medical wards at the Homerton Hospital in Hackney, East London. PATIENTS: 600 randomly sampled adult patients admitted to the medical wards of the study hospital, who were resident in the district (but not in institutions), were under the care of physicians (excluding psychiatry), and were discharged home from one of the medical wards. The sampling was conducted in three study phases, over 18 months. INTERVENTIONS: Phase I comprised base line data collection; in phase II data were collected after the introduction of the district discharge planning policy and a discharge form (checklist) for all patients; in phase III data were collected after the introduction of the discharge coordinator. MAIN MEASURES: The quality and out come of discharge planning. Readmission rates, duration of stay, appropriateness of days of care, patients' health and satisfaction, problems after discharge, and receipt of services. RESULTS: The discharge coordinator resulted in an improved discharge planning process, and there was a reduction in problems experienced by patients after discharge, and in perceived need for medical and healthcare services. There was no evidence that the discharge coordinator resulted in a more timely or effective provision of community services after discharge, or that the appropriateness or efficiency of bed use was improved. CONCLUSIONS: The introduction of a discharge coordinator improved the quality of discharge planning, but at additional cost. PMID- 10158598 TI - Clinical audit and the purchaser-provider interaction: different attitudes and expectations in the United Kingdom. AB - OBJECTIVES: To explore and describe the views on clinical audit of healthcare purchasers and providers, and in particular the interaction between them, and hence to help the future development of an appropriate interaction between purchasers and providers. DESIGN: Semistructured interviews. SETTING: Four purchaser and provider pairings in the former Northern Region of the National Health Service (NHS) in England. SUBJECTS: Chief executives, contracts managers, quality and audit leaders, directors of public health, consultants, general practitioners, audit support staff, and practice managers (total 42). MAIN MEASURES: Attitudes on the present state and future development of clinical audit. RESULTS: Purchasers and providers shared common views on the purpose of clinical audit, but there were important differences in their views on the level and appropriateness of involvement of health care purchasers, integration with present NHS structures and processes (including contracting and the internal market), priority setting for clinical audit, the effects of clinical audit on service development and purchasing, change in behaviour, and the sharing of information on the outcomes of clinical audit. CONCLUSIONS: There are important differences in attitudes towards, and expectations of, clinical audit between health care purchasers and providers, at least in part due to the limited contact between them on audit to date. The nature of the relation and dialogue between purchasers and providers will be critical in determining whether clinical audit meets the differing aspirations of both groups, while achieving the ultimate goal of improving the quality of patient care. PMID- 10158599 TI - Does your HMO stack up? PMID- 10158600 TI - Retiree health benefits: what the changes may mean for future benefits. PMID- 10158601 TI - Autopsies--VA. Final rule. PMID- 10158602 TI - Medicaid program; limitations on aggregate payments to disproportionate share hospitals: federal fiscal year 1996; correction--HCFA. Correction notice. PMID- 10158603 TI - Publication of OIG Special Fraud Alert: fraud and abuse in the provision of services in nursing facilities--HHS. Notice. PMID- 10158604 TI - Medicare and Medicaid programs; provider appeals: technical amendments--HCFA. Final rule with comment period. PMID- 10158605 TI - Medicare program: changes to the hospital inpatient prospective payment systems and fiscal year 1997 rates; correction--HCFA. Correction notice. PMID- 10158606 TI - Stern measures. AB - Andy Stern, new head of the Service Employees International Union, has set his sights on the nation's health care industry, linking workers' rights with consumer protection. The union's strategy is on display in California, where managed care has made dramatic inroads and financially pinched hospitals are shedding workers. PMID- 10158607 TI - Rise of the medical savings account. PMID- 10158608 TI - Medicare's mixed bag of problems. PMID- 10158609 TI - Reengineering healthcare. AB - In today's rapidly changing healthcare environment, managers have begun efforts to reengineer outdated and inefficient work flow practices--something that other industries have already been doing for years. However, for several key reasons, successful reengineering efforts in healthcare are more difficult than in other industries. Nevertheless, these difficulties can be overcome if the right approach is used. If done correctly, healthcare reengineering can have big payoffs. This article recommends a phased-in approach by reengineering in six steps. PMID- 10158611 TI - A real stinker ... Cooperative Purchasing Program of the Federal Acqusition Streamlining Act (FASA). PMID- 10158610 TI - Materiel management: time for a new beginning. AB - Industry forecasters have predicted that most hospitals will belong to a multi hospital system or an alliance by the end of this decade or they will simply disappear. This will concomitantly expand and contract the role of materiel managers, while creating new challenges for them in free-standing hospitals or in a multi-hospital system environment. What should materiel management's role be in this new arena? What functions or activities should materiel management be responsible for functionally or administratively? How should a hospital or multi hospital system's materiel management department be organized to meet this new challenge? What relationship should evolve between hospital divisions and the system's materiel management department? Who should control the purchasing, inventories, and distribution for hospital divisions? What functions should be centralized and what should be decentralized? The answers to these questions will be discussed in this article. PMID- 10158613 TI - The equipment planning consultant. PMID- 10158612 TI - More on the ethical implications of reengineering. PMID- 10158614 TI - How a reengineering consultant thinks. PMID- 10158615 TI - Cost modeling as a technology assessment tool for radiology department capital equipment acquisitions. AB - Changes reshaping the healthcare delivery system impact capital equipment acquisition decisions within radiology departments. During an era of rapid technological advancement, acquisition decisions often favor new imaging technology with an emphasis on volume and revenue increases. With a slowdown or plateau in new imaging technology and significant changes in the healthcare delivery structure, greater emphasis is now being given to productivity and quality improvement investments. Such investments are aimed at reducing labor and material operating costs through capital investment in electronic alternatives, such as the digital viewing and storage of diagnostic images in lieu of film. This shift in emphasis presents a dilemma for radiology departments because it is often more difficult to show a quality and productivity improvement justification. One approach is to use a formal ?technology assessment? (TA) process wherein a manager considers changes in processes, labor, equipment, space, and consumables, and then assesses that impact on cost, utilization, quality of care, and other factors. A cost model is a useful tool in this process. A review of a number of real world experiences demonstrates the benefits of more timely and informed capital equipment investment decisions. While the direct savings may not entirely offset such investments, TA analysis also evaluates in tangible benefits that may not be quantifiable in economic terms. Both tangible cost savings and intangible benefits need to be weighed against the net investment in a new technology. PMID- 10158616 TI - Conversations with health officers by the editors. PMID- 10158617 TI - Performing public health functions: the perceived contribution of public health and other community agencies. AB - As public health struggles to define its role within health care reform, the need to examine carefully the component organizations providing and/or supporting health care for the public appears critical. This article identifies the nature and extent of involvement by agencies other than the official local public health department in performing public health practices and functions within 63 local public health jurisdictions. Adequacy of overall public health performance is significantly related to the extent of participation of outside agencies. Outside agencies contribute over 26 percent to the total public health performance for the jurisdictions surveyed. Other agencies of government, both at the state and local level, are the predominant outside contributors to public health practice. Private and voluntary agencies are perceived as minor contributors. Little variation exists among communities in which outside agencies tend to perform particular public health activities. Findings suggest that local public health departments can maximize their impact by understanding better the nature of working relationships within multi-institutional arrangements, encouraging greater levels of collaboration and integration and acting as catalysts for increased support of public health activities. PMID- 10158618 TI - Internal stakeholder group participation in hospital strategic decision-making: making structure fit the moment. AB - This study examines the participation of six internal stakeholder groups in hospital strategic decision-making. Results show that internal stakeholder group participation is affected by strategic decision content and by the nature of the hospital's strategy. Results show that the participation of internal stakeholdergroups is associated with lower cost per full-time employee (fte). In particular, when the low participation stakeholder groups do participate, hospitals experience lower cost per fte. PMID- 10158620 TI - Health objectives and health system reform in Iowa: complementary approaches to health planning. AB - Current proposals for health system reform, such as that developed by the Iowa Leadership Consortium on Health care (ILC), call for the creation of agencies responsible for setting rates, monitoring quality and efficiency, and regulating capital investment. These can be described as health planning activities. However, it is planning of a very different nature than that conducted by community groups seeking to achieve the objectives of Healthy People 2000. Yet, despite their apparent differences, modern regulatory planning in the form proposed by the ILC and grass roots planning have at least the following in common: -Both seek to improve the efficiency of the health system in addressing health problems; -Both use population health status data as a basis for planning; -Both derive from a health planning tradition that focuses on restructuring the health care delivery system; -Both assume the legitimacy of the health care reform objectives relating to medical care; -Both may respond to community input regarding the nature of proposed reforms; and -Both may be criticized by radicals for railure to address the root, socioeconomic causes of disease. PMID- 10158619 TI - Health care reform? An American obsession with prescriptive incrementalism. AB - A rounded evaluation of the national health insurance proposals that now seem to be taken seriously by political elites requires conceptual organization. This article adopts a typology that describes each major proposal as a social, mixed or a private insurance scheme depending on the source(s) of funding, method of compensating hospitals and physicians, the unit of payment, and mechanism for financing capital. Not surprisingly, the analysis suggests that the social insurance model, closely resembling the Canadian system, is more likely to control inflation and redress distributional inequities than are other approaches. Why, then, has this approach not been adopted? The answer may be found in the widespread acceptance of disjointed incrementalism as a valid description of the policy process which yields an ideological orientation that can be termed "prescriptive incrementalism." This orientation is closely related to a belief in an "American exceptionalism," a belief that is not warranted by a cross-sectional examination of the political culture infusing issues about the proper role of government in health care financing and delivery. Unfortunately for advocates, the truly exceptional factor restricting the United States' ability to effect national health reform is a quite delberately obstruction oriented political structure. PMID- 10158621 TI - Casting a net. PMID- 10158622 TI - Spin me a web. Interview by Bill Siwicki. PMID- 10158623 TI - Innovators 1996. Leading the way. PMID- 10158624 TI - New generation of lab systems offers more functions, connectivity. PMID- 10158625 TI - Telemedicine. Getting down to business. PMID- 10158626 TI - A look at the integration market. PMID- 10158627 TI - Viatical settlement: a financial option for the terminally ill. PMID- 10158628 TI - Children with special health care needs: clinical pathways. PMID- 10158629 TI - A cross-training model for obstetrics home care. PMID- 10158631 TI - New benchmarking group blazes trails in a unique collaborative effort. PMID- 10158630 TI - Coping with COBRA/EMTALA and MCOs. PMID- 10158632 TI - Improve communication with primary care docs. PMID- 10158633 TI - Auto-authorization can speed up managed care. PMID- 10158634 TI - Atlanta EDs prepare for Summer Olympics. PMID- 10158635 TI - Manage 'frequent fliers' effectively in the ED. PMID- 10158636 TI - Six steps to gain the benefits you want from an information system. PMID- 10158637 TI - HHS asks SNFs to help crack down on Medicare fraud. PMID- 10158638 TI - ProPAC recommends one Medical payment for SNF and hospital care. PMID- 10158639 TI - OSHA aims at nursing facilities; HCFA survey may provide targets. PMID- 10158640 TI - Costing an HMO contract: do you lose $38 or make $55 per day? PMID- 10158641 TI - Strategy session. A subacute summit with industry leaders. PMID- 10158642 TI - Wound care cheapskates. PMID- 10158643 TI - Death of a subacute unit. PMID- 10158644 TI - Subacute success story. RIC (Rehabilitation Institute of Chicago) and West Suburban Hospital Medical Center. PMID- 10158645 TI - How did you prepare your staff for the accreditation survey? PMID- 10158646 TI - Managed care, electronic charting and documentation. PMID- 10158647 TI - The "whats", "hows" and "whys" of diagnostic and treatment centers. PMID- 10158648 TI - Biotechnology inventions in the health care environment: what to patent and how to avoid defeat. PMID- 10158649 TI - Tracing motives for change. PMID- 10158650 TI - A modality on the move. PMID- 10158651 TI - Open magnet technology for MRI. PMID- 10158652 TI - The Tower of Babel syndrome. PMID- 10158653 TI - Clarity in interface relations. PMID- 10158654 TI - What is DICOM (Digital Imaging and Communications in Medicine v3.0) conformance anyway? PMID- 10158655 TI - Phasing concept to reality. PMID- 10158656 TI - Creating multidisciplinary conferences. PMID- 10158657 TI - Technology assessment & policy determination. PMID- 10158658 TI - Surviving under capitation. PMID- 10158659 TI - Capturing lost ancillary medical supply charges. PMID- 10158660 TI - New GOP Medicaid plan gets rough reception. PMID- 10158661 TI - Co-ops and condos tap into pent-up home equity. PMID- 10158662 TI - Inside HCFA. Ever wish someone would survey the surveyors? These people do. PMID- 10158663 TI - Myths about nursing assistants. PMID- 10158664 TI - Get with the (subacute) program. Payors are pushing for proof that subacute programs are the real thing. PMID- 10158665 TI - Partnerships may tame subacute rivalry. PMID- 10158666 TI - Choosing the right type of acquisition deal. PMID- 10158667 TI - Infection control. An idea whose time has come. PMID- 10158669 TI - Developing an infection surveillance system. PMID- 10158668 TI - Designing an infection control to meet JCAHO standards. PMID- 10158670 TI - Building a focused infection control surveillance program. PMID- 10158671 TI - Infection control, HIV, & home care. PMID- 10158672 TI - Home care's role in influenza and pneumonia prevention. PMID- 10158673 TI - Infection control components of a home care employee health program. PMID- 10158674 TI - Financial analysis: two methods of case management delivery. PMID- 10158676 TI - C.E. you: a guide to con-ed credits. PMID- 10158675 TI - Designer con ed. PMID- 10158677 TI - The need to read. Knowledge is power--not to mention financially rewarding. PMID- 10158678 TI - EMS at the Olympics. PMID- 10158679 TI - The Silver Book--a buyer's guide update. PMID- 10158680 TI - The perfect service team combination. PMID- 10158681 TI - Medical waste incineration update. PMID- 10158682 TI - OSHA first aid training regulations. PMID- 10158683 TI - Delivering tender loving care: a way of life. PMID- 10158684 TI - Is America really undertaxed? PMID- 10158685 TI - Asking the right questions key to hiring managed care directors. PMID- 10158686 TI - July 1996--price and cost for screening mammography. PMID- 10158687 TI - Finding opportunities in the chaotic online world. PMID- 10158688 TI - The marketplace helps determine integration opportunities. PMID- 10158689 TI - Information technology needs for integrated delivery systems. AB - Financial managers of integrated delivery systems are becoming increasingly aware of the need to upgrade and improve their information technology strategies. Such improvements include moving toward a core-process focus that will enhance a system's ability to secure covered lives, manage risk and health status, and deliver high-quality care. PMID- 10158690 TI - IRS offers guidance on physician practice valuation. AB - Many healthcare organizations are acquiring physician practices in response to competitive pressures. But little guidance has been available in regard to issues such as private inurement and payment for referral charges. The Internal Revenue Service, however, has recently issued detailed guidance concerning such issues. PMID- 10158691 TI - Managed care strategies for rural providers. AB - The increasing prevalence of managed care outside of urban centers is forcing many healthcare providers in rural areas to carefully evaluate the demand for their services and their ability to exert leverage in pricing services. Rural providers often face different challenges and employ different strategies than their urban counterparts, but quality, cost, and access remain critical components common to both urban and rural providers. PMID- 10158692 TI - Preparing for capitated hospital services. AB - Although HMOs have been reluctant to capitate hospital services, capitated payments allow hospitals greater control over their strategic and economic position. Healthcare financial managers have a role to play in demonstrating to HMOs that capitating hospital services can create a win/win situation. PMID- 10158693 TI - Options for purchasing provider excess insurance. AB - Provider organizations accepting capitated payments often purchase provider excess insurance to protect themselves from catastrophic loss. These organizations have the option of purchasing such insurance coverage from the HMOs with which they contract or from commercial insurance companies. To determine which purchase strategy will be cost-effective, provider organizations must carefully analyze their risk, determine how much coverage they need, and exercise due diligence. PMID- 10158694 TI - Capitating physician group practices. AB - To prepare for capitated payment, physician group practices must gather essential data on service utilization and cost of services, must develop appropriate compensation and incentive plans for physicians, and must analyze and, if necessary, modify their practices's clinical and business operations. Those group practices that take these steps will be positioned to profit from capitated payment. PMID- 10158695 TI - Establishing reserves for capitation contracts. AB - Capitation introduces a number of significant considerations to financial reporting that normally are associated with insurance. These considerations arise for two reasons: (1) because providers receive revenue before services are rendered and (2) because providers assume the risk that the expenses they incur in delivering contracted services may exceed revenue. Both factors should be accounted for on financial statements by creating reserves representing actual and potential liabilities associated with capitation contracts as of the statement date. Continuous review of these reserves is necessary to ensure they remain adequate and are allocated appropriately. PMID- 10158696 TI - The role of data in a changing healthcare industry. Integrated databases will be essential in an increasingly competitive and litigious industry. PMID- 10158697 TI - Cutting healthcare costs through work force reductions. Studies find what works and what doesn't. AB - Restructuring to cut costs often involves work force reductions. Two recent studies of restructuring in healthcare organizations have found that how an organization reduces its work force is just as important as whether it does. Organizations that implemented across-the-board staff cuts achieved limited cost savings. They also experienced decreased clinical quality, reduced patient satisfaction, and increased staff turnover. However, organizations that reduced their work forces only after a thorough assessment of work processes and job roles achieved greater cost savings, improved clinical quality, higher patient satisfaction, and less staff turnover. PMID- 10158698 TI - How PHOs can avoid price-fixing charges. AB - Last fall, the U.S. Department of Justice (DOJ) sent the message to PHOs that when negotiating with third parties, they need to be careful not to break antitrust laws, or they could face heavy monetary damages--or even criminal liability. In settlements with PHOs in Danbury, Connecticut, and St. Joseph, Missouri, the DOJ said that PHOs could not become involved in pricing decisions unless they acted in one of two ways: as a qualified managed care plan in which providers share financial risk or as a messenger between providers and third parties. The two cases show how networks may and may not engage in negotiations with payers. PMID- 10158699 TI - Market changes create need for practice budgets. AB - The increasing prevalence of managed care, capitation, and physician practice acquisition is forcing physician practices to operate in a more businesslike way. As a first step toward more businesslike operations, practices of all sizes should prepare formal annual budgets to help predict and manage revenue and expenses. PMID- 10158700 TI - Integration from the small group practice perspective. AB - For small group practices, ?appropriate integration? is of critical importance because small groups are at high risk of being left behind if they are not well positioned for managed care. Small group practices, however, may find the tasks of evaluating potential partners and getting started on the road to integration rather daunting. Small group practices face unique integration challenges and must plan carefully if they are to integrate effectively. PMID- 10158701 TI - Minimizing physicians' exposure to managed care liabilities. PMID- 10158703 TI - PAYER ID: a new resource for EDI. PMID- 10158702 TI - Medicare outpatient payment reform: where does it stand? PMID- 10158704 TI - Explaining the story behind the headlines. PMID- 10158705 TI - Reviewing pension plan investment programs. PMID- 10158706 TI - Judge dismisses criminal charges for 'too-real' hospital hostage drill. PMID- 10158707 TI - Nursing home security and the hospital security director. PMID- 10158708 TI - Hospital security takes on added responsibility without added manpower. PMID- 10158709 TI - Dogs in hospital security: an underused and unappreciated protection tool? AB - According to a recent survey by IAHSS, only 2% of the hospitals surveyed listed dogs among the security tools that they employ. Yet, according to hospital security directors who use canines, they can be valuable additions to a security force and accomplish certain tasks better than human officers. In this report, we'll describe the experiences of two midwest hospitals that have used dogs in security for extended periods--one for 10 years, the other for five. PMID- 10158710 TI - Roll: survival strategies for security directors faced with downsizing. PMID- 10158711 TI - The "make vs. buy" decision. PMID- 10158712 TI - Simplifying your menu reduces costs. PMID- 10158713 TI - Words of wisdom from a home health care nurse. PMID- 10158714 TI - JCAHO requires nutrition screening within 24 hours. PMID- 10158715 TI - Take your patient surveys to a higher level of accuracy. Avoid the pitfalls of too much and inappropriate data. PMID- 10158716 TI - Making clinical decisions on facts, not 'feelings.' Meeting criteria easier with computerized records. PMID- 10158717 TI - Clinical paths: no smoking gun for malpractice cases. Help clinicians get over path anxiety. PMID- 10158718 TI - Business reengineering, information technology, and the healthcare connection. PMID- 10158719 TI - Redefining the healthcare paradigm. A proposal for successful provider integration. PMID- 10158720 TI - Problem solving in health services organizations. AB - Health services organization managers at all levels are constantly confronted with problems. Conditions encountered that initiate the need for problem solving are opportunity, threat, crisis, deviation, and improvement. A general problem solving model presenting an orderly process by which managers can approach this important task is described. An example of the model applied to the current strategic climate is presented. PMID- 10158721 TI - Hardiness, job stress, and health in nurses. PMID- 10158722 TI - Luck of the Draw. Skills testing for nursing retention. PMID- 10158723 TI - Patients' assessment of medical care quality. PMID- 10158724 TI - Ethics, resource allocation, and managerial decision making. PMID- 10158725 TI - The proletarianization of Dr. Gaylis. The changing shape of medical practice. PMID- 10158726 TI - Modified capitation and treatment incentives for end stage renal disease. AB - This study developed a modified capitation payment method for the Medicare end stage renal disease (ESRD) program designed to support appropriate treatment choices and protect health plans from undue financial risk. The payment method consists of risk-adjusted monthly capitated payments for individuals on dialysis or with functioning kidney grafts, lump sum event payments for expected incremental costs of kidney transplantations or graft failures, and outlier payments for expensive patients. The methodology explained 25 percent of variation in annual payments per patient. Risk adjustment captured substantial variations across patient groups. Outlier payments reduced health plan risk by up to 15 percent. PMID- 10158727 TI - U.S. Healthcare's quality-based compensation model. AB - U.S. Healthcare has developed a quality-based compensation model through which its primary care physicians, hospitals, and specialists can earn additional compensation based on the quality and cost-effectiveness of the care they provide to their patients. The model clearly delineates the expectations of U.S. Healthcare, and in contrast with traditional payment models, encourages improvement in performance. In addition, the model aligns the incentives of U.S. Healthcare purchasers, participating providers, and members in order to provide high-quality, cost-effective care that maximizes patient outcomes. PMID- 10158728 TI - Preferred provider organizations and physician fees. AB - Preferred provider organizations (PPOs) represent a form of managed care in which providers agree to accept discounted fees in exchange for the expectation that their patient volume will increase or at least be maintained. Managed care plans that rely on discounted fee-for-service (FFS) payments have increased from about 10 plans in 1981 to over 700 plans in 1994. In this study, we document levels of discounts achieved by two large national insurers and discuss how the size of the discount varies by type of service and how the discounted rates relate to Medicare fees. Our results show that, despite achieving large discounts (approximately 10 20 percent) relative to their indemnity plans, the two nationwide PPOs studied here pay at rates substantially above Medicare levels. PMID- 10158729 TI - Effect of mergers on health maintenance organization premiums. AB - This study estimated the effect of mergers on health maintenance organization (HMO) premiums, using data on all operational non-Medicaid HMOs in the United States from 1985 to 1993. Two critical issues were examined: whether HMO mergers increase or decrease premiums; and whether the effects of mergers differ according to the degree of competition among HMOs in local markets. The only significant merger effect was found in the most competitive markets, where premiums increased, but only for 1 year after the merger. Our research does not support the argument that consolidation of HMOs in local markets will benefit consumers through lower premiums. PMID- 10158730 TI - Changing prescription drug sector: new expenditure methodologies. AB - Estimating spending for prescription drugs has become increasingly difficult over the past 15 years as extensive changes have taken place within the retail prescription drug industry. Expenditures for prescription drugs in retail outlets grew rapidly during the 1980s and early 1990s. New retail outlets emerged and existing sites lost market share. New mechanisms for reimbursing drug purchases led to the flow of rebates between manufacturers and insurers, bypassing retailers. These and other major industry changes required the development of new estimating methodologies for tracking prescription drug expenditures within the National Health Accounts (NHA). PMID- 10158731 TI - National health expenditures, 1994. AB - This article presents data on health care spending for the United States, covering expenditures for various types of medical services and products and their sources of funding from 1960 to 1994. Although these statistics for 1994 show the slowest growth in more than three decades, health spending continued to grow faster than the overall economy. The Federal Government continued to fund an increasing share of health care expenditures in 1994, offset by a falling share from out-of-pocket sources. Shares paid by State and local governments and by other private payers including private health insurance remained unchanged from 1993. PMID- 10158732 TI - Medicare managed care: numbers and trends. AB - This article captures some key trends in Medicare managed care. The figures which accompany this article explore, among other issues: enrollment; numbers of participating plans; demographic characteristics such as geographic location, age, and income; and premium and benefit comparisons. PMID- 10158733 TI - Medicare FFS populations versus HMO populations: 1993. PMID- 10158734 TI - Health care indicators. Hospital, employment, and price indicators for the health care industry--third quarter 1995. PMID- 10158735 TI - An analysis of selectivity bias in the Medicare AAPCC (adjusted average per capita cost). AB - Using econometric models of endogenous sample selection, we examine possible payment bias to Medicare Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) risk health maintenance organizations (HMOs) in the Twin Cities in 1988. We do not find statistically significant evidence of favorable HMO selection. In fact, the sign of the selection term indicates adverse selection into HMOs. This finding is interesting, in view of the fact that three of the five risk HMOs in the study have since converted to non-risk contracts. PMID- 10158736 TI - Improving the AAPCC (adjusted average per capita cost) with health-status measures from the MCBS (Medicare Current Beneficiary Survey). AB - Using data from the 1991 Medicare Current Beneficiary Survey (MCBS), multiple regression-based models predicting 1992 Medicare costs are developed and compared. A comprehensive model incorporating demographic, diagnostic, perceived health, and disability variables is shown to be stable and to fit the data well over the full range of Medicare-covered annual per capita expenses and for a variety of beneficiary subgroups defined by their health and functional status. This model produces stable unbiased estimates of expenditures on validation samples. A variant of this model is being considered for use in setting Medicare capitation payments for the second phase of the social/health maintenance organization (S/HMO) demonstration. PMID- 10158738 TI - Health Center. Samaritan North Health Center, Englewood, Ohio. PMID- 10158739 TI - What are you worth? PMID- 10158737 TI - Risk-adjusted Medicare capitation rates using ambulatory and inpatient diagnoses. AB - Researchers at The Johns Hopkins University (JHU) developed two new diagnosis oriented methodologies for setting risk adjusted capitation rates for managed care plans contracting with Medicare. These adjusters predict the future medical expenditures of aged Medicare enrollees based on demographic factors and diagnostic information. The models use the Ambulatory Care Group (ACG) algorithm to categorize ambulatory diagnoses. Two alternative approaches for categorizing inpatient diagnoses were used. Lewin-VHI, Inc. evaluated the models using data from 624,000 randomly selected aged Medicare beneficiaries. The models predict expenditures far better than the Adjusted Average per Capita Cost (AAPCC) payment method. It is possible that risk adjusted capitation payments could encourage health plans to compete on the basis of efficiency and quality and not risk selection. PMID- 10158740 TI - Workforce planning. Keeping the baby boomers on board. PMID- 10158741 TI - Cancer care. Fighting the yawn factor. PMID- 10158742 TI - Pathology services. Path perfect. PMID- 10158743 TI - Careers profile. General managers--down, but not out. PMID- 10158744 TI - Management development. The feedback revolution. PMID- 10158745 TI - Management development. Wheels within wheels. PMID- 10158746 TI - How the other half loathes. PMID- 10158747 TI - Primary care premises. Owners and occupiers. PMID- 10158748 TI - Data briefing. The reforms. PMID- 10158749 TI - Older people. Is living longer cause for celebration? PMID- 10158750 TI - Older people. Prime and prejudice. PMID- 10158751 TI - Patient feedback. Supporting programme. PMID- 10158752 TI - Careers profile. Primary care managers. Different but equal. PMID- 10158753 TI - Your own kind. PMID- 10158754 TI - The perilous pathway from laboratory to patient. PMID- 10158755 TI - How we learn. Communities of practice. The social fabric of a learning organization. PMID- 10158756 TI - How we learn. Driving out fear. One CEO's personal journey. PMID- 10158757 TI - Case rounds: bridging the "disconnect" between values and practices. PMID- 10158758 TI - A conversation on learning organizations with Daniel Kim. We are what we can learn. Interview by Joe Flower. PMID- 10158759 TI - The process of learning--a resource guide. PMID- 10158760 TI - Log on. A guide to the online world for healthcare executives, managers, clinicians & patients. PMID- 10158761 TI - 1996 International Emerging Leaders. Smart, compassionate, committed. A quartet of young leaders honored by The Healthcare Forum and Korn/Ferry International. PMID- 10158762 TI - The engine of choice. PMID- 10158763 TI - Metaphorically speaking, Part 2. Humanizing the face of healthcare. PMID- 10158764 TI - Evaluating the benefits of antenatal screening: an alternative approach. AB - This paper presents an alternative method of valuing the benefits of antenatal screening programmes based on individual preferences. The methods of benefit measurement used to date, namely averted costs, QALYs, and willingness to pay, are critically reviewed. The alternative method assumes that screening can be regarded as an investment in improved information, and that the benefits of screening can be measured by the value placed upon this information. The information is valued by presenting individuals with standard gamble questions framed in terms of a prenatal diagnostic choice. The approach is developed in the context of antenatal screening for Down's syndrome and for cystic fibrosis carrier status. Some empirical testing of the approach is reported for the latter. PMID- 10158765 TI - Informed consent in clinical trials. AB - A review is provided in this paper on the empirical literature on informed consent from 1979 to 1995 referring to information disclosure and trial participation in clinical trials. Articles being reviewed focus upon information disclosure, reactions to disclosure and recall, features of consent and perceptions of informed consent, both in hypothetical and in real life situations. It is concluded that further research is needed to study the process of informed consent in clinical trials, to obtain a better insight into the myth and reality of informed consent in daily practice. Future studies should come forward on the limitations of previous empirical research on informed consent. Additional research should focus on the perspectives of patients who accept or decline trial participation. PMID- 10158766 TI - Incorporating quality of life changes into economic evaluations of health care: an overview. AB - The demand for economic evaluations of health care programs, especially pharmaceuticals, is steadily increasing. One of the most important issues in this field is how to measure, value and incorporate changes in quality of life into the economic evaluation. We provide an overview of the different approaches to measure changes in quality of life: quality of life instruments, the quality adjusted life-year (QALY) approach and the willingness to pay approach. Quality of life instruments have major practical advantages since they are easy to administer. The results of these instruments cannot, however, be used in economic evaluations. In economic evaluations, the quality of life has to be measured on the 0 (death) to 1 (full health) scale necessary to construct QALYs, or the willingness to pay for the changes in quality of life has to be measured. Such measurements are, however, much less straightforward to carry out. It would therefore be a major advance if it would be possible to directly translate the quality of life score into a QALY weight or the willingness to pay. It is recommended that more systematic research should be carried out on the relationship between quality of life, QALY weights, and willingness to pay. PMID- 10158767 TI - Community health promotion: concepts and lessons from contemporary sociology. AB - The idealism on behalf of community interventions from The First International Conference on Health Promotion in 1986 today seems to be reduced. This article argues that there has been too little concern with what kind of social and spatial reality the community actually is among health promotion initiators and researchers. Contemporary sociological approaches to the community, emphasizing how collective and personal identities are developed in a situation with massive external and global influences, are introduced. The article advocates a stronger concern with particular local contexts and the inhabitants' self-interpretations, to learn more about whether and how local identities and cultures can be mobilized in health promotion initiatives. This focus contrasts that on education guiding most community health promotion projects. Inspired by contemporary methodological discussions centering around the concept of mechanism and contextual analysis in community studies, the article also criticizes the quasi experimental research designs involved in many community health promotion projects. PMID- 10158768 TI - The assessment of diagnostic imaging technologies: a policy perspective. AB - Diagnostic imaging technologies are essential in health care but have high costs and poorly defined benefits. Formulation and implementation of policy on their procurement and use is made difficult by the complexity of the diagnostic process, and the limitations of available data and assessment methodology. Informed policy decisions will need to be based on a synthesis of imperfect data from a variety of perspectives, and supplemented by effective dissemination and feedback of information. A list of attributes for consideration in the policy formulation process is presented. PMID- 10158769 TI - Hospital closure: Phoenix, Hydra or Titanic? AB - Very little has been published about the effects of hospital closure in terms of the service, financial or management issues of the process. Attempts through a case-study format to redress the balance and as such represents the reflections of practitioners who have recently undergone the experience of hospital closure and the often neglected issues arising both during and after the process. PMID- 10158770 TI - What factors influence staff training in residential and nursing homes? AB - Reports on research conducted in eight residential and/or nursing homes belonging to six different charity organizations. The organizations ranged in size from local bodies dealing exclusively with care homes to large nationals involved in various other activities. However, staff training is a core issue to all of them, and activity directed towards it has met with varying degrees of success. Aims to highlight those indicators which will minimize failure of the training schedule and to make homes aware of the wider issues which affect training schemes. PMID- 10158771 TI - The importance of workforce planning in the NHS in the 1990s. AB - Considers a variety of pressures, both internal and external to the National Health Service, which in recent years have ostensibly increased the importance of sound workforce planning initiatives. These include, among others: skill shortage; the drive towards cost-efficiency and effectiveness; an altered philosophy of care through technology; the develop of competence-based training initiatives; nationwide demographic changes; and the need to develop identifiable skill shortages. Presents reprofiling (skills alignment with organizational needs) and skill mix and distribution as useful approaches to workforce planning and concludes with a brief consideration of implications for planners of professional boundaries and changed educational priorities for health service personnel. PMID- 10158772 TI - Discrimination matters. AB - Outlines the changes in legal restrictions on the eligibility of dismissed employees to pursue unfair dismissal claims. Includes a discussion of recent decisions in this area including the July 1995 decision in the case of R. v. Secretary of State for Employment ex parte Nicole Seymour-Smith and Laura Perez and Employment Protection (Part-time Employees) Regulations 1995 and assesses the impact of these decisions on personnel practice and disciplinary procedures. PMID- 10158774 TI - What is a human resources strategy? AB - Attempts to provide a practical framework in which practitioners may develop human resources (HR) strategies in line with their organizations' corporate planning processes. Proposes a four-step approach involving: development of a strategic framework; generating of HR mission statement; application of analysis; and making strategic planning decision between HR options. Outlines a four dimensional structural focus comprising culture, organization, people and systems. Concludes with a discussion of characteristic of ?good? strategic objectives. PMID- 10158773 TI - The practical use of vision in small teams. AB - Sets out to demonstrate the usefulness of vision statements to self-directed work teams, taking ideas from the development of vision within teams in an organization of around 1,000 employees. Considers barriers to the creation of a shared vision in which employees have a stake, putting forward the concept of ?team-sized vision? as a means of coping with the identified problems of ?size? and ?ownership? with regard to organization-sized vision. Outlines various advantages of team-sized vision, e.g. enabling positive discussion of change and acting as a strong motivator. Sets out a process for the generation of team-sized vision, broken down into four main steps. Concludes that the process can be undertaken with relative ease and that vision is for all levels of the organization--not just top management. PMID- 10158775 TI - EMS education. Making the grade? PMID- 10158776 TI - Can empathy and compassion be taught? PMID- 10158777 TI - Organ procurement. A new career path for paramedics. PMID- 10158778 TI - Joint Commission on Accreditation of Healthcare Organizations. Appendix B. Additional applicable standards for hospice. 1995 Accreditation Manual for Home Care, Volume 1. PMID- 10158779 TI - Sample of a 1996 hospital performance report. Joint Commission on Accreditation of Healthcare Organizations. PMID- 10158780 TI - Joint Commission to create National Library of Healthcare Indicators. PMID- 10158781 TI - Joint Commission Board approves 1996 action plan. PMID- 10158782 TI - Revision calls for using diagnostic databases to improve performance. PMID- 10158783 TI - Principles provide guidance for evaluating credentials services. PMID- 10158784 TI - Joint Commission and ASHE reach consensus on environment of care issues. PMID- 10158786 TI - Quality drivers for the milennium--II. PMID- 10158785 TI - Connecticut hospital forms accreditation compliance teams. PMID- 10158787 TI - New early survey policy option available. PMID- 10158788 TI - Joint Commission to review three CIGNA health plans. PMID- 10158789 TI - Utilization of information sources by the elderly: an empirical investigation. AB - The behavioral patterns of the elderly population as they relate to the process of obtaining information on services such as health care are not currently well understood. The research reported in this paper examines information usage behavior of the elderly based on a survey consisting of 1060 personal interviews. An examination is made of the sources of information for health care services utilized by the elderly based on demographics and behavioral dimensions. PMID- 10158790 TI - The status of marketing in the health care industry: perspectives of marketing practitioners. AB - To assess the scope and status of the marketing function in the health care industry, a mail survey of marketing professionals in health care organizations in the Greater Baltimore region was undertaken. Questions were designed to identify important responsibilities, required skills, evaluation factors, and major problems in the practice of health care marketing. Analytic ability was the skill identified as being most necessary to perform their job while quality of service was factor most used to evaluate their performance. Planning, service and the development of products/services were indicated as being their most important responsibility. Inadequate budget and top management's lack of knowledge of marketing were cited as the most important hindrances to effectiveness in marketing jobs. Failure of marketing in the health care industry appears to be internal to the organizations themselves, that is, in terms of how it is interpreted and applied in practice. Solutions require greater understanding of and commitment to the varied roles of marketing professionals. PMID- 10158791 TI - Community health status and service needs assessment: an analytic tool in a changing health care delivery system. PMID- 10158792 TI - Marketing nutrition services for the elderly. AB - The Older Americans Act of 1965 was implemented to provide assistance in the development of new or improved programs to help older persons through grants for the States. Community planning, and services for training, were established within the Department of Health, Education, and Welfare under an agency designated as the Administration on Aging (Older Americans Act of 1965, p. 1). There has been an evolution of Community Nutrition services for the elderly. The original purpose was the establishment of community based congregate dining sites where seniors would come together for food and fellowship. The homebound seniors were recognized and home-delivered meal service was developed. This home delivered meal service has steadily increased as the participant population has changed with less family support and is becoming older and frailer while congregate participation has decreased. The challenge to marketers is to continue to bring together the need for nutritional assistance in the elderly population and nutritional programs to satisfy that need. The authors have conducted a nutrition service program study that can benefit the industry that serves this segment of the population. This study observes trends and behaviors and can assist the development of new products and services for the aging. PMID- 10158793 TI - A new way of thinking: how managed care networks will affect physician and hospital marketing efforts. AB - The formation of integrated delivery networks will cause physicians and hospitals to rethink their marketing strategies. As providers align themselves into networks in conjunction with managed care plans, new approaches to marketing will be employed. PMID- 10158794 TI - Minding morale of institutional markets. AB - The definition of the term SOCIAL LIFE FEELING is offered to denote or connote a sentiment about the social world or an affect-state that comes from socializing in that world. A review of the literature in SOCIOLOGY indicates that there is an abundance of predilection among sociologists in measuring and assessing How People Feel About Society and Their Place in Society. The selection of TWELVE SOCIAL LIFE FEELING SCALES developed by Karl F. Schuessler is based on their established reliability, their ease of use, and their embodiment in covering concepts pertaining to both a person's outlook on society (cynical, pessimistic, fatalistic) and his or her frame of mind in society (demoralized, estranged, alienated). The present report is based on SLFS11 or FEELINGS OF DEMORALIZATION in Urban and Rural settings. This scale gives the subjects an opportunity to express whether they are marking time, finding it difficult to be optimistic, surmising the world as too complicated, viewing their physical condition to be good, or taking pleasure in their achievements, and so and so forth. A random sample of 398 students drawn from an urban and a rural campus was personally administered a questionnaire included in Appendix A. The data so obtained were subjected to statistical analyses through MINITAB software. High scores present a view of self as useless, helpless, aimless; low scores on the other hand, rules out such an admission of self as useless. It appears that this scale comes closest to approximating the concept of morale and its denotation of demoralization and despair. Persons of high morale have high hopes and great expectations and intend to persevere. Persons of low morale have little hope in their efforts being counted and would presumably stop trying. It is important to note that the items in this scale have principally determined the morale of older people. In this study we have attempted to find its utility in investigating undergraduate students representing the backbone of the American Society. From an empiricist's perspective, the MEAN scores for intergroup comparisons ANALYSIS OF VARIANCE for intragroup comparisons have been provided. Marketing implications of and the strategy development for the findings have been advanced. PMID- 10158795 TI - Elderly health care needs assessment: an application of marketing orientation to the nonprofit sector. PMID- 10158796 TI - A study of physician reactions to the Medicare cost containment pilot program in the State of Georgia. AB - Having reduced the unit cost of physician fees during the 1980s, the federal government set up a Medicare pilot study in the state of Georgia in 1989 to test the impact of its cost containment strategies aimed at reducing volume of services. This research has attempted not only to clarify the nature of physician reaction to the Medicare pilot study and to quantify the level of the dissatisfaction, but also to provide a richer understanding of the dynamic meaning of the dissatisfaction that Georgia physicians feel. PMID- 10158797 TI - An optimization approach to production and workforce planning at health care equipment manufacturing facilities: a marketing/production interface. PMID- 10158798 TI - The health care learning organization. AB - To many health care executives, emphasis on marketing strategy has become a means of survival in the threatening new environment of cost attainment, intense competition, and prospective payment. This paper develops a positive model of the health care organization based on organizational learning theory and the concept of the health care offering. It is proposed that the typical health care organization represents the prototype of the learning organization. Thus, commitment to a shared vision is proposed to be an integral part of the health care organization and its diagnosis, treatment, and delivery of the health care offering, which is based on the exchange relationship, including its communicative environment. Based on the model, strategic marketing implications are discussed. PMID- 10158799 TI - How to get the best reading of patient satisfaction. PMID- 10158800 TI - Will health plans make you play psychiatrist? PMID- 10158801 TI - Can you afford not to travel the Internet? PMID- 10158802 TI - Here comes more competition. Not-so-busy specialists are becoming generalists, too. PMID- 10158803 TI - Where's gatekeeping taking us? Look at Britain. PMID- 10158804 TI - How well do HMOs rein in health-care costs? PMID- 10158805 TI - Will your life become an open book? PMID- 10158806 TI - What you should know before you merge. PMID- 10158807 TI - May you never be put in this position. PMID- 10158808 TI - Getting doctors to share what they've learned. PMID- 10158809 TI - Malpractice: the good news ... and the bad. PMID- 10158810 TI - Quality of care. Costs are still uppermost in employers' minds. PMID- 10158811 TI - Every practice needs these two policy manuals. PMID- 10158812 TI - Why primary care is drawing more top graduates. PMID- 10158813 TI - Where doctors judge health plans. PMID- 10158814 TI - Will low tide for Coastal leave doctors beached? PMID- 10158815 TI - Do Americans hate capitation? Oregon will be a test. PMID- 10158816 TI - Keeping outpatients from becoming inpatients. PMID- 10158817 TI - 3 Oregon medical groups to merge into management firm. PMID- 10158818 TI - S.C. county OKs deal--with changes. PMID- 10158819 TI - Award of fifth Tricare contract to have vast impact in 16 states. PMID- 10158820 TI - Dems show few signs they learned their lesson. PMID- 10158821 TI - IRS mulls rules to open boards to more docs. PMID- 10158823 TI - Microwaves cooking up many new treatments. PMID- 10158822 TI - Group aims to raise comparison standards. PMID- 10158824 TI - Catholic providers seek recapitalization strategies. PMID- 10158825 TI - IntegraMed acquires four women's health firms in Fla. PMID- 10158826 TI - S.C. hospitals offer price freeze. PMID- 10158827 TI - Healthcare stocks still strong but no match for 1995. PMID- 10158828 TI - State MSA laws may be prod for federal legislative action. PMID- 10158829 TI - Groups decry delay of incentive regulations. PMID- 10158830 TI - Modern Healthcare's 1996 physician compensation report. AB - In response to the confusing wave of physician compensation data released by trade groups, consulting companies and physician search firms, Modern Healthcare, for the third straight year, has combined reports from 10 organizations into an easy-to-read physician compensation compendium. PMID- 10158831 TI - Report details 1995's merger mania. PMID- 10158832 TI - Premier adds APACHE to info tools. PMID- 10158834 TI - Health measures move to next level. PMID- 10158833 TI - Brisk pace continues for new bond issues. PMID- 10158835 TI - Univ. of Minn. set to vote on hospital sale. PMID- 10158836 TI - HEDIS to expand performance guidelines. PMID- 10158837 TI - AHA sets lofty goals in strategic plan. PMID- 10158838 TI - Ill. hospitals wary of managed-care move. PMID- 10158839 TI - Healthcare is a business, even for not-for-profits. PMID- 10158840 TI - Changing tunes. No more 'whining for dollars' by healthcare lobbyists in Washington. AB - Hospital margins are robust, the Medicare trust fund has made the evening news, and the competition between special-interest groups has grown intense. Such pressures have caused a revolution in the way hospital groups lobby Congress. PMID- 10158841 TI - Hospitals find hidden profits in receivables. PMID- 10158842 TI - Columbia launches service center ... and funds outcomes study institute. PMID- 10158843 TI - For-sale sign goes up at Texas public hospital. PMID- 10158844 TI - Merger pace slows slightly in 2nd quarter. PMID- 10158845 TI - Feds launch probe of proposed S.C. partnership. PMID- 10158846 TI - Congress declines action on hospital outpatient PPS. PMID- 10158847 TI - Samaritan's revolution. New pay model aims to overhaul how workers think. AB - Samaritan Health System, Phoenix, over the past five years has rolled out a completely renovated human resources model. The challenge was to change not only how employees like Terri Kubicek do their work, but how they relate to each other and to customers. PMID- 10158848 TI - Hospitals have begun cleaning up their act on mercury pollution. PMID- 10158849 TI - Wall Street's ills infect healthcare IPOs. PMID- 10158850 TI - MSA deal may clear way for reform bill. PMID- 10158851 TI - Two more N.Y. academic centers unite. PMID- 10158852 TI - Doc unrest a factor in breakup of Ky. network. PMID- 10158853 TI - Organizational skills ranked high by CFOs. PMID- 10158854 TI - After a rude awakening, a Wisconsin system jumps into the market. PMID- 10158855 TI - If at first you don't succeed ... Community Demand Management Initiative. PMID- 10158856 TI - The mother of all wellness programs? General Motors Healthcare Initiative and the United Auto Workers. PMID- 10158857 TI - Measure X-cruciating. Ventura County Medical Center and Community Memorial Hospital of San Buenaventura. PMID- 10158858 TI - Avoiding skepticism at St. Joseph's. St. Joseph's Hospital, Parkersburg, WV. PMID- 10158859 TI - When consumers fear heroes. Loma Linda University Health System. PMID- 10158860 TI - Learning from McDonald's. Making healthcare into a franchise. PMID- 10158861 TI - What's in a name brand? Performance Health Network, Cherry Hills, NJ. PMID- 10158862 TI - Trustee workbook 3. Information and the effective board. PMID- 10158863 TI - Do-it-yourself managed care. Sure, it sounds good ... but will it fly? PMID- 10158864 TI - The future is not what it used to be. A board-level approach to long-range planning pays off. PMID- 10158865 TI - Trustee compensation redux--fax poll results. PMID- 10158866 TI - Teach your children wellness. PMID- 10158867 TI - Doctors reach out. PMID- 10158868 TI - What a difference a Dad makes. PMID- 10158869 TI - Guns, money & medicine. PMID- 10158870 TI - Understanding socially inhibited behaviors in managers. AB - The authors' purpose in this study is to define and highlight socially inhibited behaviors among managers, explore the implications of these behaviors for the workplace, identify ways to assist inordinately shy managers, and help staff to understand and relate more effectively when subjected to an inhibited manager. The authors search for the origins of shyness, surveying the various perspectives in personality theory and within the concept of situational causality. PMID- 10158871 TI - Outcome evaluation in host organizations: a research agenda. AB - The organizational context in which social work is practiced is viewed as an important factor in evaluating the outcomes of social work interventions. In host organizations, the context includes forces outside the department. The author offers a framework for developing a research agenda aimed at assessing the effectiveness of social work interventions in those organizations. The author demonstrates such an agenda with reference to hospital social work. Different types of outcomes and the relationships between them are considered at both the correlational and causal levels of knowledge. Examples of research assessing these outcomes are presented, and the implications of various types of findings are considered. PMID- 10158872 TI - Theory and method: a social work approach to unmet needs. AB - Social workers who plan or administer programs are fundamentally concerned with meeting the needs of the clients served. The social work profession, while proficient at needs assessments, has paid insufficient attention to research into social bases of unmet service needs. This study is an examination of unmet needs of persons with HIV diagnosis. It utilizes the Health Behavior Model, within the framework of the ecological perspective. The study is presented as a case example to illustrate the value of this research methodology for administration, programming, and policy in the human services. PMID- 10158873 TI - Implementing child mistreatment risk assessment systems: lessons from theory. AB - Over the past ten years, public child protective services (CPS) agencies have adopted risk assessment systems in an effort to improve the quality of service delivery to children and their families. Various reviews of the impact of these models suggest that they have not lived up to their expectations and have had little or no impact on broad system indicators of service delivery. Foremost among the findings of existing studies is that these models have not been implemented and used as intended. The risk assessment field has not taken advantage of theoretical principles suggested by the organizational change literature. The researcher applies Lewin's Force Field Analysis to identify the forces for and against effective implementation of risk assessment systems in public agencies. The author suggests that lessons from theory could improve the effectiveness of the implementation of change in CPS agencies. PMID- 10158874 TI - Allocating resources for child welfare services: the effect of a caseload-driven approach. AB - The authors examine the unintended effects of a funding mechanism based on historical caseload statistics on the number of recorded investigated child abuse and neglect reports in seven California counties from January 1985 to December 1992. Forecasting results show that in five out of the seven counties, in the presence of an allocation methodology based solely on caseload statistics, the number of recorded investigated reports was approximately three to thirty-five percent higher than it would have been had only population measures been used. The findings suggest that a funding mechanism based solely on population measures may eliminate the unintended effects of increasing child welfare caseloads. PMID- 10158876 TI - Why can't we talk? PMID- 10158875 TI - Authority, control and professionalism in the post-industrial age. PMID- 10158877 TI - Taking advantage of in-house experts. PMID- 10158878 TI - The great "performance review" controversy. PMID- 10158879 TI - Office screening for hearing loss. PMID- 10158880 TI - Evaluation of a bioethics committee intervention: a limitation of medical treatment form. PMID- 10158881 TI - How HECs can better relate to physicians. PMID- 10158882 TI - Non-heart-beating organ donation: a two-edged sword. PMID- 10158883 TI - Perspectives. Renegotiating the social contract in public health. PMID- 10158885 TI - New build combined with refurbishment. PMID- 10158884 TI - The nerve centre of hospital controls. PMID- 10158886 TI - Broadmoor Special Hospital: building a community. PMID- 10158887 TI - Authorised persons (sterilizers). PMID- 10158888 TI - The 1994 CIBSE Interior Lighting Code. PMID- 10158889 TI - Architects firm boosts epilepsy research. PMID- 10158890 TI - Successful hospital floors. PMID- 10158891 TI - Security lighting. PMID- 10158892 TI - Building information systems to manage care and improve clinical quality. PMID- 10158893 TI - Reporting on customer satisfaction to senior managers and the board. PMID- 10158894 TI - Health systems go beyond satisfaction to win customer loyalty. PMID- 10158895 TI - Patient satisfaction surveys: which tool is right for you?. Interview by Elaine Zablocki. PMID- 10158896 TI - Durable power of attorney: financial planning tool or license to steal? PMID- 10158897 TI - Managed care for real people: consequences of political and financial government decisions. PMID- 10158898 TI - There is just no place like home. PMID- 10158899 TI - The social health maintenance organization. PMID- 10158900 TI - A community-based alternative: the comprehensive community health models initiative. AB - Health care is undergoing a quiet revolution in communities across America as purchasers, providers and consumers explore new options for controlling health care costs, expanding access and improving health status. A major Michigan effort in this regard is the Comprehensive Community Health Models (CCHMs) Initiative funded by the W.K. Kellogg Foundation. PMID- 10158901 TI - Reaching into the community. Winners of the 1996 MHA Patric E. Ludwig Community Service Award. AB - Webster's definitions of community and service form an accurate picture of what MHA seeks to reward with the 1996 MHA Patric E. Ludwig Community Service Award- members who have collaboratively worked with individuals and organizations in their communities to benefit the health and well-being of citizens. The nominees were judged on criteria that focused on true collaboration, leadership efforts, impact on community health status and innovative delivery methods. The winners were chosen from 24 deserving nominations. These four outstanding programs effectively demonstrate the spirit of community service in health care--providers working in concert with local organizations to improve the community's health status. All of the winning programs focused on healthier babies and school-aged youth. Congratulations to the winning programs. They are tangible proof of the important role MHA members play in their communities. PMID- 10158902 TI - Performance appraisal errors: reading the warning signs. PMID- 10158903 TI - Mid-life is upon us. Preventive care for the baby boomer. PMID- 10158904 TI - New trends, new partners. PMID- 10158905 TI - Prevent and empower. AB - In an effort to short health care from ?diagnose and treat? to ?prevent and empower,? Henry Ford Health System (HFHS) launched the Center for Health Promotion and Disease Prevention, directed by Ronald M. Davis, MD, former chief medical officer of the Michigan Department of Public Health and former director of the Office on Smoking and Health at the US Centers for Disease Control and Prevention. He also headed up three Surgeon General's reports on smoking, including the 1988 report linking smoking to nicotine dependence. PMID- 10158906 TI - The key is teamwork. AB - What does it take to be listed among the nation's top 100 hospitals? According to administrators at three Michigan facilities included in the 1995 list--Blodgett Memorial Medical Center, Grand Rapids; Butterworth Hospital, Grand Rapids; and W.A. Foote Memorial Hospital, Inc., Jackson--the key is teamwork. PMID- 10158907 TI - The future is now. Traditional health care evolves into preventive medicine. PMID- 10158908 TI - Chaos. The emerging order in health care. PMID- 10158909 TI - Balancing a teeter-totter. Leveling business strategies and educational objectives. PMID- 10158910 TI - The hope of comfort. PMID- 10158911 TI - The world at your fingertips. PMID- 10158912 TI - Public health revives. AB - Public health is the use of epidemiologic, scientific and behavioral knowledge to protect the health and well-being of the population by preventing disease and disability. The separation of medicine from public health has caused us to continuously overlook the triumphs of public health programs that have significantly improved the health of our communities. PMID- 10158913 TI - Disposal alternatives emerge. The future of medical waste disposal. PMID- 10158914 TI - A midwestern perspective: the development of community care networks. AB - One of the most significant public misconceptions today is that we have a health care system in the United States. For those of us in the industry, we know we have a hospital system, a public health system, a physician system, a financing system, an insurance system and many other systems. But all of these separate systems have not created a health care system--a system of care that is seamless, coordinated and accountable for cost and outcomes. PMID- 10158916 TI - Theory and methods of economic evaluation of health care. PMID- 10158915 TI - The value of principles. PMID- 10158917 TI - Medicare managed care: a brave new world. PMID- 10158918 TI - Caught browsing again. PMID- 10158919 TI - States wrestle with provider network regulation. AB - Across the country, states are considering whether to permit provider network participation in risk-based arrangements. Interest in this issue is driven primarily by market realities and, to a lesser extent, by two recent developments: the National Association of Insurance Commissioners' 1995 recommendation that provider networks entering certain risk arrangements be subject to state insurance regulation and last year's Federal health legislation allowing "provider sponsored networks" (PSNs) to enter Medicare risk contracts. PMID- 10158920 TI - Integrating information for community-based health care. AB - Healthcare providers are increasingly faced with the need to develop comprehensive, clinically-oriented, community-focused information systems in order to remain financially viable and meet the information demands of healthcare consumers. Some providers interface and integrate their disparate information systems on their own. Others form integrated delivery systems that take advantage of economies of scale from an enterprise approach to information technology management. Still others form health information networks that allow them to pool information technology resources while pursuing independent business goals. PMID- 10158921 TI - Affiliation: to be or not to be independent? AB - In recent years, healthcare providers have expended a great deal of energy on merger, affiliation, and acquisition activities. Before entering into any of these arrangements, however, healthcare executives should answer the question: "Does my organization need to join with others to survive and thrive?" PMID- 10158922 TI - Provider excess loss insurance: a safety net for risky business. AB - Capitation agreements are challenging healthcare providers to keep the cost of delivering care at or below their agreed-upon capitated payment. To protect themselves when this cannot be accomplished, providers are purchasing provider excess loss insurance, which reimburses providers if their patient costs exceed a deductible or per-member-per-month dollar threshold. It is important that managers understand differences among the three general types of providers excess loss insurance: per-person, aggregate, and carve-out. PMID- 10158923 TI - The use of arbitration to settle managed care contract disputes. PMID- 10158924 TI - Capitation: selecting the method, determining the rates. Can providers share risk without excessive financial exposure? AB - Healthcare providers in markets with a high degree of managed care penetration, such as western states, are aggressively pursuing capitated contracts that are comprehensive in scope and that assume a significant amount of risk sharing. Providers in other parts of the country, however, still are determining how much risk they can assume safely. Integral to this assessment is consideration of two factors: the form of the capitated payment and the capitation rate. Providers must understand the two forms of capitated payment--per member per month and percent of premium--and how each is affected by changes in market levels before they can choose the one best suited to the amount of risk they can assume. Findings from a study of capitation rates utilized by 10 large national or multiregional HMOs may serve as a point of reference for providers. PMID- 10158926 TI - Increasing revenue through fee review and adjustment. AB - Medical group practices are under increasing pressure to deliver care more cost efficiently. To remain competitive, practices must find ways to increase their fee-for-service revenue. One way for medical group practices to increase revenue is to review fees in accordance with industry standards and to adjust them, as needed. PMID- 10158925 TI - Contrasting RCC, RVU, and ABC for managed care decisions. A case study compares three widely used costing methods and finds one superior. AB - To obtain cost data needed to improve managed care decisions and negotiate profitable capitation contracts, most healthcare provider organizations use one of three costing methods: the ratio-of-costs-to-charges method, the relative value unit method, or the activity-based costing method. Although the ratio-of costs to charges is used by a majority of provider organizations, a case study that applied these three methods in a renal dialysis clinic found that the activity-based costing method provided the most accurate cost data. By using this costing method, healthcare financial managers can obtain the data needed to make optimal decisions regarding resource allocation and cost containment, thus assuring the longterm financial viability of their organizations. PMID- 10158927 TI - DOJ raises concerns about mergers and large physician networks. AB - Antitrust concerns about large physician networks typically have focused on the risk-sharing aspects of such networks; little attention has been paid to the impact these networks have had on the healthcare market. However, the Department of Justice has recently issued three business review letters regarding physician networks or mergers in New Jersey, California, and Minnesota which indicate that the level of market dominance created by proposed physician mergers or networks probably will be subject to closer scrutiny in the future. PMID- 10158928 TI - Claims status standards will benefit all. PMID- 10158929 TI - 1994 IAHSS salary, equipment, staffing and uniform survey. AB - Salaries of the person who heads a hospital's security department can range from $18,500 to $75,000. Security staffs can range from 5.6 FTE's to 136.8. Within these ranges, however, there are a number of factors which determine the size of salary or the makeup of staff. This section of the IAHSS 1994 crime survey provides the most recent information on those factors and the possible rationales behind them. In addition, it provides the latest data on what equipment, including guns and other weapons, is carried by hospital security officers, as well as reporting on current uniform preferences. Eleven charts are included. PMID- 10158930 TI - Hillcrest Nursing Home fire: a case history. PMID- 10158931 TI - Seven steps to quality security. AB - How a hospital security manager, following a seven step process, refocused departmental philosophy to make service and consulting the central themes. The change, he says, brought security more in line with business principles, added value to the security process, and enhanced the overall security of the organization. PMID- 10158932 TI - Telecommunications systems implementations in healthcare facilities. AB - The author provides guidance on implementing a new telecommunications system in a healthcare facility--from pre-sale through completed implementation. He gives advice on what to watch out for and how to avoid potential problems. PMID- 10158933 TI - A healthy approach to card access. AB - The security team at St. Luke's Hospital describes how a new card access system alleviated the need for additional personnel when the hospital expanded. PMID- 10158934 TI - Computer applications for the hospital security department--buying or developing a shift log reporting system. AB - The author presents guidelines to help a security department select a computer system to track security activities--whether it's a commercial software product, an in-house developed program, or a do-it-yourself designed system. Computerized security activity reporting, he believes, is effective and beneficial. PMID- 10158935 TI - Information security--protecting corporate assets. PMID- 10158936 TI - Police/military-type uniforms or blazers/slacks for hospital security officers? Using a survey to get some answers. PMID- 10158937 TI - Managing hostile behavior in the workplace. PMID- 10158938 TI - Evolution of a medical center management of workplace violence plan. AB - The author presents his hospital's experience in drafting and implementing a security plan to be in compliance with AB 508, JCAHO survey standards, and Cal/OSHA guidelines. PMID- 10158939 TI - Barbarians at the gates? Combating some new threats to hospital security professionals. AB - This article shows how security directors can answer simplistic security formulas used by some consultants and contractors with meaningful measurements. It presents ideas and approaches for cost-cutting, and may help the security director, if called on, to cut costs in a way that will continue to provide the most security per dollar spent. PMID- 10158940 TI - Socioeconomic differences in the utilization of health services in a Dutch population: the contribution of health status. AB - The main question addressed here is to what extent socioeconomic differences in the utilization of health services in the Netherlands can be explained by health status. Our aim is to assess whether the health services has achieved equal assess for equal needs, and which health status measures best control for need. Cross-sectional survey data from 2867 respondents with respect to utilization of six different types of health services are used for analysis. Socioeconomic differences in utilization were present for all services after we controlled for age, sex and marital status. By controlling for health status, differences changed markedly for all health services analyzed. Differences in general practitioner contacts diminished but did not disappear (adjusted odds ratio primary education/university 2.22). The pattern of excess contacts with specialist physicians reverses (adjusted odds ratio 0.74). This is also true for the physiotherapist. The pattern of hospitalizations is unclear. Use of over-the counter medicines is little affected by control for health status. Adjusted differences in use of prescription medicines become small. Control for health status is best achieved with a set of health measures covering several dimensions of health. Whether low relative utilization among those with low education reflects limited access, or whether higher use of other services is compensatory is hard to decide on the basis of the study. Monitoring access to health care is important for all sorts of systems, including those which are believed to be equitable. PMID- 10158941 TI - The monopolistic integrated model and health care reform: the Swedish experience. AB - This article reviews recent reforms geared to creating internal markets in the Swedish health-care sector. The main purpose is to describe driving forces behind reforms, and to analyse the limitations of reforms oriented towards internal markets within a monopolistic integrated health-care model. The principal part of the article is devoted to a discussion of incentives within Swedish county councils, and of how these incentives have influenced reforms in the direction of more choices for consumers and a separation between purchasers and providers. It is argued that the current incentives, in combination with criticism against county council activities in the early 1990's, account for the present inconsistencies as regards reforms. Furthermore, the article maintains that a weak form of separation between purchasers and providers will lead to distorted incentives, restricting innovative behaviour and structural change. In conclusion, the process of reforming the Swedish monopolistic integrated health care model in the direction of some form of internal market is said to rest on shaky ground. PMID- 10158942 TI - Severity of a case for outcome assessment in health care--definitions and classification of instruments. AB - Severity of a case is one of the ingredients in management systems. Severity adjustment systems have limitations, and confusion and diversity characterize definitions of severity of a case. These facts may be a consequence of lack of conceptual knowledge. Based on a holistic theory of health, we introduce a definition of severity of a case from a patient perspective. Here severity is characterized as having two basic components: disease severity and illness severity; and five dimensions: suffering, disabilities, risk of suffering, risk of disabilities and risk of death. A classification of instruments as measures of severity dimensions is presented. This classification is based on definition and application criteria. The article's main contribution is to combine theoretical and practical knowledge about severity of a case, which may empower implementations of outcome management systems in health care. PMID- 10158943 TI - EuroQol: the current state of play. AB - The EuroQol Group first met in 1987 to test the feasibility of jointly developing a standardised non-disease-specific instrument for describing and valuing health related quality of life. From the outset the Group has been multi-country, multi centre, and multi-disciplinary. The EuroQol instrument is intended to complement other forms of quality of life measures, and it has been purposefully developed to generate a cardinal index of health, thus giving it considerable potential for use in economic evaluation. Considerable effort has been invested by the Group in the development and valuation aspects of health status measurement. Earlier work was reported upon in 1990; this paper is a second 'corporate' effort detailing subsequent developments. The concepts underlying the EuroQol framework are explored with particular reference to the generic nature of the instrument. The valuation task is reviewed and some evidence on the methodological requirements for measurement is presented. A number of special issues of considerable interest and concern to the Group are discussed: the modelling of data, the duration of health states and the problems surrounding the state 'dead'. An outline of some of the applications of the EuroQol instrument is presented and a brief commentary on the Group's ongoing programme of work concludes the paper. PMID- 10158944 TI - Supermarket facelift is healthy move for inner-city neighborhood. Sister Thea Bowman Family Health Center, Brooklyn, N.Y. PMID- 10158945 TI - The new face of imaging. PMID- 10158947 TI - Make the Internet work for you. PMID- 10158946 TI - Adventures in outsourcing. PMID- 10158948 TI - Workplace violence: OSHA issues new guidelines. PMID- 10158949 TI - Empowered employees: the key to a good safety survey. PMID- 10158950 TI - Physicians and group practice: balancing autonomy with market reality. AB - Developing or joining multispecialty group practices is emerging as a premier competitive strategy for physicians. "Physicians and Group Practice: Balancing Autonomy with Market Reality" explores the driving forces causing the restructure of physician services into multispecialty group practices. The growth and characteristics of group practices are outlined as well as the advantages and trade-offs inherent in a group practice. PMID- 10158951 TI - Strategic business planning for the multispecialty group practice. AB - A clear plan for guiding the activities of the multispecialty group practice (GP) is critical for ensuring success as the health care industry undergoes profound change. This article describes the process of developing a strategic business plan, and includes examples of pertinent analyses as well as practical considerations for ensuring successful development of a strategic business plan for a GP. PMID- 10158952 TI - Economics of multispecialty group practice. AB - The number of physicians organized in multispecialty group practices is growing. Research does not suggest that such practices will achieve economies of scope. Rather, the primary economic advantage to multispecialty group practice may be its ability to coordinate the process of care in a managed care setting, a process for which relatively large practices may be necessary. PMID- 10158953 TI - Physician group sizing: a strategic framework. AB - Consistent with managed health care and associated fundamental shifts in health care economics, physician group sizing has evolved from a formula-driven analytical exercise to one which necessarily addresses a series of strategic issues relative to critical mass, scale economies, and market demands. Strategic issues, therefore, will take priority over operational considerations in determining group size. The methodology proposed considers interactions between qualitative assumptions (group goals/philosophy, market share targets) and quantitative variables (market demographics, physician capacity, physician supply, utilization rates, etc.) within the context of overall group vision relative to the market. Included is a brief case study that applies the recommended approach and illustrates three important considerations in employing the methodology. PMID- 10158954 TI - Compensation models and issues for a multispecialty group practice. AB - The methodology employed by a multispecialty group practice to compensate its physicians must complement the group's financial, strategic, programmatic, and operational objectives. Furthermore, the compensation plan must foster the group's corporate philosophy. This article presents several specific compensation models employed by multispecialty group practices and reviews the key implications associated with each model. Among the implications addressed are those associated with the shift to capitated payments, individual and groupwide objectives, the portion of compensation placed at risk, and the implications of the group practice joining an integrated delivery system. PMID- 10158955 TI - Current issues in multispecialty group practice: the Lahey Hitchcock Clinic merger experience. AB - The merger of two large not-for-profit multispecialty group practices in 1995 forced the two founding organizations into a deeper understanding of their heritage and mission. Common features of Lahey Hitchcock and similar organizations of their vintage are discussed. Issues addressed include governance, desirable leadership characteristics and growth, "incentivizing change," and workforce planning. PMID- 10158956 TI - Managing space for managed care: the challenge for a multispecialty group practice. AB - A project that began as an architectural study to determine space requirements and remedy space deficiencies for an academic medical center's faculty multispecialty group practice led to development of an analytical methodology for assessing real space needs and viable options for solutions in the context of the group's operational policies, physician practice patterns, and business goals. Major facility investments for new or renovated construction demand significant capital expenditure, which can severely affect a group's ability to complete as a financially viable player in a marketplace environment of increasingly competitive managed care delivery systems. The methodology created during this project helped the group practice to understand how they could optimize the use of existing space, minimize capital costs, and provide flexibility for future developments. PMID- 10158957 TI - Management services organization for group practices. AB - This article analyzes why management service organizations (MSOs) have become the major interface between group practices and managed care organizations as well as their advantages and disadvantages. It provides this information in the context of The University of Texas Southwestern Medical Center's development and operation of an MSO in the Dallas/Fort Worth market. PMID- 10158958 TI - Capitating multispecialty groups. AB - This article addresses the issues a medical group must consider when entering into a capitation agreement with a managed care organization. It discusses the potential risks of capitation contracts and how those risks can be limited. In addition, keys to successful contracting are explored. Specific considerations outlined include choosing a contracting partner, determining the capitation rate and contract terms, and managing risk. Internal issues regarding the distribution of capitation income, physician incentives and risk pools, and management information systems are also addressed in the article. PMID- 10158960 TI - Fire EMS making cents in Houston. PMID- 10158959 TI - What's so great about Phoenix Fire? PMID- 10158961 TI - EMS, Fire kissing cousins in Austin. PMID- 10158962 TI - Listening to deaf medics. Interview by Marion Angell Garza. PMID- 10158963 TI - Rough road ahead. PMID- 10158964 TI - Survey: integrated systems pale next to HMOs. PMID- 10158965 TI - Mobile telemedicine clinic eases care in Okla. PMID- 10158966 TI - Potshots over pox shots? PMID- 10158967 TI - Rivals ally to net managed-care pacts. PMID- 10158968 TI - Providers seek to survey satisfaction. PMID- 10158969 TI - Execs should meditate on Bulls coach's practices. PMID- 10158970 TI - Program turns promises into cold cash. PMID- 10158971 TI - Hospitals say Mass. reform won't solve indigent problem. PMID- 10158972 TI - AHA opposes easing antitrust rules for docs. PMID- 10158973 TI - Atlanta hospitals nimbly respond to Olympics emergency. PMID- 10158974 TI - IRS opening boards to more docs, ruling shows. PMID- 10158975 TI - Legislators disclose healthcare holdings. PMID- 10158976 TI - New tax law opens books of not-for-profits. PMID- 10158977 TI - Northern W.Va. hospitals in a rush to get together. PMID- 10158978 TI - Justice Dept. sues GE over imaging. PMID- 10158979 TI - Colo. hospitals again post big margins. PMID- 10158980 TI - Regional agencies in N.Y. axed again. PMID- 10158981 TI - Horror stories aside, HMOs may be curbing malpractice. PMID- 10158982 TI - Mass. to publish doc profile data. PMID- 10158983 TI - N.Y. county hospital seeks more flexibility. PMID- 10158984 TI - Ill. to offer unique Medicaid network. PMID- 10158985 TI - Groups to Congress: hasten review of lung surgery. PMID- 10158986 TI - Healthcare consolidation raises ethical questions. PMID- 10158987 TI - Will we like tomorrow's giants? AB - The healthcare industry is buying into the benefits of being big. Merger and acquisition deals hit a pace of 2.4 per day among all types of providers during the first half of the year. But critics believe the time has come to rein in the rampant consolidation. PMID- 10158988 TI - Integrated delivery looms as most significant issue for system executives. PMID- 10158989 TI - AHA to set stage for new programming at final convention. PMID- 10158990 TI - This skeptic thought she'd seen it all, but a revolutionary community initiative made her a ... true believer. AB - The board of the Fort Sanders Health System wanted to reach out and improve its community's health. As the largest provider in eastern Tennessee, the communities it served had dramatically different health problems. So they created community councils and put them to work planning for creative ways to respond to their own health needs. PMID- 10158991 TI - Getting from here to there. AB - Thinking of a redesign for your board? As your organization restructures, your board will require more than a touch-up. This excerpt from an upcoming book spells out the process you'll need to follow to make that redesign go as cleanly and efficiently as possible. PMID- 10158992 TI - Should we sell? Facing the unthinkable. PMID- 10158993 TI - Purpose is both bedrock and albatross. PMID- 10158994 TI - Reasonable expectations. Fears about managed care may lead to a more rational health care system. AB - Managed care has a bad rep with many consumers, doctors, and providers. That's because most plans appear to be making arbitrary decisions based primarily on costs. But by inviting community members to help make decisions about their health plan, Allina Health System, Minneapolis, is taking the fear out of managed care. PMID- 10158996 TI - The social and cost implications of type II diabetes. A seminar-in-print. PMID- 10158997 TI - Type II diabetes and quality of life: a review of the literature. AB - In this review, an attempt was made to describe how non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes) affects the life of the ill person. Patients are affected by and cope with this complex disease in different ways, depending on its severity and complications. Influences on well-being therefore also vary--from none to major deterioration. A substantial proportion of patients are primarily affected with fatigue, anxiety, and depression. Deteriorations in cognitive function have also been documented, although diverging evidence exists. Some negative social circumstances have also been noted. Social support, particularly specific support, appears to be helpful, although self-efficacy and health practices seem to be as important. Resistance to compliance with diabetes regimens together with reactions to the demands for increased levels of physical activity are often seen. Systematic focused studies examining how patients and significant others perceive the impact of the disease in retrospect are still awaited. There is a great need for more research on type II diabetes; broad prospective longitudinal follow-up studies monitoring natural disease progression, as well as examining the predictive significance of quality of life, would be welcome. PMID- 10158995 TI - Epidemiology of type II diabetes: an international perspective. AB - Non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes) is present in nearly all of the countries of the world, and represents a significant disease burden in most developed countries. Type II diabetes is fairly common among Caucasoid populations in the United States and Europe and, more importantly, among Native Americans, Pacific Island populations, persons of Asian Indian origin, Hispanics and African Americans. Our current understanding is that type II diabetes probably results from an interaction of genetic and environmental factors. While a genetic link is most likely a precursor to type II diabetes, a number of lifestyle behaviours, including obesity, lack of physical activity, and diet, also influence the development of the disease. Lifestyle changes and westernization that accompany economic development in developing countries have been followed in the past by substantial increases in the prevalence of type II diabetes. Thus, further increases in type II diabetes might be expected in the Third World as the economic advancement of these countries continues. PMID- 10158998 TI - Quality of life in type II diabetes: evaluation and applications. AB - Issues of quality of life (QOL) have often been considered for patients with insulin-dependent diabetes mellitus (IDDM, type I diabetes). Daily blood glucose monitoring and need for self-injections pose an obvious threat to the attainment of QOL, as does concern about long term complications. In contrast, non-insulin dependent diabetes mellitus (NIDDM, type II diabetes) may be considered less severe, and has attracted less research interest. In fact, type II patients may also be aware of their heightened vulnerability to physical complications, as well as being affected by the need for heightened vigilance and attention to diet and exercise regimens. Issues associated with the theory and development of QOL measures are discussed largely in relation to type I diabetes and cancer. Generic measures have advantages in allowing comparisons to be made across different disease groups, and are, therefore, often favoured by health economists. In contrast, disease-specific scales are more sensitive to changes in treatment regimens, and may therefore be the instruments of choice in evaluating new treatments. In general, there has been less attention paid to how the meaning of QOL changes throughout the lifespan, and our review of the literature therefore emphasises a developmental perspective when considering the processes through which diabetes may affect an individual's QOL. Measures which, at the least, take into account changes in meaning of QOL throughout the lifespan need to be developed. PMID- 10158999 TI - Economic evaluations of type II diabetes. AB - Economic analyses, which can be either descriptive or evaluative, can help to ensure that healthcare resources are used effectively. Most studies of diabetes mellitus have been descriptive and have used the cost-of-illness methodology, which estimates the burden of a disease to society. This method provides an estimate of the direct, indirect and intangible costs of a disease or illness. Methodological problems are mainly related to the measurement of indirect costs and even to whether they should be included at all. Existing studies that have measured the direct costs of non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes) serve to highlight the difficulties involved in comparing costs between countries with different healthcare systems, and the importance of defining the study population and the sources of the costs. There is a lack of recent data on the costs of treating people who have diabetes. PMID- 10159000 TI - The indirect costs of morbidity in type II diabetic patients. AB - In an attempt to obtain an appropriate estimate of the excess costs of production losses arising from morbidity in patients with diabetes, we compared the number of sick days and permanently disabled individuals in a diabetic population and the corresponding general population. These comparisons show that the rate of premature retirement for both insulin-dependent diabetes mellitus (IDDM, type I diabetes) or non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes) patients was twice that of the average population. Insulin-treated subjects also had twice as many sickness benefit days. The excess costs of production losses as a result of morbidity in people aged 20 to 64 years with type II diabetes were about $US7000 per individual and year. Most of these excess costs were attributed to permanent disability in the 40- to 64-year age groups. PMID- 10159001 TI - Cost savings associated with detection and treatment of diabetic eye disease. AB - OBJECTIVE: Diabetic retinopathy, which leads to macular oedema and retinal neovascularisation, is the leading cause of blindness among working age Americans. Research has demonstrated significant cost savings associated with detection of eye disease in Americans and Europeans with insulin-dependent diabetes mellitus (IDDM, type I diabetes) and non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes). In this report, we estimate the current and potential savings in both the United States and in a European country resulting from the screening and treatment of retinopathy in persons with diabetes. DESIGN: Computer modelling, incorporating data from population-based epidemiological studies and multicentre clinical trials. Monte Carlo simulation was used, combined with sensitivity analysis and present value analysis of cost savings. RESULTS: Detection and treatment of diabetic eye disease in both the United States and Scandinavia is not only cost effective, but is actually cost saving from the governmental perspective. Potential savings in the United States exceed $US600 million annually, while, in Sweden, potential savings of 36 million SEK might be realised. These findings are comparable given the differences in population between the 2 countries. CONCLUSIONS: Our analysis indicates that prevention programmes aimed at improving eye care for persons with diabetes not only reduce needless vision loss, but also provide a financial return on the investment of public funds. PMID- 10159002 TI - The costs of nephropathy in type II diabetes. AB - Diabetic nephropathy was first described in patients with non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes) by Kimmelstiel and Wilson in 1936. It is a classical, late diabetic complication, diagnosed by measurement of the urinary albumin or total protein excretion, and typically develops after more than 15 years of diabetes. As most studies of patients with type II diabetes have been performed in White, European or North American populations in which the highest incidence of this disease is recorded in individuals aged over 70 years, a low prevalence has generally been found in these patients. Nephropathy has been considered a rare complication in type II diabetes patients. Other ethnic groups such as Pima Indians in the USA or Pacific Islanders have totally different incidence patterns of type II diabetes, with a high incidence in the 20- to 50 year age group. These patients live long enough to develop nephropathy, and they do so at the same rate as insulin-dependent diabetes mellitus (IDDM, type I diabetes) patients. Since the prevalence of type II diabetes is increasing worldwide, particularly in the developing world, diabetic nephropathy will be a growing problem in patients with this disease. From our experience in the treatment of type I diabetes patients, we know that prevention of end-stage renal failure is possible in most patients, but that treatment of end-stage renal disease is very expensive. In this paper, some of the major risk factors for the development of nephropathy are discussed together with the potential for treatment. It is shown that, in type I diabetes patients, early detection by screening for microalbuminuria and immediate recourse to antihypertensive treatment are likely to increase life-expectancy significantly while at the same time reducing the total costs to healthcare. Whether this is also the case in patients with type II diabetes is less clear, as most of the controlled clinical trials of the effect of strict metabolic control or antihypertensive treatment have been performed in patients with type I diabetes. Thus, clinical trials in patients with type II diabetes should be performed, and further epidemiological data relating to these patients are needed. PMID- 10159003 TI - Direct and indirect costs of cardiovascular and cerebrovascular complications of type II diabetes. AB - Macroangiopathy (atherosclerosis) is a common chronic complication in non-insulin dependent diabetes mellitus (NIDDM, type II diabetes) with a significant attendant mortality and morbidity. While there are inherent difficulties in estimating the economic burden of large vessel disease in type II diabetes, this has been attempted in several studies by use of insurance claims, hospital inpatient statistics, and extrapolation from standard mortality data. This evidence suggests that the macrovascular complications of type II diabetes (ischaemic heart disease, peripheral vascular disease, and cerebrovascular disease) account for approximately one-third of all healthcare expenditures and one-quarter of disability related to type II diabetes in developed countries. The large and growing economic burden of these complications of diabetes in developing countries is unknown. PMID- 10159004 TI - The cost of diabetic neuropathy. AB - Little information is available as to the exact financial cost of the clinical features of diabetic neuropathy. At least 20% of diabetic patients have a neuropathic problem consisting of either sensory pain and discomfort, foot ulceration or impotence. This represents a large load of clinical work in any diabetes service. Such patients should be offered thorough and sympathetic clinical facilities, from careful diagnosis and assessment through to treatment and counselling, to allow them to accept, and hopefully obtain improvement in, what is essentially an incurable clinical situation. Similarly, the emotional and financial costs to the patients of such a chronic condition have not been adequately assessed. It seems reasonable to suggest that such costs are high, and it is a general impression that patients with this problem do not receive adequate time and attention in many busy diabetes services. PMID- 10159005 TI - The cost of diabetic foot problems. AB - Diabetic foot problems are the commonest and most morbid complications of diabetes and constitute a major cost to any health care system. Foot problems result in the greatest number of admissions to hospital, and these become extremely costly. The demonstration in many areas of the health service that care, education, and the provision of good support to people results in fewer foot problems must be the spur for all those involved in diabetes care to improve services in all localities. Foot ulceration is much more common in deprived areas, and urgent research is required to determine exactly why this occurs so that appropriate remedies can be applied. PMID- 10159006 TI - Evaluative approaches to type II diabetes. AB - In recent years, as a result of the rapid growth in the costs of health care, there has been an explosion of interest in the area of economic evaluation. Diabetes has emerged as an economic problem because of the increasing costs of treatments for diabetes and of educational programmes for patients with type II diabetes (non-insulin-dependent diabetes mellitus, NIDDM). In addition to the cost-of-illness analyses, cost-effectiveness, cost-utility, and cost-benefit analyses are the major methods for evaluating the economic efficiency of diabetes treatments, and educational or control programmes. This article briefly reviews some conceptual issues relating to these evaluative methods; if the methods of estimating costs are generally similar for the different evaluative methods, the 3 forms of evaluation vary in the way they assess the outcomes. A more consistent application of recent methods of economic evaluation could improve understanding of the economic consequences of type II diabetes for the individual and society as a whole. PMID- 10159007 TI - Global healthcare financing for type II diabetes: are there ways out of the crisis? AB - This article focuses on the overall situation with regard to healthcare financing in the field of diabetes. Worldwide efforts on cost containment have severely influenced the management of chronic illness. An answer as to whether or not the expected financial crisis can be prevented will be difficult to obtain. However, use of the modern tools of management sciences and health economics can bring more transparency into the picture. Solutions will have to be based increasingly on empirical economic data, which, so far, are only in the process of being generated in many countries. A research agenda is proposed that might trigger the compilation of additional data in order to ensure adequate future financing of diabetes care. PMID- 10159008 TI - Cost-effectiveness of diabetes education. AB - The costs of long term complications of diabetes to both patients and the community are considerable. However, amputation of the lower limb is an example of a costly intervention that is often preventable in patients educated to take at least partial responsibility for the management of their condition. Aside from the obvious improvement in patients' quality of life that preventive medicine of this kind entails, reductions in the amputation rate also lead to large cost savings. Unfortunately, many patients are denied adequate education about their diabetes. This is partly due to lack of educational programmes for patients and partly the result of inadequate educational methodologies used by healthcare providers. Without major investments in patient education by healthcare policymakers and administrators, however, substantial improvements in the delivery of health education to the diabetic population are unlikely, and the opportunities for making important cost savings in this area will continue to be forgone. PMID- 10159009 TI - Pharmacoeconomics of diabetes surveillance and detection programmes. AB - Primary prevention of insulin-dependent diabetes mellitus (IDDM, type I diabetes) remains a research goal. Primary prevention of non-insulin-dependent diabetes mellitus (NIDDM, type II diabetes) is likely to remain part of general health education on healthy lifestyles. However, the often delayed diagnosis of type II diabetes, accompanied by early development of complications, offers opportunities for detection programmes, provided that these can overcome the hurdle of the low annual incidence of this disease. By contrast, programmes for the detection of arterial risk factors and treatable complications of previously diagnosed diabetes are well established as an integrated, and thus efficient, annual review. The results of such review guide the different forms of management programmes such as educational programmes for foot care and smoking, drug therapy for hypertension, dyslipidaemia and early nephropathy, and crisis management (laser photocoagulation) of proliferative retinopathy. Such annual review, additional to review of lifestyle and metabolic control, offers opportunities for on-going preventive education and is now the basis of quality development and needs assessment technologies. PMID- 10159010 TI - Applying recent findings to clinical care in type II diabetes. AB - There is a global perspective to the economic consequences of diabetes, which is illustrated in the many publications now being produced on this subject. Because of the higher prevalence of type II diabetes, its impact is greater than that of type I diabetes in both developed and developing countries (but particularly in the latter). It has frequently been argued that advances in the therapy of diabetes and, in particular, advances in the prevention of diabetic complications, will reduce the costs of care. This may well be the case. However, the effects of these preventive measures on the quality of life of individuals living with diabetes and on the indirect costs of diabetes are likely to be much more marked than their effects on direct costs. The economic arguments for applying these findings are compelling in the long term but, in the short term, their application entails considerable investment. While the capacity of any country to make these investments is limited, the capacity of developing countries to make these even short term investments is severely limited and will be further taxed as noncommunicable diseases such as diabetes become more and more prevalent while the problems of treating and preventing communicable diseases remain a challenge. PMID- 10159011 TI - Perspectives. DSM: a concept coming into focus. PMID- 10159012 TI - Perspectives. Cornerstone to reform: consumer satisfaction surveys. PMID- 10159013 TI - Medical imaging systems, an overview of developments. PMID- 10159014 TI - A new approach to achieve a reduction in energy costs in Dutch hospitals. PMID- 10159015 TI - Managing medical savings accounts. AB - Medical savings accounts (MSAs) are a new option being considered by policy makers as an alternative medical benefit cost-control technique. This article begins with a detailed description of MSAs as they are currently being considered and discusses the advantages and disadvantages from the perspective of the employer and employee. Some states are already recognizing the use of MSAs for state income tax purposes, and the author provides examples of these. PMID- 10159016 TI - Medical savings accounts: why do they work? AB - This article analyzes and reviews the cost and design characteristics of medical savings accounts (MSAs). By placing premium savings from high-deductible health insurance in medical savings accounts, individuals have an incentive to shop for medical services. A more market-oriented health insurance and delivery system results, as individuals are now both users and buyers of health care. Data show that most families would accumulate balances in their MSAs that may be used for future medical expenses or savings. Through program design, the potential problems of adverse selection and cost to risk can be greatly reduced. PMID- 10159017 TI - Clinical practice improvement: management of the patient with chronic asthma. AB - Clinical practice improvement (CPI) includes research on practice patterns, access, utilization of resources, and patient perceptions of outcomes; development of practice guidelines; and education of both patients and providers. Using the CPI format, a team of healthcare professionals selected the management of the asthma patient as a project. The team's goals were to evaluate current practice patterns, review and recommend practice guidelines, recommend indicators to monitor patient outcomes and changes in practice patterns, and provide recommendations for implementing educational activities. A survey mailed to primary care physicians and selected specialists (allergists and pulmonologists) was used to determine present methods of managing asthma. A patient outcomes survey tool was piloted as part of the CPI process. The pilot indicated that this tool was appropriate for use in physician offices for both longitudinal and aggregate analysis of asthma patient outcomes. Patient and provider educational materials were developed and disseminated to providers. PMID- 10159019 TI - Toward a world-class culture in primary care: listening to the voice of the customer. AB - This article on creating a world-class culture in primary care stresses the importance of customers. The concept of patients as external customers is addressed; the emphasis, however, is on healthcare professionals' responsibilities toward one another as internal customers. PMID- 10159018 TI - Strategies for involving physicians in continuous quality improvement. AB - To realize significant and sustained improvement in quality and in overall performance, hospitals must have the support and participation of the medical staff. Although it sometimes is difficult to recruit busy physicians to join the effort, they will become champions if their experience is productive and results in improved patient care. This article outlines a number of straightforward approaches that will help healthcare quality professionals obtain physician involvement in the improvement effort. PMID- 10159020 TI - A closer look at case management. AB - Healthcare organizations throughout the United States are attempting to find solutions to spiraling healthcare costs. Hospital administrators are questioning the cost-effectiveness of their care delivery models, while healthcare professionals are developing innovative measures to increase the cost-effective use of resources. This article explores hospital-based case management measures that are being used not only to control costs but also to de-escalate the continuously accelerating cost increases. PMID- 10159021 TI - The games plans play with ER bills. PMID- 10159022 TI - Empowered patients buy more efficient care ... roundtable of experts. PMID- 10159023 TI - Can capitation save the world? PMID- 10159025 TI - Five policy shocks and one provocative question. PMID- 10159024 TI - Who'll pay the bill when health care comes home? PMID- 10159026 TI - Data watch. Integrated networks: 500 strong and growing. Does money=value to HMO enrollees? PMID- 10159027 TI - The future of practice management companies. PMID- 10159028 TI - How virtuous is "virtual" integration? PMID- 10159029 TI - How capital markets view your strategies. PMID- 10159030 TI - Consolidation continues in the S.F. Bay area. PMID- 10159031 TI - Using clinical data in program design: a family support program for families with preterm infants. AB - HMOs can use clinical data culled from computerized medical records and provider and patient interviews to examine the impact of premature infant births on the family. The results can help guide health plans in developing a clinical intervention program to address the physical and emotional consequences of low birthweight babies. The Harvard Pilgrim Health Care experience describes the data collection process administrators are taking to design such a clinical intervention. PMID- 10159032 TI - Kaiser Colorado's Cooperative Health Care Clinic: a group approach to patient care. AB - A Kaiser Permanente pilot project demonstrates that managing health status with patients on a group basis versus one-on-one office visits can improve health care delivery services and reduce unnecessary resource utilization. Kaiser's Cooperative Health Care Clinic (CHCC) in Denver, Colorado, uses a multidisciplinary team to successfully provide care to elderly members with chronic conditions. PMID- 10159033 TI - Using data to design systems of care adults with chronic illness. AB - Increased Medicare risk contracts led to rising concern with readmission rates among the senior population with chronic illness at Carondelet Health Network. Using readily available data, Carondelet providers and administrators created intervention and evaluation strategies to redesign chronic care services to reduce increased readmissions. The strategies showed health plans can develop such strategies without waiting for sophisticated information systems to be put in place. PMID- 10159034 TI - Choosing chronic disease measures for HEDIS: conceptual framework and review of seven clinical areas. AB - Few quality measures are available today that assess care for chronic conditions. Concern has been expressed by the developers of the Health Plan Employer Data and Information Set (HEDIS) that the current system may not capture the critical dimensions of quality for chronic diseases. This article provides a conceptual framework for selecting chronic diseases for which measures of quality should be developed, reviews the literature on the effectiveness of interventions for the diseases that meet the criteria, and recommends possible areas for the development of quality measures. PMID- 10159035 TI - A systems approach to asthma care. AB - This two-year asthma intervention focuses on provider education emphasizing early diagnosis of asthma, early use of oral steroids, proper use of inhalation devices, objective monitoring of patient status, and use of daily preventive treatment. Patient education is an integral part of treatment. This approach supports the primary care physician as the provider and coordinator of care by supplying monitoring and treatment devices, books, diaries, home care services, and allergy consultation. It also manifests a systems approach to asthma care in its reliance on a nurse case manager who oversees patient and family support network. PMID- 10159036 TI - Evolution of services for the chronically mentally ill in a managed care setting: a case study. AB - Managed care plans have expanded to serve individuals with severe and chronic mental illness over the past 25 years. During that time, the evolution of several key clinical phases has been witnessed: the creation of a diverse spectrum of services; the development of treatment algorithms; and the implementation of treatment outcomes measures as a way to gauge program success and develop future strategies. At the same time, a number of additional factors have had a significant impact upon the development of clinical programs targeted toward the chronically mentally ill: dollars allocated to mental health services; the influence of different models of delivery; and the incentives inherent in various methods of payment. PMID- 10159037 TI - Managing care for mental illness: paradox and pitfalls. AB - Historically mental health has been separated from physical health care, and within mental health there have been largely separate public and private systems. A managed care approach now offers the potential of integrating and rationalizing mental health care. Counihan et al. and Stelovich represent the historical forces of mental health and health care, playing out as the two key models of managed care: the carve-out and the integrated model. However, the advent of managed care in today's health care system also presents significant dangers, particularly for vulnerable populations such as adults and children with severe and longterm mental disorders. PMID- 10159038 TI - Atlanta, Macon studies reveal different attitudes toward managed care. PMID- 10159039 TI - GHA partnerships take aim at healthy communities. PMID- 10159040 TI - Physicians try several theories to remedy network "deselection". PMID- 10159041 TI - Columbus Regional: turning community benefit assessment into action. PMID- 10159042 TI - Meeting the diverse needs of the patient/resident population. PMID- 10159043 TI - 5 a day--for better health. PMID- 10159044 TI - Food safety: more than a flash in the pan. PMID- 10159045 TI - Hospital realizes benefits through induction heating technology. PMID- 10159046 TI - Motivation theories. PMID- 10159047 TI - The aging of America. AB - As America's baby boomers age, communities, states and the federal government must address an older society's needs for safe, convenient homes, transportation and care. Most of the elderly will reside in the sprawling suburbs, which many experts say must change to be more like small European villages if the aged are to live independently. PMID- 10159048 TI - Abortion providers bounce back. PMID- 10159049 TI - Disease management: caring for the whole patient. PMID- 10159050 TI - Utilization review & case management--wading through. PMID- 10159051 TI - Remedy register. Who can you turn to? PMID- 10159052 TI - New England: community leadership helps network run. PMID- 10159053 TI - Managing paper: the trend toward MSOs in managed care. PMID- 10159054 TI - Sustaining the competitive edge. PMID- 10159055 TI - IS helps simplify management operation. PMID- 10159056 TI - Case study: using IT to address overpayments. PMID- 10159058 TI - Is lowest cost the goal? In Texas, not necessarily. PMID- 10159057 TI - Outsourcing help for CIOs. PMID- 10159059 TI - 10 places where they're still looking for good doctors. PMID- 10159060 TI - Managed care's 'revolving door'. How it affects your practice. PMID- 10159061 TI - Managed care has no place for unscientific 'therapies'. PMID- 10159062 TI - Protect yourself by protecting the privacy of your patients. PMID- 10159063 TI - Our readers pummel managed health care. PMID- 10159064 TI - Smoking, slimming and seat belts: is public health part of managed care? PMID- 10159066 TI - National managed care companies increase share of HMO enrollment. PMID- 10159065 TI - When you can safely discuss fees with others in a physician network. PMID- 10159067 TI - Virtual roundtable: the do's and don'ts of negotiating a merger. PMID- 10159069 TI - Lessons from mergers that failed to click. PMID- 10159068 TI - Case study. Geisinger: can an icon of integration adapt to market competition? PMID- 10159070 TI - Leadership value added profile: a valuable self-improvement tool for leaders. AB - In order to be successful leading within today's "leaner and meaner" organizations, managers will need to shift their energies from handling day-to day operations to nurturing the cultural and structural changes that tomorrow brings. This crucial process of self-improvement begins with facts about how they specifically spend their time today. These facts, in turn, are the basis for actionable recommendations. Of course, the clock is ticking as organizations view with each other on the strength of their leaders. Time, once again, is not on our side. PMID- 10159071 TI - Team-based organizations: leading the essential transformation. AB - Transforming organizations into team-based structures is an intense professional challenge. What begins as a structural change will not be completed until the cultural transformation has occurred. This process challenges leadership skill and experience-based competencies. But, the opportunities for personal and organizational growth are phenomenal. Stay open to the process, continually question and analyze outcomes, and utilize new leadership competencies. PMID- 10159072 TI - Healthcare combinations. Part III: Cultural success through organizational involvement. Interview by Terry G. Williams. AB - Throughout the integration process, organizations must constantly envision new opportunities, create mechanisms for communication, set goals and build accountabilities at appropriate levels within the organization. Ideally, an integration process will identify and build cultural strengths wherever they are in the organization and minimize the negative impact of change. An integration process that taps the creative, productive potential throughout the organization will not only reap more benefit from the integration process itself, but also will successfully navigate the culture through the rough waters of change. PMID- 10159073 TI - Work redesign in the OR: potential improvement opportunities. PMID- 10159074 TI - Service excellence in the ED improves bottom line and patient satisfaction. PMID- 10159075 TI - Streamline storage of pediatric supplies. PMID- 10159076 TI - Guidelines ensure consistent pediatric care. PMID- 10159077 TI - Re-engineering the ED for efficiency. PMID- 10159078 TI - Community program yields big results with volunteers. PMID- 10159079 TI - Hip path helps caregivers identify patient learning needs. PMID- 10159080 TI - Avoid these pathway project stumbling blocks. PMID- 10159081 TI - Putting the pieces together eliminates puzzling documentation, paperwork. PMID- 10159082 TI - How to integrate acute and home care. PMID- 10159083 TI - Back to Marketing 101: devise a product to fit the customer. PMID- 10159084 TI - Optimizing physician performance in managed care networks. PMID- 10159085 TI - The Stark Act and the fraud and abuse statute: a Congressional and general update. PMID- 10159086 TI - Federal Emergency Medical Treatment and Active Labor Act: "Adequacy of the screening exam and off site testing facilities, two murky issues". PMID- 10159087 TI - The 1994-2005 job outlook in brief. PMID- 10159088 TI - Occupations that have it all: high earnings, fast growth, and large numbers of openings. PMID- 10159089 TI - Keys to managing diversity. PMID- 10159090 TI - How to measure the value of a development program. PMID- 10159091 TI - The 10 basic commandments of successful fund raising. PMID- 10159092 TI - Should you accept privately held stock? PMID- 10159093 TI - Instant fund raising: a baker's dozen. PMID- 10159094 TI - Charitable giving up; biggest jump in eight years. PMID- 10159095 TI - Use of covered services in Medicare home health care. AB - Using data on 295 patients entering Medicare home health care at discharge from Medicare hospital stays, we explain receipt of Medicare home health nursing, PT and OT visits, and length of stay. Care reflected need, but other factors also affected service allocation. Medicare program requirements, as well as variation in provider structure and case load, appear to introduce inequities. Critical in light of recurrent proposals to change Medicare coverage and benefits, findings underline the need to reconsider Medicare home health policies that lead to denial of needed services, inequitable allocation of benefits, and premature termination of care. PMID- 10159096 TI - The home care allowance program: a change in policy and implications for elder clients. AB - This paper reports the findings of a study exploring the effects of cutbacks in Colorado Home Care programs on frail elderly. Results indicate that these cutbacks put the respondents, who live in their own homes but are dependent on relatives, friends, or strangers for assistance in activities of daily living, at risk for long term institutionalization. These households are precursors of a growing healthcare crisis in aging populations where homecare assistance programs must supplement or supplant the resources of a thinning network of kin and friends. PMID- 10159097 TI - Beyond patient dependency: family characteristics and access of elderly patients to home care services following hospital discharge. AB - Access to Skilled Nursing and Home Health Aid services among elderly patients (N = 580) and their family caregivers post hospital discharge was examined using logistic regression. A majority of the sample (65%) were referred for Skilled Nursing services while only 28% were referred for Home Health Aid services. Caregiving situations in which the spouse was the primary caregiver were less than half as likely to be referred for either service when compared to non spouses. As expected, ADL limitations were a significant predictor of referral for both services. Women patients with the same ADL limitation as men were only about a fourth as likely to be referred for Home Health Aid services as men. Findings are discussed in terms of access to care and the need for policy to consider more than patient limitations in the referral criteria. PMID- 10159098 TI - High-tech home health care: administrative and staff perspectives. AB - This study examines staff perspectives and personnel issues related to the delivery of high-tech home health care services to older adults. Data were collected from a national sample of 154 agency directors and 92 local agency staff. Agency staff and directors consistently report an increase in high-tech service delivery over the past five years. Both agency directors and local staff agree that a variety of staff may be involved in the delivery of high-tech services, including both professional and paraprofessional staff. Although agency directors report providing training to at least one or more type of direct care staff, agency staff are less likely to report being required to participate in training programs. The provision of high tech services impacts the agency, the staff, and the patient in various ways. Most staff feel that high-tech care enhances the quality of life of older patients, although high-tech care may be somewhat difficult to define and even more difficult to deliver. Challenges related to the provision of high-tech care, including providing adequate staff training, and developing appropriate quality assurance measures, are discussed. PMID- 10159099 TI - Balancing formal and informal care: meeting needs in a resource-constrained program. AB - Implications of the presence of informal help for the adequacy of formal home care services are examined in a public program that restricts service authorizations to needs that are not addressed by informal caregivers. Four areas of need were examined: local transportation, shopping, housecleaning, and dressing/bathing. The mixture of formal and informal help varied greatly from one area of need to another. Contrary to expectations, the frequency of informal help tended to be positively associated with the reporting of unmet need. The data suggest that in some areas of need, the reporting of unmet need reflects the view that the demands on informal caregivers are excessive and that additional formal services would provide them with welcome relief. PMID- 10159100 TI - A profile of Department of Veterans Affairs hospital based home care programs. AB - This paper describes the Department of Veterans Affairs (VA) home care program and compares it to community-based programs. Structure and process data were collected on hospital based home care programs in VA facilities nationwide (n=75). Supplemental data were obtained on staffing and patient attributes. Although the VA provides program guidelines, some variability was noted. The characteristics of VA programs and patients were then compared to National Center for Health Statistics survey data. This comparison revealed that VA programs provide a more comprehensive array of services to patients including physician home visits than most community-based programs. PMID- 10159101 TI - Home health agency quality: Medicare certification findings compared to patient outcomes. AB - As part of an evaluation of the Medicare certification program for home health agencies (HHAs), we examined the extent to which certification findings were related to patient outcomes. In a previous study, we collected longitudinal patient data for a national sample of 42 HHAs and developed precise patient outcome measures. In this study, the outcome measures were compared to certification findings for the same HHAs and time period (1991-93). We found relatively little association between the two sets of measures. The findings indicate that the Medicare HHA survey process does not yet successfully incorporate patient outcomes. PMID- 10159102 TI - Foley catheter prices continue their pattern from last year: steady to falling. PMID- 10159103 TI - Considering making the move from materials management to support services? Here's what you need to succeed. PMID- 10159104 TI - Quality guidelines help get to the heart of pacemaker costs. PMID- 10159105 TI - Alexian Brothers Medical Center's strategies to cut nonsalary expenses pay off to the tune of $1.2 million. PMID- 10159106 TI - This $1 billion expense probably isn't even appearing on your financial and materials management radar screens. PMID- 10159107 TI - Market structure and the role of consumer information in the physician services industry: an empirical test. AB - This paper applies Panzar and Rosse's (1987) econometric test of market structure to examine two long-debated issues: What is the market structure for physician services? Do more physicians in a market area raise the search cost of obtaining consumer information and increase prices (Satterthwaite, 1979, 1985)? For primary care and general and family practice physicians, the monopolistically competitive model prevailed over the competing hypotheses--monopoly, perfect competition, and monopolistic competition characterized by consumer informational confusion. Although less conclisive, there is some evidence to support the monopolistically competitive model for surgeons and the consumer informational confusion model for internal medicine physicians. PMID- 10159108 TI - What are the costs of queuing for hip fracture surgery in Canada? AB - This paper investigates the effect of wait time for hip fracture surgery in Canada on post-surgery length of stay in hospital and inpatient mortality. After controlling for observed and unobserved patient and hospital characteristics, pre surgery delay has little effect on either of the two outcome variables. Patients from higher income postal-codes experience only slightly shorter delays, and income has no substantial effect on post-surgery outcomes. For hip fracture patients surgery delay may lead to greater pre-surgery inpatient costs and more patient discomfort, but we find no evidence of a detrimental impact on post surgery outcomes. PMID- 10159109 TI - Decision making in quasi-markets: a pedagogic analysis. AB - The objective of the 1991 NHS reforms was to reduce "excessive" vertical integration by constructing a quasi-market in which incentive structures and increased availability of information would enable decision makers make better use of resources. There is, however, no overall framework in which to consider the welfare gains which result from the introduction of a quasi-market or the welfare losses which arise from distortions in a quasi-market. This paper offers an analysis which can be applied to illustrate the difficulty of estimating the welfare loss from cream skimming and also to consider the impact of local monopoly. PMID- 10159110 TI - Valuing health states: a comparison of methods. AB - In eliciting health state valuations, two widely used methods are the standard gamble (SG) and the time trade off (TTO). Both methods make assumptions about individual preferences that are too restrictive to allow them to act as perfect proxies for utility. Therefore, a choice between them might instead be made on empirical grounds. This paper reports on a study which compared a "props" (using specifically-designed boards) and a "no props" (using self-completion booklets) variant of each method. The results suggested that both non props variants might be susceptable to framing effects and that TTP props outperformed SG props. PMID- 10159111 TI - Physician demand for leisure: implications for cesarean section rates. AB - Logistic regression models test whether physician demand for leisure affects both total and unplanned cesarean section rates, after controlling for relevant clinical variables. Although nature distributes births and associated problems uniformly, time-dependent dummy variables related to leisure are significant predictors of both total and unplanned c-sections. PMID- 10159112 TI - Mark Pauly on welfare economics: normative rabbits from positive hats. PMID- 10159114 TI - Resources in print: recommendations from the field of volunteer administration. PMID- 10159113 TI - A senior volunteer/home care agency national collaboration: assessment of the partnership. AB - This research has focused on a partnership between a private sector home health care entity, the Visiting Nurse Associations of America (VNAA) and the public sector Senior Companion Program (SCP) of the domestic volunteer agency now a part of the Corporation for National and Community Service. This research examined the partnerships between the two agencies in 18 local demonstration sites in order to assess how a home health agency worked. Specific areas reviewed were administration of the partnership, communication patterns between the agencies, areas of conflict, the future of the liaison, and how effectively volunteer performance matched original expectations. PMID- 10159116 TI - U.S. consumers: which jobs are they creating? PMID- 10159115 TI - Defining the elements of a successful volunteer program in the provision of AIDS services. AB - Volunteerism has been the cornerstone of HIV/AIDS services since the founding of the first AIDS service organizations (ASOs) in the early 1980s. The work of volunteers continues to be an integral part of care in the face of limited resources and the spreading epidemic. As existing ASOs seek to improve and expand services, and communities seek to establish new organizations to combat the disease, guidelines for practice are necessary to facilitate the implementation of effective, efficient, and successful volunteer programs. This article provides a synthesis of a diverse literature base on the subject and describes the current practical experience at three large American ASOs. PMID- 10159117 TI - Information Technology, Part 1: A way to streamline medical practice. PMID- 10159118 TI - Computers in the intensive care unit: promises yet to be fulfilled. AB - Computers, whether disguised as microprocessor-controlled bedside devices or obvious as electronic patient charts, are proliferating in intensive care units. The history of the relationship between computers and intensive care units suggests that their joint development has been characterized by customization of a device or a program to automate each specific task. Failure to develop standard definitions of clinical data, standards for their interpretation, or a comprehensive model of the process of critical care retards development of computer systems beyond device-dedicated microprocessors. An agenda that gives priority to systematic examination of definitions, descriptions, and processes of critical care over additional hardware and software development is recommended. PMID- 10159119 TI - Physician workforce planning: implications for the intensivist workforce. PMID- 10159121 TI - Lymphoma's latest controversy. PMID- 10159120 TI - Septic arthritis in adults: clinical features, outcome, and intensive care requirements. AB - A review of adults with septic arthritis was undertaken to evaluate outcome of treatment and intensive care requirements in a community-based teaching hospital. During an 80-month period (1986-1992), 38 cases of septic arthritis were identified. Underlying joint disease was present in 84% of patients. Mean age was 68 years, with a range of 26 to 100 years and a median of 70 years. Patients did not always initially display signs of infection; fever was present in only 42%, and leukocytosis was present in 67%. Total in-hospital mortality was 26%, but the mortality attributed to septic arthritis was 13%. Polyarticular septic arthritis occurred in 26% of patients and carried a 40% mortality. Twenty-four percent of patients required transfer to the intensive care unit (ICU); they had a 67% mortality. Three of four patients with polyarticular septic arthritis requiring intensive care died. Average length of hospital stay for survivors receiving a full course of antibiotics was 35 days; it diminished to 14 days for 5 uncomplicated cases who received home IV antibiotics. Eighty-nine percent of survivors had return of function of the affected joints. Thirty-two percent required surgical intervention, and 5% were complicated by osteomyelitis. Septic arthritis remains a costly disease affecting primarily the elderly with underlying joint disease. Polyarticular septic arthritis and the need for ICU care portend a high mortality. The functional outcome of those who recovered was generally good. PMID- 10159122 TI - Getting to the root of transfusion errors. PMID- 10159123 TI - Understanding activated protein C resistance. PMID- 10159124 TI - Getting a grip on group B strep. PMID- 10159125 TI - Improved health services for New Zealanders. PMID- 10159126 TI - CHE (Crown Health Enterprises) benefits from decision support tool. PMID- 10159127 TI - Developing a Cognitive Therapy Centre at North Shore Hospital. PMID- 10159128 TI - Government is increasing investment in Crown Health Enterprises. PMID- 10159129 TI - Cordless in health care. Improving staff accessibility and enhancing patient care. PMID- 10159130 TI - New maternity arrangements. PMID- 10159131 TI - Monitoring report on RHS's performance. PMID- 10159132 TI - Patients' beliefs about their illness are important for recovery. PMID- 10159133 TI - IS (information system) profits: the sky is the limit? PMID- 10159134 TI - Case studies. Integration has special character at physician-led teaching systems covering vast geographic areas. PMID- 10159135 TI - Work redesign. Using complaints to analyze and address customer needs. PMID- 10159136 TI - The rigors and rewards of clinical evaluation in an alliance of academic health systems. AB - The University HealthSystem Consortium (UHC), a 70-member alliance of academic health centers, was established in 1984 to help its members improve clinical practice and to strengthen their competitive position in the health care market. This article describes the programs of the UHC's Clinical Practice Advancement Center and its progress to date in promoting strategies to control cost, demonstrate value, and improve health care quality. PMID- 10159137 TI - Clinical process improvement: engage first, measure later. AB - The Institute for Clinical Systems Integration (ICSI) is a non-profit quality improvement organization that bridges 20 medical groups and integrated health care systems in the Minneapolis-St. Paul area. Created in 1992 by HealthPartners, HealthSystem Minnesota, and Mayo Clinic as a part of a contract awarded by the Buyers Health Care Action Group, a purchaser coalition, ICSI's aim is collaborative, continual improvement of the clinical care provided by its member institutions. ICSI's main focus is health care guideline developement and implementation. This article describes this process, as well as evidence of program effectiveness and "lessons learned." PMID- 10159138 TI - Clinical practice evaluation at Providence Health System. AB - Over the past seven years, Providence Health System (PHS) in Portland, Oregon, has used an outcomes research paradigm to study treatment of back pain, coronary artery disease, total joint replacement, and cancer. In presenting case studies of each of these areas, the authors chronicle the evolution of clinical practice evaluation at PHS, beginning with early studies in the 1960s, to the establishment of the Center for Outcomes Research and Education (CORE), to the formation of a new systemwide strategy that is responsive to the evolving health care marketplace. PMID- 10159139 TI - The change process and a clinical evaluation unit at University of Massachusetts Medical Center. AB - In the late 1980s, the University of Massachusetts (UMass) began its evolution toward the creation of a clinical evaluation unit (CEU). This article presents an overview of the history leading up to the formation of our clinical evaluation program and some of the projects developed to measure and improve clinical outcomes and reduce costs. Our experience in establishing the UMass CEU reflects an attempt to change clinical practice through effecting organizational change. PMID- 10159140 TI - Academic quality improvement: new medicine in old bottles. AB - Academic medical centers and clinicians have been slow to embrace continuous quality improvement. The Mount Sinai Medical Center in New York has created a new Department of Health Policy that combines an academic research mission with an administrative mission to demonstrate improving quality of care. This article discusses the conceptual framework that undergirds this new effort, its organizational structure and initial agenda of activities, and why we believe it will succeed in engaging academic physicians in quality improvement. PMID- 10159142 TI - Guideline-based performance measurement creates education and training imperatives. AB - Clinical practice guidelines have introduced a new dimension to facility-level performance measurement--one which requires caregivers to change the way they have traditionally evaluated patient care practices. To successfully integrate guideline-derived evaluation tools into their performance measurement activities, practitioners and quality management professionals face new education and training challenges. PMID- 10159141 TI - Emory University Center for Clinical Evaluation Sciences: a model for clinical practice evaluation in the changing environment of the academic health center. AB - Changes in the health care marketplace have had a profound effect on academic health centers and their traditional missions: teaching, patient care, and research. Many academic health centers have recognized the need to develop a capability for evaluating clinical practices and organizational restructuring. The Center for Clinical Evaluation Sciences at Emory University represents a model for the integration of evaluative capabilities into academic clinical practices. PMID- 10159143 TI - Chaos theory and clinical pathways: a practical application. AB - Nonlinear analysis can improve the adaptive ability of clinical paths and aid in providing improved continuity of care. This article continues our exploration of the ways "chaos theory" can be applied in health care by focusing on clinical applications. It describes a specific application of nonlinear techniques to knee arthroplasty, but the generalized nature of the technique suggests it can be applied in many other settings. The approach offers an innovative means for both improved patient care and cost savings. PMID- 10159144 TI - Update on the Safe Medical Devices Act of 1990: current hospital requirements and recommended actions 1996. AB - This document updates the recent changes in the Safe Medical Devices Act. Facilities must comply with the new changes effective July 31, 1996. Some information in this document is taken from a previous technical document written in 1992 by Henry Alder. Also included in this document is some FDA information, which can also be obtained through the Freedom of Information Act. Please also note information being offered by the American Hospital Association on page 18. PMID- 10159145 TI - Medicaid Program; Medicaid eligibility quality control, progressive reductions in federal financial participation for FYs 1982-84, payment for physician billing for clinical laboratory services, and utilization control of skilled nursing facility services: removal of obsolete requirements--HCFA. Final rule. AB - This final rule removes several obsolete sections of the Medicaid regulations that specify rules and procedures for disallowing Federal financial participation for erroneous medical assistance payments due to eligibility and beneficiary liability errors as detected through the Medicaid eligibility quality control program for assessment periods from 1980 through June 1990. The Medicaid regulations that contain the rules and procedures for the progressive reductions in Federal financial participation in medical assistance expenditures made to the States for fiscal years 1982 through 1984 are removed to reflect the repeal of the statutory bases for the reductions. The Medicaid regulations that provide for physician billing for clinical laboratory services that a physician bills or pays for but did not personally perform or supervise are removed to reflect the statutory repeal of this provision. In addition, the rule removes obsolete regulations that prescribe requirements concerning utilization control of Medicaid services furnished in skilled nursing facilities. This rule is part of the Department's initiate to reinvent health care regulations and eliminate obsolete requirements. PMID- 10159146 TI - Making sense of conflicting reports: what patients really think of managed care. PMID- 10159147 TI - Why it pays to go 'online'. PMID- 10159148 TI - Know these five things before you're capitated. PMID- 10159149 TI - Physician-owned HMOs turn up the heat in Florida. PMID- 10159150 TI - Making guidelines effective takes more than a memo. PMID- 10159151 TI - The dangers--and opportunities--of a maturing health care market. PMID- 10159153 TI - 'Managed care has become the norm'. PMID- 10159152 TI - Ethics catches up to law: what is most fair for all? PMID- 10159154 TI - Who pays salaried physicians best? PMID- 10159155 TI - What it's like to be a salaried physician. PMID- 10159156 TI - Are salaried doctors happier? PMID- 10159157 TI - When they want your network, but don't want all its members. PMID- 10159158 TI - The 30-minute practice checkup. PMID- 10159159 TI - Teaching tomorrow's doctors to choose cost-effective care. PMID- 10159160 TI - Accountability in managed care: what should we expect from patients? PMID- 10159161 TI - Xerox hires middlemen to manage day-to-day health plan activities. PMID- 10159162 TI - How managed care affects hospitalization. PMID- 10159163 TI - Revised variance tracking system sparks better documentation, data. PMID- 10159164 TI - How to cover the gap between acute, home care. Guidelines--not pathways--guide care. PMID- 10159165 TI - CHF (congestive heart failure) path cuts length of stay, saves $2,300 per case. PMID- 10159166 TI - Cross training is key to cross-continuum success. PMID- 10159167 TI - Keep case management out of cyberspace void. PMID- 10159168 TI - AIDS. Crisis, what crisis? PMID- 10159169 TI - AIDS. To the lighthouse. Interview by Janet Snell. PMID- 10159170 TI - Emergency admissions. Acute relief. PMID- 10159171 TI - Dentistry. Crowning glory. PMID- 10159172 TI - Data briefing. PFI (Private Finance Initiative): RIP? PMID- 10159173 TI - Increased Medicare margins are catching Congress's eye. PMID- 10159174 TI - Los Angeles moves to managed care for Medi-Cal. PMID- 10159176 TI - Steps to smoother collaboration. Being aware of common obstacles makes for successful negotiations. PMID- 10159175 TI - Merging with for-profits: flawed strategy. Such affiliations benefit neither the Catholic hospital nor society. AB - Some Catholic healthcare organizations, seeking new sources of capital, are eyeing mergers with for-profit systems. However, such mergers raise questions about their effects on both the mission of particular Catholic institutions and the well-being of society at large. For-profit organizations are driven by the pursuit of profit. They market ?products.? This pursuit naturally shapes their decision-making rationales, employee relations, and business priorities. Not for profits, on the other hand, provide ?public goods?--goods that for-profits either will not provide or will not provide adequately--and this mission shapes their priorities, decision making, and employee relations differently. What is more, economic power is unequal between the two kinds of organization. Since not-for profits are seeking capital when they merge with for profits, they usually do so from a position of relative disadvantage. When conflicts arise, the for-profit partner generally prevails. The not-for-profit partner then finds itself, not merged with, but acquired by the for-profit. Throughout U.S. history, not-for profits have performed a function neglected by both government and private companies. Now, in the 1990s, the whole social welfare framework of our society is under attack. A moral-political crisis questions the very concept of the voluntary sector. If Catholic healthcare organizations allow themselves to be swallowed by for-profits, who will care for the voiceless and the vulnerable? PMID- 10159177 TI - Improving pain management practice. A medical center moves beyond education to document and manage patient care. AB - In 1993 nurses at Providence/ Portland Medical Center, Portland, OR, initiated a quality improvement project to assess pain levels in the facility's inpatients. A convenience sample in April 1993 showed an average pain intensity of 6.30 on a 0 10 scale (where O equals no pain and 10 is the worst pain imaginable). With the nursing administrator's support, pain management nurses presented a four-hour course in the basics of pain assessment and intervention to more than 850 nurses and 100 other professionals. In August 1993 nurses found that the intensity of patient pain had dropped to 5.70 on the 0-10 scale. Still dissatisfied with this situation, the nurses proceeded with a three-pronged approach to improve the medical center's quality of pain management: making the problem visible by better documentation and communication about pain; making an institutional commitment to pain management, including establishing pain management quality improvement as the medical center's first patient outcome institutional objective; eliciting the endorsement of influential committees. In August 1994 a random sample revealed patient pain had decreased to 3.21. The next step focused on empowering patients and families through education (e.g., revising the booklet on patient rights and responsibilities, posting signs in rooms encouraging patients to report pain) and clearing up myths and misconceptions through inservices and posters. A sampling in November 1995 showed that the average pain intensity of inpatients had been reduced to 2.32. Plans for continuous quality improvement interventions will further enhance patient comfort and recovery. PMID- 10159179 TI - "Spiritlinking": a key to dynamic change. Fostering chaos enables leaders to form the networks and unity needed to fulfill their mission. AB - To contend with the anxiety and chaos inherent in rapid change, leaders can turn to ?spiritlinking,? the deliberate and untiring act of building the high-energy networks where new ideas are born and new ways of delivering service take form. Spiritlinking leaders are able to envision and promote the paradox of disequilibrium. They seek truth, pushing the organization into a condition of imbalance where staid settledness gives way to new paradigms founded on constant transformation. Spiritlinking leaders are not bound by organizational charts. They have discovered that the greater the participation in the organization, the greater the access to vast amounts of information and insight, which will ultimately lead to profound transformation. Spiritlinking is directed toward networking, community forming, and coalition building, often across chasms of ideological differences. Leaders must have the skill to manage the vision, which entails generating courage and belief through the cloudiness of ambiguity. Spiritlinking leaders must also create synergy from conflict, gathering strong minded, self-assured persons who perhaps hold vastly differing perspectives, yet, in working for the common good, arrive at surprising, wonderful decisions. Finally, spiritlinking leaders assist the organization in working through resistance by identifying the mode, motive, and meaning of the resistant behavior and determining the action the organization is willing to take to move beyond it. PMID- 10159178 TI - Selling from a position of strength. A Charlotte, NC-based congregation gives up two hospitals. AB - In 1993 the leaders of Mercy Health Services, a two-hospital system in Charlotte, NC, decided to seek a collaborative arrangement with another organization. They did this because, although Mercy was financially sound, it was generating less revenue and attracting less managed care business than its two competitors. In September 1994 Mercy's leaders signed a partnership agreement with the Charlotte Mecklenburg Hospital Authority (CMHA), a public system that was the area's largest. Unfortunately, the agreement failed to integrate the two systems, so they continued to behave as competitors. It was also clear that CMHA, having eight board members to Mercy's four, would dominate the partnership. By early 1995 Mercy's sponsors, the Sisters of Mercy of North Carolina, had concluded that their presence was no longer needed in acute care in the Charlotte area. They and the system's lay leaders decided it would be best to end the partnership and sell their system outright to CMHA, which they did in June, for $115 million. The congregation used that money to create a foundation that will provide services for the unserved and underserved. PMID- 10159181 TI - Innovators in healing. 1996 Achievement Citation winners and nominees. Catholic Health Association of the United States. PMID- 10159180 TI - Flattening the hierarchy. A hospital streamlines managerial layers to meet market demands. AB - In the early 1990s it became clear to the leaders of St. Edward Mercy Medical Center, Fort Smith, AR, that the traditional ?functional? model of organization, on which their hospital was based, did not allow it to meet new market demands. A core group of managers was formed to design a new organizational model and engineer the move toward it. Analyzing the hospital's structure, the core group found that it had too many administrative layers above too many specialized departments. In 1994 the group decided to adopt a span-of-control model of organization, which would give St. Edward a higher ratio of workers per manager. In 1995 the core group streamlined the hospital's managerial layers, deciding there would be no more than five. It reduced the number of supervisory positions by 36, including one vice president's slot. No manager was fired, though some were reassigned. St. Edward's reorganization continues at present. The new structure, which has cut personnel costs, fosters more open communication and empowers its workers, leading them to think in terms of ?us and our hospital? rather than ?me and my department.? PMID- 10159182 TI - Brooklyn hospital throws a party for its community. PMID- 10159183 TI - Health planning as context-dependent language play. AB - The concept of planning as context-dependent language play is proposed as a heuristic device to overcome shortcomings which are traced to the planner centered, means-end and prescriptive orientations of much of the existing literature on health planning. The model proposed suggests that planning should be analysed not simply in terms of the capacities and/or responsibilities that it claims to assign to planners, but also in the way that different planning discourses are mobilized, for strategic effect, by a range of other players in front-stage and back-stage settings. Within this conception, a planning exercise comes to be seen as an episode in dramas which have been running for extended periods of time. What distinguishes planning episodes from others in these dramas, is not simply the entry of players designated as planners, but also the discourses that both planners and other players mobilize as they attempt to structure and contest their relationships with one another. The implications of what this conception of planning holds for future research are then discussed. PMID- 10159184 TI - Concepts and methods for assessing the quality of essential obstetric care. AB - Approaches to reducing maternal mortality and morbidity have attracted much attention in the last decade. It is recognized that availability and use of essential obstetric care (EOC) of sound quality by women in labor would reduce the burden of illness and death resulting from pregnancy. However, the literature on methods for defining, assessing and improving the quality of EOC at the point of service delivery in developing countries is quite weak. Drawing upon fundamental concepts of quality assurance, statistics, clinical practices and health service management, this article presents unifying concepts and methods for defining, assessing and improving the quality of EOC in developing country settings. It argues that any intervention that would improve the quality of EOC must act through at least one of three mechanisms: improve the clinical management of uncomplicated labor; improve the detection of complications of labor; or, improve the clinical management of complications of labor. The text presents the basis for using quantitative and qualitative methods to assess the quality of EOC. It concludes that any method to assess the quality of EOC, as a basis for improvement at the health center level, must satisfy the following seven criteria: (i) be derived from scientifically sound and locally defined guidelines for what constitutes care of good quality; (ii) enable objectively verifiable measurements of the performance of critical tasks; (iii) be sufficiently discriminating to detect variations in quality among health centers, thereby enabling managers to focus on improving care in those health centers providing care of lower quality; (iv) facilitate production of visual aids within each health center, thereby enabling midwives, doctors and their supervisors to use information for improving their work on a daily basis; (v) include qualitative assessments to facilitate interpretation of quantitative information; (vi) be reasonably simple to use without unsustainable foreign technical assistance; and, (vii) be affordable within the limited resources of public health facilities and District Health Management Teams. PMID- 10159185 TI - 'Doi moi' and health: the effect of economic reforms on the health system in Vietnam. AB - The article examines changes which have taken place in the health system in Vietnam as a result of the economic reform process dating back to the late 1980s. With the liberalization of the economy have come not only growth for many, and increased choice, but also increased income and regional disparities and the problem of access to social services for those households which are less successful in the market economy. While state official policy emphasizes equity and free access to services for the poor, health costs for patients have risen substantially in the form of official and unofficial payments to staff and payments for drugs. The public sector faces an unprecedented challenge in the form of dramatic decreases in the utilization of public facilities; a shift towards self-prescription and, to a lesser extent, private practice by public employees; and, increasing reliance on foreign donors for support to preventive programmes. The article makes some recommendations on priorities for health policy in Vietnam to face these challenges. PMID- 10159186 TI - A time to gain, a time to lose: new directions for western European HIV/AIDS alliances. AB - The complex and varied needs of people with HIV/AIDS have prompted major changes in the way that health care is organized and delivered. In the USA, the Netherlands and the UK, many HIV service providers have formed alliances to better coordinate policies and programs. These structural reforms have been accompanied by extensive reforms in the financing of health services. Drawing upon case studies of seven HIV/AIDS alliances in the Netherlands and the UK, the article examines how alliances are adapting their missions, organizational structures and functions to be responsive to changing community attitudes and the gradual elimination of earmarked HIV/AIDS funding. The case studies suggest strategies for maintaining interorganizational cooperation around public health issues in unstable and competitive funding environments. PMID- 10159188 TI - Economic effects of the outmigration of obstetric services in a rural county. AB - Obstetrical health care resources have been declining in rural areas since 1980, resulting in reduced prenatal care that can result in higher medical costs. Loss of health care services is known to have negative economic consequences for rural communities. This article illustrates how hospitals and other providers of medical services can be used as vehicles for local economic development. Provision of medical services is an important component of the economic base of all communities and especially of small rural communities with hospitals. When a community loses medical services to another community, it loses both direct and indirect economic benefits. The research presented here analyzes the economic effects of outmigration of obstetric services from a rural "perimeter" community in Wyoming. The combined direct and indirect economic losses are shown to be significant. Annual revenue losses to the local hospital were estimated as high as 12 percent. It is important to make explicit the economic losses that result from reductions in health care. Such research, combined with knowledge of negative health and social factors can provide community leaders with additional motivation to find solutions to declining health care in rural areas. PMID- 10159187 TI - Shoring up protection of personal health data. PMID- 10159189 TI - An epidemiologic approach to assessing primary care needs in rural Illinois. AB - One persistent problem that faces state and federal health policy-makers is determining the level of primary care needs of the citizens they serve. To refine the decision making process in Illinois, a model was developed to compare the 84 rural counties of Illinois and their potential need for additional primary care interventions. Using expert panel methods, a group of public health professionals selected a set of 31 health status indicators that were available at the county level throughout the state. Next, the panel developed a weighting system for those indicators. These weighted values were then applied to the demographic and epidemiologic data from each of the counties to rank the counties on the basis of need. Indicators having the highest correlation with the weighted sum were the percent of the population enrolled in Medicaid, lung cancer mortality rate, general population mortality rate, proportion of population at poverty level, and percent of births to teens. Data also showed that the rural counties with the greatest needs clustered in five geographic regions. The identification of these five geographic clusters may facilitate collaborative efforts in meeting the primary care needs of these populations. PMID- 10159190 TI - Breast cancer screening in rural populations: a pilot study. AB - This report describes the development and implementation of a pilot intervention project designed to determine the economic, logistic, behavioral, and attitudinal variables that influence rural women's participation in a community-based breast cancer screening program. This paper reports on survey responses of women who registered for this pilot breast cancer screening program. It includes information on all women who registered for the project--both those who received breast cancer screening and those who did not. The study is a pilot intervention project, the overall goal of which was to develop a network of community providers, organizations, and volunteers to facilitate breast cancer screening among rural women. Of the 159 women registered for this pilot program, 101 (63.5%) were screened (receiving both a clinical breast examination and mammogram). The attitudes of women surveyed through the project confirm the importance of a physician recommendation for breast cancer screening. More than 90 percent of both the screened and unscreened groups of women stated that a doctor's recommendation to have breast cancer screening is important. Further, nearly 42 percent of the unscreened group had never had a physician recommend breast cancer screening. Despite existing barriers to screening, this pilot study demonstrated that health care professionals and regional organizations that have not traditionally been associated with delivering health care in this particular community setting can successfully work together to implement breast cancer screening programs. PMID- 10159191 TI - Identifying health care needs of rural Ohio citizens: an evaluation of a two stage methodology. AB - The purpose of this study was to determine the health care needs of rural Ohio from the perspectives of health care providers and consumers using a two-stage methodology. In stage one, 12 focus groups were conducted in six rural areas: six groups of consumers and six groups of health care providers. A total of 53 consumers and 53 health care providers participated in the sessions. The participants identified 124 health care issues. In stage two, a questionnaire was developed to determine the importance of all issues identified in the focus group sessions. The questionnaire was mailed to all focus group participants and also to individuals invited to participate in the focus groups who were unable to attend. Individuals were asked to rate the importance of each health care issue in their community on an 11-point scale (0=not important, 10=extremely important). A total of 207 (56.9%) usable questionnaires were returned. Mean (+S.D.) values were calculated for each health care issue, and the most important were (1) issues related to the financing and cost of health services and insurance, and (2) concerns associated with characteristics and behaviors of rural residents. The two-stage methodology provides a mechanism for identifying the concerns of providers and consumers and allows for these perspectives to be considered in the planning and development of strategies to address issues surrounding rural health care. PMID- 10159192 TI - Providing birthing services in rural health networks: coping with change in New York State. AB - Making prenatal and birthing services accessible in rural communities no longer able to support a local full-service hospital and the introduction of managed care cost control has led to consideration of alternative models. One such model, the freestanding birth center located in an isolated rural community, challenges the guidelines of several state and professional organizations directed at assuring adequate emergency response, including cesarean sections. An extensive review of freestanding birth centers and their effect on birth outcomes revealed little outcomes data about birth centers distant from full-service hospitals. Most states have modeled their birth center regulations on recommendations from the National Association of Childbearing Centers, but others, such as New York, have more rigidly defined transport parameters that exclude many rural locations. A consensus panel convened by the New York State Rural Health Council concluded that demonstrations projects featuring a rural birthing center farther than 20 minutes from a full-service hospital and operated within a networked rural health system should be developed. Consumers would need to be fully informed about the implications of their choice of birth services and all qualified providers, including midwives, should be included in a team approach to care giving. PMID- 10159194 TI - AHA developing plan for new trade group library. PMID- 10159193 TI - The influence of insurance status and income on health care use among the nonmetropolitan elderly. AB - The objective of this research is to examine the influence of income and type of insurance coverage on the use of health services among the nonmetropolitan elderly. A model of health services utilization is used as the foundation for examining this issue with data from a telephone survey of a randomly selected sample of residents from four nonmetropolitan counties in Pennsylvania. Results indicated that those elders with Medicaid coverage were less likely to visit a doctor than respondents with private insurance or Medicare only, even after controlling for income and other relevant factors. Further, lower income respondents with Medicare were less likely to visit the dentist than those with private insurance (Medicare does not cover dental care). In contrast, neither income nor insurance predicted hospital use. As such, the health and dental care needs of many lower income nonmetropolitan elders may potentially be going unmet. In general, findings highlight the continued relevance of economic barriers to the use of such services among the nonmetropolitan elderly. PMID- 10159195 TI - AHA elects board members, issues awards. PMID- 10159196 TI - 2 AHA marketing societies merge. PMID- 10159197 TI - Providers undaunted by PacifiCare-FHP link. PMID- 10159198 TI - JCAHO, OSHA team up on safety. PMID- 10159199 TI - Medicare, Medicaid are next targets for reform. PMID- 10159200 TI - Insurance reform brings good news and bad news. PMID- 10159201 TI - Reform may spur long-term-care insurance sales. PMID- 10159202 TI - AHA delays action on 'value statement' until year-end. PMID- 10159203 TI - Curtain closes on AHA summer convention. PMID- 10159204 TI - Going for a knockout. Dems sense GOP vulnerability over future of Medicare. PMID- 10159205 TI - More doc candidates entering the ring. PMID- 10159206 TI - Not-for-profits doing more cash deals. PMID- 10159207 TI - Power struggle with system leads to hospital board's ouster. PMID- 10159209 TI - Accreditation growing to fit health systems. PMID- 10159208 TI - 'Clinical integration' means key shifts for OR managers. PMID- 10159210 TI - Should scrub suits be laundered at home? PMID- 10159211 TI - Seizing competitve edge in outpatient surgery. PMID- 10159212 TI - Outpatient changes that will make surgeons want to stay. PMID- 10159213 TI - Benchmarking and supplier networking--best practice approaches. AB - This article examines the approach adopted by a health service to benchmark outside the health industry and to network with its own suppliers in its quest for best practice. The Maryborough District Health Service was selected for funding under the Commonwealth Government's Best Practice in the Health Sector Program. This rural health service is setting a fine example of how generic benchmarking can be used to increase efficiency and improve outcomes in an environment of change, increasing demands, and contracting resources. The organisation has networked with its suppliers with a view to ensuring that, as a customer, it has access to the best quality goods and services. The objective is to improve the services and quality of patient care provided by the health service and to minimise its cost structures. PMID- 10159214 TI - The Australian Cancer Network--a strategy to improve cancer health outcomes. AB - Cancer control in Australia has become a major social priority because of the increasing impact of cancer on providers and users of health care. In recognition of this situation there is now an increased response by government agencies, nongovernment organisations, health planners, and the community at large to focus on cancer as part of a National Health Goals and Targets Strategy for better health outcomes in the next century. The following paper explores how the Australian Cancer Network effectively contributes to a national cancer control strategy. PMID- 10159215 TI - Casemix funding in psychiatry: some problems and common pitfalls. AB - The aims of this study were to evaluate the accuracy of AN-DRG version 2.0 codings. Ninety-two separations, covering three of the most commonly occurring AN DRG in psychiatry, were reviewed by a psychiatrist. The AN-DRG diagnosis was then compared to that given by morbidity coders. There was agreement for 69 (79 per cent) separations and disagreement for 18 (21 per cent) separations. Recoding of the 18 separations altered average length of stay data and the funding received. The high error rate of coding stimulated changes to the training of morbidity coders and registrars. PMID- 10159216 TI - An outcomes approach to population health at the local level in NSW: practical problems and potential solutions. AB - While a health outcomes approach has the potential to improve the health status of Australians as well as health service efficiency, such a policy will be successful only if practice at the local level follows suit. This paper briefly reviews the health outcomes approach and describes how the Central Sydney Area Health Service has established a Needs Assessment & Health Outcomes Unit to help improve health outcomes. The paper discusses issues in working with population health outcomes at the local level, such as the usefulness and limitations of routinely collected data for planning and managing health services, problems of small area data, gaps in the documentation of national health goals and targets, problems of attribution of improved outcomes to specific interventions, and definition of responsibilities for action at the local level. It offers some potential solutions relevant at the local level. PMID- 10159217 TI - Does the NAIP classification predict length of stay in rehabilitation, geriatrics and palliative care? AB - The Australian National Non-Acute Inpatient Project (NAIP) reported its findings on casemix in rehabilitation and slow stream geriatric medicine in October 1992. It proposed a per diem NAIP classification of 19 classes using six major clinical groups and the resource utilisation groups version three activities of daily living index (RUG III ADL index). Weightings were determined based on time spent by clinical staff in treating these patients. A quality management study was undertaken in the rehabilitation, geriatrics, and palliative care wards of the Illawarra Area Health Service for three months in 1993, analysing length of stay and cost against the predictive weights of the NAIP classification. The study concluded that this classification was an acceptable predictor of per diem costs of care in these wards of the Illawarra but was not a good predictor of length of stay. PMID- 10159218 TI - The new market in health care: prospects for managed care in Australia. AB - Most developed countries are experimenting or moving at full speed to implement new forms of health delivery based in part on capitation arrangements and stronger accountability of health service providers. Proposals for introduction of capitation or managed care have been advanced in Australia but have attracted strong opposition from the medical profession. This paper reviews the policy issues surrounding the introduction of managed care, including how Australia's current institutional forms may evolve into managed care provision. PMID- 10159219 TI - An overview of the role of government in the organisation and provision of health services in Japan. AB - This article is illustrated with reference to health services in the Tokyo Prefecture. It seeks to describe the role of government in the organisation and provision of health services in Japan. It is based on experiences gained from a three-month placement at the Tokyo Metropolitan Government Bureau of Public Health in late 1994. Wherever possible the article identifies similarities and differences between the Japanese and Australian health care systems. Part of the analysis has been to identify areas where opportunities exist for Australian health service providers to develop further cooperation with particular sectors of the Japanese health system and also where the potential for the export of health services may exist. The health systems of Australia and Japan have points of similarity and difference. Essentially both systems operate within the context of a compulsory universal health insurance system. However, unlike Australia, the bulk of service provision in Japan is left to the private sector, while government retains the primary role of regulator. It is interesting to observe that while the Australian health care system is currently exploring options to expand the service range and level of participation of private sector services in health care delivery (within the context of universal health insurance), the Japanese health care system appears to be examining options through which further government intervention can improve service access and service efficiency. Japan presents opportunities to observe the benefits and disadvantages of predominantly private sector provision within the context of universal health insurance coverage. PMID- 10159220 TI - Silk road: opportunities for foreign-owned health care clinics in China. AB - Hospitals and other health care providers are being squeezed by declining reimbursement and capitated revenues. As this happens they are looking to expand into rapidly developing and newly industrialised countries. This article will focus on the People's Republic of China as a country with opportunities for developing private hospitals and health care facilities. PMID- 10159221 TI - Bringing scheduling to the enterprise. PMID- 10159222 TI - Making the executive decision. PMID- 10159223 TI - The CPR: the great data debate. PMID- 10159224 TI - The clinical data repository: provider survey '96. PMID- 10159225 TI - Moving & managing images. PMID- 10159226 TI - The quest for intelligence. PMID- 10159227 TI - Healthcare and the Internet: a friendship in the works. PMID- 10159228 TI - The Functional Imaging Laboratory, 12 Queen Square, London. PMID- 10159229 TI - Ashworth Special Hospital, Liverpool. PMID- 10159230 TI - Fire training in a community based NHS trust. PMID- 10159231 TI - Hospitals benefit from district cooling scheme in Sweden. PMID- 10159232 TI - The quality movement in higher education in the United States. AB - Continuous quality improvement (CQI), often implemented as part of an integrated management system called total quality management (TQM), has been institutionalized within many manufacturing, military and service organizations in the USA as a response to declining market share, low productivity and customer complaints about poor quality. Signs and symptoms suggest that higher education has similar problems which are systematic and relate to the quality ot higher education, financing, facilities, curriculum and graduates. In the 1990S, the quality movement has begun to spread to the field of education as a means of diagnosing and treating the problems widely recognized as residing in US educational institutions, especially in colleges and universities. Many business leaders and authors believe that 'quality is the most important strategic issue facing top management in the 1990s'. This belief arises partly due to the fact that managers are beginning to understand the relationship between healthy, high quality organizations and healthy profits. This article traces the recent US quality movement from its roots in manufacturing and the military, its adoption by service institutions, and its more recent application by higher education institutions. PMID- 10159233 TI - Using scientific evidence to improve information practice. AB - The recent policy statement of the Medical Library Association (MLA) takes the position that scientific evidence is the basis for improving the quality of library and information sciences now and in the future. Research activity is seen as the foundation of an evolving knowledge base for the profession--a knowledge base that will set health sciences librarians apart from others in an increasingly competitive world of information service providers. The statement represents the culmination of many years of activity by association members, during which the role of research in health information practice has been debated. Over a similar time period, the quality movement, with its increasing demand for the collection and use of data, has been growing. Developments such as total quality management (TQM) and continuous quality improvement (CQI) reinforce the centrality of research with its increasing demand for the collection and use of data, has been growing. Developments such as total quality management (TQM) and continuous quality improvement (CQI) reinforce the centrality of research and its relationship to efficient and effective information practice as envisioned in the MLA policy statement. PMID- 10159234 TI - Using evaluation research methods to improve quality. AB - The idea of evaluation, or the measurement of a person, a service or a programme against some type of yardstick, has been around for a long time. In everyday language, the term evaluation is used to refer to everything from employee performance appraisal, to informal opinions about whether a particular service appears to be working well, to carefully planned and executed programmes of evaluation. In the past, librarians have tended to rely on their own professional judgement as a primary means of informal evaluation, and as long as the librarian was considered competent by others in the organization, this method seemed to work reasonably well. In the rapidly changing fiscal climate of the 1990s, greater demands for accountability are altering the standards of evaluation, and informal methods based on professional judgement are less and less likely to be seen as adequate. Formal evaluation is becoming even more important as management strategies, such as total quality management (TQM) and continuous quality improvement (CQI), are adopted--strategies that rely on gathering and using data for measuring service quality. Although programme jargon such as TQM and CQI may change in the future, it is likely that the evaluation process inherent in these approaches will continue to be an important management tool for deciding on the allocation of scarce resources. PMID- 10159235 TI - Quality assurance in health sciences literature searching: applying the ISO 9000 quality standard. AB - Medicine is a literature-based discipline. Ensuring that the literature review which precedes a significant piece of medical research has met predetermined standards is essential. A list of items reviewed carries no guarantees that all appropriate items have been included in the survey of the literature, or that appropriate sources have been efficiently searched. This would be a matter for concern in any discipline. In medicine it is a matter of life and death. Quality assurance procedures that offer guarantees of the standards built into the process, rather than quality control which measures only outputs, can provide the necessary reassurance. The ISO 9000 quality standard offers a much needed quality assurance process. A methodology for applying the ISO 9000 standard to the task of searching the medical literature is outlined in this paper. A new role for medical librarians in promoting a rigorous methodology in the literature review equal to that of the research it supports is defined. PMID- 10159236 TI - The quality and impact of MEDLINE searches performed by end users. AB - Evidence suggests that MEDLINE is becoming an important clinical tool that can improve the care and health of patients. Efforts to improve the quality and impact of end-user searching are needed and ongoing. End users are completing many MEDLINE searches. They appreciate and value training along with feedback on their searching techniques. Practice, is however, the biggest single factor in improving the quality of searching. Key roles for the library in end-user searching include, providing the most effective MEDLINE access possible to the maximum number of users, and providing training that includes feedback and practice opportunities. System-wide advances in structured abstracts, indexing, system design, informatics research and the literature itself will make searching easier and more effective in the future. More important than the quality of search results per se is the impact that end-user searches have on patient care and patient outcomes. Growing evidence shows that both patient care and patient outcomes are improved by end-user searches. PMID- 10159237 TI - The value of information supplied to clinicians by health libraries: devising an outcomes-based assessment of the contribution of libraries to clinical decision making. AB - The Value project, a study funded by the British Library Research and Development Department and a group of postgraduate medical deans, has examined the effectiveness of NHS library and information services. Clinicians at 11 hospital library sites were asked to describe the purposes for which they needed information, the steps they took to obtain it, and to assess the value of the information obtained from interlibrary loan requests, database searches and end user searches. A sample of non-library users and of users of the BMA Dial-Up MEDLINE service were also asked similar questions. Results show that information did, or would in the future, assist in personal clinical decision-making and which kinds of decisions were most supported. Information new to clinicians was often provided. Follow-up interviews provided illustrations of the ways in which developments aimed at more cost-effective patient care were supported by information obtained from the library. Results are being used to guide the production of a quality assurance toolkit to help libraries audit their services and improve the delivery of information to clinicians. PMID- 10159238 TI - Improving interlibrary loan quality through bench-marking: a case study from the Health Science Information Consortium of Toronto. PMID- 10159239 TI - Selecting processes to bench-mark; a key step in quality improvement--a case study in an academic medical library setting. PMID- 10159240 TI - Yet more evidence ... R&D in health information. PMID- 10159241 TI - Investigating indoor air quality complaints. PMID- 10159242 TI - Multi-disciplinary patient assessment throughout the continuum of care. PMID- 10159243 TI - Coming to terms with the impact of a hospital merger. PMID- 10159244 TI - Establishing a successful point-of-service collection program. PMID- 10159245 TI - Mercy Medical Center: a true healthcare system for a rural community. PMID- 10159246 TI - Identifying and using key clinical, financial, and efficiency indicators for patient-focused care. PMID- 10159247 TI - Capitated contracts: managing financial risk. PMID- 10159248 TI - Use of malpractice data in medical staff credentialing. PMID- 10159249 TI - Health care risk management: security perspective. PMID- 10159250 TI - Developments in health care risk management. PMID- 10159251 TI - Malpractice claims closed against hospital defendants in Florida: 1986-1993. PMID- 10159252 TI - Stats. In the track of case carts. PMID- 10159253 TI - Thrill of victory lights team spirit in Mat. Man. Olympics. PMID- 10159254 TI - Picking up some things from grocers. PMID- 10159255 TI - OR services get a boost from 'quick wins'. PMID- 10159256 TI - Six findings on latex may change the way you buy. PMID- 10159257 TI - Supply pricing update. Price comparison shopping. PMID- 10159258 TI - Shift myths: misguided scheduling could cost you. PMID- 10159259 TI - Kilowatts and BTUs: generating a plan for energy procurement. PMID- 10159260 TI - Monitoring quality: the front office versus the front line. Interview by Elaine Zablocki. PMID- 10159261 TI - Creating an integrated credentialing system. PMID- 10159262 TI - HEDIS 3.0 released; outcomes measures added. PMID- 10159263 TI - Effect of system restructuring on quality leadership, Part 2. PMID- 10159264 TI - The coalition movement grows up. PMID- 10159265 TI - The Minnesota experiment. PMID- 10159266 TI - Small-employer co-ops pick up speed. PMID- 10159267 TI - Can coalitions expand coverage? Collective purchasing won't make the difference. PMID- 10159268 TI - Can coalitions expand coverage? Progress on two fronts yields advances on a third. PMID- 10159269 TI - Coalition close-ups. PMID- 10159271 TI - Demand management: dial-a-nurse. PMID- 10159270 TI - Stopping the bucks. PMID- 10159272 TI - Flirting with the financials of fat in the workforce. PMID- 10159273 TI - Data watch. Differing views of what should be covered. PMID- 10159274 TI - Disease management: partnering for better patient care. AB - Disease management is having a profound effect on the evolution of health care delivery toward an integrated system. Management strategies include coordinating professional services, empowering patients, and analyzing outcomes data. The managed care approach to disease management has expanded, to some degree, across all models of HMOs in an effort to document cost-containment efforts and improved outcomes. Pharmaceutical manufacturers and pharmacy benefit management companies are highly active in developing programs. The author discusses 10 steps toward implementing a successful disease management program through partnering with other organizations. PMID- 10159276 TI - Establishing a central structure for supporting guideline implementation. AB - Devising practice guidelines is one thing, implementing them is another, perhaps more difficult task. The key to quickest acceptance and greatest utility is to provide the support structure that will create buy-in on the part of clinicians. PMID- 10159275 TI - Should health plans retain their nonprofit status? PMID- 10159277 TI - Medicare and supplementary insurance policies. PMID- 10159278 TI - The ethics of efficiency: a guide to medical decision making for managed care plans in an antagonistic era. PMID- 10159279 TI - A conversation with Nancy Gorshe. PMID- 10159280 TI - How well will HEDIS 3.0 address the Medicaid population? AB - State Medicaid agencies have been looking for a standardized method to address the performance of managed care plans with which they contract. Although the recent release of the Health Plan Employer Data and Information Set for Medicaid plans was intended to satisfy this need, in the current and rapid evolution of performance measurement, it may be too little and too late. The author, one of the members of the original Medicaid HEDIS work group, describes some of the core challenges HEDIS 3.0 will face in improving on the Medicaid data set. PMID- 10159281 TI - Advancing economic evaluations of drug therapy. PMID- 10159283 TI - Is partnering beneficial or "sleeping with the enemy"? PMID- 10159282 TI - A pharmacoeconomic study of the management of major depression: patients in a TennCare HMO. AB - The purpose of this study was to evaluate the direct medical costs of treating patients diagnosed with major depression in a TennCare managed care setting. This retrospective analysis was conducted on paid-claims data (including a 10-month lag) from January through December 1994 for patients who met criteria for major depressive disorder and were receiving tricyclic antidepressants (TCAs) or selective serotonin-reuptake inhibitors (SSRIs), for at least three consecutive months. Expenditures measured included office visits, hospital charges, emergency room charges, and drug costs. A total of 976 HMO beneficiaries were identified, and 76 randomly selected patients who were receiving TCAs were compared with 76 randomly selected patients who were receiving SSRIs to evaluate total cost of therapy associated with these two classes of antidepressants. The results of this analysis indicate that the total cost of treatment for Medicaid patients suffering major depression is similar between these two classes of antidepressants. Also, among the three SSRIs, the average daily dose was lowest for paroxetine (21.1 mg/day) and highest with sertraline (81.3 mg/day) and concomitant antidepressant therapy highest with fluoxetine (7.4%). PMID- 10159284 TI - Incentives to promote quality improvement in long-term care. AB - Long-term care acute care providers are using innovative, data-based approaches and information systems solutions to position themselves for the future. These approaches will significantly improve the ability of these providers to treat patients, justify their continued existence, and compete in the marketplace. PMID- 10159285 TI - A quality assessment and improvement system for long-term care. AB - This article describes a model quality assessment and improvement system for long term care facilities and outlines ongoing research and pilot-testing of its component parts. The model is based on six guiding principles identified as appropriate for the long-term care industry and four highly interrelated key functions of quality assessment. PMID- 10159286 TI - Long-term acute care: meeting the strategic needs for outcomes information. AB - Nursing home quality improvement has historically relied on annual surveys conducted by state agencies for its impetus. Such reviews play an important role for assuring that minimum standards are met. However, we need to search for incentives that will make it in the best interest of nursing homes to improve beyond the minimum. This article explores incentives that may play that role. PMID- 10159287 TI - A regulatory approach to improving long-term and residential care. AB - After a 10-year collaborative effort by researchers, policy makers, and fieldworkers in Israel, the national regulatory systems for long-term and residential care institutions have been transformed. Use of the RAF Method for Regulation, Assessment, Follow-up and Continuous Improvement of Quality of Care has led to a dramatic improvement in the quality of care in these institutions. PMID- 10159288 TI - Satisfaction of residents and families in long-term care: I. Construction and application of an instrument. AB - A consortium of eight long-term care facilities in Ontario devised a new instrument to measure patient satisfaction in long-term care settings. A standardized protocol for administration was developed that included a program to train volunteers to conduct in-person interviews. Nine facilities have carried out the survey using the standardized protocol. PMID- 10159289 TI - Satisfaction of residents and families in long-term care: II. Lessons learned. AB - This is the second of four articles describing the construction and use of an instrument to evaluate resident and family satisfaction with care provided in long-term care settings. It addresses operational issues that arose in the application of the instrument. PMID- 10159290 TI - Using indicators to structure quality improvement initiatives in long-term care. AB - Quality indicators and a quality-monitoring system developed for use in the regulatory survey process offer a quality improvement tool for nursing home staff. The systematic use of resident assessment data can aid in the identification of quality of care problems and the determination of the nature of those problems. This approach is particularly useful for continuous quality improvement efforts. PMID- 10159291 TI - Outcomes management and asthma education in a community hospital: ongoing monitoring of health status. AB - An outcomes management system was implemented to evaluate the effectiveness of an asthma education program and to test its feasibility as a quality improvement tool. The study demonstrated the value of continuous monitoring of health status and the advantages of a multidimensional approach to outcome assessment and program evaluation. PMID- 10159292 TI - Improvement strategy for local health departments. AB - Local public health departments face unprecedented challenges in today's changing health care market: movement toward Medicaid managed care, privatization of public health services, and resource shortages. Internal weaknesses include divergence from the core public health mission, an unfavorable public image, inefficiency in work processes, and inadequate data management. Quality management offers health departments a strategy for addressing these challenges through heightened service effectiveness and improved resource utilization. PMID- 10159293 TI - Define your health plan's value with quality reporting. PMID- 10159294 TI - Buyer beware when purchasing clinical information systems. PMID- 10159295 TI - Grasp operational processes before selecting system. PMID- 10159296 TI - Healthcare I/T consultants. PMID- 10159297 TI - Hotlist. Computer-based patient records/electronic medical records. Assess your current processes before selecting CPR vendors. PMID- 10159298 TI - Integrated delivery systems continue struggle with enterprisewide automation. PMID- 10159299 TI - Developing a master set of contract forms for design and construction. AB - The planning, design and construction process of a health care facility is constantly in motion. Contracts are involved in all phases, whether they be short and simple or detailed and comprehensive. This document examines the various contract forms available, and when their use is appropriate. PMID- 10159300 TI - More about hospital generator sizing, testing and exercising. AB - The National Fire Protection Agency (NFPA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements for testing and exercising on-site standby generators are intended to prevent testing with insufficient load. However, engineers grapple with local and state enforcement agencies who require needlessly oversized standby generators, putting the engineer in the difficult position of using supplementary load banks because of insufficient building load for testing. This document examines the latest changes in NFPA codes and the JCAHO policy that aim to resolve testing issues. PMID- 10159301 TI - Report of a continuous quality improvement program in a tertiary-care medical center. AB - OBJECTIVE/DESIGN: Changes in the health system in Israel have led to an increasingly competitive environment, decentralization, and economic constraints. We evaluated the use of a continuous quality improvement (CQI) program. SETTING: Three medical departments and three administrative wings in a 700-bed, tertiary care, teaching hospital in Jerusalem. INTERVENTION: The program was planned as a short-term pilot project for long-term extension throughout the institution. The objectives were improved institutional efficiency and provision for change. The program was implemented through departmental improvement teams under a hospital management team and a steering committee, guided by an outside consultant firm. RESULTS: The Orthopedics Department experienced a 3-day reduction in patient length of stay (P<.008). The Emergency Room experienced a significant reduction in time to discharge through reduced waiting times for consulting physicians (P<.007) and for blood tests (P<.001). The Office of Patient Admissions streamlined procedures for admission and discharge, accomplished physical restructuring, and installed a telephone hot line. In Medical Records, a significant improvement in records availability was realized. In Outpatient Clinics, reductions in waiting times were realized, but were not statistically significant. The Supply Division showed savings on monthly orders and increased efficiency, with 95% of orders completed promptly and accurately. CONCLUSIONS: Several factors were identified as essential to the success of the program, including staff cooperation and commitment. We conclude that the CQI program was a useful tool to help our tertiary-care medical center adjust to changes in the Israeli healthcare system. It also served as a valid vehicle for maintaining and furthering optimal quality of care. PMID- 10159302 TI - Complications, adverse events, and iatrogenesis: classifications and quality of care measurement issues. AB - Accountability in the healthcare system demands the development of valid and reliable measures of quality, particularly outcome measures that have been risk adjusted for factors that increase the probability of a poor outcome. Although the literature documents the existence of complications, adverse events, and iatrogenic illness, these concepts have not been compared and discussed thoroughly. This article ponders complications as a measure of quality of care by proposing a three-level classification scheme and by examining the incidence, consequence, and determinants of these events. PMID- 10159303 TI - The epidemiology of missed medication doses in hospitalized patients. AB - OBJECTIVE: To identify determinants of missed medication doses in hospitalized patients. DESIGN: A prospective study of 63,031 medication doses was performed. Missed doses were detected through active surveillance. To analyze the potential impact of missed antibiotic doses, we performed a retrospective cohort study of adults with bacterial meningitis. SETTING: A general medical ward and an intensive-care unit in a tertiary-care hospital. PATIENTS: Adult inpatients. RESULTS: There were 906 missed doses (1.4% of all doses). The risk of missing a dose increased directly with the number of daily doses per patient (P<.01). An individual dose was more likely to be missed if the medication was short-acting than if it was long-acting (odds ratio, 1.4; 95% confidence interval, 1.2 to 1.6). Antimicrobials were the most frequently ordered short-acting agents and the most frequently missed class of drug. Patient absences from the floor were common, but only 3% of missed doses occurred during a scheduled absence. A survey revealed that nurses thought missed doses were the predictable result of a system involving multiple personnel and procedural steps. Missed doses were not associated with increased mortality in the cohort study. CONCLUSIONS: Missed doses correlated strongly with the number of daily doses. Efforts to decrease missed doses should focus on minimizing the number of daily doses and streamlining the administration system. PMID- 10159304 TI - Evaluating the effectiveness of communication skills training: a review of research. AB - This review considers the effectiveness of communication skills training programs within medical school settings. Several components of training are evaluated: microcounseling, standardized patients, role play, and videotape review. Overall, these interventions have been shown to be effective in improving targeted communication skills (ie, use of open-ended questions). However, outcome data that support the transfer of training to actual patient encounters and subsequent patient outcomes (ie, satisfaction, adherence) are lacking. PMID- 10159305 TI - Multidisciplinary patient management by means of a high social risk screening tool. AB - OBJECTIVE: The long-term goal in this study was for the Memorial Hospital of Salem County, Inc (MHSC), to create a seamless system of continuity of care for patients. This continuity of care begins before patients require acute admission through the hospital course and extends beyond discharge and into the post hospital setting or alternate care situation. DESIGN: In a retrospective study in 1993, through the first 6 months of 1994, it was discovered that MHSC patients experienced a longer-than-average Medicare length of stay than was seen in other hospitals. MHSC embarked on a program to reduce discharge planning request time to the social work and home care departments by using a patient screening system that began at the time of admission. The nursing, social work, and home care departments collaboratively designed a system that allowed for immediate transfer of vital discharge planning information to the social work and home care departments at the time of the patient's admission. A tool was jointly developed called the multidisciplinary patient management record. RESULTS: The benefits of this process far exceeded the cost of implementing the tool. The average skilled nursing facility length of stay decreased below the national average by almost one full day. Patients experienced earlier access to social service intervention: discharge planning needs were identified more accurately; and the social services and home care departments' productivity rose because they could anticipate problems before a crisis arose. CONCLUSIONS: Critical to the success of this overall effort was not designing the new tool, but integrating the tool into a reengineered multidisciplinary patient management process. PMID- 10159306 TI - Medical care reform is necessary, but not sufficient, for healthcare reform. PMID- 10159307 TI - Safeguarding health record security and confidentiality in the electronic era. PMID- 10159308 TI - Systems thinking and the patient. PMID- 10159309 TI - Digital Equipment issues detailed 'marching orders' for its HMOs. PMID- 10159310 TI - Payment by capitation comes on strong--but so far, mostly in primary care. PMID- 10159311 TI - When physicians jointly discuss fee information with purchasers. PMID- 10159312 TI - Making heads or tails of for-profit health care. PMID- 10159313 TI - Is your practice overstaffed? PMID- 10159314 TI - The corporate practice of health care ... a panel discussion. AB - The pros and cons of treating health care as a profit-making business got a lively airing in Boston May 16, when the Harvard School of Public Health's "Second Conference on Strategic Alliances in the Evolving Health Care Market" presented what was billed as a "Socratic panel." The moderator was Charles R. Nesson, J.D., a Harvard Law School professor of 30 years' standing whose knack for guiding lively discussions is well known to viewers of such Public Broadcasting Service series as "The Constitution: That Delicate Balance. "As one panelist mentioned, Boston was an interesting place for this conversation. With a large and eminent medical establishment consisting mostly of traditionally not for-profit institutions, the metropolis of the only state carried in 1972 by liberal Presidential candidate George McGovern is in one sense a skeptical holdout against the wave of aggressive investment capitalism that has been sweeping the health care industry since the 1994 failure of the Clinton health plan. In another sense, though, managed care-heavy Boston is an innovative crucible of change, just like its dominant HMO, the not-for-profit but merger minded Harvard Pilgrim Health Care. Both of these facets of Beantown's health care psychology could be discerned in the comments heard during the panel discussion. With the permission of the Harvard School of Public Health--and asking due indulgence for the limitations of tape-recording technology in a room often buzzing with amateur comment--MANAGED CARE is pleased to present selections from the discussion in the hope that they will shed light on the business of health care. PMID- 10159315 TI - Whose right to die? Assisted suicide and managed care. PMID- 10159316 TI - Are for-profit HMOs winning the day? PMID- 10159317 TI - Which executive earns most at an HMO? (Hint: it's not the chief medical officer.) PMID- 10159318 TI - Does managed care increase your malpractice exposure? PMID- 10159319 TI - An emergency physician's complaint: 'Your patients are costing me money!'. PMID- 10159320 TI - Dealing with 'deal-killers' in managed care contracts. PMID- 10159321 TI - After physicians protest, an HMO changes its mind. PMID- 10159322 TI - The smart way to take 'the capitation plunge'. PMID- 10159323 TI - Reader questions HMO's call on home tracheostomy care. PMID- 10159324 TI - 'Model HMO' contract lets St. Louis employers compare. PMID- 10159326 TI - This year, more of the premium dollar goes to medical care. PMID- 10159325 TI - The attorney-client privilege: what it does and doesn't cover. PMID- 10159327 TI - World mental health: needs and resources. PMID- 10159328 TI - The 1996 elections: implications for behavioral healthcare. PMID- 10159329 TI - How to measure the value of behavioral healthcare: adding the patient to the equation. PMID- 10159330 TI - Dialogue. Value and values: can we provide value and respect professional and community values? PMID- 10159331 TI - Making the connection in rural mental health. PMID- 10159332 TI - Client satisfaction and clinical outcomes--do we need to measure both? PMID- 10159333 TI - How will managed behavior health plans be regulated? PMID- 10159334 TI - Shared vision statement of the Joint Dialogue Task Force: Behavioral healthcare delivery. National Association of Psychiatric Health Systems and National Community Mental Healthcare Council. PMID- 10159335 TI - Reclaiming behavioral healthcare. PMID- 10159336 TI - Cost/benefit analysis of hospital operations: reducing length of stay. AB - Today's healthcare environment continues to become more competitive. Mergers and affiliations occur at breakneck speed, and anxiety regarding managed care contracts increases. In this fast paced environment integrated hospital systems need to become more in tune with the ?business? side of healthcare, which includes the cost of providing and receiving payment for health care services. Too often providers do not realize the total cost of providing care, nor do they understand the nature of payment/reimbursement for services provided. This article looks at how to analyze the cost of hospital operations from a provider's point of view. PMID- 10159337 TI - Technology assessment and equipment management: a practical approach to cost reduction. AB - The Medical University of South Carolina (Charleston, SC) responded to the necessity of reducing costs in a competitive marketplace by developing a program called Technology Assessment and Equipment Management. The program uses a process that systematically evaluates clinical equipment acquisitions and provides over sight on equipment management within the 587-bed tertiary care center. This article reviews how equipment is evaluated and purchased emphasizing cost control. PMID- 10159338 TI - How Hermann Hospital is saving resources through enterprise-wide reengineering. AB - Hermann Hospital, a 650-bed tertiary care facility and teaching hospital (Houston, TX), recognized the need for institution wide reengineering if they were to remain viable in a changing healthcare environment. Having already implemented total quality management (TQM) programs in various departments, Hermann wanted to provide a comprehensive line of healthcare services that worked cohesively with other areas, such as business development, community relations, and finance, and to do it competitively. Management knew that anticipated changes would require a holistic understanding of their system, so that reengineering efforts in one area didn't ?break things? in another. PMID- 10159339 TI - Changing costs, changing conclusions. PMID- 10159340 TI - Designed studies: their role in assuring quality and controlling costs. PMID- 10159341 TI - How to make your equipment purchases support your hospital's strategic plan. PMID- 10159342 TI - Managing change: people, partnerships, process, and persistence. PMID- 10159343 TI - Managed care trends for the next four years. Price competition, open access networks, and provider-sponsored HMOs. PMID- 10159344 TI - Rethinking Kaiser as a model for 21st century HMOs. PMID- 10159345 TI - Top ten trends for managed care in the 1990s. PMID- 10159346 TI - AHCPR's research on managed care. PMID- 10159347 TI - Put it in writing. Focus groups reveal what women look for in health care publications. PMID- 10159348 TI - Exploring the possibilities. Health plans offer connections to better information through the World Wide Web. PMID- 10159349 TI - Looking stateside: top issues for '96. PMID- 10159350 TI - The evolution of accreditation. PMID- 10159351 TI - Arms outstretched. PMID- 10159352 TI - Hospice & managed care. PMID- 10159353 TI - Should the FDA regulate pharmacoeconomic studies? PMID- 10159354 TI - Comparing outcomes in managed care. PMID- 10159355 TI - Kaiser forges ahead with alliance strategies in Northern California. PMID- 10159356 TI - Kaiser creates virtual medical group with Modesto pilot project. PMID- 10159357 TI - Developing a strategy to align physicians with your hospital. PMID- 10159358 TI - Ranks of salaried physician continue to grow. PMID- 10159360 TI - FIs (fiscal intermediaries) begin implementing HCFA's new official limits for routine costs. PMID- 10159359 TI - Facilities get more money, give "OK" to HCFA demo project. PMID- 10159361 TI - How to avoid problems when forming partnerships. PMID- 10159362 TI - Educate, involve staff to build effective interdisciplinary teams. PMID- 10159363 TI - Maryland law fuels hospital, freestanding SNF competition. PMID- 10159364 TI - Gaining more by considering the widest definition of partnering. PMID- 10159365 TI - Reengineering radiology. PMID- 10159366 TI - Public positions on antitrust changes. PMID- 10159367 TI - Computerized patient management. PMID- 10159368 TI - The "plug & play" scenario. PMID- 10159369 TI - Interconnectivity testing. PMID- 10159370 TI - Comparing conformance statements. PMID- 10159371 TI - Making network connections. PMID- 10159372 TI - A national imperative. PMID- 10159373 TI - A new golden age. PMID- 10159374 TI - Inpatient billing in an FSC (freestanding center). PMID- 10159375 TI - Are you in violation? PMID- 10159376 TI - Power plays. Let there be light! PMID- 10159377 TI - Remote control. Telemedicine revolutionizes EMS in rural America. PMID- 10159378 TI - Cut to the chase! How can you get ED docs to OK what you need? PMID- 10159379 TI - Dispatcher teamwork. Enhancing communications-center training. PMID- 10159380 TI - Terrorism's bloody trail. Learning tragic lessons in scene safety from the Israelis. PMID- 10159381 TI - 10 minutes with ... Jeffrey L. Margulies, MD, FACEP. Interview by Nancy Perry. PMID- 10159382 TI - Tips on the 1996 JCAHO survey. PMID- 10159383 TI - Motivating workers. PMID- 10159384 TI - Interactive supply inventory at Wadley RMC. PMID- 10159385 TI - Take environmental services into the future. PMID- 10159386 TI - Improving health and utilization: can vendors help? PMID- 10159387 TI - Incentives have to be balanced to achieve optimal delivery system performance. PMID- 10159389 TI - Urban hospitals use community, business ties to improve public health, reduce violence. PMID- 10159388 TI - If the gut works, use it; the appropriate provision of medical foods can save a bundle. PMID- 10159390 TI - Accordant meets the challenges that rare chronic diseases pose for managed care. PMID- 10159391 TI - HMOs' stock debacle changes the game. PMID- 10159392 TI - LOS could soar for patients in observation status. PMID- 10159393 TI - Develop observation stay protocols now. PMID- 10159394 TI - Study prompts overhaul of COPD/pneumonia care. PMID- 10159395 TI - Use survey data to zero in on what patients want. PMID- 10159396 TI - Lessen your path-related liability concerns. PMID- 10159397 TI - East, west, north's best. PMID- 10159398 TI - Managers' careers. I got out of the NHS but now I'm back. PMID- 10159399 TI - Paediatric services. Child benefit. PMID- 10159400 TI - Commissioning. Life preservers. PMID- 10159401 TI - Minor injuries. A wonder at the Western. PMID- 10159402 TI - IT update. Layers, players, delayers. PMID- 10159403 TI - IT update/year 2000. All systems gone. PMID- 10159404 TI - IT update. Just what the doctor ordered. PMID- 10159405 TI - Chaplaincy. Is God good value? PMID- 10159406 TI - Chaplaincy. Blessings in disguise? PMID- 10159407 TI - Clinical audit. Room for improvement. PMID- 10159408 TI - Data briefing. Tuberculosis. PMID- 10159409 TI - First-line managers: scope of responsibility in a time of fiscal restraint. AB - Fiscal restraint and government cost control have contributed to the downsizing and restructuring of Canadian health care organizations. As key players in the hospital sector, the role and responsibilities of first-line nurse managers have been significantly affected by these changes. This paper presents data from a survey of 200 first-line nurse managers in British Columbia which investigated the current scope of the first-line manager's role, the number of hierarchical levels within nursing departments, and views on managerial union membership. PMID- 10159410 TI - Citizen participation in the reform of health care policy: a case example. AB - The trend toward greater citizen participation in health care policy reform has its roots in the consumerism of the 1960s. This era witnessed the beginning of a dispersion of power in health care and an increase in the number and variety of stakeholders involved in the policy development process. Using the reform Ontario's long-term care policy as a case example, this paper offers observations about the benefits and challenges of participative policy-making. Despite the challenges and the paucity of hard evidence pointing to benefits, the author concludes that broad citizen participation in health care policy reform is a desirable goal. However, the capacity for genuine collaboration remains underdeveloped and requires more systematic refinement. PMID- 10159411 TI - Partners in Health: a case study of a comprehensive disability management program. AB - When absenteeism threatened to raise health care costs and affect the quality of care at Tillsonburg District Memorial Hospital, a multidisciplinary team came together to develop a strategic response. The hospital seized the opportunity to initiate the ?Partners in Health? program, an innovative and collaborative disability management program designed to improve its response to the health issues of all its staff. This paper describes how the program was developed and outlines its comprehensive approach. Partners in Health has proven to be extremely successful at increasing attendance awareness, improving work accommodation and/or rehabilitation after illness or injury, and reducing costs associated with health and lost-time claims. Partners in Health was recognized with the 1995 Health Care Quality Team Award sponsored by the Canadian College of Health Service Executives and 3M. PMID- 10159412 TI - The Drug Utilization Review Network of Quebec. AB - Drug utilization review programs have been recognized as an effective way to control health care spending while maintaining quality services. This article describes the structure, mandate and activities of Quebec's Drug Utilization Review Network. This 112-member network, which represents 45% of health care facilities in the province, was established to promote the optimal utilization of drugs through the provision of support to pharmacology committees, therapeutic committees and pharmacy departments. The network's main role is to coordinate multi-centre drug utilization studies. Future challenges include maintaining member interest and evaluating the clinical and economic impact of the network's efforts. PMID- 10159413 TI - Skill mix literature review. AB - Administrators are currently being challenged to maintain high quality patient care in the face of shrinking health care resources. The introduction of different skill mix ratios has been suggested as one way to help manage health care costs. This paper briefly reviews the literature and research data on skill mix, discussing the relevant issues and identifying the positive and negative implications of this approach. It concludes with suggestions for further research. PMID- 10159415 TI - Design for healing: cancer treatment under one roof. PMID- 10159414 TI - Considerations for regional health authorities in the provision of environmental health services. AB - As population health programs, environmental health services differ fundamentally from other forms of health service delivery. At a time when the health sector is striving for integration, the incorporation of these unique services into the delivery system presents a unique challenge to policy makers and administrators across the country. The University of Alberta recently completed a comprehensive review and redesign of locally governed and delivered environmental health protection services in Alberta. This paper outlines the key issues and unique features surrounding the delivery of environmental health services and presents the study team's suggested approach to addressing these issues. PMID- 10159416 TI - Bright ideas. Facility managers come up with hands-on methods for cutting energy bills. PMID- 10159417 TI - Getting along with the neighbors. PMID- 10159418 TI - Designing clean air. PMID- 10159419 TI - EPA med waste incinerator rule delayed, but not derailed. PMID- 10159420 TI - Teach your technicians to share (their expertise). PMID- 10159421 TI - Water-soluble products solve a solid waste dilemma. PMID- 10159422 TI - Savvy asset management will help you buy better later. PMID- 10159423 TI - Price survey. Recent suture prices sliding downward, as hospital buyers cast votes for Ethicon. PMID- 10159424 TI - Radiology supply contracts reflect plummeting prices. PMID- 10159425 TI - Chicago hospitals shedding independence in purchasing, hoping that bigger is better. PMID- 10159426 TI - As technology races for the stars, so do costs. PMID- 10159427 TI - Computers: the next stethoscope. PMID- 10159428 TI - Is the Internet a health hazard? PMID- 10159429 TI - Meaning in action. PMID- 10159430 TI - Telemedicine brings health care to the home. PMID- 10159431 TI - Stereotactic core breast biopsy: 'Lap chole for breast disease.'. PMID- 10159432 TI - Changing the technology of thinking. PMID- 10159434 TI - Special report: ValuJet Flight 592. PMID- 10159433 TI - The changing role of hospice and its fit in an integrated delivery system. PMID- 10159435 TI - Critical incident stress management: is it worth it? PMID- 10159436 TI - Best EMS Web sites. PMID- 10159437 TI - Flying high: EMS in the air. PMID- 10159438 TI - Overseas adventures in EMS. PMID- 10159439 TI - When the reality check bounces. PMID- 10159440 TI - Do you really want to be the boss? PMID- 10159441 TI - Is life saving a crime? PMID- 10159442 TI - Hospital response to prospective payment: moral hazard, selection, and practice style effects. AB - In response to a change in reimbursement incentives, hospitals may change the intensity of services provided to a given set of patients, change the type (or severity) of patients they see, or change their market share. Each of these three responses, which we define as a moral hazard effect, a selection effect, and a practice-style effect, can influence average resource use in a population. We develop and implement a methodology for disentangling these effects using a panel data set of Medicaid psychiatric discharges in New Hampshire. We also find evidence for the form of quality competition hypothesized by Dranove (1987). PMID- 10159443 TI - Explaining variations in inpatient length of stay in the National Health Service. AB - This paper seeks to explain variations in acute inpatient length of stay in the National Health Service in England. A model is proposed in which the length of stay is allowed to vary according to patient characteristics, the local supply of NHS care. the local pressure on NHS resources, other non-NHS health care supply factors, and local policy effects. Length of stay data are obtained from the 1991/1992 Hospital Episode Statistics. They are standardized for age, sex and broad specialty group, and are aggregated to the level of small areas with populations of about 10,000. Explanatory variables include socio-economic data from the 1991 Census of Population, health status data, waiting time data, measures of access to inpatient and GP services, and measures of local private health care provision. The paper finds that variability in length of stay is greatest in the over-65 age group. The most important determinants of variations in length of stay are access to NHS hospitals, access to private hospitals, waiting times for elective surgery, indicators of poverty, and indicators of the availability of informal care. PMID- 10159444 TI - Specialized service offerings and patients' choice of hospital: the case of cardiac catheterization. AB - Patients' choice of hospital is modeled as a function of their expectation of needing a specialized service (option demand). The estimation tests whether cardiac patients' choice of hospital responds to changes over time in the availability of a specialized cardiac service. Results suggest that availability of cardiac catheterization has a strong, significant effect on the choice of hospital, even after controlling for other quality characteristics. However, the effect appears confined to those patients whose diagnosis indicates some probability of needing the service. Patients with no 'option demand' do not appear to use specialized services as a signal of quality. PMID- 10159446 TI - A note on the estimation of the equity-efficiency trade-off for QALYs. AB - In this note the veil of ignorance approach is tested as a basis for empirically determining the shape of the social welfare function for QALYs. An experiment is carried out where the participants choose between different societies that differ with respect to per capita QALYs and the distribution of QALYs. The answers are analyzed using logistic regression analysis. According to the results the respondents are willing to give up I QALY in the group with more QALYs to gain 0.45 QALYs in the group with fewer QALYs, but this trade-off is independent of the size of the difference in QALYs between the groups. PMID- 10159445 TI - Quality of health care, survival and health outcomes in Ghana. AB - This paper analyzes the effect of quality and accessibility of health services and other public infrastructure on the health of children in Ghana. We focus on child survival, child height and weight using data from the Ghana Living Standards Survey. The results suggest an important role for public health policy in eliminating the rural-urban disparities in health status and particularly in improving the health status of rural children and reducing their mortality rates. Increased availability of birth services and other related child programs, as well as Improved water and sanitation infrastructure would have an immediate payoff. PMID- 10159447 TI - Uncertainty and investment in health. PMID- 10159448 TI - Consumer utility, social welfare, and genetic testing. A response to "Genetic testing: an economic and contractarian analysis". PMID- 10159449 TI - Can a good mom be a good doctor? PMID- 10159450 TI - Can functional-status surveys improve your care? PMID- 10159452 TI - Is this the toughest medical assignment in the world? PMID- 10159451 TI - When a problem doctor threatens to destroy a practice. PMID- 10159453 TI - We can cut costs and improve care at the same time. PMID- 10159454 TI - Look who's on the malpractice hot seat now, but don't think doctors are off the hook. PMID- 10159455 TI - Indemnity insurance: down but not out. PMID- 10159457 TI - How to negotiate effectively. PMID- 10159456 TI - House staff pay is barely keeping pace with inflation. PMID- 10159458 TI - Gaining patient trust in health care delivery by managed care plans. PMID- 10159459 TI - Capital--its application, access and attitudes. AB - Access to capital for group or network development is generally through one of three sources: current revenue, borrowing, or outside investors. Groups often have not planned well for their financial future, and consequently when integration or managed care opportunities arise, they can be without the necessary funds. This article addresses the acquisition of capital in the context of application (need), access (resources), and attitudes (concerns). Determining capital needs is the starting point, followed by investigating institutional resources, and then investigating the attitudes of the group toward accessing the needed capital. PMID- 10159460 TI - Capital: the medical practice's life blood. AB - As physician organizations grow in size and stature, capital must be obtained for investment. One of the more common avenues is through either debt or equity. Some pros and cons of these sources are presented, along with some particular sources. In addition, examples of medical practices that have gone one route or the other are presented. PMID- 10159461 TI - Negotiating for care contracts depends on provider needs. PMID- 10159462 TI - Electronic medical records in the outpatient setting (Part 2). AB - Electronic medical records are on the verge of becoming the standard within ambulatory practice. Some of the savings available to medical groups are summarized, including labor savings in clerical, front-desk, transcription, nurse and medical assistant, and physician personnel, as well as malpractice premiums, and storage and supplies. In addition to savings, an expanded revenue base may be available as electronic medical records allow personnel to see more patients. The article gives some examples of how medical practices have used electronic medical records to obtain increased revenues. PMID- 10159463 TI - Centers of excellence: a medical measurement or marketing myth? AB - Managed care organizations, physician groups and hospital systems are all increasingly pressured to identify new modes of treatment that produce verifiable outcomes while reducing the revolving door pattern of health care for the chronically ill. Providers are also faced with creating systems of care to differentiate themselves from the competition in the marketplace. Disease specific health management programs are being used to address both issues. When used properly, they can be promising tools in the battle to maintain health care quality while containing costs. Skillful balancing of these two important factors can ensure maximum value for both patients and payers. Are centers of excellence the critical pathway of the future? Or are they merely a marketing ploy to generate incremental growth and profitability for savvy business executives and medical group management entrepreneurs? This article provides an overview of the center of excellence concept, addresses its misuse in the industry and discusses the strategic and marketing implications for organizations considering this approach as a tool to demonstrate full accountability and meritorious outcomes. PMID- 10159464 TI - An analysis of exam room utilization in U.S. medical schools. AB - Examination room utilization in U.S. academic practices has not generally included clinical space used in the teaching of medicine. The lack of planning guidelines at some medical schools for examination room space may have them operating inefficiently by as much as 50 percent or 60 percent. Not having guidelines may be causing medical schools to commit valuable resources to develop unnecessary space. A survey of 126 U.S. medical schools determined their estimated maximum annual examination room visit capacity at 40 percent to 50 percent of their EMAERVC during the study period yet planned to add examination room capacity. PMID- 10159466 TI - Longtime rival hospitals in S.C. break unlikely link. PMID- 10159465 TI - Single specialty capitation--wheel of (mis)fortune? PMID- 10159467 TI - Ga. to review hospital conversions. PMID- 10159468 TI - Hospitals wake up to welfare reform impact. PMID- 10159469 TI - Law would prod private, VA hospitals to compete. PMID- 10159470 TI - Loss of AHA annual meeting will hurt integration efforts. PMID- 10159471 TI - CEOs with the right stuff are worth the big money. PMID- 10159472 TI - Branding time at Columbia. AB - This week Columbia/HCA Healthcare Corp. introduces a national advertising blitz believed to be the largest ever by a healthcare provider. The hospital giant wants to instill its brand name in the American lexicon, and it's willing to spend millions to do so. PMID- 10159473 TI - MSO model is new favorite among docs. PMID- 10159474 TI - Iowa privatizes data venture, expands goals. PMID- 10159475 TI - Centers aim to cut MI misdiagnoses. PMID- 10159476 TI - Off-balance-sheet deal by hospital gets bond-insurer backing. PMID- 10159477 TI - AHA's contributions to GOP since 1995 total nearly $200,000. PMID- 10159478 TI - AHA poised to buy firms after stock sale. PMID- 10159479 TI - Study: Medicare risk HMOs overpaid. PMID- 10159480 TI - Capital acquisition and the administrator: an expanding role. PMID- 10159481 TI - A visual guide to PACS. AB - Picture archiving and communication systems (PACS) is a complex and vast subject, about which much has been written. A Visual Guide to PACS is an overview of the subject presented as an efficient reference for hospital and department administrators planning for and implementing PACS. A Visual Guide to PACS is adapted from presentation materials developed by Integration Resources/GORCA to capsulize issues relating to PACS. The authors aim to communicate the broad parameter and some of the complexity of the subject. PMID- 10159482 TI - TQM, management fads and 'getting poofed'. PMID- 10159483 TI - A devil's dictionary of business buzzwords. PMID- 10159484 TI - AHRA staff utilization survey measures technologist productivity. AB - The AHRA Staff Utilization Survey is an increasingly valuable reference for administrators trying to increase productivity, maintain patient satisfaction and maintain a reasonable working environment for their employees. This article presents highlights of the full survey, which will be published separately and mailed to all AHRA members in July. The highlights are presented in text, tables and full-color charts. PMID- 10159485 TI - Radiology and community-based healthcare: building a coalition against breast cancer. AB - When the authors recognized the need for a breast cancer support group in their community, their hospitals were engaged in a highly-publicized battle over major expenditures and duplication of services. Despite that, they built a coalition of hospitals, volunteers, community agencies, businesses and private volunteers to decrease mortality from breast cancer through education and increased access to mammography. The authors describe the process they used, including special outreach to minority and impoverished women. Nielsen and Donlea believe that radiology services must be adapted to participate in this kind of community-based healthcare. PMID- 10159486 TI - Radiology administrators and the JCAHO: what you need to know to survive. AB - Revisions by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) to the Accreditation Manual for Hospitals emphasize the interrelatedness of the systems and processes that are used to delivery clinical care. Mihalik discusses quality control, measurement and assessment procedures, leadership and scope of service. Generally, JCAHO standards have become more permissive in ways that demand greater cooperation and collaboration between hospital departments. PMID- 10159487 TI - America's best hospitals. PMID- 10159488 TI - America's best hospitals. Breaking down the walls. PMID- 10159489 TI - America's best hospitals. Behind the rankings. PMID- 10159490 TI - Fighting teen pregnancy. Student volunteers make persuasive role models. PMID- 10159491 TI - Looking for volunteers? Here are a few creative ideas to assist your search. PMID- 10159492 TI - Know your neighbors. Most hospitals today say they want to work with the community--but who is that exactly? PMID- 10159493 TI - Seniors helping seniors. Foundation grants encourage HMOs to start 'service credit banks'. PMID- 10159494 TI - Granting community wishes. Foundations help hospitals reach out. PMID- 10159495 TI - Retirees as resources. Tapping their business skills produces big rewards--for your hospital and for them. PMID- 10159496 TI - Renovation is on the right track. PMID- 10159497 TI - Vendors sell range of digital products. PMID- 10159498 TI - CCD or pick-up tube: R&F camera technology. PMID- 10159499 TI - Deciding when and if digital is right move. PMID- 10159501 TI - Principles of flow cytometry. AB - Clinical flow cytometry is a relatively new and rapidly growing medical technology. According to estimates, there were less than 1000 instruments in operation globally prior to 1985. Most of these instruments were used exclusively for research, and required dedicated facilities and operators with extensive backgrounds in electronics. In the mid-1980s, with the availability of benchtop clinical models, the number of flow cytometers jumped dramatically, surpassing 4000 by 1990. Most of the instruments that have been sold in the past decade are equipped with low power, air-cooled argon ion lasers with a fixed emission light wavelength at 488 nm. They are capable of multi-color immunophenotyping, and are usually connected to powerful personal computers for data analysis. By 1992, there were an estimated 7000 flow cytometers in operation worldwide. Today, the three general fields where this technology is well established are clinical immunology, laboratory hematology, and medical oncology. The most prominent uses of flow cytometers are for immunological characterization of lymphomas and leukemias, crossmatching tissues for organ transplants, and counting lymphocyte subpopulations in the peripheral blood of HIV-infected individuals. In this review, a brief historical introduction will be followed by a general description of some of the salient features of clinical flow cytometers. PMID- 10159500 TI - An assay for hemoglobin A1c testing. PMID- 10159502 TI - Flow cytometry related to hematopoietic malignancy. AB - Flow cytometry is used in the workup of hematological malignancies to establish the immunophenotype of a given malignancy and/or to determine DNA ploidy and S phase fractions. Flow cytometric data is used as an adjunct to routine morphology and can have diagnostic, confirmatory and prognostic relevance. Samples that can be analyzed include blood, bone marrow, lymph nodes, fine needle aspirates and effusions. DNA analysis can be performed not only on fresh and frozen tissue but also on archival material. PMID- 10159503 TI - Flow cytometry in the management of infection with human immunodeficiency virus. PMID- 10159504 TI - Applications of flow cytometry in the analysis of blood leukocytes. AB - Flow cytometric analysis of blood leukocytes is currently used for both routine clinical measurements as well as for cutting edge research applications. This technology has enabled rapid and accurate determination of leukocyte antigens and quantitative analysis of leukocyte subsets, tests of leukocyte function, determination of the presence of antineutrophil and antilymphocyte antibodies in plasma and on cells, measurement of CD34+ hematpoietic stem cells in peripheral blood and bone marrow samples, measurement of apoptosis, and detection of virus infected leukocytes. This review will focus on the use of the flow cytometer for investigations of blood leukocytes in transfusion medicine. PMID- 10159505 TI - Flow cytometry related to red cells. AB - Researchers in Transfusion Medicine Science have benefited from the use of the flow cytofluorometer. The flow cytometer has distinct advantages over visual examination of antigen-antibody reactions. The flow cytometer measures fluorescence per cell, and through the use of anti-IgG tagged with a fluorochrome, cells with differing levels of cell-bound IgG can be quantitated. This has been used in the study of allo- and autoantibodies. Immunohematologists, with the wide range of red cell alloantibodies in many blood group systems, have a seemingly unending supply of materials to enable studies of red cells. This article describes the published reports involving flow cytometry related to red cells. Four areas are discussed: detection of red cell-bound IgG, detection of red cell immunogobulins other than IgG, detection and quantitation of red cell antigens, and detection and quantitation of red cell populations. PMID- 10159506 TI - Analysis of platelets by flow cytometry. AB - Transfusion medicine has become a multi-disciplinary field with many recent technical developments and the flow cytometer has had a significant impact in transfusion medicine, especially at the level of platelet immunobiology. Many routine tests in platelet immunology are now performed by flow cytometry laboratories, including assessment of platelet-associated allo- and auto antibodies and complement components. Platelet analysis by flow cytometry has been applied to detection of platelet antigens, platelet surface-bound proteins, platelet activation, measurement of reticulated platelets, intracellular calcium studies, and the measurement of platelet microparticles in vivo and in vitro. This review will focus on the use of the flow cytometer in these applications in investigations of platelet immunology. PMID- 10159507 TI - International forum: France. The national survey of plasma exchange and therapeutic cytapheresis in France. AB - Created in 1985, the French Society of Haemapheresis (SFH) Registry is the largest data base of plasma exchange (PE) in the world. Data analysis shows that neurological diseases are the most frequent indications for PE in France and that improvement in technique has reduced early complications. As for therapeutic cytapheresis, peripheral blood stem collection represents the major activity (64%). The second most common activity is UVA extracorporeal photochemotherapy. PMID- 10159508 TI - LDL-apheresis in treatment of two patients with heterozygous familial hypercholesterolemia and extremely elevated lipoprotein (a) levels. AB - In hyperlipidemia and, in particular, elevated lipoprotein (a) [Lp(a)] levels there appears to be pronounced linkage between the development and progression of atherosclerosis. Our study concerned two Caucasian male patients with heterozygous forms of familial hypercholesterolemia and extremely high Lp(a) concentrations. Maximal diet regimens and the use of lipid lowering drugs achieved a serum total-, LDL-cholesterol and triglyceride reduction of up to 30%, but no reduction of the Lp(a) level was discernible. Both patients suffered three myocardial infarctions and several coronary angiographies with percutaneous transluminal angioplasties (PTCA) were necessary. In 1989, we commenced treatment with LDL-apheresis. At present, after 78 LDL-aphereses in the case of the 41-year old patient (48 months, dextran sulfate adsorption, KANEKA, Japan) and 38 aphereses in the case of the 35-year old patient (8 months, immunoadsorption, special Lp[a] columns, LIPOPAK, POCARD, Russia), the Lp(a) has dropped an average of 53%, total cholesterol 31%, LDL-cholesterol 40% and triglycerides 42%. During this period neither mycardial infarctions nor cardiac complaints were observed. In the course of treatment, both patients experienced an improvement in general well-being and increased performance. These results are very encouraging: LDL apheresis may be effective in the treatment of patients, the only risk factor for premature atherosclerosis being an extremely high Lp(a) concentration. PMID- 10159509 TI - Are there options for donor-derived i.m. anti-D IgG preparations other than to prevent Rh(D) sensitization? The intravenous route. AB - The use of i.v. anti-Rh(D) IgG for conditions other than prevention of Rh(D) sensitization is discussed. Besides highlighting the platelet response in ATP, a putative distinctive effect on the hemorrhagic threshold is suggested. Accordingly, we have included discussion of cases of aplastic anemia, myelodysplasia, heavy chemotherapy, coagulation deficiency, and senile vascular atrophy. We have also considered attempts to replace the high-dose pooled i.v. IgG (IVIG) with the much smaller amounts of IgG present in anti-Rh(D) preparations used to prevent Rh-sensitization in pregnancy. Both Fc and variable fragments of the IgG molecule may play a role, the former potentiated by manufacture-induced IgG aggregation and the latter by donor hypersensitization. A role for IgG-anti-F(ab')2 molecules cannot be ruled out. PMID- 10159511 TI - Pediatric interventional cardiology: a specialty comes of age. PMID- 10159510 TI - A case of idiopathic myelofibrosis with alloimmunization to HLA-identical platelet transfusions not responsive to antibody absorption over protein-A columns. AB - A case of idiopathic myelofibrosis has been treated with HLA-identical platelet apheresis concentrates. After a short period the patient also developed refractoriness to the haploidentical siblings. Protein A columns were used to absorb the platelet antibodies with no result. Now two apheresis platelet concentrates are used every month, crossmatched negative products produce good results maintaining cell counts between 20 and 30 x 10(9)/L. The immune mechanism involved is difficult to understand. PMID- 10159512 TI - Balloon valvuloplasty for pulmonary valve stenosis. AB - Balloon valvuloplasty for pulmonary valve stenosis by static dilation is the treatment of choice for the treatment of isolated valvular pulmonary stenosis in the infant, child, and adolescent. The procedure is also effective in neonates; however, the complications of the procedure are significantly higher and the efficacy is less. This article reviews the background, indications, technique, acute and long-term results, and complications of balloon valvuloplasty for pulmonary valve stenosis in the infant, child, and adolescent with pulmonary valve stenosis. The application of this technique in neonates with critical pulmonary stenosis or membranous pulmonary atresia with intact ventricular septum is also discussed. The determinants of a successful outcome in each group are addressed. PMID- 10159513 TI - Balloon-expandable stenting in pediatric cardiology. AB - Intravascular stent placement in Pediatric Cardiology has provided one of the most interesting and effective means of catheter treatment of congenital lesions. In the 5 years since it has been performed, balloon-expandable stent placement has provided relief of many previously untreatable vascular stenoses and has resulted in improvement of blood flow, reduction of right ventricular pressure and, in many cases, dramatic improvement of symptoms. In this article, the background of balloon-expandable stent placement is discussed, and specific observations are offered regarding the technique of implantation. The generally excellent results are presented and a number of novel problems and pitfalls are outlined. Finally, a brief summary of the wide ranging applicability of stent implantation is discussed, along with some of the important and imaginative new directions for the therapy. PMID- 10159514 TI - Balloon aortic valvuloplasty for aortic stenosis in neonates, children, and young adults. AB - Balloon aortic valvuloplasty is a safe and effective treatment for aortic stenosis in neonates, children, and young adults. The indication for balloon valvuloplasty in children is a peak systolic gradient > 70 mmHg or > 50 mmHg in any patient with symptoms. Published results indicate that the procedure results in an acute reduction in gradient ranging from 49%-70%, and this reduction appears to persist through at least an intermediate follow-up. The percentage reduction in gradient is similar for neonates as well as older children. In neonates, it is imperative to evaluate the size of the left ventricle prior to balloon valvuloplasty since mortality is highest in those with variants of hypoplastic left heart syndrome. Though morbidity and mortality is higher in the neonatal age group, the results are similar to those following surgical intervention. In children older than 1 month of age, the major complication is the development of aortic regurgitation, although it usually appears to be well tolerated. Previous surgical valvotomy is not a contraindication to balloon aortic valvuloplasty. In the current era, we believe that balloon aortic valvuloplasty should be considered as the first option in neonates, children and young adults with significant aortic valve obstruction. PMID- 10159515 TI - Balloon angioplasty for native coarctation of the aorta. AB - Balloon angioplasty of native coarctations of the aorta is one of the most controversial facets of the pediatric interventional cardiologist's practice. We have evaluated the history and experimental rationale of this technology. Presently accepted techniques are outlined and controversies intrinsic in performance of this procedure are discussed. Acute, short-term, and long-term results are reviewed with particular emphasis on differences in success of the procedure as related to patient age. Common and significant complications are discussed and in some cases compared to analogous surgical complications. Newer technologies and approaches to interventional therapy for coarctation of the aorta are also discussed. PMID- 10159516 TI - Balloon angioplasty for postoperative recurrent coarctation of the aorta. AB - Surgical repair for recurrent or residual postoperative coarctation of the aorta is associated with some morbidity, mortality, and an incidence of recurrent coarctation that may be as high as 20%. Balloon angioplasty for recurrent or residual postoperative coarctation has become the standard treatment of choice for this condition. In this article, we review the protocol we use, and the acute and long-term results of this procedure. Since 1983, over 400 patients have undergone balloon angioplasty for recurrent coarctation with excellent immediate relief of the gradient and improvement in the diameter. On long-term follow-up, the majority of these patients enjoyed a lasting beneficial effect of the balloon angioplasty. We discuss the future use of stents for selected patients who are not amenable or failed balloon angioplasty of recurrent or residual postoperative coarctation. PMID- 10159517 TI - Transcatheter occlusion of patent ductus arteriosus. AB - This article reviews the current status of transcatheter technology, which has been applied to close the patent ductus arteriosus (PDA). Pioneering work in this field was performed by Porstmann in the 1960s and Rashkind in the 1970s. Devices which have been implanted in the PDA have basic designs as plugs, umbrellas, or coils. The experience reported with each type of device is detailed. Issues and controversies are examined. It appears that coils should be the preferred method for closing smaller PDAs (3-mm diameter or smaller), and Rashkind or similar devices, if available, should be reserved for larger PDAs (> 3-mm diameter). Surgery is necessary for neonatal and for rare large PDAs. Transcatheter technology is still evolving and may become more effective and cheaper. PMID- 10159518 TI - Transcatheter closure of atrial septal defects. AB - The first transcatheter closure of an atrial septal defect (ASD) was performed by King and Mills in 1976. The Lock Clamshell occluder and the buttoned device are the latest devices to undergo clinical trials. Successful transcatheter closure has been possible with minimal morbidity and mortality. Small residual shunts may remain, however, in up to 20% of patients 1 year after the procedure. The clinical significance and natural history of these small residual atrial communications remains to be determined. This article reviews the history and development of the current ASD closure techniques, with emphasis on the experience with the Lock Clamshell occluder and the buttoned device. PMID- 10159519 TI - Embolization therapy in pediatric cardiology. AB - Transcatheter embolization therapy has assumed an important role in the management of patients with congenital heart disease. A variety of embolization materials, most commonly steel coils, is available to treat or palliate patients with aortopulmonary collateral vessels or surgical shunts, arteriovenous malformations, and anomalous venovenous connections (common after surgical intervention for the univentricular heart). At many centers, coil occlusion has recently become the treatment of choice for patients with a restrictive patent ductus arteriosus (PDA). This article describes the materials and techniques of embolization therapy, as well as the common indications encountered in the practice of pediatric interventional cardiology. PMID- 10159520 TI - The use of radiofrequency energy in pediatric cardiology. AB - The use of radiofrequency energy for the treatment of supraventricular tachycardia in pediatric patients has gained widespread acceptance, especially for tachyarrhythmias associated with palpitations, dizziness, presyncope or syncope, cardiomyopathy, and cardiac arrest. Ablation of the substrate supporting atrioventricular reentry, atrioventricular node reentry, and automatic atrial tachycardia yields a 90%-98% success rate with low incidence (< 1%) of complications and adverse side-effects. Ablation of intra-atrial reentry, including atrial flutter and fibrillation, appears to be promising and would be a significant advance in the management of patients following extensive atrial surgery for congenital heart disease. Radiofrequency energy is also used to treat various forms of idiopathic ventricular tachycardia. Finally, radiofrequency energy has been extended to control the ventricular rate associated with malignant atrial tachycardia by either modification or ablation of the atrioventricular node, and subsequent pacemaker implant. Long-term outcome of radiofrequency ablation is unknown, but the short-to-intermediate (1-5 yrs) outcome is excellent, with low recurrence rate of the tachycardia, no proarrhythmic effect, and excellent clinical state. PMID- 10159521 TI - The use of echocardiography in pediatric interventional cardiac catheterization procedures. AB - The last decade saw a dramatic change in the management of congenital heart defects. The introduction and development in echocardiography and Doppler modalities enable definitive diagnosis of congenital lesions without cardiac catheterization. At the same time, new therapeutic procedures for congenital defects using the catheter as a channel for different procedures were developed. These therapeutic procedures have replaced cardiac surgery in many types of defects. The new developments in echocardiography and Doppler modalities provide accurate imaging and visualization of the transcatheter devices and brought these two imaging modalities into a close marriage. The use of echocardiography and Doppler in the catheterization laboratory became a must, especially when used in atrial (ASD) and ventricular septal defect (VSD) closure. In this article we will detail the role of echocardiography in the different transcatheter interventional procedures in the catheterization laboratory. Those include atrial septostomy, blade atrial septectomy, balloon dilation, ASD closure, VSD closure, patent ductus anterior closure, and pericardiocentesis. PMID- 10159522 TI - Cost-effectiveness analysis of interventions for congenital heart disease. AB - Expansion of the options available for the treatment of congenital heart disease has been accompanied by an increasing realization of the limits of our available health care resources. Cost-effectiveness analysis is one of several analytic approaches that can improve decisions about the appropriate use of technology in interventional pediatric cardiology and other fields. In this article, cost effectiveness analysis is distinguished from related approaches, such as cost benefit analysis. Then, basic principles of cost-effectiveness analysis are described. Next, the application of these principles is illustrated, using a recently published comparison of transcatheter versus surgical closure of patent ductus arteriosus. Finally, potential research implications of the surprising findings of this study are discussed. PMID- 10159523 TI - Cost containment through a hospital-based blood donor center. AB - Hospitals must find ways to decrease costs in the face of decreasing reimbursements. The cost of blood products and special testing services provided by a regional blood center may be a source of excessive expense. Our facility has had its own blood donor program since June of 1950 and has achieved significant cost savings by collecting and processing blood for the facility rather than buying it from an outside agency. This article describes the benefits and disadvantages of having a hospital-based blood donor program. Benefits include cost savings, safety, better customer service for patients, meeting special physician needs, and enhanced community relations. Disadvantages include difficulty in meeting blood inventory and special testing needs, extra inspections by the Food and Drug Administration, and start-up costs. With proper research, planning, and management, a hospital-based blood donor program can be effective in containing costs in a laboratory. PMID- 10159524 TI - The spirit of partnerships, cooperative networks, and regionalism. PMID- 10159525 TI - An introduction to case management. AB - Health-care professionals are constantly being challenged to find innovative ways to maintain quality of care with diminishing resources. Case management has emerged as a viable method of identifying resources and using those resources efficiently while providing the appropriate levels of care. The American Nurses Association defines case management as health assessment and planning, procurement, delivery, coordination, and monitoring to ensure that the multiple needs of the client are met. Organizations that have implemented case management report significant decreases in length of stay and substantial cost savings. The components of a successful case management team include a System Design Team to initiate the process, a Steering Committee to move the process forward, a Case Manager to coordinate and advocate for those patients who fall outside standard protocols or guidelines (critical pathways), an Interdisciplinary Specialty Team to assist in developing critical pathways, identifying variances, and evaluating data and outcomes, and an information system that provides accurate and current information. The ?team? in case management team cannot be emphasized enough- medical staff and health-care providers should be involved in and understand case management practices. Collaboration and cooperation are essential to ensure patient satisfaction, hospital marketability, and presentation of a positive image to the community. PMID- 10159526 TI - Restructuring clinical laboratories in Ontario--a '90s revolution. AB - The results of the first-ever province-wide survey of laboratory restructuring initiatives in Ontario, Canada are presented. These initiatives coincide with the historically largest financial cuts to the publicly funded health-care delivery system in Ontario, Canada's most populous province. The laboratory system includes both public hospital and commercial sectors. A survey was mailed to every laboratory director in the province, with a 73% response rate from the hospital sector. The results show that most hospital laboratories are restructuring, the bed count of the hospital is not a determinant of change, and downsizing and multiskilling of staff are the most frequent strategies. Many hospital laboratories were also considering regional alliances or contracting out part or all of their services. Also, the survey showed that the majority of laboratories in community hospitals did not have Laboratory Information Systems, in contract to the situation in teaching facilities. Most hospitals employed some form of utilization management, with the most popular being education of their users. Many respondents viewed the effect of these changes on staff morale with disquiet and expressed anxiety about the potential adverse effects on quality. In many ways, these findings mirror those reported in the United States. PMID- 10159527 TI - Career development strategies. Techniques for taking charge: Part 2. PMID- 10159528 TI - Be your own best fan. AB - As clinical laboratory personnel move into the 21st century, these individuals will find a changed workplace. It will be imperative that individuals take responsibility for their own career paths and for promoting themselves as though they were a business entity. Highlighted in this article are the major changes predicted for clinical laboratories. This article encourages clinical laboratory personnel to take ownership of their careers and to develop a strategy for success that includes becoming their own ?I Am Valuable? Team. Included in this article is a discussion of how to manage your career and be your own best fan. PMID- 10159529 TI - Automated urine dipstick analyzers. PMID- 10159530 TI - Being productive. PMID- 10159531 TI - Managed care and breakeven analysis: a clarification. PMID- 10159532 TI - Considering the costs of downsizing: severance pay. PMID- 10159533 TI - Cost accounting review: benchmark data for strategic cost management. PMID- 10159534 TI - Waste management for health care facilities. PMID- 10159535 TI - Medical gas and vacuum systems. Second edition. PMID- 10159536 TI - Radiologic studies and cost-effectiveness in health injuries. PMID- 10159537 TI - Can computer-aided systems engineering tools enhance the development of health care information systems? A critical analysis. AB - Computer-aided systems engineering (CASE) is a software technology that helps systems developers write complex application programs. CASE has been identified as having the potential to help health information systems developers complete large-scale projects such as the computer-based patient record or community health information network. The article evaluates the current use of CASE in health care and other settings through a review of the literature. There is no consensus on the value of CASE. Many experts believe that it is an emerging technology that will become widespread, whereas others see it as expensive and cumbersome to use. PMID- 10159538 TI - Concurrent process redesign and clinical documentation system implementation: a 6 month success story. AB - The need for accurate, timely, and complete clinical information has become critical as health care organizations compete on the basis of cost and quality. The automation of clinical documentation as part of the development of the computer-based patient record is a vital step in providing such information. As processes such as clinical documentation become automated, it is important that they are first redesigned both to maximize the capabilities of the new system and to increase their operational efficiencies. Riverside HealthCare in Kankakee, Illinois recognized this opportunity and successfully redesigned and automated its clinical documentation in 6 months. The article describes the necessary organizational commitment and project structure. Resource dedication, staff empowerment, physician involvement, and vendor partnership also are discussed. In addition, the documentation redesign, automation objectives, and lessons learned are reviewed. PMID- 10159539 TI - Motivation: revitalizing performance. AB - It is difficult for health information managers to maintain their career motivation in times of financial cutbacks, reforms, and changing technologies. Diminished motivation leads to poor job performance, which harms the department's productivity and the manager s job security. Revitalizing performance through improved motivation does not depend on fate. The article explains why motivation diminishes and suggests a plan for recapturing lost motivation. PMID- 10159540 TI - Obstacles encountered in the use of the medical record and cancer registry abstract in breast cancer research. AB - A historical-prospective study is being conducted to determine whether there is a relationship between obesity and breast cancer recurrence and survival in African American women. The primary data sources for the study are the medical record and cancer registry abstract. It has been found that data items such as occupation, menopausal status, height, weight, estrogen receptor and progesterone receptor values, stage, tumor size, number of positive nodes, family history of cancer, and tumor status are not always documented. Suggestions for improving documentation of the primary data sources are provided. PMID- 10159542 TI - Research review: A comparison of levels of job satisfaction between traditional hospital coders and coders using computerized encoders. AB - Computerized encoders that assist medical record department coders in making ICD 9-CM disease and operative code selections have been available for approximately 10 years but there have been no studies to evaluate job satisfaction among coders using this technology. The purpose of this study was to determine whether there is a difference in job satisfaction between coders who use computerized encoders and those who do not. The Job Descriptive Index was mailed to hospital medical record departments in Cleveland, Columbus, and Cincinnati, Ohio; the return rate was 93.5 percent. Results indicated that individuals in these three cities coding by the traditional manual method were more satisfied with their jobs than those who used computer technology. The coders in the traditional group were more challenged by their jobs and had more positive interactions with their peers and supervisors. Also traditional coders were satisfied with the pay they received; coders using computerized encoders believed that their pay was inadequate. PMID- 10159541 TI - Commentary: Is outsourcing an appropriate alternative for delivering health information management service? PMID- 10159543 TI - Research review: Survey of automation in health information management departments. AB - Automation has infiltrated most areas of health care including the health information environment. The article reports a study conducted to determine the degree to which computerized systems are being used in health information departments of acute care hospitals in Pennsylvania. Analyses of urban and rural facilities revealed the extent of automation, systems currently in use, development/purchasing issues, age of systems, and plans for future automation. PMID- 10159544 TI - Research review: Perceptions of curriculum enhancement for baccalaureate programs in health information management. AB - Chairs of 21 baccalaureate programs in health information management in schools of the allied health professions with membership in the Association of Schools of the Allied Health Professions were surveyed in 1994 via a three-round Delphi process to identify desired competencies for graduates beyond those required for professional accreditation and credentialing and appropriate courses to develop them. Eighteen chairs (86 percent) completed the final questionnaire. Statistical analysis, including one-sample, upper-sided mean Z tests, indicated consensus among the 18 chairs that 27 items of knowledge and skills and 13 courses are most important. PMID- 10159545 TI - Education review: Meeting statewide needs for health information management education through distance education. AB - In 1990 a need was expressed for a baccalaureate degree in health information management (HIM) for HIM employees who could not leave their jobs and/or families to attend classes 150 miles away. Faculty from the Medical College of Georgia, the state's health sciences university, began teaching one class per quarter at St. Joseph Hospital in Atlanta in 1993. In conjunction with DeKalb College in Atlanta, the Medical College of Georgia now offers the entire HIM curriculum leading to a baccalaureate degree. Classes are taught by faculty at the Medical College of Georgia through the use of ?electronic classrooms? equipped with two way interactive video cameras and monitors, special detail cameras, and state-of the-art computers. The Medical College of Georgia now offers the only baccalaureate degree in HIM in the state university system. PMID- 10159546 TI - Education review: Crossing borders--delivering health information management education across state lines. AB - Since its inception in 1992, the associate degree program in health information management (HIM) of the University of Alaska Southeast has been distance delivered across the state; it was the first distance degree program to be approved by the university's Board of Regents. In the spring of 1995, the HIM program was selected to be part of a pilot brokering project of the Western Interstate Consortium on Higher Education, in which member institutions would offer programs to or receive programs from other member institutions. The university's HIM program was selected by New Mexico and Wyoming, and classes for two groups of Wyoming students were initiated in the fall of 1995. The article summarizes the results of the project for the HIM program and future plans. It also provides an overview of some of the challenges facing institutions with out of-state or multistate program delivery. PMID- 10159547 TI - Midwifery: promotion and integration into Canada's healthcare system. PMID- 10159548 TI - Beyond the hype: thinking about the information highway. PMID- 10159549 TI - Negotiating your way through the new healthcare minefields. PMID- 10159550 TI - Ethics for regional boards. AB - When regional health boards choose how to allocate limited resources on the public's behalf, they are exercising ethical judgment. When board members are familiar with the study of ethics and the tools it has produced, they are able to make informed and consistent ethical choices. One board in P.E.I. drew upon ethical principles to first codify its core values, and then develop a process for making decisions which conformed to those values. As boards across Canada assume greater authority and responsibility for public health, a clear understanding of ethical principles can guide their difficult choices. PMID- 10159551 TI - Healthcare information: opportunities and challenges. PMID- 10159552 TI - Legal developments in healthcare. AB - Two recent judgments by the Supreme Court of Canada limit the liability of doctors and hospitals. One decision confirmed that the contract between a physician and patient is primarily for provision of a service, not the sale of goods. The other held that the manufacturer of a highly technical product is responsible for informing the ultimate consumer of its product's risks. It is a risk physicians may not be able to assume on the manufacturer's behalf. PMID- 10159553 TI - Health in Action. PMID- 10159554 TI - Who you gonna call? Telemedicine in Canada takes off. Interview by Aileen Leo. PMID- 10159555 TI - Can we be partners? Leadership in healthcare partnerships. PMID- 10159556 TI - Reform of the Quebec healthcare system. AB - This article briefly describes issues surrounding the reform process in Quebec and discusses its major thrusts--regionalization, definition of healthcare objectives, strengthening frontline services and greater use of outpatient services--and their effect on institutions which must above all come to terms with the reduction of the provincial deficit. Fewer human resources, longer waiting periods, institutional autonomy and the creation of integrated networks are some of the issues of current concern to the Quebec healthcare community. PMID- 10159557 TI - Med waste incinerator rule delayed, but not derailed. PMID- 10159558 TI - Materials management takes patients for a free ride. PMID- 10159559 TI - Results from our 1996 Product Committee Survey. Some win, some lose. Why? PMID- 10159560 TI - Team re-focuses management of respiratory therapy equipment and supplies. PMID- 10159561 TI - A sticky issue: do sharps containers protect health care workers? PMID- 10159562 TI - Non-CS staff learn to wrap right. PMID- 10159563 TI - Regional purchasing alliance is born well before its time. PMID- 10159564 TI - Stats. Take the 50 percent challenge. PMID- 10159565 TI - Behind the scenes of the managed care backlash. PMID- 10159566 TI - Chomping at the health care system. PMID- 10159567 TI - Who should you trust with tough coverage questions? PMID- 10159568 TI - Can point-of-service go the distance? PMID- 10159569 TI - Pacifying stomach pain without peril to the pocketbook. PMID- 10159570 TI - Data watch. An expensive grandfather clause. PMID- 10159571 TI - Data watch. Who knows what hospitals are buying into? PMID- 10159572 TI - Inquest on QUEST. AB - Describes how a group of nurse managers developed a tool for measuring the quality of care in mental hospital wards and how this was adapted for use within general elderly services. Examines the impact of the tool on service provision within a group of small local community hospitals and evaluates it using a matrix composed of Donabedian's structure/process/outcome model of quality and Maxwell's six dimensions of quality. PMID- 10159573 TI - Activity-based cost management in health care--another fad? AB - By providing improved information for strategic planning purposes activity-based cost management (ABM) systems can help hospitals and other health care providers improve the quality and efficiency of the care they provide control costs and manage their resources better. The NHS is starting to evaluate the ABM approach. Describes a research project in one specialist hospital in Sheffield UK which found that conventional approaches to costing can be inaccurate by as much as 100 per cent; conventional approaches will consistently undercost complex, specialist, infrequent episodes of care and overcost straightforward frequent episodes; and the resulting information from ABM about costs and processes significantly improves the decision-making capabilities of managers particularly in relation to ?what if? situations. PMID- 10159574 TI - Clinical benchmarking: results into practice. AB - Describes the way benchmarking data are used in a district general hospital to influence clinical practice. Wirral Hospital Trust is a site for the Electronic Patient Record Project; as such there is a large amount of patient based data available for research and internal benchmarking. Includes working examples of internal benchmarking which have been used by both clinicians and hospital management to improve hospital effectiveness. Discusses the ways in which this information is being used to develop initiatives such as clinical pathway development. PMID- 10159575 TI - Does the service at a large oncologic out-patient clinic satisfy the patients' perceived need? AB - Describes the physical status and quality of life in ambulatory oncologic patients seen at the Norwegian Radium Hospital (NRH) and assesses their satisfaction with the out-patient service. During a two-week period in 1993 517 consecutive patients completed a qualify-of-life questionnaire (EORTC QLQ-C30) during their out-patient visit at the NRH. The results of the EORTC QLQ-C30 were compared with those from a similar study performed in 1991 (211 patients evaluated during one week). PMID- 10159576 TI - European prototype for integrated care. AB - Describes the EPIC (European prototype for integrated care) project which was set up in 1992 with the aim of ?improving the quality of care provided to vulnerable people living in the community through the development of a prototype information system for integrated care capable of supporting the sharing of information between health and social care professional?s. The main application was for care of the elderly with pilot sites in Northern Ireland, Finland, and Spain. The prototype supports multidisciplinary assessment, care planning, and delivery of care. The project ended in 1994 and further development of the prototype as a generic community information system is being undertaken in the ITHACA project, within the European Commission Fourth Framework Health Telematics Programme. PMID- 10159577 TI - Continuous quality improvement in health maintenance organizations: an application of the HEDIS model. AB - One aspect of the Clinton Healthcare Reform programme is to assist health maintenance organizations (HMOs) in collecting and analysing data for the purpose of continuous quality improvement. The HEDIS 2.0 quality performance measurement model is currently in use and endorsed by the National Committee for Quality Assurance (NCQA). Outlines a process using HEDIS 2.0 by which an HMO can identify crucial problem areas and track the success of the solution process. Discusses the use of other relevant statistical tools. PMID- 10159579 TI - The issue of noncompliance. PMID- 10159578 TI - Preventive rehabilitative cardiology: the Mayo Clinic approach. AB - Coronary artery disease is a chronic condition that requires careful patient management to ensure the best possible outcome. The optimal control of the major modifiable risk factors for coronary atherosclerosis (cigarette smoking, dyslipidemia, hypertension, sedentary lifestyle) have been demonstrated to improve the cardiac event rate and cardiac mortality, to reduce the need for revascularization, and result in lower utilization of health care resources in patients with documented disease. Risk factor intervention in patients who have not yet developed atherosclerosis is also highly effective in preventing cardiac events. The major limitation of current efforts at aggressive risk factor modification is a relative lack of efficient ?systems? for providing ongoing care specifically aimed towards risk reduction. This paper describes one such system. PMID- 10159580 TI - Pharmaceutical counseling and medication adherence monitoring: an essential component of any drug benefit program. AB - Prescription drugs are an essential component of any health benefit. This is hardly a controversial statement, yet it is only relatively recently that prescription drugs have been included as part of the benefits package available to most Americans. The United States has lagged behind most other industrialized countries in providing a drug benefit, and such a benefit is still lacking for one of the most needy segment of our society--the elderly. PMID- 10159581 TI - An integrated care system for musculoskeletal disorders in a managed care setting. AB - Practice guidelines, education, consensus building, and extensive communication were the tools used in developing a musculoskeletal care system. Primary care physicians directed patient care using practice guidelines for common musculoskeletal conditions. Patient education and empowerment were emphasized. Specialist consultations were made available by telephone/voicemail to advise primary care physicians regarding treatment plans and the need for specialty referrals. Significant reductions in medical service utilization for this patient population were achieved while high levels of patient satisfaction were maintained. Such integrated systems are likely to work well within other MCOs. PMID- 10159582 TI - Disease management: a contracting primer. AB - This article provides an understanding of the issues and steps that are required for negotiating a disease management contract. Because most of the author's experience derives from representing pharmaceutical companies and other provider driven entities, the tenor of the comments often reflects that perspective on negotiations. This article focuses on disease management contracting whereby a provider network or case manager assumes risk relating to the cost of providing care to a certain type of patient. PMID- 10159583 TI - Centralizing contract negotiations. AB - Regional focus of sales of pharmaceuticals and other supplies to MCOs, with generic, one-size-fits-all value-added programs, will not help ensure marketshare in the managed care environment. According to the author, a centralized approach to managed care sales must be taken, offering customized programs to individual health plans. PMID- 10159584 TI - Cancer and the Internet. PMID- 10159585 TI - Outsourcing provides option to field your team of MCO pros. PMID- 10159586 TI - Will your practice-management system connect to the HIS (hospital information system) or AMR (ambulatory medical record)? PMID- 10159587 TI - Alphabet soup: the latest on CHINs, RHINs and HINs. PMID- 10159588 TI - Enhance regional presence with videoconferencing. PMID- 10159589 TI - Book offers 'Prescription for the Future'. PMID- 10159590 TI - Consider how an LIS fits into your enterprise's strategy. PMID- 10159591 TI - Motivate healthcare I/T staff to supplant mistrust for mutality. PMID- 10159592 TI - Medicare HMOs. Georgia providers gear up for HCFA demonstration. PMID- 10159593 TI - Hospitals ready as 'world comes to Georgia'. PMID- 10159594 TI - Final HCFA rule governing physician incentive plans in Medicare and Medicaid programs. PMID- 10159595 TI - Professional satisfaction of doctors working in a super-speciality hospital in Bangalore. AB - The doctors' assessment of their jobs provides an insight into those facets of the profession which need attention. This study assessed the professional satisfaction of 80 doctors who responded to the 80 item multifaceted questionnaire. Although the doctors were generally satisfied with the various facets of their jobs and career, variation in the level of satisfaction was noted. Personal background revealed that 80% of doctors had good academic and family background. The most satisfied group of doctors were the consultants with a performance based pay scale. Housekeeping, interpersonal relationship among doctors, nursing care and the pay scale of junior doctors are areas to which the administration should pay special attention if the professional satisfaction of doctors is to be improved. PMID- 10159596 TI - Can health system reform in Africa be driven by improving the efficiency of public hospitals? The case of Zambia. PMID- 10159597 TI - Assessing the need to establish new hospitals. AB - During recent decades, the underdeveloped and the developing countries have witnessed modern or large hospitals, as well as other health facilities, being largely centered in capitals or metropolitan areas, leaving the remaining areas with less-accessible medical services. Many organizations provide in-patient services within the same neighbourhood, which leads to duplication and overlapping, ultimately resulting in wastage of capital resources. And, once built, hospitals are extremely difficult to close. In his paper the author assesses both the need to establish new hospitals and discusses the criteria to be met and investigations and studies to be carried out prior to their construction. PMID- 10159598 TI - Spectrum of healthcare delivery from hospital to home in the United Kingdom. AB - Technological, economic and demographic levers for change are radically modifying patterns of health care delivery and the subsequent built environment that houses the service. In particular the nature of the hospital is changing to a smaller more acute facility. This paper sets out some recent analyses of where service delivery might be located on the spectrum of hospital to home in the UK and identifies some of the alternative patterns of delivery currently being pursued. The underlying imperative for change is economic but could be an opportunity for innovation in health building design. PMID- 10159599 TI - The invisible hospital--or, what patients experience but managers often don't see. AB - This paper is an extract from The Invisible Hospital and the Secret Garden--an Insider's Commentary on NHS Reforms and is based on a paper presented at The Royal Society of Medicine in London on 11 April 1994. The author discusses the need to identify the invisible hospital--what patients experience but managers often don't see--through Non-Executive Directors, for it is perhaps only they, he maintains, who, if more active and influential, can fulfill the potential of the reforms to change it. In addition to justifying the author's (now widely discussed) visit to a hospital as a wheelchair patient, the paper is drawn primarily from Mr. Spier's own experience of Chairman of Brighton Health Care NHS Trust and the implementation--or not--of his own initiatives. PMID- 10159600 TI - Medical devices; medical device reporting; baseline reports; stay of effective date--FDA. Final rule. PMID- 10159601 TI - Analyzing strategies for developing information systems. PMID- 10159602 TI - A glossary of information systems terms. PMID- 10159603 TI - Information systems for integrated delivery systems. PMID- 10159604 TI - Industry giant plans to ante up $1 billion. PMID- 10159605 TI - Intranets in health care. PMID- 10159606 TI - Automated protocols: will they ever be commonplace? PMID- 10159607 TI - Blue Cross/Blue Shield plans take the lead in building health information networks. PMID- 10159608 TI - Patient scheduling made easy. PMID- 10159609 TI - POTS (plain old telephone systems) shouldn't be panned. PMID- 10159610 TI - Tracking claims coding software companies. PMID- 10159611 TI - The future of academic medical centers. Will they be hub-and-spoke networks, specialty carveouts, or "Switzerland"? PMID- 10159612 TI - Top 10 strategies for academic medical centers. PMID- 10159613 TI - South Dakota to propose patient outcomes project. PMID- 10159614 TI - Outcomes management system helps TheraTx in managed care markets. PMID- 10159615 TI - Malpractice and vicarious liability for providers of complementary & alternative medicine. PMID- 10159616 TI - To be freestanding or not to be. PMID- 10159617 TI - Order of Excellence 1996 Awards. Design principles. PMID- 10159618 TI - The directory of architects & interior designers. PMID- 10159619 TI - Pleasing the palate. PMID- 10159621 TI - Facility-wide networks are now a necessity. PMID- 10159620 TI - For hospice, success is in the details. PMID- 10159623 TI - Contemporary Long Term Care's 1996 software showcase. PMID- 10159622 TI - Creamed corn caper baffles multi-service provider. PMID- 10159624 TI - Alternative therapies: a spiritual journey? PMID- 10159625 TI - Spiritual retrieval: bringing spirituality to work. PMID- 10159626 TI - Shaping a preferred future. PMID- 10159627 TI - Living spirituality: the essence of being human. PMID- 10159628 TI - Spirit that matters. PMID- 10159629 TI - Integrated health systems: promise and performance. AB - Today's ?virtually? and vertically integrated health systems increasingly are much better positioned than the multihospital systems of the 1980s to respond to the healthcare challenges of the twenty-first century. The authors argue that the control of the health services ?value chain? will devolve naturally to those market players who have the comparative advantage in coordinating the flows of information, human, and physical resources along the continuum of services required to improve and maintain the health of populations. Available evidence does not render a clear verdict on whether superior performance is generated by the virtual integration of strategic alliances and affiliations or the vertical integration represented by unified single ownership of all system components. While inertia, acute care-based ?mental models,? weak incentives, and insufficiently developed information systems represent important barriers to the creation and sustainability of integrated systems, the authors argue that system evolution is occurring and offers promise of enhanced efficiency and patient benefit. However, the full potential of these systems will only be realized as they accept explicit accountability for meeting the health needs of their local communities. The transition from ?covered lives? to accountability for the community population is crucial. PMID- 10159630 TI - Price, quality, and barriers to integration. PMID- 10159631 TI - Permeating organizational boundaries: the challenge of integration in healthcare. PMID- 10159632 TI - Overcoming barriers to integrated health delivery. PMID- 10159633 TI - Strategic alliances: an integrated health system alternative. PMID- 10159634 TI - The evolving role of the health care supervisor: shifting paradigms, changing perceptions, and other traps. AB - As health care comes under mounting pressure to reduce costs, organizations are restructuring. Delivery systems are changing. As layoffs occur and changes are made in numbers and responsibilities of managers, supervisors find themselves in dramatically changing roles. Job security has become as illusory in health care as elsewhere. Morale among health workers is sagging, and motivational concerns are increasing. The supervisor has been put in the position of having to do more with less and to do it in the face of demoralized forces. The paradigms that were once operational are shifting, and the evolving role of the health care supervisor suggests that a completely new set of paradigms is taking over that suggests the supervisor's future security lies in the ability to learn new things and to shift and change with the environment. PMID- 10159635 TI - If you monitor e-mail, have a policy. AB - As the use of e-mail has increased, so has employer monitoring of e-mail messages. But what a health care employer deems its right to protect a vast amount of confidential patient information from improper use, employees may view as a privacy violation. If employees are violating a health care organization's confidentiality or other workplace policies, the health care provider can be held liable for their actions and the e-mail communication could be the proverbial smoking gun. Health care institutions that monitor employee e-mail must have a monitoring policy in place and communicate it to employees. PMID- 10159636 TI - Finding heroes and heroines: fads, fantasies, and foibles of search and screen committees. AB - Search and screen committees have many agendas other than finding candidates for a job vacancy. They are essentially political processes whereby special interest groups inside and outside the organization can express opinions, monitor diversity, and review and fine-tune the organizational culture with respect to planned change. Search committees reflect the fads of the institutional culture, have fantasies about the kinds of persons they will attract to the position, and commit foibles that may affect the outcome of the search. PMID- 10159637 TI - Maintaining confidentiality: health care's ongoing dilemma. AB - Confidentiality of patient information is an ethical obligation of health care professionals. The exercise of confidentiality is not a simple process; it is dynamic rather than static and must be upgraded with changes in technology. This article discusses some of the common issues that arise in maintaining confidentiality in the health care environment, including spoken and written breaches of confidentiality, use of the computer, confidentiality as an ethical rather than legal obligation, and the use of programs in health care institutions to maintain confidentiality. PMID- 10159638 TI - Boundaries in the workplace. AB - Employees in all health care settings are vulnerable to violations of boundaries: crossing that sometimes blurry line drawn between staff and patient. Accepting gifts, financial transactions, and romantic entanglement could lead to various negative consequences for the agency, staff, and patients. Supervisors need to be aware of early warning signs of boundary violations as well as training issues. The authors outline a successful program for addressing these issues and argue for rehabilitating the chronic boundaries violator. PMID- 10159640 TI - The obligation of health care professionals and supervisors to report child sexual abuse. AB - Child sexual abuse is a problem that often can be stopped or prevented if reported. This article summarizes child sexual abuse: its incidence, signs and symptoms. and legal and ethical issues. Through a case study, a five-step approach to the reporting of child sexual abuse is presented to help health care professionals and supervisors in fulfilling their ethical and legal obligations. PMID- 10159639 TI - Job satisfaction among selected hospital CEOs. AB - The purpose of this study was to identify the contributors to job satisfaction of hospital chief executive officers (CEOs) using a multidimensional approach of demographic characteristics. environmental traits, and person environment fit traits. By analyzing the concept of hospital executive job satisfaction in a multidimensional approach, a more comprehensive model of the most salient determinants of job satisfaction was developed. CEOs ranked their performance highest on employee and staff relations and managerial team building and lowest on information management systems. The results of this study can be used to better understand the intricacies and uniqueness of being a hospital CEO as well as the professional and personal requirements of success. PMID- 10159641 TI - Building hospital TQM teams: effective polarity analysis and maximization. AB - Building and maintaining teams require careful attention to and maximization of such polar opposites (?polarities?) as individual and team, directive and participatory leadership, task and process, and stability and change. Analyzing systematic elements of any polarity and listing blocks, supports, and flexible ways to maximize it will prevent the negative consequences that occur when treating a polarity like a solvable problem. Flexible, well-timed shifts from pole to pole result in the maximization of upside and minimization of downside consequences. PMID- 10159642 TI - Examining the applicability of market forecasting models to new pharmaceutical products. AB - Developing new products is a complex and risky business, particularly in the pharmaceutical industry. In recent years, several pretest and test market models have been proposed to evaluate the performance of a new product. Although these models have been tested and validated with a wide variety of frequently purchased products, certain unique characteristics of the market for pharmaceutical products render the models subject to modification. This study examines and evaluates the applicability of three types of market forecasting models (Awareness forecasting models, Pre-test market models, and Test market models) in predicting the market potential of new pharmaceutical products. PMID- 10159643 TI - Quality measures in health care. AB - This article discusses measurement of quality in health care. The authors attempt to answer the following questions: why measure quality, and what will quality measurement do? The current quality measurement system is described including definitions of the measurable aspects of health care and current measurement tools. Finally, suggested benchmarks for various health care measurements are included. PMID- 10159644 TI - College student's blood donation behavior: relationships to demographics, perceived risk, and incentives. AB - A study was undertaken to empirically investigate whether the student market could be further segmented into blood donor and nondonor markets based on their demographic characteristics, perceived risks, and influence on non-monetary incentives. While significant differences were found between donors and nondonors based on their gender, blood type, student classification, and influence of incentives, no differences were found between the four (physical, psychological, social, or time) dimensions of perceived risk. Discussion focuses on strategies for blood collection agencies for student markets. PMID- 10159645 TI - Over-the-counter pharmaceuticals: exploratory research of consumer preference toward solid oral dosage forms. AB - The capsule dosage form in nonprescription pharmaceuticals persists as being one of the most vulnerable to product tampering. This study examines consumer preference toward three solid oral dosage forms (capsules, caplets, and tablets) in nonprescription products. Thirteen independent variables representing dosage form attributes are measured on semantic differential scales. The data are analyzed using analysis of variance (ANOVA) and factor analysis. Implications for the pharmaceutical marketer are noted. Future directions for research are also outlined. PMID- 10159646 TI - Segmenting the senior health care market. AB - This paper addresses the issue of health market segment comparisons for the senior population. The analysis demonstrates how initial self-assessed health comparisons among three racial/ethnic categories can be adjusted to reflect compositional (age and income) differences among the three groups. The adjustments provide additional insight into the nature of these segments. PMID- 10159647 TI - Relationships of physicians with pharmaceutical sales representatives and pharmaceutical companies: an exploratory study. AB - Physicians were surveyed in Northwestern Pennsylvania to examine how they viewed their relationships with pharmaceutical sales representatives (PSR) and the pharmaceutical industry. Physicians viewed the PSR as an important source of information, but felt that they could get needed information from other sources without the PSR's assistance. Physicians also had friendly relations with PSRs and did not distrust them, but they did not view PSRs as a vital part of their practice. Samples and gifts provided by the pharmaceutical companies were not viewed as vital to gaining access to physicians. However, the financial support the companies provided for continuing medical education was seen as vital. The selling approaches used by PSRs was not considered as manipulative, nor were PSRs thought to be perceived negatively by the medical community. A majority of the physicians said they would accept honoraria for delivering lectures to pharmaceutical companies. Twenty-five percent of the responding physicians also owned stock in pharmaceutical companies. PMID- 10159648 TI - The relative effect of price and personal referral cues on consumers' perception of dental services. AB - This paper reports on an experimental study that examines the relative effect of price and personal referral cues on the consumers perception of dental services. The results of the study show that price and personal referral do effect the perceived competence of the dentist as well as consumer purchase probability. PMID- 10159649 TI - Legislative responses to managed care pressures. AB - Changes brought about by the increasing presence of managed care have sparked responses in a number of states. While proponents of managed care contend that it fosters competition and allows the market to influence its nature and functioning, the legislators' responses call into question the notion that managed care will bring greater freedom to insurers and providers and, at the same time, will benefit health care consumers. PMID- 10159650 TI - Accreditation & clinical engineering. PMID- 10159651 TI - 1996 survey of salaries & responsibilities for hospital biomedical/clinical engineering & technology personnel. AB - The Journal of Clinical Engineering conducted its eleventh annual survey of the salaries paid to biomedical/clinical engineering and technology personnel in U.S. hospitals. This paper reports the salary and work responsibility data obtained from 907 professionals in relationship to: Certification; Region of the U.S.; Teaching versus Nonteaching Facilities; Years of Experience; Education; Union Membership; and Gender. Data are included on Wage Increases and Job Responsibilities. Data are as of 12/31/95 and are compared with data as of 12/31/94. The average BMET I has 3.6 years of experience and earns $24,439 + $5,800 (nationwide mean + standard deviation). The average BMET II has 7.4 years of experience and earns $32,592 + $7,300. The average BMET III has 14.7 years of experience and earns $39,844 + $7,100. The average BMET Specialist has 16.1 years of experience and earns $44,484 + $10,400. The average BMET Supervisor has 15.4 years of experience and earns $42,939 + $8,500. The average Clinical Engineer has 11.7 years of experience and earns $44,844 + $9,600. CE Supervisors average 15.9 years of experience and have an average salary of $49,053 + $12,100. The overall group or department Director or Manager has 16.6 years of experience and earns $52,120 + $12,900 on average. PMID- 10159652 TI - Developing an in-house software system for medical equipment inventory management. PMID- 10159653 TI - Technical note: Rationale, development, use and evaluation of an equipment management and image storage system. AB - Lack of space and organization have become significant problems in the contemporary business world. Modern industries must eliminate mountains of paper and better organize themselves. With the incorporation of a fully automated equipment management system and image storage system, the Jacobi Medical Center has succeeded in correcting these problems. This technical note shows how the use of computer software and hardware components can be integrated to manage electronic patient care equipment. The adoption of this new technology was applied to equipment maintenance, tracking and record-keeping, thereby accomplishing the aims of space conservation and organization. As the components became more advanced, the technology included computer software products that could store more information and electronically effect a more rapid document retrieval. This will eventually allow for a paperless operation. The latest available equipment management software is supported by an image storage system that may contain important signature documents and outside vendor information. The applicability of these systems to the biomedical engineering field is obvious: (a) space efficiency eliminates folders and files; (b) simultaneous technician access to equipment history; and (c) rapid archive retrieval of data as well as vendor information and safety alerts. PMID- 10159654 TI - Biomedical engineering education in Canada, 1996. AB - This paper updates the information contained in a previously published paper, ?Bioengineering Education in Canada, 1988,? which appeared in the Journal of Clinical Engineering (Volume 13, No. 5). It describes the current biomedical engineering and biomedical engineering technology programs available in Canada, but does not attempt to evaluate them. There are no undergraduate degree programs specifically in biomedical engineering, although three universities have created options in biomedical engineering in undergraduate programs. Also, the clinical engineering program at the University of British Columbia has been discontinued. PMID- 10159655 TI - Can chaos theory be used to increase preventive maintenance effectiveness? AB - Clinical engineering programs typically establish the content and frequency of a device's inspection and preventive maintenance procedures at the time of implementation. In some programs, these are not altered throughout the device's useful life. In others, history data and traditional statistical methods are used to adapt procedures to change in risk measures. Such methods are essentially reactive in that they are based upon past trends and do not readily consider potentialities for future change in the performance and utilization environments. Chaos theoretical concepts and related measures, when implemented in artificial intelligence programs such as neural networks and genetic algorithms, and used as an adjunct with computerized technology management programs, can assist in asking and answering the more dynamic, proactive questions necessary for effective inspection and preventive maintenance optimization. Today's healthcare environment is ideal for exploring their utilization. PMID- 10159656 TI - Mirror, mirror, on the wall. Interviewers' tendency, however illegal, is to prefer applicants who resemble themselves. PMID- 10159657 TI - Embracing workplace diversity. PMID- 10159658 TI - Know your financing options. PMID- 10159659 TI - Employee commitment in community-based LTC organizations. PMID- 10159660 TI - In-house training raises knowledge and morale. PMID- 10159662 TI - Examining job demands among Pennsylvania administrators. PMID- 10159661 TI - Residents' morale can be improved through organizational changes. PMID- 10159663 TI - New design and management approach improves quality of life. PMID- 10159664 TI - Diverse staff means diverse nursing attitudes and styles. PMID- 10159665 TI - Hospital price inflation: what does the new PPI (Producer Price Index) tell us? PMID- 10159666 TI - The CPI (Consumer Price Index) for hospital services: concepts and procedures. PMID- 10159667 TI - Physician services in the emergency department require accurate coding. PMID- 10159668 TI - Neural networks in urologic diagnosis. PMID- 10159669 TI - A guide to nephrostomy tubes. PMID- 10159670 TI - Urologic frontiers in helical CT. PMID- 10159671 TI - TUNA: a promising new therapy for BPH. PMID- 10159672 TI - Understanding health care's effect on GNP. PMID- 10159673 TI - The perceived efficacy of complementary and orthodox medicine in complementary and general practice patients. AB - A total of 216 patients attending either the British School of Osteopathy, a large acupuncture centre (City Health Centre), the Royal Homeopathic Hospital or a large general practice in South London completed a questionnaire on the perceived efficacy of orthodox and complementary medicine. The questionnaire covered 1) demographic information and experience of complementary medicine; 2) the Health Locus of Control scale; (3) attitudinal variables: belief in the importance of a scientific base to medicine, the importance of psychological factors in illness and the possible side effects of modern medicine; and 4) ratings of the perceived efficacy of acupuncture, osteopathy, homeopathy, herbalism and orthodox medicine for 16 illnesses, divided into four categories: major, minor, chronic and psychological. Whilst there was no difference between the four groups, health locus of control beliefs showed the acupuncture patients believed less in the scientific basis of orthodox medicine and more in its harmful effects compared with all other groups. Again, acupuncture patients more than any other group tended to believe in the efficacy of that therapy to 'cure' major, minor, chronic and psychological problems. Beliefs in the efficacy of complementary therapies were associated with a belief in importance of psychological factors in illness and concerns about the harmful effects of orthodox medicine. Results are discussed in terms of three things: differences between lay and professional medical beliefs; the health education implications for this research, and the role of complementary therapies in general practice and health promotion. PMID- 10159674 TI - A critical review of peer education with young people with special reference to sexual health. AB - This paper presents a critical review of selected literature about peer education initiatives with young people principally in the area of sexual health. Reported work in this area was found to be diverse in terms of aims, objectives, methods, findings and levels of evaluation. The paper highlights the promise of the method but draws attention to its potential problems. Examples of peer health education are reviewed and the issues surrounding them discussed. These include: theoretical background, rationales, cultural constraints, ethical and operational issues, and the challenges for monitoring and evaluation. The paper concludes by suggesting that practitioners and evaluators must reflect on the difficulties inherent in artificially reconstructing a social process. PMID- 10159675 TI - The feasibility of a proactive stepped care model for worksite smoking cessation. AB - Worksite smoking cessation interventions have achieved some success, but until recently have only intervened on those smokers at a stage of readiness to volunteer to participate in cessation programs. The present study assesses whether a sustained, proactive smoking cessation program based on a stepped care model that targets all smoking employees in the worksite can actually be delivered. In one worksite in Seattle (N = 273), a worksite-wide survey with a 99.3% response rate identified 53 smokers; subsequent new-hires added an additional 14 smokers to the worksite. This study delivered increasingly intensive intervention to those smoking employees who failed to quit smoking during the study period of 1.5 years. Telephone contacts (every 3 months) provided motivational messages tailored to the smokers' stage of cessation. Subsequent more intensive steps included self-help manuals and referrals to formal programs. The intervention also used community organization strategies, such as employee guided worksite activities to complement the individual and stepped strategies. In the study period, 18% of the smokers quit smoking. Participation rates in activities were good and on average worksite smokers moved over one stage of change from baseline toward quitting smoking. PMID- 10159676 TI - A brief office-based intervention to facilitate diabetes dietary self-management. AB - There is a pressing need for brief, practical interventions that address diabetes management. We have developed an office-based intervention to prompt both patients and providers to focus on behavioral issues relevant to dietary self management that is being evaluated in a randomized trial. The intervention is designed to be broadly applicable to the majority of adult diabetes outpatients during medical visits; uses touchscreen computer assessment to provide immediate feedback on key issues to patients and providers just prior to their interaction; and provides goal setting and problem-solving assistance to patients following their meeting with the physician. Follow-up components include phone calls and videotape or interactive video instruction as needed. The program is described, and demographic and behavioral characteristics of participants are presented for the first 95 patients randomized. Initial process results suggest success in producing modest, targeted behavior changes among a broad cross-section of patients. If the long-term results are equally positive, this intervention could provide a prototype for a feasible, cost-effective way to integrate patient views and behavioral management into office-based care for diabetes. PMID- 10159677 TI - The effects of access to health care on infant mortality in Indonesia. AB - This paper examines the impact of access to health facilities and personnel on infant and child mortality in Indonesia. Demographic and Health Survey data are combined with village-level censuses of infrastructure collected by the Central Bureau of Statistics. Because the village-level data are available from two points in time, it is possible to analyse the effects on mortality risks within the village of changes in access to health care. Factors about villages that might affect both access to health care and mortality risks are held constant. Adding a maternity clinic to a village decreases the odds of infant mortality by almost 15 per cent, in comparison to the risk before the clinic was added. An additional doctor reduces the odds by about 1.7 per cent. PMID- 10159678 TI - A computer model comparing normovolemic hemodilution, hypervolemic hemodilution, and neither on intraoperative blood loss and final hematocrit. AB - Homologous blood transfusion, while frequently life-saving, is attended by risks and complications. Autologous blood transfusions have become an increasingly common alternative. Volume expansion, which is simpler, also is used. This study was designed to construct computer models of hypervolemic hemodilution and normovolemic hemodilution to compare them with each other and with normal (neither hypervolemic nor normovolemic hemodilution). Each model started with blood volume (BV) equal to 5,000 mL. Initial hematocrits (HCTs) were varied from 25% to 50%. Following phlebotomy and hemodilution or volume expansion, which ranged from 0 to 2,500 mL (50% of initial BV), the models were then bled 250 to 2,500 mL (5% to 50% of initial BV). In the phlebotomy model, the autologous blood was then returned. Final HCTs were then calculated. Preoperative phlebotomy of 500 to 1,000 mL, an amount commonly withdrawn, provides a minimally higher final HTC. Volume expansion by hypervolemic hemodilution provides almost the same low level of benefit. Benefits (3% higher HCT) are not seen until larger volumes are phlebotomized or hemodiluted and accompanied by large intraoperative blood losses. Autologous blood drawn by preoperative phlebotomy for intraoperative transfusion should not be used until studies show that these large volumes are safe and actually save blood. PMID- 10159679 TI - Doing more with less in histology. PMID- 10159680 TI - When is death heat-related? AB - Chicago's heat wave put its chief medical examiner on the hot seat and underscored the need for a uniform definition of heat-related death. PMID- 10159682 TI - Pap devices seek to star in clinical galaxy. PMID- 10159681 TI - Specimen collection made easier with bar codes. PMID- 10159683 TI - Coagulation testing at the bedside. PMID- 10159684 TI - How to manage quality in forensic pathology. PMID- 10159685 TI - Perspectives. CHAMPUS revamped: doing managed care the military way. PMID- 10159686 TI - Perspectives. NCQA: setting the standard in setting the standard. PMID- 10159687 TI - Off duty. Watch out: managers at play. PMID- 10159688 TI - Ambulance services. The times they are a changin'. PMID- 10159689 TI - Outpatient investigation. Once and for all. PMID- 10159690 TI - Clinical guidelines. Guidelines and brownie points. PMID- 10159691 TI - Will the states get tough with HMOs? Anti-managed-care proposals pile up nationwide. PMID- 10159692 TI - Are doctors faring better in liability suits? PMID- 10159693 TI - Physician recruitment. More and more doctors opt for salaried jobs. PMID- 10159694 TI - Patients. How their bad habits can hurt your bottom line. PMID- 10159695 TI - My costly lesson in leasing equipment. PMID- 10159696 TI - The best ways to divide income. PMID- 10159697 TI - For the first time in one place: HMO quality data. PMID- 10159698 TI - Employees paying bigger share of healthcare--report. PMID- 10159699 TI - Kaiser, ACEP seek federal emergency services rules. PMID- 10159700 TI - HCFA decision could cause some hospitals to drop clinics. PMID- 10159701 TI - 20th anniversary. Celebrating the past, looking to the future. AB - This special section marks the 20th anniversary of Crain Communications' ownership of Modern Healthcare. On the following pages, the staff of Modern Healthcare examines the three most important developments of the past two decades (p. 44) and then reviews in detail the news events, trends and people that shaped each year (pages 46-84). A compilation of some of the best work of editorial cartoonist Roger Schillerstrom can be found on p. 86. Finally, with the help of healthcare futurists, we'll take a peek at the next 20 years of healthcare (pages 92-96) as this most changeable of industries undergoes ever more profound transformations. PMID- 10159702 TI - Provider compensation: the next generation. PMID- 10159703 TI - Social ecological approach to health promotion. PMID- 10159704 TI - The social ecology of health promotion: implications for research and practice. PMID- 10159705 TI - Social ecological strategies for promoting healthy lifestyles. PMID- 10159706 TI - An ecohistory of health: the role of 'Healthy Cities'. PMID- 10159707 TI - Building academic-community linkages for health promotion: a case study in Massachusetts. AB - Using select practice variables from Rothman's typology of models of community organization, this case study of the Massachusetts Community-Based Public Health Consortium analyses potential sources of conflict in collaborations between academic institutions and community coalitions. Based on different socialization experiences and organizational expectations, the goals, assumptions, basic change strategies, salient practitioner roles, conceptions of the client population, and client roles of the respective organizations were found to differ between these two partners and to be a source of chronic, unproductive tensions in consortium deliberations. The article concludes with recommendations for facilitating the development of more mutually trustworthy academic-community linkages to achieve public health promotion goals. These recommendations include (1) developing a greater awareness of the respective kinds of assumptions academic and community partners are likely to bring into new partnerships and (2) developing a more highly integrated model of community-based public health that capitalizes on the strengths of both the social planning and locality development approaches. PMID- 10159709 TI - Translating social ecological theory into guidelines for community health promotion. AB - Health promotion programs often lack a clearly specified theoretical foundation or are based on narrowly conceived conceptual models. For example, lifestyle modification programs typically emphasize individually focused behavior change strategies, while neglecting the environmental underpinnings of health and illness. This article compares three distinct, yet complementary, theoretical perspectives on health promotion: behavioral change, environmental enhancement, and social ecological models. Key strengths and limitations of each perspective are examined, and core principles of social ecological theory are used to derive practical guidelines for designing and evaluating community health promotion programs. Directions for future health promotion research are discussed, including studies examining the role of intermediaries (e.g., corporate decision makers, legislators) in promoting the well-being of others, and those evaluating the duration and scope of intervention outcomes. PMID- 10159708 TI - Ecological foundations of health promotion. AB - In this article, human ecology is defined; its historical and intellectual roots are traced through various disciplines to its applications in public health and health promotion today; its strengths and limitations are described; some potential contributions of systems theory are suggested; and some emerging ecological models of health promotion are anticipated. PMID- 10159710 TI - The ecology of urban violence: its relationship to health promotion behaviors in low-income black and Latino communities. AB - PURPOSE: The purpose of this review is to identify and examine relationships between exposure to violence and health promotion behaviors in low-income black and Latino groups. DESIGN: Based on computer surveys of the psychologic, public health, medical, and sociologic literature, approximately 90 previous studies of the impact of exposure to violence on psychologic functioning, perceptions of health and well-being, and health decisions and behavior were identified. This article reviews those studies that examine the relationships between experiences of violence and subsequent feelings of alienation, powerlessness, and hopelessness, and perceptions of health and well-being and studies that examine relationships between alienation, hopelessness, and powerlessness and health promotion behaviors. Studies of health promotion behavior that did not examine or address the impact of exposure to violence are not reviewed in this article. RESULTS: Violence affects low-income communities directly by contributing to rates of mortality, and indirectly by affecting health promotion behaviors. Exposure to violence can result in feelings of powerlessness, hopelessness, and alienation that significantly limit motivation, the extent of involvement, and persistence in overcoming barriers to health promotion behavior. CONCLUSIONS: Future researchers must consider the confounding effects of exposure to violence when investigating differences in health promotion behaviors for low-income black and Latino groups. Community empowerment programs that address the impact of violence and focus on developing control over life and health outcomes may be needed to successfully address the effect of violence on health promotion behavior in low-income, black and Latino communities. PMID- 10159711 TI - Assessment of the integration of the ecological approach in health promotion programs. AB - PURPOSE: This article proposes a model of the ecological approach in health promotion programs. Based on system theory, the model identifies intervention settings and targets as two independent dimensions for assessing the integration of this approach in programs. Additional objectives are to present and pretest an analytical procedure that allows the assessment of integration of the ecological approach in programs. DESIGN: This was a descriptive study of the integration of the ecological approach in a sample of health promotion programs. SUBJECTS: Subjects were 44 health promotion programs drawn from the population of Canadian federally funded programs. MEASURES: Descriptions of programs were obtained by telephone interviews. A coding scheme was applied to the data to identify intervention settings and targets for each program. Using this information, a summative score of the integration of the ecological approach was estimated for each program. RESULTS: Single-setting programs were the dominant pattern in the sample. Individuals whose health was of concern were very frequently the direct targets of the programs. However, organizational and interpersonal environments were also often directly targeted. Single-setting or single-intervention strategy programs outnumbered ecological programs. CONCLUSION: The proposed model and analytical procedure is a useful framework for the assessment of integration of the ecological approach in health promotion programs. The pilot test having been conducted on a convenience sample, future work should replicate the study in a representative sample of programs. PMID- 10159712 TI - Strabismus. PMID- 10159713 TI - Lacrimal disease. AB - The lacrimal gland has been investigated by a number of authors with specific interest in the relationship between keratitis sicca and systemic disease. Neoplastic involvement of the lacrimal gland and lacrimal sac have drawn the attention of others. Imaging of the lacrimal drainage system by ultrasonography, computerized axial tomography, and magnetic resonance imaging has been reviewed. Finally, surgical approaches to dacryocystorhinostomy and attendant complications have been studied. PMID- 10159714 TI - Comitant strabismus. AB - This review reports on articles written on comitant strabismus during the past year. Congenital esotropia was a recurring theme in these publications. Included in this review are articles that provide an insight into the basis for motor epiphenomena such as optokinetic nystagmus asymmetry and latent nystagmus. The optimum window of opportunity to achieve quality binocular vision by surgical alignment in congenital esotropia is discussed. We also report on articles that address various aspects of the management of comitant strabismus including the amount of medial rectus recession for esotropia, the target angle for best results in accommodative esotropia with high accommodation convergence/accommodation ratio, and issues related to comitant exotropia. PMID- 10159715 TI - Paralytic strabismus. AB - This review of the year's literature on paralytic strabismus contains some especially interesting contributions on epidemiology of ischemic ocular motor palsies, new imaging diagnostic techniques in sixth and fourth nerve palsy and in Graves' ophthalmopathy, and bilateral histological findings in one case of clinically monolateral Duane's retraction syndrome. Some reports concern the reliability of diagnostic tests routinely used for measuring cyclotorsion in superior oblique palsies. PMID- 10159716 TI - Brain pathology and strabismus. AB - If we consider the complex and articulate organization of the oculomotor neural system, ie, infranuclear, nuclear, internuclear, and supranuclear levels, how many neuronal structures are implicated and their widespread localization in the central nervous system, and if we understand the various relationships within the oculomotor system and with other cerebral structures, we may easily realize that cerebral diseases and oculomotor disturbances are tightly and reciprocally connected. Many diseases may be associated with ocular movement impairment, sometimes acting on different sites of oculomotor organization. These alterations may have a clear pathophysiologic meaning and a relevant topographic localizing value, otherwise correlations and mechanisms are simply hypothetical. Last but not least for conceptual relevance are the modifications of neuronal anatomy and physiopathologic mechanisms induced by the strabismus. In the past year many articles have been published that analyze the relationships and the pathogenetic role of cerebral anomalies in the context of strabismus syndromes. Of outstanding interest is the proof of cortical and subcortical neural stations' plasticity, and the evidence of a cerebral anatomophysiologic basis of strabismus and amblyopia. In this context the midbrain, pontine, and brain stem nuclei and neuronal organizations have a peculiar importance. We will try to systematically expose, even if briefly, the main contributions in this area. PMID- 10159717 TI - Visual function deficits in children. AB - In the past year, new work on sensory testing in preverbal infants has expanded our knowledge in three areas: 1) visual acuity testing in infants in varying levels of illumination; 2) visual evoked cortical potential-evidence for binocular function in infantile esotropia; and 3) a new time-efficient method to evaluate color vision in newborns and infants. A newly reported sequel to loss of binocularity is the development of A and V pattern strabismus. In another study, loss of fusion, as with acute concomitant esotropia, was shown to be a sign of serious intracranial disease. Regarding motor visual function deficits, new treatments of infantile esotropia syndrome and nystagmus with botulinum toxin type A are presented. Regarding social issues, visual function deficit of abused children and infants born to drug-abusing mothers are presented as a timely reminder that child abuse is still an enormous social problem, and that the visual system is far from exempt from damage. PMID- 10159718 TI - Nystagmus. AB - Electronystagmographic studies with an attempt to quantify various parameters of congenital nystagmus are interesting although not conclusive clinically. This is due to the spontaneous variability of congenital nystagmus. A qualitative study (position and velocity) may be sufficient for clinical examination and treatment of congenital nystagmus. The quantification of the optokinetic response is also clinically difficult. This comes from the fact that various factors can affect the response; even healthy patients can have variable gain. However the optokinetic test, which compares the response to a nasotemporal and temporonasal stimulation, is useful. It enables us to identify patients who never had a visual binocular experience in their first year of life and who keep a directional asymmetry of the monocular optokinetic response. PMID- 10159719 TI - Lasers in oculoplastic surgery. AB - Applications of laser-assisted surgery in oculoplastics are varied because the enormous scope of the specialty overlaps with ear, nose and throat, dermatology, plastic surgery, and ophthalmology, for example. All of these specialties have applications for lasers that in one fashion or another find their way into our armamentarium. In this article we present the last year's advances in laser applications in oculoplastics. By far, endonasal dacryocystorhinostomies are the most controversial and interest producing. Several articles address different approaches and conclusions. No final determination is available yet as to the effectiveness and ultimate success of this procedure. Dermatologic surgery for lesion removal and for cosmetic surgery also features in this year's review. The use of lasers for tattoo removal was reported in detail in a superb article. Overall there were no major breakthroughs in laser surgery, however, several well thought-out articles have added to our understanding of this surgical modality. PMID- 10159720 TI - Periocular and orbital anatomy. AB - Both classic descriptions and new findings in human anatomy have been limited in the past to cadaveric dissections. Although dissection still supplies most of new information, refinements in technique and the advent of high-resolution soft tissue imaging available with magnetic resonance have certainly provided a new perspective on our understanding of anatomy. In this review, the most recent descriptions of periocular and orbital anatomy will be discussed, along with comments on their clinical implications. PMID- 10159721 TI - Infections, inflammations, and immune-mediated orbital disease. AB - In recent months, many authors have described distinct surgical approaches to orbital decompression in thyroid ophthalmopathy. Comparison of outcomes data should allow the surgeon to decide on the best approach to orbital decompression in an individual patient. Patients with thyroid-associated lid retraction may also benefit from approaches that allow for postoperative suture adjustment, because alignment of the lids can be particularly challenging in these patients. The clinical evaluation of patients with thyroid disease has evolved with the recognition that magnetic resonance T2 relaxation time prolongation may correlate with an inflammatory disease phase and, perhaps, with improved response to medical management. Medical management of orbital inflammation and infection should be tailored to the specific disease process and, in many cases of infection, to the age of the patient. PMID- 10159722 TI - Orbit and adnexal neoplasia. AB - This article reviews the major orbital and adnexal tumors and focuses on clinical diagnosis and management. It emphasizes recent reports and reviews. Orbital tumors can be divided into vascular, mesenchymal, neural, epidermal, lymphoid, and metastatic lesions. Although derived from similar elements, the tumors of the lacrimal gland and eyelid form a separate category. Within the realm of vascular tumors, this article reviews recent literature regarding the treatment of capillary hemangiomas. It summarizes important information concerning the treatment of rhabdomyosarcomas published during the preceding year. The article also reviews case reports and studies of orbital tumors derived from neural, epithelial, and lymphoid elements. It provides general information regarding orbital metastatic disease and presents several recent case reports on lacrimal and adnexal tumors. PMID- 10159723 TI - Blepharospasm and related facial movement disorders. AB - The variable clinical features and the relatively good response of blepharospasm to botulinum-toxin type A are now well established. The etiology and pathophysiology of blepharospasm and related facial movement disorders are still poorly understood. Genetic and histopathologic studies over the last year have contributed to our understanding of this disease. The most significant progress has been made in the electromyographic studies of the the levator palpebrae and orbicularis oculi muscles. Subclassification based on the electromyographic abnormalities of these two muscles have begun to improve our understanding of the variable responses to botulinum-toxin type A. Further electromyographic studies may help identify the best sites of injection for optimal response and differentiate patients requiring limited or complete myectomy. The development of the limited myectomy has provided excellent functional and cosmetic results with quick recovery times in selected patients. PMID- 10159724 TI - Amblyopia. AB - Although the studies of amblyopia, especially the amblyopiogenic factors, symptomatology, terminology, and classification have been well clarified both in clinical aspects and in animal models, detailed pathophysiological mechanisms and psychophysical symptoms have still remained nuclear in many respects. As von Noorden (Helveston et al., Symposium on strabismus: Transactions of the New Orleans Academy of Ophthalmology, St. Louis: CV Mosby; 1978: 1-9) mentioned, the complexity of the amblyopia syndrome is symbolized as an iceberg and reduced visual acuity is the most tangible of many disturbances of visual function. This past year, several articles on amblyopia were published in many journals, and the authors review these articles which are grossly classified into three categories: 1) pathophysiology; 2) symptoms, examinations and diagnosis; and 3) treatment. PMID- 10159725 TI - Design and development of a pressure relief seating apparatus for individuals with quadriplegia. AB - Persons with spinal cord injury above C7 lack the ability to extend their elbows and grip with their hands. Consequently, when seated, they are unable to press down to shift their weight to relieve pressure on the ischial tuberosities. This can ultimately cause serious pressure sores to develop on the buttocks. Those with adequate insurance coverage can eliminate this problem with an electric power recliner wheelchair. With the touch of a button, the backrest will fold down to a laying position, thus relieving the pressure on the ischial tuberosity. Unfortunately, not all individuals with quadriplegia possess this type of coverage. Therefore, the problem requires an alternate design that will utilize mechanical rather than electrical power to produce a cost-effective solution. The purpose of this project was thus to design and build an affordable apparatus adaptable to wheelchairs that allows individuals with quadriplegia to shift their weight from one side to the other thus relieving the pressure on the ischial tuberosities. A pneumatic system that utilizes two inflatable air bladders was employed. One cushion is placed under each buttock and inflated separately to tilt the user from one side to the other. The inflated cushion elevates one side of the buttock, which relieves the pressure from the other side. The power required to operate the system is generated using repetitions of elbow flexion. The system was evaluated on an individual with C6 quadriplegia. The subject demonstrated independent pressure relief without intrusion on cosmesis or independence. PMID- 10159726 TI - Development of the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). AB - This study's purpose was to develop a clinical instrument designed to evaluate user satisfaction with assistive technology devices. This paper describes the methodology used to develop the instrument entitled the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). Based on the theoretical and practical foundations of assistive technology as well as on the concept of satisfaction, preliminary versions of the instrument were created and examined by a panel of team participants. After the panel's recommendations were incorporated, a pretest of the revised instrument was conducted and the final French version of QUEST emerged. The originality of QUEST lies in its inter activeness and user-directed approach to assessing satisfaction with assistive technology. From a set of 27 variables, the user is asked to indicate the degree of importance he/she attributes to each of the satisfaction variables and then to rate his/her degree of satisfaction with each of the variables considered (quite or very) important. While QUEST remains a clinical instrument undergoing pilot testing, it holds much promise in our quest for a reliable and valid means of assessing assistive technology outcome from the user's perspective. PMID- 10159727 TI - Technology competencies for occupational therapy practitioners. AB - A task force has created a recommended set of technology competencies for occupational therapy practitioners at three levels of practice: entry/basic, intermediate, and advanced. The competencies relate to assistive technology (AT) evaluation, intervention, and resource coordination and reflect minimum knowledge and skills for registered occupational therapists (O.T.R.'s) and certified occupational therapy assistants (C.O.T.A.'s). The competencies were reviewed by members of the American Occupational Therapy Association (AOTA), the COTA network and RESNA, and were coordinated with RESNA's ongoing AT quality assurance and certification efforts. They represent a base for the component of outcome management related to ensuring the quality and competency of AT service deliverers. PMID- 10159728 TI - Extracorporeal circulation for great vessels surgery: a review of 131 cases. AB - A retrospective analysis of 131 cases of major vascular surgery, mainly aneurysms of the ascending and descending aorta, was undertaken to determine whether use of different bypass methods chosen according to location of the individual lesions resulted in improved results. For the 93 cases of ascending aortic aneurysm, the method for cardiac protection was improved by the use of continuous retrograde coronary sinus perfusion with cardioplegic blood. In sixteen cases with dissection involving the aortic arch, deep hypothermic circulatory arrest and continuous retrograde cerebral perfusion through the superior vena cava was employed for brain protection. The safe brain circulation arrest time was thus prolonged to the longest record of 81 minutes. Among the group of 93 cases, there were four operative and four hospital deaths, giving a mortality rate of 8.6% (8/93). For the 34 cases of descending aortic aneurysms, left heart bypass was employed to avoid ischemia of the heart, lungs, brain, and the abdominal organs; the operative mortality rate was 8.8% (3/34). In three cases of interrupted aortic arch, separate upper and lower body perfusion under deep hypothermia with low flow rate perfusion for the upper body provided the necessary conditions for radical surgery. In one patient with Budd-Chiari syndrome, a total corrective surgery was achieved under right heart bypass. PMID- 10159730 TI - Out-of-hospital use of a pulse oximeter to determine systolic blood pressures. AB - STUDY OBJECTIVE: Blood pressure (BP) in the out-of-hospital setting is one of the most important diagnostic tools used by emergency medical services (EMS) providers. Conventional methods of palpation and auscultation can be time consuming, and the measurements often are inaccurate because of the adverse working conditions encountered. Pulse oximetry waveform systolic blood pressure (POWSBP) measurement has been used successfully in emergency departments to monitor BP. The objective of this study was to compare the accuracy of field POWSBP measurements obtained by noninvasive electronic BP measurement (NIBPM), auscultation, and palpation in the out-of-hospital environment. DESIGN: Blood pressure measurements used for this study were obtained by POWSBP, NIBPM (PROPAQ model 102; Protocol Systems, Beaverton, Oregon USA), auscultation, and palpation on patients in moving ambulances. Measurement of POWSBP was accomplished by observing the return of the waveform on the pulse oximeter at the time of cuff deflation. The order in which the readings were obtained as well as the arm chosen for measurement were randomized. SETTING AND PARTICIPANTS: Paramedics and emergency medical technicians in an urban, inner-city emergency medical services (EMS) system. MEASUREMENTS AND MAIN RESULTS: Blood pressure measurements were sampled from 69 patients. Regression analysis identified significant correlation between POWSBP and the four methods utilized, with r = 0.92 for NIPBM, r = 0.95 for auscultation, and r = 0.97 for palpation, all significant at p < 0.0001. CONCLUSIONS: The use of POWSBP measurement is a fast, easy, and accurate technique with which to measure systolic BP in the field. It may have special importance for noisy environments and moving vehicles in which conventional methods of auscultation or palpation may be difficult. PMID- 10159729 TI - Does the level of prehospital care influence the outcome of patients with altered levels of consciousness? AB - HYPOTHESIS: Significant differences exist in the outcome of patients with altered level of consciousness (ALOC) cared for by advanced life support (ALS) compared with basic life support (BLS) prehospital providers. METHODS: Patients transported by ambulance to a community teaching hospital during an 11-month period were studied retrospectively. Study patients were those considered not alert by prehospital personnel. Exclusion criteria included; trauma, intoxication, drowning, shock, and cardiac arrest. Data were abstracted from the ambulance reports and hospital records. RESULTS: Two hundred three patients with an ALOC were identified; 113 were transported by ALS providers (56%) and 90 (44%) by BLS providers. Prehospital levels of consciousness, according to the "alert, verbal, painful, unresponsive" scale (ALS vs BLS) were: "verbal" (40% vs 51%), "painful" (23% vs 23%), and "unresponsive" (37% vs 25%). The mean value for some time was 15 +/- 6 minutes for ALS versus 10 +/- 4 minutes for BLS (p < 0.001). On arrival in the emergency department, the LOC of 72 (64%) ALS patients and 58 (64%) BLS patients had improved to "alert." The level of consciousness in one ALS patient worsened. Fifty-two ALS (46%) and 38 (42%) BLS patients were admitted. Principal final diagnoses were seizure (27% ALS vs 38% BLS), hypoglycemia (23% ALS vs 23% BLS), and stroke (22% ALS vs 20% BLS). Remaining diagnoses each constituted less than 7% of total discharge diagnoses. No statistically significant differences in measures of outcome were noted between ALS or BLS patients. Diagnoses of seizure, stroke, and hypoglycemia were studied individually. No differences in admission rate, mortality rate, or disposition were identified. Hypoglycemic patients conveyed by ALS providers had significantly shorter emergency department treatment times than did those transported by BLS providers (160 +/- 62 minutes ALS vs 229 +/- 67 minutes BLS [p < 0.005]). CONCLUSION: Advanced life support levels of care of patients with an ALOC does not significantly change outcome compared with those receiving BLS care with the exception of shorter emergency department treatment times for hypoglycemic patients. PMID- 10159732 TI - AIDS and prehospital personnel: knowledge and prevention of occupational exposure. AB - OBJECTIVES: Prehospital personnel, including law enforcement officers, paramedics, and fire-fighters, may be exposed to the human immunodeficiency virus (HIV) while working. This study of prehospital personnel sought to determine: 1) their knowledge of the acquired immune syndrome (AIDS) and HIV transmission; 2) the extent of AIDS training received; 3) self-assessment of risk for HIV infection; and 4) precautions adopted to reduce occupational risk of exposure to HIV. METHODS: A survey was administered to pre-hospital personnel in a large Southern California jurisdiction. The response rate was 41% (n = 1,756) in 10 city and county departments where respondents were employed. Law enforcement officers (44%), firefighters (44%), and paramedics (12%) comprised the sample. RESULTS: Respondents had accurate knowledge about AIDS, but incorrect perceptions about HIV transmission. A minority believed that HIV could be contracted from casual contact. Training relating to AIDS was not frequent. Preventive practices were infrequent in the work setting, with precautions used less than 50% of the time on eight of 10 measures. One-third of these prehospital personnel assessed their risk for HIV infection as medium to high, largely attributable to fear of occupational exposure. CONCLUSIONS: Improved educational programs regarding HIV/AIDS are needed for prehospital personnel to increase the use of preventive occupational practices in the field. PMID- 10159731 TI - Core temperature monitoring of firefighters during hazardous materials training sessions. AB - OBJECTIVE: To determine core temperature (Tc) elevations in hazardous materials (HazMat) technicians wearing level-A fully encapsulated, chemically resistive suits (FECRSs) during training scenarios. DESIGN: Cross-sectional, observational feasibility study with Institutional Review Board approval. SETTING: HazMat training scenarios held during the summer of 1994. Weather conditions included both rainy and sunny days, with a mean ambient temperature of 75.8 degrees F (24.3 degrees C) (range 69-83 degrees F [20.6-28.3 degrees C). PARTICIPANTS: Nine male firefighters participating in training scenarios in the Midwestern United States. INTERVENTIONS: Each volunteer swallowed a capsule containing a Tc sensor developed by the National Aeronautics and Space Administration. The capsule continuously monitored Tc and stored data in an ambulatory recorder worn under the level-A FECRS during training. RESULTS: Mean age of the volunteers was 34 years, mean weight was 92.6 kg, and average baseline Tc was 36.7 degrees C (97.1 degrees F) (range 35.3-38.2 degrees C [95.5-100 degrees F]). Time in the FECRS averaged 25.4 minutes (range 14-35 minutes). All subjects demonstrated increased Tc while in the suit; the mean Tc increase was 0.8 degree C (1.4 degrees F) (range 0.2-1.3 degrees C [0.4-2.3 degrees F]). The Tc continued to increase during wet decontamination procedures and after suit removal. Mean heat storage values (delta Tcx LBMx 3.47 kJ) were calculated, and found to be moderately elevated to 3.6 kJ/kg (range 2.1-4.6 kJ/kg). CONCLUSION: These observations support the validity and significance of implementing prophylactic measures for firefighters using protective clothing. Simple protective measures include enforced time limitations, hydration, and efforts to minimize heat buildup by avoiding both direct sunlight and unnecessary time encapsulated in the suit. PMID- 10159733 TI - Disaster triage: START, then SAVE--a new method of dynamic triage for victims of a catastrophic earthquake. AB - Triage of mass casualties in situations in which patients must remain on-scene for prolonged periods of time, such as after a catastrophic earthquake, differs from traditional triage. Often there are multiple scenes (sectors), and the infrastructure is damaged. Available medical resources are limited, and the time to definitive care is uncertain. Early evacuation is not possible, and local initial responders cannot expect significant outside assistance for at least 49 72 hours. Current triage systems are based either on a shorter time to definitive care or on a longer time to initial triage. The Medical Disaster Response (MDR) project deals with the scenario in which specially trained, local health-care providers evaluate patients immediately after the event, but cannot evacuate patients to definitive care. For this type of scenario, a dynamic triage methodology was developed that permits the triage process to evolve over hours or even days, thereby maximizing patient survival and resulting in a more efficient use of resources. This MDR system incorporates a modified version of "Simple Triage and Rapid Treatment" (START) that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed, "Secondary Assessment of Victim Endpoint" (SAVE). The SAVE triage was developed to direct limited resources to the subgroup of patients expected to benefit most from their use. The SAVE assesses survivability of patients with various injuries and, on the basis of trauma statistics, uses this information to describe the relationship between expected benefits and resources consumed. Because early transport to an intact medical system is unavailable, this information guides treatment priorities in the field to a level beyond the scope of the START methodology. Pre existing disease and age are factored into the triage decisions. An elderly patient with burns to 70% of body surface area is unsalvageable under austere field conditions and would require the use of significant medical resources-both personnel and equipment-and would be triaged to an "expectant area." Conversely, a young adult with a Glasgow Coma Scale score of 12 who requires only airway maintenance would use few resources and would have a reasonable chance for survival with the interventions available in the field, and would be triaged to a "treatment" area. The START and SAVE triage techniques are used in situations in which triage is dynamic, occurs over many hours to days, and only limited, austere, field, advanced life support equipment is readily available. The MDR SAVE methodology is the first systematic attempt to use triage as a tool to maximize patient benefit in the immediate aftermath of a catastrophic disaster. PMID- 10159734 TI - Cardiopulmonary resuscitation (CPR) performance. PMID- 10159735 TI - Practicing emergency procedures on recently deceased patients. PMID- 10159736 TI - An attempt at more accurate estimation of the number of ambulances needed at disasters in The Netherlands. AB - A more accurate estimate of the number of ambulances needed at disasters prevents vehicles from being withdrawn unnecessarily from their "normal" duties, thereby curtailing needless expense and helping to ensure that disaster sites are not overcrowded with emergency workers impeding each other's effectiveness. This article discusses a formula for determining the number of ambulances needed at a disaster. PMID- 10159737 TI - Prehospital transport time and mode of transportation in Zenica, Bosnia. AB - STUDY OBJECTIVES: To provide a descriptive analysis of the prehospital emergency medical transportation system operating in and around a major Bosnian city, and to discuss the effect of the war on that transportation system. DESIGN: A prospective, consecutive sample study. SETTING: The largest tertiary-care referral hospital currently operating in central Bosnia. PARTICIPANTS: 158 consecutive patients who sought care in the trauma and medical receiving rooms at Zenica Hospital. METHOD AND MEASUREMENTS: Patients were surveyed as to time of transportation to the site of first medical care and to Zenica Hospital, and modes of transportation used. RESULTS: Time to transport to first care within the city of Zenica is 30 +/- 21 minutes. Time to transport to Zenica Hospital from within Zenica is 51 +/- 39 minutes. Time to transport to first care outside of Zenica is 77 +/- 56 minutes. Time to transport to Zenica Hospital from outside the city of Zenica is 178 +/- 94 minutes. The prehospital emergency medical service was used in 11.7% of cases reviewed. CONCLUSION: The majority of patients with major injury and illness are unable to obtain prehospital transportation and medical care through informal modes of transportation. The existing prehospital emergency medical services system is inadequate for the numbers of patients requiring such services, and transportation time from outside the city of study is especially prolonged. PMID- 10159738 TI - A decentralized trauma system design for a rural area. AB - Most trauma-care systems are based on an urban model in which patients are found in sufficient proximity to the trauma center to allow preferential triage. The roles of other hospitals in the community are limited. In rural areas, patients may be remote from the trauma center and may require initial stabilization at a closer, nontrauma "center" designated hospital. An inclusive trauma system design is more appropriate in such situations. The Emergency Department Approved for Trauma (EDAT) is a program implemented in a rural area of northeastern California that establishes minimum standards for nontrauma center designated hospitals in remote areas. It integrates these hospitals into the trauma system through transfer guidelines and agreements and participation in systemwide quality assurance/improvement programs. The EDAT program promotes both improved initial treatment of rural trauma patients and appropriate transfer of patients to designated trauma centers. PMID- 10159739 TI - Does the ambulance environment adversely affect the ability to perform oral endotracheal intubation? AB - OBJECTIVE: Oral endotracheal intubation (ETI) is the preferred method of controlling the airway in critically ill or injured patients. It was postulated that time could be saved if intubation was performed in the ambulance en route to the hospital. This study was designed to determine whether the ambulance environment adversely affected the ability of emergency medical technicians at the advanced-intermediate level (EMT-AI) to perform oral ETI. HYPOTHESIS: The restrictive environment of a moving ambulance would affect adversely the ability of EMT-AIs to perform ETI compared with a controlled setting. This would result in a significant increase in the time necessary to perform ETI in the ambulance compared with a controlled setting not complicated by restrictive space and motion. METHODS: Twenty on-duty EMT-AIs were recruited to volunteer for this prospective, nonrandomized, nonblinded trial. All participants performed three consecutive oral ETIs on an airway mannequin in two settings: 1) in the back of a moving ambulance; and 2) on a table in the rescue squad station. Of the participants, 10 performed the intubations in the ambulance first; the remainder performed the intubations at the station first. Time for intubation with the mannequin was recorded by stopwatch. The mean times for intubation in both settings were compared by Student's t-test (p < 0.05). RESULTS: All intubation attempts were successful. The mean time for intubation in the station was 13.0 +/ 3.4 seconds. The mean time in the ambulance setting was 13.2 +/- 5.3 seconds. There was no significant difference between the intubation times in the two settings (p = 0.88). CONCLUSION: The environment of a moving ambulance does not appear to hinder the ability of EMT-AIs to perform oral ETI in a laboratory setting with a mannequin model. PMID- 10159740 TI - Anaphylactoid reaction to adenosine. AB - Adenosine (Adenocard) is an endogenous purine nucleoside that has been approved recently for intravenous treatment of paroxysmal supraventricular tachycardia. With a serum half-life of 10 seconds, reported side effects including facial flushing, dyspnea, and chest pressure are common, but very transient. An elderly woman who received adenosine for paroxysmal supraventricular tachycardia had a prolonged anaphylactoid reaction that required pharmacological treatment. This is the first reported case of a prolonged anaphylactoid reaction to adenosine. PMID- 10159741 TI - Natural disasters: causes and effects. Lesson 8--desertification. PMID- 10159742 TI - Disaster medical response research: a template in the Utstein style. Task Force on Quality Control of Disaster Management World Association for Disaster and Emergency Medicine. PMID- 10159743 TI - Physicians' experiences with prehospital do-not-resuscitate orders in North Carolina. AB - INTRODUCTION: Many states are implementing prehospital do-not-resuscitate (DNR) programs through legislation or by state or local protocol. There are no outcome studies in the literature regarding the utilization of, access to, or barriers to prehospital DNR programs, nor are there studies that evaluated whether they meet the patients' needs. STUDY OBJECTIVE: To explore physicians' perceptions of the utilization of, access to, and barriers to a southeastern state's prehospital DNR program, and to identify key professional groups needing information about prehospital DNR issues. METHODS: A convenience sample survey and a descriptive review using retrospective, self-report questionnaires sent to all physicians who requested and obtained a supply of the state's out-of-facility DNR forms in 1993. RESULTS: Respondents reported that the most common terminal conditions for patients with prehospital DNR orders are cancer and multiple chronic diseases in elderly patients. More than half of the physicians recalled that enrolled patients had engaged the services of emergency medical services (EMS), most often because the patients' conditions worsened, and the families were uncertain about what to do. Most of the enrolled patients have at least one other DNR order in another health-care setting, and are at home with hospice care or home-health care at the time of the prehospital DNR order implementation. The most frequent barrier to honoring dying patients' wishes in the prehospital environment is a lack of knowledge of prehospital issues by patients, families, primary care physicians, and nursing home staff. Ninety-eight percent of the respondents support a single, universal DNR order that would apply across all health-care settings. CONCLUSIONS: Patients, families, and key health-care professional groups need to be targeted with educational programs regarding prehospital DNR issues. Primary care physicians, using the current prehospital DNR program, support more comprehensive approaches to DNR orders across health-care settings. PMID- 10159744 TI - Nutrition and optic nerve disease. AB - The syndrome characterized by papillomacular bundle damage, central or cecocentral scotoma, and reduction of color vision can be produced by toxic, nutritional, or hereditary causes. Patients who present with such a picture should be evaluated for toxic sources such as tobacco or alcohol use. Nutritional deficiencies must be considered and a good family history should be obtained to explore hereditary factors. DNA mutation analysis is available to detect genetic abnormalities. A trial of nutritional replacement may be advisable even in the face of normal laboratory values. Previous reports have shown dramatic visual improvement with intramuscular hydroxocobalamin and other oral vitamin B complexes, even when specific deficiencies are not found. PMID- 10159745 TI - Hereditary optic neuropathies. PMID- 10159746 TI - The optic neuritis treatment trial: implications for clinicians. PMID- 10159747 TI - Anterior ischemic optic neuropathy. AB - AION is the most common acute optic neuropathy in patients over 50 and, although the diagnosis is often straightforward, our methods for managing the associated visual loss are inadequate. Analysis of the wealth of information gained from recent clinical studies may move us closer to an effective therapy. PMID- 10159748 TI - Retinal disease in neuro-ophthalmology: paraneoplastic retinopathy and the big blind spot syndrome. PMID- 10159749 TI - Color Doppler imaging in disorders of the orbit, retina, and optic nerve. AB - In summary, CDI is being increasingly used in both clinical and research settings to investigate vascular disorders of the orbit, retina, and optic nerve. It is essential for the clinical investigator to be critical and cautious when interpreting the color Doppler flow data, especially when assessing for quantitative orbital hemodynamic changes over serial examinations. Hopefully, application of this technology will continue to provide insight into the pathogenesis of additional ischemic ocular diseases. PMID- 10159750 TI - Idiopathic intracranial hypertension. AB - Although the cause of IIH remains obscure, it has become clear that loss of visual function is common and patients may progress to blindness. Diagnosis should adhere to the modified Dandy criteria. Recent case-control studies cast doubt on the validity of many frequently cited conditions associated with IIH. Valid associations include obesity, recent weight gain, female gender, vitamin A intoxication, and steroid withdrawal. IIH patient management should include serial perimetry using a sensitive disease-specific strategy. This is done so the proper therapy can be selected and visual loss prevented or reversed. PMID- 10159751 TI - Surgical management of lesions affecting the anterior optic pathways. AB - Although benign neoplasms are the most common lesions of the anterior visual pathways that lend themselves to a combined neurosurgical and ophthalmic surgical treatment, malignant neoplasms, infections (especially fungal), and vascular lesions are also sometimes treated via a combined approach. Recent advances in the field of skull base surgery have made it possible to treat complicated lesions in precarious locations with increasing margins of safety and decreasing morbidity. The role of the neurosurgeon in managing selected patients with lesions of the anterior a visual pathway should not be underestimated. PMID- 10159752 TI - A prospective randomized trial of 0.010" versus 0.014" balloon PTCA systems and interventional fellow versus attending physician as primary operator in elective PTCA: economic, technical, and clinical end points. AB - BACKGROUND: The cost of performing percutaneous transluminal coronary angioplasty (PTCA) is accelerating. The angiographic, clinical, technical, and procedural variables associated with PTCA cost are largely unknown. METHODS: To determine an interrelationship between equipment size, operator experience, and PTCA cost, 50 patients were randomized to have PTCA performed with large (0.014") or small (0.010") balloon systems. A secondary randomization determined the primary operator of the procedure; either experienced attending physician or inexperienced fellow in interventional cardiology. END POINTS: Primary: PTCA cost (equipment, supplies, support personal, post-PTCA room, and physician (utilizing resource-based relative value scale); Secondary: measures of technical procedural and clinical outcome. RESULTS: The total cost of the PTCA was $4,047 +/- $2,133 for 0.010" systems versus $3,451 +/- $1,004 for the 0.014" systems, P = NS. Independent variables associated with increased cost included: age, diabetes, and duration of procedure in the cardiac catheterization laboratory. There was no significant difference in procedural duration, complications, or outcome between the smaller or larger PTCA catheter systems, and, the less experienced PTCA operator required additional fluoroscopic time to cross the lesion, as well as procedure time compared with the attending physician. CONCLUSIONS: Neither miniaturization of equipment size nor primary operator experience led to PTCA cost savings. Clinical and procedural characteristics are independently correlated with increased PTCA cost. Additional study is needed to determine the exact determinants of PTCA cost, in order to stabilize the cost of this procedure. PMID- 10159753 TI - Rotablation and stent placement in an unprotected left main coronary ostial stenosis. AB - We report the case of a patient with postinfarction rest angina, high grade ostial left main (LM) stenosis, and right and circumflex coronary occlusion. Coronary artery bypass was performed, yet all grafts failed within 2 months of surgery. We elected to proceed with coronary intervention on the ostial LM lesion with intracoronary ultrasound lesion characterization and percutaneous cardiopulmonary bypass support. Rotablation followed by stent deployment achieved a successful angiographic outcome with no associated clinical complications. At 1 year follow-up, the patient remains stable with evidence of mild restenosis. Interventional approaches in unprotected LM coronary stenoses are associated with high procedural risk. Combined atherectomy/ablation with stent placement guided by intracoronary ultrasound may enhance procedural and long-term outcome. PMID- 10159754 TI - Percutaneous transluminal coronary angioplasty of the left main coronary artery with a 5Fr catheter system. AB - The protected left main coronary artery (LM) is accessible to percutaneous transluminal coronary angioplasty (PTCA), and the procedure is usually performed with large size catheter systems. This report describes a successful PTCA of a partially protected LM through a 5Fr diagnostic catheter system in a patient with previous coronary artery bypass grafting. Such an approach is time- and cost efficient when combined with the diagnostic study. PMID- 10159755 TI - Reduced vasoreactivity and thrombogenicity with pulsed laser angioplasty: comparison with balloon angioplasty. PMID- 10159756 TI - The changing profile of patient selection, procedural techniques, and outcomes in excimer laser coronary angioplasty. Participating Investigators of the Percutaneous Excimer Laser Coronary Angioplasty Registry. AB - During the course of development of excimer laser angioplasty, several changes in patient selection and technique have occurred. It is uncertain, however, whether these changes have been associated with improved procedural outcome. In this study, multivariable regression methods were used to identify the factors responsible for clinical success, major complications, and vessel perforation in 2,041 consecutive patients treated with excimer laser coronary angioplasty. The overall rates of clinical success were 89%, major complications 7.5%, and vessel perforation 2.1%. Clinical success was 86% in patients treated with prototype catheters, 89% with flexible catheters, 92% with extremely flexible catheters, and 95% in patients treated with directional eccentric catheters (P < 0.001). By multivariable analysis, clinical success increased with each subsequent catheter design (odds ratio [OR] = 1.4 per iteration [95% confidence interval 1.2, 1.6]), and with improved lesion selection. Major complications were reduced when operators had performed more than 25 cases (rate = 6.5%, OR = 0.7 [0.5, 0.9]), and the incidence of vessel perforation was decreased when the size of the target vessel was > 1.0 mm larger than the diameter of the laser catheter (rate = 1.1%, OR = 0.3 [0.2, 0.5]). In conclusion, during the course of clinical investigation with excimer laser angioplasty, procedural outcome has improved. These results emphasize the importance of careful patient selection and procedural technique to enhance the success of excimer laser angioplasty. PMID- 10159757 TI - Laser-assisted coronary angioplasty in patients with severely depressed left ventricular function: quantitative coronary angiography and clinical results. AB - Laser-assisted coronary angioplasty can be successfully applied to lesions not ideal for balloon angioplasty. Patients with severely impaired left ventricular (LV) function and complex coronary artery stenoses who call for percutaneous revascularization are considered a high risk group for balloon angioplasty. In order to determine the feasibility, safety, and acute clinical outcome of a solid state, pulsed wave, mid-infrared (2.1 micron) laser facilitated angioplasty in these patients, data from 112 patients with 129 lesions were analyzed. Patients were identified according to angiographic LV function; group I included 22 patients with left ventricular ejection fraction (LVEF) < or = 40% (mean = 25% +/ 10%) and group II included 90 patients with LVEF > or = 40% (mean = 58% +/- 8%). No difference in age, gender, diabetes, hypertension, tobacco use, history of previous coronary artery bypass surgery (CABGS) or percutaneous transluminal coronary angioplasty was registered between the two groups. Multivessel disease, previous myocardial infarction (MI), and severe angina were more prevalent among group I patients (P = 0.03). No difference was found in lesion location, complexity, length, or calcification between the two groups; although group I had more eccentric lesions. Both groups were treated with the same laser energy level followed by adjunctive balloon angioplasty. One hundred percent procedural success was obtained in group I versus 93% in group II (P = NS). By Q.C.A. (independent core lab), minimal luminol diameter increased in group I from 0.9 +/ 0.5 mm preprocedure to 2.0 +/- 0.5, as compared to 0.8 +/- 0.5 mm to 1.9 +/- 0.5 mm (P = NS) in group II. Stenosis severity improved from 69% +/- 16% preprocedure to 37% +/- 13% postprocedure in group I, as compared to improvement from 78% +/- 16% to 37% +/- 12.7% in group II (P = NS). Overall complication rate was remarkably low, with no death or perforation in either group; emergency CABGS 0% in group I and 1.1% in group II; dissections 4.5% in group I and 8.8% in group II. There was no significant difference in complication rate between the two groups. The results of this study suggest that holmium:YAG laser facilitated coronary angioplasty can be safely performed in patients with severe LV dysfunction, achieving a remarkably high procedural success and low complication rate. PMID- 10159758 TI - Coronary ultrasound angioplasty: an update of an expanding technology. PMID- 10159759 TI - Atrial flutter ablation: electrophysiological landmarks. AB - Understanding the configuration of the whole flutter circuit is for us the only valid parameter allowing the design of an ablation strategy. Fragmented or double electrograms may have different meanings in different parts of the circuit, and full activation mapping is the best clue to their interpretation. Correlation of anatomy with activation sequence will mark the best ablation target (isthmus) in each case. Multiple simultaneous recordings from the septum and right atrial anterior wall are very helpful to rapidly diagnose circular activation of the right atrium. In cases without this type of activation, coronary sinus recordings and the study of postentrainment cycles are helpful to localize the reentry circuit. PMID- 10159760 TI - Animal models of atrial flutter. PMID- 10159761 TI - Ablation of atrial flutter using the anatomical method: results and long-term follow-up. PMID- 10159762 TI - Mechanisms of atrial flutter: implications for ablative therapy. AB - Much has been learned about atrial flutter mechanisms from studies in animal models and in patients. In fact, it seems virtually always due to some form of reentry. Furthermore, it seems likely that there is more than one location of the atrial flutter reentrant circuit in patients, although the reentrant circuit in most instances of atrial flutter seems to be activation up the interatrial septum and then down the posterior right atrial free-wall. Other locations of the reentrant circuit may include the right atrial free-wall alone or the tricuspid valve annulus, among others. Resolution of this awaits better mapping data from human studies. Clearly, an understanding of mechanism is central to achieving effective ablation. Thus, if it is possible to identify a critical aspect or aspects of the atrial flutter mechanism vulnerable to therapy with ablative energy, effective treatment using ablative techniques should be successful. PMID- 10159763 TI - Thrombogenesis in acute coronary syndromes. AB - It is well-established that intracoronary thrombosis, which may be associated with plaque fissure and enhanced coronary vasoconstriction, is the immediate cause of a sudden impairment of regional myocardial perfusion, which is transient in unstable angina and is, eventually, irreversible in acute myocardial infarction. It is also well-known that increased platelet reactivity, increased procoagulant activity, and reduced endogenous fibrinolysis are risk factors for acute coronary events. Nevertheless, the primary causes responsible for sudden intracoronary thrombosis and for coronary vasoconstriction causing acute coronary syndromes are still largely speculative. Recent studies have shown activated inflammatory cells both in the coronary arterial wall and in the systemic circulation of patients with unstable angina. Furthermore, the intensity of the inflammatory response is correlated with an adverse prognosis. This inflammatory component may have important pathogenetic and prognostic roles because an outburst of inflammatory cytokines has the potential to increase the sensitivity of platelets to agonists, to turn the anticoagulant and vasodilator physiological properties of the endothelium into procoagulant and vasoconstrictor properties, and to cause plaque fissure by the release of proteolytic enzymes. PMID- 10159764 TI - The treatment of myocardial infarction. PMID- 10159765 TI - Randomized trials on PTCA and stenting in the treatment of De Novo coronary artery stenosis: an overview on existing data in June 1994. AB - This is a review on prospective randomized comparisons of PTCA and stents in the treatment of de novo native coronary artery lesions. BENESTENT and STRESS, two multicentric studies, used the articulated Palmaz-Schatz stent. In Lausanne, a single center trial limited to right coronary artery lesions, was conducted using the Wiktor stent. During the in-hospital phase. BENESTENT and STRESS showed the composite clinical end point to be less in the stent than in the PTCA groups (p < 0.05). In Lausanne, there was no difference between groups. The incidence of subacute closure was similar with both treatments in three trials. Angiographically, both postprocedural minimal luminal diameter (MLD) and percentage stenosis were larger in the stent group (P < 0.05). At 6 months, in both BENESTENT and STRESS, a composite clinical end point was reached by less stent patients than PTCA patients, with a reduced need for repeat nonsurgical reintervention by stenting. However, in Lausanne, there was no difference between stent and PTCA groups. At 6 months in both BENESTENT and STRESS, a persistent lower MLD, a larger percentage of stenosis, and a higher incidence of angiographic restenosis were found in the PTCA groups (P < 0.05). In Lausanne, no differences in MLD, percentage stenosis and angiographic restenosis were found between groups. Effective stenting of de novo lesions does improve immediate results compared to conventional balloon PTCA. The long-term outcome of stenting with Palmaz-Scharz stents is also improved compared to PTCA. PMID- 10159766 TI - Coronary laser angioplasty. AB - Balloon angioplasty was introduced among the armament of therapy for coronary heart disease in 1977 by Gruentzig in Zurich. Since the first case was successful, this method of treatment spread out rapidly so that at the present time, more than 400,000 procedures are being performed per year in the U.S. The reasons for such on explosive success includes the relative safety of the procedure, the reduction in cost as compared to surgical bypass procedures, the short in-hospital stay, and short recovery time. PMID- 10159767 TI - Balloon aortic valvuloplasty in the first year of life. AB - Between February 1988 and September 1993 balloon aortic valvuloplasty was attempted in 33 consecutive patients in the first year of life: 20 patients (61%) were younger than 1 month. Major associated anomalies such as mitral stenosis, coarctation, and hypoplastic left ventricle were found in 11 cases (33%). The balloon dilation of the aortic valve was accomplished through the right carotid cut-down approach in neonates and patients with body weight < 5 kg, through a percutaneous femoral approach in the others; the procedure was completed in all. The peak systolic gradient across the aortic valve measured at catheterization fell from 80 +/- 33 mmHg (range 25-165) before the dilation to 27 +/- 17 mmHg (range 0-65), afterwards (p < 0.0001). The left ventricular ejection fraction increased from 44% +/- 26% to 61% +/- 17%, 24-48 hours after the procedure (p < 0.0001). Aortic insufficiency developed in 17 cases, being moderate in 2, mild in 6, and trivial in 9. Seven patients (21%), all in the first month of life, died within 30 days from the valvuloplasty; major associated anomalies were present in six; the death was due to a procedure related complication in one. No mortality was observed among the patients undergoing valvuloplasty beyond the first month of life. On follow-up (6 months to 6 years) aortic restenosis occurred in 3 cases; 1 was treated by surgical valvotomy, 2 by repeat balloon valvatomy; in another 2 cases, a subvalvular aortic obstruction developed and was relieved by surgical resection. There was no late mortality. Thus, balloon valvuloplasty appears to be an effective palliation for critical aortic stenosis in infancy. Early mortality is mainly related to associated anomalies. PMID- 10159768 TI - Endovascular stents in pediatric cardiovascular medicine. AB - Acquired or de novo vascular obstructions can adversely affect the outcomes of management algorithms for children with congenital heart lesions. Although surgical repair is frequently feasible, some acquired or congenital obstructions are difficult to address in the operating theater. Discussed is the recent experience with endovascular stents to relieve such stenoses, and their impact on patient care. PMID- 10159769 TI - Left cardiac sympathetic denervation in long QT syndrome patients. AB - The idiopathic long QT syndrome (LQTS) is an unusual clinical disorder characterized by a prolongation of the QT interval and by syncopal episodes occurring among young subjects, most often during exercise, stress, or other conditions of increased sympathetic activity. Both an imbalance in sympathetic innervation and an intracardiac defect in membrane currents have been proposed as pathogenetic mechanisms. The latter appears substantiated by recent advances in molecular genetics showing a linkage on chromosomes 11, 3, 7, and 4, with identification of the genes for chromosomes 3 and 7. For symptomatic patients with the long QT syndrome, beta-adrenergic blockade, with efficacy in approximately 80% of patients, currently remains the therapy of first choice. For the patients who continue to suffer syncope or cardiac arrest despite beta blockade, evidence has been provided that left cardiac sympathetic denervation represents a very effective treatment. The improvement in the understanding of the molecular mechanisms involved may soon lead to gene specific therapy in most long QT patients. PMID- 10159770 TI - Indications of implantable defibrillator. AB - Implantable cardioverter defibrillators are devices capable of detecting and terminating ventricular tachycardias or fibrillations. They are utilized in the treatment of severe ventricular tachyarrhythmias, and their efficacy in the prevention of sudden death is demonstrated. As a matter of fact, despite the new antiarrhythmics available, and despite nonpharmacological therapies like radiofrequency ablation or surgery, the prognosis of such tachyarrhythmias remains serious. PMID- 10159771 TI - The role of catheter ablation in atrial tachycardia, flutter, and fibrillation. AB - The first experiences of nonpharmacological treatment of ectopic atrial tachycardia (EAT), common atrial flutter (AFl), and atrial fibrillation (AF) were performed by surgical techniques. Many studies reported a very high success rate on the use of catheter ablation with radiofrequency current for the treatment of supraventricular arrhythmias; and recently, various preliminary reports are dedicated to the treatment of EAT, AFl, and AF with that source of energy. To our knowledge 108 cases of EAT treated by catheter ablation of the ectopic focus are reported in the literature with a success rate superior to 90%. On the basis of our personal experience regarding 11 cases (4 of right atrium EAT and 7 of left) we discuss here the essential role of unipolar leads derived from the mapping catheter to select the target for radiofrequency applications. Two hundred and one cases of AFl tested by catheter ablation were previously reported. The majority of them (> 80%) were successfully treated with radiofrequency. Some working groups performed the procedure as the basis of electrophysiological findings, while others preferred an anatomical approach applying radiofrequency energy at the isthmus lying between the coronary sinus ostium and the tricuspid ring, near the vena cava orifice. On the basis of these assumptions, we obtained 83% of final success in 12 cases of AFl treated by radiofrequency. Finally, we discuss the problem related to the modulation of atrioventricular (AV) nodal conduction during AF. In our laboratory, five cases with chronic AF and very fast ventricular response were treated with radiofrequency with a posterior septal approach. In all patients, we obtained very encouraging results with a constant decrease of ventricular rate (from 137 +/- 33 to 69 +/- 14 beats per minute). All cases treated by modulation of AV nodal conduction demonstrated an appropriate chronotropic response to the variations of the functional state that persists during the follow-up. More experience with longer follow-up and accurate pre- and postprocedure evaluations are needed to finalize the most appropriate technique of radiofrequency applications in these cases. PMID- 10159773 TI - Catheter ablation of ventricular tachycardia in patients with coronary heart disease. PMID- 10159772 TI - Catheter ablation of left accessory atrioventricular connections: the transseptal approach. AB - BACKGROUND: In the past few years, there has been a relative explosion of activity in the realm of interventional cardiology. The high rate of success of radiofrequency energy ablation have transformed catheter ablation from an investigational procedure into the first-line therapy for symptomatic Wolff Parkinson-White syndrome. Radiofrequency catheter ablation for preexcitation syndrome is commonly based on a ventricular approach. Such an approach might be associated with the risk of prolonged arterial catheter manipulation, retrograde left ventricular catheterization, and production of multiple, potentially arrhythmogenic, ventricular lesions created during ablation. Potential risks can be avoided using atrial insertion ablation procedures. The transseptal procedure that was developed in the 1950s and 1960s as a diagnostic procedure and then shelved in the 1970s and early 1980s has now come back into prominence as a therapeutic technique in the treatment of valvular heart disease, and then in the ablation of the left accessory atrioventricular connections. METHODS: Atrial aspect of mitral annulus is a relatively smooth, nonobstructed surface that simplifies catheter movement, thereby permitting rapid and accurate accessory pathway location. Although primary use of earliest endocardial retrograde atrial activation as a marker of accessory pathway atrial insertion is sufficiently accurate to permit successful ablation, direct recording of an accessory pathway potential is an important predictor of successful ablation site. Moreover, the analysis of the unipolar atrial electrogram, recorded during sinus rhythm from the tip of the ablation catheter, provides further information for localizing the atrial insertion of the accessory pathways. Shortest atrial-accessory pathway and negative delta-accessory pathway intervals have been found to be the best predictors of the successful site. RESULTS: A 90.5% success of the transseptal approach on an overall population of 328 patients, higher for overt than for concealed pathways, is comparable with the results of the retrograde. Complications are 0.5%. CONCLUSION: In conclusion, the transseptal approach for ablation at the atrial site is very safe and highly effective, and avoids prolonged arterial cannulation and catheter manipulation in the ascending aorta and left ventricle. PMID- 10159774 TI - Magnetocardiographically-guided catheter ablation. AB - After more than 30 years since the first magnetocardiographic (MCG) recording was carried out with induction coils, MCG is now approaching the threshold of clinical use. During the last 5 years, in fact, there has been a growing interest of clinicians in this new method which provides an unrivalled accuracy for noninvasive, three-dimensional localization of intracardiac source. An increasing number of laboratories are reporting data validating the use of MCG as an effective method for preoperative localization of arrhythmogenic substrates and for planning the best catheter ablation approach for different arrhythmogenic substrates. In this article, available data from literature have been reviewed. We consider the clinical use of MCG to localize arrhythmogenic substrates in patients with Wolff-Parkinson-White syndrome and in patients with ventricular tachycardia in order to assess the state-of-the-art of the method on a large number of patients. This article also addresses some suggestions for industrial development of more compact, medically oriented MCG equipments at reasonable cost. PMID- 10159775 TI - Catheter ablation in competitive athletes: indication. AB - Some supraventricular tachyarrhythmias (SVT), particularly if paroxysmal and/or related to Wolff-Parkinson-White syndrome (WPW), may in some cases endanger an athlete's professional career due to hemodynamic consequences during athletic activity, which in some instances may be life-threatening. One must also take into account that in Italy the law makes antiarrhythmic drug treatment (AAD) incompatible with sport eligibility. For these reasons, the utilization of radiofrequency ablation (RFA) in athletes has different indications as opposed to the normal population, since the primary goal is "the eligibility of the athlete." In our study, we discuss the criteria for indication of RFA in athletes with SVT on the basis of the data obtained from our population of athletes, studied over a 20-year period, from 1974 to the 31st of December 1993. These athletes were evaluated for arrhythmic events, utilizing a standardized cardioarrhythmological protocol: 1,325 athletes (1,125 men, 200 women, mean age 20.7 years). One subgroup included 380 athletes with WPW (28.7%), 22 athletes with aborted sudden death (1.6%), 6 of whom had WPW, 13 athletes with sudden death (0.98%), and 2 of whom had WPW. Another subgroup was formed by 116 top level elite professional athletes (TLA) (mean age 22.9 years), of which 10 of 116 (8.6%) had WPW and 12 of 116 (10.3%) had paroxysmal SVT. The most important indications for RFA in athletes are represented by: WPW asymptomatic at risk, symptomatic during athletic activity, and/or requiring AAD treatment: paroxysmal junctional reentrant tachycardia: when this condition is disabling and related to exercise and therefore compromising an athlete's performance and sports career. Paroxysmal junctional reentrant tachycardia is easily reproduced via transesophageal atrial pacing (TAP) during exercise (bicycle ergometer), common in athletes but normally the recurrences are concentrated only during the period in which the athlete is engaged in sport. Rare indications for RFA are focal or reentry, permanent SVT, and particularly junctional reentrant tachycardia. For each individual athlete, we have to consider the possible side-effects of RFA, the possible recurrences with psychobiological traumatic consequences, the effective recovery period, and the natural history of the tachyarrhythmias, which frequently disappear after interruption of the sports career. PMID- 10159776 TI - Transcatheter ablation of tachyarrhythmias: a critical overview. PMID- 10159777 TI - New horizons in catheter ablation. AB - Catheter ablation has evolved into the dominant therapeutic modality in the treatment of a variety of arrhythmias, particularly supraventricular arrhythmias with the mechanisms of atrioventricular (AV) nodal reentry and AV reciprocating tachycardia via an accessory pathway. The mode of catheter ablation used in the great majority of cases is radiofrequency (RF) catheter ablation. This technology is well-suited for the above arrhythmias because the targets and the RF lesions are both small and discrete. Using temperature monitoring may improve the outcome of these procedures by decreasing procedure time and incidence of coagulum formation on the catheter after a sudden rise in electrical impedance. New RF catheter designs and new modalities of creating catheter-induced focal myocardial injury will allow operators to have improved success with the ablation of less approachable arrhythmias, including atrial flutter and reentrant ventricular tachycardia. Studies are currently underway to create a catheter based "maze" procedure for the treatment of atrial fibrillation. As techniques and technologies evolve, a greater proportion of patients with symptomatic or threatening arrhythmias may be approached with catheter ablation as a curative or palliative procedure. PMID- 10159778 TI - Is there space for surgery in the treatment of tachyarrhythmias? AB - Curative treatment of both supraventricular and ventricular tachyarrhythmias started with the introduction of surgical therapy. Surgical treatment modalities were often very successful and associated with low mortality and morbidity, especially in patients with various supraventricular tachyarrhythmias. However, results were acceptable in patients with ventricular tachyarrhythmias, with often a very complex and extended arrhythmogenic area associated with structural heart disease. Because of the development and proven effectiveness of catheter ablation and defibrillator implantation, the role of surgical therapy became limited. In the treatment of supraventricular arrhythmias, surgical therapy is an option after failure of catheter ablation. Since His-bundle catheter ablation is only a palliative treatment for atrial fibrillation, the potentially curative Maze operation may be an acceptable alternative. However, its potential against formation of intracavitary thrombi has not yet been proven. In the treatment of ventricular tachyarrhythmias, ischemia related polymorphic ventricular tachycardia and ventricular fibrillation can be treated very effectively by revascularization. Map-guided surgery is an appropriate treatment modality for patients with monomorphic ventricular tachycardia and an extended arrhythmogenic area. However, patients with very poor left ventricular function may have an unacceptable perioperative risk. In patients with congenital long QT syndrome who are refractory to beta blocking agents, left-sided sympathectomy is the most appropriate choice. PMID- 10159779 TI - Mechanisms of AV node modulation in AV node reentry tachycardia. AB - Atrioventricular nodal reentrant tachycardia has been recognized for many years as a very common cause of supraventricular tachycardia. First curable by surgery, this tachycardia is now successfully approached by selective radiofrequency current application to the slow pathway of the reentrant circuit. Importantly, these curative treatments brought evidence that the reentrant circuit of this arrhythmia was not confined to the compact atrioventricular (AV) node. These findings stimulate anatomists and basic and clinical electrophysiologists to fundamentally reconsider the atrioventricular junction in order to better understand the mysteries of atrioventricular junctional reentrant tachycardia, as we still do not know exactly what we are doing in AV node region procedures. This article will focus on the different hypotheses regarding the effect of selective slow AV pathway ablation in AV junctional reentrant tachycardia. PMID- 10159781 TI - The Vital Signs Quality-Of-Life Questionnaire: a managed care tool for monitoring quality of life. PMID- 10159780 TI - Ambulatory patient groups (APGs): ending the price spiral for hospital outpatient services. PMID- 10159782 TI - HEDIS reporting: the challenges and the benefits. PMID- 10159783 TI - Setting the home care record straight. PMID- 10159784 TI - Provider credentialing and the quality revolution. PMID- 10159786 TI - Perspectives. Many agendas converging on President's Commission. PMID- 10159785 TI - Playing the accreditation game: strategies for networks. PMID- 10159787 TI - Hospital and physician partnership in the acquisition and use of high-cost niche technology. AB - The addition of the ventricular assist device to the compliment of interventions within a high-quality cardiovascular program can be justified based on the potential reduction in ICU days for patients with right ventricular failure and/or left ventricular failure following open heart surgery. The improved outcomes associated with appropriate patient selection further serves to strengthen the justification. Close cooperation among physicians, administrators, manufacturers, and competing centers can make even highly specialized technology a valuable and cost-effective addition to the community. PMID- 10159788 TI - Price, value, and chaos theory in strategic management. PMID- 10159789 TI - New methods for effective cardiac care. PMID- 10159790 TI - Supplier/vendor cooperation leads to enhancements. PMID- 10159791 TI - Are irradiated foods really safe? Separating myth from reality. PMID- 10159792 TI - Continuity of nutrition care. PMID- 10159793 TI - The Joint Commission's new approach to establishing health care indicators. PMID- 10159794 TI - Managers, leaders, and teams in a team-based environment. AB - In order to succeed in today's dynamic environment, abundant with corporate restructuring and downsizing, into what must today's manager transform? Part of the answer lies in "leadership." Some managers are leaders, some leaders are managers, but the two are not synonymous. There are notable differences between managers and leaders, particularly in the role each plays in the transition towards organizations that are customer-focused, empowered, and team-based. The evolution towards team-based organizations begins with three different, concurrent transitions: of managers into leaders, of employees into teammates, and of functional hierarchical organizations into those of team empowerment. PMID- 10159795 TI - Strategy: the key to financial payback from reengineering. AB - This article will present the differences between restructuring, reengineering, and reinventing. It will identify a process for developing a leadership position that is difficult or impossible to duplicate and show how to develop a business strategy that leads to correctly identifying the core value-added processes of your business--the right ones to reengineer. PMID- 10159796 TI - Leading change, overcoming chaos--making change succeed in your organization. AB - The recent emphasis on reengineering has brought a lot of attention to the need to create a compelling vision. It has also forced management to face the realities of making a grand vision a concrete reality. This article focuses on the pragmatic elements--strategic tools and practical solutions--of implementing the change necessary to make your organization succeed. PMID- 10159797 TI - How to create imagineering employees. AB - Imagineering is a philosophy that unleashes the latent potential of a company's employees. The end result is a highly motivated group of employees who will dramatically cut operating costs, improve quality, and solve the day-to-day management headaches. If employees have an "I don't give a damn" attitude, then it is management that must make the changes in the company culture. Management is responsible for most of the problems, directly and indirectly, in the company. Imagineering will solve most small and large problems in the company. However, be forewarned that imagineering requires the total commitment of management. And it is the management that must make the most changes. PMID- 10159798 TI - Visioneering: how to unleash creative and imaginative thinking for manufacturing vision planning. AB - The author describes a creative approach to visualize and document your organization's ideas for the future. Visioneering is a proven methodology used to unleash the creative potential of people, the most valuable asset of any organization. PMID- 10159799 TI - The peopleware paradigm. AB - Manufacturing managements and practitioners alike are at long last realizing that the heartbeat of competitive advantage springs from peopleware, not hardware and software. But despite this heightened awareness the problem persists even among manufacturing professionals--they may talk a good game about priortizing people and quality, but all too many have precious little idea of how to go about it with constancy of purpose. This article bridges the gap and addresses the key issues in adopting the powerful new peopleware paradigm that provides the positive motivational climate for the improvement-change journey toward world class performance through teamwork, innovation, and continuous improvement. PMID- 10159800 TI - Succession planning--how to perpetuate your leadership. AB - The author describes the concept of "orchestra style leadership," by which corporations seek to create a culture that permits their associates to seek their own career directions while simultaneously advancing the mission and vision of the corporation. PMID- 10159801 TI - Achieving integrity of purpose: using experiential learning to align vision, systems, and people. AB - To truly improve our organizations, we must align three key areas: our organizational vision, our systems, and the people who work there. There must be integrity of purpose to accomplish this. This article explains how, using experimental learning techniques, to make the kinds of organizational improvements we desire. It includes descriptions of more than 10 experiential learning exercises that can be used to align vision, systems, and people. PMID- 10159802 TI - Trying to imagineer the future? ... Don't just "imagine" inventory integrity! AB - Inventory integrity has been discussed, debated, and argued many times, in many organizations. The attempts at a solution have been numerous, from corrective action teams and inventory accuracy committees, to subtask groups and mandates. For a number of reasons, however, the required 95 percent integrity is seldom achieved, and never permanently. This article presents a proven, tested methodology to increase inventory integrity to 95 percent and to keep it there, in a nine-step process that takes no more than 120 days to implement. PMID- 10159804 TI - Children's clinic. Children's Cancer Center, Texas Children's Hospital, Houston. PMID- 10159803 TI - Visions of the future: two success strategies for software selection. AB - The first and most crucial step in any system implementation is the specification and subsequent selection of the software. It is important to make the "right" choice--one where the software works with the hardware to integrate the users so it helps them do their jobs better now and into the future. This article will review the software selection process utilized by two companies to choose the software that was "right" for them. Insights and experiences will also be shared to assist others in their software selection activities. PMID- 10159805 TI - Psychiatric services. Keep it in the family. PMID- 10159806 TI - General practice. Inquire within. PMID- 10159807 TI - Overseas healthcare. Middle East piece process. PMID- 10159808 TI - Mental health. Crisis points. PMID- 10159809 TI - Mental health. Only connect. PMID- 10159810 TI - Costing services. Group therapy. PMID- 10159811 TI - On the evidence--breast cancer. PMID- 10159812 TI - Healthcare profits keep on climbing. PMID- 10159813 TI - Columbia network in Ala. draws scrutiny. PMID- 10159814 TI - Providers applaud relaxed guidelines. PMID- 10159815 TI - Hospital's closing doesn't halt care. PMID- 10159817 TI - AHA panel needs to revamp processes. PMID- 10159816 TI - Health groups keep giving to Dems. PMID- 10159818 TI - Quality of life is the issue in care for terminally ill. PMID- 10159819 TI - Democrats vow to protect Medicare. PMID- 10159820 TI - A house divided. It's physician vs. physician in battle over Medicare fee schedule. AB - Medicare is turning the house of medicine into a house divided against itself. Three different Medicare payment bases for different procedures practiced by the numerous specialties is pitting primary-care doctors against surgeons and sometimes against procedure-oriented specialists. PMID- 10159822 TI - Conferences spring up as demand surges. PMID- 10159821 TI - Outsourcing firms ride changing tides. PMID- 10159823 TI - Columbia finds success in 50-50 formula. PMID- 10159824 TI - MGMA, HFMA detail plans for alliance. PMID- 10159825 TI - Huge savings expected from new EDI standards. PMID- 10159826 TI - AHA's 1995 dues, profits fell; operations shrank. PMID- 10159827 TI - Political events prove to be illuminating, fun. PMID- 10159828 TI - Public facilities going private. L.A. County moves forward after crisis. PMID- 10159829 TI - Public facilities going private. New Yorkers fight mayor's plan. PMID- 10159830 TI - Expansion takes NYLCare cross-country. PMID- 10159831 TI - CFO's creative solutions win Cain Bros. Award. PMID- 10159832 TI - Uninsured to hit 46 million in 2002--AHA. PMID- 10159833 TI - Survey: CFOs lack faith in their business departments. PMID- 10159835 TI - Hospitals fight HCFA over payment classification. PMID- 10159834 TI - 8 VHA-linked HMOs form alliance. PMID- 10159836 TI - Reform legislation eases fraud-and-abuse squeeze. PMID- 10159837 TI - New standard may ease sharing of data. PMID- 10159838 TI - Hospital deals stretch 'merger' definition. PMID- 10159839 TI - Rating the HMOs. PMID- 10159840 TI - Downsizing column stirs our readers. PMID- 10159841 TI - Hospital execs get healthy compensation packages. PMID- 10159842 TI - MRI demonstrates pelvic anatomy and pathology. PMID- 10159843 TI - Open MRI complements high-field systems. PMID- 10159844 TI - Open systems redefine MRI's role in trauma. PMID- 10159845 TI - MRA depicts vascular lesions in head and neck. PMID- 10159846 TI - Interventional MRI rides wave of new technology. PMID- 10159847 TI - Scanner design assists MRI of the breast. PMID- 10159848 TI - Cost models analyze value of clinical PACS. PMID- 10159849 TI - Conflict between FDA and medicine inevitable. PMID- 10159850 TI - Voluntary accreditation aims to deter regulation. Ultrasound practitioners are advised to jump on the bandwagon before the federal government gets involved. PMID- 10159851 TI - Checkup yields healthy prognosis for telemedicine. One lesson learned is that the technology used for telemedicine must be dictated by need. PMID- 10159853 TI - Breast implant imaging homes in on tiny leaks. PMID- 10159852 TI - What payors want from radiology. PMID- 10159854 TI - MSAs designed to tame managed-care juggernaut. PMID- 10159855 TI - Contracts minimize risks for teleradiology services. PMID- 10159856 TI - MRI probes biophysical structure of cartilage. AB - MRI of cartilage will likely remain a controversial topic for some time on account of disagreement over the appearance of normal cartilage and the accuracy of MRI for detecting early changes of osteoarthritis. This is an area, however, that may be amenable to the application of advanced imaging techniques, including magnetization transfer MRI, because of its relatively simple structure. PMID- 10159857 TI - Investigators refine MR angio methods. PMID- 10159858 TI - Rehabilitation technology assessment practices in vocational rehabilitation agencies. AB - A rehabilitation technology assessment is an essential element in the array of rehabilitation technology services provided for vocational rehabilitation (VR) clients. As a part of a comprehensive survey of rehabilitation technology services in VR agencies, information was collected on current practices in rehabilitation technology assessment. Some variation in length, components included, and professionals involved were found among agencies. A complete description of these assessments as reported by VR agencies is discussed and commonalities in current practice are described. PMID- 10159859 TI - Evaluation of an active seating system for pressure relief. AB - In the first part of this study, the inflation-pressure and interface-pressure profiles of an active cushion system, the Talley active air bellows cushion, were examined continuously for one complete working cycle using the dynamic pressure monitor. The relationship between the inflation pressure and the interface pressure was explored. A well-defined relationship was found in the areas directly over the air bellows. In the second part of this study, the pressure relieving characteristics of the active cushion were assessed quantitatively and compared to two types of passive cushions--the Roho high-profile air floatation cushion and the polyurethane (PU) foam cushion. Eight non-disabled subjects were positioned on the active cushion at two inflation-pressure levels--30 mmHg and 60 mmHg, or on the Roho or the PU foam cushions. Interface pressures were recorded using the Oxford pressure monitor. For the active cushion it was shown that the higher the inflation pressure was, the better the pressure-relieving characteristics seemed to be. In general, the pressure-relieving characteristics of the active cushion were not as good as those of the passive cushions being tested. The active cushion could alter the pressures over the ischial tuberosities cyclically but the amount of pressure alternation depended on the relative position of the ischial tuberosities and the air bellows. PMID- 10159860 TI - Credentialing--for ourselves and our customers. PMID- 10159861 TI - Mechanical effects of rear-wheel camber on wheelchairs. AB - Giving the rear wheels of manually propelled wheelchairs negative camber (by angling them such that the bottoms of the wheels are farther apart than the tops) has become increasingly popular, especially among active users. This study's purpose was to evaluate how changing camber affects a wheelchair's mechanics and the extent of these changes. Using a representative wheelchair occupied by an anthropomorphic dummy, we altered the camber from +15 degrees to -15 degrees and measured the effects on nine selected variables. In addition to increasing the wheelchair's track width, negative camber increases the wheelchair's wheelbase and decreases the height of the frame. With negative camber, the center of gravity (CG) of the occupied wheelchair moves backwards. Negative camber causes a backwards tilt of the frame which, in turn, causes toe-out of the rear wheels, a positive caster-inclination angle and an increase in the caster-trail distance. It is apparent that a change in one component of a wheelchair can affect many others, which should be taken into consideration and, where appropriate, compensated for when changing the camber of the wheelchair. PMID- 10159862 TI - Perception of the impact of assistive devices on daily life of three individuals with quadriplegia. AB - This qualitative study investigated the perceptions of three men with spinal cord injuries regarding the impact of assistive devices on their daily lives. Data were collected through open-ended face-to-face interviews and observations in the participants' homes. Thematic analysis yielded three recurrent themes; "getting out,'' "what do I do with all this time,'' and "I found an easier way.'' Concerns relating to personal freedom, choices, independence, and feelings regarding usefulness and control over daily lives were evident as main issues underlying the three themes. Assistive devices perceived as "advantageous'' were simple, appropriate for use in the home, and easy to use in the home. Devices perceived as "complex'' were abandoned or modified. PMID- 10159863 TI - Rehabilitation engineering training for the future: influence of trends in academics, technology, and health reform. AB - A perspective is offered on rehabilitation engineering educational strategies, with a focus on the bachelor's and master's levels. Ongoing changes in engineering education are summarized, especially as related to the integration of design and computers throughout the curriculum; most positively affect rehabilitation engineering training. The challenge of identifying long-term "niches" for rehabilitation engineers within a changing rehabilitation service delivery process is addressed. Five key training components are identified and developed: core science and engineering knowledge, synthesized open-ended problem solving skill development, hands-on design experience, rehabilitation breadth exposure, and a clinical internship. Two unique abilities are identified that help demarcate the engineer from other providers: open-ended problem-solving skills that include quantitative analysis when appropriate, and objective quantitative evaluation of human performance. Educational strategies for developing these abilities are addressed. Finally, a case is made for training "hybrid" engineers/therapists, in particular bachelor-level engineers who go directly to graduate school to become certified orthotists/prosthetists or physical/occupational therapists, pass the RESNA-sponsored assistive technology service provision exam along the way, then later in life obtain a professional engineer's license and an engineering master's degree. PMID- 10159864 TI - Evaluating silicone tubing. AB - Many of the applications of silicone tubing involve pumping operations, carried out in often critical conditions. Concerns are sometimes expressed about the risks of using silicone, particularly with regard to the quantity of extractables that are produced during use. This article addresses those concerns by describing pumping trials performed to determine the life span of two types of silicone tubing. PMID- 10159865 TI - Fuzzy logic and medical device design controls. AB - The second article in this series concentrated on the application of fuzzy logic in drug delivery systems and presented a specific example of respiratory therapy. This article completes the picture with a discussion of the regulatory issues, with particular reference to hardware and software design controls and applicable standards. PMID- 10159867 TI - Medical device reporting: the US final rule. AB - On 11 December 1995, the United States (US) Food and Drug Administration (FDA) published new medical device reporting (MDR) regulations for reports submitted by manufacturers and user facilities. The new regulations, which also revise the regulations for registration and listing, become effective on 11 April 1996. They also impose requirements on nonUS medical device manufacturers. This article discusses the new MDR requirements, including those related to nonUS medical device manufacturers. PMID- 10159866 TI - Silicon, silicone, and silica: the importance of the right ending. AB - Although organic polymers based on carbon have revolutionized the use of commodity materials during the latter half of the twentieth century, polymers based on silicon have also had a remarkable impact in certain speciality areas, especially in medical technology. This article clarifies some of the chemical uncertainties associated with these materials. PMID- 10159868 TI - Safety by design in electromedical equipment, Part III. AB - In this series on electromedical equipment, design tips on how to minimize the safety risks have been provided. Part III considers electromagnetic compatibility. It also discusses the requirements for accompanying documentation and areas that were not considered prior to the IEC 601 series, including thermoplastic polymers and software. PMID- 10159869 TI - An engineering challenge: incontinence. AB - The search for better incontinence products is under way. This article reports on issues that have inhibited new developments until now and the areas that offer the greatest potential. A diversity of views are aired on this unexplored product sector. PMID- 10159870 TI - Medical Device Technology sterilization survey. AB - This fourth Medical Device Technology sterilization survey reports on trends in the use of sterilization methods in the European medical device and diagnostic manufacturing industry. It compares the levels of in-house and subcontracted sterilization and provides comment on the future of sterilization by electron beam. PMID- 10159871 TI - Staying calm under pressure: the secrets of bioceramics. AB - For very good reasons, ceramics as a class of material have limited uses in medical devices. They do, however, have some interesting, relevant, and unique properties. This article explains this paradox in terms of the structural characteristics of those materials. PMID- 10159872 TI - An overview of current opinions on automation in blood transfusion services. PMID- 10159873 TI - Automation/computerization in donor sessions. AB - Automation and computerization are steadily being introduced into donor session procedures, the prime objective being to improve the quality and safety of the donation process. This progress can be reviewed from two aspects, that relating to the donor, and that relating to the donation. While permanent donation sites can maintain an appropriate layout, suitable equipment, permanent data and power cabling, and direct links to the relevant Information Systems, this is much harder to achieve for mobile blood collection teams. Hall-based and "bloodmobile" mobile collection teams are responsible for the vast majority of blood donations taken in the U.K., and require different technical solutions. It is in this area that most recent developments have taken place. PMID- 10159874 TI - Automation of mandatory testing of blood donations. PMID- 10159875 TI - A co-ordinated IT system for the improved management of the blood supply. AB - Historically, most computer systems have been backward looking and have been introduced as a method of dealing with increasingly complex practices. For the Service to exploit the potential benefits of information technology, today's systems must be forward looking, support the Service's strategy and help shape the Service, not merely reflect it. To do this the starting point for the design of the Service's information systems must be the needs of the customer. It is therefore intended to replace the Service's current 12 incompatible computer systems with a single, standard system. Benefits will begin to be realized immediately following implementation of the chosen system in the first site; however, the benefits will not be fully realized until after successful implementation of the last site. The following is a non-exhaustive list of some of the benefits that the Service is seeking to achieve by implementing a coordinated IT system. PMID- 10159876 TI - Automation in quality assurance of blood components and the complementary role of audit. PMID- 10159877 TI - Automation in transfusion science. PMID- 10159878 TI - Automation/computerization in blood processing. PMID- 10159879 TI - Automation in blood components processing: NLBTC perspective. PMID- 10159880 TI - ISBT 128--a new international standard for labelling and data management in blood transfusion. PMID- 10159881 TI - Some ramblings on automation for a hospital blood transfusion laboratory. PMID- 10159882 TI - International forum: Saudi Arabia. Peripheral blood stem cell harvest in Saudi Arabia. A review of the first decade. PMID- 10159883 TI - What's happening?: Stem cells. Current developments in haematopoietic progenitor cell transplantation. PMID- 10159884 TI - Current trends: evolving concepts in transfusion medicine. Leukodepleted cellular blood components for prevention of transfusion-associated graft-versus-host disease. PMID- 10159885 TI - Characterization and transfusion of in vitro cultivated hematopoietic progenitor cells. AB - Our study is to show the safety of transfusion and the number, phenotype, and proliferative potential of in vitro cultivated autologous hematopoietic peripheral blood progenitor/stem cells (PBPCs). An in vitro long-term liquid culture using PBPC suspension from consenting patients with metastatic breast cancer was established. The medium was supplemented with a variety of hematopoietic growth factors. The mononuclear cells (MNCs), their viability, CD34+ subsets, clonogenic cells, and neutrophil function were measured prior to, during, and after liquid culture for 14 days. The total cell number increased during incubation in vitro from 2.5 x 10(8) to 5 x 10(9). The clonogenic and CD34+ cells increased during the first week 6- and 3.5-fold, respectively, and were almost undetectable after 2 weeks. Maturation into the myeloid cell series was demonstrated by standard cytology and increase of CD33+ and CD38+ cell numbers. On average, 1.5 x 10(9) cells were transfused to consenting patients with metastatic breast cancer after high-dose chemotherapy and PBPC transplantation at nadir of WBC < or = 0.1/nL. One hour later, the mean WBC was measurable at 0.3/nL. Subsequently, WBC counts dropped to 0.2/nL and 0.1/nL at 6 and 24 h post transfusion. No side effects and complications were observed. In summary, an in vitro expansion can produce a > or = 20-fold increase of maturing PBPCs for an effective and safe autologous transfusion. This unique approach, when refined, could lead to a safer post-transplant period and a decrease of complications due to neutropenic fever. PMID- 10159886 TI - Cold activation of complement as a marker of hepatitis C viremia in sera from blood donors. AB - Sera from 49,088 blood donors were tested for markers of hepatitis C virus (HCV) infection and decreased hemolytic activity after they had been stored at 4 degrees C for 24 h, a phenomenon known as the cold activation of complement. Antibody to HCV (anti-HCV) was detected in 315 (0.64%) units, of which 181 (57%) were positive for HCV RNA. The cold activation of complement was detected in 170 (0.35%) units, and HCV RNA was detected in 140 (82%) of them. Thus, the cold activation of complement was observed in 140 (77%) of 181 blood units with HCV RNA. The close association of HCV viremia with the cold activation of complement would be useful as a surrogate test in preventing post-transfusion HCV infection in developing areas where anti-HCV assays are not easily performed. PMID- 10159887 TI - Physico-chemical properties of membranes of recovered erythrocytes in blood autologous transfusion: a study using fluorescence technique. AB - Using fluorescence polarization of 1,6-diphenyl-1,3,5-hexatriene (DPH) and its derivative trimethylammonium-1,6-diphenyl-1,3,5-hexatriene (TMA-DPH), we have investigated the fluidity in erythrocyte membranes isolated from intraoperatively and postoperatively recovered erythrocytes, compared to membranes isolated from untreated erythrocytes or stored red blood cells (RBCs). Fluorescence polarization (Pf) of DPH and TMA-DPH was not significantly modified in membranes isolated from intraoperatively and postoperatively recovered RBCs compared to membranes isolated from untreated fresh RBCs or stored RBCs. However, using 2 dimethyl-amino-6-lauroyl-naphtalene (Laurdan), a very sensitive molecule, a significant increase in polarity in membranes from stored RBCs compared to untreated, intraoperatively and postoperatively recovered RBCs was observed. Moreover, there was significantly higher susceptibility to oxidative stress in membranes isolated from stored RBCs, compared to untreated and intraoperatively or postoperatively recovered RBC membranes, both at baseline and after oxidative stress. Our results suggest that intraoperative and postoperative recovered RBCs are less damaged than stored RBCs. PMID- 10159888 TI - Social context of HIV infection in Uganda. AB - Some of the important policy and research implications of accumulating HIV/AIDS data are being ignored because of the attraction of social science research focused on the "multiple sexual mechanism' of infection and transmission. Attention is drawn to the other policy and research issues relating to information on the timing of infection through a reanalysis of existing data on cumulative AIDS cases. The most urgent need is to supplement the mainstream research on risk groups with studies of the timing and circumstances of entry into sexual activity in the pre-teen years. PMID- 10159889 TI - The effects of HIV and AIDS on fertility in East and Central Africa. AB - Concern has been expressed about the fertility of people infected with HIV: the worry has been that on learning of their condition, HIV-affected individuals may attempt to accomplish unmet reproductive goals knowing that they will not live a normal life span. This article addresses the potential effects of AIDS on fertility and reproductive decisions in East and Central Africa. The problem is seen in terms of a tightly knit continuum of biological, epidemiologic and cultural contexts, and the prevailing conditions of response to the epidemic. AIDS can influence fertility among individuals and groups regardless of any awareness of serostatus by increasing death rates among reproductive populations, and damaging the physical capacities of infected men and women to reproduce. In much of the region, high prevalence of STDs may simultaneously impair the fertility of men and women and increase their risk of contracting HIV. These biological conditions are compounded among those for whom fertility is a highly valued marker of adult status, where the social and economic marginality of young women contributes to reliance on commercialized sex, where the mobility of young men leads to instability in sexual partnerships and frequent partner change, or where women lack the ability to negotiate their fertility with spouses. It appears that even focused programs of testing and counselling with HIV-positive women in Europe and in Africa have not motivated a significant change in reproductive action. Were there a demonstrable effect of counselling on the fertility choices of infected persons, there are numerous practical limitations on the role that interventions can play in affecting the fertility of HIV positive people. PMID- 10159890 TI - Impact of AIDS on the family and mortality in Uganda. PMID- 10159891 TI - Impact of AIDS on marriage patterns, customs and practices in Uganda. PMID- 10159892 TI - Care for AIDS orphans in Uganda: findings from focus group discussions. PMID- 10159893 TI - The declining HIV seroprevalence in Uganda: what evidence? PMID- 10159894 TI - Women's attitudes to men's sexual behaviour. PMID- 10159895 TI - The dilemma of Jehovah's Witness children who need blood to survive. AB - Medical researchers must continue to develop and test non-blood oxygen-transport products. Resources provided by the Jehovah's Witness Hospital Assistance Line must be consulted. Sickle cell researchers must continue to test non-blood treatment. Information about non-blood treatments must be disbursed. Ways to enhance parental comfort as the laws further and further support children's best interest must be provided. Information regarding cultural diversity must be disseminated. Hospitals and healthcare agencies that have not done so must institute the use of ethics consulting or ethics committees. Nurse ethicists must continue development of the role of educating staff; mediation, arbitration and negotiation; problem solving; obtaining legal opinion; providing patient, family, or staff advocacy; and helping to reduce suffering on the part of the providers. Difficult ethical decisions should continue to be debated. Were the staff X Med Center correct in overriding parental wishes and breaking tenets of their faith? In the doctor's, nurse's, lawyer's, and judge's view they were. The child, now eight years old, is alive and well. The stroke resolved, and imminent death averted. The parents' and child's views are not presently available. Whether the family is suffering from the child's loss of his relationship with God, or are secretly relieved in their hearts that they are not, like Rita Swan, mourning their dead son, is unknown. What is known, is that this was a difficult case for all involved, and that such cases will continue to present themselves in the future. PMID- 10159896 TI - On second thought: a Canadian reflection. Informing after the fact: AIDS, confidentiality, and the duty to warn. PMID- 10159897 TI - Selected bibliography on HECs, 1994-1995. PMID- 10159898 TI - Document information management and workflow solutions in the healthcare enterprise. PMID- 10159899 TI - The death of managed care. PMID- 10159901 TI - A CHIN grows in Greater Dayton. PMID- 10159900 TI - CHINS: choking or championing? PMID- 10159902 TI - The CPR: balancing quality and cost. PMID- 10159903 TI - Modeling the enterprisewide information architecture. PMID- 10159904 TI - Inventory detectives tap IT (information technology). PMID- 10159905 TI - The state of the lab. PMID- 10159906 TI - Barcodes: streamlining specimen collection. PMID- 10159907 TI - Barcoding at the bedside. PMID- 10159908 TI - Rumors and reality at the Joint. PMID- 10159909 TI - Technology and Software Guide 1996. PMID- 10159910 TI - Practice brief. Issue: Authentication of medical record entries. American Health Information Management Association. PMID- 10159911 TI - The quest for quality and comparability in the national healthcare database: announcing "A Payer's Guide to Health Care Data Quality and Integrity". Coding Policy and Strategy Committee, AHIMA. PMID- 10159912 TI - Facility closure. PMID- 10159913 TI - ISO 9000 is not a phone number. PMID- 10159915 TI - The CPR in physician practice may be just a click away. PMID- 10159914 TI - Health Level Seven: the clinical data interchange standard. PMID- 10159916 TI - Making the outsourcing decision. PMID- 10159917 TI - Internet security: what health information managers should know. PMID- 10159918 TI - Defending your data: minimizing risks in a networked environment. PMID- 10159919 TI - Update on healthcare informatics standards development in the United States. PMID- 10159920 TI - Case studies. Prestigious systems pool thinking and data to measure and improve outcomes across a continuum. PMID- 10159921 TI - Work redesign. Data analysis and clinical pathways pay off. PMID- 10159922 TI - Shoulder dystocia: a risk manager's perspective. PMID- 10159923 TI - Truth and justice: dispelling the myths of medical malpractice. PMID- 10159924 TI - The impossible dream? A workers' compensation program in an integrated delivery network. PMID- 10159925 TI - Quality assurance and continuous quality improvement within air transport programs. AB - INTRODUCTION: In June of 1993, the Association of Air Medical Services (AAMS) Quality Management Committee surveyed 240 air medical programs regarding their Quality Assurance and Continuous Quality Improvement activities. METHODS: The survey tool consisted of questions related to Quality Assurance/Continuous Quality Improvement program structure and specific Quality Assurance indicators contained in the AAMS/NFNA Quality Assurance Resource Document. Comparisons were made among fixed-wing, rotor-wing, and combined programs, for use of the Quality Assurance Resource Document, for availability of computers and for hospital-based versus profit or public service programs. RESULTS: Returned surveys totaled 148 for a 62% return rate, with most of the respondents being single hospital based programs. Ninety-three percent of those surveyed have a Quality Assurance program in place to monitor indicators, whereas 63% have also begun to include the Continuous Quality Improvement team process. Only 50% of respondents use computers in their Quality Assurance/Continuous Quality Improvement activities. CONCLUSION: Significant differences among groups were found for several Quality Assurance indicators. PMID- 10159926 TI - The impact of multiple patient transport on patient care in helicopter emergency medical services. AB - INTRODUCTION: Many helicopter emergency medical services can transport either one (singles) or two (doubles) patients. The purpose of this study was to investigate whether the additional patient in the doubles flight had an adverse impact on patient care because of the deceased provider-to-patient ratio. SETTING: Patients were flown by a Level 1 trauma center-based helicopter emergency medical service staffed by a nurse and paramedic. METHOD. A retrospective record and trauma registry review comparing 124 randomly selected scene trauma singles frequency matched to 100 doubles (1/89 through 6/92) was performed. Data collected included patient demographics, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, mechanism of injury, scene time, and ground ALS and helicopter emergency medical services procedures performed. RESULTS: Doubles accounted for 6.5% of all on-scene helicopter emergency medical service trauma patient transports. Paired comparison of Glasgow Coma Scale, Revised Trauma Score, and Injury Severity Score revealed that only one of the doubles patients had a field Glasgow Coma Scale as low, or a Injury Severity Score as high as the average singles. Revised trauma scores were equivalent. Although more procedures were performed during doubles missions, no procedures were performed in most singles missions (58%) and a substantial minority of doubles missions (41%). No differences were found between the groups in change in Glasgow Coma Scale during flight. CONCLUSION: Only of the two patients during doubles missions was as severely injured as the average patient in a singles transport. The decreased ratio of helicopter emergency medical service crew to patients in doubles missions does not jeopardize patient care because few procedures were performed during either singles or doubles missions. PMID- 10159927 TI - Mission, staffing, and budget data of flight programs in the United States. AB - INTRODUCTION: Manage care and other health care reform initiatives have forced all hospitals to evaluate their work processes. In this era of cost containment, many flight programs are examining the structure of their programs to determined whether they are functioning in an efficient, cost-effective fashion. METHODS: A survey was sent to the chief flight nurse of 240 flight programs in the United States. RESULTS: Eighty-five programs (35.4%) responded. Data were collected on demographics, management structure, mission information, staffing issues, and budgets. Results in each program varied widely. CONCLUSION: Benchmark data are available against which programs can compare themselves. Such comparisons may allow the discovery of opportunities to enhance program efficiency and cost effectiveness. PMID- 10159928 TI - Basics of research (Part 7): Archival data research. PMID- 10159929 TI - Is the target income hypothesis an economic heresy? PMID- 10159930 TI - The impact of financial incentives on physician behavior in managed care plans: a review of the evidence. PMID- 10159931 TI - The effect of the ACOG guideline on vaginal births after cesarean. PMID- 10159932 TI - Competition under fixed prices: effects on patient selection and service strategies by hemodialysis providers. PMID- 10159933 TI - Health care's consumer revolution. PMID- 10159934 TI - Think customer when downsizing, restructuring, and repositioning. PMID- 10159935 TI - Seven leading trends in customer focus, service, and quality. PMID- 10159936 TI - Purchasers and payers drive the definition of value and quality in integrated healthcare systems. PMID- 10159938 TI - Differentiating products by market segment helps IDS stay ahead of competitors. PMID- 10159937 TI - A frayed link in the healthcare continuum: integrated delivery and financing systems. PMID- 10159939 TI - Primary care physicians have their day in the compensation sun. PMID- 10159940 TI - Subacute care providers prepare for higher-acuity patients. PMID- 10159941 TI - Simplify credentialing, organizing medical staff with the right steps. PMID- 10159942 TI - Managing change. PMID- 10159943 TI - Another season in the big casino. PACS development. PMID- 10159944 TI - Managed breast care. Are you ready for the future? PMID- 10159945 TI - Caring for incarcerated patients. PMID- 10159946 TI - Incidence ratio of procedures. PMID- 10159947 TI - The problem with power. PMID- 10159948 TI - AIDS--meeting the challenge of home care. PMID- 10159949 TI - Crossing cultural barriers to care for people with AIDS. AB - The delivery of high-quality home care to HIV/AIDS patients is often complicated by the cultural barriers present when caring for minority populations. Developing trust, listening skills, and a nonjudgmental approach are essential to providers who care for people of varied cultural backgrounds. PMID- 10159950 TI - Creating partners in HIV care. AB - Home care teams caring for people with AIDS often must depend on informal caregivers to help their patients. If the informal caregivers have better tools to help, patients are more likely to get the best care possible. This training program for care partners is a perfect way to provide those tools. PMID- 10159951 TI - Nutrition for in-home AIDS patients. AB - Early medical nutrition intervention with in-home AIDS patients can help prolong and improve the quality and quantity of their lives. Teaching the basics of good nutrition both early on as well as in the later stages of AIDS can save thousands of health care dollars through preventive care at home. PMID- 10159952 TI - Pediatric AIDS program addresses whole families. AB - Families of children with AIDS are often at risk for substance abuse, child neglect, and homelessness. Effective service delivery to the pediatric AIDS population requires a holistic, team-oriented approach for the whole family. PMID- 10159953 TI - Needle exchange programs benefit the community. AB - Needle exchange programs, illegal in many communities, provide HIV-prevention services to a hard-to-reach population--injection drug users (IDU). Reaching IDUs, who are among society's most at-risk members for HIV infection, protects the health of the community at large. PMID- 10159954 TI - Passive hyperimmune therapy: buying time at what cost? AB - Some AIDS physicians are now turning to passive hyperimmune therapy as an alternative to try to protect and rebuild AIDS patients' ravaged immune systems. This is a labor-intensive and expensive treatment that raises many questions. PMID- 10159955 TI - Home HIV tests: the need for regulation. AB - In-home testing for HIV/AIDS will be available nationwide in early 1997. Because laws regulating these over-the-counter test kits vary widely from state to state, national uniform regulations are needed to safeguard the rights of consumers and to protect health care providers from professional liability. PMID- 10159956 TI - HIV/AIDS resources on the Internet. AB - Both HIV/AIDS patients and their caregivers can find a wealth of information about HIV and AIDS on the Internet, if they know where to look for it. Below is a guide to get both professionals and lay people started on their search for HIV/AIDS information. PMID- 10159957 TI - Congress reauthorizes the Ryan White CARE (Comprehensive AIDS Resources Emergency) Act. PMID- 10159958 TI - Finance a humane system of AIDS care. PMID- 10159959 TI - Home Detox: a cost-effective alternative. AB - The scope of home care is expanding to include specialty services such as substance-abuse detox programs. One company serves as liaison with home care agencies to help patients with alcohol-related illnesses recover in the privacy of their homes. PMID- 10159960 TI - The anatomy of an endowment/capital campaign. PMID- 10159961 TI - "Resources unused are resources abused" syndrome. PMID- 10159962 TI - Who's in charge of fund raising? PMID- 10159963 TI - Acquiring and keeping donors in the new healthcare environment. PMID- 10159964 TI - Tie pediatrics services to family care and community health. PMID- 10159965 TI - Hospital, school district lead efforts to better service western Massachusetts communities. PMID- 10159966 TI - IntegraMed starts specialty division that targets adult women's health care. PMID- 10159967 TI - Providing the continuum of care and disease management for the catastrophically ill. PMID- 10159968 TI - Digest: integrated systems can save. PMID- 10159969 TI - Healthcare Financial Management Association. Leading & learning 1946-1996. The first 50 years and beyond. PMID- 10159970 TI - MSAs: defining terms and setting boundaries. PMID- 10159971 TI - Intranet: information technology for a limited universe. PMID- 10159972 TI - Joint operating agreements: a new integration model. AB - Many healthcare system integrations are inherently contradictory: The participants want the benefits of integration but do not want to give up self governance, relinquish title to their assets, or assume unwanted liabilities. A new integration model--the joint operating agreement--appears to resolve some of these concerns. PMID- 10159973 TI - Lessons learned from 10 years of MSO development. AB - Lessons learned over 10 years of management services organization (MSO) development can help financial managers increase their healthcare organizations' odds of success in such ventures. If administered appropriately, with a focus on managing and retaining covered lives, MSOs can be valuable vehicles for tying community physicians to organizations interested in developing integrated delivery systems. PMID- 10159974 TI - When should primary care groups become multispecialty networks? AB - A difficulty confronting many primary care groups is determining whether--and when--to evolve into multispecialty networks. Internal triggers that signal the need to transition to a multispecialty group include having a sufficient number of primary care physicians in the group and the solidification of an effective primary care management system. External triggers include a decline in average per-member-per-month (PMPM) rates, carve-outs of portions of the PMPM payment for an increasing number of healthcare services, and increases in Medicare managed care enrollment. Primary care groups that make the transition to multispecialty networks may find it is the best model for managing the health of the population in their community. PMID- 10159975 TI - Underwriting: a key to healthy capitation agreements. AB - In some markets, healthcare providers in integrated delivery systems have been assuming full-risk capitated contracts. Some of these contracts have been profitable, but others have produced inconsistent financial results. These results may reflect inadequate underwriting practices. For providers and HMO insurers to establish financially successful capitation agreements, they must develop and audit an underwriting process to evaluate the health risk of the population entering the managed care system. PMID- 10159976 TI - Investing: reducing risks to enhance returns. AB - The financial assets of a healthcare organization can present many opportunities for investment. In order to develop a profitable investment program that avoids risky speculation, however, healthcare financial managers must fully understand the nature and risks of their organizations' investments. They must define and monitor their investment objectives, limitations, levels of acceptable risk and policies and conditions through a statement of investment policy and comprehensive investment guidelines. PMID- 10159977 TI - The benefits of data integration: HFMA study findings. AB - An HFMA study of "best practices" integrated delivery systems that have integrated their clinical and financial data has found that these systems employ some common strategies--they buy rather than build their system software and they strictly adhere to industry standards for EDI and data conversion. The data integration study also shows that best practices systems are concentrating more on automating ambulatory care processes rather than their inpatient care processes and on developing comprehensive order-entry systems. Study findings were used to refine a conceptual data model that healthcare financial managers can use to implement integrated data collection activities in their organizations. PMID- 10159978 TI - Outsourcing real estate lease administration. AB - Real estate lease administration is becoming increasingly important to healthcare organizations; however, not all organizations possess the in-house expertise to carry out this specialized function. For such organizations, outsourcing lease administration may be a more efficient way to manage their real estate portfolios and possibly improve their bottom lines. PMID- 10159979 TI - Options for nonqualified deferred compensation plans. AB - Tax-exempt organizations are subject to more stringent IRS rules than their for profit counterparts in terms of how they can provide nonqualified deferred compensation plans for highly paid employees. Nevertheless, alternatives are available to tax-exempt organizations seeking to set up such plans. by subjecting employer-paid, tax-defer compensation to risk of forfeiture or by paying the required taxes, tax-exempt organizations can develop workable alternatives for funding nonqualified deferred compensation plans. PMID- 10159980 TI - Developing a group perspective. AB - Increasing numbers of physicians are forming group practices to secure managed care contracts. In doing so, they face challenges they did not experience in solo practices. Physicians new to group practice must develop a group perspective that reflects the different values, goals, governance structure, and decision-making approach needed for a group to succeed. PMID- 10159981 TI - Medicare risk contracting places new demands on physician group practices. AB - Physician group practices new to Medicare risk contracting face unfamiliar financial and practice imperatives. Financial imperatives include accepting capitation and the risks associated with it. Practice imperatives include adhering to critical paths and admission and discharge criteria. By familiarizing themselves with the risks and rewards of Medicare risk contracting, physician group practices can make more informed decisions about entering into such arrangements. PMID- 10159982 TI - Hospitals prevail in disproportionate share adjustment litigation. PMID- 10159983 TI - Throw away your old RFP. PMID- 10159984 TI - Data trends. September 1996--growth and return on assets: 1993-1995. PMID- 10159985 TI - Downtown hospital's CCTV system upgrade helps local police as well. PMID- 10159986 TI - From Alaska to Alabama: preparing for next winter's snow and ice. PMID- 10159987 TI - An interview with: Dennis Wozniak on enhancing the quality of hospital security services. PMID- 10159988 TI - Compensation of hospital security directors: how does it compare with other industries and with other managers in the healthcare industry? What can you do to earn more? AB - A number of studies have been published recently which enable hospital security directors to evaluate where they currently stand compensation-wise and what their potential might be. These studies also enable them to compare salary levels with those of their counterparts in other industries and with those of other middle managers in their own field. In this report, we'll review some of the findings and what we believe they imply. We'll also present our recommendations on what can be done, if anything, to achieve salary levels more commensurate with the levels of responsibility held by security directors in the three fields that provide public accommodations--health care, higher education, and lodging. PMID- 10159989 TI - Managers' health. All stressed up and nowhere to go. PMID- 10159990 TI - Mental health. Divisions and revisions. PMID- 10159991 TI - Consumer involvement. Getting engaged. PMID- 10159992 TI - Managerial responses to Medicaid prospective payment in the nursing home sector. AB - The United States must soon address long-term care policy. Policymakers have sought cost containment through reimbursement policies that contain incentives for efficiency. Nursing facility administrators were surveyed twice following a significant change in Maine's Medicaid reimbursement policy to determine the effects of the change on their managerial practices. The administrators responded to some of the policy changes as profit maximizers, including instituting cost controls and benefiting from incentives. In other areas, such as staffing, staff pay, and accepting heavy care patients, the administrators did not seem to behave entirely as expected. Insights from organizational theory are useful for explaining some of the other behaviors. As long-term care reform is undertaken, a policy framework should include aspects of the internal environment of nursing facilities, such as administrator goals and organizational structure and mission. PMID- 10159993 TI - Church ownership and hospital efficiency. AB - Using a sample of California hospitals, the effect of church ownership was examined as it relates to nonprofit hospital efficiency. Efficiency scores were computed using a nonparametric method called data envelopment analysis (DEA). Controlling for hospital size, location, system membership, and type of church ownership, church-owned hospitals were found to be more frequently in the efficient category than their secular nonprofit counterparts. The outcomes have policy implications for reducing healthcare expenditures by focusing on increasing outputs or decreasing inputs, as appropriate, and bolstering the case for church-sponsored hospitals to retain the tax-exempt status due to their ability to manage their resources as efficiently as (or more efficiently than) secular hospitals. PMID- 10159994 TI - An exploratory analysis of market-based, physician-organization arrangements. AB - The growth of physician-organization arrangements (e.g., PHOs, MSOs) by physician specialty groups and delivery organizations is widely acknowledged. Yet, little is known about these new organizational forms. This paper presents a descriptive analysis of physician-organization arrangements (POAs) using survey data obtained from 79 organizations. The analysis examines the extent to which healthcare delivery organizations are engaged in the development of POAs, the number of physicians involved in POAs, and the decision-making control and strategies associated with POAs. These attributes are examined for the sample as a whole and relative to the institutional and market conditions facing study participants. Results are discussed in terms of their implications for health services managers. PMID- 10159995 TI - Understanding hospital referrals to home health agencies. AB - Using resource dependency theory and transaction-cost economics theory, we examined the simultaneous effects of a vertical integration strategy and environmental complexity on home health agency (HHA) referrals by hospitals. Discharge data for calendar year 1990 from 61 Pennsylvania hospitals were analyzed. Using hospital ownership of home health agencies and urban versus rural location as the primary independent variables, a logistic regression model calculated the probability of HHA referral, after controlling for long-term care beds and patient characteristics. Results showed that HHA ownership was a significant predictor of home health referrals for both rural and urban hospitals, although the effect was greater for urban hospitals. These results suggest that hospitals are actively using referrals to home healthcare in response to environmental pressures. As these pressures increase, hospitals will benefit from tight linkages with home health providers. PMID- 10159996 TI - Vertical integration strategies: revenue effects in hospital and Medicare markets. AB - The purpose of this study was to evaluate the revenue effects of seven vertically integrated strategies on California hospitals. The strategies investigated were managed care contracts, physician affiliations, ambulatory care, ambulatory surgery, home health services, inpatient rehabilitation, and skilled nursing care. The study population included 242 not-for-profit hospitals in continuous operation from 1983 to 1990. Many hospitals developed vertically integrated programs in the 1980s as inpatient utilization fell in response to the Medicare Prospective Payment program. Net revenue rose on average by $2,080 from 1983 to 1990, but fell by $2,421 from the Medicare program. On the whole, the more physicians affiliated with a hospital, the higher the net revenue. However, in the Medicare population, the number of managed care contracts was significant. The pre-hospital strategies generated significant revenue, while the post hospital strategies did not. In the Medicare program, inpatient rehabilitation significantly reduced revenue. PMID- 10159997 TI - Research and continuous improvement: the merging of two entities? AB - Hospital administrators are under pressure to provide a quality product at reasonable prices. As a result, all aspects of hospital structure and culture are under review, which places continuous improvement (CI) programs addressing quality and satisfaction in a more prominent role. Although the theory, data collection methods, and analysis techniques of continuous improvement have grown considerably since the days of quality assurance, clinical problems in healthcare organizations are also increasingly complex and difficult to solve. From this perspective, research has a great deal to offer our current continuous improvement efforts. This paper proposes that CI and research are similar problem solving approaches, based on philosophies that provide direction for theorizing, collecting and analyzing data, and identifying solutions. A clinical problem elaborates on the similarities of each approach. Finally, common misconceptions are discussed. PMID- 10159998 TI - Differences in characteristics of hospitals with sustained high and sustained low profitability. AB - The organizational and operational characteristics of 140 private Florida hospitals with sustained high profitability and sustained low profitability were compared using pretax operating margin (PTOM) and pretax return on assets (PROA) measures. Approximately 15 to 20 percent of hospitals were defined as PTOM or PROA high-profit or low-profit for the years 1990, 1991, and 1992. The PTOM or PROA high-profit groups had a lower adjusted average length of stay and debt utilization, and a higher labor yield, occupancy rate, and percent with high hospital accreditation ratings (p < .05). In addition, the PROA high-profit group had a higher case-mix index and Medicare mix (p < .05). Characteristics that were different for high-profit and low-profit groups were within the scope of management. PMID- 10159999 TI - Venturing into new territory--health systems as Medicare risk contractors. AB - With each congressional budget debate, hospital and health system executives are reminded of their vulnerability to Medicare reimbursement rates. As health maintenance organizations (HMOs) have entered into Medicare risk contracts and negotiated separate hospital reimbursement rates, hospital and health system executives have recognized even less control of their Medicare reimbursement. One way for health systems to regain control of the Medicare dollar is to develop a Medicare risk contract that directly receives and distributes the Medicare risk premium. Before hospital and health system executives invest in the start-up and operational capital necessary to bid for a risk contract, careful analysis of the efficacy of the contract's contribution to the margin should be undertaken. The following will review observations and lessons from HMO Medicare risk contracting and introduce a methodology that health system executives can use to evaluate the annual financial impact of entering the business of direct Medicare risk contracting. PMID- 10160000 TI - The impact of healthcare reform on HMO administrators. AB - Over the years, congressional legislation toward healthcare reform has evolved, moving toward channeling indigent populations into managed care plans. Health Maintenance Organizations (HMOs) will have to respond to increased competition caused by this shift enrollment as each entity attempts to funnel these patients into its own provider network. It is likely that some HMOs may bid too low when contracting for patients, putting these organizations at risk for financial insolvency. This paper discusses the impact of Medicaid waivers on HMO administrators. HMO executives need to develop a strategy for monitoring the financial integrity and contractual performance of new and existing HMOs in light of changes taking place with respect to healthcare reform. The transition to managed care and the shift in enrollment pose many challenges for directors of HMOs as will be discussed by analyzing lessons learned from Medicaid managed care plans in Arizona and Oregon. PMID- 10160001 TI - Redrawing the line. PMID- 10160002 TI - Violence--a public health crisis. PMID- 10160003 TI - Healing a violent society. PMID- 10160005 TI - Log on. A continuing guide to the online world for healthcare executives, managers, clinicians, & patients. PMID- 10160006 TI - Vertical integration: is the bloom off the rose? PMID- 10160004 TI - Violence prevention initiatives and resources. AB - Violence is so pervasive and debilitating in America that it often seems to defy solution. But there are some among us who believe the problem can be solved, and they are doing something about it. Their strategies: establishing partnerships among stakeholders in the community and creating practical prevention and treatment methodologies. Here is a sampling of programs--several directly related to healthcare--dedicated to addressing the problems of violence in our society. PMID- 10160007 TI - The IDS as moving target. PMID- 10160008 TI - The learning advantage. Enhancing team performance. PMID- 10160009 TI - Leonard Marcus: healthcare diplomat. PMID- 10160010 TI - American College of Healthcare Executives. Key industry facts. PMID- 10160011 TI - The changing face of hospital governance. PMID- 10160013 TI - Preparing for job interviews. PMID- 10160012 TI - Governance challenges for managed care organizations. Interview by Ann C. Bartling. AB - When Healthcare Executive asked managed care organization CEOs and board chairs to identify governance challenges, they found the question so easy that it was difficult to limit their responses. while all the healthcare leaders interviewed pointed to the need to--and challenge of--staying ahead of the changes affecting the healthcare field, many identified challenges that were more specific to their organizations, markets, or patient population. Some also pointed out that while their challenges may be shared by hospitals and other provider organizations, there were aspects of each that were particularly relevant to managed care organizations, which often offer a variety of products in a number of different of markets. PMID- 10160014 TI - Measuring physician satisfaction. PMID- 10160015 TI - Handling job uncertainty during a merger. PMID- 10160016 TI - Medicare choices demonstration projects. PMID- 10160017 TI - Boards of all types and sizes are facing some common issues and challenges. PMID- 10160018 TI - Signals of board distress. By recognizing warning signs, CEOs can help get the board back on track. Interview by Cathy Tokarski. PMID- 10160019 TI - Panellist consistency in the assessment of medical appropriateness. AB - Where information about the appropriateness of a surgical procedure is lacking, expert panels have been used to establish guidelines for medical practitioners. Such a panel was convened to assess the appropriateness of percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery in the Netherlands. The panel, consisting of interventional cardiologists and cardiothoracic surgeons, used a modified Delphi process to rate 1126 clinical indications over two rounds. This article describes the degree of change in both agreement amongst members and in the appropriateness ratings over the two rounds, and examines the internal consistency of the ratings of individual panellists. Over the two rounds, agreement increased. Although most appropriateness ratings remained unchanged, there was significant movement from equivocal ratings to determinate ratings. While individual members showed some degree of inconsistency in their scoring, the panel as a whole scored very consistently. The observed changes in appropriateness were consistent with expectations, showing that the appropriateness method is used logically and consistently by panellists. PMID- 10160020 TI - The economics of ageing: on the attitude of Swedish people to the distribution of health care resources between the young and the old. AB - The Swedish Priorities Investigation [1] proposes that no account should be taken of a patient's age when allocating health care resources. Measures to save an old person's life are to be given the same priority as measures to save a young person's life. In the present study it is shown that the attitude of the Swedish population to this age-related problem is dramatically different from that laid down in the priorities investigation. On average, people are willing to sacrifice thirty-five 70-year-olds to save one 30-year-old. It is also shown that a measure which increases life-expectancy by 1 year, conditional on having survived until the age of 75 years, is given a low weighting. The (maximum) insurance premium the average Swede is willing to pay for such a programme is about 700 pounds. PMID- 10160021 TI - Making cost assessments based on RCTs more useful to decision-makers. AB - The appropriateness of results from economic evaluation for allocation-decisions in health care is a point of major concern for decision-makers. Much attention has been focused on potential biases stemming form the methodological shortcomings of economic evaluation. This article adds to this and concentrates on the 'real world' relevance of results from economic evaluation as an additional step towards making results more useful to decision-makers. Being the accepted standard for economic evaluation, the RCT is used as the reference case; yet, many of the issues raised are also relevant for other research designs. Three classes of biases are examined. The first relates to the limited scope that economic analysts sometimes choose in RCTs. The second class involves the methodological aspects of RCTs and questions the 'real world' relevance of the tools with which economic analysts estimate costs on the basis of RCTs. The third class concerns the representativeness of RCT results, i.e. the generalizability of these results and their usefulness in other treatment contexts. options for limiting the potential confounding influences of these biases are discussed. A check-list is provided which should be applied by decision-makers when using constructing and describing RCTs. This will enhance the relevance of the results of economic evaluation in decision-making and improve the information basis for actual allocation decisions in health care. PMID- 10160022 TI - Clinical practice, ethics and economics: the physician at the crossroads. AB - In recent years health services have faced the challenge of increasingly complex services and rising costs, thus the consideration of costs is a key factor in health policy decisions. The introduction of an economic perspective has sometimes been viewed as conflicting with the ethics of the health care system, especially at the physician-patient level. this article explores the important role of the physician from the ethical and economic perspective in the distribution and allocation of services. An understanding of economic and ethical principles reveals that these two perspectives are compatible with good clinical practice: more efficient health care implies better care for the individual patient and makes it possible to increase the resources available to improve care for the population as a whole. Thus, being efficient is an ethical objective. The selective elimination of ineffective services would free resources to care for those who need effective diagnostic or therapeutic procedures. This requires a better understanding of the determinants and outcomes of clinical practice, physician motivation, the appropriate design and application of incentives, and the best use of limited resources. The physician can play a key role in increasing the efficiency, equity, and quality of the health system without restricting the provision of effective services. PMID- 10160023 TI - Incorporating quality of life changes into economic evaluations of health care. PMID- 10160024 TI - Savvy service and innovative design help patients feel right at home. PMID- 10160025 TI - Picturing the future of telecommunications. Is your facility still living in the past? PMID- 10160026 TI - Benchmarking just the tool for environmental services. Interview by Pamela L. Blyth. PMID- 10160027 TI - Sitting idle. How do you plan the future of your unused health facilities? PMID- 10160028 TI - Are you ready? FDA final rules on devices are on the way. PMID- 10160029 TI - Fighting TB: a program for air quality management. PMID- 10160030 TI - Health facility renovation departments on the wane. PMID- 10160031 TI - Hospital liability for independent contractors: a practitioners' guide to handling ostensible agency issue in medical negligence trial. PMID- 10160032 TI - Common law tort liability of health maintenance organizations. PMID- 10160033 TI - Corporate practice of medicine: last stand or final downfall? PMID- 10160034 TI - Diagnosis-related group system. Can we still earn a living caring for sick people? AB - Medicare and Medicaid patients are starting to enroll in managed care organizations, as government tries to lower costs of caring for the elderly, disabled, and poor. Because they are the most likely to be sick, taking care of them imposes serious risks on hospitals and medical groups. The federal government uses the diagnosis-related group (DRG) system to reimburse hospitals. The system depends on physicians documenting diagnoses and complications. Physicians see illness as unpredictable, and so feel that detailed documentation of severity is futile. The government and health plans nevertheless follow case mix index and create hospital and physician profiles, relying on the existing imperfect system. For providers to be recognized for the value they add to the care of the sick, physicians must learn to use the DRG system to best advantage, or risk being driven out of business. PMID- 10160035 TI - Physician glut. Physicians--the next victims of "downsizing?". AB - Should physicians really be polishing up their CVs or preparing to enter another line of work? In a word: No. What a recent survey makes clear is that, while managed care is driving physicians from some markets, jobs are still available in other markets traditionally underserved by physicians. This is not to suggest that the physician employment market has gone unchanged. Many physicians, particularly specialists, have taken income hits, and some specialists truly are in need of work. Primary care physicians, however, have seen their stars rise and are now in a position to work wherever they want. Physicians may no longer be able to practice within 50 miles of where they were raised or where they were trained, as has been their wont. Instead, they will have to do what other professionals have long done--go where job opportunities take them. In short, they will have to add a career strategy to their scientific mindset, and that means an aggressive job search, coupled with a strong consumer orientation. PMID- 10160036 TI - The changing academic health center. The death of the traditional academic physician. AB - Organizational change is required if academic health centers (AHCs) are to survive the decreased societal commitment to them. The changes will generate significant emotional responses in the physicians employed by such institutions. This article presents an analogy between the reactions of academic physicians to the changes they are experiencing, and the stages of grief that Dr. Kubler Ross described in terminally ill patients. By placing physician responses in this context, emotional responses to organizational changes can be more easily understood and managed, allowing academic physicians to devote more energy to facing the threats to AHCs in an innovative and constructive manner. PMID- 10160037 TI - Reengineering a health care facility. Turning an organization on its head. AB - How can you foster change in your organization? Accomplishing major organizational change is difficult and extremely risky. However, change is necessary if health facilities are to survive in a competitive managed care world. Thrust into this environment, military health facilities are finding they must improve access and quality, while reducing costs. Keller Army Community Hospital at West Point was reengineered to meet this challenge. The results? A nontraditional hospital structure and management philosophy. Pipeline hierarchical chains of command and traditional professional boundaries have been modified. The strategy and transition process, as well as the obstacles to change, are explored in this article. Three years into a multi-year process, expected obstacles to change have been experienced, and success is predicted. PMID- 10160038 TI - The angry physician-Part 1. The temper-tantruming physician. AB - Angry physicians create problems--for the people they treat and work with, for their administrators, and for their loved ones. Addressing negative emotions is one of the most prevalent organizational and personal challenges facing physician leaders. Solving this problem starts with taking an honest look at the factors and processes that shape physicians' coping patterns. Learning effective emotional management skills is underscored by a simple fact: Emotions are contagious. The Type A behavior pattern (TYABP) refers to an aggressive coping mode. Cross-cultural research suggests that, compared to the general population, physicians show elevated scores on TYABP measures, and that women physicians are at particular risk of developing TYABP. In Part 2 of this series, interpersonal anger management strategies will be presented. PMID- 10160039 TI - The five fundamentals of dealing with change. PMID- 10160040 TI - Information technology, Part 2: Interactive media enhances medicine. PMID- 10160041 TI - The era of accountability. PMID- 10160042 TI - Provider-sponsored networks. Physicians organize for direct contracting. AB - The Provider Service Network (PSN) concept is part of a wider movement by physicians to restructure for managed care to improve bargaining leverage for America's more than 600,000 active medical practitioners. Direct contracting has a simple appeal--no intermediaries. Imagine managed care contracts without the costs or hassles of an HMO or third-party intermediary. The PSN is a new form of managed care organization, but without the middleman. Savvy, self-insured employers, business coalitions, and government health programs are the potential "buyers." Doctors and hospitals are the "sellers," organizing provider networks on a regional and statewide basis. Up for grabs are over 225 million consumers whose health benefits are currently managed by insurance plans, HMOs, and third parties. This new marketplace of direct contracting may sound to doctors like the Garden of Eden, but there is plenty of opposition. PSNs will not become a national trend without a fight. PMID- 10160043 TI - Race differences in the proportion of low birth weight attributable to maternal cigarette smoking in a low-income population. AB - PURPOSE: To quantify race differences in the public health impact of maternal cigarette smoking on infant birth weight and to estimate the proportion of low birth weight births that could be prevented by maternal smoking cessation. DESIGN: A cohort that consisted of 77,751 mother-infant pairs was evaluated retrospectively. SETTING: Statewide study of Women, Infants and Children participants in North Carolina. SUBJECTS: African-American and non-Hispanic white women who delivered a single live infant during 1988, 1989, or 1990. MEASURES: Logistic regression estimates of the relative risk of low birth weight births for smokers were used to calculate adjusted population attributable risk percentages for smoking. Separate population attributable risk percentages were calculated for total low birth weight, moderately low birth weight, and very low birth weight, and all estimates were adjusted for prepregnancy body mass index, gestational weight gain, age, education, parity, and timing of entry into prenatal care. RESULTS: Non-Hispanic whites had a much higher prevalence of smoking and were heavier smokers than African-Americans. For both moderately low birth weight and very low birth weight, the population attributable risk percentages for smoking were twice as high for non-Hispanic whites than for African-Americans. Overall, after adjustment, 30.7% of low birth weight births among non-Hispanic whites and 14.4% of low birth weight births among African Americans were attributable to smoking. CONCLUSIONS: Although the public health impact of maternal cigarette smoking on infant birth weight was twice as high for non-Hispanic whites as for African-Americans in this low-income population, smoking cessation by all low-income pregnant women would result in significant improvements in infant health and well-being. PMID- 10160044 TI - Cigarette smoking and self-reported health problems among U.S. high school seniors, 1982-1989. AB - PURPOSE: To estimate the independent effect of cigarette smoking on respiratory tract symptoms and health status indicators among high school seniors. DESIGN: Consolidated data sets from one-time cross-sectional survey designs. SETTING: High schools in the United States, 1982-1989. SAMPLE: A total of 26,504 high school seniors, with an 83% response rate. MEASURES: Odds ratios for respiratory tract symptoms and health status indicators for cigarette smokers compared with nonsmokers, while controlling for sex, socioeconomic status, and use of other drugs. RESULTS: High school seniors who were regular cigarette smokers and who began smoking by grade nine were significantly more likely than never smokers to report shortness of breath when not exercising (adjusted odds ratio [OR] = 2.7), coughing spells (OR = 2.1), productive cough (OR = 2.4), and wheezing or gasping (OR = 2.6). These smokers were also more likely to have seen a doctor or other health professional for an emotional or psychologic complaint (OR = 3.0) and to rate their overall health as poorer than average (OR = 2.4). We found strong dose response relationships for most outcome measures. CONCLUSIONS: Cigarette smoking among high school seniors is associated with respiratory tract symptoms and poorer overall physical health and may be a marker for underlying mental health problems. Smoking prevention activities directed at adolescents should include information on the early adverse health consequences of cigarette smoking. PMID- 10160045 TI - Occupational stress, physician-excused absences, and absences not excused by a physician. AB - PURPOSE: This study explores two possible mechanisms through which occupational stress is linked to absenteeism. The extent to which physician-excused absenteeism and absenteeism not excused by a physician are related to employee reports of perceived stress is assessed. DESIGN: A plant wide survey was conducted in January 1990. Employee reports of occupational stress gained from this survey were linked with 1990 absenteeism data from the employees' records. SETTING: A mid-sized manufacturing plant. SAMPLE: Complete data were available for 998 of the 1534 (65%) unionized employees in the plant. MEASURES: Measures of both physician-excused absences and absences not excused by a physician were created. Stressors included role ambiguity, lack of control over work pace, and being paid on a piece-rate basis. Perceived stresses included role conflict, physical environment stresses, and overall work stress. RESULTS: For physician excused absenteeism, role conflict (OR, 1.54, p < .01), overall work stress (OR, 1.24, p < .05), and physical environment stress (OR, 1.34, p < .05) had significantly elevated odds ratios, even after adjusting for demographics. For absences not excused by a physician, none of the stressors or stresses had significant odds ratios after controlling for demographic characteristics. CONCLUSIONS: Employees in this plant were not using short-term voluntary absenteeism as a way of coping with work stress. However, high levels of perceived work stress were associated with subsequent physician-excused absences. PMID- 10160046 TI - Behavior change at the worksite: does social support make a difference? AB - PURPOSE: This study examines whether social support for behavior change at work is associated with changes in employee heart disease risk factors. DESIGN: A prospective correlational design was used with data sets collected 12 months apart. SETTING: Twenty-five small to medium worksites in Oregon. SUBJECTS. Participants were 689 men and 421 women volunteers who participated in two health assessments at the worksite on company time. MEASURES: Demographic characteristics, gender, social support, smoking behavior, dietary fat intake, and total blood cholesterol. RESULTS: Employees reporting strong social support at work for not smoking and for limiting dietary fat were less likely to smoke (r = -.11, odds ratio [OR] = .86) and to consume fat in their diets (r = -.10) at baseline. Employees who reported the most change in social support over a 12 month period were most likely to have stopped smoking (r = .15, OR = 1.31). Social support at baseline, however, was unrelated to change in smoking, dietary fat, or total blood cholesterol in a prospective design. Although women reported more social support at work than did men, no differential gender effects of social support were reported on heart disease risk status or change in risk status. CONCLUSION: Baseline social support at work did not predict future behavior change. The observed association between social support and lifestyle may be better explained as cognitive rationalization than by the impact of social support on behavior. PMID- 10160047 TI - A comparison of Omaha worksite health promotion activities to the 1992 national survey with a special perspective on program intervention. AB - PURPOSE: The purpose of this study was to compare the results from a survey of Omaha worksite health promotion activities with the results of a 1992 national survey. Comparisons were made on: (1) the kinds of health promotion activities offered, (2) progress toward the Healthy People 2000 worksite objectives, (3) types of program intervention offered, and (4) administrative factors. DESIGN: A one-time, written, mail-out/mail-back survey design was used. SETTING: The study took place in Omaha, Nebraska. SUBJECTS: All area public and private worksites with 250 or more employees were sent surveys. Individuals who were preselected and identified as the best qualified within the company completed the survey instrument. Of the 176 worksites surveyed, 86 completed the survey (49%). MEASURES: Descriptive statistics (percentages) were used to compare the two surveys on kinds of programs offered, progress toward Healthy People 2000 related to worksite health promotion, the types of program intervention offered, and administrative factors. RESULTS: Generally, a greater percentage of respondent worksites from the national survey are offering more health promotion activities and have made more progress toward the Healthy People 2000 worksite objectives than the Omaha worksites. Results from both surveys showed that low levels of intervention are more prevalent than high levels of intervention, and that health promotion activities in most worksites are coordinated by human resources departments and not by someone professionally prepared in health education. CONCLUSIONS: Traditionally, major goals of worksite health promotion programs have focused on important organizational outcomes such as improved productivity/morale, reduction in absenteeism, and health care cost-containment. It is important to recognize, however, that low levels of intervention have less impact than more intensive programs on these desired outcomes. Future goals for local and national worksite health promotion programs may need to encourage implementation of more intensive intervention programs. PMID- 10160048 TI - Characteristics of health promotion programs in Federal worksites: findings from the Federal Employee Worksite Project. AB - PURPOSE: To describe how well-established health promotion programs at selected federal worksites were designed, organized, and implemented and to identify factors related to employee participation. DESIGN: This descriptive study related characteristics of the health promotion program, worksites, and workforce to employee participation and perceptions of program impacts. SETTING: The study was conducted at 10 established federal worksite health promotion programs in various regions of the country. SUBJECTS: A total of 3403 of 5757 federal employees (59%) sampled completed employee surveys. MEASURES: Study data were collected from on site observations, interviews, focus groups, and employee surveys. RESULTS: Overall, program participation rates were high, and employees reported positive impacts on their health and attitudes toward the agency. Participation in health screening, perceived program convenience, and perceived support by management and others were important determinants of participation and of perceived work-related outcomes. CONCLUSIONS: Although site selection and response rate limit generalizability, the sites evaluated represent a broad cross-section of different types and sizes of agencies. The findings should be relevant in many other settings. Study programs compare favorably with private sector programs. Employees viewed the programs very positively. The most cogent challenge in justifying these, and perhaps other, worksite programs is that most participants already or simultaneously engage in health promotion activities elsewhere "on their own." PMID- 10160049 TI - Comparison of maternal absenteeism and infant illness rates among breast-feeding and formula-feeding women in two corporations. AB - PURPOSE: A comparison was made between breast-feeding and formula-feeding among employed mothers. Absenteeism directly related to child care was examined. DESIGN: This quasi-experimental study followed convenience samples of breast feeding and formula-feeding mothers until their infants were weaned or reached 1 year of age. SETTING: Two corporations with established lactation programs were used. One had approximately 100 births annually among 2400 female employees, and the other had approximately 30 births annually among 1200 female employees. SUBJECTS: A sample of 101 participants, 59 feeding breast milk and 42 using commercial formula, was composed of employees returning from maternity leave for a medically uncomplicated birth. INTERVENTION: The programs provided counseling by a lactation professional for all participants and facilities to collect and store breast milk. MEASURES: Confidential participant diaries provided descriptive data on infant illnesses and related absenteeism that the lactation consultant verified with health care providers and through employer attendance records. ANALYSIS: Attribute counts of illnesses and absenteeism were reported as percentages. Single degree of freedom chi square tests were used to compare rates between nutrition groups. RESULTS: Approximately 28% of the infants in the study had no illnesses; 86% of these were breast-fed and 14% were formula-fed. When illnesses occurred, 25% of all 1-day maternal absences were among breast-fed babies and 75% were among the formula-fed group. CONCLUSIONS: In this study fewer and less severe infant illnesses and less maternal absenteeism was found in the breast-feeding group. This was not an experimental study. Participants were self selected, and a comparison group was used rather than a true control group. Corroboration of these findings from larger experimental studies is needed to generalize beyond these groups. PMID- 10160050 TI - Correlates of high-fat/low-nutrient-dense snack consumption among adolescents: results from two national health surveys. PMID- 10160051 TI - A survey of health promotion programs in U.S. and Canadian medical schools. AB - The results of the survey indicate that 55 of 142 schools currently offer a health promotion/well-being program for their students. A total of 11 programs have been added since a similar survey was conducted in 1988. A diversity of program components that could be individualized to the needs of each student were offered, as can be seen in Table 1. Eight different components were offered in more than 50% of the schools, with support groups and substance abuse services being offered in 74.5% of the schools. It is noteworthy that health promotion/well-being programs are only offered at about 20% of medical schools for interns/residents and faculty/staff, although it is possible that they might participate in other programs. It should be pointed out that in more than 95% of the schools, physical/medical and psychologic services were offered; however, specific programs designed to prevent substance and alcohol abuse were only offered in about 54% of the programs. PMID- 10160052 TI - Psychosocial factors associated with fruit and vegetable consumption. AB - PURPOSE: This study examined the relationship between various psychosocial factors and fruit and vegetable consumption. DESIGN: The 5 A Day Baseline Survey, conducted in August 1991, just before the initiation of the 5 A Day for Better Health Program, obtained data on adults' intakes of, and their knowledge, perceptions, and attitudes regarding, fruits and vegetables. SETTING: The survey was conducted by telephone. SUBJECTS: Subjects were 2811 adults (response rate, 43%) aged 18 years and older in the 48 coterminous United States. MEASURES: Fruit and vegetable intake was measured as self-reported frequency of use; most of the psychosocial variables were measured using Likert scales. RESULTS: This study estimates that only 8% of American adults thought that five or more servings of fruits and vegetables were needed for good health. Of the factors studied, the most important in determining someone's fruit and vegetable intake were the number of servings they thought they should have in a day, whether they liked the taste, and whether they had been in the habit of eating many fruits and vegetables since childhood. These few factors accounted for 15% more of the variation in fruit and vegetable consumption than did demographic variables alone (8%). CONCLUSIONS: Nutrition education should stress the need to eat five or more servings of fruits and vegetables per day because few adults are aware of this recommendation and such knowledge is strongly associated with increased intake. Furthermore, efforts to increase the palatability of fruits and vegetables, especially among children, should be promoted. PMID- 10160053 TI - The U.S. Pharmacopeia's role in establishing public standards for aerosols. AB - USP, a non-governmental and not-for-profit organization, establishes public standards for and information on articles used in the healing art through an elected body of Committee of Revision comprised of scientific experts in the fields of medicine, pharmacy, pharmaceutical chemistry, analytical chemistry, and others. To be consistent with latest developments in manufacturing and analytical technologies, USP has a continuous revision policy. Major revisions to the General Chapter on Aerosols officially adopted recently that include detailed descriptions of multi-stage cascade impactor apparatus, two different single stage impaction devises used in particle size of determination, uniformity of assage units, minimum fill and other tests are discussed. Further revisions to the chapter on Aerosols under consideration such as test procedure for nebulizers, extractables and particulate matter are discussed. PMID- 10160054 TI - MDIs: physics of aerosol formation. AB - The aerosol clouds produced by metered dose inhalers are very dynamic and dramatic changes in both droplet size and velocity take place within the first few centimeters of the spray plume. It is the interaction of this dynamic cloud with the geometry of the mouth and oropharynx that controls the extent of oral deposition and hence the ability of the MDI to deliver a respiratory therapeutic to the lung. Oral deposition is controlled by inertial mechanisms and in order to develop meaningful in-vitro test methods consideration must be given to both the velocity and droplet size distribution of the cloud. The correct design of the inlet ports used to convey MDI clouds in aerosol sizing instruments is therefore crucial to the development of successful in-vitro methodologies. The use of large sampling chambers or the characterization of residual aerosol droplets is unlikely to produce meaning product comparisons or satisfactory product control data. PMID- 10160055 TI - The physico-chemical basis of radiolabelling metered dose inhalers with 99mTc. AB - Over the past decade, a number of different approaches have been proposed for the radiolabelling of metered dose inhalers (MDIs) in order to permit gamma scintigraphic imaging of emitted aerosols following inhaled administration. More recently, methods have been described for the indirect 99mTc-labelling of drugs incorporated into commercial MDI products. This paper attempts to rationalise such methods from a surface chemical perspective in order to: I) elucidate the mechanism of association of the radiolabel and drug; 2) predict the appropriateness of the techniques to all MDI products and; 3) propose in vitro testing methods to validate the labelling efficiency prior to in vivo evaluation. PMID- 10160056 TI - Pharmaceutical evaluation of new drug submissions for metered-dose inhalers- Canadian style. AB - New proposals for the testing of dose delivery from metered-dose inhalers (MDI's) are discussed. Data are presented to show that overdosing may be a problem the first time an inhaler is used. Delivery of amounts of drug in excess of 2-3 times the label claim was observed for the first spray in one product. The problem was less severe for a second product but was still present. Dose delivery problems remain after initial use of the MDI's studied but underdosing was observed. The severity of the problem depends on the product and on a number of factors, including valve orientation during periods of inactivity and whether an unprimed or a primed spray is examined. Testing protocols and requirements that would be appropriate during product development and for quality control are discussed. PMID- 10160057 TI - Characteristics of radiolabelled versus unlabelled inhaler formulations. AB - The total and regional deposition patterns of aerosols released from pressurized metered dose inhalers (MDIs) may be determined by gamma scintigraphy. Owing to difficulties in chemically labelling drug molecules themselves, the formulation may be radiolabelled with a suitable gamma-ray-emitting radionuclide (usually 99mTc). Validation measurements must then be performed to check that the drug formulation has not been altered significantly by the radiolabelling process and that the radiolabel acts as an adequate marker for the drug across the full range of particle sizes. These radiolabelling techniques have proved widely applicable, not only to pressurized MDIs, but also to dry powder formulations. PMID- 10160058 TI - In vitro measurements of delivery of medications from MDIs and spacer devices. PMID- 10160059 TI - Scintigraphic techniques for measuring in vivo deposition. PMID- 10160060 TI - Factors in measurement of dose by gamma scintigraphy. PMID- 10160061 TI - In vivo measurements of aerosol dose and distribution: clinical relevance. AB - Mathematical and in vitro models, that incorporate particle diameter, normal breathing frequencies and tidal volumes, have been used to predict the deposition fraction of respirable aerosols within the lungs. Although very useful in drug development, determinations of dose and the distribution of dose based solely on such models may be less accurate than in vivo measurements, which are performed under conditions that combine the effects of all the factors that determine aerosol deposition, including the effect of disease. Gammascintigraphy provides a method for in vivo quantification of the total deposited fraction and the distribution of the dose within the lower respiratory tract. Using this technology, it has been shown that deposition fraction in the lower respiratory tract may vary between 1-30% of the dose actuated from an MDI or nebulizer. This wide range in deposited dose suggests that variations in the clinical response to inhaled aerosols may be explained by alterations in the dose delivered, especially if the aerosolized medication has a narrow therapeutic range. Alterations in the distribution of inhaled drugs within the lungs may also affect the clinical response, such that some disorders may best be treated by targeting drug to specific locations of the lung, while others may respond best to homogeneous distribution of aerosolized drug. In vivo measurements would provide confirmation of the dose deposited as well as the pattern of distribution, which should improve the therapeutic outcome of most aerosolized medications. PMID- 10160062 TI - The pulmonary deposition of two aerosol preparations of nedocromil sodium delivered by MDI assessed by single photon emission computed tomography. AB - The pulmonary deposition and pharmacokinetics of fine and coarse radioactive aerosols of nedocromil sodium, of mass median aerodynamic diameters 16 microns and 24 microns respectively, delivered by metered dose inhaler (MDI) have been investigated. The corresponding geometric standard deviations of the particle size distributions were 5.32 and 3.93. Pulmonary deposition was assessed by both planar radionuclide scintigraphy and multi-modality three dimensional imaging using single photon emission computed tomography (SPECT) and x-ray computed tomography (CT). The three dimensional data were analysed by transformation to a hemispherical shape based on the fractional radial distance of each point in the lung from the centre to the corresponding extrapolated point on the periphery. This enabled parameters on the variation of both concentration of deposition and total amount deposited with penetration distance to be calculated. For both planar and SPECT data the central to peripheral concentration ratio (C/P ratio) was calculated. The three dimensional C/P ratio showed a median value (3.21) which was significantly higher than for the planar imaging (2.03) (p < 0.001). The parameter used to express the variation of total amount deposited was the median dose position. This showed that for both aerosols 50% of the dose was deposited at sites with a percentage central to peripheral distance of greater than 68%. There was a trend for total percentage of the fine aerosol in the lungs to be higher than for the coarse and for its deposition to be more peripheral. In addition the mean concentrations in blood were measured to be greater for the fine aerosol. However these differences were relatively small and none were individually statistically significant. The technique of combined SPECT and CT imaging was shown to be valuable in obtaining more accurate information on pulmonary distribution of inhaled aerosol deposition. The merits, limitations and potential applications of the technique are discussed. PMID- 10160063 TI - Laser hazard evaluation method for middle infrared laser systems. AB - Hazard evaluation methods for lasers, with wavelengths greater than 1.4 microns (mostly in the middle infrared), have changed significantly in the current version of the American National Standard for the Safe Use of Lasers, ANSI Z136.1 1993. A correct evaluation involves comparing the hazard potential based on two evaluation models; one based on individual pulses and the other based on an equivalent continuous-wave exposure. An example of the hazard evaluation method within this spectral region is provided. PMID- 10160064 TI - A strategy to promote the rational use of laboratory tests. IFCC Education and Management Division Committee on Rational Laboratory Use. International Federation of Clinical Chemistry. AB - The following guidelines suggest ways in which clinical chemists can promote rational laboratory use by critically evaluating the tests they offer. This may be done by documenting the clinical uses and limitations of tests in the same way that clearly written method descriptions outline analytical procedures in a particular laboratory. This information can then be disseminated on result report forms, during discussion, or through investigational protocols or clinical guidelines. For the information to be of value, it should be the result of clinical and laboratory input reflecting the local practice and facilities. The material should be clearly written, easily accessible to the users, and updated whenever there is a change in methodology or clinical practice. Much can be achieved by applying common sense to common knowledge, and laboratories of all sizes can prepare their own material. In addition, national scientific societies and other professional organizations can assist local endeavors by providing educational material on test evaluation, selection, and use. PMID- 10160065 TI - Laboratory cost management. AB - Laboratory cost management deals with the economical use of laboratory resources such as capital, equipment and manpower. Cost analysis is a tool for cost management, by means of which the laboratory manager can properly set priorities, choose appropriate test procedures, set personnel policies and make better investments of his resources. This article sets out some important aspects of cost analysis, such as the construction of cost curves, the factors that enter into cost analysis, the context in which cost analysis is used, and the limitations of this type of analysis. PMID- 10160066 TI - The Australian health care system. AB - Medicare is Australia's universal system of health insurance, which is based on the principles of equity. It provides free accommodation and treatment in public hospitals and entitlement to medical services. Laboratories receive reimbursement from Medicare if they are accredited. Hospital funding may be directly funded, whereas in some States the funding is through structures such as Health Areas. There are increasing moves to determine the hospital share of funding based on the number and types of hospital cases. To lower the cost of Medicare, the Federal Government is considering reforms including those which will allow private health insurers to negotiate with doctors and hospitals. Some of the major issues facing the health care system are: (1) how best to deliver care to Aboriginal Australians, (2) overspending, particularly in high-technology medicine, and (3) provision of health care for the small but significant number of Australians who do not live in major metropolitan centers. PMID- 10160067 TI - Accurate placement of central venous catheters using a 16-cm catheter. AB - We determine if use of 16-cm central venous catheters (CVC) minimizes dangerous intracardiac catheter placements. We conducted a prospective study in a large community teaching hospital. Consecutive patients (n = 127) who required a CVC via either the internal jugular (IJV) or the subclavian vein (SCV) were assessed using 16 (n = 102) or 20-cm (n = 25) catheters. The main outcome measurements were (1) intracardiac placement of central venous catheters, and (2) relationship of right- or left-sided internal jugular or subclavian vein insertions to intracardiac catheter placement. Use of a 20-cm CVC resulted in 14 of 25 (56%) intracardiac placements compared with 11 of 102 (11%) using a 16-cm catheter (p < 0.0001). All intracardiac placements with the 16-cm CVC were from right-sided approaches: IJV 7 of 38 (16%), SCV 4 of 18 (18%). Use of a 16-cm CVC to access the central circulation from either the SCV or the IJV results in a significantly greater proportion of safe catheter placements than using longer CVCs, and it should become the standard of care. PMID- 10160068 TI - Mechanical circulatory assist devices. AB - A ventricular assist device (VAD) is a heterotopic mechanical pump that augments or replaces the output of a failing ventricle. In the past decade, investigation and use of these devices has greatly improved our understanding of their potential roles and limitations. Successful univentricular and biventricular support has allowed for myocardial recovery and survival in several settings of intractable cardiogenic shock. The development of long-term VADs has allowed for successful bridging of patients to heart transplantation, and it has laid the groundwork for a permanent implantable replacement ventricle. In this review, we address indications, complications, management, and results of mechanical support in postcardiotomy, bridge to recovery, and bridge to transplantation settings. The tools to achieve ventricular support in the United States, and the VADs themselves, are described, with emphasis on unique features, indications, and limitations. PMID- 10160069 TI - Cardiogenic shock: thrombolysis or angioplasty? AB - Cardiogenic shock (CGS) occurs in 3 to 20% of patients presenting with acute myocardial infarction (MI), and it generally involves dysfunction of at least 40% of the total myocardial mass. Prior to the advent of balloon angioplasty and thrombolysis, in-hospital mortality was greater than 75%. This mortality rate has been consistent in reported series despite the advent of cardiac intensive care units, vasopressor, inotropic, and vasodilator therapy. Intra-aortic balloon counterpulsation therapy provides hemodynamic improvement, and it may provide some mortality benefit when used in conjunction with appropriate revascularization. Survival studies have shown that patency of the infarct related artery is a strong predictor of survival. No randomized trials have been completed to examine which reperfusion therapy best treats this emergent situation. Subgroup analysis of large scale, multicenter trials, although underpowered, has shown no improvement in mortality with use of thrombolytic agents, leading many to advise use of mechanical intervention. In patients who present with acute MI with contraindications to thrombolysis, primary angioplasty is the treatment of choice. At selected centers, primary angioplasty is comparable to or better than thrombolytic therapy for patients presenting with acute MI, with or without CGS. Studies examining angioplasty in patients with CGS have shown high procedural success rates (75%) and reduced in-hospital mortality (44%), particularly in those patients with successful revascularization. Emergency bypass surgery may improve survival, but it is costly, unavailable to many, and often leads to excessive delays in therapy. If available, we believe that primary angioplasty is the treatment of choice for patients with CGS. PMID- 10160070 TI - Peripherally inserted central catheters in the intensive care unit. AB - We report the success rate and complications of peripherally inserted central catheters (PICCs) in patients hospitalized in an intensive care unit (ICU). We performed a cohort study in the ICU of a large tertiary care, university affiliated community hospital. All ICU patients for whom their attending physicians requested a PICC service consultation were included. Main outcome measurements included (1) the success rate for initial PICC placement, (2) the placement complication rate, and (3) the overall success and complication rate. Of the 91 consecutive attempts at PICC placement, 89 (97.8%) were successful: of the 89 successful placements, 25 (28%) required cutdown procedures. There were 20 complications of initial placement and 8 delayed complications, which occurred in 19 PICCs. Complications included recatheterization after first attempt was unsuccessful (10), catheter malposition (7), palpitations or catheter clotting (3 each), heavy bleeding or mechanical phlebitis (2 each), and arterial puncture (1). The overall success rate for completion of therapy using the PICC was 74.7%. The most frequent reasons for failure to complete therapy were catheter dislodgment in 8 patients and "infection" in 9 patients. Of these 9 patients with "infections," 8 catheters were discontinued due to potential infection, and only 1 was removed due to confirmed infection. The confirmed infection rate was 6/10,000 patient days. The PICC appears to be a reasonable alternative to other approaches to peripheral and central venous access. The initial and overall success rates from this preliminary study justify further evaluation of the PICC in critically ill patients. PMID- 10160071 TI - Cost-effectiveness guidelines. The experience of Australian manufacturers. PMID- 10160072 TI - The economics of orphan drug policy in the US. Can the legislation be improved? AB - This review of the US Orphan Drug Act (ODA) 1983 outlines how the ODA is intended to stimulate orphan drug research and development of drugs for rare diseases. We also evaluate the effectiveness of the ODA in the past decade and provide recommendations for ODA improvements in the future. The economic incentives embedded in the ODA are presented in a simple economic model, in which a guarantee of market exclusivity plays a central role in encouraging firms to pursue the development of orphan products. Some evidence suggests that this provision has been a major impetus for the rise in orphan drug applications and designations in the last decade. Market exclusivity is the key incentive for orphan drug research, and should be retained. Concerns about a limited number of highly successful 'blockbuster' orphan drugs should be evaluated in terms of the useful economic incentives. In the future, exceptionally high profits could be limited by more precise evaluation of disease prevalence, elasticity of demand, and the other uses of orphan compounds. We further recommend an expansion of the ODA tax credits and research grants programme and targeting of 'priority' diseases. We conclude that the ODA has been a valuable legislative initiative, but it can be strengthened with some simple extensions of the current incentives that it contains. PMID- 10160074 TI - The economic effects of introducing vigabatrin, a new antiepileptic medication. AB - Epilepsy is a common disorder, the prevalence of which is estimated at between 0.1 and 1% of the population. Although there are a number of medications available for treating the disorder, 20 to 35% of affected individuals are resistant to standard treatments. Many of these patients could benefit from a new anti-epileptic, vigabatrin. Because the current indication for vigabatrin is as an adjunct in a specific subgroup of epileptic patients, which implies an increased cost of drug therapy, an ex ante economic appraisal of the expected consequences of its introduction in the treatment of epilepsy is valuable. This would provide decision makers with information to complement standard clinical data. Using administrative records of healthcare services utilisation by epileptic patients, we performed a simulation of the expected economic repercussions of vigabatrin use on direct costs related to disease management. The results show that whether or not the introduction of vigabatrin results in an increase or a reduction in costs to the healthcare system depends largely on 3 factors: (i) the administered dosage of vigabatrin; (ii) the effect that vigabatrin has on hospital admissions; and (iii) the proportion of epileptic patients who take the drug. Moreover, this study underlines the usefulness of administrative data in forecasting the economic impact of new health technologies. PMID- 10160073 TI - Cost effectiveness of antituberculosis interventions. AB - The treatment of tuberculosis (TB) is ranked as the most cost effective of all therapeutic programmes in terms of cost per year of life saved. Nevertheless, TB kills or debilitates more adults aged between 15 and 59 years than any other disease in the world; furthermore, about 2 to 4% of the burden of disease, 7% of all deaths and 26% of all preventable deaths are directly attributable to TB. About one-third of the world's population is infected with the TB bacillus. In the developing world, more women of childbearing age die from TB than from causes directly associated with pregnancy and childbirth. The death of adults in their prime, who are parents, community leaders and producers in most societies, causes a particularly onerous burden besides being a serious public health problem. In the poorest countries, where the magnitude of the TB problem is greatest, those TB control strategies that are economically feasible tend to be less effective. Therefore, in low and middle income countries, cost-effectiveness considerations aimed at prioritising resource allocation in the health sector in general, and in TB control programmes in particular, are of paramount importance. Operationally, the main components of a TB control programme are: (i) detection and treatment of TB; and (ii) prevention of TB through BCG vaccination and chemoprophylaxis. Priority should be given to ensuring that TB patients complete their prescribed course of chemotherapy. Adequate treatment is the most effective way of preventing the spread of TB and the emergence of drug resistance. This article reviews evidence of the effectiveness and cost effectiveness of different approaches to TB care, particularly those that are applicable to low income countries, in both HIV-infected and noninfected patients. Financial implications and ways to implement directly observed therapy for TB in large urban areas are discussed, and the need to address some relevant operational issues is highlighted. The current role of chemoprophylaxis and BCG vaccination is also reviewed. PMID- 10160076 TI - Recycling patients' own medication: Reducing wastage and drug costs. PMID- 10160075 TI - The cost effectiveness of Helicobacter pylori eradication versus maintenance and episodic treatment in duodenal ulcer patients in Sweden. AB - This study compares the cost effectiveness of Helicobacter pylori eradication and conventional treatment in duodenal ulcer patients treated by a general practitioner. Using a Markov chain approach, Swedish cost data and a study period of 5 years, we conclude that H. pylori eradication with omeprazole and appropriate antibiotics is a cost-effective alternative compared with both maintenance and episodic treatment. Of the patients entering the eradication strategy, most are cured and will have no relapse during a 5-year period. H. pylori eradication results in higher initial costs but, because of a very low risk of recurrence after successful eradication, the expected future costs are reduced. The investment pays off within 1 year when compared with maintenance treatment, and within 3 years when compared with episodic treatment. PMID- 10160077 TI - The effect of competition on drug prices. PMID- 10160078 TI - Economic and quality-of-life impact of NSAIDs in rheumatoid arthritis: A conceptual framework and selected literature review. AB - In this review, we provide a conceptual framework of the ideal pharmacoeconomic model for nonsteroidal anti-inflammatory drug (NSAID) use in rheumatoid arthritis, together with a review of selected literature focusing on those areas identified in our model. An ideal pharmacoeconomic model fully accounts for the benefits and costs of this therapy. The benefits include: decreased pain and swelling; increased functional status, which may in turn lead to increased earnings potential; and decreased use of adjunctive therapies. The costs include costs for drug acquisition and administration, monitoring and treatment for adverse effects, as well as preventive measures. Noneconomic 'costs' (i.e. losses in quality of life and/or functional status) must also be included in this equation. Our literature review led to the following conclusions. NSAIDs are highly effective agents for the control of musculoskeletal pain and inflammation, and as such are among the most widely used drugs worldwide. It is well recognised that marked improvements in quality of life occur among arthritic patients receiving NSAIDs. Although careful patient selection and monitoring for potential adverse effects is essential, these drugs are well tolerated by most patients. NSAID-induced gastrointestinal events, ranging from dyspepsia to severe complications that can lead to hospitalisation, surgery and death, are reported more commonly than adverse effects from any other class of drugs. These events represent a substantial economic burden to society and have well documented negative effects on quality of life. Although misoprostol (a prostaglandin analogue) prevents the development of clinically defined NSAID-associated ulcers, its effectiveness on clinically important outcomes such as haemorrhage and perforation is somewhat more modest. Furthermore, there is evidence that some patients may experience substantial losses in quality of life because of the adverse effects of medication (particularly diarrhoea). Therefore, the widespread use of misoprostol prophylaxis not only has important economic consequences, but has important consequences for quality of life. More research is needed to address the critical trade-offs between cost and quality of life that are inherent in the use of NSAIDs. PMID- 10160080 TI - Selective versus nonselective beta adrenoceptor antagonists in hypertension. AB - The application of cost-effectiveness methodology is particularly important in widespread diseases such as hypertension. However, because prospective cost effectiveness analyses comparing different antihypertensive drugs are not currently available, differences in the cost effectiveness of these drugs can only be estimated. The purpose of this review is to estimate and compare the costs of drug therapy with selective and nonselective beta adrenoceptor antagonists in hypertension. The global costs of antihypertensive treatment are largely determined by drug costs. In most countries, drug costs do not appear to vary substantially between beta 1-selective and nonselective beta-blockers. The adverse sequelae of hypertension include stroke, myocardial infarction, cardiac hypertrophy and renal failure. There are no obvious differences in effect on stroke and cardiac hypertrophy between beta 1-selective and nonselective beta blockers. However, compared with beta 1-selective antagonists, nonselective drugs might be less effective in preventing myocardial infarction in smokers and may impair renal function in patients with both increased peripheral resistance and declining cardiac output. There is a clear difference between beta 1-selective and nonselective beta-blockers on quality-of-life (QOL) perception. During treatment with nonselective beta-blockers, QOL perception is lower than during treatment with beta 1-selective drugs. Preservation of quality of life during long term antihypertensive treatment deserves considerable weight in economic analyses. Consequently, the more favourable effects of beta 1-selective agents on quality of life may outweigh the possible higher costs of these drugs, and suggest that beta 1-selective agents may be more cost effective than nonselective beta-blockers. PMID- 10160081 TI - Modelling the cost effectiveness of antidepressant treatment in primary care. AB - The aim of this study was to estimate the cost effectiveness of nefazodone compared with imipramine or fluoxetine in treating women with major depressive disorder. Clinical decision analysis and a Markov state-transition model were used to estimate the lifetime health outcomes and medical costs of 3 antidepressant treatments. The model, which represents ideal primary care practice, compares treatment with nefazodone to treatment with either imipramine or fluoxetine. The economic analysis was based on the healthcare system of the Canadian province of Ontario, and considered only direct medical costs. Health outcomes were expressed as quality-adjusted life years (QALYs) and costs were in 1993 Canadian dollars ($Can; $Can1 = $US0.75, September 1995). Incremental cost utility ratios were calculated comparing the relative lifetime discounted medical costs and QALYs associated with nefazodone with those of imipramine or fluoxetine. Data for constructing the model and estimating necessary parameters were derived from the medical literature, clinical trial data, and physician judgement. Data included information on: Ontario primary care physicians' clinical management of major depression; medical resource use and costs; probabilities of recurrence of depression; suicide rates; compliance rates; and health utilities. Estimates of utilities for depression-related hypothetical health states were obtained from patients with major depression (n = 70). Medical costs and QALYs were discounted to present value using a 5% rate. Sensitivity analyses tested the assumptions of the model by varying the discount rate, depression recurrence rates, compliance rates, and the duration of the model. The base case analysis found that nefazodone treatment costs $Can1447 less per patient than imipramine treatment (discounted lifetime medical costs were $Can50,664 vs $Can52,111) and increases the number of QALYs by 0.72 (13.90 vs 13.18). Nefazodone treatment costs $Can14 less than fluoxetine treatment (estimated discounted lifetime medical costs were $Can50,664 vs $Can50,678) and produces slightly more QALYs (13.90 vs 13.79). In the sensitivity analyses, the cost-effectiveness ratios comparing nefazodone with imipramine ranged from cost saving to $Can17,326 per QALY gained. The cost-effectiveness ratios comparing nefazodone with fluoxetine ranged from cost saving to $Can7327 per QALY gained. The model was most sensitive to assumptions about treatment compliance rates and recurrence rates. The findings suggest that nefazodone may be a cost-effective treatment for major depression compared with imipramine or fluoxetine. The basic findings and conclusions do not change even after modifying model parameters within reasonable ranges. PMID- 10160082 TI - An assessment of the hidden and total antibiotic costs of four parenteral cephalosporins. AB - The aim of this study was to compare the hidden costs, and their impact on total antibiotic costs, of ceftriaxone therapy with those of cefotaxime, ceftazidime and cefuroxime in nosocomial infection. The total antibiotic costs of 7-day standard courses of the 4 cephalosporins were compared. The costs were divided into 3 parts: (i) the cost of the drug itself; (ii) the preparation and administration (labour) costs; and (iii) the consumables and waste costs. The latter 2 costs together comprised the hidden cost of an antibiotic course. Hidden costs were higher for cefotaxime, ceftazidime and cefuroxime, which are normally administered 3 times a day, than for ceftriaxone, which is administered once daily. The percentage contribution of hidden costs to total antibiotic costs increased with decreasing antibiotic cost, and were lower with higher dosages of all antibiotics. With cefotaxime, ceftazidime and cefuroxime, and with ceftriaxone at the lower dosage given by bolus intravenous (IV) injection, the labour component of hidden costs exceeded the consumables/waste component. However, when costs were calculated for ceftriaxone administered at the higher dosage by IV infusion, the costs of consumables and waste were greater than the labour costs. Ceftriaxone had the lowest hidden costs of all the antibiotics studied. The total antibiotic cost of low dosage ceftriaxone (1 g per dose) was comparable with that of cefuroxime, and was substantially less than the costs of cefotaxime and ceftazidime. At the high ceftriaxone dosage (2g per dose), the total antibiotic cost of cefuroxime was less than that of ceftriaxone; however, the total antibiotic cost of ceftriaxone remained substantially less than that of cefotaxime or ceftazidime. PMID- 10160079 TI - Formulary management of macrolide antibiotics. AB - Selection of macrolide antibiotics for formulary addition can be a difficult task, with the increasing availability of new agents as well as the numerous differences in pharmacokinetic and pharmacodynamic properties of available agents. Nonetheless, appropriate evaluation of the important characteristics of macrolide antibiotics should allow selection of the most cost-effective agents for formulary addition. Most importantly, differences in antimicrobial activity and efficacy, product formulation, tolerability and cost should be carefully considered when making formulary decisions. Notably, evidence from in vitro studies and clinical trials indicate differences between the macrolide antibiotics, especially in the management of a variety of opportunistic infections in immunocompromised patients. For selected clinical situations, it may be important to select an effective agent available in both oral and intravenous formulations, especially in severe pneumonia caused by Legionella spp. In addition, the availability of generic formulations should be considered for its potential to reduce cost. Comparative drug costs, as well as costs associated with noncompliance, should also be evaluated carefully. Dosage regimens should also be considered, as shorter durations of therapy and less frequent dose administration may lead to increased compliance and thereby improved effectiveness and economic efficiency. PMID- 10160083 TI - Noncompliance with antihypertensive therapy. Economic consequences. PMID- 10160084 TI - A review of the quality-of-life aspects of urinary urge incontinence. AB - Urinary incontinence (UI) is prevalent and costly, occurring in 15 to 30% of the US population over the age of 60 years. Among people aged 15 to 64 years, UI occurs in 1.5 to 5% of men and 10 to 25% of women. Severe incontinence occurs in 6% of the general US population, and it is estimated that $US10 billion per year is spent in direct costs alone on care for these patients. This review presents a description of the various types of UI and describes the prevalence and costs of the condition. In addition, 3 approaches to assessing the impact of UI on quality of life are discussed, namely generic measures, disease-specific measures and qualitative approaches. We also review papers on UI and sexual functioning, UI in men, and some aspects of treatment. The review was conducted in the process of developing a new disease-specific measure for urinary urge incontinence (UUI). In general, the literature suggests that UUI has a greater impact than stress incontinence on quality of life, and that UI affects social and psychological functioning more than physical functioning. Only in a minority of individuals is the impact of UI disabling; however, most individuals with UI show significant reduction in their social functioning. Several studies suggest that the impact of UI is not solely a function of its severity, but also depends on individual coping abilities. Some studies also indicate that the social problems associated with UI grow with time, but it is not clear if that is a function of increasing severity of the condition, or the particular adaptations required for coping with this problem. An important distinction appears to be the ability of individuals to avoid public notice of their condition because of uncontrolled accidents. In summary, there is a need for a new measure of the quality-of-life impact of UUI that is based on the literature and on in-depth interviews with patients. PMID- 10160086 TI - Formulary management of drugs for cancer-associated hypercalcaemia. AB - Hypercalcaemia associated with cancer is seen not infrequently in hospital practice and can be a source of considerable morbidity. Over the past decade, our understanding of the pathogenesis of this syndrome has advanced, allowing improved treatment protocols. Because one of the principal abnormalities relates to an increase in bone resorption, antiresorptive agents such as calcitonin and the bisphosphonates have been shown to be of value. In the medium to longer term, the bisphosphonates -particularly pamidronic acid[pamidronate;aminohydroxypropylidene bisphosphonate (APD)] and clodronic acid [clodronate; dichloromethyl bisphosphonate (Cl2MDP)]? appear to be more efficacious in terms of their calcium-lowering effect than calcitonin, and also appear to be associated with fewer adverse effects than most other agents. However, the importance of energetic re-expansion of the extracellular space with 0.9% sodium chloride before bisphosphonate therapy is extremely important. Cancer associated hypercalcaemia, especially with squamous cancer, is often associated with the production of parathyroid hormone-related protein (PTHrP). Where this is the case, it usually reflects the presence of more advanced disease with shortened life expectancy, and poorer response to calcium-lowering therapy. Multiple treatments with larger doses of bisphosphonate may be required for these patients. PMID- 10160087 TI - Economic evaluation of vaccination against influenza in New Zealand. AB - The objective of this study was to evaluate the costs and benefits of influenza vaccination for the population aged 65 years and over, from the perspectives of individuals and health insurers, government and society. The annual incremental direct medical costs and benefits of influenza vaccination (compared with the nonvaccination, or 'do nothing', option) were evaluated using New Zealand healthcare resource usage and unit cost data [in 1992 New Zealand dollars ($NZ); $NZ1 = $US0.5458, June 1992] applied to cohort studies reported in the literature. The costs and benefits to society as a result of vaccination of people aged 65 years and older (20% of people in this age group are currently vaccinated) were estimated to be: (i) additional direct medical costs of vaccination of $NZ1.42 million [$NZ17.78 per vaccination]; (ii) direct medical costs avoided of $NZ5.35 million ($NZ67.18 per vaccination); and (iii) net benefits of $NZ3.93 million ($NZ49.40 per vaccination). The direct medical costs avoided per dollar cost of vaccination were $NZ1.04 for individuals, $NZ4.69 for government and $NZ3.78 for society as a whole. If the vaccination uptake for this group is increased in 20% increments, the net benefit to society increases by a further $NZ3.93 million per year at each step. If the economic evaluation is extended to include vaccination of at-risk individuals under 65 years of age, net benefits to society increase by 15%. Influenza vaccination for people aged 65 years and over is cost effective from the perspective of society, government and the individual. If the vaccination rate for at-risk individuals in New Zealand could be increased to 60%, the net benefits reported in this study would increase by 200%. However, the costs of promotion and education to achieve this vaccination rate would need to be deducted from the net benefits. Strategies to increase the vaccination rate include altering the cost of vaccinations to the individual, intensifying education and promotion programmes, and changing the mode of delivery. PMID- 10160085 TI - Costs of insulin-dependent diabetes mellitus. AB - Insulin-dependent diabetes mellitus (IDDM) is a prevalent chronic disease that causes marked personal and financial costs for patients, their families and society. Accurate information on costs of the disease is scarce. In this article, we review studies on disease and disease stage-connected costs at the individual and societal levels, and discuss possibilities of decreasing or preventing costs attributable to IDDM. The 3 disease stages are the initial treatment, follow-up after the initial treatment and late treatment. Total costs of IDDM in a given country depend on the incidence of the disease and the efficiency (cost effectiveness) of treatment. Besides everyday treatment costs, the acute and long term complications of the disease cause major additional costs. The lifetime financial costs of IDDM and the amount of human suffering are always substantial. The costs of the 3 clinical stages of IDDM differ markedly. The initial and late periods induce cost peaks, but the costs of follow-up after initial treatment are small. During initial treatment, costs depend mostly on the possible length of hospitalisation. During the late treatment period, costs begin to accumulate rapidly because of long term complications such as diabetic nephropathy, retinopathy, neuropathy and macrovascular disease. Intensive ambulatory care, effective patient education that results in normoglycaemia or near-normoglycaemia in patients and, if needed, shortening of hospitalisations, are the only means to restrict or decrease the costs of IDDM until primary prevention is available. Postponing complications by any length of time will always decrease human suffering and lead to marked savings in healthcare resources. PMID- 10160088 TI - Switching the histamine H2 receptor antagonist famotidine to nonprescription status in Canada. An economic evaluation. AB - The aim of this study was to compare the direct medical costs associated with the treatment of patients with heartburn/nonulcer dyspepsia under 2 scenarios: (i) no nonprescription histamine H2 receptor antagonist (H2RA) is available (the 'status quo scenario'); and (ii) the H2RA famotidine (at a daily dosage of 10mg) is available over-the-counter (OTC) at retail pharmacies (the 'OTC scenario'). We employed a decision analysis model over a 16-week period that considered direct medical costs from 2 alternative perspectives: (i) society, including the cost of self-medication borne by patients; and (ii) a provincial third-party payer for healthcare. Data concerning direct medical costs associated with consumer self medication and physician prescription of medication (including pharmacist dispensing fees), tests and procedures, and consultations with general practitioners and specialists were drawn from a clinician panel, published unit costs, and special surveys of institutional databases. All costs are reported in 1993 Canadian dollars ($Can; $Can1 = $US0.72, October 1995). From a societal perspective, the expected cost per patient over a 16-week period is not substantially different between the status quo and the OTC scenarios ($Can98 and $Can96, respectively). From a provincial third-party payer perspective, the expected costs per patient for the same scenarios are $Can95 and $Can89, a saving of $Can6 per patient. These results are sensitive to the proportion of patients who initially choose to see their physician rather than self-medicate, and the percentage of patients achieving successful treatment of symptoms. Changes in the rate or the cost of nonprescription medication, tests/procedures and physician visits do not affect the relative cost rankings. The total number of physician visits remained constant in both scenarios. From the societal cost perspective, the availability of famotidine in nonprescription form yields total costs that are similar to the status quo. However, from the perspective of the provincial payer, the expected costs per patient are likely to be slightly lower than the status quo if famotidine is available in unrestricted OTC scenario use. To generate significant savings to provincial payers, the number of people choosing immediate physician contact would have to be reduced, although not substantially, in the OTC scenario. PMID- 10160089 TI - The role of public opinion in drug resource allocation decisions. AB - Drug resource allocation decisions have a very real and direct impact on the public, due to cost and availability constraints resulting from these decisions. This presents an opportunity for public opinion to play an important role in influencing decisions that have far-reaching effects. Public opinion regarding pharmaceutical issues is influenced by drug companies, special interest groups, researchers and others. Since these groups often have conflicting goals, they may send contradictory messages to the public. In this article, we examine the issues of who comprises the public, how public opinion is influenced and what impact public opinion does and should have on drug resource allocation decisions. We emphasise that, for appropriate resource allocation decisions to be made, there is a continuing need to conduct high quality outcomes research and to continue the trend of increasing interest in how drugs are used rather than how much is sold or how much they cost. There is also a major role for pharmacoeconomic research to play in this issue, with a real need to make such research accessible and understandable by the public, including patients, physicians, pharmacists and policy makers, so that policy decisions can be based on such research. PMID- 10160090 TI - The decision rules of cost-effectiveness analysis. AB - It has become increasingly popular to carry out cost-effectiveness analyses in economic evaluations of healthcare programmes. Cost-effectiveness analysis is based on the maximisation of the health effects for a given amount of resources. However, many published studies fail to report the results of cost-effectiveness analysis in a way that is consistent with this underlying aim. The aim of this article is to demonstrate the decision rules of cost-effectiveness analysis in an easily accessible way for practitioners in the field. A hypothetical example is used to demonstrate the decision rules of cost-effectiveness analysis, and we also show how to estimate the appropriate incremental cost-effectiveness ratios and how to exclude dominated alternatives. It is then shown how fixed budgets or predetermined prices per effectiveness unit can be used as decision rules to maximise health effects and to determine which programmes to implement on the basis of incremental cost-effectiveness ratios. We hope that the article will contribute towards an increased understanding and application of the appropriate decision rules of cost-effectiveness analysis, so that the results of cost effectiveness analyses can be interpreted meaningfully by decision makers. PMID- 10160091 TI - The Prescription Drug User Fee Act of 1992. A 5-year experiment for industry and the FDA. AB - The Prescription Drug User Fee Act of 1992 authorises the US Food and Drug Administration (FDA) to collect in excess of $US332 million in user fee revenues over a 5-year period. Not only did Congress determine that the revenues would be dedicated to expediting the FDA's review of human drug applications, the FDA articulated formidable time-specific performance goals to be achieved by fiscal year 1997. At the mid-point in the 5-year programme, the FDA reported that it had met or exceeded its performance goals. In this article, we review the history of the user fee scheme in the US, outline the details of the legislative provisions, and discuss the challenges confronting the agency as it works to simultaneously meet the user fee goals and respond to political forces calling for substantive FDA reform. User fees loom large for the global pharmaceutical and biotechnology industries as economic pressures force a number of countries to consider shifting a portion of the cost of regulatory review to the regulated industry. This article provides a reference on the US framework and may be useful in future international comparisons as the user fee phenomenon spreads. PMID- 10160093 TI - Economic evaluation of an educational campaign for early diagnosis of cutaneous melanoma. AB - Public educational campaigns for the early diagnosis of cutaneous melanoma are considered an effective approach in the prevention of this disease, since they increase the number of cases detected early and consequently lengthen patients' life expectancy. We performed an economic evaluation of such a campaign in Bergamo, Italy, in order to quantify its costs and consequences. We used cost effectiveness analysis to compare the costs and effects of the campaign with those of the 'do nothing' option. The analysis was performed from the perspective of the Italian National Health Service [the Servizio Sanitario Nazionale (SSN)]. Accordingly, only direct costs related to publicly financed healthcare services were considered. No indirect costs or benefits were considered because they are not relevant to the SSN. Incremental analysis was used to obtain results in terms of additional costs per life-year saved (LYS). Overall LYS were quantified by comparing the survival curves for 4 subgroups of patients with different lesional thicknesses at diagnosis ( < 0.76mm, 0.76 to 1.50mm, 1.51 to 3.00mm and > 3.00mm). All costs were estimated in 1993 Italian lire (L). Overall effectiveness amounted to 233.49 LYS. Using a 5% discount rate, the value of effectiveness was 171.3 LYS. The total cost of the educational campaign (i.e. the sum of the organisational and 'induced' costs minus the costs saved) was estimated at L817 million (approximate 1993 exchange rate $US1 = L1573), and L905 million after discounting at a rate of 5%. Thus, using discounted cost and effectiveness data, the cost of the educational campaign was L5.28 million per LYS. PMID- 10160092 TI - Clinical issues related to the costs of alcoholism. AB - Alcohol (ethanol) use disorders are prevalent in many countries and are associated with significant social and health costs. Little is known, however, about the comparative cost effectiveness of treatments for alcoholism. Pharmacoeconomic evaluations are largely (if not wholly) absent from the alcoholism treatment outcome database. We discuss pharmacological approaches to the treatment of alcohol withdrawal and dependence, describing agents that ameliorate withdrawal symptoms, deter alcohol consumption, reduce alcohol craving and produce conditioned alcohol aversion. Cost-relevant clinical considerations are elucidated and recommendations for cost-conscious pharmacological treatment of alcohol dependence are proffered. PMID- 10160094 TI - Heart failure. A decision analytic analysis of New Zealand data using the published results of the SOLVD Treatment Trial. Studies of Left Ventricular Dysfunction. AB - This study sought to evaluate the changes in direct medical costs and life-years gained or lost by adding enalapril to conventional treatment (digoxin and diuretics) for heart failure (HF). The published results of the Studies of Left Ventricular Dysfunction (SOLVD) Treatment Trial, and a decision analytical model developed by the University of Pennsylvania, were used in combination with New Zealand data to undertake the evaluation. All costs were measured in 1993 New Zealand dollars ($NZ) [$NZ1 = $US0.5509, September 1993]. Potential net cost savings per patient treated over a 4-year period were $NZ652 together with an additional 2 months of life gained. If these individual potential cost savings are extended to the New Zealand population who have HF (but are at present not receiving an ACE inhibitor) then $NZ6 517 000 in discounted health sector costs could be avoided. The model was sensitive to changes in the price of enalapril, to estimates of the population with HF, the percentage of the population with HF treated with enalapril, and to hospital unit costs for nonfatal cases of HF. The study demonstrated that the addition of enalapril to the conventional treatment of HF was cost effective when compared with conventional medical therapy alone. PMID- 10160095 TI - Timing and timeliness in medical care evaluation. PMID- 10160096 TI - The pharmacoeconomics of ACE inhibitors in chronic heart failure. AB - Because heart failure is common and disabling, patients with this condition utilise healthcare resources to a considerable extent. In particular, patients with heart failure frequently require hospital admission, and inpatient care is often protracted. Patients with the most advanced stages of heart failure make the greatest demands on the healthcare system. Expenditure related to the consumption of healthcare resources accounts for the 1 to 2% of total healthcare spending related to heart failure. Between two-thirds and three-quarters of this is due to the costs of hospital care. ACE inhibitors reduce progression of heart failure and also reduce the need for hospitalisation by approximately 30%. In so doing, these drugs substantially or totally offset their cost and the cost of extended life. Five independent economic analyses collectively show ACE inhibitors, at worst, to be very cost effective (in comparison to other cardiovascular therapies), cost neutral or to lead to overall cost savings when used to treat heart failure. PMID- 10160097 TI - Outcomes assessment of drug treatment in multiple sclerosis clinical trials. AB - The purpose of this review is to evaluate the clinical outcomes of drug therapy in the treatment of multiple sclerosis (MS) in those studies which purported to include an assessment of quality of life. Pharmacological management of MS is primarily directed towards control of symptoms and prevention of disease progression or relapse. Although there are many drug and nondrug approaches used in the treatment of MS, this review focuses largely on approaches that incorporate some method of clinical outcome assessment. To aid in the interpretation of the data presented, a short descriptive summary of these assessment methods has been included. Although most studies incorporate at least one clinical outcome measure into the evaluation of efficacy, only one study has examined the economic impact of intervention in MS. The authors of that study demonstrated good correlation between the level of disability assessed using conventional quality-of-life measures and associated healthcare costs. Surprisingly, although many treatment approaches used in MS have significant associated toxicity and only modest benefits in terms of disease control, there is a remarkable paucity of data on the impact of these treatments on patients' quality of life. Studies that incorporate pharmacoeconomic and health-related quality-of-life consequences related to the treatment of MS are required. PMID- 10160099 TI - Direct costs of osteoporosis for New Zealand women. AB - The burden of illness of osteoporosis in New Zealand is substantial. Prevalence estimates based on international research suggest that up to 30% of postmenopausal women may have osteoporosis. The projected increase in population of women aged >or= 60 years suggests that the burden of illness associated with osteoporosis will escalate. Currently, cost estimates in New Zealand for specific procedures are severely limited by the absence of a comprehensive, nationwide, case-mix system of costing. In this analysis, first-year total direct costs of hospitalisation, recovery and residential care associated with osteoporotic hip fractures, assuming an annual incidence of 1537.63 such fractures in New Zealand women aged > or = 60 years, were estimated at $NZ41,684,460 [1995 dollars ($NZ1 = $US0.65 in 1995)]. Second-year costs were $NZ24,952,895. The combined total over 2 years post-hip fracture was estimated to be $NZ66,637,355. Annual non-hip fracture costs for women aged > or = 45 years were estimated at $NZ4 401 248. Pharmacotherapy data for the treatment of osteoporosis indicate that the societal costs of treating the diagnosed condition for men and women in New Zealand are $NZ3 385 590 per year (1995 dollars). PMID- 10160100 TI - Drug use in relation to clinical activities as an instrument for prospective drug budgeting. The Belgian experience. AB - In an effort to control escalating health expenditures, especially in hospitals, many countries are planning or experimenting with prospective budgeting systems. Belgium is no exception and has recently introduced, with some success, limited fixed charges per hospital admission and/or per hospitalisation day for laboratory tests and radiographic investigations. More recently, the focus has shifted to hospital drug expenditures, which have shown high growth rates over the past few years. Until now, such expenditures have been reimbursed on a fee for-service system, often with limited out-of-pocket charges for hospitalised patients. In order to curb the growth of drug expenditures, it is appropriate to investigate whether the financing of hospital drugs through a prospective budgeting system could be a feasible solution. Therefore, we constructed a database of over 270 000 admissions from a sample of 23 Belgian general and teaching (university) hospitals for the year 1991. Data were obtained from the official Minimum Basic Data Set or Resume Clinique Minimum, which contains summarised clinical and administrative information, plus detailed expenditures (including medications) for each hospital stay. This information allowed us to categorize each stay into an appropriate diagnosis-related group (DRG). Our first descriptive analysis identified a number of major variables that influenced patients' drug expenditures: all-patient DRG (APDRG), age, disease severity, length of stay in an intensive care unit, emergency admission, death during hospitalisation, and hospital type (teaching or general). A covariance analysis was then performed on all hospital stays combined, and separately on surgical and medical stays. The results indicated that these variables taken together account for between 56.5 and 76.3% of drug expenditures in medical and surgical stays, respectively, with the major variance explained by differences in APDRG category. However, when the data were disaggregated according to major diagnosis category, a large degree of heterogeneity in the explained variance was observed. In patients with drug use- and alcohol-related disorders, 5.2% of drug billings/expenditures were attributable to the APDRG, and the corresponding figure in patients undergoing circulatory system surgery was 84%. This means that, if DRGs are used to define a global prospective drug budget for a hospital, using the hospital's historical case mix as a weighting factor, we should pay particular attention to the hospital profile because the predictive power of such a system could be relatively low in some hospitals. Consequently, we need to construct larger confidence intervals for hospitals in which historical drug expenditures have low predictive power, or search for additional explanatory variables for expenditures in these hospitals. PMID- 10160098 TI - Cost-effective policies for cervical cancer screening. An international review. AB - Screening programmes for cervical cancer have been credited with reducing the incidence of and mortality from cervical cancer. The main components of these screening programmes are: (i) their level of organisation; (ii) the age at which women begin screening; (iii) the age at which women discontinue screening; (iv) the interval between repeat screens; (v) the frequency at which the programmes provide screening; and (vi) the response to an abnormal screening test. However, not all screening programmes are equally efficient and differences in programme components can result in big differences in their cost effectiveness. Studies that employ cost-effectiveness analysis (CEA) to examine the efficiency of different programme components can inform the development of cost-effective programmes. This article presents findings of an international review of cost effectiveness studies of cervical cancer screening. These studies consistently find that certain types of programmes are more cost effective than others. Programmes that are centrally organised and implemented by the public sector are reported to be more cost effective than those that use public funds for screening at other medical visits (convenience screening), or those that provide guidelines for healthcare professionals and the public to promote spontaneous discretionary screening. There is also substantial agreement about the cost effectiveness of other programme components. When multiple screenings are possible, studies report that they should generally begin at age 25 to 35 years and end at age 65 to 70 years, although it is important that older women have 3 normal Papanicolaou (Pap) smears before the discontinuation of screening. The interval for repeat screens that is reported to provide the best balance between cost and life-years saved is between 3 and 5 years. However, when a choice must be made between screening more women fewer times, or screening fewer women more times, most studies indicate that it is more cost effective to prioritize resources to obtain at least one screening for each woman. The screening of previously unscreened and high-risk populations has been shown to be especially cost effective. Despite this agreement, many studies report that models of the cost effectiveness of screening for cervical cancer are sensitive to a number of parameters. Changes in the attendance rate of the programme, the quality of the Pap smear, and the cost of the Pap smear can markedly change the cost effectiveness of a screening programme. Finally, this review discusses different perspectives of social choice analysis (e.g. CEA and cost-benefit analysis), when the objective is to prevent cervical cancer and the options are to screen, detect and treat, to reduce behavioural risk factors, and/or to pursue promising biological research. PMID- 10160101 TI - A strategy for collecting pharmacoeconomic data during phase II/III clinical trials. AB - This article presents an overview of the process and organisational aspects required to support the collection of pharmacoeconomic (PE) data during phase II and phase III clinical trials of pharmaceutical products. The process described requires early involvement of the PE study team in clinical trials design and planning, as well as continuing close collaboration between the PE study team and the clinical study team as the data collection plans are implemented. Adequate resources must be made available for staffing and funding the PE component of data collection and analysis. If the suggested procedures are adequately resourced and implemented, the result should be a comprehensive, complete and accurate database that will allow the PE study team to characterise the economic value of the new drug at the same time as the clinical study team characterise its safety and efficacy. Integrated clinical and economic evaluations are essential for the appropriate use of pharmaceutical products in rapidly changing markets. PMID- 10160102 TI - Cost considerations in the drug treatment of hypertension. Is older better? PMID- 10160103 TI - Drug utilisation patterns in the Third World. AB - Drugs are not available to the majority of the population in developing countries. Aggravating factors include weak healthcare structure, inadequate financial resources, nonavailability of pharmaceuticals, lack of drug legislation and policy, ineffective drug utilisation and the prevalence of self-medication. Although most of the population lives in rural areas, available funds are mostly utilised for urban areas. The use of drugs by injection is common in developing countries. In addition, many patients self-medicate because most drugs are available without a prescription from a doctor. There is therefore a great need for prescriber education in rational drug use, and for public education in the use of commonly used drugs. National health and drug policies should be formulated which incorporate the essential drug concept, and drug legislation needs to be revamped and implemented effectively. These measures may be helpful in providing better healthcare to the majority of the population in developing countries. PMID- 10160104 TI - Treatment of urinary tract infection. Clinical and economic considerations. AB - The epidemiology, clinical manifestations, natural history and management of urinary tract infection (UTI) are briefly reviewed as background to the economic considerations of diagnosis and treatment. Specific pharmacoeconomic analyses, such as cost-effectiveness and cost-benefit analyses, of UTI are not available. Analysis of the direct costs of diagnosis and treatment reveal that laboratory costs comprise the largest proportion, followed by physician consultation and pharmaceutical costs, respectively. Antimicrobial treatment has focused on acquisition cost without due regard to costs associated with method of delivery (especially with parenteral therapy), drug monitoring, complications, suboptimal therapy, drug wastage and waste disposal. These factors indicate a preference for ambulatory therapy using oral antimicrobials rather than institutional care using parenteral agents. Indirect costs, such as lost work time and quality-of-life factors, are not readily available. Evidence suggests that nosocomial UTIs add significantly to hospital costs. Studies citing the cost effectiveness of infection control programmes have often lacked detail and may have accrued benefits to the service without apportioning full costs. Future research directions include analysis of laboratory economics in relation to the clinical encounter, improved analysis of the utility and total costs of newer antimicrobials, quantifying home versus hospital treatment and improved costing of infection control programmes. PMID- 10160106 TI - Do physicians' perceptions of drug costs influence their prescribing? AB - This study examines general practitioner (GP) attitudes towards and knowledge of prescribing costs, and the influence of these 2 factors in the doctor's demand for drugs. The main emphasis of the study is on the influence of perceived cost of drugs on prescribing habits. A postal questionnaire was sent to all 273 GP principals in the Grampian region of Scotland. This questionnaire assessed GPs' attitudes and knowledge with respect to prescribing costs. Information was also collected on the prescribing habits of 176 of these GPs. This information was linked to look at the influence GPs' knowledge of drug costs has on their actual prescribing behaviour. Three drug groups were studied: ulcer-healing drugs, pain killers and penicillins. The results showed that although most GPs agreed that costs should be borne in mind when prescribing medicines, their actual knowledge of the drug costs was often inaccurate. Furthermore, for certain therapeutic groups, prescribing habits are influenced by GPs' perceptions of drug costs. This implies that GPs are not as averse to considering costs as is often assumed, and that giving GPs better information about drug costs might promote more rational prescribing. PMID- 10160105 TI - Clinical and economic factors in the treatment of onychomycosis. AB - Onychomycosis is a fungal infection of fingernails and toenails, most cases of which are caused by dermatophytes. The disease accounts for 15% of all nail disease, and affects approximately 2 to 3% of people of all ages and both sexes. Topical treatment with tioconazole, amorolfine or ciclopirox has limited effectiveness. Oral griseofulvin 500 to 1000mg daily has been the mainstay of treatment, but prolonged therapy is required and success rates are low. Therapy with itraconazole 200mg daily for 3 to 6 months is more effective (70 to 85% success), although so-called 'pulse' therapy has shown similar success with potentially fewer adverse effects. Terbinafine 250mg daily produces clinical and mycological cure in approximately 80% of patients treated for 6 and 12 weeks for fingernail and toenail infections, respectively. The overall costs of treating onychomycosis are substantial, and it has been estimated that direct costs for Medicare patients with the disease were $US43 million in 1 year. In addition, the disease has a negative impact on quality of life, in the domains of mental functioning, health concern, social functioning, and physical appearance. Few pharmacoeconomic analyses have been published, but all have indicated an advantage of oral terbinafine over griseofulvin and other oral agents. To date, no economic studies have been performed on topical agents, pulse therapy or combination treatments. PMID- 10160107 TI - The economic costs of caring for people with HIV infection and AIDS in England and Wales. AB - The objectives of this study were firstly to estimate total lifetime care costs for an individual with HIV/AIDS, and secondly to estimate the total costs of caring people with HIV infection and AIDS in England and Wales between 1992 and 1997 inclusive. Questionnaires and monthly diaries were used to collate data on healthcare utilisation from patients with HIV infection over a 6-month period. These data were then used to estimate the annual total direct costs of care (stratified by disease stage), total lifetime costs of care, and present and future total national care costs for England and Wales. Costing data were obtained from providers of services throughout Greater London. In total, 235 patients with HIV infection were recruited from 2 clinics in Greater London. All costs were calculated in 1992-93 pounds sterling (pound; 1 pound = $US1.58, December 1995). Annual care costs were estimated at 4515 pounds ($US7134) for a person with asymptomatic HIV disease, 8836 pounds ($US13,961) for a person with symptomatic non-AIDS and 15 268 pounds ($US24,123) for a person with AIDS. Lifetime care costs were estimated at 84,522 pounds ($US133,545) per patient. The total costs of care for England and Wales were forecast to increase from 116,627,400 pounds ($US184,271,300) in 1992 to 162,638,100 pounds ($US256,968,200) in 1997. In conclusion, our study further emphasises the continued shift in hospital services from the inpatient sector to the outpatient sector. The importance of community care and informal care, in terms of the associated direct economic costs, is also highlighted. This emphasises the need for close collaboration between different agencies and strategic coordination of services. Finally, the study forecasts an increase in care costs in England and Wales during the 1990s. PMID- 10160108 TI - The November 1995 revised Australian guidelines for the economic evaluation of pharmaceuticals. AB - In November 1995, the revised Australian Guidelines for the Economic Evaluation of Pharmaceuticals ('the Guidelines') were published. The new document is to be seen as a measured bureaucratic response to the perceived shortcomings of the August 1992 document. The new document sets substantially more demanding and more rigorous evidentiary standards in the reporting of randomised clinical trials and in the justification of the selected evaluation methodology. It also introduces the requirement for a trial- or efficacy-based preliminary economic evaluation, and it recognises the need, under certain circumstances, to model economic evaluations. Although this document has an immediate appeal to those coming to pharmacoeconomic evaluations from a clinical perspective, the approach taken is unlikely to appeal either to economists (the Guidelines continue to discourage cost-benefit analysis) or to health system evaluators working in a competitive delivery environment (such as the US). The Guidelines, in a US environment, would be seen as not only unreasonable in their evidentiary demands and in the task imposed on evaluators, but limited in their failure to take an explicit modeling or system approach to therapy intervention evaluations. PMID- 10160109 TI - Industry comment on the 1995 revised Australian pharmacoeconomic guidelines. PMID- 10160111 TI - Current principles and application of pharmacoeconomics. AB - Anti-infective drugs account for between 3 and 25% of all prescriptions, between 6 and 21% of the total market value of drugs in a single country, and up to 50% of the drug budget in hospitals. Not surprisingly, in an era when cost containment policies are at the top of the agenda, issues related to pharmaco economics of antibacterial treatment have assumed an important part in these policies. However, there are still some misunderstandings regarding the precise terminology and difference in methodology of pharmacoeconomics. The aim of this paper is to explain the genealogy of pharmacoeconomics and various methods currently used in the application of this young discipline to anti-infective treatment. PMID- 10160110 TI - Granisetron. A pharmacoeconomic evaluation of its use in the prophylaxis of chemotherapy-induced nausea and vomiting. AB - The efficacy of granisetron in preventing acute nausea and vomiting during the 24 hours following chemotherapy in patients with cancer is equivalent to that of other serotonin 5-HT3 receptor antagonists (ondansetron and tropisetron) and similar to or greater than that of conventional antiemetic regimens such as metoclopramide plus dexamethasone. Like other 5-HT3 receptor antagonists, granisetron is generally well tolerated by most patients and its antiemetic efficacy is enhanced when used concomitantly with dexamethasone. To date, pharmacoeconomic evaluations of granisetron have involved intravenous administration of the drug to adult patients with cancer receiving single-dose or fractionated chemotherapy of moderate to high emetogenic potential. In economic analyses conducted in France, a single dose of granisetron 3mg was associated with a mean direct treatment cost per patient (or per well-controlled patient) approximately 50% lower than that for ondansetron 8mg intravenously followed by 8mg orally every 8 hours for 3 days, in patients receiving single-dose chemotherapy. Direct costs per patient were approximately 20 to 30% lower with granisetron (usually 3 mg/day) than ondansetron (usually 24 to 32 mg/day intravenously) in patients receiving chemotherapy fractionated over several days. Sensitivity analysis showed that the results, were robust to variations in the acquisition costs of the antiemetics. Granisetron also remained more cost effective than ondansetron with variations in the antiemetic dosage regimens, except when the granisetron dosage remained unchanged while the ondansetron dosage was reduced to a single 8mg intravenous dose on each day prior to chemotherapy (and no change in efficacy was assumed). Other economic evaluations suggest that granisetron may be more cost effective than a combined antiemetic regimen of high dose metoclopramide plus dexamethasone, and selected use of granisetron or ondansetron in patients receiving emetogenic chemotherapy can be implemented with relatively small incremental increases to the total cancer treatment budget, albeit with a marked increase in antiemetic acquisition costs. In conclusion, granisetron is an effective and well tolerated agent for the prophylaxis of acute chemotherapy-induced nausea and vomiting, and its selective use in this clinical setting can provide cost-effective antiemetic therapy. PMID- 10160112 TI - Pharmacoeconomics and formulary decision making. AB - Pharmacoeconomic assessment of formulary actions has become increasingly common in local, national, and international formulary decision making. Tactics for managing medication use include formulary management and drug policies. Pharmacoeconomic data can provide support for these formulary decisions. For example, pharmacoeconomic data can support the inclusion or exclusion of a drug on or from the formulary and support practice guidelines that promote the most cost-effective or appropriate utilisation of pharmaceutical products. Various strategies can be used to incorporate pharmacoeconomics into formulary decision making. These include using published pharmacoeconomic studies and economic modelling techniques, and conducting local pharmacoeconomic research. Criteria for evaluating the pharmacoeconomic literature, suggestions for employing economic models, and suggested guidelines for conducting pharmacoeconomic projects are discussed. Although most formularies are viewed as cost-containment tools, formularies should not be a list of the 'cheapest' alternatives. Today's formulary should contain agents that optimise therapeutic outcomes while controlling cost. Pharmacoeconomic assessments of formulary decisions help to ensure that the agents promoted by our formularies yield the highest outcome per dollar spent. A discussion of the process for formulary action in a US hospital, the influence of pharmacoeconomics on US formularies, and strategies for incorporating pharmacoeconomics into formulary decision making are presented in this paper. PMID- 10160113 TI - Using pharmacoeconomics to assess the comparative value of antibacterials. A UK perspective. AB - In the UK there is increasing pressure on prescribers to contain drug costs, the only aspect of the healthcare budget about which information is readily accessible. However, this information is often incomplete, making choices between drugs difficult. By following a defined series of steps based on identification of clinical and practical differences between 2 drugs and an evaluation of the economic consequences of these differences, prescribers can use pharmacoeconomics to make difficult decisions regarding drug choices. In doing so, prescribers can ensure that the health service spends money to provide the maximum benefit for patients. PMID- 10160114 TI - Costs, innovation and efficiency in anti-infective therapy. AB - This paper provides an overview of issues related to the emerging discipline of pharmacoeconomics and its relationship to the outcomes movement. The focus is upon the evolving Management Care Organisation (MCO) and the demands placed upon the pharmaceutical industry as it attempts to provide new innovative anti infective treatments. Similarly, the challenge is to meet the ever increasing requirements for approval and reimbursement of new anti-infective pharmaceutical products. Outcomes research is playing an increasingly important role in such decisions throughout the world, including the United States. Unfortunately, most decisions and analysis at the national level and within MCOs regarding the adoption and utilisation of pharmaceuticals are rather unsophisticated in terms of the proper utilisation of pharmacoeconomic data. There is a prevalent need to better utilise this information to develop cost-effective disease and therapy intervention models and guidelines. Also, information on the application of pharmacoeconomics for the evaluation of pharmaceutical care services that enhance the cost effectiveness of drug therapy needs to be seriously considered. Specifically, this should include a consideration of the economic consequences of drug-related problems and the potential impact of pharmaceutical care on drug related morbidity/mortality associated with the treatment of infectious disease. PMID- 10160115 TI - The role of pharmacoeconomics in disease management. A pharmaceutical benefit management company perspective. AB - In the US, managed-care organisations (MCOs) have turned to pharmacy benefit management (PBM) companies to contain costs and provide total disease management packages. The demand for pharmacoeconomic research and information by purchasers of healthcare has contributed to the growth of PBM companies and to recent acquisitions by pharmaceutical manufacturers. PBMs influence prescribing via formulary management and drug utilisation review (DUR). Formularies are generally open, and pharmacoeconomic data contribute to formulary management decisions. Prospective and concurrent DURs used in hospitals can soon be integrated into community pharmacy, as PBMs obtain integrated online information about prescribing. PBM prescription databases are used as as educational tools for physicians, providing drug utilisation data, formulary compliance, generic prescribing rates, and guidelines for pharmacotherapy for particular conditions. They can also evaluate medication regimens for patients with particular problems such as drug-drug interactions. However, PBM databases typically lack patient diagnostic, outcome and medical claim data. PBMs will be better placed to move from medication management to disease management when they can obtain these data and link them appropriately to their own prescribing and physician databases. PMID- 10160116 TI - Choosing the right health care partners: lessons from Louisiana. PMID- 10160117 TI - Choosing your partners wisely. PMID- 10160118 TI - Demand-side management: characteristics of a successful self-care program. PMID- 10160121 TI - Using a database marketing strategy to successfully market managed care. PMID- 10160119 TI - Making the case for robust provider credentialing. PMID- 10160120 TI - Using uncredentialed network providers. PMID- 10160122 TI - A database to select and inventory services, measure value, and assist redesign. AB - The services of a three-hospital quality resource department (QRD) were redesigned over a 5-year period. The intention was to provide high-level database management services to improve hospital operations and ensure accountability for performance. There were three key components to the redesign efforts: planning, learning, and measuring performance. This article focuses on planning and measuring the QRD's service using a project registry database. PMID- 10160123 TI - Reengineering: a manager's survival guide. AB - Reengineering has become a fact of life for all professionals in the healthcare industry. It is a time of dynamic change and challenge. This article describes ways in which healthcare professionals can assess the situation, evaluate the environment, and actively participate and cope with changes--in other words, ways to "survive" the process of reengineering. PMID- 10160124 TI - The patient care process: a framework for change. AB - Healthcare organizations across the United States recognize that they must change the way in which they deliver case. As organizations reengineer to reduce costs and change the way in which services are delivered, it is critical that decisions about reengineering be communicated throughout the entire service-delivery enterprise. There must be a framework to provide a common ground for change. The process approach to delivering service provides the greatest opportunity for organizations to achieve their goals to facilitate care, achieve the best patient outcomes, and deliver services on time and at the right price. Processes that are built around core competencies and that address customer needs are the most successful. Organizations that adopt a common framework built around the delivery of patient care and the patient care process can establish a common frame of reference for the entire organization and therefore can enhance the delivery of service for their patients and achieve organization-wide commitment to common goals. PMID- 10160125 TI - Readers' forum: some commonly asked questions about reengineering. PMID- 10160126 TI - The human side of reengineering. AB - This article on the human side of reengineering describes the issues and concerns faced by healthcare executives who are considering or who already are involved in a reengineering project. It offers a practical approach to understanding issues such as the importance of assessing the culture and its readiness for change, the importance of human resource policy development prior to initiating a reengineering project, and how to ensure buy-in and support from the healthcare organization and its community. PMID- 10160127 TI - Managing reengineering implementation. AB - Reengineering provides the means to radically affect the way in which services are provided and results in significant change within an organization. Many reengineering efforts fail to deliver on their promises, however, because of poor implementation. This article reviews some key issues that organizations must address in order to manage the change effectively. PMID- 10160128 TI - The Safe Medical Devices Act: final regulations affecting user facilities. PMID- 10160129 TI - An operational model for malpractice claims interventions. PMID- 10160130 TI - Building risk management into integrated healthcare delivery systems. PMID- 10160131 TI - As others see us: physicians' perceptions of risk managers. PMID- 10160132 TI - Designing a self-administered professional liability claims program for self insured healthcare entities. PMID- 10160133 TI - Falls prevention study: a practical approach. PMID- 10160134 TI - Informed consent and managed care: has capitation re-written the rules? PMID- 10160135 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1997 rates--HCFA. Final rule. AB - We are revising the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes arising from our continuing experience with the systems. In addition, in the addendum to this final rule, we are describing changes in the amounts and factors necessary to determine prospective payment rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes are applicable to discharges occurring on or after October 1, 1996. We are also setting forth rate of-increase limits as well as policy changes for hospitals and hospital units excluded from the prospective payment systems. PMID- 10160136 TI - Medicare program: schedule of prospectively determined payment rates for skilled nursing facility inpatient routine service costs--HCFA. Final notice with comment period. AB - This final notice with comment period sets forth the schedule of payment rates for low Medicare volume skilled nursing facilities for prospective payments for routine service costs for Federal fiscal year 1997 (cost reporting periods beginning on or after October 1, 1996 and before October 1, 1997). Section 1888(d) of the Social Security Act requires the Secretary to establish and publish the prospectively determined payment rates 90 days prior to the beginning of the affected Federal fiscal year. PMID- 10160137 TI - Healthy gains posted since 1991 in primary care physicians' earnings. PMID- 10160138 TI - New employer guide designed to move prevention to the health care mainstream. PMID- 10160139 TI - What's in store for physicians who treat the elderly. PMID- 10160140 TI - 'Prenuptial' planning for your next managed care contract. PMID- 10160141 TI - When patients ask for backdated referrals. PMID- 10160142 TI - Get ready! Electronic prescriptions are coming. PMID- 10160143 TI - Don't flirt with fraud when delegating to support personnel. PMID- 10160144 TI - How and how much should physicians be paid? PMID- 10160145 TI - Next HMO quality hurdle: integrating medical and pharmacy data. PMID- 10160147 TI - Automation may be cost-cutting alternative. PMID- 10160146 TI - Case managers: take up the baton now to orchestrate automation. PMID- 10160148 TI - Better education means fewer readmissions. PMID- 10160149 TI - Skin flap path incorporates 30-day LOS for rehabilitation. PMID- 10160150 TI - Design an inner-hospital early warning system. PMID- 10160151 TI - Risk management. Meeting the operational challenges of home care. PMID- 10160152 TI - Putting together a risk management program for home care providers. AB - The need for risk management in home care has grown because of several factors- increased consumer awareness, advanced technology, and the loss of charitable immunity for health care organizations. A solid risk management program will prepare providers to meet these challenges with confidence. PMID- 10160153 TI - A basic risk management manual: a step in the "write" direction. AB - Written policies are central to successful risk management. The task of developing a risk management manual may seem overwhelming at first. To approach this task, agencies might start first with the most important aspects of risk management. PMID- 10160154 TI - The synergy of quality management & risk management in home care. AB - For a number of years the health care risk management industry has been addressing unplanned and unanticipated adverse events. Organizations that are proactive in their approach to risk and quality management will have big payoffs in clinical quality improvement, service quality improvement, employee satisfaction, and customer satisfaction. PMID- 10160155 TI - Organizational risk management: a case study. AB - Risk management models can provide not only decreased liability, but also quality improvement. One agency in New Jersey created a risk management model that helped them achieve both of these goals. PMID- 10160156 TI - Workers' compensation and liability exposures. PMID- 10160157 TI - Reducing risk from drug-abusing patients on home i.v. therapy. PMID- 10160158 TI - Getting the most out of life at John Knox Village. Interview by Lisa M. Marinik. PMID- 10160159 TI - The new work of the nonprofit board. AB - Too often, the board of a nonprofit organization is little more than a collection of high-powered people engaged in low-level activities. But that can change, the authors say, if trustees are willing to discover and take on the new work of the board. When they perform the new work, a board's members can significantly advance the institution's mission and long-term welfare. Doing the new work requires a board to engage in new practices. First, the board must go beyond rubber-stamping management's proposals and find out what issues really matter to the institution. It can do that by making the CEO paint the big picture of the organization's strategic concerns, by understanding key stakeholders, by consulting experts, and by deciding what needs to be measured in order to judge the institution's performance. Second, a board doing the new work must take action: the board must not only set policy but also work with management to implement it. Third, the board must go beyond strictly functional organization: the new work requires flexibility and encourages ad hoc arrangements. Finally, board meetings--where boards underperform most visibly--should be driven by goals, not by processes. The authors give many examples of boards that have successfully embraced the new work. The stakes are high: if boards demonstrate that they can change effectively, the professional staff at the institutions they serve just may follow suit. PMID- 10160160 TI - The use of the waiting list in a fair selection of patients for nursing home care. AB - When health care resources are scarce, waiting lists may be used as a distribution measure in order to enhance the fair allocation of resources through selection of patients. In this study, the structure and use of a waiting list for a fair selection of patients for nursing home admission was studied. Qualitative research took place in two regions in the Netherlands, where scarcity exists in nursing home care. Selection meetings were attended and 39 health care workers were interviewed. Not only did waiting list criteria like urgency and chronology determine the final selection decision, but also efficiency and quality of care considerations (patients' preferences for particular nursing homes and nursing homes' considerations of matching the unit and work load). These considerations, their relative importance, and the resulting need for enforcement of the decision making procedures, should be part of the discussion of patient selection. This acknowledges the complexity of the selection of patients. PMID- 10160161 TI - Reforming China's 50,000 township hospitals--effectiveness, challenges and opportunities. AB - The 50,000 publicly-owned Rural Township Hospitals (RTHs) in China play an important role in providing both curative and preventive services to China's 800 million rural population. Since the market oriented rural economic reform initiated in the early 1980s, the RTHs' position has been threatened by low efficiency and financial crisis. More than half of the RTH resources have been wasted and about one-third of the RTHs have run into deficit. Reforms have been undertaken, but the problems are still challenging. Several policy options are now being discussed including revolutionary strengthening of the RTHs to attract patients, leaving the RTHs as they are but guaranteeing the funds for prevention services, and strengthening the RTHs having relatively high efficiency. However the discussions have not been translated into national policies. The statistics for 1995 show that the RTHs are taking a turn for the better after a decade of continuous decline in both the number of visits and bed occupancy rates. These changes can be explained by the widespread government concerns with the development of RTHs, the incremental capacity-strengthening of RTHs, and government's efforts to construct a workable Cooperative Medical System (CMS). The authors recommend that the government should play a major and active role in regulating and financing the RTHs and CMS. Demand deflection through promoting CMS and repricing the RTH medical services at relatively low level is important, and government support to strengthen the RTHs is essential for maintaining the deflected demand. Neither of the two conditions can be ignored. Interventions should be made on both supply and demand side. PMID- 10160162 TI - Health care and income distribution in Finland. AB - This paper examines the effects of health care on income redistribution in Finland. In contrast to earlier studies in this area, the redistributive effect is analysed with noncash transfers from health care utilisation included in household income. Distributional consequences of changing health care financing towards one system or another are analysed in terms of municipality provided public services and sickness insurance based public services. Our results show that, overall, the public health care system distributed income from the rich to the poor. The poorest one-third of the population financed only about one-third of the public health care services they utilised. The distributional implications were, however, markedly different depending on the definition of income used. Whereas health care financing had only a marginal redistributive effect, the effect was substantially increased as noncash transfers from health care utilisation were taken into account. PMID- 10160163 TI - Economic analysis at the global level: a resource requirement model for HIV prevention in developing countries. AB - Agencies operating at the international level have a need for economic analysis to help develop global health policies and determine resource requirements to support their advocacy efforts. This paper presents work commissioned by the Global Programme on AIDS to estimate the total resource requirements of implementing a package of HIV prevention strategies in developing countries. The modelling approach identified a hypothetical package which should be implemented and developed a set of assumptions relating the size, number and coverage of programmes required for each strategy to a set of demographic and other characteristics of individual countries. Costs were attached to estimate the total costs of the package for individual countries, regions and the developing world. Results are presented for regions and their implications discussed. Conclusions are drawn on the value of this type of modelling approach to estimating resource requirements. PMID- 10160164 TI - Hip implant prices edge downward; hospitals intensify standardization push. PMID- 10160165 TI - Saving on sutures: a new perspective on one of the oldest surgical products. PMID- 10160166 TI - Like other industries, hospitals can cut costs by cutting lead times for delivery. PMID- 10160167 TI - Health care institutional planning for civil and criminal enforcement of environmental laws in the 1990s. PMID- 10160168 TI - Medical waste disposal: new technologies on the horizon. PMID- 10160169 TI - Maintaining confidentiality of environmental audits: legal protections. PMID- 10160170 TI - Implementing environmental compliance: the role of attorney-client privilege. AB - There are a number of important steps that a hospital can and should take to maximize confidentiality and privilege in the development of systems to implement environmental compliance. One of the most important steps is to become familiar with the attorney-client privilege and the important role of the privilege in the development of systems to implement environmental compliance. PMID- 10160171 TI - Antitrust issues facing multiprovider networks. PMID- 10160172 TI - Apparent agency: estoppel/detrimental reliance/proximate cause--an evolution from case law to statute. PMID- 10160173 TI - Environmental compliance for hospitals: a practical guide. PMID- 10160174 TI - Criminal prosecution of health care providers for clinical mistakes and fatal errors: is "bad medicine" a crime? PMID- 10160175 TI - Institutional review boards (IRBs) and reproductive medicine: guidelines for compliance. PMID- 10160176 TI - "Stark II" and state self-referral restrictions. PMID- 10160177 TI - Integration options. PMID- 10160178 TI - ERISA preemption of medical negligence claims against managed care providers: the search for an effective theory and an appropriate remedy. PMID- 10160179 TI - Avoiding antitrust pitfalls in the home health care industry. PMID- 10160180 TI - The nonprofit board's duty of loyalty in an 'integrated' world. PMID- 10160181 TI - Operation Restore Trust and the voluntary disclosure of health care fraud and abuse. PMID- 10160182 TI - A policy approach to sexual harassment in medicine. PMID- 10160183 TI - Over my dead body: recognizing property rights in corpses. PMID- 10160184 TI - Of chaos, Merlin and the future of medicine. AB - Chaos theory is a good way to describe what has taken place in the recent history of health care. A prevailing dynamic in nature is for seemingly small variations in an initial set of circumstances to cause very large variations in behavior. In health care, an innocuous policy made at some point in the system may have drastic effects on other parts. Merlin was the fabled wizard of King Arthur's court who was born in the future and lived backward through time, enabling him to foretell events. Similarly, medical practice administrators should envision the future they want for themselves and make the changes now that will result in that future. A methodology for accomplishing that is presented. PMID- 10160185 TI - Feasibility studies help provide roadmap for mergers. PMID- 10160186 TI - Commercial paper--not just for the Fortune 500. AB - The capital needs of medical practices are shifting from the traditional working capital, buildings and equipment to management information systems, practice acquisitions and integrated delivery systems. Among the capital options for physician groups is commercial paper. Generally backed by major New York City banks, commercial paper notes usually mature within 270 days of issue. They also usually return 1/4 percent to 3/4 percent above comparable Treasury bills. Often viewed as the province of large corporations with unquestionable credit ratings, commercial paper can be structured to provide medical group practices a flexible financing option enjoyed by major corporate borrowers. The commercial paper market may be the cheapest, most efficient wource of funding for some medical groups. PMID- 10160187 TI - Single specialty renaissance: the promise of disease management. AB - The conventional wisdom that all single-specialty providers outside of primary care will lose their ability to be significant contributors in the managed care marketplace is now being questioned. Subspecialty groups and single-specialty practices have the opportunity to reinventing themselves and offer their services with a disease management strategy. While groups have the opportunity to challenge the stasus quo, they must develop new ways of providing the services for which they are best qualified. The structures that can be utilized to implement this include group practice mergers, carve-out managed care networks, development of hospital relationships and fostering a relationship with a physician practice management company that focuses on their area of health care. PMID- 10160188 TI - Opportunities and issues for medical group practices. AB - For the second consecutive year, McManis Associates, a health care management consulting firm and subsidiary of MMI Companies Inc., held, in conjunction with the 1996 MGMA/AMA joint legislation conference, an executive forum for leaders of medical group practices for a discussion of some of the key trends and issues they are facing today. The forum included five group practice executives from a variety of organization types and situations, and was structured to encourage them to engage in a candid exchange about their own opinions and experiences. Discussion was facilitated by Gerald L. McManis, president of McManis Associates, Louis Pavia Jr., executive vice president, and F. Kenneth Ackerman Jr., FACMPE, principal associate. This article provides a summary of the forum proceedings, as well as some commentary by the authors, based on their experience in working with medical group practices around the country. PMID- 10160189 TI - Using financial ratios to assess physician practices. AB - Purchasing physician practices has become commonplace in the health care environment today. The most commonly used method to evaluate a physician's practice is the medical practice assessment. Although assessments include examining revenues, expenses, staffing ratios, collection ratios and other pertinent statistics, one of the often overlooked financial areas is the balance sheet. Evaluating a business, such as a medical practice, requires a thorough examination of the total financial picture including assets, liabilities, owner's equity or net worth, and the relationship of all the variables to each other. Ratios put the numbers into perspective by creating relationships between the balance sheet variables of assets, liabilities and owner's equity, and key income statement components of revenues, expenses and net income. As a result, ratios provide a unique perspective to the assessment process and enable a more complete analysis. This article examines the types and uses of ratios to assist physicians, managers, and hospital executives to better evaluate the financial viability of a physician's solo or group practice. PMID- 10160190 TI - Will an integrated medical delivery system deliver? PMID- 10160191 TI - Information systems drive health care into the 21st century. AB - Beyond the initial cost of upgrading and networking computer information systems, outcome measures are diminishing in cost as technological advances occur. Physicians, labs, pharmacies, teaching institutions, financial monitors, and administrative offices can be linked electronically to communicate and share information in real time. With the aid of electronic databases connected by satellite, health care systems of the future will rely on a seamless network of information sources, forming integrated delivery systems. Philosophical and control issues may always present challenges to establishing integrated delivery systems. But the advantages of an integrated delivery system, tied together by electronic management and clinical software, seem to far surpass the risks for both providers and insurers. This article explores the overwhelming benefit to physicians who wish to practice medicine with fewer of the traditional administrative burdens. PMID- 10160192 TI - Prevention of violence in the workplace. AB - Violence, crime and trauma at work cost employers millions of dollars annually in time lost and disability claims, poor customer service, crisis public relations, increased turnover and difficult lawsuits. The core problem of violence in the health care setting is that it is associated with the main purpose of the organization--providing a service to the public. Clearly the task of preventing violent incidents is integral to the business of managing a medical group practice. While there are no good statistics on the actual incidence of violence in the health care professions, more than ever before, health care providers are responding to the cumulative abuse they experience as "part of their job" with lingering psychological and physical reactions. A sad outcome is frequently witnessed when these same staff erupt in angry or aggressive behavior toward unsuspecting coworkers, supervisors, clients and even their own families. The author offers a systematic approach to assessing the risk of workplace violence, including practical methods for risk control and prevention. Additionally, understanding the potential hazards and associated costs of workplace violence, allows managers to take the appropriate measures to decrease risk to the work force and consequently to the organization. PMID- 10160193 TI - Practice guidelines 101. PMID- 10160194 TI - Slicing the pie. AB - Case rate contracts take the onus of dividing payment from the insurer and places it on the provider. There are a number of methods which can be used to respond to this challenge. One method which has a number of significant advantages is the floating conversion factor reimbursement method. It is based on a very simple concept, is transparent and delivers the market reality of the plan performance directly to participating physicians, without any convoluted calculations or cushions in between. A withhold can be added to this method, though it is unnecessary. A profit/loss sharing plan with the hospital can be helpful in completing the alignment of incentives. PMID- 10160195 TI - Surviving a CLIA inspection. PMID- 10160196 TI - Lab safety, Part 2. Safety in the lab: practices and predictions. AB - Precautions related to bloodborne pathogens, and the handling of specimens and waste are among the chief concerns of laboratorians today. Find out how your lab stacks up and how safety will impact tomorrow's lab workers in the conclusion to MLO's latest survey. PMID- 10160197 TI - Radiology needs training in quality improvement. PMID- 10160198 TI - Tailoring managed care to needs of individuals. PMID- 10160199 TI - The anatomy and physiology of the bronchial circulation. AB - The origin and distribution of the bronchial vasculature vary considerably between and among species both at the macro- and microvascular level. Bronchial vessels usually originate from the aorta or intercostal arteries, entering the lung at the hilum, branching at the mainstem bronchus to supply the lower trachea, extrapulmonary airways, and supporting structures; this fraction of the bronchial vasculature drains into the right heart via systemic veins. Bronchial vessels also supply the intrapulmonary airways as far as the level of the terminal bronchioles where they form extensive anastomoses with the pulmonary vasculature; this systemic-to-pulmonary blood drains via pulmonary veins to the left heart. Repeated arborization of the bronchial artery along the length of the tracheal bronchial tree results in a vast increase in the total surface area of the vascular bed. The tracheal bronchial vasculature consists of a continuous dense network of subepithelial capillaries that converge to form venules extending to a deeper plexus of larger venules and arterioles on the adventitial side of the smooth muscle. Innervation is under the control of vasodilatory parasympathetic nerves that release acetylcholine and vasoactive intestinal polypeptide; vasoconstrictor sympathetic nerves that release norepinephrine and neuropeptide Y; and sensory nerves that release substance P, neurokinin A, and calcitonin gene-related peptide, all of which are vasodilators. Mechanical factors such as the downstream pressure and alveolar pressure also influence the distribution of blood flow through the tracheal bronchial vasculature. PMID- 10160200 TI - Drug uptake in the trachea. AB - For hydrophilic drugs and agents the major barrier to diffusion from the airway lumen into the mucosa is the epithelium, but for lipophilic agents epithelial permeability is high. Destruction of the epithelium increases the permeability of hydrophilic but not lipophilic agents. Changes in mucosal blood flow, induced either by vasoactive drugs or by changing the rate of arterial perfusion, lead to changes in drug uptake from the lumen to venous blood. Increases in flow decrease uptake, and vice versa for decreases in flow. The most likely explanation of this apparently paradoxical result is that increases in vascular pressure and flow result in a greater interstitial liquid volume and thus perfusion barrier, and induce solvent drag across the vascular endothelial wall, which will limit uptake of agents into the vascular lumen. PMID- 10160201 TI - Liposomal aerosols in the management of pulmonary infections. AB - The combination of liposomes and aerosols has been utilized to directly target the lungs with chemotherapeutic agents that might not have been used because of low solubility or toxicity. There are a variety of antibacterials, antifungals, and antivirals that have good in vitro activity, but are not effective because of their systemic toxicity and/or poor penetration into the lungs. Incorporation of many lipophilic drugs into liposomes decreases their toxicity without affecting effectiveness, thus increasing the therapeutic index. We have focused on aerosol delivery of amphotericin B (ampB) for the treatment of pulmonary and systemic fungal diseases. We have tested a variety of ampB-lipid formulations for the optimal treatment regimen for Cryptococcus and Candida infections in mouse models. The AeroTech II nebulizer (MMADs of 1.8-2.2 microns) produced aerosols with the highest concentrations in the breathable range. Pharmacokinetic studies revealed that pulmonary drug was present for hours to weeks. AmBisome retained its anticryptococcal activity even when animals were challenged 14 days after aerosol treatment. Aerosols may also be effective in systemic diseases. In our Candida-mouse model, systemic candidiasis and mortality were reduced by aerosolized ampB-liposome treatment. The ability to utilize lipophilic drugs, to deliver high concentrations of drug directly to the site of infection, and to reduce toxicity makes aerosol liposomes an attractive, alternative route of administration. PMID- 10160202 TI - Therapeutic aerosols and airway secretions. AB - Despite common misconceptions, airway mucus is not an impermeable barrier that entraps and clears all inhaled material. To be therapeutically effective, an aerosol medication must efficiently deposit in the airway and then diffuse or translocate across the mucous barrier while retaining bioactivity. Characteristics of aerosols that affect their ability to penetrate the mucous barrier include particle charge, solubility, and size. Aerosol medications can also change the biophysical properties of secretions and influence how rapidly mucus is cleared. Surfactant is probably responsible for the displacement of inhaled particles through the mucous layer (Schurch et al., 1990). As well, exogenous surfactant has been shown to increase tracheal mucociliary clearance in anesthetized dogs (de Sanctis et al., 1994) and to improve the mucociliary clearability of secretions from babies with neonatal respiratory distress syndrome (Rubin et al., 1992). Using measurements of sputum-substrate contact angle and interfacial tension, cystic fibrosis (CF) sputum had been shown to have an abnormally high adhesion tension, (Girod et al., 1992). We assessed the in vitro effects of synthetic surfactant (Exosurf, Burroughs-Wellcome, Research Triangle Park, NC) on the physical and transport properties of sputum from 15 patients with CF and 30 patients with stable chronic bronchitis (CB). The concentration of ExosurfTM used was 13.5 mg of DPPC/ml corresponding to the reconstituted concentration for aerosol administration. The sputum was divided so that aliquots each were treated with Exosurf and amphibian Ringer's solution layered on the sputum at a concentration of 1:5 v/v for 15 min at 24 degrees C. There was a reduction in spinnability (p < 0.0001) in CF sputum from baseline and a fall in adhesion tension (0.05 < p < 0.1) with Exosurf treatment. Potentially important increases in both mucociliary and cough clearability were noted without associated changes in sputum rheology. In bronchitis sputum, surfactant reduced adhesiveness (p < 0.01), but this was not associated with improved clearability. Adhesive forces are involved in ciliary coupling and cough transport. This raises the possibility of using surfactant as a mucokinetic agent in the therapy of chronic suppurative lung disease. PMID- 10160203 TI - Asthma therapy with aerosols: clinical relevance for the next decade. AB - Inhaled therapy is the mainstay of modern asthma management, as this optimizes the therapeutic ratio. Short-acting beta 2-agonists are the most effective bronchodilators and when given by inhalation give rapid relief of symptoms, without adverse effects, although there are concerns about overuse of these drugs. Inhaled long-acting beta 2-agonists are useful in some patients. Inhaled anticholinergics are particularly useful in patients with COPD and in the future long-acting drugs, such as tiotropium bromide, will be available. Inhaled glucocorticoids are the most effective therapy in controlling chronic asthma symptoms, and systemic effects are not a problem in the vast majority of patients. Improved inhalation devices and steroids with reduced oral bioavailability have resulted in reduced systemic side effects, which now arise largely from absorption from the lungs. In the future it is likely that new classes of drug will be developed, but whether they will be used by inhalation or given by mouth will depend on the frequency of side effects and the mode of action of the drugs. There are likely to be several improvements in inhaler delivery systems, so that the inhaled route will remain predominant for many years to come. PMID- 10160204 TI - Surfactant: current and potential therapeutic application in infants and adults. AB - Exogenous surfactant administration is currently being evaluated for the Acute Respiratory Distress Syndrome (ARDS). Although surfactant supplementation is now a routine therapy for babies born with neonatal RDS, this treatment modality for adults does not appear to result in a predictable improvement in lung function as is noted in neonates. This article will review the basic abnormalities of the surfactant system in patients with ARDS and contrast them with the primary surfactant deficient state of nRDS. Various factors that have been shown to influence an individual's response to exogenous surfactant will the be outlined. Finally, potential treatment approaches for patients with ARDS utilizing exogenous surfactant will be proposed. PMID- 10160205 TI - Consensus on surfactant and inhaled nitric oxide for ARDS. AB - Adult respiratory distress syndrome (ARDS) remains a major problem in intensive care medicine. While the triggers are not well understood, the process often involves generalized neutrophil activation and sequestration in the lung which initiate inflammatory cascades. These effects can be localized to the pulmonary tissues as well as diffusely throughout the body. Should the latter occur, the patient presents with multiple organ failure (MOF). Attempts to interfere with this series of events have included replacement therapy for surfactant and its components because of observations that the natural surfactant mechanisms are impaired or damaged. The effectiveness of replacement therapy has been tested in various protocols involving synthetic composites and animal (bovine) surfactants. While major differences in protocol design have led to conflicting results, there appears to be evidence that installation of bovine surfactant can reduce mortality in ARDS. A major limitation in adult therapeutics utilizing surfactant is the method of delivery; direct instillation utilizes large quantities, thus limiting its availability. Aerosolized therapy may have promise if smaller amounts delivered by this modality are more effective. Inhaled nitric oxide may also have therapeutic potential in ARDS. By improving ventilation perfusion mismatch, ventilatory requirements can be reduced. PMID- 10160206 TI - Clinical perspectives: role of the airway circulation in drug therapy. AB - Theoretically, the airway circulation can regulate the absorption of inhaled drugs, redistribute inhaled drugs within the respiratory tract, and influence the distribution of systemic drugs to the airway. Some of these functions of the airway circulation have been verified experimentally, but not in human subjects. Since pharmacological manipulation of airway blood flow could have therapeutic implications in airway disease, the development of new methods to measure airway blood flow noninvasively in human subjects is needed. PMID- 10160207 TI - An approach to deposition and clearance measurements in human airways. AB - By using the aerosol bolus inhalation technique, aerosol particles can be delivered into the airways of the human respiratory tract. For that purpose the aerosol bolus is injected near the end of a clean air inhalation. It could be shown experimentally and theoretically that the particles were only deposited in the airways. Radioactive labeled particles were deposited with this technique and clearance from the airways was determined. It could be shown that the mucociliary clearance from the airways was particle size dependent. The clearance efficiency from the airways increased with increasing particle size. PMID- 10160208 TI - Particulate air pollution and daily mortality: who is at risk? AB - Major episodes of air pollution, such as the London fog incident in 1952, have shown conclusively that relatively high levels of particulate air pollution can lead to serious adverse health effects, including death. Recent data suggest that exposure to respirable particulates [with an aerodynamic diameter < or = 10 microns (PM10)] under the current American standard (150 micrograms/m3 for 24 h) is associated with increased daily mortality. These results have sparked an intense debate regarding the veracity of the reported associations and whether they should be interpreted causally. Most investigators have relied on a time series approach to investigate the short-term effects of air pollution on daily mortality. Concerns have been expressed that the results may vary with the type of statistical methods used and the potential for uncontrolled and residual confounding effects. Of perhaps greater importance is that cause-specific mortality, temporal aspects of the exposure-disease relationship, and subgroups of the population have not been studied adequately. Under the hypothesis that only persons with impaired physiologic systems should be at risk, the identification of susceptible subgroups is of great importance in discerning causal mechanisms and in setting public health policies. In this paper, the main methodologic issues are discussed and a novel design to identify at-risk subgroups is presented. PMID- 10160209 TI - Effect of add-on devices for aerosol drug delivery: deposition studies and clinical aspects. AB - Add-on devices for pressurised metered dose inhalers (MDIs) improve "targeting" of drug to the lungs and can correct for hand-breath dyscoordination. Measurements of drug delivery from add-on devices by gamma scintigraphy have shown that compared to an MDI, oropharyngeal deposition is always reduced, and that lung deposition is generally either increased or unchanged. The total body dose may be reduced by over 80%. Increases in lung deposition may not result in improved bronchodilator response if the top of the dose-response curve has been reached. Add-on devices with one-way valves and mouthpiece or mask may enable asthma to be controlled with a smaller delivered dose of drug than from an MDI, and have proved to be viable lower cost alternatives to the use of nebulizers for delivering high dose bronchodilators to patients with severe acute asthma, and steroids to chronic asthmatics. PMID- 10160210 TI - Aerosol clearance by the bronchial circulation. AB - The importance of the tracheobronchial circulation in supporting mucociliary clearance is unclear. In anesthetized, ventilated sheep (n = 8), mucociliary transport of 99mTc-labeled sulfur colloid particles (2.1 microns) was measured during control perfusion of the cannulated bronchial branch of the bronchoesophageal artery or when perfusion through this artery was stopped. Particle retention 60 min after aerosol delivery of particles averaged 55% during control bronchial blood flow conditions. When perfusion was stopped, average retention was significantly increased to 76% (p < 0.05). These results indicate that the bronchial vasculature exerts an important modulating influence on mucociliary transport. PMID- 10160211 TI - Aerosol delivery in infants and young children. AB - Despite extensive use of aerosol therapy to treat infants and young children with respiratory disease, our knowledge of factors influencing drug delivery in this age group remains relatively rudimentary. Recent work with filters used in conjunction with pumps or patients have emphasised some of the factors that will maximise the dose inhaled using different devices though results obtained particularly when used with patients should be interpreted with caution and in context. There are few pharmacokinetic or radiolabelled deposition studies on which to base statements regarding dose likely to reach the lungs of children in this age group. Lung function and clinical results suggest that drugs can be delivered via nebulisers and holding chambers with face masks and inevitably performance of such devices will vary. However, factors such as screaming and non compliance with treatment are likely to influence the lung dose to a great extent. Hence choice of drug delivery system must be based on patient/parent acceptability as much as on theoretical grounds. Aerosol therapy in this age group is further complicated by our lack of knowledge related to the aetiology of recurrent respiratory symptoms in young children and hence it is quite likely that many children are being treated with effective delivery systems but inappropriate therapeutic agents. Much work is still required before we have a clear understanding of the aetiology and pathology of the distinct sub groups of respiratory disease in young children. Until we have a greater understanding in this area together with improved understanding of delivery systems, drug therapy in this age group will remain very much an empirical art. PMID- 10160212 TI - Liposomes and viruses for gene therapy of cystic fibrosis. AB - Cystic fibrosis (CF) is a common, life-threatening autosomal recessive disease caused by mutations in the CFTR gene. It affects the function of the lung, gut, and liver. Present strategies for CF aim to correct the defect by introducing a normal copy of the CFTR gene into affected epithelial cells. Two vector systems have been proposed for gene therapy trials, replication defective adenovirus and cationic liposome/DNA complexes. Adenoviral vectors have been used in Phase I trials and in most cases give transient molecular and/or electrophysiological restitution of the ion transport cellular defects of CF. However, a dose of 10(9) pfu/ml applied to the lung led, in one patient, to a transient inflammatory reaction. New adenoviral vectors are presently being developed to solve this problem. Our studies using liposome/DNA complexes to deliver CFTR cDNA to the nasal epithelium were carried out in the double blind trial and showed no treatment-related local or general adverse reactions and significant small but transient correction of the ion transport defect. The results for both current approaches demonstrate the need for substantial improvement of the efficiency and duration of transgene expression to reach therapeutically relevant levels. PMID- 10160213 TI - Comparative evaluation of therapeutic response to antiasthma drugs: dry powder vs. conventional aerosol delivery systems. AB - Dry powder inhaler (DPI) delivery systems provide advantages over the metered dose inhaler (MDI) systems. Of the anti-asthma agents studied, most of the trials have focused on the beta adrenergic agonists with a lesser degree of inhaled cromoglycate and corticosteroids. The results of the studies show either similarities or a lesser effect on pulmonary function for the DPI systems but, in most cases, clinical symptoms are comparable. The trials reported vary in the type of controlled designs, doses, and systems evaluated, hence scrutiny of resultant data should follow assessment of methodology in order to clinically interchange these systems in asthmatic patients. PMID- 10160214 TI - Molecular genetic techniques and applications in ophthalmology. PMID- 10160215 TI - Diagnostic issues with inherited retinal and macular dystrophies. PMID- 10160216 TI - The ophthalmologic manifestations of mitochondrial disease. AB - The cardinal eye manifestations of mtDNA diseases are ophthalmoplegia, optic neuropathy, and pigmentary retinopathy. A number of other eye structures may also be affected in these disorders and the ophthalmologist is in a unique position to detect and interpret these findings. The presence of these ophthalmologic manifestations may be the first clue that the patient has an underlying mitochondrial disease with the eye as the initial or most prominently affected organ. The phenotypic manifestations of mitochondrial disease are protean and variable, and there are no clear-cut, minimal features that define these disorders. The possibility of a mitochondrial disorder should be raised when any of the mitochondrial eye manifestations (Table 1) are present, either alone or in concert with the neurological and systemic (Table 2) manifestations of mitochondrial disease. A maternal family history of an ophthalmologic, neurological, or systemic illness is also compatible with a mitochondrial disorder. The ophthalmologist should not loose sight of the fact that mitochondrial disorders have systemic manifestations and implications, even when the primary manifestations are ocular. Detection of and proactive intervention into comorbid features (eg, diabetes mellitus, hearing loss, heart block) is an important component. PMID- 10160217 TI - The interplay of genetics and surgery in ophthalmic care. PMID- 10160218 TI - Practice guidelines for the patient with suspected ocular nonretinal genetic disorder. PMID- 10160219 TI - Complex disorders in ophthalmology. PMID- 10160220 TI - Preventive ethics in the management of ophthalmic genetic disorders. PMID- 10160221 TI - Browsing Mendel's library: appreciating the enormous heterogeneity of human genomes. PMID- 10160222 TI - On defining the genetic test. PMID- 10160223 TI - A look at the possible impact of new genetic technology on the life insurance industry. PMID- 10160224 TI - Underwriting dominantly inherited diseases. PMID- 10160226 TI - Community-wide youth nutrition education: long-term outcomes of the Minnesota Heart Health Program. AB - The Class of 1989 was part of the Minnesota Heart Health Program, a research and demonstration project designed to reduce cardiovascular disease in three intervention communities. This paper describes the long-term outcomes of a school and community-based intervention on healthy eating behaviors in one intervention and matched reference community. Beginning in the sixth grade (1983), seven annual waves of behavioral measurements were taken from both communities (baseline N = 2376). Self-reported data were collected at each time period including measures of knowledge and preferences for certain foods, and food salting behavior. Data were analyzed using an ANCOVA model adjusting for baseline dependent variable differences, with the school as the unit of analysis. Knowledge, healthy food choices and restraint in food salting behavior variables were significantly higher throughout most of the follow-up period in the intervention community for females. Males also indicated greater knowledge of healthier choices in the intervention community and greater restraint in salting behavior but results are less conclusive for healthy food choices. These results suggest that multiple intervention components such as behavioral education in schools coupled with community-wide health promotion strategies can produce modest but lasting improvement in adolescent knowledge and choices of heart healthy foods and less frequent food salting practices, and that this improvement is most notable among females. PMID- 10160225 TI - Comparative mortality by sex and age in residents of Rochester, Minnesota with acute myocardial infarction during 1960-1979 (sudden deaths included). PMID- 10160228 TI - Staff stress in AIDS prevention and service organizations: implications for health education practice. AB - The purpose of this study was to identify the frequency of staff stressors and their association with programmatic factors in 51 AIDS prevention and service projects funded by the Robert Wood Johnson Foundation. The methodology included both quantitative (i.e. closed-ended survey questions) and qualitative (i.e. in depth, open-ended interviews) data to identify the important sources of staff stress. The findings suggest that staff working in AIDS prevention and service projects perceive significant levels of stress regardless of project focus. The most frequently reported staff stresses were too much work, rapid organizational growth, burnout, and problems with staff retention and communication. Among the issues rarely reported as a source of staff stress were too little work, discomfort with the target population and personal health risk concerns. The programmatic factor most often associated with staff stress was obtaining additional funding. Health education interventions need to take a comprehensive approach that includes altering the psychosocial-environmental conditions that give rise to stressors and strengthening the individual and organizational factors that may modify the effects of stress on the AIDS workforce. PMID- 10160227 TI - HIV-preventive cognitions amongst secondary school students in Uganda. AB - A self-completion questionnaire was used to survey HIV-preventive cognitions among secondary school students in Kabarole district, Uganda. An encouraging pattern of HIV-preventive beliefs was observed, suggesting that health education efforts have been effective in establishing basic transmission knowledge, accurate risk perception and an understanding of effective precautions. Further analysis explored the prerequisites of men and women's HIV-preventive self efficacy, and intentions and tolerance of people with AIDS. Approximately a third of variance in men and women's condom use self-efficacy, half the variance in women's condom use intentions and a quarter of the variance in men's condom use intentions was accounted for by specified variables. Results offered support for psychological relationships proposed by social cognition models and suggested specific health education targets for young Ugandan men and women. PMID- 10160229 TI - Incorporating mobile mammography units into primary care: focus group interviews among inner-city health center patients. AB - Mammography screening is underutilized, especially among women of lower socioeconomic status (SES). Mobile mammography units reduce cost and patient burden of mammography, and therefore might enhance screening rates among underserved populations. Few studies have explored factors associated with the acceptability of mobile mammography; none have targeted low-SES women. To explore these issues, we conducted focus group interviews in five university-affiliated urban primary-care clinics. The forty-three participants were 74% African American, ranged in age from 40 to 70 years and most (67%) had household incomes below $15,000. A trained moderator led the groups of eight to 12 women through standardized, open-end interview questions exploring perceptions of mobile mammography. Findings suggest mammography vans are acceptable under only certain circumstances, including advance notice and assurance of privacy and quality. Convenience was important; 53% related being more likely to have mammograms if scheduled in conjunction with primary-care visits. Participants felt strongly that vans were inappropriate for public forums such as shopping centers. Association with primary-care health centers seemed to legitimize mammography vans and to allay concerns. If mammography screening is to become more widespread among low-income populations, these exploratory findings must be addressed in research and intervention development. PMID- 10160231 TI - Do tailored behavior change messages enhance the effectiveness of health risk appraisal? Results from a randomized trial. AB - Health risk appraisal (HRA) remains one of the most widely used health promotion tools despite only equivocal evidence for its effectiveness. Theories of behavior change predict conventional HRA's ineffectiveness because risk information alone is seldom sufficient to change complex behaviors. In this study, a randomized trial compared the effects of feedback from an enhanced HRA with a typical HRA and a control group among adult patients from eight family medicine practices. The enhanced HRA assessed behavior-specific psychosocial factors and provided patients with computer-generated, individually-tailored behavior change information in addition to typical HRA risk feedback. Changes in seven behaviors were assessed at a 6 month follow-up. Overall, patients receiving enhanced HRA feedback were 18% more likely to change at least one risk behavior than were patients receiving typical HRA feedback or no feedback (OR = 1.18, 95% CI = 1.00, 1.39). The enhanced HRA feedback appeared to promote changes in cholesterol screening, dietary fat consumption and physical activity, but not in smoking, seat belt use, mammography and Pap smears. We conclude that the addition of theory-based, individually-tailored behavior change information may improve the effectiveness of HRA. PMID- 10160230 TI - The use of television series in health education. AB - This paper reviews evidence of the impact which television generally, and drama series in particular, can have on health beliefs, attitudes and behaviours. It describes how a television series, The Family House, was planned in Egypt to disseminate key health messages in an entertaining context. As only a very small number of television series were specifically developed to address health issues, and even fewer were evaluated, this paper presents important new data derived from focus group discussions and survey interviews which help in understanding the potential television series can have for health education. Finally, the paper presents data on the cost-effectiveness of The Family House series. PMID- 10160232 TI - Reasonable accommodation for employees with mental disabilities: a mandate for effective supervision? AB - Reasonable accommodation under Title I of the Americans with Disabilities Act (ADA) for employees with mental disabilities is explored from a behavior analytic perspective. Although much of the attention in issues of reasonable accommodation is concentrated on persons with physical disabilities, it is argued that the needs of individuals with mental disabilities are in greater need of further study. The criteria for successful accommodation in the workplace for employees with mental disabilities is seen to be structurally different, but functionally similar to successful accommodations for employees with physical disabilities, and is based on the development of enabling environments. Behavior analysis offers a theoretical basis and performance management presents a methodological basis for analyzing, developing, implementing, and evaluating reasonable accommodation for persons with mental disabilities, largely in terms of effective supervision. It is concluded that Title I of the ADA may be seen as providing a mandate for effective supervision, which may also be extended to all employees. PMID- 10160233 TI - Cybersex: regulating sexually explicit expression on the Internet. AB - While the First Amendment restricts the power of the government to control access by adults to sexually explicit expression that is not obscene, the government may restrict access by children, provided that those restrictions do not limit adults to reading only "what is fit for children." Controlling access by children presents special problems in the context of broadcasting, because broadcast programming is accessible to children too young to read and because of the impossibility of segregating adults and children in the audience. The Supreme Court therefore permits the government to require "channeling" of sexually explicit programming to times when fewer unsupervised children are in the audience, to facilitate parental control over children's access to sexually explicit material. Although Internet content includes less than one percent of sexually explicit expression, that material has been the subject of intensive media and government attention. Much of that attention ignores (1) the high level of constitutional protection applicable to non-obscene, sexually explicit expression; (2) features of the Internet which facilitate controlling access by children to sexually explicit expression far more effectively than in broadcasting or print media; and (3) the First Amendment values served by permitting expression of all forms on the Internet. PMID- 10160234 TI - Assumptions and beliefs about the role of AD dolls in child sexual abuse validation interviews: are they supported empirically? AB - The use of anatomically detailed dolls in child sexual abuse validation interviews is based on a number of underlying assumptions and beliefs. However, only over the last 12 years have researchers begun to evaluate the validity of these assumptions and beliefs systematically. This consideration of the existing AD doll empirical literature reveals that the support for some of the assumptions underlying the use of the dolls, as well as the surrounding beliefs, is available. However, for other assumptions and beliefs support is less firm, frequently contradictory, and sometimes absent. The evidence of support for these assumptions and beliefs is discussed and future research needs are identified. PMID- 10160235 TI - A further examination of validity for the sexual experiences survey. AB - The Sexual Experiences Survey (SES) is designed to identify victims of sexual assault, including ones whose experiences meet the Ohio legal definitions (Ohio Revised Code, 1980) for rape or attempted rape (Koss, Gidycz, and Wisniewski, 1987). Ratings from 156 Ohio prosecuting attorneys indicate that three of the five items used to identify victims of rape or attempted rape as a result of actual or threatened force are commensurate with the sex offense statutes for these acts, while the two questions describing attempted and completed rape experiences involving the use of drugs and alcohol are not. The ratings could not be accounted for by demographic, work experience, or rape myth acceptance variables. Two additional items not intended to measure specific code violations were found to describe felony sex offenses. The implications of the current findings for identifying sexual assault victims are discussed. PMID- 10160250 TI - The re-emergence of tuberculosis and its economic implications. PMID- 10160251 TI - Treatment of traveller's diarrhoea. Economic aspects. AB - Traveller's diarrhoea (TD) is an enteric infective disease seen in 30 to 50% of the 30 million people who travel annually from the developed world to developing countries. It is the commonest disorder affecting international travellers. Although usually trivial, a significant minority of patients may develop a more protracted disease with an attendant increase in morbidity. This may then incur financial costs to the travellers themselves and to the healthcare systems of the host and origin countries. Advice regarding risk avoidance has so far proved ineffective in altering the behaviour of travellers and consequently the incidence of TD among them. Hard data are lacking on the cost effectiveness and cost benefit of prophylaxis and treatment of TD. Thus, we have attempted to quantify, as far as is possible, the total cost of TD and to set this against the potential savings from avoiding TD if prophylaxis or treatment options were universally employed. It must be noted that the financial benefit-cost ratio of an intervention may not be the most suitable measure of its desirability. However, such concepts as the success of travel are inherently difficult to quantify in economic terms. This analysis applies to travellers from the UK and economic variations between countries will after the outcomes obtained. Nevertheless, given these necessary constraints, all possible treatment options have a more favourable benefit-cost ratio than prophylaxis. In conclusion, the case for prophylaxis is not strong except in selected high risk groups, and limited self-treatment seems economically justified. PMID- 10160252 TI - ACE inhibitors in patients with diabetes mellitus. Clinical and economic considerations. AB - The advent of the ACE inhibitors has been one of the major developments in cardiovascular pharmacology this century. Aside from their role as potent anti hypertensive drugs with few adverse effects, ACE inhibitors have numerous other effects that have only been partially explained. Antihypertensive therapy is the most effective treatment in patients with diabetic nephropathy, postponing the development of end-stage renal failure. Although this effect can apparently be obtained with all antihypertensives (except nifedipine), recent meta-analyses have indicated that the beneficial effects of ACE inhibitors on proteinuria and preserved renal function are greater than with other drugs. In nondiabetic patients, treatment with ACE inhibitors may delay or prevent the development of congestive heart failure following acute myocardial infarction. Whether this also occurs in diabetic patients is still unknown, but subgroup analysis of existing studies and controlled clinical trials in this area should be encouraged. In conclusion, ACE inhibitors are the only drugs that have been proven, in controlled clinical trials, to be effective in preventing progression from micro albuminuria to overt nephropathy. Furthermore, they are more effective in diminishing albuminuria at low levels of blood pressure reduction compared with other antihypertensives. In comparison with beta-blockers, ACE inhibitors have the advantage that they do not mask the subjective symptoms of hypoglycaemia, nor do they affect the serum lipid profile. PMID- 10160253 TI - Assessing quality of life in patients with epilepsy. AB - The importance of quality-of-life (QOL) assessments in providing quantified information about the impact of chronic illness and its treatment is now generally accepted. For epilepsy, QOL assessment is a relatively recent development, but it is increasingly included within clinical trial protocols. Clinical trials in epilepsy that have included a comprehensive QOL assessment, although still relatively few in number, have examined the effectiveness both of broad management policies and of individual drug therapies. There are a number of important conceptual, methodological and practical issues behind the measurement of quality of life as an outcome of care in epilepsy that are being addressed through current efforts to develop standardised QOL instruments. In trying to assess quality of life in epilepsy, as in any other condition, it is important to satisfy the universal requirements of a scientific instrument-that it be valid, reliable, sensitive in change and practical. To date, the main 'formal' approaches to QOL assessment in epilepsy have involved the development of a novel QOL measure from first principles, customising of a previously developed generic measure, identification of a battery of generic and disease-specific scales addressing specific QOL domains, and adoption of an individual patient-generated approach. These various efforts have produced a battery of potentially valuable tools and approaches. Although QOL assessment is now mainly on the epilepsy research agenda, some important challenges remain to be met. These include the development of comprehensive, age-related measures for children with epilepsy, further investigation of the psychometric properties of the available measures for adults, issues of cross-cultural application and use with proxy informants, and the development of utility-based measures. PMID- 10160254 TI - Criteria for the appropriate drug utilisation of immunoglobulin. AB - Intravenous immunoglobulins (IVIGs) are prepared from human plasma pools and further modified enzymatically or chemically. Despite careful selection of donors and inclusion of effective virus elimination steps in the production process, contamination with hepatitis C virus can still occur. IVIGs possess most of the characteristics of native immunoglobulins, such as antigen neutralisation and complement activation. The serum half-life of native immunoglobulin is about 21 days, and comparable half-lives have been reported for several IVIG preparations. IVIGs have received general approval for the treatment of primary immuno deficiencies such as agammaglobulinaemia. Of the secondary immuno-deficiencies, only paediatric AIDS, chronic lymphocytic leukaemia and multiple myeloma, as well as allogeneic bone marrow transplantation, are accepted indications for IVIGs. Because of their immunomodulatory action, IVIGs are also recommended for the treatment of idiopathic thrombocytopenic purpura, Kawasaki disease (mucocutaneous lymph node syndrome) and, recently, Guillain Barre syndrome IVIGs have been investigated in a wide range of immunodeficient states (e.g. prematurity) and autoimmune diseases (e.g. multiple sclerosis), but conclusive results are not available. Since IVIGs are associated with a certain risk of transmission of viral infections and, secondly, because they are generally acknowledged as expensive drugs, their use requires careful consideration of risk, benefit and cost. PMID- 10160256 TI - An economic evaluation of finasteride for treatment of benign prostatic hyperplasia. AB - This evaluation was conducted at the request of a Canadian provincial government considering finasteride for formulary inclusion. The comparator therapies, in accordance with Canadian pharmacoeconomic guidelines, were the most prevalent treatment [transurethral resection of the prostate (TURP)] and the lowest cost treatment (watchful waiting). All costs were measured in 1994 Canadian dollars ($Can), and both costs and outcomes were discounted at 5% per annum. Cost effectiveness and cost-utility ratios were calculated, and were found to be dependent on initial symptom severity and the anticipated duration of treatment with finasteride. The drug was shown to be the dominant alternative compared with both TURP and watchful waiting for patients with moderate symptoms, when the duration of drug therapy is 3 years or less. However, finasteride is a weak alternative for patients with severe symptoms who are treated for 4 years or more. For other groups of patients (i.e. moderate symptoms and on finasteride for 4 years or more; severe symptoms and on treatment for 3 years or less), the drug can improve health-related quality of life, but at a cost of between $Can3000 and $Can97,000 per incremental quality-adjusted life year (1994 dollars). Our study also indicated that it would cost between $Can2.7 million and $Can5.6 million, depending on the severity mix of the patients, to treat cohort of 10,000 men aged 60 years or older with finasteride. PMID- 10160255 TI - Selective serotonin reuptake inhibitors. Assessment for formulary inclusion. AB - Depression is a common and significant health problem associated with impairment in a patient's ability to function in their role (e.g. student, worker, home maker), and may have a fatal outcome in the case of suicide. Recently there has been progress in developing new antidepressant medications, such as the selective serotonin reuptake inhibitors (SSRIs). These agents, while no more effective than the tricyclic antidepressant (TCA) drugs, are generally better tolerated than traditional medications used to treat depression. Further, because of their adverse effect profiles, they are generally better tolerated, and safer in overdose, than the TCAs. In response to concerns about aggregate healthcare costs, formularies are being employed to control the direct costs of prescription drugs. When direct drug costs alone are considered, the TCAs are initially less expensive than the SSRIs. However, compared with those taking SSRIs, patients taking TCAs withdraw from treatment more frequently, have more accidents, experience more adverse effects that require treatment, and are more likely to die from an overdose (if it occurs). Furthermore, unsuccessful treatment may be due to noncompliance, which is frequently related to adverse effects. Medications have effects on indirect costs. For example, adverse effects may impair productivity and lead to accidents in the home and at work. There are increased hospital and indirect costs of drugs used in overdose. Medication non-compliance may lead to failure to recover from depression, which results in ongoing expense to the state in the form of disability benefit payments. The largest cost savings are often associated with indirect costs, such as reduced benefit payments and improved productivity and earnings when treatment is successful. Taking all these considerations together, it does not appear that TCAs, taken over time, are any less expensive than the newer antidepressant medications. PMID- 10160258 TI - In microbiology labs, the squeeze is on. PMID- 10160257 TI - Pharmacoeconomic analysis of stress ulcer prophylaxis for critically ill patients. AB - The objective of this study was to evaluate the economic outcomes of drug options for stress ulcer prophylaxis in critically ill and/or intensive care unit patients. Decision analytic modelling was used to compare the costs of stress ulcer prophylaxis and possible clinical outcomes [acute upper gastrointestinal bleeding (AUGB) and nosocomial pneumonia]. The regimens evaluated were: antacids, histamine H2 receptor antagonists (H2RAs), sucralfate and no prophylaxis. The results of published studies were pooled to determine the expected probability of AUGB and nosocomial pneumonia following stress ulcer prophylaxis with each of the agents under study. The costs of stress ulcer prophylaxis, treatment of AUGB and treatment of nosocomial pneumonia were identified from various sources. Sucralfate was the least costly agent for stress ulcer prophylaxis. The average net costs per patient for sucralfate, antacids, no prophylaxis and H2RAs were $US1457, $US1737, $US2268, and $US2638 to $US2712, respectively (1994 dollars). No prophylaxis was found to be less costly than giving H2RAs. Sucralfate and antacids, which induced net savings of $US7373 and $US4321 per case of AUGB averted, respectively, were more cost effective than H2RAs. Sensitivity and threshold analyses revealed that the results were constant over a wide range of cost and probability values. Break-even analysis suggested that sucralfate was the optimal agent for stress ulcer prophylaxis unless the acquisition cost of a prophylactic course of sucralfate was > $US304.05 per patient. At that point, antacids become the optimal agent. Based on this analysis, sucralfate may be the most cost-effective agent for stress ulcer prophylaxis in critically ill or intensive care patients. PMID- 10160259 TI - Safety tips for anatomic studies of possible CJD. PMID- 10160261 TI - 'Clandestine' prostate cancer haunts. PMID- 10160260 TI - H. pylori picture coming together. PMID- 10160262 TI - Big future in store for biochemical bone markers. PMID- 10160263 TI - Cytogenetics labs embrace FISH. PMID- 10160264 TI - Blood & politics. PMID- 10160265 TI - Testing for a troublesome gene. PMID- 10160266 TI - How neuropathologists fit into community practice. PMID- 10160267 TI - Knowing when and how to notify donors, recipients. PMID- 10160268 TI - Cracking the cases of infection clusters. PMID- 10160271 TI - Lab automation systems at the crossroads. PMID- 10160270 TI - Getting the MD-hospital relationship right. PMID- 10160269 TI - DNA collections: a vital aspect of the autopsy. PMID- 10160272 TI - Apoptosis tantalizes researchers, labs. PMID- 10160273 TI - Striking the right balance with TDM. PMID- 10160274 TI - Academic pathology: being muscled out by managed care? PMID- 10160275 TI - Care pathways' 'pluses' adding up. PMID- 10160276 TI - Mammographic breast biopsy: what's needed, what's noted. PMID- 10160277 TI - When a residency program is cut back or cut out. PMID- 10160279 TI - Financial performance of safety-net hospitals in a changing health care environment. AB - Safety-net hospitals serving the poor and indigent in inner-cities have received inadequate research attention regarding the determinants of their financial performance in the changing health care environment. We analyze how the 1990-92 financial performance of 275 such hospitals is related to exogenous and endogenous factors such as payer mix, service mix, staffing and ownership. Models of hospital financial performance are developed using operating margin, cost per discharge and revenue per discharge as measures of performance. Stepwise regression is used to test the model with data from the American Hospital Association (AHA) and Health Care Investment Analysts (HCIA). Results suggest that: 1) The profitability of inner-city hospitals appears positively related with technical complexity of care; 2) High interest and low operating surplus may constrain the addition of technically sophisticated services to enhance profitability; 3) There is some evidence that new governmental programs, e.g. Medicaid managed care and Medicaid Diagnosis Related Groups (DRGs), may not have improved operating margins, though Medicaid DRGs appear to have contained costs. Follow-up research is needed on this issue; 4) Given external fiscal realities, internal management strategies for inner-city hospitals require research, e.g. developing appropriate managed care systems and timely expansion of sub-acute services and; 5) Services such as AIDS treatment and community health education represent opportunities to respond to community needs, especially since unit cost of such services will decline with high volume. PMID- 10160278 TI - Prediction of the financial performance of Ontario hospitals: a test of environmental determinist and adaptationist perspectives. AB - While other industries for many years have been concerned with the problem of financial distress, it is only recently that this issue has become a matter of interest to hospital managers, policy makers, and the general public. However, the determinants of hospital financial performance are neither well studied nor understood. The objectives of this study were to identify factors that affect the financial performance of Ontario hospitals and to construct a model that could be used to predict financial performance in the future. A number of organization and environmental factors that could influence financial performance were postulated and then tested for their statistical impact and predictive ability. Cross sectional data over the 3-year-period 1986-1988 for 223 Ontario public hospitals were used. The first 2 years of data served as a derivation sample for hypothesis testing and development of a predictive model. The third year of data was used as a holdout sample for cross validation. Information on the variables investigated came from secondary sources, in particular Statistics Canada's Annual Hospital Returns. Univariate analyses revealed distressed hospitals were more likely to earn more revenues from non-government sources, to be non-teaching institutions and have longer chronic lengths of stay, and to be found in areas with higher per capita incomes, number of females in the population, physician supply, and area wage rates. A five variable prediction model was developed which accounted for 25% of the variance in financial performance in the derivation sample and on cross validation dropped to 21%. The model identified greater hospital size, older plants, higher technological complexity, more intensive care services, and location in areas with more females to be significant predictors of financial distress. Overall, environmental factors (community and structural characteristics) were more important in influencing financial performance. The implication for hospital managers is to underscore that an important dimension of successful leadership requires they remain outwardly focused and involved in managing the external environment. For policy makers the need is to develop funding formulae which encourage efficiency and are also responsive to differences in community and structural characteristics across hospitals. PMID- 10160280 TI - Benefits of hospital capacity reduction: estimates from a simulation model. PMID- 10160281 TI - Impact of capitation contracts on financial risk: a Monte Carlo simulation. PMID- 10160283 TI - Changing clinical practice: messages, messengers, and methods. PMID- 10160282 TI - Business planning in Hong Kong hospitals: the emergence of a seamless health care management process. AB - This paper examines the progress made by public hospitals in Hong Kong in implementing a business planning approach. A review of available literature suggests two main exploratory themes. The first establishes the key features of business planning in the private sector. The second theme discusses the problems of adapting this approach to the distinctive requirements of the public sector. The literature also suggests three dimensions for evaluating planning: incremental-developmental; reactive-proactive; ends-means. Qualitative data were collected by scrutinizing relevant organizational documentation and by discussions with focus groups formed by participants in the planning process. The data were analyzed against eight key elements of a business plan identified from the literature and from panels of business experts. These elements were found to be present in the Hospital Authority's plans but were less evident in hospital level plans. Because of the unitary nature of hospital organization in Hong Kong, it has been difficult for hospitals to break out of a reactive, incremental and ends-based pattern to a more imaginative identification of the distinctive business and market that they may be in. This is, however, changing rapidly and it is clear that there is in place a robust and 'seamless' health care management process. PMID- 10160284 TI - Barriers to timely mammography. AB - A survey of 399 women between 50 and 59 years of age was conducted to learn how we could improve their compliance with mammography screening guidelines. Our results showed that 78% of the women surveyed believed their physician would tell them if they needed a mammogram. Women who had not had a mammogram were more likely to be misinformed about indications for mammography than women who had had a mammogram. Women who had not had a mammogram were less likely to visit a health center than were women who had had a mammogram. A multifaceted approach including patient education to correct misinformation, reminder systems for women not seen regularly in health centers, and physician reminders may have the most impact. PMID- 10160285 TI - The relationship between characteristics of obstetrician-gynecologists and rates of recommended prenatal care screening tests. AB - OBJECTIVE: To examine the relationship between characteristics of obstetrician gynecologists and rates of recommended prenatal care screening tests. DESIGN: Retrospective review of prenatal care records. SETTING: Prudential HealthCare. PARTICIPANTS: Enrolled women (2184) between 14 to 47 years of age who delivered a live birth in 1992, and saw an obstetrics and gynecology (OB/GYN) physician for prenatal care. MAIN OUTCOME MEASURE: Receipt of routine prenatal care screening tests. RESULTS: Pregnant women received most of the recommended prenatal care screening tests more than 90% of the time, with the exception of urinalysis (68.3%), alphafetoprotein (72.1%), glucose challenge (87.5%), and repeat haemoglobin/hematocrit (71.0%). Rates of receiving recommended screening tests varied by obstetrician's gender and number of years since medical school graduation. Women were more likely to receive an antibody test if they saw a female rather than a male obstetrician (p < 0.05), and more likely to receive syphilis serology, rubella, glucose challenge and repeat hemoglobin and/or hematocrit tests if they saw an obstetrician who graduated from medical school within the past 30 years (1965 or later), rather than an obstetrician who graduated more than 30 years ago (p < 0.05). CONCLUSION: The receipt of prenatal care screening tests varies by characteristics of OB/GYN physicians. The results of this study suggest that targeting educational opportunities to OB/GYN physicians whose year of medical school graduation is 1965 or earlier may improve rates of recommended prenatal screening tests. PMID- 10160286 TI - The effect of education and drug samples on antihistamine prescribing costs in an HMO. AB - OBJECTIVE: To examine the effect of an intervention designed to reduce antihistamine prescribing costs in an HMO. DESIGN: A quasi-experimental design with clinicians at one HMO site receiving an intervention. Their prescribing behavior before and after the intervention was compared to the prescribing behavior of clinicians at other HMO sites in a non-randomized control group. SETTING: A mixed model HMO in metropolitan Washington, DC. PARTICIPANTS: Group model clinicians at a single site received the intervention; network and group model clinicians at other sites composed the control group. INTERVENTION: An education memo addressed to clinicians discussing antihistamine prescribing costs and strategies for initial use of nonprescription or less expensive prescription agents, coupled with free antihistamine sample "trial packs" for patient use. OUTCOME MEASURE: The prescribing costs of the intervention group were compared to the prescribing costs of the non-randomized control group. The intervention group was surveyed regarding their attitudes toward the intervention. RESULTS: A 2% decline in costs was noted between the baseline and intervention year for both the intervention and control groups. Though clinicians indicated they were well disposed toward the intervention, they believe patient expectations were a major obstacle to the use of cheaper agents. CONCLUSION: We conclude that an effective intervention would require the targeting of major patient-related barriers to clinician behavior change. PMID- 10160287 TI - Hospital-based internists--hospital care of the future? PMID- 10160288 TI - More effective care for low back pain. PMID- 10160289 TI - Addressing a neglected coronary heart disease risk factor in an HMO: exercise counseling and fitness testing at group health cooperative. AB - Group Health Cooperative, following the lead of the American Heart Association (AHA), the Centers for Disease Control (CDC), and the US Preventive Services Task Force (USPSTF), has identified inactivity as one of the most significant risk factors for the prevention of coronary heart disease (CHD). This paper reports on the programs being developed at Group Health Cooperative to address inactivity. A clinical tool designed to make fitness testing and comprehensive exercise counseling practical in routine primary care was designed and piloted. The fitness test was based on the One-Mile Walk Test, with computerization of the results analysis and reporting. The test helped the physician assess the patient's current exercise habits and physical fitness in terms of Vo2max (maximal oxygen consumption). The computer program showed the patient and the physician how the individual's Vo2max compared to norms for the patient's age and gender. The program provided comprehensive written exercise counseling and individualized advice about activity and fitness based on the patient's current exercise habits. The test cost little to administer, and helped reduce the time and effort of the primary physician in providing exercise counseling, while making optimal use of the physician's power to motivate. Exercise counseling is a very cost-effective preventive intervention. We believe that an organized and systematic exercise counseling program, together with a program for measuring fitness, would be the most effective intervention. Evidence indicates that effective exercise counseling should result in substantial reduction in disease in our population. PMID- 10160290 TI - Occupational health services in the HMO setting. PMID- 10160291 TI - One HMO's experience with the management of hyperemesis gravidarum. PMID- 10160292 TI - Perspectives. Budget pressures ease, but welfare bill jolts Medicaid. PMID- 10160293 TI - Multi-institutional strategic planning. PMID- 10160294 TI - The soothsayers. PMID- 10160295 TI - Successful fund raising in an outrageous era. 10 survival tips. PMID- 10160296 TI - The job search process. PMID- 10160297 TI - Make physicians your top prospects with charitable gifting. PMID- 10160298 TI - An immodest proposal. Balance your fund-raising program with corporate and foundation dollars. PMID- 10160299 TI - Online communications and today's health care development professional. PMID- 10160300 TI - The how and why of strategic planning. PMID- 10160301 TI - Making a difference. How you can help shift the focus back to patient care. PMID- 10160302 TI - New design technologies: using computer technology to improve design quality. PMID- 10160303 TI - Plenary session: creating a new future--pushing the edges of the envelope. PMID- 10160304 TI - Environmental design technology: discovering new color skills. PMID- 10160305 TI - Environmental design technologies: designing the ergonomically correct medical environment. PMID- 10160306 TI - Environmental design technology: using color & light as medicine. PMID- 10160307 TI - Environmental design technologies: strategies for incorporating art as a healing force. PMID- 10160308 TI - New design skills toolbox: a workshop for designing the ER of the future. PMID- 10160310 TI - Healthcare Design Competition. PMID- 10160309 TI - New design skills toolbox: structuring the design process for better results. PMID- 10160311 TI - Healthcare Environment Awards. PMID- 10160312 TI - Nightingale Awards. PMID- 10160313 TI - Exemplary healthcare facilities. PMID- 10160314 TI - Plenary session: understanding & applying the therapeutic benefits of gardens. PMID- 10160315 TI - Pre-symposium workshop: exploring the life-enhancing potential of design. PMID- 10160316 TI - Primary care design: health promotion centers--a new model for healthcare delivery. PMID- 10160317 TI - Primary care design: the premise & the promise. PMID- 10160318 TI - Acute care design: a workshop on patient-centered environments. PMID- 10160319 TI - Long-term care design: strategies for planning the next generation of assisted living facilities. PMID- 10160320 TI - Keynote address: making your healthcare dreams come true. PMID- 10160321 TI - Long-term care design: a revolutionary prototype for assisted living. PMID- 10160322 TI - Designing for healthier communities: the hospital of the future is in your home. PMID- 10160323 TI - International design: business opportunities for healthcare design in Mexico. PMID- 10160324 TI - Physiological responses to environmental design: improving lighting quality & energy efficiency with light spectrum. PMID- 10160325 TI - Physiological responses to environmental design: understanding psychoneuroimmunology (PNI) & its application for healthcare. PMID- 10160326 TI - Future design trends: facility design strategies for operational restructuring. PMID- 10160327 TI - Future design trends: hospital-based fitness centers--a new business opportunity. PMID- 10160328 TI - New design technologies: healing architecture--a case study of the Vidarkliniken. PMID- 10160330 TI - Aging: the endgame. PMID- 10160329 TI - The new hands-off nursing. PMID- 10160331 TI - Preparing for healthcare in the next century. PMID- 10160332 TI - Security combines awareness with technology issues. PMID- 10160333 TI - Client/server system cuts I/S costs in half. PMID- 10160334 TI - Hotlist. Software for wireless devices. Install wireless systems after gaining user acceptance. PMID- 10160335 TI - Services and supports to the homebound elderly with mental health needs. PMID- 10160336 TI - The admission process in nursing homes: a clinical model for ethical decision making. AB - With increases in the number of older persons in our society, especially in the ranks of the oldest-old, practitioners in long-term-care settings will be faced with greater numbers and more complex issues in the nursing home admission process. This article discusses and includes case examples of some of the major problems involved in nursing home admission. Furthermore, the article proposes a clinical model which helps practitioners identify and organize information about admissions to select an appropriate course of action. PMID- 10160337 TI - Current good manufacturing practices for blood and blood components: notification of consignees receiving blood and blood components at increased risk for transmitting HIV infection--FDA. Final rule. AB - The Food and Drug Administration (FDA) is amending the biologics regulations to require that blood establishments (including plasma establishments) prepare and follow written procedures for appropriate action when it is determined that Whole Blood, blood components (including recovered plasma), Source Plasma and Source Leukocytes at increased risk for transmitting human immunodeficiency virus (HIV) infection have been collected. This final rule requires that when a donor who previously donated blood is tested on a later donation in accordance with the regulations and tests repeatedly reactive for antibody to HIV, the blood establishment shall perform more specific testing using a licensed test, if available, and notify consignees who received Whole Blood, blood components, Source Plasma or Source Leukocytes from prior collections so that appropriate action is taken. Blood establishments and consignees are required to quarantine previously collected Whole Blood, blood components, Source Plasma and Source Leukocytes from such donors, and if appropriate, notify transfusion recipients. The Health Care Financing Administration (HCFA) is also issuing a final rule, published elsewhere in this Federal Register, which requires all transfusion services subject to HCFA's conditions of Medicare participation for hospitals to notify transfusion recipients who have received Whole Blood or blood components from a donor whose subsequent donation test results are positive for antibody to HIV (hereinafter referred to as HCFA's final rule). FDA is requiring transfusion services that do not participate in Medicare and are, therefore, not subject to HCFA's final rule, to take steps to notify transfusion recipients. FDA is taking this action to help ensure the continued safety of the blood supply, and to help ensure that information is provided to consignees of Whole Blood, blood components, Source Plasma and Source Leukocytes and to recipients of Whole Blood and blood components from a donor whose subsequent donation tests positive for antibody to HIV. PMID- 10160338 TI - Medicare and Medicaid programs; hospital standard for potentially HIV infectious blood and blood products--HCFA. Final rule. AB - This final rule requires hospitals participating in the Medicare and Medicaid programs to take appropriate action when the hospitals learn that they have received whole blood, blood components (including recovered plasma), source plasma, and source leukocytes (hereafter referred to as blood or blood products) that are at increased risk of transmitting Human Immunodeficiency Virus (HIV) infection. If the hospital learns that it has received blood or blood products collected from a donor recently exposed to HIV, before the donor has a sufficient level of antibody to be detected by the screening test for antibody to HIV, the hospital must quarantine any blood or blood products remaining in inventory pending confirmation testing. If the presence of HIV is confirmed by more specific testing, the hospital must notify patients who received the blood or blood product. This final rule is intended to ensure that proper health and safety steps are taken to minimize further spread of HIV infection. A final rule published elsewhere in this Federal Register by the Food and Drug Administration applies the same requirements to entities furnishing transfusion services that do not participate in the Medicare and Medicaid programs and clarifies the responsibilities of blood establishments to identify and notify the transfusion service that received affected blood and blood products. PMID- 10160339 TI - Let's throw grandma in jail. PMID- 10160340 TI - Length of stay. It's not just an inpatient concern. AB - This article outlines five strategies that can help reduce LOS, a key indicator for improving both service to the patient and cost reduction for the hospital. 1. Reduce the Roles Within the Emergency Department. Expand staff job descriptions, and as a result, the ED's flexibility by reducing the number of separate and distinct roles in the ED. 2. Streamline the Admission Process. Avoid the backup in the ED by streamlining the admission process, paying special attention to ensuring that incentives are aligned to get the patients into inpatient beds. 3. Redeploy and/or Cross-train Key Ancillary Services. Cut down on the delays associated with coordinating with outside ancillary departments by bringing those services which make sense into the ED or at a minimum streamlining the process for accessing them. 4. Use Technology Wisely. Look at available technology as a means to put more information into the hands of your staff or reduce the overall work involved in the process. 5. Establish Team Accountability and Measure Performance. Develop a baseline LOS, measure it going forward, and most importantly, push down accountability for improving it to your clinical and support teams. PMID- 10160341 TI - Leadership spotlight. A clinician's perspective on clinical leadership and teams. AB - Moving a large organization to a team-based environment is both challenging and rewarding for any hospital leader. It is essential for hospital leaders to remove barriers and provide adequate resources to teams for them to develop fully. Striking the proper balance between no intervention and too much intervention in the team's development is critical Our experience has shown that selecting strong clinical leaders helps facilitate the development of clinical teams. Not only do these clinical leaders direct the work being performed by the team, they also ensure that care quality remains high. PMID- 10160342 TI - Restructuring critical care services. Part III: Successful implementation preparation. AB - Successful implementation in a redesigning organization does not happen without a sound design, good implementation planning and effective leadership. The focus of the implementation preparation must change prior to and after the "go live" implementation date. Implementation preparation requires intentional steps to build systems, communicate effectively and develop operational understanding among clinicians, physicians and management. Early effort should focus on planning for efficient day-to-day operations, development of measurement systems and contingency planning. Immediately prior to and after implementation the focus should be on communication, goal setting, issues prioritization and fact-based issues resolution. After the first couple of months of implementation, the focus should move toward mentoring teams/individuals, building outcome measurement systems, identifying sources of future improvement and transferring more authority as appropriate to teams. Commit to comprehensive implementation preparation. Time spent on implementation preparation will pay large dividends during the challenging times of transitioning your organization to a redesigned world. PMID- 10160343 TI - An operating strategy for true integration--the next frontier for healthcare systems. PMID- 10160344 TI - Hidden in health care reform: soft mandate for standard EDI. PMID- 10160345 TI - Enticing physicians to use a network. PMID- 10160346 TI - At home in health care and with computers. Interview by Fred Bazzoli. [corrected]. PMID- 10160347 TI - Utilization software evolves. PMID- 10160349 TI - Advice on how to get started on the electronic records journey. PMID- 10160348 TI - Creating electronic records. A progress report. PMID- 10160350 TI - Making the strategic decision on whether to outsource. PMID- 10160351 TI - Providers point to index software as key element of integration plans. PMID- 10160352 TI - Disaster planning protects technology investments. PMID- 10160353 TI - Building a Web site strategy. PMID- 10160354 TI - Building a case for bar coding. PMID- 10160355 TI - Live, via satellite. PMID- 10160356 TI - Enabling a claims dialogue. PMID- 10160357 TI - Complying with new HCFA rules for physicians-in-training. PMID- 10160358 TI - START triage plan for disaster scenarios. PMID- 10160359 TI - DMAT teams: there when disaster strikes. PMID- 10160361 TI - Atlanta EDs rise to challenge of tragic bombing in Centennial Olympic Park. PMID- 10160360 TI - Managing hazardous materials in the ED. PMID- 10160362 TI - Scandinavians champion resident independence. PMID- 10160363 TI - Surviving the war against fraud and abuse. PMID- 10160364 TI - Assisted living. How to prepare for a market "correction". PMID- 10160365 TI - Ducking the hazards. PMID- 10160366 TI - Therapy that fits. Patients' individual goals should inform rehab efforts, researchers say. PMID- 10160367 TI - Welcome, neighbor. Greeting new residents with understanding can ease their transition. PMID- 10160368 TI - One way to spell liability relief. PMID- 10160369 TI - Subacute strategies. Don't try to be a jack-of-all-trades. PMID- 10160370 TI - Ability to pay for health care: concepts and evidence. AB - In many developing countries people are expected to contribute to the cost of health care from their own pockets. As a result, people's ability to pay (ATP) for health care, or the affordability of health care, has become a critical policy issue in developing countries, and a particularly urgent issue where households face combined user fee burdens from various essential service sectors such as health, education and water. Research and policy debates have focused on willingness to pay (WTP) for essential services, and have tended to assume that WTP is synonymous with ATP. This paper questions this assumption, and suggests that WTP may not reflect ATP. Households may persist in paying for care, but to mobilize resources they may sacrifice other basic needs such as food and education, with serious consequences for the household or individuals within it. The opportunity costs of payment make the payment 'unaffordable' because other basic needs are sacrificed. An approach to ATP founded on basic needs and the opportunity costs of payment strategies (including non-utilization) is therefore proposed. From the few studies available, common household responses to payment difficulties are identified, ranging from borrowing to more serious 'distress sales' of productive assets (e.g. land), delays to treatment and, ultimately, abandonment of treatment. Although these strategies may have a devastating impact on livelihoods and health, few studies have investigated them in any detail. In depth longitudinal household studies are proposed to develop understanding of ATP and to inform policy initiative which might contribute to more affordable health care. PMID- 10160371 TI - The cost of coverage: rural health insurance in China. AB - China has undergone great economic and social change since 1978 with far reaching implications for the health care system and ultimately for the health status of the population. The Chinese Medical Reform of the 1980s made cost recovery a primary objective. The urban population is mostly protected by generous government health insurance. A high share government budget is allocated to urban health care. Rural cooperative health insurance reached a peak in the mid-1970s when 90% of the rural population were covered. In the 1980s rural cooperative health insurance collapsed and present coverage is less than 8%. The decline has been accompanied by reports of growing equity problems in the financing of and access to health care. This article is the first in a four-year study of the impact on equity of the changes in Chinese health care financing. The article examines the relationship between rural cooperative health insurance as the explanatory variable and health care expenditure, curative vs. preventive expenditure and tertiary curative care expenditure as dependent variables using a natural experimental design with a 'twin' county as a control. The findings support the hypothesis that cooperative health insurance will induce higher growth of health care expenditure. The findings also support the hypothesis that cooperative health insurance will lead to a shift from preventive medicine to curative medicine and to a higher level of tertiary curative care expenditure. The empirical evidence from the Chinese counties is contradicting World Bank health financing policies. PMID- 10160372 TI - Regulating the private health care sector: the case of the Indian Consumer Protection Act. AB - Private medical provision is an important constituent of health care delivery services in India. The quality of care provided by this sector is a critical issue. Professional organizations such as the Medical Council of India and local medical associations have remained ineffective in influencing the behaviour of private providers. The recent decision to bring private medical practice under the Consumer Protection Act (COPRA) 1986 is considered an important step towards regulating the private medical sector. This study surveyed the views of private providers on this legislation. They believe the COPRA will be effective in minimizing malpractice and negligent behaviour, but it does have adverse consequences such as an increase in fees charged by doctors, an increase in the prescription of medicines and diagnostics, an adverse impact on emergency care, etc. The medical associations have also argued that the introduction of COPRA is a step towards expensive, daunting and needless litigation. A number of other concerns have been raised by consumer forums which focus on the lack of standards for private practice, the uncertainty and risks of medicines, the effectiveness of the judiciary system, and the responsibility of proving negligence. How relevant are these concerns? Is the enactment of COPRA really appropriate to the medical sector? The paper argues that while this development is a welcome step, we need to comprehensively look into the various quality concerns. The effective implementation of COPRA presumes certain conditions, the most important being the availability of standards. Besides this, greater involvement of professional organizations is needed to ensure appropriate quality in private practice, since health and medical cases are very different from other goods and services. The paper discusses the results of a mailed survey and interview responses of 130 providers from the city of Ahmedabad, India. The questionnaire study was designed to assess the opinion of providers on various implications of the COPRA. We also analyze the data on cases filed with the Consumer Disputes and Redressal Commission in Gujarat since 1991. Four selected cases filed with the National Commission on Consumers Redressal are discussed in detail to illustrate various issues affecting the implementation of this Act. PMID- 10160373 TI - Evaluating the community education programme of an insecticide-treated bed net trial on the Kenyan coast. AB - Increased interest in the potential contribution of insecticide-impregnated bed nets (ITBN) to malaria control has led to research efforts to determine the impact and sustainability of ITBN programmes in differing environments. There is a need to develop effective, feasible educational strategies that will both inform and motivate community members, and thus maximize the correct usage of ITBN. This is especially true in communities where indigenous usage of bed nets is low. This paper describes the educational component of a randomized controlled community intervention trial of ITBN, with childhood malaria morbidity as an outcome. The educational approach and messages for the ITBN trial were developed from anthropological survey data collected 4 years before the trial, and from community surveys conducted by project researchers. Low levels of understanding amongst mothers of the aetiological link between mosquitos and malaria led to the exclusion of the term 'malaria' from the initial educational messages promoting the use of ITBN. Appropriate individuals within the existing district health care structure were trained as community educators in the project. These educators conducted intensive teaching in the community through public meetings and group teaching in the first 6 months of the trial. The impact of these initial activities was assessed through interviews with a random sample of 100 mothers and 50 household heads. This allowed the identification of messages which had not been well understood and further educational methods were chosen to address the areas pinpointed. The community assessment also demonstrated that, in 1994, over 90% of mothers understood a protective role for bed nets against malaria and the ITBN education messages were changed to take account of this. The school programme was evaluated through determining outreach (the number of households accessed), changes in participant children's knowledge, post-teaching assessment of mothers' knowledge and discussions with parent-teacher associations. It was shown that 40% of intervention homes with children in the target group were accessed, participant children learned the educational messages well (scores increased from a pre-teaching mean of 59% to a post-teaching mean of 92%) and a high level of awareness of the ITBN trial was achieved in these homes (75%). However, specific messages of the education programmed were not well transferred to the home (30%). The discussion emphasises the need for allocation of adequate resources for education in programmes dependent on achieving a change in community practices. We also describe the value of ongoing communication between programme planners and a target population in maximizing the effectiveness of messages and methods used. PMID- 10160374 TI - Implementing a nationwide insecticide-impregnated bednet programme in The Gambia. AB - Earlier studies in The Gambia suggested that the use of impregnated bednets might prove to be a useful malaria control strategy. Based on the results of these studies, in 1992 the Government of The Gambia was encouraged to initiate a National Impregnated Bednet Programme (NIBP) as part of the National Malaria Control Programme Strategy. This paper describes the implementation process/procedure of the NIBP. Evaluation results showed that, overall, 83% of the bednets surveyed has been impregnated, and 77% of children under the age of five years and 78% of women of childbearing age were reported to be sleeping under impregnated bednets. PMID- 10160375 TI - Maintaining compliance to ivermectin in communities in two West African countries. AB - We have investigated various aspects related to managing wide-scale ivermectin distribution schemes within randomized controlled trials in communities where onchocerciasis is endemic. Multiple logistic regression analysis of determinants of compliance to five doses of ivermectin in 589 people in Sierra Leone showed independent significant associations with leopard skin depigmentation, the severity of side effects of treatment, fulfilling the exclusion criteria for treatment, and long-term residence in the community. These results are useful for tailoring health promotion messages in Sierra Leone, but the associations may differ in other West African societies. In Nigeria 1847 people were interviewed about various subjective responses, including itching. None of these showed clear improvement after three years of ivermectin treatment. Positive comments about treatment were generally non-specific and similar in the placebo and ivermectin groups. Negative comments were usually related to adverse reactions, especially itching and rash, and were more common after ivermectin. The lack of any benefit attributable to ivermectin that is discernible to its recipients may make it difficult to maintain the high compliance rates needed for long periods if mass dosing programmes are to have a lasting impact on onchocerciasis. In addition, no consistent effects of ivermectin were found by measuring visual acuity, height, weight or haematocrit in comparison with placebo. This may indicate that evidence of clinical impact is very slow to develop and is hard to measure using simple objective methods after only three doses of treatment. At present it seems that parasitological, entomological and detailed ophthalmological or dermatological methods are required to demonstrate the impact of ivermectin treatment in the medium-term. PMID- 10160377 TI - Ethnicity, nationality and health care accessibility in Kuwait: a study of hospital emergency room users. AB - In mid-1994, non-Kuwaiti expatriates constituted 61.7% of the total population of Kuwait (1.75 million). Despite this numerical majority, non-Kuwaitis exist as a social minority. Non-Kuwaitis may be grouped into three broad categories along ethnic/nationality lines into Bidoon (without nationality), Arabs, and Asians. The objective of this paper was to compare the relative accessibility of the various groups to health care services in Kuwait. The study is based on data collected as part of a survey of 2184 Emergency Room (ER) users in January February 1993. All patients attending the hospital ERs between 7:30 am and 9:00 pm were interviewed about their reasons for coming to the ER instead of going to the primary health care (PHC) centres, as required. The major reason given was low accessibility of the PHCs. Compared to Kuwaiti nationals, 92% of whom were registered at the PHC centres, only 62% of the Arabs and 39% of the Asians were registered. Multiple logistic regression of the factors in registration indicated that nationality was the most important reason for lack of registration, with Asians only about one-quarter as likely to be registered as Kuwaitis. Also, people who had been in Kuwait for shorter durations (< 5 years) were less likely to be registered than the Kuwaiti nationals or expatriates who had been here for 10 years or longer. In the absence of registration at the PHC centre, the civil identification card (ID) may be used as a valid means to enter the health system. Among the Arabs and Asians, 22% and 29% did not have a civil ID card. Thus, for many expatriates, the hospital ER, which does not provide the necessary follow-up care is often the only source of health care available. PMID- 10160376 TI - The impact of face-to-face educational outreach on diarrhoea treatment in pharmacies. AB - Private pharmacies are an important source of health care in developing countries. A number of studies have documented deficiencies in treatment, but little has been done to improve practices. We conducted two controlled trials to determine the efficacy of face-to-face educational outreach in improving communication and product sales for cases of diarrhoea in children in 194 private pharmacies in two developing countries. A training guide was developed to enable a national diarrhoea control programme to identify problems and their causes in pharmacies, using quantitative and qualitative research methods. The guide also facilitates the design, implementation, and evaluation of an educational intervention, which includes brief one-on-one meetings between diarrhoea programme educators and pharmacists/owners, followed by one small group training session with all counter attendants working in the pharmacies. We evaluated the short-term impact of this intervention using a before-and-after comparison group design in Kenya, and a randomized controlled design in Indonesia, with the pharmacy as unit of analysis in both countries (n = 107 pharmacies in Kenya; n = 87 in Indonesia). Using trained surrogate patients posing as mothers of a child under five with diarrhoea, we measured sales of oral rehydration salts (ORS); sales of antidiarrhoeal agents; and history-taking and advice to continue fluids and food. We also measured knowledge about dehydration and drugs to treat diarrhoea among Kenyan pharmacy employees after training. Major discrepancies were found at baseline between reported and observed behaviour. For example, 66% of pharmacy attendants in Kenya, and 53% in Indonesia, reported selling ORS for the previous case of child diarrhoea, but in only 33% and 5% of surrogate patient visits was ORS actually sold for such cases. After training, there was a significant increase in knowledge about diarrhoea and its treatment among counter attendants in Kenya, where these changes were measured. Sales of ORS in intervention pharmacies increased by an average of 30% in Kenya (almost a two fold increase) and 21% in Indonesia compared to controls (p < 0.05); antidiarrhoeal sales declined by an average of 15% in Kenya and 20% in Indonesia compared to controls (p < 0.05). There was a trend toward increased communication in both countries, and in Kenya we observed significant increases in discussion of dehydration during pharmacy visits (p < 0.05). We conclude that face-to-face training of pharmacy attendants which targets deficits in knowledge and specific problem behaviours can result in significant short-term improvements in product sales and communication with customers. The positive effects and cost effectiveness of such programmes need to be tested over a longer period for other health problems and in other countries. PMID- 10160378 TI - The cost-effectiveness of mammography screening: evidence from a microsimulation model for New Zealand. AB - Mammography screening currently represents the only means by which the mortality rate from breast cancer can be modified substantially. A national mammography screening programme is being considered for New Zealand, and pilot programmes were established in two regions (Otago/Southland and Waikato) in 1991 to determine the potential costs and benefits of mammography for New Zealand women. The aim of this paper is to explore the cost-effectiveness of mammography screening in New Zealand relative to no screening, and to examine the marginal change in costs and benefits of altering programme characteristics such as the age of women invited and screening frequency. Cost-effectiveness is measured by the net cost (the costs of screening minus the treatment savings averted by the early detection of cancers) per year of life gained, from the perspective of the public health care sector. A microsimulation computer model, MICROLIFE, was developed to facilitate the estimation of mortality reduction and cost effectiveness. The results show that, while mammography screening does not 'save money' overall, the cost per year of life saved for a range of policies compares favourably with other New Zealand health services, and is comparable to the results from economic evaluations of mammography screening overseas. Of those regimes considered, screening women 50-64 years of age at 3-yearly intervals appears to be most cost-effective. PMID- 10160380 TI - Are decisions taken by health care professionals rational? A non systematic review of experimental and quasi experimental literature. AB - Systematic overviews of the effectiveness and cost effectiveness of health care interventions are increasingly available, and yet there has been relatively little attention upon putting their important findings into practice. Furthermore, close attention to the decision making behaviour of health professionals in situations of uncertainty indicates that this may not always be 'rational'. This paper examines developments in the understanding of rationality in decision making from outside the health care setting, particularly the interesting work on 'regret theory', and begins to apply this framework to health care. PMID- 10160379 TI - The costs of nursing turnover: evidence from the British National Health Service. AB - This article reports empirical evidence on the costs of nursing and other staff turnover in the National Health Service. It begins by considering the possible costs and benefits associated with turnover. It then examines current turnover rates in the NHS and existing estimates of the direct administrative costs and the short-term productivity losses associated with turnover. Using these estimates, it compares the cost-effectiveness of a policy which uses across-the board pay increases to reduce turnover with one which targets pay rises to certain groups only. Next, possible indirect costs of turnover are evaluated using data collected from a large cross-section of providers and other sources. No relationship is found between turnover rates and crude measures of patient service or staff morale measures. The paper concludes with a brief discussion of the main findings and some suggestions for future research. PMID- 10160381 TI - At Lutheran General, comfort is a central issue for cancer patients. PMID- 10160382 TI - Legionnaires': a prescription for prevention. PMID- 10160383 TI - High-tech security. PMID- 10160384 TI - Off balance sheet financing: a solution to low construction budgets? PMID- 10160385 TI - Year-end regs: what is OSHA doing for the holidays? PMID- 10160386 TI - Innovative new equipment lowers risks of needlesticks. PMID- 10160387 TI - Improve your people skills to get more out of trade shows. PMID- 10160388 TI - The real costs of continuous emissions monitoring. PMID- 10160389 TI - Rude awakening. One marketer faces reality as daughters experience their first service encounter. PMID- 10160391 TI - You want to market a 'what'? PMID- 10160390 TI - Shoot for the 'stars'. Hospitals should hire worker types most likely to satisfy patients. PMID- 10160392 TI - Competing for patients and profit. Analytical framework can help marketers determine the competitive strengths and weaknesses of hospitals. PMID- 10160393 TI - Matching dental offerings with expectations. Filling perceptual gap gives marketers something to sink their teeth into. PMID- 10160394 TI - The role of emotions in health care satisfaction. Positive feelings have the expected effect, but negative ones do not always result in dissatisfaction. PMID- 10160396 TI - Minister as midwife. PMID- 10160395 TI - Color makes a better message. PMID- 10160397 TI - A moment in my ministry. PMID- 10160398 TI - Sacred cows head to pasture, though some are still grazing. PMID- 10160399 TI - Consensus emerging on polished fingernails. PMID- 10160400 TI - How much cleaning is needed for OR floor? PMID- 10160402 TI - New laser standard reflects practical input. PMID- 10160401 TI - What makes a well-oiled scheduling system? PMID- 10160403 TI - Interviewing skills for selecting top performers. PMID- 10160404 TI - Internet offers world of information to nurses. PMID- 10160405 TI - Look for leadership qualities to manage changes. PMID- 10160406 TI - National Hospital Ambulatory Medical Care Survey: 1994 outpatient department summary. PMID- 10160407 TI - Social workers' perceptions of their power and service outcomes. AB - While social workers are becoming increasingly interested in methods of client empowerment, little attention has yet focused on the links between workers' own power and the services they provide to clients. The authors examine the link between workers' perceptions of their power on the job and perceived service outcomes. Bivariate and multivariate analyses were conducted on survey responses from 591 direct practice social workers in Israel. Results indicate that power perceptions are significantly associated with an array of perceived service outcomes. These findings highlight the relevance of self-efficacy and control theory in understanding social workers' efforts toward effective service delivery. Further, they underscore a need to consider more carefully direct practitioners' own power concerns as they increasingly consider empowerment of their clients. PMID- 10160408 TI - The impact of declining resources and purchase of service contracting on private, nonprofit agencies. AB - The increasingly precarious and vulnerable position of the private, nonprofit social service agency in an environment of government contracting and declining funding has been the subject of a number of articles over the past few years. Nonprofit agencies have been characterized as being controlled by powerful government agencies that dictate the terms and conditions of contracts, the types of services to be provided, the methods of delivery, and the price to be paid for services. One would expect to find nonprofits anxious to terminate their relationships with various units of government, and return to a more independent status. That is not happening. If anything, purchase of service contracting (POSC) with nonprofit agencies is increasing. This national study of nonprofit agencies explores the impact of declining funding from all sources (including POSC), and seeks to determine its impact on clients, staff, and organization. PMID- 10160409 TI - Tax incentives for corporate giving programs: what measures increase funds available? AB - Policy differences in the treatment of corporations and nonprofit private corporate foundations raise several issues of interest to those who administer and receive donations, as well as those who hope to augment government funds with private charitable donations. Of the $6 billion donated by corporations to charity in 1994, approximately one-fourth came through corporate foundations. What determines the choice of giving through a foundation or directly to charity? The author examines the financial implications for each type of corporate giving by presenting specific elements of current policy on tax rates and deductions for giving. Specific factors considered are (1) differences in the treatment of corporate and foundation income, (2) deductibility of different types of gifts, (3) occurrence of donations to non-U.S. (non-tax-deductible) charities, (4) sales of assets to fund corporate foundations, (5) effects of giving on corporate image, and (6) effects of contributions over time. Analysis of regulations illustrates motivating factors for why corporate executives make certain types of gifts in certain ways. The author clarifies how social workers, fundraisers, nonprofit managers, and corporate officials alike benefit from understanding the differences among types of gifts, methods of giving, and deductibility of corporate donations. PMID- 10160410 TI - Strategic philanthropy: an opportunity for partnership between corporations and health/human service agencies. AB - The study is a national survey of corporate philanthropy programs. The original problem underlying the study is the long-term decline in the percentage of total corporate contributions to health and human services. A questionnaire, mailed in May of 1993, was used to investigate the impact of strategic philanthropy on the relationship between corporations and health/human service organizations. Corporations strategically prioritizing their philanthropic support were expected to create new opportunities for partnerships between business and health/human service agencies. The survey resulted in a sample of 226 corporations. The results showed statistically significant support for the hypothesis that highly strategic philanthropy programs will be more likely to enter into a health/human service partnership than less strategic programs. The multiple regression analysis method was used to control for the effects of corporate size, industry type, the (corporate) contributions management organization, and United Way credibility. Based upon the results of the study, United Way is recommended to consider new roles for itself as a facilitator of partnerships between business and health/human service organizations. PMID- 10160411 TI - Total quality management: organizational transformation or passing fancy? PMID- 10160412 TI - Vascular disease. AB - This last year has been a particularly busy one in the field of neuro ophthalmology. The publication of the second, important, randomized multicentered trial in neuro-ophthalmology highlights the power of randomized trials to answer important clinical questions. This and other publications emphasize the pivotal role of vascular pathophysiology in production of neuro-ophthalmic disease. The progress in our understanding of mechanisms of vascular obstruction, risk factors for vascular disease and ocular manifestations, as well as technical advances in our approach to patients with vascular problems have continued the broad-front advancement in neuro-ophthalmology. PMID- 10160413 TI - Ocular manifestations of various systemic diseases. AB - Transsphenoidal encephalocele is associated with tongue-shaped retinochoroidal coloboma and optic disc dysplasia. Non-Graves' orbital polymyositis is associated with giant cell myocarditis. Ocular embolic disease can result from papillary fibroelastoma of the heart. Cutaneous melanoma can metastasize to the eye in the form of intraocular pigment without a discrete mass leading to heterochromia, glaucoma, and visual loss. Patients with atopic dermatitis are prone to develop retinal detachment similar in configuration to traumatic retinal detachment. The retinal hamartomas in tuberous sclerosis are usually stable, but occasionally the hamartomas show new or increased calcification, and rarely new lesions appear de novo. PMID- 10160414 TI - Pupillary light reflex. AB - A wealth of new information has recently come to light concerning the pupillary response to various types of visual input. Much of this information is recent, and has either been published in the last year, is in press, or has just been reported at meetings. This new information is important because it is resulting in reexamination of the pupillary input pathways and the clinical role for using pupillary movements to understand the physiology and pathology of the visual system. This review will focus on this new information and its clinical implication. The review is organized in the following sections: 1) the pupillary response to full-field, global light stimuli; 2) "pupil perimetry" or the pupillary response to focal light stimuli; 3) the pupillary response to isoluminant stimuli, eg, color spatial frequency, motion; 4) receptive field organization in the pupillary light reflex pathway. PMID- 10160415 TI - Eye movement disorders. AB - The ophthalmic, neurologic, and neuro-ophthalmic literature over the past year have included a wide variety of interesting case reports, patient series, and reviews involving eye movement abnormalities. This review highlights some of the more important articles and how they contribute to our understanding, diagnosis, and treatment of these disorders. A few topics will receive particular emphasis. In patients with sixth nerve palsies, botulinum toxin injection of the ipsilateral medial rectus muscle has been advocated. Recent results suggest that this treatment has no beneficial effect in acute sixth nerve palsies, but it may have a role in chronic cases. Two groups of authors, each supplying retrobulbar botulinum toxin injection for patients with acquired nystagmus and debilitating oscillopsia, obtained mixed results. One group of patients was moderately satisfied, whereas in the other group, no patients elected to repeat the treatment because of side effects such as ptosis, diplopia, or discomfort from keratitis. Finally, skew deviation is becoming a more recognized cause of vertical double vision from a central or peripheral basis. Articles published recently showed that cyclodeviation may be seen in skew deviation, and that binocular cyclotorsion distinguishes this motility abnormality from a fourth nerve palsy, which exhibits monocular excyclotorsion. PMID- 10160416 TI - AIDS and neuro-ophthalmology. PMID- 10160417 TI - Optic neuritis and demyelination. AB - The Optic Neuritis Treatment Trial continues to generate information and controversy on the visual and neurologic outcome and treatment of optic neuritis. At the same time, other researchers explored cerebrospinal fluid parameters in multiple sclerosis, treatment of experimental optic neuritis, corticosteroid treatment of multiple sclerosis, and variations and mimickers of optic neuritis. PMID- 10160418 TI - Neuro-ophthalmology of degenerative neurological disorders. AB - A number of degenerative disorders of the nervous system are associated with visual or ocular motor disturbances. Over recent years, these problems have attracted a great deal of interest because they may aid diagnosis and also improve our understanding of pathophysiology. In this review, we discuss both of these aspects of the study of degenerative conditions and attempt to demonstrate the clinical significance of a number of new findings. PMID- 10160420 TI - Recent advances in the electrophysiology of visual disorders. AB - There have been a number of technical developments in the field of visual electrodiagnosis in recent years, some of which are beginning to "bear fruit" in terms of improving accuracy of diagnosis. In addition there is more information available from electrophysiology and neurochemistry of retinal function that will lead to a clearer understanding of the physiological basis of clinical tests. PMID- 10160419 TI - Recent advances in hereditary disease and neuro-ophthalmology. AB - Recent advances in genetics tend to center on the discoveries of molecular biology. A disease is first linked to a region on a chromosome, a gene is later cloned, or a candidate gene identified, point mutations described, phenotype genotype correlations made, and rationales for treatment proposed. Several neuro ophthalmological diseases have recently been studied in this way; including Leber's hereditary optic neuropathy and other mitochondrial diseases, autosomal dominant (Kjer) optic atrophy, Wolfram syndrome, or DIDMOAD (diabetes insipidus, diabetes mellitus, optic atrophy, and deafness), Usher syndrome, neurofibromatosis types I and II, and two disorders of the paired box genes: aniridia and Waardenburg's syndrome. Apart from molecular biology there are still some new disease entities being described and new inheritance patterns identified for some syndromes, such as periodic alternating nystagmus. PMID- 10160421 TI - Diabetes and thyroid-related eye disease. AB - During the past year, the results of the Diabetes Control and Complications Trial became available. This event is expected to influence all future diabetes eye disease research. For this reason, this article starts with a discussion of these results. PMID- 10160422 TI - Ocular manifestations of genetic and development diseases. AB - Significant advances were reported this year in the identification of the chromosomal location of mutated genes on the 13 and 6 chromosomes which cause forms of autosomal dominant Stargardt's macular dystrophy. Observations in monozygotic twins with age-related macular dystrophy were described. Mitochondrial DNA mutations in Cubans with optic and peripheral neuropathy were reported. A new autosomal dominant proximal myotonic myopathy was described. Persistence of the tunica vasculosa lentis was suggested as a helpful sign of congenital myotonic dystrophy. The panoply of ocular findings in acromesomelic dysplasia were presented. Genetic characterization of the ocular findings in Duchenne type and Becker's muscular dystrophy was reported. Finally, a new syndrome of autosomal dominant cerebellar ataxia with retinal degeneration was described. PMID- 10160423 TI - Ocular manifestations of metabolic disorders. AB - Major advances in the molecular basis of oculocutaneous and ocular albinism have been published. In addition to mutations of the P gene, some patients, with so called autosomal recessive ocular albinism, were found to have a tyrosinase gene mutation in one allele and a nucleotide substitution of the same gene, which was considered as a polymorphism, in another allele. This finding has great impact on the diagnosis and genetic counseling of albinism. Flash visually evoked potentials may be a useful tool to show the asymmetry pattern in albino patients especially in infants. Some reports suggested that there may be an overlap between corneal amyloidosis and other forms of corneal dystrophy. Lattice dystrophy, granular dystrophy, and Avellino (granular-lattice) dystrophy were mapped on the same locus of chromosome 5q. Histopathologic findings supported that these different phenotypes were derived from defects of the same gene. Gelatinous droplike dystrophy and spheroidal band-shaped degeneration were also suggested to be allelic disorders by clinical and histopathological findings. PMID- 10160424 TI - Ocular manifestations of AIDS. AB - AIDS causes severe depression of the immune system through selective infection of CD4+ T lymphocytes. As such, certain infections and neoplasms occur in these patients often with ocular involvement. Among these, cytomegalovirus retinitis is by far the most common and remains a leading cause of visual loss. Intravenous ganciclovir and foscarnet, the two Food and Drug Administration-approved treatments for cytomegalovirus retinitis, are effective in most cases, but recurrences are the rule. In addition, these virustatic drugs require lifelong administration and dose-limiting toxicity affects many of these patients. Ongoing investigation into current and alternative therapies has produced some promising developments which are discussed here. Also reviewed are recent findings associated with other opportunistic pathogens and neoplasms that affect the eye in AIDS, including varicella-zoster virus, Toxoplasma gondii, and lymphoma. PMID- 10160425 TI - Ocular manifestation of systemic infections. AB - Patients with various systemic infections can often be diagnosed on the basis of their presenting ocular signs and symptoms. Recognition of the ocular manifestations of systemic infections will expedite diagnosis and allow rapid institution of appropriate therapy thereby reducing morbidity and mortality. Recent literature discussing ophthalmologic findings in the following diseases are reviewed: Whipple's disease, endogenous endophthalmitis, cat-scratch disease, toxoplasmosis, and hepatitis C. PMID- 10160426 TI - Ocular manifestations of immunological and rheumatological inflammatory disorders. AB - Further exploration of ocular manifestations in systemic immunologic and inflammatory disease continues to yield new information regarding the genetic associations, diagnosis, and treatment of these disorders. The use of color Doppler ultrasound to diagnose giant cell arteritis is reported to be of diagnostic promise. The prognosis of scleritis associated with systemic immunologic and inflammatory disease is recently highlighted in two articles. The treatment of scleritis and uveitis associated with inflammatory bowel disease is reviewed. Two reports of Vogt-Koyanagi-Harada syndrome in monozygotic twins provide further understanding of the genetic factors involved in this disease. Unusual presentations of sarcoidosis and Wegener's granulomatosis are also reported. PMID- 10160427 TI - Ocular manifestations of cardiovascular and hematologic disorders. AB - During the past year, there has been increased understanding of the ocular manifestations of various cardiovascular and hematologic disorders. Carotid and vertebral artery lesions may lead to significant and varied ophthalmic pathology. Disorders of blood pressure may influence the intraocular pressure and play a role in the progression of glaucoma. Cardiovascular risk factors such as smoking, hyperlipidemia, hypertension, and diabetes mellitus, may also play a role in the development of anterior ischemic optic neuropathy. Several cardiac anomalies as well as the cardiac use of streptokinase have been reported to have secondary ocular involvement. Both benign and malignant hematologic disorders may result in serious ocular morbidity. Recent publications have focused on the secondary ophthalmic complications from the hemoglobinopathies, problems with blood viscosity, the lymphomas, the leukemias, and bone marrow transplantation. PMID- 10160428 TI - Cataract surgery in patients with uveitis. AB - Until recently, cataract surgery in a patient with uveitis was regarded as a hazardous procedure that yielded unpredictable and often disappointing results. With an increasing number of ophthalmologists recognizing the consequences of chronic low-grade inflammation and therefore treating uveitis patients more aggressively, with a better selection of cases for surgery, and with better surgical techniques, more patients with a history of uveitis who need cataract surgery enjoy a successful outcome than ever before. Careful management and control of inflammation preoperatively and after surgery is critical to success. An in-the-bag posterior chamber lens implant can be part of the surgical plan in selected cases. The aims of the authors in this article are to emphasize the ideas of, intolerance to inflammation, a limited tolerance for steroids to minimize the incidence of cataract and irreversible damage of ocular structures essential to good vision, and strict criteria for selection and management of those patients with uveitis who need cataract surgery. PMID- 10160430 TI - Multifocal intraocular lenses. AB - Since the publication of my last article in Current Opinion in Ophthalmology in 1991 (2:33-34), the use of multifocal intraocular lenses (IOLs) has not gained general acceptance among ophthalmologists. Despite this situation, major IOL companies have continued to invest in clinical trials of new designs. Recently, large optic multifocal lenses used mainly with extracapsular extraction provided good results, with 94% to 100% of best-corrected cases having distance correction of 20/40 vision or better; 77% to 100% similarly had J3 near vision or better, and approximately 52% to 63% of patients became eyeglass independent. Between 50% to 80% of eyes in which 20/40 vision or better was obtained and in which J2 or better resulted were unaided. However, all multifocal lens designs showed some reduction in contrast sensitivity compared with monofocal designs using Regan charts and Vistech 6500 tests. Contrast sensitivity loss was probably only significant when reading very small print or in low-contrast light. Small incision surgery with phacoemulsification and more accurate IOL power calculations have made the goal of emmetropia more possible. Also, less eyeglass dependence with the use of multifocal IOLs is a more realistic expectation. PMID- 10160429 TI - Anesthesia and preoperative and postoperative medications. AB - Although certain methods such as retrobulbar blocks are used extensively, improvements in procedure can always be implemented. The use of ultrasound, low concentrations of anesthesia, careful monitoring, and, in the case of risk patients, anesthesia standby are all important considerations to ensure uneventful treatments. Topical anesthesia eliminates needle risk as well as risk of ptosis and bruising. Because it has been demonstrated that bacteria routinely enter the anterior chamber during uncomplicated cataract surgery, certain irrigation solutions are helpful, but still debatable. Postoperatively, diclofenac, flurbiprofen, and timolol have all been proven to be effective in reducing ocular inflammation, reducing incidence of CME, and controlling pressure increase, respectively. PMID- 10160431 TI - Refractive aspects of cataract surgery. AB - The emphasis in cataract surgery has shifted to perfecting the refractive outcome. More accurate lens power calculations and refinement in techniques to reduce or eliminate surgically induced and preexisting astigmatism have moved us closer to the ultimate surgical result-emmetropia. Multifocal lenses and surgically induced multifocal corneas have the potential to eliminate not only myopia and hyperopia but also the loss of accommodation resulting from the pseudophakic state. PMID- 10160432 TI - The evolving technique of cataract surgery. AB - Advances in cataract surgery revolved around using existing technology in more efficient manners. Recent reports described methods that purport to offer simpler techniques for phacoemulsification, capsulotomy, nucleus expression, and even for reducing postoperative inflammation. PMID- 10160433 TI - Corneal topography in cataract surgery. AB - Keratometry and corneal topography remain the most important means of evaluating induced corneal changes after surgery and have comparable sensitivities in the paracentral region of the cornea. However, keratometry gives no information about the peripheral cornea or about asymmetry of the cornea. Videokeratography should be performed after cataract surgery in cases in which best-corrected visual acuity is not adequate and there are no other obvious causes for poor vision to determine whether corneal irregularities are present. The recent literature on corneal topographic evaluation of induced astigmatism after cataract surgery suggests that in general, smaller, temporal incisions result in less astigmatism. Preoperatively, corneal topography can be used in the calculation of intraocular lens power as well as incision planning. Postoperatively, it can be used to detect tight sutures, torsion of the wound, internal wound gape, and irregular astigmatism, as well as to guide suture removal. In the future, corneal topography will become increasingly important in the determination of intraocular lens power in difficult cases such as patients undergoing combined cataract extraction and penetrating keratoplasty as well as patients with a history of radial keratotomy or photorefractive surgery. PMID- 10160434 TI - Perioperative antibiotic, steroidal, and nonsteroidal anti-inflammatory agents in cataract intraocular lens surgery. AB - Ophthalmologists are choosing topical antibiotics and corticosteroids more frequently than injectable agents for their current cataract surgical techniques. The preoperative use of povidone-iodine 5%, dilute intracameral antibiotics (via the balanced saline solution infusion), and postoperative impregnated collagen shields or soft contact lenses augment the therapeutic armamentarium. Nonsteroidal anti-inflammatory drugs, especially diclofenac 0.1%, have played an important role in decreasing postoperative convalescence through maintaining preoperative mydriasis, reducing anterior chamber reactions, and inhibiting cystoid macular edema. With fewer side effects, nonsteroidal anti-inflammatory drugs are minimizing the role of topical steroids. PMID- 10160435 TI - The cornea in cataract and intraocular lens surgery. AB - Advances in cataract surgery and intraocular lens implantation techniques continue to allow improved safety for the cornea. Complications can include mechanical or toxic injury of the endothelium, stripped Descemet's membrane, epithelial toxicity and disruption, infectious keratitis, or epithelial ingrowth. Most of the recent work has addressed endothelial cell survival after cataract extraction and lens implantation or in cases following secondary lens implantation. A great deal of controversy has been raised over the past year as to whether flexible open-loop anterior chamber lenses, iris-fixated posterior chamber lenses, or transsclerally sutured posterior chamber lenses are safest for the cornea. Even with additional data accumulating, it still is not clear which type of implant provides the best degree of safety in cases requiring secondary implantation. Certainly, both flexible open-loop anterior chamber lenses and bag fixated posterior chamber lenses placed at the time of cataract surgery have a good record of safety for the cornea. Patients with keratoconjunctivitis sicca require extra lubrication to prevent epithelial toxicity at the time of surgery and also postoperatively. Methylcellulose-containing lubricants appear to be most protective of the corneal epithelium. Overall, cataract surgery and intraocular lens implantation is extremely safe with modern techniques. PMID- 10160436 TI - PhacoTmesis. AB - I was extremely delighted to be invited to write a review of PhacoTmesis. However, there is not enough existing literature to review other than a few short articles authored by myself and a few short statements made by some investigators commenting on their short one-time trial of PhacoTmesis. The reason for this is that it has taken Chiron (Clairmont, CA) and myself more than 5 years to develop and evolve the concept and the machine to the level at which it can be used clinically with safety and efficiency prior to making it available to other ophthalmologists to explore its capabilities. PMID- 10160437 TI - Management of coincident glaucoma and cataract. AB - Cataract and glaucoma are two very common conditions that frequently are coincident within the same patient. The surgical treatment of the patient with both cataract and glaucoma has changed considerably in the era of small-incision cataract surgery. Additionally, many surgeons are employing antimetabolites routinely in combined phacoemulsification and trabeculectomy. This article reviews the literature as it pertains to combined cataract and glaucoma surgery within the 1-year scanning period. This is not a comprehensive review in that many very important articles are excluded because they were published either before or after the scanning period. The important topics included within this article involve the use of mitomycin C in combined surgery, the comparison of combined phacoemulsification and combined standard extracapsular procedures, long term results of combined cataract and glaucoma surgery, the survival of filtration blebs after cataract extraction in eyes that had previous trabeculectomy, new techniques of combined surgery including clear corneal cataract extraction combined with trabeculectomy, and the effect of phacoemulsification on intraocular pressure in patients with and without glaucoma. PMID- 10160438 TI - Testing time for the sunlight hypothesis of cataract. AB - The proceedings of a 2-day workshop on the role of sunlight in cataract formation have provided an opportunity to assess the importance of this widely discussed risk factor. There seems to be no role in nuclear cataract, and any role in cortical or posterior subcapsular cataract is scarcely measurable. PMID- 10160439 TI - Pediatric cataracts. AB - The treatment of an infant or child with a cataract requires a different decision process and surgical technique compared with the treatment of an adult with a cataract. The pediatric cataract literature of the past year reminds the reader that the indications for surgery and preoperative management of the pediatric cataract patient are different, that the response to surgery is different, necessitating the use of new techniques for surgery, and that complications after surgery are more common. These differences are caused by the anatomy of the pediatric eye and the susceptibility of the developing visual system to amblyopia. The literature of the past year supports with laboratory study and clinical reports the current trend toward more common use of intraocular lenses in children. PMID- 10160440 TI - Lensectomy, vitrectomy indications, and techniques in cataract surgery. AB - Removal of a cataract during a vitrectomy can be performed to improve visualization for the surgeon or to facilitate visual rehabilitation for the patient. Because aphakic eyeglasses or contact lenses are often poor options to correct aphakia, placement of an intraocular lens during or after a vitrectomy is becoming increasingly common. A cataractous lens can be removed by pars plana lensectomy, phacoemulsification, or extracapsular cataract extraction. Options for intraocular lens placement include no intraocular lens, anterior chamber lens or sutured posterior capsular lens in the absence of capsular support, "in-the bag" posterior capsular lens, or sulcus-fixated posterior capsular lens. This article reviews the current indications and techniques for cataract removal with or without intraocular lens placement in patients undergoing vitrectomy. PMID- 10160441 TI - Methods to control astigmatism in cataract surgery. AB - The correction of astigmatism during cataract surgery has evolved due to recent basic and clinical studies. To control surgically induced astigmatism, the surgeon has many options, including varying incision parameters, astigmatic keratotomy, scleral flap recession and resection, toric intraocular lens implantation, and modifying postoperative medical treatment. The recent literature is reviewed, and our current approach for cataract surgery is discussed. PMID- 10160442 TI - Radiologists are responsible for the appropriate management of imaging. PMID- 10160443 TI - Fasten your seatbelt: MR in for a wild ride. PMID- 10160444 TI - Making sense of health services research. PMID- 10160445 TI - MS researchers assess MRI as outcome tool. PMID- 10160447 TI - Significant safety advantages gained with an improved pressure-regulated blood pump. AB - A prototype of a non-occlusive pressure-regulated blood pump (M-pump) was evaluated in-vitro for safety in a comparative study with the roller and centrifugal pumps. The M-pump consists of collapsible tubing of unique design wrapped under tension around a rotor without a stator. The prototype M-pumps were tested in vitro to evaluate performance with respect to flow/ pressure characteristics, hemolysis, bubble generation (cavitation) and durability. The M pump and centrifugal pump did not overpressurize at any RPM when the pump outlet was occluded, but the roller pump reached pressures in excess of 1000 mmHg. The M pump did not generate negative pressures upon occlusion of the inlet, whereas the roller and centrifugal pumps produced near-vacuum pressures. Furthermore, the M pump was unable to empty a blood reservoir when the height of the pump inlet was placed slightly above the reservoir outlet. The levels of microbubbles in the M pump were significantly lower than the roller and centrifugal pumps upon sudden restriction of the pump inlet as determined with an ultrasonic bubble detector. The results of our in-vitro evaluation of the M-pump have shown it to have lower hemolysis than the centrifugal pump and lower or comparable hemolysis to roller pumps at flowrates of 0.1, 0.5, 4.0 and 6 L/min. We determined that the M-pump design possesses important safety advantages over roller and centrifugal pumps for cardiopulmonary bypass applications. PMID- 10160446 TI - Comparison of three methods to estimate heparin loading dose for cardiopulmonary bypass. AB - Three available methods used to determine heparin loading dose were studied to determine the most reliable method for reaching a target pre-bypass activated clotting time (ACT) of 510 seconds. One hundred and seven patients were randomly assigned to one of three treatment methods: A) 300 units/kg; B) Hemostasis Management System (HMS); C) RX/DX. Five different lots of heparin were assigned to Groups A and B, and Group C had one heparin lot. Different lots were used to account for possible variations in heparin activity. Post-skin incision ACTs, post-heparin pre-bypass ACTs, and heparin loading doses were compared. The mean and standard deviation of the post-heparin pre-bypass ACTs were used to determine which method was most reliable to obtain a desired ACT. There was no statistical difference between different heparin lots. There was no difference in the post heparin ACTs for the three methods (A:487 +/- 135 vs. B:474 +/- 105 vs. C:474 +/- 111 sec). There was a statistically significant difference between the standard deviation for the HMS and 300 u/kg standard deviations (p < 0.05). The HMS has the smallest deviation which makes it the most reliable predictor of heparin loading doses to reach a target ACT for cardiopulmonary bypass. PMID- 10160448 TI - Investigation of fatigue failure of S-65-HL "Super Tygon" roller pump tubing. AB - A failure analysis was performed on Norton S-65-HL Tygon tubing. Fatigue testing was performed on four sizes of this tubing, and essentially showed how the tubing wears out. A dynamic "life hours to failure" test, which was performed on the 3/8" internal diameter (ID) size, quantified when the tubing ruptured. Based on results of laboratory testing and the institution's clinical extracorporeal membrane oxygenation (ECMO) experience, a reasonable life expectancy for the 3/8" S-65-HL Tygon size was determined for use in this institution's neonatal ECMO system. An understanding of the expected performance of roller pump tubing-an integral component of the ECMO system-is imperative to providing safe, effective extracorporeal life support. PMID- 10160450 TI - The need to certify products to CDRH Regulations. AB - Laser products that are sold in the United States are required to comply with the regulations published by the Center for Devices and Radiological Health (CDRH) within the US Food and Drug Administration [1]. The need to certify products is straightforward in most instances, however, the applicability of the regulations is not as clear for: lasers sold only to Original Equipment Manufacturers (OEMs) as components for incorporation into end-use products, end-use products that contain lasers which have already been certified by their manufacturers, and end use products that are being imported into the US and that already comply with international laser safety standards. This article will discuss these applications in an attempt to clarify the need for certification by laser product manufacturers and importers. The discussion applies equally for lasers and laser systems. PMID- 10160449 TI - Scavenging anesthetic gas from a membrane oxygenator during cardiopulmonary bypass. AB - Concerns remain about the acute and chronic effects on personnel of waste anesthetic gases in the operating room environment. This study demonstrates a simple and effective means of scavenging waste anesthetic gases when halogenated anesthetics are administered through the pump oxygenator during cardiopulmonary bypass. This technique safeguards workers' health by reducing ambient anesthetic levels below the National Institute for Occupational Safety and Health (NIOSH) recommended exposure limits. PMID- 10160451 TI - Where have all out leaders gone? PMID- 10160452 TI - Authoritarianism, inner/other directedness, and sensation seeking in firefighter/paramedics: their relationship with burnout. AB - INTRODUCTION: Burnout in firefighter/paramedics (FF/EMT-Ps) is widely believed to exist, but few empirical data support its existence, symptomatology, or intervention. Understanding the extent, nature, and cause of burnout is crucial to improving employee morale and performance. STUDY POPULATION: Ninety-one FF/EMT Ps employed by Salt Lake County Fire Department. HYPOTHESES: Three specific hypotheses were tested: 1) FF/EMT-Ps who score high on burnout will also score high on authoritarianism; 2) FF/EMT-Ps who score high on burnout also will score high on inner-directedness; and 3) FF/EMT-Ps who score high on burnout also will score high on sensation seeking. METHODS: In this descriptive study, FF/EMT-Ps completed four standardized instruments measuring authoritarianism, burnout, inner-directedness versus other-directedness, and sensation seeking. RESULTS: Firefighters who scored high on burnout also scored high on authoritarianism and on the sensation-seeking subscale of boredom. Burnout did not correlate with the overall sensation-seeking scale or with its other subscales (thrill, experience, and disinhibition), or inner-directedness versus other-directedness. CONCLUSION: A focus on control issues needs to be an integral part of programs for decreasing employee burnout among FF/EMT-Ps. Specific components of such programs should include stress management and counseling. In addition, management personnel need to be taught not only to assist direct-service staff, but also to recognize and deal with their own control issues as they affect job performance. PMID- 10160453 TI - Safe out-of-hospital treatment of chest pain without direct medical control. AB - INTRODUCTION: The use of direct medical control (DMC) in the out-of-hospital setting often is beneficial, but has the disadvantage of consuming emergency medical services (EMS) resources. HYPOTHESIS: Uncomplicated, nontrauma, adult patients with chest pain can be treated safely and transported by paramedics without DMC. METHODS: Retrospective chart review of all nontrauma, adult patients with chest pain treated in a combined rural and suburban EMS system during a 2 year period (December 1990 through November 1992) was conducted. Before November 1991, DMC was mandatory for all patients with chest pain. Beginning 01 November 1991, if a patient had resolution of a pain either spontaneously, with administration of oxygen, or after a single dose of nitroglycerin, DMC was at the discretion of the paramedic. Using the above criteria for inclusion, three study groups were defined: Group 1, before protocol change; Group 2, after protocol change without DMC; and Group 3, after protocol change when physician contact was obtained, but not required. These groups were compared for the following parameters: 1) scene time; 2) time to administration of first dose of nitroglycerin; 3) time interval between measurement of vital signs; 4) oxygen use; 5) intravenous access; and 6) electrocardiographic monitoring. Continuous and categorical variables were analyzed by multivariate and univariate analysis of variance and chi-square tests, respectively. RESULTS: Of 308 nontrauma, adult patients with chest pain, 71 met inclusion criteria in Group 1, 40 in Group 2, and 34 in Group 3. No statistically significant differences were identified in any of the study parameters. CONCLUSION: Adult patients with chest pain who have no other symptoms or complicating conditions can be treated appropriately be paramedics without DMC. PMID- 10160454 TI - The consequence of land mines on public health. AB - An estimated 110 million land mines scattered in 64 countries continue to terrorize people and destroy human lives long after wars and fighting have ceased. Despite efforts to clear these devices, their numbers continue to increase and their presence constitutes a substantial threat to public health in affected countries. Direct consequences include both the physical and emotional injuries from the impact, flying debris, and structural collapse associated with their detonation. Indirect consequences include increases in the incidence of waterborne diseases, diarrhea, malnutrition, infectious diseases, and spread of the human immunodeficiency virus associated with the increased use of blood. Those at highest risk of these later consequences are mostly the disadvantaged poor, especially children. Psychiatric disorders, such as post-traumatic stress disorder, occur in those not directly injured as well as those physically wounded by the explosion. Besides efforts to ban production, stockpiling and export of land mines, a comprehensive and integrated health program aimed at the prevention, treatment, and rehabilitation of those injured directly or indirectly by land mines is needed urgently. Strategies should include mine-awareness programs, enhanced transport of those directly injured, training the villagers in first aid, augmenting the capacity and quality of treatment facilities, improving the psychological support and treatment capabilities, development of rehabilitation programs, and the institution and enhancement of public-health programs directed at the indirect consequences associated with the presence of land mines. Land mines constitute a major public health problem in the world that must be addressed. PMID- 10160455 TI - Evaluation of the Pediatric Trauma Triage Checklist as a prehospital pediatric trauma triage tool for the state of Florida. AB - INTRODUCTION: Triage of injured children poses a significant challenge for prehospital care providers because there is not single trauma triage tool in use that has been developed specifically for children. The pediatric trauma score (PTS) probably is the single most studied and tested trauma triage tool developed solely for the pediatric population, and is an effective predictor of both severity of injury and potential mortality in injured children. However, the pediatric trauma score has been found to be an ineffective prehospital triage tool because it is not "user friendly" for field personnel. As such, the PTS has been modified to generate the more user-friendly "pediatric trauma triage checklist (PTTC)." METHODS: This study retrospectively reviewed 106 prehospital run reports to determine whether the patient met one or more of the criteria in the PTTC. By applying the MacKenzie algorithm to outcome data for each case, it was possible to determine whether the patient should have been sent to a trauma center. RESULTS: The PTTC demonstrated a sensitivity of 86.2%, a specificity of 41.6%, and an accuracy of 66.0% The PTTC demonstrated an overtriage rate of 58.3% and an undertriage rate of 13.8% When compared with a previous study, the PTTC demonstrated a 74% increase in overtriage. However, the 59% reduction in undertriage is more important. CONCLUSIONS: Use of the PTTC appears to have merit as a pediatric prehospital trauma triage tool but further study is recommended. The PTTC should be tested in a prospective, multiregional study involving a sample size sufficient to reach statistical significance. PMID- 10160457 TI - Treatment of casualties of military conflicts at the Critical Medicine Clinic of the Central Hospital in Georgia. AB - INTRODUCTION: Local military conflicts continue in many areas of the world. These conflicts produce multiple casualties to military personnel and civilians. This paper describes one aspect of the medical care required for victims of the civil conflict in the Republic of Georgia. METHODS: Interviews with patients and their accompanying persons and abstraction of medical records. RESULTS: Data were acquired on 108 victims admitted to the Center for Critical Medicine in Tbilisi. Three stages in the care of these victims are described: 1) battlefield and transportation; 2) regional, front-line hospitals; and 3) the Central Hospital. The performance of each stage is described. Distribution of injuries and procedures performed in the third stage of treatment are described and survivors are defined. For illustration, two cases are reviewed in detail. CONCLUSIONS: The results are encouraging. Major problems existed in the treatment and evacuation of the wounded. Furthermore, many of the victims were injured because of their carelessness and lack of experience on the battlefield. PMID- 10160456 TI - The development and evaluation of a paramedic-staffed mobile intensive care unit for inter-facility patient transport. AB - OBJECTIVE: As the role of paramedics evolves, evaluation of their ability to accomplish an expanded scope of practice is necessary. The objective of this study was to determine whether specially trained paramedics can monitor and treat patients appropriately during interfacility transports that traditionally have required the use of supplemental, hospital-based personnel. METHODS: A paramedic staffed mobile intensive care unit was developed as a cooperative program between Huron Valley Ambulance and the Washtenaw/Livingston County Medical Control Authority. This prospective observational study involved 111 patients requiring interfacility transport, conveyed by a paramedic-staffed mobile intensive care unit. A change in the Acute Physiologic and Chronic Health Evaluation (APACHE II) score components of mean arterial pressure, heart rate, and respiratory rate at the beginning and end of the transport was used to evaluate the ability of the paramedics to accomplish the transfer appropriately. RESULTS: APACHE II scores increased in 20 patients, decreased in 16, and were unchanged in 75. The mean value for the change in APACHE score was 0.11 (95% confidence interval: -0.11 0.33). CONCLUSION: Specially trained paramedics can monitor and treat patients appropriately during interfacility transfers that traditionally would have required supplementation with additional hospital staff. PMID- 10160458 TI - An analysis of demand for first-aid care at a major public event. AB - INTRODUCTION: First aid is the initial care of the ill or injured. It aims to preserve and protect life, prevent further injury or deterioration of illness, and help promote recovery. At major public events, there is a large gathering of people, physical spectacles, and equipment within a concentrated area, where organized first-aid care is provided. OBJECTIVE: To analyze the demand for primary medical care at a public event by identifying the patients and initial symptoms that may predict that demand, and to use such information to improve the efficiency and delivery of medical care. METHODS: A questionnaire was completed by St. John Operations Branch personnel after each patient consultation and a retrospective analysis of the data was conducted. RESULTS: A total of 1,276 questionnaires were returned. Mean patient presentation rate (PPR) was 1.9 +/- 0.47 per 1,000 show attendees. This correlated best with the maximum daily temperature (r = 0.715, p <0.02) and show day (r = 0.615, p <0.05). There was poor correlation with daily attendance (r = -0.235, p >0.54). Mean presentation time was 15:13 h. Of those whose gender was recorded, 58.4% were females, and 41.6% were males. The most frequent age group was 13 to 20 years. The nature and number of initial symptoms are listed. Basic first-aid skills were used for 96.7% of symptoms; 2.4% of patients were referred to the hospital. CONCLUSIONS: Temperature and show day significantly contributed to variability of PPR. These factors, together with an estimated PPR and predicted attendance, can be used to forecast demand. Most cases required only basic first-aid skills. Guidelines are suggested for management by nonmedical personnel. A medical officer's role is not reliably defined, but involvement in consultation is suggested. PMID- 10160459 TI - Use of on-line medical command to randomize patients in a prehospital research study. AB - OBJECTIVE: To describe the efficiency of using on-line medical command (OLMC) to conduct a prospective, randomized clinical trial addressing safety and patient enrollment. DESIGN, SETTING, AND PARTICIPANTS: Prospective design using OLMC to randomize adult asthmatics into one of three treatment groups. After verifying inclusion and exclusion criteria, OLMC physicians removed a covering label on study sheets and ordered the treatment specified underneath the label that had been assigned in a random sequence. RESULTS: A total of 204 patients were seen with dyspnea and wheezing during the three-month study. Of these, 68 (33%) were excluded from the study. Of the 136 (67%) patients who were eligible for study, 87 were enrolled (enrollment efficiency 64%), with 79 fully evaluable (evaluable efficiency 91%). The study safety was 100% because no enrolled patients met any exclusion criteria. CONCLUSIONS: The design was random and prospective, with patient entry blinded, using paramedics to enroll patients and OLMC physicians as gatekeepers, thus ensuring appropriate patient eligibility and study-arm assignment. Use of OLMC physicians to perform prospective randomized studies is safe and efficient, and results in a high yield of evaluable patients. PMID- 10160460 TI - The esophageal detector device: accuracy and reliability in difficult airway settings. AB - INTRODUCTION: The esophageal detector device (EDD) recently has been found to assess endotracheal (ET) tube placement accurately. This study describes the reliability of the EDD in determining the position of the ET tube in clinical airway situations that are difficult. METHODS: This was a prospective, randomized, single-blinded, controlled laboratory investigation. Two airway managers (an emergency-medicine attending physician and a resident) determined ET tube placement using the EDD in five swine in respiratory arrest. The ET tube was place in the following clinical airway situations: 1) esophagus; 2) esophagus with 1 liter of air instilled; 3) trachea; 4) trachea with 5 ml/kg water instilled; and 5) right mainstem bronchus. Anatomic location of the tube was verified by thoracotomy of the left side of the chest. RESULTS: There was 100% correlation between the resident and attending physician's use of the EDD. The EDD was 100% accurate in the determining tube placement in the esophagus, in the esophagus with 1 liter of air instilled, in the trachea, and in the right mainstem bronchus. The airway managers were only 80% accurate in detecting tracheal intubations when fluid was present. CONCLUSIONS: The EDD is an accurate and reliable device for detecting ET-tube placement in most clinical situations. Tube placement in fluid-filled trachea, lungs, or both, which occurs in pulmonary edema and drowning, may not be detected using this device. PMID- 10160461 TI - In-field extremity amputation: prevalence and protocols in emergency medical services. AB - OBJECTIVE: To determine current experience, attitudes, and training concerning the performance of in-field extremity amputations in North America. DESIGN: Cross sectional, epidemiological survey. PARTICIPANTS: Emergency medical services (EMS) directors from the 200 largest metropolitan areas in North America and attendees at the 1992 Mid-Year National Association of EMS Physicians Meeting. INTERVENTIONS: The survey consisted of five questions focusing on demographic and operational data, the frequency of occurrence of the performance of in-field amputations, personnel responsible for performing the procedure, existing written protocols for the procedure, and the scope of training provided. RESULTS: A total of 143 surveys was completed. Eighteen respondents (13%) reported a total of 26 in-field extremity amputations in the past five years. The most common cause for the injuries requiring amputations was motor-vehicle accidents. In the majority of cases (53.2%), trauma surgeons were responsible for performing the amputation, followed by emergency physicians (36.4%). Of respondents, 96% stated that there was no training available through their EMS agencies related to the performance of in-field extremity amputations. Only two EMS systems had an existing protocol regarding in-field amputations. CONCLUSIONS: The results suggest a need for established protocols to make the procedure easily accessible when needed, especially in large metropolitan EMS systems. This information should be emphasized during EMS training and reinforced through continuing education. PMID- 10160462 TI - Human health concerns from pet ownership after a tornado. AB - INTRODUCTION: Although 50% to 60% of North American households own pets and many of these pets are considered family members, there is little information on the impact of pet ownership on pet-owning families affected by disasters. METHODS: This case report describes some of the effects of a tornado on 17 families whose dwellings were destroyed. The setting was a typical urban trailer park. RESULTS: After a tornado at the Sagamore Village Trailer Park in north central Indiana, 104 families were evacuated. Seventeen (16.3%) of these families owned pets. For 14 families (13.5%), pet ownership had an important impact on the families' recovery from the tornado. Public- and mental-health concerns that arose from pet ownership included failure to evacuate a dangerous site, attempts to re-enter a dangerous site, separation anxiety leading to psychosomatic disturbances, and the need for additional animal care. CONCLUSIONS: In urban disasters, the behaviors of families with a human-animal bond are likely to pose a significant risk to their own and others' health and safety in urban disasters. In this small study of families affected by a tornado, the most prominent public-health concerns were failure to evacuate because of a pet and attempts of re-entry to save a pet; the most common mental-health concerns resulted from separation anxiety from a pet and refusal to accept medical treatment until a pet's well-being can be assured. These are thought to be typical issues that will arise out of the human-animal bond in urban disaster situations and differ considerably from traditional public health concerns over dog bites, spread of zoonotic diseases, and human food contamination. Medical disaster preparedness planning should consider the substantial effects that the human-animal bond is likely to have on human recovery from large-scale urban disasters. PMID- 10160464 TI - Patient-data collection system used during medical operations after the 1994 San Fernando Valley-Northridge earthquake. PMID- 10160463 TI - Natural hazards: causes and effects. Lesson 7-Drought. AB - Drought has long been recognized as one of the most insidious causes of human misery. Today, it is the natural disaster that annually claims the most victims. Its ability to cause widespread misery is estimated to be increasing. While generally associated with semiarid climates, drought may occur in areas that normally enjoy adequate rainfall and moisture. In the broadest sense, any lack of water for the normal needs of agriculture, livestock, industry, or human population may be termed as a drought. The cause may be lack of supply, contamination of supply, inadequate storage or conveyance facilities, or abnormal demand. Drought is a condition of climatic dryness severe enough to reduce soil moisture and water below the minimums necessary for sustaining plant, animal, and human life. Drought usually is accompanied by hot, dry winds and may be followed by damaging floods. More socially relevant than technically correct is the definition used by Ari Toubo Eibrahim, the minister of agriculture in Niger, who has said that a drought is "Not as much water as the people need." PMID- 10160465 TI - Laser prostatectomy or TUIP for BPH? AB - Management of benign prostatic hypertrophy has been and continues to be a major focus of urologic care. Every year, some 300,000 transurethral resections are performed annually in the United States. In this Point and Counterpoint, Drs. Madsen, Bruskewitz, and Kabalin review the relative merits of transurethral incision and laser prostatectomy, two newer treatments for BPH. PMID- 10160466 TI - Antibiotic-associated diarrhoea. A costly problem. PMID- 10160467 TI - The societal value of pharmaceuticals. Balancing industrial and healthcare policy. AB - Pharmaceutical policy arises through an ongoing process of negotiation and interaction among the key players in the pharmaceutical market: consumers, industry, healthcare providers and government. There is constant discussion about the just distribution of reward between cost-containment goals and the goals of research and development in the pharmaceutical arena. All industrial countries are under pressure to control healthcare costs, but it is unclear how cost containment policies will influence industrial policies for pharmaceuticals. The pharmaceutical industry is an easy target for governmental cost-containment policies. The industry is driven by 3 issues: access to consumers, access to new technology and new competitive realities. The launch of a new, innovative product that represents a significant therapeutic breakthrough is becoming increasingly difficult, and a major challenge for politicians and governments will be to balance the need for cost-effective use of drugs and the need to create a favourable climate for innovation. Previously, there was generally little competition between pharmaceutical companies, but those companies will now have to undergo fundamental and comprehensive changes. Particularly, it will be important to have extremely well developed and integrated management systems focusing on both consumers and costs. PMID- 10160468 TI - Colony-stimulating factors and peripheral blood progenitor cell transplantation. Benefits and costs. AB - High dosage chemo- or radiotherapy followed by the administration of autologous bone marrow-derived stem cells [i.e. autologous bone marrow transplantation (ABMT)] is an established protocol for treating acute myeloid leukaemia and malignant lymphoma. The approach is also under investigation in the treatment of acute lymphocytic leukaemia, multiple myeloma and solid tumours. In all of these diseases, the optimisation of indications, conditioning schemes, stem cell harvest techniques and supportive care with growth factors is subject to continuous preclinical research and clinical phase II and III studies. Recently, the administration of peripheral blood stem cell preparations to cancer patients as rescue therapy after high dosage antitumour therapy has been received with much enthusiasm. At first glance, the technique looks rather easy to perform. The faster recovery of haemopoiesis, compared with ABMT, leads to shorter durations of hospitalisation. Moreover, in most studies, peripheral blood progenitor cell transplantation (PBPCT) resulted in fewer septic episodes, fewer intensive care admissions, fewer red blood cell and platelet transfusions, reduced use of anti infectives and parenteral nutrition, and reduced hospital costs compared with ABMT. The overall conclusion is that the treatment costs of PBPCT are 15 to 30% lower than the treatment costs of ABMT. However, a formal comparison between PBPCT and ABMT, assessing the differences in toxicity, costs and quality of life, is still awaited. PMID- 10160470 TI - Comparing dihydroergotamine mesylate and sumatriptan in the management of acute migraine. A retrospective cost-efficacy analysis. AB - The annual cost of managing migraine totals billions of US dollars. This retrospective economic analysis of a clinical trial comparing subcutaneous dihydroergotamine mesylate (DHE) with subcutaneous sumatriptan in the treatment of acute migraine is appropriate because, although each product has been shown to be efficacious, the acquisition cost of sumatriptan is over 3 times that of DHE. Total costs in each treatment group were calculated and applied independently to 11 clinical trial efficacy measures. Three of the efficacy measures showed no statistically significant difference between treatment arms, leading to a decision to use the less expensive DHE. In 4 of the efficacy measures. DHE was the obvious choice because it is more efficacious and less expensive. For the final 4 efficacy measures, where sumatriptan is more efficacious and more expensive, incremental cost-efficacy ratios were calculated to determine the additional expenditure required to achieve outcomes associated with quick relief. Depending on the efficacy variable chosen and the assumptions used in the model, the incremental cost-efficacy ratios ranged from $US4000 to $US6700 per year (1993 dollars) for each additional patient who is successfully treated with sumatriptan compared with DHE. Therefore, in a population of 100 migraineurs, an additional 13 to 22 patients would achieve these short term benefits of sumatriptan, although it would cost an additional $US88 395 annually, given the assumptions made. Because each product has unique advantages, we conclude that the more cost-efficacious product is dependent on the outcome of interest and the amount that the patient or provider is willing to pay to achieve that outcome. PMID- 10160469 TI - Cost-effective treatment of lower respiratory tract infections. AB - Pneumonia is one of the most frequent causes of hospitalisation, accounting for many deaths each year. Elderly patients, especially those in extended care facilities, are at particular risk for pneumonia and have a higher mortality rate than younger patients. The cost of treating patients with lower respiratory tract infections (LRTIs) is staggering, especially for patients who require hospitalisation. Less extensive diagnostic testing may be utilised in the future to minimise the cost of LRTIs, although this in turn might compromise our knowledge of the pathogens involved and their resistance patterns. Currently, the prevalence of various pathogens is known, and varies on the basis of underlying risk factors such as age, structural or functional lung disease, mental status, immune system function and geographical region. However, resistance patterns of commonly implicated pathogens are ever-changing. For example, Streptococcus pneumoniae, which is the most frequent cause of community-acquired pneumonia, has become resistant to benzylpenicillin (penicillin G) in recent years. This is especially disturbing because cross-resistance with other classes of antibiotics frequently occurs. Many antibiotics have been used in the treatment of LRTIs. Cephalosporins are popular because of their broad spectrum of activity and excellent safety profiles. Penicillins have also been popular, although resistant strains of S. pneumoniae now pose a serious threat. The macrolides have recently enjoyed increased popularity because of their activity against atypical pathogens. Although the fluoroquinolones are second-line agents for community acquired pneumonia, they have a place in the treatment of LRTIs encountered in the nursing home or hospital setting, and even have activity against atypical bacteria. A variety of innovative programmes have been developed in recent years to control the cost of treating LRTIs. Although limited formulary choices have been used in the hospital setting for years, and are now becoming popular in managed care, there is no proof that this mechanism saves money when looking at the overall picture. A rational approach is to conduct a rigorous pharmacoeconomic evaluation of treatment options, thus identifying the therapies that provide the best value in each setting. Equally important are various programmes that encourage the cost-conscious use of the antibiotics chosen. Some of the methods evaluated in the literature include: notifying prescribers of the true cost of treatment alternatives, notifying prescribers whether or not third party coverage is available for the prescription, streamlining from combination therapy to a single agent, early switching from parenteral to oral therapy, initiating treatment with oral agents, administering parenteral antibiotics at home from the outset of therapy, and antibiotic streamlining programmes that are partnered with infectious disease physicians. For the most part, these programmes have not been rigorously evaluated. Newer, more innovative ways to provide cost conscious treatment of LRTIs will undoubtedly be developed. The basic premise for these programmes should be rigorous, well-designed pharmacoeconomic evaluations. Such studies will help ensure that all facets of therapy are evaluated and should prevent choices being made simply on the basis of the lowest acquisition cost. PMID- 10160471 TI - Pharmacoeconomics of Pneumocystis carinii pneumonia in HIV-infected and HIV noninfected patients. AB - Despite the proven effectiveness of Pneumocystis carinii pneumonia (PCP) prophylaxis in both HIV-infected and HIV-noninfected patients, PCP remains an important cause of serious pulmonary infection. Because PCP is a frequent event requiring inpatient admission at our institution, we conducted a study to define the pharmacoeconomics of this infection and the incidence of adverse events associated with anti-PCP therapy. In a retrospective review, 133 patients (101 HIV-positive, 32 HIV-negative) with documented PCP were identified. Significant differences in age, initial arterial oxygen tension (paO2), intensive care unit admission and mortality were evident between HIV-infected and non-HIV-infected patients; however, there were no differences in the duration of hospitalisation or the duration of anti-PCP therapy. The incidence of biochemical abnormalities was similar between the groups. Leucopenia occurred at an incidence of 52 and 31%, while thrombocytopenia occurred at a rate of 7 and 44%, in HIV-positive and HIV-negative patients, respectively. Drug toxicity or treatment failure necessitated a change of therapy in 43% of HIV-positive and 59% of HIV-negative patients. PCP treatment cost, pharmacy cost, hospital cost and net loss (i.e. the difference between hospital cost and reimbursement) were all significantly greater in HIV-negative than in HIV-positive patients. The duration of anti-PCP therapy and the hospital cost for cotrimoxazole (trimethoprim-sulfamethoxazole)- and pentamidine-treated patients were similar, although the treatment cost and pharmacy cost were statistically different in favour of cotrimoxazole. Overall, cotrimoxazole is an inexpensive treatment option. However, the high incidence of adverse events attributed to this agent often necessitates a change to a more costly therapy. PMID- 10160472 TI - Decision analysis of Helicobacter pylori eradication therapy using omeprazole with either clarithromycin or amoxicillin. AB - In patients with duodenal ulcer, omeprazole plus clarithromycin (OC) has achieved Helicobacter pylori eradication rates of about 80%, compared with 50% for omeprazole plus amoxicillin (OA). The drug acquisition costs for OC are 102.92 pounds sterling (pounds) compared with 38.96 pounds for OA using generic amoxicillin and 51.63 pounds using the proprietary brand 'Amoxil' (costs for 2 week regimens in 1995). The aim of this analysis was to estimate the total healthcare costs to the general practitioner (GP) of eradication therapy using a simple generalised model. Data about current practice in the UK were obtained from 502 respondents in a survey of hospital specialists and GPs. It was assumed that patients would derive no benefit from eradication therapy unless they had a duodenal ulcer, and that all OA patients received generic amoxicillin. The survey confirmed that OA was the commonest eradication therapy prescribed by UK GPs at that time. Three distinct patient groups were identified: patients with proven duodenal ulcer who were already receiving maintenance treatment with a histamine H2 receptor antagonist, and new patients with dyspepsia who were subdivided into those aged above or below 45 years. Patients receiving maintenance treatment for a duodenal ulcer would be prescribed eradication therapy by their GP without further endoscopy. If dyspepsia recurred after eradication therapy, they would be referred to a gastroenterologist, who would perform an endoscopy to confirm the recurrence of ulceration. In this model, the expected total healthcare costs (i.e. the costs of drug acquisition and subsequent treatment when required) following prescription of eradication therapy were lower for OC (157 pounds) than for OA (173 pounds). New patients aged over 45 years would be referred for endoscopy because of the risk that dyspepsia might be the initial presentation of gastric cancer. If duodenal ulceration was found, eradication therapy would be prescribed and, if dyspepsia remained or recurred, the patient would be referred back to the gastroenterologist. In this case, it was considered unlikely that a further endoscopy would be performed. Thus, the healthcare costs associated with failure of eradication in these patients were less than for patients on maintenance treatment, and the expected total healthcare costs were higher for OC (349 pounds) than for OA (335 pounds). Finally, a new patient aged under 45 years with dyspepsia would have eradication therapy prescribed on the basis of a clinical diagnosis of duodenal ulcer plus serological evidence of infection with H. pylori. Continuation or recurrence of dyspepsia would result in referral to a gastroenterologist, who would perform an endoscopy. The total expected healthcare costs were higher for OC (253 pounds) than for OA (251 pounds). The cost effectiveness of OA was sensitive to changes in the default costs (i.e. the average costs from the survey used in the decision analysis), particularly in patients < 45 years old. In these patients, OC would become the cheaper option if amoxicillin were prescribed by brand name instead of in generic form. In this patient group, the outcome was crucially dependent on the accuracy of the clinical diagnosis of duodenal ulcer; if this was at least 60%, then OC would be the cheaper regimen. Overall, the model clearly shows that the higher drug cost of OC is likely to be substantially offset by savings in other healthcare costs. If the direct healthcare costs of OC are higher than OA, then the decision maker must consider the indirect and intangible costs associated with failure of eradication therapy. PMID- 10160473 TI - Cost effectiveness and the allocation of therapies in a treating population. AB - The purpose of this paper is to challenge the uncritical use of incremental cost outcomes ratios as decision variables. A scenario is presented which describes conditions under which increasing costs per unit of outcome prevail. Marginal costs increase as the proportion of patients treated under a given therapy increases. If the health system's objective is to maximise health benefits then patients will be switched until the marginal benefits per dollar expended are equal between the 2 therapies. In an example where the costs of the new therapy are greater, for a given proportion of patients treated, patients are switched from the existing to the new therapy until an equilibrium is achieved in the allocation of therapies among the treating population. At this point, the overall costs of treatment are at a minimum. This outcome could only be predicted if the underlying cost-outcomes functions are known and the consequent patterns of therapy substitution and cost impacts assessed. The paper concludes by raising concerns as to the role of incremental cost-outcomes ratios as decision variables where increasing costs may be expected to prevail and there is failure to consider the implications of these increasing costs in formulary decision making. If increasing costs are present then conventional cost-outcomes and incremental cost-outcomes ratios are of limited utility as decision variables in the choice of therapy options. PMID- 10160474 TI - Hidden costs of antibiotics. PMID- 10160475 TI - The impact of user charges on the consumption of drugs. Empirical evidence and economic implications. AB - Expenditure on drugs is increasing rapidly in many countries, and this has led to increased interest in measures to contain drug expenditure. One measure that has been discussed is to increase user charges for prescription drug. In this article, we consider whether or not raising user charges decreases the consumption of drugs. We also discuss how to judge if increased user charges for drugs are desirable from an economic viewpoint. We conclude that the decision to increase user charges for prescription drugs should not be viewed as an issue of cost containment, but as a matter of balancing the societal costs against the societal benefits of increased user charges. PMID- 10160476 TI - Is there scope for improving the cost-effective prescribing of nonsteroidal anti inflammatory drugs? AB - Nonsteroidal anti-inflammatory drugs (NSAIDs) are used widely throughout the world to relieve the symptoms of musculoskeletal disorders, in particular osteoarthritis and rheumatoid arthritis. These drugs have significant adverse effects, including gastrointestinal ulceration and the associated complications of perforation and bleeding. The relative toxicity of competing forms of branded and generic NSAIDs varies considerably. Their acquisition cost also varies considerably, sometimes with relatively more toxic drugs being more expensive. Thus, it may be possible to reduce both adverse effects and pharmaceutical expenditures associated with NSAIDs, if doctors' prescribing behaviour can be changed. A tentative exploration of alternative patterns of NSAID use demonstrates that it may be possible to reduce expenditures on NSAIDs in the UK to below the 1994 level, and reduce adverse events. If prescribing of NSAIDs was reduced by 25%, average dosage reduced by 10% and patients switched to less toxic NSAIDs, up to 86 million pounds sterling could be saved per year in the UK, the number of serious adverse events per year reduced by 189 (from a baseline figure of around 500) and the annual number of gastrointestinal complications reduced by 127 (from a baseline figure of around 315). Such results may be achieved without reductions in the quality of life of patients using these drugs. The available clinical and economic information about NSAIDs is limited, and the publication of numerous poor quality studies has corrupted the knowledge base. Despite these problems, there appears to be enough evidence to indicate that expenditure on NSAIDs could be considerably reduced and significant adverse effects could be avoided if general practitioners were persuaded to change their prescribing behaviour. Inefficient and inappropriate prescribing of these often beneficial, but sometimes dangerous, drugs appears to be wasting scarce UK National Health Service resources and harming patients. PMID- 10160477 TI - Clinical and cost considerations in the pharmacotherapy of vulvovaginal candidiasis. AB - Vulvovaginal candidiasis (VVC) is a frequent cause of morbidity in women of reproductive age. Most women will experience 1 or 2 episodes in their lifetime, but a smaller population develop chronic recurrent disease. There are few data on cost or pharmacoeconomic considerations in the management of this condition. The disease does not usually result in long term disability, loss of employment or death, but could affect a woman's work performance through irritability, frustration and unhappiness. This review attempts to estimate the least costly programme or regimen (as the efficacy of different regimens is similar) that would be applicable to patients, third-party payers and society. Nonprescription or over-the-counter (OTC) antifungal preparations could have an impact on overall cost in the management of VVC. In the management of infrequent acute VVC, an OTC preparation would be least costly to the healthcare system (provided that the diagnosis was correct). The strategies used to control symptoms in patients with chronic recurrent VVC should be based on the frequency of recurrent episodes. For patients with less than 12 episodes a year, empirical self-treatment at the onset of symptoms with an OTC agent (e.g. intravaginal clotrimazole 500mg) is less costly and preferable to patients than monthly prophylaxis. Patients with a greater frequency of recurrences may benefit from monthly, daily or twice weekly prophylaxis. At present, for very frequent recurrences, intravaginal clotrimazole 200mg twice weekly appears to be as effective as daily oral ketoconazole, and may be safer and less costly. However, because of the lack of prospective controlled studies, most of these recommendations are based on hypothetical reasonings. Furthermore, the disadvantages of OTC antifungals include the potential for overuse and inappropriate use, possibly resulting in the delayed diagnosis and treatment of other conditions. On balance, OTC preparations may provide patients with faster and more economical care, and improve healthcare delivery. PMID- 10160478 TI - Statistical analysis in pharmacoeconomic studies. A review of current issues and standards. AB - The increasing number of economic evaluations of healthcare interventions, and of drug therapies in particular, has been well documented. However, surveys have demonstrated that standards of conduct of such studies have not similarly increased. Of particular concern is the lack of development or even consideration of statistical techniques in the reporting of studies. This article addresses issues that must be considered both in the conduct and in the assessment of the quality of studies. Throughout the paper, examples of pharmacoeconomic analyses are used to illustrate the points made. Recommendations for the conduct of future pharmacoeconomic studies are given. Such recommendations specifically relate to the level of testing that is conducted, the choice of statistical tests and the manner in which statistical significance is reported. In addition, existing methods for the statistical analysis of cost-effectiveness ratios and for the determination of sample size in economic evaluations are discussed, and a partial solution to this issue is offered. PMID- 10160479 TI - A cost analysis of alprostadil in liver transplantation. AB - Alprostadil (prostaglandin E1) administration to liver transplant recipients has been shown to result in a significant reduction in the duration of hospital admission for transplantation, and in the need for re-operations (other than re transplants) and renal support. To study the economic impact of this finding, we examined data from a controlled trial for all single-transplant surviving patients (42 alprostadil, 49 controls) for whom complete billing records were available for transplant days -2 to +150. All costs were measured in 1992 US dollars. Patients given alprostadil had lower total charges [mean +/- standard deviation (SD) $US175 297 +/- $US70 652] than patients given placebo (mean +/- SD $US225 672 +/- $US187 208) [p = 0.043]. The data suggest that the use of alprostadil may have a significant favourable impact on the cost of liver transplantation. PMID- 10160480 TI - Estimating the cost effectiveness of atovaquone versus intravenous pentamidine in the treatment of mild-to-moderate Pneumocystis carinii pneumonia. AB - Pneumocystis carinii pneumonia (PCP) is the most common severe opportunistic infection, and one of the most costly, among people with AIDS. Over 50% of patients experience toxic effects of the major anti-PCP medications- cotrimoxazole (trimethoprim-sulfamethoxazole) and pentamidine. Recently, the US Food and Drug Administration approved a new oral drug therapy, atovaquone, as an alternative to pentamidine for the treatment of people with mild-to-moderate PCP who are intolerant of cotrimoxazole. We developed a decision tree model to estimate the costs and cost effectiveness of atovaquone therapy compared with intravenous pentamidine therapy for cotrimoxazole-intolerant patients with mild to-moderate PCP. Clinical outcomes were based on data from a phase III trial comparing the 2 medications. Our economic outcomes were based on treatment algorithms derived from discharge data, published reports and the clinical judgement of the co-authors. We estimate the total expected cost of treating a patient for an episode of PCP with atovaquone to be $US3990 compared with $US6545 for pentamidine under our baseline scenario (1995 dollars). Our decision model also provides insight into the large cost-savings benefits of treating mild-to moderate PCP on an outpatient basis. PMID- 10160481 TI - Canadian guidelines for economic evaluation of pharmaceuticals. Canadian Collaborative Workshop for Pharmacoeconomics. AB - In 1994, Canada became the second country to release national guidelines for the economic evaluation of pharmaceuticals. The guidelines were developed over a period of 18 months through an elaborate process of broad consultation with a wide variety of relevant stakeholders. The intent of the guidelines is to provide guidance to doers and users of studies, by laying out the general 'state of the art' regarding methods, and by providing specific methodological advice on many matters. The aim is to improve the scientific quality and integrity of studies, and to enhance consistency and comparability across studies. This article presents the Canadian guidelines, both in summary and in detail. Because the techniques of economic evaluation are widely applicable beyond pharmaceuticals, the guidelines will be of interest to researchers and decision makers in all fields of healthcare. Because the methods are not country specific, the guidelines will be of interest to those in other countries as well as in Canada. PMID- 10160482 TI - The clinical efficacy of influenza vaccination. AB - Inactivated influenza vaccine was developed approximately 50 years ago. The formulation has been continually improved, and its efficacy in preventing morbidity in healthy adults repeatedly demonstrated. Whether or not the vaccine is able to prevent hospitalisation and other complications of influenza in older individuals has been resolved by recent observational studies. During period of influenza virus circulation, the vaccine has also been shown to be effective in preventing hospitalisation and, in some cases, death from all causes and specific causes such as all respiratory conditions. Antivirals are also available for use against type A influenza, and may be especially valuable when antigenic change in the virus occurs. Now that questions regarding clinical effectiveness have been answered, vaccine and antivirals should certainly be more extensively used then in the past. The determinations of positive clinical effectiveness, which are based on observations of actual use of the vaccine, can form a basis for calculation of cost effectiveness. PMID- 10160483 TI - Health impact of influenza in the United States. AB - Influenza infection is associated with significant morbidity and mortality. The purpose of this investigation was to describe the health effects of influenza in the US. Although a number of different data sources have been used to provide estimates of the health impact of influenza in the US, estimates provided in this article are primarily based upon the experiences reported in community-based studies performed in Houston, Texas, and Tecumseh, Michigan. Estimates of the annual average are provided for the following: (1) infection rate; (2) number of influenza-associated respiratory illnesses; (3) number of ill days with influenza; (4) number of bed and activity restriction days due to influenza illness; (5) physician visits; (6) hospitalisations and days hospitalised; and (7) mortality. Large differences were found between estimates from Houston and Tecumseh, and possible explanations for these are provided. However, all estimates find that influenza is an important cause of morbidity and mortality in the US. PMID- 10160484 TI - Weekly monitoring of influenza impact in Belgium (1993-1995). AB - The primary objectives of an influenza monitoring programme are early detection of an epidemic and the identification of the viruses responsible. The healthcare impact of the disease is often some time after the epidemic. In Belgium data on the consequences of influenza are recorded weekly, which provides an early estimate of the severity of the epidemic. Data collected during 3 influenza seasons (1993-95) showed that during the peak of the very moderate influenza A/H3N2 outbreak in 1993-94, general practitioner consultations for acute respiratory infections increased by 100%, work absenteeism by 56%, total sales of pharmaceuticals by pharmacists by 26% and overall mortality by 14%. From these data, we estimated that 498,400 working days were lost during the peak week in Belgium in 1993, and 848 excess deaths were observed during the whole of the 1993 94 epidemic. 12% of those who died were aged less than 60 years. Hospitalisation data must be included in the future in order to complete the information that is essential for formulating public health policies on influenza vaccination. PMID- 10160485 TI - The impact of three influenza epidemics on primary care in England and Wales. AB - The numbers of persons with influenza presenting to general practitioners in England and Wales during the epidemics of late 1989, late 1993, and early 1995 are estimated to be approximately 760,00, 480,000 and 192,000, respectively. The expected numbers used to derive these estimates were obtained by averaging incidence by week over the 9 winters of 1986/87 to 1994/95, excluding those weeks in which influenza was prevalent. These 3 epidemics varied in magnitude and in the relative impact on persons in different age groups. The influenza B epidemic in 1995 scarcely affected elderly people. During the 3 epidemic periods, increased numbers of persons consulted their general practitioners with other respiratory diseases, including pneumonia, acute bronchitis and otitis media. The patterns of increase were not consistent between the epidemics, partly because of the differing impact on the various age groups and partly because of the effect of other respiratory viral illnesses prevalent at the same time. No increase occurred in the numbers of persons reported with new episodes of cerebrovascular accident or of acute myocardial infarction. A similar method was used to estimate excess deaths, which amounted to 25,000 in 1989, 13,000 in 1993, and 500 in 1995. In the periods immediately following the influenza epidemics, the observed pattern of deaths conformed to the expected, demonstrating that persons dying during the epidemics were not just dying a few weeks prematurely. PMID- 10160486 TI - Choosing between competing health priorities. A government payer perspective. AB - Policy makers in developed countries are increasingly having to look at how they are to control the cost of healthcare in the face of the pressures of an aging population, the introduction (and cost) of new technologies and the increasing expectations of patients. To some extent, costs can be contained by concentrating on those technologies with proven clinical effectiveness. However, if priorities have to be set, some method of appraisal of the relative values of different interventions is required. Increasingly, economic analyses are being used to justify policies and the use of resources, by introducing measures of cost and quality as well as effectiveness. Those economic evaluations most commonly used, and their shortcomings, are described. Priority setting cannot, however, be reduced to a purely technical exercise. Decisions on what should and should not be funded from the public purse will be influenced by the overall framework of national aims and objectives and by professional opinion and public values; they will be more firmly based and defensible if they are subject to wide public discussion and debate. PMID- 10160487 TI - Influenza in The Netherlands. AB - This paper reports on the occurrence of influenza and the associated burden of illness in The Netherlands. In addition, attention is paid to the effectiveness of vaccination vaccination status and the national strategy to raise the vaccination rate among risk groups. The incidence of influenza in the community appears to be 3 to 6 times higher than the incidence observed in general practice, since most cases do not present to the general practitioner (GP). Annually, 15,000 to 30,000 hospital admissions (1 to 2 per 1000 inhabitants) and 2000 to 2200 deaths (1.3 to 1.5 per 10,000), mostly among the elderly, are related to influenza. Vaccination has been shown to prevent about 50% of the influenza cases. Between 1991 and 1994 the vaccination rate among risk groups increased from 28 to 43%. In this period, a very active campaign was mounted. Much energy is being invested in further raising the vaccination rate among risk groups, with GPs holding a key position. In addition, the Dutch Health Council advises vaccination for persons > or = 65 years of age. PMID- 10160488 TI - Evaluating the impact of influenza vaccination. A North American perspective. AB - Recent studies in the US and Canada have shown that influenza vaccination prevents approximately 30 to 50% of all pneumonia and influenza hospitalisations and deaths that occur among elderly persons during 3-month influenza outbreak periods. These population-based studies have used retrospective methods and large computerised administrative databases. In addition, earlier cost-effectiveness studies have been supplemented by recent research from prepaid health plans showing that influenza vaccination can be cost saving. The use of influenza vaccine increased in the US and Canada throughout the 1980s and early 1990s, despite different methods for providing reimbursement for vaccination. The North American experience regarding the clinical effectiveness, cost effectiveness and epidemiology of influenza vaccination may provide European scientists and health officials with useful although sometimes limited insight into their own efforts to understand and improve influenza vaccination. PMID- 10160489 TI - French economic evaluations of influenza and influenza vaccination. AB - The cost-of-illness studies of influenza performed in France or the years 1985 and 1989 have shown that the major economic consideration in the respective sizes of indirect and direct costs. Depending on the point of view (from the perspective of National Health Insurance or the societal perspective) and the method used for measuring indirect costs, it was estimated that they could be between 1.5 and 9 times higher than direct costs. A cost-benefit study of influenza vaccination for the employed adult population showed that vaccination is a cost-saving strategy, although this was also contingent upon the problems associated with measuring indirect benefits as well as the effectiveness rate of vaccination in real conditions. PMID- 10160490 TI - Economic evaluation of influenza vaccination and economic modelling. Can results be pooled? AB - Scientific reviewing methods were applied to economic studies of influenza vaccination, and an economic model of influenza vaccination was developed from these primary sources. Issues arising from the secondary literature review include the quality of evidence on the effectiveness of the vaccines, the absence of a traditional population-based approach to reviewing economic data, confusion in terminology, and how to generalise from resource data contained in primary evaluations. Data from the literature review were summarised in terms of resource units used in the prevention and treatment of influenza. An economic model was constructed using local unit costs (from the Emilia region of Italy) and applying the data to a notional population. The model was sensitive to length of stay in hospital but not to variation in incidence of influenza, days off work or number of medical consultations. The model was predicated on and is sensitive to an estimate of 80% vaccine effectiveness. The approach is constrained by the available data, but could be more generally useful in that it allows variations in the quantity of inputs to be considered separately from variations in their values. The model may be used locally as a decision-making tool, although the method needs further development. PMID- 10160492 TI - Socioeconomics of influenza and influenza vaccination in Europe. AB - Although the effectiveness of influenza vaccination is established vaccination policies and their implementation differ considerably across Europe. Historically the selective policies for influenza vaccination were based on the proven efficacy of influenza vaccine in healthy volunteers, and recognition that influenza complications and death occur mostly in elderly people with chronic medical conditions. Healthcare providers are faced with increasingly aging populations and costly new technologies and are more likely to extend immunisation policies if new initiatives are cost effective compared with accepted measures. Few studies of vaccine effectiveness focus on elderly cohorts with and without high risk conditions. Accordingly, healthcare providers in Denmark, Sweden, The Netherlands and the UK may require further data on vaccine effectiveness in elderly people without high risk conditions before reconsidering their policies. Scandinavian countries may also require data demonstrating benefits in people with diabetes. Review of recent US studies indicates that the available data on vaccine effectiveness in preventing influenza-related hospitalisation and death are applicable in Europe, but vaccine costs and cost effectiveness, and the overall economic burden of inpatient and outpatient care, need to be assessed country by country. PMID- 10160491 TI - Economic evaluation of influenza vaccination and economic modelling. PMID- 10160493 TI - What do we not know? What work is required? PMID- 10160494 TI - Economic evaluation of vaccination. AB - With increasing expenditures in healthcare, in absolute terms as well as in relative terms, interest in the efficiency of certain interventions in healthcare has also increased. Faced with the limitations of the healthcare budget, budget holders try to find the optimal way of dividing their funds over different healthcare provisions, without discarding human and medical considerations. In economic terms, this process could be called the 'optimal allocation of scarce resources over the inputs of a function of production'. The means of production would then be 'the provision of healthcare', whereas the output would be 'improvement of health'. Clearly choices have to be made with regard to spending the healthcare budget. One of the instruments that can help in making such choices is the economic evaluation. In economic evaluations of vaccinations, different vaccination strategies are defined. The consequences in terms of costs and effects of each strategy are being calculated and compared with a reference strategy, which is often the nonintervention strategy, i.e. 'no vaccination'. According to the way in which the benefit or the output of vaccination 'improvement of health'-is measured, a distinction is made between various methods of economic evaluation: in a cost-effectiveness analysis, health gains are measured in natural units (e.g. prevented infections, prevented illness days, life-years gained, etc.); in a cost-utility analysis, the quality of the health gains is taken into account (e.g. quality-adjusted life-year); and in a cost benefit analysis, health gains are converted into monetary units. Costs can be divided into direct and indirect costs. Direct costs are directly related to medical treatments (medication, laboratory tests, consultations, etc.) or to vaccination (e.g. purchasing price of the vaccine, costs for administering the vaccine, treatment of side effects, etc.). Costs indirectly related to treatments and vaccination are mainly costs of lost productivity due to disease morbidity or mortality, and opportunity costs. In comparison with other vaccine-preventable infections, influenza vaccination for the elderly seems acceptable from an economic point of view (about $US650 per life-year gained, in 1981). Cost effectiveness ratios of other vaccinations range from about $US720 per life-year gained for universal hepatitis B vaccination to about $US190,000 per life-year gained for universal Haemophilus influenzae type by vaccination. Because of differences in methods, the representation of results, and country-specific parameters, different economic evaluations of the same vaccination strategy may show divergent results. Therefore, until sufficient standardisation of economic evaluations exists, comparisons of the sort we are making here should be interpreted with prudence. PMID- 10160495 TI - A self-management approach to diabetes care: the Harvard Community Health Plan experience. PMID- 10160496 TI - Disease management demystified: what can it do? PMID- 10160497 TI - Pharmacy benefit management companies: redefining their role in health care risk management. PMID- 10160498 TI - Due diligence for silent PPO practices. PMID- 10160499 TI - Vision care benefits: opportunities for managed care. PMID- 10160500 TI - Workers' compensation and injury duration: evidence from a natural experiment. AB - This paper examines the effect of workers' compensation on time out of work. It introduces a "natural experiment8 approach of comparing individuals injured before and after increases in the maximum weekly benefit amount. The increases examined in Kentucky and Michigan raised the benefit amount for high-earnings individuals by approximately 50 percent, while low-earnings individuals, who were unaffected by the benefit maximum, did not experience a change in their incentives. Time out of work increased for those eligible for the higher benefits and remained unchanged for those whose benefits were constant. The estimated duration elasticities are clustered around 0.3-0.4. PMID- 10160501 TI - The silent secret to health care reform: information. PMID- 10160502 TI - Sharps containers: testing for puncture resistance. PMID- 10160503 TI - Coordinating and supporting the development of health care informatics standards: the private/federal balance. PMID- 10160504 TI - Computed tomography: the most important advancement in radiography since the discovery of x-rays. PMID- 10160505 TI - The new standard guide for electronic signatures: "doctor, your signature please.8. PMID- 10160506 TI - The anesthesia workstation: no longer just a gas machine. PMID- 10160507 TI - Every patient's right: an endoscope that is "patient ready8 and safe for patient use. PMID- 10160508 TI - Homologizing pregnancy and motherhood: a consideration of abortion. PMID- 10160509 TI - The economics of health and health care: what have we learned? What have I learned? PMID- 10160510 TI - The cost and financing of health care. PMID- 10160511 TI - Uncertainty, health-care technologies, and health-care choices. PMID- 10160512 TI - Carcinogen regulation: risk characteristics and the synthetic risk bias. PMID- 10160513 TI - Risks to selves, risks to others. PMID- 10160514 TI - Rationalizing observed health and safety legislation: a Pascalian approach. PMID- 10160515 TI - The cost of medical progress. PMID- 10160516 TI - The state antismoking campaign and the industry response: the effects of advertising on cigarette consumption in California. PMID- 10160517 TI - Information and advertising: the case of fat consumption in the United States. PMID- 10160518 TI - Regulating information about aspirin and the prevention of heart attack. PMID- 10160519 TI - Information, marketing, and pricing in the U.S. antiulcer drug market. PMID- 10160520 TI - Physician payments and infant mortality: evidence from Medicaid fee policy. PMID- 10160521 TI - Significance of underclass residence on the stage of breast or cervical cancer diagnosis. PMID- 10160522 TI - The time and monetary costs of outpatient care for children. PMID- 10160523 TI - Estimating the moral-hazard effect of supplemental medical insurance in the demand for prescription drugs by the elderly. PMID- 10160524 TI - An assessment of health-care expenditures within and across racial and ethnic groups. PMID- 10160525 TI - Prenatal care demand and birthweight production of black mothers. PMID- 10160526 TI - What cost savings could be realized by shifting patterns of use from hospital emergency rooms to primary care sites? PMID- 10160527 TI - Nutrition and health investment. PMID- 10160528 TI - The "common sense" of the nonprofit hospital tax exemption: a policy analysis. AB - Although rarely discussed prior to the 1985 Utah Supreme Court ruling against Intermountain Health Care Inc., the question of whether to grant tax exemptions to nonprofit hospitals is currently being debated by federal, state, and local legislators, and by the courts. Changes to current policy seem likely. This policy analysis: (1) presents the historical and legal background; (2) examines the economic, political, and organizational implications of current tax-exemption policy; and (3) offers three alternatives to this current policy. The analysis indicates that the current policy provides little incentive for nonprofit hospitals to make contributions of charity care. Of the alternatives, eliminating the exemption is not politically feasible at this time; regulating hospital operations and outputs portends an implementation nightmare; and tying tax subsidy levels to output levels of charity care--perhaps the strongest and most efficient incentive--would require an unlikely political consensus on what constitute valid and reliable measures of charity care. If there is a movement toward subsidies, then linking subsidy amounts to levels of charity care will depend on whether policy analysts can design satisfactory empirical measures. With the advent of universal health coverage, the demand for charity care will decrease. The problem for tax-exempt hospitals will then become justifying the exemption by demonstrating the extent to which they generate community benefits at no or reduced cost to society. PMID- 10160529 TI - Personification of life and death among Swedish health care professionals. AB - The aim of this study was to determine how people working in health care in Sweden personify life and death. The questions of special interest were whether there are archetypal notions of life and death, and what emotional tone is associated with them, especially with death. Totals of 22 women and 25 men working in health care were interviewed individually. The results showed that 84% of the men and 65% of the women personified death as an old man. The descriptions were archetypal, the reaper figure being the most evident personification. Death was often given a rural location, it was seasonally associated with autumn, and its time of day was evening or night. The emotional tone associated with death by more than 50% of the interviewees was serenity, peace, and melancholy; 25% saw death as something frightening. The corresponding personifications of life showed the opposite characteristics in nearly all respects. The results indicate that archetypal notions of life and death do exist and that these notions are culturally influenced. PMID- 10160530 TI - Relationship of death anxiety/fear to health-seeking beliefs and behaviors. AB - The relationship of death anxiety/fear to health beliefs and behaviors was examined. One hundred and three college students completed the modified Death Anxiety Scale (DAS), the Death Anxiety Questionnaire (DAQ), the Death Attitude Profile (DAP), the Health Opinion Survey (HOS), and an item asking whether the participant had visited a physician at least once a year for a routine examination. The results indicated that those scoring higher on the DAS were less likely to be actively involved in their health care. Males were found to be less likely to prefer health information and to visit the doctor for an annual routine examination than females. In addition, females with high death anxiety (DAQ) were more likely to prefer health information than males with high death anxiety. These results underscore the need to examine the relationship of gender role to health-related beliefs. PMID- 10160531 TI - Predictors of husbands' and wives' grief reactions following infant death: the role of marital intimacy. AB - This follow-up study examined how bereaved couples' grief reactions change over time and how the quality of the marriage can predict these reactions for men and women. A group of 31 bereaved couples who 2 to 4 years earlier had lost an infant ( greater than 20 weeks gestation and less than 1 year of age) were revisited in their home 24 months after the initial home visit. With the exception of somatization, couples' grief reactions were less intense at follow up than at the initial visit. Overall, husbands experienced less guilt, meaninglessness, yearning, and morbid fear than wives. Both husbands and wives who reported lower levels of marital intimacy soon after the loss experienced more intense grief at follow-up. Finally, couples continued to be vulnerable to a resurgence of grief even years later. PMID- 10160532 TI - Physiological effects of chronic grief: a biofeedback treatment approach. AB - This article makes explicit the implicit links among chronic grief, psychological stress, physiological functioning, and treatment via biofeedback and relaxation training. A brief review of recent literature shows the connections among these areas, and from these connections emerges a simple model describing the interactions of chronic grief and psychological stress with the physiology of the bereaved. This model focuses on bereaved persons with pre- or co-existing medical conditions likely to worsen with prolonged grief. A brief discussion of emotional aspects of chronic grief follows. Finally, a specific treatment modality--relaxation training with biofeedback assistance and desensitization--is applied to this model as well as to the emotional dimension, and the benefits thereof are discussed. PMID- 10160533 TI - Barriers that predict resistance to completing a living will. AB - We sought to identify perceived barriers and benefits to completing living wills for 176 medical outpatients or their family members, using a questionnaire based on the Health Belief Model. The regression equation of the patient data identified two items that functioned as significant barriers: "I am not very interested in a living will because I believe that I will live a lot longer," and "Completing a living will now is difficult because I would likely change my mind about how I want to be managed during terminal illness." No variables remained in the equation when family member data were analyzed. We conclude that a major barrier to the completion of living wills (and perhaps advance directives generally) is that they connote personal death. Implications are explored. PMID- 10160534 TI - Managed care as a public cost-containment mechanism. AB - This article identifies the impact of managed-care reforms on the utilization of medical services within the military health-services system. The data come from a recent demonstration project that substituted an HMO and PPO for traditional FFS arrangements. Results from a semiparametric model indicate that the generosity of benefits in the HMO increased demand for ambulatory services. Unlike the private-sector experience with managed care, aggressive utilization review did not significantly curtail inpatient stays. These results vitiate the presumed effectiveness of reform strategies that rely on large, geographically diffused managed-care networks to contain public-sector health costs. PMID- 10160535 TI - Scale, scope, and spillovers: the determinants of research productivity in drug discovery. AB - We examine the relationship between firm size and research productivity in the pharmaceutical industry. Using detailed internal firm data, we find that larger research efforts are more productive, not only because they enjoy economies of scale, but also because they realize economies of scope by sustaining diverse portfolios of research projects that capture internal and external knowledge spillovers. In pharmaceuticals, economies of scope in research are important in shaping the boundaries of the firm, and it may be worth tolerating the static efficiency loss attributable to the market power of large firms in exchange for their superior innovative performance. PMID- 10160536 TI - Physician financial incentives and cesarean section delivery. AB - The "induced-demand" model states that in the face of negative income shocks, physicians may exploit their agency relationship with patients by providing excessive care. We test this model using an exogenous change in the financial environment facing obstetrician/gynecologists: declining fertility in the United States. We argue that the 13.5% fall in fertility over the 1970-1982 period led ob/gyns to substitute from normal childbirth toward a more highly reimbursed alternative, cesarean delivery. Using a nationally representative microdata set for this period, we show that there is a strong correlation between within-state declines in fertility and within-state increases in cesarean utilization. PMID- 10160537 TI - Gender differences in parental grief. AB - Gender differences in grief of parents who lost their child were examined using the Grief Experience Inventory. Participants were 35 bereaved couples who ranged in age from 27 to 73. Results showed that the mothers' scores were significantly higher than those of fathers on the following scales: Atypical Responses, Despair, Anger/Hostility, Guilt, Loss of Control, Rumination, Depersonalization, Somatization, Loss of Vigor, Physical Symptoms, and Optimism/Despair. No significant differences were found on the scales of Denial, Social Desirability, Social Isolation, Death Anxiety, and Loss of Appetite. The potential usefulness of the GEI in helping the bereaved is discussed. PMID- 10160539 TI - Mortality awareness and risk-taking in late adolescence. AB - The relationship of mortality awareness to sexual, drug, and athletic risk-taking by male and female college students was measured using two questionnaires. Regression analyses of Study 1 data revealed: (a) significantly greater sexual risk-taking among males (n = 68) than among females (n = 119) beta = -.20, p less than .01; (b) a significant negative relationship of mortality awareness to sexual risk-taking in males, beta = -.36, p less than .01; and (c) no relationship of mortality awareness to reported drug use or athletic risk-taking. Regression analyses of data from Study 2, which included only male subjects (n = 40), revealed that initial mortality awareness was significantly related to sexual risk-taking (beta = -.33, p less than .05), but that manipulated awareness of death did not affect willingness to take sexual risks. It was suggested that mortality awareness may reduce the taking of risks that present nonsalient consequences, and that the consequences of risky sexual behavior may be less salient for males than for females. PMID- 10160538 TI - Grief among gay men associated with multiple losses from AIDS. AB - Few quantitative studies have examined the phenomena of multiple loss and cumulative grief occurring in gay men as a result of the AIDS epidemic. In this study, Sanders's Integrative Theory of Bereavement (1989) was used to examine the relationship between multiple loss and the intensity of grief experienced by gay men. The relationship of selected situational factors and internal characteristics of the bereaved to the numbers of losses and intensity of grief was also explored. Ninety-three gay men living in San Francisco, whose own HIV status was negative or unknown, and who had lost at least three friends, lovers, or relatives to AIDS, completed the Grief Experience Inventory and a demographic questionnaire. There was no significant relationship between the number of individual losses reported and the intensity of grief experienced. There were significant relationships among social and demographic variables. Factors influencing the bereavement response found in this study are consistent with several of the external and internal mediators presented in Sanders's theory. The findings suggest that an adaptive process of habituation may be occurring and that these men may be remaining in Sanders's conservation-withdrawal phase of bereavement. PMID- 10160540 TI - The ethics of suicide and suicide prevention. AB - Is suicide ever a defensible choice, particularly for the terminally ill? The present article debates this difficult question, examining the relevance of such issues as the morality, rationality, and dynamics of the suicidal act, and the legitimacy of physician-assisted suicide. Contrasting perspectives on these issues are articulated by two prominent suicidologists, as a spur to the reader's deeper reconsideration of the ethics of suicide and suicide prevention. PMID- 10160541 TI - Rational suicide reconsidered: AIDS as an impetus for change. AB - At the present time, there does not appear to be an acceptable alternative to intervening to prevent the suicide of persons who display suicidal ideation. This absolutist and, at times, paternalistic view may change, however, as a result of professionals' contact with persons with AIDS. The growing number of persons with AIDS and the incidence of suicide within this population make it increasingly likely that individuals in a number of professions that subscribe to the policy of mandatory suicide intervention will have contact with a suicidal person with AIDS. Given the life circumstances and implications associated with a diagnosis of AIDS, there is the possibility that some of these suicidal persons with AIDS may have made what could be considered to be a rational decision to end their own lives. By taking into account the circumstances that precipitated the suicidal ideation and allowing some individuals to follow through with their plans, professionals will be empowering and returning autonomy to these individuals. Thus, by forcing professionals to think about and deal with the issue of rational suicide, AIDS may provide an impetus to change the traditional absolutist approach of suicide intervention and prevention into a contextual approach in which the intensity of suicide intervention required is viewed as varying along a continuum. PMID- 10160542 TI - Progeria: medical aspects, psychosocial perspectives, and intervention guidelines. AB - This article discusses progeria, a rare genetic childhood disorder that invariably results in the individual's death during early adolescence. The article begins by describing the major medical aspects of progeria. This is followed by a discussion of the psychosocial implications of the disorder with particular emphasis upon grief-triggered reactions. The article concludes with an overview of psychosocial intervention guidelines for caregivers who work with families of dying children and adolescents. PMID- 10160544 TI - An empirical exploration of selected policy options in organ donation. AB - This paper presents findings from a mail survey of 414 persons regarding organ transplantation and donation policy issues. Three measures of support for organ donation were measured: donor card commitment, required request of next-of-kin support, and weak presumed consent support. High levels of support exist for organ donor cards and the required request of next-of-kin law. Little support was found for the policy of weak presumed consent. PMID- 10160543 TI - The Medicare Hospice Benefit: ten years of federal policy for the terminally ill. AB - The Medicare Hospice Benefit has served terminally ill persons and their families since 1983. The political and social development of this policy combined both humanitarian and cost-saving strategies. Although this federal hospice program has mainstreamed care of the terminally ill and provided multiple services, four major constraints of the benefit package are identified and explored. As the United States draws closer to health care reform, it is important that we analyze this policy before we devise new ways to care for the dying and their families. PMID- 10160545 TI - Suicide in relation to AIDS. AB - One of the array of clinical and ethical challenges faced by the practitioner who works with people with AIDS is dealing with clients who feel they prefer the option of suicide to living with the disease. The many dimensions of suicide among the terminally ill, including preemptive, surcease, and rational suicide, are explored. The critical issues addressed are the incidence of suicide in HIV positive individuals, contributing factors associated with the risk of suicide among people with HIV/AIDS, and the clinical and ethical implications of this issue for the practitioner. PMID- 10160546 TI - Negotiating life for the dying: hospice and the strategy of tactical socialization. AB - Hospice is often discussed as a social movement that is attempting to change not only the way particular patients experience dying, but the nature of death and dying for society as a whole. Participant observation research was conducted in the home care components of and a free-standing inpatient facility associated with several northeastern hospice organizations over the course of almost three years. The data are reported using negotiated order theory as a framework for understanding the hospice movement, and tactical socialization is identified as a major strategy of hospice workers for accomplishing their goals. PMID- 10160547 TI - Death education in paramedic programs: a nationwide assessment. AB - In an exploratory study, we obtained information on death education in paramedic programs. A self-administered survey was sent to all U.S. paramedic training programs (N = 537). The survey ascertained the method of instruction, educational supplements, assessment techniques, and integration of death education into general course work. The status of past, present, and future death education offerings in paramedic programs was also elicited. Analysis was performed on the usable surveys (response rate = 51%). The overwhelming majority (95%) of programs offer death education, with more offerings now than 10 years ago. Legal--ethical topics were the most often included death-related instruction. In the majority of programs, a lecture (didactic) format was used for instruction and closed-ended tests were used for assessment. Results on other educational supplements and assessment techniques are also presented. PMID- 10160548 TI - Oncologists' attitudes to treatment of cancer patients. AB - This study, based on questionnaire responses of 46 Israeli oncologists, explores the factors influencing these physicians' beliefs and decisions regarding chemo- and radiation therapy. A simple discriminant analysis identified five physician related variables with a significant impact on the subjects' attitudes to treatment: age, sex, years of oncology experience, pity for the patient, and whether they believed all cancer patients suffer from pain. In the absence of an unambiguous clinical protocol, the major influences on decisions to treat with chemo- or radiation therapy include, in addition to diagnosis, the patient's overall health, the physician's perception of treatment effectiveness, and the stage to which the illness has progressed. The discussion of the findings centers on their implications for practice. PMID- 10160549 TI - Psychometric properties of the Suicidal Behaviors Questionnaire. AB - In order to assess the reliability and validity of Cole's (1988) four-item version of the Suicidal Behaviors Questionnaire (SBQ), 57 clinical outpatients completed it and the Reasons for Living Inventory (RFL), and 86 undergraduates completed it and the Scale for Suicide Ideation (SSI). Two weeks later, 30 undergraduates completed the SBQ again. Cronbach alphas were moderate (clinical sample = .75; nonclinical sample = .80). Test--retest correlations were also significant (r = .95). The SBQ and SSI were significantly correlated (r = .69). The SBQ and RFL were also significantly correlated (r = -.34), although modestly. In view of its moderate to strong reliability, its construct and fact validity, its ease of administration and scoring, and its brevity, the SBQ is recommended as a brief screening instrument for suicidality for researchers and clinicians. PMID- 10160550 TI - The effect of Medicaid expansions on public insurance, private insurance, and redistribution. PMID- 10160551 TI - HMO penetration and the cost of health care: market discipline or market segmentation? PMID- 10160552 TI - A dangerous direction: legal intervention in sexual abuse survivor therapy. AB - In this Article, Professors Bowman and Mertz question recent popular and academic commentary that disputes the validity of all delayed-recall memories of childhood sexual abuse. They examine one court's decision to allow a father, accused by his daughter of childhood sexual abuse, to recover malpractice damages from his daughter's therapist in connection with therapy during which the daughter recovered memories of the abuse. The authors argue that such third-party liability is unsound in terms of established principles of tort doctrine and in terms of public policy. After a review of the scientific evidence, the authors further conclude that, although some memories may be inaccurate, delayed-recall memory can also accurately reflect that past abuse occurred. Permitting third party liability against therapists when accurate memories of abuse surface in therapy gives abusers a weapon to use against their victims. Because such suits exclude the party in privity (the client), they effectively erase the victim's voice. Professors Bowman and Mertz argue that such a novel extension of third party liability is at best a misuse of the courts' resources and ultimately harms abuse survivors, therapists, and the community far more than it helps any wrongfully accused parents. PMID- 10160553 TI - Death of a child at home or in hospital: experiences of Greek mothers. AB - The purpose of this study was to investigate the experiences of Greek mothers who cared for a child dying of cancer at home or in the hospital, and to highlight some of their major needs during the terminal period. Fifteen mothers were interviewed and both quantitative and qualitative procedures were used to analyze the findings. Ten families (67%) chose to care for the child at home without having access to home care services, while the remaining five sought hospital care. Their decision was primarily based upon the child's expressed wish and parental preference. The family network played a significant role in supporting the mother-child unit, especially when death occurred at home. Mothers assessed positively the services provided by nurses and social workers, and had expectations that physicians would support them on a psychological level during the terminal period. The care of the dying child is influenced by cultural factors predominant in Greek society and some of the findings are discussed in this light. PMID- 10160554 TI - Assessment of need for a children's hospice program. AB - Canuck Place, North America's first free-standing pediatric hospice of its kind, opened in 1995 in British Columbia, Canada. The province-wide program encompasses a broad spectrum of services intended to support community-based care and provide periodic, facility-based respite and palliative care to children with life-threatening, progressive illness and to their families. Loss and grief support is another integral component of the program. The concept of pediatric hospice care is founded on the premise that dying children and their families can benefit from care designed to maximize present quality of life; yet, the creation of such programs must be based on demonstrated need. One vital step in the development of the Canuck Place program was assessing the need for such a program within the province. Data from both traditional quantitative and less traditional qualitative sources were used to document and put forth an argument in support of developing a children's hospice program. The final report addressed several components that are summarized in this article for the purposes of assisting others who may wish to undertake similar projects in their own communities. PMID- 10160555 TI - Occupational stress, social support, and the costs of health care. AB - Relationships among health care costs, social support, and occupational stress are investigated. Health care cost data were collected over two years for 260 working individuals. Multiple regression analyses were used to control for initial health care costs, age, and gender in predicting later costs; independent variables were stress, strain, social support, and their interactions. Main effects and interactions each accounted for significant proportions of the variance in various health care costs. PMID- 10160556 TI - Consistency and change in functional status among older adults over time. AB - Consistency and change between 1984 and the last reinterview (either two, four, or six years later) on 22 individual functional status markers and the five summary scales that they form are examined among the 5,986 members of the Longitudinal Study on Aging who were reinterviewed at least once. At baseline, at least three-fifths of the respondents are without limitations on any individual marker. At the last reinterview, at least 43.4% of the respondents are without such limitations. Among those who had limitations at baseline, at least one-fifth get better. For those without limitations at baseline, one seventeenth to two-fifths get worse. Difficulties in walking and doing heavy housework were the most common, most likely to develop, and least likely to resolve of any of the ADL or IADL items, and lower body limitations were more common, more likely to develop, and less likely to resolve than upper body limitations. Linear panel analysis of the five summary scales indicates that the top predictors of increased functional limitation are baseline levels of functional limitation, older age, decedent status, and poorer perceived health (in that order). Other less consistent and less robust predictors include the length of the exposure window, being female, having a history of arthritis, lower educational attainment, having fewer nonkin social supports, higher prior physician visit levels, and not living alone. PMID- 10160557 TI - Prior and current costs in capitated health plans: the effects of health status at enrollment. AB - We compared the prior and current costs of persons age 65 and older enrolling in a Social/Health Maintenance Organization in each of four sites with samples of persons using standard Medicare benefits in each site. Analyses were adjusted for individual health differences using case mix scores. Costs were examined in the year before S/HMO enrollment or prior to the sampling of a person using regular Medicare services as well as costs during the study. Costs during the study are analyzed using a two-stage procedure where first the propensity to enroll in a S/HMO is modeled and then costs derived from either Medicare sources or shadow prices assigned to service units provided in a S/HMO are modeled. The costs for case mix groups with different health and functional characteristics varied significantly. Cost differences between case mix classes differed between the S/HMO and FFS populations. PMID- 10160558 TI - Do racial differences in hypertension persist in successful agers? Findings from the MacArthur Study of Successful Aging. AB - The objective of this study was to determine whether racial differences in hypertension in a random sample of community-dwelling older adults also remained significant in a sample of successful agers. Data for the random sample of community-dwelling older adults came from the Duke University Established Populations for Epidemiologic Studies of the Elderly (4,162 community-dwelling adults age 65 and older) and showed strong racial differences in hypertension. Data for successful agers came from the Duke MacArthur (428 of EPESE respondents in the top 30% in terms of physical, cognitive, and psychosocial performance). The mean of two sitting blood pressure measurements was the dependent variable for both sets of analyses. Independent variables included demographics and health factors. Using logistic regression, odds ratios in the Duke EPESE and Duke MacArthur samples for race were similar (Duke EPESE odds ratio = 1.30; Duke MacArthur odds ratio = 1.29). Sample size differences affected statistical significance. However, race differences in hypertension in older adults appear to be unexplained by socioeconomic status or other usual explanatory variables. Even among successful agers, racial differences in hypertension persist. PMID- 10160559 TI - Survival in the oldest old: death risk factors in old and very old subjects. AB - Factors predicting death in the ninth decade of life may differ from predictors in younger age groups. A prospective study was carried out on 210 subjects entering a residential home at the age of 68 to 79 years and of 287 subjects aged greater than or equal to 80 years who included 91 survivors from the first group; all subjects were followed until 78% of them had died. A Cox analysis was carried out with death as end point and 13 potential risk factors as covariates. Mildly impaired mobility at entry, defined as the need for help to walk 300-400 yards for various reasons, smoking, bacteriuria, and presence of ECG abnormalities were significant death risk predictors before age 80. Beyond this age, only mildly impaired mobility and serum cholesterol levels less than or equal to 5.9 mmol/L, as compared with levels greater than or equal to 8.0 mmol/L, remained significant. Higher hematocrit levels were predictors of survival before and after age 80. Systolic blood pressure, age, sex, weight, and socioeconomic status had no effect in either group. The data show that survival after age 80 is related only to adequate physical mobility and high hematocrit and cholesterol levels, regardless of the levels of other common risk factors. PMID- 10160560 TI - Clinical validation of the Geriatric Depression Scale (GDS): Chinese version. AB - This study has attempted to validate the Geriatric Depression Scale translated version (Chinese) with a psychiatric outpatient sample (N = 461) of males and females aged 60 or above, from 10 government-maintained psychiatric outpatient clinics between January 1992 and February 1993. Reliabilities and validities were exceptional. Internal consistency reliability was .89 (alpha), and the test retest reliability was .85 (alpha). Criterion-related (psychiatrist diagnosis) validity was good at .95, and concurrent validity (with CES-D) was .96. Item analysis also confirmed consistency--all 30 items were significantly correlated with the full GDS. However, its sensitivity (70.6%), specificity (70.1%), false negatives (29.4%), and false positives (29.9%), though acceptable, were not as impressive. The overall result has shown that the GDS is generally applicable to the Chinese elderly population and is good for measuring depressive symptoms. The scale can be easily applied in the community by health care professionals. However, further follow-up studies are recommended. PMID- 10160561 TI - Leisure activities and service knowledge and use among the rural elderly. AB - This exploratory study uses Andersen's service utilization model to examine the relationship between the leisure activity patterns of older people and their knowledge and use of health and social services. Hierarchical stepwise multiple regression analyses of data from 418 people ages 65 and older in rural Qu/ebec revealed that leisure activity patterns may explain a greater amount of variation in service knowledge and use than conventional need characteristics such as physical and psychological health. Various activity patterns were significantly related to knowledge and use of services even after controlling for variables such as age and health status. Although some types of leisure activities appeared to augment knowledge and use of services, others seemed to deter it. Future explanatory models of service utilization among the elderly should be expanded to include leisure activity patterns. PMID- 10160562 TI - Patterns and determinants of health services use and mortality after VA nursing home care. AB - Risk factors for institutionalization and death for up to four years for a nationwide cohort (n = 6,488) of males discharged alive from Department of Veterans Affairs (DVA) nursing homes were identified through linked records of the DVA. Two-year cumulative probabilities of nursing home readmission, hospitalization, and death among nursing home dischargees were 0.30, 0.61, and 0.24, respectively. Using multivariate survival analyses, chronic functional impairments and past nursing home use were important predictors of nursing home readmission, whereas hospitalizations for exacerbations of chronic medical conditions were predictors of hospitalization and death. Past hospitalizations predicted all three outcomes. Differences in risk factors for nursing home readmission as compared with hospitalization or death among DVA nursing home dischargees suggest that high-risk patients can be identified at nursing home discharge and that different types of interventions will be necessary to decrease nursing home readmission as compared with hospitalization or death. Future development of linked record systems across multiple settings, both within and outside the DVA, will help to further characterize persons at high risk of institutionalization or death and to design and evaluate targeted interventions to decrease this risk. PMID- 10160563 TI - Lay explanations of chronic illness in later life. AB - This study explores lay explanations of chronic illness in later life. More specifically, perceived causes, treatment strategies, and perceived outcomes of arthritis and heart/circulatory problems from the perspective of older adults who have such problems are examined. Variations in these explanations according to selected sociodemographic and health status characteristics are explored. Among the arthritis sufferers, the most prevalent explanations were physical work/working conditions, age, and injury, whereas those with heart/circulatory problems most often explained the cause as due to tension/stress, physiology, or heredity. A variety of treatments were identified, including doing nothing, seeking or continuing medical treatment, altering lifestyle, and using folk remedies. Selected sociodemographic and health status characteristics appear important for understanding explanations about arthritis, although it is primarily health status indicators that emerge for heart/circulatory problems. Directions for future research are highlighted. PMID- 10160564 TI - Medicare's mental health benefits: coverage, use, and expenditures. AB - Estimates of the proportion of persons aged 65 and older with diagnosable mental disorders, residing both in the community and in institutions, range from 13.5% to 22%. Mental health services, both inpatient and outpatient, short and long term, are necessary for the well-being of these older Americans. Mental health benefits are covered under Medicare. However, less than 3% of the $90.5 billion Medicare budget in 1988 was spent on mental health services. Of that 3%, $2.2 billion was used for Part A (hospital insurance) and $300 million for Part B (medical insurance). In contrast, in the same year, payments for mental health services represented 20% to 30% of total health expenditures made by private insurers. Differences in payments abound when comparing freestanding psychiatric facilities with both exempt and nonexempt psychiatric units in general hospitals. This article describes these differences and how they influence the use of mental health services by Medicare beneficiaries. PMID- 10160565 TI - Perceived adequacy of instrumental assistance: implications for well-being in later life. AB - Beginning with the premise that care recipients' perceptions of inadequate help may have long-term negative consequences, this study examined whether seniors' perceptions related to patterns of well-being over a 12-year period. Patterns of change in physical health (i.e., number of chronic health conditions, self-rated health), psychological well-being (i.e., life satisfaction), and independence (i.e., functional and instrumental) were compared for older men and women who initially reported that their level of IADL assistance was either adequate or inadequate. Seniors who perceived their support as inadequate experienced more severe losses of independence. This was true for both men and women with respect to their ability to independently conduct instrumental ADLs. With respect to the ability to independently conduct functional, that is, basic ADLs, it was true only for women. These findings may imply that perceptions of support inadequacy have a more detrimental effect for women than for men. PMID- 10160566 TI - Factors associated with enrollment of older adults into a physical activity promotion program. AB - This article investigates the extent to which a proactive two-phased recruitment approach resulted in recruitment of a representative sample of older adults from two lower income congregate housing facilities into a physical activity promotion program. Enrollees were similar to nonenrollees with respect to education, gender, marital status, race/ethnicity, self-rated health, physical functioning, psychological distress, exercise frequency, level of social contact, having a confidant, use of alcohol, and smoking status. However, enrollees were younger, more likely to speak English as a primary language, less likely to be completely sedentary, and more likely to be overweight. Overall, 21% of the target population were recruited into the program. Recruitment strategies such as those used in this study appeared to enable enrollment of a reasonably representative sample of a small well-defined population. PMID- 10160567 TI - OTC drug use in an HMO: comparing the elderly and younger adults. AB - The study described the self-reported use of over-the-counter (OTC) drugs among older adult and younger adult HMO members, and identified the factors associated with their use. The study population was 1,642 HMO members aged 65 and over, and 3,417 members 18 through 64 years of age. Sources of data were a mail questionnaire, and automated outpatient pharmacy, and visit data. The findings showed the elderly were less likely to use most kinds of common OTC drugs. They also used them less intensely, and were less likely to use OTC drugs in conjunction with prescription drugs, than young adults. For both age groups, OTC drug use did not appear to be a substitute for formal medical services. The major factors associated with the use of OTCs in both age groups were female gender and increased bodily pain. PMID- 10160568 TI - The use of psychoactive medications and cognitive function in older adults. AB - This study examined the relationship between cognitive function and psychotropic medication use in a population sample (n = 743) of elderly persons. Approximately one third of subjects received such agents, which consisted primarily of anxiolytics, hypnotics, and antidepressants. Subjects received a battery of cognitive tests at three time points: when they were 70, 75, and 79 years of age. Data on medication use revealed that the use of psychoactive agents increased with age, and was greater for females. A cross-sectional analysis showed that those using psychoactive medicines had lower cognitive test scores compared with those who did not receive such drugs. Repeated measures analysis of variance demonstrated that psychotropics had a negative and cumulative effect on cognition, with the function of subjects who received psychoactive agents consistently poorer than those who did not. The magnitude of this effect is relatively small and for several cognitive tests subjects who received these drugs averaged only a few points lower than individuals not using psychoactive medicines. PMID- 10160569 TI - Tolerance for physical pain in suicidal subjects. AB - This study investigated the tolerance for physical pain in suicidal subjects. Suicidal, psychiatric nonsuicidal, and normal young males and females were administered pain measures including electric shocks, appraisal of shocks, and a measure of thermal pain. Additional study variables included diagnosis, past suicide attempts, severity of suicidal intent, and length of hospitalization. Suicidal individuals showed higher tolerance for pain and appraised the pain as less intense than the other groups, regardless of diagnosis, length of hospitalization, and motivation to participate in the study. These findings were explained as a result of dissociative processes inherent in the development of suicidal tendencies and in terms of pain management strategies. PMID- 10160570 TI - Toward a comprehensive model of death anxiety. AB - An integrative, comprehensive model of death anxiety is presented. The model postulates three immediate antecedents of death anxiety: past-related regret, future-related regret, and meaningfulness of death. Past-related regret refers to a person's unfulfilled aspirations that should have been achieved but were not. Future-related regret refers to the anticipation that, as a result of premature death, one cannot achieve important goals in the future. Meaningfulness of death refers to one's concept of death and ability to make sense of it. These three antecedents are related to death salience in a complex way, mediated by coping mechanisms and their effects on one's beliefs about self and the world. The coping mechanisms include (but are not necessarily limited to) life review, life planning, identification with culture, and self transcending processes. The model's developmental and practical applications are explored. PMID- 10160571 TI - Models for understanding adolescent coping with bereavement. AB - Several issues impinge on scholars and practitioners interested in adolescent bereavement. First and foremost, adolescent bereavement over the death of a family member or a friend is more prevalent than many persons recognize. Second, scholars and practitioners need models that link adolescent development with adolescent coping during bereavement. Third, models are needed (a) to assist in rethinking what "recovery from bereavement" denotes and (b) to afford criteria for assessing recovery from bereavement. The author reviews findings on bereavement during adolescent development and gives particular attention to three models that enhance our understanding of coping with the life crises bereavement presents to adolescents. One model links grief during adolescence to developmental tasks; another model presents adaptive tasks and coping skills; and the third model identifies sentiments essential for human wholeness. Findings from a variety of studies with bereaved adolescents provide data to test the usefulness of the models. The closing discussion centers on implications for working with bereaved adolescents. PMID- 10160572 TI - Issues and implications in the counseling of survivors of multiple AIDS-related loss. AB - Survivors of multiple AIDS-related loss face a unique phenomenon for which existing theories and diagnostic criteria regarding grief and trauma are inadequate. Unresolved grief and complicated bereavement are normal responses to multiple loss. This distinctive experience and the resulting symptoms have implications for counselors. Suggestions are offered for counselors to help clients process the aggregate and individual losses arising from this experience. AIDS provides a rare opportunity to analyze concurrent traumatization and complicated bereavement occurring on an ongoing basis. This analysis and its implications may therefore be useful in the future in regard to tragedies that share these characteristics. PMID- 10160573 TI - The escape theory of suicide and perfectionism in college students. AB - A preliminary model of the escape theory of suicide was tested in 168 college students (52 males, 116 females), who completed self-report measures of self oriented, other-oriented, and socially prescribed perfectionism, negative life stress, depression, hopelessness, anxiety, reasons for living, and suicidal behaviors. A path analysis provided only partial validation for the model and accounted for 26% of the variance in suicidal behaviors. None of the three dimensions of perfectionism significantly accounted for any additional variance in suicidal behaviors above and beyond the other variables used in the study. Socially prescribed perfectionism was the only dimension of perfectionism that showed a statistically significant bivariate correlation with suicidal behaviors. The path analysis indicated that this correlation was an indirect effect through reasons for living. Depression was a better predictor of suicidal behaviors than hopelessness. Perhaps one reason for these equivocal results was the limited amount of variability in suicidal behaviors in this nonclinical sample. PMID- 10160574 TI - In vitro fertilization: insurance and consumer protection. PMID- 10160575 TI - Nabumetone in elderly patients with osteoarthritis: economic benefits versus ibuprofen alone or ibuprofen plus misoprostol. AB - Nonsteroidal anti-inflammatory drugs (NSAIDs) vary in their potential to produce gastropathy. We compared the 3-month direct medical costs, including those associated with treating NSAID-induced adverse events, of nabumetone, ibuprofen, or ibuprofen plus misoprostol in 171 elderly patients with osteoarthritis. Total direct medical costs per patient treated were $US183 for nabumetone, $US252 for ibuprofen, and $US270 for ibuprofen plus misoprostol. Differences resulted from higher costs associated with treatment of drug-related adverse events with ibuprofen, and higher drug acquisition prices with the combination regimen. Sensitivity analyses demonstrated that direct costs with nabumetone approached those for the other 2 regimens if the price of nabumetone increased by 60%, the probability of lesion formation with nabumetone increased 4-fold, the probability of a lesion greater than 0.5cm being symptomatic and needing treatment was 31%, or the price of misoprostol decreased by 50%. Although this study found more lesions because of mandated endoscopies than might be recognised or treated in clinical practice, the results suggest an economic benefit of nabumetone. PMID- 10160576 TI - Pulling the right economic levers. AB - Efforts throughout your restructuring program should be as focused as your targets. If you are targeting large amounts of savings through infrastructure reduction, push for extensive service redeployment, implement new operational enablers and reexamine burdensome policies. If the savings are expected to come from skill mix reduction, analyze the workload, study licensure laws, get comfortable with competency thresholds and understand training costs. If management hierarchy reduction is the key, then put in place qualified managers, foster employee involvement to optimize SDWTs and modify your environment to reward risk taking and initiative. Lastly, if reduced LOS is the savings opportunity, rethink your patient groups. LOS reduction can also be achieved through improved care team continuity with physicians and patients. Understanding how your savings opportunities are influenced by ++your project decisions, direction and emphasis, will help you pull the "right" economic levers to meet your goals. Ultimately, that economic health will allow you to continue to provide uncompromised care and service quality to your communities. PMID- 10160577 TI - Estimating your educational investments. Tips, tricks and traps. AB - Education investments will more than likely consume the majority of every restructuring dollar you spend. So start estimating them early. Additionally, ensure they are properly budgeted in the appropriate years. Base your investment estimates on the number of people you intend to educate and the time required to do it. Lastly, when it comes time to actually spending the money, "layer-in" your educational requirements over time, when appropriate educate where the work gets done, and "back-fill" staff only when necessary, always using the least cost approach available at the time. Most importantly, don't undervalue the return on your educational investment. It will undoubtedly be one of the best "moves" you ever make. PMID- 10160578 TI - Health care worker's legal duty to disclose HIV-positive status to patients before performing invasive procedures. PMID- 10160579 TI - Clarifying the costs of theophylline toxicity. PMID- 10160580 TI - Mental healthcare spokesman. PMID- 10160581 TI - Journalist benefits hospital board. PMID- 10160582 TI - Navigating difficult issues earns trustee respect. PMID- 10160583 TI - PPOs are her preference. PMID- 10160584 TI - Policymaker looks to the people. PMID- 10160585 TI - JCAHO critic named to new advisory panel. PMID- 10160586 TI - Leading the way in her field. PMID- 10160587 TI - Larry McAfee, invisible man. The disabled: the agonizing fight to prevent a legalized 'suicide'. PMID- 10160588 TI - Michel C. Leger, trustee at large. PMID- 10160589 TI - Jean-Claude Martin: a man of vision. PMID- 10160590 TI - A French revolution. PMID- 10160591 TI - Sen. Pryor charges into influential healthcare role. PMID- 10160592 TI - Technology's role in care. PMID- 10160593 TI - A manager's challenge: enforcing OR policy. PMID- 10160594 TI - Looking ahead. Interview by Wesley Curry. PMID- 10160595 TI - The chief of staff and the medical director. AB - To understand the roles of the medical director and the chief of staff, it is important to consider the environment in which they operate. If both the environment and the roles are designed for collaboration and cooperation, these physicians can contribute to the success of the institution. PMID- 10160596 TI - Physician managers can play key financial management role. AB - Societal and technological changes experienced in the past few years have been instrumental in the creation of a new medical specialty--medical management. In this age of scarce resources for health care, physicians must be involved in management and leadership roles in the financial, managerial, and strategic planning aspects of their institutions. PMID- 10160597 TI - Dealing with the era of parsimony. PMID- 10160598 TI - Profile of a program director. Vern Bartley puts ideas into action. PMID- 10160599 TI - Wilensky off and running. PMID- 10160600 TI - CEO's courting meets opposition. PMID- 10160601 TI - Service-oriented philosophy epitomizes top executive's style. PMID- 10160602 TI - Challenging himself and others. AB - The new CEO of American Medical International, Harry Gray, is tackling healthcare for the first time at age 70. But he comes fully equipped with a reputation for achievement, a penchant for 90-hour weeks, and an ambition to devote the corporate office to tasks that add value to its hospitals. PMID- 10160603 TI - Medicated atmospheres (inhalation therapy in the 1800s). 1876. PMID- 10160604 TI - He's savvy beyond his years. AB - Joseph A. Ruffolo, 33, chief financial officer of Millard Fillmore Hospitals, Buffalo, N.Y., is the winner of the 1990 Cain Brothers, Shattuck & Co. award for hospital CFOs. He'll go to Harvard this summer for an intensive course on corporate financial management. PMID- 10160605 TI - Reining in mental health costs. AB - A leader in the management of mental health costs, Walter Afield says hospitals are no place for mentally ill people and substance abusers unless they are a danger to themselves or others. "Hospitals should do the right thing" and halt unnecessary inpatient stays, he said. PMID- 10160606 TI - Years of transition. Internal developments under Fr. Schwitalla, 1928-1947. AB - Dedicated to helping Catholic hospitals keep pace with rapid changes in the healthcare field, CHA flourished under the leadership of its first president, Rev. Charles B. Moulinier, SJ, who served from 1915 to 1928. The second in a series of Health Progress articles on the Catholic Health Association's history (March 1990) recounted Fr. Moulinier's efforts to expand CHA's role as a national organization serving Catholic hospitals. This article describes the work of Rev. Alphonse M. Schwitalla, SJ, to reorganize CHA and to develop a program for evaluating Catholic schools of nursing. In May, a fourth article will focus on CHA's developing relationships with other national Catholic organizations and its expanded role as an advocate of healthcare policy reform. PMID- 10160607 TI - Church and society. developments during the Schwitalla years, 1928-1947. AB - As CHA evolved and expanded in the 1930s, it became a more complex organization with wider responsibilities--and more intractable problems--than it had had before. The third article in the six-part Health Progress series on the history of CHA (April 1990) described the struggles of Rev. Alphonse M. Schwitalla, SJ, the association's second president, to develop effective CHA programs and policies on nursing education. CHA's relations with other national Catholic organizations, the growth and eventual autonomy of its Canadian member hospitals, and its role as an advocate of federal healthcare legislation during the Depression and World War II are covered in this article. Next month's installment will describe CHA's modernization and expansion under the leadership of Rev. John J. Flanagan, SJ. PMID- 10160608 TI - Keith Golden, 1990 IFMA Silver Plate Award winner/healthcare. PMID- 10160609 TI - The many hats of Doug Hawthorne. PMID- 10160610 TI - The best hospital administrator in the world. AB - Today's hospitals require executives who can create meaning, motivation, and cohesion for a broad array of people. Somebody who can combine resoluteness with flexibility. Somebody who is hard-headed and soft-hearted. There's a good role model in Boston. PMID- 10160611 TI - Old-fashioned turnaround. AB - Joel Bergenfeld came to a failing Los Angeles community facility in the shadow of two world-renowned institutions and turned Century City Hospital into a high profile revenue generator within four years. PMID- 10160612 TI - Lessons from the past. AB - Rosemary Stevens decided to study healthcare's history as a way of understanding what it had become. The one-time hospital administrator gradually became an academic expert and author, whose work earned the 1990 Baxter Health Services Research Award. PMID- 10160613 TI - From go-go to hospital CFO. AB - Before making her mark as a chief financial officer and rising notable in the Healthcare Financial Management Assn., Bonnie Phipps spent part of the 1960s as a rising notable in The Peppermint Rainbow, a rock group that enjoyed Top-10 popularity and a gig on "American Bandstand." PMID- 10160614 TI - Columbia tabs Vandewater for no. 2 post. PMID- 10160615 TI - Talk-show host and CEO. AB - Erie Chapman's idea of being a hospital chief executive extends to hosting a television talk show and spending work days as a patient escort or janitor. A critic of executives who rule their hospitals from their offices, Mr. Chapman advocates being visible and accessible to front-line staff and the public. PMID- 10160617 TI - '90s to be expansionary for medical management. Interview by Wesley Curry. PMID- 10160616 TI - Focus on quality of physician/hospital relationships. AGPA (American Group Practice Association) survey results. Part II. PMID- 10160618 TI - No pattern seen in survey for overreader qualifications. AB - A survey was conducted in the fall of 1989 to determine how hospitals handle the task of overreading of computer-generated electrocardiograms. All hospital-based members (1,451) of the American College of Physician Executives were sent questionnaires. Responses were received from 413 physician executives, a response rate of about 28 percent. The results of the survey are summarized in this article. PMID- 10160619 TI - Why physician managers fail--Part one. PMID- 10160620 TI - Smooth moves. PMID- 10160622 TI - Dual-purpose Duncan McNeill. PMID- 10160621 TI - Quality telephone medicine. Training and triage. AB - The telephone is an integral part of medical care, yet it ranks as the number one source of patient and clinician dissatisfaction. Problems fall into three categories: (1) volume overload with access difficulties, (2) staffing and telephone triage, and (3) the stress on clinicians of non-emergency night calls. This paper summarizes a telephone medicine satisfaction survey among HMO pediatric department chiefs, reviews the variables that influence the quality of telephone medicine, and discusses the importance of training in telephone management skills. A four-step approach to improving telephone medicine is presented along with a telephone quality-of-care checklist applicable to most practices. PMID- 10160623 TI - Supreme Court nominee has hospital background. PMID- 10160624 TI - Between jobs: the search for a management position. AB - Being out of work for physicians traditionally has meant that period after a severe illness or disability and before resumption of practice. As physician executives, we should think of the unthinkable. It also can mean being unemployed. That possibility is quite real, and yet we are ill-prepared to handle it. By inference from the national unemployment rate, there may be 200-300 members of the College who are "between jobs" at any given time. PMID- 10160625 TI - Chief of staff and medical director: conflict or cooperation? AB - Inevitably as the role of the medical director expands, it will directly affect power structures already existing in the hospital hierarchy, including department chiefs, other administrators, and the chief of staff. This article will attempt to define the roles of the medical director and the chief of staff, explore possible conflicts, and provide suggestions to help avoid confrontation. Finally, an attempt will be made to look into the future direction of the medical director's position. PMID- 10160626 TI - New challenges for medical directors. AB - Much of the future success of managed care organizations will depend on the quality of the direction provided by medical directors. The increasing complexity of the health care industry, manifested by intense competition for patients and reduced levels of reimbursement, will necessitate that HMOs, PPOs, IPAs, and utilization review firms begin to differentiate their services according to clinical protocols and outcome measures. PMID- 10160627 TI - Where will the leaders come from? PMID- 10160628 TI - Lucretia Spears, RRA, at 100: still one of the best and the brightest. PMID- 10160629 TI - Perspectives on health. Institute of Health Services Management annual conference 1990. PMID- 10160630 TI - Motivational patterns of management team members in a large hospital. AB - Management teams have been introduced as a means of solving conflicts and providing highly required co-ordination between professional groups, sub-units and their individual leaders in large, complex organizations such as hospitals. This study examines the motivational patterns of the three members of management teams of four clinical departments at a large university hospital. A strong professionalism was the dominant motivational orientation of all nurse managers (nursing directors of the clinics) and to a great extent also of the physician managers (head physicians of the clinics). The business managers' dominant motivational pattern was hierarchy in two out of the four teams, and professionalism in two teams. The respective comparison groups had rather similar motivational patterns in common with their leaders: ordinary physicians and nurses had a professional and administrative staff hierarchic orientation. The comparison group of mid-level managers from private firms was also hierarchically oriented, although task orientation was also often high in their motivational pattern. The results are consistent with the educational background and differences in the tasks of the groups studied. The role of different professional cultures in determining and designing efficiently functioning management teams is an important task for further research. PMID- 10160631 TI - Forging new paths in medical control. PMID- 10160632 TI - Physician turned politician. AB - Robert Marder, M.D., went from medicine to politics the day he became project manager of indicator development at the Joint Commission on Accreditation of Healthcare Organizations. Just assembling the task forces was a challenge to represent all disciplines affected by clinical indicators. PMID- 10160633 TI - Profiles. Faces to watch in foodservice. PMID- 10160635 TI - Doctors' orders. PMID- 10160634 TI - Profiles. Faces to watch in foodservice. PMID- 10160636 TI - Occupational health services for hospital workers: who does it best? AB - Occupational health services in hospital do not carry the same clout as clinical departments and are regarded by the medical staff as peripheral functions at best. Although some large teaching hospitals have recognized the need to put occupational health services for employees under medical directors trained in occupational health, most community hospital and long-term care facilities have not. These institutions need to reassess their occupational health program if hospitals, which are committed to healing, are not to be viewed as backward, regressive employers. PMID- 10160637 TI - For doctor executives, two careers are better than one. PMID- 10160638 TI - 'Public service junkie'. AB - A self-proclaimed "public service junkie," Drew Altman has held high positions in government health administration, healthcare program development and research. Colleagues say he sees past the academic and bureaucratic outlook on healthcare policy and focuses on people in need. PMID- 10160639 TI - Health Care Hall of Fame. Abraham Flexner, 1866-1959. PMID- 10160640 TI - Health Care Hall of Fame. Thomas F. Frist Sr., M.D., 1910. PMID- 10160641 TI - Health Care Hall of Fame. Robert Wood Johnson, 1893-1968. PMID- 10160642 TI - Health Care Hall of Fame. Mary Woodard Lasker. PMID- 10160643 TI - Health Care Hall of Fame. Andrew Pattullo, 1917- . PMID- 10160644 TI - Health Care Hall of Fame/previous inductees--Ray E. Brown, Robin C. Buerki, George Bugbee, Wilbur J. Cohen, Benjamin Franklin, Sidney R. Garfield, Eleanor C. Lambertsen, Malcolm T. MacEachern, John R. Mannix, Foster G. McGaw, Boone Powell Sr., C. Rufus Rorem, Saint Elizabeth Ann Seton, Lillian Wald. PMID- 10160645 TI - Fighting for world health. PMID- 10160646 TI - Physician relationships in troubled hospitals. Symptoms, causes, cures. PMID- 10160647 TI - Cancer survivor Richard Bloch gives hope to others. PMID- 10160648 TI - A doctor in the pulpit. AB - After a bumpy start that tagged him as a political naif, HHS Secretory Louis W. Sullivan is tackling his agency's herculean mission by exhorting the public on preventive health issues that don't bust the budget. PMID- 10160649 TI - Medical directors to carry more weight. PMID- 10160650 TI - From department to directorate. PMID- 10160651 TI - The Leicester experience. AB - Clinical directorates have been successfully working at Leicester Royal Infirmary for five years. Paul Barker charts their progress and looks forward to the next stages of resource management. PMID- 10160652 TI - A better way than clinical directives. PMID- 10160653 TI - Coping with charity burden. AB - Through financial crunches, political reversals and accreditation threats, Elliott Roberts has summoned the patience to persevere as chief executive officer of Charity Hospital at New Orleans. PMID- 10160654 TI - 'Catalyst for change.'. AB - Ralph Pollock left medical school just months before he would have earned a degree, but the lure of government development programs in the 1960s was too strong for a practical idealist to resist. Now 51, he's still on the lookout for ways to serve people in the healthcare field. PMID- 10160655 TI - Hospital medical director. Documenting roles and responsibilities. AB - Establishing the position of medical director for a hospital entails making a clear exposition of the role of the medical director in relation to the board, the basic administrative structure, and the medical staff. The responsibilities assigned to the medical director in one hospital may differ in more than a minimal manner from those in another institution, and the nature of these relationships may also vary because hospitals differ in their traditions, internal power relationships, and functions. Because of these differences, the need to be precise about roles and responsibilities becomes even more obvious. PMID- 10160656 TI - Pros and cons of clinical practice. AB - Physician executives, especially those who are new to the profession or who are beginning career moves to positions of increasingly higher management responsibilities, are faced with the decision of maintaining a level of clinical practice or leaving practice altogether. This article explores the advantages and the disadvantages of mixing practice and management that have been expressed by physician executives. PMID- 10160657 TI - A pivotal role for physician executives. AB - Physician leaders are needed to fill a pivotal role in the health care industry of the '90s. Medical education based solely on traditional scientific methods will continue to produce physicians with excellent clinical and research skills. However, study of science alone will not produce physician leaders. Effective leaders will also need to understand the tools and concepts of organization and management. These leaders will need to participate in the process of formulating and implementing policies to promote the development of economical financing and delivery arrangements while simultaneously improve the quality of care provided. PMID- 10160658 TI - Why physician managers fail--Part Two. AB - In this second part of the authors' two-part article, they continue with the list of flaws that can cause failure for a physician manager and offer some suggestions for avoiding or overcoming potentially destructive flaws. The authors' findings are based on interviews with a sample of 14 physician executives and on comments received from attendees at workshops of the American College of Physician Executives. PMID- 10160659 TI - Laboratory direction: a functional approach. PMID- 10160660 TI - Taking on the medical establishment. PMID- 10160661 TI - Trustee profile. J. Harold Stafford. PMID- 10160662 TI - Mark E. Schlussel receives 1990 Governance Award. PMID- 10160663 TI - Strano resigns as AOHA president. PMID- 10160664 TI - Back among the troops. PMID- 10160665 TI - McCarthy quits AHA. PMID- 10160666 TI - Running the Medicaid Bureau. AB - Christine Nye brings 14 years of solid experience in health policy to her new job as federal Medicaid director. She also brings strong feelings about providing maternal and child care, the result of a personal loss. PMID- 10160667 TI - Fighting the mad-scientist label. AB - David Margulies, M.D., has to fight the "mad scientist" image. He's one of a new breed of physician who loves computers, and he's using his interest and expertise to develop systems that other physicians will love. PMID- 10160668 TI - Performance Citation Award 1990. PMID- 10160669 TI - A day in the life of Shari E. Pollard, Assistant Administrator, Human Resources Department, Sibley Memorial Hospital. PMID- 10160670 TI - Executive housekeeper works two jobs and thinks positively. PMID- 10160671 TI - American Academy of Medical Administrators calls for health reform. PMID- 10160672 TI - Depending on donations. AB - St. Jude Children's Research Hospital relies on donations for more than half its operating income. But that doesn't worry Joseph Simone, M.D. After 23 years at the Memphis, Tenn., hospital, its director has learned to trust the generosity of others. PMID- 10160673 TI - News from the inferno: a patient's view of Bellevue Hospital. PMID- 10160674 TI - Trustee profile. PMID- 10160675 TI - 1990 Yater Award for distinguished service. George B. Plain, M.D., South Bend, Indiana. PMID- 10160676 TI - Standing up to Hugo. AB - On September 21, 1989, Hurricane Hugo blasted into Charleston, South Carolina. Gary R. Nimocks did more than just follow the rule book to meet the needs of the disaster victims. He marshalled the forces of his department to deliver nutrition & emotional support to thousands of patients, staff & community members for weeks & even months following the storm. PMID- 10160677 TI - Edward S. Thomas, MHA Corporate Board Chairman: a leadership style grounded in reality. PMID- 10160678 TI - The capacity of enabling. Lawrence of Arabia faced a challenge remarkably similar to the one represented by today's physicians. PMID- 10160679 TI - What does it cost, and does it help the patient?. Interview by Wesley Curry. AB - At the ACPE National Conference in San Antonio on May 17, 1990, David M. Eddy, MD, PhD, described serious problems with the information infrastructure for medicine, and discussed the implications of these failings for the quality and cost of medical care. Physician Executive discussed the issues raised in Dr. Eddy's presentation and reports his comments in this article. Dr. Eddy is Professor of Health Policy and Management, Duke University, Durham, N.C. PMID- 10160680 TI - The making of a hospital physician executive. AB - Physicians are accustomed to having the "buck" stop with them in the clinical arena. Indeed, they resist any attempt to have it otherwise. Management has only recently come back into their consciousness as a career possibility. Management is the "buck" that now belongs to the enemy, represented by managed care, paperwork, and regulation. The thoughts in this article have grown from the author's experience over the past six years as a physician executive in a community hospital, a career that followed 25 years in clinical and anatomical pathology. PMID- 10160681 TI - Behavioral quality assurance: a transforming experience. AB - The captains of the health care industry are leading a transformation in health care. Increasing numbers of physician executives are acquiring the knowledge, skills, and attitudes essential to both the science and the art of management. If they wish to practice the art of management at a high professional level, however, physician executives must be willing to experiment with their behavior in interactions. Change and growth in this aspect of human nature will also bring them face-to-face with their self-images. More important, attention throughout an organization to behavior toward one another will have a significant bearing on the quality of the organization's services to clients. PMID- 10160682 TI - Applying futuristic technology to the priorities of the past. AB - The hot topic in health care executive suites across the nation is outcomes management: measuring the effects of interventions on the quality of life of patients. The halls of our institutions are buzzing about the shifting focus from the board room to the bedside, and from the balance sheet to the patient's chart. Is outcomes management just another fad that will result in an additional layer of space-age overhead with little relevance to our patients' goals? Aren't we already concerned enough about our patients? What happened to the old saw, "If it ain't broke, don't fix it?" PMID- 10160683 TI - Defensive barriers to communication. AB - To be an effective communicator, the manager must understand the obstructions that exist in sending and receiving messages. These barriers to communication are infinite in number and include language, education, experience, understanding, perception, semantics, faulty transmission, environment, personal interests, and physical, physiological, and psychological factors. One of the most serious barriers to communication is defensiveness, which creates negative feelings and counterproductive results. PMID- 10160684 TI - Filling the management/physician niche. AB - New regulations implementing the Omnibus Budget Reconciliation Act of 1987 bring focused attention to the medical care provided to nursing facility residents. The expectations for meeting the clinical needs of residents will demand additional physician participation. How will facilities integrate the expanded role of the physician as manager? PMID- 10160685 TI - Medical directors complete interdisciplinary team. PMID- 10160686 TI - Marguerite d'Youville: woman of compassion. AB - The Church canonized one of our own: the "Mother of Universal Charity," as Pope John XXIII so aptly called her in 1959, a sister of action and contemplation who opened her heart to the urgent needs of her time, a Canadian wife and mother who innovated hospital and health care, a person for whom love knew no boundaries. PMID- 10160687 TI - Change or be changed. Group practices in the 1990s. The Institute for Physician Executives and Group Practice Management--designed to solve problems today and tomorrow. PMID- 10160688 TI - Enhancing healing. PMID- 10160689 TI - Zale-Lipshy names new CEO. PMID- 10160690 TI - Spectrum goes outside for new top officer. PMID- 10160691 TI - 1991 Trustees of the Year. AB - Modern Healthcare announces its selections for the annual honor: Edwin A. Jaffe, in the category of hospitals with fewer than 250 beds, for his role in restoring relationships between administrators and physicians at Miriam Hospital, Providence, R.I.; Merle Yontz, in hospitals of more than 250 beds, for his 42 years of guidance at Memorial Medical Center of Illinois, Peoria. PMID- 10160692 TI - Physician executive salaries outpace inflation but don't skyrocket--study. AB - A new study compares the salaries of full-time physician executives between 1987 and 1990. It concludes that while the pay outpaced inflation, it didn't skyrocket. And it shows that perks are declining and formal contracts are more common. PMID- 10160693 TI - Mona Edgecombe Going. PMID- 10160694 TI - Who's responsible for medical oversight? PMID- 10160695 TI - Blending religious and executive life at helm of Chicago's oldest hospital. PMID- 10160696 TI - The leadership and executive potential of physicians in an era of managed care systems. AB - The emergence of managed care signals a need for an expanded role for physicians. Physician executives, trained in management, have the potential to become champions of clinical integrity, negotiators with patient agent organizations, public interpreters of hospital performance data, consultants to the profession, and designers of health care systems. Nonclinically trained administrators have been slow to recognize the unique skills and perspective that physicians bring to the managerial suite. The clash of professional and managerial cultures has often been perceived as precluding a strong working alliance between physician and nonphysician executives. As hospital margins are threatened, decision protocols must not be designed to incorporate teams of leaders who are able to overcome the managerial/clinical divide. The management of this interface will demand the attention of both administration and boards and may require the establishment of new structures in health care organizations. PMID- 10160697 TI - Community health activist. AB - J. Emilio Carrillo's experience as a researcher and physician in the Latino sections of Cambridge, Mass., has groomed him for leadership of the nation's largest municipal healthcare system, New York City Health and Hospitals Corp. PMID- 10160698 TI - CFO spends two grueling weeks at Harvard. AB - Joseph A. Ruffolo spent two grueling weeks at Harvard Business School last June- the top award in the third annual Cain Brothers, Shattuck & Co. contest that recognizes an outstanding member of the healthcare financial community. Mr. Ruffolo, vice president of finance at Millard Fillmore Hospitals in Buffalo, N.Y., gives some advice to the next winner: Stock up on sleep before you go, and leave the tennis racket at home. PMID- 10160699 TI - Profile of a flight nurse. PMID- 10160700 TI - Karl A. Menninger: psychiatrist and moralist. AB - Karl Augustus Menninger, whom the American Psychiatric Association declared "America's greatest living psychiatrist," died July 18, 1990, in Topeka, KS. He had lived there his entire life. In 1993 he would have been 100 years old. The name "Menninger" has become synonymous with psychiatry, principally through the work of this one man. In 1925, with his father and his brother William, he established the Menninger Foundation, a world-famous center for research, education, and treatment of mental illness. A leader in psychiatry for more than 70 years, Menninger wrote more than a dozen books and hundreds of articles. He gave thousands of lectures and directly helped thousands of psychiatric patients in addition to the hundreds of thousands of people he touched through his writings. PMID- 10160701 TI - The decision makers: Perrin Beatty. PMID- 10160702 TI - Trustee profile: Ed Smith. PMID- 10160703 TI - Management education at the Nordic School of Public Health. AB - This article introduces the Program of Health Services Management at the Nordic School of Public Health in Gothenburg, Sweden, after its reorganization in 1987. The school is a joint effort of the governments of Denmark, Finland, Norway, Iceland, and Sweden. As background, some research on the effects of management training for physicians and on the significance of leadership is presented. This article focuses on the relationship between administration, management, and leadership. The program aims at a holistic approach. The appendix presents the main purposes and content of the program. PMID- 10160704 TI - A strategy to enhance accountability in health care delivery. AB - The New York State Department of Health surprised many in the hospital industry and medical community when, in June 1987, it proposed as regulation that the governing body of each acute care hospital appoint a medical director who would be assigned responsibility for the direction of the organized medical staff. Such a proposal, without modification, has been incorporated in the New York State Hospital Code--Minimum Standards, effective January 1, 1989. While a strong case can be made for this position in hospitals, its value has long been recognized by a wide variety of organizations. PMID- 10160705 TI - Support network depends on position. Interview by Wesley Curry. PMID- 10160706 TI - Executives share management tips. AB - Members of the American College of Physician Executives were asked earlier this year to share their experiences in solving particularly nettlesome management problems. The goal was to construct a problem-solving tool for the widest possible array of problems in the full range of health care environments. This article is a distillation of the responses that were received, including contacts for further information on the problems and their solutions. PMID- 10160707 TI - Hospital size determines department director policy. AB - Early in 1990, the American College of Physician Executives undertook a survey of its hospital-based members to determine the extent to which hospitals had department directors and the roles, responsibilities, and compensation of those directors. The survey form was mailed to about 1,400 College members; responses were received from 734--approximately a 52 percent response rate. This article reports the results of the survey. PMID- 10160708 TI - Persuasion strategies for physician executives: Part I--Influencing superiors. AB - Little is known about the way physicians function as managers in influence situations. In an effort to fill this gap in the literature and to illuminate how a "target's" communication style affects "agents" strategic decisions, this study examined 222 physician executives' choices of compliance-gaining strategies when seeking to influence superiors who communicate with them in attractive and unattractive styles. PMID- 10160709 TI - Hail the Belfast pioneers. PMID- 10160710 TI - The New York City Department of Health under Lowell E. Bellin, MD. PMID- 10160711 TI - Focus: CIOs in healthcare. G. Ward Keever, Senior Vice President of Information Services, Medical Center of Delaware. PMID- 10160712 TI - Architecture for psychiatric treatment. PMID- 10160713 TI - Trustee profile: Dan de Vlieger. PMID- 10160714 TI - Management training. Taking a doctor on board. PMID- 10160715 TI - Profitability analysis and the physician/administrator team. PMID- 10160716 TI - Leaders and leadership: fact or fancy? AB - What is leadership? What does it look and feel like? How does it work? Can we recognize it if we see or experience it? Moreover, can we (the administrators) provide the leadership required of us? Author Wilson Graves, M.A., M.P.A., details several leadership theories, tying them together to show what it takes to be an effective leader. PMID- 10160717 TI - Power and authority: their meaning for group practice administrators. AB - The word power is filled with meaning. It can't be spoken without creating some type of reaction. Power is a key issue in our lives. Authors Mikel Lynch and Seth Allcorn, Ph.D., look at power and authority through a scenario involving a physician and an administrator to show how it can be used effectively in a group practice setting. PMID- 10160718 TI - A physician's guide to practice governance. AB - Riddle: Everyone wants the title but few want the job. Everyone wants the glory but none want the drudgery. It has to be done but few want to do it--and even fewer want to allow someone else to do it. What is it? The answer, according to author Joan Wagner Zinober, Ph.D., M.B.A., is practice management and governance. This is her first article in a series on people management and leadership in which she describes several governance structures and their pros and cons. PMID- 10160719 TI - Compensating hospital medical staff leaders for organizational duties. AB - Physician leadership in hospital affairs is important to physicians, patients, and the public, as well as to hospitals. In this article, the author advocates payment to medical staff leaders for performance of the patient-protective functions of the traditional organized medical staff, including ensuring the qualifications of practitioners (credentialing) and monitoring their current performance, and focuses on questions concerning specific duties, qualifications, selection, orientation and evaluation of medical staff leaders. PMID- 10160720 TI - From medicine to management: the female physician executive. AB - In a 1988 article in Physician Executive, Bonbrest recorded the number of women members (74) of the American College of Physician Executives (then the American Academy of Medical Directors) and urged senior managers to facilitate the entry of women physicians and minorities into management positions. This article relates historical trends for women in medicine and medical management and calls for increased attention to the slowness with which advancement for women has been achieved. PMID- 10160721 TI - Helping physicians manage challenging patient encounters. Part II. AB - In the Nov.-Dec. 1990 issue of Physician Executive, the author discussed some of the problems and effects of poor physician-patient interactions and described a program designed to develop physician skills in dealing with challenging patients. In this issue, the author details a method for implementing this program in a health care provider organization. PMID- 10160722 TI - How much administration is today's physician doing? AB - The substantial changes in the organization and financing of health care services that have occurred in the United States over the past decade have helped to facilitate a growing role for physicians in health care management. These administrative roles for physicians are becoming increasingly important within many health care institutions with regard to such issues as cost containment and cost effectiveness, quality assurance and professional standards, and access to care. The growing complexity and diversity of the delivery system have created the need for more physicians to become involved in "orchestrat(ing)" the management of the medical-industrial complex." PMID- 10160723 TI - Persuasion strategies for physician executives: Part II. Influencing subordinates. AB - The investigation reported in this article is the second of two studies examining the way physician executives use persuasion strategies. Despite the research on physician executives and the importance attributed to physicians' being in management, there is still much to learn about how physicians actually manage, particularly in influence situations. The goal of this study is to examine physician executives' choices of persuasion strategies to influence subordinates who communicate with them in attractive and unattractive styles. In the November December 1990 issue of Physician Executive, the author reported on a study of strategies used to persuade superiors. PMID- 10160724 TI - What governing boards expect from physician executives. AB - Governing boards of health care organizations have undergone major changes in the past two decades. Structurally, today's typical not-for-profit hospital board is smaller, includes 1-4 physicians, and limits trustees' terms in order to infuse the board periodically with new talents and fresh ideas. Even more important, today's trustees aren't there just for prestige or to contribute money. They are committed to the organization's mission and willing to work hard for its success. PMID- 10160725 TI - Caldwell resigns as Ancilla chief. PMID- 10160726 TI - Focus: CIOs in healthcare. Fred Pirman, Jr., Senior Vice President of Information Systems, Humana, Inc. PMID- 10160727 TI - Md. hospital exec Davidson named president of AHA. PMID- 10160729 TI - A perceptual study of the role of the president of the medical staff. AB - This study examines how medical staff presidents and hospital administrators perceive the president's role. The perceived role of the president is compared to hospital typology as measured by hospital size, technology, and form of ownership. Overall, there is little difference between how hospital administrators and presidents view the president's role. There is substantial agreement on steps that should be taken to increase the effectiveness of the president. A widespread view is that the president should receive formal management training and be an active member of the hospital's board of trustees. PMID- 10160728 TI - CFO award winner has record of results. AB - For Arlan R. Yoder's part in turning around the financial fortunes of a Kansas hospital system and maintaining its strong credit rating, the 40-year-old chief financial officer has been named the winner of the Cain Brothers, Shattuck & Co. award, which recognizes an outstanding member of the healthcare financial community. The award will send Mr. Yoder to Harvard Business School this summer for a two-week, intensive course in corporate financial management. PMID- 10160730 TI - Rockefeller eyes presidency. PMID- 10160731 TI - Focus: CIOs in healthcare. Betty G. Hudson, Chief Information Officer, Michael Reese Hospital & Medical Center, Chicago, IL. PMID- 10160732 TI - Invest in personal quality, Chairman urges. PMID- 10160733 TI - O'Leary to leave VHA for the top job at AMI. PMID- 10160734 TI - Trustee profile: Gwen Haliburton. PMID- 10160735 TI - N.E.H.A.'s (National Executive Housekeepers Association) Canadian contingent. Whether you say "purchase" or "commission," the responsibilities are the same. PMID- 10160737 TI - Is the grass really greener for a medical director? PMID- 10160736 TI - Emerging leaders 1991. Six who have arrived. AB - "I would quibble with the idea that Cheryl is an 'emerging leader,"' observes a colleague of one of this year's honorees. "I believe she has arrived." In truth, each of the six extraordinary people cited as 1991's Emerging Leaders have had a major impact on their organizations and, by example and design, on the nature and quality of healthcare in their communities. But then, the annual call for nominations demands nothing less. Sponsors Korn/Ferry International and The Healthcare Forum are "looking for...talented people with the proven ability to nurture the growth of the industry. They are dynamic, decisive young leaders who have already made a mark." Five men and one woman, all age 40 or younger, were selected as this year's Emerging Leaders in two separate categories. Three represent large healthcare organizations, three smaller urban or rural institutions--generally hospitals with fewer than 200 beds. Interestingly, nearly all were influenced to pursue careers in healthcare at an early age. Two had physician parents, two were sons of healthcare administrators, two worked in hospitals as teenagers. All, of course, have shown their mettle in difficult times and complex, uncomfortable situations. All have been pivotal in turning around failing--or at least beleaguered--organizations. Yet, while each has labored diligently to further the interests of his or her own organization and constituency, each has also sought to shape a more cooperative system. As honoree Larry Sanders observes, "Competition without conscience will deny our claim to a true community leadership role." Marveling at the accomplishments of honoree Kevin Fickenscher, an awed peer declared: "One of these days we'll all be working for him!"(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10160738 TI - How should Medicare pay doctors? PMID- 10160739 TI - Passing the torch. PMID- 10160740 TI - Dolores J. Strenko. 1991 IFMA Silver Plate Award winner/healthcare. PMID- 10160741 TI - Davidson: innovative leader who recognizes the importance of trustees. PMID- 10160742 TI - Executive program in practice management: a new concept in management education. PMID- 10160743 TI - The physician as department administrator in an academic institution. AB - As the delivery of health care is operated like a business, physicians feel a sense of loss of autonomy and control over their profession. As both the payor and the consumer play more participatory roles in health care decisions, physicians are beginning to see an administrative role as partial satisfaction of the need to proactively plan for their specialty's future. This paper examines the physician administrator's role in an academic setting. PMID- 10160744 TI - Organizational conflict: strong department heads versus central administration. AB - Academically oriented physicians and physician leaders are generally not advocates of strong centralized organization. This paper examines St. Mary's Medical Center's attempts, over a five-year period, at integrating departmental and central administrative functions. PMID- 10160745 TI - The creation of a coordinated ambulatory care system. AB - This case study addresses the efforts of the School of Medicine (SOM) of a major American university to develop a coordinated ambulatory care system. For a number of years, each of the clinical departments of the SOM operated its clinic independently from the SOM and from the other departments. This is a description of the development of a plan to coordinate the efforts of these clinics. PMID- 10160747 TI - Greater future role seen for physicians, physician executives. Interview by Tony Joseph. PMID- 10160746 TI - Networking--getting to know more people. AB - One of the first and often the most difficult tasks for job seekers is increasing their networks--the number of people they know. A large percentage of people get jobs because people knew them and thought they would be good at it. People must know who you are and what you do in order to recommend you for a job. Networking should be an ongoing process, so that when you need a new position, you have people you already know that you can contact. PMID- 10160748 TI - Myths and misconceptions of the medical staff organization. AB - Many of the problems that confront hospitals in a rapidly changing and increasingly hostile environment are of their own making. Chief among these self destructive tendencies has been misjudgment of the characteristics and functions of the medical staff organization. This article explores some common misconceptions and provides a more plausible reality. PMID- 10160749 TI - Negotiating with interactive scenarios and strategies. AB - Physician executives need to negotiate effectively with a wide range of parties. In those negotiations, they should consider the relative importance of both substantive and relationship outcomes in selecting initial negotiation strategies. Of course, these strategies may or may not be successful, depending on the strategies used by the other party. Hence, the physician executive must consider the other party's strategy and how it and his or her initial strategy are likely to interact both before and during negotiations. PMID- 10160750 TI - The roles and responsibilities of the medical staff organization. AB - The increasing complexity of hospitals and the emergence of corporate responsibility calls for greater trust amongst the Board, Administration and Medical Staff. Physicians will play a more important role in the hospital decision-making process. Boards will expect the medical staff organization to better define and monitor processes for physician credentialling, evaluation, peer review and discipline. Because these issues are complex and sensitive, only the organized medical staff can appropriately address them. Clarification of roles and responsibilities of the President of the Medical Staff, the Chief of Staff and the medically qualified administrative officer is crucial in the development of appropriate relationships and processes. PMID- 10160751 TI - A day in the life of John Stavros, Director of Marketing, UCSD (University of California) Medical Center. PMID- 10160752 TI - A day in the life of Robert H. Stiefel, manager of Clinical Engineering Services, Johns Hopkins Hospital. PMID- 10160753 TI - Back to school at Cleveland Clinic. Interview by Carolyn Dunbar. AB - When the new chief executive officer at the Cleveland Clinic Foundation decided to decentralize an overburdened administrative structure, he sent clinical department heads and administrators back to school for intensive practice management education. The training for physicians and administrators included much more than a passing acquaintance with information systems. PMID- 10160754 TI - A son's death. PMID- 10160755 TI - Duties and potential liability of nonhospital entities in credentialing physicians. AB - This article discusses the duties of hospital governing boards, medical staffs, medical staff officers, and individual medical staff members regarding the credentialing of physicians, including the potential liability of these groups for negligent medical care and wrongful denial of staff privileges. This article also proposes possible measures these groups may take to avoid or limit their exposure to such liability. PMID- 10160756 TI - Two pioneers of today's partial hospital and their ideas. AB - Inspiration for the modern-day hospital comes from two sources, the hospital based work of D. Ewen Cameron and the community-oriented approach of Joshua Bierer. Examination of their respective viewpoints sheds light on the baffling diversity which partial hospitalization, at the interface of hospital and community, has manifested over the last four decades. Such an intellectual history offers insights into the provision of more rational day programming. PMID- 10160757 TI - John Guest. PMID- 10160758 TI - Once the choice is made: a close look at the joint venture option. Part two. PMID- 10160759 TI - The professional image of medical record practitioners: perceptions from administrative officers, financial officers, and chiefs of medical staffs. AB - The study's findings provide insights into the relationship between medical record practitioners and the disciplines whose members were surveyed. This relationship is an important one. Much has been written about the team concept in the provision of care. Teamwork and maintaining a mutually respectful relationship is just as important to the administrative aspects of health care. A positive professional image is a prerequisite for gaining respect. Nurturing a positive professional image is the responsibility of individual practitioners as well as the medical record profession as a collective entity. One way in which these findings can be utilized is for self analysis of MRPs: how would they evaluate themselves and how they perceive others would evaluate them. Answers to these questions may suggest areas where improvement in necessary. A second way in which findings can be used is in the recruitment arena. Positive findings can be used as recruiting and marketing tools to attract potential members into the medical record profession. Efforts in the recruitment area are necessary to meet predicted manpower shortages in the profession. While the study assisted in the understanding of the relationship of MRPs and other professionals with whom they must work closely, further study is necessary. This study's response rate and limitations to the parameters may preclude generalization; therefore, replication of the study is needed before findings can be universally applied. Additional study is necessary to determine others' perceptions of not only the image of MRPs but the identity as well. Are MRPs perceived as safekeepers of medical records or as health information leaders? PMID- 10160760 TI - Determining domain. The issue of medical control. PMID- 10160761 TI - Yale-New Haven's Smith takes post of president, CEO of VHA alliance. PMID- 10160762 TI - Up and comers: Lt. Cmdr. Robert J. Burg, Maura Loughlin Carley, Pete Delgado, John P. Glaser, Glen Nessel, Kevin Potter, Laura J. Redoutey, Vicki Romero, Nancy Schlichting, Paul Viviano, Greg Wozniak, Lorraine Zippiroli. AB - Modern Healthcare's 1991 Up and Comers, the fifth annual group, are scattered all over the map, from Boston to the Bay Area, from Flint, Mich., to El Paso, Texas. They work in managed care, associations and specialty hospitals; one even administers the office that cares for members of Congress. At least two are "healthcare brats" whose fathers managed hospitals. One spent time working in a salmon cannery; another was a Peace Corps volunteer in Swaziland. Despite their differences, they share many common traits. They are bright, committed and know how to motivate and involve others. Maura Loughlin Carley, an area administrator for Kaiser Permanente Foundation Health Plans, put it best when she said her goal is to "hire the best people, develop them and keep them happy." They're also committed to seeking new ways to improve healthcare delivery. As Kevin Potter said, "What keeps me humble is that there's so much that I'm learning every day." Each of these emerging leaders is making a mark on the healthcare industry. They were chosen from a field of almost 50 candidates, all 40 or younger, compiled by the editorial staff of Modern Healthcare and readers. PMID- 10160763 TI - Revamp selection of clinical leaders. PMID- 10160764 TI - Prescription for physician executives: take care of your doctors. AB - Considerable attention is paid to employee assistance plans in business and medical groups. Successful plans have improved employee retention, productivity, and morale. But physicians tend to resist these plans, because inherent in a physician's egostructure is a perception that physicians do not need support. In assessing unrest among the doctors in our clinic, it seems to me that our physicians clearly need tender, loving care. This article is a summary of areas in which care can be usefully provided. PMID- 10160765 TI - The challenge for women physician executives. AB - After half a century of constituting 5 percent of the physician population, women will soon make up more than one-third of U.S. physicians. Women now practice in virtually every specialty. This enormous change has created both opportunities and tensions. Within the broader context of the changing role of women in U.S. society, women physicians are exploring new career paths--paths that are both similar to and different from those of their male colleagues. A future challenge for women physicians will be achieving significant representation in the medical management ranks. PMID- 10160766 TI - Physician executives in the '90s: report of a national survey. AB - In fall 1990, Witt Associates again catalogued the progress of physicians as they obtain management positions of increasing importance. The firm has conducted a continuing study of the position since 1979. The current survey of vice presidents of medical affairs/medical directors renders a candid portrait of the physician manager. The profile that emerges is a 53-year-old white male, working almost 50 hours a week in a full-time position, appointed by the hospital and reporting to the Chief Executive Officer. This individual is board certified and has major responsibilities for quality assurance, credentialing, risk management, and utilization review. His or her salary is into six figures. PMID- 10160767 TI - Negotiating for more than a slice of the pie. AB - Negotiation is an important way for physician executives to manage conflict and to accomplish new projects. Because of the rapidly changing nature of the health care environment, as well as conflicts and politics within their organizations, managers need to effectively negotiate with a wide range of other parties. Managers should consider the relative importance of both the substantive and relationship outcomes of any potential negotiation. These two factors may guide the executive's selection of initial negotiation strategies. PMID- 10160768 TI - Employee/independent contractor determinations. AB - Among the areas receiving increased scrutiny recently from the Internal Revenue Service is employee/independent contractor determinations. The IRS estimates an annual $1.5 billion loss of revenues because of misclassification of workers as independent contractors rather than employees. Organizations found to be in violation of the FICA withhold payment requirements could be subject to significant penalties and assessments. PMID- 10160770 TI - Health Care Hall of Fame: Robert M. Cunningham Jr. PMID- 10160769 TI - Principles of successful contracting for emergency physician coverage. PMID- 10160771 TI - Health Care Hall of Fame: Gerhard Hartman. PMID- 10160772 TI - Health Care Hall of Fame: William A. Hillenbrand. PMID- 10160773 TI - Health Care Hall of Fame: Harold W. Hinderer. PMID- 10160774 TI - Health Care Hall of Fame: Margaret Daugherty Lewis. PMID- 10160775 TI - Survey provides overview of profession's responsibilities. AB - At the end of 1990, the Physician Executive Management Center, Tampa, Fla., undertook a survey of College members to determine levels of compensation and benefits and to provide a glimpse at the roles and responsibilities of physician executives. The results of the survey have recently been published by the Management Center. In this article, the roles and responsibilities of physician executives for the overall sample are summarized. PMID- 10160776 TI - Managing continuity of medical care. AB - A key consideration in decisions on allocation of work load in physician groups is preservation of continuity--so key, in fact, that the word continuity is often used as a holy incantation that implies any further argument is blasphemy. But what is continuity? If we can examine the concept along with its advantages and how it is achieved, health system planners on the micro level can design systems rationally incorporating continuity of medical care. PMID- 10160777 TI - Gov. Booth Gardner: a quiet voice on health care. PMID- 10160778 TI - Flexibility reigns supreme for housekeeping in mental health facility. PMID- 10160779 TI - Talk about challenges! This executive wears many hats. PMID- 10160780 TI - The "medical piece" of hospital strategy. PMID- 10160781 TI - Casey named president, COO of American Medical. PMID- 10160782 TI - P-A prospects ... continuing-care retirement communities. AB - In this first installment of a series on clients, P-A Prospects talks with decision-makers in the field of continuing-care retirement communities. At a time when architectural commissions are getting scarcer, it is all the more important that design professionals understand the interests and needs of clients. P-A Prospects is meant to give architects insight into the minds of prospective clients: how they judge architects' proposals, how they respond to their presentations, and how they evaluate them at interviews. Profiles of decision makers inside client organizations will let architects and designers see how things look from the other side of the table. PMID- 10160783 TI - Part-time practice in an HMO. AB - Part-time practice--practicing fewer clinical work hours than one's HMO norm--is common at Harvard Community Health Plan. Physicians choose part-time practice for diverse reasons: to allow time for other professional activities, such as management or teaching, to facilitate their lives as working mothers, or to ease their work lives. A great potential for difficulties with practice management exists when physician colleagues who devote different proportions of their time to clinical practice collaborate. This can be resolved by a facilitated approach that allows team members to identify problems and generate their own solutions. PMID- 10160784 TI - The man behind the machine. PMID- 10160785 TI - CHAC Performance Citation Award 1991. PMID- 10160786 TI - The decision makers: Nellie J. Cournoyea. PMID- 10160788 TI - Serving in the inner city: three perspectives. Interview by Judy Cassidy. PMID- 10160787 TI - Decision making, goal consensus, and effectiveness in university hospitals. AB - This article examines changes in the influence of several key actors (state and university officials, board members, and hospital and medical school administrators) in management and policy decisions for university hospitals (UHs). We propose that the decreasing influence of external actors in UH decision making and the increasing influence of UH and medical school actors as well as UH medical school goal consensus will be related to higher levels of UH performance. Data are drawn from a national sample of 52 UHs that participated in a study of UH decision making in 1981 and 1985. Results indicate that state and university actors lost influence in UH policy decisions between 1981 and 1985, while actors internal to academic health centers (AHCs) gained influence in such decisions. The data indicate a similar trend, although not as strong, regarding influence in UH management decisions. Results from regression analyses indicate that decreasing levels of external influence on UH decision making are related to UH effectiveness, but increasing levels of AHC influence and goal consensus have weak or inconsistent relationships with UH effectiveness. Implications for improving the performance of UHs are discussed. PMID- 10160789 TI - Medical administration and health education needs. AB - The purpose of this paper is to describe the role of the Royal Australian College of Medical Administrators in the training of medical graduates who wish to pursue a career in health services management. The Royal Australian College of Medical Administrators, founded in May 1968 with an initial membership of 279, is a specialist educational body conducted along similar lines to the other medical colleges in Australia and the United Kingdom. The development of the educational requirements of the college, and the evolution of its training program over the past twenty years, is examined, as well as the appropriateness of the British college model for the training of medical administrators, and the impact that the changes in Australian health care services may have on future educational programs. PMID- 10160790 TI - "To hell with the ethicists. I'm a real physician.". PMID- 10160791 TI - Jack and Jill's crowning achievement. AB - In this article, Irwin Rubin examines the dialogue from an article which appeared in the March/April MGM Journal on power and authority. Rubin dissects the dialogue from this first article as he delves further into the meaning behind power and authority and how to use compromise as a buffer. PMID- 10160792 TI - Physician leaders see eye-to-eye. AB - Late in 1990, the American College of Physician Executives conducted a survey of hospital-based physician executives and chiefs of staff. Each was asked to judge the performance of the other in a wide range of activities. The results show a surprising degree of mutual regard and agreement. The differences, however, are also telling. PMID- 10160793 TI - From quality assurance to continuous quality improvement. AB - To change from punitive and legalistic QA to positive and productive CQI, both attitudes and methods must change. This is a difficult challenge, but potential rewards for both the organization and its individual members suggest that the effort is worthwhile and deserves high priority. Members of the executive/management team will likely turn to physician executives for guidance on how to proceed. PMID- 10160794 TI - Projects. Ellerbe Becket. PMID- 10160795 TI - MHA Chairman Ed McRee: profile of a visionary leader. PMID- 10160796 TI - Cumulative trauma disorders: the occupational illness of the nineties? PMID- 10160797 TI - Humana to ask judge to overturn award. PMID- 10160798 TI - New JCAHO standards require board certification or equivalent for all clinical department heads. AB - Among several changes in standards for 1992 by the Joint Commission on Accreditation of Healthcare Organizations is one requiring that physicians heading clinical departments in hospitals be board certified in that clinical specialty or demonstrate comparable competence in the specialty. Previously, only a handful of clinical department heads faced that requirement. PMID- 10160799 TI - Stephen Smith. Pioneer of American surgery and public health. PMID- 10160800 TI - Made to measure. AB - Progress in drawing clinicians into management has been slow, but would a new role entail a new breed of manager or just an adaptation from general management? In the first of two articles Louise Fitzgerald looks at the challenges. PMID- 10160801 TI - This year's model. AB - The clinical directorate model has been swiftly adopted as a way of getting clinicians into management. In the second of two articles, Louise Fitzgerald looks at its limitations and at the alternatives. PMID- 10160802 TI - Target practice puts managers in Sir Donald's firing line. PMID- 10160803 TI - P/A Annual information sources, 1991-1992. Professional information. PMID- 10160804 TI - Versatile professional has come up through the ranks. PMID- 10160805 TI - The 1991 FM Award For Humanitarian Service presented to Mary Tim Griffin, R.D., for directing a grass roots Harvest program. AB - By establishing Owensboro Harvest, a food collection and distribution program, Mary Tim Griffin, R.D., is achieving huge improvements in the quality of the food and the level of the nutrition being served to the needy and homeless in Owensboro, Kentucky. Here's how the hospital food-service director accomplished so much in her community. PMID- 10160806 TI - Staffing ERs. No easy task. PMID- 10160807 TI - 1991 Trustees of the Year. A driving force in a dramatic turnaround--HealthEast. PMID- 10160808 TI - 1991 Trustees of the Year. A pillar of strength during tough times--Stringfellow Memorial Hospital. PMID- 10160809 TI - Initiative 119 and Kevorkian: beaten but not dead. AB - Two events--the close defeat of Washington State's Initiative 119 and the disclosure that Jack Kevorkian, M.D., had provided two more women with the means to die--are promoting a great deal of nationwide soul-searching and reflection over the ties between and the reasons behind these events. The following articles summarize some of the predominant explanations. PMID- 10160810 TI - Proposed scoring guidelines for the Accreditation Manual for Hospitals, 1992 edition, "Medical Staff" chapter. PMID- 10160812 TI - Roger Spoelman: creating a climate for success. PMID- 10160811 TI - The use of physician extenders in nursing homes: a review. PMID- 10160813 TI - Frank McCarthy: 16 years of distinguished service. PMID- 10160814 TI - James MacCallum: still room for the entrepreneur in hospital administration. PMID- 10160816 TI - Doctors in management. PMID- 10160815 TI - Housekeeping does its share to help make children whole again. PMID- 10160817 TI - Vernon Smith: the man at the helm of the MSA (Medical Services Administration). PMID- 10160819 TI - Community public healthcare. PMID- 10160818 TI - Prototype handrail. PMID- 10160820 TI - Dr. Weiss brings physician views to board decisions. PMID- 10160821 TI - AOHA's new chair decided early on his hospital administration career. PMID- 10160822 TI - Paul Emerson, challenged by medicine, serves 20 years on Brighton Board. PMID- 10160823 TI - Cooperation will be key for hospitals in the future says Brighton's James Donovan. PMID- 10160824 TI - Wilensky leaves HCFA to take Bush post. PMID- 10160825 TI - A 'lifetime' of accomplishments by age 38. AB - At age 38, he's already created hospital departments from scratch, taken charge of a $149 million expansion project, taken a children's hospital independent after a 35-year link to another facility and found time to reverse losses at Texas Children's Hospital in Houston. He's Mark Wallace, the American College of Healthcare Executives' Young Healthcare Executive of the Year. PMID- 10160826 TI - Ed Solvibile sees responsibilities change in move from chief financial officer to CEO. PMID- 10160827 TI - Warren Bolten is new chairman of Suburban General Hospital board. PMID- 10160828 TI - Physician pay, perks vary by employer. PMID- 10160829 TI - Hospitals lag in physician exec pay. PMID- 10160830 TI - Training doctors for clinical resource management. PMID- 10160831 TI - Physician activity: a physician administrator's view. PMID- 10160832 TI - Physician activity: an independent practitioner's view. PMID- 10160833 TI - P/A prospects. The healthcare market. Interview by Peter Morris Dixon. PMID- 10160834 TI - P/A inquiry: hospitals made simple. AB - The humane hospital presents its complexities modestly. Straightforward plans, like the nine in the following portfolio, are fundamental to a healthy patient environment. PMID- 10160835 TI - Clinical directorates. Will the glass ceiling be double-glazed? PMID- 10160836 TI - The effects of music on the selected stress behaviors, weight, caloric and formula intake, and length of hospital stay of premature and low birth weight neonates in a newborn intensive care unit. AB - The purpose of this study was to examine the effects of music on selected stress behaviors, weight, caloric and formula intake, and length of hospital stay. Subjects were 52 preterm and low birth weight newborns in a newborn intensive care unit (NBICU) who were in stable condition and restricted to isolettes. Subjects in the experimental and control groups were matched for equivalency based on sex, birth weight, and diagnostic criticality. Eleven males and 15 females were assigned to the control group and received routine auditory stimulation. The experimental group of 11 males and 15 females received music stimulation, which consisted of approximately 60 minutes of tape recorded vocal music, including lullabies and children's music, and routine auditory stimulation. Thirty-minute segments of the recording were played alternatively with 30 minutes of routine auditory stimulation three times daily. Exposure to music stimulation occurred only during the infants' stay in the NBICU. Results suggest music stimulation may have significantly reduced initial weight loss, increased daily average weight, increased formula and caloric intake, significantly reduced length of the NBICU and total hospital stays, and significantly reduced the daily group mean of stress behaviors for the experimental group. Data analyses suggest the length of hospital stay may be correlated with the amount of stress experienced by the neonate and not with weight gains. Theoretical and practical aspects of these results are discussed. PMID- 10160837 TI - The president's report: the future of medicine and management education. PMID- 10160838 TI - CFO can add award to long list of credits. AB - For his part in righting a topsy-turvy financial cycle at Lee Memorial Hospital in Fort Myers, Fla., and bolstering the facility's creditworthiness, 44-year-old CFO Dennis A. Pettigrew has been chosen as this year's winner of the Cain Brothers, Shattuck & Co. award, which recognizes an outstanding member of the healthcare financial community. PMID- 10160839 TI - A tribute to Khalid Mahmud. AB - Dr. Khalid Mahmud, oncology specialist and founder of the innovative CareVan system that facilitates physician house calls, reveals the early influences that directed his life and his recommendations for accessible, effective home health care in the future. PMID- 10160840 TI - Why doesn't your hospice program have a strong medical director? AB - The question is not whether you need a medical director but what is his or her role. The agency should empower the director--an appropriately trained physician- to assure quality of care and take an active role in marketing and other administrative functions. PMID- 10160841 TI - Jarrett Clinton: shaking up medical care. PMID- 10160842 TI - The ethical man. AB - Sorting out the painful dilemmas of medicine is an everyday duty for Stanford Medical School's biomedical ethicist Ernle Young. PMID- 10160843 TI - D.O.N. (Director of Nursing) of the year. PMID- 10160844 TI - In transit from physician to manager--Part II. AB - In the March-April 1992 issue of Physician Executive, the authors described the six transitions that are required for a successful management career. In the second part of the two-part article, the authors describe some of the obstacles to successful transitions that were disclosed in their research. PMID- 10160845 TI - Physician executives' characteristics and attitudes. AB - This monograph reports on a survey of physician executives who are members of the American College of Physician Executives. The survey emphasized four areas- factors in an individual's move into management as a career choice; satisfaction with management as a career or as an element of a career; factors that prepare a physician to manage; and factors in future development of physician managers. PMID- 10160846 TI - The Tenderloin AIDS Resource Center. PMID- 10160847 TI - Boss of a $1 trillion world. PMID- 10160848 TI - Process and structure: resource management and the development of sub-unit organisational structure. AB - Resource Management (RM) requires hospital units to manage their work in new ways, and the new management processes affect, and are affected by, organisation structure. This paper is concerned with these effects, reporting on the basis of a three-year evaluation of the national RM experiment that was commissioned by the DH. After briefly indicating some of the major characteristics of the RM process, the two main types of unit structures existing in the pilot sites at the beginning of the experiment, unit disciplinary structure and clinical directorates, are analysed. At the end of the experiment, while clinical directorates had become more popular, another variant, clinical grouping, had replaced the unit disciplinary structure. Both types of structure represent a movement towards sub-unit organisation, bringing the work and interests of the service providers and unit managers closer together. Their properties are likewise analysed and their implications, particularly in terms of training and organisational development (OD), are then considered. The paper concludes by considering the causes for these structural changes, which, in the immediate time scale, appear to owe as much to the NHS Review as to RM. PMID- 10160849 TI - The radiologist as an executive physician. PMID- 10160850 TI - Current Medicare carrier medical directors. AB - The following is a list of each state's Medicare carrier and their medical directors. Chapters that want advice on how to work with their local Medicare carriers are encouraged to contact James Haug, Director of the Socioeconomic Affairs Department at College headquarters. PMID- 10160851 TI - A tribute to Congresswoman Mary Rose Oakar: friend of the elderly, advocate for women, health care reformer, and champion for Cleveland. AB - Striking a balance between sensitive caring and political muscle, between aiding her Ohio constituents and mounting national crusades, Congresswoman Mary Rose Oakar is one of the most active members of the House Aging Committee. Her goals for the future are growing every day. PMID- 10160852 TI - Blowin' in the wind. Executive handles seasonal winds, bilingual challenges. PMID- 10160853 TI - 1992 IFMA Silver Plate Award winner--healthcare. Keith J. O'Neill, R.D. PMID- 10160854 TI - His vacation became a medical crusade. PMID- 10160855 TI - High-wire act. AB - Food and Drug Administration chief David A. Kessler balances the instincts of a tough regulatory enforcer against the political realities of serving a President who preaches free-market values. PMID- 10160856 TI - Management training for the physician executive. AB - At conferences of physician managers, the issue almost always arises of whether or not a physician manager needs to obtain a formal management degree. There is no clear answer to such a question, reason enough for its perennial appearance at such meetings. These decisions are the result of both personal and environmental factors, each creating unique situations that will dictate the direction taken. In this article, one such direction is described. PMID- 10160857 TI - Developing loyal physicians: a five-point plan. AB - Now, more than ever, health care centers are forced to compete for physicians. There could be no greater argument in favor of establishing the position of Vice President for Medical Services. A physician executive is infinitely more qualified and better prepared to understand the probable reaction of different types of physicians when "loyalty" to the organization is the central issue. The Vice President for Medical Services seems best positioned to remind the Chief Executive Officer and the Board to keep sight of the legal, and moral, duty to "exercise reasonable care in the selection of a medical staff and in granting specialized privileges," including selecting practitioners who are "worthy in character and matters of professional ethics." PMID- 10160858 TI - In transit from physician to manager--Part I. AB - Physicians are finding themselves in increasing numbers in significant management roles. Physician managers interviewed about their experiences in changing careers identified six critical transitions, three involving psychological adjustments and three requiring development of new skills. A framework is developed in this two-part article that relates career events that trigger transitions, the transitions themselves, and the obstacles that can hinder or block success. The challenges that physicians encounter in management are similar to those faced by other professional groups, and the chances of successful transition can be improved by individual and organizational actions. PMID- 10160859 TI - I was a medi-cop. AB - When I became an inspector for the New York State Health Department, I realized that I would not win any popularity contests, but I believed that I would be improving the quality of care in the 32 hospitals controlled by our area office. I decided to take the job in a desperate move to escape from primary care responsibilities that had been growing more onerous daily. This article tells of my experience as a health care regulator and why I returned to work for a health care provider. PMID- 10160861 TI - Country life, human values. AB - With small-town roots and statewide vision, Larry Krupala takes on the THA chairmanship. Meet the man who'll be leading THA through the 1992-93 year. PMID- 10160860 TI - The physician executive can help improve doctor-patient relationships. AB - An integral part of the physician executive's job, but one that is not relished, is confronting clinicians when they are doing something wrong. If the problem involves medical skills, the confrontation cannot be delayed, but if it involves interpersonal relationships, individuals and organizations will sometimes let the issue slide too long. If physicians have good clinical skills but bad bedside and office manners, they will lose patients. As competition increases, organizations are increasingly realizing that they must address these problems and solve them quickly before patients take their business elsewhere. PMID- 10160862 TI - An issue-charged first year for AHA's Davidson. AB - Reclassification and reform were major issues in Richard Davidson's first year as president of the American Hospital Assn. Those issues, as well as a litany of other budget and legislative battles, promise to rank among his biggest challenges during his second year in office. He's cleared the first hurdle in the reform battle--finding a plan most AHA members can accept. PMID- 10160863 TI - Maine trustee: "outstanding citizen". PMID- 10160864 TI - The state of quality management in HMOs. AB - Interest in total quality management (TQM) in health care is increasing rapidly as leaders search for positive strategies to deal with both costs and quality. We conducted a national telephone survey of 200 HMO medical directors, 451 physicians affiliated with managed care organizations, and 550 corporate health benefits officers to obtain their reports of the potential contributions, the current interest in, and the degree of implementation of TQM activities in their own managed care systems. A large majority of all respondents felt that TQM could help greatly in health care, as it has in other industries. Among HMO medical directors, 81% claimed that their organizations placed "a great deal of emphasis" on TQM, while only 34% of physicians and 35% of benefits officers agreed. Areas of implementation claimed by the HMOs tended to involve abstract matters such as mission statements and leadership commitment, while technical components of TQM, including data systems, training, and supplier management, appeared much less well-developed. The managed care organizations surveyed seem to be in the early phases of commitment to TQM. To achieve the results seen in other industries, these organizations will need much deeper levels of investment, understanding, and deployment of TQM than this survey reveals. PMID- 10160865 TI - Technology management information exchange (TEMINEX). Applied technology assessment for HMOs. AB - In an effort to obtain timely, comprehensive and valid information, The HMO Group medical directors have pooled resources to facilitate decision-making on the appropriate use of new or unfamiliar technologies. The HMO Group has responded to over 175 requests for information on topics such as organ transplants, testing and screening procedures, drugs and devices. PMID- 10160866 TI - Louisville's slugger goes to bat for health reform. PMID- 10160867 TI - One doctor's Rx for the recession. PMID- 10160868 TI - Conflicts in radiology-vendor relationships. PMID- 10160869 TI - AHP: a heritage of professionalism. Association for Healthcare Philanthropy. PMID- 10160870 TI - Health Care Hall of Fame. St. Cabrini. PMID- 10160871 TI - Health Care Hall of Fame. Donald W. Cordes. PMID- 10160872 TI - Health Care Hall of Fame. Anne Ramsey Somers. PMID- 10160873 TI - Health Care Hall of Fame. Kenneth T. Wessner. PMID- 10160874 TI - Service niche: key for trustee. PMID- 10160875 TI - High-frequency ventilation in newborn and pediatric intensive care. PMID- 10160876 TI - High-frequency ventilation in newborn and pediatric intensive care--Part II. PMID- 10160877 TI - The use of the CO2 laser in pilonidal sinus disease: preliminary results of an ambulatory prospective study. AB - During a period of 18 months, from January 1988 to June 1989, 70 patients were treated for pilonidal sinus disease in a Multi-Specialty Military Clinic. There were 62 men and 8 women, with a median age of 19 years (range 18 to 35). All were managed as outpatients under local anesthesia. When an abscess was involved, the surgical procedure included incision, drainage, curettage, peroxide irrigation, and CO2 laser therapy. For the other processes, the surgical procedure included excision of sinus tissue and lateral fistulas, curettage, peroxide irrigation, and CO2 laser therapy with secondary healing. Morbidity was minimal. Healing time ranged from 14 days to 8 weeks, yet most sinuses healed in 4 weeks. The complications observed--pain, bleeding, and skin bridging--were minor. All recurrences but three were minor and healed completely after additional local treatment (4.3 percent major recurrences). Preliminary satisfactory results are reported, supporting a more conservative approach in the treatment of this often overtreated disease. PMID- 10160878 TI - Electric sympathetic block: a review of electrotherapy physics. AB - Electric sympathetic block is the procedure whereby blockage of the sympathetic nerve fiber is achieved by applying controlled electrical pulses via electrodes placed on the skin. An electric block of the sympathetic fiber can occur with a direct monophasic current to achieve an anodal block, a middle-frequency or Endosan current to effect sustained depolarization, or an interferential current to achieve a fatiguing effect. The physics and theoretical framework underlying the currents used in this procedure will be reviewed. PMID- 10160879 TI - Plasmapheresis--the Indiana connection. PMID- 10160880 TI - On the removal of diffusable substances from the circulating blood by means of dialysis. Transactions of the Association of American Physicians, 1913. PMID- 10160881 TI - Plasma removal with return of corpuscles (plasmaphaeresis). The Journal of Pharmacology and experimental therapeutics Vol. V. No. 6, July, 1914. PMID- 10160882 TI - Regulatory intensity, hospital size and the formalization of medical staff organization in hospitals. AB - Using a theory of organizational response to regulation, this study examined the effects of regulatory intensity and hospital size on the formalization of medical staff organization in Canadian hospitals. The general hypothesis was that, in provinces with greater regulatory intensity, hospitals would exhibit greater formalization of medical staff, and greater involvement of physicians in hospital governance and management; larger hospitals would have greater formalization of medical staff than smaller hospitals. Data from 574 hospitals indicated that both hospital size and provincial regulatory intensity were important factors predictive of the overall formalization of medical staff organization. Depending upon the provincial location, hospitals have developed different patterns of formalizing their medical staff structures. PMID- 10160883 TI - Westview Hospital's David Dyar--slugging away at single successes. PMID- 10160884 TI - Dr. Oliver, chief of medical staff, also serves on Westview Hospital board. PMID- 10160885 TI - Riverside's Norval Copeland works for progress and with patience. PMID- 10160886 TI - Judge Herlihy serves as Riverside's chairman. PMID- 10160887 TI - Osteopathic Medical Center's Phil Sowa calls for collaboration. PMID- 10160888 TI - Chairman Sandelin generates new ideas for Osteopathic Medical Center of Texas. PMID- 10160889 TI - Lessons from Lambarene. Part II. PMID- 10160890 TI - Lessons from Lambarene. Part I. AB - The following two-part article is Dr. Mattison's reflections on his experiences with Albert Schweitzer at Hopital du Dr. Albert Schweitzer, Lambarene, Gabon, Africa, from December of 1961 through April of 1963. Gabon, once a part of French Equatorial Africa, is located on the west coast of Africa. Dr. Mattison has chronicled and provided unique insight into Dr. Schweitzer's career and beliefs through both written text and photography. The photographs accompanying this article were taken by Joel and Jean Mattison, and are here borrowed from the archives at Princeton Theological Seminary. These and other photographs were recently complied in "Visiting Hours at Lambarene: Photographic Reminiscences of Albert Schweitzer, 1961-1963" for an exhibition for the International Albert Schweitzer Colloquium in August of 1990 at the United Nations, in commemoration of the silver anniversary of Schweitzer's death. PMID- 10160891 TI - Predictors of international health status. AB - This study presents a new measure of health status, called the Health Status Scale (HSS). The HSS is composed of five indicators: three measuring adult mortality and two measuring mental and social health. The scale is created to conform to the World Health Organization (WHO) definition of health as including physical, mental, and social components. The scale is used as the dependent variable in a regression equation, using six common predictors of health status. The predictors relate to health personnel, nutrition, and health facilities. The results of the regression analysis indicate that health facilities are the most significant predictors of health status, using the HSS. Their significance may be due to the relationship between adult mortality and the absence of facilities to treat chronic disease in adults. PMID- 10160892 TI - A discussion of group practice governance issues. AB - The following article on group practice governance is followed by four short commentaries from various MGMA members across the country as well as the director of the MGMA Consulting Service. This article, and the commentaries that follow it, are intended to stimulate your thinking regarding the governance structure in your group. PMID- 10160893 TI - People skills key for OR manager of the year. PMID- 10160894 TI - Physician executives: where they are and what they do. AB - As hospital operations become increasingly complex, so does the institution's management and organizational structure. Physician executives with titles of medical director, vice president for medical affairs, medical administrator, chief of staff, medical staff president, etc., are playing more important roles than ever before. This article will briefly review some recent literature describing physician executive profiles. The results from a survey of ten university teaching hospitals are also presented as supplementary information regarding current staffing models. Finally, several physician executive staffing related issues will be discussed in light of the literature and the survey results. PMID- 10160895 TI - Working with an executive search firm: Part I--The candidate's perspective. AB - This article is the first in a two-part series on how to work with executive search firms. Part one describes how the physician executive can build an effective relationship with an executive search firm as a candidate or potential candidate. Part two will cover how the physician executive can work with an executive search firm--either as a client or as a member of an executive search committee--to attract high-quality management talent. PMID- 10160896 TI - Quality management remains top medical manager responsibility. AB - Earlier this year, the Physician Executive Management Center conducted a survey of physician executives in management positions in hospitals, group practices, managed care organizations, and industry. Information was obtained for physician executives in both full-time and part-time roles. In addition to gathering compensation information, the survey sought to define the scope and intensity of the responsibilities of physician CEOs and senior medical managers (medical directors or the equivalent) in these organizations. In this article, the authors summarize the findings on responsibilities for senior medical managers in hospitals, group practices, and managed care organizations. PMID- 10160897 TI - Trustee appreciates quality improvement in historical context. PMID- 10160898 TI - The flames of a crusader. The gadfly of nursing homes vows to fight on. PMID- 10160899 TI - The facilitator. AB - Marvin Cole, the Texas Hospital Association's vice president for rural health affairs, wears many hats. He's an advocate for rural health issues at both the state and federal levels. For Texas rural hospitals, he's a resource and a facilitator. And he's an educator of hospital administrators and boards about rural health delivery options. PMID- 10160900 TI - Community benefits study takes award. PMID- 10160901 TI - Court supports firing of medical staff head. PMID- 10160902 TI - Nurses: conscience of the board. PMID- 10160903 TI - 1992 EMT of the year. PMID- 10160904 TI - Brereton Jones: first he put his money on health care--now he's betting on reform. PMID- 10160905 TI - Special report. Louis Sullivan bids farewell to Washington. PMID- 10160906 TI - MHA Chairman Dick Hiltz: basic values at the helm. PMID- 10160907 TI - Working with an executive search firm: Part II--The hiring organization's perspective. AB - This article is the second part in a two-part series on how to work with an executive search firm. The first article, which appeared in the September-October 1992 issue of Physician Executive, focused on executive search from the candidate's perspective. This article focuses on how organizations can work with an executive search firm to recruit and retain top management talent. PMID- 10160908 TI - Interviewing for a position. AB - The interview may be the barrier that stands between you and an exciting new career. It's a time when we all want to seem intelligent, charming, eloquent, and full of dazzling stories of great achievements. But, in fact, many have experienced anxiety that left them stuttering over answers or chattering aimlessly trying to calm themselves. Preparing ahead of time and practicing the interview will give you the best chance of making a good first impression on an organization. PMID- 10160909 TI - Housing for people with AIDS. PMID- 10160910 TI - Trustees' role on the 'high wire' of executive compensation: Hay survey. PMID- 10160911 TI - Union Hospital's Vic Fresolone turns crises to challenges. PMID- 10160912 TI - Union's chair, Bonjavanni: concern for the community is central to trustee role. PMID- 10160913 TI - Chairman Michael Roman puts quality first. PMID- 10160914 TI - Judge stresses community involvement key to success at Community Hospital of Lancaster. PMID- 10160915 TI - Vincent leads Doctors Hospital, Columbus, in programs to adapt to community needs. PMID- 10160916 TI - Doctors Hospital chair Costin stresses active role of DOs on boards. PMID- 10160917 TI - Information sources 1992-93. PMID- 10160918 TI - He's preaching what he practiced. PMID- 10160919 TI - Commissioner of Health David Smith's job title is impressive. PMID- 10160920 TI - Case mix management education in a Canadian hospital. AB - The Sunnybrook Health Science Centre's matrix organization model includes a traditional departmental structure, a strategic program-based structure and a case management-based structure--the Clinical Unit structure. The Clinical Unit structure allows the centre to give responsibility for the management of case mix and volume to decentralized Clinical Unit teams, each of which manages its own budget. To train physicians and nurses in their respective roles of Medical Unit directors and Nursing Unit directors, Sunnybrook designed unique short courses on financial management and budgeting, and case-costing and case mix management. This paper discusses how these courses were organized, details their contents and explains how they fit into Sunnybrook's program of decentralized management. PMID- 10160921 TI - Judy Feder: out of the starting blocks in the health reform race. PMID- 10160922 TI - New twist on public accountability. PMID- 10160923 TI - Clinton's health care reforms: can his think-tank royalty pull it off? PMID- 10160924 TI - C. Everett Koop as Surgeon General: a national survey of public health educators. PMID- 10160925 TI - Claremont Park Family Care Center, Bronx, NY. PMID- 10160926 TI - Quality assurance for respiratory care services: a computer-assisted program. AB - At present, the principal advantage of computer-assisted quality assurance is the acquisition of quality assurance date without resource-consuming chart reviews. A surveillance program like the medical director's alert may reduce morbidity and mortality. Previous research suggests that inadequate oxygen therapy or failures in airway management are important causes of preventable deaths in hospitals. Furthermore, preventable deaths tend to occur among patients who have lower severity-of-illness scores and who are not in ICUs. Thus, surveillance of the entire hospital, as performed by the HIS medical director's alert, may significantly impact hospital mortality related to respiratory care. Future research should critically examine the potential of such computerized systems to favorably change the morbidity and mortality of hospitalized patients. The departments of respiratory care and medical informatics at LDS Hospital have developed a computer-assisted approach to quality assurance monitoring of respiratory care services. This system provides frequent and consistent samples of a variety of respiratory care data. The immediate needs of patients are addressed through a daily surveillance system (medical director's alert). The departmental quality assurance program utilizes a separate program that monitors clinical indicators of staff performance in terms of stated departmental policies and procedures (rate-based clinical indicators). The availability of an integrated patient database allows these functions to be performed without labor intensive chart audits. PMID- 10160927 TI - Dreamin' ... 'til her dreaming comes true. PMID- 10160928 TI - Resistance to flow through the valves of mouth-to-mask ventilation devices. AB - We conducted this study to determine the inspiratory and expiratory flow resistance of the valves of eight commercially available mouth-to-mask ventilation devices. METHODS & MATERIALS: We evaluated the valves of Intertech, Laerdal, Life Design Systems (LDS), Res-Q, Respironics, Rondex, Vital Signs, and White. The devices were supplied by the manufacturers and included the valve and any filter or extension tube supplied with the valve. Expiratory resistance was evaluated by directing air through the valve in the direction of flow when the patient exhales. Inspiratory resistance was evaluated by directing air through the valve in the direction of flow when a breath is delivered to the patient. Flow was controlled by a Timeter 0-75 flowmeter and measured using a calibrated Timeter RT-200. Flows of 10, 20, 30, 40, 50, 60, 70, 80, and 90 L/min were used. 'Back' pressure due to the resistance of the valves was measured using a calibrated Timeter RT-200. Resistance was calculated by dividing back pressure by flow. Five measurements were made at each flow setting for each valve. RESULTS: We observed significant differences in back pressures and resistances between the flows evaluated (p < 0.001 for both inspiratory and expiratory flows), and between the commercially available devices (p < 0.001 for both inspiratory and expiratory flows). At a flow of 50 L/min, the inspiratory back pressures produced by the devices were [mean (SD) in cm H2O] Intertech 5.2 (0.06), Laerdal 4.6 (0.09), LDS 4.7 (0.03), Res-Q 3.1 (0.04), Respironics 3.3 (0.04), Rondex 1.1 (0.02), Vital Signs 4.0 (0.06), and White 4.3 (0.10). At this same flow, the expiratory back pressures were Intertech 4.8 (0.30), Laerdal 9.1 (0.10), LDS 3.3 (0.02), Res-Q 3.7 (0.35), Respironics 0.5 (0.01), Rondex 1.4 (0.01), Vital Signs 3.6 (0.05), and White 13.7 (0.48). CONCLUSIONS: In some cases, the resistance through these devices might be considered excessive; however, most of the devices meet the International Standards Organization (ISO) standard (back pressure < 5 cm H2O at 50 L/min). PMID- 10160929 TI - Trustee makes collaboration 'easy'. PMID- 10160930 TI - Hospitals, chains pay physician execs more, survey shows. PMID- 10160931 TI - Kevin Lofton. Financial turnaround at Howard merits award as Young Healthcare Executive of the Year by ACHE (American College of Healthcare Executives). PMID- 10160932 TI - Shattering the glass ceiling. PMID- 10160933 TI - Centralised or devolved medical records services? That is the question. PMID- 10160934 TI - Executive thrives on challenges. PMID- 10160935 TI - A future for clinical management. AB - The NHS has been moving rapidly towards establishing clinical directorates in all specialties. It has been part of an attempt, along with the resource management initiative, to involve doctors in management, and to encourage them to take responsibility for the managerial and resource dimensions to clinical activity. Haydn Cook identifies a problem. PMID- 10160936 TI - Health care managers in British Columbia, Part I: Who manages our system? AB - Part I of this article provides, for the first time, the supply side overview of middle- and high-level managers in the B.C. health care system. It presents findings from two province-wide surveys and describes the sociodemographic characteristics and the employment experiences of the population of interest. Part II presents a detailed analysis of management tasks and management roles, and of competency requirements for future managerial roles. PMID- 10160937 TI - Clinton picks Vladeck to head HCFA. PMID- 10160938 TI - Management ... working day of a health services manager. PMID- 10160939 TI - DON (Director of Nursing) of the Year. PMID- 10160940 TI - Clinical management. Pole to pole. PMID- 10160942 TI - Activism comes easy to trustee. PMID- 10160941 TI - Gesundheit! PMID- 10160943 TI - Life after being N.E.H.A. (National Executive Housekeepers Association) president. PMID- 10160944 TI - Physician executives' persuasive styles of communication in downward influence situations. AB - In the January-February 1991 issue of Physician Executive, the author reported on the persuasive strategies used to influence both attractive and unattractive subordinates. The focus in the earlier study was on what was communicated. In this investigation, attention is devoted to the way physician executives communicate. The results strongly suggest that physician executives' communicator style preferences are affected by whether or not they like or dislike the subordinates they are attempting to persuade. PMID- 10160945 TI - Interviewing from the organization's perspective. AB - Hiring medical professionals is an expensive process. It is important to conduct an effective interview to help you determine the qualifications of a candidate and to persuade the candidate to join your organization if that's what you decide you want. PMID- 10160946 TI - Rx for death. The return of Dr. Death. PMID- 10160948 TI - 1993 Silver Plate Award winner--healthcare. Helen T. Doherty, R.D. PMID- 10160947 TI - Thunder on the left? AB - In the view of some critics, Donna E. Shalala is a bleeding-heart liberal, turned loose in the biggest domestic federal agency. But the new Health and Human Services Secretary has a strong pragmatic streak. And the President seems to have hired her less as an architect of social policy than as a general contractor. PMID- 10160949 TI - Ethical issues faced by clinician/managers in resource-allocation decisions. AB - This article explores the ethical issues faced by clinicians with management responsibilities (clinician/managers) when making decisions related to resource allocation and utilization at a Canadian teaching hospital. Using a focus group method, 28 individuals participated in four homogeneous groups that included nurse managers, managers from other professional groups, and physician managers. Ethical issues that recurred throughout the discussions included fairness, concern with preventing harm, consumer/patient choice, balancing needs of different groups of patients, conflict between financial incentives and patient needs, and professional autonomy. The particular issue of conflict is analyzed from two perspectives--a theory of professional-bureaucratic roles and of obligation--that illustrate how both management and philosophical issues are related. The findings suggest that decentralizing resource allocation and utilization decisions does raise ethical issues for clinician/managers and that a better understanding of these issues can be obtained using an interdisciplinary perspective. PMID- 10160950 TI - The quality of mercy. PMID- 10160951 TI - Facilities spread their cash around. Gap between pay of CEOs, other execs narrows as hospitals seek to build management teams. PMID- 10160952 TI - Compensation for elected hospital medical staff leadership. AB - As physicians' practices become more complex and their practice incomes more difficult to maintain, hospitals concurrently require more physician input into organizational, utilization, and strategic planning matters. Physicians and hospitals across the country are discussing the question of financial compensation to physicians for the time they spend performing these hospital administrative tasks. It is already common practice for hospitals to pay a salary for medical direction of hospital departments such as intensive care units or pulmonary laboratories. The question has become whether this practice should be extended to elected medical staff leadership. PMID- 10160953 TI - Career paths for women physician executives. AB - The career path leading toward being a physician executive is similar for men and women, but there are some issues that have unique elements for women. Thus, any person interested in developing a medical management career can follow the advice in the following pages, but it is especially useful for women or for those who are coaching women in career development and management. PMID- 10160954 TI - The 'Captain' charts a steady course: advocacy for children's issues. PMID- 10160955 TI - Adversity stimulates creativity. PMID- 10160956 TI - Department directors may share responsibilities. PMID- 10160957 TI - Physician participation makes for a good survey outcome. PMID- 10160958 TI - Bruce Vladek takes HCFA's helm. PMID- 10160960 TI - Village, not. The unfulfilled promise of Yale's Psychiatric Institute. PMID- 10160961 TI - A program for children with asthma. PMID- 10160959 TI - Sister Kathleen Coughlin takes the helm. PMID- 10160962 TI - Perspectives. Making up for lost time: the new AIDS czar. PMID- 10160964 TI - Kaiser's Dr. Smith brings real-world perspective to AIDS policy. PMID- 10160963 TI - Health reform leadership. Obsessed by politics and Andy Griffith. PMID- 10160965 TI - Good things come in small hospitals. PMID- 10160966 TI - Variables in effective CEO-medical director relations. AB - It is becoming commonplace that physicians are not just working in hospitals but are helping run them as well. This means that chief executive officers are working side by side with chief medical officers. What are the factors that influence the working relationship between these roles? The author presents data from a survey that helps to answer this question. PMID- 10160967 TI - The minds of a medical director. AB - This article is offered in a nod to all those readers who have been exposed to "whole brain" theory, either through the American College of Physician Executives or elsewhere. As managers struggle with balancing the "left brain" and "right brain" aspects of their work, the author says, they might consider exploiting a third area of activity, or inactivity--the "no brain." This center position can be especially effective in dealing with the high-technology aspects of delivering health care. PMID- 10160969 TI - The prescriptions of Dr. Yes. PMID- 10160968 TI - Hospitals moving to payment of physicians for administrative duties. AB - This article deals with whether physicians who devote considerable time to leadership and committee responsibilities are compensated, how they are compensated, who pays that compensation, and other related issues. To gather the information, the American College of Physician Executives surveyed a sample of 600 of its hospital-based members. There were 195 responses, representing hospitals of all sizes and types (community, government, for-profit, not-for profit, urban, suburban, and rural) and medical staff sizes ranging from as few as four to as many as 1,300. Uncovered was what appears to be a trend to payment of physicians for these leadership services. PMID- 10160970 TI - Perspectives. Surgeon General nominee ignites controversy. PMID- 10160971 TI - Donna Shalala: a liberal in moderate's clothing? PMID- 10160972 TI - Political advocacy begins at home--trustees educate legislators. PMID- 10160973 TI - Transition from clinician to manager--a case study. AB - The experiences of a group of five psychiatrists who made the transition from clinicians to managers in the Victorian Mental Health system are described. The paper reflects upon the action learning methodology for professionals in transition. Problems related to the painful gaining of experience, dissonance between the clinical and the management roles and the need to develop new rationalizations for understanding work are discussed. PMID- 10160974 TI - Elder's troops could use a general. PMID- 10160975 TI - Keeping the menus modern. PMID- 10160976 TI - D.C. hospital's top execs partners at home, at work. PMID- 10160977 TI - A new commander for an uphill battle. PMID- 10160979 TI - Different worlds. PMID- 10160978 TI - Distinguished fellow--in honor of Victor Fuchs. PMID- 10160980 TI - The 'Captain' charts a steady course: advocacy for children's issues. PMID- 10160981 TI - James Ford: striving for unity, preparing for reform. PMID- 10160982 TI - The changing role of the group medical director. Part 1. AB - This article is the first in a two-part series focusing on the changing role of the group Medical Director. While this article will address the typical job responsibilities of today's Medical Director, the next article will highlight stylistic considerations which often make the difference between the individual's success and failure. PMID- 10160983 TI - For Magaziner, reform is the road to paradise. But can he take Congress along for the ride? PMID- 10160984 TI - Tackling health reform by the numbers. PMID- 10160985 TI - Problem-solving executive keeps his department at capacity. PMID- 10160986 TI - In debate: should medical staff presidents be voting members of the hospital board. Yes. AB - In summary, the hospital must demonstrate its willingness to create a new paradigm in physician-hospital relationships. One that is built on trust, mutual respect, and enhanced communications. Most important, the hospital needs to understand the medical staff's perspective, identify mechanisms to integrate clinical and organizational values, and recognized the medical staff's ability to contribute to the overall operations of the hospital through key decision-making roles. By establishing a new paradigm, the medical staff and the hospital++ can provide a full range of health services for the community. And, this collaborative effort will strengthen the ability of the hospital and the medical staff to better compete on the basis of quality, cost, and value. PMID- 10160987 TI - In debate: should medical staff presidents be voting members of the hospital board? No. PMID- 10160988 TI - Implantable cardioverter defibrillators in cardiovascular practice: report of the policy conference of the North American Society of Pacing and Electrophysiology. PMID- 10160989 TI - Nebulizer possibilities and limitations. AB - The ban of chlorofluorocarbon (CFC) propellants in metered dose inhalers (MDIs) gives rise to many alternatives and innovations: 1. CFC substitution by non-CFC propellants in MDIs. 2. battery driven miniaturized mechanical and piezoelectric nebulizers 3. revitalization of hand driven pocket nebulizers 4. self actuated dry powder inhalers (DPI's). All devices can be used with or without spacers. The choice for solid or liquid particles, e.g. powder or droplet aerosols, will also depend on the drug properties and the availability on the market for aerosol use. The nebulizer device will be chosen according to the medical need (emergency or long term treatment), the technical alternatives available in different countries, the possibility of patient cooperation (children, severely ill patients), and last not least marketing strategies and costs. The bronchial circulation is an important distribution system for medicine deposited by aerosol routes in the lung. PMID- 10160990 TI - Hand therapy: comprehensive rehabilitation of the upper extremity. PMID- 10160991 TI - Contact Nd:YAG laser surgery of the temporomandibular joint. PMID- 10160992 TI - Long-term results on VK partial and total temporomandibular joint systems. AB - This article reviews the results obtained on 262 VK partial and total temporomandibular joint (TMJ) procedures followed up to 10 years. VK I total joint (placed 1982 to 1986) cumulative success rate was 44% at 6 years and 20% at 10 years, while VK II (placed 1986 to 1990) cumulative success rate was 80% at 6 years. Material wear of the Teflon FEP surface of the VK I fossa was the most common reason for failure. There were no VK II material failures. A significant improvement in clinical success parameters for both prostheses was found if no previous surgeries were done before VK I or VK II total joint placement. Rib grafts were not helpful after removal of total joint prostheses if patients had a history of multiple procedures. Total TMJ prostheses must be reserved for patients with alternative surgical failures or when these procedures are no longer indicated. Close monitoring by clinical examination and imaging is necessary. PMID- 10160993 TI - New York's Axelrod leaves substantial legacy. PMID- 10160994 TI - He's not "Mr. Health," but "Big John" Dingell is having his say. PMID- 10160995 TI - Executive sets high standards for caring and compassion. PMID- 10160996 TI - A steadier pace leads to success. PMID- 10160997 TI - The role of the physician in executive management. PMID- 10160998 TI - Managing the gray areas. Exploring the administrator/physician team relationship. AB - The effectiveness of the physician/administrator leadership team impacts issues from day-to-day operations to strategic visioning, according to author Joseph Fiorelli, Ph.D. Yet, given the importance of this relationship, surprisingly little is known about it, which is what Fiorelli set out to investigate and now write about. PMID- 10160999 TI - 1993 Governance Award recipients announced. AB - In honor of outstanding service to hospitals and the community, two trustees of Michigan hospitals were awarded the 1993 Hospital Governance Award at the Michigan Hospital Association's Fall Medical Staff-Trustee-Administrator Forum. Each year, the MHA presents the Hospital Governance Award to recognize trustees who demonstrate exceptional service based on overall leadership, overall contributions, and improved community relations. This year's forum was held at the Grand Traverse Resort in Traverse City. James E. Coleman, chairman of the board of directors of Pennock Healthcare System, Hastings, and Alan R. Ryan, chairman of the board of trustees of Saint Mary's Community Health Care System, Grand Rapids, were named the 1993 Governance Award winners. PMID- 10161000 TI - OR manager of the year is Stephen F. Knoll. PMID- 10161001 TI - Physician executives' persuasive styles of communication in upward influence situations. AB - This article examines the communicator style choices of physician executives when attempting to persuade a superior whose own style of communication is attractive and unattractive. In the November-December 1990 issue of Physician Executive, the author reported on persuasive strategies physician executives use to influence such targets of influence. Whereas the earlier study focused on what physician executives communicate to be persuasive, the present investigation treated the way physician executives communicate to persuade attractive and unattractive superiors. The results suggest that the way physician executives communicate in upward influence situations is affected by the way their superiors communicate with them. PMID- 10161002 TI - Building physician managers and leaders: a model. AB - A needs assessment identified leadership, management, and interpersonal skills as training and development areas for hospital's physician executives. Training sessions were developed and occurred quarterly over a two-year period. Development strategies were designed to enhance transfer of learning from the classroom setting and incorporated personalized coaching sessions, development of a peer mentoring program, group redesign of the performance appraisal process, strategic planning, and performance feedback sessions. The comprehensiveness of the approaches taken in this program is critical to successful training and development efforts of physician executives. PMID- 10161003 TI - Should the physician executive be the physician's advocate? AB - Medical staff commonly want to know if a prospective physician executive will serve as their advocate to management. A successful physician executive must like and respect physicians. But the question of advocacy must be answered thoughtfully, because the candidate must not imply that he or she will defend any action by any physician. A three-part conditional response is advisable. PMID- 10161004 TI - What do you have to do to become a medical director? AB - Medical management is a large and growing profession. The need for physicians in management roles grows unabated in hospitals, managed care organizations, group practices, and myriad other environments. But entry is not merely a matter of wishful thinking. Painstakingly assembled credentials and skills are the order of the day. The advice in this column is distilled from Medical Directors: What, Why, How, a new College monograph. PMID- 10161005 TI - Leadership for the next millennium: the physician executive. AB - We continue to muddle through using tourniquets and bandaids on a health care system that is in dire straits. And the future is even less promising. There will be millions without basic health care, let alone basic health care coverage. Rural and inner-city hospitals will close, with progressive public apathy, as we focus on the marvels of expensive technologies that serve only the few. Costs will continue to rise at double digit rates, and our nation's employers will fall further behind in the global marketplace. Preventive care will be uncommonly provided and only more rarely reimbursed, while a couple more children die of measles in Mississippi. It's not a pretty picture, and it simply doesn't have to come to pass. "What we really need is leadership," the public cries. That leadership can and should come from medicine through physician executives. PMID- 10161006 TI - A study of the scope of occupational health services. AB - In order to define the scope of corporate occupational health services as they exist today, a questionnaire was designed and sent to members of the College's Society of Corporate Medical Services. Industries represented in the survey include manufacturing, utilities, transportation, communications, research and development, banking, insurance, and publishing. The emphasis in this report is on data indicating trends in the provision of services. PMID- 10161007 TI - Constituting management requires more than creating hierarchy and providing information. AB - Current efforts to realign authority relationships within hospitals are important, but not sufficient. The rules which underpin the autonomy of medicine and those which are required for constituting management in clinical settings are not 'things' which can be decreed in and out of existence either by altering the lines on a hospital organisation chart, or by improving hospital information systems and allocating managerial responsibility to some clinicians. Accordingly, the ultimate success of the current hospital reform program will depend on the willingness of players in health policy circles to broaden their reform agenda to encompass issues which go well beyond factors internal to the organisation of hospitals. Included here are initiatives in areas such as hospital casemix funding and budgeting; clinical protocols; establishing linkages between the managerial and clinical roles of clinician managers; and recasting the employment of hospital medical staff. PMID- 10161008 TI - Health reform insight. Ron Pollack: Clinton politico or reform advocate? PMID- 10161009 TI - What makes an effective medical director? AB - This article is the second in a two-part series on the changing roles and responsibilities of today's medical director within a medical group setting. As the complexity and demands of the health system have changed, so have the challenges that the new medical director must face to be successful. The first article focused on the duties and responsibilities of the new medical director while this last installment addresses the stylistic considerations that are likely to determine the individual's success or failure. PMID- 10161010 TI - 1993 EMT/paramedic of the year. PMID- 10161011 TI - Health Care Hall of Fame 1993 inductees: each a legendary reformer. Clara Barton; Graham Davis; William Graham; Andrew Still, D.O.; Robert Toomey. PMID- 10161013 TI - Quality in art therapy: a panel honoring Elinor Ulman. PMID- 10161012 TI - Trustee helps build Georgia network. PMID- 10161014 TI - The 1993 FM Award for Humanitarian Service presented to Mary Hoffman for nutrition education to families. PMID- 10161015 TI - Toward the new pattern of medical practice. AB - As this article is being written, in the fall of 1993, we are waiting for the details of the President's plan for extending health insurance coverage of some kind to all members of the population while also containing costs. All observers, including practicing members of the medical profession itself, believe that a sharp break with the past is developing, most particularly a break with the old pattern of practice that flourished during the golden years between the end of World War II and the end of the 1960s, when the federal government made its first effort to control costs. In this article, I will discusses changes in the conditions of American medical practice that most observers can agree on. Then, I will summarize the major conceptions of the future shape of medical practice. I will conclude with my own view of critical issues in the constitution of practice, issues whose resolution depends not only on broad public policy initiatives, but also on the activities of physician executives within the medical community. PMID- 10161016 TI - The real Jack Kevorkian. PMID- 10161017 TI - Leading Michigan health care into the future. PMID- 10161018 TI - Group execs' pay linked to revenues. PMID- 10161019 TI - Physician leadership for the 21st century. AB - This article examines how rapidly evolving health care delivery structures are radically altering the traditional clinical and organizational autonomy enjoyed by physicians. These changes may render maintenance of prior levels of physician autonomy virtually impossible. The author calls for the emergence of a new breed of physician leaders who will preserve the best of traditional medical practice culture but also effectively implement a nascent form of integrated health care practice. PMID- 10161020 TI - Rough ride. AB - Anne K. Bingaman, the Justice Department's top trustbuster, has pledged vigorous enforcement of the antitrust laws. But lack of money, hostile judges and skepticism elsewhere in the Administration could make it hard for her to deliver. PMID- 10161021 TI - M.A.S.H. in the Arctic. AB - From Toronto to the Northwest Territories, this home care nurse moved into another world. But providing home care in unique situations, she has found, provides the same fulfillment that it does in the most mundane of settings. She was lucky to experience M.A.S.H. in the Arctic. PMID- 10161022 TI - A young hero in home care. AB - Trinity School in Manhattan has instituted an award for high school students who exhibit dedication in the field of aging. Trinity presented the award to an energetic, articulate, cheerful young woman who has gone beyond the expected and made a close friend through her community service. PMID- 10161023 TI - Caregiver of the Year award. Long-overdue recognition for lay caregivers. AB - One home care agency has established an award to honor those caregivers who contribute so much to home care yet are often overlooked: ordinary people who give their time and dedication to family members and neighbors who need them. PMID- 10161024 TI - Doctors as managers. AB - In order that a hospital function efficiently, it is imperative that the management use its skills to best effect. On this subject, Dr Dixon discusses 'organizational bonding', a bonding which, among other things, will improve planning, budgetary control and quality control and speed up decision-making, by means of decentralization. '... the vertical divisions between different professional groups and hierarchies', she concludes, 'have to be replaced by horizontally integrated service units.' PMID- 10161025 TI - Performance appraisal in the age of TQM. AB - Performance evaluation is often used as a tool to determine salary adjustment as well as an opportunity to improve job performance. When inappropriately applied, performance evaluations may be perceived as being unfair, wasteful, and demeaning. In some organizations, there has been a trend to break down job functions to their most detailed level, weight each activity, judge it, and then add up all the invalid numbers to achieve a more invalid judgment of a person's performance. This non-Gestalt evaluation is an inspection philosophy that has not served manufacturing or health care very effectively. Over the past four years, we have evolved a performance evaluation process at Minneapolis Children's Medical Center for physicians in both patient care and management roles. In this article, we will describe the evolution to the present system and discuss its dovetailing with customer service-driven continuous quality improvement efforts and our plans to improve the process. PMID- 10161027 TI - Responsibilities under the Family and Medical Leave Act. PMID- 10161026 TI - Utilizing the rich resources of a diverse workplace. AB - The dynamic and ever-increasing diversity of the U.S. workforce challenges those in executive management to utilize human resources in a manner that maximizes those resources and produces optimal results. A diverse organization is itself laden with rich resources of human capital waiting to be tapped in creative ways. In order to be competitive and remain so, physician executives in today's market must engage in the management of diversity on a continuous basis. PMID- 10161028 TI - Medical practices: hot properties of the '90s. AB - The buying and selling of medical practices is big business around the country. Fueled by fears of where health reform is headed, frustrated by reduced reimbursements and mountainous paperwork, physicians are bailing out of solo practices, and small group practices are approaching large groups looking for safety in numbers. The large groups are aligning themselves with hospitals, and hospitals are luring large groups by offering to build them clinics. Clearly, this is a trend that will be heightened by anticipated structural reform of the health care system, but it is not without its dangers for all those who participate in the process. PMID- 10161029 TI - Role stress among physician executives. AB - On the one hand, physician executives are clinicians who place value on professional autonomy. As clinicians, the best interests of the patient drive their decision making and their value system. On the other hand, as managers, physician executives serve as agents of an organization. Because of the differences in the two cultures, some physicians have called the physician executive position a "no man's land" To address these issues and answer the questions that surround them, the authors developed a survey that was mailed to a random sample of the membership of the American College of Physician Executives. Parts of the survey served in other studies of role conflict and role ambiguity. Parts of the survey are new, developed specifically to analyze the physician executive role. The findings are reported in this article. PMID- 10161030 TI - Clinicians into management: the experience in context. AB - This paper interprets the experience of a sample of 60 clinicians becoming involved in formal management, mainly at hospital unit level, in the historical context of changing health service organisation. This includes the introduction of managerialism and the evolution of the NHS into a structured network based around purchaser/provider relationships. The conclusion is that these clinicians are becoming involved in management, and making the personal and social adjustments necessary for this, but in a way that leaves medical culture, and their allegiance to it, at the present largely intact. This is achieved largely through the organisational mechanism of clinical directorates, which promise to function as professional groups from the clinical point of view and as business units from the managerial perspective. An argument is put forward, based on a theoretical view compatible with the data from the clinicians' experience, that this mode of medical involvement in management may operate without undue conflict in the longer term if: (a) clinicians accept the degree of local professional regulation that this model applies; and (b) the conflict between medical need and available resource can be dealt with elsewhere in the system without passing it back to hospitals and clinical directorates. On the other hand it is possible that conflict will increase if the consequences of management control systems and objectives percolate down through the management hierarchy and cross into the medical domain, via clinical directorates. PMID- 10161031 TI - Professional oligarchy in medical group practice: toward the development of a middle-range theory. AB - The article presents the findings from a study of 27 large, multi-specialty medical groups that suggests a new middle range theory that the governance of medical groups is evolving away from professional autonomy due to environmental changes resulting from the expansion of managed care. The article takes a contingency theory approach to the governance of medical groups to determine the locus-of-control for strategic and management decision making. The findings support the contention that successful medical groups limit decision making at the highest level in the organization to a small number of physician leaders, thereby creating a new organizational form, professional oligarchy. PMID- 10161032 TI - 1994 Trustees of the Year. PMID- 10161034 TI - Information sources: design and practice; technics; manufacturers' literature. AB - There are three parts to this, the eighth annual publication of Information Sources in P/A. The first section, covering design and practice, identifies organizations that offer information about various building types, practice related topics, design tools and specialties, and disciplines allied to the field. Reference to recent P/A Plans issues are also included. PMID- 10161033 TI - 1994 Trustees of the Year. PMID- 10161035 TI - Hospital leadership team: roles and responsibilities. PMID- 10161036 TI - Perspectives. Donna Shalala: at year one, angling for center stage. PMID- 10161037 TI - New HCFA chief tries to put a human face on agency. PMID- 10161039 TI - "Pete Mitchell" of Arabia. PMID- 10161038 TI - Cooperation or conflict over child health surveillance? Views of key actors. AB - OBJECTIVE: To describe the views of general practitioners, health visitors, and clinical medical officers on child health surveillance, recent changes, perceptions of each other's roles, and attitudes to audit. DESIGN: Postal questionnaire survey. SETTING: Three health districts in North West Thames health region. SUBJECTS: All 602 general practitioners, 272 health visitors, and 42 clinical medical officers in these districts. MAIN MEASURES: Attitudes to and perceptions of child health surveillance and audit. Questionnaires were completed by 440 general practitioners (response rate 73%), 164 health visitors (60%), and 39 clinical medical officers (93%). RESULTS: Attitudes to child health surveillance were less positive among general practitioners than health visitors or clinical medical officers. Few respondents agreed that child health surveillance was a cost effective use of general practitioners' time (general practitioners 28%, 113/407; health visitors 28%, 40/145; clinical medical officers 39%, 15/39) and most thought that health visitors should carry out more of the doctors' examinations (68%, 262/387; 65%, 89/136; 66%, 25/38). General practitioners thought that clinical medical officers were less supportive than other relevant groups of their doing more child health surveillance. Most (72%, 105/146) health visitors thought that the 1990 contract had reduced parental choice of where to attend for child health surveillance. General practitioners were less enthusiastic than health visitors about most forms of clinical audit. CONCLUSIONS: Despite reservations about the impact of recent changes all groups were willing to explore innovative ways of delivering child health surveillance. IMPLICATIONS: There is scope for health visitors to increase their responsibilities and for more varied relationships between general practitioners and community child health doctors. PMID- 10161040 TI - Mind your language. PMID- 10161041 TI - Managerial effectiveness and the public sector. A Health Service example. AB - Attempts to address the question of managerial effectiveness in the UK's National Health Service, with particular reference to doctors holding managerial positions as clinical directors. Emphasizes a systems framework as a model for analysis of the concept of effectiveness. Identifies and discusses the importance of various managerial inputs (for example, managerial behaviour) and outputs such as objectives in business plans. Highlights the difficulty of establishing outcome measures in a service organization. Contrasts this approach with an alternative subjectivist approach which questions the validity of objective measures of effectiveness. The two approaches are not necessarily incompatible but require a convergence in the philosophical assumptions underpinning analysis. May be relevant to medical managers and other professionals acting as managers in service organizations. PMID- 10161043 TI - ACHE award. William Groneman: Young Executive of the Year. PMID- 10161042 TI - Remembering W. Edwards Deming (1900-1993). PMID- 10161044 TI - Attitudes of local VA leadership toward the VA health care system. AB - A nationwide survey of directors, associate directors, and chiefs of staff of Department of Veterans Affairs (VA) Medical Centers was conducted to (1) determine the attitudes of these local health care executives toward the public's perception of the VA health care system, their own job satisfaction, and the level of job support they receive; and (2) assess how these attitudes relate to the stated intention of the local leadership to leave the VA health care system before retirement. A total of 268 responses were analyzed. Significant differences between local executive positions were identified, including a less favorable perception of the public's attitude toward the VA system and less satisfaction with the VA system by chiefs of staff; and less general job satisfaction and satisfaction with the local VA facility by associate directors. Variables related to public perception, job satisfaction, and job support were significant predictors of plans for each group to leave the VA; 34 to 49 percent of the variance in a multiple linear regression model could be explained by these factors. PMID- 10161045 TI - Physician executives: managers first, clinicians second. AB - The literature is replete, many would say depressingly so, with accounts of the changes that are rocking the health care delivery system. The demands on the system's leadership increases with every change. And the future holds even more changes, with a level of uncertainty that will makes today's demands seem childplay. Physicians, especially physician executives, will surely be key factors in helping the system maintain its fundamental charge of high-quality patient care provided at reasonable cost, but what exactly is expected of them? One point is clear: While their clinical backgrounds will continue to arm them well for reaching the executive suites of health care organizations, physicians who hope to fully succeed in management will have to acquire and master a widening range of management skills. An indication of just how demanding the health care management job will be is provided in this report, based on interviews with physician executives and the people who seek and sell their services. PMID- 10161046 TI - Managing risk. A priority in the Health Service. PMID- 10161047 TI - Bill Clinton's Dr. Fixit. PMID- 10161048 TI - Women physicians in medical leadership. AB - The path to top management positions is often made more accessible with the aid of a mentor relationship. Myra Isenhart, Ph.D., shares the highlights of a structured mentoring program at Kaiser Permanente of Colorado where women physicians are encouraged to strive for medical leadership positions. PMID- 10161049 TI - Part-time medical director: way station or end of the line? AB - This article is mostly directed to physicians who are contemplating a career change into management. You may be one of those persons who is contemplating taking a part-time position and continuing part-time clinical practice to see if you might enjoy management. It is important to understand that a part time medical director is there primarily because management perceives a need for a physician's skills and license. When a physician is hired on a part-time basis, it is unlikely that management realizes the larger benefits that can accrue to the organization from the physician manager's knowledge of health care and unique approach to the problems and opportunities in the delivery of that health care. Part-time medical directors seldom have an opportunity to be exposed to real management issues and activities and are usually sequestered and limited to functions that a naive management team thinks are most appropriate to a physician's skills and temperament. Be cautious in extrapolating a part-time experience to a full-time role. Consider taking the plunge to full-time management without a part-time transition phase. PMID- 10161050 TI - Elected medical staff leaders: who needs 'em? AB - Authority, influence, and power are not synonyms. In working with elected medical staff leaders, a physician executive who chooses to exert authority may soon find him- or herself relatively powerless. But one who chooses to downplay authority, to influence through persuasion, and to coach leaders to lead effectively soon generates support for his or her ideas. The need to coax, cajole, explain, persuade, and "seek input" frustrates many leaders in all kinds of organizations. It would be much easier just to order people about. It's so tempting to think: "Who needs 'em? I'm the 'chief physician.' I know what needs to be done. Let's weigh anchor, take her out, and do what it takes to sail those rough, uncharted seas." If you really enjoy sailing a large ship in rough seas without a crew, go right ahead. Or if you think it makes sense to run an organization with only an executive staff and no knowledgeable middle managers, by all means let clinician leaders know that, now that you're aboard, they're just window-dressing. If you can make this approach work, well and good. Your life will be much less complicated, each day will have far fewer frustrations, and progress toward established goals will be much faster. However, given the reality of traditionally thinking physicians, it would be best to keep an up-dated resume in the locked lower left-hand drawer of your desk. PMID- 10161051 TI - The emerging role of the physician in administration. AB - Physicians often find it difficult to determine the type of training needed to prepare themselves for administrative roles in health services organizations. Without extensive knowledge about organizations and how they function and how administrators contribute to organizational performance, physicians tend to view management roles as either overwhelmingly complex, or, conversely, simply a matter of using good judgment. In an attempt to help clarify this issue, we have outlined six management problems that an entry-level physician executive should be able to deal with successfully without asking for help. If physicians find that they are unable to deal with these issues, they should seek additional training before considering a management role. PMID- 10161052 TI - What kind of leaders will be successful? AB - The U.S. health care system is fundamentally changing. The pace of change is swift but will vary, depending on regional market forces and state legislative mandates. This complex change is leading to rapid market consolidation of providers and insurers into organizations called "integrated health care systems." There is, as yet, no proven role model that will guarantee success. The purpose of this article is two-fold: To help individuals who see an expanding role for themselves in integrated health care management decide if they have what it is going to take to be successful. To identify individual management training needs by use of a self-evaluation tool. Some of the needed skills can be enhanced by education and experience. However, some are personality and style characteristics that may not be changeable. PMID- 10161053 TI - The mother of invention ... executive uses ingenuity to create window washing equipment. PMID- 10161054 TI - Special report. Training. PMID- 10161055 TI - Reconciling two solitudes: the example of physicians and managers in Ontario's hospitals. AB - This paper describes five aspects of the traditional relationship of physicians to hospitals and their administrators which fail to facilitate cost control or quality assurance. Several significant obstacles to changing this relationship are described, including the inertia of tradition, the fallacy of costless care and the chasm between medical and management cultures. It argues that to achieve care which is both cost-efficient and of high quality, physicians and hospital managers must unite to pursue common goals in a well-integrated management structure. Five suggestions for developing an effective new relationship are made, including the adoption of a "social contract" for all hospitals, the integration of physicians into hospital management and quality assurance programs, improved patient-level data collection and obligatory cost-awareness programs for hospital physicians. PMID- 10161056 TI - William Robinson, Mr. Fixit for several hospitals, wins Cain Brothers recognition. PMID- 10161057 TI - Nixon was a forerunner on reform. PMID- 10161058 TI - Health reform's other woman. PMID- 10161059 TI - The ultimate team player: a purchasing director's sporting attitude. PMID- 10161060 TI - Amidst antiques--she's still going strong. PMID- 10161061 TI - The physician manager in Eastern Europe and the former Soviet Union. AB - The physician manager feels hassled. There are increasing budgetary restraints, concerns over the appropriateness of resource utilization, and steadily increasing worry over governmental bureaucracy. In addition, there are concerns over patient satisfaction and increasing dissatisfaction by health care personnel. For all of this, the physician manager feels responsible. Sound familiar? Except that this physician manager is in one of the countries behind what formerly was called the "Iron Curtain," in Central and Eastern Europe or in one of the New Independent States of the former Soviet Union. Despite the striking political, economic, social, and organizational issues currently present, many of the problems faced by the physician manager in Central and Eastern Europe and in the New Independent States are remarkably similar to those encountered in the United States and Western Europe. PMID- 10161062 TI - Physician executives strive for balance in their changing roles. AB - Many physicians are apprehensive about healthcare reform and what it will mean for them. As physician executives, our job is to help construct systems that cost effectively deliver high-quality services and achieve positive outcomes in a competitive environment. To this end, we must understand management and all of its ramifications--from finance to organizational dynamics to marketing to systems thinking and information management. PMID- 10161063 TI - The organization man. PMID- 10161064 TI - A Sister in Lawrence. PMID- 10161065 TI - AHA's No. 2 exec to focus on reform. PMID- 10161066 TI - Will exec's record hold for new public company? PMID- 10161067 TI - Anesthesiologists show an interest in OR director role. PMID- 10161068 TI - So you are not paying attention. AB - In May 1993, a 13-item questionnaire was sent to physicians and nonphysicians who have attended the ACPE-sponsored program "The Management of Professionals" (now called "Building Organizational Cooperation: The ABCs of Win-Win Relationships." Of the 125 questionnaires distributed, 52 were returned. The objective of this article is to share some of the findings of the survey on win-win behaviors that can be of use to physician executives. PMID- 10161069 TI - Clinical nurse specialist promotes burn prevention. PMID- 10161070 TI - Rick Scott: health care's $10 billion man. PMID- 10161071 TI - Administrative behavior of directors in hospitals: the Israeli case. AB - This article presents research findings on the behavior of directors in hospitals in Israel. According to the findings, hospital directors devote most of their time to internal organization processes and less time to the management of the external organizational environment. The findings also reveal that the orientation of these directors is toward centralization of authority and concentration of the decision-making process. PMID- 10161072 TI - Management training for medical managers. AB - In the light of changes in the NHS requiring medical staff to take on managerial roles, the North Western RHA carried out a survey of clinical directors' need for management training. Dr David Allen and Sue Brimelow outline the results. PMID- 10161073 TI - Adam Smith as health economist, redux. Professor Smith on the market for physician services. PMID- 10161074 TI - Execs' compensation rises 5.5% in 1993. AB - Propelled by soaring bonuses, compensation for healthcare executives rose 5.5% last year, according to MODERN HEALTHCARE'S annual compensation survey. The survey also showed a growing reliance on variable pay and incentive programs as demands on executives increase. PMID- 10161075 TI - Job content and salary survey. Part I: Administrative director of radiology. AB - The AHRA Statistical Resource Committee presents the results of a recent survey of members about their job satisfaction, responsibilities, benefits and salaries. Data from the survey is analyzed in text and presented in tables to most accurately portray how administrators are compensated throughout the country. Part II will focus on chief technologists and will be published in the summer issue of Radiology Management. PMID- 10161076 TI - Sinai's CIO realizes dream position. PMID- 10161077 TI - Medical management: reflecting on some ripples in the pond. AB - Using current research into the management training of doctors in the UK, looks at some of the personal rather than just the organizational issues which arise from the development of doctors as managers. The variety of interpretations of the role raises a number of questions, some of which are highlighted: for example, the status of the management activity for doctors; the option of professional retreat from, or isolation in, difficult managerial roles; part-time management; disempowerment of other professionals; re-entry needs to full-time professional clinical work; women doctors as managers and the double- or even triple-glazed ceilings which they face. Some positive trends are evident, e.g. the impact of successful female chief executives as role models, the impact of training, but no one solution has emerged and this trend itself is seen as encouraging, given the context of a complex and ever changing environment. PMID- 10161078 TI - Doing more with less. St. Elizabeth Hospital Medical Center, Lafayette, IN. PMID- 10161080 TI - Compensation for chiefs of staff: a '90s phenomenon. AB - As part of its annual survey of physician executive compensation levels, the Physician Executive Management Center, a Tampa, Fla.-based physician executive search firm, sought information on compensation of medical staff leaders. In this report, the Center's findings are summarized. Forty percent of the responding hospitals compensate these leaders in cash, with an additional 34 percent providing noncash benefits. Three-quarters of the hospitals thus indicate recognition that some kind of compensation for voluntary medical staff leaders is warranted. PMID- 10161079 TI - Infused with enthusiasm. Long Island College Hospital, Brooklyn, New York. PMID- 10161081 TI - Administrative knowledge and skills needed by physician executives. AB - A survey was mailed to 100 physician executives identified through the 1991 American College of Physicians Executives directory. The subjects were asked to rate 17 managerial areas on their value to the subjects' current work, on the subjects' preparation in the areas, and on the need for training in the areas. In addition, the subjects were asked how best to accomplish training in the areas and for a list of areas of greatest importance in the future for physician executives. The subjects rated communication skills, quality assurance, utilization review, and personnel management as being of primary value in their current roles. Preparation was most adequate in communication skills and most inadequate in the areas of finance and organizational management. Training was deemed desirable in all areas, but was thought to be most necessary in communication skills, negotiations, strategic planning, and organizational management. There was least desire for training in the areas of labor law and employment law. The most popular means of training were doing a fellowship in administrative medicine, receiving continuing education through seminars or workshops, or getting a degree in management. PMID- 10161082 TI - Getting a firm grip on the realities for physician executives. AB - Today, physician executives can be found in every health care setting-group practices, hospitals and academic medical centers, insurance companies, drug companies, airlines, the government, and more. But before physicians land these positions, they must negotiate the often difficult passage from clinician to manager to executive to business-minded leader. To manage this transition successfully, physicians must be aware of and understand some basic realities of management positions. The nature of these realities and how physicians interested in management can deal with them are the subject of this article. PMID- 10161083 TI - Finding the win/win solution. PMID- 10161084 TI - Need for cardiac execs grows; salaries increase. PMID- 10161085 TI - A public/private partnership scores. PMID- 10161086 TI - McGuire: a keen eye toward the future. PMID- 10161088 TI - The new health care civilization: integration of physician land and manageria. AB - Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula. PMID- 10161087 TI - Difficulties in the transition from clinician to manager. AB - Medical clinicians have for many years been managers. However, this management role has most often been in groups of other clinicians and other health personnel. Only recently have increasing numbers of medical clinicians been asked to accept responsibilities for managing hospital and health services divisions that carry financial and administrative responsibility in addition to traditional clinical responsibility. In these circumstances, it is appropriate to seek to gather information about the various issues that surround the transition from clinician to manager in a systematic way and to begin to explore the issue and any actions that might be taken to ameliorate transitional problems. Such a study was undertaken by the School of Health Services Management at the University of New South Wales, Sydney, Australia, and is reported in this article. PMID- 10161089 TI - A matter of degree: the trend toward physician executives' pursuing master's degrees. AB - As the health care delivery system continues to change, there is certain to be an increasing demand for the services of physician executives. For the moment, potential employers seem to be seeking managers with solid physician credentials and proven management experience. But will the criteria remain at this level, or will employers demand more formal management credentials? And if the latter is likely, what credentials will best serve the physician executive in the employment marketplace? Those and other questions are explored in the following article through interviews with physician executives and recruiters. PMID- 10161090 TI - 1st Annual Research awards. Housing for the elderly. PMID- 10161091 TI - Eulogy to the master: W. Edwards Deming. PMID- 10161092 TI - Where salaried practice feels like private practice. PMID- 10161093 TI - Medical board's authority in question. PMID- 10161094 TI - Sharing the power. PMID- 10161095 TI - Developing an accountable health plan: the role of the medical director. PMID- 10161096 TI - Impact of AIDS/HIV on medical directors. AB - The decade of AIDS/HIV has changed the way insurance medicine is practiced by medical directors. One director details some of these changes. PMID- 10161097 TI - Critical aspects of the function of inspiratory flow driven inhalers. AB - Powder inhalers rely on the patient's inspiratory flow for delivery and aerosolization of the medicament. Different inhalers offer different resistances to inspiration through the device. The flow rate attained by a patient depends on the effort expended and on the air flow resistance of the device; flow rate is thus a device-dependent variable. A comparison between powder inhalers should therefore take their air flow resistances into account. An empirical relation between the peak inspiratory flow rate through a device and the flow resistance of the device has been developed using results from healthy subjects and verified to a limited extent using data from asthmatic patients. The flow resistance was measured as the pressure drop at a fixed flow rate. The empirical relation can be used to predict the change in peak inspiratory flow rate resulting from a change in flow resistance. Matching flow rates, representing equal inspiratory efforts, may thus be calculated for different inhalation devices. PMID- 10161098 TI - Inspiratory capacity through the Turbuhaler in various patient groups. AB - The effect of the Turbuhaler depends upon the inspiratory flow rate generated by the patient during the inhalation. In children both the peak inspiratory flow rate and the volume of air inhaled at that inspiratory flow rate are important. An inspiratory flow rate greater than 30L/min is usually considered sufficient to achieve an optimal effect. The exact volume which should be inhaled at flow rates above that level is not known. It is probably low (around 0.1-0.2L). In our clinic, virtually all children older than 5 years can inhale a sufficient volume at an inspiratory flow rate greater than 30L/min after careful tuition. With decreasing age an increasing proportion of children will be unable to inhale a sufficient volume at a flow rate greater than 30L/min, and generally children younger than 5 years should not be prescribed Turbuhaler treatment unless they have shown they are able to use it optimally. Both inspiratory flow rate and inhaled volume are decreased during episodes of acute wheeze. In clinical practice this is only important in the young age groups. The vast majority of school children will still be able to benefit optimally from Turbuhaler treatment during episodes of acute wheeze. Although there is a correlation between expiratory pulmonary function and peak inspiratory flow rate, measurement of expiratory pulmonary function cannot be used to predict whether an individual child can use the Turbuhaler optimally. PMID- 10161099 TI - Clinical efficacy and safety of Turbuhaler as compared to pressurized MDIs-beta 2 agonists. AB - Beta 2-agonists are one of the cornerstones in the management of patients with obstructive lung diseases. The Turbuhaler containing terbutaline has been available in several countries for a few years only but has proven to have effects comparable to those of the conventional metered dose inhaler (MDI) and other powder inhalers in the treatment of obstructive lung diseases. Even in acute severe asthma, treatment with terbutaline via the Turbuhaler has proven as effective as treatment with the conventional MDI in combination with the 750ml spacer. These results indicate that the conventional MDI containing terbutaline can be exchanged by the Turbuhaler for most clinical purposes. Thereby this new method of treatment can contribute to the reduction of chlorofluorocarbon (CFC) pollution of the atmosphere. Furthermore, CFC-provoked bronchoconstriction can be avoided. PMID- 10161100 TI - The effects of different percentages of dietary fat intake, exercise, and calorie restriction on body composition and body weight in obese females. AB - PURPOSE: The goal of this study was to determine the effect of varying the amount of dietary fat, while holding calories at 1,200 kcals/day, on body weight and percent body fat in 35 obese women. DESIGN: A pretest, midtest, posttest experimental design was employed, and subjects were randomly divided into one of four dietary fat groups, with 10%, 20%, 30%, or 40% of caloric intake as dietary fat. INTERVENTION: Subjects consumed 1,200 kcals/day and a specified percentage of total energy as fat, depending on their dietary group. Protein was held constant at 20%. All subjects engaged in a five day/week walking program. SETTING: Participants were recruited from the general community using newspaper advertisements. SUBJECTS: Thirty-five obese women 25 to 45 years of age (means=38 +/- 4.97) served as subjects. All were at least 20% above ideal weight and 30% to 52% body fat. MEASURES: Percent body fat, body weight, and anthropomorphic measurements were taken at baseline, six and 12 weeks. Dietary intake was recorded daily by each subject, and exercise walking logs were maintained by each participant. RESULTS: All subjects lost body weight and body fat; however, there were no significant differences in the rate or amount of body weight or percent body fat lost across the four groups during the intervention. CONCLUSIONS: It appears that during calorie restriction and exercise for 12 weeks, percent of calories derived from dietary fats does not influence loss of body weight or percent body fat in adult obese women. PMID- 10161101 TI - The shadow president. For Bob Dole, the health-care battle is the first primary in his own campaign for the White House. PMID- 10161102 TI - The role of an agency medical director. AB - No two agencies provide care in the exact same way. Thus, it is difficult to come up with a definitive description of what a medical director should do. But one medical director undertook a description; through intense examination of his personal perspective and his professional experience, he presents a total view of the role of a home care agency medical director. PMID- 10161103 TI - The governance team: a firsthand look at leadership practices. The Partnership Study--preliminary findings from Phase 2. PMID- 10161105 TI - MGMA rejects proposal to require docs on board. PMID- 10161104 TI - Physician enrollment in health administration programs. PMID- 10161106 TI - Oncopolitics. The new dynamic between healthcare administration and business. PMID- 10161107 TI - Creative problem-solving techniques: relevance to doctors in management? AB - Recent NHS reforms have had a profound impact on the role of clinicians in the field of management. Traditionally this has been a role eschewed by clinicians, but the evolution of the clinical directorate model has now encouraged senior members of the medical profession to address more positively managerial and management issues. If clinicians are to embrace enthusiastically the management role, it is clear that their awareness of the range of techniques available to them is raised to its maximum potential. In this respect, explores the relevance of some more radical creative problem-solving techniques within a practical environment. The concentration is on two specific techniques which were put to trial in real working situations. However, in addition to the techniques addressed, there are a range of alternative problem-solving techniques which may be more appropriate. Having piloted the two creative problem-solving techniques described, the practical conclusions were that their application had developed better team working and spirit, enhanced the quality of patient care delivered by the team and improved productivity and outcomes. PMID- 10161108 TI - Purchasing and public health: the state of the union. AB - The purchasing role of health authorities has been in existence for two years and public health physicians are expected to play a central part within this role. While the first year was dedicated to maintaining a "steady state", differences are now appearing between authorities is the way in which purchasing is managed. Based on the views of senior managers and public health physicians working in purchasing authorities, considers how the purchasing process is developing and reports how public health medicine is perceived to be contributing to it. Identifies sub-regional resource allocation as a major factor influencing the purchasing process. Conflicting views were found on the purchasing role of public health medicine, in particular with respect to health needs assessment. As purchasing evolves it remains unclear whether pubic health medicine will come to fulfil a largely technical role, or a more wider one in which it acts as advocate for the population's health. PMID- 10161109 TI - It's not the goal ... it's the journey. AB - His first real odyssey began 18 years ago in Alaska. The goal was Ecuador. He got as far as the Panama Canal. Traveling man John Glaser, now vice president of Information Systems at Boston's Brigham and Women's Hospital, learned long ago that the actual goal sometimes matters less than what happens along the way. PMID- 10161110 TI - A new general in the war on AIDS. PMID- 10161111 TI - 1994 EMT of the Year announced. PMID- 10161112 TI - Focus on Michele Fairchild. PMID- 10161113 TI - The physician manager in Central and Eastern Europe. PMID- 10161114 TI - The physician-administrator team revisited. PMID- 10161115 TI - Three trustees make their mark on hospital governance. PMID- 10161116 TI - Staff leadership a younger crowd. PMID- 10161117 TI - Manager of the Year sees change as benefit. PMID- 10161118 TI - Influence by learning how people process information. AB - To have a successful career in management, you have to pay more attention to refining your communication skills than you ever thought was necessary. In a survey of 100 physician executives, 94 percent felt training was needed in communication skills if you are thinking about becoming a physician executive. When recruiters talk to us about the basic requirements for physician executives, one of the things they say the person needs to have is excellent communication skills. Most people have good communication skills, but what can move you into the category of excellent is paying careful attention to how the person you are talking to processes information. You can only do this if you listen before you do much talking. What do I mean by processing information? When we get up in the morning, the world is out there separate from us. We have to take in information about that world and make decisions all day long. We don't all do this in the same way. In this article, I am going to discuss four ways to process information. PMID- 10161119 TI - The Informatics Institute: why do we need it? AB - Why should physician executives care about medical informatics? For that matter, what is medical informatics anyway? Broadly defined, medical informatics is the study of the collection, storage, retrieval, and analysis of data and information in health care to support clinical and administrative decision making. Informatics is important because, in the past 10 years, powerful computer, software, and information technologies have been developed to enable health care organizations to automate some of the work of decision making, for improved quality of care and cost control, and for successful managed care contracting. This new emphasis on informatics in health care was the impetus for the founding by ACPE earlier this year of The Informatics Institute, which will be involved in educational and research activities in the growing area of medical informatics. In this new column in Physician Executive, Dr. Marshall Ruffin, President and CEO of the Institute, will discuss the role of medical informatics in health care delivery and financing and its relation to physician executives. PMID- 10161120 TI - The governance team. A firsthand look at leadership practices. AB - Findings from Phase 1 of the Partnership Study--a national, random sample of board chairmen, chief executive officers and medical staff presidents--paint a detailed picture of national practices of hospital governance teams. In addition, the findings point to a number of inconsistencies regarding the views that board chairmen, CEOs and medical staff presidents have about their leadership roles. Conducted by the American College of Healthcare Executives (ACHE), the American Hospital Association, the American Medical Association and Ernst & Young, Phase 1 Partnership Study findings were reported in the January issue of Trustee (page 16). In Phase 2, of the Partnership Study, in-depth case studies were conducted to address these questions: How do the board chairman, CEO and medical staff president interact one-on-one and as group? How do these three health care leaders perceive one another? What attributes of effective working relationships exist among the three leaders? To answer these questions, confidential site visits were made to six hospitals identified in this article as Metropolitan, North Woods, Midwest, Suncoast, Mountain Valley and Southland (see Study Sites, page 13). Following are some preliminary impressions, based on five completed case-study site visits. The sixth study site visit was in progress at press time. PMID- 10161121 TI - Risk takers. Clinical leadership in an era of health care reform. PMID- 10161122 TI - CHEM profile: Michael L. Rawson, HEM. PMID- 10161123 TI - Lawanda Spotts. York Hospital, York, Pennsylvania. PMID- 10161124 TI - Self-protection from stress. Its meaning for medical groups. AB - Seth Allcorn, Ph.D., M.B.A., associate dean for fiscal affairs at the Loyola University Chicago Stritch School of Medicine, writes how self-protection can initially reduce stress in the individual but is detrimental to the group. He investigates self-protective behavior from a psychological view and offers his analysis on the nature of self-protection, its impact on others and how to minimize the effects. PMID- 10161125 TI - Decentralization of decision-making in Canada's health system: the Sunnybrook experience. AB - Though there is a significant literature which notes that physicians are fast becoming organizational members, there has been little research evidence to suggest that the adoption of new management models have actually facilitated their involvement. This study sought to examine whether a conscious effort at decentralizing decisions at the clinical unit level would actually result in increased involvement of physicians and other clinicians in decision-making at that level. Two major surveys examining individual roles and responsibilities and unit relationships with other units were conducted, at two points in time, in a large Canadian tertiary care centre. Results suggest that physicians had experienced an increase in administrative discretion. There was an overall increase of many groups in influencing clinical unit decisions with a perceived decrease in senior management influence in budget administration at the unit level. Lessons learned in conducting this type of research are described. PMID- 10161126 TI - CHEM profile: Martha Anderson, HEM. PMID- 10161127 TI - Medicare and Medicaid programs; revisions to conditions of participation for hospitals--HCFA. Final rule. AB - This final rule establishes as a condition of participation (which facilities must meet in order to participate in the Medicare and Medicaid programs) the requirement that hospitals have a discharge planning process for patients who require such services and specifies the elements of that process. It also changes the required qualifications of a hospital's medical director. These provisions implement sections 9305(c) of the Omnibus Budget Reconciliation Act of 1986 (OBRA '86) and 6025 of the Omnibus Budget Reconciliation Act of 1989. Also, we are not adopting several minor proposed revisions to the conditions for coverage of suppliers of end-stage renal disease (ESRD) services. We are now developing comprehensive revisions to the ESRD regulations and believe that it would be appropriate to reconsider the proposed changes as part of that rulemaking process. PMID- 10161129 TI - When should a manager intervene? PMID- 10161128 TI - The 1994 FM honorable mention for humanitarian service presented to Robert Dostis, M.S., R.D. for expanding nutrition services for persons with AIDS. PMID- 10161130 TI - Health reform bridging gaps between physician executives and CEOs. AB - Recently, Hospitals & Health Networks reported the results of a study it conducted, in conjunction with Premier Health Alliance, Inc., and among hospital CEOs and COOs to gauge their preparedness and level of concern about various health care reform issues. Because administrators and physician executives are not always in agreement, we wondered how physician executives would rate the same issues. To find out, the American College of Physician Executives polled some members and posed the original survey questions. The results and subsequent interviews revealed that health care reform appears to be a catalyst in bringing the two factions closer in their thinking. PMID- 10161131 TI - Just the right amount of seasoning. PMID- 10161132 TI - Commanding general. PMID- 10161133 TI - AIDS--memoire. AB - A czar was born when President Clinton named Kristine M. Gebbie to be his national AIDS policy coordinator. But a year later, under unrelenting fire from AIDS activists, Gebbie resigned. Her departure underscores the trouble that some activists have had shifting from the outsider's game to the insider's. PMID- 10161134 TI - Physician opportunities in management: signs and portents. AB - There are many trends today that spell great opportunity for physicians who seek to shift their careers into management. Some of those trends are outlined here, with commentary on each opportunity presented. Like much in life, most opportunities contain uncertainties and unanticipated consequences. Thus, no opportunity comes without some possible negative side effects and blind alleys for the unaware. Some of these pitfalls are also presented, along with some suggested strategies for physicians who seek major roles in the management of the health enterprises of the future. PMID- 10161135 TI - Health care reform: Believe it or not, the ball is back in our court. AB - SYSTEM: Orderly arrangement of parts into a whole; a comprehensive plan. SCENARIO: A series of activities or events. In the 1950s, President Eisenhower warned of the waste and danger inherent in a "military-industrial complex" controlled by elected officials who were professional politicians. In the 1960s, some worried that a similar "medical-industrial complex" could develop and that health care could become a "political football." Sure enough, in the 1970s and '80s, a U.S. health care scenario evolved that is characterized by financial, political, and legal maneuvering rather than by genuine interest in providing dependable medical care on the scariest days of people's lives. If problems of dependability, affordability, and access are truly to be solved, this scenario must change. And until these problems are truly solved, unwelcome pressure on providers will continue. Furthermore, political action can only create a system. The scenario is created by the attitudes, motivations, and actions of health care providers. PMID- 10161136 TI - The case for a physician director of the surgical suite. AB - A typical hospital operating room can generate revenue of $1 to 3 million per year. About 30 to 40 percent of the total income of a hospital is produced in the surgical suite. This is a high-cost area in terms of personnel, equipment, and supplies, so strong management is increasingly important in the area. In the past few years, a number of hospitals have found a solution in a physician director for the surgical suite. Although the physician for this position may be of any specialty, the chief of anesthesiology or an anesthesiologist with strong management and communication skills is the best choice. Usually, an anesthesiologist spends the most time in surgery and does not have special allegiance to any surgical specialty. He or she has a vested interest in smooth functioning and success of the surgical suite. PMID- 10161138 TI - 1995 Trustees of the Year. AB - Modern Healthcare's 17th annual Trustee of the Year awards salute Beatrice Knowles of Sebasticook Valley Hospital, Pittsfield, Maine, and Robert Harrell of Orlando (Fla.) Regional Medical Center for their efforts to improve the quality of healthcare in their communities. PMID- 10161137 TI - Physician executives of the future moving from management to leadership. PMID- 10161139 TI - What lies ahead for medical management? AB - The consensus is that, in spite of a reluctance in Washington to undertake any drastic reform of the health care financing and delivery system, the changes that are already in place in individual organizations and that are in place or being contemplated at the state level are certain to make the health care system of tomorrow very different from that of today. Physician executives can play an important role in the transition that will be required, but they will have to use a flexible, especially nondogmatic approach if they wish to cope successfully in this increasingly whirling environment. For such physicians, the author says, the opportunities, though unknown, are enormous. PMID- 10161140 TI - The physician executive "arrives"--a new generation prepares for the future. AB - The recent rise in the number of physician executives in the health care industry vividly demonstrates that a genuinely new generation of physician executives is seeking to combine the sensitivity of their clinical skills with the business acumen that today's health care organizations need to prosper and grow. But physicians who are preparing themselves to be selected one day as chief executive officers by hospitals, integrated systems, and managed care organizations should understand that the CEO role is radically different from that of the CEO of a physician practice. The corporate CEO role requires the management of managers and responsiveness to the organization's board. Those who imagine that the corporate CEO role bears any resemblance to the autonomous, independent existence of the practitioner are certain to have a rough time. PMID- 10161141 TI - The future of American health care in the "post-reform" era. AB - "As the debate over health care reform rages in Washington, the market is reforming itself. For any given market, it's a question of 'How soon will it hit?', not 'Will it hit?'" Health care reform and market restructuring are ushering in a new era of integrated health care. Although the future is not fully clear, there are at least three competing models for the creation of regional and statewide health systems that will integrate the financing and delivery of services to large enrolled populations of consumers: Payer-driven networks. Provider-sponsored systems. Partnership models. Whatever the future scenario, physician executives will play a larger, more dominant role. Research on integrated health systems has identified three critical success factors for future success: physician-hospital integration, clinical integration and information integration. For managed care to be successful, there must be clinical leadership. The essence of managing care is clinical efficiency, based on "critical-path" treatment protocols and real-time patient care management, supported by integrated information systems. PMID- 10161142 TI - Lonely at the top and loving it: physicians as CEOs. AB - As little as five years ago, most hospital board members scoffed at the idea of hiring physicians as chief executive officers or chief operating officers. Physicians, they maintained, belonged at the bedside, not in the board room. For the most part, physicians didn't take issue with this thinking. Profit and loss statements, strategic planning, and other CEO duties were alien. Besides, being a "suit" was unconscionable, a total fall from the true grace of medicine: patient care. Dramatic changes in health care have wrought dramatic changes in the mindsets of both board members and physicians. Today, both sides have developed a new perspective on physicians in top hospital administrative positions. In this article, the author reports on the experiences of physician executives who have made the trip to the top. PMID- 10161143 TI - Managed care information needs: a summary perspective. AB - The key to survival in managed care is management of financial risk. You need to know what is in your contract and what you are obligated to do for which population during which period. Information systems can be an enormous help in managing managed care contracts and the financial risks they entail, but poorly selected and configured information systems will do little good for the organization that licenses them. The most important activity of a physician executive who is moving his or her organization into managed care contracting is to lead the process to define the functional requirements for information the organization will need to manage managed care contracts successfully. PMID- 10161144 TI - Management style key to success. PMID- 10161146 TI - Surgeon general nominee: 'Top-flight' or 'Elders-lite'? PMID- 10161145 TI - Healthcare reform perspectives of rural and urban hospital leaders--issues and attitudes. AB - What are the perspectives of rural and urban hospital leaders--administrators, physicians, and board members--regarding healthcare reform? Both groups support substantial reform in healthcare delivery. They agree that changing malpractice and tort laws is one of the leading strategies for reforming healthcare and that reform should be financed by income tax credits or a combination of employer premiums and government taxes. PMID- 10161147 TI - CHEM profile: James Speelman, HEM. PMID- 10161148 TI - The case for physician direction in health plans. AB - Advanced managed care organizations limit costs by having nonphysician managers make medical management decisions. Physicians should be included on the board of medical managers to assurse that the patients' best interests are considered when management decisions are made. PMID- 10161149 TI - The role of the principal clinical coordinator in the Health Care Financing Administration's Health Care Quality Improvement Initiative. AB - The Health Care Quality Improvement Initiative (HCQII) is the Health Care Financing Administration's latest approach to quality management by peer review organizations (PROs) of the health care delivered to Medicare beneficiaries. The principal clinical coordinator (PCC) of each PRO, a physician with both clinical and methodological expertise, has the overall responsibility for all HCQII related activities. The PCC works with a clinical coordinating team to analyze patterns of care and provide feedback about these patterns to the medical community for the purpose of improving the quality of care. Each PRO provides its PCC with the necessary infrastructure and expertise to conduct pattern analyses and implement the dissemination process. However, the effectiveness of the HCQII will depend largely on the PCC's ability to maintain the full support and cooperation of the local medical community. The success of the PCC role under the HCQII may enable it to serve as a useful model of physician leadership in the quality oversight organizations that will accompany national health care reform. PMID- 10161150 TI - Leadership skills for the physician manager. PMID- 10161151 TI - Physician involvement in the governance of integrated systems. PMID- 10161152 TI - 1995 Health Care Hall of Fame. Ford found a new role for nursing. PMID- 10161153 TI - 1995 Health Care Hall of Fame. Hiltz led system to victory. PMID- 10161154 TI - 1995 Health Care Hall of Fame. Kinzer had a passion for ideas. PMID- 10161155 TI - 1995 Health Care Hall of Fame. McMahon was made for his role. PMID- 10161156 TI - 1995 Health Care Hall of Fame. Thompson inspired a generation. PMID- 10161157 TI - Loosening the Gordian Knot of governance in integrated health care delivery systems. AB - A new organizational species is emerging--the integrated health care delivery system. Aligned with both the anticipated provisions of federal and state health care reform initiatives and emerging purchaser demands, integrated delivery systems could dominate many health care markets by the end of this decade. Integration is both the defining feature and key imperative of such systems. Because of the unique position of boards, governance is potentially the ultimate integrator. Yet little attention had been focused on integrated delivery system governance. Accordingly, this article will address the governance of integrated delivery systems through three questions: (1) What are the distinguishing characteristics of integrated health care delivery systems? (2) What are the distinctive issues and challenges associated with governing integrated delivery systems? and (3) What different forms of governance can be employed by these systems and what factors influence the effectiveness of these forms? PMID- 10161158 TI - The art of negotiation. Getting what you want out of a managed care contract. AB - As managed care takes a firm hold in the marketplace, healthcare organizations are hurrying to align. While some executives are skilled negotiators, well versed in the complexities of managed care contracting, others are new to the process. Those seeking direction in the art of negotiation can benefit by reviewing the principles that follow. While basic, they will help you make the most of the negotiation process. PMID- 10161159 TI - Organizing and managing primary care practice networks. PMID- 10161160 TI - Careers. Transitioning to managed care. PMID- 10161161 TI - Lessons learned from practice acquisition. PMID- 10161162 TI - Wash. CEO scores big as Young Executive of 1995. PMID- 10161163 TI - Bill Gates eyes healthcare market. AB - The entrepreneurial spirit is still top in Bill Gates' mind as he look toward healthcare and other growth industries. Microsoft's CEO has not intention of going the way of other large technology companies that became obsolete before they could compete today. PMID- 10161164 TI - Look back in anger. PMID- 10161165 TI - Comparing architectural and verbal wayfinding clues. PMID- 10161166 TI - Management: the one disease consultants did not think existed. AB - Considers progress made in involving doctors in management, drawing on available ethnographies of local health-care systems and a small-scale study of consultants who have moved into clinical director roles or the equivalent. Specifically considers the extent to which the sample believes consultant roles have changed as a result of the recent reorganization of the NHS and general concerns about the involvement of doctors in management. PMID- 10161167 TI - Relationships between doctors and managers: the Scottish experience. AB - Based upon empirical research conducted in 1993, attempts to illustrate the implications of efforts to bring doctors into management. It addresses in particular the role of key appointments such as the medical director and clinical directors and the perceptions of these roles. Doctors continue to demonstrate themselves to be reluctant managers and this continues to pose problems for the aspirations contained in Working for Patients. Crucial questions must be asked about whether management represents a productive use of doctors' time and whether the NHS can afford premium rates for largely inexperienced managers. Identifies changes that have taken place to date and indicates that doctors are, for the most part, still lukewarm about a career in medical management. PMID- 10161168 TI - The clinical director in the NHS: utilizing a role-theory perspective. AB - Reviews the role of the clinical director in the NHS, based on data collected in a qualitative research study. Utilizes role theory to invite insight into a relatively new but important managerial role. Suggests that effectiveness in the role may be measured by the extent to which managers are able to meet the expectations of their role set, and also that the overall effectiveness of the clinical direction may be the extent to which he or she is able to influence, adapt, modify or change these role expectations. PMID- 10161169 TI - CHEM profile: Larry Sweeney, HEM. PMID- 10161170 TI - Moving clinicians into management. A professional challenge or threat? AB - Examines the issue of involving clinicians in management and the management processes. Considers the effect of the changing context of practice and the pressures that are imposed on the medical profession by this involvement. PMID- 10161171 TI - Do special health authority doctors make special managers? AB - Reviews management training for doctors undertaken in the special health authorities in London. These are postgraduate research institutes in clinical medicine. Compares methodology and outcome issues with the national research programme completed a year earlier, and identifies the context of comparative change between the research programmes. The finds, although similar to the national evaluation the previous year, identify some additions, in particular the lack of formal accountability for the management role in the NHS being undertaken by these university employees, and the differing nature of the working arrangements for these academic doctors who are usually working as knowledge based networkers across a number of organizations. PMID- 10161172 TI - The care plan conundrum. PMID- 10161173 TI - A behavioral profile of physician executives. AB - In late 1993, ACPE and Tyler & Company, a national health care executive and physician search firm based in Atlanta, Ga., jointly conducted a survey of physician executives to determine their most likely behavioral patterns. It is the first of a two-part survey that, when complete, will create a multifaceted profile of the "ideal" physician executive as seen through physician executives' eyes and through the eyes of hospital management. Questionnaires based on the DiSC method of behavioral analysis were mailed to 750 randomly selected members of ACPE. More than 170 responses were received. The survey results showed that the majority of physician executives have strong communications skills, are people-oriented, and are strong leaders. The majority of respondents are self motivated and industrious and are driven by accomplishments. The second part of the survey, which will be conducted later this year, will poll hospital CEOs and boards of directors about their preferences for behavioral patterns in their executives. Comparisons and consistencies will be analyzed between the two surveys to develop a comprehensive profile of the "ideal" physician executive, and the results will be reported in Physician Executive. PMID- 10161174 TI - Hospital medical directors, quality of care, and financial returns. AB - You are a physician executive working very hard within a hospital on all sorts of medical staff issues and quality of care. You answer to the board. The latter, through its administrators, may still have difficulty documenting the precise value of a full-time physician executive. Your hospital is losing money or not making enough profit for capital expenditures and salary raises. It is considering or will have to consider staff cuts. What can you do that will influence the bottom line, produce a quality image, and quantify your value? PMID- 10161175 TI - The physician's alternative career transition model: a stepwise approach. AB - The recent intense focus on marketplace reform has stimulated a reassessment of career planning options for some physicians. These socioeconomic changes have created unique opportunities beyond the traditional arenas of clinical practice and medical management for physicians to leverage their medical degrees and experiences in the business world. This paper presents three case reports of physician executives who have successfully pursued medically related business career options, each following different motivations at various stages of their medical careers. It then discusses the Physicians' Alternative Career Transition (PACT) model developed by the authors to assist other physicians who are considering making transitions into business-related careers. The PACT model is based on four critical steps for practicing physicians to make these transitions successfully: an internal self-evaluation process, an external environmental evaluation process, seeking the best "career match," and securing the career match. PMID- 10161176 TI - The views of an industry maverick. PMID- 10161177 TI - The superhighway to buying criteria. PMID- 10161178 TI - A catalyst for the networking movement. AB - Charles Jones has a clear vision for how community health information networks can improve health care delivery in West Virginia. He's seen what EDI has done for retailing and manufacturing industries. Now, he's trying to turn his dreams into reality by heading a consortium that's developing a strategy for building several networks in the state. Jones is demonstrating how one hospital executive with strong personal convictions can spark a sweeping effort to change the way a state health care system functions. PMID- 10161179 TI - A 26-year quest for the ultimate electronic record. AB - W. Edward Hammond is well-known nationally as a champion of electronic records. He's been instrumental in developing standards for electronic formats and record content. For 26 years, he's been working on computerized patient records development at Duke University. But despite substantial progress, the pioneering researcher says the field still has a ways to go before it achieves his vision of the ultimate medical record. PMID- 10161180 TI - Revisions to the conditions of participation for hospitals. PMID- 10161181 TI - The hospital director and the quality circle. PMID- 10161182 TI - The role of the physician executive in the changing medical world. PMID- 10161183 TI - Frontier skills come in handy. PMID- 10161184 TI - EDI USA president attempts to build a survivor. PMID- 10161185 TI - Pay gap widening between plan executives and physicians. PMID- 10161186 TI - Target: technology, training, teamwork. PMID- 10161187 TI - New opportunities in medical group management. PMID- 10161188 TI - American College of Healthcare Executives. Professional policy statement: lifelong learning and the healthcare executive. PMID- 10161189 TI - From street gang to surgeon. PMID- 10161190 TI - Resolving conflicts: principles and practice. AB - Physicians and other medical professionals undergo extensive professional training for the privilege of obtaining their professional licenses. For most physicians, clinical training is conducted in extremely competitive circumstances. Many physicians endorse competition as an appropriate method for producing greater individual and collective competence within the profession. Competition, however, is a very limited way to resolve conflicts. And, in the current environment of greater resource restrictions and reform, the competitive model, at best, seems short-sighted. Many of the current relationships involving physicians and others are transitional, involving various partners in numerous practice and professional relationships. For example, medical practices are merging; hospitals are engaging physicians in numerous business structures, even employment. However, longer term relationships are enhanced by mutual respect and collaboration, rather than chronic competition to "win" one's rights over another. Thus, the need among physicians to enhance their conflict resolution skills is expanded in today's environment. PMID- 10161192 TI - Taming your telephone. AB - In this modern age of communications, with computers, FAX machines, and the videoconference, the decision-making process has been accelerated. Use of the telephone has become more important and intensive. The physician executive must constantly strive to hone the edge of his or her skills to increase productivity and soften the stress of each day. In the 1990s and in the era of health care reform, the physician executive will face increasing pressures and demands. Telephone skills will become increasingly important to organizations and to physician executives' peace of mind. This article considers some fundamental aspects of telephone usage: (1) reasons for provider behavior, (2) the value of the phone as a negotiating tool, (3) suggestions for phone efficiency, (4) guidelines for a successful telephone encounter, and (5) pitfalls. PMID- 10161191 TI - Development of a local Physician Executive Leadership Program. AB - Dramatic changes are occurring at a rapid pace throughout the United States in virtually all aspects of health care delivery. Physicians, hospitals, consumer groups, and others are thus facing new and greater uncertainties and are forced to adapt to a continually shifting environment. Fundamental change of this magnitude has and will continue to result in the formation of new alliances and organizations within which physicians and others will be forced to function. To participate effectively in these processes of change and to maintain influence within these new organizations, physicians will need leadership and management skills. To address the challenges facing current physician leaders and the need to develop more effective leaders, Sharp HealthCare developed its Physician Executive Leadership Program. This article describes the program and summarizes some of the lessons learned regarding the training of physician executives and leaders in today's changing health care environment. PMID- 10161193 TI - Re-forming the traditional organization medical staff. AB - The traditional, two-bylaws-model organized medical staff was created in another age (1919) to serve a simple health care system, controlled by physicians, in which the only players were patients, doctors, nurses, and small hospitals. This medical staff model does not meet the needs of the U.S. health care system of the 1990s. The purpose of this article is to provide the physician executive with a resource to use when he or she is called on to help determine what, if any, changes are needed in his or her organization to make the role of physician leaders more effective. Finding the right answer to this question is part of discovering ways to reduce health care costs without reducing the funds available to pay for direct delivery of health care services. Maintaining traditional, bureaucratic, legalistic organized medical staff activities is a very expensive game that we can no longer afford to play. PMID- 10161194 TI - Shortell wins Baxter prize for work on large hospital systems. PMID- 10161195 TI - Foster defends his record as GOP readies effort to kill nomination. PMID- 10161196 TI - 1995 IFMA Silver Plate Award Winner healthcare. Ed Noseworthy, Florida Hospital Medical Center, Orlando. PMID- 10161197 TI - S.D. CFO honored as outstanding exec. PMID- 10161198 TI - How much fluoride is too much? The new guidelines. AB - Prescribing fluoride supplements isn't always a simple matter. Fluoride in drinking water, other beverages, and toothpaste can push intake above therapeutic levels and cause fluorosis. New guidelines from the American Dental Association and American Academy of Pediatrics help you decide when and how much supplementation your patients need. PMID- 10161199 TI - Influenza: a yearly challenge. PMID- 10161202 TI - Raises slow to a trickle. Compensation survey's results reflect healthcare's uncertainties. AB - Hospitals and healthcare systems, reflecting the uncertain times in the industry, are trying out new ways to compensate executives, with an emp basis on flexibility. For many positions, that has amounted to minuscule raises or no raises at all. PMID- 10161201 TI - Physician, heal thy organization. PMID- 10161203 TI - Was that really funny? The politics of humor. AB - Everybody loves a comic--or do they? A Human Resources Department picked up a pattern when several departing employees, all excellent performers, said they liked their jobs but felt "excluded" from the camaraderie. One said he'd found the humor "barbed." Another said she's never seen anything funny in jokes that seemed to convulse everyone else. The past five years have been so gloomy, economically speaking, that, in many hospitals and health care organizations, laughter is a mega-event. But lately I've been listening to what employees joke about and watching how their humor affects others. Physician executives need to be alert to some kinds of humor that are weapons used by employees against other employees, their managers, and the company generally. PMID- 10161204 TI - Communication skills: a prerequisite for leadership. AB - A man once said, "He who would be first among you, let him be your servant." I think he also would have said, "If you would be the leader of the troops in health care, you must be able to communicate." You must be a good listener, be able to facilitate conflict resolution, be a good interviewer, deal effectively with problem physicians and employees, speak effectively in front of an audience, and communicate well in writing. Do not assume that you are good at any of these skills because you went to medical school. All of us need improvement in these areas. PMID- 10161205 TI - Doctors in management. Harder than brain surgery. PMID- 10161207 TI - What would you earn if you became a medical director? PMID- 10161206 TI - Androscopy and treatment of human papillomavirus (HPV) with CO2 laser surgery. AB - Dysplasia and cancer of the cervix may be related to human papillomavirus infection. To determine the presence of cancer in cases of genital warts we have been using a technique, androscopy, for examining male genitals with magnified lens previously sprayed with white vinegar (5% acetic acid). This paper explores the methods of using colposcopy and androscopy on both sexual partners for a thorough examination of genitals and the anorectal area. It also discusses treatment advantages of the CO2 laser. In our investigation plain, pedunculated warts and a giant condyloma (Buschke-Loewenstein tumor) were found and treated with CO2 laser surgery. PMID- 10161208 TI - Traditions of housekeeping excellence ... Northeast Baptist Hospital, San Antonio, TX. PMID- 10161209 TI - Using leadership criteria to measure and reward performance. AB - Physicians speak of performance and outcomes. They speak of customers and patients. While many leaders nod their heads, shake hands in agreement, and establish liaisons, agreements are implemented without an appropriate understanding of how to recognize and measure leadership performance. How are physicians and other management team members measured? Are you measuring the right things? Physician executives should be measured for simplicity, for streamlining, for standardization, and for knowing the right processes. That's productivity. They should be measured for taking risks, for being creative, and for exploring and initiating new ways to use existing resources. That's entrepreneurship. And they should be measured for kindness, for empathy, for building trust, for sharing with colleagues, and for working together. That's teamwork. PMID- 10161210 TI - Management knowledge and skills required by U.K. and U.S. medical directors. AB - A survey was undertaken of the medical directors of National Health Service trusts in the South Thames Regional Health Authority of the United Kingdom. The purpose of the survey was to ascertain medical directors' views regarding the importance of various areas of administrative practice, their preparedness in these areas of administrative knowledge prior to taking up their roles as medical directors, and their views as to the body of knowledge required for future medical directors. The study was compared with a similar study undertaken in the United States. While there were many areas of agreement between the English and the American medical administrators, there were also areas of significant differences of opinion. The need to develop a recognized training program in medical administration is acknowledged. PMID- 10161211 TI - The telephone encounter: the cast of characters encountered by the physician executive. AB - Volumes have been written about telephone productivity, decorum, behavior, and economic impact. Although every physician is skilled in telephone communication, medical directors must approach this communications modality from a different vantage point. The attending physician uses it as an information receiver and transmittal station. The medical director uses it as a negotiation platform. It is estimated that 50 to 90 percent of the medical director's time is spent on the phone. "Working smarter" can increase productivity to save time and stress. This article identifies and categorizes many of the problems that the medical director deals with on a daily basis. It pertains to phone conversations in which there is a question about a procedure, appropriateness of care, medical necessity, or quality of care. PMID- 10161212 TI - Administrative fellowships in emergency medicine. AB - Physicians today need to be effective managers, as well as clinicians. In previous years, physicians gained managerial experience either through on-the-job training, degree programs, or continuing medical education courses. The specialty of emergency medicine began its first administrative fellowship in 1990 in California. Currently, three administrative fellowships exist nationally in emergency medicine. This article will describe the purpose of the fellowships and their curricula. Each fellowship has a different emphasis, with the goal to educate physicians who are interested in developing administrative skills to manage emergency departments or management groups or accept roles in hospital leadership. The existence of these fellowships will ideally influence the establishment of administrative fellowships in other specialties. PMID- 10161213 TI - You have the job you wanted--now what? AB - We've had calls from physicians who finally have the medical management job they always wanted and then a month later they wondered why they wanted it. I asked seven physician executives to come together as a group and talk to me about this issue. I also asked them what skills they needed most when they first got the job and, as time passed, which skills continued to be most useful. I have not used their names because they were open enough to talk about some very sensitive issues. PMID- 10161214 TI - Surviving a new CEO. AB - In the emerging era of integrated networks and alliances, as health care entities merge and re-form themselves, changes can be expected in management teams, particularly at the top. For those in senior management positions below the CEO, these times are fraught with peril. A new leader can frequently mean a new team. And in many cases, the best advice is to move on. But how can a manager navigate these treacherous waters, so that the decision to leave or stay belongs to the manager and not to the new leadership. In this regular column of the journal, the author offers some advice on what is apt to become a recurrent issue. PMID- 10161215 TI - Dr. Augusto Ortiz: recipient of the Robert F. Allen Symbol of H.O.P.E. Award. PMID- 10161216 TI - Material contribution--the supply side of a Great Comeback. PMID- 10161217 TI - Guidelines for the role of the clinical director of anesthesiology. The Association of Anesthesia Clinical Directors. PMID- 10161218 TI - Repetitive strain injury: an overview of the condition and its implications for occupational therapy practice. AB - The incidence of occupationally induced upper extremity disorders, often referred to as Repetitive Strain Injury (RSI), has increased dramatically in the last decade. An overview of recently published literature is presented which discusses economic impact, etiology, and historical and sociopolitical factors influencing these conditions. A number of prospective studies which conceptualize RSI as a complex biopsychosocial phenomenon framed within a chronic pain model offer some insights into the importance of a multidisciplinary, multifactorial approach to treatment. Opportunities exist for occupational therapists to make a significant contribution to enhancing the health of the worker in the workplace through participation in a team approach to treatment and in health promotion through workplace education with a view to prevention. PMID- 10161219 TI - 94 years old--and still practicing. PMID- 10161220 TI - The medical director and company liability beyond the insurance policy. PMID- 10161221 TI - Prepare and be a good witness. PMID- 10161222 TI - Who should lead in the NHS? AB - Until recently, health care was regarded in the UK as something exception, and distinct from the world of business. In the last few years, the vocabulary of the health market has changed beyond recognition. Very rapid changes are taking place in the NHS and the service is being fragmented. New relationships are emerging and new roles are being created. Argues that it is becoming evident that the new reforms are not understood clearly by those who are charged with carrying them out, and that as a consequence of all these and other factors, the workforce is confused and demoralized. There is a need for leadership to help people cope. Concludes that the professionals, not managers, are best equipped to provide this leadership. PMID- 10161223 TI - Doctors in management or the revenge of the conquered. The role of management development for doctors. AB - Takes a historical perspective on the role of doctors in management, using this approach as a way of describing the current situation and the problems inherent in doctors as managers without appropriate training. Describes the changes occurring in the attitudes of doctors following participation in management training programmes and the importance of encouraging doctors to continue to participate in such programmes designed specifically for their needs. PMID- 10161224 TI - The expanding role of ICU medical directors: from patient management to unit management. AB - Over the past three decades the focus of physicians delivering intensive care has been on patient management whereas the management of critical care units has been done primarily by nurses. This article reviews existing literature and the arguments supporting a more active role for physicians in the management of critical care units. PMID- 10161226 TI - AHRA gold award. Three members to receive highest honor. PMID- 10161225 TI - Defining the role of the physician manager through ethics. PMID- 10161227 TI - Radiology uses of the Internet. AB - The Internet promises to be an essential resource for radiology administrators. In addition to offering remarkable access to colleagues all over the world, the Internet offers specialized information resources for radiology, many of which are described in this article. The Internet is many networks that communicate with each other and whose general purpose is to share information. Although there are several consortium organizations that support and regulate it, no single body or organization "owns" the Internet. Many employees and students at large teaching centers already have access to the Internet through their institution's connection. Individuals and small institutions can contract with independent service providers for Internet access. Internet functions covered in this article include: e-mail, listservs, newsgroups, file transfer protocols, Gopher, and the World Wide Web. The rapid pace of information exchange is making the world of radiology smaller and more intimate. Communication and knowledge are becoming so accessible that individuals are privy to the most minute happenings in the industry. Sharing information on the Internet will benefit not only individual users and the industry, but also patients. PMID- 10161228 TI - Finance. Multiple division. PMID- 10161229 TI - A journey into program management: clinical perspectives. AB - Facing restraint and reform agendas, our healthcare system is undergoing profound changes. This article outlines key clinical issues encountered in the journey from a management-by-functional-departments approach to a program management approach. The author relates his experience as a program director in the traditional system, through a transition year, and then "going live" with program management as the clinical director of a new grouping of services. PMID- 10161230 TI - Ascendancy of primary care will create role intensification for physician executives. AB - The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensified. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented. They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians accommodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive. PMID- 10161231 TI - Hospital preparedness for chemical accidents: the effect of environmental legislation on health care services. AB - BACKGROUND: Chemical accidents occur often across the United States, endangering the health and safety of many people. The Superfund Amendments and Reauthorization Act of 1986 (SARA) requires that communities increase their planning for medical response to these accidents. So far, little evidence has come forth that supports the notion that environmental legislation, such as SARA, improves preparedness for such accidents. METHODS: A one-group pretest/post-test longitudinal design was used to survey the medical directors of emergency departments in all acute care hospitals in the State of New York. Data were collected by mail survey and telephone follow-up in 1986 before the passage of SARA (Time1), and in 1989 after its implementation (Time2). RESULTS: Ninety-four percent of the directors responded at Time1 and 72% at Time2. In New York State, hospital preparedness for chemical accidents improved significantly during the study interval. The longer a hospital had a plan for response to chemical accidents, the more elements of preparedness were in place. Further, as a group, the hospitals that were the least prepared were located in the areas at highest risk. CONCLUSION: Environmental legislation can influence the manner by which health care organizations prepare for environmental emergencies. PMID- 10161232 TI - Catching the wave at its crest. AB - Leland Kaiser, PhD, a long-time member of the ACPE faculty, describes opportunities in terms of surfers. Many smaller and insignificant waves will appear before the surfer senses "the big one." The knowledgeable and skilled surfer will distinguish these small waves (mere fads in management terms) from the real one (a significant trend for the medical manager). If the surfer catches the big wave before its crest, there is a formidable danger of being too far in front and being crushed by it. If the surfer misjudges the wave and starts behind the crest, the wave will leave the surfer behind. It is only by catching the wave at or near its crest that the surfer has a chance for a long and exciting ride. And, of course, even having judged the wave perfectly, there is no guarantee of success. The surfer must still use his or her skills with daring and precision if the ride is to end in the calmer waters of the shore and not in the toss and tumble of a spill. PMID- 10161233 TI - The changing role of physician executives. AB - Throughout the nation, physician executives are taking on new and emerging roles from brokering the purchase of information systems and creating managed care networks to functioning as systemwide consultants, facilitators, and educators. This article offers profiles of eight creative physician executives-including their current roles and responsibilities, recommendations for emerging physician executives, and forecasts for the years ahead. PMID- 10161234 TI - Making a match: inexperienced physician executives and the job market. AB - Hospitals and other health care organizations are adding physician executives at such a rate that demand is outstripping supply-there are more opportunities for seasoned physician executives than there are physicians with track records as medical managers. It is possible that hiring management will have to consider the employment of a physician who wants to be in management but has no track record as a physician executive. In some cases, it may even be preferable to employ a neophyte physician executive, especially when the physician is a respected clinician already on the organization's medical staff. In selecting such a physician, however, an evaluation must be made of the probability that the physician will be successful in the new role. The author points to 10 criteria that the hiring organization should observe in hiring inexperienced managers. PMID- 10161235 TI - Wanted--seasoned veterans. Diamonds in the rough need not apply. AB - Health care organizations looking for physician executives prefer seasoned veterans--doctors who have already done the job. They want job-specific experience. Most organizations do not provide training grounds and orderly career ladders for aspiring physician executives. The Permanente Medical Groups, Family Health Plans, and some very large group practices are exceptions, but, for the most part, rising medical directors in these organizations stay with them. Most hospitals are not large enough to have associate or assistant medical directors or an environment that could provide a training ground for rising physician executives. On the other hand, hospitals, larger group practices, health insurance companies, and managed care organizations provide ample opportunities for nonphysician managers to train, gain experience, and climb the ladders. How can the novice physician executive break into the world of management and begin establishing management credentials? The author provides some key steps that can lead to success. PMID- 10161236 TI - In-house recruiters: on the inside looking out. AB - Few smaller hospitals or managed care companies have in-house physician recruiting departments. Their low hiring volume simply doesn't support such an operation. But most health systems and large managed care organizations say they literally couldn't afford to be without an internal system for the recruitment of physician executives and other health care professionals. They also claim they can find a better candidate faster than their counterparts on the outside. A number of them explain why. PMID- 10161237 TI - Health care downsizing: a survival guide. AB - One would be hard pressed today to find a profession that has not experienced the effects of downsizing. Health care management is no exception. Although physicians were once regarded as relatively safe from layoffs, it is now estimated that "at least" 10 percent of physician executives will fall victim to health care downsizing in 1995. Furthermore, with a 14.3 percent turnover rate of hospital CEO positions in 1994, reversing a two-year drop, health care downsizing appears to be on the upswing. This article analyzes downsizing in the health care industry and gives some advice on how physician executives can deal with it successfully. PMID- 10161238 TI - Physician executive contracts: negotiating the future. AB - Once viewed as a matter of standard protocol, physician executive contracts have become as complex as the health care industry itself. Historically, hospital administration and physicians negotiated a few key points, then sent the ideas to an attorney for insertion of standard legalize and boilerplate. Today, physician executive contracts are an important part of the changes in health care. They not only cover traditional hospital and physician relations, but increasingly apply to new types of relations (such as employment) between hospitals and physicians, physicians and physicians, and health plans and physicians. In this article, we will explore both the "content" and the "context" of physician executive contracts. Content will deal with the specific provisions typically included in contracts. Context will address issues associated with preparing for and negotiating a contract. PMID- 10161239 TI - Stress: a major problem for physician executives. PMID- 10161240 TI - Planning your career after retirement. AB - As a physician executive plans the steps of his or her career, some emphasis should be placed on what is to happen at the end of the professional career. At some point, everyone has to consider retirement plans, and the earlier they begin, especially for financial considerations, the better. In the following article, a member of the College and of its faculty discusses how this process might be initiated. The advice is augmented by information the author obtained in interviews conducted with others who have begun to give retirement some thought or who have already sailed into this aspect of their lives. PMID- 10161241 TI - Job analysis. Equipping therapists to deal with the increasing number of work related injuries. PMID- 10161242 TI - A tribute to leadership: Maggie Kuhn. PMID- 10161243 TI - Potential cost savings using GnRH agonists as preoperative therapy for uterine leiomyomas. AB - Women with large uterine leiomyomas traditionally have had just one choice for therapy--abdominal hysterectomy. Recently, gonadotropin-releasing hormone (GnRH) agonist therapy has been introduced as an option to shrink tumors before surgery. When administered preoperatively, usually for 2 months, GnRH therapy has been shown to reduce tumor size enough to permit an endoscopic myomectomy or a vaginal hysterectomy. It has also been shown to reduce blood loss associated with the tumors and increase hemoglobin levels. When assessed for its economic impact, preoperative GnRH therapy reduces both direct and indirect costs associated with a hysterectomy. PMID- 10161244 TI - Healthcare architecture re-formed. PMID- 10161245 TI - Excellence honored--1995 Governance Award winners. PMID- 10161246 TI - Medical practice and physician executives face the uncertain future. Strategic stakeholder management III. AB - This article, third in a series addressing stakeholder management, presents preliminary findings of Round Two data from the "Facing the Uncertain Future" study. One purpose of this study is to determine how experts define key stakeholders of medical group practices now and how these stakeholders might change by the year 2000. This analysis highlights a comparison of two expert panels: medical practice executives (MPEs) and physician executives (PEs). The purpose was to ascertain whether or not MPE and PE perspectives for the present and predictions for the future differed on a series of key issues. The key issues discussed are: organizational goals, who will be responsible for managing the organization towards these goals, assessment of the external environment and identification of key stakeholders. MPEs and PEs, with the exception of the physician manager and several current organizational goals, view the present similarly and also showed convergence in their predictions for 2000. Despite different training and career experiences, our analysis found that MPEs and PEs view the present and future in surprisingly similar ways. As a result, MPEs and PEs are encouraged to be less preoccupied with perceived differences in perspective and, instead, focus their energies on developing clear strategies and specific tactics to strengthen their organization's position in this turbulent environment. PMID- 10161248 TI - Prehospital communications during the Loma Prieta earthquake. AB - INTRODUCTION: On 17 October 1989, the Loma Prieta Earthquake shook the San Francisco Bay area, home to more than 6 million people. This study examined the effectiveness and function of emergency medical services (EMS) communications after this event. METHODS: The six Bay area counties most affected by the Loma Prieta Earthquake were surveyed using a 156-part questionnaire. This study examined the functioning of the primary 9-1-1 county dispatch centers. Paramedics involved in a set of defined activities during the period after the earthquake also were surveyed. Emergency medical services directors also were questioned by telephone using an interview tool developed for this purpose. All areas concerning disaster response were not queried. Ten specific areas were considered, including: 1) preparation for disaster; 2) the impact of the earthquake; 3) reconnaissance; 4) call volume; and 5) others. RESULTS: Coordination among the various agencies responsible for disaster response and mitigation needs more study. Uniform response plans for medical mutual aid need development. Government support similar to police and fire department arrangements for mutual aid are not in place. Additional planning and training for disasters at all levels need reassessment. The communication-center personnel indicated that they did not call for more resources, but instead accepted volunteers at dispatch centers and extra assistance. Once engaged, however, most communications centers (CCs) had great difficulty tracking and controlling all the units under their jurisdiction. In some large urban counties, some ambulances were idled awaiting calls but lost their communications centers, while other ambulance personnel were trying to handle multiple patients and requests for services. CONCLUSIONS: Significant help from a state or federal agency likely will be unavailable for a substantial period after a catastrophic regional event. Important coordination among EMS agencies for disaster response is poor or absent. Although fatalities and casualties were limited compared to what could have occurred, great confusion reigned for varying periods of time after the earthquake. Communications among local agencies, counties, and the state were problematic. Information flow to hospitals was cited frequently as a problem, making it difficult for hospitals to prepare adequately. Medical mutual-aid help was disorganized and inadequately controlled. The training of personnel and the method of recall for disaster response need to be examined. PMID- 10161247 TI - Cost of treatment and prevention of Haemophilus influenzae type b disease. An international perspective. AB - On the basis of immunogenicity and protective efficacy studies, 4 Haemophilus influenzae type b (Hib) conjugate vaccines have been licensed for administration to infants and children. Population based studies of Hib disease from Australia, Chile, Finland, Gambia, Israel, Switzerland, UK and US show that the relative and absolute incidence of Hib disease varies significantly. These differences in Hib epidemiology, and associated sequelae and hospital costs affect the cost-benefit analysis of preventive vaccination, necessitating unique calculations for each country. Published papers on the cost of Hib disease and the cost-benefit relationship of Hib vaccination have been based primarily on reports from the US, but more recently also on studies from Australia, Finland, Israel, Switzerland, UK, Sweden and Chile. All studies to date have produced favourable cost-benefit ratios. The implementation of Hib vaccination has led to the virtual disappearance of Hib disease in some of these countries. The lessons gained from these analyses are instructive not only for better understanding of the epidemiology of Hib disease, but also as a template for assessing the cost benefit ratio of the implementation of preventive vaccination for other diseases. PMID- 10161249 TI - Medical director for air medical transport programs. Air Medical Committee, National Association of Emergency Medical Services Physicians. PMID- 10161250 TI - AAMA forms division for home-care execs. PMID- 10161251 TI - Vital signs records omissions on prehospital patient encounter forms. AB - INTRODUCTION: A reported in-field, prospective evaluation of 227 prehospital patient assessments by advanced life support (ALS) emergency medical technicians (EMTs) found a frequent failure to measure vital signs. The objective of this retrospective review was to report the omission frequency of vital signs found in a centralized emergency medical services (EMS) data collection system. METHODS: The EMS database contained information from 90,480 optically scanned, prehospital patient encounter forms. Each record identified EMT skill levels, response times, dispatch type, vital signs, medical and trauma information, treatment, and patient disposition. Records for 1989 and 1990 were collected from 92 rural EMS providers who responded to emergency medical and trauma events. RESULTS: Of 90,480 emergency responses, 14,129 (15.6%) were false alarms, deceased, or canceled without vital patient contact. Valid encounters were documented for 76,351 (84.4%) patient contacts. Systolic blood pressure measurements were not recorded for 13,262 (17.4%) patients. Diastolic blood pressure was not recorded for 14,272 (18.7%) patients. A pulse record was not recorded for 12,125 (15.9%) patients. A ventilatory rate was absent in 12,958 (17.0%) patient records. CONCLUSION: This study found a frequent failure by non-metropolitan basic life support (BLS) and advanced life support (ALS) EMTs to record vital signs on prehospital emergency patient encounter forms. It supports a previous report of direct in-field observations of ALS EMTs failing to measure vital signs during patient assessment. The impact of vital sign omissions upon individual patient care can be assessed only by receiving medical control physicians. In the absence of effective emergency physician networking, the statewide magnitude of the problem among BLS and ALS EMTs has not been recognized as a system issue. PMID- 10161252 TI - SARA three years later. Emergency physician's knowledge, beliefs, and actions. AB - OBJECTIVE: Investigate Emergency Physicians' knowledge about the Superfund Amendments and Reauthorization Act (SARA) Title III legislation, passed by the United States Congress in 1986, and to determine the factors contributing to their level of preparedness in dealing with patients exposed to toxic chemicals. METHODS: A 115-item questionnaire was mailed to the medical directors of all emergency departments (EDs) in the State of New York. The results of the cross sectional survey were analyzed using standard statistical methods. RESULTS: One hundred and eighty-seven (72%) of the directors of EDs in New York State responded to the survey. Three years after SARA was enacted, only 33% of the directors had heard about this legislation. Only 18% had been invited to attend the meetings of the Local Emergency Planning Committees (LEPC). Sixty percent of the directors knew whether or not the LEPC had devised plans that defined a role for their EDs in responding to environmental emergencies. This knowledge about community planning mainly had an effect on preparedness of the EDs. Preparedness also was predicted by how recently the EDs had treated patients exposed to toxic chemicals, the perception that emergency physicians had a legitimate role in planning for and responding to chemical emergencies, and how often emergency physicians had attended continuing education courses about hazardous materials. CONCLUSION: Despite the finding that some emergency physicians are involved in community preparations, two main problems persist in planning a medical response to environmental emergencies. First, the ED directors generally are unaware of the legislation that mandates these preparations and are not interacting with community planners. Second, there is not full involvement by the local EDs in the LEPC planning efforts. RECOMMENDATIONS: A procedure is needed to disseminate information about legislation which affects emergency physicians, such as SARA, and about regional planning for environmental emergencies. Dissemination should include education about the professions' role in planning for and providing care for patients exposed to toxic chemicals. PMID- 10161254 TI - How is the medical director's role evolving in LTC? PMID- 10161253 TI - Exec on a mission to aid poor children. PMID- 10161256 TI - Medical directors and their crucial role in network success. PMID- 10161255 TI - Halotherapy for treatment of respiratory diseases. AB - This work elucidates the questions upon the development of a new drug-free method of a respiratory diseases treatment. Halotherapy (HT)--is mode of treatment in a controlled air medium which simulates a natural salt cave microclimate. The main curative factor is dry sodium chloride aerosol with particles of 2 to 5 mkm in size. Particles density (0.5-9 mg/m3) varies with the type of the disease. Other factors are comfortable temperature- humidity regime, the hypobacterial and allergen-free air environment saturated with aeroions. The effect of HT was evaluated in 124 patients (pts) with various types of respiratory diseases. The control group of 15 pts received placebo. HT course consisted of 10-20 daily procedures of 1 hour. HT resulted in improvements of clinical state in the most of patients. The positive dynamics of flow-volume loop parameters and decrease of bronchial resistance measured by bodyplethysmography were observed. The changes in control group parameters after HT were not statistically significant. The specificity of this method is the low concentration and gradual administration of dry sodium chloride aerosol. Data on healing mechanisms of a specific airdispersive environment of sodium chloride while while treatment the respiratory diseases are discussed. PMID- 10161257 TI - Role of the medical director/chief medical officer in managed care organizations. PMID- 10161258 TI - A manager's role in facility planning, design. PMID- 10161259 TI - Falsely low calcium measurements after high volume plasma exchange in a patient with liver failure. AB - A 63-year-old male with lactic acidosis secondary to fialuridine-induced liver failure underwent seven plasma exchanges while awaiting orthotopic liver transplantation. Following plasma exchange, total serum calcium concentrations measured by conventional clinical chemistry methods were significantly lower than the elemental calciums determined by atomic absorption spectroscopy (P = 0.004). The difference in calcium measured by atomic absorption and by conventional methods correlated with serum citrate concentration (R = 0.77) Following the first exchange, the serum lactic acid concentration decreased from 10.2 to 4.4 mmol/L. These results suggest that plasma exchange may aid in the removal of metabolic products such as lactic acid in patients with liver failure. However, the accumulation of unmetabolized citrate may also result in falsely low total calcium measurements in some patients who undergo plasma exchange. PMID- 10161260 TI - CHEM profile: Frank Mozdy, HEM. PMID- 10161261 TI - The 1995 FM Award for Humanitarian Service presented to Melodie Wilkey for recruiting hunger campaign volunteers. PMID- 10161262 TI - The 1995 FM Honorable Mention for Humanitarian Service presented to Steve Scranton for involvement in community anti-hunger efforts. PMID- 10161263 TI - Berlanga honored with first THA Advocacy Leadership Award. PMID- 10161264 TI - Where the reforms did not reach: doctors as front line managers. AB - The importance of the behavioral dimension of the management of front line teams in the health service has been neglected both in the training of doctors and in the recent reforms of the health service. Drawing on three case studies carried out by doctors, explores the influence of the level of understanding of behavioral factors in determining the effectiveness or ineffectiveness of management at this level. Concludes by considering some implications of the discussion for giving a more central place to these factors in the selection, training and promotion of doctors. PMID- 10161265 TI - The charge nurse. Making a difference to patients. PMID- 10161266 TI - 1995 salary survey results. Flexibility a formidable weapon in health care battles. PMID- 10161267 TI - Developing the doctor manager: reflecting on the personal costs. AB - These reflections focus on the development of doctors as managers in the National Health Service and the way that their participation is directly influenced by the personal costs perceived to their professional roles as doctors. Research has indicated some of the problems surrounding the development of doctors as managers. Although training has led to a reduction in stress, women doctors are having to contend with a glass ceiling which is double and even sometimes triple glazed, team development is not being addressed adequately, and succession planning is occurring by default rather than design. The application of domain theory to the issue can provide some guidance for the organisation, but as individual organisations like hospitals interpret these changes in a unique way, it is suggested that the key training for the future will need to focus on transition skills between organisations, and will require interpretive and adaptive responses from both doctors and managers if they are to continue to collaborate successfully in the managerial domain. PMID- 10161268 TI - Promoting audit in primary care: roles and relationships of medical audit advisory groups and their managers. AB - OBJECTIVES: To investigate perceptions of family health service authorities and medical audit advisory groups of advisory groups' involvement in clinical audit and wider quality issues; communication with the authorities; and manager satisfaction. DESIGN: National postal questionnaire survey in 1994. SETTING: All family health services authority districts in England and Wales. SUBJECTS: Chief executives or other responsible authority officers and advisory group chairpersons in each district. MAIN MEASURES: Priorities of advisory group and authority for audit; involvement of advisory group in wider quality issues; communication of information to, and contacts with, the authority and its involvement in planning the future work of the advisory group; and authorities' satisfaction. RESULTS: Both groups' views about audit were similar and broadly consistent with current policy. Advisory group involvement in wider quality issues was extensive, and the majority of both groups thought this appropriate. Much of the information about their activities collected by advisory groups was not passed on to the authority. The most frequent contact between the two groups was the advisory group's annual report, but formal personal contact was the most valued. Most authority respondents thought their views had been recognised in the advisory group's planning of future work; only a small minority were not satisfied with their advisory groups. Dissatisfied respondents received less information from their advisory groups, had less contact with them, and thought they had less input into their plans. There was some evidence that advisory groups in the "dissatisfied districts" were less involved in clinical audit and with their authorities in wider quality issues. CONCLUSIONS: Most advisory groups are developing their activities in clinical audit and have expanded their scope of work. The quality and availability of information about progress with audit is a cause for concern to both groups. PMID- 10161269 TI - Medical directors now play a leading role. PMID- 10161270 TI - PHOs are "training wheels" for PSN direct contracting. PMID- 10161271 TI - Pandora's Box: clinical directorates and the NHS. AB - Reports on the research concerning the current debate surrounding the maturity of clinical directorates. Indicates that there is some ambiguity as to how directorates should be structured and strategically managed. Finds evidence that trust executive boards need to involve clinicians in setting strategy and to support clinical directors with suitable business managers to manage the boundary between strategic and operational issues. PMID- 10161272 TI - No longer a solo practice: how physician leaders lead. AB - The authors conducted a national study to determine the factors associated with the success of physician leaders. They utilized the Leadership Practices Inventory (LPI) and a demographic survey followed by individual interviews with respondents. Data analysis revealed several implications for the selection, training, management, and career development of physician leaders. The results suggest that: Physician leadership training should have a strong focus on the "human side" of management, including negotiation, organizational "politics," conflict resolution, team building, and motivation. Data management and finance should be a focus represented in the curriculum. Mentoring relationships should be developed as an aspiring physician leader pursues a career shift. Self assessment, including an analysis of style, strengths, best potential organizational fit, and specific areas of strength and weakness should be an integral part of the development of an aspiring physician leader. Screening mechanisms to ascertain a physician's motivation to move toward a full-time leadership role should be developed to ensure appropriate intent. To facilitate this implication, more effective assessment tools need to be developed. PMID- 10161273 TI - Physicians in transition. AB - The study of physicians as managed care executives has been relatively recent. Much of what was written in the past focused primarily on doctors who had taken hospital-based administrative positions, especially as medical directors or vice presidents of medical affairs.1 But the '80s brought rising health care costs and the emergence of the "O's"--HMOs, PPOs, UROs, EPOs, PHOs, H2Os, and Uh-Ohs--in response. It also brought a growing number of physicians who traded their white coats and their particular "ologies" for the blue suits of executive management. I am convinced that it is important now, and will be increasingly important in the future, to better understand that transition. That belief led me to undertake, with the help and support of ACPE, the survey that is reported in this article. A questionnaire was sent in 1994 to a random sample of 300 managed care physician executive members of ACPE. Responses were returned by 225 members, a response rate of better than 80 percent. Twenty-five of the responses were not applicable, having been returned by physicians who had never made a transition from clinical careers. The remaining 230 responses form the basis for this report. PMID- 10161274 TI - The purpose of a job interview is a job offer. AB - Perhaps empathy has been overdone in recent years. Most of us would admit to some cynicism or disbelief when we hear the words, "I know how you feel." Having said that, however, I actually do know how you feel. If I can't identify exactly where you are coming from, I do know where you are likely to be going and how bumpy the ride is likely to be. I'm a physician and a physician executive. I am also an executive search consultant who is daily in the field interviewing physicians who may or may not be the right individuals for a client's situation. If I don't exactly feel your pain, at least I know its sources. I know how difficult it is to make the move from challenging clinical work to an administrative role in health care. While, as a group, physicians are multiskilled and multitalented, it's an unfortunate fact that some of the skills and talents that made you an excellent physician may be blocking you from succeeding in an executive capacity. My hope is that, through an occasional entry in this column, I can share my experiences and relate the remarkable wisdom of the impressive physician executives whom I meet every day. The first issue I'm opening up for discussion is employment interviewing: Why the interview is so important, what the interviewing process is, and how you can become more adept in this critical skill area. PMID- 10161275 TI - Seven deadly assumptions for new physician managers. AB - You've just been, or are about to be, named to a management position, your first. Success will not be easy, but it can be achieved. Just avoid seven common assumptions that are the chief culprits in the demise of many a physician executive: All human beings make rational decisions, so the way to resolve conflicts is by giving people more data. Clinical teams are the same as management teams. Your new title confers all the decision-making authority, trust, and power needed to do the job. Bedside communication techniques are the same ones used in the board room. A financial statement is pretty much the same as a checking account statement. There are no politics in management. Just reading every important management text will make you a great manager. PMID- 10161276 TI - Career file. Mary O'Shea. PMID- 10161277 TI - This physician wears many hats. Interview by MargaretAnn Cross. PMID- 10161278 TI - Developing real and "virtual" medical groups: governance, compensation, capital, and culture are the keys. PMID- 10161279 TI - Common mistakes in physician practice acquisition and compensation and how to avoid them. PMID- 10161280 TI - 1996 Almanac. State EMS directors. PMID- 10161281 TI - Will state licensing boards become managed care's police? AB - Physicians might win back some lost autonomy if every ?No? decision from an HMO medical director were subject to review by a state medical licensing board. But views differ on whether the boards should undertake such oversight responsibilities. PMID- 10161282 TI - Physician organizations positioned to take on managed care. PMID- 10161283 TI - CEO behavioral pattern expectations for physician executives. AB - This is a report on the second part of a two-stage survey. The first part of the survey, reported in the Nov. 1994 issue of Physician Executive, dealt with physician executive behavior tendencies as viewed from the perspective of physicians, largely in hospitals. In the follow-up portion of the survey, the views of hospital CEOs on this subject were sought. CEOs were also asked for their views on the roles of physician executives and on what they were seeking in physician leaders. CEOs were asked to assess these issues in terms of the ideal physician executive, not the persons currently holding such positions in their organizations. Finally, this second report draws on the results of both parts of the survey in order to make comparisons between the views of the two groups of managers. PMID- 10161284 TI - Bringing reality to the job hunt process. Interview by Barbara J. Linney. AB - A substantial percentage of the positions that open in medical management are filled through the use of recruitment firms. This is especially true of more senior positions, but it applies across the full spectrum of openings. If the working arrangement between the recruitment firm and the potential candidate is to be effective, certain key ingredients are necessary. The author interviewed a selection of principals of recruitment firms that operate extensively or exclusively in the medical management sector of executive recruitment. What she discovered about their "wish lists" for candidates' characteristics and levels of job hunting sophistication are summarized in the following statements. PMID- 10161285 TI - 1996 Trustees of the Year. Utah trustee was born to serve. PMID- 10161287 TI - Doctors in management. What's at stake? PMID- 10161286 TI - 1996 Trustees of the Year. There's no stopping Maine trustee. PMID- 10161288 TI - Crafting the new physician executive. AB - We are at the beginning of a new revolution that will redefine work, the organizations in which the work gets done, and the relationships among organizations. The future for physician executives is imbedded in the phenomenon of such fragmentation and change. As a result, a new class of physician executives is emerging. The physician executive of the future will be an information builder, a visualizer, and a strategist--among other things. PMID- 10161289 TI - The evolution of the VPMA (vice-president, medical affairs). AB - In the past, the VPMA's role was clearly defined. So were the skills required to do the job. Initially VPMAs served an inside role in an organization as the liaison with the medical staff and the hospital administration. That role has matured and is currently evolving. Ultimately the expansion of the VPMA role will provide alternative career directions for physician executives. The wise physician executive learns from those who have knowledge--or who are in the process of acquiring it. That means keeping an eye on active managed care markets nationwide for trends that may be coming to his or her locale. The physician who does not do this kind of professional introspection and evaluation of the national market may find him- or herself professionally behind the curve. PMID- 10161290 TI - Designing the future: physician poll rates the trends. AB - A recent interactive electronic poll of 160 physicians attending an educational conference at ACPE's Future Forum reveals some opinions physicians have about the transition of medicine into the 21st century. Emerging issues include capitation, quality, law, and how to manage integrated delivery systems. Overall, respondents are concerned about remaining solvent is a capitated managed care environment. PMID- 10161291 TI - Managing the media: pointers from the pros. Interview by Donna Valvala. PMID- 10161292 TI - The politics of being an "Acting". PMID- 10161293 TI - A "new-age" leader. PMID- 10161294 TI - How to steer your case management program through tumultuous mergers. PMID- 10161295 TI - Why will physicians in this new environment replace MHAs? AB - The competitive forces of managed care, capitated payment, cost constraints, and the formation of health networks are among the major precipitating factors leading to the employment of additional executives and middle managers with clinical backgrounds. These factors will require our health leaders to know how to cut costs without seriously impinging on the accessibility and quality of patient care. Physicians with leadership and management skills, and with prior hands-on patient care expertise, will continue to be sought after in the foreseeable future by various types of health organizations. With this scenario, health services management generalists are predicted to experience increasing difficulties to secure senior positions in the health industry, PMID- 10161296 TI - Will physicians replace MHAs?: reflections from Australia. AB - Tom Weil, in the preceding article, sees the physician executive playing an increasingly significant role in negotiations between payers and service providers, in offering the public acceptable explanations for the inevitable changes in the provision of care, and in developing more cost-effective methods of delivering high-quality health care at affordable prices. Effective involvement of physician executives will be facilitated by their having received professional training somewhat different from that of the traditional MHA. How do these prognostications relate to the health care scene in Australia? Factors that must be taken into account in considering their applicability to Australia include differences in the structure and management of the Australian health care system, the current state of that system, the background of the leadership that makes the key managerial decisions in the Australian system, and emerging trends within the system. PMID- 10161297 TI - Medical staff handling of concerns with physicians' performance. AB - Medical staff organizations and their leaders are frequently confronted with concerns about physician knowledge, performance, or behavior. Dealing with these concerns is a serious and time-consuming task. Poorly handled issues may result in serious legal consequences. In highly structured organizations, authority for responsibilities, income, and employment rests with individuals who must manage these problems, but medical staff structures do not always lend themselves to dealing with these issues. Introduction of quality improvement processes into medicine has been received as a panacea for physician problems. Certainly the majority of physicians understand quality improvement and work toward common goals to improve patient care. Unfortunately, a small minority remain problem physicians. Steps that can be taken to deal with problem physicians, particularly for issues of quality management, are described in this article. PMID- 10161298 TI - Seven lessons in medical management. AB - In more than 15 years of functioning as a medical director, addressing the needs and wants of patients, physicians, hospitals, and ancillary health care suppliers, I have accumulated pieces of ?wisdom? that I now feel I should share with others in medical management. The concepts are fairly simple, but they are of significant value in the ?real-life? management of people. The seven simple ideas outlined in this article are not meant to be the end-all to management philosophy. Books have been written about each idea, and there are hundreds of good ideas in many sources I do not touch on here. However, I have found these seven items of significant value in dealing with others and hope others find them similarly useful. PMID- 10161299 TI - Career Rx: counsel on a "hairy" subject. PMID- 10161300 TI - Should you use an executive temporary? PMID- 10161301 TI - Many chief information officers will be physician executives. PMID- 10161302 TI - Will this verdict chill hospital-medical staff relations? PMID- 10161303 TI - How to hire a medical director. PMID- 10161304 TI - The real reason a prestige hospital hired me. PMID- 10161305 TI - The clinical side: the roles of physicians. Physician executives. PMID- 10161306 TI - Applying profit centers to the management of cardiology practices. PMID- 10161308 TI - Rising from the ashes: the aftermath of being fired. Interview by Barbara J. Linney. PMID- 10161307 TI - Clinicians as managers: organisational change at the Illawarra Regional Hospital. AB - In 1990 a decision was made to merge the Port Kembla (160 beds) and Wollongong (290 beds) Hospitals into the Illawarra Regional Hospital and to change the traditional functional management structure to one of product line institute management, with medical officers as part-time clinical directors. This transformation in health care management had been occurring in other sections of the Illawarra Area Health Service, with medical directors of programs and with allied health and nursing heads of departments throughout the system. A survey was conducted among 22 clinician managers for their impressions of the 'new' management organisation. The respondents felt that the change had been a positive one and that it had particularly improved communication and accountability among clinicians. PMID- 10161309 TI - Stay and fight or cut your losses? PMID- 10161310 TI - Born to teach: Louise E. Casey, C.E.H. PMID- 10161311 TI - Building partnerships: the physician executive's role. PMID- 10161312 TI - Dysphagia diets: the state of the art. PMID- 10161313 TI - Managing relationships in the hospital. PMID- 10161314 TI - 1996 Health Care Hall of Fame. Edwin L. Crosby, M.D. PMID- 10161315 TI - 1996 Health Care Hall of Fame. Sister Irene Kraus. PMID- 10161317 TI - 1996 Health Care Hall of Fame. Walter McNerney. PMID- 10161316 TI - 1996 Health Care Hall of Fame. Richard Stull. PMID- 10161318 TI - Hospital president named Young Executive of '96. PMID- 10161319 TI - 1996 GHA Distinguished Service Award: Charles Eberhart: "An outstanding leader, a caring person and a very special friend". PMID- 10161320 TI - The changing role of physicians in hospital governance. PMID- 10161321 TI - Changing hats: reflections on patients and patience. PMID- 10161322 TI - Excellent communication skills required. PMID- 10161323 TI - Message from a dinosaur. PMID- 10161324 TI - PHO growing pains. Hospital executives can expect a variety of issues to surface as their PHOs evolve. PMID- 10161325 TI - Cultivating physician talent: 5 steps for developing successful physician leaders. PMID- 10161326 TI - How to write a winning resume. PMID- 10161327 TI - Recognizing conflicts of interest. PMID- 10161328 TI - Stretch your way to a healthier workday. PMID- 10161329 TI - Would some business education boost your career? PMID- 10161330 TI - NHS reforms. Rites of passage. PMID- 10161331 TI - Toward a world-class culture in primary care: reflections on empowerment. AB - It is recognized that in primary care, the staff is at the heart of the healing community. Primary care, which recognizes the wholeness of patients, cannot be successful unless the organizational culture also recognizes the wholeness of the staff. The effectiveness of total quality management (TQM) in an organization depends on a staff that is healthy and whole. This article relates how the creation of a culture that fosters the staff's health and wholeness is the most important factor in the implementation of a TQM program. PMID- 10161332 TI - Junior doctors and management: myth and reality. AB - Uses an empirical investigation based on a survey of junior doctors in five NHS trust hospitals, to examine their attitudes towards both the general principle of clinical involvement in hospital management and the particular prospect of exercising such a role themselves. Finds that junior doctors, with few exceptions and irrespective of grade, were very positive towards clinical management roles in NHS trusts and were almost universally keen to assume management responsibilities when they were more senior. At the same time, finds junior doctors to have little concept of the doctor manager role or the recognized and demanded specific preparation for assuming management responsibilities. PMID- 10161333 TI - Learning from adversity: diary of a medical manager. AB - This article is one physician's account of his experiences in managing a large multispecialty group practice. While he was able to accomplish much in his tenure during the latter half of the 1980s, it was, on balance, a negative experience. He describes both the high and the low points of the period and assesses how both contributed to his eventual downfall. While personal, the account has important implications for others involved in the rapidly changing, personally rewarding, and eminently challenging health car system in which physician executives work. PMID- 10161334 TI - When push comes to shove: implementing VBAC practice guidelines. AB - The dramatic increase in U.S. cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response to this trend, clinical guidelines recommending vaginal birth after cesarean-section (VBAC) have been promulgated by national organizations. Adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate, and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment. To examine implementation of these guidelines by health care organizations, the authors surveyed 156 members of the American College of Physician Executives to determine their policies, practices, and attitudes toward VBAC guidelines. Those surveyed generally were medical directors in HMOs, hospitals, and other practice settings. The findings indicate that the health care organizations represented by these physician executives have not consistently implemented VBAC guideline and that they are reluctant to hold physicians, their patients, or hospitals accountable for the financial, utilization, and quality impact of the elective decision ot to pursue appropriate VBACs. We conclude that, even when widely accepted, clinical practice guidelines may be ineffective in reducing the costs or improving the quality of medical care. PMID- 10161335 TI - Women need to learn the rules of the game to advance in medical management. PMID- 10161336 TI - Factors in successful move to organized care systems. PMID- 10161337 TI - Career file: Christine Burns. PMID- 10161338 TI - Career file: Letsie Tilley. PMID- 10161339 TI - The integration rush: some second thoughts. Interview by Donna Vavala. PMID- 10161341 TI - Career Rx: don't just get a life--write it down! PMID- 10161340 TI - Focus on the fundamentals. AB - What business are we in? Who are our customers? as health care evolves, the answers to these questions become increasingly complex. And as physicians become more involved in the business side of medicine and the business side of medicine becomes more sophisticated itself, we must not forget the fundamentals. Successful business people do not lose touch with the essential concerns of their industry. Future success in the medical marketplace will require physicians and physician leaders to keep in mind what business we are in and who our customers are. This article offers a set of answers to these questions. PMID- 10161342 TI - Vaccination's bicentennial: a surgical landmark. PMID- 10161343 TI - 1996 Silver Plate Award winner. Healthcare. PMID- 10161344 TI - Antiretroviral drugs: new agents, new combinations line up against HIV. PMID- 10161345 TI - A modified collection and rapid infusion system for shed whole blood autotransfusion during aortic aneurysm surgery. AB - We describe our experience in 10 patients (5 males) undergoing resection of a descending thoracic aortic aneurysm or a thoracoabdominal aortic aneurysm in which a modified shed whole blood collection and autotransfusion system was used. This modification allows several options for the processing and autotransfusion of shed blood: use of the cell saving device or the ultrafiltration of collected blood, and the autotransfusion of unprocessed shed whole blood. Either low dose heparin or sodium citrate was used for anticoagulation. All 10 patients underwent autotransfusion and volume resuscitation with the modified rapid infusion device. Total autotransfusion ranged from 1400 ml to 7843 ml. Ultrafiltration volumes ranged from 600 ml to 1100 ml. There were no intraoperative deaths and no patient reoperations for bleeding. Arterial blood gases, potassium, and platelet counts were all within the normal laboratory ranges. This modification enables the clinician to process poor quality shed blood and reinfuse whole blood, in an attempt to decrease the need for homologous blood products. PMID- 10161346 TI - The physician executive: strong medicine or good business? AB - The second generation of physician executives is rapidly displacing the first wave of clinicians who entered the ranks of management. These younger physician managers are on the fast track to success within MCOs, according to the author. PMID- 10161347 TI - Genetic testing: a challenge to the preventive paradigm. PMID- 10161348 TI - The new academic health center hybrids: part business, part academic. AB - Academic health centers have flourished since the 1960s and even managed to survive the shift toward prospective payment. But in their current quest to expand the number of managed care patients and compete with the private sector, they often must price services below cost and reduce the number of faculty members and other personnel. Unless their prices are competitive, managed care companies will not do business with them. AHCs that cannot compete find they are overbedded, underused, and in turmoil. This article explores what successful AHCs are doing to stay healthy in the managed care era. PMID- 10161349 TI - Lessons from the trenches in physician integration. AB - Beyond the theoretical basis for integration, three core considerations stand out as the primary reasons for pursuing integration from a physician's perspective. In the authors' experience, the ability to make a case for physician integration stands or falls based on the ability of the integrated delivery system to address these considerations: Gain greater access to capital; develop human resources with talents in managed care and the full spectrum of care services; and sustain an information infrastructure. This article explores the lessons learned in pursuing physician integration. PMID- 10161350 TI - A physician's view from the Hill. AB - Rarely do physicians have the opportunity to participate in our political system on a day-to-day basis. The Robert Wood Johnson Health Policy Fellowship, a one year program for mid-career medical professionals, provides just such an experience. The Fellows begin with a two- to three-month orientation phase before selecting a congressional work assignment. As a member of a congressional staff, a Fellow has the opportunity to learn from, as well as contribute to, the legislative process. The health policy experience provides another tool to complement the clinical and management expertise of the physician executive. PMID- 10161351 TI - Breaking the rules. PMID- 10161352 TI - New medical director roles emerge as units emphasize medical model. PMID- 10161353 TI - Ergonomics: no longer a fad--now it's a health issue. PMID- 10161354 TI - Do we really want doctors to be managers? PMID- 10161355 TI - Laboratory manager's financial handbook. Cost accounting: the road map to financial success. AB - Cost accounting is the most basic element of the laboratory's financial management structure. Historically, cost accounting in the nonmedical world referred to accumulating and assigning costs to units of production and departments, primarily for inventory valuation and income determination. In the health industry, microcost accounting is distinguishable from macrocost (management/internal) accounting and serves multiple purposes. Microcost accounting pertains to gathering and providing information for decision making. The range of decisions include managing recurring operations, making nonrecurring strategic decisions, and formulating major organizational policies. Macrocost accounting fulfills the legal requirements of reporting to stockholders, auditors, governmental agencies, and other external parties. PMID- 10161356 TI - Leadership of health care networks clarified in revision to intent statement. PMID- 10161357 TI - Riding high. Hospital CEO pay has surged as bonus plans proliferate. Other managers haven't kept pace. AB - Healthcare, the deep thinkers say, is coming more and more to resemble other businesses. For many hospital chief executive officers, that's fine and dandy. Like other corporate chieftains, they're smiling all the way to the bank, according to Executive Compensation Survey data. PMID- 10161358 TI - What to do while things are changing. AB - No longer able to support an entitlement culture, the business of health care is rapidly giving way to a culture of marketability. However, effective career management within a changing professional landscape doesn't have to be nightmare. Physician executives can learn to work with the dynamics and principles of change management to significantly reduce their error rate and increase their chances for success. Using change management strategies and tools effectively is the best way to transform any sense of urgency you may feel into energy, information, and action. This is the optimal time to create a better work environment for yourself, and become a better resource for the community you serve. PMID- 10161359 TI - The physician glut: a different view. Interview by Donna Vavala. AB - An interview with nationally known futurist Leland Kaiser, PhD, on the changes physician executives are likely to face as a result of the coming dislocation in the health professions. Or will there be a shrinking career pie at all? The real question is: What new mental models are we going to use and as a result of the new models, what new jobs are going to be created that will ameliorate some of the surplus we've created in the old model? Dr. Kaiser predicts a model will soon emerge that will open a myriad of new career opportunities for physicians. The new model he foresees is community-based medicine. PMID- 10161360 TI - The new management competencies: a global perspective. AB - How will tighter controls over health expenditures, an increased supply of qualified doctors, and clinical acumen becoming more critical in allocating health resources under market-driven, capitated payment-type plans affect physicians? Throughout the world, they will play a greater role in the management of health facilities and services. To train doctors to provide leadership in these new, more market driven environments, education should focus more on the integration and coordination of clinical and managerial processes, an approach outside the scope of most curricula now offered. New managerial competencies will be required by the paradigm shift away from simply delivering quality health services to tighter cost containment efforts. Physicians will play an increasing role in how medical facilities and services are organized and financed--the blending of clinical and managerial-financial-information science processes will be paramount in these educational pursuits. PMID- 10161361 TI - Will you be ready when the pink slip arrives? AB - Are you prepared to ride the waves of change? Will you be ready when the pink slip arrives? Health care executives who can jump a little higher and run a little faster will go further in the draft. Those of you who are prepared for change will always be appealing to recruiters and prospective employers. How can you ride these turbulent waves and not capsize? This article explores some suggestions for positioning yourself: Proper positioning with the inevitable changes in mind will help you move your career in a forward direction. PMID- 10161362 TI - How do you communicate? Managing the change process. AB - Change is a difficult and emotionally charged issue in any organization. Clear, effective communication is essential to deal with people's fears and expectations. Multiple tools and schools of thought are available to increase organizational effectiveness, including systems theory, TQM, and change management. Physician managers are under the gun to incorporate these ideas and use them to effect organizational change. But the biggest challenge is how to bring the techniques home and put them to use, one-on-one with another person. How can you become a more effective communicator and change agent? The basis for win-win relationships revolves around being aware of how we communicate--not just our words, but our body language and tone of voice. PMID- 10161363 TI - Change happens. PMID- 10161364 TI - Do you have an exit strategy? PMID- 10161365 TI - Will there be a demand for physician executives?. Interview by Barbara J. Linney. PMID- 10161366 TI - "Without question, most of us wish we'd started earlier". AB - Physician leaders and CIOs share what they've learned about implementing clinical information systems. Among their lessons: Link the IS vision with the organization's strategic plan, build in flexibility to accommodate growth, get departments to engage in systems thinking that goes beyond their own areas and, above all, start early. PMID- 10161367 TI - Average physician exec salary tops $180,000. PMID- 10161368 TI - Is this FP a criminal for doing UR? PMID- 10161369 TI - Outcomes assessment in osteoporosis: strategies for improvement. AB - The judicious use of resources in the managed care setting requires that outcomes assessment be used in selecting the most cost-effective alternative strategies for preventing and treating diseases. Osteoporosis has major medical and economic costs and consequences for society, yet the most effective strategies to pursue in reducing these costs and consequences are uncertain. Selecting appropriate screening, preventive, and therapeutic strategies will require careful evaluation of data from clinical trials and from outcomes research in determining the most appropriate course of action. These issues represent a major challenge for the decision maker in the managed care setting. PMID- 10161370 TI - Physician executives report an increase in both job scope and responsibilities due to managed care. PMID- 10161371 TI - Filgrastim. A reappraisal of pharmacoeconomic considerations in the prophylaxis and treatment of chemotherapy-induced neutropenia. AB - Neutropenia is a frequent and often dose-limiting complication of chemotherapy and is associated with considerable patient morbidity and mortality. Standard treatment in patients who become febrile includes hospitalisation and empirical antibiotic therapy. Filgrastim is a recombinant human granulocyte colony stimulating factor (rHuG-CSF). It significantly decreases the incidence of febrile neutropenia in patients receiving standard-dose chemotherapy, and shortens the duration of febrile neutropenia in patients undergoing autologous bone marrow transplantation (BMT) or peripheral blood progenitor cell (PBPC) infusion after myeloablative chemotherapy regimens. These effects are usually associated with a decrease in hospitalisation and antibiotic requirements. The contribution of filgrastim therapy to beneficial effects on other clinically important end-points (e.g. quality of life, tumour relapse rate, and short and long term survival) remains to be accurately determined. Pharmacoeconomic data concerning the use of filgrastim as an adjunct to standard-dose chemotherapy are derived largely from the results of phase III trials. Cost analyses based on hospital charges suggest that the cost of providing filgrastim therapy can be fully recouped if the drug is used as primary prophylaxis in previously untreated patients, for whom the risk of developing febrile neutropenia is at least 40%. Reserving filgrastim for use in patients who have developed febrile neutropenia in a previous chemotherapy cycle may result in further cost savings. However, careful patient selection is required, since potential cost savings will vary depending upon the risk of hospitalisation in the absence of filgrastim treatment. Infusion of filgrastim-mobilised PBPCs is emerging as a preferred strategy in patients receiving myeloablative chemotherapy, and promising results have been obtained from cost analyses. From a pharmacoeconomic viewpoint, future research should be directed towards defining optimum dosage regimens and hence improving the cost-effective use of filgrastim. Data evaluating patient quality of life and treatment preferences would help define the cost utility of filgrastim therapy. In the meantime, available pharmacoeconomic data support the use of filgrastim as an adjunct to chemotherapy in selected clinical situations. PMID- 10161372 TI - PHS recommends preventive drugs for HIV exposures. PMID- 10161374 TI - CIO of the Year. Getting the job done. PMID- 10161373 TI - The times, they are a changin'. AB - Significant changes are taking place and will continue to take place in U.S. health care and medicine. Many of these changes are not, and will not be, to the benefit of physicians. Reduced personal autonomy, probably lower compensation than expected, fewer and less adequate resources, and overall significantly reduced power are some of the likely outcomes of the changes underway. Perhaps of greatest personal interest is the high likelihood of lack of employment in medicine for upwards of 200,000 physicians over the next 20 years. PMID- 10161375 TI - Physician-directed managed care organizations. Interview by William F. Seward. PMID- 10161376 TI - Physician executive track gaining credibility as a real career. PMID- 10161377 TI - Tessie Guillermo: recipient of the Robert F. Allen symbol of H.O.P.E. Award. PMID- 10161378 TI - Kinematic MRI increases scope of joint imaging. PMID- 10161379 TI - Using filgrastim efficiently. PMID- 10161380 TI - Genetic developments in breast cancer. AB - In this paper I have reviewed the current literature on the genetic mutations found in association with breast cancer. More emphasis has been given to BRCA1 because of the excitement generated with the cloning of this breast cancer susceptibility gene. A number of somatic mutations have been described (loss of heterozygosity, overexpression, and other mutations) in breast cancers. While strides have been made in unraveling the genetic basis of hereditary breast cancer (10 to 15 percent of all breast cancers), the genetic causes of most sporadic breast cancer (which comprise 85 to 90 percent) have yet to be discovered but they are likely the result of a step wise progression of cumulative genetic events, similar to those seen in colon cancer. PMID- 10161381 TI - Roles of hospital administrators in South Carolina. AB - Using discriminant analyses of data on 916 returned questionnaires from a mailing to 1,650 administrators in 82 South Carolina hospitals, this study examines the allocation of interpersonal, informational, decisional, and treatment roles among executive, administrative, and clinical directors. Educational attainment, years of experience, and gender were found to influence respondents' positions. Results also indicate that executive directors assume responsibility for the organization and its relation to the environment. As expected, those in clinical and administrative positions assume more responsibility for interpersonal and treatment roles than do executive directors. PMID- 10161382 TI - Physician-sponsored networks. Will physicians take back medicine? AB - Until about the late 1980s, American physicians and their allies, hospitals and the health care manufacturing industries, dominated all facets of the health system--the clinical, the economic, and the political. The bulk of these providers' revenue flowed to them from a highly fragmented insurance system whose governing principle was to provide each insured patient free choice of doctor and hospital. Two distinct, concurrent shifts threaten to erode the medical profession's traditional dominance. The first is a rapid, general shift of control from the supply side of the health sector to its demand side. The second is a shift away from government control, over which organized medicine held much sway in the past, toward private regulators--the executives of the managed care industry. Is the trend towards greater dependence of practicing physicians on non physician executives inevitable, or can physicians retain--and, in part, regain- their hitherto autonomous position in the health system? PMID- 10161383 TI - Smart people, dumb choices. PMID- 10161384 TI - Balancing certitude and ambiguity. PMID- 10161385 TI - Plenary session: what Florence Nightingale would tell us today. PMID- 10161387 TI - Can a suicide machine trigger the murder statute? PMID- 10161386 TI - Mentoring for a change: from Homer to health care. AB - This article explores the applications for mentoring in health care administration that are appropriate for both physician and nonphysician administrators. While clinical mentoring has a long history in most health care settings, mentoring is underused as a way to develop individual administrators and help organizations cope with change. The article describes both formal and informal approaches to mentoring, as well as the benefits for mentor, mentee and medical organization. It establishes guidelines for successful programs and examines variables related to success. PMID- 10161388 TI - How Britain's doctors are changing. PMID- 10161389 TI - Main political parties' health policies. PMID- 10161390 TI - New acute psychiatric unit designed to make patients feel 'at home' and secure. PMID- 10161391 TI - Western Bay Health benefits from Trendstar solution. PMID- 10161392 TI - Perspectives. HCFA holds ground on physician incentive plans. PMID- 10161394 TI - Perspectives. Government as purchaser: making policy by contract. PMID- 10161393 TI - Perspectives. Medicaid population challenges managed behavioral care. PMID- 10161395 TI - The siren call of the slogan. AB - The siren call of the slogan can be alluring. It also can lead to bad news for you and your organization if you are not careful. One should thoughtfully examine slogans, bearing in mind some of the gratuitous comments made above. In a lighter vein, slogans are fun. They give us something to talk about at conferences other than the occasional peculiar behaviors of some of our colleagues. PMID- 10161396 TI - IS profits: the sky is the limit? PMID- 10161397 TI - FDA & clinical software vendors: a line in the sand? PMID- 10161398 TI - Automating human resources. PMID- 10161399 TI - Bringing healthcare up to speed with financial and clinical integration. PMID- 10161400 TI - CPR distinction: three organizations furthering the cause. PMID- 10161401 TI - Harnessing intranet technology. PMID- 10161402 TI - The CPR: getting physicians on board. AB - The CPR is a powerful concept. In practice, it collects and presents information. It communicates among patients, health plans and all who participate in the healthcare delivery process. The CPR's value extends from supporting better clinical decision making to helping save time and money while making the clinical practice more rewarding. To get the CPR working in your organization, you must ensure that, aside from all the data collection and analysis benefits it might provide healthcare planners, the system must actively support and reward the clinicians who use it every time they come into contact with it. PMID- 10161404 TI - Optical imaging: when one record is needed at multiple sites right now. PMID- 10161403 TI - The CPR's hidden impact: reducing malpractice risk. PMID- 10161405 TI - Cyberhealth or cyberhysteria? PMID- 10161406 TI - Putting clinical & financial reports on line. AB - Healthcare Informatics has been following the progress of Sarasota Memorial Hospital's search for IT solutions with great interest--ever since the hospital innovative "Sarasota Summit" held in May 1994. Now, two years after the legendary brainstorming session among 10 of the nation's top healthcare CIOs--attended by more than 250 hospital personnel, consultants and members of the press and general public--SMH is busily implementing new components of the hospital's resulting information system redesign. On the following pages, SMH Vice President and CIO Jim Turnbull describes the hospital's new centralized electronic repository for information from medical records and patient accounting. Watch for another update soon as Healthcare Informatics continues to observe SMH's transition as influenced by Turnbull's unique approach to information system selection. PMID- 10161407 TI - Automating the reluctant physician. AB - The DISC played an essential role in the development of the organization strategic IS plan and has become a resource of knowledgeable doctors for participation in ongoing IS projects Communications and collaboration among the doctors and other care giver, the administration and the IS department have improved. The DISC model is one that other hospitals and healthcare organizations can use to involve and mobilize their own medical staffs in IS issues. It should be particularly applicable on the medical staff with the time, interest or clinical IS expertise to provide the needed medical staff IS vision and leadership. PMID- 10161408 TI - Linking docs with docs. PMID- 10161409 TI - Clinical systems do not enamor group/physician practices. PMID- 10161410 TI - Improving reimbursement with coding. PMID- 10161411 TI - Politics and standards. PMID- 10161412 TI - 10 reasons you need a healthcare information systems integrator. PMID- 10161413 TI - The role of the Internet in systems integration. PMID- 10161414 TI - The CPR: perspective from the physician's office. PMID- 10161415 TI - Moves & countermoves: the strategies driving vendor consolidations. PMID- 10161416 TI - Distribution strategies for the computer-based patient record. PMID- 10161417 TI - EDI: a boost for medical group practices. PMID- 10161418 TI - Safety--the engineer's responsibility? PMID- 10161419 TI - Construction (design & management) regulations 1994. The role and responsibilities of designers. PMID- 10161420 TI - CDM briefing. PMID- 10161421 TI - AlaHA Chairman Dana Hensley. Interview by Culley Scarborough. PMID- 10161423 TI - True identity. PMID- 10161422 TI - Helping in the hinterlands. PMID- 10161424 TI - Responsibility accounting in a dynamic environment: activity-based cost management. PMID- 10161425 TI - The CPA's role in detecting fraud. PMID- 10161426 TI - Using seasonal forecasting to improve resource management. PMID- 10161427 TI - Philanthropy and the identity crisis in health care. PMID- 10161428 TI - A not-for-profit/for-profit partnership. PMID- 10161429 TI - How do you staff this new animal? PMID- 10161431 TI - Canadian health care reform and its effect on philanthropy. PMID- 10161430 TI - Teacher, coach, advocate. PMID- 10161432 TI - Integrated communications: fund raising, marketing, and public relations. PMID- 10161433 TI - Informed donors. PMID- 10161434 TI - The cost of acquiring new donors. PMID- 10161435 TI - Giving with the best of intentions. PMID- 10161436 TI - ICD-9-CM revisions--effective October 1, 1996. PMID- 10161437 TI - Online coding using an imaging system. PMID- 10161438 TI - The other off-site storage. PMID- 10161439 TI - Selecting a computer system for a physician practice. PMID- 10161440 TI - Long-term care insurance: new product on the block. PMID- 10161441 TI - How data is organized, stored, retrieved, and used within a physician practice. PMID- 10161442 TI - Managing trauma data in Texas. PMID- 10161443 TI - Using a clinical and financial database in the development and evaluation of clinical pathways--the HIM professional's role. PMID- 10161444 TI - HIM Week: a time to celebrate. PMID- 10161445 TI - Congratulations to the 1996 AHIMA award winners. PMID- 10161446 TI - Fellows in Congress: an interview with Senator Bill Frist, MD, FACS, and Representative Greg Ganske, MD, FACS. Interview by Cynthia A. Brown. PMID- 10161447 TI - Is "caring" cognitive? PMID- 10161448 TI - In their own words. Surgeon representatives discuss legislative and regulatory issues. PMID- 10161449 TI - Suggestions for accreditation of surgeons who perform image-directed breast biopsies. PMID- 10161450 TI - Statement on principles underlying perioperative responsibility. American College of Surgeons. PMID- 10161451 TI - What surgeons should know about HCFA's proposed Medicare five- year review regulations. PMID- 10161452 TI - Beyond demand: the case for an integrated, needs-based approach to health system funding. PMID- 10161453 TI - Promoting multiculturalism in healthcare on a zero budget. AB - When a B.C. health commission proposed strategies for promoting cultural awareness in healthcare, members of one hospital staff took up the challenge. With no budget and in addition to their regular duties, they researched and developed practical tools for healthcare workers in the midst of Victoria's diverse community. PMID- 10161454 TI - Riding the care path wave: a focus on collaboration at a community hospital. PMID- 10161455 TI - Illness and healing: images of cancer by Robert Pope. AB - Leadership's articles usually adopt a manager's perspective on the healthcare system. It is a system, however, whose purpose is to serve Canadians who are injured, ill and, sometimes, dying. After he was diagnosed with a terminal illness, artist Robert Pope painted striking images on his experience with illness and healing. In this issue Leadership shares some of these images with our readers, reminding us all of the personal experience at the centre of a system concerned with the health of human beings. PMID- 10161456 TI - Person-based information from Canadian hospital discharge data. AB - Statistics summarizing Canadians' use of hospital services are usually based on simple discharge totals, without any attempt to distinguish which discharges may have belonged to the same person. This leads to a distorted view of the prevalence of illness and the resources required to serve each patient. Statistics based on the number of people going to hospital shed new light on the demand for resources by various groups, now and in the future. PMID- 10161457 TI - Abuse policies for healthcare institutions. AB - Few hospitals have standard approaches to recognizing and treating victims of abuse. When staff at the Toronto Hospital realized they had no guidelines for handling such cases, they formed a task force to research the issue. The result was a set of policies and procedures which clearly outline the duties of staff who suspect abuse and, at the same time, make clear the hospital's role in addressing this serious issue. PMID- 10161458 TI - Hospital restructuring in Ontario. AB - Ontario's healthcare services are only loosely organized into a "system." Attempts at reform before 1995 were scattered and uncoordinated. Following the landslide victory of the Conservative government under Mike Harris, however, an Ontario Health Services Restructuring Commission has assumed responsibility for all reform. Political will, economic necessity and the presence of proper tools may finally organize Ontario's healthcare delivery into an efficient, coordinated system. PMID- 10161459 TI - CHOICE for Edmonton's elderly. PMID- 10161460 TI - Can I get there from here? Wayfinding systems for healthcare facilities. AB - Because people seldom visit hospitals unless they have to, they are generally unfamiliar with the facilities and have trouble finding their way on their own. Moreover, patients and families in a hospital are often distracted by other concerns. This makes a well-designed wayfinding system particularly important. Two facilities' dealings with professional designers illustrate some solutions which help both hospital and patients. PMID- 10161461 TI - Legacy, Abbott-Northwestern use systems thinking concepts to hone competitive strategy. PMID- 10161462 TI - Integration strategy: alignment of incentives with physicians. PMID- 10161463 TI - From sea to shining sea. Your job and the Internet. PMID- 10161464 TI - Leaders of the pack. These materials managers hit the comeback trail and came up winners. PMID- 10161465 TI - For single use only? PMID- 10161466 TI - Teams: the terrible truth. PMID- 10161467 TI - How do your laundry and linen operations stack up, then and now? PMID- 10161468 TI - Brain power paves the way to better infection control. PMID- 10161469 TI - Cancer. The enemy within. PMID- 10161471 TI - Fertility. How to coax new life. PMID- 10161470 TI - Genetics. Keys to the kingdom. PMID- 10161472 TI - Alternative therapies. Challenging the mainstream. PMID- 10161473 TI - Mental disorders. Targeting the brain. PMID- 10161474 TI - Technology. Doc in a box. PMID- 10161475 TI - Plagues. Guerilla warfare. PMID- 10161476 TI - AIDS. The exorcists. PMID- 10161477 TI - Manage with care. PMID- 10161478 TI - Transplants. Organ concert. PMID- 10161479 TI - An epidemic of discovery. PMID- 10161481 TI - Pocket-size medicine. PMID- 10161480 TI - Health roundup. The human condition. PMID- 10161482 TI - Offering a healing hand. PMID- 10161483 TI - The budget meets the Boomers. PMID- 10161484 TI - Helping families care for loved ones. AB - Families struggling with decisions about care of loved ones who are dying will forever remember the help and advice provided by healthcare providers. But often providers disagree about the care patients should have to control pain and preserve life, which creates confusion and frustration among caregivers. Here, three people--a researcher who works with dying patients and their families, a supportive care expert and a family member--speak out on the kinds of help they believe that professional healthcare providers should provide to caregivers. PMID- 10161485 TI - Quality agenda. Resources on care of the dying. PMID- 10161486 TI - Care of the dying: can we do better? AB - The same healthcare system that excels at defining best practices and coordinating care for cardiac surgery and other acute illness has paid little attention to defining and implementing care models for the terminally ill. This issue of THE QUALITY LETTER looks at the care of the dying as a quality improvement priority. Experts say that many patients' dying days are spent in pain, isolated from loved ones and subject to extraordinary lifesaving measures unwanted by the patients--often because their caregivers lack adequate training in meeting their needs. The objective, say the experts, is a compassionate and patient/family-centered model of care. Use the self-assessment tool provided to determine whether your system shows the danger signs that care of the dying is inadequate and review six ways that your community can start improving service to the dying. PMID- 10161487 TI - Federal insurance reform. The ripples that will reach your desk. PMID- 10161488 TI - Federal insurance reform. A drop in your state's bucket? PMID- 10161489 TI - Federal insurance reform. Who will jump into the MSA pond? PMID- 10161490 TI - Federal insurance reform. Big employers get splashed, too. PMID- 10161491 TI - Federal insurance reform. All the other ripples. PMID- 10161492 TI - Should you let the FDA decide what drugs you pay for? PMID- 10161493 TI - Breathing lessons: the costs of COPD. PMID- 10161494 TI - In picking a health plan, the buck stops with you. PMID- 10161496 TI - Time-off benefits that give more bang for the buck. PMID- 10161495 TI - Is the health of families considered less valuable? PMID- 10161497 TI - When companies get together, don't let benefits fall apart. PMID- 10161498 TI - Perks for part timers. PMID- 10161499 TI - Controlling costs for the new flood of retirees. PMID- 10161500 TI - Mental health matters. PMID- 10161501 TI - Digging out savings in diabetes care. PMID- 10161502 TI - When a PPO is silent. PMID- 10161503 TI - What's fair and what's affordable in mental health coverage? No good deed goes unpunished. PMID- 10161504 TI - What's fair and what's affordable in mental health coverage? There's no excuse for discrimination. PMID- 10161505 TI - Outsourcing is big business. PMID- 10161506 TI - The future of provider-sponsored HMOs. PMID- 10161507 TI - Antiemetic therapy in managed care oncology: roundtable discussion. AB - Few diagnoses are feared more by patients than cancer. In addition to the life threatening nature of many cancers, the spectre of very difficult the treatment provides patients with little or no level of comfort. However, recent advances in the treatment of the side effects of cancer chemotherapy are helping to change these attitudes. On April 4, 1996, a panel of experts was convened to discuss these issues and how they affect MCOs. PMID- 10161508 TI - Quality initiatives and health care reform. AB - Problems associated with health care in the United States will be resolved when the four dimensions of health care reform are addressed: (1) How do we reduce variation and confirm quality care? (2) How do we make necessary/appropriate care accessible to all citizens? (3) How do we pay for health care? and (4) How do we stop the drain of dollars paying for ineffective care? In this article, the authors address the first question about how quality is confirmed. They make six specific recommendations to those MCOs that intend to move beyond just establishing a quality management program. PMID- 10161509 TI - The cost effectiveness of oral rehydration therapy for U.S. children with acute diarrhea. AB - Diarrheal disease is a common cause of morbidity among U.S. children under five years of age and exerts a heavy burden on the health care system. Oral rehydration therapy (ORT), a simple, inexpensive treatment modality that can prevent most diarrhea-related complications, is grossly underutilized in the United States. Using a decision-analysis model, this article describes the financial burden of childhood diarrhea in the United States for children under five years of age and discusses the substantial economic benefits of ORT programs. If fully implemented, such programs would save our health care system close to $1 billion annually. PMID- 10161510 TI - The burgeoning correctional populations. PMID- 10161511 TI - Are medical groups a threat to managed care organizations? PMID- 10161512 TI - Maternity education and risk management. PMID- 10161513 TI - A model for developing longitudinal health records. AB - The future of population health management will focus on treatment of chronic diseases and avoidance of acute disorders for targeted populations. The key tools for managing population health must involve outcomes measurement and management, wellness/preventive programs, care management programs, and cost management. This can be achieved by the implementation of a computerized patient health record for longitudinal health information (lifetime) recording and management. PMID- 10161514 TI - Strange symbiosis. PMID- 10161515 TI - Selected topical antifungal use in managed care. AB - When a new product is marketed, information obtained from strictly controlled clinical trials may not accurately predict its use within a managed care plan. Identifying the most cost-efficient therapy or service is of paramount concern. Although managed care plans can easily justify the formulary addition of a low cost per unit product, more difficulty arises when considering a higher-cost product. A retrospective analysis of pharmacy claims related to topical antifungal therapy for an HMO plan was conducted to determine the refill frequency and the total topical drug treatment cost for each of the antifungal agents researched. In this study, a manufacturer's claims of higher potency and shorter course of treatment could not be substantiated. PMID- 10161516 TI - Statistical regression toward the mean: guaranteed disease state management success. PMID- 10161517 TI - Disease management carve-out: caveat emptor. PMID- 10161518 TI - Elder abuse: diagnosis, management, and prevention. PMID- 10161519 TI - Provider deselection: "cause" or "no cause". AB - Termination of provider contracts by MCOs rankles most in the provider community. Oftentimes, no cause is given for the termination, as permitted in the contract between the MCO and the provider. Yet, there is always a cause for termination, and providers generally don't like the reason. PMID- 10161520 TI - The gatekeeper effect on managing acute medical conditions. AB - This study was designed to analyze whether the gatekeeper approach, by itself, is effective in changing physicians' practice patterns. The effect of the gatekeeper could be isolated, because a 95% overlap existed between contracted physicians in the PPO plan and the POS plan used in the study. In treating low-to-moderately resource-intensive conditions, the results of this episode-of-care study showed that the POS system of care (gate-keeper in place) was no more efficient than the PPO system of care (no gatekeeper mechanism) in terms of overall medical costs. PMID- 10161521 TI - Some variations in 1994 National Health Expenditures. PMID- 10161522 TI - The PPO advantage. PMID- 10161523 TI - Integrating the office staff of a newly acquired medical group. PMID- 10161524 TI - Sorting out contradictions within managed care. PMID- 10161525 TI - Disease state management programs: demonstrating success. PMID- 10161526 TI - Understanding the basis of treatment choices for varicose veins: a model for decision making with the repertory grid technique. AB - OBJECTIVES: To use the repertory grid technique as a method for identifying and rating the criteria that clinicians use to make a choice between the different treatment options for patients with a common condition such as varicose veins. DESIGN: The "expert panel" consensus method for rating the appropriateness of clinical procedures was modified with an existing psychometric method, the repertory grid technique. To identify the criteria used to decide about treatment, the panel members compared and contrasted a range of nine "treatment prototypes". They were then required to rate each criterion for its relevance to each treatment prototype. SETTING: The panel was selected from different geographical locations in the South Western Regional Health Authority. SUBJECTS: The expert panel was composed of six vascular surgeons, three from teaching and three from non-teaching hospitals; two general practitioners who were also clinical assistants in vascular surgery; and one honorary senior lecturer in general practice. MAIN MEASURES: Decision making criteria were categorised according to their content. Their frequency of replication was noted-that is, how many clinicians used the same criterion. Computer analysis of the rating scores for the nine panel members identified the relative importance of each treatment criterion for each treatment option. RESULTS: 161 criteria for the treatment of varicose veins were elicited from the nine participants. These criteria were wide ranging, from clinical indications (48% of those used), to social (32%), and organisational factors (20%). Clinical indications were more likely to be used when deciding about surgery as a high priority, whereas social and organisational criteria were more likely to be applied in decisions about surgery as a low priority, day case surgery, and cosmetic surgery. CONCLUSIONS: The repertory grid technique proved to be effective in modelling decision making for a condition such as varicose veins: its use enabled both the identification of the wide range of criteria underlying the decision to treat and the exploration of the relative importance of these criteria in relation to several treatment options. Its potential as a method for reducing variation in clinical decision making and thus improving distribution of high quality care lies in its ability to pinpoint dilemmas of decision making rather than as the basis for drawing up guidelines to regulate decision making practice. PMID- 10161527 TI - Organisation of asthma care: what difference does it make? A systematic review of the literature. AB - OBJECTIVES: To evaluate the effectiveness of different forms of organisation (delivery) of asthma care. METHODS: A systematic review of the published evidence of effectiveness organisational methods of asthma management. Searches on computerised databases including Medline, CINAHL, and HELMIS, and relevant citations and letters to experts were used to identify relevant studies. RESULTS: 27 studies were identified that evaluated different organisational methods of delivery across both primary and secondary sectors, such as shared care, general practice asthma clinics, outpatient programmes, inpatient admissions policies, and the use of specialists. Only one third of the studies used a randomised controlled trial and many had small sample sizes. No conclusive evidence was found to favour any particular organisational form, although limited evidence would suggest that specialist care is better than general care and that shared care can be as effective as hospital led care. CONCLUSIONS: There is little good published research evaluating different ways of organising the delivery of asthma care. There is need for quality research on organisational methods of delivery of asthma care that could be used to inform policy makers, in particular examining whether patients treated by healthcare professional with expertise and interest in asthma will experience better outcomes. PMID- 10161528 TI - Patients' satisfaction with care after stroke: relation with characteristics of patients and care. AB - OBJECTIVES: To evaluate stroke patients' satisfaction with care received and to identify characteristics of patients and care which are associated with patients' dissatisfaction. DESIGN: Cross sectional study. SETTING: Sample of patients who participated in a multicentre study on quality of care in 23 hospitals in the Netherlands. PATIENTS: 327 non-institutionalised patients who had been in hospital six months before because of stroke. MAIN MEASURES: Data were collected on (a) characteristics of patients: socio-demographic status, cognitive function (mini mental state examination), disability (Barthel index), handicap (Rankin scale), emotional distress (emotional behavior subscale of the sickness impact profile) and health perception; (b) characteristics of care: use of various types of formal care after stroke, unmet care demands perceived by patients, unmet care demands confirmed by their general practitioners, continuity of care, and secondary prevention, and (c) patients' satisfaction with care received. RESULTS: 40% of the study sample were dissatisfied with at least one type of care received. Multivariate analyses showed that unmet care demands perceived by patients (odds ratio (OR) 3.2, 95% confidence interval (95% CI) 1.8-5.7) and emotional distress (OR 1.8, 95% CI 1.1-3.0) were the main variable associated with dissatisfaction. CONCLUSIONS: Patients' satisfaction was primarily associated with emotional distress and unmet care demands perceived by patients. No association was found between patients' satisfaction on the one hand and continuity of care or secondary prevention on the other; two care characteristics that are broadly accepted by professional care givers as important indicators of quality of long term care after stroke. IMPLICATIONS: In view of these findings discussion should take place about the relative weight that should be given to patients' satisfaction as an indicator of quality of care, compared with other quality indicators such as continuity of care and technical competence. More research is needed to find which dimensions of quality care are considered the most important by stroke patients and professional care givers. PMID- 10161529 TI - Adapting total quality management for general practice: evaluation of a programme. AB - OBJECTIVE: Assessment of the benefits and limitations of a quality improvement programme based on total quality management principles in general practice over a period of one year (October 1993-4). DESIGN: Questionnaires to practice team members before any intervention and after one year. Three progress reports completed by facilitators at four month intervals. Semistructured interviews with a sample of staff from each practice towards the end of the year. SETTING: 18 self selected practices from across the former Oxford Region. Three members of each practice received an initial residential course and three one day seminars during the year. Each practice was supported by a facilitator from their Medical Audit Advisory Group. MEASURES: Extent of understanding and implementation of quality improvement methodology. Number, completeness, and evaluation of quality improvement projects. Practice team members' attitudes to and involvement in team working and quality improvement. RESULTS: 16 of the 18 practices succeeded in implementing the quality improvement methods. 48 initiatives were considered and staff involvement was broad. Practice members showed increased involvement in, and appreciation of, strategic planning and team working, and satisfaction from improved patients services. 11 of the practices intend to continue with the methodology. The commonest barrier expressed was time. CONCLUSION: Quality improvement programmes based on total quality management principles produce beneficial changes in service delivery and team working in most general practices. It is incompatible with traditional doctor centred practice. The methodology needs to be adapted for primary care to avoid quality improvement being seen as separate from routine activity, and to save time. PMID- 10161530 TI - Studies of avoidable factors influencing death: a call for explicit criteria. AB - OBJECTIVE: To analyse studies evaluating cases of potentially "avoidable" death. DESIGN: The definitions, sources of information, and methods were reviewed with a structured protocol. The different types of avoidable factors,--that is, deficiencies in medical care that may have contributed to death--were categorised. The presence of explicit classifications and standards was examined. basic criteria for quality of the studies were defined and the numbers of studies fulfilling these criteria were assessed. SETTING AND PARTICIPANTS: 65 studies, published during 1988-93 in peer reviewed medical journal for which the title, or abstract, or both indicated that they had analysed potentially avoidable factors influencing death. Studies analysing aggregated data only, were not included. RESULTS: Only one third of the studies fulfilled basic quality criteria,--namely, that the avoidable factors examined should be defined and the sources of information and people responsible for the judgements presented. The definitions used comprised two levels, one stating that there had been errors in management (process) and the other that the errors may have contributed to the deaths (outcome). Only 15% of the studies explicitly defined what type of factors they had looked for and 8% referred to specified standards of care. CONCLUSIONS: Studies of avoidable factors influencing death may have considerable potential as part of a system of improving medical care and reducing avoidable mortality. At present, however, the results from different studies are not comparable, due to differences in materials and methods. There is a need to improve the quality of the studies and to define standardised explicit definitions and classifications. PMID- 10161531 TI - Preliminary assessment of patients' opinions of queuing for coronary bypass graft surgery at one Canadian centre. AB - OBJECTIVES: To explore psychological and socioeconomic concerns of patients who queued for coronary artery bypass surgery and the effectiveness of support existing in one Canadian cardiovascular surgical center. DESIGN: Standardised questionnaire and structured interview. SETTING: Victoria General Hospital, Halifax, Nova Scotia. SUBJECTS: 100 consecutive patients awaiting non-emergency bypass surgery. RESULTS: Most patients (96%) found the explanation of findings at cardiac catheterisation and the justification given for surgery satisfactory. However, 84 patients complained that waiting for surgery was stressful and 64 registered at least moderate anxiety. Anger over delays was expressed by 16%, but only 4% thought that queuing according to medical need was unfair. Economic hardship, attributed to delayed surgery, was declared by 15 patients. This primarily affected those still working--namely, blue collar workers and younger age groups. Only 41% of patients were satisfied with existing institutional supports. Problems related mainly to poor communication. CONCLUSIONS: Considerable anxiety seems to be experienced by most patients awaiting bypass surgery. Better communication and education might alleviate some of this anxiety. Economic hardship affects certain patient subgroups more than others and may need to be weighed in the selection process. A more definitive examination of these issues is warranted. PMID- 10161533 TI - Health promotion and disease prevention: a look at demand management programs. AB - This Issue Brief describes employers' efforts to contain health expenditures through demand management programs. These programs are designed to reduce utilization by focusing on disease prevention and health promotion. Demand management includes work site health promotion, wellness programs, and access management. Work site health promotion is a comprehensive approach to improving health and includes awareness, health education, behavioral change, and organizational health initiatives. Wellness programs usually include stress management, smoking cessation, weight management, back care, health screenings, nutrition education, work place safety, prenatal and well baby care, CPR and first aid classes, and employee assistance programs (EAPs). These programs are often viewed positively by workers and can have long-term benefits for employers above and beyond health care cost containment. Demand management can benefit employers by increasing productivity, employee retention, and employee morale and by reducing turnover, absenteeism, future medical claims, and ultimately expenditures on health care. Even though a growing number of employers are offering wellness programs, only 37 percent of full-time workers employed in medium and large private establishments were eligible for wellness programs by 1993. However, a recent survey found that 88 percent of major employers have introduced some form of health promotion, disease prevention, or early intervention initiative to encourage healthy lifestyles among their salaried employees. Distinctions must be drawn between short- and long-term strategies. Demand management can be thought of as a short-term strategy when the focus of the program is on creating more appropriate and efficient health care utilization. Disease prevention is characterized by longer-term health improvement objectives. Whether the purpose is to reduce utilization in the short term or in the long term, the ultimate goal remains the same: to reduce health care expenditures while improving overall health. This goal can be achieved through the use of health risk appraisals, organizational health risk appraisals, high risk programs, awareness programs, medical call centers, return to work programs, EAPs, and smoking cessation programs. Studies of a health program's cost effectiveness must disentangle the effects of many competing factors on cost effectiveness. For example, a health risk appraisal program may identify health problems of which the patient and the health care provider were unaware, resulting in the treatment of these health problems. At the same time, the employer may have switched from a nonmanaged pharmaceutical program to a managed program with incentives for participants to utilize generic and/or mail order drugs. As a result, when evaluating a health promotion program, the long-run impact on the program's cost effectiveness is most important. PMID- 10161532 TI - Why are we trying to reduce length of stay? Evaluation of the costs and benefits of reducing time in hospital must start from the objectives that govern change. PMID- 10161534 TI - HOPENET puts center on path for year 2000. City of Hope Medical Center. PMID- 10161535 TI - Outsourcing supports 'super PHO'. PMID- 10161537 TI - Prescribe the right hardware to fit your organization's needs. PMID- 10161536 TI - Home health moving toward 'high touch, high tech'. PMID- 10161538 TI - UNMC: taking steps toward better healthcare. AB - To be successful, the system will need to be easily modified. Do not dissolve the tailoring team when the clinician screens are "done." Anticipate constant change in how patients are cared for and plan to change the system accordingly. Communicate with the vendor so that the company understands your changing needs and so you can keep current with new functionality. Above all, listen to your clinician users--"The customer is always right." PMID- 10161539 TI - Take a holistic view when planning your network. PMID- 10161540 TI - Client/server: minefield or garden path? PMID- 10161541 TI - Automate simplicity to cut costs. PMID- 10161542 TI - Hotlist. EDI software and services. PMID- 10161543 TI - Yesterday's technology troubles foretell today's PC problems. PMID- 10161544 TI - The qui tam provision of the Federal False Claims Act: the statute in current form, its history and its unique position to influence the health care industry. PMID- 10161545 TI - Q & A with Pam Stephenson. PMID- 10161546 TI - Centennial Park explosion: as bomb detonates, Georgia hospitals rise to the challenge. PMID- 10161547 TI - Current issues for managed care organizations. PMID- 10161548 TI - Completion of records legally speaking: clinical or clerical? PMID- 10161549 TI - Discussion of case mix systems--DRG versus HRG. PMID- 10161550 TI - Accreditation and development of health records programme. PMID- 10161551 TI - Health records management in transition in the United Kingdom. PMID- 10161552 TI - Health and human rights in the information age. PMID- 10161553 TI - Medicare program; reporting of interest from zero coupon bonds--HCFA. Final rule. AB - This final rule requires Medicare providers to report all interest expense and interest income from zero coupon bonds in the cost reporting period in which the interest was accrued. This final rule is necessary to add provisions to the Medicare regulations that specifically address the reporting by providers of interest expense and income from zero coupon bonds. PMID- 10161554 TI - Medicare program; waiver of recovery of overpayments--HCFA. Final rule. AB - This final rule duplicates in HCFA's regulations the content of two sections of the Social Security Administration's regulations concerning waiver of recovery of overpayments. In the past, regulations in 20 CFR part 404 were applicable to both the Federal Old-Age, Survivors and Disability Insurance program (OASDI), which provides monthly Social Security checks directly to beneficiaries or their representatives, and the Medicare program. Since the Social Security Administration (SSA) is now independent of HHS, and SSA is restructuring its regulations to apply only to the OASDI program, we are establishing the content of these sections in 42 CFR part 405 to preserve provisions that are applicable to the Medicare program. PMID- 10161555 TI - Medicare program; Part B advance payments to suppliers furnishing items or services under Medicare Part B--HCFA. Final rule. AB - This rule establishes requirements and procedures for advance payments to suppliers of Medicare Part B services. An advance payment will be made only if the carrier is unable to process a claim timely; the supplier requests advance payment; we determine that payment of interest is insufficient to compensate the supplier for loss of the use of the funds; and, we expressly approve the advance payment in writing. These rules are necessary to address deficiencies noted by the General Accounting Office in its report analyzing current procedures for making advance payments. The intent of this rule is to ensure more efficient and effective administration of this aspect of the Medicare program. PMID- 10161556 TI - Medicaid program; final limitations on aggregate payments to disproportionate share hospitals: Federal fiscal year 1996--HCFA. Notice. AB - This notice announces the final Federal fiscal year (FFY) 1996 national target and individual State allotments for Medicaid payment adjustments made to hospitals that serve a disproportionate number of Medicaid recipients and low income patients with special needs. We are publishing this notice in accordance with the provisions of section 1923(f)(1)(C) of the Social Security Act and implementing regulations at 42 CFR 447.297 through 447.299. The final FFY 1996 State DSH allotments published in this notice supersede the preliminary FFY 1996 DSH allotments that were published in the Federal Register on May 9, 1996. PMID- 10161557 TI - Federal employees health benefits program: limitation on physician charges and FEHB Program payments--Office of Personnel Management. Final rule. AB - The Office of Personnel Management (OPM) is making final its interim regulation that amends current Federal Employees Health Benefits (FEHB) Program regulations. The final regulation requires that the charges and FEHB fee-for-service plans' benefit payments for certain physician services furnished to retired enrolled individuals do not exceed the limits on charges and payments established under the Medicare fee schedule for physician services. PMID- 10161558 TI - Protection of human subjects; informed consent--FDA. Final rule. AB - The Food and Drug Administration (FDA) is amending its current informed consent regulations to permit harmonization of the Department of Health and Human Services' (DHHS) policies on emergency research and to reduce confusion on when such research can proceed without obtaining an individual subject's informed consent. This regulation provides a narrow exception to the requirement for obtaining and documenting informed consent from each human subject, or his or her legally authorized representative, prior to initiation of an experimental intervention. The exception would apply to a limited class of research activities involving human subjects who are in need of emergency medical intervention but who cannot give informed consent because of their life-threatening medical condition, and who do not have a legally authorized person to represent them. FDA is taking this action in response to growing concerns that current rules are making high quality acute care research activities difficult or impossible to carry out at a time when the need for such research is increasingly recognized. PMID- 10161559 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); FY97 DRG updates--DoD. Notice of DRG revised rates. AB - This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY 1997 under the CHAMPUS DRG-based payment system. It also describes the changes made to the CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS). PMID- 10161560 TI - Welfare law could cost hospitals. PMID- 10161561 TI - Getting stuck with the tab. PMID- 10161562 TI - Outcomes measurement: collecting data for payors, providers & patients. PMID- 10161563 TI - Decision support: simplifying the information. PMID- 10161564 TI - How can information systems aid in the collection & analysis of patient satisfaction? PMID- 10161565 TI - Report writing: bringing client-server simplicity to the desktop. PMID- 10161566 TI - Information technology consultants: value & expertise help MCOs. PMID- 10161567 TI - America's most computer advanced PPOs 1996. PMID- 10161568 TI - Credentialing: data collection made easier. PMID- 10161570 TI - Beyond cost containment: achieving quality care. PMID- 10161569 TI - Florida: systems integrator is key to success. PMID- 10161571 TI - Election will affect behavioral healthcare. PMID- 10161572 TI - Five levels of primary care/behavioral healthcare collaboration. PMID- 10161573 TI - Behavioral healthcare risk-sharing and medical cost offset. AB - Medical offset savings have been demonstrated clearly and repeatedly in a variety of settings. Taking advantage of these savings improves quality of care and lowers direct healthcare expenditures. However, most organized systems of care lack the infrastructure or incentives to measure offset savings, nor can they recycle these savings to find the behavioral services required to produce cost off-sets. The author provides actuarial models and case studies to demonstrate how this problem can be solved. PMID- 10161574 TI - How should primary care address the problem of psychiatric disorders? Can primary care physicians deliver quality mental healthcare? PMID- 10161575 TI - How should primary care address the problem of psychiatric disorders? Psychiatric treatment in primary care: choice or requirement? PMID- 10161576 TI - How should primary care address the problem of psychiatric disorders? Demand-side analysis of mental health services in primary care. PMID- 10161577 TI - Mental disorders in general medical practice an opportunity to add value to healthcare. PMID- 10161578 TI - Health policy implications of the RAND medical outcomes study: improving the value of depression treatment. PMID- 10161579 TI - Coordinating physical and behavioral healthcare services for Medicaid populations: issues and implications in integrated and carve-out systems. AB - A history of government-funded health and behavioral health services has resulted in separate and parallel systems of care for Medicaid beneficiaries. Accountability for coordination of medical and behavioral services has been poorly delineated, with adverse consequences for the medically indigent population. The author defines current opportunities and approaches for service coordination within the Medicaid arena. PMID- 10161580 TI - Integrating behavioral and medical/surgical data. PMID- 10161581 TI - Integrating mental health and primary care: solution or problem? PMID- 10161582 TI - Lessons from the front: implementing outcomes projects. AB - These issues are representative of the challenges facing those wishing to implement outcomes evaluations in the dramatically different settings of today's behavioral healthcare. To maintain acceptable levels of credibility, difficult issues such as these need to be addressed openly and assertively. We remain optimistic about the value of measuring the effects of behavioral healthcare interventions. Such measurement facilitates the development of communication across service providers and creates accountability where once there was none. When standards of quality research are applied, outcomes management offers great potential benefit to consumers, providers, and behavioral healthcare organizations. PMID- 10161583 TI - Mind and body primary mental healthcare: new model for integrated services. AB - Primary mental healthcare is different from consultation-liaison psychiatry and behavioral medicine yet has elements of both. This approach calls for complete integration of behavioral health services within the primary care and general medical setting. Primary care providers, rather than mental health specialists, retain direction of patient care. In this model, developed at the Group Health Cooperative of Puget Sound, primary behavioral health clinicians are on site, not on call. PMID- 10161584 TI - Formulary: what it is and how it works. AB - Estimates for healthcare expenditures in 1993 exceeded $900 billion, approaching 15% of GNP. Of this, approximately 7.5% ($62 billion) was spent on drugs. More recently, costs show that the US spends over $3,000 per person per year on healthcare. Although no one disputes that the cost of healthcare is rising, generally the rate at which it rises is not as rapid in a managed care environment compared to a fee-for-service one. Because of this, the boundaries of managed care and pharmacy benefits management (PBM) continue to expand. Outpatient drug benefits, for instance, are being carved out of the medical benefit offered by several types of insurance programs. This is mainly a result of point-of-sale claims processing and enhanced information system data base reporting making the drug portion easier to identify and separate from other medical claims. Self-funded employers are now actively seeking PBM companies to contract with for this type of service. The services being offered by PBM companies include: Pharmacy networks in which plan members fill prescriptions at a discounted or contracted rates. Disease state management. Drug utilization review. Financial reporting. Formulary management. The main component of formulary management is the development and distribution of a drug formulary. This article discusses what a drug formulary is and how it works. PMID- 10161585 TI - Formularies in integrated health systems: Sharp HealthCare. AB - Formulary management implications are described for a California health system comprising 7 hospitals, 4 skilled-nursing centers, 22 medical clinics, 8 urgent care facilities, and a health maintenance organization. Sharp HealthCare serves nearly one million people in the San Diego area. A single institutional care division (ICD) pharmacy service has been created under the guidance of a steering committee comprising a pharmacy operations coordinator and a staff pharmacist from each site, the system pharmacy director, the system senior pharmacy information systems specialist, and the system senior clinical pharmacy specialist. Operations at each site are overseen by an operations coordinator instead of a pharmacy director. Functional teams reporting to the steering committee are standardized pharmacy processes, including formulary management; this is particularly important because the ICD has pharmacists and nurse per diem pools. Until 1995, formularies were independently managed at each site. Now, one system formulary is being developed. Standard policies and procedures, a nonformulary drug request form, and a monograph format have been completed. The hospitals' autonomous medical staffs have thus far elected to retain individual pharmacy and therapeutics (P&T) committees but approved a revamped formulary review process and system-wide P&T subcommittees. The computer system is being enhanced so that pharmacists will have access to applicable P&T committee approved guidelines for drug use. Since vendors were advised that the system is establishing one formulary, Sharp has been able in some cases to achieve better pricing than it previously could through its purchasing group. PMID- 10161586 TI - Streamlining breast disease management. AB - New technology has been developed for performing percutaneous (non-surgical) breast biopsy and tracking the outcome of breast disease patients. The procedure, mammotomy, takes a biopsy of breast tissue lesions quickly during the same office visit at which the screening mammography discovers an abnormality. Because the procedure is non-invasive, it bypasses the extra time and expense of open surgical biopsies. In conjunction with mammotomy, Breast Cancer Manager (BCM) software is intended to streamline breast care data management. These technologies provide the cornerstone of a comprehensive breast health plan that can streamline patient care across specialties. This plan uses an organ-based, multispecialty coalition of practitioners related to the diagnosis and treatment of breast disease. The BCM software provides a central, complete record of all care given to a patient from the first screening mammogram through surgery and adjuvant therapy. All practitioners will have access to its information and at the same time be able to add to it, making it the repository of patient and practice data for management analysis and outcomes reporting. This article looks at the treatment paradigm of breast disease and details the potential cost savings made possible by mammotomy and the BCM software. PMID- 10161587 TI - Where Dole and Clinton stand on healthcare issues. PMID- 10161588 TI - Decision making by committee. PMID- 10161589 TI - Critical pathways: pluses and minuses. PMID- 10161590 TI - A community-based alternative. The Comprehensive Community Health Models Initiative. PMID- 10161591 TI - Finding the right chemistry. AB - For most hospital executives, learning that a physician group on their staff plans to affiliate with a practice management company causes significant concern. Unsettling images of a widening gulf between physicians and the hospital, accompanied by struggles over ancillary services, come to mind. PMID- 10161592 TI - Observation medicine. Overcoming the Achilles heel of emergency medicine. PMID- 10161593 TI - Developing leaders. The key to successful organizations. PMID- 10161594 TI - Physician/hospital relationships. PMID- 10161595 TI - Meeting community needs. Should charitable hospitals become for-profits? PMID- 10161596 TI - Partnerships with for-profits. PMID- 10161597 TI - Moving for motion. PMID- 10161598 TI - Rules' complexity increases. New physician incentive regulations described. PMID- 10161599 TI - Reference checking. Not an illegal move. PMID- 10161600 TI - Partnership of the first degree. PMID- 10161601 TI - Health care is plugging in new relationships and data connections are the future. PMID- 10161602 TI - An integrated health care system approach to case management. PMID- 10161603 TI - Reengineering integrated patient care at an academic medical center. PMID- 10161604 TI - Hospital-based social work HIV case management: reducing continuity of care barriers. PMID- 10161605 TI - Opportunities for pharmacists in clinical research. AB - Drug development requires the cooperation and efforts of industry and investigators. If the process is to be successful (i.e., FDA approval), then both industry and investigators must be committed and clearly understand the goals and objectives of the other. The clinical pharmacist is an important part of the development process and has participated in all phases of the research effort. Because of their unique role in the health care system, they have provided industry with a perspective which has contributed immensely to the drug approval process. PMID- 10161606 TI - Combination antibiotic therapy in critically ill patients. AB - Combination antibiotic therapy may be used for a number of reasons in critically ill patients. The potential benefits of combination therapy include prevention of resistance, treatment of polymicrobial infections, to decrease toxicity, or for synergy. Selected literature is reviewed which examines the use of combination therapy in critically ill patients. Research reports have not uniformly demonstrated the benefits of combination therapy. The situations where combination therapy has been beneficial are discussed. PMID- 10161607 TI - Drug-usage evaluation by disease state: developing protocols. AB - The Joint Commission definition of drug-usage evaluation (DUE) also applies to DUE by disease state. The criteria for disease process selection, key processes being evaluated, methods to develop initial DUE protocols, and DUE validation and approval processes are reviewed. The treatment of community-acquired pneumonia is a disease state DUE performed at Saint Joseph Health Center in Kansas City, Missouri. The preliminary protocol was developed by a collaborative network of clinical pharmacists in the metropolitan area. Outcome measures were included in the evaluation. The results were used as baseline data in the development of a pneumonia clinical pathway. PMID- 10161608 TI - Designing drug-usage evaluation to meet Joint Commission requirements. AB - Strategies for influencing prescribing practices utilizing the drug-usage evaluation (DUE) process are described. Our DUE program has evolved into a collaborative program that provides significant pharmacy involvement while maintaining medical staff responsibility, as outlined by the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission). A multidisciplinary approach is utilized to identify prescribing problems, develop prescribing criteria, and provide educational initiatives. Pharmacists provide drug therapy monitoring, engage in clinical interventions, and document the outcomes of these interventions. DUE pharmacists report results of these initiatives to the medical staff and quality assessment program. Physician performance compliance is incorporated into the credentialing process. Corrective measures are determined by the Pharmacy and Therapeutics Subcommittee, with subsequent actions carried out by peer physicians. The net result is a positive influence on prescribing practices that improves the appropriate and effective use of drugs, while meeting Joint Commission standards. PMID- 10161609 TI - Pharmacoeconomics: disease-based management applications. AB - Pharmacoeconomic information is rapidly becoming an accepted format for evaluating and comparing various treatment options. Such information may either supplement or replace standard methods for evaluating new drugs for possible inclusion on the formulary. It is important to recognize the pitfalls that may accompany different methods of collecting and evaluating pharmacoeconomic studies. Such information is important because drug use and outcomes in a real world setting may differ substantially from those within the confines of a clinical trial setting. PMID- 10161610 TI - Cost and quality considerations in antibiotic formulary management. AB - Numerous factors are considered in the design of an antibiotic formulary, consisting primarily of indicators of clinical efficacy and safety, as well as economic viability. Similarly, there are many potential strategies for subsequent antibiotic formulary management ranging from global educational efforts to comprehensive required antibiotic justification programs. Antibiotic formulary management programs should be tailored to individual institutions and utilize a multidisciplinary approach where possible. The primary outcome goals of such programs are generally controlled antibiotic costs, optimized clinical efficacy, minimization of adverse events, and reduced microbial resistance development, although quantification of program impact on these parameters continues to be a challenge. PMID- 10161611 TI - Antibiotic streamlining: monitoring and compliance. AB - The principles of antibiotic streamlining are discussed. At the University of Nebraska Medical Center, antibiotic streamlining is conducted through the coordination of decentralized pharmacists and a comprehensive drug-usage evaluation program. Streamlining is focused on reducing redundant antibiotic coverages and converting from i.v. to oral therapy whenever possible. Examples include switching from i.v. to oral ciprofloxacin and reducing the number of ampicillin-sulbactam, clindamycin combinations. Benefits and drawbacks of the program are discussed. PMID- 10161612 TI - Antibiograms. AB - In most hospitals, the results of countless cultures and sensitivities are summarized and reported in the form of antibiograms. The advantages and limitations of antibiograms must be considered when contemplating empiric therapeutic recommendations. Methods to optimally utilize this resource are described. Antibiograms may also be used to guide formulary decisions, although practically they are more useful in monitoring recent additions or deletions. Antibiograms that incorporate formulary, drug of choice, dosage, cost, and hospital-specific restrictions will facilitate patient-specific decisions. PMID- 10161613 TI - Single daily dose and simplified dosing regimens as a method to improve antibiotic therapy. AB - Pharmacists can be an important member of the patient care team by assisting with the development of dosing regimens. By optimizing the pharmacokinetic properties of the antimicrobial agents, regimens can be developed that are simple to manage. Newer approaches to simplifying dosing regimens include once-daily aminoglycoside therapy, continuous infusion beta-lactams, and utilizing agents with long half lives such as ceftriaxone and azithromycin. These efforts could result in improved compliance and in some instances decrease costs and toxicities associated with antibiotic therapy. PMID- 10161614 TI - Society of Infectious Diseases Pharmacists (SIDP) position papers. AB - The Society of Infectious Diseases Pharmacists (SIDP) is an organization, comprised mainly of Pharm D.s in academia, industry, and hospital practice, whose professional orientation is in the area of infectious disease pharmacotherapy. SIDP membership has deemed it necessary to produce position statements on issues of concern to the infectious disease community. This article is an overview of SIDP, along with a description of their guidelines for position statement development. The value of any organization's position statement(s) is influenced by a multitude of factors (e.g., author's expertise, accuracy, evidence, opinion, etc.); thus, some degree of scrutiny is advised. PMID- 10161615 TI - Methods of documenting cost savings associated with an antibiotic management program. AB - Documenting the financial impact of an antibiotic management program is important for demonstrating the value of these pharmacy-driven or interdisciplinary services. There are several cost-saving methods that may be utilized in justifying such programs. These include intervention analysis, drug purchasing comparisons, specific agent tracking, patient length of stay analysis, and evaluation of antimicrobial therapy for a specific disease state. Several of these methods have been utilized for successfully documenting the financial impact generated by our institutions antibiotic management program. PMID- 10161617 TI - Provider-sponsored HMOs emerging as new competitive strategy. PMID- 10161616 TI - Selecting antibiotics based on pharmacokinetic and pharmacodynamic principles. AB - Key pharmacokinetic and pharmacodynamic parameters influencing antimicrobial selection include the area under the curve (AUC) and minimum inhibitory concentration (MIC). These concepts can be integrated to describe the unique triangular relationship between the antibiotic, infecting organism, and patient. Antibiotic pharmacodynamics have been described as the ratio of AUC/MIC, maximum concentration to MIC, and time above MIC. These relationships can help define whether an antibiotic class kills by concentration-dependent or concentration independent mechanisms. For example, aminoglycosides and fluoroquinolones have concentration-dependent killing while beta-lactams are concentration-dependent. This killing is also reflected in the post-antibiotic effect (PAE) that describes the prolonged activity even when the antibiotic levels are undetectable. These principles allow antibiotic classes to be selected and dosed via new strategies such as once daily aminoglycosides and continuous infusion beta-lactams. PMID- 10161618 TI - Profile of provider-sponsored HMOs. PMID- 10161619 TI - Should case managers absorb UR, discharge planning? PMID- 10161620 TI - 'Staircase' replaces traditional pathways. AB - Tired of using traditional clinical pathways, case managers at an Arizona hospital developed a "staircase to wellness" for patients instead. The staircase approach allows more flexibility for the patient's recovery because it doesn't mandate certain procedures or goals be met on certain days. Instead, the patients follows certain "steps" to recovery in the preoperative, intensive care, recovery, and discharge portions of the hospital stay. Physicians and nurses like the new approach of mapping the patient's progress better than older methods because it allows for individual differences in patients and continuity of care is improved. PMID- 10161621 TI - New pathway saves neonatal unit thousands. PMID- 10161622 TI - Want more recognition for your critical pathways? AB - Case managers at the Daniel Freeman Memorial Hospital in Inglewood, CA, planned a "celebration of success" earlier this year to highlight their accomplishments. Individual critical pathways teams presented data for their different areas, such as orthopedics and cardiac surgery. Team members were able to educate staff about their efforts and show off their accomplishments to administrators. It was so successful, that another celebration is planned for next year. PMID- 10161623 TI - Give your critical paths an annual checkup. PMID- 10161624 TI - Fast-shifting market conditions call for agile strategies. PMID- 10161625 TI - Contact capitation: a transitioning tool for the brave. PMID- 10161626 TI - Managed care calls for new physician compensation formulas. PMID- 10161627 TI - Win-win strategies for successful medical practice management. PMID- 10161628 TI - Medicare fiscal intermediaries defend limiting pay for therapies. PMID- 10161630 TI - AHCA satisfaction questionnaires focus on subacute patient views. PMID- 10161629 TI - HCFA hears stakeholders agree: survey doesn't get job done. PMID- 10161631 TI - HCFA publishes SNF routine cost limits for FY 1997. PMID- 10161632 TI - Ability to offer range of subacute services is key to success. PMID- 10161633 TI - Pathways can be a strong subacute tool, but get staff "buy-in". PMID- 10161634 TI - Five trends point to subacute opportunities in managed care. PMID- 10161635 TI - Subacute care providers prepare for higher acuity patients. PMID- 10161636 TI - Rehab network gets managed care work with outcomes, quality data. PMID- 10161637 TI - Hospital-based subacute: strategy or shell game? PMID- 10161638 TI - Target your billing practices before Medicare does. PMID- 10161639 TI - Get ready: Medicare risk HMOs are coming on strong. PMID- 10161640 TI - Will they bite? Ten ways to entice docs into using your facility. PMID- 10161641 TI - Data connection. The right preadmission screening process can create a data base and strengthen your bottom line. PMID- 10161642 TI - Subacute success story. Montowese Health and Rehabilitation Center. PMID- 10161644 TI - Stark II regulations anticipated. PMID- 10161643 TI - Here come the HMOs. PMID- 10161645 TI - Provider contract joint ventures; are they defensible under the Medicare/Medicaid Anti-Kickback Statute? PMID- 10161646 TI - Disease management contracting: an overview of risk reduction provisions. PMID- 10161648 TI - FTC issues antitrust advisory opinion; disapproves of pediatric network. PMID- 10161647 TI - Physician recruitment incentives: a regulatory primer. PMID- 10161649 TI - Development of laser operations; avoiding Certificate of Need requirements. PMID- 10161650 TI - A new way to choose a personal physician. PMID- 10161651 TI - Healing body and mind. PMID- 10161652 TI - McData project moves closer to national standards. PMID- 10161653 TI - Bringing prevention home. PMID- 10161654 TI - Getting better all the time. PMID- 10161655 TI - A friendly voice in the night. PMID- 10161656 TI - The heart of the matter. PMID- 10161657 TI - Measuring satisfaction. PMID- 10161659 TI - Linking physician reimbursement to quality and patient satisfaction. PMID- 10161658 TI - An imperative partnership. PMID- 10161660 TI - Informed choices. PMID- 10161661 TI - Six tips for Medicare marketing. PMID- 10161662 TI - Quality assurance for delegated services. AB - Delegation of specified administrative and quality assessment activities is an effective and cost-efficient alternative for many health plans. But regardless of which services are delegated or subdelegated, the health plan remains responsible and accountable for the quality of care and services provided to health plan members. Appropriate oversight and monitoring of delegated activities allows the health plan to ensure that the delegate meets the standards and goals of the health plan and assures a consistent, high standard of care. PMID- 10161663 TI - Improving care for the frail elderly. PMID- 10161664 TI - Sharing expertise. PMID- 10161665 TI - Lessons from AWP (any willing provider). PMID- 10161666 TI - Assessing health technology. PMID- 10161667 TI - Trends for Medicaid and Medicare. PMID- 10161668 TI - Can this building be saved? PMID- 10161669 TI - Can design save money? PMID- 10161670 TI - Directory of architects & interior designers. PMID- 10161671 TI - Designing for dementia. PMID- 10161672 TI - Facilities in transition. PMID- 10161673 TI - Can they go home for the holidays? PMID- 10161674 TI - Not-for-profits and for-profits become less distinct. PMID- 10161675 TI - How times have--and haven't--changed. PMID- 10161676 TI - A rising star. Adult day services find a place in the constellation of services. PMID- 10161677 TI - "Inadequate care" and the False Claims Act. PMID- 10161678 TI - Ten steps to follow in systems selection. PMID- 10161679 TI - Re-engineering for managed care. PMID- 10161680 TI - Norms the creation of a common culture. AB - When two health care providers merge into one, management is presented with a daunting task: How do you make employees from two different work environments work together as a team? One agency solved this problem by creating a common culture. PMID- 10161681 TI - Patients focus with an eye on the bottom line: using patients surveys for quality improvement. AB - Measuring patient satisfaction is one of the best ways to measure quality. Measuring patient satisfaction, however, is not as simple as writing a few questions. Agencies need to consider many factors as they develop questionnaires that will help them determine specific points to improve. PMID- 10161682 TI - Cost versus quality. Making ethical decisions in home care today. PMID- 10161683 TI - Transforming chaos turning health care trends into success strategies. AB - These days simple survival is a key issue for many home care administrators. Some providers will thrive amid the chaos--those that can recognize and develop a strategy to deal with the major trends that are driving the rapid evolution of the industry. PMID- 10161684 TI - Surviving the chaos of merger mania. AB - Mergers are the watchword of the decade as managed care changes how health care is delivered. Beyond changing day-to-day operations, mergers can affect staff personally. How can home care and hospice managers help their staff to keep priorities straight and morale high? PMID- 10161685 TI - Driving change versus reacting to chaos: one VNA's story. AB - Fluctuations in the current home care environment--increased competition, reimbursement reforms, and the impact of managed care--are a source of anxiety for many providers. One VNA carved a strategic plan for itself despite the chaos, motivated by a desire to lead rather than be led. PMID- 10161686 TI - Safeguards for managed care. PMID- 10161687 TI - Productivity of registered nurses in home care. AB - The need for reliable home care industry data is increasing every year because of managed care organizations' focus on outcomes. A 1987 study (published in February 1988 CARING and recently updated with 1996 data) examines the important area of home care nurses' productivity. PMID- 10161688 TI - Never give in. PMID- 10161689 TI - Earnings and major field of study of college graduates. PMID- 10161690 TI - Contingent workers. AB - Federal laws affect contingent workers and the companies using their services, but do not directly address compliance in the context of such workers. Congress enacted employment laws, as well as employee benefit laws, prior to popular use of contingent workers. This article examines fact-specific applications of federal employment laws and existing contingent worker regulations, particularly within the benefits and compensation arena. PMID- 10161691 TI - When Johnny can't breathe. Should paramedics perform pediatric intubation in the field? PMID- 10161692 TI - Jonas Matz, EMT-I, LVN. A hollywood movie-studio medic cares for Tinsel Town's finest. Interview by Nancy Perry. PMID- 10161693 TI - Forcible entry. PMID- 10161694 TI - The Long Island experience: EMS & wildfires. PMID- 10161695 TI - Head bangers and fender benders. PMID- 10161696 TI - When disaster hits home. EMS agencies aren't immune to catastrophes. PMID- 10161697 TI - Just a gut feeling. PMID- 10161699 TI - 10 minutes with... Kate Dernocoeur, EMT-P -interview by Nancy Perry-. PMID- 10161698 TI - Bee-ware! Los Angeles EMTs, paramedics and fire fighters are preparing to do battle with the Africanized honeybee. PMID- 10161700 TI - Standardization offers IHC hospitals a recipe for success. PMID- 10161701 TI - Challenge: how to encourage dysphagia patients to increase their daily intake. PMID- 10161702 TI - Making the most of merchandising, promotions & special events. PMID- 10161703 TI - Managed care, healthy communities and the new healthcare foundation. PMID- 10161704 TI - A health care safety net. PMID- 10161705 TI - Market memo: managing utilization: the old way and the new way. PMID- 10161706 TI - What's in it for you? HealthShare Technology answers the question with data analysis. PMID- 10161707 TI - Providers use foundation grant to improve mental health care for rural women. PMID- 10161708 TI - Reinventing AHCs to meet financial, clinical, research and educational demands. AB - Declining profit margins for clinical services are forcing academic health centers to look for other ways to increase revenues to support their research and education missions. One revenue source is the sale of research and education products on the private market. PMID- 10161709 TI - Three health care competitors cooperate to create health campus in Shakopee, Minn. AB - Allina Health System, Benedictine Health System and HealthSystem Minnesota collaborated to build the South Valley Health Campus in Shakopee, Minn. A special governance structure has been created to ensure that the partners all live happily under one roof. PMID- 10161710 TI - Multihospital systems are leaner operators. PMID- 10161711 TI - Managed care continues move into Medicaid mental health. PMID- 10161712 TI - The door to Kaiser's closed system opens a crack as Permanente's physicians unite. PMID- 10161713 TI - The future of integrated health care delivery systems isn't what it used to be. PMID- 10161714 TI - Integrating Ashtabula, Ohio: find somebody to represent the deal, not the dealers. PMID- 10161716 TI - Look for associations to lead behavioral change efforts. PMID- 10161715 TI - Fearful forecasts for 1997: moderation in Washington? PMID- 10161718 TI - HHS Inspector General Brown: we all must work together to fight healthcare fraud. Interview by Wendy Herr. PMID- 10161717 TI - Safeguarding the confidentiality of electronic medical information. PMID- 10161719 TI - Core competencies create value. AB - In the past, healthcare providers have created value by delivering care on demand to their patients. In the future, however, providers will create value by mastering four core competencies: effective management of health and wellness, effective care delivery, effective population enrollment, and effective management of financial risk. PMID- 10161720 TI - Assessing options for developing the continuum of care. AB - Healthcare financial managers have an important role to play in developing the healthcare services continuum. They can provide guidance as their organizations consider options for developing the continuum and thereby facilitate the creation of both effective care delivery models and viable business arrangements. PMID- 10161721 TI - Partner risk: the hidden threat of capitated provider networks. AB - As provider networks align risk-sharing incentives, they must avoid partner risks that could pose a threat to the network. Partner risk results when actions taken by one or more partners in a network threaten to adversely affect other partners in the network. Such risk can arise from the way partners manage cost drivers under capitation or through passing risk to one another. PMID- 10161722 TI - Must a risk-assuming healthcare provider have an insurance license? AB - With the growth of managed care has come the question of whether a risk-assuming provider organization must be licensed to sell insurance. The debate centers on whether capitation arrangements represent an insurance risk or a business risk and whether states have the right to regulate agreements between providers and self-insured employers. A flexible, reasonable approach will be needed if legislators decide to regulate providers that assume varying degrees of risk. PMID- 10161723 TI - Understanding the financial implications of APGs (ambulatory patients groups). AB - The ambulatory patient group (APG) system, a new prospective payment system for reimbursing outpatient services, is being adopted by increasing numbers of third party payers and may soon be used in the Federal Medicare program. APGs involve the grouping of healthcare services provided during a specified service period. Payment rates are complicated by the assigning of multiple APGs to a single patients encounter and by discounting schedules. APG cost management tools must be developed to assess the financial impact of this complex system. PMID- 10161724 TI - Implementing SFAS No 121: Accounting for Impaired Assets. AB - In March 1995, FASB issued Statement of Financial Accounting Standards (SFAS) No. 121: "Accounting for the Impairment of Long-Lived Assets and for Long-Lived Assets to be Disposed Of." It establishes accounting standards for assets whose carrying costs have been overstated due to a variety of circumstances that have reduced the value of the assets. Healthcare financial managers should fully understand the statement's implications for their organizations. PMID- 10161725 TI - Cost-justifying electronic medical records. AB - As interest in electronic medical record systems increases, the need to cost justify these systems is becoming more important. But determining the cost benefit ratio of such systems is difficult. The cost of implementing a system includes more than the price of hardware and software. It can be difficult to quantify the qualitative benefits associated with computerizing clinical information. Healthcare financial managers should be aware of the uses and limitations of financial tools for assessing electronic medical records technology. PMID- 10161726 TI - Developing a cost accounting system for a physician group practice. AB - Physicians in group practices must gain a competitive edge to survive in a healthcare environment in which cost efficiency has become critical to success. One tool that can help them is a cost accounting system that yields reliable, detailed data on the costs of delivering care. Such a system not only can enable physicians and group administrators to manage their operations more cost effectively, but also can help them accurately assess the potential profitability of prospective managed care plans. An otolaryngology practice located in Mississippi provides a model for developing a cost accounting system that can be applied to physician group practices. PMID- 10161727 TI - Strategic plan can start physician network on path to success. AB - Forming physician networks can improve the ability of healthcare organizations to attract managed care contracts. However, forming physician networks can be risky for organizations new to such affiliations. One way healthcare organizations can reduce the risk and improve the odds of success in network participation is to develop a strategic plan. PMID- 10161728 TI - Do your Medicare claims and reports tell the whole story? PMID- 10161729 TI - New disbursement services need new RFPs. PMID- 10161730 TI - Avoiding the legal pitfalls of DRG window regulations. PMID- 10161731 TI - Sustaining security's effectiveness as a hospital continues to expand. PMID- 10161732 TI - Hospital drills test staff response to 'infant abduction'. PMID- 10161733 TI - How hospital security met the challenges of winter floods in PA, OR. PMID- 10161734 TI - Special report. NIOSH: new facts about violence against healthcare workers and security officers. AB - A definitive compilation and analysis by NIOSH (National Institute For Occupational Safety and Health) of recent studies measuring violence in the workplace presents the clearest picture to date of the nature and frequency of such violence and which employees are at greatest risk. For managers in security and health care, the NIOSH statistics are especially important. In this report, we'll review what we believe are the most significant findings of NIOSH and other sources and present details of programs designed to prevent healthcare workers from becoming victims of violence. PMID- 10161735 TI - When tornadoes hit: how hospital disaster plans were carried out. PMID- 10161736 TI - How Kessler Institute secures the privacy rights of its rehab patients. PMID- 10161737 TI - Some ABC's about hospital computer thievery from expert Dan Bowers. PMID- 10161738 TI - HCFA's peer review agencies turn collegial, but keep clout. AB - The evolving peer review format, called the Health Care Quality Improvement Program, uses CQI techniques to ensure quality of care for Medicare recipients instead of the more punitive, case-by-case method used traditionally. The program offers opportunity to measure hospitals against widely accepted standards of care, against organizations of comparable size, against statewide averages, and against national averages. PROs can still assess fines and recommend removal of physicians from Medicare. PMID- 10161739 TI - PROs emerge as rich source for indicators. PMID- 10161740 TI - RNs make great case managers. PMID- 10161741 TI - Hospital breaks new ground with ED discharge planning. AB - Utilization management extends into the emergency department. Utilization managers look at reducing length of stay hours, not days, and also act as gatekeeper for inpatient admissions. Inpatient and outpatient follow-up is key to good outcomes and patient satisfaction. PMID- 10161742 TI - Payoff's worth the price in UR/discharge merger. AB - Combining discharge and utilization review functions eliminates duplication of effort in chart review and assessing patient needs. Cross trained staff can better cover for each other on sick days and vacation. Increased efficiencies led to reduction in staffing needs. PMID- 10161743 TI - The staff survey cafe: we never close. AB - Let the staff who well be impacted by the survey help create it. Don't ue generic questions--tailor them to the survey respondents. Make the survey fast, fun, and convenient. Assign team members responsibility for obtaining answers. PMID- 10161745 TI - 1996 salary survey results. Largest salary increases at the top in the South. PMID- 10161744 TI - Verbal complaints key for monitoring satisfaction. AB - Patient complaints often do not get recorded or collected for meaningful interpretation or reaction. Informal complaint data should be compiled organization-wide, not department-wide. An institution-wide policy and procedure concerning patient complaints can keep staff aware of importance of patient complaints and how they should respond. A standardized, hospital-wide method for handling complaints enhances the public's image of the hospital and substantiates the hospital's concern for high-quality patient care and services. PMID- 10161746 TI - Software breakthrough makes data sharing easy. AB - Technical barriers have made sharing health care data difficult among systems with different data collection tools and software; modifications to data collection tools also present difficulties when comparing new data with old. Software program standardizes indicators or questions so sharing data becomes easier. Data bank of thousands of indicators or questions are stored making survey development much easier. PMID- 10161747 TI - Having trouble selecting improvement priorities? PMID- 10161748 TI - QIOs offer costs savings, quality, but will they last? AB - Set priorities for quality management programs to ensure their success. Focus on defined mission, vision, and values statement to define priorities and avoid temporary "sore thumb" problems. An organization must face its barriers to becoming focused and answer tough questions. PMID- 10161749 TI - Joint Commission alters environment standards. PMID- 10161750 TI - Family clinic. Sister Thea Bowman Family Health Center, Brooklyn, New York. PMID- 10161751 TI - A cut above the rest. PMID- 10161752 TI - Perceptions of the NHS. Not exactly a picture of health. PMID- 10161753 TI - Communications. Secret admirers. PMID- 10161754 TI - Hospital discharge. Short but sweet. PMID- 10161755 TI - Emergency admissions. Driving range. PMID- 10161756 TI - Bed management. Preferential treatment. PMID- 10161757 TI - Community care. Face values. PMID- 10161758 TI - Cancer services. 3-D for C. PMID- 10161759 TI - At La Palestra, past and present meet in pursuit of wellness. PMID- 10161760 TI - Squeeze play. PMID- 10161761 TI - Some tips on solving those pesky power quality problems. PMID- 10161762 TI - Flexible facilities by design. PMID- 10161763 TI - Whoops! Safe health care facility floors are no accident. PMID- 10161764 TI - They're here: what to expect from an OSHA house call. PMID- 10161765 TI - Safety in numbers: mergers create opportunities. PMID- 10161766 TI - Warning! Monitoring workers' calls can backfire. PMID- 10161767 TI - Should your project budget include cost of equipment? PMID- 10161768 TI - Accepting patients' refusals of treatment. PMID- 10161769 TI - Third Circuit allows physician's federal antitrust suit to be tried. PMID- 10161770 TI - Intermediate sanctions worry officers and boards of exempt organizations. PMID- 10161771 TI - Two Circuit Courts of Appeal reject Title VII claims. PMID- 10161772 TI - Stress and coping strategies in nurses from palliative, psychiatric and general nursing areas. AB - Briefly looks at the stress and coping strategies in nurses from palliative, psychiatric and general nursing areas. Examines the results of a recent study where 308 nurses completed questionnaires on sources of stress and coping strategies. Identifies five major sources of stress, concluding that, if patients are to receive quality care, then the needs of nurses must also be taken into consideration. PMID- 10161773 TI - Whither career development in the NHS? AB - Observes that changes in the nature of employment and career development in the private sector have also affected the National Health Service in a similar way. Highlights how economic pressures have forced organizations to rationalize their workforces, and with this has come an end to the psychological contract which has existed between employers and employees. Outlines the nature of those changes, and their effect on individuals who need to take responsibility for their own career development. Suggests that there is now a need to develop a new moral contract between employers and employees. In return for job security, employers can offer a range of developmental opportunities to enable employees to become more employable when new employment is required. PMID- 10161774 TI - Image and identity: performance appraisal in a trust hospital. AB - Looks at performance appraisal (PA), which has become an important tool in the overseeing of employees in contemporary society. Notes, however, that little work has focused on its mediation or actual practice, beyond simple descriptions informing its implementation. First examines the changing nature of employee management under PA, before investigating the contemporary usage of PA regarding its emphasis on the issue of managing and controlling the "images" of performance. Illustrates this with research, gathered from a case study in the Midlands. More specifically, focuses on the requirement on individuals to present the right image/self-presentation as a means of subordination. Highlights, with the use of a hospital case study, some of these issues in relation to the changes taking place in the public service sector, which faces fundamental transformations to its concept of service. Concludes that, whatever the original intentions of PA were, they have seriously failed, and are superseded by the management of the subjectification of performance. PMID- 10161775 TI - Medical staffing--the Calman Report: implications and costs. AB - Introduces the 1993 Calman Report on specialist medical training, summarizing the report's recommendations and then exploring its implications for service purchasers and providers. Illustrates these using discussions within University College London Hospitals NHS Trust and The Royal Hospitals NHS Trust. PMID- 10161776 TI - The impact of the EN conversion programme on the NHS nursing workforce. AB - States that the number of enrolled nurse conversions completed during the last ten years has had a significant impact on the number of registered nurses (RNs) available for employment in the National Health Service (NHS), and the contribution made by the enrolled nurse conversion course programme to the NHS workforce may have delayed the impact of the "demographic time bomb" on nursing recruitment. Emphasizes that the winding down of the conversion programme, and a fall in the number of RNs employed in the NHS, combined with a decline in entries to preregistration (initial) training, could signal the beginning of the long awaited crisis facing the nursing profession. PMID- 10161777 TI - Compensation in the year 2000: pay for performance? AB - Notes the attempts by many companies today to identify innovative compensation strategies that are directly linked to improving organizational performance. Observes that there are many approaches to incentive compensation such as cash bonuses, stock purchase and profit sharing. Examines the individual and group incentive concepts that reward performance based on predetermined organizational goals and metrics, several behavioural theories that can be associated with reward and compensation, and convergent and divergent views and conclusions from the business community. PMID- 10161778 TI - Stress in junior hospital medical and dental staff: a descriptive account of their concerns and needs. AB - Examines the issues of work-related stress in the healthcare professions, focusing on junior medical and dental staff. Identifies the stressors, and reports on an interview survey conducted as part of a larger study funded by the National Health Service Management Executive to identify the levels of stress. Concludes that outsourcing to an independent counselling service could prove to be an effective stress-management strategy. PMID- 10161779 TI - Managerialism and professionalism in general practice: teamwork and the art of "pulling together". AB - Considers the impact of recent government policy on the organization of primary care in England and Wales. Discusses the notion and practice of "teamworking" currently in vogue, and analyses implications for doctors, nurses and managers working in/attached to general practices. Draws on the findings of a study of primary care team building which took place in a UK health authority (here referred to as "Weston"), and focuses on the experience of four general practices as they have attempted to develop as multidisciplinary partnerships. Gives consideration to the "new managerialism" evident in the NHS and its attempt to redefine professionalism and professional autonomy. PMID- 10161780 TI - Performance appraisal and women's "performance" in a Trust hospital. AB - Reports that performance appraisal (PA) has become an important tool in "controlling" employees in modern public industries. Little work, however, has focused on its mediation or actual practice in relation to different groups, such as women and ethnic groups. Examines the changing nature of employee management under PA in relation to how it affects the role of women in organizations. Illustrates with research, gathered from a case study in the midlands. Moves analysis beyond the individual-collectivist tradition towards assessing the subtle control strategies now employed in the contemporary form of 1990s management. More specifically, illustrates the requirement for women to make the correct self-presentation as a means of "getting on" and, from a managerial stance, of subordinating them. The use of a hospital case study highlights some of these issues in relation to the changes taking place in the public service sector, which faces fundamental transformations to its concept of service. Concludes that PA has seriously affected the role of women in public health organizations and that PA has seriously failed to meet the needs of women. PMID- 10161781 TI - Teaching health economics to medical personnel from developing nations. AB - Outlines the author's experiences and the lessons learnt from work in the field of management training for doctors and other medical personnel. Explains the policy of using a dual approach: economic concepts and ideas in practical situations. States that by adopting this participative, problem-solving approach and involving the discipline of economics in tandem with other skills and subjects, it addresses some of the issues which medical personnel face in their places of work. PMID- 10161782 TI - Thinking beyond the box. AB - Contends that as techniques to motivate, empower and reward staff become ever more sophisticated and expensive, one of the most obvious, though overlooked, ways of tapping the creativity of employees is the suggestion scheme. A staff suggestion scheme may well be dismissed as a simplistic and outdated vehicle by proponents of modern management methods, but to its owners it can be like a classic model--needing just a little care and attention in order for it to run smoothly and at a very low cost. Proposes that readers should spare some time to consider introducing a suggestion scheme as an entry level initiative and a precursor to more sophisticated, elaborate and costly change management mechanisms. PMID- 10161783 TI - Simulation in hospitals. AB - Health care costs continue to rise because increased demand for services and limited budgets put pressure on resources, however efficiently they may be used. Proposes discrete event simulation as an effective tool in the search for more efficient health care systems. Looks at the application of a desktop computer simulation package to model part of a hospital subsystem. The simulation package shows how efficiency might be improved by moderating available resources and times taken to complete tasks. Maintains that the principles expounded here are applicable to many different aspects of health care management. PMID- 10161784 TI - Are there alternatives to merger? AB - The reconfiguration of the supply side of the National Health Service (NHS) has stimulated an extensive debate about the need to merge NHS Trusts to maintain viable organizations. The result has been a number of mergers across the UK. Considers the underlying advantages of mergers and their drawbacks and argues that consideration must be made to addressing the long-term strategic direction of an organization rather than regarding mergers as ends in themselves. Undertakes an appraisal of alliances and joint partnerships as alternatives to merger. Considers the conditions necessary to create effective alliances and joint partnerships and the factors which will sustain them. Appraises these requirements in the context of the NHS Trusts, in which little detailed work has been undertaken on classifying, understanding and developing what effective alliances mean for these organizations. PMID- 10161785 TI - IOL (intraocular lens) prices may be stabilizing as payment structures, technology undergo changes. PMID- 10161786 TI - Food for thought: how to keep kosher yet cut kitchen costs. PMID- 10161787 TI - Review suctioning systems with an eye to cost containment. PMID- 10161788 TI - Savings were an early byproduct of outsourcing. PMID- 10161789 TI - Who won what in the Kassebaum/Kennedy struggle? PMID- 10161791 TI - HCFA approaches Medicare managed care. Administrator focuses on choice and quality for beneficiaries. PMID- 10161790 TI - From ministry to market. Catholic healthcare can survive in an age of commercialization. AB - Large, for-profit healthcare corporations now dominate hospital and physician services in many parts of the nation. Such organizations are under unrelenting pressure to produce profits; news stories show that these pressures can lead for profits to engage in questionable, even illegal activities. Also, for-profits are unlikely to provide much care for the poor and uninsured. Unfortunately, Catholic providers have several disadvantages when competing with for-profits, and one is the fact that they do provide care for the poor. Catholic providers are handicapped also by: Problems with their geographic locations. Difficulties in creating partnerships with physicians. Lack of access to capital. Loss of political influence. On the other hand, Catholic healthcare providers have several advantages over for-profits. Among them are: A reservoir of public goodwill. Experience in forming networks The potential for prudent growth. A common vision. Access to Church pulpits. The influence of women and men religious Given theses advantages, Catholic health ministry leaders could boldly restructure their own organizations, and, in doing so, mitigate the commercialization of healthcare in the United States. PMID- 10161792 TI - Prepare for Medicare/Medicaid managed care. PMID- 10161794 TI - What are true community benefits? AB - Not-for-profit healthcare organizations have increasingly recognized the need to document their community benefit services, but not all healthcare services should be included in a community benefits report. Some services are reasonably expected of any high-quality healthcare organization, regardless of its tax status. Others are provided as part of a commitment to the community, but they cannot or should not be quantified. A third group of services, however, can be counted and reported in an inventory of benefits. To qualify as a true community benefit, an activity must respond to a particular health problem in the community, especially one involving special populations. In addition, it must be financed through philanthropic contributions, volunteer efforts, or an endowment; generate a low or negative margin; or be a service that would be discontinued if the decision were made on a purely financial basis. Once an organization has determined that an activity is a community benefit and not a basic service or promotional program, organizational leaders must decide whether to include the service in a quantitative inventory or in a more general narrative without assignment of specific financial benefit. The community benefit services might be further broken down according to the intended recipient, whether it is the poor or the broader community. PMID- 10161793 TI - Three factors critical for end-of-life care. AB - Appropriate care of persons with life-threatening illnesses requires a different, perhaps higher level of response from organized healthcare than has been typical in the past. This involves three critical components: Leaders must be committed, visible advocates of high-quality end-of-life care. This enables them to plan changes, deploy resources, and integrate this commitment throughout the organization's strategic plan. Ensuring appropriate care of the dying requires adequate human and financial resources. First, the organization must fully identify the educational and service needs of patients, families, and care givers experiencing life-threatening illnesses. The organization must work well with other community-based organizations to address identified needs. Senior managers can improve care by personally commissioning teams, acknowledging success, and rewarding performance. Finally, organizational goals, strategies, and performance objectives must be shaped by a commitment to ensure appropriate care of the dying. Our commitment to the dying must be based on our values. An organizational "statement of rights and responsibilities" is one way of providing a visible expression of the mission, core values, and mutual responsibilities among care givers and patients, residents, HMO members, and clients. PMID- 10161795 TI - Under one roof. AB - Poverty, drug abuse, lack of prenatal and primary care, and lack of skills to find a job or run a household dog the heels of those who live in Boston's Dorchester neighborhood. These problems prompted the Caritas Christi Health System, sponsored by the Archdiocese of Boston, to shed its acute care mentality and begin building a service mix that responds to the needs of the neighborhood beyond healthcare, including maintaining a physical presence in the neighborhood itself. To accomplish its vision, the health system folded the services of St. Margaret's Hospital for Women into St. Elizabeth's Medical Center of Boston and turned the St. Margaret's building into a campus for interdependent services, some of which are funded by the health system and some of which are funded by government or other sources. The result is St. Mary's Women and Infants Center, which not only gives each of those agencies a presence in the neighborhood they serve, but has the more important benefit of coordinating services for people with multiple needs. PMID- 10161796 TI - Two hospitals revive school-based care. PMID- 10161797 TI - Demystifying values assessment. AB - The current climate of networking and restructuring among healthcare providers calls for measurable methods to assess an organization's adherence to its fundamental values. In response to that need, the SSM Health Care System (SSMHCS) prepared a guide to assessing values integration. This innovation tool has proven to be adaptable for many uses: it helps organizations examine the compatibility of potential partners' values, as well as their own progress toward integration of their stated mission, values, and philosophy. The guide outlines 10 key areas that serve to focus and define the values assessment: Vision. Serving the poor. Serving the community. Continuous quality improvement. Employment practices. Role of leaders. Stewardship Advocacy. Wellness. Church. The guide includes a discussion of the significance of each of these key areas: the implications of including each area; and key indicators, or standards statements, for assessment. Users' response to the guide has been overwhelmingly positive. This guide should provide valuable systemwide data and identify areas of strength or needed growth. PMID- 10161798 TI - Chaplains' roles expand in redesign. AB - CARE 2000, the patient-focused redesign at Mercy Hospital Scripps Health San Diego, is significantly changing the roles of the facility's chaplains. On one hand, Mercy's chaplains have received training the roles of other care givers, learning, for example, how to give bed baths, take vital signs, and apply CPR. On the other the chaplains have taught courses in which other care givers learned, for example, about the differences between spirituality and religion, the grieving process, and spiritual growth. Through such cross training, Mercy's chaplains have increased their visibility in the hospital and the community, improved their communication with other care givers, and enhanced other care givers' understanding of the importance of spiritual care. PMID- 10161799 TI - Bone marrow donor campaign expands hospital's outreach. PMID- 10161800 TI - A ministry, not a business. PMID- 10161801 TI - Heeding God's voice. PMID- 10161802 TI - Exploring the international role of clinical engineers. Part II.. Interview by Joe Dyro. PMID- 10161803 TI - Validating the integrity of one-way check valves for the delivery of contrast solution to multiple patients. AB - The infusion of contrast solution into multiple patients from a single infusion bag is desired in clinics concerned with the high cost of the solution. Using one way check valves in the infusion line is a protection method to reduce the risk of blood-borne cross-contamination. The suitability of this method is assessed through testing of the operating characteristics of the valves and infusion system and the high back pressure testing of the valves. The results indicate that the use of back-flow valves can ensure the prevention of flow from the patient to the injector. Results also indicate that the use of sprung valves, those which require a significant forward pressure to open them, are more appropriate for this application. PMID- 10161804 TI - A network-based prototype for interactive telemedicine & automated management of distributed, clinical databases. AB - A network-based prototype has been developed to automate the process of generating and maintaining distributed databases of medical images and clinical reports, and for conducting interactive consultation among disparate clinical and research sites irrespective of the architecture of interacting computers. Pathologists routinely interpret gross and microscopic specimens to tender diagnoses and to engage in a broad spectrum of research. This assessment process leads to clinical decisions often limited by time constraints and by the availability of local expertise. Consultation with peers at other institutions is typically achieved by direct transfer of slides rather than images. A network of heterogeneous computer platforms, graphical user interfaces, and operating systems was established to test the performance of the software. Clinical diagnoses rendered by pathologists using the prototypical system and software were consistent with those reported two years earlier using conventional light microscopy in more than 97% of the cases studied. PMID- 10161805 TI - Reaching underserved women with cancer screening: different strategies needed for different groups. PMID- 10161806 TI - Hospital capital projects show selective growth. PMID- 10161807 TI - Expanding the outcomes management process. PMID- 10161809 TI - Understanding the forces driving medical group practice activities: an overview. AB - This article provides the historical context for examining the current forces driving medical group practice organizations. Prepayment has been around for some groups since the 1930s and the dual objectives of lowering costs and improving the quality of patient care were among the original reasons for forming group practices. Some of the basic issues for group practices today are discussed in light of evolution of this model of service delivery and the intensity of today's changing environment. PMID- 10161808 TI - Implementing an electronic medical record system in ambulatory care. PMID- 10161810 TI - Managed care plans and the organizational arrangements with group practices. AB - This article addresses the variety of structural and legal arrangements between group practices and health plans. The continuum of relationships will be discussed, including long-term arrangements whereby in exchange for long-term commitments to provide physician capacity, providers are given a capital contribution from managed care plans; management services organizations whereby managed care plans create management companies that provide turnkey management services in exchange for capital, with a commitment by the group practices to provide physician services to the health plan over a long period of time; mixed equity relationships where physicians and managed care plans jointly own the group practice, which group practice also has an ownership interest in the managed care plan itself; and acquisition of the group practice by the managed care plan. Each of these structures will be described, along with the legal issues that may be considered in any of these relationships. PMID- 10161811 TI - Physician compensation models in medical group practice. AB - This article examines physician compensation models in medical groups and the factors affecting physician compensation and their impact on individual physician behavior and group practice performance. Four categories of physician compensation models are identified: (1) production-based compensation, (2) salary, (3) group-based compensation unrelated to individual physician productivity, and (4) capitation-based compensation. The statistics and the economic incentives of different compensation methods are presented. Finally, the impacts on health resources consumption, charges in medical group procedures for utilization and care management, and quality of care are discussed. PMID- 10161812 TI - Physician profiling in group practices. AB - Profiling is a technique that large, multispecialty group practices, like many insurers, can use to monitor and improve quality and efficiency. Groups can examine physician performance by calculating ratios of medical inputs to patient or population outputs. Physician control can help to achieve balance between clinical benefits and economic considerations. Profiles need to reflect a group's multiple missions, such as clinical care, research, and education; philosophy of care; and organizational ethos regarding physician compensation systems. Groups may need to customize standard approaches because of their emphasis on early utilization of specialists and the atypical case mixes often found in referral practices. PMID- 10161813 TI - Ambulatory care heads for the 21st century. AB - There is increasing market pressure to deliver ambulatory care in a most traditional manner, that is, with a high level of service and personal touch. The ambulatory care providers of the future will meet this demand. However, they will do so with approaches and support systems that are anything but traditional. Care is increasingly being delivered in large, integrated systems. Extraordinary service levels are being made feasible again--this time through a combination of new support systems, including total quality management task forces, patterns of care software, consolidated phone centers that can provide access from anywhere anytime, electronic data interfaces, and the Internet. PMID- 10161814 TI - The measurement of physician work and alternative uses of the resource based relative value scale. AB - On January 1, 1992, the Medicare program implemented a new payment system for physician services based on the Resource Based Relative Value Scale (RBRVS). The RBRVS has been widely accepted as a rational and systematic approach to measuring the resource costs associated with physician services. In addition to deriving physician payment rates, the RBRVS provides a useful metric that allows the measurement and comparison of provider utilization rates and productivity across physicians performing a varied mix of services. In this study we describe the measurement of physician work, discuss alternative ways in which work values can be used to monitor physician service utilization (e.g., profiling physician practice patterns), measure physician productivity, and determine physician compensation. PMID- 10161815 TI - Physician profiling: applications for the Robert Wood Johnson Profiling Project database. AB - An overview of the applications and limitations of the Center for Research in Ambulatory Health Care Administration (CRAHCA) Profiling Project database funded by The Robert Wood Johnson Foundation is presented. The Profiling Project collects data from 77 practices and links organizational, provider, and patient demographics to administrative data. The Project's database has the capacity (1) to profile physicians based on the Resource Based Relative Value Scale (RBRVS) relative value units as a measure of work and (2) to identify practice patterns as defined by procedures used by physicians with the same diagnosis. The Project will further explore variations between physicians and specialties based on systems of care, physician specialty, and patient differences. The comparative reports generated from these data provide comparisons on selected indicators for participating practices. PMID- 10161816 TI - Clinical and health service research needs in the group practice organization. AB - Clinical and health services research will play a more important role in group practice organizations because it provides a vehicle to identify and answer critical questions. Study initiatives can identify, describe, quantify, and help predict trends in clinical practice. Systematic investigation is a means to link structure and processes of care to clinical parameters, patient outcomes, and cost variables. Findings can be used to support sound clinical, quality of care, and educational decision making. The ultimate goal of research is to promote the appropriate access and delivery of quality care in a cost-effective manner. PMID- 10161817 TI - Education to improve the quality of clinical care in group practices. AB - Intervening to improve the quality of medical care is an essential component of an effective quality improvement program. Although interventions may take many forms, most have some educational component. This article discusses different types of educational strategies that may be used in group practices and describes our experience with a continuing medical education (CME) program based on the results of clinical performance measurement. Data are presented showing the effectiveness and acceptability of the educational intervention in the DEMPAQ project. PMID- 10161818 TI - Emerging state policy trends related to medical group practice: Alpha Center. AB - This article examines how state health care policy affects new ventures involving medical group practices. It will review briefly traditional state authorities related to the health care sector in general and physician organizations in particular. The article will then discuss state policies related to a range of physician organizations, including those aligned with larger provider systems. State policies related to physician organization in the competitive marketplace include several topics: referral practices, tax exemption, corporate practice of medicine, and antitrust and insurance regulation. Finally, it will discuss the implications of these trends for future enterprises undertaken by medical group practices. PMID- 10161819 TI - Federal health policy and group practices: the double-edged sword. AB - This article explores the various major federal policies affecting medical group practices and whether these policies support, are neutral, or detract from group practice operations. Policies reviewed will consist of the Stark I and II laws with their self-referral and group practice organizational requirements; the Clinical Laboratory Improvement Act; physician reimbursement policies through the Medicare fee schedule (Resource Based Relative Value Scale); and other Medicare reimbursement policies related to teaching physicians, home health, rehabilitation, and rehabilitation services. The article concludes with recommendations as to how federal health policy might be reformed to be more supportive of and compatible with group medicine. PMID- 10161820 TI - Provider payment reforms in Russia: the economic lever for health sector performance improvement. PMID- 10161821 TI - A call for a new social compact in the former Soviet Union. PMID- 10161822 TI - The context of provider payment reforms in the Russian Federation: a challenging arena for managerial development for twenty-first century Russia. PMID- 10161823 TI - A framework for developing Russian health accounts. PMID- 10161824 TI - Hospital payment policies and reforms: issues and options in Russia. PMID- 10161825 TI - Methods of payment for outpatient care. PMID- 10161826 TI - Cost finding and market oriented pricing of medical services in Russia: new issues and options. PMID- 10161827 TI - Capitation and integrated health care systems. AB - Integrated health care systems: a concept being discussed throughout Russia and the world. A concept with three different applications and a confusing interaction with the concept of "capitation payments." The health reform debate in Russia and the NIS can only advance if greater clarity is found for these concepts, and if medical leaders are prepared for the substantial changes in provider behavior that are required with integrated health care systems fueled by capitation payments. This article explores the twin concepts of capitation and integrated health care systems, and then the leadership challenges for Russian health sector managers as they prepare for these challenges of the twenty-first century. PMID- 10161828 TI - Merit pay and incentive compensation systems for physicians and managers. AB - In Russia, as in all countries, physicians are and will continue to be central actors in health sector reform and in health sector resource allocation decisions. How they are recognized and rewarded for their work will therefore dramatically influence the ultimate success of reforms and health sector expenditure patterns. Much of the debate in Russia and many of the articles in this special edition of the Journal are focused on creative ways to move money from purchasers to provider institutions. There has not been enough discussion nor analysis of how money needs to move within institutions to individual physicians and managers as a means to influence their behavior. A new approach to base and merit pay is needed. This article explores conceptual and practical dimensions of alternate ways to compensate physicians as clinicians and managers. New forms of recognition and types of rewards will be summarized. Managerial skills and systems needed to support such new methods will also be highlighted. PMID- 10161829 TI - Quality improvement in an era of payment reform. AB - As Russia responds to the imperative of implementing payment reforms, careful attention must be focused on the protection and enhancement of the quality of patient care. New contracts that specify the relationship between purchasers and providers of health care services should not be limited to defining levels, frequency, and methods of payment. These documents must also clarify mutual expectations as to which indicators will be used to measure quality, as well as the frequency and methods to be used in measuring and reporting on issues of quality. These new contracts also need to emphasize that the quality of health services will now be assessed not only on the basis of traditional measures focusing on the process of care, but also in terms of clinical outcomes and patient satisfaction. PMID- 10161830 TI - Building health promotion into health care reform in Russia. PMID- 10161831 TI - Information systems need to support new payment reforms. PMID- 10161832 TI - Preparation of managers for twenty-first century health care in Russia. PMID- 10161833 TI - The advancing anatomy of an ambulance. PMID- 10161834 TI - 1996 ambulance manufacturers directory. PMID- 10161835 TI - Turbulent times persist for air medical transport. PMID- 10161836 TI - Fear and loathing on the EMS campaign trail. An insider ponders the upcoming elections. PMID- 10161837 TI - How Manitoba medics cope with the ban on trauma pants. PMID- 10161838 TI - Use a little restraint. PMID- 10161839 TI - New Minnesota board. PMID- 10161840 TI - Prescription for membership drive success. PMID- 10161841 TI - EMS marks turning point in history. PMID- 10161842 TI - Crossing boundaries. PMID- 10161843 TI - Potential scenarios for EMS primary care. PMID- 10161844 TI - Marketing research in hospitals. PMID- 10161845 TI - Market orientation and organizational culture in hospitals. AB - Hospitals have been advised to respond to environmental pressures by changing from a product to a market orientation. Such changes are difficult to accomplish because of the entrenched behaviors and attitudes of hospitals employees. This article proposes organizational cultures as the avenue to a market orientation. It describes the role of hospital culture as an antecedent to market orientation. It also suggests ways to develop and maintain a market-oriented culture in hospitals. PMID- 10161846 TI - Total quality in health organizations. PMID- 10161847 TI - An approach to improving hospital advertising. AB - Newspaper ads from hospitals in Ohio were rated for their effectiveness and explicit use of marketing principles. Analysis showed that the advertising could be improved by increasing the motivation for action, emphasizing how the organization's products and services are different from competitors and more thoroughly identifying the benefits the consumer would receive. Use of the two forms in the study can contribute to improved health care advertising. PMID- 10161848 TI - Health care marketing: doctors to patients and hospitals to doctors. AB - The adoption and usage of formal marketing practices by hospitals and physicians have increased exponentially over the past twenty-five years. This article examines marketing developments within the doctor-patient and hospital-patient associations, as well as the impact of managed care on these two relationships. Conclusions are drawn and suggestions for future research are provided. PMID- 10161849 TI - The effect of consumer perceptions of quality and sacrifice on hospital choice: a suburban vs. urban competitive scenario. AB - The primary objective of this research was to determine how a suburban hospital located near an urban center fares when local consumers are selecting a hospital. A significant portion of the 161 suburban respondents to the study's mail survey perceive the quality of care available at alternative urban hospitals to be higher than that available at their local suburban hospital on the vast majority of quality-related attributes. Most respondents, however, select their local hospital for both major and minor medical treatment. Te greater value represented by suburban hospitals, due to their relative closeness to the consumer, represents a significant competitive advantage. PMID- 10161850 TI - The relationship of service user closeness and belief in departmental values with perceived marketing effectiveness of hospital pharmacy directors. AB - This study examines the relationships between department values, service user closeness and marketing effectiveness as perceived by hospital pharmacy directors. Data from 171 hospital pharmacy directors, representing a cross section of hospitals, revealed that departments of pharmacy characterized as having superior perceived marketing effectiveness also have shared department value profiles. However, no significant relationship was found between perceived level of marketing effectiveness and perceived service user closeness. More years of experience as a director and the larger the size of pharmacist staff each positively influence the director's perception of marketing effectiveness. The results of the study indicate that hospital pharmacy directors generally perceive the services offered by their respective departments are marketed effectively. PMID- 10161851 TI - Length of patient stay at Kameda Medical Center. PMID- 10161852 TI - Brief comments on medical system in Japan background of the longest lifespan in the world. PMID- 10161853 TI - What's needed for Japanese academic hospital? PMID- 10161854 TI - Diversified needs and aging population. PMID- 10161855 TI - Study on nursing care for elderly patients by standardization of nursing information. PMID- 10161856 TI - Deregulation and business opportunities. PMID- 10161857 TI - Hospital management in Japan. PMID- 10161858 TI - An empirical study of emergency transportation of traffic accident victims in Tokyo. PMID- 10161859 TI - Hospital deployment in mass sarin poisoning incident of the Tokyo subway system- an experience at St. Luke's International Hospital, Tokyo. PMID- 10161860 TI - Health care expenditure and hospital management. PMID- 10161861 TI - The experience of a community hospital in providing medical relief services in a national disaster. PMID- 10161862 TI - Earthquake damages to hospitals and clinics in Kobe, Japan. PMID- 10161863 TI - The Great Hanshin-Awaji Earthquake Disaster--evaluation of medical response performed. PMID- 10161864 TI - A simple shortcut to greater office efficiency. PMID- 10161865 TI - What's really behind the attack on silicone breast implants. AB - Millions of dollars are being awarded by injuries and a major company has been forced into bankruptcy because of litigation over silicone breast implants. Yet scientific research hasn't established a link between the implants and disease, notes Marcia Angell, executive editor of the New England Journal of Medicine. When she began studying the issue, this self-described feminist and liberal Democrat expected to uncover iniquities of big business and the implant manufacturers. Instead, she's written an indictment of the tort system, junk science, and the gullibility of the news media. Attorneys have twisted facts and played on the emotions of juries, with the consent of judges and often to the cheers of the press. Angell worries that it's now become politically correct to bash the scientific method in the name of diversity, multiculturalism, and feminism. PMID- 10161866 TI - Making call duties more equitable. PMID- 10161867 TI - Could better care beat managed care? PMID- 10161868 TI - Will brain trauma finally be taken seriously? PMID- 10161869 TI - (Why Medicare stopped complaining about my handwriting). PMID- 10161870 TI - Use these simple charts to manage managed care. PMID- 10161872 TI - What the Medicare police look for. PMID- 10161871 TI - Doctors' earnings: an uphill struggle. PMID- 10161874 TI - We can't let managed care make us $10 docs. PMID- 10161873 TI - Cancer coverage. Why are insurers paying for this "experimental" therapy? PMID- 10161875 TI - Managed care comes to licking county. But guess who's in charge. PMID- 10161876 TI - How an innocent doctor got tried for rape. PMID- 10161877 TI - Protect yourself against a sexual-misconduct charge. PMID- 10161878 TI - Do you need a broker to help sell your practice? PMID- 10161879 TI - Forget Chicago. Set "ER" here. PMID- 10161880 TI - Don't let coding errors torpedo your managed-care contracts. PMID- 10161881 TI - The best ways to group up. PMID- 10161882 TI - How big is your group's generation gap? PMID- 10161883 TI - How the new health insurance law affects you. PMID- 10161884 TI - When doctors spurn a giant health plan. PMID- 10161885 TI - Paying doctors for non-clinical services. PMID- 10161886 TI - Feds relax interpretation of antitrust regulations. PMID- 10161887 TI - The cost-effective of a small transfusion service laboratory. PMID- 10161888 TI - HIV/AIDS Internet resources: a selective guide. AB - With so many options available for answering questions on the network, this guide is intended as a subject-specific tool for reference librarians to use when assisting patrons in retrieving AIDS-related information. It focuses on the major electronic sites, resources, listservs, online journals, and databases on HIV/AIDS that are available free of charge on the network, listed in alphabetical order. The Internet is constantly evolving, and while the resources in this guide have been carefully examined online for content and accuracy, files and sites are continuously being eliminated, added, and updated. Users, therefore, are encouraged to be flexible and adaptable when browsing, and to try new modes of access on the network. PMID- 10161889 TI - The hospital library as provider of consumer health information. AB - The health care environment of the 1990s demands that hospital libraries develop creative strategies for providing consumer health information (CHI). Librarians at the Reuben L. Sharp Health Sciences Library at Cooper Hospital/University Medical Center have developed a multifaceted approach to the problem. Using a combination of institutional resources, private funding, and cooperative arrangements with public libraries, the Sharp Library helps to serve the consumer health information needs of the southern New Jersey community. PMID- 10161890 TI - Medical jargon: ethnography of language in a hospital library. PMID- 10161891 TI - More NLM proximity searching hints. PMID- 10161892 TI - In-house databases as an informational tool: the New Mexico Health Resources Registry. PMID- 10161893 TI - County hospitals in Carolinas desired. PMID- 10161894 TI - In Columbia vs. Columbia, hospital chain wins first round. PMID- 10161895 TI - Ark. health data effort lacks specifics. PMID- 10161896 TI - HCFA pitches bundled payment plan for PHOs. PMID- 10161897 TI - A new way to spell relief from antitrust: NCRPA. PMID- 10161898 TI - Healthcare ads getting aggressive. AB - Contrary to some expectations that managed care would negate consumer advertising, it has instead increased competition in many markets, forcing providers to sell themselves more aggressively. Some hospitals' marketing strategies have competitors crying foul. PMID- 10161899 TI - Purchasing groups add to their bulk. PMID- 10161900 TI - Ky. moving ahead with Medicaid realignment. PMID- 10161901 TI - In Nevada, less is more when it comes to profits -news-. PMID- 10161902 TI - Cardiac scanning has industry abuzz. PMID- 10161903 TI - Data security. PMID- 10161904 TI - Hospitals healthy, CHIPS (Center for Healthcare Industry Performance Studies) study shows. PMID- 10161905 TI - Calif. official gets power to reject healthcare deals. PMID- 10161906 TI - R.I. coalition's goal: stop Columbia. PMID- 10161908 TI - Smaller hospitals quicker to use Maine merger law. PMID- 10161907 TI - IRS rules against 'shell' joint entities. PMID- 10161909 TI - Not-for-profit hospitals win antitrust triple play. PMID- 10161910 TI - Okla. network in link with state telemedicine group. PMID- 10161911 TI - AHA buffeted by industry changes. PMID- 10161912 TI - AMA in drive to keep industry role. PMID- 10161913 TI - Hefty health lobbying expenditures reported. PMID- 10161914 TI - Honored trustees look to the future. PMID- 10161915 TI - A capital offense. CFOs overlook the value of hospitals' real estate assets. AB - Healthcare providers are sitting on billions of dollars in assets. Real estate holdings constitute 35% to 50% of a typical system's balance sheet, but few chief financial officers are actively managing those assets. In these turbulent times, how can CFOs neglect such a large chunk of their holdings? PMID- 10161916 TI - One slice of healthcare. Two key players. Two distinct approaches. PMID- 10161917 TI - HMO satisfaction slipping: consumers. PMID- 10161918 TI - Fla. system's overhaul wringing out savings. PMID- 10161920 TI - Patients can surf the Web to choose their physician. PMID- 10161919 TI - Calif. groups invest in HMO quality. PMID- 10161921 TI - Expanded obligated group adds options. PMID- 10161922 TI - Clinic keeps upper hand in Cleveland. PMID- 10161923 TI - HHS faces AHA's first federal suit in six years. PMID- 10161925 TI - N.Y. HHC pressed on privatizations. PMID- 10161924 TI - ACHE survey response spurs expedited sexual harassment policy. PMID- 10161926 TI - Insurance cost slowdown not likely to continue. PMID- 10161927 TI - Hospital districts become dealmakers. PMID- 10161928 TI - Charity care strains Mass. hospitals. PMID- 10161929 TI - Community rallies to buy hospital from Columbia. PMID- 10161930 TI - Not your father's Blue Cross/Blue Shield. AB - The Blues landscape is a swirl of activity as the nation's 62 independent plans struggle to remain competitive in today's managed-care environment. Collectively, Blue Cross and Blue Shield plans serve 66.3 million people in widely differing markets. Although the plans have unique cultures, they're merging, affiliating in consortia, creating for-profit subsidiaries and converting to for-profit status. And to borrow from the Oldsmobile slogan, these are definitely not your father's Blues plans. PMID- 10161931 TI - Wellness program payback. PMID- 10161932 TI - Some answers to the big questions in healthcare. PMID- 10161933 TI - Firms see opportunity in new federal law. PMID- 10161934 TI - Third-quarter bond sales highest since '93. PMID- 10161935 TI - OR managers' raises take dip but compare well. PMID- 10161936 TI - Managers are stretched thin under pressures. PMID- 10161938 TI - Gap narrows between ASC (ambulatory surgery centers), hospital salaries. PMID- 10161937 TI - Managers on the front line tell their own story. PMID- 10161940 TI - Job interview needs to be carefully planned. PMID- 10161939 TI - Smoke issue gathers steam on Capitol Hill. PMID- 10161941 TI - Waste reduction also means cost reduction. PMID- 10161943 TI - Job market is softening for managers of ORs. PMID- 10161942 TI - OR manager of the year is a master of change. PMID- 10161944 TI - Automating the business office. AB - To measure the success of automating the business office with electronic billing and document management systems, the hospital's original goals were reviewed: Had the number of FTEs been maintained or reduced: Yes--claims volume is up 58% over 6 years with a 22% reduction in FTEs (see Exhibit 3). Was the cost of maintaining the paper filing system reduced? Yes--and the cost saving from the hospital's document imaging system will allow a 4.4 year payback. Is better customer service being provided? Yes--online access to patient demographic and financial information has improved response time. Having met all its goals, North Kansas City Hospital considers the installation of both systems to have been complete success. The facility expects to continue expansion of the document management system into accounts payable, payroll, home health, and other document-intensive areas to achieve further cost savings in the future. PMID- 10161945 TI - Insurance portability bill signed into law; includes HFMA's administrative simplification provisions. PMID- 10161946 TI - Automated coding technology holds potential to expedite APG-based claims. PMID- 10161947 TI - Physician leadership. Learning to be a leader. AB - As the business role of health care delivery expands and complex reform is imposed, physicians must assume leadership roles and imprint medical expertise on business dynamics. Before the end of this century, health care and its delivery will likely become unrecognizable to those who ended their practices only a decade ago. Traditional management will wither away to be replaced by self managed, self-trained, and self-motivated workers, no longer employed in jobs but working through processes, projects, and assignments in integrative health care delivery systems. Becoming a leader is an active and arduous process that can no longer be approached haphazardly. To be effective, the physician must plot a course with clear and calculated intent and effort, which requires acquiring organizational tools and administrative skills to innovatively alter medical care for the good of all. PMID- 10161949 TI - Physician leadership. How do physician executives view themselves? AB - Most physician executives today have acquired substantial management training and experience, and many have worked with and relied on the expertise of mentors for their career guidance and development. Physician executives are actually becoming executives who happen to be physicians. They view themselves first as leaders, then as physicians, and finally as managers. That is a remarkable transformation in perception. To chronicle this process, Witt/Kieffer, Ford, Hadelman & Lloyd conducted a national survey this spring among senior physician executives in both payer and provider organizations. The data provide a "snapshot" of their role, and may also suggest some future scenarios for the industry. The primary reasons for choosing to pursue a management role noted by most participants include a desire to be part of the health care solution and an interest in management and leadership challenges. PMID- 10161948 TI - Physician leadership. An emerging leadership position. AB - Demand is growing for Vice Presidents for Medical Management. This is a new physician executive position that enhances the ability of hospitals and health systems to more fully integrate delivery of care and thus attract managed care contracts. Located at a hospital, a health system's headquarters, or at a hospital's MSO, this position complements the traditional role of a hospital Vice President for Medical Affairs (or Medical Director), as well as the role generally played by the Medical Director in a managed care organization, linking them via a continuum of responsibilities. Compensation and prospects are high for qualified candidates. PMID- 10161950 TI - Physician leadership. Physician executives share insights. AB - Senior physician executives were asked to share their insights about how the medical management field has evolved. The Physician Executive Management Center, a Tampa, Florida-based search firm, has been surveying senior physician executives each year for the past decade. This year's report on physician executive compensation and duties in hospitals, managed care organizations, and group practices provides an excellent picture of the growth of the profession, as well as a broad perspective of anticipated changes for the future of medical management. The respondents addressed the following questions: What are the skills necessary for success? How have their jobs changed over the years? Have they made the right choice in pursuing medical management careers? PMID- 10161951 TI - Physician leadership. Leadership education for medical students. PMID- 10161952 TI - Reengineering the medical staff. Thirteen equals two. AB - Managed care forces were putting pressure on Athens Regional Medical Center, Inc., and its medical staff to sustain quality of care, and simultaneously tighten the budget, achieve continued improvements in efficiency, and retrain employees. To ensure its leadership position in Northeast Georgia, ARMC decided to restructure the organization to avoid a "slash and burn" crusade later. This article addresses the medical staff restructuring and how it came about. The strategy eliminated five committees and reduced 13 Medical Staff departments to two. PMID- 10161953 TI - The angry physician--Part 2. Managing yourself while managing others. AB - One of the most difficult aspects of physician leadership is addressing angry colleagues. The first article in this series called attention to the problems that come with the Type A coping styles of many physicians and outlined strategies for managing oneself. Part 2 provides specific strategies that can be helpful in managing others' anger-generating behaviors and anger reactions. There are eight practical communication guidelines recommended by experts in the field for managing anger in others. They include: Strike while the "iron is warm." Match, then lead. Stay in your own zone. De-escalate the other's angry reactions. Do something different. Be assertive, not aggressive. Use effective negotiation tactics. Operationalize the problem. PMID- 10161954 TI - Physician leadership. The time is now. AB - During the past 30 years, third party payers have imposed virtually every imaginable form of external cost controls on the traditional health care system. All have failed. And now those paying the bills--the large-scale health care purchasers--have finally seized control. They are fomenting fundamental structural change in the health care system. In order to continue doing business with these purchasers, health care providers are finding that they must form alliances to present a comprehensive "package" of health services for the constituents of these purchasers. In short, they must form integrated delivery systems. Current developments have created a unique opportunity for physician leaders to take a commanding role in shaping the emerging American health care system. PMID- 10161955 TI - What employers are looking for right now. AB - What specific skills are employers and recruiters looking for in physician executive candidates? Here are the top dozen characteristics that were invariably mentioned in interviews with high profile headhunters, as well as in analyzing open job orders. The most sought-after skill is leadership. Employers want someone who has courage. Expect this list to change in 1997 as the industry changes. However, there will be more additions than deletions, in keeping with overall trends toward higher, not lower, expectations of physician managers. PMID- 10161956 TI - Information technology, Part 3. The technology hierarchy. AB - The era of the networked society--and medical care depending on networked intelligence--is dawning. Physicians need to plan for office practice information systems in common, with an eye to conveying data electronically between all the locations of care and all the providers involved in caring for defined populations of people. The shared database will become the most important asset of the collection of providers who make up the delivery system that creates it. This will be accomplished by layering technology on local and wide-area networks of group practices, hospitals, health plans, and payers and developing standards that make data accessible in the same format to all users, no matter where they are. PMID- 10161957 TI - Coming of age on the World Wide Web. AB - Figuring they had better join the crowd, hospitals and healthcare companies are in the midst of a blind rush to establish sites on the Internet. The number of medical sites on the Web increased dramatically during the summer. Most of the pioneers, however, are building their sites without specific marketing goals in mind. And the experts who have been on the Internet longest caution that there are surprises everywhere. PMID- 10161958 TI - To get the word out across great distances, Lutheran Health gets its annual report to do double duty. Lutheran Health Systems, Fargo, North Dakota. PMID- 10161959 TI - A Chicago specialty hospital uses its report to burnish its advocacy image. Schwab Rehabilitation Hospital, Chicago, Illinois. PMID- 10161960 TI - Refusing to borrow from its consumer ads, CIGNA shows dentists the bottom line. AB - Looking for dentists, CIGNA Dental sent prospective providers calculators that they could use to figure out just how much more money they could make if they joined the network. The result: 20,000 responses. PMID- 10161961 TI - Raising questions, teasing consumers. PMID- 10161962 TI - Going public at last. Giving an "old" acquisition a system brand, 18 months later. Advocate Home Health Services, Oak Brook, Illinois. AB - When Advocate Health Care arose in 1995 from the combination of two big hospital systems in Chicago, strange legal voodoo left its home health care auxiliary languishing under its old name and old image. After 18 months of lobbying and plunging morale, Advocates has finally gotten to put its brand on the orphaned service. PMID- 10161963 TI - Morton Plat ties its brand to an ambitious public health campaign. AB - Look to stake out a market position in the Tampa Bay area, Morton Plant Mease didn't just claim it cared about community health. It launched a 10-step "action plan" that included white papers, press conferences and a coordinated ad campaign aimed at education, prevention and early detection. PMID- 10161964 TI - Riverview Medical finds linking a newsletter to a market position isn't just nice, it's critical. Riverview Medical Center, Red Bank, New Jersey. PMID- 10161966 TI - Enabling residents to entertain. PMID- 10161965 TI - Preparing its first national brand, Columbia seeds an identity among its local hospitals. Columbia/HCA, Nashville, Tennessee. AB - Columbia/HCA, the industry's 800-pound gorilla, is at last building a national brand. In the process, it has created one of the largest-circulation in-house magazines in the U.S. and found a way to build an enviable direct mail database at the same time. PMID- 10161967 TI - Taking on risk: embracing capitation. PMID- 10161968 TI - Ethics: blending resident rights with safety. PMID- 10161969 TI - On-the-job injury tied to job satisfaction. PMID- 10161970 TI - Labor status of nurses remains unclear. PMID- 10161971 TI - Caring for people who have AIDS. PMID- 10161972 TI - Making the data collection connection. PMID- 10161973 TI - Lessons from Arizona on managing costs. PMID- 10161974 TI - Serving the managed care customer base. PMID- 10161975 TI - Learning the ropes of contracting. PMID- 10161976 TI - The managed care voyage. PMID- 10161977 TI - Hospitals lured by assisted living. PMID- 10161978 TI - Providers try out alternative therapies. PMID- 10161979 TI - Cultivating managed care referral sources. PMID- 10161980 TI - Managing data for managed care. PMID- 10161981 TI - South Dakota seeks survey alternative. PMID- 10161982 TI - Easing the trauma of placement. PMID- 10161983 TI - Managed care future promising for respite. PMID- 10161984 TI - Flying solo. Independents find unique ways to compete. PMID- 10161985 TI - Going green. Providers do their part for the environment. PMID- 10161986 TI - Director of nursing as business manager. PMID- 10161987 TI - Training staff in the hospitality mode. PMID- 10161988 TI - Long term care salaries rising. PMID- 10161989 TI - Long-term care companies add physician services. PMID- 10161990 TI - The future of long-term care insurance. PMID- 10161991 TI - What to do when the union comes. PMID- 10161993 TI - Advise and consent. PMID- 10161992 TI - Sea change. IDNs may be the wave of the future, but don't dive in with your eyes closed. PMID- 10161994 TI - Naturally interested. PMID- 10161995 TI - Lights, camera, action! PMID- 10161996 TI - Yea or Nay? PMID- 10161997 TI - The sane solution--easing the trauma of rape. PMID- 10161998 TI - For mercy's sake, let's cover kids. PMID- 10161999 TI - A big case of the Blues. As the insurers change, who benefits from their $75 billion in assets? PMID- 10162000 TI - National Hospital Ambulatory Medical Care Survey: 1994 emergency department summary. PMID- 10162001 TI - Human resource management in hospitals: a contested arena for jurisdiction. AB - During the past 10 years, financial pressures on health service providers have led to a quest for more efficient service delivery and many consequential changes to the organisation and utilisation of staff. This study investigated the organisational responses to such pressures by four major South Australian hospitals and the level of involvement of hospital human resource staff in the staffing issues associated with strategic planning. With one exception, there was little contribution from qualified human resource professionals to staffing decisions involving medical and nursing personnel and little value was placed on their potential input by other professional groups. If, as suggested by writers on strategic human resource management, human resource practice is moving toward a more strategic approach, then there is a large credibility gap for human resource staff to overcome within the South Australian health service. PMID- 10162002 TI - Leadership as a management competency in rural health organisations. AB - The management competency of leadership was measured on 34 middle and senior health managers from the Murray Health Service, using Situational Leadership Questionnaires. Using self-analysis, the managers found their leadership behaviours to be entrenched, inflexible and less effective than they might otherwise be. This conclusion was supported by results of the questionnaires completed on each manager by their followers. In almost half of the cases, followers had a different perception of their manager's leadership style than did the manager. This paper discusses these findings in the context of management assessment centres and the Charter for Change now facing all health organisations. PMID- 10162003 TI - Turning around patient complaints in a regional hospital. AB - This paper describes the introduction by a regional general hospital of a different system for handling complaints from patients. It outlines the underlying philosophy of the new system and the experiences of the hospital as the new system matured. The paper provides data for the first six quarters of operation of the system. PMID- 10162004 TI - The hospital utilisation and costs study 1991-92. PMID- 10162005 TI - Australian registered nurses and sex-based harassment in the health care industry. AB - This paper discusses sex-based harassment in the nursing profession in Australia. The paper generates industry-specific hypotheses which may provide insights into sex-based harassment in the Australian context. A good understanding of sex-based harassment in health care is essential for reducing and eliminating the problem and its toxic sequelae. PMID- 10162006 TI - Hospital input price indexes in Australia: are they worth the effort? AB - This paper summarises aspects of the design and use of hospital input price indexes, and describes four indexes produced in Australia in the last decade. It argues that there would be some benefit in establishing a routine national index, if it were designed to be low-cost. However, care should be taken to avoid excessive reliance on the results in the resource allocation and funding context. Input prices contribute relatively little in hospitals' expenditure changes. It is also necessary to monitor and manage changes in the volumes of inputs, and this is likely to be a more rewarding task. PMID- 10162007 TI - Episodes of care: should we have them? AB - In this paper the authors discuss the introduction of 'episodes of care', a new system for monitoring hospital-linked patient care services. They consider the proposal in the context of clinical, financial and technical frameworks. The authors conclude that health planners are likely to benefit from the the introduction of this form of monitoring. The proposed change would also allow more accurate analysis of the true cost of interventions. However, it is likely to require significant investment in information technology and there may be loss of patient confidentiality. PMID- 10162008 TI - Differences in patient throughput between community health centre and private general practitioners. AB - This study sought to compare the rate of patient throughput by community health centre general practitioners (GPs) and their private practice fee-for-service counterparts. The study group comprised 44 community health centre GPs (out of an identified 51) in 16 community health centres; the control group comprised 268 GPs. Community health centre GPs were found to have significantly fewer consultants and significantly smaller rebates than their private practice counterparts. The difference of means for consultation numbers and rebates was 30.3 per cent. The pattern was reversed in the case of rural community health centre GPs (who retain fee-for-service arrangements). Figures are uncorrected for patient status, and data relate to Medicare billing practices rather than observed activity or outcome. However, at face value they would indicate that if Australian general practice moved to a community health centre model, with predominantly salaried GPs, then patient throughput in general practice could be expected to drop. Whether these reflect the impact of incentives on throughput and, if so, whether this indicates a difference in the quality or accessibility of the service provided to patients is not certain. PMID- 10162009 TI - Health personnel: perceived differences in professional relationships and work role. AB - This study questions the validity of the assumption that the workplace culture and experiences of health personnel are largely similar. The study compares nurses, occupational therapists, physiotherapists and speech therapists concerning their perceptions of professional issues within their own profession, and their perceptions of professional issues within the medical profession. Respondents completed a questionnaire containing 55 items referring to their own profession, and 55 items referring to the medical profession. Six scales were derived from the large survey instrument addressing issues regarding status/cohesiveness of the profession, professional relationships, and the role of the patient in health delivery in the respondent's profession, and in the medical profession. Nurses emerged as different to other health personnel on most dimensions. Few differences emerged among allied health professionals. Physiotherapists were more positive than occupational therapists about the status/cohesiveness of their profession, and regarded the contributions of the patient to health delivery as less important. Speech therapists did not differ significantly from occupational therapists on any dimension. PMID- 10162010 TI - Development of a casemix classification system for inpatient rehabilitation services: stage 1 of the Victorian Rehabilitation Project. AB - This study examines the feasibility of classifying rehabilitation patients according to relative cost and proposes an option for a casemix classification and payment system for rehabilitation services in Victoria. The classification system proposed has 16 mutually exclusive groups based on patient diagnosis, change in functional status, admission functional status and age, using patient length of stay as a proxy for cost. Data relating to five hospitals were collected over three months during 1994, resulting in 483 inpatient episodes from a variety of impairment groups. The data were analysed using an analysis of variance model (PC Group), with the resulting model accounting for 30 per cent of the variance in length of stay. The study also considers the implications of incentives to contain cost and concludes by suggesting that such a payment system would be feasible to implement following further research to validate and refine the system. PMID- 10162011 TI - The need for acute hospitals to provide counselling following motor vehicle accidents. AB - This paper examines the need for a systematic way of detecting individuals likely to encounter moderate to severe psychological sequelae after being injured in a motor vehicle accident. It presents the findings of assessments of consecutive adult admissions during a six-month period to the Accident and Emergency Department of Royal Melbourne Hospital, a major acute hospital in Melbourne, within two days of being injured in a motor vehicle accident. Seventy of the 250 subjects surveyed completed the General Health Questionnaire 12 and the Impact of Event Scale questionnaire, with 77 per cent found likely to have had a psychiatric disorder. Seventy-four per cent had at least moderate levels of intrusion or avoidance phenomena. Forty-four per cent had severe levels of one or the other. Prevalence of these psychological sequelae was greater than that found in several recent studies on the effects of motor vehicle accidents. A small number (11-15 per cent) sought or received professional counselling within the first three months. This group did not differ, according to levels of intrusion, avoidance, or scores on the GHQ 12, to subjects who did not seek or receive such assistance. Results identify the necessity of investigating and implementing methods of detecting and treating the many who apparently sustain significant psychological sequelae following injury in a motor vehicle accident. PMID- 10162012 TI - The newest species on the block: the integrated health-care system. Clinical Laboratory Management Association. PMID- 10162013 TI - Redefining work in the integrated delivery system. PMID- 10162014 TI - The reemergence of the hospital-based laboratory. AB - The Reference Laboratory Alliance (RLA) in Pittsburgh is an example of multiple hospital laboratories integrated for the purpose of delivering competitive outpatient laboratory services in a managed-care environment. Developed in 1994, the RLA model includes a "virtual" core laboratory (comprising four tertiary care centers of excellence) and a distributed network of more than 30 community hospitals. Linked through information systems, logistics, and an extensive committee structure, the RLA is capable of delivering a "seamless" service to the region's managed-care organizations. In its first full year of operation, the RLA is expected to shift between $12 and $15 million worth of laboratory activity back into the community's hospitals. Through its pathology component, the RLA is now actively engaged in redefining the role of the clinical laboratory in the managed-care environment. PMID- 10162015 TI - Outreach, consolidation, and networking: Columbia's approach to successful integration of laboratory services in California. AB - At the forefront of integrated laboratory services, Columbia Bay Area Healthcare Network's Lab Link provides a unique approach to operating hospital-based laboratories in today's heavily penetrated managed-care environment. Columbia recognizes that a combined strategy of laboratory consolidation, outreach, and networking is essential to compete successfully with commercial reference laboratories for local and statewide contracts. Implementing this model enables hospital laboratories to produce high quality, cost-effective test results while increasing volume and reducing duplication. When hospital laboratories consolidate and network with local and regional laboratories, inpatient and outpatients information is cross-fertilized through a web of information systems. Patients information can then be accessed easily and monitored throughout the continuum of care. The goal of this article is to provide hospital laboratories with a streamlined approach to structuring and delivering services while maintaining a competitive edge in the tumultuous healthcare market. The future of laboratory services within the hospital setting lies in the aggressive use of three elements--consolidation, outreach, and networking--to ensure quality service as well as economic viability. PMID- 10162016 TI - The Tulane University Medical Center/Columbia partnership: opportunities and challenges for pathology. AB - A joint venture between the largest health-care corporation in the country (Columbia/HCA) and Tulane University Hospital/Clinic was established about 1 year ago. Early indications are that the partnership is successful and mutually beneficial. For Tulane University Medical Center, the joint venture provides financial stability and support for academic centers of excellence. Tulane University Hospital/Clinic will become the referral center for complicated cases from the regional Columbia hospitals. The Tulane University Hospital laboratories are positioned to become the regional referral laboratory for esoteric testing. For the pathologists of the regional Columbia hospitals, the opportunity beckons to form a group of equal partners that will contract with Columbia to provide laboratory services at Columbia hospitals and to consolidate the laboratories in the New Orleans division. Columbia has brought corporate expertise, capital, and opportunities for cost-saving economies of scale to the partnership. Quality and cost-effectiveness of patients care will be emphasized as will research on clinical outcomes. This model of corporate/academic partnership represents a new option for academic medical centers around the country as they respond to the rapid changes in the health-care environment. PMID- 10162017 TI - Evolving delivery systems for clinical laboratories: the Albany Medical Center Regional Laboratory Network. AB - The Albany Medical Center is a not-for-profit institution consisting of the Albany Medical College and the Albany Medical Center Hospital. Before 1989, the college's pathology department was not affiliated with the clinical laboratories of the hospital and no regional laboratory program existed. Subsequent to 1989, with the recruitment of a new chairman of the department of pathology, the department and the clinical laboratories of the hospital merged to create the Department of Pathology and laboratory Medicine. The strategic plan for the redesign included goals to respond to new opportunities and seek new contracts in the community, to enhance the efficiency within the clinical laboratories, and to increase the volume of anatomic pathology specimens. The newly formed department decided to explore the opportunities to work with hospitals, physician groups, and insurers in the area to create a regional laboratory network. This article describes how changes were implemented, including some of the problems that were encountered. An assessment of the result evaluates the success of the network and discusses its future direction. PMID- 10162018 TI - Baptist Medical Center/St. Vincent's merger. AB - Hospitals are merging at such a fast pace that there may be no freestanding hospitals in this country by the end of this century. The economics of the times are making it more and more difficult for hospitals to function alone. When hospitals merge, one of the clinical departments involved in integration is the clinical laboratory. This article discusses a merger involving five hospitals in Jacksonville, Florida and how it affected the separate hospital laboratories. PMID- 10162019 TI - Competitive and strategic positioning of national clinical reference laboratories in response to managed care. PMID- 10162020 TI - Implementing complex networking laboratory information systems in a health maintenance organization. AB - Kaiser Permanente, Northern California Region (KPNCR) currently consists of 17 medical centers and 28 medical office building clinical laboratories plus a large, centralized reference laboratory. Before 1977, KPNCR processed laboratory information manually. With the opening of the Kaiser Permanente Regional Laboratory in Berkeley in 1977, a card punch system was used to capture that laboratory's data. In 1985, the Regional Laboratory installed a mini-mainframe system. In 1990, KPNCR Implemented a Region-wide Integrated Laboratory Information System. The software used was manufactured by Cerner Corporation, Kansas City, Missouri. The hardware platform consisted of for DEC VAXs. The decision was based on flexibility, supportability, and well established customer base. Work on the database began in September of 1991. The first "go-live" was in August of 1992. All facilities--46 laboratories--were "live" by February of 1995. Total implementation time was 27 months. PMID- 10162021 TI - Antitrust implications of alternative delivery systems. AB - Collaborative arrangements between clinical labs have created new opportunities for market development and the efficient delivery and production of services. As with any joint effort between otherwise competing entities, however, these arrangements are subject to federal and, some cases, state antitrust laws designed to ensure that the market performs in the most efficient way possible, a result believed best achieved through the preservation of competition. As a result, both the formation and operation of the new arrangement will be analyzed to ensure that its anticompetitive effects, if any, are minimal and are outweighed by the arrangement's procompetitive efficiencies. At the formation stage, the new entity will be analyzed to determine whether the participants would be able to exercise market power, which, in antitrust jargon, means the ability to raise prices above the competitive level. At the operational stage, the new entity will be analyzed to determine whether agreements among participants, primarily agreements on price, are necessary for the efficient operation of the new enterprise. This article addresses these basic antitrust principles. PMID- 10162022 TI - Move from patient-focused care model to point-of-care testing: transitioning of laboratory services. AB - During the past several years, the Clinical Laboratories of the Lee Memorial Health System (LMHS) have been involved extensively in adjusting the delivery systems for the provision of clinical laboratory services as the industry, competitive market, and health system moved through periods of rapid transition. This environment has allowed the opportunities for laboratory services to be provided through a variety of delivery models: central laboratory, point-of service testing, and point-of-care testing. The Orthopedic Center at Lee Memorial Hospital was designed as a patient-focused care center and operated as a "mini hospital," housing most of the services required to care for the System's orthopedic patients, including a point-of-service (decentralized) laboratory. LMHS decided to conduct a trial of hand-held chemistry analyzers in the Orthopedic Center. The analyzer's test cost and ease of operation were as expected; however, it was found that the analyzers were not appropriate for continued use in the Orthopedic Center. Responsibility for testing for the Orthopedic Center was returned to the Central Laboratory. With the exception of certain traditional point-of-care procedures, the Central Laboratories now provide laboratory services for all of the facilities' patient care areas. PMID- 10162023 TI - Award-winning hospital makes performance improvement an organizational standard. PMID- 10162024 TI - Joint Commission revises restraint and seclusion standards. PMID- 10162025 TI - Patient satisfaction report paves way to improved care. AB - In this article, the second in a two-part series, we show how a data-driven clinical model was implemented to improve care using patient satisfaction reports. Last month, we outlined the essential components of a data-driven clinical model and summarized two research paradigms that provide the theoretical foundation for such a model. PMID- 10162026 TI - Roundtable discussions prepare staff for emergencies. PMID- 10162027 TI - Perspectives. Right-to-die cases stir profound ethics controversy. First of two articles. PMID- 10162028 TI - Perspectives. Death with dignity or 'slippery slope' after court rules? Second of two articles. PMID- 10162029 TI - Home care IS: still booming, steadily maturing. PMID- 10162030 TI - Home healthcare IS products & services. PMID- 10162031 TI - Multimedia networking of disparate healthcare facilities. PMID- 10162033 TI - Geisinger gets the gold. PMID- 10162032 TI - The CPR: patient empowerment paradigm. PMID- 10162035 TI - Telemedicine's legal & financial battlefields. PMID- 10162034 TI - Privacy in an IT world: can it be? PMID- 10162036 TI - Automated appointment reminders: cutting costs while communicating "We care". PMID- 10162037 TI - What are the standards for standards? Round table discussion. PMID- 10162038 TI - Reuse of disposable medical products. PMID- 10162039 TI - What's up, doc: safety and physician practices. PMID- 10162040 TI - Point-of-service collections. PMID- 10162041 TI - Installing an integrated information system: issues to be considered. PMID- 10162042 TI - Patient ID success stories. PMID- 10162043 TI - A true continuum care: the development of a comprehensive outpatient rehabilitative facility. PMID- 10162044 TI - Electronic technology is changing reimbursement processes. PMID- 10162046 TI - Information systems to improve healthcare services. PMID- 10162045 TI - Management strategies in the Jimenez Diaz Foundation. PMID- 10162047 TI - Medicare fraud: a federal priority. What is it and how to avoid it. PMID- 10162048 TI - America's most wanted .... AB - Years of lax oversight let providers get sloppy about billing Medicare. Now the feds are paying close attention, and may hospitals are finding themselves faced with federal fraud charges. The authors, Philadelphia-based health lawyers, propose ways to stay on the straight and narrow. PMID- 10162049 TI - The tough choices commission. AB - With each passing year, Medicare's financial stability gets worse and the policy options become more daunting. Congress and the White House appear incapable of administering tough medicine. Could a new independent body do any better? PMID- 10162050 TI - Outsourcing: asking the right questions. PMID- 10162051 TI - Labor pains. AB - Unions have targeted health care for their next surge of organizing and political action. They have lots of money and, they believe, the health consumer on their side. PMID- 10162052 TI - And now the good news .... PMID- 10162053 TI - The big picture: a conversation with Stephen Shortell. Interview by Craig Havighurst. PMID- 10162054 TI - Charting the new delivery universe. PMID- 10162055 TI - Solid foundations. AB - For non-profit selling to investor-owned companies, no question is more critical than what will be done with the proceeds. Private foundations have become the preferred vehicle for redirecting those charitable assets to the public good. But great care is required, lest they be squandered. PMID- 10162056 TI - The silent deceiver. PMID- 10162057 TI - Conventional wisdom. A hopeful look forward. PMID- 10162058 TI - Conventional wisdom. Bob Dole and the return of Federalism. PMID- 10162059 TI - "To be" or not to be. PMID- 10162060 TI - Data ... hospital transactions in the U.S. in 1995. PMID- 10162061 TI - It's not just a good idea, it's the law. PMID- 10162062 TI - Forget "ambulatory" in ambulatory care planning. PMID- 10162063 TI - Punishment that fits the crime. PMID- 10162064 TI - From nicety to necessity: outcome measures come of age. PMID- 10162066 TI - The brand: second thoughts about a big business decision. AB - UniHealth was evolving into the essence of a modern integrated delivery network. Should it hang its name on the parts of its system? One architect of that decision takes a look back at a debate that forced fundamental questions about the identity and soul of an organization. PMID- 10162065 TI - What's in a name? AB - How should an integrated health care network sell itself? Four very different systems talk it over with the president of the American Hospital Association's Society for Healthcare Strategy & Market Development. PMID- 10162068 TI - HMOphobia: who's afraid of managed care mergers? PMID- 10162067 TI - Are you brand savvy? A self-assessment report card. AB - Aurora Healthcare in Wisconsin gets high marks in the marketing community for conveying a strong and consistent image to its potential customers. Here, the VP for business development and market planning for Aurora's St. Luke's Medical Center offers a way to think through how your organization sells itself. PMID- 10162069 TI - Rising stars. PMID- 10162070 TI - Tracking care in San Diego. AB - Standardizing care cost-effectively, while carefully tracking individual patients' progress through the care continuum, has challenged health systems around the country. In an excerpt adapted from a new book, the author, the operations strategist at ScrippsHealth, describes how one of the nation's leading integrated delivery organizations has answered the call. PMID- 10162072 TI - Data ... growth and consolidation of HMOS. PMID- 10162071 TI - Real places, people, profits .... AB - Forget "stage four" markets and the managed care revolution for a second. Hospitals have to focus on the basics: cutting costs and delivery high quality care. A consultant shares two tales from the road to high performance. PMID- 10162073 TI - Taking care of health care. PMID- 10162074 TI - Practice Brief. Issue: managing health information in facility mergers and acquisitions. American Health Information Management Association. PMID- 10162075 TI - Weathering the storm: quality review manager survives change. PMID- 10162076 TI - Applying HIM skills to radiology management. PMID- 10162078 TI - A CHAP to meet: the Community Health Accreditation Program. PMID- 10162077 TI - Should external reviewers have access to patient records? PMID- 10162079 TI - E-mail security. PMID- 10162080 TI - Reengineering the documentation process. PMID- 10162081 TI - Winning performance improvement strategies--linking documentation and accounts receivable. AB - When the HIM department at The University of Texas Medical Branch set out to improve documentation and accounts receivable management, it established a plan that encompassed a broad spectrum of data management process changes. The department examined and acknowledged the deficiencies in data management processes and used performance improvement tools to achieve successful results. PMID- 10162082 TI - The HIM professional's role on the ethics committee. PMID- 10162083 TI - AHIMA reengineers FORE. PMID- 10162084 TI - Dimensions of quality: a framework for quality management in healthcare. AB - The quality of healthcare services is as much a matter of perception as of hard clinical data. Therefore, to improve quality, it is necessary to understand the way in which customers perceive, rank, and weigh the variety of elements that make up this elusive attribute. Otherwise, the management of quality becomes a hit-or-miss affair, with misses more likely than hits. Thus, a proper framework for quality management must include a profound understanding of the customer's "dimensions of quality." This article offers an approach for developing such an understanding. PMID- 10162085 TI - Protecting patient privacy and data quality in a community health information network. AB - The healthcare industry is under mounting pressure to cut costs without reducing the quality and quantity of healthcare services. One method to streamline operations is to implement community health information networks (CHINs). This article describes ways in which CHINs can offer subscribers improved efficiency, decreased costs, and improved patient care. It also addresses the fact that membership in a CHIN, if not controlled, greatly increases legal risks. Details on how many of these risks can be minimized or avoided are provided. PMID- 10162086 TI - Negotiating with the gatekeepers of the new healthcare universe. PMID- 10162087 TI - Statistical and methodological issues in the evaluation of case management studies. AB - For the past 3 years, the nursing case management team at North Shore University Hospital in Manhasset, NY, has been involved in a project to implement more than 50 clinical pathways, which provide a written "time line" for clinical events that should occur during a patient's hospital stay. A major objective of this project was to evaluate the efficacy of these pathways with respect to a number of important outcomes, such as length of stay, hospital costs, quality of patient care, and nursing and patient satisfaction. This article discusses several statistics-related issues in the design and evaluation of such case management studies. In particular, the role of a research approach in implementing and evaluating hospital programs, the choice of a comparison (control) group, the exclusion of selected patients from analysis, and the problems of equating pathways with diagnosis-related groups are addressed. PMID- 10162088 TI - Applying control charts to quality improvement. AB - This article reviews the definitions and principles that should guide the use of control charts in healthcare quality. Several examples from the literature are used to illustrate significant problems and issues in control chart construction. PMID- 10162089 TI - Comparing providers' performance: problems in making the "report card" analogy fit. AB - This article examines the applicability of a "report card" strategy as a means of differentiating among providers on the basis of performance. The specific focus is on the potential effect of differences in data collection processes on the meaningfulness of subsequent comparisons among similar types of providers. Variations in reported nosocomial infection rates are analyzed in light of differences in reported surveillance practices; data for similar nursing units are analyzed as well. Thirty-one rural, rural referral, and urban acute care hospitals in the midwest participated in the study. The reported nosocomial infection rates for different types of nursing units and different hospital groups varied substantially. Likewise, there were marked variations in the nosocomial infection surveillance practices at the hospitals, which were found to explain some of the variation in the reported nosocomial infection rates for specific types of nursing units and nosocomial infections. The study conclude that differences in data collection processes may result in incorrect conclusions about differences in the quality of care provided by various providers. PMID- 10162090 TI - In their own words. Surgeon representatives discuss legislative and regulatory issues. Part II. AB - This is the second of a two-part series featuring surgeons who serve on panels, committees, and other groups that offer advice or comments on health policy issues to the federal government; Part I appeared in the September 1996 Bulletin. In their own words, these surgeons describe the issue areas they are addressing and their significance to the profession. PMID- 10162091 TI - Patient relations: a little generosity creates a lot of good will. PMID- 10162092 TI - Embryonic law: a legal development. PMID- 10162093 TI - The training of the pediatric surgeon. PMID- 10162094 TI - Case study. Unions help restructure care and preserve low-cost positioning at public Valley Medical Center, Renton, Washington. PMID- 10162095 TI - Merger case study. Florida's Intracoastal: merger of competing not-for-profits. PMID- 10162096 TI - Easy touch. Computer survey update. PMID- 10162097 TI - Muzzle-free at BJC. PMID- 10162098 TI - MMIS: choosing the next generation. PMID- 10162099 TI - Four-in-one: multiple vendors agree to a single capitated contract. PMID- 10162100 TI - Case cart smarts--and how to get some. PMID- 10162101 TI - Training of flight nurses on fixed-wing air ambulance services. PMID- 10162102 TI - Emergency scene endotracheal intubation before and after the introduction of a rapid sequence induction protocol. AB - INTRODUCTION: A change in airway management protocol provided the opportunity to evaluate scene airway management by air medical crew before and after the introduction of a rapid sequence induction protocol. METHODS: A retrospective chart review and a descriptive study of scene trauma patients whose airway was established primarily by an air medical crew during two study periods: April 1994 through March 1995 (group 1, before rapid sequence induction) and April 1995 through March 1996 (group 2, after rapid sequence induction). Data collected included demographics, type of airway, Glasgow Coma Scale score, scene time, and outcome. The setting included a four helicopter air medical transport program using nurse/paramedic crews with a service area of 25,000 square miles in central, southeastern, and northeastern Ohio. RESULTS: Group 1 patients (n = 148) averaged 31.6 years of age and were primarily male (79.7%) with blunt injuries (92.6%) with an average Glasgow Coma Scale score of 7.7. Group 2 (n = 95) was similar, averaging 31.1 years of age, primarily male (77.9%) with blunt injuries (94.7%) and a Glasgow Coma Scale score of 8.6. Groups 1 and 2 differed in oral endotracheal intubation rate (19/118 versus 36/95 [p = 0.03]) and in scene time (15.7 minutes versus 20.1 minutes [p = 0.0012]). The groups did not differ in rate of successful intubation or the rate of subsequent cricothyrotomy. CONCLUSION: Rapid sequence induction added significantly to ground time without significantly increasing intubation success rate or decreasing cricothyrotomy rate. Its use at the scene of injury may not be appropriate. PMID- 10162103 TI - Accuracy of trauma triage in patients transported by helicopter. AB - INTRODUCTION: Our objective was to study the accuracy of the American College of Surgeons Trauma Triage Scheme in trauma patients transported by helicopter from the scene of injury. METHODS: This is a case series of 333 patients transported by helicopter from the scene of injury to a University Hospital Level 1 Trauma Center. We constructed 2 x 2 tables with the use of injury Severity Score > 15 as the "gold standard" for major trauma and assessed the Trauma Triage Scheme (overall) and its physiologic, situational, and age/comorbidity components individually. RESULTS: Physiologic criteria had high specificity (85.7%) but low sensitivity (55.6%), whereas situational criteria had high sensitivity (86.6%) but low specificity (19.9%). Use of physiologic criteria alone would miss 67 of 151 patients with injury Severity Score > 15 and five of 31 fatalities. Situational criteria capture 58 of the 67 major trauma patients missed by the physiologic criteria but also 125 minor trauma patients. Age/comorbidity criteria had low positive (22.7%) and negative (10%) predictive values. CONCLUSIONS: Physiologic triage criteria alone identify only half of trauma patients with injury Severity Score > 15. Situational criteria are needed to identify most patients with injury Severity Score > 15, but this also captures many patients with minor injury. If the Trauma Triage Scheme situational criteria could be improved, trauma overtriage might be reduced with resultant health care cost savings. PMID- 10162104 TI - Scoring systems in air medical transport: a primer. PMID- 10162105 TI - Basics of research (Part 8): Unique aspects of nursing research. PMID- 10162106 TI - Selling your practice: tips for structuring a successful sale--Part I. PMID- 10162107 TI - The heart of the matter: redefining perspectives, processes, and performance in cardiovascular services for the year 2000. PMID- 10162108 TI - How to organize and manage a lipid clinic. PMID- 10162109 TI - Cardiovascular information systems in the '90s. PMID- 10162110 TI - Choices for equipment service, after the sale. PMID- 10162111 TI - Information technology--the new paradigm shift in healthcare. PMID- 10162112 TI - Seven leading trends in customer focus, service, and quality. PMID- 10162113 TI - The equipment warranty: what's really in the fine print? PMID- 10162114 TI - Selling your practice: tips for structuring a successful sale--Part II. PMID- 10162115 TI - Results of a multidisciplinary approach to fast-track recovery for cardiac surgery patients. PMID- 10162116 TI - The California consolidation game. PMID- 10162117 TI - A priority queuing model to reduce waiting times in emergency care. AB - Investigates the increased waiting time costs imposed on society due to inappropriate use of the emergency department by patients, seeking non-emergency or primary care. Proposes a simple economic model to illustrate the effect of this misuse at a public or not-for-profit hospital. Provides evidence that non emergency patients contribute to lengthy delays in the ER for all classes of patients. Proposes a priority queuing model to reduce average waiting times. PMID- 10162118 TI - The quality of prescribing in general practice. AB - General practitioner prescribing is a subject of legitimate interest to all those concerned with the quality of patient care. The analysis of prescribing and cost data can reveal much about this quality. Suggests that both general practitioners and those who administer and advise on family practitioner services will need to understand the issues involved. Warns that, taken in isolation, prescribing data can be misleading, and it must be compared with other aspects of patient care. Simple calculations can suggest areas of possible under-prescribing and over prescribing, and in turn lead to consideration of the criteria for diagnosis of common chronic diseases such as asthma and diabetes, as well as their subsequent management. Suggests that the prescribing of both new drugs and those of dubious merit is a subject for particular scrutiny, and those who prescribe these drugs must accept the duty of extra vigilance this imposes on them. PMID- 10162119 TI - A glossary of terms encountered in quality and customer service. PMID- 10162120 TI - Can we measure the effectiveness of our organizations? PMID- 10162122 TI - Customers and contractors in the new NHS. AB - Presents the results of a study in the former Yorkshire region to discover the effect of the changes in the NHS on relationships between Community Health Councils (CHCs) and health service authorities. Respondents were asked to comment on how the changes had affected these relationships in six aspects; interaction with the public, accountability, independence, effectiveness, representativeness and prioritization of work. Identifies a number of questions about the relationships which can be grouped under four headings: CHCs' identity problem; the effect of the greater discretion which health service authorities have in their relationships with CHCs; the balance between independence and co-operation in these relationships; and the influence of superior bodies on the relationships. Suggests that answers to these questions will help to release the potential of CHCs to contribute to the quality and effectiveness of the NHS, in accordance with the priority given in the reforms to obtaining the views of the public. PMID- 10162121 TI - Pregnancy care of the low risk woman: the community-hospital interface. AB - Aims to determine the extent to which women suitable for community-based antenatal and intrapartum care will require hospital contact. Reports on an historical cohort study of low risk women who underwent standard shared care and for whom the records for both pregnancy and delivery were complete at The City Hospital and University Hospital, Nottingham. Concludes that the shift to community-based care aims to bring many improvements to the overall care and satisfaction of pregnant women. However, it may not reduce the workload of hospital-based services to a great extent as the majority of women, even if low risk at booking, will require some hospital input at some time during pregnancy or labour. PMID- 10162123 TI - Factors influencing audit in general practice. AB - Since 1990, the changes introduced in UK general practice, such as fund holding and national incentives, have altered the process of care. Audit, defined as "the systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for patients", is one method of monitoring change and raising standards. Presents a successful co-ordinated audit in Warwickshire, 1991-1993, involving 53 general practices. Highlights and influence of attitudes and communication within practices on the success of audit strategies. Associates aspects of practice culture, such as team working and decision-making processes with successful audit. Postulates six descriptive practice types, largely related to culture factors. Suggests that if cultural factors within practices are identified, external assistance with audit may be more focused and effective. PMID- 10162124 TI - Developing microcomputer-based quality assurance systems for health care. AB - Points out some important issues that must be dealt with when developing microcomputer-based QA systems for health care. While no single solution to the problems associated with quality assurance (QA) system development exists, the first step towards an efficient and effective approach is problem identification and commitment to developing a strategy which addresses the issues discussed in this paper. Examines potential solution alternatives and associated pitfalls, and gives an example of designing a QA system, including a database management system with suggestions for spreadsheet templates. PMID- 10162125 TI - Clinical audit, the case for ethical scrutiny? AB - The UK Government's White paper stated their commitment to the development of medical audit. The subsequent growth of audit activity by all health-care professions has led to a proliferation of activity, often involving direct contact with the patient. However, there seems to be wide acceptance that there are no ethical dimensions to audit activity, even though it may be wide-ranging and uncoordinated. Argues that, while research has a well-developed mechanism for ethical scrutiny, audit activity can sometimes be indistinguishable from research and so, in some cases, it should be submitted to external scrutiny in order to protect the patient. Suggests five criteria as activities where ethical scrutiny should be considered. PMID- 10162126 TI - Using simulation in out-patient queues: a case study. AB - Overwork and overcrowding in some periods was an important issue for the out patient department of a local hospital in Chia-Yi in Taiwan. The hospital administrators wanted to manage the patient flow effectively. Describes a study which focused on the utilization of doctors and staff in the out-patient department, the time spent in the hospital by an out-patient, and the length of the out-patient queue. Explains how a computer simulation model was developed to study how changes in the appointment system, staffing policies and service units would affect the observed bottleneck. The results show that the waiting time was greatly reduced and the workload of the doctor was also reduced to a reasonable rate in the overwork and overcrowding periods. PMID- 10162127 TI - Quality in provision of forensic psychiatric services: room for improvement. AB - Highlights some of the tensions which impede the development of an effective and efficient system of service delivery in forensic psychiatry. Reports on an investigation exploring the quality of care in a relatively small unit providing forensic psychiatric care in a secure setting and the constraints which impede the development of such services. Discusses the findings from the investigation which point to the need for the organizational structure surrounding forensic psychiatric care to be altered so that there are no perverse incentives for purchasers of services and to enable the contracting process, considering both cost and quality issues, to take place on a level playing field. PMID- 10162129 TI - Blood and money. The marketplace has helped spread AIDS. PMID- 10162128 TI - Motivating physician behaviour change: social influence versus financial contingencies. AB - The recent development of clinical practice heuristics is a logical consequence of outcomes and effectiveness research. Proponents of clinical practice guidelines (CPGs) believe they will lower costs, enhance quality, and reduce the incidence of malpractice claims. Although the process for generating CPGs appears relatively uncomplicated, guidelines alone do not produce lasting changes in physician behaviour. Discusses strategies for implementing CPGs based on the various factors that influence physician behaviour. Recommends direct behaviour management strategy based on financial contingencies. PMID- 10162130 TI - Making patient records meaningful to patients. PMID- 10162131 TI - Telemedicine applications clear time and distance barriers easily. PMID- 10162132 TI - Strategic planning for managed care information systems. PMID- 10162133 TI - Network architectures and configuration choices. AB - Network architectures that take advantage of new, switch-based building blocks have just begun to appear. Some are designed to relieve specific bottlenecks; others revitalize the entire network. PMID- 10162135 TI - Enterprisewide scheduling systems will become more responsive to users' needs. PMID- 10162134 TI - Client/server allows faster addition of new members and benefits. PMID- 10162136 TI - Radiology information systems hotlist. Radiology systems continue pushing technology envelope. PMID- 10162137 TI - Survey shows Americans doubt accuracy of cancer diagnoses. PMID- 10162138 TI - Navigating through the winds of change. PMID- 10162139 TI - Managing hospital access. AB - As health care facilities grow, it becomes easier to lose track of how well access functions are performing--individually or system-wide. This document examines a process to evaluate current access functions in order to determine their effectiveness and target areas for improvement. PMID- 10162140 TI - Research, decay and an antidote. PMID- 10162142 TI - Casemix funding of hospitals: ethical objections. PMID- 10162141 TI - Casemix funding of hospitals: objectives and objections. AB - Reform of the funding of hospitals and other health services has been one of the most important health policy initiatives undertaken by governments in recent years. A number of countries have adopted the casemix approach to payment, or are currently exploring the feasibility of its introduction. Under casemix arrangements hospitals are funded on the basis of the numbers and types of patients they treat. This paper analyses, and finds inadequate, various objections to casemix funding, including those which appeal to considerations of ethics and equity. PMID- 10162143 TI - Moral strangers and the health care market. AB - In order to reflect on the morality of the health care market this paper critiques some of H.T. Engelhardt's presuppositions. Engelhardt has created the vivid term 'moral stranger' and suggested that there can be a 'morality of moral strangers'. However his position relies either on certain necessary presuppositions which he leaves unmentioned or on presuppositions that are--in a strict sense--not moral ones. Engelhardt advocates the market economy as the guiding principle of health care, and claims that the market needs no moral presuppositions. But when the preconditions of a functioning market are examined it turns out that a functioning market requires property and ownership, and that property and ownership are moral institutions. Therefore the application of the idea of the market to health care undoubtedly has morally serious consequences: most important, the difference between commodities and human beings is obscured. PMID- 10162144 TI - Designing ethicists. AB - In the United States, disturbing concerns pertaining to both how putative bioethicists are perceived and the potential for the abuse of their power in connection with these perceptions compel close examination. This paper addresses these caveats by examining two fundamental and interrelated components in the image-construction of the ethicist: definitional and contextual. Definitional features reveal that perceptions and images of the ethicist are especially subject to distortion due to a lack of clarity as to the nature and qualifications of the ethicist. Furthermore, the clinical, professional, political, academic, and linguistic contexts in which these ethicists are engaged are contexts of disquieting degrees of power. I argue that the lack of definitional clarity as to what constitutes an ethicist combined with the above volatile contexts together set the stage for the abuse of power on the part of ethicists. Throughout, I question the extent of self-critical analyses among ethicists, and, in view of these components in image-construction and their relationship to power, I challenge the degree of integrity within the field. In conclusion, I propose some areas for further investigation. PMID- 10162145 TI - Medical manslaughter: a reply to Paterson. PMID- 10162146 TI - Community psychiatric care: from libertarianism to coercion. Moral panic and mental health policy in Britain. AB - This article discusses recent developments in mental health policy in Britain, focusing on the move towards compulsory supervision of mentally ill people in the community. It is argued that the desire for compulsion reflects moral panic rather than rational appraisal of the undoubted problems with community mental health care. Alternative strategies involving education of the patient and cares, the deployment of psychological treatments of psychosis and an emphasis on the negotiation of treatment plans, are advocated. PMID- 10162147 TI - Change management in the British National Health Service: a worm's eye critique. PMID- 10162148 TI - The AHCPR guidelines on heart failure: comparison of a family medicine and an internal medicine practice with the guidelines and an educational intervention to modify behavior. AB - OBJECTIVES: The objectives of this study were to apply the Agency for Health Care Policy and Research (AHCPR) guideline for heart failure to the measurement of quality of care in the ambulatory setting, to compare the results for two large practices and to design an educational intervention for the two practices being studied. METHODS: A retrospective chart review was conducted on a random sample of 50 patients with heart failure selected from each of two outpatient practices: the general internal medicine practice and the family medicine practice at a large academic medical center. Five medical review criteria were developed from the AHCPR guideline for heart failure to compare the two practices with each other and the guidelines. An educational intervention was developed to modify physician behavior in regard to compliance with guidelines. RESULTS: Assessment of left ventricular function occurred in 79% of all cases. Of eligible patients, 68% were treated with angiotensin-converting enzyme inhibitors (ACE-Is). Of those patients treated with enalapril and captopril, 30% and 12%, respectively, were receiving the target dose as defined in the AHCPR guidelines. Of patients not eligible for treatment with ACE-Is, none were treated with hydralazine and nitrates. When the ejection fraction was less than or equal to 40%, 81% of eligible patients were treated with ACE-Is, whereas 59% were treated with ACE-Is when the ejection fraction was greater than 40%. Calcium channel blockers were used in the treatment of 42% of patients. A statistical difference (P = .05) was found between the two practices for documentation of left ventricular function, the use of ACE-Is for patients with ejection fraction less than or equal to 40%, and the use of calcium channel blockers and beta blockers. CONCLUSIONS: In the practices studied, there is underutilization of the documentation of left ventricular function, ACE-Is in eligible patients, target doses of ACE-Is, and the use of hydralazine and nitrates for ineligible patients. A higher proportion of patients receive ACE-I therapy when the ejection fraction is less than or equal to 40%. There may be inappropriate use of calcium channel blockers in some patients. There is unexplained clinical variation between the two practices studied. PMID- 10162149 TI - Patterns of care for HIV-related Pneumocystis carinii pneumonia in a university medical program: a case study. AB - BACKGROUND/OBJECTIVE: Previous studies have identified large variations in patterns of in-hospital acquired immunodeficiency syndrome (AIDS) care among groups of hospitals and physicians. We evaluated the patterns of care for patients with AIDS-related Pneumocystis carinii pneumonia (PCP) care at a single university program with patients treated at an adjacent county and Veterans' Administration (VA) hospital. All medical care was provided by physicians in a single residency program, but attending physician staffs were separate. SETTING AND PATIENTS: A randomized sample of patients with human immunodeficiency virus (HIV)-related PCP from the two hospitals who received care between 1987 and 1990. RESULTS: During the study years, the VA hospital provided care for approximately one fourth as many AIDS patients as the county hospital. Patients at the VA hospital had a higher bronchoscopy rate (39.7% versus 27.7%, P = .05), higher intensive-care unit (ICU) rate (11.8% versus 2.9%, P = .008), longer hospitalizations (mean length of stay of 18.9 versus 13.9 days, P = .004), but delayed initiation of anti-PCP therapy (median of day 2 versus day 1, P < .05). The odds of death were significantly different between the VA and county hospitals, even after adjusting for differences in important patient characteristics. CONCLUSION: Patterns of in-hospital PCP care differed between the two hospitals of this medical school. Possible explanations include organizational differences related to level of attending physician HIV experience, hospital case loads of AIDS patients, or specific hospital considerations such as concerns over tuberculosis exposure. PMID- 10162150 TI - Quality improvement projects: attributing variation between physician and nonphysician causes. AB - Healthcare systems may be unique among the systems that have used a total quality management (TQM) approach to improve quality. The physician is considered centrally placed within the system, because most, and possibly all, core processes are driven by physician decision. A conceptual approach is offered to aid early understanding and success in improvement efforts. This approach is to begin TQM efforts with a distinction between physician causes and all other causes of variation. The example provided is a collaborative, clinical, quality improvement project with six acute-care facilities involving hip fracture surgery. In this project, the process of interest was the prevention of thrombus formation. The variation in facility performance on this indicator was split into two parts: physician and nonphysician. The variable "nonphysician" included all other causes of variation. Facility responses to this presentation are recounted. PMID- 10162151 TI - Artificial stupidity. PMID- 10162152 TI - Systems thinking, boundaries, and role clarity. AB - Confused or ambiguous expectations among healthcare professionals, and between them and patients, can result in reduced quality of care. Conversely, clear role expectations have benefited, specifically, improved communication and information provided to physicians, and generally have benefited overall healthcare system flexibility and responsiveness. Such benefits are not confined to patient-care teams alone, but can accrue to teams in all phases of healthcare practice and support. PMID- 10162153 TI - Managing managed care. AB - Managed care creates several dilemmas for the physician executive. Effective management is hindered by lack of analytical tools that stem from current limitations in outcomes research and treatment protocols, altered financial incentives that are controversial and that seem at odds with traditional incentives, and values that create conflict between the needs and expectations of individual patients and populations or groups under managed care. The executive must manage a process that resolves apparent conflict in an explicit ethical framework that acknowledges the limitations of data, with full awareness of the potential conflict between financial incentives and clinical judgement. PMID- 10162154 TI - Second National Healthcare Conference on Measuring Performance and Implementing Improvement: a Practical Approach, held June 3-4, 1996, in Washington, DC. PMID- 10162155 TI - Changing provider behavior: is it possible? PMID- 10162156 TI - Indicators: the final common pathway in your quality improvement program. PMID- 10162157 TI - JCAHO-SHEA project to monitor indicators. PMID- 10162158 TI - The value of indicators. PMID- 10162159 TI - The facts about FACCT (Foundation for Accountability). PMID- 10162160 TI - Statistics: all you need to know you didn't learn in kindergarten. PMID- 10162161 TI - Case mix: effect on health outcome assessment, with examples in the outpatient setting. PMID- 10162163 TI - Practice guidelines: how can they really guide your practice? PMID- 10162162 TI - Satisfaction surveys: does the information make a difference? PMID- 10162164 TI - Informatics: how to insert computer checks into your medical information system. PMID- 10162165 TI - Reducing costs: the case for disease management. PMID- 10162166 TI - Maintaining quality while reducing costs. PMID- 10162167 TI - Medicare and Medicaid Programs; new payment methodology for routine extended care services provided in a swing-bed hospital--HCFA. AB - The final rule revises the regulations governing the methodology for payment of routine extended care services furnished in a swing-bed hospital. Medicare payment for these services is determined based on the average rate per patient day paid by Medicare for these same services provided in freestanding skilled nursing facilities (SNFs) in the region in which the hospital is located. The reasonable cost for these services is the higher of the reasonable cost rates in effect for the current calendar year or for the previous calendar year. In addition, this final rule revises the regulations concerning the method used to allocate hospital general routine inpatient service costs for purposes of determining payments to swing-bed hospitals. These changes are necessary to conform the regulations to section 1883 of the Social Security Act (the Act), and section 4008(j) of the Omnibus Budget Reconciliation Act of 1990. PMID- 10162168 TI - Medicare and state health care programs and program fraud civil remedies: fraud and abuse; civil money penalties inflation adjustments--Office of Inspector General, HHS. Final rule. AB - In accordance with Federal Civil Monetary Penalty Inflation Adjustment Act of 1990, as amended by the Debt Collection Improvement Act of 1996, this final rule incorporates the penalty inflation adjustments for the civil money penalties for health case fraud and abuse. These inflation adjustment calculations are not applicable to those civil money penalties contained in the Social Security Act, which are exempted from this adjustment. PMID- 10162169 TI - Medicare program; monthly actuarial rates and monthly supplementary medical insurance premium rate beginning January 1, 1997--HCFA. Notice. AB - As required by section 1839 of the social Security Act, this notice announces the monthly actuarial rates for aged (age 65 and over) and disabled (under age 65) enrollees in the Medicare Supplementary Medical Insurance (SMI) program for 1997. It also announces the monthly SMI premium rate to be paid by the enrollees during 1997. The monthly actuarial rates for 1997 are $87.50 for aged enrollees and $110.40 for disabled enrollees. The monthly SMI premium rate for 1997 is $43.80. PMID- 10162170 TI - Cost of hospital and medical care and treatment furnished by the United States; certain rates regarding recovery from tortiously liable third persons--OMB. PMID- 10162171 TI - Medicare program; inpatient hospital deductible and hospital and extended care services coinsurance amounts for 1997--HCFA. Notice. AB - This notice announces the inpatient hospital deductible and the hospital and extended care services coinsurance amounts for services furnished in calendar year 1997 under Medicare's hospital insurance program (Medicare Part A). The Medicare statute specifies the formulae to be used to determine these amounts. The inpatient hospital deductible will be $760. The daily coinsurance amounts will be: (1) $190 for the 61st through 90th days of hospitalization in a benefit period; (b) $380 for lifetime reserve days; and (c) $95 for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period. PMID- 10162172 TI - Reining in the HMOs. AB - As managed health care proliferates, states are enacting laws to ensure patients' access to specialists and treatment information, among other protections. Congress is following suit. Managed care plans have gone along with the changes to an extent but fear over-regulation. PMID- 10162174 TI - Ok, now what? PMID- 10162173 TI - Motherhood, apple pie and Medicare. PMID- 10162175 TI - What organizations offer when they recruit physicians. PMID- 10162176 TI - Do doctors need a union label? PMID- 10162177 TI - Trading your independence for a guaranteed salary. PMID- 10162178 TI - Physicians must create their own HMOs. PMID- 10162179 TI - Building the right incentives into a physician payment system. PMID- 10162180 TI - Stitching a new HMO from whole blue denim. PMID- 10162181 TI - Don't let one bad apple spoil your medical bunch. PMID- 10162182 TI - Bound or gagged? Privacy, confidentiality and CPR. PMID- 10162183 TI - Where's the growth? In HMOs and point-of-service plans. PMID- 10162184 TI - How to set up a charitable foundation. Interview by Meg Matheny. PMID- 10162185 TI - The conversion foundations: a pot of gold or Pandora's Box for communities. AB - The new charitable foundations being created when tax-exempt hospitals and HMOs go for-profit are enriching their communities with grants for health, education, housing and other worthy causes, but critics charge some deals shortchange the public. HSL Founding Publisher Barry S. Badfer looks at what the conversion foundations are doing and how to increase their accountability to serve the public good. PMID- 10162186 TI - The challenge to medical research in a cost-competitive environment. Interview by Mark Harris. AB - As managed care and government actions threaten the financial base of research and education at America's teaching hospitals, they must find new sources of funds. Mary Woolley of the advocacy group Research!America notes that the heads of healthcare systems can help reverse the downward trend in funding and gain a competitive edge with the public, who favor spending more on research. PMID- 10162187 TI - Case study. Shands Hospital/University of Florida Health System: ahead of the game in adjusting to a changing marketplace? AB - This academic medical center anticipated the effects of a managed care market and, under the leadership of a management team that was willing to take risks and embrace change, has established a healthcare network that promises a good delivery system based on clinical pathways and a secure patient base. PMID- 10162188 TI - Anti-fraud effort to focus on quality of care issues. PMID- 10162189 TI - The new reality: academic medical centers partner with the community. AB - As academic medical centers face a price-sensitive market dominated by managed care, their survival, says Association of American Medical Colleges' Robert Dickler, will depend on the combination of strategies they use in response. HSL looks at three centers' solution--building alliances to secure patient bases, focusing on expanding primary care capabilities, and downsizing and reorganizing for greater cost savings. PMID- 10162190 TI - A partnership to affect real cost reduction: a guaranteed savings of $20 million. AB - In 1994 Brigham and Women's Hospital and Massachusetts General Hospital joined forces to form Partners HealthCare System, Inc. (Boston, MA), an integrated healthcare delivery system. Both teaching affiliates of Harvard Medical School, the two hospitals comprise approximately 1,750 beds with 80,000 inpatient admissions and 1.3 million outpatient visits annually. The two campuses have over 16,000 employees in facilities covering 6.5 million square feet. The key goals of their partnership were to reduce cost and improve quality. Partners HealthCare System (PHS) set a goal to save $240 million in the first three years. These savings were to be achieved through consolidating departments and programs, adopting best practices between institutions, and wise purchasing. This article looks at the supplier partnering process followed by PHS to affect a guaranteed savings of $20 million. PMID- 10162191 TI - Optimizing primary care services. AB - One of the most recent and pervasive trends in healthcare is the restructuring of primary care. In many markets, the solo family practice physicians increasingly family practice physician is a thing of the past. Primary care physicians increasingly are aligning themselves with larger players such as multispecialty groups, hospitals, health plans, or practice management companies. This article draws on the authors' research into 20 healthcare systems in various stages of development as well as their own consulting experience to answer several questions: Why is the establishment or purchase of primary care physician practices an exploding national trend? What are the pros and cons of this approach? Is it better to purchase existing practices or establish new ones from the ground up? What are the pros and cons of virtual integration (affiliation without purchase) versus other forms of integration? PMID- 10162192 TI - HMO partnering: the provider dilemma. AB - While the growth of HMOs has slowed patient visits to doctors, it also has created a deluge of press clippings. On July 16, 1996, three articles on the subject appeared in the Wall Street Journal, front section. The headlines painted a vivid picture of the forces acting on HMOs and providers alike (Figure 1). The articles portended more change for healthcare. The "shake-out," a term applied to industries in serious transformation, brings shedding of excess capacity and loss of jobs and income. Providers, in particular, find themselves in a difficult dilemma. They must not only cut costs as reimbursement drops, but also retain patients with good outcomes and high quality service. Patient retention means keeping the individual patient from switching to another provider and keeping the insurer's group of patients as an authorized provider for that insurer. The relationship between provider and HMO lies at the heart of the provider dilemma. The HMO structure, which shifts financial risk for care, is quickly setting the standard, for healthcare pricing, medical standards, and management practices. Understanding and responding to HMO needs are vital to competitive advantage and survival. The article discusses the inherent dilemma of HMO and provider partnering and suggests provider responses. PMID- 10162193 TI - Managed care backlash. PMID- 10162194 TI - The role of partnering. PMID- 10162195 TI - Paperless office: Fact and fiction. PMID- 10162196 TI - Healthcare managers' stress test. PMID- 10162197 TI - Symposium: Perspectives on psychological burnout, VI (Part 2). PMID- 10162198 TI - An examination of methodological issues in burnout phase research. AB - This study explores the impact of three operationalizations of burnout phase on the relationship between burnout and health care utilization of 238 employed adults. Burnout was measured by the Maslach Burnout Inventory and health care utilization by insurance company records regarding these employees' health care costs and number of times they accessed health care services over a one-year period. Similar results were found for all three operationalizations of burnout phase. Burnout phase was also found to be related to experienced emotional strain under all three operationalizations. PMID- 10162199 TI - Factors affecting decisions to adopt medical technologies in acute care hospitals. AB - The results of this research have added an expanded perspective on the decision to adopt particular technologies. The perception had been that, given the current state of health care reimbursement, decisions to acquire radical and often expensive devices will center around economic or strategic considerations. However, it was discovered that technology acquisition appeared to be a physician centered activity with less consideration given to strategic or economic factors. While these data suggest that hospitals have not been listening to complaints about rising health care costs and continue to operate in a "business as usual" manner, it may because physicians continue to be the dominant players in what is for them an unrestrained free market. This trend, if continued, may ultimately lead to a reimposition of heavy handed government regulation in the adoption of even the most routine medical technology. As a result, it is vital that health care administrators begin to explore ways for moving from physician centered and tactical considerations to a more strategic focus which builds upon the needs and interests of the medical staff to serve the community in a more responsible fashion before that ability is taken away from them. PMID- 10162200 TI - Pleasing the patient. PMID- 10162202 TI - A new training initiative. PMID- 10162201 TI - Musical medicine. PMID- 10162203 TI - Synchronized caring. PMID- 10162204 TI - The human touch. PMID- 10162205 TI - Has patient-focused care helped? Discussion. PMID- 10162206 TI - A midpoint evaluation. AB - The Fall 1995 issue of Michigan Health & Hospitals magazine featured an article about a patient-focused care (PFC) program that was getting under way. The article included basic information about changes that had been made and goals that had been set in an effort to increase patient satisfaction and lower operating costs. After 18 months of PFC, St. Luke's Hospital in Saginaw has discovered some of the struggles and triumphs that accompany change. PMID- 10162207 TI - Four routes to the future. AB - The following is a synopsis of four potential scenarios for American health care in the year 2005 that were proposed at the most recent Health Care Outlook meeting (see sidebar). These scenarios provided a framework for discussion and debate for MHA's Next Wave Task Force, and a complete report on observations from a Michigan perspective will be made available to the membership soon. PMID- 10162208 TI - From my point of view. PMID- 10162209 TI - Who speaks for the uninsured? PMID- 10162210 TI - A revolutionary redesign. AB - Patient-focused care (PFC) has been around for years and has been written about extensively. A survey conducted by Hospitals magazine in February 1993 indicated that nearly one half of all US hospitals were implementing or considering some type of PFC. But what does it mean to be patient focused? What can you expect if you become patient focused? What is the role of PFC in light of managed care and emerging integrated delivery systems? This article is written from the viewpoint of consultants and industry leaders who have participated in PFC work. PMID- 10162211 TI - On-call physicians gain access to records. PMID- 10162212 TI - Health Tech Internet guide. PMID- 10162213 TI - Homework pays off. Interview by Howard J. Anderson. PMID- 10162214 TI - Paper pushers no more. PMID- 10162215 TI - Clinics face a daunting task. PMID- 10162218 TI - Reading tissues from a distance. PMID- 10162216 TI - Bringing medical expertise to the desktop. PMID- 10162217 TI - Have a heart. PMID- 10162219 TI - Provider as payer. Technology helps manage risk. PMID- 10162220 TI - Building an I.S. strategy in the wake of a merger. PMID- 10162221 TI - PPOs face an EDI struggle. PMID- 10162222 TI - Research takes on a second life. Interview by John McCornack. AB - The health care industry is embracing the artificial intelligence concepts that Edward H. Shortliffe, M.D., developed in the 1970s. His current work on Web-based information dissemination may yield applications for the next century. PMID- 10162223 TI - Solving a rural hospital problem. PMID- 10162224 TI - Restoring the image of networks. AB - The struggles of some high-profile CHIN initiatives have damaged the reputation of community networks. But proponents believe that integrated delivery systems and the Internet will aid their cause in the long run. PMID- 10162225 TI - Data repository. Early users learn valuable lessons, reap benefits. PMID- 10162226 TI - Addressing security in the networking era. PMID- 10162227 TI - Tracking electronic claims growth. AB - Providers are submitting a growing majority of claims electronically. But physicians trail hospitals and pharmacies in the use of EDI. PMID- 10162228 TI - Digital imaging catches on at the VA. PMID- 10162229 TI - Managed care. Making the grade. PMID- 10162230 TI - Kicking the prescription pad habit. PMID- 10162231 TI - Carrying out the mandate. PMID- 10162232 TI - Planning for the future. Ten national industry trends in behavioral health. PMID- 10162233 TI - ACEP and Kaiser Permanente strike landmark managed care agreement. PMID- 10162234 TI - Trauma, training, and videotape: a new approach. PMID- 10162235 TI - Business plans can provide focus, increase efficiency. PMID- 10162236 TI - Treat prisoners in ED with caution, dignity. PMID- 10162237 TI - Jersey ED surveys parents who witness resuscitations, finds positive results. PMID- 10162238 TI - Mandatory-reporting laws provoke controversy. PMID- 10162239 TI - Alcoholism curtailed with innovative program. PMID- 10162240 TI - New ventilator can speed patient transport. PMID- 10162241 TI - When no one knows who you are, the first strategic goal is name branding. PMID- 10162242 TI - Evaluating managed care contracts. PMID- 10162243 TI - Growing a medical group: insights from the CEO of a young network in Baltimore. PMID- 10162244 TI - What providers need to know about starting up an HMO. PMID- 10162245 TI - ProPAC assesses new option to link acute, post acute payments. PMID- 10162246 TI - Hospital patients using SNF care may be sicker than other patients. PMID- 10162247 TI - Hospital SNF views doctors as customers to get high occupancy. PMID- 10162248 TI - Geriatric nurse practitioner role grows in newer delivery system. PMID- 10162249 TI - Hospital dual units require solid planning. PMID- 10162250 TI - New Medicare systems require strict costs controls. PMID- 10162251 TI - Direct admission is bright under managed care. PMID- 10162252 TI - Bedside manners. Put a pharmacist in your care picture. PMID- 10162253 TI - Join the IV league. PMID- 10162254 TI - Subacute success story. Plaza Healthcare. PMID- 10162255 TI - The CON game. PMID- 10162256 TI - New law stiffens penalties for fraud and abuse and sets up advisory opinion process. PMID- 10162257 TI - Internal Revenue Service to have increased power to police not-for-profits. PMID- 10162258 TI - Healthcare provider compliance plans. PMID- 10162260 TI - PPOs consider the Medicare market. PMID- 10162259 TI - The midwife option. Health plans and certified nurse midwives are offering women choices in how they give birth. PMID- 10162261 TI - Seniors helping seniors. PMID- 10162262 TI - Identifying the moment of value. PMID- 10162263 TI - Trends in growth among network health care plans. PMID- 10162264 TI - Listening and learning. Health plans are taking action to address diverse member needs. PMID- 10162265 TI - Medicaid HEDIS: from paper to practice. PMID- 10162267 TI - A bioethical compass. PMID- 10162266 TI - Serving vulnerable populations. PMID- 10162268 TI - American Association of Health Plans. Words to live by. PMID- 10162269 TI - Seeing clearly. PMID- 10162270 TI - Ballot initiatives: the next roadblock? PMID- 10162271 TI - A training ground. PMID- 10162272 TI - Care for children. PMID- 10162273 TI - The time for teamwork. PMID- 10162275 TI - A broad spectrum. PMID- 10162274 TI - Chronic care innovations. PMID- 10162276 TI - Making tough questions easier. PMID- 10162277 TI - Enriching the life of the community. PMID- 10162278 TI - Complementary medicine. PMID- 10162279 TI - Making distance smaller. PMID- 10162280 TI - Just what the doctor ordered. PMID- 10162281 TI - Physicians speak out. PMID- 10162282 TI - Reaching out. Health plans respond to their communities in times of crisis. PMID- 10162283 TI - Promoting straight talk. PMID- 10162284 TI - Emphasizing active partnerships. PMID- 10162285 TI - Israel's experiment in health reform. PMID- 10162286 TI - A look at physicians in network-based care. PMID- 10162287 TI - Senior housing operators plan for aging in place. PMID- 10162288 TI - Hospitals and nursing homes: friends or foes? PMID- 10162289 TI - What's wrong with the MDS (Minimum Data Set)? PMID- 10162290 TI - Top job, bottom line ... surveys the earnings of administrators and assistant administrators. PMID- 10162291 TI - Learning from the past. PMID- 10162292 TI - A provider tries a new tack: welcoming the surveyors. PMID- 10162294 TI - Making healthy communities. PMID- 10162293 TI - A new paradigm opens the next millennium. PMID- 10162295 TI - Quality improvement never stops. PMID- 10162296 TI - Assessing acuity for the developmentally disabled. PMID- 10162297 TI - Are your employees satisfied? PMID- 10162298 TI - Joint Commission: back to basics. 1997 Codes emphasize handwashing. PMID- 10162299 TI - The Joint Commission's new policy on sentinel events. PMID- 10162300 TI - Proper positioning makes a difference. PMID- 10162301 TI - Diabetes update 1996--trends & technical advances. AB - Treatment for diabetes can range from balancing a meal plan to maintaining a complex insulin regime. Without allocating large amounts of time and resources, home care providers can take steps to improve service delivery to patients with diabetes. PMID- 10162302 TI - Cancer care at home: past, present, and future. AB - Cancer patients can now receive chemotherapy in the privacy and comfort of their own homes. This innovation in home care service delivery challenges providers to maintain high-touch patient care while using high-tech procedures. PMID- 10162304 TI - Hospice concepts in home care. AB - Hospice incorporates concepts--such as the interdisciplinary team, palliative versus curative care, and bereavement programs--that distinguish it from other types of care delivery. The quest to increase quality of life for the dying while controlling costs will drive the future of hospice. PMID- 10162303 TI - Antimicrobial acetate fibers: a step forward in health care textiles. AB - Health care providers are constantly battling the microorganisms that cause disease and infection. New textile products give professionals another weapon against these microscopic enemies. PMID- 10162305 TI - Revisiting the core values of hospice. AB - In today's climate of mergers and reimbursement cuts, the hospice community faces the challenge of maintaining its founding core value system. With some extra effort hospices will find that good values and good business practices do go hand in hand. PMID- 10162306 TI - Helping to heal through hospice. PMID- 10162307 TI - Angels of mercy. PMID- 10162308 TI - Collaborating to compete: a national study of horizontal networks. AB - Horizontal networks offer providers challenges as well as options. To help providers explore the idea of joining a network, a national study presents the experiences of successful and unsuccessful home care networks. PMID- 10162309 TI - Using research to develop home care programs. AB - For a number of reasons, specialty physicians are hesitant to make referrals to home care. One rural-area provider found that the use of research is an effective strategy for obtaining referrals from specialty physicians. PMID- 10162310 TI - Terror at the Olympics. PMID- 10162311 TI - Paying the price. PMID- 10162313 TI - Nuclear nightmares. PMID- 10162312 TI - Sitting ducks? PMID- 10162314 TI - Lean, mean EMS machines. PMID- 10162315 TI - OSHA celebrates silver anniversary. PMID- 10162316 TI - Columbia Jefferson Medical Center: environmental services--just the right medicine. PMID- 10162317 TI - Setting standards. AB - To ensure that a housekeeping department operates smoothly, various standards must be established and applied. Standards serve as a guide to quality and quantity. The standards will be determined cooperatively by members of top management with input from the housekeeping director and the user department. An appraisal of the facility needs to be made in order to establish proper standards. Once the appraisal has been completed, time standards, frequency standards, and quality standards can be established. PMID- 10162318 TI - The role of the health service ombudsman. PMID- 10162319 TI - Health care experiences of Vietnamese families in Nottingham. AB - There is a dearth of information on the health needs of Vietnamese refugees in Britain. In May 1993, a structured interview survey was undertaken to determine the health care experiences and health-related behaviour of Vietnamese adults living in Nottingham Health District. One hundred and thirty-five adults (66 women) were successfully interviewed in Vietnamese or Cantonese, from 71 to 77 eligible households. Levels of English usage were extremely low, and between 27% and 69% of respondents reported considerable difficulty during the various stages of a consultation with their general practitioner. Data on breast screening services suggested a pattern of low uptake, and the prevalence of male smoking was estimated to be 47%. These results suggest that Vietnamese communities suffer high levels of disadvantage in their use of primary care services; remedial action is required. PMID- 10162320 TI - The effect of patient ethnicity on prescribing rates. AB - The issuing of a prescription is central to any doctor-patient interaction. Prescribing variation exists and remains largely unexplained. There is little documented evidence of the effect of patient ethnicity on prescribing patterns. We carried out a secondary analysis of data from the General Household Surveys to examine the association between being given a prescription and patient ethnicity. After modelling, we found that Pakistanis and Indians were significantly more likely to receive a prescription from their general practitioner at a consultation compared to white and West Indian ethnic groups. In addition, consultation rate explained the different prescribing rates among women and men in the white group only. This study raises further questions of the underlying reasons causing these differences which need answering. PMID- 10162321 TI - Ethnicity and variations in the nation's health. AB - The variations in the Health of the Nation (HoN) key areas among ethnic minorities living in England and Wales are examined, based on a national mortality study by country of birth for the latest possible period (1988-1992). It addresses the 10 mortality indicators in the HoN White Paper (covering coronary heart disease [CHD] and stroke, cancers, mental illness and accidents), using age-standardised rates adjusted to the European Standard Population. The findings establish variations in the recent health experience of ethnic minorities born outside England and Wales who are now living in England and Wales. CHD among persons aged under 65 years was highest in those born in the Indian Subcontinent, 55% above the normal rate in England and Wales. Caribbeans, and African groups experienced the lowest rates. Stroke mortality under 65 years of-age was highest in Bangladeshis, followed by other Commonwealth Africans, and then by Caribbeans. Patterns of cancer deaths also varied, with breast cancer mortality rates being lower in all ethnic groups, and lowest in those born in the Indian Subcontinent. By contrast, lung cancer deaths were higher in Irish men and women; lung cancer mortality among Bangladeshi men was significantly higher than Indians and Pakistanis, being only 15% less than that of the rates in England and Wales. Suicides were lowest in Bangladeshis and Pakistanis and highest among Indians and the Irish. Accidental deaths in children were highest in Pakistanis followed by the Irish, who also experienced higher rates among young persons. It is suggested that the HoN strategy should consider setting appropriate and achievable targets, including ones in new areas of relevance to these groups. The National Health Service purchaser/provider framework should respond to the needs of its populations, including ethnic groups. PMID- 10162322 TI - Piloting short workshops on the critical appraisal of reviews. AB - This paper describes a pilot programme of short workshops on the critical appraisal of review articles. The twelve workshops, which ran in various parts of the United Kingdom during 1992 and 1993, lasted either one or two half-days, and consisted of a mixture of large-group sessions and critical appraisal in small groups of a systematic review. The 274 participants came from varied backgrounds, though chiefly in public health and purchasing. The workshops were well received and were oversubscribed. Participants reported that they found them useful and that they raised their awareness of the place of evidence about effectiveness in decision-making. The challenge now is to evaluate the impact of such workshops more rigorously. PMID- 10162323 TI - Children with asthma in schools: an opportunity for "healthy alliances" between health and education authorities. AB - Head teachers of all primary and secondary schools in County Durham were surveyed during 1994 to investigate school policy and management of children with asthma. Results indicate a need and opportunity to improve asthma care for children at school through healthy alliances between the health and education authorities. PMID- 10162324 TI - Deliberate self harm: the hidden population. AB - Population-based epidemiological surveys of deliberate self harm (DSH) exclude homeless people and do not represent them in their conclusions. However, DSH in the homeless is commonly seen in inner city hospitals and the homeless are probably at higher risk of eventual suicide. We examined the demographic characteristics of all patients who presented to an inner London hospital after an episode of DSH over a period of three years and found that 15% of patients were of no fixed abode. Alternative methods of studying DSH need to be explored if suicide is to be prevented in this group of people. PMID- 10162325 TI - Leg ulcer care: an audit of cost-effectiveness. AB - Our objective was to establish an audit mechanism to determine the cost and effectiveness of leg ulcer care across two Health Authorities. Following identification of all patients with active ulcers over a two-month period, leg ulcer treatment, costs and outcome were prospectively audited over three months. We found that leg ulcer care is currently expensive and appears to be largely ineffective, especially when compared to the community clinic approach. PMID- 10162326 TI - Chefs & dietitians. Round table. Mastering the menu mix. Interview by Mitchell Schechter and Lisa Peterson. PMID- 10162327 TI - Not just one market: operators prepare to feed millions of elderly. PMID- 10162328 TI - Masonic Homes. A retirement community in transition. PMID- 10162329 TI - Building the urban health care model for the 21st Century. PMID- 10162330 TI - The American College of Healthcare Executives' commitment to ethical conduct. PMID- 10162331 TI - Achieving ethical behavior in healthcare rhetoric still reigns over reality. PMID- 10162332 TI - The ethical basis for the physician-patient relationship: covenants or contracts? PMID- 10162333 TI - Creating a new patient-provider relationship: a personal challenge. PMID- 10162334 TI - Promisekeeping: an institutional ethos for healthcare today. AB - The relationship between a physician and a patient, which survived unchanged for decades--indeed centuries--has in recent years undergone a serious change due to the advent of managed care. Controlling costs and maximizing profits are now as equally important as medical concerns, and ethical, economic, and political issues have forever changed the way physicians perform their duties. This article proposes the concept of promisekeeping as a remedy to the sometimes contradictory positions in which patients and providers find themselves. Composed of honesty, explicit disclosure, flexible decision making, and, most of all, beneficence, promisekeeping is one method to ensure that all parties in the managed care system can succeed. PMID- 10162335 TI - Price wars are no-win games for health care systems. PMID- 10162336 TI - MRI outsourcing: a cost-effective alternative. PMID- 10162337 TI - Increasing number of older alcoholics puts new demands on treatment programs. PMID- 10162339 TI - Aetna-U.S. Healthcare merger new challenge. PMID- 10162338 TI - Omnia signs up OB/Gyns, negotiates MCO contracts and provides outcomes research. PMID- 10162340 TI - Developing a true partnership with physicians. PMID- 10162341 TI - Data trends. November 1996--Medicare trends for top 10 volume DRGs. PMID- 10162342 TI - Strategic alliances are good for HFMA. PMID- 10162343 TI - The new health insurance act: a powerful weapon for fighting fraud and abuse. PMID- 10162344 TI - How secure is secure? PMID- 10162345 TI - Health care and the 1996 presidential campaign. PMID- 10162346 TI - Using PC-based decision-support technology to improve efficiency. AB - Healthcare organizations do not need advanced information technology systems to take advantage of the information they gather regarding clinical and operational efficiency. PC-based decision support technology is available to analyze an integrated delivery system's (IDS) existing data and integrate it with competitive healthcare industry data from public and proprietary sources. Many system executives have purchased such technology for their IDSs, but few use the data they generated properly or successfully. PMID- 10162347 TI - Assumptions and realities concerning home healthcare and integrated delivery systems. AB - A variety of assumptions exist concerning home healthcare programs and integrated delivery systems (IDSs). These assumptions need clarification in order for IDS executives to fully realize how home healthcare programs can contribute to improved patient care throughout the continuum. PMID- 10162348 TI - Contracting for Medicaid managed care. AB - State and Federal officials are turning to managed care to help control the costs of providing healthcare services to Medicaid recipients. However, most managed care plans and providers have little experience with this unique population. The socioeconomic profile, medical needs, healthcare utilization, and cost patterns of Medicaid recipients are very different from those of the commercial population. Managed care plans and providers that want to participate in Medicaid managed care programs must develop new approaches to providing benefits and developing capitation rates. PMID- 10162349 TI - Reducing insurer-denied days of care. AB - To help reduce inpatient expenses, insurers establish utilization management protocols and perform utilization reviews of the care provided in inpatient settings. As a result of these reviews, insurers may deny reimbursement for specific inpatient days or entire admissions. To avoid incurring denied days of care, providers must understand how to apply insurer protocols, streamline care management processes to avoid delays in care, appeal denials, and ensure that managed care contracts contain fair utilization management and quality assurance provisions. PMID- 10162350 TI - Cost accounting helps ensure group practice profitability. AB - Physician practice managers are faced with the challenge of developing overall practice budgets, identifying strategies for the practice, and negotiating profitable managed care contracts. To accomplish these objectives, they need to understand and manage the costs associated with practice operations. Practices that have used cost accounting methodologies to identify their operational costs in greater detail and have developed methods to effectively manage their costs are likely to be more attractive partners to health plans and better positioned to thrive under managed care. PMID- 10162351 TI - Key provisions strengthen hospital capitation contracts. AB - Hospitals that accept capitation payments can expect both risks and rewards. The rewards include a dependable revenue stream and economic incentives aligned with those of physicians. The risks are related to payment issues, provision of services, utilization projections, and contract disputes. By ensuring that capitation contracts adequately address these and other issues, hospitals can minimize their exposure to risk. PMID- 10162352 TI - Improving communication in a diverse healthcare environment. AB - Ethnic and racial diversity enriches the healthcare environment just as it enriches the nation. But diversity in the healthcare environment also can cause communication difficulties that impede effective service delivery. Many communication difficulties stem from differences in cultural values, languages, and points of view, and usually they can be overcome by understanding their source and applying techniques to resolve them. Techniques that can be used to help resolve communication difficulties include: listening carefully to what is said, repeating messages that are not readily understood, accepting responsibility for a lack of understanding, phrasing questions in different ways, and creating a relaxed atmosphere. PMID- 10162353 TI - Revised DOJ and FTC policy statements offer more options for physician joint ventures. AB - Physician networks and multi-provider networks that do not demonstrate financial integration through substantial risk sharing present antitrust risk and face possible scrutiny by the Department of Justice and Federal Trade Commission. However, the DOJ and the FTC have recently revised statements 8 and 9 of their Statements of Enforcement in Health Care. The revised statements allow increased flexibility in the formation of provider networks and describe in detail the extent of integration--financial or otherwise --required for a joint venture to be lawful. PMID- 10162354 TI - Drafting a sound physician employment agreement. AB - Group practices that employ physicians on a contractual basis face a number of risks. Among these risks are the possibility of employee-physicians engaging in competitive activities; the practice's potential liability for outside services its physicians may perform; and the possibility of breaches of patient and practice confidentiality. By drafting employment agreements that include provisions that minimize such risks, practices can strengthen their market position and protect themselves from potential losses. PMID- 10162355 TI - The debate over payment for Medicare managed care. PMID- 10162356 TI - Winning hearts and minds. PMID- 10162357 TI - Outsourcing investing services. PMID- 10162358 TI - Profits for nonprofits: find a corporate partner. AB - Here's a familiar story. A nonprofit organization joins forces with a corporation in a caused-related marketing campaign. It seems like a win-win deal, but the nonprofit--and the media--find out several weeks into the campaign that the corporation's business practices are antithetical to the nonprofit's mission. The nonprofit's credibility is severely damaged. Is the moral of the story that nonprofits should steer clear of alliances with for-profit organizations? Not at all, Alan Andreasen says. Nonprofit managers can help their organizations avoid many of the risks and reap the rewards of cause-related marketing alliances by thinking of themselves not as charities but as partners in the marketing effort. More than ever, nonprofits need what many companies can offer: crucial new sources of revenue. But nonprofits offer corporate partners a great deal in return: the opportunity to enhance their image--and increase the bottom line--by supporting a worthy cause. Consider the fruitful partnership between American Express and Share Our Strength, a hunger-relief organization. Through the Charge Against Hunger program, now in its fourth year, American Express has helped contribute more than +16 million to SOS. In return, American Express has seen an increase in transactions with the card and in the number of merchants carrying the card. How can nonprofit managers build a successful partnership? They can assess their organization to see how it can add value to a corporate partner. They can identify those companies that stand to gain the most from a cause related marketing alliance. And they can take an active role in shaping the partnership and monitoring its progress. PMID- 10162359 TI - The top 10 reasons for integrated enterprise management. PMID- 10162360 TI - Accelerating the culture change! AB - Exide Electronics, a major supplier of uninterruptible power system equipment, embarked on a journey of changing a culture to improve quality, enhance customer responsiveness, and reduce costs. This case study examines the evolution of change over a period of seven years, with particular emphasis on the most recent years, 1992 through 1995. The article focuses on the Raleigh plant operations and describes how each succeeding year built on the successes and fixed the shortcomings of the prior years to accelerate the culture change, including corrective action and continuous improvement processes, organizational structures, expectations, goals, achievements, and pitfalls. The real challenge to changing the culture was structuring a dynamic approach to accelerate change! The presentation also examines how the evolutionary process itself can be created and accelerated through ongoing communication, regular feedback of progress and goals, constant evaluation and direction of the process, and measuring and paying for performance. PMID- 10162361 TI - Accountability: the force behind empowerment. AB - The first part of this article will focus on an examination of the more traditional practice of "process accountability," which typically uses policy based methods that rely on the development, measurement, and reporting of standards. This will be followed up by an examination of the more ephemeral, though vastly more valuable and powerful "attitude" of "personal accountability." PMID- 10162362 TI - Visions happen when you make them actionable with Total Quality Control 2. PMID- 10162363 TI - Continuous improvement for winning in the marketplace: the Granite Rock experience. AB - Leadership and the employee involvement approach are features of continuous improvement (CI). The experiences of Granite Rock with the strategy and practices for quality improvements are presented. The major factors to be focused on to move quality from the dismal levels that exist today toward world-class quality status are examined. PMID- 10162364 TI - Nothing is so good it can't be made better. AB - The concept of continuous improvement can be viewed from the perspectives of the elimination of waste or the improvement of quality. The waste elimination approach attacks all forms of waste, whereas quality improvement uses the concept of total customer satisfaction. This article describes an eight-step model for continuous improvement that addresses waste elimination and customer satisfaction. PMID- 10162365 TI - Customer delight and demand management: can they be integrated? AB - This article will supply methods of becoming trading partners in today's global market and will provide world-class approaches to improved responsiveness and customer satisfaction. Guidelines and actual how-to's for implementing and managing a customer-driven supply chain will be offered. Examples will be given of how both large and small organizations have increased profitability by eliminating non-value-added paperwork, improved their ability to respond to customer demand, and reduced procurement cycle times along the entire supply chain. PMID- 10162366 TI - Improving health care means spending more time with patients and less time with inventory. AB - In most hospitals and medical establishments, about 35 percent of their budgets are spent on supplies and labor to manage the inventories, material, and information flows; typically, these are managed as multiechelon systems. The importance of reducing inventory costs, among others, has become relevant in today's health care management. This research applies just-in-time concepts to health care inventories. PMID- 10162368 TI - Performance measurements for a continuous improvement strategy. AB - In many organizations, performance measurement systems have not appreciably changed to reflect organizational and environmental changes. The objective of this article is to analyze the results of an inappropriate performance measurement system, define the characteristics required of a performance measurement system in a continuous improvement (CI) organization, and give some examples of more appropriate performance measures in a CI company. PMID- 10162367 TI - A new focus on inventory performance and bottom-line profits. AB - This article is about a new way to measure inventory performance and about putting a dollar focus on inventory management priorities. It reviews the financial impact of inventories and shows how the information from any materiel requirements planning (MRP), MRP II, ERP, DRP, or orderpoint system can be used for setting individual objectives for inventory reduction, measuring performance by inventory segment, and monitoring continuous improvement. It will also consider the merits of paying performance bonuses to materiel planners and review some inventory reduction results. PMID- 10162369 TI - Change your performance measurements of there may be no future. AB - Performance measurements help to define and promote desired behaviors, activities, and attitudes within an organization. The "right" behavior must be consistent with and supportive of the strategies an organization has adopted to move it toward its preferred future. There must be vertical and horizontal integration of all performance measures to support consistent activities at all levels and in all functions. In today's world of rapid change and greater reliance on teams, there must be recognition of both individual performance and a new set of measurements to promote teamwork. PMID- 10162370 TI - MOM (motive, opportunity, and means) in the workplace--your path to competitive advantage. PMID- 10162372 TI - Healthcare Design Research Alliance. PMID- 10162371 TI - E.L. Cord Cardiac Intensive Care Unit, Saint Mary's Regional Medical Center, Reno, Nevada. PMID- 10162373 TI - Children's Memorial Hospital Pediatric Isolation Unit, Chicago. PMID- 10162374 TI - Health Management Guide. Disease management. AB - Disease management has been described as a comprehensive, integrated approach to care and reimbursement based on the natural course of a disease. It requires a management approach which brings together research evidence, best practice and inter-professional and inter-agency working. Starting with the ideal of continuity of care for individual patients, it implies structured co-ordination of care over time and across primary, secondary and tertiary settings. The appeal of disease management is that it promises reduced costs, combined with increased quality of care and patient satisfaction. But the concept is open to different definitions and interpretations and its effectiveness in improving UK healthcare is still largely untested. This Health Management Guide removes the mystique behind disease management and puts it in the context of existing knowledge and practice. Treating it as a concept, rather than a specific technique, it distinguishes between its different potential applications, offers practical guidance on implementation, and reports on how NHS organisations are taking it forward. PMID- 10162375 TI - General practice. GPs on work, rest and play. PMID- 10162376 TI - Needs assessment. Lore unto themselves. PMID- 10162377 TI - Health promotion. Leader of the pack. PMID- 10162378 TI - Mental health. The powers that be. PMID- 10162379 TI - Data briefing. Measuring efficiency. PMID- 10162380 TI - Careers profile. Health promotion. From foot soldiers to chiefs. PMID- 10162381 TI - Facilities management. Accident prone. PMID- 10162382 TI - Facilities management. Water management. Tapping liquid assets. PMID- 10162383 TI - Facilities management. Information management. News agent. PMID- 10162384 TI - Facilities management. Portering services. Our friends electric. PMID- 10162385 TI - Patient's charter. Unchartered territory. PMID- 10162386 TI - NHS entrants. That was the year, that was. Interview by Barbara Millar. PMID- 10162387 TI - IT update/outcome data. In their element. PMID- 10162388 TI - IT update/networking. Circuit breakers. PMID- 10162389 TI - IT update/HISS. Slowly but surely. PMID- 10162390 TI - Corporate governance. Remorse codes. PMID- 10162391 TI - Absence minded. PMID- 10162392 TI - Careers profile. Human resources managers--the people persons. PMID- 10162393 TI - Insiders and business directors on hospital boards and strategic change. AB - Many hospitals are eager to incorporate practices of boards in business organizations. Yet little evidence exists on the desirability of "corporate" board features in hospital settings. We examined the effects of two characteristics of corporate boards--the relative dominance of insiders and of directors with business-related occupations on strategic changes within hospitals. We studied 335 hospitals in California immediately following legislative reforms in 1982. We found that hospital boards with a higher proportion of insiders and business directors made more changes in their mix of services in response to legislative reform. In addition, this relationship held for nonproprietary hospitals but not for proprietary hospitals. Limitations and implications of the results are discussed. PMID- 10162394 TI - Prediction of hospital failure: a post-PPS analysis. AB - This study investigates the ability of discriminant analysis to provide accurate predictions of hospital failure. Using data from the period following the introduction of the Prospective Payment System, we developed discriminant functions for each of two hospital ownership categories: not-for-profit and proprietary. The resulting discriminant models contain six and seven variables, respectively. For each ownership category, the variables represent four major aspects of financial health (liquidity, leverage, profitability, and efficiency) plus county marketshare and length of stay. The proportion of closed hospitals misclassified as open one year before closure does not exceed 0.05 for either ownership type. Our results show that discriminant functions based on a small set of financial and nonfinancial variables provide the capability to predict hospital failure reliably for both not-for-profit and proprietary hospitals. PMID- 10162395 TI - Hospital community benefits other than charity care: implications for tax exemption and public policy. AB - Recent policy initiatives attempt to link the tax treatment of nonprofit hospitals more closely with the provision of social benefits. A key issue in defining these benefits is the treatment of "community benefit" programs and services. While their costs are often unreimbursed, these programs differ from traditional charity care in terms of the populations whom they benefit and the motivation for their provision. Community benefit programs are typically targeted to the general population, rather than the poor or other underserved groups, and often serve a marketing function. PMID- 10162396 TI - English-only work rules: balancing fair employment considerations in a multicultural and multilingual healthcare workforce. AB - Most healthcare organizations are currently or will shortly be composed of a multicultural and multilingual workforce. In attempting to manage such diverse workforces. English-only work rules may be necessary to ensure effective communication among workers. However, care must be taken to insure that the employees' rights to free speech and a harassment-free workplace are not infringed by utilizing English-only work rules. This article attempts to assist the healthcare manager in dealing with the legal aspects of English-only work rules. Specifically, an examination of two legal cases is provided to illustrate the various legal aspects of such work rules. Also, suggestions are offered as to how and when, or when not, to implement English-only work rule in order to avoid possible liability. PMID- 10162397 TI - Management development for mid-level managers: results of a demonstration project. AB - This article examines a demonstration program to develop skills and experience for middle managers at a mid-sized urban hospital. Many of the middle managers selected for the program lacked formal management training or management experience prior to their present position. Elements of the program are summarized and first year accomplishments examined. Issues associated with continuation and replication of the program are discussed so that other hospitals may benefit from the lessons learned during development and implementation. PMID- 10162398 TI - Discriminant analysis: a technique for adding value to patient satisfaction surveys. AB - Quality improvement in healthcare organizations requires effective measurement of patient satisfaction. This paper describes a methodology that identifies dimensions of care most closely associated with overall perceptions of quality. A patient satisfaction survey was mailed to 2,055 discharged patients of 13 home health agencies. Patients were asked to evaluate service dimensions of home health relating to scheduling, nursing care, home health aide services, and discharge arrangements. Overall satisfaction with quality of services was used as the dependent variable in two discriminant analysis equations. Eleven dimensions discriminated between "excellent" and "good" quality, and seven dimensions discriminated between "satisfactory" and "unsatisfactory" quality. Using discriminant analysis, items most closely associated with quality indeces can be identified and used in CQI initiatives. PMID- 10162399 TI - Keys to patient satisfaction in the emergency department: results of a multiple facility study. AB - Patient satisfaction is a significant issue for emergency departments. The special nature of the emergency encounter calls for a sound understanding of the factors that influence patient satisfaction. This study uses a national sample of emergency departments to identify specific elements that increase the likelihood of patients recommending the facility. We find that demographic variables such as age and sex do not significantly influence the decision to recommend. Nursing/staff items, physician issues, and waiting time are the key factors that drive satisfaction with emergency departments. PMID- 10162400 TI - Internal complexity and environmental sensitivity in hospitals. AB - Theory suggests that organizations should respond to external complexity with internal complexity. We examine whether "environmentally sensitive" hospitals are more internally complex than "environmentally insensitive" hospitals. Results show that environmentally sensitive and insensitive hospitals differed on three of the measures of internal complexity: goal complexity, strategic complexity, and relational complexity. PMID- 10162401 TI - Whatever works. PMID- 10162402 TI - The mainstreaming of alternative medicine. PMID- 10162403 TI - Glossary of some alternative therapies. PMID- 10162404 TI - Guided imagery gets respect. PMID- 10162405 TI - Healthcare information systems. Spend more, get less. PMID- 10162406 TI - Managed care mythology: supply-side dreams die hard. AB - As managed care gains increasing influence over the American health financing system, economic pressures and emerging market realities have created a fertile climate for wishful thinking on the part of hospital executives and physicians. Rather than accept the inevitability of reducing excess capacity and incomes, providers cling to self-serving myths about managed care's strategic direction. Here are five of these myths along with their contrasting market realities. PMID- 10162407 TI - Placebos and nacebos. PMID- 10162408 TI - Branding. PMID- 10162409 TI - Log on. A continuing guide to the online world for healthcare executives, managers, clinicians and patients. PMID- 10162410 TI - Jump-start your career. PMID- 10162412 TI - The art of the deal. PMID- 10162411 TI - Exploring the gender gap in healthcare management. AB - A 1990 study by ACHE and the University of Iowa compared the career attainments and attitudes of a group of male and female healthcare executives. The research showed that among men and women who had entered the field at the same time and had achieved similar educational levels, women did not fare as well as men in terms of salary, position level, or job satisfaction. A follow-up to this study, which consisted of two parts, was conducted in 1995 by ACHE, the University of Alabama at Birmingham, and Lamalie Amrop International to learn whether the gender gap had narrowed. The 1990 study divided respondents into groups according to the year they entered healthcare management: 1971-1975, 1976-1980, or 1981 1985. The first part of the 1995 project was a replication study that paralleled the 1990 study, dividing a new pool of respondents into three groups: 1976-1980, 1981-1985, and 1986-1990. The second part of the follow-up project was a panel study, in which respondents from the 1990 study were surveyed again. Following are highlights from the 1995 study. PMID- 10162413 TI - Managing physician practices. PMID- 10162414 TI - Ensuring compliance with advance directives. PMID- 10162416 TI - Antitrust laws under review. PMID- 10162415 TI - American College of Healthcare Executives. Public policy statement. Preventing and addressing sexual harassment in the workplace. PMID- 10162417 TI - Defining career success. PMID- 10162418 TI - ProMED global monitoring of emerging diseases: design for a demonstration program. AB - The emergence and reemergence of infectious diseases, as the result of recent and ongoing social and environmental changes, urgently calls for a global surveillance system, so that unusual outbreaks can be recognized and controlled at an early stage. ProMED, an international non-governmental group of infectious disease experts, was organized by the Federation of American Scientists to promote the establishment of a global Program to Monitor Emerging Diseases. ProMED proposes the establishment of a demonstration program by prioritizing a small number of strategically-located institutions in the developing world, mainly those least in need of upgrading, for development as sentinel centers. In this way a functional, although limited, network with capabilities for monitoring both endemic and emerging diseases could be rapidly established at minimal cost. The network would serve as an experimental model for future expansion. Initially, each center would develop its own local/regional network with which it would exchange information and assistance, and through which it would collect clinical data and specimens for monitoring the emergence of a limited number of defined syndromes. A central program office would provide protocols, assistance, training, quality assurance, communications, etc. and would coordinate fundraising and program activities. If successful, the syndromes monitored would be expanded and additional institutions strengthened to become new network centers. PMID- 10162419 TI - Is community financing necessary and feasible for rural China? AB - The collapse of the Cooperative Medical System (CMS) in China after the agricultural reforms of the early 1980s caused serious concern and doubt about the viability of community financing of basic health care for the low-income population. This paper examines the rise and fall of China's community financing schemes and ascertains the need for and feasibility of community financing. Of the Chinese rural population, 90% now pay out-of-pocket for their health services. Both the problems with the fee-for-service system on the one hand and the observed advantages of the existing community financing schemes on the other indicate the necessity and desirability of revitalizing community financing as a major rural health care reform strategy. However, the feasibility of the community financing approach depends on adequate financial and social resources. Our study found that there are multiple potential funding sources for health care in rural areas, including households, village welfare funds, local enterprises, and the government. We designed several illustrative benefit packages and estimated their costs. It appears that a basic benefit package with high co insurance would be affordable if funds could be mobilized from multiple sources. More importantly, community financing would require governmental promotion and support. PMID- 10162420 TI - Aid coordination for health sector reform: a conceptual framework for analysis and assessment. AB - Recent widespread interest in health sector policy and institutional reform in lower income countries has coincided with heightened concern for aid coordination. Because the health budgets of many low income countries are highly aid dependent, donors are strongly placed to make aid conditional on health care reforms. However, given the growing number and heterogeneity of multilateral, bilateral and international non-governmental donors operating in many of these countries, there is concern that if external efforts are not coordinated, the aims of health care reform--namely improving efficiency, effectiveness and equity -will not be met. Evidence is mounting that without effective coordination arrangements, donors may weaken rather than improve fragile health systems, undermining attempts to reform those systems. This paper traces the factors fuelling current interest in coordination, in particular with reference to its contribution to the goals of health sector reform. Aid coordination is defined and its principles elaborated. A framework is developed by which to assess the variety of coordination mechanisms which are evolving at the county level. In light of this framework, a case is made for greater and more critical analysis of aid coordination arrangements. The paper concludes that if health sector reform is to be successful in low income countries, current enthusiasm for coordination needs to be harnessed. The framework offered here provides a way of assessing the variety of coordination mechanisms currently proliferating, which could be used to enhance health sector reform. PMID- 10162421 TI - Modelling valuations for health states: the effect of duration. AB - An important issue which has been raised in the measurement of health status is the effect that the time spent in a health state may have on the way that state is perceived. Recently a set of valuations for health states defined in terms of the EuroQol Descriptive System was generated from a study of over 3000 members of the UK general public. The valuations were elicited using the visual analogue scale (VAS) and time trade-off (TTO) methods and were for states that lasted for 10 years. Using VAS valuations for states lasting 1 month, 1 year and 10 years derived from a subset of respondents to the general population study, this paper presents valuation "tariffs" for all EuroQol states based on the different durations. The results support those of previous studies which suggest that poor states of health become more intolerable the longer they last. Such findings suggest that the results of studies in which the value given to a health state is assumed to be linearly related to the time spent in that health state should be treated with caution and subjected to sensitivity analysis over an appropriate range of values. PMID- 10162422 TI - Exploring approaches to the administration of a long-term care facility: The application of a community planning and development process. AB - This article outlines the approaches taken to the management of two long-term care facilities by the County of Huron in southwestern Ontario in 1994. Lay-offs, a move to new facilities, loss of local political confidence, changes in key administrative personnel and low staff morale prompted the county to ask an interim administrative team to develop and implement an appropriate response. The article explains how community development and planning principles and techniques were applied to the management of the homes to achieve an overall improvement in communication, staff morale and attitude. These approaches may prove helpful to other administrations facing major change. PMID- 10162423 TI - Physician impact analysis predictions in Ontario hospitals: does the emperor have clothes? AB - Physician impact analysis (PIA) is a human resource planning tool used to predict the impact on hospital resources of adding a new or replacement physician to a hospital's medical staff. This article describes the findings of a study which examined the extent to which PIAs are used in Ontario acute care hospitals and the accuracy of PIA predictions. The results suggest that although PIA appears to be widely used, there is no evidence that it meets the intended policy objective of accurately predicting physician hospital resource use. PMID- 10162424 TI - An assessment of the introduction of a multi-skilled worker into an acute care setting. AB - The first reengineering project undertaken by the Sunnybrook Health Science Centre after adopting a philosophy of patient-focused care was the introduction of a new category of worker: the multi-skilled service assistant. This article describes the experiences of the first two cohorts of service assistants and assesses the changes made to the work itself and the integration of the new workers into the work environment. It concludes by sharing recommendations for introducing a new work role. PMID- 10162425 TI - Portfolio management for off-line revenue initiatives. AB - During the past decade, the health services sector has experienced a period of rapid change that has resulted in the creation of a large number of new services. This article advocates the use of a service development matrix as a planning aid for senior managers seeking to attract additional revenue through the development of new services. By strategically selecting and developing new services, rather than simple imitating other health care providers, marketers will be better able to focus limited corporate resources on new service initiatives that generate positive returns. PMID- 10162426 TI - Purposes and structures of Canadian hospital-based research: results of a national survey. AB - Little is known about the current extent, purpose and organization of research within Canadian hospitals. As hospitals face the challenge of reorganization, such information would seem essential. To explore this issue, the authors surveyed Canadian hospitals with more than 100 beds. The results, reported here, reveal that almost all of responding hospitals had engaged in some form of research in the previous 12 months, although the type and number of research projects tended to vary with size of hospital and the status of university affiliation. The study also found that most hospitals have resources specifically dedicated to research, conduct ethical reviews and engage in interdisciplinary research. The vast majority of respondents felt that hospital-based research would assume more importance in the future. PMID- 10162427 TI - Centers of excellence: an assessment tool for cardiovascular and orthopedic programs. AB - As payers place more weight on contracting with hospital/health system programs that can differentiate themselves in the market as a "true" center of excellence (COE), it becomes imperative that hospitals/health systems understand the payer perspective about those programmatic attributes that can truly differentiate them from other programs. This report describes an evaluation and rating methodology for hospital/health system subspecialty programs, particularly cardiovascular and orthopedic programs, that can be used as a self-assessment tool. Using as its core a Rating Scale and Ranking Taxonomy, the evaluation and rating methodology presented here allow cardiovascular and orthopedic programs to do the following: Understand the differentiating characteristic of COE. Rate itself against detailed criteria that are being used by payers. Compare aspects of its program to premier or benchmark programs. Interpret the results to assist with strategic and operational direction. Allocate scarce resources to implement a subspecialty program that will attract payers. The Rating Scale and Ranking Taxonomy has 20 criteria for assessing cardiovascular programs and 18 criteria for orthopedic programs. The assessment process is designed to produce two important results: dialogue and action. The underpinnings of any action is a solid business plan that clarifies the program's vision, values, and mission. They are important because most programs will ultimately pursue very similar strategies and tactics; however, the most successful subspecialty programs and practices will be the ones that can execute the strategies and tactics quickly and effectively. In addition, the changes that are engendered by this targeted yet comprehensive assessment process can lead to improved clinical and functional outcomes for patients, as well as systemic improvements in the delivery of care. PMID- 10162428 TI - Public policy and private sector provision of health services. AB - Public sector policies often try to extend access and redirect public resources, depending on private sector actions. These strategies focus on reducing demand, improving efficiency, and generating increased revenues in the public sector. In order to provide incentives for efficiency, acquire capital, and redirect limited public resources to public priorities, there must be an expanded role for the private market in the provision of health services. This presents opportunities to improve the focus of resources on high-priority health activities in the public sector and to make more effective and efficient use of the resources of the private sector. The authors discuss the form that such policies may take. However, while the overall set of options available to policy makers can be identified, what is an effective strategy in one country may be neither appropriate nor feasible in another. The challenge to policy research is not to identify what works, but rather to understand the conditions that make a policy effective in some settings but not in others. The objective is not to prescribe the actions to take but to understand the factors that create the current experience in a specific setting. PMID- 10162429 TI - The political process and the private health sector's role in Vietnam. AB - Vietnam has experienced a period of economic and political transition from a command economy to one of market socialism. This transition has precipitated a shift in the policies concerning the private sector, as well as increased demand for services from the private health sector. The private sector has evolved, though more rapidly in the Ho Chi Minh City area, with the passing of laws and regulations concerning private practice. The policy maker's concern is to maintain the equity gains realized under the public health system while using the private sector growth to make improvements in the system's efficiency. The political process enabling expansion of the private health sector has been slow, and will continue to be measured as it seeks to create a national health system with a rational integration of the public and private sectors. PMID- 10162430 TI - The role of health insurance in the growth of the private health sector in Korea. AB - The Korean health care system has been recognized by other countries for its rapid expansion of national health insurance. The government's policy of promoting the private sector, relying on market forces for various allocation decisions, and using the fee-for-service payment system has created a number of challenges for the Korean health system. Among these are rapid growth of health care expenditure, proliferation and duplication of medical technology, and lack of access for low-income groups due to high out-of-pocket payments for services covered by insurance. A number of recommendations are made concerning national health policy, modifying health insurance, and developing political consensus for bringing about health reform. PMID- 10162431 TI - Regulation of the private health sector in India. AB - The expansion of the private sector in India has forced the passages of a number of regulations to promote quality of care and protect consumers. This has expanded the role of government in developing and enforcing regulations in three areas of the health sector: drugs, medical practice, and health facilities. These regulations have been promulgated by both national and state governments. Three particular Acts are examined: the Consumer Protection Act, Medical Councils, and the Nursing Home Act. These Acts have provided basic guidelines for regulation of certain aspects of the health sector, but have also created new challenges, as consumers have become more involved in monitoring health service delivery. The challenge for the future will be to ensure the quality and efficiency of health services in both the public and private sectors through these regulatory mechanisms while seeking to promote national health objectives. PMID- 10162432 TI - Improving quality in public sector hospitals in Indonesia. AB - Indonesia has successfully expanded its health system to improve access and quality of care for the population, promote equity, and expand primary health care. More recently, it has sought to undertake policy initiatives to promote involvement of the private sector and to introduce both incentives for efficiency and payment mechanisms which will increase sustainability. Certain public health sector facilities have been given financial autonomy to set prices, introduce and retain user fees, and promote prepayment mechanisms. The autonomous hospitals, Unit Swadana hospitals, have increased revenue sustainability while promoting quality assurance practices. The managers of these hospitals have become adept at introducing business practices into the hospital's operations to promote efficiency. These have attracted private investors to invest in public hospitals. PMID- 10162433 TI - Study shows higher quality of care in facilities administered by ACHCA members. PMID- 10162434 TI - Pre- and post-OBRA '87 psychoactive drug use in long-term care facilities. PMID- 10162436 TI - Single entry point provides cost-effective long-term care. PMID- 10162435 TI - The neighborhood concept as a model for long-term care. PMID- 10162437 TI - Caught in the middle. PMID- 10162438 TI - It's not just a nursing home anymore. PMID- 10162439 TI - Correlation between administrator turnover and survey results. PMID- 10162440 TI - Is leadership turnover healthy or hazardous? AB - The factors that compel administrators to move on are many and complex. Bad survey outcomes may be a catalyst for such a movement but I believe the reasons are more intricate and demand more research. Investment in a leader is necessary for organizations to face the challenges of the future with confidence. Perhaps the length of tenure will be less important than what the leader can achieve during his or her tenure. Finally, it is important to note that leadership, as Gilmour (1988) points out, "is not an exclusive property at the top of the organization; it is critically necessary at all levels." The leader acts as a sort of boundary rider mediating, translating and articulating the goals and aspirations of the organizations. Gilmour sees leaders "as shock absorbers mediating between the wider environment and the organization, buffeting and transforming external pressures into workable challenges for the internal divisions of the organization." It becomes a matter of how long leaders can cope with the buffeting and still experience satisfaction that they are making a difference. PMID- 10162441 TI - Joint Commission implements long-term care pharmacy accreditation. PMID- 10162442 TI - New hand-washing examples to appear in accreditation manuals. PMID- 10162444 TI - Management of Human Resources standards clarified. PMID- 10162443 TI - Implementing functional standards: the road to empowerment and positive patient outcomes. PMID- 10162445 TI - Medical record authentication standards revised. PMID- 10162446 TI - Rationale guiding the evaluation of sentinel events. PMID- 10162447 TI - Can't get no (patient) satisfaction? Try charm school. PMID- 10162448 TI - Speeding insurer's approval of hospital admissions. PMID- 10162449 TI - Disarming hired guns. PMID- 10162450 TI - The Hippocratic oath didn't help me here. PMID- 10162451 TI - New survey results. Managed-care participation--and income--keep rising. PMID- 10162453 TI - Health issues. Has John Q. Public tuned out? PMID- 10162452 TI - Sharpen your bargaining skills. AB - As the health-care revolution continues, bargaining skills have become more crucial for doctors than ever before. If you want your practice to thrive, you must regularly negotiate with colleagues, practice administrators, allied health professionals, managed-care plans, business groups, hospitals, and the government. Yet medical schools and residency programs devote little if any time to negotiating skills. The "golden days," when physicians could afford to be mavericks, are over. Doctors must develop a new collaborative outlook to be successful and happy in their careers, says Leonard J. Marcus, Ph.D., lead author of the book "Renegotiating Health Care: Resolving conflict to Build Collaboration." He and his co-authors often conduct seminars for health professionals on improving bargaining skills. The following excerpt concerns the role of conflict in negotiation, and how to resolve it. PMID- 10162454 TI - Where the jobs are now. PMID- 10162455 TI - How to win a malpractice suit. PMID- 10162456 TI - Does your physician network violate antitrust law?. Interview by Michael Pretzer. PMID- 10162457 TI - Are PODS (physician-organized delivery systems) the way to go? PMID- 10162458 TI - Is it finally time to lease your office staff? PMID- 10162459 TI - Are we selling out our patients? AB - In an open letter that follows, a former proponent of managed care describes how his group has let marketplace forces and greed jeopardize patients. The letter is addressed to the group's MSO physician shareholders, who've proposed selling the organization and its managed-care contracts--in effect, the group practice itself -to a capital partner. To preserve patients' privacy, names and identifying details have been changed. The author has been granted anonymity. PMID- 10162460 TI - A better way to keep in touch with patients. PMID- 10162461 TI - Turn a problem employee into a valuable staffer. PMID- 10162462 TI - When you must fire, aim away from your foot. PMID- 10162463 TI - What the candidates prescribe for American medicine. PMID- 10162464 TI - What the public wants. Interview by Lauren M. Walker. PMID- 10162465 TI - Is there a future for single-specialty groups? PMID- 10162466 TI - "I'm a lawyer. I don't like doctors". PMID- 10162467 TI - Elderly and nonelderly expenditures on necessities in the 1980s. PMID- 10162468 TI - An experimental consumer price index for the poor. PMID- 10162469 TI - Flowcharting in the lab. PMID- 10162470 TI - Restructuring the hospital lab. The view from Ontario. PMID- 10162471 TI - Develop powerful leadership skills. PMID- 10162472 TI - How to solve problems using the labor-management partnership. PMID- 10162473 TI - New and emerging pathogens, Part 6. Sick-building syndrome and building-related illness. PMID- 10162474 TI - The report cards are in: how safe is your lab? PMID- 10162475 TI - New and emerging pathogens, Part 7. The fight against TB: a new laboratory arsenal fights back. PMID- 10162476 TI - How CQI increases the prevention of TB exposure. PMID- 10162477 TI - Staff alert: a new PTT reagent is coming! PMID- 10162478 TI - 50:50 RN-tech ratio: a staffing model that works. PMID- 10162479 TI - Will your OR be prepared for the competition on quality? PMID- 10162480 TI - 'Joint camp' gets patients back on their feet. PMID- 10162481 TI - Cost is not main driver, say nurse executives. PMID- 10162483 TI - Common mistakes to avoid when interviewing. PMID- 10162482 TI - Streamlined reprocessing takes close analysis. PMID- 10162484 TI - A dozen ideas for improving patient account cash flow. PMID- 10162485 TI - Clinical reengineering. A benchmark strategy. AB - The health care provider marketplace continues to undergo dramatic changes with the advent of hospital mergers, acquisitions, and physician and hospital alliances. In this era of managed care, cost containment is still vital to a hospital's success, but many stakeholders--patients, employers, and physicians- are determined that quality of care also remain paramount. How can hospitals reduce their expenses and maintain a quality focus? The answer lies in a successful clinical reengineering initiative. One progressive model of clinical reengineering is presented, as well as examples of initiatives at three health care institutions. Initial results of clinical redesign programs have been dramatic and encouraging, with documented evidence of simultaneous cost savings and improved patient care. PMID- 10162486 TI - Quality assessment tools add value. AB - The rapid evolution of the health care marketplace can be expected to continue as we move closer to the 21st Century. Externally-imposed pressures for cost reduction will increasingly be accompanied by pressure within health care organizations as risk-sharing reimbursement arrangements become more commonplace. Competitive advantage will be available to those organizations that can demonstrate objective value as defined by the cost-quality equation. The tools an organization chooses to perform quality assessment will be an important factor in its ability to demonstrate such value. Traditional quality assurance will in all likelihood continue, but the extent to which quality improvement activities are adopted by the culture of an organization may determine its ability to provide objective evidence of better health status outcomes. PMID- 10162487 TI - Quality. A tightrope for the '90s. AB - How accurately can you measure quality of care in health care? Recently, HMOs and other types of managed care organizations have been in the process of defining quality in quantitative terms. Physicians who utilize fewer resources and who care for more patients per-unit-of-time are valued as providing better care than colleagues who may work at a slower (more expensive?) pace. The pressure to evaluate or treat greater numbers of patients in shorter periods of time can produce adverse consequences. And numbers do not necessarily take into account the quality of the care delivered. There is clearly a middle road. Physicians must take care of a sufficient number of patients with a given problem to gain and maintain expertise and mastery. But they must also guard against the insidious pressure for the procedure to become the end in itself. PMID- 10162488 TI - Learning how to learn: the key to CQI. AB - All CQI/TQM efforts share a common purpose: to learn something that can correct past mistakes and/or to create better futures. Because learning is a dynamic circular process, the information about a problem or an opportunity will be limited unless four perceptions of the truth--each valid, and each incomplete- are accepted. These four types of learning styles or ways of perceiving are: abstract conceptualizers, active experimenters, concrete experiencers, and reflective observers. Unless all the stages of the learning process have been fully completed, unless all the strokes work in harmony, we cannot be confident that a CQI effort has added its full value. A CQI team's interpersonal process, the tools by which individually limited truths are forged into a consensual holistic truth, must ensure that the group's effort goes "around in circles." PMID- 10162489 TI - Organizational effectiveness. Primary care and the congruence model. AB - The congruence model is a framework used to analyze organizational strengths and weaknesses and pinpoint specific areas for improving effectiveness. This article provides an overview of organizations as open systems, with examples in the primary care arena. It explains and applies the congruence model in the context of primary care issues and functions, including methods by which the model can be used to diagnose organizational problems and generate solutions. Changes needed in primary care due to the managed care environment, and areas of potential problems and sensitivities requiring organizational changes to meet market and regulatory demands now placed on PCOs are examined. PMID- 10162490 TI - Integrating acquired physician practices. AB - Many strategies have been suggested to accomplish successful physician integration, including stock ownership in a for-profit entity created by the health system, sharing in the cost efficiencies caused by changing practice patterns, and compensation attached to service and access standards. One thing that executives overlook goes beyond financial concerns and yet hits at the heart of what is important to most physicians. That is maintaining their ability to make decisions regarding their own practice environment both clinically and administratively. United Health describes its physician-administrator team model, developed to enhance the physician integration process. PMID- 10162491 TI - Consulting--Part 1. Why consultations fail. AB - The first article in this series describes a research project--a survey of more than 300 physician executives. Asked to share their personal experiences of unsuccessful consultations, our correspondents painted a picture of what can go wrong when organizational consultants enter health care systems, and described the lasting destructive sequelae to failed consultations. The two issues responsible for most failed consultations were the intrusion of internal politics into the consultation process and the failure to clearly establish and maintain consensual goals. Part 2 of this series will explore the consultation process from a different perspective, examining the issues that often trigger requests for consultation services and the dynamics that can foreshadow success or failure before consultants are even engaged. PMID- 10162492 TI - Clinical reengineering. Integrating medical and operational management. AB - In the continuing push for cost containment in health care, many organizations have turned to cost reduction methods that fundamentally change the way care is delivered. As health care organizations continue to make financially-driven staffing changes that impact patient care, medical leadership must take on greater responsibility for operational management. Physician executives are uniquely qualified to take on leadership roles in work redesign, and must do so to ensure excellent and fiscally-responsible patient care. This article presents a proven methodology for work redesign that helps physician executives apply their clinical skills to operational management in designing new health care delivery models. PMID- 10162493 TI - The root ideas in dealing with change. AB - Is there a prototype for dealing with change, a fixed and reliable strategy? Although the answer to this question is no, there are certain fundamental ideas that can help us think about our situations. These ideas come from a wide variety of sources, including: theories dealing with chaos and complexity; systems thinking and complex adaptive systems theory; family dynamics, and organizational development. None of these are simple ideas, easily implemented to make us masters of change. But we have to start somewhere, and the best place might well be a quick discussion of some of these fundamental ideas, PMID- 10162494 TI - What managers can find out from exit interviews. AB - What are the best ways to find out not only why people leave the organization, but how to improve the environment and increase productivity or those that stay? Exit interviews can give you hints about what's going on that you can't get any other way. You can learn more about worker expectations, even if they were disappointed, from exit interviews than from a hiring interview. Exit interviews can also show when situations are worsening before that becomes clear through official channels. An exit interview may reveal a developing pattern of departures before the statistics are tabulated. Here are some guidelines for finding out what's really going on without wrecking the political climate and sending turnover to new levels. PMID- 10162495 TI - How do you get experience?. Interview by Barbara J. Linney. PMID- 10162496 TI - The ultimate goal? It depends. AB - The knowledge that cervical cancer should be a preventable disease has provided the impetus to improve the Pap smear. Now, for the first time in 50 years, two new computerized technologies are available--the AutoPap and Papnet systems--that could change the way they are interpreted. Of course, these new innovations come at a price, perhaps doubling or tripling the cost--by one estimate, the new technologies could add $1 billion per year. The health policy issue is whether these innovations address the limitations of cervical cancer screening programs in an efficient way. The analysis is entirely different when cast as an individual patient care issue. Here the patient and physician, who serves as her advocate, want to use the best screening method. The goal is not how to best allocate resources to improve the health of the overall population, but instead how to get the best care for the individual patient. PMID- 10162497 TI - Health care technology--information technology/Part 4. Why will the Internet be important to clinicians? AB - As the popularity of the Internet's World Wide Web exploded in 1994 and 1995, corporations began adopting the browser software called Mosaic (and its derivatives) for their networks. Why? That same software can be used to "surf" the Internet. Since Intranets are easier to maintain and less expensive, they are replacing the more expensive "groupware" applications based on client-server architectures that corporations installed over the past five years. These Intranets are based on widely-available technologies designed for the Internet, not proprietary software designed for a relatively few customers. Organizations with communication networks integrated with their transaction systems and electronic medical records will be more effective in managing health care resources--and more attractive to employers and insurers for managed care contracting. PMID- 10162498 TI - Next-generation informatics. A new picture of quality medicine. AB - It's up to the physician executive to make an informed choice when selecting a "next-generation" information system. Look for systems that truly integrate (not merely interface) managed care components, clinical capabilities, and other features in a model that mimics the workflow of an actual practice. Take the time to learn about the technology. Consider how a vendor's product will work at every point within your organization. Seven critical features that physician executives should consider in their decision-making are described. PMID- 10162499 TI - Community health information networks. Threat or opportunity in the doctor patient relationship? AB - The last half of the 20th Century has been witness to numerous changes in the delivery and financing of health care services. These changes have impacted the one-to-one doctor-patient relationship that may have existed in the past to become a complex of relationships. The contemporary physician collaborates with many other professionals to assist in the delivery, financing, and monitoring of health care services. These clinicians and other professionals require access to patient information to deliver care and secure payment. The patient understands this. Yet the patient has concerns about the widening circle of persons authorized to access his or her information. These concerns have been amplified by the development of community health information networks--(CHINs). This article focuses on CHINs, both patient concerns and the role physicians can take in developing them. PMID- 10162500 TI - Medical informatics. The future is here. AB - Informatics is an indispensable discipline for leaders and managers--of patients, facilities, and organizations--because the most important assets of those organizations are their information processing technologies, and the key skills are those that help them to manage information. Managers and executives will increasingly need to anticipate trends in information management technologies that could affect their business. In health care, computer-based patient records, integration engines, online analytical processing systems, telemedicine, expert systems, and the Internet have become vital to having the competitive advantage. Those who do not understand the promise and limitations of these technologies and the need for strong leadership to establish standards for data and transaction systems will not lead their organizations well. PMID- 10162501 TI - Consulting--Part 2. The art and science of using consultants. AB - Part I of this series described a research project--a survey of more than 300 physician executives. Asked to share their personal experiences of unsuccessful consultations, our correspondents painted a clear picture of what can go wrong when organizational consultants enter health care systems, and described the lasting destructive sequelae to failed consultations. The two issues responsible for most failed consultations were the intrusion of internal politics into the process and the failure to clearly establish and maintain consensual goals. In Part 2, the consultation process is explored from a very different perspective. What are the issues that often trigger requests for consultation services, as well as the dynamics that can foreshadow success or failure before consultants are even engaged? What are the pitfalls and pointers for the successful use of consultation services? PMID- 10162502 TI - The skills of the change master. AB - What are the fundamental skills for dealing with change? Presented here are nine skills that can help you become a change master in an uncertain and turbulent health care environment. These skills range from active listening to seeing the big picture. Managing change--whether solving a problem immediately or knowing that the best decision is to wait--will be fundamental for success. PMID- 10162503 TI - Why acting managers rarely survive. AB - Can acting managers win the job? Or are the scales tipped so far in the outside candidates' favor that it's not worth venturing into this shaky territory? If you want to be your former boss' successor, take note of the cautionary tales offered here. From power and control issues to strategies for protecting yourself if the unmentionable happens--you lose the position to some outsider--insights are offered on why you should think twice about accepting the acting manager job. PMID- 10162504 TI - The MBA mystique. AB - Is an MBA the solution for you? Do physician executives need to have a business degree to compete in today's competitive marketplace? What are clients looking for when they make hiring decisions? The answers may surprise you. This column is an attempt to dispel myths about physician executives and the MBA degree. Clients want to attract and hire physician executives who possess sometimes intangible skills--with or without the MBA credential. These intangible skills include the ability to educate other physicians to the new health care realities, a sales orientation emphasizing effective communication that focuses on patients and payers as customers, comfort with ambiguity, flexibility, and tact and sensitivity in negotiations. PMID- 10162505 TI - Information technology: the next wave. Clinician acceptance of information technology. AB - Information systems have yet to make a significant inroad at the interface between clinicians and patients. The obstacles to implementing information systems at the clinical level are formidable. As these systems have begun to mature and marketplace pressures have created changing needs for clinicians and the integrated delivery systems they are working in, the need for these systems has increased. Understanding the pressures that managed care brings to bear on clinical processes will facilitate clinicians' acceptance of these technologies. PMID- 10162506 TI - The computerized patient record and confidentiality. The nabobs of negativism are wrong. AB - The handwritten medical record has been the method of choice for documenting health care data since the last millennium. Given this successful tenure, it would be natural to greet any new information system that purports to be an advancement with skepticism. Moreover, physicians as a group are hardly progressive. Yet health care is taking a giant leap and is finally accepting computerization. The advantages and drawbacks of computerized information systems have long been thoroughly tested in such diverse industries as the military, banking, and the airlines. It is difficult to imagine any of these industries in their modern form without an advanced information system. PMID- 10162507 TI - Holy Cross builds a comeback on grass-roots neighborhood doctors' offices. AB - In Chicago, a hospital pretty much on its last legs figured its last, best chance to survive was to appeal to the polyglot market around it. Unlike most other healthcare institutions, however, it succeeded at what might be the era's hardest marketing problem. Its secret: a gritty, sophisticated, unrelenting block-by block community relations effort. PMID- 10162508 TI - In Virginia, Trigon and its opponents fight over how to split up the Blues' money. Trigon BlueCross BlueShield, Richmond, Va. AB - Blue Cross/Blue Shield organizations around the country are all undergoing radical change, and not without controversy. A citizens group in California, for example, won a raucous public relations battle, getting the Blues to put $3.2 billion into two charitable trusts. Then, in Virginia, Trigon BlueCross BlueShield squared off against a citizens group when it, too, tried to reorganize itself. PMID- 10162509 TI - By going to the dogs and featuring its patients, Memorial Hospital gets on CBS. PMID- 10162510 TI - Positioning a statewide physician group becomes "quite a process" in Iowa. PMID- 10162511 TI - Word Incarnate's audio promos turn to a vast self-help library. Incarnate Word Health Services, San Antonio, Tex. AB - Rescuing a specialty that was guilty by association with rapacious for-profit clinics, Word Incarnate Health Systems in Texas came up with an audio cassette promo that just kept going and going. As a result, it has created a vast self help library that appears to be among the best-distributed wellness campaigns in the land. PMID- 10162512 TI - Started on a whim, M.D. Anderson's Children's Art Project grapples with business growth issues. PMID- 10162513 TI - The life and afterlife of AT&T's HealthSite. AB - What was going to be the richest, most potent healthcare web site died only 30 days after it debuted. Its strategic partners, surprised and feeling a little abandoned, say they learned a critical lesson in the new field of marketing on the Internet. PMID- 10162514 TI - The wheels on the bus go round. Health care leaders and public transit officials help smooth the road to better health. PMID- 10162516 TI - The hospital's conscience. Interview by Lauren Phillips. PMID- 10162515 TI - How to get money--tricks of the trade. Sure we want healthy communities, but can we afford them? PMID- 10162517 TI - Beyond competition. Learning to dance with your competitors. PMID- 10162518 TI - Auditing senior management communication practices in the NHS: a regional study. AB - Increasingly, organizations are being confronted with significant strategic change. This process can only be managed effectively if human resource implications, including how effectively managers and staff communicate with each other, are taken into account. This paper outlines how communication audits provide managers with insights into patterns of communication within their organizations. The nature of communication audits are briefly delineated and explained. An investigation from within the National Health Service (NHS) is offered, which illustrates how a communication audit focusing on relationships between regional, district and local levels of management illuminated patterns of communication between senior managers at these levels. This resulted in the development of an action plan for the improvement of communication practices. The generalizability of these findings to the NHS is discussed. PMID- 10162519 TI - Attitudes and knowledge about case mix reform among hospital staff in Australia. AB - This paper reports some of the findings of a national survey of staff in acute care hospitals about their knowledge of case mix and their attitudes towards it. Our findings suggest that, despite the range and scope of activities that have been pursued under the Australian Casemix Development Program (ACDP), knowledge of case mix among acute care hospital staff remains patchy. The evidence also shows that significant aspects of the DRG classification system and the uses to which it can be put are not accepted by many hospital staff, particularly medical staff. The paper concludes with a discussion of what some of these findings imply for future activity on case mix reform. PMID- 10162520 TI - Surgical ICU underutilization does not significantly discourage discharge. AB - An SICU must have sufficient capacity to handle peak weekly demand to prevent re admission and/or poor quality of care. Excess capacity may, however, encourage unnecessary SICU utilization. The goal of this study was to assess the influence of availability of SICU beds on patient discharge and re-admission rates. The case series included 1,492 days, 36,816 patient days, 8,821 discharges, and 186 re-admissions within 3 days from a 24-bed multidisciplinary SICU at a tertiary care center. Census was defined to equal the total number of patients in the SICU each day. We found low census levels were not associated with significantly lower discharge rates. Decreasing the census from 19-24 to 13-18 patients per day decreased discharge rates from 31% to 30%. Odds ratio that a decrease in census by five from 24 decreased discharge rate equaled 1.01 (95% confidence interval 0.96 to 1.06). We conclude that when hospital managers choose an appropriate SICU capacity they need not be concerned that intermittent excess capacity will prompt physicians to significantly decrease their discharge rates. PMID- 10162521 TI - Sexual harassment of female nurses in a hospital in Turkey. AB - Sexual harassment has been identified as a universal factor that can affect nursing performance and work productivity in any type of health care facility. Few studies in the area of sexual harassment have been conducted in developing countries, and this is the first study of its type to be conducted in the country of Turkey. The general purpose of this study is to examine whether the problem of sexual harassment truly is "universal' and to begin to address whether it exists among female nurses in Turkey. Translated surveys were distributed to selected nurses in Ankara, Turkey, asking about their experiences of sexual harassment during their nursing practice. With a response rate of 58% (n = 229), 75% of the respondents reported having been sexually harassed during their nursing practice. The most commonly reported forms of sexual harassment included sexual testing, jokes, remarks or questions and pressure for dates. Harassment by physicians (44%), by patients (34%), by relatives of patients (14%) and others (9%) were noted. Further, a significant relationship was found between sexual harassment of nurses who work in inpatient or outpatient clinics. In general, these findings suggest that sexual harassment of female nurses remains a disturbing problem in this developing country. Based on the findings, implications for policy and further study are suggested. PMID- 10162522 TI - Perceived quality of management information and the influence of overspending penalties in the NHS. AB - The information needs of managers have changed considerably since the introduction of the internal market and many NHS units have invested in new management information systems to enhance the organization's performance. The characteristics of good quality information include accuracy, timeliness and comprehension. Information for management control also benefits from participation between the provider and the user. There are behavioural implications of using information as a control device and managers must internalize the financial objectives of the organization, usually expressed in budget reports. Failure to meet targets must attract penalties that will influence the managers' behaviour. They must respond to the information provided if control is to be exercised. This paper gives the results of a study into managers' perceptions of the adequacy and usefulness of financial information and the impact of penalties for overspending. It concludes that the financial information currently provided fails to meet many of the criteria of good quality information. Any perceived penalty for failing to attain budget-related goals is better than none, and there is little distinction between an overt reprimand and the ultimate sanction of dismissal. PMID- 10162523 TI - Development of a psychometrically valid training needs analysis instrument for use with primary health care teams. AB - The growing demand for professional updating and training within the health service has created a proliferation of post-registration courses, many of which fail to reach the appropriate personnel or the real training objectives of the participants and their managers. One reason behind this problem relates to the fact that many such courses are constructed and delivered in a haphazard way, without systematic reference to the direct and indirect consumers of the educational programmes. A more rational approach to post-experience provision of this sort might involve the methodical collection of information regarding the training needs of target health professional populations. Such a data base would afford a global overview of competencies and deficiencies, both within and between individuals. From this the content, level and focus of training could be customized to meet the reported needs, thereby streamlining the commissioning process to enhance efficiency and effectiveness. Previous attempts to rationalize provision through the prior use of training needs analysis instruments have been compromised by the shortcomings of the analysis tool. This study, then, was an attempt to redress this problem, using a training needs analysis instrument developed along traditional psychometric principles. The tool was intended to be used with primary health care teams because of the increasing role this sector of the health service will play in the future delivery of care, although this would not preclude its use with other health care professionals (following appropriate modification), since the principles behind its construction and format are transferable. The instrument has demonstrable construct, content and face validity and significant reliability. Moreover, preliminary investigations suggest that it also has criterion validity in the areas tested. These findings suggest that the instrument is unique of its kind. Early use of the tool has demonstrated its value in a variety of ways, such as in team building exercises and skill mix reviews as well as in precise and effective commissioning of training and education in a range of areas. PMID- 10162524 TI - Perspectives. Will for-profit trend hold up as HMO margins decline? PMID- 10162525 TI - Perspectives. Chronic care challenges prompt industry partnerships. PMID- 10162526 TI - Robot installations in action. PMID- 10162527 TI - The PFI (Private Finance Initiative) and its processes. PMID- 10162528 TI - Bridging the finance gap. PMID- 10162529 TI - PFI (Private Finance Initiative) and IT (information technology) managed services. PMID- 10162530 TI - The NHS research and development programme and its impact on health care library and information resource centres. AB - This paper looks at the likely impact of the NHS research and development (R & D) programme on health care library and information centres. A brief description of the NHS R&D programme stresses the importance of the management of research and development findings to its success. This paper identifies a number of obstacles to the successful dissemination of R&D findings and discusses the role of health care libraries and information centres in overcoming some of these. It focuses on the essential contribution they can make in supporting the use of systematic reviews as the main source of quality evidence on the effectiveness of health care interventions. PMID- 10162531 TI - From intelligence to evidence-based healthcare: a purchasing odyssey. AB - Since the appearance of the NHS Executive's guidance document, Purchasing Intelligence (1991), efforts have been concentrated on the development of 'purchasing intelligence facilities' staffed, in the main, by health librarians. However, the concept of 'intelligence' has a wider dimension that impacts upon the whole culture of an organization. The authors examine purchasing organizations against popular theories of organizational development. The characteristics of Handy's Task culture, with Athena as its patron, may be observed in many authorities. Using the results of two surveys, conducted in March 1995, they identify some key information management issues involving structure, tasks, technology and people. Skills in information 'transformation' must be acquired by all staff in purchasing authorities. The intelligence officer must become a modern-day Odysseus if the intelligence facility is to 'survive and thrive'. PMID- 10162532 TI - Changes in the National Health Service and the effects on the hospital library service: case study based on the Cumberland Infirmary. AB - The perception of change so often differs from the reality. This article traces the effect on one hospital library of some of the major changes within the NHS during the past 10 years. It explores the importance of external factors such as location and proximity to other professional groups and questions the survival of the multidisciplinary hospital library. PMID- 10162533 TI - Implications of the UNNDERPIN study at St George's Hospital, Morpeth, Northumberland. AB - UNNDERPIN (University of Northumbria at Newcastle DEvelopment of and Research into the Provision of Information to Nurses and nurse educators) was an 8-month research project at St George's Hospital, Morpeth, Northumberland. The general aim of the project has been to undertake an examination of library and information services in a climate of change where user information needs are changing and demanding changed services to be provided to meet those needs in order to support patient care and clinical developments. The paper gives an overview of the project describing its background and presenting a summary of the research findings, conclusions and wider implications of the work. PMID- 10162534 TI - Information in primary health care. AB - The results of two recently completed studies, one in the Trent Region and the other in the Anglia and Oxford Region, of the information-related behaviour of general medical practitioners (GPs) and of information activities within the general practices illustrating the information seeking behaviour of GPs, their generation of information, and communication within, to and from the practice. GPs stated that there is a need for more information to enable practices to function within the changing NHS environment. The increasing emphasis on evidence based medicine also creates the need for appropriate information sources. The Trent study resulted in guidelines for best information practice, especially the need for each practice to have an information strategy. The Anglia and Oxford Study examined the role which the library and information services could play in supporting primary health care. PMID- 10162535 TI - Measuring segment performance. PMID- 10162536 TI - A methodology for evidence-based health policymaking: the Welsh Protocol Enhancement Project. AB - The emergence of evidence-based health care at an operational level is well underway in the National Health Service, driven on by clinical effectiveness initiatives. Unless evidence-based care is supported by evidence-based policymaking, the environment will not be conducive to effective professional practice. The article describes a methodology that has been developed to meet the needs of the Project for the Enhancement of the Welsh-Protocols for Investment in Health Gain. A detailed description of the background, aims, methods, planning, and supporting documentation of the project is given. The methodological principles are transferable to other policymaking scenarios. PMID- 10162537 TI - Measures implemented to project personal privacy for an on-line national patient index: a case study. AB - Increasing use of electronic data storage and exchange is inevitable. Although of considerable benefit to all concerned, they pose a potential threat to personal privacy. Measures to protect personal privacy in national information networks are essential. These and related security issues require the highest priority in strategic planning because experience shows that poor handling of security is the single factor most likely to lead to rejection of a system. It is increasingly important to be able to identify individuals uniquely for health-related purposes, and implementation of an on-line master index is the approach that has been adopted in New Zealand to address this need. Such an index, however, contains personal information, the privacy of which must be respected. Substituting the unique identifier for all personal details in electronic messages can provide a degree of security as long as access to the index is controlled and usage is monitored. The article outlines the measures, technical and otherwise, implemented to manage security concerns successfully in that context. PMID- 10162538 TI - A neural network approach to analyzing health care information. AB - The article describes an investigation into the use of artificial neural networks for the analysis of health information. The Kohonen self-organizing map technique was used to group 39 European countries according to data extracted from the World Health Organization's Health for All database. The groups were seen to exhibit significantly different characteristics with respect to life expectancy, probability of dying before 5 years of age, infant mortality rate, standardized death rate (SDR) for diseases of the circulatory system, and SDR for external causes of injury and poisoning. Results obtained using the technique were subsequently confirmed by the use of traditional statistical tests. PMID- 10162539 TI - A prodigious information systems failure. AB - The article reports a case study in the conception and implementation of a regional information systems project in a Regional Health Authority in England in the 1980s. The project was technically ambitious and involved far-reaching organizational changes throughout the region. The project failed, after considerable expenditure, because support in the region dwindled. With reference to the context of changing management practice in the National Health Service in the 1980s, the project is assessed in the light of its technocratic focus and its effects on the organization, including implicit changes in power relationships. PMID- 10162540 TI - Evaluating methodologies for assessing the value of information: sifting the evidence. AB - The article evaluates methodologies for studying the clinical benefits of information provision and use, particularly the impact on clinical decision making (and hence on patient care). The problems of replication of research are discussed, and the ways in which the Value Project consolidated and extended previous studies are considered. Comparisons among studies demonstrate that some of the impact findings are qualitatively and quantitatively similar, but there are also some contradictory findings. Methodological variations and differences in health care cultures account for some of the differences. Implications for the reliability and validity of these methods for assessing the value of information to clinicians are considered. PMID- 10162541 TI - Implementing a distributed intranet-based information system. AB - The article discusses Internet and intranet technologies and describes how to install an intranet-based information system using the Merle language facility and other readily available components. Merle is a script language designed to support decentralized medical record information retrieval applications on the World Wide Web. The goal of this work is to provide a script language tool to facilitate construction of efficient, fully functional, multipoint medical record information systems that can be accessed anywhere by low-cost Web browsers to search, retrieve, and analyze patient information. The language allows legacy MUMPS applications to function in a Web environment and to make use of the Web graphical, sound, and video presentation services. It also permits downloading of script applets for execution on client browsers, and it can be used in standalone mode with the Unix, Windows 95, Windows NT, and OS/2 operating systems. PMID- 10162542 TI - Commentary: Where has health informatics come from? Where is it going? PMID- 10162544 TI - Ambulance chasing. PMID- 10162543 TI - Education review: A professional development program in health information management. AB - The article describes the professional development program in health information management offered at the University of Sheffield. The program leads to the award of either the Diploma or the Master of Science in Health Information Management. The aims and objectives of the program are presented, along with the overall program structure, entry, registration, and attendance requirements. The available modes of study are described, along with the assessment methods employed. An outline of the modules offered by the program is provided. Finally, the current status of the program and proposed future developments are discussed. PMID- 10162545 TI - The role of reengineering in health care delivery. AB - Health care reengineering is a powerful methodology that helps organizations reorder priorities, provide more cost-effective care, and increase value to customers. It should be driven by what the customer wants and what the market needs. Systemwide reengineering integrates three levels of activity: managing community and health plan partnerships; consolidating overlapping delivery system functions among participating providers and vendors; and redesigning administrative functions, clinical services, and caregiving programs to improve health status. Reengineering is not a panacea; it is a critical core competency and requisite skill for health care organizations if they are to succeed under managed care in the future. PMID- 10162546 TI - Linking reengineering to revitalization. AB - A health care organization that embarks on reengineering without a strategy for revitalizing is courting disaster. What does it take to get reengineering right? It takes vision, unflinching commitment, new kinds of leadership and business strategies, and new behaviors to challenge the old manager-physician power dynamic. A low-cost health care provider must be able to promote trust, partnerships, and competencies that are specifically linked to accessible, cost effective patient care. PMID- 10162547 TI - Can managed care save Medicare? Achieving high quality and low costs through managed care. AB - The article tackles the broad questions that currently engage policy makers grappling with Medicare managed care: quality, satisfaction, selection bias, disenrollment trends, cost savings, and the full savings potential of HMOs. HMOs have been shown to perform well in both the private sector and the Medicare Risk program on all of these dimensions, although the Risk program's flawed payment methodology limits the overall cost savings to Medicare. PMID- 10162548 TI - Using research for successful Medicare and Medicaid risk marketing. AB - Medicare/Medicaid risk marketing is a vital business challenge, one that countless managed care organizations are facing right now. Early entry into new markets and aggressive participation in existing markets are essential to meet competitive pressures. Health plans intent on success in government risk programs should conduct research to learn the medical needs, wants, and desires of older persons in the geographic area they serve. Original, market-specific research yields critical marketing and clinical data that can be used to improve care and member satisfaction along with customer loyalty and retention. PMID- 10162549 TI - Collecting and using information from patients: a summary guide of recent practical research. AB - This article will provide the reader with an appreciation of why health professionals should collect information from patients, information a patient can provide and the uses to which this information can be put, cultural competency and understanding of social class differences, and future areas of research. PMID- 10162550 TI - Consumer issues and threats to health care market reform. AB - Health care market reform is moving at a rapid pace across the United States. Providers, payers, and government are all developing policies and programs to fit into a new scheme that is taking shape as managed health care. With the changes come a series of challenges and consumer concerns, including choice of health care providers, treatment options, and health plans; access to a full range of providers; and lack of information on quality of care. Legislative bodies have responded with proposals such as "any willing provider" laws and expansion of antitrust exemptions, which are likely to have even more negative consequences on market reform. Health Policy Corporation of Iowa (HPCI) makes a series of recommendations to ensure effective health care market reform. PMID- 10162551 TI - Managed care and cost reductions for entitlements. AB - When managed care plans are used by Medicare and Medicaid beneficiaries, the results experienced to date are at best mixed. There are usually higher costs for the public sector. This procompetitive thrust focusing on micromanaging benefits should only be viewed as an interim step, as more macro-oriented health reform initiatives like Medicaid block grants to the states are in the process of being implemented. Other unsettling issues for managed care plans to resolve include: potentially providing benefits to the 40 million uninsured Americans; possibly negotiating reimbursement rates within global budgetary targets; and satisfying the public as health maintenance organizations must further restrict choice of provider. PMID- 10162552 TI - Models of managed care: the potential power of the IPA. AB - As managed care changes medical practice organization, Individual or Independent Practice Associations (IPAs) have theoretically superior attributes as compared with the more centralized large integrated multispecialty group on the one hand, and the less centralized "direct gatekeeper" model on the other. IPAs preserve the small, entrepreneurial, efficient, personal practice model of care delivery, while grafting on necessary business, informational, and care rationalizing functions at the collective level. The IPA also offers practitioners political leverage against the centralizing forces, particularly if the IPA establishes multiple HMO and PPO relationships. Physician autonomy will be best served if practices are allowed multiple IPA memberships. Competition in this model will be multicentric. PMID- 10162553 TI - Why nutrition care should be incorporated into HEDIS 3.0. AB - Good nutritional status is integral to an individual's ability to prevent injury and chronic disease. It affects quality of life, healing, and the costs associated with treatment of disease, illness, and injury. Therefore, measures to assess provision of nutrition care should be incorporated into HEDIS 3.0. Managed care plans and purchasers of health care benefit when the appropriate nutrition screening and interventions are provided. Every managed care organization serves members at nutritional risk. Those at the greatest risk include the elderly, pregnant women, young children, and people with chronic and acute conditions. Nutrition care is low-cost, easily implemented, and can often be incorporated into existing services. PMID- 10162554 TI - One-stop shopping: the rest of the story. AB - The premise of home care one-stop shopping is that one company with an array of services will be more efficient, and therefore, cost-effective, for a managed care organization than several different companies providing services. As home care companies race to become one-stop shops, there are advantages and disadvantages to entering alliances, developing in-house expertise, or acquiring other companies. This article takes a realistic look at one-stop shopping and argues that it may not always be the best way to serve managed care organizations and their patients and should not be the only long-term solution for the home care industry. PMID- 10162556 TI - How HMOs structure primary care delivery. AB - To promote a shared understanding of how health maintenance organizations (HMOs) deliver primary care, the primary care staffing strategies of 23 HMOs are described: who they use as "gatekeepers," how they use nurse practitioners (NPs) and physician assistants (PAs), their referral policies, and their views on how the scope of practice of primary care may change. The study is based on on-site interviews with senior health plan personnel, and finds wide variations in primary care strategies, from open access to primary care and loose referral policies, to tight gatekeeping systems. In network/independent practice association (IPA) model plans, provider groups and IPAs, not the HMO, often determine who provides primary care. Implications are discussed. PMID- 10162555 TI - Riding a Trojan horse: computerized psychiatric treatment planning using managed care principles. AB - Efforts to curtail health care costs have triggered new emphasis on resource management and accountability, entailing explicit documentation of the rationale for treatment and the resulting outcome of care. This article discusses the development of a computerized psychiatric treatment planning database that embodies principles and language of managed care, including specific admission criteria, severity ratings, and time frames for completion of interventions. The program is designed to balance goals of clinical utility, usefulness of the database as a tool for utilization review, quality improvement, and health services research, while providing an interface that is acceptable to clinicians. PMID- 10162557 TI - Health care integration: the role of information technologies. AB - Information technologies are rapidly becoming the major process drivers of health care system integration. These integrated information systems will emanate from MCOs and pervade the entire health care system at each level of service delivery. Suggestions for facilitating the integration process and the role of pharmaceutical industry, wholesalers, service providers, and end users are discussed herein. PMID- 10162558 TI - Any willing provider debate heats up in the courts. AB - No anti-managed care initiative has received more attention in the 1990s than any willing provider (AWP) proposals. Interestingly, state AWP enactments have recently slowed. However, litigation focused on the interpretation of existing laws is heating up in both state and federal courts around the country. PMID- 10162559 TI - Physician recruitment strategies for rural hospitals. AB - How can rural hospitals continue to attract physicians to their facilities? For most rural hospitals, the number of dollars they spend in medical education equates to the number of physicians they are able to retain on staff. What will be the cost to the consumer versus the physicians if the shortage is not addressed and corrected? PMID- 10162560 TI - The growth of managed care enrollment. PMID- 10162561 TI - A conversation with Harriet Brown. PMID- 10162562 TI - Facing the next challenge of pharmaceutical care: patient noncompliance. AB - Medication misusage is a costly problem. Fixing the matter will not be easy because it means reshaping pharmaceutical care. Yet, the business reasons for undertaking such an action are compelling. Not only would MCOs and payers reduce expenditures, but drug companies, pharmacists, and pharmacy benefit managers could vitalize their positions in the marketplace. This article proposes how an integrated program might overcome noncompliance. PMID- 10162563 TI - Process versus outcomes: what is acceptable evidence of success in developing disease state management programs? PMID- 10162564 TI - Cancer carve outs and outcomes measurement programs: an emerging paradigm. AB - Determining how to provide optimal, cost-efficient cancer care may well be one of the most critical issues facing health plans in the 1990s. Although challenging today, the provision of cancer care promises to become even more complex in the near future. To meet the challenge presented by the modern health care environment, some health plans are using the services of a new breed of cancer care delivery system--the cancer carve out. PMID- 10162565 TI - Information technologies in health care: an investment strategy. AB - This article presents an overview of the current state of the health care industry with regard to information technologies. Three areas are outlined where investment is necessary to sufficiently confront the challenges that face the health care industry: (1) infrastructure, (2) business process reengineering, and (3) information systems. PMID- 10162566 TI - The net present value of investments in health. PMID- 10162567 TI - To sue or not to sue? PMID- 10162568 TI - How safe is the safety net for poor children? PMID- 10162569 TI - Is the whole greater than the sum of the parts? Interaction effects of three non income-tested transfers for families with children. PMID- 10162570 TI - Power quality issues and interactions in modern electrical distribution systems. AB - With the increasing rate of electronic equipment installation, there is a greater need for understanding how equipment affects and is affected by the electrical system that serves it. This document addresses these issues as well as principles of electricity magnetism and electrical system construction as they apply to potential problems. The document is geared for those without an electrical engineering background but do have a basic knowledge of electrical systems and terms. PMID- 10162571 TI - Senate candidates respond to GHA questions. PMID- 10162572 TI - Revised antitrust safety zones allow provider networks more flexibility. PMID- 10162573 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); five separate changes--DoD. Final rule. AB - This final rule addresses five separate changes to comply with provisions affecting CHAMPUS. These changes will update this part to include as a benefit, a screen to check for the level of lead in the blood of an infant; to eliminate the implied statement that ambulance services are covered only to, from, and between hospitals; to include other forms of prescribed contraceptives by eliminating the reference that limits prescribed contraceptives only to those taken orally; to identify three additional Gulf Conflict groups eligible for the delay in the increased deductible; and to establish lower limits on the fiscal year catastrophic cap from $10,000 to $7,500 for all eligibles except dependents of active duty personnel, whose limit remains at $1,000. PMID- 10162574 TI - Income security. Do it yourself. AB - Washington--and Americans--are at a crossroads between the collective approach to social security and medicare and the corporate trend toward self-reliance. Workers may become more prudent consumers as they assume responsibility for retirement and health care costs, but the disadvantaged may find it difficult to provide for their own needs. PMID- 10162575 TI - Has managed care been a success so far? Where is the managed care IS industry headed? PMID- 10162576 TI - EDI: accelerating on the information highway. PMID- 10162577 TI - Seeing is believing: the Multicare claims management story. PMID- 10162578 TI - The next step in managing managed care. PMID- 10162579 TI - Electronic reimbursement: what's the hurry? PMID- 10162580 TI - Health information networks: an industry barometer. PMID- 10162581 TI - Electronic enrollment: helping everyone make wise decisions. PMID- 10162582 TI - Take it on the CHIN. PMID- 10162583 TI - Complaints: reference questions in disguise. PMID- 10162584 TI - Professional development for the OPL (one person librarian): possibilities. PMID- 10162586 TI - Accessing Internet--tips for hospital librarians. PMID- 10162585 TI - Multi-site workflow in an integrated health care system. PMID- 10162587 TI - News from NLM DOCLINE--still delivering after all these years. PMID- 10162589 TI - Integrating lab services for cost efficiency. AB - This article focuses on Sun Health, parent company of Boswell Memorial Hospital (Sun City, AZ), and Del E. Webb Memorial Hospital (Sun City West, AZ). Boswell, in a survey of 3,600 acute care facilities by KPMG Peat Marwick, was ranked as the most cost-effective hospital in the nation; Webb ranked sixth. A contributing factor to the efficiencies at both non-profit hospitals is the technology used in the laboratory. This article discusses the need for healthcare officials to look beyond bottom line figures to understand the important role that technology in the lab can play. Using the advantages of technology allows the lab to provide information quickly to patient care providers, allowing them to make clinical decisions. Having the information in a timely fashion can help reduce the length of patient stay and allow for faster processing through the ER. PMID- 10162588 TI - New paradigms for new problems: expanding information technology in healthcare. AB - As healthcare moves from individual fee-for-services and single hospital systems to capitated contracts and integrated delivery systems (IDS), and then into Community Health Information Networks (CHINs), implementing a data warehouse is a realistic way to collect and transform data into meaningful information. However, healthcare differs from other industries because of its complexity. The software is more specialized, and many vendors have adopted proprietary operating systems that hold critical data hostage. Even when available, data is not integrated and is more convoluted than in other industries. To have a complete patient profile, there can be 750 critical data elements in a healthcare transaction, as compared to an estimated 150 data elements in a financial transaction. Historical, behavioral, and diagnostic information is needed at multiple points along the continuum of care: physician's office, rehabilitation, pharmacy, emergency room, laboratory, and hospital. Additionally, these points along the continuum must communicate with the community they serve and the purchasers of healthcare. This article looks at data warehousing and the different technologies available for consolidating and integrating information in the healthcare environment. PMID- 10162590 TI - Health informatics. PMID- 10162591 TI - Paperless office: fact and fiction, Part II. PMID- 10162592 TI - Work-site wellness: a model hospital-operated program. AB - Work-site wellness programs are hardly new to most US healthcare markets. Emerging out of the 1980s fitness craze, traditional wellness programs usually consisted of classes that encouraged healthy lifestyle practices among company employees. Since the prevalent fee-for-service environment didn't provide an inherent incentive for keeping people well, hospital-operated work-site wellness programs rarely advanced past this basic level of service. Corporations, payers, and hospitals see the economic value of managing health, therefore, these types of programs are becoming a part of hospital delivery systems and a growing revenue center. This article presents a hospital-operated, work-site wellness model that was developed for the WorkingWell Network, the corporate wellness program offered by The Methodist Hospitals, Inc. (Gary and Merrillville, IN). PMID- 10162593 TI - Home health care in the continuum: a review. AB - An aging population, financial and technical changes, and consumer preference will drive the increase in the types and volume of service clients receive at home. Financial and technical changes will influence the structure of home care services, but home health agencies will continue to partner with primary, acute, and long-term institutional care to provide a continuum of services. However, the health care system will need to allocate sufficient resources to home health if it is to serve an increasing number of more frail and unstable clients. Lacking such resources, home care may not able to contribute appropriately to the continuum of care, and the effectiveness of the overall health care system may be compromised. Challenges to home health agencies' successful operations include decreased resources, changing payment methods, staff shortages, and structural changes in health care systems that fragment care of decrease attention to home health. Home health care's traditional goals of serving clients and caregivers directly and educating them toward health and independence can continue if these problems are resolved. PMID- 10162594 TI - The family meeting: a benchmark of high-quality geriatric care. PMID- 10162595 TI - Program profile: "I count too"--supporting the children of the terminally ill. PMID- 10162596 TI - Program profile: "It's about you"--raising self-esteem for school-based pregnancy prevention. PMID- 10162598 TI - Rural ED expands services to benefit community. PMID- 10162597 TI - Meeting the managed care challenge: bigger may be better. PMID- 10162599 TI - Reduce risks of patients who leave against advice. PMID- 10162600 TI - International expeditions: a life-changing experience. PMID- 10162601 TI - Create a safe, effective heliport for your ED. PMID- 10162602 TI - Intermediate tax and fraud sanctions provide realistic enforcement threat. PMID- 10162603 TI - Department of Justice and Federal Trade Commission issue further guidance relating to physician network joint ventures. PMID- 10162604 TI - Confidentiality and privacy issues in telemedicine. PMID- 10162605 TI - Developing antitrust compliance policies. PMID- 10162606 TI - Strategic viability of oncology carve-outs. PMID- 10162607 TI - Enhanced outcomes in a managed care model. PMID- 10162608 TI - Perspectives on ultrafast CT. PMID- 10162609 TI - The basics of treatment management. PMID- 10162610 TI - The evolution of American medicine. PMID- 10162611 TI - PACS. The human side. PMID- 10162612 TI - Variability in mammogram interpretation. PMID- 10162613 TI - The ABCs of federally funded programs for kids. PMID- 10162614 TI - Scanning the industry for high-tech solutions. PMID- 10162615 TI - Measuring outcomes in long-term care. PMID- 10162616 TI - The problem with weekends and holidays. Tips for arranging coverage. PMID- 10162617 TI - Diversity in delivery: the Medicare home health benefit. AB - Most home care providers know that Medicare covers home care nursing; home care aide and medical social services; physical, speech, and occupational therapy; as well as medical supplies and durable medical equipment. However, few agencies realize that they can also use dietitians and respiratory therapists to help meet their patients' needs. Also, few agencies use available resources or establish programs to deliver care to special-needs populations. Yet all of these home care services are reimbursable under the Medicare home health benefit. PMID- 10162618 TI - Alternative medicine--an overview. PMID- 10162619 TI - The need to teach alternative medicine. AB - Americans are turning more and more to alternative medicine for treatment of chronic conditions. Western medicine, however, has so far failed to recognize this trend. Many aspects of health care need to address this shift--beginning with training for health care practitioners. PMID- 10162620 TI - Adult day services--the next frontier. AB - Even within the home care industry, the benefits of adult day care services may not be recognized. Yet the market in the changing health care system is ripe for their expansion. For home care, adult day care represents a logical addition to services as well as a good business opportunity. PMID- 10162621 TI - Psychiatric home care--reflecting on the past, evaluating the present, envisioning the future. AB - Psychiatric home care is gaining recognition and acceptance in the home care industry, but there is still a long way to go before it becomes a service that both providers and payors no longer question. A retrospective look will help determine how smooth the journey into the future will be. PMID- 10162622 TI - Providing social work without insurance. AB - Home care agencies, particularly nonprofit ones, often face financial dilemmas when patients who do not qualify for insurance coverage desperately need social work services. One visiting nurse association found a way to provide social services to these patients through innovative funding sources. PMID- 10162623 TI - Postpartum home visits: the answer to "drive-through deliveries". AB - New mothers get little time in the hospital for uncomplicated deliveries before they are sent home to fend for themselves. Early home care visits to new mothers can identify any number of complications and address them before they become serious problems. PMID- 10162624 TI - Cost accounting: toward a measure of truth. AB - With the reimbursement systems for home care changing and evolving, home care agencies need to be careful in choosing a cost accounting system. There is the traditional system that focuses on compliance, or the cost accounting information system, which caters to the needs of management decision making. Which system is appropriate, and when? PMID- 10162625 TI - Helping children with the death of someone close. AB - Death is difficult for everyone involved, but perhaps more so for children and adolescents, who may not understand what is happening or why changes are occurring. Hospice staff need to be aware of family dynamics and help adults help children through these troubling times. PMID- 10162626 TI - Children's hospital. Connecticut Children's Medical Center, Hartford. PMID- 10162627 TI - Management training. Following in the fast track. PMID- 10162628 TI - Environment. Eco-nomic upturn. PMID- 10162629 TI - Complaints. Vicious circles. PMID- 10162630 TI - Managers' image. Devil of a job; hell of an image. PMID- 10162631 TI - Support workers. Suspicious minds. PMID- 10162632 TI - Breast cancer. On the cards. PMID- 10162633 TI - Cancer services. Takes your breath away. PMID- 10162634 TI - Patient information. Finding local heroes. PMID- 10162635 TI - Mental health inquiries. Deadly serious. PMID- 10162636 TI - Transport. Reinventing the wheel. PMID- 10162637 TI - Community care. Nobody's baby? PMID- 10162638 TI - Joint planning. Get together. PMID- 10162639 TI - Learning disability. A fitting response. PMID- 10162640 TI - Mental health. Screen test. PMID- 10162641 TI - On the evidence. Total hip replacement. PMID- 10162642 TI - Is Regret Theory an alternative basis for estimating the value of healthcare interventions? AB - This paper presents an argument for the existence of "regret' influencing the valuation of alternative outcomes when making treatment decisions in healthcare. It is argued that valuation techniques as currently formulated rely upon the axioms of Expected Utility Theory (transitivity and independence). This potentially leads to a misrepresentation of the respondents true preferences over treatment alternatives, and thus results in the potential for "irrational' decisions being observed. A modified version of Regret Theory is outlined, and the results of a tentative empirical analysis provided to illustrate the importance of accounting for regret in the valuation of health states. It is concluded that regret is an important element in individual valuation and decision making in health care. PMID- 10162643 TI - Preventing sudden infant deaths--the slow diffusion of an idea. AB - The sudden infant death syndrome (SIDS) is among the leading causes of post neonatal mortality in industrialised countries. Research has highlighted that many of these deaths are avoidable by adopting a few simple precautions. These include sleeping in the supine position, avoiding exposure to tobacco smoke, breast feeding where possible, and avoiding over heating. The paper traces the development of understanding of the role of sleeping position in the aetiology of SIDS and the diffusion of this knowledge among and within industrialised countries. In retrospect, evidence began to become available in the early 1980s but it was several years before it was acted upon, initially in The Netherlands and subsequently in New Zealand, the United Kingdom and Scandinavia. Several countries have mounted major national preventive campaigns, of various kinds, each of which has been associated with a reduction in deaths from SIDS, but others have not. The reasons for these differences are explored. The evidence for a causal link between sleeping position and SIDS is now very strong and the costs of implementing a policy to change behaviour is small, compared with other health care interventions. This information is now widely available in the international literature. The example of SIDS provides information on the barriers to adoption of knowledge as well as the factors that promote it. PMID- 10162644 TI - Informed choice? Health service quality and outcome information for patients. AB - People need information to choose a physician, a hospital, or to take part in a decision about their treatment. There is little knowledge about what information people want or need to make these choices. Yet there is a growing view in Europe that more and better information should be available to the public about service quality and outcomes. This paper considers the collection, analysis and presentation of health service quality and outcome information for use by patients to make decisions about a provider and about a treatment. It considers why this subject is now a public health and policy issue in Europe, reviews experience in the USA and Europe to gathering and giving this information, and describes the technical, socio-political and ethical issues involved. It concludes that whilst advances have been made in overcoming the technical and cost problems, we do not yet know enough about the information which people want or can use to justify large scale publicity schemes. It proposes that global quality information about a hospital or other service as a whole is less useful. Progress is best made on a specialty or treatment basis, especially where there are large unexplained variations, and by involving patient groups in defining the information which patients with specific health conditions most value. It notes how these developments are leading to new types of collaboration between health workers and patients to increase both patient's and professional's knowledge of the course of an illness or treatment. PMID- 10162645 TI - Outsourcing: lightening the load as the road gets rougher. PMID- 10162646 TI - Physicians referral services on the World Wide Web. PMID- 10162647 TI - Private intranets hold promise as new health care information delivery system. PMID- 10162648 TI - Turn your computer into a money machine. PMID- 10162649 TI - Practice expenses creep back up. PMID- 10162650 TI - Why I've been on Medicare review for seven years. PMID- 10162651 TI - Practice marketing. An untapped source of new patients? PMID- 10162652 TI - Is the classic staff-model HMO a dinosaur? PMID- 10162653 TI - Discharging primary-care doctors from hospital rounds. PMID- 10162654 TI - Teaching patients to take care of themselves. PMID- 10162655 TI - Giving terminal patients peace of mind. Interview by Anita J. Slomski. PMID- 10162656 TI - Which doctors are quitting medicine? PMID- 10162657 TI - Capitation is still a small slice of the pie. PMID- 10162658 TI - Why the anti-HMO initiatives failed on Election Day. PMID- 10162659 TI - Are patient-satisfaction surveys fair to doctors? PMID- 10162660 TI - Worker's compensation doesn't have to be a headache. PMID- 10162661 TI - Win the productivity battle. PMID- 10162662 TI - Cost analysis of immunochemistry instrumentation. PMID- 10162663 TI - Countdown to success. A fresh approach to quality in the laboratory. PMID- 10162665 TI - Columbia off GAO self-referral hook. PMID- 10162664 TI - Reengineering the clinical laboratory. Transitioning to an open laboratory. PMID- 10162666 TI - A good year for 'patient protection' laws. PMID- 10162667 TI - Vouchers, managed care features in La. reform plan. PMID- 10162668 TI - Data projects win national recognition. PMID- 10162669 TI - State ballots include healthcare issues. PMID- 10162670 TI - Year of the doc, nurse in politics. PMID- 10162671 TI - Intermediaries told: rethink therapy reviews. PMID- 10162672 TI - Uncle Sam could ease merger costs. PMID- 10162673 TI - Balancing risk. The rapid formation of provider networks is leaving some liability issues overlooked. AB - Provider networks are being created at a furious pace, often without regard for the accompanying risks. The sixth annual Excellence in Healthcare Risk Management Awards showcase three organizations that have successfully, and innovatively, addressed risk management concerns. PMID- 10162674 TI - New supply deals strive for simplicity. PMID- 10162675 TI - Home-care firms fill chronic-care niche. PMID- 10162676 TI - More bond deals include 'Columbia clause'. PMID- 10162677 TI - AHA to re-examine operations of personal membership groups. PMID- 10162678 TI - Survey confirms HMOs' bad press. PMID- 10162679 TI - SEIU charges Columbia facility with fixing survey. PMID- 10162680 TI - For-profit conversions prompt defense strategy, media scrutiny. PMID- 10162681 TI - All sides lose as Conn. hospital closes. PMID- 10162682 TI - UCI, potential managers in talks. PMID- 10162683 TI - AFL-CIO wants return on campaign investment. PMID- 10162684 TI - Integrating docs into system takes patience and vision. PMID- 10162685 TI - Going natural by design. Annual design awards show facilities are emphasizing integration of the indoors with the outdoors. AB - Modern Healthcare's annual Design Awards Competition finds that healthcare is bringing nature indoors. Several of the 12 winning facilities featured indoor courtyards and gardens, a reflection of the healing role of nature. PMID- 10162686 TI - HMOs, providers using team sell. PMID- 10162687 TI - JCAHO raising stakes for data management. PMID- 10162688 TI - Consumers snub quality data--survey. PMID- 10162689 TI - System, docs in management venture. PMID- 10162690 TI - Hospital closings up for first time since 1988. PMID- 10162691 TI - HCFA mulls anti-gag rules for Medicare HMOs. PMID- 10162692 TI - Boston deal puts top exec to test. PMID- 10162693 TI - One-stop shopping. AB - The long-term-care industry's new mantras are "continuum of care" and "one-stop shopping." Companies are trying to please consumers who are clamoring for more senior-living options and managed-care organizations that want administratively simple contracting arrangements. PMID- 10162694 TI - Mergers, affiliations spell survival for VNAs. PMID- 10162695 TI - A new question: 401(k) or 403(b)? PMID- 10162696 TI - AHA executives may have violated bylaws on report. PMID- 10162697 TI - JCAHO earnings rebound in '95. PMID- 10162698 TI - Uncompensated-care costs rose in '95 for Mo. hospitals. PMID- 10162699 TI - Baxter's blood substitute OK'd for trauma testing. PMID- 10162700 TI - New liver transplant rules favor acutely ill. PMID- 10162701 TI - Lesion policy riles Fla. seniors, docs. PMID- 10162703 TI - Ohio hospitals find public disclosure in deals pays off. PMID- 10162702 TI - Two sons let hospital CEO legacy live on. PMID- 10162704 TI - CNA's next fight: San Francisco merger. PMID- 10162705 TI - MGMA launches staffing overhaul. PMID- 10162706 TI - Critics of privatizing N.Y. hospital miss its promise. PMID- 10162707 TI - Like house guests who never leave. AB - Makers of diagnostic imaging equipment have found a way never to say goodbye. Although sales of big-ticket imaging devices have withered, manufacturers are growing roots at hospitals by expanding maintenance and consulting services. PMID- 10162708 TI - CalPERS tells plans, providers: get along. PMID- 10162709 TI - Book adds new chapters to managed-care debate. AB - Managed-care plans have become the nation's whipping boys, under attack from consumers, policymakers and some physicians alarmed by charges of treatment information being withheld and life-threatening denials of medical care. The issue of drive-through deliveries became a lightning rod for politicians who rushed to pass legislation requiring minimum stays for new mothers and their babies. Reports of forced outpatient treatments for mastectomy patients has reignited criticism. A new book by Wall Street Journal reporter George Anders promises to be a pivotal publication in the debate. PMID- 10162710 TI - Med center, school finalists for award. PMID- 10162711 TI - Med schools feel managed-care pinch. PMID- 10162712 TI - SCAN, Calif. social HMO, plans for-profit conversion. PMID- 10162713 TI - Sharp decision rocks another Calif. deal. PMID- 10162714 TI - Tenn.'s Erlanger public hospital plans $50 million in cost cuts. PMID- 10162715 TI - Internet technology turns PC into radiology station. PMID- 10162716 TI - PacifiCare, in curious move, plans to sell Florida business. PMID- 10162717 TI - Teamwork not the rule as groups push PSO bills. PMID- 10162718 TI - Medipolitics, to coin a word, is here to stay. PMID- 10162719 TI - Top 100 hospitals. Reaching for the clouds. AB - The nation's Top 100 hospitals combine razor's edge management with an ability to take a marketplace punch and maintain their balance sheet. And more often than not, they're found in markets highly influenced by managed care and for-profit healthcare companies. PMID- 10162720 TI - Imaging gear draws window shoppers. PMID- 10162721 TI - Emerging health entities devouring capital. PMID- 10162722 TI - Verbal abuse most common problem, OR managers say. PMID- 10162723 TI - What can be done about problem behavior? PMID- 10162724 TI - Hospital policy on disruptive conduct. PMID- 10162725 TI - Policies help to curb inappropriate conduct. PMID- 10162726 TI - Safety program to prevent 'wrong side' errors. PMID- 10162727 TI - A tale of misplaced risk communication: the case of the Landmark Midline Catheter. PMID- 10162728 TI - Using data-driven clinical models can improve health care performance and quality. PMID- 10162729 TI - CDC creates provisional guidelines on occupational HIV exposure for health care workers. PMID- 10162730 TI - Perspectives. Seeking sharper focus on hospital, HMO ownership issues. PMID- 10162731 TI - Perspectives. User-friendly HMOs could stem tide of laws in West. PMID- 10162732 TI - The benefits of combined heat and power. PMID- 10162733 TI - Saving energy in the health sector and in hospitals. PMID- 10162734 TI - Autonomous technologies research at BSRIA. PMID- 10162735 TI - Barnsley District General Hospital NHS Trust install new waste management system. PMID- 10162736 TI - The changing face of hospitals. PMID- 10162737 TI - Cleaning the air in hospitals. PMID- 10162738 TI - MSOs. Key factors surgeons should consider. PMID- 10162739 TI - Young surgeons at managed care's ground zero. PMID- 10162740 TI - Identifying the ethical aspects of clinical practice. PMID- 10162741 TI - Compliance with Medicare teaching physician payment regulations. PMID- 10162742 TI - Case study. Cedars-Sinai, Los Angeles, makes progress toward disease state management as the ideal of managed care. PMID- 10162744 TI - Joint Commission to post quality reports on the Internet. PMID- 10162743 TI - Redesign case study. Creating a caring environment at University Medical Center, Tucson. PMID- 10162745 TI - Team work. Blueprint builds effective ergonomic program. PMID- 10162746 TI - Do you earn what you're worth? Are you worth what you earn? PMID- 10162747 TI - Finance fundamentals for wily managers. PMID- 10162748 TI - Fit to equip? You've just ordered the latest million-dollar clinical contraption. Now what? PMID- 10162749 TI - Dialing for dollars. PMID- 10162750 TI - Smart tips for tackling the pesky no-show problem. PMID- 10162751 TI - Could pricier surgical gowns prove to be a bargain? PMID- 10162752 TI - Stats. Who's minding the stores? PMID- 10162753 TI - Health-care reforms in the Czech Republic. AB - Health-care reform is everywhere. Although different countries are moving at different speeds, using somewhat different means and different routes, they are all trying to arrive at the same place. The place is called "better value for money in health care". Presents details of the health-care reforms taking place in the Czech Republic, identifying and discussing the main strands of Czech reforms: the dissolution of the regional health authorities; the reorientation of district health authorities; the move to a pluralistic semi-competitive insurance based system; hospitals receiving funding by winning contracts with purchasers; contracts becoming more sophisticated and being based on cost, volume and quality factors; changes in the incentives and rewards for GPs; the drive towards a primary-care-led health-care system; and privatization. PMID- 10162754 TI - Aspects of the management of change. AB - Discusses the origins of change in our lives and proposes a pyramidal model to understand these interrelationships. Discusses responses to these changes with particular reference to organizations. Considers some of the models proposed for introducing change, which appear to be developed from the perspective of the organization, rather than the workforce. Finally, considers the factors which need to be taken into account, from a personnel perspective, for change to be introduced to the benefit of all in the organization. The prime consideration, when introducing change, should be respect for the wellbeing of the people involved. PMID- 10162755 TI - Communications between professional groups in an NHS trust hospital. AB - Discusses an audit of communications between doctors and other professional groups in a National Health Services trust hospital. The project was undertaken as a result of senior management's perception that there were problems regarding the interface between professionals and junior doctors particularly, and that these have a potentially detrimental impact on patient care. The aim of the study was to improve the work environment of medical practitioners and professional staff by researching the factors affecting communication and the sources of conflict which exist between the groups. Describes the methodology and provides an overview of the main findings grouped into themes. A large number of recommendations for change have been made to the hospital concerning systems, procedures, structures, training and inter-professional boundaries. Implementation of some of these recommendations has taken place already. Full evaluation of their impact is yet to be determined. PMID- 10162756 TI - Strategic alliances and hospitals: a US perspective. AB - The number of hospital providers in the USA is shrinking and the market is becoming increasingly competitive. Many financially challenged hospital institutions are searching for a better way to compete. Contends that strategic alliances offer many attractive solutions for hospital management which include: scale economies, relative low cost for risk sharing and improved efficiency. Argues that the future of alliances focuses on capitation, quality information systems for co-ordination, and the continuum of care which a strategic alliance can provide to a community. PMID- 10162757 TI - Recent trends, future needs: management training for consultants. AB - Describes the results of a postal questionnaire survey of all 1,383 hospital consultants in the North Western Region of the UK in 1994; updating a similar survey conducted in 1987. In both surveys, consultants were asked to describe their current management role, management training received and any perceived future training needs. A series of open questions in the 1994 survey explored barriers and incentives to the take-up of management training. The results show that in 1994 more doctors were taking on greater management responsibility and from an earlier age. Consequently, the proportion of consultants expressing a need for management training had risen from 62 per cent in 1987 to 73 per cent in 1994. The most useful courses were local budgeting and business planning. However, many consultants described problems in accessing training. Concludes by highlighting policy implications arising from the surveys which will need to be addressed if consultants are to fulfil their management potential. PMID- 10162758 TI - Understanding the roles of NHS trust board members. AB - The establishment of NHS trust boards on a business format was a recent innovation resulting from the NHS reforms. In order to realize benefits for patients, it is essential that boards operate effectively. Explores within the framework of corporate governance, the practical implications of board member roles. Drawing on experience of strategy formulation at board level, analyses and clarifies the roles, and presents recommendations to increase board effectiveness. PMID- 10162759 TI - Doctors and management--the development dilemma. AB - Identifies managerial knowledge and skills from undergraduate to medical director level and considers the development of a core management training strategy and development programme, transferable on a national basis. Reports on a questionnaire survey plus in-depth interviews with doctors and senior managers divided between grades covering hospitals, general practices and public health services. Explains that the model evolved is a synthesis of managerial models set in the context of doctors' work. Concludes that doctors agreed that more support and training from their organizations would have been useful, and that managers were generally supportive of doctors becoming involved in management, although some harboured doubts about their willingness or the effects such moves would have on established management career structures. Contends that there appears to be a 30:70 split between doctors receptive to the concept of management and those against. PMID- 10162760 TI - General practice partnerships: an exploratory review. AB - Presents the results of a literature review on general practice partnerships. The objective was to find out what has been written and by whom. The results of the review indicate that very little empirical work has been carried out and most of the publications are by doctors addressing the practical problems of working in partnerships. Given this paucity of material, goes on to discuss relevant literature from social science disciplines and presents five perspectives on partnerships. Each perspective yields questions worthy of further investigation particularly at a time when primary care is experiencing rapid change and development. PMID- 10162761 TI - The significance of age and duration of effect in social evaluation of health care. AB - To give priority to the young over the elderly has been labelled 'ageism'. People who express 'ageist' preferences may feel that, all else equal, an individual has greater right to enjoy additional life years the fewer life years he or she has already had. We shall refer to this as egalitarian ageism. They may also emphasise the greater expected duration of health benefits in young people that derives from their greater life expectancy. We may call this utilitarian ageism. Both these forms of ageism were observed in an empirical study of social preferences in Australia. The study lends some support to the assumptions in the QALY approach that duration of benefits and hence old age, should count in prioritising at the budget level in health care. PMID- 10162762 TI - Extracts from an address by the former Minister for Crown Health Enterprises to the Auckland Divisional Conference of the New Zealand National Party. 25 June 1995. Debunking the myths and restoring reality. PMID- 10162763 TI - Uncovering some assumptions. PMID- 10162764 TI - Who is doing the myth-making? PMID- 10162765 TI - East: A compass correction. PMID- 10162766 TI - Cultural diversity, and some advice for the minister. PMID- 10162768 TI - Health care confidentiality: recent legal developments in Canada and Australia. PMID- 10162767 TI - Rationing, barbarity and the economist's perspective. PMID- 10162769 TI - Legal developments in good medical practice. A new code. PMID- 10162770 TI - Patient compliance, client participation and lay reskilling: a review of some sociological work on lay participation in health care decision making. PMID- 10162771 TI - Medical dominance, over-treatment and lay participation: a brief comment on Short's review. PMID- 10162772 TI - Lay participation: a doctor writes. PMID- 10162773 TI - The ethics of randomised controlled trials: a matter of statistical belief? AB - This paper outlines the approaches of two apparently competing schools of statistics. The criticisms made by supporters of Bayesian statistics about conventional Frequentist statistics are explained, and the Bayesian claim that their method enables research into new treatments without the need for clinical trials is examined in detail. Several further important issues are considered, including: the use of historical controls and data routinely collected on patients; balance in randomised trials; the possibility of giving information to patients; patient choice and patient autonomy; and how widely the results of clinical trials can be used. It is concluded that good statistical techniques in the design and analysis of medical studies are essential, but the statistical school used in developing such techniques is relatively unimportant. PMID- 10162774 TI - Learning from past, can lawmakers set new course for health reform? PMID- 10162775 TI - Georgia health facilities embrace minority management program. PMID- 10162776 TI - Health Insurance Reform bill addresses fraud and abuse. PMID- 10162777 TI - Where's your proof? Evidence-based health care and the clinical data manager. PMID- 10162778 TI - A profile of regional coding workload. PMID- 10162779 TI - Coding beyond 2000? The encoder experience at Echuca. PMID- 10162780 TI - Access and confidentiality of medical records: a legislative response in the United States. AB - The Bennett Bill was introduced to the US Senate with the intention by its sponsors to ensure personal privacy with respect to medical records and health care-related information in the United States. The Bennett bill has been passed into legislation by the US Senate as the Medical Records Confidentiality Act of 1995. PMID- 10162781 TI - Clinical supervision. PMID- 10162782 TI - Are medical records in their current form a liability? AB - The Audit Commission in its publication entitled "Setting the Record Straight - A study of Hospital Records" - HMSO July 1995 states that "badly organised medical records do endanger patients". Much emphasis is placed regarding the safe storage and retrieval of medical records in order, for example, to guarantee that in respect of an incident 15 years ago involving a neonate, that medical records, results etc. are easily retrievable. PMID- 10162783 TI - Quality guidelines No. 9. The protection & use of patient information. Institute of Health Record Information and Management. PMID- 10162784 TI - Seeking for knowledge. Computer-based patient record (CPR) (paperless patient record). PMID- 10162785 TI - Medical records standards. PMID- 10162786 TI - Beneath the veil. Medical records in the Middle East--the role of women in the United Arab Emirates (UAE). PMID- 10162787 TI - Medical and dental reimbursement rates for fiscal year 1997--DoD. PMID- 10162788 TI - Medicaid and Aid to Families with Dependent Children; certain provisions of the National Voter Registration Act of 1993--HHS. Final rule. AB - These final rules would remove certain regulatory restrictions that conflict with implementation of the National Voter Registration Act of 1993 (NVRA), Pub. L. 103 31. The NVRA provisions will make it easier for individuals to vote in elections for Federal office. PMID- 10162789 TI - Medicare and Medicaid Programs; new payment methodology for routine extended care services provided in a swing-bed hospital; correction--HCFA. Correction notice. AB - This document corrects the final rule published October 3, 1996 (61 FR 51611) that revised the methodology for payment of routine extended care services furnished in a swing-bed hospital. The final rule also revised the regulations concerning the method used to allocate hospital general routine inpatient service costs for purpose of determining payments to swing-bed hospitals. PMID- 10162790 TI - Future of VA Long-Term Care Advisory Committee, notice of establishment--VA. PMID- 10162791 TI - The President flunks a history test. PMID- 10162792 TI - Evaluation of South Carolina's HIV/AIDS community long-term care Medicaid waiver: cost comparison and patient satisfaction. AB - South Carolina's HIV/AIDS community long-term care Medicaid (Section 2179) waiver is evaluated via cost comparison and patient satisfaction measures. The waiver offers personal care aids, adult day care, counseling, home meals, hospice, private-duty nursing, and foster care supervision in addition to regular Medicaid services. Services to 111 eligible individuals and 52 individuals pending eligibility are evaluated by five methods. A cost comparison is conducted by comparing the cost per patient eligible day of the waiver recipients with those of a comparable group of HIV/AIDS Medicaid patients who did not participate in the waiver. The waiver services are shown to cost less than services delivered to comparable recipients. Costs per patient eligible day were $35.68 and $68.56 for the waiver patients and non-waiver patients, respectively. Telephone surveys, focus groups, provider compliance reviews, and patient record reviews were used to assess patient satisfaction and quality of care. Waiver patients were satisfied with the program overall and with the service managers who are responsible for coordinating services. Problems are identified with personal care aid performance and TB testing for health care providers. A shortage of dentists willing to see waiver patients and delays in the eligibility process are also identified. In spite of small problems, the South Carolina's HIV/AIDS community long-term care Medicaid waiver program is considered a success. PMID- 10162794 TI - AHCA's 1996 "Facts and Trends" gauges key performance measures. PMID- 10162793 TI - Community service management systems: stepping beyond case management. PMID- 10162795 TI - Savvy contracting contributes to managed care success. PMID- 10162796 TI - Interdisciplinary clinical care teams. PMID- 10162797 TI - Stress management. PMID- 10162798 TI - Retooling for the PACS age. PMID- 10162799 TI - Outsourcing for technological strength. PMID- 10162800 TI - Let my MRI go. PMID- 10162801 TI - Analyzing your patient surveys. PMID- 10162803 TI - Who needs "protections" like Boren's? PMID- 10162802 TI - Looking beneath the surface. PMID- 10162804 TI - Correcting consumer misconceptions about cost. PMID- 10162805 TI - Protect your rights as a customer. PMID- 10162806 TI - The CLTC 75-plus. Chain reactions. PMID- 10162807 TI - While you were sleeping. PMID- 10162808 TI - What to do before the union knocks on your door. PMID- 10162809 TI - Nurse practitioners. PMID- 10162810 TI - Consent: what is the role of health care workers? AB - This article considers legal and ethical aspects of consent, as well as the need for consent to be a communication process that informs patients about procedures. Recent examinations of the use of agents (such as nurses and allied health professionals) in securing consent are discussed. While there is a clear role for nonphysician health care workers in advocating for the patient and assuring that consent has been secured; their actual role in securing consent in the absence of a physician is less clear. PMID- 10162811 TI - Point-of-care systems, informatics, and health care delivery. AB - Evolving information technology has had profound effects on business operations and the marketplace. The health care services industry, particularly hospitals, clinics, and medical offices, has historically lagged behind other industries in the implementation of comprehensive, integrated, computerized data management tools. Health care reformers are looking to the promises of the information technology "revolution" as a means of improving systemic efficiency and health care quality. This study discusses the impact of informatics, or information technology, on the delivery of health care services. We present the evolution of informatics and the predicted future benefits of integrated computerized patient records and point-of-care systems. PMID- 10162812 TI - Leadership in the formation of new health care environments. AB - The capacity for managers to be effective leaders is clearly being challenged by rapid changes in the health care environment. In this climate, transformational leadership is considered superior to hierarchy-dependent, transactional leadership. This approach may also be very effective in motivating staff and fostering organizational transformation. The article describes six processes that are critical for those who seek to be dynamic leaders: visioning, communicating for meaning, creating possibilities, developing stakeholders, building spirit and will, and sustaining focus. PMID- 10162813 TI - Have you become a handwringer? PMID- 10162814 TI - Value-added service in health care institutions. AB - In today's highly competitive atmosphere, the survival of health care institutions depends largely on the ability to provide value-added services (VAS) at the lowest possible cost. Managers must identify their customers and delineate the needs and expectation of those customers. A strategy for satisfying these needs and expectations is essential. While technical advances and reasonable charges are important, a successful "high-tech," "high touch" approach demands the combination of process reengineering and employee training in customer relations. PMID- 10162815 TI - Implications of reengineering in health care. AB - Currently the United States spends 12 percent of its gross national product on health care, far more than any other industrialized nation. Technology accounts for 15 percent to 50 percent of the rise in hospital costs. No country is immune from public calls for strategic developments to maintain or lower costs and guarantee high quality while maintaining access for all patients. To achieve these goals of adequate access, high quality, and greater efficiency, hospitals must discard complicated and unwieldy administrative practices that have evolved. How to best deploy technology in health service organizations requires a strategic perspective that results in operational break-throughs. Accelerated alignment of clinical and management processes, systems integration, and health care process redesign are required to achieve the goals of lower costs, higher quality, and greater access. An environmental background of reengineering is presented for health service organizations to use in their processes. Some critical relationships between reengineering and total quality management (TQM) in the health care setting are addressed. Implications of reengineering for health service organizations are offered to facilitate the implementation of the concept. PMID- 10162816 TI - Succeeding with succession planning. AB - Succession planning is the process of identifying people who could presently move into key positions or could do so after specifically targeted development occurs. The process identifies the better people in the organization and takes a consistent approach to assembling, analyzing, and retaining information about potential leaders and planning for their further development. At its simplest level, it is the development of a backup and potential successor to each manager; at is most formal, it is a documented plan for management succession at all levels in the organization. Strongly supportive of a policy of development and promotion from within the organization, succession planning also represents a proactive posture in respect to inevitable management turnover. In these days of rapid change in health care, no modern organization that expects to keep up with increasing competition can afford to drift--or even to let a single department drift--while replacements are recruited for managers who resign, retire, or otherwise leave. PMID- 10162817 TI - The role of human resources in supporting reengineering. AB - To ensure the successful reengineering of a large, complex, unionized, urban teaching hospital, communication, education, and employee participation are key aspects. Human Resources-designed training supports the transition in concert with reengineering management, organizational development, labor relations, and external consultants. Education improves patient care and raises employee self esteem as new teams focus together on excellence. PMID- 10162818 TI - Hospital prevention efforts fight rising costs of violence. PMID- 10162819 TI - Cardinal Glennon designs a family-focused critical path for dying children. PMID- 10162820 TI - Houston's Methodist Hospital targets international multiple sclerosis patients. PMID- 10162821 TI - Physician compensation programs don't meet requirements of managed care environment. PMID- 10162822 TI - Internet will promote collaboration. PMID- 10162823 TI - Directed blood donation: a matter of public trust. AB - Trust is the key issue in blood treatment with respect to public policy. Public trust in the blood system in Canada continues to be exceedingly low. According to the February, 1996 Gallup poll conducted by Janssen-Ortho Inc., 89% of those surveyed chose alternatives to the Red Cross (volunteer) blood. Strategies directed at improving the safety of the blood system will fall short of this goal unless public knowledge and consumer participation are considered. Consumers need to participate in decision making for themselves with the physicians, as well as in the decision making process at the level of public policy. Consumer involvement would contribute to an overall plan of rebuilding public trust. Canadian health care consumers have been significantly affected by the blood tragedy of the 1980s. Public perception of blood safety has been characterized by misunderstanding and fear. The search for alternate methods of transfusion, such as directed donation, are based on a lack of trust of the current blood system. As introducing a program of directed blood donation would not increase safety or decrease the expense of blood transfusions, such a program should not be introduced in Ontario at this time. PMID- 10162824 TI - Long-term care planning challenges in the Post-MSA era. PMID- 10162825 TI - Advance directives for research: ethical guidelines. PMID- 10162826 TI - Bill 26: towards the restructuring of Ontario's health care system. PMID- 10162827 TI - The contemporary hospital board what is it and what does it do? PMID- 10162828 TI - 41 patients settle with hospital in 'sedated' sexual assault case. PMID- 10162829 TI - How hospital officials are dealing with Legionnaire's disease outbreak. PMID- 10162830 TI - New hospital garage stresses perception of personal security. PMID- 10162831 TI - Security's role seen essential in checking applicants' background. PMID- 10162832 TI - VA investigator: hospital workers' comp arrests first of many to come. PMID- 10162833 TI - Infant abduction, fire safety concern hospital child care center. PMID- 10162834 TI - Integrating security in multiple, remote, and diverse facilities: how major health systems are meeting today's and tomorrow's technological and organizational challenges. AB - As the trend to mergers and diversification of healthcare facilities grows, so too does the challenge to security directors to effectively and efficiently protect not only acute care, emergency, and outpatient facilities, but physician office buildings, parking garages, long-term-care units, medical schools, technical service units, and even health clubs. Besides the different security and communications problems posed by each type of facility, the problem of distance between facilities and their geographic location must also be met. In this report, we'll update you on the approaches being taken by security and planning executives at three leading health systems and how they are dealing with current and future problems. PMID- 10162835 TI - Anti-violence program cuts incidents sharply at VA med center. PMID- 10162837 TI - Hospital upgrades access control to improve perception of garage safety. PMID- 10162836 TI - Software system allows security officials to do self-assessments. PMID- 10162838 TI - Special report. Bombs, bomb threats, and crowds: how Atlanta hospitals met the security challenges of the 1996 Olympic Games. AB - Despite immense crowds and the early-morning bomb blast that killed two and injured more than 100 persons during the summer Olympics in Atlanta, GA, months of preparation and some good weather protected local health care facilities from serious problems, according to security directors of five major Atlanta hospitals. Here are details of how these hospitals dealt with the additional security problems presented by the Olympics, including the Centennial Park bombing and a number of bomb threats. PMID- 10162839 TI - Medicare and Medicaid statistical supplement, 1996. U.S. Department of Health and Human Services, Health Care Financing Administration. PMID- 10162840 TI - GP commissioning. Fluid drives. PMID- 10162841 TI - Mental health purchasing. Team games. PMID- 10162842 TI - Price survey. Overall, i.v. solution prices edging up. PMID- 10162843 TI - Risk-sharing payoff requires attention to smallest details. PMID- 10162844 TI - Is there life after outsourcing and consolidation? PMID- 10162846 TI - JEMS' 1996 salary survey: the facts and figures. PMID- 10162845 TI - Voices from the street. Roundtable conversation. PMID- 10162847 TI - 1997 Buyer's Guide. PMID- 10162848 TI - The effects of mental health factors on ambulatory care visits by rural teens. AB - This study sought to determine the effects of mental health variables on rural adolescents' use of ambulatory health care services and whether these effects varied across common outpatient settings. Using a cross-sectional survey design, 2,297 adolescents who attended public schools in grades 7 through 12 in one isolated rural Mississippi River Delta county were assessed via a standardized health behavior survey. This self-report measure inquired about relevant health behaviors such as alcohol use, depressive symptoms, and health service use. The students' mean age was 15 years and 58 percent of the sample were black. Approximately 11 percent of the sample reported symptoms of depression, 16.5 percent reported problem drinking, and slightly fewer than 6 percent reported both. After controlling for predisposing, enabling, and need factors, the reporting of depressive symptoms, problem drinking, or both was related to an increased number of outpatient visits in three of four sites examined. However, differences among sites were observed. These data suggest that mental health problems are associated with increased visits to ambulatory settings, and these problems affect service use differentially. Thus, effective interventions and better linkages between ambulatory settings and mental health providers may reduce unnecessary use. PMID- 10162849 TI - Knowledge, attitudes, and patterns of cancer screening: a self-report among foreign born Hispanic women utilizing rural migrant health clinics. AB - Hispanics are the fastest growing minority in the United States and are currently Washington state's largest minority, with the highest growth rates found in the rural agricultural areas of eastern Washington state. Because breast and cervical cancer mortality rates are higher in Hispanics than other U.S. women, subgroups of Hispanic women with the lowest cancer screening utilization rates need to be identified and targeted for cancer control intervention to most effectively reduce late-stage cancer diagnoses and mortality. A study was conducted at six migrant health clinics located throughout eastern Washington state to discern age specific proportions for utilization of mammography, breast self-examination, and Pap smears among Hispanic migrants to the United States. Knowledge and attitudes regarding these procedures also were assessed and face-to-face interviews were completed with 512 women. Among women 20 years or older, 15 percent had never heard of a Pap smear, only 78 percent had ever received a Pap smear, and only 44 percent had received a Pap smear within the prior year. In all, 73 percent of the women had been taught breast self-examination, 62 percent performed breast self examination, and 41 percent had performed a breast self-examination in the prior month. Among women 40 years or older, only 38 percent had never heard of a mammogram, 38 percent had ever received a mammogram, and only 30 percent had received a mammogram in the prior two years. Cost was reported as a major barrier for screening in this population. Additionally, a substantial proportion of the women perceived Pap smears and mammography as unnecessary or diagnostic procedures, rather than preventive health measures. PMID- 10162850 TI - The relationships among gender, perceived financial barriers to care, and health status in a rural population. AB - This study examined the relationships among gender, perceived financial barriers to health care, and selected health status indicators in a randomly selected rural Appalachian sample. The data were gathered through the Johnson County Health Survey. The survey was conducted through personal interviews with 207 females and 178 males representing 197 households. The Duke Health Profile was used to measure the perceived health of the respondents. Analysis of variance, t tests, and descriptive statistics were used to analyze the data. Analysis of the data revealed that women perceive financial barriers to health care significantly more than men (P < 0.01), even when living in the same household; women had significantly poorer health than men (P < 0.01); and both women and men with perceived financial barriers experienced poorer health (P < 0.01) than those who did not perceive such barriers. Conclusions from the study suggest that in this rural sample women were the most compromised by both gender and health status, and that they perceived that their health care needs were not being adequately met. PMID- 10162851 TI - Selected comparisons and implications of a national rural and urban survey on health care access, demographics, and policy issues. AB - As the national health debate evolved over the past two years, a need to better understand the differential constraints of rural health delivery and popular attitudes toward policy initiatives became apparent. Selected 1994 and 1995 results of two national surveys designed to compare rural and urban household responses are reported. The average distance those living in rural households must travel to access medical providers and emergency care is nearly double that of urban household residents. Rural household resident responses show a higher level of acceptance of nonphysician health care providers such as physicians assistants and registered nurses. Means testing of Medicare programs and use of special indicators for providing more Medicaid funds to states with medically underserved and sparsely populated areas are examples of two policy initiatives that receive favorable responses from both urban and rural household residents, but would disproportionately benefit rural areas. PMID- 10162852 TI - Barriers to preventive health services for minority households in the rural south. AB - Health values, behaviors, and status are shaped by place of residence, region, race, and socio-economic status, among other social factors. Consequently, this article examines barriers to preventive health services for lower-income blacks in five rural counties in Georgia. Qualitative and quantitative data were collected through 281 household, 51 community leader, and six focus group interviews. Female respondents who had been pregnant were most likely to have received pregnancy-related services and all respondents least likely to have received vision and dental screenings. Six of the seven types of services inquired about were most likely to have been received in a private practice setting. Primary barriers to preventive service utilization included ability to pay, perception of need, service availability, accessibility of services, and the perception of racism. The relationship between structural and nonstructural barriers, their impact on preventive service utilization, and research recommendations also were developed and presented. PMID- 10162853 TI - Is health status related to residence in medically underserved areas? Evidence and implications for policy. AB - This study sought to compare the health status of adult residents of medically underserved areas (MUAs) with adult residents of nonshortage areas (non-MUAs). A random digit dialing telephone survey was used. Respondents were subsequently classified by their county of residence as residing in an MUA or non-MUA. A sample of 421 adults (aged 18 years or older) residing in Kentucky during 1993 were included in the analysis. Health status was measured by the Medical Outcomes Study 20-item Short-Form Health Survey's (SF-20) six subscales. After controlling in the multiple regression for demographic variables there were no significant differences between residents of MUAs and non-MUAs for the physical functioning, role functioning, general mental health, self-perception of health, or pain subscales. The social functioning subscale was significantly related to the residence in an MUA. The demographic variable "education" was a consistent predictor of each of the health status subscales. Excepting the social functioning subscale, residents of MUAs do not have significant differences in health status when compared to residents of non-MUAs. Future policy may need to focus on other health services shortage area designators that are more highly associated with the health status of residents. Consideration should be given to including the education demographics of areas or populations in health services shortage designation criteria. PMID- 10162854 TI - The mobile hospital technology industry: focus on the computerized tomography scanner. AB - This study of firms offering mobile hospital technology to rural hospitals in eight northwestern states found that several permanently parked computerized tomography (CT) units were found where mobile routes had atrophied due to the purchase of fixed units by former mobile CT hospital clients. Based on a criterion of 140 scans per month per unit as a threshold of profitable production, units owned by larger firms (those that operate five or more units) were more likely to be profitable than units owned by smaller firms (71% versus 20%, P = 0.03). A substantial number of rural hospitals lose money on mobile CT due to low Medicare reimbursement. In some areas, mobile hospital technology is a highly competitive industry. Evidence was found that several firms compete in some geographic areas and that some firms have lost hospital clients to competing vendors. PMID- 10162855 TI - Rural mental health care. PMID- 10162856 TI - Developing the National Institute for Occupational Safety and Health's cancer control demonstration projects for farm populations. PMID- 10162857 TI - Teens teach skin cancer prevention. AB - Cumulative sun exposure has been linked to about 95 percent of all skin cancers. Farmers and their families, by nature of their occupations, are exposed to an abundance of sun over a long period of time and, therefore, are at an increased risk for skin cancer. Because education is known to be a primary means of health, Future Farmers of America (FFA) peer facilitators (teen educators) provided third graders in rural communities sun protection education with the hope that the message would reach the entire family. The FFA facilitators (n = 217) from 39 FFA organizations throughout Wisconsin were trained with skin cancer and sun protection information. The FFA facilitators then gave presentations on sun protection to third graders (n = 2,007) in their school districts. Control schools included 57 facilitators and 669 third graders. Evaluation involved pre-, post-, and six-month follow-up surveys testing knowledge gained by the third graders. Students who correctly responded to a question on the post-survey after incorrectly answering it on the pre-survey were said to have had a knowledge gain for that question. By using chi-square tests, the intervention group demonstrated a statistically significant (P < 0.001) higher proportion of students experiencing knowledge gain than did the control group from pre- to post-surveys for nine of the 10 questions. Summary statistics were used to describe the study population. In addition to skin cancer knowledge questions, the survey of facilitators included sun protection behavior and attitude questions. This intervention was able to use peer educators as instructors to demonstrate knowledge gain in the youths of the target population. The pilot project materials costs were +0.55 per third grade student and +3.50 per facilitator. Using a school-based organization such as FFA provided a cost-effective means of reaching the rural population. PMID- 10162858 TI - Wisconsin farmer cancer mortality, 1981 to 1990: selected malignancies. AB - Cancer mortality risks for Wisconsin white male farmers were examined during the years 1981 to 1990. Four malignancies were studied: Non-Hodgkin's lymphoma, melanoma, colon cancer, and rectal cancer. Occupation coded deaths were segmented into farmer and nonfarmer groups and population counts for the groups were estimated from 1980 and 1990 Bureau of the Census data. Standardized mortality ratios (SMRs) were constructed from the ratio of observed farmer deaths and the expected number of farmer deaths. Expected deaths were generated from the underlying statewide nonfarmer rate for the malignancy multiplied into the farmer population at risk. Farmers had significantly lower mortality risks for melanoma (SMR: 0.659; 95% CI: 0.993-0.326) and colon cancer (SMR: 0.763; 95% CI: 0.928 0.599). Farmers also exhibited a nonsignificant decrement for non-Hodgkin's lymphoma (SMR: 0.930; 95% CI: 1.214-0.645). For rectal cancer, farmers experienced a slightly higher but essentially the same risk as nonfarmers (SMR: 1.013; 95% CI: 1.418-0.608)--the SMR was not significant. This study corroborates a number of cancer incidence and mortality investigations demonstrating that farmers generally experience the same or lower mortality risks for these malignancies. PMID- 10162859 TI - Mammogram utilization among farm women. AB - Utilization of preventive health care services is lower in rural populations than in urban populations, possibly as a result of barriers to preventive health care that are characteristic of rural settings. This study was conducted to identify factors associated with mammogram utilization among farm women. Mammogram utilization among farm women from six southern Minnesota counties was examined as part of a larger community-based cancer intervention study. Farm women aged 40 and older were randomly selected from a list of farm households and interviewed by telephone to determine mammogram utilization and factors related to utilization. Of the 606 respondents, 78 percent reported ever having a mammogram and 49 percent reported a mammogram within the past year. Physician recommendation for a screening mammogram and family history of breast cancer were found to be associated with ever having a mammogram. Correct knowledge of mammogram screening guidelines was associated with a mammogram within the past 12 months. Overall, physician recommendation was the most influential determinant of utilization. As more emphasis is placed on prevention, patient education by physicians can have the greatest impact on mammogram utilization. PMID- 10162860 TI - Georgia's harvesting healthy habits: a formative evaluation. AB - Occupational safety and health researchers seek to conduct effective cancer awareness campaigns to increase agricultural workers' skin cancer prevention and detection behaviors. Georgia undertook such a project using a social cognitive theory (Bandura, 1986) conceptual model, with its objectives focusing on personal determinants of and environmental influences on farmers' behavior. One underused strategy to increase the success of health campaigns, formative evaluation, was undertaken during year one of the demonstration project, with four goals. These included an assessment of: (1) the availability of societal resources to support farmers' practices, (2) the affordability for farmers to follow through with behaviors being promoted, (3) the social support for behaving in ways that reduce farmers' skin cancer risk, and (4) farmers' current knowledge, outcome expectations, and self-efficacy in this regard. Formative evaluation revealed an absence of information, products, services, and social support for farmers' skin cancer prevention and detection. As a result, the Georgia project's plan was refined to include specific activities aimed at increasing the environmental support for health promotion activities relating to farmers' skin cancer prevention and detection. These include a seminar for rural primary care physicians and public health nurses to increase knowledge and skills relating to conducting clinical skin exams; programs for agricultural extension agents, cotton scouts, and 4-H groups to provide opportunities to learn more about and practice sun safety; and a feed and seed store campaign. PMID- 10162862 TI - Skin cancer prevention and detection practices in a Michigan farm population following an educational intervention. AB - Farmers face an increased risk of skin cancer, presumed to be secondary to their increased occupational exposure to sunlight. This study examines skin cancer prevention and detection beliefs and practices among adult farmers in defined control and comparison farming communities in four contiguous counties of Michigan, before and after a community-based educational intervention. The educational intervention included mailing packets containing information on skin cancer risks and community sources for screening, disseminating articles in local newspapers on skin cancer prevention and control measures, and providing information and screening at local county fairs and agricultural community fairs. The responses of 2,999 survey participants were analyzed to identify the interrelationships among their beliefs and their descriptions of their (primary preventive) self-care and professional medical care seeking (for detection and treatment) practices. Factors associated with the likelihood of skin cancer screening and with measures of knowledge and practices associated with medical care of skin cancer were examined. The intervention appeared to improve the practice of preventive behaviors and seeking medical care. PMID- 10162861 TI - Factors associated with safe use of agricultural pesticides in Minnesota. AB - How farmers protect themselves against pesticide exposure has important public health consequences. To obtain insights into pesticide self-protection, this study obtained data on chemically resistant glove and other protective equipment use as they relate to the type of farming practice, demographic characteristics of farmers and their farming operations, farmers' preventive health beliefs and behaviors, and factors related to their health care. Data were obtained by telephone interviews conducted in six rural Minnesota counties. Survey respondents totaled 1, 327 (87% response rate), with 502 reporting pesticide use. Ninety-five percent of the latter respondents believed in the effectiveness of protective equipment and 88 percent believed that pesticide exposures are harmful. Fifty-six percent of the subjects wore chemically resistant gloves and 22 percent wore other protective clothing 75 percent of the time or more when using pesticides. Glove use and certification to use restricted pesticides was less frequent for women. The use of protective equipment in this group of Minnesota farmers was weakly related to being certified to apply restricted pesticides, believing in the effectiveness of protective clothing, believing that smoking causes serious health problems, using crop insecticides, and distance to a health care facility. PMID- 10162863 TI - Utilization of cancer early detection services among farm and rural nonfarm adults in Iowa. AB - An increase in the proportion of advanced malignancies among rural residents has been noted and may be due to a combination of factors, including availability of screening services, demographic characteristics, and access to health care facilities. A cross-sectional study was conducted in 33 nonmetropolitan Iowa counties among randomly selected middle-aged farm and rural nonfarm adults to compare utilization of cancer early detection services. A total of 1,126 adults in 600 farm households and 1,092 adults in 589 rural nonfarm households provided information through a 155-item in-home interview. Differences in income, age, and health insurance coverage (including preventive services) between the farm and nonfarm study populations were found. Although farm men were less likely to have had a checkup during the past year than men in the nonfarm population, no difference was found for women. Overall, differences in screening behaviors were small. Larger differences between both populations were observed for use of mammograms, prostate examinations among men age 50 and older, use of sigmoidoscopy among women age 50 and older, and skin cancer examinations among both sexes. When controlling for demographic characteristics and insurance coverage, members of the farm and rural nonfarm population were equally likely to use multiple screenings according to ACS guidelines. Because of the increased risk of breast cancer, interventions aimed at increasing utilization of mammography among women age 50 and older should be implemented. Although the farm population was more likely to use skin examinations, prevalence should be increased substantially to counteract the continuing rise in skin cancer. PMID- 10162864 TI - Obstacles and opportunities in designing cancer control communication research for farmworkers on the Delmarva Peninsula. AB - Little is known about the incidence of cancer among farmworker populations or about effective strategies for communicating with farmworkers about cancer prevention. Some studies suggest that farmworkers may have unusually high incidences of skin and cervical cancers. With these two cancers as the focus, a group of interviewers, researchers, and health communication specialists set out to create, implement, and evaluate a cancer control demonstration project geared toward farmworkers. In 1994, a situation analysis was conducted to identify constraints and opportunities for providing farmworkers with cancer control information and services. The situation analysis provided valuable information to aid in developing intervention and evaluation strategies. This paper outlines how and why the situation analysis was conducted and what was learned with regard to the farmworker population on the Delmarva Peninsula. Living conditions and the local availability of cancer control services are described. Obstacles to conducting research and interventions with farmworkers are highlighted. Based on what was learned, recommendations are made for designing cancer control research and intervention for farmworkers. PMID- 10162865 TI - Cancer prevention strategies among California farmworkers: preliminary findings. AB - This study was conducted to identify barriers to cancer prevention and evaluate the effectiveness of a cancer prevention project to increase screening for cervical and breast cancer among Spanish-speaking farmworkers in California's Central Valley. Bilingual health educators met with farmworker communities near Merced and Modesto, CA, to determine barriers that prevented women from seeking screening for breast and cervical cancer. Using information from focus groups and health fairs, a targeted outreach protocol was developed that will eventually enroll 2,500 farmworkers in a cancer education and screening program. Participants received a presentation in Spanish on breast and cervical cancer that included a pretest and post-test to assess increases in knowledge. Clients were encouraged to attend Golden Valley Health Centers Inc. (GVHC) to receive free breast and cervical cancer screenings. Vouchers, redeemable for modest personal hygiene gifts by clients, were tracked to assess prevention behavior when appointments were kept at GVHC. Sixty farmworkers attended focus groups and 363 attended health fairs to provide input to The cancer prevention program. As of December 1, 1995, 1,732 female farmworkers were enrolled in an outreach program designed to increase knowledge and promote cancer screening. Data from pretests and post-tests indicated a statistically significant increase in knowledge about cancer and its prevention among participants. Furthermore, 317 participants redeemed vouchers for cancer screenings at GVHC. Active community collaboration and culturally appropriate intervention strategies, employed in conjunction with clinical services, can be successful in increasing cancer prevention awareness and screenings among female farmworkers. PMID- 10162866 TI - Ensuring the dissemination of Cancer Control Demonstration Projects for Farmers. AB - The successful dissemination of the Cancer Control Demonstration Projects for Farmers depends not only on the effectiveness of the grants funded under this program but also on factors external to the grants. In this article, three health related external factors are examined: the cancers amenable to prevention and control, intervention methodologies, and the organization of rural health care. Changes between 1989 and 1996 in each of these factors and the effects of these changes on the dissemination of grantee findings to public health and medical practitioners are described. Suggestions are offered on actions that the National Institutes for Occupational Safety and Health can undertake to increase the likelihood of adoption of grantee findings. PMID- 10162867 TI - The missing link in most doctor's plans. PMID- 10162868 TI - Can't stay on schedule? Here's a solution. PMID- 10162869 TI - I almost enjoyed my malpractice trial. PMID- 10162870 TI - Can a gatekeeper do what's right for the patient? PMID- 10162871 TI - Joining a capitated IPA: should you, or shouldn't you? AB - The "bygone" doctor practiced in the good old days under a relatively uncomplicated, clearly defined system. Physicians could afford to be independent. To survive in practice today, say the authors of "Renegotiating Health Care: Resolving Conflict to Build Collaboration," physicians must adapt to change or the health-care market will pass them by. Today's "evolving" doctor is a partner, contributing to and deriving benefit through collaborative patient-care networks, physician practice organizations, and medical services organizations. Historical rivalries have been forgotten as hospitals, insurers, and physicians seek and achieve innovative alliances. Still, resistance to these plans runs strong. The following story typifies one dilemma that faces physicians today. It concerns a hypothetical group practice that must decide whether to form a capitated individual practice association. PMID- 10162872 TI - Community health and managing the care of a population. AB - The new health care marketplace requires a rethinking of the way care is given, including fiscal responsibility, medical accountability, a priority on the needs of society and objective but fluid definitions of standards and quality. These developments are being driven by escalating costs and dwindling competition within the private sector. The health care delivery system is being called to change the present "managed care" to "managing" care, requiring the resurgence of the doctor-patient relationship. This relationship must not neglect its relationship to the community and populations who make up the neighborhoods, cities and our nation. The reality of economic and financial incentives cannot be denied, but the ultimate result of the current transformation of the health care delivery system will be the re-establishing of the core moral and ethical incentives and principles of health care at the front of the decision tree and before economic incentives. PMID- 10162873 TI - Developing and implementing an investment strategy. AB - Establishing a network or expanding a practice to take advantage of the managed care market requires finding ready sources of capital. Once you have found your capital, however, what do you do with it? A sound investment strategy is necessary to ensure that the organization meets its financial goals. In this day and age, a strong balance sheet is increasingly important to medical groups and their capital providers. Starting with a review of your group's cash management systems, this article presents how to establish an investment strategy. The process includes reviewing historical financial information, developing an investment policy and using outside investment management (if needed). PMID- 10162874 TI - The equity market for physician practice management companies. AB - Initial public offerings or selling out to physician practice management (PPM) firms may be an option for raising capital in large physician groups. This article will address whether this is an accurate perception, whether the markets have cooled and if the heat will return, and the various equity-based options by which physicians can raise equity capital and the advantages and disadvantages of each alternative approach. PMID- 10162875 TI - Financial applications using the cost per RBRVS methodology. AB - In this article, the resource-based relative value scale (RBRVS) is used as a basis to allocate physician salaries, malpractice insurance and practice expense to determine the cost of providing physician services. With this information, practice administrators can readily apply this cost accounting methodology to fee schedule analysis and managed care contract evaluation. Other applications of this method include determining floor capitation rates, allocating the capitation payment among the group and third party payer profitability analysis. PMID- 10162876 TI - Developing physician leaders in academic medical centers. Part 1: Their changing role. AB - While physicians have historically held positions of leadership in academic medical centers, there is an increasing trend that physicians will not only guide the clinical, curriculum and scientific direction of the institution, but its business direction as well. Physicians are assuming a greater role in business decision making and are found at the negotiating table with leaders from business, insurance and other integrated health care delivery systems. Physicians who lead "strategic business units" within the academic medical center are expected to acquire and demonstrate enhanced business acumen. There is an increasing demand for formal and informal training programs for physicians in academic medical centers in order to better prepare them for their evolving roles and responsibilities. These may include the pursuit of a second degree in business or health care management, intramurally conducted courses in leadership skill development; management, business and finance; or involvement in extramurally prepared and delivered training programs specifically geared toward physicians as conducted at major universities, often in their schools of business or public health. This article article was prepared by the author from research into and presentation of a thesis entitled. "The Importance of Leadership Training And Development For Physicians In Academic Medical Centers In An Increasingly Complex Healthcare Environment, " prepared for the Credentials Committee of the American College of Healthcare Executives in partial fulfillment of the requirements for Fellowship in the College (ACHE). Part 2 will appear in the next issue of the Journal. PMID- 10162877 TI - Value management: decision making using the value paradigm. AB - Health care delivery systems must address the sometimes conflicting expectations of its stakeholders. The people who pay for the service or a set of benefits are not always the people who receive the service. The challenge is to meet the expectations of the patient for high quality and to meet the expectations of the employer and/or insurance plan for low costs. We are no longer managing just quality. We are managing the total value of service from the perspective of out stakeholders. Stakeholder satisfaction is defined as achieving or exceeding the stakeholder's expectations from the resources committed. An operational definition of value is useful in helping administrators and physicians to focus on the interactions of the key management variables of cost, effectiveness, efficiency and access. The development of decision models based on these key variables is a helpful tool for quantifying the value of the decision from the perspective of each stakeholder. PMID- 10162878 TI - Organizing specialty networks for capitation. AB - Two of the byproducts of the shift to managed care--risk-based contracting and surplus specialist capacity--has fostered the growth of specialty networks. To remain competitive in a selective market for specialty services, specialists must develop the clinical an business capabilities to manage risk and outcomes and must adapt practice culture to the operational demands of managed care. Also, specialists must create effective delivery networks that meet payer and patient expectations for clinical excellence, patient access and business efficiency. This article addresses matching the specialty network to the market and building the specialty network. PMID- 10162879 TI - New HCFA rules to impact physician incentive plans. PMID- 10162880 TI - Paracelsus hit with suits; some facilities may be sold. PMID- 10162881 TI - Purchase of OrNda adds bulk to No. 2 chain Tenet. PMID- 10162882 TI - Calif. public hospitals dodge a bullet. PMID- 10162883 TI - Suppliers endure large doses of change. PMID- 10162884 TI - Doc recruitment aggressive again. PMID- 10162885 TI - It's politics as usual in Puerto Rican healthcare. PMID- 10162886 TI - Communities lose when hospitals reach for dollars. PMID- 10162887 TI - Securing the Internet frontier. AB - Just as in the Wild West, security strategies are being mobilized for the untamed Internet frontier. Technology developed by settlers from the banking and merchandising industries is being retooled for healthcare, where security conscious industries see a big market opportunity. PMID- 10162888 TI - Docs are from Mars, hospital execs Venus. PMID- 10162889 TI - Feedback prompts HEDIS revisions. PMID- 10162890 TI - Columbia offering stake to academic docs. PMID- 10162891 TI - Self-evaluation: mark of good governance. PMID- 10162892 TI - Satisfaction guaranteed. How to see care through the eyes of the patient. PMID- 10162893 TI - Soul search. If you don't know where you are, how can you get to where you want to go? Governance symposium. PMID- 10162894 TI - Small towns, big ideas. PMID- 10162895 TI - A walk on the corporate side. PMID- 10162896 TI - Creating organizational vision in a hospital social work department: the leitmotif for continuous change management. PMID- 10162897 TI - Union Rescue Mission, Los Angeles, California. PMID- 10162898 TI - Reducing the risks and liabilities associated with medical research activities. PMID- 10162899 TI - Patient awareness during general anesthesia poses risks. PMID- 10162900 TI - Perspectives. The '96 elections. A fight for the center on Medicare. PMID- 10162901 TI - Perspectives. Insurance reform sleeper: Medicare contracting overhaul. PMID- 10162902 TI - Validity and reliability issues in published public health and social policy research. AB - This paper reviews basic measurement concepts associated with objective instruments, argues for the importance of addressing the validity and reliability of instruments in articles reporting the results of empirical research, and discusses common measurement issues through examples observed in public health and social policy journals. PMID- 10162903 TI - Questionnaire development. AB - The mail questionnaire is one of the most common forms of research conducted in applied health. It is used primarily for assessing community health needs, exploring opinions on health issues, determining self-reports of health behavior, and aiding program evaluations (Torabi, 1991). The accuracy of conclusions based on questionnaire responses depends upon many factors, including the wording of questions, the physical appearance of the questionnaire (Berdie, Anderson & Niebuhr, 1986; Sudman & Bradburn, 1982), and the response rate (Jones, 1993). Therefore, careful planning must precede the development and administration of any questionnaire. This article, providing a summary of some of the issues and techniques to consider when developing and administering a questionnaire, is organized into two main topics: Writing the questions and increasing response rate. Several subtopics are discussed within each of these two main topics, and suggestions for improving questionnaires are made throughout. PMID- 10162904 TI - The effects of non-response on statistical inference. AB - Surveys have been, and will most likely continue to be, the source of data for many empirical articles. Likewise, the difficulty of making valid statistical inferences in the face of missing data will continue to plague researchers. In an ideal situation, all potential survey participants would respond; in reality, the goal of an 80 to 90% response rate is very difficult to achieve. When nonresponse is systematic, the combination of low response rate and systematic differences can severely bias inferences that are made by the researcher to the population. It is important for the researcher to assess the potential causes of nonresponse and the differences between the observed values in the sample compared to what may have been gained if the sample was complete, particularly when the response rate is low. There are methods available that substitute imputed values for missing data, but these methods are useless if the researcher lacks knowledge of how the responders and nonresponders may differ. With regard to statistical inference, the researcher also should be aware of the difference between a convenient sample and a probability sample. Valid statistical inference assumes that the probability of characteristics observed in the sample bear some relationship to their occurrence in the population. For example, in a simple random sample each member of the accessible population has an equal chance of inclusion in the sample. A convenient sample lacks the statistical properties of a probability sample that allow the validity of its inferences to be assessed strictly from a mathematical framework. The context of the research and the type of data being gathered greatly affect the validity of any generalizations the researcher makes with regard to the population the convenient sample attempts to represent. PMID- 10162905 TI - Seven reasons why you should not categorize continuous data. AB - I have shown that there are a variety of logical, philosophical, measurement, and statistical reasons why every attempt should be made to measure continuous attributes using measures which reflect that continuity and that following statistical analyses should also retain that continuity. I encourage you to look back at some of the research articles which you have read and see if any of these issues is pertinent. Check out the conclusions and see if they are warranted by the data. PMID- 10162906 TI - Reading qualitative research from a methodological point of view. PMID- 10162907 TI - Scale development. PMID- 10162908 TI - Obstacles to conducting program evaluations: implications for public health evaluators. AB - This article presents a number of obstacles to conducting program evaluations which include: the "word" evaluation itself, the politics of evaluation, inadequate resources, the tendency of organizations to resist change, and a lack of understanding of the context of program evaluations. Underpinning these obstacles is the longstanding definitional dilemma between program evaluation and social science research. Although the article's implications are directed toward public health evaluators, they are generalizable to other evaluators in other disciplines. These obstacles highlight the fact that a major role of any evaluator is to confront and negotiate successfully around them. PMID- 10162909 TI - How corporations cope when death intrudes. PMID- 10162910 TI - Defining value. Eye on outcomes. PMID- 10162911 TI - No firm is an island. PMID- 10162912 TI - Lightening the load of major depression. PMID- 10162913 TI - Finding the right care for chronic pain. PMID- 10162914 TI - The pain coverage conundrum. PMID- 10162915 TI - Empowering the patient. PMID- 10162916 TI - The price of pain in the workplace. PMID- 10162917 TI - Advancing observational quality methods for the measurement of forensic psychiatric care. AB - Discusses some of the current problems associated with observational quality measurement. Uses Lerninger's conceptual theory-generating model as the basis of discussion. Puts forward a qualitative approach which breaks away from the traditional methods. PMID- 10162918 TI - Improving the quality of out-patient services in NHS hospitals: some policy considerations. AB - One of the key objectives in the Patient's Charter was to reduce the amount of time typically spent waiting for treatment in NHS out-patient clinics, a documented source of discontent. Presents the results of a quality improvement programme instituted at Leicester General Hospital. Discusses some of the techniques and problems encountered in the measurement exercise. While the results of the monitoring exercise indicated that waiting times were being radically reduced, doubt is expressed as to whether this one simplistic indicator is sufficient to measure the overall quality of out-patient clinics. There is a danger that measurement systems have concentrated on that which is measurable rather than that which is significant. In particular, the voice of the patient is not incorporated into the league table approach to out-patient quality. Discusses several approaches to the measurement of overall quality and the problems and dangers inherent in adopting a league table approach to quality measurement. PMID- 10162919 TI - Licensing, quality of care and the surveillance process. AB - As part of the evaluation of an experimental programme of surveillance of institutions for the semi-independent and frail elderly using the regulation, assessment, follow-up (RAF) method, an examination was made of the licensing status, quality of care, and completeness of the surveillance process. Included in the examination were 126 institutions which underwent the surveillance process between 1990 and 1993. Aims to investigate whether the RAF method of surveillance was being implemented in a professional and uniform manner. Concludes that surveyor's recommendations to grant or not grant a licence were usually based on findings about the quality of care. Nevertheless, in order to reinforce the relationship between licensing and quality of care, it was suggested that surveyors be given clear criteria of quality on which to base their recommendations regarding conditional licensing. It was found that the surveillance process is indeed implemented uniformly in long-term care institutions of varying quality. PMID- 10162920 TI - Disease management at the system level--an effective way to improve health care. AB - The disease management approach to improving health care, at the system as well as the hospital level, has proved to be very powerful, producing unprecedented results in reducing costs while improving quality of care and patient satisfaction. The Boston Consulting Group (BCG), working with a variety of leading managed care providers and pharmaceutical clients, has pioneered the development and dissemination of the disease management concept. Defines the disease management approach and outlines how it differs from the traditional component management approach. Also describes the key elements of disease management, characteristics to look for in a candidate disease, and results achieved so far. Finally, discusses the three strategic roles a healthcare player can take in disease management. PMID- 10162921 TI - Annotated bibliography: integrated approaches to quality improvement in health care: Part I. PMID- 10162922 TI - Measuring service quality at the University of Texas M.D. Anderson Cancer Center. AB - Evaluates the service quality of four clinics at the University of Texas M.D. Anderson Cancer Center using a questionnaire methodology. The SERVQUAL instrument was administered to patients of the Medical Breast, Leukemia, Medical Gastroenterology and Bone Marrow Aspiration clinics. Results show that, according to the service gap methodology of comparing expectations and perceptions, across all four clinics the issues of billing accuracy and waiting times are deemed by patients as significant problems. In comparing the individual clinics, the Medical Gastroenterology and Leukemia clinics are best performers and the Medical Breast clinic is the worst. However, these differences in performance are due to differences in patients' expectations of service quality, rather than differences in perceptions. Concludes that customer expectations can have a strong impact on a firm's evaluation of its service quality. PMID- 10162923 TI - Beyond guidelines: promoting clinical change in the real world. AB - There is widespread recognition that simply publishing research findings is not enough to ensure that they are carried into clinical practice. One response to this has been the burgeoning "guidelines movement" of recent years, which has now reached the stage of generating guidelines for the production of guidelines. Argues that guidelines, and other forms of intervention to change clinical practice in an evidence-based direction, will succeed only to the extent that they engage actively with the real world of clinical decision making. This world is more complex than guidelines writers acknowledge, and includes economic, administrative, professional and personal incentives as well as those provided by research evidence. Engaging with this real world may be difficult, but it opens up new possibilities for understanding how clinicians act and how evidence may be used to inform clinical practice. Such possibilities include social influences, educational outreach, providing information to patients, negotiating local coalitions on specific issues and changing the administrative environment. PMID- 10162924 TI - Development of human resources for medical research. AB - Acknowledges that progress in health care depends on achievements in biomedical research. Discusses the continuing professional development of research workers and the role of international organizations such as the WHO and UNESCO. Argues that a creative approach is necessary to ensure stability in health development. PMID- 10162925 TI - Involving doctors in management. A survey of the management development career needs of selected doctors in NHS Wales. AB - Reports the results of a survey of 209 senior registrars and 269 consultants throughout Wales to identify the management development needs of doctors and ascertain their views of the value and utility of current management development course offerings in Wales. Finds that, currently, management development for doctors in Wales is unstructured and uncoordinated but, despite this, many doctors, especially senior registrars, appeared keen to increase their future involvement in management and held positive views regarding management and management development. The questionnaire also required doctors to rank order six managerial topics and their elements: financial, human resource, strategic, operational, service quality and self-management. Of these, self-management issues were rated highest and there was some congruity in the rankings of the six topics by senior registrars and the other three consultant categories. Overall, managing a budget, medical and clinical audit, negotiating skills and leadership skills were ranked highest for inclusion in management development while project management, quality circles and equal opportunities received the lowest ratings. PMID- 10162926 TI - The remuneration of dentists in a special project of the Israeli Defence Forces. AB - The behavior of health care professionals is known to be influenced, in part, by their method of remuneration and the financial incentives they face. Describes how the Medical Corps of the Israel Defence Forces (IDF) went about choosing a reimbursement method to increase incentives for dentists and decrease waiting time for the public. Based on q questionnaire sent to all 23 dentists working in a unique IDF civilian dental clinic, and on other information which was available on the productivity and income of these dentists, a new method of remuneration was suggested and accepted, by which a combined method of fee-for-service and salary will be introduced. The base hourly pay and per crown fee were set on levels which provide for a larger compensation range and increase the incentive for improved productivity levels. This suggested method will be investigated further and re-evaluated one year after its implementation. PMID- 10162927 TI - Medicare health maintenance organizations. An industry analysis for the elderly in the USA. AB - Provides a review and analysis of Medicare health maintenance organizations in the USA. The Porter model of industry structure is used. Discusses the issues of suppliers, buyers, market entry and substitutes. Indicates there is currently no intense rivalry among Medicare risk-based HMOs. However, the Porter model reveals crucial information regarding the forces which drive industry competition. Trends in the field of managed care and Medicare financing continue to be a real challenge regarding future research. PMID- 10162928 TI - The cost effectiveness of renal provision in the UK. AB - Discusses the need for reliable research-based evidence detailing the costs and benefits provided by different operational and strategic structures of renal replacement therapy. Suggests that in choosing the most appropriate form of dialysis the treatment options may be limited for clinical, practical or financial reasons. Proposes that the renal services must support patients in empowering them to make informed choices concerning the dialysis modality which offers them the highest quality of life. Brings into perspective the need for a balance between patients' quality of life and the financial constraints on the NHS. PMID- 10162929 TI - Decentralization in a sick fund: lessons from an evaluation. AB - In 1988, Israel's largest sick fund embarked on a process of decentralization, which consisted of the delegation of authority from central management to two regions that were chosen as demonstration sites. Aims to examine the extent to which the decentralization plan was implemented, to identify the major difficulties in implementation and to evaluate the process of implementing organizational change. Contends that the demonstration programme was implemented in part only, and that difficulties did arise during implementation. Our evaluation of the decentralization process led us to develop conceptual diagnoses of the various problems that might arise during decentralization and derive lessons for successful implementation. Evaluation taught us that when implementing a plan of decentralization, it is beneficial to make a clear division of responsibilities; develop control instruments and an information infrastructure; improve the skills of managers; appoint a team responsible for implementing decentralization, and establish a joint forum for working out problems between central management and sub-units; and clarify organizational policy on the central operational issues facing sub-units. Expresses the hope that the conclusions drawn here will help other organizations in Israel and abroad in planning and implementing decentralization. PMID- 10162930 TI - Time studies in A&E departments--a useful tool for management. AB - A time and motion study was conducted in an accident and emergency (A&E) department in a Hong Kong Government hospital in order to suggest solutions for severe queuing problems found in A&E. The study provided useful information about the patterns of arrival and service; the throughput; and the factors that influence the length of the queue at the A&E department. Plans for building a computerized simulation model were dropped as new intelligence generated by the study enabled problem solving using simple statistical analysis and common sense. Demonstrates some potential benefits for management in applying operations research methods in busy clinical working environments. The implementation of the recommendations made by this study successfully eliminated queues in A&E. PMID- 10162931 TI - Using ritual to reduce barriers between sub-cultures. AB - Examines the potential for reducing the dysfunctional consequences of demarcation between work groups and professions in the NHS. Suggests that change may be achieved by interpreting and manipulating rituals which preserve the negative aspects of professional and work group autonomy. Discusses a number of rituals observed in a case study hospital during an extensive research exercise and demonstrates how they help maintain potentially dysfunctional culture norms and behaviours which, consciously or not, serve to resist moves to achieve more flexible, team-orientated, patient-centred changes. In addition, explores new rituals which may question current practices, and argues that attention to rituals in the wider change process may facilitate the desired change. Suggests that changes which confront unnecessary demarcation, but which do not undermine professional integrity, can create real benefits for NHS hospitals. PMID- 10162932 TI - Acting on complaints about mental health services. Implications of power imbalances. AB - Complaint procedures are meant to provide an effective safeguard for users of services, but they do not always work well. Applies an analysis of three views of power to complaint procedures in mental health services. Identifies three factors which might affect the effectiveness of complaint procedures: the lack of credibility often accorded users of mental health services; the fear service users may have about complaining; and the difficulties they might experience in knowing what they can expect from a service. Uses this analysis to identify what managers need to do to ensure the complaint procedures are effective. PMID- 10162934 TI - Cultural conflict in a bacteriology department: Apollo v. Athena. AB - Aims to explore the employees' perception of the organizational culture, as well as their cultural preference, and assess what might be the implications of any differences between the two. A questionnaire, largely based on one previously used by Charles Handy, was given to the MLSOs and the medical staff working in a bacteriology department. Analysis of the replies showed that there was a conflict between what was perceived as the existing culture and the preferred culture, and that the intensity of this conflict was associated with either stress or job dissatisfaction. The increased pace of changes affecting this department and the nature of the workforce profile, with many highly qualified and skilled employees, also suggested that a cultural change might be appropriate. Contains a number of recommendations which are budget neutral and which aim to achieve cultural change and increasing motivation. PMID- 10162933 TI - Patients' complaints as a management tool for continuous quality improvement. AB - Continuous quality improvement focuses on the customer and, therefore, requires attention to customers' feedback as a vital input. Customers' feedback in general hospitals includes utilization statistics of various services, patient satisfaction surveys and patients' complaints. The role of complaint data as a management tool, and particularly as applied to quality improvement, has received little attention in the literature. As a quality control tool, complaints are investigated on the individual, unit and organizational levels. Repeated complaints about the same units, procedures or individuals, are especially important for quality review. The role of the hospital administration is to draw on the human, technological and procedural resources at its disposal, along a solution time interval (immediate, short and long term), in designing its policy for quality improvement. Presents three examples of policy changes. The aggregate of complaint data serves, in addition, for follow-up of the effect of changes introduced by policy decisions. PMID- 10162935 TI - The managerial and clinical implications of patient-focused care. AB - Discusses five elements of patient-focused care (PFC). Clarifies issues surrounding the first element--aggregating patients--and debates the strengths and weaknesses of the second element--centralizing services in PFC units. Explores arguments for and against the third element--multiskilling and cross training--including staff activity in conventional hospitals and PFC units, in depth. Discusses the structure of PFC teams and their management. Describes the main components of the fourth PFC element--integrated carepaths--and explores their role in clinical audit, computerization and seamless care. Examines the costs of PFC by comparing actual with expected costs. Makes managerial, clinical, educational and research implications throughout for staff working in or with PFC units. PMID- 10162937 TI - Quality matters: junior doctors' perceptions. AB - Presents the results of an empirical study of junior doctors' views on quality and clinical audit in health care. Claims that the requirement for annual efficiency gains and rising patient expectations, together with the realization that the "costs of quality" can consume between 30 and 50 per cent of costs, has brought quality in health care to the forefront. In this context, and because much of the medical care is delivered by junior doctors, studies their perceptions on dimension of quality in health care, their knowledge of, and participation in, clinical audit and the obstacles to providing quality care. Makes a striking finding--the low priority given to patient satisfaction--a perspective which is out of alignment with the priorities of government policy, and the whole philosophy of "quality in service". Asserts that the role, significance and outcome of clinical audit as a quality improvement tool is cast into doubt by these consultants of tomorrow. PMID- 10162936 TI - Effective contracting of high-tech health care for patients at home. AB - High-technology treatments such as total parenteral nutrition or intravenous antibiotics may increasingly be provided to patients at home. In the past, these services have been funded by the NHS prescribing budget. The aim of the Department of Health's Executive letter EL(95)5, Purchasing High Tech Healthcare for Patients at Home was to ensure that contracts placed by health authority purchasers maintain effective patient services and obtain better value for money by encouraging competition between potential homecare providers. Examines contracting for high-tech health care for patients at home and suggests that efficiency could be improved when contracting with commercial home-care organizations by lead purchasing arrangements. In the long-term, contracting with NHS tertiary centres is most likely to ensure continuity of care and appropriate clinical monitoring of patients. PMID- 10162938 TI - Developing a market orientation in the Health Service: a survey of acute NHS Trusts in Scotland. AB - Argues that the introduction of the quasi market mechanism into the Health Service has required that managers within NHS trusts acquire new managerial skills relating to market operations and, more importantly, reorientate their organizations towards the marketplace. Examines the pattern of development which has occurred within acute trusts across Scotland in the past three years, and argues that managers in the majority of trusts have developed a remarkably robust and relevant conceptualization of the nature and application of marketing within the NHS, reflecting the difficulties managers have faced in selling the concept of marketing to a generally sceptical body of clinicians. Notes, in part owing to such professional scepticism, that the development of marketing as an implementable approach to operations has lagged significantly behind the managerial conceptualization, although this cannot be attributed solely to resistance from clinicians and other health care professionals. Rather, suggests that such limited progress in implementing a market orientation reflects a range of "structural" barriers, both within individual trusts and the specific market environment faced by trusts. PMID- 10162939 TI - Practical public health in a primary care setting. Discrete projects confer discrete benefits but a long-term relationship is needed. AB - Investigates a mechanism for delivering public health advice in a primary care setting--three West Yorkshire general practices--by seconding a public health physician (PHP) to each practice for six months, each practice receiving one day per week. Describes how the topics to be addressed--developing a practice plan for managing information; improving services available for Asian patients; and exploring "value for money" in fundholding--were chosen. Details the procedures and lists the main outcomes. Concludes that placing a public health physician in practices may not be the optimal approach for transferring public health knowledge, but topics important to the practice lend themselves to such an intervention, with potential long-term benefit for public health and primary care. PMID- 10162940 TI - Purchaser and provider relations in the UK: a perspective from the private sector. AB - Gives an overview of the major features of the general changes in the UK health care system, and describes how PPP healthcare is taking advantage of those changes in developing and implementing strategies for relations with both hospitals and specialists. Notes that similar issues are faced by public sector purchasers. Points out that many of the initiatives described are being adopted, in one form or another, in health care industries across the world. Suggests that new insights or understandings may be found by seeing and considering those issues and initiatives in the context of health care economies. PMID- 10162941 TI - Accreditation at what cost? AB - Analyses the implications of the management of labour for an organization undertaking an accreditation exercise. Considers the King's Fund Organizational Audit (KFOA) accreditation scheme, which is concerned with process and facilities, and assesses the quality of the hospital environment in which the health care product is supplied. Concludes that, given the current enthusiasm for finding best practice in health care and the ever-increasing number of cost effectiveness analyses of therapeutic interventions, it seems somewhat contradictory that interventions which cover the whole environment in which health care interventions are performed are not treated in the same way. PMID- 10162942 TI - Re-engineering operating theatres: the perspective assessed. AB - Refers to the widely experienced and appreciated difficulties in scheduling hospital operating theatres to make effective use of resources, and to avoid delays and overruns that can adversely affect patient care and staff morale. Reports the findings and recommendations of a project based in the Surgical Directorate of Leicester General Hospital NHS Trust which sought to address these problems from a business process re-engineering perspective. Covering the whole patient trail, from referral to discharge describes the project's progress through four phases concerning process mapping, the collection of staff opinions and ideas through a combination of interviews and surveys, collection of data on patient flows and procedure times, and a final "handover" phase in which broad recommendations were passed back to the Surgical Directorate for implementation with staff involvement. Details the recommendations which include a shift to cross-functional teamworking in a number of areas, along with the development of a revised theatres policy and a strengthened theatres co-ordination function. In view of recent substantial and harsh criticisms of the re-engineering perspective, seeks to offer a balanced assessment of the perspective applied to a health care setting, exploring both the problems and benefits. PMID- 10162943 TI - The end of AIDS? PMID- 10162944 TI - Targeting a deadly scrap of genetic code. PMID- 10162945 TI - I have learned to hope. PMID- 10162946 TI - Sources of health insurance and characteristics of the uninsured. Analysis of the March 1996 Current Population Survey. AB - This Issue Brief provides summary data on the insured and uninsured populations in the nation and in each state. It discusses the way health protection has changed for the insured, how the states rank in health insurance protection, and the characteristics most closely related to whether or not an individual is likely to have health insurance. The report is based on Employee Benefit Research Institute analysis of the March 1996 supplement to the Current Population Survey (CPS) and represents the most recent data available. In 1995, there were 231.9 million civilian, nonelderly Americans in the United States, 163.9 million (70.7 percent) of whom were covered by private health insurance. Almost 148 million individuals (63.8 percent) were covered by an employment-based plan. Over 38.4 million individuals (16.6 percent) were covered by publicly financed health insurance, and 29 million (12.5 percent) were covered by Medicaid. In 1995, 17.4 percent of the nonelderly population, or 40.3 million individuals, were not covered by health insurance. This is an increase from 39.4 million, or 17.1 percent, in 1994. In general, the percentage of the population without health insurance has been increasing. In 1988, 15.2 percent of the U.S. population was uninsured. The 104th Congress passed the Health Insurance Portability and Accountability Act of 1996 in the interest of making health care more portable and affordable. Additional legislation was passed addressing mental health benefits and maternity length of stay. These bills will do little to decrease the size of the uninsured population. They include provisions for group-to-group portability, group-to-individual portability, an increase in the self-employed health deduction, medical savings accounts, mental health parity, and minimum length-of-stay requirements for childbirth. These provisions in large part benefit individuals who already have health insurance. They do not directly address the larger problem of its affordability. Data from the Survey of Income and Program Participation indicate that 50.7 million individuals lacked health insurance coverage for at least one month during calendar year 1992. Approximately 43 percent were uninsured between one and four months. The median spell without health insurance was six months. These data would seem to indicate that even though many individuals may lose health insurance during any given month, the majority are uninsured for a short period of time. PMID- 10162947 TI - Medicaid estate planning: Congress' ersatz solution for long-term health care. PMID- 10162948 TI - NCQA raises the quality bar for plans--and physicians. PMID- 10162949 TI - The role of physicians in disease management. PMID- 10162950 TI - What health plans should know about clinical practice guidelines--round-table discussion. AB - Quality is the watchword for health plans that wish to survive to see the new century, and accreditation by the National Committee for Quality Assurance is becoming quality's indispensable stamp. Practice guidelines are an imperative for that accreditation. Here's what seven managed care leaders had to say about guidelines in a recent round-table discussion. PMID- 10162951 TI - Medical savings accounts and managed care: a mismatch? PMID- 10162952 TI - The smart way to enhance your online data capability. PMID- 10162953 TI - Advance directives in managed care: are they inspired by love or money? PMID- 10162954 TI - The right way to apply noncompete provisions. PMID- 10162956 TI - What managed care does to physician income in single-specialty and multispecialty practices. PMID- 10162955 TI - Are provider-sponsored networks ready to compete with HMOs? PMID- 10162957 TI - Selection bias in prenatal care utilization: an interdisciplinary framework and review of the literature. PMID- 10162958 TI - Leadership for quality improvement in health care; empirical evidence on hospital boards, managers, and physicians. PMID- 10162959 TI - Economies of scale in physician practice. PMID- 10162960 TI - Long-term alcoholism treatment costs. PMID- 10162962 TI - 1997 forecasts. Market pressures will continue to fuel networking. PMID- 10162961 TI - Equalizing physician fees had little effect on cesarean rates. PMID- 10162963 TI - 1997 forecasts. A shift to an outpatient focus for electronic records. PMID- 10162964 TI - 1997 forecasts. Big changes lie ahead for claims processors. PMID- 10162965 TI - 1997 forecasts. Managed care is aligning its automation priorities. PMID- 10162967 TI - Crisis of the century. Fixing codes for the year 2000 is costly. PMID- 10162966 TI - 1997 forecasts. Desktop systems, Internet are hot telemedicine trends. PMID- 10162968 TI - 1997 resource guide--associations; standards groups. PMID- 10162969 TI - A guide to health data terms. PMID- 10162970 TI - Strategic planning in changing times. PMID- 10162971 TI - The jargon of the Internet. PMID- 10162972 TI - 1997 resource guide. Health care information technology companies. PMID- 10162973 TI - 1996 salary survey results. Computer proficiency, community involvement key to job success. PMID- 10162974 TI - Experts split over best AMI therapy: thrombolysis or PTC angioplasty? PMID- 10162975 TI - 'Plan-do-check-act' develops clinical paths. PMID- 10162976 TI - Inpatient chemotherapy path reduces LOS to three days. PMID- 10162977 TI - Strengthen mental health case management. Avoid over- or underutilization of resources. PMID- 10162978 TI - HHS announces Medicare policy changes, physician fees for 1997. PMID- 10162979 TI - HCFA responds to questions on exceptions and exemptions. PMID- 10162980 TI - New HCFA information system to offer central eligibility data. PMID- 10162981 TI - Rising SNF spending contributes to Medicare shortfall, report says. PMID- 10162982 TI - Beyond science: healing as a mission. PMID- 10162983 TI - Formularies and state regulation. PMID- 10162984 TI - Clearing the air. PMID- 10162985 TI - Ending the paper chase. Health plans are weighing the benefits and drawbacks of computer-based patient record systems. PMID- 10162986 TI - The comforts of home. PMID- 10162987 TI - Sharing information. PMID- 10162988 TI - A partnership mentality. PMID- 10162989 TI - Caring for depression. PMID- 10162990 TI - Putting workers first. PMID- 10162991 TI - By the numbers. Care for arthritis and other chronic conditions. AB - This issue's "By the Numbers" highlights recent findings on care for patients with rheumatoid arthritis in HMO and fee-for-service (FFS) settings. It also looks at the prevalence of arthritis and other chronic conditions in these plans. PMID- 10162992 TI - Caring for your carpet--the "big picture". PMID- 10162993 TI - Indoor air quality: filtering out facts and learning lessons from cleanrooms. PMID- 10162994 TI - Quality and efficiency are no accident. PMID- 10162995 TI - Florida hospital debuts new vending system. PMID- 10162996 TI - Challenge: to improve casual dining in an eldercare setting. PMID- 10162997 TI - How to find out what your customers really want. PMID- 10162998 TI - 1997 HFM resource guide. Your guide to hundreds of companies with products and services for the healthcare industry. PMID- 10162999 TI - Is your organization's tax-exempt status at risk? AB - Not-for-profit healthcare organizations benefit enormously from their tax-exempt status. But in recent years, the IRS, Congress, and state and local governments have begun scrutinizing these organizations in an effort to find potential sources of new tax revenue. Since the survival of an organization may depend on retaining its tax-exempt status, healthcare executives must be able to justify their organizations' status by developing a written charity care policy, promoting the concept of community benefit, reviewing physician recruitment and retention policies to identifying and reporting unrelated business income, and submitting a concise Form 990 tax return to the Federal government. PMID- 10163000 TI - Saving Medicare: what the 105th Congress can do. PMID- 10163001 TI - Managing corporate knowledge can yield significant dividends. AB - Integrated delivery systems (IDSs) that track projects, initiatives, and task force undertakings system-wide are better able to effectively manage their corporate knowledge. IDS executives must understand how valuable corporate knowledge is, and should manage their organizations' corporate knowledge as carefully as their capital investments. PMID- 10163002 TI - Improving patient care delivery with integrated case management. AB - Providers and payers in an integrated delivery system can increase the coordination and cost-effectiveness of the services they provide by developing a strong case management program. Integrated case management can provide the common thread for developing and meeting joint goals, such as reduced lengths of stay, cost-per-case reductions, decreased admission/readmission rates, and increased patient satisfaction. Providers and payers should design and integrate their case management services to allow for greater sharing of resources and integration of patient care goals and incentives. PMID- 10163003 TI - Structuring networks for maximum performance under managed care. AB - Healthcare providers interested in forming delivery networks to secure managed care contracts must decide how to structure their networks. Two basic structural models are available: the noncorporate model and the corporate model. The noncorporate model delivery network typically has a single governing body and management infrastructure to oversee only managed care contracting and related business. The corporate model delivery system has a unified governance management infrastructure that handles all of the network's business. While either structure can work, corporate model networks usually are better able to enforce provider behavior that is in the best interest of a network as a whole. PMID- 10163004 TI - Taking control of managed care contracting. AB - Healthcare providers new to managed care must carefully examine managed care contracts before signing them to be sure the contracts will be beneficial and sustainable in the long run. Providers must scrutinize managed care contracts to ascertain the level of risk and reward they will share, how well patient care efficiencies will be promoted, how much their patient volume will increase, the feasibility of the pricing structure, and the quality of the physicians targeted for inclusion on the managed care panel. PMID- 10163005 TI - Telemedicine and the law. AB - Telemedicine is a compelling healthcare delivery option that allows physicians in isolated and rural areas to access a full range of specialists and cutting-edge technologies usually available only at large, urban medical centers. However, there is uncertainty in the healthcare community about the impact this new technology will have on professional liability. A lack of legal precedents makes it difficult to determine how the courts would respond to malpractice claims related to the practice of telemedicine. Providers of telemedicine can limit the potential for liability exposure by clarifying physician licensure issues, revising physician credentialing procedures, establishing practice standards, videotaping telemedical procedures, safeguarding computerized medical records, and learning more about the impact of telemedicine on malpractice insurance rates. PMID- 10163006 TI - Reporting community benefits. AB - Healthcare organizations increasingly are coming under community and legislative pressure to define and quantify their charity care and community benefits. The results of a survey suggest that healthcare providers are engaged in some of these activities, but that more healthcare organizations need to implement them. Some of the strategies providers can employ are adopting and communicating mission statements, setting goals for the amount and types of charity care and community benefits to be provided, gathering data to support the achievement of those goals, and forming or joining community health boards. PMID- 10163007 TI - SFAS No. 124, accounting for investments: the rules have changed. AB - Under SFAS No. 124 "Accounting for Certain Investments Held by Not-for-Profit Organizations," issued in November 1995, not-for-profit healthcare organizations must report investments in equity securities that have readily determinable market values and all debt securities at fair value. SFAS No. 124 significantly modifies the way healthcare organizations' account for such investments and brings greater accountability to healthcare financial managers regarding the management of their organizations' investments. PMID- 10163008 TI - Practice management agreements: the core of the MSO-group practice alliance. AB - Physician group practices increasingly are negotiating practice management agreements with management service organizations (MSOs). Understanding the issues surrounding the creation and implementation of practice management agreements is critical to maintaining a successful MSO-group practice relationship. The scope of the management commitment must be established and the agreement must provide sufficient flexibility to allow the physicians and MSO to mutually benefit from market-place changes. PMID- 10163009 TI - How to choose the right capitalization option. AB - Physician group practices and networks must have ready access to capital to finance their working capital needs, capital equipment acquisitions, and real estate purchases, as well as to fund the acquisition of additional practices. At least three options for capitalization are available to group practices and networks: debt financing, equity financing, or a combination of the two. The best option for physician group practices and networks depends on the costs of capital and the impact the strategy will have on decision making and governance. PMID- 10163010 TI - Hospital associations challenge government's tactics. PMID- 10163011 TI - The clock is ticking. PMID- 10163012 TI - Data trends. Key organizational performance indicators. PMID- 10163013 TI - Ambushed by a catastrophic error? Expect quick JCAHO response. PMID- 10163014 TI - JCAHO clamps down on restraint use. PMID- 10163015 TI - Do not let your clinical path efforts fall flat. PMID- 10163016 TI - Advance directives: making them more available to hospitals patients. AB - This article details methods developed to facilitate patients' understanding and execution of an advance directive (e.g., living will, treatment preferences, and durable power of attorney for healthcare). The approach takes advantage of the computerization of patient records, using automatically generated e-mail messages sent to an advance directives consultation team. PMID- 10163017 TI - Reflections on the minority elderly in healthcare. PMID- 10163018 TI - The Canadian healthcare system: the future of American healthcare? AB - Market-driven healthcare reform is now a reality. As the federal government grapples to control open-ended entitlements, Medicare and Medicaid, and as the private and public sectors continue to wrestle with the costs of healthcare coverage and delivery, it is useful to review the Canadian healthcare system. Canada's system underwent considerable analysis during the Clinton administration's attempt at healthcare reform. Then, as now, the system was heralded or reviled by disparate interests. Canada's system deserved another look in light of current U.S. interest in healthcare reform. PMID- 10163019 TI - Confidentiality, privacy, and restrictions for computer-based patient records. AB - The public wants four things from our healthcare system: quality, affordability, security, and access (Taylor 1993). To improve quality and affordability of, and access to, healthcare, we turn to information technology for support. With the increased use of information technology in healthcare, concerns associated with the security of patient records are also increasing. Personal privacy and information technology are on a collision courses with respect to the privacy and confidentiality of computer-based patient medical records. PMID- 10163020 TI - Availability and use of advance directives. AB - Hospitals need to assure themselves that advance directives are available to caregivers, especially physicians, and that the patient's wishes expressed in them are being followed. This can be done only with data collection and analysis and improvement of the processes that support availability and use of advance directives. On a broader, societal perspective, it has been suggested that wide spread use of advance directives such as natural death act declarations might encourage systematic rationing of healthcare to the elderly. If a right to die becomes a duty to die, the living will and its progeny, the natural death act declaration, will have become a Frankenstein monster. Indeed, in the mid-1980s the suggestion by then-governor Richard Lamm of Colorado, as well as officials at Health and Human Services that the elderly should be required to have living wills raised a storm of protest. Regardless of true motives, such suggestions are often seen as motivated by economics. The hospital must be alert to the ethical issues of advance directives, which are present regardless of a natural death act statute or a living will. Hospitals and their managers must consider these issues prospectively and develop policies that enable them to respect and meet patients' wishes, consistent with the organizational philosophy. PMID- 10163021 TI - Reaping the whirlwind: legalizing assisted suicide. PMID- 10163022 TI - The emergence of employer-led health care purchasing organizations: a new market for providers. AB - A new form of purchaser--the employer-led, community-based health care purchasing organization--is appearing in the health care marketplace. This article uses the author's experience with coalitions to describe the basic anatomy of private health care purchasing organizations, and suggests several strategies for marketing to this new buyer. The article also presents a market share/presence formula developed to test coalition viability. PMID- 10163024 TI - Physicians contracting with managed care, Medicare, and Medicaid. AB - Managed care has become an ever important form of health care delivery, yet little is known about the characteristics of providers contracting with managed care organizations. Using data from a national survey of 4,729 physicians, we find that market conditions, specialty, and sociodemographics all affect a physician's decision to contract with managed care. Moreover, most of these characteristics also have similar effects on a physician's decisions to participate in Medicare and Medicaid. The latter result implies that physicians view managed care, Medicare, and Medicaid similarly when making contracting decisions, although financial incentives in these insurance programs are different. PMID- 10163023 TI - How the elderly and young adults differ in the decision making process of nonprescription medication purchases. AB - The study compared elderly and young adults in their behavior and involvement in the decision making process of over-the-counter (OTC) medication purchases. Elderly subjects were more involved in the decision making process to purchase OTC medications compared to young adults. The elderly not only purchase and spend more money on medications but also read OTC labels completely. They requested help from the pharmacist more frequently than young adults. Needs of the elderly in making an OTC medication purchase were different compared to young adults. The two age groups differed on importance rating for several attributes regarding OTC medications, such as; ease of opening the package, child resistant package, side effects of medicine, manufacturer of medicine, print size on package labels, and greater choice of medicine. PMID- 10163025 TI - Affective responses towards service providers: implications for service encounter satisfaction. AB - This study investigates the influence of affective responses towards service providers on service encounter satisfaction within the context of health care services. A model of Service Encounter Satisfaction that incorporates affective responses is proposed and tested. The results suggest that affective responses may exert significant influence on perceived performance of the service provider. Managerial implications and future research directions are discussed. PMID- 10163026 TI - Hispanic preferences for health care providers and health care information. AB - In a 1994 telephone survey, only 13% of 522 adult Hispanic respondents in the Southwest used media as the main source of information for physicians, while 19% used media for information regarding health services. Family and friends were main sources. About 75% of the respondents had a family physician with the mother (68%) making health care decisions for the family. A large majority of respondents said that neither the physician's sex, nor race were factors in choosing physicians. PMID- 10163027 TI - An exploratory study of services marketing in global markets: major areas of inquiry for the health care services industry. AB - It has been stated that one of the major challenges for the international marketer is the design of an efficient strategy for marketing services to international markets. This paper reviews some of the issues associated with services marketing in global markets along with the basic variables of service industries. An exploratory assessment of the health care services industry results in a list composed of several inquiry areas which should be examined by multinational companies. It is hoped that the review of the issues raised in this paper provides a basis for decision making and further research. PMID- 10163028 TI - Developing private health care in Macedonia. AB - The Republic of Macedonia is the sole former Yugoslavian republic that has had a peaceful transition to independence. The current socialist health care system is bankrupt with an over-emphasis on specialty care and too many doctors. While clinical standards equal those in Western Europe, customer service is at a low level. Private initiatives are being encouraged by most members of the health care community. However, the current state system should be retained with a sound financial base. Private initiatives have a high potential for success. PMID- 10163029 TI - Community care. Lessons for life. PMID- 10163030 TI - First person. Death comes home. PMID- 10163031 TI - Clinical effectiveness. Heart to heart. PMID- 10163032 TI - Fast-track justice. Fair or flawed? PMID- 10163033 TI - Law/evidence-based medicine. Burden of proof. PMID- 10163035 TI - Law/arbitration. Getting in on the act. PMID- 10163034 TI - Law/resuscitation. Life-and-death decisions. PMID- 10163036 TI - Law/clinical negligence. There may be troubles ahead. PMID- 10163037 TI - Law/patient consent. Forcing the issue. PMID- 10163038 TI - Management education. The skilling fields. PMID- 10163041 TI - Something old, something new unite to improve care at St. Agnes. PMID- 10163039 TI - Mental health. Inner-city blues. PMID- 10163040 TI - Data briefing. Relegating league tables. PMID- 10163042 TI - It's alive! Well, not really. But your building is smart--and it will soon get smarter. PMID- 10163043 TI - Going up. PMID- 10163044 TI - Linen use in an era of managed care. PMID- 10163045 TI - EPA prescribes 'painless' rules for med waste incinerators. PMID- 10163046 TI - Time to bone up on the latest guidelines for disaster plans. PMID- 10163047 TI - Salary survey reveals ups and downs of pay trends. PMID- 10163048 TI - Courts wrestle with consent issues. PMID- 10163049 TI - Price survey. Glove prices face conflicting forces. PMID- 10163050 TI - Regional group loyalties endure despite lure of national deals. PMID- 10163051 TI - Distribution central to supply chain of the future. PMID- 10163052 TI - Getting the paperwork done can be costly process. PMID- 10163053 TI - Community health assessment is a marketing job now. PMID- 10163054 TI - From fried rice to sushi. To market an integrated delivery system, throw out the old menu. PMID- 10163055 TI - Women's health centers and specialized services. AB - More than 75% of the female respondents in this study would choose a women's health center (WHC) over a standard health facility. Women who worked outside the home perceived a greater WHC need. And almost all respondents were interested in communications from the center via a quarterly newsletter. Significant test results related to age, income, education, and work status as segmentation variables, offering WHC's an opportunity to target their patients with specialized services such as cosmetic surgery, infertility treatment, breast imaging, etc. If enough resources are allocated, a WHC can design itself to attract highly lucrative patients. Little difference was found in the opinions of women regarding the need for a WHC or the core services desired, but the specific service mix decision must be carefully considered when designing a WHC. PMID- 10163056 TI - Eliminate the negative. Managers should optimize rather than maximize performance to enhance patient satisfaction. AB - Performance on a particular attribute has an asymmetric impact on patient satisfaction. Gaining insight into this asymmetric effect can help refine management tools such as impact analysis. For overall satisfaction, negative performance on an attribute will have a much larger impact than positive performance. Therefore, managers should optimize, rather than maximize attribute level performance to maximize patient satisfaction. Because of this asymmetry, the benefit from eliminating negative performance may be larger than the benefit gained from increasing positive performance on an attribute. So you can increase overall satisfaction faster by eliminating the negatives. PMID- 10163057 TI - Who needs a needs assessment? You do! PMID- 10163058 TI - Satisfaction with nursing homes. The design of employees' jobs can ultimately influence family members' perspectives. AB - Organizational commitment on the part of nursing home employees can be a determinant of service quality. Proper design of health care jobs and clarity of roles make employees feel more dedicated to their jobs, enable them to do their jobs well, and enhance family members' evaluations of nursing home care. When management develops a dynamic, interactive, high-quality environment, nursing home employees feel encouraged to report shortcomings without fear because they are involved in the process. PMID- 10163059 TI - Linking quality and performance. Quality orientation can be a competitive strategy for health care providers. AB - Many organizations are not convinced a quality orientation pays off and are looking for ways to link quality with performance. The authors' exploratory study found that a quality orientation is a differentiating factor between low performing and high-performing general service hospitals. They also developed a quality scale to assess the performance implications of quality-based strategies in the health care industry. Successful health care organizations (1) develop a strategic quality orientation at the management level, (2) support the pursuit of quality at the contact level, and (3) monitor external customers' perceptions of quality. PMID- 10163060 TI - Whose business is fitness? PMID- 10163061 TI - A pound of cure. Take steps to limit liability based on marketing materials. PMID- 10163062 TI - Obstetrical patient satisfaction. PMID- 10163063 TI - "Leaving footprints": the practice and benefits of hospital chaplains documenting pastoral care activity in patients' medical records. PMID- 10163064 TI - Consumer prices in 1995. PMID- 10163065 TI - U.S. consumers: which jobs are they creating? PMID- 10163066 TI - Election casts no surprises. PMID- 10163067 TI - Hawaii loosens the reins on its public hospitals. PMID- 10163068 TI - Status quo comes out big winner in ballot initiatives. PMID- 10163069 TI - NCQA certifies credentialing firms. PMID- 10163070 TI - Pa. hospital tax exemption lost over doctor practices. PMID- 10163071 TI - S.C. hospitals argue case for merger. PMID- 10163072 TI - Providers fear effects of reimbursement proposals. PMID- 10163073 TI - Mo. hospitals not fulfilling disclosure vow. PMID- 10163074 TI - Government buying plan provokes private sector. PMID- 10163075 TI - Docs getting organized to care for HIV patients. PMID- 10163076 TI - Dallas area hurting for skilled workers. PMID- 10163077 TI - Congressional watchdog issues caution on VA competition plan. PMID- 10163078 TI - Medicaid makeovers. PMID- 10163079 TI - Judge OKs denial of Ohio Blues' national link. PMID- 10163080 TI - Hospital saves by working weekends. PMID- 10163081 TI - Medication managers cut drug costs. PMID- 10163082 TI - Healthcare must be wary of Red Queen Principle. PMID- 10163083 TI - Asset-backed securities draw healthcare interest. PMID- 10163084 TI - Drug firms seek ties to providers via investments. PMID- 10163085 TI - Healthcare agency survives budget battle. PMID- 10163086 TI - Bernardin leaves legacy of dialogue. PMID- 10163087 TI - Hospital staff cuts may be slowing. AB - It hardly seems possible, but the era of wholesale shedding of hospital labor could be drawing to a close, or at least a hiatus, according to a Deloitte & Touche/Modern Healthcare survey. But the good word seems to elude hospital employees, whose morale is still curving downward to record lows. PMID- 10163088 TI - Doc-patient communication a priority at Minn. system. PMID- 10163089 TI - More firms seeking slice of healthcare advisory business. PMID- 10163091 TI - Health policy reform and the states. PMID- 10163090 TI - Friendly Hills execs' feud with MedPartners gets ugly. PMID- 10163092 TI - State choices for voluntary health reform initiatives. PMID- 10163093 TI - Development of the Utah Prepaid Mental Health Plan. PMID- 10163094 TI - Cost and quality information and health care market reform. PMID- 10163095 TI - Risk adjustment and state health reform. PMID- 10163096 TI - Florida's managed competition approach to health care reform. PMID- 10163097 TI - State tax reform and state health insurance reform. PMID- 10163098 TI - Estimating the short-run impacts of an employer insurance mandate on small businesses. PMID- 10163099 TI - Managing the safety net: hospital provision of uncompensated care in response to managed care. PMID- 10163100 TI - Cost analyses of the Arizona Health Care Cost Containment System: lessons from an eleven-year evaluation. PMID- 10163101 TI - Massachusetts Medicaid managed health care reform: treatment for the psychiatrically disabled. PMID- 10163102 TI - Creating risk management reports that work. PMID- 10163103 TI - What to expect during random visits by the Joint Commission. PMID- 10163104 TI - The integration of primary care and case management in chronic disease. AB - Case management historically has been facility based and has focused on discharge planning and utilization review. Integrated case management needs to include risk screening, disability prevention programs, linked information processes, and interdisciplinary teams that manage care over time and across settings. This article describes one such model that can change primary care into a process that involves the entire team, including the patient. PMID- 10163105 TI - Using computer systems to enhance case management. AB - This article describes how an on-line computer system can enhance case management by improving communication within internal departments and adding consistency and objectivity to the referral process. At PacifiCare, the computer system has supported case management's efforts to provide members with cost-effective medical care and has improved satisfaction with the health plan. PMID- 10163106 TI - Thinking outside the box: linkages between admissions and case management. AB - Admissions gatekeeping can enhance integration of case management efforts focusing on problems prior to care provision. Most effective as a part of the continuum of care currently being called medical management, it helps to eliminate variability and waste in processes. This medical management approach can increase quality of care, reduce cost, and draw outcomes toward a median that payers, patients, and physicians can expect and accept. PMID- 10163107 TI - Population-based case management. AB - Harris Methodist Health System is an integrated health system that has developed and implemented integrated health management (IHM) as a new care delivery model. IHM provides a focused, differentiated approach to case management based on the concept of population-based care. Unlike traditional case management, IHM goes beyond managing acute care across clinical settings to provide health care across a continuum that includes health promotion and illness prevention. PMID- 10163108 TI - Managing and redesigning the continuum of care: the value chain model. AB - Systems of care have to be managed, measured, and continuously improved. In the current health care environment, the integration of clinical medicine, systems thinking, and quality management disciplines provides needed tools and skills and identifies key leverage points and learning opportunities to improve the quality of services delivered. This article presents the value chain model and plan, designed to assist managers, physicians, and organizations in managing and redesigning the continuum of care. PMID- 10163109 TI - Human-microcomputer relations in an integrated laboratory service: the users' perspective. AB - The Motala Clinical Chemical Laboratory includes both central (hospital) and peripheral primary health care units. A laboratory computer system has been developed that is shared by all units. In order to illuminate the crucial human computer interaction, the authors did a questionnaire study of the attitudes and experiences of the whole laboratory staff. The null hypothesis of the study-that computerizing is a threat to the users-was rejected. The quality of the laboratory work and reports was also felt to be improved. PMID- 10163110 TI - A Fellowship in Quality Management. AB - The U.S. Healthcare Fellowship in Quality Management at Hahnemann University was developed by a managed health care organization and health science university in order to train physicians in the theory and practice of quality management and clinical outcomes measurement. This article describes in detail the program content and the characteristics of applicants. PMID- 10163111 TI - Case management as a mindset. AB - Melanie Richards was a $3.5 million baby who provided the motivation for developing the case management model used by Friendly Hills HealthCare Network. Born five years ago with gastroschisis, Melanie was transferred from Friendly Hills Regional Medical Center to a tertiary care hospital, where she spent 11 1/2 months in the neonatal intensive care unit. No discharge plans were ever made, and it wasn't until Friendly Hills HealthCare Network started to manage Melanie's care that anyone imagined that this infant could go home, should go home, and would thrive at home. Case management saved Melanie's life, saved money in the long run, and is credited with changing the entire method Friendly Hills HealthCare Network uses for complicated cases. PMID- 10163112 TI - Let the games begin. PMID- 10163113 TI - Comparing ICD-9-CM and ICD-10 classification systems in a primary health care setting: some initial observations. AB - The ICD-10 is due to be introduced into Australia during the late 1990s, superseding the current and widely used ICD-9-CM. Improvements in areas such as number of codes, an expanded external cause framework, and more context to injuries are expected to make the ICD-10 a more streamlined system for practitioners. The present study examined both classification formats using data from 1183 presentations to primary health clinics at island tourist resorts. Some initial observations are made about differences in the two systems, highlighting the greater coding detail provided by the ICD-10, particularly in the area of injuries. It is recommended that further empirical testing be undertaken using the ICD-10 in a variety of settings so as to identify benefits in the coding of both medical conditions and injuries. PMID- 10163114 TI - Training course for coders from private same day hospital facilities. PMID- 10163115 TI - The future is electronic. AB - Electronic patient records are a central feature of many national policies on health information technology. The present article provides an overview of definitions for various degrees of medical record computerisation and current obstacles to implementation. A summary of progress in the areas of standards, specific technological developments and legal issues is provided. The wide ranging benefits of electronic patient records and the implications for health information managers and clinical coders are discussed. PMID- 10163116 TI - Medical device recall authority--FDA. Final rule. AB - The Food and Drug Administration (FDA) is establishing procedures for implementing the medical device recall authority provided in the Safe Medical Devices Act of 1990 (the SMDA). This statutory authority protects the public health by permitting FDA to remove dangerous devices from the market promptly. This authority complements other provisions of the device law, including tracking and notification. PMID- 10163117 TI - Medicaid program: family planning services and supplies for individuals of child bearing age--HCFA. Correcting amendment. AB - This document makes a technical amendment to a Medicaid regulation under 42 CFR 440.40(c) to restore an inadvertent omission of a paragraph designation related to family planning services and supplies for individuals of child-bearing age. PMID- 10163118 TI - Special issuance of third-class airman medical certificates to insulin-treated diabetic airman applicants--FAA. Policy statement. AB - This document announces the new policy of the Federal Aviation Administration (FAA) regarding individuals with insulin-treated diabetes mellitus (ITDM) who apply for airman medical certification. It also addresses comments received concerning this policy as requested in a December 1994 Federal Register notice. The new policy will permit special issuance of third-class airman medical certificates to certain ITDM individuals who meet selection criteria and who successfully comply with an FAA-approved monitoring protocol. PMID- 10163119 TI - Take 50% off the list price with this healthcare card. PMID- 10163120 TI - California's roadblock latest of Sharp HealthCare's merger woes. PMID- 10163121 TI - Ohio hospital JOA (joint operating agreement) gets IRS thumbs up. PMID- 10163122 TI - Community health group quietly drops Medicaid suit. PMID- 10163123 TI - States must guard charitable assets. PMID- 10163124 TI - Babes in managed care land. Provider-sponsored networks are stepping cautiously into risk contracting. AB - Provider-sponsored networks are babes in managed-care land. Except for a few mature, sophisticated systems, PSNs have a lot of learning to do when it comes to the very grown-up business of bearing financial risk for patients' healthcare coverage. PMID- 10163125 TI - Big picture in mind, NCQA gives plans a break. PMID- 10163126 TI - Rewards rising for talented doc group execs. PMID- 10163127 TI - Capitation surging ahead--survey. PMID- 10163128 TI - Community's 'no' vote kills S.C. deal. PMID- 10163129 TI - A primer on insurance. PMID- 10163130 TI - HCFA's Correct Coding Initiative: implications for radiology. PMID- 10163131 TI - A managed care contract analysis. PMID- 10163133 TI - Patient surveys and quality improvement. AB - Patient satisfaction may be the ultimate measure of quality but it is only part of the quality measurement and improvement equation. Customers may be good at telling you what needs fixing but they cannot be expected to tell you how to fix the problem. It is important to let patient satisfaction measures guide the focus of your process improvement efforts, but these efforts must include the appropriate process measurement tools. A customer-focused survey will be valid only if it emphasizes key quality characteristics (KQCs), as defined by patients. You'll need to develop a sampling plan that will produce useable data. The design of the questionnaire and the reliability of the survey tool are critical to using patient surveys for quality improvement (QI). Surveys that don't meet standard criteria have a greater potential for error. Another challenge is the report format and analysis that are used to understand the patient responses. Having an external benchmark is critical to accurate measurement in patient surveys. Comparative data can also help prioritize QI projects. In summary, a well designed patient survey system can identify key quality characteristics, determine which KQCs have the most impact, help prioritize QI efforts, and measure patients' satisfaction in a reliable manner. PMID- 10163132 TI - The role of radiology coders and fee coordinators. AB - The coding process for radiology procedures is more than just looking at a report, writing in the codes and sending it on. In the radiology department, coders/fee coordinators play a key role in troubleshooting, since they are able to see the entire process from patient visit to billing. Vital to the billing operation is having competent and skilled coders who understand radiology from order to revenue. Responsibility for proper coding should rest with the radiology department, even when fee coordinators are paid from different sources. If other people are writing codes that can influence its bottom line, the department needs to know that coding is being done correctly. Thousands of dollars can be lost when the coding and billing process breaks down and incorrect coding is overlooked. A quality control program is vital so that mistakes are found and corrected prior to codes being entered. Insisting on accuracy also means finding and following up on errors through a troubleshooting system to prevent legal action. Codes must be able to look at reports, ask questions about inconsistencies and possible errors and compare the ordered procedure to what was actually done. Issues that affect proper coding are pointed out so that today's coders can be more watchful. Although it is labor intensive, it is important for coders to match reports with dictation from technologies and radiologists to ensure accuracy. PMID- 10163134 TI - A bitter struggle for integration survival. AB - The state of California created the El Camino Hospital District in 1961, one of 77 such districts created as a way to fund rural hospitals. During the 1990s, hospital administrators began to look for ways to streamline operations and cut costs to remain competitive. In 1992, the hospital District Board voted to turn over El Camino's management to a nonprofit company, believing the hospital could form business partnerships with doctors. The District created a private, nonprofit corporation, approved the appointment of volunteers and physicians to the board, and instructed the board to develop on alliance with other physicians. It became evident that several philosophies were at work regarding the healthcare system. In 1995, the District attempted to void the 1992 agreements and take back the hospital. Legal investigations were initiated. Meanwhile, reimbursement rates were decreasing and the hospital's 600 doctors were dissatisfied. Legal struggles continue, public controversy and physician anger are ongoing, and the Santa Clara County District Attorney's office has begun an audit of records. Camino Healthcare, despite all the ongoing difficulties, continues to provide excellent care to patients and the community. PMID- 10163135 TI - Transformational leadership. AB - In these uncertain times in the healthcare industry, administrators are asked to do more with less time and resources. Because of the extended roles they are playing in today's organizations, radiology administrators are looked upon as agents of change. What leadership skills do they need in this turbulent and uncertain healthcare environment? What are the trait's of tomorrow's leaders? The transformational leader is the one who will guide us through this changing healthcare environment. Several behavioral patterns emerge as important traits for tomorrow's leaders to have-individual consideration, intellectual stimulation and charisma. Tomorrow's leader must view each person as an individual, showing genuine concern and belief in each person's ability to perform. Transformational leaders stimulate others by encouraging them to be curious and try new ideas. The final characteristic, charisma, is the ability to inspire others. Luckily, leaders are made, not born: today's leaders can learn to be responsive, to draw out new ideas from employees, and to communicate self-esteem, energy and enthusiasm. PMID- 10163136 TI - Coding for medical imaging. PMID- 10163137 TI - Perspectives. Top stories of '96: HMO backlash, quest for quality. PMID- 10163138 TI - Wireless and mobile: moving ahead. PMID- 10163139 TI - Document imaging vs. the pesky persistence of paper. PMID- 10163140 TI - Document imaging & workflow: making the right decision. PMID- 10163141 TI - Reengineering radiology services with PACS. PMID- 10163142 TI - Creating a radiology department without walls. PMID- 10163143 TI - Client/server RIS: assessing the risks. PMID- 10163144 TI - Prescriptions by modem. PMID- 10163145 TI - Creating the pharmacy CIS: find the user. PMID- 10163146 TI - Fluorescent lights: future hazardous waste of America? PMID- 10163147 TI - Health care spending accounts: a flexible solution for Canadian employers. AB - Flexible benefits plans have grown more slowly in Canada than in the United States, largely because of certain legal and regulatory considerations. Health care spending accounts (HCSAs) provide a cost-effective way for Canadian employers to address the health care benefit needs of a diverse workforce. A flexible health care spending account is a versatile and cost-effective instrument that can be used by Canadian employers that wish to provide a full range of health care benefits to employees. The health care alternatives available through an HCSA can provide employees with an opportunity to customize and optimize their benefits program. Regulatory requirements that an HCSA must meet in order to qualify for available tax advantages are discussed, as are the range of health care services that may be covered. PMID- 10163148 TI - COBRA compliance. Audit guidelines. AB - An employer should evaluate the status of its records on COBRA compliance, paying particular attention to items the IRS will request. Prompt correction of any short-comings can help to decrease exposure during a COBRA audit. An added advantage will be a more systematic administration of this area of employee benefits. PMID- 10163149 TI - Regulating health insurance: the challenges of managed networks. AB - The role of the regulator in health insurance is examined in the context of the change in nature of regulatory oversight necessary to monitor the activities of the regulated parties. Health insurance to this point has been largely regulated by insurance departments that have historically focused on monitoring the solvency and meeting the contractually required reimbursements for indemnity carriers. Now as the indemnity carrier has either migrated to managed care or faced a declining book of business, the historic role of regulation must change to match the new environment. This article examines the role of the health insurance/managed care regulator department under this new paradigm and identifies where and how the regulator can exert influence in such a system. PMID- 10163150 TI - Quality improvement--emerging issues to controlling medical costs. AB - While quality evaluation issues are very important to providers and managed care organizations in marketing their service and managing the care provided, they should also be a focus of any employer or other plan sponsor that is financially responsible for providing managed care benefits. Certainly employers can begin to use information regarding the quality of managed care networks to help determine the better networks to offer participants. In addition, managed care networks are employing a variety of techniques to improve the quality of service that employers can and should try to emulate--and that are explored in this article. PMID- 10163151 TI - How aware are employees of their benefits? Findings from two companies. AB - This study examines benefit awareness of employees in two companies. Contrary to previous research, the results show that employees are generally accurate in their perceptions of the benefits available to them. However, the results also show a lack of awareness of unemployment insurance and disability insurance as benefits. In addition, employees were somewhat uncertain regarding costs of benefits to employers. These findings suggest that employers should monitor employee awareness of benefits and target communications to specific problem areas. PMID- 10163152 TI - Reinventing the workforce contingents at large--commentary. PMID- 10163153 TI - Practice brief. Issue: Retention of health information. American Health Information Management Association. PMID- 10163154 TI - American Health Information Management Association. Resolutions from the 1996 House of Delegates. PMID- 10163155 TI - Overview of the 105th Congress. PMID- 10163156 TI - Team facilitation skills: a step beyond running a good meeting. PMID- 10163157 TI - Your resume--a checklist for today's trends. AB - This article presents one general method for resume preparation that is both straightforward and logical. These common-sense concepts will allow you to prepare a resume for maximum effectiveness. Most people already have a resume so there is no need to reinvent it. Take what you have, apply these ideas, and feel proud of the result. PMID- 10163158 TI - Seeing your way through to AHIMA's Vision 2006. PMID- 10163159 TI - Steps to implementing an imaging project. PMID- 10163160 TI - Defining the UMLS Metathesaurus. PMID- 10163161 TI - Growing demand for accurate coded data in new healthcare delivery era. PMID- 10163162 TI - Regional analysis of functions and demographics of health information managers. AB - Based on the findings of this study, HIM professionals' tasks or functions tend to vary across regions and in relation to levels of experience. As experience increased for RRAs, the task performed by them tended to be more management related. All other HIM professionals performed tasks that were more related to data collection than management. The most frequent title for the RRA (Director/manager/chief of medical records or HIM) was also more related to management activities while the title for the ART (Coder) was directly related to data collection. The majority of all HIM professionals work in acute care with approximately 3-8 percent working in long term care, ambulatory care, mental health care, and other healthcare settings such as software companies or health departments. The two most important predictors of salary across all regions were years of experience and educational level. When experience and education were controlled for, there was a slight salary advantage for males in the Midwest and West regions. PMID- 10163163 TI - Health information management and health education--a professional progression. PMID- 10163164 TI - Presidential address. "Some of the king's horses...". PMID- 10163165 TI - ACS survey explores retirement and the surgeon. PMID- 10163166 TI - Antitrust guidelines for joint ventures and networks. PMID- 10163167 TI - Times have changed: complexity and opportunity are at hand. PMID- 10163168 TI - Automated outpatient scheduling: a step toward the integrated delivery system. PMID- 10163169 TI - Toward an integrated health care information system: a case study for group practices. PMID- 10163170 TI - Medical group practice information needs in a changing health care environment. PMID- 10163171 TI - Provider-sponsored coordinated care organizations: designing systems for patient centered care. AB - PCCOs should take inventory of the information demands in the critical areas of quality, resource, and outcomes management, and standardize the data elements and definitions as the enterprise data model. The focus must be on internal and external reporting requirements as, ultimately, the data model must expedite clinical practice improvement initiatives. The Informational Processing Architecture utilizes the data warehouse for enterprise decision support to derive clinical/business rules and the operational data store/applications for clinical decision support to deploy those same rules at the point of care. As a result, clinical and financial systems should be tightly linked, associating outcomes, process, and cost. In designing these systems, the Systems Development Life Cycle methodology has the advantages of documented deliverables and a well proven methodology for outlining requirements put forth in an RFP, which is indispensable for vendor evaluation and selection. Employing these techniques ensures a user driven process that has the best chance of implementing the complex requirements of PCCOs. PMID- 10163172 TI - OneView strategy aligns physicians with Carilion. AB - Carilion's OneView strategy will ultimately integrate and link our ambulatory activities to our members, patients and community. It is our technology level to lift Carilion, our physician partners and patients to a new level of communication, cooperation, service and quality health care. It will take several years to complete the project, but by the turn of the century we will have OneView of our ambulatory world. PMID- 10163173 TI - Voice recognition: current status as an enabling tool for clinical data capture. PMID- 10163174 TI - A managed care demand model for ambulatory care. PMID- 10163175 TI - Strategies for ambulatory care. PMID- 10163176 TI - OSHA 3148: Analysis of workplace violence guidelines. AB - OSHA has developed guidelines that are the agency's recommendations for reducing workplace violence, specifically in the health care and social services work environments. These guidelines are intended to be advisory in nature as well as informational in content to assist employers in establishing a safe workplace by creating effective violence prevention programs. These guidelines should be used and adapted to meet the specific needs and resources of each place of employment. PMID- 10163177 TI - Medicare program; changes concerning suspension of Medicare payments, and determinations of allowable interest expenses--HCFA. Final rule with comment period. AB - We are revising the Medicare regulations concerning suspension of Medicare payments and determination of allowable interest expenses. These changes are being made to conform the regulations with law and established policy, to provide necessary clarification, and to protect the Government's interests. PMID- 10163178 TI - Medicare: round two. AB - The stakes have risen in the fight to save medicare from demise at its own hands. The program could go bankrupt as early as 2001, and campaign rhetoric may have harmed chances for bipartisan cooperation. Here's a look at some key administration, congressional and health care players in next year's second round. PMID- 10163179 TI - Bye-bye block grants? PMID- 10163180 TI - Can one physician's campaign end payment by capitation? PMID- 10163181 TI - Is paying physicians by capitation wrong? PMID- 10163182 TI - Four ways to avoid being deselected. PMID- 10163183 TI - Three new kinds of liability stalk managed care. PMID- 10163184 TI - 'Alternative' medical treatments raise ethical questions for managed care. PMID- 10163185 TI - A too-tough noncompete clause could defeat its own purpose. PMID- 10163186 TI - Union Carbide uses education to improve patient compliance. PMID- 10163187 TI - Health insurance premiums show smallest hike in recent history. PMID- 10163188 TI - Building a useful hospital library book collection. PMID- 10163189 TI - Collaboration and the three Ts: time, trust and turf constraints. PMID- 10163190 TI - Collaborating on a statewide immunization registry. PMID- 10163191 TI - Planning strategies for 1997 and beyond: focus on how the market is transitioning to prepaid care. PMID- 10163192 TI - Case study. Fairfax Family Practice Centers and Inova Health System: how strong is this marriage? PMID- 10163193 TI - Collaborating with competitors for healthier communities. PMID- 10163194 TI - Child and family focus. Upholding legal and ethical principles in child welfare in the age of managed care. PMID- 10163195 TI - A global view of behavioral health informatics initiatives: the vision for tomorrow must start today. PMID- 10163196 TI - Value online: making the most of the Internet. PMID- 10163197 TI - From managed care to managed information. PMID- 10163198 TI - Dialogue. Who owns the data? PMID- 10163199 TI - Linking child welfare information across the complete continuum of services. PMID- 10163200 TI - Outcomes management makes strides in quality accountability. PMID- 10163201 TI - 21st century information systems for integrated delivery systems. PMID- 10163202 TI - The electronic medical record: a work in progress. PMID- 10163203 TI - Nurses' role in disease case management. AB - The escalating cost of chronic disease and the increasing age of the US population calls for a new healthcare model. Disease management systems may be the answer to these changing demands. The nurse case manager as educator, planner, and administrator can ensure the best use of resources in a disease management model. This article explores the role of nurse case management in a disease management model. PMID- 10163204 TI - Telemedicine: the next frontier. PMID- 10163205 TI - Performance measurement: who's doing what and why? PMID- 10163207 TI - The Internet & WWW. The healthcare resource connection. PMID- 10163206 TI - The value of reference checks. PMID- 10163208 TI - Patient ID: the enabling link to superior outcomes. PMID- 10163209 TI - Strategic resource management. AB - No one in healthcare can challenge the fact that expense reduction is and will continue to be one of the primary concerns of the industry. Everyone also knows that these cost pressures are merely beginning. All indications point to a future environment of intense competition, managed care based on cost-per-covered-life reimbursement, reduced reimbursement from Medicare and Medicaid, and further reconfiguration of the industry to shift patients from in- to out-patient settings. When we focus on the future, the $64,000 question is: "What is the healthcare industry doing to control non-labor expenses, and who is responsible for this ambitious undertaking within each hospital or network?" With nearly 30% of every hospital dollar consumed by non-labor expenses, are current efforts adequate to meet future demands? This article focuses on a strategic plan for reducing non-labor expenses. PMID- 10163210 TI - Leaders of the future. Seven trends for 21st century health care executives. PMID- 10163211 TI - Future work: the new millennium's health care workplace. PMID- 10163212 TI - Does the federal Family and Medical Leave Act of 1993 create a hole in ERISA preemption? AB - ERISA's board preemption provision has survived many challenges to its scope and effect. Now it may have succumbed in the face of a few statements tucked into the legislative history of the federal Family and Medical Leave Act (FMLA). Language in the legislative history presents the view that the Act was meant to overturn ERISA preemption of state family and medical leave laws. The text of the FMLA contains no corroborating language to support that view. However, at least one court found the statements in the legislative history to be persuasive and ruled that under the FMLA, ERISA does not preempt state family and medical leave laws that regulate ERISA plans. If other courts follow that decision, there will be great implications to employee benefit plan regulation and administration. This article explores the court's decision and the relationship between the FMLA and ERISA preemption. PMID- 10163213 TI - Congress advances on health care reform: one step at a time. AB - In adopting the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Congress made a series of small but significant steps toward improving access to health care benefits. The Act's centerpiece is its new requirements for group health plans and for the health insurance industry for assuring portability, access, and renewability of health insurance coverage. Of nearly equal importance is the pilot program established for testing the viability of medical savings accounts. Other health-related changes include adjustments in the rules governing duplication and coordinating of Medicare-related plans, recommendations with respect to privacy of health information of employees, an increase in the deduction for health insurance costs for self-employed individuals, and permission for unemployed persons to make withdrawals from IRAs and other qualified plans for certain medical services' costs. This article summarizes these and other key provisions of HIPAA. PMID- 10163214 TI - Corporate restructuring--strategic planning and redesign of employee benefits. AB - Many intricate legal, actuarial, design and fiduciary issues arise during corporate restructuring. It is critical to create a process approach that clearly defines and evaluates the human resource and benefits issues that are involved, giving consideration to legal and regulatory, operational, administrative, financial and labor-related concerns. PMID- 10163215 TI - ERISA litigation: what every trustee should know. AB - ERISA litigation is complex and requires knowledgeable counsel. Trustees must have some working knowledge of ERISA litigation in order to understand the tactics and procedure involved. At a minimum, they should be able to determine whether fund counsel is adequately protecting the interests of both the trustees and the fund. PMID- 10163216 TI - Managing health care costs in the small business environment. AB - Managed care is bringing down health care costs. But few small business employers find the time to manage their own health, much less that of their employees. Despite time constraints and other factors, small business employers need to embrace managed care. A critical first step is to encourage and support the implementation of important medical management initiatives. PMID- 10163217 TI - Long-term care insurance: a private sector challenge. AB - Powerful demographic and economic forces are fueling the looming crisis related to providing medical and social services for the elderly. However, the American public remains largely oblivious to the devastating implications of the need for institutional or home-based care among senior citizens. Employers have a key role to play in resolving the situation by evaluating competing long-term care policies, endorsing the program of a strong carrier, assisting in offering the policies through payroll deduction and educating employees on the importance of selecting policy riders that best meet their evolving needs. PMID- 10163218 TI - Buyer's guide issue. PMID- 10163219 TI - Health management awards. Nobody does it better. PMID- 10163220 TI - Continuing care. Silent progress. PMID- 10163221 TI - Race and health. Butetown's proud pioneer. PMID- 10163222 TI - Community care. Charge card. PMID- 10163223 TI - Career profile. Finance--the great divide. PMID- 10163224 TI - Secretaries. More than tea and typing. PMID- 10163225 TI - Health policy. Dividing the spoils. PMID- 10163226 TI - Another year older and deeper in debt. PMID- 10163227 TI - Archives. Priceless heritage. PMID- 10163228 TI - On the evidence. Provision revision. PMID- 10163229 TI - Working for the common good of the Catholic health ministry. CHA's 1996-97 strategic plan: a report to the members of the Catholic Health Association. PMID- 10163230 TI - Small-city hospitals need to collaborate. Key questions for healthcare and community leaders. PMID- 10163231 TI - Changing the culture of dying. A new awakening of spirituality in America heightens sensitivity to needs of dying persons. AB - Americans increasingly believe there are material solutions to all problems. Though we once accepted death as a part of life, we now think that--with enough technology--death can be controlled and postponed. Throughout this century, we have moved the dying process from the home to institutional settings. But institutions have a tendency to push all care to its logical end, which leads to alienation, fragmentation, and diminishment. Alienation is the result of the isolation and regimentation found in acute and skilled nursing care facilities. When care givers are indifferent to patients' pain, or do not know how to control it, they further impair the ability of dying persons to interact with others. Care for the dying person, "system by system, organ by organ," as is typical in institutional settings, fragments the dying process into a series of medical events. And, finally, institutionalized care often results in a diminishment of respect by care givers, who may come to view the dying person more as an object of academic interest than as a human whose spiritual needs may transcend physical ones. Such behavior has begun to show us the human costs of denying death and is contributing to a reawakening of spirituality in this country. The devastating effects of alienation, fragmentation, and diminishment can be ameliorated by a heightened sensitivity to the dying person's spiritual needs. With the proper supports, the dying process can be relocated from institutions to the home. Specialized training can educate healthcare professionals about palliative care and human needs at the end of life. We can rehumanize dying persons by first rehumanizing their care givers, specifically addressing the issues of stress and burnout on the job. Ultimately, the way we give care at the end of life reflects broader issues in U.S. culture. Only when communitarian values replace individualistic ones will resources be reallocated in a manner that best serves the most people. Only then will physicians, nurses, and other care givers receive rewards for supporting the dying person when tests and treatment are no longer needed. PMID- 10163232 TI - A feminist case against euthanasia. Women should be especially wary of arguments for "the freedom to die". AB - Feminists, among others, should not be too quick to hail assisted suicide and euthanasia as extensions of human freedom. Indeed, there are good reasons why women should be especially suspicious of such "reforms." First, it is not clear that a person has a moral right to end his or her existence. Feminists understand that suicide and murder are irretrievably linked, and that a person is not a monad. We often hear of suicide attempts in which the person's body--by vomiting up poison, for instance--overrules his or her mind. If there can be such miscommunication between a mind and a body, how are we to trust the communication between a person and the physician ready to assist his or her suicide? Ambivalent motivation and ambiguous meanings have always characterized human relations. In the past, however, an absolute taboo against suicide or euthanasia cemented a patient's right to expect the care of his or her physician, family, and community. If we were to discard that taboo, we would subtly alter these relationships and make each other more vulnerable. History suggests that women, minorities, the ill, the old, and the handicapped would be most at risk. Finally, the assisted-suicide debate has even larger social implications. Unconditional respect for the gift of life is eroding in the United States. The suicide rate is already climbing at all levels of society, especially among teenagers. Wouldn't the acceptance of suicide and euthanasia make it even more acceptable for people to check out of all kinds of uncomfortable situations--marriages or life? PMID- 10163233 TI - Strengthening family ties. Practical ways LTC facilities can involve family members in residents' care. PMID- 10163234 TI - Bridging the gaps in geriatric care. Volunteers help meet the elderly's nonmedical needs. AB - Concerned about the paucity of services for elderly who need care but prefer to live at home, Our Lady of Lourdes Medical Center, Camden, NJ, embarked on an effort to obtain grant funds while seeking creative ways to meet the elderly's nonmedical needs. One of the first programs developed was a Senior Companion Program. This federally funded program recruits low-income elderly citizens, trains them, and places them in the homes of seniors who need nonmedical services to remain in the community. The program's success led to the establishment of Helping Hands in the Community, which recruits volunteers of all ages and incomes to serve as companions for seniors. An extension of this program, Helping Hands in Business, sought to help employers reduce the costs associated with lost productivity because of employees' responsibilities as care givers for elderly family members. Finally, the Camden Senior Community Support Program uses aggressive case management in the emergency room and the hospital to determine whether the elderly need to be admitted to the hospital or can receive support from family or others to remain in the community. PMID- 10163235 TI - Exercise restores seniors' strength and spirits. Fitness plans keep residents of retirement community independent and socially active. AB - Statistics, an independent study, and anecdotal reports are documenting the health benefits of regular exercise for older adults living at the McAuley Center, a continuing care retirement community in West Hartford, CT. As part of its commitment to holistic health, the center links residents with an on-site fitness counselor, who develops an individualized exercise program and helps motivate residents to stick with it. Residents can choose from individual personal training or rehabilitation programs or group programs such as aerobics or line dancing. The results speak for themselves. For the past five years, only 0.05 percent of the falls at the McAuley Center occurred among the 21 percent of the residents who exercise regularly. In addition, residents and staff alike report increased social interactions among those who exercise. Overall, residents and staff say the benefits of regular exercise contribute significantly to the goal of independent living at the McAuley Center. PMID- 10163236 TI - Making tough resource decisions. A process for considering both values and costs. AB - Effective resource management involves prospective decision making, including setting priorities. This enables healthcare facilities to provide services that are consistent with institutional commitments and, under some circumstances, to limit or deny services that are inconsistent with those commitments. The challenge is to apply explicit moral analysis to resource allocation efforts to ensure that facilities are treating patients consistently and fairly. Not only are allocation decisions unavoidable, they also can promote holistic, socially responsible medical practice. But current mechanisms, which are largely hidden from view and informal, can negatively affect important relationships with constituents. The just allocation of our precious healthcare resources rests on values that can either conflict with or complement one another. The core values in resource management include respect for persons, professional integrity, due process, informed consent, stewardship, and the common good. An interdisciplinary team of providers should oversee an ongoing review of resource management mechanisms. The group should meet regularly to look at how the mechanism works, what its goals are, what unit of care it evaluates, and what measurements are used to reach the goals. The measures might include severity of illness, effectiveness, cost, and social factors. Examining questions related to each of these areas can help the group determine whether an existing or proposed resource management mechanism is morally defensible. PMID- 10163237 TI - Sharing your culture with a new partner. Catholic system implements plan to integrate values when it acquires a for-profit hospital. AB - In 1994 Orange County, CA's St. Joseph Health System (SJHS), aiming to strengthen its position in the regional market, acquired Mission Hospital Regional Medical Center, a for-profit hospital believed to be the premier healthcare facility in the southern part of the county. SJHS's leaders began integrating the two cultures at the top, replacing Mission's board but keeping its top managers in place. A member of the Sisters of St. Joseph joined the managers as the hospital's new vice president of sponsorship. In a series of orientation meetings, the hospital's leaders explained SJHS's mission and values to the staff, announcing that Mission would add a pastoral care department, emphasize care of the medically underserved, and discontinue abortion and sterilization procedures. Some Mission staff were disappointed when the hospital terminated a project that offered assisted reproductive technologies. In addition, capitation and exclusive contracting has caused conflict among area physicians, which affects the hospital. And Mission needs to further educate physicians and staff about bioethical issues. On the other hand, Mission has launched a center to help strengthen area families, a transportation system for senior citizens, and a dental clinic for underserved children. It has also taken over sponsorship of a clinic for underserved families. And, in 1994, the hospital opposed Proposition 187, which called for denying state services to illegal immigrants. Many Mission staff have been heartened to learn that the hospital considers justice a core value. PMID- 10163238 TI - HMO's senior enrollees hear a familiar voice. PMID- 10163239 TI - Withdrawal of life support: mistaken assumptions. PMID- 10163240 TI - "Parity" politics shows how reform can be won. PMID- 10163241 TI - Protecting the immunocompromised patient: the role of the hospital clinical engineer. AB - While the discipline of clinical engineering has long been limited to the area of medical equipment management, few areas in hospital engineering practice so closely meet the literal definition of "clinical" engineering as the care of the immunocompromised patient. Although ventilation has been the domain of the plant maintenance department, the increasing numbers of clinical engineers being given responsibility for plant functions, as well as the critical nature of the topic, make the care of the bone marrow transplant (BMT) patient an appropriate area of clinical engineering practice. Further, as clinical engineering branches out of the equipment management area, the clinical engineer can be truly termed the "hospital engineer". PMID- 10163242 TI - Medicine and management: a combined educational program. AB - Rapidly evolving characteristics of our health care system are creating new and expanding opportunities for physician managers. Formal graduate degree training in management has become desirable to prepare the physician for these new professional responsibilities. The Schools of Medicine and Management at Northwestern University instituted a formal combined degree program eight years ago. Directed by a physician holding faculty appointments in both schools, the program offers an integrated five year curriculum. During the past eight years, 16 students have matriculated in the program without attrition. Eleven students have completed both degrees on schedule. The results of a comprehensive telephone survey of all U.S. and Canadian medical schools concerning dual degree programs are presented. The advantages and disadvantages of pursuing management training at various stages of a physician's career are discussed. PMID- 10163243 TI - Health services administration education: meeting the challenge of a culturally diverse work force. AB - Curriculum revision is a continuous and an ongoing process. Health services administration programs must revise course offerings to reflect current demands and changing trends within our society. Given the expected changes in the work force by the year 2000, health services administration programs must consider incorporating cultural diversity issues as they relate to the management of a diverse work force within the health care industry. Labor force and population trends are projected to include a slowly growing work force population, a decline in the pool of young workers, entrance of more females, increased participation of minorities into the labor force, an increased non-white percentage of new entrants and the largest work force increase attributed to increasing numbers of immigrants. In preparation for the diversity within the work force by the 21st century, health administration programs may find the approaches outlined as conducive for teaching students to become sensitive and cognizant of culturally diverse employees. Incorporation of cultural diversity issues may occur in a variety of ways, however, a close examination of the best way to integrate this content lies within each educational program. PMID- 10163244 TI - Recruitment and training of minority health care managers: a case study. AB - This paper describes a cooperative learning model that uses six critical points of intervention at which learning can be facilitated for minority students. These six points were identified in the Health Career Opportunity Program (HCOP). The HCOP initiative model is used because it has been demonstrated that this strategy has been successful in increasing the number of minority health care professionals. The paper is presented in two parts. The first part gives an overview of the six critical points of intervention. The recommendations presented will focus on incorporating mechanisms that can facilitate the learning and achievement of minority students once they have been identified and admitted. The second part presents a case study of how these intervention strategies were implemented in the Health Services Administration Program at Meharry Medical College between the years of 1989 through 1993. PMID- 10163245 TI - The Baxter Foundation Prize address. PMID- 10163246 TI - Ethics teaching in health administration programs: a report. PMID- 10163247 TI - Collecting and using student satisfaction data. PMID- 10163248 TI - Counting gender: does gender count? PMID- 10163249 TI - Professor Bugbee: a road well traveled. PMID- 10163250 TI - The death of the ambulance driver. PMID- 10163251 TI - Time for change. PMID- 10163252 TI - Technology led the way. PMID- 10163253 TI - The right people--the right training. PMID- 10163254 TI - Something special happened at DG (Denver General). PMID- 10163255 TI - When men were men, women were women, and equipment was heavy. PMID- 10163256 TI - How a group's personality affects its members. PMID- 10163257 TI - I was the target of a medical witch hunt. PMID- 10163258 TI - Are doctors working smarter? PMID- 10163259 TI - Don't leave a single patient on hold. PMID- 10163260 TI - Gen-ethics: more than just an academic exercise. PMID- 10163261 TI - Supreme Court of New Jersey to AABB (American Association of Blood Banks): 'You're guilty and that's final'. PMID- 10163262 TI - New CLIA survey processes empower labs to police themselves. PMID- 10163263 TI - National survey results: automation is everywhere. PMID- 10163264 TI - Staff training and competency assessment the right way. PMID- 10163265 TI - Streamline your automated hematology laboratory. Roundtable discussion. AB - How three hematology laboratories improved efficiency by automating the preanalytical process, reorganizing lab workspace, using data management systems to identify which samples need further verification, and setting strict criteria limiting the need for nonautomated processes. PMID- 10163266 TI - Humana blazes trails using medical savings accounts. PMID- 10163267 TI - JCAHO rushes to trouble spots. Hospitals question motives behind quick inspections. PMID- 10163268 TI - HUD halts its foreign-doc visa program. PMID- 10163269 TI - Execs must brace for consumer age. PMID- 10163270 TI - Another record year for dealmaking. Activity among medium-size companies fuels continued drive toward consolidation. AB - The nation's hospitals continued to change hands at a record-setting pace in 1996, according to Modern Healthcare's third annual list of healthcare transactions. The bulk of this year's deals came from an increased number of corporate deals by medium-size companies. PMID- 10163271 TI - Let's call 1996 the year of the consumer. PMID- 10163272 TI - Topsy-turvy industry posts merger record. PMID- 10163273 TI - Patient, employee happiness are job one. PMID- 10163274 TI - Hospitals withstanding managed care. PMID- 10163276 TI - Negotiate the salary you want. AB - How can physician executives negotiate the salary and terms that they want for a new position? The idea of negotiation raises the anxiety level of all but a few people, those who thrive on the thrill of competitive bargaining. Most physicians do not relish the process and view it as a type of conflict. But without knowing what you want to accomplish and preparing to ask for it, you may well leave the meeting frustrated and unhappy with the offer. Determine what you want before you get into an important negotiation. You will get clear on what you want much quicker and you will remember the points better when you talk to the other person. PMID- 10163275 TI - Physician fee abstracting: preventive medicine for fraud and abuse. PMID- 10163277 TI - Will your academic department survive managed care? AB - The current form of academic department is likely to vanish from many institutions. Changes occurring in health care are part of the evolution other industries have experienced, following the product life cycle. Physicians are becoming "deprofessionalized" and as such are beginning to resemble technical workers seen in other industries. The rearrangements in health care are bringing together organizations with different missions, priorities, culture and even language. An academic department may not be considered as an asset to the larger organization or network, representing but one option for product differentiation in the market place. There are strategies for maintaining the viability of the academic component of an organization that necessitate congruence with the overall strategy for the greater organization. PMID- 10163278 TI - Managed care in the pediatric subspecialty of neonatology. The challenges, impact, and consequences. AB - As our health care system moves toward a more managed competition model, the delivery of pediatric and pediatric specialists' services, especially the intensive and procedural services of neonatology, will be impacted. Pediatricians and pediatric subspecialists cannot avoid being buffeted from the powerful market forces that are now driving revolutionary changes in our health care system; they, like nonpediatric physicians, are often concerned and bewildered about the new realities of the day. PMID- 10163279 TI - Does disease management work? AB - Is disease management the "solution of the month" or a valid approach to organizing patient care? In the era of rapid change in health care, disease management is emerging as one technique suited to improving measurable health care outcomes at greater cost effectiveness. By taking a leading role in the process, those physician executives who commit to this approach can greatly enhance the potential of these programs to accomplish the desired results. PMID- 10163280 TI - Recommendations for new medical directors and physician advisors. Administrative clinical pearls. AB - Presented here are "administrative pearls" that evolved out of a health plan's program to help new physician advisors and medical directors in their daily operations and decision-making process. The list of eight recommendations represents accumulated wisdom from experienced medical directors, physician advisors, and nurse managers. PMID- 10163281 TI - More skills of the change master. AB - What are the skills of the change master? How can you become better prepared to deal with the change and ambiguity that has become the trademark of the health care industry? From shifting focus, to being able to act in uncertainty, to having a capacity for paradox, here are nine skills to help you deal with change effectively. These are not easy skills to acquire if they are not a natural part of your tool kit already. You can't pick them up in a few hours at a conference, or by reading a few books. It calls for a long-term, passionate commitment to becoming a learning organization, and a willingness on the part of everyone in management to follow that path even when it gets uncomfortable, difficult, and surprising. PMID- 10163282 TI - Resolutions to make and keep. AB - From mastering the latest technology to becoming an industry expert, listed here are nine career resolutions to seriously consider for 1997. You needn't wait until January to make or implement resolutions that will build your body, your soul, or your career. Start today. PMID- 10163283 TI - Negotiating. Biases physicians bring to the table. AB - What are some of the obstacles that physicians face as they seek to become more effective at the bargaining table? The author's thesis, based on experience in both the classroom and the front lines of medical practice, is that physicians face a set of systematic "biases" derived from physician training and professional culture that make negotiation especially difficult for them. They outline the biases they have observed, explore some possible explanations, and suggest solutions for physicians who wish to negotiate more effectively. PMID- 10163284 TI - New, customized news. AB - How can you get the news that you want, when you want it, no matter where you are? The idea of customized news is indeed new. Instead of sitting passively in front of the TV or turning the pages of your newspaper, you can program your computer to search for the news that is of interest to you from myriad sources. The idea of getting the news as you like it is all a product of the wonderful world of cyberspace. Browse the Web and find out if these news services are right for you. PMID- 10163285 TI - Halfway technologies. AB - An extraordinary gamut of medical and surgical therapies could be considered "halfway technologies," addressing mere symptoms or manifestations of disease, rather than the underlying pathogenesis. When a "halfway" technology is also lifesaving, its value cannot be underestimated by the individual patient. The example of organ transplantation explored in this column represents a halfway technology. It does not treat the underlying disease itself, but reflects the absolute failure of all efforts at medical and conservative therapy and is a last ditch, gerry-rigged lifesaving solution. And what about "quarter technologies"- the bridge to transplant devices--designed to get the patient halfway to the final halfway procedure? PMID- 10163286 TI - Power negotiating for physician executives. AB - Whenever you deal with another person, you use exactly the same techniques that international negotiators use to reach agreement on world problems. Learning to improve your negotiating skills is the highest and best use of your time. You can't make money faster than you can when you're negotiating well. Presented here are negotiating gambits to use to your advantage at the bargaining table. PMID- 10163288 TI - If it ain't broke, don't fix it. PMID- 10163287 TI - Helping moms in need. PMID- 10163289 TI - Teach your children wellness. PMID- 10163290 TI - You can help save Medicare. PMID- 10163291 TI - What a difference a dad makes! Hospital teaches parenting skills to new dads. PMID- 10163292 TI - New law won't help 40 million uninsured. PMID- 10163293 TI - Helping the AHA create healthy communities. Interview by Kevin Lumsdon. PMID- 10163294 TI - Risk factors for cardiovascular disease among exercising versus non-exercising women. AB - As expected, overall, women who exercised had lower body weights, BMIs, and lower risk blood profiles than did those who did not exercise, with exceptions occurring only in the 40 to 49 age group for total cholesterol and LDL cholesterol. Systolic and diastolic blood pressure differences were small between exercisers and nonexercisers, but significant overall. Women who exercised perceived their health, feelings of well-being, and energy to accomplish daily tasks as higher and they missed fewer days of work than did their nonexercising counterparts. PMID- 10163295 TI - La Commande du Coeur ("Shop for Your Heart"): a point-of-choice nutrition education campaign in a low-income urban neighborhood. AB - This research suggests that point-of-choice campaigns can be implemented in low income communities, although store personnel began to view campaign materials and activities as a nuisance after 2 months, and their enthusiasm and commitment decreased. Employee interest might have been more sustainable if the campaign had been shorter or if it had been implemented 1 or 2 weeks at a time rather than being continually present in the store. This approach would necessitate easily removable displays and materials. Items such as the kiosk were too cumbersome for easy setup and removal. Despite widespread advertisement and 4 months in the community, awareness of the campaign was moderate and use was low. Not surprisingly, awareness and use were higher among women, older persons, and persons who lived in St-Henri, possibly because they do the shopping or have the time and interest to notice promotional messages. Awareness and use of specific campaign components appeared to be higher for easily available, highly visible materials and activities that required little or no effort by consumers. Others have suggested that consumer effort required to recognize, view, read, and internalize point-of-choice messages is important and have recommended methods such as videocassettes of nutrition messages or brand-specific shelf labels that reduce customer effort to absorb information. Both the intervention agent and retailers reported that the cholesterol screening events were very popular and that they should have been offered more frequently. Although these events are relatively complex and costly, this response suggests that they are an appropriate and effective way to increase awareness and heighten interest. By contrast, almost no interest was shown in supermarket tours. Although our publicity might have been ineffective, it is more likely that this kind of activity did not interest the target group, possibly because of lack of time or low perceived need or usefulness. PMID- 10163296 TI - Nutrient and food intake in obese women on a low-fat or low-calorie diet. AB - The low-fat group consumed significantly fewer calories from fat and more calories from carbohydrate at both 6 and 12 months than the low-calorie group, but their fat intake was still about twice their goal at both 6 months (39 gm per day) and 12 months (46 gm per day). The low-calorie group achieved their fat goal of 30% of calorie intake, but they consumed from 300 to 700 kcal more than their calorie goal. Caloric intake, physical activity, palatability, satiety, quality of life, and weight loss were not significantly different by treatment. Two studies, which gave patients hypocaloric diets of varying fat and carbohydrate content (fat calories 10% to 45%) for from 10 to 12 weeks, found no effect of diet composition on weight loss. In addition, one study, which gave patients a low-fat, energy-unrestricted diet (fat calories 19%), reported a weight loss of 10.1 lb at 16 to 20 weeks and 5.7 lb at 9 to 12 months, which is similar to that seen in the low-fat group in the this study. Most of the decrease in fat intake (90%) in the low-fat group resulted from a reduction in intake of fat from fat and oils; meat, fish, and poultry; dairy products; and sweets. The dietary changes in the low-fat group are consistent with those found in one study, which prescribed a 15% fat calorie diet to women with breast cancer. Intake of vitamin C increased in the low-fat group and decreased in the low-calorie group. This difference was significant and was caused by an increased intake of fruits and vegetables in the low-fat group and a decreased consumption of fruits in the low calorie group. Calcium intake decreased significantly more in the low-calorie group because of a decreased intake of dairy foods. PMID- 10163297 TI - Health promotion mini-grants: grassroots implementation in New Mexico. AB - The populations of New Mexico are ethnically diverse, with large Hispanic and Native American components, and live in communities that are geographically dispersed and economically challenged. The University of New Mexico is located in Albuquerque, the state's only major urban area, and houses the state's only academic health sciences center. In 1986, the University received a grant from the W.K. Kellogg Foundation to establish health promotion/disease prevention curricula for health science students and create two Wellness Centers on campus. The Wellness Centers train students to be providers of health information and learn how to counsel and assist people with changing health-related behaviors. A campus-wide employee health promotion program was also implemented. Most of the instructional and service programs initiated by the grant have continued with stable institutional support. A later phase of the project was to encourage other agencies and organizations throughout New Mexico to adopt or expand their own health promotion initiatives. An operating premise of this phase was that local initiatives should respond to locally perceived priorities. To accomplish this, a program of mini-grants was designed to assist in creating health promotion programs within a variety of topic areas. Thirteen mini-grants were awarded to agencies representing diverse groups and cultures throughout New Mexico. Our experience with the mini-grants and the ability of organizations to sustain the activities past the period of grant support are described. The successful use of mini-grants has been reported elsewhere in the literature. PMID- 10163298 TI - An experience with health promotion in the inner city. PMID- 10163299 TI - Longitudinal shifts in employees' stages and processes of exercise behavior change. AB - PURPOSE: This study examines the usefulness of using the stages and processes of change model to explore exercise adoption and maintenance over time. DESIGN: Data for this study were collected as part of the baseline and follow-up survey of participants in a worksite health promotion project. SUBJECTS: Three hundred fourteen employees completed exercise questionnaires. The average age was 41 years, mean body mass index was 26, average years of education were 13, and 66% were women. SETTING: The study was conducted in two worksites, a retail outlet and a manufacturing company. MEASURES: Previously validated questionnaires to determine stages and processes of exercise adoption were administered at baseline and 6-month follow-up, along with questions about demographic variables. RESULTS: Four patterns of stage change emerged: subjects who became more active (adopters, 26%), those who became less active (relapsers, 15%), and those who did not change over time (stable sedentary, 32%; stable active, 27%). Adopters displayed increases in use of the processes of change, whereas relapsers displayed decreases in process use. Stable profiles were associated with no change in process use. CONCLUSIONS: These findings have important implications for research on exercise adoption and maintenance. Interventions tailored specifically to subjects' stage of readiness to be active and using specific processes to help in the change process are warranted at this time. PMID- 10163300 TI - Determinants of intention to adopt a low-fat diet in men 30 to 60 years old: implications for heart health promotion. AB - PURPOSE: The purpose of the study was to identify the determinants of intention to have a low-fat diet in 30- to 60-year-old men. DESIGN: The survey design was cross-sectional and consisted of a self-administered questionnaire. The dependent variable was the intention to have a low-fat diet within the next 4 months, and the independent variables were those suggested by the theory of planned behavior. SETTING: The study population was drawn from three districts representing a modal sample of Laval, the second most populous city (N = 314,398) in the province of Quebec. SUBJECTS: The sample comprised 3200 people. Of the 3200 questionnaires sent out, 2583 were received and 2269 were eligible (i.e., were answered by 30- to 60-year-old men), giving a response rate of 70.9%. Of the 2269 questionnaires, 430 were incomplete, resulted in 1839 being usable for analysis. MEASURES: Multiple regression analysis was conducted to determine the influence of the independent variables on the dependent variable, the intention to have a low-fat diet. The independent variables were (1) direct and indirect determinants of intention as suggested in the theory of planned behavior and (2) sociodemographic and concomitant variables and their interactions. Discriminant analysis was used on the significant variables obtained in the regression to establish the cognitive profile of respondents' intention, strong or weak. RESULTS: In the final model, five variables 51% of the total variance. Respondents who had a stronger intention perceived that their important referents would approve them having a low-fat diet. They scored higher in seeing the advantages of adopting the target behavior and had a more positive attitude toward the behavior. They also perceived themselves as having control over the target behavior, and scored higher in terms of recognizing the perceived power of this control factor. CONCLUSIONS: The results suggests that the theory of planned behavior can be an effective tool in the planning of heart health promotion. They indicate that low fat diet programs for men should target the work site and peer-group organizations, and place emphasis on adapting usual recipes. Though accenting the health and nutritional benefits of a low-fat diet, messages should appeal to emotion as well as reason. PMID- 10163301 TI - The impact of the transcendental meditation program on government payments to physicians in Quebec. AB - PURPOSE: This study evaluated whether governmental medical payments in Quebec were affected by the Transcendental Meditation (TM) technique. DESIGN: This retrospective study used a pre- and postintervention design in which government payments for physicians' services were reviewed for 3 years before and up to 7 years after subjects started the technique. Payment data were adjusted for aging and year-specific variation (including inflation) using normative data. No separate control group was used; thus it is impossible to determine whether the changes were caused by the TM program or some other factor. SUBJECTS: A volunteer group of 677 provincial health insurance enrollees was evaluated. The subjects had chosen to practice the TM technique before they were selected to enter the study. The subjects (348 men, 329 women) had diverse occupations. Their average age was 38 years and ranged from 18 to 71 years at the start of the TM program. INTERVENTION: The TM technique of Maharishi Mahesh Yogi is a standardized procedure practiced for 15 to 20 minutes twice daily while sitting comfortably with eyes closed. SETTING: Province of Quebec, Canada. RESULTS: During the 3 years before starting the TM program, the adjusted payments to physicians for treating the subjects did not change significantly. After beginning TM practice, subjects' adjusted expenses declined significantly. The several methods used to assess the rate of decline showed estimates ranging from 5% to 7% annually. CONCLUSIONS: The results suggests that the TM technique reduces government payments to physicians. However, because of the sampling method used, the generalizability of these results to wider populations could not be evaluated. PMID- 10163302 TI - The effects of the child and adolescent trial for cardiovascular health intervention on psychosocial determinants of cardiovascular disease risk behavior among third-grade students. AB - PURPOSE: The Child and Adolescent Trial for Cardiovascular Health is a multi-site study of a school-based intervention designed to reduce or prevent the development of risk factors for cardiovascular disease. The goal was to change (or prevent) related risk behaviors and the psychosocial variables that theoretically influence those behaviors. DESIGN: A nested design was used in which schools served as the primary unit of analysis. Twenty-four schools participated at each of four sites (Austin, San Diego, Minneapolis, and New Orleans). Each site had 10 control and 14 intervention schools. SETTING AND SUBJECT: Ninety-six schools (with more than 6000 students) in the four sites were randomized to three treatment conditions: control, school-based interventions, and school-plus-family interventions. The sample included approximately equal numbers of males and females and was 67.5% white, 13.9% African-American, 13.9% Hispanic, and 4.7% other. MEASURES: The psychosocial determinants included improvements in dietary knowledge, intentions, self-efficacy, usual behavior, perceived social reinforcement for healthy food choices, and perceived reinforcement and self-efficacy for physical activity. RESULTS: The findings indicated significant improvements in all the psychosocial determinants measured (p < .0001). The results revealed a greater impact in the school-plus-family intervention schools for two determinants, usual dietary behavior and intentions to eat heart-healthy foods. CONCLUSIONS: These findings support theory-based interventions for changing selected psychosocial determinants of cardiovascular disease risk behavior among children. PMID- 10163303 TI - An evaluation of Duke University's Live for Life health promotion program and its impact on employee health. PMID- 10163304 TI - Smoking prevalence in Harlem, New York. PMID- 10163306 TI - Coorscreen: a low-cost, on-site mammography screening program. AB - SETTING: Coors Brewing Company is a self-insured corporation of 10,600 employees located in Golden, Colorado. Management has long believed in the value of a healthy workforce and has instituted ongoing health and wellness programming since 1981. PROGRAM DESIGN: Coorscreen was started in September 1985 to create an ongoing awareness of breast cancer screening and prevention for all female employees, spouses, and retirees and to lower the health care costs for the company through early detection of breast cancer. PROGRAM IMPACT: From 1985 through 1993, 12,210 mammograms were completed on 3729 employees, spouses, and retirees. The participation rate was 83%. Forty-seven malignant conditions were confirmed during the first 8 years. Pathology reports confirmed 43 early detections (10 employees) and four late detections (two employees). The 10 cases of malignant disease detected early among employees cost an average of $12,388 in terms of direct medical costs, short-term disability, temporary replacement, and ongoing benefits. The two cases detected late among employees cost an average of $143,398. Among spouses, cases of malignant disease detected late have cost an average of $69,230 more than cases detected early. On the basis of early detection for 10 employees and 26 spouses, the total savings are estimated to be $3,110,000. DISCUSSION: The Coorscreen program cost savings for the first 8 years were $3,110,080 because of the lower cost of early versus late detection. Total screening and procedural costs to the company have equaled $668,690. Thus the company has realized a total cost savings of $2,441,190. PMID- 10163305 TI - Double jeopardy: workplace hazards and behavioral risks for craftspersons and laborers. AB - PURPOSE: To address three specific questions in a sample of craftspersons and laborers: (1) Do craftspersons and laborers exposed to workplace hazards have higher behavioral risks, such as smoking and high-fat diets, than those with few job risks? (2) Compared to workers with few job risks, do workers exposed to risks on the job have higher intentions to reduce their behavioral risks? (3) Does concern about the level of exposure to risks on the job increase workers' intentions to reduce behavioral risks? DESIGN: A cross-sectional self administered survey was conducted in participating worksites. SETTING: Twenty-two predominantly manufacturing worksites in Massachusetts. SUBJECTS: Craftspersons and laborers responding to the survey and employed in these 22 worksites (completion rate = 61%, N = 1841). MEASURES: By using standardized items, this survey measured self-reported exposure to workplace hazards, concern about job exposures, smoking status, fat and fiber intake, readiness to quit smoking, plans to reduce fat intake, plans to eat more fruits and vegetables, and sociodemographic variables. RESULTS: Workers reporting exposure to chemical hazards on the job were significantly more likely to be smokers than were unexposed workers, even when results were controlled for gender. Compared with unexposed workers, smokers exposed to chemical hazards were significantly more likely to be thinking of quitting or taking action to quit, when results were controlled for gender, race, and education. Among workers exposed to occupational chemical hazards, concern about this exposure was significantly associated with intentions to decrease fat intake and increase fruit and vegetable intake, and, among men, intentions to quit smoking. CONCLUSIONS: Efforts aimed at integrating health promotion and health protection are needed to address simultaneously the job risks and personal risks these workers face. PMID- 10163307 TI - Normative beliefs of health behavior professionals regarding the psychosocial and environmental factors that influence health behavior change related to smoking cessation, regular exercise, and weight loss. AB - PURPOSE: To examine the degree of consensus among health behavior change professionals regarding the personal and environmental factors they believe most strongly influence health behavior decisions related to smoking cessation, regular exercise, and weight loss. DESIGN: A factorial survey design was implemented. This method combines the positive elements from simple sample surveys and factorial experiment designs. A total of 44 independent psychosocial and environmental variables are used to randomly construct vignettes, or short stories, to collect dependent variable data. SUBJECTS: A probability sample of 311 health behavior change professionals was selected from the Society for Public Health Education, Inc., the Society of Behavioral Medicine, and faculty from the 1986 Harvard University Symposium on Health Promotion in the Work Place. MEASURES: Judgment ratings on the probability that the person described in each vignette would initiate the behavior in question. RESULTS: Multivariate analysis indicates that the multidimensional model explained approximately one half of the variance in the judgments across the three health behaviors (smoking cessation, R2 = .52; weight loss, R2 = .49; and regular exercise, R2 = .49). CONCLUSIONS: These data suggest a high degree of consensus among the sample regarding the personal and environmental factors that influence health behavior judgments. Here, the subjects perceive both behavioral intentions and self-efficacy as the most powerful determinants of judgments to initiate weight loss, regular exercise, and smoking cessation. PMID- 10163308 TI - A review and analysis of the health and cost-effective outcome studies of comprehensive health promotion and disease prevention programs at the worksite: 1993-1995 update. PMID- 10163309 TI - A comprehensive review of the effects of worksite health promotion on health related outcomes. AB - PURPOSE: This article provides the foundation for a series of literature reviews that critically examine the effectiveness of worksite health promotion programs. This issue reviews the exercise, health risk appraisal, nutrition and cholesterol, and weight control literatures; a future issue will review the alcohol, HIV/AIDS, multicomponent program, seat belt, smoking, and stress management literatures. METHODS: The literature search used a four-step process that included a computerized database search, a reference search, a manual search of relevant health promotion journals, and the writing of the review by a recognized expert in the area being searched. The databases were searched from 1968 through 1994 and included Medline, Aidsline, Psychological Abstracts, Combined Health Information Database, Employee Benefits Infosource, National Prevention Evaluation Research Collection, National Resource Center on Worksite Health Promotion, National Technical Information Service, and the Substance Abuse Information database. A total of 288 articles were identified by the search, not including the 37 articles in the hypertension literature. Authors of each review were requested to incorporate additional studies not identified by the search, provide a research rating for each individual article, and a rating for the overall literature for their respective area. The authors reviewed 316 studies. FINDINGS: The overall ratings for the reviews reported in this issue were suggestive for exercise, weak for health risk appraisals, suggestive/indicative for both nutrition and cholesterol, and indicative for weight control. The ratings for the other reviews will be reported in the subsequent issue. CONCLUSIONS: Research reported in these reviews suggests the effectiveness of worksite health promotion programs, however, additional research is required to provide conclusive evidence of their impact. PMID- 10163310 TI - Worksite fitness and exercise programs: a review of methodology and health impact. AB - PURPOSE: To examine the methodology of worksite fitness and exercise programs and to assess their effect on health-related fitness, cardiac risk factors, life satisfaction and well-being, and illness and injury. SEARCH METHODS: The 52 studies reviewed cover English-language literature for the period from 1972 to 1994, as identified by a search of the Cumulative Index Medicus, Medline, the Canadian Sport Documentation Centre's "Sport Discus," computerized bibliography, and my own files. Reports were divided into five controlled experimental studies, 14 quasi-experimental studies with matched controls (one reported in abstract), and 33 other interventions of varied quality. SUMMARY: Methodologic problems include difficulty in allowing for Hawthorne effects, substantial sample attrition, and poor definition of the intervention (exercise or broad-based health promotion). Findings are analyzed by specific fitness and health outcomes. Program participants show small but favorable changes in body mass, skinfolds, aerobic power, muscle strength and flexibility, overall risk-taking behavior, systemic blood pressure, serum cholesterol, and cigarette smoking. Claims of improved mood state are based heavily on uncontrolled studies. Quasi-experimental studies suggest reduced rates of illness and injury among participants, but seasonal and year-to-year differences in health weaken possible conclusions. CONCLUSIONS: Participation in worksite fitness programs can enhance health related fitness and reduce risk-taking behavior, but population effect is limited by low participation rates. PMID- 10163311 TI - The health impact of worksite nutrition and cholesterol intervention programs. AB - PURPOSE: To summarize and provide a critical review of worksite health promotion program evaluations published between 1980 and 1995 that address nutrition and hypercholesterolemia. The article discusses and critiques both intervention methods and research methodologies to identify the most effective strategies. METHODS: Core articles are 26 original, data-based studies that report on measures of health status, behavior, attitudes, and knowledge as outcomes of worksite nutrition and cholesterol interventions. Only work published since 1980 that clearly describes nutrition or cholesterol interventions and that includes identifiable nutrition-related outcomes is reviewed. The main search method was the same one used for this special issue; supplementary sources included those found in earlier reviews or identified through backward searches or expert contact. SUMMARY OF IMPORTANT FINDINGS: Ten worksite nutrition education programs were reviewed and were categorized as group education, group education plus individual counseling/instruction, cafeteria-based programs, and group education plus cafeteria-based programs. Four of these were randomized studies, and one used the worksite as the unit of randomization and analysis. Sixteen worksite cholesterol programs were reviewed, in five categories: monitoring; individual counseling; group sessions or classes; mediated methods using print, audiovisual, telephone, and self-help kits; and combination approaches. Of these, eight were randomized controlled trials; most tested interventions for persons with elevated cholesterol levels, although four studies reported cholesterol education programs for the general employee population. Six large controlled trials of worksite nutrition and cholesterol interventions in progress are also described. MAJOR CONCLUSIONS: The conclusions that can be drawn from this review are limited by the study designs used, which often lacked control groups, used nonrandomized designs, or relied on self-selected high-risk or volunteer participants. Our rating for the quality of the evidence in the literature as a whole lies between suggestive and indicative. It is clear that worksite nutrition and cholesterol programs are feasible and that participants benefit in the short-term. Conclusive evidence about a causal relationship between worksite nutrition and cholesterol programs and improved behavior or health is not yet available, although studies currently underway hold promise for providing more solid evidence about the potential efficacy of these interventions. PMID- 10163312 TI - Worksite intervention for weight control: a review of the literature. AB - PURPOSE: Published research on worksite weight-control programs is reviewed with the objective of assessing success in (1) reaching populations in need, (2) achieving sustained weight loss, and (3) improving employee health and productivity. SEARCH METHOD: Reviewed are 44 data-based articles published between 1968 and 1994. The initial search was part of a larger review on the health impact of worksite health promotion programs conducted by Centers for Disease Control and described in the introduction to this issue. We supplemented the resulting list with articles found in a search of our own reference files. IMPORTANT FINDINGS: Methodologically the literature is relatively weak, consisting largely of uncontrolled case studies. Worksite interventions appear to be successful in reaching large numbers of people: the median participation rate among overweight employees was 39% in the six studies that provided this type of information. Worksite programs produced reasonable short-term weight loss: typically 1 to 2 pounds per week. Long-term weight loss, reductions in sitewide obesity prevalence, and health or productivity benefits have yet to be demonstrated. MAJOR CONCLUSIONS: Recommendations for future research include improved methods, more attention to recruitment and secondary outcomes, more direct comparison of different programs, and more creative use of worksites as environments and social units in designing programs. PMID- 10163313 TI - The impact of worksite-based health risk appraisal on health-related outcomes: a review of the literature. AB - PURPOSE: To provide a brief history of the development and evolution of health risk appraisal (HRA) and to review studies published in peer-reviewed journals that address the impact of worksite-based HRA on health-related outcomes. METHOD: The Centers for Disease Control and Prevention conducted the primary literature search, identifying seven articles through a bibliographic search of major health databases, manual search of specific journals, and reference list search. We identified four additional studies from our personal experience and our manual search of previous reviews. IMPORTANT FINDINGS: Several studies reported positive changes in seat-belt use and self-reported physical activity associated with HRA participation, and changes in other health-related outcomes after HRA participation were also reported. Evidence supporting causal inference is lacking, however, because of the many threats to internal validity in studies completed to date. Almost no research has addressed the impact of HRA on health related outcomes in the early "prebehavioral" stages of the change process, despite the theoretical and applied focus of HRA on these types of outcomes. CONCLUSIONS: On the basis of the small number of studies in the literature, evidence is weak regarding the impact of HRA itself on health-related outcomes. There is suggestive evidence for the effectiveness of HRA when it is used in a comprehensive worksite health promotion program. Future research should focus on the impact of HRA on variables in the early stages of the change process, such as awareness and commitment, rather than on behavioral outcomes. Research should also address specific characteristics of HRA instruments and implementation approaches. PMID- 10163314 TI - Glaucoma. PMID- 10163315 TI - Latanoprost as a new horizon in the medical management of glaucoma. AB - Latanoprost is a new prostaglandin F2 alpha analogue specifically developed for the treatment of glaucoma. Latanoprost is a selective FP receptor agonist, with a primary mode of action of increased uveoscleral outflow of aqueous humor. A dose of 50 micrograms/mL (0.005%) once daily has been found optimal in clinical trials. Latanoprost reduces the nocturnal intraocular pressure in addition to the diurnal, and has been shown to be additive to other glaucoma medication. In long term phase III clinical trials, latanoprost 0.005% once daily has been proven to be at least as effective as timolol 0.5% twice a day. The main side effect of latanoprost is increased iridial pigmentation, which is relatively frequent in patients with mixed color of the iris. This unique side effect is based on the ability of prostaglandins to stimulate melanin formation in melanocytes. The advantages of latanoprost compared with other glaucoma medication comprise different mode of action, good intraocular pressure-reducing effect, once-daily dosing, and absence of systemic side effects. The long-term consequences of increased iridial pigmentation need to be further studied. PMID- 10163316 TI - Medical treatment of glaucoma and the promising perspectives. AB - Although great progress has been made in defining the spectrum of diseases known as glaucoma, its pathogenesis is still poorly understood. One common element seems to be the rise of intraocular pressure (IOP) beyond physiologic limits. The lowering of the existing IOP is accomplished either pharmacologically or surgically by decreasing the production of aqueous humor or by increasing aqueous humor outflow facility. Quite a number of pharmacologic agents are available to decrease IOP through distinctly different mechanisms. Since these drugs have their own mechanisms of action, some are used in combination in attempts to reduce the IOP to acceptable levels that will stabilize the optic nerve head excavation or the visual fields. In most patients with glaucoma beta-blockers are the treatment of initial choice. However, in almost 50% of these individuals therapy with beta-blockers alone does not reduce IOP adequately. Therefore, there is a need for new classes of topical IOP-lowering agents that can be used alone or in a combination with beta-blockers. This review summarizes the possible perspectives of some of the antiglaucomatous drugs that have been introduced in 1995 as well as those still under clinical investigation. PMID- 10163317 TI - The role of small-incision cataract surgery in combined cataract and glaucoma surgery. AB - Small-incision cataract surgery widens the scope of combined cataract and glaucoma surgery. Phacoemulsification is gaining in importance, although extracapsular extraction techniques are still commonly used. Trabeculectomy remains the standard filtration operation combined with cataract surgery. There are currently a number of areas of contention in combined trabeculectomy surgery, including-the use of shared or separate incisions, the use of antimetabolities, and the type of intraocular implant. Other adjunctive procedures such as trabeculotomy and endocyclophotocoagulation are also discussed in the context of combined surgery. PMID- 10163319 TI - Polarimetry of the retinal nerve fiber layer. AB - Retinal nerve fiber layer (RNFL) examination is a useful tool in the diagnosis and follow-up of glaucoma. Because the clinical techniques to date have been subjective, there is a definitive need to develop instruments that are capable of making accurate and reproducible measurements of the RNFL. Introduction of new quantitative methods, such as confocal scanning laser ophthalmoscopy and optical coherence tomography raises high expectations in clinical practice. In the Nerve Fiber Analyzer (Laser Diagnostic Technologies, San Diego, CA) the measurement technique is based on the assumption that the RNFL has birefringent properties. The change in the polarization state, called retardation, can be quantified by determining the phase shift between polarization of light returning from the eye with the known state of polarization of the illuminating laser beam. The retardation shows a typical double-hump pattern of the RNFL thickness around the optic disk. After elimination of artifacts produced by the anterior segments of the eye, the retardation is related linearly to histopathologic thickness measurements of the RNFL in monkey and human eyes. Prior to large-scale implementation of this technique into clinical practice, however, several questions need to be answered. PMID- 10163318 TI - Current techniques in wound healing modulation in glaucoma surgery. AB - The wound healing response is the single most important determinant of the final intraocular pressure after glaucoma surgery. The use of antiscarring agents, particularly the antimetabolites 5-fluorouracil and mitomycin C, have revolutionized glaucoma surgery over the past decade. This subject has become more important with the realization that simply lowering the intraocular pressure to below 21 mm Hg is inadequate, and that optimal lowering of the intraocular pressure should be achieved in all patients undergoing surgery for glaucoma. However, the antimetabolites still have many potential problems and side effects, some of which are potentially sightthreatening. This review concentrates on the recent publications in this field that have determined the current "state of the art," with a view toward optimizing results and minimizing side effects for our patients with glaucoma in this exciting and challenging area of progress. PMID- 10163320 TI - Vascular risk factors in glaucoma. AB - The role of the villain in high-pressure glaucoma is played by ocular hypertension. Alterations of lamina cribosa, other mechanical alterations, and a possible loss of optic nerve head capillaries are all accountable, and from a therapeutic standpoint most clinicians readily perceive that lowering ocular pressure is the single most important management goal and are satisfied with such results. Yet, when confronted with normal intraocular pressure, other perturbing factors or at least other accomplices must be studied; in this case, an ischemic origin becomes the primary suspect, potentially engendering therapeutic consequences of a different nature. PMID- 10163321 TI - Use of medicated drops and oral tablets in glaucoma treatment. AB - This paper addresses the many forms of treatment for glaucoma. We studied particularly the topical drops and oral medications that are most frequently prescribed by ophthalmologists, specifically examining the reasons for the side effects experienced by certain patients taking topical drops and oral medications. Some of the side effects and interactions are discussed, and the importance of proper procedure for application of topical eye drops is stressed. Finally, we emphasize that proper drug usage is critical to the well being of the patient. PMID- 10163322 TI - Early visual disturbances in glaucoma. AB - Early visual loss in glaucoma may not be detected with conventional perimetry because this technique uses simple spots of light that are perceived by any type of ganglion cells. Visual tests for central or peripheral vision have been designed to more specifically address subsets of cells that are impaired in the early phases of the disease. The rationale for use of these tests and their current clinical evaluation are reviewed in this paper. Many tests assessing different visual pathways give abnormal results in patients with suspected glaucoma and ocular hypertensive patients, favoring the hypothesis that multiple pathomechanisms are involved in the onset of glaucoma. PMID- 10163323 TI - Diagnostic value of short-wavelength automated perimetry. AB - Short-wavelength automated perimetry (SWAP) uses a bright yellow background and a large blue stimulus to isolate and measure the sensitivity of short-wavelength sensitive mechanisms throughout the central 30 degrees visual field. After more than 8 years of cross-sectional and longitudinal studies of patients with early glaucoma, ocular hypertensive patients, and age-matched control subjects, SWAP has been shown to be a sensitive indicator of early damage and progression of loss in glaucoma. It is now available as an optional visual test procedure for routine clinical use on the most widely distributed automated perimeter. Recent investigations have been directed toward refinement and standardization of the technique, as well as toward the influence of other clinical factors (ocular media opacities, macular pigment, statistical interpretation, and related issues) on SWAP. This paper provides a brief overview of current research on SWAP as a clinical diagnostic test procedure. PMID- 10163324 TI - Current cost-effective work-up of the glaucoma suspect. AB - Given the limited resources for medical care, ophthalmologists are increasingly being called on to provide care in a cost-effective manner without compromising quality. This review provides a framework for the difficult task of working up suspected glaucoma in a cost-effective manner. Several new developments in early detection of glaucoma will also be described. PMID- 10163325 TI - The glaucomas in pseudophakia. AB - The glaucomas in pseudophakia are not uncommon. Because they can be related to different mechanisms, each case should be evaluated individually. Once glaucoma has been established and medication fails to maintain the intraocular pressure at a safe level, several options are available. As a group, the glaucomas are considered both difficult to manage with medications and also at high risk for failure of filtration surgery. Trabeculectomy adjuvated with anti-metabolites, draining implants, and cyclodestructive procedures are all effective procedures. Although complications and loss of vision as a consequence of glaucoma surgery are not frequent, they were reported by several authors. The likelihood of any given treatment to preserve the quality of life should be discussed with each patient and should be part of the decision-making process. This article reviews studies on the glaucomas in pseudophakia published from October 1994 to September 1995. PMID- 10163326 TI - The toxicology of mitomycin C on the ciliary body. AB - Over the past few years, the use of mitomycin C (MMC) to reduce surgical failures following filtering procedures has largely increased. After topical application, significant amounts of MMC can be detected intraocularly. In both rabbit and human eyes, a reduction of the normal and elevated intraocular pressures could be achieved with subconjunctival injections of MMC without filtering procedures. Histopathologic examination of the ciliary body in a human eye shortly after surgery with MMC revealed moderate, diffuse toxic changes of the two layers of the ciliary epithelium. By fluorophotometry, eyes after trabeculectomy with MMC had a decreased production of aqueous humor compared with eyes that underwent trabeculectomies without antimetabolites. Independent studies suggest that the toxicity of MMC for the ciliary epithelium may be a significant factor contributing to postoperative hypotony. PMID- 10163328 TI - Value of ultrasound biomicroscopy for ciliodestructive procedures. AB - Ciliodestructive procedures are commonly performed by the transscleral approach because ciliary processes are seldom visible. Thus the ablative energy is directed toward an "invisible" target whose position can only be estimated on the basis of experimental data. Ultrasound biomicroscopy has been recently introduced in ophthalmologic practice. This high-frequency ultrasound B-scan method gives real-time images of the subsurface structures of the anterior portion of the living eye at microscopic resolution. Ultrasound biomicroscopy perfectly visualizes the ciliary body and its surrounding structures and is a promising complementary tool for ciliodestructive procedures. The system has been used to image early and late ciliary body alterations after transscleral cyclophotocoagulation, to establish the position of the ciliary body to ensure correct laser probe placement, to locate ciliary body residuals for retreatment, and to rule out scleral damage after the procedure. An apparatus has been designed for simultaneous contact cyclophotocoagulation and ultrasound biomicroscopy analysis. A prospective randomized clinical trial is now needed to clarify the influence of ultrasound biomicroscopy on the success rate of ciliodestructive procedures. PMID- 10163327 TI - Side effects of antiglaucomatous drugs on the ocular surface. AB - An increasing number of studies, both experimental and epidemiologic, have shown that filtering glaucoma surgery has progressively become less effective than initially described. Of a number of risk factors for failure, duration and number of antiglaucoma drugs before surgery seem to play a critical role, and high accumulated antiglaucoma topical treatments significantly reduce success rates. Histopathologic studies have confirmed that topically applied drugs may exert toxic effects to the corneoconjunctival surface and induce chronic infraclinical inflammation, as shown by the presence of immunologic changes and inflammatory infiltrates in multitreated eyes. The origin of topical inflammation has not yet been clearly determined, but benzalkonium chloride, which is used as a preservative in almost all antiglaucoma preparations, has shown strong evidence of toxicity to the ocular surface. A number of questions remain to be investigated, but suppression of preservatives from chronically applied drugs should be a critical issue in the near future. PMID- 10163329 TI - Glaucoma risk factors observed in the Baltimore Eye Survey. AB - The Baltimore Eye Survey identified race, intraocular pressure, systemic hypertension, perfusion pressure, family history, and quite possibly the structure and organization of the optic nerve head as potential etiologically significant risk factors in the development of glaucomatous optic nerve damage. These findings have been confirmed by subsequent, sometimes equally rigorous population-based studies in other communities and countries. The Baltimore Eye Survey failed to demonstrate a role for diabetes but revealed that estimates of the significance of diabetes, like that of family history, are subject to considerable selection bias. PMID- 10163330 TI - Current imaging of the optic disk and retinal nerve fiber layer. AB - The optic nerve head and the retinal nerve fiber layer (RNFL) are the sites of clinically detectable glaucomatous tissue damage. Photographic techniques are used to document the optic disk and the RNFL to monitor patients with suspected primary open-angle glaucoma or to follow-up patients already suffering from this disease. New techniques such as laser scanning tomography (LST), scanning laser polarimetry, and optical coherence tomography have been introduced to quantify structural alterations with the aim of early detection of optic nerve or RNFL damage prior to functional loss. These novel, additional diagnostic tools are currently being evaluated in clinical practice. While scanning laser polarimetry and optical coherence tomography are discussed elsewhere in this volume, articles on LST and conventional techniques are considered here. Imaging and computed data processing allow for three-dimensional in vivo measurements in the range of micrometers. With regard to the structure of the optic nerve head, this aspect in the evaluation of the optic disk can be based on quantitative topographic data. We expect "topometry" to become an important additional tool in the early diagnosis and follow-up of patients with glaucoma. However, computed parameter readings should always be evaluated in a clinical context. The goal is to improve, combine, and integrate all the different diagnostic approaches to improve patient care for the benefit of those suffering from glaucoma. PMID- 10163331 TI - Maintenance treatment in the prevention of gastric ulcer recurrence: results of a 3-year multicenter study. AB - This study reports data from the third year of a multicenter, prospective, open, 3-year trial in which 290 patients with gastric ulcer followed different treatment protocols (ranitidine or sucralfate or no drug) during the first 2 years. One hundred forty-two patients completed the first 2 years; 50 of them completed the third-year investigation. All 50 patients were left untreated and underwent clinical tests every 3 months and endoscopic checkups every 6 months and for every painful episode lasting more than 3 days. During year 3 follow-up, 1 patient dropped out and 2 had relapses. Mean consumption of antacids ranged from zero to three tablets per week. No gastric neoplasms were detected during the third year of follow-up. These findings suggest that no treatment may be needed in the long-term management of patients with gastric ulcer. No malignancies were found during the second and third years of follow-up, suggesting that close endoscopic examination is necessary only for 6 months after the acute lesion has healed. Maintenance therapy with antisecretory or cytoprotective drugs may be advisable for 1 year. PMID- 10163332 TI - The impact of 5-alpha-reductase inhibitors on the number of prostatectomies for benign prostatic hyperplasia. AB - To determine the impact of a 5-alpha-reductase inhibitor on the need for surgical treatment of symptomatic benign prostatic hyperplasia (BPH) in clinical urologic practice, we retrospectively reviewed records of 794 patients treated with pharmacotherapy or surgery (or both). The number of transurethral resections of the prostate (TURPs) performed during the 30 months since introduction of finasteride was compared with the number performed during the 30 months before finasteride became available. The alpha-blockers doxazosin and prazosin were used during both times for the treatment of BPH. Of the 619 patients treated with drugs, 88.5% received finasteride for a mean of 249.6 days. The alpha-blockers, either alone or combined with finasteride, were prescribed for 11.5% of patients for a mean of 179 days. In the 30 months after the introduction of finasteride, 65 patients underwent TURP: 28 of these men had initially received drug therapy. In contrast, 138 TURPs were performed in the 30 months prior to the availability of finasteride. The use of a 5-alpha-reductase inhibitor as primary medical therapy for symptomatic BPH decreased the number of prostatectomies by 52.9% (65 vs 138). This observation warrants corroboration through additional prospective studies. PMID- 10163333 TI - Bileaflet valve replacement: complications and costs. AB - A meta-analysis of the available literature on the CarboMedics and St. Jude Medical valves was conducted to compare their clinical performance. Frequency of valve-related complications for aortic, mitral, and double-valve replacements served as a measure of performance. An economic model was created to estimate the economic impact of valve-related complications. Overall, fewer events occurred with the St. Jude Medical valve than with the CarboMedics valve. As a result, use of the St. Jude Medical valve is expected to save up to $13,201 over 10 years. PMID- 10163334 TI - Management of skin tears and stage II skin ulcers with two topical regimens: a study of cost minimization. AB - A health-economic study of newly formed skin tears and stage II ulcers used an unblinded, comparative, parallel-group design to evaluate two topical regimens as to time required for complete healing and assessment of cost minimization. Thirty six elderly patients, at risk for developing indolent wounds of the skin and underlying tissues, were assigned to receive either a saline spray and a topical antibiotic ointment (TAM, n = 14) or Dermagran Spray and Dermagran Ointment (DSO, n = 22). The 76 wounds that appeared in these patients had comparable pretreatment surface areas of 3.73 +/- 0.96 cm2 in the DSO group versus 5.57 +/- 1.13 cm2 in the TAM group (P = NS). All wounds were treated twice daily, starting within 24 hours of their appearance, until complete healing. The 19 wounds in the TAM group healed within 48.0 +/- 25.3 days versus 15.4 +/- 1.9 days for the 57 wounds in the DSO group (P < .05). The cost of wound management for a given patient was calculated by adding the costs of nursing labor and the amount of product consumed to effect complete healing. To this end, the cost of the TAM regimen was $323.23 +/- 171.70 versus $104.75 +/- 12.92 for the DSO regimen (P < .05). Results are presented in light of the increasing pressure on long-term care facilities to provide effective and affordable treatment. PMID- 10163336 TI - Lancets for capillary blood collection. PMID- 10163335 TI - The management of lower-extremity ulcers with zinc-saline wet dressings versus normal saline wet dressings. AB - Zinc-saline wet dressings were compared to normal-saline wet dressings for the management of lower extremity ulcers in a pilot study of 28 elderly patients. Although both study groups were comparable at baseline, the data suggest that the use of zinc-saline wet dressings creates a wound environment that is associated with trends toward faster healing and enhanced rates of epithelialization, as well as significantly more efficient wound management than the normal-saline controls. These data are presented in light of the requirement for maintaining a moist, acidic environment within a wound in order to permit the best possible healing and remodeling. PMID- 10163337 TI - The analysis of lead in urine. PMID- 10163338 TI - Evaluation of between-sample carryover on an automated coagulation instrument: recommendations for quality control procedures. AB - OBJECTIVE: To assess sample probe carryover levels in a modern automated coagulation analyzer. SETTING: Washoe Medical Center Clinical Laboratory, Reno, Nevada. DESIGN: Analysis of the relative degree of prolongation of coagulation assays using a sequential series of samples following a sample with inherent or added components with the potential for prolonging or accelerating coagulation when significant sample probe carryover is present. PARTICIPANTS: Not applicable. MAIN OUTCOME MEASURE: The extent of prolongation or acceleration of APTT or PT assays. RESULTS: The first sample positions assayed subsequent to specimans with potential accelerating or prolonging coagulation activity were affected by 3.9% to 17.8%. CONCLUSION: Results suggest that a potential exists in automated sampling coagulation analyzers. A mechanism for quality control analysis of carryover should be incorporated in automated probe coagulation analyzers. A suggested "1-2-1" control sequence is discussed as a possible quality assurance tool for measuring carryover within individual assay runs. PMID- 10163339 TI - The Women's Health Initiative: studying interventions over the long term. AB - The women's health initiative is studying the effectiveness of several preventive measures among postmenopausal women. The ambitious project is also examining a wide variety of biomarkers and could uncover new and important disease markers over the next 10 years. PMID- 10163340 TI - Physician satisfaction survey for continuous quality improvement of the transfusion service. PMID- 10163341 TI - Analytical performance characteristics of the T4 method in the Abbott AxSYM immunoassay analyzer. AB - OBJECTIVE: To evaluate the tetraiodothyronine (T4) method in the Abbott AxSYM immunoassay analyzer. DESIGN: The single-value criteria proposed by Westgard et al. were employed. Assays of control materials established random error (RE) analytical sensitivity, and linearity. Constant error (CE) was established by studying the effects of interferents on T4 quantification. The AxSYM random access immunoassay analyzer was compared with TDx batch analyzer to determine systematic error (SE). Critical concentrations of T4 are 3.0 micrograms/dL and 13.0 micrograms/dL, as these concentrations represent medical decision points. Allowable error at these critical concentrations are 1.0 and 2.6, respectively. SETTING: Peninsula Regional Medical Center Clinical Laboratories. RESULTS: Based on Health Care Financing Administration [HCFA] allowable error goals, RE, SE, and CE were acceptable for concentrations of T4 ranging from 3.0 micrograms/dL to 13 micrograms/dL. PE was virtually absent. Total error (TE) = RE + SE was acceptable at 13 micrograms/dL but exceeded allowable error at the lower critical value of 3.0 micrograms/dL. Abbott AxSYM was sensitive to T4 at a concentration of 0.34 microgram/dL. Linearity was excellent and consistent with the manufacturer's claim over a range 1.0 microgram/dL to 24 micrograms/dL. Of the interferents studied only hemoglobin caused a > 15% change in the measurement of T4. CONCLUSION: The AxSYM immunoasssay analyzer performed to manufacturer's specifications and met HCFA allowable error limits for quantifying T4. PMID- 10163342 TI - Cost accounting applied to the clinical laboratory. AB - OBJECTIVE: To review cost accounting procedures and the applications for the clinical laboratory. DATA SOURCES: Laboratory management textbooks, journal articles, and symposium speakers; NCCLS Guidelines; and personal experiences. DATA SYNTHESIS: Costs in the laboratory fall into several categories: direct, indirect, fixed, and variable. In calculating costs of various tests, all costs must be estimated and included; when prices or wages change, the impact on total costs can then be assessed quickly and accurately. Computer software is available to help with collection and manipulation of data. CONCLUSION: Being able to determine the cost of a laboratory procedure is important in the economic climate of today. A formet for collecting cost components is given and its use discussed. PMID- 10163343 TI - Evaluation of One Touch II hospital in a community-hospital setting. AB - OBJECTIVE: To compare the linearity and precision of the One Touch II hospital, a bedside reflectance meter for measuring blood glucose, to the Kodak Ektachem 700 and to discuss a few essential elements needed for an excellent bedside testing program. SETTING: Prince George's Hospital Center (PGHC), Cheverly, Maryland, a community hospital with approximately 400 beds. PATIENTS OR OTHER PARTICIPANTS: Blood was selected randomly from 100 patients for whom a blood glucose test had been ordered. All patients were adults. INTERVENTION(S): Not applicable. RESULTS: A high degree of correlation (r = 0.984) was observed between the One Touch II hospital glucometer and the Kodak Ektachem 700. The linear regression equation was y = 1.1x - 2.0. CONCLUSION: The One Touch II hospital meter is an accurate and practical instrument when it is used by trained individuals. PMID- 10163344 TI - Evaluation of a satellite educational program. AB - OBJECTIVES: To evaluate the effectiveness of an educational program using a combination of live satellite programming and individualized instruction. A secondary goal was to develop an evaluation strategy that would be useful to other educators who provide distance-based educational programs. SETTING: A program designed for public health officers who would serve as laboratory directors in local public health laboratories was presented live by satellite in June 1993. PRACTICE DESCRIPTION: The course emphasized good laboratory practice as needed to direct a laboratory performing moderate complexity tests. Physicians who completed the course received 20 continuing medical education credits and qualified as laboratory directors under the Clinical Laboratory Improvement Amendments of 1988 (CLIA 88). MAIN OUTCOME MEASURES: Increase in participants' knowledge of good laboratory practices and application of the practices in their laboratories. RESULTS: Participant satisfaction levels in areas ranging from quality of the video transmission to meeting the course objectives were favorable. Participants demonstrated a significant gain in scores on a test given before and after the course. Problem solving exercises posed during the telecast demonstrated that the participants were actively involved and had completed the self-study material. A sample of participants surveyed several months after the course indicated that many had applied the course material in their workplaces. CONCLUSIONS: Distance-based education using a combination of interactive videoconferencing and self-study material can be a useful tool to enhance cognitive skills for a geographically diverse group of individuals. If carefully planned in advance, evaluation of distance-based educational programs can provide information that verifies the effectiveness of the program. PMID- 10163345 TI - Using a problem-based learning format to teach CLS students interdisciplinary health care practice. AB - OBJECTIVE: To simulate interdisciplinary collaborative practice using a problem based format so students can increase their knowledge and understanding of health care disciplines other than their own. The basic premise of this approach is that learners are more likely to master necessary subject matter if it is presented in a manner that is realistic. SETTING: University of Kentucky Center for Rural Health. PARTICIPANTS: Eight student participants-three undergraduate clinical laboratory science students, three students in the masters degree nursing program, one family practice resident, and one visiting student from a physician's assistant program. MAIN OUTCOME MEASURES: Group discussion, peer review, and student questionaires. CONCLUSION: The interdisciplinary, case-study approach to learning offers the clinical laboratory science student an opportunity to work with other health care providers in an informal setting as an introduction to group interaction, interdisciplinary health care, and evaluation of health care access in any community. PMID- 10163346 TI - What's new in blood banking? Plenty. AB - With appointment of new federal committees, creation of quality plans, increased oversight of blood banking services, and the advent of HIV antigen and other methods of testing, blood safety is making news again. The channels through which blood is distributed are also facing challenges and changes. PMID- 10163347 TI - Viral vs. bacterial meningitis. PMID- 10163348 TI - Gaining links: health information networks arise--with integration challenges. AB - As chins gain favor and efficiency in several regions of the country, they are increasingly used to speed both financial and clinical data interchanges. Technologic advances in information management are shifting the laboratory from a passive entity generating data to an active medical support service. PMID- 10163349 TI - Airway surfactant, a primary defense barrier: mechanical and immunological aspects. AB - Epidemiologic studies have shown strong associations between mortality and morbidity from respiratory and cardiac causes and exposure to fine (PM10), but not coarse, particulates. A plausible mechanistic explanation for these associations is lacking. It has been shown that particles may be retained for an extended period of time in the airways, and that their clearance is inversely proportional to particle size. Such particles are localized in close association with the airway epithelium, and if they consist of low surface energy material, will be coated with an osmiophilic layer, consistent with surfactant. Particles are displaced into this position by surface and line tension forces exerted by the surfactant film at the air-aqueous interface. Particle displacement due to line tension is much greater for smaller particles in the micrometer range. The surface forces acting on the particles leave deep indentations on the epithelial cells. During the displacement process they may come into contact with airway macrophages in the mucous layer and/or dendritic cells situated in the airway epithelium. The smallest particles may even penetrate the mucosa to enter the interstitial compartment. In addition to altering the physical properties of particles, surfactant coatings reduce particle toxicity and enhance phagocytosis by opsonization. We speculate that surfactant acts as a primary defense barrier and plays a role in antigen presentation and elimination at the air-mucus interface of the airways. PMID- 10163350 TI - Aerosol bolus dispersion and aerosol-derived airway morphometry: assessment of lung pathology and response to therapy, Part 1. AB - review discusses the potential utility of two methods using inhaled aerosols to detect and diagnose lung disease and to evaluate the efficacy of therapy. Aerosol bolus dispersion measures convective gas mixing; aerosol-derived airway morphometry assesses the calibers of airway and airspaces. These two methods are discussed in terms of their ease of use (simplicity and acceptability) and current data regarding their validity, reproducibility, specificity, sensitivity, and detection of lung improvement with therapy. Part 1 of this review focuses upon aerosol bolus dispersion; Part 2(1) focuses upon aerosol-derived airway morphometry. Aerosol bolus dispersion has many features that make it clinically attractive. It is simple to administer and patients can successfully perform the maneuvers. It detects known alterations in the lungs. It is reproducible and has high specificity and sensitivity. However, every lung disease or condition known to be detected by aerosol bolus dispersion is also detected by spirometery, maximal expiratory flow-volume curves, or another conventional lung function test. This, aerosol bolus dispersion appears best reserved as a specialized method to supplement conventional lung function tests and to characterize convective gas transport. PMID- 10163351 TI - Effect of inhalation flow rate on the dosing characteristics of dry powder inhaler (DPI) and metered dose inhaler (MDI) products. AB - Both the dose delivered from the device and the particle size of the medication are important parameters for inhalation products because they influence the amount of drug that is delivered to the patient's lung. The inspiratory flow rate may vary from dose to dose in a given patient and between patients. The Marple Miller Cascade Impactor, a new multistage inertial impactor that operates at two flow rates (30 and 60 liters/min) with comparable particle size cut-offs, provides a means to study the effect of inhalation flow rate on the particle size distributions of inhalation products. The medication delivery, mass median aerodynamic diameter (MMAD), and fine particle mass were determined, in a randomized fashion, for albuterol, beclomethasone, budesonide, and terbutaline in both metered dose inhaler (MDI) and dry powder inhaler (DPI) products as a function of flow rate. In all cases, independent of drug or device used, the MDI products had a more reproducible respirable dose than the breath-actuated DPI products tested as a function of inhalation flow rate. PMID- 10163352 TI - The effect of pulmonary-delivered insulin on blood glucose levels using two nebulizer systems. PMID- 10163353 TI - Lack of desensitization to aerosol pentamidine with long-term use. AB - OBJECTIVE: To assess whether long-term exposure to aerosol pentamidine (AP) results in desensitization. STUDY DESIGN: Phase I-A retrospective, two group comparative study. Phase II-A prospective intervention study. METHODS: Patients were selected from a 5-year database of 1200 individuals infected with the human immunodeficiency virus (HIV) who received AP as prophylaxis for Pneumocystis carinii pneumonia (PCP). In phase I, serial pre- and post-AP spirometry data of 33 subjects with significant bronchospasm on initial exposure to AP, who thus received aerosol salbutamol (AS) as regular pre-AP premedication for over 18 months, were compared to 33 matched controls who did not use AS. In phase II, 13 of the original group of 33 patients who required regular AS consented to a follow-up AP treatment without AS premedication to examine the effects of discontinuing AS premedication. RESULTS: Phase I: on their initial AP treatment without AS premedication, the drop in mean FVC, FEV1, and FEV1/FVC values post-AP therapy was significantly lower for the AS group compared to the control group. The mean FEV1/FVC value for the AS group was 84% pre-AP and dropped to 75% post AP therapy. For the control group the corresponding FEV1/FVC values were 83% (pre AP) and 79% (post-AP). After using AS as premedication for AP for 18 months, the AS group did not show any reduction in flow rates as the mean FEV1/FVC values were 77% (pre-AP) and 80% (post-AP). The values in the control group were 80 and 78%, respectively. In phase II, when the 13 subjects who needed regular AS premedication were exposed to AP without premedication with AS, the flow rates are reduced in the same magnitude as observed at initial exposure to AP. CONCLUSIONS: The results of this study show that the prevention of bronchospasm with AS premedication while receiving long-term AP administration is due to the bronchodilator effect of AS, as desensitization is not achieved after over 18 months of exposure. These findings support long-term regular premedication with AS in patients with documented AP-induced bronchospasm. PMID- 10163354 TI - A study of laser-based removal of polymethylmethacrylate bone cement. AB - Complications are often produced with the removal of bone cement from the femoral cavity in the treatment of a failed hip prosthesis. Apart from being slow and difficult the conventional process runs the risk of producing damage to the femur. Ultrasonic techniques have been suggested to achieve these ends but removal of the cement by this approach is not entirely easy. The alternative laser-based approach would seem to have significant advantages over conventional techniques. The laser is capable of delivering energy to a specific region or surface under close control. The choice of laser is determined by its ability to ablate the cement and the ease with which it can be delivered to the base of the femur cavity. This paper examines several laser wavelengths: CO2 (10.6 microns), excimer (248 nm), Hol:YAG (2.12 microns), and presents polymethylmethacrylate (PMMA) vaporization thresholds for each laser. PMID- 10163355 TI - First metatarsophalangeal joint arthroplasties in the Commonwealth of Virginia. AB - This retrospective analysis of arthroplasty of the first metatarsophalangeal joint documents the incidence of surgery as well as the selection of the commercially available implants. During a 1-year period, 1994, arthroplasties were performed in 47 of the 1.7 million subscribers to Trigon Blue Cross Blue Shield of Virginia. Women received the majority of the arthroplasties (83%). Of the 47 cases, the silicone implant was predominantly used (83%). The most common indications for arthroplasty were hallux valgus (30%) and hallux rigidus (28%). Podiatrists performed 79% of the procedures, while orthopedic surgeons performed the remaining 21% of the cases. A prospective study is needed that will assess the long-term performance of the different implants. PMID- 10163356 TI - Wound cleansing by irrigation for implant surgery. AB - Wound irrigation is an adjunct to all implant surgeries involving surgical incisions or arthroplasties. An understanding of the physics of wound irrigation provides a scientific basis for recommending wound irrigation systems for implant surgery. When inserting implants through surgical incisions, a low-pressure irrigation system is recommended for removing blood from the wound surface. In contrast, high-pressure irrigation systems are indicated to cleanse the intramedullary canal before cemented arthroplasty. With the advent of static and dynamic pressure transducers, irrigation systems can now be specifically designed to achieve these goals. PMID- 10163357 TI - Evolution of powered surgical instruments. AB - The history of powered surgical instruments has paralleled their need in surgery, particularly surgery involving hard tissue like bone or teeth. This development was of great importance, as the sophistication of procedures became more demanding, requiring the use of implants. The fields of neurosurgery, orthopaedics, otology, and dentistry have all played key roles in the development of the high-powered surgical instruments that are now used in every surgical and dental subspecialty. Power modalities that include pneumatic and electric sources along with the development of interchangeable accessories have revolutionized the surgical field, making procedures both safer and faster. Many physicians, dentists, and companies continue to contribute to this exciting and rapidly evolving industry. PMID- 10163358 TI - New instruments, bone liners, and tray for finger joint arthroplasty. AB - Titanium circumferential grommets have been developed for finger joint arthroplasty that fit on the base of the silicone implant stems to protect the flexible hinge from tearing and fracture. To facilitate grommet insertion, new intramedullary bone rasps have been devised with a reverse cutting tooth pattern, an extended shaft for an improved view of the surgical field, and a redesigned cutting head to allow for grommet insertion. Surgical accessibility and ease of recognition have been facilitated by the development of color-coded sizers. All of the instruments necessary for finger joint surgery are available in a molded tray that has also been redesigned with a transparent lid and clearly labeled compartments for accurate determination of instruments and implant sizers. PMID- 10163359 TI - An overview of first metatarsophalangeal joint implant arthroplasty. AB - The metatarsophalangeal joint of the great toe often requires an arthroplasty to correct joint disease and pain. Today, joint replacement systems are combinations of components manufactured to optimize biological ingrowth, mechanical interlock, press fit, and cementing. Three different types of arthroplasties are available to foot surgeons: the double stem hinged silicone implant, the two-component joint mimicking implant, and a hemi-implant available for the phalanx. No comprehensive studies on very large populations have been conducted to accurately evaluate the beneficial long-term effects of these implants. This review article describes the development of the toe arthroplasty, details the commercially available implants, and addresses the advantages and adverse effects of each implant. PMID- 10163360 TI - Passive surveillance of heart valve devices: Bjork-Shiley outlet strut fracture rates. AB - The Bjork-Shiley Convexo-Concave heart valve has a mechanical failure mode called outlet strut fracture (OSF). Previous analyses have found that the hazard function for OSF is constant over time. This article uses the valve manufacturers implant database to examine the shape of the hazard function over time, employing a previously developed model to impute patient survival times. Decisions about patient management (e.g., elective explant) are based on projecting this risk into the future. An analysis that incorporates the decrement of patients at risk due to death and explant provides estimates of the actual occurrences of OSF over calendar time. PMID- 10163361 TI - The histologic features of the interfacial membrane of intramedullary nails. AB - Thirty-six interfacial membranes collected at the time of removal of intramedullary L316 stainless steel nails were studied histologically. The membranes consisted of bland fibrous tissue in a minority of cases. Most often, the nails were enclosed within a synovial-like membrane. Palisading macrophages and fibroblasts abutted on the metallic surface of the nails. Foreign body giant celled granulomas were scattered in the midzone of the membranes, mono- and polykaryonic macrophages having phagocytozed small metallic particles, necrotic bony debris, and, sometimes, lipidic compounds. Aggregates of hemosiderin containing macrophages occasionally marked the sites of previous hemorrhages. When present in the retrieved specimen, the bone underlying the membrane was undergoing remodeling. Interfacial motion, consequent on dissimilar stiffness of the bone and nail, as well as deposition of metallic and bony debris, are likely responsible for the formation of the synovial-like interfacial membrane. PMID- 10163362 TI - Titanium metal release after posterior cervical spine plate placement in a canine model. AB - The local tissue concentration of released titanium from Ti-6Al-4V posterior cervical spine plates in canines was determined using inductively coupled plasma atomic emission spectroscopy. The plates were also evaluated for percentage of surface area damage. The highest titanium levels (> 100 ppm dry weight) and most severe surface damage were associated with screw-plate interfaces. A model to explain the metal release mechanisms was proposed, consisting of a combination of fretting wear, diffusion through the passive oxide layer, and dissolution of this layer. PMID- 10163363 TI - A new hypothesis of tumorigenesis induced by biomaterials: inhibitory potentials of intercellular communication play an important role on the tumor-promotion stage. AB - A possible mechanism of tumorigenesis induced by the polyetherurethanes (PEUs) is clarified as follows: the tumor-promoting activities of the PEUs were stronger than the initiating activities; the promotion was facilitated by the polyether soft segment moiety such as poly (tetramethylene oxide) (PTMO), resulting in the inhibition of the gap-junctional intercellular communication; this inhibition was caused by leachable oligomers, degradation, and direct cell/material interaction. On the basis of our recent studies, we also propose a new hypothesis that inhibitory potentials of the intercellular communication play an important role on the tumor-promoting stage in various biomaterials. PMID- 10163364 TI - Studies on the tumor-promoting activities of additives in biomaterials: inhibition of metabolic cooperation by additives such as pigments and phenolic antioxidants. AB - The inhibitory activities on the intercellular gap-junctional communication were investigated using the V79 metabolic cooperation (MC) assay for the detection of tumor-promoting activities of additives such as pigments and phenolic antioxidants. Among six pigments, four chemicals showed inhibitory activities. The inhibitory potencies were ranked in the following order: sudan I > purple 201 > blue 204 > green 202. Sudan I and purple 201 showed stronger inhibitory activities than lithocholic acid, which is known to be a tumor promotor. However, quinizarine and red 225 did not inhibit at any concentration. Relating to eight phenolic antioxidants, four chemicals also showed inhibitory activities. Combining the present findings with previous ones, there are many factors that have tumor-promoting activities via inhibitory action on gap-junctional intercellular communication in biomaterials. PMID- 10163365 TI - Studies on the tumor-promoting activity of polyethylene: inhibitory activity of metabolic cooperation of polyethylene films containing an antioxidant. AB - Tumor-promoting activity, inhibitory activity on the gap-junctional intercellular communication of polyethylene (PE) film containing a model antioxidant, 2,2' methylene-bis(4-methyl-6-tert-butylphenol) (MBMBP), at various amounts was assessed by V79 metabolic cooperation (MC) assay. The extracts prepared from PE film containing MBMBP showed the inhibitory activities and the potencies of the inhibitory activities depended on the amount of MBMBP involved in the film, whereas the extract prepared from MBMBP-free PE film did not show any inhibitory activities. However, the inhibitory activities were observed when MC assay was carried out on the surface of the MBMBP-free film. These findings indicate that tumor-promoting activity of PE film is influenced by the surface property of the film as well as by amount and kind of additives incorporated. PMID- 10163366 TI - Reduction in tumor formation on polyethylene by collagen immobilization. AB - After surface modification with collagen immobilization through covalent binding, porous polyethylene pieces were implanted subcutaneously into the back of rats for 1 year and the tumorigenesis-reducing effect was examined. In the virgin pieces without collagen immobilization, tumors were observed in 11 out of 24 pieces implanted (45.8%). On the other hand, in the collagen immobilized pieces a tumor was found only in one of 24 implanted pieces (4.2%). These results suggest that immobilization of collagen on the surface of an artificial material through covalent binding is very effective for a reduction of tumor formation. PMID- 10163367 TI - The importance of being authorized. AB - Medical device companies located outside the European Economic Area (EEA) and without subsidiaries in the EEA will need to designate authorized representatives to perform certain duties under the European medical device Directives. The duties and responsibilities of those representatives should be clearly understood by medical device companies and prospective authorized representatives before any designation contract is signed. This article will discuss the role of the authorized representative as specified in the published Directives and as defined in the proposed European Directive on in vitro diagnostic medical devices. PMID- 10163368 TI - Advances in medical packaging. AB - The specialist medical packaging sector is in a period of change. Product innovations, new manufacturing methods, and increasingly stringent demands are the features of today. Aside from the evolving requirements of medical device manufacturers, the driving forces for change are prompted by new packaging legislation, environmental pressures, and, above all, the need to maximize cost effectiveness. The adoption of new production processes and products looks set to increase. PMID- 10163369 TI - Surface analysis of packaging materials. Part I. AB - The surface composition and chemistry of medical device packaging can affect critical characteristics, such as biocompatibility, of the enclosed device. Seal and interface failure of packaging can threaten the long-term sterility of the devices it holds. Techniques to examine all these factors are introduced in Part I of this two-part article, with particular reference to adhesion failure and additive migration. PMID- 10163370 TI - EC declaration of conformity. AB - The CE-marking procedure requires that manufacturers draw up a written declaration of conformity before placing their products on the market. However, some companies do not realize that this is a requirement for all devices. Also, there is no detailed information concerning the contents and format of the EC declaration of conformity in the medical device Directives or in EC guidance documentation. This article will discuss some important aspects of the EC declaration of conformity and some of the guidance that is available on its contents and format. PMID- 10163371 TI - Polymeric membranes. A review of applications. AB - The applications of polymeric membranes are varied and have developed in recent years to provide sophisticated filtration devices for the medical industry. This article presents a review of the uses of polymeric ultrafiltration and microfiltration membranes in health care. It focuses on three main areas: hydrophilic, hydrophobic, and diagnostic membrane applications. PMID- 10163372 TI - Developing safety-critical software. AB - The role of safety-critical software in the development of medical devices is becoming increasingly important and ever more exacting demands are being made of software developers. This article considers safety issues and a software development life-cycle based on the safety life-cycle described in IEC 1508, "Safety-Related Systems: Functional Safety." It identifies relevant standards, both emerging and published, and provides guidance on methods that could be used to meet those standards. PMID- 10163373 TI - Life-span indicator for resterilizable plastic products. AB - Disposable medical products have obvious advantages for users, in particular, assured sterility. Yet, one-time use creates large amounts of waste that cannot easily be reprocessed. Despite this, resterilizable products are not common, principally because of problems in monitoring the level of resterilization. This article suggests a solution in the form of an indicator that changes colour according to the number of sterilization cycles it undergoes. PMID- 10163374 TI - Surface analysis of packaging materials. Part II. AB - The surfaces of medical device packaging can affect critical characteristics of the enclosed devices, such as biocompatibility and sterility. Techniques to evaluate surface modification and contamination in packaging applications are described in the second part of this two-part article. PMID- 10163375 TI - Documenting outcomes of wound care. PMID- 10163376 TI - Establishing a value for your services. PMID- 10163377 TI - Growth hormones: how to decide when they are appropriate. PMID- 10163378 TI - Planning, implementation, and process monitoring for prehospital 12-lead ECG diagnostic programs. AB - Prehospital 12-lead electrocardiographic (ECG) diagnostic strategies have been proven feasible and effective, provided they are designed and implemented properly. The authors of this communication have expended considerable time and effort in determining appropriate planning, implementation, and process monitoring necessary for successful implementation of a variety of prehospital diagnostic strategies. Many of these issues may not be obvious to an emergency medical services (EMS) director initiating a 12-lead ECG program. This level of attention to protocol development, education, training, inservice education, coordination of the health-care community, objective program assessment, monitoring and continuous quality improvement can serve as a model for other diagnostic EMS programs that may develop as an expanded role for EMS. PMID- 10163380 TI - Epidemiology of pediatric EMS practice: a multistate analysis. AB - OBJECTIVE: To describe the epidemiology of pediatric emergency medical services (EMS) practice in a large patient population from several geographic areas. DESIGN: Retrospective computer analysis of EMS databases from four states using a common data set and analysis system. SETTING: Pennsylvania, Tennessee, Mississippi, and Nevada (except Clark County), 1990 through 1992. METHODS: All patient-care reports of patients 14 years old and younger were extracted from the EMS databases and analyzed for the following factors: age, gender, date, elapsed prehospital times, incident type, mechanism of injury, call disposition, illness or injuries encountered, severity of illness/injury (by abnormal vital signs), and basic life support (BLS) and advanced life support (ALS) treatment delivered. RESULTS: A total of 1,512,907 patient care reports were reviewed. Those of 61,132 children were extracted for analysis. These children comprised about 4% of prehospital responses. Male subjects predominated (56%), and children aged 7 through 14 years represented 46% of cases. Most calls occurred in the evening and daylight hours. Children were transported by ambulance in 89% of cases, and care was refused in 7.7%. Mean response time was 9 +/- 16 minutes, mean scene time 12 +/- 14 minutes, and mean transport time 14 +/- 20 minutes. Traumatic incidents predominated at 42%, with motor vehicle accidents and falls the most common mechanisms. Blunt injuries accounted for 94% of trauma, whereas respiratory problems, seizures, and poisoning/overdose were the most common medical problems. Vital signs were obtained in 56% of cases. Abnormal vital signs were noted in 21% of these, and the presumptive causes were similar in distribution to those of the general population, with the addition of cardiac arrest. The most commonly used treatments were spinal immobilization, oxygen administration, intravenous access and several ALS medications. An ALS capability was available in more than half the runs, but ALS treatment was delivered in only 14% of those cases. Outcome data were not available. CONCLUSION: This multistate analysis of pediatric EMS epidemiology confirms findings reported in smaller regional studies, with several exceptions. Excessive scene times were not noted. Few children had serious disorders as evidenced by abnormal vital signs. An ALS treatment, when available, was used infrequently. These findings have implications for EMS planners and educators. PMID- 10163379 TI - The 1994 Northridge earthquake disaster response: the local emergency medical services agency experience. AB - INTRODUCTION: This paper describes the 1994 Northridge earthquake experience of the local emergency medical services (EMS) agency. Discussed are means that should improve future local agency disaster responses. METHODS: Data reported are descriptive and were collected from multiple independent sources, and can be reviewed publicly and confirmed. Validated data collected during the disaster by the Local EMS Agency also are reported. RESULTS: The experience of the Los Angeles County EMS Agency was similar to that of earthquake disasters previously reported. Communication systems, water, food, shelter, sanitation means, power sources, and medical supplies were resources needed early in the disaster. Urban Search and Rescue Teams and Disaster Medical Assistance Teams were important elements in the response to the Northridge earthquake. The acute phase of the disaster ended within 48 to 72 hours and public health then became the predominant health-care issue. Locating community food and water supplies near shelters, providing transportation to medical care, and public-health visits to shelter locations helped prevent the development of long-term park encampments. An incident command system for the field, hospitals, and government responders was necessary for an organized response to the disaster. CONCLUSION: Disaster preparedness, multiple forms of reliable communication, rapid mobilization of resources, and knowledge of available state and federal resources are necessary for a disaster response by a local EMS agency. PMID- 10163382 TI - Emergency medical vehicle collisions in an urban system. AB - INTRODUCTION: Emergency medical services collisions (EMVCs) are a largely unexplored area of emergency medical services (EMS) research. Factors that might contribute to an EMVC are numerous and include use of warning lights and siren (WL&S). Few of these factors have been evaluated scientifically. Similarly, the incidence and severity of EMVCs is poorly documented in the literature. This study sought to define the incidence and severity of, and where possible, identify any contributing factors to EMVCs in a large urban system. METHODS: Retrospective study of all collisions involving vehicles assigned to the EMS Division of the Houston Fire Department in calendar year 1993. Fifty-one ambulances were operational 24 hours per day during calendar year 1993. Houston EMS received 150,000 requests for assistance, made 180,000 vehicular responses, and accrued 2,651,760 miles in 1993. RESULTS: Eighty-six EMVCs were identified during the study period. The gross incidence rate was therefore 3.2 EMVC/100,000 miles driven or 4.8 collisions/10,000 responses. Of the 86 EMVCs, 74 (86%) files were complete and available for evaluation. Major collisions, determined according to injuries or vehicular damage, accounted for 10.8% of all EMVCs. There were 17 persons transported to hospitals from EMS collisions, yielding an injury incidence of 0.64 injuries/100,000 miles driven or 0.94 injuries/10,000 responses. There were no fatalities. The majority of collisions (85.1%) occurred at some site other than an intersection. There was no statistical association between occurrence at an intersection and severity, day versus night, weekend versus weekday, presence or absence of precipitation, or use of WL & S versus severity of collision. Drivers with a history of previous EMVCs were involved in 33% of all collisions. The presence of prior EMVCs was associated (p < 0.001) with the number of persons transported from the collision to a local hospital. Five drivers, all with previous EMVCs, accounted for 88.2% (15/17) of all injuries. CONCLUSIONS: A few drivers with previous EMVCs account for a disproportionate number of EMVCs and nearly 90% of all injuries. This risk factor -history of previous EMVC--has not been reported in the EMS literature. It is postulated that this factor ultimately will prove to be the major determinant of EMVCs. Data collection of EMS collisions needs to be standardized and a proposed collection tool is provided. PMID- 10163381 TI - Patient care and daily stress among emergency medical technicians. AB - INTRODUCTION: There is conflicting research regarding the extent to which patient care is a source of stress for emergency medical technicians (EMTs). Some research indicates that it is important, whereas other studies suggest that it takes a "back seat" to administrative and organizational problems. This study sought to explore this issue further by investigating the relationship between caring for patients, daily workday stress, and daily non-workday stress among EMTs. METHODS: All EMTs employed by East Baton Rouge Parish Emergency Medical Services were eligible for participation. After the study was described, subjects completed a demographic information sheet and informed consent was obtained. Participants then completed 30 days of monitoring with a standardized measure of daily stress (the Daily Stress Inventory) and a measure of patient care stress designed for use in this study (Emergency Call Questionnaire). RESULTS: A very large portion of the variance in the EMTs' overall daily workday stress was associated with patient care (r = 0.677, p < 0.001). Additionally, patient care stress on workdays significantly predicted overall daily stress on the following nonworkday (i.e., postworkday) (r = 0.633, p < 0.001). Finally, EMTs who had stressful pre-workdays rated their patient care as more stressful on the following workday (r = 0.512, p < 0.01). CONCLUSIONS: Results suggest that patient care is a critical factor in daily stress among EMTs, both on workdays and post-workdays, providing preliminary evidence for a carryover effect. Evidence also suggests that stress on the day before work may influence EMTs' perceptions of their patients on workdays. PMID- 10163383 TI - Into the fray: integration of emergency medical services and special weapons and tactics (SWAT) teams. AB - INTRODUCTION: The purpose of this study was to determine current experience and training of emergency medical support personnel for special weapons and tactics (SWAT) teams in North America. METHODS: This cross-sectional, epidemiologic survey was sent to SWAT unit commanders from the 200 largest metropolitan areas. Questions included basic demographics, specialized training of emergency medical services (EMS) personnel, and where such personnel are deployed during tactical operations. Unit commanders also were asked to estimate the number and type of injuries sustained during tactical operations and to list any recommendations to improve the EMS response. RESULTS: A total of 150 surveys was completed, for a response rate of 75%. The most common medical support (69%) was a civilian ambulance on standby at a predesignated location. Ninety-four percent of these prehospital care providers had no specialized training, and could not enter an area that was not secured tactically. Police officers with first aid or EMT training comprised the next largest group of medical support. Overall, 31% of SWAT commanders depended on remote EMS dispatch by radio to the scene when injuries occurred. Thirty-eight percent of respondents reported a significant injury had occurred during their tactical operations within the past 24 months. Common injuries included gunshot wounds, chemical exposure, and fractures. However, 78% (117/150) of respondents did not have a medical director, and 23% (35/150) of teams did not have an EMS preplan or protocol. CONCLUSION: The results suggest a need for established EMS protocols, medical direction, and specialized tactical medical training, especially in large metropolitan areas. PMID- 10163384 TI - An analysis of Michigan EMT licensure examination results as a predictor of paramedic licensure examination success. AB - INTRODUCTION: Predicting paramedic candidate performance on the written licensure examination is of considerable importance to educators, students, employers, and state regulators. There has been little investigation of the available statistical data regarding examinee pass rate and examination score. No studies have measured an examinee's sequential success pattern on the basic emergency medical technician (EMT) or paramedic examinations. There has been no analysis of the relationship between the number of examinations required for successful paramedic licensure and examination score. OBJECTIVE: The purpose of this study was to determine the frequency with which paramedic licensure examinees successfully pass the State of Michigan written examination on the first or subsequent attempts; to determine the frequency with which the paramedic examinees pass the prerequisite basic EMT licensure examination; to determine whether the frequency of paramedic examination attempts is related to examination score; and to determine whether there is a relationship between successfully passing the basic EMT examination and successfully passing the paramedic examination. METHODS: A retrospective study of Michigan paramedic licensure examination results for 1994 was done on the basis of a review of reports prepared for Michigan Department of Public Health Emergency Medical Services (MDPH-EMS) by Professional Examination Services. Analysis of paramedic examination score and the number of examination attempts is correlated to EMT score and number of attempts required to pass. Success in the first or subsequent paramedic examinations is correlated to paramedic score, and success in passing the first or subsequent EMT examination is then related to success in passing the paramedic examination. RESULTS: Paramedic examinees (n = 869) generated a 72.1% pass rate in 1994 (mean score = 82.2%). The minimum passing score is 80%. The average score for examinees who passed (n = 627) was 86.2% (95% confidence interval [CI] = 85.8-86.6%); those who failed (n = 242) averaged 71.9% (95% CI = 71.1-72.6%). Paramedic examinees successful on the first attempt (n = 500) had higher average scores (mean = 87.1%; 95% CI = 86.7-87.5%) than did those who required multiple attempts (mean = 82.8%; 95% CI = 82.3-83.3%; n = 127). A total of 702 (90.5%) paramedic examinees passed the EMT examination on the first attempt. Examinees who passed the EMT examination the first time averaged fewer attempts on the paramedic examination (mean 1.5; 95% CI = 1.4-1.6) than did those who required multiple EMT examinations (mean 2.3; 95% CI = 2.0-2.6). Paramedic examinees passing the EMT examination in one attempt had higher average paramedic scores (82.6%; 95% CI = 82.1-83.2%) than those needing multiple EMT attempts (75.5%; 95% CI = 73.4-77.5%). CONCLUSION: Paramedic examinees who pass their EMT licensure examination on the first attempt have a significantly better chance of passing the paramedic licensure examination. Paramedic licensure examinees who pass the paramedic examination on the first attempt score significantly higher than do examinees who require additional attempts. Paramedic programs should incorporate EMT examination performance into their student selection criteria. Further study of variables predictive of success is needed. PMID- 10163385 TI - Does ambulance crew size affect on-scene time or number of prehospital interventions? AB - INTRODUCTION: While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care. HYPOTHESIS: Two-person EMS crews perform the same number and types of interventions as three person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews. METHODS: Data for the two most common advanced life support calls in this system--seizures and chest pains--were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, two-person EMS crews responded to seizure calls; two person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calls. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls. RESULTS: One hundred twenty six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0 +/- 4.2 minutes for three-person crews and 19.4 +/- 8.3 minutes for two-person crews (p < 0.001). Mean on-scene time for patients with chest pain was 13.6 +/- 4.9 minutes for three-person crews, and 15.4 +/- 3.2 minutes for two-person crews assisted by fire department personnel (p > 0.05). CONCLUSION: Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer on-scene times than three-person EMS crews. PMID- 10163387 TI - Prehospital use of a prototype esophageal detection device: a word of caution! AB - OBJECTIVE: To determine the effectiveness of a prototype esophageal detection device (EDD) during use in the prehospital setting. DESIGN/SETTING: Prospective convenience sample in a prehospital setting. POPULATION: Intubated adult patients. INTERVENTIONS: The study device was used to determine esophageal or endotracheal placement of endotracheal tubes in intubated patients. Clinical means were used to confirm tube location. A data sheet was completed for each patient. RESULTS: Of 105 uses of the device, 17 of 17 esophageal tubes were identified correctly (100% sensitivity). Sixty-five of 88 tracheal tubes were correctly identified (78% specificity). There was intermediate reinflation of the device on 13 of the 65 tracheal tubes. Five tests were indeterminate. There were no false negatives (negative predictive value 100%), but 18 false positives (positive predictive value 48%). CONCLUSION: This prototype EDD adequately identifies esophageally placed endotracheal tubes. Correct identification of endotracheally placed tubes was less sensitive. Much work needs to be done regarding the use of negative aspiration devices to identify placement of endotracheal tubes. PMID- 10163386 TI - Comparison of high-dose epinephrine versus standard-dose epinephrine in adult cardiac arrest in the prehospital setting. AB - OBJECTIVE: To compare the efficacy of high-dose epinephrine (HDE) with standard dose epinephrine (SDE) in the management of cardiac arrest in adults in the prehospital setting. HYPOTHESIS: The use of HDE will improve the outcome of adult patients in cardiac arrest. METHODS: In a general population of 700,000 persons, in a mixed geographical area of 2,200 square miles, a 12-month retrospective study of SDE and a 12-month prospective trial of HDE were conducted involving adult patients in cardiac arrest in the prehospital setting. Treatment was provided by paramedic-level clinicians. In the control group, patients were treated according to existing American Heart Association cardiac resuscitation guidelines using SDE (defined as 1.0 mg boluses to a maximum dose of 4 mg). In the test group, the same guidelines were revised to use HDE (defined as a rapid sequence of 5, 10, and 15 mg boluses to a total dose of 30 mg). RESULTS: The control group included 594 patients; the test group consisted of 580 patients. The overall survival rate to hospital admission in the control group was 14.5% (84 patients) and in the test group 15.3% (89 patients). The survival rate to hospital discharge in the control group was 4.9% (29 patients) versus 4.8% (28 patients) in the test group. For patients whose initial rhythms were ventricular fibrillation, survival to admission in the control group was 20.4% (39 patients) versus 24.4% (43 patients) in the test group. Survival to discharge for patients with ventricular fibrillation in the control group was 8.9% (17 patients) versus 10.8% (19 patients) in the test group. CONCLUSION: There was no statistically significant difference in overall rate of survival to hospital admission or discharge between patients treated with SDE and those treated with HDE, regardless of the initial rhythm. PMID- 10163388 TI - The relevance of the occult cervical spine controversy and mechanism of injury to prehospital protocols: a review of the issues and literature. PMID- 10163389 TI - Evaluation of agricultural rescue course by providers. AB - STUDY OBJECTIVE: To assess the characteristics of rural emergency medical services providers involved in the prehospital care of victims of agricultural injuries and determine which aspects of an agricultural rescue course were perceived as most useful. DESIGN: A questionnaire was sent to participants of a course designed for agricultural prehospital providers who had attended a farm accident rescue course between 1986 and 1993. SETTING: A rural referral center in central Wisconsin. PARTICIPANTS: The questionnaire was sent to all persons who had participated in the course. Respondents to the questionnaire characterized their service experience and rated the topic areas in usefulness and whether the subject should be included in future courses. RESULTS: A total of 459 surveys (44% of potential respondents) was returned. Of the respondents, 316 (74.4%) were men, and the mean age was 39.4 years. There were 247 (60.8%) who were volunteers, and an additional 126 (31%) were paid, on-call workers. There were 232 (56.4%) basic providers, and 365 (87.5%) were from a rural area. Many (n = 149; 36.9%) had not responded to farm accidents during the past year. Training course topics rated most useful were machinery extrication, tractor overturn, and enclosed space rescue. CONCLUSIONS: Respondents to an evaluation of an agricultural rescue course primarily were rural, basic providers. Future development of courses for emergency medical technicians involved in agriculture rescue must account for this level of training. Such courses should be short and modular with an emphasis on continuing education, practice, and focus on the identified needs of the participants. PMID- 10163390 TI - Gene therapy in Europe. PMID- 10163391 TI - Legal and ethical challenges in gene therapy. AB - This paper addresses implications of applying the ethical principle of justice to gene therapy. Regarding somatic cell gene therapy as a treatment of last resort for life-threatening or seriously disabling disorders may be inconsistent with subjecting therapy to the preliminary scientific and ethical scrutiny given to research proposals. Emergency care may justify disregarding legal conditions of care, and be governed by different ethical priorities than research. Excluding gene therapy for reasons of enhancement rather than cure is widely agreed, but cosmetic procedures are considered legitimate in private markets. Intergenerational justice is a principle that may justify concentrating therapy on conditions afflicting children rather than older patients. PMID- 10163393 TI - Gene therapy with physical methods of gene transfer. PMID- 10163392 TI - A rational approach to regulation of gene therapy in Canada. AB - Gene therapy offers prospects of dramatically improved treatments for and possibly true cures of previously intractable diseases, and has therefore attracted much public interest and hopeful expectation. At the same time, it involves new and exploratory techniques and potential risks to patients. The definition of a drug in the Canadian Food and Drugs Act clearly includes materials used to effect gene therapy and also the products of genetic manipulations. The regulatory framework in Canada is based on risk management. The potential hazards and benefits of gene therapy and similar interventions will be assessed for categorization according to risk and an appropriate level of control, with the additional principle of deriving positions that are harmonized with those of counterpart regulatory agencies. PMID- 10163394 TI - Microencapsulation--an alternative approach to gene therapy. AB - Non-autologous somatic gene therapy' is a novel approach to gene therapy which does not depend on genetic modification of the patient's own cells. Recombinant cell lines secreting a desired therapeutic gene product can be implanted into different patients requiring the same product replacement. Graft rejection is avoided by enclosing these cells in immuno-isolation devices whose permeability excludes the host's immune mediators but permits the transit of nutrients and recombinant gene products. The feasibility of this strategy is demonstrated by expression of recombinant human enzymes, hormones and coagulation factors from fibroblasts or myoblasts enclosed within alginate-poly-L-lysine-alginate microcapsules. Its clinical efficacy is demonstrated by the correction of pathological phenotypes in murine models of human endocrine and lysosomal storage diseases. Hence, this approach may lead to a potentially cost-effective method of gene-based therapy. PMID- 10163395 TI - Transfusion practice in a Canadian hospital. Use of a major European study of transfusion practice for comparison as a form of audit. AB - Blood transfusion practices in a Canadian hospital have been compared, as a form of audit, to those reported in a multi-hospital study in Europe, to identify possible deviations from desirable practice. Blood product use for four surgical procedures: laparatomic cholecystectomy, total hip replacement, coronary artery bypass graft (CABG) and abdominal aortic aneurysmectomy (AAA), was determined from this hospital's blood bank data base, and is compared to use for the same procedures in European hospitals. Blood product use here is less than in the majority of European centres, in respect of red cells for all four procedures and plasma for CABG and AAA. Platelet use in association with CABG and AAA is greater than the majority of European centres reporting data. As a consequence, platelet use here will be subjected to closer review. PMID- 10163396 TI - The Self-Help Clearinghouse of Metropolitan Toronto: reflections on seven years of survival and beyond. AB - In May of 1987, Health and Welfare Canada awarded the Self-Help Clearinghouse of Metropolitan Toronto a three-year demonstration grant. Today, the Toronto Clearinghouse remains the only free-standing self-help resource of its kind in Canada and is a registered charitable organization whose mandate is to facilitate the growth and development of self-help/mutual-aid groups, networks, and resources. This paper describes the unique Toronto Clearinghouse model which from its earliest beginnings has been a partnership between the self-help community and interested and supportive professionals. The success of this model stems from its strong grassroots origins, respect for a community empowerment approach, and focused goals and objectives. Using information gleaned from the archival history of the Toronto Clearinghouse and through a series of interviews with past and current members of the Clearinghouse board of directors, program staff, and local self-help group members, the paper explains the "roller coaster ride" which has characterized the history of the Clearinghouse to date. Finally, the paper illustrates that while the achievement of financial stability has been an ongoing challenge in the face of variable community and political support, the Toronto Clearinghouse is, today, a strong centre of self-help activity and promotion, involved in a unique exercise to determine the role that self-help can play as a strategic component of an overall health and social services system-and with every reason to be optimistic about its future. PMID- 10163397 TI - Self-help/mutual-aid clearinghouses and groups in Canada: recent developments. AB - This paper reports on recent developments in the self-help movement in Canada based on the findings of a country-wide survey of self-help clearinghouses and interviews with key informants. Among the outcomes of this survey are an estimate of the number of self-help groups in various communities in Canada as well as a presentation of current trends in the growth of these entities. The author also explores recent fiscal and policy trends in the Canadian context and discusses their impact on the development of self-help groups and clearinghouses in the country. PMID- 10163398 TI - Social support, support groups, and breast cancer: a literature review. AB - A review of medical, social science, and "grassroots" literature on support groups and breast cancer, this paper concerns the need among women living with breast cancer and their caregivers for more information on the efficacy of social support as a therapeutic intervention. The literature has been subdivided into reviews of articles dealing with professionally led support groups, community based support groups, support groups and survival, and support groups and psychological adjustment. PMID- 10163399 TI - Research on mutual aid and social support: progress and future directions. AB - Signs of progress in the study of mutual aid and social support include a greater emphasis on the collection of empirical data to evaluate program effects and to comprehend relations between professional and informal sources of aid, as well as a clearer delineation of concepts and creative integration of practices associated with mutual aid. Several directions for future research on support interventions are addressed, including the nature and timing of outcome measures, analyses of the optimal fit of participants to different intervention formats, and the need for research designs that yield information about the necessary and cost-effective components of support interventions. PMID- 10163400 TI - [Mutual aid as a complement to professional intervention]. AB - This paper aims to illustrate and emphasize the relevance of Frank Riessman's futurist new paradigm for human services which proposes a restructuring that enables those who ordinarily receive help to function as providers of help. Some of the best known mutual-aid programs are briefly presented, followed by a more detailed description of pilot projects which have used the mutual-aid principle with multi-problematic clientele. Most of these pilot projects took place in the province of Quebec and aimed at bridging the gap between public services and local communities by linking with informal support systems. Two specific modalities of mutual aid are discussed: pairings between clients and pairings between clients and natural helpers. The integration of mutual-aid strategies within clinical practice is not easy because of the important changes it requires of the professional both at the practical and the organizational level. PMID- 10163401 TI - Utilization Management. Whose job is it? PMID- 10163402 TI - Functional rehabilitation. A protocol for management of the lateral ankle sprain. PMID- 10163403 TI - Satisfaction measurement of rehabilitation services. Woodrow Wilson Rehabilitation Center works to get ahead of the game in client satisfaction. PMID- 10163404 TI - Minor traumatic brain injury: review of clinical data and appropriate evaluation and treatment. AB - The clinical entity of minor traumatic brain injury (MTBI) is secondary to signs and symptoms encompassing neuropathological, neurochemical, neurobehavioral, neuropsychological and behavioral deficits. The patients who suffer this disorder are often given little help, medically, secondary to issues regarding the perceived reality of the disorder. A few individuals deny the existence of MTBI. Some believe the symptom complex to be strictly functional, while others believe that spontaneous recovery will occur and no treatment is necessary. When discussing traumatic brain injury the descriptors, "mild, moderate, and severe," are used to describe the severity of the acute injury. These labels do not describe the severity of the sequelae nor are they indicative of the intensity of specific treatment. A clear understanding of MTBI, its sequelae and necessary treatment is imperative to insure timely intervention. Delay or lack of early intervention appears to be responsible for "persistent sequelae" in MTBI. This paper will describe various aspects of the etiology of MTBI, with recommended evaluation and treatment guidelines. A functional assessment scale specifically for persons with MTBI is also presented. Several case histories are included for illustration purposes. PMID- 10163406 TI - Health research: need for a methodological revolution? PMID- 10163405 TI - Experiences in C.D.T. testing. AB - The value of carbohydrate deficient transferrin (CDT) as the most direct and most accurate indicator of alcohol abuse has been amply demonstrated in the scientific literature. The CDT assay used by GIB Laboratories to assess serum samples for significant levels of alcohol abuse was validated using 184 clinically defined positive and 203 clinically defined negative specimens. Using a defined cutoff of significance and a special testing algorithm, GIB Laboratories has determined, in this study, that the sensitivity of the commercial CDT enzyme immunoassay (CDT EIA) is 88 percent, the specificity is greater than 99 percent, and the intra- and inter-run reproducibility is less than seven percent, about three times more precise than most confirmatory tests for CDT. Given the very low expected frequency of true physiological causes of non-specificity (less than one percent), the excellent specificity of the assay (in GIB Laboratories' experience), and the technical problems, time delays, and costs associated with all "confirmatory" technologies, it cannot be recommended that CDT confirmatory testing be performed, unless an individual laboratory experiences unacceptable specificity in its screening tests. It would appear that, performing CDT "confirmatory" testing when the specificity of the screening test is as high as this study has found it to be, can result in three probabilities: 1) an increase in the number of false negative results; 2) few corrections in the very small number of false positive results; and 3) in greater cost and delay for the laboratory's clients. PMID- 10163407 TI - Monitoring community response to malaria control using insecticide-impregnated bed nets, curtains and residual spray at Nsukka, Nigeria. AB - A project testing the efficacy of insecticide (permethrin)-impregnated bed nets, compared with impregnated door and window curtains, residual house spraying, and a control group was implemented in 12 village clusters in the Nsukka Local Government Area of Enugu State, Nigeria, using epidemiologic and entomologic indicators. The appropriate materials and services were given free to all families. During the first year of study, three monitoring exercises were carried out in a random selection of homes where children under 5 years of age resided. Information was collected on perceived effectiveness of the interventions, condition of nets and curtains, reasons for not sleeping under nets, and recall of steps required in caring for nets and curtains. Bed nets were perceived as more effective in reducing mosquito bites compared with the two other interventions. At the last monitoring period, which occurred a few weeks before a re-impregnation exercise, respondents also perceived bed nets to be most effective in preventing malaria. These findings coincided with epidemiologic evidence. Curtains, especially those at doors, were more likely to be torn and dirty than bed nets. Although holes would not reduce the effectiveness of the insecticide, they could reduce the 'beauty' of the curtains, a perceived benefit that initially attracted villagers to both curtains and nets. Bed net owners reported significantly less frequent use of other mosquito control measures in their homes than did members of the other groups. Finally, bed net users demonstrated increased knowledge of use and care steps than did those with curtains. These findings suggested a high level of social acceptability of bed nets, and point to the need to test their acceptability further under conditions where people would pay for nets and communities would manage distribution and re impregnation systems. PMID- 10163408 TI - Appropriateness of Hispanic print materials: a content analysis. AB - Hispanic women living in the US have a higher rate of later-stage diagnosis of breast cancer, thereby decreasing their chances of surviving the disease. Research shows print materials are more heavily relied on than any other medium to inform this population about early detection and treatment of the disease. Hispanics, moreover, are more likely to read English at below the fourth-grade level than the general US population and have a lower educational attainment than that of non-Hispanic whites. This paper discusses the results of a content analysis of 26 national print breast cancer educational artifacts distributed to Hispanic women. The purpose was to assess the linguistic appropriateness and cultural sensitivity of the materials in efforts to establish preliminary guidelines for the development of future materials. The author concluded that though many of the artifacts displayed elements of cultural competency, all 26 failed to include components essential to reaching and impacting the designated target audience. Even more significant was a survey of health clinics nationwide that determined the 26 print materials as the most heavily relied upon to provide Hispanic women with information on breast cancer. PMID- 10163409 TI - Telephone counseling for smoking cessation: rationales and meta-analytic review of evidence. AB - We review the various ways in which telephone counseling has been used in smoking cessation programs. Reactive approaches--help lines or crisis lines--attract only a small percentage of eligible smokers but are sensitive to promotional campaigns. While difficult to evaluate, they appear to be efficacious and useful as a public intervention for large populations. Proactive phone counseling has been used in a variety of ways. In 13 randomized trials, most showed significant short-term (3-6 month) effects, and four found substantial long-term differences between intervention and control conditions. A meta-analysis of proactive studies using a best-evidence synthesis confirmed a significant increase in cessation rates compared with control conditions [pooled odds ratios of 1.34 (1.19-1.51) and 1.20 (1.06-1.37) at short- and long-term follow-up, respectively]. Proactive phone counseling appeared most effective when used as the sole intervention modality or when augmenting programs initiated in hospital settings. Suggestions for further research and utilization are offered. PMID- 10163410 TI - Health and development: knowledge systems and local practice in rural Thailand. AB - The specific framing of health within a development context has implications for constructions of wellness and illness and how people react in times of ill health. In Thailand, recent national HIV/AIDS education-prevention campaigns commonly use topdown relay of public health information. This pattern replicates numerous development projects that aim to bring useful and beneficial knowledge to rural villagers. How villagers integrate this information depends, in part, on previous experiences with development programs in general and public health programs in particular. This paper considers the political economy of medical knowledge and multiple local health strategies in rural Northeast Thailand as a background to the contingent response to public health directives. PMID- 10163411 TI - Informal care for illness in rural southwest Uganda: the central role that women play. AB - In rural Uganda care for those who are ill tends to be home based because of inadequate and expensive health care facilities, lack of medication and poor staffing levels in health units. Research findings suggest that women are responsible for the bulk of caring activities. This paper questions the assumption that female informal carers are in a position to cope with illness episodes in the home. Data were collected from 54 female informants in a rural population in southwest Uganda. Supplementary data from in-depth interviews with survey participants and counsellors were also collected. Findings suggest that women are the main providers of informal care within the home. Many women, particularly in female-headed households, did not own or have direct access to the necessary finances to meet the family's health care needs as expected of them. Although relatives and friends were seen as a valuable resource, because of poor household proximity and financial constraints they were not always in a position to offer or provide assistance. The women also identified themselves as responsible for a variety of home and agricultural tasks; such activities were frequently disrupted by illness episodes. As women take on the additional burden of care for those with HIV/AIDS an inevitable conclusion is that their resources, both social and economic, will not be adequate. These data indicate the need for additional research and stress the importance of appropriate support and relief programs for those responsible for informal care. PMID- 10163413 TI - Combination antiretroviral therapy in HIV infection. An economic perspective. PMID- 10163412 TI - Current controversies in the treatment of HIV infection and AIDS. An economic perspective. PMID- 10163414 TI - Economic evaluation in healthcare. A brief history and future directions. AB - Over the last decade there has been tremendous interest in economic evaluations of healthcare programmes, especially in the pharmaceutical field. Economic evaluations started about 30 years ago as rather crude analyses, in which the value of improved health was measured in terms of increased labour production. Now, more refined methods are available to measure health changes in terms of quality-adjusted life-years gained or willingness to pay. It is important to continue this development, and major fields for future work include the incorporation of quality-of-life measurements into economic evaluations and the linking of cost-effectiveness and cost-benefit analyses into a unified framework of economic evaluation. How to incorporate distributional issues is another important area. Finally, it seems crucial to further explore the link between economic evaluation and decision making, since the purpose of economic evaluations is to affect decision making. PMID- 10163415 TI - The expanding role of pharmacy and therapeutics committees. The 1990s and beyond. AB - Traditionally, pharmacy and therapeutics (P&T) committees have been responsible for overseeing the drug use process, using formulary systems to control drug costs. Primarily, these committees act in an advisory capacity as policy recommending bodies within healthcare systems, for the specific purpose of promoting rational drug therapy. Methodologies utilised by these committees include drug use evaluation, medical staff education, continuous quality improvement, formulary restriction and therapeutic interchange. Future roles of P&T committees will include the evaluation of clinical outcomes information, including quality-of-life issues, to establish policies governing the use of drugs at all levels and in all types of healthcare. PMID- 10163417 TI - The cost effectiveness of diclofenac plus misoprostol compared with diclofenac monotherapy in patients with rheumatoid arthritis. AB - The objective of our study was to estimate the cost effectiveness of treatment with a fixed-dose combination of diclofenac and misoprostol compared with diclofenac monotherapy in the prevention of nonsteroidal anti-inflammatory drug (NSAID)-induced ulcers in rheumatoid arthritis (RA) patients. A model was used to incorporate estimates of costs, incidence of ulcers and their complications, death rates and the efficacy of misoprostol. The costs per ulcer-free period gained and costs per additional survivor were calculated. Cost effectiveness was calculated for the treatment of all RA patients, and of risk groups only. All costs were measured in 1995 Netherlands guilders (NLG; exchange rate at the time of the study: NLG1 = $US0.60). The analysis showed that if 100 RA patients receive 3 months of treatment with diclofenac plus misoprostol, instead of diclofenac alone, this will lead to overall additional costs of NLG773, while 0.82 symptomatic ulcers and 0.019 deaths will be prevented. If misoprostol is given only to patients at high risk for NSAID-induced ulcer, cost savings will occur instead of additional costs. Univariate sensitivity analysis showed that the outcomes are sensitive to changes in: (i) the percentage of ulcers treated in the ambulatory setting; (ii) the price difference between diclofenac and the fixed-dose diclofenac-misoprostol combination; (iii) the percentage of ulcers with complications; and (iv) the efficacy of misoprostol. In conclusion, it can be stated that treatment with diclofenac-misoprostol is cost saving in RA patients at high risk for NSAID-induced ulcers. For RA patients in general, the cost-effectiveness of this intervention compares favourably with that of other prophylactic treatments. PMID- 10163416 TI - Cost-effective prophylaxis of surgical infections. AB - There are few formal pharmacoeconomic studies of antibacterial prophylaxis in surgery. An important reason for this is that such prophylaxis is difficult to study, because extremely large patient samples are needed to demonstrate differences or equalities with reasonable statistical power. When the cost effectiveness of various regimens is evaluated, indirect methods must often be used. Clearly, the ideal prophylactic regimen, both clinically and economically, is one that is easy to administer, has a low acquisition cost, can be given as a single dose and provides maximal protection against postoperative infections. However, if and when such a regimen is identified, its universal acceptance and use might have negative ecological consequences (e.g. the selection of resistant organisms in the hospital environment). Thus, the search for the ideal prophylactic regimen must be a continuous process. PMID- 10163418 TI - Hypnotics. Drug selection by means of the System of Objectified Judgement Analysis (SOJA) method. AB - Selection of hypnotics for drug formularies in The Netherlands, France and the UK is made by means of the System of Objectified Judgement Analysis (SOJA) method. The following criteria are included in the method: clinical efficacy (maximal 300 points), adverse effects (250 points), clinical documentation (150 points), cost (120 points), pharmacokinetic properties (80 points), toxicity (50 points), drug interactions (30 points) and the number of tablet strengths available (20 points). In all 3 countries, zolpidem, zopiclone and temazepam showed the highest score, followed by lormetazepam. High scores favour inclusion in formularies. Nitrazepam and loprazolam scored 75 to 130 points less than the top 3, and flunitrazepam shows the lowest score (119 to 183 points less than zolpidem, zopiclone and temazepam). Therefore, the first 3 (or 4) hypnotics are most suitable for formulary inclusion while the others are not. PMID- 10163419 TI - Cefpodoxime proxetil. An appraisal of its use in antibacterial cost-containment programmes, as stepdown and abbreviated therapy in respiratory tract infections. AB - Cefpodoxime proxetil is an orally administered prodrug which is converted in vivo to the third generation cephalosporin cefpodoxime. Cefpodoxime has a similar spectrum of antibacterial activity to the parenteral cephalosporins ceftriaxone and cefotaxime and a long elimination half-life, which allows once- or twice daily administration. Cefpodoxime proxetil has proven efficacy in the treatment of community-acquired pneumonia and upper respiratory tract, skin and soft tissue and urinary tract infections. It has been evaluated for use in cost-containment programmes, as stepdown (parenteral-to-oral conversion) therapy in the treatment of community-acquired pneumonia and as abbreviated therapy in upper respiratory tract infections. Substituting oral for parenteral therapy can achieve considerable savings (in acquisition, delivery and labour costs). Moreover, oral administration has advantages for the patient in terms of comfort and mobility, avoids the hazards of parenteral delivery and may allow earlier discharge from hospital, or even allow home treatment from the outset in low-risk patients. As hospitalisation is usually the major cost component in treating serious infections, considerable savings can be made in this way. Pharmacy-driven stepdown programmes in 2 US hospitals have achieved cost savings by targeting patients with community-acquired pneumonia for early conversion from intravenous ceftriaxone therapy to oral cefpodoxime proxetil. Costs were compared with those from a control group of patients who continued to receive intravenous ceftriaxone until physicians deemed that oral therapy (with various agents) was appropriate. In one study, duration of parenteral therapy in the cefpodoxime proxetil group was reduced from 6.18 to 3.82 days and duration of hospitalisation was reduced from 10.06 to 6.23 days (p < 0.02), with corresponding hospitalisation cost reductions of $US7300 per patient. However, clinical trial data relating to the efficacy of cefpodoxime proxetil as stepdown therapy in patients initially requiring parenteral antibacterials are lacking. Abbreviated (4-to 7-day) cephalosporin regimens appear to be as effective as traditional 10-day penicillin regimens in the treatment of upper respiratory tract infections. Short regimens may improve patient compliance and tolerability, thereby reducing the costs of adverse effects and treatment failures. Data from preliminary clinical studies suggest that a 5-day course of cefpodoxime proxetil is as effective as an 8-day course of amoxicillin/clavulanic acid in treating either acute otitis media or sinusitis, and as effective as a 10-day course of amoxicillin/ clavulanic acid and more effective than a 10-day course of phenoxymethyl- penicillin in the treatment of pharyngotonsillitis. Cefpodoxime proxetil tended to be better tolerated and was associated with better compliance than penicillin-based regimens. Indeed, a pharmacoeconomic study showed that a 10-day regimen of cefpodoxime proxetil was associated with lower costs for treating adverse effects and treatment failures than a 10-day regimen of amoxicillin/clavulanic acid in the treatment of acute otitis media in children. A 5-day course of cefpodoxime proxetil had a lower cost per patient treated per month free of recurrence than a 10-day course of phenoxymethylpenicillin (non-generic) or amoxicillin/clavulanic acid in the treatment of recurrent pharyngotonsillitis. Thus, evidence to date suggests that cefpodoxime proxetil has potential for use as stepdown therapy in community-acquired pneumonia and in abbreviated therapy courses in upper respiratory tract infections. These preliminary observations require confirmation in well designed studies. PMID- 10163421 TI - Orphan drug policy. PMID- 10163420 TI - Enoxaparin. A pharmacoeconomic appraisal of its use in thromboembolic prophylaxis after total hip arthroplasty. AB - Total hip arthroplasty (THA) is a major orthopaedic procedure with a high risk of postoperative thromboembolism. Increasing demand for this type of surgery, together with its high cost, has led to examination of means by which the cost of THA may be minimised. Current clinical opinion favours the use of suitable pharmacological thromboprophylaxis in patients undergoing THA; such prophylaxis may be provided with subcutaneous standard unfractionated heparin (UFH), oral warfarin or subcutaneous low molecular weight heparin (LMWH). Traditionally, LMWHs have been perceived as being more expensive to use than UFH or warfarin because of their relatively high acquisition cost. However, recent pharmacoeconomic data have shown that cost savings are possible when LMWHs are used. This is attributed mainly to reduced frequency of administration, reductions in costs associated with diagnosis and treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and the lack of need for laboratory monitoring of blood coagulation parameters. LMWHs have proportionally less anti factor IIa (antithrombin) activity relative to anti-factor Xa activity than UFH. Enoxaparin, a LMWH with a mean molecular weight of 4 to 5kD, is reported to have approximately 5 times less activity against thrombin than UFH, for equivalent anti-factor Xa activity. Randomised clinical trials in patients undergoing THA have shown enoxaparin to be at least as effective as UFH in the prevention of DVT and PE, with consistent trends towards a lower incidence of DVT with enoxaparin than with UFH. Similar rates of haemorrhagic complications were reported for enoxaparin and UFH in most trials, although a significantly higher total transfusion requirement was reported for UFH than for enoxaparin in a double blind study. A significantly higher incidence of bleeding was observed with UFH than with enoxaparin in another study, with similar transfusion requirements for both treatment groups. Cost comparisons in which costs were assigned retrospectively to clinical data have shown cost advantages for LMWHs in general over UFH when costs of administration, hospital bed occupancy and laboratory/radiology procedures are calculated. Cost savings with LMWHs were attributed mainly to reductions in the cost of managing thromboembolic complications in patients receiving these drugs. One meta-analysis showed a saving of $US50 000 (1993 figures) for LMWH over UFH (both subcutaneously twice daily) for every 1000 patients. Subcutaneous enoxaparin at a dosage of 30mg twice daily was shown to be more cost effective than oral warfarin in the prophylaxis of DVT and PE in 2 North American studies in which costs were related to outcomes. One study comprised the application of a decision analysis to a hypothetical group of 10 000 patients; an incremental cost effectiveness of $US12 288 (1993 figures) per death averted was reported for enoxaparin. Enoxaparin was also associated with an overall incremental cost effectiveness of $Can29 140 (1992 figures) per year of life saved (YLS) in the other study, in which costs were applied to clinical data obtained retrospectively from 10 randomised trials. Although no cost-effectiveness analyses have been carried out to compare enoxaparin with UFH, a UK cost comparison reported an overall cost saving of pounds 20 per patient (figures from 1989 to 1990) with enoxaparin 40mg once daily subcutaneously over subcutaneous UFH 5000IU 3 times daily. It has also been suggested that the use of once- or twice-daily enoxaparin in preference to UFH may reduce the overall length of hospital stay; a significant difference emerged in 1 analysis (9.9 or 9.5 vs 11.3 days). Pharmacoeconomic data therefore support the use of enoxaparin as an effective thromboprophylactic treatment with potential cost advantages over warfarin and UFH. Cost-effecti PMID- 10163422 TI - The socioeconomic impact of insomnia. An overview. AB - Insomnia is an extremely common symptom both de novo and in the context of other medical and psychiatric disorders. The impact of insomnia is often ignored both by the individual and by society in terms of its clinical and socioeconomic ramifications. Insomnia is therefore under-appreciated and almost certainly under treated, thus making it a serious health concern. It is estimated that more than 60 million Americans suffer from insomnia annually, and this figure is expected to grow to 100 million by the middle of the 21st century. Whether it be difficulty initiating or maintaining sleep, the disruption of nocturnal sleep will invariably impact on daytime activities and often results in daytime fatigue, performance deficits (including memory and other cognitive deficits), an increase in the number of sick days taken by an individual and accidents (some catastrophic). This review examines the costs directly related to insomnia in various sectors of healthcare, the indirect costs associated with accidents, sick days and decreased work productivity, and related costs resulting from insomnia but which meet neither the criteria of direct nor indirect cost categories. The total direct, indirect and related costs of insomnia are conservatively estimated at $US30 to 35 billion annually in the US (1994 dollars). Economic gains can be made by treating patients on an outpatient basis in sleep centres. PMID- 10163424 TI - Sleep disturbance. A component of health status. AB - Insomnia clearly impairs the quality of life of patients because it interferes with the ability to function, both physically and psychologically. Well-being and satisfaction with daily life may also be impaired by sleep disorders. The assessment of quality of life in patients with insomnia should rely on the use of a recognised validated clinical scale and a specific questionnaire targeted to areas of interest for the patient, namely daily functioning and well-being. The final choice of scale depends on the context of clinical use and study objective. PMID- 10163423 TI - Impact of insomnia on health-related quality of life. AB - With the increased interest in sleep disorders, the definition of insomnia has been refined and extended so that the aetiology of these disorders is considered in addition to their operational characteristics. The International Classification of Sleep Disorders is the most advanced nosology available. It encompasses, although it does not define, the concept that sleep may be disturbed either through disruption of the mechanisms that control sleep and wakefulness, or by factors external to those mechanisms. Formal measures of quality of life invariably include assessment of sleep or the consequences of disturbed sleep, such as fatigue. Generally, when these assessments are used, sleep has been disturbed by external factors, rather than by disruption of the mechanisms that control sleep. Occasional insomnia does not necessarily need medical treatment, but it may nevertheless cost national economies significant sums through absenteeism and sleep-related accidents. Profound, longer term insomnias may arise either because of failure of the mechanisms central to sleep (i.e. as sleep disorders) or as a consequence of medical disorders (i.e. as disordered sleep). These insomnias should be treated, because the former may lead to the development of costlier and more intransigent psychiatric disorders, whereas the latter should be treated for compassionate reasons, within the framework of palliative medicine. Insomnia as a sleep disorder can require either psychological or pharmacological treatment, depending on the diagnosis, whereas insomnia as a symptom may require treatment with newer hypnotics, e.g. zopiclone. PMID- 10163425 TI - Clinical management of patients with insomnia. The role of zopiclone. AB - Insomnia, especially when chronic, is associated with disturbances in daytime well-being and performance, resulting in a poor quality of life for those affected. Zopiclone has been proven as a drug that favourably balances sleep induction and maintenance as well as an improvement in daytime well-being (efficacy) with a low potential for adverse effects (safety) in the symptomatic treatment of insomnia. Management of chronic insomnia with zopiclone needs a multidimensional approach involving the proper diagnosis of possible underlying causes, and combined use of causal treatment, general sleep hygiene measures, basic elements of psychological treatment and adjunctive medication. It is recommended that therapy with the nonbenzodiazepine hypnotic zopiclone should conform to the guidelines for the use of hypnotics, which are valid for all benzodiazepine receptor agonists. PMID- 10163426 TI - Health-related quality of life in patients with insomnia treated with zopiclone. AB - Insomnia can cause impaired productivity and absenteeism from work, increased risk of accidents, and impaired quality of family and social life. Thus, it can compromise quality of life in affected individuals and result in costs to society as a whole. The nonbenzodiazepine hypnotic zopiclone is effective and well tolerated in the treatment of insomnia. Importantly, it also has minimal effects on next-day performance and psychological function. 458 patients treated with zopiclone for 14 days showed significantly greater improvement compared with placebo recipients in sleep evaluation questions and scores for activity, social and professional quality-of-life aspects. After 8 weeks, the improvement in scores for sleep, activity and social questions remained significantly higher in patients who had received zopiclone compared with placebo recipients. No significant differences were observed between 167 patients who had been taking zopiclone for at least 12 months and a control group of 381 persons with no sleep problems in virtually all of the 5 aspects of the quality-of-life questionnaire. Some important aspects such as relationships and professional life were not modified by zopiclone. When insomnia is treated appropriately, compared with no treatment, patients' feelings about their quality of life are improved and, furthermore, do not appear to differ significantly from perceptions of quality of life in those without sleep-related problems. PMID- 10163427 TI - Healthcare reform in the US. Momentum shifts from federal to state governments. AB - In the absence of federal leadership on comprehensive healthcare reform, a major restructuring of the delivery of healthcare in the US has occurred in the private sector and is well underway in many state legislatures. The influence of managed care continues to be pervasive. In 1994, 80%, or some 230 million, of the insured population in the US were included in a managed-care setting of some kind. This represents a 6-fold increase over the preceding decade. Healthcare reform has remained high on the list of legislative priorities for many states. Although initiatives vary, an increasing number of states are seeking federal waivers to broaden and restructure their Medicaid programmes so that groups of uninsured individuals can be included and all Medicaid recipients shifted into a managed care setting. This paper provides an overview of the Medicaid waiver programme and other state initiatives. In addition, the paper reviews a decision of the US Supreme Court that recently established guidelines for states considering the imposition of surcharges or other revenue-generating mechanisms on private insurers as a means of funding uncompensated care. PMID- 10163428 TI - Longer patents for increased generic competition in the US. The Waxman-Hatch Act after one decade. AB - The 1984 Waxman-Hatch Act had two main objectives. Title I was designed to promote price competition by establishing an abbreviated new drug application (ANDA) process for generic market entry. Title II was designed to encourage drug innovation by restoring some of the patent life lost during the lengthy FDA regulatory process. In this paper, we consider whether these twin objectives have been realised during the first decade of the Act's existence. First, we investigate the pattern of generic and brand name prices and market shares for the major products whose patents expired between 1984 and 1993. A regression model indicates that generic competition has been intensifying significantly in recent periods. Major brand name products now typically lose more than half their market share within the first year after patent expiration. In addition, we examine changes in patent protection for new chemical entities introduced over the period 1984 to 1993. For 1991 to 1993 new drug introductions, the average effective patent life was 11.8 years with 2.3 years resulting from Waxman-Hatch extensions. In the final section of the paper, we consider how the US law compares with that in Europe and discuss possible legislative improvements in the 1984 Act. PMID- 10163429 TI - Drug use in academic medical centres in an era of ferment. AB - The causes and implications of streamlining and consolidation in academic medical centres in the US have a number of parallels in the research-intensive pharmaceutical industry. In both cases there is increasing competition between institutions (centres or companies), and the costs of research and innovation are rising sharply. However, with increasing emphasis on cost reduction in healthcare, fewer and fewer payers are willing to help underwrite the costs of research and innovation within academic health centres or for new drug development. At the Brigham and Women's Hospital, an ongoing study is investigating the effects of 'reminding' doctors, through an interactive hospital computer system, that the drug they are about to prescribe may not be the most clinically appropriate or cost-effective in a given situation. While physicians are not deprived of the right to prescribe a 'deviant' drug, it is hoped that, unless exceptional circumstances prevail, they will improve their prescribing choice if provided with the correct information at the time of decision-making. This approach reflects a new understanding that teaching institutions are required to educate trainees about the fact that resources are not infinite, and that critical selection among competing products must be a prominent concern for the rest of their professional lives. Attention to such concerns is vital to quality assurance and cost management. However, it is also true that the most cost-effective drug may not necessarily be the one with the lowest acquisition cost, provided that one conducts a thorough interdisciplinary analysis of clinical outcomes and expenditures. As academic medical centres redefine their priorities while attempting to preserve their leadership in innovation, research oriented drug manufacturers are also developing more creative and efficient goals for their constrained research budgets. Liaisons between academic medical centres and research-driven pharmaceutical companies can help ensure that both types of innovation-based organisations are able to continue their respective missions of discovery into the next century. PMID- 10163431 TI - Defining our future work. PMID- 10163430 TI - Towards a research agenda for pharmaceutical issues. AB - Currently, the most important issue in US pharmaceutical policy is probably cost containment. Research into pharmaceutical issues should therefore concentrate on this area. Analysis of changing trends in pharmaceutical expenditures, particularly during the early 1990s, would be a useful starting point. Research into the costs and returns associated with the development of pharmaceuticals, and into the levels, constituent parts, and impact on system costs of pharmaceutical expenditures would also be helpful. Cost-containment systems themselves should also be studied, particularly in terms of how they work, what they cost, what they save, their effects on patients, their effects on patterns of drug diffusion, and their impact on drug research and development as well as on international competitiveness. PMID- 10163432 TI - The UK pharmaceutical market. An overview. AB - The National Health Service (NHS) accounts for more than 98% of the UK prescription medicines market, which is the sixth largest pharmaceutical market in the world. Most of this market is driven by the UK's approximately 35,000 general practitioners (GPs). It is an open market, with most leading foreign pharmaceutical companies having a strong presence. While the growth rate of this market has been decelerating, it remains one of the fastest growing components of NHS expenditure. The NHS does not operate any kind of national reimbursement list, but the UK government has adopted several means to keep medicines expenditure under control. These include cash incentives and constraints for GPs relating to expenditure on medicines, individual quarterly updates on GP prescribing, the publication of a list of medicines that cannot be prescribed by GPs, the switching of some prescription-only medicines to over-the-counter medicines, and a co-payment system. The main form of economic regulation in the UK, however, remains the Pharmaceutical Price Regulation Scheme (PPRS). This limits the rate-of-return on capital attributable to medicines sales to the NHS, with the intended rate-of-return being equal to that of UK industry overall. The pharmaceutical industry has generally performed relatively well in the UK market, managing to preserve incentives to innovation. This reflects the fact that UK GPs have been able to maintain their clinical freedom, as well as government recognition of the economic contribution made by the pharmaceutical industry. Current issues of interest in the UK pharmaceutical market context include the future of the PPRS, the debates over the imposition of a national formulary and generic substitution, and over parallel trade, the potential impact of managed care protocols and computer-based prescribing on pharmaceutical expenditures, and possible political changes. PMID- 10163433 TI - Drug pricing and reimbursement in France. Towards a new model? AB - The pharmaceutical market in France is characterised by low prices and high sales volumes. Despite these advantageous market conditions, the French pharmaceutical industry has in general been an underperformer in the global context. Acknowledgement of the contributory role made by state regulation of drug expenditures in creating this situation has resulted in a number of attempts to correct problems within the market. At best, these have achieved only temporary improvements. Since 1993, however, a new drug policy, which emphasises voluntary moderation by physicians of their own prescribing activities rather than the use of budgetary means to cut expenditures, has been in operation in France. This 'medicalised strategy' involves 2 main instruments, viz., a list of guidelines for clinical practice (References Medicales Opposables) and a set of 'industrial conventions' (agreed between each drug company and the government) for determining drug prices. While it is too early at this stage to determine whether these new approaches will be beneficial in the long term, some changes in drug prescribing have already been observed, and it is clear that the new policy has also encouraged more healthy relationships between policymakers, the medical profession, and the pharmaceutical industry in France. PMID- 10163434 TI - Consequences of implementing a drug budget for office-based physicians in Germany. AB - For many years, drug prices in Germany were the highest in Europe and the level of regulation of the pharmaceutical industry was lower than in other states. This situation has, however, changed radically in recent years. Pharmaceutical prices have been regulated, without the introduction of direct price controls, through a combination of pressures exerted by the authorities and the German sickness funds, which are responsible for reimbursement. The process of price restriction began in 1984 with the imposition of a negative pharmaceuticals list, which was further extended in 1989. A reference pricing system was also introduced in 1989, and a drug budget for office-based physicians in 1993. An overview of these measures is provided in the first section of this article. This is followed by a report of a study of the impact of Germany's global pharmaceutical budgets for office-based general practitioners and internists. PMID- 10163435 TI - An introduction to three studies assessing the impact of specific restraints on the delivery of pharmaceutical benefits. PMID- 10163436 TI - The clinical practice improvement (CPI) model and how it is used to examine the availability of pharmaceuticals and the utilisation of ambulatory healthcare services in HMOs. Results from the Managed Care Outcomes Project (MCOP). AB - Many American healthcare facilities have come to understand that quality controls cost. Clinical practice improvement (CPI) is a methodology that creates a clinical laboratory, built into the everyday practice setting, to find and test best practices. A CPI study is an analysis of the content and timing of individual steps in a medical care process aimed at producing better clinical outcomes for the least necessary cost over the continuum of a patient's care. Statistical regression analyses are used to determine whether and how much a particular step actually improves medical outcomes. Systematic determination of individual process steps that improve medical outcomes is the best way to develop demonstrably better care and practice. Combining CPI methodology and a data monitor creates a dynamic environment in which all patient encounters potentially contribute to improving the process of care. We describe a recent multisite study: the Managed Care Outcomes Project (MCOP). The MCOP study design permits us to compare the effects of various pharmaceutical treatments on resource utilisation in actual practice in managed-care organisations. The MCOP database is an important resource for developing information required to design systems based disease management programmes. PMID- 10163438 TI - Cost sharing for pharmaceuticals--the Swedish reimbursement system. AB - Public drug expenditure has increased in Sweden over the past 5 years, primarily because of increased spending on new and more expensive drugs. This increase has placed greater pressure on the existing pharmaceutical reimbursement system, and in turn there has been a tendency for government to increase the level of regulation of this system in order to improve its efficiency and to control costs. Plans to reform the reimbursement system are being formulated both in terms of financing and patient co-payment (cost sharing) for prescription drugs. If these plans are implemented, the cost of prescription pharmaceuticals will be transferred from the Swedish National Social Insurance Board to the country councils, thus ending the open-ended public insurance scheme for prescription drugs and integrating this expenditure within the global healthcare budget for each council. A number of issues will need to be resolved if this transfer takes place, however, not the least of which will be the regulation of cost sharing. In this article, the consequences of cost sharing and the impact of 5 different models for patient co-payment for prescription drugs are analysed and compared with the present reimbursement system in Sweden. PMID- 10163437 TI - A framework for cost-sharing policy analysis. AB - To assess the effect of cost sharing, a framework for describing and evaluating cost-sharing programmes was constructed, followed by a comprehensive search of the international literature on the subject. The results indicated that cost sharing carries many potential advantages, one of which includes increased consumer attention to healthcare costs. However, proper design of cost-sharing programmes is necessary to mitigate regressivity and other common problems associated with many current programmes. These findings should help policy makers to understand and anticipate the effects of cost sharing, and to create innovative benefit design solutions that are targeted to promote health system goals. PMID- 10163439 TI - The 1996 pricing and reimbursement policy in The Netherlands. AB - In The Netherlands, the government operates a reference price system in which medicines are categorised into groups of interchangeable drugs. The reimbursement within groups is limited. In addition, since drug prices in The Netherlands are currently among the highest in Western Europe, a law was implemented in March 1996 to lower the prices of drugs in The Netherlands to the mean of pharmacy buying prices in 4 surrounding countries (UK, France, Belgium and Germany). Maximum prices for oral formulations will be in force from 1 June 1996, and maximum prices for other formulations will be operational soon thereafter. Reducing the price level will lead to a substantial decrease in discounts for pharmacists. Lower discounts will also mean weaker 'golden chains' between wholesalers, the industry, and pharmacists, and will therefore create business opportunities for companies wishing to compete on the basis of price. Liberalising the distribution of pharmaceuticals and creating a cost-conscious demand side will stimulate price competition in the pharmaceutical market and make it easier for new participants to enter the Dutch market. Price competition will lead to lower prices and, consequently, to lower costs. Further exemptions from the reimbursement list will be recognised. Considerable efforts are also being made to rationalise the prescribing behaviour of physicians and the dispensing behaviour of pharmacists. Through this programme, which has many components, The Netherlands hopes to restrain and effectively control its expenditures on pharmaceuticals. PMID- 10163440 TI - Healthcare reform and expenditure on drugs. The German situation. AB - Germany is in a period of transition with regard to healthcare reform. The number and intensity of cost control interventions increased during the last decade in an attempt to contain healthcare expenditure. The German legislature has implemented long term macroeconomic measures such as contribution rate stability and global budgeting. The mid-term goal is to reduce the structural deficits of the current system. This paper argues that reference prices, introduced in the 1989 Healthcare Reform Act, did not produce the expected savings. An analysis of the effects of the 1993 Healthcare Structure Act on pharmaceutical expenditure is also presented. Compared with the implementation of the reference price system, the introduction of global budgeting in 1993 has had a more effective and lasting cost-containment impact. The paper concludes with a review of the main aspects of the current reform discussion. PMID- 10163441 TI - Culture and politics in healthcare reform. Reflections on solidarity, healthcare, and the welfare state. AB - Language can be a useful tool for probing cultural attitudes. In continental Europe, for instance, it is not possible to talk about healthcare systems for long without encountering the word 'solidarity'. Not only is it used in conversation, it is also found in government documents where it is referred to as a fundamental principle on which health systems are based. Furthermore, a literature search will identify multiple references that relate the term solidarity to healthcare in Europe. By contrast, the word is seldom heard in American dialogue and is rarely referred to in the American literature. This article briefly explores the possible significance of this difference in language, and how it relates to healthcare reform and the welfare state. PMID- 10163442 TI - Healthcare reform in Europe. AB - The European welfare states are currently struggling with tremendous budget problems. Most debate appears to be concerned with how to cut healthcare costs. Unfortunately, limiting the state's costs, rather than enhancing the people's well-being, has become the prime focus of new healthcare strategies in the European welfare states. The result has been a reduction in the quality and availability of healthcare services and a diminishing contribution to medical innovation by most European countries. Abandonment of the 'pay-as-you-go' financing system is the only solution to increasingly unsustainable welfare state healthcare systems. A system financed by a capitalisation mechanism would be protected from the increasing costs associated with demographic evolution, while providing all members of society with the opportunity for affordable healthcare coverage. PMID- 10163443 TI - Navigating the seven Cs of consumer-driven Medicare managed care plans. PMID- 10163444 TI - How to settle the maternity stay issue. PMID- 10163445 TI - Technical considerations for building or outsourcing information systems for managed care applications. PMID- 10163446 TI - Creative strategies for promotion of worksite health services: the employee ambassador program. PMID- 10163447 TI - Improving employee health and wellness: a pilot study of the employee-driven Perfect Health Program. AB - These preliminary findings suggest that participation in the account may have modified participant behaviors associated with risk for death from heart attack and lung cancer. Although further research and development is needed before stronger conclusions about the impact of the program can be made, these findings suggest positive effects of participation in an innovative employee-driven health and wellness program. PMID- 10163448 TI - The shape up challenge: a community-based worksite exercise competition. AB - PURPOSE: To assess organizational and employee participation during three community-wide worksite exercise competitions in two communities. DESIGN: A one group, posttest-only design was used. Lack of controls, exercise baseline, and the short-term nature of the interventions were limitations. SETTING: The Minnesota Heart Health Program conducted annual exercise campaigns between 1982 and 1989 within three intervention communities to reduce behavioral risk for cardiovascular disease. The Shape Up Challenge was a worksite exercise competition designed, in conjunction with other campaign activities, to increase levels of physical activity. SUBJECTS: A total of 119 participating companies in two Minnesota communities, and 17,626 employees within these worksites, composed the subjects in this study. INTERVENTION: Eligible worksites were invited to participate in a month-long competition during which employees recorded minutes spent daily in aerobic activities. Incentives were established to promote intragroup cooperation and intergroup competition. Companies competed for awards that were based on average minutes of exercise per employee versus per participant. MEASURES: Numbers of companies recruited and participating, campaign activities, minutes of exercise, and costs were recorded on implementation logs. Companies completed surveys describing business type, number and sex of employees, existing health promotion programs, and perceived benefits of participation. RESULTS: Of the 365 companies invited to participate, 33% participated (range 15% to 50%). Participating companies were more likely than nonparticipating companies to offer other health promotion programs and perceived greater benefits from participation. Women and smaller companies had significantly greater participation rates than men and larger companies. Average employee participation rates ranged from as high as 84% in smaller organizations to as low as 16% as organization size increased. CONCLUSIONS: Community-based worksite exercise competitions appear to be a viable strategy for promoting employee exercise, particularly in smaller companies. Group-based contingencies applied in natural work units may facilitate employee participation. Further research is needed to assess the relative efficacy of this approach, compare alternative incentives, and identify strategies to enhance exercise maintenance after the intervention has ceased. PMID- 10163449 TI - Strength training and hypercholesterolemia: an epidemiologic study of 8499 employed men. AB - PURPOSE: This study was conducted to determine the relation between the quantity of strength training and hypercholesterolemia (total cholesterol > or = 240 mg/dl) in men. A secondary objective was to ascertain the effects of age, smoking, alcohol use, body mass, and participation in physical activities other than strength training on the association between strength training and hypercholesterolemia. DESIGN: A cross-sectional research design was used. SETTING: Data were collected at the worksites of subjects throughout the United States. SUBJECTS: The participants were 8499 male employees of more than 50 companies. MEASURES: Blood was drawn while the subjects were in a fasting state, and a questionnaire was used to collect the demographic and lifestyle information, including the data about strength training. The subjects were divided into five groups according to their self-reported duration and frequency (i.e., quantity) of participation in strength training. RESULTS: Subjects who reported regular involvement in strength training had a reduced risk of hypercholesterolemia. However, after controlling for all the potential confounders, only the high-quantity lifters, those who completed 4 to 7 hours of strength training each week, maintained a reduced risk of hypercholesterolemia. CONCLUSIONS: High-quality strength training is strongly associated with a reduced risk of hypercholesterolemia, even after controlling for numerous, potentially confounding factors (odds ratio = .46; 95% confidence interval = .23 to .91). PMID- 10163450 TI - Dietary patterns of men and women suggest targets for health promotion: the Framingham Nutrition Studies. AB - PURPOSE: The goal of the study was to characterize the dietary patterns of adult men and women. DESIGN: The study used a cross-sectional analysis of food consumption behaviors and nutrient intake measured from 1984 through 1988. SETTING: The Framingham Offspring/Spouse Study, Framingham, Massachusetts. SUBJECTS: The population-based sample comprised 1831 men and 1828 women between 20 and 70 years of age. MEASURES: Dietary patterns were defined by cluster analyses, which used the estimates of usual daily food intake from food frequency questionnaires, and the patterns were compared with Food Guide Pyramid recommendations. Nutrient intakes were independently estimated from 24-hour recalls and compared with Year 2000 nutrition recommendations. RESULTS: Cluster analyses identified five groups of men and five groups of women with distinctive dietary patterns. Men differed on intakes of all food groups except vegetables and snacks plus sweetened beverages. Specific dietary behaviors, including low intakes of whole grains, fruits, vegetables, and other complex carbohydrates; high intakes of beer and liquor; and high intakes of high-fat animal foods warrant targeted intervention messages for men. Women's patterns differed across all food groups except red meats and fattier poultry and beer. Dietary behaviors of women that deserve attention include low fruit, vegetable, starch, and dietary intakes; chronic dieting; high alcohol intake; and sources of hidden fats. No cluster met the current recommendations for food and nutrient intake. CONCLUSIONS: Distinct dietary patterns in Framingham men and women vary in compliance with national nutrition and health policy objectives and provide insights for developing behavioral interventions to improve food and nutrient intake. PMID- 10163451 TI - The relationship between perceived stress and self-reported illness-related absenteeism. AB - PURPOSE: To investigate the association between perceived stress and illness related work absenteeism. DESIGN: A standardized health profile questionnaire developed by Johnson & Johnson Advanced Behavioral Technologies, Inc., was used to collect demographic and personal health data between June 1988 and January 1993. Chi-square, odds ratio, and stepwise regression tests were used to analyze perceived stress and self-reported absenteeism data. SETTING: Worksite health promotion programs in 250 U.S. companies. SUBJECTS: Subjects consisted of 79,070 employees. MEASURES: Stress data, grouped as low, moderate, and high, were correlated with absenteeism data grouped by annual days missed (None, 1 to 2, 3 to 4, and 5+). RESULTS: Significant relationships were found (p < or = .05) between high stress and absenteeism for both genders. Female workers reported higher stress levels and absenteeism than men. Those with high stress were 2.22 more likely to be absent 5+ days per year than those with low stress. Work, finances, and family were the highest stress sources. Greatest absenteeism predictors were health, legal, social, and financial stress. CONCLUSIONS: These data primarily represented self-selected white workers and may not apply to all employees. However, if high stress relates to absenteeism, these data may provide valuable information for program design in stress management. PMID- 10163452 TI - The Olympic Games: opportunities for health promotion. PMID- 10163453 TI - Asymptomatic rhegmatogenous retinal detachment. AB - The vast majority of patients with rhegmatogenous retinal detachments present with either acute or chronic symptoms. In these cases repair of the retinal detachment is almost always recommended to either improve vision or prevent further visual loss. In a small subgroup, rhegmatogenous retinal detachments were detected as incidental findings in asymptomatic patients. Such asymptomatic detachments are often caused by atrophic holes in lattice degeneration and are more commonly located in the inferior quadrants. Demarcation lines are often present. Asymptomatic retinal detachments also occur in a younger age group of patients when compared with symptomatic rhegmatogenous retinal detachments. The management of eyes with an asymptomatic retinal detachment is controversial. The risk of complications during surgical repair must be weighed against the chance that the retinal detachment will progress. Recently published clinical data suggest that the risk of progression of asymptomatic rhegmatogenous retinal detachments is small. Consequently, observation can be considered as a reasonable management option in reliable patients until progression is documented or symptoms occur. Patient education geared toward instruction on self-monitoring of the visual field and a review of the risks and benefits of retinal detachment repair versus observation are important in patients with asymptomatic retinal detachment. PMID- 10163454 TI - Causes of vitreous hemorrhage. AB - It is often a challenge for the ophthalmologist to find the underlying cause of a vitreous hemorrhage. Unless clinical signs clearly point in another direction, the first suspicion should always be a posterior vitreous detachment causing a retinal tear. The other two major causes, diabetic retinopathy and retinal vein occlusion, remain common complications in spite of recent years' improvement in retinal treatment. Macroaneurysm is one of the most often overlooked causes of vitreous hemorrhage. An ocular tumor sometimes presents with a vitreous hemorrhage. In all cases of dense vitreous hemorrhages, the use of diagnostic ultrasonography is mandatory. PMID- 10163455 TI - New treatment modalities for retinoblastoma. AB - The management of retinoblastoma has evolved tremendously for the past century, and recently there is a trend toward focal conservative treatments. This trend is due primarily to the earlier detection of the disease when the tumors are in a smaller stage of development as well as to advanced, more focused treatment modalities. Enucleation is still used for advanced retinoblastoma, especially when there is a concern that there may be invasion of the optic nerve, choroid, or orbit. The hydroxyapatite implant has provided improved cosmetic rehabilitation of the socket after enucleation. External-beam radiotherapy continues to be an important method of treating advanced retinoblastoma, especially when there is diffuse vitreous seeding. Plaque radiotherapy is a useful tool for controlling medium or small retinoblastomas, especially tumors with focal vitreous seeding or those that recur after other methods have failed. Cryotherapy and photocoagulation provide excellent control of small tumors, and advanced laser delivery systems have improved the visualization and ease of treatment of retinoblastoma. Thermotherapy and chemothermotherapy are the newest focal methods that are showing promising results for small to medium-sized retinoblastoma. Recent developments with chemotherapy regimens have allowed dramatic control of intraocular retinoblastoma, and they play an important role in the initial management of many cases. PMID- 10163456 TI - New treatment modalities for uveal melanoma. AB - The management of uveal melanoma has evolved tremendously for the past century, and more recently there is a trend toward more focal conservative treatment. Enucleation is still performed for large uveal melanoma when there is no hope for useful vision with conservative treatment. Plaque radiotherapy is particularly recommended for medium- or small-sized uveal melanoma. Special custom-designed plaque radiotherapy can be used for iris, ciliary body, or juxtapapillary choroidal melanoma. Charged-particle irradiation constitutes an alternative treatment modality for posterior uveal melanoma. However, charged-particle therapy is limited by the availability of appropriate therapeutic facilities. Local tumor resection using lamellar sclerouvectomy is mainly suitable for selected iris, ciliary body, or anterior choroidal tumors with smaller basal dimension and greater thickness. Ablative laser photocoagulation is indicated for very selected cases of small posterior choroidal uveal melanoma. Combined plaque radiotherapy with indirect ophthalmoscope laser therapy appears to be a more effective local tumor treatment plan than plaque radiotherapy alone. Transpupillary thermotherapy is the newest modality used as primary treatment or as complementary method to brachytherapy for treatment of selected choroidal melanomas. Hyperthermia with infrared irradiation below photocoagulation level produces tumor necrosis with few ocular complications. Based on the published ophthalmic literature, it seems that enucleation carries the same survival prognosis as each of the conservative treatment modalities. PMID- 10163457 TI - Macular disease and optical coherence tomography. AB - Optical coherence tomography (OCT) is a new diagnostic tool for high-resolution cross-sectional imaging of the retina. By measuring the "echo" delay time of light as it reflects from tissue at different ranges and by performing multiple axial scans in the transverse direction, OCT generates two-dimensional images detailing retinal architecture. OCT is a powerful new modality because it has a longitudinal resolution of 10 microns in the retina, which is superior to other currently available imaging techniques. Examinations are exceptionally tolerable for patients because OCT is noninvasive, the probe beam is near-infrared and thus not very bright, and scan acquisition time is only 2.5 seconds. OCT appears to be a useful device for evaluating a variety of retinal diseases, including macular holes, macular edema, and central serous chorioretinopathy. PMID- 10163458 TI - Visual prognosis and sympathetic ophthalmia. AB - Sympathetic ophthalmia is probably the ocular disorder best known to practitioners outside of ophthalmology. It is characterized by a bilateral, nonnecrotizing granulomatous panuveitis that occurs after intentional or unintentional trauma to the exciting eye. So far, the identity of the inciting antigen has not been delineated with certainty. The sequelae from sympathetic ophthalmia have declined markedly in this century as a result of earlier diagnosis, use of corticosteroids, and better management of ocular injuries, in large part due to improved surgical techniques. Cases of sympathetic ophthalmia, however, still occur with their severe sight-threatening complications, which impose on ophthalmologists the importance of prompt diagnosis and aggressive treatment in order to achieve good visual outcome. PMID- 10163459 TI - Recent developments in indocyanine green angiography. AB - For the past year, indocyanine green angiography has been applied to evaluation of choroidal neovascularization, pigment epithelial detachment, retinal vascular disorders, and choroidal diseases and tumors. These applications have expanded the potential use of this technique. The relative safety of indocyanine green angiography has contributed to its continued wide-spread application. PMID- 10163460 TI - Outcome of prematurity and retinopathy of prematurity. AB - Retinopathy of prematurity is a disease that manifests soon after birth in the premature infant and may lead to a lifelong disability. More infants at risk for developing the retinopathy are surviving, and the ophthalmologist must be aware of possible vision abnormalities, such as decreased acuity, strabismus, nystagmus, retinal scarring, and retinal detachment, that occur during childhood and in adult life. These abnormalities may occur in children who developed only mild forms of retinopathy of prematurity during early life. PMID- 10163461 TI - Current concepts in the identification and treatment of stage 2 macular holes. AB - Over the past decade, a better understanding of the pathogenesis and evolution of idiopathic macular holes has developed. Theories implicating the role of the vitreous in hole formation have led to surgical interventions that have met with surprising success. Recent advances in identifying early lesions, coupled with variations in surgical results based on the hole's preoperative stage, have led some authors to suggest earlier intervention. This report reviews current concepts of macular hole development, focusing on the pathoanatomy, natural history, surgical approach, and surgical outcomes of stage 2 macular holes. PMID- 10163462 TI - Are antioxidants or other supplements protective for age-related macular degeneration? AB - As the number of individuals with age-related macular degeneration increases, the economic and social consequences of this blinding disease rise. No proven preventive measures exist to halt development or progression of this disease. The specific insults that trigger and perpetuate age-related macular degeneration are unknown; however, it may be the result of repetitive oxidative injuries. Several studies suggest a possible protective role for antioxidant micronutrients and other trace minerals, but data for specific antioxidants have been inconsistent between studies. Although promising, the preliminary evidence is limited. Reliable data on whether antioxidant vitamins or trace minerals decrease the development or progression of age-related macular degeneration will emerge from several ongoing large-scale randomized clinical trials. Based on the currently available information, it is not possible to recommend antioxidant micronutrient supplementation to protect against development or retard progression of age related macular degeneration. PMID- 10163463 TI - Ocular manifestations and treatment of Lyme disease. AB - Ocular manifestations in Lyme disease have been considered rare. In surveys and epidemiologic studies the possibility of ocular Lyme disease has usually not been taken into account. Patients with late ocular. Lyme disease may be seronegative by routine enzyme-linked immunosorbent assays, but immunoblot or detection of Borrelia DNA by polymerase chain reaction may help in diagnosing those cases. An ophthalmologist may suspect the diagnosis of Lyme disease in inflammatory ocular syndromes with unusual biomicroscopic or angiographic findings. Intraocular Lyme disease is usually treated with intravenous ceftriaxone or cefotaxime. Jarisch Herxheimer reaction may occasionally complicate the antibiotic treatment of ocular manifestations. Overtreatment with ceftriaxone should be avoided because of a possibility of biliary complications. PMID- 10163464 TI - Age of onset of posterior vitreous detachment. AB - Recently published literature on the onset of posterior vitreous detachment is reviewed here. Aging causes posterior vitreous detachment, and its prevalence increases proportionally with age. The onset of posterior vitreous detachment is associated with refractive error. Investigation of the prevalence and onset age of posterior vitreous detachment indicates that the higher the degree of myopia, the earlier the onset age. There are some reports on the onset age of posterior vitreous detachment in men compared with women. One indicates that posterior vitreous detachment occurs earlier in women, and another reports no difference. No difference has been found between blacks and whites or between whites and Japanese. PMID- 10163465 TI - Long-term results of pars plana vitrectomy in the management of intermediate uveitis. AB - Pars plana vitrectomy is a useful tool for the management of certain complications in chronic intermediate uveitis. Media opacities obscuring the visual axis, vitreous membranes causing tractional retinal detachment, macular puckers, and ciliary traction leading to hypotony are clear indications for this approach. Furthermore, it has been suggested that vitrectomy may have a favorable long-term effect on the course of disease. The procedure may achieve regression of inflammation, tapering of immunosuppression, and improvement of cystoid macular edema. However, randomized prospective trials are still needed to define the role of vitrectomy in altering the course of uveitis. PMID- 10163466 TI - Laser therapy for central retinal vein obstruction. AB - The Collaborative Central Retinal Vein Occlusion Study has recently reported information on the early natural history of central vein occlusion that includes a 16% conversion of perfusion to nonperfusion within the first 4 months. The Collaborative Central Vein Occlusion Study randomized trial of laser photocoagulation for macular edema and for the management of iris neovascularization suggested that grid laser photocoagulation is not useful for the improvement of visual acuity that is decreased because of perfused macular edema and that iris neovascularization is best managed by applying panretinal photocoagulation after the first appearance of iris neovascularization. A recent report has suggested that chorioretinal venous anastomosis can be achieved in some patients with vein occlusion to permit venous outflow through the choroid, lessen the likelihood of progression to ischemia, and improve visual acuity by lessening macular edema. PMID- 10163467 TI - Optimal management of postoperative endophthalmitis and results of the Endophthalmitis Vitrectomy Study. AB - The Endophthalmitis Vitrectomy Study was a multicenter randomized clinical trial. A total of 420 patients who had developed acute endophthalmitis after cataract surgery were randomly assigned to undergo vitrectomy or tap and biopsy and to receive either systemic antibiotics (ceftazidime and amikacin) or no systemic antibiotics. At 9 months patients were assessed for final visual acuity and media clarity. There was no difference in final visual acuity or media clarity whether or not systemic antibiotics were used. Patients who presented with hand motion acuity or better did not show a benefit from immediate vitrectomy. However, patients who presented with light-perception-only visual acuity had substantial benefit over immediate vitrectomy, with a threefold (33% vs 11%) increased frequency of achieving 20/40 vision or better, double the frequency of achieving 20/100, and a decrease by half in the frequency of severe visual loss to less than 5/200. These differences were statistically significant. PMID- 10163468 TI - Management of supracondylar fractures proximal to total knee arthroplasty with the GSH supracondylar nail. AB - The management of a supracondylar fracture above a total knee arthroplasty requires a cautious surgical approach. Currently, the standard method of plate/screw internal fixation of this type of fracture has yielded only fair results. A new technique of retrograde intramedullary nailing through the femoral component using the GSH supracondylar nail is described in this report. A review of four series in which more than 50 patients were treated using the GSH nail indicates a significant difference in bone grafting (10% versus 75%), delayed union (7.2% versus 50%), nonunion (1.9% versus 10%), and surgical revision (0 versus 10%) compared to plate/screw fixation of similar fractures. The findings in this review indicate that the GSH supracondylar nail provides excellent biomechanical stability in these complex fractures, resulting in minimal complications and allowing early return of the patient to functional activities. PMID- 10163469 TI - Allograft safety: viral inactivation with bone demineralization. AB - A study was performed to validate the effectiveness of a bone demineralization process with respect to its inactivation of viruses. The viruses selected for study included human immunodeficiency virus (HIV), duck hepatitis B virus (a model for human hepatitis B), bovine viral diarrheal virus (a model for human hepatitis C), human cytomegalovirus, and human poliovirus (a model for small nonenveloped viruses, e.g., hepatitis A). This study was performed in compliance with Good Laboratory Practice regulations using validation methodology similar to that used to ensure the safety of blood derivatives and other products. Use of the bone demineralization process described in this report resulted in a reduction in infectivity of greater than one million (10(6)) for all viruses and as much as one trillion (10(12)) for the poliovirus. PMID- 10163470 TI - CT angiography earns role in thoracic aorta. PMID- 10163471 TI - Double-helix scans aid diagnosis in infants. PMID- 10163472 TI - Dual-phase scan enhances hepatic imaging. PMID- 10163473 TI - Volumetric data key to wrist evaluation. PMID- 10163474 TI - Fast scanning permits imaging of heart defects. PMID- 10163475 TI - 3-D imaging: a look at the future of patient care. PMID- 10163476 TI - Tailored contrast suits imaging needs. PMID- 10163477 TI - What is imaging's role in managed-care world? PMID- 10163478 TI - Policy on MR angio mystifies radiologists. PMID- 10163479 TI - Fast CT assists diagnosis of pulmonary embolism. PMID- 10163480 TI - Mammography central to treatment planning. PMID- 10163481 TI - Spiral CT can improve liver lesion detection. PMID- 10163482 TI - Beclomethasone dipropionate given to adult asthmatics through a new spacer device: effects of high-dose administration. AB - The usefulness of a metered-dose inhaler equipped with a new spacer device (Jet spacer) was evaluated and compared with that of a standard actuator in the administration of high-dose inhaled beclomethasone dipropionate (0.5 mg four times daily) to adults with moderate asthma. After a 2-week run-in period, 36 patients were enrolled in a 4-week study according to a randomized, parallel group design. Efficacy was assessed by measurements of pulmonary function and daily beta 2-agonist consumption. Morning serum and 24-hour urinary cortisol levels were measured at baseline and after treatment; adrenocorticotropic hormone (ACTH) stress testing was also done. Spirometric parameters significantly improved in both groups; peak expiratory flow rate measured at the final visit was significantly higher (P < .01) in the group using the Jet spacer than in patients using the standard actuator. Beta 2-agonist consumption decreased in both groups. The number of patients with a normal response to ACTH was significantly higher (P < .01) in the Jet group than in the standard actuator group; concomitant urinary cortisol excretion decreased significantly (P < .05) in the standard actuator group. Local irritation was reported by 1 patient in the Jet group and by 2 patients in the standard actuator group. Use of the new Jet spacer was found to reduce the potential for adrenal suppression and increase the efficacy of high-dose inhaled beclomethasone dipropionate given to adults with asthma. PMID- 10163483 TI - Trichomoniasis: its clinical significance and diagnostic challenges. AB - Trichomoniasis is a significant STD worldwide. Clinical studies have demonstrated that trichomoniasis may have serious side effects both in pregnancy and in a predisposition to retrovirus infection. Therefore it is important that clinicians request the most accurate diagnostic test available. This is mandated by the significant percentage of both male and female patients that may be asymptomatic. Numerous clinical studies have indicated that the most sensitive test for T. vaginalis is with culture. The InPouch TV culture test has demonstrated high sensitivity, long shelf life, and microscopic advantages over other culture procedures. PMID- 10163484 TI - Comparison of slide platelet aggregation reagents. PMID- 10163485 TI - Point-of-care testing. Meeting regulatory guidelines with nonlaboratory personnel. PMID- 10163486 TI - Quality control for the point-of-care activated clotting time test. PMID- 10163487 TI - The FDA's perspective on clinical laboratory devices. The premarket review and evaluation process. PMID- 10163488 TI - Automation of laboratory urinalysis. PMID- 10163489 TI - A reagent for stabilizing blood samples. PMID- 10163490 TI - Chronic lymphocytic leukemia with concomitant acute myeloid leukemia. PMID- 10163491 TI - Comparing the learning outcomes of lecture and self-instruction methods in a senior clinical laboratory science course. AB - OBJECTIVE: To compare the relative effectiveness of lecture and self-instruction methods of instruction in a senior clinical laboratory science course. DESIGN: Posttest repeated measures design or within subject design. SETTING: The Department of Medical Technology in the School of Allied Health Professions, Louisiana State University Medical Center, New Orleans. PARTICIPANTS: Clinical laboratory science students (27) enrolled in clinical parasitology agreed to participate, which was a sample of convenience. There were 16 females and 11 males; 70% Caucasian, 23% Asian, and 7% African-American. The 2 students who did not sign a consent form were excluded from the study. INTERVENTION: Subjects were taught clinical parasitology course material by 2 different methods of instruction, lecture and self-instruction. All subjects received both treatments. MAIN OUTCOME MEASURE: Examination scores from each half of the course were compared using descriptive statistics and a paired t-test to determine the effectiveness of each instructional format. RESULTS: Results showed no statistically significant difference in learning outcomes between the 2 instructional formats (a = 0.05, p = 0.13). CONCLUSION: The results of the study generally support the hypothesis that the self-instruction method is as effective as the lecture method in teaching clinical parasitology. By incorporating self instruction into a clinical laboratory science curriculum, many hours of lecture can be eliminated, and students can learn the material at their own pace. Students comprehend the material effectively, and are relieved from some of the intensity of the didactic approach to instruction that dominates clinical laboratory science curricula. PMID- 10163492 TI - The laboratory diagnosis of tuberculosis in a period of resurgence: challenge for the laboratory. AB - OBJECTIVE: To review the current and contemporary approaches to the laboratory diagnosis of Mycobacterium tuberculosis and related mycobacteria. DATA SOURCES: Current literature. STUDY SELECTION: Determined by the author. DATA EXTRACTION: Determined by the author. DATA SYNTHESIS: The definitive diagnosis of mycobacterial disease depends upon the laboratory for the isolation and identification of the infecting microorganism. Laboratory studies encompass microscopic examination for the presence of AFB; isolation and recovery of the organism by cultural methods; phenotypic biochemical or other contemporary means to identify the recovered organism; and anti-tuberculosis susceptibility testing. Because of the extended growth period of this group of organisms, it is imperative that the lab use the most rapid means to provide information to the clinician for isolation of the patient if needed and for the initiation of prompt rational therapy as determined by susceptibility testing. More than 25 species in the Mycobacterium genus are capable of causing human disease. In the United States, the five most frequently encountered species are M. tuberculosis, M. avium, M. kansasii, M. fortuitum and M. chelonei. CONCLUSION: Tuberculosis is a reemerging disease with significant health problem implications in the US and worldwide. Diagnosis and appropriate treatment are dependent on the prompt response of the laboratory. PMID- 10163493 TI - Interstitial laser photochemotherapy with new anthrapyrazole drugs for the treatment of xenograft tumors. AB - Photodynamic therapy (PDT) with lasers and new dyes has gained popularity in recent years as a minimally invasive technique with high tumoricidal effects in vitro and in some cancer patients. However, because new laser dyes are not FDA approved at present, the clinical evaluation of PDT may be years away. During the past 6 years we have used laser alone for photothermal ablation in both preclinical studies and in a large number of patients with an observed 60% tumor response rate. The 40% treatment failure led us to explore the possibility of combined therapy with lasers and standard chemotherapeutic drugs. We have recently tested a promising preclinical alternative using implantation of a bare 600-microns KTP 532 laser fiberoptic in multiple tumor sites 30 min after intratumor injection of the anthrapyrazole DUP-941. As a control, this drug was injected in 3 sites of P3 human squamous cell tumor transplants in nude mice, which led to tumor stasis without regression. Similar 400-600 mm3 tumors exposed to laser illumination alone (0.8 W for 5 sec) at multiple sites resulted in tumor regrowth after 10 weeks in 80% of the animals. However, combining interstitial laser illumination with intratumor DUP-941 injections led to complete tumor regression in 85% of the mice. We propose that intratumor drug injection followed by interstitial laser fiberoptic treatment represents a potentially useful new method for tumor ablation in advanced cancer patients. PMID- 10163494 TI - Solid-state, pulsed-wave, mid-infrared coronary laser angioplasty in de novo versus restenosis lesions: observations from a multicenter study. AB - The following is a study of the response of de novo versus restenosis coronary lesions to pulsed-wave, mid-infrared (holmium:YAG) laser assisted angioplasty. De novo lesions contain thrombi, cholesterol, and fibrosis, whereas restenotic lesions are composed of smooth muscle cells corresponding to injury caused by preceding balloon inflations. It is not known whether the different composition affects results of treatment by laser. In a clinical multicenter study, a mid infrared, solid-state, pulsed-wave laser (holmium:YAG, 2.1 microns wavelength, 250-600 mJ/pulse, 5 Hz) was applied for revascularization of de novo and restenosis coronary lesions. Analysis of data was undertaken to document laser success, complications, and restenosis rate and to define whether the type of lesion treated had an effect on laser success and related complications. A total of 1340 patients with 1465 stenoses presented with symptomatic coronary artery disease. Laser success was 87 and 86% in these lesions, respectively. Overall procedural success of 93% was achieved. Restenosis lesions, known to be composed of smooth muscle proliferation, needed more laser energy for ablation than de novo lesions, which contain an atherosclerotic plaque (130 +/- 123 pulses vs 109 +/- 31, p = 0.001). Procedure-related Q-wave myocardial infarction was significantly higher in patients with de novo lesions over patients with restenosis lesions (1.4 vs 0.2%, p = 0.05). With the mid-infrared, pulsed-wave, holmium:YAG laser, the composition of the target lesion affects the energy level required, as well as the procedure-related complications. PMID- 10163495 TI - Gynecologic cancer recurrences and photodynamic therapy: our experience. AB - The incidence of locoregional recurrences of gynecological tumors is still a major problem. Many authors suggest that it is the major cause of death in patients affected by cervical-endometrial cancers. The results achieved by retreating these patients with conventional therapies are still unsatisfactory. Since 1982, in our department, we have been using photodynamic therapy (PDT) for treatment of locoregional recurrences in gynecological cancers. We have treated 26 patients. In the majority of the cases, vaginal recurrences were on the vaginal vault. Out of 26 cancers, 17 were epidermoid cancers. Lasers used were the argon dye laser (Meditec) and, in some cases, the CO2 laser. Light dose ranged between 60 and 500 J/cm2. The photosensitizing drug used was hematoporphyrin (HP) (Monico Farmaceutici, Venezia, Italy) at a dose of 5 mg/kg body weight. Patients were evaluated 45 days after treatment with gynecological examination and again after 75-90 days with a vaginal smear. Results were divided into 2 groups: objective and symptomatic. The symptomatic response concerned only patients treated with a palliative aim and, in this case, a complete response (CR) was a complete absence of symptoms for at least 60 days. In this group the complete response rate was 66.6%. In the curative group, the complete response was a cytological and/or histological absence of lesion. In this group we had 12 CR (70.58%). The survival rate of patients treated only with PDT ranged between 3 and 92 months (mean 50.7 months). No major acute or side effects were recorded. PMID- 10163496 TI - The use of CO2 laser for inguinal hernia repair in elderly, pacemaker wearers. AB - Interference of electrical current with pacemaker activity is well known and has long been described. Almost every surgical procedure is now performed with the electrical knife, or electrocautery. In patients wearing a pacemaker this poses a problem, because of the danger of electronic interference within the pacemaker with consequent firing-frequency changes and the higher risk of intra- and postoperative bleeding and oozing when using a scalpel instead of cautery. We have performed 25 hernioplasties in elderly patients with permanent pacemakers using the CO2 laser technique. All operations were technically successful, and the immediate and long term (1 year) follow-up proved uneventful. Additionally normal pacemaker function was maintained during surgery and through the follow-up period. CO2 laser surgery is advantageous over electrocautery in patients with pacemakers because it does not interfere with pacemaker activity. Moreover, the laser produces normal hemostasis and does not stimulate muscle and nerve activity during surgery. PMID- 10163497 TI - Carbon dioxide laser applications in thoracic surgery. AB - The use of laser for thoracic surgery is increasing with research and bringing new techniques to the clinical level. The carbon dioxide laser has been used for thoracic surgery to make thoracotomy incisions, to cut the muscular plains, to resect peripheral tumors, to cut interlober fissures, to resect off chest wall tumors, and to treat empyema, with minimum tissue trauma and blood loss. We have developed a method for treating recurrent and persistent pneumothorax with a carbon dioxide laser that we call laser vaporization of parietal and visceral pleurae. Since January 1985, 49 pneumothoraces have been treated with excellent results. PMID- 10163498 TI - Centrifugal pump failures. AB - Centrifugal pumps will not pass gross quantities of gaseous emboli due to the nonocclusive nature of the pump. However, retrograde flow can occur under circumstances that include: product malfunctions, low flows, and human errors. Negative pressure created by falling arterial perfusate can draw air into the cannula. Food and Drug Administration (FDA) records about centrifugal pump malfunctions were obtained. Out of 350,000 cases completed with centrifugal pumps over a 23 month period, the FDA received reports of 68 malfunctions, 22 electrical burning smells, and three speed surges, yielding a failure rate of 1 in 3,763 cases. FDA records revealed five death reports and three serious injury reports. A survey was sent to 2,424 Society of Thoracic Surgeons' members to obtain more information; 285 who use centrifugal pumps responded. Sixty surgeons (21%) reported 108 malfunctions, including 46 complete pump failures. Fifty-one of 243 surgeons (21%) who use centrifugal pumps for bypass reported that perfusionists have forgotten to clamp the pump line, resulting in backflow. We conclude centrifugal pumps are generally safe, but malfunctions, low flows, and human errors can lead to retrograde flow and occasionally air embolization. There are valves that can be added to the bypass circuitry to prevent this risk. PMID- 10163499 TI - In vitro testing of a current cell salvaging device for the removal of malignant cells from contaminated blood. AB - The efficiency of a current cell washing device for removing tumor cells from bovine blood was examined under laboratory conditions. In the in-vitro laboratory, anticoagulated bovine blood was seeded with known numbers of immunocytochemical stained human malignant epithelial cells (KB) grown in culture. The blood was subjected to cell washing. Blood samples were taken before and after cell washing for identification of the tumor cells. The samples were then analyzed under florescence microscopy and pre- and post-cell washing tumor cell counts in 20 microscopic fields were recorded. It was determined that the mean tumor cell removal efficiency was 86% +/- 13% using the cell salvaging technique. Two-way ANOVA revealed a significant difference between the pre- and post-cell washing samples (p < 0.001) with no difference between trials (p = NS). The results are discussed in terms of the potential safety of cell salvaged blood for the surgical care patient. PMID- 10163500 TI - Ultrafiltration of the waste plasma effluent from cardiopulmonary bypass circuit contents processed with a cell-washing device. AB - Blood conservation methods are commonly practiced throughout most hospitals that conduct cardiothoracic surgery. In an effort to reduce patients' exposure to homologous blood products and due to cost effectiveness of blood conservation techniques, this present study combines autotransfusion of the remaining blood in the extracorporeal circuit and ultrafiltration of the plasma effluent, and describes the resulting product. Seven patients, greater than 19 years of age, requiring cardiopulmonary bypass (CPB) were incorporated into this study. Exclusion criteria included age limitation. At termination of CPB, the remaining blood in the circuit was transferred to an autotransfusion machine and processed. Plasma (1054 +/- 206 ml) effluent was collected directly from the centrifugal bowl and processed through a ultrafiltrator, with a constant flow rate and negative pressure, until the plasma effluent concentrated down to an end processed volume of approximately 150 ml. The following variables were either measured or calculated: plasma-concentrate volumes per three minute interval, inlet/outlet pressures of an ultrafiltrator, transmembrane pressure (TMP), plasma free hemoglobin, fibrinogen, total protein, and colloid osmotic pressure. The average ultrafiltrate volume taken off from the plasma effluent was 828 +/- 237 ml, with an average ultrafiltrate volume of 115 ml in every three minute interval. The TMP did not change over the first 15 minutes of processing but became significantly elevated at the 18th minute interval and continued to increase and reach a maximum TMP of 286.5 +/- 2.1 mmHg at the end of concentration. Fibrinogen levels increased from pre-concentration values of 118.2 +/- 64 to 317 +/- 177 mg/dl (p = .03) along with increases in plasma free hemoglobin from 97.7 +/- 46 to 402.1 +/- 180 mg/dl (p = .0002). The total protein concentration increased by over 330% from baseline values. Ultrafiltrating plasma effluent from autotransfused cell salvaged CPB circuit contents could prove beneficial, but further study is required to discover ways to separate unfavorable products, such as activated platelet-leukocyte products and reduced plasma free hemoglobin, and to lower heparin concentrations of the plasma concentrate. PMID- 10163501 TI - Cytoreduction of small intestine metastases using the Cavitron Ultrasonic Surgical Aspirator. AB - The Cavitron Ultrasonic Surgical Aspirator was used to reduce the volume of the small intestine metastases in 37 patients. Thirty-four patients had epithelial carcinoma of the ovary, and one each had tubal adenocarcinoma, papillary peritoneal tumor, and mesothelioma. Thirty-one patients had stage IIIC disease, and six had stage IV. Initially, 18 patients had small bowel disease greater than 15 mm in diameter (of any single nodule), and 10 had disease 6-15 mm in diameter. After cytoreduction using standard means, 18 patients had disease greater than 15 mm in diameter, and 9 patients had disease 6-15 mm in greatest diameter. After using the Cavitron, 13 patients had no gross residual disease, and 24 patients had disease 1-5 mm in diameter. The Cavitron Ultrasonic Surgical Aspirator is invaluable to obtain minimal residual disease of small bowel metastases while avoiding intestinal resection. PMID- 10163502 TI - Vaginal hysterectomy: technique and results in the last twenty years. AB - The objective of this work was to describe patient characteristics and the effect of vaginal hysterectomy in a University hospital in the last two decades. A retrospective review of women undergoing vaginal hysterectomy was performed. The type of hysterectomy and complications were determined. From 1974 to 1994, a total of 6420 hysterectomies were performed. The vaginal route was used for 1530 patients. In the last decade, the Heaney method was used. A comparison of the periods 1974-1984 and 1984-1994 revealed that with the Heaney technique, we had significantly fewer complications, including less febrile morbidity, bleeding requiring transfusion, and injuries. Vaginal hysterectomy, specially using the Heaney method, is a rewarding challenge for any gynecologic surgeon. There are a low postoperative morbidity rate and a low mortality rate, which is well below the average mortality rate associated with abdominal hysterectomy. PMID- 10163503 TI - Effects of intraperitoneal Ringer's lactate instillation and infusion on postsurgical adhesion formation. AB - We compared the effects of continuous Ringer's lactate infusion and Ringer's lactate instillation on postsurgical adhesion formation in the rat model. The results show that intraperitoneal Ringer's lactate instillation reduces postsurgical adhesions. However, its efficacy is not improved by additional infusion of Ringer's lactate. PMID- 10163504 TI - Early performance appraisal of the Omniflow II Vascular Prosthesis as an indicator of long-term function. AB - The search for the ideal vascular prosthesis for below the knee replacement or coronary surgery continues. Long-term explant analysis of a biosynthetic composite vessel, the Omniflow Vascular Prosthesis I, has previously shown sound structural durability. An important determinant in defining durability has been the evaluation of the degree of persistence of the original biological components and the augmentation by new tissue. The development of a panel of specific monoclonal antibodies to collagens, that allow detection of new host collagen among the original collagens of the prosthesis has been a key factor. In the present study, these antibodies have been used to investigate the degree and rate of new collagen tissue infiltration in an improved version of the Omniflow prosthesis. The data show that new collagen types III and VI can be detected as early as 3 months in the adventitial tissue, and that complete tissue augmentation throughout the entire vessel wall is apparent by 6 months after implant. The novel explant analyses serve as a good predictive indication to the in vivo performance of the device and would be useful in rapid monitoring of further modifications to this vessel or to other collagen-based prostheses. PMID- 10163505 TI - A review of 198 patients (389 implants) who had breast implants removed. AB - Because of the large number of women now returning to their plastic surgeons with concerns about their breast implants many years after surgery, we are afforded an ideal opportunity to evaluate these patients over the long-term. This study reviewed 198 patients (389 implants) who underwent explantation by two surgeons over a 2-year period, correlating prosthesis type, location, and length of time since implantation with two adverse endpoints, implant rupture and symptomatic capsular contracture. Significant findings included a relatively high rate of implant rupture in patients whose implants had been in place over 20 years, an increased incidence of both symptomatic capsular contracture and implant rupture in single lumen gel implants and a positive correlation between severity of capsular contracture and implant rupture. PMID- 10163506 TI - The enhancement of nerve regeneration using growth factors: a brief review. AB - The management of peripheral nerve injuries continues to challenge the surgeon. Despite advances in surgical technique, return of normal function is uncommon after the repair of a transected nerve. It is now possible to enhance the process of nerve regeneration in animals using growth factors carried in silicone nerve guides. In this article the biological process of nerve regeneration is described and contemporary research involving the use of growth factor implants to facilitate nerve regeneration is reviewed. PMID- 10163507 TI - Experience with the penile prosthesis and artificial urinary sphincter. AB - The therapy of two common urologic problems, erectile dysfunction and urinary stress incontinence, has been revolutionized over the last 20 years by the incorporation of principles of hydraulic mechanics into the field of silicone prosthesis implantation. The inflatable penile prosthesis is surgically implanted into men with impotence due to organic or psychogenic etiology. The artificial urinary sphincter has found widespread use in males and females in both the adult and pediatric populations with stress incontinence from a variety of causes. Associated with these popular devices are various complications relating to the anatomic site as well as the host's immunologic response. The use of these implants, as well as the technologic innovations resulting from various adverse effects, are reviewed herein. PMID- 10163508 TI - Arterial substitutes in peripheral vascular surgery: a review. AB - A large proportion of general vascular surgery involves diagnosis and operative treatment of disorders of the arterial system. To a great extent, advances in the operative care of patients with arterial disease have been dependent on the development of clinically satisfactory arterial substitutes. Currently, based on extensive basic research and clinical experience, prosthetic grafts are preferred as substitutes for larger caliber arteries, while autogenous veins provide the best results as substitutes for smaller, lower flow vessels in the extremities. In this review, we examine the arterial substitutes that have been and are currently important in the clinical practice of general vascular surgery. From this material, it should be apparent to the reader that the perfect arterial substitute does not exist and all, when implanted in humans, are associated with well-recognized short and long term complications. PMID- 10163509 TI - Effect of HA coating on the long-term survival of dental implant: a review of the literature. AB - Hydroxyapatite (HA)-coated dental implants have been used clinically for over ten years. Several types of HA-coated implants are available commercially, and a number of clinical and basic studies evaluating the effect of HA coating have been reported. Concerns regarding microbiological susceptibility, resorption, fatigue, and Fracture in long-term application have been pointed out. However, in spite of the aggressive use of HA-coated implants for compromising cases, high success rates have been reported. Our review of the literature suggests that the advantages of using HA-coated dental implants are early bone response and a higher interface shear strength with bone. PMID- 10163510 TI - Commentary: obstacles to scientific discovery. AB - Over the last two centuries, obstacles to scientific discovery frequently have been encountered by visionary scientists. From Semmelweis to Marshall, many scientists have faced rigid and nonintellectual academic environments that refused to recognize innovative advances. Their heroic journeys should be a constant reminder to us to create an academic environment that fosters intellectual freedom. PMID- 10163511 TI - Histologic analysis of the periprosthetic tissues of long-term surviving cemented total hip arthroplasties. AB - Qualitative and semiquantitative features of the interfacial membranes of five long-term (> 16 years) surviving cemented total hip arthroplasties (four revision cases and one autopsy case) were compared with those of thirty short-term surviving (< 15 years) cemented hip prostheses. Cement granulomas, micron-sized polyethylene particles-induced giant-celled granulomas, sheets of submicron-sized polyethylene particles-laden macrophages, and aggregated, metallic particles laden macrophages were scattered in the fibrous tissue of all interfacial membranes. Quantitatively, characteristics of the interfacial membranes of the two groups differed from one another. The dominant species of prosthetic debris in the interfacial membranes of the short-term surviving joint replacements was derived from the polyethylene acetabular socket, and, correspondingly, giant celled granulomas and macrophagic sheets predominated. Metallic particles and the macrophagic reaction thereto dominated in the interfacial membranes of the long term surviving arthroplasties, and large cement and polyethylene chunks typically were incorporated in the fibrous tissue of the membranes without an accompanying macrophagic response. In long-term surviving hip arthroplasties, metallic particles may be at least as important as polymeric detritus in stimulating the formation of the bone-resorbing, granulomatous interfacial membrane, which is the hallmark of aseptically loosened arthroplasties. Differences in mechanical settings may account for unlike modes and rates of generation of prosthetic breakdown products, explaining the disparate survivorship of different patients' artificial joints. PMID- 10163512 TI - Does the immune system play a role in loosening and osteolysis of total joint replacements? AB - Total joint replacement is a highly successful surgical procedure with an excellent outcome over many years. However, because this procedure is now being performed in younger patients, and because the average age of our population continues to increase, greater expectations have been placed on joint implants in the hope that they will last forever. Aseptic loosening and osteolysis of total joint replacements are the main processes limiting long-term implant survival. This paper focuses on the possible role of immunological mechanisms in the processes of loosening and osteolysis of joint replacements, with special emphasis on polymeric materials. This topic is very controversial: In vitro experiments and in vivo studies in animals and humans are reviewed and provide evidence for both sides of the debate. In some patients, immunological processes appear to be activated after a total joint replacement has been implanted. Specific materials or their by-products might function as haptens and elicit a T lymphocyte-mediated, delayed hypersensitivity reaction. Many factors probably are important, including the genetic makeup and immune competence of the patient, prior exposure to the same or similar materials, degree of exposure (rate of generation of particles and the efficacy of clearance mechanisms), and characteristics of the particles themselves. PMID- 10163514 TI - Recommendation on mean molar activity coefficients and single ion activity coefficients of solutions for calibration of ion-selective electrodes for sodium, potassium, and calcium determination. IFCC Scientific Division Working Group on Selective Electrodes. AB - In principle, flame photometry measures substance concentration, and ion selective electrodes (ISEs) measure ion activity. However, the situation regarding the comparison of results from the two techniques when applied to blood plasma is complex. The problem can be approached experimentally from the point of view of calibration of ISEs with concentration calibrators, and similar procedures are adopted for commercial ISE-based clinical analyzers. Nevertheless, there is interest in the evaluation of single ion activities in blood plasma and solutions simulating its ionic composition. Solutions are proposed for calibrating ISEs for the determination of sodium, potassium, and calcium. It is recommended that the values for single ion activities derived from the Pitzer treatment of mixed electrolyte solutions be adopted, because, although this has some empirical features, it has a sounder theoretical basis than the previously used Stokes-Robinson-Bates hydration approach. PMID- 10163513 TI - Trace elements in pediatrics. AB - This review discusses biologic roles, metabolism, and clinical aspects of three essential trace elements, zinc, copper, and selenium. Clinical situations that result in disturbed trace element metabolism, and signs or symptoms that may suggest a trace element problem are listed. Important issues for trace element assay development are emphasized, and examples of pediatric reference ranges provided. PMID- 10163515 TI - Laboratory assessment of protein energy status. AB - Protein energy malnutrition (PEM) is widespread throughout the world in both community and hospital settings. Assessment of PEM in an individual consists of good dietary and clinical assessment, followed by laboratory measurements. Recent changes in body weight and simple anthropometric measurements are also useful. Laboratory measurements have the advantage in that they are independent of body size, they can be made precisely, and allow monitoring of progress. However, laboratory measurements must be interpreted with caution, especially in seriously ill patients in the hospital. PMID- 10163517 TI - Medical education: challenges and opportunities. AB - New curricula and educational methods are needed in medical education to take account of changes in the material taught, and the way in which education is delivered. We describe two approaches to these challenges--an internationally developed slide-text-based program and a multimedia clinical case-based CD-ROM project. PMID- 10163516 TI - Development of a reference system for the international standardization of HbA1c/glycohemoglobin determinations. AB - The essential role of glycohemoglobin measurements in diabetes care and the currently poor comparability of results between different methods used in clinical laboratories makes an international standardization absolutely necessary. The IFCC working group on HbA1c standardization is going to develop a reference system for the international standardization which is based on HbA1c as the biochemically well-defined major glycohemoglobin component, and consisting of primary and secondary reference materials, a reference method and adjusted reference and target values. The system will serve for the standardization of all glycohemoglobin assays. PMID- 10163518 TI - A US FDA medical device update, Part II. AB - This column in last month's edition discussed answers to some of the questions raised at a recent Food and Drug Administration (FDA) conference held in Paris. This article continues that discussion and includes questions and answers concerning harmonization and good manufacturing practice (GMP) requirements. As in the preceding column, the answers were provided by FDA speakers at the conference or subsequently confirmed in discussions with the author. PMID- 10163519 TI - Complements of the season: the hazards of testing for complement activation. AB - As some of the subtleties of the new era of biological testing become appreciated, a few of the more recently introduced tests are starting to cause concern. The evaluation of the ability of a material to activate complement comes into this category. This article explains complement and its activation and attempts to rationalize the need for testing in this complex area. PMID- 10163520 TI - Rheumatoid arthritis: new concepts in disease evolution, pathogenesis, and treatment. PMID- 10163521 TI - Total hip replacement arthroplasty in patients with inflammatory arthritis. AB - 1. Hip involvement in inflammatory arthritis is a relatively common entity. 2. Total hip replacement offers the most reliable surgical treatment option for pain relief and the restoration of hip function when medical management is exhausted. 3. Preoperative evaluation and perioperative medical management should focus on the particular medical problems of patients with systemic rheumatologic conditions. 4. In patients without protrusio deformity, cemented total hip replacement with modern cement technique offers excellent long-term functional results. PMID- 10163523 TI - Rheumatoid arthritis of the knee: the role of total knee arthroplasty. PMID- 10163522 TI - Diagnosis of infected joint prostheses. PMID- 10163524 TI - Rheumatoid arthritis of the ankle: the role of total ankle arthroplasty. AB - The indications for total ankle replacement are limited to older patients with rheumatoid arthritis, especially those with multiple joint involvement and limited physical activity. The recommended surgical technique for total ankle arthroplasty includes an anterior surgical approach, minimal bone resection, and meticulous technique for cemented fixation of components. The results of published studies suggest total ankle arthroplasty should not be performed in patients who have had previous surgery on the ankle or foot, or who are younger than 57 years of age. PMID- 10163525 TI - Rheumatoid arthritis of the cervical spine. AB - There is a high incidence of cervical involvement in patients with rheumatoid disease. Early evaluation of the neck, close follow-up with dynamic radiographs of the cervical spine, and careful neurological assessment are important in the care of these patients. Surgical stabilization should be considered early even in the absence of neurological findings when significant instability is noted since outcome is related to preoperative neurological function. The type of fusion performed is determined by a careful assessment of the location of instability, patient factors, and the experience of the surgeon with various techniques. The type of postoperative immobilization should be decided on an individual basis depending on the quality of fixation achieved at surgery. Patients must be observed closely in the postoperative period for development of early complications and followed-up for the appearance of pseudarthrosis or late instabilities. PMID- 10163526 TI - Surgical options in the treatment of arthritis of the shoulder: alternatives to prosthetic arthroplasty. AB - Reconstructive options for glenohumeral arthritis revolve around the timing and success of hemi-joint arthroplasty and total joint arthroplasty techniques. The purpose of this article is to discuss the alternative treatment options of shoulder arthritis. Specific options include arthroscopic debridement, synovectomy, capsular release, osteotomy, resection arthroplasty, interposition arthroplasty, and arthrodesis. In the early stages of the arthritic process, arthroscopic debridement, synovectomy and capsular release, may delay the onset of more severe symptoms and degenerative changes requiring a prosthetic reconstruction. However, their role as a definitive procedure is limited. The use of resection arthroplasty and arthrodesis represent salvage procedures used when an implant has failed or become infected. However, function will be predictably diminished. PMID- 10163527 TI - Humeral head replacement for glenohumeral arthritis. AB - From July 1977 through March of 1983, humeral head replacement was performed on 35 shoulders with osteoarthritis and 32 shoulders with rheumatoid arthritis and followed-up for an average of 9.3 years. Satisfactory pain relief was achieved in 44 (66%) and 52 of the shoulders (78%) were described by patients as being much better or better. Active elevation was improved from an average of 84 degrees to an average of 110 degrees with external rotation improving from 20 degrees to 44 degrees. Strength improvement also occurred. Only three complications developed, and these did not affect the final outcome. Because of moderate or severe pain, 12 shoulders (18%) required revision to total shoulder arthroplasty, and all patients were relieved of their pain. The result ratings were excellent in 10 shoulders, satisfactory in 23, and unsatisfactory in 34 (51%). With longer follow up, a satisfactory level of pain relief may not continue for those patients with osteoarthritis and rheumatoid arthritis who have had humeral head replacement alone. Whereas this form of treatment should certainly be considered in those patients who have inadequate glenoid bone to support a glenoid implant and probably be considered in younger patients or patients who wish to remain more active, these latter patients must be fully appraised that the probability of continuing pain relief is less than has often been appreciated. PMID- 10163528 TI - Biomechanics of total shoulder arthroplasty: a preoperative and postoperative analysis. AB - To successfully perform a total shoulder arthroplasty, it is essential to understand the normal anatomy and biomechanics of the shoulder joint. Currently, nonconstrained prostheses offer the most consistent and durable long-term results, allowing for the restoration of normal anatomy and motion close to that of the normal shoulder joint. To determine the effects of the disease process, surgical technique, and postoperative rehabilitation on glenohumeral biomechanics after nonconstrained total shoulder arthroplasty, a prospective clinical trial was undertaken to evaluate preoperative and postoperative shoulder motion clinically and roentgenographically in nine patients with severe arthritis. Preoperatively, the ratio of glenohumeral to scapulothoracic motion was 1:2; for every degree of glenohumeral movement there were two degrees of scapulothoracic motion. This was associated with significant pain and decreased motion in the shoulder and represented the patient's attempt to immobilize the glenohumeral joint for pain relief and maximize shoulder movement with scapulothoracic motion. After total shoulder arthroplasty, significant improvements were observed in pain relief, motion, and function; however, the ratio of glenohumeral to scapulothoracic motion was not significantly different. The abnormal ratio indicates that less motion occurs between the prosthetic components compared with a normal joint, whereas scapulothoracic motion is unchanged. Abnormal shoulder biomechanics seem to be a function of the underlying disease process and were not restored after total shoulder arthroplasty. Despite the successes to date, improvements on the current state of the art are still needed, and will occur with better understanding of the complex biomechanics of the shoulder joint. PMID- 10163529 TI - Measuring outcomes in shoulder arthroplasty. AB - No standard assessment for the patient with a shoulder arthroplasty has been universally accepted to date. Traditional assessment tools can be divided into three levels of resolution including: (1) assessments of the quality of life and general health, (2) global shoulder assessments, and (3) assessments for a particular disorder of the shoulder. In this article, examples of each of these groups are discussed. Each of these levels of sensitivity offers a different perspective on the outcome of shoulder arthroplasty and until the ideal, universal outcome measure is developed, outcomes should be reported using assessments in each of these levels. PMID- 10163530 TI - Total shoulder arthoplasty: pearls and pitfalls in surgical technique. AB - Total should arthroplasty is recommended for the treatment of shoulder arthritis that causes severe pain and loss of function. Successful shoulder arthroplasty is a technically demanding procedure because of lack of intrinsic stability of the glenohumeral joint. The tension of the rotator cuff and glenohumeral capsule must be balanced for mobility and stability. Attention to important anatomic landmarks and glenohumeral relationships ("pearls") minimizes the risk of complications ("pitfalls"). PMID- 10163531 TI - Rotator cuff insufficiency in the arthritic shoulder: treatment alternatives. AB - Shoulder arthroplasty can relieve the pain and improve the functional status of an arthritic shoulder. Because of the unique anatomic characteristics of the glenohumeral joint, the rotator cuff provides stability and control of shoulder motion. Thus, an intact, functioning rotator cuff is necessary for successful shoulder arthroplasty. There are clinical situations where the rotator cuff is torn, absent, or incompetent and an arthritic condition affects the shoulder. The patient must understand that, when confronted with rotator cuff insufficiency and shoulder arthritis, the goal of surgical treatment is limited to pain relief, with shoulder function often limited by the condition of the rotator cuff. We will discuss the incidence of rotator cuff disease associated with differing arthritic conditions, the treatment options available, and expected outcomes in these difficult and challenging clinical situations. PMID- 10163532 TI - Failure of total shoulder arthroplasty: why does it occur? AB - From a historical perspective, shoulder arthroplasty has evolved significantly from its inception. Much like arthroplasty of the lower extremities, shoulder implant design had its roots in a constrained device. Unfortunately, the inherently high loads that these devices generated across the implant articulation and the glenoid bone interface resulted in an unacceptably high failure rate. Beginning with Neer's original hemiarthroplasty of the 1950s and the more recent implant designs, there has been a strong trend toward less constraint and a greater emphasis on soft tissue preservation in shoulder replacement. In the ideal arthroplasty patient with an intact rotator cuff and a stable, yet degenerative, glenohumeral joint, arthroplasty invariably yields good to-excellent results 90% of the time. However, owing to the enormous functional range of motion of the joint and its inherent dependence on soft tissues for both stability and motion, there are many areas for potential complications. This article addresses the etiology, recognition, and treatment of these problems. PMID- 10163533 TI - Instability after shoulder arthroplasty: causative factors and treatment options. AB - Instability is an uncommon complication after shoulder arthroplasty. In this article, we review the literature, discuss causative factors, and outline treatment options for instability after arthroplasty of the shoulder. PMID- 10163534 TI - Shoulder rehabilitation for the arthritic glenohumeral joint: preoperative and postoperative considerations. AB - Arthritis of the glenohumeral joint can cause pain, weakness, and limit motion. Preoperative treatment consists of physical therapy to manage pain, increase shoulder motion, and increase rotator cuff and scapulothoracic muscle strength. The postoperative three-phase rehabilitation program described is structured, supervised, and involves the cooperation of the patient, surgeon, and physical therapist. Rate of progression and ultimate outcome is based on underlying pathology, surgical technique, and patient tolerance to exercise. Patients with an intact rotator cuff should be expected to tolerate a more aggressive rehabilitation program and expect a higher functional outcome. Those with a deficient cuff mechanism can expect more modest gains oriented toward restoring pain-free functional activity. PMID- 10163535 TI - The WAA next presidency--Genoa as a micro-image of apheresis evaluation over the next few years. PMID- 10163536 TI - Royal College of Physicians of Edinburgh Consensus Conference on autologous transfusion: final consensus statement. PMID- 10163537 TI - New horizons in blood transfusion medicine: present status and future trends. AB - In the past two decades, we have witnessed enormous advances in all areas of transfusion medicine, from simple and practical aspects of blood component collection and processing to the development of "designer products" and the use of recombinant products or other alternatives. Considerable efforts were directed, in particular, towards transfusion support for specific categories of patients, such as neonates and those undergoing transplant procedures, where patients' clinical states ultimately influence the choice of product(s) and where emphasis should be placed on both the optimisation of clinical effectiveness and safety, as well as minimising the adverse/untoward effects of transfusion. The objective of this Forum Discussion is to provide an overview of what is currently on the horizon and then describe the potential changes that are expected on the new horizon, within the next decade. In this BBTS-Component Special Interest Group, therefore, we have attempted to build a bridge between the new expanding areas of related specialties at both cellular and molecular levels and the equally important practical and clinical aspects. Thus, alongside the presentation on the overall safety/efficacy of standard products, the potential use of some alternatives and recombinant products were discussed. Emphasis is also placed on the new generation test for function testing and the potential application of DNA-based technologies in blood transfusion, which will continue to be more innovative in respect to the avoidance of transfusion associated infections and its immunological risks, and will bring about continual improvement of the clinical effectiveness of products derived from human blood. PMID- 10163538 TI - Future trends for provision of safer blood components/blood products. PMID- 10163539 TI - Fibrin sealant: update on clinical studies. PMID- 10163540 TI - Comparative clinical studies of platelet concentrates: effects on clinical outcome and the use of healthcare resources. NBS Platelet Study Group. AB - The Platelet Study Group are developing proposals to conduct a prospective randomised trial of different platelet products in the transfusion support of patients with haematological malignancy. All patients will receive prestorage leucodepleted red cells and will be randomised to receive either multiple donor non-apheresis buffy coat platelets which are non-leucodepleted (BCP), single donor apheresis platelets non-leucocyte depleted (SDP) or single donor (LD-SDP). All leucocyte depleted products will contain fewer than 5 x 10(6) WBC/transfusion. The primary objective of the study is to compare clinical efficacy, the incidence of adverse reactions treatment outcome and the use of healthcare resources. PMID- 10163541 TI - The biological significance and therapeutic potential of megakaryocyte growth and development factor (Mpl-ligand). PMID- 10163542 TI - Application of DNA-based technology in blood transfusion. PMID- 10163543 TI - Molecular biology of human immunodeficiency virus type-1. AB - Tremendous progress has been made in our understanding of the multiplication and pathogenesis of the human immunodeficiency virus, the causative agent of acquired immunodeficiency syndrome (AIDS). To block virus multiplication several targets in the life cycle of the virus have already been identified for which antiviral drugs can be developed and gene therapy can be envisaged as a possible treatment or cure of AIDS. The combination of several therapies might be needed for effective treatment. Prevention of HIV infections through effective vaccines still awaits novel, unconventional strategies. PMID- 10163544 TI - A risk-to-benefit analysis for central venous catheters. AB - Reliable venous access is an important consideration in the management of the cancer patient, where long-term intravenous therapy is needed. A single institution retrospective analysis of 205 catheter placements allowed comparison of different lines and techniques. This experience shows that surgical introduction under general anaesthetic of a double-lumen, 12 gauge, silastic catheter in the superior vena cava, via the internal jugular vein and using a 15 cm anterior chest wall tunnel, resulted in longest survival, fewest infections, and enjoyed a high patient acceptability. A substantial cost-saving, particularly in antibiotic usage, was observed as a result of the improved technique. PMID- 10163545 TI - A method for the cryopreservation of red blood cells using hydroxyethyl starch as a cryoprotectant. AB - A simple, quick, inexpensive and long term method of cryopreserving human red cells using hydroxyethyl starch (HES) as a cryoprotectant is described. No sophisticated equipment or skilled labour is required. As HES is a plasma expander, it does not have to be removed prior to transfusion, thereby obviating the requirement for a washing stage. This allows 60 units/h to be prepared. As the microbiological integrity of the system is maintained, there is potential for prolonged storage post-thaw at 4 degrees C. Recoveries of 99% and 30 min saline stabilities in excess of 91% have been consistently achieved. P50O2 and 2,3DPG values are not significantly decreased. PMID- 10163546 TI - Blood transfusion and deep venous thrombosis in primary total hip and knee replacement surgery: a retrospective analysis of 339 patients. AB - Autologous blood transfusion (ABT) has become widely practiced as a useful procedure in preventing the side effects of allogeneic blood transfusion (allo BT) and in coping with a cost-containment policy. We report on a retrospective analysis of blood support of 339 patients undergoing orthopedic elective surgery in the period 1988-1994. We observed a progressive decrease of allo-BTs (from 54.5 to 14.8% in males and from 73.7 to 15.5% in females undergoing total hip replacement), and assessed the usefulness of post-operative blood salvage in reducing the need for allo-BT when a concomitant pre-deposit program is conducted. In addition, we carefully reviewed charts in order to establish Deep Venous Thrombosis (DVT)-related morbidity, and found a surprisingly low incidence (only 3.2%) of this dreadful complication in our patient series. It is yet to be established whether anticoagulant prophylaxis and early mobilization are strongly effective in preventing DVT, or that many DVTs happen after hospital discharge and are not identified and/or reported to the orthopedic team. PMID- 10163547 TI - Effect of cold storage on the haemostatic cascade systems. AB - This study dealt with the effect of citrate phosphate dextrose adenine (CPDA) whole blood stored at 4 degrees C for 5 weeks and fresh frozen plasma at -30 degrees C for 12 months on coagulation, fibrinolytic and kallikrein system activation. Stored whole blood showed a significant decrease in ATIII activity by the second week with a significant decrease in thrombin-antithrombin complex by the fourth week. alpha 2-antiplasmin and plasminogen decreased significantly by the first and second week, respectively, accompanied by a significant increase in D-dimer level by the fourth week. A significant decrease in C1-inhibitor activity occurred by the first week associated with a significant increase in kallikrein activity by the third week. However, all measured parameters were minimally affected in fresh frozen plasma. Therefore, fresh frozen plasma supplemented with packed RBCs are preferred to whole blood stored over 3 weeks especially in patients with proteolytic enzyme system activation. PMID- 10163548 TI - Plasma exchange in chronic inflammatory demyelinating polyneuropathies. AB - Chronic Inflammatory Demyelinating Polyneuropathies (CIDP) are characterized by demyelination of peripheral nerves with mononuclear cell infiltrates, electrical conduction slowing or block and elevated cerebrospinal fluid protein with no cells. An immune mediated pathogenesis has been suggested. Immune suppressive therapy, as well as plasmapheresis and intravenous immunoglobulins have been used with variable success. Our objective was to review our results of plasma exchange in this disease in 20 patients with very different underlying diseases, none of them eligible for the Canadian CIDP plasmapheresis study, and define certain guidelines of predictability for the effectiveness of plasma exchange. Five patients had monoclonal gammopathies of unknown significance, two had lung cancer, one breast cancer, one hairy cell leukemia and later carcinoma of the pancreas; two had hepato-splenomegaly and hemolytic anemia; nine were idiopathic (two with autoimmune markers). Plasmapheresis varied from 4 to 31 plasma volumes and procedures with a median of 12, always with 5% albumin. Two excellent responses, one very good, two moderate transient and 12 had no change in clinical or conduction status. Best response occurred in paraproteinemias. Thus immune modulation with plasma exchange may be useful in CIDPs with paraproteinemias and autoimmune manifestations. PMID- 10163550 TI - Combining IgG and interferon alpha-2b in chronic hepatitis C virus infection. AB - Treatment of chronic active hepatitis C virus (HCV) liver disease remains unsatisfactory. Interferon alpha 2b (IFN) has shown favorable though often unsustained effects. Besides its antiviral properties, IFN is a recognized immune modulator. We present data showing the favorable evolution of a case treated with IFN and IgG. Besides the antibody repertoire, the influence of IgG on the immune network is increasingly considered. The complex interactions resulting from combining drugs with immunomodulatory properties, such as IFN and different IgG preparations, may sound confusing. However, it might provide an insight into the outcome of chronic HCV infection, in which, evidently, immune components are heavily implicated. Prolonged treatment, with high-dose intravenous immunoglobulin (IVIG) seemed to be effective, either independently or by potentiating IFN. PMID- 10163549 TI - Peripheral blood stem cell collection from healthy donors for allogeneic transplantation. AB - There is great interest in the use of peripheral blood stem cells (PBSC) for allogeneic transplantation, based on the good results seen with autologous PBSC infusion. Reasonable caution exists regarding the use of allogeneic PBSC for transplantation because of donor toxicities due to rhG-CSF administration and the risk of graft-versus-host-disease (GVHD) in the recipient because of the large number of T-cell infused. We present preliminary data on allogeneic PBSC collections and transplantation in ten patients affected by advanced leukemia (eight patients), severe aplastic anemia (one patient) and sickle cell anemia (one patient). Seven donors were HLA-identical siblings, while the other three were mismatched for three, two and one locus, respectively. All donors received rhG-CSF at a dose of 12 micrograms/kg for a mean of 5 days. Leukaphereses were performed with the aim of collecting a minimum of 5 x 10(6)/kg (recipient's weight) CD 34+ cells. Collection timing was determined by monitoring CD 34+ cells in the donor's peripheral blood from the second day of rhG-CSF therapy. The PBSC collections yielded a mean of 10.05 x 10(8) MNCs/kg and of 10.48 x 10(6) CD 34+ cells/kg (recipient's weight). PBSC were immediately infused after collection in patients given myeloablative therapy. Engraftment was observed in each patient at a mean of 13.2 days for an absolute neutrophil count (ANC) more than 0.5 x 10(9)/L and of 26.5 days for a platelet count of more than 20 x 10(9)/L. Eight patients experienced no or moderate acute GVHD, whereas two patients died of grade 4 GVHD, notwithstanding GVHD prophylaxis with cyclosporine and prednisone. Two other patients died of viral and fungal infections, respectively, despite prophylaxis. The remaining six patients are alive between 58 and 430 days after transplant. Our results document that allogeneic PBSC are capable of engraftment after a myeloablative regimen. Controlled trials are necessary to compare the potential benefits of this approach with the results obtained in allogeneic bone marrow transplantation. PMID- 10163551 TI - Hemapheresis listening post. Certification of the hemapheresis practitioner HP (ASCP). PMID- 10163552 TI - The current status of extracorporeal immunomodulation. AB - A course of extracorporeal immunomodulation is defined as a treatment which intervenes and consequently modulates or, in other words, activates and/or suppresses the immune mechanisms utilizing an extracorporeal procedure. Such treatment has traditionally depended on administration of drugs, typically steroids and/or immunosuppressants. Most of the apheresis techniques currently available belong to or are very similar to those used for blood purification and involve the removal of the pathogenic substances such as antibody(ies) and/or immune complex(es). The cellular components are also treated in extracorporeal immunomodulation. As some of the extracorporeal immunomodulation techniques have already demonstrated clinical effectiveness that cannot be achieved by conventional therapies, it is appropriate to propose a new therapeutic approach to the immunological disorders. PMID- 10163553 TI - Specific removal of anti-acetylcholine receptor antibodies in patients with myasthenia gravis. AB - In short-term therapy for myasthenia gravis caused by an antibody-mediated attack on the acetylcholine receptor (AChR) in skeletal muscle, a specific system for antibody removal, the use of tryptophan-bound immunoadsorbent and synthetic AChR peptide-bound immunoadsorbent, offers advantages over plasma exchange. These two types of immunoadsorption provided selective or semi-selective removal of pathogenic substances from the circulation without the use of plasma products, and minimized side-effects. A difficulty is that the former removed about 65% of the total IgG, and the latter removed only a fraction of the pathogenic antibodies. In neither case can a radical method of treatment for myasthenia gravis be expected. Hopefully, an adsorbent which has a well-balanced bioimmunological specific binding reaction and physicochemical adsorptive affinity will be developed in the future. PMID- 10163554 TI - Removal of anti-A/B antibodies for successful kidney transplantation between ABO blood type incompatible couples. AB - A growing shortage of cadaveric donors has prompted expansion of the criteria for acceptable living donors. Because of this, ABO-incompatible kidney transplantation has been carried out. To remove anti-A and/or anti-B antibodies, the recipients received one or two sessions of double filtration plasmapheresis (DFPP) and three or four sessions of immunoadsorption prior to transplantation until the anti-A IgG/IgM titers and/or anti-B IgG/IgM titers decreased to 1:16 or less. Our immunosuppressive protocol involved treatment with the drugs methylprednisolone, cyclosporine, azathioprine, anti lymphocyte globulin and deoxyspergualin. The patient survival was 98% at 1 month, 98% at 3 months, 94% at 6 months, and 92% at 1-5 years. Graft survival was 92% at 1 month, 88% at 3 months, 85% at 6 months, 81% at 1 year, and 76% at 5 years. Both DFPP and/or immunoadsorption eliminated anti-ABO antibodies from ABO-incompatible kidney transplant recipients effectively and safely. The results of the ABO-incompatible kidney transplantation were acceptable and not different from those of ABO compatible cases. PMID- 10163555 TI - Extracorporeal granulocytapheresis for cancer and rheumatoid arthritis. AB - In cancer and rheumatoid arthritis, granulocytosis is often observed and indicates the progress of disease. We developed a granulocytapheresis system to permit granulocyte reduction. Cellulose acetate was found to be a selective and effective adsorbent. In an in vivo study using an acetate bead column, 9.2 x 10(8) leukocytes were collected. Initially, granulocytapheresis was applied to terminal patients or those with stage IV cancer. Pain, cough and bloody sputum were reduced in spite of no decrease in tumor size. Granulocytapheresis appears to prevent inflammatory damage in or around the tumor site. This granulocyte reduction technique was also applied to patients with rheumatoid arthritis. The Lansbury index markedly improved after treatment. As cytokines and adhesion molecules might contribute to symptoms, granulocytapheresis may be useful in improving the "Quality of Life" in these diseases. PMID- 10163556 TI - Stem cells: what's happening? Megakaryocyte growth and development factor and platelet aggregation. PMID- 10163557 TI - Platelet loss during peripheral blood progenitor cell collections. PMID- 10163558 TI - Rethinking research relationships in qualitative research. AB - The research relationship within qualitative research methods, that is, the relationship between researcher and research participant, is reexamined in this paper. We draw upon our own research experiences of working with high-risk individuals and vulnerable communities in reframing a discussion of the interview process. We illustrate the emotionally provocative and volatile nature of the research relationship and argue for the necessity of social research protocols which extend beyond a utilitarian research framework, the expansion of the researcher's role to include skillful navigation of the intersubjective aspects of research interviewing, and participant advocacy. PMID- 10163559 TI - Community integration and quality of life: a comparison of persons with psychiatric disabilities in housing programs and community residents who are neighbors. AB - Fifty-one persons with psychiatric disabilities in housing programs in the Ottawa Carleton area were compared with a matched sample of 51 community residents on several aspects of community integration and subjective quality of life. Matching criteria included sex and location (i.e., living within one square block). Results showed persons with psychiatric disabilities reporting lower levels of social contact with neighbours and general life satisfaction than community residents. Both groups showed similar levels of physical presence and sense of community in the neighbourhood. Implications of the findings for planning and improving community mental health services are discussed. PMID- 10163560 TI - Payor provider alliances. PMID- 10163561 TI - Hand therapy for the general therapist. PMID- 10163562 TI - Hospital-based fitness centers. PMID- 10163563 TI - Controversies in the management of asthma. AB - The debate persists on the relative role of beta 2-agonists, corticosteroids, and other antiasthmatic drugs, in part because asthma can be so difficult to control. Exploration of the concerns about therapy is followed by practical recommendations. PMID- 10163564 TI - Achieving 'best practice' in health promotion: improving the fit between research and practice. AB - This paper is based on the proposition that transfer of knowledge between researchers and practitioners concerning effective health promotion interventions is less than optimal. It considers how evidence concerning effectiveness in health promotion is established through research, and how such evidence is applied by practitioners and policy makers in deciding what to do and what to fund when addressing public health problems. From this examination it is concluded that there are too few rewards for researchers which encourage research with potential for widespread application and systematic development of promising interventions to a stage of field dissemination. Alternatively, practitioners often find themselves in the position of tackling a public health problem where evidence of efficacy is either lacking, or has to be considered alongside a desire to respond to expressed community needs, or the need to respond to political imperative. Several different approaches to improving the fit between research and practice are proposed, and they include improved education and training for practitioners, outcomes focussed program planning, and a more structured approach to rewarding research development and dissemination. PMID- 10163565 TI - An extensive literature review of the evaluation of HIV prevention programmes. AB - This paper draws out and distils three key themes that have emerged from a substantial bibliographical review of a range of HIV intervention programmes, implemented throughout the world between years 1987 and 1995. Specifically, the paper assesses (1) to what extent intervention programmes have been tailored to meet the requirements and needs of specific target groups; (2) to what extent intervention programmes are supported by social and psychological theory of attitudinal and behavioural change, and also to what extent the results and findings from the interventions have amended existing theory; and, finally, (3) the range of methodologies employed in evaluating intervention programmes and also to what extent behavioural measures have been used in examining a programme's effectiveness. In light of these themes, the paper presents and discusses the principal factors thought to contribute towards the effectiveness of HIV intervention programmes. PMID- 10163566 TI - Choice and accountability in health promotion: the role of health economics. AB - Choices need to be made between competing uses of health care resources. There is debate about how these choices should be made, who should make them and the criteria upon which they should be made. Evaluation of health care is an important part of this debate. It has been suggested that the contribution of health economics to the evaluation of health promotion is limited, both because the methods and principles underlying economic evaluation are unsuited to health promotion, and because the political and cultural processes governing the health care system are more appropriate mechanisms for allocating health care resources than systematic economic analysis of the costs and benefits of different health care choices. This view misrepresents and misunderstands the contribution of health economics to the evaluation of health promotion. It overstates the undoubted methodological difficulties of evaluating health promotion. It also argues, mistakenly, that economists see economic evaluation as a substitute for the political and cultural processes governing health care, rather than an input to them. This paper argues for an economics input on grounds of efficiency, accountability and ethics, and challenges the critics of the economic approach to judge alternative mechanisms for allocating resources by the same criteria. PMID- 10163567 TI - Evidence for success in health promotion: suggestions for improvement. AB - This paper argues that health promotion needs to develop an approach to evaluation and effectiveness that values qualitative methodologies. It posits the idea that qualitative research could learn from the experience of quantitative researchers and promote more useful ways of measuring effectiveness by the use of intermediate and indirect indicators. It refers to a European-wide project designed to gather information on the effectiveness of health promotion interventions. This project discovered that there was a need for an instrument that allowed qualitative intervention methodologies to be assessed in the same way as quantitative methods. PMID- 10163568 TI - The economics of shared care packages. PMID- 10163570 TI - An historical survey of UK government measures to control the NHS medicines expenditure from 1948 to 1996. AB - Since the inception of the National Health Service in 1948, successive British governments have taken various measures to restrain the growth of the medicines bill. A total of 10 different measures have been introduced with very limited success. The most effective measures have been those directed at increasing the level of generic prescribing; such measures mean that the patient is treated with older, off-patent medicines which, although cheap, are not necessarily cost effective or the most clinically effective. Possible future directions for curtailing expenditure include controlling the price of off-patent branded medicines to the level of generic products, and the initiation of a government policy to actively encourage prescribing of newer medicines where these are shown to be more clinically effective or more cost effective. PMID- 10163569 TI - Interferon-alpha in hepatitis C. Dosage, costs and benefits. PMID- 10163572 TI - Dynamic competition as an exploratory model of healthcare policy for the antihypertensive market. AB - Dynamic competition based on innovation, rather than classical competition based on price, may better explain the research-intensive pharmaceutical market. In an exploratory comparison of these models, economic indicators of annual change in price and price elasticity of demand were tested in a repeated-measures design by analysis of variance. Between 1990 and 1992, updated US prescribing guidelines for hypertension provided a framework in which the contrast between 2 newer classes and 2 older classes of first-line therapies served as a marker for innovation. The principal hypothesis was that newer classes would be less elastic than older classes, but with such innovation-based differences eroding over time. Although temporarily greater inelasticities for newer classes supported dynamic competition, initially extreme inelasticities for newer classes indicated a market distortion or a shifting demand curve. These exploratory results, although requiring substantiation, point toward using dynamic competition in crafting healthcare policy for the pharmaceutical market. PMID- 10163571 TI - Economic implications of resistance to antimalarial drugs. AB - The widespread evolution of drug resistance in malarial parasites has seriously hampered efforts to control this debilitating disease. Chloroquine, the mainstay of malaria treatment for many decades, is now proving largely ineffective in many parts of the world, particularly against the most severe form of malaria- falciparum. Alternative drugs have been developed, but they are frequently less safe and are all between 50 and 700% more expensive than chloroquine. Choice of drug clearly has important budgetary implications and national malaria control programmes need to weigh up the costs and benefits in deciding whether to change to more effective but more expensive drugs. The growth in drug resistance also has implications for the choice of diagnostic tool. Clinical diagnosis of malaria is relatively cheap, but less specific than some technological approaches. As more expensive drugs are employed, the cost of wasted treatment on suspected cases who do not in fact have malaria rises and the more worthwhile it becomes to invest in more specific diagnostic techniques. This paper presents an economic framework for analysing the various malaria drug and diagnostic tool options available. It discusses the nature of the key factors that need to be considered when making choices of malaria treatment (including treatment costs, drug resistance, the costs of treatment failure and compliance) and diagnosis (including diagnosis cost and accuracy, and the often overlooked costs associated with delayed treatment), and uses some simple equations to illustrate the impact of these on the relative cost effectiveness of the alternatives being considered. On the basis of some simplifying assumptions and illustrative calculations, it appears that in many countries more effective drugs and more specific and rapid diagnostic approaches will be worth adopting even although they imply additional expense. PMID- 10163573 TI - A comparison of the cost effectiveness of alternative prophylactic therapies in childhood asthma. AB - An economic analysis was conducted comparing the cost effectiveness of fluticasone propionate with that of sodium cromoglycate (cromolyn sodium) in a group of children aged 4 to 12 years old with asthma, who required inhaled prophylactic therapy. Over an 8-week study period, 115 patients received sodium cromoglycate 20mg 4 times daily, via the spin operated dry powder inhaler, and 110 patients received fluticasone propionate 50 micrograms twice daily, via the Diskhaler (trademark held by the Glaxo Wellcome Group of Companies). Patient healthcare resource use was examined in terms of study medication, the use of rescue medication [salbutamol (albuterol) 200 micrograms] and the number of hospitalisations. The effectiveness of both treatments was examined over a range of success and failure criteria embracing peak expiratory flow rate (PEFR) improvement, symptom control and the level of adverse events related to the study medication. Results indicate that, for each UK pound spent, fluticasone propionate was associated with twice as many successfully treated patients as sodium cromoglycate, using a range of outcomes based on the goals of treatment defined in the British Thoracic Society's asthma guidelines. It is concluded that fluticasone propionate was more cost effective than sodium cromoglycate in improving PEFR and symptom control in this group of children with asthma who had a clinical requirement for prophylactic therapy. PMID- 10163574 TI - Impact of selective financing of drugs on pharmaceutical expenditure control in the province of Valladolid, Spain. AB - In July 1993, public financing for 1692 drug specialities was stopped in Spain (a drug speciality is a medicine with a defined composition, particular pharmaceutical form and dosage, prepared for immediate use, ready and packaged for dispatching to the public, with uniform name, packaging and labelling which has been granted authorisation by the State Administration and registered in the Pharmaceutical Specialities Register). We designed a study to assess the repercussions of this so-called 'selective financing' on expenditure control. The aims of the study were 2-fold: first, to forecast the consumption of drug specialities that are reimbursable on the Spanish National Health Service, had selective financing not been applied; and, secondly, to estimate the impact of selective financing on drug consumption. For short- and medium-term forecast estimates, time-series analysis was used, and was applied to monthly consumption data. The measures of consumption used were the number of prescriptions per 1000 patients, and cost [in Spanish pesetas (Pta; $US1 = Pta123.9, February 1996)] per 1000 patients. Data were analysed from January 1986 up to the introduction of selective financing. We found that drug specialities excluded by selective financing showed, overall, a negative increase (i.e. the consumption of drugs that were excluded under selective financing decreased). The repercussion forecast, both in terms of prescription numbers and cost, of the 13 excluded drug specialities that had the highest pre-selective financing consumption is decreasing compared with total consumption. The assessment of the repercussions of selective financing up to December 1994 was made by calculating the difference between actual expenditures and forecast expenditures in the absence of selective financing. This repercussion, in prescriptions, was lower than the percentage of the 1692 excluded drug specialities relating to total consumption in 1992. The repercussion in cost, nevertheless, was greater than expected during the first year of selective financing application. This could be attributable to average price containment of drug specialities due to causes other than selective financing itself. The economic impact of selective financing after 1 year of application was reduced because of accommodation phenomena. PMID- 10163576 TI - ACE inhibition in diabetic patients. Economic implications. PMID- 10163575 TI - Streptokinase. A pharmacoeconomic appraisal of its use in the management of acute myocardial infarction. AB - Thrombolytic therapy with streptokinase and other agents reduces mortality and is now well accepted as the mainstay of revascularisation options for most patients after an acute myocardial infarction. Streptokinase is as efficacious as alteplase (recombinant tissue plasminogen activator; rt-PA) when given as a 3 hour infusion, anistreplase, reteplase and saruplase in reducing mortality. However, in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial, an accelerated alteplase regimen (1.5-hour infusion) plus intravenous heparin demonstrated a statistically significant 1% absolute mortality reduction compared with streptokinase plus heparin. Treatment with streptokinase is consistently clinically superior to conventional treatment and is cost effective: the marginal cost per year of life saved (cost/YLS) is less than $US/$Can20,000 (1990 or 1991 currency) assuming 5 year survival. In addition, streptokinase treatment is associated with fewer intensive care days and total days spent in hospital and a decrease in the use of intensive care services compared with conventional therapy. Importantly, the cost/YLS of treating older patients (70 to 80 years) with streptokinase is similar to that in younger patients (approximately $US22,000, 1990 currency). In 1 study, the cost of in-hospital treatment and associated 1-year follow-up costs did not differ significantly regardless of whether patients received streptokinase or anistreplase. In the most comprehensive cost-effectiveness analysis to date, GUSTO investigators determined that the incremental cost/YLS in patients who received the accelerated alteplase regimen instead of streptokinase was $US32,678 (1993 currency); the projected life expectancy was about 15 years. Thrombolytic therapy is generally more cost effective in patients at high risk than in those at low risk. The cost effectiveness of streptokinase is dependent on infarct location and time to treatment, but is more favorable in patients with anterior than inferior infarctions and those treated as soon as possible after symptom onset. There are as yet no comparative data to indicate a clinical benefit for one thrombolytic agent over another in patients treated more than 6 hours after symptom onset; therefore, in all likelihood, streptokinase will be preferred on the basis of cost minimisation. Streptokinase is associated with a slightly higher rate of severe bleeding than alteplase but a lower incidence of stroke. Although quality-of-life information comparing thrombolytics is unavailable, most patients who received streptokinase or alteplase rated their quality of life as high on the basis of results from time trade-off assessments and health surveys. In summary, streptokinase is undeniably cost effective compared with conventional treatment. It is up to individual healthcare systems to determine whether the mortality advantage and cost differential of the accelerated alteplase regimen over streptokinase, as seen in the GUSTO trial, are affordable and justifiable. However, it is important to realise that treatment options may be limited by healthcare resources; thus, streptokinase can be regarded as a cost-effective thrombolytic strategy which is both efficacious and affordable within the constraints of most healthcare budgets. PMID- 10163577 TI - A review of the progress towards developing health-related quality-of-life instruments for international clinical studies and outcomes research. AB - This article reviews the international adaptation and use of generic health related quality-of-life (HRQL) measures over the last several years. It focuses, as examples, on the Nottingham Health Profile (NHP), the Sickness Impact Profile (SIP), the Medical Outcomes Study Short-Form 36 Item Health Survey (MOS SF-36), the EuroQoL, Dartmouth Primary Care Cooperative Information Project (COOP) chart system, the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ) and the World Health Organization's WHOQOL. These instruments exemplify several different models for developing or adapting HRQL measures described in the literature, each model choosing unique approaches to the process of validation for cross-national use. There has been considerable scientific activity in recent years aimed at advancing the capabilities for international HRQL assessments. Whereas prior adaptation work was focused exclusively on translation issues, recent work has begun to rely on common methodology for translation and validation of key measurement properties across language versions. Although the major HRQL measures reviewed have not yet reached the point at which there is sufficient evidence for measurement equivalence across different language versions, internationally coordinated projects are planned and under way for these instruments to advance and refine this capacity. Preliminary evidence suggests that there are few prominent differences between countries in ranking of health states that are representative of major HRQL dimensions, and in the levels of impact of illnesses on well-being within those dimensions. Future studies should collect additional psychometric data to more fully quantify measurement equivalence among the various language versions in which each instrument is available. Additionally, more work is required to address cultural differences within nations or language groups. PMID- 10163580 TI - The economics of a pharmacy-based central intravenous additive service for paediatric patients. AB - This study was designed to compare the costs of a pharmacy-based Central Intravenous Additive Service (CIVAS) with those of traditional ward-based preparation of intravenous doses for a paediatric population. Labour costs were derived from timings of preparation of individual doses in both the pharmacy and ward by an independent observer. The use of disposables and diluents was recorded and their acquisition costs apportioned to the cost of each dose prepared. Data were collected from 20 CIVAS sessions (501 doses) and 26 ward-based sessions (30 doses). In addition, the costs avoided by the use of part vials in CIVAS was calculated. This was derived from a total of 50 CIVAS sessions. Labour, disposable and diluent costs were significantly lower for CIVAS compared with ward-based preparation (p < 0.001). The ratio of costs per dose [in 1994 pounds sterling] between ward and pharmacy was 2.35:1 (2.51 pounds:1.07 pounds). Sensitivity analysis of the best and worst staff mixes in both locations ranged from 2.3:1 to 4.0:1, always in favour of CIVAS. There were considerable costs avoided in CIVAS from the multiple use of vials; the estimated annual sum derived from the study was 44,000 pounds. In addition, CIVAS was less vulnerable to unanticipated interruptions in work flow than ward-based preparation. CIVAS for children was more economical than traditional ward-based preparation, because of a cost-minimisation effect. Sensitivity analysis showed that these advantages were maintained over a full range of skill mixes. Additionally, significant savings accrued from the multiple use of vials in CIVAS. PMID- 10163579 TI - Characterisation of asthma management in the Fallon Community Health Plan from 1988 to 1991. AB - In order to characterise asthma management in a managed care setting, we identified 10,301 patients who were diagnosed with asthma between 1 January 1988 and 31 December 1991 at a group model health maintenance organisation in central Massachusetts, US. We obtained for these patients automated utilisation files containing data on medications, hospitalisations, emergency room visits, office visits, and estimated costs of these services. The medication dispensed to the greatest proportion of patients was beta 2 agonists either by inhalation (56%) or orally (21%). Theophylline was dispensed to 23% of the patients. Maintenance therapy was inhaled anti-inflammatory medication was uncommon, as inhaled corticosteroids (17%) and sodium cromoglycate (cromolyn sodium) [8%] were dispensed to fewer patients than other asthma medications. Among patients who had been hospitalised in the previous year, 36% were presently receiving inhaled corticosteroids, and among patients who used at least one beta 2 agonist metered dose inhaler per month, 49% were presently receiving inhaled corticosteroids. Economic analyses showed that only 8% of the patients had either a hospital admission or an emergency room visit, but hospital costs among these patients accounted for 25% of the total costs of asthma care. In addition, the top 10% most expensive patients accounted for 42% of the total cost of asthma care. We conclude that a substantial proportion of patients at increased risk of a severe attack, by virtue of having a recent hospitalisation, do not receive maintenance anti-inflammatory therapy, and that hospitalisations among a relatively small proportion of asthma patients contribute significantly to the cost of asthma care. PMID- 10163581 TI - Full-cost determination of different levels of care in the intensive care unit. An activity-based costing approach. AB - We applied an activity-based costing methodology to determine the full cost of intensive care service at a community hospital, a university hospital and a health maintenance organisation (HMO)-affiliated hospital. A total of 5 patient care units were analysed: the intensive care unit (ICU) and surgical ICU (SICU) at the university setting, the ICU at the community setting, and the SICU and cardiac care unit at the HMO setting. The selection of the different ICU types was based on the types of critical care units that were found in each setting (e.g. the HMO did not have an ICU). Institution-specific cost data and clinical management parameters were collected through surveys and site visits from the 3 respective organisation types. The analysis revealed a marked increase in patient minute cost associated with mechanical ventilation. Higher costs associated with prolonged neuromuscular blockade have important economic implications with respect to selection of an appropriate neuromuscular blocking agent. PMID- 10163578 TI - Pharmacoeconomics of chronic nonmalignant pain. AB - Pain is one of the most common reasons for patients to seek medical care. In most settings, the model of acute pain treatment, with its emphasis on pharmacological therapy, is used for acute and chronic pain alike. Persistent chronic pain, however, often leads to complex social and psychological maladaptations, as well as substantial direct and indirect costs. Thus, the proper treatment of chronic pain usually involves pharmacological, behavioural and psychological interventions. Pain is a subjective sensation, but persistent chronic pain often results in long term neurophysiological and psychological changes that might be more appropriately considered disease manifestations. Unfortunately, the subjectivity of pain has meant that the assessment of the epidemiology, pharmacotherapy and economic costs of chronic pain has been difficult. As a result, many of the techniques for chronic pain management are unfamiliar to practising physicians. Even those healthcare professionals who are familiar with the special techniques for the management of chronic pain may be unable to identify the subpopulations for which they might be most effective. The clinician must evaluate patients for the appropriateness of a number of alternative drug delivery methods, novel analgesic agents, neuromodulatory techniques and multidisciplinary behavioural and psychological treatment programmes. The most effective treatment will often involve a combination of these techniques, as determined by the unique features of the patient's pain condition as well as individual patient characteristics. The costs and outcomes of various treatment strategies vary considerably and there is a need for comparative studies. Increasing emphasis on diagnosis and treatment in the primary care setting will place more importance on knowing the relative efficacies and appropriate use of a widening array of choices for chronic pain treatment. The management of chronic pain is remarkably complex and resource-intensive, and there is clearly a need for more intensive pharmacoeconomic studies, especially those comparing the many alternative strategies for management. PMID- 10163582 TI - Use of confidence intervals in health economic studies. PMID- 10163583 TI - Economics of serotonin 5-HT3 antagonists. PMID- 10163584 TI - Helping gatekeepers refer patients to appropriate specialist care. PMID- 10163586 TI - Technological equipment financing options and strategies: an automated pharmacy dispensing system example. PMID- 10163585 TI - The rationale for a National Spine Network. PMID- 10163587 TI - An approach to the selection and termination of providers in managed care organizations. PMID- 10163588 TI - Satisfaction with outcome as a function of patient expectation: the national antibiotic patient satisfaction surveys. PMID- 10163589 TI - Rural network extends reach of teleradiology. PMID- 10163590 TI - Studies strive to place fMRI on firm foundation. AB - Research designed to reproduce and extend the scope of fMRI studies found that startling results could be produced, but that there was also a disconcerting variability among subjects. Some patients consistently showed marked changes, others showed little or no effect and a third group displayed quite variable results. PMID- 10163591 TI - Bitter struggle imminent over emergency imaging. PMID- 10163592 TI - Back pain study relies on intermediate outcomes. PMID- 10163593 TI - Physician profiling trend homes in on radiology. PMID- 10163594 TI - Ultrasound holds edge in carotid screening. PMID- 10163595 TI - Recent developments in cardiac pacing. AB - Indications for cardiac pacing continue to expand. Pacing to improve functional capacity, which is now common, relies on careful patient selection and technical improvements, such as complex software algorithms and diagnostic capabilities. PMID- 10163596 TI - A comprehensive review of the effects of worksite health promotion on health related outcomes: an update. PMID- 10163597 TI - Getting smarter and maybe wiser. PMID- 10163598 TI - Stress management in work settings: a critical review of the health effects. AB - PURPOSE: To review critically the research literature on the health effects of worksite stress-management interventions. SEARCH METHODS: Stress-management interventions were defined as techniques that are designed to help employees modify their appraisal of stressful situations or deal more effectively with the symptoms of stress. Stress-management studies that were worksite based, assessed a health outcome, and were published in the peer-reviewed literature were included in this review. The main search method was the one described in the lead article to this special issue of the JOURNAL, but supplementary sources included prior reviews of the research literature and expert contacts. Sixty-four studies met the criteria for inclusion in this review. SUMMARY OF FINDINGS: A variety of stress-management techniques was used in worksite studies, including muscle relaxation, meditation, biofeedback, cognitive-behavioral skills, and combinations of these techniques. The most common techniques used were muscle relaxation, cognitive-behavioral skills, and combinations of two or more techniques. Outcome measures to evaluate the success of stress interventions included physiologic and psychologic measurements, somatic complaints, and job related measures. Nearly three-fourths of the studies offered the training to all workers and did not specifically recruit high-stress employees. Over half the studies were randomized control trials, but only 30% conducted posttraining follow-up evaluations. The effectiveness of stress interventions varied according to the health-outcome measure used; some techniques were more effective for psychologic outcomes (e.g., cognitive-behavioral skills), whereas others were more effective for physiologic outcomes (e.g., muscle relaxation). Biofeedback was the least frequent technique used in work settings and also seemed to be the least effective technique. Meditation produced the most consistent results across outcome measures but was used in only six studies. In general, studies using a combination of techniques (e.g., muscle relaxation plus cognitive-behavioral skills) seemed to be more effective across outcome measures than single techniques. CONCLUSIONS: The large number of different stress-management techniques coupled with the wide range of health outcome measures used in stress intervention studies makes it difficult to draw firm conclusions about the efficacy of each technique and each outcome. Also, the quality of the methodology varied substantially among studies. Nevertheless, the most positive results across the various health outcomes were obtained with a combination of two or more techniques. None of the stress interventions was consistently effective in producing effects on job/organization-relevant outcomes, such as absenteeism or job satisfaction. To produce changes on these types of measures, stress interventions will need to alter or modify the sources of stress in the work environment. It can be said that stress management in work settings can be effective in enhancing worker physical and psychologic health, but the choice of which stress-management technique to use should be based on the specific health outcomes that are targeted for change. PMID- 10163599 TI - Alcohol: a review of the impact of worksite interventions on health and behavioral outcomes. AB - PURPOSE: To review, evaluate, and summarize research published in scientific journals linking alcohol-related interventions in the worksite to either individual or organizational outcomes. METHODS: A review of the literature published in peer-review journals between 1970 and 1995 identified 24 articles that reported the results of studies on the impact of worksite programs on alcohol control on health and behavioral outcomes. IMPORTANT FINDINGS: There is strong suggestive evidence and some conclusive evidence that worksite interventions including core components of employee assistance programs are effective in rehabilitating employees with alcohol problems. There is suggestive and conclusive evidence that worksite training oriented toward alcohol problems affects the attitudes of supervisors and employees for reasonable periods after the completion of training. CONCLUSIONS: Investment in worksite interventions directed at reducing alcohol-related problems appears to be a sound strategy, although considerably more research is needed. This research should include broad representation of appropriate worksite populations. Similar measurements should be used across studies. To the extent possible, randomized control group designs should be employed. Without significant external sponsorship, it is not likely that such an improved body of research data will emerge. PMID- 10163600 TI - The health effects of worksite HIV/AIDS interventions: a review of the research literature. AB - PURPOSE: To examine the individual and organizational health effects of HIV/AIDS interventions conducted at the worksite. SEARCH METHODS: This review is part of a series of reviews that used search methods described in an introductory article. To supplement these methods, HIV/AIDS-specific periodicals were searched to include journals that might not be incorporated in the computerized databases. Twelve of the 20 articles identified through the Centers for Disease Control and Prevention and our own subsequent searches met the criteria and were included in this review. FINDINGS: Ten of the 12 studies reviewed reported positive effects of employee education programs on knowledge or attitudes. Nine of the studies involved health care workers or employees with potential occupational exposure to HIV, and nine lacked a comparison or control group. None of the studies however, examined the effects of policies, manager training, or family education on the organization or person. CONCLUSIONS: Methodologic weaknesses in many of the studies reviewed, coupled with the small number of studies, led us to conclude that the research literature on worksite HIV/AIDS interventions is weak. Impact is, however, plausible. Future research should be directed toward developing valid measures of key variables, controlling for confounding factors, and ultimately examining the impact of organizational factors. PMID- 10163601 TI - The theory of planned behavior: a review of its applications to health-related behaviors. AB - PURPOSE: To review applications of Ajzen's theory of planned behavior in the domain of health and to verify the efficiency of the theory to explain and predict health-related behaviors. METHODS: Most material has been drawn from Current Contents (Social and Behavioral Sciences and Clinical Medicine) from 1985 to date, together with all peer-reviewed articles cited in the publications thus identified. FINDINGS: The results indicated that the theory performs very well for the explanation of intention; an averaged R2 of .41 was observed. Attitude toward the action and perceived behavioral control were most often the significant variables responsible for this explained variation in intention. The prediction of behavior yielded an averaged R2 of .34. Intention remained the most important predictor, but in half of the studies reviewed perceived behavioral control significantly added to the prediction. CONCLUSIONS: The efficiency of the model seems to be quite good for explaining intention, perceived behavioral control being as important as attitude across health-related behavior categories. The efficiency of the theory, however, varies between health-related behavior categories. PMID- 10163602 TI - Characteristics of participants and nonparticipants in worksite health promotion. AB - PURPOSE: To identify demographic characteristics associated with worksite health promotion participation and to determine whether employees with high-risk health related behaviors, as measured by a health risk appraisal, were participating in programs designed to address these behaviors. DESIGN: Descriptive. SETTING: A petrochemical research and development company where employees were offered a health risk appraisal questionnaire, a series of on-site wellness programs, and an on-site fitness center. SUBJECTS: All employees (n = 2290) working continuously from May 1, 1990, through February 28, 1992. MEASURES: Demographic and behavioral risk characteristics of participants and nonparticipants. RESULTS: Participation was 37% (health risk appraisal), 64% (all wellness programs), and 10% (fitness center), with women participating at higher rates than men in all programs. Most programs attracted 10% to 40% of the employees at risk for the particular behavior addressed by the program, although lower penetration (7% to 9%) was observed for the on-site fitness center and blood pressure education programs. With the exception of wellness programs for weight, smoking, and blood pressure, employees at lower behavioral risk tended to be more likely to participate than employees at high risk. CONCLUSIONS: Efforts to increase participation by all company employees, especially among those with high-risk behaviors, would benefit all health promotion programs, particularly the on-site fitness center. PMID- 10163603 TI - Enhancing critical thinking in paramedic continuing education. AB - Critical thinking has become a buzzword, especially in medical education. The challenge is first to determine what skills compose critical thinking and what teaching techniques promote critical-thinking skills, and then to determine how to apply these techniques effectively and efficiently to a given population in the classroom. This article begins with a working definition of critical thinking and explores the parameters and skills implied or stated in the definition. Then a teaching environment constructed around a model of critical thinking and characteristics of the audience is described. A specific teaching method, suggested by research and designed to exercise critical-thinking skills, is then applied to a specific patient problem in a continuing education class. Preliminary outcomes are presented. The purpose of this article is to propose a productive and efficient educational method for promoting and enhancing critical thinking skills appropriate for paramedic-level continuing education. PMID- 10163604 TI - EMS knowledge and skills in rural North Carolina: a comparison with the National EMS Education and Practice Blueprint. AB - INTRODUCTION: Many state and local emergency medical services (EMS) systems may wish to modify provider levels and their scope of practice to align their systems with the recommendations of the National Emergency Medical Services Education and Practice Blueprint. To determine any changes that may be needed in a typical EMS system, the knowledge and skills of EMS providers in one rural area of North Carolina were compared with the knowledge and skills recommended in the National Emergency Medical Services Education and Practice Blueprint. METHODS: A survey listing 175 items of patient care-oriented knowledge and skills described in the National Emergency Medical Services Education and Practice Blueprint was developed. EMS providers from five rural eastern North Carolina counties were asked to identify on the survey those items of knowledge and skills they believed they possessed. The skills and knowledge selected by the respondents at the five different North Carolina levels of certification were compared with the knowledge and skills listed for comparable provider levels delineated by the National Emergency Medical Services Education and Practice Blueprint. The proportions of the recommended skills reported to be possessed by the respondents were compared to determine which North Carolina certification levels best correlate with the Blueprint. RESULTS: One hundred forty-five EMS providers completed the survey. The proportion of recommended skills and knowledge reported to be possessed by Emergency Medical Technicians (EMTs) ranked significantly lower than did the skills and knowledge reported to be possessed by respondents at other levels in five of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Defibrillator-level personnel ranked lower than did those reported to be possessed by respondents at other levels in seven of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Intermediates ranked lower than did those reported to be possessed by respondents at other levels in nine of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Advanced Intermediates ranked lower than were the skills and knowledge reported to be possessed by respondents at other levels in two of the 10 Blueprint elements. Finally, the proportion of recommended skills and knowledge reported to be possessed by EMT-Paramedics ranked lower than were those reported to be possessed by respondents at other levels in one of the 10 Blueprint elements. CONCLUSION: In North Carolina, combining the EMT and EMT Defibrillator levels and eliminating the EMT-Intermediate level would create three levels of certification, which would be more consistent with levels recommended by the Blueprint. The results of this study should be considered in any effort to revise the levels of EMS certification in North Carolina and in planning the training curricula for bridging those levels. Other states may require similar action to align with the National Emergency Medical Services Education and Practice Blueprint. PMID- 10163605 TI - Requiring on-line medical command for helicopter request prolongs computer modeled transport time to the nearest trauma center. AB - INTRODUCTION: Rapid transport from scene to closest trauma center requires optimal use of public safety first responder (FR), basic life support (BLS), advanced life support (ALS), and transport resources (ground or air). In some parts of this regional emergency medical services (EMS) system, on-scene ALS requires contact with on-line medical command (OLMC) to obtain authorization for air medical helicopter (AMH) dispatch, because some EMS medical directors believe that this may decrease overutilization of AMH services. HYPOTHESIS: The hypothesis of this study was that requiring prior OLMC for AMH dispatch prolongs mean time to a trauma center versus either FR or BLS request for AMH. METHODS: Computer mapping programs were used to model the most rapid driving time to the closest trauma center from 167 actual AMH responses to the scene of a motor vehicle accident. In an OLMC-ALS model, only OLMC-ALS can request an AMH. In a BLS model, BLS units arrive on the scene and the crew requests simultaneous dispatch of an ALS response and an AMH. In the FR model, on arrival at the scene, a FR requests simultaneous dispatch of a BLS unit, an ALS unit, and an AMH. RESULTS: The OLMC-ALS model resulted in a longer mean value for time to trauma center by an AMH than did the computer model for all ground transport settings. The FR model yielded a shorter mean time for AMH compared with the mean values for time to trauma center for all settings. Differences in mean values for time in urban settings were small (ground: 42 minutes, air: 36 minutes), whereas those for the suburban (ground: 52 minutes, air: 41 minutes), and those for rural (ground: 69 minutes, air: 47 minutes) were significant clinically. For the BLS model, these differences persisted, but were significant clinically only in the rural setting (ground: 68 minutes, air: 53 minutes). CONCLUSIONS: Optimal use of AMH requires balancing the need for early helicopter dispatch to fully exploit its speed advantage with the disadvantage of expensive overutilization. This computer model indicates that the best person to request AMH varies by venue: in urban settings, the OLMC physician should request AMH dispatch; in suburban venues, BLS should request AMH dispatch; and in rural venues, FRs should request AMH dispatch. PMID- 10163606 TI - A survey of emergency medical services systems on college and university campuses. AB - INTRODUCTION: Many colleges and universities appear to exist in relative isolation from community-based emergency medical services (EMS) systems. In response, some have developed their own EMS systems. OBJECTIVE: To determine the extent of this phenomenon and to delineate the characteristics of these systems. DESIGN/METHODS: Questionnaires were mailed to 1,503 colleges/universities in the United States and Canada. The questionnaire asked whether the institution had an EMS system and included 19 questions about the characteristics of the system. RESULTS: A total of 919 (61%) responses were received. Of the institutions responding, 234 (25%) had an EMS system and 31 (3.4%) were considering starting a system. Characteristics of the systems were as follows: 1) Types of patients-the two most common call types were medical and trauma/surgical; 134 (57%) reported one-fourth of calls to be medical and 91 (39%) reported one-fourth of calls to be trauma/surgical. 2) Type of service-133 (57%) services transport patients; 195 (83%) respond only to the campus or other university property; the remainder also respond to the community; and 135 (58%) function all year. 3) Dispatch-178 (76%) are dispatched by the campus police, although most services are dispatched by several sources; 46 (20%) use 9-1-1. 4) Personnel-two systems (0.85%) exclusively employ paramedics; 141 systems (60%) have at least one emergency medical technician; the remainder use emergency care attendants and first-aid providers; 118 (50%) have medical directors, of these 76 (64%) are student health physicians and 21 (18%) are community physicians. 5) Demographic Information-The majority of the campus-based EMS systems exist on small campuses in urban areas. CONCLUSIONS: A significant number of colleges/universities have EMS systems and one-half transport patients. However, the level of training of the personnel and medical direction may be below the standard for the EMS systems in the communities in which these campus-based systems exist. PMID- 10163607 TI - Lessons in emergency evacuation from the Miamisburg train derailment. AB - Hazardous materials incidents result from the release of materials considered to be harmful or potentially harmful to human beings or the environment. This article describes a train derailment and subsequent hazardous materials release with the evacuation of approximately 50,000 citizens. The hazardous materials release took five days to control and resulted in 561 patient visits to local emergency departments for symptoms related to chemical exposure. The evacuation and emergency medical operations are described and serve as a model for developing community emergency preparedness plans and managing victims involved in hazardous materials incidents. PMID- 10163608 TI - Carbon monoxide and nonquantitative carbon dioxide detection. AB - INTRODUCTION: The capnometric demonstration of end-tidal carbon dioxide (CO2) is a reliable method of differentiating between a correct endotracheal tube position and an accidental misplacement of the tube into the esophagus. Recently, several CO2 detectors have been introduced for monitoring end-tidal CO2 in the "out-of hospital" setting, where quantitative capnometry with capnography is not yet available. HYPOTHESIS: These devices are not influenced by carbon monoxide (CO) present in lethal concentration. METHODS: A heated (37 degrees C) 2.3 L reservoir bag filled one-third full with water (representing the stomach in esophageal misintubation) was machine ventilated (tidal volume: 450 ml; frequency: 16/min) with the following mixtures for three minutes each: 1) 95% O2, 5% CO; 2) 45% O2, 5% CO, 50% N2O; and 3) 44% O2, 5% CO, 50% N2O, 1% halothane. The presence of end tidal CO2 was monitored with each of the following devices: 1) MiniCAP III CO2 Detector; 2) StatCAP CO2 Detector; 3) EasyCAP CO2 Detector; 4) PediCAP CO2 Detector; and 5) Colibri CO2 Detector. RESULTS: In none of the cases was the presence of CO2 signaled by the detector. CONCLUSION: The presence of 5% CO does not interfere with infrared spectrometry detection (MiniCAP and StatCAP) or chemical detection (EasyCAP, PediCAP, and Colibri) of CO2. The devices can be used safely in patients with CO poisoning for monitoring of endotracheal tube position. PMID- 10163610 TI - Does basic life support in a rural EMS system influence the outcome of patients with respiratory distress? AB - PURPOSE: The purpose of this study was to determine whether basic life support, prehospital emergency medical care in a rural area affects the hospital course of patients with respiratory distress. METHODS: Medical records for patients admitted from the emergency department with a discharge diagnosis related to respiratory disease were reviewed. Data collected included: 1) mode of arrival; 2) initial symptom; 3) vital signs; 4) prehospital interventions applied; 5) hospital days; 6) discharge status; and 7) principal diagnosis. Multiple logistic regression analysis was used to predict length of hospital stay. RESULTS: Charts for 603 patients were reviewed. Complete data for all variables included in the logistic regression analysis were available for 471 patients (78.1%). Because 55 patients died, only 416 (69.0%) were included in the multiple regression analysis conducted to predict length of hospital stay. Logistic regression analysis demonstrated that patients who arrived by ambulance and older patients were more likely to die; patients with higher systolic blood pressures were more likely to survive. Only patient age predicted length of hospital stay, with older patients having longer stays. CONCLUSIONS: Basic life support prehospital care in this rural emergency medical services system does not result in a lower mortality rate or a shorter hospital stay for a broad group of patients with respiratory distress who require hospital admission. Although this study is limited to a single population and a single emergency medical services system, it is one of only a few studies of outcome in basic life support systems. PMID- 10163609 TI - Comparison of inhaled metaproterenol via metered-dose and hand-held nebulization in prehospital treatment of bronchospasm. AB - INTRODUCTION: Although the efficacy of the administration of beta-adrenergic bronchodilators has been demonstrated, the best method available for the delivery of these drugs in the prehospital setting has not been defined. This paper compares the effects of administration of metaproterenol when administered by paramedics using either a metered-dose inhaler (MDI) or a hand-held nebulizer (HHN). HYPOTHESIS: There is no difference in the effects produced in patients suffering from smooth bronchiolar muscle spasm by metaproterenol when delivered either by a standard metered-dose inhaler or with a hand-held nebulizer. PARTICIPANTS: Consecutive prehospital patients complaining of difficulty breathing with clinical evidence of bronchospasm and with a history of asthma, chronic obstructive pulmonary disease, or emphysema who were not in extremis. METHODS: Prior to the administration of metaproterenol, a peak expiratory flow rate (PEFR) was obtained. This measurement was repeated five minutes following the conclusion of the administration of metaproterenol. Patients in Burbank, California, received the treatment using a standard metered-dose inhaler, and those in Madison, Wisconsin, received the drug using a hand-held nebulizer. Peak expiratory flow rates were compared using Student's t-tests with Bonferroni's correction. Statistical significance was set at p < 0.05. RESULTS: Data were collected from 36 consecutive patients by the paramedics of the Burbank Fire Department and from 32 consecutive patients by the paramedics of the Madison Fire Department. For the metered-dose inhaler group, the mean value for peak expiratory flow rate for the pre-treatment test was 95.4 +/- 88.1 l/min, and after treatment was 109.4 +/- 89.3 l/min (p < 0.001). For the hand-held nebulizer group, the mean value for peak expiratory flow rate before the administration of the metaproterenol was 96.1 +/- 76.3 l/min and following the treatment was 149.1 +/- 92.9 l/min (p < 0.001). The mean values for the differences between the control peak expiratory flow rate and the post-treatment peak expiratory flow rate for the metered-dose inhaler group was + 140.0 +/- 27.4 l/min, and for the hand-held nebulizer group was + 53.0 +/- 69.1 l/min (p < 0.003). CONCLUSIONS: In the prehospital setting, the administration of metaproterenol using a hand-held nebulizer is more effective than delivering the drug using a metered-dose inhaler. The hand-held nebulizer is easier to use and delivers a higher dose of the drug than is convenient using the metered-dose inhaler. PMID- 10163611 TI - A comparison of EMS continuing education for paramedics in the United States. AB - OBJECTIVE: To determine characteristics of continuing education programs for paramedics in large metropolitan areas, and to make recommendations for changes in the Chicago Emergency Medical Services (EMS) system. DESIGN: A survey of 95 metropolitan areas from each state in the United States. PARTICIPANTS: EMS medical directors, coordinators, and administrators. RESULTS: The survey population included 56 respondents. Within this group, 23% were from areas of 1 million people or more, 61% in areas with populations of 100,000 to 1 million and 16% from areas populated by < 100,000 people. Several system types were represented in the survey. In the systems surveyed, 98% mandate didactic continuing education requirements. Clinical continuing education was required by 34% of the systems. Ten systems (18%) awarded continuing education hours for documented in-field experience. This method did not have a specific structure by the majority of users. Both written and skills testing were used by most EMS systems to evaluate paramedic competency. No statistically significant differences (p > 0.05) could be found among population subgroups or EMS system types when evaluating the use of these various methods. CONCLUSION: EMS systems primarily use didactic sessions to meet their continuing education requirements. Nearly half of the systems requiring clinical continuing education use in-field credit to fulfill these requirements. In-field credit systems are poorly developed to date. This mechanism may be an effective alternative to usual clinical experiences for paramedics and deserves further investigation. PMID- 10163612 TI - Sources of stress among emergency medical technicians (Part I): What does the research say? AB - Research repeatedly has demonstrated that organisms exhibit adaptive physiological, emotional, and behavioral responses when exposed to noxious or threatening environmental stimuli. However, when the noxious stimuli are excessive or prolonged, efforts to cope may become overwhelmed, and the adaptive responses can turn into maladaptive reactions (e.g., illness, depression, and impaired performance). According to this model of stress, people who work in occupations that continually place them in danger or repeatedly force them to encounter psychologically demanding or distressing situations would appear to be at greater risk for developing adverse stress reactions. Both anecdotal evidence and empirical research suggest that prehospital emergency medical services (EMS) may be a particularly high-stress field, placing emergency medical technicians (EMTs) at risk for developing such maladaptive stress reactions. This article reviews and synthesizes the empirical literature investigating the sources of stress among EMTs, and concludes with critical comments and guidelines for future research. The authors intend this review to be a resource for investigators conducting research in this area, as well as a convenient summary for anyone interested in learning more about the stressors EMTs experience, particularly mental health professionals and EMS administrators coordinating stress-management programs for EMTs. PMID- 10163613 TI - The effects of stressors on emergency medical technicians (Part II): A critical review of the literature, and a call for further research. AB - Part I of this series of articles about stress among emergency medical technicians (EMTs) reviewed the potential sources of EMT stress. This article investigates the other side of the stress equation and provides a critical review of the empirical literature on the effects of stressors on EMTs. It is subdivided into sections corresponding to trends in the research, including: 1) predictors of higher stress levels; 2) differences in stress responses among EMTs, other health professionals, and firefighters; and 3) various physiologic, psychologic, and job performance responses. It identifies some of the methodologic flaws found in the EMT-stress literature that are noted in Part I, and provides further direction for future research. To maintain homogeneity, this review is limited to those articles published in scholarly journals. Studies investigating constructs such as job dissatisfaction and burnout were not included unless the study also included a measure of stress or stressors. PMID- 10163614 TI - Acceptance of an injury-prevention program in rural communities: a preliminary study. AB - INTRODUCTION: Considerable attention is being addressed to injury prevention. This study addresses the acceptance of a home injury-prevention survey as an injury-prevention tool in rural communities. PURPOSE: The purpose of this study was to evaluate public acceptance of a home injury-prevention survey as a tool to educate and enlighten the public about home injuries. METHODS: All patients with home injuries who came to Wetzel County Hospital Emergency Department were asked if they would participate in a home injury-prevention survey. The study was conducted from 01 May to 01 July 1995. Paramedics were used as interviewers because of the closeness they enjoy with the community. RESULTS: During the study period, 2,104 patients came to the emergency department of Wetzel County Hospital. Of these, 386 sought care because of an injury sustained in their homes. From this group, 23 (5.9%) patients agreed to participate in a home injury prevention study; 363 (94.1%) refused. CONCLUSION: A home injury-prevention survey alone does not seem to be an effective tool to aid in the reduction of home injuries, because it is not embraced by the general public. PMID- 10163615 TI - Nebulized lidocaine as an adjunct to endotracheal intubation in the prehospital setting. PMID- 10163616 TI - Saliva testing, one Canadian company's experience. PMID- 10163617 TI - Older age applicants: a geriatrician's perspective. PMID- 10163618 TI - Prognosis of hypertrophic cardiomyopathy. AB - BACKGROUND: The actual prognosis of hypertrophic cardiomyopathy, a disorder previously thought of to be notorious for an increased risk of untimely death is poorly defined. OBJECTIVE: The present study describes the findings of patients with Hypertrophic Cardiomyopathy followed for more than nineteen years in a large clinic population. MATERIALS AND METHODS: A clinic population of 113 patients with Hypertrophic Cardiomyopathy was prospectively studied to assess cardiac mortality in the overall groups and in selected subgroups commonly thought to be at high risk for sudden death. Diagnosis of hypertrophic cardiomyopathy was based on the presence of left ventricular hypertrophy without a known cause. Left ventricular hypertrophy was determined by echocardiography. RESULTS: During follow-up there were 11 cardiac and 2 non cardiac deaths. The annual cardiac mortality was 1% (95% confidence interval 0.2-1.8%). Relative risk for cardiac death was not significantly different in the presence of young age (< 30 years), family history for Hypertrophic Cardiomyopathy (HCM) and sudden death, history for syncope or previous cardiac arrest or both, ventricular tachyeardia on 24 hour, holter monitoring or operation for refractory symptoms and out-flowtract obstruction. CONCLUSION: HCM has a relatively benign prognosis (1% cardiac annual mortality) that is 2-4 times less than previously thought. These findings might have important consequences for risk assessment in individual patients. Echocardiography is obligatory to determine the presence, and extent of myocardial hypertrophy. In addition, the technique allows differentiation between Hypertrophic Cardiomyopathy and Athlete's Heart. PMID- 10163619 TI - Liver transplantation: the European experience. PMID- 10163620 TI - Tumor markers: role in screening insurance applicants. PMID- 10163621 TI - Medical aspects of traveler's insurance. PMID- 10163622 TI - The non mortality of hypertrophic cardiomyopathy in an unselected, community diagnosed and treated population. AB - Hypertrophic Cardiomyopathy (HC) is portrayed in past literature as having an ominous prognosis. However, most studies emanated from medical centers and suffered from potential referral bias. A population based, community diagnosed and treated survival study is analyzed by the life table method. Despite potential causes for both underestimation of the observed mortality as well as for overestimation of expected mortality, the study appears to reveal a more favorable prognosis for HC in this population. PMID- 10163623 TI - Membranous nephropathy: case study. PMID- 10163624 TI - The principles of insurance medicine. PMID- 10163625 TI - Men, women & alcohol: a distinctly unequal & dangerous relationship. AB - This article illustrates how women who abuse alcohol are at greater risk physically, emotionally and socially than their male counterparts. As a result, I recommend that clinical assessment and underwriting of women, who abuse or have the potential to abuse alcohol, change to reflect the increased risks which these women face. PMID- 10163626 TI - Cost implications of prehospital emergency drug administration. The case of prehospital thrombolytics. PMID- 10163627 TI - Treatment options in acromegaly. Benefits and costs. PMID- 10163628 TI - Approaches to rationing drugs in hospitals. An Australian perspective. AB - The increasing need to consider rationing strategies within the healthcare environment is being driven by pressures such as the development of new medical technologies, the aging population, patient awareness and expectations, healthcare professionals' appetite for new treatments, and government restrictions on healthcare costs. Solutions to these pressures will need to be sought urgently to avoid a situation in which quality of healthcare is affordable only for the wealthy. The fundamental principles of equity and fairness will need to be applied universally if the solutions are to be accepted by the community, patients and practitioners. There are several measures that a hospital must have in place before the concept of drug rationing can be contemplated. The approach essentially involves ensuring rational drug approval processes based on critical review of the available data, coupled with ongoing education and audit. Thus, accurate information and clinical budgeting systems, processes which encourage and ensure structural and technical efficiencies within the drug use sequence and an effective Drug and Therapeutics committee are required to facilitate this approach. To assist with its overriding goals of the quality use of medicines and optimal patient care, the Drug and Therapeutics committee needs to implement an effective formulary system, obtain detailed guidelines governing drug use within the institution, conduct an ongoing drug utilisation review programme, and provide education and training. The move to consider allocative decision making (rationing) will become increasingly necessary as limits on structural and technical efficiency measures are reached. An institution will then need to decide whether to treat a particular group of patients, or provide a certain form of treatment. Improved methods for community consultation need to be explored and there must be a partnership between the health provider and the consumer in enunciating the existence of scarcity, determining priorities and ensuring that ethics and equity are not abandoned through this process. PMID- 10163630 TI - Alcoholism. The cost of illness in the Federal Republic of Germany. AB - The purpose of this study was to estimate the direct and indirect costs of alcoholism in the Federal Republic of Germany. Direct costs comprised treatment costs, while indirect costs consisted mainly of costs incurred as a result of work time lost, as well as costs related to premature retirement and premature mortality. The costs of alcoholism were estimated using the aggregated statistics of several social security organisations and official statistics. For the purposes of this study, alcoholism was defined as alcohol dependence syndrome [9th revision of the International Classification of Diseases code (ICD) 303], alcoholic chronic liver disease and cirrhosis (ICD 571.0 to 571.3), and alcoholic psychoses (ICD 291). The reference period consisted of the years 1985 to 1991. All statistics and all analyses were limited to the so-called old states of Germany, within the boundaries as they were before 3rd October 1990. The overall monetary burden (in 1990 Deutschemarks) of alcoholism in the western part of Germany in 1990 was estimated to be DM5975 million. Alcoholism is associated with considerably more indirect costs (DM4422 million) than direct costs (DM1553 million). The predominance of indirect costs is mainly the result of the very high premature mortality of patients with alcoholism. Thus, the cost of premature mortality makes up more than half of the indirect costs of alcoholism (DM2284 million), while about a quarter of the indirect costs (DM1150 million) are associated with inability to work. Early retirement accounts for a similar amount (DM988 million). The majority of direct costs is accounted for by treatment in acute hospitals (DM869 million). Costs incurred as a result of rehabilitation treatment (DM373 million) and ambulatory care (DM331 million) are also considerable. PMID- 10163629 TI - A cost-effectiveness analysis of typhoid fever vaccines in US military personnel. AB - Typhoid fever has been a problem for military personnel throughout history. A cost-effectiveness analysis of typhoid fever vaccines from the perspective of the US military was performed. Currently 3 vaccine preparations are available in the US: an oral live Type 21A whole cell vaccine; a single-dose parenteral, cell subunit vaccine; and a 2-dose parenteral heat-phenol killed, whole cell vaccine. This analysis assumed all vaccinees were US military personnel. Two pharmacoeconomic models were developed, one for personnel who have not yet been deployed, and the other for personnel who are deployed to an area endemic for typhoid fever. Drug acquisition, administration, adverse effect and lost work costs, as well as the costs associated with typhoid fever, were included in this analysis. Unique military issues, typhoid fever attack rates, vaccine efficacy, and compliance with each vaccine's dosage regimen were included in this analysis. A sensitivity analysis was performed to test the robustness of the models. Typhoid fever immunisation is not cost-effective for US military personnel unless they are considered imminently deployable or are deployed. The most cost effective vaccine for US military personnel is the single-dose, cell subunit parenteral vaccine. PMID- 10163631 TI - The economic impact of once-daily versus conventional administration of gentamicin and tobramycin. AB - This retrospective, observational study was designed to compare once-daily with conventional aminoglycoside administration for costs while determining equivalency in efficacy and toxicity. 100 consecutive patients who had been treated with once-daily aminoglycosides after 1st August 1993, were evaluated via retrospective chart review. For comparison, 100 consecutive patients who were treated with conventional regimens of aminoglycosides, over the same calender period 1 year earlier (beginning on 1st August 1992), were evaluated in a similar manner. Aminoglycoside antibacterials, excluding amikacin, were administered as a single daily dose of 6 mg/kg. 89 patients were cured or improved with once-daily administration versus 90 patients with conventional administration. One patient in each group developed definite aminoglycoside-induced renal toxicity. The total cost [in 1993 Canadian dollars ($Can)] per patient for once-daily and conventionally administered aminoglycosides was $Can97.62 and $ Can199.43, respectively. Thus, once-daily administration of aminoglycosides is as effective and well tolerated, while considerably less expensive than, aminoglycoside treatment utilising conventional regimens. PMID- 10163632 TI - Tear film deficiencies pharmacology of eye drops and toxicity. AB - Our knowledge of the diagnosis and treatment of multifactorially induced dry eye has increased dramatically during the past few years. Major progress has taken place in the development of objective methods of evaluating and differentiating disturbances of the ocular lubrication. Various in vivo techniques for the diagnosis of tear film and corneal pathologies, including fluorophotometric tear flow, scanning confocal microscopy, infrared thermography, and fluorogenic substrate techniques, can be used quantitatively and qualitatively in clinical research. Eyedrop side effects such as epithelial cell toxicity and, especially, changes in epithelial membrane permeability after the administration of locally applied ophthalmic preparations are now detectable under in vivo conditions. PMID- 10163633 TI - The clinical use of contact lenses and collagen shields. AB - Contact lens wear before and after photorefractive or phototherapeutic keratectomy with excimer lasers has become an increasingly interesting subject. No negative side effects of contact lens wear prior to photorefractive keratectomy have yet been shown and refractive errors postoperatively do not seem to constitute a major practical problem. Normal side effects include the risk of bacterial infection and keratitis. The major pathogen in this context is still Pseudomonas aeruginosa, although increased insight into the mechanisms of bacterial adhesion and improvements in cleaning procedures now allow more effective preventive care of contact lenses themselves and of contact lens cases. Tear fluid research using leucotriene C4 as a possible indicator for subclinical inflammation has led to interesting results, and the importance of the arachidonic pathway and its metabolites has become more evident. These advances contribute considerably to the safe use of contact lenses in clinical ophthalmology, although major innovations such as the multifocal contact lenses have not reached the stage of perfection. PMID- 10163634 TI - Extracellular matrix and growth factors in corneal wound healing. AB - The crystal clear cornea has been challenged by refractive surgeries. The surgical outcome depends on the healing responses of the cornea. The factors responsible for the corneal wound healing have been characterized. The orchestrated action of extracellular matrix proteins, growth factors, cytokines, and their receptors have been investigated extensively over the past decade. The clinical results with refractive surgeries provide us various important information with regard to the physiology and pathology of the cornea. The role of basement membrane or Bowman's membrane is now challenged for the maintenance and repair of the epithelium. Furthermore, the interactions between epithelium and stroma is another field to be investigated. The regulatory mechanisms of the maintenance of stromal collagen by keratocytes is also studied. This review discusses the current advancement in the healing responses of the cornea to various injuries and refractive surgeries. PMID- 10163635 TI - The cornea and systemic diseases. AB - Multiple systemic diseases imply corneal involvement. Corneal pathology may also be a presenting sign or may herald a forthcoming relapse of chronic disease. The presence of ulcerative keratitis in patients with rheumatoid arthritis can be associated with systemic lethal vasculitis. Epithelial fragility of the cornea is correlated to the presence of diabetic retinopathy. Rarely, interstitial keratitis may be the presenting sign of sarcoidosis. Corneal involvement in oculomucocutaneous syndromes continue to present a therapeutic challenge. Infectious and possibly drug-induced corneal pathology is a recurrent problem in patients with AIDS. PMID- 10163636 TI - Tumors of the cornea and conjunctiva. AB - This article reviews literature regarding tumors and tumor-like lesions of the conjunctiva and cornea as published in 1995. Causative and prognostic factors, as well as treatment options, are discussed. Ocular surface squamous neoplasia has been suggested as an "umbrella" term for dysplastic and carcinomatous lesions of the cornea and conjunctiva. Squamous cell carcinoma shows a higher incidence in patients with AIDS. A high prevalence (36%) of primary acquired melanosis is reported in one article, and the need for biopsy of all these lesions is questioned. Reviews of conjunctival myxoma, corneal pyogenic granuloma, and limbal juvenile xanthogranuloma are also included. The pathogenesis and newer treatment options for pterygia are discussed. Simple excision or resection of the pterygium followed by conjunctival autografting or intraoperative or postoperative mitomycin C application seems to be equally effective in reducing the rate of recurrence. PMID- 10163637 TI - Storage of donor corneas, surgery, outcome, and complications of penetrating keratoplasty. AB - A review of current literature reveals continuing concerns regarding the safety and success of penetrating keratoplasty. Quality assurance within eyebanks is directed inter alia at the prevention of transmission of infection from donor to host. Recent controversy in the United Kingdom regarding the transmission of Creutzfeldt-Jakob disease underscores the need for constant vigilance and regular review of eyebank standards. The improvement of the success rates for keratoplasty in difficult cases and the elimination or reduction of side effects assume increasing importance as the technical difficulties in more straightforward cases are solved. This review discusses some recent publications in this field. PMID- 10163638 TI - Mechanical methods in refractive corneal surgery. AB - The past year has seen considerable advances and debate with regard to several new and some established mechanical means of refractive surgery. Lamellar in situ keratomileusis is gaining increased interest, especially for the treatment of moderate and high myopia, although considerable questions still exist with regard to its safety, predictability, and the possibility of loss of lines of best corrected visual acuity. Mini-radial keratotomy may be of benefit in reducing the risk of traumatic rupture of radial keratotomy incisions, and a refinement of the nomograms for astigmatic keratotomy in the treatment of congenital astigmatism has been proposed. Another report on the use of hexagonal keratotomy for the treatment of hyperopia again raised concerns of its predictability. A blind eye study of intrastromal corneal rings has provided some reassurance with regard to its safety but has also raised doubts over its predictability. Meanwhile, several more reports of the use of both anterior and posterior chamber phakic intraocular lenses for the treatment of myopia have been presented. PMID- 10163640 TI - Corneal complications of cataract surgery. AB - Recent advances in cataract surgery have reduced the incidence of corneal complications. Review of the current literature reveals a trend toward early visual rehabilitation and minimization of postoperative astigmatism by careful selection of incision type and location for small-incision cataract surgery. Since the introduction of intraocular lenses, endothelial cell loss has been a concern. Preservation of corneal endothelial cell function continues to be a major goal as cataract surgery continues to evolve. Recent studies have been undertaken to determine the effect of incision location and size on endothelial cell loss. Several reports on iatrogenically induced corneal decompensation are of interest as this complication can be avoided if proper precautions are taken. Although improvements in surgical technique have lead to a decreased incidence of Descemet's membrane detachments and of epithelial and fibrous downgrowth, early recognition and intervention are imperative. PMID- 10163639 TI - Refractive corneal surgery with lasers. AB - Laser refractive surgery is on one hand in a phase of consolidation regarding the routine treatment of mild to moderate myopia by means of spheric excimer laser photorefractive keratectomy. On the other hand, exciting new developments are taking place in the field of high myopia, myopic astigmatism, and new alternative lasers. PMID- 10163641 TI - Mechanical ocular trauma. AB - Mechanical ocular trauma remains a leading cause of visual loss and blindness and often affects young individuals. Approximately 75% of people with trauma-induced visual impairment are monoculary blind. Furthermore, the human, social, and economic consequences of eye injuries are enormous in all parts of the world. Because most eye injuries are preventable, efforts could be spent much more effectively on preventing eye injuries rather than treating them. It is important to make the public aware of the benefits of using protective equipment, which is almost universally available, and was the main concern of most of the authors reporting on ocular trauma in the past year. Of great importance seems to be the introduction of an international standardized classification of ocular trauma. PMID- 10163642 TI - Infectious diseases of the conjunctiva and cornea. AB - The modern local antibiotics, such as the aminoglycosides and quinolones, are very successful in treating infectious conjunctivitis and keratitis. More notably in some Third World countries, however, suppurative keratitis is found in more than half of the infectious disease cases caused by Fusarium species. Here, of course, treatment should be antifungal. The emergence of some problematic microorganisms is related to contact lens wear. Pseudomonas, for example, have the ability to adhere to contact lenses and thus form microcolonies, which are protected by biofilm that predisposes to infection. Acanthamoeba infections of the cornea are a direct consequence of inappropriate or inadequate disinfection of contact lens systems. Occasionally the diagnosis of herpes simplex manifestations of the outer eye can be very difficult. Even more confusing is the delayed appearance of zoster manifestations, such as pseudodendrites, particularly in cases of zoster sine herpete eruptione. The polymerase chain reaction is of particular value in demonstrating the presence of varicella zoster DNA. Although infectious disease of the outer eye remains common, the incidence and complications have increased because of frequent use of antimicrobial agents. In the under-developed areas of the world, however, infections are still very common, are frequently caused by fungi, and are the cause of serious ocular complications. In the Western World infectious eye disease does not seem to be a major diagnostic or therapeutic point at present. Some organisms that have been in the environment all along, however, have emerged in the past half century as a major problem. Thus, in the past years a number of new techniques in diagnosis as well as new insights in pathophysiology and new developments in treatment have emerged that are of interest. PMID- 10163643 TI - Corneal dystrophies and keratoconus. AB - This year's reports have given us a better understanding of several dystrophies as well as improvements in diagnosis and treatment. Eight corneal dystrophies have now been mapped to specific chromosomes and of these lattice, granular, Avellino, and Reis Buckler's dystrophies map to the same region of chromosome 5q, raising the question whether they are the result of mutations in separate genes or of mutations within alleles of a single gene. Phototherapeutic keratoplasty appears to offer an advantage in the initial treatment of several dystrophies whose symptoms arise from superficial corneal change. Some success has been reported in reducing the degree of hyperopic shift that accompanies deeper ablations. Further support for the genetic basis of keratoconus comes from a study in monozygotic twins and from improvements in quantitative videokeratographic indices, which have also improved our ability to distinguish keratoconus from other topographic abnormalities of the cornea. A new hypothesis for the mechanism of keratoconus proposes that an increased expression of interleukin-1 receptors, acting through a paracrine pathway, may disturb keratocyte activity and turnover, leading to a loss of stromal mass. PMID- 10163644 TI - Corneal topography, ultrasound biomicroscopy, and scatterometry. AB - This paper presents a review of corneal topography, including history, literature, physics and technology, data analysis, and recent advances in the field. Clinical applications are also discussed and include contact lens fitting, diagnosis of keratoconus, and refractive surgery. PMID- 10163645 TI - Virtual endoscopy flies viewer through the body. PMID- 10163646 TI - Teleradiology falls short of meeting rural needs. PMID- 10163647 TI - Battles over turf persist in managed-care era. PMID- 10163648 TI - Managed-care inpatients receive fewer imaging tests. Discrepancy may be linked to length of stay. PMID- 10163649 TI - Groups best governed by physician CEOs. PMID- 10163650 TI - Contrast media markdown. PMID- 10163651 TI - PET begins to prove itself in cancer care. PMID- 10163652 TI - High-res ultrasound guides cryosurgery. PMID- 10163653 TI - Addressing emerging infectious diseases. The critical role of the laboratory. PMID- 10163654 TI - The laboratory's role in nutrition support. PMID- 10163655 TI - Practical detection of a respiratory virus. PMID- 10163656 TI - Techniques to improve flow cytometric detection of light chain restriction. AB - OBJECTIVE: To compare 3-color flow cytometry (using a permeabilization step to detect cytoplasmic immunoglobulin in selected cases) with 2-color flow cytometry in the detection of light chain restriction (LCR). DESIGN: Analysis of clinical specimens submitted for lymphocyte immunophenotyping using both methods. SETTING: Marshfield Laboratories serving Saint Joseph's Hospital (525 beds) and the Marshfield Health Care Network. MAIN OUTCOME MEASURE(S): Sensitivity and specificity for detecting LCR in B-cell neoplasms. Final diagnosis based on review of clinical, laboratory and histologic data. RESULTS: Of 61 specimens, the 3-color method yielded better sensitivity, detecting LCR in 30 of 39 cases of B cell neoplasms (77%) versus 16 of 39 (41%) for the 2-color method (P < 0.001). Both methods had comparable specificity (95-100%). The 3-color cytoplasmic technique identified another 4 cases yielding an overall sensitivity of 87% for a 2-tiered testing strategy. CONCLUSION: A 3-color surface technique, backed up by a permeabilization step in selected cases, provides a cost-effective and sensitive technique for detecting LCR. PMID- 10163657 TI - Point of care testing: regulation and accreditation. AB - OBJECTIVE: To provide an overview of point of care testing (POCT) regulatory and accrediting agencies and their requirements. DATA SOURCES: Current literature and the author's experience. DATA SYNTHESIS: To develop and successfully run a POCT program that meets the federally mandated standards evaluated by accrediting agencies with Health Care Financing Administration (HCFA) status, requires that participants are aware of CLIA '88 requirements. Joint Commission on Accreditation of Healthcare Organizations (JCAHO), College of American Pathologists (CAP) and Commission on Office Laboratory Accreditation (CQLA) are the 3 principal organizations currently inspecting and accrediting POCT programs. They have included all CLIA '88 requirements on their inspection checklists. This paper covers requirements of JCAHO and CAP. In order to successfully meet the accreditation requirements of HFCA and their deeming agencies, JCAHO and CAP, these issues must be addressed: direction and supervision of the program, procedures performed, proficiency testing, quality assurance, quality control, procedure manuals, specimen handling, results reporting, reagents, calibration and standards, instrument selection and maintenance, personnel training and competence, and safety. CONCLUSION: CLIA '88 states that all testing is site neutral, therefore the same regulations apply regardless of where the test is performed. All POCT programs must apply for a CLIA certificate and choose an appropriate accreditation agency for their needs. All accreditation agencies must follow the requirements listed in the federal register; some agencies are more stringent than others. PMID- 10163658 TI - Data security for health care. Volume I: Management guidelines. PMID- 10163659 TI - Data security for healthcare. Volume II: Technical guidelines. PMID- 10163660 TI - Data security for health care. Volume III. User guidelines. PMID- 10163662 TI - Modeling techniques for inhaled particle deposition: the state of the art. AB - Mathematical modeling of aerosol deposition in the human lung is based on idealized assumptions regarding the morphometry of the lung, the fluid dynamics behavior of the inspired air under defined breathing conditions, the transport of particles through the branching airway system, the physical mechanisms acting upon inhaled particles, and the deposition of particles within airways, airway bifurcations, and alveoli. Current models of particle deposition in the human lung, ranging from experimentally based semi empirical to rather sophisticated stochastic and numerical mathematical models, permit the prediction of particle deposition at different levels of complexity, ranging from total deposition in the whole lung to localized deposition patterns within single airway bifurcations. In this paper, the present state of the art in aerosol deposition modeling will be reviewed, focusing on the discussion of different conceptual ideas rather than on a complete listing of all published modeling efforts. The selection of specific contributions by various authors relevant to our present understanding of particle deposition in the human lung reflects the subjective view of the author. In addition, illustrations of salient features of different modeling approaches are based primarily on the author's own research. PMID- 10163661 TI - Assessment of deposition of inhaled aerosol in the respiratory tract of man using three-dimensional multimodality imaging and mathematical modeling. AB - Multimodality medical imaging enables measurement of the three-dimensional spatial distribution of a radiolabeled aerosol within the lung. Using a conceptual spatial morphological model these data may be transformed to provide information on deposition per airway generation. This methodology has been used to study the intrapulmonary deposition patterns of two formulations of a metered dose inhaler and two nebulizers in control subjects. The nebulizer study has also been stimulated using a computer model of deposition. The comparison between derived experimental results and those from computer modeling shows areas of agreement, although there are also areas of discrepancy. The new methodology has considerable potential value in the fields of inhalation therapy and deposition modeling, although more detailed validation is still required. PMID- 10163663 TI - Aerosol transport and deposition in the rhythmically expanding pulmonary acinus. AB - Little is known about factors controlling the dynamics of aerosol dispersion and deposition in the lung periphery, though this knowledge becomes increasingly important in many fields such as environmental and occupational exposure, diagnostic applications, and therapeutic deliver of drugs via aerosols. For the last several years, we have been studying aerosol behavior in the pulmonary acinus, where the airway structure and the associated fluid mechanics are distinctly different from those in the conducting airways. Our major research efforts have been focused on the basic physics underlying acinar fluid mechanics and particle dynamics, which are likely to be conditioned by the two key geometric factors of acinar airways: structural alveolation and rhythmic expansion and contraction of the alveolar walls. A combination of computational and experimental analyses revealed that due to these unique geometric features acinar flow can be extremely complex despite the low Reynolds number, and can have substantial effects on particle dynamics. In particular, chaotic mixing can occur in the lung periphery. In the course of such a mixing process, the inhaled aerosol particles quickly mix with the residual alveolar gas in a manner that is radically different from the previously considered classical diffusion process. The objective of this paper is to briefly review our current understanding of these processes, to discuss existing deposition models, and to describe our ongoing research efforts toward a basic understanding of aerosol behavior in the pulmonary acinus. PMID- 10163664 TI - Inertial and interceptional deposition of fibers in a bifurcating airway. AB - A computer model of a three-dimensional bifurcating airway was constructed in which the parent and daughter airways had different lengths but equal diameters. A diameter of 0.6 cm was chosen for the airways based on the third generation of Weibel's symmetric lung model. Different bifurcation angles of 60 degrees, 90 degrees, and 120 degrees were studied. Airflow fields in the airway were obtained by a finite-element method (FIDAP, Fluid Dynamics International, Evanston, IL) for Reynolds numbers of 500 and 1000, assuming uniform parent inlet velocities. The equations of motion for fiber transport in the airways were obtained, and deposition by the combined mechanisms of impaction and interception was incorporated. A computer code was developed that utilized the flow field data and calculated fiber transport in the airways using the equations of motion for fibers. Deposition efficiency was obtained by simulating a large number of fibers of various sizes. Fiber entering the daughter airways tended to orient themselves parallel to the flow. A site of enhanced deposition (or hot spot) was observed at the carina. The dominant parameter for the deposition was the fiber Stokes number. Flow Reynolds number and airway bifurcation angle were also found to affect the deposition. PMID- 10163665 TI - Three-dimensional fluid particle trajectories in the human larynx and trachea. AB - A computational fluid dynamics software package (FIDAP) has been employed to obtain three-dimensional flow data, which are used herein to calculate the trajectories of fluid particles. Our computations have demonstrated that the flow fields inside the larynx are very complex including eddies in the lumen and reverse motion along the surface. The effects of such flow fields will be to increase the residence times of entrained drug particles. Our computations have also demonstrated that the larynx has pronounced effects on the motion of air in the trachea. PMID- 10163666 TI - Acute pulmonary effects of three nebulizers for administering aerosol pentamidine: comparison of Parineb to Fisoneb and Respirgard II. AB - We conducted a prospective, unblinded, nonrandomized, multiple crossover study to assess the acute pulmonary effects of a new jet nebulizer-Parineb, comparing it to Respirgard II (jet nebulizer) and Fisoneb (ultrasonic nebulizer) for administering aerosol pentamidine (AP). Twenty-three HIV patients received AP at 60 mg dissolved in 3 ml sterile water with Parineb and Fisoneb and 300 mg dissolved in 5 ml sterile water with Respirgard II on three successive clinic visits. Twelve patients known to develop bronchospasm with AP received 200 micrograms of salbutamol as premedication for all three nebulizers. Eleven subjects received AP without bronchodilator premedication. All subjects had a reduction in flow rates with AP. No significant difference was noted in the reduction of flow rates between the three nebulizers in those patients without prior history of bronchospasm with AP. However, there was a significantly greater reduction in flow rates with Parineb in patients with known AP-induced bronchospasm despite premedication with bronchodilator. This decrease in flow rates with Parineb was not felt by patients based on the subjective rating of cough using a visual analog score when compared to the other two nebulizers. Parineb should be used cautiously in individuals with known AP-induced bronchospasm. PMID- 10163667 TI - Quality management and standardization programs in hemostaseology. AB - Total quality management (TQM) of laboratory services is connected with a comprehensive system of quality assurance, which integrates quality development, quality maintenance, and quality improvement. TQM concentrates not only on analytic performance and organizational issues, including specimen collection, reporting, and interpretation of results, but focuses also on the benefits to society related to the use of specific laboratory tests in prevention, early detection, and therapy monitoring, as well as on outcome measures. A prerequisite to TQM are international and national standardization programs for the establishment of optimized and standardized methods, as well as for the development and evaluation of suitable reference materials. Reference materials that have been or are being prepared, calibrated, and certified by international and national reference institutions will certainly contribute to the harmonization of results, with different test systems in hemostaseology, improving their quality and value. PMID- 10163669 TI - The European regulation of drug-delivery devices. AB - All parties concerned with the marketing of drug-delivery devices in Europe will need to comply with applicable European regulatory requirements. The European directives for medical devices address the regulation of devices intended to administer medicinal products. Also, the European Commission is developing a guidance document on the demarcation between medical devices and medicinal products. This article will discuss the European approach to the regulation of drug-delivery devices and some important regulatory issues that should be considered during the design and development phase of these products. PMID- 10163668 TI - Automation in coagulation testing. AB - Belatedly, automation is being introduced into hemostasis laboratories. Now, new analytic systems are also available for less specialized laboratories. New tests have been added as knowledge of the mechanisms of coagulation increases. This article will review the new technologies in coagulation testing and their diagnostic applications. PMID- 10163671 TI - Conducting business in China. AB - Chinese culture is governed by an ancient set of values. Despite the gradual infiltration of Western culture, these historical practices remain highly visible in all interactions between Chinese people. For Western companies to set up and maintain viable businesses in China, it is essential that they have an understanding of Chinese heritage. This article identifies key elements of Chinese customs and business practices and explains their significance. PMID- 10163670 TI - Predicting long-term performance of irradiation polymers. AB - Material degradation occurs during and after irradiation sterilization. The degree of post-degradation can be accelerated by altering the temperature, environment, and irradiation dose. This article discusses methods to accelerate post-degradation and how this can be used as a predictive technique for evaluating new or improved polymer formulations. PMID- 10163672 TI - "'Tis virtue not birth that makes us noble:" the role of noble metals in medical devices. AB - Gold, silver, platinum, and other noble metals are enigmatic with respect to their biological uses. On the one hand they are considered to be highly inert with excellent all-round biocompatibility and useful for electrodes and a variety of implanted and nonimplanted medical devices. On the other hand some noble-metal complexes are highly potent biologically. This column attempts to dispel some of the confusion. PMID- 10163673 TI - Meeting European and US requirements for design and development documentation, Part I. AB - Developing design and development procedures and documentation is one of the most important activities in the implementation of a formal design-control programme. Also, companies wishing to comply with the European and the forthcoming United States (US) requirements face a dual challenge. Part I of this series of articles will provide an overview of design control elements and some differences between the European and US requirements. The next two parts will discuss the types of procedures and documentation that are needed to comply with these requirements and a method for organizing documentation to facilitate its use by the company and auditors. PMID- 10163674 TI - Selecting the correct medical-grade polymer. AB - Developments in polymers and associated clean-room extrusion and moulding techniques give manufacturers greater scope to maximize a product's performance and durability through careful selection of materials with optimal characteristics. This article considers the selection criteria for materials for different types of tubing applications and evaluates suitable polymers for each. PMID- 10163675 TI - FDA: friend or foe? AB - Delays in FDA product approvals have weakened the US medical device market. Reduced investment returns and the erosion of industry's confidence in FDA procedures have slowed the introduction of new products and threatened the market's potential for growth. This article examines the background to those issues and describes FDA's attempts to overcome its procedural shortcomings. PMID- 10163676 TI - Alginate fibres and wound dressings. AB - Alginates are characterized by their gel-forming and absorbent nature, a feature that makes them ideally suited for use in wound-care applications. This article examines the structure, properties, and performance of alginates and highlights the differences between the various types. The characteristics that should be built into the next generation of dressings are discussed, together with applications that are ripe for development. PMID- 10163677 TI - Paying and playing with plastic. The meaning of plastics, plasticity, and plastic surgery. AB - Plastics are not only the proverbial everyday commodity, but they also permeate almost every aspect of medical devices, from technology to clinical application. This article addresses some of the confusing features of plasticity as they relate to the materials called plastics, to the phenomena of material plasticity, and to the clinical and biological usage of the word. PMID- 10163678 TI - Quality in obstetrics using a telematic system. AB - A telematic based system for antenatal care has been developed to be used in service integration between primary and secondary health care units. The system is based on low cost platforms and has a user friendly human computer interface. This system will provide better integration and coordination between the health care providers involved, improving the quality of the services. This experiment is being funded in the framework of the EC.Project-A 2007-EPIC. Quality indicators, agreed in the "European concensus conference of quality indicators for perinatal care", organized in conjunction with OBSQID project (AIM.2125) were integrated in the system. Data collection has started and the outcome will be used to validate the indicators on a transeuropean basis under the framework of the OBSQID Project. PMID- 10163679 TI - Analysis of discharge data in a large hospital in Slovakia. Its application to diabetic patients. PMID- 10163680 TI - Equity productivity and case mix in the Greek hospital sector. PMID- 10163681 TI - Computer assisted clinical data analysis. AB - The Diagnosis Related Groups patient classification scheme coupled with desk top PC technology permits sophisticated analysis of patient medical data. Individuals with no programming knowledge can produce sophisticated analysis. The functionality and structure of the 3M Analytical Workstation are described and example analysis reports are presented. PMID- 10163682 TI - Capturing data from distant hospital databases for cancer registration. AB - The particular logistical problems of collecting cancer registration data in the South-Western region of England are discussed. The Regional Cancer Registry has endeavoured to overcome these through developing electronic links to hospital based patient-information systems. Some of these involve data transfer on magnetic media, but there are also interrogation facilities which operate on a realtime, interactive basis, and complement these other facilities. A PC-based program (SNODEV5), which can accept data from histopathology computer systems, translate SNOMED codes to ICD-9, and produce files suitable for processing by the registry's Batch Data Entry system is described. Its contribution to the achievement and monitoring of equity in health care provision is discussed. PMID- 10163683 TI - Case-Mix: a new approach towards financing hospital care in Belgium. PMID- 10163684 TI - Development of standards and data quality control. AB - Health care expenses represent 6 to 10% of the Gross National Product in most European countries. This budget exceeds by far those devoted to Defence or Education. The rising cost of health care concerns all governments. In each country of the European Community, measures were and will further be taken in order to increase efficiency in the delivery of health care. Recent advances in information technology offer new opportunities to collect, process and exchange data to document health practices. In Belgium the Ministry of Public Health collects uniform medical summaries for all acute care hospital inpatients, while detailed health care activities are documented for each patient through a very precise billing system. The use of Minimal Clinical Data and Minimal Nursing Data Sets in hospitals became mandatory four years ago. The fundaments for any data collection is reliability, no matter what the preconceived aim was. PMID- 10163685 TI - Case-based telematic systems towards equity in health care in Belgium. PMID- 10163686 TI - Using Videotex in public health in Belgium. AB - In public health, access to information is more and more felt to be an urgent need. In this matter Videotex has shown to be a good working tool, though its utilisation in Belgium is not widespread yet. The Institute for Hygiene and Epidemiology has implemented EPITEL, a databank allowing for consultation of data on health and environment. The rationale for the choice of Videotex as a consulting tool is analysed here. Though very user-friendly, its high technicality allows for certain applications to function in real time mode, generate graphics, or even to consult an expert system, as the one used in the application on immunisations. In this way Videotex can also be a helpful tool in primary prevention, besides its data consulting function. This demonstration will present the five applications: health and travelling, health indicators, allergenic pollen, biological quality of the swimming waters at the coast, air pollution data. It shortly presents the hardware and software supporting the system, as well as a few results of a two-year experience running the system. Some shortcomings of the actual system may be highlighted, and possible evolutions might be discussed. PMID- 10163687 TI - Problem oriented medical record, a prerequisite towards equity in health care (?). PMID- 10163689 TI - WHO/EURO as a European Health Information Centre. PMID- 10163688 TI - Using a database to query for diabetes mellitus. PMID- 10163690 TI - Information technology in support of health for all. PMID- 10163691 TI - The ORATEL project. Telematic system for quality assurance in oral health care. AB - ORATEL is a 3-year project of which WHO/EURO is prime partner and which is partially supported financially by the Advanced Informatics in Medicine programme of the Commission of the Europe Communities. ORATEL has the ultimate objective of improving oral health through use of appropriate telematic information tools for quality assurance and development. These tools have the potential to promote quality assurance in oral health care by using common quality indicator standards which allow for comparison of outcome and resource utilization. The project has completed its first phase. The main challenge of this Phase I was to develop and reach European consensus on indicators for quality in oral health care. Based on the Phase I activities, a manual on the basic minimum set of indicators for quality in oral health care was prepared. Phase II covered development of the three telematic information tools and the preparation of a technical manual. Phase III is testing and evaluation of the tools started in February 1994 and is taking place during. PMID- 10163692 TI - Quality of care development policy implications for case-based telematic systems in Europe. PMID- 10163693 TI - Equity and improvement in outcome of breast cancer in Denmark. AB - The trend in the prognosis for female breast cancer patients was investigated by comparing Kaplan-Meier survival curves of different patient cohorts diagnosed during the period 1948-87. The study is based on 71,448 patients from the Danish Cancer Registry. The cohorts were defined by age at diagnosis, year of diagnosis, and residential area. The survival time from diagnosis nearly doubled from 1948 57 to 1978-87, the most important improvement taking place after 1978. Patients diagnosed in 1948-77 in the Copenhagen area had a far better prognosis than patients diagnosed during this period in other parts of Denmark. For patients diagnosed in 1978-87 the prognosis, however, reached an equal level in all parts of the country. Thus, it is reasonable to assume that the national programme introduced in 1977 by the Danish Breast Cancer Cooperative Group (DBCG) has played an important role and not only brought about therapeutic improvements in breast cancer treatment in Denmark, but also ensured equity in the outcome on a national scale. PMID- 10163695 TI - A networked patient-based integrated care system as a basis for the achievement of quality in practice. AB - Traditionally, telematics initiatives have mainly been used to link patients with specific conditions to monitoring services located in acute hospitals. However, latest application of telematics to the networking of integrated electronic records for ambulatory or community care has great potential to measure and assure the quality of health care delivery to a large sector of the population in a structured and comprehensive way. This paper categorizes the major quality opportunities of a pioneering initiative now achieving operational status. PMID- 10163694 TI - Case-based information systems in Swedish health care. General aspects and experiences from the Stockholm County Council. AB - The paper gives a brief overview of some national case-based information systems in Swedish health care together with an application from the Stockholm County Council. A background section on the Swedish health care system is also included. Several case-based information systems have been developed within Swedish health care. They have different purposes and operate on different levels. General national registries include: discharge registry, medical birth registry, cancer registry and cause of death registry. They have been used mainly for research and planning of health services. Another type of national registries are related to specific patient groups. Such registries include information on results and complications of treatment. The initiative to these registries have come mainly from groups of consultants. The Stockholm County Council has replaced the traditionally global budgets of clinical departments with an activity based income. An evaluation project on health care utilization in five surgical specialties are presented. Preliminary results were: no division of in-patient care into multiple hospital stays and an increase in the number of discharges among the elderly. The Swedish health care system of today is characterized by organizational changes. Case-based information systems give the opportunity to study the developments of equity, quality and resource management in the new health care models. There is today an increased interest to use case-based information systems for quality assessment and continuous quality improvement. An increasing number of analyses are made at the local level. However, national case based data are still very valuable to make regional comparisons possible and to produce relevant reference data in local applications. PMID- 10163696 TI - Integrated specialty and operational system for diabetes management in south west England. AB - The management and control of diabetes throughout South West England has been assisted by the use of a networked computerised information system which is totally integrated with hospital and community information systems. The objectives of the diabetes system are to produce an aid to diabetes management, which includes the creation of a district diabetes register accessed and maintained by clinicians based in both the hospital and in the community, whilst at the same time providing auditable information. PMID- 10163697 TI - The OBSQID project. Obstetrical quality development through integrated use of telematics. AB - OBSQID is a one-year project with the ultimate objective of identifying and validating European quality development indicators in perinatal care which will make it possible to exchange data at regional, national and transnational levels through the use of telematic and computerized information systems. This will make it possible to monitor, evaluate and identify "best practices" in order to use this experience to improve the quality and outcome of perinatal care in the European region. The project is a collaboration between WHO/EURO, counterparts in perinatal and obstetrical care in the Member States, and the Advanced Informatics in Medicine programme of the Commission of the European Communities. PMID- 10163698 TI - DIABCARE-FRANCE, Un Menu a la Francaise. PMID- 10163699 TI - CARE Telematics: towards a trans-European Network for Health Statistics. PMID- 10163700 TI - Lessons from a child health system on opportunities and threats to quality from networked record systems. AB - The British Child Health System has been designed and widely implemented to support equity of access to preventive child health services, using case-based integrated records. Lately, telematics has been increasingly applied to improve the timeliness of data entry. A special project has been established to monitor overall quality of the system's use and of the resultant preventive services. The telematics application has been found to be a potential threat to quality in a way which would apply to all remote networked patient-based systems. The demonstration will show the methodology and interim results. PMID- 10163701 TI - The evolution of case-mix measurement using DRGs: past, present and future. AB - The Diagnosis Related Groups patient classification scheme has been evolving for over twenty years. The wide variety of DRG applications in the U.S. has resulted in the development of three major versions of DRGs. The alternative DRG systems are described and compared. Comparative statistical data for each DRG system are presented. PMID- 10163702 TI - Lessons from Sharing Hospital MBDS in the CAMISE project: need for further standardization. AB - Hospital MBDS is a powerful tool for improving the knowledge on hospital performance. Within CAMISE, a BIOMED research, a databank of about 4,000,000 discharges from 420 hospitals in 12 countries has been collected, and a lot of effort has been devoted to make them comparable and therefore useful for research purposes. Results from CAMISE shows important opportunities from cooperation of European level. It points out the need for making them available to researchers under the suitable conditions of confidentiality, security and control. PMID- 10163703 TI - Case-based telematic systems towards equity in health care. Introduction to the symposium. AB - The theme of this International Symposium, co-sponsored by EFMI (the European Federation for Medical Informatics) and WHO-Eur (the European Office of the World Health Organisation) is made of four components: (1) an ethical principle: equity in health care, that aims to social justice; (2) measurements of equity that should be case-based/population related; (3) communication of this information at a wide scale, using telematics, e.g. integrated computer systems at distance; (4) actions to improve health care and equity in its delivery by using resource management tools and developing quality of care. The combination of these four elements is recommended as a coherent scheme for future actions of public authorities in health care. They were therefore associated in the somewhat complex title of the symposium. A special attention is given to the present degree of availability of a large number of case based/population related data sources in Europe, as well as on the need to develop generic models in telematics, rather than too strict standards at the user level. These information systems can be made easily accessible to clinicians and epidemiologists as an aid to their decision making in the European region. PMID- 10163704 TI - BERTE--a database for children with congenital heart defects. AB - To secure the follow-up of children with congenital heart defects in Norway the Dept. of Pediatric Cardiology has developed a tailor-made database. This also simplifies the regular flow of information about these patients both inside the hospital and between the hospital and the others who are in charge of the patient care on various levels. PMID- 10163705 TI - From guidelines to decision support in the management of asthma. AB - Asthma is a common chronic disease of the lungs caused by inflammation of the airways affecting 6-7% of the population. Asthma is becoming commoner and there is evidence of under-diagnosis and poor management. Guidelines have been developed aimed at improving quality of care and in reducing social costs of asthma. The paper discusses an approach to implementing guidelines through decision-support system in primary care, based on methods developed in the AIM GAMES-II project. We also describe a prototype system that has been developed and a programme of clinical evaluation. PMID- 10163706 TI - Act management and clinical guidelines. AB - Clinical activity has always demanded close co-operation and co-ordination between clinicians and specialties. This applies especially in hospitals and in the future it will apply equally in primary and community care. Co-operation and co-ordination require two things: access to guidelines to control shared, distributed clinical activity, and common access to the patient record. Act management facilitates this by managing the process of care as it passes from one performer to another, enabling each to know at what point in the process (or cycle) they stand, what is expected of them, what is expected of others, and enabling them to access the information that they require. This paper describes act management with reference to guidelines and it is a contribution to the process, presently under way, that is intended to bring the leading examples of act management from the AIM NUCLEUS project and guideline support from the AIM DILEMMA project into close interworking in the same system. PMID- 10163707 TI - Quality assurance in clinical neurophysiology: the ESTEEM project example. AB - This paper describes the current status of the utilisation of clinical practice guidelines (protocols) in the ESTEEM project as one form of the clinical quality assurance procedures considered in the project. The performance of electrodiagnostic studies, in terms of which types of conclusions need to be inferred during the examination plan, is briefly described. The main focus of the paper is a description of an European multicentre clinical audit in the field of Clinical Neurophysiology, using a common data-entry protocol for prospective EMG case collection and assessment with the ultimate objective of building up a multicentre reference database of EMG cases. PMID- 10163708 TI - The development of protocols to cover clinical care in cardiology. AB - PROCAS (PRofiles Of CAre System) is one of the AIM projects whose objectives are to improve the quality and efficiency of medical treatment. These will be realised in establishing a methodology for defining and developing what are termed "Profiles of Care". These are sets of options for clinicians which are meant to create acceptable ways of managing patients with similar conditions and which represent good clinical practice. Moreover, a prototype system will be realised by the application of informatics and telematics, to enhance the provision of efficient and effective care in both hospitals and outpatient departments. Because of the retrospective nature of the ICD-9-CM system for the classification of cardiological patients, a draft for a Prospective Patient Data Model, which involves the assessment of somatic, psychosocial, environmental and demographic axes, is being presented. This multi-axial evaluation allows for the generation of the smallest unit of diagnostic-therapeutic procedures, based on the definition of the patient's health problem; that is: the patient-orientated diagnosis or the appropriate indication. PMID- 10163709 TI - Protocol-directed shared care in cardiology. AB - In the new market-oriented UK National Health Service, hospitals succeed or fail on the quality of service they provide to their customers. It is therefore important that institutions like the Royal Brompton Hospital can meet the information and communication needs of General Practitioners and hospitals who use their services so that co-ordination between healthcare professionals involved in the co-operative care of individual patients can be ensured. One method of improving the relationship between healthcare professionals is by the use of consensus-based clinical protocols which define "best practice' co operative care for a particular condition. The Royal Brompton Hospital has been a clinical partner in the AIM project DILEMMA which has been examining technology and methodologies for applying clinical protocols supported by telematics to general practice and shared care. A detailed requirements analysis has been carried out to look at the problems of shared care in cardiology and this has resulted in a demonstration system being developed to show how protocol-directed shared care and its supporting technology could be implemented to solve real clinical problems. Conclusions have been drawn that concern the use of protocols and information technology generally in routine clinical care. PMID- 10163710 TI - Telematics and protocols of care in critical care environments. AB - The paper discusses the potential roles for protocols of care within critical care environments from the perspective of providing real-time support for their application. The discussion is based around a conceptual model of care in critical care environments. This model has been developed in the wider context of developing information technology systems to support clinical care in critical care environments. The conceptual model of care is a three layer model which demonstrates both the hierarchical and temporal aspects of the care delivered to patients. It is proposed that if the value of protocols of care is to be realised in critical care environments then they must be seamlessly integrated into the routine data management associated with the care of patients. In order to demonstrate this and to evaluate the utility of this concept in the clinical environment, the systems from the AIM TANIT (Telematics in Anaesthesia and Intensive Therapy) project have been used as prototype platforms. The application of the concepts developed are described in two critical care environments: the anaesthesia department and the intensive care unit. Problems in using protocols of care in intensive care units suggest that integrating these with a problem solving methodology to create an integrated care plan may be a more appropriate approach to patient management. PMID- 10163711 TI - Disseminating quality care for upper gastrointestinal cancer. AB - This presentation discusses the problem involved in providing quality care for patients with Upper GI Cancer throughout a healthcare delivery system. It is argued that appropriate telecommunications technology exists for widespread dissemination of "best clinical practice", but that it cannot be used effectively at present because of some limiting factors. These include lack of precisely defined aims concerning use of technology, lack of interactive quality control, and insufficient involvement of end-users. Upper gastrointestinal cancer is selected as a model for discussion-since there is wide discrepancy between outcome of therapy in early and late cases, there is evidence that early diagnosis is possible-and there is substantial evidence that it does not take place widely in practice. Prospects for the future (with special reference to the 4th Framework) are discussed. It is argued that considerable opportunities exist. Future work should build on existing experience in informatics (eg. the "Telegastro" program) and in clinical practice (e.g. the Leeds "outreach" programmes) for (a) widespread dissemination of effective "best" clinical practice; and (b) continuing medical education. PMID- 10163712 TI - Clinical practice should reflect clinical science. AB - The Cochrane Collaboration was set up in 1992 as a world-wide network for creating and disseminating systematic reviews of randomised controlled trials (RCTs) in healthcare. Systematic reviewing of RCTs is an essential stage, prior to the creation and dissemination of clinical guidelines, in the practice of evidence-based medicine. This paper is intended to provide the health telematics community with an introduction to the motives, aims and activities of the Cochrane Collaboration. PMID- 10163713 TI - Guideline based care: the challenge for knowledge based decision support. AB - The EPISTOL action was included in the accompanying measures of AIM '91-'94 as a strategic study, aimed at clarifying the impact in the near future of knowledge based systems and techniques for the health sector, and provide recommendations with respect to the research and development work required within this period. In all the EPISTOL events, namely the Munich and Brussels workshops, the topic of clinical guidelines and protocol and based care raised considerable interest. This paper summarises these discussions, focussing on the KBS support for clinical guidelines. PMID- 10163714 TI - A model for the structured description of healthcare activities and related data. AB - Rehabilitation involves long-term, interdisciplinary processes. A model was developed, for the structured description of typical healthcare activities. Telematic services based on this model can support accurate data acquisition and communication among healthcare teams. Presentation of data within their context and according to the specific user's view is envisaged, based on deviations from the typical behaviours. Benefits are also expected in better understanding of the care processes themselves, easier comparison of different approaches, and diffusion of consensus-based knowledge. PMID- 10163715 TI - Prescription guidelines in OPADE: what are they, how are they used? AB - Many computerised drug prescription systems have been developed, but they are rarely used in clinical practice; among the reasons are their lack of integration with the functioning of medical institutions and the lack of consideration of general and local clinical practice rules. We present in this paper how OPADE, a computerised drug prescription system does answer this shortcoming by introducing prescription guidelines called Prescribing Principles. We argue that introduction of these Prescribing Principles will not only allow for integration of the computer in medical practice but will also introduce a positive feed back loop in the prescribing process. PMID- 10163716 TI - Integrating guidelines and the clinical record: the role of semantically constrained terminologies. AB - The extent to which protocols and guidelines will be used depends critically on how well they are integrated with existing medical records and each other. Effective integration requires consistent information structures and content, but if the union between components becomes too intimate it may restrict interaction with other applications. Such isolation leads to operational inefficiencies and can be financially unattractive. Systematic representation methods for protocols address part of the problem but are hampered by the unsuitability of existing medical terminologies; the effort required for bespoke development is prohibitive. Unifying and generalising terminological functions in a single "Terminology Server" that can support both construction of systems and their operational use promises to reduce development effort whilst allowing individual designers considerable independence. However, significant theoretical and practical questions remain about how far the problems of communication can be mitigated by a generalised, use-independent terminological system. PMID- 10163717 TI - Framework for quality assessment of knowledge. AB - One of the key issues in the development (and subsequent application) of medical knowledge-be it in terms of a KBS or otherwise-is the assessment of its quality. We present a framework for how to manage and make measurable the quality of the semantic as well as pragmatic aspects of the knowledge embedded in classification models during the development of such models. PMID- 10163718 TI - Informatics for care protocols and guidelines: towards a European knowledge model. AB - The DILEMMA Generic Protocol Model (DGPM) is a trans-national ontology of clinical protocols designed using a blend of logic engineering and business modelling techniques, and developed as part of the AIM programme's DILEMMA project. It allows the declarative representation of clinical activities and the knowledge associated with them. It is being used to represent protocols of all sorts-including standards and guidelines-for use in acute, primary, home and shared care. Central to the model are the states that protocol-derived actions can assume, and the statements that must be true before transitions between those states can be proposed. Proposed transitions may then be scrutinised by clinicians, patients and carers, and approved or rejected. This approach enables the model to handle anticipated exception situations, as well as more normal protocol selection and application. Links to multi-media material are being investigated, to enable users to examine the evidence upon which protocols are based, and to provide decision support where deterministic reasoning is not readily available. The model is being discussed with other AIM projects, with a view to developing a European consensus, and generating a version of the model for submission to CEN TC251 as a European pre-normative standard. PMID- 10163719 TI - Practice guidelines and healthcare telematics: towards an alliance. AB - This chapter reviews the motives behind the promotion, development and application of practice guidelines, defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'. It surveys the state of progress and future prospects for telematics applications in this area, and reports the action points recommended by the 1994 AIM Conference. There exists significant evidence that use of guidelines can improve healthcare process and outcome, and that computerised aids assist this effect, they may also enhance the potential uses of guidelines and protocols for audit, resource management and shared care. A standard generic model for computerised representation of guidelines as knowledge bases in a common format has been proposed and may be a key factor in future progress. The development of computerised patient records of adequate scope and quality is generally recognised as an essential condition for computer-aided guideline use. Support for development, dissemination and application of healthcare guidelines and use has emerged, notably through the AIM EPISTOL study, as a feasible and useful application area of medical knowledge-based systems. It is essential that telematics developments in this field are grounded in an understanding of the healthcare practices to which guidelines are being applied, and of the changes in practice which guideline use may entail. PMID- 10163720 TI - Computerized guidelines for preventative care in general practice. AB - Computer-based guidelines for preventative care is an example of the way in which protocols can be put to use in an effective and useful way. However, computerised medical protocols will only be used on a large scale if they are integrated with the computer-based medical record. The AIM-project ISAAC is working on the development of integrated tools for use in Primary Health Care, and especially General Practice. One of the tools under development is prevention. In this article, prevention is used as an example of the implementation of protocols. After a short definition of prevention, the implementation of preventative modules (or protocols) in the ISAAC GP information system is discussed. There are several conditions or critical factors if the implementation of prevention (and protocols) in a GP information system and in a GP practice is to be successful. In the discussion, some of the opportunities that are emerging with the use of information systems and telematics in primary health care are also discussed, together with the potential of ISAAC and the crucial role that must be played by healthcare providers. PMID- 10163721 TI - Computerised guidelines in primary health care: reflections and implications. AB - This chapter introduces the role of clinical guidelines in improving the quality of care in Primary Health Care. It goes on to describe the literature with respect to the development, dissemination and implementation of clinical guidelines while attempting to highlight factors liable to impede their use. It concludes with a discussion of the role of informatics in ensuring the difficulties described are avoided. PMID- 10163722 TI - Knowledge engineering for drug prescribing guidelines. AB - Prescribing drugs for the treatment of medical conditions is a very common activity for a doctor. Prescribing has enormous economic importance. Costs are rising quickly and there is an urgent need for doctors to have easy assess to advice about the cheapest, most effective therapy. On average 80% of GPs in the UK use a computer for their medical work and the figure is rising rapidly. Currently available systems provide only very simple checks and reminders. More sophisticated advice is provided by our prototype program. The program uses logic engineering to give advice, based on simple protocols for prescribing, tailored both to the condition being treated and the individual patient. The essential logical elements of the prescribing decision are discussed. These simple prescribing protocols may be the final common pathway for prescribing advice from many, more complex protocols for recommendations for drug treatment. PMID- 10163723 TI - Computerized assessment with primary care guidelines in The Netherlands. AB - To promote quality assurance and expertise in primary health care in the Netherlands the Dutch College of General Practitioners develops protocols, called standards. These standards concern medical action-taking in case of regular complaints and diseases in common practice. To improve dissemination of the standards and to develop effective and useful methods for quality assurance on the basis of the standards a project, called the Guidelines Automation Project (Richtlijnen Automatiseringsproject) was started to develop a computer program that can support quality assurance of medical action-taking in general practice on the basis of the NHG-standards. The main feature of the program is educational assessment. Other features of the program are: guidance for case data collection, stating of differential diagnoses, and disease profiles. These features also use patient case data as a starting point. In conclusion it is argued that all efforts towards an "electronic' use of protocols in the health care delivery system will fail, unless we arrive at a care record that both with respect to its structure and to its content, is being founded on sound formal principles. Several problems need to be solved first. The implementation, and exploitation of protocols, though relatively simple from a knowledge representation point of view, is not a straightforward task. PMID- 10163724 TI - Primary care guidelines from an organizational point of view. AB - Guidelines in primary health care have been developed to reduce assumed and undesired variation in certain aspects of care delivery by professionals. If systematically applied guidelines no doubt effect the quality of care. It is argued however that taking an organizational point of view on quality management yields new requirements with respect to development and application of guidelines. It is considered to be essential for managerial control purposes that guidelines have simple and valid indicators to monitor the actual application and to measure the preferred outcome. It is essential that the choice of guidelines to be implemented in an organization is determined in the context of an explicit plan for quality management. PMID- 10163725 TI - Security of the electronic health care record--professional and ethical implications. AB - Many challenges face developers of secure computerised clinical systems but the technical problems are overshadowed by procedural, professional and ethical issues. The development and use of computerised systems must be controlled through compliance with standards and procedures for information security, enforced through national legislation and professional codes of conduct, if serious abuse of the data is to be avoided. Health care professionals cannot be expected to acquire working knowledge of how information systems are made secure since this is a technical and highly complex subject. However, it is essential that health care professionals understand why it is important to maintain a secure environment for the records they keep about patients and their care and how this can be organised. This is best achieved through a well structured educational programme involving all trainee and qualified health care staff, a task which should be coordinated by the national professional bodies. A management structure is needed within health care facilities that recognises the responsibility of health care professionals to keep the health care data relating to their patients secure. An arrangement is proposed that gives the most senior clinician in a health care facility the ultimate responsibility for security of health care data held in the organisation. Where appropriate, this would be delegated to a senior clinician with training and experience in information systems and their security. This 'information doctor' would, with the assistance of computer experts and health care managers, implement and monitor the organisation's information security strategy. Contracts should be developed between health care facilities and their patients, defining the limits to the use and disclosure of personal health data. Similar contracts with external agencies should also stipulate the minimum level of security to be applied to health records shared between the organisations. PMID- 10163726 TI - Risk analysis in health care establishments. PMID- 10163727 TI - The SEISMED High Level Security Policy for Health Care. AB - The proliferation of the use of automated Health Information Systems in the everyday practice of health professionals has brought a number of issues related to the security of health information to a critical point. The preservation of security of health-related information can only be achieved through a concerted approach, comprising legal, organisational, technical and educational actions. These classes of actions constitute a complete "security framework", a key aspect of which is the set of rules, laws and regulations that govern the usage of information within a Health Care Establishment. This set is commonly referred to as "Security Policy". In this paper, the SEISMED High Level Security Policy for Health Care Establishments is presented. PMID- 10163728 TI - Security standards for medical information systems. AB - This paper has provided an overview of some of the aspects of medical information systems security and the standards that are available to implement security solutions. There is a need to address a complete solution for the security of medical information systems: technical, procedural and legal protection of medical records, databases, applications, hardware and software, networks and the management of the system. The existing standards cover some of these topics but not all. There is still room for further work and the development of standardised technological solutions supported by legal and procedural measures. PMID- 10163729 TI - How to assure security: CEN standards, directives, or European Guidelines? AB - It is argued, that to assure security, we need to make use of all three vehicles mentioned in the title, provided we select carefully which type to use in what circumstances. Many useful activities in these areas are under way. There is an important danger, however: if we do not take into account the needs of practical applicability, the net result of all efforts might be an increase of the gap between theory and practice, and thus a contrary effect of the intended one. PMID- 10163730 TI - The SEISMED guidelines for host systems security. AB - The increasing use of and reliance upon information technology within modern healthcare establishments underlines a need for adequate security controls to protect the confidentiality, integrity and availability of systems and data. Whilst the consideration of security is now generally accepted as part of the design and implementation of new systems, many systems are already in operation in which these needs have not been adequately addressed. This paper presents a summary of the recommendations arising from the AIM SEISMED (Secure Environment for Information Systems in MEDicine) project relating to the addition and enhancement of security in existing healthcare systems. The paper is based upon material originally presented at the SEISMED Workshop "Security and Legal Aspects of Advanced Health Telematics", Brussels, 11 July 1994. The content has been revised in light of the workshop discussion and the further development of the guidelines since that time. PMID- 10163731 TI - Data protection and security within TANIT. AB - The word "TANIT" means "Telematics for ANaesthesia and Intensive Therapy". The objective of the TANIT project is to develop information and telematic systems in critical care environments that are integrated in the hospital information space. The goal is to produce an integrated European reference computer for Critical Care Environments (CCE). For this purpose, TANIT is developing methods and guidelines for the design, implementation, introduction and evaluation of systems, successful patient data management, medical/nursing activities, clinical audit, and departmental management for Anaesthesia and Intensive Care. In this context, the task of Workpackage PROTEC-Data Protection, Security and Confidentiality- was to develop confidentiality rules for personal and management data which arise in a CCE context, and at the same time to establish procedures that will allow medical personnel all data access needed for successful treatment of their patients. Furthermore, PROTEC proposed technical methods to protect sensitive data in the computerized records. PMID- 10163732 TI - Open information systems and data security in medicine. AB - The realization of the German law for a new structure of health care delivery by the assurance of efficient structures and processes in hospitals calls for an optimal design of informational processes. To realize applications near to the users and just in time as well as to build up the complex functional relationships between departments and subsystems in big hospitals, a new design for Hospital Information Systems (HIS) is necessary. The features of modern HIS outlined in the paper can only be established by open systems, which guarantee portability, scalability and interoperability. This is also true in regionally distributed systems like the tumour register at Cancer Centres. In the paper the necessity and possibilities of open systems and different levels of application integration are discussed. The general statements are illustrated by practical realizations in the HIS of the Magdeburg University Hospital as well as in the tumour register at the Cancer Centre of Magdeburg/Sachsen-Anhalt. The creation of integrated structures for communications makes great demands on the assurance of data security and data protection, especially for the inclusion of external partners from the region. In the context of high sensitive data of cancer patients data protection is of top priority. The legal problems of data collection, data storage and exchange in medicine are discussed first. The paper presents some aspects of the concept for data security and data protection in the Magdeburg University HIS and of the related concept for data protection in the tumour register of the Cancer Centre Magdeburg/Sachsen-Anhalt. Appropriate steps of realization are demonstrated. The application of hardware based modern access control systems with integrated encryption of data follows. The statements are extended to the planned installation of hardware based network access control systems with integrated encryption of data in the LAN. PMID- 10163733 TI - Guidelines for secure system development and secure implementation. AB - In this paper the present state of development of the guidelines for both secure system development and secure implementation, as being drafted within the scope of the SEISMED project, are briefly described. For system development there is a lot of literature how to cope with security requirements. For secure implementation of systems within an organization hardly any literature was found. By consequence there is a significant difference in maturity of the two sets of guidelines. PMID- 10163734 TI - Safety and security of information systems. AB - This paper discusses some of the similarities and differences between the attributes of safety and security. It places these attributes within the broader topic of dependability and tries to identify what aspects of safety and security are unique and which aspects may be viewed within the attributes of reliability and availability. The paper then suggests that, rather than analyse systems from the single perspective of safety or security, they should be analysed from the broader perspective of dependability. PMID- 10163735 TI - The EDITH approach: the management of authorisations and security in healthcare information systems. AB - This paper provides a summary of the approach adopted by EDITH for the definition and management of the security aspects within a generic healthcare information system, organised according to a common architecture based on characteristics of modularity, openness and federation of the individual healthcare organisations and healthcare information systems. The specification and actual development of the Authorisation Server, shortly described in this paper, is the result of the joining of the activities carried out by GESI in the frame of the NUCLEUS (AIM 2025) and EDITH-Italy (ESPRIT 7058) projects. PMID- 10163736 TI - Issues of security and network security in Health Care Information Systems. AB - A Health Care Establishment (HCE) is an establishment where medical services are rendered. The above services are provided by the health care personnel. The infrastructure of a HCE may include Information Technology (IT) equipment that stores and processes HC information. Previously, IT equipment consisted solely of stand-alone systems, whereas in recent years, the trend has been towards computer networks and distributed systems in HCEs. The spread of distributed information technology in HCEs have necessitated the implementation of Security in HCISs, to assure confidentiality, integrity and availability of HCE information. This paper discusses the issues of Security and Network Security in Health Care Information Systems (HCISs). It also suggests a method in establishing Network Security Guidelines and describes Principles for the provision of Network Security in HCEs. PMID- 10163737 TI - Security standards in telematic networks for EU Administrations: lessons drawn from the ENS Program. PMID- 10163738 TI - Cryptographic mechanisms for health care IT-systems. AB - Present health care information and communication system sufficiently respect neither the interests of the professional users (physicians, nurses, etc.) nor those of the usees (patients) concerning informational self-determination, integrity, and non-repudiation. The EU-AIM-SEISMED project has attacked this challenge. There is consensus that legal regulations and organisational measures around health care IT-systems have to be revisited and harmonised. However, the increasing processing capacities of IT-systems demand that the legitimate security interests of users and usees are enforced in advance--not only after the fact. This cannot be achieved against -----stems but only by the help of IT systems. Since cryptographic mechanisms are an essential tool to this end SEISMED provides guidelines and technical recommendations on cryptographic mechanisms. PMID- 10163739 TI - Trusted Health Information Systems: a project within the DG XIII/INFOSEC programme on Electronic Signatures and Trusted Third Parties. PMID- 10163740 TI - Legal issues in medical informatics: a bird's eye view. AB - The present paper is the result of a study investigating the legal issues, problems and obstacles which have arisen as a result of the R&D projects financed by the AIM Program 1991-94. Two parallel lines of investigation were adopted in this study. First of all, a questionnaire was sent to all project partners listed in the AIM 93 Report, with the objective of collecting information on the legal questions with which the individual projects were confronted in the course of their R&D work. This allowed for an initial mapping out of the legal aspects relevant in the field of medical informatics. Secondly, the actual projects were studied as to their legal content and in particular those which included a legal workpackage. This allowed for an assessment of further legal questions, some of which had as yet perhaps not been perceived as such. The present paper deals with five key aspects, describing the nature of the issues and the relevant law and case law or legal vacuum as it may be. It must be emphasised that, as pointed out in the title, this study offers an overview of the legal issues debate in medical informatics and is somewhat exploratory in nature. It is not intended to offer a critical analysis of existing picces of legislation or case law. This would call for more fundamental legal research. Instead the study restricts itself to a general description of existing legal principles and their relevance in the health care sector. As the reader will gather from this paper, legally speaking information technology is still a relatively new entity in the health care sector, which means that legal research and any resulting recommendations may have a real impact on the future course of the law in this field. PMID- 10163741 TI - Low end interactive image-directed neurosurgery. Update on rudimentary augmented reality used in epilepsy surgery. AB - Our experience with a very low end interactive image-directed (IIDS) neurosurgical system is presented. The system was developed by the author and consists of a personal desktop computer and a magnetic field digitizer. This low cost solution was pursued as an alternative to available commercial devices which were expensive and not readily modifiable for novel ideas and new applications targeted for Epilepsy surgery. The rationale and description of the system was presented last year at Medicine Meets Virtual Reality III. Included in that detailed report were the fundamental mathematics forming the basics of transformation between the surgical and the digital data spaces. Since then the system has been used in an additional 20 cases now totaling 40 in all. Its advantages and short comings will be described. The theoretical advantages of magnetic field technology over other localization methods is reviewed. Also, our experience with alternative low cost off-the-shelf interfacing devices and other related modifications are described. We have accumulated clinical data to suggest that craniotomy sizes have been reduced, electrode placement has been improved, and that interactive image-directed techniques offer advantages over other common intra-operative localization modalities such as ultrasound. Our conclusion is that interactive image-directed techniques improve neurosurgery and that inexpensive enabling technology is already available providing the technological substrate for low cost devices using virtual reality notions for surgery and medicine. This particular technology offers advantages to traditional surgical techniques demonstrating the attractiveness of rudimentary virtual reality medical applications. PMID- 10163742 TI - Medical virtual reality. The current status of the future. PMID- 10163743 TI - Advanced telepresence surgery system development. AB - SRI International is currently developing a prototype remote telepresence surgery system, for the Advanced Research Projects Agency (ARPA), that will bring life saving surgical care to wounded soldiers in the zone of combat. Remote surgery also has potentially important applications in civilian medicine. In addition, telepresence will find wide medical use in local surgery, in endoscopic, laparoscopic, and microsurgery applications. Key elements of the telepresence technology now being developed for ARPA, including the telepresence surgeon's workstation (TSW) and associated servo control systems, will have direct application to these areas of minimally invasive surgery. The TSW technology will also find use in surgical training, where it will provide an immersive visual and haptic interface for interaction with computer-based anatomical models. In this paper, we discuss our ongoing development of the MEDFAST telesurgery system, focusing on the TSW man-machine interface and its associated servo control electronics. PMID- 10163744 TI - The virtual aneurysm. Virtual reality in endovascular therapy. AB - Image guided therapies, such as new endovascular procedures for treating brain aneurysms are now in clinical use. To plan these procedures, physicians currently use angiography to view projectional images of anatomy and blood flow. There are currently no available tools for visualizing the details of complex blood flow or predicting the effects of specific treatments. To address this problem, we have created a virtual environment for the visualization of blood flow and the simulated effects of therapy in brain aneurysms. The "Virtual Aneurysm" is composed using a combination of image processing, flow simulation, scientific visualization, and virtual reality techniques. PMID- 10163745 TI - Three-dimensional computer-assisted design of plastic reconstructive surgery procedures. PMID- 10163746 TI - Geometric and physical representations for a simulator of hepatic surgery. AB - Despite the large interest in simulators of minimally invasive surgery, it is still unclear to what extent simulators can achieve the task of training medical students in surgical procedures. The answer to that question is certainly linked to the realism of displays and force-feedback systems and to the level of interaction provided by the computer system. In this paper, we describe the virtual environment for anatomical and surgical training on the liver, currently under construction at INRIA. We specifically address the problems of geometric representation and physical modeling and their impact on the two aforementioned problems: realism and real-time interaction. PMID- 10163747 TI - A virtual simulation environment for learning epidural anesthesia. PMID- 10163748 TI - Virtual echography. The simulation of ultrasonographic examination. AB - We present a Virtual Echographic System. Because this examination is particularly difficult, developing a simulator is very useful to give students some common databases of pathological samples on which they could experiment image acquisition and evaluate their understanding of clinical cases. We have applied our method to the simulation of thigh ultrasonographic examination for thrombosis diagnosis. A preliminary system, focusing on image generation, has been developed. Virtual echographic slices are generated using a particular interpolation technique and a deformation model of significant structures. Resulting images have a visual quality similar to usual ones. PMID- 10163749 TI - Virtual holography in diagnosis and therapy of sensorimotor disturbances. AB - It has been shown that VR techniques can be usefully applied in the field of sensorimotor disturbances. Virtual scenarios can be created in which patients perform specific motor tasks. Using an optoelectronic position tracking system for motion recording as well as for interaction with virtual objects, and using Virtual Holography as an adequate visualization technique, we are now developing and testing suitable scenarios. Furthermore, an advanced visualization and animation tool using VR technology for diagnosis purpose and therapy planning has been developed, which the physician can profit from during motion analysis. PMID- 10163750 TI - Incorporating visible human project data into the undergraduate anatomy and physiology curriculum. AB - The University of Wisconsin-La Crosse is developing a software environment which will allow undergraduates in anatomy and physiology to directly manipulate the Visible Human Data Set. The software environment provides students with a "personal digital cadaver" for study. The system incorporates a volume rendering daemon for imaging the digital cadaver. Central to the system is the concept of an anatomical notebook in which students record and annotate the studies. PMID- 10163751 TI - Developing a virtual reality-multimedia system for anatomy training. AB - The University of California, San Diego, School of Medicine's Learning Resources Center is developing a prototype next-generation application for anatomy education which combines virtual reality and multimedia curricular resources. The anatomy lesson utilizes polygon-based 3-D models of the hepatobiliary system created by BioGraphics Inc. of Fort Collins, Colorado which were derived from the National Library of Medicine's Visible Human Project Dataset. This article describes the needs assessment, learning objectives, and preliminary design of the current prototype. The multivariate design, the development strategy for implementing functionalities, and the engineering of critical software interface components are also outlined. PMID- 10163752 TI - Initial clinical experience with an interactive volume sonography visualization system. PMID- 10163753 TI - Introduction of new technologies to the medical undergraduate curriculum. AB - The rate at which new educational technologies are introduced is growing at a tremendous pace. This is in large part due to the recommendations of the AAMC Steering Committee on the Evaluation of Medical Education which strongly supported the use of Medical Informatics technologies for education. Some institutions have attempted to implement these technologies; however, a scientific study has not yet been conducted to document their potential benefit. Our attempts to conduct such a study were met with obstacles of resistance from faculty, administration, and students. To overcome these obstacles we have developed a solution which addresses all of the resistance that we encountered. This solution is based upon three premises: 1) adjunct introduction, 2) multicenter studies, and 3) scientific educational benefit analyses. PMID- 10163754 TI - The Hyper Hospital. Virtual reality-mediated networked medical care system. PMID- 10163755 TI - Telemedicine in the North Carolina prison system. A cost-benefits analysis. PMID- 10163756 TI - Remote access to neurosurgical ICU physiological data using the World Wide Web. AB - There is a significant demand by physicians and clinical researchers for remote access to continuously acquired physiological patient data. Until recently such access was technically unfeasible. However, with the recent development of Internet-based World Wide Web (WWW) client/server applications and underlying communication protocols, there is now a real possibility for the development of cost-effective, platform independent solutions to this problem. We have devised a way using existing WWW tools and minimal startup costs to provide access to current as well as previously acquired physiological patient data. Physicians and clinical researchers can obtain access to these data through personal computers located in the office, at home or even through portable computers while traveling to conferences or while on vacation. PMID- 10163757 TI - Primary care and hemodialysis monitoring through telemedicine. AB - Telemedicine offers the primary care physician an opportunity to improve time management while continuing to provide optimal, cost efficient care. The following paper offers a means with which to deliver such care and describes the relationship required between physician and patient to deliver optimal telemedical care. The Texas Telemedicine Project offered an avenue for the physician participants to explore the best delivery system with which to successfully employ telemedicine in the practice of medicine. Patients became comfortable with interactive healthcare delivery quickly, and preferred it as a means of receiving primary care as well as continuous physician monitoring during dialysis treatments. This study leads the authors to the opinion that telematic healthcare delivery will only be successful when the patient/physician relationship most closely mimics that of face-to-face contact. PMID- 10163758 TI - Medical emergency aid through telematics (MERMAID). PMID- 10163759 TI - The Cybermensch simulation server for the planning of clinical trials 2.0. PMID- 10163760 TI - Virtual reality enhanced surgical conference system. AB - We present our ongoing work on an enhanced surgical conference system with a technology of virtual reality (VR). We reported on a surgical simulation support system by using a technology of virtual reality last year. In the present time, while using our VR simulation system, we realized that many surgeons and nurses needed to see both a solid real image and a virtual image of the surgical operation at the same time. According to this reason we added a solid video system to our previous VR simulation system. The new system can display both real and virtual images on 100 inch wide screen and a console monitor of Onyx computer. The doctors can see both images with shutter glasses on the screen or console. We can now simulate various cancer surgery while watching the real solid surgical picture. We expect our enhanced surgical conference system to be beneficial for surgeons and nurses with limited experience to familiarize surgical procedures. The system could be also employed in planning a surgical procedure and educating medical staffs. Here we discuss about the aim of the system, current implementation, its limitations and its future directions. PMID- 10163761 TI - Toward virtual teleconferencing for telemedical applications. PMID- 10163762 TI - Telemedicine and security. Confidentiality, integrity, and availability: a Canadian perspective. AB - The health care system is undergoing major reform, characterized by organized delivery systems (regionalization, decentralization, devolution, etc); shifts in care delivery sites; changing health provider roles; increasing consumer responsibilities; and accountability. Rapid advances in information technology and telecommunications have led to a new type of information infrastructure which can play a major role in this reform. Compatible health information systems are now being integrated and connected across institutional, regional, and sectorial boundaries. In the near future, these information systems will readily be accessed and shared by health providers, researchers, policy makers, health consumers, and the public. SECURITY is a critical characteristic of any health information system. This paper will address three fields associated with SECURITY: confidentiality, integrity, and availability. These will be defined and examined as they relate to specific aspects of Telemedicine, such as electronic integrated records and clinical databases; electronic transfer of documents; as well as data storage and disposal. The guiding principles, standards, and safeguards being considered and put in place to ensure that telemedicine information intrastructures can protect and benefit all stakeholders' rights and needs in both primary and secondary uses of information will be reviewed. Implemented, proposed, and tested institutional, System, and Network solutions will be discussed; for example, encryption-decryption methods; data transfer standards; individual and terminal access and entry I.D. and password levels; smart card access and PIN number control; data loss prevention strategies; interference alerts; information access keys; algorithm safeguards; and active marketing to users of standards and principles. Issues such as policy, implementation, and ownership will be addressed. PMID- 10163763 TI - Vestibular telemedicine and rehabilitation. Applications for virtual reality. AB - This paper will discuss the use of Virtual Reality (VR) technologies in the rehabilitation of patients with vestibular disorders and in the provision of remote medical consultations for those patients. Patients with a vestibular problem are very common (vertigo is the second most common neurological complaint after headache) and yet there are very few vestibular neurotologists: specialists in their diagnosis and treatment. New treatments for various disorders causing vertigo now exist. This means that appropriate diagnosis can significantly improve patients' well-being. Remote medical diagnosis and treatment facilities could make the few vestibular disorder specialists much more available to patients. An analysis of the technological and economic factors influencing the provision of this service is necessary. The main long term effect of many vestibular disorders is damage to the sensing apparatus of the inner ear. The damage can lead to inappropriate interaction between visually driven orientation sensing and sensing of orientation by the inner ear. The consequence for the patient is vertigo (a sensation of turning), motion sickness and imbalance. Current rehabilitation efforts are intended to drive the nervous system to adapt to the disordered vestibular input. Adaptation appears to occur slowly in many subjects, even those within rehabilitation programs. An appropriately designed VR experience could greatly increase the rate of adaptation in these patients. PMID- 10163764 TI - A system for the delivery of remote obstetrical care by telepresence. AB - This paper describes the development of a system to provide obstetrical care to remote and/or medically underserved areas. The ROC project is an attempt to develop new telemedicine hardware and software which will enable the provision of high quality obstetric care to individuals who are normally denied access to this care by reasons of distance, handicap, economics, or other causes. As broadband data communications links and increasingly powerful and affordable computing resources become widely available, the barriers of distance and economics will no longer prevent the provision of this care. Increased efficiency and access may also meet society's requirements for cost containment and productivity. PMID- 10163765 TI - Complex task performance in Cyberspace. Surgical procedures in a telepresence environment. AB - To assess the capabilities of our fully functional, prototype telepresence surgery system, experienced surgeons performed complete operative procedures on live, anesthetized pigs. Cholecystectomy, the prototypical procedure for evaluating the integration of surgical skills, was successfully performed in six animals. There were no aborted attempts or complications. Other procedures completed included gastrotomy and enterotomy closures, anastomosis of the small intestine, and nephrectomy. No specific training was required for using the telepresence surgery system, and the "feel" of the system was described as intuitive. Operative times were longer than required in conventional, open surgery, most likely the result of the four degrees of freedom available in the manipulators of the current-generation system. Force feedback and high resolution, stereoscopic video input facilitated performance. Surgeons operating through a first-generation telepresence system can achieve technical results equivalent to those obtained in conventional surgery. PMID- 10163766 TI - The role of computer-based simulation for training surgeons. AB - The effectiveness of computer based simulation (CBS) technology for training surgeons has yet to be determined. However, there is a body of research that demonstrates the effectiveness of this technology for other training applications. This research also indicates the substantial savings in cost, time, and effectiveness of simulation. PMID- 10163767 TI - Volume rendering of visible human data for an anatomical virtual environment. AB - In this work, we utilize the axial anatomical human male sections from the National Library of Medicine's Visible Human Project to generate three dimensional (3-D) volume representations of the human male subject. The two dimensional (2-D) projection images were produced by combining ray tracing techniques with automated image segmentation routines. The resultant images provide accurate and realistic volumetric representations of the Visible Human data set which is ultimately needed in medical virtual environment simulation. Ray tracing techniques provide methods by which 2-D volume views of a 3-D voxel array can be produced. The cross-sectional images can be scanned at different angles to produce rotated views of the voxel array. By combining volume views at incremental angles over 360 degrees a full volumetric representation of the voxel array, in this case the human male data set, can be computer generated and displayed without the speed and memory limitations of trying to display the entire data array. Additional texture and feature information can be obtained from the data by applying optical property equations to the ray scans. The imaging effects that can be added to volume renderings using these equations include shading, shadowing, and transparency. The automated segmentation routines provide a means to distinguish between various anatomical structures of the body. These routines can be used to differentiate between skin, fat, muscle, cartilage, blood vessels, and bone. By combining automated segmentation routines with the ray-tracing techniques, 2-D volume views of various anatomical structures and features can be isolated from the full data set. Examples of these segmentation abilities are demonstrated for the human male data set which include volume views of the skeletal systems, the musculoskeletal system, and part of the vascular system. The methods described above allow us to generate lifelike images, NURBS surface models, and realistic texture maps of specific anatomical structures. We have the capability to generate images that are both accurate and lifelike, much like photographic anatomical atlases. We can also generate images, models, and textures that have the clarity of medical artwork/illustrations, by highlighting the coloring of the ray traced structures with conventional colors instead of the natural color of the specimen. We are currently in the process of generating a comprehensive reference atlas of volume rendered images of the human body, soon to be published by Mosby-Year Book. The segmentation techniques needed to create this atlas also offer the accuracy and realism needed to create surface models and texture maps for a virtual environment for surgery simulation. PMID- 10163768 TI - Applied virtual reality for simulation of endoscopic retrograde cholangio pancreatography (ERCP). AB - Researchers from the Georgia Institute of Technology and the Medical College of Georgia (GIT/MCG) have developed an interactive computer simulation of Endoscopic Retrograde Cholangio-Pancreatography (ERCP). ERCP is a minimally invasive technique for evaluating and treating pathologic conditions of the biliary and pancreatic ducts. While ERCP provides the patient with substantial advantages over traditional methods, ERCP requires advanced skills and extensive experience to minimize the risk of complications. Computer simulation offers many advantages for efficiently and safely training physicians in ERCP. The GIT/MCG proof of concept simulation provides realistic training with both visual and force feedback while an endoscopist practices the ERCP procedure. PMID- 10163769 TI - Virtual design prototyping applied to medical facilities. AB - Over the past five years, MITRE has developed rapid 3D modeling and immersive environment capabilities that supports the application of virtual environment technology to many traditional and non-traditional domains [1]. This paper provides background information on these capabilities and describes the application of this technology to the experimental design prototyping of operating rooms of the future and to the design and retrofit of existing or proposed medical facilities. These capabilities employ contemporary commercial hardware and software and exploit stereoscopic projection displays and headsets. A unique user interface facilitates object manipulation within these immersive environments and addresses two key areas: 1) Visualization of the contents on the model server or library in a catalog form; and 2) Natural interaction and immersion of the user with the visualized catalog and selected visualized objects in a 3D synthetic environment. A brief discussion of two developing applications of this technology will be presented. In one application example, the modeling environment can be used to synthesize physical replicas (potentially full stereo scale) of actual surgical rooms used for training of medical personnel. Alternatively, it can be employed as the infrastructure for a new form of collaborative interactive visualization, namely, telesurgery. In another example, the rapid modeling capability provides designers, architects and medical personnel with a means of rapidly developing synthetic renderings of (potentially interactive and remotely operative) proposed medical facilities prior to construction. We also discuss key issues needing to be resolved for successful model interchange. PMID- 10163770 TI - A virtual reality interface to an intelligent dental care system. AB - The design and fabrication of teeth restorations in dentistry rely increasingly on CAD/CAM techniques. We present an approach for interactive design of the occlusal surface of teeth based on simulation of jaw articulation and computer aided diagnosis of occlusal disorders. To bridge the cognitive gap between the dentist and the computer system, we propose a virtual reality user interface, which applies the metaphors of tools and techniques known in dentistry. This makes the restoration design more intuitive for dentists. The system uses Virtual Reality Modeling Language (VRML) and HTML standards to generate a treatment report and exchange data in an electronic form. The simulation of jaw articulation requires fast calculation of multi-point contacts and detection of collisions between surfaces of teeth and restorations. We have developed a distance maps technique which exhibits realtime performance for objects with complex geometry and is suitable for other virtual reality systems dealing with complex contacts. The characteristics of contacts between teeth acquired during lower jaw motion are compactly represented as accumulated distance maps. These maps are then used for automatic removal of interferences between the restorations and the opponent teeth, and provide the dentist with information for further manual adjustments of the occlusal surfaces. PMID- 10163771 TI - Interactive computer technologies in dentistry. Virtual reality in orthodontics. PMID- 10163772 TI - Computer-assisted planning of oral implant surgery. An approach using virtual reality. AB - A planning system for oral implant surgery is described. This system allows the interactive placement and adjustment of models representing oral implants on CT volume data. These CT data can be shown as two-dimensional (2D) slices, or as a three-dimensional (3D) surface-rendered model. The viewpoint is fully adaptable, and stereoscopy results in an enhanced insight in the interrelation between implants and structures. This approach offers many advantages when compared with the traditional manual planning or with a 2D computer based planning. Clinical trials are being performed. PMID- 10163773 TI - Cranial base tumor visualization through high-performance computing. AB - Tumors of the skull base in general are considered among the more difficult head and neck pathological entities to treat surgically; some surgeons, in fact, consider lesions in this area inoperable. The most appropriate and safest surgical approach to lesions of the anterior and lateral skull base can be devised only with accurate and precise pre-operative assessment. The literature demonstrates the constant evolution of and search for more efficient less invasive, and safe surgical approaches to this region. With the development of a more exact three-dimensional, interactive anatomical "road map" for each patient's disease and anatomy, the skull base surgeon can not only achieve a more accurate pre-operative assessment leading to a less invasive and less morbid approach, but also can continue to develop and refine new approaches without fear of actual morbidity and mortality. An interdisciplinary team approach, the advent and continued development of faster high performance computers, and the development of new and innovative rendering algorithms can lead to surgical simulation. A prototype of an interactive system has been developed. The system will be iteratively modified through a stepwise evaluation of its clinical usefulness by continually reassessing the system with clinical trials. The current state of the system and the potential benefits are presented. PMID- 10163774 TI - Simultaneous planning and execution in cranio- and maxillofacial surgery. AB - This paper describes the development of a system for simultaneous planning and execution of surgical operations in the cranio-maxillo facial area. Simultaneous planning and execution is the process of taking an implicit task description, planning a sequence of explicit execution commands e.g. for robots and monitoring their execution. As the execution planning process is running completely on-line, that means during the actual execution of the assembly task, the planning process is highly reactive based on sensor information about the robot's present environment. In order to meet the problem that medical data is usually complex and needs time-costly preprocessing an appropriate architecture for evaluating sensor data has been developed. In this paper, a detailed presentation of the phases of execution planning and sensor data evaluation is given. As an example, the execution of a LeFort I osteotomy is presented. PMID- 10163775 TI - Patient-specific anatomic models. Geometric surface generation from three dimensional medical images using a specified polygonal budget. AB - Virtual reality offers the promise of highly interactive, natural control of the visualization process, greatly enhancing the scientific value of the data produced by medical imaging systems. Due to the computational and real time update requirements of virtual reality interfaces, however, the complexity of polygonal surfaces which can be displayed is limited. In this paper, we present a novel method for the production of a polygonal surface containing a pre-specified number of polygons from volumetric data. To preserve surface detail, we extract a set of curvature weights from the volumetric data and use these weights as the input vectors to a 2-D Kohonen network. The adaptation of the network to the input vectors results in a display surface that preserves useful detail relative to the number of polygons used. PMID- 10163776 TI - Wideband holographic three-dimensional ultrasonic imaging of breast and liver phantoms. AB - Wideband ultrasonic 3-D holography is a unique technique for volumetric imaging with extremely high lateral and depth resolution. The large frequency bandwidth, which is typically 25% to 100%, provides excellent depth resolution. The synthetic aperture provides optimum lateral resolution of one-half wavelength at the pulse center frequency. Wideband impulse holography is a multi-frequency detection and imaging technique where the reflected target's broadband time waveform signals are recorded over a defined aperture. The signals are then decomposed into their discrete frequency components as single frequency holograms, combined in the spatial frequency domain, and reconstructed into a 3-D composite image. The composite image may then be viewed with stereo glasses in 3 D. Recent 3-D holographic images of human female breast and liver phantoms with internal cysts (5 to 10 mm) at 5 MHz illustrate the efficacy of this technique for medical ultrasound 3-D volumetric imaging. A video of the breast and liver phantoms may be presented at the meeting. PMID- 10163777 TI - Surface electromyogram for the control of anthropomorphic teleoperator fingers. AB - Growing importance of telesurgery has led to the need for the development of synergistic control of anthropomorphic teleoperators. Synergistic systems can be developed using direct biological control. The purpose of this study was to develop techniques for direct biocontrol of anthropomorphic teleoperators using surface electromyogram (EMG). A computer model of a two finger teleoperator was developed and controlled using surface EMG from the flexor digitorum superficialis during flexion-extension of the index finger. The results of the study revealed a linear relationship between the RMS EMG and the flexion extension of the finger model. Therefore, surface EMG can be used as a direct biocontrol for teleoperators and in VR applications. PMID- 10163778 TI - Surgical simulation of facial paralysis. AB - We are developing a prototype of a surgical simulation system for restoring facial expression lost in cases of facial paralysis. Correcting facial paralysis requires careful planning of surgery procedures and accurate prediction of the surgical results. So far techniques to perform this task largely relied on the physician's experience, and there were few quantitative data to refer to. The system we propose is finally aimed at helping the surgeon plan the surgery and predict the results. The 3D model of the face used in our system is generated directly from the CT scan of the patient. The face model consists of skin, skull and selected facial muscles based on anatomy. The mass and spring lattice approach is used to give physical attributes to the face model. The present prototype system lets the user directly manipulate graphical representations of facial expression. PMID- 10163779 TI - Virtual reality volumetric display techniques for three-dimensional medical ultrasound. AB - Ultrasound imaging offers a safe, inexpensive method for obtaining medical data. It is also desirable in that data can be acquired at real-time rates and the necessary hardware can be compact and portable. The work presented here documents our attempts at providing interactive 3-D visualization of ultrasound data. We have found two volume rendering visualization packages to be quite useful and have extended one to perform stereographic volume visualization. Using a relatively inexpensive pair of commercial stereo glasses, we believe we have found a combination of tools that offers a viable system for enhancing 3-D ultrasound visualization. PMID- 10163780 TI - Simulation and modeling of penetrating wounds from small arms. PMID- 10163781 TI - Real-time visually and haptically accurate surgical simulation. AB - The Visible Human Database provides a complete submillimeter photographic and radiological description of both a male and a female cadaver. The Center for Human Simulation has developed real-time algorithms that allow a user to wield a virtual scalpel and produce arbitrary cuts into the reconstructed body. Real-time interaction is achieved by producing the appropriate texture mapped surfaces directly from the Visible Human Database. We are currently combining a 3 degree of freedom PHANToM haptic device (SensAble Devices) with our surgical cutting algorithms to produce a system with the look and feel of surgical cutting. PMID- 10163782 TI - An intelligent system with EMG-based joint angle estimation for telemanipulation. AB - Bio-control of telemanipulators is being researched as an alternate control strategy. This study investigates the use of surface EMG from the biceps to predict joint angle during flexion of the arm that can be used to control an anthropomorphic telemanipulator. An intelligent system based on neural networks and fuzzy logic has been developed to use the processed surface EMG signal and predict the joint angle. The system has been tested on various angles of flexion extension of the arm and at several speeds of flexion-extension. Preliminary results show the RMS error between the predicted angle and the actual angle to be less than 3% during training and less than 15% during testing. The technique of direct bio-control using EMG has the potential as an interface for telemanipulation applications. PMID- 10163783 TI - A ray-traced texture mapping for enhanced virtuality in image-guided neurosurgery. AB - 3D imaging systems and algorithms give virtual representations of the real world. New emergent hardware systems can combine virtual information and the real world. Virtual and real information must be also visually confronted in order to facilitate our comprehension of the data. We propose a solution which entails the superimposition of a real image of the anatomical areas visualised in a surgical operation with 3D digital data sets. Unlike other solutions which display virtual images in the real world, our method involves ray traced texture mapping which displays real images in a computed world. PMID- 10163784 TI - Linking anatomy and physiology in modeling respiratory mechanics. AB - We present an integrated 3D virtual environment for the quantitative modeling of the anatomy and the physiology of the pulmonary system. Our approach formally integrates 3D deformable object modeling with conventional models of respiratory mechanics. We demonstrate quantitatively, aspects of the behavior of the respiratory system qualitatively known to clinicians, such as normal quiet breathing and an open sucking chest wound. Our methodology is general and can be used to model both the anatomy and the physiology at many levels of detail. Another important aspect of our approach is that based on our previously developed computer vision techniques we can make such a simulation patient specific. The usefulness of such a system is manifold. Medical education, surgical planning, disease diagnosis are some of the many areas such a system can be applied. PMID- 10163785 TI - Virtual environments technology to aid needle biopsies of the breast. An example of real-time data fusion. PMID- 10163786 TI - Assessing a virtual reality surgical skills simulator. AB - The Institute for Defense Analyses (IDA) was contracted to perform a military standard task analysis of laparoscopic cholecystectomy, and to study the effectiveness of a virtual reality surgical skills simulator as a tool for surgical training and as a method for recording psychomotor behavior. This report describes the purpose of the study, its design, initial results, and implications for the field of medical education. PMID- 10163787 TI - Computer-aided locoregional assessment of soft tissue sarcoma and three dimensional simulator surgery. PMID- 10163788 TI - Simplified access to medical resources on the Internet. How to get clinicians on the Web. PMID- 10163789 TI - Introduction of new TeleMedicine applications into ophthalmology. Standardized evaluation of transmission modalities. PMID- 10163790 TI - Breast cancer lighthouse CD-ROM. Using personal stories for patient and clinician education. PMID- 10163791 TI - CAD modeling of the birth process. Part II. AB - We are engaged in studying the process of human birth by developing a computer based dynamic model that can be adapted to specific birth scenarios. The individual characteristics of a given pregnant woman and fetus, embedded in their clinical measurements and CT and MRI images, are captured in the model. One can thereby predict adverse events that might happen during labor and delivery. Based on our findings from a preliminary design and execution of this model, we believe it holds great promise as an accurate, cost-effective diagnostic and teaching tool that will help predict conditions during individual labor scenarios that might cause traumatic birth injuries, and thereby enable us to make the most informed clinical decisions possible. PMID- 10163792 TI - A desktop image processing system for computer-assisted orthopedic surgery (DISOS). AB - Within the framework of our research activities in orthopedic surgery a PC-based imageprocessing system for the processing of x-ray computer-tomographic data has been developed. The system is used as a work platform for the investigations concerning interaction modalities, strategies and techniques for an efficient planning and execution of surgical interventions in orthopedic surgery by means of individual templates. The method of individual templates has been presented in /1,2/ and will not be subject of this paper. PMID- 10163793 TI - PIXEL: experiences with the element. PMID- 10163794 TI - Stereoscopic visualization system for clinical angiography. AB - Four dimensional visualization (FDV) project for clinical angiography has started at National Cancer-Center since 1995 in cooperation with medical virtual reality projects in our center. All stereo pair of x-ray angiographic images, both digital images and film based conventional x-ray images, are available in this system. FDV system software was developed on a Silicon Graphics platform. Every stereo pair angiographic images can be viewed stereoscopically using a stereoscopic visualization interface. Series of image data sets provide three dimensional blood flow dynamics that is very useful to diagnose vascular encasement by the tumor and to determine vessel of purpose which locates in front or in back from superimposed angiographic images. FDV system is expected to improve the accuracy and efficiency of diagnostic radiology and interventional radiology (IVR) procedures. In future, angiography system will equipped with a stereoscopic visualization interface that will provide a more flexible and more effective guidance tool for diagnostic radiology, especially for IVR that requires image-guided procedure. PMID- 10163795 TI - Human body textbook with three-dimensional illustrations. AB - We made a toolkit for making education softwares using 3D computer graphics, and using the toolkit, we made an education software based on 3D illustrations for learning about the human body. The toolkit enables us to make such kind of education software based on 3D illustrations easy and systematic. In the education software, the human body structure is illustrated with 3D models. The user can see the 3D objects with real-time rotation and walk through the virtual space, and their functions are expressed in the 3D virtual space. PMID- 10163796 TI - Computational visualization of cardiovascular blood flow. PMID- 10163797 TI - Distributed medical intelligence. A systems approach for developing and integrative health care information distribution infrastructure. AB - Recent trends in healthcare informatics and telemedicine indicate that systems are being developed with a primary focus on technology and business, not on the process of medicine itself. Distributed Medical Intelligence promotes the development of an integrative medical communication system which addresses the process of providing expert medical knowledge to the point of need. PMID- 10163798 TI - Integrated medical environments. Magnifying the healing power of information. PMID- 10163799 TI - The evolution of virtual reality from surgical training to the development of a simulator for health care delivery. A review. PMID- 10163800 TI - Standardisation in health care informatics and telematics in Europe: CEN TC 251 activities. AB - This article describes the actual user requirements of the Health Care sector in connection with Telematics. The importance of standardisation is stressed. The paper further gives an overview of the current standing of the activities of CEN TC 251 (European Standardisation Committee, Technical Committee on Health Care Informatics). PMID- 10163801 TI - ASTM E31.15 on health knowledge representation: the Arden Syntax. AB - ASTM subcommittee E31.15 on Health Knowledge Representation was formed to promote standards for defining and sharing health knowledge bases. Its first standard, the Ardan Syntax, is focused on knowledge bases that can be represented as a set of independent modules called Medical Logic Modules (MLMs). The standard is in clinical use and has generated significant interest in industry and academics. The Extensions task group plans to extend the syntax where appropriate, to expand to other types of knowledge bases. The Validation/Verification task group is approaching the enormous problem of evaluating knowledge bases and the process of sharing them. PMID- 10163802 TI - Standardisation work in the European Workshop for Open Systems' expert group healthcare (EG MED). AB - Following the issue of a "Study and Investigation" mandate by the European Commission in 1989, there has been a very substantial amount of work in the field of Medical Informatics, mainly undertaken by CEN and EWOS. This paper discusses the work being undertaken by the EWOS Healthcare Expert Group. PMID- 10163803 TI - Investigation of syntaxes for existing interchange formats to be used in healthcare. AB - This paper gives a summary of the work done by CEN TC 251 PT 004. The project team objective has been to investigate syntaxes of existing interchange formats (IFs) to be used in healthcare. A set of evaluation criteria have been developed based on functional requirements from two healthcare domains. 5 IFs; ASN.1, ASTM E1238, EDIFACT, Euclides and ODA have been evaluated. ASN.1 scores highest in the evaluation. However mapping from General Message Models (GMDs) to IF dependent message models (IFMDs) shows that all the IFs can be used. The project team recommends a strategy for development of GMDs, IFs and IFMDs. PMID- 10163804 TI - Development of standard healthcare EDI messages. AB - The development of standard healthcare messages requires a full understanding of user needs, an appropriate organisation structure for developing consensus and a suitable methodology. This paper presents the current state of development in the European Standardisation Organisation's Working Group on Healthcare Messages and Communications (CEN TC251 WG3). PMID- 10163805 TI - Communication of structured medical information by computers: the Oxford experience. PMID- 10163806 TI - Development and current use of ASTM/HL7 messages for health care communications in the USA. AB - Two influential organizations in the development of medical data exchange standards in the United States of America are ASTM and HL7. A shared message structure has been adapted to diverse applications including hospital information systems and clinical laboratories. The basic approach is the exchange of ASCII messages. Messages segments relate to clinical entities and support a hierarchy of entities. Individual data fields are of variable length and bounded by delimiter characters. The feasibility of this approach has been confirmed by its adoption by a number of medical institutions and information system vendors. PMID- 10163807 TI - ANSI's Health Informatics Planning Panel (HISPP)--the purpose and progress. PMID- 10163808 TI - Health Level 7. A protocol for the interchange of healthcare data. PMID- 10163809 TI - Medical EDI message specification and interchange formats. AB - Assessment of the current medical edi environment learns that "old" interchange formats are being used to represent information of highly complex and quickly evolving nature. Whenever the domain requirements are translated into acceptable messages according to these interchange format specifications, system developers use the latest technologies to implement the messages towards the distorted view imposed by the interchange format constraints. This situation, combined with the fact of coexistence of several interchange formats and the urgent need for more standardised message types, led to the specification of a new meta-syntax, supporting easy message definition and allowing the data-driven conversion between multiple interchange formats. As such, and supported by the development of interchange format independent message descriptions, it may become a tool to support the medical edi needs of the future. PMID- 10163810 TI - UN EDIFACT--an EDI standard for health care. PMID- 10163811 TI - Implementing ASTM 1238 on a national scale in France: the H.PR.I.M. experience 1990-1992. PMID- 10163812 TI - Multi media and broadband communication services: a new paradigm for medical imaging. AB - This paper is attempting given a summery of the major building blocks and driving forces in the developments of medical informatics and medical imaging in special. The role of multi-media and broadband communication will be described. The paper should give an indication where the author sees medical imaging in the world of informatics, focusing from R&D to product developments, with emphases on standards and prototyping. The author will also define the molecule and atoms of medical informatics and medical imaging. The architecture of the CEN TC 251/4 draft standard will be described in relation to the general objectives of CEN TC 251. PMID- 10163813 TI - Recent progress in standardization of medical imaging in America. PMID- 10163814 TI - Standard interchange for computerized electrocardiography. AB - In the SCP-ECG project (AIM #1015) of the pilot AIM Programme a standard communications protocol was developed for computerized electrocardiography, consisting of standards for the interchange, encoding and storage of digital ECG data. Part of this work is continued under the main AIM Programme (January 1992- December 1994) as AIM Project #2026, entitled "Open European Data Interchange and Processing for Computerized Electrocardiography (OEDIPE)" and was taken up by the CEN/TC 251 Committee as a priority item, for implementation into an official European Standard in Health Care Informatics. The objectives and implementation of this Standard are described in the present paper. PMID- 10163815 TI - Data interchange for clinical neurophysiology. AB - Clinical Neurophysiology is rapidly moving towards complete dependence on digital instrumentation and computer-based systems. ASTM E 1467-92 "Standard Specification for Transferring Digital Neurophysiological Data Between Independent Computer Systems" was developed to allow exchange of multichannel electrophysiological waveforms, embedded textual annotations, results of mathematical processing, and clinical interpretive reports between various instruments and systems. This will permit integration of the neurophysiology laboratory interaction with hospital and clinic informations systems, and sharing of data between institutions for clinical or research purposes. PMID- 10163816 TI - Standards of medical informatics in Japan. AB - Standardization activities related to medical informatics in Japan are briefly introduced in this paper. Because two kinds of portable media that are MODs (Magneto Optical Disk) and IC cards are supposed to be practically used in medicine, standardization works are currently supported by Japanese government. With an introduction of the organizations their standards and policy are explained. PMID- 10163817 TI - Health care security and privacy, quality and safety. AB - Working group 6 of CEN/TC251 is concerned with the broad field of Security and Privacy, Quality and Safety in Health Care. In line with the priorities given by SOGITS, the first areas to be looked into, are those concerned with Data Protection in Health Care Information Systems. In order to successfully work on standardisation in this field, one has to take into account the generally low awareness for these problems, and the necessity to avoid increasing the gap between theory and practice. Work of WG6 will build to a large extent on the results of a related AIM-project (SEISMED). A sketch is given of ongoing work on this subject. Briefly, also other work items for WG6 are reviewed. PMID- 10163818 TI - Standardization in health care informatics opportunities for international cooperation. PMID- 10163819 TI - Developments in health informatics within the standards associations of Australia and New Zealand. AB - Activities to support the development and adoption of Standards in health informatics are now well started. The Standards Association of Australia formed a committee (IT/14) on Medical Informatics which met for the first time in February 1991: early in 1992 it changed its name to reflect a broader concern with "Health Informatics" rather than the rather narrower interpretation that many had chosen to place on the term "Medical Informatics". The Standards Association of New Zealand held the inaugural meeting of persons interested in constituting committee SC606 on Health Informatics in August of this year. A growing program of active collaboration between Australia and New Zealand was formalised in July of this year, whereby standards will for the most part be jointly developed and adopted regionally, and whereby the separate committees will be merged wherever practicable to form a single head Joint Technical Committee (JTC) for each domain of involvement. The focus in Australia and New Zealand is at present very much on the need for standards to implement national health information networks. The progressive definition of network standards is prompting increased interest in the standards implemented within the systems and installations that must connect to the networks. The initial implementation of a national health information system in New Zealand is scheduled for 1st July 1993: detailed plans for an Australian health communications network are well advanced although no date for its implementation has been proposed. This paper outlines the general structure of the standards committees in the Antipodes, and of their various sub committees. It will also outline broad terms of reference of these groups, and the major areas of current interests, activity and developments. PMID- 10163820 TI - Health care telematics in the European communities. PMID- 10163821 TI - Activities of EFMI WG III on standards in health care informatics. PMID- 10163822 TI - Health care informatics: data development for medical effectiveness research. PMID- 10163823 TI - Recommendations for an object oriented healthcare information model. AB - The need for a healthcare information model as a component in a framework of standards for healthcare data interchange is identified. Key requirements for a method to support development of a healthcare information model are defined and recommendations for development of an Object Oriented Healthcare Information Model are presented. PMID- 10163824 TI - Medical informatics vocabulary. AB - In order that medical informaticians can create Open Systems for health care, they need to have a common language. Efforts in the 1980s at the National Library of Medicine to create a Medical Informatics Vocabulary (MIVoc) have been useful for document indexing purposes, but need to be continued and extended. The Committee of European Normalization Technical Committee 251 has created a project team for MIVoc, and that team has used both automatic and manual methods and referenced many sources in producing a vocabulary that has support from numerous experts in Europe. MIVoc has both a glossary and a tree structure. The glossary has about 250 terms with detailed definitions that include various explanations and pointers. One critical pointer is the semantic link to other terms in MIVoc from a which a tree-structure is inferred. The success of MIVoc clearly depends on its being used, which in the long run depends also on the vocabulary being maintained. PMID- 10163825 TI - American National Standards Institute (ANSI) Healthcare Informatics Standards Planning Panel. Subcommittee on Scope of Medical Record Standards. PMID- 10163826 TI - A proposed standard for registration of coding schemes. AB - This paper describes a proposed European standard for the Registration of Coding Schemes used in electronic healthcare information exchange. The requirements for such a standard are outlined together with the manner in which the work to meet these requirements has been carried out. The paper includes a summary of the main points contained in the proposed standard and in the supporting documents delivered by the project team. The paper concludes with a report on the progress of this proposal towards acceptance as a standard and a brief comment on how it may influence other work in medical informatics standardisation. PMID- 10163827 TI - A model for coding and multiaxial classification examplified. AB - A model of a coding and classification scheme is examplified in the domain of clinical laboratory sciences. It is for a multilingual thesaurus based on coded elementary concepts used to form coded composites or aggregates of preferred terms. These are for transmission over alphabet and language barriers. PMID- 10163828 TI - Is preventing violence health care's new frontier? PMID- 10163829 TI - The prevalence and impact of psychological disorders in primary care: HMO research needed to improve care. AB - OBJECTIVE: To estimate the prevalence and impacts of psychological disorders among primary care patients. SETTING: Primary care clinics at Group Health Cooperative of Puget Sound participating in a multi-center, international World Health Organization study. DESIGN: Prevalence survey of a stratified sample of consecutive primary care patients. MAIN OUTCOMES MEASURES: Psychiatric diagnosis, work disability, and health care costs. RESULTS: Depression, anxiety and somatoform disorders were common among primary care patients. They were associated with significant disability, unfavorable health perceptions and increased health care costs. CONCLUSIONS: Psychological disorders are common among primary care patients and these disorders have significant societal impacts including work disability and increased health care costs. HMOs with integrated delivery systems that have developed public domain research capabilities have a critical role to play in efforts to reduce the burden of these disorders by evaluating innovations in health care services for psychological disorders. PMID- 10163830 TI - Behavioral health and the medical cost offset effect: current status, key concepts and future applications. PMID- 10163831 TI - Health care providers and violence: opportunities for action. AB - Staff at Group Health Cooperative of Puget Sound have undertaken numerous strategies and community alliances in an effort to decrease violence in their community. Beginning with pilot programs and interventions for their own providers and enrollees, programs now focus on strengthening the community, controlling firearms, and supporting youth. PMID- 10163833 TI - Firearm patient education and firearm regulation: health care providers' attitudes and practices. AB - A survey of two large HMOs was conducted to assess health care providers' attitudes and practices regarding firearm patient education, firearm patient counselling, and firearm regulation. Survey results were intended to provide background data on barriers to be addressed and opportunities to be used in developing day-to-day office practice interventions to reduce enrollees' risk of firearm injury. PMID- 10163832 TI - Domestic violence is a health care issue. PMID- 10163835 TI - Providers, patients, plans and payors: gag rules in purchaser-driven health reform. PMID- 10163834 TI - HMO-bashing: a most popular Washington pastime. PMID- 10163836 TI - Eighteen years of mammography experience in an HMO: 1975-1992. AB - OBJECTIVE: To describe the mammographic experience for the years 1975 to 1992 at Kaiser Permanente, Northwest Region (KPNW). SETTING: Large, group practices HMO. DESIGN: Clinical databases. PARTICIPANTS: KPNW women in various subgroups. MAIN OUTCOME MEASURES: Mammogram rates. RESULTS: The rate of mammography at KPNW was fairly low (2% to 5%) until 1983, when it began to rise rapidly, almost exclusively as a result of a great increase in screening examinations of otherwise normal women. By 1992 the annual rate of mammography had increased to 40.2% for all women over age 40, and 52.4% for women aged 50 to 69. Women aged 40 to 49 and those over 70 had rates 10% to 15% lower than women aged 50 to 69. Summary figures for all KPNW women hide the striking effect of duration of membership in this HMO. Women aged 50 to 69 who had been members for at least 2 years had mammography rates (at least one examination in that 2-year period) of 75% to 76%. Longer membership resulted in gradually higher rates. The annual mammogram rate for women with 4 years of membership was 58%. CONCLUSIONS: Though there may be significant personal barriers to regular mammography, the effect may be less important in the HMO setting. An efficient, organized system can effect high rates of mammographic screening. The longer a woman remains a member of such an organization the greater her likelihood of receiving regular screening mammograms. PMID- 10163837 TI - Guidelines for prevention of perinatal group B streptococcal disease. PMID- 10163838 TI - An HMO approach to nutrition screening in the elderly. PMID- 10163839 TI - Perspectives. Slowed growth signals changing environment for Medicaid HMOs. PMID- 10163840 TI - Considering cost effectiveness in the hospital setting. PMID- 10163841 TI - Hospital industry cash flow ratio analysis: a sufficiency and efficiency perspective. PMID- 10163842 TI - Man of the Year. The disease detective. PMID- 10163843 TI - Man of the Year. The Tao of Ho. PMID- 10163844 TI - Man of the Year. A team effort. PMID- 10163845 TI - Man of the Year. The global epidemic. PMID- 10163846 TI - Man of the Year. Hope with an asterisk. PMID- 10163847 TI - Man of the Year. Now it's AIDS Inc. PMID- 10163848 TI - Adding pharmacists to the healthcare team enhances outcomes. Interview by Mary Ellen Deily. PMID- 10163849 TI - Drug therapy assessment: areas of focus. PMID- 10163850 TI - Expanding pharmacy's role to reduce drug-related problems. PMID- 10163851 TI - What physicians want from a restructured delivery system. PMID- 10163852 TI - The disconnect between providers' expectations and incentives. PMID- 10163853 TI - Using physician profiles to measure performance. PMID- 10163854 TI - Physician alignment: which approaches produce the best results? AB - An IPA-model MCO, a facility-based integrated health system, a physician practice management company and a large multispecialty group practice are using a variety of incentives to bring physicians in line with corporate goals. PMID- 10163855 TI - Coming of age in New York. PMID- 10163856 TI - Arizona Samaritan merges with Catholics. PMID- 10163857 TI - Social HMOs: lessons learned and future direction. AB - Brandeis University researchers collaborated with the Health Care Financing Administration (HCFA) to develop the "social HMO" concept in the early 1980s. Four initial sites in Portland, Oregon; Minneapolis; Brooklyn, New York; and Long Beach, California, implemented programs in 1985. Its success has prompted HCFA to expand the program, which is similar to a Medicare risk-contracting HMO but with more comprehensive benefits and a modified funding mechanism, to six new sites by the end of this year. PMID- 10163858 TI - Building bridges: marketing managed care to ethnically diverse populations. AB - America's population "stew" creates specific challenges to health plans attempting to reach ethnically differentiated enrollee groups. In this article, the author provides snapshots of four ethnic groups, suggests some marketing considerations when preparing communications to these groups, and helps draw some conclusions about marketing managed care products to a culturally diverse population. PMID- 10163859 TI - Opportunities and challenges of managed Medicare. PMID- 10163860 TI - Improving disease state management: identifying how service beliefs differ. PMID- 10163861 TI - A systems-based disease management model: achieving optimal health care outcomes. AB - In this article, the "disease management system model" is presented, which is applicable to health care providers practicing in community, hospital, and long term care settings. The core service of patient information for diabetic care is used to demonstrate how the model integrates individual system components involved in health care delivery. PMID- 10163862 TI - Preventing and defending lawsuits against elder-care facilities. PMID- 10163863 TI - Flunk the gene test and lose your insurance. PMID- 10163864 TI - Hospital cost shifting, a continuing debate. AB - This Issue Brief examines the evidence on hospital cost shifting. It defines cost shifting, explores the incentives facing hospitals and payers, reviews and critiques the new evidence on cost shifting, and discusses the policy concerns that arise from the new learning. Cost shifting has a precise and easily understood meaning. It does not mean that some payers pay different prices than others. Different prices are commonplace throughout the economy. Rather, cost shifting exists when the prices faced by one group of payers are higher because another group pays less. To be able to cost shift, a hospital must have market power, and it must not yet have fully exercised that power. There has been a spate of recent cost-shifting studies. The better known studies focus on industrywide, revenue-to-cost margins by payer. They find that the extent of cost shifting declined in the mid-1990's. The methods underlying these studies have been criticized in the academic literature, with the strong suggestion that the studies overstate any true cost shifting. Cross-sectional studies compared measures of prices across individual hospitals. These studies have failed to find evidence of hospital cost shifting. However, they suffer from a potential inability to control for levels of service, quality, and amenities that may simultaneously have changed as well. Dynamic studies compare individual measures of hospital prices through time and allow each hospital to serve as its own control. These studies find no evidence of hospital cost shifting. As one analysis concluded: "We found no evidence to suggest that cost-shifting strategies that might protect hospital revenues in the face of financial pressure were undertaken successfully." Rather than cost shifting, the existing evidence points to hospital competition limiting the provider's ability to raise prices. Whatever market power hospitals once enjoyed is disappearing--and with it the ability to cost shift. This research suggests that Medicare reform or Medicaid restructuring will have little direct effect on the hospital prices that employers and their workers pay for health care. The author argues that cost shifting is dead. However, the increased hospital competition necessarily squeezes hospital profits. This reduces the amount of charity care they can provide. Expect to see more and more examples of hospitals unable to provide care to nonpaying patients. This also suggests that care for the indigent will become a more pronounced public issue. This is a form of "cost" shifting, one that the "system" will need to deal with. PMID- 10163865 TI - Materials management systems: "... all about controlling costs". PMID- 10163866 TI - A GUI (graphic user interface) glue: customized software interfaces hold an HMO's information system together. PMID- 10163867 TI - Handheld healthcare. PMID- 10163869 TI - Behavioral health software attracts attention. PMID- 10163868 TI - Optimize your network for a better return on investment. PMID- 10163871 TI - User understanding, ANSI standards, and the Internet are keys to electronic data interchange growth. PMID- 10163870 TI - In search of safe harbor. For integrated healthcare delivery networks, EDI technologies solve thorny issues of compliance with HCFA's 3-Day Payment Window provision. PMID- 10163872 TI - HotList. Outcomes measurement. Regardless of provider size, need and demand for outcomes measurement software grows. PMID- 10163873 TI - Knowledge, power and comparative information. PMID- 10163874 TI - 1997 GHA (Georgia Hospital Association) legislative initiatives. PMID- 10163875 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1997 rates; corrections--HCFA. Final rule; correction. AB - In the August 30, 1996 issue of the Federal Register (61 FR 46166), we published a final rule revising the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes arising from our continuing experience with the system. In the addendum to that final rule, we announced the amounts and factors for determining prospective payment rates for Medicare hospital inpatient services for operating costs and capital-related costs applicable to discharges occurring on or after October 1, 1996, and set forth rate-of-increase limits for hospitals and hospital units excluded from the prospective payment systems. This document corrects errors made in that document. PMID- 10163876 TI - Promises, promises. AB - Once again, Congress and the President will try to balance the budget by slicing more out of nondefense discretionary spending. But there's not much meat left on those bones. The budget-meisters will try to spend and save. The result could be empty promises. PMID- 10163877 TI - Confronting the future of the FDA. PMID- 10163878 TI - Health care trends 1997. Top 10 trends for "Health Reform Debate II". PMID- 10163879 TI - Benchmarking answers question on hospital-based SNF bed needs. PMID- 10163880 TI - "Other" medicine enters the managed care mainstream. PMID- 10163881 TI - Occupational health should be a strategic initiative, not a product line. PMID- 10163882 TI - Evolving medical group models need special leadership skills for success. PMID- 10163883 TI - Choosing your investment in reforming consumer health demand. PMID- 10163884 TI - Public opinion mixed on health care "crisis". PMID- 10163885 TI - HCIA releases list of top 100 hospitals, updates performance benchmarks for 1997. PMID- 10163886 TI - Intranet applications can strengthen relationships with physicians. PMID- 10163888 TI - Steps for winning state approval of integration transactions. AB - The powers attorneys general have to regulate integration transactions between for-profit and not-for-profit organizations may differ from state to state, but regardless of location, health-care executives planning integration transactions should take steps to help ensure that such transactions receive state approval. Executives should familiarize themselves with the attorney general's approval process in their state, be prepared to defend the valuation of any not-for-profit assets to be transferred as part of an integration transaction, review articles of incorporation and state statutes to make certain that the proposed transfer of assets is permissible, and ensure that the process for securing board approval to proceed with the integration is free from conflicts of interest. PMID- 10163887 TI - Mastering the physician integration challenge. AB - Healthcare delivery systems must plan their physician integration strategies carefully to align the interests of their diverse physician constituents. Primary care physicians and specialists often have conflicting agendas, and physician integration attempts by healthcare systems frequently create networks of competing organizations with conflicting goals. Systems have a variety of options to choose from in implementing physician integration, including PHO- and MSO related strategies. In every instance, however, the main goals should be to build a tightly structured primary care physician network that has an appropriate level of specialist participation and to avoid alienating physician specialists, who still generate significant fee-for-service volume. PMID- 10163889 TI - Using actuarial models to assess managed care risk. AB - Actuarial models can be used to illustrate the financial risks inherent in healthcare provider operations. They are especially useful in analyzing the implications of managed care agreements, which revolve around risk and the financing of risk. Simple actuarial models may focus on inpatient utilization and reimbursement under capitation. More sophisticated models detail risks associated with individual diagnosis-related groups, as well as with many types of outpatient and physician services. Actuarial models can provide an objective basis for planning for the future and can be used to build consensus on strategies that will ensure success under managed care agreements. PMID- 10163890 TI - Four techniques for managing the risk of capitation contracts. AB - Organizations that provide managed care must manage four major cost drivers if they are to achieve financial success under capitation. These cost drivers-number of lives covered, service frequency, service intensity, and cost per unit of service-represent risk factors that can be minimized using several insurance risk management strategies: bearing risk, sharing risk, transferring risk, and undertaking risk-reduction activities. No one strategy will be sufficient to ensure success under capitation; contracting organizations, therefore, should use a portfolio of strategies to manage risk. PMID- 10163891 TI - Tax-exempt/proprietary partnerships: how the deal gets done. AB - Joint venture partnerships between tax-exempt healthcare providers and proprietary companies represent a type of provider-sponsored network. Tax-exempt /proprietary partnerships can help tax-exempt providers attain their strategic objectives and, at the same time, retain some governance involvement and healthcare decision-making authority. Proprietary companies that enter into such partnerships are able to expand their market presence and revenue potential without spending capital on an acquisition. Proprietary companies also gain the tax-exempt partners' goodwill, which could take them years to develop on their own. Before negotiating a partnership agreement, potential partners must assess their respective financial, cultural, organizational, and strategic strengths and weaknesses as well as their overall compatibility. Then they must develop contract terms to bring into the partnership negotiations. These terms include purpose, legal structure, assets/liabilities, governance, management, valuation, profit/loss sharing, capitalization/working capital, human resources, withdrawal from the partnership, noncompete covernants, and tax exemption issues. PMID- 10163892 TI - Creative alliances offer alternatives to corporate mergers. AB - Healthcare organizations form strategic alliances for several reasons: To achieve economies of scale, to provide specialized clinical or other expensive services, and to pursue common charitable missions. To accomplish these objectives, however, not all organizations need to enter into the binding legal agreements that characterize statutory mergers or acquisitions. For those healthcare organizations, variations of traditional arrangements-such as joint ventures, management, and service agreements- and less traditional arrangements-such as rights of first refusal, limited sponsorship arrangements, joint resolutions, overlapping committee arrangements and similar structures-may provide a solution. PMID- 10163893 TI - Tax-deferred annuity plans: meeting the IRS audit challenge. AB - A growing number of nonprofit organizations are being fined for violations of IRS regulations following IRS audits of their tax-deferred annuity (TDA) plans. To ensure that their organizations can withstand the scrutiny of an IRS audit, TDA plan administrators must ensure that plans meet IRS regulations and be prepared for IRS audits. Documentation--particularly of the TDA plan itself, and procedures related to salary reduction programs, compensation limits, excess deferrals and other excess contributions, loans, and distributions--must be comprehensive and in compliance with IRS regulations. PMID- 10163894 TI - ABC the best method for determining physician group practice costs. PMID- 10163895 TI - Streamlining the accounts payable function with EDI. AB - Kaiser Permanente of Southern California is expanding its use of EDI as a way to enhance the efficiency of its procurement effort and reduce administrative costs. Based on the results of surveys of key suppliers, Kaiser executives identified four EDI-based process improvements: 1) using the X12 832 standard to reconcile contracting data, which can eliminate up to 33 percent of mismatches among purchase orders, invoices, and receiving documents; 2) using procurement cards for many purchases, which can eliminate 20 percent of all invoices and related check payments; 3) using the X12 810 standard to obtain electronic invoices from Kaiser's largest suppliers; and 4) implementing the X12 820 standard, which lowers both supplier and claims payment costs. PMID- 10163896 TI - Developing a secure healthcare information network on the Internet. AB - Healthcare professionals across the country are using the Internet for a variety of activities, including the transmission of medical record data via e-mail. The transmission of confidential information, however, is a serious concern of healthcare consumers, providers, and payers alike. At Indiana University School of Medicine, security on the Internet is no longer a concern. The Internet is, in fact, the heart of a healthcare information network currently in development for the Indianapolis area. A complex set of encryption/decryption algorithms and user identifier and private passwords currently in development should greatly reduce the risk of security breach on the network. PMID- 10163897 TI - Ensuring the profitability of acquired physician practices. AB - Healthcare organizations are aggressively acquiring physician group practices to create primary care networks and broaden their managed care market penetration. However, few are realizing a positive return on investment after acquisition. The odds that acquired practices will be profitable can be improved if healthcare organizations plan carefully by establishing separate acquiring entities, setting clear goals for the practices, forming skilled management teams with strong physician leadership to manage the acquired practices, and carefully structuring their physician incentive compensation plans. PMID- 10163899 TI - HCFA clarifies Medicare outpatient observation policy. PMID- 10163898 TI - Strategies for selling and consolidating physician practices. AB - The changing dynamics of healthcare service delivery is forcing many physicians to consider selling their practices to hospitals or health plans or consolidating them with other practices. Besides being subject to the corporate and tax requirements that apply to the sale of any business, the sale of physician practices is also subject to Federal fraud and abuse and self-referral laws. Several sale strategies are available to physicians who desire to sell or consolidate their practices, including asset sales, stock sales, forward mergers, drop down consolidations, spinoffs, and statutory mergers. Each strategy has advantages and disadvantages, but whichever strategy is chosen, both sellers and buyers must ensure that tax issues are addressed and that the transaction complies with the requirements of Federal anti-kickback and self-referral laws. PMID- 10163900 TI - Using EDI for eligibility reporting. PMID- 10163901 TI - New directions for healthcare financial managers. PMID- 10163902 TI - Data trends. Factors influencing nursing unit costs. PMID- 10163903 TI - Negotiating a gain-gain agreement. PMID- 10163904 TI - Skills for a new marketplace. PMID- 10163905 TI - Finding your fit. PMID- 10163906 TI - Using healthcare data in advertising. PMID- 10163907 TI - Status quo may still bring changes. PMID- 10163908 TI - An introduction to the Internet. PMID- 10163909 TI - Measuring up under managed care. PMID- 10163911 TI - The temple of technology. PMID- 10163910 TI - After a false start, telemedicine is off to the races. PMID- 10163912 TI - A preliminary examination of patient loyalty: an application of the customer loyalty classification framework in the health care industry. AB - The present article applies the customer loyalty classification framework developed by Dick and Basu (1994) to the health care industry. Based on a two factor classification, consisting of repeat patronage and relative attitude, four categories of patient loyalty are proposed and examined, including true loyalty, latent loyalty, spurious loyalty, and no loyalty. Data is collected and the four patient loyalty categories are profiled and compared on the basis of perceived risk, product class importance, provider decision importance, provider awareness, provider consideration, number of providers visited, and self-reported loyalty. PMID- 10163913 TI - The changing power equation in hospitals. AB - This research traces the origins, development, and reasons for change in the power equation in the U.S. hospitals between physicians, administrators and accountants. The paper contains three major sections: a review of the literature concerning authority, power, influence, and institutional theory; a review of the development of the power of professions, especially physicians, accounting and healthcare administrators, and the power equilibrium of a hospital; and, a discussion of the social policy implications of the power struggle. The basis for physicians' power derives from their legal ability to act on which others are dependent, such as choosing which hospital to admit patients, order tests and procedures for their patients. The Federal Government's prospective payment system and the hospitals' related case-mix accounting systems appear to influence the power structure in hospitals by redistributing that power. The basis of the accountants' power base is control of financial information. Accountants have a definite potential for influencing which departments receive financial resources and for what purpose. This moves hospital accountants into the power equation. The basis of the hospital administrators' power is their formal authority in the organization. Regardless of what actions federal government agencies, hospital accountants, or hospital administrators take, physicians are expected to remain the dominant factor in the power equation. Without major environmental changes to gain control of physician services, only insignificant results in cost containment will occur. PMID- 10163914 TI - Managed health care: a review of the recent literature and suggestions for future research. AB - The United States health care system has, over the past decade, shifted from an almost exclusively indemnity insurance system to a managed care system. The managed care system is discussed in terms of its causes and major players. Given the importance of health care to the U.S. economy, an examination of the forces in this dynamic market is overdue. PMID- 10163915 TI - Essential dimensions of a marketing strategy in the hospital industry. AB - This paper reviews existing literature and defines essential dimensions of a hospital's marketing strategy for each of two business strategies; using the results of a national survey, this study confirms that hospitals make different marketing decisions based on the type of business strategy adopted by the hospital. PMID- 10163916 TI - Damn the data--full speed ahead! PMID- 10163917 TI - Target marketing for the hospital-based wellness center. AB - The American population is aging, medical technology is advancing, and life expectancies are on the rise. At the same time hospitals are looking for additional sources of income due to the pressures of government regulations and managed care. One of the options for hospitals looking for additional sources of income is the hospital-based but free-standing comprehensive wellness and fitness center. Such centers go beyond the facilities, programs and services offered by traditional health and fitness centers. In addition to physical fitness programs, hospital-based wellness centers offer programs in CPR, nutrition, weight control and many other programs of interest to an aging but active American populace. This research documents the hospital industry, wellness industry and the prospects of success or failure for he hospital attempting such a venture. The focus of the research is the experience of a particular hospital with regard to the programs, facilities and services deemed most important by its target market. PMID- 10163918 TI - Decision behavior, organizational structure, and the recruitment of female hospital pharmacists. AB - Given the increasing opportunities to practice outside the hospital setting, the role of hospital marketing in recruitment of pharmacists has increased in importance. It is the assumption of this paper that the decision behavior of prospective female recruits is different than that of male pharmacists and such perceptions influence decision behavior. It is the proposition of this paper that structural variables peculiar to hospitals must be considered when marketing strategy is set. Key literature is reviewed and conclusions reported. PMID- 10163919 TI - Marketing impact of health education programs. AB - A study evaluating whether a lay public education program caused initiation of health-related behaviors was conducted at the Cleveland Clinic Foundation. Attendees of three individual "Health Talks" were surveyed: endometriosis (n = 78), men's health (n = 62) and cancer (n = 57). Participants were surveyed at three points: (a) before the talk, (b) immediately following the talk and (c) six weeks after the talk concerning their knowledge and health behaviors. The results indicated that community health education produces a substantial improvement in health-related knowledge and after attending the seminars, 81.3% of respondents initiated a positive health behavior. Of interest to health care marketers are the 30.8% of attendees who initiated health behaviors which have marketing implications. PMID- 10163920 TI - Another privatization. University of Cincinnati Hospital is latest public facility to convert. PMID- 10163921 TI - Wis. OKs deal, with strings. City's only 2 hospitals reach antitrust settlement with state. PMID- 10163922 TI - PROs branch out. Broadening quality-assurance efforts. PMID- 10163923 TI - Outlook 1997. Batten down the hatches. Execs need to prepare for scrutiny of deals by citizens, regulators and the media. AB - Our reporters make their prognostications for a dozen major segments of the healthcare industry in 1997. A common thread runs through them: as mergers and consolidations continue to sweet through the industry, communities and regulators are becoming increasingly concerned about whether the public interest is being served. And, our reporters say, scrutiny of such deals is going to get even more intense. PMID- 10163924 TI - Retooled survey. VHA to focus on link of physicians and data sources. PMID- 10163925 TI - Firm expanding its reach. Debt, equity capital fuel HealthCare Financial Partners for growth. PMID- 10163926 TI - A blow to providers. Minn. urges HMO-like rules for risk-bearing networks. PMID- 10163927 TI - The HMO scramble. Hospitals, systems team up for managed care. PMID- 10163928 TI - A new spacer device for administration of inhaled salbutamol: use in elderly asthmatics. AB - This randomized, parallel-group study compared the use of a metered-dose inhaler (MDI) equipped with a new spacer device (Jet spacer) with that of a standard actuator in the administration of salbutamol (two puffs, 100 micrograms four times daily) to 36 elderly patients with moderate asthma and poor inhalation technique. After a 1-week run-in period, patients entered the 1-week study. Forced expiratory volume in 1 second (FEV1) and peak expiratory flow rate (PEFR) were measured at screening (both groups using the standard actuator) before and 30, 60, 120, and 240 minutes after administration; these measurements were repeated at the start and end of treatment (patients using the spacer or standard actuator). Ratings of efficacy and tolerability by investigators and of acceptability by patients were recorded at the end of treatment. Increases from baseline (from 0 to 240 minutes) in FEV1 and PEFR were comparable in the two groups at screening visit but proved higher (significantly for FEV1: P < .01) in the Jet group than in the standard-actuator group after both the first and last doses of the 7-day treatment period. the Jet group reported greater acceptability than the standard-actuator group. One patient in each group had tremors. The new spacer device is thus a valid alternative to the conventional actuator in patients with definitely or potentially poor hand-mouth coordination. PMID- 10163929 TI - Measuring the relationship of assistive technology use, functional status over time, and consumer-therapist perceptions of ATs. AB - Two consecutive studies addressed device use post-discharge in relation to functional status among 47 persons with mixed diagnoses discharged from an acute inpatient rehabilitation unit. Telephone interviews were used to ascertain device use; functional status was obtained using the telephone version of the Functional Independence Measure (FIM). Among all participants, 128 devices were prescribed; of these, 86 devices were still used at 3-month follow-up. The four types of devices most frequently abandoned were adapted grooming aids (55% nonuse), quad canes (43%), walkers (36%), and manual wheelchairs (36%). The most frequent reason given for nonuse was that the device was no longer needed. In study two, it was found that functional improvement (at follow-up) corresponded with device nonuse for about half the devices. The study also documented discrepancies in perception between therapists and consumers regarding utility and aesthetic aspects of devices. Strategies to maximize appropriate use of devices are presented. PMID- 10163930 TI - Frequency measures of behavior for assistive technology and rehabilitation. AB - Documenting assistive technology outcomes has grown in importance, but outcome measurement remains problematic. A new approach uses natural science measures and a model (selectionism) from the field of Behavior Analysis. Selectionism defines behaviors by their effects (functional performance) and the environment (including technology) within which they occur, and explicitly treats variation in patterns of behavior over time for individuals (intervention effects). Its basic metric is frequency of behaviors (count per unit time) which is similar to robust engineering measures like centimeters, grams, and seconds. This approach eliminates many of the problems inherent to more traditional psychometrics. Selectionism based on frequencies also provides an empirical structure or taxonomy to organize efforts and outcomes, unified by the notion of fluency. Composite behaviors are combinations of smaller component behaviors that are required for performance of the composite. A frequency above which a component behavior is readily retained, generalized, and recruited into the more complex composite behavior is called fluency; thus individuals fluent on the critical components easily and efficiently demonstrate the composite. This model suggests that when assistive technology interventions raise component behavior frequencies to fluent levels, they will be integrated usefully into an individual's life. This selectionistic approach has been used successfully in the field of education. It has the added benefit of not only empirically defining measurable outcomes, but also of providing useful ongoing measurement of change during treatment. This paper briefly describes this "Precision Measurement" strategy and its data-driven feedback process and makes suggestions for further research and development efforts. The method provides a basis for better documentation, control, and outcomes of assistive technology and related interventions. PMID- 10163932 TI - Outcomes measurement: health-related quality of life. AB - Outcomes research is rapidly expanding and evolving in the assessment of medical treatment and has significant potential contributions to the assistive technology field. Over the past two decades, numerous instruments have been developed and are widely used to collect data for evaluating the efficacy and effectiveness of traditional medical interventions. Although this methodology may not transfer seamlessly to assistive technology, the basis of its instrumentation and many of its concepts are highly relevant. Many current and emerging medical and assistive technology interventions are vigorously advocated but have inadequately demonstrated their positive impact on outcome. A key concept used in medical technology outcomes measurement is health-related quality of life, which represents the functional effect of an illness and its consequent therapy as perceived by the individual receiving treatment. People tend to make decisions about alternative health care services by estimating the effects of an intervention on outcomes important to themselves, by comparing intervention benefits and harms and by deciding whether the outcomes are worth the costs. Numerous valid, reliable, and responsive health-related quality of life instruments are available and are designed to discriminate between individuals, to evaluate change over time, or to predict outcome. Many are worth examining for potential use or adaptation in assistive technology outcomes measurement. Some of these instruments are generic, some specific, and others deal with health state preference. Generic health-related quality of life instruments are broadly applicable across various diseases, conditions, or populations. Specific instruments focus on a given disease, condition, or population. Health state preference instruments assess an individual's desirability for a given health state or outcome. Assistive technology practitioners claim that they improve the quality of life for the individuals they serve. Health-related quality of life must then be considered an integral component of the evaluation of service effectiveness. This paper reviews the concepts and instrumentation used in medical technology assessment for consideration and potential application in assistive technology measurement. PMID- 10163931 TI - Measuring the outcomes of assistive technology: challenge and innovation. AB - Documenting outcomes is becoming an essential function in assistive technology. Successfully documenting outcomes, however, depends on having appropriate measurement instruments and methodologies available. This is a challenge, as few measures are available which target the measurement of assistive technology outcomes. New instrumentation and approaches may need to be created or older measures radically adapted for assistive technology applications. This paper reviews measurement issues specifically relevant to assistive technology outcomes assessment. Many of the issues relate to measurement theory, as it is important to understand how instruments based on traditional psychometric concepts may not be the most appropriate for applications of assistive technology outcomes assessment. Fortunately, the assistive technology field also has innovative ideas being developed and tested. These may hold some promise as we all pursue better ways to document the outcomes of our assistive technology devices and services. PMID- 10163933 TI - Outcomes measurement: health state preferences and economic evaluation. AB - A major health care policy issue in this era of accountability is controlling the introduction and utilization of increasingly sophisticated and expensive health care technologies. Data are needed about both the effectiveness and the costs of assistive technologies before making decisions without relying on "that's what we did last time," "gut feelings," or even "educated guesses." Services, such as assistive technology, fall in the category where rigorous scientific evidence about cost-effectiveness is virtually nonexistent. The field of medical technology assessment has been studying cost-effectiveness for decades and offers many methodological ideas to related fields such as assistive technology. Based on the experiences of medical technology assessment, the measurement of health state preferences and its use to estimate quality-adjusted life years is discussed in this paper. Economic evaluation can be defined as the comparative analysis of alternative courses of action in terms of both costs and consequences. Information from economic evaluation studies, including the use of quality-adjusted life years as an outcome measure, helps us to determine which health care services we can afford to incorporate into routine clinical practice. The major forms of economic evaluation for health care described in this paper are cost-benefit, cost-effectiveness, and a special form of cost-effectiveness, cost-utility. Important national and state health care policies are being considered and implemented on the basis of economic evaluation data and these are bound to have major implications for assistive technology. The assistive technology field needs to be aware of these methods both to understand how large scale health-related policy decisions are impacted by economic evaluations and to become participants in and contributors to this process. PMID- 10163934 TI - NASL: an advocate for long-term care providers. PMID- 10163935 TI - Aging workers: disability management strategies. PMID- 10163936 TI - Balance and mobility disorders in older adults. Assessing and treating the multiple dimensions of balance. PMID- 10163937 TI - Integrated postacute care networks. Opportunities exist to create a more efficient delivery system. PMID- 10163938 TI - The postacute continuum: consumer participation & outcomes research. PMID- 10163939 TI - Therapeutic use of botulinum toxin type A in cerebral palsy. Botulinum-toxin therapy shows promising future. PMID- 10163940 TI - Sport-specific training techniques in an older population. Research and findings of exercise programs designed for the older adult. PMID- 10163941 TI - Medicare fraud and the new HCFA instructions. PMID- 10163942 TI - Rehabilitation, ethics, and managed care. PMID- 10163943 TI - Creating limits where there are none. PMID- 10163944 TI - Actuarial implications of entitlement. PMID- 10163945 TI - BRCA 1, BRCA 2 models. PMID- 10163947 TI - Genetic testing in Europe. PMID- 10163946 TI - Gene therapy. PMID- 10163948 TI - Morbidity and mortality associated with transient ischemic attack (TIA). AB - Transient ischemic attack (TIA) is defined as "an episode of focal loss of brain function attributed to ischemia that lasts less than 24 hours, is localized to a portion of the brain supplied by one vascular system, has no persistent deficit, and is not attributable to any other cause." Most TIAs are caused by small thromboemboli that originate in atheromatous areas in neck vessels or the heart. Other mechanisms include nonatherosclerotic vascular diseases, mitral valve prolapse, hematologic diseases, and abnormal blood pressure fluctuations. Even in series of fully investigated cases, there remains a group in which no cause can be found. The great majority of TIAs are extremely brief. In one series, 24% ended within 5 minutes, 39% in 15 minutes, 50% in 30 minutes, and 60% in 1 hour. PMID- 10163949 TI - T wave lability: a clue for separating the good from the bad, when ugly. AB - Non-specific T wave abnormalities have challenged both the clinician and the insurance medical director for decades. Distinction between pathologic and physiologic T wave changes often requires costly and time-consuming diagnostic studies. The literature is reviewed on the subject of T wave manipulation by the oral administration of both potassium and glucose, introducing the concept of T wave lability. Based on this concept, a simple technique is suggested which, in many cases, can safely, expeditiously and inexpensively distinguish between organic and functional T wave changes. When employed in the investigation of asymptomatic insurance applicants with unexplained T wave abnormalities but no known cardiovascular or renal disease, this technique appears to be sufficiently reliable to classify the risk posed by non-specific T wave changes without resorting to a sophisticated, lengthy and costly cardiovascular investigation. PMID- 10163950 TI - Health care fraud control: understanding the challenge. AB - The study summarized here examined the fraud-control apparatus currently used within the health care industry, and assessed the assumptions, policies, and systems that constitute the industry's current approaches to fraud control. The objective was to develop a better understanding of the strengths and weaknesses of existing approaches. Since 1992, with Health Care Reform under debate, the issue of health care fraud has received unprecedented legislative and administrative attention. Nevertheless disturbing and somewhat surprising lapses in control persist. The fraud problem shows no sign of abatement. Background knowledge of the health care fraud issue was derived from literature searches and from four years of interaction with concerned public and private organizations. Fraud control systems, policies and procedures were examined in detail at eight field sites, representing a cross section of private, not-for-profit, and public programs. The National Institute of Justice funded the study under grant number #94-IJ-CX-K004. This study finds the science of fraud control scarcely developed and little understood by industry practitioners. Academia has paid little attention to the problem. Within the health care industry, the task of fraud control is complicated by the social acceptability of insurers as targets, the invisible nature of most fraud schemes, the separation between administrative budgets and "funds", the respectability of the health care profession, and the absence of clear distinctions between criminal fraud and other forms of abuse. Existing approaches to control are more effective in controlling billing errors, overutilization, medical unorthodoxy, and other forms of abuse than in dealing with criminal fraud. The complexity of the fraud control challenge is seriously underestimated by the health care industry Existing control systems are not targeted on criminal fraud and cannot be expected to control it. Scientific measurement of the fraud problem is a prerequisite effective control. PMID- 10163951 TI - Political development in genetic testing. PMID- 10163952 TI - The health promoting school: some reflections on evaluation. PMID- 10163953 TI - Factors associated with screening mammography and breast self-examination intentions. AB - The factors associated with the use of two methods for the early detection of breast cancer were assessed using a theoretical framework derived from the theory of reasoned action and the Health Belief Model. Telephone interviews were conducted with 170 women aged between 50 and 70 years, randomly selected from the telephone directory of a provincial city in Victoria, Australia. The model explained 47% of the variance in intentions to have a mammogram and 22% of the variance in intentions to practise breast self-examination (BSE). The data supported the prediction that different variables would be associated with each method of early detection of breast cancer. Intentions to have a mammogram were associated with perceived susceptibility to breast cancer, knowing a woman who has had a mammogram, previous mammography history and Pap test history. Intentions to do BSE were associated with self efficacy, knowledge of breast cancer issues, concern about getting breast cancer and employment status. Both screening methods were associated with prior behaviour and concern about getting breast cancer. PMID- 10163955 TI - Is long-term maintenance of health-related physical activity possible? An analysis of concepts and evidence. AB - The phenomenon of maintenance of health-related physical activity is explored through an analysis of the underlying concepts and of the existing empirical evidence. The following targets were used for the analysis: (1) the concept of health-related physical activity, (2) the concept of maintenance, (3) common manifestations of maintenance in everyday living, (4) the promotional and behavioral characteristics of health-related physical activity, (5) the known determinants of free-living physical activity, and (6) intervention trials on physical activity in free-living groups. The analyses revealed the inherent resistance to adoption and maintenance of physical activity, particularly that of high-intensity and program-centered activities, the persistence, however, of many simple everyday routines and habits, the multiple determinants discovered for free-living physical activity and a few empirical demonstrations of the successful promotion of the maintenance of physical activity over a year or two. The promotion of the maintenance of health-related physical activity seems thus a distinct possibility provided that (1) the promotional situation is analyzed thoroughly, (2) the activity is chosen carefully with an emphasis on moderation in intensity and integration into the participant's life-style, (3) multiple promotional contacts are used, and (4) support from the participant's social and physical environment is provided. There is a need for more research on the maintenance of health-related physical activity using the stages of change models, behavior modification principles, self-control concepts, the concept of intrinsic motivation and the Relapse model. The method of analysis used here could apply to other health-related behaviors as well. PMID- 10163954 TI - Factors related to choosing oral contraception at age 15. AB - This report aims to identify factors which are related to use of oral contraceptives at an early age. A self-administered questionnaire was completed at schools in 1988 and 1992 in southern and western Finland (N = 1339). Sexually experienced girls (mean age 15.8 years) who had answered the question concerning their oral contraceptive use were included (N = 389). Logistic regression analysis was used to compare oral contraceptive users (N = 121) with the group of non-users. Total number of coital experiences was associated with oral contraceptive use: the odds ratio for those having at least 10 coital experiences was 6.30 compared with those with only one intercourse. The proportion was 73% among oral contraceptive users and 30% among non-users. Girls using oral contraceptives perceived more often (67%) that parents accept their sexual relationship (30% among non-users). Oral contraceptive users were less afraid of getting pregnant (9% compared with 31% among non-users) and felt more often that sex was very important in their life (31 and 13%, respectively). Other factors that entered the model were age at menarche, having a steady partner and frequency of disco visits. When a young girl asks for oral contraceptives, she is probably at true risk of pregnancy, and regular contraception should be considered both in view of effective prevention of pregnancies and sexually transmitted diseases. PMID- 10163956 TI - Changes in newspaper coverage of cardiovascular health issues in conjunction with a community-based intervention. AB - Numerous community-based prevention projects, with significant media components, have been conducted over the past decade. Multiple evaluation strategies have been used to document the effectiveness of these interventions, including intermediate measures of community impact such as assessment of media coverage. As part of the evaluation of a community-based intervention (the Bootheel Heart Health Project), dissemination of information on cardiovascular disease (CVD) was measured through a media content analysis of newspapers. Data were analyzed from 23 newspapers in six rural counties in southeastern Missouri for the period October 1988 through August 1993. An increase was observed in CVD-related coverage in the pre-intervention period (mean articles per month = 31.5) compared with the post-intervention period (mean articles per month = 50.7) (F = 10.2; P = 0.003). In supporting data from a separate randomized risk factor survey of 1510 residents in the same area, respondents reported hearing of heart health coalitions primarily through local newspapers. The current study documents increasing print media coverage of cardiovascular health issues in a high-risk, rural area and shows that media content analysis can be a useful evaluation tool in community-based interventions. PMID- 10163957 TI - Reducing the burden of coronary heart disease: health promotion, its effectiveness and cost. AB - Coronary heart disease (CHD) is one of five key areas identified in the Health of the Nation white paper produced by the Department of Health in 1992. The main CHD targets are to reduce death rates from CHD by at least 40% in people below 65 and 30% in those between 65 and 74 by the year 2000, respectively. Improvements in treatment and rehabilitation are expected to contribute to reducing the burden of CHD; however, in the long term, prevention is believed to hold the greatest potential. CHD health promotion therefore has a big role to play in securing the Health of the Nation targets. In contrast to treatment interventions, however, little is known about the effectiveness or cost-effectiveness of health promotion. The purpose of this article is two-fold. Its main aim is to illustrate the potential of health promotion in reducing the health burden of CHD to the turn of the century and beyond for a representative health purchaser. This is achieved with the use of an epidemiological model, Prevent, developed in the Netherlands to simulate the health outcomes associated with health promotion and prevention. A subsidiary aim is to present tentative information about the relative costs associated with different health promotion options. PMID- 10163958 TI - The adaptability of the health promoting schools concept: a case study from Australia. AB - The adoption of the concept of the health promoting school internationally indicates that it is a timely and flexible concept that can be utilized by different countries to accommodate their particular contexts. Political, economic and socio-cultural factors are powerful forces that shape the construction of health promoting schools globally. How some of these factors operate will be exemplified through a description of the health promoting school movement in Australia with commonalities and variations with activities in member countries of the European Network of Health Promoting Schools highlighted. The unique role globally of the Australian Health Promoting Schools Association, as a non government organization specifically established to promote the concept of the health promoting school, is described. Its contribution is as a neutral body representing diverse interests that can advocate in different settings and at all levels of influence. Additionally it provides a mechanism for networking, awareness raising and information exchange. The structure of the health and education sectors in Australia has shaped the conceptualization of a health promoting school, one that accommodates the country's specific context. Barriers, facilitating factors and challenges that exist for future work in the area are described. PMID- 10163959 TI - Durability of tobacco control activities in 11 north American communities: life after the Community Intervention Trial for Smoking Cessation (COMMIT). AB - Durability of tobacco control activities in the 11 intervention sites of the Community Intervention Trial for Heavy Smokers (COMMIT) was examined. Although continuation of COMMIT activities was not a major goal, all communities made plans to continue some tobacco control activity. Information was gathered at focus groups of former COMMIT volunteers and staff who were assembled in each community and asked to describe tobacco control activities in their communities during the past 12-16 months-the period after the termination of COMMIT funding. It was found that a tobacco coalition, board or other structure was still operating in nine of the 11 communities and 10 had some level of paid staff dedicated to smoking control. There was also substantial activity in three of the four channels that COMMIT used as an intervention framework: worksites, public education and cessation resources. Many communities were currently engaged in considerable smoking control activity aimed at youth, an area that was intentionally de-emphasized by COMMIT. Implications for the durability of health promotion programs by communities are discussed. PMID- 10163960 TI - An interactive videodisc program for low back pain patients. AB - Decisions about back pain treatment are often made in the presence of both physician and patient uncertainty. Therefore, we developed a computerized, interactive video program to help patients make informed decisions about undergoing low back surgery. Program development was guided by the shared decision-making model, a comprehensive literature synthesis, information from administrative databases, and focus groups of patients and physicians. Core segments are tailored to each patient's age and diagnosis; and include a narrative, excerpts from patient interviews, animated graphics illustrating spinal anatomy, and tabular summaries of the benefits and risks of both surgical and non-surgical treatment. As part of a multifocal information dissemination effort, interactive videodiscs were placed in five medical facilities in two Washington State counties. Patients (N = 239) who viewed the video program completed short evaluation forms. The majority rated the video's understandability (84%) and interest (64%) as very good or excellent. Most patients felt the amount of information provided was appropriate (75%) and over half (56%) believed the discussion of surgical versus non-surgical treatment was completely balanced. Fewer patients (17%) remained undecided about therapy after watching the program than before (29%). We conclude that interactive videodisc technology offers substantial promise as a means of involving patients in their own medical decision making. PMID- 10163961 TI - Age bias, but no gender bias, in the intra-household resource allocation for health care in rural Burkina Faso. AB - Household survey data, time allocation data, and qualitative interviews were used to examine whether households allocate their resources for health care differently between age and gender groups. Households allocated significantly fewer resources to the health care of sick children compared to that of sick adults. In contrast there were no such differences with regard to gender. The underlying household rationale is to concentrate its resources spent for health care on productive members rather than to spread them equitably among all its sick members. While children are not productive, women were shown to contribute as much to household production as men, hence their health is valued equally with that of men. Unless we understand intra-household biases in resource allocation, policies will be undermined. Further research is needed to test the hypothesis for the households' preference of production maintenance over health maximization. PMID- 10163962 TI - Cross-sectional anthropometry: what can it tell us about the health of young children? AB - It has become common practice in health surveys to collect anthropometric measurements from young children. These datasets comprise one-point-in-time measurements for a number of children, and are very different in character from longitudinal data such as those collected during growth monitoring. This paper explores the nature of cross-sectional data, their applications and their limitations, using sample data from Burundi, Uganda and Zimbabwe. Methods of analysis which treat the data as continuous or dichotomous are compared. The conclusion is that cross-sectional data can make a valuable contribution to health research provided their application and interpretation are properly understood. PMID- 10163963 TI - Searching for solutions: health concerns expressed in letters to an east African newspaper column. AB - This study examined health care questions from an unusual data set: 1252 unsolicited letters written over a three-year period to an advice column in an East African newspaper. Analysis of the letters was a non-intrusive method of ascertaining prevalent health questions and opinions. People wrote seeking information, advice, solutions, and reassurance about health problems. Emotions expressed in the letters ranged from hope to fear and frustration. The written format allowed questions which are generally too embarrassing or stigmatized to present in other public or interpersonal settings. More than half the total letters raised questions about sexual behaviour, sexually transmitted diseases, and HIV/AIDS. The letters present not only personal health concerns, but also expectations of health-care quality and reflections on the medical options presently available in Uganda. As a whole, the letters express dissatisfaction not only with the outcomes of health encounters, but with the process. Of the letter writers with specific physical complaints, more than one-third had already sought medical care and were dissatisfied with the results. The letters were seeking solutions, especially for alleviation of symptoms and discomfort. Almost equally prevalent was a plea for accurate and relevant health information; people not only want to feel better, but they also want to understand their own health. PMID- 10163964 TI - Key issues in the treatment of advanced breast cancer. Expectations and outcomes. AB - Advanced breast cancer is common and can cause extensive morbidity, often over long periods of time. A variety of treatments, including symptomatic measures, surgery, radiotherapy, endocrine treatment and cytotoxic drugs, may be applicable for individual patients. Cytotoxic chemotherapy is the most contentious therapy because of its potentially severe adverse effects. While clinical trials give information concerning objective response rates, they are of relatively little value in ascertaining the true value of treatment in routine practice. In recent years, increasing importance has been attached to the evaluation of symptom relief and quality of life. A scoring method for outcome analysis has been developed, in which the resultant of beneficial and adverse effects of treatments is estimated. Sensitivity analysis demonstrated the robustness of this method, which indicated that only about 20% of all patients with advanced breast cancer given first-line chemotherapy gain net benefit. This result was corroborated in a prospective study in which patient reports of benefit were systematically recorded. Most of the expenditure incurred when treating patients with advanced breast cancer is derived from treatment of serious illness rather than from specific antitumour treatment; cytotoxic drug therapy accounts for less than 10% of total expenditure. PMID- 10163965 TI - Quality of life as an outcome in breast cancer. Clinical application. AB - In clinical trials of anticancer agents, the assessment of objective effects has historically been the primary end-point. However, because of the limited impact of these agents on survival, the study of quality of life (QOL) has become increasingly important. QOL evaluation is difficult and the approaches of physicians and reimbursors of healthcare are quite different. In addition, QOL is not a simple concept and several different methods have been used to evaluate it. These methods can be divided into the following 2 groups: experimental methods [the best known is the quality-adjusted life-year (QALY), which utilise some kind of experimentation; and observational methods, which use questionnaires and are often multifactorial. Some of these questionnaires are used for patients with all types of pathologies, while others are cancer-specific; all questionnaires must be validated. We conducted 3 QOL studies in patients with breast cancer using the Functional Living Index-Cancer (FLIC) questionnaire. In the first, a French translation of the FLIC questionnaire was validated. The FLIC and Functional Living Index-Emesis (FLIE) questionnaires were used to assess QOL in a second study comparing 2 different antiemetics for the control of nausea and vomiting. Finally, QOL was evaluated in patients with breast cancer during adjuvant chemotherapy. Several other studies employing different questionnaires in patients with breast cancer have been published. Clinical applications for QOL evaluation in oncology may be the prognostic implications of QOL, evaluation of toxicity and duration of treatment, and evaluation of utility and QOL. However, although assessment of QOL is important for both physicians and funders, there is no gold standard method available, and the results of QOL studies have to be interpreted cautiously. PMID- 10163966 TI - Role of decision analysis in relation to clinical trials and a US perspective of the Battelle model. AB - Economic assessment of evolving technologies is assuming increasing importance worldwide. One form of economic assessment uses decision analysis, a simulation technique, to determine whether performing a clinical trial is worthwhile. This type of assessment may streamline data collection within a clinical trial, and can aid in the interpretation of a trial result with substantial benefits and toxicities. Although second-line chemotherapy for patients with metastatic breast cancer is in common use, its benefit is unclear and it is associated with substantial cost. A database search of currently active or recently closed randomised phase III comparative trials for metastatic breast cancer found only 6 trials involving a comparison of chemotherapies. Only 1 trial allowed prior chemotherapy for metastatic disease. Given the paucity of forthcoming clinical data, decision analysis is an appropriate tool for estimating the effectiveness of potential treatments with second-line agents for metastatic breast cancer. The findings of the Battelle decision analysis model, described in this issue, identified response rates and 1-year mortality as the key areas of focus for comparative trials. Decision analysis can improve the design and efficacy of prospective, comparative trials but cannot replace them. PMID- 10163967 TI - A new decision model for cost-utility comparisons of chemotherapy in recurrent metastatic breast cancer. AB - In the absence of comparative clinical and pharmacoeconomic trial data for docetaxel versus paclitaxel as second-line therapy for patients with anthracycline-resistant metastatic breast cancer, a computer-based decision analysis model was designed to evaluate the comparative utility to patients of these two taxoids. The model used the Markov process to analyse disease states (response, stable disease, progressive disease) and toxicities (acute, cumulative) for each treatment during the period from commencement of up to six 3 weekly cycles of chemotherapy, to death. A cost-utility analysis was carried out using the model, with a probability, a cost and a utility determined for each health state. Response rates were obtained from clinical trial data supplemented by expert clinical opinion. Costs were taken from UK national databases and published sources and the published UK prices of docetaxel and paclitaxel. Utilities for the various health states were established by use of standard gamble and visual analogue methods assessed by 30 oncology nurses in the UK who were acting as proxy patients. The results of the model showed that response rate is the key parameter determining the utility and cost utility of treatments for metastatic breast cancer. Although the total per-patient cost associated with docetaxel was marginally higher than that for paclitaxel (8233 pounds vs 8013 pounds), the higher response rate associated with docetaxel produced an improvement in utility to the patient at an incremental healthcare cost that is acceptable according to available defined limits. Sensitivity analyses revealed that, although the model was sensitive to changes in response rate and drug costs, the cost-utility ratio for docetaxel versus paclitaxel varied within acceptable limits in response to all likely changes in key parameters. In summary, in the base case used in this model, docetaxel produces a substantially larger utility benefit than paclitaxel, at a small additional cost per QALY gained (equivalent to 7 pounds per additional day of perfect health). PMID- 10163969 TI - Reaffirming core managed care values. PMID- 10163970 TI - Working together to "manage" managed vision care: one company's approach. PMID- 10163968 TI - Advantages of outsourcing your customer service and marketing phone operations. PMID- 10163971 TI - 1997 resource guide. PMID- 10163972 TI - The CIO's position in today's emerging health care system: lessons learned. AB - The integrated delivery network is a new concept. Using information technology as a rallying point has allowed people to come together in a non-threatening way. They discuss new ideas and possibilities for improving the performance of their individual institution and thus, the entire Network. How quickly and how well business adapts to this new model will dictate long-term viability in the marketplace. Technology will not be the limiting factor to success in this new endeavor. It will be a facilitator that can help the organizational transition from single institutions to an IDN. The challenge is in managing how well personnel accept this change and seek ways to work together in this new endeavor. The ability to perform competently at these new levels comes from the ability to perform as a senior executive, acting in partnership and peer relationships as a facilitator and leader. To manage the change required in these new organizations, there must be common vision, the creation of new roles, agreed upon priorities, flexibility, and standardization when necessary. While there is not one right solution, leadership and shared vision and the ability to deliver are key success factors. PMID- 10163973 TI - Ambulatory systems for managed care. AB - Providence Health System is successfully making the transition from an acute care based holding company of health care business to a diversified, operating, managed care company with the mission of improving the health status of the populations it serves, and being at financial risk for doing so. Information systems have been a leading change agent in this transition, not only from the standpoint of consolidating and standardizing practices within Providence Health System, but also by facilitating the exchange and integration of information within the health care community. ProvNet has made available the tools to accomplish this information integration in the physician's office and to extend it not only to Providence, but to other health systems as well. PMID- 10163974 TI - Optimizing clinical information systems in complex computing environments. Panel discussion. PMID- 10163975 TI - Structured cabling: foundations for the future. PMID- 10163976 TI - Designing a clinician-user interface for a health care information system. PMID- 10163977 TI - Automating critical pathways: one hospital's initial experience. PMID- 10163978 TI - Academic health centres: can we afford to fund them? Can we afford not to? PMID- 10163979 TI - Emergency room services in rural hospitals. AB - Boards are faced with the dilemma of deciding both the role of rural hospitals and the level of service they should provide. Decisions on emergency room services should be based upon the hospital's relation to other hospitals and the entire trauma care system; demographic information on the present and future population served; data on ER visits and motor vehicle accidents; and existing guidelines and standards for emergency room services. PMID- 10163980 TI - In transition: human resource management in Atlantic Canadian hospitals. PMID- 10163981 TI - Reform of the New Zealand healthcare system. AB - New Zealand's healthcare reform has come in two waves. In 1983, Area Health Boards assumed responsibility for purchasing and providing all secondary healthcare; but a parallel, centralized system of primary healthcare benefits persisted, frustrating attempts to integrate services. In 1991, a new government reorganized public hospitals into "Crown health enterprises," and planned to introduce user fees, competition with the private sector and a list of core benefits. Over the following few years, some of these attempts progressed slowly or were abandoned altogether. They are also attempts to shift risk and expenditure, rather than design a more fair and efficient healthcare system. PMID- 10163982 TI - Suggestions for improving AIDS treatment in hospitals. AB - On July 26, 1994, John William George Swaffer died of AIDS in an Ottawa hospital. His partner shares his experience while caring for John at the hospital. While the hospital did many things well, it seemed that requests for palliative care were poorly communicated among the various physicians involved with John's care. Coordination between hospital doctors and those from a local HIV clinic also seemed poor. The author recommends eight changes to better serve patients with AIDS and other terminal illnesses. PMID- 10163983 TI - Creutzfeld-Jakob disease: the Grace General Hospital experience. AB - After some patients were exposed to a blood product from a donor with Creutzfeld Jakob disease, Winnipeg hospitals had to decide whether to inform them of the possibly minuscule health risk. The Salvation Army Grace Hospital decided to inform its patients, citing their fundamental right to facts regarding their own health; their need to make a responsible, informed decision regarding donation of their own blood or organs; and the need to maintain the trust and confidence of the public in the wake of the Krever inquiry. PMID- 10163984 TI - Creutzfeld-Jakob disease: what we know. PMID- 10163985 TI - Clinical quality improvement: a system in need of some systems thinking. PMID- 10163986 TI - A systems thinking toolkit. PMID- 10163987 TI - Massachusetts' HMO Blue bows out of group report card project; claims star rating system unscientific. PMID- 10163988 TI - Systems thinking applications in healthcare: a tool for optimizing change. PMID- 10163989 TI - Holding the line on elusive ailments. PMID- 10163990 TI - Case study. This town made wellness a way of life. PMID- 10163991 TI - Can employers see beyond price? The results of our 1996 executive opinion poll. PMID- 10163992 TI - Do-it-yourself (flexible) benefits. PMID- 10163993 TI - Financial facts about treating breast cancer. PMID- 10163994 TI - Data watch. COBRA: adverse selection is the rule. PMID- 10163995 TI - Asbestos management and removal in hospitals. AB - Asbestos has been used in a vast assortment of materials installed in hospitals since the turn of the century. While there is a perception that many regulations pertaining to asbestos have become less stringent, new regulations are continuing to be enacted that require building owners and facilities managers to implement methods of recognition and control for asbestos-containing building materials. Several states have initiated regulations on asbestos consultants and contractors that supersede federal requirements. This document is intended to summarize some of the most important management practices that hospitals should undertake when conducting work that would disturb, or have the potential to disturb, asbestos containing building materials. PMID- 10163996 TI - Look what they've done to my law, Ma: COBRA's implosion. PMID- 10163997 TI - A pragmatic defence of health status measures. AB - A family of instruments has been developed over the last twenty five years in order to measure the individual's subjective view of his health. The instruments vary in how broadly they define health. A wide range of critiques have challenged both the validity of these measures and their uses. This paper argues that disproportionate attention has been given to one form of health status measure- the so-called utility-based measures. The ensuing controversies have distracted from the substantial progress achieved in the application of health status measures. This paper identifies the major areas of progress and argues that any serious critique needs to engage with this now sizeable body of applied knowledge. PMID- 10163998 TI - Measuring health status? A review of the sickness impact and functional limitations profiles. AB - Recent years have witnessed a growing interest in the measurement of health status. One of the most well-known health status instruments is the Sickness Impact Profile (SIP). This paper examines the nature, development and testing of the SIP (and its UK equivalent the FLP). The practical merits of these instruments are explained, and some cautionary remarks are offered about their limitations. PMID- 10163999 TI - Using subjective health assessments in practice and policy-making. AB - This paper discusses the use of subjective health assessment in medical practice and social policy-making. The importance of recognising patients' perceptions of their health when attempting to improve patient-practitioner relationships and formulate effective health care policies is stressed. The paper describes some of the tensions that exist between objective and subjective assessments of health. It is argued that there is a need for unifying theory to underpin the use of subjective health perceptions. Suggestions are made for the effective employment of these indicators. PMID- 10164000 TI - New Zealand health care financing 'reforms' perceived ideological context. AB - Health sector financing reforms that have been ongoing over the last decade in most developed countries are rooted in philosophical terms in the ideology of economic rationalism. The ideology suggests that it is possible to artificially create markets for activities in contexts where markets do not develop naturally, and that the creation of these artificial markets leads to resource allocations that are both more efficient and more equitable than historical arrangements. The application of the ideology to New Zealand's health sector has generated some benefit--for example, a more rational approach to influencing the decisions of self-interest health care providers; but it has also generated some costs--for example, on ideological grounds it has brought into question the non-market rationales for maintaining a national health service system. PMID- 10164001 TI - Haven't we been here before? In defence of the NHS. PMID- 10164002 TI - Plus ca change, plus c'est la meme chose. PMID- 10164003 TI - The medical marketplace and the diffusion of technologies. PMID- 10164004 TI - Patient consumerism and health care reform: compromise without commodification. PMID- 10164005 TI - The NHS: who is attacking, who is defending? PMID- 10164006 TI - Promoting confusion. PMID- 10164007 TI - Consent forms--forms without substance? A case for model disclosure and consent forms. PMID- 10164008 TI - Empathy and its importance in long-term home health care. PMID- 10164009 TI - Demographic, economic, and health factors likely to affect public policy. PMID- 10164010 TI - Ending elder homelessness: one city's solution. PMID- 10164011 TI - Must the young and old struggle over health care resources? PMID- 10164012 TI - Georgia Coalition for Health to tackle Medicaid reform. PMID- 10164013 TI - Protecting the confidentiality of medical records: an update. PMID- 10164014 TI - Manufacturer audit guidelines and dispute resolution process 0905-ZA-19--HRSA. Final notice. PMID- 10164015 TI - Medicare program; electronic cost reporting for skilled nursing facilities and home health agencies--HCFA. Final rule. AB - This final rule adds the requirement that, for cost reporting periods ending on or after February 1, 1997, most skilled nursing facilities and home health agencies must submit cost reports currently required under the Medicare regulations in a standardized electronic format. This rule also allows a delay or waiver of this requirement where implementation would result in financial hardship for a provider. The provisions of this rule allow for more accurate preparation and more efficient processing of cost reports. PMID- 10164016 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); clarification of the CHAMPUS exclusion of unproven drugs, devices and medical treatments and procedures--DoD. Final rule. AB - This final rule clarifies the CHAMPUS exclusion of unproven drugs, devices and medical treatments and procedures and describes the process that the Office of CHAMPUS follows in determining when such drugs, devices, treatments and procedures have moved from the status of unproven to the position of proven medical effectiveness. This clarification is necessary to ensure the CHAMPUS beneficiary and provider population understand the process the Office of CHAMPUS (OCHAMPUS) follows prior to endorsement by CHAMPUS of a new emerging medical technology, drug, or device for which the safety and efficacy have been proven. PMID- 10164017 TI - Base salaries paid by HMOs to family physicians and internists. PMID- 10164018 TI - Two western states' voters reject measures to limit managed care. PMID- 10164019 TI - Doctor, are you really listening? PMID- 10164020 TI - Has productivity become a bad thing? PMID- 10164021 TI - Technology offers an answer to 'information overload'. PMID- 10164022 TI - Should doctors guarantee results? Or, whose disease is it, anyway? PMID- 10164023 TI - Problems that arise when a physician leaves a group. PMID- 10164024 TI - Hospitals, health plans and employers unite to reduce cesarean deliveries. PMID- 10164025 TI - Is Clinton's America a managed care America? PMID- 10164026 TI - Case management in rehabilitation: a logical transition for social work? PMID- 10164027 TI - Online resources for cancer patients and social workers. PMID- 10164028 TI - The future of specialty care services: forming integrated specialty service organizations and specialty networks. PMID- 10164029 TI - Ten-year experience in managing a capitated ophthalmology carve-out by an academic eye center. AB - A 10-year experience of managing a capitated opthalmology carve-out by an academic health unit is presented. Lessons learned regarding pricing, utilization, and managing this contract are discussed. Handling the cost of education and remaining competitive is presented as a not-insurmountable hurdle. Academic health units can compete in today's environment; however, the learning curve is steep and the problems many. PMID- 10164030 TI - A replicable and customizable approach to improve ambulatory care and research. AB - Health care is a service industry. A fundamental attribute of many successful service industries is the "small replicable unit (SRU)." There are three essential elements of an SRU: (1) the smallest core unit of activity, (2) micromeasures designed to help manage the core activities, and (3) combinations of the activities and measures to match local customer needs. In this article, we describe a model for geriatric care based on "SRU thinking." We demonstrate how this approach places measurement of patient values, clinical improvement strategies, and research objectives into day-to-day health care delivery. PMID- 10164031 TI - Building research capacity into a national physician database. AB - The range of physician financial arrangements with managed care and insurers, as well as practice arrangements, is becoming increasingly complex. Little is known systematically about these changes, yet there is growing evidence that financial arrangements, utilization management, and other practice characteristics make a substantial difference in treatment patterns, patient mix, and costs of care. Current data systems and surveys frequently do not capture the new information needed to track these changes. New elements of information should be included in national surveys and in a national physician database. A list of recommended data items for a national data base is provided as a starting point for identifying a minimal data set to be included in national statistical systems. PMID- 10164032 TI - An effective methodology for surveying a Medicaid population: the 1996 Oregon Health Plan client satisfaction survey. AB - There are many barriers to measuring client satisfaction for a Medicaid population. This vulnerable group is poor, often undereducated, and highly mobile, making both telephone surveys and mail-return surveys difficult to administer successfully. The Oregon Health Plan (OHP), a Medicaid managed care delivery system, has developed a client satisfaction survey and approach that yielded a 63% response rate. Readability, satisfaction indicators reflective of a Medicaid population, and survey administration are all identified as essential to an adequate response rate. The data from the 1996 Oregon Health Plan Client Satisfaction Survey are being used in the OHP's analysis and evaluation program and its ongoing quality improvement process. PMID- 10164033 TI - Physician and plan effects on satisfaction of Medicaid managed care patients with their health care and providers. AB - As many Medicaid patients move into managed care, it is important that physicians competing to serve these patients understand the factors that lead to patient satisfaction. This study uses survey data from 7,313 Oregon Medicaid managed care patients to create a model describing how provider effects and health plan effects relate to patients' satisfaction with their medical care and provider. Path analysis was used to test the explanatory power and strength of relationships in the model. Perceived technical and interpersonal physician quality and health plan rating were most strongly linked with these patients' satisfaction with their care and provider. PMID- 10164034 TI - Linking primary care centers and hospitals. AB - Primary care centers (PCCs) are increasingly entering into linkages with hospitals that go far beyond the traditional arrangements in which the hospitals serve as backups to the PCCs. The linkages can be for managed care purposes, for training of health professionals in primary care settings, or for other reasons. This article explores the advantages of such arrangements, the organizational forms that the linkages can take, the legal issues, and negotiating the deal. PMID- 10164035 TI - Physician and other ambulatory care services in Germany. AB - The Germany multipayer universal health insurance plan in 1992 consumed 8.7% of its nation's total expenditures. Nevertheless, its macromanaged approach has allowed until recently for pluralism, decentralization, and self-regulation among providers and sickness funds (not-for-profit, third party payers). With 34.8% more physicians per 1,000 persons, German doctors provided twice as many patient contacts per capita than in the United States. Due to economic constraints and increases in payroll taxes, the Federal Republic of Germany's parliament, with its 1993 health reform plan, virtually froze all payments to providers for a 3 year period. Among other contentious provisions were the following: (1) limiting the entry of new physicians into municipalities that are considered by government health manpower planning experts to be oversupplied in that specialty; (2) requiring community-based physicians to participate in controlling pharmaceutical costs; and (3) eliminating some of the German traditional barriers between their in- and out-of-hospital physicians. This article focuses on how the Germans now micromanage their physician and other ambulatory care services within a macromanaged system that, in terms of patient access, benefits, quality, and cost, should be the envy of the Americans. PMID- 10164036 TI - Adverse selection and regulation in health insurance markets. AB - In this paper we look at various ways to regulate the health insurance market and ask whether they provide an answer to the problem of adverse selection. To avoid inefficiency, government policy must either effectuate some cross-subsidization of insurance policies within the state sector or grant private insurance firms an exclusive right to serve certain groups of the population. Recent reforms in the Netherlands and Germany and President Clinton's proposals for the US could be adapted to fulfil these requirements. Efficiency cannot be achieved, on the other hand, if the regulator tries to "prescribe" cross-subsidization within the private sector. PMID- 10164037 TI - Employment, unemployment, and problem drinking. AB - The misuse of alcohol is estimated to result in enormous economic costs, composed largely of reduced labor market productivity. However, there has been debate on this issue. The purpose of this paper is to help to resolve this debate by presenting sound structural estimates of the relationship between measures of problem drinking and of employment and unemployment. The analysis is based on the 1988 Alcohol Supplement of the National Health Interview Survey. We find that for both men and women, problem drinking results in reduced employment and increased unemployment. PMID- 10164038 TI - Alcohol policies and highway vehicle fatalities. AB - This study investigates the impact of beer taxes and a variety of alcohol-control policies on motor vehicle fatality rates. Special attention is paid to omitted variables biases resulting from failing to adequately control for grassroots efforts to reduce drunk driving, the enactment of other laws which simultaneously operate to reduce highway fatalities, and the economic conditions existing at the time the legislation is passed. In the preferred models, most of the regulations have little or no impact on traffic mortality. By contrast, higher beer taxes are associated with reductions in crash deaths and this result is relatively robust across specifications. PMID- 10164039 TI - The effects of enriched prenatal care services on Medicaid birth outcomes in New Jersey. AB - This paper uses a health production function framework to evaluate the race specific effects of participation in New Jersey's HealthStart program on birthweight and newborn hospitalization costs in 1989 and 1990. HealthStart provides enriched prenatal and health support services to pregnant women on Medicaid. The program also attempts, through outreach, to attract women into care earlier. For blacks, the results indicate increased birthweights, lower newborn hospitalization costs and reduced rates of low birthweight and very low birthweight for those participating in HealthStart. There is no evidence, however, that the HealthStart program was associated with improved birth outcomes or lower costs for whites. PMID- 10164040 TI - The choice of medical providers in rural Benin: a comparison of discrete choice models. AB - In this paper we estimate three different discrete choice models of provider choice using data from the rural District of Ouidah in Benin. These three model are: Multinomial Logit (ML); (2) Independent Multinomial Probit (IMP); (3) Multinomial Probit (MP). A comparison of IMP and MP allows us to reject the independence assumption between providers. Furthermore, the cross-price elasticities computed from the restrictive specifications (ML and IMP) are dramatically different from those computed from the more general one (MP). These results cast some doubt on the validity of the previous findings and policy recommendations that are typically based on the ML specification. PMID- 10164041 TI - Do cigarette producers price-discriminate by state? An empirical analysis of local cigarette pricing and taxation. AB - This study analyzes the interactive effects of oligopoly pricing, state taxation, and anti-smoking regulations on retail cigarette prices by state, using panel data for the 50 US states between 1960 and 1990. The results indicate that cigarette producers do price-discriminate by state, though the effect is not large relative to the final retail price. There are two further results: (1) state taxes are more than passed on - a 1-cent state tax increase results in a price increase of 1.11 cents, and (2) sellers offset state and local anti-smoking laws with lower prices, thereby blunting effects of the regulations. PMID- 10164042 TI - State abortion rates. The impact of policies, providers, politics, demographics, and economic environment. AB - This paper uses data on abortion rates by state from 1974-1988 to estimate two stage least squares models with fixed state and year effects. Restrictions on Medicaid funding for abortion are correlated with lower abortion rates in-state and higher rates among nearby states. A maximal estimate suggests that 19-25% of the abortions among low-income women that are publicly funded do not take place after funding is eliminated. Parental notification laws for teen abortions do not significantly affect aggregate abortion rates. A larger number of abortion providers in a state increases the abortion rate, primarily through inducing cross-state travel. PMID- 10164043 TI - The effect of Medicaid abortion funding restrictions on abortions, pregnancies and births. AB - This paper considers whether state Medicaid abortion funding restrictions affect the likelihood of getting pregnant, having an abortion and bearing a child. We exploit a natural experiment afforded by Supreme Court decisions and employ more traditional multivariate models with alternative fixed effect specifications. An analysis of 12 years of state-level data indicate that restrictions are associated with a reduction in abortions and either no change or a reduction in births, implying fewer pregnancies. Subsequent analysis of the National Longitudinal Survey of Youth (NLSY) is consistent with these findings and show the response is concentrated among the low-income population. PMID- 10164044 TI - State reproductive policies and adolescent pregnancy resolution: the case of parental involvement laws. AB - State laws regulating abortion have increased markedly in the wake of recent Supreme Court decisions. We test whether laws that require minors to notify or obtain consent from a parent before receiving an abortion affect the likelihood that a pregnancy will be terminated. We use individual data on births and abortions from three southern states, South Carolina, Tennessee, and Virginia. We find that South Carolina's parent consent statute is associated with a decline of 10 percentage points in the probability of abortion among non-black minors of 16 years of age. We find no effect for any other age or racial group and conclude that the impact of parental involvement laws on the pregnancy resolution of minors is not large. PMID- 10164045 TI - Health insurance: the tradeoff between risk pooling and moral hazard. AB - Choosing optimal health insurance coverage involves a trade-off between the gain from risk reduction and the deadweight loss from moral hazard. This paper examines this trade-off empirically by estimating both the demand for health insurance and the demand for health services. It relies on data from a randomized controlled trial of cost-sharing's effects on the use of health services and on the health status for a general, non-elderly population. PMID- 10164046 TI - Mathematical programming for the efficient allocation of health care resources. AB - Previous discussions of methods for the efficient allocation of health care resources subject to a budget constraint have relied on unnecessarily restrictive assumptions. This paper makes use of established optimization techniques to demonstrate that a general mathematical programming framework can accommodate much more complex information regarding returns to scale, partial and complete indivisibility and program interdependence. Methods are also presented for incorporating ethical constraints into the resource allocation process, including explicit identification of the cost of equity. PMID- 10164047 TI - Characteristics of elderly home health care users: data from the 1994 National Home and Hospice Care Survey. AB - OBJECTIVE: This report presents the demographic characteristics, service utilization, and primary admission diagnosis of elderly current home health care patients and discharges. METHODS: The data used for this report are from the National Center for Health Statistics' 1994 National Home and Hospice Care Survey's (NHHCS) sample of current patients and discharges age 65 years and over. The 1994 NHHCS is the third annual survey of home health care agencies and hospices and their current patients and discharges. RESULTS: The overall results of the survey indicate that the elderly in both the current patient and discharge samples were predominantly women, 75-84 years old, white, non-Hispanic, widowed, and lived in a private residence with their family. For both elderly men and women, the most commonly used home health care service was skilled nursing services and the primary admission diagnosis was heart disease. PMID- 10164048 TI - Neural network rescreening for the detection of abnormal cervical cells. PMID- 10164049 TI - The cytology proficiency dilemma: the case for computer-based testing. PMID- 10164050 TI - Non-destructive evaluation of membrane lung gas exchange performance. AB - This paper describes a method of evaluating the gas exchange effectiveness of hollow fiber oxygenators utilizing gas on both sides of the membrane. The goal of the study was to develop an evaluation technique which was accurate, reliable, and did not harm or contaminate a new, sterile oxygenator. Three pediatric oxygenators were tested and compared: the Medtronic Minimax Plus, the Terumo Capiox 320, and the Sorin Masterflo 34 (all with rated blood flows of 2-2.5 L/min). Gas entering the "blood" side was a mixture of CO2, O2, and N2 in a mixture matching typical venous blood partial pressures. The "blood" flows used were 0.5, 1, 1.5, or 2 L/min. Gas entering the gas port had an FiO2 of 0.4 flowing at 0.5, 1, 1.5, 2, 2.5, 3, or 3.5 L/min. Fractional contents of CO2 and O2 at all inlets and outlets were determined using a gas analyzer and converted to partial pressures. Efficacy indices and gas transfer rates were calculated and compared. Of the devices studied, the Masterflo 34 had the highest gas transport rates and effectiveness followed by the Minimax-Plus and the Capiox 320. Reversing the direction of the flow through the "blood" phase of the Minimax-Plus greatly changed its gas exchange effectiveness. The techniques described in this study should allow for a more uniform and consistent evaluation of gas exchange by membrane lungs which can be made inexpensively and relatively quickly. In addition, these methods should allow manufactures to evaluate gas exchange effectiveness and transfer rates of individual units during production as well as reduce the complexity involved when evaluating newly developed oxygenators. PMID- 10164051 TI - Evaluation of a variable ratio cardioplegia system. AB - Gish Biomedical has designed a blood cardioplegia delivery system (MyoManager) which is purported to provide rapid control of blood and crystalloid solution ratios for myocardial preservation. The present study was designed to evaluate the ability of this device to provide cardioplegia solutions of specific hematocrit and potassium ion concentrations ([K+]). An in vitro circuit was designed whereby a blood perfusate with a [K+] of 5 mEq/L was mixed with a base crystalloid solution containing 210 mEq/L of K+. Data was collected at several blood to crystalloid ratios (1:1, 4:1, 8:1, 16:1, 25:1), and at four delivery rates (100, 150, 200, 250 ml/min). Predicted and observed values of total cardioplegia volume, hematocrit, crystalloid volume, and [K+] were statistically (ANOVA) analyzed, and statistical significance accepted at p 0.05. There were no statistically significant differences observed at any flows or ratios in hematocrit. However, at 100 ml/min flow rates, the crystalloid delivery volume difference of 2.4 +/- 2.0 ml was significantly higher than that observed at 250 ml/min, 1.5 +/- 1.5 ml (p < 0.02) and at 200 ml/min flow rates, 1.5 +/- 1.6 ml (p < 0.02). There was no statistical significance in [K+] difference between flows across all ratios. However, within ratios, a significant difference in [K+] at 100 ml/min, 1:1 blood to crystalloid ratio, was observed (p < 0.0001) versus all other ratios and flows. The only statistically significant difference that was shown in total cardioplegia delivery volume was observed between 100 and 200 ml/min (p < 0.04) when analyzed across all ratios. The data suggests that the MyoManager effectively provides precise control of [K+] and hematocrit at cardioplegia flows greater than 100 ml/min. PMID- 10164052 TI - Meeting European and US requirements for design and development documentation, Part II. AB - Part I of this series of articles provided a comparison of the European and the proposed United States (US) Food and Drug Administration (FDA) design control requirements. Since writing Part I, the US Good Manufacturing Practice (GMP) final rule has been published. This article will discuss the changes made to the design control requirements in the US final rule. It will also discuss some of the types of procedures and documentation that companies can develop to comply with the European and US design control requirements. PMID- 10164053 TI - Using hydrogel polymers for drug delivery. AB - The leading cause of mortality and morbidity in the developed world is cardiovascular disease. The development of surgical procedures such as coronary stenting has benefited those patients with coronary artery disease. However, coronary stenting carries associated risks of thrombosis. The article evaluates a nonthrombogenic phosphorylcholine coating that could also incorporate and deliver drugs to the local area, thereby reducing the toxic side effects associated with systemic delivery. PMID- 10164054 TI - Managed care--evolution or revolution? AB - What are the key influences on today's highly competitive health care market? Are they relevant to medical devices and will they affect device manufacturers? This article attempts to answer these key questions and suggests that Managed Care will become the single most important issue in the next five years. PMID- 10164055 TI - The paradox of being unique and ubiquitous: the nature of surfaces. AB - The surfaces of biomaterials are extremely important, but it is far from clear exactly which characteristics of material surfaces control medical device performance. This article discusses some of the classical features of surfaces that may be involved, including surface chemistry and energy. PMID- 10164056 TI - The economic potential of dual individualisation methodologies. AB - Cost-effective treatment of patients with bacterial infections can best be accomplished by facilitating a rapid response. Achieving a more rapid cure of the infection should result in reduced utilisation of healthcare resources. An innovative means of achieving a more rapid response to antibacterial therapy has been termed dual individualisation. Dual individualisation allows for the simultaneous consideration of the pharmacokinetic interaction between an antibacterial agent and a patient, with the pharmacodynamic interaction between the antibacterial agent and the bacterial pathogen. Integrating the pharmacokinetic parameter of area under the curve (AUC), with the pharmacodynamic measure of minimum inhibitory concentration (MIC) yields a ratio called the area under the inhibitory curve (AUIC). Clinical studies using dual individualisation to achieve a target AUIC24h of 125-250 have been performed with cephalosporins and fluoroquinalones. Economic evaluation of the results demonstrate that dual individualisation is cost-effective. Dual individualisation can be implemented in most practice setting using existing clinical data. Use of a computer model allows for cost-effective calculation of AUIC24h without having to measure serum drug concentrations of bacterial MIC. By adjusting antibacterial regimens to achieve a target AUIC, optimisation of antibacterial therapy can be achieved with resultant economic benefits. PMID- 10164057 TI - A case for the adoption of pharmacoeconomic guidelines in Japan. AB - In recent years, more and more Japanese pharmaceutical companies have been submitting pharmacoeconomic data to the government, following the official request that such data may help in setting pharmaceutical prices. The companies have cooperated because, by doing so, they could influence pricing decisions for new products. However, the quality of these data at present is considered to be poor and heavily biased. The introduction of pharmacoeconomic guidelines that outline a set of standardised factors to be included in evaluations are necessary, so that an appropriate comparison of the cost effectiveness of the many new drugs that are introduced into the Japanese market each year can be made. In addition to supporting the development of standardised guidelines, the Ministry of Health and Welfare should clarify how pharmacoeconomic data are to be used to aid policy decisions and also mandate the publication of pharmacoeconomic data. PMID- 10164058 TI - Rational prescribing of antibacterials in ambulatory children. AB - The rational prescribing of oral antimicrobial agents for bacterial infections in children who can be treated in an ambulatory setting is the subject of this review. First, restrictive use of antibacterials is advocated to avoid widespread development of bacterial resistance. The use of simple methods, suitable for office use, to discern viral from bacterial infections is recommended. Second, in selecting an antimicrobial agent, the physician should consider a number of distinctive features of each agent. Besides aspects of pharmacokinetics, antibacterial spectrum and tolerability, the number of daily doses and, of particular importance for children, the palatability of suspensions plays an important role in achieving patient compliance. Agents that can be administered once or twice daily and possess an agreeable taste in addition to proven efficacy, established tolerability and a reasonable price are to be preferred. Specific paediatric aspects in choosing among penicillins, cephalosporins, macrolides and other oral antibacterials are discussed. For pharmacoeconomic reasons, the optimal duration of antibacterial treatment and the role of short course therapy for various bacterial infections should be studied in more detail. Finally, rational antimicrobial treatment of common paediatric bacterial infections, such as streptococcal tonsillopharyngitis, acute otitis media, acute sinusitis, bacterial pneumonia, pertussis, Lyme borreliosis (early stage) and lower urinary tract infection is reviewed. PMID- 10164059 TI - Rational prescribing of antibacterials in hospitalised children. AB - The subject of this review is the rational prescribing of antimicrobial agents for the therapy of serious community-acquired infections in hospitalised infants and children. First, cost-containment strategies such as streamlining of antibacterial therapy, outpatient parenteral antibacterial therapy and sequential ('stepdown') therapy with parenteral followed by oral therapy are reviewed. In most of these areas, paediatric studies are scant or lacking. Then specific paediatric aspects of the choice of parenteral antibacterials such as penicillins, cephalosporins, aminoglycosides, macrolides and other agents are discussed. With particular reference to cost containment, rational treatment strategies for some serious bacterial infections such as meningitis, occult bacteraemia, endocarditis, osteomyelitis, arthritis, pyelonephritis, Lyme borreliosis (advanced stages) and pneumonia are proposed. In most of these disease, there is potential for cutting treatment costs and studies that compare these newer strategies with traditional treatment regimens are urgently needed. PMID- 10164061 TI - Evaluation of the diabetes quality-of-life questionnaire in a Spanish population. An experience of translation and reliability. AB - The aim of this study was to evaluate the reliability of a version of the diabetes quality-of-life (DQOL) questionnaire adapted and translated into Spanish. The DQOL questionnaire consists of 46 items and is not sensitive to treatment regimens or self-monitoring; therefore, the instrument might be useful to a wide range of patients with diabetes who use different methods of diabetes management. 105 patients with insulin-dependent diabetes mellitus volunteered to complete the questionnaire. This Spanish version of the DQOL achieved a high global internal consistency (alpha = 0.90), and some outcome similarities, such as more favourable scores among younger patients (up to 21 years of age) and adult male patients compared with the original DQOL. These data show that the Spanish version of the DQOL has a high internal consistency (reliability) and might be a useful comparable tool to evaluate quality of life in Spanish-speaking patients with diabetes mellitus. PMID- 10164060 TI - Formulary management of ACE inhibitors. AB - An increasing number of ACE inhibitors have become available in recent years. Because these agents are all similar, careful scrutiny is required in order to determine specific advantages of particular agents when making formulary decisions. Differences between agents with regard to structure and tissue specificity have been identified, but the clinical relevance of these differences is not clear. ACE inhibitors vary greatly with regard to bioconversion, distribution and elimination. Disease states such as congestive heart failure (CHF) and hepatic or renal insufficiency may affect the disposition of specific ACE inhibitors. These agents may differ substantially in duration of action, and ACE inhibitors that are given once daily may optimise patient compliance and decrease costs. ACE inhibitors have been extensively studied in patients with hypertension, CHF or nephropathy, and following myocardial infarction (MI). Differences in efficacy between agents are often a result of variations in study design, or because nonequipotent dosages were compared. It is likely that the benefits of ACE inhibitors are class effects, and it is probably reasonable to use an agent even if large scale clinical trials have not been performed with that particular drug. Few differences have been found between ACE inhibitors with regard to adverse effects or drug interactions, and these factors are of minor importance when making formulary decisions. Cost and availability may vary among agents, and will depend on geographical location and institution-specific purchasing contracts. ACE inhibitors have shown positive effects on quality of life when compared with agents of other classes. Quality-of-life studies that have directly compared ACE inhibitors have produced conflicting results. In the setting of hypertension, cost-effectiveness evaluations typically find that the newer, longer-acting ACE inhibitors provide the greatest financial benefit. Differences in cost effectiveness in the post-MI patient population are typically the result of variations in protocol design, including duration of treatment and nondrug costs. ACE inhibitors are fairly homogeneous and selection between agents can be difficult. Clinical efficacy, time course of action, and cost are the primary concerns in selecting agents for inclusion on a formulary. PMID- 10164062 TI - A utility assessment of oral and intravenous ganciclovir for the maintenance treatment of AIDS-related cytomegalovirus retinitis. AB - The purpose of this study was to determine the magnitude of the difference in patient preference/utility for intravenous (i.v.) ganciclovir compared with oral ganciclovir for maintenance treatment of cytomegalovirus (CMV) retinitis. We used a cross-sectional, interviewer-administered time trade-off (TTO) exercise with hypothetical health state descriptions, based upon data from clinical trials and the published literature. The study was conducted in a private clinic in Sydney Australia, specialising in the care of people with HIV. A total of 80 individuals with HIV infection who had not developed AIDS were administered the TTO instrument. The main outcome measure was the difference between each respondent's utility score for oral and i.v. ganciclovir maintenance therapy. When the 80 HIV positive patients were presented with information on drug efficacy, adverse effects and mode of administration, 60 (75%) preferred oral ganciclovir, 4 patients preferred i.v. ganciclovir, and 16 were indifferent. The median utilities were 0.837 (oral ganciclovir) and 0.475 (i.v. ganciclovir). The difference in rankings was statistically significant by Wilcoxon's signed-ranks test (Z = -6.69, p < 0.00005). The median utility scores suggest that, all other things being equal, individuals with HIV infection would prefer an oral formulation of ganciclovir to i.v. administration in the event of CMV retinitis infection. PMID- 10164064 TI - The application of multiple quality-of-life instruments in individuals with mild to-moderate psoriasis. AB - The 36-item Short-Form Health Survey Questionnaire (HSQ SF-36), Psoriasis Disability Index (PDI), and Dermatology Life Quality Index (DLQI) were administered to individuals with mild-to-moderate psoriasis to validate the general quality-of-life instrument against the dermatosis-specific, and the dermatology-specific, disability measure. The population consisted of 644 adults with psoriasis involving up to 20% of the body surface area, who were enrolled in 2 US multicentre, evaluator-blinded, parallel-group clinical trials for a new psoriasis medication. Patients averaged 16.5% of maximum possible disability as measured by the PDI, and 23.4% of maximum possible disability as measured by the DLQI. Normalised T-scores showed that the patients approximated US population means on all 8 of the HSQ SF-36 dimensions. The HSQ SF-36 scales did not reflect substantial quality-of-life impairment, although all showed statistically significant correlations with both the PDI and DLQI (correlation coefficients ranging from -0.13 to -0.45). Moreover, while the disability indices were more responsive to psoriasis characteristics than the HSQ SF-36 quality-of-life scales, all 8 HSQ SF-36 dimensions demonstrated sensitivity to at least some objective and/or subjective ratings of severity. The strongest relationships were observed between the PDI, DLQI and the HSQ SF-36 Mental Health and Social Functioning dimensions, suggesting that the HSQ SF-36 is sensitive to psychosocial suffering related to psoriasis, which is not conveyed in objective clinical measures of severity. PMID- 10164063 TI - Prescribing practice and cost of antibacterial prophylaxis for surgery at a US Veteran Affairs hospital. AB - This study retrospectively compared the actual drug-related cost of antibacterial prophylaxis for specific operative procedures with the theoretical costs based on recommendations published in Medical Letter on Drugs and Therapeutics, the Surgical Infection Society, and those of the chiefs of each surgical subspecialty at our institution. We identified all patients who received in intravenous bacterial for prophylaxis before a clean or clean-contaminated operation between 1st January and 30th September 1993, using the medical centre's computerised information system. The information included comprehensive surgical case histories, and pharmacy and microbiology records. Only those operations in which recommendations for surgical prophylaxis were present in all 3 guidelines were included. The outcome measures were antibacterial-related costs (drug acquisition and administration costs), the number of antibacterial doses dispensed, and choice of antibacterial agents. During the study period, 3,322 operations were performed, 2,993 of which were excluded. Thus, 329 patients undergoing operations in 6 subspecialties were included in the analysis. The actual mean cost per patient significantly exceeded the projected costs using Medical Letter Consultants' and Surgical Infection Society guidelines for all 6 subspecialties [mean excess cost per patient: $US49.04 and $US34.95, respectively (1994 values)] and institutional guidelines for 4 of the 6 subspecialties (mean excess cost per patient: $US24.36). The actual mean number of doses per patient significantly exceeded those projected using Medical Letter Consultants' and Surgical Infection Society guidelines for all 6 subspecialties (mean excess number of doses per patient: 6.0 and 4.0, respectively) and institutional guidelines for 4 of the 6 subspecialties (mean excess number of doses per patient: 2.9). The choice of antibacterial was appropriate in approximately 90% of cases. We conclude that the practice of antibacterial prophylaxis for specific operative procedures performed by 6 subspecialties is not in accordance with institutional or published guidelines, and the excess cost is primarily a result of prolonged duration of antibacterial prophylaxis. PMID- 10164065 TI - Legal aspects of data protection in medical informatics. PMID- 10164066 TI - Data protection issues in database management and expert systems. PMID- 10164067 TI - Benefits and threats of new technologies. AB - In this paper first the effect of new hardware and software technologies on threats to data integrity and usage integrity is considered. Next the potential is considered of new technical facilities for improving the protection. It is concluded that the increasing risks for data and usage integrity are not counter balanced at present by new protection measures. A concerted action is proposed to face this problem. Especially action is proposed to develop methods for quality assurance of software, for access control in networks and to improve data/usage integrity around PC's. PMID- 10164068 TI - Safety standards in medical software. PMID- 10164069 TI - Medical database security. PMID- 10164070 TI - Security in medical networks. PMID- 10164071 TI - Data protection in networks. AB - Health Data are sensitive to loss, manipulation and breach of confidentiality. Systems handling health data must be especially secure. Anyone accessing health data-be they stored in data banks or in personalized chip-cards-must be specifically authorized to do so and must be strongly authenticated before access is granted. PMID- 10164072 TI - Medical network security and viruses. AB - Medical network as connecting Hospital Information Systems are needed in order to exchange, compare and make accessible data. The use of OSI standard communication protocols (open-network environment) will allow to interconnect multiple vendor systems and to accommodate a wide range of underlaying of communication technologies. The security of information on a given host may become dependent of the security measures employed by the network and by other hosts. Computer viruses modifies the executable code and thrive in network environment filled with personal computers and third-party software. Most networks and computers, permit users to share files; this, let the viruses to bypass the security mechanisms of almost every commercial operating system. However, computer viruses axes not the only threat to the information in a network environment. Other as deliberate (passive attacks -wire-tapping-) and accidental threat (unauthorized access to the information) are potential risks to the security information. Cryptographic techniques that now are widely used can resolve the external security problems of the network and improve the internal security ones. This paper begins describing the threats to security that arise in an open-network environment, and goes to establish the security requirements of medical communication networks. This is followed by a description of security services as: confidentiality, integrity, authentication, access control, etc., that will be provided to include security mechanisms in such network. The integration of these security mechanisms into the communication protocols allows to implement secure communication systems that not only must provide the adequate security, but also must minimize the impact of security on other features as for example the efficiency. The remainder of the paper describes how the security mechanisms are formed using current cryptographic facilities as algorithms, one-way functions, cryptographic systems (symmetric and asymmetric), etc. Emphasis is placed on the method to obtain these mechanisms. We will obtain several mechanisms of varying strength for the provision of each security service. Finally, the security mechanisms are structured into several mutually related areas of network security and are presented in a formal form. PMID- 10164073 TI - User authorization in distributed hospital information systems. PMID- 10164074 TI - The six safety first principles of health information systems: a programme of implementation. Part 1. Safety and security. PMID- 10164075 TI - Management and staff issues in data protection. PMID- 10164077 TI - Risk analysis and management. PMID- 10164076 TI - Administrative aspects of data protection. PMID- 10164078 TI - The individual, society and the protection of personal data. PMID- 10164079 TI - The European challenge in health information systems. AB - The challenge for Europe in the field of information and communication technologies applied to health care is that of "integration, modularity and security" of health information systems in order to obtain greater efficiency of health care, to assure quality of care and to promote industrial competitiveness. PMID- 10164080 TI - Medical requirements in data protection. PMID- 10164081 TI - Data protection in nursing in Europe. PMID- 10164082 TI - Data protection in nursing. PMID- 10164083 TI - Evolution and protection of the health care record as a European document. PMID- 10164084 TI - Ireland's competent authority initiatives. AB - Ireland is one of the countries in the European Union, that have transposed both directives on medical devices into national legislation. A detailed discussion on issues regarding the transposition of the directives, the implementation of the vigilance system, the registration requirements in Ireland as well as the Department's view in current developments, particularly the potential use of EDI for the information exchange between all Competent Authorities, is presented in this paper. PMID- 10164085 TI - The Netherlands' competent authority activities. PMID- 10164086 TI - Spain's competent authority initiatives. AB - In Spain, only the Active Implantable Medical Device Directive has been transposed into national legislation, with the Medical Device Directive relevant Decree still in a draft edition. However, the notification of serious adverse incidents is compulsory for manufacturers and users, both for CE-marked devices and non CE-marked devices. Manufacturers of all medical devices classes must be registered at the national competent authority, though the directives do not require it. PMID- 10164087 TI - Sweden's competent authority initiatives. PMID- 10164088 TI - Activities in other European countries. AB - This paper comprises a compilation of five papers, originating from Austria, Belgium, Denmark, Portugal and the United Kingdom. It describes the actions and measures taken for the transposition of the medical devices directives as well as the implementation of a vigilance system. It also includes aspects of the implementation of a trans-European system for data exchange in the field of medical device vigilance system. PMID- 10164089 TI - Experience of BSI as a notified body. PMID- 10164090 TI - EUCOMED's position. PMID- 10164091 TI - Medical device vigilance at FDA. AB - This overview of medical device vigilance at the U.S. Food and Drug Administration (FDA) discusses the basic reporting regulation and program at FDA. The FDA program has grown to the point where we now receive over 100,000 reports per year. How FDA examines the data patterns in overall reporting, to identify signals in the database, and the potential actions FDA takes to respond to these problems are also presented. New initiatives include, for example, new methods to triage reports and the move developing an internationally harmonised nomenclature. PMID- 10164092 TI - Data exchange in the European pharmacovigilance. AB - Recent research work on feasible solutions for electronic data exchanges in the european pharmacovigilance domain (EPhV) has facilitated a better understanding on strategic and operational factors inherent to such a class of transnational vigilance information systems. Most of the material presented here has resulted from the CARE-Pharmacovigilance Pilot project of the ENS-Telematics Programme, and from other subsequent research activities like the IDA feasibility study and the TEDIS-EuroSCape project. Attention has been paid to design principles and features of a communication scheme that must be used to support cooperative problem solving within a network of loosely connected autonomous and hetereogeneous agents. Experience confirmed two key-success factors: a) the users leading role, and b) the Pilot approach putting the focus on standardized electronic data interchange for communicating existing different local systems. PMID- 10164093 TI - Finland's competent authority initiatives. AB - Finland, as a member state of the European Union, has taken all necessary actions to implement the medical device directives. This paper presents the current situation in the area of manufacturers' registration as well as adverse incident notification. The establishment of a trans-european network between member states is strongly supported, as it could provide an efficient tool for the information exchange. PMID- 10164094 TI - France's competent authority initiatives. PMID- 10164095 TI - Germany's competent authority initiatives. AB - A decentralised approach on the enforcement's' responsibility of the medical devices act, which includes the directives and the guidelines for the vigilance system, has been adopted in Germany. DIMDI under this act, had been nominated to set up a database-supported information system, that would ensure secure usage of medical devices in Germany. The necessary measures taken in order to fulfil the German legislation as well as DIMDI's points of view for the international data exchange on medical devices are being discussed in this paper. PMID- 10164096 TI - Results of the Clinical Laboratory Management Association's industry trends survey. PMID- 10164097 TI - Improving performance through an organizational culture of employee expertise. AB - Managers can do many things to improve organizational performance, but the accomplishments of the most skillful employees often are most important. This article makes the point that managers should be aware of employee expertise and its relationship to organizational performance. The article also describes the components of an organizational culture of employee expertise. An organizational culture of employee expertise builds on the learning organization metaphor that has frequently appeared in the management literature. How employees develop expertise to do their jobs is emerging as a critical issue for organizations, and managers will likely play a key role in that process. PMID- 10164098 TI - Medical technologist career commitment and satisfaction with job benefits. AB - The purpose of this study was to determine the impact of career commitment on satisfaction with job-related benefits. A validated seven-point career commitment scale was used to measure career commitment. A 31-item benefits survey was used to collect data on satisfaction. In addition, salary information was collected. An analysis of variance was used to analyze the data. The high career commitment group was significantly more satisfied with 29 of the 31 benefits. There was no significant difference in salary among high, medium, and low career commitment groups. Low commitment individuals comprised only 11.5% of the respondents. The positive attitudes of the majority of medical technologists are a useful asset to the laboratory during this time of change in the practice of laboratory medicine. PMID- 10164100 TI - The troubled phlebotomist: training new employees in an ethical organization. AB - V.W. is a day-shift phlebotomist at Sunny View Cancer Hospital, located in a mid sized southern city. She is a high-school graduate from an underprivileged background who has had no exposure to the hospital environment and has been recently trained "on the job" for her current position. She has been extremely troubled recently and has been unable to report to work because of stress-related symptoms. All of this began when, on a routine phlebotomy sweep one day, an extremely cachectic cancer patient looked her in the eyes and asked her why his blood had to be drawn again, saying that he did not expect to live through the night. What should V.W. do? What should V.W.'s manager do? PMID- 10164099 TI - A taste of our quality: our experience with reengineering, developing and introducing new technology, and organizational renewal. AB - As recipient of the 1995 CLMA Quality Management Award, MDS Ontario Laboratory Division (MDS) has the great opportunity to share with the CLMR readers, through this article, highlights of our change process. These highlights have proven to be valuable learning experiences to us as an organization in health care that has undergone and continues to undergo significant change. In the course of our 5 year journey, MDS has undertaken two main change processes: restructuring and Renewal. Restructuring was a result of financial pressures placed on the organization by our single payer of service, the Ontario Government. Restructuring achieved the required results of reducing the operating expenses of the Ontario Laboratory Division. It was foreseen that one of the greatest challenges at the end of the Restructuring process would be restoring employee morale. The Renewal process began with a leaner, more flexible organization. We needed to address employee morale, and focus the organization on the future and the opportunities that it holds for the employees and the organization. Thus, we began "Building Our Future Together." The key learnings that have enabled us to transform the division successfully are based on the five principles of change: context, communication, commitment, culture, and celebration. These principles have provided the foundation from which our renewed organization will move forward. PMID- 10164101 TI - Automation solutions: what to look for and what to avoid. AB - The author's intention in this article is to share some of the knowledge and experience gained by an organization from the successful implementation of automation tools in two different laboratory locations. The article examines the application of these tools from a strategic and business prospective rather than from a technical point of view. It is intended that the information provided will reduce some areas of risk for the reader when considering or installing automation tools. PMID- 10164102 TI - Beyond traditional service, Part I. PMID- 10164103 TI - Educating Healthcare Ethics Committees (EHEC 1992-1996): the evaluation results. PMID- 10164104 TI - Ethics committee education: report on a Canadian project. PMID- 10164105 TI - Hospital ethics committees in the United Kingdom. PMID- 10164106 TI - Ethics committees in Israel. PMID- 10164107 TI - Perspectives. AHCs on edge as Congress meets, market pressures build. PMID- 10164108 TI - Perspectives. Outcomes hard to track in kids' behavioral care. PMID- 10164109 TI - Special report. A look at HRSA from the top. Interview by Stephanie Stapleton. PMID- 10164110 TI - Clinical ethics: balancing praxis and theory. PMID- 10164111 TI - The clinic as testing ground for moral theory: a European view. PMID- 10164112 TI - Informed consent and clinical research. PMID- 10164113 TI - Modern vs. contemporary medicine: the patient-provider relation in the twenty first century. PMID- 10164114 TI - Refusals of treatment and requests for death. PMID- 10164115 TI - Death and dying in Japan. PMID- 10164116 TI - Ethics and the allocation of organs for transplantation. PMID- 10164117 TI - Catholic social teaching and the allocation of scarce resources. PMID- 10164118 TI - Medical care for the homeless: a practical approach to an academic problem. PMID- 10164119 TI - Shift in power to hospital accountants. AB - With the introduction of the Prospective Payment System, hospital accountants' role changed from reimbursement maximizers to an important role in decision making. Faced with increased competition, many hospitals are installing financial controls. Many hospitals are engaging in promotion and health awareness campaigns and expanding their services to stabilize income and reduce the effects of a changing environment. Thus, hospitals operate in a more competitive environment with much uncertainty. When faced with uncertainty, organizations often believe that they must convince society that their existence is legitimate. Increasing specialization and organizational complexity in healthcare professions have made the expert important. Experts, such as the role assumed by hospital accountants, maintain power because the organization depends on them for their special skills and information. Scarce resources coupled with uncertainty move hospital accountants as experts into the power equation in the changing control of the U.S. healthcare system. Since accountants often serve as monitors of scarce resources, information about the resource allocation directly affects the distribution of power. This places hospital accountants in a critical role of assisting their institutions in adapting to a new environment. PMID- 10164120 TI - Government spending on health care: a cross-national study of public attitudes. AB - The economic constraints of the last decade have led western industrialized nations to consider, if not actually adopt, more stringent controls over costly social policies such as health care. Using recent, nationally representative data from the United States, Great Britain, West Germany, Italy and Australia, this paper provides an international comparison of attitudes towards government spending on health care. Attitudes are found to differ by country, with Great Britain being most supportive of increased spending and West Germany and the United States most opposed. Multiple regression techniques are used to determine significant socio-demographic and political ideological factors in relation to predicting attitudes towards government spending. In many countries, those who often bear the heavier tax burden, for example, the middle classes and those with higher status jobs, were consistently more likely to oppose an increase in government spending on health; compared with them, women were found to be more supportive of such action. Measures of political ideology were found to be quite consistent and strong predictors of attitudes--political conservatism and more negative attitudes towards government generally were inversely related to support for government increases in health spending. The policy implications of these findings are discussed in the conclusion. PMID- 10164121 TI - Medical services in urban China: does the 'free' care policy induce greater demand? AB - In this paper we discuss the nature of the medical services and the free medical care programs in urban China, then using the data collected in a large city, we also explored the differences between those covered by a free program and those not in perceived illness, doctor visit, hospital admission, and emergency use. Our findings may show that Chinese experience in medical service use is consistent with the common idea that a free medical care policy could induce greater demand while it also has its own nature. PMID- 10164122 TI - The quality of life of persons with severe emotional disability: a review of empirical studies. AB - Following the deinstitutionalization of persons with serious mental illness from state hospitals, many persons with serious mental illness did not receive the care that they needed and encountered unexpected negative experiences. Among the negative experiences were frequent rehospitalizations, involvement in the criminal justice system, and homelessness. Seeing these negative outcomes, mental health professionals in the 1980s debated the quality of life of persons with severe and persistent mental illness and concluded that the main goal of treatment was to improve the quality of life of those afflicted. Thus, the quality of life became a critical variable in determining the effectiveness of mental health treatment. This paper reviews studies that used quality of life as an outcome measure in treatment services for persons with serious and persistent mental illness and the policy implications of these studies. PMID- 10164123 TI - Looking beyond the symptoms. Hospitals examine societal factors to improve community health. PMID- 10164124 TI - AlaHA's living legacy. Favorite memories from those who have lived our healthcare history. PMID- 10164125 TI - Gaining professional respect. PMID- 10164126 TI - Tales from the ripped. PMID- 10164127 TI - Case study. On Florida's competitive "Space Coast", Health First combines hospitals, physicians, and HMO. PMID- 10164128 TI - Patient education: it's a material kind of business. PMID- 10164130 TI - Don't get steamed about new sterilization standards. PMID- 10164129 TI - Support service centers are back--now it's your call. PMID- 10164131 TI - Un-stuck: needlesticks have declined--but can hospitals take the credit? PMID- 10164132 TI - Mask man: IC manager tracks true costs of TB protection. PMID- 10164133 TI - Stats. No, you do it! PMID- 10164134 TI - Is there a right to die? PMID- 10164135 TI - How business is dealing with the AIDS epidemic. AB - Employers geared up for astronomical HIV-related claims, but the avalanche never came. As new treatments improve prognoses and increase costs, the innovations of forward-thinking companies suggest useful strategies. PMID- 10164136 TI - Why bother with long-term care coverage? PMID- 10164137 TI - Managing health benefits. The birth of the on-line age. PMID- 10164138 TI - Prostate cancer: sometimes it pays to do nothing. PMID- 10164140 TI - Data watch. HMO/indemnity trade-offs: the consumer perspective. PMID- 10164139 TI - Failure's lessons. PMID- 10164141 TI - Improving care at the primary-secondary care interface: a difficult but essential task. PMID- 10164142 TI - A natural survey of audit activity across the primary-secondary care interface. AB - OBJECTIVE: To document the nature of audit activity at the primary-secondary care interface; to explore participants' experiences of undertaking such interface audit; to identify factors associated with these experiences; and to gather views on future interface audit activities. DESIGN: A three phase national survey by postal questionnaire with a cascade sampling approach. SETTING: England and Wales. RESULTS: Response rates were: 65% to the first questionnaire; 34% to the second questionnaire; and 45% to the third questionnaire. 56% of the audits covered some element of management of patients or disease; only 33% of the audits were within a single topic area. Most audits had more than one trigger: for 61% the trigger was a perceived problem; for 58% it was of mutual interest. Only 18% of audits were initiated collaboratively; doctors were the most frequent initiators (72%), and most audits (63%) involved collaborative groups convened specifically for the audit. 58% of groups had between three and eight members, 23% had 12 or more. Doctors were the most frequent group members. There was differential involvement of group members in various group tasks; the setting of guidelines was highly dominated by doctors. Of reportedly complete audits, only two fifths had implemented change and only a quarter had evaluated this change. There was widespread feeling of successful group work, with evidence of benefit in terms of the two sectors of care being able to consider issues of mutual concern. Levels of understanding of the group task and of participation were positively related to the duration of meetings. Joint initiation of audits facilitated greater understanding of the group task. Larger group sizes allowed primary and secondary carers to discuss issues of common concern; however, larger groups were more likely to experience disagreements. Having previously worked with group members increased trust and good working relations. The main lessons learnt from the experience included the importance of setting clear objectives and good communications between primary and secondary carers. Factors identified as important for future audit activity at the primary-secondary care interface included commitment, enthusiasm, time, and money. CONCLUSIONS: Audit at the primary-secondary care interface is taking place on a wide scale and has been an enjoyable experience for most of the respondents in this study. IMPLICATIONS: Despite being a positive experience most audits stopped short of implementing change. Care must be taken to complete the audit cycle if audit at the primary secondary care interface is to move beyond the roles of education and professional development and to fulfil its potential in improving the quality of care. PMID- 10164143 TI - Improving the quality of health care through contracting: a study of health authority practice. AB - OBJECTIVES: To investigate approaches of district health authorities to quality in contracting. DESIGN: Descriptive survey. SETTING: All district health authorities in one health region of England in a National Health Service accounting year. MATERIAL: 129 quality specifications used in contracting for services in six specialties (eight general quality specifications and 121 service specific quality specifications) MAIN MEASURES: Evaluation of the use of quality specifications; their scope and content in relation to established criteria of healthcare quality. RESULTS: Most district health authorities developed quality specifications which would be applicable to their local hospital. When purchasing care outside their boundaries they adopted the quality specifications developed by other health authorities. The service specific quality specifications were more limited in scope than the general quality specifications. The quality of clinical care was referred to in 75% of general and 43% of service specific quality specifications. Both types of specification considered quality issues in superficial and broad terms only. Established features of quality improvement were rarely included. Prerequisites to ensure provider accountability and satisfactory delivery of service specifications were not routinely included in contracts. CONCLUSION: Quality specifications within service contracts are commonly used by health authorities. This study shows that their use of this approach to quality improvement is inconsistent and unlikely to achieve desired quality goals. Continued reliance on the current approach is holding back a more fundamental debate on how to create effective management of quality improvement through the interaction between purchasers and providers of health care. PMID- 10164144 TI - Audit in the therapy professions: some constraints on progress. AB - AIMS: To ascertain views about constraints on the progress of audit experienced by members of four of the therapy professions: physiotherapy, occupational therapy, speech and language therapy, and clinical psychology. METHODS: Interviews in six health service sites with a history of audit in these professions. 62 interviews were held with members of the four professions and 60 with other personnel with relevant involvement. Five main themes emerged as the constraints on progress: resources; expertise; relations between groups; organisational structures; and overall planning of audit activities. RESULTS: Concerns about resources focused on lack of time, insufficient finance, and lack of access to appropriate systems of information technology. Insufficient expertise was identified as a major constraint on progress. Guidance on designing instruments for collection of data was the main concern, but help with writing proposals, specifying and keeping to objectives, analysing data, and writing reports was also required. Although sources of guidance were sometimes available, more commonly this was not the case. Several aspects of relations between groups were reported as constraining the progress of audit. These included support and commitment, choice of audit topics, conflicts between staff, willingness to participate and change practice, and concerns about confidentiality. Organisational structures which constrained audit included weak links between heads of professional services and managers of provider units, the inhibiting effect of change, the weakening of professional coherence when therapists were split across directorates, and the ethos of regarding audit findings as business secrets. Lack of an overall plan for audit meant that while some resources were available, others equally necessary for successful completion of projects were not. CONCLUSION: Members of four of the therapy professions identified a wide range of constraints on the progress of audit. If their commitment to audit is to be maintained these constraints require resolution. It is suggested that such expert advice, but also that these are directed towards the particular needs of the four professions. Moreover, a forum is required within which all those with a stake in therapy audit can acknowledge and resolve the different agendas which they may have in the enterprise. PMID- 10164145 TI - What proportion of primary psychiatric interventions are based on evidence from randomised controlled trials? AB - OBJECTIVES: To estimate the proportion of psychiatric inpatients receiving primary interventions based on randomised controlled trials or systematic reviews of randomised controlled trials. DESIGN: Retrospective survey. SETTING: Acute adult general psychiatric ward. SUBJECTS: All patients admitted to the ward during a 28 day period. MAIN OUTCOME MEASURES: Primary interventions were classified according to whether or not they were supported by evidence from randomised controlled trials or systematic reviews. RESULTS: The primary interventions received by 26/40 (65%; 95% confidence interval (95% CI) 51% to 79%) of patients admitted during the period were based on randomised trials or systematic reviews. CONCLUSIONS: When patients were used as the denominator, most primary interventions given in acute general psychiatry were based on experimental evidence. The evidence was difficult to locate; there is an urgent need for systematic reviews of randomised controlled trials in this area. PMID- 10164146 TI - Comparison of appropriateness of cholesterol testing in general practice with the recommendations of national guidelines: an audit of patient records in 20 general practices. AB - OBJECTIVE: To compare the profiles of those patients selected by general practitioners for measurement of serum cholesterol with the recommended profiles for opportunistic cholesterol testing described in the national practice guidelines published by the Dutch College of General Practitioners. DESIGN: Retrospective audit of general practitioners' records. MATERIALS: Practice records of 3577 adult patients systematically sampled from 20 general practices. MAIN MEASURES: With criteria set by the national guidelines, the proportion of patients per practice (a) for whom cholesterol testing would be considered justified, and (b) for whom cholesterol testing would be considered unjustified, and the proportion of patients within each of these groups who had had a cholesterol measurement recorded. RESULTS: Cholesterol tests were performed on 415 (11.7%) of the 3577 patients. National guidelines on the management of hypercholesterolaemia state that a positive cardiovascular risk profile is an indication for cholesterol measurement. Just under one fifth (668) of the patients in this study were recorded as having a positive cardiovascular risk profile, but only 31% of these had had their cholesterol measured. Of the patients without recorded evidence of a positive cardiovascular risk profile cholesterol had been measured in 8%. Restricting the analyses to the age group 18 65 (n = 3060) of whom 12.5% had a positive risk profile, did not improve the results. In practices with a computerised information system 37% of patients with recorded evidence of a positive cardiovascular risk profile had had their cholesterol measured. CONCLUSIONS: Cholesterol testing was not targeted as selectively as recommended by the national guidelines. The major problem was failure to test those likely to benefit. Improving the targeting of cholesterol measurements would undoubtedly increase the workload of general practitioners. If the national guidelines are to have an effect on health promotion the first step must be to increase the proportion of patients with positive cardiovascular risk profiles who get their cholesterol tested. A major factor in successfully selecting cases seems to be that practices are equipped with a computerised medical information system. PMID- 10164147 TI - Must we choose between quality and cost containment? PMID- 10164148 TI - Low profile, high impact: the role of the sociologist in quality in health care. PMID- 10164149 TI - Research and development in quality of care: establishing the research agenda. PMID- 10164150 TI - Preventing falls and subsequent injury in older people. PMID- 10164152 TI - Weighing the right to die. The Supreme Court will decide: can doctors help their patients kill themselves? PMID- 10164153 TI - Complying with current Joint Commission Statement of Conditions (SOC) requirements. AB - This Technical Document has been developed to provide the reader with insight into the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) Statement of Conditions (SOC) process and recent changes for completing the SOC for Business Occupancies. The intent of this document is not to replace the instructions in Part 1 of the SOC or to give a complete review of the National Fire Protection Agency's (NFPA) Life Safety Code for health care or business occupancies, but rather to complement them. PMID- 10164154 TI - Medicare and Medicaid programs; requirements for physician incentive plans in prepaid health care organizations--HCFA. Final rule. AB - This final rule amends the regulations established by a March 27, 1996, final rule with comment period. The regulations govern physician incentive plans operated by Federally-qualified health maintenance organizations and competitive medical plans contracting with the Medicare program, and certain health maintenance organizations and health insuring organizations contracting with the Medicaid program. As explained in the March 27 rule, the provisions of this final rule will also have an effect on certain entities subject to the physician referral rules in section 1877 of the Social Security Act. PMID- 10164151 TI - Management of primary breast cancer. PMID- 10164155 TI - Lists of designated primary medical care, mental health, and dental health professional shortage areas--HRSA. Notice. AB - This notice provides lists of all areas, population groups, and facilities designated as primary medical care, mental health, and dental health professional shortage areas (HPSAs) as of September 30, 1996. HPSAs are designated or withdrawn by the Secretary of Health and Human Services (HHS) under the authority of section 332 of the Public Health Service (PHS) Act. PMID- 10164156 TI - The search for synergy. AB - Pharmacy practice education has been part of the mission of academic medical center hospitals for a long time. Practitioners, faculty members, students, and pharmacy managers work to develop relationships that support the training of future pharmacy practitioners. Increasing financial and operating pressures created by managed care have caused hospital pharmacies and colleges of pharmacy to re-examine the nature of the relationships that support this training. The University HealthSystem Consortium Pharmacy Advisory Council undertook a survey and commissioned a study of the methods and resources used to support pharmacy practice education. Based on this assessment, relationships were characterized as educational affiliation, affiliated, and fully integrated. The current status and future prospects for each of these relationships are described. PMID- 10164158 TI - Creating synergy to restructure a college of pharmacy's teaching site. AB - Colleges of pharmacy and clinical teaching sites have a history of collaboration to create teaching and practice innovations. Radical changes in health care delivery have placed a strain on these relationships and may jeopardize the continued success of these programs. Goals of collaborative planning for a renewed model include integrating teaching into the professional culture of the pharmacy department, moving pharmaceutical care resources to the patient care unit, and training all staff in teaching skills. A model that combines these attributes is defined, and development of the model at a university teaching hospital is described. Revising the pharmacy practice and teaching agenda has a positive effect on both care delivery and educational outcomes. PMID- 10164157 TI - Analysis of a survey of UHC hospitals--College of Pharmacy relationships. AB - The University HealthSystem Consortium (UHC) Pharmacy Advisory Council commissioned a survey of the methods and resources used to support pharmacy practice education. This article presents the results of the two-part survey, and presents a brief description and analysis of the results. Fifty-two of the UHC's member hospitals' pharmacies replied to the survey. An unblinded study sought to characterize the types and numbers of students and staff involved. A second blinded portion of the survey requested the opinions and comments of pharmacy managers. PMID- 10164159 TI - The implementation of a pharmaceutical care practice system. AB - The growing emphasis on a well-rounded clinical pharmacy practitioner, combined with the implementation of the six-year Doctor of Pharmacy degree requires innovative training strategies. A method to integrate clinical practice and training missions is described in Development of a Patient Care Unit(PCU). Pharmacist practice is described. PMID- 10164160 TI - A primer on the assessment of medical technologies. AB - As health care costs continue to escalate, the assessment and management of medical technologies have become vitally important to health care providers. Evaluation and comparison of the safety, effectiveness, efficiency, cost, and clinical outcomes of new and existing technologies provide the critical information necessary to make appropriate clinical resource decisions in an increasingly cost-conscious environment. Technologies to be assessed include pharmaceuticals, devices, medical and surgical procedures, and health care delivery systems. Clinical trial results, literature reviews, expert opinions, and group consensus are used in preparing technology use decisions, which often include the preparation of background information, specific recommendations, use guidelines, and reimbursement analyses. PMID- 10164161 TI - Multifaceted approach to medication use policy development: the restriction of meperidine. AB - As institutions continue to expand their drug policy development efforts in order to improve care and reduce cost, the use of multifaceted approaches offer several benefits. Population data on drug use support the need for policy action. The use of institutional outcomes data in conjunction with published evidence augments the process, and the consensus approach to guideline development engenders medical staff support. Such efforts, however, require significant dedication of human resources. Institutions with limited personnel to allocate to drug policy activities may consider increasing the depth of their efforts (using a multifaceted approach) while limiting the breadth of their efforts (only attempting one or two major targets per year, and doing them well). PMID- 10164162 TI - An overview of types of relationships between hospitals and colleges/schools of pharmacy. AB - Three vignettes describe the details of each of the three types of practice education relationships in academic hospitals identified in a survey by the University HealthSystem Consortium. The educational affiliation at Penn State's Hershey Medical Center, the affiliated relationship of the Medical College of Virginia, and a fully integrated relationship at the University of Illinois at Chicago are described by the Director of Pharmacy at each institution. The advantages, disadvantages, and future goals are described. PMID- 10164163 TI - Financial management of health system pharmacy practice. AB - The financial management of pharmacies and health systems is a combination of the traditional management of personnel and drug and supply costs with the management of the total costs of care. It includes determining the consequences of less than optimal drug therapy, improving drug therapy, and reengineering pharmacy departments and services across all patient care settings to deliver optimal pharmacotherapy. Prevention and reduction of adverse drug events, disease state management, and other methods to improve quality of care are of major importance. Future articles in this series on the financial management of pharmacy practice in health care systems will provide examples of applications of financial management in acute care, ambulatory care, long term care, and across sites of care. They also will include the justification of the development of new types of patient care services. PMID- 10164164 TI - Emergency marketing: the ED is best choice for PR campaign. PMID- 10164165 TI - Telephone advice lines can benefit patients, ED. PMID- 10164166 TI - 'Family-centered' focus comes to the ED. PMID- 10164167 TI - 1997 will be seminal year for emergency medicine. PMID- 10164168 TI - Developing GI bleeding paths requires flexible, complex approach. PMID- 10164169 TI - New York study finds poor CHF counseling methods. PMID- 10164170 TI - Want to improve clinical path implementation? PMID- 10164171 TI - New stent procedures in children reduce LOS. PMID- 10164172 TI - Is follow-up care needed for short postpartum LOS? PMID- 10164173 TI - CHF path reduces LOS by improving follow-up care. PMID- 10164174 TI - Abdominal aortic aneurysm path reduces charges by 33%. PMID- 10164175 TI - Tension drops in second year of revised enforcement survey. PMID- 10164176 TI - HCFA wants inspectors to focus on SNFs that violate standards. PMID- 10164178 TI - HCFA told to revise exceptions to better differentiate atypical costs. PMID- 10164177 TI - Industry sees long battle over SNF inspection process in 1997. PMID- 10164179 TI - New Chicago LTC hospital shapes itself for high-acuity patients. PMID- 10164180 TI - New federal anti-fraud law turns up the heat. PMID- 10164181 TI - The agony and ecstasy of financing assisted living. PMID- 10164182 TI - Ambassadors to the world of managed care. PMID- 10164183 TI - Capitol offense. With Washington promising action this year, what kinds of cuts can providers expect? PMID- 10164184 TI - How much risk can you really negotiate? PMID- 10164186 TI - Marketplace directory. PMID- 10164185 TI - Helping with the high cost of living with AIDS. PMID- 10164187 TI - The 1997 Joint Commission standards. PMID- 10164188 TI - Research supports need for RDs (registered dietitians). PMID- 10164189 TI - Clinical pathways span the continuum of care. PMID- 10164190 TI - Meal delivery. PMID- 10164191 TI - Mail delivery. Special diets shipped to the home. PMID- 10164193 TI - Aid instruments and health systems development: an analysis of current practice. AB - There has been a clear shift in the policy of many donors in the health sector away from discrete project assistance towards more broad-based sectoral support. This paper, based on interviews with officials in a number of bilateral and multilateral agencies, explores whether this shift in policy has been matched by similar changes in the form or range of aid instruments. The paper develops a framework for examining current practice in relation to the different objectives that donors seek to promote through technical and financial assistance. In particular, it looks in some detail at the advantages and disadvantages of budgetary support compared to more traditional forms of project assistance. It concludes that the debate should not be about whether one form of aid is better than another. Ideally, they should be complementary and the forms, channels and systems used for managing aid need to be assessed in relation to how they help to achieve the mix of development objectives that are most appropriate to the country concerned. The review demonstrates that this is a complex task and that to achieve an effective balance is not easy. The final section summarizes the main themes emerging from the discussion and suggests some preliminary conclusions and proposals for future action. PMID- 10164192 TI - Integrating MCH/FP and STD/HIV services: current debates and future directions. AB - The issue of integrating MCH/FP and STD/HIV services has gained an increasingly high priority on public health agendas in recent years. In the prevailing climate of health sector reform, policy-makers are likely to be increasingly pressed to address the broader concept of "reproductive health' in the terms consolidated at the Cairo International Conference on Population and Development, and the UN Conference on Women in Beijing. Integrated MCH/FP and STD/HIV services could be regarded as a significant step towards providing integrated reproductive health services, but clarity of issues and concerns is essential. A number of rationales have emerged which argue for the integration of these services, and many concerns have been voiced. There is little consensus, however, on the definition of "integrated services' and there are few documented case studies which might clarify the issues. This paper reviews the context in which rationales for "integrated services' emerged, the issues of concern and the case studies available. It concludes by suggesting future directions for research, noting in particular the need for country-specific and multi-dimensional frameworks and the appropriateness of a policy analysis approach. PMID- 10164195 TI - Developing a plan for primary health care facilities in Soweto, South Africa. Part I: Guiding principles and methods. AB - The new political era in South Africa offers unique opportunities for the development of more equitable health care policies. However, resource constraints are likely to remain in the foreseeable future, and efficiency therefore remains an important concern. This article describes the guiding principles and methods used to develop a coherent and objective plan for comprehensive primary health care facilities in Soweto. The article begins with an overview of the context within which the research was undertaken. Problems associated with planning in transition are highlighted, and a participatory research approach is recommended as a solution to these problems. The article goes on to describe how the research methods were developed and applied in line with the principles of participatory research. The methods were essentially rapid appraisal techniques which included group discussions, detailed checklists, observation, record reviews and the adaptation of international and local guidelines for service planning. It is suggested that these methods could be applied to other urban areas in South Africa and elsewhere, and that they are particularly appropriate in periods of transition when careful facilitation of dialogue between stakeholders is required in tandem with the generation of rapid results for policy-makers. PMID- 10164196 TI - Developing a plan for primary health care facilities in Soweto, South Africa. Part II: Applying locational criteria. AB - This article is the second of a two-part series describing the development of a ten-year plan for primary health care facility development in Soweto. The first article concentrated on the political problems and general methodological approach of the project. This second article describes how the technical problem of planning in the context of scanty information was overcome. The reasoning behind the various assumptions and criteria which were used to assist the planning of the location of facilities is explained, as well as the process by which they were applied. The merits and limitations of this planning approach are discussed, and it is suggested that the approach may be useful to other facility planners, particularly in the developing world. PMID- 10164194 TI - Costs and financing of improvements in the quality of maternal health services through the Bamako Initiative in Nigeria. AB - This paper reports on a study to assess the quality of maternal health care in public health facilities in Nigeria and to identify the resource implications of making the necessary quality improvements. Drawing upon unifying themes from quality assurance, basic microeconomics and the Bamako Initiative, locally defined norms were used to estimate resource requirements for improving the quality of maternal health care. Wide gaps existed between what is required (the norm) and what was available in terms of fixed and variable resources required for the delivery of maternal health services in public facilities implementing the Bamako Initiative in the Local Government Areas studied. Given such constraints, it was highly unlikely that technically acceptable standards of care could be met without additional resource inputs to meet the norm. This is part of the cost of doing business and merits serious policy dialogue. Revenue generation from health services was poor and appeared to be more related to inadequate supply of essential drugs and consumables than to the use of uneconomic fee scales. It is likely that user fees will be necessary to supplement scarce government budgets, especially to fund the most critical variable inputs associated with quality improvements. However, any user fee system, especially one that raises fees to patients, will have to be accompanied by immediate and visible quality improvements. Without such quality improvements, cost recovery will result in even lower utilization and attempts to generate new revenues are unlikely to succeed. PMID- 10164197 TI - The privatization of health care in three Latin American social security systems. AB - Most Latin American social security institutes are direct providers of medical care services to their beneficiaries. As many of the institutes have developed serious financial problems over the course of the last decade and a half, they have come under increasing attack for (a) exacerbating inequalities in access to and use of health care, (b) further heightening the geographic overconcentration of services, (c) focusing a disproportionate amount of resources on high technology, curative care to the near total exclusion of primary health care, and (d) being administratively top heavy and, more generally, inefficient. In the past few years, many Latin American countries have begun searching for methods to ameliorate these problems. This paper analyzes three recent efforts, all of which involve some degree of privatization: (1) El Salvador's partial privatization of specialty physician outpatient consultations, (2) Peru's minor surgery and its decentralized ambulatory care programme, and (3) Nicaragua's "administrative services only' approach wherein social security beneficiaries choose to join a certified public or private provider organization for one year, and, on behalf of the individual, social security pays the organization a fixed, annual, per capita fee to provide all health care for the enrollee. The paper also identifies political and technical considerations, as well as health care market characteristics that have shaped these efforts and that condition their likelihood of success, including: the size, composition, level of capacity utilization, degree of organization and geographic distribution of private sector resources; relative prices in the private vis-a-vis the public sector; and the size and nature of the private health insurance market. Other Latin American countries would do well to examine these factors and characteristics before embarking on efforts to reform their own social security health care delivery systems. PMID- 10164198 TI - Confidentiality and HIV status in Kwazulu-Natal, South Africa: implications, resistances and challenges. AB - This article provides a contextualized comparison and analysis of the former Kwazulu and the new Kwazulu-Natal policy documents on HIV confidentiality, the differing practices within the region, and their implications for support and gender. It is based on interviews with key players in the regional NACOSA (National AIDS Convention of South Africa), and participation in meetings between August and November 1995. The main division is between those influenced by other rural African models, especially the Zambian concept of "shared confidentiality' as a way of ensuring support, and who have gone on to develop more community based practices to destigmatize the disease, in contrast with the stronger emphasis in the new document on individual rights, assuming a more urban constituency, and where "shared confidentiality' is much more circumscribed. One of the difficulties of the new policy in which "confidentiality' is interpreted as "secrecy', is that it would seem to foreclose and neutralize lay and community support, as distinct from the earlier and unacknowledged policy of former Kwazulu. It also seeks to provide an enhanced role for professional counsellors. This psychologizing of the infection and the distancing from "community', and from women's groups, is surprising in a country in whose townships "community' remains a powerful motivating symbol, and where NGOs and peer groups have been identified everywhere as central to effective HIV/AIDS related prevention, care and support for behavior change. PMID- 10164199 TI - Willingness to pay for district hospital services in rural Tanzania. AB - This paper describes a study undertaken to investigate the willingness of patients and households to pay for rural district hospital services in north western Tanzania. The surveys undertaken included interviews with 500 outpatients and 293 inpatients at three district level hospitals, interviews with 1500 households and discussions with 22 focus groups within the catchment areas of the primary health care programmes of these hospitals. Information was collected on willingness to pay fees for certain hospital services, willingness to become a member of a local insurance system, and exemptions for cost-sharing. The willingness to pay for district hospital services was large. Furthermore, most respondents favoured a local insurance system above user fee systems, a finding which applied at all places and in all the surveys. More female respondents were in favour of a local insurance scheme. The conditions needed for the introduction of a local insurance system are discussed. PMID- 10164200 TI - Domain analysis for qualitative public health data. PMID- 10164201 TI - Coming home to roost. PMID- 10164202 TI - Job shift. A (scary) conversation with William Bridges & Neilson Buchanan. Interview by Joe Flower. PMID- 10164203 TI - Resources on change. PMID- 10164204 TI - Thinking in the future tense. PMID- 10164205 TI - The evolution of the specialist. PMID- 10164206 TI - Hot concepts in strategy. PMID- 10164208 TI - Just between us: security, privacy and confidentiality. PMID- 10164207 TI - Five irresistible forces. PMID- 10164209 TI - Conceptions and misconceptions. PMID- 10164210 TI - Potential savings involved in the purchase of low-cost, high-volume medical commodities as established from a community hospital survey. AB - Health technology refers to the instruments, equipment, drugs and procedures used in health care delivery, as well as the organizations supporting it. Health technology assessment, which is the process of conducting investigations to establish the criteria for efficacious, effective and efficient patient care, is becoming increasingly important in an era of diminishing resources. This survey of 39 community hospitals in southwestern Ontario found that improved purchasing strategies can result in substantial cost savings which can in turn be used to improve patient care. The study shows that optimizing the price of basic hospital commodities could save an average community hospital as much as $625,000 per year. PMID- 10164211 TI - Reminding and monitoring: new uses of administrative data for preventive care. AB - This article illustrates how administrative data can be used to improve population health in an environment of fiscal constraint. In our universal single payer health system, health care providers submit standardized data. This allows provinces to create health information utilities that generate population-based data that can be used for research and health care delivery. Although more study is needed to determine the cost-effectiveness of using such data to raise the rates of primary and secondary prevention, it appears that appropriately designed information systems could improve population health with relatively little additional cost. PMID- 10164212 TI - Human health resources: issues concerning the number, distribution, mix and role of physicians in the Canadian health care system. AB - This article focuses on key health policy issues related to physician health resources. Using the 1991 Barer/Stoddart report, Toward Integrating Medical Resource Policies for Canada, as the starting point for discussion, the author examines such issues as the number and geographic distribution of physicians, reimbursement, licensing standards, specialty mix and scope of practice. The article concludes with recommendations for future directions in public policy. PMID- 10164213 TI - In search of informed input: a systematic approach to involving the public in community decision making. AB - Given the task of distributing scarce resources, decision makers are faced with the question of how to involve an increasingly threatened and disenfranchised public in decisions affecting their communities. This article introduces a systematic approach to public involvement in community decision-making and identifies key elements in the design of institutional driven public participation exercises. Examples are drawn from the health care system restructuring experiences of three Ontario communities. PMID- 10164214 TI - Downsizing in the hospital system: a restructuring process. AB - In an effort to maintain fiscal viability, hospitals have been undergoing major restructuring. This article reports on a study that examined innovative downsizing strategies used by 20 acute care hospitals in Ontario. The study team reviewed hospital operating plans and analysed the results of interviews conducted with administrators and employees about the downsizing process. Results revealed no uniformity of approach to downsizing. Although many administrators expressed the need for a cooperative approach, downsizing was typically conducted in a top down fashion, and was perceived very differently by staff and administrators. The authors suggest ways to improve restructuring efforts and put forward questions to guide future research. PMID- 10164215 TI - Revolutionary versus evolutionary change: the experience of a university hospital department of psychiatry. AB - In the spring of 1991, the Department of Psychiatry at Sunnybrook Health Science Centre chose to undergo a major reorganization in an attempt to better meet the needs of patients as well as the academic and research requirements of the University of Toronto. This brief report describes the circumstances leading up to the decision to make a "revolutionary" change, the department's experiences during the period of radical change and the impacts of the change process. PMID- 10164217 TI - Joint venture. Interview by Catherine Quayle. PMID- 10164216 TI - Mercy Hospital creates an intimate space for moms and newborns. PMID- 10164218 TI - Power managing waste. Understanding hospital waste composition for recycling. PMID- 10164219 TI - Solving HVAC problems. PMID- 10164220 TI - Positive advice on negative pressure for TB isolation rooms. PMID- 10164221 TI - Environment of Care standards: a guide to the clarifications. PMID- 10164222 TI - Empowerment: the right medicine for improving employee commitment and morale in the NHS? AB - States that in recent years, empowerment of National Health Service (NHS) Trust employees has been given substantial political and managerial support. Examines the extent to which the commitment and morale of staff in two NHS Trust hospitals has altered following the introduction of a raft of techniques under the empowerment label. The researchers interviewed substantial numbers of staff with managerial responsibilities, personnel specialists and conducted written surveys seeking employee opinion. Reports the findings, which confirm that, under empowerment, the work of both managers and staff has become more intensive, but managers claim that their commitment has risen, while for non-managerial employees, severe problems of commitment to the Trust, declining morale and high stress were exposed. Identifies reasons for these difficulties which were: the salience of budgetary and operational priorities; lack of training; resistance to the implementation of empowerment; and recognition that little real authority was being devolved to employees. Concludes that the limited effects attributable to empowerment could be explained by its association with harder-edged manpower policies introduced to meet financial and competitive pressures. Under favourable contextual conditions, empowerment may exert more positive effects. PMID- 10164223 TI - Training for organizational success. AB - Describes a major programme of change embarked on by Kingston Hospital NHS Trust, UK in 1992 to deliver care to its patients more effectively and efficiently. Reports on the training strategy which was required to facilitate this important organizational change and establish it as the new culture at Kingston Hospital. PMID- 10164224 TI - Local pay determination. AB - Discusses the building blocks required for National Health Trusts in the UK to move effectively towards local pay determination as part of an overall coherent reward strategy. Concludes that the current preoccupation with purely the pay part of the reward strategy, combined with the absence of many of the other required building blocks, may well result in an extremely patchwork approach to reward and will leave the National Health Service in the position where it has lost the advantages of a national system, while failing to achieve the benefits of local pay determination. PMID- 10164225 TI - Managing workforce diversity--a response to skill shortages? AB - Explores the strategy of managing workforce diversity as a possible response to skills shortages within the UK National Health Service. Stresses that, if health care organizations truly wish to harness the diversity of their workforce, ways must be found of understanding personal motivations and creating employment opportunities which, as far as it is reasonable, meet these needs and expectations. Emphasizes that failure to adopt such an approach could alienate, possibly permanently, sectors of the potential workforce. PMID- 10164226 TI - Competitive strategy for providers. AB - National Health Service (NHS) Trusts are struggling to determine a long-term strategic direction for their organizations in response to the competitive pressures generated by the NHS reforms. The development of long-term strategic direction and the methods to implement this are presenting real challenges to the Trusts which have inherited service configurations based on bureaucratic planning frameworks rather than service configurations suited to a more competitive environment. Examines the strategic choices available to these organizations; explores the importance of identifying positive strategic choices; and discusses the advantages and disadvantages in the context of the NHS internal market. PMID- 10164227 TI - Appraising the state of performance appraisal. AB - Relates performance appraisal in the National Health Service to performance management and emphasizes the need for integration of diverse management initiatives. Identifies the multiple purposes of appraisal and a number of perennial issues. Outlines rules of thumb for enabling appraisal systems and states that these form the basis for specifying success (and failure) criteria for the design of appraisal systems. Stresses the importance of the context within which appraisal exists. PMID- 10164228 TI - Price survey. Syringe prices down; needles up. PMID- 10164229 TI - Loaner fees: who'll blink first in the approaching face-off? PMID- 10164230 TI - Testing the testers: how to choose and use a reference lab. PMID- 10164232 TI - Technology diplomacy and the role of the ambassador. PMID- 10164231 TI - At Partners, materials management talks, vendors listen. PMID- 10164233 TI - Quality in health care. PMID- 10164234 TI - Legal issues of emergency psychiatric patients: the application of EMTALA and state civil commitment laws. PMID- 10164235 TI - ERISA and managed care: the law abhors a vacuum. PMID- 10164236 TI - A primer on PHO capitation contracts. PMID- 10164237 TI - Much ado about networks. PMID- 10164238 TI - The SUPPORT study: can one die a "good death" in the hospital? Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. PMID- 10164239 TI - Advances in AED (automatic external defibrillator) technology. PMID- 10164240 TI - Who should defibrillate? PMID- 10164241 TI - Early defibrillation--it's time! PMID- 10164242 TI - Legal, regulatory issues impact AED (automatic external defibrillator) deployment. PMID- 10164243 TI - Early defibrillation. Making waves across America. PMID- 10164244 TI - EMS 2000. Expanded scope of practice. PMID- 10164245 TI - 1997 almanac. JEMS 200-city survey. PMID- 10164246 TI - 1997 almanac. Information resources. PMID- 10164247 TI - Medics in the emergency room. A Michigan paramedic explains how it can work. PMID- 10164248 TI - Will paramedics survive? PMID- 10164249 TI - Care on a shoestring. Volunteer retention in emergency services. PMID- 10164250 TI - You can't fire me; I'm a volunteer! PMID- 10164251 TI - The scientific evidence for critical incident stress management. PMID- 10164252 TI - Assisted living and state policies. PMID- 10164253 TI - ACHCA standards of practice for assisted living administrators. PMID- 10164254 TI - Marketing: a matter of identity. PMID- 10164255 TI - Predictors of quality of care in nursing facilities. PMID- 10164256 TI - What is assisted living? PMID- 10164257 TI - Survey, certification and enforcement procedures for nursing facilities. PMID- 10164258 TI - The missing link: adding assisted living to your existing services. PMID- 10164259 TI - Rehabilitation services in the skilled nursing facility. PMID- 10164260 TI - The revolving door (and why it turns). PMID- 10164261 TI - The future of nursing homes: facing the contradictions. PMID- 10164262 TI - Improving the environment to enhance the bathing process. PMID- 10164263 TI - Making risk contracting work in specialty networks. AB - For the next several years, capitation of specialties will increasingly influence contracting arrangements. Specialists and their networks must position themselves to operate in this environment amid a shrinking market for their services and consolidation of delivery systems and accepting capitation can be a necessary step. The specialties that can quantify the costs of specific services within a defined range, and can manage appropriate utilization of those services within acceptable parameters through wellness, patient intervention and disease management techniques, are most likely to be successful in risk contracting. This article presents how to investigate risk contracting in specialty networks and what infrastructure is required for successful risk contracting. PMID- 10164264 TI - Converting new antitrust guidance into action. AB - The "Statements of Antitrust Enforcement Policy in Healthcare" that were passed in August 1996, represent efforts by the Department of Justice and the Federal Trade Commission to meet health care industry demands for more guidance regarding the application of the federal antitrust laws to the business activities of physicians and provider-sponsored organizations. This article translates the safety zone guidelines into practical language covering the basic requirements, economic integration and clinical integration, the messenger model used in non integrated networks, and the implications for physician group practices. PMID- 10164265 TI - The physician office laboratory: profitability under managed care. AB - CLIA has forced many physician offices to close their labs because the costs of operating them have been out-weighed by the revenues they generated. Managed care has imposed even further restrictions because managed care organizations (MCO) limit reimbursement to a very few in-house procedures. To reverse this trend, physician offices must make their labs attractive to MCOs by emphasizing quality, promoting customer satisfaction, discussing cost effectiveness and discounting laboratory fees. Once these are set, the next step is negotiating with the MCOs. PMID- 10164266 TI - Developing physician leaders in academic medical centers. AB - While physicians have historically held positions of leadership in academic medical centers, there is an increasing trend that physicians will not only guide the clinical, curriculum and scientific direction of the institution, but its business direction as well. Physicians are assuming a greater role in business decision making and are found at the negotiating table with leaders from business, insurance and other integrated health care delivery systems. Physicians who lead "strategic business units" within the academic medical center are expected to acquire and demonstrate enhanced business acumen. There is an increasing demand for formal and informal training programs for physicians in academic medical centers in order to better prepare them for their evolving roles and responsibilities. These may include the pursuit of a second degree in business or health care management; intramurally conducted courses in leadership skill development, management, business and finance; or involvement in extramurally prepared and delivered training programs specifically geared toward physicians as conducted at major universities, often in their schools of business or public health. While part one of this series, which appeared in Volume 43, No. 6 of Medical Group Management Journal addressed, "The changing role of physician leaders at academic medical centers," part 2 will examine as a case study the faculty leadership development program at the University of Texas M.D. Anderson Cancer Center. These two articles were prepared by the author from his research into, and the presentation of a thesis entitled. "The importance of leadership training and development for physicians in academic medical centers in an increasingly complex health care environment," prepared for the Credentials Committee of the American College of Healthcare Executives in partial fulfillment of the requirements for Fellowship in this College.* PMID- 10164268 TI - Point-of-service plans: does capitation make sense? PMID- 10164267 TI - When patterns are broken, new patterns emerge. A story of community collaboration for health. AB - The Bridge Community Health Clinic (BCHC) is the result of a multifaceted community effort that persevered though seven years of analysis and planning to achieve a community health center that met the entire community need. An influx of Southeast Asian emigrants who held different beliefs regarding medical care showed how the established health system was not meeting the needs of the changing population. This article describes how the Wausau community came together with the help of health care businesses and formed BCHC, promoting community health. PMID- 10164269 TI - Reinventing government for the clinical lab. AB - Learn how the power of teamwork fueled by a common goal enabled members of a California government agency to educate thousands of diverse clinical laboratory scientists--despite unanticipated dilemmas and limited resources. PMID- 10164270 TI - Automation in the laboratory--Part 2. Choosing wisely from a plentiful market. PMID- 10164271 TI - Streamline your automated hematology laboratory. Roundtable discussion. PMID- 10164272 TI - The lab manager's role in assessing new technology. AB - Without the benefit of the lab manager's experience, as well as the ability to solicit input from all necessary parties, a lab's short-term ?savings? due to new technology could amount to long-term disaster. Here are some common mistakes made by labs and how to avoid them. PMID- 10164273 TI - Surgical specialties racing to develop outcome measures. Second in a series. PMID- 10164274 TI - Policy could force hospitals to shed outpatient facilities. PMID- 10164275 TI - No new standards is the big news for 1997. PMID- 10164276 TI - Age competencies, restraints are challenges. PMID- 10164277 TI - RN with HIV heads campaign for safer devices. PMID- 10164278 TI - 85% of injuries are preventable. PMID- 10164279 TI - More work needed on injuries in anesthesia. PMID- 10164280 TI - Competition, flexibility are managed care trends. PMID- 10164281 TI - New APIC guideline on disinfection, sterilization. PMID- 10164282 TI - Payment collections: start the process before starting the treatment. PMID- 10164283 TI - Transition to capitation. Aligning incentives for success. AB - Horror stories abound about providers that have failed to modify their incentive systems and have exhausted their annual capitation budget in the first six months of the plan year. Aligning the business strategy and financial incentives in advance is the best way to ensure that your integrated delivery system's transition to capitation is a success story. Rarely are physicians or hospitals with experience limited to the fee-for-service arena prepared to jump into a managed care or capitated compensation system. The transition can be eased by implementing a "shadow" capitation or similar arrangement that will test physician performance under a risk arrangement in advance. The information can be used to restructure the compensation system to ensure that the behaviors being encouraged will promote successful care and fiscal management. PMID- 10164285 TI - Power points: related information on capitation. PMID- 10164284 TI - Capitation conundrum. AB - There are clearly many differences between fee-for-service and capitation. Making the transition to capitation poses some special problems and areas of risk that are not apparent from looking at either reimbursement method in isolation. The boundary and transition issues require special attention during the next several years as capitation is implemented in new markets. PMID- 10164286 TI - Health care reform. Gridlock and pork? AB - Can Americans expect the same gridlock and pork between now and the 21st Century? What are the possible directions that the United States can move in regarding health care reform and the long-term financing of health entitlement programs? Here, the author offers a snapshot of current politics and some predictions for the next four years. And explores the question: Are Americans willing to make the necessary sacrifices for future generations to profit by the significant changes needed by entitlement and health reform, or will it be business as usual? America's centrist perspective was recently reinforced by the 1996 election, suggesting that no major innovations in entitlement or in the health system should be anticipated in the next four years. PMID- 10164287 TI - Medical savings accounts. Power and choice. AB - As the market becomes more saturated and matures, keeping people healthy will become a bigger source of profits and true health maintenance will become increasingly important. Right now, however, the name of the game is restricting services, particularly in new markets. What is sorely needed is a balance between the individual and organizational agendas, between the individual and society. There is a tremendous opportunity for hospital-physician groups contracting directly with employers using Medical Savings Accounts (MSAs) and catastrophic insurance as a core strategy. Are MSAs a viable insurance vehicle? Some argue that those enrolled in MSAs will put off receiving needed medical care. But it can also be viewed that MSAs, by their very nature, put costs back into the negotiation phase between patients as customers and physicians and hospitals as providers--and save money and resource consumption as patients shop around for competitive prices to do what needs to be done. PMID- 10164288 TI - Where can we learn about change? AB - Presented here are some resources--books, consultants, and personal growth practices--that you might find useful in the struggle to become adept at dealing with change. Mastering change is a long process, but unlike building a cathedral or growing apples, as soon as you start you will have something that you can use- some insight, a different way of looking at what is confronting you, something to help jar you to a more creative strategy. PMID- 10164289 TI - Can you communicate cross-generationally? AB - What is fractured cross-generational communication? When what one person heard was not what the other person said. Regardless of your age, you need to understand some of the differences in communication styles that must be overcome if people are to work well together. This is especially important in health care right now when there are other pressing issues. Interpreters are at a premium because so much misunderstanding clouds the communication process. Two management strategies are presented that will help bridge the gaps between communication styles. PMID- 10164290 TI - Hospital-sponsored networks. The rush to consolidate and the future of medical practice. AB - As the medical delivery system undergoes fundamental change, there is a growing pressure on hospitals to form networks with physicians. The prime motivation for these entities is to preserve market share and fill beds. There is likewise intense pressure on physicians to join them, even if these networks do not serve their best interests, or the goal of fostering physician-centered practice. A transformation is under way, however, that may well place doctors again in the central role of guiding the new modes of medical practice in the United States. PMID- 10164291 TI - A great position before a great 'package'. AB - Should employment agreements (EAs) be the deciding factor in considering a new position? EAs are details--important details, but background just the same--to the key issue: Do you want the job? And because of the way many health care organizations create their EAs, there really is little room for negotiation. Perceptions persist that this is an entirely open area, a blank canvas upon which each physician executive, in each situation, must don his or her battle gear and fight fiercely for the best possible deal. And yet, this is an area in which you are unlikely to have control. PMID- 10164292 TI - Transition to capitation. Core competencies for physician practice success. AB - The growth of managed care--with the resulting consolidation, cost control, and profit-oriented players entering the market--is a major source of concern. Largely due to this market evolution, physicians find themselves in the position of working within a single management paradigm and attempting to apply it in two different contexts: capitated payment systems and traditional fee-for-service medicine. This article identifies, compares, and contrasts the competencies necessary for successful practice in a managed care, as opposed to a fee-for service, environment. PMID- 10164293 TI - Board job descriptions. PMID- 10164294 TI - All politics is local. Making government work for the good of your community. PMID- 10164295 TI - All fired up! Georgians find a healthy outlet in workplace wellness. PMID- 10164296 TI - Case study. Managed care + quality = value. Lovelace Health System has the proof that its equation works. PMID- 10164297 TI - Managed care: are trustees up for the challenge? (Part one). Panel discussion. PMID- 10164298 TI - Champions for healthy communities. PMID- 10164299 TI - Death rights. PMID- 10164301 TI - Judges who support the right to die. PMID- 10164300 TI - Euthanasia's home. PMID- 10164302 TI - Perspectives. Clinton cuts a threat to growth of Medicare HMOs? PMID- 10164303 TI - What nursing researchers think about librarians. PMID- 10164304 TI - An evaluation of the costs and effectiveness of different methods used to publicize a telephone healthline. PMID- 10164305 TI - Yet more evidence ... changing professional practice. PMID- 10164306 TI - The 'market' for medical and health information in transition: the case of the Hong Kong Hospital Authority libraries. AB - The last few years have been a period of transition not only for hospitals and their governance but also for post-graduate medical education in Hong Kong. Both trends have a direct impact on the information market place. This article starts by studying the provision of medical and health-related information in Hong Kong. The two university medical and dental libraries, together with the hospital and health sciences libraries in government hospitals and the Department of Health, house the major collections on medicine and health care. The demand for medical and health care information is increasingly felt with the takeover of 39 hospitals by the statutory Hong Kong Hospital Authority in 1991. The major problems and issues in planning for library information services are the historically uneven development of libraries, discrepancies in funding, the changes in organizational and management structure, and the competition with higher development priorities within the organization. In view of current technology and the availability of rich external resources, the adopted strategies tend towards the formation of 10 library service networks, development of integrated library information systems on the Health Authority-wide area network, and the devolution of management responsibilities. The future challenges in store for the information professional are examined. PMID- 10164307 TI - Selection of library services by post-registration nursing, midwifery and health visiting students. AB - This paper describes a small-scale survey undertaken with 300 nurses, midwives and health visitors on post-registration courses and registered for the ENB Higher Award. The aim was threefold: first to examine reasons for electing to use particular libraries; second, the relationship between workplace, home, teaching site and choice of library services; and third, the use of library enquiry services. There was a 56% response rate to the postal questionnaire and results indicated that the key factor in selecting a library was availability of resources rather than convenience to home or workplace. The third largest group of respondents worked in community organizations with little or no on-site access to resources and were dependent on access to other libraries. Most who used the library for literature searching needed to seek help in spite of preliminary user education sessions. Similar levels of assistance were needed to locate journals and use the computerized book catalogue. The paper recommends explicit information on strategic entry points, necessity of a broad central collection, integration of information retrieval into post-registration courses, use of self study packs, better trust/university liaison and recognition of the need for resource transfer from teaching to learning. PMID- 10164308 TI - Balancing a 3-legged stool: how to match your network to your needs. PMID- 10164309 TI - Looking back: looking ahead. PMID- 10164310 TI - Across the continuum. A nursing leadership perspective on patient care. PMID- 10164311 TI - Taxpayers Bill of Rights 2. The emergence of intermediate sanctions. PMID- 10164313 TI - Unseen dangers of expansion. PMID- 10164312 TI - More Taxpayers Bill of Rights 2. Implications for physicians and administrators. PMID- 10164314 TI - The continuum of care ... discussion. PMID- 10164315 TI - A revolutionary redesign. PMID- 10164316 TI - A synergistic relationship. PMID- 10164317 TI - Subacute care. Is it just old wine in new bottles? PMID- 10164318 TI - Thousands immunized. PMID- 10164319 TI - A holistic approach to care. Tribal organization along the continuum of care. PMID- 10164320 TI - Look into a new crystal ball. PMID- 10164321 TI - Outreach clinics. Dr Livingstone, I presume? PMID- 10164322 TI - Head injury services. Brainchild of the north. PMID- 10164323 TI - Bed management. In search of a ... block buster. PMID- 10164324 TI - Medical education. Class act? PMID- 10164325 TI - Why a dusty death registry made me proud. PMID- 10164326 TI - Are you missing out on a valuable profit center? PMID- 10164327 TI - Get health plans to play by your rules. PMID- 10164329 TI - We should let dying patients write their own final scene. PMID- 10164328 TI - Should you help patients die? PMID- 10164330 TI - Overcoming the biggest hurdle in a malpractice trial. PMID- 10164331 TI - Health-care companies stampede onto Wall Street. PMID- 10164332 TI - Health plans. In this survey, familiarity breeds content. PMID- 10164333 TI - What Washington has in store for you in 1997. PMID- 10164334 TI - How an HIV diagnosis can get you sued. PMID- 10164335 TI - Why medical-device stocks belong in your portfolio. PMID- 10164336 TI - Should doctors see patients in group sessions? PMID- 10164337 TI - Doc income data impact. PMID- 10164339 TI - Back in public hands. PMID- 10164338 TI - Teaching docs to save. PMID- 10164340 TI - U.S. Diagnostic sued. PMID- 10164341 TI - A loss of confidence. AHA report: public believes hospitals' priorities have changed. PMID- 10164342 TI - For-profits spurned. PMID- 10164343 TI - Outsourcing moves into new territory. AB - More and more healthcare executives are hiring outsiders to shoulder burdens they once carried in-house. Delegating some support services, such as laundry, is nothing new. But relentless pressure to cut costs and rapid system consolidation have executives scrambling for new solutions to business problems. These days few functions are exempt from being contracted out. PMID- 10164344 TI - Surveying best practices. Eight health plans offer lessons for other HMOs. PMID- 10164345 TI - Identity crisis. PMID- 10164346 TI - Cranking up the volume. Healthcare bond sales hit highest level in three years. PMID- 10164347 TI - Michigan hangs tough. PMID- 10164348 TI - Burned by success. ProPAC advises rate freeze as hospital Medicare profits soar. PMID- 10164349 TI - Pols PAC it in. PMID- 10164350 TI - Managed care's seamy side. PMID- 10164351 TI - 1997 Trustees of Year. AB - Modern Healthcare's 19th annual competition honors two quiet leaders who share many attributes, including modesty, diplomacy and dedication to their communities. This year's winners are J. Patrick McGillis, who helped turn around Powell County (Mont.) Memorial Hospital, and William H. Rincker, who was instrumental in creating vibrant United Health Services in Binghamton, N.Y., from a disparate cluster of hospitals. PMID- 10164352 TI - Rope 'em in. Kan. ties together payers to launch performance standards. PMID- 10164353 TI - Will docs embrace unions? PMID- 10164354 TI - For the duration. Analysis tool helps CFOs prevent assets, liabilities from getting out of whack. PMID- 10164355 TI - Tenet moves on St. Louis. Acquisition of 3 hospitals would pose new market possibilities. PMID- 10164356 TI - Setting the table. Conn. systems forming coordinated delivery networks. PMID- 10164357 TI - Medicare winners, losers. Managed care takes biggest hit in Clinton budget plan. PMID- 10164358 TI - A new tactic for Tenet. Firm plans more managed-care deals on Columbia turf. PMID- 10164359 TI - Cost-of-benefits analysis. Study shows employer healthcare spending on rise. PMID- 10164360 TI - Hospitals make peace. Six-year struggle in Wash. ends with 50-50 partnership. PMID- 10164361 TI - The baseline game. Setting the rules for Medicare, Medicaid budgeting. PMID- 10164362 TI - A monumental task. AB - President Clinton is hoping to secure a place in history by balancing the federal budget, a prospect that has many in the healthcare industry worried. With Medicare and Medicaid eating up major portions of federal spending, any move to trim the deficit will require painful cuts in provider payments. And funds for programs like children's access to healthcare are likely to be scarce. PMID- 10164363 TI - A bow to quality. St. Luke's in Kansas City, Mo., gets '97 NCQHC award. PMID- 10164364 TI - Homing in on home care. Columbia quietly builds largest hospital-based home-care firm in just two years. PMID- 10164365 TI - For sale or lease. More for-profits opt for leasing route in hospital deals. PMID- 10164366 TI - TransCare receives $40 million infusion. PMID- 10164367 TI - Learning the health reform lessons and working out what to do next. PMID- 10164368 TI - A dedicated theatre for acute surgery. PMID- 10164369 TI - Coalition brings big changes to health. PMID- 10164370 TI - Credentials and degrees--what's the difference? PMID- 10164371 TI - Nothing permanent but change. PMID- 10164372 TI - Are you ready for the Internet? PMID- 10164373 TI - The ins & outs of managing transcription. PMID- 10164374 TI - Case study. Public San Francisco General moves diverse population toward managed care and continuity. PMID- 10164375 TI - New economic rules reconfiguring the clinical laboratory industry will affect hospitals and networks. PMID- 10164376 TI - Meeting patients' needs: quality care in a changing environment. AB - Recent surveys of patients in New York and Cleveland, among other cities, indicate that there is substantial room for improvement in meeting patients' needs and preferences, particularly in the areas of emotional support, coordination of care, discharge preparation, and the involvement of family and friends. Hospitals are using a variety of techniques to improve patient care and organizational efficiency in this challenging environment. One prominent approach, reengineering, offers a means by which hospitals can integrate highly specialized departmental structures and functions by focusing on interdisciplinary teamwork and organizing the delivery of care around patients. Key elements of successful hospital reengineering efforts have included: - the involvement and commitment of senior management and other key stakeholders, particularly physicians, nurses, and union representatives; - investment in staff training and retraining, and the redesign of staff evaluation and compensation systems; - timely, unit-specific measures of patient satisfaction and the clinical quality of care; - consistent and frequent internal communication between staff and leadership; and - treatment that emphasizes communication among caregivers, patients, and their family members. Several basic issues need to be addressed if hospitals are to offer technically sophisticated medical care that is also responsive to their patients' personal needs, including: - variations among patients regarding the amount of information they want and need, and the amount of involvement they want in their care; - the means by which patients will get information about their medical care, and who will provide any additional support that may be needed by non-English-speaking or socioeconomically disadvantaged patients; and - the specific changes in medical practice and hospital processes that will promote the involvement of patients in their care. PMID- 10164377 TI - Specialist survival strategies. PMID- 10164379 TI - Controlling costs through portion control. PMID- 10164378 TI - Hospital mutual aid evacuation plan. AB - Health care facilities need to be prepared for disasters such as floods, tornadoes and earthquakes. Rochester, NY, and its surrounding communities devised a hospital mutual aid evacuation plan in the event a disaster occurs and also to comply with the Joint Commission. This document discusses the plan's development process and also provides the end result. PMID- 10164380 TI - Computers in foodservice: keeping up to speed. PMID- 10164381 TI - Alternative financing helps healthcare foodservice sector manage more with less. PMID- 10164382 TI - Irving Healthcare puts a terminal at every bedside. PMID- 10164383 TI - Clean dishes aren't enough. Warewashers must save water, money, labor too. PMID- 10164384 TI - Scratch or mix baking? Both have advantages. PMID- 10164385 TI - A special foodservice challenge: cooking for patients with eating disorders. PMID- 10164386 TI - Branding case study: Burger King holds court at VA. PMID- 10164387 TI - Improved tray delivery efficiency can reduce waste. PMID- 10164388 TI - Large and small facilities can learn from each other. PMID- 10164389 TI - A few good tools to start HACCP (Hazard Analysis Critical Control Point) program. PMID- 10164390 TI - "If they could see me now!". PMID- 10164391 TI - Working in Rome, Italy. PMID- 10164392 TI - Life in Jakarta. PMID- 10164393 TI - Arabian nights. PMID- 10164394 TI - The New Zealand experience. PMID- 10164395 TI - North American nostalgia. PMID- 10164396 TI - Cambridge: life in a university town. PMID- 10164397 TI - Experience of coding ambulatory visits to outpatient clinics. AB - Clinical data for all current outpatients at a large tertiary hospital has been collected for analysis. Patient diagnoses for selected "key" clinics have been coded to ICD-9-CM standards. Methods to reduce the volume of coding required for such data collection are discussed, and include short-lists of codes, default assignment of diagnoses codes according to the nature of visit, and producing a "discharge" summary for outpatients, similar to that routinely produced for inpatients. PMID- 10164398 TI - HIMs and the Internet. PMID- 10164399 TI - International Federation of Health Records Organizations. PMID- 10164400 TI - Adopt an MRA--an education program for clinicians. AB - The 'Adopt an MRA' program aims to facilitate communication between clinicians and Medical Record Administrators (MRAs) regarding medical record documentation, coding, DRG assignment and general casemix issues, within the realms of a 650 bed Sydney Teaching Hospital. This paper aims to provide the reader with some insight into the background, processes and outcomes of the program. PMID- 10164401 TI - Notification procedures for states implementing "alternative mechanisms" in the individual health insurance market--HCFA. Notice. AB - This notice generally describes the statutory provisions under section 111 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that guarantee availability of individual health insurance coverage to certain individuals with prior group coverage. It also provides procedural guidance for States that intend to implement an alternative mechanism under section 111 of HIPAA. Finally, this notice describes the statutory provisions that will apply in a State that does not implement an acceptable alternative mechanism. This notice does not establish new policy or requirements. PMID- 10164402 TI - Intranet helps new system tell the rules. PMID- 10164403 TI - Putting his support on the line. Interview by Fred Bazzoli. PMID- 10164404 TI - Provider automation. Knowing when it's time for a sequel. PMID- 10164405 TI - Claims in cyberspace. PMID- 10164406 TI - Software, Internet create new avenues for patient education. PMID- 10164407 TI - Health tech Internet guide. PMID- 10164408 TI - Finding clinical data in claims: the search for gold. PMID- 10164409 TI - Home care providers turn to automation to improve efficiency. PMID- 10164410 TI - Exploring the Internet frontier. AB - M-Bone, multimedia e-mail and teleconferencing are drawing providers to the Internet as a telemedicine network alternative. But security and reliability issues remain unresolved. PMID- 10164411 TI - Managed care. Payers begin the migration to a new architecture. PMID- 10164412 TI - Reassessing health care integrations. "Five stages" of market consolidation, clinical rationalization, and cost competitiveness. PMID- 10164413 TI - Seven essential strategies for integration. PMID- 10164414 TI - Determinants of institutionalization in old age. PMID- 10164415 TI - The impact of the community long-term care insurance law on services for the elderly in Israel. PMID- 10164416 TI - The effect of public provision of home care on living and care arrangements: evidence from the channeling experiment. PMID- 10164417 TI - Social protection for dependence in old age: the case of Germany. PMID- 10164418 TI - Determining the long-term care needs of individuals living in private households: results from a survey. PMID- 10164419 TI - The long-term costs of public long-term care insurance in Germany. Some guesstimates. PMID- 10164420 TI - Long-term care insurance and trust saving in a two-generation model. PMID- 10164421 TI - Long-term care--an inter- and intragenerational decision model. PMID- 10164422 TI - The assessment and the regulation of quality in long-term care. PMID- 10164423 TI - Effects of strategic behavior and public subsidies on families' savings and long term care decisions. PMID- 10164424 TI - Women's role in the provision of long-term care, financial incentives, and the future financing of long-term care. PMID- 10164425 TI - Integrated delivery systems. Virtual organizations emerge in many different forms. PMID- 10164426 TI - Translating common sense, country doctor techniques into a management services business for the 90s. PMID- 10164427 TI - Multispecialty groups, post-managed care style. PMID- 10164428 TI - Conflicting models put specialists and primary care physicians at odds. PMID- 10164429 TI - Physician recruitment is on the upswing. PMID- 10164430 TI - New physicians lack managed care savvy. PMID- 10164431 TI - Capitation negotiating tips: the more you question, the better off you'll be. PMID- 10164432 TI - Gaining physician support for managed care. PMID- 10164433 TI - The uninformed elderly. A challenge for home care. AB - Older Americans, who often live in isolation, encounter barriers to accessing health care and frequently lack basic knowledge about disease prevention. With a growing elderly population, providers will need to focus on prevention education and health promotion strategies. PMID- 10164434 TI - Delivering mental health services in the inner city. AB - Inner-city clients pose challenges for home care providers in terms of access. When they are at risk for mental health problems, that adds another layer to the difficulty of access. One program in the South Bronx uses unique structure and staff to gain family acceptance for intervention. PMID- 10164435 TI - The five A's of rural home care. AB - Providing rural home care demands a knowledge of and sensitivity to rural culture. An understanding of the five A's of rural home care--affordability, availability, accessibility, acceptability, and administratability--will help providers to orient their staff to the intricacies of rural home care delivery. PMID- 10164436 TI - The challenges of hard-to-reach patients. PMID- 10164437 TI - Rural home care: social work intervention in social isolation and safety concerns. PMID- 10164438 TI - National Association for Home Care. 1996 Award winners. AB - CARING is pleased to begin the new year with profiles of the annual home care award winners. Each year at its annual meeting, the National Association for Home Care (NAHC) announces winners from among the many deserving individuals nominated by their peers, supervisors, and patients. These winners exemplify the dedication, professionalism, and caring attitude that define this industry. PMID- 10164439 TI - Outcomes for home and community nursing in integrated delivery systems. AB - In these tumultuous times in health care, nursing providers are under pressure to capture data that demonstrate the effectiveness of nursing interventions on client health. At the University of Iowa, researchers are attempting to develop a client outcome classification system that uses a standardized language across different health care settings to capture this vital information. PMID- 10164440 TI - Loose lips? Chicago transplant unit garners unwanted scrutiny. PMID- 10164441 TI - Accreditation watch status an evolving process. PMID- 10164442 TI - Medical records privacy: buzzword for 1997. PMID- 10164443 TI - In-hospital subacute reimbursements under fire. PMID- 10164444 TI - Don't let paths slow down your ideal charting system. PMID- 10164445 TI - An empirical study of the influence of demographic variable on the choice criteria for assisted living facilities. AB - Despite the growth and prevalence of assisted-living facilities, empirical marketing research for these facilities is scarce. The objectives of this study were to determine the relative importance of three sets of evaluation criteria in the initial selection of an assisted-living facility, and determine whether the relative importance of these three sets of criteria differed by gender, marital status, level of household, age, or income of the consumer. Survey responses from 279 households indicates that primary service criteria are relatively more important than facilities amenities or organized social activities in the initial selection of an assisted-living facility. The relative importance of the choice criteria differed markedly by gender of the consumer, but marital status, level of household income, and age of the consumer did not have as great an impact on consumers' choice criteria. PMID- 10164446 TI - Analysis of the physiotherapy industry: challenges for marketing. AB - The physiotherapy industry can be analysed using Porter's (1979) five forces. Physiotherapy uses medical, geographic and funding segmentation. The power of the buyers in these segments is considerable. Substitutes are posing a threat to physiotherapy with few barriers to entry to operate in the health care environment. The suppliers, particularly doctors, have significant power in referring clients. Competitive rivalry for these clients can exist between individual physiotherapists and multi-disciplinary clinics. The difference in orientation of private and public physiotherapy can also be a basis for rivalry. Repositioning to view the client as both the supplier and recipients enables the physiotherapy industry to gain competitive advantage and ensures long term growth. PMID- 10164447 TI - An experiment in designing effective warning labels. AB - This paper proposes a model for the design of effective warning labels concerning drinking and driving. One important aspect of the model is that producing a multiplicity of warning labels should result in a higher probability that at least a few of the warning labels will be of high quality and effectiveness. Secondly, greater similarity between the warning label designer and the intended target group should enhance the effectiveness of the warning label. In the present study, 49 warning labels were created by university undergraduates, and the effectiveness of these warning labels was assessed by a group of university students (target group members). A number of labels were judged as being effective, and more effective than the government warning label. Extending the notion of being close to the target group, warning labels designed by male and female university students for university students of the same sex were judged as more effective than warning labels designed for the opposite sex. PMID- 10164448 TI - Implementation of ISO 9000 in the healthcare sector: a case study. AB - In order to compete at the international level, companies are beginning to recognize ISO 9000 registration as a virtual necessity. As a result, the number of ISO certifications issued in the U.S. and Canada tripled between 1992 and 1994. By means of a case study, this paper describes how a large healthcare manufacturing organization recently achieved its ISO 9001 certification. Specifically, the strategies and the process used by the organization in obtaining the registration is explained. PMID- 10164449 TI - Patient satisfaction: the new area of focus for the physician's office. AB - Using an importance-performance approach, current and ex-patients of a physician were contrasted in terms of their assessments of their expectations and perceptions toward various medical practice attributes or characteristics. Results suggest that differences across attributes exist, expectations and perceptions of most of the key dimensions are distinguishing characteristics between the two patient groups. The variations are with the performance of the physician and his staff and not with the importance of the attributes or characteristics. These results provide some insights and interesting debate concerning the potentially changing nature of the private practice physician. PMID- 10164450 TI - Health marketing in the supermarket: using prompting, product sampling, and price reduction to increase customer purchases of lower-fat items. AB - Reducing purchase and consumption of higher-fat foods is an important health objective for the nation since these behaviors are associated with cardiovascular disease and some cancers. Public health agents attempt to promote health-related behaviors, such as purchases of lower-fat foods, by changing key features of relevant environments. This study examined the effects of a marketing intervention in a supermarket on customer purchases of lower-fat products. Customers of one store of a major supermarket chain participated in this study. Direct observations of customer purchases of lower-fat milk, salad dressings, and frozen desserts were conducted. The supermarket intervention consisted of prompting, product sampling, and price reduction (store coupons). Using an interrupted time series design with switching replications, we found low to moderate increases for the lower-fat counterparts of milk, frozen desserts, and salad dressing. The greatest increase in purchases was found with frozen desserts. Findings from this study suggest that prompting, product sampling, and price reduction can increase customer purchases of some lower-fat products. Implications of these findings for the development and evaluation of health marketing interventions are discussed. PMID- 10164451 TI - Caring as a (not so) new technology of curing. PMID- 10164452 TI - Allocating resources: community involvement is not easy. AB - Resources for health care are limited in all societies; decisions have to be made about who gets what health care. A case study is discussed. Jaymee Bowen was a British child whose Health Authority refused to provide free treatment for her advanced leukaemia. The media advertised her case and public opinion was mobilized in favour of treating her with public funds. Cost-effectiveness can be used to identify treatments that provide value-for-money. The public can express an opinion on what kinds of care are wanted--for example, what are the relative benefits of preventing morbidity or mortality, or of helping children rather than young people? Rational criteria can be developed with public involvement--in the case of Jaymee Bowen, the proposed treatment really did not appear to offer value for money. But some individual cases that contradict the 'rational' criteria for the population as a whole will always be able to attract public sympathy and interest. PMID- 10164453 TI - Application of 'futures' in the community-level health promotion with special reference to Latin America. AB - Health promotion strategies are built upon the notion of creating healthy communities who are participating in taking a greater control over their own destinies. Social participation has a long tradition in Latin America and current movements to strengthen this are represented in the municipios saludables. Innovative frameworks for community involvement draw on the work developed in the 'futures' field, harnessing collaboration between communities and policy makers in order to formulate visions of health which empower communities. This article explores the methodologies used by futurists and their potential and application in the Latin American context, and in particular, it illustrates the work by the Pan American Health Organization aimed at improving the health condition of the various communities in the region. PMID- 10164454 TI - Building capacity through collaborative leadership. AB - This paper is based upon material from the manuals and training program underpinnings the 'Sustaining community-based initiative' from the Healthcare Forum with the W.K. Kellogg Foundation in the USA. In order to address the problems of American urban communities a new approach is proposed using the concept of 'collaborative empowerment'. This is a planning and organizational method that lets community- and neighbourhood-based organizations design, implement and assess problem-solving strategies that increase their effectiveness at dealing with community issues. The use of organizational management principles and practices in community involvement and strengthening community leadership is illustrated through practical examples. PMID- 10164455 TI - Measuring participation: its use as a managerial tool for district health planners based on a case study in Tanzania. AB - While community participation has become widely practised there has been little systematic assessment of the processes involved. A framework has been developed to measure participation on a number of dimensions and this article applies this framework to a project in Tanzania. The framework helps to systematically assess the nature and extent of community participation, but a number of problems were identified as well. Suggestions are made as how to improve upon the framework and make it a useful tool for managers. PMID- 10164456 TI - How to be glad you merged. PMID- 10164457 TI - Something extra I do when a patient dies. PMID- 10164458 TI - Model programs for defusing physician stress. PMID- 10164459 TI - What's holding back capitation? PMID- 10164460 TI - Here come patients who've "studied" medicine on-line. PMID- 10164461 TI - Practice acquisitions. Holding less appeal for hospitals? PMID- 10164462 TI - Integrated health systems. Seen one? You haven't seen 'em all. PMID- 10164464 TI - The downcast drunk reeking of stale vodka? It was me. PMID- 10164463 TI - Managed care. How fast can things change? Just look at Philadelphia. PMID- 10164465 TI - Building the electronic health sciences library for the twenty-first century: the Galter Library experience. AB - Constructing home pages for World-Wide Web access has become a major activity in academic health sciences libraries. At the Northwestern University, Galter Health Sciences Library staff are creating the library's new health information system using Web resources and integrating them with existing library systems-NUmed (OVID MEDLINE) and LUIS/NUcat (NOTIS). Development of Web pages, including selection and organization of electronic information, has become the building process for the electronic library. Selection, organization, design, and construction are important factors in the creation of an efficient and useful information system. Using resources like the World-Wide Web and tools like Netscape, library staff are designing an interface, defining policies and guidelines, and creating the tools that will give users easy access to local and international electronic, scholarly information resources. In this paper, the process used at Northwestern is shown as a model of an electronic health sciences library for the twenty-first century. PMID- 10164466 TI - Health resources on the Internet: a basic list. AB - With the plethora of health sites on the Internet, it is sometimes hard to know where to start. This is a basic list of health sites that either cover a subject area comprehensively, or are good general sites to lead to more specific information. Most of these sites include both full-text information as well as links to many other sites on the World-Wide Web. Included are medical, nursing, dental, alternative health, consumer health, organization, and government sites. PMID- 10164467 TI - The literature of women and the acquired immunodeficiency syndrome (AIDS): implications for collection development and information retrieval. AB - The purpose of the study was to identify the pattern of publication about women and AIDS in scientific journals. Bradford zones were identified in each of six databases. The study determined that journal scatter for this subset of AIDS literature differed from the scatter in the general literature; further, the information indexed in the six electronic sources demonstrated little overlap. Consequently, key journal and newsletter titles identified by this study should form the core of any collection focusing on women and AIDS. The assurance of quality patient care management demands that librarians consult multiple resources for information retrieval that can assist health care providers, patients, and caregivers to enhance quality of life as well as to provide optimum care. PMID- 10164468 TI - One-stop shopping: the Hazardous Substances Data Bank. PMID- 10164469 TI - Identifying and documenting objects and services on the Internet: the Uniform Resource Locator. PMID- 10164470 TI - Evidence-based medicine: an opportunity for health sciences librarians. PMID- 10164471 TI - Librarians as players in improvisational theater: our roles in the changing clinical environment. PMID- 10164472 TI - Computers and medical information: an elective for fourth-year medical students. AB - The Computers and Medical Information elective is a collaborative effort to expose students to a variety of computer applications for medical information management. The course has a modular format so that students can work with a variety of people who are enthusiastic users of computer-based information systems. The elective emphasizes learning by doing. Faculty introduce concepts and systems and serve as guides in the use of systems. Students have rated the course positively and, after four years as an elective, some of the course's content has been integrated into the required curriculum. PMID- 10164473 TI - 1994 summary: National Hospital Discharge Survey. AB - OBJECTIVES: This report presents national estimates of the use of non-Federal short-stay hospitals in the United States during 1994. Numbers and rates of discharges, diagnoses, and procedures are shown by age and sex. Discharges are also shown by geographic region of hospital. Average lengths of stay are presented for discharges and selected diagnostic categories. METHODS: The estimates are based on medical abstract data collected through the National Hospital Discharge Survey for 1994. The survey has been conducted annually by the National Center for Health Statistics since 1965. Diagnoses and procedures presented are coded according to the International Classification of Diseases, 9th Revision, Clinical Modification, or ICD-9-CM. PMID- 10164474 TI - Perspectives. Medicare HMO advocates fend off critics left and right. PMID- 10164475 TI - Perspectives. Opposing lobbies gird for battle over PSOs. PMID- 10164476 TI - Interview: BCBSA Chief Pat Hays talks markets and Medicare. PMID- 10164477 TI - Perspectives. Conquering the last frontier: computerizing patient records. PMID- 10164478 TI - Special report. From here to 2002: a roadmap to Clinton's $100 billion Medicare cuts. PMID- 10164479 TI - Future demands on the healthcare FM (functional management) team. PMID- 10164480 TI - Productive use of IT in support of FM (functional management) solutions. PMID- 10164481 TI - Quality improvement through review of inpatient deaths. AB - Emphasis on hospital mortality as a monitoring tool has raised concerns about the validity of mortality rates as a measure of quality of care. An indepth review of all mortalities at Beth Israel Medical Center was conducted from 1988 through 1993. Clinical issues identified from chart review were referred for departmental physician peer review, and quarterly reports of trends and issues were disseminated to all levels of the institution. Mortality rates declined 21% over the 6 years, from 3.3% to 2.6% of all discharges. Clinical quality issues were identified in less than 3% of all mortalities. The majority of problems were related to delays and appropriateness of treatment (57% of quality issues). The review program identified specific hospital processes for improvement, and, more importantly, created a "watchful concern" about quality-of-care issues throughout the hospital. PMID- 10164482 TI - Reducing EKG use with the support of physicians and patients. AB - In an era of increasing emphasis on cost-effectiveness and efficient utilization of resources, physicians and patients can expect to face changes in clinical practices. Smooth transition from inefficient and expensive practices of the past to more cost-effective, newer practices would require strategies to identify and address the concerns of both physicians and patients. The involvement of patients will be important to maintaining patient satisfaction and patient empowerment. This article describes an example of effective solicitation of cooperation from physicians and patients for cost containment and reduction of inappropriate use of electrocardiograms. PMID- 10164483 TI - Courier robot keeps hospital staff 'on the job'. AB - A courier robot at Abington Memorial Hospital has allowed the hospital to maintain high standards of patient care in the face of budget constraints. The robot handles after-hours deliveries of meals and supplies efficiently and cost effectively, thus freeing support staff to focus on other tasks. PMID- 10164484 TI - Using graphs to consolidate reports to the board. AB - Reports to the author's hospital's board of directors on quality, risk management, infection control, and safety issues were complex and lengthy. Board members found the reports uninteresting and difficult to understand. To improve the reports, several ongoing measurements were identified from key areas, teams, and functions, and were reported graphically. These measurements now are reported on a quarterly basis; they include results from the current time period and the previous time period, as well as benchmarking goals. The revised presentation of material has been well received by the hospital's board, medical executive committee, and administrative staff. PMID- 10164485 TI - Shaping healthcare: developing a program evaluation questionnaire. AB - Healthcare delivery today emphasizes quality improvement in program management. The focus on consumer needs and satisfaction challenges us to develop effective tools to evaluate our services from the user's perspective. This article delineates the development, implementation, analysis, and outcomes of a program evaluation questionnaire that was designed to evaluate program staff and treatment services from the perspectives of both patients and families. The potential this type of consumer opinion gauge and tool has to shape healthcare delivery is outlined within the context of a rehabilitation program. PMID- 10164487 TI - Data watch. Companies shake up benefit offerings. PMID- 10164486 TI - Measuring nonmedical psychiatric treatment interventions with statistical software. AB - This article addresses, from both research and political perspectives, the issue of quantifying data on nonmedical psychiatric treatment activity in large residential treatment settings. It presents a method of collecting this type of data that includes the use of readily available statistical software. It describes the methodology in detail and examines the variables. The system has had an impact on treatment, administration, and personnel at the facility. PMID- 10164488 TI - Why health costs got smaller in 1994. PMID- 10164489 TI - Health care reform in the states. Tennessee--shock treatment for a sick system. PMID- 10164490 TI - HEDIS: almost ready for prime time. PMID- 10164491 TI - Could this approach cut retiree costs? PMID- 10164492 TI - Data watch. Cardiac rehab for women: a solid investment. PMID- 10164493 TI - Data watch. Health-care reforms won't shrink the workforce. PMID- 10164494 TI - Repetitive stress injuries: relieving pain at the bottom line. PMID- 10164495 TI - Is knowledge really power for patients? PMID- 10164497 TI - Health care reform in the states. Oregon--philosophy collides with finance. PMID- 10164496 TI - Experimental treatment: can you do the right thing without going broke? PMID- 10164498 TI - Voodoo regulation. PMID- 10164499 TI - Joining forces to eliminate errors. PMID- 10164500 TI - Medicare's bloat is an opportunity for business. PMID- 10164501 TI - Managed care stock index. Buy low, sell high. PMID- 10164502 TI - From management of disease to disease state management. PMID- 10164503 TI - Hormone replacement therapy: a review of the risk versus benefit--Part II. AB - As the large ?baby-boom? cohort of women enters the period of menopause, much attention is being focused on the potential public health benefits of hormone replacement therapy (HRT) and its relative safety. Increasingly, economic models derived from these studies define populations of women most likely to benefit from this treatment. This paper will review the clinical efficacy and safety of HRT and examine published pharmacoeconomic studies evaluating the use of HRT for post-menopausal women. Ultimately, the cost effectiveness of HRT is dependent on the extent of the cardioprotective effect of estrogen and estrogen-progestin combination therapy. Part II of this article describes the pharmacologic evidence that serves as a basis for evaluating HRT. PMID- 10164504 TI - A breakdown of the changes in HMO premiums. PMID- 10164505 TI - A conversation with David Pockell. PMID- 10164506 TI - A conversation with Alan Hoops. PMID- 10164507 TI - A managed care timeline, 1988-1996. PMID- 10164508 TI - Formularies in long-term care. PMID- 10164509 TI - Use of a geriatric formulary in long-term care. AB - The use of drug formularies in nursing facilities (NFs) is a fairly new idea. A large long-term care pharmacy provider prepared a formulary specific to a geriatric population. This open formulary is contained within a handbook of clinical monographs, complete with dosing information, cost comparisons, and references to NF regulations affecting the use of particular drugs. PMID- 10164510 TI - Replacement parts. PMID- 10164512 TI - Information networks. A CHIN primer. PMID- 10164511 TI - Fallon Healthcare takes integrated delivery model into the future. AB - Fallon Healthcare System now shares voice and data among 50 different sites. Its crowning glory will be a new ?medical mall? called Medical City. PMID- 10164513 TI - Turnover rate high for many healthcare CIOs. PMID- 10164514 TI - Hotlist. Clinical decision tools. PMID- 10164515 TI - The captive medical malpractice insurance company alternative. PMID- 10164516 TI - Equicare: a model for quality health care and consumer choice in state health system reform. PMID- 10164517 TI - Rights of the terminally ill patient. PMID- 10164518 TI - National repositories of information: a comparison of the National Practitioner Data Bank in the United States and the National Confidential Enquiry into Perioperative Deaths in the United Kingdom. PMID- 10164519 TI - Causation issues in medical malpractice: a United Kingdom perspective. PMID- 10164520 TI - The embryonic self-evaluative privilege: a primer for health care lawyers. PMID- 10164521 TI - Investigational treatments: coverage, controversy, and consensus. PMID- 10164522 TI - Legal and political issues facing telemedicine. PMID- 10164523 TI - Three-day Window Project. Law targeted at Civil War vendors used against more than 4,600 hospitals. PMID- 10164524 TI - Ruling shows tax complexities in hospital sale transaction. PMID- 10164525 TI - Three-Day Window Project: road to compliance paved with four options. PMID- 10164526 TI - Georgia Medicare FI (Fiscal Intermediary): 'our responsibility to HCFA has changed'. PMID- 10164527 TI - Balanced budget v. Medicare? PMID- 10164528 TI - The growth of capitation continues. PMID- 10164529 TI - The most satisfying HMO--what it's doing right. Capital District Physician's Health Plan, Albany, N.Y. PMID- 10164530 TI - Getting ACE inhibitors into the right hands. PMID- 10164531 TI - Lessons America should learn from a land of 'free' health care. PMID- 10164533 TI - The age of mergers is here: decide now how to decide. PMID- 10164532 TI - Should insurance pay for preventive services suggested by genetics? AB - Physicians, plans and patients are discovering that the promise of genetic testing will be hard to fulfill. Even when a test can show predisposition toward a disease, performing it can't necessarily improve medical outcomes. Unfortunately, doing these tests can have some unintended negative effects. PMID- 10164534 TI - How much should doctors, patients and plans care about each other? PMID- 10164535 TI - Managed care makes room for the elderly and the poor. PMID- 10164536 TI - Point/counterpoint: the proposed Grand Rapids merger. AB - When the federal circuit court decided not to grant an injunction to prevent a merger of one city's two major hospitals, the FTC filed an appeal--and a complaint with an administrative law judge. FTC lawyers say this action is within the realm of their responsibility; one hospital's CEO says that FTC complaint has a taint of vengefulness. PMID- 10164537 TI - Case study. Centura Health--two faiths in alliance. AB - Threatened with increased for-profit competition, two Colorado hospital systems- one Catholic and the other Adventist--decided to joint forces. Leaders of that alliance--Centura Health--believe it has the edge over its competition because of its not-for-profit status and its geographic coverage, the best in the state. Will Centura succeed? Experts say the jury is still out, but prospects look good. PMID- 10164538 TI - Healthcare practices vary widely from town to town: regional Dartmouth Atlas. AB - Healthcare practices in neighboring towns vary as much as 33-fold, according to the Dartmouth Atlas of Health Care analysis of claims and census data. Still unknown is the effect that this variation has on outcomes. The new regional version of the atlas makes it possible to compare care at the local community level and decide what to do about it. PMID- 10164539 TI - Changing antitrust prospects for hospital mergers. AB - The courts recently decided in favor of plans in three cities to merge hospitals, despite government arguments that such mergers would be anticompetitive. Is this a harbinger of a change in prospects for merger? Lawyers and consultants say that final court disposition of current appeals could determine future government action to enforce the antitrust laws. In the meantime, they offer seven tips for optimizing chances of winning approval of a merger. PMID- 10164540 TI - Charting reengineering potential: a PFCA benchmark study. A first look at outcome measures across reengineering hospitals. PMID- 10164541 TI - 1996 salary survey results. Computer proficiency, community involvement key to job success. PMID- 10164542 TI - VBAC (vaginal birth after cesareans): are cost concerns outweighing possible safety risks? PMID- 10164543 TI - Case managers develop 'indicators of success'. PMID- 10164544 TI - Lacking community-based case management? PMID- 10164545 TI - Use interdisciplinary approach for coronary pathway. PMID- 10164546 TI - SNFs challenge HCFA's latest exemption policy. PMID- 10164547 TI - ProPAC recommends limiting Medicare payments for SNF services. PMID- 10164548 TI - Three answers to major threats independent subacute providers face. PMID- 10164549 TI - Now & then. PMID- 10164550 TI - TWA flight 800. PMID- 10164551 TI - Reflections of an EMS warrior. PMID- 10164552 TI - Touch and go. Technology shouldn't override compassion. PMID- 10164553 TI - Exit the stone age: make basic knowledge the cornerstone of your infection control program. PMID- 10164554 TI - Innovation marks Mass. General's renovation. PMID- 10164555 TI - Viewpoint interview--Ron Paul. PMID- 10164556 TI - Protecting patients and professionals from blood-borne disease. PMID- 10164557 TI - Are you ready? Cap changes could threaten your next accreditation. PMID- 10164558 TI - New medical ID number one step closer to reality. PMID- 10164559 TI - To design or not to design? PMID- 10164560 TI - Quality efforts can be derailed by superbugs. PMID- 10164561 TI - Prepare for age wave: assess elderly now. PMID- 10164562 TI - Automated discharge summary enhances communication. PMID- 10164563 TI - Simple changes reduce discharge waiting time. PMID- 10164564 TI - Purchasing. The wasted millions. AB - In the wake of the Child B rationing controversy, the Anti-Rationing Group challenged purchasers to allow them to scrutinise their practice. Eight health authorities accepted and, say Colin Roberts and colleagues, the results show public money being needlessly wasted on a staggering scale. PMID- 10164565 TI - Emergency admissions. Ours to reason why. AB - Is GP fundholding a factor in the steep rise in emergency admissions? Guy Boersma's research suggests that managers should investigate why fundholders have been able to contain the pressure for growth in emergency admissions far more successfully than non-fundholders. PMID- 10164566 TI - Community nursing. Weight-lifters. AB - As hospital stays get shorter, the pressure on community nursing teams is becoming greater. Gill Frame and Paula O'Donnell describe how one trust devised a scoring system for patient dependency to ensure a fair workload within and between teams. PMID- 10164567 TI - Primary care night services. Getting it together. AB - Jointly funding salaried night doctor posts allowed a GP co-operative to cover unpopular shifts and a trust to deal with increasing demand for primary care. Melvyn Jones explains. PMID- 10164568 TI - Data briefing. AIDS research. PMID- 10164569 TI - Medical education. Speak to me before it's too late. AB - Doctors' failure to communicate with patients is at the root of many complaints. But an increasing number of medical schools are now teaching their students how to talk to patients. Wendy Moore reports. PMID- 10164570 TI - Children's services. The youth of today. AB - Few authorities have joint commissioning of mental health services for children and adolescents. But the introduction of children's services plans in April offers an important opportunity, argues Bob Hudson. PMID- 10164571 TI - The day hospital model of care for patients with medical and rehabilitative needs. PMID- 10164572 TI - Enlisting a patient's adult children as allies. PMID- 10164573 TI - Has the demand for primary-care physicians peaked? PMID- 10164575 TI - Drug formularies. Is their growth among HMOs leveling off? PMID- 10164574 TI - Are organs easier to come by these days? PMID- 10164576 TI - Why treatment varies so greatly. PMID- 10164577 TI - Here, nurses take the calls that doctors hate. PMID- 10164578 TI - Clinton budget aims to extend coverage for kids. PMID- 10164580 TI - The art of the flip-flop. PMID- 10164579 TI - A gift from St. Luke's. PMID- 10164581 TI - Systems. Does integration really cut costs? PMID- 10164582 TI - The debate continues. National Institutes of Health panel won't back mammograms for women over 40. PMID- 10164583 TI - Flow of IPOs ebbs. PMID- 10164584 TI - Information systems. Back to basics. Survey: execs refocusing on technology nuts and bolts. PMID- 10164585 TI - Experience isn't everything. Tax status, size of managed-care organization have more impact on info execs' pay. PMID- 10164586 TI - Information systems. Buying, investing right. PMID- 10164587 TI - Keeping immigrants healthy. Providers, insurers, churches, schools prop up safety net. PMID- 10164588 TI - Team spirit. Projects aim to get docs and others to work together. PMID- 10164589 TI - The public eye. Published outcomes reports effect change at Pa. hospitals. PMID- 10164590 TI - NCQA sets new standards. Reviews mixed for managed behavior healthcare rules. PMID- 10164591 TI - System's buyer thinking big. Forstmann Little accelerating Community Health's growth. PMID- 10164592 TI - The hidden debate. Providers fear impact of regulations on assisted suicide. PMID- 10164593 TI - And they're off. Interest in first Medicare-only PSO exceeds expectations. PMID- 10164594 TI - Not together yet. Allina, seen as system model, struggles to integrate. PMID- 10164595 TI - After the fall. N.Y. hospitals adjusting to era of rate deregulation. PMID- 10164596 TI - Under new authority. KU Hospital joins movement toward independence. PMID- 10164597 TI - Two solid foundations. Denver's community endowments may explore alliance. PMID- 10164598 TI - The state of hospitals. AHA releases statistics detailing the health of the U.S. hospital industry for 1995. PMID- 10164600 TI - Just say no. Calif. providers aren't dispensing medicinal marijuana. PMID- 10164599 TI - JCAHO launching academy for surveyors. PMID- 10164601 TI - Ad budget drop. Hospital marketing budgets up, ad budgets down. PMID- 10164602 TI - Solo practitioner. The American Medical Association often goes it alone in Washington, which leaves other lobbyists unhappy. PMID- 10164603 TI - Tightening the budget. As nurses have found, some programs inevitably get squeezed. PMID- 10164604 TI - Retooling healthcare. 'Focused factory' model can help build a patient-friendly, service-driven system. PMID- 10164605 TI - Information systems. T-minus 34 months and counting. The year 2000 has ominous implications for computer systems. AB - The countdown has started to the year 2000, which has ominous implications for computer systems. Healthcare executives are discovering that changes in their industry further complicate solving the "century date" problem. Meanwhile, a survey of healthcare executives shows they are refocusing on the nuts and bolts of information technology and reining in their ambition to have it all at once. PMID- 10164606 TI - Promoting treatment of an 'overdiagnosed' problem, Presbyterian Healthcare walks a fine line. PMID- 10164607 TI - Hoping to influence patient satisfaction levels, Integris goes for laughs. The funniest hospital in Oklahoma. PMID- 10164608 TI - Location, location, location. Seeking visibility and credibility, a cancer center publicizes its local success stories. PMID- 10164609 TI - Summa enters the new, competitive age with line drawings, high ambitions and just about every medium available. PMID- 10164610 TI - Plastering its gold seal everywhere, Bridgeport shows off its commendation. "A third-party endorsement of our quality". PMID- 10164611 TI - Internal communications. Growing and merging at a mind-boggling rate, Anthem tries to lay down the graphics law. PMID- 10164613 TI - How to support your CEO. In a stress-filled world, the board can be the CEO's worst nightmare or a dream come true. PMID- 10164612 TI - Indiana Med Center junks its "Big Red Book" for a tiny, four color disk. The end of a medium? PMID- 10164614 TI - The big picture. Sizing up your future? Ask community members what they want and need. Ignore them at your peril. AB - A health care provider can only do so much to improve the health ot its community. With limited resources, the one thing you don't want to do is spin your wheels doing the wrong things. By conducting an expanded health assessment of your service population, you'll have the information you need to focus on the right problems with the right partners. PMID- 10164615 TI - Managed care: are trustees up for the challenge? (Part two). Panel discussion. PMID- 10164616 TI - Case studies. A question of ethics. Can three different faith-based hospitals collaborate on a "futile care" policy? PMID- 10164617 TI - Simple elegance. Making the right connections for systems governance. AB - Before you can really think in terms of a system rather than individual hospitals, you need to understand how to operate as a single team without individual agendas or interests. The next step is to create a streamlined board structure--the simpler the better. See how Crozer-Keystone Health System developed a board triumvirate and how it avoids the common problems of ?governance gridlock.? PMID- 10164618 TI - Money & markets. An experiment worth trying. PMID- 10164619 TI - Perspectives. Medicaid managed care still evolving; costs could grow. PMID- 10164620 TI - Perspectives. Hodgepodge of Medicare cost-sharing staggers beneficiaries. PMID- 10164621 TI - Enterprise computing: the access manager's role. PMID- 10164622 TI - Closing the loop with your referring physicians. PMID- 10164623 TI - Outsourcing access management: friend or foe? PMID- 10164624 TI - Pre-admission testing in the access department comes of age. PMID- 10164625 TI - Principles of service. Can a value-based system survive in a healthcare atmosphere? PMID- 10164626 TI - Changing trends in outsourcing healthcare information technology. PMID- 10164627 TI - Advanced directives: the JCAHO and you. PMID- 10164628 TI - Process analysis and re-engineering: a survival tool. PMID- 10164629 TI - Living dangerously. PMID- 10164630 TI - Hot software for the fire protection community. PMID- 10164631 TI - Expected value technique useful in HMO negotiations. PMID- 10164632 TI - Setting standards for health care: the National Committee for Quality Assurance. PMID- 10164633 TI - With liberty and justice for all. PMID- 10164634 TI - Fellows respond to capitation issues. PMID- 10164635 TI - Medical savings accounts. PMID- 10164636 TI - Germ warfare! Infection control rules, regulations and guidelines. PMID- 10164637 TI - Safety sabotage. Why workers don't follow infection control precautions. PMID- 10164638 TI - Teaming up. JCAHO and OSHA join forces to promote safety. PMID- 10164639 TI - Microbe police. Who's watching disinfection and sterilization? PMID- 10164640 TI - What's up in pricing? PMID- 10164641 TI - Liaisons prove that everyone's responsible for infection control. PMID- 10164642 TI - Stock tips take shape. EHCR's (Efficient Health Care Consumer Response) first findings. PMID- 10164643 TI - The power and potential of capitation. AB - Capitation creates a financial incentive to deliver care in the most appropriate setting. All major stakeholders in the health care industry (plan members, employers, practitioners, delivery systems, community organizations, and the government) share a common interest in managing risk sooner and better. Capitation can be a catalyst that encourages and reinforces this commonalty of purpose. PMID- 10164644 TI - Continuous quality improvement at the crossroads: contradictions and challenges. AB - Continuous quality improvement stands at a crossroads. One road is dominated by the frenzied competition in the current health care marketplace. Another road is traveled both by a desire to compete against disease and by vulnerable employees, many of whom are represented by a weakened union movement. This article reviews this history and lessons and its relationship to CQI. Employee involvement, not just from a psychologic, but also a decision-making and even ownership perspective is necessary for CQI to succeed in the long term. Only with this type of involvement in hand can the trust between employee and employer required for genuine CQI be created. PMID- 10164645 TI - Integrating payer and provider risk through capitation. AB - Capitation payment mechanisms promote conservative use of medical resources by transferring risk to the decision maker, the physician. However, there is another view of capitation: defining common risk between provider-driven organizations (i.e., physician/hospital organizations (PHOs) or integrated delivery systems (IDS), and risk-managing entities such as HMOs or insurance companies. This article discusses a strategy to align provider and risk manager incentives to share the risks and rewards for a total book of business or population. PMID- 10164646 TI - Consumer-driven health care marketing. AB - In this article, a health care marketing executive takes an opposing view: That the consumer will not only continue to exercise choice but also, at annual renewal time, veto power. In part, that is because the consumers are feeling the rising cost of health care much more directly than in the past, through ever higher premiums, deductibles and copayments. As they assumed more of the burden of medical care delivery, consumers are becoming more knowledgeable about and discriminating toward the health care system and provider plans they are offered. They understand--as does their employer--that no longer are all health care plans alike or at parity with each other. The consumer is also demanding greater access to freedom of provider choice, quality of health care coverage. PMID- 10164647 TI - Reducing technology costs and risks in a managed care environment. AB - In the managed care environment, technology life-cycle management is necessary to minimize costs and maximize the quality of patient care. A careful approach to equipment acquisition and management can help managed care providers reduce the cost of delivering services while ensuring the right technology is available when and where it is needed to best serve patients. Proper management of technology assets from planning and budgeting through acquisition, usage and disposal can help managed care facilities reduce cost and risk, increase control, and improve productivity. PMID- 10164648 TI - Comparison of inpatient utilization to optimal standards. AB - This article summarizes recent analysis concerning variation in the utilization of inpatient hospital benefits by geographic area and for different sources of benefits (health maintenance organization [HMO] versus non-HMO), in comparison to a nationwide standard defined as best observed performance. Observations include significant geographic variations relative to the standard, and the possibility of additional improvements in utilization by managed care organizations. It also notes the importance to benefit plan sponsors of reviewing data concerning the utilization levels of the managed care organizations with which they contract, and references recent comparative results presented for HMOs participating in the New England HEDIS Coalition. PMID- 10164649 TI - Value-based formulas for purchasing. Pursuing value in Medicaid managed care: access to care and enrollee information management. AB - Medicaid and other publicly funded health coverage programs face special challenges in managed care purchasing. This article discusses two of those challenges based on the state of Minnesota's experience: how to develop, evaluate, and communicate access to care; and how to manage the transfer of enrollee eligibility and health status information. PMID- 10164650 TI - Value-based formulas for purchasing. Employers shift to quality to evaluate and manage their health plans. AB - Employers have traditionally focused on cost and plan design in the management of their employees' health care programs. This cost focus has led most large employers to enroll employees in managed care programs and resulted in a new focus on the quality of care delivered by these plans. By evaluating cost and quality, employers attempt to understand the total value these health plans deliver. Hewitt Associates' Health Value Initiative, a health plan analysis based on employers' increased need for cost and quality information, is an example of a tool used by some employers to evaluate and strategically manage their health plans. A case study shows how one large employer used this information to shift to a more comprehensive cost and quality analysis, resulting ultimately in better health care costs and quality for its employees. PMID- 10164651 TI - Value-based formulas for purchasing. Does managed care offer value to society? AB - To assess whether managed care is, all things considered, a good investment for our society, we can measure its performance relative to five essential health care goals: promote efficiency; expand access; improve quality; preserve freedom of choice; and protect patient advocacy. These goals, which have shaped and continue to shape health care policy, define what is important to us in our health care system. Concerns about managed care's ability to advance these goals and thus to offer value are heightened if recently observed trends continue. PMID- 10164652 TI - Value-based formulas for purchasing. PEHP's designated service provider program: value-based purchasing through global fees. AB - In many circles, managed care and capitation have become synonymous; unfortunately, the assumptions informing capitation are based on a flawed unidimensional model of risk. PEHP of Utah has rejected the unidimensional model and has therefore embraced a multidimensional model of risk that suggests that global fees are the optimal purchasing modality. A globally priced episode of care forms a natural unit of analysis that enhances purchasing clarity, allows providers to more efficiently focus on the Marginal Rate of Technical Substitution, and conforms to the multidimensional reality of risk. Most importantly, global fees simultaneously maximize patient choice and provider cost consciousness. PMID- 10164653 TI - Value-based formulas for purchasing. Loyalty renaissance: the rebirth of loyalty in health care. AB - As more consumers join managed care organizations, the personal bond between patient and physician or medical group has been transformed into an economic relationship driven chiefly by the price of health care services. Managed care organizations now face the same pressures as the airline and retail industries: To gain and retain client loyalty through product differentiation and consistently high levels of service. How do managed health care plans create and maintain loyalty among their members? What is the value proposition that consumers will respond to in this era of managed care? Discussion will focus on the consumer as the critical variable in the economic model of a health care system and how the consumer will impact the continued evolution of managed care. PMID- 10164654 TI - The spin doctors: an invitation to health care professionals to reflect on the organizational dynamics of the Last Supper and why Judas was not the traitor. AB - The dynamics of The Last Supper are used to describe how organizations' members frequently make unethical, organizationally destructive decisions and then become "spin doctors" who collude in creating explanations that deflect attention from their contributions to the ensuing debacles. The implications of that process for a variety of organizations, including those engaged in health care, are discussed. PMID- 10164655 TI - Clinical improvement: commentary on developing healthy physician-hospital relationships. AB - Central to the success of clinical improvement programs is the degree to which hospitals and physicians can work together to achieve mutually beneficial goals. The purpose of this article is to provide a clear understanding of what is ultimately required for hospitals and physicians to form constructive relationships that deliver greater value to the marketplace. PMID- 10164656 TI - Physician incentive plan regulations may frustrate efforts to expand Medicare and Medicaid managed care programs. PMID- 10164657 TI - Direct contracting. Direct contracting between providers and employers, or searching for El Dorado. PMID- 10164658 TI - Direct contracting. Business reasons for direct contracting: the group purchaser's perspective. PMID- 10164659 TI - In the middle of the Pacific, no "islands of automation". PMID- 10164660 TI - Widening the pipe: plain talk about fast and switched Ethernet. PMID- 10164661 TI - The healthcare enterprise Web and the future of clinical information systems. PMID- 10164662 TI - Technology and chronic conditions: an employer's perspective. PMID- 10164663 TI - Putting the servers in client-server. PMID- 10164664 TI - Focus survey. Pharmacists aren't impressed with old systems; majority surveyed plan upgrades, replacements. PMID- 10164665 TI - Hotlist case management tools/systems. A road map for navigating the maze of case and utilization management software. PMID- 10164666 TI - Using the Internet to support provider-patient collaboration. PMID- 10164667 TI - Network migration requires an understanding of real-life needs. PMID- 10164668 TI - Cutting through the clutter of group practice medical records software. PMID- 10164669 TI - The unrealized potential of malpractice arbitration. AB - Although the use of arbitration in the commercial arena has increased tremendously in recent years, there has been a reluctance to adopt arbitration of medical malpractice claims in place of litigation. After discussing the benefits of arbitration in medical malpractice cases, Professor Metzloff examines why the use of arbitration has not become predominant, discussing such factors as judicial hostility, failure of state statutes designed to encourage arbitration, and lack of hard evidence that arbitration works. Professor Metzloff then explores the future of arbitration in medical malpractice cases, citing examples from his own work experience with Duke Law School's Private Adjudication Center, and discusses attributes which would make malpractice arbitration successful in the future. PMID- 10164670 TI - How will Clinton's second term influence the use of IT in managed care? PMID- 10164671 TI - Architecture: client/server moves into managed healthcare. AB - The healthcare industry is in transition from indemnity-based products to managed care during a period marked by consolidation, competitiveness and increasingly demanding consumers. This powerful combination of industry change and customer interest requires more efficient operations and flexible information systems. Host-based managed care systems are running into limitations meeting business needs, creating a demand for client/server architectures. PMID- 10164672 TI - Two steps forward, one step back. AB - Participants at a community health information network in Glens Falls, N.Y., have come face-to-face with obstacles that could have meant the end to this rural health network that the New York Department of Health and the John A. Hartford Foundation helped launch more than two years ago. Instead, John Laliberte, Glens Falls Hospital's director of information systems, and the rest of the IS team are recovering from some setbacks and preparing to increase the CHIN's capabilities. PMID- 10164673 TI - Market mapping: a guide to the future. AB - The main difference between healthcare planning efforts of yesteryear and those of today is simple: Today's sophisticated, computerized mapping programs supply health plan member and demographic data, while health planners of yesterday pushed pins through colored road maps to try to predict marketshare. PMID- 10164674 TI - Lasso the power of the Internet. AB - News about the Internet is everywhere. The reality, however, is that the Internet is neither a passing fad nor a false alarm. It is a dynamic new way for healthcare organizations to disseminate and retrieve information, conduct market research, communicate with broad provider networks, educate consumers and sell products and services. PMID- 10164675 TI - Risk management. Betting on good information. AB - Eating potato salad left out in the sun, flying a kite in a rainstorm, sticking a fork in a light socket--we don't need an actuarial table to know that these and many other actions are downright life-threatening. Most of us grow up learning these basic lessons and think of them as common sense, not as a measure of risk. But what about having a heart attack? Contracting a fatal disease? Experiencing unusual side effects from medicine? These risks aren't so obvious. But in each situation, information is available that can identify the chances of any one of us experiencing a stroke or food poisoning. In fact, conclusions about the incidence and potential health risks are key in the daily business decisions of healthcare. Just knowing the gambles, however, is not what risk in healthcare is all about. Instead, it is about the potential costs of those risks to health planners footing the bill. PMID- 10164676 TI - Ensuring cost-effective investments for the future. AB - According to an analyst report from Smith Barney, the market for managed care information systems is about $2 billion, growing to more than $5 billion by 2000. Nonetheless, these systems must prove a cost-effective for managed care organizations. Systems should add value and, over time, offer a return on investment. These goals are accomplished through solutions that recognize and anticipate expanding information requirements in the evolving healthcare market. PMID- 10164677 TI - Critical pathways. AB - A critical Pathway (CP) is a clinical management tool that helps medical care providers coordinate the delivery of patient care for a particular case type or condition. As a guide to usual treatment patterns, a CP gives a view of the "big picture." The CP usually recommends a total treatment regimen. Treatment regimens are formulated through the consensus of a multi-disciplinary collaboration of all those involved in a patient's care. If developed and implemented properly, critical paths can lead to desirable outcomes for the patient and improved operating effectiveness/efficiency for the healthcare facility. Components of CPs often include protocols, algorithms, and clinical practice guidelines. Metrics, bench-marks, compliance, and variances become common terms among members of the healthcare team. Although CPs have gained wide acceptance as inpatient management tools, they are rapidly being sought for outpatient settings as well. This article details the CP process and cites examples of two hospitals that have used CPs to reduce length of stay and cut costs. PMID- 10164678 TI - Pharmacy formularies in integrated health systems. AB - Formulary management implications are described for an Oklahoma integrated health system comprising 14 acute care facilities, numerous owned medical practices, and a fledgling HMO. A systemwide pharmacy director has yet to be appointed; however, the position of pharmacy operations management for the Oklahoma City area has been created. A physician group has been formed that is expected to address system-wide pharmacy and therapeutics (P&T) committees and formulary strategies. Currently P&T committee activities take place at the individual hospital level. The hospitals do not have restrictive formularies. An overall formulary system would likely be patterned after the largest hospital's system, including a formal approval process in which a P&T subcommittee reviews drug use outside established guidelines and the P&T committee asks the appropriate medical department to address the problem. For ambulatory care, the HMO has contracted with a pharmacy benefit manager (PBM), and there is no coordination of formulary efforts between the PBM and health system entities. Although this and other problems remain to be resolved, some standardization of drug use has begun. Also, all entities in the system use the same purchasing group and plan to use the same information system. Drug use among hospitalized patients in this integrated health system is influenced by the usage guidelines established at the largest hospital, and drug use among ambulatory managed care patients is influenced by an external PBM. PMID- 10164679 TI - Finding ground in a new Washington. PMID- 10164680 TI - Can Affirmative Action be justified? PMID- 10164681 TI - 10 suggestions for successful Web site strategy. PMID- 10164682 TI - Digital imaging lowers costs, improves care. PMID- 10164683 TI - Healthcare pay: belts tighten--but who feels the squeeze? AB - A CEO of a renowned acute care facility echoes what many in the healthcare industry are experiencing: "At no time in my memory are we changing so much so fast ... with so little time in which to make changes." The once mighty fortress of the healthcare industry has been invaded by a Trojan horse: managed care. Consequently, managed care has become the primary impetus for industry change. Managed care penetration has increased dramatically over the past few years, and all indications point to its continued growth throughout the US. In 1995, 71% of employees covered under an employer-sponsored health plan received their care through a managed care arrangement (health maintenance organization, preferred provider organization, point of service plan) and only 29% were covered under a traditional indemnity plan. In contrast, 52% of employees had indemnity plans in 1992. Managed care is growing in the public sector as well. Government-sponsored programs such as Medicare and Medicaid increasingly rely on managed care to help control costs and utilization. Though Medicare managed care enrollment today represents only about 10% of the Medicare population, enrollment has more than doubled between 1990 and 1995. Almost every state has some form of Medicaid managed care program in place. Fifteen states have received waivers to mandate that recipients receive care through managed care arrangements, and an additional ten states await federal approval to do the same. Between the years 1993-95, the number of Medicaid beneficiaries enrolled in managed care plans increased 140% to a national enrollment of close to 12 million. In addition to factors in the healthcare field such as uncompensated care, increased outpatient services, excess bed capacity, and restrictions in government reimbursement, the shift to managed care has forced hospitals to find new ways to operate within the healthcare delivery system. In particular, because hospitals' human resource costs are a substantial portion of their budgets, compensation policies are an important component of managing the cost of day-to-day operations. The 1996 Coopers & Lybrand Compensation in the Healthcare Industry Survey summarizes the responses from 207 healthcare organizations, primarily hospitals, in terms of their efforts to survive this constantly changing environment. Respondents included acute care and specialty hospitals, community-based hospitals, academic medical centers, public, and private organizations. The survey addresses operational issues, compensation incentives, special pay, and other compensation related programs. This article analyzes the results of the Coopers & Lybrand survey. PMID- 10164684 TI - Provider based strategic alliances. PMID- 10164685 TI - Hospital's 'carrot-and-stick' approach wins employee safety involvement. PMID- 10164686 TI - Color cameras in psychiatric wing assist nursing and security staffs. PMID- 10164687 TI - New fire safety system pinpoints exact location of fire. PMID- 10164688 TI - Special report. Designing security for a garage serving a new medical school: from concept to reality. AB - The Paterson Street Deck, New Brunswick, NJ, cited by the International Parking Institute (IPI) for excellence in design, employs a number of modern security concepts to protect its customers. The deck was built by the New Brunswick Parking Authority, which worked with the city's medical community to develop the 1,010-space structure located next to the newly built Robert Wood Johnson Medical School. The spaces are used by approximately 800 medical patrons--students of the medical school and employees of Robert Wood Johnson University Hospital, as well as an additional 200 visitors. Staffers and students pay for parking services biweekly on a graduated scale based on the level of their job title, according to Joseph Bernasz, director of administrator, Robert Wood Johnson Medical School. And they have been very receptive to the new facility, says Kevin McTernan, vice president of administrative services, Robert Wood Johnson University Hospital, New Brunswick. In this report, we'll present in detail the security concepts employed, the reasons behind them, and how they have been employed since the deck opened about two years ago. PMID- 10164689 TI - In the eye of the hurricane: how NC hospitals dealt with 'Fran'. PMID- 10164690 TI - The Joint Commission still doesn't get it. PMID- 10164692 TI - Hospital groups form alliance. PMID- 10164691 TI - Not-for-profits push for antitrust relief. PMID- 10164693 TI - PSOs seen as cure for image woes. PMID- 10164694 TI - 1995 a record year for hospital earnings. PMID- 10164695 TI - The clock is ticking. Study: health system needs to prepare for next century. PMID- 10164696 TI - 1997 Health Care Hall of Fame. Social work trailblazer. PMID- 10164697 TI - 1997 Health Care Hall of Fame. Mr. Hospital. PMID- 10164698 TI - Hospitals push PSO agenda. PMID- 10164699 TI - Lawmakers cool to federal PSO oversight. PMID- 10164700 TI - 1997 Health Care Hall of Fame. Cleveland Clinic co-founder. PMID- 10164701 TI - 1997 Health Care Hall of Fame. America's health conscience. PMID- 10164702 TI - 1997 Health Care Hall of Fame. An industry visionary. PMID- 10164703 TI - The inpatient's best friend. 'Hospitalists' specialize in managing care of the very ill. AB - Weston Chandler's business card reads: "Inpatient internal medicine specializing in the care of the hospitalized patient." In other words, he's a hospitalist, or a physician who cares for sick people in hospitals and nowhere else, and he's part of a new movement emerging in medicine. Modern Healthcare spent a day with Chandler to explore what hospitalists do and why their role may lead to more economical healthcare. PMID- 10164704 TI - Dialysis outcomes in works. HCFA may set quality, practice guidelines for ESRD program. PMID- 10164705 TI - Information systems. Sending in the military. PMID- 10164706 TI - The REIT stuff. PMID- 10164707 TI - Cost-benefit evaluations in mental health: implications for financing policy. PMID- 10164708 TI - Financial risk and behavioral implications of prospective payment for psychiatric services. PMID- 10164709 TI - Equity, public policy and outpatient specialty mental health services. AB - This study provides evidence on the role of the public sector in the allocation of ambulatory specialty mental health services across income groups in the adult population. Results suggest that in the early to mid-1980s, the tax and transfer system effectively lowered the price of services to the poor and the rich, thus causing the highest use by persons at the extreme ends of the income distribution. High utilization at the low end of the income scale can be largely attributed to publicly provided insurance. A comparison of demand prior to the Medicaid cuts brought on by the Omnibus Budget and Reconciliation Act (OBRA) of 1981 with post-OBRA estimates reveals the extreme sensitivity of demand to changes in coverage. Among upper income groups the results imply that the implicit price of specialty mental health care falls as income rises. This finding is consistent with the hypothesis that the government's exclusion of health benefits and expenditures from taxation effectively lowers the price of medical services to individuals in high marginal income tax brackets. It also suggests that recent proposals to limit the tax exclusion of employer-paid premiums may lead to a more equitable distribution of resources in the specialty mental health sector. PMID- 10164710 TI - The RBRVS for psychiatry. PMID- 10164711 TI - The anatomy of cost estimates--the "other" outcome. PMID- 10164712 TI - The demand for health care for the treatment of mental problems among the elderly. PMID- 10164713 TI - State government choice of organizational structure for local mental health systems: an exploratory analysis. PMID- 10164714 TI - Cost-containment in mental health care: the role of utilization review. PMID- 10164715 TI - Insurance coverage, reimbursement policy, and hospital care for the seriously mentally ill. PMID- 10164716 TI - Contracting for community-based public mental health services. PMID- 10164717 TI - The effect of managed mental health care on use of outpatient mental health services in an employed population. PMID- 10164718 TI - PPS and TEFRA effects on charges for treatment of depression. PMID- 10164719 TI - People with AIDS as residents: preparedness and acceptance by Connecticut long term care facilities. AB - The management of AIDS has become an issue of chronic care as well as acute treatment. As the number of people with AIDS increases, the demand for ongoing care and support, both informal and formal, is expected to increase. The present study is based on a survey of all licensed nursing homes in the state of Connecticut with respect to prevailing attitudes toward the admission of residents with AIDS, and the level of staff, resident and procedural preparedness that exists. Both positive attitudes among the various LTC constituent groups as well as the level of preparation in a number of areas are correlated with the admission of residents with AIDS. Implications are discussed and recommendations are offered for policy development. PMID- 10164720 TI - Effects of local conditions on program outcomes: analysis of contradictory findings from two programs for homeless mentally ill. AB - A demonstration program for the homeless mentally ill that succeeded at one site and failed at another serves as the basis for analysis of the effects of local conditions on program implementation and outcomes. Chen's program implementation framework is utilized. Implications are drawn for funders, service providers, and evaluators. PMID- 10164721 TI - A model to improve the utilization of health and social services in Latino communities. AB - There are two salient issues beginning to impact drastically on health and social services in the nation: nativist anti-immigrant hysteria among the populace and President Clinton's national health care proposal. This article is neither an examination of the nativist anti-immigrant hysteria nor of the merits of the President's health care plan. Rather, the focus here is to propose a model to improve the utilization of health and social services to Latinos despite nativism and outcome of the final health care program. PMID- 10164722 TI - Do HMOs restrict access to health care among the chronically ill? AB - Health Maintenance Organizations are enrolling an increasing number of people for the delivery of their health care. Observers are asking whether this trend has resulted in the underprovision of health care to vulnerable population groups. This study asks whether HMOs under-provide care to the chronically ill. We use Ronald Andersen's Behavioral Model to derive predictive expectations about the provision of hospital and physician services to the chronically ill. The results indicate that HMOs do not under-provide health care to the chronically ill, compared to traditional fee-for-service insurance arrangements. We further found that HMOs provide more physician services to those in excellent health, compared to those in fee-for-service arrangements. PMID- 10164723 TI - Flurry of activity on latex. PMID- 10164724 TI - Buyer and seller ask each other, 'How am I doing'? PMID- 10164725 TI - Look before you lop. PMID- 10164726 TI - Mapping new territory. Pioneering effort makes it easier to track supply use. PMID- 10164727 TI - Scoping out the UPN. A progress report on implementation of universal product numbers. PMID- 10164728 TI - Ethical ways to reuse single-use devices. PMID- 10164730 TI - Basics of research (Part 9): Practical aspects of performing clinical research. PMID- 10164729 TI - Reshaping inpatient care: efficiency and quality in New York City hospitals. AB - Between 1992 and 1995, the United Hospital Fund engaged two groups of New York City hospitals in collective efforts to address crucial issues of length of stay and patient-centered care; the three-year, $1.1-million Length of Stay Initiative, which supported projects in seven New York City hospitals to identify and change practices that unnecessarily prolong inpatient stays; and the two year, $700,000 Patient-Centered Care Consortium, through which 15 hospitals surveyed patients and received grants and technical support to design, implement, and evaluate improvements in meeting patients' expressed needs for more personalized care. Specific strategies and interventions developed and tested through the Length of Stay Initiative included continuous quality improvement programs to reduce delays and prevent duplication of diagnostic tests; clinical pathways to reduce unnecessary and inefficient variations in the treatment of common conditions and diseases; and a variety of other techniques, such as work redesign, diagnostic-specific clustering of patients, interdisciplinary design teams, and interdisciplinary rounds. Activities undertaken by the hospitals participating in the Patient-Centered Care Consortium included an initial survey of 3,423 patients and subsequent focus groups, individual interviews, and additional surveys to better understand the nature and causes of problems with care and to target, design, and test small-scale improvements. Among the first products to the consortium were patient education and information programs; daily treatment plans; improvements in the coordination of care and in teamwork among health care professionals; redesigned interpreter services, and improved methods of providing emotional support. Through their projects in the Length of Stay Initiative and Patient-Centered Care Consortium the participating hospitals learned some important lessons about what it takes to increase efficiency, improve the quality of patient care, and provide better service to patients. Strong leadership, institutional support, the involvement of medical staff, an interdisciplinary approach, an investment in staff training, the ability to work through resistance to change, systems and support for collecting performance data, and ways to evaluate how well improvements work were found to be especially key. PMID- 10164731 TI - Data watch. The ins and outs of mental health care. PMID- 10164732 TI - Data watch. The slimmest salaries for health-care execs. PMID- 10164733 TI - What to watch out for when your local hospitals merge. PMID- 10164734 TI - Health care reform in the states. Massachusetts--high prices in a managed care stronghold. PMID- 10164735 TI - Telemedicine starts to pay off. PMID- 10164736 TI - Will big HMOs stamp out competition? PMID- 10164737 TI - Two routes to reform in Alabama's premier city. PMID- 10164738 TI - Managed care needs a partner to keep its promise. PMID- 10164739 TI - Employee health: not just a fringe benefit. PMID- 10164740 TI - How would MSAs work in the real world? PMID- 10164741 TI - Health reform in the states. Vermont--treading lightly in lieu of revolution. PMID- 10164742 TI - 1995 executive opinion poll. The new variety in managed care. PMID- 10164743 TI - A bend in the river. PMID- 10164744 TI - When one purchaser has the clout of many. PMID- 10164745 TI - Data watch. Brushing up on dental benefits. PMID- 10164746 TI - Do you have what it takes to self-insure? PMID- 10164747 TI - Managed mental health--finding coverage that fits. PMID- 10164748 TI - Why you want tort reform. PMID- 10164749 TI - Accreditation: what's the big deal? PMID- 10164750 TI - Self-insured group borrows the best of an HMO. PMID- 10164751 TI - Data watch. Hospital execs navigate troubled waters. PMID- 10164753 TI - Data watch. Restructuring is the watchword at hospitals nationwide. PMID- 10164752 TI - Data watch. Domestic violence: what's your role? PMID- 10164754 TI - The conservative agenda. Pushing business out of health care. PMID- 10164755 TI - Health reform 2. Should Congress look to the states? PMID- 10164756 TI - Health reform. 2. Why malpractice reform is risky business. PMID- 10164757 TI - What you can bargain for when HMOs compete. PMID- 10164758 TI - Health care reform in the states. Texas--is the Lone-Star State reform's last holdout? PMID- 10164759 TI - Mediplan reforms: there's still no free lunch. PMID- 10164760 TI - Where size is not an obstacle. PMID- 10164761 TI - The Supreme Court sheds a very narrow light on ERISA. PMID- 10164762 TI - True reform takes more than tucks and trims. PMID- 10164763 TI - Data watch. Computerization: health care at the forefront. PMID- 10164764 TI - Is subacute care worth your money? PMID- 10164765 TI - Health care reform in the states. California--edgy at the cutting edge. PMID- 10164767 TI - One size (almost) fits all. PMID- 10164766 TI - Scalpel or cleaver: does Congress know the difference? PMID- 10164768 TI - It's ERISA vs. state law on employee incentives. PMID- 10164770 TI - Data watch. Even couch potatoes have good intentions. PMID- 10164769 TI - Don't choose an HMO just to save money. PMID- 10164771 TI - Data watch. Here's some real fat in health spending. PMID- 10164772 TI - Drive-through delivery: bargain or blunder? PMID- 10164773 TI - Calculating the workplace cost of chronic disease. PMID- 10164774 TI - Do health plans change course when doctors take the helm? PMID- 10164775 TI - Health care reform in the states. Ohio--market forces lead the way. PMID- 10164776 TI - Direct contracting comes to the HMO heartland. PMID- 10164777 TI - Head-to-head on MSAs. The devil is in the details. PMID- 10164778 TI - Head-to-head on MSAs. The route to real choice. PMID- 10164779 TI - The mind, the body and the benefits budget. PMID- 10164780 TI - Pinning down the value of premier benefits. PMID- 10164781 TI - Finding the value in screening. PMID- 10164782 TI - Economic pains of rheumatoid arthritis. PMID- 10164783 TI - (Almost) risk-free health plan selection. PMID- 10164784 TI - Data watch. The latest breakdown on benefit dollars. PMID- 10164785 TI - Pain management guidelines: implications for managed care--a roundtable discussion. AB - One of the most important concerns of patients with cancer, particularly those with metastatic disease, is "Will I be in constant pain?" This is a similar concern voiced by patients with late-stage human immunodeficiency virus infection. The management of chronic pain has enormous implications on a patient's ability to function and on his or her quality of life. In June 1996, Medical Interface convened a panel of experts in Chicago to discuss pain management therapies, guidelines, and how these issues will affect, and be affected by, the managed care environment. PMID- 10164786 TI - The 1996 Justice Department/FTC statements on physician joint ventures and multiprovider organizations. AB - The 1996 Justice Department/FTC statements suggest that under some market conditions, competitors who are members of a provider organization may fix prices if the agreement on price is reasonably necessary and subordinate to potential efficiencies created by the group. The author discusses to what extent agencies' statements protect an agreement on price among competitors from being challenged under the antitrust laws. PMID- 10164787 TI - A vendor's guide to six managed care trends. AB - Heraclitus said it 23 centuries ago: "Nothing endures but change." People naturally resist change; therefore, it is important to construct a formal plan to help our people adapt and embrace change. The author provides six movements that have overtaken managed health care and some suggestions as to how the vendor can survive and thrive through these changes. PMID- 10164788 TI - Point-of-service outcomes data and its effect on asthma treatment: a salmeterol pilot investigation. AB - Outcomes data have enabled physicians to have a much more complete overview of the patient's quality of life and health than their predecessors. One medical center has sought to develop a comprehensive point-of-service outcomes measurement tool for the assessment of patients with asthma. This information may provide a real-time overview on a desktop computer system of the patient's progress. A pilot project involving a therapeutic intervention in patients with asthma was conducted to test the utility of this outcomes tool in a practice setting. PMID- 10164789 TI - Health care's move toward differentiation. AB - As the basis of competition changes, so will the focus of the health care industry's senior managers. The author believes that health plans that differentiate their product offerings, in the eyes of their customers, will be most successful. PMID- 10164790 TI - Managed care and information needs for consumers. PMID- 10164791 TI - The Internet revolution: transforming health care delivery. PMID- 10164792 TI - Managed care stock index. Stock market history doesn't teach us much. PMID- 10164793 TI - A conversation with Sean Sullivan. PMID- 10164794 TI - How managed care could coopt the public sector. AB - Since current public officials lack the courage and political will to significantly raise payroll taxes or constrain Social Security, Medicare, and Medicaid benefits, it can be expected that long-term deficit spending will continue, effecting a predictable series of events that have strong, negative ramifications for the American health care system. The author suggests modifications to how our nation's health system should be organized and financed in order to avert these dire predictions. PMID- 10164795 TI - HMOs irreversibly changing the role of the hospital. PMID- 10164796 TI - Changing the rules: coverage of nonprescription drugs. PMID- 10164797 TI - Over-the-counter drugs as a new managed care benefit. AB - Nonprescription or over-the-counter (OTC) drugs represent many opportunities for physicians, insurers, manufacturers, and pharmacies to work together synergistically to provide more cost-effective care for patients. The authors review the reasons for offering an OTC drug benefit and provide two proposals on how to implement the benefit in an HMO environment. PMID- 10164798 TI - Disease state management: who should pay? PMID- 10164799 TI - Is your HMO OK--or not? PMID- 10164800 TI - Casemix--issues for the next decade. PMID- 10164801 TI - HIMAA response to the Issues Paper:"The Future of Casemix Development in Australia; July 1996". Health Information Management Association of Australia. PMID- 10164802 TI - The new ACHS (Australian Council on Healthcare Standards) accreditation program. Will it help health information managers to add value to their service? PMID- 10164803 TI - Future health services managers' and health information managers' views on information technology: a pilot survey. AB - This pilot survey examined the views of a sample of health service managers (HSMs) and health information managers (HIMs) undertaking tertiary studies about the application of information technology (IT) in health care. The survey was based on a questionnaire designed as part of a 1994 study of health service executives (HSEs) commissioned by the Australian College of Health Service Executives (ACHSE). We examined views about current and future IT expenditure, satisfaction with IT, impact of IT on quality and efficiency and the future use of electronic medical records and optical disk storage. Results identify differences and some similarities between respondent groups on these issues. The paper explores these differences and similarities and provides insight into the views held by future HSMs and HIMs. PMID- 10164804 TI - Enterprise bargaining and the health sector. PMID- 10164806 TI - Criteria for the release of individuals administered radioactive materials--NRC. Final rule. AB - The Nuclear Regulatory Commission (NRC) is amending its regulations concerning the criteria for the release of patients administered radioactive material. The new criteria for patient release are based on the potential dose to other individuals exposed to the patient. The new criteria are consistent with the recommendations of the National Council on Radiation Protection and Measurements (NCRP) and the International Commission on Radiological Protection (ICRP). This final rule required the license to provide written instructions to patients on how to maintain the doses to others as low as is reasonably achievable if the total effective dose equivalent to any other individual exposed to the released patient is likely to exceed 1 milisievert (0.1 rem). This final rule responds to three petitions for rulemaking regarding the criteria for release of patients administered radioactive material. PMID- 10164805 TI - The Quality in Australian Health Care Study (QAHCS)--a review. AB - The author reviews the politics, publicity, methods and findings of the Quality in Australian Health Care Study, which was released to a blaze of media attention in 1995. The study is a significant contribution to the growing literature on the identification and categorisation of preventable adverse events, using expert retrospective review of medical records, and a mix of explicit and implicit criteria. However, its potential impact has been lessened by the way its findings were released. PMID- 10164807 TI - Malpractice fight looms. PMID- 10164808 TI - Slouching toward the Medicare fix. PMID- 10164809 TI - Grappling with tough decisions: the board's role. PMID- 10164810 TI - Case study. Crozer-Keystone puts its money where it sees its future--in the community. PMID- 10164811 TI - Special report. Managed care review: market developments in Denver and the Twin Cities. PMID- 10164812 TI - Determining if a fitness complex is right for your system. PMID- 10164813 TI - The rise and fall of integration icons. PMID- 10164815 TI - Strategic planning for managed care: a child welfare example. PMID- 10164814 TI - The role of risk-sharing arrangements. AB - This paper addresses a variety of issues related to risk in a child and family service system of care that uses managed care techniques. A strong emphasis is placed on sharing rather than shifting risk. How to optimize or balance competing interests is still an imprecise art, but most would agree that successful implementation of a comprehensive service system for children and families will depend in large part on identifying potentially competing interests and realigning them so that all parties share the same interests. Too much risk can paralyze; too little risk can limit creativity, resourcefulness, and industry. PMID- 10164816 TI - Mediation--an alternative for dispute resolution in managed behavioral healthcare. PMID- 10164817 TI - Successful mechanisms for conducting evaluations of public/private partnerships. PMID- 10164818 TI - Whither the solo and the group practice? IDS and the future of public sector initiatives. PMID- 10164819 TI - Dialogue. How should profits from public/private behavioral healthcare partnerships be reinvested? PMID- 10164820 TI - Passage of mental health parity shows political strength. PMID- 10164821 TI - New TennCare program improves service with carve-out. PMID- 10164822 TI - Improving public/private partnership in managed behavioral healthcare. AB - This paper is the second version of a working document developed to explore opportunities and difficulties in the national shift to managed care in the public sector. Leaders in the public and private sectors continue their collaboration in contributing new models of integration that preserve the best of the public system but challenge the field to combine social mission with good business practice. The first version was developed by the American Managed Behavioral Healthcare Association and the National Association of State Mental Health Program Directors. This document, developed by AMBHA, NASMHPD, the National Association of County Behavioral Health Directors, and the National Council of Community Mental Health Centers, expands on the first white paper, published here in October 1995, and is based on developing issues and concerns in public sector managed behavioral healthcare. This paper is not intended to represent prescriptive standards but rather to articulate "best practice" in an area that continually changes as public payors privatize significantly larger portions of public mental health. In April 1996, Behavioral Healthcare Tomorrow published a response from the consumer advocacy perspective, and the ideas presented in this paper remain open to input and discussion. PMID- 10164823 TI - Patient assessment systems using the World Wide Web. AB - Of the major issues in developing a Web patient assessment system, I have emphasized two main points. First, the World Wide Web can provide substantial leverage in the development of online patient assessment systems. Second, although the existence of Internet technologies does not alter the need to resolve issues that preceded their arrival, current trends suggest that in the home and the office, patient assessment systems will increasingly employ Internet technologies. PMID- 10164824 TI - Competition and cooperation: public sector coalitions for outcomes measurement. PMID- 10164825 TI - Public behavioral healthcare: managing to change. PMID- 10164826 TI - Physicians embrace path development when data spotlight performances. PMID- 10164827 TI - Patient education speeds joint replacement recovery. PMID- 10164828 TI - CABG pathway cuts intubation time, LOS, telemonitoring. PMID- 10164829 TI - Remember beta-blockers for older MI patients. Study: 21% of eligible patients receive treatment. PMID- 10164830 TI - Beyond the gatekeeper: managed care evolves. PMID- 10164831 TI - Medical staff analysis is key to meeting recruitment goals. PMID- 10164832 TI - The future of managed care. PMID- 10164833 TI - How to keep your sanity while caring for both traditional and Medicare managed care patients. PMID- 10164834 TI - Four steps to take to prepare for Medicare managed care. PMID- 10164835 TI - HCFA reorganizes agency, integrates managed care. PMID- 10164836 TI - Internal Revenue Service approves tax-exempt hospital's participation in dialysis facility joint venture. PMID- 10164837 TI - Tax-exemption for hospital sponsored professional corporations. PMID- 10164838 TI - Of railroads and radiology. PMID- 10164840 TI - Refining image quality and calibration. PMID- 10164839 TI - The pursuit of PET. PMID- 10164841 TI - Charting your way to the top. PMID- 10164842 TI - Health reform. We could start by beginning. PMID- 10164843 TI - Outsourcing technology. PMID- 10164844 TI - Fielders, gloves, carpenters and tools. PMID- 10164845 TI - Managing cancer through synergy. Radiation and molecular medicine. PMID- 10164846 TI - Managed care. Perception vs reality. PMID- 10164847 TI - The future of breast biopsy. PMID- 10164848 TI - DICOM (Digital Imaging and Communications in Medicine) state of the nation. Are you afraid of data compression? PMID- 10164849 TI - DICOM's (Digital Imaging and Communications in Medicine) next obstacle--the information system. PMID- 10164850 TI - Baltimore gets co-nnec-ted. PMID- 10164851 TI - Are you ready to deal with managed care? PMID- 10164852 TI - The art of electronic transmission of the MDS (minimum data set). PMID- 10164853 TI - Get down to business and improve quality of life. PMID- 10164854 TI - A terminal case. PMID- 10164855 TI - Animal magnetism. PMID- 10164856 TI - Anti-kickback laws and the sins of commission. PMID- 10164857 TI - The right plan of correction can offer protection. PMID- 10164858 TI - Dysfunctional dispatch. PMID- 10164859 TI - Victories and violence. PMID- 10164860 TI - Donors needed to revive hospital annual campaigns. PMID- 10164861 TI - Snatching victory from the jaws of defeat. PMID- 10164862 TI - Physicians as executives: barriers to success. PMID- 10164863 TI - Physicians as executives: boon or boondoggle? AB - It should come as no surprise to any observer of trends in the U.S. healthcare delivery system that physicians are taking a keener interest in the organization and management of that system. The practice of medicine has become, to a large degree, overtaken by events. Managed care and system integration have tended to place decision making at points further and further removed from patient care, the natural purview of the physician. It is to regain the initiative on how patient care is provided that physicians are moving in greater numbers into management. It is our contention that this move portends well for the future of the system. The unique advantage of the physician executive is the ability to bring to bear on healthcare management an understanding of the clinical processes that are its essential content. With strong clinical credentials and excellent management training, the physician is poised to make significant contributions to a healthcare organization's success. PMID- 10164865 TI - Do physician executives make a difference? PMID- 10164866 TI - Focusing and aligning hospitals through hoshin planning. PMID- 10164864 TI - Physician executives: additional factors impinging on their future success. PMID- 10164867 TI - Making a big Kaiser out of two little ones. PMID- 10164868 TI - Tenet hoping to take control of markets through new acquisitions. PMID- 10164869 TI - Beware the myths of network ownership and control; agility is better than size. PMID- 10164870 TI - Columbia moving towards being super med. PMID- 10164871 TI - Healthcare reform: will the minimalist approach continue? PMID- 10164872 TI - Government agencies soften stance on what constitutes price fixing. AB - The Federal Trade Commission and the Department of Justice have modified their views on what constitutes price fixing by integrated delivery systems. Recently released enforcement policy statements indicate that joint agreements on price between competing providers will not necessarily constitute price fixing, even without risk sharing, if the system is sufficiently integrated. The enforcement policy statements indicate that if integration arises from the combined efforts of previously competing providers, involves improvements in clinical efficiency or quality, and demonstrates no anticompetitive intent, it will be sufficient to withstand Federal scrutiny. PMID- 10164873 TI - Nurse practitioner center expands access to primary care. AB - In response to a need for increased patient access to primary care services in an area with a shortage of primary care physicians, not-for-profit Oconee Memorial Hospital, Seneca, South Carolina, opened a primary care center staffed solely by nurse practitioners. In addition to reducing the number of patients using the hospital's emergency room for nonurgent care, the center has improved patients' access to primary care services, strengthened the community's primary care base, and helped the hospital's managed care network win contracts. PMID- 10164874 TI - New capitation scenarios for HMO Medicare risk contracting. AB - Medicare's current method for setting capitation rates does not provide adequate financial incentives for HMOs to offer managed care products; more than 60 percent of the nation's HMOs still do not participate in Medicare risk contracts. Possible changes to the capitation calculation method could provide the necessary financial incentives for Medicare HMOs to proliferate and ease the strain on the Medicare trust fund. Managed care organizations need to prepare to enter the Medicare risk-contracting arena. PMID- 10164875 TI - Clinical pathways can help manage managed care. AB - Clinical pathways are designed to map the course of medical or surgical interventions and their expected outcomes. They take into account standards of care and the human and material resources needed to provide specific services. Clinical pathways promote cost-effective, high-quality care and thereby help to standardize practice protocols and coordinate care. Healthcare organizations can decrease lengths of stay, reduce costs, and win more managed care contracts by developing and implementing comprehensive clinical pathways. Pathways can also make carve-outs and other specialty contract services easier to manage. PMID- 10164876 TI - Evaluating and negotiating a profitable capitation contract. AB - Evaluating the financial terms of capitation contracts and negotiating their nonfinancial provisions are becoming increasingly important responsibilities for healthcare financial managers. To evaluate the financial terms of a contract, financial managers must understand both incremental and replacement pricing strategies. They also must understand when strategic positioning objectives make a capitated plan attractive despite limited financial rewards. Before a contract is accepted, financial managers can take steps to increase its potential profitability by negotiating the nonfinancial provisions that can help control contract expenses. These provisions are related to services to be provided, payment terms, withholds and risk pools, access to data, provision of eligibility data, utilization review and quality assurance procedures, filing of grievances, contract renewal terms, and contract termination. PMID- 10164877 TI - Aligning incentives using risk-sharing arrangements. AB - Most managed care arrangements do not properly align provider and HMO incentives and thus unintentionally promote conflicting care management patterns. But appropriate risk-sharing arrangements encourage HMOs and providers to agree on the best methods to achieve member satisfaction; high-quality, cost-effective care; and healthy profits. Quality- and cost-based risk-sharing arrangements withhold a certain portion of providers' payments for placement in a risk pool fund. Providers are penalized financially for poor quality and unsatisfactory cost performance; providers are financially rewarded with risk pool funds for the cost-efficient delivery of high-quality health care. Percent-of-premium or capitation risk-sharing arrangements divide member premiums among the parties to the risk-sharing arrangement based on how much financial risk each party is willing to assume for providing care. The risk of controlling variations in cost is assumed by providers, thus minimizing HMOs' financial exposure. Inpatient case rate risk-sharing arrangements pay providers a flat rate for uncomplicated cases. Such arrangements can improve the relationship between HMOs and providers by giving providers primary control over case management and benefits HMOs by reducing their utilization review activities. PMID- 10164878 TI - Designing a successful investment program. AB - Healthcare organizations have various asset pool funds that can be invested to increase nonoperating revenues. In order to maximize the long-term success of investment efforts, healthcare organizations need to develop comprehensive investment management programs. Such programs identify the assets that can be invested, establish the level of risk each asset type can be exposed to, and match long-term and short-term investment opportunities to the appropriate asset pool. Programs can be managed internally or outsourced to investment management firms with objectives and procedures that are compatible with those of the healthcare organizations' investment policies and guidelines. These policies and guidelines must address asset allocation. Oversight committees must be established to monitor investment performance and reallocate assets, as needed, to take advantage of market movements. PMID- 10164879 TI - MGMA: who we are. PMID- 10164880 TI - Making acquired physician practices profitable. AB - Many healthcare organizations that acquire physician practices do not realize a return on their investments. Instead, acquisitions often create excess capacity, drive up costs, and reduce an organization's ability to attract managed care contracts. Healthcare systems that acquire physician practices can help ensure that the acquisitions will be profitable by recognizing the benefits and eliminating the barriers to integration, developing a shared strategic vision, developing a progressive governance policy, implementing sound financial management, and achieving critical mass over which to spread fixed costs. PMID- 10164881 TI - Detecting and detering employee theft. AB - Physician group practices can limit their vulnerability to employee theft by taking steps to detect theft when it occurs and to deter future occurrences. Steps for detecting theft include being wary of an employee's refusal to take earned time off, conducting periodic credit checks on employees, rotating employees' duties, and conducting impromptu reviews of the practice's finances. Steps for detering theft include routing the practice's checks to a lock box; reviewing cash reports; reconciling check with deposit statements; separating employees' duties; reviewing bank, credit card, and ATM statements; setting the tone for prudent financial management; and reporting cases of theft when they occur. PMID- 10164882 TI - HCFA on-line: a new plan for improving service to customers. PMID- 10164883 TI - Education is key to successful EDI implementation. PMID- 10164884 TI - Improving investing outcomes through interest rate management. PMID- 10164885 TI - Evaluating patient financial services in the managed care environment. PMID- 10164886 TI - Data trends. Key organizational performance indicators. PMID- 10164887 TI - The eyes have it. PMID- 10164888 TI - The people's charter. PMID- 10164890 TI - It's all at the co-op. PMID- 10164889 TI - Perspectives on purchasing. Think globally, act locally. PMID- 10164891 TI - Managers' careers. Over the hill? PMID- 10164892 TI - Diagnostic services. Restricted access. PMID- 10164893 TI - How well trained are nursing home administrators? AB - Nursing home administrators represent wide variations in academic training. General education levels do not seem to affect administrative preparation in key domains of practice--specific academic fields of study are more relevant. Hence, sole emphasis on higher educational requirements for licensure appears to be a misdirected strategy for improving quality of care and enhancing management efficiencies in nursing homes. Educational paradigms studied have strengths and weakness in furnishing various job skills. These results are helpful in defining strategic actions for addressing both current deficiencies and future training needs. A specialized long-term care model that incorporates appropriate clinical and business skills is recommended. The roles of continuing education and executive educational offerings also need streamlining. These initiatives would require a joint effort from policymakers, academicians, and practitioners. PMID- 10164894 TI - A comparative analysis of revenue and cost-management strategies of not-for profit and for-profit hospitals. AB - Not-for-profit (NFP) and for-profit (FP) hospitals were compared on several performance indicators including revenues, costs, productivity/efficiency, and profitability. The indicators were adjusted, where appropriate, for outpatient activity and a case-mix index for all patients. FP hospitals had higher profit margins as well as higher gross and net revenues per case-mix adjusted admission. On the other hand, NFP hospitals had lower total cost per case-mix adjusted admission even after subtracting taxes from FP hospital costs. There were no significant differences between the two groups on efficiency and productivity indicators--paid hours per case-mix adjusted admissions, occupancy levels, and case-mix adjusted ALOS. The higher profits of FP hospitals were attributed to revenue management rather than cost and efficiency management. PMID- 10164895 TI - Customer service in health care: a new era. AB - Intensified competition in healthcare is stimulating an enhanced focus on consumer satisfaction. Critical barriers to customer service are being dismantled and hospitals are instituting comprehensive models to promote consumer-oriented environments. PMID- 10164896 TI - Mortality rates as an indicator of hospital quality. AB - This study examines the relationship between outlier status based on adjusted mortality rates and theoretical underlying quality of care in hospitals. We use Monte Carlo stimulation to determine, in the absence of case mix variation, if random variation noise could obscure the signal of differences in underlying rates of quality of care problems. Classification of hospitals as "outliers" is done compared with "true" hospital quality, based on underlying rates for quality of care problems in mortality cases. Predictive error rates with respect to "quality" for both "outlier" and "non-outlier" hospitals are substantial under a variety of patient load and cutoff point choices for determining outlier status. Using overall death rates as an indicator of underlying quality of care problems may lead to substantial predictive error rates, even when adjustment for case mix is excellent. Outlier status should only be used as a screening tool and not as the information provided to the public to make informed choices about hospitals. PMID- 10164897 TI - An ethics framework for assisting clinician-managers in resource allocation decision making. AB - In response to continued pressure on the Canadian healthcare system, hospitals are implementing structural changes to address issues of cost containment, utilization, and resource allocation. One strategy has been to decentralize managerial decision making to clinicians, creating "clinician-managers" (CMs). We surveyed 3,000 hospital-based CMs in Ontario, Canada (including physicians, nurses, and other health professionals), in order to understand the nature and frequency of the ethical issues they face as a consequence of their involvement in resource allocation decisions, and to identify mechanisms for dealing with these problems in their hospitals. Based on the survey results, we developed a Management Ethics Framework to assist CMs to reach an ethically justifiable resolution of these types of problems, both individually, and in the context of their membership in the healthcare team. The results, and particularly the discussion that follows, represent a confluence of philosophical, clinical, and organizational perspective on ethics and resource allocation by clinicians. PMID- 10164898 TI - Trends and implications of visiting medical consultant outpatient clinics in rural hospital communities. AB - The emergence of visiting consultant clinics (VCC) represents an unstudied but potentially important mechanism for importing specialty physician services into rural areas. An analysis of five years of one state's VCC experience reveals a substantial increase in both availability and geographic accessibility. This study documents the market's response to the oversupply and hypercompetition among urban-based physician specialists. Patterns of VCC growth have varied markedly for different specialties. PMID- 10164899 TI - Organizational and environmental factors in hospital alliance membership and contract management: a resource-dependence perspective. AB - Using a resource-dependence perspective, we analyze the association between organizational and environmental characteristics and the likelihood that non profit hospitals will enter into one of two forms of interorganizational relationship (IOR): hospital alliance membership or contract management (n = 1,661). The former is representative of high autonomy IORs, while the latter is representative of low autonomy IORs. Results of logistic regression analysis indicate that hospitals with greater resources and more favorable payer mix are more likely to join alliances, an IOR form which minimizes loss of autonomy. In addition, facilities operating in less favorable environments are more likely to be contract managed and less likely to be alliance members. PMID- 10164900 TI - Board development in two hospitals: lessons from a demonstration. AB - A recently concluded demonstration project examined efforts to improve the effectiveness of nonprofit boards. This article focuses on the interventions at two participating healthcare organizations and examines the outcomes of these efforts. Changes made at the Alpha Health Care system included: reduction in the number of boards, term limits established for board members, election of new board chairs for two of the fewer boards, reduction in the size of those boards, implementation of a consent agenda, and reorganization of the boards' committee structure. Fewer changes were implemented at the Beta Hospital, where several initiatives were started but only some of which were retained by the projects' conclusion. Key factors limiting the extent of changes there were the modest interest in an active board by a new CEO and the limited investment of trustees in change. The article concludes with a discussion of lessons learned about board assessment, the use of retreats to initiate board development, and the importance of time management and CEO support to strengthen board effectiveness. PMID- 10164901 TI - Outcomes--an introduction. PMID- 10164902 TI - Health outcomes and infectious disease control. AB - With the development of improved health systems, antibiotics and vaccines throughout the 20th century, the prospects of control of infectious diseases improved. During the same time-frame, an approach to disease control was developed which used the health outcomes resulting from various interventions to choose, guide and modify those interventions. Despite these major advances in the control of diseases, infectious diseases have (with occasional exceptions) not only continued to occur but in many instances the situation had deteriorated with the emergence and re-emergence in recent years of a range of infectious diseases. In this paper we consider why infectious disease control has not benefited from the move towards a health outcomes approach, why infectious disease control might benefit from such a move, and the differences between infectious and non infectious diseases when considering health outcomes. We follow-up with some practical approaches to the use of health outcomes. We argue that appropriate use of health outcomes when planning and evaluating infectious disease control programs will improve human health. PMID- 10164903 TI - Multiplying health gains: the critical role of capacity-building within health promotion programs. AB - Health outcomes in populations are the product of three factors: (1) the size of effect of the intervention; (2) the reach or penetration of an intervention into a population and (3) the sustainability of the effect. The last factor is crucial. In recent years, many health promotion workers have moved the focus of their efforts away from the immediate population group or environment of interest towards making other health workers and other organisations responsible for, and more capable of, conducting health promotion programs, maintaining those programs and initiating others. 'Capacity-building' by health promotion workers to enhance the capacity of the system to prolong and multiply health effects thus represents a 'value added' dimension to the health outcomes offered by any particular health promotion program. The value of this activity will become apparent in the long term, with methods to detect multiple types of health outcomes. But in the short term its value will be difficult to assess unless we devise specific measures to detect it. At present the term 'capacity-building' is conceptualised and assessed in different ways in the health promotion literature. Development of reliable indicators of capacity-building which could be used both in program planning and in program evaluation will need to take this into account. Such work will provide health-decision makers with information about program potential at the conclusion of the funding period, which could be factored into resource allocation decisions, in addition to the usual information about a program's impact on health outcomes. By program potential, we mean ability to reap greater and wider health gains. PMID- 10164904 TI - Caring: the neglected health outcome? or input? AB - In most forms of evaluation of health care--and it is certainly true of economic evaluation--and is considering the outcomes of such care, caring tends to be omitted, or simply forgotten. It is often the case that little more than lip service is paid to the inclusion of caring as an input. This paper takes a closer look at caring, the neglected outcome of health care. The perspective starts from that of economics but other disciplines are examined briefly along the way to determine whether they deal better with caring than does the dismal science of economics. It is concluded that there is a need for greater consideration of caring as both an outcome and an input in evaluation of health care and that in the specific context of economic evaluation, when considering caring, economists might usefully look to other disciplines to broaden and deepen their conceptualisation of both benefits and costs in their economic evaluation studies. PMID- 10164905 TI - Health outcomes are about choices and values: an economic perspective on the health outcomes movement. AB - The aim of the health outcomes movement is to reorientate health services so that the spotlight shines less on what is done and more on what is achieved. The health outcomes movement, thus far, has been most successful in addressing what appear to be technical questions relating to the measurement and analysis of health outcomes and in placing their routine use on the agenda of clinical practice and health services planning. If there is one lesson to be drawn from an economic perspective, however, it is that health outcomes are about values and not just technicalities. The need to make choices forces one to consider whether what is achieved is also what is most valued. The success of health service delivery, be it at a clinical, planning or systems level, must therefore be measured against agreed objectives. It follows that time must be taken to establish what patients and the community want from their health services and what each is prepared to give up to achieve its ends. Value judgements are unavoidable. The challenge lies not in measuring the outcomes of health interventions but in deciding what the objectives of the health system ought to be. PMID- 10164906 TI - When outcomes threaten incomes: a case study of the obstruction of research to reduce teenage smoking. AB - A case study is presented of Australian efforts to promote an evidence-based, outcome-oriented intervention designed to reduce purchasing of cigarettes by minors. The intervention was supported by a wealth of international research literature, yet for several years was declared unethical by local institutional ethics committees. Eight objections that were raised are reviewed. Each of these objections was spurious yet initially influential. Various advocacy strategies were employed by proponents of the intervention to reframe its public definition. These gradually transformed perceptions of the intervention from one that considered it unethical, to one that considered it a virtual 'vaccine against teenage access to cigarettes' that should be incorporated into routine public health best practice. Those advocating outcome-oriented interventions should not assume that the imperative of influencing health outcomes will dominate perceptions of best practice within the health care system. In situations where competing definitions of the meaning of an intervention dominate decision makers' perceptions of outcome-oriented research, advocacy can be used to reframe these definitions more toward perceptions which are conducive to support and implementation. PMID- 10164907 TI - Outcomes-based resource allocation for indigenous health services: a model for northern Australia? AB - Wide differentials continue to exist in mortality rates and other health outcomes between Aboriginal and non-Aboriginal Australians. In the Northern Territory (NT), where Aborigines make up 24% of the population, the all-causes age-adjusted Standardised Mortality Ratio for Aborigines compared to non-Aborigines has remained above 3 since the late 1970s, with significant regional variations. During 1995 an expenditure analysis was undertaken for primary health care (PHC) services in different regions of the NT and compared to mortality ratios. At the same time a method for needs-based funding was being developed which could replace the existing historical funding arrangements. In the first instance, the application of a simplified version of this Resource Allocation Formula (RAF) resulted in a significant shift of resources for new prevention program funding to regions of relatively high mortality and low per capita PHC expenditure. However, developing RAFs to redistribute at the margin within the NT is likely to generate further inequities between losing NT programs and counterparts in other states. If outcomes-based resource allocation is to be meaningful nationally, the reference point for the RAF should be national average PHC expenditure rather than existing state averages. There is a need for a combined approach to outcomes based planning which takes into account both the equity arguments of resource allocation models and efficacy arguments to maximise health gains. Some of these arguments are explored in this paper. PMID- 10164908 TI - Vertical equity: weighting outcomes? or establishing procedures? AB - Considerations of equity in the health policy literature have in the main focussed on horizontal equity (the equal treatment of equals) and as a consequence have tended to overlook vertical equity (the unequal, but equitable, treatment of unequals). There is evidence from earlier, if preliminary, work carried out by the authors and a colleague that health care decision makers may well want to embrace concerns for vertical equity in the allocation of health service resources. This paper examines some possibilities for incorporating vertical equity into health care policy through distributive and/or procedural justice. While no firm solutions are offered, it is suggested that the idea of fitting John Broome's notion of 'claims' within a communitarian framework holds promise. PMID- 10164909 TI - Recipe for healing: a blend of U.S. standards and Mexican culture. PMID- 10164910 TI - Designing for health in the new millennium. Architects have a bigger nut to crack in the 21st century: the health network. PMID- 10164911 TI - Healing from the inside out. PMID- 10164912 TI - Clear the floor! Five steps to better-looking (and safer) corridors. PMID- 10164913 TI - Patient-focused care: can multi-skilled workers work for you?. PMID- 10164915 TI - Premier rolls out latest pacts; discounts are leaner this time. PMID- 10164914 TI - Price of paper down; heading up. PMID- 10164916 TI - Prices to rise in early 1997, then stabilize. National Association of Purchasing Management. PMID- 10164917 TI - Capitated supply agreements not for everyone. PMID- 10164918 TI - Directory of CE & biomedical organizations. PMID- 10164919 TI - Power quality issues and the effects on medical equipment. AB - Power quality issues are becoming more important as more medical equipment utilizes microprocessor controls and switched DC power supplies. Externally and internally induced power surges and harmonics can have a dramatic effect on equipment performance. The effectiveness of a good "Equipment Management Program" can be greatly affected by poor power quality in today's hospitals. With many hospitals having been constructed in the 1970's, there is an increased likelihood that this issue will play a part in equipment downtime, and more importantly in "unable to duplicate" findings by the Clinical Engineering staff. Resolving power quality problems can have a dramatic impact on equipment performance, uptime, and cost of maintenance. This presentation will focus on identifying power quality problems, solutions, and an overall management scheme to minimize the impact on the performance of critical equipment that your facility and staff rely on to deliver cost effective patient care. PMID- 10164920 TI - Defining the scope of an equipment management program. PMID- 10164921 TI - ETT (endotracheal tube) alert. PMID- 10164922 TI - Disaster medical response. What are the Feds doing? PMID- 10164923 TI - Behind every good IC ... there's a Radar. Successful incident command demands a creative use of diversity and resources. PMID- 10164924 TI - Bang! A simulated shooting brings MCI response to life. PMID- 10164925 TI - Prime time. Make the most of the media's golden hour. PMID- 10164926 TI - Joint Commission announces creation of performance improvement awards. PMID- 10164927 TI - Orion-Tennessee: "live" field laboratory. PMID- 10164928 TI - New Comprehensive Accreditation Manual for Hospitals supports continuous performance improvement. PMID- 10164929 TI - Long-Term Care Accreditation Program celebrates 30 years anniversary. PMID- 10164930 TI - Oklahoma hospital uses interdisciplinary approach to prepare for survey. Valley View Regional Hospital. PMID- 10164931 TI - Joint Commission to offer accreditation services in other countries. PMID- 10164932 TI - Long-term care surveyors to use laptops in 1997. PMID- 10164934 TI - Accredited laboratories have 30 days to report mergers and acquisitions. PMID- 10164933 TI - New Early Survey Policy option modified. PMID- 10164935 TI - A volunteer program at a supportive residence for people with AIDS. AB - Bonaventure House in Chicago is one of two adult licensed supportive residences in the State of Illinois for people living with AIDS. Residents have access to medical case management, pastoral care, social workers/counselors, and recovery programs for substance addiction. Over 120 volunteers provide practical and supportive services for the residents. This article reports on management procedures and challenges faced by the Bonaventure House volunteer program. PMID- 10164936 TI - Pay now, cut later. N.Y. Medicare project aims at slowing teaching costs. PMID- 10164937 TI - IMGs (international medical graduates) targeted. Residency slot cuts could hit foreign grads hardest. PMID- 10164938 TI - JCAHO tries again. Agency moves to accredit providers based on outcomes. PMID- 10164939 TI - HealthSouth's new horizons. Latest purchase would give it lock on inpatient rehab. PMID- 10164941 TI - Campaign coffees. Healthcare executives perk up Democrats' coffers. PMID- 10164940 TI - It's a done deal, but ... details will delay PacifiCare-FHP consolidation. PMID- 10164942 TI - Here comes PPS. Post-acute providers gear up for prospective payment. PMID- 10164943 TI - Patient preferences driving healthcare services. PMID- 10164944 TI - Optimizing integrated systems governance. PMID- 10164945 TI - Understanding variation to help manage resources. PMID- 10164946 TI - Exploring elements that make mergers work. PMID- 10164948 TI - Getting the most from information technology. PMID- 10164947 TI - Fixing management service organizations. PMID- 10164949 TI - Underscoring ethics in healthcare management. PMID- 10164950 TI - Developing rural healthcare delivery systems. PMID- 10164951 TI - Pondering the future of JCAHO. PMID- 10164952 TI - Scrutiny from the states. Except for Columbia, probes having little effect on deals. PMID- 10164953 TI - Three challenges facing hospitals: what kind of regulation? What kind of payment? What kind of linkage? PMID- 10164954 TI - What kind of regulation? An academic medical center perspective. PMID- 10164955 TI - What kind of linkage? A community hospital perspective. PMID- 10164956 TI - What kind of linkage? A community hospital perspective. Containing health care costs through linkage: regionalization, collaboration, and strategic planning, among community hospitals. PMID- 10164957 TI - What kind of regulation? A system perspective. PMID- 10164958 TI - What kind of regulation? A community hospital perspective. PMID- 10164959 TI - What kind of regulation? A community hospital perspective. PMID- 10164960 TI - What kind of payment? An introduction. PMID- 10164961 TI - What kind of payment? An academic medical center perspective. PMID- 10164962 TI - What kind of payment? A system perspective. PMID- 10164963 TI - What kind of payment? A community hospital perspective. PMID- 10164964 TI - What kind of payment? A community hospital perspective. PMID- 10164965 TI - What kind of linkage? An introduction. PMID- 10164966 TI - What kind of linkage? An academic medical center perspective. PMID- 10164967 TI - What kind of linkage? A system perspective. PMID- 10164968 TI - Physician-hospital organizations and PHO executives. What lies ahead for the PHO? AB - The 1996/97 Profile of Physician-Hospital Organizations and PHO Executives, jointly conducted by the American Association of Physician-Hospital Organizations/Integrated Delivery Systems (AAPHO/IDS) and Tyler & Company, takes a closer look at the PHO and trends within the health care system. In examining contracting, enrollees, staff size and experience, compensation, incentives, and projected salary increase for CEOs, the survey found that the PHO is in the midst of transformation into an integrated delivery system. As physicians and hospitals form a team to deliver more efficient and cost-effective health care to patients, they are paving the way to the integrated delivery system. The survey also focuses on the details of the PHO and PHO executives, including an in-depth look at all aspects of compensation for the CEO. PMID- 10164969 TI - An evolving medical leadership position. Tomorrow's Vice President for Medical Affairs. AB - The role of medical leadership in hospitals and health systems is under constant scrutiny and change. The nature of the Vice President for Medical Affairs (VPMA) position and its relationship to leadership in the health care system is explored through a national panel survey conducted recently. The effective VPMA will: be an aggressive manager able to implement change, address strategic planning and quality of care issues; have a high level of integrity; and be a good communicator and problem solver. The results of the research are presented in three sections. The first section describes the background characteristics and compensation of the VPMAs who participated in the survey. The second section focuses on the current role of the VPMA, including duties and responsibilities, job performance barriers and required skills. The final section addresses respondents' perceptions regarding areas for improvement in the role of the VPMA, as well as projections for future changes in this position. PMID- 10164970 TI - Organization theory. Analyzing health care organizations. AB - Organization theory (OT) is a tool that can be applied to analyze and understand health care organizations. Transaction cost theory is used to explain, in a unifying fashion, the myriad changes being undertaken by different groups of constituencies in health care. Agency theory is applied to aligning economic incentives needed to ensure Integrated Delivery System (IDS) success. By using tools such as OT, a clearer understanding of organizational changes is possible. PMID- 10164971 TI - Revised antitrust guidelines. Forming physician network joint ventures. AB - What do physician executives need to know about antitrust guidelines? This article presents an overview of the revised "Statements of Antitrust Enforcement Policy in the Health Care Area," released in late 1996. Antitrust concepts and implicated federal statutes are described, and implications for forming physician network joint ventures are explored. Requirements of the revised standards used by the agencies to determine a permissible integration are addressed, as well as the factors considered in antitrust scrutiny of physician ventures. PMID- 10164972 TI - Health care fraud and abuse. What physician executives need to know. AB - Fraud and abuse, which can occur in all industries, also exist in the health care industry. This problem is compounded by the reality that "American medicine, although undergoing evolution, now faces changes of a magnitude that has never before been encountered." These changes are creating new realities for physician executives and also new challenges. As there are changes in business practices, there will be changes in how fraud occurs in health care. Physician executives need to be sensitive to the possibility of fraud and abuse as an unwanted component in medical losses in managed care systems. PMID- 10164973 TI - Touching what is, touching what might be. AB - How do you master change? You have to master the paradox of changing while staying grounded. To make use of the power living inside any new thing that comes your way, you first have to touch it--not tentatively but profoundly--at the same time that you maintain a firm connection with that which is deepest and most fundamental within you. Here, some ideas on how to create "touch points," the ability to look at a problem or impending change from many different angles, thus broadening your understanding and possible response. A key tactic in creating a variety of touch points is quite simple: Ask a lot of questions. Ask especially the questions that have difficult answers, or for which you suspect there is no answer. PMID- 10164974 TI - Conquer job overload. AB - How can you handle job overload? Think intensively about what you're doing. One of the least recognized facts is that jobs expand, even when managers are actively bent on reducing workloads. Prioritizing tasks--on paper--can help eliminate tasks that clog your day and are enemies of productivity, things that someone else could--and should--be doing. Until you see, in writing, how you spend your time how can you change? PMID- 10164975 TI - Organizational politics: did you hear? AB - How do you define organizational politics? The underground system of communication, the grapevine, what's really going on in the organization, rumors, knowing who really has the power? However you define it, all sources agree you'd better not ignore it. According to one physician executive: "Organizational politics is how things really get done, who really has the power, how decisions get made. Things are not always what they appear to be on the organizational chart." Presented here are some thoughts about organizational politics from physician executives and their stories of when it helped or hurt their careers or prevented them from accomplishing something in their organizations. PMID- 10164976 TI - The chasm: what can be done, and what should be done. AB - The case study of growth hormone in short-stature children offers an example of the high cost of bioengineered therapies and the attendant ethical concerns. Despite uncertainties as to its efficacy, it is estimated that the annual U.S. expenditure for growth hormone, which costs about $20,000 per year for a 30 kg child, exceeds $375 million dollars. Ultimately, at this point in its evolution, the use of GH therapy illustrates the dilemma commonly created by new medical technology--the chasm between what can be done and what should be done. Unfortunately, the knowledge of what can be done precedes the understanding of what should be done. PMID- 10164977 TI - Reinventing a medical specialty. Using anesthesiology as a model for change. AB - In only a decade, anesthesiology has reversed its fortunes from an underrepresented specialty in the 1980 Graduate Medical Education National Advisory Committee report to "a specialty in trouble" featured in The Wall Street Journal. This article focuses on anesthesiology and its work force dilemma as an evolving specialist model for change. What is happening to anesthesiology will not be unique--managed care competition will affect all physicians. Most specialties will have to reshape curricula and redesign education programs and academic delivery systems concentrating on fewer trainees. What are the options for coping with physicians grieving over lost dreams, such as autonomy and solo practice, while redesigning a medical specialty? The authors untangle fact from fear, mission from myth, and offer strategic thinking and solutions. PMID- 10164978 TI - Changing practice expense values: impact on radiology payment. PMID- 10164979 TI - Home-based radiology transcription and a productivity pay plan. AB - Shands Hospital in Gainesville, Fla., decided to evaluate the way it provided transcription services in its radiology department. It identified four goals: increased productivity, decreased operating expense, finding much needed space in the radiology department and increasing employee morale. The department performs 165,000 procedures annually, with 66 radiologists, 29 faculty, and 37 residents and fellows on staff. Six FTEs comprised the transcription pool in the radiology department, with transcription their only duty. Transcriptionists were paid an hourly rate based on their years of service, not their productivity. Evaluation and measurement studies were undertaken by the hospital's management systems engineering department. The transcriptionists' hours were then changed to provide coverage during the periods of heaviest dictation. The productivity level of the transcription staff was also measured and various methods of measurement reviewed. The goal was a pure incentive pay plan that would reward employees for every increase in productivity. The incentive pay plan was phased in over a three month period. Transcriptionists were paid for work performed, with no base pay beyond minimum wage. The move to home-based transcription was planned. The necessary equipment was identified and various issues specific to working at home were addressed. Approximately six months later, the transcriptionists were set up to work at home. The astounding results achieved are presented: 28% increase in productivity, operational cost savings exceeding $25,000 and a space savings of 238 square feet. PMID- 10164980 TI - Simplifying the management of the environment of care. AB - In 1995, the JCAHO introduced a new chapter for its manual called "Management of the Environment of Care (EC)." The chapter provides a common-sense organization to a department by grouping similar subjects around the common goals of safety, security, hazardous materials, emergency preparedness, life safety, medical equipment and utility systems. Its focus always remains on patient care. Forty five individual standards are listed in the EC chapter under four categories: design, implementation, measuring outcomes and implementation, and social environment. Follow the step-by-step instructions to determine the policies and procedures you'll need to generate in your own organizational plan. Teaching becomes critical and requires nearly an almost continuous effort to maintain competency and ensure safety--no one can afford to take chances and put either patients or staff in jeopardy. For each of the standards in the design section, the JCAHO manual identifies exactly what to teach. Regarding medical equipment, the EC chapter indicates what to measure, along with the necessary steps for maintaining an information collection and evaluation system. When you design your quality improvement plans, evaluate how your medical equipment might improve the quality of patient care or staff safety. Evaluate your medical equipment plan (or policies) annually by asking your staff if it works. PMID- 10164981 TI - Changing the face of radiology: redesigning patient-focused care. AB - Mercy Hospital began the redesign of its patient-focused care in 1991. A steering committee composed of members from multiple disciplines was asked to create a seamless, patient-focused environment that would coordinate and align hospital resources in the service of patients and families. The director of diagnostic and clinical services served on that committee and used the committee's operating goals and principles to transform Mercy's radiology department into a diagnostic center. As part of its redesign effort, the radiology department reviewed its outpatient environment. Since so many of its patients came to have at least one of three procedures (EKGs, radiology exams and phlebotomy services) and since they must all register, the department decided to concentrate first on its registration procedure. A meeting with the medical records department resulted in the reception and scheduling staffs learning the registration process. After the two staffs went through an aggressive training program of about three months, it was possible to combine the two positions into one. Training staff members to schedule all modalities in the radiology department was next. With further cross training, staff members now perform centralized scheduling for radiology, endoscopy and osteoporosis. Physicians can schedule such exams with only one phone call. Could technologists learn to draw blood too? Members of the healthcare team accepted the challenge to become more diversified and expand their skills. The author explains how the technologists became certified phlebotomists. With that success underway, the team accepted volunteers for EKG training. The author presents the benefits of the various steps taken, and looks at possible future opportunities in cross-training at the hospital. PMID- 10164982 TI - A guide to parents' participation in pediatric imaging. AB - Family-centered care requires collaboration between the caregivers and the care seekers at all levels of healthcare. Even the JCAHO Handbook outlines what families can expect from those providing care. Managers of pediatric imaging departments need to evaluate how far to incorporate these Joint Commission requirements into their own hospitals regulations. The house rules of the radiology department at Children's Hospital in Omaha, Neb., where this author is manager, are discussed. State radiation regulations, radiologists' preferences and staff experience in promoting patient cooperation must all be considered when a hospital is preparing to define its own regulations. The Children's Hospital radiology department surveyed 40 children's hospitals across the United States. Although 54% of the responding hospitals allow both parents to accompany a child into the examining room, Children's Hospital elected not to change its practice of allowing only one parent in the room. Although it may not fully meet the needs of parents and children, the hospital believes its practice meets the best interests of its patients. PMID- 10164983 TI - Managing a multicultural radiology staff. AB - Opportunities for minorities in healthcare increased with the Civil Rights movement in the 1960s. More recently, funds from the U.S. Public Health Service have been targeted toward disadvantaged minorities. The workforce in healthcare, and in business in general, has become increasingly multicultural. Much of the literature in healthcare management lacks practical guidelines for managing a diverse workforce. Communication, both verbal and nonverbal, and culture are closely intertwined. Managers, as they develop multicultural teams, will need to understand how culture influences communication in their organizations. Space, spatial behavior, and cultural attitudes influence people's behavior. This is a particularly important consideration for a radiology staff, which must often work in close quarters. For some cultural groups, the family as an organization has more significance than even personal, work-related or national causes. People's orientation to time, whether for the past, present or future, is usually related to the culture in which they grew up. Again, this may become an important issue for a radiology administrator whose organization must run punctually and time efficiently. How patients feel about their environment, whether they believe they are in control or believe in an external locus of control, is of particular interest to those who attempt therapeutic changes in a patient's healthcare. Does the patient believe that illness is divine will or that suffering is intrinsic to the human condition? There is increasing research in the United States to show that people do differ biologically according to race. Such differences exist among patients as well as among staff members. It has been popular to assume that differences among races do not exist. Unfortunately such an attitude does not allow for different attributes and responses of individuals. Managing a multicultural staff presents a challenge to administrators who must be skilled in working with culturally diverse people and must help their staff members do the same. PMID- 10164984 TI - An overview of nursing homes and their current residents: data from the 1995 National Nursing Home Survey. AB - OBJECTIVE: This report presents data on the characteristics of nursing homes, utilization by current residents and number of employees. Characteristics of the nursing homes include ownership, certification, bed size, location, and affiliation. Current residents are presented by age, sex and race. Selected trend data are presented from three previous National Nursing Home Surveys. METHODS: Data presented in this report are from the 1995 National Nursing Home Survey (NNHS). The 1995 NNHS consisted of a two-stage design with a probability sample of 1,500 nursing facilities in the first stage and up to six current residents in the second stage. RESULTS: About 1.5 million residents were receiving care in 16,700 nursing homes in 1995. Nearly 1.8 million beds were available for use and these facilities operated at about 87 percent of their capacity. The residents were elderly, predominantly female, and white. Since 1985, the number of nursing homes decreased by 13 percent while the number of beds increased by 9 percent. PMID- 10164985 TI - Curtailing medical staff privileges: a case study. PMID- 10164987 TI - CHEM seminar offers help for violence prevention efforts. PMID- 10164986 TI - How to use risk-adjusted quality indicators to assess hospitals. PMID- 10164988 TI - Horizontal accounting considered for the hospital setting. PMID- 10164989 TI - Fatal doses. Assisted suicide soars in an afflicted community. PMID- 10164990 TI - The mammogram war. PMID- 10164991 TI - Beyond the mammogram. PMID- 10164992 TI - A surgeon's challenge. PMID- 10164993 TI - Issues in mental health care benefits: the costs of mental health parity. AB - This Issue Brief discusses issues in mental health care benefits. It describes the current state of employment-based mental health benefits and discusses studies and issues regarding full mental health parity. It also includes an analysis of the effect of full mental parity on the uninsured population and the effects of the limited mental health parity provision contained in the VA-HUD appropriations bill. The final section discusses the implications of mental health parity for health plans and health insurers. When employers began to provide health insurance benefits to their employees and their families, they extended coverage to include mental health benefits under the same terms as other health care services. Many employers continued to add mental health benefits through the 1970s and early 1980s until cost pressures required employers to re examine all health care benefits that were offered. They quickly found that, while only a small proportion of the beneficiaries used mental health care services, the costs associated with this care were very high. As a result, employers placed limits on mental health benefits in an attempt to make the insurance risk more manageable. The general strategies employers have used to manage their health care costs are cost sharing, utilization review, managed care, and the packaging of provider services. Employers' cost management strategies may be restricted, however. Five states have mental health parity laws, but three of the states--Rhode Island, Maine, and New Hampshire--apply these laws only to the seriously mentally ill. In addition, 31 states mandate that mental health benefits be provided. However, state mandates apply only to insured plans, not to self-insured employer plans, which are exempt from state regulation of health plans under the Employee Retirement Income Security Act of 1974 (ERISA). A number of recent studies have examined the effect of mental health parity on health insurance premiums in a "typical" preferred provider organization and on the uninsured. In general, the studies concluded that mental health parity could increase health insurance premiums, decrease health insurance coverage for non-mental health related illnesses, and increase the number of uninsured individuals. All studies of mental health parity, and mandated benefits in general, assume that there is a strong likelihood that increased health benefit costs would be passed along to workers in the form of higher cost sharing for health insurance, lower wage growth, or lower growth in other employee benefits. PMID- 10164994 TI - Improving the quality of care for depressed patients with comorbid psychiatric disorders: a review. AB - Comorbidity of depression complicates diagnosis and makes treatment more difficult. The broad efficacy of selective-seratonin reuptake inhibitors makes these compounds of particular benefit as monotherapy for depression comorbid with anxiety disorders, especially panic disorder and obsessive-compulsive disorder. PMID- 10164995 TI - Infection control to quality improvement: the right time, the right place, the work to be done. AB - Many infection control epidemiologists are moving into the quality improvement field. The marriage of epidemiology with quality improvement is a logical step. Several things have to happen for this union to be successful, however. Most importantly, collaborative relationships must be forged with a variety of healthcare providers and practical, reliable, and valid indicators, and the methods for measuring them must be developed. This will take time, but epidemiologists should insist on and support the development of a robust discipline that combines the best of both worlds. PMID- 10164996 TI - Use of variance from clinical paths: coming of age. AB - The introduction of critical paths, generically referred to as clinical paths, into the planning, delivery, documentation, and evaluation of patient care provided a tangible method for clinical experts to identify elements they collaboratively perceived to represent a stable, predictable, patient-care episode. Variance is the difference between the planned, stable process for a homogeneous group of patients and the actual, individual, unique care delivery experience. Building the formal use of both task (intervention) and outcome variance into a clinical path approach is fundamental to the individualization of care given concurrently and the creation of an aggregate database for retrospective evaluation, continuous quality improvement, and research. As clinical paths have become more accepted and sophisticated over the last decade, the use of variance also has evolved, albeit one step behind. Variance from length of stay and task (intervention)/resource still predominates clinical path application and literature. Real progress in healthcare practice will not be made until variances from measurable intermediate goals and patient responses and outcomes are combined with other data and transformed into knowledge. The use of variance, from past to future stages, provides a mirror of the transformation of healthcare delivery in the United States and other countries. PMID- 10164997 TI - Social and economic impact of infectious diseases--United States. AB - Despite major strides in the prevention and control of infectious diseases, they continue to take a significant economic and social toll in the United States. While progress toward meeting the Healthy People (HP) 2000 goals related to infections is generally on target, major disparities among certain groups (e.g., low-income, racial and ethnic minorities) still exist with regard to indicators such as immunization rates and rates of preventable infections. Preventable services for infectious diseases are among the most cost-effective. Progress toward meeting and sustaining the HP 2000 goals would be improved by universal entitlement for certain prevention services; reducing inconvenience as well as economic costs; appropriate utilization of all healthcare professionals and lay experts, as well as physicians; reducing inappropriate and costly use of resources such as antibiotics and specialist time; and engagement of the public and providers in national dialogue about risk benefit decision making, prioritization of use resources, and a focus on prevention rather than cure. PMID- 10164998 TI - SatelLife: pioneering the path for electronic communication and health information in the developing world. AB - Information poverty is one of the most significant obstacles to better health in the developing world. To address this problem, SatelLife, a Boston-based nonprofit organization has created HealthNet, a computer-based network linking healthworkers throughout the world to facilitate the exchange of health-related information. Using low-cost, sustainable technologies, SatelLife provides both electronic mail communications services and a variety of information services including electronic publications, electronic access to remote databases, and ongoing electronic conferences on topics of special relevance to health in the developing world. The article cautions that simply bringing high-speed Internet access to the developing world will not solve problems of information poverty, because such technology will be prohibitively expensive for all but the elite private sector and because of the need to provide targeted, high-quality information, not simply access to the vast, disorganized universe of information available on the Internet. PMID- 10164999 TI - Marketplace challenges and opportunities for faculty practice plans. AB - Because of marketplace challenges related to the growth of managed care, faculty practice plans (FPPs) now are faced with issues similar to community group practices. Emphasis on primary care and price discounts are particularly thorny concerns. Unreimbursed care looms as a hazards for the FPPs affiliated with teaching hospitals in low socioeconomic areas. However, as the marketplace cultivates more global pricing strategies, the FPP-hospital relationship also could prove a distinct advantage. Additionally, the recent emergence of practice management corporations could represent opportunities for FPPs, who need new competencies, and even capital, to remain competitive. This article also discusses the promise of integrated delivery networks and addresses the construction of community partnerships. PMID- 10165001 TI - Confidentiality of medical quality assurance (QA) records and delegation of authority to Deputy Secretary of Defense; removal--DoD. Final rule. AB - This document removes the Department of Defense's Confidentiality of Medical Quality Assurance (QA) Records and the organizational charter on the Delegation of Authority to Deputy Secretary of Defense codified in the CFR. The parts have served the purpose for which they were intended in the CFR and are no longer necessary. PMID- 10165000 TI - Resource-based relative-value scale expansion: implications for performance and quality of care. AB - OBJECTIVE: To assess the impact on the delivery of physician services from expanded use of Medicare's Resource-Based Relative-Value Scale (RBRVS) by multiple payers. DESIGN: A 1993 survey of insurers and targeted case studies of payers. RESULTS: Approximately one third of surveyed payers were using RBRVS in some fashion to pay for physician services, while another 40% were considering its adoption. The RBRVS is spreading to many types of payers--both public and private--and to health insurance product lines. Penetration of RBRVS is most prevalent within managed-care arrangements, accounting for 75% of all RBRVS-based products among payers. Many payers were found to be modifying aspects of the RBRVS and applying payment policies tailored to their specific needs. Most payers expect to achieve cost control, and several may be using RBRVS to profile physician service utilization. CONCLUSIONS: The diffusion or RBRVS to multiple payers may have a profound impact on the distribution of services provided, how these services are delivered, and the quality of care provided. Providers may respond to RBRVS by reducing some types of services, while increasing others, and using new resource combinations. Managed-care payers are likely to continue using RBRVS for negotiating fee schedules or for allocating payments for bundled service packages and capitation and sub-capitation products among physicians. As larger shares of physicians' incomes are driven by RBRVS, the underlying incentives become more critical. Nevertheless, RBRVS will remain an important payment approach in the future. The impact on quality and delivery of physician services from broader use of RBRVS cannot be measured adequately until future empirical studies are undertaken. PMID- 10165002 TI - VA homeless providers grant and per diem program clarification of per diem eligibility--VA. Final rule. AB - This document amends the regulations implementing the VA Homeless Providers Grant and Per Diem Program concerning per diem assistance by: Establishing more detailed criteria for determining which entities are eligible for obtaining per diem assistance; establishing a priority for funding eligible entities: Clarifying the requirements for continued receipt of per diem payments; and clarifying the maximum amount payable for per diem assistance. This rule is designed to ensure that the appropriate entities receive the appropriate amount of per diem assistance under fair and objective procedures. PMID- 10165003 TI - Gramm slam. AB - A presidential loser in 1996, Sen. Phil Gramm, R-Texas, is back. The head of the Republicans' health care task force and the new chairman of a key Finance subcommittee, Gramm is pushing for dramatic changes in medicare. PMID- 10165004 TI - Providers seek assurances on Internet reliability. PMID- 10165005 TI - Users groups offer valuable opportunities to compare notes. PMID- 10165006 TI - Comparing hospital I.S. departments. PMID- 10165007 TI - Managed Care. Pay now, save later. PMID- 10165008 TI - Telemedicine. Pick a line, any line. PMID- 10165010 TI - A guide to the guides. PMID- 10165009 TI - Vocabulary lessons. PMID- 10165011 TI - Where do VANS (value added networks) fit in? PMID- 10165012 TI - A physician leads the technology team. Interview by Lynne Brakeman. PMID- 10165013 TI - Computers in the curriculum. PMID- 10165014 TI - Electronic purchasing pays off. PMID- 10165015 TI - Enterprise networks. Strategies for integrated delivery systems. AB - More integrated delivery systems are making progress toward building computer networks that link all their care delivery sites so they can efficiently and economically coordinate care. A growing number of these systems are turning to intranets--private computer networks that use Internet-derived protocols and technologies--to move information that's essential to managing scare health care resources. PMID- 10165016 TI - Can object technology meet health care's programming needs? AB - Although object technology is just starting to make inroads in programming for health care applications, some observers predict it will drive information systems into the next century and beyond. Objects technology could play a major role in quicker development of the computer-based patient record and in easing the creation of links between systems. PMID- 10165017 TI - The battle between Unix and Windows NT. AB - For more than a decade, Unix has been the dominant back-end operating system in health care. But that prominent position is being challenged by Windows NT, touted by its developer, Microsoft Corp., as the operating system of the future. CIOs and others are attempting to figure out which system is the best choice in the long run. PMID- 10165018 TI - Records on the Internet. AB - Many in health care see great promise in transmitting clinical information over the Internet because the protocols and technologies that make the global network of computer networks function are widely used and accepted. But so far, only a handful of organizations are actually using the Internet to send medical information. More are testing the concept on intranets, private networks that use Internet protocols and technologies. Security and reliability of the Internet remain top concerns for providers. PMID- 10165019 TI - ER: boon for emergency medicine? PMID- 10165020 TI - Nurse actors on ER get input from field. PMID- 10165021 TI - Design choices can increase ED's efficiency. PMID- 10165023 TI - Be proactive with an alternative airway box. PMID- 10165022 TI - Hands-on input is key to the design process. PMID- 10165024 TI - 1997 Presidents' Forum. PMID- 10165025 TI - Role of consumer information in today's health care system. AB - This overview discusses articles published in this issue of the Health Care Financing Review, entitled "Consumer Information in a Changing Health Care System." The overview describes several trends promoting more active consumer participation in health decisions and how consumer information facilitates that role. Major issues in developing consumer information are presented, stressing how orientation to consumer needs and use of social marketing techniques can yield improvement. The majority of the articles published in this issue of the Review discuss different aspects of information for choice of health plan, ranging from consumer perspectives on their information needs and their comprehension of quality indicators, to methods used for providing such information, such as direct counseling and comparative health plan performance data. The article concludes with thoughts on how we will know if we succeed in developing effective consumer health information. PMID- 10165026 TI - Employer-specific versus community-wide report cards: is there a difference? AB - This article describes preliminary results from a natural experiment that tested the impact of report cards on employees. As part of the 1995 enrollment process, some members of the State of Minnesota Employee Group Insurance Program received report cards on the plans offered to them, and others did not. Both groups of employees had a chance to review a second community-wide report card covering all Minnesota plans that had been distributed by an independent organization through local newspapers. Both groups were surveyed before and after they made their health plan selections. We compare the likelihood of seeing, the intensity of reading, and the perceived helpfulness of the first, employer-specific report card with the second, community-wide report card for consumers who make plan selections. PMID- 10165027 TI - Medicare beneficiary counseling programs: what are they and do they work? AB - Medicare beneficiaries face myriad rules, conditions, and exceptions under the Medicare program. As a result, State Information, Counseling, and Assistance (ICA) programs were established or enhanced with Federal funding as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. ICA programs utilize a volunteer-based and locally-sponsored support system to deliver free and unbiased counseling on the Medicare program and related health insurance issues. This article discusses the effectiveness of the ICA model. Because the ICA programs serve as a vital link between HCFA and its beneficiaries, information about the programs' success may be useful to HCFA and other policymakers during this era of consumer information. PMID- 10165028 TI - Personal decisionmaking styles and long-term care choices. AB - To learn more about how older people make decisions about long-term care (LTC), in-depth interviews were conducted with 63 elderly individuals and 56 of their relatives to obtain information on the decisionmaking process. This qualitative research showed that LTC decisionmaking does not always follow typical consumer decisionmaking models, in which a consumer seeks a product or service, selects among the alternatives, and assesses the choice. Further, the interviews yielded four long-term care decisionmaking styles among older adults related to their degree of planning or not planning. This study underscores the need to develop tailored communications for older people and their families aimed at encouraging appropriate and cost-effective use of LTC services. PMID- 10165029 TI - Consumer information development and use. AB - The availability of informational materials to aid consumer health care purchasing decisions is increasing. Organizations developing and disseminating materials include public- and private-sector employers, providers, purchasing cooperatives, State agencies, counseling programs, and accreditation bodies. Based on case study interviews with 24 organizations, we learned that 10 included consumer satisfaction ratings and performance measures based on medical records. An additional four organizations developed materials with consumer satisfaction ratings exclusively. Printed materials were the most common medium used to convey information to consumers. However, other mechanisms for conveying the information were also employed. On the whole, the materials have not been rigorously evaluated. Evaluations are needed to determine if consumers find the information useful and how different individuals prefer to receive the information. PMID- 10165030 TI - Medigap reform legislation of 1990: have the objectives been met? AB - The 1990 medigap reform legislation had multiple objectives: To simplify the insurance market in order to facilitate policy comparison, provide consumer choice, provide market stability, promote competition, and avoid adverse selection. Based on case study interviews with a cross-section of individuals and organizations, we report that most of these objectives have been achieved. Consumers of medigap plans are able to make more informed choices, largely because they can adequately compare policies based on standard benefits. Marketing abuses have apparently declined, as evidenced by a decrease in the number of consumer complaints. Finally, no major detrimental impact on the insurance industry was detected. Beneficiaries still face some confusion in this market, however, such as understanding the rating methodologies used to set premiums and how this may affect their choices. Confusion could increase with the growth of managed care options. PMID- 10165032 TI - Border-crossing adjustment and personal health care spending by state. AB - This article presents the results of a pioneering effort by the Health Care Financing Administration (HCFA) to measure interstate border crossing for services used by Medicare and non-Medicare beneficiaries. A major focus is to provide estimates of per capita expenditures by State for individual services. Such estimates are not possible without adjustment for interstate border-crossing flows. This is HCFA's first attempt to furnish a unified per capita personal health care expenditures data base comprising all services and covering total population. The study also analyzes interstate differences in expenditure flows by computing rates of inflow and outflow of expenditures, and highlights Medicare/non-Medicare flow differences. PMID- 10165031 TI - National health expenditures, 1995. AB - This article presents data on health care spending for the United States, covering expenditures for various types of medical services and products and their sources of funding from 1960 to 1995. In 1995, $988.5 billion was spent to purchase health care in the United States, up 5.5 percent from 1994. Growth in spending between 1993 and 1995 was the slowest in more than three decades, primarily because of slow growth in private health insurance and out-of-pocket spending. As a result, the share of health spending funded by private sources fell, reflecting the influence of increased enrollment in managed care plans. PMID- 10165034 TI - Medicare beneficiary information needs: 1994. AB - The Medicare Current Beneficiary Survey (MCBS) is a powerful tool for analyzing enrollees' access to medical care (Adler, 1994). Based on a stratified random sample, we can derive information about the health care use, expenditure, and financing of Medicare's 36 million enrollees. We can also learn about those enrollees' health status, living arrangements, and access to and satisfaction with care. In the charts that follow, we have presented some findings on enrollee information needs in 1994, number of beneficiaries with information needs met, and sources of information used by beneficiaries. These charts attempt to answer the following questions: What types of needs do our beneficiaries have? How well do our beneficiaries understand Medicare? PMID- 10165033 TI - Use of Medicare data to identify incident breast cancer cases. AB - Surveillance, Epidemiology and End Results (SEER) data from the National Cancer Institute (NCI) provide reliable information about cancer incidence. However, because SEER data are geographically limited and have a 2-year time lag, we evaluated whether Medicare data could provide timely information on cancer incidence. Comparing Medicare women hospitalized for breast cancer with women reported to SEER, Medicare data had high specificity (96.6 percent), yet low sensitivity (59.4 percent). We conclude that Medicare hospitalization data can identify incident cases for cancers that usually require inpatient hospitalization. For cancers that often only receive outpatient treatment, such as breast cancer, additional Medicare data, such as physician bills, are needed to understand the entirety of treatment practices. PMID- 10165035 TI - Hospital, employment, and price indicators for the health care industry: first quarter 1996. PMID- 10165036 TI - Role of information in consumer selection of health plans. AB - Considerable efforts are underway in the public and private sectors to increase the amount of information available to consumers when making health plan choices. The objective of this study was to examine the role of information in consumer health plan decisionmaking. A computer system was developed which provides different plan descriptions with the option of accessing varying types and levels of information. The system tracked the information search processes and recorded the hypothetical plan choices of 202 subjects. Results are reported showing the relationship between information and problem perception, preference structure, choice of plan, and attitude towards the decision. PMID- 10165037 TI - Consumer perspectives on information needs for health plan choice. AB - The premise that competition will improve health care assumes that consumers will choose plans that best fit their needs and resources. However, many consumers are frustrated with currently available plan comparison information. We describe results from 22 focus groups in which Medicare beneficiaries, Medicaid enrollees, and privately insured consumers assessed the usefulness of indicators based on consumer survey data and Health Employer Data Information Set (HEDIS)-type measures of quality of care. Considerable education would be required before consumers could interpret report card data to inform plan choices. Policy implications for design and provision of plan information for Medicare beneficiaries and Medicaid enrollees are discussed. PMID- 10165038 TI - Comprehension of quality care indicators: differences among privately insured, publicly insured, and uninsured. AB - This study explores consumers' comprehension of quality indicators appearing in health care report cards. Content analyses of focus group transcripts show differences in understanding individual quality indicators and among three populations: privately insured; Medicaid; and uninsured. Several rounds of coding and analysis assess: the degree of comprehension; what important ideas are not understood; and what exactly is not understood about the indicator (inter-rater reliability exceeded 94 percent). Thus, this study is an educational diagnosis of the comprehension of currently disseminated quality indicators. Fifteen focus groups (5 per insurance type) were conducted with a total of 104 participants. Findings show that consumers with differing access to and experiences with care have different levels of comprehension. Indicators are not well understood and are interpreted in unintended ways. Implications and strategies for communicating and disseminating quality information are discussed. PMID- 10165039 TI - HCFA's consumer information commitment. AB - This article provides examples of how the Health Care Financing Administration is providing Medicare and Medicaid beneficiaries with information that will allow them to become more active participants in decisions affecting their health and well-being. The article emphasizes how HCFA has incorporated a beneficiary centered focus and social marketing techniques in its consumer information activities. The work described in this article represents a cross section of the innovative and excellent work being done by staff throughout the Agency and by our partners and agents in meeting the information needs of beneficiaries. PMID- 10165040 TI - Condition-specific performance information: assessing salience, comprehension, and approaches for communicating quality. AB - This study assesses how consumers view condition-specific performance measures and builds on an earlier study to test an approach for communicating quality information. The study uses three separate designs: a small experiment, a cross sectional analysis of survey data, and focus groups. We test whether providing information on the health care context affects consumer understanding of indicators. Focus groups were used to explore how consumers view performance measures. The cross-sectional survey analysis used survey data from the experiment and the focus groups to look at comprehension and the salience of condition-specific performance measures. Findings show that a general consumer population does view condition-specific performance measures as salient. Further, the findings provide evidence that information on the health care context makes a difference in how consumers understand performance measures. PMID- 10165041 TI - The regional distribution of doctors in Mexico, 1930-1990: a policy assessment. AB - The results of the doctor distributional policy in Mexico is evaluated. Despite the government's efforts to achieve a better distribution of doctors throughout the country between 1930 and 1990, important disparities still exist among geographic areas. Diverse factors ranging from the underdevelopment of some areas, to the resistance of doctors to leave the urban areas, are related to this unequal distribution. Early programmes aimed at redressing the original distribution in the 1930's had limited effects. In subsequent years, additional programmes were implemented. However, a lack of coordination and the short time span of many programmes produced only minor changes to the distributional pattern. Although in recent years the distribution has improved, southern states still suffer an acute scarcity while northern states have a relative abundance. Finally, the paper discusses how economic, political and social variables, as well as the structure of the health system, have shaped the current distribution of Mexican doctors. PMID- 10165042 TI - Risk-adjusted capitation payments for catastrophic risks based on multi-year prior costs. AB - In many countries regulated competition among health insurance companies has recently been proposed or implemented. A crucial issue is whether or not the benefits package offered by competing insurers should also cover catastrophic risks (like several forms of expensive long-term care) in addition to non catastrophic risks (like hospital care and physician services). In 1988 the Dutch government proposed compulsory national health insurance based on regulated competition among insurer as well as among providers of care. The competing insurers should offer a benefits package covering both non-catastrophic risks and catastrophic risks. The insurers would be largely financed via risk-adjusted capitation payments. The government intended to use a capitation formula that is, besides some demographic variables, based on multi-year prior costs. This paper presents the results of an explorative empirical analysis of the possible consequences of such a capitation formula for catastrophic risks. The main conclusion is that this formula would be inadequate because it would leave ample room for cream skimming. PMID- 10165043 TI - China's health care sector in transition: resources, demand and reforms. AB - Economic development and reforms have had profound impacts on China's health care sector. As a result, the health care sector in China is in transition. This report reviews the major changes, and the possible policy response to these changes in China's health care sector. It discusses resource availability in the Chinese health sector, and analyses the trend of household demand for health care goods and services. This study also examines the trade and investment situations in China's health sector and investigates the major forces that are driving the transition in health care and comments on the potential policy responses. PMID- 10165044 TI - Cost-variance analysis by DRGs; a technique for clinical budget analysis. AB - In this article it is shown how a cost accounting system based on DRGs can be valuable in determining changes in clinical practice and explaining alterations in expenditure patterns from one period to another. A cost-variance analysis is performed using data from the orthopedic department from the fiscal years 1993 and 1994. Differences between predicted and observed cost for medical care, such as diagnostic procedures, therapeutic procedures and nursing care are analyzed into different components: changes in patient volume, case-mix differences, changes in resource use and variations in cost per procedure. Using a DRG cost accounting system proved to be a useful technique for clinical budget analysis. Results may stimulate discussions between hospital managers and medical professionals to explain cost variations integrating medical and economic aspects of clinical health care. PMID- 10165045 TI - Costs of dying: alternatives to rationing. AB - In western industrialised countries, about 30% of health-care expenditure of retired people is incurred by individuals in their last year of life. The corresponding high costs of dying have led medical philosophers to ask for a rationing of health-care services according to age. By contrast, this paper pursues an individualistic approach. High costs of dying are identified as a consequence of moral hazard on both the demand and supply side of the health-care sector. Health insurance prevents demand for health-care services from decreasing when an individual's residual life expectancy shrinks. Age-related moral hazard can be limited by a coinsurance scheme with a deductible that increases with the age of the insured. Given the high costs of dying, the optimal insurance policy links the coinsurance rate to the age-specific mortality risk. PMID- 10165046 TI - Patient classification and cost analysis of AIDS and HIV: the case of Belgium. AB - The study calculates inpatient costs generated at the University Hospital in Antwerp (Belgium) and outpatient costs generated at the Institute of Tropical Medicine or at the University Hospital of 213 seropositive patients without AIDS and of 48 AIDS patients, for the year 1991. Outpatient drug use other than Zidovudine was excluded. An HIV + patient has an average annual total billing cost of 2062 ECU, 43% of which is spent in hospital, 29% on Zidovudine and 28% for follow-up at the Institute of Tropical Medicine. The average cost of care for an AIDS patient is 5.5 times higher and amounts to 11,277 ECU--hospitalisation costs (8349 ECU) and costs of Zidovudine (2031 ECU) are much higher. Costs vary with the severity of illness. In comparison to 1987, costs decreased due to lower drug prices and reduced hospitalisations. Life time costs of a seropositive patient are estimated at about 35,000 ECU, based on cost calculations per CD4 class for a follow-up period from 1991 to 1993. PMID- 10165047 TI - When waiver of deductible and copayment amounts is not considered remuneration. PMID- 10165048 TI - When specialists buy out gatekeepers. PMID- 10165049 TI - How an HMO doctor determines 'medical necessity'. PMID- 10165050 TI - Today's security systems: much more than burglar alarms. PMID- 10165051 TI - Can a health plan deselect you "without cause"? PMID- 10165052 TI - Firming up weak spots in your patients' care. PMID- 10165053 TI - Health-care employment. Where the jobs will be when the next millenium begins. PMID- 10165054 TI - State health rankings. The smoking problem just won't go away. PMID- 10165055 TI - For me, Kevorkian has become a referral option. PMID- 10165057 TI - CQI by committee: a multidisciplinary approach. AB - Developing a continuous quality improvement program in preparation for a JCAHO survey can be a perplexing and sometimes redundant talk, especially if you're trying to define and remedy a new problem with old tools. Here's how one laboratory found a fresh approach to CQI by finding out what other hospital departments thought of the laboratory's service. PMID- 10165056 TI - Six steps to a successful practice buy-in. PMID- 10165058 TI - New and emerging pathogens--Part 8. From out of nowhere: Cyclospora cayetanesis. PMID- 10165059 TI - Streamline your automated hematology laboratory. Roundtable discussion. PMID- 10165060 TI - Don't miss the mark. PMID- 10165061 TI - Self-empowerment: the way to go on the job. PMID- 10165062 TI - An operational approach to competency assessment. PMID- 10165063 TI - Centralized solution. Albany (N.Y.) Medical Center turns faculty practice around. PMID- 10165064 TI - Oryx gears up. JCAHO outcomes measurement plan causes few ripples. PMID- 10165065 TI - Providers eye vendors on JCAHO list. PMID- 10165066 TI - Virginia foes targeted. Columbia maneuvers to derail rivals' merger plans. PMID- 10165067 TI - Valuing Value Health. Growth stagnant at Columbia's $1.3 billion acquisition. PMID- 10165068 TI - Surgeons face changes. Medicare fee adjustments will affect doc-hospital relations. PMID- 10165069 TI - Ohio venture dissolves. Blues, Meridia cite different reasons for breakup. PMID- 10165071 TI - Hardly marginal. Projections rosy for hospitals' Medicare profits. PMID- 10165070 TI - PPRC challenge. Groups battle over PSO recommendation. PMID- 10165072 TI - Regaining control. Community partnerships would restore healthcare's patient centered focus. PMID- 10165073 TI - Young Executive of the Year. ACHE awards Brody for establishing Fla. hospital as progressive community facility. PMID- 10165075 TI - Checkmate. Docs are pawns in game of creating integrated systems. PMID- 10165074 TI - Gold Medal Awards winner. ACHE recognizes Wilford's career commitment, leadership achievements. PMID- 10165076 TI - 2 bills call for required ER services. PMID- 10165077 TI - Dental firms extract market. Managed-care growth forcing industry to brush up on change. PMID- 10165078 TI - A not-for-profit spin. PR firm takes up battle against for-profit healthcare. PMID- 10165079 TI - New hospice horizons. HMO expansion could boost providers' popularity. PMID- 10165080 TI - Help for doc practices. AMA unit to endorse, negotiate with software vendors. PMID- 10165081 TI - Cutting the paperwork. VHA promotes use of charge cards for small purchases. PMID- 10165082 TI - Pathways: what role do they play in the OR? PMID- 10165083 TI - South sets pace for the top 100 hospitals of '96. PMID- 10165084 TI - Latex allergy. Managers' actions can aid latex-sensitive employees. PMID- 10165085 TI - Latex allergy. Employee health issue begins to heat up. PMID- 10165086 TI - Latex allergy. No one formula for glove purchasing decision. PMID- 10165087 TI - Tips on developing patient satisfaction survey. PMID- 10165088 TI - For better or worse, change is challenging the OR. PMID- 10165089 TI - Avoiding fraud and abuse using corporate compliance programs. PMID- 10165090 TI - Hospital superbugs. Physician, wash thyself, and other medical safety tips. PMID- 10165091 TI - Death with more dignity. PMID- 10165092 TI - Healing garden monitors patients by remote control. PMID- 10165093 TI - Health clinic for people sensitive to building materials. PMID- 10165094 TI - The myth of "healthism" in organized sports: implications for health promotion sponsorship of sports and the arts. AB - PURPOSE: The study examines the association of involvement in sports and arts with five health risk factors. The aims were to evaluate the argument that promotion of sports alone will achieve health objectives and to assess the suitability of sports and arts populations as targets for health promotion sponsorship. DESIGN: Personal and telephone cross-sectional surveys were performed in Western Australia in 1992 (N = 2629) and 1994 (N = 2031). SETTING: Sports and arts venues in Western Australia. SUBJECTS: Random samples of household respondents aged 16 to 69 years. MEASURES: Measures of association between risk factors and involvement in sports and the arts were adjusted for sex, age, residence, income, and other types of sports/arts involvement. RESULTS: Spectators attending sports events, who were not members of organized sports clubs, were more likely to possess three or more risk factors than nonparticipants (OR = 1.43; 95% CI 1.20-1.70). They were more likely to report cigarette smoking, unsafe alcohol drinking, and poor sun protection practices. Sports club members had a similar profile of risk factors, except that their prevalence of smoking was reduced and they were much less likely to report inadequate physical exercise. The most elevated risk factor in sports populations was unsafe alcohol drinking (OR = 1.81 in club members, 1.88 in spectators, and 2.25 in spectators who were also members). Arts populations were less likely than average to report elevated risk factors, especially in the case of members of arts organizations who also attended arts events (for three or more risk factors, OR = 0.59; 95% CI .45-.75). However, the majority of arts respondents had at least two risk factors. Levels of inadequate exercise in arts populations were the same as those in sports populations. CONCLUSIONS: The promotion of sports alone is unlikely to achieve health objectives. Highest priority in the use of health promotion sponsorship funds should be given to the populations attending sports events and involved as members of sports clubs. Investment in arts sponsorship is warranted, but at a lower level than health sponsorship of sports. PMID- 10165095 TI - The effects of a telephone-based intervention on weight loss. AB - PURPOSE: To evaluate minimal-contact and telephone-assisted weight-loss programs for overweight persons. DESIGN: Participants were randomized to a minimal-contact group or one of two telephone-assisted weight-loss groups. All participants attended two group-based behavioral weight-loss classes and received written educational materials and diaries. For the subsequent 24 weeks, the minimal contact group received no contact and the telephone-assisted group members received weekly calls to monitor their weight, food intake, and exercise. SETTING: Baseline educational sessions and data collection were conducted at a university site. SUBJECTS: Sixty-four healthy subjects (4 men) who were from 120% to 150% of ideal weight and were 25 to 55 years of age participated in the study. MEASURES: The major outcome of interest was change in measured weight over a 24 week period. Data on calories expended in exercise, dietary intake, and demographics were also gathered at baseline and 24 weeks. RESULTS: Weight loss did not differ significantly by treatment. Unexpectedly, the minimal-contact group lost almost twice as much weight as the telephone-assisted groups (12.7 vs 7.9 lb). CONCLUSIONS: There appears to be an audience for low-contact and telephone-assisted weight-loss programs, and such programs can be delivered easily. However, because the data show only modest weight-loss success, work should continue to identify the optimal content and design of such interventions. PMID- 10165096 TI - School-based weight management services: perceptions and practices of school nurses and administrators. PMID- 10165097 TI - The role of health consciousness in predicting attention to health warning messages. AB - PURPOSE: Guided by information processing theory and the health belief model, this paper considers the relationship between health consciousness among the general population and attention to environmental health warnings about alcohol consumption. Mechanisms of exposure to three dominant types of impersonal alcohol related health messages in the environment are explored. DESIGN: Cross-sectional survey using telephone interview data. SUBJECTS: A representative nationwide sample of adults was interviewed in 1993 (n = 1026), with a response rate of 63%. MEASURES: Key variables include exposure to warning labels on alcoholic beverages, to point-of-sale posters, and to advertisements in the media, as well as respondents' alcohol consumption, health problems (indicative of salience of health warnings), and level of health consciousness assessed by items tapping concern with nutrition and seeking information on health topics. RESULTS: In the total sample, over a third had seen a warning label or poster and almost all had seen an advertisement about the risks associated with alcohol consumption in 1993. Survey respondents scored very high on five individual items that make up the health consciousness scale introduced here, with 69% endorsing all items. The scale demonstrated good internal reliability (alpha = .70) and was significantly correlated (p < .01) with not enjoying getting drunk and with usually reading product warning labels, suggesting construct validity. Yet the hypothesized strong relationships between health consciousness and attention to health warnings about drinking were not observed; nor was salience of messages a predictor of recall. Importantly, high proportions of underage drinkers and young adults at elevated risk for drinking problems are reached by container warning label messages. Mechanisms of exposure recall vary based on message source, with "container label recall" associated with heavier drinking, younger age, and purchasing patterns; "poster recall" associated with purchasing and health consciousness; and "advertisement recall" associated with heavy consumption and younger age. CONCLUSIONS: These results are contrary to predictions from skeptics of broad-based informational interventions, who argue that only the already health conscious are attentive to health warnings about the risks of alcohol consumption. These data suggest that the label is reaching intended target audiences, especially younger people, males, and heavier alcohol consumers. Future research in predicting attention to impersonal health warnings in the environment should continue to improve the assessment of constructs such as salience and health consciousness, and should further test the applicability of available theoretical models. Subsequent research should also consider additional measures to tap mechanisms of exposure to impersonal health messages to enable a better understanding of the population that is not being reached by such public health interventions. PMID- 10165098 TI - Social learning versus traditional teaching in an elementary school cardiovascular health promotion program. PMID- 10165099 TI - Preliminary investigation of a culturally specific smoking cessation intervention for Hispanic smokers. AB - PURPOSE: The purpose of this study was to compare a culturally specific, multicomponent behavioral smoking cessation program for Hispanic smokers with a low-intensity, enhanced self-help control condition. DESIGN: Participants who completed pretreatment assessment were randomly assigned to treatment conditions. Smoking status was evaluated at posttreatment, 6-month follow-up, and 12-month follow-up intervals. SETTING: The study was based in predominantly Hispanic neighborhoods in Queens, New York. PARTICIPANTS: Ninety-three Hispanic smokers participated: 48 men and 45 women. INTERVENTION: The multicomponent treatment involved a clinic-based group program that incorporated a culturally specific component consisting of videotaped presentations of culturally laden smoking related vignettes. The self-help control program was enhanced by the use of an introductory group session and follow-up supportive telephone calls. MEASURES: Smoking outcomes were based on cotinine-validated abstinence and self-reported smoking rates. Predictors of abstinence were examined, including sociodemographic variables, smoking history, nicotine dependence, acculturation, partner interactions, reasons for quitting, self-efficacy, and linguistic competence. RESULTS: Significant group differences in cotinine-validated abstinence rates in favor of the multicomponent group were obtained, but only at posttreatment. With missing data included and coded for nonabstinence, validated abstinence rates at posttreatment were 21% for the multicomponent group and 6% for the self-help group. At the 6-month follow-up, the rates were 13% for the multicomponent group and 9% for the self-help group. By the 12-month follow-up, the rates declined to 8% and 7% for the multicomponent and self-help groups, respectively. A dose response relationship between attendance at group sessions and abstinence status was shown at posttreatment and 6-month follow-up intervals. CONCLUSIONS: The results of the present study failed to show any long-term benefit from use of a clinic-based, culturally specific multicomponent smoking cessation intervention for Hispanic smokers relative to a minimal-contact, enhanced self-help control. PMID- 10165100 TI - The conceptualization and measurement of perceived wellness: integrating balance across and within dimensions. AB - PURPOSE: The impact of individual perceptions on health is well-established. However, no valid and reliable measure of individual wellness perceptions exists. Therefore, the purpose was to introduce a measure called the Perceived Wellness Survey (PWS). DESIGN: Convenience sampling facilitated recruitment of a sample large enough to perform factor analysis with adequate power (.85). The appropriateness of factor analysis is supported by Bartlett's test (chi 2 = 7110, p < or = .01) and the Kaiser-Meyer-Olkin measure of sampling adequacy (.91). SETTING: The sample (n = 558) was composed of 3M Inc. employees from multiple sites in Austin, Texas (n = 393); employees from MuRata Electronics, Inc., College Station, Pennsylvania (n = 53); and students enrolled at the University of Texas at Austin (n = 112). SUBJECTS: Racial, gender, and age distribution was, respectively, 6.3% African-American (n = 35), 8.2% Asian (n = 46), 73.3% Caucasian (n = 409), 9.5% Hispanic (n = 53), and 2.7% other (n = 15); 47.8% male (n = 267), and 52.2% female (n = 291); and 36.8 years. MEASURES: Measures included the Perceived Wellness Survey, and two additional versions of the Perceived Wellness Survey designed to measure both discriminant and face validity. Perceived Wellness Survey subscales include physical, spiritual, intellectual, psychological, social, and emotional dimensions. RESULTS: All subscales were correlated (p < or = .05) with the Perceived Wellness Survey composite and with each other. Evidence of internal consistency (alpha = .88 to .93), and discriminant, face, and factorial validity was provided. Finally, the Perceived Wellness Survey appears to be a unidimensional scale. CONCLUSION: The unidimensional nature of the Perceived Wellness Survey suggests that perceptions of wellness in various dimensions are intertwined by their affective nature. The Perceived Wellness Survey appears to be reasonably valid and reliable; however, further research is needed. PMID- 10165101 TI - Strabismus. PMID- 10165102 TI - Comitant strabismus. AB - Comitant strabismus has been investigated and treated for centuries. Advances in understanding the etiology of this disorder have improved our ability to successfully treat it. This article addresses recent insights into the causes and treatments of comitant strabismus, with a focus on congenital esotropia, intermittent exotropia, and adult strabismus. PMID- 10165104 TI - Brain pathology and strabismus. AB - This article reviews some of the past year's important papers, with particular emphasis on interesting connections between congenital pathology of the central nervous system and infantile strabismus, neuroimaging findings in meningomyelocele sustaining A-pattern strabismus, surgical outcome in strabismic children with cerebral palsy, and oculomotor problems in cerebral vascular diseases. Oculographic findings in myasthenic ocular palsies and a new form of congenital ocular fibrosis are also reviewed. PMID- 10165103 TI - Paralytic and incomitant strabismus. AB - During the past year, there have been interesting reports on the association of head tilt, facial asymmetry, and congenital superior oblique palsy. The etiology of sixth nerve palsy and its outcome in adults and children have been studied in two large series, and an orbital surgical approach has been reported to be valuable in cases of Brown's syndrome and superior oblique overaction. PMID- 10165105 TI - Pediatric ophthalmology. AB - In the recent pediatric ophthalmology and strabismus literature, there have been some important papers. Topics have included ocular outcomes in children born before 32 weeks of gestation, a practical correlate of Teller visual acuities and visual behavior in a real environment in a severely handicapped child, and a debate on the indications and efficacy of population screening for amblyopia. New information on the creation of refractive errors by earlier eyelid closure than used previously and a new torsionometer represent new sensory information. New information about motor adaptations in strabismus includes a new evaluation of saccade disconjugacy in deep amblyopia and in anisometropia. Spasmus nutans may be a long-term rather than a self-limiting disease, and the debate on neuroimaging in this condition has been evaluated. A subtle predictor of outcome in the surgical treatment of partially accommodative esotropia is presented, as well as an important case report on the treatment of a metabolic cause of strabismus in chronic progressive external ophthalmoplegia with coenzyme Q10. Finally, some information is presented on the treatment of hereditary retinal dystrophies with nonautologous retinal pigment epithelial cell transplants to the subretinal space of the dystrophic retina-the first experimental model of a successful biologic treatment of which I am aware and a possible indicator of future trends in human disease. PMID- 10165106 TI - CO2 laser skin resurfacing in oculoplastic surgery. AB - Although CO2 lasers have been used in medicine for almost 30 years, recent developments have changed the way they are being used. Several laser technologies have altered the CO2 laser delivery system, making it useful for the treatment of wrinkles, photoaged skin, and acne scarring. Histopathologically, the resurfacing CO2 lasers produce morphologic alterations similar to medium-depth chemical peels. Many of the same principles applied to chemical peels and dermabrasion are useful in the evaluation and treatment of patients undergoing laser resurfacing. The results of laser therapy appear to be more predictable than those from dermabrasion and chemical peeling and produce fewer sequelae. Laser resurfacing can be used alone or as an adjunct to other cosmetic surgical procedures. PMID- 10165107 TI - Orbital imaging techniques. AB - Recent years have seen refinements in techniques of orbital imaging. CT scanning remains the standard technique of orbital imaging. Magnetic resonance imaging has become a useful adjunct; progressive refinements will further enhance its utility. Modifications of time-honored ultrasonography have resulted in color Doppler imaging, a diagnostic test presently in its evolutionary-developmental phase. PMID- 10165108 TI - Management of thyroid ophthalmopathy. AB - The pathogenesis of thyroid ophthalmopathy and its relation to thyroid gland dysfunction defies elucidation, and thus only palliative therapy exists. If and how antithyroid therapy affects the course of thyroid eye disease remains controversial. Research continues to try to reveal a subset of patients who respond best to corticosteroid or radiation treatment. Innovations in the surgical correction of upper eyelid retraction, orbital decompression technique, and the approach to restrictive myopathy help improve outcome. Preliminary knowledge concerning octreotide suggests that it may play a role in thyroid ophthalmopathy treatment and prevention. Future studies still need to answer basic questions about the treatment of thyroid ophthalmopathy. PMID- 10165109 TI - Ptosis evaluation and management in the 21st century. AB - Determining the etiology and appropriate management of ptosis requires a directed evaluation seeking specific signs and symptoms. The clinical significance of such concomitant findings as motility deficits, pupillary abnormalities, levator function abnormalities, ocular manifestations, and associated systemic symptoms are discussed. Management options for correction of specific types of ptosis are reviewed. The clinical application of new technologies, such as the CO2 laser, or molecular biology, such as muscle cell transplantation or gene mapping, open exciting possibilities for future novel therapeutic alternatives. With an emphasis on newer and better, the fundamental question of indications and outcomes will remain relevant. PMID- 10165111 TI - ER physicians defend their film interpretation skills. PMID- 10165112 TI - Info systems expand consulting role of radiologists. PMID- 10165110 TI - Amblyopia. AB - New knowledge of the pathophysiology of amblyopia has evolved through animal research over the past 30 years. We now know that development and treatment of amblyopia have a critical and sensitive period. After more than a millennium, patching of the dominant eye remains the cornerstone of amblyopia treatment, and compliance plays an important role in its effectiveness. Compliance can now be measured objectively with an occlusion monitoring device. The first successful attempts have been made to pharmacologically influence the plasticity of the human visual system. PMID- 10165113 TI - Ultrasound evolves as implant imaging tool. PMID- 10165114 TI - Inhaled beclomethasone dipropionate administered through a new spacer device: a controlled clinical study. AB - This 4-week, randomized, parallel-group study compared the efficacy and safety of a metered-dose inhaler equipped with a new spacer device (Jet spacer) with those of a standard actuator in the administration of inhaled beclomethasone dipropionate (0.5 mg twice daily) in 66 adults with chronic obstructive pulmonary disease (COPD) who were responsive to beta 2-agonists. Lung function values, symptom scores, and daily consumption of a beta 2-agonist determined efficacy. At baseline and after treatment, levels of morning serum and 24-hour urinary cortisol were measured in half of the patients (one center). Ease of use of the two devices was expressed by patients at the final visit. Lung function values and clinical symptoms improved in both groups (P < .01 at the final visit); the Jet group reported a better outcome (P < .05 between groups) than the standard actuator group for predicted normal values of forced expiratory volume in 1 second, forced vital capacity, and bronchial noises. Salbutamol consumption decreased in both groups. One patient in the Jet group and 5 patients in the standard-actuator group reported adverse reactions. No significant between-group differences were found in plasma and urinary cortisol levels. The Jet device was judged easier to use (P < .05 between groups) than the standard actuator. In conclusion, the jet device was more effective than a standard actuator in reducing local adverse reactions to inhaled beclomethasone dipropionate in adults with COPD, with a better efficacy profile. PMID- 10165115 TI - Distance education outcomes in clinical laboratory science. AB - OBJECTIVE: To compare 2 types of delivery methods for clinical laboratory science students-the technology-driven method at distance sites versus the on-site method on campus-in terms of learning outcomes. DESIGN: The independent variable in this quasi-experimental study was the delivery method consisting of interactive videoteleconferencing and on-site classroom methods. The dependent variables were learning outcomes that were determined by 2 methods: the average score on 8 posttests scheduled at periodic intervals and a national certification examination score. SETTING: Clinical laboratory science (CLS) education program at the University of Nebraska Medical Center in Omaha and at 6 clinical sites in other cities across Nebraska. PARTICIPANTS: 40 senior CLS students enrolled in a baccalaureate degree program. Control group participants were assigned to 2 clinical sites in the Omaha area, and the experimental group were assigned to 6 distant clinical sites. MAIN OUTCOME MEASURES: Data analysis consisted of descriptive statistics, 2-way analysis of variance (ANOVA), 2-way analysis of covariance (ANCOVA), repeated measures analysis of variance, and Hotellings T2. RESULTS: Results showed no significant difference between the students' examination scores based on delivery method (p > 0.05), except in the chemistry topic area. There was no significant difference in the pattern of the examination scores over the semester of learners who were instructed by interactive videoteleconferencing methods and learners who were instructed by on-site classroom methods. CONCLUSION: Results of the study generally support the use of interactive videoteleconferencing as an effective, alternative delivery method for CLS students who cannot attend class on campus. Analysis by topic areas suggests that additional studies are needed to validate the variance found in the chemistry subject area. PMID- 10165116 TI - Needle aspiration and biopsy in the diagnosis and monitoring of bone marrow diseases. AB - OBJECTIVE: To review the procedures required to perform and evaluate needle aspiration and biopsy of bone marrow. DATA SOURCES: Journal articles, monographs and authors' experience. DATA SYNTHESIS: The performance of bone marrow needle aspiration and biopsy requires close cooperation between the physician and the clinical laboratory scientist (CLS). Several tests require special handling when obtaining and processing bone marrow samples. Serial bone marrow aspiration and biopsy studies can help in the management of some bone marrow diseases. This article reviews the procedures required to obtain and to process bone marrow aspirates and biopsies. It also reviews the interpretation of light microscopic studies of bone marrow samples. CONCLUSION: Current procedures for obtaining and procuring bone marrow needle aspirates and biopsies require close interaction between the CLS and the physician. Multiple specialized assays require special handling at the time marrow samples are obtained. Serial bone marrow needle aspirates and biopsies can be very useful in guiding the clinical care of certain patients. PMID- 10165117 TI - Cutting edge technologies in the evaluation of bone marrow samples. AB - OBJECTIVE: To review cutting edge technologies for evaluation of bone marrow samples. DATA SOURCES: Professional literature and authors' experience. DATA SYNTHESIS: Novel technologies for evaluating bone marrow specimens that have prognostic and therapeutic value in chronic and acute leukemia have been recently developed. Polymerase chain reaction-based assays that are useful in detecting chromosomal translocations in CML and AML are relevant to diagnosis and initial therapy. These assays can also be used to detect minimal residual disease after therapy and thus have prognostic value. In addition, a novel and elegant technique for determining leukemic cell resistance to chemotherapy agents (in vitro drug sensitivity) has prognostic and therapeutic value in AML. Use of these assays may lead to greater diagnostic precision, improved prognostication and more effective therapy. CONCLUSION: Cutting edge technologies that have utility in the evaluation of bone marrow specimens include polymerase chain reaction based assays for detecting specific chromosomal translocations, particularly useful in CML and AML, as well as in vitro drug sensitivity testing in AML. PMID- 10165119 TI - Inhalation device, pulmonary deposition and clinical effects of inhaled therapy. PMID- 10165118 TI - Clinical applications of flow cytometry in hematology and immunology. AB - OBJECTIVE: To review the major applications of flow cytometry in the diagnosis of hematologic and immunologic disease. DATA SOURCES: Professional literature and authors' experience. DATA SYNTHESIS: Flow cytometry is evolving as a major diagnostic tool for evaluating hematologic disease, monitoring HIV infection and assessing peripheral blood and bone marrow for CD34 positive stem cells in marrow transplantation. This review highlights the opportunities and pitfalls of this area of diagnostic laboratory medicine. CONCLUSION: The applications of flow cytometers in diagnostic hematology and immunology are expanding, providing new opportunities for enhanced precision in diagnosis. As in any relatively new field much work remains in order to optimize accuracy and efficiency while minimizing cost. PMID- 10165120 TI - Performance characteristics of pressurized metered dose inhalers in vitro. PMID- 10165121 TI - In vitro performance of plastic spacer devices. PMID- 10165122 TI - Delivery options for inhaled therapy in children under the age of 6 years. PMID- 10165123 TI - Delivery options for inhaled therapy in children over the age of 6 years. PMID- 10165124 TI - Diagnosis of Helicobacter pylori infection. AB - A number of reliable methods are currently available for the diagnosis of Helicobacter pylori infection. These diagnostic tests can be classified into invasive methods that require endoscopy and gastric biopsy, and noninvasive methods. Invasive methods include gastric mucosal biopsies at endoscopy for bacteriologic culture, histology, and the rapid urease test. Noninvasive methods include the urea breath test and serologic tests. Each of these diagnostic tests has its advantages and disadvantages. Histologic examination remains the gold standard for diagnosis. It can also detect coccoidal forms of the bacteria and be used to assess the severity of gastritis. Culture of H pylori should be performed if antibiotic sensitivity of the organism is required. A rapid urease test is the quickest test for H pylori status. The urea breath test detects urease activity in the entire stomach, thus eliminating the possibility of a sampling error, which occurs in random gastric biopsies. Serologic tests using either ELISA or latex-agglutination methods are excellent for diagnosis of H pylori infection, but not useful for monitoring effects of therapy. Recently, the polymerase chain reaction has been applied to fixed-tissue biopsies, as well as body secretions in the diagnosis of H pylori infection. PMID- 10165125 TI - Laboratories in the new Swiss health care system. AB - The objectives of the health reforms introduced in 1994 include universal coverage and cost containment. With these reforms, a new uniform for schedule and standards for laboratories have been introduced. The impact of these reforms is yet to be realized. It is predicted that with the imposition of new standards, many laboratories based in physicians' offices will disappear. Standards will also require more scientists and physicians trained in laboratory medicine. PMID- 10165126 TI - Dental plans and managed care: getting your systems up to speed. PMID- 10165127 TI - Deliveries, readmission rates and practice guidelines to reduce variations in obstetrical practice. PMID- 10165128 TI - Stacking of PPOs: potential liability for payors. PMID- 10165129 TI - Next wave of change in managed health care will sweep away antiquated prescription practices. PMID- 10165131 TI - VA hospitals in New York State link up in telemedicine network. PMID- 10165130 TI - BellSouth exec urges look at telemedicine for rural health care. PMID- 10165132 TI - Portable ultrasound tested in Bosnia. PMID- 10165133 TI - Imaging company creates retina telemedicine network. PMID- 10165134 TI - Success and major market share for telemedicine elusive. PMID- 10165135 TI - Evolving technology thwarts aim of cost analyses. AB - Paucity of financial data obscures the risks and rewards of telemedicine and may have public policy implications. Study findings suggest potential private benefits to hospitals that implement the service, but tracking and analysis are critical. PMID- 10165136 TI - Web-based records spin closer to reality. AB - Primary goals are to enable practitioners to use the Web to manage computer-based patient records, facilitating input and updating, not just retrieval and review. Early adopters are tackling a host of complex technical and operational issues. PMID- 10165137 TI - Java sparks inventive solutions for clinical data management. PMID- 10165138 TI - Industry observers predict growth trends spurred by bellwether bill. PMID- 10165139 TI - 3rd annual program review. PMID- 10165140 TI - Store-and-forward teledermatology. PMID- 10165141 TI - The Israel Center of Telemedicine. Telecardiology in the Negev. PMID- 10165142 TI - The emergence of telemedicine: will the law keep pace? PMID- 10165143 TI - Lighting design & layout of a telemedicine conference room. PMID- 10165144 TI - Making the telecommunications decision: a case study. PMID- 10165145 TI - Tele-ophthalmology project, UTMB. New tools for tele-ophthalmology. PMID- 10165146 TI - California passes Telemedicine Development Act. PMID- 10165147 TI - Teleradiology service providers. PMID- 10165148 TI - Teleradiology, mini-PACS, PACS and the digital medical image system. PMID- 10165149 TI - Telemammography feasibility. PMID- 10165150 TI - Australian telemedicine. Gearing up down under. PMID- 10165151 TI - Surprises from the rural telemedicine survey. PMID- 10165152 TI - Rising swell of telemedicine legislation. PMID- 10165154 TI - Clinical efficacy of telepsychiatry. PMID- 10165153 TI - External vs. internal funding: does it matter who pays the bills? PMID- 10165155 TI - Confidentiality and telemedicine: the need for a federal legislative solution. AB - Legal and ethical rules for the confidentiality of health records are incomplete, unclear, and inadequate. Structural and technological changes in the health care industry are resulting in increased uses and disclosures of patient records without adequate guidance to recordkeepers or protections for patients. Because of the interstate nature of medical practice, especially telemedicine, federal legislation based on a code of fair information practices is the best solution. PMID- 10165156 TI - Design of a cooperative teleradiology system. AB - The article describes a teleradiology system intended to provide a user-friendly environment for exchanging images and working cooperatively on them. With the development of a hospital-wide picture archiving and communication system (PACS), the University Hospital of Geneva and several other health institutions in the region became interested in teleradiology. Because of the heterogeneous needs of the potential participants, the following requirements were identified: (1) remote consultation and interpretation of images; and (2) cooperative interpretation of medical images, allowing real-time interaction between physicians. To satisfy these needs, a multipoint teleradiology system has been implemented that incorporates an innovative image display and manipulation software program known as OSIRIS, which supports the full spectrum of imaging modalities. Images and data are transmitted over the public telecommunications Integrated Services Digital Network (ISDN). To accommodate different computing environments at the various locations, platform-independent software has been designed that has the same "look and feel" for PC-Windows, Macintosh, and UNIX X11 work-stations. The teleradiology system can be used in two modes: synchronous (cooperative) or asynchronous. Special efforts have been made in the development of the synchronous mode. Within the European Telemed Project, a specific protocol has been designed to allow cooperative work between remotely located workstations. PMID- 10165157 TI - Analysis of telemedicine from an organizational perspective. AB - OBJECTIVES: To conduct an in-depth case analysis of the University of Kansas Telemedicine Program in order to identify organizational and communications elements that may be hindering the program's effectiveness. METHODS: A case analysis was done, employing a combination of methodologies (direct observation, interview, and survey) involving extensive data collection from telemedicine program personnel throughout the state of Kansas. Analysis of this program's organizational communication focused on structure and boundaries, definitions and goals, leadership and decision making, and membership and roles. RESULTS: Significant organizational communication deficits were identified. These included a dearth of perceived central leadership, lack of information about the technology itself, poorly designed and cumbersome means for scheduling and utilizing telemedicine technology, absence of explicit strategic goals; and poor communication in introducing this technology to medical personnel and to the public. Other important findings were: organizational members expanded the scope of this organization beyond the providing of a simple consultation; the perception that decision making falls into the hands of almost everyone but the referring physician; and the role that language (or lack of common terminology) plays in confusion about this innovation. CONCLUSION: Organizational factors may be critical determinants of success or failure of a telemedicine program. Innovations in telemedicine technology need to be matched by innovations in organizational communication and structure. Findings from this study can be applied to existing or planned programs. Examples include redefinition of the roles and responsibilities of certain personnel, increasing the efficiency and decreasing the complexity of the consultation scheduling process, clarification and formalization of leadership and decision making, and development of a universal terminology of telemedicine. PMID- 10165158 TI - Telemammography: implementation issues. AB - Telemammography has the potential to improve access to centralized expertise for the interpretation of breast imaging studies. Digital mammography has more demanding spatial resolution requirements than other forms of medical imaging because of the need to detect microcalcifications, the fine details of lesion margins, and subtle architectural distortion. The resolution requirements for mammography have important implications for image acquisition and display technologies. The large size of the resulting image data sets places significant demands on local and wide area networks as well as storage media. Image data compression will be particularly important for telemammography to help make systems practical and affordable. This article describes how existing technologies can be adapted to implement telemammography systems in the near future. PMID- 10165159 TI - The Georgia State Telemedicine Program: initiation, design, and plans. AB - This paper describes the genesis, implementation, and operation of the Georgia Statewide Telemedicine Program, a full-service system that provides a comprehensive range of clinical and consultative services to all residents of the state through a hub-and-spoke network. When completed, it will consist of several tertiary-care centers and a set of secondary hubs at medical centers throughout the state. Each hub will, in turn, serve several remote sites. The system enables connectivity throughout the network, and the overall coordination, implementation, and oversight is provided by the Center for Telemedicine at the Medical College of Georgia. The evolution of the system is described, together with lessons learned from the experience. PMID- 10165160 TI - Telemedicine and health care policy: the new federalism taking hold. AB - The new federalism is now taking hold in Washington, with far-reaching implications for the role of the federal government in health, education, and welfare programs; financial support for such programs; and the shift of control to the states. For telemedicine, the implications of these changes include having to make do with less external financial support and a need to establish partnerships between state and local governments, public sector developers and vendors, third-party payers, and community-based telemedicine programs. The long term challenge for telemedicine programs, particularly in rural, medically underserved areas, is likely to be their sustainability in an adverse financial environment. The problem is further compounded by the lack of reimbursement for teleconsultations. PMID- 10165161 TI - Telemedicine: an annotated bibliography: Part II. PMID- 10165162 TI - Pain and the ethics of pain management. PMID- 10165163 TI - Death by definition and process. PMID- 10165164 TI - The ethics committee as Greek chorus. PMID- 10165165 TI - Reconsidering the distinction of ordinary and extraordinary treatment: should we go "back to the future"? PMID- 10165166 TI - Lost and (not yet) found. PMID- 10165167 TI - Bioethics in Puerto Rico. PMID- 10165168 TI - Perspectives. Managed care, capitation slowly take root in home care industry. PMID- 10165170 TI - Records on the move at Exeter Hospital. PMID- 10165169 TI - The Royal Marsden Hospital--Diagnostic Imaging Department. Case study of planning supervisor (CDM) involvement. PMID- 10165171 TI - Building contractor hands cover completed health centre on time. PMID- 10165172 TI - Compaction should be an integral part of your waste management strategy. PMID- 10165174 TI - Major hospital projects bring two national awards to city. PMID- 10165173 TI - Focus: National Health Service. PMID- 10165175 TI - Practice Brief. Issue: Developing information capture tools. American Information Management Association. PMID- 10165176 TI - The politics of information system integration. PMID- 10165177 TI - Information system integration. Open systems and healthcare. PMID- 10165178 TI - Information system integration. Integration challenges in managed care organizations. PMID- 10165179 TI - Information system integration. Making standards work for you: content vocabulary for computer-based patient records. PMID- 10165180 TI - Assuring an accurate enterprise patient index: the difference between internal duplicate files and overlap patient files. PMID- 10165181 TI - Joint Commission modifies delinquent record form. PMID- 10165182 TI - Kaiser Permanente Northern California Region's coding guidelines for perioperative anemia. PMID- 10165183 TI - Integrated delivery and its demand for integrated information. PMID- 10165184 TI - AHIMA's satellite conference: finding the keys to information security. PMID- 10165185 TI - Technology is 1997's 'differentiator'. PMID- 10165186 TI - The end of the paper wait: document imaging. PMID- 10165187 TI - HIMSS: growing fast, growing smart. Interview by Mark Hagland. PMID- 10165188 TI - Mercy delivers with mobile technology. PMID- 10165189 TI - Creating a "clean" information system. PMID- 10165190 TI - Referrals in minutes rather than days. PMID- 10165191 TI - It takes a "health" village on the Internet. PMID- 10165192 TI - As prices drop and demands increase, ATM becomes a technology whose time is now. PMID- 10165193 TI - Devices as dynamic as the people who use them. PMID- 10165194 TI - Justifying PACS. PMID- 10165195 TI - Hotlist. Practice management systems. The elements of a successful practice management system. PMID- 10165196 TI - 1997 annual market directory issue. AB - This year's Market Directory lists information on hundreds of companies within the healthcare information technology market. There are two ways to find information with this Directory: 1. Alphabetically-Companies can be located alphabetically within the first half of the Directory. 2. Product Breakout Companies also can be located by the products or services they offer in the second half of the Directory. The Product Breakouts section lists over 200 products and the vendors that offer each of those products or services. All information has been compiled through surveys conducted by the HMT staff. PMID- 10165197 TI - Patient-psychotherapist privilege: access to clinical records in the tangled web of repressed memory litigation. PMID- 10165198 TI - Achieving excellence: four Georgia hospitals make "Top 100" list. PMID- 10165199 TI - Medicaid--a prescription for good health. Coalition paves gradual transition to managed care. PMID- 10165200 TI - 1997 GHA Distinguished Service Awards. Georgia Hospital Association. PMID- 10165201 TI - Medicare and state health care programs: fraud and abuse; issuance of advisory opinions by the OIG--HHS. Interim final rule with comment period. AB - In accordance with section 205 of the Health Insurance Portability and Accountability Act of 1996, this final rule establishes a new part 1008 in 42 CFR chapter V to address the new OIG advisory opinion process. Specifically, these regulations set forth the specific procedures by which the Office of Inspector General, in consultation with the Department of Justice, will issue advisory opinions to outside parties regarding the interpretation and applicability of certain statutes relating to the Medicare and State health care programs. PMID- 10165202 TI - Administration wants to bundle post-acute Medicare payments. PMID- 10165203 TI - Outcomes study suggests subacute SNFs may be providing too much therapy for hip patients but not enough for stroke victims. PMID- 10165204 TI - Survey finds that consumer advocates hold a negative view of subacute care. PMID- 10165205 TI - Preparing for a Joint Commission survey. PMID- 10165206 TI - Really high volume scratch cookery. PMID- 10165207 TI - Food service outsourcing. PMID- 10165208 TI - Dietitians are working smarter. PMID- 10165209 TI - An overview of Joint Commission revisions: Part 2. PMID- 10165210 TI - Making managed care organizations work for you. PMID- 10165211 TI - Balancing hospital productivity, health care utilization and medical expenditures. PMID- 10165212 TI - The newest gatekeepers: nurses take on the duties of primary care physicians. PMID- 10165213 TI - Green acres: rural hospitals are lucrative targets for investor-owned hospital chains. PMID- 10165214 TI - Crime in hospitals 1995--the latest IAHSS survey. AB - Overall crime in hospitals participating in the tenth annual IAHSS survey increased by 7% in 1995 versus 1994. On a per-hospital basis, five crime categories showed increases--murder, suicide, physical assault, sexual assault, and theft (except auto). Six categories showed decreases--robbery, arson, burglary, auto thefts, bomb threats, and vandalism. While crime in urban/suburban hospitals in 1995 leveled off after a sharp increase reported for 1994 over 1993, rural hospitals showed a 9% increase in crime in 1995 over the previous year. The 1995 crime rate was 11% higher than the preceding eight-year average, with physical assault 36% higher than the eight-year average, and sexual assault 88% higher on a per-hospital basis. Some 38 Tables and Graphs are included. PMID- 10165215 TI - Saving on training expenses: IAHSS training accepted by New York State. AB - How the author and his hospital were granted a training waiver to use IAHSS's 40 Hour Basic Certification Course in lieu of the new York State-mandated 16-Hour On The-Job Training Course. By obtaining the waiver, he says, he was able to save budget dollars and get more effective training for his security officers. PMID- 10165216 TI - Management commitment to safety minimizes worker compensation costs. PMID- 10165217 TI - When the subject is hospital security, do administrators have an attitude? AB - The author discusses why a national standard for security guards in Canada and the U.S. is needed. A common training standard for protection services must be adopted, he says, and professional associations can help. PMID- 10165218 TI - Violence to health care workers in rural Alaska hospitals. AB - The authors selected five rural Alaska hospitals for a survey of ED workers. The goal was to identify risk factors and preventive strategies to protect workers in these environments. PMID- 10165219 TI - Terrorism and reality: a healthcare center's response to a campus terrorist threat. AB - Thanks to its strong and professional security department, a healthcare center was able to stay open while the university campus suffered a shutdown when a terrorist threat was received. PMID- 10165220 TI - A personal account of workplace violence from a nursing perspective. AB - The author describes the incident that changed her life--when she was taken hostage by a psychiatric patient. She discusses the healing process and why healthcare workers must be aware of the potential for violence. PMID- 10165221 TI - Understanding national guidelines for infant abduction prevention and response. AB - The author addresses the latest NCMEC guidelines which establish national standards for infant abduction prevention and response. The healthcare security manager with birthing and/or pediatric care units can use these guidelines to construct or enhance policy development and to assess risk. PMID- 10165222 TI - How safe is your dialysis unit? AB - The author suggests that the physical plan of the dialysis unit be evaluated, along with the training and skill level of the staff, in handling disruptive patients and de-escalating violence. The unit should be safe and secure for those who work in it and all who receive care there. PMID- 10165223 TI - A survey to determine the long-term effects of reductions in security staff on the safety and security of employees, patients, and visitors. AB - After reviewing the results of 146 surveys from U.S. hospital safety and security managers, the author found that departments experiencing staff reductions over the last two years reported significant increases in crime, increased officer response time, lower morale, and increased dissatisfaction. PMID- 10165224 TI - Conflict resolution in the healthcare setting. AB - Understanding conflict and its causes in order to learn to deal with it, and possibly avoid it, in the workplace. PMID- 10165225 TI - Needed: regulation of the contract security guard industry. AB - The author expresses his concerns about the quality and level of training of hospital security officers. He asks the question: When are we going to shake the image of being rent-a-cops or wannabes and truly become a professional workforce? PMID- 10165226 TI - The Environment of Care and what it means to me. PMID- 10165227 TI - The security professional--how did I get here. PMID- 10165228 TI - Will AMAP (American Medical Accreditation Program) help or hurt your facility? PMID- 10165229 TI - Reusing single-use devices OK in some cases. PMID- 10165230 TI - Follow 3 steps to manage laser surgery quality. PMID- 10165231 TI - Standardization of orthopedic hip and knee implants. AB - The standardization of orthopedic hip and knee implants was a collaborative endeavor by material management, orthopedic surgeons, and operating room nursing staff. The key concept was to eliminate paying list price for hip and knee implants and to standardize to one vendor and establish the hospital as the premier center for total joint replacement. PMID- 10165232 TI - Materiel management and internal audit: a team approach. AB - Materiel management and internal audit share common objectives--the promotion of organization efficiency, the prevention of fraud and abuse, and an interest in the creation of and adherence to policies and procedures. By working together, these two departments can help each other meet their objectives and, in the process, better serve their institution. PMID- 10165233 TI - Bracing for survival. AB - As health care continues to move toward smaller, more consolidated support services, materiel managers will face constricted promotion and employment opportunities. Flexibility and a willingness to embrace change as the occasion for personal and professional advancement will be two hallmarks of success. This article focuses on outsourcing and integrated delivery networks by discussing the challenges and opportunities they present. PMID- 10165234 TI - Career survival strategies for materiel managers. AB - The skill sets and attitudes required for materiel management professional survival continue to change. Just as the industry has evolved for calculators and three-part forms, so too must today's managers evolve into facilitators and information-oriented management. While these new skills are being perfected, three focused strategies initiated right now can enhance your chance for survival. First, get to know your customers intimately. Go to their meetings. Tour their departments. Second, assume responsibility and report materiel cost data that has meaning to senior management and customers. Fill rates and inventory turns offer little value to other managers, but supply cost per discharge can be of value. Third, be proactive in competing with outsourcing competitors. Do not wait until they are on your doorstep before developing a strategy to compete. PMID- 10165235 TI - Survival strategies in the era of managed care. AB - The era of managed care has forced an unprecedented restructuring of the health care environment. As hospitals downsize in response, materiel managers should consider adopting strategies that may help ensure their survival, including innovative approaches to supply management and the development of individual responses that will best position them to succeed in this new reality. PMID- 10165236 TI - Recent initiatives in U.S. hospital supply management. AB - A variety of health care industry changes affect hospital/system materiel management directors as never before. Among them: the switch to patient care in alternative sites, system integration, new health care partnerships, and evolving technology and benchmarking needs. The key drivers for management include total product cost, compliance, standardization, utilization, and long-term partnering. PMID- 10165237 TI - Organizational change and survival skills for materiel managers. AB - In an effort to be cost effective and meet changing customer needs, organizations are evolving in their structure. In this environment, leading edge organizations change their culture and create knowledge to continuously improve. Hospital materiel managers need to understand and support their organization's culture changes and respond by adapting or acquiring new skill sets. PMID- 10165238 TI - Carry the fire. AB - Materiel managers of today have survived the initial cuts brought about through mergers, closures, and acquisitions. Continued survival requires embracing change, practicing instant alignment, and leveraging effectiveness. This case study provides an example of taking a new approach to the old problem of product standardization and utilization reduction, and challenges all of us to bear the torches and "carry the fire." PMID- 10165239 TI - Materiel management reengineering: value creation through innovation. AB - By reengineering their department's core processes, materiel managers can expand their role in the health care setting while realizing significant cost savings. Using a team model, Inova Health System materiel management staff integrated their processes for vendor selection, purchasing, inventory reduction, and utilization across three hospitals and ancillary services. An integrated approach at all levels of the organization gained buy-in from administrators and staff systemwide. PMID- 10165240 TI - ISO 9000: a guide to world-class quality standards. AB - World standards for determining companies' commitment to continuous quality improvement (CQI) have been established. These standards are collectively known as ISO-9000. Prudent buyers of goods and services for health care organizations that are also committed to CQI should understand these standards and use them to facilitate supplier certification. PMID- 10165241 TI - Inventory count strategies. AB - An important principle of accounting is that asset inventory needs to be correctly valued to ensure that the financial statements of the institution are accurate. Errors is recording the value of ending inventory in one fiscal year result in errors to published financial statements for that year as well as the subsequent fiscal year. Therefore, it is important that accurate physical counts be periodically taken. It is equally important that any system being used to generate inventory valuation, reordering or management reports be based on consistently accurate on-hand balances. At the foundation of conducting an accurate physical count of an inventory is a comprehensive understanding of the process coupled with a written plan. This article presents a guideline of the physical count processes involved in a traditional double-count approach. PMID- 10165242 TI - Strategies for materiel management executives. AB - With a more centralist political philosophy emulating on Capital Hill, this article focuses on potential effects on materiel management executives of a half competitive (managed care) and a half-regulatory (Medicare and Medicaid) environment in organizing and financing health services. It predicts a far more contentious field; further cutbacks in nonpatient care personnel, including senior positions for material management executives; the centralization of tertiary services; and the possibility of additional regulatory approaches to protect the public. PMID- 10165244 TI - Linking information for competitive advantage. PMID- 10165243 TI - Executive roundtable I. Talking about quality. PMID- 10165245 TI - Putting information technology to use. Healthcare executives explore the technological era. PMID- 10165246 TI - Delivering first-class healthcare in today's environment means giving physicians easy access to computer-based patient information. PMID- 10165247 TI - American College of Healthcare Executives ethics self-assessment. PMID- 10165248 TI - Why you should be board certified in healthcare management. PMID- 10165249 TI - Not-for-profit leaders face new IRS sanctions. Board members, key managers, and tax counsel for your organization will need to review these legislative changes. PMID- 10165250 TI - What type of Internet provider is right for you or your organization? PMID- 10165251 TI - Interview with ACHE's new chairman. PMID- 10165252 TI - 1996 VISTA Awards. Celebrating teamwork and excellence in health facility design and construction. PMID- 10165253 TI - Will your building work on opening day? PMID- 10165254 TI - Make it or make it over: when (and when not) to renovate. PMID- 10165255 TI - First impressions. Good access management gives your patients the welcome they deserve. PMID- 10165256 TI - How to comply with JCAHO's latest SOC (Statement of Conditions) requirements. PMID- 10165257 TI - Product review yields cleaner, greener use of chemicals. PMID- 10165258 TI - 10 easy steps to preventing workplace violence. PMID- 10165260 TI - Predicting outcomes of cardiac surgery: models proliferate. PMID- 10165259 TI - Health care construction will continue to build. PMID- 10165261 TI - Women, men, and treatment for heart disease. PMID- 10165262 TI - Chunking systems of the mind. PMID- 10165263 TI - Scale and scope economies among health maintenance organizations. AB - We examine scale and scope economics among Group and IPA Health Maintenance Organizations (HMOs) over the period 1988 to 1991 using a national sample of HMOs. We allow for the multiproduct nature of HMO production by estimating the cost of producing a member month of non-Medicare and Medicare coverage, and we examine the effect of HMO market structure on costs. We find that HMOs benefit from scale economies. There are scope diseconomies associated with providing both non-Medicare and Medicare products. Group HMOs in more competitive markets have lower costs but IPA costs are not affected by competition. PMID- 10165264 TI - Economies of scale and scope as an explanation of merger and output diversification activities in the health maintenance organization industry. AB - This paper tests for the existence and magnitude of economies of scale and scope as possible explanations for the recent observed trends in increasing health maintenance organization (HMO) scale (through merger and acquisition) and scope (through greater participation in public enrollee markets) using firm level data from a sample of California HMOs for the time period 1986-1992. The results suggest that economies of scale provide a strong justification for mergers only in the case of relatively small HMOs (i.e. those with fewer than 115,000 enrollees), and economies of scope do not explain the increasing HMO enrollment of public enrollees. PMID- 10165265 TI - Externalities in hospitals and physician adoption of a new surgical technology: an exploratory analysis. AB - Much recent work on the economics of new technology adoption has investigated the roles of information and externalities. However, studies of technology adoption by physicians have not addressed these issues. This paper examines the adoption by general surgeons of laparoscopic cholecystectomy, a new surgical procedure which was introduced in 1989. The paper addresses the informational and cost externalities which may be generated when the first surgeon in a hospital adopts a new procedure. The findings suggest that access to information about laparoscopic cholecystectomy influenced surgeons' adoption behavior, and that externalities in hospitals may have hastened the diffusion of the procedure. PMID- 10165267 TI - Not enough warning. GAO report finds FDA's medical device monitoring lacking. PMID- 10165266 TI - An empirical examination of the implications of assortative matching on the incidence of HIV. AB - Using data from The San Francisco Home Health Study (SFHHS), this paper analyzes the degree to which the incentives to avoid HIV infection result in infection dependent (assortative) matching patterns based on HIV status. The incidence implications induced by such matching are compared to infection independent matching, an implicit assumption in canonical models within epidemiology. We estimate that an HIV-positive individual is more than twice as likely as an HIV negative individual to have an HIV-positive partner, and that this results in a decrease in HIV incidence of about one-third compared to the predictions implied by standard epidemiological models. PMID- 10165268 TI - Question of ethics. HMOs establish protocols for 'last chance' treatments. PMID- 10165269 TI - How many docs? Establishing proper staffing levels under managed care requires some new math. PMID- 10165270 TI - Venturing into elder care. Aging population to bring explosive growth in senior services. PMID- 10165271 TI - N.J. hospital sale nixed. Judge says United violated federal bankruptcy rules. PMID- 10165272 TI - Becoming friends of Bill. Long-term-care execs gave big money to Democrats. PMID- 10165273 TI - Columbia's big ad bucks. Giant chain outspends other hospitals on advertising. PMID- 10165274 TI - Doc group mergers push dealmaking pace. PMID- 10165275 TI - Labor gets tough. Chicago SEIU vows to probe understaffing, undertraining. PMID- 10165276 TI - Latino kids underinsured. L.A. children fall through Medicaid cracks, study finds. PMID- 10165277 TI - Civil war. Pa. rehab provider's board, ex-chief battle for control. PMID- 10165278 TI - Blues goes global. New program includes overseas inpatient care. PMID- 10165279 TI - Millennium-unready. Survey finds majority of hospitals haven't begun to fix 2000 related computer flaws. PMID- 10165280 TI - Stalled on the on-ramp. Many in healthcare aren't on the data superhighway. PMID- 10165281 TI - Large employers gain voice. Joint Commission creates Business Advisory Group. PMID- 10165282 TI - More dumping cases. Three hospitals agree to pay a total of $75,000 in fines. PMID- 10165283 TI - Pressure for privacy. Panel urges steps to force providers to secure clinical data. PMID- 10165284 TI - Medicare benefit imbroglio. Critics see home health respite as a pricey proposition. PMID- 10165285 TI - Don't hold your breath. Everybody claims to hate campaign finance system, but few really want change. PMID- 10165286 TI - Scared of the bull. Not-for-profit hospitals are costing themselves millions with timid investment strategies. AB - While level-headed noncasino-going people have accumulated tidy sums by judicious investing in higher-yielding debt and equities, the culture of hospital management and governance frowns on any financial risk. There are stirrings of change, especially among cash-rich systems. But naive as it sounds, some hospitals would rather stick with the tried-and-true than run with bulls. PMID- 10165287 TI - Quiet giant. Among managed-care plans, Cigna HealthCare is the biggest and most often overlooked. PMID- 10165288 TI - Bureaucracy to adhocracy. A possible structure for the Department of Health and Family Services. AB - At a meeting on Friday, 7 June 1996, the Minister for Health and Family Services, The Hon. Michael Wooldridge MP, asked the authors to prepare a paper on a possible structure for the Department of Health and Family Services. This followed our explanation to him of navigating women's and children's health service issues through the existing departmental structure. We had explained that such navigation included nearly all of the divisions within the department; and then within those divisions there were different branches responsible for different activities. It has been our experience that rarely do the different divisions, branches or sections exchange ideas, views or policies that might affect women and children. The result is a fragmented approach to this important group of the population. We know that this same approach, exists for other key population groups. This paper has been prepared at the request of the Minister, and follows an approach based on population and outcome. PMID- 10165289 TI - Matching needs to services: the quick response. Case study: St George Hospital and Community Health Services Best Practice Project. AB - A Quick Response Program (QRP) was developed and implemented at St George Hospital during 1995 and 1996. The program sought to improve the service provided to elderly people presenting to the emergency department by offering a new rapid response service pathway to community-based care. Emergency department discharge planning and crisis intervention evolved as important QRP functions during the program's life. Evaluation findings indicated that QRP penetration into the elderly sub-acute emergency department patient population was high, and that hospital admissions were avoided without affecting emergency department process times. Health outcomes were not compromised by the program, and patient and general practitioner satisfaction were high. The program grappled with the inherent conflict of interest between the aims of the hospital (acute care services) and those of the community service (support and maintenance). The program sought to bridge the gap between these service parameters in the name of meeting patient needs. PMID- 10165290 TI - No matrix magic. PMID- 10165291 TI - A typology for legal risk management in patient care in Australian hospitals. AB - The author reviewed the literature on legal risk management in patient care, and carried out research in two acute care hospitals. The hospital research involved auditing policies and procedures, interviewing key people in the hospital, reviewing external legal and policy trends, and examining selected complaints files and legal cases. The results were used to develop a 'typology' of legal risk management to provide guidelines and assistance to hospital management in improving their hospital's strategic response to legal vulnerability. The model sets out four levels of legal risk management programs, and identifies specific components classified as promoting loss prevention, or loss minimisation. PMID- 10165292 TI - Computerised data collection for a cancer centre: a Queensland perspective. AB - The Queensland Radium Institute has had a computerised database for 15 years but there was little uniformity in the data collected and there was considerable scope for improvement. In 1991 the institute decided to upgrade and standardise its data collection system. The improvements will allow easier access to the data for research and audit purposes. The process was effective and the implementation straightforward because of effective planning and training. This paper outlines the process used in the review and implementation of the new database system and describes the date sets in some detail. PMID- 10165294 TI - Australia's health 1996. PMID- 10165293 TI - Reorganising health. PMID- 10165295 TI - Australian medical labour force data available. PMID- 10165296 TI - Political before bureaucratic reform. PMID- 10165297 TI - The process of developing and validating national core competencies for diabetes educators. AB - The National Core Competencies for Diabetes Educators were developed on behalf of the Australian Diabetes Educators Association between July 1994 and November 1995. This paper traces the development of the competencies including the rationale for undertaking the project, the process involved and the measures taken to ensure their relevance and validity. The limitations of applying the competency concept to health professionals are discussed. The paper also explores issues affecting professional bodies which attempt to define and document competencies and describes some of the obstacles which may be encountered during the process. PMID- 10165298 TI - Aboriginal health: a discussion of some current issues. AB - This paper explores some health status differences between the Aboriginal and total Australian populations, and investigates trends in Aboriginal mortality and morbidity within the context of some of the socioeconomic, lifestyle and environmental influences. It identifies that Aboriginal people continue to suffer from a number of health problems at significantly higher rates than the rest of the population, and discusses some of the effects of early fertility and alcohol misuse on health status. Drawing on some findings of the 1994 National Aboriginal and Torres Strait Islander Survey, the paper concludes with the proposition that it is impossible to consider the economic implications of sub-standard Aboriginal health without also considering the social issues, and that programs aimed at improving this situation must be demand-driven, economically responsible responses to identified problems in specific regions. PMID- 10165299 TI - Tourists as inpatients in Queensland regional hospitals. AB - This study analysed medical record data from seven regional hospitals in Queensland to determine the types of medical conditions and injuries that resulted in overseas and interstate tourists being admitted to hospital. From a total of 135,128 admissions to the participating hospitals, 695 (0.51 per cent) were identified as overseas tourists and 3479 (2.57 per cent) were from interstate. The main reasons for admission of overseas tourists, based on principal diagnoses, were injuries and poisonings (37.6 per cent), circulatory disorders (11.7 per cent), digestive conditions (9.8 per cent), and genito urinary disorders (8.8 per cent). For interstate tourists, the main reasons for admission were genito-urinary disorders (19.8 per cent), injuries and poisonings (15.4 percent), neoplasms (11.4 per cent) and circulatory disorders (10.6 per cent). These findings are discussed in relation to current literature in the field of travel medicine, emphasising the burden of care placed on the admitting hospital's resources, and the growing number of visitors to Queensland needing health care. PMID- 10165300 TI - Best practice in the health sector. AB - The Commonwealth Government is increasing its emphasis on public health and quality of care, which will require a capacity to measure health outcomes and develop strategies for continuous improvement. The reforms being considered by the Council of Australian Governments (COAG) are designed to improve the quality of health services by allowing the Commonwealth to concentrate on broader strategic analysis and performance measures. The health industry will need to take a pivotal role in improving service delivery through collaboration with industry leaders and aiming for best practice. PMID- 10165301 TI - Communication--the vital link in best practice organisations. Case study: the Princess Alexandra Hospital Best Practice Communication Project. AB - The critical issue of communication has been addressed by the Princess Alexandra Hospital in Brisbane. The hospital commissioned a communications audit, benchmarked outside the health sector in the service industry, and designed and piloted communication strategies at an organisational level and in selected clinical settings. The communications models developed have emphasised the importance of planning, evaluation and flexibility to enable the modification of communication strategies to continually improve communication in the organisation. It is envisaged that regular communication assessments will be conducted with the use of audit tools which have been developed to compare results over time. PMID- 10165302 TI - Waiting times: the search for equitable solutions. Case study: Mater Misericordiae Adult Public Hospital Continuum of Care Model. AB - For the survival of any health care organisation, evidence-based practice is fundamental, particularly in today's economic climate. The Mater Misericordiae Adult Public Hospital in Brisbane is committed to providing a flexible health care system that is responsive and accountable to the needs of the customers. As part of the Mater's continuous quality improvement program, a Continuum of Care Service Delivery Model was developed. This model comprises many innovative clinical management systems which have evolved over recent years. Clinical pathways, care management, pre-admission clinics, variance management and evidence-based practice are core components of the model. PMID- 10165303 TI - Transition from high to replacement-level fertility in a Kerala village. AB - This paper uses a micro-approach to examine the motivation and processes of rapid fertility decline in a Kerala village. Fertility declined in the village substantially during the 1970s and continued to decline to reach replacement level at the time of study. The proximate determinants are postponement of marriage and extensive use of contraceptives. However, the changes in these factors were the result of changing socio-economic conditions. At the time of study the singulate age at marriage was 29 years for males and 23 years for females, higher than elsewhere in India. Delayed age at marriage was a combined effect of favourable attitudes to education and economic changes. Smaller families became advantageous because of decreasing agricultural opportunities, expanded education and mortality decline. Contraceptives were available with the implementation of the family planning program. Higher use of contraceptives can be attributed to favourable conditions resulting from socio-economic changes. PMID- 10165304 TI - Fertility decline in Bangladesh: toward an understanding of major causes. AB - Bangladesh has undergone a considerable decline in fertility, despite the absence of conditions believed to be necessary for such reproductive changes. Indeed, Bangladesh is the only one among the world's twenty poorest countries where such a change has occurred. The paper examines the nature of fertility transition in Bangladesh, looks at the trends in contraceptive use and fertility, and identifies the major factors accounting for the fertility decline, despite poor socio-economic conditions. Two types of factors in the decline are: (a) positive factors which encourage eligible couples to contracept, and (b) negative factors which compel women to contracept, for spacing or limiting births. The effects of positive and negative factors on contraceptive use and fertility are analysed with data from a rural sample of 4,194 women from the 1993-94 Bangladesh Demographic and Health Survey (BDHS), 2,597 women from the MCH-FP Extension Project area, and 8,110 women from the Matlab MCH-FP Project area. Logistic regression is used in the analysis. Strong and highly significant effects of female education, female employment and access to media on contraceptive use and fertility have been found. PMID- 10165305 TI - The quantity/quality of children hypothesis in developing countries: testing by considering some demographic experiences in China, India and Africa. AB - Initially a general regression equation is estimated, making use of cross-country data, relating the level of the total fertility rate to a range of variables, including the level of per capita real income. There is a statistically significant negative relationship between the level of the total fertility rate and real income per capita. Once the theory of the quantity-cum-quality of children hypothesis is set out formally, and in a flexible form, it is clear that this statistical relationship is not inconsistent with this theory. However, this relationship is not a strong, or convincing, test of this hypothesis. To provide more satisfactory tests of this hypothesis, additional relevant information from various developing countries is used. Information on recent demographic changes in China provides a comparatively powerful, direct test of the theory. More indirect tests of the theory are provided by drawing on data for India in the 1960s, and for sub-Saharan African countries in the 1980s and early 1990s. These various tests suggest that the quantity-cum-quality hypothesis, in its flexible form, appears to explain some of the changes in fertility rates observed in various developing countries in recent decades. PMID- 10165306 TI - What Yugoslavia means: progress, nationalism, and health. AB - Theories of modernization have assumed that the creation of nation-states involved the breakdown of parochial ethnic boundaries and increasing secularism, all of which resulted in a demographic transition from high to low fertility and mortality. Recent experiences suggests, however, that in some circumstances nation-states may be highly unstable as ethnic minorities assert their rights to self-determination. Under such conditions, converging patterns of mortality may begin to diverge as growing inequalities appear between newly independent region of once unified states. The recent history of Yugoslavia is described to provide an example of how this process might occur and what the results might be. PMID- 10165307 TI - Health transition research in Nigeria in the era of the Structural Adjustment Programme. PMID- 10165308 TI - The family and demographic change in Sri Lanka. AB - Sri Lanka has almost completed the demographic transition with low mortality rates and fertility rates approaching replacement levels. Sri Lanka shares these characteristics with the South Indian states of Kerala and Tamil Nadu in contrast to elsewhere in South Asia where mortality and especially fertility rates remain much higher. A key part of the explanation for these differences lies in the nature of the family. The Sri Lankan family is essentially the conjugal unit of husband, wife and dependent children whereas in northern South Asia agnatic relations between son and parents are central to family structure. Related to this family system the position of women in Sri Lankan society was relatively high in South Asian terms. Consequently women had a strong say in health and fertility behaviour. When required, for example, mothers take the initiative in seeking health care for themselves and their children. Importantly family structure has facilitated female education which is associated with both mortality and fertility decline. There are few concerns that the values imparted by secular education are contrary to the values of the family or to women's roles within it. The egalitarian family structure has also contributed to fertility decline by raising the costs of children and reducing the long-run benefits to be gained from them. Sri Lanka is particularly distinctive in the contribution of changes in female age at marriage to its fertility decline, marriage age having risen six years this century. This change has been accompanied in recent times by a shift from family-arranged to self-selected (love) marriage. The explanation lies in changes in the socio-economic system which have reduced the centrality of the family in wider social and economic relations, and placed a greater premium on an individual's own abilities and attributes. PMID- 10165310 TI - Interferon-beta in multiple sclerosis. Can we control its costs? AB - The recent licensing of interferon-beta for use in patients with multiple sclerosis has caused concern, in view of the equivocal evidence of efficacy, pressure of public expectation towards its use and the high expected cost if widespread use were to be sanctioned. Whether such alarm is justified remains a moot point. Owing to the limited range of circumstances of proven efficacy and the lack of cost-effectiveness data, it remains unclear whether sanctioned usage will proliferate to the anticipated extent. Unit costs may well fall in the future owing to competition in the pharmaceutical market. Interferon-beta is simply one example of a growing trend in actively promoted high-cost preparations over which rationing decisions will have to be reached. PMID- 10165309 TI - Pricing and reimbursement of pharmaceuticals in Belgium. AB - The Belgian healthcare system has a tradition of access and equity at affordable prices. As in other countries, the system becomes pressured by increasing healthcare costs. This paper describes the actual situation in Belgium with special focus on pharmaceutical products and the potential role of pharmacoeconomics in decision making on price and reimbursement. Nearly all people in Belgium are covered by compulsory health insurance. The system is paid for by social security, the patients and the federal and regional authorities. The part of the consumption of pharmaceuticals that is charged to insurance was about 62.1 billion Belgian francs (BeF), i.e. about 50% of the pharmaceutical market in 1994. Price setting in Belgium has been rather low due to the positive reimbursement list, where the price of a new drug is compared to existing drugs in a comparable therapeutic class (so-called reimbursement criteria). The expenditure on pharmaceuticals is increasing faster than global funding for public health. In order to control drug budgets, different cost-containment measures have been or are being taken, i.e. a mix of price, reimbursement and volume controls. These cost-containment measures are not necessarily in accordance with a health economic approach. This paper suggests the scope for better implementation of pharmacoeconomic evaluation, which can lead to more flexible reimbursement systems in specific indications. Therefore, a formal recognition of the role of objective economic evaluations is needed for both hospital and ambulatory care. This process should be proceeded by improving the understanding and robustness of pharmacoeconomic evaluations. PMID- 10165311 TI - Is Helicobacter pylori eradication a cost-effective treatment of duodenal ulcer disease? AB - Treatment strategies aimed at eradicating Helicobacter pylori have shown positive results in the management of duodenal ulcer disease. Several cost-effectiveness studies comparing these regimens with traditional therapy have recently been conducted, and results are discussed in this review. Cost comparisons of different treatment strategies cannot be performed without first identifying whether the cost of ulcer diagnosis is included in the study. Assuming that only 20% of patients with dyspepsia actually have ulcer disease, costs may vary, depending on the study population. Importantly, treatment costs should not be compared between a patient population with confirmed ulcer disease and one without confirmed disease. In patients with confirmed ulcer disease, studies consistently show that H. pylori eradication strategies are associated with greater efficacy and lower costs than traditional treatment, and are therefore a more cost-effective alternative to standard therapy. Although all models used in the cost-effectiveness analyses assume that patients discontinue treatment following successful eradication of the microorganism, in clinical practice some patients continue antisecretory treatment beyond this period. Thus, savings as a result of H. pylori eradication may be less substantial than indicated in cost effectiveness studies. PMID- 10165312 TI - Peripheral vascular disorders. A pharmacoeconomic and quality-of-life review. AB - The purpose of this article is to review the literature on the pharmacoeconomics and quality of life of therapy interventions for patients with peripheral vascular disorders. The paper is in 4 parts. The first presents a framework for the analysis of such drug interventions, which contrasts studies that have a clinical focus with those that take a system or modelling focus and presents a research typology for studies in this area. The second part of the paper reviews pharmacoeconomic studies of selected interventions and assesses their contribution to decision-making within healthcare systems. The particular focus is on the pharmacoeconomics of therapy for atherosclerosis. While there are no studies which have evaluated the overall costs of treatment in this disease area or considered the cost effectiveness of the range of alternative treatment strategies, the issues of good clinical practice and the implicit cost effectiveness of identifying patients for treatment options and prevention strategies has been addressed. The few studies which have considered the cost consequences of particular intervention strategies, specifically pentoxifylline therapy and surgical options, are limited in scope and are difficult to generalise due to their age, their study design or the treating environment from which data are drawn. The third part reviews quality-of-life studies and, once again, assesses their contribution to formulary decision-making. There are no published studies which have compared quality-of-life outcomes associated with alternative treatment approaches or which have reported changes associated with pharmacotherapy in patients with peripheral vascular disorders. Finally, given the dearth of studies in this area, a research agenda is proposed for ongoing investigations. PMID- 10165313 TI - A pharmacoeconomic comparison of antithymocyte globulin and muromonab CD3 induction therapy in renal transplant recipients. AB - Antithymocyte globulin (ATG) and muromonab CD3 (OKT3) are currently the only antilymphocyte preparations that are commercially available for induction immunosuppressive therapy for renal allograft transplantation in the US. ATG, in the usually prescribed doses, is more expensive than muromonab CD3, but muromonab CD3 is associated with more severe adverse effects that may affect clinical outcome and overall cost. We performed a retrospective study of all adult recipients of a first cadaveric renal allograft, who underwent transplantation between January 1991 and December 1994 who received either ATG (n = 92) or muromonab CD3 (n = 91) for induction therapy at our transplant centre. The average age of recipients was older (50 vs 44 yrs; p = 0.001) and extended donors were more commonly used in the ATG group (41 vs 13%; p = 0.0001) compared with the muromonab CD3 group. Nevertheless, at 1 year post-transplant, the incidence of rejection was lower (34 vs 47%) and graft survival was better (93 vs 85%; p = 0.03) in the ATG group. Patients who received ATG were discharged earlier (9.4 vs 13.3 days; p = 0.0001) and had similar serum creatinine levels on the day of discharge (2.4 +/- 1.5 vs 2.1 +/- 1.1 mg/dl; p = 0.25). Overall, the 1-year hospitalisation costs of transplantation and readmissions were similar [$US39,937 +/- 17,014 vs $US42,850 +/- 20,923 (currency year 1994); p = 0.22]. This is the first comparison of ATG and muromonab CD3 in renal transplant recipients to consider clinical as well as economic outcomes. For renal transplant patients in whom induction therapy is used at our centre, the initial expense of ATG can be justified by improved graft survival, fewer rejection episodes, and shorter hospital stays, which are associated with similar overall transplantation costs. PMID- 10165314 TI - Measuring the variability of prescription use in patients with HIV infection or AIDS. The contribution of a French hospital longitudinal database. AB - This study is based on a sample of 937 patients with HIV infection or AIDS who were treated in 5 French hospitals. It sets out to describe the prescription of antiretroviral and prophylactic drugs used in treating such patients and, aims to interpret the various treatment strategies used. The study showed the contribution of longitudinal data in the descriptive analysis of patient follow up, given the evolving nature of the illness. The Principal Components Analysis method allowed the temporal and quantitative aspects of the data, as well as their combination with qualitative variables, to be taken into account. The results revealed the stability over time of the choice of prescriptions, and allowed joint prescription/substitution phenomena between drugs to be evaluated. At the same time, the study provided evidence for a "site' effect, which showed that the heterogeneity of professional practice is not solely the result of differences in patients or in severity of the illness. PMID- 10165315 TI - Economic evaluation of antiviral therapy for the treatment of herpes zoster in immunocompetent adults. AB - Shingles (herpes zoster) affects 20% of the population at some stage during their lives. The economic consequences can be significant. For example, in the UK, the costs of post-herpetic neuralgia, a complication that affects between 10 and 14% of patients with shingles, have been estimated between 4.8 million and 17.9 million pounds sterling (Pounds). This study is the first formal assessment of the cost-effectiveness of the 2 most commonly used oral antiviral treatments that have proven efficacy in patients with shingles: famciclovir and aciclovir (acyclovir). It shows that the clinical advantages of famciclovir over aciclovir are accompanied by potential economic advantages in the form of savings in direct costs to the UK National Health Service of between 2.04 pounds and 16.85 pounds per patient treated. Future economic research to validate the benefits of antiviral treatment should focus on prospective assessments alongside controlled trials incorporating resource use analysis, quality-of-life appraisal, assessments of pain severity, and long term follow-up with continuation protocols. PMID- 10165316 TI - Changing patterns of antidepressant use and costs in a health maintenance organisation. AB - This study examined changes in the utilisation and costs of different antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), and changes in the use of mental health services in a US health maintenance organisation (HMO) over the 8-year period following the introduction of SSRIs. It was hypothesised that SSRIs would be used increasingly in this setting, and that SSRI users would show a pattern of mental health service utilisation that was indicative of more severe psychiatric illnesses or prior treatment failures. Both hypotheses were accepted. The use of antidepressants nearly tripled over the 8-year period, with SSRIs showing the largest increase; per capita antidepressant costs increased more than 10-fold, largely because of the high cost per unit of SSRIs. Estimated daily doses of SSRIs were largely within the recommended ranges, although the duration of use was short if their primary purpose was the treatment of depression. Incident (first-time) users of SSRIs, and patients who switched to SSRIs from other antidepressants, used more inpatient and outpatient mental health services than users of other antidepressants. Use of the psychiatric hospital among antidepressant users increased, then decreased back to its first year level, psychiatric hospital days appeared to decrease over time, and outpatient mental health visits increased. The inverse relationship between use of SSRIs and use of inpatient mental health services suggests the need for a cost-effectiveness analysis in this setting. PMID- 10165318 TI - Publication bias in health economic studies. PMID- 10165317 TI - Efficient use of G-CSF. PMID- 10165319 TI - On the definition and evaluation of telemedicine. AB - Issues related to the definition and evaluation of telemedicine are articulated as a basis for conducting theoretically based, empirically sound, and policy relevant evaluation. This paper includes a proposed operational definition of telemedicine, a discussion of the role of telemedicine in the healthcare system and economic analysis of telemedicine, an analysis of the basic approaches and requirements for telemedicine evaluation, and an identification of basic issues for evaluation. Telemedicine is conceived of as an integrated system of health care delivery that employs telecommunications and computer technology as a substitute for face-to-face contact between provider and client. It has the potential for ameliorating seemingly intractable problems in healthcare such as limited access to care among segments in the population--especially the geographically disadvantaged--uneven quality of care, and cost inflation. Its true merit has yet to be determined by systematic empirical study. Such study should include a clear and precise identification of inputs and output and the nature of the relations between them, an assessment of the changes that might occur in the process of care as a consequence to telemedicine, and, ultimately, an evaluation of the effects of telemedicine on the healthcare system in terms of cost, quality, and accessibility. Several basic questions regarding the effects of telemedicine are posed as potential hypotheses for future research. PMID- 10165320 TI - Analytic framework for evaluation of telemedicine. AB - This paper discusses two conceptual models intended to facilitate research on the effects and effectiveness of telemedicine. The first is a conceptual framework to study the efficacy of telemedicine as a diagnostic medium. Using conditions that are carefully chosen to serve as indicators of effectiveness, we recommended the analysis of sensitivity and specificity to establish the accuracy of telemedicine in relation to conventional health care delivery. Suggested guidelines for interpretation of the results are discussed. The second model is a scheme for classification of telemedicine applications that is based on processes of care rather than on specialties or disorders. The purpose of this classification scheme is to facilitate research on such variables as costs, access, acceptability, and effects on practice patterns. PMID- 10165321 TI - Patient satisfaction with teleoncology: a pilot study. AB - OBJECTIVE: To assess levels of satisfaction among rural cancer patients being seen for clinic visits by their remote university-based oncologist, using interactive videoconferencing (IAVC). METHODS: A 12-item survey instrument assessing satisfaction with the patient-physician clinical interaction was administered to 39 cancer patients who were seen using IAVC. A similar survey, comprised of 9 of the 12 items used in the initial survey, was administered to 21 of these patients after a subsequent on-site clinical interaction. All items were responded to on a five-point Likert scale. Levels of satisfaction with the two consultation modes (IAVC mediated and on-site) were compared. RESULTS: Relatively high levels of patient satisfaction with the telemedicine encounter were recorded both at the time of the initial IAVC-mediated clinical visit, as well at the follow-up on-site visit. With one exception, for each of the survey items, both initially and on follow-up, mean score was above 3.0 (i.e., positive). CONCLUSION: This small pilot study suggests that rural cancer patients may be satisfied with seeing their oncologist via telemedicine, at least on an occasional basis. Although the accrual numbers are too small to allow the results to be generalizable, the results suggest that patient acceptance is high enough to warrant further investigation of this modality in the care of rural cancer patients with limited access to cancer specialists. PMID- 10165322 TI - Tele-endoscopic otorhinolaryngological examination: preliminary study of patient satisfaction. AB - OBJECTIVE: Modern telecommunications and computer technologies enable the delivery of expert consultations and remote diagnoses that previously required transportation of patients or medical specialists. The purpose of this study was to determine whether patients are satisfied with one form of telemedicine consultation. METHODS: A general practitioner was trained to perform endoscopic otorhinolaryngological examinations. After the training period, he examined patients at a local health center in Alta, 250 km from Tromso. Images from the endoscopic examination were transmitted to the otorhinolaryngologist at the University Hospital of Tromso for real-time consultation. Twenty-six patients, on a randomly selected day, were asked to complete a questionnaire after the tele endoscopic examination. The questionnaire was returned anonymously by 24 of the patients. RESULTS: Although patients interacted with the specialist only via videoconferencing, the results show that most (23/24) were satisfied with this type of consultation, and they reported more advantages than disadvantages. Twenty-one patients indicated that they would accept another tele-endoscopic consultation if they required examination by an otorhinolaryngologist in the future. CONCLUSION: Although the sample is limited, the results justify continued investigation of this and other types of telemedicine consultations. PMID- 10165323 TI - Telemedicine and teleradiology: a tale of two cultures. PMID- 10165324 TI - Technical considerations in planning a distributed teleradiology system. AB - A large-scale teleradiology project is under way to link a Florida imaging center to the UCLA Department of Radiology. The initial goal is to provide Florida patients in a routine clinical practice environment with subspecialty consultation by academic radiologists. The plan then calls for the addition of other domestic and international sites. Technical issues in planning to establish the necessary teleradiology infrastructure include wide area network design, image compression, distributed archiving, and special viewing station features. Special emphasis is placed on archive design that makes intelligent use of information, such as triggering events from the radiological information system (RIS) for image prefetching and visual cues from photo-icons for full-size image retrieval. Concepts such as teleconsultation and remote procedure monitoring are aimed at providing the same level of services at distant sites that would be available in-house. This article highlights the system design parameters that must be considered to engineer a scalable distributed teleradiology system. PMID- 10165325 TI - MDTV Telemedicine Project: technical considerations in videoconferencing for medical applications. AB - In spite of the many advances in technology, complex problems must be addressed in establishing and maintaining a telemedicine system. Although most such systems are built around interactive videoconferencing (IAVC) equipment, clinical requirements dictate that these systems offer more than traditional IAVC systems. Input from system users should be obtained early in the design process to ensure the functionality necessary to achieve maximum utilization. Surprisingly, audio, rather than video, signals may present the greatest challenge to achieving consistent, high-quality videoconferencing encounters. Audio technical problems can be frustrating for patients and providers alike and can undermine user confidence in IAVC as a vehicle for healthcare delivery. A capability for remote access and control of components at distant sites seems essential to providing cost-effective and technically reliable service. PMID- 10165326 TI - Telemedicine in the U.S. Army: case reports from Somalia and Croatia. AB - Recent advances in information systems technology improved the abilities of U.S. Army physicians in Somalia and Croatia to obtain clinical consults from U.S. Army Medical Centers in Germany and Washington, D.C. Through commercial satellite transmission of voice, facsimile, and high-resolution still, digital images, the Remote Clinical Communications System (RCCS) has expanded the Army Medical Department's means to provide better healthcare to our armed forces. This paper describes the RCCS technology and illustrates, through specific case reports, how this telemedicine system helped the Army Medical Department accomplish its mission during overseas deployments. PMID- 10165327 TI - Health policy and telemedicine. PMID- 10165328 TI - Case triage model for the practice of telepathology. AB - OBJECTIVE: To implement and evaluate a practice model for telepathology. METHODS: A case triage practice model was devised in which general pathologists review all cases and refer them to subspecialists only when necessary. In 1993, the Arizona International Telemedicine Network (AITN), a high-resolution static imaging telepathology diagnostic network, linking six sites to the University of Arizona in Tucson, began testing the model. Work flow through the network was analyzed, and diagnostic concordance was assessed in 150 surgical cases by comparing the diagnoses of the referring (transmitting) pathologists with diagnoses of the consulting (receiving) telepathologists as well as by comparing the referring pathologists' diagnoses with the consensus diagnoses reached by an independent review panel. Data analysis was controlled for subspecialty case type. Telepathologists had access to the referring pathologists' preliminary diagnoses, and the review panel had access to the original glass slides and the surgical pathology reports prior to rendering their respective diagnoses. RESULTS: The triage pathologist completed the telepathology consultation without the assistance of a subspecialty pathologist in 66% of the cases. The review panel examined the original glass slides from 134 cases by light microscopy. Concordance rates of the telepathologists' or review panel's diagnoses with the referring pathologists' diagnoses were not statistically different (93.1% v 83.6%, respectively; P > 0.05). CONCLUSION: The case triage model is suitable for the practice of telepathology. It significantly reduces the need for subspecialty pathologists. Static imaging telepathology is useful and reasonably efficient for rendering diagnostic opinions in the majority of referred cases. Tissue sampling limitations imposed by static imaging occasionally resulted in diagnostic errors. PMID- 10165329 TI - Quality assurance in teleradiology. AB - Teleradiology is the electronic transmission of radiologic images from one location to another for the purpose of interpretation or consultation. The use of teleradiology expands the responsibilities of the supervising radiologists, physicists, and engineers. Teleradiology is being utilized increasingly to provide remote primary diagnoses rather than just preliminary interpretations or overreads. Consequently, it is essential that regular quality assurance and improvement mechanisms be in place. This article details the facets of quality initiatives that should be a component of every comprehensive teleradiology program. PMID- 10165330 TI - Challenges to the implementation of telemedicine. AB - In the United States, we are witnessing a renewed emphasis on the potential role of telemedicine in redressing issues of accessibility, cost, and quality of medical care. This paper describes several major problems confronting the current generation of telemedicine projects as they move toward maturity. In fact, it is argued here, the future development of telemedicine as an integral component of the health care system depends on the successful resolution of these concerns. Included for discussion are issues related to physicians, institutions, patients, and the general public. On the basis of the tenets of telemedicine and its capacity to transcend traditional boundaries of medical care via telecommunications, informed speculations are presented that are intended to stimulate discussion and provide direction for addressing a number of potential problems. Included are suggestions pertaining to restructuring the medical licensure system to accommodate telemedicine and the virtual regionalization of health care; implications for provider liability and reimbursement; patient privacy; system design; and diffusion of information. PMID- 10165331 TI - Texas Telemedicine Project: a viability study. AB - OBJECTIVE: The purpose of this research was to investigate viability factors in the implementation of telemedicine systems. The Texas Telemedicine Project examined the viability of a rural network where multiple facilities shared a switchable long-distance network rather than using fixed point-to-point connections. METHODS: During Phase I, conducted in 1989, staff at participating institutions analyzed applications for the proposed network and developed methodologies for data collection. The capital costs and potential savings of a telemedicine network linking institutions in Austin and Giddings, Texas, were estimated. In April of 1991, Phase II of the system was implemented, and the first year's actual capital expenditures and savings (e.g., trips avoided, salaries of traveling specialists saved, reduced mileage and patient transport expenses, redundant tests avoided, reduced long distance telephone charges) attributed to the network were calculated. RESULTS: On the basis of the data collected in Phase I, it was projected that each $1.00 applied toward installation and operation of the network should yield $1.50 in benefits, with return on investment (break-even) within 1 year. In practice, there was a net deficit during the first year, although linear extrapolation predicted return on investment in 2.7 years. CONCLUSION: Linking multiple users over a shared infrastructure has the benefit of distributing cost among the participants and achieving an economy of scale for telecommunications services. The chief barriers to greater savings were the failure of five of the six network sites to design mission-oriented telemedicine policies and the absence of Medicare reimbursement. PMID- 10165332 TI - Evaluation of remote stethoscopy for pediatric telecardiology. AB - OBJECTIVE: To investigate the interobserver reliability and diagnostic validity of a commercial electronic stethoscope for pediatric telecardiology. MATERIALS AND METHODS: Pairs of blinded pediatric cardiologists made independent diagnoses, recommendations concerning follow-up echocardiography, and specific judgments regarding heart sounds, murmurs, and congenital heart disease using an electronic (ES) or an acoustic (AS) stethoscope on 78 pediatric cardiology outpatients and at a distance of 450 km (280 miles) with 38 telemedicine cardiology outpatients. The kappa statistic (K) indexed the instruments' interexaminer reliabilities. The validity of ES was measured by K for ES versus AS and by the percentage of cases where the findings for ES and AS differed sufficiently to suggest an important ES screening error. RESULTS: For heart disease, AS, ES, and tele-ES reliabilities were satisfactory (K = 0.80, 0.67, and 0.80, respectively), as were AS agreement with hands-on ES (K = 0.65) and with tele-ES (K = 0.64). The AS and ES reliabilities and ES/AS agreement were also satisfactory for systolic regurgitant and diastolic pulmonic murmurs (K = 0.63-0.78) but were unsatisfactory for evaluable heart sounds and other murmurs (K = 0.16-0.60). The ES yielded clinically important disagreements with AS in 5.4% of the clinic cases and 10.5% of the telemedicine cases (P = 0.67). In determining the need for additional work up (echocardiography) or follow-up appointments, hands-on ES and tele-ES had a combined accuracy of 92%, with a sensitivity of 88% and a specificity of 97%. CONCLUSIONS: Hands-on ES provided reliable and valid screening for congenital heart disease. Tele-ES was highly reliable but had reduced diagnostic validity. Examiner blinding, bandwidth limitations, and artificial restrictions on the remote assistant may have contributed to this reduced performance. As these factors are easily correctable, we regard the ES as a highly promising tool for pediatric telecardiology. PMID- 10165333 TI - Telemedicine and health policy: is there life after the recissions? AB - Recent Congressional budget recissions are likely to reduce the development of telemedicine in the United States, yet federal support is considered essential for such development. Both the executive and the legislative branches continue to show interest in the field. Pressure is mounting for research data documenting the effects of telemedicine on health care cost, quality, and access. Other policy issues arise from the recent revolution in the telecommunications industry and changes in health care delivery. PMID- 10165334 TI - Telemedicine: an annotated bibliography: Part I. PMID- 10165335 TI - National Library of Medicine telemedicine activities. PMID- 10165336 TI - Malpractice issues in the practice of telemedicine. PMID- 10165337 TI - How to minimize the risk of disclosure of patient information used in telemedicine. PMID- 10165338 TI - Current issues in telepathology. AB - Telepathology involves rendering diagnostic opinions on specimens at remote locations using computer and telecommunications technologies. Consultations are a routine practice pattern in pathology, as there is a large amount of diagnostic and prognostic information available from the examination of biopsy material that requires an extensive knowledge of diseases and their clinical implications. Pathologists therefore frequently request opinions from those who subspecialize in various diseases. The use of video technology to examine and consult on microscopical slides has been validated, although sparsely and with a number of technical issues as yet unresolved. There are two principal paradigms for telepathology: remote dynamic screening by robotic video microscopy and remote diagnosis from selected still video microscopical images. The former is more appealing to most pathologists; however, it requires very high speed telecommunications links that are expensive and may not be available in a given location. The latter method entails a significant reduction in the data on which the diagnosis is rendered, as one is dependent on the fields selected at the remote location. In addition, there are hybrid systems that combine limited robotic capabilities with high-resolution still images. Image compression can increase the number of images that can be transmitted over an otherwise-limiting telecommunications infrastructure. JPEG is the current standard for such compression. Despite certain limitations, telepathology has been demonstrated successfully at several sites around the world. As this technology matures, systems will offer higher resolution, standardization of file formats, and better compression at lower cost. PMID- 10165339 TI - Teledermatology in a changing health care environment. AB - To avoid marginalization and an attendant decline in the quality of care delivered, dermatologists must take the lead in defining those services that can be delivered remotely and move aggressively to create standards of nomenclature, protocols for imaging, and methods of care delivery that can be implemented in a primary-care setting. Because of the rigorous training of its practitioners in visual analysis, it may be possible for dermatology to shift from its traditional face-to-face model to an image-based, remotely practiced one. Transition to remote practice may even be critical to the survival of the specialty. Chief among the issues in the implementation of teledermatology is whether the use of video conferencing or store-and-forward technology provides the most efficient, high-quality remote diagnosis. Ancillary issues, including image protocols, bandwidth requirements, reimbursement, licensing, liability, and patient and provider satisfaction, are important as well. These issues are discussed in a framework of capitated payment in urban, integrated delivery systems. Teledermatology has many challenges to meet before competing with face-to-face delivery of dermatologic care. PMID- 10165340 TI - Response to a telemedicine inquiry from the Florida House of Representatives and text of model act to regulate the practice of telemedicine. AB - This past summer, the Federation of State Medical Boards (FSMB) drafted model legislation on the practice of medicine across state lines and sent it to each state medical board for consideration. The Florida House of Representatives Committee on Business and Professional Regulation posed a series of questions about telemedicine covering issues of licensure, malpractice, insurance reimbursement, technology, physician interest and acceptance, quality of care, and cost benefit. The author's responses having been modified for this article, are presented, as is the model legislation. Appendix I is the Executive Summary of the FSMB. Appendix II is the model legislation. PMID- 10165341 TI - Second Invitational Consensus Conference on Telemedicine and the National Information Infrastructure. Augusta, Georgia, May 2-4, 1995. PMID- 10165342 TI - Telemedicine: an annotated bibliography: Part III. PMID- 10165343 TI - Joint federal initiative for creating a telemedicine evaluation framework. PMID- 10165344 TI - The Center for Telemedicine Law. PMID- 10165345 TI - Health care on the information highway: the politics of telemedicine. PMID- 10165346 TI - An Ohio telemedicine system for prison inmates: a case report. AB - BACKGROUND: A project was established by The Ohio State University Medical Center (OSUMC) and the Ohio Department of Rehabilitation and Corrections (ODRC) to investigate the use of telemedicine in providing health care to Ohio's prison inmates. OBJECTIVES: To determine the effects of telemedicine on continuity of inmate care, the sense of isolation experienced by health care providers at remote institutions, the security risks incurred when transporting inmates to outside facilities, and the overall cost of care. In tracing the initial adoption and implementation of the project, the authors describe health care in Ohio's prisons and the unique nature of providing that care. METHODS: The project was conducted over a 1-year period, from November 1994 through December 1995, using a variety of methods: direct observation of inmate consultations; participation in task force meetings; unstructured interviews with physicians, prison administrators, ancillary health care personnel, and security guards; and initial collection of survey data. RESULTS: Telemedicine enables Ohio's inmates to receive health care in a more timely fashion than before. Physicians and inmates were generally satisfied, and the costs of providing inmate medical care were reduced by lessening or eliminating the need for additional security guards, vans, chase vehicles, and travel time for physicians. CONCLUSIONS: Some initial hurdles in using the system, such as scheduling and triage, are being overcome as new methods are devised, and additional incentives for specialty physicians to use the system are being investigated. The OSUMC/ODRC project suggests that the advantages of using telemedicine in prison settings are immense, and the ODRC plans to expand the network to include two more remote sites early in 1996. PMID- 10165348 TI - The process of elimination: video compression in telemedicine. PMID- 10165347 TI - The University of Texas Medical Branch--Texas Department of Criminal Justice Telemedicine Project: findings from the first year of operation. AB - BACKGROUND: The University of Texas Medical Branch (UTMB) and Texas Tech Health Science Center (TTHSC) are responsible for providing health care for approximately 130,000 inmates of the Texas Department of Criminal Justice through a health maintenance organization (HMO). Telemedicine was considered a way to solve some of the problems presented. OBJECTIVES: To develop approaches to patient care, technology, support systems, evaluation, and uses of the system for applications other than patient care as part of the first stage of implementation. METHODS: Four prison delivery unit models were utilized. After a pilot study, the first patients were seen from October 1994 to November 1995, when 1715 consults were conducted in 18 scheduled specialty telemedicine clinics. Patients and providers were surveyed by interviews and questionnaires for their views on this form of providing care. RESULTS: Ninety-five per cent of the telemedicine consults saved one or more trips to UTMB for outpatient specialty appointments. User surveys indicated a high degree of satisfaction on the part of patients, presenters, and specialty consultants. CONCLUSIONS: Preliminary review of the data indicated favorable care outcomes, and initial economic analyses suggested that telemedicine is likely to be cost-effective in this environment. The project will be continued. PMID- 10165349 TI - Rural telemedicine: a national snapshot. AB - OBJECTIVES: To estimate the use of telemedicine in rural hospitals in the U.S. and to identify and describe those rural hospitals that are active in telemedicine. MATERIALS AND METHODS: Nationwide mailed survey, with telephone follow-up, to all hospitals not located in a Metropolitan Statistical Area. RESULTS: The overall response rate was 95% of all rural hospitals. Of these, 416 (17.55%) reported having telemedicine, and more than 530 more have plans to begin telemedicine programs during the next few years. Rural hospitals of all sizes and in all regions of the country are initiating telemedicine programs, but there is significant variation by region. Specifically, hospitals located in more populous rural counties near metropolitan areas are less likely to have telemedicine than are hospitals located in less populous rural counties in more remote areas. Conservatively, more than 4000 teleconsults per month are estimated among rural hospitals nationwide in 1995, including all forms of telemedicine. CONCLUSIONS: Telemedicine is becoming an important means of providing specialty medical services in rural areas. This screening survey generated information about the extent of telemedicine use in rural communities, but it also raised many new questions. These questions are being pursued through a detailed follow-up survey. PMID- 10165350 TI - Telemedicine: an annotated bibliography: Part IV. PMID- 10165351 TI - Alternative licensure systems for telemedicine. PMID- 10165352 TI - Experience-related differences in diagnosis from medical images displayed on monitors. AB - OBJECTIVE: To compare diagnostic accuracy using conventional versus monitor displayed medical images in order to determine if years of experience as a board certified clinician influences diagnostic performance in either modality. MATERIALS AND METHODS: In separate observer performance studies, six radiologists and six pathologists differing in years of experience viewed clinical images, once in the conventional modality (X-ray film or light microscopy) and once using a monitor display. Readers also were surveyed regarding their experience with digital/video display systems. RESULTS: In both studies, performance was similar for conventional and monitor modalities. For the conventional displays, there was a positive correlation between years of clinical experience and performance. For the monitor displays, however, there was a strong negative correlation between years of clinical experience and performance. Performance using the monitor displays correlated highly with experience using digital/video systems in general. CONCLUSION: More exposure to and use of monitor displays, such as recreational video games and computers, may influence positively the clinician monitor display system interaction and improve diagnostic performance. PMID- 10165353 TI - State initiatives to promote telemedicine. AB - OBJECTIVE: To identify states that have played a key role in promoting, developing, and supporting telemedicine initiatives aimed at improving access to basic health care and to characterize the range of actions and policy-making roles taken by the states. METHODS: State agencies involved in telemedicine initiatives and state-funded telemedicine programs were interviewed by telephone. An informal case study approach was used with a standard, open-ended questionnaire. Twenty-seven states were contacted in early 1995. RESULTS: Sixteen states have been active in telemedicine development since 1989, with the level of activity expanding considerably in the last 2 years. Some states, particularly Georgia, Kansas, Texas, South Dakota, and Louisiana, have well-developed programs. Policy actions taken by the states in support of telemedicine differ considerably. They include planning and coordination, development of networks, more limited program development, funding, building a telecommunications infrastructure for telemedicine, and regulatory support and clarification. A wide array of funding sources has been used, including state tax dollars and state earmarked federal monies and regulatory judgments. The level of funding by the states has also varied, ranging from less than $100,000 to tends of millions of dollars. CONCLUSION: There are varied roles and policy actions that states have assumed in promoting and supporting telemedicine development. States are investing considerable dollars and effort in telemedicine and appear likely to continue this activity in order to promote its development and improve access to health care. PMID- 10165354 TI - "Robo-Rad": an inexpensive user-friendly multimedia report system for radiology. AB - BACKGROUND AND PURPOSE: The complex information obtained by CT, MR, and ultrasound examinations is often difficult to convey with a written report. Today's multimedia computer technology provides a medium within which the audio and the visual components of a radiologic consultation can be made available simultaneously, with the projected capability of remote access from any personal computer. A system was developed to run on low-end computer systems with image quality adequate for reporting purposes and prudent memory management (each report occupies < 4 MB). With this system-"Robo-Rad"-the image and radiologist are recorded simultaneously while he or she describes and points out (with a mouse) areas of interest. This dynamic report, along with patient data, can be retrieved and viewed by the consulting physician at his/her convenience using a low-end PC or Macintosh computer. MATERIALS AND METHODS: To assess the clinical utility of Robo-Rad, survey responses were solicited from clinical physicians at the Penn State University Hospital (41.5% faculty/fellows, 31.7% residents, 11.8% medical students, 2% clinical nursing; n = 101) during a hands-on demonstration using studies of 35 consecutive inpatients whose CT scans had been dictated into the system. RESULTS: In an average week, the surveyed professionals ordered 3.2 +/- 3.0 CT studies, reviewed 3.8 +/- 3.0 CTs, spent 1.5 +/- 2.0 hours locating Ct studies, and discussed 2.3 +/- 1.9 CT cases with a radiologist. The average time spent discussing a single CT case with a radiologist was reported as 9.4 +/- 5.9 minutes. On a five-point rating scale (1 = not at all to 5 = very much so), respondents indicated that the Robo-Rad report was helpful (4.3 +/- 0.7) and provided clinically important information that would be difficult to convey with current dictation systems (4.2 +/- 0.8). Desire to discuss the case with a radiologist in addition to viewing the Robo-Rad report scored 3.2 +/- 1.0. If such a system were readily available, 91.8% of the respondents indicated that they would use it in addition to the currently available written report and audio dictation system, and 96.6% would use it instead of the current system. Local area network and modems were the modalities of highest interest for remote access (69.3% and 44.6%, respectively). CONCLUSIONS: Judging by these data, the Robo-Rad system would be of benefit to clinicians. It provides a user-friendly, low-cost multimedia radiology report utilizing readily available technology to improve radiologist-clinician communication. PMID- 10165355 TI - Wavelet compression of medical imagery. AB - Wavelet compression is a transform-based compression technique recently shown to provide diagnostic-quality images at compression ratios as great as 30:1. Based on a recently developed field of applied mathematics, wavelet compression has found success in compression applications from digital fingerprints to seismic data. The underlying strength of the method is attributable in large part to the efficient representation of image data by the wavelet transform. This efficient or sparse representation forms the basis for high-quality image compression by providing subsequent steps of the compression scheme with data likely to result in long runs of zero. These long runs of zero in turn compress very efficiently, allowing wavelet compression to deliver substantially better performance than existing Fourier-based methods. Although the lack of standardization has historically been an impediment to widespread adoption of wavelet compression, this situation may begin to change as the operational benefits of the technology become better known. PMID- 10165356 TI - Dermatology teleconsultations to Central Prison: experience at East Carolina University. AB - OBJECTIVE: To review our experience with dermatology teleconsultations between East Carolina University School of Medicine in Greenville and Central Prison in Raleigh, NC. MATERIALS AND METHODS: Consultation forms kept on file in the Department of Internal Medicine served as the source of data. One physician reviewed the forms from the initial 22 months of our dermatology teleconsultation service to Central Prison. Patient demographics and the diagnoses made by the consulting physician were recorded. Recommendations were tabulated as either diagnostic or therapeutic. Diagnoses and recommendations for known HIV-positive individuals were separately recorded. RESULTS: One hundred thirty-eight dermatology teleconsultations were performed over the 22-month period. Seventy two per cent of the patients seen were African-American. The average age was 32 years. One hundred fifty-nine diagnoses were made. The most common problems were eczema and acneiform eruptions. Fifty-nine diagnostic and 252 therapeutic recommendations were made. CONCLUSION: Consultants generally were confident of their diagnoses and management decisions. Dermatologists can assist primary care physicians through telemedicine consultation. PMID- 10165357 TI - "Telepsychometry": a remote psychometry consultation in clinical gerontology: preliminary study. AB - OBJECTIVE: Evaluation of the clinical feasibility of remote psychometric consultation with elderly patients. METHODS: Remote consultation with six women and four men (average age 87) was compared with a standard consultation. An interview and two psychometric tests were used: the Mini-Mental Status Examination (MMSE) and the Clock Face Test (CFT), which were administered by a clinical psychologist and controlled by a psychologist observer who remained in the room with the patient. The experimental setting consisted of two rooms linked by a coaxial cable. Each room was equipped with a camera, television screen, and microphone. The clinician was able to operate the mobile camera in the patient's room by remote control. The clinician was assisted by a computer, which helped to focus on standardized points. A video camera recorded the consultation for documentation purposes. RESULTS: Decreased performance was observed in the remote versus the standard consultation for both tests (MMSE: p = 0.008; CFT: p = 0.006). Physiologic hearing loss may have been responsible for a fall in the patients' attention. CONCLUSION: Remote psychometric consultation can be applied successfully to the psychological examination of elderly patients provided that communication problems are solved. PMID- 10165358 TI - Telemedicine: an annotated bibliography: Part V. PMID- 10165359 TI - Telemedicine and economic realities. PMID- 10165360 TI - Prospects for telediagnosis using ultrasound. AB - Ultrasound imaging is currently used as a primary diagnostic tool in cardiology, abdominal disorders, pulmonary medicine, trauma, and obstetrics. Because of its relatively low capital and operating costs as well as its growth potential, it represents one of the major diagnostic modalities of future health care. However, the use of ultrasonography as a mobile and powerful modality is controlled by the availability of a highly skilled technician to acquire the images and an experienced physician to interpret them. This paper discusses the technology required to increase the availability of a diagnosing physician by employing telerobotics. With this technology, the physician can guide the motion of the transducer by the technician from a remote location. Thus, the physician controls the examination and renders the diagnosis. It is shown that communication lines at 1.5 Mbits/s (T-1 speed) can, with appropriate compression, support both real time viewing of the ultrasound images and telerobotic manipulation of the transducer. The incremental costs of telediagnosis for an examination are estimated to be a small fraction of the base charges and significantly less than the expense of bringing a physician to a remote location or transporting a patient to a regional medical center. Telediagnosis can, in addition, provide benefits from immediate interpretation and consultation that cannot be duplicated using store-and-forward scenarios. PMID- 10165361 TI - Transmission of full-length echocardiographic images over ISDN for diagnosing congenital heart disease. AB - OBJECTIVES: To study the feasibility of transmitting full-length diagnostic quality echocardiograms with video conferencing systems linked by ISDN. METHODS: Forty-three previously video-recorded full-length echocardiograms (22 complete two-dimensional Doppler studies, 21 separate M-mode studies) were transmitted from a site 30 miles distant using desktop video conferencing systems linked with one ISDN line (128 kbps). Blinded interpretations of the original recorded and transmitted studies were made by two pediatric cardiologists (two-dimensional Doppler) and a pediatric sonographer (M-mode). RESULTS: Diagnoses of normal (N = 12) and abnormal (N = 10) conditions were made from the original tapes; the same interpretations were made from the transmitted studies. Twenty-one specific abnormalities in the 10 abnormal studies were seen on both original and transmitted videotapes. These abnormalities ranged from simple congenital heart defects, including ventricular septal defect, atrial septal defect, and patent ductus arteriosus, to complex ones, such as coronary artery fistula, double outlet right ventricle, and complete atrioventricular canal. Qualitatively, there was mild degradation in gray scale, brightness, and contrast of the images. Six M mode variables from the transmitted images had excellent concordance with the original tracings (P = 0.506 to 0.838; r = 0.86 to 0.97). CONCLUSIONS: Although our sample size was small, this preliminary experience indicates that video conferencing equipment utilizing ISDN technology is a reliable method for transmitting full-length diagnostic-quality echocardiographic studies from remote sites. This technology may have a significant impact on the management of pediatric patients with suspected heart disease. Further evaluation is warranted. PMID- 10165362 TI - Accuracy of interpretation of microscopic images of cytologic, hematologic, and histologic specimens using a low-resolution desktop video conferencing system. AB - OBJECTIVE: To determine the accuracy of interpretation of microscopic images for pathologic study transmitted over Switched-56 lines using a desktop interactive video conferencing system. MATERIALS AND METHODS: In subjective studies, two systems were connected using null-modem cables, which allowed evaluation of different bandwidths from 56 kbps to 384 kbps. Objective studies were done with two systems connected at distant sites via paired Switched-56 lines that produced an effective bandwidth of 112 kbps. A video camera mounted on a microscope was attached to the sending system. The resolution of the video image on the video conferencing system was 352 x 288 lines. Cases for cytology, hematology, and histopathology studies were selected from archives; one pathologist transmitted microscopic images, and a second pathologist made interpretations. The three pathologists were Board certified with similar experience that ranged from 20 to 35 years. Categories of interpretations or observations were predetermined for each study to allow the data on agreement between the direct microscopic interpretation or observation and that recorded by the receiving pathologist to be corrected for agreement attributable to chance alone. The results were analyzed using the kappa statistic. RESULTS: In the subjective studies, image degradation prevented interpretation while the microscope stage was moved. This problem occurred at all bandwidths tested. Image quality limited microscopic details. Organisms < 1 micron in diameter could not be seen reliably. In objective cytologic studies, overall agreement was recorded on 89 of 99 observations. In the four categories of specimens, observed agreement ranged from 0.778 to 0.958, and kappa was 0.704 to 0.948. For hematology specimens, overall agreement was found on 69 of 80 observations; observed agreement on eight types of nucleated blood cells ranged from 0.5 to 1.0, and kappa was 0.429 to 1.0. Poorer color definition and image quality prevented accurate identification of lymphoblasts and eosinophils in particular. For histologic specimens, overall agreement was obtained on 56 of 66 observations, observed agreement on four categories of histologic change ranged from 0.73 to 0.93, and kappa was 0.47 to 0.9. CONCLUSIONS: The desktop interactive video conferencing system, as configured in this study, was unsuitable for making definitive diagnoses from transmitted microscopic images. PMID- 10165363 TI - Telephone transmission of 20-channel digital electroencephalogram using lossless data compression. AB - BACKGROUND: The use of telecommunications for computer-assisted transmission of neurophysiological signals is a relatively new practice. With the development of digital technology, it is now possible to record electroencephalograms (EEGs) in digital form. Previous reports have demonstrated the possibility of real-time telephone transmission of a limited number of EEG channels. OBJECTIVES: To assess the effectiveness of specific data-compression software to improve the transmission of digital 20-channel EEG records over ordinary public telephone lines. METHODS: A prototype system was built to transmit digital EEG signals from one computer to another using two 14.4-kbps modems and proprietary lossless data compression software. RESULTS: Forty compressed digital EEG records of 20 channels each were sent from different locations at variable distances using "plain old telephone service" (POTS). The mean compression ratio was 2.2 to 2.8:1 using a sampling frequency of 128 Hz and 2.8:1 at a sampling rate of 256 Hz. Transmission time was reduced proportionately. CONCLUSION: Although this study used a store-and-forward approach, the results suggest that it may be possible to transmit a large number of compressed EEG channels in real time using data compression. PMID- 10165364 TI - Status of electronic reporting of notifiable conditions in the United States and Europe. AB - OBJECTIVE: To improve the computer connectivity and network strategies to connect U.S. county health departments (CHDs), state health departments (SHDs), and the Centers for Disease Control (CDC) for reporting notifiable conditions. METHODS: HSPNET-L mailing list discussions and individual Internet communications were used to compare selected features of notifiable conditions networking in the United States, France, and the United Kingdom. RESULTS: In the US, the CHD is the agency that first responds to an infectious disease outbreak on receiving notifications from physicians. Prompt recognition by the SHD that a widespread outbreak has occurred depends on the way in which county data are received, the "age" of the data, and the time taken to analyze them. Similarly, the recognition of the national scale of the outbreak depends on the promptness with which SHDs report to the CDC and the age of the data. An analysis of the French Communicable Disease Network suggests that an expansion of electronic links between US CHDs and SHDs will improve timeliness. Electronic data exchange allows CHDs to set up a local database and reduces transcription errors, mailing costs, and telephone costs. CONCLUSION: A fuller use of e-mail or other electronic communication by US CHDs will allow them to use a local database as a tool for managing local disease outbreaks more effectively and independently. Federal and state agency access to the CHD databases will enable early reporting of epidemic outbreaks. Periodic posting of public health information on Internet servers is recommended for immediate access to the public health data by Internet users worldwide. PMID- 10165365 TI - Beyond adoption to sustained use: telemedicine for rural communities. AB - The objective of this paper is to identify factors that affect the sustained use of telemedicine in rural communities and to suggest possible ways to improve such utilization. We draw on innovation and network theory to develop hypotheses about conditions that will hinder or facilitate sustained use of telemedicine. Telemedicine systems are expected to achieve sustained use in communities with higher physician-to-population ratios, greater availability of nonphysician providers, and greater consumer knowledge of and support for telemedicine. Additionally, telemedicine is more likely to be used in settings where hospital medical staff structures use contractual arrangements that encourage the use of telemedicine or reimburse through capitated systems. Rural physicians are more likely to use telemedicine if they have previous experience in facilities that serve as telemedicine hubs and if they have strong relationships with physicians in a hub location or with local physicians who are supportive of telemedicine. Physicians whose primary offices are geographically closer to the remote telemedicine installation are more likely to order telemedicine consultations for their patients than are their counterparts further away. Also, telemedicine systems that are well managed and easy to use are more likely to achieve sustained utilization by rural physicians. These hypotheses should be considered by supporters, providers, and managers of telemedicine. A proactive approach to managing telemedicine networks, with an emphasis on the issues raised here, should help telemedicine achieve its potential, namely, improved access and enhanced quality and efficiency of health services in rural communities. PMID- 10165366 TI - Telemedicine and distributed medical intelligence. AB - Recent trends in health care informatics and telemedicine indicate that systems are being developed with a primary focus on technology and business, not on the process of medicine itself. The authors present a new model of health care information, distributed medical intelligence, which promotes the development of an integrative medical communication system addressing the process of providing expert medical knowledge to the point of need. The model incorporates audio, video, high-resolution still images, and virtual reality applications into an integrated medical communications network. Three components of the model (care portals, Docking Station, and the bridge) are described. The implementation of this model at the East Carolina University School of Medicine is also outlined. PMID- 10165367 TI - Health systems evaluation of telemedicine: a staged approach. AB - Telemedicine promises greater access to health care of higher quality, potentially at lower cost. The diverse applications of telemedicine technology developed to date have not been evaluated systematically in terms of their ability to achieve these goals. Furthermore, the great variety in telemedicine applications and the far-reaching consequences of new information systems for health care delivery pose challenges to traditional methods of technology assessment. Methods appropriate for mature technologies may not be suitable for emerging ones and, indeed, may risk stifling their development with premature negative conclusions. The staged approach to technology assessment proposed here matches the analysis to the technology's stage of development. It focuses on access, quality, and cost and considers the communication pathway employed in the telemedicine application. A staged approach to technology assessment can inform and foster the development of new telemedicine technology while allowing health care delivery systems to make rational decisions about adopting telemedicine. PMID- 10165368 TI - Motion-compensated discrete-cosine transform as the enabling technology for video conferencing and telemedicine. PMID- 10165369 TI - Provider attitudes toward a rural telepathology program. AB - OBJECTIVE: To assess the attitudes of referring and consulting pathologists toward a recently initiated live video telepathology network in rural Vermont. METHODS: A semistructured interview was conducted with each referring pathologist before implementation of the telepathology program and again 9 months later. The interview consisted of questions concerning reasons for seeking a consultation in general and attitudes toward telepathology specifically. A questionnaire with Likert-type response categories was administered at the 9-month timepoint to the referring (N = 4) and consulting (N = 10) pathologists. This questionnaire contained items regarding communication, cost, education, quality, and timeliness aspects of telepathology. In addition, a brief mail survey was sent to attending physicians who utilized pathology services at the rural hospitals. RESULTS: The referring pathologists found the timeliness of consults using telemedicine to be a significant advantage. They also cited educational benefits both from attending telepathology conferences and from the interactive nature of the consultations. Two areas of concern were difficulties in minimizing scheduling inconveniences and uncertainty about the financial sustainability of the network. Overall, the telepathology system was well received by the consulting pathologists. Recurrent technical difficulties with the system were mentioned as a problem area. CONCLUSION: The pathologists participating in the Vermont telepathology network have reported benefiting from using this technology. Whether these benefits will outweight the costs of using telepathology for routine consultations remains to be determined. PMID- 10165370 TI - Association of ownership and system affiliation with the financial performance of rehabilitation hospitals. AB - This study used a cross-sectional design in which regression models were used to test the association of ownership and system affiliation of private rehabilitation hospitals with profit, revenue and expense measures. The study also examined the association of ownership and system affiliation with other choice variables. The study found that new for-profit rehabilitation hospitals had higher revenues and expenses than older non-profit rehabilitation hospitals. In addition, new for-profit hospitals charged more for their ancillary services and treated more of their patients on an inpatient basis. Study findings show higher revenues and expenses per adjusted discharge for new for-profit facilities. Given the cost-based system of reimbursement for Medicare, there appears to be a strong incentive for new for-profits to maximize costs. PMID- 10165371 TI - Analysis of hospitalization rates by electoral ward: relationship to accessibility and deprivation data. AB - The objective of this paper is to investigate the relevance of access to hospital services in explaining utilization rates at a District Health Authority level in the UK. In order to test the hypothesis that access is important, it is necessary to develop a means of scoring access factors and then combining these scores with other more recognized influences on hospitalization rates e.g. deprivation measures. Acknowledging that hospitalization rates are not merely products of a population's socio-economic characteristics, the effect of accessibility to hospital services for the resident population is investigated through the derivation of an access score using both private and public transport from electoral ward of residence. Deprivation and accessibility to services were both found to be significant factors in determining hospitalization rates at electoral ward level. The chosen supply variable--number of GPs--was not found to be significant in any of the models developed using linear regression techniques. To conclude, it appears that access plays an important role in determining hospitalization rates within a given population. If high hospitalization rates are accepted as an indicator of effectively met demand then policy makers may have to consider increasing the accessibility of hospital services. PMID- 10165372 TI - Health care rationing: can we afford to ignore euthanasia? AB - Explicit rationing decisions are being made to encompass a wide range of health care issues. Voluntary euthanasia has largely been excluded from this debate due to, in my view, the emotive nature of the issue. Euthanasia is an issue in which economists have been largely excluded and in which ethicists and philosophers dominate. It is the purpose of this paper to review the economic and ethical literature on euthanasia and to discuss their compatibility within the debate on euthanasia. The potential cost savings by the use of advance directives, do-not resuscitate orders, and futile care withdrawal are then reviewed, as are the potential cost savings created by hospice care. As a conclusion, the ethical and economic arguments are then balanced to assess their compatibility. It is the contention of this paper that reducing medical care costs near the end of life should not be a taboo subject, and that rationing decisions could focus on an exploration of this area and the approaches to it, which are ethically justifiable and economically worthwhile. The introduction of a policy of voluntary euthanasia could have a large impact on the rationing of health care resources whilst also promoting patient choice and an arena for a more dignified death. PMID- 10165373 TI - Utilization of hospital services by the elderly: geriatric crisis in one Canadian single payer system. AB - As the number and proportion of elderly persons in the Canadian population increase, utilization of health services by the elderly becomes a growing concern for health service insurers, financial managers and policy makers, as well as for care providers. The purpose of this paper is to present the results of a study to analyse the use of hospital services by the elderly in Alberta since the introduction of a universal single payer health care insurance system in 1970. The study period coincides with the implementation of publicly-financed comprehensive medical and hospital insurance programmes for all Alberta residents, making it possible to perform historical and population-based utilization analyses. Thus the data used for the study included all hospital discharge abstracts generated by all Alberta hospitals from 1971 to 1991. Trends in hospital service utilization by the elderly in terms of total number of separations, patient-days, and per case measures such as average length of stay as well as per capita utilization rates were reviewed to identify utilization patterns over the study period. Further, relative per capita utilization measures, in comparison with the base year (1971), age group 15-44, male, metropolitan residents, were derived and historical trends identified. A series of regression analyses were carried out to estimate the effects of age, sex and origin on utilization rates. In addition, for the period of 1984-1991, Diagnosis Related Groups (DRG) case weights were used to measure per capita and per case rates and to analyse historical relative utilization rates over the 8-year period. In general, there has been a significant decline in hospital utilization by Albertans under the publicly-financed single payer system, but utilization rates for elderly have remained high, resulting in high relative utilization rates in comparison with other age groups. It was also noted that per capita utilization rates for rural residents were substantially higher than urban residents. It appears that these higher utilization rates by the elderly and rural residents in combination with tight bed and financial control by the government have been causing significant bed shortage problems for non-elderly elective patients in urban areas. PMID- 10165374 TI - Developing purchasing strategy: a case study of a District Health Authority using soft systems methodology. AB - This paper examines the attempt by a District Health Authority (DHA) to create structures (called Purchasing Strategy Groups or PSGs) to facilitate the effective development of its purchasing strategy. The paper is based on a case study design conducted using Soft Systems Methodology (SSM). The research contribution the paper makes is twofold. First, it analyses some of the fundamental management-related difficulties that a DHA can experience when attempting to come to terms with its role and responsibilities in the 1990s. Second, it provides a discussion and evaluation of the utility of SSM for qualitative research in the National Health Service (NHS) in the UK. PMID- 10165375 TI - Who decides which pharmacy services are provided in UK National Health Service hospitals? AB - An interview survey of 129 UK National Health Service doctors, nurses, pharmacists and managers at eight acute care hospitals was conducted in 1994. The survey examined several topics including whether the introduction of the internal market had affected hospital pharmacy services and what those effects had been. An internal market has been introduced and it has had significant effects on the nature and structure of hospital pharmacy services. Directorate pharmacy services were available at six sites. Contracts for specific, usually novel, services had been implemented at one site and contracts had been introduced widely at another hospital. However, all the features of a market were not present at any site. Market orientation also has implications for the equity of service provision, primarily because decision-making regarding service provision is increasingly in the hands of the clinical directors, rather than pharmacy managers. The effects of this change are not yet clear. PMID- 10165376 TI - Perspectives. Midwest buyers seek provider-specific performance data. PMID- 10165377 TI - Health systems reforms: 1996 state legislative wrap-up. PMID- 10165378 TI - The AAOO (American Academy of Ophthalmology and Otolaryngology) centennial: using past achievements to address future challenges. PMID- 10165379 TI - The thoracic surgical workforce. PMID- 10165380 TI - Marketing your surgical practice to managed care plans and gatekeepers. PMID- 10165381 TI - Risk management and insurance (Part I). PMID- 10165382 TI - The cancer registry: a clinical repository of oncology data. AB - Health care institutions need complete and accurate data to plan, monitor, and evaluate their oncology programs. Although financial and discharge data are available, clinical repositories generally are not. For oncology, the cancer registry database serves as a clinical repository. The data in the registry are complete, accurate, and readily available. They can be used to plan new services, evaluate existing programs, and monitor patient care. PMID- 10165383 TI - Update from the Commission on Cancer. AB - A model for an integrated, comprehensive program for high-quality, cost-effective patient care can be found in cancer programs approved by the Commission on Cancer. A key component in assessing the effectiveness of the model is the cancer registry. Changes in the health care delivery system are behind increased demands for and use of cancer registry data. To support this shift and expanded activity, the Commission on Cancer has instituted a series of initiatives. These steps address refinements of the standards for approval, collaborative relationships, performance measurement information, new educational opportunities, and an organized communications campaign. PMID- 10165384 TI - Has there been a real drop in the number of expected cancer cases in the United States? AB - In 1993, after more than 20 years of increases, there was an observed decrease in the number of new cancer cases reported and in the overall cancer incidence rate in areas covered by the Surveillance, Epidemiology, and End Results Program based at the National Cancer Institute. Most of the decrease is attributed to a reduction in the number of prostate cancers diagnosed in 1993, a result of the introduction of a new screening tool for prostate cancer in the late 1980s. The article examines a number of possible reasons for the decrease in both overall cancer rates and prostate cancer rates and discusses whether the decrease is real or a statistical anomaly. PMID- 10165385 TI - Comparability and compatibility: issues in combining data from central cancer registries. AB - Before combining or comparing data from different registries, one should consider similarities and differences in data collection methods, data quality, and underlying populations. What are important population demographic differences? What about differences in data quality: How can these be measured and evaluated? What factors can affect data compatibility? How can one assess data comparability? If registries are compatible, are they always comparable? Are comparable data from registries compatible data? When data are combined, what issues should be considered to determine whether the combined result is meaningful? These are some of the common questions that need to be addressed to determine whether and when data from different registries should be combined or compared. PMID- 10165386 TI - Development and use of the North American Association of Central Cancer Registries standards for cancer registries. AB - Lack of standardization in data items, definitions, and codes in cancer registries has complicated analyses of pooled cancer data and has limited sharing of methods and software. The North American Association of Central Cancer Registries (NAACCR) has successfully developed and implemented extensive standards for data items and processes used by cancer registries in the United States and Canada. The article describes NAACCR's approach to achieving concensus and facilitating adoption of standards by combining volunteer and staff efforts, including broad-based representation in committees and providing shared automated software. Specific standards and their rationales are provided. PMID- 10165387 TI - The National Cancer Data Base and physician network. AB - The National Cancer Data Base (NCDB) is a nationwide outcomes database for oncology presently including 1,600 hospitals in 50 states. Half of all U.S. cancer cases are accessioned annually. It is important for U.S. clinicians and health information management professionals to become familiar with the NCDB to increase the usefulness of this comparative database in their hospital quality assurance programs. The NCDB's unique characteristics include its implementation by clinicians, its provision of access to data from hospitals participating in the Approvals Program of the Commission on Cancer, and its affiliation with a 2,200-member national physician network. The NCDB annual data are augmented by patient care evaluation studies, which provide a capability for cross-sectional surveys with an expanded data set. The NCDB has participated in the significant data standardization effort for U.S. cancer registries. The procedures used maintain confidentiality of the patient, physician, and participating hospital, and physical access to the data files is limited. The three primary products of the NCDB are hospital comparative reports, state and local reports, and scientific reports. PMID- 10165389 TI - The effects of automated encoders on coding accuracy and coding speed. AB - Encoded data on diagnoses and procedures are put to a broad range of uses. Coding accuracy and speed are imperative. One method that coding experts have recommended to improve coding accuracy and speed is automated encoders. The article describes the effect of automated encoders on coding accuracy and speed when used by trained coding staff. A study involving six Veterans Administration medical centers found that, overall, coding accuracy improved 19.4 percent after implementation of encoding software. The effect on coding speed, however, depended on the system set-up, with some set-ups actually reducing the number of discharges coded per day. PMID- 10165388 TI - All-payer severity-adjusted diagnosis-related groups: a uniform method to severity-adjust discharge data. AB - Measuring severity of illness within diagnosis-related groups (DRGs) has become increasingly important because of the growing need to compare outcomes across providers. In response to these needs, the Health Care Financing Administration (HCFA) has developed a DRG-based severity system as a refinement to its current Medicare DRG structure. As a result of this recent HCFA research, all-payer severity-adjusted DRGs (APS-DRGs) have been developed to provide a uniform approach for severity classification that is also applicable to the all-payer population. PMID- 10165390 TI - Outpatient infusion clinics: a strategy for the successful management of advanced heart failure. AB - During the past four years, the Heart Failure Unit a Columbia Michael Reese Hospital and Medical Center in Chicago has used outpatient intermittent low-dose inotropic therapy to improve care and quality of life while reducing the number of hospital admissions, decreasing lengths of stay, and lowering the number of emergency room visits. PMID- 10165391 TI - Managed care in cardiology. AB - Today, some 60 million individuals suffer from some form of cardiovascular disease, at a cost of +151 billion. Thirty-one billion dollars is spent on coronary artery bypass, angioplasty, and cardiac catheterization alone. Cardiology is being scrutinized by the government, payers and purchasers of healthcare. PMID- 10165392 TI - Developing an integrated computer system for cardiac catheterization laboratories. AB - The system's success extends beyond the clinical and technical arena: the process the authors undertook to develop the system can provide an effective model for other departments in their institution and at other hospitals. PMID- 10165393 TI - Making the "Web" work for you. PMID- 10165394 TI - Health care megatrends 1997. PMID- 10165395 TI - Reassessing the value of vertical integration. PMID- 10165396 TI - Planning in a health district--an application of computer modelling. AB - Considers the application of a computer model to aid the contracting process between purchasers and providers in the NHS. Analyses the difference between needs and wants and shows how the model can be used for considering "what if" options. PMID- 10165397 TI - Improving out-patient appointment systems. AB - The Patient's Charter has recently set the standard for hospital out-patient clinics that patients will "be given a specific appointment time and will be seen within 30 minutes of that time". Describes the successful application of an operational research/operations management approach to out-patient appointment systems at the Royal Lancaster Infirmary. Draws the conclusion from a comparison of this and other studies that many hospitals face very similar problems with similar solutions; but that localized studies may often be required to achieve these solutions. PMID- 10165399 TI - Introduction: quality improvement in health care. PMID- 10165398 TI - The quality of community nursing services: report of an exploratory study in a UK health authority. AB - Describes a study of three community nursing services provided by North Staffordshire Health Authority, which was carried out during the summer of 1991. Both the type and focus of quality measurement reported here are fairly unique. While the development of quality measures is yet at an early stage, most measures to date are quantitative. These can inform about volume of use of a service, but not its quality. The measures designed for this study were qualitative. These, when combined with quantitative data (statistics, routinely collected), yield much richer and more complete information as a basis for decision making in service planning. Quality data on the use of community services are also under represented in the quality literature--most studies to date have used hospital patient services as their source for data collection. Goes some way towards redressing the imbalance. PMID- 10165400 TI - Quality management and operational research initiatives in a health service context. AB - Explores the history of quality management, commenting on the work of many of the quality "gurus". Considers the relationship between quality management and the management science of operational research. PMID- 10165401 TI - Improving out-patient clinic waiting times: methodological and substantive issues. AB - In the Patients' Charter, a standard is laid down that all patients who attend out-patient clinics should be seen within 30 minutes of their appointment time. Discusses how a statistical monitoring system using a "low technology" approach was implemented at Leicester General Hospital during 1992-93. This was instrumental in raising the proportion of patients seen within 30 minutes from under 50 per cent to over 80 per cent in 15 months. Points to the fact that statistical monitoring alone is not sufficient to deliver quality improvements. Suggests that only enlightened management action which brings both management and clinicians into a quality improvement programme is likely to be effective. Discusses some of the measurement problems involved. Warns against the fact that over-reliance on purely quantitative measures (as indicated in "Charter" standards) to the neglect of more qualitative measures may be counterproductive. Suggests that qualitative approaches need to complement the normal statistical monitoring. PMID- 10165402 TI - Total quality management as a health care corporate strategy. AB - Total quality management (TQM) must become a part of corporate strategy if it is to become a way of life in health care. TQM should be understood in the context of a cultural transformation. The greatest challenge for top management is to create an organization in which every employee, department and function is linked inextricably to the organization's mission and vision. One of the key benefits of TQM is the use of teams to work on and achieve organizational objectives. Health care managers must understand motivation in order to carry the workforce with them to attain those objectives. PMID- 10165403 TI - Dealing with complaints--are we doing well? AB - Investigates the views of complainants and how they felt that their complaints had been handled. Complainants from a three-month period were sent a nine question questionnaire to which the response rate was 52.3 per cent. Shows that, on the whole, complaint-response times were being met; the complaints system was seen as user friendly; and overall, complaints were satisfied with the way in which their complaints were handled. PMID- 10165404 TI - Methodological issues in patient satisfaction surveys. AB - Examines some of the methodological problems encountered in conducting patient satisfaction surveys, including the sampling frames, quality of survey data and instruments, non-response problems, and reporting and interpretation of results. Proposes guidelines and lays out an agenda for future research. PMID- 10165405 TI - Monitoring performance in a community mental health centre. AB - Reports on a three-month period of evaluation of changes in the perceived life stress, coping and strain of 60 consecutive new attenders at a community mental health centre, which served to monitor performance. Emphasizes the need to incorporate good measurement into a systematic approach to quality assurance. PMID- 10165406 TI - An evaluation of TQM in primary care: in search of best practice. AB - Presents an evaluation of a TQM initiative which was designed to help the general level of awareness and knowledge within general practices and to encourage the implementation of TQM in primary care. The purposes of the initiative were to assess the effectiveness of the TQM approach used, not only in terms of tangible results but also in terms of cost effectiveness suitability and workability; and to check the transferability of the model used and its replicability with similar levels of benefits in other general practices on a nationwide basis. PMID- 10165407 TI - The electronic patient record: it won't be optional. PMID- 10165408 TI - Why managed care is getting a bad rap. PMID- 10165410 TI - Get your competitor's patients this ethical way. PMID- 10165409 TI - No, most physicians need not create their own HMOs. PMID- 10165411 TI - Drug dealing in the doctor's office, or who's the criminal, who's the victim? PMID- 10165412 TI - Don't put off planning how your group would allocate proceeds from a sale. PMID- 10165413 TI - Managed care outlook. HMO members happier than those in POS plans. PMID- 10165415 TI - Statement of Intent. Declaration of support for implementation of a prospective payment system for Medicare home health services, September 25, 1996. PMID- 10165414 TI - Mean physician income rises 6.7%. PMID- 10165416 TI - Prospective payment in action. The National Home Health Agency Demonstration. AB - After one year of the Health Care Financing Administration's per-episode prospective payment system (PPS) demonstration, participating agencies have learned valuable lessons on what it will take to implement an ongoing PPS programs. Home care providers can use these lessons to plan for the future. PMID- 10165417 TI - The revised unified PPS proposal. Some frequently asked questions. AB - The home care industry has proposed a unified plan for prospective payment. Providers, however, are still unclear about what factors are involved and what will change for them under this plan. This article answers some of the most common questions. PMID- 10165418 TI - Medicare prospective payment. One agency's response. AB - A Medicare prospective payment system (PPS) will have major operational implications for home care providers. Recent history has shown that health care providers' behavior is dramatically affected by the incentives inherent in new payment systems. One agency explains how it is changing its behavior in preparation for PPS legislation. PMID- 10165419 TI - Prospering under PPS. A guide for financial managers. AB - The survivors of PPS will be those organizations that gain knowledge and control of their true costs, learning how to manage them within the constraints imposed by the new payment system. It is difficult to predict the exact details of PPS legislation; however, several principles of PPS appear to be emerging that will probably be a part of the finished legislative product. Together they provide a framework sufficient to begin the process of analyzing how to prepare for PPS. PMID- 10165420 TI - The rehabilitation nursing paradigm: implications for home care. AB - Just as patient care delivery is shifting to the home, the focus of patient care is changing to wellness, illness prevention, and self-care promotion. The new approach to patient care will require an applicable theoretical basis. Rehabilitation nursing theory presents a valid paradigm for trends in patient care, particularly in the home setting. PMID- 10165421 TI - Benchmarking in home care. AB - Recognizing that continuous quality improvement will be imperative for success in the future, six visiting nurse associations of northwestern Pennsylvania used benchmarking as a tool to improve their respective agencies' performance. The agencies benchmarked three areas: continuity of care, patient rehospitalization, and nosocomial infection rate. PMID- 10165422 TI - Psychiatric home care and care paths: step by step. AB - As mental health services shift from institutional to community-based care, the psychiatric caseload for home care providers has increased. To satisfy the quality measurement demands of managed care organizations, providers can implement care paths for psychiatric home care programs. PMID- 10165423 TI - The chairperson's guide to effective meetings. AB - Meetings are a costly, sometimes cumbersome and frequently inefficient, but often necessary way of doing business. Initial planning for a meeting should actually involve consideration of how to do without it if possible. Given that a meeting is necessary, there are specific steps for the chairperson to take to ensure that the proper kind of meeting is planned and that steps are taken to make it as efficient as possible. The chairperson is responsible for making all arrangements, preparing and distributing an agenda, and leading the meeting in a manner that facilitates maximum productivity. Whether any particular meeting is ineffective or not is largely dependent on the chairperson's meeting leadership skills. PMID- 10165424 TI - Floating: a nurse's nightmare? AB - Floating is the process of reassigning nurses from their regular assignments to short-staffed areas. Although viewed as cost-effective, there are a number of legal and ethical dilemmas to consider in this practice. Nurses tend to oppose floating, which may lead to rifts between management and staff. This article reviews some important considerations in floating, including some action strategies for management and staff. Not being proactive in the process can lead to compromised patient care. PMID- 10165425 TI - Giving encouragement as a transformational leadership technique. AB - Giving encouragement is not generally stated as a high priority role of health care supervisors. Traditionally, technical skills and productivity on the job were aspects that received the supervisor's primary focus. However, there is a growing appreciation that encouragement is a transformational leadership technique that is related to productivity on the job and to quality work. Use of encouragement is a leadership technique that fits in today's people-oriented work climate. PMID- 10165426 TI - The art of giving an effective presentation. AB - Presentation skills are important, especially for supervisors, who need to communicate effectively with various audiences. There are a number of guidelines for effective presentations, including overcoming performance anxiety, knowing the subject, using an effective nonverbal style, planning, communicating enthusiasm and charisma, attention to the environment, and, perhaps most important, involve the audience in the presentation and meet audience needs. Even in today's "high-tech" world, attention to the basics of presentation skills will help supervisors in being professionals and leaders for their organizations. PMID- 10165427 TI - Rethinking the future of tenure in the health professions: new wine in old bottles. AB - The purpose and meaning of tenure and the tenets surrounding it are not likely to change. The uses of tenure and accountability on the part of the giver and holder of tenure are both under scrutiny. Tenure or the process for attaining it is not appropriate for health professionals who intend to be providers of health care. Not everyone needs to be tenure to perform a quality service. The constraints of tenure for today's practicing health professionals are discussed. PMID- 10165428 TI - Comprehensive case management: implications for program managers. AB - Management of comprehensive case management programs could be improved with an understanding of work issues facing case managers. Interviews with case managers from health departments revealed these issues to be types of client, case manager, program, and community problems in doing the work of case management, as well as solutions and perceptions about case management. Implications for having and managing case management programs are organized and discussed using a Model of Comprehensive Case Management. PMID- 10165429 TI - Do you feel like an impostor? AB - Individuals who are unqualified to fulfill a role are impostors. Often, competent practitioners feel they are unable to successfully practice their profession and suffer from an impostor syndrome. In health care, this can have a number of negative outcomes, including a poor reflection of the institution through the individual's actions. In many cases, impostorship can be prevented or remediated through the use of techniques such as identification, mentoring, and promotion of positive self-concepts. This article reviews a number of these techniques to help supervisors, especially new supervisors who may have feelings of inadequacy and impostorship, in developing a positive self-image. PMID- 10165430 TI - Reducing your risk of burnout. AB - Burnout is a common phenomenon of today's workplace. Burnout is attributed to stress in the work environment. Today's health care environment with its rapidly changing requirements is an especially obvious example. Prevention of burnout, then, becomes particularly crucial. Certain personality types are resistant to burnout; unfortunately, other personality types are susceptible to burnout. However, managers and supervisors can use knowledge of personality types and their corresponding strengths and vulnerabilities to protect themselves and their subordinates from burnout. There are also general and type-specific coping efforts that people can use. PMID- 10165431 TI - Collaborative conflict resolution. AB - With change comes conflict. Conflict can be positive or negative depending on the attitude and skills of the participants. Collaborative conflict is characterized by an approach in which people attack problems rather than each other. Essential components of collaborative conflict resolution include selection of basic technique, preparation for confrontation, and viewing the situation from the other person's perspective. PMID- 10165432 TI - Data-driven decision-making. Integrating operational, organizational, and clinical benchmark data. PMID- 10165433 TI - Reforming managed care: what are the issues? PMID- 10165434 TI - Net worth of the Internet, Intranets, and Extranets. PMID- 10165435 TI - Using case management systems to integrate clinical and financial data. AB - Integrated delivery systems can use automated case management information systems to better manage relevant clinical and financial data across the continuum of care. Effective case management systems can help caregivers track clinical and financial information; match appropriate resources to patient needs; and analyze populations to identify risk, enhance adherence to clinical guidelines, and understand provider treatment profiles. PMID- 10165436 TI - IRS eases rules for physician representation on governing boards. AB - In September 1996, the IRS eased its policy prohibiting extensive physician representation on governing boards of tax-exempt integrated delivery systems (IDSs). The IRS now allows increased physician participation on governing boards if the organizations institute conflict-of-interest safeguards that prohibit physicians from obtaining private inurements. A section of the Internal Revenue Code, enacted in 1996 by the Taxpayer Bill of Rights 2, strengthens the IRS's enforcement policy by providing targeted sanctions against individual violators of the private inurement rule rather than penalizing entire IDSs and the communities they serve by revoking their tax-exempt status. PMID- 10165437 TI - Rating managed care plans as business partners. AB - Managed care plans are driven to meet consumer quality of care demands. But, plans that meet these consumer demands do not necessarily meet provider expectations for quality business partnerships. Therefore, providers need to develop not only clinical performance indicators but also indicators that will help them evaluate managed care plans as business partners. Performance indicators should be developed to measure managed care plans' medical loss ratio, compensation cost/benefit, payment promptness, authorization convenience and promptness, insurance verification convenience and promptness, payment accuracy, medical management, provider relations responsiveness, member education effectiveness, recorded complaints, risk transfer, contract terms, and contract equity. PMID- 10165438 TI - Provider-sponsored HMOs: make, buy, or joint venture? AB - Providers can sponsor their own HMOs in one of three ways: by creating their own HMO, by joint venturing with an existing HMO, or by purchasing an existing HMO. When selecting the best option, providers must consider various market conditions. Managed care penetration in the area, potential competitive responses of existing HMOs, market demand, provider reputation, and provider marketing ability will all influence the feasibility of each option. Providers also must examine their own organizational identity, their ability to raise the necessary capital to start an HMO, their managed care expertise and risk contracting experience, and their information systems capabilities. PMID- 10165439 TI - Billing Medicare for investigational devices: what's OK, what's not. AB - In 1993-1994, the Office of Inspector General (OIG) conducted an investigation of allegations that numerous hospitals had fraudulently billed the Medicare program for investigational cardiac devices. OIG found evidence of fraud related to these devices as well as to certain investigational procedures. Partly as a result of this probe, Senate hearings were held in 1996 to ascertain whether fraud and abuse in Medicare billing was a widespread problem. Investigational devices and procedures received particular attention during these proceedings. Hospitals involved in the 1993-1994 OIG investigation maintained that the Federal government previously sanctioned billing for the use of some investigational or experimental devices, that the devices and procedures in question had already been proven to be safe and effective, and that the devices or procedures resulted in better patient care or shorter lengths of stay. For these and other reasons, the hospitals contended, billing Medicare for these devices was appropriate. Although HCFA has allowed the Medicare program to pay for the use of some investigational devices and procedures since November 1995, Federal fraud and abuse investigators continue to scrutinize the billing practices of hospitals engaged in clinical trials. Financial managers in healthcare organizations that use investigational devices--even those not engaged in clinical trials--need to carefully review their organizations' compliance with Medicare billing requirements. PMID- 10165440 TI - The impact of consolidation on Medicare reimbursement. Mergers, acquisitions, and other types of consolidations involve a change in ownership that implies termination of Medicare participation for the consolidating providers. AB - In order to fully understand the ramifications of consolidations, mergers, and acquisitions on Medicare reimbursement issues, healthcare financial managers must be well versed in the nuances of governance and managerial control, legal and regulatory compliance, and reimbursement. For example, when consolidations occur, there may be a desire for more shared control of a consolidated organization than would result if assets were sold outright. In addition, three important legal and regulatory issues must be dealt with when consolidations occur: change of ownership rules, cost-reporting consistency rules, and capital PPS rules. Finally, the consolidation of two or more organizations under a single Medicare provider number has several ongoing effects on Medicare reimbursement. DRG standardized amount and area wage index, rural referral centers, sole community providers, disproportionate share hospitals, and medical education are five areas affected. PMID- 10165441 TI - PSNs: a new model for Medicare risk contracting. AB - The 1995 Republican House Medicare reform proposal introduced the provider services network (PSN) concept as a new healthcare delivery model for accepting and administering Medicare risk contracts. A PSN operates much like an HMO, but is not subject to the reserve requirements established for HMOs. Providers that want to enter the Medicare risk contracting arena and exercise more control over the delivery of healthcare services may consider forming a PSN. To form a PSN, providers must be sufficiently capitalized to compete with HMOs, create a formal legal organization, and develop a financial plan. To ensure that its goals are met, the PSN must develop a sales promotion plan, enroll members, control and monitor financial resources and clinical outcomes, and implement a management information system. Other crucial capabilities that a PSN must develop include establishing mechanisms for utilization review, membership information maintenance, claims adjudication, physician credentialing, quality assurance, and member grievance procedures. PMID- 10165442 TI - Overcoming the physician group-hospital cultural gap. AB - In order for integration between physician practices and hospitals to be successful, each will have to overcome cultural differences that have contributed to a sometimes adversarial relationship. Such differences can be attributed to opposing views related to focus, perspective, working environment, decision making, goals, working style, and management style. PMID- 10165443 TI - Conducting a practice management review. AB - A practice management review can be used by a physician practice to identify problems within the practice, introduce operational improvements, and ensure that the practice is being run as profitably and efficiently as possible. Such a review involves scrutiny of nearly every aspect of a practice's operations--from reimbursement to personnel issues. Before deciding to have a practice review performed, the practice's management team must establish objectives for the review and must ensure that physicians and practice staff understand the review process. Once the review process is initiated, the steps that must be taken to identify and diagnose problems within a practice include conducting interviews, collecting data, analyzing data, and suggesting remedies. PMID- 10165444 TI - Improving the healthcare supply chain using EDI. PMID- 10165445 TI - What does it take to attract top executives? PMID- 10165446 TI - Opening the books. AB - For years, small companies have experimented with forms of open-book management. Open-book systems have smoothed change efforts by giving workers the why instead of just the how of initiatives; they have enabled employees to think like owners. Now divisions of large organizations such as R.R. Donnelley & Sons and Amoco Canada are finding opening the books can work for them, too. It isn't easy, and companies must adapt the principles to their own situations. AES Corporation, for example, found that it had to declare all its employees "insiders" when it went public. One of the reasons for large companies' interest in open-book management is the success of a role-model company, Missouri-based Springfield ReManufacturing. Leaders of divisions of large companies have been able to visit and ask questions. Other early adopters are also showing competitive advantages. Among them are Wabash National, now the nation's leading truck and tractor manufacturer, and Physician Sales & Service, a distributor of supplies to doctors' office. Open-book principles are the same whether a company is large or small: every employee must receive all relevant financial information and be taught to understand it; managers must hold employees accountable for making their unit's goals; and the compensation system must reward everyone for the overall success of the business. Hexacomb Corporation is one large organization that has done well. Workers at the company's seven plants are inspired by a system of splitting profits over budget fifty-fifty: half goes to the company and half to the bonus pool. Such companies are learning the benefits of having everyone work to push the numbers in the right direction. PMID- 10165447 TI - Entering China: an unconventional approach. AB - Conventional wisdom has it that the best way to do business in China is through an equity joint venture (EJV) with a well-connected Chinese partner. But pioneering companies are starting a trend toward a new way to enter that market: as a wholly foreign-owned enterprise, or WFOE. Increasingly, says the author, joint ventures do not offer foreign companies what they need to succeed in China. For example, many companies want to do business nationally, but the prospects for finding a Chinese partner with national scope are poor. Moreover, there are often conflicting perceptions between partners about how to operate an EJV: Chinese companies, for example, typically have a more immediate interest in profits than foreign investors do. By contrast, the author asserts, WFOEs are faster to set up and easier to manage; and they allow managers to expand operations more rapidly. That makes them the perfect solution, right? The answer is a qualified yes. First, foreign companies will still need sources of guanxi, or social and political connections. Second, managers must take steps to avoid trampling on China's cultural or economic sovereignty. Third and perhaps most important, foreign companies must be prepared to bring something of value to China-usually in the form of jobs or new technology that can help the country develop. Companies willing to make the effort, says the author, can reap the rewards of China's burgeoning marketplace. PMID- 10165448 TI - Virtuous capital: what foundations can learn from venture capitalists. AB - U.S. foundations and nonprofits work diligently on behalf of society's most needy and yet report that progress is slow and social problems persist. How can they learn to be more effective with their limited resources? Foundations should consider expanding their mission from investing only in program innovation to investing in the organizational needs of nonprofit organizations as well. Their overemphasis on program design has meant deteriorating organizational capacity at many nonprofits. If foundations are to help nonprofits be assured of making payroll, paying the rent, or buying a much-needed computer, they must develop hands-on partnering skills. Venture capital firms offer a helpful benchmark. In addition to putting up capital, they closely monitor the companies in which they have invested, provide management support and stay involved long enough to see the company become strong. If foundation officers familiarize themselves with such practices, they can begin to build organizational capacity in the nonprofit sector. Foundations can hire organizational experts to assist grantees; they can lengthen grant terms to allow nonprofits to build up organization strengths; and they can create new classes of grants that allow for organizational effectiveness. Nonprofits in turn should articulate their organizational needs when applying for grants; they should apply to foundations known for longer-term grants; and they should create plans that justify long-term support from foundations. PMID- 10165449 TI - The living company. AB - What can explain the longevity gap between a company that survives for centuries- the Swedish company Stora, for example, which is more than 700 years old--and the average corporation, which does not last 20 years? A team at Royal Dutch/Shell Group explored that question. Arie de Geus, a retired Shell executive, writes about the team's findings and describes what he calls living companies organizations that have beaten the high mortality rate of the average corporation. Many companies die young, de Geus argues, because their policies and practices are based too heavily on the thinking and language of economics. Their managers focus on producing goods and services and forget that the organization is a community of human beings that is in business--any business--to stay alive. In contrast, managers of living companies consider themselves to be stewards of a long-standing enterprise. Their priorities reflect their commitment to the organization's long-term survival in an unpredictable world. Like careful gardeners, they encourage growth and renewal without endangering the plant they are tending. They value profits the same way most people value oxygen: as necessary for life but not the purpose of it. They scuttle assets when necessary to make a dramatic change in the business portfolio. And they constantly search for new ideas. These managers also focus on developing people. They create opportunities for employees to learn from one another. Such organizations are suited for survival in a world in which success depends on the ability to learn, to adapt, and to evolve. PMID- 10165450 TI - Building effective R&D capabilities abroad. AB - In the past, companies kept most of their research and development activities in their home country because they thought it important to have R&D close to where strategic decisions were being made. But today many companies choose to establish R&D networks in foreign countries in order to tap the knowledge there or to commercialize products for those markets at a competitive speed. Adopting a global approach entails new, complex managerial challenges. It means linking R&D strategy to a company's overall business strategy. The first step in adopting such an approach is to build a team to lead the initiative--a team whose members are sufficiently senior to be able to mobilize resources at short notice. Second, companies must determine whether an R&D site's primary objective is to augment the expertise that the home base has the offer or to exploit that knowledge for use in the foreign country. That determination affects the choice of location and staff. For example, to augment the home base laboratory, a company would want to be near a foreign university; to exploit the home base laboratory it would need to be near large markets and manufacturing facilities. The best individual for managing both types of site combines the qualities of good scientist and good manager, knows how to integrate the new site with existing sites, understand technology trends, and is good at gaining access to foreign scientific communities. As more pockets of knowledge emerge around the globe and competition in foreign markets mounts, only those companies that embrace an informed approach to global R&D will be able to meet the new challenges. PMID- 10165451 TI - Strategies for surviving a shakeout. AB - Shakeouts are a fact of life in almost every industry-witness the shrinking number of players in areas as diverse as banking, software, and hospital supply distribution. The key to survival is sensing your industry's shakeout before the competition does. And the first hurdle for managers to overcome is the belief that it can't happen to them. It can and it probably will. George Day describes two shakeout syndromes that affect different types of industries. A boom-and-bust shakeout afflicts hot emerging markets or highly cyclical businesses. A glut of competitors enter the market during boom times, but many of them fail when growth slows or a dominant design emerges. A seismic-shift shakeout strikes mature industries that have enjoyed years of protected prosperity as a result of, for example, local regulations or import barriers. But deregulation, globalization, or technological change can pull the rug out from under them. Day outlines how companies can detect the early warning signs of a shakeout. He explains how adaptive survivors, such as Dell Computer, successfully adjust their businesses in the midst of a bust, and how aggressive amalgamators, such as Arrow Electronics, cut costs and acquire smaller rivals in order to remain standing after a seismic shift. But the fact remains that most companies will get squeezed out during a consolidation. Although it is enormously difficult for executives to come to terms with the grim news, the sooner they do so, the better. And, as Day points out, all is not necessarily lost: with the right timing, also-rans can make a profitable exit from an industry. PMID- 10165452 TI - Pursuing the elusive integrated delivery network. Part 1: Overcoming our obsession with autonomy. PMID- 10165453 TI - Integration in the real world. Practical aspects of integration in three diverse markets. PMID- 10165454 TI - "Medical futility." Managed care and the powerful new vocabulary for clinical and public policy discourse. PMID- 10165455 TI - The age of heretics. Interview by Joe Flower. PMID- 10165456 TI - The beginnings of the end. PMID- 10165457 TI - Future scanning. PMID- 10165458 TI - Log on. A continuing guide to the online world for healthcare executives, managers, clinicians and patients. PMID- 10165459 TI - Being there. PMID- 10165460 TI - Cost effectiveness scenario analysis for a proposed trial of hormone replacement therapy. AB - Whereas evaluation of resource implications and quality of life are often incorporated into assessments of health technology, the decision to undertake the assessment is still mostly driven by interests in the clinical outcomes alone. A systematic approach to evaluating expected returns to health technology assessment has not been readily taken up by research funders or assessors. This paper sets out a specific methodology for ex ante evaluation or triage and proposes a decision procedure, using alternative outcome scenarios and the associated policy changes and costs and benefits, against a background of likely clinical practice in the absence of the assessment. The methodology is used to consider implications of a proposed major clinical trial to assess the long term costs and benefits of hormone replacement therapy. PMID- 10165461 TI - Implementing quality of programmes in three Swedish county councils: the views of politicians, managers and doctors. AB - This articles deals with quality assurance within the Swedish health care system at the regional and local levels. The overriding issue concerns the degree to which changes in Swedish health care in recent years with respect to increased freedom of choice for the individual, the purchaser-provider split and new forms of financial reimbursement have affected quality assurance. Special attention is directed toward the relationship between the political-administrative level in the county councils and the medical profession at the local level. Since political responsibility for health care is strongly decentralized and different organizational solutions can be found, Sweden offers a good opportunity for systematic comparisons within the health care sector. Following an overview of certain national initiatives with regard to the quality of health care, three Swedish county councils are compared. The aim is not to provide a general overview of the situation in Sweden with regard to quality assurance, but to compare the strategies and outcomes in county councils with different organizational configurations. The study is based on 35 interviews conducted in 1995 with health care politicians, health care administrators, hospital directors and clinical department heads. The article concludes that indirect incentives can be very strong factors in affecting care providers' active interest in quality assurance. This interest is aroused when providers feel they are in competition in that the number of patients decreases, or in that their activities are being called into question, such as in the form of discussions about possible structural changes in the county council. PMID- 10165462 TI - Hospital adaptation to risk-bearing: managerial implications of changes in purchaser-provider contracting. AB - A number of countries have adopted contracting reforms in which hospitals are placed at financial risk. This risk has stimulated a number of adaptive strategies to achieve organizational success. This paper presents a model of six forms of contracting relationships and reviews the adaptation strategies observed in three health systems: the USA, England and the Netherlands. These strategies include service diversification, improved management information systems, the employment of marketing and contract managers, the use of clinical pathways, case management and concurrent/retrospective review of hospital stays, quality management and quality assurance programs, pre-admission authorization, discharge planning, and physician profiling and participation in management. These adaptive strategies have three implications for managers: increased 'partnering', with purchasers, collaboration with medical staff, and assumption of managed care roles. Two groups of institutions are at risk from the changes in hospital contracting: university teaching hospitals and inner-city hospitals serving socially deprived populations. The paper ends with implications for the education of hospital managers and research on hospital management and adaptation to contracting. PMID- 10165463 TI - Taiwan's 1995 health care reform. AB - Under considerable domestic political pressure, the Taiwan government inaugurated a compulsory universal health insurance scheme on 1 March 1995. This new scheme is financed mainly by payroll tax and provides comprehensive health care benefits with a moderate cost sharing. In order to gain efficiency in delivering health services, the scheme enters contracts with health care providers and has been developing a prospective payment system. Meanwhile, the scheme uses a uniform fee schedule and makes all payments through a public single-payer system to control health care costs. By the end of the inaugural year, the scheme covered 92% of the population and the utilization pattern of the newly insured became close to that of the previously insured. However, there is the beginning of a financial crisis because the payments of the scheme are rapidly increasing and expect to exceed the premiums in the coming year. Besides, the scheme did not bring in the efficient use of health care resources and probably caused it to worsen. Taiwan's health care reform has an unfinished agenda. PMID- 10165464 TI - Cost-utility analysis from a societal perspective. AB - In this paper, we outline how to use cost-utility analysis from a societal perspective and the arguments that could be made for using data such as a model for economic evaluation of health care. We show that to include all the costs in the analysis, a price per quality-adjusted life years (QALY) gained rather than a given budget should be used as the decision rule. Using cost-utility analysis this way is based on a willingness to pay per QALY gained that is constant and the same for everyone. To use a fixed price per QALY gained is consistent with societal utility maximization if aggregated QALYs are a measure of societal utility and if the mix of financing sources is the same for all health care programmes. If, furthermore, the price per QALY gained is set at the optimal level, cost-utility analysis will lead to a maximization of societal utility. To get more information on the willingness to pay per QALY gained so as to provide cost-utility analysis with a useful decision rule should be a research priority. PMID- 10165465 TI - Worthwhile visits on the World Wide Web. AB - Using personal experience and recommendations from other users in compiling a selection of reviews, provides a taste of the diversity of resources available on the World Wide Web, looking at sites to visit and detailing what each site has to offer. Covers information sources, journals, management development, networking, skills and directories. PMID- 10165466 TI - Developing elements of a learning organization in a metropolitan ambulance service: strategy, team development and continuous improvement. AB - First, presents a new model for developing a learning organization which is well within the grasp of today's organizations, since many of these already have the main components which provide the platform for this. Second, provides four measures of how an experiential workshop used to develop learning organization components may be evaluated. Despite huge international popularity for experiential workshops, effectiveness measurements are rarely used. Third, presents a case study of how to begin developing a learning organization through developing middle management in a metropolitan ambulance service. PMID- 10165467 TI - Funeral for a friend (an existential view on hospital closure). AB - Views the closure of a hospital in an unusual manner. Questions the role of health workers as "care in the community" comes to the fore. Raises questions about psychiatric hospitals, people with mental health problems and mental health workers. PMID- 10165468 TI - Viewpoint: the information age and the changing nature of work. PMID- 10165469 TI - Integrating the Internet into health manpower management. AB - Highlights recent dramatic changes in communications technologies, with an increase in the number of users, providers and applications. Explores the advantages to health-care professionals of various Internet services, both as a source of information and as a communications platform for management development. Warns that full integration of the Internet into health manpower management will involve radical organizational and process re-engineering. PMID- 10165470 TI - Buyers aren't lulled by pack prices. PMID- 10165471 TI - Materials costs push prices up; contracts hold them steady. PMID- 10165472 TI - Emergency rooms can save money while saving lives. PMID- 10165473 TI - Tailoring home care services to meet physician and patient needs: a market-based approach. AB - The services offered by the home care division of a medical center should correspond to the needs of both physicians and patients who are to be served. This study addresses the physician segment, the primary referral source for home care. It measures both the absolute and the relative importance of a range of offerings which a home care services division provides in a mid-sized, full service, medical center. PMID- 10165474 TI - Reform of primary health care: effective use of advanced practice nurses. AB - Never before has American society undergone such dramatic and pervasive changes as those currently effecting national health care needs. New strategies to meet the health care needs created by societal changes must be identified. Consumers, employers, providers, and third-party payers are calling for more cost effective health care, better access and better quality. Simultaneously, the United States has a shortage of primary care physicians. While many people claim that one strategy necessary for health care reform is to change the primary care physician/specialty mix of providers, there are some inherent fallacies in this argument. Training for primary care medicine has historically been available; however, the majority of physicians choose specialty practice. The financial rewards are much better in specialty practice than in primary care. If the U.S. were to alter the reward structure and make primary care more attractive to physicians, the objective of controlling costs could not be met. However, there is another alternative and that is to change the provider mix. Since advanced practice nurses (APNs) have a long and successful history of taking care of primary care patients, why not make them the point of first contact? APNs working collaboratively with physicians could more cost effectively manage care for large numbers of ambulatory patients than are being adequately handled at present. APNs, defined as nurse practitioners, certified nurse midwives and clinical nurse specialists, provide high quality, cost effective, and comprehensive primary care services. Increased use of APNs in disease prevention, illness management, and health education is one way of meeting health care needs of Americans. Innovative strategies for more effectively using APNs must also be identified and implemented. Also, artificial and politically imposed barriers to effective utilization of APNs must be removed. PMID- 10165475 TI - Improving client satisfaction and clinic revenues through systems simulation: the case of a university nutrition clinic. AB - A client-responsive strategy was developed based upon input from nutrition clinic personnel, administrators, and clients. Systems simulation identified the strategy most likely to lead to client satisfaction while also meeting the needs of clinic personnel and administration. The strategy was subsequently introduced into the clinic and patient satisfaction and operating revenues were monitored following implementation. Both measures of impact demonstrated significant improvement. PMID- 10165476 TI - Recruitment and retention of allied health personnel. PMID- 10165477 TI - Social responsibility, politics, and fiscal viability: strategic issues in the development of a regional health care system for children in South Texas. AB - A case study of the proposed development of a regional children's health care system in South Texas is described. Strategic plans for the system are overviewed and the community response to plans are presented. The political, social responsibility and fiscal viability issues raised are reviewed and the research literature base relevant to the health care needs of a key (Hispanic) market is summarized. PMID- 10165478 TI - Poverty and prenatal health care in America: trends, costs, and recommendations. PMID- 10165479 TI - Health care services for the elderly: a study of the market and their needs. PMID- 10165480 TI - The influence of reference price on the acceptance of new healthcare services among the elderly. AB - Reference price has been postulated in the consumer behavior literature to be an important determinant of new product acceptance in the marketplace. This study was undertaken to assess the influence of reference price on the acceptance of new healthcare transportation services among the elderly. Over five hundred elderly, chosen at random, were studied in a major metropolitan area. The proposed new healthcare transportation services were: a shuttle service (from the hospital to a satellite healthcare center) and an escort service (from the hospital to the patient's home). The results show that reference price is the main influence on the acceptance of the shuttle service superseding the effects of the traditional demographic variables of gender and marital status. However, reference price was not found to be an influence on the acceptance of the escort service. It appears that the use of reference price as a guide in the acceptance of a new product is not universal but rather contingent on the product being offered. PMID- 10165481 TI - Continuing care retirement communities. PMID- 10165482 TI - Total quality management in health services: historical development, conceptual meaning, and comprehensive model. AB - Today's health care environment is characterized by burgeoning costs and increasing concern about service quality. Not surprisingly, researchers and practitioners are turning to Total Quality Management (TQM) in their quest for creating high quality health care delivery systems. Despite the central importance of TQM, there is practically no common definition of total quality in medical care research. In this paper, we trace the historical development of the quality concept, offer a valid definition of "total quality," and detail a comprehensive model of TQM for health care research. Implications of our model for academicians and practitioners are discussed. PMID- 10165483 TI - The importance of various healthcare quality dimensions from the physician's viewpoint. PMID- 10165484 TI - Health care cost containment: rationing medical technology. AB - Effective and efficient delivery of health care is one of the critical issues facing the nation today. Currently, nearly 13% of the nation's GDP in spent on Health Care. Perhaps one-half of the increase in health care costs have been linked to the acquisition of new medical technology. This paper examines some of the issues relating to the acquisition and dissemination of the use of medical technology by acute care and outpatient facilities and discusses the rationing of medical technology. The paper concludes by identifying some of the approaches to controlling health care costs through the rationing of technology that have been presented in the literature and outlines the evolving new paradigm that is being advanced to address the issues of cost containment and access to health care. PMID- 10165485 TI - Market planning: the key to ambulatory care success. PMID- 10165486 TI - Physician's attitudes toward occupational medicine: an empirical study. PMID- 10165487 TI - Understanding physicians' decisions to practice in rural areas as a basis for developing recruitment and retention strategies. AB - The shortage of providers in rural areas is threatening the quality and availability of health care in many communities. The causes of the provider shortage are many and varied-from economic to social to personal. Government programs have addressed the issue of provider supply by offering scholarships and loan repayment programs for medical students who then must fulfil service obligations in underserved settings, among which are rural areas. Experience has shown that once providers complete their obligations under these grant programs, retention of providers in rural areas becomes an even more critical issue. Using focus group research, this study explores the practice setting choices of a group of physicians currently practicing in rural areas. The discussion reveals that personal values are one of the primary motivators for choosing to practice in rural settings while lack of availability of career opportunities for spouses and educational opportunities for children are major obstacles. The health care system poses barriers to success for providers in rural settings. The key rewards from rural practice are the ability to become integrated into the local community and the provider/patient relationships that develop in such settings. These findings are used as the basis for proposing recruitment and retention strategies for providers to improve access to medical care by patients in rural areas. PMID- 10165488 TI - Why a 200-physician group died. PMID- 10165489 TI - How family physicians can keep their gains. Interview by Neil Chesanow. PMID- 10165490 TI - 10 rules for leaving a group to go solo. PMID- 10165491 TI - Making a career move: look beyond money. PMID- 10165493 TI - Is this the end of the line for independent practice? PMID- 10165492 TI - Rating HMOs. Thumbs-up from patients--but not from doctors. PMID- 10165494 TI - Add a new revenue stream to your practice. PMID- 10165495 TI - Mo. Blues joins crowd. Failed link with St. Louis system adds to plan's woes. PMID- 10165497 TI - Pa.'s AHERF to buy Coventry's docs. PMID- 10165496 TI - Testing antitrust boundaries. N.Y. hospital merger probe may break new ground. PMID- 10165498 TI - CNA nurses to strike at 45 Kaiser hospitals. PMID- 10165499 TI - Providers post robust earnings. PMID- 10165500 TI - Calling the shots. Calif. hospital's plight illustrates doctors' growing clout. PMID- 10165501 TI - New coalition plans to fight against for-profits. PMID- 10165502 TI - Demise of 'double-dipping'. Balanced-budget law to curb Medicare post-acute costs. PMID- 10165503 TI - Root of all evil? Capitation critics assume physicians are too easily influenced by money. PMID- 10165505 TI - AMA's seal of approval. Group plans to start universal accreditation of docs this summer in Massachusetts. PMID- 10165504 TI - Can marriage of academic, community hospitals work? AB - Can marriage of academic and community hospitals work? Executives at Fairview Health System in Minnesota believe it can--they have begun merging their system with University of Minnesota Hospital and Clinic, which Fairview purchased in January. But they admit the consolidation of two very diverse cultures will pose some intimidating challenges. If they succeed, Fairview's CEO says, "the potential is incredible." PMID- 10165506 TI - Special treatment. Study compares results of care by different kinds of docs. PMID- 10165507 TI - Shopping spree. Equipment servicing firm COHR sees rapid growth. PMID- 10165508 TI - Provider groups seek Medicare contracts. PMID- 10165510 TI - Software buyer's guide. PMID- 10165509 TI - The house that managed care built. Software programs generate data providers need. PMID- 10165511 TI - Protecting facilities from pest infections. PMID- 10165512 TI - Calculating costs for managed care. PMID- 10165513 TI - Best graduate schools--medicine. Innovative programs prepare students for managed care. PMID- 10165514 TI - The medical rankings. Top schools--no. 1: Harvard University. PMID- 10165515 TI - Mary Elizabeth Roth: recipient of the 1997 Robert F. Allen Symbol of H.O.P.E. Award. PMID- 10165516 TI - Smoking relapse prevention methods for pregnant women: a formative evaluation. PMID- 10165517 TI - Evaluation of a phone intervention to promote mammography in a managed care plan. PMID- 10165518 TI - Reducing risk factors for cumulative trauma disorders (CTDs): the impact of preventive ergonomic training on knowledge, intentions, and practices related to computer use. PMID- 10165519 TI - A certificate curriculum in worksite health promotion. PMID- 10165520 TI - Relationship of trait, Type A behavior, and physical fitness variables to cardiovascular reactivity and coronary heart disease risk potential. AB - PURPOSE: This research investigated the effects of individual characteristics on cardiovascular reactivity, and in turn on the potential for developing coronary heart disease. DESIGN: Path analysis was performed using LISREL, a structural equation modeling program providing maximum likelihood estimators and goodness-of fit measures. SETTING: Data were collected during a health assessment program, from participants attending a Department of Defense senior service school. SUBJECTS: Participants were 134 senior-ranking male military and civilian employee volunteers, representing approximately 84% of all students in training. MEASURES: Five individual characteristics, four measures of cardiovascular reactivity, and one coronary heart disease risk potential variable were investigated. These included Physical Fitness, Type A behavior, Trait Anger and Trait Anxiety, Diastolic and Systolic Blood Pressure measures, and Coronary Heart Disease Risk. RESULTS: Significant path coefficients (critical ratios > 2) indicated that the mean diastolic blood pressure under a video stress condition was predictive of increased potential of developing coronary heart disease (.51), while hard driving Type A behavior was a cardiovascular reactivity antecedent associated with an increase in coronary heart disease risk directly (.14) and indirectly (.39). Physical fitness, on the other hand, had a positive affect in that increased fitness was related to lower cardiovascular reactivity when participants were stressed (-.58). CONCLUSIONS: Physical fitness is indirectly beneficial in reducing coronary heart disease risk potential by reducing an individual's diastolic blood pressure response, while scoring high as a Type A Hard Driving personality increases cardiovascular reactivity and coronary heart disease risk. This study is limited to middle-aged males who were generally healthy and displayed concern for their health. PMID- 10165521 TI - The impact of worksite-based safety belt programs: a review of the literature. AB - PURPOSE: The purpose of this paper is to provide a literature review of the research that examines the effectiveness of worksite intervention programs designed to increase the use of safety belts by employees. SEARCH METHODS: The literature search, which identified 14 research studies on worksite safety belt programs conducted between 1968 and 1994, originated as part of a larger review on the health impact of worksite health promotion programs that was conducted by the Centers for Disease Control and Prevention (CDC). In addition, the authors conducted an additional search in an effort to validate the CDC search, but found no additional research articles. SUMMARY OF IMPORTANT FINDINGS: The literature specific to the effectiveness of safety belt programs is limited to only 14 studies. The safety belt intervention most commonly evaluated used behavioral modification principles involving incentives. These and other interventions demonstrated effective increases in seat belt utilization that, upon withdrawal of the intervention, achieved a recidivism rate above baseline levels. However, the vast majority of studies failed to incorporate control groups into their research design, which caused significant threats to internal validity. Thus, a summary of findings is only suggestive at best. MAJOR CONCLUSIONS: Based on the literature, there appears to be an insufficient number of quality research studies from which to derive a clear view of the impact of worksite safety belt programs. While the evidence is suggestive of a positive impact on safety belt use, there is a clear need for new, well-designed research initiatives on the effectiveness of theory-based safety belt intervention programs. PMID- 10165522 TI - A review of health-related outcomes of multi-component worksite health promotion programs. AB - PURPOSE: The purpose of this article is to critically review evaluation studies of the health-related effects (i.e., health risk modification and reduction in worker absenteeism) of multicomponent worksite health promotion programs. SEARCH METHOD: A comprehensive literature search conducted under the auspices of the Centers for Disease Control and Prevention identified 36 articles that examined health-related outcomes of multi-component programs. The authors identified 11 additional articles through manual searches of recent journal issues and through personal contacts with worksite health promotion researchers. Forty-seven studies describing the results of 35 worksite health promotion programs were reviewed. IMPORTANT FINDINGS: The worksite health promotion programs reviewed for this article varied tremendously in the comprehensiveness, intensity, and duration of the intervention activities. All of the programs provided health education to employees. In a majority of the programs, opportunities to learn and practice new skills were also offered. A smaller number of programs incorporated modifications in organizational policy or the physical work environment. Results from well conducted randomized trials suggest that providing opportunities for individual risk reduction counseling for high risk employees within the context of comprehensive programming may be the critical component of an effective worksite health promotion program. Just offering low intensity, short duration programs aimed at increasing awareness of health issues for the entire employee population may not be sufficient to achieve desired outcomes. MAJOR CONCLUSIONS: The results of the studies reviewed provide both cautious optimism about the effectiveness of these worksite programs and some general guidance as to the critical components and characteristics of successful programs. Overall, the evidence suggests that a rating of indicative/acceptable may best characterize this literature. PMID- 10165523 TI - Career choices and professional attitudes of graduating clinical laboratory science students: a nationwide survey. AB - OBJECTIVE: To conduct a nationwide survey of graduating clinical laboratory science students in order to gather descriptive data and to determine how graduates felt about their profession and what their career goals were for the next 5 years. DESIGN: Survey PARTICIPANTS: A total of 866 clinical laboratory science seniors from hospital-based and university-based clinical laboratory science programs in the United States. OUTCOME MEASURES: Results of questions designed to gather descriptive data and professional goals as well as scales measuring professional attitudes about various aspects of the clinical laboratory science profession. RESULTS: Respondents indicated a high level of satisfaction with their chosen profession as indicated by the positive ratings of their clinical laboratory science program and immediate and long-term employment goals. CONCLUSION: Graduating clinical laboratory science students displayed satisfaction with their profession as evidenced by their career choices immediately following graduation, their professional goals 5 years after graduation, and their responses assessing professional attitudes. PMID- 10165524 TI - A new paradigm for clinical laboratory science education: a case study for survival and growth. AB - Clinical laboratory science (CLS) education programs are faced with declining numbers of qualified students and resources. A solution is to move toward a new education paradigm. The new paradigm emphasizes cooperation between institutions, asynchronized learning and advising, the use of technology for teaching and advising and the decentralization of the teaching process. This article presents a case study describing how 1 CLS program was able to go from a scarcity mentality to an abundance mentality by implementing the new paradigm. PMID- 10165525 TI - Outcomes assessment applied to CLS curriculum revision evaluation. AB - OBJECTIVE: To describe the application of outcomes measurement and assessment to curriculum revision. SETTING: A baccalaureate level clinical laboratory science (CLS) program in an academic health center. PRACTICE DESCRIPTION: Professional portion of CLS educational program. PRACTICE INNOVATION: Curriculum revision. MAIN OUTCOME MEASUREMENTS: Student retention, remediation and performance data; student, employer and faculty feedback. RESULTS: Outcome measures indicated which innovations were successful and which were less successful. CONCLUSION: Outcome measures can provide valuable information and guidance for curriculum evaluation, renewal, improvement and redesign. PMID- 10165526 TI - Acute medical costs of fluoxetine versus tricyclic antidepressants. A prospective multicentre study of antidepressant drug overdoses. AB - Despite demonstrated differences in toxicity profiles between tricyclic antidepressants (TCAs) and selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs), no studies have examined hospital costs associated with acute antidepressant overdoses. Given the high incidence of such overdoses, it is important to examine treatment patterns and associated costs. This prospective, multicentre cohort study compared the hospital and physician costs associated with TCA and fluoxetine drug overdoses. Over a 30-month period, 622 consecutive patients with a fluoxetine or TCA overdose presented to the emergency departments, or were admitted to intensive care or medical units, of 9 participating medical centres across the US. Inclusion criteria were: ingestion of a single antidepressant (fluoxetine or a TCA), without clinically significant co-ingestants; laboratory confirmation of the overdose; and retrievable hospital bills. Patients were followed until discharge from the emergency department or hospital. Hospital and physician charges were collected from billing data. Hospital charges were adjusted using Health Care Financing Administration cost: charge ratios to estimate costs; physician charges were adjusted to estimate costs. Patient demographic and clinical data were prospectively gathered during the course of medical treatment. Clinical data recorded included level of consciousness, cardiopulmonary complications, vital sign or ECG abnormalities, agitation, seizures, CNS depression and death. 136 patients (121 with TCA overdose and 15 with fluoxetine overdose), representing 21.8% of the 622 patients entered, met the inclusion criteria. Mean length of stay varied from 0.73 [+/ standard error of the mean (SEM) 0.33] days for fluoxetine overdose patients to 3.59 (+/-SEM 0.48) days for TCA overdose patients (p = 0.038). Mean hospital costs were $US668 for patients with a fluoxetine overdose compared with $US4691 for those with a TCA overdose (p < 0.0001). No significant differences were observed between the TCA and fluoxetine overdose groups with regard to physician costs. Median hospital and physician costs increased from $US3029 to $US4396 from the first 15-month period of the study to the second 15-month period of the study for the TCA overdose group, but decreased from $US881 to $US396 for the fluoxetine overdose group. Patients with fluoxetine overdoses had lower hospital and total medical costs compared with patients with TCA overdoses. There was some evidence supporting a reduction in the medical costs of treating fluoxetine overdoses over the 30-month study period. PMID- 10165527 TI - The cost of medicines in the United Kingdom. A survey of general practitioners' opinions and knowledge. AB - Prescribing costs in general practice continue to grow. Their importance is underlined by the amount of information concerned with costs that general practitioners (GPs) receive, and by the existence of target budgets. In 1986 and 1991, surveys showed that GPs agreed that cost should be borne in mind when choosing medicines, but that their knowledge of drug prices was often inaccurate. This study assessed the current knowledge and attitudes of GPs in the UK in respect of prescribing costs, and examined the influence of various developments in general practice since 1986 on the accuracy of drug price estimation. 1000 randomly selected GP principals (500 in Scotland and 125 in each of 4 English health regions) were sent a postal questionnaire. The GPs' level of agreement with 5 statements concerned with prescribing costs, and the accuracy of their estimates of the basic price of 31 drugs, were analysed. Most GPs (71%) agreed that prescribing costs should be taken into account when deciding on the best treatment for patients. Fundholders were more likely than non-fundholders: (i) to agree that prescribing costs could be reduced without affecting patient care; (ii) to agree that providing more information on costs would lower the cost of prescribing; and (iii) to comment that cost guidelines had changed their prescribing habits. Fundholders were less likely than non-fundholders to reject the principle of fixed limits on prescribing costs. Overall, one-third of the price estimates given were accurate (within 25% of the actual cost). For the most expensive drugs in the survey [those priced over 10 pounds sterling (Pound) per pack], half of the price estimates were accurate. There were significant differences between non-fundholders' and fundholders' estimates of the price of less expensive drugs (those priced at less than 10 pounds per pack). Use of a formulary or computer-displayed drug price information did not affect the accuracy of price estimates. It may be that GPs who were more knowledgeable and concerned about costs were more likely to become fundholders. It is also possible that the expansion of fundholding, or other mechanisms that give GPs responsibility for resource allocation, might improve accurate cost awareness in prescribing. Clinical and economic review of repeat prescribing is recommended. PMID- 10165528 TI - Cost-effectiveness of abbreviating the duration of intravenous antibacterial therapy with oral fluoroquinolones. AB - Comprehensive economic analyses should include outpatient as well as inpatient resources. A healthcare system that includes both inpatient and outpatient care, such as prescriptions, physician care, laboratory tests and multiple other items, has been termed an Integrated Healthcare Network (IHN). Thus, cost-effectiveness analyses from the perspective of an IHN are necessary. We report a cost effectiveness analysis from an IHN perspective on 187 evaluable hospitalised patients with serious infection who participated in randomised clinical trials that evaluated either: (i) standard regimens of intravenous (i.v.) antibacterial therapy, usually followed by oral antibacterial therapy; or (ii) an abbreviated regimen of intravenous antibacterials for 2 to 4 days, followed by either oral ciprofloxacin or oral enoxacin as early switch therapy. Clinical success rates were similar for the 2 treatment groups. The median number of days of in-hospital antibacterial treatment was 11 for standard i.v. therapy and 10 for switch therapy. Adverse events occurred in 33% of the standard i.v. therapy group and in 50% of the switch therapy group. Sensitivity analysis of drug price and hospital bed cost showed that switch therapy was consistently more cost effective than standard i.v. therapy. Standard i.v. therapy would have to be 10% more effective than switch therapy to change the economic decision. In this analysis, switch therapy was a cost-effective treatment with no demonstrated change in efficacy compared with standard i.v. therapy. PMID- 10165530 TI - Teleradiology moving into the mainstream. PMID- 10165529 TI - Sensitivity analysis in health economic and pharmacoeconomic studies. An appraisal of the literature. AB - The objective of this study was to analyse the extent of reporting of sensitivity analyses in the health economics, medical and pharmacy literature between journal types and over time. 90 articles were chosen from each of the bodies of literature on health economics, medicine and pharmacy. MEDLINE, EMBASE and International Pharmaceutical Abstracts were searched for English-language economic studies published between 1989 and 1993. The studies chosen for inclusion had to be original articles published in one of the selected journals between January 1989 and December 1993, involving a comparison between drugs, treatments or services, and evaluating both costs and outcomes. 123 articles initially met these criteria; however, 16 were inappropriate, 17 were randomised out, leaving 90 studies (73%) that were used (30 from each literature group). Data were extracted independently by 5 raters using a validated checklist. Inter rater reliability was assessed by calculating kappa. 53 of the 90 articles (59%) conducted sensitivity analyses. 39 (74%) stated explicitly that a sensitivity analysis was being performed; this was noted in the Methods section of 35 papers (67%). 80% of health economics journals, 70% of medical journals and 20% of pharmacy journals conducted sensitivity analyses. Despite the fact that all published pharmacoeconomic guidelines suggest the use of sensitivity analysis, only 59% of studies between 1989 and 1993 did so. Improvement is required, especially in the pharmacy literature. No time trends in the conduct of sensitivity analyses were detected. However, the sample may not have been sufficient to detect such trends. Pharmacoeconomic guidelines should provide more details on preferred methods of sensitivity analysis and on desired parameters. PMID- 10165531 TI - Comments to the proposed model legislation regarding cross-state licensure drafted by the Federation of State Medical Boards. PMID- 10165532 TI - Licensure barriers to the interstate use of telemedicine. PMID- 10165533 TI - Organizational structure in telemedicine programs. PMID- 10165534 TI - Telepathology. Is there a future? PMID- 10165535 TI - Developing better relationships in telemedicine practice. Organizational and interpersonal factors. PMID- 10165537 TI - Intranet vs. Internet. PMID- 10165536 TI - Operational issues at the East Carolina University School of Medicine. PMID- 10165538 TI - Wait a minute, you want your telemedicine program to volunteer to be audited? PMID- 10165540 TI - Strategy for medical readiness: transition to the digital age. PMID- 10165539 TI - Low band with real time over ISDN. PMID- 10165541 TI - Telemedicine and telepathology at the Armed Forces Institute of Pathology: history and current mission. AB - The Armed Forces Institute of Pathology uses telepathology and telemedicine programs to support its mission of providing pathology consultation, education, and research. The telepathology service is based on a static imaging or "store and-forward" approach using both proprietary equipment and open systems through the Internet. Initiated in 1993, the service provides rapid expert consultation to pathologists globally. Diagnoses are provided by pathologists in 22 specialized departments. Educational programs are delivered through the World Wide Web. Category I continuing medical education credits can be obtained through Internet-based courses. Research activities are focused on forensic applications and the creation of image databases. PMID- 10165542 TI - Virtual reality and telemedicine: exploring advanced concepts. AB - Virtual reality (VR) has provided a new methodology for interacting with information. Since telemedicine is principally involved with transmitting medical information, VR has the potential to enhance the telemedicine experience. The two principle ways in which VR can be applied are as an interface, which enables a more intuitive manner of interacting with information, and as an environment that enhances the feeling of presence during the interaction. Since there are no current clinical applications of VR in the telemedicine experience, this report reviews concepts and experiences with the potential to enhance the delivery of telemedicine. PMID- 10165543 TI - Tertiary telemedicine support during global military humanitarian missions. AB - OBJECTIVE: The U.S. military medical units face the challenge of delivering the latest medical knowledge and advances to remote areas of the world. This study details the tertiary care telemedicine support by Walter Reed Army Medical Center (WRAMC) for these humanitarian missions in several locations worldwide. METHODS: This study encompasses data from all clinical consults received at WRAMC, from the earliest deployment of a satellite-based system in February 1993 through February 1996. The analysis of the consultations include type of consult, medical specialty consulted, response time, and technology used. RESULTS: Two hundred forty consults were received from 12 remote telemedicine sites supporting military medical missions. The consults used a combination of "store-and-forward" technologies and interactive video conferencing systems. Establishment of a telemedicine service at WRAMC, including medical and technical support personnel, facilitated the delivery of telemedicine consultations. Several concurrent missions were supported. The distribution of consults included medicine (40%), surgery (36%), radiology (21%), and dentistry (3%). The most frequently consulted medical subspecialty was dermatology (29%) followed by orthopedic surgery (16%). Most consults were routine (88%). Ninety-four percent of the consults were completed within the predefined telemedicine response criteria (24 hours for routine consults and 3 hours for emergencies). CONCLUSION: The study illustrates the importance of a responsive telemedicine service at a tertiary facility supporting simultaneous medical missions. Access to the complete spectrum of medical and surgical specialties was essential to enhancing the delivery of medical care. The critical analysis and evaluation of this experience will assist in designing future prospective studies for evaluation of telemedicine. PMID- 10165544 TI - Operation Joint Endeavor in Bosnia: telemedicine systems and case reports. AB - OBJECTIVE: For the last several years the U.S. Department of Defense (DoD) has operated a telemedicine test bed at the U.S. Army Medical Research and Material Command's Medical Advanced Technology Management Office. The goal of this test bed is to reengineer the military health service system from the most forward deployed forces to tertiary care teaching medical centers within the United States by exploiting emerging telemedicine technologies. METHODS: The test bed has conducted numerous proof-of-concept telemedicine demonstrations as part of military exercises and in support of real-world troop deployments. The most ambitious of those demonstrations is Primetime III, an ongoing effort to provide telemedicine and other advanced technology support to medical units supporting Operation Joint Endeavor in Bosnia. RESULTS: Several of the first instances of the clinical use of the Primetime III systems are presented as case reports in this paper. These reports demonstrate capabilities and limitations of telemedicine. CONCLUSION: The Primetime III system demonstrates the technical ability to provide current telecommunications capabilities to medical units stationed in the remote, austere, difficult-to-serve environment of Bosnia. Telemedicine capabilities cannot be used without adequate training, operations, and sustainment support. Video consultations have eliminated the need for some evacuations. The system has successfully augmented the clinical capability of physicians assigned to these medical units. Fullest clinical utilization of telemedicine technologies requires adjustment of conventional clinical practice patterns. PMID- 10165545 TI - Telemedicine in Micronesia. AB - Distance and isolation profoundly affect the delivery of health care in the islands of Micronesia. The lack of specialty services on most of the islands has led to a costly off-island referral system that strains health care budgets. Care providers there have incorporated advances in telecommunications to create a telemedicine network amongst themselves and with a tertiary care hospital in Hawaii. They developed an interactive video conferencing system, a still-image transmission network, and a data transfer network for use principally in patient care and continuing education. Patients now receive earlier evaluation by off island specialists as part of an effort to improve the appropriateness of off island referrals. Regularly scheduled medical lectures are broadcast from Pohnpei, a main island, to physicians in several more remote locations. Transmission costs are kept low by using, when possible, preexisting public service satellites, such as the PEACESAT system that serves the entire Pacific basin. The telemedicine system is evolving, and its success depends greatly on the cooperative relationships among the partners. PMID- 10165546 TI - Experimenting with feasibility of telemedicine in Alaska: successes and lessons learned. AB - Alaska may be ideally suited as a test site for telemedicine. It is by far the nation's largest state, with a population of only 550,000 clustered around a few cities and towns or widely spread across an area almost two and a half times as large as Texas. Its ratio of doctors to patients is the second lowest in the nation, and the cost of medical care exceeds that in the lower 48 states by 90%. Almost half of its residents are affiliated with the federal government in some way. Active duty and retired members of the military and their families (including children) represent 70,000 of the state's residents, and another 160,000 are affiliated with the Coast Guard, the Indian Health Service, and the Department of Veteran Affairs. In 1995, a telemedicine initiative was launched under the auspices of the 3rd Medical Center at Elmendorf Air Force Base. Its mission was to integrate video conferencing and store-and-forward technology into patient care. Brief but well-documented efforts yielded many valuable lessons on how relatively simple, low-bandwidth technology can be effectively used and its limitations. In addition, unexpected changes were observed in the way health care was delivered. This experience should provide valuable lessons for those embarking on this path to health care delivery. PMID- 10165547 TI - A brief survey of Department of Defense Telemedicine. AB - This paper describes current telemedical projects sponsored by the Department of Defense (DoD) and provides points of contact for further communication. The scope and scale of these projects demonstrate the DoD commitment to the development and deployment of telemedicine and advanced medical information technologies in health care delivery. PMID- 10165548 TI - Department of Defense Telemedicine Test Bed on the World Wide Web. PMID- 10165549 TI - Immunization tracking systems: experience of the CDC Vaccine Safety Datalink sites. AB - Recognizing the potential of large databases within HMOs for the evaluation of vaccine safety, the Centers for Disease Control and Prevention (CDC) funded the Vaccine Safety Datalink project, linking outcome and vaccine exposure information at Group Health Cooperative of Puget Sound, Kaiser Permanente Northwest, Kaiser Permanente Medical Care Program Northern California, and Southern California Kaiser Permanente. Integral to the Vaccine Safety Datalink Project was the development of Immunization Tracking Systems at each site; this report describes the effort required to establish these tracking systems. Essential requirements are the methods used to insure data quality and to educate system users. Tracking systems can be a valuable means for assessing vaccine coverage, evaluating barriers to complete immunization, and studying the effectiveness of interventions design to improve immunization coverage. Finally, we report on recent efforts to link HMO Immunization Tracking Systems with developing regional tracking systems. PMID- 10165550 TI - Increasing bicycle helmet effectiveness: the importance of proper helmet fit and wearing position. PMID- 10165552 TI - Preventive services in HMOs. PMID- 10165551 TI - Smoking cessation benefits in HMOs. AB - A survey was undertaken in the Spring of 1994 to understand the types of smoking cessation services offered by HMOs to one state's employees. Responses documented that the vast majority of HMOs offered nicotine replacement therapy, as well as behavioral classes and courses, with no difference in availability of programs by HMO model type. Considerable variance was found among plans with respect to the structure of the services, and the conditions for accessing benefits. This variation in part may reflect the lack of empirical evidence concerning which approach is most effective. HMOs have provided leadership within the health services and insurance industry with respect to inclusion of cessation benefits. A challenge for HMOs is to design coordinated systems for their smoking cessation services including development of appropriate monitoring systems. Such monitoring will allow plans to better assess participation and effectiveness, and to make benefit and operational decisions on the basis of performance. PMID- 10165554 TI - Chiropractic services in a staff model HMO: utilization and satisfaction. AB - Utilization of chiropractic services was assessed in the continuously enrolled, non-Medicaid membership of Group Health Cooperative of South Central Wisconsin in 1993 and 1994. In addition, a random sample of 500 members using chiropractic services in the last quarter of 1994 was surveyed about satisfaction with the services. A total of 5.1% and 5.3% of members used the services in 1993 and 1994, respectively. Highest utilization occurred among women aged 35 to 49, with rates of 9.5% and 9.9%. Satisfaction levels were high in all areas; 95.8% indicated overall satisfaction with chiropractic care and services. PMID- 10165553 TI - Nicotine replacement therapy in a group model HMO. AB - OBJECTIVE: To examine patient response to a smoking cessation program that combined a nicotine replacement system (patch) with telephone support. DESIGN: Randomized trial. SETTING: A large Midwestern HMO. PARTICIPANTS. Five hundred and nine smokers who attended orientation sessions where an overview of the study and the use of the nicotine patch was presented. INTERVENTION: All subjects received a prescription for a nicotine replacement patch (Prostep, Lederle Laboratories, Wayne, NJ). Participants were randomly assigned to one of three intervention groups. Group I participants (n = 166) received no additional support. Group II participants (n = 167) were registered with a 24-hour telephone hotline. Group III participants (n = 167) were registered with the 24-hour telephone hotline and received four follow-up telephone calls from health educators. OUTCOME MEASURE: The primary outcome measure was smoking cessation. Subject satisfaction with study components was also evaluated. RESULTS: Overall, there was no significant difference by group in smoking cessation rates: 20% of patients in all three groups were smoke-free after 12 months. Few patients (1%) used the telephone hotline. The telephone follow-up did not have an impact on cessation rates, and most patients (92%) reported that the orientation session was useful. CONCLUSIONS: The study experience has helped the HMO evaluate various study components and has had an impact on currently used telephone intervention strategies and educational materials. PMID- 10165555 TI - Building a patient registry for implementation of health promotion initiatives: targeting high-risk individuals. PMID- 10165556 TI - The Colon Cancer Prevention Program (CoCaP): rationale, implementation, and preliminary results. AB - Although there is now solid evidence to support the efficacy of colorectal cancer screening, few health care systems have developed comprehensive screening programs. This report describes the scientific rationale, development and implementation strategies, and preliminary results of the Colon Cancer Prevention Program (CoCaP) of the Northern California Region of the Kaiser Permanente Medical Care Program. CoCaP is a sigmoidoscopy-based screening program that aims to provide screening to all average-risk program members once every 10 years beginning at age 50. During the first 2 years of the program, more than 100,000 sigmoidoscopies were performed in age-eligible members (age 50 years and above). Seventy-five percent of these were screening examinations. Participating endoscopists include gastroenterologists, generalist physicians, and a growing number of non-physicians, primarily nurses, nurse-practitioners or physicians' assistants. Data on depth of insertion and polyp yield suggest that non physicians quickly become as proficient as physician endoscopists. The long-term goals of the CoCaP program are to reduce the incidence of and mortality from colorectal cancer. Collection and analysis of data from the screening examinations and follow-up colonoscopies will enable CoCaP to refine its screening algorithm and to quantify program effectiveness. PMID- 10165557 TI - Work process redesign for blood banks and transfusion services. AB - Blood banks and transfusion services generally have been slower than other clinical laboratory areas to look into redesigning their work processes. Work process redesign (WPR) provides a tool for facilities to critically review their current work processes for improvement opportunities. This article provides blood banks and transfusion services with a redesign road map and the experiences of a large, metropolitan transfusion service in undertaking a WPR project. PMID- 10165558 TI - Managers as facilitators. Making meetings work and leading effective teams. AB - When considering the long history of management, the manager as a facilitator is a relatively new concept. It takes on added importance because facilitation is a key element of the quality movement. By definition, to facilitate means "to make easy." Thus, the facilitator meets the requirements of his or her customers, i.e., the team, and makes it easy for them to succeed. This represents a major shift from the traditional role of the manager. The real challenge for many managers is to make the transformation from being the person in charge to the person who serves others so they can succeed. PMID- 10165559 TI - Coaching: the art of creating exceptional results. AB - Functioning as a Coach is a key role for a manager and, in fact, distinguishes the manager as a leader. Coaching focuses on two distinct areas: 1) coaching to orient employees to new situations, and 2) coaching for performance with employees who are showing marginal performance, who are meeting expectations, or who are showing high performance. This article describes coaching for orientation and for performance, identifies coaching skills, and provides a coaching self assessment. PMID- 10165560 TI - Integrating academic and community laboratory needs: developing a successful outreach program. AB - Remarkably few large regional laboratory programs involving academic health centers exist in Canada. We present a model of a successful laboratory outreach program established by the Queen's University Department of Pathology (Kingston, Ontario) and its affiliated hospital laboratories. Community hospitals in small urban and semi-rural areas benefit from a diffusion of specialty expertise in laboratory medicine and technology, which enables them to increase their local testing capabilities and improve turn-around time. Testing and services of a more complex nature are referred to the academic hospitals. The result has been a steady improvement in the quality of laboratory services in the region with increased cost-effectiveness through shared services and focused economies of scale. PMID- 10165561 TI - Key performance indicators to assess laboratory operations. Gauging the past ... pointing the way. PMID- 10165562 TI - The Reference Laboratory's quality quest. AB - The reference laboratory began development of a Quality Assurance Program in 1991. This program evolved into Total Quality Management supported by strategies, systems, policies, and procedures. We also developed powerful Vision and Value Statements. We are proud of our accomplishments and of the Special Recognition awarded from the clinical laboratory management association for our Human Resources Management and Client Service/Education Programs. PMID- 10165563 TI - Integrated regional laboratory systems: implications for staffing and skill mix requirements. AB - Significant changes are occurring in the organization and delivery of clinical laboratory services. Many laboratorians are concerned that these changes will adversely affect the quality of these services as well as their own careers. The purpose of this paper is to review the changes occurring in health care and to discuss their impact on laboratory and other health-care services. It will present the concept of the postmodern laboratory and the skills and skill mix of personnel needed by the new organizational paradigm. PMID- 10165564 TI - Observations on the 1996 clinical laboratory conferences. AB - The author reviews five trends in the laboratory and diagnostic industries. The five trends are: consolidation of both the diagnostic companies and clinical laboratories (hospital and commercial); pressure to cut costs; robotics; implication of new technology; and the pressure to cut costs by transitioning certain tasks to nontechnical personnel while dealing with an abundant labor supply. PMID- 10165565 TI - As we see it. Beyond traditional service, Part II. PMID- 10165566 TI - Perspectives. CHCs' loss of Medicaid stealth subsidy jeopardizes uninsured. PMID- 10165567 TI - Perspectives. New chief at AHCPR has eclat, but not much cash. PMID- 10165568 TI - Perspectives. Denver demonstration tests use of enrollment broker. PMID- 10165570 TI - NFPA Journal buyer's guide 1997. PMID- 10165569 TI - Taming the paper tiger: computerized HAZCOM systems. PMID- 10165571 TI - Case study. University of Pennsylvania Health System looks to be a leader in disease management. PMID- 10165572 TI - On-unit pharmacists at 720-bed Saint Francis Medical Center, Peoria. PMID- 10165573 TI - Asthma care at University of Pennsylvania: cost savings through "functional redundancy and the teachable moment. PMID- 10165574 TI - Record-breaking year: mergers and acquisitions soar in 1996. PMID- 10165575 TI - New math: division = unity. PMID- 10165577 TI - Sick of those physician preference cards? Toss 'em! PMID- 10165576 TI - Committed contracts: what happens after you take the pledge? AB - For years, hospitals played under shifting rules at the high-stakes purchasing table. Manufacturers, groups and providers all dealt and bluffed. Each made commitments to one another, but afterward the manufacturers would try to go in the back door if a competitor shut them out at the front, and hospitals would join multiple groups and shift loyalties at will to get the lowest price. Sure, all agreed that solid contract commitments would be better for everyone. But when it was time to ante up, what really mattered to each was getting the best deal. And "best" meant something different to each player. PMID- 10165578 TI - Disinfection guidelines: the great debate. PMID- 10165579 TI - Getting fired isn't fatal! Here's how to survive. PMID- 10165580 TI - Poke around to save money on needles and syringes. PMID- 10165581 TI - Can you use a 'greener' cleaner? PMID- 10165582 TI - Instrument repair: make sure you're paying the right price. PMID- 10165583 TI - Stats. Guide compares data on supply costs, length of stay and best practices. PMID- 10165584 TI - The heavy load of implementing portability. PMID- 10165585 TI - Fixing dysfunctional family leave. AB - Intended to accommodate workers' personal needs and family commitments, FMLA has proved to be a headache for employers--even those with generous leave policies in place. Here are some tips avoiding the pitfalls. PMID- 10165586 TI - Another health cost explosion: it's not inevitable. PMID- 10165587 TI - Who's saying no to uninsured kids? PMID- 10165588 TI - Will direct contractors be the cost and quality champs? PMID- 10165589 TI - Employee rewards, employer perceptions. PMID- 10165590 TI - Uncovering the hidden costs of allergies. PMID- 10165591 TI - On Medicare cuts and a coalition. PMID- 10165592 TI - Bound and gagged. HMOs need to be reformed--but in the right way. PMID- 10165593 TI - Rx: thirty minutes on the StairMaster twice weekly. Hospitals court the sweaty set with health clubs. PMID- 10165594 TI - A bitter new battle over partial-birth abortions. Did pro-choice advocates distort statistics? PMID- 10165595 TI - Patient education or health information service: what's the difference? PMID- 10165596 TI - Intranet!! PMID- 10165597 TI - Nursing collections in DOCLINE and non-DOCLINE libraries: an Oklahoma survey. PMID- 10165598 TI - Biblio-link II and Pro-Cite: software updates. PMID- 10165599 TI - Accessing needs for published information. PMID- 10165600 TI - New technologies emerge. AB - Technology vendors continue to invent new devices, systems and processes to sell to the health care industry. Drugs, instruments and procedures continue to improve and address disease and injury treatment needs. In addition to these direct medical treatment innovations and enhancements, a number of new supporting systems and products have emerged. These support technologies hold significant promise for managers to make day-to-day execution of health care delivery more cost effective and customer friendly. PMID- 10165601 TI - Two are better than one. AB - On March 29, 1996, Marwan Abouljoud, MD, and Francisco Escobar III, MD, of Henry Ford Hospital, Detroit, performed the first split liver transplant in Michigan on two patients who were both dying from liver disease. At that time, fewer than 20 such procedures had been done nationwide. PMID- 10165602 TI - Celebrating life; coping with loss. AB - We're all part of the same story. Each life represents a separate chapter in the book, beginning and ending in turn, yet each is part of a greater tale that continues to unfold. Donor families know first hand the pain of loss. They have also experienced unexpected comfort from knowing that their decision regarding eye, tissue and organ donation offered a new beginning for someone else. PMID- 10165603 TI - Hands on learning. AB - Davenport College, Lansing, has been known for its business programs for more than 150 years. Davenport has expanded its offerings to include a career in allied health. The addition of allied health to the college's offerings in Lansing is due to a unique partnership that began in 1992 between the college and area health care providers. PMID- 10165604 TI - Making your telepresence known. Current applications of videoconferencing. PMID- 10165605 TI - The prudent investment process. AB - Are you a CFO, CEO or treasure of your organization? Are you a member of the board of directors or investment or pension committees? If you answered "yes" to these questions, you are likely to be considered a fiduciary of investment assets. This position carries with it prestige, responsibility, and potential personal liability should something go wrong. Of course, liability will most likely occur only if a failure has occurred in carrying out fiduciary responsibilities. But what are those responsibilities? And what is the most appropriate way to manage investment decisions? PMID- 10165607 TI - Ethical stewards of resources. PMID- 10165606 TI - Proceed with care. Hospital board fiduciary responsibilities. AB - Historically, there has been a tendency to give deference to the business deliberations and decisions of non-profit hospital boards. Today there is growing evidence that these decisions are coming under closer scrutiny as the result of an increase in transactional activity in the health care corporate environment and corresponding regulatory initiatives. PMID- 10165608 TI - Miracle microscope offers hope. AB - There are thousands of instruments and machines that physicians and health care professionals use for medical treatment. The great majority help perform tests and treatments that are fairly routine. But once in a while something distinctively different and exciting comes along, something like the MKM (Microscope Koordinate Manipulator) robotic microscope. PMID- 10165609 TI - Turning over a new leaf. Using work simulations to assess candidates. PMID- 10165610 TI - Issues in long-term care. AB - The US Supreme Court is reviewing the issue of physician assisted suicide after two lower court cases, Quill v. Vacco and Washington v. Compassion in Dying, struck down state statutes that prohibited assisted suicide in New York and Washington on constitutional grounds. The debate over physician assisted suicide has been a concern for health care personnel, as well as the public, for several years. PMID- 10165611 TI - The costs of medical technology. PMID- 10165612 TI - Invitation to rural hospitals: lead efforts to fight impaired driving. AB - Those working in health care have long known the human and economic costs of injuries and deaths caused by impaired driving accidents. Researchers found that Michigan traffic crashes cost more than $12 billion in hospital bills, lost wages and property damages. PMID- 10165613 TI - George Jetson, here we come! PMID- 10165614 TI - Managing the Paradox. AB - In the information age, one of the paradoxes is how to get the information your organization needs to where it's needed when it's needed. At the MHA, we've made a strategic decision to employ the Internet (MHAnet), fax on demand (MHA QuickFax), and videoconferencing capabilities to communicate, almost instantaneously, with key staff at member institutions. These methods don't replace face-to-face meetings and documents through the mail, but they do offer members additional avenues for immediate access to the resources and services of the MHA. PMID- 10165615 TI - But we want to have a baby. AB - Janice Jean has some words of encouragement for couples who have given up hope of ever having a child of their own. "Look at my son." Janice, 37, believes little Jacob Michael, born July 31, 1995, to her and her 40-year-old husband, Ron, is truly a miracle. And she feels Michael H. Fakih, MD, director of the Fakih Institute of Reproductive Sciences and Technologies (FIRST) and in whose honor Jacob received his middle name, is a miracle worker. "We never thought there was hope. With one fallopian tube and a zero sperm count? But I believe in miracles- and I believe in Dr. Fakih." PMID- 10165616 TI - Work redesign adds multi-lingual advocates for culturally responsive services. PMID- 10165617 TI - Nuts and bolts of home care social work: Part 1--Reimbursement. PMID- 10165618 TI - A nationwide insurance counseling service for older adults. PMID- 10165619 TI - The Live & Learn Model for culturally competent family services. PMID- 10165620 TI - Turnaround strategies for primary care networks. Retooling, restructuring, and repositioning primary care physician organizations. PMID- 10165621 TI - Will primary care physicians be gatekeepers to the system? Or, should they become patient advocates? PMID- 10165622 TI - Making primary care networks viable. Twenty-five strategies to achieve financial stability and market power. PMID- 10165623 TI - Managed care: a commentary. PMID- 10165624 TI - Managed care and integrated health care. AB - Managed care and integrated care may be viewed as stages in the evolution of the U.S. health care system. The authors discuss the essential characteristics of an integrated delivery system, including patient satisfaction, maintenance of clinical skills, cost-effective practice, and professional reputation. PMID- 10165625 TI - Increasing cost-consciousness for managed care: reforming the tax treatment of health insurance expenditures. AB - The current Internal Revenue Code encourages employees who receive health insurance as part of their benefits package to choose more costly coverage than they would buy with their own money. The authors propose an approach that corrects this problem as well as the inequities experienced by self-employed and unemployed people. PMID- 10165626 TI - Managed care and the business of risk management. AB - The emergence of managed care creates the need for a new paradigm of risk management because of its emphasis on comprehensive services and prospective payment. Information systems, contracts and pricing, utilization management, and outcome research are key elements in devising the new paradigm. PMID- 10165627 TI - Managed care in the Organization for Economic Cooperation and Development countries: prospects for quality, effectiveness, and equity. AB - The perceived need to contain the level of health expenditure has driven reform in many OECD countries over the past decade. Using various countries as examples, the author examines the interaction between cost containment and the three desired goals of health care: quality, effectiveness, and equity. PMID- 10165628 TI - International models of managed care. AB - Outside North America health care resources are raised in two main ways: (1) taxation (the Beveridge model) and (2) compulsory social insurance (the Bismarck model). In practice, most European countries rely on a mixture of the two. The author examines the degree to which recent reforms have promoted divergence or convergence of the North American and European systems. PMID- 10165629 TI - Moving toward managed care: the United Kingdom National Health Service reforms. AB - The divergence between health care in the United States and the United Kingdom appears to be lessening. Although the starting points of the two countries are quite different, the demand for cost containment in the U.S. and the interest in increased competition in the U.K. have led to a similar emphasis on managed care. The author examines the benefits and problems of reform in the U.K. PMID- 10165630 TI - Health care utilization in the British National Health Service. AB - Four national surveys of primary care services in England and Wales demonstrate that utilization rates have not continued to increase significantly since the initiation of the National Health Service in 1948, despite an initial surge in demands for medical services. The author examines morbidity surveys, consultation patterns, and referrals to secondary care and examines the ethical dilemma of basing services on costs. PMID- 10165631 TI - Israel's National Health Insurance Law: expectations and concerns. AB - An historical overview of the Israeli health care system is followed by detailed discussion of recent reforms mandated by the government to control rising yearly expenditures. The author examines the advantages and disadvantages of the reforms, concluding that they are only a first step toward long-term success. PMID- 10165632 TI - The Canadian health care system as a managed care model for the United States. AB - After discussing the evolution of the Canadian health care system and its current cost trends, the authors address the degree to which the Canadian system provides direction for reform in the United States. Accessibility, quality, and cultural acceptability provide the focus of their approach. PMID- 10165633 TI - Medical leadership in an era of managed care and continual improvement. AB - Because clinicians control more than 70% of the total costs of medical care, the success of managed care systems in containing expenditures depends to a large degree on their leadership. Clinicians must make cultural changes and develop core competencies and technical skills to promote the continuous improvement needed for the success of managed care. PMID- 10165634 TI - Health care without managed care in Hong Kong. AB - Although managed care may be more effective than fee-for-service in containing health care costs in the United States, it is less effective in countries with a national health service. In Hong Kong, costs have been contained despite the fact that 95% of general practitioners still practice on a solo, fee-for-service basis. The author describes in detail how the system of tax-based hospitals guarantees universal access without escalating costs. PMID- 10165635 TI - Implementing managed care in New Zealand. AB - Reforms at the level of the national government and regional health boards have encouraged the principles of budget-holding and managed care in New Zealand. The author describes how each principle is implemented in New Zealand and draws comparisons with managed care in the United States. PMID- 10165636 TI - Health care without managed care in Japan. AB - The best gross health indices in the world and universal coverage with no overt signs of rationing characterize the Japanese health care system. The delivery system, which consists primarily of private physicians and private hospitals, is functionally independent, but the financing system is strictly regulated. The author argues that this combination is the key to the system's unique success. PMID- 10165638 TI - Good and bad models of market reform for managed care. AB - The author argues that free market competition has not been given a fair chance in the health care industry and that the basic characteristics of a sound market can be met in the United States if the problem of asymmetric information is efficiently addressed. He proposes the "Buy-Right" system as an effective model for market reform. PMID- 10165637 TI - Consolidation and restructuring: the next step in managed care. AB - Rising expenditures on health care in the U.S. have been facilitated by the fundamental problems of asymmetric information and insurance-induced moral hazard. If managed care is to succeed, it must take both into account through strategies such as information-based consumer education and provider risk sharing. Because larger networks offer significant advantages in implementing such strategies, hospital mergers, physician-hospital alliances, and economies of scale are major trends in the evolution of managed care. PMID- 10165639 TI - Glossary of managed care terms. Health Care Reform Project. PMID- 10165640 TI - Managed care and Medicaid: lessons and strategies for public health. AB - The authors review the status of managed care within Medicaid populations, focusing on the program in Tennessee, where the entire Medicaid population receives health services through managed care structures. Attention is given to barriers to implementation and implications for public health. PMID- 10165641 TI - Managed competition and the health care crisis. AB - The politics of health care reform has created gridlock despite public support for control of increasing costs, expanded coverage, and greater patient satisfaction. Managed care has become the watchword for meeting such goals, despite serious doubts about its ability to succeed. The author examines the pitfalls of managed care, particularly in regard to cost containment and patient satisfaction. PMID- 10165642 TI - Managed care: a foundation for evolution. AB - An examination of the history of managed care organization over the past 30 years, in both private and public sectors, forms the basis for evaluating the success of such programs in meeting the expectation of both physicians and consumers. The authors point to areas that must receive special attention if managed care organizations are to satisfy the quality and cost demands of the future. PMID- 10165643 TI - Mandated managed care for Medicaid recipients. AB - The need to control governmental health expenditures has led to experiments with mandated managed care for Medicaid recipients. Loss of freedom to choose care providers was considered a worthy sacrifice. The authors examine the historical and legislative background, including research and demonstration projects. Although they view some form of rationing as inevitable, they argue that Medicaid recipients should not be singled out to bear the main part of the burden. PMID- 10165644 TI - Evaluating quality in managed care networks. AB - If managed care is to succeed, methods for evaluating individual networks are essential. The author outlines crucial areas of the evaluation process, including rights, responsibilities, and ethics; continuum of care; education and communication; network leadership; human resources management; management of information; and performance improvement. Public disclosure of such evaluations is necessary to ensure their efficacy. PMID- 10165645 TI - Quality management in managed care. AB - Managed care creates a corporate environment in which competitiveness demands close attention to quality. Although the health care sector may benefit from solutions derived in other industries, it attaches unique importance to noneconomic, intangible factors. Adequate cost-utility analysis must take such factors into account instead of relying on artificial numerical values. PMID- 10165646 TI - To manage or to be managed: that is the question. AB - As managed care becomes more common, physicians must take part in its evolution or lose their autonomy. The author proposes "the Ben Franklin scenario," which emphasizes six elements: consumer-provider choice, enrolled population, community weighted capitation, organized practice, prospective budgets, and cost-effective health care. Prototypes for health care reform are also examined. PMID- 10165647 TI - Who should own case management within the continuum of care? PMID- 10165648 TI - Home visits cut LOS for lumbar discectomy. PMID- 10165649 TI - Renal transplantees have special education needs. PMID- 10165650 TI - Implementing care paths on inpatient psychiatric units. PMID- 10165651 TI - Do your patient education programs pull their weight? How to assess effect of education on outcomes. PMID- 10165652 TI - How a complex, physician-driven IDS partnered to finance the urban 'medical campus of the future'. PMID- 10165653 TI - Supporting future IDS capital needs. PMID- 10165655 TI - In recruiting young physicians: money talks. PMID- 10165654 TI - Integration growth poses legal challenges for systems. PMID- 10165656 TI - HCFA lifts moratorium on SNF fines, directs states to review CMPs. PMID- 10165657 TI - OIG issues rule on getting advice to avoid Medicare anti-kickback violations. PMID- 10165658 TI - Continuous quality improvement seen as crucial to future survival of subacute facilities. PMID- 10165659 TI - Cowen's post-acute stock price index. PMID- 10165660 TI - Vision. PMID- 10165661 TI - 1997 buyer's guide. PMID- 10165662 TI - Demographics is destiny. PMID- 10165663 TI - Appropriate use of antibiotics. PMID- 10165664 TI - Logging on. Health plans are starting to use World Wide Web sites to recruit employees. PMID- 10165665 TI - Healing the home. AB - Domestic violence is one of the biggest threats to the health of women in the U.S. Here's how health plans are preventing, identifying, and treating abuse. PMID- 10165666 TI - Opportunities and challenges. Policy highlights from 1996 offer a preview of what health plans can expect for 1997. PMID- 10165667 TI - Exporting expertise. AB - A number of American health plans have established or invested in HMO- and PPO type plans in other countries. Although these health plans face many challenges, they're finding that managed care has appeal in foreign markets. PMID- 10165668 TI - Informed choices. AB - To be active partners in their care, consumers need information to help them make informed health care decisions. Here's a look at information about health plans that's being released to the public by consumer magazines and other sources. PMID- 10165669 TI - Healthy habits. PMID- 10165670 TI - Preventing strokes. PMID- 10165671 TI - Patients first. PMID- 10165672 TI - New partnerships. PMID- 10165674 TI - The rewards for a job well done. The American Association of Health Plans has honored health plans for improving the quality of patient care. PMID- 10165673 TI - By the numbers. Women's health care in HMOs and PPOs. PMID- 10165675 TI - President's budget proposal bodes ill for providers. PMID- 10165676 TI - In planning a project, bigger is not always better. PMID- 10165677 TI - U.S. forges link between poor care and fraud. PMID- 10165678 TI - When Medicare won't cover the Medicare-eligible. PMID- 10165679 TI - Wide open spaces. Creative rural providers are finding ways to fill gaps in service. PMID- 10165680 TI - A rare breed. A subacute nurse must have an unusual set of skills--and not all of them can be taught. PMID- 10165681 TI - Formulas for success or cause for concern? PMID- 10165682 TI - The importance of measuring patient satisfaction. AB - Managed care has demonstrated its ability to contain costs. Its emergence as a dominant factor in the health care marketplace has raised concerns about measuring health care quality. As the field of quality assurance is evolving, it is becoming clearer that patient satisfaction surveys should be an integral component of assessing care. PMID- 10165683 TI - Prudent methods for evaluating, selecting and monitoring professional advisors. AB - Multiemployer fund trustees have a significant responsibility to the plans and beneficiaries they serve. Fortunately, the law allows trustees to retain professionals to assist them in this important function. This article reviews trustees' relationships with these professional advisors, provides an overview of the general legal standards that govern this area and offers a brief description of the types of services trustees can expect from their advisors. PMID- 10165684 TI - Fighting the symptoms of merger mania. AB - Hospital mergers and acquisitions create uncertainty and confusion among philanthropists. How can we reassure them about the future use of their gifts? PMID- 10165685 TI - Power, philanthropy, and potlatch: what tribal exchange rituals can tell us about giving. PMID- 10165686 TI - Applying behavior change theory to donor management. PMID- 10165687 TI - Lamentations and letter writing. PMID- 10165688 TI - Changes in giving and volunteering. PMID- 10165689 TI - Investing for the small non-profit. PMID- 10165690 TI - Government directions in the confidentiality of health information. PMID- 10165691 TI - Safeguarding government-held health information. PMID- 10165692 TI - Linkages for health services research. PMID- 10165693 TI - A legal examination of format, signature and confidentiality aspects of computerized health information. PMID- 10165694 TI - Electronic sharing of health information: examples and privacy concerns. PMID- 10165695 TI - The Privacy Commissioner's perspective. PMID- 10165696 TI - Issues in the development of a statute governing health information. PMID- 10165697 TI - Importance and limits of medical confidentiality. PMID- 10165698 TI - Ethical issues in privacy and genetic data: implications for public policy. PMID- 10165699 TI - Last fall's crippling snowstorms: how Seattle hospitals fared. PMID- 10165701 TI - Computer system trains employees to meet JCAHO safety ED requirements. PMID- 10165700 TI - Growing number of foreign patients pose potential security problems. PMID- 10165702 TI - Special report. Infant kidnapping update: electronic security, officer training, parent alertness help foil abductors in 1996. AB - A dramatic reduction in infant abductions from healthcare facilities nationwide- 82% from 1991-1995--has been reported by the National Center for Missing and Exploited Children. For 1996, the NCMEC reports four abductions from healthcare facilities, down from 11 in 1991. It credits concentrated educational efforts and unique electronic security being used by hospitals as the major factors in reducing the number of abductions. When infant abductions do occur, however, they attract widespread attention and media coverage, and usually lawsuits. In this report, we'll highlight some of the more recent incidents and present comments from security directors and other hospital officials on steps their institutions have taken in an effort to prevent further occurrences. PMID- 10165703 TI - Monitoring and evaluating the delivery of services under managed care. AB - This overview discusses the importance of monitoring and evaluating the delivery of services under managed care, particularly with respect to assessing access and quality in managed care. It also lists recent Health Care Financing Administration (HCFA) initiatives in this area, and presents an introduction to the articles published in this issue of the Review. The topics addressed by these articles range from assessing and monitoring access and quality provided by traditional types of managed care organizations (MCOs) serving Medicare and Medicaid beneficiaries to issues that must be considered in developing and monitoring new delivery system models. PMID- 10165704 TI - Evaluation of the Arkansas Medicaid primary care physician management program. AB - Arkansas implemented a primary-care case-management program in February 1994. This study evaluates the program during its first 17 months. Using quarterly data collected for the Health Care Financing Administration (HCFA), a pooled cross sectional time series analysis (1991:4-1995:2) estimates the effect of eligibles' program enrollment on expenditure (total, inpatient hospital, outpatient hospital, physicians, prescription drugs, laboratory and X-ray) and utilization measures (outpatient visits, physician visits, prescription drugs). The Arkansas Medicaid managed care program appears to have somewhat reduced growth in total vendor payments and also appears to have improved access to primary medical services. PMID- 10165705 TI - Medicaid managed care: how do community health centers fit? AB - Managed care has brought about important changes in how the health care system is financed and services delivered. The authors describe the approaches adopted by community health centers to participate in Medicaid managed care and argue that these providers, commonly referred to as providers of last resort, have a role to play in this system. Many challenges lie ahead for these centers, such as the potential imposition of Medicaid block grants, the increasing number of uninsured persons, and cuts in both Federal grants and State budgets. These various forces may adversely impact health centers, leaving them with more uninsured patients and fewer resources. PMID- 10165707 TI - Business, households, and government: health spending, 1994. AB - During the 1990s, growth in health care costs slowed considerably, helping to lessen the spending strain on business, government, and households. Although cost growth has slowed, the Federal Government continues to pay an ever-increasing share of the total health care bill. This article reviews important health care spending trends, and for the first time, provides separate estimates of the employer and employee share of the premium costs for employer-sponsored private health insurance. This article also highlights some of the emerging trends in the employer-sponsored insurance market, including managed care, cost-sharing, and employment shifts. PMID- 10165706 TI - Potential effects of managed competition in rural areas. AB - This article assesses the extent to which managed competition could be successful in rural areas. Using 1990 Medicare hospital patient origin data, over 8 million rural residents were found to live in areas potentially without provider choice. Almost all of these areas were served by providers who compete for other segments of their market. Restricting use of out-of-State providers would severely limit opportunities for choice. These findings suggest that most residents of rural States would receive cost benefits from a managed competition system if purchasing alliances are carefully defined, but consideration should be given to boundary issues when forming alliances. PMID- 10165708 TI - Prescribed medicines: a comparison of FFS with HMO enrollees. PMID- 10165709 TI - Health care indicators. Hospital, employment, and price indicators for the health care industry: fourth quarter 1995 and annual data for 1987-95. PMID- 10165710 TI - Profiling resource use by primary-care practices: managed Medicare implications. AB - Variations in elderly Medicare beneficiaries' health service use are examined using a 100-percent sample of fee-for-service (FFS) claims data from Alabama, Iowa, and Maryland. Provider specialty, group practice type, practice size, and location are found to be significant factors affecting hospital and ambulatory care utilization and cost, after controlling for patient and regional characteristics. These results provide insights into utilization and cost expectations from different types of primary-care gatekeepers as the Medicare managed care market develops. PMID- 10165711 TI - Report to Congress. Evaluation of Medicare SELECT Amendments. PMID- 10165712 TI - Bringing managed care incentives to Medicare's fee-for-service sector. AB - The Health Care Financing Administration (HCFA) could work with eligible physician organizations to generate savings in total reimbursements for their Medicare patients. Medicare would continue to reimburse all providers according to standard payment policies and mechanisms, and beneficiaries would retain the freedom to choose providers. However, implementation of new financial incentives, based on meeting targets called Group-Specific Volume Performance Standards (GVPS), would encourage cost-effective service delivery patterns. HCFA could use new and existing data systems to monitor access, utilization patterns, cost outcomes and quality of care. In short, HCFA could manage providers, who, in turn, would manage their patients' care. PMID- 10165713 TI - Shifting the paradigm: monitoring access in Medicare managed care. AB - Medicare managed care enrollment growth points to the need to develop an approach for monitoring access to care for the increasing number of beneficiaries who use these arrangements. This article describes the issues to be addressed in designing a system for monitoring managed care plan enrollees' ability to obtain needed medical care on a timely basis. We review components of the monitoring approach used for traditional fee-for-service (FFS) Medicare, including the conceptual framework, data, measures, and subgroups targeted in monitoring efforts, and discuss the adaptation of that approach for monitoring access in Medicare managed care. PMID- 10165714 TI - Health status of Medicare enrollees in HMOs and fee-for-service in 1994. AB - We compared the health status of 863 health maintenance organization (HMO) enrollees with that of 4,576 non-enrollees, controlling for demographics and area of residence, using 1994 data from the Medicare Current Beneficiary Survey (MCBS). HMO respondents were less likely to report fair or poor health, functional impairment, or heart disease. Average predicted costs based on various health-status measures were substantially lower for HMO respondents than for respondents in fee-for-service (FFS) arrangements. The Medicare payment formula for HMOs does not adequately adjust for the better health and consequent lower expected costs of HMO enrollees. The addition of health-status measures would improvement payment accuracy and reduce average HMO payments significantly below current levels. PMID- 10165715 TI - Medicaid managed care encounter data: what, why, and where next? AB - Managed care now serves 23 percent of the Medicaid population. With the shift to capitation, the fee-for-service (FFS) billing mechanism that has generated much of the administrative data used in policy planning and research no longer exists. This article provides an overview of the types of encounter data currently being required for plans and the problems and issues with providing and analyzing such data. It is based on a review of documentation and interviews with representatives of nine States and the Health Care Financing Administration (HCFA). The article concludes by providing recommendations for HCFA, States, and plans in creating and improving encounter data systems. PMID- 10165717 TI - Care of the elderly. Grey matters. PMID- 10165716 TI - System change: quality assessment and improvement for Medicaid managed care. AB - Rising Medicaid health expenditures have hastened the development of State managed care programs. Methods to monitor and improve health care under Medicaid are changing. Under fee-for-service (FFS), the primary concern was to avoid overutilization. Under managed care, it is to avoid underutilization. Quality enhancement thus moves from addressing inefficiency to addressing insufficiency of care. This article presents a case study of Virginia's redesign of Quality Assessment and Improvement (QA/I) for Medicaid, adapting the guidelines of the Quality Assurance Reform Initiative (QARI) of the Health Care Financing Administration (HCFA). The article concludes that redesigns should emphasize Continuous Quality Improvement (CQI) by all providers and of multi-faceted, population-based data. PMID- 10165718 TI - Continuing care. Joint account. PMID- 10165719 TI - Commissioning. Local call. PMID- 10165720 TI - Mental health. Security cheques. PMID- 10165722 TI - Mental health. Shift keys. PMID- 10165721 TI - Telephone advice. It's good to talk. PMID- 10165723 TI - Local pay. Less than was bargained for. PMID- 10165724 TI - Mental health. Labour intensive. PMID- 10165725 TI - Community nursing. Beating the blues. PMID- 10165726 TI - IT update/HISS. Full steam ahead. PMID- 10165727 TI - IT update/networking. The message is the medium. PMID- 10165729 TI - Security. Uniform approach. PMID- 10165728 TI - IT update/EPR. For the record. PMID- 10165730 TI - Service reviews. Out in the field. PMID- 10165731 TI - Mental health. All the way there and back again. PMID- 10165732 TI - Risk management. Safety in numbers. PMID- 10165733 TI - General practice. Drawing young blood. PMID- 10165734 TI - Workforce planning. The human factor. PMID- 10165735 TI - Physiotherapy services. Different strokes. PMID- 10165736 TI - Data briefing. Inflation. Does it really matter? PMID- 10165737 TI - Management development. Great Ormond Street grows up. PMID- 10165738 TI - Nursing. Power dressing. PMID- 10165739 TI - Mental health. Paper chase. PMID- 10165740 TI - Mental health. Home at last. PMID- 10165741 TI - NHS boards. Behind closed doors ... trouble and strife. PMID- 10165742 TI - Community care. Everybody counts. PMID- 10165743 TI - Physiotherapy services. Positive re-alignment. PMID- 10165744 TI - On the evidence. Birth control. PMID- 10165745 TI - Insuring the children. PMID- 10165746 TI - Healthcare's Brother Joseph. PMID- 10165747 TI - Managing managed care. The task calls for an integrated management team. AB - Healthcare providers must learn the art of "managing care," a concept integral to but broader than managed care. Managing care has four dimensions: recruiting skilled operations managers; developing systems, procedures, practices, and protocols that meet the demands of capitation and risk management; fully integrating physician leaders; and preserving society's resources by providing care on the wellness, rather than the sickness, model. Managing managed care, which is now usually the task of a single executive, will tomorrow require a team comprising these four roles: The CEO articulates the system's vision, helps develop its strategic plan, and leads the effort to educate all its associates and employees about managed care. The operations leader (which may in fact be a group of operations executives) redesigns the systems organizations, redeploys its managers, and dismantles its obsolete methods. The physician leader (which may also be a group, rather than an individual) helps retool the system's practices and protocols in a way that enables it to deliver the highest quality of care at the lowest possible cost. The managed care executive acts as the broker between the system and insurance firms. In larger systems, this executive designs long-term partnerships between the system and insurers. PMID- 10165748 TI - Pursuing justice in an era of managed care. Seattle-based system makes room for the underserved and uninsured. AB - The Sisters of Providence Health System (SPHS), based in Seattle, is dedicated to the search for justice. In 1983 the system's leaders decided to create SPHS-owned and -operated managed care plans for residents of the Pacific Northwest because they saw such plans as both the best way to rationalize the region's healthcare delivery and an opportunity to serve its poor and underserved. In Oregon, where the legislature passed the Oregon Health Plan in 1989, 21,000 persons are covered by Providence Health Plans; another 15,000 receive care through SPHS providers and networks. In Washington, whose Basic Health Plan enables customers to purchase coverage through payments adjusted to family sizes and incomes, 13,600 persons are enrolled in the version offered by SPHS; another SPHS plan covers 20,000 beneficiaries of the state's Aid to Families with Dependent Children program; in addition 18,600 elderly Washingtonians are enrolled in an SPHS sponsored Medicare supplement program. SPHS has found that ownership of its plans enables it to integrate mission and business. But ownership also carries certain challenges. SPHS must, for instance, compete with for-profit organizations without compromising its core values. It must carefully coordinate the insurer and provider parts of its organization. And it must train all its employees in Catholic values and insist that its leaders create and enhance an ethical corporate culture. PMID- 10165749 TI - Working for the common good. Catholic healthcare's opportunity to shape values based managed care. AB - Managed care has come under fire lately, and states and the federal government have stepped in to regulate some plans' deficiencies. Some say regulation is not enough; managed care is morally flawed. But the evils of managed care are the result of letting it be shaped solely by market-driven forces rather than mission driven values. In the Catholic tradition, healthcare is part of the common good. Viewed in this light, managed care becomes more than just a way to control costs. For managed care to serve the common good, we will have to collaborate with other providers that demonstrate a commitment to human life and dignity that is similar to our own. Such collaborations may force us to negotiate (without compromising) our values, but this gives us the opportunity to recognize a hierarchy of goods to be pursued and evils to be avoided. Through our involvement in managed care, we can help shape the greater culture, as well as the culture of healthcare. But we must prioritize our commitments according to values and principles grounded in the Catholic moral tradition. Without these values to guide us, Catholic healthcare will lose its identity and fade away. PMID- 10165750 TI - The place of spirituality in managed care. Attending to spiritual needs can help managed care systems achieve their goals. AB - If managed care leaders are able to achieve their goals of enhancing total well being within a capitated system of care, they must attend to the broad new societal interest in spiritual perspectives and find ways to integrate them into their structure of care. Imaginative and sensitive members of many professions, particularly those who acknowledge the value of spirituality in their own lives and are convinced of its value in healing, will likely spearhead this integrated movement. Promoting individuals' total well-being necessitates an acknowledgement that everyone has a unique personal spirituality that needs to be addressed at times of crisis, such as illness or hospitalization. Further, attention to the spiritual dimensions of problems that result in high healthcare costs, such as violence, alcoholism, and the fear of death, can help reduce those costs. The process of grief also needs to be addressed in healthcare settings, for professionals as well as patients, to enhance understanding, acceptance, and the quality of care. People recover and retain health through a balanced integration of physical, spiritual, and community aspects of their lives. If professional chaplains who have emphasized crisis and acute care in their ministry styles are to contribute to this integrative healing and its adoption into managed care systems, they may need to explore broader frameworks, holistic concepts of healing processes, motivations for self-care, and a personal holistic balance. PMID- 10165751 TI - Fulfilling the sisters' promise. The heritage of healthcare's early days. AB - Members of religious orders--the sisters--built not just Catholic healthcare, but healthcare in America. A good 50 years before Henry and Edgar Kaiser got the idea, prepaid capitated health insurance was being offered by sisters who looked at what was needed and realized this was simply the best way to get it done. The sisters also created the integrated healthcare system at a time when the emerging medical elite wanted nothing to do with any patient who was not socially acceptable and potentially curable. They arranged a continuum of care for the aging sisters within their own communities. And they understood the concept of social medicine, of population-based healthcare, of healthy communities, long before these ideas became commonplace. But the sisters are gone, most of them. The question today is, How do we preserve the sisters' heritage and transfer it to a new millennium, a new healthcare system, and a new set of rules? First, it is important to understand that much of what we remember the sisters for- courage, compassion, vision-was not unique. They created many of the structures that today are the new models; but they were not alone. However, three aspects of how they expressed their vision and their faith were unique to the sisters and must be understood by those who wish to treat the path the sisters blazed. The purity of their commitment and its underlying philosophy--that the helpless and the sick must always be the point of the exercise--should pervade Catholic healthcare to its soul. These women, living in poverty, represented, and still represent, a singular group: a group of women who, having told the world that their only wish is to serve others, humble became CEOs of vast systems and trustees of huge enterprises, without ever abandoning that simple, original pledge. Although they bowed to the rule of obedience, and they were humble, the were fighters. They spoke out against poverty, bigotry, the shunning of those with certain diseases, lack of access to healthcare, stupidity, ignorance, and hate. PMID- 10165752 TI - Finding new strength in unity. Four Cincinnati-area Mercy hospitals form an integrated regional system. AB - In early 1993 the leaders of the Sisters of Mercy in Cincinnati decided to form their four area hospitals into a new integrated regional system, The creation of this system--Mercy Regional Health System Greater Cincinnati--was made difficult by the fact that each of its four facilities had its own culture. Change, moreover, can be threatening to even the boldest. As a result of these factors, formation of the new system did not proceed as smoothly as we had planned. Things improved after we began to acquaint ourselves with the histories and cultures of the four hospitals. After that, we created a new regional leadership structure that enabled us to form administrators and employees into teams, breaking down the compartmentalization traditional in healthcare. We showed our employees that the system would open opportunities for them. We also created a new regional board of trustees to develop the system's strategic plan, manage its business infrastructure, and draw up its budget. We established a holistic health and wellness center to encourage focus on the connections between body, mind, and spirit. Through new corporate publications, newspaper advertisements, and lobby displays, we have explained our evolution both to our employees and the residents of the region. As a result, we are now in virtually all of greater Cincinnati's managed care plans. PMID- 10165753 TI - Community networks. Partnerships between Catholic charities and Catholic healthcare organizations. PMID- 10165754 TI - Beyond the hospital walls. Saint Raphael's vision of care includes jobs, home loans, and a reading room. AB - Saint Raphael Health System is based in inner-city New Haven, CT, an area plagued by poverty, unemployment, and high infant mortality. Its leaders have long realized that healthcare involves more than curing diseases and patching wounds. Thus, in 1922, they launched Saint Raphael's Neighborhood Plan, which has five main components. The Neighborhood Reading Room, in a police substation, gives children a place to read, do homework, and get off the streets. The Neighborhood Home Ownership program helps Saint Raphael employees buy homes in the neighborhood. The Neighborhood Scholarships program gives eligible residents an opportunity to study full time at a state university or vocational school. The Neighborhood Career Counseling and Job Skills Assistance program has enabled Saint Raphael to hire 30 neighborhood residents and help others find jobs elsewhere. Reaching beyond its immediate neighborhood, Saint Raphael also operates school-based health centers, clinics for elderly, a mobile clinic for pregnant women and new mothers, a parish nurse program in 21 area churches and congregations, and a home care network. In addition, Saint Raphael is working with the local United Way and other organizations to conduct a community needs assessment; working with Yale University and other organizations to increase neighborhood stability; and operating a program for the early detection of breast and cervical cancer in uninsured and underinsured women. PMID- 10165755 TI - Making quality work for you. PMID- 10165756 TI - Managed care: our ministry obligation to shape change. PMID- 10165757 TI - Who speaks for us? EMS on the national agenda. PMID- 10165758 TI - Ignorance is voluntary misfortune. PMID- 10165759 TI - Battlefield Charlotte: the war over EMS. PMID- 10165760 TI - Managed care and EMS. What's really happening? A managed care expert looks at innovative programs. PMID- 10165761 TI - How good are paramedics at knowing what patients need? PMID- 10165762 TI - Managed care and EMS. What's really happening?. Interview by Lauren Simon Ostrow. PMID- 10165763 TI - Ruling out C-spine injuries in the field. Maine taps medics' spinal skills. PMID- 10165764 TI - From 24 to 12. The benefits of shift modification. PMID- 10165765 TI - Geriatric assessment. Special considerations of the over-65 patient. PMID- 10165766 TI - Don't let a merger spook your employees. PMID- 10165768 TI - Use your HMO profile to your advantage. PMID- 10165767 TI - What I've learned from 135 patient deaths. PMID- 10165769 TI - 12 myths about selling your practice. PMID- 10165770 TI - Taking back health care. New owners drive this group to unionize. PMID- 10165771 TI - Health reform. Clinton, voters agree: take care of kids first. PMID- 10165772 TI - Physician recruitment. More hospitals may draw lightning from Uncle Sam. PMID- 10165773 TI - Getting patients to pay. PMID- 10165774 TI - Winning times for primary-care physicians. PMID- 10165775 TI - Workers' compensation: finding a cure for the silent money eater. PMID- 10165776 TI - An alliance for service. PMID- 10165777 TI - Insights into managed care--operational, legal and actuarial. AB - Understanding the operational, legal and actuarial dimensions of managed care is essential to developing managed care contracts between managed care organizations and individual health care providers or groups such as provider-sponsored organizations or independent practice associations. Operationally, it is important to understand managed care and its trends, emphasizing business issues, knowing your practice and defining acceptable levels of reimbursement and risk. Legally, there are a number of common themes or issues relevant to all managed care contracts, including primary care vs. specialist contracts, services offered, program policies and procedures, utilization review, physician reimbursement and compensation, payment schedule, terms and conditions, term and termination, continuation of care requirements, indemnification, amendment of contract and program policies, and stop-loss insurance. Actuarial issues include membership, geography, age-gender distribution, degree of health care management, local managed care utilization levels, historical utilization levels, health plan benefit design, among others. PMID- 10165778 TI - Success factors of risk based specialty networks. AB - Specialty physicians are feeling the heat from managed care because of shrinking reimbursement, selective paneling and clinical re-engineering. They have felt the need to leverage their influence by developing specialty groups and networks. While each network is unique in its external circumstances, there are several common elements to successful specialty networks, including having a clear network mission, obtaining adequate capitalization, obtaining equity, accepting only a manageable amount of risk, gaining member volume establishing and maintaining payer diversity, being high quality and efficient, developing and using information tools, supporting network efficiencies, allying with other physician organizations, exercising network panel selection and deselection, and empowering physicians with knowledge. PMID- 10165779 TI - Evaluation of the business side of the group practice. AB - Because of the changes and complications affecting the business of health care, medical practices need to evaluate whether or not they are getting the best management for their money. Two options presented in this article are hiring a professional management firm or creating an internal management team. The points to be addressed include evaluating the various professional management firms available, determining the necessary skills for an internal management team, determining the business functions the team or firm will perform, considering the right factors when selecting a legal or accounting firm, and evaluating performance on an ongoing basis. PMID- 10165780 TI - New accounting rules: asset allocation and portfolio management. AB - New accounting rules went into effect at the end of 1995 that are now starting to affect how medical practices must report income from equity and fixed income investments. This article explores the new accounting rules and considers the other factors that help practices determine investment strategies, including desired investment return, comfort with level of risk, appropriate time horizons, liquidity needs and legal restrictions. The author also presents an example that examines the different considerations that may affect an asset allocation decision, including endowments and operating reserve funds. PMID- 10165782 TI - Evaluation and improvement of MGMA/CRAHCA survey operations (Center for Research in Ambulatory Health Care Administration). PMID- 10165781 TI - In search of practice performance data? Call the hospital. AB - Comparative performance data is increasingly being used by hospitals and managed care plans to evaluate physician practices. Outcomes data can also be a valuable tool for continuous improvement within a practice. Administrators need to understand the different categories and sources of physician practice data. Hospitals are a particularly good, yet often underutilized, data resource. Descriptive, financial and clinical information available from hospital systems can be used to compare one physician's performance to norms for specific case types (e.g. DRG's), focus internal review efforts and support managed care marketing and negotiation. Administrators need to identify key hospital contacts, make specific data requests and knowledgeably (and cautiously) interpret the data received. Finally, the administrator plays a crucial role turning data into information: identifying and presenting key findings and insuring that the information is used to the group's competitive advantage. PMID- 10165783 TI - Improving patient access. AB - A patient's ability to get through to, or get in to see, a medical care provider can impact a practice's standing in the community and patient base. Market volume is there for the taking by organizations that can gain a truly differentiated position through service excellence. Medical organizations potentially lose patients for reasons that have nothing to do with actual clinical care; they lose patients because of the experiences those patients must endure to access that care. The dimensions that influence patient access and customer service include telecommunications systems, daily clinic operations, understanding process improvement, provider availability and measurements and standards. PMID- 10165785 TI - The JCAHO/CLIA survey ... a pleasant experience! PMID- 10165784 TI - I didn't have this in mind when I went to medical school. PMID- 10165786 TI - Preparing the lab for the year 2001: workstation consolidation. AB - Laboratories willing to integrate workstation by reorganizing lab space and staffing, advancing ancillary services, and purchasing flexible, high-throughput instrumentation are on the fast track to success as they head toward the 21st century. PMID- 10165787 TI - Reach beyond your grasp. How to make the whole equal more than the sum of its parts. PMID- 10165788 TI - No advice wanted. HHS' new advisory opinion system goes untested. PMID- 10165789 TI - Slow growth in charity care. Rise in uncompensated-care spending slowest since '86. PMID- 10165790 TI - Ohio Blues gives up. Insurer agrees to call off Columbia deal, remove CEO. PMID- 10165791 TI - Plenty of talk, little action. Washington's answer to myriad crises--form a commission--is usually no answer at all. PMID- 10165792 TI - Design and conquer. Larry house's blueprint for MedPartners results in phenomenal growth. PMID- 10165793 TI - Teaching wins out. UC hospitals say indigent care is obstacle to education. PMID- 10165794 TI - Caring for kids at home. Pediatric services continue to shift away from the hospital. PMID- 10165795 TI - PSO tug of war. PMID- 10165796 TI - Incinerators draw fire. Hospitals battle environmentalists over waste burning. PMID- 10165797 TI - The corporate model. Analysts at odds over system's rewards and risks. PMID- 10165798 TI - Uniting to fight for-profits. Five W.Va. hospitals consider creating statewide system. PMID- 10165799 TI - Ariz., Ga. raise scrutiny. New laws will make not-for-profit hospital sales public. PMID- 10165800 TI - Docs hire lobbying guns. Surgeons, specialists try to stall Medicare fee change. PMID- 10165801 TI - 1997 construction & design survey. AB - Managed care might seem to be putting a damper on healthcare construction, but in fact it's one of several industry changes creating opportunities for architectural and design firms. One example of a trend toward making surroundings as pleasant as possible is the west campus expansion at East Texas Medical Center in Tyler (left). Designed and built by Ellerbe Becket and completed in 1995, the project, including a nine-story medical office building, features artwork and rooftop gardens. PMID- 10165802 TI - AHA to address conversion issue. PMID- 10165803 TI - Domestic dispute. Insurers see limited potential in domestic partner benefits. PMID- 10165804 TI - Reining in docs. Tougher accounting rules urged for physician practice management firms. PMID- 10165805 TI - State actions against docs flat. PMID- 10165806 TI - Health care evolution. Or is it? AB - Should we be using evolution as our theory for understanding the radical changes overtaking medicine? Evolution is a theory for explaining changes in biological systems. The power and simplicity of evolutionary theory have made it the major scientific framework for looking at why certain animals and plants dominate ecosystems, and why one species dies out only to be replaced by another. Health care is a socio-economic system--changes occur because of scientific, economic, and political reasons. Using evolutionary jargon and examples can lead us astray. So, why do we often use evolutionary language and ideas and what is a better way of looking at the changes confronting the industry at such a rapid pace? This author finds the answer in dialectic thinking. PMID- 10165807 TI - Attitude adjustment. AB - How can you motivate physicians so that their decisions and behavior reflect what is best for the group practice, instead of themselves or their department? By clearly stating expectations and goals, physicians can learn that the priority must be the success of the group practice. Presented here is an example of how the Orlando Health Care Group (OHCG), a primary care medical group with 85 physicians in four specialties, addressed this challenge and the physicians' positive response to the change. To survive as a group, the OHCG had to abandon old ways of managing conflict and agree upon a list of core values around which it could evaluate all future physician behavior. The list became known as the "10 Commandments." They were meant to give every individual a sense of place and purpose within the group, knowing that the best way for an individual to prosper was to be part of a successful group. PMID- 10165808 TI - The business of education: a new paradigm. AB - Business as usual is not the answer these days. But how do you create a new paradigm for academic educational and research endeavors? There is increasing pressure to separate the costs of providing care to patients from those of educating students and residents. It is evident already that we will not enjoy the flexibility of the past to cross-subsidize the academic effort. Presented here is a case study--a joint venture between Harvard Medical School and Beth Israel HealthCare created to sustain the academic mission, as distinct from its clinical business, and promote innovation in medical education and research through intellectual leadership, dedicated state-of-the-art facilities, and a focused development effort. PMID- 10165809 TI - Paying physicians in advanced managed care markets. AB - Physician compensation in managed care environments has undergone dramatic change over the last five to 10 years. Early goals that originally involved reduction in unit price have been replaced by a variety of variable pay formulas for primary care physicians and specialists alike. Criteria for determining provider variable pay include demonstrable member access, patient satisfaction, and economic performance. Based on emerging trends, physician payment should be modified to include measurements based on productivity and quality of life. PMID- 10165810 TI - Running toward the roar. AB - How do you embrace paradox, changing and growing without losing your sense of who you are? We talked last time about the paradox of reaching for the new, without losing your ground in the old. Paradox is the place of insight. Accepting paradox, not as a momentary distraction but as a place to live, lies at the heart of dealing successfully with change. We can see this most clearly if we ask ourselves, "What business am I in? What am I about?" In health care, this did not used to be a meaningful question. Today, it is a critical one. But to really develop, we have to seek out the situations that are the most difficult for us, work them through, hang out with them long enough to begin to be at home in the paradoxical, ambiguous, and strange circumstance. PMID- 10165811 TI - The new look of office politics. AB - Is a sea change occurring in the organizational politics of health care institutions? How is information informally spread throughout the office? It used to be that gossip was the vehicle by which employees learned much about the organization's culture and news. But now, organizations are characterized by a growing faction of staff who are emotionally detached and have a "day-laborer" mentality. The grapevine is not as effective as it once was. Non-participation includes ignoring the grapevine both as listener and feeder. What implications does this have for your organization? PMID- 10165812 TI - Health care is sales. AB - Health care is all about sales--everyone today in the competitive arena of health care is a salesperson. Your selling days began when you applied to medical school. Your product was yourself, and you worked hard to sell it. That was only the beginning. In your daily work as physician executives, you are selling yourself and your ideas-your ideas about relationships, management structures, partnership issues, merger questions, etc. It's a complicated world, and the concepts are often abstract and difficult. But it is your job to communicate with others to get things done. It is the most important part of your job. It is selling, in fact, at a sophisticated level. How do you communicate and sell yourself and your ideas effectively? Here, some ideas on how to listen and communicate. PMID- 10165813 TI - The microprocessor and medicine. AB - Technology continues to accelerate at an amazing pace. Where have we been, where are we going, and what do these technology enhancements mean to the health care industry? We are entering the era of the personal computer becoming the window to the multimedia digital world of cyberspace. Microprocessors will continue to improve from one generation to the next to make cyberspace as realistic as possible-and with their improving capabilities will come myriad applications for health care services, either not cost-effective, or not even contemplated, until now. As a leader of an organization, one who approves substantial budgets for information technology, you must ask yourself what new products and services these startling technological advances will create. How will they change health and medical care? PMID- 10165814 TI - Which degree should you choose? AB - Which degree should physician executives pursue to enhance their careers--an MBA, MHA, MPH, MS in Administrative Medicine, JD, or other graduate degree? While options abound and the debate continues over which graduate degree physicians preparing for senior management roles in the health field should select, several variables are analyzed in this article that must be considered. Physicians need to be trained to provide leadership in the new, more market-driven environment- their education must focus more on the integration and coordination of clinical and managerial processes. New managerial competencies will be required by the paradigm shift away from simply delivering effective and efficient health services to one that emphasizes improved access, social equity, and particularly on cost containment and quality of care efforts. PMID- 10165815 TI - Breaking the glass ceiling. AB - The glass ceiling is a form of organizational bias and discrimination that prevents qualified professionals from achieving positions of top governance and leadership. This article examines glass ceiling barriers that keep physicians from the upper reaches of management. While these factors apply mainly to women and minority physicians in academia, and are attributable to sexual harassment and discrimination, physicians as a class are frequently denied executive management positions. Such denial results from inadequate preparation for a career in health care administration. Important issues in the professional development of physician executives include mentoring, training and education, administrative experience, and cultural and personality factors. All of those must be considered when making the transition from medicine to management. PMID- 10165816 TI - Center takes hard line with press. The missing infant incident at Columbia Trident Medical Center. AB - When the body of a stillborn infant went missing from the Columbia Trident morgue, the press pounced. The hospital was accused of everything from neglect to a police-protected cover-up. Reporters stopped patients in the parking lot to ask them if they felt safe. Others used the incident to question Columbia's proposed merger with the local university medical center. In response, Columbia Trident initiated a strict policy that prohibits the press from showing up unannounced and stridently protects the rights of patients and employees. The case provokes questions about the role of public relations professionals in an age of sensationalism. When is withholding information justified and when is it an obstruction of justified inquiry? How far is too far for the press? PMID- 10165817 TI - Locals take on Columbia. AB - Smallish Lawrence Memorial Hospital turned down an offer from Columbia/HCA, then found itself in a public relations war with the deep-pocketed competitor. Advertising, letter writing and general rabble rousing helped Lawrence win the first battle, but now the case is in the courts. Marketing 101 was never like this. PMID- 10165818 TI - An anti-Columbia cottage industry begins to emerge. AB - At least two agencies now specialize in helping local hospitals take on larger competitors. See examples of their work and strategies. PMID- 10165819 TI - IDS proves benefits with report card. AB - Everyone says integrated delivery reduces costs while improving quality, but The Health Alliance of Greater Cincinnati sets out to prove it. Its data-filled report for payers takes seriously the new trend in report card marketing. PMID- 10165820 TI - Making it in a 'saturated' market. How the Spence Center wins women's hearts with grass-roots marketing. AB - The Spence Centers, full-service, independent clinics for women, depend on grass roots outreach to cultivate customers and build brand equity. The Centers have garnered national and international press coverage and made enough friends to open a fourth operation. PMID- 10165821 TI - Patients unhappy, AHA/Picker say. AB - The American Hospital Association and The Picker Institute say Americans want more information and empowerment from their providers. Fully one-third of those surveyed by the organizations say they have problems getting answers to important health-related questions. Marketers need to reconsider their own assessments of patient satisfaction and get patients more information. CHESS, a computerized information-distribution package, provides one elegant--and cost-saving--example. PMID- 10165822 TI - Cheshire Medical Center puts wellness on the Web, with a marketing-savvy physician and cute babies. AB - Cheshire Medical Center is devoted to wellness. Unlike many, its physician designed web site reflects its mission and works hand-in-hand with its other marketing communications. Patients love the easy access to information about seminars and prescription drugs, but regional antagonists might soon provide compelling competition. PMID- 10165823 TI - The role of the US Food and Drug Administration's patient information initiative in cost-effective drug therapy. AB - The use of drug and biological products often entails complex risk-benefit deliberations by prescribers. Yet, there is often little or no information shared by prescribers or dispensers with patients about the potential risks and benefits of taking a prescription drug as part of the patient's therapeutic regimen. In 1994, drug-related morbidity and mortality has been estimated to cost $US76.6 billion. The largest component of this cost was associated with patient misadventures with their prescription medications. Industry experts, practitioners, and consumers agree that patients must have some basic information about prescription drugs to adhere successfully to their prescribed drug therapy. Patients today are discharged from hospitals more quickly than in the past and are expected to assume greater responsibility for their own care on discharge. Recently, there has been new and encouraging evidence that a greater percentage of patients are now receiving written information with their prescriptions. Developments in computer technology have made it relatively easy for pharmacies and physicians' offices to store and generate written information for patients. The US Food and Drug Administration (FDA) believes written information should be used to support, enhance and reinforce oral counselling. The FDA also believes that improved patient education will improve adherence to prescribed regimens and will give patients the information they need to make truly informed decisions about the drugs they take, thereby decreasing costly and unnecessary physician visits and hospitalisations. PMID- 10165824 TI - The economics of osteoporosis and its prevention. A review. AB - A systematic review of all published economic evaluations of treatments for the prevention of osteoporosis since 1980 was undertaken. 21 published studies were identified. The majority of the studies were set in the context of the US healthcare system. Non-US studies were heavily influenced by the methodologies of 1 US research group. All studies published before 1990 only considered the use of hormone replacement therapy (HRT) at the menopause for osteoporosis prevention. Since 1990 a number of studies have looked at other therapies as well as HRT in older women. All studies that have made a direct comparison between using HRT at the menopause with HRT in older women have suggested that it is more cost effective to initiate therapy in older non-perimenopausal women. However, there is a paucity of evidence from randomised controlled trials on which to base assumptions on costs and effectiveness. Large randomised trails with hip fracture as the main outcome measure are required to answer key economic and clinical questions. PMID- 10165825 TI - The economics of pharmacotherapy for diabetes mellitus. AB - Diabetes mellitus is a chronic disease that has a major social impact. Proper planning for the management of patients with diabetes mellitus requires consideration of the important costs that diabetes imposes on the health system. Most of the indirect costs (lost productivity as a result of disability, absenteeism, loss of potential productive years of life), are related to diabetic complications, which greatly exceed the rest of the costs, and are also very difficult to classify in a standard manner. Direct costs (pharmacy, hospitalisation, consultations) mostly derive from healthcare strategies that aim to reduce late complications of the condition and maintain day-to-day quality of life. Therefore, it does not seem difficult to estimate pharmaceutical expenditures. The consumption of oral antihyperglycaemic agents, insulin, injection equipment and self-monitoring equipment indicates prescription tendencies and shows the influence on costs, and provides indirect information about the quality of healthcare or patients with diabetes mellitus. Over the last few years, some developed countries have shown a progressive increase in pharmaceutical expenditure on diabetic care, whereas economically depressed countries have experienced a dramatic shortage of basic medicines such as insulin. Considering the increase in consumers, and the international distribution of illnesses, both a hypothetical excess cost (related to consumerism; incurred by the health system and the diabetic population) and an irregular distribution of economic resources are evident. A co-ordinated health plan for patients with diabetes mellitus, involving the collaboration of diabetologists and epidemiologists with the pharmaceutical industry, and appropriate training measures for patients and professionals, would improve pharmacoeconomic efficiency in managing this disorder. PMID- 10165826 TI - An economic evaluation of the use of granulocyte colony-stimulating factor after bone marrow transplantation in children. AB - Studies that have assessed the use of granulocyte colony-stimulating factor (G CSF) following bone marrow transplantation have shown a significantly reduced time to neutrophil recovery with the use of this agent, which may translate into a reduced duration of antimicrobial therapy and hospitalisation. We performed a pharmacoeconomic study evaluating the elective use of G-CSF after bone marrow transplantation in children. 22 consecutive children who underwent bone marrow transplantation and received G-CSF 5 micrograms/kg/day were compared with 18 such children (control group) who did not receive G-CSF. Despite a significant reduction in time to recovery of the absolute neutrophil count (ANC) to > 0.5 x 10(9)/L in G-CSF recipients compared with the control group (14 days vs 20.9 days; p < 0.0001), there was only a trend towards a reduction in the duration of intravenous antimicrobial therapy (14.5 days vs 18.6 days; p = 0.15), and there was no significant difference in the duration of hospitalisation (25.3 days vs 29.8 days). Reasons for prolonged hospitalisation beyond ANC recovery included continued use of total parenteral nutrition, treatment of graft-versus-host disease and treatment of ongoing infection. Overall, the mean total cost for patients receiving G-CSF was Pounds 15001, compared with Pounds 15482 for the control group (1995 values). In conclusion, while there appears to be no benefit in financial terms, the release of a child from strict isolation as a result of early ANC recovery must be taken into consideration. PMID- 10165828 TI - Telemedicine permits overnight dialysis at home. Health care workers watch for problems from office. PMID- 10165827 TI - Terazosin. A pharmacoeconomic evaluation of its use in benign prostatic hyperplasia. AB - Benign prostatic hyperplasia (BPH) is a common disorder in elderly men which carries a substantial economic burden. Urinary symptoms associated with moderate to severe disease can significantly interfere with daily activities and reduce quality of life. Obstruction of urine flow in men with BPH can result from nonmalignant enlargement of the prostate gland (static component of BPH) and from alpha 1 receptor-mediated increased smooth muscle tone of the bladder neck and prostate (dynamic component of BPH). Transurethral resection of the prostate (TURP) is generally very effective and has traditionally been the standard treatment for men with moderate to severe BPH. However, response to therapy with TURP is not universal and the procedure is associated with a number of potential complications. Moreover, many men prefer to avoid or are not suitable candidates for this invasive procedure. Thus, there is an increasing role for less invasive treatment, including drug therapy, in men with moderate to severe BPH. Terazosin is an alpha 1 receptor antagonist which has been shown in placebo-controlled trials to significantly improve American Urology Association (AUA) symptom and quality-of-life scores and symptom problem index ('bother' score), as well as increase peak urinary flow rate, in men with BPH. In a recent large randomised US trial, treatment for 1 year with terazosin titrated to 10 mg/day improved mean AUA symptom score and peak urinary flow rate to a significantly greater extent than finasteride 5 mg/day in men with moderate to severe BPH. The most frequently reported adverse events associated with terazosin include dizziness, asthenia, postural hypotension, somnolence, headache, peripheral oedema, nasal congestion/rhinitis and syncope. Approximately 5% of men with BPH discontinue terazosin because of adverse events. Results of an economic evaluation of terazosin, in which both clinical and economic data were collected prospectively in a randomised placebo-controlled study design, showed similar total direct treatment costs per 1000 patients associated with 1 year of therapy with terazosin ($US3.57 million) and placebo ($US3.78 million) in men with moderate to severe BPH (1992 dollars). The analysis, which was conducted from the perspective of a managed care organisation in the US, demonstrated that the lower medication costs in the placebo group relative to the terazosin group were offset by increased inpatient care costs. Thus, terazosin (titrated to response up to a maximum of 10 mg/day) was significantly more effective than placebo in improving disease-specific symptoms and quality of life, but at a similar overall cost to placebo. Another economic analysis, also conducted from a third-party payer perspective in the US, modelled direct treatment costs associated with terazosin, finasteride and TURP during the first 2 years after initiating therapy in men with moderate to severe BPH. Results of the study favoured terazosin; the private insurance cost per patient undergoing primary treatment with TURP was $US6411, compared with $US2860 with finasteride (45% of the cost of TURP) and $US2422 with terazosin (38% of the cost of TURP). Medicare costs were lower for all 3 treatment groups but the relative comparisons were similar; corresponding costs per patient were $US3874, $US2161 and $US1820 (1992 dollars). A companion break even cost analysis used a hypothetical cohort of men with BPH starting treatment at age 67 years. Private insurance costs associated with terazosin remained lower then those associated with TURP for approximately 15 years (the corresponding break-even point was 10 years for finasteride vs TRUP). Medicare costs associated with terazosin would not exceed those of TURP for approximately 7 years (5.5 years for finasteride vs TURP). In conclusion, a limited number of detailed pharmacoeconomic analysis of terazosin have been conducted to date, although it has not been compared with other a1 receptor antagonists. PMID- 10165829 TI - Medical malpractice liability may cross state lines through telemedicine. PMID- 10165830 TI - New telemedicine law changing insurance reimbursement policies in California. PMID- 10165831 TI - Government--industry--academia team to develop virtual colonoscopy tests. Official outlines goals for clinical trials. PMID- 10165832 TI - TelePath enters phase 2 studies. PMID- 10165833 TI - Distance learning to jump-start Irish rehab program. PMID- 10165834 TI - Video equipment testing: there's more to it than meets the eye. PMID- 10165835 TI - Cream of the crop: 10 outstanding telemedicine programs. PMID- 10165836 TI - Up-and-comers: programs demonstrate top potential. PMID- 10165837 TI - Universities launch new Internet with high-speed backbone. PMID- 10165838 TI - Perspectives. Hybrids take center stage as new phase in cost war looms. PMID- 10165839 TI - Health care equipment management. PMID- 10165840 TI - Unification of the engineering profession. A proposal by the Stage II Policy Group. PMID- 10165842 TI - Recycling, little things often begin environmental push in hospitals. PMID- 10165841 TI - Strategic asset management. PMID- 10165843 TI - Decisions, decisions. AB - A hospital bed in the Intensive Care Unit sits ominously vacant. The family of the patient has just made the gut-wrenching decision to remove the ventilator, and life-support equipment. End-of-Life issues are some of the most common ethical dilemmas that face hospitals every day. But there are a large number of other questions and conflicts that confront hospital personnel. To tackle the issues, many hospitals have formed multi-disciplinary ethics committees to help patients, families and staff approach the really tough problems. PMID- 10165844 TI - AlaONE looks to keep quality of care responsibility on hospitals. PMID- 10165845 TI - Healthcare and the environment. Hospitals search for ways to offset negative effects on the environment. AB - Regulations, accreditation, economics and public outcry are just some of the reasons hospitals are becoming more environmentally conscious. Others just want to do their part to help the environment. Whatever the reason, healthcare organizations seem to be searching for ways to mitigate their effect on the environment. PMID- 10165846 TI - Improving patient flow, patient satisfaction, and productivity with performance budgeting: a case study. AB - This issue of HCMA features a case study based on a quality improvement study conducted in 1996 in a primary care clinic owned and operated by a teaching hospital identified as ABC Hospital. The study was a team effort of the following participants: E. Jeff Ballow, Beatrice L. Bridglall, Javad Ghalamchi, Maria-Elena Hodgson, and Miriam Rodriguez. PMID- 10165847 TI - What about the kids? AIDS strikes thousands of children in the U.S. but they don't always get the latest treatment. PMID- 10165848 TI - Report cards: how relevant are they for patients? AB - Two advocates for providing consumers the information they need to make informed choices among HMOs point out that the data being gathered for purchasers and others steeped in health plan analyses have little meaning for the end user. Foundation for Accountability President David Lansky, Ph.D., and PacifiCare's Vice President of Health Services Sam Ho, M.D., discuss the outcomes information consumers need, the style they need it in and the steps being having taken to ensure they get it. PMID- 10165849 TI - What consumers should be asking about health plans. AB - The Medicare Rights Center has come up with a Top 10 list of questions consumers should ask before enrolling in an HMO. How prepared is your plan to answer these key questions? PMID- 10165850 TI - JCAHO introduces ORYX for outcomes-based accreditation. AB - With ORYX, healthcare organizations will have to report two measures of the quality of care provided 20% of its population. Can we interpret this as evidence of JCAHO's commitment to change? Critics say not yet. PMID- 10165851 TI - HMOs: responding to bad report cards. AB - Differentiating one health plan from another is becoming increasingly difficult. But a plethora of report cards on plans' performance are now available to help purchasers pick and choose managed care for their members. When a health plan receives a low score--or a score lower than its competitors, be it ever so slight -does it respond appropriately? Are leaders adequately following up to determine the significance of the scoring, rectify the problem--and communicate that to purchasers? Is quality improvement an outcome of publishing report cards? TQL spoke with health plan leaders, healthcare consultants and purchasers to find out what some plans are doing--and what many should be doing. PMID- 10165852 TI - Acute coronary artery deficiency treatment process. Managing scarce resources and maintaining a level of service with the help of computer simulation. AB - Surgical treatment can be planned well in advance or arrive in a near emergency. If careful control is not exercised there is always the possibility that patients may suffer as a result. Discrete event simulation is an effective tool which can be used to find the most efficient ways of managing such a service's timetable. Examines the application of a desktop computer simulation package to model the work of a cardiac diagnosis and treatment system. The simulation package suggests how efficiency might be improved by moderating times taken to complete activities and staff and other resources required to perform the activities. Suggests the principles outlined can be readily expanded into a more complex model. PMID- 10165853 TI - Promoting clinical effective practice. Attitudes of fundholding general practitioners to the role of commissioning. AB - Aims to evaluate the acceptability of commissioning to improve clinical effectiveness in secondary care and explore the conditions under which fundholders would be willing to use commissioning in this way. Describes how fundholders in two contrasting districts in North Thames Region were interviewed in 1995-1996. Respondents were selected from a list of all fundholders in the district with few fundholding practices and from lists of fundholders holding contracts with specified hospitals in the district with many fundholders. Interviews were analysed using the constant comparison method of content analysis. All fundholders in the districts were eligible. The sample represented a broad range of fundholders, containing all fundholding waves and large and small practices. Managers and general practitioners from multifunds outside the districts were also interviewed to assess whether they faced different issues from single practice fundholders. Many respondents felt unable to use commissioning to improve clinically effectiveness despite their awareness of the policy. Reasons identified included the problem of agreeing complex commissioning arrangements to reflect clinical issues, and an unwillingness to use fundholding to challenge hospital practice. Respondents from early wave fundholding practices and those with training in critically appraising research literature expressed more readiness to review research evidence, but only a few early wave fundholders said they would consider evidence-based commissioning. Concludes that steps should be taken to educate fundholders in clinical effectiveness and provide appropriate information to them. Also, they must be persuaded that clinical effectiveness is not a politically-driven policy or they will resist it. PMID- 10165855 TI - Beyond the market in public service. AB - Critiques of the implementation of a market in health care have so far concentrated on conceptual, practical and ethical objections, it is not a real market, say the theorists; it is not delivering say the realists; it does not have public consent, say the moralists. Argues, from a more fundamental critique: the implementation of the market confuses means with ends. Problems lie not in the introduction of the market-which, is argued, has served well in breaking up the frozen paradigm of the welfare state-but in seeing it as an end state rather than a transition. Posits that this has left us trapped in a scenario about buildings, about restructuring and about contracts instead of resolving chronic human problems of ill health. Postulates that the issue is not to argue for or against the market, or indeed to set it against the alternative of the old welfare state: rather to ask how to learn from this transitional state and how to create the mixed economy which lies beyond both market and welfare state. Drawing on previous work on professional bureaucracies, markets and networks relocates the primary challenge not in managing the market but in meeting need within the remit of public consent. PMID- 10165854 TI - Managing informed purchasing. A survey of decision makers. AB - As part of an ongoing study developing and evaluating the use of programme budgeting (PB) and marginal analysis (MA) within purchasing organizations, conducts a survey of a health authorities' requirements of a decision-making tool based on PBMA. PB is a management decision-making system. It provides a summary of resource use categorized according to the programme or end product to which it applies. This explicit description of current activities focuses attention on competition for resources among programmes and on the effectiveness of resource use within programmes. MA is an economist's tool to evaluate options for changing the balance of resource use between or within programmes. Finds general support for PBMA techniques, although this waned with the higher functions of the tool. There was consensus that a health authority ought to know fundamentals like, for example, what proportion it spends on tackling coronary heart disease; and a majority view that PB will assist in revealing the key margins for service review. PMID- 10165856 TI - Seven women GPs' perceptions of their stresses and the impact of these on their private and professional lives. AB - Explores the stresses of seven women GPs and the impact of these on their work and home life. It is a qualitative study which uses a free flowing interview approach. The aim is to reflect the perceptions of these women GPs rather than the assumptions of the researcher. It is an in-depth investigation which gives some insights into the lives of these women doctors working as general practitioners. It adds to the knowledge and understanding of the stresses of GPs in general and women GPs in particular. PMID- 10165857 TI - Making the connection: far from a central hospital, network access is critical. PMID- 10165858 TI - How "WebCare" is changing health care delivery, hit by hit. PMID- 10165859 TI - Migration to client-server transforms the role of once-mighty mainframes. PMID- 10165860 TI - What works. Restructuring and an opportunity to integrate financial applications. PMID- 10165861 TI - What works. Children's Hospital ER automates records to save lives and money. PMID- 10165862 TI - What works. Imaging saves Pascack Valley Hospital $200,000 a year ... not counting paper. PMID- 10165863 TI - What works. In a solo physician's office, CPR results in more information, new energy. PMID- 10165864 TI - HotList. Ambulatory systems: trying to balance clinical, delivery needs. PMID- 10165865 TI - Taking control of workflow with business office EDI. PMID- 10165866 TI - Infrastructure is the key to HIN reality. PMID- 10165867 TI - Treatment termination in long-term care: what about the physician? What about the family? PMID- 10165868 TI - Caregiver safety. PMID- 10165869 TI - Commentary ... managed care and physician-assisted suicide by default. PMID- 10165870 TI - Appropriateness of total hip replacement in the United Kingdom. AB - The paper discusses the use of consensus models in determining the application of Total Hip Replacement surgery. The paper notes the wide national and international variation in use of this procedure but considers it in the broader context of reaching consensus on other surgical interventions. PMID- 10165871 TI - Disseminating information about effective clinical care. AB - The article calls for use of rigorous scientific evidence as the basis for decision making in healthcare. The author links this concept with the growth of evidence-Based Medicine communications through internet systems. He supports the development of the Cochrane Collaboration as a basis for communication of new findings relating to the cost and benefit of medical procedures. PMID- 10165872 TI - Hospital-based technology assessment programmes: two Canadian examples. AB - Interest in Health Technology Assessment (HTA) has grown considerably in recent years. Organizations established specifically to conduct HTA and disseminate HTA results have sprung up in many countries. These have been, to a large extent, financed by governments. However, the relevance of HTA clearly goes beyond governments, and there are many sectors in health care that are potential consumers of HTA information. In particular, those running healthcare facilities are constantly faced with decisions on new equipment to purchase and new clinical procedures to offer. HTA is important not just to the senior administrators of such facilities but those in other levels of hospital management as well. In this paper, a brief review of Canadian and US studies on hospitals' technology assessment and acquisition is presented. Two specific examples of Canadian healthcare facilities and how HTA has been addressed in these institutions are discussed. Finally, this paper contains a discussion of some of the practical issues involved in introducing a formalized programme of HTA in hospitals. PMID- 10165873 TI - The politics of implementing intersectoral policies for primary health care development: experience and lessons from Tanzania. AB - The paper reviews the initiatives made by the Government of Tanzania to develop intersectoral collaboration for the implementation of Primary Health Care(PHC). It explains why there has been little in those directions. A number of shortcomings were identified during the different phases of PHC implementation, these include: misconception of PHC by the MoH as PHC was paradoxically initiated in the MoH (national level) as a vertical programme alongside other vertical programmes which were not coordinated, formation of the PHC coordinating committees alongside development committees existing at village, district and regional levels gave rise to unnecessary multiplication of committees at these levels: a tendency by the MoH to refrain from implementing its past decisions such as dropping the formation of a National Health Council to guide the PHC oriented policy formulation process at national level; weakening the national level coordinating mechanism by lack of political legitimacy it deserves; and inadequate legal mechanisms proposed in the 1983 PHC guidelines to back up PHC implementation which were made in reference to only the village level PHC committee. Experience of implementing PHC in Tanzania highlights the point that intersectoral collaboration is not simply a technical issue but as influenced by socio-political factors. This article has raised a number of issues which have to be noted in order to improve intersectoral collaboration in Tanzania. First, is the need to place PHC on Tanzania's political agenda. This may taken time but it is a necessary exercise to undertake. Second, effective mechanisms to foster policy coordination at national level should be developed. Third, intersectoral coordination processes at national level should guide similar processes at subnational levels. Fourth, is always to be aware of an counteract the problems presented by the medical model in health programmes implementation processes. PMID- 10165875 TI - National Practitioner Data Bank: change in user fee--HRSA. Notice. PMID- 10165874 TI - Hospital design--the end of history? AB - The paper considers societal and technology changes which are causing us to rethink hospital design. It calls for technology decentralisation and bed flexibility to allow for seasonal and severity patient beds. The authors conclude that is not the end of the hospital but the beginning of an exciting new era. PMID- 10165876 TI - The Internet's impact on EDI. AB - Explosive growth of the Internet in a number of industries has created an information distribution channel that is likely to alter and leverage every aspect of electronic commerce. With the levels of IS integration and technological innovations in development in healthcare today, it is not unreasonable to predict that this industry soon will be similarly driven. PMID- 10165877 TI - Document imaging improves care with less management. PMID- 10165878 TI - The big squeeze. Mergers and acquisitions. PMID- 10165880 TI - Remedy register. Fourth annual managed care information systems update. PMID- 10165879 TI - Taking aim at healthcare's moving target. AB - The healthcare market has been in a state of continual transition for the last several years. In response, IT vendors are developing technologies specifically for managed care. Some of these new technologies are beginning to play a more prominent role in addressing some of managed care's specific needs, such as cutting costs and providing outcomes information under capitation. PMID- 10165881 TI - IS challenges in the move to capitation. PMID- 10165882 TI - Millennium management. Strategies for managing 21st century health care organizations. PMID- 10165883 TI - The ecology of health care. Time to take a stand on the environment. PMID- 10165884 TI - Ten new rules. Processes, pathways, and strategies for managing the future. PMID- 10165885 TI - ProPAC recommends a bundled Medicare payment for post acute care. PMID- 10165886 TI - Assistant U.S. Attorney considers fraud charges against hospital-based SNFs. PMID- 10165887 TI - OSHA begins inspections under its nursing home safety initiative. PMID- 10165888 TI - Joint Commission to require outcomes data from accredited organizations. PMID- 10165889 TI - Camden County Health Services Center, Blackwood, NJ. PMID- 10165890 TI - Private finance. The PFI jungle. PMID- 10165891 TI - Private finance/going live. Eastern promise. PMID- 10165892 TI - Private finance/guide. Reality check. PMID- 10165893 TI - Private finance/politics. Flexible friends. PMID- 10165894 TI - Private finance/IT. The IT pearls. PMID- 10165895 TI - Private finance/primary care. Niche opportunity. PMID- 10165896 TI - Management development. How to grow leaders. PMID- 10165897 TI - Admissions wards. Admitting a need for change. PMID- 10165898 TI - Patients' willingness to pay for autologous blood donation. AB - Most cost-effectiveness analyses of autologous blood donation show very small health benefits for a substantial increase in resource utilization. However, these analyses do not consider the psychological benefits of peace of mind to patients participating in the program. In order to quantitate these benefits, we employed contingent valuation methodology to measure the willingness of patients undergoing elective surgery, to pay for autologous blood donation. The internal consistency of patient responses was investigated through correlations of willingness-to-pay values with risk perceptions and patient characteristics. Two hundred and thirty-five patients completed the self-administered questionnaire which included demographic, willingness-to-pay and risk perception questions. Median population willingness to pay for autologous blood donation was approximately $900 per patient. In multivariate analysis, willingness to pay varied significantly with dread of allogenic transfusion, perceived risk of requiring a blood transfusion and income. Patients who participate in autologous blood donation programs value the procedure highly and state they are willing to pay significant amounts out of pocket to assure themselves of available autologous blood. Willingness to pay correlated significantly with factors expected to influence value decisions. PMID- 10165899 TI - Future health scenarios as a tool in the surveillance of unintentional injuries. AB - Health policy needs effective public health surveillance systems. In order to support injury control in the Netherlands we established a surveillance system which monitors trends in the epidemiology of injuries due to traffic accidents, occupational accidents and home and leisure accidents. We introduced the combination of traditional monitoring methods with a new tool: the use of future health scenarios. Trends in the epidemiology of injuries since 1985 were compared with observations from the preceding period (1970-1985) and to future health scenarios (1985-2000). These scenarios were based on the opinions of 80 Dutch experts, which had been collected with the help of a Delphi-study. We identified interruptions of the actual injury mortality trends in the Netherlands. In the second half of the 1980s the rapidly declining injury mortality trends of the period 1970-1985 slowed down (traffic accidents), slightly reversed (occupational accidents) or stabilised (home and leisure accidents). The transitions into less favourable developments were already foreseen by Dutch experts. The future health scenarios appear to have added value for health policy. They offer a well-defined conceptual framework for monitoring and facilitate the early detection of trend interruptions. Moreover, they provide information on the most likely future development and on the feasibility of health policy goals. The results of our study show that health policy goals of the Dutch government will not be reached and that new initiatives in injury control are needed. PMID- 10165900 TI - Evaluation of provision and availability of health care services in Iran: a human rights approach. AB - In this review article, we have attempted to illustrate the provision and availability of health care services in Iran using a human rights approach. First and foremost, we should emphasize that we have not come across any text which endeavours to address holistically the aforesaid issue in the context of Iran. It appears to us to be a very complex issue and in order to satisfactorily address this issue, we have argued some of its various associated aspects. Basically, we believe that the right to health care should be a human right, but whether this right should be to basic care or comprehensive care, whether legally enforceable or not, are issues which are political and must echo the socio-political climate and resources of a particular country. However, this deliberation may be of vital importance in the development and nurturing of the health care services sector of a country; in determining the attitudes associated with the dynamics of the various sub-system/sub-process components, and finally the actual access and availability of health care to its citizens. Our own views are given in this text when appropriate. PMID- 10165901 TI - Does budget-holding have a long-term effect on expenditure, staff and patients? AB - Kupat Holim Clalit (KHC), Israel's largest sick fund, initiated a unique demonstration program to transform primary care clinics into autonomous budget holding units. The program was accompanied by an evaluation study that examined the influence of the program on clinic staff, level of expenditure, quality of service and patient satisfaction. Few studies have empirically examined the influence of a budget-holding program in relation to such a wide range of expected outcomes. A longitudinal study was conducted from 1991 to 1994 employing two methodologies: (a) a controlled case study of one experimental and one control clinic and (b) monitoring of all nine budget-holding clinics over time, compared to other clinics in the district. Multiple research tools were used: staff surveys, patient surveys, in-depth interviews, and analysis of financial data. The findings indicate that the budget-holding program has the potential to achieve cost containment without injuring staff morale, the service to patients or patient satisfaction. However, the KHC program did not lead to the expected improvement in staff motivation and attitudes, clinic services and clinic responsiveness to patients' needs. Implications for the literature on organization and management and for organizations considering the implementation of budget-holding programs are discussed. PMID- 10165902 TI - After compulsory licensing: coming issues in Canadian pharmaceutical policy and politics. AB - Bills C-22 and C-91 eliminated compulsory licensing for pharmaceutical products in Canada. However, in the wake of these bills there are pressing issues of pharmaceutical policy that need to be decided. The value of additional spending in pharmaceutical R and D has yet to be evaluated. There needs to be a public debate about how far government policy should go in encouraging pharmaceutical R and D as opposed to investing resources in other areas. There has been a continuing escalation in the cost of the average prescription, due to the introduction of newer, but not necessarily more effective, medications. So far government has not been willing to commit resources to promote cost-effective prescribing. Pharmaceutical companies are now lobbying for more rapid approval of products and an extension to the normal patent period to make up for the time that drugs spend in the regulatory process. The process that the government uses to resolve these issues will be just as important as the ultimate decisions. PMID- 10165903 TI - You can thrive under managed care. PMID- 10165904 TI - How low can fees go? PMID- 10165905 TI - Will the big, bad antitrust wolf blow your IPA down? PMID- 10165906 TI - Preparing your practice for capitation. PMID- 10165907 TI - Don't miss out on Medicare managed care. PMID- 10165908 TI - What it takes for big groups to succeed. PMID- 10165909 TI - What it takes for small practices to succeed. PMID- 10165910 TI - Creating personality. To market your organization effectively, differentiate it from competitors. PMID- 10165912 TI - Caught in the tide. Not-for-profit Kaiser rides the HMO merger wave, too. PMID- 10165911 TI - The big wave. Wall St. loves managed-care mergers, but selling patients and providers on the deal isn't always a smooth ride. AB - Managed-care companies have caught a big merger wave, winning applause from Wall Street and some analysts who say the deals offer great financial potential. But others, including consumer groups and some providers, say the health plans could be surfing toward a spill. Critics question the tactics the companies are using and contend the firms are serving the short-term demands of the financial community but aren't helping their long-term business. PMID- 10165913 TI - A fuzzy picture. So far, high start-up costs, low volume make teleconsults pricey. PMID- 10165914 TI - What about the uninsured? Achieving universal coverage no longer a burning issue. PMID- 10165915 TI - First scandal, now this. Fight looms as Calif. teaching facility plans for-profit affiliation. PMID- 10165916 TI - Care from a distance. Web sites, video, e-mail have growing treatment roles. PMID- 10165917 TI - Audacious in Milwaukee. Aurora Health Care uses sharp elbows to change market. PMID- 10165918 TI - Another thorn for Columbia. PMID- 10165919 TI - HMOs enter Internet age. Plans begin electronic interaction with enrollees. PMID- 10165920 TI - Community benefit. Partnership feeds capital-starved health centers. PMID- 10165921 TI - Columbia's storm builds. PMID- 10165922 TI - Risks of risk-sharing. Survey gives hospitals a guide on pitfalls to avoid. PMID- 10165923 TI - Boston hospital wants in. Shut-out teaching facility seeks entrance to major HMO. PMID- 10165924 TI - Nursing home group wary of PSO measure. PMID- 10165925 TI - NCQA's road map. Health plans given timeline for info system upgrades. PMID- 10165926 TI - Managed indigent care. Ind. county latest to coordinate health services to poor. PMID- 10165927 TI - Social problem. Small Calif. HMO fears conversion makes it a target. PMID- 10165928 TI - SEIU targets Columbia. Union uses El Paso raid as basis for attack on chain's patient-care record. PMID- 10165929 TI - Hospital CEO turnover by state. PMID- 10165930 TI - Capping therapy pay. HCFA proposes 'salary equivalency' as funding basis. PMID- 10165931 TI - Kaiser probed. Deaths of 4 patients at hospital prompt investigation. PMID- 10165932 TI - Psychological break. Split on 'rights' highlights fight over managed care. PMID- 10165933 TI - Alta Bates in limbo. Berkeley's about-face endangers obstetrics expansion. PMID- 10165934 TI - Anti-fraud agency expanding. PMID- 10165935 TI - Broadly written 'gag clause' bill faces opposition. PMID- 10165936 TI - Fighting TB: a second chance to do it right. PMID- 10165937 TI - The effect of the proposed national data protection regime on the health sector in Australia. AB - The Commonwealth Government and a number of State governments are proposing to introduce legislation based on the Information Privacy Principles contained in the Privacy Act 1988 (Cwlth). This will allow individuals access to any personal information held on them by an organisation or person, including private practitioners, private health facilities and State government agencies. This article discusses this proposed legislation and its implications for the health sector. Although in the public health area patients can already gain access to their medical records through the use of the various Freedom of Information Acts and, in the case of Commonwealth government agencies, the Privacy Act 1988 (Cwlth), the proposed data protection legislation will provide more than access rights to individuals. The effect of the proposed legislation on the private sector, where no obligation exists on the part of the doctor to grant a patient access to his or her records, will be substantial. PMID- 10165938 TI - The Balmain Hospital General Practice Casualty: an alternative model of primary health care provision. AB - The Balmain Hospital General Practice Casualty is a unique casualty style service, staffed and run by local general practitioners. It is a joint initiative of the Central Sydney Area Health Service and the Division of General Practice, Central Sydney Area, and is jointly funded by the Area Health Service and the Commonwealth. The casemix seen and type of services provided suggest that the service is intermediate between that provided by general practitioners and that provided by emergency departments. The service is well accepted by patients and local general practitioners. A number of benefits are seen by both service providers and users in terms of continuity of care and increased general practitioner skills. PMID- 10165939 TI - Hospital leadership for quality: theory and practice: II. Quality performance evaluation. AB - Hospitals need excellent leadership to be efficient in the use of scarce stakeholder resources and to be effective in the competitive provision of services to multiple customers. This paper is the second report on a study conducted with cooperation of the executive team at a large government-funded hospital in Brisbane, Australia. The overall study focused on linking the leadership concepts and attributes of the members of the executive with an overall evaluation of quality practice in the hospital. The first paper reported the leadership results. This paper reports the quality practice and its links with leadership. The study revealed use of data, understanding of processes and the formation of supplier partnerships as the areas of hospital activity most limiting the ability to improve. Little impact of leadership attributes was found, contrary to studies conducted elsewhere. This may be due to the strong influence of different professional groups within the hospital, since domains of leadership influence largely coincided with these groups. PMID- 10165940 TI - Using partner hospitals in collaborative benchmarking.. AB - In May 1994 the Physiotherapy Department at John Hunter Hospital received a Commonwealth Best Practice in the Health Sector grant to design a critical pathway for the treatment of stroke. The implementation of the pathway at John Hunter Hospital and the introduction of the methodology to secondary sites (The Alfred Healthcare Group, Melbourne, and Royal Hobart & Repatriation General Hospitals, Hobart) resulted in the development of a Benchmarking Consortium. This paper will discuss the importance of benchmarking in understanding clinical processes, and the methodology employed to ensure that meaningful benchmarks were achieved. PMID- 10165941 TI - The research and educational priorities of rural occupational therapists. AB - The aim of this pilot research project was to identify the research and educational priorities of occupational therapists practising in rural New South Wales. Eight participants were recruited in the south-western region of the State. The Delphi technique was used to obtain the most reliable consensus of the research participants. Priorities emerged in four designated areas: (1) research that would be of value to clients; (2) research that would be of value in providing community care for clients; (3) research that would be of value in facilitating health promotion and disease prevention; and (4) research that would be of value to professional and educational needs. In the final phase of the study, 23 high priorities were identified. The findings of the study suggest directions for research and continuing education in occupational therapy which may benefit rural practitioners and their clients. PMID- 10165942 TI - Strengthening health promotion in Australian workplaces. AB - The Australian workplace has emerged as an important venue for influencing the health of employees through regulations and behaviour change programs. Recent surveys have highlighted a growth in this activity but the effectiveness of these programs in changing unhealthy work practices and policies is questionable. The need for strengthening programs by stronger designs and evaluation, and addressing organisational factors and employee participation in planning and implementation processes is documented. Efforts in that direction in Queensland are cited, Building on these existing foundations, redirecting existing resources, and building intersectoral cooperation in public-private partnerships hold a creative, exemplary vision of the future for Australian workplace programming. PMID- 10165943 TI - Bioethics: a balancing of concerns in context. AB - Ethics is a philosophical approach which is increasingly being used to identify acceptable behaviour in a health context. Bioethics has emerged as a term for ethics in health and medical contexts. Bioethics is about the application of reasoning to a health context. It relies on the people in each context to reflect on ethics concerns, and to make acceptable decisions on how to behave. This paper canvasses current concerns in bioethics, and demonstrates the essential features of context, and players in the context, in ethical discussion. PMID- 10165944 TI - Managing the gap: balancing advances in technology with advances in management practice. AB - Expenditure on information systems is widely anticipated to lead to improved management of health care resources. Despite large investments in hardware and software, these expectations are difficult to realise. Part of the difficulty lies in the manner in which information systems are applied to, rather than integrated within, organisations. This paper considers some of the the personal and organisational issues that need to be addressed to 'manage the gap' in balancing advances in information technology with advances in management practice. The issues identified are consistent with the concept of a learning organisation dealing with environmental change. PMID- 10165945 TI - Utilisation of Australian health care services by ethnic Chinese. AB - Australia is a multicultural society in which migrants from non-English-speaking backgrounds may be more vulnerable to illness after their new settlement, and language difficulties and cultural differences may affect their use of health services. The present qualitative study used focus group interviews to explore the health services used by Chinese migrants from Hong Kong and China. The general findings included strong preference for Chinese-speaking general practitioners, insufficient interpreter services, low use of preventive services, and lack of knowledge about the existence and role of ethnic health workers. The paper reports specific differences between migrants from China and Hong Kong, and by age group. It discusses reasons for these findings and notes the implications. PMID- 10165946 TI - The effect of age and chronicity on patient recall of public hospital outpatient clinic use. AB - This paper reports on an investigation of the effect of age and chronicity on the accuracy of recall by allied health patients of their attendance at outpatient clinics at a public hospital over the previous 12 months. Patients consistently under-reported use of outpatient clinics, when compared with hospital records. Age and chronicity were not found to be determinants of the observed differences. Other potential influences on patient recall were identified to assist future testing. PMID- 10165947 TI - The quiet revolution: reporting of health outcomes in general medical journals. AB - This study reviews the extent of evaluation of health outcomes in three general medical journals over the past decade by examining papers published in the original research section of the New England Journal of Medicine (NEJM), The Lancet, and the Medical Journal of Australia (MJA) in 1982 and 1992. Evaluations were identified and classified according to the type of comparison group and the type of outcome measures employed. They were divided into three categories: those employing a comparison group; those employing a before-and-after study design (or own comparison group); and those with no comparison group. The categories of outcome measures were mortality, clinical or intermediate measures of health state, and final outcome measures (quality of life). Results show that the proportion of papers evaluating a health services intervention remained stable over the period. However, the MJA published considerably fewer evaluations than the other journals. In the NEJM and The Lancet, 75 per cent of evaluations incorporated comparison groups, in the MJA, less than 40 per cent. Overall, the proportion of papers reporting final outcome measures increased significantly between 1982 and 1992 (p = 0.04) but the change in each journal individually did not reach statistical significance. This study indicates that the reporting of health outcomes evaluations has remained constant but there has been some change in the use of comparison groups and final outcome measures over time. PMID- 10165948 TI - Fetal lung maturity assessment by thin layer chromatography: the need for good laboratory practices and training. PMID- 10165949 TI - Gerontechnology. The aging of rehabilitation. PMID- 10165950 TI - CTDs: the payor's perspective. PMID- 10165951 TI - Diabetes and rehab. PMID- 10165952 TI - Diabetes and rehab. Treating the diabetic foot. PMID- 10165953 TI - The impact of age on the quality of life in persons with HIV infection. AB - The authors administered the Medical Outcomes Study (MOS 20) Short Form Health Survey to 369 persons with HIV disease. The MOS survey measures six domains of health: physical function, role function, social function, mental health, health perception, and pain. Additional data included sociodemographics, HIV risk group, time since HIV diagnosis, symptoms (dyspnea, diarrhea, fever, chills, sweats, weight loss, weakness, numbness, memory trouble, seizures), and CD4 lymphocyte count within 3 months of the MOS survey. Bivariate analyses revealed worse MOS scores associated with older age in five health domains: physical function (p less than .01), health perception (p <.10), role function (n.s.), social function (n.s.), and mental health (n.s.). Older subjects reported less pain. When controlling for CD4 count and for sociodemographic and clinical variables, older age was significantly (p less than .05) associated with worse MOS scores in physical function, social function, and health perception, nonsignificantly associated with worse MOS scores in role function and mental health, and nonsignificantly associated with less reporting of pain. PMID- 10165954 TI - Symptom reporting during physician consultation. Results of a health diary study. AB - Most studies of physician consultation focus on decisions to contact health care providers. In this article, the authors examine decisions regarding which symptoms to report once people contact physicians. Data for the analysis were gathered through interviews and health diaries completed by a probability sample of 667 elderly people, based on a subsample of 152 respondents who consulted physicians during the 3-week reporting period. A qualitative analysis produced behavioral patterns underlying decisions to report some but not other symptoms experienced on the day of physician contact. Logistic regression was used to explore the extent to which predispositions of individuals that precede the onset of symptoms and the type of symptom experience explain the distribution of these reporting patterns. Variation in the percentages of people reporting particular symptoms indicates that these reporting patterns cannot be explained solely by the type of symptoms people experience. The decisions regarding which symptoms to report reflect respondents' attribution of cause, the impact of symptoms on their daily lives, and the broader health and social context in which they confront particular symptoms. PMID- 10165955 TI - Cognitive impairment, caregiver burden, and the utilization of home health services. AB - This study addresses the relationship between caregiver burden and the use of home health services among older adults with cognitive impairment. Analyses draw on data from personal interviews conducted with 327 older adults with cognitive impairment and living in the community of their primary caregivers. Using the Andersen-Newman framework, the results of ordinary least squares and logistic regression analyses reveal that caregiver burden and formal home health service use are only weakly related. Possible explanations for the findings are discussed. PMID- 10165956 TI - Changes in functional ability from ages 70 to 75. A Danish longitudinal study. AB - The purpose of this article is (a) to describe changes in functional ability from the age of 70 to 75 years, (b) to examine whether a new functional ability measure is a good predictor of dependency, and (c) to examine whether sociodemographic factors are associated with transitions. The investigation is part of the longitudinal study of the 1914 population in Glostrup, Denmark, and comprised 576 men and women who were interviewed in their homes about functional ability, social situation, and so forth when they were 70 and 75 years old. Tiredness in mobility and daily activities measured by two functional ability scales at age 70 were independent predictors of need for help in mobility and daily activities at age 75. Among the sociodemographic variables, education among women and income among men were found to be independent predictors of dependency at age 75. PMID- 10165957 TI - Perceived health and functional status among spouse caregivers of frail older persons. AB - This national interview study examined the health impact of caring for frail elders in a sample of 437 spouse caregivers. The principal findings were that (a) caregiver emotional strain was the strongest common predictor of both poor perceived health and functional limitations, (b) wife caregivers' poor health was associated with care recipients' perceived unmet needs and increased depression, (c) husband caregivers' poor health status was predicted by longer caregiving duration, and (d) non-White wife caregivers reported poorer perceived health than did their White counterparts. PMID- 10165959 TI - Policy watch: Medicare. AB - Public policies are often made without much recourse to economic reasoning. Economists are sometimes unaware of what is happening in the world of public affairs. As a result, both the quality of public decision making and the role that economists play in it are less than optimal. This feature contains short articles on topics that are currently on the agendas of policymakers, thus illustrating the role of economic analysis in illuminating current debates. Suggestions for future columns and comments on past ones should be sent to Daniel Weinberg, c/o Journal of Economic Perspectives, HHES Division, Bureau of the Census, Department of Commerce, Washington, D.C. 20233. PMID- 10165958 TI - Attitudes toward age-based health care rationing. A qualitative assessment. AB - This study is designed to contribute to recent efforts to assess public views on age-based rationing of health care by reporting findings from a qualitative research project using focus group interviews. Group interviews find that respondents are concerned about the high costs of health care, but few attribute these costs to overuse by older people. Respondents reject the notion of specific policies limiting health care based on the age of the patient. Respondents of all ages tend to reject the idea of paying for treatment to extend the life of the hopelessly ill when all beneficial treatment efforts have been attempted. Although expressing strong feelings about equality of opportunity for health care, respondents are ambivalent about the role that government should play to accomplish this goal. Differences in attitudes toward allocation of health care appear to be associated more with differences in socioeconomic status and political orientation than with differences in age of respondents. PMID- 10165960 TI - A phenomenological alternative to the "ADL research tradition". AB - Since the development of the Index of Independence in Activities of Daily Living, ADL tools have been used to describe older persons' status and to predict outcomes. It is suggested that this approach is grounded in an ADL research tradition. An alternative that is based upon Husserl's phenomenology is proposed. A phenomenological study of older widows' lived experience is described. Distinctions between phenomenological inquiry and the ADL research tradition are addressed in terms of focus (tasks vs. lived experience) and interpretation of key terms such as independence. PMID- 10165961 TI - Living with an impaired elderly person: the informal caregiver's physical and mental health. AB - Although it is acknowledged that providing an elderly relative with informal assistance can be stressful and burdensome, previous research does not provide clear evidence of the impact of informal caregiving on the physical and mental health of caregivers. The objective of this research was to compare health indicators of coresidents of elderly people who have physical or cognitive impairments with those of two comparison groups: individuals living with a nonimpaired person aged 55 or over and individuals who were not living with a person of that age. Samples were drawn from the Qu/ebec Health Survey database. Although very few differences in physical health were observed between coresidents (n = 292) and individuals in the comparison groups, coresidents systematically presented poorer psychological health indicators. This result supports previous findings related to the low level of psychological well-being of informal caregivers. This suggests that informal caregivers should be regarded as a target population for which health and social services should be carefully planned. PMID- 10165962 TI - The structure of physical health status. Comparing proxies and self-respondents. AB - Because gerontological studies often need to rely on the use of proxy respondents, the comparability of proxy and self-respondents is of particular interest. However, it is often impossible to evaluate response agreement between proxy and self-respondents because the necessary data are not available. This study addresses the problem by using a model of health status to evaluate differences between proxy and self-respondents regarding the conceptualization of health status. The model included three dimensions of physical health: chronic illness, functional limitations, and subjective health. Three groups of respondents who differ regarding proxy status and/or physical health status were compared. A subset of matched self-respondents (n = 146) was selected to be comparable in objective health status to respondents who have proxies (n = 140). The third group consisted of physically healthier self-respondents (n = 1,425). Data came from the Study of Well-Being of Older People in Cleveland, OH. No support was found for the expectation that proxies and self-respondents would weight objective health information differently when providing summary statements of subjective health. The results suggest that proxies rely on a conceptualization similar to self-respondents when providing information about another person's health. PMID- 10165963 TI - Readiness of older adults to stop smoking in a televised intervention. AB - Smokers aged 60 and older who enrolled in a televised smoking cessation program were compared with older smokers in the target population, using data from telephone interviews. Multiple logistic regressions identified factors that differentiated older smokers at various stages of readiness to quit. Within the target population, smokers planning to quit someday (N = 238) were more likely to have had greater concern about health effects of smoking and perceived a stronger desire by others for them to quit than smokers with no such plan (N = 127). Compared with older smokers in the target population who were planning to quit someday, program registrants (N = 95) perceived greater severity of lung cancer, had greater concern about the health effects of smoking, perceived greater reduction of lung cancer risk from quitting, and had more determination to quit. These findings indicate important factors according to the stage in the smoking cessation process that must be considered when intervening with older smokers. PMID- 10165964 TI - Resident selection in a Connecticut nursing home. A view from within. AB - Using data from a year of participant observation, this study provides a detailed description of resident selection procedures in a for-profit Connecticut skilled nursing facility. A system of multiple payers for nursing home services created a hierarchy of admission preferences that privileged those who could pay and denied access to the least profitable and the sickest individuals. Prescreening and waiting list juggling were strategies employed by the home to maximize the selection of private-paying residents and residents requiring the least care. PMID- 10165965 TI - Physical performance and physical self-efficacy in the elderly. A pilot study. AB - This study examined the relationship between physical performance and physical self-efficacy beliefs in older adults. It was hypothesized that subjects who perform better on physical tasks would show more positive beliefs of physical self-efficacy. Information was obtained from 124 subjects (61 men and 63 women) aged 55 to 85 years. Tests of mobility, strength, and dexterity were administered, as well as a self-report questionnaire of physical self-efficacy. Although most physical performance indexes were observed to be at lower levels after 75 years of age, physical self-efficacy beliefs in women did not show this pattern if the drop in physical performance was relatively small. Male subjects in the age group of 75 years and older however, showed substantial lower levels of performance in most of the tests, which was associated with more negative beliefs of physical self-efficacy. This was corroborated by multiple regression analyses, showing that sex was a significant predictor of physical self-efficacy beliefs in most performance tests. This prediction was moderated by age such that older men had more negative beliefs of physical self-efficacy than older women. PMID- 10165966 TI - Are educational differentials in adult mortality increasing in the United States? AB - Two recent studies have compared the size of educational mortality differentials among adults in the 1980s to estimates for 1960. Both studies have concluded that educational differentials have increased for males. One study finds a similar increase for females. We reconsider this question by introducing a data source that is better suited to estimating recent differentials than either of the two that have been employed. We also evaluate the quality of the 1960 baseline estimates and introduce broader measures of inequality. We conclude that educational inequalities have widened for males but contracted for working age females. For both sexes, inequality trends are more adverse for persons aged 65+ than for persons aged 25-64. The role of national health insurance in shaping these trends is briefly considered. PMID- 10165967 TI - The everyday impacts of providing informal care to dependent elders and their consequences for the care recipients. AB - Longitudinal data were used to identify the relationship between different areas of negative impact and elder and caregiver characteristics. The extent and predictors of persistence and development of negative impact in different areas and the relationship between caregiving impact and subsequent caregiving patterns, including termination of care and institutionalization of the elder, were also examined. Caregiving exerted the greatest toll on a caregiver's personal life reported by 61%, in comparison to family life (18%), or employment (15%-20%). Those at particular risk of negative impact included offspring and other-relative caregivers who resided with the elder. All areas of negative impact persisted over time but did not result in any major disruption in care for the elder. However, those elders whose caregivers experienced personal impact were twice as likely to be institutionalized. PMID- 10165968 TI - Mammography interventions for 65- to 74-year-old HMO women. Program effectiveness and predictors of use. AB - This study evaluated the impact of two interventions designed to encourage mammography use among HMO women aged 65-74 who had not had a mammogram within the past year and had not used their referral for a free mammogram. Ninety days after the referral mailing, women were randomized to receive (a) a survey, (b) a survey in addition to telephone mammography counseling, or (c) a survey, telephone counseling, and a letter. Follow-up data indicated that only 13% of control group women compared to 27% who received phone counseling and 32% who received counseling and a letter obtained a mammogram within 120 days following the baseline survey and/or intervention. Results of the logistic regression analysis indicated that having received either of the interventions, mammography history, access ease, breast cancer/mammography beliefs, and having a friend or family member with breast cancer were independently and significantly related to mammography use. PMID- 10165969 TI - My parent--not myself. Contrasting themes in family care. AB - We studied 100 adult child caregivers providing care to dependent parents and found that although the vast majority supported family care for older persons in general and their own parent in particular, 46% did not want family care for themselves if they became dependent. For many the contrast between their general statements supporting care of parents and eschewing it for themselves was quite sharp. Caregiver variables significantly associated with not wanting family care for self included age, conflict with relatives over caring, caregiving burden, number of caregiving tasks performed, poorer mental health, and number of years has provided care. Caregivers not wanting family care for self were also more likely to consider placing their parent in a nursing home. Our data reveal contrasting themes in caregiving that may affect caregiver well-being and burden, and that may have implications for the future care of dependent older persons. PMID- 10165970 TI - Functional status and the use of formal home care in the year before death. AB - A national sample of persons who died in 1986 was analyzed to obtain a valid estimate of the relationship between functional status and the provision of formal home care during the last year of life. Community-based care has become increasingly important as the size of the elderly population increases and the cost for institutional care rises. When people need help in caring for themselves because of illness, frailty, or disability, community-based care may be more appropriate than acute or institutional care. The year before death is often a time of dependence and a high intensity of health service consumption. Although care at home is provided primarily by families, formal home care is also a critical component in any continuum of care. PMID- 10165971 TI - Medicare nursing home residents with a stroke. Characteristics and 90-day outcomes of care. AB - The objective of this article is to describe the characteristics and outcomes of Medicare patients admitted to nursing homes with a primary diagnosis of stroke. This study used longitudinal clinical information prospectively collected in National Health Corporation (NHC) nursing homes on admission and at discharge or death. In total, 2,345 residents met the following study criteria: age 40 and over, newly admitted from a general hospital to a NHC home under Medicare, and previously living in the community. The outcomes were functional status and discharge disposition within 90 days. By 90-days postadmission, 27.4% remained in the nursing home, 22.4% had gone home, 25.7% had been readmitted to a general hospital, 8.7% had entered another facility, and 15.6% of the patients with stroke had died. Residents who went home showed the greatest improvement in functional status in Barthel Index scores, from 35.2 (SD21.1) to 47 (SD 25.6); 20% were totally dependent and only 34% scored above 60 on the index. Further study is needed to examine the functional outcomes of stroke survivors over the longer term and compare the relative effectiveness of nursing home interventions with other postacute care options. PMID- 10165972 TI - Symptom consultation in lay networks in an elderly population. AB - Although lay referrals are known to be important as factors affecting the use of professional services, less is known about how individuals use lay consultation in evaluating symptoms. The amount and type of advice given by persons in the social network is especially important with respect to self care of symptoms that never reach the attention of professional caregivers. This article provides information on how often and from whom elderly citizens seek and receive consultation, such as family and friends, when they experience common symptoms. Findings suggest that female relatives are important sources of advice but that neither gender nor living arrangements are closely related to the tendency to seek lay advice for common symptoms. Subjects who consulted lay advisers about arthritic symptoms also were more likely to seek professional consultation. PMID- 10165973 TI - The epidemiology of pad consumption among community-dwelling incontinent women. AB - The aim of the study was to explore the use of incontinence pads among community dwelling women in a well-defined area of western Norway (total female population 122,516). In Norway incontinence aids are prescribed by doctors and paid for by the national insurance. Data were collected at local insurance offices and through interviews with an age-stratified (20-89 years) random sample of incontinent women. Identified were 2,991 pad users (1-year period prevalence 2.4%). Prevalence rose sharply with advancing age, reaching a maximum of 30.1% in the 90+ age group. Median number of pads used per day was 1.8. Middle-aged women used fewer and smaller pads than the rest. When compared with the number of pads actually delivered, the incontinent women tended to overestimate their consumption. PMID- 10165974 TI - The impact of a spouse-caregiver support group on care recipient health care costs. AB - Frail elderly veterans who received care at a Department of Veterans Affairs medical center and whose spouse-caregivers participated in support groups to which they had been randomly assigned had lower health care costs over a 1-year period than did control participants. The greatest impact was observed for participants perceived by their spouse-caregivers to be in the poorest health. What is important to consider about this result in terms of health care policymaking is that support groups targeted for spouse-caregivers of elderly veterans in poor health produced significant outpatient, inpatient, and total cost savings for the care recipients, and were cost effective. PMID- 10165975 TI - Telemedicine and malpractice: old liabilities and new risks. PMID- 10165976 TI - Patents may provide better protection than copyrights for computer software. PMID- 10165977 TI - Hospital and nursing home use in the last three months of life. AB - We describe decedents' days of care and changes in residence due to episodes of hospital and institutional care in the last 90 days of life. Data are from the National Institute on Aging's Survey of the Last Days of Life (SLDOL) with informants' responses for a sample of 1,227 decedents age 65 years and older from Fairfield County, Connecticut. Overall, three-fourths of the decedents made only one transition to or from a health care facility in the last 3 months of life and another 10% made two or three transitions. Hospital days decreased slightly with age, but nursing home days increased dramatically. Physical disability, lack of social contacts, incontinence, and a diagnosis of dementia were significantly associated with a long, terminal, institutional stay. Future cost savings are likely to be achieved more through the reduction of nursing home care in the last months of life than in a reduction of hospital care. PMID- 10165978 TI - Multidimensional patterns of aging in 70-year-olds: survival differences. AB - This article examines the predictive ability for survival of five multidimensional patterns of aging found in 335 70-year-olds from the geriatric and gerontological studies in Gothenburg, Sweden (H-70). The multidimensional patterns were identified by cluster analysis of the domains of cognitive performance, physical health, functional capacity, subjective well-being, and social contacts. Survival differences are found among the patterns and between genders within the patterns. Patterns with higher domain scores at age 70 have higher median survival rates over 20 years. Conversely, patterns with lower domain scores at age 70 have earlier mortality. However, one group, with the lowest cognitive score, has a survival pattern similar to the group with low scores in every domain, substantiating the finding that poor cognitive performance is an important single predictor of mortality. Females exhibit at least a 4-year survival advantage over males in all but one group, in which the males resemble the females in their survival. PMID- 10165979 TI - Imbalance in an older population: an epidemiological analysis. AB - Difficulties with balance are associated with limitations in activities of daily living. There is little information, however, about the epidemiology of imbalance. Imbalance, defined as the inability to maintain a full-tandem stand for 10 seconds, was assessed as part of an interview with 2,018 residents of Marin County, California, age 55 and older. The likelihood of imbalance was greater in women, those aged 85 and older, and those with less than 12 years of education. It was also associated with specific chronic conditions, including a history of hypertension, stroke, or cataracts. Even after adjusting for these conditions, imbalance was associated with reduced lower-body strength as well as poor short-term memory, hip pain, vision problems, abstention from alcohol, and current cigarette smoking. With those aged 85 and older representing the fastest growing age group in developed nations, imbalance may become a major health problem. PMID- 10165980 TI - SES differentials in health by age and alternative indicators of SES. AB - Despite the general persistence and even increase of strong socioeconomic status (SES) differentials in health in the United States, research suggests that SES differentials in health may diminish or become nonexistent at older ages. However, most research has used only limited measures of SES (e.g. education, income), and has not thoroughly investigated intra-elderly age differences in this trend. The current study investigates how SES differentials in health vary by age in the United States, using fairly detailed age categories (through ages 85+), and 2 alternative indicators (home ownership and liquid assets) of a major additional dimension of SES, financial assets, which may be especially important at older ages. We address (a) how strongly financial assets are associated with health, considered both alone and net of education and income; (b) if the health effects of financial assets vary by age; and, more specifically, (c) if their effects are especially pronounced in older age, again considered both alone and net of or relative to education and income. Results show that financial assets, especially liquid assets, considered both alone and net of education and income, are associated with health throughout adulthood and old age, at least until ages 85+. Furthermore, financial assets remain associated with health until quite late in life and become more important relative to education and income at older ages for some measures of health. PMID- 10165981 TI - Stress in the life course: a life history approach. AB - This article examines the relationship between stress and distress in the life course, emphasizing the time elapsed between the event and measurement of psychological distress. Stressors are conceptualized as either distal or proximal based on how recently they occurred. Distal stressors are further classified as status changes or undesirable life changes. Using a life history calendar approach, we examine stressors occurring over a 15-year-period. We explore whether distal stressors affect current depressive symptomatology above and beyond the effect of more recent stressors and how these stressors vary in frequency and affect over 3 empirically defined age groups. While some events decrease in frequency over age, others occur consistently across age groups. Most important, distal stressors significantly impact current depressive symptomatology, independent of proximal stressors. Types of distal stressors affecting depression vary over age, indicating that the stage of life at which a stressor occurs is a significant determinant of the stressor's effect on depression. PMID- 10165982 TI - Attitudes toward and use of subsequent nursing home services among a national sample of older adults. AB - This study was designed to examine the relationship between attitudes toward nursing homes and subsequent nursing home utilization, and assess the impact of prior nursing home utilization on subsequent attitudes among a national sample of older Americans. Multivariate estimation procedures for complex survey designs were performed on the National Long-Term Care Survey data set. Although prior nursing home use did not directly affect subsequent attitudes toward nursing homes, having favorable attitudes about nursing homes increased the odds of using subsequent nursing home services by 1.5 and increased the total nursing home length of stay by 17%. Implications of this research for public policy and long term care treatment planning are discussed. PMID- 10165983 TI - Predictors of physical function among the oldest old: a comparison of three outcome variables in a 24-year follow-up. AB - This study has measured physical function in a nationally representative sample of persons aged 77 to 98 (N = 508) in 1992. Three measures of function are used: activities of daily living (ADL), an index of mobility, and performance tests. These are used as outcomes and analyzed in relation to variables gathered in a survey in 1968. Variables from 1968 include education, mobility, smoking, and an index of circulation problems. All four variables predict some limitations in physical function in old age. However, there are different patterns of predictors found for the three outcome measures. All three outcomes are associated with age, education, and previous circulation problems. ADL limitations are also associated with poor previous mobility and smoking; mobility limitations are also associated with sex and smoking; performance limitations are also associated with sex. PMID- 10165984 TI - Standardizing case management processes improves quality. PMID- 10165985 TI - Establishing a legal compliance program. PMID- 10165986 TI - Legislating access. PMID- 10165987 TI - Cutting through the deja vu. PMID- 10165988 TI - Planning for gold at HIMSS (Health Information Management Systems Society) '97. AB - The nation's largest health information management trade show took place in late February. For the second year in a row, health care management and information technology consultant Peter Wenzlick reports on the state of the art. PMID- 10165989 TI - Looking forward--a CEO roundtable. PMID- 10165990 TI - Closer inspection: the recent evolution of technology assessment. PMID- 10165992 TI - Real-time informatics. PMID- 10165993 TI - A technology anthology. Recent writings and remarks on the state of the state-of the-art. AB - Early this year, the Health Care Financing Administration (HCFA) backed down from plans to publish a final regulation governing the criteria for coverage of medical technologies in the Medicare program. Originally drafted in 1989, the rules spawned an eight-year controversy, largely because they proposed making "cost-effectiveness" one factor in deciding whether certain procedures would be reimbursed. It was one of the first attempts to articulate the precise role cost effectiveness should play in coverage policy in either the public or private sectors. Many groups opposed the introduction of cost-effectiveness into the equation, but none so actively as medical device manufacturers, represented by the Health Industry Manufacturers Association (HIMA). Following are excerpts from their exchanges, beginning with HCFA's proposed rule in January of 1989. PMID- 10165991 TI - Buying machines. PMID- 10165994 TI - A benchmarker's benchmark. PMID- 10165995 TI - The direct approach. AB - In the following excerpt from Dealing Direct: A Strategy for Business-Provider Partnerships, published in February by American Hospital Publishing, authors Gee and Fine discuss the right and wrong reasons for considering one of health care's most talked about new relationships. PMID- 10165996 TI - Harnessing technology. PMID- 10165997 TI - Data ... national health expenditures for 1995. PMID- 10165998 TI - Practice brief. Issue: Telemedical records. American Health Information Management Association. PMID- 10165999 TI - Sell your skills, says data quality expert. PMID- 10166000 TI - Keeping our eyes on the prize: computer-assisted patient care management. PMID- 10166001 TI - The medical transcription industry: where has it been and where is it going? PMID- 10166002 TI - Document imaging and workflow technology in healthcare today. PMID- 10166003 TI - Electronic information warehousing. PMID- 10166004 TI - A look at the AAAHC (Accreditation Association for Ambulatory Health Care). PMID- 10166005 TI - Building a database from the ground up. PMID- 10166006 TI - Fraud and abuse implications for the HIM professional. PMID- 10166007 TI - A summary of the associate and baccalaureate degree curriculum models for health information management, Part I. PMID- 10166008 TI - Linking costs and quality improvement to clinical outcomes through added valued. AB - A byproduct of outcome measures is the provision of financial benefit to the healthcare providers while ensuring healthcare access and quality to the patient. Consequently, a framework for measuring outcomes must integrate the "customer's perspective" of perceiving value of the services provided, the "provider's perspective" of acting as the patient's fiduciary, and the "business's perspective" of achieving net income. Value-based cost management (VBCM) accomplishes this integration by linking several measures with three financial tools: activity-based costing, value-added analysis, and cost of quality. This article illustrates the use and benefit of VBCM to the laboratory as a partner in the delivery of healthcare services with an example of chest pain triage. PMID- 10166009 TI - Teaching total quality management: developing and deploying education throughout a healthcare system. AB - Healthcare organizations are faced with the responsibility of teaching their entire staff the founding principles, concepts, and practices of total quality management (TQM), to improve organizational effectiveness. Purchasing training products from outside consultants can be costly, but healthcare leaders can design and develop their own TQM training products, integrating each product with their organization's mission and values. This article describes how a Catholic healthcare system successfully developed and deployed a compendium of TQM educational products throughout the health-care system. PMID- 10166010 TI - From hard copy to computer integration: developing clinical indicators for quality improvement. AB - The Clinical Indicator Workbook is a computerized tool that allows users to develop measures of healthcare quality. The electronic workbook, which includes selected clinical indicators to measure various aspects of patient care and teaching examples, was developed by using a major word processing package and uses a point-and-click feature. Its distribution and installation are managed by a program that enables users to select one of three options: (a) installation of the required files and indicator documents, (b) duplication of material on two diskettes for future distribution within the user's facility, and (c) on-line help. Once the workbook is installed, users are able to copy and customize the indicators for use with interdisciplinary teams in clinical settings. A survey of initial users, who are, for the most part, quality managers in the Veterans Affairs system, indicated that they are satisfied with this tool overall. PMID- 10166011 TI - Disease chronicity and quality of care in hospital readmissions. AB - The study described in this article examined disease chronicity and quality of care and their relationship to hospital readmissions during a 3-month period. Results showed that readmissions due to disease chronicity were significantly more prevalent than for other categories. Illnesses, including pulmonary disease, heart failure, and cancer, ranked as leading causes for readmission, whereas readmissions due to quality of care or complications most often resulted from a previous admission for surgery. This study's findings demonstrate that using readmission rates alone as indicators of poor care can be misleading. PMID- 10166012 TI - More about the Internet. PMID- 10166013 TI - Meeting information needs of families of critical care patients. AB - Families of patients in critical care experience extreme anxiety and frustration while awaiting their loved ones' recovery or stabilization. To study the hypothesis that meeting families' informational needs can reduce their anxiety and help them cope with the initial crisis, a small task force at a Midwest acute care facility, using a CQI approach, studied possible solutions. Initial findings showed low satisfaction for families of critically ill patients with the present system of imparting information to them. After initiation of a storyboard to present information by the critical care team, families reported increased satisfaction and greater knowledge recall. PMID- 10166014 TI - Negotiating contracts with physician practice management companies. PMID- 10166015 TI - The resource utilization system for cost allocation in invasive cardiology. PMID- 10166016 TI - Managing the interface between primary-care provider and specialist. AB - Confusion abounds regarding what constitutes a minimum standard of primary-care management and when it is appropriate to refer. Regardless of the cost containment methods employed, financial-incentive models applied in the absence of clinical appropriateness criteria may result in implicit rationing of healthcare services. Software-embedded clinical criteria are essential in these changing times. PMID- 10166017 TI - Cost reduction in cardiopulmonary and neurology services. AB - A plan was developed and implemented to reduce costs per unit of service in three departments (pulmonary, cardiology, and neurology services), which resulted in a 19% reduction in cost per RVU over two years. These savings were attained primarily by a reduction of supplies and the redesign of work practices, which resulted in a reduction of both personnel and purchased service expenses. The departments have continued to improved the quality of services provided while reducing the costs of these services through this proactive approach to cost containment. PMID- 10166018 TI - Expansion of an existing program for the prevention and reversal of heart disease. AB - The expansion of the heart-disease-prevention and -reversal program within the Alegent Health System has been met with enthusiasm by the public, physicians, and hospital administration. The expansion was developed to effectively and efficiently utilize existing staff whenever possible in order to maintain costs. The additional delivery site allows additional access to this valuable program and promotes Alegent Health as a true "system," with the health of the community as its driving force. The development of the Cardiac College provides a much needed educational program for the public with the intent of reducing suffering and death due to heart disease. PMID- 10166019 TI - Applied home care research. AB - Posits that Canadian home care services compete with hospitals and other community and public health agencies for scarce financial resources but as yet regional authorities are not responsible for paying physicians. Investigates all the various facets of home care services and concludes that by using joint ventures, there may be the possibility of making informed decisions for the Canadian healthcare system. PMID- 10166020 TI - The Canadian Healthcare Association comments upon the final report of the National Forum on Health. PMID- 10166021 TI - Beyond Medicare: a Determinants of Health perspective. AB - Taken and adapted from an article by the Determinants of Health working group of the National Forum on Health. Discusses people's ideas about health and healthcare and their views on medicare. PMID- 10166022 TI - Linking the healthcare continuum with technology. AB - Looks at healthcare and technology and how home care service is coming more to the fore. Discusses IT and how it will further improve both cost and clinical procedures without losing the human contact part of it. PMID- 10166023 TI - Continuous quality improvement in acute health care: creating a holistic and integrated approach. AB - Reviews the range of quality activity in a National Health Service hospital trust, using a staff questionnaire survey, self-assessment against the Baldrige Quality Award criteria, and the application of the SERVQUAL approach to service quality assessment. Reviews the acute health care quality programme literature. Finds that there are needs for greater integration of quality effort, to engage with patients in a more meaningful manner, and to achieve greater commitment and involvement from clinicians and managers. Identifies lack of time and resources as a major barrier to greater application of quality programmes. Explores ways of developing a more holistic and integrated programme of quality improvement. Describes the creation and implementation of a model for continuous improvement in health care quality. PMID- 10166024 TI - Practices of excellent companies in the drug industry. AB - Examines excellence in three major pharmaceutical companies: Merck, Lilly, and Glaxo. Provides an overview of recent trends in the health care industry. Shows that although all three companies are facing tough competition and strict cost containment pressures, they continue to develop innovative strategies for increasing the quality of their product offering. Analyses Merck's recent acquisition of Medco and its implications; also highlights Merck's "Vital Interests" programme. Discusses Lilly's recent purchase of PCS from McKesson Drug and Lilly's recent efforts to concentrate on its core business. Introduces Helix, Glaxo's new computer network for pharmacists and explains the benefits of this unique service, both to its users and the sponsor. PMID- 10166025 TI - Don't throw out the customer. AB - Addresses the severe criticism by the Health Service Commissioner of NHS trusts for their handling of patient complaints, particularly the attitude of managers and the new NHS trust culture, which emphasized that patients should be considered as more than just customers. Argues that the word "customer" should not be thrown out because managers are uncomfortable with it; takes the view that while they may have tried to adopt the term, they have failed to appreciate its meaning. Makes a comparison between customer and consumer and presents a case for regarding patients as customers. Concludes that lessons can be learned from private business in developing the provider-customer relationship and that attitude and behaviour changes can be brought about by a long-term cultural change programme. PMID- 10166026 TI - Sisters' and charge nurses' attitudes to quality. AB - Discovers sisters' and charge nurses' thoughts about quality assurance and whether their needs and those of their patients were satisfied by the process. Reports the results of qualitative research conducted with sisters and charge nurses working within specific clinical areas in a community trust. Shows the differences of opinion within the sample towards quality and illustrates that, although sisters and charge nurses have a good knowledge of what quality is, they acknowledge that others working within their clinical areas may not be similarly aware. Finds that, while some of the respondents felt that quality assurance would benefit patients to some degree, others felt that quality initiatives actually disadvantaged patients. Members of the sample were unhappy with certain problems of quality assurance, associated with external and internal auditing, training needs and financial implications. Recommends that quality needs to be formally included in pre-and post-basic training. PMID- 10166027 TI - Annotated bibliography: integrated approaches to quality improvement in health care: Part II. PMID- 10166028 TI - Patient's perceptions of quality in a Northern Ireland hospital trust: a focus group study. AB - Explores the value of focus group methodology in a patient satisfaction initiative intended to identify quality improvement targets in a large general hospital. Analyses the transcripts from ten focus groups selected from hospital discharge lists, using simple cut-and-paste techniques. Finds that the focus group methodology was successful in amplifying feedback previously gleaned from surveys. Highlights patients' tolerance of shortcomings and their appreciation of staff providing high quality care while under pressure. Concludes that patients regard the National Health Service as deteriorating generally. PMID- 10166029 TI - Medical participation in and leadership of quality programmes. AB - Notes that medical participation in organization-wide quality programmes and leadership of quality is commonly viewed as the key to a successful programme. Reviews and reports research into doctors' involvement in such programmes as distinct from doctors' involvement in medical quality activities. Reveals the lack of systematic evidence on the subject, suggests areas for future research, and summarizes what is known. Gives recommendations based on reported research and experience for quality training for doctors and how medical managers might engage their colleagues and other professions in quality programmes. PMID- 10166030 TI - Understanding practice management: a qualitative study in general practice. AB - Reports a qualitative study of practice managers' roles and responsibilities in eight practices in the Grampian region of Scotland. Observes wide variations in the roles and responsibilities of managers associated with the size and fundholding status of the practice. Notes that larger practices had better developed management structures allowing the managers to delegate tasks and undertake a more proactive planning and executive role, and that medium and smaller practices had less well developed management structures and managers were more likely to act as practice administrators with limited autonomy. Concludes that practice managers are playing an increasingly important role in general practice. Also that the influential role of the practice manager in the development of practice policies and the transfer of administrative responsibilities from the partners to the manager have all contributed to a change in general practitioners' perceptions of the practice manager. PMID- 10166031 TI - Communication in the NHS: using qualitative approaches to analyse effectiveness. AB - Argues in favour of utilizing qualitative methods to assess the effectiveness of internal communications in the National Health Service (NHS), as a supplement to the more standard quantitative measures normally employed. Presents a case study from an NHS Trust, demonstrating the type of data which is generated. Compares these data to findings derived by quantitative methods. Argues that the quantitative findings both confirm and supplement those derived by quantitative methods, and that both can identify the types of major problems prevalent within the NHS at present. Suggests that the further study of these issues should become an important part of efforts to create national standards for communication effectiveness in the future. PMID- 10166032 TI - Viewpoint. Doctors' dilemma--the emerging dual role of clinicians. PMID- 10166033 TI - The value of an outcomes information resource. An evaluation of the UK Clearing House on Health Outcomes. AB - Reports on the first phase of an evaluation of the UK Clearing House on Health Outcomes (UKCHHO) undertaken by a sample survey of purchasers and providers on its mailing list and users of its enquiry service. Explores user satisfaction with the services and publications of the project, uses made of the information provided and perceptions of the future role of a UKCHHO. Reports overwhelming satisfaction with the enquiry service and agreement about the usefulness of Outcomes Briefing. States that the main areas of use for the information provided were within clinical audit, guidelines and the exploration of outcomes within routine clinical practice. Also that the findings provide evidence of the need for an expanded brief for a UKCHHO, to include the provision of an enquiry service on study design and demonstrations of the value of the collection of outcomes data. Notes there is an urgent need to show that the systematic collection and use of outcomes data makes a difference to the quality of care provided to patients and to the purchase of services. PMID- 10166034 TI - Pharmaco-economic information and its effect on prescriptions. AB - Reports on a small-scale study of 30 general practitioners and 30 specialists in Greece where pharmaco-economic information was presented to these prescribers and an attempt made to observe changes in reported choice of treatment consequent on this exposure. Concludes with a credible level of statistical significance, that information which also takes into account economic performance criteria is likely to influence the prescription decision of the practitioners. Suggests, from a commercial point of view, that this offers the opportunity to pharmaceutical companies to complement their offerings so that they can be better targeted to those prescribers most likely to be influenced by this information. Notes that, from a general societal point of view, the question needs to be raised about the extent to which the independence of the prescriber might be eroded through the presence or absence of such information and thus the best interests of the patient safeguarded. PMID- 10166035 TI - The effects of demographics on determinants of perceived health-care service quality. The case of users and observers. AB - Notes that previous research suggests the components of perceived service quality are industry specific, and that calls have been made for academics to integrate their theory into practice. Investigates the effects of demographic factors on users and observers of perceived hospital quality. Reports results suggesting perceived quality is industry specific, users and observers differ in their perceptions of hospital quality and demographic factors do make a difference in perceived hospital quality. PMID- 10166036 TI - Taking lessons from a different AMA. PMID- 10166037 TI - Federal tax developments affecting health care organizations--Part 1: New legislation. AB - Health care providers face numerous federal tax law changes in 1997 through legislation, agency rulings, and court decisions. The author provides an overview of these changes. The first part of this two-part series discusses the legislation enacted in 1996 that will affect health care today. PMID- 10166038 TI - As the world of managed care turns. AB - Health maintenance organizations have become predominant in the health care industry and continue to evolve as expectations for quality and affordability change. Although initially limited, managed care options have grown extensively and will continue to develop as America's needs change. The author describes the early impetus for the growth of MCOs and the legislation that guided the maturation of managed care. PMID- 10166039 TI - Secrets and tips for weaving a Web of success. Part 1. PMID- 10166040 TI - The crossroads of graduate medical education. PMID- 10166041 TI - Managing patient demand on-line. AB - Patient self-management, or demand management, has found a fertile field on the Internet. Web sites containing both good and bad health care information are budding throughout the world. The author describes two attempts to harvest the relevant, credible information for a rapidly growing population of on-line health care consumers. PMID- 10166042 TI - Managed care changes everything. PMID- 10166043 TI - The role of consultant pharmacist in subacute care. AB - In a role that is complicated, yet rewarding, the consultant pharmacist has the daily opportunity to affect the care of many patients. Consultant pharmacists have traditionally practiced in the long-term care/nursing home setting; however, the subacute facility is an emerging area of responsibility for consultant pharmacists. PMID- 10166044 TI - Underestimation: a barrier to implementation of disease management. PMID- 10166045 TI - Case studies in disease management for congestive heart failure. AB - Today, case management is neither science nor art. Successful programs have little in common except corporate commitment, the right people for the right job, and an understanding of the playing field. The author provides three case studies of HMOs who tried to jump into the field, with varying levels of success. PMID- 10166046 TI - Health care safety management: a regulatory update for 1997. AB - If management fulfills its responsibilities by meeting both Occupational Safety and Health Administration (OSHA) and Environment Protection Agency (EPA) regulations, a safe and healthful operation then depends largely upon employees who are properly informed and aware of potential hazards as well as impending regulatory actions which will impact the health care industry. This document details OSHA compliance and regulatory review as well as EPA compliance and regulatory review. PMID- 10166047 TI - Tautology and value: the flawed foundations of health economics. PMID- 10166048 TI - Monitoring expenditure in relation to epidemiological and demographical characteristics of AIDS in South East England. AB - In the UK, over 70% of AIDS, including new cases, is located in a few Districts in central London where the distribution of previously occurring and new cases is essentially confined to the original risk groups of homosexual/bisexual men, drug addicts of both sexes, and some of their sexual partners and consorts. But control policy is still based on the assumption that HIV has already spread from persons in these risk groups into the general population, and that it will spread hereafter at an increased rate because of heterosexual transmission to cause a widespread epidemic of AIDS. The basis and implications of this policy were investigated in the South East region adjacent to London. Analysis of demographic and epidemiological data shows that, with one exception, there is very little extension of AIDS from affected Districts in London to the surrounding region or even to the suburban fringe. Where AIDS is prevalent, as in this exception, the distribution follows the same, original pattern which relates essentially to risks arising from life-styles. There is no significant association between the prevalence or spread of AIDS and conventional markers of deprivation, economic and social disadvantage. Allocations of personnel, services and expenditure, assessed from returns required under the AIDS Control Act of 1987 and official registration data, continue to follow the original policy assumptions. They are therefore unrelated to the numbers of existing and new cases, disproportionate and unrealistic. Claims that this widespread excess of effort is justified by the fact that AIDS has not spread to the general population are falsified by the continuation of cases almost exclusively in risk groups. There is nothing in the data required under the Act or in registrations in this main locus of AIDS in the UK to suggest any change in this or to justify continuation of current expenditure and redundant activities. There is no evidence in these data that ethnic variations in the resident populations of Districts are associated with variations in the prevalence of AIDS. However, the larger figures available in some of the national data do indicate a disproportionate increase in some minority ethnic groups. Further detail about risks factors in these groups are required and, meanwhile, effort and expenditure should be re-orientated toward treatment, contact tracing and other public health measures for more effective containment of the continuing spread of AIDS in all the high risk groups. PMID- 10166049 TI - A 'Code of Patients' Rights' for New Zealand. PMID- 10166050 TI - Rethinking children's rights. PMID- 10166051 TI - Pornography: some implications for nursing. PMID- 10166052 TI - Effective team work in health care: a review of issues discussed in recent research literature. PMID- 10166054 TI - Can we close the ethics-technology gap? PMID- 10166053 TI - Assessing community values in health care: is the 'willingness to pay' method feasible? AB - In this paper an economics approach to assessing community values in health care priority setting is examined. The approach is based on the concept of 'willingness to pay' (WTP). Eighty two parents were interviewed with regard to three aspects of provision of child health services. For each aspect a choice of two courses of action was presented. Parents were asked which course of action they preferred and what was the maximum amount of money they would be prepared to pay for this rather than their less preferred option. WTP responses are acceptable to the majority of respondents and appear to 'behave' in accordance with a priori expectations. A method of assessing the influence of ability to pay on preferences and WTP is outlined. Preferences and WTP do not appear to have been unduly distorted by ability to pay. Use of WTP data does have the potential to provide health care purchasers and providers with information on intensity as well as direction of the preferences of members of the community. PMID- 10166056 TI - The ethics of non-commercial IVF surrogacy. An open letter to the National Ethics Committee on Assisted Human Reproduction (NECAHR). PMID- 10166055 TI - Principals of design and evaluation of an information system for a department of respiratory medicine. AB - OBJECTIVES: To evaluate a departmental computer system. DESIGN: a. Direct comparison of the time taken to use a manual system with the time taken to use a computer system for lung function evaluation, loan of equipment and production of correspondence. b. Analysis of the accuracy of data capture before and after the introduction of the computer system. c. Analysis of the comparative running costs of the manual and computer systems. SETTING: Within a department of respiratory medicine serving a hospital of 1323 beds. MAIN OUTCOME MEASURES: a. Time taken to perform functions with the assistance of computerised methods, in comparison to the manual method used alone. b. Accuracy of data capture. c. Relative running costs. RESULTS: a. The computer system (CS) was significantly faster than the manual system (MS) for lung function evaluation (CS = 7.63 min/test, MS = 12.25 min/test), loan of equipment (CS = 0.40 min/loan, MS = 2.07 min/loan), and checking for overdue equipment (CS = 0.49 s/record, MS = 9 s/record). The production of correspondence was slightly slower with the computer (CS = 9.30 min/letter, MS = 8.54 min/letter). b. All outpatient episodes, but only 43 of 65 (66%) of in-patient episodes, were captured. Lung function and managerial report data were accurate using both manual and computerised methods. The manual system for equipment loans was inefficient, and use of the computer resulted in the recovery of 221 nebulisers. c. Development costs for 1988-1990 were high (72,178 pounds). Only 1200 pounds to 1845 pounds per year was recovered directly from staff time saved by the computer but larger savings resulted from changes in work practice (4049-4765 pounds). After 10 years the projected deficit is 10,000 pounds per annum in running costs. CONCLUSIONS: In comparison with the manual methods, the computer system has shown significant advantages which provide accurate information, with significant favourable effects on working practices. In evaluating computer systems used in clinical practice it is essential to ensure that the projected work practice benefits are achieved without unacceptable costs in staff time, inaccurate data and high financial outlay. PMID- 10166057 TI - Will you be ready for the year 2000? PMID- 10166058 TI - Health records 2001 (and beyond), a real oddity. PMID- 10166059 TI - Medicare program; revisions to payment policies and five-year review of and adjustments to the relative value units under the physician fee schedule for calendar year 1997; correction--HCFA. Correction of final rule with comment period. AB - This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on November 22, 1996 entitled "Medicare Program; Revisions to Payment Policies and Five-Year Review of and Adjustments to the Relative Value Units Under the Physician Fee Schedule for Calendar Year 1997." PMID- 10166060 TI - Publication of the OIG model compliance plan for clinical laboratories--HHS. Notice. AB - This Federal Register notice sets forth the recently issued model compliance plan for clinical laboratories developed by the Office of Inspector General in cooperation with, and input from, several provider groups and industry representatives. Many providers and provider organizations have expressed an interest in better protecting their operations from fraud through the adoption of compliance plans. We believe the development of this initial model compliance plan for clinical laboratories will serve as a positive step towards promoting a higher level of ethical and lawful conduct throughout the health care industry. PMID- 10166061 TI - Annual update of the HHS poverty guidelines--HHS. Notice. AB - This notice provides an update of the HHS poverty guidelines to account for last (calendar) year's increase in prices as measured by the Consumer Price Index. PMID- 10166062 TI - Case management. AB - Providing cost-effective high quality healthcare services ranks as the number one concern for anyone involved with the healthcare delivery system. While quality of care should always be the number one priority, controlling healthcare costs receives most of the attention. With limited healthcare dollars and providers assuming more of the financial risk for services rendered, a whole assortment of cost-containment strategies are being introduced in an effort to maintain some semblance of financial viability. Healthcare providers can approach cost control from two different angles. On the fixed-cost operational overhead side, traditional cost-containment techniques have focused on downsizing, maximizing productivity, staffing redesign, improved purchasing contracts, standardization, inventory control, and other more individualized restructured service models. On the variable-cost clinical side, cost control has been approached by introducing a variety of cost-containment strategies designed to improve efficiency and effectiveness of provider performance. While many of these strategies, previously discussed in the Journal of Healthcare Resource Management have stressed the importance of education, guidelines, pathways, and other clinical "tools for improvement," the success of many of these tools resides in the ability to provide real-time intervention. Real-time intervention rather than the more passive retrospective variance analysis has the greatest potential for producing cost savings by actually making a recommendation that prevents the unwanted event from occurring. In many institutions, the case manager bears the responsibility for monitoring and managing these programs. This article describes various case management models currently used by different institutions. PMID- 10166063 TI - Networking computers. AB - This decade the role of the personal computer has shifted dramatically from a desktop device designed to increase individual productivity and efficiency to an instrument of communication linking people and machines in different places with one another. A computer in one city can communicate with another that may be thousands of miles away. Networking is how this is accomplished. Just like the voice network used by the telephone, computer networks transmit data and other information via modems over these same telephone lines. A network can be created over both short and long distances. Networks can be established within a hospital or medical building or over many hospitals or buildings covering many geographic areas. Those confined to one location are called LANs, local area networks. Those that link computers in one building to those at other locations are known as WANs, or wide area networks. The ultimate wide area network is the one we've all been hearing so much about these days--the Internet, and its World Wide Web. Setting up a network is a process that requires careful planning and commitment. To avoid potential pitfalls and to make certain the network you establish meets your needs today and several years down the road, several steps need to be followed. This article reviews the initial steps involved in getting ready to network. PMID- 10166064 TI - GPO survival strategies. AB - Over the last two decades we have witnessed the genesis of a rapidly consolidating market with nearly all healthcare providers now participating in a handful of purchasing organizations either alliance-based or major national GPOs. For a traditional GPO to survive, even thrive in today's rapidly consolidating customer environment, it needs to focus on five essential issues: negotiating agreements, electronically-formatted contract information, sales force and support staff, value-added programs, and equity ownership. This articles discusses these five issues giving suggestions for their implementation. PMID- 10166065 TI - Purchasing's global village. PMID- 10166066 TI - Performance measurement at a crossroads. PMID- 10166067 TI - Wake up to the Internet. PMID- 10166068 TI - Medical non-wovens: benchmarking cost-in-use. PMID- 10166069 TI - Health care reform in the American states: administrative capacity building. AB - As the nation moves to reform Medicare and the health care industry becomes more competitive which will dramatically change the means by which health care is organized and financed, state governments ought to be establishing administrative capacity to administer new systems. This article describes past experiences of states in similar efforts and uses the legislation written in 13 states to analyze in greater detail current state health reform activities. Policies that create new central authorities have the greatest likelihood of building the appropriate administrative infrastructures. Provisions related to establishing data bases, creating regional authorities or advisory committees, establishing uniform claims, and facilitating integrated systems of care are common to several proposals. Previous state experiences with health planning and citizen involvement are evident in the schemes being proposed and enacted. PMID- 10166070 TI - A compilation of state activities in legislatively mandated reporting of health services data. AB - The health care crisis and efforts for reform have taken a variety of forms. Apparently a majority of states have decided that the federal government will develop solutions to this problem slowly, if at all, and have undertaken a variety of activities on their own to address the problem. One state response has been to mandate the collection of data related to health services in an effort to assist purchasers of health care to make more prudent buying decisions. This article contains the results of a survey conducted among the states that have legislatively mandated the collection of health-related data and presents a compilation and discussion of their activities. PMID- 10166071 TI - Controlling defensive medical practices and costs through state health policy reform. PMID- 10166072 TI - Implementing TQM in state public health agencies. PMID- 10166073 TI - Coping with the health care crisis: state government responses. PMID- 10166074 TI - Switching to bedside registration increases patient satisfaction. PMID- 10166075 TI - New form facilitates mental status exam. PMID- 10166076 TI - Tips on managing psychiatric patients. PMID- 10166077 TI - Pearls of wisdom from ED leaders. PMID- 10166078 TI - Disease management; an advanced review of risk arrangements. PMID- 10166079 TI - Fraud and abuse provisions in the Health Insurance Portability and Accountability Act. PMID- 10166080 TI - Charter for health care workers: a fresh face for Catholic bioethics teachings. PMID- 10166081 TI - Contemporary challenges for Catholic healthcare. AB - In this article, Father Morrisey uses a legal approach to analyze the challenges facing Catholic healthcare in a time of rapid change, drawing his observations from his work with Catholic healthcare institutions both in Canada and in the United States. PMID- 10166082 TI - Parish nursing: reclaiming the church's healing mission. PMID- 10166083 TI - Shaping a preferred future: Catholic healthcare beyond the year 2000. AB - The Catholic Health Association of Canada recognizes that the Canadian healthcare system is changing. In a special supplement to the summer edition of the Review, we explored the forces at play within our healthcare environment and identified significant emerging trends. In Part II of this review, we look at the role for Catholic healthcare in Canada beyond the year 2000 by presenting the perspectives of four key spokespersons. These spokespersons outline the valuable contribution Catholic healthcare make within the Canadian healthcare system. PMID- 10166084 TI - A more humane approach to employee termination. PMID- 10166085 TI - Community commitment in action: a look at a parish nursing pilot project. PMID- 10166086 TI - Celebrating the unique life experiences of seniors through art. PMID- 10166087 TI - Encouraging signs: Is the corporate world developing a social vision? PMID- 10166088 TI - Juridic persons: a practical guide. PMID- 10166089 TI - The healing ministry of the church in the health care system. PMID- 10166090 TI - When love hurts. PMID- 10166091 TI - Robbed of innocence. Signs and symptoms of pediatric sexual abuse may be subtle. PMID- 10166092 TI - That's Italian! Italy's EMS providers are striving to standardize care throughout their country. PMID- 10166093 TI - Bridging the gap. How to communicate with pediatric patients and their families. PMID- 10166094 TI - Splitsville casualties. A family history of divorce should alert you to a variety of potential problems. PMID- 10166095 TI - Leadership through enthusiasm. PMID- 10166096 TI - Managing successful construction and renovation projects. AB - If you are the lead person during a project, it is your responsibility to follow up on every detail and task involved to guarantee overall success. Team members look to you as the example and as the communicator. Although other people may fail to accomplish their tasks, you must have the ability and energy to push the issue to completion without losing your cool or throwing your hands up. Projects usually require the coordination of multiple issues, tasks, and personnel. The process can be rewarding, or it can be your worst nightmare. Make it fun, but keep it organized. Communicate properly, and design each project process to fit the project needs. PMID- 10166097 TI - Selling your customers on meal solutions. PMID- 10166098 TI - Gender and equity in health sector reform programmes: a review. AB - This paper reviews current literature and debates about Health Sector Reform (HSR) in developing countries in the context of its possible implications for women's health and for gender equity. It points out that gender is a significant marker of social and economic vulnerability which is manifest in inequalities of access to health care and in women's and men's different positioning as users and producers of health care. Any analysis of equity must therefore include a consideration of gender issues. Two main approaches to thinking about gender issues in health care are distinguished--a 'women's health' approach, and a 'gender inequality' approach. The framework developed by Cassels (1995), highlighting six main components of HSR, is used to try to pinpoint the implications of HSR in relation to both of these approaches. This review makes no claim to sociological or geographical comprehensiveness. It attempts instead to provide an analysis of the gender and women's health issues most likely to be associated with each of the major elements of HSR and to outline an agenda for further research. It points out that there is a severe paucity of information on the actual impact of HSR from a gender point of view and in relation to substantive forms of vulnerability (e.g. particular categories of women, specific age groups). The use of generic categories, such as 'the poor' or 'very poor', leads to insufficient disaggregation of the impact of changes in the terms on which health care is provided. This suggests the need for more carefully focused data collection and empirical research. PMID- 10166099 TI - Health seeking behaviour and the control of sexually transmitted disease. AB - What people do when they have symptoms or suspicion of a sexually transmitted disease (STD) has major implications for transmission and, consequently, for disease control. Delays in seeking and obtaining diagnosis and treatment can allow for continued transmission and the greater probability of adverse sequelae. An understanding of health seeking behaviour is therefore important if STD control programmes are to be effective. However, taboos and stigma related to sex and STD in most cultures mean that gaining a true picture is difficult and requires considerable cultural sensitivity. At the moment relatively little is known about who people turn to for advice, or about how symptoms are perceived, recognized or related to decisions to seek help. It is argued that such knowledge would assist programme planners in the development of more accessible and effective services, that studies of health seeking behaviour need to include a combination of qualitative and quantitative methods, and that studies should include data collection about people who do not present to health care facilities as well as those who do. A pilot protocol for studying STD-related health seeking behaviour in developing countries is briefly presented. PMID- 10166100 TI - Using cost-effectiveness analysis to evaluate targeting strategies: the case of vitamin A supplementation. AB - Given the demonstrated efficacy of vitamin A supplements in reducing childhood mortality, health officials now have to decide whether it would be efficient to target the supplements to high risk children. Decisions about targeting are complex because they depend on a number of factors; the degree of clustering of preventable deaths, the cost of the intervention, the side-effects of the intervention, the cost of identifying the high risk group, and the accuracy of the 'diagnosis' of risk. A cost-effectiveness analysis was used in the Philippines to examine whether vitamin A supplements should be given universally to all children 6-59 months, targeted broadly to children suffering from mild, moderate, or severe malnutrition, or targeted narrowly to pre-schoolers with moderate and severe malnutrition. The first year average cost of the universal approach was US$67.21 per death averted compared to $144.12 and $257.20 for the broad and narrow targeting approaches respectively. When subjected to sensitivity analysis the conclusion about the most cost-effective strategy was robust to changes in underlying assumptions such as the efficacy of supplements, clustering of deaths, and toxicity. Targeting vitamin A supplements to high risk children is not an efficient use of resources. Based on the results of this cost effectiveness analysis and a consideration of alternate strategies, it is apparent that vitamin A, like immunization, should be provided to all pre schoolers in the developing world. Issues about targeting public health interventions can usefully be addressed by cost-effectiveness analysis. PMID- 10166101 TI - Health policy development in wartime: establishing the Baito health system in Tigray, Ethiopia. AB - This paper documents health experiences and the public health activities of the Tigray People's Liberation Front (TPLF). The paper provides background data about Tigray and the emergence of its struggle for a democratic Ethiopia. The origins of the armed struggle are described, as well as the impact of the conflict on local health systems and health status. The health-related activities and public health strategies of the TPLF are described and critiqued in some detail, particular attention is focused on the development of the baito system, the emergent local government structures kindled by the TPLF as a means of promoting local democracy, accountability, and social and economic development. Important issues arise from this brief case-study, such as how emerging health systems operating in wartime can ensure that not only are basic curative services maintained, but preventive and public health services are developed. Documenting the experiences of Tigray helps identify constraints and possibilities for assisting health systems to adapt and cope with ongoing conflict, and raises possibilities that in their aftermath they leave something which can be built upon and further developed. It appears that promoting effective local government may be an important means of promoting primary health care. PMID- 10166102 TI - Operational factors affecting maternal mortality in Tanzania. AB - Identification of the main operational factors in cases of maternal death within and outside the health care system is necessary for safe motherhood programmes. In this study, a follow-up was done of all 117 cases of maternal deaths in Ilala district, Dar es Salaam, 1991-1993, at all levels of care. In all, 79% received some medical care whereas 11% arrived too late for treatment. For each case the major operational factors and all health care interventions were defined through interviews with family members and health care staff and from hospital records, and the avoidability of each case was determined. In the health institutions where the women had consulted, the available resources were assessed. It was found that in most cases the husband (29%) or the mother (31%) of the woman decided on her care in cases of complications, and together with the lack of transport, this often caused delay at home. Also, delay in transfer from the district hospital was common. Cases of abortion complications were often not managed on time because of the delay in reporting to hospital or misleading information. Suboptimal care was identified in 77% of the cases reaching health care. Inadequate treatment was identified by the district health staff in 61% and by the referral centres in 12% of their cases. Wrong decision at the district level and lack of equipment at the referral centre were the main reasons for inadequate care. It is concluded that although community education on danger signs in pregnancy and labour is important, provision of the core resources and supplies for emergency obstetric interventions, as well as clear protocols for management and referral, are absolutely necessary for improvement of maternal survival. PMID- 10166103 TI - The status of ORT (oral rehydration therapy) in Bangladesh: how widely is it used? AB - During 1980-1990 BRAC, a Bangladeshi non-governmental organization, taught over 12 million mothers how to prepare oral rehydration therapy (ORT) at home with lobon (common salt) and gur (unrefined brown sugar). This was followed by a strong promotion and distribution of prepackaged ORS by various agencies including the government. In 1993 we assessed knowledge of ORT preparation, its local availability and its use for the management of diarrhoea. Over 9000 households in 90 villages were revisited; 306 government outreach health workers, 296 drug sellers, and 237 village doctors were interviewed; 152 government facilities and 495 pharmacies/shops were visited. ORT prepared by mothers in a sub-sample of the households was analyzed for chloride content and interviewers collected information on use of ORT for diarrhoeal episodes occurring in the preceding two weeks. The data quality was assessed through a resurvey of sample respondents within two weeks of the first interview. Over 70% of the mothers could prepare a chemically 'safe and effective' ORS. A significant proportion of these mothers were very young at the time of the mass campaigns using house to house teaching, implying an intergenerational transfer of the knowledge on ORT. ORT was found to be used in 60% of all diarrhoeal episodes, but the rate varied with the type of diarrhoea, being highest for daeria (severe watery diarrhoea) and lowest for amasha (dysentery). Drug sellers and village doctors now recommend ORT much more frequently than before. Members of the medical profession (qualified and unqualified) still lag behind in prescribing the use of ORT. The availability of pre-packaged ORS in rural pharmacies has improved enormously. There is convincing evidence that the widescale promotion in the past of ORS for dehydration in diarrhoea has led to this marked improvement today. Nevertheless the use of rice-based ORS, culturally appropriate messages and the promotion of ORS with food offer opportunities to further improve the utilization of ORT. PMID- 10166104 TI - Sustaining malaria prevention in Benin: local production of bednets. AB - Through a Benin-Canada participatory research initiative which included both Benin and Canadian non-governmental organizations, a local capacity to produce and market bednets for the prevention of malaria was developed. The development process began following a community-based assessment of local needs and skills. All materials for the manufacture and distribution of the bednets were obtained locally with the exception of the netting which was imported from Canada. The sustainability of the enterprise is enhanced by the community's recognition of the importance of malaria and the culturally acceptable practice of bednet use. PMID- 10166105 TI - Tuberculosis in Bombay: new insights from poor urban patients. AB - This study explores the health seeking behaviour of poor male and female tuberculosis patients in Bombay, and examines their perceptions of the causes and effects of the disease on their personal lives. Sixteen patients who attended an NGO's tuberculosis clinic were interviewed in-depth. Almost equal numbers of respondents stated 'germs' and 'worry' as the cause of tuberculosis. Men worried about loss of wages, financial difficulties, reduced capacity for work, poor job performance, and the consequences of long absence from work. Women were concerned about rejection by husband, harassment by in-laws, and the reduced chances of marriage (for single women), in addition to their concerns about dismissal from work. During the first two months of symptoms most patients either did nothing or took home remedies. When symptoms continued, private practitioners were the first source of allopathic treatment; they were generally unable to correctly diagnose the disease. Respondents shifted to municipal and NGO health services when private treatment became unaffordable. Respondents shifted again to NGO-based services because of the poor quality of municipal tuberculosis control services. The wage-earning capacity of both men and women was affected, but women feared loss of employment whereas men, being self-employed, lost wages but not employment. Married men and single women perceived a greater level of family support to initiate and complete treatment. Married women tried, often unsuccessfully, to hide their disease condition for fear of desertion, rejection or blame for bringing the disease. Women dropped out from treatment because of the pressure of housework, and the strain of keeping their condition secret particularly when the reasons for their movements outside the home were routinely questioned. Health programmes will have to be sensitive to the different needs and concerns of urban men and women with tuberculosis; in the case of women, health care providers will have to make particular efforts to identify and treat married women with tuberculosis completely. PMID- 10166106 TI - How to do (or not to do) ... media analysis for policy making. PMID- 10166107 TI - Will telemedicine become as common as the stethoscope? PMID- 10166108 TI - Outcomes-based accreditation evolves slowly with JCAHO's Oryx initiative. PMID- 10166109 TI - Managing short-term market changes and long-term plans and investments. PMID- 10166110 TI - Hospitals and communities don't need more physicians than HMOs currently require. AB - In an article in the March 1995 Health Care Strategic Management, titled "Physician resource planning must keep pace with evolving markets," health care consultants Richard J. Lohkamp, Ph.D., and H.J. Simmons III presented a set of physician need rates for the more than 30 medical specialties that constitute the typical medical staff for a general community hospital. Since publishing that article, the consulting firm of Longshore+Simmons has used those need rates to help hospitals in several states develop physician resource plans. That experience and subsequent research have led Lohkamp to update his findings and conclusions, and he shares them here. PMID- 10166111 TI - ORYX: how will it affect you? PMID- 10166112 TI - Pneumonia diagnosis? Maybe send them home. PMID- 10166113 TI - Video phones add new twist to home care. PMID- 10166114 TI - Discharge planning in the ED meets patient needs. PMID- 10166115 TI - Don't waste your measurement resources. PMID- 10166116 TI - OSHA indoor air quality regulations would increase health care facilities' compliance burden. PMID- 10166117 TI - Overview: health care facilities must comply with a variety of environmental laws. PMID- 10166118 TI - Environmental hazards and children: policy issues and implications. PMID- 10166119 TI - Powerful networks could result in public utility-style regulation of health care. PMID- 10166120 TI - The tortoise takes the lead: Republicans take small steps on health reform. PMID- 10166121 TI - Spinning straw into gold: converting health accounts receivable to cash via securitization. PMID- 10166122 TI - Assessing and managing risks in acquiring and using health care information systems. PMID- 10166123 TI - Will national cuts in nurses endanger patient care and general litigation? PMID- 10166124 TI - Will funneling seniors into managed care reduce costs? PMID- 10166125 TI - IRS increases scrutiny of tax-exempt hospitals' physician recruitment strategies. PMID- 10166126 TI - FDA delays, unaccountability, raise health care costs and imperil American consumers' lives. PMID- 10166127 TI - Quantum leap: robots run the show in Beth Israel's new laboratory. PMID- 10166128 TI - Make the connection. A wise technology manager could be telemedicine's missing link. PMID- 10166129 TI - A plan for parking. Why you need it--and how to develop it. PMID- 10166130 TI - Up on the roof. That's where you should spend some quality time performing state of-the-art preventive maintenance. PMID- 10166131 TI - NFPA 101 and JCAHO: how to make sure you stay prepared. PMID- 10166132 TI - CDC's new needlestick guidelines get to the point. PMID- 10166133 TI - Rural physician satisfaction: its sources and relationship to retention. AB - This study uses survey data to identify areas of satisfaction and dissatisfaction for primary care physicians working in rural areas across the country. It also identifies the specific areas of satisfaction associated with longer retention within a given rural practice, as well as the characteristics of individuals, practices, jobs, and communities associated with the areas of satisfaction that predict retention. Study subjects comprised a sample of 1,600 primary care physicians who moved to nonmetropolitan counties nationwide during the years 1987 through 1990, with oversampling of those who moved to federally designated health professional shortage areas (HPSAs). Physicians serving in the National Health Service Corps (NHSC) were excluded. Sixty-nine percent of the eligible subjects returned completed mail questionnaires in 1991. Analyses for this study were limited to the 620 primary care physicians who worked more than 20 hours per week in towns of fewer than 35,000 population; who were neither in the military nor the NHSC; and who were not in urgent care, emergency room, or full-time teaching positions. Analyses revealed that the areas of rural physicians' greatest satisfaction were their relationships with patients, clinical autonomy, the care they provided to medically needy patients, and life in small communities. Physicians were least satisfied with their access to urban amenities and the amount of time they spent away from their practices. Retention was independently associated only with physicians' satisfaction with their communities and their opportunities to achieve professional goals. Retention was also marginally related to physicians' satisfaction with their earnings. Among the areas of satisfaction not related to retention were satisfaction with autonomy, access to medical information and consultants, and the quality of doctor-patient relationships. In a subsequent series of analyses of the factors that predict the three areas of satisfaction that were associated with retention (satisfaction with the community, professional goal attainment, and earnings), a variety of physician, work, and community factors were identified. These findings reveal that specific features of rural physicians, their work, and their communities predict each of the various aspects of satisfaction and that only certain aspects of satisfaction predict rural physicians' retention. There are no magic bullets to make rural physicians satisfied in all ways. Nevertheless, there are identified approaches to elevate the specific aspects of rural physicians' satisfaction important to their retention. Programs to improve the satisfaction of rural physicians should focus on those areas of satisfaction that predict longer retention and other important outcomes. PMID- 10166134 TI - Predictors of alcohol use among rural adolescents. AB - There is increasing evidence that alcohol use is becoming more common during childhood and early adolescence. However, little is known about alcohol use among rural youths. This article reports a study of alcohol use among 367 fifth-grade students in two rural South Carolina school districts. More than one third (n = 131) of the fifth graders reported having used alcohol. Of these, 34 percent (n = 44) reported drinking during the previous month; 8 percent had been intoxicated during the previous two months; and 54 percent reported drinking in the home with or without parental approval. Logistic regression analysis was used to determine the predictors of alcohol use by fifth graders. The results indicated that gender (OR = 2.82), mother's alcohol use (OR = 1.86), father's alcohol use (OR = 2.13), and smoking (OR = 8.30) were significantly associated with alcohol use. The findings suggest that prevention programs address cigarette smoking and drinking behaviors of parents to reduce alcohol use and the acquisition of other health compromising behavior by youths. Early intervention approaches must go beyond the schools and target families as well as community populations. PMID- 10166135 TI - Hills, ridges, mountains, and roads: geographical factors and access to care in rural Kentucky. AB - Access to health care remains an important issue facing many individuals. Barriers to health care include financial factors, characteristics of the individuals and of the health care delivery system, as well as geographical factors. Using a telephone survey of Kentucky residents, this study investigated the relationship between the road quality and county elevation and access to health care for individuals in rural and urban areas of the state. Controlling the comparison for known individual characteristics, community characteristics, and medical infrastructure characteristics, this study uncovered that worse road conditions, measured by a road "rideability" index, were associated with longer times to reach medical care. It also found an association between higher county elevations and shorter times to reach medical care. PMID- 10166136 TI - Volume/outcome relationships in small rural hospitals. AB - This article summarizes a study of relationships between hospital volume and patient outcomes for diagnoses commonly treated and procedures commonly performed in smaller rural hospitals. Literature review findings and results of analyses using secondary data for several conditions suggest few if any volume/outcome relationships (with mortality being the main outcome for which data were available). A basic finding of the study is that most conditions and procedures for which volume effects on mortality have been found typically do not pertain to small rural hospitals. However, the available secondary data are weak, and many conditions and procedures have not been studied for small rural hospitals. Therefore, continued monitoring and review are important, as well as improved data systems, further research, and information dissemination on volume/outcome relationships. In particular, examining relationships between volume and outcomes in addition to mortality is critical to a thorough understanding of this topic. PMID- 10166137 TI - State legislation and policy affecting rural hospital conversion and closure. AB - Many rural hospitals have closed or converted to organizations that provide health services other than general, acute inpatient care. However, little is known about why rural hospitals convert rather than close. This study evaluates the relationship between state policy and rates of rural hospital conversion relative to rates of rural hospital closure. The expectation was that the relationship among state policies and rates of conversion and rates of closure differs as a function of whether a state policy facilitates rural hospital transition to alternative models of care or supports them in their existing form. National data were analyzed for all rural hospitals from 1984 to 1991. Results indicate that state policies have done little to facilitate widespread adoption of conversion among rural hospitals. Despite these findings, results also indicate that some state policies have resulted in an increase in the rate of rural hospitals conversions as an alternative to closure. PMID- 10166138 TI - International medical graduates in rural America: the 1987 distribution of physicians who entered the U.S. medical system between 1969 and 1982. AB - This study examines the differential location on Dec. 31, 1987, in nonmetropolitan U.S. counties of a cohort of international medical graduates (IMGs) (n = 246,754) certified by the Educational Commission for Foreign Medical Graduates between 1969 and 1982, and a matched group of U.S. medical graduates (USMGs). Analysis of counties grouped into categories of population size revealed disparities across certain U.S. census divisions. IMGs were distributed disproportionately in the West North Central and East South Central census divisions. The implications of the IMG presence in numerous rural counties is discussed from the perspective of recent policy proposals to reduce the number of IMGs in the United States. PMID- 10166139 TI - An assessment of practice support and continuing medical education needs of rural Pennsylvania family physicians. AB - Family physicians provide the greatest proportion of care in rural communities. Yet, the number of physicians choosing family practice and rural practice has continued to decline. Undesirable aspects of rural practice, such as professional isolation and a lack of or inadequate resources, are assumed to be associated with this decline. This article reports on the practice support and continuing medical education needs of rural family physicians. A mail survey was conducted in 1993 on a purposive sample of family physicians in 39 of 67 rural-designated or urban Pennsylvania counties with low population densities. The physicians identified needs that included patient education materials and programs, community health promotion, federal regulation updates, technical assistance with computers and business management, database software and a videotape lending library, a drug hotline, and mini-fellowships on clinical skill development. A majority of respondents were willing to participate in clinical educational experiences for students and residents. Some physicians indicated a lack of interest in access to information through telecommunications, e.g., video conference referrals and consultations. Overall, findings revealed that family physicians need and are receptive to a variety of practice support and continuing education programs. A practice support program coupled with policy coordination among public and private organizations is likely to lessen complaints by rural primary care physicians. PMID- 10166140 TI - Baby boomers fuel demand for more plastic surgeries. PMID- 10166141 TI - In benchmarking, draping shows big variations. PMID- 10166143 TI - Biggest challenge to cost reduction is total hip replacement. PMID- 10166142 TI - Moving beyond preference card saves millions. PMID- 10166144 TI - Advanced RNs support care across continuum. PMID- 10166145 TI - Supply chain efficiencies could save billions. PMID- 10166146 TI - The five big challenges OR managers face. PMID- 10166147 TI - Meetings: do we all know why we're here? PMID- 10166148 TI - Is your job out of control? You're not alone. PMID- 10166149 TI - Coding for emergency department services. PMID- 10166150 TI - New England ponders managed care. PMID- 10166151 TI - The road ahead. Health care reform will be a driving force in long-term care in 1997. PMID- 10166153 TI - Making first impressions count. PMID- 10166152 TI - Top 1996 nursing facility chains. PMID- 10166154 TI - Filing for routine cost limit exceptions. PMID- 10166155 TI - Medical device reports raise and red flag. PMID- 10166156 TI - From data gathering to care management. PMID- 10166157 TI - Death be not swift enough. Fraud fighters begin to probe the expense of hospice care. PMID- 10166158 TI - New health and nutrition surveys launched. PMID- 10166159 TI - New Health Information Council. PMID- 10166160 TI - National Health Committee advice on fairer treatment for depression. PMID- 10166161 TI - Breathing just a dream for thousands of New Zealand children. PMID- 10166162 TI - All must seek ways to better deliver health services. PMID- 10166163 TI - Mental health workforce development. PMID- 10166164 TI - National Health Committee calls for more consumer certainty. PMID- 10166165 TI - North Health serving older people well. PMID- 10166166 TI - Pathways to integrated services. Ministry of Health. PMID- 10166167 TI - New centre offers early intervention and education on youth health problems. PMID- 10166168 TI - Examples of CHE (Crown Health Enterprises) initiatives over the past three years. AB - In the Overview to the briefing on Crown Health Enterprises to the incoming Minister, produced by the Crown Company Monitoring Advisory Unit and released under the Official Information Act, two observations were made. The first was that, despite the fact that 21 out of the 23 CHEs were in deficit, there had been considerable improvement in the effective and efficient management of many CHEs. It was also observed that there needed to be a recognition that with any organisation, particularly when it is a health organisation undergoing a period of major change, its day-to-day successes tend to be invisible while its failures tend to be glaring. An appendix detailing some of the major successful initiatives CHEs consider they have made over the past three years reads as follows. PMID- 10166169 TI - Perspectives. Regs awaited as telemedicine braces for life after subsidies. PMID- 10166170 TI - Resource scheduling: improving services through access management. PMID- 10166171 TI - Finally, a uniform insurance card is on the way! PMID- 10166172 TI - The Ambassador Program. PMID- 10166174 TI - Unveiling of health care reform proposal postponed. PMID- 10166173 TI - Integration of clinical and finance. PMID- 10166175 TI - The balancing act of access management. PMID- 10166176 TI - "Access to accounts receivable.". PMID- 10166177 TI - Smoke out. AB - This year the EPA will finalize rules that will make medical waste incineration nearly a thing of the past. The author reports on an array of alternative approaches. PMID- 10166178 TI - Autopsy of a smear. PMID- 10166179 TI - Conversion factor. An interview with California Attorney General Dan Lungren. Interview by Craig Havighurst. PMID- 10166180 TI - Resistance movement: the antibiotic crisis in hospitals. AB - The near-miraculous healing power of antibiotic is being undermined by the rapid evolution of drug-resistant bacteria. The costs, in human and economic terms, could be staggering for all caregivers and patients, but especially for institutional providers like hospitals. In an article adapted from the Journal of the American Medical Association, Dr. Goldmann explains why antibiotic resistance is a crisis and how the danger can be mitigated. PMID- 10166181 TI - Rational capacity: right-sizing delivery in the health systems era. PMID- 10166182 TI - Medicare risk and reform: a survival manual. PMID- 10166183 TI - From theory to practice: AHCPR's new mission. AB - Clifton Gaus recently announced that he would step down after three years as head of the Agency for Health Care Policy & Research. Many give him credit for ensuring the Agencies very survival during the last two years of budget negotiations. AHCPR's future largely hinges on its ability to shift its mission. PMID- 10166184 TI - Managing and delivering care. PMID- 10166185 TI - ERA for hospitals? PMID- 10166186 TI - Data ... health spending, Medicare, Medicaid, managed care, and insurance. PMID- 10166187 TI - Under siege. PMID- 10166188 TI - Getting with the program. AB - Corporate compliance programs are rapidly becoming essential. The author, a corporate compliance officer from a six hospital system in Omaha, Nebraska, offers a concise guide to their design and implementation. PMID- 10166189 TI - The Mammography Quality Standards Act and interventional mammography procedures. AB - The Food and Drug Administration (FDA) is in the early stages of developing regulations regarding mammographic interventional procedures. When implemented, the regulations have a significant impact on the way these procedures are performed. As part of the development process, the FDA is working with the American College of Surgeons (ACS), the American College of Radiology (ACR), and other interested professional and consumer groups. The goal is to ensure access to high-quality services for the diagnosis of breast cancer. PMID- 10166190 TI - The 1997 Medicare fee schedule and results of the five-year review. PMID- 10166191 TI - The effects of health care reform on graduate medical education and research. PMID- 10166192 TI - Practice guidelines and liability implications. AB - It should be clear that the authors of this article are not enamored of practice guidelines, thinking them of much more potential harm than good. On the other hand, if practice guidelines are deemed essential, then they must be written with the goal of quality patient care advocacy and with an eye toward the possible damage they may do. PMID- 10166193 TI - Outcomes assessment: a primer. AB - The routine assessment of outcomes, including clinical and functional outcomes, charges, cost and effectiveness data, and complications of treatment, as well as HRQOL and patient satisfaction, are essential to demonstrate and ensure the quality of care. Secondary to patient-related concerns, outcomes data provide a tool for use by the surgeon in proving (and improving) the quality of care rendered. These tools, as well as surgical input into the development of outcomes indicators, will allow surgeons to practice more effectively in a managed care environment. PMID- 10166194 TI - The fraud and abuse provisions of the Kassebaum-Kennedy bill. PMID- 10166195 TI - Adding value: what healthcare can learn from industry. AB - How can superior outcomes be provided to satisfied patients using the appropriate amount of resources? That's the $64,000 question that healthcare organizations are striving to answer--indeed, must answer--to survive in the managed care marketplace, says Stephen Shortell, Ph.D., A.C. Buehler Distinguished Professor of Health Services Management of Northwestern University. The business world can teach healthcare leaders how to increase their organizations' competitive edge, he says, in four areas: having a deep knowledge of the customer, looking for ways to add value, using innovation as a key to adding value and defining value in economic terms. PMID- 10166196 TI - The three components of a patient-friendly scheduling system. AB - Carle Clinic, which serves the Champaign-Urbana, Ill., area, has built a reputation for making efficient use of patients' time at the facility. How does it do it? With state-of-the-art scheduling software, established rules for setting up appointments, and a trained and knowledgeable staff. PMID- 10166197 TI - Seven steps for adding value to integrated delivery systems. AB - "Value is a spectrum of needs that you seek to fulfill," says Dean C. Coddington, senior author of Making Integrated Health Care Work. And adding value to products and services is becoming more crucial as healthcare organizations look for ways to stand out among competitors. The seven basic components of value for an integrated system, says Mr. Coddington, are improving quality of care, improving service, improving accessibility, reducing unit costs, increasing operating efficiency, strengthening customer ties and enhancing product offerings. In this issue, The Quality Letter reports on how several systems have used these seven components to increase patient and purchaser satisfaction. PMID- 10166198 TI - Driving fear out of the workplace. Interview by Mary Darby. AB - Healthcare organizations grappling with market demands to reduce costs and demonstrate superior quality are especially vulnerable to workplace fear, says consultant and author Kathleen D. Ryan. When fear paralyzes change efforts, systems suffer. Ms. Ryan discusses strategies and policies for building trust, collaboration and respect. PMID- 10166199 TI - Staggered dosing chart improves i.v. antibiotic scheduling. AB - At St. Marys Hospital Medical Center in Madison, Wis., some 38% of i.v. antibiotics had more than a two-hour delay in initiating therapy or were not being administered within standard dosing schedules. QI team members developed a simple chart that reinforces the need to start the first dose as soon as possible and guides staff on staggering doses to transition dosing to a standard i.v. dosing schedule. The result--one problem virtually eliminated. PMID- 10166200 TI - Closing the gap between what we know and what we do. AB - Too often, clinical investigators have identified techniques to improve patient care for certain conditions, but those techniques slowly find their way into practice. At the Institute for Healthcare Improvement, new methods that accelerate the implementation of improved clinical practices are being taught to participants in Breakthrough Series collaboratives. These methods have to do with testing change in small increments, based on "just enough" measurement; analyzing the results to ensure the change is an improvement; and moving on to the next small-scale change test. Several experts and participants talk about breakthroughs they've seen as a result of several incremental improvements. Using breakthrough methods, they've dealt with several clinical problems, resulting in improvements such as reduced emergency room delays and improved scheduling of i.v. therapy. PMID- 10166201 TI - The impact of the NHS internal market on the merger of colleges of midwifery and nursing. Not just a case of putting the cart before the horse. AB - Presents and discusses the findings from a research project into the impact of the NHS internal market on the merger of colleges of midwifery and nursing. Begins by briefly describing the major changes which have been introduced in the NHS since 1979 and sets these within the context of the charging nature of the public sector in the UK. Second, describes the background to the research and the methods employed. Continues with a brief review of the approaches to the change management process, which in particular draws attention to the importance of the environment in which the organization operates, and of the relationship between management styles and the different approaches to organizational change. Presents a case study of the merger of five colleges of nursing and midwifery. Follows with a discussion of the case study and the conclusions drawn from it for the process of change within the NHS. PMID- 10166202 TI - Problems in the delivery of medical care to the frail elderly in the community. AB - Describes how closure of hospital long-stay wards for the frail elderly and their replacement by care in the community has led to a mismatch of skills and patients. Restrictive practices within the medical profession, and rigid adherence to the existing referral system from general practitioner to hospital consultant can operate against the interests of patients in the community. Some means must be found to bring skilled medical care to patients in residential and nursing homes. If this cannot be achieved within existing NHS structures, local authorities and the private sector should consider appointing their own consultants to liaise with NHS personnel as necessary. PMID- 10166203 TI - Adapting a strategic management model to hospital operating strategies. A model development and justification. AB - Industrial organizations have employed the process of strategic management in their attempts to cope effectively with global competitive pressures, while attempting to build and maintain competitive advantage. With health-care organizations presently trying to cope with an increasingly turbulent environment created by the uncertainty as to pending legislation and anticipated reform, the need for such organizational strategic planning is apparent. Presents and discusses a methodology for adapting a business-oriented model of strategic planning to health care. PMID- 10166204 TI - The dilemma of life and death decision making: the conflict between reason, rationing, and relatives. PMID- 10166205 TI - A case of successful technology transfer to health care. Total quality materials management and just-in-time. AB - Describes one approach to meeting the healthcare cost reduction challenge through the hospital materials management function. Highlights the value of taking a proactive stance to meet the challenge; transferring technology across industry sectors, such as employing a just-in-time inventory management system in clinical areas of hospital materials management, and adopting a win-win managerial philosophy. Features a case study to demonstrate the ideas in practice. PMID- 10166206 TI - Information strategy in the NHS: issues and challenges. AB - There has been considerable discussion of the nature and scope of information that purchasers and providers must acquire and use in the post-review NHS. Somewhat surprisingly, this has not been complemented by discussion of the potential for computer systems to support information management. This in spite of the publication of the NHS Information Management and Technology Strategy, which seems set to shape the way in which purchasers and providers manage data into the next century, and expenditure on computer systems which will be in the order of hundreds of millions of pounds over the next few years. Discusses some of the key challenges involved in implementing an IT infrastructure across the NHS, and identifies five issues which will substantially determine the success of the strategy. PMID- 10166207 TI - Strategic marketing in the NHS: Kwik-health NHS Trust. AB - Unlike managers in most service organizations, hospital managers do not have significant control over the shape or cost of the service product or the manner of its delivery. Hence, the crucial issue for hospital management to address is how to develop the marketing of a service the control of which is divorced from those with the strategic market perspective. While the internal management of hospital care in NHS is in its infancy, initial developments such as clinical directorates point the way forward in creating a market orientation within provider units. Ultimately, it must be considered what degree of influence over clinical decisions affecting hospital services is realistic, ethical and desirable for strategic marketing and business services. Arguably there is a case for the adoption of some middle ground, with both sides moving from their present positions but perhaps with the clinicians moving furthest. PMID- 10166208 TI - Privatizing health services: alternative models and emerging issues for public health and quality management. AB - Concerns about the cost, quality, and efficiency of services provided within public sector health care systems are leading policy makers and health care administrators to reinvent government and develop alternative methods for the delivery of services traditionally offered in the public sector. Privatization structures that incorporate strong quality management principles, both through formal accountability systems and through financial risk-sharing arrangements, appear to hold the greatest promise for achieving quality and efficiency goals. PMID- 10166209 TI - Privatization of a public hospital: a quality improvement strategy. AB - Public hospitals face mounting challenges posed by the rise of managed care, increasing hospital competition, growing responsibilities in indigent care, and stagnant public sector revenues. Privatization exists as a viable strategy for reengineering the structure and operation of public hospitals to meet the new demands of quality and efficiency imposed by a rapidly changing health care environment. PMID- 10166210 TI - Providing public health services through an integrated delivery system. AB - This article examines a recently implemented strategy to transfer responsibility for local public health service delivery from a county health department to a hospital-based integrated delivery system. Innovative quality management efforts at both local and state levels offer opportunities for sustained improvement in the availability and adequacy of public health services under this arrangement. PMID- 10166211 TI - Privatizing maternal and child health services in Texas: reinventing Title V programs. AB - In November 1994, the Texas Department of Health embarked upon a major initiative to "reinvent" maternal and child health services funded through the Title V Maternal and Child Health Block Grant and related state general revenue. This article describes the rationale, planning process, and implementation issues associated with the initiative to redefine the fundamental roles and priorities of the department and traditional public health entities in the delivery of maternal and child health services. PMID- 10166212 TI - Ensuring quality and access in managed care: how well are we doing? AB - Through mergers, acquisitions, joint ventures, and contracting, proprietary managed care organizations are steadily assuming health care responsibilities formerly delegated to government-owned and not-for-profit health care institutions. An examination of existing quality assurance initiatives for managed care organizations reveals several areas of concern: incentives for providing substandard services; a shortage of visible, measurable, and enforceable quality standards; and inadequate data and reporting systems for producing reliable quality indicators. PMID- 10166213 TI - Privatizing public mental health and substance abuse services: issues, opportunities, and challenges. AB - Much like the medical care system, delivery systems for mental health and substance abuse services are being transformed rapidly by managed care. Public sector systems are now facing challenges to transfer service delivery responsibilities to private managed behavioral health care organizations as a way of containing treatment costs and realizing operational efficiencies. These privatization efforts entail a range of quality management issues that are specific to mental health and substance abuse problems, treatments, and clients. PMID- 10166214 TI - Bridging public and private sector quality assurance. AB - Just as the private sector has emerged as the predominant force the greater efficiency in the delivery of health care services, so too is the private sector gaining importance as a source of quality oversight strategies. Public reliance on private sector quality assurance efforts is being fueled by such developments as the growth in the number and diversity of private health care accrediting agencies, and the increase in consumer and purchaser-driven demands for comparative information about the quality of health care providers. PMID- 10166215 TI - Public health, privatization, and market populism: a time for reflection. AB - The political, social, and economic ideology fueling the movement toward privatization in health care may be characterized as "market populism." Whether or not public health agencies retain their traditional roles in personal health services delivery, these organizations must serve as the predominant external source for quality monitoring, oversight, enforcement, and advocacy for communities in an environment that regards the private market as a panacea. PMID- 10166216 TI - Risk-adjusted quality outcome measures: indexes for benchmarking rates of mortality, complications, and readmissions. AB - This article describes a risk-adjusted approach for profiling hospitals and physicians on quality outcomes using readily available administrative data. By comparing risk-adjusted rates of mortality, complications, and readmissions to rates for peers, national norms, and benchmarks, this approach enables purchasers and providers to compare the performance of providers in terms of both favorable and adverse outcomes. PMID- 10166218 TI - Benchmarks: investing in civil rights and diversity. AB - HSL talks to leaders of four healthcare organizations in various states of developing programs for ensuring a workforce representative of the communities they serve. Programs range from internships for future leaders to creating diversity ambassadors among the workforce. PMID- 10166217 TI - Averting a doctor glut. PMID- 10166219 TI - New York reforms mean new deals, affiliations for hospitals. PMID- 10166220 TI - Sentara Health System--reinventing the organization. AB - This Norfolk, Va.-based system began a five-year effort to change the way it does business by streamlining governance and involving physicians in management. Now in its third year of "Reinventing Sentara," it's focusing on increasing covered lives and cutting costs while increasing quality; some 15 priority redesign projects were identified and half of those have been implemented. PMID- 10166221 TI - Sharp/Columbia deal terminated; raises questions about future arrangements. PMID- 10166222 TI - A civil rights primer for healthcare organizations. AB - "Diversity helps us build a better product for the diverse customers we're serving," says University of Michigan Hospitals' Ellen J. Gaucher. And several healthcare organizations stand out for their efforts to build a diverse workforce. Leaders agree that an atmosphere open to diversity starts at the top. They identify four major steps that board members and senior executives can take to ensure a system that welcomes all racial and ethnic groups into the fold. PMID- 10166223 TI - Help wanted. PMID- 10166224 TI - Reaching beyond the expected. Interview by John McCormack. PMID- 10166225 TI - Home care giant builds an IT plan. AB - A satellite network and other technologies enable Apria Healthcare Group to tie together sites across the nation and improve service. PMID- 10166226 TI - Building faster networks. PMID- 10166227 TI - Assessing document imaging's role. PMID- 10166228 TI - HMOs test the Internet. PMID- 10166229 TI - No more late-night hospital trips. PMID- 10166230 TI - Pharmacotherapy quality improvement: use of a clinical rule-based application. AB - Heritage's drug usage evaluation (DUE) program focuses on analyzing the dynamics of prescribing, dispensing, and medication usage data for insurers, managed care organizations (MCO), and others involved in the management of pharmacotherapy in the ambulatory care setting. The addition of a new clinical rules-based system (Athena) has increased the flexibility, scope, and speed of Heritage quality improvement products. Its integration into benchmarking, profiling, and disease management programs is described. PMID- 10166231 TI - Formulary management: antibiotics and therapeutic interchange. AB - A well-managed formulary provides pharmacy managers with opportunities for decreasing drug expenditures. Therapeutic interchange constitutes one of the many programs under a formulary system which may yield cost savings as improved patient outcomes. The process of therapeutic interchange is described and compared with therapeutic substitution and generic substitution. A procedure for developing and implementing a therapeutic interchange program is presented with case studies. PMID- 10166232 TI - Antibiotic streamlining: development and justification of an antibiotic streamlining program. AB - Several techniques can be applied to streamline or optimize antimicrobial therapy in the hospitalized patient. As soon as there is a documented clinical response to intravenous therapy, the antibiotic can be switched to the oral route of administration. This antimicrobial streamlining technique is called switch therapy. This article presents the development of the switch therapy concept, the good clinical outcome obtained with switch therapy in patients with community and nosocomial pneumonia, as well as the cost-savings to our institution after the implementation of this program. PMID- 10166233 TI - A comparative profile of clinical pharmacy activities for pharmacotherapists and residents in a university hospital. AB - Due to increasing financial pressure on maintaining and improving pharmacy services, there is a need for productivity data and time distribution among different activities for pharmacy practice residents and their faculty preceptors (pharmacotherapists). This study measured the clinical productivity of 13 residents and 25 pharmacotherapists for a 14-day period. The study identified the average time (minutes) and frequency spent each day on categories of activities, which included direct patient care, chart use, rounds, professional encounter, teaching, research, and administration. Results showed that the productivity profiles for residents and pharmacotherapists were comparable. Findings were utilized to defend the educational programs for the department and as a baseline for periodic monitoring of the productivity of these programs. PMID- 10166234 TI - Interviewing pharmacists for positions in patient-focused health care organizations. AB - Providing pharmaceutical care requires pharmacists to have the personal attributes necessary to function as part of a health care team. Assessing candidates' personal or behavioral values during the employment interview can be a valuable tool to determine future performance. The use of a structured interviewing format designed to identify predetermined key behavioral indicators as an assessment tool is described. Through detailed probing, candidates' previous actions in specific situations are used as predictors of future performance by the interviewing organization. Use of the interviewing tool described improves the likelihood of selecting candidates with behavioral values deemed important to the organization. PMID- 10166235 TI - Outsourcing inpatient i.v. compounding: expense and medication error implications. AB - A quasi-experiment was conducted to evaluate differences in intravenous (i.v.) drug compounding costs and frequency of medication administration errors of omission before and after outsourcing the hospital's i.v. admixture refill program to an alternate site home i.v. infusion pharmacy. As part of the outsourcing changes, the pharmacy redeployed an i.v. admixture technician to do i.v. recycling on the nursing units. The study was a single subject, pretest, posttest (within subjects) design using an observer. The independent variables were outsourcing and having an i.v. recycling technician. The dependent variables were medication errors of omission and costs directly associated with the two i.v. programs. A statistically significant reduction in the frequency of medication administration errors of omission was associated with implementation of the outsourcing program. In addition, first year expenses were reduced by an estimated $86,356. PMID- 10166236 TI - Developing critical pathways containing antimicrobial therapy. AB - Today's health care institutions are being challenged to provide high quality health care in the most efficient way possible. One approach taken by many organizations has been the development of critical pathways in order to minimize delays in therapy, facilitate the best outcomes, optimize resources, and maximize quality. Opportunities exist for these protocols to address a number of antimicrobial therapy issues and the multidisciplinary development process provides an excellent opportunity for pharmacist involvement. PMID- 10166237 TI - Implementation of a service improvement program for ambulatory pharmacy services. PMID- 10166238 TI - Downsizing implication. PMID- 10166239 TI - Medication error prevention: profiling one of pharmacy's foremost advocacy efforts for advice on error prevention. AB - Medication errors have become a growing concern with the increase in the number of critically ill patients, in the complexity of drug therapy and in the use of more potent, dangerous drugs. The Institute for Safe Medication Practices (ISMP), a nonprofit organization founded three years ago, is in the forefront of medication error prevention efforts. Working with practitioners, regulatory agencies, healthcare institutions, professional organizations and the pharmaceutical industry, both nationally and internationally, ISMP provides timely and accurate medication safety information through its educational programs, site-reviews, and ongoing publications. This article reviews the work of ISMP and offers recommendations for managers to begin error prevention strategies. PMID- 10166240 TI - The role of the pharmacy department in the prevention of adverse drug events: a survey of current practices. AB - Adverse drug events have received a great deal of publicity during he past several years. The tracking and prevention of medication errors is an important part of ensuring quality care for patients. The American Society of Health-System Pharmacists, and the Institute For Safe Medication Practices are two groups who have published recommendations on the prevention of adverse drug events in hospitals. This study provides an informative analysis of the status of implementation of these recommendations by hospital pharmacists in Louisiana. PMID- 10166241 TI - Computerized medication administration records decrease medication occurrences. AB - Studies have demonstrated that medication errors occur at a number of locations in the continuum between ordering of drug therapy and administration of the medication. Computer management of patient medication profiles offers the opportunity to enhance communication between pharmacists and nurses, and to decrease medication errors and delays in delivery of therapy. A number of authors have postulated that computerization of medication profiles would enhance medication delivery accuracy and timeliness, but no study has demonstrated this improvement. We report the results of a retrospective analysis undertaken to assess the improvements resulting from sharing a computerized medication record. We used a broader definition of medication occurrences that includes the more traditional definition, and averted errors, delays in delivery of medications and information, and disagreements between pharmacy and nursing medication profiles. We compared medication occurrences reported through an existing internal system between two periods; the first when separate pharmacy and nursing medication records were used, and the second period when a shared medication record was used by pharmacy and nursing. Average medication occurrences per admission decreased from 0.1084 to 0.0658 (p < 0.01). Medication occurrences per dose decreased from 0.0005 to 0.0003 (p < 0.01). The use of a shared medication record by pharmacy and nursing led to a statistically significant decrease in medication occurrences. Information shared between the two professions allowed timely resolution of discrepancies in medication orders, leading to better execution of drug therapy, decreased medication occurrences, and increased efficiency. PMID- 10166242 TI - Pharmacist clinical practice. PMID- 10166243 TI - Team approach to patients receiving conscious sedation. PMID- 10166244 TI - Performance measures in ambulatory pharmacy. PMID- 10166246 TI - Observation units key to the future. PMID- 10166247 TI - Create an express admissions unit. PMID- 10166245 TI - Formulary management at a tertiary care teaching hospital. PMID- 10166248 TI - Inspector General clarifies billing rules. PMID- 10166249 TI - Pearls of wisdom from ED leaders. PMID- 10166250 TI - Teaching physicians about managed care: the upsides of integrated systems. PMID- 10166251 TI - Frequently asked questions about recruiting mid-level providers. PMID- 10166252 TI - Physician executive followed gut instincts to succeed. PMID- 10166253 TI - Integration pushing the emergence of new physician management positions. PMID- 10166254 TI - Stressed-out docs in IDSs. PMID- 10166255 TI - Integration leads to change, which can also mean failure if certain needs are not met. PMID- 10166256 TI - Physician extenders are part of the team in the '90s. PMID- 10166257 TI - Warning: COBRA contract conflicts can leave you some litigious decisions. AB - Many managed care contracts run contrary to federal law when it comes to the screening and treatment of out-of-plan patients who present to the emergency department. Understanding the law and writing and using specific policy guidelines can help you avoid an unpleasant meeting with federal prosecutors. PMID- 10166258 TI - Don't let COBRA cut your economic lifeline. PMID- 10166259 TI - Looking to save millions each year? Try global pricing. AB - Global pricing is gaining in popularity as managed care payers look for efficient and innovative ways too provide care. Properly structuring global deals requires physician-hospital organizations to accurately define what services they are efficient at providing and also proving to the payer that they have the administrative and clinical ability to effectively manage global deals. PMID- 10166260 TI - To blaze the best trail, get physicians to lead. AB - Global packaging of medical services can potentially save physician-hospital organizations millions of dollars annually. Key is to aggressively involve physicians in structuring the program. PMID- 10166261 TI - Viatical settlements: easing the financial burden. AB - Most types of life insurance policies can be sold. Viatical companies can purchase the life insurance policies of people who are terminally ill and pay those people a lump sum; the payment the patient receives is tax free and can be used to pay medical expenses while the patient is still living. PMID- 10166262 TI - Labor law for the nonunion agency. AB - Providers should not assume that because they are union free they need not worry about labor law. An agency can have obligations under labor laws even when no union is involved. Who are nonunion employees, legally speaking? What rights do they have, and how can agencies ensure that they are in compliance with those rights? PMID- 10166263 TI - Protecting urban home care workers. AB - Unfortunately, violence against home care workers is on the increase. The varied work schedules and plans of home care staff can present challenges when instituting a safety program; not all urban agency staff work in an office, nor do they all get to their job sites the same way. One agency has developed a comprehensive security and safety program to protect both office and field staff. PMID- 10166264 TI - Understanding the Family and Medical Leave Act. AB - In April 1995 final regulations for the Family and Medical Leave Act (FMLA) of 1993 were issued. The act is very detailed, complicated, and difficult to implement for home care agencies. Agencies need to gain a good working understanding of the FMLA to avoid inadvertent violations. PMID- 10166265 TI - Charting by exception. AB - Documentation takes up a significant portion of a home care nurse's daily workload. As cost containment measures reduce the amount of time nurses can spend with each patient, they need to find ways to make documentation more efficient to avoid compromising patient care. One agency found that charting by exception reduces documentation time so that nurses can devote more hours to hands-on care. PMID- 10166266 TI - Informed consent issues in home care. AB - Providers have a responsibility to inform patients about the care they receive. With this responsibility, however, come liabilities. Agencies need to be aware of both the responsibilities and liabilities involved with informed consent and address them in everyday operations--failure to comply with the federal requirements can result in termination or nonrenewal of a provider's Medicare agreement. PMID- 10166267 TI - Home care aides and disenfranchised grief. AB - Home care aides have been called the core of the home care industry. They spend up to three times more time with clients and their families than other health care professionals, and are often with the patients until death occurs. Results from a survey of aides' feelings about the death of their patient point to the need for timely acknowledgment and affirmation of the aides' grief and feelings of loss. PMID- 10166268 TI - Labor issues should be caring issues. PMID- 10166269 TI - Influence OSHA regulations and enforcement. PMID- 10166270 TI - The Medicare Transaction System: an update. PMID- 10166271 TI - Creating and managing the electronic mailroom. PMID- 10166272 TI - Preserving patient confidentiality. PMID- 10166273 TI - Data trends. Key organizational performance indicators. PMID- 10166274 TI - Managed care and quality: a contradiction in terms? PMID- 10166275 TI - Achieving functional integration: a continuum case study. AB - Inova Mount Vernon Hospital, a part of the Inova Health System in northern Virginia, has developed a plan to redesign its joint replacement service to better coordinate patient care across the entire continuum. The redesign incorporates services, such as presurgery therapy and patient education, registration and insurance activities, rehabilitation, and home care, into an existing acute care joint replacement clinical pathway to create a continuum of care. To encourage the provider partners to integrate the joint replacement service, Inova Mount Vernon Hospital developed new types of clinical, economic, and service outcome measurements to view episodes of care from a system perspective. These measurements will be used to assess the success of the functional integration effort. PMID- 10166276 TI - OIG solicits modifications to safe harbor enforcement policies. AB - One of the provisions of the Health Insurance Portability and Accountability Act of 1996 requires the Office of the Inspector General (OIG) to seek proposals and recommendations regarding OIG Medicare/Medicaid enforcement policies each year. The OIG is required to report to Congress on the recommendations it receives and the action it decides to take on them. One policy that the OIG specifically is seeking input on relates to safe harbors. The enforcement policy on safe harbors is of particular interest to healthcare providers seeking to integrate because it allows them to request modifications that will facilitate integration. Providers in integrated delivery systems that have legitimate business arrangements but that do not qualify for existing safe harbors can use the OIG's invitation as an opportunity to make a case for safe harbor protection. PMID- 10166277 TI - Achieving incremental volume increases. AB - Despite provider assumptions that managed care contracts will yield incremental increases in patient volume, there are no guarantees that volume increases will be realized. Providers can improve the likelihood that incremental volume increases will be achieved, however, by including certain provisions in managed care contracts related to volume-based discounts, limitations on network size and composition, access to physicians, provider directory listings, patient financial incentives, service scope/carve-outs, and participation in all service products offered by the managed care organization. Negotiating such provisions may be difficult, but providers and managed care organizations that reach agreement on these provisions gain mutual understanding and frequently can form more successful relationships. PMID- 10166278 TI - The Oregon Health Plan: lessons learned. AB - The widely publicized Oregon Health Plan (OHP) was established in 1989 to provide the residents of Oregon with universal access to health insurance. The OHP encompassed provisions to reform Medicaid, which included relaxing eligibility requirements and requiring Medicaid beneficiaries to enroll in managed care plans. To date, the OHP has improved access to health care facilitated the efficient use of healthcare services. However, problems with the program exist- failure of Medicaid beneficiaries to choose a health plan and primary care physician, inadequate education of the enrollee population, and frequent enrollee turnover, for example. These problems offer lessons to the rest of the nation as Medicaid managed care plans proliferate. PMID- 10166279 TI - How much does excess inpatient capacity really cost? AB - Traditional healthcare cost-accounting methods determine the cost of unused inpatient beds by calculating the fixed cost per patient-day using the number of patient days of inpatient care expected to be provided. Unfortunately, this approach can result in a misleading estimate of fixed costs per patient-day that fluctuate over time as expected levels of inpatient care fluctuate. A recommended alternative approach, practical capacity cost accounting, determines the cost of unused inpatient beds by calculating fixed costs per patient-day using the maximum feasible patient days of inpatient care that can be provided in a year. This approach yields stable fixed costs for more accurate costing of unused capacity and better long-range planning and decision making. PMID- 10166280 TI - Self-reporting Medicare and Medicaid overpayments. AB - Refunding a significant overpayment to the Medicare or Medicaid program can subject a healthcare organization to government scrutiny that can consume the time and energies of key staff members, risk potential litigation by shareholders, and possibly lead to severe sanctions. Delaying a refund, however, may precipitate even more costly consequences, such as triple damages and heavy monetary penalties. The government has stepped up its efforts to detect and punish fraud and abuse; therefore, providers should refund overpayments promptly. Failure to do so may constitute a crime, increase the likelihood of a whistleblower exposing the offense, or result in an increase in the amount of penalties imposed. Healthcare organizations can prevent overpayment abuses from occurring by following recommended procedures for making refunds, addressing underlying billing problems, and ensuring that senior management oversees the entire claims payment process. PMID- 10166281 TI - Making unofficial inventory official. Financial managers who record and control unofficial inventory make the most of a valuable asset. AB - All healthcare organizations maintain supplies in their facilities that have not been booked as assets on their general ledgers. This unofficial inventory is often overlooked because it is not as significant a cost-driver as salaries and capital equipment. But unofficial inventory can affect an organization's bottom line when it is not reflected as an asset on statements of activities. Healthcare financial managers, working with their organization's materials managers, and other department personnel, can take steps to correct the problem of unofficial inventory by identifying locating, and controlling such inventory throughout the facility. Appropriate accounting procedures to handle the conversion of unofficial inventory to official inventory status also should be implemented. PMID- 10166282 TI - The impact of IRS-mandated employee reclassification. AB - The IRS requires healthcare organizations to properly classify their workers as either independent contractors or organizational employees. In order to protect their organizations from IRS-imposed monetary fines, healthcare financial managers must understand how the IRS evaluates employment status and the consequences their organizations will face if they misclassify employees. Changes involving the status of independent contractors and organizational employees instituted by the Small Business Job Protection Act of 1996 are favorable to employers and clarify safehaven provisions under section 530 of the 1978 Revenue Act. Significant changes include requiring the IRS to notify employers of section 530's relief provisions when an audit begins, expanding section 530 relief, clarifying industry practice relief provisions, and shifting the burden of proof to the IRS. In addition to Federal legislation, the IRS introduced administrative initiatives, such as those contained in Announcement 96-13, to clarify worker reclassification issues. In Announcement 96-13, the IRS implemented a three-part plan that includes a test classification settlement program, an appeals process, and a training manual to clarify these issues. PMID- 10166283 TI - Clinical observation units help manage costs and care. AB - Clinical observation units were created to avoid questionable admissions and short inpatient stays that were likely to result in Medicare payment denials. With the rise of managed care, these units also can contribute to ensuring optimal reimbursement by helping manage patient flow. Hermann Hospital, a facility affiliated with the University of Texas, Houston, initially opened an improved observation unit in 1992, but recorded a 13 percent Medicare payment denial rate and operating losses of as much as $20,000 per month during the first five months of the unit's operation. A multidisciplinary team was formed to address the observation unit's low utilization and payment denial problems. The problems identified included missed opportunities for admissions, inappropriate admissions, and extended stays. The facility took corrective measures based on the quality team's assessment and corrective measures developed by the utilization management committee and quality teams. The clinical observation unit now sustains a zero denial rate and steady revenue increases resulting from improved utilization of the unit. PMID- 10166284 TI - Effects of the Health Insurance Portability and Accountability Act of 1996. AB - As small business employers, physician group practices will be subject to provisions of the Health Insurance Portability and Accountability Act of 1996 related to coverage guarantees. The act prevents currently insured individuals from losing coverage if they change jobs, limits insurance exclusions related to preexisting conditions, and requires insurers that offer small group coverage to make such policies available to all small employers. While the act's coverage guarantees may help group practices to attract good employees who formerly feared losing their coverage if they changed jobs, it also is likely to increase administrative costs, lead to premium increases, and limit to the choices for practices that must shop for health plans. Practices planning to purchase health insurance can ensure that they receive the best coverage possible by carefully comparing policy features and the claims services potential insurers provide. PMID- 10166285 TI - Physician equity alliances: attractive alternatives to PHOs. AB - Physician equity alliances are becoming attractive alternatives to PHOs as integrative models for partnering with physicians, securing managed care contracts and increasing revenue. Unlike many PHOs, these alliances provide mechanisms for asset integration and long-term relationships along with utilization management, sophisticated information systems, access to capital and opportunities for physicians to integrate clinically. There are six major types of physician equity alliances: majority physician-owned, clinic without walls, health system joint venture, publicly held physician practice management company, specialty network, and venture capital. The type of alliance that a physician group practice ultimately develops depends on vision, values, method of capitalization, initial organizer of the alliance, level of involvement of physicians in business issues, corporate structure desired, and characteristics of the managed care market in which the alliance will operate. PMID- 10166286 TI - A cybernetic approach to burnout. The case of the hospital administrator. PMID- 10166287 TI - From unpleasant surprises to productive relationships. Becoming team builders. PMID- 10166288 TI - Mentoring in healthcare organizations. Implications for female healthcare managers. AB - Although the already large number of women in the healthcare field and the demand for healthcare administrators are expected to grow into the next millennium, there are comparatively few women in healthcare management. Mentoring programs can help guide women into administrative positions in healthcare organizations. PMID- 10166289 TI - The developing crisis in medical staff organization. PMID- 10166290 TI - Tidal effects of managed care. The power of a sea change. PMID- 10166291 TI - Joint Commission introduces accreditation process for PPOs. PMID- 10166292 TI - IMSystem focuses on continued enhancements to products and services. PMID- 10166293 TI - Joint Commission and OSHA form three-year partnership. PMID- 10166294 TI - Joint Commission to adopt 1997 edition of Life Safety Code. PMID- 10166295 TI - Decision rules revised for Plan for Improvement in Statement of Conditions. PMID- 10166296 TI - Revisions made to survey process for network components. PMID- 10166297 TI - The next evolution in accreditation. PMID- 10166298 TI - Home Care Accreditation Services responds to needs of evolving field. PMID- 10166299 TI - Joint Commission and Institute for Medical Quality to evaluate California's health plans. PMID- 10166300 TI - Random unannounced survey topics for 1997. PMID- 10166301 TI - Feds offer merger advice. Guidelines address 'economic efficiencies' defense. PMID- 10166302 TI - Columbia taken to task. Ruling in Ky. case portrays chain as militantly anti union. PMID- 10166303 TI - VHA seeks Internet link. Alliance, IBM close to $100 million deal to launch network. PMID- 10166304 TI - Inside the predator. Former Columbia executives tells how to avoid becoming the giant's next victim. PMID- 10166305 TI - Changing course. Columbia the buyer becomes Columbia the builder as the company seeks to overcome market impediments. AB - In an attempt to overcome market roadblocks, Columbia/HCA Healthcare Corp is revising its strategy from buying existing hospitals to constructing new ones. In this issue we take a look at the investor-owned giant's changing tactics as well as its sometimes rocky relations with the media. We also examine Columbia's performance in its former headquarters city, Louisville, Ky. PMID- 10166306 TI - A Mickey Mouse operation. Louisiana hospital learns customer service lessons from Disney. PMID- 10166307 TI - Denver role model. City turns public hospital into integrated system. PMID- 10166308 TI - Price is right. Ultrasound makers bank on mid-range systems. PMID- 10166309 TI - Managed care. Legislative overkill? Media begin to question push for more mandates. PMID- 10166310 TI - Gaining flexibility. Bond issues boost system's dealmaking agility. PMID- 10166311 TI - Law promotes long-term care insurance. PMID- 10166312 TI - Uniting generations. Providers set up programs to include youths. PMID- 10166313 TI - Managing census fluctuations under managed care. PMID- 10166314 TI - Anti-kickback law extends to marketers. PMID- 10166315 TI - Facilities need effective infection control. PMID- 10166316 TI - Investing in an information systems partner. PMID- 10166317 TI - Preparing for an accreditation survey. PMID- 10166318 TI - The right precautions stem epidemics. PMID- 10166319 TI - Agency initiates outcomes-based survey. PMID- 10166320 TI - Creating a home for the holidays. PMID- 10166322 TI - The American Health Care Association presents 1996 Quality Awards. PMID- 10166321 TI - Long term care financing hits its stride. Lenders eager to make loans. PMID- 10166323 TI - Renewed tax credit offers opportunity to providers and employees. New program attached to minimum wage bill. PMID- 10166324 TI - Restraint use drops sharply at national chain. Beverly well on its way to being restraint free. PMID- 10166325 TI - The gift of time. ACHA Volunteers of the Year 1996. PMID- 10166326 TI - Financing projects with tax-exempt bonds. PMID- 10166327 TI - Network contracting presents legal issues. PMID- 10166328 TI - Prescribing to control resistant bacteria. PMID- 10166329 TI - Staff skills key to computer effectiveness. PMID- 10166330 TI - Tight cap could cause provider headaches. PMID- 10166331 TI - Designing for life. Provider LifeSpace Award winners offer blueprint for success. PMID- 10166332 TI - One-stop shopping wave of future. PMID- 10166333 TI - When a handshake just won't do. PMID- 10166334 TI - Focus on caregiving. Support staff boosts quality, reduces injury rate. PMID- 10166335 TI - Technology and research. Making the right call. PMID- 10166336 TI - Orientation: basic building blocks of an effective board. PMID- 10166337 TI - Weight loss. A painless approach to a sleeker governance model. AB - Slimming down your board structure to meet the demands of system governance doesn't have to be painful. The seven tips offered here provide a "heart-healthy" diet for systems that don't want to alienate longtime trustees who won't be serving on the parent board. PMID- 10166338 TI - Can you make the grade? Leading employers want proof of quality. AB - Employers want proof of quality, so hospitals must now document and justify how they give care. To do that effectively, you need an information system that can track the right data and a quality program that compares performance to regional and national norms. Above all, you need to listen closely to what the public wants. PMID- 10166339 TI - Perception is reality. An informal survey yields surprises for trustees. PMID- 10166340 TI - Planting the seeds for a healthy community--kids take charge. PMID- 10166341 TI - The data game. Play it right, and you could win more managed care contracts. AB - If you could see how your organization was performing as easily as you read the gas gauge and speedometer on your car, making decisions in the boardroom would be much easier (and more reliable). See how you can get the information you need in a format that makes sense. The payoff could be more managed care contracts. PMID- 10166342 TI - The quality of mercy. Effective pain treatments already exist. Why aren't doctors using them? PMID- 10166343 TI - Easing hurt in small bodies. New knowledge is ending the dark ages. PMID- 10166344 TI - Caught in pain's vicious cycle. He helped his patients--and lost his license. PMID- 10166345 TI - Development of a customer service program in a large, multi-site blood bank. AB - The concepts of Total Quality Management (TQM) and Continuous Quality Improvement (CQI) have been widely applied but not in the unique ambulatory care setting represented by Irwin Memorial Blood Centers (IMBC). The traditional definition of quality for blood banks has been concerned with the products offered to physicians, hospitals and patients. This program expanded the definition to include customer service. A Quality of Service Steering Committee (QSSC) identified the needs and requirements of Irwin's key customer groups as a first step in embarking on its Quality of Service Program (QSP). PMID- 10166346 TI - An analysis of the factors affecting the average length of stay in the otolaryngology unit. AB - Specific factors which have an influence on the average length of stay in the otolaryngology unit of a University Hospital are studied; the patients are covered by some type of insurance and have no out-of-pocket expenses. The effect of the following variables on the average length of stay is evaluated: age, sex and type of pathology. The periods of hospitalisation are significantly longer (Mann-Whitney test) in males (p < 0.0001), in older patients (p < 0.008) and in the case of tumours, which prolong the period of stay especially of males (p < 0.0001). It is suggested that the shorter stay in the case of females may be conditioned by social and family factors. PMID- 10166347 TI - Injecting quality into the health care building process. AB - This article, which draws on material from a study undertaken by Rawlinson Kelly Whittlestone (RKW) for the King Edwards' Hospital Fund for London, explores the interrelationships between quality in health buildings and the health building process. It describes the new context for quality improvements in the UK, and attempts to define health building quality from a variety of differing perspectives. It also describes some of the lessons learned and threats to quality from the last 25 years of new health buildings in the UK. Decision points which can compromise quality during the health building process are highlighted. Prerequisites for ensuring that quality is both safeguarded and injected into the health building process are identified and discussed. PMID- 10166348 TI - Bring statistics to life. PMID- 10166349 TI - Releasing resources for reinvestment in health gain. AB - The National Health Services in Wales has adopted a strategic approach based on health gain. Five approaches to meeting this problem are considered (i) eliminating basic inefficiencies; (ii) eliminating unnecessary clinical activity; (iii) doing what is done now but differently; (iv) investing now to save later and (v) withdrawing from a particular area of activity, because it is less important than other competing claims. Each of these is briefly considered with particular reference to the Welsh situation. Three particular lines of advance are identified to achieve the above: creating new sources of information; working more effectively across organisational boundaries; and making the cultural changes to make it all possible. PMID- 10166350 TI - A successful transport scenario for the health sector in developing countries. AB - The role and operation of transport in the health sector in developing countries is important, costly but often taken for granted. This article suggests the need for a fresh look at the policy, planning and management of transport through the analysis of the essential components of a successful transport scenario for health services in developing countries i.e. transport and health planning; transport and organisational responsibility; the role of health sector donors; decision-making and procurement of transport and spares; transport and human resources; monitoring and control of transport and information; maintenance and repair; the budget. The article concludes with a checklist of key questions that may be used in assessing the contribution of transport to the health services. PMID- 10166351 TI - Effects of common techniques on accuracy and precision of pipetting results. PMID- 10166353 TI - Health Insurance Portability Act: fraud and abuse provisions. PMID- 10166352 TI - Protecting the integrity of clinical laboratory test results. AB - The authors' inspection reports demonstrate that the improper alteration of patient data is not a rare aberration in private commercial clinical laboratories. Although laboratory surveyors could be trained to recognize this problem, the availability of unprotected test systems makes even trained inspectors ineffectual. Both regulatory agencies and professional accrediting agencies should be concerned that their surveyors may be placing a seal of approval on what are, in reality, compromised or even fabricated data. In proposing the regulations discussed in this paper, the FDA sought to "preserve the integrity of the agency's enforcement process." This goal will remain unattainable, however, until a mechanism has been devised to secure the original raw data produced by all of the analytical systems being used not only in clinical laboratories but also in environmental laboratories, pharmaceutical laboratories, etc. Laboratories, as well as regulatory agencies and accrediting bodies, need to be concerned on behalf of the patient, but laboratories may also need to be concerned on their own behalf. In the coming era of unprecedented cost constraints and competitive bidding, unscrupulous testing facilities or groups of such facilities could have a significant edge over their conscientious competitors if the issues raised here continue to be ignored. Although the analytical data management systems provide tremendous benefits, some have serious problems in ensuring the security of their data. However, if regulatory agencies, accrediting bodies, professional organizations, and the analyzer vendors make a united commitment, the problem of securing the integrity of analytical data could eventually be resolved. It is hoped that such a commitment will be made in the near future. PMID- 10166354 TI - Certification and licensure. PMID- 10166355 TI - Themes in student attrition. AB - OBJECTIVE: To characterize similarities and differences in attrition in clinical laboratory science and clinical laboratory technician education programs by identifying general themes, specific academic and nonacademic reasons, and other relevant data. DESIGN: Mailed, written survey. PARTICIPANTS: Program directors of 208 clinical laboratory science and clinical laboratory technician educational programs. MAIN OUTCOME MEASURE: Responses to a 36-item forced-choice survey eliciting information about program attrition and the importance of reasons for student attrition. DATA SOURCES: Clinical laboratory science and clinical laboratory technician program directors across the United States. RESULTS: Students were found to withdraw from educational programs for both voluntary and nonvoluntary reasons in approximately equal numbers. Academic underpreparedness was a predominant general theme underlying student attrition in both levels of programs. The importance of certain specific reasons cited for student attrition differed significantly by program level. CONCLUSION: To be effective, it may be necessary to design retention programs that address academic concerns, as well as nonacademic concerns, of students. The level of educational program (clinical laboratory technician or clinical laboratory scientist) should be considered, because reasons for attrition vary in degree of importance. ABBREVIATIONS: CLT = clinical laboratory technician; CLS = clinical laboratory scientist; CAHEA = Committee on Allied Health Education and Accreditation. INDEX TERMS: Clinical laboratory technician students; clinical laboratory science students; education; attrition; retention. PMID- 10166356 TI - Evaluation of DRI enzyme immunoassays for drugs-of-abuse screening on the Cobas Mira. AB - OBJECTIVE: To establish optimal performance parameters (ratios of sample and reagents, reaction time, and distinction of absorbance values between calibrators) on the Roche Cobas Mira analyzer for the evaluation of Diagnostic Reagents Inc enzyme immunoassay reagents for urine screening of amphetamines, cannabinoids, cocaine metabolite, opiates, and phencyclidine. SETTING: Laboratory in a physician's office. PRACTICE DESCRIPTION: Two laboratorians analyze a daily average of 25 urine samples for employment screening purposes. PRODUCT COMPARISON: DRI reagents were compared to Syva EMIT reagents. RESULTS: Within-run and between-run precision at the cutoff concentration for DRI reagents ranged from 1.1% to 1.6% CV and 2.2% to 5.7% CV respectively. Results (positive or negative) using DRI or Syva EMIT reagents were identical for cannabinoids, cocaine metabolite, opiates and PCP. Direct comparison for amphetamines was not possible because of different cutoff concentrations of the 2 reagents systems. CONCLUSION: DRI reagents are acceptable alternatives to EMIT reagents for the analysis of amphetamines, cannabinoids, cocaine metabolite, opiates and phencyclidine in urine on the Cobas Mira analyzer. Utilization of DRI reagents for more than 12 months demonstrated the reliability of the reagents and allowed cost comparison. ABBREVIATIONS: DRI = Diagnostic Reagents Inc; EMIT = enzyme multiplied immunoassay technique; d.a.u. = drugs of abuse; PCP = phencyclidine; GC/MS = gas chromatography/mass spectrometry. PMID- 10166357 TI - Non-pretreatment digoxin assays and developments in immunoanalyzers. AB - OBJECTIVE: The performance of a new, non-pretreatment digoxin assay for the Abbott IMx analyzer (Abbott Park IL) was evaluated to determine its reliability and suitability for routine clinical use. The operational characteristics of 1st, 2nd and 3rd generation immunoanalyzers are compared and contrasted. DESIGN: Within-run and day-to-day precision of the assay was determined, as well as its limit of detection. The effect of digoxin-like immunoreactive factors and carryover were evaluated. Serum from patients receiving digoxin was analyzed using the Dade Stratus II (Miami FL) digoxin test as the reference method and the IMx digoxin test as the comparison method. SETTING: An independent reference laboratory specializing in serving long-term care facilities. PATIENT POPULATION: Specimens were analyzed from geriatric patients in long-term care facilities who receive digoxin as a therapeutic drug for cardiac arrhythmias. Specimens were also tested from individuals in this same population, not receiving digoxin but demonstrating the presence of digoxin-like immunoreactive factors. MAIN OUTCOME MEASURE: Comparability of results from a new nonpretreatment digoxin with the standard digoxin assay (Stratus II) was used to determine the suitability of the new test for routine clinical use. RESULTS: The limit of detection is 0.27 ng/mL; day-to-day precision ranges from 3.4% CV to 5.9% CV. Linear regression analysis generated the following equation: IMx = 0.968 Stratus + 0.1043, r = 0.9776, n = 237. No significant interference from digitoxin-like immunoreactive factors was noted. CONCLUSION: The IMx nonpretreatment digoxin assay's performance matches the manufacturer's claims, compares favorably with another common automated digoxin test, and is suitable for routine clinical use. PMID- 10166358 TI - Attrition in a clinical laboratory technician associate degree program. AB - OBJECTIVE: To determine the reasons for attrition in a clinical laboratory technician-associate degree program, a retrospective study was done on classes entering from 1987 to 1992. Suggestions are made to increase retention. SETTING: The medical laboratory department at the Community College of Philadelphia in Pennsylvania. PRACTICE DESCRIPTION: There were 43,987 students enrolled for the 1993 to 1994 academic year; 17,846 full time equivalents at the college. Clinical laboratory technician students averaged 26.2 years and were 26% male and 74% female, which closely paralleled the college. The ethnic make-up of the clinical laboratory technician classes was 54% White, 32% African American, 11% Asian, and 3% Latin American, compared to 48% African American, 36% White, 10% Asian, and 6% Latin American students in the college. PRACTICE INNOVATION: A retrospective study was performed to evaluate attrition rates for the classes entering the clinical laboratory technician program at the Community College of Philadelphia from 1987 to 1992. Reasons for this attrition were tabulated and evaluated. RESULTS: One hundred twenty-nine students entered the program and 75 graduated, producing an attrition rate of 42%. There were 6 categories of reasons given for not completing the program: academic difficulties, dislike of the laboratory science field, family problems, financial problems, substance abuse, and other problems not specified. CONCLUSION: Because 80% of the attrition was due to poor academic performance and a dislike of the field, several changes are being made in the Community College of Philadelphia's retention program. An enhanced orientation will be given to all students, and students will be required to visit a hospital laboratory. Early faculty intervention and peer counseling for students with poor academic performance will be instituted. PMID- 10166359 TI - Effect of nebulizer configuration on delivery of aerosolized tobramycin. AB - Differences in the reported efficacy of aerosolized aminoglycosides may be due, in part, to differences in aerosol delivery. Optimization of delivery systems of bench testing of nebulizers in a manner that simulates clinical conditions can lead to enhanced lung deposition in subsequent clinical studies. In the present study, we assessed the effects of varying nebulizer configuration on the performance of ultrasonic and jet nebulizers. Tobramycin was mixed with a radiotracer (99mTc) to facilitate measurement of nebulizer output and particle size. A piston ventilator provided a simulated breathing pattern, and the dose delivered to a filter corresponded to what would have been inhaled by a patient (percentage of nebulizer charge inhaled). Particle size was measured using a cascade impactor, sampling at 1 L/min. An ultrasonic nebulizer (Ultra-Neb; DeVilbiss, Somerset, PA), ventilated at 20 breaths per minute, charged with 600 mg of tobramycin (in 30-mL volume) and fitted with its standard tubing, was tested with and without the addition of one-way valves to the inspiratory and expiratory ports of the mouthpiece. In order to assess the degree of environmental contamination associated with jet nebulizer therapy, a filter was placed at the expiratory port of all jet nebulizer experiments. The addition of the valves reduced the percentage of charge inhaled from a mean +/- standard deviation (SD) of 29.2% +/- 1.4% to 7.6% +/- 2.3% and reduced mass median aerodynamic diameter [MMAD (sigma g) from 4.3 microns (2.1) to 1.45 microns (1.65)]. A Circulaire (Westmed, Tucson, AZ) jet nebulizer (7 L/min flow, 50 pounds per square inch gauge (psig), 20 breaths per minute, containing 160 mg of tobramycin in a 4-mL volume) was tested in two configurations: using a plain T piece and using a valved inflatable aerosol chamber. The use of the holding chamber resulted in an almost twofold reduction in MMAD [MMAD (sigma g) = 2.45 microns (2.0); T-piece; 1.25 microns (2.0), holding chamber]. A slight reduction in the percentage of nebulizer charge inhaled using the holding chamber, compared to the plain T-piece, was not statistically significant (mean +/- SD of percentage inhaled with holding chamber = 20.8% +/- 1.6%; with T-piece = 23.6% +/ 0.5%). With both the jet and ultrasonic nebulizers, breathing frequency influenced percentage inhaled, with a higher percentage inhaled at 20 breaths per minute compared to 15 breaths per minute. The use of the plain T-piece at 20 breaths per minute was associated with more environmental contamination than the use of the holding chamber with the same breathing pattern (26.7% +/- 1.0%, T piece; 4.5% +/- 0.3%, holding chamber, P < 0.0001). We conclude that nebulizer configuration can potentially affect both the amount of aerosol inhaled and the particle size, and needs to be specified precisely in treatment protocols. PMID- 10166360 TI - An under-occluded roller pump is less hemolytic than a centrifugal pump. AB - The purpose of this study is to measure and compare the hemolysis produced by roller pumps with varied occlusion settings and a centrifugal pump. The null hypothesis is that there is no difference in the Index of Hemolysis (IH = gm Hb/100 L pumped) produced by a roller pump (RP) at four different occlusion settings and a centrifugal pump (CP) at the same blood flow rate (4.5 L/min) and afterload (250 mmHg, +/-10 mmHg) over three hours. Five identical closed-loop circuits were assembled and primed with saline. The pumps were then calibrated and occlusions were set. In three circuits, the occlusion for the RP was opened at 5 RPMs to support 150, 225, or 300 mmHg (+/-10 mmHg) against a clamped line. In one circuit, a RP was adjusted to a barely non-occlusive setting (1 cm drop/30 inch gradient). The fifth circuit employed a CP. Prior to testing, the saline in each circuit was replaced with one liter of fresh bovine blood (Hct = 22 +/- 2%). The IH for each treatment was compared in six trials yielding a statistical power > 0.80. Analysis of variance with multiple comparison (p < or = 0.05) demonstrated that compared to the barely non-occlusive setting, the IH in the centrifugal pump was not significantly greater. Under-occluded RP settings yielded IHs significantly less than the CP. It appears that opening the occlusion on a roller pump allows a lower IH compared to traditional RP occlusion setting or centrifugal pumping. PMID- 10166362 TI - Adding hetastarch to the adult cardiopulmonary bypass prime does not affect patient outcomes. AB - Hespan (hetastarch), a synthetic colloid, is often used in priming cardiopulmonary bypass circuits. The purpose of this study is to determine the efficacy of adding hetastarch to the prime compared to adding no hetastarch. Twenty-four adult patients undergoing cardiopulmonary bypass received Hespan in the prime, while twenty-nine patients did not. Outcomes were compared using paired t-test, analysis of variance, analysis of covariance, and descriptive statistics, where p < 0.05 was considered significant. There were no significant differences in change in lung compliance, weight gain, time on the ventilator, or length of stay in the intensive care unit. Adding colloids to the adult CPB prime does not improve patient outcomes over priming exclusively with crystalloids. PMID- 10166361 TI - New roller pump disposable provides safety and simplifies occlusion setting. AB - A new disposable insert for the arterial roller pump, the Better-Header, provides safety and functionality beyond what standard tubing provides. It automatically limits pump outlet pressure to a level determined by the user and provides a self contained, simple means to set pump occlusion. The Better-Header consists of a Starling-like pressure relief valve connected across standard header tubing. As long as arterial line pressure at the pump outlet remains below a set limit, the valve is closed. If line pressure approaches the pressure limit, the valve opens, preventing overpressurization by shunting blood from pump outlet to inlet. The Better-Header can also be used to set occlusion by the "dynamic method" to obtain nonocclusive settings. The Better-Header was evaluated in the lab for its pressure-flow characteristics. Even when the arterial line was completely clamped at a pump flow of 7 L/min, line pressure was limited to a safe level and all circuit connections were preserved. The Better-Header has been used successfully at North Shore University Hospital in over 500 clinical cases covering a wide range of patients and procedures. In several instances, the user was alerted to high pressure situations by fluid flow through the valve and by an audible alarm, allowing rapid correction of the source of pressure. Compared to the standard setup, the Better-Header maintains outlet pressure within safe, user-settable limits, and permits consistent, nonocclusive settings with predictable retrograde flow. PMID- 10166363 TI - Blood anion gaps and venoarterial carbon dioxide gradients as risk factors in long-term extracorporeal support. AB - Increases in the blood anion gap (AG) and venoarterial carbon dioxide gradients [p(V-A)CO2] may indicate changes in intracellular acid concentration not demonstrated by blood gas measurements. This prospective study examines these two physiologic markers to determine their relationship to extracorporeal membrane oxygenation (ECMO) survival and duration in 100 patients. Serum electrolytes were drawn every 6 hours and the AG calculated. Simultaneous arterial blood gases and venous blood gases were drawn every 4 hours and the p(V-A)CO2 calculated. Cumulative averages were then calculated from all the AG and p(V-A)CO2 values during each ECMO treatment. The average AG was 11 mEq/L. The average p(V-A)CO2 was 9 mm of mercury (mmHg). Patients with an AG of 11 mEq/L or less had a 12% mortality and those with a higher AG had a 43% mortality (p = 0.0005). Patients with a p(V-A)CO2 of less than 9 mmHg had a 13% mortality and those with a 9 mmHg or higher gradient had a 35% mortality (p = 0.0126). Patients with both a low AG and a low p(V-A)CO2 had a 7% mortality and survivors were on ECMO 100 (+/-37) hours. Patients with both a high AG and a high p(V-A)CO2 had a 56% mortality and survivors were on ECMO 190 (+/-105) hours. Both mortality and survivors' ECMO time increase as one or both risk factors increase. Patients with increases in both risk factors have a mortality rate 8 times greater and survivors remain on ECMO almost twice as long as those without increased risk factors. Patients may benefit from a perfusion strategy that seeks to minimize the AG and p(V-A)CO2. PMID- 10166364 TI - Servicing: meeting US and European quality system requirements. AB - Medical device manufacturers whose products must be serviced and who wish to meet both United States (US) and European quality system requirements should pay particular attention to the servicing provisions of these requirements. The current US medical device good manufacturing practice (GMP) regulation and the new US quality system regulation contain requirements that are not included in the European quality system standards. This article will discuss the major aspects of US and European servicing requirements and some important differences. PMID- 10166365 TI - Assembling medical devices: the essential steps for success. AB - Designers of complex medical devices face many challenges in taking a product from prototype to mass production. There are numerous obstacles that can bring a project to a standstill and at the same time take it considerably over budget. This article will examine some of the engineering issues related to medical device assembly, such as the management of the project, choice of component and assembly system suppliers, and quality. PMID- 10166366 TI - The impact of regulation. AB - The medical device industry in the United States is facing a number of challenges, for example, work on Food and Drug Administration reform and a global move towards European-style regulation and harmonization. This article examines those challenges and their effect on the industry and on patients. PMID- 10166367 TI - New products: benchmarking the critical success factors. AB - New-product development is emerging as the key strategic endeavour of companies in fields such as medical devices. Drawing on the findings of a recent study, the author suggests that the critical factors that influence the success of new products are process, strategy and resources. Process was found to have the strongest impact on the performance of a new product. This article describes a stage-gate process that provides companies with a template for driving new product projects from idea through to launch. PMID- 10166368 TI - Mutagenesis: the power to do harm. AB - Among the portfolio of tests that may have to be performed on medical devices is the test for mutagenicity. It is far from clear, however, just how significant the risk is of mutagenicity from biomaterials, and how the results of these tests should be interpreted. This article discusses some of the salient features of this difficult subject. PMID- 10166369 TI - The need for a global health disaster network. AB - When a disaster occurs, a major difficulty is knowing where to find accurate information, and how to help coordinate efforts to share accurate information in a quick and organized manner. The establishment of a global information network, that is in place before a disaster occurs, could link all the communication efforts for relief. We propose that a Global Health Unit for Disaster and Relief Coordination be set up as part of the Global Health Network, utilizing the Internet as its backbone. This Unit would establish the links for the disaster information mosaic. PMID- 10166370 TI - Criteria for the assessment of disaster preparedness--II. AB - By defining the chain of medical care and the capacities of the successive phases within this chain, an attempt is made to analyze and grade the determinants of these capacities. In this way, calculations that indicate overall disaster preparedness can be expressed in a figure ranging from 1-5. The capacity of the system is taken as the lowest score obtained for the components of the system. The methodology used for this assessment of preparedness is described and an example is used to show the efficacy of this methodology. PMID- 10166371 TI - Privatization and emergency medical services. AB - Osborne and Gaebler's Reinventing Government has sparked discussion amongst elected officials, civil servants, the media, and the general public regarding advantages of privatizing government services. Its support stems from an effort to provide services to municipalities while reducing taxpayer expenditure. Many echo the sentiment of former New York Governor Mario Cuomo, who said, "It is not government's obligation to provide services, but to see that they're provided." Even in the area of public safety, privatization has found a "market." In many localities, privatizing Emergency Medical Services (EMS) is a popular and successful method for providing ambulance services. Privately owned ambulance services staff and respond to medical emergencies in a given community as part of the 9-1-1 emergency response system. Regulations for acceptable response times, equipment, and other essential components of EMS systems are specified by contract. This allows the municipality oversight of the service provided, but it does not provide the service directly. As will be discussed, this "contracting out" model has many benefits. Privatizing EMS services is a decision based not only on cost-savings, but on accountability. A thorough evaluation must be utilized in the selection process. Issues of efficiency, effectiveness, quality, customer service, responsiveness, and equity must be considered by the government, in addition to cost of service. The uncertain future of health care in the United States has led those in EMS to look beyond the field's internal market to explore additional opportunities for expanding and redefining its roles beyond emergency care. It is important, however, to consider how emergency medical care, the original role of EMS, can be best delivered. Responding to emergencies is not just one of the functions involved in this field, it is the principal function from which public perception of EMS is formed, and from which support for entering other markets can be fostered. The purpose of this paper is to present several important concepts and considerations that public officials, medical directors, and the public must be aware of when contemplating the possibility of privatizing their Emergency Medical Services. A review of the general concepts of privatization and issues of accountability will be presented, referencing policy experts, followed by an examination of how advocates of privatization might see these issues as they relate to providing EMS. The conclusion will present prescriptions for both municipal and commercial ambulance providers. PMID- 10166372 TI - The role of EMS systems in public health emergencies. AB - INTRODUCTION: Until now, the public health response to the threat of an epidemic has involved coordination of efforts between federal agencies, local health departments, and individual hospitals, with no defined role for prehospital emergency medical services (EMS) providers. METHODS: Representatives from the local health department, hospital consortium, and prehospital EMS providers developed an interim plan for dealing with an epidemic alert. The plan allowed for the prehospital use of appropriate isolation procedures, prophylaxis of personnel, and predesignation of receiving hospitals for patients suspected of having infection. Additionally, a dual notification system utilizing an EMS physician and a representative from the Office of Infectious Diseases from the hospital group was implemented to ensure that all potential cases were captured. Initially, the plan was employed only for those cases arising from the Centers for Disease Control and Prevention (CDC)/Public Health Service (PHS) quarantine unit at the airport, but its use later was expanded to include all potential cases within the 9-1-1 system. RESULTS: In the two test situations in which it was employed, the plan incorporating the prehospital EMS sector worked well and extended the "surveillance net" further into the community. During the Pneumonic Plague alert, EMS responded to the quarantine facilities at the airport five times and transported two patients to isolation facilities. Two additional patients were identified and transported to isolation facilities from calls within the 9-1-1 system. In all four isolated cases, Pneumonic Plague was ruled out. During the Ebola alert, no potential cases were identified. CONCLUSIONS: The incorporation of the prehospital sector into an already existing framework for public health emergencies (i.e., epidemics), enhances the reach of the public safety surveillance net and ensure that proper isolation is continued from identification of a possible case to arrive at a definitive treatment facility. PMID- 10166373 TI - The emergency medical services system response to a commercial airliner incident at the very remote location of Shemya, Alaska. AB - INTRODUCTION: A multiple patient incident involving a commercial airliner is a challenge for any community EMS system. When the community is on a remote island in the North Pacific Ocean, where there is no hospital and only a small clinic staffed by just one physician and several nurses and technicians, the challenge is much greater. The incident described herein necessitated providing emergency care at the airport, and at the same time, activating a response capability from hundreds of miles away to transport the patients to definitive care. The situation was compounded further by the fact that most of those injured spoke little or no English. This paper reviews the events that occurred and the lessons learned. OBJECTIVE: To identify the events that occurred when a commercial airliner, with more than 250 passengers and crew aboard, experienced an in-flight "upset" that resulted in many being injured. What was learned may help other areas be better prepared for such events. STUDY POPULATION: A commercial airliner incident that occurred in April, 1993 resulted in the need for emergency medical care at the remote island location of Shemya, Alaska initially, and fixed-wing transport of the injured to definitive care in Anchorage, Alaska, USA, which is about 1,300 miles (2,130 km) from Shemya. METHODS: A case review methodology was used that included interviews with key persons involved in the response to this incident to learn first-hand what occurred; by review of the National Transportation Safety Board (NTSB), reports, and by having agencies involved in the event review draft report materials to ensure accuracy. RESULTS: This study showed how a remote site with a small cadre of medically trained personnel could organize and effectively provide initial emergency care for > 200 persons, and have them transported more than a thousand miles to definitive care. CONCLUSIONS: Valuable lessons were learned from this incident that may help other areas be better prepared, particularly in remote areas, for large multiple patient events. PMID- 10166374 TI - The psychosocial aftermath of the Chernobyl disaster in an area of relatively low contamination. AB - INTRODUCTION: There has been relatively little attention paid to the mid- and long-term effects of large-scale disasters, particularly their effects on children and young people. At the present time, the impact of the Chernobyl catastrophe on the daily lives of the affected population may include one of strong psychological stress due to uncertainty about ultimate health outcomes. Persons in the Chernobyl region in specific areas of low contamination may be affected similarly. This investigation assesses radiation concerns and attitudes about health and government information, nine years after the disaster, in a group of adults and adolescents residing in a relatively uncontaminated village in the Chernobyl area. METHODS: Questionnaires were administered to 94 adults and 50 adolescents. Items assessed beliefs about extent of radiation exposure, health concerns regarding oneself and family members, past and current preoccupation about the disaster, and trust in the accuracy of government information about health effects. RESULTS: Considerable uncertainty was demonstrated in both adults and adolescents about the extent of their and their families exposure to radiation. Marked distrust of past and current government information about health effects was evident. A large proportion of subjects reported that they still thought frequently about the Chernobyl accident. They worried about health problems related to radiation exposure whenever they or their family members exhibited physical symptoms or complaints, and they urged family members to go to a medical clinic for evaluation to assess these symptoms. CONCLUSIONS: The extent of long-term concerns about the personal and family health effects of the Chernobyl disaster in this population residing in a relatively uncontaminated village is striking: the psychological impact on adolescents is considerable. The stress generated is maintained by the realistic uncertainty about the ultimate health consequences to the overall population as a result of radiation exposure and distrust in government information about contamination levels in this particular village. The level of stress and its effects on physical and mental health may increase over time if there is a rise in morbidity in the area. The continuing health needs of the extremely large population affected by the Chernobyl disaster need to be addressed. PMID- 10166375 TI - Domestic violence: efficacy of health provider training in Utah. AB - The purpose of this project was to improve the identification, treatment, and referral of domestic violence victims by prehospital care providers (Emergency Medical Technicians (EMTs) and paramedics) and emergency department personnel. The training focused on the definition of domestic violence, procedures to use when questioning patients about abuse, Utah's mandatory reporting law, and the referral of victims to community resources. While the training did improve the participant's knowledge concerning referral options and the law, health care providers still did not believe that domestic violence was a problem in their community. Although providers felt confident asking questions about abuse, the providers did not question patients unless they suspected domestic violence was the cause of the injury. Further training needs to be offered to staff to encourage regular screening for all adult patients. PMID- 10166376 TI - Comparison of a colorimetric end-tidal CO2 detector and an esophageal aspiration device for verifying endotracheal tube placement in the prehospital setting: a six-month experience. AB - INTRODUCTION: Hand held, colorimetric, end-tidal CO2 detector devices are being used to verify correct endotracheal tube (ETT) placement. The accuracy of these devices has been questioned in situations of cardiac arrest. The use of the esophageal detector device (EDD) is an easy alternative for detection of ETT placement, and may be more accurate in situations of cardiac arrest. HYPOTHESIS: The use of the esophageal aspiration device in comparison with a colorimetric end tidal CO2 detector is more accurate in detecting proper ETT placement and easier to use in the prehospital setting than is the colorimetric end-tidal CO2 detection device. METHODS: This was prospective alternating weeks, 6-month study in a prehospital setting. Participants included all patients older than 18 years who were intubated by the Portsmouth, Virginia Emergency Medical Services (EMS) personnel from 01 July 1993 through 31 December 1993. The aspiration device used, also known as an esophageal detector device (EDD), was a 60 ml, luer-lock syringe attached to a 15 mm ETT adapter. Its efficacy was compared with an already accepted method of ETT position detection, the colorimetric end-tidal CO2 detector. Each device was used on alternating weeks, and correct ETT placement was determined by the receiving emergency department physician using standard techniques. Chi-square analysis and Fisher's Exact test were used to compare parameters, time of device use, and ease of use. Sensitivity and specificity were calculated, and provider preference was assessed using a survey instrument administered following completion of the study. RESULTS: There were 49 patients who met the inclusion criteria, but six were excluded because of situational circumstances rendering use of the device a possible compromise of patient care. Twenty-five patients were in the EDD group, and 18 were in the end-tidal CO2 detector group. There was no statistically significant difference detected between groups for the gender ratio, underlying condition, CPR in progress, perceived difficulty of intubation, or percentage of nasotracheal intubation. The EDD was significantly easier to use (p < 0.005). There was no statistically significant difference in time required for use of end-tidal CO2 detector device versus the EDD. The sensitivity and specificity for correct tracheal placement using the EDD was 100%, and the sensitivity for correct tracheal placement using the end-tidal CO2 detector device was 78%. Use of the EDD was preferred over use of the end-tidal CO2 detector device by 75% of participating EMS providers. One case of nasotracheal intubation with an ETT placement above the cords raised the question of accuracy of this device in situations where direct visualization is not utilized. CONCLUSION: The EDD was accurate in all cases of orotracheal intubation, and was easier to use than was end-tidal CO2 detector device. It was preferred by 75% of participating EMS providers. In cases in which the ETT may be above the vocal cords, caution must be used with interpreting the results obtained by use of the EDD. PMID- 10166377 TI - Portable, but suitable: devices in prehospital care might be hazardous to patient or to aviation safety. AB - INTRODUCTION: Devices used for support of patients requiring air rescue or conveyance are subjected to severe environments that may affect their ability to function when needed or may affect other systems within the transporting vehicle. METHODS: The ability of four portable ventilators, a suction device, and plastic and rubber tracheal tubes to withstand changes in temperature, vibration, sudden deceleration, and electromagnetic fields was studied in the laboratory setting. In addition, the effects of the operation of these devices on the flight instrumentation was investigated. RESULTS: All of the ventilators tested delivered stable minute volumes at temperatures above zero, but in sub-zero temperatures problems were encountered with the driving gas. Vibrations produced alterations in the performance of two of the ventilators, and resonant frequencies were detected that are identical to those produced by the rotors of the helicopter used. Suctioning became difficult at temperatures below -5 degrees C as the mucus froze in the collecting tubing. The motor produced electromagnetic fields that interfered with the aircraft instrumentation, and resonant frequencies had a deleterious effect on the circuit boards. Plastic tubes were adversely affected by cold, and these chilled tubes were excessively sensitive to vibration and shocks. CONCLUSIONS: The devices used in various aircraft influence certain vital maneuver systems of the craft. Studies on portable ventilators, a suction device, and tracheal tubes showed that, under specific conditions, the equipment was safe to patients and was not hazardous to the aviation safety. However, under certain conditions commonly encountered during air rescue operations, the equipment became dysfunctional or presented safety hazards to the aircraft, and, hence, the crew. The Swedish Air Force has adopted three different criteria constellations: 1) operative; 2) storing; and 3) transport environment. PMID- 10166378 TI - Mass gathering medicine: a review. AB - The provision for emergency medical care for spectators and participants at large events is a growing area of interest. This article describes the definition and characteristics of medical care at mass gatherings. The literature is reviewed with regard to the planning, organization, personnel, and staffing required at these events. The equipment and transportation assets needed are also discussed. Disaster and mass casualty planning implications also are described. PMID- 10166379 TI - Medical and surgical issues in the Persian Gulf War. PMID- 10166381 TI - Developing outcomes management tools. PMID- 10166380 TI - Safe Medical Devices Act. PMID- 10166382 TI - Overuse injuries and the elite child athlete. PMID- 10166383 TI - Ergonomic certification update. PMID- 10166384 TI - Pulmonary rehab. PMID- 10166385 TI - Under the watchful eye. PMID- 10166386 TI - Rehabilitative rheumatology. PMID- 10166387 TI - Rehab staff retention. AB - Despite "extras" such as tuition reimbursement, volume bonuses, and research opportunities, the rehab employees at St Francis come to work each day for good wages and benefits, a clean, modern place to work, nice people to work with, and a supportive management staff. The time and effort that was dedicated to developing, processing, and implementing the employee survey was well spent. We now know what makes our employees tick, and are focusing on these areas in an effort to maintain high employee satisfaction. One year ago, approximately one half of our physical and occupational therapy slots were vacant. Now we are recruiting for only one of each. In fact, we now have only five vacant slots in the entire rehab product line, and two of those are for newly created positions. Employee morale is up, and so are inpatient and out-patient volume. PMID- 10166388 TI - Reducing the risk of CTDs. PMID- 10166389 TI - Outcomes evaluation in subacute care. PMID- 10166390 TI - Ergonomic protection standard. PMID- 10166391 TI - Of hands and other rehab tools. AB - Considerable evidence supports the premise that manual and technology-based physical therapy can coexist and complement each other. The knowledge and experience of the PT is ultimately the key in designing patient treatment programs that provide the most appropriate and cost-effective level of care. The practice of physical therapy should proceed with enthusiasm tempered by common sense in the continued integration of technology within the profession. While offering a valuable complement to traditional therapy practices, technology will never replace the traditional manual skills and techniques that have earned physical therapy a prominent place in the health care delivery system. PMID- 10166392 TI - A look at rehab outcomes. Interview by Anne Framroze. PMID- 10166393 TI - Rehab and the female patient. PMID- 10166394 TI - Musicians and overuse syndrome. PMID- 10166395 TI - Technology and pain management. PMID- 10166396 TI - Cost-effectiveness of subacute rehab. PMID- 10166397 TI - Hand-to wrist combat. PMID- 10166398 TI - Rehab's PhDog. PMID- 10166399 TI - Wound management. PMID- 10166400 TI - Rehab administration under managed care. PMID- 10166401 TI - Building an effective team. PMID- 10166402 TI - Pediatric pain management. PMID- 10166404 TI - Curbing insurance fraud & abuse. PMID- 10166403 TI - Providing rehabilitation care in rural areas. PMID- 10166405 TI - Rehabilitation outcomes in subacute care. PMID- 10166406 TI - Will managed care work in Europe? AB - This paper examines major trends in healthcare reforms in the European Union Member States during the last decade. It focuses on managed care developments and shows that, to a certain extent, managed care in Europe is moving towards a consensus. The paper analyses major trends observed across the European Union including the establishment of overall budgets for health services, separation of purchasers from providers, competition between providers, capitation payments for doctors, budget controls on pharmaceutical expenditure and priority-setting methodologies. It then discusses the potential introduction of new forms of managed care and the current weaknesses in information needs and systems. Finally, the policy-makers' dilemmas for resource allocation are examined and a frame-work for policy debate is suggested. PMID- 10166407 TI - The impact of drug therapy on quality of life in headache and migraine. AB - Although headache is among the most common and costly disorders in primary care, our understanding of its direct impact on the quality of life of affected individuals is incomplete. While studies evaluating the role of headache on health-related quality of life and healthcare economics are starting to appear in the medical literature, the effect of pharmacotherapy in improving quality of life is only beginning to be studied. At present, studies evaluating health related quality of life in patients with migraine who are undergoing treatment are limited to 3 agents: sumatriptan, flurbiprofen and diclofenac. Several studies have consistently indicated that these drugs benefit patients by improving key dimensions of health-related quality of life or patients' sense of well-being to a significant extent. Given the magnitude of functional and emotional impairment associated with chronic headache disorders, assessing patients' perceptions of their quality of life makes a useful contribution to the evaluation of therapeutic interventions and should supplement traditional clinical endpoints in determining the effectiveness of new drugs. PMID- 10166408 TI - Indications for plasma drug monitoring in patients with epilepsy. Implications for reducing costs. AB - Plasma anticonvulsant drug concentration monitoring has considerable potential to make the therapy of seizure disorders more efficient, provided that the approach is optimal. However, in recent years, a tendency has developed towards using monitoring as an unthinking routine in patients, rather than as an aid in resolving clinical problems. Such uncritical use of monitoring, particularly when the drug concentration values are allowed to take precedence over the assessment of the patient's clinical state in formulating treatment policy, is undesirable. It may lead to unnecessary therapeutic action and sometimes to therapeutic misadventure. Monitoring is indicated when an inappropriate anticonvulsant drug dosage is suspected on clinical grounds, or when a provisional indication of the potential adequacy of therapy is likely to be useful early in the course of a patient's treatment. The best 'yardstick' against which to assess plasma anticonvulsant drug concentrations in a given patient is the therapeutic threshold value for that individual, when it is practical to determine this. When it is not, the therapeutic range for the treated population is used, although the prescriber should remain aware that the optimal value for the individual may not lie within this range. Preoccupation with achieving plasma drug concentrations in the therapeutic range must never be allowed to override clinical common sense when treating patients with epilepsy. PMID- 10166409 TI - General practitioner fundholding and prescribing expenditure control. Evidence from a rural English health authority. AB - In April 1991, the fundholding and indicative prescribing schemes introduced budgets for expenditure on prescribed drugs into UK general practice. Although both schemes were designed to be equally effective at containing prescribing-cost inflation, several studies suggest that expenditure growth has been lower in fundholding practices, compared with nonfundholding practices. This study attempts to ascertain how fundholding practices control their expenditure by examining data from a rural English health authority for the financial year 1993 to 1994. The fundholding practices sampled were found to control their expenditure through: (i) reduced overprescribing; (ii) using fewer drugs that have limited clinical value; (iii) substituting similar, but less expensive, drugs; (iv) more generic prescribing; and (v) appropriate use of expensive preparations. However, whether the cost differential between fundholding and nonfundholding practices is sustained in future years will depend upon: (i) the ability of fundholding practices to generate further savings; (ii) the characteristics of the practices that enter the fundholding scheme in subsequent waves; (iii) the way in which the scheme is organised; and (iv) the level at which budgets are set. PMID- 10166410 TI - Cost-minimisation analysis of sequential treatment with ofloxacin or ciprofloxacin in hospitalised patients. AB - This study evaluated the cost of sequential treatment with once-daily ofloxacin or twice-daily ciprofloxacin in 474 hospitalised patients in different countries. The patients were treated intravenously for at least 3 days, then orally for 7 to 10 days or for 3 days beyond the disappearance of infection-related symptoms. The overall clinical cure rate (86.8% with ofloxacin and 89.6% with ciprofloxacin) and the overall bacteriological response rate (89.9 and 89.0%, respectively) were similar, and a cost-minimisation analysis was conducted. The acquisition costs for ofloxacin and ciprofloxacin in Greece, Israel, Slovenia and Turkey were used and converted to Deutschmarks (DM), and the costs of administration were analysed for each hospital. The different cost categories for oral and intravenous (IV) treatment (e.g. antimicrobial acquisition, drug monitoring, drug delivery costs) were used to identify any differences. The total costs per patient varied between the countries involved, but were higher for ciprofloxacin (ofloxacin: DM239 to DM724; ciprofloxacin: DM540 to DM976). In a sensitivity analysis using identical daily acquisition costs for the 2 fluoroquinolones, the total cost of treatment was higher for ciprofloxacin, as a result of the lower cost of administration of ofloxacin in the once-daily regimen. Continuing IV therapy would be approximately 50% more expensive than switching to oral administration; however, whenever possible, both drugs can be switched from IV to oral treatment. PMID- 10166411 TI - Cost-effectiveness analysis of different strategies for treating duodenal ulcer. Helicobacter pylori eradication versus antisecretory treatment. AB - Helicobacter pylori has recently been recognised as a causative agent for duodenal ulcer, and the efficacy of various combinations of antibacterials and antisecretory agents in eradicating this pathogen has been assessed. The objective of this study was to determine the efficiency of 2 treatment strategies for patients with H. pylori-positive duodenal ulcer. Cost effectiveness was analysed for antisecretory therapy (omeprazole 20 mg/day for 4 weeks), and eradication therapy (triple therapy: omeprazole 40 mg/day plus clarithromycin 1 g/day plus amoxicillin 2 g/day for 1 week). In a Markov model, a hypothetical cohort of 5000 patients was followed for 10 years through 6 disease states. Cyclic eradication therapy (i.e. in the first duodenal ulcer episode and in relapses) was the most cost effective [21 Spanish pesetas (Pta) per day free of symptoms (DFS); Pta128 = $US1 (October 1995)] of the eradication options evaluated [antisecretory in the first episode, then eradication for relapses (Pta22.3/DFS), and eradication therapy first, then antisecretory therapy (Pta27.3/DFS)]. Antisecretory therapy alone was less cost-effective (Pta39/DFS) than each of the 3 eradication options. Eradication treatment in the first episode of duodenal ulcer and relapses has savings in direct costs per patient of up to 56% compared with antisecretory therapy alone. Sensitivity analyses showed the model to be very robust. It is, therefore, advisable to treat initial episodes of H. pylori-positive duodenal ulcer and relapses with triple therapy. The improved cost-effectiveness ratio was largely explained by the long term reduction in relapses obtained with the eradication strategies. PMID- 10166412 TI - For free PSA, it's all in the numbers. PMID- 10166413 TI - HEDIS sharper but still coming up short. PMID- 10166414 TI - Self-test for pro-times: some day, for some patients. PMID- 10166415 TI - For device makers, too, new focus is outcomes. PMID- 10166416 TI - LIS stars in lab utilization show. PMID- 10166417 TI - Past is future for blood banks. PMID- 10166418 TI - Choosing the best Chlamydia trap. PMID- 10166419 TI - When screening for wellness is right. PMID- 10166420 TI - For urine HIV screen, confirmatory test in the works. PMID- 10166421 TI - Hematology analyzer decisions not 'automatic'. PMID- 10166423 TI - Wrestling with resident responsibility and Medicare's rule. PMID- 10166422 TI - HPV test: antidote to ASCUS headache? PMID- 10166424 TI - How cows got blamed for CJD strain. PMID- 10166425 TI - Less becomes best in microbiology. PMID- 10166426 TI - New technology born of FISH. PMID- 10166428 TI - Labs making leap to telepathology. PMID- 10166427 TI - Using biochemical bone markers. PMID- 10166429 TI - Cancer algorithm may help find 'needle in a haystack'. PMID- 10166430 TI - Lowly 'bugs' demand sharp minds. PMID- 10166431 TI - Pounding the drum for quality: a new beat. PMID- 10166433 TI - Nebraska network passes milestone with 509 patient encounters. PMID- 10166432 TI - How to diagnose and manage heparin-induced thrombocytopenia. PMID- 10166434 TI - Federal coalition outlines steps for industry progress. PMID- 10166435 TI - Tele-endoscopy demonstrates potential for remote diagnosis. PMID- 10166437 TI - Rural telemedicine may fail to fill pot-of-gold hopes. PMID- 10166436 TI - Multimedia medicine: the basics. PMID- 10166438 TI - ATSP offers exit strategy for payment policy maze. PMID- 10166439 TI - Evaluation studies show telemedicine's impact on outcomes. PMID- 10166440 TI - The case of Powhatan Correctional Center/Virginia Department of Corrections and Virginia Commonwealth University/Medical College of Virginia. AB - OBJECTIVE: To implement a cost/benefit analysis of telemedicine subspecialty care provided between the Powhatan Correctional Center (PCC) of the Virginia Department of Corrections (Corrections) and the Medical College of Virginia campus of Virginia Commonwealth University (MCV/VCU). METHODS: We evaluated the costs and benefits of the implementation of telemedicine for HIV-positive inmates. Benefits included dollar savings in transportation and medical reimbursement. Costs included those of operating the telemedicine system and of medical care. Non-dollar benefits included implementing more consistent and timely treatment of inmates and reducing security risk. RESULTS: Over the 7-month study period, the total number of HIV consults by telemedicine was 165. The Department of Corrections was able to achieve transportation and medical savings of $35,640 and $21,123, respectively. The operating costs for the telemedicine services totaled $42,277. The net benefit, which is the difference between cost savings and total operating costs, was $14,486. CONCLUSION: Telemedicine increased access to care for HIV-positive inmates and generated cost savings in transportation and care delivery. PMID- 10166441 TI - Requirements for urology and renal dialysis PC-based telemedicine applications: comparative analysis. AB - The Imaging Science and Information Systems (ISIS) Center of the Department of Radiology at Georgetown University Medical Center (GUMC) has been developing technical requirements for different telemedicine applications. This paper details the process through which those technical requirements are determined and shows how they may differ substantially, depending on the clinical need. This information is presented in light of two telemedicine applications being undertaken at GUMC: a urology application for the management of patients with surgical stone disease and a nephrology application for monitoring of renal dialysis patients. PMID- 10166442 TI - Dermatopathology via a still-image telemedicine system: diagnostic concordance with direct microscopy. AB - OBJECTIVE: To determine the concordance of dermatopathology diagnosis by still image telemedicine technology and direct microscopy. MATERIALS AND METHODS: Skin specimens (N = 79) were examined by a dermatopathologist using a still-image phone system, and the diagnoses were compared with those made by the same dermatopathologist 1 year earlier by direct microscopy. The telemedical diagnoses were reached first without, and then with, patient histories. RESULTS: When the patient history was available, identical diagnoses were made in 66 of the 79 cases (84% concordance rate). Without patient history, the concordance rate was 80%. The diagnostic concordance rate for the diagnosis of benign nevocytic nevi, inflammatory diseases, and benign and malignant non-squamous cell carcinoma neoplasms was statistically significantly greater than the concordance rate for the diagnosis of squamous cell carcinoma and squamous cell carcinoma in situ (P = 0.005). CONCLUSIONS: The diagnostic concordance rate achieved by teledermatopathology using a still-image phone system fell short of the 99% intraobserver diagnostic concordance rate using direct microscopy. PMID- 10166443 TI - Blueprint for multimedia telemedicine networks in the Rocky Mountain Veterans Integrated Service Network (VISN-19). AB - A multimedia telemedicine network is proposed for a VISN-19 test bed and it will include picture archiving and communication systems (PACS). Initial tests have been performed, and the technical feasibility of the basic plan has been demonstrated. PMID- 10166444 TI - Teleophthalmology: rationale, current issues, future directions. AB - Relatively little information exists concerning the delivery of ophthalmic services via telemedicine, yet ophthalmology is particularly amenable to the utilization of such applications. This paper discusses the technological issues pertinent to the research, development, and assessment of teleophthalmology delivery systems and begins to define the parameters that will determine the sustainability of teleophthalmology. A prototype urban teleophthalmology delivery system is presented in the context of improving access to eye care for an underserved inner-city population. Potential enhancements to the prototype telephthalmology system are discussed. PMID- 10166445 TI - Remote medical consultation for vestibular disorders: technological solutions and case report. AB - Complaints of vertigo and imbalance are common presentations to primary care physicians, yet there are few specialists who diagnose and treat these problems as a significant part of their practices. We demonstrated the feasibility of remote consultation for a patient presenting with vertigo using a two-way digital video and audio network. It was possible to take an appropriate history, examine the patient, and provide a diagnosis and treatment. The patient had a common problem that causes dizziness: benign positional vertigo (BPV). An essential component of the examination was the use of a head-mounted display with embedded cameras. The cameras allowed viewing of the patient's eye movements, which were diagnostic. PMID- 10166446 TI - Health care providers' perceptions of telemedicine services. AB - OBJECTIVE: To assess the level of consensus among the administrative and health care leaders at rural Iowa hospitals regarding service gaps and priorities for developing telemedicine services. METHODS: In the summer of 1994, a survey was conducted of all rural hospital chief executive officers, chiefs of medical staffs, and directors of nursing in Iowa concerning their perceptions of telemedicine services. RESULTS: With the exception of teleradiology, few clinical specialties received high ratings as areas of need or priorities for the development of telemedicine. There was a general lack of agreement among respondents from the same hospital on such priorities. In contrast, respondents expressed higher priorities for the development of telemedicine-based educational services. CONCLUSIONS: The interest in teleradiology is consistent with the fact that teleradiology has been more thoroughly tested for medical efficacy than other telemedicine applications. Continuing medical education may represent another potential for widespread successful telemedicine application. Financial issues were reported as the greatest barriers to the development of telemedicine systems. PMID- 10166447 TI - First trial of home ECG and blood pressure telemonitoring system in Macau. AB - OBJECTIVE: To determine the feasibility of home monitoring of patients with cardiac disease or hypertension. METHODS: An improved home electrocardiographic and blood pressure telemonitoring system linked to a central workstation was tested in 10 patients in Macau for 3 months. RESULTS: The total number of connections was 1377. Of the automatic alarm connections, 32.5% were false positive, with the percentage of false positives ranging from 7.6 to 54.6 for different patients. Both patients and physicians found the system easy to use. CONCLUSIONS: Further investigation is required to match the number of patients with the system capacity. A more robust dysrhythmia detection algorithm is needed to reduce the number of false alarms. Nevertheless, the results were sufficiently good that the trial is being expanded. PMID- 10166448 TI - Telecare: the need for understanding. PMID- 10166449 TI - Practice Brief. Issue: Information security: a checklist for healthcare professionals. American Health Information Management Association. PMID- 10166450 TI - Creating open doors: employing initiative in career development. PMID- 10166451 TI - National Research Council releases report on protecting electronic health information. PMID- 10166452 TI - A holistic approach to network system security. AB - Networks and information systems change continuously, so it is important to create a security process that adapts to change. Here's how to ensure effective network security through a process of assessing, implementing, monitoring, and identifying. PMID- 10166454 TI - Ambulatory care computerized patient record systems: benchmark security features and safeguards. AB - Computerized patient record systems require organizations to come to terms with issues such as privacy and confidentiality. The author describes the minimum privacy requirements and systems security features that ambulatory care CPR solutions should address. PMID- 10166453 TI - A team approach to managing an information security program. AB - How can HIM professionals step into the spotlight as facilities establish information security policies and procedures? At Hartford Hospital, HIM practitioners collaborated with other departments and formed a team that creatively implements and manages the security process. PMID- 10166455 TI - Implementing computer-based patient records for American Indian/Alaskan Native populations. PMID- 10166456 TI - Curriculum model for baccalaureate degrees programs in HIM, Part II: Focus on educational outcomes and curriculum content. AB - This the second in a series of three articles discussing curriculum models for associate and baccalaureate degree programs in health information management (HIM). Part I discussed the development of the models and presented a composite summary of selected key sections within the models. Part II focuses on the educational outcomes, curriculum content, and clinical experience expectations for the baccalaureate degree curriculum model. Part III will do the same for the associate degree curriculum model. PMID- 10166457 TI - New York's "grouping up" phenomenon, while accelerated, is by no means unique. PMID- 10166458 TI - "Flex" jobs and "blended" jobs create efficiencies at Albert Einstein Healthcare Network. PMID- 10166459 TI - The implementation of TRENDSTAR in NSW. PMID- 10166461 TI - Recent developments in information management for primary and community health services. AB - While health services provided outside the hospital environment are utilised by the majority of the community, until recently there has been little interest in developing a standard approach to information management in community health settings. With greater accountability for health services expected in the future, State and Federal governments have begun to set the necessary standards by the design of a common data model and data definitions for Primary and Community Health Services. This model will affect the manner in which the National Health Data Dictionary develops--from a primarily institution-based document to a broader approach which encompasses non-institutional care. Two new high level concepts have been introduced: "issue" and "activity". Four States have also formed a consortium to design and implement an information management system for Community Health Services. This necessitates adoption of standard classification systems which could be applied in this environment, especially to the two new high level concepts. This paper outlines recent developments in information management for Community Health and provides a brief summary of available classification systems. PMID- 10166460 TI - The WA Hospital Morbidity Data System: an evaluation of its performance and the impact of electronic data transfer. AB - The paper evaluates the performance of the Hospital Morbidity Data System, maintained by the Health Statistics Branch (HSB) of the Health Department of Western Australia (WA). The time taken to process discharge summaries was compared in the first and second halves of 1995, using the number of weeks taken to process 90% of all discharges and the percentage of records processed within four weeks as indicators of throughput. Both the hospitals and the HSB showed improvements in timeliness during the second half of the year. The paper also examines the impact of a recently introduced electronic data transfer system for WA country public hospitals on the timeliness of morbidity data. The processing time of country hospital records by the HSB was reduced to a similar time as for metropolitan hospitals, but the processing time in the hospitals increased, resulting in little improvement in total processing time. PMID- 10166462 TI - Privacy and security: are your health information systems up to standard? AB - As electronic patient health information systems become more fully developed and widespread, there are persistent concerns about the privacy and confidentiality of the personal health data being stored and disseminated. Standards Australia has released two Standards which provide useful guidelines for the organisational, technological and human behavior solutions required to protect privacy and confidentiality in health care organisations. The major requirements of these Standards are outlined and the implications of the Standards for health information managers are discussed. PMID- 10166463 TI - Accredited clinical coder examination 1996 results. AB - In September 1996, 148 candidates sat for the first Australian Clinical Coder (ACC) accreditation examination at 19 sites across Australia and New Zealand. This event was an important milestone for clinical coders in Australia. Around one third of the candidates who sat for the exam gained accreditation. The results show that the candidates who were most likely to be successful in gaining accreditation: worked in public hospitals (of any size) or private hospitals with more than 150 beds spent 25 hours or more each week on coding or coding-related activities had been coding for three or more years. The greatest percentage of successful candidates had been coding for 10 or more years. PMID- 10166465 TI - Who benchmarks anyway? What does it really mean? PMID- 10166464 TI - Identifying indigenous people in health data collections. Current status and recent strategies to improve data quality. PMID- 10166466 TI - Changing faces. PMID- 10166467 TI - Kidnapped. AB - Recent battle cries to boost health care coverage for children might suggest help is on the way. Yet as politicians tout their new-found generosity, they've also been snatching away some government money for kids. PMID- 10166468 TI - Mapping Medicare. AB - For senior citizens enrolled in medicare HMOs, the size of payments depends on where they live. As HMOs for seniors become uneconomical in rural areas, the system is in danger of breaking down. PMID- 10166469 TI - Vision adds value. AB - Both HMOs and vision service providers say vision will continue to gain popularity as an ancillary benefit. And some believe that carve-out eyecare plans that combine exams, corrective lenses, and medical benefits also will grow. PMID- 10166470 TI - Choosing the right PBM. AB - A growing number of HMOs are turning to pharmacy benefit management firms to administer their prescription benefit programs. A consultant offers tips on how to evaluate PBMs and the services they provide. PMID- 10166471 TI - Prevalence of chronic illness in HMOs and indemnity plans. PMID- 10166472 TI - Preserving antitrust. AB - The forces of organized medicine are arguing for changes in antitrust laws to allow exemptions for physicians. But, given the growing number of provider sponsored health plans, are such changes necessary? PMID- 10166473 TI - Purchasing alliances: still in the picture. AB - In 1993, purchasing alliances were a hotbed of legislative activity. Today, 13 states have enacted laws establishing them. Here's a brief update of how these alliances are working. PMID- 10166474 TI - Information architects: data by design. AB - HMOs and other network-based health plans are harnessing the power of information -building integrated data infrastructures to meet the needs of members, caregivers, and employers. PMID- 10166475 TI - Disease management: a team approach to chronic care. PMID- 10166476 TI - A breath of fresh air. PMID- 10166478 TI - Social HMOs: ten years and counting. PMID- 10166477 TI - Listening to Medicaid recipients. PMID- 10166479 TI - Medical savings accounts: in the spotlight on Capitol Hill. AB - Medical savings accounts (MSAs) have emerged as one of the key health care proposals under consideration in the 104th Congress. These tax-free accounts, which are viewed as an alternative to traditional "comprehensive" health care coverage, would allow individuals and their employers to set aside money to pay for major health care expenses. Depending on how they are designed, MSAs could have significant implications for HMOs and other managed care arrangements. PMID- 10166480 TI - Fifty years of caring. Kaiser Permanente turns 50 this year. AB - It's been said that major, landscape-changing events can sometimes stem from the humblest of origins: The gentle flutter of a butterfly's wings, the theory states, can begin a sequence of events that profoundly alters the weather pattern of an entire continent. In the world of science, this phenomenon is known as "chaos theory." But in the dynamic environment of the U.S. health care system- where the HMO philosophy has profoundly alter the way health care is delivered and financed--it has another name: Kaiser Permanente. From the humble yet revolutionary idea of a young surgeon caring for Depression-era workers in the Mojave Desert, to the current 6.7-million-member organization that has served as a model for plan administrators and policy makers across the country, Kaiser Permanente has originated, endured, and contributed more to the health care marketplace over the past 50 years than probably any other entity. Now, on Kaiser Permanente's golden anniversary, as the health plan reflects on its accomplishments and influence, it is plotting a course for quite challenging times ahead. PMID- 10166481 TI - The right choice for Medicare. PMID- 10166482 TI - Blurred boundaries: state regulation of PHOs. AB - Health plans that look alike to patients don't all have to meet the same standards for quality of care, benefits, and solvency. A recent GHAA 50-state survey looks at the regulation of one of the newer health plan models--the PHO. PMID- 10166483 TI - Preventing motor vehicle injuries. PMID- 10166484 TI - A house call for rural America. PMID- 10166485 TI - Medicaid expansion: getting off the ground. PMID- 10166486 TI - Evaluating new medical technology: science or politics? PMID- 10166487 TI - Point/counterpoint. The HMO pharmacy benefit. In-house pharmacy administration: the benefits of integration. PMID- 10166488 TI - Point/counterpoint. The HMO pharmacy benefit. Contracted pharmacy services: the value of a carve-out PBM. PMID- 10166489 TI - Better care for breast cancer. AB - HMOs have made a priority of improving mammography rates. Now some plans are teaming with the Health Care Financing Administration to share best practices. PMID- 10166490 TI - Easing the pain of arthritis. PMID- 10166491 TI - Broker appeal. PMID- 10166492 TI - A commitment to community. PMID- 10166493 TI - By the numbers. A dynamic and growing industry. PMID- 10166494 TI - Doctors unite. Physician practice management companies offer healthy returns. PMID- 10166495 TI - Minding our NVQs (national vocational qualifications). PMID- 10166496 TI - Fine degrees. PMID- 10166497 TI - Two heads. PMID- 10166498 TI - High interest. PMID- 10166499 TI - Shaping up. PMID- 10166500 TI - NHS structure. Out for the count? PMID- 10166501 TI - Primary care. Are GP fundholders wasting money? PMID- 10166503 TI - Play it again, Steve. PMID- 10166502 TI - Keeping the channels open. PMID- 10166504 TI - Compensation claims. Pay-back time. PMID- 10166505 TI - Law of averages. PMID- 10166506 TI - Law. A fast recovery. PMID- 10166507 TI - Australian operating room registered nurse education: a national study comparing two types of healthcare technology. AB - A random sample of operating room registered nurses (N = 258) working in hospitals throughout Australia was surveyed to compare how and what they initially learned about two types of healthcare technology--the count procedure and the electrosurgical unit (ESU)--and the consequences of their use. The most frequently identified method of initially learning to use both technologies was receiving instruction from a staff member on their unit. A comparison of what registered nurses initially learned about the technologies revealed that nurses were significantly more likely to learn more about the count procedure. The count procedure and ESU caused less than one-third of nurses to experience stress; participants were significantly less likely to have had an inaccurate count procedure result in patient harm (10.1%) than to have used an ESU that caused patient harm (17.4%). PMID- 10166508 TI - Economic and ethical considerations in managed care. AB - The growth of managed care has had a significant impact on the way hospitals provide medical services, the relationships between hospitals and physicians, and the relationships between providers and patients. This impact arises primarily from the economic constraints that managed care places on the provider. As hospital employees or contractors, and as consumers of health care services, clinical engineering personnel need to understand the effects of managed care on the hospital and the physician. Beyond general information, this knowledge can play a useful role in understanding the impact of managed care on the acquisition and use of medical technology, and the increasing role that clinical engineering can play in guiding investment in, use and maintenance of hospital medical equipment. Ironically, this potential for increased value occurs at a time when clinical engineering services and departments themselves are under increased scrutiny for their more measurable costs and value. PMID- 10166509 TI - Compliance with the ethylene oxide standard during exhaust system upgrade at a hospital sterilizer. AB - This case study documents the problem-solving approach used to implement all pertinent sections of the Ethylene Oxide Standard (29 CFR 1910.1047) during an exhaust ventilation system upgrade at an ethylene oxide hospital sterilizer unit. The approach for implementation of the standard utilized the following methodology: A. Review of proposed work plan with hospital and contractor representatives to identify items which must be addressed to assure compliance. B. Establishment of regulated areas and implementation of engineering controls and work practices to minimize potential exposure. C. Development of written project program which addresses chemical and physical characteristics, project hazards, permissible exposure limits, safe handling precautions, personal protective equipment, monitoring strategy, emergency procedures (29 cfr 1910.38) and project tasks and timing. D. Development and implementation of a project respiratory program to include employee respirator training, fit testing, and preparation of a written respirator program. E. Field inspection and procurement of real time area samples and full shift personal samples to verify safe working conditions and characterize and document worker exposures during project. The industrial hygiene concerns addressed here are unique since they involve a retrofit maintenance program implemented by tradesmen working around a potentially hazardous chemical not regularly encountered in routine circumstances. PMID- 10166511 TI - Message from Jacksonville: don't threaten the Blues with your PHO. PMID- 10166510 TI - An evaluation of three oscillometric non-invasive blood pressure simulators. AB - A number of simulators have been developed for testing and evaluating oscillometric non-invasive blood pressure (NIBP) monitors. These simulators may be used to assist with the routine and corrective maintenance of NIBP monitors; for training clinical staff in the use and limitations of oscillometric NIBP monitors; to complement clinical trials in the process of evaluating new NIBP monitors; and to assist with the development of new NIBP monitors. We assessed three NIBP simulators (Bio-Tek BP-Pump, Dynatech CuffLink, and Metron QA-1280A) in the light of these applications, considering such features as the ability to calibrate NIBP monitors; the range of simulated waveforms; weak and strong pulses and artifact; graphical displays of the cuff pressure and the oscillometric waveform; and the recording of performance measures of each NIBP determination such as determination time, inflation rate and peak cuff inflation pressure. PMID- 10166512 TI - Explaining things to an angry managed-care patient. PMID- 10166513 TI - Should you accept deferred compensation? PMID- 10166514 TI - Are we taking care of patients--or charts? PMID- 10166515 TI - Bypassing primary-care physicians. PMID- 10166517 TI - Health reform. Execs tell Washington: keep up the fight. PMID- 10166516 TI - When problem visitors rile your hospital patient. PMID- 10166518 TI - Physician manpower. A tougher job market for newcomers to primary care? PMID- 10166519 TI - Raising capital. Deal a hospital a minority stake in your doctor group. PMID- 10166520 TI - Raising capital. Try a do-it-yourself public offering. PMID- 10166521 TI - Raising capital. Issue bonds backed by a letter of credit. PMID- 10166522 TI - Referrals that leave both you and the specialist happy. PMID- 10166523 TI - Can you trust an HMO with your elderly patients? PMID- 10166524 TI - Changing value. Columbia's Value Health stock swap becomes cash deal. PMID- 10166525 TI - A look back, a look forward. Rise of systems, for-profits challenge a changing VHA. PMID- 10166526 TI - Why was Blues deal nixed? Some say Kansas plan feared K.C. insurer's reputation. PMID- 10166527 TI - AHA unveils exec shakeup, plans data unit. PMID- 10166528 TI - In the same boat. For-profit, not-for-profit hospitals face peril of tax reform. AB - The ongoing, escalating rift between for-profit and not-for-profit hospitals could be the crowbar that pries open the Pandora's box of tax reform, an issue so complicated and fraught with political peril it makes Medicare reform look easy. While everyone waits for congressional leaders to signal their intentions, people from both ownership sectors are laying the groundwork for future action. PMID- 10166529 TI - Starting your own PPM (physician practice management company). PMID- 10166530 TI - Accident insurance. Dana-Farber seeks foolproof ways to stop medical errors. PMID- 10166531 TI - A corporate calling. Nun's seat on Columbia's board boosts order's mission. PMID- 10166532 TI - The rest of the story. AHA lobbyists wail, but ProPAC says industry doing fine. PMID- 10166533 TI - Impact of the Health Insurance Portability and Accountability Act on electronic processing. PMID- 10166534 TI - On creativity and cookbooks, discipline and freedom. AB - Is cookbook medicine a major threat to patients and physicians alike? Should this management tool be condemned as yet another disdainful and questionable aspect of managed care? Presented here are arguments for and against cookbook medicine- with some surprising conclusions. Could it be that cookbook medicine actually fosters creativity, discipline, and freedom? PMID- 10166535 TI - Improve clinical processes in three meetings. AB - Many health care organizations have developed methodologies to improve their processes of care. Most have outputs, such as clinical paths and/or algorithms, that require dozens of meetings over many months to design. Morton Plant Health System has taken a "SWAT team" approach and created a multi-hospital, multi disciplinary team that develops recommendations and process changes after only three meetings of the entire team over two to three months. The organization has been highly successful, with process changes resulting in improve outcomes and savings in charges (1995 compared to 1994) of more than $22 million. What was the evolution of this process, what is the "SWAT" team approach and how does it work, and why has Morton Plant Health System been so successful in its efforts? PMID- 10166537 TI - Head for open space. AB - Is it possible that the herd mentality, the "Follow The Other Guy" idea is not the golden road to transformation? In fact, the three questions that are most helpful in deciding your path, as a person or an organization, lie almost completely in the other direction: (1) "What am I really good at?" (2) "What am I afraid of?" and (3) "What is no one else doing?" Heading for the open space means looking for the hole in the market, searching for what no one else is doing. Only by going toward open space can you or your organization stay ahead of the pack in a turbulent health care environment. Get out in front of the pack, either as a leader or quarry, and you have a measure of control. How does the quarry control the pack that is hunting it? By choosing the terrain, choosing the ground on which the chase will take place. PMID- 10166536 TI - Success in managed care: improving clinical quality. AB - What are the economic elements for success in managed care? Although they are quite simple, achieving them can be difficult. The criteria for success in the fee-for-service medical delivery system, generally characterized as "see more--do more--get more," are no longer valid for delivering care in a managed care system. This article identifies the economic elements for success in managed care, and offers a disciplined approach to achieving them, combining both actuarial and clinical expertise. PMID- 10166538 TI - How could I have gotten it wrong? AB - Can you avoid ending up in a career-denting job: Are there potential pitfalls to recognize on the search for a rewarding position? Finding oneself in an impossible job, working for a boss who brings out your worst qualities and deepest insecurities, or joining an organization that is doomed are nightmare scenarios. How do these judgment errors happen? We asked physicians who've been there and, unfortunately, done just that. What they learned might help the rest of us skip the experience. PMID- 10166539 TI - Some thoughts on becoming an ACPE Fellow (American College of Physician Executives). AB - Why pursue Fellowship in the American College of Physician Executives? Three physician executives talk about their experiences and explain why becoming an ACPE Fellow is an opportunity to become a leader in shaping the future of the College and medical management. The greatest value of Fellowship is that it shows that you have stature in the profession and it distinguishes you from your colleagues. Becoming a Fellow is evidence of attaining a next higher level of expertise. The process and requirements for becoming a Fellow are outlined, along with many ways to contribute to the field of medical management. PMID- 10166540 TI - The best leaders. AB - Today's movements away from authoritarian leadership emphasizes team development. People are experiencing with a leadership that empowers, rather than a leadership that is, itself, powerful. But how do you become a leader who empowers others? What are the characteristics of "best leaders"? From listening skills to getting feedback and including people in the process of change, effective leaders help others move towards the goal, ultimately thinking, "We did this ourselves." PMID- 10166541 TI - Haunts on the Web for physician executives. AB - Listed here are some medical management and health care related Web sites on the Internet worth visiting, as well as favorite search engines and how to use them. From health care systems and hospitals, to health plans and insurers, the industry is using Web technology to promote programs and outcomes, and to provide information on health and wellness. PMID- 10166542 TI - The courageous follower. AB - With the recent changes in the delivery of medical care in the United States, physicians are being thrust into new and unsettling roles. Many are finding themselves for the first time in the role of the follower, subject to myriad types of leadership. Leaders frequently complain that leading physicians is like "herding cats." What are the characteristics of followers? Do physicians make good followers? This article examines the role of the "cats"--what is effective followership, why physicians may fall short in followership skills, and how physicians might become better "followers." PMID- 10166543 TI - Building an equipment asset management partnership. PMID- 10166544 TI - Negative mood and urban versus rural residence: using proximity to metropolitan statistical areas as an alternative measure of residence. AB - The purposes of this report is to describe the distribution of reported negative mood by place of residence focusing on proximity to metropolitan statistical areas (MSA's) as an alternative to the traditional urban versus rural residence variable using the 1991 National Health Interview Survey's Health Promotion and Disease Prevention (NHIS-HPDP) supplement. The self-report of negative mood comes from the negative affect items of the Bradburn Affect Balance Scale categorized as high and low presence. The proximity to MSA's is a county-based measure developed as a combination of the MSA/non-MSA residence variable from the NHIS HPDP and the United States Department of Agriculture (USDA) adjacency code from the Area Resource File (ARF). The proximity to MSA's measure has four categories: 1. MSA central city 2. MSA not central city 3. non-MSA adjacent (contiguous) to MSA 4. non-MSA not adjacent to MSA The odds ratios for negative mood were 1.24 (95 percent confidence limits [CL] = 1.11,1.38) for MSA central city and 1.26 (95 percent CL = 1.05,1.52) for non-MSA not adjacent to MSA as compared with MSA not central city. The odds ratio for non-MSA adjacent to MSA was not significantly different from MSA not central city. Data are presented by age, sex, race, and education. Thus, the proximity measure demonstrated greater discrimination in rates of negative mood than did urban versus rural or other measures of place of residence. PMID- 10166546 TI - Neuro-ophthalmology. PMID- 10166545 TI - Characteristics of patients receiving hospice care services: United States, 1994. AB - OBJECTIVE: This report presents data on current hospice care patients. Numbers and percents are shown by selected characteristics of the agencies from which the patients received services, by selected patient characteristics, by services provided, by types of personnel that provided the services, and by diagnoses of these patients. METHODS: The data used for this report are from the National Center for Health Statistics' 1994 National Home and Hospice Care Survey. This is an annual survey through which data are collected on the use of hospices and home health care agencies in the United States. RESULTS: An estimated 61,000 patients were receiving hospice care services from 1,300 hospices and home health agencies in 1994. Fifty-five percent were women, 69 percent were 65 years of age and over, 81 percent were white patients, 48 percent were married, and 31 percent were widowed. Eighty-four percent were living in a private or semi-private residence, and 90 percent had a primary caregiver. Sixty percent received help from the agency with at least one activity of daily living (ADL), 46 percent with at least one instrumental activity of daily living (IADL), and 26 percent with walking. At admission, there was an average of 2.2 diagnoses per patient; 57 percent had a primary diagnosis of a malignant neoplasm and 9 percent had a primary diagnosis of heart disease. PMID- 10166547 TI - Neuro-ophthalmologic manifestations of rheumatologic and associated disorders. AB - Inflammatory diseases affecting the eye, the orbital content, or the endocranium are various. The clinical or radiologic presentation are multiple and their diagnosis can be a real challenge. Most relevant studies or case reports on systemic lupus erythematosus, Wegener's granulomatosis, Churg-Strauss syndrome, giant cell arteritis, Behcet's disease, Takayasu's arteritis, relapsing polychondritis, or inflammatory pseudotumor of the orbit are summarized in the present review. PMID- 10166548 TI - Neuro-ophthalmology of multiple sclerosis. AB - Multiple sclerosis remains a pathophysiologic enigma. The epidemiology has recently been reexamined and appears to lend credence to a greater genetic basis than previously believed. Neuro-ophthalmologic signs and symptoms in multiple sclerosis are extremely common and often present to the eye care practitioner. Although diagnostic methodology is progressing, treatment of multiple sclerosis is currently undergoing a revolution. PMID- 10166549 TI - Migraine. AB - Current research has focused on several aspects of migraine. Epidemiologic studies have described the general health characteristics of migraineurs. Case reports of unusual manifestations of migraine abound, and advances in the application of neurologic imaging offer the promise of prompt, efficient diagnosis of unusual vascular headaches. Investigations into physiologic and biochemical parameters of migraine continue to advance theories of pathogenesis. Finally, as a wide range of therapeutic modalities continue to be used in these diseases, the efficacy, complications, and relative costs of different therapies are discussed. PMID- 10166551 TI - Ocular myasthenia gravis. AB - Ocular myasthenia gravis may mimic any pupil-spared, painless, nonproptotic ophthalmoplegia with or without ptosis. This review references recent papers regarding clinical features, diagnostic techniques, and treatment for ocular myasthenia gravis. PMID- 10166550 TI - Paraneoplastic disorders of neuro-ophthalmologic interest. AB - Certain paraneoplastic disorders associated with degeneration of the retina, optic nerve, brainstem, and cerebellum may cause visual loss, impairment of ocular motility, or nystagmus and other saccadic intrusions and oscillations. Most of these remote effects of cancer are probably autoimmune conditions. Many affected patients have circulating antineuronal antibodies that serve to identify the autoimmune nature of their clinical presentation and allow the treating physician to target the evaluation to certain organs likely to be harboring an occult malignancy associated with that particular remote effect. Because patients with paraneoplastic disorders affecting vision and eye movement frequently develop symptoms before their underlying cancer is diagnosed, they will typically seek the assistance of an ophthalmologist first. Recognition that their symptoms or findings reflect a paraneoplastic syndrome may allow the tumor responsible for its presentation to be diagnosed at an earlier stage, which might positively influence the patient's overall prognosis. PMID- 10166552 TI - Nystagmus. AB - Acquired nystagmus causes excessive motion of images on the retina, which often reduces visual acuity and produces oscillopsia (illusory motion of the seen world). The pathogenesis of several forms of acquired nystagmus is now better understood and can be related to abnormalities of mechanisms that normally hold gaze steady. Basic research on the pharmacology of the neural pathways responsible for gaze holding has demonstrated an important role for gamma aminobutyric acid and led to new drug treatments for acquired nystagmus and its visual consequences. PMID- 10166553 TI - Disorders of facial motor function. AB - This review deals with a variety of disorders of facial movement. Recent publications on blepharospasm, facial spasm, facial myokymia, apraxia of lid opening and facial paralysis are referenced and discussed. In blepharospasm, carefully performed electromyographic studies reveal a variety of abnormal patterns of contraction of the oribicularis oculi and the levator palpebrae muscles confirming the clinical impression that blepharospasm is not a homogeneous disease. Similar studies are furthering the understanding of apraxia of lid opening, which may involve sustained contraction of the orbicularis oculi with or without failure of levator palpebrae inhibition. In both conditions botulinum toxin A injected pretarsally appears to be the preferred treatment. Of interest with respect to apraxia of lid opening is that it may be the result of a failure to sustain eye opening as well as an inability to open the eyes voluntarily. Although the fact that bilateral facial spasm was found in only five of 702 patients with spasm suggests that it is infrequent, it is also possible that bilateral facial spasm may be underdiagnosed because of lack of awareness of its existence. Despite the continued enthusiasm of neurosurgeons for microvascular decompression, the preferred treatment for facial spasm continues to be botulinum toxin A injections. It appears that a lesion of the dorsolateral pontine postgenu portion of the facial nerve is responsible for the facial myokymia of patients with multiple sclerosis. Interest in the study of lid function has increased as a result of the advent of the search coil technique for recording lid movements. Recordings with this technique have proven useful in facial nerve palsy for monitoring the degree and course of recovery and as a means of judging the effectiveness of therapy. PMID- 10166554 TI - Plasticity in the adult visual cortex: implications for the diagnosis of visual field defects and visual rehabilitation. AB - It has recently been shown that, contrary to long-held beliefs, sensory and motor maps are not stable in the adult cerebral cortex. Alteration of input from the periphery results in changes in topography in the cortex, including the primary visual cortex. Mechanisms involved consist mainly of reshaping the receptive field of cortical cells and increasing the sensitivity of deprived cells in the visual cortex. Cortical plasticity allows the brain to adapt to background modifications or to damage of the nervous system. It also underlies learning and attention processes. Cortical changes occurring after focal visual differentiation modify visual perception by filling in visual field defects with information from the area surrounding the scotoma. This modification causes affected subjects to ignore or underestimate their defects. With visual field defects, cortical plasticity also causes distortion in spatial perception. Although the effects of cortical plasticity are prominent in neuro ophthalmological daily practice, they are usually unrecognized or greatly underestimated. These effects cause delay in recognizing visual field defects, and hence in receiving therapy, while affecting the results of some procedures for testing the visual field. Affected individuals who are unaware of their defects may have increased difficulty in coping with activities in everyday life. Up to now, phenomena related to plasticity in the visual system have been investigated mainly by psychophysicists and neurophysiologists. It is essential to start considering the various effects of cortical reorganization in clinical practice. It is especially important to introduce into clinics the concept of dissociation between actual and perceived defects in the visual field, resulting from the filling-in process, and the need to measure it. This dissociation should also be demonstrated to the affected subjects. PMID- 10166555 TI - Ocular manifestations of systemic disease. PMID- 10166556 TI - Diabetes- and thyroid-related eye disease. AB - There is significant morbidity associated with diabetes- and thyroid-related eye diseases. Many different ocular changes are associated with these endocrine disorders. Vitreous hemorrhage from diabetic neovascularization remains the leading cause of blindness, and several recent studies of the etiology of this disorder are of great importance. However, in addition, other research examined aspects of diabetic visual loss that are not blinding, and the prevention of such impairment became significant this past year. During this same interval, specific diagnostic criteria for thyroid ophthalmopathy were established and are included in this review; these findings will aid in future research and patient care. PMID- 10166557 TI - Ocular manifestations of genetic and developmental diseases. AB - Although ophthalmic involvement in developmental and genetic abnormalities has been recognized for centuries, it is only recently, due to new discoveries in molecular biology, that our classification and pathophysiology of congenital eye diseases have been advanced. In the next few years these advances will increasingly influence aspects of diagnosis classification, and therapy in ophthalmology. Tests for acquired and inherited diseases in opthalmology are being revolutionized by biotechnical innovations. The molecular genetics of ocular diseases is currently undergoing changes in classification due to intense investigations using advanced biotechnology. The potential for new treatment modalities, such as gene therapy, for molecular eye diseases, once thought to be pure fiction, is now a reality. This paper will outline recent changes in classification, organization, and general knowledge regarding inherited eye diseases. PMID- 10166559 TI - Ocular manifestation of systemic infections. AB - Careful examination of external and internal ocular structures in patients with systemic infections may assist in early diagnosis and institution of appropriate therapy. Recent literature discussing ocular manifestations in the following systemic infectious diseases are reviewed: tuberculosis, Lyme borreliosis, cat scratch disease, toxocariasis, congenital toxoplasmosis, and invasive aspergillosis. PMID- 10166558 TI - Ocular manifestations of metabolic disorders. AB - Articles published during the past year on the ocular manifestations of metabolic disorders and related issues are reviewed. Fewer articles on this topic were available this year than previous years. Ornithine-delta-amino transferase deficient mice were produced by gene targeting in the hope of creating an animal model for gyrate atrophy. The mice developed unexpected hypoornithinemia in the neonatal period and died 24 to 48 hours after birth. One human infant also had hypoornithnemia without serious symptoms. Both mice and human develop hyperornithinemia later. Arginine supplementation rescued the mice, but they developed central retinal degeneration by 7 months. Coexistence of autosomal dominant congenital or early onset cataract and hyperferritinemia, not related to iron overload, was discovered in three pedigrees, two Italian and one not mentioned, by two different groups. Mutations of the ferritin L-subunit gene in the iron-responsive element were identified, with autosomal dominant inherited cataract associated with hyperferritinemia. PMID- 10166560 TI - Ocular manifestations of immunological and rheumatological inflammatory disorders. AB - Our understanding of ocular manifestations in immunological and rheumatological inflammatory disorders has continued to expand over the past year. A report on the characteristics of ocular disease in children with Behcet's disease is presented. Two reports of Vogt-Koyanagi-Harada syndrome in 4-year-old children are discussed, and the uncommon complication of macular edema in this syndrome is highlighted. An article reporting the presence of Epstein-Barr virus DNA in the vitreous of a patient with Vogt-Koyanagi-Harada syndrome is reviewed. Radiologic imaging patterns of orbital disease in Wegener's granulomatosis are presented. Unusual manifestations of sarcoidosis, systemic lupus erythematosus, and Wegener's granulomatosis are also reported. PMID- 10166561 TI - Ocular manifestations of various systemic diseases. AB - Renal failure in association with uveitis should raise the possibility of sarcoidosis even with a normal chest radiograph. Diode laser photocoagulation using the indirect ophthalmoscope delivery system is shown to be safe in the therapy of eyes with threshold retinopathy of prematurity and especially in eyes with tunica vasculosa lentis and is safer than argon laser, which is known to cause cataract formation. Eyes with retinopathy of prematurity stage 5 remain with a flat electroretinogram despite surgical reattachment, implying the existence of a severe irreversible dysfunction in these retinas. Choroidal metastases from prostate carcinoma can resolve after total androgen deprivation. Optic nerve metastases respond poorly to the radiation dose usually given for choroidal metastases and therefore require a higher dosage of radiation. PMID- 10166562 TI - Telerehab. A perspective of the way technology is going to change the future of patient treatment. PMID- 10166563 TI - Diagnosis of the spine. PMID- 10166564 TI - The other side of the coin. Applying spinal diagnosis technologies. PMID- 10166566 TI - Outpatient outcomes. PMID- 10166565 TI - Hand therapists, are you prepared? PMID- 10166568 TI - Cancer rehabilitation: an investment in survivorship. PMID- 10166567 TI - Occupational therapy goes home. PMID- 10166569 TI - Aquatic rehabilitation of the spine. PMID- 10166570 TI - Perspectives. Workers' comp: a complex adaptation for managed care. PMID- 10166571 TI - Marketplace. Can for-profit chains save troubled academic hospitals? PMID- 10166572 TI - Perspectives. Managed care brings danger and opportunity for research. PMID- 10166573 TI - Physician recruitment in a rural area. PMID- 10166574 TI - What your physicians want. Hospitals try to solve the age-old mystery. AB - Hospitals have always considered physicians to be among their primary "customers," but dwindling reimbursements and other major changes in healthcare over the years have had adverse effects on the hospital/physician marriage. Today, factors such as managed care and risk contracting make the relationship even more uncertain but also provide an incentive for facilities and their medical staffs to become closer. PMID- 10166575 TI - Sisyphus comes to Alabama. Starting an HMO an uphill battle for health systems. PMID- 10166576 TI - Prospective payment hits outpatient services. PMID- 10166577 TI - The new topography. A changing landscape for hospital marketing. PMID- 10166578 TI - The surgeon's role in palliative care. PMID- 10166579 TI - Congress considers issues related to managed care. PMID- 10166580 TI - Presidential disability and the XXV Amendment. AB - Following an attempted assassination on March 30, 1981, President Reagan had an operation under anesthesia and was seriously ill during the postoperative period. At that time, no one in the Administration suggested that the President invoke Section 3 of the 25th Amendment to the Constitution. That amendment, which was ratified in 1967, provides for voluntary transfer of powers to the Vice-President (Section 3) or for the possibility of involuntary transfer of powers and duties (Section 4). The amendment also defines the Vice-President's role after transfer as that of Acting President so that when the President recovers, he or she can resume the powers and duties of office. Such a transfer of authority did take place in July 1985, when President Reagan had a colectomy for colon carcinoma, but he initially denied that he was using the amendment. This reluctance to employ the mechanisms available for transfer of power led to the formation of a Working Group on Disability in U.S. Presidents under the leadership of a prominent neurologist, James F. Toole, MD, FACS, of Winston-Salem, NC. The working group has held meetings at the Carter Center at the invitation of President Jimmy Carter, at Wake Forest University with the participation of President Gerald Ford, and most recently, at the White House Conference Center in Washington. As a representative of the American College of Surgeons, the author participated in the latter meeting, where agreement was reached on nine specific recommendations that provide guidelines for use of the amendment. PMID- 10166581 TI - Postoperative lengths of stay: can they be defined by a specific number of days? PMID- 10166582 TI - Development of guidelines for severe head injury. PMID- 10166583 TI - Risk management and insurance (Part II). PMID- 10166584 TI - Neurosurgery in Nepal. PMID- 10166585 TI - Heart-to-heart partnerships cut costs of cardiac products. PMID- 10166586 TI - Helping hands. Materials managers pitch in to boost community initiatives. PMID- 10166587 TI - It's almost midnight. Do you know where your computer is? PMID- 10166588 TI - Wait watchers. Don't just stand there--do something about slow elevators. PMID- 10166590 TI - Pack fat! Ride herd on custom costs. PMID- 10166589 TI - Want to keep good workers? Try the buddy system. PMID- 10166591 TI - Easy as 1, 2, 3. Validation isn't as tough as you think. PMID- 10166593 TI - Backlash against HMOs. PMID- 10166592 TI - Mammogram two-step. PMID- 10166594 TI - Twin Cities' friendly plans. PMID- 10166595 TI - Randomised controlled trials in nursing. PMID- 10166596 TI - Randomised controlled trial of reminders to enhance the impact of audit in general practice on management of patients who use benzodiazepines. AB - OBJECTIVE: To determine whether reminder cards in medical records enhance the effectiveness of audit with feedback in improving the care of patients taking long term benzodiazepine drugs. DESIGN: Randomised trial, practices receiving feedback only in one group and practices receiving feedback plus reminder cards in the other group. SETTING: 18 general practices in Leicestershire. SUBJECTS: Random samples of patients who had been taking a benzodiazepine anxiolytic or hypnotic drug for four weeks or longer. MAIN OUTCOME MEASURES: Entries in medical records indicating compliance with five criteria of care: assessment of suitability for withdrawal; being told about dependency; withdrawal being recommended; withdrawal or continuing medication; and a consultation with the general practitioner in the past year. Data were collected before and after feedback or feedback plus reminders. RESULTS: Of a total population of 125,846 registered with the 18 practices, 2409 (1.9%) had been taking a benzodiazepine for four weeks or longer. Of the 742 in the first samples, 543 (73.2%) were women, the mean (SD) age was 68.7 (14.9) years, and they had been taking a benzodiazepine for 10.1 (6.7) years. The number of patients whose care complied with the criteria rose after the interventions to implement change. The increase was greater in practices receiving feedback plus reminders for only two of the five criteria "told about dependency" increasing from 52 (11.1%) to 118 (25.8%) in the feedback only group, and from 27 (10.5%) to 184 (43.0%) in the feedback plus reminders group; odds ratio (OR) 1.46 (95% confidence interval (95% CI) 1.32 to 5.21); and "consulted in the past year" increasing from 434 (93.1%) to 411 (95.8%) in the feedback only group and 255 (96.6%) to 400 (99.8%) in the feedback plus reminders group, OR (95% CI) 13.5 (2.01 to 330.3). CONCLUSIONS: Reminder cards had only a limited effect and cannot be recommended for routine use. There were improvements in the care of patients of both groups of practices and further studies are indicated to determine the impact of both systematically developed criteria and reminders embedded into restructured medical records. PMID- 10166597 TI - Changing preventive practice: a controlled trial on the effects of outreach visits to organise prevention of cardiovascular disease. AB - OBJECTIVES: To assess the effects of outreach visits by trained nurse facilitators on the organisation of services used to prevent cardiovascular disease. To identify the characteristics of general practices that determined success. DESIGN: A non-randomised controlled trial of two methods of implementing guidelines to organise prevention of cardiovascular disease: an innovative outreach visit method compared with a feedback method. The results in both groups were compared with data from a control group. SETTING AND SUBJECTS: 95 general practices in two regions in The Netherlands. INTERVENTIONS: Trained nurse facilitators visited practices, focusing on solving problems in the organisation of prevention. They applied a four step model in each practice. The number of visits depended on the needs of the practice team. The feedback method consisted of the provision of a feedback report with advice specific to each practice and standardised instructions. MAIN OUTCOME MEASURES: The proportion of practices adhering to 10 different guidelines. Guidelines were on the detection of patients at risk, their follow up, the registration of preventive activities, and teamwork within the practice. RESULTS: Outreach visits were more effective than feedback in implementing guidelines to organise prevention. Within the group with outreach visits, the increase in the number of practices adhering to the guidelines was significant for six out of 10 guidelines. Within the feedback group, a comparison of data before and after intervention showed no significant differences. Partnerships and practices with a computer changed more. CONCLUSION: Outreach visits by trained nurse facilitators proved to be effective in implementing guidelines within general practices, probably because their help was practical and designed for the individual practice, guided by the wishes and capabilities of the practice team. PMID- 10166598 TI - Identification and analysis of randomised controlled trials in nursing: a preliminary study. AB - OBJECTIVES: To describe preliminary work undertaken for development of a nursing contribution to the Cochrane Collaboration. To ascertain whether there are randomised controlled trials (RCTs) on nursing care which need to be identified for inclusion in systematic reviews of the effects of health care. DESIGN: Searches by Medline (1966-94) and by hand of 11 nursing research journals from inception to the end of 1994 to identify RCTs and systematic reviews; and a comparison of searches by hand and by Medline for three nursing research journals. MAIN MEASURES: Total number of RCTs identified and number of RCTs published in nursing journals; the sensitivity of Medline searches; and aspects of nursing care evaluated by RCT. RESULTS: The work is ongoing and 522 reports of RCTs and 20 systematic reviews of effectiveness have been identified so far. The sensitivity of Medline searches for RCTs in nursing journals is as low as 36% for one journal and the lack of reference to research design in the title or abstract was the main reason for the lack of sensitivity. CONCLUSIONS: There are RCTs that evaluate aspects of nursing care, and are published in nursing and non-nursing journals, and are largely undertaken by nurses. These must be reviewed in ongoing systematic reviews of the effects of health care (including those undertaken as part of the Cochrane Collaboration). Nursing journals must be hand searched to identify these studies as the lack of reference to study design in the titles and abstracts of nursing trials leads to poor indexing in electronic databases such as Medline. PMID- 10166599 TI - Use of the critical incident technique in primary care in the audit of deaths by suicide. AB - OBJECTIVE: To explore the usefulness of the critical incident technique in primary care to improve policy and practice to prevent cases of suicide. DESIGN: Inviting all primary care teams in County Durham with a patient who committed suicide between 1 June 1993 and 31 May 1994 to take part in a critical incident audit with an external facilitator. RESULTS: 49 cases of suicide were available for study, registered with 31 practices. 19 (61%) practices accounting for 27 (55%) cases agreed to take part. Case discussions showed areas where practice could be improved, but no substantive preventive measures were identified within primary care, which would reduce the number of people committing suicide. The wider social and economic context was thought to be more important. CONCLUSIONS: The use of the critical incident technique in primary care may have only a limited role in improving the management of people at risk from suicide. However, one of the potential strengths of this approach is to encourage reflection on practice in a difficult emotional area. PMID- 10166600 TI - Practitioner based quality improvement: a review of the Royal College of Nursing's dynamic standard setting system. AB - OBJECTIVE: To explore and describe the implementation of the Royal College of Nursing's approach to audit--the dynamic standard setting system--within the current context of health care, in particular to focus on how the system has developed since its inception in the 1980s as a method for uniprofessional and multiprofessional audit. DESIGN: Qualitative design with semistructure interviews and field visits. SETTING: 28 sites throughout the United Kingdom that use the dynamic standard setting system. SUBJECTS: Quality and audit coordinators with a responsibility for implementing the system; clinical staff who practice the system. MAIN MEASURES: Experiences of the dynamic standard setting system, including reasons for selection, methods of implementation, and observed outcomes. RESULTS: Issues relating to four themes emerged from the data: practical experiences of the system as a method for improving patient care; issues of facilitation and training; strategic issues of implementation; and the use of the system as a method for multiprofessional audit. The development of clinical practice was described as a major benefit of the system and evidence of improved patient care was apparent. However, difficulties were experienced in motivating staff and finding time for audit, which in part related to the current format of the system and the level of training and support available for clinical staff. Diverse experiences were reported in the extent to which the system had been integrated at a strategic level of quality improvement and its successful application to multiprofessional clinical audit. CONCLUSIONS: The Royal College of Nursing's dynamic standard setting system can successfully be used as a method for clinical audit at both a uniprofessional and multiprofessional level. However, to capitalise on the strengths of the system, several issues need to be considered further. These include modifications to the system itself, as well as a more strategic focus on resources and support for audit, better integration of quality initiatives in health care, and a continuing focus on ways to achieve true multiprofessional collaboration and involvement of patients in clinical audit. PMID- 10166601 TI - Essential dataset for ambulatory ear, nose, and throat care in general practice: an aid for quality assessment. AB - OBJECTIVE: To describe the documentation of care for the usual range of ear, nose, and throat (ENT) problems seen in primary care as a basis for developing a computerised information system to aid quality assessment. DESIGN: Descriptive study of the pattern of ENT problems and diagnoses and treatment as recorded in individual case notes. SETTING: The primary health care centre in Mjolby, Sweden. PATIENTS: Consultations for ENT problems from a 10% sample randomly selected from all consultations (n = 22,600) in one year. From this sample 375 consultations for ENT problems (16% of all consultations) by 272 patients were identified. MAIN MEASURES: The detailed documentation of each consultation was retrieved from the individual records and compared with the data required for a computer based information system designed to help in quality management. RESULTS: Although the overall picture gained from the data retrieved from the notes suggested that ENT care was probably adequate, the recorded details were limited. The written case notes were insufficient when compared with the details required for a computerised system based on an essential dataset designed to allow assessment of diagnostic accuracy and appropriateness of treatment of ENT problems in primary care. CONCLUSION: There is a gap between the amount and the type of information needed for accurate and useful quality assessment and that which is normally included in case notes. More detailed information is needed if general practitioners' notes are to be used for regular quality assessment of ENT problems but that would mean more time spent on keeping notes. This would be difficult to justify. IMPLICATIONS: The routine information systems used at this primary healthcare centre did not produce sufficient documentation for quality assessment of ENT care. This dilemma might be resolved by specially designed desktop computer software accessed through an essential dataset. PMID- 10166602 TI - Systematic design of healthcare processes. PMID- 10166603 TI - Maryland Hospital Quality Indicator Project in the United Kingdom: an approach for promoting continuous quality improvement. PMID- 10166605 TI - One man's meat. Should you eat, and diet, according to your blood or body type? Or is this a new type of nonsense? PMID- 10166604 TI - Impact of litigation on senior clinicians: implications for risk management. AB - OBJECTIVES: To investigate the impact of litigation on consultants and senior registrars and to establish their views on methods of reducing adverse events and litigation. DESIGN: Postal survey. SETTING: Acute hospitals in the North Thames (West) Regional Health Authority. SUBJECTS: 1011 consultants and senior registrars in acute hospitals. MAIN MEASURES: Perceived causes and effects of adverse events; views on methods of reducing litigation and adverse events. RESULTS: 769 (76%) doctors responded. 288 (37%) had been involved in litigation at some point during their career; 213 surgeons (49%) and 75 (23%) doctors in the medical specialties. Anger, distress, and feeling personally attacked were common responses to litigation. Clinicians' views on reducing litigation emphasised the need for change at the clinical level. Supervision of junior staff, workload, and training in communication skills were to the fore. CONCLUSIONS: The high frequency of doctors who have experienced litigation and the emotional responses described indicate that clinicians require support at several levels. At a personal level, support can be offered to clinicians going through the litigation process or after an adverse event. Also, managerial support is needed by offering financial and practical help in correcting the factors that have been consistently identified as producing high risk situations to minimise the possibility of a reoccurrence. Accidents in medicine are, by their very nature, costly in human and financial terms and the root causes must be tackled. Recommendations are made for clinicians and risk management teams. PMID- 10166606 TI - Take my freedom, please! HMOs that let you choose doctor's aren't the right choice. PMID- 10166607 TI - Compensation monitor. Residents' income expectations rise despite wariness about managed care. PMID- 10166608 TI - What quality measurements miss. AB - Measurable indices of health care quality are all the rage these days. But physicians know that not everything in health care can be quantified. If reportable numbers become our principal focus, what is in danger of falling through the cracks? PMID- 10166609 TI - If we build it, will they come? ... and other critical marketing questions for integrated health care systems. PMID- 10166610 TI - A visit with Margaret O'Kane. PMID- 10166611 TI - Participants in asthma study have fewer inpatient days, higher functional status. PMID- 10166612 TI - Detroit: intersection of business, health care and community activism. PMID- 10166613 TI - Medicine by legislation: can physicians learn techniques patients and HMOs already know? PMID- 10166614 TI - Kennedy-Kassebaum law means greater fraud scrutiny. PMID- 10166616 TI - Hospital librarians and the hospital web page--why get involved? PMID- 10166615 TI - Managed care outlook. Employer health costs rise only 3% for 1997. PMID- 10166617 TI - Hospital librarians and the hospital web page: getting started. PMID- 10166618 TI - Library economics--fee for service. PMID- 10166619 TI - The DOCLINE times ... they are a'changing. PMID- 10166620 TI - The Citizens Internet Empowerment Coalition (CIEC). PMID- 10166621 TI - National Network readers' survey: results and responses. PMID- 10166622 TI - Internet training manuals. PMID- 10166624 TI - A prescription for change: Ventura County. PMID- 10166623 TI - Measuring outcomes in the changing environment of child welfare services. AB - Child welfare service organizations are undergoing profound changes with the advent of managed care. Expensive development of new infrastructures is required, including information systems to track services and outcomes. The authors examine key considerations in designing an outcomes measurement program for child welfare agencies and challenges for implementation. In addition, they review national initiatives to determine best practices for outcomes measurement of children's services, and how these initiatives can help guide others' efforts. PMID- 10166625 TI - Gag clauses: an overview of state activity. PMID- 10166626 TI - At-risk for results: guaranteeing performance based on patient outcomes. AB - The author examines how managed care organizations can circumvent purchasers' overemphasis on price by proposing outcomes-based reimbursement arrangements. He explains the necessity for an organization to first develop an information system and outcomes measurement infrastructure that will support such an arrangement. He then explains the types of outcomes that purchasers express most interest in using for reimbursement, and several types of arrangements that have been proposed. He also speculates about how such arrangements might also be made between managed care organizations and contracted providers. PMID- 10166627 TI - Missouri's statewide outcomes study: lessons and surprises from the public sector. AB - Demand is increasing for statewide outcomes initiatives and greater focus on studies of treatment effects for publicly funded patients. Such initiatives pose enormous challenges in management--to involve key stakeholders, to protect confidentiality, and to comply with methodological standards. The state of Missouri is taking a leadership role in this direction. PMID- 10166628 TI - Measuring treatment effectiveness. Part one: Newly emerging outcomes databases for organizations. AB - Provider organizations are under increased pressure from payors to produce outcomes data that demonstrate the effectiveness of their treatment services. More and more, providers are collaborating on joint outcomes projects that allow them to benchmark their results with similar organizations. Here are five brief descriptions of such projects. They span a wide spectrum of organizations and include hospitals and comprehensive healthcare systems, behavioral group practices, child welfare agencies, and psychosocial rehabilitation programs. Part one begins below, part two, on page 45. PMID- 10166629 TI - Measuring treatment effectiveness. Part two: Newly emerging outcomes databases for individual practitioners. AB - Individual practitioners are under pressure from the provider and managed care organizations with which they contract to participate in the provider's outcomes measurement initiatives. While many practitioners respect the potential value of outcomes measurement, they can experience these requirements as burdensome and of little benefit to their own professional work. This section describes two research networks initiated and supported by professional associations. The goals of networks are to address research questions that will advance the field and to give clinicians feedback that is of immediate help in their clinical practice. PMID- 10166630 TI - Dialogue. Promises and pitfalls of the newly emerging outcomes databases. PMID- 10166631 TI - Making the grade: update on report card initiatives for 1997. AB - Report cards for healthcare services are increasingly in the news, offering the hope that objective information on the quality of health plan and providers services will eventually enable purchasers and consumers to make selections based on true value. Following is a series of five brief articles that review ongoing report card initiatives in private and public sectors of the behavioral healthcare system. The first four articles review actual report cards designed to hold organizations--particularly managed care--accountable for the quality of their services. The last article reviews research on performance measurement across all segments of the behavioral healthcare industry. PMID- 10166632 TI - Twelve partnerships. What's it all about? PMID- 10166633 TI - Managed care. The right degree of separation. AB - An integrated delivery system in California grants its managed care plan some autonomy. The result is targeted information systems solutions. PMID- 10166634 TI - Telemedicine. Legal issues could slow growth. PMID- 10166635 TI - Improving service to patients. AB - Kaiser Permanente is testing an intranet that enables patients to get quicker answers. If all goes well, the project could spread nationally. PMID- 10166636 TI - Back to the drawing board. AB - An integrated delivery system in Mississippi prepares for managed care with a massive information systems overhaul that scraps old systems in favor of new. PMID- 10166637 TI - HMO automation strategies. PMID- 10166638 TI - Trends in patient ID cards. Assessing the role of new card technologies. PMID- 10166639 TI - Interest in wireless technology grows, but its future role is far from clear. PMID- 10166640 TI - Management services organizations make the most of information technology. PMID- 10166641 TI - Computers simplify the task of comparative analysis. PMID- 10166642 TI - Mandates on clinical practice could threaten patient care. PMID- 10166643 TI - Project gives nurses primary care duties, pay. PMID- 10166644 TI - Indiana hospital revamps path for continuum care. PMID- 10166645 TI - Pediatric asthma protocol covers continuum. PMID- 10166646 TI - Rehab center cuts LOS with interdisciplinary teams. AB - Faced with an average length of stay (LOS) a full twenty days longer than the national average for spinal cord-injured patients, case managers at one hospital took advantage of their rehab center's existing spirit of interdisciplinary cooperation to foster a pathway that would bring LOS in line. The pathway team rejected a discipline-specific approach, choosing instead to break the pathway down by areas of outcome for the patient. By focusing on outcomes rather than specific responsibilities, members of the spinal cord team are encouraged to act collaboratively in helping patients achieve positive outcomes. Staff perform concurrent monitoring of patient compliance with the pathway in an effort to collect outcomes measures beyond LOS and cost per case. PMID- 10166647 TI - Contract managers help with high-volume DRG. PMID- 10166648 TI - Restructuring an IDS's physician group to better align system interests. PMID- 10166649 TI - Physicians position to take on risk contracting. PMID- 10166650 TI - Frenzy surrounds practice management companies. PMID- 10166651 TI - Now that your IDS is in place, how do you market it? PMID- 10166652 TI - HCFA's Hoyer says SNFs are attempting to take over hospital business. PMID- 10166653 TI - HCFA plans to bundle Medicare payments to SNFs, phase in PPS. PMID- 10166654 TI - How to resolve conflicts with managed care organizations. PMID- 10166655 TI - Hospice care. Growth, standards, and a critical issues. PMID- 10166656 TI - Team participation. The key to effective menu planning. PMID- 10166657 TI - Applying critical analysis to cafeteria decisions. PMID- 10166658 TI - More recruiters making first move toward medical school residents. PMID- 10166659 TI - Inventiveness pays off for low desert recruiter. PMID- 10166660 TI - Primary care physician pay posts sharp gain. PMID- 10166661 TI - Unstress your physicians to unstress yourself. PMID- 10166662 TI - HCFA loosens rule on use of nonphysician providers. PMID- 10166663 TI - Doctors, not report cards, shape consumer choices. PMID- 10166664 TI - Implementing the pension simplification and health portability laws: practical problems and solutions. PMID- 10166665 TI - Fortune 500 largest U.S. corporations. PMID- 10166666 TI - Fortune 500 medians. PMID- 10166667 TI - Fortune 500 ranked by performance. PMID- 10166668 TI - Fortune 500 ranked within states. PMID- 10166669 TI - Fortune 1,000 ranked within industries. AB - Call this the big picture. Here we take a wider cut at the performance of American industry, sizing up the top 1,000 companies by 12 different measures, including profits, employees, and bottom-line ratios, like return on equity. You'll find enormous differences among industries--and within them. For example, the health care group showed profit growth of 24% but a -23% return to investors. Computer peripherals companies, on the other hand, had zero profit growth but 101% total return. Among peers, check out Compaq's profits, up 66%; Apple's, down 292%. PMID- 10166670 TI - Hospital slashing incident prompts state action to restrict parolees. PMID- 10166671 TI - Scott E. Kangas on conducting a parking garage security audit today. PMID- 10166672 TI - Dealing with power failure: how Spokane hospitals survived the ice storm. PMID- 10166673 TI - Confronting and dealing with problems of latex-based products. AB - The use of powdered latex gloves and other latex-based products and allergy problems related to them have become a major safety and environmental health concern of hospitals. In this report, we'll present the findings and viewpoints of allergists and anti-latex activists as well as those of manufacturers of latex products. We'll also give details on steps two major medical centers are taking to protect their employees and patients. PMID- 10166674 TI - Report growing use of bullet-resistant protection in hospital ERs. PMID- 10166675 TI - Enhancing security in one new and two renovated hospitals. PMID- 10166676 TI - IT update/networking. Bridging the missing link. PMID- 10166677 TI - IT update/staffing. Close to the edge. PMID- 10166678 TI - IT update/staffing. Assisting ambition. PMID- 10166679 TI - Hospital activity. Barred facts. AB - Barcode technology is applicable to a number of crucial management issues in the NHS, including internal efficiency, contract pricing and the effectiveness of care. Its enormous potential lies in the ability to record in detail over a number of dimensions such as time, staff group, patient type, and cost. But the effort involved is considerable. Projects have to be actively managed, users have to be willing participants and data has to be analysed. Where short cuts have been sought, projects have failed to deliver their full potential. The data is merely a means to an end, but a very powerful one. It brings together people who may normally work independently, and the process of collecting barcode data is a perfect mechanism for bringing together the patient, the professional and the purse strings. PMID- 10166680 TI - Mental health. All for one or one for all? PMID- 10166681 TI - Data briefing. BSE, CJD and cost-benefit analysis. PMID- 10166682 TI - Emergency admissions. Admissions of difficulty. PMID- 10166683 TI - Emergency admissions. Open all hours. PMID- 10166684 TI - Hospital pharmacy. Prescription for change. PMID- 10166685 TI - Diabetes services. Sweet and sour. PMID- 10166686 TI - Heart valve prices moving up again. PMID- 10166687 TI - Kaiser's national buying effort reveals lots of room for saving. PMID- 10166688 TI - How patient volume affects non-salary expenses. PMID- 10166689 TI - Children's may develop new twist on distribution contract. PMID- 10166690 TI - Picture this: radiology files can pay for themselves. PMID- 10166691 TI - Getting the surgical staff to sign on to risk-sharing plan. PMID- 10166692 TI - Hospital conversions: does not-for-profit status matter? PMID- 10166693 TI - How to avoid flying blind. To truly improve U.S. healthcare, leaders must consider seven moral values. AB - To genuinely improve U.S. healthcare, we must base it on seven moral values familiar to Americans: Preserving individual dignity. Patients have a right to information about their medical condition and a right to participate in decisions about treatment. Society should make a basic package of healthcare available to all who need it. Caring for patients' welfare. As providers are obliged to have compassion for patients' suffering, they should also put patients' interests above their own and avoid conflicts of interest. Protecting the least well-off. Many who are poor, less educated, or members of racial or ethnic minorities bear disproportionate burdens of morbidity and mortality. They should receive care that compensates for those disadvantages. Seeking the common good. Our society has a strong disposition toward excessive individualism. We need greater emphasis on public health and preventive measures, as well as more opportunities for the public to help shape the healthcare system. Containing the healthcare costs. Waste is offensive both economically and morally. We can contain costs only by grappling explicitly with the need for healthcare rationing, which should be applied according to ethical criteria. Retaining a sense of responsibility. Society can help renew a sense of responsibility b anchoring it in the concept of subsidiarity, according to which the best government is the least government necessary to perform its appropriate tasks. Establishing high standards of quality. Providers should pursue excellence as measured by improved medical outcomes, uniform use of appropriate procedures, and increased consumer satisfaction. Quality-of-life judgments can be useful in making healthcare decisions, especially for persons who are dying. PMID- 10166694 TI - The mission imperative: our foundation and market advantage. AB - Simply put, MISSION means being sent as Jesus was sent to be a presence of radical healing in the world on behalf of the kingdom of God. Our capacity to sustain Catholic healthcare as a ministry of the Church depends on our realization that all our activities must flow from the core of who we are, that is, from our spirituality. Thus MISSION requires certain attitudes and behaviors, including that we reach out to all persons in need, that we be immersed in the world, that we be prophetic, and that we express the kind of love that led Jesus to give his life. As ministry, we must provide witness as well as service because of the call to be MISSION in the world is also the call to build up the kingdom of God within. Several basic committees lie at the heart of who we are: supporting the dignity of all persons, caring for the poor and vulnerable, building up the common good, and practicing responsible stewardship. Changes within the environment and within the ministry itself present some potential perils but also great opportunities. For example, although managed care, when misused, is a flawed system, it is also has possibilities that are very consistent with ministry values and commitments, forcing us to look at the needs of communities, not just individuals. The requirements of MISSION should also be understood as ways to gain market advantage. Unless we have sufficient advantage in the markets where Catholic health ministry is present, our capacity to effectively transform the present reality on behalf of God's kingdom will be limited. PMID- 10166695 TI - Catholic identity: realized in conversation. AB - Catholic literature leaders must constantly engage the Catholic tradition, because it provides the framework for everything we do. The way they can do this is through conversation--discussion about the profound values and philosophical and theological assumptions that are at the heart of our ministry. Yet many healthcare boards and senior managers do not engage in such conversations. This is a serious omission, with potentially serious consequences. Too often mission and pastoral care values are regarded as separate from the business aspects of a healthcare organization. If we are to understand and integrate our mission into our healthcare work, this must change. The entire organization must make a commitment to foster an understanding of Catholic identity through conversation. As important as the dialogue is, some Catholic healthcare leaders let obstacles prevent them from delving into Catholic identity. They may not understand it, or they may be deterred by our cultural tendency to regard religion as personal, not part of the business realm. Some may be embarrassed, uncomfortable with abstraction, or reluctant to spend the time required. To encourage the conversation among Catholic healthcare leaders, we may take a lesson from our counterparts in Catholic education, who struggle with the same questions. A model Catholic university, where Catholic values are incorporated at all levels, may be a model for Catholic healthcare. PMID- 10166696 TI - A dynamic force for change. The common good provides the rationale for a healthcare system for all. AB - In advocating for a reformed healthcare system, the Catholic healthcare community has claimed that responsibility for the common good is of the highest ethical importance. Yet to many the concept of the common good remains elusive. As the common good evolved in Catholic social teaching, it grew to include its anthropological origins, the principle of subsidiarity, and the virtue of solidarity. Above all, it is characterized by justice and refers to a social order that reflects peace, unity, and harmony. As an organizing principle for civil governments, the common good calls on them to foster societies that provide spiritual, cultural, political, and economic conditions in which all persons can realize their human dignity. By viewing healthcare and the right to security in case of sickness as among the particular goods that make up the societal common good, Catholic social teaching provides the rationale for a just healthcare system on a national level. In addition to advocating for a national healthcare system designed to serve the common good, Catholic healthcare entities must evaluate their own programs and services in light of the common good and examine proposed initiatives with other providers, especially for-profit organizations, in that context, as well. PMID- 10166697 TI - Catholic healthcare as "leaven". To penetrate and renew society, Catholic healthcare must meet five requirements. AB - Pope Paul VI described the church as the "leaven" of civil society. Catholic healthcare should strive to be the leaven of U.S. healthcare. To achieve this, it must do five things: Immerse itself in civil society. Catholic healthcare professionals and organizations should participate in efforts to improve public health, even when they are not in full agreement with those efforts. Provide high quality care. Such care is not always easy to define, but Catholic healthcare can and should set high objective standards for the well-being of its patients. Minister to the suffering and dying. The Catholic view of suffering and death as necessary for human fulfillment is a countercultural idea in our society. Catholic healthcare should, while eliminating physical pain when possible, help people to die in a holy atmosphere. Be a responsible, just employer. Catholic healthcare should treat employees as individuals worthy of respect, not as economic units. Be advocates for the poor. Catholic healthcare should not only provide charity care for the poor; it should also work for universal coverage, care based on need rather than on ability to pay for it. PMID- 10166698 TI - Give-and-take in an ecumenical system. HealthEast St. Joseph's shared its traditions and gained a better balance. AB - When St. Joseph's Hospital in St. Paul, MN, owned and operated by the Sisters of St. Joseph of Carondelet, joined the ecumenical HealthEast healthcare system in 1987, many observers were skeptical of the venture's success. But an emphasis on their shared Judeo-Christian values has enabled the Catholic, Lutheran, and Baptist facilities to build a strong system. The beginnings of the merger were difficult, as facilities closed, others expanded their services, and staff shifted between them. An open communications policy between HealthEast leaders and staff members and dedication to the mission of healthcare that all the system facilities shared helped blend denominational identity and traditions at each member hospital and establish a corporate identity. The HealthEast system has adopted some of St. Joseph's policies and practices, particularly in the areas of mission, ethics, and spiritual care. HealthEast St. Joseph's has also benefited from being part of the HealthEast system, gaining a more diverse staff respectful of each others' beliefs, expanded spiritual care, and the means to continue serving its community. HealthEast plans to discontinue inpatient services at HealthEast St. Joseph's in downtown St. Paul and build a suburban facility, but the Sisters of St. Joseph of Carondelet are working with HealthEast to assess the downtown community's healthcare needs, especially among the homeless and immigrant populations, and ensure those needs will continue to be met. PMID- 10166699 TI - A pragmatic look at hospital reengineering. Successful reengineering requires the right leadership. AB - The market turbulence of recent years has made healthcare leaders particularly open to the management tool called "reengineering." Unfortunately, many such efforts fail because they do not go beyond simple cost cutting to create processes that, by adding value to product, attract customers. A healthcare organization planning reengineering should: Find leaders who will educate themselves in reengineering tools and techniques, talk to both proponents and opponents of reengineering, consult those staff members who are most knowledgeable about the organization's processes, and skillfully communicate the organization's vision for the future. Determine its customers' needs by, first, learning who its customers actually are and, second, consulting with them. Reengineered processes should have the built-in data-collecting and reporting mechanisms that will help the organization meet customers' standards. Get the organizations' managers on board. Since satisfying customers' needs is the reason for reengineering, the organization must not let hidden agendas torpedo the effort. Redesign its processes. To accomplish this, the organization must allocate sufficient resources for the redesign effort, assign talented employees to it, and overcome such organizational limitations as "innumeracy" among its work force. PMID- 10166700 TI - The Church and the public discussion of assisted suicide. A pastoral statement on how we can keep company with the dying. PMID- 10166701 TI - What's in a name? PMID- 10166702 TI - Can mission-driven organizations provide community services? PMID- 10166703 TI - Puncturing the myths about rubber latex gloves. PMID- 10166704 TI - Image-based information integration: a new role for radiology. PMID- 10166705 TI - Now there are four: Carvedilol takes its place in therapeutical line-up for heart failure. PMID- 10166706 TI - Deciding when to treat pneumonia at home. PMID- 10166707 TI - Evaluating outsourcing prospects. PMID- 10166708 TI - Community health assessment: a new generation. PMID- 10166709 TI - A comparison of academic curricula in the MPH and MHA-type degrees in health administration at the accredited schools of public health. AB - Based on a survey of the departments of health services administration in accredited schools of public health, this study presents (1) a profile of the M.P.H. and M.H.A. (and similar) programs concentrating in health administration, and (2) a comparison of the M.P.H. and M.H.A. degrees. All 27 schools currently accredited by the Council on Education for Public Health (CEPH) are represented in this research. The curriculum from each school was broken down and classified into eight components: (1) epidemiology, (2) statistics, (3) accounting/finance, (4) management theory, (5) management application, (6) public health policy, (7) electives, and (8) other. That the M.H.A. programs compared to the M.P.H. programs, have higher course requirements to furnish skills in business management and quantitative/analytical areas is the main hypothesis tested. Statistically significant differences were found in seven of the eight curriculum components for M.P.H. and M.H.A. degrees. Overall, the M.H.A. degree was found to be more rigorous in applied management and analytical courses. Implications and recommendations are discussed. PMID- 10166710 TI - Medical and health administration education in managed care: needs, content and readings. AB - With both public and private reform initiatives moving toward managed care, curriculum designs are timely and useful to a diverse audience. This paper discusses the need for and design of education in managed care in medical schools and health services programs. The pressures for offering education regarding managed care are derived from interests of various actors of the health system e.g. regulators, purchasers, providers and consumers. The content of education in managed care is defined in seven areas: (1) managed care and health systems design-history and concepts; (2) environment and governmental policy; (3) models, products, services, outcomes and quality; (4) managed care economics and finance; (5) organization and strategic management; (6) legal issues; and (7) future designs/redesigns. Education in managed care is delivered by universities, professional associations and private training and development corporations. All can benefit from a dialogue on curricular content. PMID- 10166711 TI - The Baxter Foundation Prize address. PMID- 10166712 TI - Educating tomorrow's health administrators for accountable practice. PMID- 10166713 TI - The integration of strategic decision support systems in health administration education. PMID- 10166714 TI - Meeting critical health administration education needs for the managed care environment. PMID- 10166715 TI - Assessment in a quality improvement framework: applications in health administration education. PMID- 10166716 TI - Physician practice-managemnt company buyouts: is taking the leap worth the risk? PMID- 10166717 TI - Don't let a PPM (physician practice management company) play you for a sucker. PMID- 10166718 TI - HMO finances. The cost of cutting costs is beginning to hurt. PMID- 10166719 TI - Reality. Young doctors' salary expectations exceed going rates. PMID- 10166720 TI - How good doctors can avoid bad errors. PMID- 10166721 TI - Save 50 percent on office and medical equipment. PMID- 10166722 TI - Little things that go over big with patients. PMID- 10166723 TI - What defines a good doctor is about to change. Interview by Ken Terry. PMID- 10166724 TI - Dump managed care? This doctor did. PMID- 10166725 TI - A tool to help doctors review each other. PMID- 10166726 TI - Revision of the CPI hospital services component. AB - Upcoming modifications are designed to capture current service delivery patterns, reimbursement methods, and payment sources for hospital visits, rather than what the hospital charges for individual treatment inputs; the result will be an index that better reflects price changes in the dynamic health care field. PMID- 10166727 TI - Rehab rival. Easter Seals is a healthcare force to be reckoned with. PMID- 10166728 TI - IRS finally issues loose rules on doc recruitment. PMID- 10166729 TI - Bills focus on raising number of insured kids. PMID- 10166730 TI - The original hospitalists. Critical-care specialists' training for inpatient care far exceeds that of internists. PMID- 10166731 TI - Communities strike back. Residents oppose ceding control to outside not-for profit chains. AB - "We want our hospital back!" is the rallying cry in more communities as they fight outsider not-for-profit healthcare systems for control of their local hospitals. To date, most of the policy debate has centered on acquisitions of community hospitals by for-profit chains. But the rapid development of regional systems, which merge a number of once-independent hospitals, means even more bitter clashes lie ahead involving deals with the not-for-profit sector. PMID- 10166732 TI - Miss. rivalry grows. Hospitals, home-care agencies at odds over state's CON laws. PMID- 10166733 TI - A difficult pill to swallow. Hard sell on disease management raises eyebrows. PMID- 10166734 TI - Jockeying for position. Healthcare REIT hopes to ride tax loophole to winner's circle. PMID- 10166736 TI - Joint Commission moves to require data on outcomes. PMID- 10166735 TI - Projects define what nursing contributes to patient care. PMID- 10166737 TI - System puts outcomes management to work. PMID- 10166738 TI - Are middle managers an endangered species? PMID- 10166739 TI - Keep a 'bad attitude' from infecting workplace. PMID- 10166740 TI - 60 Minutes expose targets surgical assisting. PMID- 10166741 TI - Novel contract helps cut costs in perfusion. PMID- 10166742 TI - Marketing in a managed care setting. PMID- 10166743 TI - AHRA survey: film library practices. AB - Presented here are the highlights of the Film Library Practices Report, taken from the 92-page report published by the AHRA in November 1996. Administrators may find information useful for improving their departments, which function most efficiently with smooth running libraries. The survey of AHRA members covers such topics as staffing, storage, copy policies, PACS and problem areas. PMID- 10166744 TI - A new payment system for outpatient services? The implications for radiology. AB - Congress is now contemplating the most significant change in outpatient payment methodology in Medicare's 31-year history. It may approve a proposal by the Health Care Financing Administration (HCFA) to establish a Medicare prospective payment system for hospital outpatient departments. In March 1955, five years after a Congressional directive to develop a new outpatient payment system, HCFA delivered its proposal recommending use of the ambulatory patient groups (APG) classification system for determining payment of hospital outpatient services. The APG system, which uses outpatient procedures as its primary variable, divides all such procedures into one of three categories: 1) significant procedures or therapies (including therapeutic and other significant radiological procedures); 2) ancillary test and procedures (including 11 radiology ancillary service APGs); or 3) medical visits. Outpatients can be assigned to one or more of the 290 APGs, each comprising a number of clinically and resource intensity-similar procedures, medical visits or ancillary tests. Any new payment methodology for outpatient procedures would broadly impact the radiology community. How radiology providers will fare under the system being proposed will depend on several issues that have not yet been resolved, such as how the basic unit of payment is defined (e.g., a service, a visit, or an episode of care) and whether payment rates will be adequate to compensate for the costs of providing services. One key issue will be whether contrast media and radiopharmaceuticals will continue to be paid as pass through costs, giving providers the flexibility to choose the specific agent that is most appropriate for their patients. PMID- 10166745 TI - The ten successful elements of an ambulatory care center. AB - Experts in healthcare predict that in the future, over 80% of all care will be provided either in the home or ambulatory care centers. How radiology facilities position themselves for this shifting market is critical to their long-term success, even though it appears there are endless opportunities for providing care in this atmosphere. The ten most critical elements that healthcare providers must address to ensure their preparedness are discussed. Location is critical, particularly since patients no longer want to travel to regional medical centers. The most aggressive providers are building local care centers to serve specific populations. Ambulatory care centers should project a high tech, high touch atmosphere. Patient comfort and the appeal of the overall environment must be considered. Centers need to focus on their customers' needs in multiple areas of care. A quick and easy registration process, providing dressing gowns in patient areas, clear billing functions--these are all important areas that centers should develop. Physicians practicing in the ambulatory care center are key to its overall success and can set the tone for all staff members. Staff members must be friendly and professional in their work with patients. The hours offered by the center must meet the needs of its client base, perhaps by offering evening and weekend appointments. Keeping appointments on schedule is critical if a center wants satisfied customers. It's important to identify the target before developing your marketing plan. Where do your referrals come from? Look to such sources as referring physicians, managed care plans and patients themselves. Careful billing is critical for survival in the ambulatory care world. Costs are important and systems that can track cost per exam are useful. Know your bottom line. Service remains the central focus of all successful ambulatory care center functions. PMID- 10166746 TI - New tools from the ACR (American College of Radiology): appropriateness criteria and utilization analysis. AB - Performing a clinically unnecessary study can cost a practice money under managed care and capitation contracts. The American College of Radiology (ACR) has developed two tools to help radiology facilities practice cost-efficient medicine without sacrificing quality of care: appropriateness criteria and utilization analysis. Appropriateness criteria were established by the ACR Board of Chancellors in 1993 to help imaging facilities determine appropriate imaging studies; these were first published in 1995; a subsequent edition will be published in 1996 and annually thereafter. Development of the criteria was based on Agency for Health Care Policy and Research guidelines. A task force which clinical conditions and variants were to be studied. The task force then performed a literature search. Members then reviewed the literature and reached a conclusion about the appropriateness of the various procedures. Because capitated contracts require some knowledge of the utilization of services, the ACR formed the utilization analysis committee in 1994. Facilities submit utilization data on a quarterly basis to the ACR. The data is then combined into both regional and national databases. These databases report back to the participating facilities, which can then compare themselves with other groups. All such information is confidential and is used for peer review only. A practice that participates in utilization analysis can view its own contract analysis, particularly in capitated contracts. Since many managed care organizations will not do business with a practice that hasn't performed this type of analysis, utilization analysis can be a way of winning contracts. Utilization analysis can also be a way to identify and control the risks that a practice has with managed care contracts. It offers the means for measuring a practice's performance against regional and national databases, and identifies areas of weakness. A practice is then able to take action to improve its quality of care in those areas. PMID- 10166747 TI - Performance appraisal: can we 'manage' away the curse? AB - Call them what you will--appraisals, evaluations or reviews--performance appraisals seem to be the one organizational ritual that is universally hated. The shortcomings of this ritual, the annual documenting of bouquets and brickbats, are obvious to those who give them and those who receive them. Why do companies continue to do them? To align employee goals with those of the organization; to provide feedback on (and improve) employee performance; to identify training needs; as a basis for merit increases; to document poor performance in case it becomes necessary to defend personnel decisions in court. How can any evaluation satisfy all these objectives? One solution is performance management, a system that helps people manage their actions as a way of helping the organization achieve its goals. Ongoing effort is key to making performance management work. And it gives the employee who's off the track time to climb back on. One company put its appraisal forms online, which allows both employees and managers to update progress continuously. A goal of performance management is to enable employees to see how their objectives tie to the business objectives. Regardless of the system or methods for performance appraisal an organization uses, it will only be as good or helpful as the managers who use it. PMID- 10166749 TI - The politics of breast cancer. PMID- 10166748 TI - Keep your eye on the competition. PMID- 10166750 TI - Expected principal source of payment for hospital discharges: United States, 1990. PMID- 10166751 TI - National Ambulatory Medical Care Survey: 1991 summary. PMID- 10166752 TI - AIDS-related behavior among women 15-44 years of age: United States, 1988 and 1990. PMID- 10166753 TI - Nursing homes and board and care homes. Data from the National Health Provider Inventory. PMID- 10166754 TI - 1993 summary: National Hospital Discharge Survey. PMID- 10166755 TI - Ambulatory care visits for asthma: United States, 1993-94. AB - OBJECTIVE: This report describes ambulatory visits for asthma in the United States across three ambulatory care settings. The primary focus is on visits to office-based physicians. METHODS: The data sources include the National Ambulatory Medical Care Survey (NAMCS), a national probability survey of visits to office-based physicians in the United States, and the National Hospital Ambulatory Medical Care Survey (NHAMCS), a national probability survey of visits to hospital emergency and outpatient departments in the United States. Most estimates presented are annual averages for the 2-year period, 1993-94. Visits for asthma are defined as those for which asthma was the first-listed diagnosis. A trend analysis compares office visit data collected in 1993-94 to data in the 1980-81 NAMCS. RESULTS: There was an average annual estimate of 13.7 million ambulatory care visits for asthma in 1993-94, an annual rate of 53.4 visits per 1,000 persons. Four-fifth of ambulatory care utilization for asthma was conducted in physician offices. Relative utilization of office-based physicians was less for adolescent and black patients. The office visit rate for asthma increased 50 percent between 1980-81 and 1993-94. During 1993-94, use of office visits for asthma averaged 43 visits per 1,000 persons of 11 million office visits per year. The office visit rate in the Northeast was almost 2.5 times that in the South, although the prevalence of asthma was similar among regions. There were 5.8 return asthma visits for every new problem encounter. More than 40 percent of asthma visits had one or two comorbidities, mostly other respiratory conditions. Spirometry was used in 28 percent of asthma visits by new patients. Bronchodilators and anti-inflammatory agents were the most common medications prescribed. The use of corticosteroids and beta2-adrenergic agonists, either alone or in combination, increased substantially since 1980-81. The rate of utilization of methylxanthines decreased 61 percent between 1980-81 and 1993-94. CONCLUSIONS: The patient populations receiving care for asthma vary depending on the ambulatory care setting. Patients relying on hospital outpatient care for chronic asthma conditions may receive differential treatment and have different outcomes compared with patients of office-based physicians. For office-based ambulatory care, visits for asthma have increased substantially since 1980. Medication is the primary method of treatment with an increasing use of anti inflammatory agents. The preferred bronchodilator has changed from methylxanthines to beta2-adrenergic agonists. PMID- 10166756 TI - Mary Parker Follett: epilogue to or return of a social work management pioneer? AB - The authors present an overview of the major concepts and contributions of Mary Parker Follett to the development of social work management theory, past and present. The case is made for Follett to be afforded a more visible role in the profession's understanding and teaching of modern management theory and practice. The authors show how Follett's work served as an important bridge between changing eras in management thought, specifically as related to scientific management and the subsequent human relations models. Even after six decades, Follett's work, in its timelessness and timeliness, remains contemporary, for it is rooted in her keen ability to grasp the complexities inherent in the human services enterprise, and thus it continues to inform one's understanding and behavior within the organizational context. PMID- 10166757 TI - Performance measurement: the new accountability. AB - Over the years, "accountability" in the human services has focused upon issues such as the legal framework, organizational management, financial responsibility, political concerns, and client inputs and expectations. Within the past decade, the meaning of "accountability" has been extended to the more dynamic organizational functions of "efficiency" and " effectiveness." Efficiency and effectiveness increasingly must be put to the tests of performance measurement and outcome evaluation. Forces outside the social work profession, including, among others, federal expectations and initiatives and the increased implementation of the concept of managed care, will ensure that efficiency and effectiveness will be central and highlighted concerns far into the future. This "new accountability" is demanded by the stakeholders in the nonprofit sector and by federal requirements built into the planning, funding, and implementation processes for nonprofits and for-profits alike. PMID- 10166758 TI - The influence of organizational and personal characteristics on community planning activity. AB - The authors identify the influence of organizational and personal characteristics on the tendencies of community organizational workers in Israel to implement planning activities. The research examines these factors in relation to two planning styles, rational and organizational-political, and also distinguishes among factors influencing the tendency for implementation of each style. The principal findings indicate that the tendency of workers to implement rational activities is influenced by mechanical characteristics of the organization. On the other hand, the tendency of the workers to implement organizational-political activities is influenced significantly by organic characteristics--variety and conflict--with the organization. The frequency of use of both styles is influenced by professional education in community organization. PMID- 10166760 TI - Quality circles, human service organizations, and the law. PMID- 10166759 TI - Supervisor ideology and organizational response: HIV/AIDS prevention in outpatient substance abuse treatment units. AB - Distinct practice ideologies or ideologies of care are deemed to influence greatly the selection of intervention methods and the mix of services adopted by the providers. Examined here is the relation between clinical supervisor ideology and variation among human service organizations in their provision of HIV/AIDS prevention services. Data were drawn from a 1990 national, representative sample of outpatient substance abuse treatment (OSAT) units. The study affirms that ideology is central to both means and ends in HSOs, helping to define the organization's mission and goals, and establishing guidelines for practice and procedures. Future research on the relationship between ideology and HIV/AIDS education can benefit from efforts to develop alternative strategies for measuring ideologies of care among both managers and staff in substance abuse settings. PMID- 10166761 TI - Heads it's yes, tails it's no: current perspectives on strategic decision making. PMID- 10166762 TI - Developing a collaborative strategic plan for a quality/risk management department. PMID- 10166763 TI - The role of the nurse as an expert fact witness. PMID- 10166764 TI - "Agenda for Change" ends, enter ORYX. PMID- 10166765 TI - 1997 HIMSS/Hewlett-Packard leadership survey results. Survey results highlight infrastructure--the building block approach to IT strategy. AB - "Infrastructure" is the buzzword that emerged from the 1997 HIMSS/Hewlett-Packard Leadership Survey. Of the 1,220 survey respondents, 37 percent identified upgrading infrastructure as the most significant IT projects their organizations undertook over the last year. "In the past, organizations were not deliberately against building infrastructure; they just did not know what it takes," says researcher and survey analyst John Pollock, Princeton, N.J. "It is evident now they are looking more at the framework." Increasing pressure to achieve a competitive advantage has led to a real interest in integrating healthcare delivery systems, he explains. PMID- 10166766 TI - Passwords aren't enough. PMID- 10166767 TI - Learn about information technology--or die! PMID- 10166768 TI - Dam it! How to harness EMR (electronic medical record) power. PMID- 10166769 TI - Imaging, workflow and electronic medical record systems review. PMID- 10166770 TI - Insecurity. How safe are your data? PMID- 10166771 TI - Master patient index. Will your patient data merge with you? PMID- 10166772 TI - Enhancing IT executive influence. PMID- 10166773 TI - Jamming with the Joint: EC [Environment of Care] clarifications and the top Type 1 recommendations. PMID- 10166774 TI - Streamlining patient access with a paperless system. PMID- 10166775 TI - The "Aesop" theory of healthcare delivery. PMID- 10166776 TI - The Cleveland Health Network: a new integrated delivery system. AB - CHN and its subsidiary CHN MCO have significantly impacted the Cleveland market place in the two years since their inception. CHN will continue to expand geographically with hospital and physician partners who are committed to providing quality care in the most cost-effective manner. Medical management will continue to be the central focus and over-riding success of the CHN MCO, making this organization extremely attractive to the payer market. The integrated CHN and its medical management focus could become a model for other integrated delivery systems. As the market place continues to experience an increase in managed care and more consolidation of healthcare providers (and in some cases, mergers with payers), more integrated delivery systems will emerge. Senior- and mid-level administrators and managers with operational responsibilities need to take into consideration how their patient access systems will need to be modified to meet the demands of managed care through the formation of integrated delivery systems. How patients access the systems is of critical importance in ensuring financial success, ease of access for the patient, and tracking of appropriate medical care. PMID- 10166777 TI - Tax-paying healthcare providers bring increased accountability and a changing access role. PMID- 10166778 TI - Coming changes to the hospital admitting environment. PMID- 10166779 TI - Education committee re-engineering. PMID- 10166780 TI - Thumbs up for positive patient identification. PMID- 10166781 TI - Improving patient satisfaction scores using decision support systems. PMID- 10166782 TI - Process and outcome cycle: a case study of total quality management. PMID- 10166783 TI - "Market"ing patient access: Columbia-style. PMID- 10166784 TI - DRGs and hospital social work: when policy guides practice. AB - Since the early 1980s cost containment policies have changed the practice of hospital social work. Diagnosis Related Groups (DRGs), a cost containment mechanism, have increased the caseloads of hospital social workers, and placed a greater emphasis on discharge planning. In this article DRGs are described, and their function is discussed from a social work perspective. The literature surrounding DRGs and the role of the hospital social worker is addressed. Recommendations are made for social workers to evaluate the policies affecting their practice. It is proposed that if social workers understand policies, their origins, and how policies affect practice, then they can have greater influence as advocates and policy makers. PMID- 10166785 TI - HIV risk among low-income African American mothers of elementary school children. AB - Data from 119 African American low-income mothers of school aged children in Oakland, California show that 38% engaged in behavior that might place them at risk of exposure to the human immunodeficiency virus (HIV). Risk behaviors that were investigated included having multiple partners and having a partner with an incarceration history. Of women studied, 23% were at risk because of multiple partners, while 15% were at risk as a result of having had an incarcerated partner. Women who were < or = 35 years of age were three times more likely to report having had an incarcerated partner compared to women > or = 36 years of age (22% vs. 6%) mean 2 = 5.59, P < or = .01). Single women were also more likely to report having had a partner who had been incarcerated, 21% compared to 9% of married women (mean 2 = 3.73, P < or = .05). Although no significant relationships were found with respect to condom use, a larger proportion of women with an incarcerated partner reported never using condoms (71%) compared to women without an incarcerated partner (63%); whereas, fewer women with multiple partners reported never using condoms (56%) compared to women without multiple partners (67%). Findings suggest that low-income African American women outside of traditional high-risk groups (i.e., generally studied in high-risk settings such as drug treatment centers, sexually transmitted disease [STD] clinics, hospitals or from the sex industry) may be at risk and should be targeted in HIV risk prevention programs. These women may not consider themselves to be at risk and are not generally targeted in HIV risk prevention programs because they are mothers, housewives, and working women. PMID- 10166786 TI - Public health issues concerning American Indian and non-Indian uranium millworkers. AB - An exploratory study of 170 former American Indian (83) and non-Indian (87) uranium millworkers who worked in six mills was conducted in the southwestern United States. It was found that over 80 percent of the former millworkers felt they were not informed about the hazards of radiation during their employment and a majority reported respiratory diseases or symptoms. Study findings include a comparison of Indian and non-Indian perceptions of mill working conditions and self-reported health histories. The Indians have not been studied previously as a distinct group and, given their low smoking incidence, an epidemiologic study is warranted. Issues related to adequate diagnoses of workers' health problems are presented. PMID- 10166787 TI - Perception of medical symptoms according to gender of reporting person and type of symptom. AB - Two hundred and eight male and female participants were given unanticipated memory and recognition tasks with which to recall and recognize medical symptoms, described on audiotapes by male and female individuals. Half of the presented symptoms were among those typically experienced by males; half were among those experienced mostly by females. Both memory and recall were better when the audiotaped reporting persons was male. Gender orientation of symptoms (male versus female orientation) was not associated with better recall or recognition, nor was the factor of subject gender. Although neither "male" nor "female" symptoms were seen generally as more serious overall, an interaction effect showed that symptoms were seen as more serious, especially in the case of the male audiotape, when they were incongruous with the gender of the reporting person. Some possible implications of the results are outlined. More research is required to assess the differential perception of medical and other types of symptoms. PMID- 10166788 TI - The development and implementation of health policy: New Zealand and Hong Kong compared. AB - Contemporary health sector reform is frequently underpinned by market-influenced public policy "prescriptions." Such prescriptions provide details of what policies ought to look like, but little by way of how they should be implemented. This article compares the experience of New Zealand and Hong Kong, two locations in which recent health reforms were based upon the policy prescription. Where the respective health policies bear similarities, implementation styles differ with interesting consequences. New Zealand's apparent "success" in implementation may ultimately prove counterproductive; it seems more likely that Hong Kong, whose implementation success has been, to date, moderate, will achieve objectives of providing a better public health service. PMID- 10166789 TI - Hospital profits up and so are for-profit conversions. PMID- 10166790 TI - Managing the urge to regulate. PMID- 10166791 TI - You don't have to be the biggest to get the best deals. PMID- 10166792 TI - What's up on the Web. PMID- 10166793 TI - HMOs and self-insurance go head to head. PMID- 10166794 TI - Attacking expenditures for asthma. PMID- 10166795 TI - Guidelines: don't get caught without 'em. AB - A court ruling emphasizing the legal protection that medical protocols provide should make any employer offering on-site health services sit up and take notice. PMID- 10166796 TI - Data watch. Public-private about face. PMID- 10166797 TI - Give me equity or give me death: equity as a determinant in cost-effectiveness analysis. PMID- 10166798 TI - Federal tax developments affecting health care organizations--Part II: New rulings and court decisions. AB - Health care providers face numerous federal tax law changes in 1997 legislation, agency rulings, and court decisions. In the conclusion of this article, the author covers agency rulings and court decisions, with particular focus on tax exempt hospitals forming delivery systems with for-profit entities. PMID- 10166799 TI - Restoring a fair workers' compensation system for employer and employee. AB - The costs of workers' compensation have curtailed in recent years, perhaps in part as a result of MCO's efforts in this area. Managed care organizations that consider jumping into the workers' compensation arena often make basic errors in developing their programs and networks. The author reminds MCOs of the practical points they need to consider. PMID- 10166800 TI - The Montreal Protocol and metered dose inhalers. PMID- 10166801 TI - Loss of bronchodilator medication in priming a conventional metered dose inhaler: a cost of treating asthma. AB - The direct and indirect costs of lost medication resulting from the required "test dose" to reestablish the prime of active drug in the conventional metered dose inhaler (MDI) valve and the uncertainties associated with "tail-off" increase the cost of using a conventional chlorofluorocarbon driven MDI to deliver aerosolized bronchodilator in the management of asthma. In this article, the author establishes a basis for estimating the cost of wasted medication. PMID- 10166802 TI - Facts & figures. Selection of long-term care by and for older Americans. PMID- 10166803 TI - Managed care stock index. Stupid Dow tricks. PMID- 10166804 TI - Secrets and tips for weaving a Web of success: Part II. PMID- 10166806 TI - Small businesses are seeking changes to managed care environment. AB - For the small business owner, health care premiums never decreased. These employers only experienced lower cost increases. All businesses now face rising premiums. To contend with the increases, small business owners are now making their own demands of health plans. PMID- 10166805 TI - Role remodeling and teamwork: priorities for managed care realignment. AB - The realignment of work and processes in MCOs is underway. Senior executives are now looking to senior health care managers for skills, behaviors, attitudes, thinking, and leadership that are very different from traditional expectations. To help define these revised expectations, a national survey was conducted of managed care executives who were asked to assess current versus future roles, values, and characteristics they see as essential to senior health care managers in managed care pharmacy. PMID- 10166807 TI - The increasing sophistication of patient targeting. PMID- 10166808 TI - Challenges to identifying actual diabetes case-mix complexity and total treatment charges. AB - Patient management programs are being used to improve the quality of care and decrease charges for both high-cost and potential high-cost claimants. Adequate information is key to program development, planning, and implementation. Claims based data are a ready source of valuable information, but without proper processing, true case-mix complexity and total charges for patients will not be identified. PMID- 10166810 TI - Let's hear it for the users! Diagnostic imaging on the Internet. PMID- 10166809 TI - Employee benefits, retirement patterns, and implications for increased work life. AB - This Issue Brief examines why policymakers are concerned about the trend toward early retirement and how it relates to Social Security, Medicare, and employee health and retirement benefits. It reviews the rationale for the effects of economic incentives on early retirement decisions and includes a summary of empirical literature on the retirement process. It presents data on how employee benefits influence workers' expected retirement patterns. Finally, it examines the implications of public policies to reverse early-retirement trends and raise the eligibility age for Social Security and Medicare. An employee Benefit Research Institute/Gallup survey indicates that there is a direct link between a worker's decision to retire early and the availability of retiree health benefits. In 1993, 61 percent of workers reported that they would not retire before becoming eligible for Medicare if their employer did not provide retiree health benefits. Participation in a pension plan can be an important determinant of retirement. Twenty-one percent of pension plan participants planned to stop working before age 65, compared with 12 percent among nonparticipants. Workers whose primary pension plan was a defined benefit plan were more likely to expect to stop working before age 65 (23 percent) than workers whose primary plan was a defined contribution plan (18 percent). Expected income replacement rates effect retirement patterns, indicating that as the expected replacement increases, the probability of expecting to stop working before age 65 increases. Twenty-two percent of workers with an expected income replacement rate below 60 percent expected to stop working before age 65, compared with 29 percent for those in the 60-69 percent replacement range, and 30 percent for those in the 70-79 percent replacement range. Workers expecting to receive retiree health insurance are more likely to expect to stop working before age 65 than workers who do not expect to have retiree health insurance. Twenty-one percent of workers with retiree health insurance expected to stop working before age 65, compared with 12 percent of workers not expecting to receive retiree health insurance. The Social Security Old-Age and Survivors Insurance (OASI) program depends on obtaining sufficient revenue from active workers' payroll taxes to fund the benefits received by retired beneficiaries. Funding the program in the past was in large part effortless because of the relatively large number of workers per retiree. Today, funding the program is a greater challenge because the ratio of workers to retirees has fallen. Policymakers have been able to agree that reform of the program is necessary for its survival; however, the debate over options to reform the program is just beginning, and it is likely to be a long time before a consensus emerges. PMID- 10166811 TI - Buyers and sellers. AB - How closely do the offerings of technology vendors match the real world needs of health care organizations? Closer than they used to, say IS professionals and vendors. PMID- 10166812 TI - What works. Voice recognition: 100+ words per minute saves $130,000 per year. PMID- 10166813 TI - What works. Exercising creativity: cardio, strength equipment is linked to patient records. PMID- 10166814 TI - What works. Practice system provides temporary relief for locum tenens physicians. PMID- 10166815 TI - What works. Network link with 1,500 doctors cuts hospital's report costs, delays. PMID- 10166816 TI - Information at the speed of light. AB - Once cutting edge, fiber optic cable is now the backbone of choice for health care organizations with growing networks. The question today is not whether to use fiber, but how much and where. PMID- 10166817 TI - Health care videoconferencing options cover wide range of applications, prices, quality. PMID- 10166818 TI - The lay of the land: GIS and mapping software. PMID- 10166819 TI - Hotlist. Managed care systems: new capabilities for growing markets. PMID- 10166820 TI - Migrating from a transaction-based to an information-based managed care system. PMID- 10166821 TI - Managing with decision support tools. PMID- 10166822 TI - "Going bare": insurance and the pre-existing condition problem. PMID- 10166823 TI - Interim rules for health insurance portability for group health plans--HCFA. Interim rules with request for comments. AB - This document contains interim rules governing access, portability and renewability requirements for group health plans and issuers of health insurance coverage offered in connection with a group health plan. The rules contained in this document implement changes made to certain provisions of the Internal Revenue Code of 1986 (Code), the Employee Retirement Income Security Act of 1974 (ERISA), and the Public Health Service Act (PHS Act) enacted as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Interested persons are invited to submit comments on the interim rules for consideration by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury (Departments) in developing final rules. The rules contained in this document are being adopted in an interim basis to accommodate statutorily established time frames intended to ensure that sponsors and administrators of group health plans, participants and beneficiaries, States, and issuers of group health insurance coverage have timely guidance concerning compliance with the recently enacted requirements of HIPAA. PMID- 10166824 TI - Health insurance portability for group health plans--IRS. Notice of proposed rulemaking by cross-reference to temporary regulations. AB - Elsewhere in this issue of the Federal Register, the IRS is issuing temporary regulations relating to group health plan portability, access, and renewability requirements added to the Internal Revenue Code by section 401 of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The IRS is issuing the temporary regulations at the same time that the Pension and Welfare Benefits Administration of the U.S. Department of Labor and the Health Care Financing Administration of the U.S. Department of Health and Human Services are issuing substantially similar interim final regulations relating to the group health plan portability, access, and renewability requirements added by HIPAA to the Employee Retirement Income Security Act of 1974 and the Public Health Service Act. The temporary regulations provide guidance to employers and group health plans relating to the obligation of plans to comply with new requirements relating to preexisting condition exclusions, discrimination based on health status, access to coverage, and other requirements. The text of those temporary regulations also serves as the text of these proposed regulations. PMID- 10166825 TI - Interim rules amending ERISA disclosure requirements for group health plans--DoL. Interim rules with request for comments. AB - This document contains interim rules governing the content of the summary plan description (SPD) for group health plans, the furnishing of summaries of material reductions in covered services or benefits by group health plans, and the disclosure of SPD and related information through electronic media. The rules contained in this document implement amendments to the disclosure provisions of the Employee Retirement Income Security Act of 1974 (ERISA) enacted as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Newborns' and Mothers' Health Protection Act of 1996 (NMHPA). Interested persons are invited to submit comments on the interim rules for consideration by the Department in developing final rules. The rules contained in this document are being adopted on an interim basis to accommodate statutorily established time frames intended to ensure that sponsors and administrators of group health plans, as well as participants and beneficiaries covered by such plans, have timely guidance concerning compliance with the recently enacted amendments to ERISA. PMID- 10166826 TI - Individual market health insurance reform: portability from group to individual coverage: federal rules for access in the individual market; state alternative mechanisms to federal rules--HHS. Interim final rule with comment period. AB - This interim final rule with comment period implements section 111 of the Health Insurance Portability and Accountability Act of 1996, which sets forth Federal requirements designed to improve access to the individual health insurance market. Certain "eligible individuals" who lose group health insurance coverage are assured availability of coverage in the individual market, on a guaranteed issues basis, without preexisting condition exclusions. In addition, all individual health insurance coverage must be guaranteed renewable. This rule also sets forth procedures that apply to States that choose to implement a mechanism under State law, as an alternative to the Federal requirements, with respect to guaranteed availability for eligible individuals. It also sets forth the rules that apply if a State does not substantially enforce the statutory requirements. PMID- 10166827 TI - Interim rules for health insurance portability for group health plans and individual market health insurance reform: portability from group to individual coverage; and federal rules for access in the individual market; state alternative mechanisms to federal rules--HCFA. Interim rule; correction. AB - Federal Register documents 97-8217 and 97-8275 in this issue include provisions that implement the health insurance portability, availability, and renewability provisions of the Health Insurance Portability and Accountability Act of 1996. Those documents contain a technical error in amendments because of differing effective dates. The rule with the earlier effective date establishes a new part in a subchapter established by the rule with the latter date. This document corrects the error. PMID- 10166828 TI - Cancer Society's political antidote. PMID- 10166829 TI - Opinion outlook. Views on the economy. PMID- 10166830 TI - Interim final rule: OIG advisory opinion process. PMID- 10166831 TI - Insurance restrictions on provider risk assumption. PMID- 10166832 TI - People: overlooked by re-engineering. AB - Three years ago, re-engineering became the "next big thing" with the publication/Re-engineering the Corporation: A Manifesto for Business Revolution by Dr. Michael Hammer and James Champy, who proposed that marketing, sales and service people could be formed into streamlined "process" teams which, with less supervision, would combine tasks and make the most of computer technology. The concept, designed to cut costs, is now a catch-all for layoffs and unreasonable performance expectations. PMID- 10166833 TI - Information conversion: between physician allies and business adversaries. PMID- 10166834 TI - Back to the future: final rule for Medicare program revisions. PMID- 10166835 TI - PACS: Model T = model for tomorrow. PMID- 10166836 TI - Advanced marketing 101. PMID- 10166837 TI - Your prospects under prospective payment. PMID- 10166838 TI - Investing for improvements. Aging in place is a problem for physical plants, too. PMID- 10166839 TI - Using quality assurance to improving survey scores. PMID- 10166841 TI - A higher calling. Choose nursing assistants carefully, train them well, and your turnover rates will dwindle. PMID- 10166840 TI - Who needs assisted living? No two markets are alike, experts say, so look before you leap. PMID- 10166842 TI - Contractor or employee? Better ask the IRS. PMID- 10166843 TI - Communication is key in multi-facility installations. PMID- 10166844 TI - Get ready for the next stage in the LTC life cycle. PMID- 10166845 TI - Managed care hits the Big Apple. PMID- 10166846 TI - Cafeteria promotions that really work. PMID- 10166847 TI - Continuing care for seniors: a fast-growing market segment. PMID- 10166848 TI - Caregiver burnout. A major reason for nursing home admissions. PMID- 10166849 TI - The role of the dietitian in palliative care. PMID- 10166850 TI - Street weapons. What you don't know can kill you. PMID- 10166851 TI - The crash of Valujet flight 592. PMID- 10166852 TI - "Please help me--not!" The FCC assigns a new national nonemergency phone number: 311. PMID- 10166853 TI - Hospital finds diversity training for employees no simple matter. PMID- 10166854 TI - The NC Amtrak disaster: dealing with the media swarm. PMID- 10166855 TI - Appeals court affirms hospital's negligence in attack on employee. PMID- 10166856 TI - How one hospital applies TQM to security problems. PMID- 10166857 TI - Special report. Workplace violence: what all employers should know. AB - Violence in the workplace has been declared a national epidemic by the Centers of Disease Control and Prevention (CDC), Atlanta, GA, which found that homicide was the cause of death for an average of 750 workers annually between 1980 and 1989, making it the third leading cause of death in the workplace. Over 111,000 incidents of workplace violence were reported in 1992 alone. In its first-ever national census of workplace fatalities, the Bureau of Labor Statistics reported 1,004 workplace homicides in calendar year 1992. More than one-third of the 479 human resource professionals, responding to a recent survey by the Society of Human Resource Management, said incidents of violence had occurred where they work. Over half said that between two and five acts of violence were committed in their workplaces in the last five years. In this report, we'll present a number of approaches that all employers might consider in formulating programs for preventing incidents of violence. PMID- 10166858 TI - Hospitals form regional system to improve disaster response. PMID- 10166859 TI - Emerging MD specialty can help you cut costs, optimize LOS. PMID- 10166860 TI - In the crosshairs of ProPAC's scope? Medicare freeze may push hospitals to the brink. PMID- 10166861 TI - JCAHO will broadcast results on the Internet. Hospitals question new practice. PMID- 10166862 TI - Revamp data sources for measuring performance. PMID- 10166863 TI - Executive roundtable II. Talking about quality. AB - In the last issue of Healthcare Executive, we introduced the first in a two-part series on quality in healthcare. The series, which is predicated on a five-hour roundtable discussion among eight healthcare leaders, was moderated by Thomas C. Dolan, Ph.D., FACHE, CAE, ACHE's president and chief executive officer, and jointly sponsored by ACHE and the Bayer Quality Network, an educational forum for sharing innovative and effective continuous quality improvement methods with healthcare executives. In Part I, participants spoke about current issues as they relate to quality. They discussed the reliability of existing quality data and expressed a need for more practical indicators and measurement systems. The consumer mindset was discussed, as leaders debated the value of customer satisfaction surveys and ways to create more realistic consumer expectations. In terms of employers and third parties, participants suggested tailoring quality information and presenting it in a simplified fashion. Finally, leaders emphasized the need for better performance information, as well as the use of outcomes data for both educational and quality improvement purposes. In Part II, the dialogue remains compelling. Participants cover new ground as they talk about the role of accreditors in regulating quality, of governance teams and senior management in creating an organizational culture to support quality, and of physicians in attracting both business partners and patients based on quality. Following is the second in our two-part series. PMID- 10166864 TI - Healthcare and the World Wide Web. Does your organization need a homepage? PMID- 10166865 TI - Overcoming antitrust obstacles to integrated delivery. PMID- 10166866 TI - Having an action plan can help you recover quickly if you get "downsized". PMID- 10166867 TI - The most important role of healthcare executive can play in easing this transition to managed care is that of a coach. PMID- 10166868 TI - Proposed reductions in Medicare hospital and health system payments are the largest ever. PMID- 10166869 TI - American College of Healthcare Executives. Public policy statement. Organ donation. March 1997 (revised). PMID- 10166870 TI - Addressing ethics accusations. PMID- 10166871 TI - Search tool mastery can ease your quest for information on the World Wide Web. PMID- 10166872 TI - Finding the optimal service mix in a changing marketplace. Are you meeting your customers' needs? PMID- 10166873 TI - Under the full moon. Inner city EMS: it's not what you think. PMID- 10166874 TI - Minding the nuts and bolts. New tools for keeping emergency fleets running. PMID- 10166875 TI - MEDLINEing. Why and how to conduct a literature search. AB - Have you ever proposed a new prehospital intervention at your local medical advisory committee only to be stopped dead in your tracks when another participant calmly asserts that your idea is not field appropriate, has too many risks or is simply ineffective, then cites medical literature that says so? If you haven't done your homework, you must fold up your notes and quietly return to your seat. To be sure you're prepared with the best, current research for such a proposal, you need the same research tool your physician colleagues use, and that's the ability to search the MEDLINE database. Read on to learn a free and easy way to access this very powerful research tool via the Internet. PMID- 10166877 TI - Lab staff in the midwest swings into action for National Medical Laboratory Week. PMID- 10166876 TI - With'ems. The rest of the story ... caring for those close to the patient. PMID- 10166878 TI - On-site drug testing on the rise and growing strong. AB - On-site workplace drug testing is fast becoming an attractive alternative to traditional methodologies. Among the reasons for its growing popularity is that these assays can be performed quickly and inexpensively by nonlaboratorians using simple equipment. PMID- 10166879 TI - Redirect stress to increase energy. PMID- 10166880 TI - Roundtable, Part 4. Streamline your automated hematology laboratory. PMID- 10166881 TI - Medicaid reform: new key, same tune. PMID- 10166882 TI - Entering the world of home care. Long term care providers extend the continuum. PMID- 10166883 TI - Provider 1997 transportation survey. PMID- 10166884 TI - Avoiding the empty bed syndrome. PMID- 10166885 TI - Notes from an appraiser. PMID- 10166886 TI - Feds scrutinize long-term care wages. PMID- 10166887 TI - Focus on caregiving. Making restraint-free care work. PMID- 10166888 TI - Provider 1997 corporate profiles. AB - As the long term care industry seeks out new products, new solutions, and new ways of providing quality care, it is important for long term care providers to know more about the companies they do business with. The following corporate profiles showcase information about leading companies in the long term health care industry. Some of the areas highlighted include: mission of company, history, product lines, support services. We hope you will find this information useful when making purchasing decisions, and we're confident you'll keep this issue of Provider as a handy reference guide. The information in the following corporate profiles was supplied by the companies. Neither Provider magazine nor the American Health Care Association endorses the products and services listed in this section. Provider magazine and the American Health Care Association disclaim any and all liability related to or arising from the information contained in the profiles. PMID- 10166889 TI - Kids at risk. Uninsured children increasingly come from middle-class families. PMID- 10166890 TI - National Hospital Ambulatory Medical Care Survey: 1995 emergency department summary. AB - OBJECTIVE: This report describes ambulatory care visits to hospital emergency departments in the United States. Statistics are presented on selected patient and visit characteristics. METHODS: The data presented in this report were collected from the 1995 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey, which measures health care utilization across various types of providers. NHAMCS is a national probability survey of visits to hospital emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data were weighted to produce annual estimates. RESULTS: During 1995, an estimated 96.5 million visits were made to hospital emergency departments (ED's) in the United States, about 36.9 visits per 100 persons. Persons 75 years and over the highest rate of emergency department visits. There were an estimated 37.2 million injury-related emergency department visits during 1995, or 14.2 visits per 100 persons. There were 225 thousand visits related to injuries caused by firearms, including 144 thousand visits for gunshot wounds. One-fifth of the injury visits were work-related for persons 18 64 years of age. Four-fifths of the ED visits involved medication therapy with pain relief drugs accounting for 30 percent of the medications mentioned. Acute upper respiratory infection was the leading illness-related diagnosis for ED visits. PMID- 10166891 TI - The challenge of genuine power sharing in participatory research: the gap between theory and practice. AB - Participatory research is often suggested as a strategy to overcome power imbalances between researchers and research "subjects" because it values equally the knowledge of each individual who participates in the project. However, there is little documentation of the dilemmas that may arise when a complex community service organization attempts to engage in participatory research. In our experience of a participatory research project with multiple partners, power imbalances arose from organizationally based perspectives that were unaccounted for in the participatory research literature, demonstrating that power is a complex and elusive factor in establishing equal relations. PMID- 10166892 TI - Consumer/survivor participation in the operation of community mental health agencies and programs in metro Toronto: input or impact? AB - The main purpose of this study was to obtain an overview of consumer/survivor participation in the operation of community mental health agencies in Metro Toronto. This article describes, from the viewpoint of agency executive directors, the nature and extent of consumer/survivor involvement and the difficulties encountered in implementing it. It appears that while involvement is increasing in specific, measurable ways in many agencies, the actual impact of consumers/survivor input on agency philosophies, policies, and practices is, at best, unclear. Agency directors tend to account for this in terms of the failure of consumers/survivors to "fit in" and meet agency expectations. Drawing on the literature on consumer/survivor involvement, the author suggests that the more fundamental problem is the continued imbalance of power between consumers/survivors and agency staff and the failure of agencies to create an environment conducive to meaningful consumer/survivor participation. There is, however, a high degree of interest in receiving support to address the issues encountered in developing partnerships with consumers/survivors. PMID- 10166893 TI - Past the velvet ropes. PMID- 10166894 TI - [My experiences with the mental health care system]. PMID- 10166895 TI - Beyond "bad manners": the power relations of "consumer participation" in Ontario's community mental health system. AB - This article describes the work of the legislation subcommittee of the steering committee responsible for the implementation of the Graham Report, Ontario's current blueprint for community mental health. It describes barriers to psychiatric survivor participation in the subcommittee's 1990 provincial consultation, including professional/bureaucratic characterization of survivor actions during the event as "bad manners." I argue that this naming is an act of power. Conflicts arose because the two groups operate from different behavioural codes in which the pivotal issue, acted out indirectly in all kinds of interactions, was whether and how deeply to include personal experience and emotions as forms of knowledge. The cultural dimensions of "consumer participation" must be more broadly recognized and more consciously considered if this policy is to remain viable, particularly in a time of major economic restructuring. PMID- 10166896 TI - Consumer empowerment in the mental health field. AB - This article is an overview of consumer empowerment and involvement in the mental health field, with a focus on some recent Canadian developments as described in the formal literature. A brief description of traditional approaches to treatment and support for persons with serious mental health problems is provided, followed by a discussion of the principles of consumer empowerment and involvement. Three categories of involvement are described with a discussion of some of the associated benefits and barriers and methods for overcoming them. A discussion of directions for future work is also included. PMID- 10166897 TI - Loud, sad or bad: young people's perceptions of peer groups and smoking. AB - This paper suggests that most 13 year olds and many 11 year olds have a clear and detailed grasp of their own social map, recognize the pecking order which is established amongst their peers and are aware of the different levels of risk taking behaviour, including smoking, adopted by different peer groups in their school year. Thirty six 11 year olds and 40 13 year olds took part in the study. Their remarkably consistent views about which pupils adopt or reject smoking are closely related to their perceptions of their social map. Their accounts differentiate top girls, top boys, middle pupils, low-status pupils, trouble makers and loners, associating smoking behaviour consistently with three of the five groups--the top girls, the low-status pupils and the trouble makers. Top boys, although sharing many of the characteristics of top girls, have an added protection factor--their keen interest in football and physical fitness. From their descriptions, it is apparent that different groups of pupils smoke for different reasons which are related to pecking order and group membership. The implications of these young people's views for health education programmes to prevent smoking and other risk-taking behaviours are far reaching. PMID- 10166898 TI - Changes across 3 years in self-reported awareness of product warning messages in a Hispanic community. AB - This study investigated the self-reported awareness of product warning messages among independent random samples of Hispanics in San Francisco surveyed from 1989 through 1992. Messages tested were primarily related to cigarette smoking and the consumption of alcoholic beverages. In general, respondents reported low levels of awareness of product warning messages with the exception of those messages dealing with the consumption of alcohol or cigarettes during pregnancy. Nevertheless, there were increases in awareness across years for the alcohol related warning messages and for one of the cigarette messages, indicating that continued exposure increases awareness of the message. A notable proportion of the respondents reported being aware of a bogus message implying the presence of socially desirable responses in self-reports of message awareness. Gender, education, age and acculturation level of the respondents also showed effects on reported awareness of specific messages. Continued exposure to product warning messages seems useful in producing health-enhancing behaviors among Hispanics. PMID- 10166899 TI - Measuring intermediate outcomes of violence prevention programs targeting African American male youth: an exploratory assessment of the psychometric properties of six psychosocial measures. AB - This study examined the psychometric properties of six psychosocial measures that may be useful indicators of intermediate outcomes of violence prevention programs targeting African-American male youth. Baseline and 6 month follow-up survey data are used from 223 African-American male 12-16 year olds participating in a violence prevention program evaluation study. The constructs of interest are beliefs supporting aggression, aggressive conflict-resolution style, hostility, ethnic identity, self-esteem and hopelessness. Each construct is measured as a multi-item scale. Exploratory factor analysis results provided limited support for the unidimensionality of these scales, thus suggesting that further scale development is warranted. Reliability coefficients for the scales ranged from 0.55 to 0.80. Bivariate analyses with baseline data indicate that all six measures have construct and criterion-related validity, as they are associated with each other and with four behavioral criteria in the expected directions. Predictive validity was also demonstrated for beliefs supporting aggression, aggressive conflict-resolution style, hostility and hopelessness which were associated with weapon-carrying behaviors measured in the 6 month follow-up survey both before and after controlling for corresponding behaviors measured in the baseline survey. PMID- 10166901 TI - Correlates of child care providers' interpretation of pediatric AIDS: implications for education and training. AB - A total of 212 child care providers residing in a southeastern state were surveyed about their knowledge and attitudes toward AIDS and child care policies. Providers' feeling about caring for an HIV-infected child, rather than their perceived knowledge of AIDS, were most consistently correlated with their factual knowledge and positive attitudes toward AIDS. These results suggest that providers may pay more attention to AIDS information and become more accepting of recommended child care policies when they are able to personalize AIDS within the context of their work with young children. Implications for education are discussed within the context of the Health Belief Model. PMID- 10166900 TI - A worksite smoking intervention: a 2 year assessment of groups, incentives and self-help. AB - Sixty-three companies in the Chicago area were recruited to participate in a worksite smoking cessation program. Participants in each worksite received a television program and newspaper supplement (part of a community-wide media campaign), and one of three conditions: (1) self-help manuals alone (M), (2) self help manuals and incentives for 6 months (IM) or (3) maintenance manuals, incentives and cognitive-behavioral support groups for 6 months (GIM). Results at the 2 year assessment are examined using a random-effects regression model. In addition, various definitions of quit-rate commonly used in smoking cessation research are explored and the advantages of using a public health approach in the worksite are examined. PMID- 10166902 TI - The contribution of interagency collaboration to the promotion of young people's sexual health. AB - This paper employs a case study approach in order to examine the contribution of interagency working to the delivery of education and services in the difficult field of young people's sexual health. It reports on a collaborative UK initiative involving teachers, community health practitioners, health promotion staff, and youth and community workers. The provision included school-based sex education, drop-in advice and information facilities, 'detached' street work, and a young person's clinic. A qualitative study was completed involving detailed interviews with 25 staff from the different agencies involved. The findings suggest that interagency collaboration can enhance the work of each organization, and can achieve a comprehensive response to young people's sexual health needs by making positive use of the distinctive roles, skills, knowledge and approaches of the different agencies. The potential that such a collaboration will have a significant impact on young people's sexual health is discussed. PMID- 10166904 TI - Community health outcomes and the public good. PMID- 10166903 TI - Modeling the impact of prostate cancer early diagnosis on managed care plans. AB - Efforts to improve decisions about the appropriate use of new and existing technologies have prompted the development of technology assessment committees and advisory panels within managed care plans. As part of this development, plans are using a variety of sophisticated tools to aid their decision making. One such tool is the actuarial model, a method of quantitatively estimating the risk associated with providing care to specified populations. PMID- 10166905 TI - Strategic considerations in clinical laboratory management: a laboratory leadership role in clinical pathways. Establishing the laboratory's direct contribution to the institution's performance. AB - This clinical laboratory serves a unique, though incompletely recognized, function in medical care as the source, moderator, and conduit of vital information supporting the detection, confirmation, and monitoring of disease states. To carry out that function effectively, the laboratory must actively participate in developing clinical pathways based on medical programs. Clinical pathways define the operational and quality requirements for the services involved in meeting the medical program objectives. Because of the laboratory's unique position in the acquisition and flow of information, its contribution must continue as a planned process--based on accurate assessment of value, cost, and resource inputs--rather than in a discrete, event-driven manner. Two examples of clinical pathway development, partly given by the laboratory, illustrate its application in nutritional screening and monitoring for metabolic support and in emergency department admitting decisions on myocardial damage at Bridgeport Hospital (Bridgeport, CT). The paper suggest two activities, point-of-care testing and screening for fetal lung development, that could benefit considerably from clinical pathway information shared across the experiences of several institutions. PMID- 10166906 TI - Appraising the performance of medical technologists in a clinical laboratory. AB - Medical technologists and their coworkers serve as a critical link in the delivery of health care, yet their performance typically is appraised in a traditional way, causing stress for both managers and workers. Drawing on Total Quality Management concepts, this article proposes a framework for appraising performance in a clinical laboratory context and shows how it can be used to address the problems that managers face in providing constructive appraisals to laboratory personnel. PMID- 10166907 TI - The value-added laboratory: an opportunity to merge research and service objectives. AB - The changing health-care environment is creating a new opportunities for laboratory medicine professionals that correspond with the new health services research agendas. Proving cost-effectiveness and conducting outcomes assessment are becoming vital functions of laboratories in this era of managed care. Laboratorians must take advantage of the resulting opportunities to show how they add value and medical relevance to the health-care delivery system. PMID- 10166908 TI - Using patient satisfaction as an indicator of the quality of laboratory services. Applying social science methods to evaluate outcomes in laboratory medicine. AB - The authors discuss methods of outcomes research using patient satisfaction as a quality indicator for evaluating point-of-care (POC) laboratory methods. After commenting on the rationale for using this approach, we focus on specific techniques for developing questionnaires, collecting survey response data, and building a database for analysis. We also address problems that arise in incorporating data from medical records into a research database and the linkage of records from disparate sources. Approaches to cost analysis are discussed, including problems with the use of financial and billing records. Preliminary results thus far show no significant effects from the use of POC prothrombin time testing on hospital inpatient evaluations of their overall care. Using laboratory charges and total reimbursements for treatment as proxies for cost, we found a significant (p < 0.0001) difference in the costs for POC testing over those for testing in the central laboratory. PMID- 10166909 TI - Nursing ethics committees and policy development. PMID- 10166910 TI - Development of a home health agency nursing ethics committee. PMID- 10166912 TI - Why nursing ethics committees? PMID- 10166911 TI - The perioperative nurse's role as moral agent. PMID- 10166913 TI - Are nursing ethics committees necessary? PMID- 10166914 TI - Everyday nursing concerns: unique? trivial? or essential to healthcare ethics? PMID- 10166915 TI - The establishment and development of nursing ethics committees. PMID- 10166916 TI - Developing and maintaining ethical competence. PMID- 10166917 TI - Annotated bibliography: nursing ethics committees. PMID- 10166918 TI - Perspectives. Kids' deal must seek to build on workplace coverage. PMID- 10166919 TI - Marketplace. Can Blues maintain identity despite merger mania? PMID- 10166920 TI - Perspectives. Adversaries seek detente on clinical research arrangements. PMID- 10166921 TI - Special report. Budget agreement fits the bill at the White House. PMID- 10166922 TI - Outcomes management. A system long overdue. PMID- 10166923 TI - Client/server system. The answer in a distributed environment. PMID- 10166924 TI - Emerging technologies. From fascination to application. AB - When Medtronic founder Earl Bakken saw the 1931 film Frankenstein, a fascination was born that grew into a conviction that technology could be harnessed to improve life. And so it has. But information technologies dominate some of the newest breakthroughs in healthcare--have you heard of network computers, extranets, thin clients, patient informatics, peopleware, Webtops, or zero administration? If not, you will. Meantime, what do they mean to you? For the most part they promise a return to a simpler, cheaper, easier to run, less scary model for systems development. And also, a returned focus on everyone's ultimate goal--improving patient care. The truth about emerging technologies? As our story suggests, it's as obvious as the scars on Frankenstein's face: Keep it simple. PMID- 10166925 TI - Planning for the unexpected: art or science? PMID- 10166926 TI - Health Level Seven. '96 Health Insurance Portability and Accountability Act. PMID- 10166927 TI - Palm top computing with Windows CE. PMID- 10166928 TI - 1997--a quick look forward. PMID- 10166929 TI - Telecom reform. The slow dawning of a new age. PMID- 10166930 TI - "Virtual" network management through outsourcing. PMID- 10166931 TI - The computer-based patient record. A new object of component-object computing. PMID- 10166932 TI - Installing systems successfully in managed care organizations. AB - The installation of a new administrative system is a tremendous undertaking for any organization, affecting every area of the operation. Often, because of time and budget constraints as well as the perception that change is not immediately necessary, many organizations wait until there is no option but to change systems -then make the changes under short time frames. For a large, multisite organization, the issues are the same but the complexity increases tremendously. PMID- 10166933 TI - Hiring a winning team. PMID- 10166934 TI - CPRI (Computer-based Patient Record Institute) seeks industry-wide standards compliance. PMID- 10166935 TI - CPRs that cure. PMID- 10166936 TI - 1997: year of the "Internet backlash"? PMID- 10166937 TI - Competition heats up in online medical information. PMID- 10166938 TI - Winner--Baystate Health Systems. 1997 most computer-advanced healthcare organization. PMID- 10166939 TI - Honorable mention--1997 most computer-advanced healthcare organization. PMID- 10166940 TI - CPR update. Where we've been and where we're headed. PMID- 10166941 TI - Nursing systems '97. Time for new thinking. AB - The nursing information systems challenge in 1997 is to identify and implement technology and information systems solutions that provide more breadth, depth, flexibility and standardization than ever before, and at a faster pace. To meet the challenge we need more than application checklists. We need to challenge the old approaches to defining needs, implementing systems and training users. Nurses must be educated, involved and accountable for the integration of systems into the patient care process. It's time for new thinking; it's time to ask why we are doing things the same way we did them 20 years ago when everything else about healthcare has changed. PMID- 10166942 TI - Automating the bedside. PMID- 10166943 TI - Home healthcare meets managed care. PMID- 10166944 TI - Hardware: the power beneath it all. PMID- 10166945 TI - The bug that ate the millennium. PMID- 10166946 TI - SAIC (Science Applications International Corp.) and UCSD (University of California San Diego) tackle Web security. PMID- 10166947 TI - The thin client. Let the feast begin. PMID- 10166948 TI - Data mining goes multidimensional. AB - The success of a healthcare organization depends on its ability to acquire, store, analyze and compare data across many parts of the enterprise, by many individuals. While relational databases have been around since the 1970s, their two-dimensional structure has limited--or made impossible--the kind of cross dimensional trend analysis so necessary to healthcare today. Enter online analytical processing (OLAP), in which servers store data in multiple dimensions, opening a world of opportunity for data-mining across the enterprise. In this issue of HEALTHCARE INFORMATICS, we feature our first report from the National Software Testing Laboratories (NSTL) about technologies that will change the way healthcare does business. A division of The McGraw-Hill Companies, NSTL is an independent software and hardware testing lab offering services that include compatibility testing, bug testing, comparison testing, documentation evaluation and usability. PMID- 10166949 TI - Wireless and mobile computing. Healthcare's slow but sure awakening. PMID- 10166950 TI - Wireless networking speeding up to real-time scheduling. PMID- 10166951 TI - Striving to survive? You lose. PMID- 10166953 TI - Just-in-time Internet benefit enrollments. PMID- 10166952 TI - Health Level Seven. Shedding light on HL7's Version 2.3 Standard. PMID- 10166954 TI - What do doctors want from the Web? PMID- 10166955 TI - Magnetic resonance imaging (MRI) in clinical radiology: recent advances, future directions and planning. PMID- 10166956 TI - Technology and equipment for renal transplantation. PMID- 10166957 TI - Automated microbiology culture system for upgradation of the emergency microbiology services for better patient care. PMID- 10166958 TI - Scope of nuclear medicine in India. PMID- 10166959 TI - Impact of high technology in clinical radiotherapy. PMID- 10166960 TI - Hospital waste disposal system & technology. PMID- 10166961 TI - A management technique for effective management of medical store in hospitals. Medical store management technique. AB - BACKGROUND: Almost one third of hospital' annual budget is spent on buying material and supplies including medicines. There is wide variation in cost of these items and effective management of store is necessary to ensure optimal use of money spent. OBJECTIVES: (i) To explore the feasibility of alphabetical analysis (where items are classified into A, B and C categories depending on their annual consumption value) in effective management of a medical store and to compare the present (fixed period re-order) and the proposed (fixed quantity re order) as alternative inventory management technique. METHODS: Using multistage random sample technique, two sub-categories out of total of 37 listed in stock register (medicine) of a large hospital of Delhi were selected for detailed analysis. Alphabetical (ABC) analysis based on total annual consumption value of different items was done. Six medicines, the first and the last from each of the ABC categories, were also analysed for fixed quantity re-order. RESULTS: It was observed that ABC analysis, if practised, would allow effective control over two third of the total expenditure by controlling only one fourth of the items. The existing order size (based on fixed period re-order) was more than three times order size if based on fixed quantity re-order. CONCLUSIONS: Alphabetical analysis is a feasible and efficient technique for effective management of store in hospitals. Considerable financial savings is possible if the order size is based on fixed quantity re-order. RECOMMENDATIONS: The Assistant Store Officer should apply alphabetical analysis for more efficient management of the medical store. The present practice of fixed period re-order should be replace by fixed quantity re-order. PMID- 10166962 TI - Medical technology--a dilemma. PMID- 10166963 TI - Ambulance services. PMID- 10166964 TI - Managing medical technology and business opportunities. PMID- 10166965 TI - Equipment planning considerations for hospital laundry. PMID- 10166966 TI - Patients' reference for evening pay clinic at a tertiary care hospital. AB - To lessen overcrowding in the regular morning OPD and obtain better patient satisfaction, Evening Pay Clinic in a tertiary care hospital with daily OPD attendance between 1000 and 1200 patients was conceptualised. To elicit patients' response to the proposed system a survey with a structured questionnaire among 202 randomised sample of patients was conducted. Patient preference depended on distance of their home from the hospital as well as availability of suitable transport to reach the pay clinic and the likelihood of their being able to go back by the same evening after their encounter with the hospital was over. The majority of the patients preferred the proposed system as it promised quick and personalised service and the attendance by the doctors of their choice. PMID- 10166967 TI - Biomedical equipment and medical services in India. AB - Varieties of Biomedical Equipment (BME) are now used for quick diagnosis, flawless surgery and therapeutics etc. Use of a malfunctioning BME could result in faulty diagnosis and wrong treatment and can lead to damaging or even devastating aftermath. Modern Biomedical Equipments inevitably employ highly sophisticated technology and use complex systems and instrumentation for best results. To the best of our knowledge the medical education in India does not impart any knowledge on the theory and design of BME and it is perhaps not possible also. Hence there is need for a permanent mechanism which can maintain and repair the biomedical equipments routinely before use and this can be done only with the help of qualified Clinical Engineers. Thus there is a genuine need for well organized cadre of Clinical Engineers who would be persons with engineering background with specialization in medical instrumentation. These Clinical engineers should be made responsible for the maintenance and proper functioning of BME. Every hospital or group of hospitals in the advanced countries has a clinical engineering unit that takes care of the biomedical equipments and systems in the hospital by undertaking routine and preventive maintenance, regular calibration of equipments and their timely repairs. Clinical engineers should be thus made an essential part of modern health care system and services. Unfortunately such facilities and mechanism do not exist in India. To make BME maintenance efficient and flawless in India, study suggests following measures and remedies: (i) design and development of comprehensive computerized database for BME (ii) cadre of Clinical engineers (iii) online maintenance facility and (iv) farsighted managerial skill to maximize accuracy, functioning and cost effectiveness. PMID- 10166968 TI - Key note address for 'National Symposium on Hospital Equipment, Appliances & Technology'. PMID- 10166969 TI - The technology of benefits outsourcing: helping employees help themselves. AB - The exponential growth of health plan offerings and increased use of defined contribution retirement plans has caused a fundamental shift in the way that benefits management is done. Specifically, the authors point out that we are moving into an era of "self-service" in employee benefits, with employees often taking the role of management of their own benefits through use of technology. Outsourcing benefits management through the use of technology has meant the role of HR departments has shifted from personnel administrators to strategic business partners. By outsourcing administrative functions and maximizing the power of new interactive technology, human resource departments are able to focus on the strategic needs of the company to adapt to the challenges of the future. PMID- 10166970 TI - Managing health and welfare plans instead of letting them manage you. AB - The explosive growth and change in the health care provider industry is presenting a considerable challenge to employers that manage these benefits for their employees. Corporate mergers, supportive federal and state legislation expanding benefit availability and access to new consumer markets are a few of the forces changing the shape of the industry. Furthermore, participants are more knowledgeable about their benefit plans and are more vocal about their needs. The authors discuss these challenges and possible solutions for the employer that is attempting to determine how plan delivery and management needs can be served in a way that supports business environment and strategy. PMID- 10166971 TI - The new millennium--what will health benefits be for the small employer? AB - With the impending approach of the year 2000, the author considers the evolution of health benefits over the last few decades and the forces that are bound to affect health benefits for the small employer in the next millennium. This article suggests that it will be necessary to spread the cost of health care as well as other reform initiatives in order to make it possible for small businesses to have a greater voice as well as an equal share in health benefits, particularly considering that the majority of Americans work for small employers. PMID- 10166972 TI - Practice brief. Issue: Managing health information relating to infection with the human immunodeficiency virus (HIV). American Health Information Management Association. PMID- 10166974 TI - CARF ... the Rehabilitation Accreditation Commission. PMID- 10166973 TI - HHS publishes semiannual regulatory agenda. PMID- 10166975 TI - Aspects and applications in veterinary health information management. PMID- 10166976 TI - New collaborative approach by Minnesota Peer Review Organization reduces CPT coding disagreements. PMID- 10166977 TI - On the road to personal effectiveness. PMID- 10166978 TI - Mid-decade report on the computer-based patient record--the National Summit on Health Information Solutions. PMID- 10166979 TI - Reviewing medical documents online when the information is not available in the medical record. PMID- 10166980 TI - Singing the St. Louis Blues. PMID- 10166981 TI - Columbia/HCA under seige. PMID- 10166982 TI - How HMOs assess medical groups and IPAs. AB - California health maintenance organizations (HMOs) frequently capitate physician organizations--independent practice associations (IPAs) and multispecialty medical groups--to export their risk for professional and outpatient ancillary services. Physician organizations benefit when successful in managing the risk, and from having greater control over medical management decisions. HMOs carefully assess the physician organization's ability to manage capitated risk and provide high-quality care. HMOs gather information on the physician organization's finances, business relationships, physician compensation arrangements, credentialing, hospital relationships, ancillary contracts, procedures for 24 hour care, claims administration, member services, information systems for reporting and tracking utilization, and procedures for utilization/quality management. These data are analyzed to determine whether capitation contract negotiation should proceed. PMID- 10166983 TI - Pricing specialty carve-outs and disease management programs under managed care. AB - The drive toward improved efficiency and effectiveness in health care has spawned disease management programs to address the needs of patients with certain conditions. These programs parallel traditional case management programs in monitoring patients, but disease management differs from case management in early assessment of patient risk, with proactive clinical interventions and educational efforts. The most comprehensive programs include a coordinated delivery system that can be "carved out" from other health care benefits. Pricing disease management can benefit from the analysis of detailed, disease-specific and community-specific data from public or private sources. PMID- 10166984 TI - Solution to patient access to specialist care lies in a balanced approach. AB - Managed care economic and administrative measures designed to coerce "gatekeepers" to limit patients' access to specialist care need to be balanced by sound clinical protocols. Balance is maintained when appropriateness of care, not costs, guides care and referral decisions. This article explores how appropriateness can be achieved through the use of clinical decision support criteria or guidelines. Not only do the guidelines enable providers to deflect demand appropriately and prevent unnecessary interventions, they help mitigate the financial risk that providers assume under managed care. PMID- 10166985 TI - University MSO: an academic medical center's managed care strategy. AB - In all markets of the country, academic medical centers (AMCs) are organizing their response to increasing managed care penetration. This is true in New York City, home of six academic medical centers, as well as in the New York metropolitan, tristate area with a total of nine AMCs. The adaptable structure of a management services organization (MSO) offers the AMC the mechanism to position itself in the managed care market, to integrate its institutions and physician practices, and to link community physicians, affiliated institutions, and ancillary service providers. This article describes the approach used by New York University Medical Center and its clinical faculty to form an MSO and the MSO's strategic expectations for the future. PMID- 10166987 TI - Antitrust issues for the physician organization. AB - This article will explore three of the most viable approaches to structuring antitrust arrangements: (1) arrangements sharing substantial financial risk; (2) arrangements that will achieve substantial clinical integration in their operations; and (3) participation in a "messenger model" physician (or multiprovider) network. PMID- 10166986 TI - Single-specialty networks, carve-outs, and consolidations. AB - Throughout the country health care provider groups seem to be merging at a record pace. This consolidation sharply brings into question the traditional role specialty providers have played within the health care system--causing many specialty practitioners to evaluate the myriad of specialty organizations being formed (IPA, PPM, MSO). A single-specialty organization that is able to deliver focused, consistent services to the payer that demonstrates value beyond the clutter of today's multi-specialty groups and PPMs is a very attractive entity to the managed care market. Some of the most attractive specialties for development of networks, carve-out products, and consolidations include oncology, cardiology, orthopedics, ophthalmology, and occupational medicine practices. PMID- 10166988 TI - Building managed care networks for rural communities. AB - Managed health care networks in both urban and rural communities seek to improve quality, cost, and access; however, rural community health care systems must also curb patient outmigration. A primary care network (PCN) can effectively keep more of the patient care within the rural community. This PCN can then expand to include secondary contractual relationships with the rural community hospital and specialist physicians. As this expanded PCN affiliates with a tertiary provider network, an integrated delivery system (IDS) emerges. This enables the full health care service continuum to be managed by the rural primary care physicians. Such managed cooperation initiatives are best carried out as a joint effort between community employers and providers. PMID- 10166989 TI - Physician partnerships: keep the entrepreneurial spirit alive. AB - With the advent of managed care, physicians who practice on their own and compete against other doctors are becoming a vestige of the past. More and more doctors are learning there is strength in partnering with other physicians and a corporate health care provider to bolster their practices, take advantage of economies of scale, and have more clout when competing for managed care contracts. One corporate provider in the business of establishing such partnerships has learned the key to success in physician partnerships is investing time to build solid relationships with the doctors considering the venture. PMID- 10166990 TI - Physician practice management: a private equity investor's perspective. PMID- 10166991 TI - The year of the consumer. PMID- 10166992 TI - A resurgence of PHO activity in Minneapolis and St. Paul. Interview by William S. Gedge. PMID- 10166993 TI - Managing hospital emergency power testing programs. AB - All hospitals must have an emergency power testing program that includes generator load testing and emergency power supply system maintenance. This document examines a management program that uses lessons learned from an emergency power testing program to improve the hospital's facilities and training. PMID- 10166994 TI - Tougher penalties arrive for upcoding, 'unnecessary' care. PMID- 10166995 TI - Survey finds physicians dissatisfied with many aspects of managed care. PMID- 10166996 TI - Web site helps Californians become informed purchasers of health care. PMID- 10166997 TI - Staff doctors' pay up 2.9% in '96, but 1 out of 4 received no raise. PMID- 10166998 TI - The new workers' comp: will you be part of it? PMID- 10166999 TI - Screen patients quickly for workers' comp fraud. PMID- 10167000 TI - Doctor, have you had your day out of court? PMID- 10167001 TI - Insights from an outcomes researcher. PMID- 10167002 TI - Defeat of Propositions 214 and 216: the end of health care reform? PMID- 10167003 TI - Reinventing the PBM (pharmacy benefit manager). PMID- 10167004 TI - Avoiding 'bad faith' denials of medical claims. PMID- 10167005 TI - Have you tried these six time-savers? PMID- 10167006 TI - Capitation contracts: time for a new attitude. PMID- 10167007 TI - The dawning of the age of accountability. PMID- 10167008 TI - Bellin Health System: strategic alliances and strategic measurements guide a hospital into an integrated system. AB - Managed care has only recently come to Green Bay, Wis., and healthcare providers are setting up systems designed to capture market share. Bellin's strategy includes creating strong relationships through alliances, integrating services using techniques learned from quality improvement experts and teaching an uncertain public that managed care can improve care and save money. PMID- 10167009 TI - Government antifraud efforts intensify. AB - "Business as usual" is going by the wayside as new legislation strengthens penalties for fraud and abuse of federal healthcare contracts. Five experts warn of the consequences and emphasize the need for compliance programs to ensure appropriate billing decisions. PMID- 10167010 TI - Maintaining ethical conduct throughout an organization. Defense contractor Lockheed Martin's ongoing compliance program can serve as a model for healthcare leaders. AB - How can healthcare organizations guard against fraudulent practices? Setting up a compliance program is an important step, and defense contractor Lockheed Martin's program can serve as an example. PMID- 10167011 TI - Are specialists staging a comeback? AB - Recent studies have shown that certain conditions are better managed by specialists than by primary care physicians. Patients are telling systems they want increased access to specialist care. In the wake of these developments, HMOs are moving away from gatekeeper models and returning control to specialists. How are specialists faring in this new climate? Those willing to get organized and manage risk seem to have the edge, say these analysts and proponents of specialist care. PMID- 10167012 TI - Ambulatory purchasing: harnessing supply costs. AB - The healthcare system remains in a dynamic state of flux. We have all heard the story: the changing healthcare market brings reduced reimbursement for services, increased competition, and steadily increasing supply, maintenance, and equipment costs. Ambulatory surgery centers (ASCs) must keep in sync with this change or fail to survive the current market forces. However, because they represent a small contract to various vendors, many ASCs pay premium prices for inventory while receiving less from Managed Care Plans (MCPs) and Health Maintenance Organizations (HMOs). This dilemma makes control of supply costs a top priority for ASCs. In reality, purchasing is becoming more strategically connected to the ASC balance sheet than ever before. Apart from personnel costs, supply and pharmaceutical purchasing represents the greatest expense category on our financial statement. Harnessing these costs directly relates to bottom line profitability. In addition, while performing cost savings magic, ASCs must maintain patient and surgeon satisfaction with the superior outcomes and state-of the-art technology their reputations are based upon. Sound impossible? This article details how Surgery Center Plus, Inc. (SCP) implemented a cost containment project. PMID- 10167013 TI - A hospital pioneers reform of its state's procurement code. AB - In today's changing healthcare marketplace, hospitals across the US are rapidly moving toward developing integrated healthcare delivery networks. In addition, the emergence of managed care and the growing trend toward capitation have compelled hospitals to reduce costs in response to these changes. Moreover, this impetus to provide quality care at reduced cost has affected the purchasing behavior of many hospitals, forcing material managers to pursue innovative procurement methods. This article describes how the Medical University of South Carolina (MUSC) Medical Center, (Charleston, SC) obtained significant savings in purchasing as a result of pioneering legislative reforms in the procurement process. PMID- 10167014 TI - Contracting educational and library services. AB - In a partnership that characterizes the evolving trends of mutual goals and improved productivity between contractor and facility, Park Medical Center (Columbus, OH) contracts with Resources, Inc. to provide informational and educational services. As a result of this partnership, the staff has been reduced from six full-time, three part-time, and one volunteer to one full-time, two part time, three as-needed, and one volunteer. Library patrons can obtain literature searches within 24 hours and have access to materials in the nation's major libraries. Resources, Inc. also administers the Continuing Medical Education Program provides documentation services for the podiatry residency program, and develops patient education materials for specific purposes. This article reviews how contracting library and educational services helped Park reduce costs, improve quality, and expand services. PMID- 10167015 TI - Medicare makeover. PMID- 10167016 TI - Maybe we have more in common.... PMID- 10167017 TI - Strategic equipment planning for the outpatient environment: a practical guide to equipment planning for ambulatory construction. PMID- 10167018 TI - Establishing ROI (return on investment) for healthcare on the Web. PMID- 10167019 TI - Annual physical specialist. PMID- 10167020 TI - The future of rural health care. Networks, managed care, and cost-management are key to growth and development. PMID- 10167022 TI - Ten survival strategies for rural health care networks. PMID- 10167021 TI - Ten common problems will drive rural providers together. PMID- 10167023 TI - Subacute care industry questions HCFA's recently proposed salary equivalency guidelines. PMID- 10167024 TI - Medicare payments to nursing facilities ranked fourth last year. PMID- 10167025 TI - The key to maximizing profit. PMID- 10167026 TI - Preparing the outpatient practice for a health plan certification audit. PMID- 10167027 TI - Can there be too much information? Using the Internet as a primary source of information for business decisions. PMID- 10167028 TI - A clear pathway to success. Integrated care management tools for managing cost and quality. PMID- 10167029 TI - The Institute for Medical Quality. California's answer to continuous quality improvement? PMID- 10167030 TI - The facts about subacute care in skilled nursing facilities. PMID- 10167031 TI - The dilemma of full-time ICU physician coverage. PMID- 10167032 TI - Joint Commission survey preparations. PMID- 10167033 TI - Healthcare online. PMID- 10167034 TI - A short course in continuing medical education. PMID- 10167035 TI - Streamlining the physician credentialing process. AB - It is not anticipated that the demand for physician credentialing information will lessen. Organizations will have to become more cost-efficient in the way that the credentialing process is managed. The use of a uniform application and the emergence of CVOs can help streamline the process. Additional methods for implementing cost reductions and avoiding duplication of efforts in the area of physician credentialing will result as competition increases in the managed care arena. PMID- 10167036 TI - Avoiding problems in practice acquisition and recruitment. PMID- 10167037 TI - How do you eat an elephant? AB - As the need for home care and hospice services expands around the globe, the need to exchange information on an international scale grows with it. The World Homecare and Hospice Organization is stepping in to fill this niche. PMID- 10167038 TI - A global perspective: quality versus cost. AB - Finding the balance between maintaining quality of services and keeping costs down is a global problem. CARING asked home care colleagues around the world to respond to a question about cost versus quality issues. Their answers reveal some differences in health care delivery systems from country to country, but they also highlight some similarities: home care providers everywhere are grappling with financial issues and are concerned about maintaining high-quality care in a changing environment. PMID- 10167039 TI - Aging in Ghana. AB - The growing dilemma of caring for the elderly is truly a global problem, as evidenced by the aging issues in countries such as Ghana. Like many countries, Ghana faces the breakdown of traditional families, which in turn affects the tradition of family members taking responsibility for informal care of the elderly. PMID- 10167040 TI - Japan's Gold Plan emphasizes home care and the consumer. AB - Japan's population is increasingly weighted to the elderly. The health care system to date has relied on long institutional stays for their care, but a new plan--the Golden Plan--focuses on the importance of care at home, and care that the elderly desire. PMID- 10167041 TI - Where all care is home care: HIV/AIDS in Thailand. AB - In Thailand the concept of professional home care services does not exist in either the language or the culture. Virtually all health care, including care of people with HIV/AIDS, is provided by family caregivers in the home. PMID- 10167042 TI - Health care struggles down under. AB - As Australia struggles to cope with rising health care costs and diminishing public funds, the country must make tough decisions and create new solutions to provide care for its citizens. The United States should take note as it struggles with similar issues. PMID- 10167044 TI - Hospital's focus shifts to community services. AB - As one community hospital sought ways to reduce it costs, it discovered home care as a means to that end. The hospital used a consultant company to help it make the transition. It serves as a model for other hospitals and home care agencies to follow. PMID- 10167043 TI - Using supportive services to manage cost while improving quality. AB - Supportive services have traditionally been viewed as secondary to the skilled services in home care. Yet increasingly these supportive services can be more important to clients than many organizations recognize--and more important in managing costs as well. PMID- 10167045 TI - Criminal background checks for home care aides. AB - The Health Care Financing Administration recently proposed a rule requiring criminal background checks for all home care aides as a condition of employment. The purpose of the rule is to safeguard against the potential for fraud and abuse in home care, but is it the only solution? And should it be limited to just home care aides? PMID- 10167046 TI - Home care aides and the business of people. AB - A home care aide (HCA) needs both patient care skills and people skills to do the job well. Recruiting HCAs with those skills can assist in HCA retention while improving customer service. PMID- 10167047 TI - How to make an impression on members of Congress. AB - Individuals elect Members of Congress, and individuals can also affect what those elected officials do once in office. It is vitally important that agencies and individuals get involved in influencing what their representatives and senators do, as those congressional votes will have a direct impact on how the home care and home care aide industry does business. PMID- 10167048 TI - Issues and answers in latex sensitivity. PMID- 10167049 TI - Succession planning: a long-overlooked need. AB - As home care organizations become larger and more complex, the time has come to plan for structured succession. A successful planning process enhances organizational cohesiveness and helps ensure the continuity of cost-effective, high-quality patient care through the constant change within home care organizations. PMID- 10167050 TI - HCFA proposes changes to conditions of participation. PMID- 10167051 TI - Evidence-based care. Who's acting on the evidence? PMID- 10167052 TI - Ethics. Moral maze. PMID- 10167053 TI - Nurse education. At the heart of the matter. PMID- 10167054 TI - Independent nurse practitioners. Going it alone. PMID- 10167055 TI - Election focus. It's party time. PMID- 10167056 TI - Emergency referrals. Stern approach. AB - A five-year study of a south London health authority's admissions to hospital shows a marked rise in emergency inpatient referrals--with an adverse effect on planned inpatient activity. Jacqueline Mallender and colleagues summarise their findings. PMID- 10167057 TI - Mental health. Joint resolutions. PMID- 10167058 TI - Referrals. Access roads. PMID- 10167059 TI - Local pay. Performing rights. PMID- 10167060 TI - Data briefing. The English patient. PMID- 10167061 TI - Fraud and abuse enforcement: federal agencies are not waiting for Clinton's health care reform. PMID- 10167062 TI - Dealing with physician's legal and business problems during transition to retirement. PMID- 10167063 TI - Circuits split on ERISA preemption of state hospital rate systems. PMID- 10167064 TI - Federal three-pronged attack on physician self-referrals and possible kickbacks. PMID- 10167065 TI - Mergers and acquisitions: advantages and pitfalls for health care providers. PMID- 10167066 TI - The effect of fundholding on prescribing and referral costs: a review of the evidence. AB - In 1990 the UK Government announced the introduction of general practitioner (GP) fundholding whereby GPs were given a budget from which to purchase some health care services. The UK Government is at present piloting total fundholding which extends the partial model by allowing GPs in some practices to purchase all their health care services. If other countries intend to adopt schemes similar to the fundholding model then it is important that the success or otherwise of the UK experience informs their health care policy. The objective of this paper, therefore, is to review all the available quantitative evaluative evidence of the effect of (partial) fundholding on general practice. A total of 17 published quantitative studies evaluating fundholding were found, however, 8 of these were papers relating to 2 studies, therefore only 13 studies were reviewed. These studies examined the impact of fundholding only with regard to prescribing and referral behaviour. The results of these studies indicate that fundholders appeared to: (i) constrain their prescribing and referral costs; (ii) increase their generic prescribing rate; and (iii) not inflate their costs prior to joining the scheme. This review showed that there is a dearth of high quality research evidence evaluating fundholding referral behaviour whereas data on differences in prescribing costs is relatively abundant. The studies reviewed did not evaluate the effect of fundholding on patient health status, quality, patient choice or equity criteria. The difficulties involved in evaluating fundholding model presents a considerable challenge to the evaluation of total fundholding. PMID- 10167067 TI - Regulating biotechnology: a rational-political model of policy development. AB - While technology assessment is seen as a mechanism for achieving effective and efficient use of health care resources, it has not as yet made the impact on policy decisions that its potential would suggest. Considerable barriers have been encountered in translating assessment results into policy concerning the adoption and use of technologies, with 'political' factors often being decisive. This paper places technology assessment in the content of the policy process to clarify both (a) how conflicting interests and organizational features can often hinder the selection of optimal policies, and (b) the potential roles technology assessment could nonetheless play. The resulting framework is termed the 'rational-political' model of policy development. The paper uses the example of policy making about the regulation of biotechnology, drawing on information from a survey of decision-makers (n = 561) involved in issues concerning the development, approval, and payment for pharmaceutical products. PMID- 10167068 TI - Health policy as a fuzzy concept: methodological problems encountered when evaluating health policy reforms in an international perspective. AB - Investigating health policy reforms at a national level is a troublesome task, since it is difficult to establish exactly when a certain policy change took place and it is also difficult to determine the content of the reform. In this paper three main causes are distinguished that contribute to the 'fuzziness' surrounding reforms. Firstly, ordinary mistakes occur, even experts err. Secondly, in some countries responsibility for (part of the) health care system is delegated to the regional level, causing regional variations which lead to uninterpretable effects at country-level health care system descriptions. Thirdly policy reforms are often not a straightforward process. Implementations can be characterized as a gradual process which can be disturbed at any point in time. For example, the use of framework legislation, effects of public discussions and law enforcement problems contribute to the fuzziness. To strengthen the validity of information from secondary sources (often the best available and linguistically accessible sources) the use of primary sources and expert consultation highly recommended, respectively giving insight in formal rules and initial intentions of policy measures and in the impact of reforms at performance level. The fuzziness can be captured into an index (reform implementation index), containing the gathered information and thus facilitating statistical analyses controlling for process-information. PMID- 10167069 TI - Choice and participation in the health services: a survey of preferences among Swedish residents. AB - Extending the possibilities for health-service consumers to choose among providers has been an important objective on the political agenda in Sweden and elsewhere. Little is known, however, about individual and group preferences concerning the demand for choices. It is often implicitly assumed that individuals can be treated as a group with similar values and demands, but is this true? To what extent do individuals want more options in health care? Do preferences vary depending on age, education and place of living? This article explores these questions, starting from a survey of 2,000 residents in four Swedish counties. The results of the survey point to many similarities, but also indicate important differences among residents. In particular, preferences seem to vary significantly depending on age and level of education. On the other hand, older people are more favourably inclined towards the free choice of physician. On the other hand, members of the younger generation, as well as well-educated residents, demand a more active part in the process of medical decision making. These differences, as well as expectations from younger generations, pose a great challenge to the future management of health services. PMID- 10167070 TI - Analysing changes in the nature of health service management in England. AB - Health service management maintains a balance between collective values concerned with service provision and individual values concerned with health practice. It is also balanced between the application of co-ordinative and directive approaches to management. Over the last quarter century economic and ideological factors have caused health service management to experience more directive. Today, the role of health service management becoming more directive. Today, the role of health service management appears further threatened by staffing cuts and changes in traditional patterns of organising work. This, while it may lead to bifurcation between specialist and general management roles, is unlikely to restore the dominance of practitioner values or notably soften the form of management. PMID- 10167071 TI - A framework for assessing the performance of integrated health delivery systems. AB - Competing demands for resources within the health care system require health care providers to ensure the most effective and efficient use of resources. The evidence from the United States, the United Kingdom and other jurisdictions suggests that integrated health delivery systems (IDS) may be a cost-effective way to meet the health care needs of a population. This article introduces a framework for use in monitoring and evaluating the performance of an integrated delivery system. The establishment of a consistently used evaluation framework for integrated delivery systems will provide the government, governing bodies and other evaluators with an effective assessment tool that will enable greater understanding of the impact of the IDS on the health care system. It will also provide information to enable ongoing performance improvements within the system. PMID- 10167072 TI - Development of a crosswalk from the Minimum Data Set 2.0 to the Alberta Resident Classification System. AB - Ontario has mandated the use of the Minimum Data Set 2.0 (MDS) to classify patients in all chronic care hospital beds as of July 1996. The MDS, widely used in several other jurisdictions, has been shown to have several advantages over other assessment systems. However, Ontario currently classifies residents of homes for the aged and nursing homes under the Alberta Resident Classification System (ARCS). Since there is not a single system to assess the elderly in institutional settings, it is not possible to create a funding system for all institutions based on patient rather than facility characteristics. The author reports on the development of a crosswalk algorithm to compute ARCS levels of care based on clinical items from the MDS. This algorithm may be used to support a transitional approach to move to a funding system for long-term care based on Resource Utilization Groups (RUG-III). PMID- 10167073 TI - Innovation theory and its applicability to our understanding of the diffusion of new management practices in health care organizations. AB - There has been a longstanding interest in understanding how new management practices and organizational structures are diffused through the health care system. This article reviews current literature on innovation and diffusion to provide insight into how new management practices and organizational structures are introduced into the system. Understanding the process may help in accommodating new developments and provide managerial opportunities to take a more active role in encouraging or discouraging their further evolution. PMID- 10167075 TI - Clinical program development in an Alberta Capital Health Authority. AB - Developing a continuum of service delivery with provider input in a new health region has posed a major challenge. Planning service delivery by program has recently been considered an improvement over site-specific and discipline specific planning. Implementing program councils has fundamentally restructured service planning in the Capital Health region: providers now plan together, focusing on the needs of patients/clients and the community. PMID- 10167074 TI - Canada deserves a national health system. AB - A defining--some would say peculiar--feature about Canada and Canadians is the strong position that we give social programs within our national identity. FORUM presents an essay by Dr. Thomas Noseworthy based on an address to the annual meeting of the Association of Canadian Medical Colleges in April 1996. In it, Dr. Noseworthy calls for a national health system. He sees the federal government retaining an important role in preserving medicare and, in fact, strengthening its powers in maintaining national consistency and standards. Dr. Noseworthy's views are contrary to the governmental decentralization and devolution of powers occurring across the country. In a "point/counterpoint" exchange on this issue, we have invited commentaries from three experts. Raisa Deber leads off by noting that while a national health system may be desirable, constitutional provisions would be an obstacle. Governments, says Deber, have an inherent conflict of interest between their responsibility for maintaining the health care system and their desire to shift costs. Michael Rachlis reminds us that medicare fulfills important economic as well as social objectives. It helps to support Canada's business competitiveness among other nations. The problem, say Rachlis, is that public financing of health care does not ensure an efficient delivery system. Michael Walker offers some reality orientation. He observes that Canada's health care system is based upon ten public insurance schemes with widely different attributes. While he supports a minimum standard of health care across the country, citizens should be able to purchase private medical insurance and have access to a parallel private health care delivery system. Ultimately, this debate is about who should control social programs: the provinces or the federal government? We'll let you, the readers, decide. PMID- 10167076 TI - Restructuring Canada's Blood System: what will be the impact on hospitals? AB - With the amount of publicity given to the Commission of Inquiry on the Blood System in Canada (Krever Commission), hospitals will be pressured to change policies and procedures regarding transfusions and the use of drug alternatives to surgical blood transfusions. Over the next year, hospital administrators will be forced to implement changes regarding allocation of resources, upgrades to information systems and revised patient care practices for patients requiring transfusions or blood alternatives. At a series of focus groups organized by the Canadian College of Health Service Executives and Janssen-Ortho Inc. in early 1996, 57 health care administrators from across Canada discussed their vision of how the Krever Commission has and will affect hospital policies and procedures over the next few years. This article summarizes the groups' findings relating to the changes that hospital administrators are likely to implement across Canada in the next two to three years as a result of the Commission's activities. PMID- 10167077 TI - The view from here ... PMID- 10167078 TI - Quality expert Don Berwick reflects on getting better at getting better. Interview by Matthew D. Pavelich. PMID- 10167080 TI - Bench press. Can't get your ES benchmarking off the ground? Here's how to get started--and keep going. PMID- 10167079 TI - Watts up? A lighting retrofit may be the best way to beat high energy costs. PMID- 10167082 TI - How health care plant operations really operate. PMID- 10167081 TI - Got the SOC (statement of conditions) blues? Here's a refresher course. PMID- 10167083 TI - Comprehensive telemedicine legislation enacted in California. PMID- 10167084 TI - Generic drug prices continue to slide. PMID- 10167085 TI - Columbia/HCA's new system keeps tight rein on compliance. PMID- 10167086 TI - Contrast media costs can be reduced still more. PMID- 10167087 TI - Bar code standards help ease adoption. PMID- 10167088 TI - More VHA hospitals find savings are worth compliance. PMID- 10167089 TI - Assumption of risk: federal regulation of physician incentive plans. PMID- 10167090 TI - Charitable trust laws and the evolving nature of the nonprofit hospital corporation. PMID- 10167091 TI - Legal and institutional policy responses to medical futility. PMID- 10167092 TI - The Health Insurance Portability and Accountability Act of 1996 and the evolution of the government's anti-fraud and abuse agenda. PMID- 10167093 TI - Nonprofit hospitals: is the public getting its money's worth? PMID- 10167094 TI - A new prescription for pain. PMID- 10167095 TI - The many benefits of facility accreditation. PMID- 10167096 TI - Use a quality balance sheet to weigh assets and liabilities. PMID- 10167097 TI - Regulations to watch for in 1997. PMID- 10167098 TI - Nursing facilities and NCQA (National Committee for Quality Assurance) standards: a vital connection. PMID- 10167099 TI - The importance of spirituality. PMID- 10167101 TI - Diversity training sometimes causes more problems than it solves. PMID- 10167100 TI - Is religion relevant? PMID- 10167102 TI - Diversity training: facing the truth about pitfalls and benefits. PMID- 10167103 TI - Candy stripers work alongside nurses in long-term care facility. PMID- 10167105 TI - Guarding patient confidentiality under managed care. PMID- 10167104 TI - Internal medicine's identity crisis. Interview by Neil Chesanow. PMID- 10167106 TI - Please, doctor. Turn off my pacemaker. PMID- 10167107 TI - Are HMOs taking a second look at minority doctors? PMID- 10167108 TI - Who needs HMOs? This Twin Cities experiment may reveal nobody does. Employers are buying care directly from doctors. PMID- 10167110 TI - Patient dissatisfaction. New evidence that managed care is to blame? PMID- 10167109 TI - How to help your lawyer build a malpractice defense. PMID- 10167111 TI - Managed-care patients treat us like hired hands. PMID- 10167113 TI - Should you offer your staff medical savings accounts? PMID- 10167112 TI - Shoot-out in Wichita. PMID- 10167114 TI - Made a bonehead mistake? Apologize. PMID- 10167115 TI - States reassess certificate of need statutes. PMID- 10167117 TI - Top 25 assisted living chains. PMID- 10167116 TI - Assisted living flourishes. Industry may experience growing pains in 1997. PMID- 10167118 TI - Network market analysis guides providers. PMID- 10167119 TI - Choosing from the field of lenders. PMID- 10167120 TI - Networks can avoid antitrust scrutiny. PMID- 10167121 TI - Using quality indicators to improve quality of care. PMID- 10167122 TI - Answering staff questions about unionization. PMID- 10167123 TI - Perspectives. Up from denial: more medical groups to seek to manage care. PMID- 10167124 TI - Marketplace. Assessing medical innovations: how health plans pick what technology to cover. PMID- 10167125 TI - IT? Give me what I'll use. PMID- 10167126 TI - 9 keys to success. PMID- 10167127 TI - Wrestling over best practices. The rise of computer-aided decision-making. PMID- 10167128 TI - Venturing off the beaten path. It's time to blaze new CPR trails. PMID- 10167129 TI - Internet overdrive. No place for Sunday drivers. PMID- 10167130 TI - Internet. For sale. PMID- 10167131 TI - Open vs. proprietary operating systems. Finding the right fit. PMID- 10167132 TI - Resource guide addendum--1997. AB - The following is an addendum to the 1997 Healthcare Informatics Resource Guide in our December 1996 issue. The companies listed below made a special effort to inform us of their absence from the original Resource Guide. As a service to the companies and our readers alike, we are publishing company information as it would have appeared in the 1997 Resource Guide. PMID- 10167133 TI - The proof is in the planning. How to champion IT spending. PMID- 10167134 TI - Waste not, want a lot: the new DOT medical waste regulation. PMID- 10167135 TI - Earthquakes and healthcare facilities. PMID- 10167136 TI - Protecting workers' safety and health in nursing homes. PMID- 10167137 TI - Antitrust's expanding universe. PMID- 10167138 TI - Ten grains of salt: why not rely solely on the new federal guidelines in evaluating antitrust risks. PMID- 10167140 TI - The new HEDIS boon or burden? PMID- 10167139 TI - The Medical Ethics Committee: dinosaur or phoenix? AB - Just when managed care is forcing providers to confront new ethical dilemmas, ethics committees are preoccupied with formal compliance programs. A proposal for renewal. PMID- 10167141 TI - Out of the darkness: hospitals begin to take mistakes seriously. PMID- 10167142 TI - The managed care avalanche. PMID- 10167143 TI - Price controls rest in (relative) peace. PMID- 10167144 TI - Welfare reform as we know it. PMID- 10167145 TI - Fighting Medicaid fraud: a page from Florida's rule book. PMID- 10167146 TI - TennCare: model or mayhem? PMID- 10167147 TI - 1996 state health policy survey. PMID- 10167148 TI - The "Pushmi-Pullyu" of Medicare. PMID- 10167149 TI - Human recourses: winning the support of employees in an era of limits. Medicare isn't health care's only entitlement problem. PMID- 10167150 TI - Data. Trends identified by NAPHS. National Association of Psychiatric Health Systems. PMID- 10167151 TI - Hurdles. PMID- 10167152 TI - What benefits managers should know about the Mental Health Parity Act of 1996. AB - In consideration of the statutory requirements of the Mental Health Parity Act of 1996, the author stresses that benefits managers should consider three issues. First, the financial impact of the act should be minimal for most plans. Second, minimal compliance may require more extensive changes to the plan than originally anticipated. Finally, the process of compliance offers opportunity to examine broader issues of mental health coverage. The article explains what the act does and does not require. The article concludes with a presentation of a comparative analysis of the cost impact of the act on five prototype plan designs. PMID- 10167153 TI - Collectively bargained public health benefit plans. AB - The marketplace for health benefits for public sector employees is large and complex with a great variety of approaches for providing care and a difficult patchwork of regulatory and collective bargaining regulation to deal with in designing a plan. Public sector workers' plans are subject to an additional constraint provided by the political nature of the process. The products sold to public sector plans are not regulated as ERISA plans, given the exclusion of government plans and the differential regulation of collectively bargained plans under the HMO act. This article attempts to guide the reader through some of the difficulties of this marketplace, pointing out pitfalls and opportunities where they appear. PMID- 10167154 TI - Retiree health benefits in the United States: a strategic critical management review. AB - This article provides a critical review of studies associated with retiree health benefits in the United States. An attempt is made to determine if logical conclusions or trends could be identified regarding this issue of health care policy debate. The forms of retiree health benefits are covered, as is a discussion of Medigap policies and insurance coverage for the elderly. Employer sponsored retiree benefits and the effects of supplemental coverage on the use of services are also reviewed. Lastly, a discussion and conclusion regarding this research agenda is presented with a critical analysis of the health care policy management debate for the future. PMID- 10167155 TI - Undercontribution bias in health care spending account decisions. AB - Results from this work describe 239 responses to a mailed survey regarding employee benefits decisions at a large eastern university. The primary objective of this work is to test for an undercontribution bias in health care financing decisions. The results establish the existence of an undercontribution bias in both actual employee decisions and hypothetical flexible spending account contribution decisions. We describe this bias within the context of related biases including loss aversion, mental accounting, status quo and omission biases. Surprisingly, we find a significant order effect in this study and posit that preference construction in this context is an active, reference-dependent process. In addition, results from this work demonstrate the endogenous nature of health care flexible spending account expenditures. The results have important implications both for the descriptive framework of and the normative solution to the flexible spending account contribution decision. PMID- 10167156 TI - The Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191). AB - The purpose of this article is to provide a general overview and reference source for the Health Insurance Portability and Accountability Act, which was signed into law by President Clinton last August. The focus of the article is on Title I -Improved Availability and Portability of Health Insurance Coverage, and on Title III--Tax-Related Health Provisions. The author points out that due to the trend towards an incremental approach to health care legislation, this act must be viewed as one of a series of initiatives being taken by the federal government intended to impact the cost of the U.S. health care delivery system. PMID- 10167157 TI - Professional development during a career break: building your own program. AB - Professional organizations offer healthcare quality management professionals a myriad of opportunities for professional development. Healthcare professionals taking a break from their careers can take advantage of these and other opportunities to build a program for professional development that is not job specific, with a focus on reentry into the workforce. Options include continuing education via certificate, credentialing, and fellowship programs, writing, networking, doing volunteer work, and providing resume or marketing services. PMID- 10167158 TI - Quality improvement pitfalls and how to overcome them. AB - Analysis of the quarterly quality improvement reports submitted by departments and teams at the University of New Mexico Hospital identified several common pitfalls: monitoring someone else's performance, choosing irrelevant or meaningless indicators, working with inadequate samples, changing measurement techniques or indicators too frequently, taking ineffective actions, and jumping to solutions. To overcome these pitfalls, managers and team leaders can use tools such as indicator worksheets, data collection plans, report forms, team-tracking mechanisms, and comprehensive guidelines as their guides through the quality improvement process. PMID- 10167159 TI - Using insurance claims data and medical record reviews to assess the quality of medical care. AB - This article examines the possibilities and limitations of using computerized insurance claims and outpatient medical records to evaluate a Medicaid managed care program. The quality of medical care delivered to enrollees 1 1/2 years into the MassHealth managed care program's operation is discussed in the context of an evaluation that was conducted by the University of Massachusetts-Boston's McCormack Institute in 1993. Study results suggest that these two data sources offer adequate information to determine the quality level of primary and preventive services and lead to further suggestions for evaluating care. PMID- 10167160 TI - Using beepers to keep family members involved in the patient's care. AB - The 1994 Veterans Health Administration (VHA) National Customer Feedback Survey of 43,594 recently discharged inpatients revealed that problems relating to emotional support were reported two to three more frequently by VHA patients than by patients in the private sector. The scores related to emotional support that were reported by 130 Oklahoma City Veterans Affairs Medical Center surgery respondents were the facility's least favorable scores in benchmark comparisons with all VHA surgery patients and with surgery patients at Picker Institute, a nonprofit, private sector research and education organization. These scores prompted the initiation of a successful program to loan radio and digital beepers to patients' family members. PMID- 10167161 TI - Medical management committees promote quality and cost-effective managed care. AB - MedSpan, a managed care organization, believes it should provide physicians with maximum input regarding utilization management and practice guidelines. This has been accomplished through nine committees, all of which report to a Medical Management/Quality Management Committee. This committee structure has allowed MedSpan to avoid the unilateral imposition of guidelines and has enhanced the quality of care and service while decreasing utilization and reducing costs. Examples of specific physician committee actions are included in this article. PMID- 10167162 TI - Using continuous quality improvement strategies to reduce repeated admissions for inpatient psychiatric treatment. AB - A multidisciplinary performance improvement team was chartered to examine the problem of repeated admissions to psychiatric hospitals. It was also asked to devise an intervention strategy to reduce the number of readmissions, including the number of patients with three or more admissions in a 12-month period and the number of days patients spend in hospital beds. Multivoting, benchmarking, and a review of medical records for 88 psychiatric patients who had been hospitalized three or more times in 1 year were the methods used to gather data on client characteristics. An analysis of the data suggested that these high-end users had similar patterns of service utilization prior to their hospitalizations. The team identified 11 of these patterns as triggers that appear to signal early stages of decompensation that can lead to hospitalization. The team implemented an early intervention and prevention system by using the triggers as criteria for initiating a change in treatment plans. A study of the effectiveness of the Triggers Intervention and Prevention System (TIPS) was undertaken over the next 2 years. An automated program for deriving the triggers from the emergency services database was developed. Initial results that TIPS is an effective means of reducing recidivism and that the triggers can identify high-end users. Some of the triggers were deemed to be more effective than others in the early identification of individuals who may need to be hospitalized. A comparison of hospitalization rates for the pre- and postimplementation periods of TIPS showed a significant reduction in the number of patients who had three or more hospitalizations, fewer total admissions, and a shorter average length of stay. During 1995, the triggers were successful in the early identification of all patients who had more than one admission. The teams used the Design, Measure, Assess, Improve method recommended by the Joint Commission on Accreditation of Healthcare Organizations. PMID- 10167163 TI - Physician-sponsored managed care networks: two suggestions for antitrust reform. PMID- 10167164 TI - Is antitrust anti-autonomy? PMID- 10167165 TI - Resolving consumer grievances in a managed care environment. PMID- 10167166 TI - Physician terminations in managed care: why are they occurring? How do we ensure they are just? PMID- 10167167 TI - Access to investigational treatments. PMID- 10167168 TI - Medical necessity determinations: the need for a new legal structure. PMID- 10167169 TI - Direct financial incentives in managed care: unanswered questions. PMID- 10167170 TI - Capitation & physician autonomy: master of the universe or just another prisoner's dilemma? (What can Britain's National Health Service experience teach us?) PMID- 10167171 TI - The Tay-Sachs disease screening program in the U.S. as a model for the control of genetic disease: an historical view. PMID- 10167172 TI - How are Jewish women different from all other women? Anthropological perspectives on genetic susceptibility testing for breast cancer. PMID- 10167173 TI - BRCA1: to test or not to test, that is the question. PMID- 10167174 TI - Stop gagging physicians! PMID- 10167175 TI - The corporate practice of medicine: a call for action. PMID- 10167176 TI - Clinical implications of BRCA1 genetic testing for Ashkenazi-Jewish women. PMID- 10167177 TI - A public health perspective on the control of predictive screening for breast cancer. PMID- 10167178 TI - Di Goldine Medina (The Golden Land): historical perspectives of eugenics and the east European (Ashkenazi) Jewish-American community, 1880-1925. PMID- 10167179 TI - Jewish theological and moral reflections on genetic screening: the case of BRCA1. PMID- 10167180 TI - Breast cancer, the genetic "quick fix," and the Jewish community. Ethical, legal, and social challenges. PMID- 10167181 TI - The CQI process and cultural change: a case example from the SSM system experience. PMID- 10167182 TI - At Saddleback Memorial, care maps detail birth process interventions, cutting C section rate and raising VBACs. PMID- 10167183 TI - Hypoxemia on the general care floor: an emerging risk. PMID- 10167184 TI - Risk management in a geriatric hospital. PMID- 10167185 TI - Organ procurement: charting a course through unexplored territory. PMID- 10167186 TI - Avoiding the legal pitfalls of testimonials and endorsements. PMID- 10167187 TI - Pathways: improving outcomes, not just 'cookbook medicine'. AB - A Kaiser Permanente medical director cites four benefits to be derived from using clinical guidelines: better outcomes, faster patient recovery, reduced costs, and increased physician accountability. And, he notes, physicians are free to deviate from the guidelines--so long as they can justify their actions. PMID- 10167188 TI - Using external case managers to improve care, lower costs. PMID- 10167189 TI - Getting physician buy-in to standardization efforts. AB - The healthcare industry in recent years has been aggressively developing guidelines for physicians to follow in providing patient care--and physicians have just as aggressively resisted using them, arguing they stifle creativity in addressing patients' specific needs. But with studies showing that following best practices results in better outcomes and lower costs, systems are looking for ways to bring physicians on board. And they've learned a number of things to do and do not do--among them, do involve physicians in developing the guidelines, don't lock physicians into outdated protocols. PMID- 10167190 TI - The care of the family during transport. PMID- 10167191 TI - Parents as passengers during pediatric transport. AB - INTRODUCTION: The transport environment presents a unique setting in which the feasibility, advantages, and disadvantages of passengers accompanying a patient must be assessed carefully. The purpose of this study was to describe the current practice of including parents as passengers during pediatric interfacility transport. METHODS: One-hundred-eighty-eight critical care transport programs in the United States responded to a voluntary mail survey, providing information about current policies, practices, and crew perceptions of the advantages and disadvantages of carrying parents as passengers. RESULTS: Extra seating for passengers was available in 96% of ambulances, 86% of fixed-wing aircraft, and 54% of helicopters used for pediatric transport. Parents traveled as passengers in all types of vehicles; most frequently in ambulances and fixed-wing aircraft. Twenty percent of helicopter programs allowed parent passengers on more than half of their pediatric transports in this vehicle. Advantages of parent passengers included emotional benefit for the parent and child, availability of parents for history and consent, good public relations, and having the parent present if the child dies. Disadvantages included potential parent anxiety, crew distraction, and space limitations. DISCUSSION: This study reflects the widely diverse policies, practices, and opinions relevant to this topic and confirms a need for further study. PMID- 10167192 TI - Analysis of patients discharged from receiving hospitals within 24 hours of air medical transport. AB - INTRODUCTION: Use review has become increasingly important in the current atmosphere of cost justification for air medical transport. One criterion for use review is patient discharge from receiving hospitals within 24 hours of transport. The objective of this study was to determine the frequency and characteristics of patients discharged within 24 hours of air transport; the goal was to identify particular patient types likely to be discharged soon after air transport. METHODS: Flight records from November 1994 to September 1995 were reviewed. Follow-up identified patients who were discharged within 24 hours of air medical transport; these were designated the "24-hour group." Other patients were designated the "overall group." Comparisons between groups were made using the t test, Wilcoxon rank sum, and chi-square analysis (alpha = 0.05) for the following factors: age, vital signs, Glasgow coma score, percentage of intubated patients, and percentage of trauma and scene transports. RESULTS: Of the 945 flights analyzed, 42 (4.4%) transported patients who were discharged within 24 hours of air transport. Patients in the 24-hour group were younger, less likely to be intubated, and more likely to be scene-trauma transports compared with the overall group. CONCLUSION: This study demonstrates that air medical transports meet currently accepted criteria for helicopter transport. This study suggests that inappropriate air medical transport is rare, even in patients discharged from receiving hospitals within 24 hours of air transport. PMID- 10167194 TI - Going the distance: a critical infant in need of ECMO bypass. PMID- 10167193 TI - The impact of a helicopter emergency medical services program on potential morbidity and mortality. AB - INTRODUCTION: The evaluation of the effectiveness of helicopter emergency medical services is currently a major focus of air transport research, and dispatch judgment likely will play a significant role in any research aimed at measuring outcome or impact. SETTING: Two rotor-wing programs in Alberta, Canada. METHODS: A panel of experts evaluated the effectiveness of a helicopter service in Canada. Four hundred sequential patient records were examined and categorized into four risk levels. Level 1 included patients who required critical intervention. Level 2 included patients in whom a major deterioration of vital signs could be expected. Level 3 patients were those for whom transport by an advanced life support ground unit would have been adequate. Level 4 was strictly for missions in which patient transport by any other means would have been impractical, such as remote locations (these cases were double-rated). RESULTS: Risk level 1 included 98 cases (24.5%); risk level 2, 266 cases (66.5%); risk level 3, 36 cases (9%); and risk level 4, 16 cases, two of which were rated level 1, 11 rated level 2, and three rated level 3. CONCLUSION: The results indicate that in 91% of the reviewed cases, helicopter transport was appropriate, representing a reasonable and judicious use of a helicopter emergency medical service. PMID- 10167195 TI - Benefits: one size does not fit all. PMID- 10167196 TI - Managed care's last frontier. PMID- 10167197 TI - It takes more than a phone call to manage demand. AB - While the term coined to characterize 24-hour advice lines has been copyrighted and castigated, demand management itself has grown into a major force in health care. PMID- 10167198 TI - Advice or diagnosis? A legal perspective. AB - Nurses cannot diagnose, but they can--and do--assess, inform and advise. A nurse attorney offers advice on choosing a demand management service and on understanding the sometimes-subtle distinction. PMID- 10167199 TI - A big niche for a lower notch of care. PMID- 10167201 TI - Data watch. How PPOs meet the competition. PMID- 10167200 TI - A hard look at hormone replacement. PMID- 10167202 TI - How old is too old? PMID- 10167203 TI - The numbers racket. An HMO's approval rating may not say much about its quality. PMID- 10167204 TI - The making of Orion-Georgia. GHA/JCAHO partnership aims for continuous accreditation. PMID- 10167205 TI - OIG offers new information on Medicare/Medicaid anti-kickback law. PMID- 10167206 TI - AHA's Davidson responds to President's budget proposal. PMID- 10167207 TI - South Georgia hospitals, physicians get approval to compete against insurers. PMID- 10167208 TI - Georgia Insurance Commissioner John Oxendine. PMID- 10167209 TI - Fraud and abuse advisory opinions: consider new regulations carefully before asking. PMID- 10167210 TI - The Office of the Future Project: the integration of new technology into office practice. Academic detailing through the super highway. Quebec Research Group on Medication Use in the Elderly. AB - Effective management of drug therapy in the elderly is a challenge for primary care physicians. There are 20,400 drugs approved for marketing in Canada. Most elderly patients will fill 33 prescriptions per year and take 5 different medications. To be a safe prescriber in the 1990s, physicians need to be aware that 33,000 drug interactions, 6,500 drug-disease contraindications, and 3,500 drug-allergy contraindications have been documented. Inappropriate prescribing is a problem in the elderly. At least one inappropriate prescription is given to 12% to 46% of seniors, and 25% of drug-related hospital admissions are due to prescribing errors. Half of all physicians will write at least one inappropriate prescription for an elderly patient each year, and one quarter of inappropriate prescriptions will be created by the presence of multiple prescribing physicians. Academic detailing is the most effective approach to improve physician prescribing. However, it is an expensive intervention that must be limited to a small number of drugs and conditions, and it must be continued to retain its effectiveness. Furthermore, it fails to address the problems created by multiple prescribers. In this project, we developed a prototype of the future office practice. Physicians are equipped with personal computers and expert prescribing system software. This electronic academic detailer reviews all current medications for a patient, identifies therapeutic duplications, generates alerts for 50 prescribing problems that have been identified as clinically relevant by a Canadian expert panel, suggests suitable alternatives, and reviews all new prescriptions for potential problems. Information on all prescriptions received by the physicians' elderly patients is downloaded weekly from the provincial prescription claims database, so that the primary physician is able to coordinate and manage all drugs prescribed to their patients by all physicians. The effectiveness of this intervention is being evaluated in a randomized controlled trial of 110 physicians and approximately 16,000 elderly patients in Montreal. We will test whether the intervention reduces the rate of inappropriate prescribing, as well as the rate of drug-related injuries and hospitalizations among patients treated by physicians in the experimental group. PMID- 10167211 TI - An overview of Canadian physician work force databases. AB - Physician-resource planning activities have increased dramatically in Canada since the release of the Barer-Stoddart report, "Toward Integrated Medical Resource Policies for Canada" in 1991. One of the key concepts of the Barer Stoddart report is the "medical career life cycle," beginning with entry to medical school and ending with exit from practice. To apply this concept in a planning context, it is essential to have a current information base that will contain data on numbers of physicians, where they are, what they do, and how active they are. In addition, a longitudinal capability is important for understanding issues such as retention and attrition. The objective of this article is to review and assess recent initiatives in the establishment of physician-resource databases in Canada by medical associations, governments, licensing bodies, certifying colleges, and other groups with a respect to comprehensiveness and comparability of key data elements and their ability to address key policy questions in physician-resource planning and to identify opportunities for collaboration and links. PMID- 10167212 TI - Knowledge-based interpretation of serologic tests for hepatitis on the World Wide Web. AB - HEPAXPERT is a knowledge-based system that interprets the results of routine serologic tests for infection with hepatitis A and B viruses. The following tests are included: hepatitis A virus antibodies, IgM antibodies to the hepatitis A virus, hepatitis A virus in stool, hepatitis B surface antigen and antibodies, antibodies to hepatitis B core antigen, and hepatitis B envelope antigen and antibodies. HEPAXPERT/WWW, an implementation of HEPAXPERT-III for the World Wide Web, can be reached by URL http://www.med-expert.co.at/hepax. After selecting HEPAXPERT/WWW, serologic test results can be entered and will be transferred as an E-mail message for subsequent interpretation, which is done off-line with HEPAXPERT-III. The textual interpretation is sent back via E-mail. Each qualitative test for hepatitis A and B antibodies and antigens may produce one of four possible results: positive, negative, borderline, and not tested. To cover the resulting 64 (A) and 57,344 (B) combinations of findings, the knowledge base of HEPAXPERT/WWW contains 16 rules of hepatitis A and 131 rules for hepatitis B serology interpretation. This basic knowledge is structured such that all possible combinations of findings can be interpreted, and there is no overlap in the premises underlying the rules. The reports that the system automatically generates include the transferred results of the tests; a detailed analysis of the results, including virus exposure, immunity, stage of illness, prognosis, infectiousness, and vaccination recommendation; and, as an option, an identification, to distinguish the origin of the interpretation requests. PMID- 10167213 TI - The quality of dietary information on the World Wide Web. AB - The quality of dietary information on the World Wide Web (WWW) is determined solely by the organizations and individuals who publish it. To evaluate the accuracy of nutrition resources on the Internet, a survey of WWW sites that provided dietary recommendations were reviewed and compared to the "Canadian Guidelines for Healthy Eating and Nutrition Recommendations for Canadians." Web sites were accessed using "diet," "food," and "nutrition" as keywords in searches. Of the 365 documents accessed, 167 contained dietary recommendations. Forty-five percent (n = 76) of these provided information that was not consistent with one or more of the Canadian eating standards and included information in the forms of advertisements recommending supplements, herbal remedies, weight-loss products, and promotion of specific diets. The total number of web sites that provided information that was inconsistent with Canadian guidelines per each keyword search was 25 (29.8%) for "diet," 11 (13.1%) for "food," and 48 (57.1%) for "nutrition." Sources of differing information included individual web pages (n = 31, 40.8%), private vendors (n = 44, 57.9%), and health organizations (n = 1, 1.3%). Because Internet resources continue to increase at an incredible pace, health professionals need to take an active role in this technology and develop strategies to address inconsistent dietary information provided through this avenue. PMID- 10167214 TI - DIABCARD a smart card for patients with chronic diseases. AB - Within the European Union-sponsored project DIABCARD, the core of a chip-card based medical information system for patients with chronic diseases, exemplified on diabetes mellitus, has been developed. The long-term goal of the project is to improve the medical record and the quality of care for patients with chronic diseases. The basic idea is to have a portable electronic medical record on a smart card. This will improve the communication between the different healthcare personnel and between different institutions and, at the same time, promote shared care. The DIABCARD chip-card-based medical information system will offer controlled access to the necessary and up-to-date patient record to everyone involved in the patient's treatment, and it will help reduce the constantly rising healthcare expenditure. The system first was implemented in a small version. The system architecture contains hardware, software, and orgware. It considers especially the memory of the chip card, the processor, the data structure, security functions, the operating system on the chip card, the interface between the chip card and the application, and various application areas. The DIABCARD dataset was defined via an information model, which describes the different communication processes, via acknowledged diabetes datasets and medical scenarios. It includes, among others, emergency data, data for quality assurance, and data for blood glucose self-monitoring. The first prototype has been developed, and a pilot was run for 3 months. PMID- 10167215 TI - Application of clinical workstations: functionality and usability. AB - Clinical workstations are software systems that support physicians and nurses in all their specific activities concerned with the medical care of inpatients. In the university hospital of Saarland, we are testing several commercial systems so as to whether they can give such comprehensive support. For their evaluation, we developed a list of criteria grouped in functions to support the physicians, functions to support the nurses, and general functions, together with a grading schema. Besides scope and quality of functions, the acceptance of clinical workstations strongly depends on organizational environment and human factors. To evaluate these conditions, we interviewed all people concerned with the system, using a checklist. The following are examples of problems that we detected: "Facts" (new design of work flow, eg, for examination or nursing procedures); some tasks have to be performed twice; reaction to emergencies; frequent changes of staff. Technical deficiencies (response times too long; mobile data collection was insufficient due to width of display and lack of data consistency, eg, during the doctor's visit). Psychological factors (fear of using computers; statements such as "Medical work cannot be planned" or "Too few benefits from the system"; in view of increasing "transparency," no use for electronic scheduling; insufficient understanding of work flow of automated tasks). The consequences of this study are the introduction of clinical workstations in hospital needs, as well as reengineering the business processes of the ward as a careful and intensive training of staff. This article will present and discuss methods and results of this evaluation study. PMID- 10167216 TI - Canadian community health centres and the Internet: exploring the challenges and solutions. AB - Community Health Centres (CHCs) across Canada are providing essential health and social services to many communities, and this function is becoming more vital as provinces concentrate on cutting costs and developing more economic and efficient solutions to the current healthcare system. More than 300 of these community based organizations currently serve upwards to 13% of the Canadian population, providing a wide range of services in an attempt to promote total wellness in their communities. Over one half of all CHCs are located in rural or remote areas. However, despite the apparent need for, and success of, CHCs, they are among the most underserved health provision groups in the country. Many CHCs lack critical funding and resources, particularly in the area of technology. In this Information Age, the health sector is realizing the importance of using information technologies to increase efficiency, improve services, and maintain viability. Community Health Centres, however, often do not have money for even the most basic technologies such as fax machines, let alone computers and Internet access. Community Health Centres in Canada need to be given the tools they need in order to continue providing quality health care to their communities. This article provides an overview of the current situation of CHCs in Canada vis(-)a-vis the Internet and other information technologies. Some of the practical and organizational challenges facing CHCs in this area will be discussed, as well as potential solutions that could and are being developed to overcome these barriers. It is an objective of this article to facilitate information and resource-sharing and the creation of links between CHCs across Canada. Community Health Centres may benefit from better understanding of the implications of these new technologies, discovering ways in which their peers are using the Internet, and communicating with one another in order to begin basic planning and needs assessments. As part of this overview, a brief update on the status of the HealthNet Community Access Pilot will be provided. The HealthNet Community Access Pilot is a collaborative project aimed at educating and providing CHCs across Canada with the tools to help them begin implementing Internet systems and policies within their own context. Part of this grassroots effort involves developing appropriate technical solutions, software, training materials, and support resources to help demystify and simplify the technology. Some of these tools and recommendations will be available at ITCH '96 for use by other CHCs. PMID- 10167217 TI - Lowering physician hospital resource consumption using low-cost, low-technology computing. AB - Anderson Area Medical Center physicians have been provided disease-specific and procedure-specific profiles of their practice experiences for more than 5 years. For 4 years, physicians were provided reports, in a variety of formats, detailing their clinical outcomes and consumption of hospital resources in treating patients with acute myocardial infarction (AMI), pneumonia, cholecystectomy, stroke, congestive heart failure, and total hip replacement. For the past 18 months, physicians have been provided a uniform format of monthly physician specific reporting for stroke, AMI, pneumonia, diabetes, congestive heart failure, cholecystectomy, total hip replacement, new-born delivery, angina, and hernia repair. Using only a modest PC platform with database, word processing, and graphics programs operating in a DOS environment, an effective disease reporting and procedure-reporting program is provided to medical staff with 3 person-days of effort per month. Education-based physician-practice reporting is effective in encouraging more resource-efficient decision making on the part of medical staff members. Average length of stay and total charges can be reduced significantly by providing physicians with profiles that show them their relative ranking with peers of several outcome and resource variables. Actual aggregate reductions in average total charges for each of three groups of patients profiled following educational reporting to physicians were $203,680 (AMI), $220,296 (pneumonia), and $146,832 (hip replacement). Total benefit for these three educational reports was $570,808. If educational effects persist for 1 year in the physician groups, the annualized estimate of aggregate charge reductions for 390 AMI patients, 483 pneumonia patients, and 52 hip-replacement patients is $1,568,644. Cost savings to the hospital would be near $706,000. PMID- 10167218 TI - Dealing with information accessibility and security. AB - Changing marketplace demands and healthcare reforms are bringing about the most sweeping transformation the industry has ever seen. Increased reliance on computerized information by a wide variety of users in both caregiving and administrative roles has accelerated, necessitating a new level of security. The following article explores these issues and describes how advances in information technology can be applied to provide such an environment. PMID- 10167219 TI - Information superhighway or information traffic jam for healthcare consumers? AB - The phenomenal development and growth of the information superhighway over the past few years has brought with an ever-increasing number of sites associated with health care. At the same time, community access to the Internet and multimedia technology has allowed greater access to healthcare sites by consumers wishing to find healthcare information relevant to their needs. The Internet has greater potential for improving the healthcare knowledge of the community, especially in remote areas or in parts of the community that have limited access to community health infrastructure. However, most of the current development of healthcare sites has focused on the needs of healthcare professionals rather than consumers. Indeed, with the volume of information available over the Internet, it is easy to spend hours browsing through a maze of sites with information that often is fragmented, incomplete, or only accessible with a password. Once a relevant site is located, the information often is presented as vast amounts of text with possibly some graphics. It appears little consideration is given during the development of web sites to the actual presentation of the information. For the full potential of the information superhighway to be realized in relation to health care, more consideration should be given during the development stages of web sites to how the information is presented and how to make access more streamlined. PMID- 10167220 TI - Determining physicians' knowledge and attitudes when prescribing drugs to treat gastrointestinal disorders. AB - OBJECTIVE: Peptic ulcer disease (PUD) affects 10% to 15% of the US population. The causes of PUD are many, including high acid production, low bicarbonate secretion, and infection due to Helicobacter pylori. In 1992, the Vermont Medicaid Program noted a significant increase in prescription drug expenditures, particularly in the area of treatment of PUD. The purpose of this study was to review Medicaid prescription data and to use focus group methodology to gain an understanding of rural nonacademic and semiurban academic physicians' prescribing decisions regarding the treatment of PUD. METHODS: Pharmaceutical data from 1991 and 1992, provided by the Department of Social Welfare, Medicaid Division, was reviewed. Focus group discussions were held with primary-care providers from rural and semiurban regions with Vermont. RESULTS: Pharmaceutical review revealed that expenditures increased 21% for gastrointestinal drugs from 1991 to 1992. Drug utilization review of pharmaceutical prescriptions revealed that H2 antagonists were being prescribed for greater than the recommended 6 to 8 weeks in 60% of the cases. Focus group discussions showed that rural nonacademic and urban academic physicians had similar concerns and management plans in regard to their patients with peptic ulcer disease. However, differences existed in physician perceptions regarding pharmaceutical effectiveness of various agents for the treatment of PUD. CONCLUSIONS: Physician education outreach programs should be designed to standardize treatment methodology for PUD throughout the state. This standardization of treatment could have a significant impact on healthcare costs and the ease with which patients can eradicate this disease. PMID- 10167221 TI - Harmonization of regional health data requirements in the South Pacific. AB - The South Pacific has 22 diverse countries and territories that receive various levels of assistance, training, and financial support from International, regional, and national agencies. To support various aspects of these activities, the agencies currently request health data from the Pacific Island countries and territories on systematic bases in two major fields: health program monitoring and disease surveillance. There currently is little consultation or integration between the agencies. Communication exists mostly in terms of the exchange of various types of processed information such as reports, circulars, and other publications. The Interagency Meeting on Health Information Requirements in the South Pacific took place in December 1995 in Noumea, New Caledonia, to discuss the potential for more integration and cooperation in order to ease the pressure on the data providers (the countries) and to improve the relevance, quality, and timeliness of regional health information in the Pacific. As part of the effort to deal with the problems of both the pressure on data providers and the low quality and availability of good health information, we have developed methodological tools for evaluating both health indicators and diseases subject to surveillance in order to ascertain those most suitable for public health surveillance. PMID- 10167222 TI - Site registration fee schedule and related matters for facilities transferring or receiving select agents--CDC. Notice. AB - The Centers for Disease Control and Prevention is announcing its site registration fee schedule for facilities registered under 42 CFR 72.6. This notice includes the total fee for facilities in three categories, small, medium, and large. The fee is broken down into subtotals that illustrate how the agency derived the total fee. In return for the fee, the facility receives a 3 year site registration and is subject to inspection during that time period. Also included in this notice is clarification of the exemption of certain toxins, as well as clarification of biosafety levels for certain viruses in the regulation. PMID- 10167223 TI - Removal of certain limitations on cost comparisons related to contracting out of activities at VA health-care facilities--VA. Final rule. AB - This document amends the Department of Veterans Affairs (VA) Acquisition Regulations (VAAR) by removing certain limitations on cost comparisons related to contracting out of activities at VA health-care facilities that are not direct patient care activities nor incident to direct patient care. This reflects statutory changes made by the Veterans' Health Care Eligibility Reform Act of 1996 (Pub. L. 104-262). PMID- 10167224 TI - Medicare and Medicaid programs; quarterly listing of program issuances--third quarter 1996--HCFA. Notice. AB - This notice lists HCFA manual instructions, substantive and interpretive regulations, and other Federal Register notices that were published during July, August, and September of 1996 that relate to the Medicare and Medicaid programs. It also identifies certain devices with investigational device exemption numbers approved by the Food and Drug Administration that may be potentially covered under Medicare. Section 1871(c) of the Social Security Act requires that we publish a list of Medicare issuances in the Federal Register at least every 3 months. Although we are not mandated to do so by statute, for the sake of completeness of the listing, we are including all Medicaid issuances and Medicare and Medicaid substantive and interpretive regulations (proposed and final) published during this time frame. PMID- 10167225 TI - Big green. The $1,000,000 mark is shattered, with glamour industries leading the way. PMID- 10167226 TI - Health care costs ready for takeoff? PMID- 10167228 TI - Looking at the whole. Osteopathic health care in Michigan. PMID- 10167227 TI - Don't volunteer for trouble. AB - Gone are the days when volunteer activity was limited to delivering flowers and mail to inpatient rooms. Today's volunteers extend the capacity of health care organizations to provide compassionate and caring service by staffing immunization programs, conducting health screening activities and more. With increased reliance on volunteers and increased responsibility placed on volunteers, it is important that they are protected from any personal liability that may be incurred while working on behalf of your organization. It is equally important that the organization is protected from liability incurred by the acts or omissions of its volunteers. PMID- 10167229 TI - Teamwork succeeds again. PMID- 10167230 TI - Worker classifications: the redefined role of the independent contractor. AB - Five factors to be used in determining whether a physician is subject to the requisite level of control to be classified as a hospital employee: 1. integration of the physician's services into the hospital's operations. 2. the regularity and continuity of the physician's services 3. the authority reserved by the hospital to require the physician to comply with its operating procedures 4. whether the benefits provided to regular hospital employees are available to the physician 5. whether the physician is permitted to provide services to the general public. PMID- 10167231 TI - A journey to new heights. Providing outrageous customer service. PMID- 10167232 TI - A less scary place. PMID- 10167233 TI - Scope of practice for APNs (advanced practice nurses). Discussion. AB - A bill for Advanced Practice Nurse (APN) Prescriptive Authority was introduced into the Michigan state legislature in 1996, and again in 1997. The legislation would add registered professional nurses with specialty certification to the list of health practitioners granted independent prescribing rights. Currently, licensed dentists, medical doctors, osteopathic doctors, podiatrists, certified optometrists and veterinarians comprise the list of prescribers. PMID- 10167234 TI - If you could hear what I see. PMID- 10167235 TI - Investment in people pays off. Butterworth Hospital finds getting creative gets rewards. PMID- 10167236 TI - Wireless communication. Freeing people to care for people. PMID- 10167237 TI - Team caring. AB - Here's a glimpse of other health care professionals that I, as an occupational therapist work with daily in the hospital setting. Several players must interact to provide a patient with the best care possible. Perhaps the finance department or the risk manager isn't in the "front lines" as I am, but they provide the support I need to give quality care. PMID- 10167238 TI - A cold nose can warm the heart. AB - Chase, a three-year-old golden retriever, is a show dog with a mission! For the past six months, Chase and his owner, Carol Ruby, of Orion Township, have been visiting patients on the inpatient Physical Rehabilitation Unit at Crittenton Hospital in Rochester. Chase played a key role in the creation of the unit's new Pet Therapy Program. Currently, Chase is one of three dogs whose goal is to bring smiles to the faces of patients at the hospital. PMID- 10167239 TI - Bringing calm to the storm. PMID- 10167240 TI - The evolving role. PMID- 10167241 TI - The focus of hospice. PMID- 10167242 TI - A surmountable challenge. PMID- 10167244 TI - EDI enables big cuts in supply procurement costs. AB - Many providers are turning to information technology to improve the supply procurement process as well as reduce supply utilization. These providers are saving money and time by using such technologies as EDI, the Internet, bar coding, purchasing cards and automated supply stations. PMID- 10167243 TI - Care in the new millenmium. AB - In the new millennium, the delivery of medical care will be different from today. As we begin the next thousand years of the human journey, changes in the way medical care is provided will reflect broader changes in the social, economic and political fabric of society as a whole. There are three particularly important themes that will shape how we provide care in the future. PMID- 10167245 TI - Telemedicine. Saving children's lives. PMID- 10167246 TI - Managed care. Going on line for help. PMID- 10167247 TI - The dawn of a new hardware technology. AB - Proponents say network computers offer lower costs and easier maintenance. But skeptics are not yet convinced these benefits are real. PMID- 10167248 TI - Setting the standards for his system. Interview by MargaretAnn Cross. PMID- 10167249 TI - Charting a new course in privacy. PMID- 10167250 TI - Making the case for electronic records. PMID- 10167251 TI - Outpatient electronic records. Tackling the challenges. AB - Outpatient providers have yet to widely embrace computer-based patient records systems. Many clinics and group practices are still learning about the technology, rather than actually implementing it. But pioneering organizations are reaping many benefits from having patient records on-line. And they're learning what works--and what doesn't--when making the transition from paper to electronic records. PMID- 10167252 TI - Health Data Management top 10 special report. AB - The top 10 health care information technology companies control only about 30% of the software market. Because these leading companies do not yet dominate the market, observers predict vendors will continue to consolidate. In this in-depth special report, Health Data Management profiles the 10 leading companies, ranked on their 1996 revenues. Each corporate profile offers insights from top company executives about their strategies, as well as comments from stock analysts. PMID- 10167253 TI - Guidelines for care of the dying patient: an interdisciplinary effort. PMID- 10167254 TI - The Forget-Me-Not Program: incorporating bereavement care into the continuum. PMID- 10167255 TI - Student interns help expand hospice bereavement services. PMID- 10167256 TI - Clinical pathways can help you prevent, win malpractice lawsuits. AB - By adopting critical pathways and closely adhering to nationally accepted guidelines, you can substantially reduce your risk of facing a malpractice lawsuit and increase your chances of winning if you are sued, experts say. Pathways introduced as evidence in your defense can serve as "expert testimony," establishing that you worked in accordance with an appropriate standard of care. To avoid any appearance that you breached the standard of care, make sure you document and justify any deviations from the clinical paths in place at your institution. PMID- 10167257 TI - Inpatient specialists help cut costs, reduce LOS. Hospitalists partner with case managers. AB - Inpatient specialists, or hospitalists, represent a valuable resource in helping case managers reduce costs and lower lengths of stay. At Mercy Hospital in Springfield, MA, and Park Nicollet in Minneapolis, hospitalists have largely been responsible for a 20% reduction in costs across the board for hospital stays. Because they work full time in the hospital, these physicians tend to develop stronger professional relationships with case managers than other physicians do. They're also generally more open to quality improvement efforts, experts say. Due to their greater familiarity with "hospital illnesses," hospitalists have established a strong track record for cost-efficiency in treating patients in the acute care setting. PMID- 10167258 TI - FDA weighs policing electronic patient record. AB - New regulations now being considered by the Food and Drug Administration (FDA) could affect the software you use to run your electronic patient record and electronic clinical pathway systems. The standards would impose a federal approval process on all computerized medical record programs and financial systems currently in use at hospitals. The FDA's primary focus is on commercially developed software. Although some worry that the agency will also attempt to regulate software developed in-house by hospitals, it's now likely that such software will be exempted from regulation. Although the agency has not released a final version of the regulatory standards, FDA officials expect action to be taken within the next few months. PMID- 10167259 TI - Integrating practices across the continuum of care. PMID- 10167260 TI - Lumbar discectomy path emphasizes pain control. AB - Case managers at University of Pittsburgh Medical Center have cut costs by $1,000 per case and reduced length of stay (LOS) from 4.92 days to just under two days for patients with lumbar discectomy by taking an aggressive approach to pain management. Case managers also found that patients' expectations helped drive up LOS. They prepare patients for early discharge by giving them an easy-to-read patient pathway that details the process of care. The lumbar discectomy pathway also emphasizes postoperative ambulation over bed rest, and reduces the number of individual blood tests required prior to surgery. PMID- 10167261 TI - Equity MSO offers strategic alternative for hospitals. PMID- 10167262 TI - Physician extenders fill strategic staffing role. PMID- 10167263 TI - How employers judge health plans. PMID- 10167264 TI - Time for nurses to come to the table. PMID- 10167265 TI - Facility and medical staff cooperate to stop patient outmigration. PMID- 10167266 TI - CBO official suggests tightening Medicare coverage to slow spending. PMID- 10167267 TI - How to cost effectively manage the data collection requirements for managed care. PMID- 10167268 TI - A pocket guide to proper receiving. PMID- 10167269 TI - Central commissaries. Some show a quick return on investment. PMID- 10167270 TI - High-tech entrepreneur. PMID- 10167271 TI - Joint Commission revisions: an overview. Part 1. PMID- 10167273 TI - Getting wired can link both care and coverage. PMID- 10167272 TI - Connected information networks take the paper burden off your shoulders. AB - Electronic transfer of data within health systems and between offsite facilities, including payers, is becoming a cost-effective strategy for members of the Brookfield-based Wisconsin Health Information Network. The intranet technology is particularly well-suited for managed care because it generates even greater efficiencies and allows electronic communication between newly integrated health system partners. PMID- 10167274 TI - Self-funded employers a ripe market if you accept risk. AB - Direct contracts with self-funded employers are an often overlooked market for mature PHOs seeking additional covered lives. While such ventures often require additional PHO infrastructure, the financial rewards can be significant for those up to the challenge. PMID- 10167275 TI - Pediatric PHO requires strong heart, good partner. AB - As states convert Medicaid into managed care, pediatric PHOs must change their operating dynamics to meet the challenges and take advantage of the emerging opportunities. One of the biggest questions these PHOs face is whether to start their own HMOs and risk alienating existing payers. PMID- 10167276 TI - Healthcare: a nuts and bolts look at infection control and environmental services. AB - In short, the author of this article holds that there are many forces working to upgrade facilities, assisted by a thorough administrative sanitation program to control cross-infection, that will enable them to keep their infection rates at an absolute minimum and help them to approach ever more closely their ultimate goal of curing the sick while simultaneously protecting the well. PMID- 10167277 TI - Recycling success: managed care and managed waste. PMID- 10167278 TI - Tracking program saves $$$ for hospitals. PMID- 10167279 TI - Housekeeping prognosis at St. Peter's Medical Center: excellent. PMID- 10167280 TI - OSHA issues hepatitis B disinfectant policy. PMID- 10167281 TI - Downsizing, reengineering, and restructuring: long-term implications for healthcare organizations. AB - This article provides a framework for analyzing how downsizing and reengineering have affected healthcare organizations. These approaches are reviewed, and key tools that have been used, such as across-the-board cuts, reorganizing, and redesigning, are described. Examples are drawn from healthcare as well as other business sectors. The consequences of cost reduction strategies for an organizations's performance in terms of costs, quality of services, and satisfaction of consumers and employees are explored. The case is made that an organization's context--that is, its culture, level of trust, and leadership--is an important factor that influences the effect of cost-cutting strategies. Characteristics of organizations where downsizing has a better chance of succeeding also are described. PMID- 10167282 TI - Restructuring and organization: management's role in defining organizational culture. PMID- 10167283 TI - Organizational context: the key to implementing successful cost-reduction strategies. PMID- 10167284 TI - Are we paving cowpaths? PMID- 10167285 TI - Can Prozac cut health costs? PMID- 10167286 TI - New thinking about partnerships in health care. PMID- 10167287 TI - Strengthening community linkages: a foundation for the IDS of the future. PMID- 10167289 TI - Organ harvesting raises ethical questions. PMID- 10167288 TI - Community-based market share growth strategies for ambulatory care. PMID- 10167290 TI - MIP, MIP, hooray! Medicare integrity and you. PMID- 10167291 TI - Finding value in medical intranets. PMID- 10167292 TI - Rightsizing the delivery system. AB - In the next five to 10 years, managed care penetration in large metropolitan areas and small cities could reach 90 percent, while per-member-per-month premium payments could fall to an average of $100. At the same time market demand for acute care services is expected to decline, and demand for subacute and nonacute care services will rise sharply. Most health systems are not configured to meet these emerging market demands. But one health system analyzed its market opportunities and developed rightsizing options that could help it meet market demands and improve its cost-efficiency to ensure its survival. PMID- 10167293 TI - Six steps to successful network integration. AB - Some integrated delivery systems have not been successful for a number of reasons. Substantial expenses incurred when initially purchasing physician practices, higher than anticipated operating costs, and a lack of mechanisms whereby physicians can assume leadership roles all may contribute to network failure. As a result, participants in integration efforts are continually modifying their strategies. Implementation of six specific strategies can improve the odds that integrated delivery systems will be successful: placing physicians at risk, enabling physicians to assume leadership roles and be involved in governance, strategically incorporating specialty care, managing group practices as ambulatory care businesses, building a competitive system, and continually redefining the system's strategic focus. PMID- 10167294 TI - Maximizing financial returns by meeting employer expectations. AB - Healthcare providers that understand the needs and priorities of employers that contract for managed care services can more accurately assess what strategies they need to adopt to succeed under managed care. Such strategies include determining which health plans to contract with to best meet employers' needs and which managed care products to be a part of or offer. In addition, because the number of employer self-funded health plans is growing, providers that develop working relationships directly with employers can increase their opportunities to sell and develop additional healthcare services and increase the number of enrollees to whom they provide care. PMID- 10167295 TI - HEDIS 3.0 advances health plan accountability. AB - The National Committee for Quality Assurance recently issued Health Plan Employer Data and Information Set 3.0 (HEDIS 3.0), the third version of its performance measurement system for managed care plans. This most recent version of HEDIS contains more performance measures than the previous versions and requires health plans to use uniform definitions and data-gathering procedures for commercial, Medicare, and Medicaid members. Data must be submitted in the aggregate, and individual reports must be prepared for different types of managed care products. While HEDIS 3.0 will not be able to answer all of consumers' informational needs, it will provide purchasers and consumers with more information than they had before and, thus, make health plans more accountable for the services they provide. PMID- 10167296 TI - Thinking strategically about capitation. AB - All managed care stakeholders--health plan members, employers, providers, community organizations, and government entitites--share a common interest in reducing healthcare costs while improving the quality of care health plan members receive. Although capitation is a usually thought of primarily as a payment mechanism, it can be a powerful tool providers and health plans can use to accomplish these strategic objectives and others, such as restoring and maintaining the health of plan members or improving a community's health status. For capitation to work effectively as a strategic tool, its use must be tied to a corporate agenda of partnering with stakeholders to achieve broader strategic goals. Health plans and providers must develop a partnership strategy in which each stakeholder has well-defined roles and responsibilities. The capitation structure must reinforce interdependence, shift focus from meeting organizational needs to meeting customer needs, and develop risk-driven care strategies. PMID- 10167297 TI - Analyzing and executing mergers and acquisitions. AB - Healthcare organization are consolidating at an unprecedented rate. With the number of mergers and acquisitions not likely to abate, healthcare organizations will need to become involved in strategic planning to manage the effects of this transaction activity and exert more control over the direction it will take. In particular, healthcare organizations need to know how to respond when their organizations are approached about a consolidation opportunity and how to determine whether a consolidation transaction would be strategically advantageous. Healthcare organizations can increase the chances that a consolidation will be successful by following six steps: performing a business inventory; determining the desire business profile; setting criteria for selecting a partner; identifying potential buyers and sellers; negotiating terms; and closing the transaction. PMID- 10167298 TI - Optimizing Medical reimbursement for out-of-state providers. AB - The federal law pertaining to the creation of the Medical program, USC 42, recognizes the Medicaid beneficiaries sometimes receive healthcare services at facilities outside of their home states. This law, therefore, requires that Medicaid plan provide for the inclusion of out-of-state providers in their programs. The regulation promulgated to implement this law, 42 CFR section 341.52, states the Medicaid plans must provide a mechanism for paying out-of state healthcare providers that treat the plan's beneficiaries. The law says that a state must "pay for services furnished in another state to the same extent that it would pay for services furnished within its boundaries..." However, many providers that render service to Medicaid patients from other states often do not receive the reimbursement they are entitled to because they do not carefully monitor this segment of their patient population. Healthcare providers can take steps to ensure they receive payment for the services they provide to out-of state Medicaid patients. These steps include billing for such services properly, investigating additional sources of reimbursement, appealing reimbursement decisions, and participating in bordering states' Medicaid programs as contract providers. PMID- 10167299 TI - Evaluating technology service options. AB - Four service and support options are available to healthcare organizations for maintaining their growth arsenals of medical and information technology. These options include maintaining and servicing all equipment using a facility-based biomedical engineering and MIS service department; using a combination of facility-based service and subcontracted service; expanding facility-based biomedical and MIS service departments to provide service to other healthcare organizations to achieve economies of scale; and outsourcing all maintenance, repair, and technical support services. Independent service companies and original equipment manufacturers (OEMs) are offering healthcare organizations a wider array of service and support capabilities than ever before. However, some health systems have successfully developed their own independent service organizations to take care of their own--and other healthcare organizations'- service and support needs. PMID- 10167300 TI - Creating a financially sound primary care network. AB - Primary care networks can play a pivotal role in the delivery of healthcare services and are much sought after by integrated delivery systems that are attempting to attract managed care contracts. However, not all primary care networks are attractive prospects for affiliation; some lack the ingredients for financial success that integrated delivery systems require. A primary care network can ensure its financial soundness and thereby become an attractive candidate for affiliation by meeting the requirements of effective networks. These requirements include reaching consensus on the role the network will play in the delivery system, consolidating network practice sites, paying justifiable practice acquisition prices, using nonphysician practitioners appropriately, assuming risk, offering physicians participation packages, providing incentive compensation plans, implementing integrated information technology, securing multiple payer contracts, and implementing quality assurance standards. PMID- 10167301 TI - Santa Fe provider network goes unchallenged by the DOJ. AB - After careful consideration of possible anticompetitive harm and payer reaction, the Department of Justice has chosen not to challenge as unlawful a provider controlled, nonexclusive physician network in Santa Fe, New Mexico, even though the network will include 70 percent of the area's pediatricians. Reasons for the DOJ's decision include evidence of substantial risk sharing by the physician members, an arrangement by the network to provide a different compensation system for non-member participating physicians, and the pediatricians' promise that they will participate in the network on a nonexclusive basis. In addition, the member pediatricians will be a small minority of the primary care physicians whose compensation will be paid out of one fixed revenue pool. The DOJ's decision thus signals support for a provider network model for smaller communities. PMID- 10167303 TI - EDI applications for home care agencies. PMID- 10167302 TI - Welfare reform's effect on Medicaid eligibility. PMID- 10167304 TI - Maintaining a successful career in volatile times. PMID- 10167305 TI - Charge 'heavy' theft losses at NYC hospitals; what one facility is doing. PMID- 10167306 TI - Developing a corporate safety structure after two systems merge. PMID- 10167307 TI - Emergency phone systems: an update on new developments. AB - Emergency telephones in remote locations, which allow persons needing assistance to immediately access security, are being used extensively in parking lots and garages, especially those serving hospital and college campuses. A number of new products by leading manufacturers in the field are particularly applicable to parking facilities in all industries. In this report, we'll provide details on these new products and how they are being employed. PMID- 10167308 TI - When two hospitals merge: security changes at St. Francis, Mount Sinai. PMID- 10167309 TI - Strategic options for brand-name prescription drugs when patents expire. AB - Pharmaceutical companies face a very hostile competitive environment from generic drugs once the patents on their brand name drugs expire. Depending on the country, such patents usually last 10-15 years but no sooner do the patents expire then copies of off-patent brand name drugs, called generics, are introduced, generally by smaller-size and lesser known companies, at significantly lower prices. As health care costs escalate all over the world, efforts to control medication costs have created a major market for generic prescription drugs, particularly in government funded hospitals and in dispensing general practitioner markets of the Asia Pacific and the third world. The world market for generics is estimated at US$20 billion, doubling in only five years and capturing over 30% of the market share. Because of adverse effects on sales and profitability due to the launching of generics, most research based companies that produce original brand-name patented drugs are forced to take counter measures to overcome this problem, particularly when R&D costs for new patents are skyrocketing. This paper develops a brief perspective on this problem and then examines the experiences of many multinational companies in the Singapore market in dealing with the problem. While several different approaches are identified, only one company experience appeared to work successfully and this is discussed in relative detail. PMID- 10167310 TI - Some legal and managerial strategies for managing healthcare fraud. AB - Healthcare fraud is an increasingly serious problem in the industry. The problem is complicated by disagreement over its basic causes and how it can be managed. Attempts to manage healthcare fraud introduce privacy issues as well as the proper role of the government. Even law enforcement officials appear to be undecided concerning jurisdiction and prosecution. Healthcare fraud is everyone's loss and will require the cooperation of all if it is to be controlled. The medical and legal as well as insurance organizations and the public must get involved. PMID- 10167312 TI - Patient expectations and marketing programming for OB/GYN services. AB - A regional medical center OB/GYN practice was perceived as being too large to give personalized attention. A combination of growing market potential and declining market share caused the center administrators to take a bold step and design, open, and operate a new parallel OB/GYN practice. The practice was developed based on analysis of patient perceptions and needs. Research results were used to develop a marketing program. The project involved doctors, nurses, and staff who were interested in patient perceptions and were willing to adjust health care delivery to satisfy patients' expectations. PMID- 10167311 TI - Applying the marketing concept in health care: the no-show problem. AB - This article applies the marketing concept to the no-show problem in health care. The no-show problem at a hospital-based outpatient internal medicine clinic was analyzed to determine the determinants of no-show behavior. Two surveys were conducted: a patient questionnaire, and a telephone interview of patients that had recently missed an appointment. The surveys identified the lack of transportation as an important determinant of no-show behavior among the clinic's low-income and elderly patient population. The authors suggest that effective implementation of the marketing concept requires that health care organizations offer individualized transportation services to and from their facilities. PMID- 10167313 TI - Informal and formal care for the elderly: decision determinants and their implications. AB - In this article, a model is developed of the determinants of elderly health care choice between the options of informal care (i.e., provided by family and friends) and formal care (i.e., care provided via the market). These determinants are: Expertise Capacity, Resource Capacity, Time Capacity, Economic Rewards, Psychic Rewards, Trust, and Control. This model is based on the theoretical work of Lusch, Brown, and Brunswick (1992) in the marketing literature and a variety of empirical findings in health care literature. The Lusch et al. (1992) framework models the general determinants of an entity's choice between fulfilling needs on their own (i.e., internal exchange or self-production) or going to the market to fulfill their needs (i.e., external exchange). The goal of this article is to develop understanding of formal care and informal care use decisions, and to create managerial recommendations based on a sound theoretical understanding of the issues. PMID- 10167314 TI - Cigarettes and health: historical controversies and constraints--Part I. PMID- 10167315 TI - Improving marketability of exercise programs: implications for health promotion in the workplace. AB - Musculoskeletal stress due to sedentary work has been a problem in workplaces. Exercise programs are available to help alleviate such stress; however, they have been adopted by few companies. The acceptability of these problems, that is their "marketability" will be enhanced if employee preferences regarding exercise in the workplace are taken into account during their design. A questionnaire was administered to employees engaged in sedentary work to determine employees' preferences about exercise programs in the workplace. Respondents preferred exercises that are targeted for specific body parts, have easy-to-follow instructions, are somewhat difficult but more beneficial, and can be completed in a private room. Marketability of exercise programs may be improved by focusing on these characteristics. PMID- 10167316 TI - Professional regulation. Doctors who don't deliver. PMID- 10167317 TI - General practice. A penny for your thoughts. PMID- 10167318 TI - Mental health. Back from the brink. AB - Mental healthcare in Wolverhampton had sunk to such depths that two years ago the purchasing authority was openly discussing commissioning its services from another town. Today the situation is transformed. David Jolley and colleagues explain how such marked progress was achieved. PMID- 10167319 TI - Career profile. Health promotion. Prevention as well as cure. PMID- 10167320 TI - How to stop the cancer care lottery. The stakes are high. PMID- 10167321 TI - How to stop the cancer care lottery. Patients' needs. Opening lines. PMID- 10167322 TI - How to stop the cancer care lottery. Costing Calman-Hine. Wheels within wheels. PMID- 10167323 TI - How to stop the cancer care lottery. Team work. All pulling together. PMID- 10167324 TI - Performance management. Motive power. PMID- 10167325 TI - Pay determination. The States we're in. PMID- 10167326 TI - Clinical distribution services. The big push. PMID- 10167327 TI - Re-engineering. Allied resources. PMID- 10167328 TI - On the evidence. Largely a matter of size. PMID- 10167329 TI - Speaking with the ancients. PMID- 10167331 TI - Of communities and hired hands. Interview by Joe Flower. PMID- 10167330 TI - Creating healthier communities: a compendium of models. AB - Old paradigms are hard to change. Individual leaders in discreet organizations can no longer be solely responsible for the health of the populations they serve. Citizens cannot rely on outdated models of health, in which traditional healthcare played the primary part in defining and ensuring the well-being of the members of the community. Today, to achieve a "healthier community," individuals must join with organizations and stakeholders to listen to the needs of those they serve and to broaden their idea of what creates health. The concept of the healthier communities movement is based on improving the health and quality of life of communities by forming partnerships and collaborations among public, private, and voluntary agencies and organizations. To become healthy, a community must evaluate and understand its unique needs and pool its resources--whether human, organizational, or financial--in innovative ways. Strategies need to be established to deal with the issues faced by our communities--rural, suburban, or urban, whether it is healthcare for migrant workers, domestic violence prevention projects, or health clinics for inner-city schools. Programs and services must reside where the needs are, and often those needs become apparent only when all members of the community are engaged in a dialogue and each voice can be heard. The models on the following pages illustrate the success of the healthier communities movement--when citizens, government, and community leaders commit to making health a priority for all members of the population. PMID- 10167332 TI - In support of Dr. Mom. PMID- 10167333 TI - Graceful balance on a shaky beam. Interview by Jan Harrison. PMID- 10167334 TI - Pursuing the elusive IDN. Part 2: Five high-impact steps toward an integrated delivery network. PMID- 10167335 TI - Lulled by machinery. PMID- 10167336 TI - Bandwidths, frequencies and megahertz. PMID- 10167338 TI - The DNA of dispatch. The reasons for a unified medical dispatch protocol. PMID- 10167337 TI - The most important piece of EMS equipment? The radio! PMID- 10167339 TI - In-flight medical emergencies. PMID- 10167340 TI - A herculean effort. PMID- 10167341 TI - Economic foundations of cost-effectiveness analysis. AB - To address controversies in the applications of cost-effectiveness analysis, we investigate the principles underlying the technique and discuss the implications for the evaluation of medical interventions. Using a standard von Neumann Morgenstern utility framework, we show how a cost-effectiveness criterion can be derived to guide resource allocation decisions, and how it varies with age, gender, income level, and risk aversion. Although cost-effectiveness analysis can be a useful and powerful tool for resource allocation decisions, a uniform cost effectiveness criterion that is applied to a heterogeneous population level is unlikely to yield Pareto-optimal resource allocations. PMID- 10167342 TI - The importance of patient preferences for comorbidities in cost-effectiveness analyses. AB - When using cost-effectiveness analyses to prioritize the allocation of health care resources across patients, a standard definition of effectiveness must be used. In an informal review of cost-effectiveness analyses, we found a heterogeneity in the methods used to qualify adjust years of life. Many studies do not account for the morbid conditions that patients experience other than the index condition being studied. These studies systematically overstate health benefit relative to studies that do for comorbidities. We recommend that patient preferences for comorbid conditions be incorporated into analyses to allow a consistent and facile comparison of cost-utility ratios for societal decision making. PMID- 10167343 TI - Theoretical issues in cost-effectiveness analysis. PMID- 10167344 TI - Accounting for future costs in medical cost-effectiveness analysis. AB - Most medical cost-effectiveness analyses include future costs only for related illnesses, but this approach is controversial. This paper demonstrates that cost effectiveness analysis is consistent with lifetime utility maximization only if it includes all future medical and non-medical expenditures. Estimates of the magnitude of these future costs suggest that they may substantially alter both the absolute and relative cost-effectiveness of medical interventions, particularly when an intervention increases length of life more than quality of life. In older populations, current methods overstate the cost-effectiveness of interventions which extend life compared to interventions which improve the quality of life. PMID- 10167345 TI - Health utility indices and equity considerations. AB - The aim of this paper is to propose methods that incorporate equity concerns into cost utility analysis. The focus of the paper is on QALYs, but the results apply to health utility indices in general. Two interpretations of QALYs are considered: QALYs as (von Neumann Morgenstern) utilities and QALYs as measures of health. A justification is provided for aggregating consistently scaled "QALYs as utilities" over individuals. The conditions underlying unweighted aggregation of QALYs are identified. These conditions exclude two common types of equity concern. Algorithms are proposed that take into account equity concerns and that are relatively easy to apply. PMID- 10167346 TI - Income-related inequalities in health: some international comparisons. AB - This paper presents evidence on income-related inequalities in self-assessed health in nine industrialized countries. Health interview survey data were used to construct concentration curves of self-assessed health, measured as a latent variable. Inequalities in health favoured the higher income groups and were statistically significant in all countries. Inequalities were particularly high in the United States and the United Kingdom. Amongst other European countries, Sweden, Finland and the former East Germany had the lowest inequality. Across countries, a strong association was found between inequalities in health and inequalities in income. PMID- 10167347 TI - Is an 80% to 85% utilization a realistic target for ORs? PMID- 10167348 TI - Simplicity makes St Luke's the best performer in CABG. PMID- 10167349 TI - Info specialist is needed to guide automation. PMID- 10167350 TI - Perpetual inventory aids in controlling costs. PMID- 10167351 TI - 'Breakthrough' project helps trim OR delays. PMID- 10167352 TI - Who should be performing autotransfusion? PMID- 10167353 TI - Putting a new SPIN (Sentara Physician Information System) on information systems. When was the last time you invested in your system's future? AB - Once you have a vision and strategy for the future, an information system will probably be your biggest and most important investment. Information systems that can track clinical data are critical to providing employers with the data they're demanding and doctors with the data they need. See how and why Sentara Health System developed the Sentara Physician Information System (SPIN). PMID- 10167354 TI - Look before you leap. Boards need to ask "Why?" before merging or affiliating. AB - Everybody's doing it. But you're just asking for trouble if you don't first ask yourself why you want to merge or affiliate your hospital. Boards need to have clearly defined reasons before they choose a partner. Here's a practical guide to understanding your merger motivation and identifying the right partner. PMID- 10167355 TI - How to make systems work. PMID- 10167356 TI - Gang violence. Ain't no denying it. AB - Whether you've faced up to it or not, there are gangs in your community. They're everywhere, and gang-related violence adds more than $400 million to health care costs every year. Integris Health in Oklahoma City came out of denial and found a way to get through to gangmembers in its community. It's changing--and saving lives. PMID- 10167357 TI - A nonsurgical fix for health care. Medical savings accounts may be a painless way to reduce health costs. PMID- 10167358 TI - Cyclic fatigue of hydroxyapatite-coated titanium alloy implant material--effect of crystallinity. AB - Titanium alloy (ASTM F-136) rods were coated with hydroxyapatite (HA) of 3 levels of crystallinity, which were determined by X-ray diffraction (XRD) analysis to be 60.5%, 52.8%, and 47.8%. Fourier Transform Infrared (FTIR) spectroscopy analysis showed the removal of the hydroxyl and carbonate groups as compared to the original HA powder. It appears that these changes are caused by the high temperature plasma spray coating process. Cyclic fatigue testing in a lactated Ringer's solution to 5 million cycles showed no statistical difference in calcium dissolution among the 3 crystalline levels, whereas phosphorus dissolution was lowest from the highest crystalline coating sample. The mechanical properties, however, did not change in response to fatigue loading. PMID- 10167359 TI - Biomechanical performance of a braided absorbable suture. AB - Lactomer and Polyglactin 910 sutures are both made of copolymers of lactide and glycolide. Biomechanical performance tests demonstrated superior handling characteristics of the Lactomer sutures. Using sutures comparable in size and knot construction, the Lactomer sutures exhibited knot holding force superior to the Polyglactin 910. Moreover, the low knot rundown forces encountered by the Lactomer sutures facilitated construction of secure knots that failed by breakage rather than by slippage. PMID- 10167361 TI - Potential toxicity of retrograde uterine passage of particulate matter. AB - Dusting powders are commonly used on surgical gloves, examination gloves, and condoms. In addition, they are used in diaphragms, sanitary napkins, and toiletries. These dusting powders can gain access to the abdominal cavity through the vagina or through surgical intervention. The toxicity of these dusting powders in the abdominal cavity can be divided into acute and chronic complications that may be life-threatening. The use of medical and surgical products without dusting powders is strongly recommended. PMID- 10167360 TI - Biomechanical and clinical performance of a new synthetic monofilament absorbable suture. AB - The clinical and mechanical performance of a new, monofilament, synthetic absorbable suture (Biosyn) was evaluated and compared to that of a braided synthetic absorbable suture (Vicryl). The monofilament synthetic absorbable suture was significantly stronger than the braided synthetic absorbable suture over the 4 weeks of implantation. In addition, the monofilament suture potentiated less bacterial infection than did the braided suture. The handling characteristics of the monofilament suture were superior to the braided suture because the monofilament suture required fewer throws to achieve knot security, encountered lower drag forces in fascia and colon, and had a greater double wrapped first-throw knot security. Evaluated independently in clinical settings, the monofilament sutures were found to have excellent strength, first-throw hold, knot security, passage through tissue, knot repositioning, and ease of handling. PMID- 10167362 TI - Evolution of hydrogel polymers as contact lenses, surface coatings, dressings, and drug delivery systems. AB - Hydrogel polymers are hydrophilic resins that display excellent biocompatibility, which has allowed their application in diverse fields of surgery and medicine. The original hydrogel polymer, a copolymer of 2-hydroxyethyl methacrylate and ethylene dimethacrylate, was developed by Wichterle and Lim in 1954. The development of the first soft hydrogel contact lenses by Wichterle in 1961 represented the first successful clinical application of hydrogel polymers and remains one of the most important uses of hydrogels today. The biocompatibility of hydrogel polymers may be adapted to diverse tissue types by small variations in the makeup of the polymer, including varying the type and amount of monomers and differing the amounts and characteristics of the cross-linking agents used to create the polymer chains. Hydrogels have been successfully developed for use as coatings, soft contact lenses, wound dressings, and drug delivery systems. PMID- 10167363 TI - Toxic effects of surgical glove powders on the eye. AB - Surgical gloves are commonly coated with dusting powders that have severe toxic effects on the eye. Talcum powder causes a chronic granulomatous reaction with fibrosis and adhesion formation. Cornstarch has also been shown to cause a granulomatous reaction as well as sterile endophthalmitis. These complications are preventable by the use of powder-free gloves. PMID- 10167364 TI - Implementing outcomes. PMID- 10167365 TI - Development of a school-based nutrition intervention for high school students: Gimme 5. AB - PURPOSE: To describe a 4-year intervention targeting fruit/vegetable consumption by high school students. DESIGN: This is a cohort study involving six pairs of schools (n = 12) matched on gender, race, enrollment, and location with schools randomly assigned within pairs to intervention or control conditions. SETTING: Twelve Archdiocese of New Orleans high schools. SUBJECTS: Cohort was defined as students (n = 2339) who were ninth-graders in the 1993-94 school year who provided baseline data. INTERVENTION: Four components of the intervention are: (1) school-wide media-marketing campaign, (2) school-wide meal and snack modification, (3) classroom workshops and supplementary subject matter activities, and (4) parental involvement. MEASURES: Focus groups were conducted for target population input and program development. Process evaluation included student feedback on media-marketing intervention materials and activities reported here. Process measures also included school meal participation, student characteristics, and verification of intervention activities. RESULTS: Focus groups identified barriers to increased consumption of fruit and vegetables as lack of availability, variety, and inconsistency in taste. Student attitudes were favorable regarding a school program to improve diet and parental involvement. Low consumption of fruits/vegetables was reported. After a 2-month school-wide program introduction utilizing various media-marketing materials and activities, 93% of students were aware of the program and 96% could identify the healthy eating message. CONCLUSIONS: Program development can be guided and enriched by student input via focus groups. Media-marketing activities effectively delivered health messages and attracted students' attention. Materials and activities used were acceptable channels for increasing awareness, positive attitudes, and knowledge about fruits/vegetables. PMID- 10167366 TI - Postpartum return to smoking: who is at risk and when. AB - PURPOSE: Despite high rates of spontaneous and assisted smoking cessation during pregnancy, postpartum maintenance is disappointingly low. Predictors of return to smoking remain unclear, thus limiting the development of interventions that could protect the health of women and their children. This study followed women who had participated in a prenatal smoking cessation intervention trial and successfully stopped smoking to address two aims: (1) describe the probability of relapse in confirmed quitters during the first 6 months after the birth, and (2) identify factors that increase relapse. DESIGN: Prospective design during pregnancy and retrospective report at 6 months postpartum used survival analysis with return to smoking as the dependent variable and the Cox proportional hazards regression technique. MEASURES: Questionnaires were used at the first prenatal visit and telephone interviews at the 26th week of pregnancy and 6 months postpartum. Nonsmoking after the 20th week was measured by urine cotinine tests (m = 3); nonsmoking postpartum was measured by retrospective self-report. SETTING: The setting was an HMO-based group practice in Los Angeles. SUBJECTS: Subjects were white, black, and Hispanic women (n = 127) available for follow-up. RESULTS: The proportion of the sample classified as relapsers at 6 months postpartum was 62.9%. The final model identified the following risk factors for smoking: taking puffs in late pregnancy and having friends who smoke at the first prenatal visit, less confidence in mid-pregnancy that they could maintain nonsmoking postpartum, and a partner who smokes postpartum. CONCLUSIONS: Intervention should begin in late pregnancy, and smoking networks, including partner smoking, should be addressed. PMID- 10167367 TI - Smoking behavior among adolescents in the city, suburbs, and rural areas of Shanghai. AB - PURPOSE: The study was designed to investigate differences in predisposing factors, enabling factors, reinforcing factors, and smoking behavior among middle school students living in the city, suburbs, and rural areas of Shanghai. DESIGN: A one-time cross-sectional survey design was applied in this study. SETTING: The study was conducted in 11 schools in three areas. SUBJECTS: A total number of 1116 students from these three areas participated in this study. The response rates were 92, 88, and 84% for city, suburbs, and rural areas, respectively. MEASURE: A PRECEDE instrument including predisposing, enabling, and reinforcing factors was employed to collect data. A Multivariate Analysis of Variance (MANOVA) and Multiple Regression Analysis were used to analyze the data. RESULTS: Smoking was reported by 39.8% of boys and 5.14% of girls. Students in the city of Shanghai had the best (against smoking) predisposing factors, but students in rural areas had the best (against smoking) enabling and reinforcing factors and consumed the fewest cigarettes. CONCLUSION: Results indicated that smoking behavior in students was affected strongly by enabling factors and reinforcing factors that were related to socioeconomic, cultural, and environmental influences in China. PMID- 10167368 TI - Development of a health risk appraisal for the elderly (HRA-E). AB - The purpose of this project is to develop a health risk appraisal for the elderly (HRA-E) and test its application in both medical and nonmedical settings. The HRA E system consists of a questionnaire and software for computer-generation of personalized reports to participants, 55 years and older, and their physicians. Items in the questionnaire cover a comprehensive range of content domains relevant to health promotion in the elderly. The goal of the HRA-E system is to prevent functional decline. Samples of eligible subjects from the American Association of Retired Persons (AARP), a group practice, and a senior center were extended invitations to participate. Those responding affirmatively to the invitation were given a questionnaire and evaluation form. Each person who returned the questionnaire received his or her personal report and a second evaluation form. Four months after receiving their reports, respondents were questioned about behavior changes during the interim. Preliminary findings, based on 1895 respondents, indicate that nearly all participants found the questionnaire easy to complete and were pleased with its overall length. In addition, most participants read their reports, and many planned to take action, based on report recommendations. In the next phase of this project, the intent is to refine the questionnaire, extend the intervention protocols for longitudinal application, and evaluate its impact on health-related behaviors, medical care utilization, and functional decline. PMID- 10167369 TI - Recruiting worksites to participate in a health promotion research study. AB - PURPOSE: In this study, the type and size of participating and nonparticipating worksites in a health promotion research trial were examined. DESIGN: In-person and telephone contacts were made with representatives from a random sample of eligible worksites recruited to participate in a research trial to increase fruit and vegetable consumption. SETTING: Worksites that had 250 to 2000 employees and a worksite cafeteria were recruited. SUBJECTS: Eighty-one worksites were contacted. MEASURES: A census of eligible worksites (N = 109) formed the recruitment base, and a random selection of worksites (N = 81) was personally contacted and asked to participate in the research. Information on size, type of worksite, and a worksite representative was obtained from a privately compiled list covering the greater Puget Sound area. Eligibility for the project included the presence of an onsite cafeteria at the worksite as assessed by a brief telephone call. RESULTS: Thirty-six of the contacted worksites (44.5%) agreed to participate. There were no significant differences in participation by type or size of worksite. DISCUSSION: Worksites can be recruited to participate in research trials. No particular type or size of worksite is more likely to participate. Instituting pre-randomization participation conditions may reduce post-randomization dropout by ascertaining compliance with research requirements before randomization. PMID- 10167370 TI - Dietary intake and physical activity behaviors of male and female college students. PMID- 10167371 TI - The relationship between presence of exercise equipment in the home and physical activity level. PMID- 10167372 TI - The accuracy of a tabletop blood chemistry system on healthy, young adults. PMID- 10167373 TI - Effect of a nutrition intervention on macronutrient intake in a low English proficient Hispanic sample. PMID- 10167374 TI - Can employees successfully manage their own fitness program? PMID- 10167375 TI - Reengineering practices for oral anticoagulation monitoring. PMID- 10167376 TI - How technology is shaping pharmacy benefits management. PMID- 10167377 TI - Silent contracts and silent PPOs. PMID- 10167378 TI - Patient-oriented data: the next generation in outcomes measurement. PMID- 10167379 TI - Physician perceptions of health care reform: national versus state knowledge, input and support. AB - Health care reform directly impacts physicians and the practice of medicine. A questionnaire was sent to a random sample of 2,000 physicians in the state of Florida to obtain physician perceptions of health care reform. Physician knowledge, input, and support of both state and national health care reform were reported in the lowest categorizations. Issues deemed most important for support were tort reform and physician autonomy. The approach of the Florida plan, managed competition, was viewed as ineffective in addressing the issues of cost and access. Experience with the managed competition model and objective evaluations may alter perceptions and increase physician support. PMID- 10167380 TI - A model of nonparticipation in alcohol treatment programs. AB - Why do the vast majority of those who suffer harm from drinking fail to obtain treatment? Based on a review of research literature and educational and treatment program materials, a model of nonparticipation in treatment is proposed whereby particular population groups are separated out according to whether or not they exhibit specified characteristics related to both harm from drinking and attitudes towards treatment. Eleven groups have been identified in the model, each of which has different reasons for failing to seek and/or obtain treatment. It is suggested that differing educational program messages should be sent to each group. While the model does not purport to be wholly inclusive of all nonparticipation, it offers a basis for addressing the variety of disparate groups that suffer harm from drinking but do not obtain treatment. PMID- 10167381 TI - Health care reform, managed competition, and the urban medically underserved: some preliminary questions about structure, equity, and quality care. AB - The purpose of this article is to provide some preliminary observations and discussion on several questions relating to managed competition in health and the urban medically underserved. The shift to managed competition in health care financing and delivery from an unmanaged fee-for-service system raises several critical transitional questions for those groups in the urban arena that have been traditionally medically underserved. After an overview discussion of cost dynamics in the American health care system and selected characteristics of the health care system and the urban medically underserved, the article explores several critical transitional questions relating to structure, equity and quality care considerations in managed competition and the urban medically underserved. PMID- 10167382 TI - Worry about health status among the elderly: patient management and health policy implications. AB - Health care reform depends on reducing inappropriate utilization and improving access. Elderly people, major consumers of primary care, are a place to begin reforms, but progress has been slow. We combined primary care screening questions for objective (medical condition as wellness) and subjective (perception of health as worry) health in a study of 767 elderly people in Youngstown, Ohio. The worried well (31.2%), a group likely to consume medical care inappropriately, and unconcerned ill (4.4%), a group likely to avoid seeking necessary medical care, account for more than one-third of the elderly. The unconcerned well (57.0%) and worried ill (6.9%) pose fewer problems. Family physicians can predict utilization and access problems for targeted groups (older people, minorities, and women), along with health beliefs and other indicators of health status. Although findings in this study are preliminary, they do point to positive uses in health policy and patient management. Extensive usage of the sure would require financial reimbursement to health care providers. PMID- 10167383 TI - Forecasting techniques improve hospital budgeting. PMID- 10167384 TI - End-user support improvement at Memorial Sloan-Kettering Cancer Center. PMID- 10167385 TI - The universe of workstation-empowered medicine. PMID- 10167386 TI - New partnerships: a provider/vendor relationship in the IHDN arena. PMID- 10167387 TI - Crossing another chasm: delivering on-line medical information to consumers. PMID- 10167388 TI - A discussion of the value of interactive technology for remote supervision, telemedicine, and marketing by managed care providers. PMID- 10167389 TI - Extending the provider/vendor relationship. PMID- 10167390 TI - Provider/vendor marriage: winning through cooperation. PMID- 10167391 TI - Risk-based partnering: the new provider/vendor interface. PMID- 10167392 TI - The budget deal. The easy way out. PMID- 10167393 TI - A question of quality. PMID- 10167394 TI - Novel strategies decrease ED delays. PMID- 10167395 TI - Twelve questions to ask before buying a clinical information system. PMID- 10167396 TI - Facilitate implementation of new computer systems. PMID- 10167397 TI - Pearls of wisdom from ED leaders. PMID- 10167399 TI - OSHA focusing on ergonomic hazards; help is on the Web. PMID- 10167398 TI - Latest prudent buyer clarification still not enough, says industry. PMID- 10167400 TI - Quarterly financial results of post acute/subacute companies. PMID- 10167401 TI - Regional ties help area hospitals recruit efficiently, effectively. PMID- 10167402 TI - Personalized programs recruit candidates. Attracting staff to rural hospital requires finesse. PMID- 10167403 TI - Performance appraisal critical to managed care. PMID- 10167404 TI - Help physicians adapt to performance management. PMID- 10167405 TI - Thinking of linking? Make sure the fit is good. PMID- 10167406 TI - Converting physicians to the marketing religion. PMID- 10167407 TI - Where have all the patients gone? PMID- 10167408 TI - More new doctors are seeking security, not entrepreneurship. PMID- 10167409 TI - Physician incentive plan yields resource savings. PMID- 10167411 TI - Faithful patients good for your doctors' bottom line. PMID- 10167410 TI - Don't forget key steps in your incentive plans. PMID- 10167412 TI - PSOs hunger for Medicare risk plans; the race is on. PMID- 10167413 TI - Physicians' communication skills can hone health systems' competitive edge. PMID- 10167414 TI - PSOs enable physicians to go head to head with HMOs. PMID- 10167415 TI - Physician profiling helps improve skills, productivity. PMID- 10167416 TI - Focus groups help doctors understand patient needs. PMID- 10167417 TI - Getting top talent to sign on. PMID- 10167418 TI - Rehab hospital breaks down barriers between nurses, therapists. PMID- 10167419 TI - Ease restructuring woes with communication plan. PMID- 10167420 TI - How to redesign manager's role for PFC. PMID- 10167421 TI - Looking backward gives hospital answers for the future. PMID- 10167422 TI - Signs point the way to improved patient care. PMID- 10167423 TI - Hospital slashes discharge wait time. PMID- 10167424 TI - Family-focused care revives New Jersey children's hospital. PMID- 10167425 TI - Study shows PFC increases direct patient care. PMID- 10167426 TI - Guiding health care providers during redesign. PMID- 10167427 TI - Surveys show patients fear uncaring system. PMID- 10167428 TI - Hospital succeeds with hotel-style amenities that create loyal patients. PMID- 10167429 TI - Restructure supplies around patient. PMID- 10167430 TI - American auto maker shows hospitals how to redesign systems. PMID- 10167431 TI - GM helps Ohio hospital redesign care delivery. PMID- 10167432 TI - Computer tool takes guessing out of redesign. PMID- 10167433 TI - Focus on doctor-patient relations during redesign. PMID- 10167434 TI - Physician bedside manner linked to malpractice suit. PMID- 10167435 TI - ED's paradigm shift cuts costs, streamlines care, improves quality. PMID- 10167436 TI - Common sense staff slash overtime. PMID- 10167437 TI - Flash of inspiration becomes burst of change. PMID- 10167438 TI - Is your reorganization chasing off patients? PMID- 10167439 TI - Spreading innovation. PMID- 10167440 TI - Roundtable discussion. From Denver to Derbyshire: two physician innovators. PMID- 10167441 TI - Diffusing innovation throughout the system: Mercy Health Services. PMID- 10167442 TI - Improving follow-up care for high-risk adult asthmatics--Yale New Haven Hospital. PMID- 10167444 TI - How to prevent and cope with resistance to change. AB - Resistance to workplace changes is always to be anticipated. It can be minimized by insightful planning, and overcome by competent leadership. This article provides practical advice for both planning and leadership tactics. PMID- 10167443 TI - Job descriptions and performance appraisals: perceptions of staff occupational therapists and their supervisors. AB - OBJECTIVES: The purpose of this study was to survey pediatric hospital-based staff occupational therapists and their supervisors to determine if they are satisfied when accurate staff job descriptions are reflected in the staff performance appraisals. METHODS: Satisfaction Surveys were completed by 22 sets of staff occupational therapists and their supervisors. The supervisors also completed Department Surveys for demographic information. Correlational and t test analyses were completed. Descriptive information was also reported. RESULTS: Both staff occupational therapists and supervisors appear generally satisfied with the job descriptions and performance appraisals they utilize. Only staff therapists' responses were found to indicate relationships between job description accuracy and performance appraisal satisfaction and job description performance appraisal correspondence and satisfaction with the performance appraisal. CONCLUSION: Staff satisfaction with job descriptions and performance appraisals was high. Data regarding content of these documents may provide useful information to department directors who wish to revise their documents and increase employee satisfaction. PMID- 10167445 TI - Send me a memo on it; or better yet, don't. AB - Memos are a simple and effective form of communication in the health care system. Memos can strengthen group performance and praise individual behavior. However, all too frequently memos can be time-consuming, inefficient, and even harmful to effective interpersonal communication. The prudent manager should guard against a memo that is too long, will be taken offensively, will be perceived as negative, or is written when the manager is angry. In the long run, verbal communication is usually more effective than a memo delivered in haste. PMID- 10167446 TI - Creating a climate of mutual respect among employees: a workshop design. AB - An organizational climate that fosters mutual respect can be created. But respect does not mean the same thing to all people. This article describes a workshop design that guides facilitators through the process of examining individual and group behaviors related to respect, and for creating individual and organization wide approaches for getting respect and giving it. Readers will learn how to conduct this nine-step workshop. They will learn how to guide participants in the development of their personal, individual prescriptions for getting and giving respect, and in the establishment of consensus regarding their own organizational climate. PMID- 10167447 TI - Motivating the paraprofessional in long-term care. AB - Motivating the paraprofessional employee in the long-term care setting is one of the biggest challenges facing health care supervisors. Unlike their counterparts in industry, whose work may produce tangible results and rewards, long-term care professionals often must face patients who show little or no change over time. Supervisors must have understanding and knowledge of motivational techniques that will involve and challenge paraprofessionals. PMID- 10167448 TI - Team-based participation in the hiring process. AB - In most health care settings today, effective patient service results from medical staff members working together as a high performance team. These teams evolve through the process of hiring employees who combine the necessary technical skills, knowledge, and abilities (SKAs) to perform the job and whose interpersonal attributes will add value to services provided by the team. This article promotes the concept that those who are in the best position to determine whether a job candidate will become a productive team member are, in most cases, the team members themselves. Discussion includes types of teams and degree of member involvement. For those health care professionals interested in using greater team-based participation in employment matters, specific advantages and realistic challenges are provided. PMID- 10167449 TI - Another dimension of patient-centered care delivery: understanding the nature of demand. AB - In designing effective and efficient care delivery systems, health care practitioners should address two major perspectives to patient-focused care--the micro approach, relating to the transaction between providers and health care consumers, and the macro approach, which focuses on understanding the nature of demand, as groups of consumers collectively select and use health care services. By better understanding the nature of demand, health care providers hold the key to designing more effective delivery systems and also the power to manage the demand for services, which may result in highly efficient care delivery. PMID- 10167450 TI - Employee recognition: a little oil on the troubled waters of change. AB - Employee recognition practices and programs have suffered during the recent years of reengineering and downsizing. Frequently seen as a frill or as a direct cost that does not generate a direct benefit, recognition is often among the first expenses to go in a budget-cutting exercise. However, simple recognition can be an extremely powerful employee motivation tool. Regardless of how recognition might be treated at the organizational level, there remains much the individual supervisor can do to recognize employee accomplishments and thus enhance motivation and performance. PMID- 10167451 TI - Reengineering hospitals: evidence from the field. AB - Current estimates suggest that over sixty percent of all U.S. hospitals are involved in reengineering initiatives. The level of investment is staggering; literally billions of dollars are being spent in the name of reengineering. Surprisingly little research has been reported, however, aimed at clarifying how this money is being spent (i.e., the content of reengineering) or identifying the management practices that facilitate or impede implementation. This paper summarizes extensive field research from fourteen hospitals across the country aimed at developing a clearer picture of reengineering. The research identifies seven components of hospital reengineering present in various configurations in the hospitals examined. Methods for facilitating reengineering are explored and eight major barriers recognized. Site specific examples are provided to illustrate how the facilitators and barriers work in practice. PMID- 10167452 TI - Patient satisfaction with ambulatory healthcare services: waiting time and filling time. AB - Customer satisfaction is an important measure of service quality in healthcare organizations. This study investigated the relationship between patient waiting and satisfaction with ambulatory healthcare services, with waiting times divided into segments of the patient-care episode. Two management techniques to alter perceptions of waiting were also examined. Regression models measuring the effect of waiting times on satisfaction found that the total time spent waiting for the clinician was the most significant predictor of patient satisfaction. Informing patients how long their wait would be and being occupied during the wait were also significant predictors of patient satisfaction. These results show that waiting times, even if they cannot be shortened, can be managed more effectively to improve patient satisfaction. PMID- 10167453 TI - Organizational determinants of service quality in nursing homes. AB - This study analyzed four prominent organizational factors thought to influence service quality in nursing homes. Perceptions of service quality were collected from over 400 family members who regularly visited residents in 41 nursing homes. Service quality was measured along five dimensions identified by marketing research on customers in service industries. These five dimensions were responsiveness, reliability, assurance, empathy, and tangibles. Perceptions of service quality exhibited significant associations with each of the four organizational factors: ownership, funding mix, facility size, and nurse staffing. Implications for health services administration are discussed. PMID- 10167454 TI - What is the cost of controlling quality? Activity-based cost accounting offers an answer. AB - Achieving high-quality outcomes in healthcare organizations requires effective systems of control. Such systems consist of formal and informal transactions between patients, providers, payors, and policymakers, among others (Shortell 1972; Stiles and Mick 1997). One method for evaluating the suitability of control oriented transactions to tasks is to compare the costs of controlling the quality of the good or service produced to the cost of its material and labor inputs. Activity-based cost (ABC) accounting provides the methodology for explicating the causal relationship between healthcare organizations' control-oriented transactions, the services whose quality they ensure, and the costs of both control activities and services delivered. Understanding these relationships is of vital importance to those charged with evaluating the feasibility of proposed managed care contracts, new product lines, and existing service configurations. In this article, we explain why traditional accounting practices are poorly suited to accomplishing the control function in today's healthcare arena, highlight activity-based costing's potential to redress the shortcomings of conventional practice, and elaborate the strategic importance of adopting the new methodology. PMID- 10167455 TI - Components of the costs of controlling quality: a transaction cost economics approach. AB - This article identifies the components that contribute to a healthcare organization's costs in controlling quality. A central tenet of our argument is that at its core, quality is the result of a series of transactions among members of a diverse network. Transaction cost economics is applied internally to analyze intraorganizational transactions that contribute to quality control, and questions for future research are posed. PMID- 10167456 TI - Organizational citizenship behavior among hospital employees: a multidimensional analysis involving job satisfaction and organizational commitment. AB - As hospitals continue to face intense pressure to control operating costs, many have resorted to staff reductions and other redesign efforts. The remaining employees are frequently asked to do more with less. In these uncertain times, it is important that hospital administrators understand the concept of organizational citizenship behavior (OCB) and attempt to attract and retain those employees capable of exhibiting such behaviors. This study examined the relationships between three organizational commitment components, as well as job satisfaction (including specific facet measures) and two separate forms of OCB. Usefulness analyses indicated that satisfaction with coworkers and affective commitment were the two most important predictors of one dimension of citizenship behavior, as each construct contributed unique variance in the dependent variable. Implications for future research and practice are provided. PMID- 10167457 TI - A circular organization chart promotes a hospital-wide focus on teams. AB - Our Lady of the Way Hospital, like most hospitals in the late 1980s and early 1990s, exemplified the bureaucratic organization represented by the traditional "line and box organization chart." Additionally, as in most small hospitals, the CEO of Our Lady of the Way Hospital--a 39-bed, JCAHO accredited, general, acute care hospital in Martin, Kentucky--had direct management responsibility for several functional departments. In 1992, administration replaced the traditional, hierarchical organization chart with a circular structure that reflected its increased reliance on team processes throughout the organization. The new structure also significantly reduced the number of reporting assignments to the CEO. This article describes the hospital's transition to a team-based organization, illustrates the application of a circular organization chart, and assesses its value and limitations. PMID- 10167458 TI - Managing clinical integration in integrated delivery systems: a framework for action. AB - An integrated delivery system (IDS) in healthcare must coordinate patient care across multiple functions, activities, and operating units. To achieve this clinical integration, senior management confronts many challenges. This paper uses a cross-functional-process (CFP) framework to discuss these challenges. There are ten CFPs that fall into three categories: planning processes (strategy formulation, program adaptation, budget formulation), organizational processes (authority and influence, client management, conflict resolution, motivation, and cultural maintenance), and measurement and reporting processes (financial and programmatic). Each process typically spans several functional units. Senior management must consider how to improve both the functioning of each CFP, as well as its "fit" with the other nine. The result can be greater clinical integration, improved cost management, and more coordinated care for enrollees. PMID- 10167459 TI - Engineering organizations. PMID- 10167460 TI - HRT, BMD, and CA: boning up on estrogen. PMID- 10167461 TI - Getting a handle on adverse drug events. PMID- 10167462 TI - The dollars and sense of poison control centers. PMID- 10167463 TI - POLs with profits, Part 1. Are you missing out on a valuable profit center? PMID- 10167464 TI - A chemistry department in transition. How we became a reference laboratory. AB - By analyzing the arrival times of specimens and reorganizing laboratory instruments to accommodate a higher volume of tests, the author's chemistry department was able to profit from the additional reference testing it was able to handle. PMID- 10167465 TI - The great divide. PMID- 10167467 TI - A practical approach to reducing your costs in clinical chemistry testing. PMID- 10167466 TI - Successful aging in America--Part 3. Socioeconomic factors affecting health status in the aging adult. A primer for medical laboratory managers. PMID- 10167468 TI - Flexible staffing in the microbiology lab. PMID- 10167469 TI - Alternative finance programs improve self-pay collections. PMID- 10167470 TI - Health care futures. What lies ahead? Where are we going? Panel discussion. AB - Who would have guessed that managed care would dominate the health care industry in the final two decades of the millennium? That physicians would be joining labor unions? Or that they would be going back to school to become Fellows of the American College of Physician Executives? To find out what may be in store for health care in America five to 10 years hence, The Physician Executive asked nine health care experts to participate in a two-part panel discussion. Here's what they see ahead in managed care, information technology, and biotechnology. Part 2 will appear in the July/August Issue of The Physician Executive. PMID- 10167471 TI - The five stages of managed care. Strategies for physicians in health care's market revolution. AB - What are the five stages of managed care? From "Can't Spell HMO" to Managed Cooperation, each stage has predictable market events and strategic responses. At every stage, a new set of relationships evolves among the major players, including physicians and hospitals, HMOs and insurers, and employers and government. At each higher level of managed care penetration, the players restructure their relationships as they seek to control their market and their destiny. PMID- 10167472 TI - Managed care matures. What's behind the wave of anti-HMO legislation? AB - At first glance, it may appear as if managed care itself may be doomed. The avalanche of bills, measures, initiatives, Federal regulations, etc., seemed overwhelming in late 1996. Did this, in fact, portend a national shift away from managed care? What does the consumer protection and regulatory activity really mean? What directions for the future can be identified? This article seeks to answer those questions and highlights a case study of "reform gone awry" that may hold lessons for the national scene. The anti-HMO legislation activity does not represent a repudiation of managed care. Rather, it may be seen as a maturing of the entire process of redefining our medical delivery and financing system. PMID- 10167473 TI - The managed care world order. The revolution is here. AB - What are the belief clashes caused by the shift from a fee-for-service medical setting to a managed care environment? Right now, most physicians are enculturated in the old world order that emphasizes physician autonomy, control, security, and specialness. Physicians feel squeezed--by third-party payers wanting to be involved in the decision-making process of care delivery and by a new focus on teams versus the captain of the ship role. When traditional expectations clash with a changing reality, most people feel stressed. Physicians are no exception. If physicians have clear and realistic expectations, they can better cope with the uncertainties they face. And, the only realistic expectation in the medical profession is increasing uncertainty. Here are 10 predictions of what is happening in the health care industry--a list of the belief clashes that are so unsettling to those practicing medicine. PMID- 10167474 TI - Managed care. Preserving the quality of physician work life. AB - The cost reduction imperative of managed care represents a formidable challenge to the culture of medicine and the values of physicians. The unpredictability of practice has culminated in widespread disenchantment--medicine has lost some of the allure which previously attracted the "best and the brightest." To achieve the goal of increasing the work force of qualified primary care physicians, we must ensure that the practice of medicine remains intellectually challenging, personally gratifying, and that its demands are reasonable and realistic. PMID- 10167475 TI - Physician manpower needs under managed care. How to determine the need for MDs by specialty. AB - The concern in the last quarter century in the United States over the shortage of physicians has now been supplanted by the fear of an excess number of doctors, particularly among the subspecialists. This article outlines four methodologies to be used in parallel to determine by clinical specialty whether a predetermined population base has an inadequate, sufficient, or excess number of physicians. Based on various assumptions, physician-population ratios per 100,000 persons for 28 clinical disciplines are supplied. Possibly the most intriguing questions as a result of this study are whether a broad spectrum of HMOs will use general internists or family practitioners as their prime "gatekeepers;" and, whether, in the long-run, the fiscal incentives inherent in the managed care concept will result in a more frugal utilization of physician services. PMID- 10167476 TI - Physician organizations. Part 1: A report from the trenches of a start-up PO. AB - How has Community Health Partners, a physician organization based in Kansas City, turned the corner as it rolls into the second year of operation? The biggest indicator is that CHP hammered out the city's first professional risk contracts and the PO has grown from 23 to more than 50 physician member/owners. Looking back, there are at least 10 reasons why CHP made it this far. These are not reasons you learn about in medical school or an MBA program. There is no one-size fits-all template for building POs. No fixed organizational chart. No neon signs pointing to the best capital partner. Part I explores five reasons for success, such as having a strong board and physician leadership, as well as educating participating physicians about capitation and affiliating with any hospital or payer that really knows how to partner with physicians. Part 2 will focus on five more lessons learned from the trenches of a start up PO. PMID- 10167477 TI - Habits of mind for turbulent times. AB - How do you deal with change--in either personal circumstances or in the turbulent health care environment? Do you rail against the variables that seem to put you in the uncomfortable situation, blame yourself, take it personally? Are there ways to start looking at change differently and more effectively? Here's the key: It's all weather. Whatever you can't control, no matter who does it or why, is just part of the weather--where you are right now. How do we treat weather? We try to find out as much as we can about what's coming, but we keep its unpredictability in mind. We prepare for its extremes as wisely as possible. We grieve any losses it causes us, and celebrate the lovely spring days and quiet summer evenings it gives us. And never once do we take it personally, think that the weather is out to get us, or that lousy weather means that somehow we have failed. We just know that its not personal. PMID- 10167478 TI - Hirer, hiree, beware: new hiring trends. AB - What are the three hiring trends that trouble both human resources people and top management? From the "exploding job offer," to new hires who renege on their acceptances, to "front loading," these trends are predicted to continue, so where does this leave you in the salary negotiation process? From communicating often to interviewing more carefully, some suggestions are explored to help physician executives address these disturbing trends. There's still a sub rosa theory that only undesirable candidates back out of an offer. But that's no longer true and that attitude may make you short-handed! PMID- 10167479 TI - The emerging health care landscape. The drivers of health care. AB - Other than hold on tight, how does a health care system successfully weather the turbulent conditions facing the industry? This article focuses on key drivers in the three main segments of the health care market: employer-based, commercial/ERISA, and Medicare and Medicaid. Effectively managing the dynamics within these markets will be vital to a delivery system's success and its ability to withstand the forces of change. Given the market changes that are occurring, how does an academic medical center, emerging hospital-sponsored IDS, or a large physician clinic trying to develop a system determine the necessary components and structure? What kind of system will work best? The considerations are numerous and explored in this article. PMID- 10167480 TI - Don't be an accidental physician executive. AB - How can physicians begin crafting a career with intention and careful thought? Before you go leafing through The Physician Executive or the New England Journal of Medicine's Positions sections, you'll need to conduct a thorough career evaluation of where you are and where you want to go. There are more career tracks in more types of organizations available to you as a physician executive than ever before. There is also considerable turbulence, creating unexpected opportunities. The times have never been better for aggressive, energetic physician executives who want to move up and out. PMID- 10167481 TI - Where does informatics fit in health care organizations? AB - Why is medical informatics important to health care leaders? As an emerging science, informatics focuses on applying computing and communication technology to decision making for clinicians and managers. It enhances the understanding of how information and communication systems can impact the work health care managers must accomplish. As the cost of technology for digital information management continues to decline, organizations and individuals will look for ways to offset the human costs of managing and conveying information. The way of the paper medical record is being replaced by the less expensive and more efficient digital information systems. Leaders of health care organizations need to look for every opportunity to deploy networks and computers to reduce the labor costs of data collection, storage, retrieval, and analysis. PMID- 10167482 TI - Telling it straight. HealthEast, St. Paul, MN. AB - HealthEast promised its employees that they would be the first to know if plans for system restructuring would affect jobs. Unfortunately, the night before the big announcement, the media got wind of the story. The ten o'clock news carried sensational--and inaccurate--stories about multiple hospital closings and large scale layoffs. Employees had every right to be mad. Instead, straight-forward communication and a long history of employee support saved the day. Soon, employees were writing angry letters to local papers accusing them of crossing the lines of decency. PMID- 10167483 TI - Senior market tough to crack. MacNeal Health Network, Berwyn, IL. AB - Seniors, often thought of as a stodgy, conservative market, actually constitute one of the most vibrant, diverse age groups of all. Here's how people who have discovered the secrets of the mature market use that diversity to their advantage. PMID- 10167484 TI - Educational marketing saves hospital. Wake Medical Center, Raleigh, NC. AB - Wake Medical Center launches a politically savvy battle to stave off a proposed sale to an out-of-state conglomerate. Emotion, it finds, can work better than reason. PMID- 10167485 TI - Marketer's forgotten challenge: physician recruitment. AB - As marketing department missions continue to expand, more and more people are finding themselves not just recruiting customers, but doctors. The good news: May of the tips and tricks of direct marketing can be used to reach out to in-demand physicians. PMID- 10167486 TI - Third generation Web marketing. Siskin Hospital for Physical Rehabilitation, Chattanooga, TN. AB - The marketing challenge for rehabilitation centers lies in teaching patients and referring physicians about what rehab is. Siskin Hospital for Physical Rehabilitation has just started a Web site that aims to meet the challenge. PMID- 10167487 TI - Women's wellness club a trusted communications vehicle. Methodist Healthcare system, San Antonio, TX. AB - Methodist Healthcare System's long-standing WomanPlus program came in handy when the system announced its new partnership with Columbia/HCA. Already faithful consumers got the news through already established mediums. PMID- 10167488 TI - Where marketing meets managed care ... hospital-based fitness center launched with simple marketing. Moore Regional Hospital, Pinehurst, NC. AB - Hospital marketers these days often are called on to run political campaigns and do other tasks they'd never anticipated. Now they're probably going to be selling health club memberships, too. PMID- 10167489 TI - Small group insurance reform: how are state programs measuring up? AB - In the past decade, states have responded to the health insurance needs of small businesses by launching a number of reforms. According to authors Michael Morrisey and Gail Jensen, more than 30 states have implemented "bare-bones" policies that seek to make minimum-benefit, affordable coverage available to small employers. Almost all states have enacted legislation modifying the underwriting practices that insurers may use with respect to such things as pre existing conditions and occupational exclusions. Other states have provided tax or employer subsidies. But despite the efforts of the states, the authors found the state policies have had little success. Drawing from a survey found that the few employers who were aware of the programs found them to be unappealing. In discovering what doesn't work, the authors are able to suggest remedies for the states' small group insurance ills, such as offering long-term instead of short term subsidies. PMID- 10167490 TI - Winners and losers under medical savings accounts. AB - As legislators wait to see how the MSA approach to health care reform plays out in the laboratory of the states, authors Marilyn Moon, Len M. Nichols and Susan Wall have put the numbers to work. The researchers simulated the effects of introducing MSAs into the health insurance market. What they found is what critics of MSAs suspected: As the young and healthy shift to MSAs, the premiums for those left in the remaining insurance pool will escalate. However, the authors conclude that if you are male, young and healthy, you stand to gain a lot from the MSA experiment. PMID- 10167491 TI - New survey reveals rise in savvy equipment buyers. PMID- 10167492 TI - Good fit! Materials managers connect the pieces at the nation's top IDNs. PMID- 10167493 TI - Cutting costs or cutting corners? Cardiac cath reuse. PMID- 10167494 TI - Agencies seek discussion about reuse. No silence, please! PMID- 10167495 TI - Reach the bottom line on reuse. Weights and balances. PMID- 10167496 TI - Policies for the reuse of disposables. Reprocessing road map. PMID- 10167497 TI - Ask tough questions before going outside. The third degree. PMID- 10167498 TI - The right chemistry? Vendors weigh in on sterilant safety. PMID- 10167499 TI - The right stuff. Good questions match the candidate on the job. PMID- 10167500 TI - Sometimes sterile gowns are just too much! PMID- 10167501 TI - Doing lunch. Small talk sparks big savings. PMID- 10167502 TI - Stats. Five degrees of integrations. PMID- 10167503 TI - Internet strategies being implemented by pharmaceutical companies. PMID- 10167504 TI - Facts and figures. Chronic obstructive pulmonary disease revisited. PMID- 10167505 TI - Managed care stock index. Declines, corrections, and crashes: where are we now? PMID- 10167506 TI - A conversation with Cary Sennett, MD. PMID- 10167507 TI - Home health care: a growing industry continues to flourish. PMID- 10167508 TI - The reincarnation of disease management. PMID- 10167509 TI - Can community pharmacies contribute to managed care disease management programs? PMID- 10167510 TI - Acupuncture and herbalism on the American health care scene. AB - The increasing demand for treatment by alternative care practitioners has resulted in MCOs marketing networks of acupuncturists, herbalists, massage therapy specialists, and others to their members. However, before an alternative provider network is considered, one must understand the comparisons and differences between conventional biomedical-based therapy and alternative care techniques. This is the first part of a two-part article exploring these issues. PMID- 10167511 TI - Trends in health insurance coverage. AB - This Issue Brief presents data on trends in health insurance coverage between 1987-1995. In 1995, 70.7 percent of the nonelderly population had private health insurance coverage, compared with 75.9 percent in 1987. During this period, the percentage of the nonelderly population with employment-based health insurance declined from 69.2 percent to 63.8 percent, while the percentage covered by Medicaid program increased from 8.6 percent to 12.5 percent. The percentage of the nonelderly population without any form of health insurance increased from 14.8 percent in 1987 to 17.4 percent, or 40.3 million individuals, in 1995. The percentage of nonelderly Americans with employment-based coverage fell for both individuals with coverage in their own name and those with coverage as dependents. In 1995, 32.7 percent of the nonelderly population had coverage in their own name, compared with 33.8 percent in 1987. Similarly, 31.1 percent of the nonelderly population had employment-based health insurance as dependents in 1995, compared with 35.4 percent in 1987. One of the most important determinants of health insurance coverage is work status and hours of work. While employment based health insurance received directly from worker's employer decreased between 1987 and 1995 from 66.2 percent of 63.2 percent among full-time workers, the percentage of part-time workers with employment-based health insurance coverage in their own name increased from 17.2 percent to 20.1 percent. The percentage of workers with dependent coverage fell for both full-time and part-time workers, as did the percentage of nonworkers with dependent coverage. Workers in the manufacturing industry are most likely to have employment-based health insurance; they are also the workers most likely to have experienced a decrease in employment-based coverage between 1987 and 1995. In contrast, workers employed in most of the service sectors, experienced an increase in employment-based health insurance, self-employed workers experienced a decrease, and government workers experienced a slight increase. Cost is one of the primary factors contributing to the decline in employment-based health insurance coverage. While health insurance premium cost increases have slowed during the past three years, many health care analysts are predicting an increase in health insurance premiums during the next few years. Inflationary pressure may come from health care providers, health insurers, consumers, and/or policymakers. If inflationary pressure increases health insurance premiums, we are likely to see a continued decline in employment based health insurance and a subsequent increase in both Medicaid and uninsured populations. PMID- 10167512 TI - Outpatient clinics without the paperwork. AB - Chicago's MacNeal Health Network made several smart moves to get physician buy-in for a computer-based patient record system in its outpatient clinics. It didn't take long before paper-based patient records all but disappeared. PMID- 10167513 TI - In a changing environment, network backbone upgrades emerge as a wise investment. AB - The numbers, locations and needs of users change constantly, but they'll always want more bandwidth. Many experts say that upgrading to higher-speed backbones seems to be the smart investment for unsettled times. PMID- 10167514 TI - Measuring the value of health care dollars. PMID- 10167515 TI - Toward the year 2000 and the double-digit dilemma. PMID- 10167516 TI - The virtual focus group: decision support systems. Discussion. PMID- 10167517 TI - What works. Linking ICU costs and clinical data saves $1 million at Lehigh Valley. PMID- 10167518 TI - What works. Maine's BMS trims Medicaid, saves $3.5 million. PMID- 10167519 TI - What works. COLD technology cuts printing, paper expenses for Dallas' Presbyterian. PMID- 10167521 TI - Hotlist. Outcomes, quality measurement. PMID- 10167520 TI - What works. Telephone reminder system works with patient software to reduce no show rate. PMID- 10167522 TI - Viewpoint. Converging technologies and increased productivity. PMID- 10167523 TI - Medicaid program; third party liability (TPL) cost-effectiveness waivers--HCFA. Correcting amendment. AB - This document makes technical corrections to final regulations published on July 10, 1995, at 60 FR 35498, concerning Medicaid agencies' actions where third party liability (TPL) may exist for expenditures for medical assistance covered under the State plan. PMID- 10167524 TI - Health care programs: fraud and abuse; revised PRO sanctions for failing to meet statutory obligations--HHS. Final rule. AB - This final rule addresses revised procedures governing the imposition and adjudication of program sanctions, based on recommendations from State utilization and quality control peer review organizations (PROs), resulting from enactment of sections 214 and 231(f) of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. PMID- 10167525 TI - Medicare program; establishment of an expedited review process for Medicare beneficiaries enrolled in health maintenance organizations, competitive medical plans, and health care prepayment plans--HCFA. Final rule with comment period. AB - This final rule with comment period establishes a new administrative review requirement for Medicare beneficiaries enrolled in health maintenance organizations (HMOs), competitive medical plans (CMPs), and health care prepayment plans (HCPPs). This rule implements section 1876(c)(5) of the Social Security Act, which specifies the appeal and grievance rights for Medicare enrollees in HMOs and CMPs. This rule requires that an HMO, CMP, or HCPP establish and maintain, as part of the health plan's appeals procedures, an expedited process for making organization determinations and reconsidered determinations when an adverse determination could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. This rule also revises the definition of appealable determinations to clarify that it includes a decision to discontinue services. PMID- 10167526 TI - Statement of organization, functions, and delegations of authority--HCFA. PMID- 10167527 TI - Medicare program; update of the reasonable compensation equivalent limits for services furnished by physicians--HCFA. Notice. AB - This notice sets forth updated payment limits on the amount of allowable compensation for services furnished by physicians to providers that are not covered by the prospective payment system or per resident payments for graduate medical education. These services are paid by Medicare on a reasonable cost basis. The revised reasonable compensation equivalent limits are based on updated economic index data and replace the limits that were published in the Federal Register on February 20, 1985 (50 FR 7123). PMID- 10167528 TI - Medicare program; Medicare appeals of individual claims--HCFA. Final rule with comment period. AB - Under section 1869 of the Social Security Act, Medicare beneficiaries and, under certain circumstances, providers or suppliers of health care services may appeal adverse determinations regarding claims for benefits under Medicare Part A or Part B. This rule expands our regulations to recognize the right of Part B appellants to a hearing before an administrative law judge (ALJ) for claims if at least $500 remains in dispute and the right to judicial review of an adverse ALJ decision if at least $1,000 remains in controversy. Also, this rule codifies in regulations: Limitations on the review by ALJs and the courts of certain national coverage determinations, and the statutory authority for an expedited appeals process under Part A and Part B. PMID- 10167529 TI - Medicare and Medicaid programs; quarterly listing of program issuances; fourth quarter 1996--HCFA. Notice. AB - This notice lists HCFA manual instructions, substantive and interpretive regulations, and other Federal Register notices that were published during October, November, and December of 1996 that relate to the Medicare and Medicaid programs. It also indicates certain devices with investigational device exemption numbers approved by the Food and Drug Administration that may be potentially covered under Medicare. Section 1871(c) of the Social Security Act requires that we publish a list of Medicare issuances in the Federal Register at least every 3 months. Although we are not mandated to do so by statute, for the sake of completeness of the listing, we are including all Medicaid issuances and Medicare and Medicaid substantive and interpretive regulations (proposed and final) published during this time frame. PMID- 10167530 TI - Medicaid program; allocation of enhanced federal matching funds for increased administrative costs resulting from welfare reform--HCFA. Notice with comment period. AB - This notice with comment period announces the methodology used to determine the allocation, among the States and certain Territories, of a $500 million fund to assist them with the additional expenses attributable to eligibility determinations incurred as a result of the provisions of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, which decouples Medicaid eligibility from receipt of cash assistance for families and children. Also, it announces the actual allocation amount for each State and Territory. The special fund is available for matching a State's or Territory's allowable administrative expenditures incurred only during Federal fiscal years 1997 through 2000, and only during the first 12 calendar quarters in which the State's Temporary Assistance to Needy Families program, which replaced the Aid to Families with Dependent Children program, is in effect after August 21, 1996. PMID- 10167531 TI - Reimbursement rates for calendar year 1997--IHS. PMID- 10167532 TI - Program exclusions: April 1997--OIG, HHS. Notice of program exclusions. PMID- 10167533 TI - Medical devices; reports of corrections and removals--FDA. Final rule. AB - The Food and Drug Administration (FDA) is issuing a final rule to establish procedures for implementing the reports of corrections and removals provisions of the Safe Medical Devices Act of 1990 (the SMDA) by requiring that manufacturers, importers, and distributors report promptly to FDA any corrections or removals of a device undertaken to reduce a risk to health posed by the device or to remedy a violation of the Federal Food, Drug, and Cosmetic Act (the act) caused by the device which may present a risk to health. FDA believes that this action is necessary to protect the public health by ensuring that the agency has current and complete information regarding those actions taken to reduce risks to health caused by the devices. Reports of such actions will improve the agency's ability to evaluate device-related problems and to take prompt action against potentially dangerous devices. PMID- 10167534 TI - Medicare program; electronic cost reporting for skilled nursing facilities and home health agencies; correction--HCFA. Final rule; correction. AB - This document corrects the final rule published January 2, 1997 (62 FR 26) that added the requirement that, for cost reporting periods ending on or after February 1, 1997, most skilled nursing facilities and home health agencies must submit cost reports currently required under the Medicare regulations in a standardized electronic format. The final rule also provided for a delay or waiver of this requirement where implementation would result in financial hardship for a provider. This document is necessary to conform the description of the rule in the preamble to the regulations text. PMID- 10167535 TI - Approval of the Commission on Office Laboratory Accreditation for Immunohematology--HCFA. Notice. AB - This notice announces the approval of the Commission on Office Laboratory Accreditation (COLA), which is an accrediting organization for clinical laboratories under the Clinical Laboratory Improvement Amendments (CLIA) program, for the addition of the full specialty of immunohematology. This approval adds immunohematology to the specialties and subspecialties approved by HCFA in a notice published in the Federal Register on December 23, 1993 (58 FR 68148). We have found that the accreditation process of this organization provides reasonable assurance that the laboratories accredited by it for immunohematology meet the conditions required by Federal law and regulations. Consequently, laboratories that voluntarily become accredited by COLA for the specialty of immunohematology in lieu of receiving direct Federal oversight and continue to meet COLA requirements would meet the CLIA immunohematology condition level requirements for laboratories. These laboratories performing immunohematology testing are not subject to routine inspection by State survey agencies to determine their compliance with applicable Federal requirements. They are, however, subject to validation and complaint investigation surveys. PMID- 10167536 TI - Interagency Committee for Medical Records (ICMR); automation of medical standard form 558--GSA. Guideline on automating medical standard forms. PMID- 10167537 TI - Interagency Committee for Medical Records (ICMR); automation of medical standard form 526--GSA. Guideline on automating medical standard forms. PMID- 10167538 TI - Interagency Committee for Medical Records (ICMR). Automation of medical optional form 523B--GSA. Guideline on automating medical standard forms. PMID- 10167539 TI - Harvard Pilgrim Health Care--leading the competition and growing. AB - New England's largest HMO wants to be even bigger. The product of a 1995 merger, Harvard Pilgrim is seeking ways to reduce per-member-per-month costs, creating new health plans with greater choice of providers, changing physician relationships from staff-model to group practice and looking at other merger opportunities. PMID- 10167540 TI - Information systems on the Internet: time to make the move. AB - World Wide Web-based systems are the way to go, say the experts. They are less costly and often more flexible than internal systems. And, the experts say, concerns about security and speed, though justified, need not stop organizations from making the switch. PMID- 10167541 TI - Using PICOS workshops to identify and eliminate waste. AB - "Any human activity that absorbs resources but creates no value," says Maureen Bisognano of the Institute for Healthcare Improvement, "is waste." At war with waste--in healthcare as well as in the automobile industry--is General Motors Corp. The battle plan is an accelerated change process known as PICOS. In a four step, three-and-one-half-day workshop, GM facilitators work with teams from the healthcare organization to identify waste and plan ways to get rid of it. See if you can identify, within your organization, the seven types of waste they attack- then read about systems that have used PICOS successfully in battle. PMID- 10167542 TI - Sailing beyond safe harbors? Ask the experts. PMID- 10167543 TI - Never say downscale. Assisted living may be more affordable than you think. PMID- 10167544 TI - 1997 salary survey. The going rate. Contemporary surveys the earnings of industry nursing staff. PMID- 10167545 TI - Dueling cultures. Is your company heading for an acquisition? Here's how to protect your own hide. PMID- 10167546 TI - Strength in numbers or antitrust trouble? PMID- 10167547 TI - Cutting a piece of the long-term care pie. PMID- 10167548 TI - Five minutes with Ira Byock. Interview by Yvonne Parsons. PMID- 10167549 TI - Looking for win-win contracting? Tap new 'bricks and mortar' of health care. AB - Negotiating a win-win contract with payers is based on three factors for hospitals and physicians: predicting utilization rates based on demographic information; identifying treatment guidelines that generate the best outcomes at the lowest price; taking a "partnership" mindset when working with payers and when hospitals and physicians work together. PMID- 10167550 TI - Bedeviled by details? Heed these dos and don'ts. PMID- 10167551 TI - Ten steps to developing more accurate capitation. AB - Successful contracting requires mastering the art of presenting a good capitation proposal to payers. Do it right and your PHO can reap the rewards; do it wrong and trouble follows. Here are the keys outlined by one of the nation's experts. PMID- 10167552 TI - Going global puts everyone on same incentive page. AB - Payment schemes vary widely among hospitals and physicians, and one of the key goals of a PHO is to make payments equitable. One method of doing this is bundling services under a global pricing structure, which helps align incentives for both sets of providers. The result often is greater medical and financial efficiencies. PMID- 10167553 TI - Accreditation lets PHO stand out from the pack. PMID- 10167554 TI - Medicare managed care has huge rewards if you navigate problems. AB - Medicare managed care is one of the hottest elements of the health care industry, and offers great opportunities for profits- and losses. The key to avoiding the latter is knowing when to take the leap into Medicare capitation and then having the resources and efficiencies in place to make it profitable. PMID- 10167555 TI - Keep capitated Medicare as a separate business. PMID- 10167556 TI - Questionnaire helps keep Medicare patients healthy. AB - An Illinois PHO association targets ill capitated Medicare enrollees early to prevent illnesses from getting worse and resulting in a high-cost medical episode. The health system does this by mailing a health status questionnaire to each new enrollee and assigning case managers to those in the poorest health. PMID- 10167557 TI - If you build a solid incentive plan, resource-savings will come. AB - Proper financial incentives for physicians can often mean the difference between success and failure for health systems with efficiency driven capitated contracts. Tying physician bonuses to specific behaviors that generate efficiency and quality is an increasingly popular way to achieve positive financial and clinical output. PMID- 10167558 TI - Don't forget key steps in your incentive plans. PMID- 10167559 TI - Super PHOs provide clout and added efficiencies. AB - Joining or forming a super PHO can increase the attractiveness to payers through broader geographic coverage and also generate administrative efficiencies for the individual PHOs. The key is to make sure the organization adds value to the managed care product and is not just a cartel to leverage payers. PMID- 10167560 TI - Trust in super PHO contracting is vital. PMID- 10167561 TI - Expected HMO premium increase: more money for hospitals, physicians? AB - Lagging HMO revenues and profits over the past few years have resulted in declining or stagnant reimbursement rates paid to providers nationally. Over the next year, however, average national premium rates are expected to rise, giving HMOs more financial flexibility and providers reason to be cautiously optimistic about possible increases paid to hospitals and physicians. PMID- 10167562 TI - Is managed care diverting money for patient care? PMID- 10167563 TI - PHOs, PSOs may take stronger roles in Medicare risk. AB - Congress is considering giving physician-hospital organizations (PHOs) and other provider-sponsored organizations (PSOs) the right to contract directly for Medicare managed care. But the feds aren't likely to loosen the standards by much. All PSOs, including PHOs, will face a tough screening process. Hostile market factors also could swerve some providers away from controlling physician owned risk plans. PMID- 10167564 TI - Provider network replaces 'old way' of managed care. AB - The provider-sponsored Yellowstone Community Health Plan in Billings, MT, has discovered success by breaking many of the traditional rules in setting up a capitated insurance product. Key is to hold all parties accountable and to dissolve historic communication barriers. PMID- 10167565 TI - Positive attitude and confidence key to finding that super talent you need. PMID- 10167566 TI - Analyze practice needs when you computerize. PMID- 10167567 TI - Search for physician execs could give sticker shock. PMID- 10167568 TI - When cultures collide: how to meld practice styles. PMID- 10167569 TI - Awkward moments present marketing challenges. PMID- 10167570 TI - Outsourcing billing eases major practice hassle. PMID- 10167572 TI - Amenities, services attract physicians and patients. PMID- 10167571 TI - The feds are watching your doctors; compliance plan can ease their woes. PMID- 10167573 TI - Effective expansion means keeping doctors happy. PMID- 10167574 TI - Design outpatient centers to please patients, doctors. PMID- 10167575 TI - Physician demand calls for aggressive recruiting. PMID- 10167576 TI - Complexity of integration means PRP (physicians relations professional) opportunities. PMID- 10167577 TI - Information systems compendium. PMID- 10167578 TI - Coopers & Lybrand Study: executive compensation in HMOs. Executive compensation continues to generate controversy. PMID- 10167579 TI - Arrest that man ... aged care doctor. Do MD executives practice medicine by making decisions? PMID- 10167580 TI - A detailed analysis of the costs of a JCAHO survey. PMID- 10167581 TI - The myth of managed care. Moving beyond managing costs to really managing care. AB - Today's managed care manages costs, not care. Care is lopsided with costly physician and provider control of the information, decision-making and treatment processes that are built on outdated fee-for-service incentives. Fast moving providers who exploit opportunities to redesign care, shifting more responsibility and control to non-physician providers and to patients will gain a major competitive advantage. These providers are much more likely to stand out from their peers, enabling them to attract patients and contracts. PMID- 10167582 TI - Hiring an outside consultant--when and how to do it. Interview by Neil Baum. PMID- 10167583 TI - Fallon ER facilitator program: managed care in the ER setting. AB - Managed care systems have traditionally found ER management issues difficult to address. Patients view these facilities as points of consistent, easy, and reliable care. Providers see these facilities as necessary off load points from busy practices for problems whose intensity or complexity would overwhelm their office work flow. Emergency Department physicians understand their roles as nondiscriminate passive recipients of all patient flow through their facilities. These same providers also recognize a huge liability potential for both missed diagnosis and for perceived inadequate/unsafe treatment plans such as non hospitalization when hospitalization was needed. PMID- 10167584 TI - Citrus Valley Health Partners: toward community health improvement. PMID- 10167585 TI - Case management: beyond the walls. AB - Managed care and capitation will become increasingly familiar in the Central Valley of California as managed care arrangements capture more of the marketshare. This type of healthcare environment presents a myriad of opportunities for case management to affect quality and cost outcomes within healthcare organizations. Assessment skills (clinical outcomes), client-provider relationship (member satisfaction), and resource coordination (cost containment) are three key elements underlying the role of the case manager, making the role components congruent with the needs of a managed care population. As payers continue to mandate outcomes measurement, case management beyond the walls or outside the inpatient setting is a technique that will increasingly be used to document that the diverse needs of high-risk patients are met. PMID- 10167586 TI - Legal assessment: when credentialing becomes selective contracting. PMID- 10167587 TI - Quality improvement? PMID- 10167588 TI - Hospital-based physicians--independent contractor or ? AB - The attack by the Internal Revenue Service on the classification of workers who operate as independent contractors has continued unabated over the last nine years, and despite increased congressional concern regarding the Internal Revenue Service's handling of independent contractor audits, every business that utilizes the services of independent contractors should assume that they, in time, will be audited by the Internal Revenue Service. PMID- 10167589 TI - The pride of North Myrtle Beach. A South Carolina squad captures the EMS Gold Award. PMID- 10167590 TI - Get with the program! How to evaluate your public-education efforts. PMID- 10167591 TI - Trapped? How to negotiate the EMS ethics maze. PMID- 10167592 TI - A call to action. Violent deaths are preventable when information is available. AB - Collecting these variables, along with routine EMS data, will enhance analysis of the interpersonal violence problem. To assume that this information will be obtained further along in the health-care delivery chain jeopardizes its validity, since there is a likelihood that the story may change. Surveillance or ongoing data collection allow for better estimates and enhanced knowledge about the cost of violence to the health-care system. Timely data are needed to identify important shifts in injury patterns, as well as newly emerging problems. For example, a community may observe an increase in the use of baseball bats as weapons. That information could become vital to prevention. As EMS providers, you are in a unique position to augment public-health surveillance of interpersonal violence by virtue of the fact that you are often the first on scene and can collect data that may not be routinely collected. Without this type of information, planning, implementation and evaluation of successful violence prevention reduction efforts continue to present a major challenge to public health systems. PMID- 10167593 TI - Candid camera. You can use video to record--and learn from--your mistakes. PMID- 10167594 TI - What's it worth? A general manager's guide to valuation. AB - Behind every major resource-allocation decision a company makes lies some calculation of what that move is worth. So it is not surprising that valuation is the financial analytical skill general managers want to learn more than any other. Managers whose formal training is more than a few years old, however, are likely to have learned approaches that are becoming obsolete. What do generalists need in an updated valuation tool kit? In the 1970s, discounted-cash-flow analysis (DCF) emerged as best practice for valuing corporate assets. And one version of DCF-using the weighted-average cost of capital (WACC)-became the standard. Over the years, WACC has been used by most companies as a one-size-fits all valuation tool. Today the WACC standard is insufficient. Improvements in computers and new theoretical insights have given rise to tools that outperform WACC in the three basic types of valuation problems managers face. Timothy Luehrman presents an overview of the three tools, explaining how they work and when to use them. For valuing operations, the DCF methodology of adjusted present value allows managers to break a problem into pieces that make managerial sense. For valuing opportunities, option pricing captures the contingent nature of investments in areas such as R&D and marketing. And for valuing ownership claims, the tool of equity cash flows helps managers value their company's stake in a joint venture, a strategic alliance, or an investment that uses project financing. PMID- 10167595 TI - Using APV (adjusted present value): a better tool for valuing operations. AB - Anyone who learned valuation techniques more than a few years ago is probably due for a refresher course. For the past 25 years, managers have been taught that the best practice for valuing assets-that is, an existing business, factory, product line, or market position-is to use a discounted-cash-flow (DCF) methodology. That is still true. But the particular version of DCF that has been accepted as the standard-using the weighted-average cost of capital (WACC)-is now obsolete. Today's better alternative, adjusted present value (APV), is especially versatile and reliable. It will likely replace WACC as the DCF methodology of choice among generalists. Like WACC, APV is used to value operations, or assets-in-place-that is, any existing asset that will generate a stream of future cash flows. Timothy Luehrman explains APV and walks readers through a case example designed to teach them how to use it. He argues that APV always works when WACC does-and sometimes when WACC doesn't, because it requires fewer restrictive assumptions. And APV is less prone to yield serious errors than WACC is. But, most important, general managers will find that APV's power lies in the managerially relevant information it provides. APV can help managers analyze not only how much an asset is worth but also where the value comes from. PMID- 10167596 TI - The IT system that couldn't deliver. AB - Diana Sullivan, CIO of Lenox Insurance, thought she had done her job when, after three years of hard work, she had delivered Lifexpress on time and on budget. A sophisticated computer-aided system, it enabled Lenox's 10,000-plus agents to do everything from establish a prospect's financial profile, to select the most appropriate products from the company's myriad policies, to generate all the paperwork needed to close a sale. But now Sullivan's boss, CFO Clay Fontana, seemed to be holding her accountable not only for the creation and implementation of the system but for realizing its business goals as well. And Lenox's CEO, James Bennett, appeared to concur. Two of Lenox's competitors had launched similar systems and were training their agents on them at a faster clip. Fontana and Bennett made it clear they believed it to be Sullivan's problem that Lifexpress wasn't boosting sales productivity as much as management had expected. "It's your system," Fontana had said. "We made this tremendous investment based on your recommendations." A 20-year veteran information systems executive, Sullivan knew going into this job that computers had never been one of Lenox's strengths. And she had taken what she felt were the appropriate steps to bring the company up to speed. In this hypothetical case study, Sullivan and the other top executives at Lenox must decide who should be responsible for realizing the business goals of information technology projects. Should Sullivan have gone about the project in another way? Should Fontana and Bennett be playing more active roles? Five experts weigh in with their advice for Sullivan and for Lenox's management. PMID- 10167597 TI - The parable of the Sadhu. 1983. AB - When does a group have responsibility for the well-being of an individual? And what are the differences between the ethics of the individual and the ethics of the corporation? Those are the questions Bowen McCoy wanted readers to explore in this HBR Classic, first published in September-October 1983. In 1982, McCoy spent several months hiking through Nepal. Midway through the difficult trek, as he and several others were preparing to attain the highest point of their climb, they encountered the body of an Indian holy man, or sadhu. Wearing little clothing and shivering in the bitter cold, he was barely alive. McCoy and the other travelers who included individuals from Japan, New Zealand, and Switzerland, as well as local Nepali guides and porters-immediately wrapped him in warm clothing and gave him food and drink. A few members of the group broke off to help move the sadhu down toward a village two days' journey away, but they soon left him in order to continue their way up the slope. What happened to the sadhu? In his retrospective commentary, McCoy notes that he never learned the answer to that question. Instead, the sadhu's story only raises more questions. On the Himalayan slope, a collection of individuals was unprepared for a sudden dilemma. They all "did their bit," but the group was not organized enough to take ultimate responsibility for a life. How, asks McCoy in a broader context, do we prepare our organizations and institutions so they will respond appropriately to ethical crises? PMID- 10167598 TI - Reshaping an industry: Lockheed Martin's survival story. AB - In most industries, the loss of a few percentage points in the market is a severe setback, even a catastrophe. The U.S. defense industry has seen more than 50% of its market disappear, and the companies that make up the industry have faced the need for the equivalent of self-administered surgery with no insurance, no anesthetic, and no assurance of long-term health. In 1995, Martin Marietta and Lockheed combined to form Lockheed Martin. That company has emerged in a most coveted role: survivor. In fact, it has seen its stock price nearly double in less than two years. In this article, CEO Norman Augustine relates the company's experience and offers some difficult-and painful-prescriptions. For example, his first piece of advice: Read the tea leaves. The tremors of change in the defense industry began not when the Soviet Union imploded but when a new term entered the business lexicon: financial engineering. After narrow escapes from takeover attempts, both Martin Marietta and Lockheed learned that forced restructurings signal problems ahead. Companies in turbulent industries need road maps-even when there don't seem to be any roads. And they must seize the opportunities for making large changes that upheaval provides. But companies such as Lockheed Martin can't afford to be distracted by change. It's easier said than done, but managers must stay focused on their business, their customers, and their most important asset: employees. Companies in technology-driven industries must reinvent themselves continually. The bad news is that change requires hard decisions. The good news is that success awaits organizations willing to make those decisions. PMID- 10167599 TI - Patient Safety Act could bring one more quality standard. PMID- 10167600 TI - Nurses' report card project under way. PMID- 10167601 TI - Acquisitions to undergo closer scrutiny. PMID- 10167602 TI - Complications paint incomplete quality picture. PMID- 10167603 TI - Re-shaping services. The doctors dilemma. PMID- 10167604 TI - Treatment advances. Can more be less? PMID- 10167605 TI - Intensive care costs. Cash and carry. PMID- 10167606 TI - General practice. Time out. PMID- 10167607 TI - Ethnic health needs. A matter of interpretation. PMID- 10167608 TI - Wound dressing prices holding steady. PMID- 10167610 TI - Purchasers face the rest of 1997 with confidence. PMID- 10167609 TI - No fear: materials managers outsource work, keep control. PMID- 10167611 TI - The use of outcome assessment: the clinician's concerns. AB - In the last few years increasing attention has been paid to outcome assessment within effectiveness studies, policy analysis and quality management. Dimensions of patients outcome that can be discerned are mortality, clinical parameters, health status and patient satisfaction. Some critical remarks have been placed on outcome assessment by clinicians. They have doubts on the relevance of outcome assessment, mainly because of the ambiguous relationship between process and outcome, especially regarding the dimension of health status. Furthermore, they are concerned about submitting individual patients to policy and clinical guidelines that are derived from outcome assessment of a group of patients. Arguably, what is good for society or for groups need not to be so beneficial to individual patients. To better involve clinicians in outcome assessment, knowledge is required on the extent to which an individual patient belongs to the population for which clinical and policy guidelines are used. Furthermore, more research is needed regarding the relationship between process and outcome, and regarding the connection between the outcome dimensions of clinical parameters, health status and satisfaction. PMID- 10167612 TI - Strengthening local health care management in Bolivian districts through participatory operational research. AB - The purpose of this article is to demonstrate how the use of a participatory health care management and problem-related research methodology may help strengthen health service management and the capacities of local health care personnel. The text refers to five studies carried out in three Bolivian health districts from 1993-1995, in an Operational Research Project, conducted by an Italian N.G.O. (Cooperazione Internazionale) in agreement with the local Ministry of Health and P.A.H.O./W.H.O. The object of these studies was to assess the main problems in health care delivery and to define and implement appropriate solutions. The studies utilized a methodology based on the principles of operational research and continuous quality improvement. During the process some positive aspects and difficulties were met. The positive aspects were: the applied character of the research focused on the solution of a problem; the study of a problem related to health service management; the use of modern and simple techniques adapted to local knowledge; on-the-job training of health care personnel during the research process. Lack of a generic 'culture of research' and poor health personnel training were the main difficulties encountered. National health authorities should take these points into account to define or readjust policies on health service research, health workers' academic education and in-service training. Insisting on developing human resources and allowing them to achieve and expand their potential is the key factor for getting developing countries out of their current crisis and toward reaching a truly human and sustainable development. PMID- 10167613 TI - Strategic constraints in health informatics: are expectations realistic? AB - In response to demands to enhance the efficiency and accountability of health systems, a range of different information technologies are being promoted. These technologies include integrated hospital systems, community health information networks and data repositories. However, the record of such technologies inside and outside the health industry suggest that such technologies cannot necessarily be relied on. The reason identified is that information systems are inherently logical and rational systems, and often come into conflict with the less rational social systems of organizations. Health information is identified in terms of three basic dimensions of information; that associated with managers; with professionals; and, with patients. The information of these dimensions are focused on very different objectives, have different structures and functions and are controlled by very different social processes. The information is also very complex and diverse within the dimensions. In the clinical encounter the clinician draws on specialist expertise, satisfies administrative requirements, and provides a clinical record. Thus, these dimensions converge at that point. However, collecting information is costly, and an efficient service demands economy in data collection. However, the technologies being promoted demand 'complete' data acquisition based on consistent and stable data definitions and data structures. The article argues that there is, thus, a conflict between the requirements of these technologies, and the realities of providing efficient services within a changing organizational, professional and social environment. PMID- 10167614 TI - Medical guidelines: a valid and reliable management tool? AB - Medical practice guidelines are one instrument to improve either quality care or to encourage efficient health care production. To achieve these goals they have to be valid, reliable, clinically applicable, clear, and timely revised. This article checks whether current efforts to develop and establish guidelines meet these criteria. Unfortunately, it turns out that especially the compliance of the first two criteria is problematic. It is concluded that medical guidelines are, as yet, neither a scientifically sound way to improve quality care nor a ready means to improve efficient care production. Approaches to complement these efforts are therefore discussed. PMID- 10167615 TI - Applying management strategies in molecular epidemiology field studies. AB - In conducting field studies of human exposure, we have encountered significant methodological challenges. The management strategy our group developed to conduct two recent studies of environmental health utilizes a collaborative study design process and innovative protocol management tools, and emphasizes community outreach. We present here the phases of planning, development and realization of two studies--one conducted in an environmentally contaminated area, and another in an occupational setting. We show how the use of this management strategy increases the efficiency of field operations and improves variability assessment. PMID- 10167616 TI - This monopoly is state-approved. Maine Heart Surgical Associates. PMID- 10167617 TI - When a medical mistake becomes a media event. Interview by Mark Crane. PMID- 10167618 TI - I'll never look down on IMGs again. PMID- 10167619 TI - Managed care. Is physician discontent beginning to boil? PMID- 10167620 TI - The pitfalls of cut-rate malpractice coverage. PMID- 10167621 TI - Five noncompliant patients who will sue you. PMID- 10167622 TI - The fight over Medicare fees gets nasty. PMID- 10167623 TI - Find out what patients really think of you. PMID- 10167624 TI - Get HMOs to take your complaints seriously. PMID- 10167625 TI - Value-based leadership. A prescription for reforming the American health care system. AB - Many reforms have been suggested for health care in the last 30 years yet they are mainly treating symptoms rather than getting at the root cause of the problems. The underlying problem is a lack of vision for the health care system. There is no comprehensive, uniform vision of American medicine rooted in the needs of our society. This vision should be based on the values that significantly challenge physicians: patient satisfaction, patient empowerment, cost effectiveness and the appropriate use of resources, patent access, and continuous quality improvement based on appropriate data techniques. PMID- 10167626 TI - Complexity theory 101. AB - Health care exhibits the same attributes of self-organization that are evident in the world in general. Systems are at a critical state where there is change and upheaval in all dimensions. Health care is inching closer to a major reorganization as the fundamental issues of cost, access and quality are moving toward a critical state. This article explores some of the aspects of complexity and how they are impacting the future of the health care system. PMID- 10167627 TI - Group-level ethics in managed care. AB - Managed care, the newest scheme for health care delivery, is under fire for skimping on quality, hiding information from patients and restricting free choice of providers. Medical group managers now face ethical questions quite unlike the medical ethics taught in medical schools. The new questions are about how the entire network of U.S. health care institutions work. Five principles can guide an appropriate ethics for this group-level reflection: 1) institutions are means to support the common-wealth, not ends in themselves; 2) people have a right to shape their health care options; 3) competition does not exclude collaboration; 4) a proper cost-benefit analysis will regard the entire community, not merely one institution; and 5) mission statements should be written by the people involved in delivering the care. PMID- 10167628 TI - The value of job analysis, job description and performance. AB - All companies, regardless of size, are faced with the same employment concerns. Efficient personnel management requires the use of three human resource techniques--job analysis, job description and performance appraisal. These techniques and tools are not for large practices only. Small groups can obtain the same benefits by employing these performance control measures. Job analysis allows for the development of a compensation system. Job descriptions summarize the most important duties. Performance appraisals help reward outstanding work. PMID- 10167629 TI - Selecting practice management information systems. AB - Despite enormous advances in information systems, the process by which most medical practices select them has remained virtually unchanged for decades: the request for proposal (RFP). Unfortunately, vendors have learned ways to minimize the value of RFP checklists to where purchasers now learn little about the system functionality. The authors describe a selection methodology that replaces the RFP with scored demos, reviews of vendor user manuals and mathematically structured reference checking. In a recent selection process at a major medical center, these techniques yielded greater user buy-in and favorable contract terms as well. PMID- 10167630 TI - Are you ready for Medicare reform? PMID- 10167631 TI - Activity-based costing management in a private practice setting. AB - Activity-based costing is a method of calculating cost of a service, focusing on operations. It gives quick and tangible cost information to operations and financial managers. While this method has be used more in the manufacturing area, it is gaining acceptance in the medical practice. This article describes activity based costing and illustrates how to start utilizing it in a practice. PMID- 10167632 TI - Re-engineering physical therapy. PMID- 10167633 TI - Doc-owned health plans struggle to go it alone. PMID- 10167634 TI - A push for standards. Provider coalition proposes guidelines for health plans. PMID- 10167635 TI - GOP moves toward restoring immigrant Medicaid funds. PMID- 10167636 TI - Afflicting HMOs. Why do media ignore managed care's achievements to focus on horror stories? PMID- 10167637 TI - HMO makeover. Are managed care's efforts to overhaul its image too little, too late? AB - The HMO industry is on a mission to repair its battered image. Led by the America Association of Health Plans, the campaign includes patient-centered policy statements and an emphasis on involving doctors in quality programs. Some observers detect signs of improvement, but many industry insiders are wondering if the effort is too little, too late. PMID- 10167638 TI - Opening access. HMOs' new tack leaves question, 'Where's the managed care?'. PMID- 10167639 TI - Trouble for HMOs? Survey: customer satisfaction falls as markets mature. PMID- 10167640 TI - Cutting their losses. Hostile market prompts nursing homes to file Chapter 11. PMID- 10167641 TI - Keeping the heat on. Hospitals fight to avoid being frozen by Medicare cuts. PMID- 10167642 TI - 3 groups back AHA library. PMID- 10167643 TI - Budget musk is in the air. Here's what the healthcare players want as Washington engages in its yearly ritual. PMID- 10167644 TI - Crime and healthcare. AB - When charges were made last summer against 12 men affiliated with a New Jersey based third-party administrator firm, headlines trumpeted the arrests as the first major case of organized crime infiltrating the healthcare industry. While law enforcement experts don't believe the mob has established a major role in healthcare, they acknowledge the $1 trillion-a-year industry is a lucrative target for illicit activity. PMID- 10167645 TI - Empire Blues' fraud fighter downplays mob threat. PMID- 10167647 TI - Kid-care bill lacks AHA, AMA backing. PMID- 10167646 TI - PPMs (practice management companies) look to academia. Faculty practices targeted despite cultural, legal gaps. PMID- 10167648 TI - Aetna drops out of AAHP. PMID- 10167649 TI - Bigger slice of the budget. Info systems account for over 5% of facilities' total spending. PMID- 10167650 TI - Md.'s Medicaid move. State's ambitious managed-care initiative to start June 2. PMID- 10167651 TI - AMA accreditation data to be lean on specifics. PMID- 10167653 TI - Iowa relaxes CON. PMID- 10167652 TI - He takes it personally. CEO angry over loss of Calif. hospital's Medicare license. PMID- 10167654 TI - New AIDS therapies hurt some providers. PMID- 10167655 TI - HCFA's folly. Effort to revise docs' overhead expense pay is a failure and should be scrapped. PMID- 10167656 TI - System growth a close race. 1997 multi-unit providers survey finds not-for profits ahead by a nose. AB - For the first time in five years, the biggest dealmakers in 1996 were not-for profit systems, not their giant for-profit brethren. But it was a close race, according to this year's Multi-unit Providers Survey. Based on total hospitals, not-for-profits grew 12% vs 11.3% at for-profits. In the psychiatric sector, the number of facilities rose 17%, but the number of deals tumbled 26%. And in the post-acute sector, outpatient and rehab services led the way. PMID- 10167657 TI - Living by the code. AHIMA publicizing ethics standards for coding staffers. PMID- 10167658 TI - A year of reorganization. Number of psych facilities up; number of deals down. PMID- 10167659 TI - Post-acute progress. Outpatient, rehab services experience most growth. PMID- 10167660 TI - Lightening its debt load. As dealmaking slows, Columbia reallocates spending. PMID- 10167661 TI - Bottom-line boost. PMID- 10167662 TI - New leadership. LSU to take control of La.'s nine public charity hospitals. PMID- 10167663 TI - VA plan draws flack. PMID- 10167664 TI - Medical mecca. Foreign patients flock to Miami seeking care and service. AB - Just like every place else in the U.S., hospitals in Miami are hurting for patients, one result of high managed-care penetration in the market. But the city's healthcare facilities have found an answer. Long an international center of business and tourism, Miami has become a medical mecca, catering to overseas patients who feel at home in the heavily foreign-flavored metropolitan area. PMID- 10167665 TI - Down with paper. Ohio insurer's phone system increases electronic claims. PMID- 10167666 TI - Expert advice available. Council assists hospitals with investment strategies. PMID- 10167667 TI - Cardinal Health to buy MediQual. PMID- 10167668 TI - Catholics form East Coast powerhouse. PMID- 10167669 TI - Strategic administration of nonprofit human service organizations: a model for executive success in turbulent times. AB - Rapid and unprecedented changes in our modern society have created extremely turbulent environments for nonprofit human service organizations. These changes threaten to transform the very nature of our business in ways difficult to predict and prepare for. The author examines the collective views of 21 purposely sampled executive directors in the city of Baltimore, Maryland on the future of the nonprofit human services sector. In 1 hour face-to-face interviews, subjects were asked to respond to three questions. What major trends will impact the nonprofit sector in the near future? What potential impact do you see these trends having on the nonprofit sector? What strategies would you recommend that executive directors take today to ensure success of their organization in the future? Narrative responses to each question were aggregated, organized into dominant views, and summarized. Subjects identified a host of social, political, economic, and technological trends that will have major effects on the future of the nonprofit sector. Subjects recommend a variety of tactics for helping an agency respond successfully to these forces. These tactics emphasize three critical areas of strategic administration: planning, management, and leadership. PMID- 10167670 TI - The credibility of nonprofit boards: a view from the 1990s and beyond. AB - The wrongdoings of nonprofit organizations have become grist for the media mill. The authors explore five of the more recently publicized cases of nonprofits gone wrong: the United Way of America, National Association for the Advancement of Colored People, Foundation for New Era Philanthropy, Jewish Community Center of Greater Washington, and Upsala College, and their significance in regard to the role and functioning of the board. Discussion focuses on the implications of these cases in regard to nonprofits' credibility and strategic options for enhancing accountability. Unless governing boards address some of their deficiencies, tighter government regulations, increased donor skepticism, and greater demands and expectations upon them will result. PMID- 10167671 TI - The impact of managed care on Massachusetts mental health and substance abuse providers. AB - Medicaid managed care programs are becoming more widespread. To investigate the clinical, organizational, and financial impacts on service providers, a stratified, random sample of providers in the Massachusetts Managed Mental Health/Substance Abuse Program were surveyed by phone in Years 3 and 4 of the initiative. Providers reported that they were making widespread clinical changes such as more use of group, brief, and episodic therapies. They were increasing utilization review, Total Quality Management, and outcomes measurement. They were increasing in size, affiliating with other agencies, and providing a greater range of services. They were preparing for capitation. Compared to before the program and a year earlier, about 40 percent of providers were doing better financially and a quarter were doing worse. The study documents the hypothesis that a widespread and continuing transformation is taking place in response to managed care. PMID- 10167672 TI - A typology of child protective service cases: design and implementation issues for social work administrators. AB - Case typologies can help to delineate client problems and needs, inform the design of service delivery, and measure service outputs and outcomes. The author describes the development of a typology of the child protective services cases of one large public department of social services. To assist social work administrators develop and apply case classification schemes within their agencies, this typology is used to illustrate the following key conceptual and methodological issues: (1) reasons for case typologies: (2) identifying and selecting case attributes: (3) re-organizing and reducing the number of attributes: and (4) forming groups. PMID- 10167673 TI - Developing relevant public sector outcome measures. PMID- 10167675 TI - Healthcare facilities. Whither the hospital? PMID- 10167674 TI - Public versus business administration: are they still alike in unimportant ways? PMID- 10167676 TI - Shapiro Clinical Center, Boston, Massachusetts. PMID- 10167677 TI - Sharon Hospital, Sharon, Connecticut. PMID- 10167678 TI - Altoona, Hospital. Altoona, Pennsylvania. PMID- 10167679 TI - Alta Bates Cancer Center, Berkeley, California. PMID- 10167680 TI - The future: "Health-care delivery and design: 2000 to 2040.". AB - Before one more obsolete hospital gets built, architects must look at the future of patient care and the technologies it will demand. That's according to Robert J. Iverson, ALA, a Senior Associate Principal with Loebl Schlossman & Hackl/Hague Richards in Chicago, who has spent 28 years involved in the architecture of health-care--nursing homes, primary-care and tertiary hospitals, and research facilities. In a presentation for NeoCon this June, he identifies some medical advances that will dramatically affect the delivery of patient care, and suggests design strategies for the hospital of the coming century. PMID- 10167681 TI - Conformal coating using parylene polymers. AB - Parylene, a conformal polymer film, is being used increasingly in Europe to provide environmental and dielectric isolation. Application areas include electronic circuitry, sensors, and medical substrates. This article describes the variants of parylene and their characteristics, together with the process and applications of parylene coating. PMID- 10167682 TI - Surface-modified polyester fabrics. AB - The plasma treatment of poly(ethylene terephthalate) fabric offers new opportunities for product designers. The technique enhances surface properties while maintaining the beneficial physical characteristics of the bulk material. This article compares the surface properties of treated and untreated materials and looks at the specific application of treated fabric in the rapidly growing field of tissue engineering. PMID- 10167683 TI - Software validation. AB - This article examines the requirements of EN 60601-1-4, which states that risk management is an integral part of the development of software for medical devices. Food and Drug Administration regulations are also compared to the requirements of the Medical Device Directive to provide guidance on developing software for the European and US markets. PMID- 10167684 TI - European and US quality system requirements for packaging. AB - The packaging of medical devices bearing the CE mark must comply with the European Directives for medical devices. Packaging of medical devices marketed in the United States (US) must meet US requirements. Although these requirements are more stringent for sterile products, they apply to sterile and non-sterile products. This article will discuss the requirements, US guidance for complying with them, and some of the international and European standards for packaging that are available or being prepared. PMID- 10167685 TI - Environmental producer responsibility. AB - The Packaging and Packaging Waste Directive (P&PWD) requires manufacturers to take responsibility for recovering packaging waste. This article examines some of the challenges this presents. Product designers must now integrate environmental regulations into product and packaging design. This will entail handling the conflict between the differing requirements of the P&PWD and the Medical Device Directive, and marking products to indicate whether packaging is reusable or recyclable. PMID- 10167686 TI - Wound care management. PMID- 10167687 TI - Mild traumatic brain injury. PMID- 10167688 TI - Working stiff. PMID- 10167689 TI - Vestibular rehabilitation. PMID- 10167690 TI - Morbidity and mortality associated with intracranial aneurysms. AB - Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space. It may result from a rupture of an intracranial aneurysm, bleeding from an arteriovenous malformation, hypertensive intracerebral hemorrhage with extension into the subarachnoid space, hemorrhage from an intracranial tumor, trauma, and hematologic disorders. If trauma is eliminated as a cause of SAH, more than 80% of SAHs are due to rupture of an intracranial aneurysm. This paper will focus on morbidity and mortality associated with ruptured and unruptured intracranial aneurysms. PMID- 10167691 TI - First-year acute coronary event rates in patients with acute myocardial infarction evaluated 5-7 days post-MI for ST depression in an ambulatory monitored ECG. AB - BACKGROUND: To present rates for fatal and non-fatal acute coronary events (ACE) in patients monitored 5-7 days after acute myocardial infarction, for abnormal ST depression in a continuous ambulatory ECG, with follow-up to the end of the first year after hospital admission. Comparative first-year mortality rates are also derived. RESULTS: The comparative mortality in the ischemic group is at an excess death rate of 92 per 1,000 per year as opposed to the nonischemic group where it was 15 per 1,000 per year. Nonfatal ACE rates were 346 and 154 per 1,000 per year, respectively, in the two groups. CONCLUSION: The risk of death is extremely high in the first few minutes and the first hour after the onset of an acute MI, and the risk diminishes steadily over the ensuing days weeks and months. PMID- 10167693 TI - Life table mortality analysis of parkinsonian signs in a community population of older people. AB - BACKGROUND: A community based mortality review of individuals with parkinsonism is evaluated by a comparative life table analysis. RESULTS: Individuals with parkinsonism had an increased mortality over a nine year follow up. The presence of a gait disturbance is an additional mortality factor. However, the absence of gait disturbance is a far stronger factor for improved survival in parkinsonism than is the adverse factor of a gait disturbance being present. Bradykinesia, tremor and rigidity had no significant additional mortality effect. CONCLUSIONS: Careful risk selection should lead to a favorable mortality result. Credits can be given to those without gait disturbances and extra debits assessed to those with gait disorders. PMID- 10167692 TI - Tumor marker study: the Transamerica experience 1990-1995. AB - BACKGROUND: From the fall of 1990 through January 1995 Transamerica Occidental Life screened applicants for life insurance for cancer with Tumor Associated Antigen (TAA). RESULTS: 110,299 applicants were tested and in 13,829 positive levels of TAA were found. Of this latter number, 255 applicants were declined following various levels of evaluation. CONCLUSIONS: We concluded that TAA screening was neither sensitive, nor specific enough for a screening tool for life insurance. PMID- 10167694 TI - Perspectives on changing times: implications for insurance medicine. AB - Profound changes are occurring in medicine. These changes are in both medicine itself and also in the economic and social context. The driving forces for change include health care reform, sophisticated consumers, new technology, information explosion and ethics of controlling human biology. PMID- 10167695 TI - Effect of age on mortality experience in patients with hypertrophic cardiomyopathy. AB - Medical authors typically combine all patient groups to increase the amount of data available for analysis. Use of this statistical methodology generally conceals higher mortality ratios at younger ages and masks survival differences related to disease severity and comorbid impairments. This paper discusses the effects of age and clinical characteristics on mortality experience in patients with hypertrophic cardiomyopathy. Limited data suggest the mortality pattern associated with this impairment is similar to that observed with most disorders: excess mortality (compared to the general population) that is high at younger ages, intermediate in middle-aged people, and minimal in the very elderly. Optimism regarding generally favorable mortality at older ages must be tempered with caution since studies report much poorer experience in certain subgroups of elderly patients with this impairment. PMID- 10167696 TI - The expanded role of the office manager in the managed care medical group. PMID- 10167697 TI - Enhancing home care's off-site operations through Internet technology. PMID- 10167698 TI - Counterpoint. The PHO/MSO alternative. PMID- 10167699 TI - Health Insurance Bill of Rights Act of 1997. PMID- 10167700 TI - Due diligence of provider sponsored organizations. PMID- 10167701 TI - Good starting point for debate on health funding. PMID- 10167702 TI - Auckland Healthcare opens rehabilitation unit. PMID- 10167703 TI - Hospital creates patient-centered transportation model. PMID- 10167704 TI - How to build an managed care organization. PMID- 10167705 TI - Health plan. NFPA's investigation of a hospital fire on October 16, 1996, demonstrated that fire emergency plans work. PMID- 10167706 TI - Special delivery. Jefferson County hospitals and other organizations join together to improve healthcare delivery to uninsured. PMID- 10167707 TI - Medical savings accounts: weighing the pros and cons of this new form of healthcare coverage. PMID- 10167708 TI - Satisfactory condition? Are your employees satisfied? How's morale? Just what is your hospital doing to create a productive yet enjoyable work environment? PMID- 10167709 TI - White turns life around at Opp's Mizell Memorial Hospital. Interview by Brian Bourke. PMID- 10167710 TI - Falling through the cracks. Why the number of uninsured people in the United States continues to rise and what hospitals are doing about it. PMID- 10167711 TI - Cost analysis in medical journals: a study of current usage. PMID- 10167712 TI - Structuring a service line. AB - In 1993, Community Hospitals Indianapolis created 10 service lines--each unique to the needs of the patients it serves. Two service line leaders talk about the factors critical to successful restructuring, the working relationships established, and the importance of clear communication to ensure understanding and get buy-in to the process. PMID- 10167713 TI - A tool for evaluating the product line approach. AB - Following through on a promise to employees unconvinced of the value of reorganizing, Henry Ford Wyandotte (Mich.) Hospital built evaluation into the process. The major tool: a questionnaire sent to 120 staff member asking their opinion. The results will be used to determine priorities for continuing improvement. PMID- 10167714 TI - Reorganizing patient care around service lines. AB - Practice makes perfect, the experts remind us. And studies show that the more healthcare providers care for patients with certain conditions, the better that care becomes. In this issue, THE QUALITY LETTER talks with healthcare leaders who have implemented revolutionary changes in the way care has been delivered at most healthcare organizations for more than a century. They've reorganized care within their organizations into product lines or service lines, such as cardiology, oncology and women and children's health. Reorganization has meant establishing new reporting patterns and emphasizing multidisciplinary teamwork. Best of all, they're reaping the benefits that early measurements show, such as reduced hospital length of stay and reduced costs. Healthcare leaders who spoke with THE QUALITY LETTER all agree that such reorganization is worth the effort--and note the four major lessons they've learned about easing the transition to service line delivery. PMID- 10167715 TI - California journal. PMID- 10167716 TI - Specialist survival strategies--Part II. Year of the consumer. PMID- 10167718 TI - Informing the market: the strengths and weaknesses of information in the British National Health Service. AB - Many countries are experimenting with planned (or quasi-) markets to discover if they can efficiently deliver health care in keeping with societal objectives. This paper examines the information requirements of this approach. Information is necessary in order to compare the performance of providers, to support billing, and to monitor access to care. It should be accurate, unambiguous, and resistant to manipulation. We draw on a project to find out how information on hospitalisation could be used in contracting in the British National Health Service. We conclude that the existing British system fails to provide robust measures of how many patients are treated, for what conditions, and with what treatments. We identify some promising remedies, others that are more difficult, and some which may be impossible to implement in any planned market, given the uncertainty of clinical practice. PMID- 10167719 TI - Caesareans under duress. PMID- 10167717 TI - Ethical implications of scientific research on the causes of sexual orientation. AB - In this article, we evaluate the status of current biological research into sexual orientation and examine the relevance of such research on the legal and social status of gay men and lesbians. We begin with a review of hormonal neuroanatomical and genetic studies of sexual orientation. We argue that the scientific study of sexual orientation is, at best, still in its infancy. We turn then to the ethical and social implications of this research. We argue that even if scientists could explain how sexual orientation develops, no significant ethical conclusions would follow. Further, we suggest that the current emphasis on finding a biological basis for sexual orientation is potentially harmful to lesbians, gay men and other sexual minorities in various ways (although perhaps it is in some ways potentially helpful as well). PMID- 10167720 TI - The formation of professional and consumer solutions: ethics in the general practice setting. AB - A general practice research project on ethics is underway at the University of New South Wales, funded by GPEP (General Practice Evaluation Program, Commonwealth Department of Human Services and Health, GPEP 386). Ethical issues, as defined and explored by general practitioners and consumers, are being examined across four areas of Sydney. So far, telephone interviews have been conducted (64% response rate) with a random sample of general practitioners (GPs). Face-to-face interviews have been conducted with 107 consumers, randomly sampled using ABS collection district information. Focus groups have been formed to discuss acceptable solutions to GP and consumer identified ethical issues. This report will report on some preliminary findings to date and will explore professional and consumer roles in the formation of ethical solutions. PMID- 10167721 TI - A marriage of convenience? Combining methods of research on advice giving for over-the-counter medication. PMID- 10167722 TI - Memory recovery and repression: what is the evidence? AB - Both the theory that traumatic childhood memories can be repressed, and the reliability of the techniques used to retrieve these memories are challenged in this paper. Questions are raised about the robustness of the theory and the literature that purports to provide scientific evidence for it. Evidence to this end is provided by the authors which surveyed New Zealand families in which one member had accused another (or others) of sexual abuse on the basis of recovered memories. It is shown that a number of these allegations involve very low probability events. Since memory repression theory is not currently scientifically substantiated it is argued that care needs to be taken in the mental health, legal and insurance compensation arenas. Memories recalled during therapy may be treated as metaphorical but, in the absence of corroborative evidence, should not be considered factually true. Clinicians who wish to use memory recovery techniques should inform patients of their experimental and controversial nature, point out adverse effects, and obtain consent before proceeding. PMID- 10167723 TI - Computerized records gain ground. AB - Frustrated with the paper medical records stored in a central repository, Kaiser Permanente Northwest, a non-profit group model HMO, began using an electronic medical record system in 1995 to better serve its 414,000 members in Oregon and Washington. PMID- 10167725 TI - Decision support at the crossroads. AB - Quality, like beauty, is in the eye of the beholder--patients, physicians and payors all have their own perspective, If everyone is pleased with the outcome- the patient is cured, the physician managed the condition before it worsened and the payor saved money because the patient didn't need surgery--then isn't that quality care? Clinical decision support systems can help improve the quality of care by providing relevant information right at the time it's needed most--at the clinician's fingertips. Armed with the right information, physicians can diagnose more effectively and make better decisions about care and treatment, say some industry experts. But, caution others, clinical decision support systems are not intended to take the place of a physician's good judgement. PMID- 10167724 TI - Medicaid. Can IT help administer HEDIS? AB - Stopping the revolving door of care for Medicaid recipients is the first step in providing quality-based services regardless of an individual's income level or insurance carrier. But before these changes can be measured, managed care officials must confront some of the problems inherent to Medicaid, such as: unregulated and unrecorded migration of plan enrollees; data collection from disparate sources; and the availability of few information system resources. PMID- 10167726 TI - Remedy register. Decision support systems update. Decoding decision support. PMID- 10167727 TI - Keeping an eye on the IHS pendulum. AB - Managed care is pushing the pendulum of integration in healthcare, and it is likely to continue gaining momentum. As a result, integrated health systems (IHSs) are approaching integration from two perspectives--payor and provider--and approaching a middle ground where healthcare financing and delivery are well balanced and equal in emphasis. Still, IHS officials would like to monitor all members on a continual basis that is the only way to improve the health of their population and, ultimately, reduce the economic burden of healthcare. PMID- 10167728 TI - Confronting internal data threats. PMID- 10167729 TI - Communicating a merger: BJC's experience in the St. Louis market. AB - When BJC merged five well-known healthcare organizations in the St. Louis area, leaders developed a communications plan for establishing its new identity in the community. But setbacks forced modifications to the plan along the way. Why did setbacks happen, and how did the plan get back on track? These excerpts from the publication Anatomy of a Merger: BJC Health System provide some answers. PMID- 10167730 TI - Deaconess Billings Clinic: a 'physician-led, professionally managed' model of integrated healthcare delivery. AB - When Deaconess Medical Center and its neighbor, Billings Clinic, merged in 1993, the goal was to reduce duplication and add new services. Three years later, they refocused on a higher level of integration--and, experts say, they're over the hump in achieving their goal. PMID- 10167731 TI - OIG report identifies four characteristics of cost-effective home care agencies. PMID- 10167732 TI - Mergers of equals: understanding the dynamics. AB - The current wave of mergers in the healthcare field is marked by demands from staff that their organizations not lose autonomy--and one way leaders are getting agreements signed is to assert that each merging group will be treated as equal in power. But such mergers, says consultant Stephen L. Ummel, can lead to "inertia, indecisiveness and confusion". Leaders of three healthcare systems- Partners in Boston, BJC in St. Louis and Lifespan in Rhode Island--cite four major lessons that others planning mergers should take to heart. PMID- 10167733 TI - Defining a new term. AB - Organizations are using extranets to engage in electronic commerce with trading partners. But the definitions of what constitute an extranet vary widely. PMID- 10167734 TI - A CIO changes focus as time goes by. Interview by MargaretAnn Cross. PMID- 10167735 TI - A novel networking approach. PMID- 10167736 TI - The paperless business office. AB - Many providers are launching a variety of initiatives with the intent of eliminating paper in the business offices, thus streamlining operations and cutting costs. While there are some encouraging signs of progress, plenty of roadblocks still exist that will make such a transition difficult. Key technologies involved include EDI, the Internet, document imaging, COLD technology and automated dialers. PMID- 10167737 TI - Disease management. AB - Disease management efforts are becoming an important competitive strategy for providers and managed care plans alike. More than ever, purchasers of care want value from their health care dollars, and integrated delivery systems want to better coordinate care. Information technology will be crucial in implementing disease management programs. PMID- 10167738 TI - Crafting new methods of systems integration. AB - A handful of pioneering organizations are using intranets in their systems integration efforts. They have concluded that intranets, when used in combination with interface engines, can "virtually integrate" data. PMID- 10167739 TI - Urging HMOs to automate. PMID- 10167740 TI - The virtual radiology department. PMID- 10167741 TI - Avoid paramedic PR pitfalls: make your ED the desired destination. PMID- 10167742 TI - Confront managed care's impact on EMS. PMID- 10167743 TI - Should an ED have its own ambulance service? PMID- 10167744 TI - The cordless ED: wireless phones can improve communication. PMID- 10167745 TI - Pearls of wisdom from ED leaders. PMID- 10167746 TI - Cancellations cut by three-fourths. AB - A critical pathway of lumbar discectomy has helped Blodgett Memorial Medical Center in Grand Rapids, MI, decrease cancellations by incorporating a preoperative telephone call one to two weeks before surgery. 50% of patients are going home in 23 hours or less. A handful of those are going home the same day as the procedure. The preoperative telephone call includes registration, education, instruction about laboratory tests to be done before the day of surgery, and even discharge planning. PMID- 10167747 TI - Pneumonia pathway cut charges by $2,900 per case. PMID- 10167748 TI - Improve productivity with work-flow analysis. AB - Work-flow analysis can help you deal more efficiently with the pressure to produce more services with fewer staff by forcing you to ask the right questions of the process so improvements can be made. Bringing staff together for discussions on creating a work-flow description can improve relationships among staff members and increase people's understanding of each other's roles. Once the work flow is described, the manager and staff should evaluate their current activities in other to identify ways to improve productivity. PMID- 10167749 TI - States reject 'body part' legislation. AB - Early indications suggest that state legislatures across the country are rejecting "body part by body part" legislation that would have imposed restrictions on the clinical care for individual patients. Particularly unsuccessful have been bills mandating minimum lengths of stay for certain patients with certain procedures and bills allowing patients direct access to specialists. In light of the patchwork quilt of health care legislation at the state level, one consumer advocacy group is now pushing for broader-based federal mandates. PMID- 10167750 TI - Sloppy documentation costs millions; pathways can save your bacon. AB - At Sinai Hospital in Baltimore, physicians' inadequate documentation and their resistance to clinical pathways have resulted in a flood of denied claims from third-party payers. Case managers at Sinai are addressing the problem by eliminating duplicate documentation and folding into the pathways information physicians must consult on a daily basis, such as vital signs and patient assessments. To avoid the consequences of poor documentation, case managers must be able to identify deficiencies and be available to coach physicians on what constitutes acceptable documentation in the medical record, experts say. PMID- 10167751 TI - Understanding JCAHO's continuity requirements. AB - In assessing how well your organization shares information across the continuum of care, Joint Commission surveyors will conduct "continuity of care" interviews not only with hospital managers and staff, but with representatives from all organizationally or functionally related agencies. During the interview, you must show you have a consistent plan of action for accessing medical records maintained at different locations, including records held by affiliated home health agencies. In addition to interviews, surveyors may assess continuity-of care issues through documentation review, medical record review, and visits to different patient care settings. PMID- 10167752 TI - Just being neighborly. Grass roots alternatives to institutionalized care. PMID- 10167754 TI - Restraint, seclusion, and authentication. Joint Commission issues standards across the board. PMID- 10167753 TI - Research in food production systems. PMID- 10167755 TI - Domestic partner benefits: are you doing it right? PMID- 10167756 TI - New hospital locking system addresses employee safety concerns. PMID- 10167757 TI - 'ATMs' for dispensing medication, supplies said to cut hospital losses. PMID- 10167758 TI - Data security: an update. AB - Safeguarding patient records has always been a major concern for hospitals, but it has taken on added importance with increasing computerization that makes it easier for employees to browse medical charts, usually to check on the condition of a fellow worker, friend, or neighbor. In an effort to make records more secure, two hospitals--the University of Wisconsin Hospital and Clinics, Madison, and Beth Israel-Deaconess Medical Center, Boston, MA--have included an audit trail in their computer security systems to let them know who is accessing them. Such methods to safeguard electronic records and better protect patients' privacy were strongly recommended in March 1997 by a panel of the National Research Council, an arm of the National Academy of Sciences. In this report, we'll present details of how these hospitals are proceeding. PMID- 10167759 TI - Tips on training hospital employees to deal with workplace violence. PMID- 10167760 TI - Veterans Administration Hospital, Detroit, Michigan. PMID- 10167761 TI - Using performance measurement to clean house. PMID- 10167762 TI - Metropolitan versus nonmetropolitan differences in functional status and self care practice: findings from a national sample of community-dwelling older adults. AB - The objective of this study was to use a recent national probability survey of the noninstitutionalized older adult population to compare the functional status and self-care practices of older adults residing in metropolitan and nonmetropolitan communities and to identify differences associated with residential location. The survey used in this study was the National Survey of Self-care and Aging (NSSCA). A cross-sectional design was employed using weighted bivariate and multivariate logistic regression analyses to examine the relationship between metropolitan and nonmetropolitan residential location and self-reported ability to perform basic, mobility, and instrumental activities of daily living (ADLs), as well as to assess the degree to which the levels and types of functional limitations affect metropolitan versus nonmetropolitan older adults' performance of self-care activities. The bivariate logistic analyses pointed to modest, often insignificant metropolitan versus nonmetropolitan differences in the ability to perform functional tasks. However, larger positive effects of nonmetropolitan residence were generally observed once other factors likely to account for some of these differences were taken into account. Older adults from nonmetropolitan areas were more likely to report being able to perform functional activities but also were more likely to report performing self care activities both in the presence and absence of disability. This study, therefore, concluded that nonmetropolitan older adults may discount the significance of declining functional status, thus normalizing the trajectory of aging in a different way than do their metropolitan counterparts. If this process occurs, it may affect how nonmetropolitan persons use primary health care and/or long-term care services, challenging the economists' concept of demand, the clinicians' concept of need, and the policy analysts' concept of equity. Additional work is required to assess whether such a normalization process actually occurs and, if so, to explore its distribution, causes, correlates, and consequences. PMID- 10167763 TI - Lengthening spells of uninsurance and their consequences. AB - The lengths of time adults are without health insurance have increased since 1988, as shown by data from 1,235 household interviews completed during 1992 in Nebraska. Rural residents without insurance have experienced longer such spells than their urban counterparts. Thus, while rates of uninsurance are nearly the same between urban and rural residents, important differences exist. The relationship between insurance status and physician utilization is consistent during the five years (1989 to 1993) covered in this study. Continuously insured persons have the most physician visits, followed by those intermittently insured, followed by those continuously uninsured. The number of physician visits was expected to increase when respondents moved from uninsured to insured status. However, among urban respondents, the number of visits declined; among residents in rural frontier counties (fewer than six person per square mile) and for respondents in rural nonfrontier counties, there was no significant difference. This study points out some differences between rural and urban populations regarding insurance status, even when the overall rates of uninsurance are equal. PMID- 10167764 TI - Alcohol-related mortality and tribal alcohol legislation. AB - American Indian alcohol-related mortality rates differ widely among tribes, even within the same geographic region. In addition, there are many different legislative approaches to alcohol beverage control employed by tribes. This paper explores the association between alcohol legislation and alcohol-related mortality rates among American Indian tribes located in a region of the northwestern United States from 1979 to 1990. Both an unweighted analysis of alcohol-related mortality and a weighted analysis, using the Alcohol-Related Disease Impact (ARDI) approach, are used. Alcohol-related mortality rates did not differ significantly between reservations with alcohol prohibition statutes or where alcohol was legal in this region. However, evidence suggests that more comprehensive tribal alcohol legislation may be correlated with lower alcohol related mortality among American Indian tribes. PMID- 10167765 TI - The employment and use of nurse practitioners and physician assistants by rural hospitals. AB - Nurse practitioners and physician assistants are both important resources for the delivery of health care services in rural areas. Nevertheless, little is known about the demand for their services by rural employers. The purpose of this study was: (1) to describe and compare the employment and use of nurse practitioners and physician assistants by rural hospitals in an eight-state region in the northwestern United States (Minnesota, North Dakota, South Dakota, Iowa, Montana, Idaho, Oregon and Washington); and (2) to examine how different market and organizational factors influence the employment of nurse practitioners and physician assistants by rural hospitals. Data for the study were collected through telephone interviews of rural hospital administrators (N = 407) and analyzed using both descriptive tables and logistic regression. Study results show that rural hospitals are important employers of both nurse practitioners and physician assistants, although there is a greater demand for than supply of both types of practitioners. Moreover, there are several differences in the characteristics of hospitals that employ the different types of practitioners. Rural hospitals use nurse practitioners and physician assistants to enhance their delivery of outpatient services, and a major factor related to the employment of nurse practitioners and physician assistants by rural hospitals is the Rural Health Clinic program. The majority of hospitals that use nurse practitioners, as well as those that use physician assistants, indicate that nurse practitioners and physician assistants can prescribe medications and order lab tests and X rays, but considerably fewer report that nurse practitioners and physician assistants have admitting or discharge privileges. Physician assistants appear to provide a more expanded scope of services in rural hospitals. Nonetheless, rural hospitals seem to employ nurse practitioners and physician assistants for similar reasons: (1) to extend care, assist physicians, or increase access to primary care; (2) because physicians are unavailable or too difficult to recruit; (3) because nurse practitioners or physician assistants are considered cost-effective or more economical for rural areas; and, (4) for Rural Health Clinic certification. PMID- 10167766 TI - Rural mental health leaders' perceptions of stigma and community issues. AB - This paper provides a description of the attitudes of rural leaders toward mental health issues using data collected in two rural counties (one in Virginia and one in North Carolina). Study participants (N = 63) are individuals identified as leaders making a significant positive contribution to mental health issues in each county. While the counties were matched on a number of demographic characteristics, the counties had one difference believed important: one had a county mental health center located within the county boundary while the other had no in-county mental health center. The study found that rural leaders believed that other community members held attitudes toward mentally ill persons that were more discriminatory than their own. In addition, rural leaders expressed that mental health was a more important concern to them than it was to the community as a whole. Finally, the importance placed on issues of importance to the community and the resulting issue of priority of relevance varied in response to the occupation of respondents. The study presents an approach to understanding how occupational structures affect community issue priorities among rural leaders. PMID- 10167767 TI - The criminalization of persons with serious mental illness living in rural areas. AB - In the context of restrictive admissions policies at public inpatient facilities, rates of arrest and incarceration of persons with serious mental illness (SMI) have been increasing, leading to the perception that SMI persons are being unduly "criminalized." This paper describes the characteristics of persons with SMI (N = 177) in Mississippi who have been (1) jailed without charges while awaiting a hospital bed and (2) jailed for a criminal offense. Seventy-five percent (N = 132) of the 177 subjects had been held in local jails awaiting state hospital admission at least once in their lives, most for more than five days. Fifteen percent (N = 26) had contact with the police for a criminal offense in the past year. Rural residence markedly increased the risk for waiting in jail (OR = 4.24) but was not related to committing a criminal offense. Protective factors for any type of criminal justice contact were female gender, caucasian ethnicity, better compliance with medication regimes, and nonrural residence. The phenomenon of rural criminalization, i.e., waiting in jail without criminal charges, differs qualitatively from the criminalization that occurs in urban areas and may require a different solution. To avoid criminalization of SMI persons in rural areas, public mental health systems must develop effective crisis interventions in the community or work with local law enforcement officials and medical and mental health facilities to create more immediate access to acute inpatient care. PMID- 10167768 TI - Meeting the challenges of workload and building a practice: the perspectives of 10 rural physicians. AB - This qualitative study used in-depth interviews to identify and describe factors regarding the retention of rural physicians. A purposeful sample of 10 established rural physicians from counties of fewer than 10,000 people participated in the study. Analysis of the interview transcripts identified the increased workload involved in building a rural practice to be a major concern of the physicians. The physicians expressed this difficulty in the form of two challenging dilemmas: (1) Towns with only a few physicians presented excellent opportunities for a building practice, but the lack of physicians resulted in more difficult working conditions; and (2) building a practice was described as primarily competitive, but staying in rural practice involved working cooperatively with various competitors. The demands of family, practice, and community interact in a complex fashion. The smallest health systems, those in counties with populations of fewer than 10,000, one hospital, and fewer than five physicians, may represent situations where it is difficult to find a workable solution. PMID- 10167770 TI - Is lack of money the reason kids stay poor? PMID- 10167769 TI - Returns to nursing education: rural and nonrural practice. AB - This study uses data from a national sample of registered nurses to compare earnings of nurses in rural and nonrural practice. The comparisons, conditioned by the nurses' education level, are analogous to the concept of "returns to human capital investment" used in labor economics. A general linear model is applied within a framework of labor economics analysis. Results show that nurses with more education receive less for their investment if they practice in rural areas. Work experience and employment setting are also related to lower annualized earnings for rural practice. One exception to the otherwise consistent findings is that returns to advanced practice nursing are higher in rural areas. Results and policy implications are discussed. PMID- 10167771 TI - Radiology on the Web. PMID- 10167772 TI - Filmless radiology: how the Baltimore VA does it. PMID- 10167773 TI - How to buy 1-tesla MR scanner by the numbers. PMID- 10167775 TI - Pregnant women on Britain's Isle of Wight treated through teleobstetric system. PMID- 10167774 TI - The effects of hormone replacement therapy on antithrombin III and protein C levels in menopausal women. AB - OBJECTIVE: To determine if menopausal women taking estrogen with and without progestin are at increased risk for thrombotic disease as evidenced by decreased levels of antithrombin III and protein C. DESIGN: A case controlled study. SETTING: General community in southeastern New Hampshire. PARTICIPANTS: One hundred seventy-one healthy women aged 38 to 65 years. Women were defined as premenopausal if follicle stimulating hormone levels were < 40 mIU/ml and menopausal if follicle stimulating hormone levels were > 40 mIU/ml. Menopausal women were subdivided according to hormone replacement therapy status; women not taking estrogen or progestin, and women taking estrogen with and without progestin for at least 1 year. MAIN OUTCOME MEASURES: Significant differences in antithrombin III and protein C levels. RESULTS: Premenopausal women had significantly less antithrombin III than menopausal women not taking hormone replacement therapy. Premenopausal women had significantly less protein C than menopausal women taking estrogen for at least 1 year with and without progestin. CONCLUSION: Estrogen taken for at least 1 year with and without progestin by menopausal women will not increase the risk of thrombotic disease by lowering the levels of antithrombin III or protein C. On the contrary, estrogen is associated with an increase in circulating levels of protein C in menopausal women, and could create a protective effect not seen in premenopausal women or menopausal women not taking estrogen therapy. PMID- 10167776 TI - Defense Department awards telemedicine ophthalmic technology contract. PMID- 10167777 TI - Patients with renal disease have nephrologists online. PMID- 10167778 TI - Low-cost telemedicine product allows remote monitoring of patients. PMID- 10167779 TI - Telehealth: nursing's urban frontier. PMID- 10167780 TI - Global markets offer opportunity at a price. PMID- 10167781 TI - Market targets 1997. PMID- 10167782 TI - Linking clinical systems and the Web: state of the art. PMID- 10167783 TI - Practice makes perfect: devising technical specs for tele-ophthalmology. PMID- 10167784 TI - Harsh weather creates hospitable climate for telemedicine. PMID- 10167785 TI - The history of desktop telemedicine. PMID- 10167786 TI - Current uses of desktop telemedicine. PMID- 10167787 TI - A look into the desktop telemedicine crystal ball. AB - Health care providers are constantly moving, rarely remaining at their desks. They meet and greet, touch and examine, go from room-to-room, walk from building to building. Therefore, telemedicine tethered to a desktop is inherently foreign to the work habits of many clinicians. Rather than requiring a change in practice habits, emerging technology will be better adopted to the work styles of clinicians. Desktop telemedicine will make a difference, but personal telemedicine makes more sense. There is a distinction. PMID- 10167788 TI - PACS archiving, guidelines, fault tolerance, and comments. PMID- 10167789 TI - Telemedicine equipment and vendors: the users' perspectives. AB - The ATSP (Association of Telemedicine Service Providers) supplies current and future telemedicine providers with practical information and other services. One way to obtain useful data is to conduct focused studies on important issues. This ATSP survey of vendor and equipment satisfaction is a collaborative effort between the Telemedicine Research Center and the ATSP research staff, and addresses some basic questions that telemedicine providers might have: What kinds of equipment are programs using? Who is providing this equipment? How do users rate the equipment and the vendors? The results will be periodically updated and made available to members in the members-only section of the ATSP website (www.atsp.org). PMID- 10167790 TI - Nova Scotia Telemedicine Project. PMID- 10167791 TI - Is tele-ophthalmology the answer to diabetic retinopathy screening? PMID- 10167792 TI - Licensure quagmire continues. PMID- 10167793 TI - Perspectives. Is Medicare plan flawed by exclusion of partial risk? PMID- 10167794 TI - Marketplace. How drug company mergers affect HMOs and hospitals. PMID- 10167795 TI - Surgical smoke: a new occupational hazard? PMID- 10167796 TI - Making an impact in clinical data management. Interview by Ken Polson. PMID- 10167797 TI - HCFA issues proposed rules for home health. PMID- 10167798 TI - The data-driven era of healthcare accreditation has arrived. PMID- 10167799 TI - Accreditation requirements for ORYX: the next evolution in accreditation. AB - This year, the Joint Commission of Accreditation of Healthcare Organizations approved new requirements for participation in the accreditation process for hospitals and long-term care facilities. This article offers an ORYX overview- plus information on choosing a performance measurement system. PMID- 10167800 TI - Practice brief. Issue: E-mail security. American Health Information Management Association. PMID- 10167801 TI - The evolution of HEDIS: 3.0 and beyond. PMID- 10167802 TI - FACCT (Foundation for Accountability): a large measure of quality. AB - The founders of the Foundation for Accountability (FACCT) believe that the people who buy and use healthcare should hold the system accountable for its performance. Here's what this group is doing to articulate the interests of consumers and purchasers in acquiring better information about healthcare quality. PMID- 10167803 TI - The age of consumerism in healthcare. AB - Health plans and employers are increasingly relying on patient satisfaction surveys to evaluate care. If administered and interpreted properly, these surveys can help providers, employers, and patients mine a wealth of information. PMID- 10167804 TI - ICD-9-CM and CPT coding and billing of hospital outpatient mammograms. PMID- 10167805 TI - Change by design. PMID- 10167807 TI - The RUC--its past, present, and future. Interview by Patricia Parks. PMID- 10167806 TI - Curriculum model for associate degree programs in HIM, Part III: Focus on educational outcomes and curricular content. AB - This is the last in a series of three articles that discuss curriculum models for associate and baccalaureate degree programs in health information management (HIM). Part I discussed the development of the models and presented a composite summary of key sections within the models. Part II focused on the baccalaureate degree curriculum model sections, which addressed educational outcomes, curricular content, and clinical experience expectations. Part III addresses these same sections, but in regard to the associate degree curriculum model. PMID- 10167808 TI - A 20-year experience with malpractice screening panels. PMID- 10167809 TI - Graduate education in surgery: too long? PMID- 10167810 TI - The future of the fee schedule conversion factors and MVPSs. PMID- 10167811 TI - Using methods developed to assess drugs, a few institutions lead in weighing value of new technologies and procedures. PMID- 10167812 TI - The "100 Top Hospitals" study reveals LOS, profitability, and other trends over time. PMID- 10167813 TI - Community based health information in India. A dream or reality? PMID- 10167814 TI - List of designated primary medical care, mental health, and dental health professional shortage areas--HRSA. Notice. AB - This notice provides lists of all areas, population groups, and facilities designated as primary medical care, mental health, and dental health professional shortage areas (HPSAs) as of March 31, 1997. HPSAs are designated or withdrawn by the Secretary of Health and Human Services (HHS) under the authority of section 322 of the Public Health Service (PHS) Act. PMID- 10167815 TI - Quality time. AB - With health care costs soaring, almost everyone rushed into managed care plans to save money. But consumers have discovered that price isn't everything. And business, government and unions increasingly have embarked on a quest for health care quality. PMID- 10167816 TI - The second wave of health care re-engineering: new focus on processes and growth. PMID- 10167817 TI - Managed care's cost savings days aren't over yet. PMID- 10167818 TI - Buy, build, or rent: keys to finding the right managed care capabilities. PMID- 10167819 TI - When cultures clash after mergers and acquisitions. PMID- 10167820 TI - Accessing capital internally: good old-fashioned business sense. PMID- 10167821 TI - New ruling finalizes IRS position on physician recruitment incentives. PMID- 10167822 TI - Administration expands Medicare anti-fraud initiatives. PMID- 10167823 TI - Medicare savings from selected payment bundling estimated at $8 billion. PMID- 10167824 TI - Healing environment, 24-hour physician coverage key to Goddard Center's success. PMID- 10167825 TI - EMT--T is for teamwork. PMID- 10167826 TI - There's no place like home. PMID- 10167827 TI - High-level disinfection. PMID- 10167828 TI - The fitness buy-in. PMID- 10167829 TI - 2 views. Meshing patient focused care with team cleaning. View 1. PMID- 10167830 TI - 2 views. Meshing patient focused care with team cleaning. View 2. PMID- 10167831 TI - The lower the education, the higher the birth rate, study finds. PMID- 10167832 TI - New hospital-based fitness centers' search for dollars does not ignore community health. PMID- 10167833 TI - Treat threat of search and seizure like threat of fire. PMID- 10167834 TI - Consolidation in a climate that doesn't favor for-profit conversion. PMID- 10167835 TI - Providers can avoid price cutting game. PMID- 10167836 TI - Providers challenge imposition of retroactive salary equivalency therapy limits. PMID- 10167837 TI - The administrative cost of health care: 1997 and beyond. PMID- 10167838 TI - Floating on a sea of money? PMID- 10167839 TI - Disease management: a continuum approach. AB - Disease management is a comprehensive, integrated approach to managing the health of populations through the use of disease-specific standards and protocols and population segmentation. It has been increasing in popularity among integrated delivery systems (IDSs) and payers alike as a way to respond to competitive pressures and to shift care delivery from inpatient to alternative care sites. To successfully implement disease-management programs, IDSs must develop an organizational mind-set that stresses information-driven, evidence-based standards of care that are adhered to across a tightly integrated continuum of care. PMID- 10167840 TI - Disease management: program design, development, and implementation. AB - Disease management is an emerging approach to patient management, customer satisfaction, and cost containment that comprises disease modeling; patient segmentation and risk assessment; clinical protocols; and wellness, self management, and education. Implementing a disease management program poses significant challenges to healthcare organizations. To successfully implement a disease management program, a tightly integrated continuum of care, sophisticated information systems, and disease management support systems must be in place. Strategic partnerships with outside vendors may speed program implementation and provide opportunities to develop risk-sharing relationships. PMID- 10167841 TI - Mistakes to avoid when planning managed care strategies. AB - Hospital executives, steeped in hospital business traditions, sometimes fall victim to those traditions when planning their managed care strategies. They may fail to sufficiently evaluate their hospitals' market position or set appropriate priorities for their various business strategies. They may not recruit individuals with managed care expertise, develop effective marketing plans, or construct realistic physician networks. Some hospital executives may be ill equipped to deal with cultural clashes and reluctant to share control of their managed care organizations with physicians. Or, they may not always understand the true nature of the arrangement they have entered into, the information and technology needs of the arrangement, and their own strategic advantages. Today's hospital executives must plan their managed care strategies carefully and execute them intelligently to ensure success. PMID- 10167842 TI - Ten strategies for creating successful managed care relationships. AB - Among the many customers providers serve are managed care organizations. The strategic relationships providers develop with these payers greatly influence the long-term success of both organizations. Providers can implement 10 strategies to improve their managed care relationships: focusing on contracting with selected managed care organizations, fostering positive relationships, coordinating contract participation, establishing communication links, educating providers about managed care, providing high-quality customer service; understanding operating costs, demonstrating value, maintaining flexibility, and pursuing alternative competitive relationships with caution. At the same time, managed care organizations can implement the same strategies to develop win/win relationships with providers. PMID- 10167843 TI - Anspaugh: education and mentoring key to the future. PMID- 10167844 TI - Is your healthcare information system physician friendly? AB - An organization's healthcare information system (HIS) can be used as a tool to improve relationships with its physicians by facilitating physician work processes and research. An effective HIS should provide census reports tailored to individual physician needs, allow physicians access to information via dedicated personal computers (PCs) or terminals, and should have features, such as screen design and graphical interfaces that are easy to understand and use. In addition, the HIS should provide comprehensive reports, have online ordering capability, and respond quickly to the needs of busy physicians. A good HIS also supports physician-related activities occurring outside the hospital. For example, physician office managers should be able to access billing information, such as patient demographics and procedure codes, contained in the HIS. And, physicians should be able to retrieve archived information from their offices or homes. Critical to physicians' successful use of an organization's HIS is administration's attitude and support. An organization that places a priority on physician issues and needs can make even a basic HIS an effective tool for its physicians, while a sophisticated HIS that does not address physician needs will not maximize return on the investment. PMID- 10167845 TI - Cost modeling to justify technology acquisitions. AB - In an era of diminishing resources, healthcare providers must justify new technology acquisitions. Cost modeling is one method of evaluating the financial impact a technology acquisition will have on a healthcare facility or integrated delivery system. This methodology requires careful data collection and a thorough analysis of both current costs and future cost savings resulting from the new technology. By using a cost modeling methodology, providers will be able to achieve competitive and economic advantages by analyzing both cost and value. PMID- 10167846 TI - Study results show decline in HMO operating margins. AB - In the early 1990s, virtually all HMOs reported healthy profits, especially in markets with low managed care penetration. However, a recent survey has revealed that HMO operating margins experienced sharp declines in 1995. Some reasons for these declines include: more competition as the healthcare marketplace has become more saturated with HMOs; aggressive price negotiations by employers; and rising HMO medical and administrative expenses. The study also revealed that all types of HMOs experienced operating margin declines, demonstrating that organizational structure was an unlikely contributing factor. PMID- 10167847 TI - Using activity-based costing to guide strategic decision making. AB - Activity-based costing (ABC) is not widely used in the healthcare industry. Some healthcare provider organizations are considering ABC, however, because of its potential to improve resource management and thereby maximize efficiency. ABC supports better pricing practices through more accurate costing and can be used to identify underutilized resources as well as associated costs that can be reduced. ABC can be a useful tool for determining the cost of unused capacity and for making strategic management decisions that will reduce costs. PMID- 10167848 TI - Medicare and Medicaid HMO incentive plan rules change. AB - Physicians and physician groups that participate in incentive plans offered by Medicare and Medicaid HMOs may be affected by a change in the rules pertaining to such plans. The change, which became effective January 1, 1997, sets a threshold percentage for substantial risk sharing for referral services; obliges HMOs to conduct annual enrollment surveys; and requires HMOs that contract with physician groups that serve 25,000 or fewer patients to obtain stop-loss protection. In addition to these rule changes, Medicare and Medicaid HMOs are now required to disclose information about physician incentive plans to Medicare and Medicaid beneficiaries who request it and report changes in incentive plans to HCFA at least 45 days before they take effect. Physicians should familiarize themselves with the changes pertaining to incentive plans to ensure that the Medicare and Medicaid HMOs with which they contract are in compliance and that they do not assume an excessive degree of financial risk for referral services. PMID- 10167849 TI - Surveys yield data on practice overhead, compensation, and productivity. AB - Results of three separate surveys conducted in 1996 on group practice costs, management and physician compensation, and productivity showed surprising results. Family practice has the highest overhead of any specialty. Medical practices seem willing to pay premium rates to hire experienced managed care administrators and/or those with large medical practice experience. And even though specialty physicians' productivity is increasing faster than that of primary care physicians, the primary care physicians' pay is increasing faster. PMID- 10167850 TI - Medicare: advancing towards the 21st century, 1966-1996. PMID- 10167851 TI - Health care in the early 1960s. PMID- 10167853 TI - The house that Medicare built: remodeling for the 21st century. PMID- 10167852 TI - Medicare and physician autonomy. PMID- 10167854 TI - Medicare and hospitals. PMID- 10167855 TI - Medicare influence on private insurance: good or ill? PMID- 10167856 TI - The politics of Medicare and health reform, then and now. PMID- 10167857 TI - Politics of federal health policy, 1960-75: a perspective. PMID- 10167859 TI - What Medicare has meant to older Americans. PMID- 10167858 TI - Beneficiary profile: yesterday, today, and tomorrow. PMID- 10167860 TI - Medicare, Medicaid, and the elderly poor. PMID- 10167861 TI - Thirty years of Medicine: a personal reflection on Medicare's impact on black Americans. PMID- 10167862 TI - Why Medicare matters to people who need long-term care. PMID- 10167863 TI - Discharge summaries. Map reading. PMID- 10167864 TI - Communication chords. PMID- 10167865 TI - Beyond gurus: fitness center expands facility's role in continuum of care. PMID- 10167866 TI - Air scare. PMID- 10167867 TI - Carpet diem. PMID- 10167868 TI - Enterprise networking grows up. The intelligent building gets a new nervous system. PMID- 10167869 TI - Infection control 101--a crash course in laundry. PMID- 10167870 TI - OSHA cuts red tape on injury/illness reporting. PMID- 10167871 TI - High-tech boosts costs of clinical engineering. PMID- 10167872 TI - Scheduling nursing personnel on a microcomputer. AB - Suggests that with the shortage of nursing personnel, hospital administrators have to pay more attention to the needs of nurses to retain and recruit them. Also asserts that improving nurses' schedules is one of the most economic ways for the hospital administration to create a better working environment for nurses. Develops an algorithm for scheduling nursing personnel. Contrary to the current hospital approach, which schedules nurses on a person-by-person basis, the proposed algorithm constructs schedules on a day-by-day basis. The algorithm has inherent flexibility in handling a variety of possible constraints and goals, similar to other non-cyclical approaches. But, unlike most other non-cyclical approaches, it can also generate a quality schedule in a short time on a microcomputer. The algorithm was coded in C language and run on a microcomputer. The developed software is currently implemented at a leading hospital in Taiwan. The response to the initial implementation is quite promising. PMID- 10167873 TI - Mission impossible? The definition and functions of the medical director. AB - Seeks to throw light on both strategic and managerial aspects of the post of medical director. The medical director is a key executive member of the Trust Board, yet the role remains ill-defined. The existing published guidance gives some indication of what medical directors should be doing but gives limited information about "best practice" or how to cope with the demands being made on them. A survey of medical directors in 1994 revealed the diversity of the tasks that they can be called on to perform, often with inadequate managerial and secretarial support. The survey also indicated that problems have occurred as a result of the heavy workload and unexpected multiple facets of the role. Concludes that, to make the job somewhat easier, there should be a clear core job specification which is tailored to suit the individual circumstances. This should be combined with generous support and training, together with a suitable reward package. PMID- 10167874 TI - Trade unions and local bargaining in the NHS. AB - Examines some effects of NHS Trusts moving away at varying speeds from complex national arrangements for determining terms and conditions towards local bargaining. Notes that while there has been some research into the extent and nature of this decentralization, the impact on trade unions has largely been ignored. This research suggests that, far from marginalizing stewards, senior managers have involved them in joint discussions. Although there has not been a renewal of local trade unionism, there has not been a decline, as membership has held up. Moreover, stewards have coped remarkably well with their enhanced roles, even though faced with the increasing and conflicting demands of their work and their union duties, compounded by problems in obtaining time off work because of lack of cover. PMID- 10167875 TI - The challenge of education commissioning--Part 1: Seeking value for money. AB - The new education commissioning system in the NHS in England offers opportunities to health care employers to achieve greater value for money. This article offers five means by which this could be achieved--tighter contracting with Higher Education; moving from block to cost-per-student contracts; using alternative education providers; fostering multiprofessional core education and adopting more flexible training methods. PMID- 10167876 TI - Drug use management and IT-based medical thesauri: issues of semantics and linguistics. AB - Argues that by interpreting the semantic content of different actions, it will be possible to draw boundaries between those aspects of a system that can be computerized and those that will best serve the purpose if left alone. This will dissuade systems developers from being caught in the technology trap. The argument is conducted in the context of developing IT-based medical thesauri for drug use management. PMID- 10167877 TI - Making local pay helpful--Part 1: Surfacing the hidden challenge. AB - Reports on a project which looked into the impact of "local pay" on four different types of Trust. Notes that all four were working towards ameliorating the perceived threat of local pay. Reports the use of various methodological approaches such as semi-structured interviews and a team diagnostic exercise and comes up with numerous findings. PMID- 10167878 TI - Subordinate appraisal of managers: a useful tool for the NHS. AB - Problems in recruiting and retaining professional staff are an ongoing concern to many NHS Trusts and professional heads of service. There is evidence from a wide variety of sources that direct line managers are frequently cited as a source of worker's stress and a cause of staff turnover. Reviews these issues and suggests subordinate appraisal of managers as one possible response. PMID- 10167879 TI - The curse of the CATalytic converter. AB - Addresses the transfer of nurse education from schools of nursing, previously located within health authorities and, more recently, hospital and/or community trusts, to institutions of higher education. The pressures this has produced for both providers and participants in this relatively new educational initiative have had a direct effect on the levels of stress and anxiety that students feel both in their initial professional qualification programmes and in continuing their personal and academic development subsequently. There is a paucity of research into this area of stress and student Angst as a result of the new educational thrust. Suggests that the evidence from student evaluations has not been collated adequately and that the result is a burgeoning of anecdotal evidence which is being ignored by nursing's professional body. Higher education has encouraged and influenced an almost exponential growth in programmes of study, which the nursing profession has used to force its singular aim to create a degree-based profession. PMID- 10167880 TI - The challenge of education commissioning--Part 2: A more radical change? AB - Second in a series of articles looking at developments within the NHS. Looks at factors such as business process re-engineering and patient-focused care. Highlights the features of both and suggests that the latter is a healthcare variant of the former. Examines the educational implications of such developments, suggesting that they will present a major challenge in the next few years. PMID- 10167881 TI - Subordinate appraisal of managers: "testing the theory". AB - Identifies the qualities of "ideal" line manager as perceived by three groups of professionals allied to medicine. Makes explicit the research methodology used to gather data, and reports the findings. Surveys three groups of professionals allied to medicine (PAM), namely, speech therapists, social workers (child health and adult physical health) and clinical psychologists. Offers an analysis of the data and draws some conclusions. Concludes with a reflection on the significance of the findings. PMID- 10167883 TI - Community entry--an essential component of participation. AB - Sees community entry as a prelude to any action that will take place in a true partnership with the community. Lists a series of steps involved in achieving community entry drawn from a project in Pakistan. Considers the role of the participatory worker and project management team in terms of meetings, discussions and the development of individual relationships. PMID- 10167882 TI - Making local pay helpful--Part 2: Using action research to address the challenge. AB - Second part of an item featuring action research with four different trusts to investigate factors relating to the implementation of the local pay policy. Describes methodologies used, such as clinical team diagnosis and cognitive mapping. Looks at the way forward, listing critical factors in ensuring successful implementation. PMID- 10167884 TI - Educational preparation and attributes of community and migrant health center administrators. AB - Based on a 1994 national survey of Community and Migrant Health Center (C/MHC) administrators, this study draws a profile of C/MHC administrators in terms of their personal and work characteristics, as well as their values and beliefs regarding successful C/MHC attributes and important managerial practices. Further, the study compares C/MHC administrators with different educational preparation in terms of their personal and work characteristics, values and beliefs, as well as their perceived deficiencies. The study results indicate that critical factors in C/MHC success, in order of ranked importance, were good organizational leadership, organization's value to community and efficiency. Successful managerial characteristics, in order of ranked importance, were vision for the future of organization, honesty/integrity and open to new possibilities. Administrators with more advanced degrees expressed less deficiencies and those with no college degree showed greatest deficiency on five of eight measures. PMID- 10167885 TI - The delicate balance of law and ethics: a model for health administration educators. AB - The purpose of this paper is to provide a model for educators involved in teaching interrelated ethical, moral and legal dilemmas confronting health care delivery. For purposes of discussion, the AIDS epidemic is used as an example. Similarly complex issues, such as invitro fertilization, transplantation policy, etc. could also be analyzed using this model. A review of federal law, including a number of relevant cases, and their relationship of fundamental ethics issues is provided. PMID- 10167886 TI - 1996 Andrew Pattullo lecture. A vision of the role of health administration education in the transformation of the American health system. AB - In summary, it is my conviction that each of the AUPHA programs would be well advised to re-discover a shared vision of health care as public service, caring for communities as well as for patients and enrolled populations. I am also convinced that each program should be shaping a shared vision of the role of the academic program in providing intellectual leadership in this respect. These processes can be designed to have impact on all of the activities of the program, starting with low hanging fruit, and moving higher with growing confidence and commitment. The key task for AUPHA as an organization right now is ro re-examine its own vision as a basis for providing strong leadership to the field. This involves promoting visioning as a management tool, helping to sharpen the accreditation requirements in this respect, and carrying out the recommendation of the Pew Health Professions Commission to bring the academic and practitioner worlds into closer synch. The talent and the zeal are evident. What is required now is the will to make changes. Continued transformation of the American Health system and of the academic programs in health administration are both inevitable. Managing the transformation is more exciting, more productive, more professionally satisfying and more fun than just surviving or not surviving at all. Managing a transformation is not easy, especially in academia. Just watching it happen is not nearly as satisfying or as much fun. PMID- 10167887 TI - Commentary: scholarship in health administration education. PMID- 10167888 TI - Modeling a health care CQI class after a university-wide TQM program. PMID- 10167889 TI - Overcoming the sudden loss of a dynamic leader. PMID- 10167890 TI - Genetic conditions: who besides the patient do you tell? PMID- 10167891 TI - How I helped save 100 children from a lifetime of deformity. PMID- 10167892 TI - Desperate for a new associate? Try sharing one. PMID- 10167893 TI - Handling patients you wish you didn't have. Discussion. PMID- 10167894 TI - Requests for records driving you crazy? Here's a solution. PMID- 10167895 TI - For $25, I taught a malpractice lawyer a lesson. PMID- 10167896 TI - Is your staff suffering from burnout? PMID- 10167897 TI - "The real future of medicine lies in patients' hands". Interview by Stephen Murata. PMID- 10167898 TI - How to ace a job interview. PMID- 10167899 TI - Medicare. Who's helping the elderly navigate the HMO maze? PMID- 10167900 TI - Managed care. HMO chiefs keep getting the big bucks. PMID- 10167901 TI - End-of-life decisions. More doctors are taking an active role. PMID- 10167902 TI - Got disability insurance? Just try collecting on it. PMID- 10167903 TI - When to report abuse--and when not to. PMID- 10167904 TI - Get your specialists thinking about costs. Subcapitate them. PMID- 10167905 TI - Which industries are sensitive to business cycles? AB - An analysis of the 1994-2005 projections can be used to identify industries that are projected to move differently with business cycles in the future than in the past, and to identify the industries and occupations that are most prone to business cycle swings. PMID- 10167906 TI - Employment in 1996: jobs up, unemployment down. AB - Overall job gains were moderated by losses in nondurable goods manufacturing and Federal employment; declining unemployment was tempered by persistent long-term joblessness. PMID- 10167907 TI - Answering your questions about lab staffers bored with automated tests. PMID- 10167908 TI - Learn to deal with the work force of 2000 and beyond. PMID- 10167909 TI - Nashville sells itself. Companies unite to make city the U.S. healthcare capital. PMID- 10167910 TI - MSA (medical savings account) interest rising. Sales picking up, but 'wait-and see' attitude still prevails. PMID- 10167912 TI - Are CIOs up to the challenge? Survey of CEOs finds lack of confidence in info chiefs. PMID- 10167911 TI - Nadered. Consumer activist says Kaiser threatens patients' health. PMID- 10167913 TI - AHA loses in fight to avoid Medicare pay freeze. PMID- 10167914 TI - In Ga., not-for-profits give more unpaid care. PMID- 10167915 TI - Picking teams in N.C. Academic rivals form systems to defend against for-profits. PMID- 10167916 TI - Fresh start. New Paracelsus leaves old woes, executives behind. PMID- 10167917 TI - Solution or smoke screen? Kaiser, unions hail their alliance, CNA denounces it. PMID- 10167918 TI - Capital infusion needed. Report: senior-living industry will require $400 billion over next 35 years. PMID- 10167919 TI - HCFA computer quandary. Medicare claims system won't do the job, detractors claim. PMID- 10167920 TI - 3 more states on list. Ga., Ohio, Wash. adopt laws on sales of not-for-profits. PMID- 10167921 TI - Opening up to diversity. How your organization can better recruit and retain minorities for executive posts. PMID- 10167922 TI - Quality measures hit prime time. JCAHO's Oryx lights fire under providers. AB - Provider performance measurement systems come in a variety of approaches, but they all target the daunting management frontier of clinical results. The Joint Commission on Accreditation of Healthcare Organizations has bumped up the visibility of such systems by launching Oryx, a program that will make performance measurement an integral aspect of its evaluation efforts. PMID- 10167923 TI - Columbia by the numbers. How the more than 300 hospitals of the nation's largest healthcare company stack up. PMID- 10167924 TI - Transition squeezes vendors. Johnson report sees data market failing to reach its potential. PMID- 10167925 TI - Reversing capitation. PMID- 10167926 TI - Home-care group counters bad press with ad campaign. PMID- 10167927 TI - Filling in the blanks. PMID- 10167928 TI - More conversion laws. PMID- 10167930 TI - Kaiser unions OK pact with AFL-CIO. PMID- 10167929 TI - High court ruling a blow to ERISA plans. PMID- 10167931 TI - Medicaid target. Disproportionate-share funding cuts appear likely. PMID- 10167932 TI - PROs find role beyond Medicare cop. PMID- 10167933 TI - Nurses, it's time to talk. PMID- 10167934 TI - Gallbladder technique set trend. PMID- 10167935 TI - A precedent danger. Academic medical centers fear impact of licensing suit. PMID- 10167936 TI - Questionable combos. FASB taking a closer look at 'pooling-of-interest' deals. PMID- 10167937 TI - AHA: freeze not part of budget pact. PMID- 10167938 TI - But managed-care savings will grow--study. PMID- 10167939 TI - Case could alter scope of kickback definition. PMID- 10167940 TI - A warning over kickbacks. PMID- 10167941 TI - AMA's profits climb 17% in 1996. PMID- 10167942 TI - PPM buys a PPO. Deal expands New York company's reach to Conn., N.J. PMID- 10167943 TI - Baylor system blocked sale with bylaw change. PMID- 10167944 TI - Rivals call off deal. Local docs may benefit from Ohio hospitals' decision. PMID- 10167945 TI - More dumping cases. PMID- 10167946 TI - On its own. Mass. hospital group to sell consulting unit to managers. PMID- 10167947 TI - Calm before the storm? Study predicts modest healthcare premium increases. PMID- 10167948 TI - Blessing withheld. Vatican rejects deal involving N.J. Catholic hospital. PMID- 10167949 TI - A win for docs in Calif. Effort to raise caps on malpractice awards fails--for now. PMID- 10167951 TI - Quality assurance. PROs struggle to keep role in private Medicare plans. PMID- 10167950 TI - Care for the dying. Study urges systems to reassess patients' final days. PMID- 10167952 TI - Fraud? Error? Feds don't care. PMID- 10167953 TI - Managed change. HMOs, PPOs in flux as buyouts, mergers, competition take a toll on the market. AB - While some provider-owned managed-care plans have sold to investor-owned companies, most aren't as bottom-line oriented, according to Modern Healthcare's HMO/PPO Survey. Even plans that lost money last year are investing in information systems, new products, geographic expansion and mergers with other provider-owned plans. Several survey respondents are market leaders that have won national recognition. PMID- 10167954 TI - The care broker. Firm aids Canadians who want to go south for treatment. PMID- 10167955 TI - The state of data affairs. Providers, managed-care organizations want the patient information that state agencies have. PMID- 10167956 TI - An untapped market. Private sector targets industry of caring for the disabled. PMID- 10167958 TI - Battle over bundling. VHA, Johnson & Johnson may settle contract dispute. PMID- 10167957 TI - Not-for-profit victory. Plan to raise for-profits' Medicare payments nixed. PMID- 10167959 TI - Moving abroad. Columbia looks for opportunities to expand overseas. PMID- 10167960 TI - Getting in harmony. As markets change, hospitals struggle with pricing. AB - When it comes to tinkering with pricing strategies, hospitals are no more immune from mistakes than other corporations. Blame it on the changing healthcare market. Before managed care began taking root, most payers accepted hospital rates without much fuss. Now haggling over price discounts is the norm, and payers usually have the upper hand at the negotiating table. PMID- 10167961 TI - Getting beyond the bottom line. PMID- 10167962 TI - Will it work? Despite initial applause, the future of L.A. County's two-plan model for serving Medicaid beneficiaries remains uncertain. PMID- 10167963 TI - Booming Vegas. PMID- 10167964 TI - The doc's the anchor. PMID- 10167965 TI - New transplant policy. PMID- 10167966 TI - Mixing public and private. PMID- 10167967 TI - IPO doldrums. PMID- 10167968 TI - Mass. system gains access to capital pool. PMID- 10167969 TI - Showdown averted. PMID- 10167970 TI - Both sides claim victory. PMID- 10167971 TI - Lilly's costly gamble. PMID- 10167972 TI - Providers applaud suicide ruling. PMID- 10167973 TI - Kaiser's pledge. PMID- 10167974 TI - Who's the underdog? PMID- 10167975 TI - Conversion backlash? PMID- 10167977 TI - Anthem sings Blues. PMID- 10167976 TI - Turnabout in Nebraska. PMID- 10167978 TI - Turning defeat into victory. PMID- 10167979 TI - Prevention inattention. PMID- 10167980 TI - Trolling for dollars. PMID- 10167981 TI - It just can't let go. PMID- 10167982 TI - Looking for a change. PMID- 10167983 TI - Hefty raises. PMID- 10167984 TI - Compromise time. PMID- 10167985 TI - Outlook sunny for HMOs. PMID- 10167986 TI - Vencor takes on risk. PMID- 10167987 TI - Stand-alone vs. unit. PMID- 10167988 TI - A Jewish-Catholic link. PMID- 10167989 TI - Side effects of a deal. PMID- 10167990 TI - Rising trend. PMID- 10167991 TI - Healthcare TV. PMID- 10167992 TI - Medicare for the military. PMID- 10167993 TI - They're doctors, not videos. PMID- 10167994 TI - Injuries in OR. New study finds circulators in need of more protection. PMID- 10167996 TI - Managers help facilities brace as river floods. PMID- 10167995 TI - Lessons from Star Trek can apply in the OR. PMID- 10167997 TI - Cataract surgery tests capacity for change. PMID- 10167998 TI - Activity-based costing powerful, more accurate. PMID- 10167999 TI - Groups warn of dioxin threat in red-bag waste. PMID- 10168000 TI - HMO to contract with teams for surgeries. PMID- 10168001 TI - Paying all the bills. PMID- 10168002 TI - Providers tame risks by: preventing falls. PMID- 10168003 TI - Taming risks by: preparing for disasters. PMID- 10168004 TI - Taming risks by: conducting employee background checks. PMID- 10168005 TI - Laundry services survey. PMID- 10168007 TI - Staying in bounds. The law is quite specific when it comes to what questions employers may and may not ask job applicants. PMID- 10168006 TI - Lowering the odds. Risk management programs can reduce preventable accidents and injuries and, as a bonus, fend off lawsuits. PMID- 10168008 TI - Putting a lock on records. PMID- 10168009 TI - When a resident won't eat. Providers consider advance directives when establishing a nutrition risk protocol. PMID- 10168010 TI - Get the picture. Consumers sound off on health care. AB - You may see yourself as an altruistic volunteer for the health of your community, but the people you're serving have a very different view of you. Consumer focus groups reveal that most people think of hospitals as big businesses more interested in profits than patients. PMID- 10168012 TI - Maintaining the competitive edge through reengineering. PMID- 10168011 TI - Do the right thing. When it comes to your community, do you know what that is? Roundtable discussion. AB - What is the health care organization's responsibility to maintaining a healthy community, and how does the board fit into that role? Has the field's understandable fixation on costs and the penetration of managed care into most markets affected that role? Leaders of both for-profit and not-for-profit organizations often believe that they are fulfilling their community obligations as long as they provide uncompensated care to the indigent and the uninsured. But is that really being accountable to the community? And if it's not, then what is community accountability? The American Hospital Association's Division of Trustee Leadership and Trustee magazine posed these questions to 13 health care and community leaders last December. Their different perspectives provide for some surprising answers. PMID- 10168013 TI - Losing control. Weary of fighting with HMOs, doctors take insurance into their own hands. PMID- 10168014 TI - Mr. Community--and what he taught me. PMID- 10168015 TI - Down but not out. Good planning can spell the difference between downsizing and layoffs. AB - With good strategic planning and market analysis you can trim your organization without a massive employee bloodletting. The trick is to start the planning process before a financial crisis occurs. But it takes visionary leaders to get the efficiency ball rolling when you have a healthy bottom line. PMID- 10168016 TI - Serum cholesterol correlations with atherosclerosis at autopsy. PMID- 10168017 TI - New frontiers in food allergy testing with immunoassays. PMID- 10168018 TI - Quantification of HIV-1 viral load: using branched DNA technology. PMID- 10168019 TI - Therapeutic drug monitoring using fluorescence polarization. PMID- 10168020 TI - Comparison of anterior trunk supports for children with cerebral palsy. AB - The purpose of this study was to demonstrate outcome measures of one seating component--anterior trunk supports--when used by children with cerebral palsy during a functional activity. The functional activity was pressing a single switch to activate a computer software program. Seventeen children with a mean age of 9 years were included in the study. Subjects had mild to moderate spastic or athetoid cerebral palsy. Seven had a primary diagnosis of athetoid and 10 had a primary diagnosis of spastic cerebral palsy. All subjects needed supplemental seating to maintain an upright posture. The four trunk supports tested were an anterior chest panel, a 1-inch-wide single horizontal chest strap, an anterior shoulder support, and a tray with molded chest support. Data included prehits, response time, and the length of time the subject pressed the switch. A repeated analysis of variance test was used to analyze the data. Data for athetoid and spastic cerebral palsy subject groups were analyzed separately. No statistically significant differences were found between the four trunk supports. Therefore, the choice of trunk supports for this population should be based on client preferences, ease of removal for the caregiver, cost, and aesthetics. PMID- 10168021 TI - An analysis of the effects of ramp slope on people with mobility impairments. AB - A study was conducted to evaluate the usability of the range of ramp slopes allowed under the current ADA accessibility guidelines. One hundred seventy-one subjects of all ages and using different types of mobility aids traversed a 30 foot ramp varying in slope from 1:8 to 1:20. Data were recorded for pulse rate, energy expenditure, rate of travel, distance traveled, and the location of rest stops. Findings show that among all subjects only a few manual wheelchair users had difficulty traversing all 30 feet in ascent, even on slopes as steep as 1:8. Based on these results, changes to the technical requirements for ramp slope and length cannot be recommended at this time. PMID- 10168022 TI - Physical accessibility guidelines of consumer product controls. AB - A literature review was undertaken to compile information on the design of consumer product controls (CPCs), concentrating on physical accessibility of electronic devices. Few studies were found that addressed CPC access by people with disabilities; however, information on accessibility for the general population was found. Control guidelines were developed that include information on the application, design, size, force, switch travel, activation/position feedback, spacing, and direction of activation. This information should be helpful to designers of electronic consumer products, researchers interested in product accessibility, and possibly clinicians who are fabricating or modifying equipment for a particular group of people. PMID- 10168023 TI - Transferring technology toward the European assistive technology industry: mechanisms and implications. AB - This paper considers the need, conditions and mechanisms for successful technology transfer toward the European assistive technology industry. The discussion reveals the role of nonprofit institutions in initiating and sustaining a reasonable level of technology transfer since the industry is not likely to achieve this by itself. In particular, it is argued that, given the impediments to successful technology transfer discussed in the paper, there is a need for an organizational entity to assess the needs of the industry, evaluate alternative potential sources of technology based on their relative merits and synergies, coordinate sources and recipients, and provide a minimum infrastructure for such transfers to materialize. To this effect, general mechanisms for transferring technology from one place to another are reviewed and criteria are introduced depicting a tentative evaluation of each of the mechanisms being considered with regard to its contributions toward design for all. PMID- 10168024 TI - Evaluation of a simple approach to modify the supporting property of seating foam cushion for pressure relief. AB - To provide pressure relief at the high pressure areas of the buttocks, small holes were drilled on the polyurethane (PU) foam cushion under the ischial tuberosities areas. This modification was done to locally lower the supporting property of the cushion. This approach could be easily implemented in the clinical setting. Measurements of interfacial pressures at the ischial tuberosities on such modified cushions for eight nondisabled subjects showed an average pressure 25% lower than those measured on foam cushions without modification (p < 0.01). The maximum pressure was 30% lower after modification (p < 0.01) The peak pressure gradient also showed a 38% decrease on modified foam compared to those measured on unmodified foam cushions (p < 0.01). Simple hole drilling could potentially provide an effective approach to enhance the pressure relief characteristics of foam cushions. PMID- 10168025 TI - An interface to enhance mobility for people with hemispatial neglect. AB - The objective was to develop and test a control interface to enable people with hemispatial neglect to maneuver a powered wheelchair with increased attention to their environment. A single case study was conducted using a female (aged 72 years) who had a right cerebro vascular accident five years earlier. She drove a powered wheelchair through 20 different test courses (mazes) while a computer recorded frequency of looking to the left (left checks) and an observer recorded visual targets missed and wheelchair collisions with walls and obstacles. The Mann-Whitney test was used to determine significant differences in left checks, left collisions, right collisions, and percent left checks targets missed between baseline and strategy phases. With the interface strategy, the subject significantly increased the number of left checks and missed fewer left targets in the test course. These results indicate that a powered-wheelchair control interface shows promise in enabling people with mild hemispatial neglect to maneuver a powered chair with greater environmental awareness and ease. PMID- 10168026 TI - Educating the rehabilitation engineer as a service provider. AB - This paper reviews a 12-month masters-level rehabilitation engineering training program to prepare engineers to be rehabilitation service providers. The extent of the rehabilitation engineering shortage is discussed. The curriculum is then provided with descriptions of 16 courses, the program's internship, and a comparison with other training programs. A listing of the intended customers of the program graduates is given along with a description of the advisory committee to help interface with these customers. Four educational goals consisting of disability and technology, major rehabilitation systems, applied skills, and life long learning are discussed. The results of six years' experience with this program, including a survey of graduates, are presented. PMID- 10168027 TI - Avoiding double-counting in pharmacoeconomic studies. AB - In cost-utility analyses of pharmaceutical treatments, the costs are measured in monetary terms and the effects are measured as quality-adjusted life years (QALYs) gained. QALYs are constructed by assigning life years a quality weight between 0 (dead) and 1 (full health). A potential problem in cost-utility analysis is that some consequences, in principle, can be included both in the costs and in the quality adjustment, which can lead to double-counting. This article outlines the double-counting problem in cost-utility analysis. It shows that the potential for double-counting depends on how healthcare and income losses resulting from disease are financed, and on how the questions that assess the quality weights are phrased. Double-counting can be avoided by telling respondents to assume that healthcare costs and income losses are fully reimbursed when quality weights are assessed. The quality weights would then capture the change in health and leisure, and the other consequences could be included in the cost estimation. PMID- 10168028 TI - The effect of pharmacoeconomics on company research and development decisions. AB - There is a strong rationale for integrating pharmacoeconomics into research and development (R&D) project selection and termination decisions. The average cost for the typical new drug introduction now exceeds $US300 million. Furthermore, a growing proportion of phase III projects are terminated because of economic factors relative to efficacy and safety concerns. While the use of pharmacoeconomic studies by payers is still evolving, the pressures on firms to show that new products are cost effective will only intensify in future periods. Accordingly, it is important for firms to begin analysing the cost effectiveness of new drug candidates early in the R&D process. The cost effectiveness of a new therapy can be simulated prior to clinical testing using different assumptions about the efficacy, tolerability, pricing and formulation of the new therapy. These models can be refined and updated as data become available from clinical testing and other sources. A key objective is to make uncompetitive projects fail sooner while channelling development resources to projects with high expected returns. Cost-effectiveness analysis should be an integral component of the firms's strategic action plan and its return on investment analyses. PMID- 10168029 TI - The economic aspects of drug delivery in asthma. AB - The need for cost-effective asthma therapy is driven by the high prevalence of asthma as well as the high cost of both medical care and lost productivity through illness. Limited healthcare resources demand proven therapies that maintain sustained disease control. Optimal disease control is the essence of cost effectiveness, but this in turn is dependent on correct drug selection and appropriate drug delivery. Successful treatment depends on delivery of medication to the site of action in the airways. Although there is a substantial number of aerosol delivery systems available, there is considerable confusion as to the most suitable method in different clinical settings, and across different age groups. Optimal drug delivery can be achieved without adding substantially to the overall cost of therapy. Both drugs and delivery systems need to be individualised to the needs of the patients. The early introduction of oral corticosteroids for acute exacerbations has resulted in reduced hospitalisation and shortened illness, providing substantial cost savings. A reduction in the reliance on nebuliser therapy in both the acute and chronic setting will further optimise therapy and reduce costs. We have reviewed the current literature to determine the most cost-effective methods of drug delivery in asthma. PMID- 10168030 TI - Cost considerations in the pharmacological prevention and treatment of stroke. AB - Stroke remains the leading cause of neurological disability and the third leading cause of death worldwide, consuming a large share of total healthcare expenditures. In this review, we discuss the cost effectiveness of stroke prevention for various risk factor-modification programmes and pharmacological interventions with aspirin (acetylsalicylic acid), ticlopidine and warfarin. Cost considerations and potential cost savings resulting from acute treatment are discussed for parenterally administered anticoagulants, such as heparin and nadroparin, and for intravenous thrombolysis with alteplase (recombinant tissue plasminogen activator; r-tPA). Patients with multiple risk factors for stroke require more aggressive prevention strategies which are associated with a greater risk of complications. The rates of complications, particularly intracerebral haemorrhage, should be kept low to achieve cost benefits for warfarin and alteplase. Reduced hospital length of stay is the key factor in the implementation of cost-effective stroke therapies. The analysis of future clinical trials of new stroke therapies should also include economic parameters, such as length of hospital stay and intensity of resource usage, to help guide formulary and therapeutic decision. PMID- 10168032 TI - Drug treatments for maintaining remission in Crohn's disease. A lifetime cost utility analysis. AB - A recent literature overview has estimated the long term frequency of the main outcomes of Crohn's disease (e.g. relapses, hospitalisations and surgery). Using these frequency data, we defined a model for the long term course of the disease. In this model, the quality-of-life (QOL) scores for the main levels of disease severity were determined by a panel of expert gastroenterologists. We conducted a combined analysis of these long term clinical data and of this QOL information to determine the cost-utility ratio of long term maintenance therapy with mesalazine (mesalamine) in patients with inactive Crohn's disease. After obtaining the cost of-illness data needed for this analysis from a recent study conducted in the UK, we completed our incremental cost-utility analysis, in which mesalazine was compared with no maintenance treatment, using 2 hypothetical groups of 100 patients. These 2 groups were assumed to have the same general characteristics as those found in a group of 583 patients included in a recent meta-analysis. Our cost-utility evaluation included 5% annual discounting. In the mesalazine group, the overall lifetime costs for the 100 patients were around $US5 100,000 with an overall utility value of about 1700 quality-adjusted life years (QALYs). Both the lifetime costs and the utility values for the placebo (no treatment) group were very similar to those calculated for the mesalazine group. Our cost-utility analysis showed that mesalazine maintenance therapy was associated with a cost of about $US5000 per QALY gained. There was, therefore, a small incremental benefit obtained, albeit with a very small incremental cost. Sensitivity analyses confirmed these results. In conclusion, our study showed that long term maintenance therapy with mesalazine in patients with inactive Crohn's disease should not be discouraged on the basis of preliminary cost-utility considerations. However, long term placebo-controlled studies of mesalazine are urgently needed to better define the long term prognosis of these patients. PMID- 10168031 TI - Constraints on antidepressant prescribing and principles of cost-effective antidepressant use. Part 1: Depression and its treatment. AB - Depression is a common, recurrent, disabling and potentially fatal disorder. Its effect on quality of life is more severe than that of some other chronic medical conditions. Its cost burden (direct and indirect) has been estimated at $US26 billion to $US43.7 billion in the US (in 1990), and 3.4 billion pounds sterling in the UK (in 1992). With contemporary levels of diagnosis and treatment, and of treatment failure, the indirect economic losses to society from depression associated morbidity and mortality may be up to 7 times the direct costs, with 69 to 98% of these costs related to morbidity. Impaired capacity while at work may equal absenteeism in terms of costs. Depression carries an increased risk of suicide and suicide attempts, both of which are costly. It is ironic, then, that the drugs used to treat depression account for 9% of poisoning deaths in England and Wales. The newer antidepressants are less toxic than the tricyclic antidepressants (TCAs). The physician's choice of antidepressant should be motivated primarily by clinical considerations, but cost implications are of increasing importance. In some healthcare systems, the expenditure associated with prescribing by doctors has been successfully modified, at least temporarily, by drug formularies, audit and feedback. This may be to the disadvantage of the selective serotonin (5-hydroxytryptamine: 5-HT) reuptake inhibitors; they have higher acquisition costs than the TCAs, since they are newer and lack cheaper generic forms, and definitive evidence of benefits may be inadequate or equivocal. However, market price is only one of many factors that should affect the prescriber, and the increasing trend towards cost containment policies is liable to lead to false economies. PMID- 10168033 TI - Autologous peripheral blood progenitor-cell transplantation versus autologous bone marrow transplantation for adults and children with non-leukaemic malignant disease. A randomised economic study. AB - A prospective economic analysis of autologous peripheral blood progenitor-cell transplantation (PBPCT) versus autologous bone marrow transplantation (BMT) was performed as part of a randomised clinical trial in 129 patient (adults and children) receiving high-dosage antineoplastic therapy for non-leukaemic malignant disease. The clinical assessment criteria of the study were the duration of thrombocytopenia (< 30 x 10(9)/L and < 50 x 10(9)/L) and of granulocytopenia (< 0.5 x 10(9)/L). The cost of medical resources used was the primary economic end-point. We also calculated the cost of reaching 2 specified haematological end-points: platelet recovery (> or = 30 x 10(9)/L) and granulocyte recovery (> or = 0.5 x 10(9)/L). Economic analysis was based on the French hospital perspective. Haematological recovery was significantly quicker in the PBPCT groups (adults and children) compared with the BMT groups. Economic study revealed that the PBPCT groups were clearly less expensive with regard to costs up to discharge (17% decrease of the average cost for adults and 29% for children) and those associated with specified haematological end-points. The global costs of PBPCT were lower than those of BMT for these adult and paediatric populations. Economic arguments can clearly be added to clinical ones in favour of substitution of autologous PBPCT for autologous BMT. International comparisons of diffusion of PBPCT could be of great interest for further economic research into medical innovation. PMID- 10168034 TI - Bootstrap analyses of cost effectiveness in antidepressant pharmacotherapy. AB - In this study, we describe 'bootstrap' methodology for placing statistical confidence limits around an incremental cost effectiveness ratio (ICER). This approach was applied to a retrospective study of annual charges for patients undergoing pharmacotherapy for depression. We used MarketScanSM (service mark) data from 1990 to 1992, which includes medical and pharmacy claims for a privately insured group of employed individuals and their families in the US. Our primary effectiveness measure was the proportion of patients who remained stable on their initial antidepressant medication for at least 6 consecutive months. Our primary cost measure was the total annual charge incurred by patients taking the selective serotonin reuptake inhibitor fluoxetine, a tricyclic antidepressant or a heterocyclic antidepressant. On average, fluoxetine pharmacotherapy tended to decrease annual charges by $US16.48 per patient for each percentage increase in depressed patients remaining stable on initial pharmacotherapy for 6 months, resulting in a negative ICER point-estimate. However, the upper ICER confidence limit is positive, which means that fluoxetine treatment may possibly increase annual per patient charges. With 95% confidence, any such increase was no more than $US130 per patient for each percentage increase in patients remaining stable on initial pharmacotherapy for at least 6 months. One advantage of using a bootstrap approach to ICER analysis is that it does not require restrictive distributional assumptions about cost and outcome measures. Bootstrapping also yields a dramatic graphical display of the variability in cost and effectiveness outcomes that result when a study is literally 'redone' hundreds of times. This graphic also displays the ICER confidence interval as a 'wedge-shaped' region on the cost-effectiveness plane. In fact, bootstrapping is easier to explain and appreciate than the elaborate calculations and approximations otherwise involved in ICER estimation. Our discussion addresses key technical questions, such as the role of logarithmic transformation in symmetrising highly skewed cost distributions. We hope that our discussion contributes to a dialogue, leading ultimately to a consensus on analysis of ICERs. PMID- 10168035 TI - Sumatriptan. A pharmacoeconomic review of its use in migraine. AB - Migraine is a common illness characterised by severe, often throbbing and/or unilateral headache, which may be accompanied by sensitivity to light or noise. A minority of migraine attacks are preceded by transient visual or sensory disturbances. Migraine is associated with reductions in health-related quality of life both during and between attacks. Despite methodological limitations in cost of-illness studies, it is clear that the cost of migraine to society is substantial. Indirect costs (primarily workplace productivity losses) make up 75 to 90% of total costs. Direct costs, such as the cost of drug treatment, physician consultation, hospitalisation and emergency room treatment, make up most of the remainder. Sumatriptan is an effective and well tolerated agent in the treatment of migraine. Its main advantage over other agents used in the acute management of migraine appears to be its rapid onset of action. Sumatriptan reduces headache severity within 2 hours of oral administration in 50 to 67% of patients and within 1 hour of subcutaneous administration in 70 to 80% of patients. Headache recurs in approximately 40% of patients who initially respond to oral or subcutaneous sumatriptan; however, a second dose of the drug is effective against the symptoms of recurrence in a majority of patients. Some patients experience relief of non-headache migraine symptoms, including nausea, vomiting, photophobia and phonophobia. Adverse events reported after sumatriptan are generally mild and transient. Data from studies of patients who used their usual therapies and sumatriptan in nonblinded, sequential phases indicate that both workplace and nonworkplace productivity losses were reduced during sumatriptan therapy. A cost-benefit analysis applied to some of these workplace productivity data indicated that, including direct costs and productivity savings, sumatriptan was associated with a net reduction in total cost of migraine. In retrospective cost analyses, sumatriptan was associated with increased prescription costs: the effect of the drug on other direct treatment costs was less clear. A retrospective pharmacoeconomic model suggested that the cost-effectiveness of subcutaneous sumatriptan versus subcutaneous dihydroergotamine depended on which outcome measure was of greatest interest. For measures of rapid relief of migraine, sumatriptan was superior, but the cost of achieving rapid relief was substantial. Sumatriptan improved global quality-of life scores compared with patients' usual therapy in a randomised crossover trial and appeared to do the same when the drugs were administered in nonblinded, sequential phases in trials which used general and migraine-specific quality-of life instruments. Thus, sumatriptan is associated with a fast onset of action and improvements in health-related quality of life in patients with migraine. However, the cost of achieving rapid relief of migraine symptoms may be substantial. Compared with patients' usual treatments, sumatriptan appeared to reduce workplace and non-workplace productivity losses. However, few economic data from well controlled prospective comparisons of sumatriptan with other available agents are available to quantify the effect of sumatriptan on the overall cost of migraine. PMID- 10168036 TI - Interferon-alpha in hepatitis C. PMID- 10168037 TI - Cost utility in second-line metastatic breast cancer. PMID- 10168038 TI - Burden of migraine. A review of its socioeconomic impact. AB - According to population-based epidemiological studies using International Headache Society diagnostic criteria, the prevalence of migraine in developed countries ranges from 8 to 14%. These prevalence figures confirm the widespread nature of the disorder. Moreover, as migraine is a chronic episodic disorder that predominantly affects people during their working lives (between the ages of 25 and 55 years), indirect costs associated with reduced productivity represent a substantial proportion of the total cost of migraine. The results of health related quality-of-life studies demonstrate that migraine has a considerable impact on functional capacity, resulting in disrupted work and social activities. Many migraineurs, however, do not seek medical attention, have not been accurately diagnosed by a physician or do not use prescription medication. Therefore, the direct costs of treatment for migraine are relatively small compared with the indirect costs. Migraine is an important chronic illness that has a major impact on the working sector of a population. The overall cost attributable to migraine is unknown, but it is now established that the indirect costs of migraine outweigh the direct costs and therefore represent an obvious target for healthcare intervention aimed at reducing the impact of this chronic condition. PMID- 10168039 TI - A multinational investigation of the impact of subcutaneous sumatriptan. I: Design, methods and clinical findings. AB - This report describes the design, methods and clinical results of a prospective sequential multinational (5 countries) study conducted to evaluate the effects of subcutaneous sumatriptan on health-related quality of life, workplace productivity, clinical parameters and patient satisfaction. Adult patients with moderate to severe migraine initially received customary therapy for migraine episodes for 12 weeks, followed by 24 weeks' treatment with self-administered subcutaneous sumatriptan 6 mg. Demographic, baseline, health-related quality of life and patient satisfaction rating data were collected during visits to the clinic. Data relating to migraine symptoms, migraine therapy, work productivity and non-work activity time were collected on diary cards filled out by the patients. 749 patients were recruited to the study and 637 received at least 1 dose of sumatriptan. Overall, 75.5% of migraines were successfully treated within 2 hours with sumatriptan compared with 31.9% with customary therapy; 36% of patients reported complete relief at 2 hours with sumatriptan treatment compared with 1% of patients receiving customary therapy. 69% of patients successfully treated 70% of their migraines with sumatriptan within 2 hours, compared with 12% of patients with customary therapy. No serious adverse events were reported; 50% of patients reported an adverse event during the 12-week customary therapy phase and 89% of patients during the 24-week sumatriptan phase. These clinical results, which are consistent with those reported in randomised blinded studies of subcutaneous sumatriptan, suggest that relief of migraine symptoms occurs more often, and in less time, in patients receiving subcutaneous sumatriptan rather than customary therapy as their primary medication. PMID- 10168040 TI - A multinational investigation of the impact of subcutaneous sumatriptan. II: Health-related quality of life. AB - The aim of this prospective sequential multinational (5 countries) study was to concurrently evaluate the effects of subcutaneous sumatriptan on clinical parameters, health-related quality-of-life (HRQOL) measures, workplace productivity and patient satisfaction. This report presents the HRQOL results. 582 patients (aged 18 to 65 years) with moderate to severe migraine received their customary antimigraine therapy for 12 weeks and then subcutaneous sumatriptan for 24 weeks. The Short Form-36 Health Survey and the Migraine Specific Quality of Life Questionnaire were completed at a screening visit (base line), at the end of the 12-week customary therapy phase, and at 12 and 24 weeks of the sumatriptan phase. Scores for most of the Short Form-36 dimensions improved significantly (p < 0.05) after 12 and 24 weeks of sumatriptan therapy compared with 12 weeks of customary therapy, in each country. Similarly, scores on all Migraine-Specific Quality of Life Questionnaire dimensions were significantly (p < 0.05; paired t-test) improved after 12 weeks (in all countries) and 24 weeks (in 4 of 5 countries) of sumatriptan therapy compared with 12 weeks of customary therapy. This study demonstrates that, in 5 countries, treatment of migraine attacks with subcutaneous sumatriptan compared with customary therapy was associated with improvements in HRQOL, as measured by both general health status and disease-specific instruments. PMID- 10168041 TI - A multinational investigation of the impact of subcutaneous sumatriptan. III: Workplace productivity and non-workplace activity. AB - This report presents the workplace productivity and non-workplace activity results of a multinational study of the effects of subcutaneous sumatriptan 6 mg in the acute treatment of migraine compared with patient's customary therapy. Patients diagnosed with migraine treated their symptoms for 24 weeks with subcutaneous sumatriptan after a 12-week period of treating symptoms with their customary (non-sumatriptan) therapy. Patients used diary cards to record information concerning the effects of migraine on workplace productivity and non workplace activity time. The average workplace productivity time lost was 23.4 hours per patient during 12 weeks of customary therapy, compared with 7.2 and 5.8 hours per patient during the first and second 12-week periods of sumatriptan therapy, respectively. An average of 9.3 hours of non-workplace activity time was lost per patient during the customary therapy phase, compared with 3.2 and 2.8 hours during the first and second 12-week periods of sumatriptan therapy, respectively. Treatment of migraine with subcutaneous sumatriptan compared with customary therapy was associated with an average gain per patient of approximately 16 hours of workplace productivity time and 6 hours of non workplace activity time, over a 3-month period. PMID- 10168043 TI - Facility redesign for your future laboratory requirements. AB - Laboratories must adapt to rapid changes in equipment technology and fundamental changes in the business of health care. A project begins with the creation of a project team representing the laboratory, administration, facilities, architects, and engineers. Each phase of the project works through the various issues affecting the facility, culminating in documents for the actual construction. Review of the codes, the existing physical facility, and the costs associated with the changes are all important in achieving an efficient laboratory. PMID- 10168042 TI - A multinational investigation of the impact of subcutaneous sumatriptan. IV: Patient satisfaction. AB - This report describes the patient satisfaction results from a prospective, sequential, multinational study. The study was conducted to concurrently evaluate the effects of sumatriptan, compared with customary therapy, on clinical parameters, health-related quality of life, productivity and patient satisfaction in adult patients with moderate to severe migraine. Patients treated migraine attacks for 12 weeks with their customary therapy, followed by 24 weeks' treatment with subcutaneous sumatriptan 6 mg. A questionnaire was conducted at the end of each study phase, or retrospectively at the end of the study, to assess patient satisfaction with customary therapy and sumatriptan. Sumatriptan was considered by most patients (67 to 85%) to be dependable and fast-acting, and to have a long duration of effect, allowing a quick return to normal activities. By comparison, 15 to 32% of patients considered that their customary therapy possessed the same attributes. However, customary therapy was considered to be easy/very easy to use by 82% of patients compared with 62% for subcutaneous sumatriptan. 89% of patients indicated that they would use sumatriptan again in the future. This study demonstrates that treatment of migraine attacks with subcutaneous sumatriptan for 24 weeks is associated with greater patient satisfaction as regards specific drug attributes than customary therapy. PMID- 10168044 TI - From slogans to strategy: a workable approach to customer satisfaction and retention. AB - Too many organizations confuse slogans, good intentions, or mechanical phrases with customer service. Most recognize that the most powerful way to prosper in today's economy is to enhance customer satisfaction and loyalty. But customer service has little to do with mottos, slogans, or mechanical phrases. The real management challenge lies in translating the slogans into employee actions that create customer satisfaction and loyalty--in creating a strategy for ensuring good service intentions and exceptional service results. This article shows a logical, theoretically sound approach to building and implementing what I call an E-Plus Customer Satisfaction strategy. Incidentally, I use the term "customer" throughout this article, but I recognize that we have different terms in various organizations. So feel free to substitute "patient", "guest", "client", or any other synonym. The principles are the same. PMID- 10168045 TI - Work process redesign at Vanderbilt University Medical Center's Transfusion Service. AB - Work process redesign is an effective tool to assist laboratories in identifying areas for improvement. This article presents the experiences and results of Vanderbilt University Medical Center's Transfusion Service in undergoing a work process redesign project to reduce costs and increase growth potential. Opportunities for improvement were identified, and processes were redesigned to enhance efficiencies and increase workload capacity. Areas where opportunities for improvement were identified included work-flow, work process, personnel usage, task delegation, information transfer, physical layout, and communication. The thorough review and redesign of the work processes resulted in a greater demonstrated workload capacity of 381% for pretransfusion testing (antibody screens ABO/D typing, and immediate-spin crossmatches), using no additional FTEs. PMID- 10168046 TI - Key performance indicators to assess laboratory operations. Benchmarking for survival. PMID- 10168047 TI - Past, present, future: a continuous cycle of improvement for ancillary glucose testing. AB - As the demand for more rapid testing continues, the laboratory must take a proactive stance in needs assessment and program implementation to meet quality patient care guidelines and regulations for ancillary testing. This 256-bed hospital had a very conventional ancillary testing history. The deficiencies identified in the program by inspection criteria and the concerns of the medical staff created a focus for a laboratory/nursing/medical staff quality improvement team. The Ancillary Glucose Testing Program redeveloped by the team offers a model for active needs assessment, participation, quality assurance, ongoing improvement, and laboratory/nursing cooperation that can be applied to any ancillary testing program. PMID- 10168048 TI - Strategic planning for a small department: Part 2. PMID- 10168049 TI - Case studies in ethics. Modifying physician behavior. PMID- 10168050 TI - The power paradox. AB - Power, the capacity to influence others, produces the most constructive results when exercised in a voluntary partnership with others. Power is paradoxical because the more visible it is, the less it works. The less you have to rely on formal power to get things done, the greater your power actually is. Power begins with the desire to influence your coworkers in a productive manner. There are five potent forms of informal (invisible) power available to everyone in the workplace regardless of their formal authority: shared vision, rapport in relationships, networking, competency, and character. Power enables you to empower your colleagues to pursue the organization's success. PMID- 10168051 TI - Upsizing the downsized organization. PMID- 10168052 TI - Perspectives. States find no easy answers on Medicaid behavioral care. PMID- 10168053 TI - Perspectives. Child welfare programs try out managed care model. PMID- 10168054 TI - Perspectives. Finance puts bold, bipartisan imprint on omnibus reform. PMID- 10168055 TI - Marketplace. Capitation for specialists: plans try to make it work. PMID- 10168056 TI - Hospitals. AB - American hospitals are striving to improve both the quality of medical care and relationships with patients. Many have adopted TQM, an increasingly popular approach to improving the delivery of all services. A growing emphasis on making hospital facilities patient-friendly has resulted, for example, in women having birthing experiences that are far more pleasant they they were for those who gave birth in hospitals only a decade ago. Programs such as these are helping hospitals attract patients and stay competitive. PMID- 10168057 TI - Physicians. AB - As government agencies, insurers, managed care organizations, and employers implement a growing number of regulations and requirements, physicians are being asked to fulfill many roles. In addition to treating patients they must now serve as quality assurance officers and patient advocates. Physicians are struggling to adapt to their new roles. In response to changing public expectations, medical school educators are also changing the way in which the physicians of tomorrow are being trained. PMID- 10168058 TI - HMOs and insurers. AB - Managed care is a term that is unfamiliar to and misunderstood by many Americans. Nevertheless, as health care purchasers in the public and private sectors seek to buy affordable, quality health care, they are turning in greater numbers to various managed care plans. HMOs and insurers are adopting innovative methods with which to improve care of patients and streamline administration. PMID- 10168059 TI - Urban health care. AB - Public hospitals are straining under the burden of having to care for many of the poorest and sickest people in America. The health care problems of the nation's most disadvantaged include infectious diseases such as AIDS and tuberculosis, as well as problems related to violence and lack of access to primary care. Urban hospitals are struggling to address the needs of the indigent, and to find alternatives for those who often rely on emergency rooms for routine care. PMID- 10168060 TI - The pharmaceutical industry. AB - Pharmaceutical research once focused primarily on curing infectious diseases, many of which have been virtually eliminated. Today, there is growing emphasis on finding ways to prevent, treat, and cure chronic illnesses such as cardiovascular disease and cancer. PMID- 10168061 TI - Rural health care. AB - A critical shortage of primary care physicians exists in many rural areas of the United States. Similarly, rural residents are often far from hospitals. These situations have sparked the development of far-reaching programs designed by the federal government and private foundations, along with medical schools, state and local government, physicians, and local volunteers. PMID- 10168062 TI - Medicare and Medicaid. AB - The federal Medicare and Medicaid programs were established as safety nets for the elderly, disabled, and most disadvantaged members of our society. Today, both programs are plagued by increasing demand and diminishing resources, and both are attempting to find ways to care for current and future beneficiaries. PMID- 10168063 TI - Rising to the challenge. AB - An overview of health care in America today. An estimated 37 million men, women, and children lack access to affordable health care. As the cost of medical care continues to rise, millions more face the possibility of joining the ranks of the uninsured. These problems must be addressed. But we also need to consider the many benefits that we derive from our health care system. PMID- 10168064 TI - The state of health care in America, 1993. PMID- 10168065 TI - Employers ... continue to refine cost-cutting methods. PMID- 10168066 TI - Hospitals ... searching for strategies that will allow them to survive the price war begun by managed care organizations. PMID- 10168067 TI - Managed care organizations ... the dominant mode of health care delivery in the United States. PMID- 10168068 TI - Integrated delivery systems ... managed care organizations, hospitals, doctors, and insurers are developing new entities to compete for business. PMID- 10168069 TI - Physicians ... struggle to cope with the demise of the traditional fee-for service payment structure. PMID- 10168070 TI - The state of health care in America. PMID- 10168071 TI - The state of health care in America, 1995. PMID- 10168072 TI - Pharmaceutical manufacturers ... leaving tradition behind and forging new managed care alliances. PMID- 10168073 TI - High technology ... struggling to balance the promise of innovation with the reality of affordability. PMID- 10168074 TI - Home health care ... fastest growing segment of the health care industry. PMID- 10168075 TI - Federal government ... needs to restructure its major health programs--Medicare and Medicaid. PMID- 10168076 TI - State government ... seek greater flexibility to implement managed care solutions. PMID- 10168077 TI - Health care reform ... unprecedented shift to managed care. PMID- 10168078 TI - Can consumers capture the essence of quality? PMID- 10168079 TI - Private matters, public good. AB - Millions of individual outcomes must be analyzed to define the disease management strategies that will make America healthier. How much of our privacy must we surrender in the process? PMID- 10168080 TI - Are we squeezing the life out of hospitals? AB - A decade of cost cutting has left many hospitals in financial disarray, yet others are thriving amid the forces of change. Their creative responses are blueprints for survival. PMID- 10168081 TI - In the shadow of the managed care monolith. PMID- 10168082 TI - Who needs the middleman? AB - Provider-sponsored organizations say they keep third party players from meddling in the doctor-patient relationship. While their viability is uncertain, their focus on quality is raising the competitive stakes. PMID- 10168084 TI - The state of health care in America, 1997. PMID- 10168083 TI - Precipitating factors for pharmaceutical firms. PMID- 10168085 TI - Health reform rediscovers the patient. AB - Do the facts support the premise that our brave new health care system is finally managing care instead of cash? That's the overriding question for 1997. PMID- 10168086 TI - Bridging the consumer information gap. PMID- 10168087 TI - Unintended consequences. PMID- 10168088 TI - The consumer as health care manager. PMID- 10168089 TI - The uninsured: an American time bomb. PMID- 10168090 TI - Should American health care include assisted suicide? PMID- 10168091 TI - Reality check: a snapshot of hospital care. PMID- 10168092 TI - The generalisability of pharmacoeconomic studies. AB - Authors of pharmacoeconomic analyses understandably want their findings to apply as broadly as possible. Also, decision-makers may have to interpret the results of analyses conducted in healthcare settings other than their own. The validity of transferring or generalising results from one setting to another raises important issues for health-economic evaluation. Pharmacoeconomic analyses attempt to model the costs and benefits of alternative treatments in normal clinical practice. Usually, no single clinical study directly provides all the required information, and a variety of data sources is generally included in each analysis. Different data sources present different problems in terms of their relevance to decision-makers. At one extreme, an analysis based purely on trial outcomes and resource use may be precise, but not reflect normal practice; at the other extreme, an analysis using practice data may appear relevant, but be exposed to biases and confounding. Reviews of published studies suggest that general standards have been inadequate in the past. Reapplying such analyses in different localities may simply replicate inadequate findings. The 'perfect' should not become the enemy of the merely 'good'. Models can be helpful in decision-making, provided that they accurately communicate uncertainties in modelling and data. Even so, there will be limits to the generalisability of pharmacoeconomic models, since the required analysis differs between jurisdictions, and because of variations in normal clinical practice. The transferability of research findings re-opens the issue of credibility in pharmacoeconomics. Methodological standardisation, reporting standards and researcher independence are recognised as important factors for enhancing credibility. Where possible, pharmacoeconomic analyses should reflect the findings of systematic reviews of health outcomes to avoid the risk of biased selection of the evidence. In addition, the application of findings to individual healthcare settings must be considered, since cost effectiveness may vary markedly by setting and perspective. PMID- 10168094 TI - Cost effectiveness of smoking-cessation therapies. Interpretation of the evidence and implications for coverage. AB - Smoking cessation has been called the 'gold standard' of healthcare cost effectiveness, producing additional years of life at costs that are well below those estimated for a wide range of healthcare interventions. However, the most effective approaches to smoking cessation are not the most cost effective. As we move from the least resource-intensive interventions (e.g distribution of self help cessation guides) to those that are most resource-intensive (e.g. medical treatments, including the use of nicotine replacement products), both cost and effectiveness increase, but cost increases more rapidly. Nevertheless, it must be considered that different interventions are effective for different people. Resource-intensive treatments may actually be far more cost effective for many people who may not respond to less-intensive interventions. A considered review of the evidence recommends support of all of the major forms of smoking-cessation intervention; even the most expensive are highly cost effective compared with the majority of medical practices that have been studied. Despite their cost effectiveness, smoking-cessation services are not covered by many healthcare providers. This review concludes that such coverage is warranted, primarily because much less cost-effective secondary and tertiary care is covered, encouraging its utilisation, rather than primary prevention. However, the argument favouring coverage is not as clear-cut as might be assumed. Coverage of smoking cessation amounts to a direct subsidy for smokers who want to quit. It is not health 'insurance' in the theoretical meaning of the term. The distinction is important as healthcare systems contemplate future coverage of a range of behaviour-related preventive interventions. PMID- 10168095 TI - A pharmacoeconomic analysis of patients with symptoms of benign prostatic hyperplasia. AB - A pharmacoeconomic analysis of therapies for patients with benign prostatic hyperplasia (BPH) was conducted. The therapies compared were androgenic hormone inhibition (finasteride) and alpha-blockade (doxazosin, prazosin and terazosin). This was a cost-effectiveness analysis from the perspective of the US military. The 36-month decision-tree model considered the aforementioned drugs as initial therapy for BPH following an unsuccessful period of watchful waiting. Therapy was continued toward a successful response. All patients who did not respond to therapy received secondary interventions, including transurethral resection of the prostate (TURP). The main outcome measures were clinical effectiveness and incurred costs. A Monte Carlo sensitivity analysis was performed on all cost effectiveness ratios. The model and sensitivity analysis supported prazosin as the most cost effective alpha-blocker over finasteride: the mean difference was $US381.65 (1994 values) per successfully treated patient, with a range of $US57.83 to $US675.53, in favour of prazosin. If prazosin was used as initial drug therapy after watchful waiting for a man over 50 years of age with classical symptoms of prostatism and no other severe or confounding comorbid conditions, a cost of $US578.15 per treatment could be expected, with clinical effectiveness of 70.3%. Patients who cannot tolerate prazosin should be considered for terazosin therapy before moving on from alpha-blockers. Subsequent treatment with finasteride would cost $US1426.53, with an additional clinical effectiveness of 9.9%. For the small number of patients who fail both therapies, the cost effectiveness of a first TURP as 'third-line' intervention [$US4321.36 for an additional effectiveness of 8.62% and a repeat TURP as 'fourth-line' ($US7650.54 for 0.59%) interventional] was calculated in a similar manner. Costs were cumulative, and effectiveness was derived from the total number of patients who started prazosin therapy. Pharmacological therapy was more cost effective than surgical intervention, and alpha-blockers were more cost effective than finasteride. Among the alpha-blockers, prazosin was by far the most cost effective followed by terazosin, then doxazosin. PMID- 10168093 TI - Constraints on antidepressant prescribing and principles of cost-effective antidepressant use. Part 2: Cost-effectiveness analyses. AB - Cost-effectiveness studies are a useful tool in drug-choice decisions. They are appropriate when alternative therapies have different levels of effectiveness, as with antidepressants. The calculation of cost effectiveness is similar to that used by some authors to determine whether a drug should be included in a formulary, so it clearly has immediate practical application and potential acceptability. However, the actual acceptability of cost-effectiveness studies has been hampered by a lack of conformity over study objectives, methodology and use of available data, and this significantly affects results. Studies that focus on the same location and setting, and conducted at the same time, frequently provide different results in their conclusions, depending on the assumptions and viewpoints, and the effects of sampling error. For example, dosage can affect purchase price calculations, but also compliance and efficacy, which are important considerations. Moreover, conclusions based on cost disadvantages of new drugs are not appropriate for planning for the future, since a drug's market price tends to fall with time and increasing demand. Appropriate use of outcome measures is important, and treatment failures, as well as successes, should be considered. Cost-effectiveness analysis has been used to demonstrate an important point: even when the appropriate use of antidepressants and specialty care increases medical costs, it improves value for money. A variety of drugs for one indication should be available to the prescriber, as the most cost-effective one may differ between patient subpopulations. Many costs of morbidity, adverse effects and secondary effects of antidepressants remain to be properly quantified, but are likely to have an important influence on cost effectiveness. These costs are likely to be higher for tricyclic antidepressants than the newer reversible inhibitors of monoamine oxidase and selective serotonin (5 hydroxytryptamine; 5-HT) reuptake inhibitors. Costing in some areas of health is relatively straightforward. Depression is among the most difficult areas to cost because of its gradation in severity, its chronic and recurrent nature, and its subtle effects on working capacity. Quantification of differences resulting from the use of different drugs has many pitfalls. Until now, each cost analysis of depression has differed from the last, and most have placed excessive reliance on poorly substantiated and hypothetical assumptions. More in-depth studies are required to define the most cost-effective policies for recommendation to healthcare decision-makers and antidepressant drug prescribers. Compliance, adverse effects, and safety in overdose are important factors. The impact of indirect costs also needs to be addressed. PMID- 10168097 TI - Contemporary perspectives in three-dimensional biomedical imaging. PMID- 10168096 TI - Some aspects of the cost of schizophrenia in France. AB - This study aimed to investigate how patients with schizophrenia were treated and to evaluate the cost of treatment in medical and social terms in France. The study was questionnaire-based. 6000 French hospital and community psychiatrists in the public and private sectors received the questionnaire. The 494 psychiatrists who responded described the treatment prescribed for, and social assistance provided to, the last patient consulting for schizophrenia-as defined by the criteria of the third edition (revised) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R)-either as an outpatient or as an impatient in the last year. The clinical, epidemiological and therapeutic data collected on 356 (72%) patients receiving outpatient treatment and 138 (28%) patients receiving impatient treatment in the public (242 patients; 49%) or private (252 patients; 51%) sectors were processed by medical and economic modelling. The mean (+/-standard deviation) time from symptom onset to study entry was 11 +/- 8 years, while the mean time from first hospital admission to study entry was 9.5 +/- 8 years. The mean time from symptom onset to initial hospitalisation was 25 +/- 4 months. 224 patients had been hospitalised in a psychiatric ward at least once in the previous year (45%). The average duration of hospitalisation was 82 +/- 96 days. During the year of the study, 122 patients received part-time treatment in a day hospital or intermediate facility (e.g. occupational therapy centres, therapeutic workshops and therapeutic apartments), 39 (8%) on a daily basis and 83 (17%) one or more times a week; medical care lasted 130 +/- 137 days and 107 +/- 89 days, respectively. The annual complete cost of medical management of the 477 evaluable patients in the study was F27471511 (1992 values). The overall annual treatment cost (medical and social) was F1533724 for medication (5.6% of the complete cost), F2600673 for visits (9.5%), F8285900 for intermediate facilities (30.1%) and F15051214 (54.8%) for hospitalisation. The social allowance cost was F10926000. The average annual costs of medical care and social allowance per patient with schizophrenia were respectively estimated at F54970 and F22905. The annual cost of medical management of schizophrenia in France was thus F12.37 billion ($US2.34 billion). PMID- 10168098 TI - Optical imaging & the computer-based patient record: a step in the right direction? PMID- 10168100 TI - Review of 1993 predictions: a .900 average on forecasts. PMID- 10168099 TI - The Canadian National Calibration Reference Centre for In-Vivo Monitoring. Part II: Sources of errors in thyroid monitoring of occupationally exposed personnel. AB - This article, the second of a five-part series covering various aspects of occupational thyroid monitoring, addresses the sources of error that can affect the final result obtained from thyroid monitoring, such as geometry effects (thyroid size, thyroid depth, precision and accuracy of the detector placement, and neck-detector distance). The article also suggests ways in which these errors can be minimized and identifies those errors that are difficult to quantify. PMID- 10168101 TI - Facing choices about our beliefs regarding support personnel. AB - This article is a rejoinder to the National Perspective (Strickland, 1993) which outlined the Canadian Association of Occupational Therapist's response to the Role and use of support personnel in the rehabilitation disciplines. (Hagler, et al., 1993). An invitation is extended to the Canadian Association of Occupational Therapists to re-examine its position statement on the training, use and supervision of support personnel. The authors consider that the Association's position is based on opinion and misinterpretation, and while they believe that opinions must be respected and that misinterpretations will occur, they challenge these misinterpretations and provide data to refute some of the opinions. PMID- 10168102 TI - 1996 up & comers. Strategies for success. AB - They're bright, focused and aggressive. They're on a mission to improve the quality of America's healthcare provider organizations. They're MODERN HEALTHCARE's 1996 Up & Comers, a dozen healthcare professionals 40 and younger who are in the vanguard of the next generation. PMID- 10168103 TI - Power games. Do you know how to play in the New World of deregulation? PMID- 10168104 TI - The Temperament Program: a children's preventive mental health program. PMID- 10168105 TI - Smoking cessation and health. AB - This comment questions the conclusion of Jones (1994, 1995) that good health creates an incentive to quit smoking. It is argued that in a cross section, a "stock" of quitters and their present health are observed. Health at the time of cessation is unobserved, and the different time passed since quitting causes an unobserved heterogeneity, masking the true relation between health and smoking cessation. An empirical illustration shows that, at least among the elderly, recent quitters, who provide the most appropriate data on that relation, did so because of poor health. PMID- 10168106 TI - Academic medical centers and HMOs--our shared future. PMID- 10168107 TI - Partnerships for the delivery of cancer care. AB - Academic oncologists representing prominent academic medical centers and medical directors representing a variety of HMOs have been meeting to confront the issues separating these two groups. Collaborations for Fostering Quality Cancer Care: Examining Partnerships Between Managed Care Organizations and Academic Medical Centers and Partnerships for the Delivery of Cancer Care were conferences jointly sponsored by the Lombardi Cancer Center of Georgetown University and the Xerox Corporation which looked at the obstacles to successful joint efforts and at successful existing partnerships between academic centers and HMOs. During these sessions it became apparent that there is real concern about the survival of the academic cancer centers and for their research, education and patient care missions. But successful partnerships between academic medical centers and HMOs do exist. These offer a model of working relationships that can incorporate both the traditional missions of the academic medical centers and the need for cost effectiveness which HMOs champion. PMID- 10168108 TI - Cancer, managed care, and therapeutic research: an ethicist's view. AB - The question of whether HMOs should pay for therapeutic oncological research is an important moral question. Simply declaring that a protocol is experimental does not imply that an HMO has no obligation to underwrite the care. On the other hand, the "technological imperative", which states that care should be delivered simply because it is new and technologically advanced is also a false moral premise. HMOs and clinical investigators must both acknowledge that they have competing moral obligations that are sometimes in conflict. They should also accept the formal principle of justice that similars should be treated similarly. If the competing obligations are carefully ranked, it is possible to craft a proposal that meets the criterion of formal justice and simultaneously satisfies all the competing moral obligations. It is suggested that such a proposal would include payment by the HMO for a fraction of care proportionate to the therapeutic motive of the treatment, but that HMOs would also contribute to an all-payer pool to help support therapeutic research. If this, or similar proposals are not considered, the issue will be settled in the courts in a manner that will be detrimental to the nation as a whole. PMID- 10168109 TI - A strategic alliance for bone marrow transplant services: Kaiser Permanente and Stanford University. PMID- 10168111 TI - Growth hormone coverage policy and implementation: a four-year experience. AB - Expenditures for growth hormone (GH) in the United States approximates 400 million dollars annually. There is considerable controversy and variation around both the indications for GH treatment and insurance coverage decisions involving GH treatment. To address these issues, Harvard Community Health Plan (HCHP), now merged with Pilgrim Health Care to form Harvard Pilgrim Health Care (HPHC), developed a policy and implementation plan in 1992 which limited access to GH to those conditions for which GH has been shown to be effective. The 4-year experience of the HPHC Growth Hormone Review Committee, which determines by case review whether criteria for GH coverage are met, is described. The result has been a more rational, equitable approach to decisions about GH treatment coverage, and significant cost reductions. Caution is warranted in expanding access to GH because the potential for serious side effects has not been completely eliminated. Four years after the inception of the policy and approval process (1992-1995), it is estimated that savings have exceeded 1 million dollars. Growth hormone prescribing costs decreased from 13.4% of total to 4.4% of total drug costs 4 years after the new policy was implemented. This approach to policy development and implementation may be applicable to managing high-cost pharmaceuticals and advanced technology in other settings. PMID- 10168112 TI - Measuring patient satisfaction: a post-visit survey vs a general membership survey. AB - OBJECTIVE: To explore the implications of alternative survey approaches for measuring patient satisfaction among members of an HMO. DESIGN: Comparisons of findings on patient satisfaction from two different mail surveys conducted in 1994 of HMO members: a post-visit survey and a general membership survey. SETTING: Kaiser Permanente, Northwest Region (KPNW). PARTICIPANTS: Two random samples of KPNW members: 7680 members surveyed shortly after an HMO office visit; 2142 members from the general KPNW membership roster. MAIN OUTCOME MEASURES: Patient or member ratings of satisfaction with various aspects of services received from physicians, other clinicians, and non-clinician staff, as well as the overall level of satisfaction with the care and service provided by KPNW. RESULTS: Satisfaction is greater for all aspects of care when patients are reporting on specific visits than when members are generalizing about the care they receive from KPNW. But the pattern of satisfaction is highly consistent across the two surveys. Among the sociodemographic characteristics of patients and members, age is the best predictor of satisfaction. CONCLUSIONS: Both surveys have value for managing, monitoring, and evaluating HMOs. The member survey probably reflects something of the reputation of the HMO while the patient survey mirrors more its current functional status. The member survey is probably more useful for managing and monitoring the health care system (which in turn will create its future reputation), but the visit survey provides valuable information for those purchasers and individuals making choices among contemporary health care options. PMID- 10168110 TI - An approach to decisions about coverage of investigational treatments. PMID- 10168113 TI - How to survive and prosper in the health care revolution. PMID- 10168115 TI - A method to reduce high inpatient psychiatric utilization and improve care. PMID- 10168114 TI - Treatment of somatization in primary care: evaluation of the Personal Health Improvement Program. AB - The objective of this evaluation is to examine the clinical utility of a behavioral medicine intervention for treatment of prevalent, ill-defined physical symptoms in primary care. Commonly known as somatization, these symptoms have no known organic or psychiatric cause, and are poorly treated by biomedicine alone. Designed to treat these mood-related physical symptoms, the Personal Health Improvement Program (PHIP) is a 6-week structured group intervention which includes classroom videos, exercises and home study assignments. Data were collected from 21 PHIP courses offered at both staff and group model delivery sites at Harvard Pilgrim Health Care. One hundred and seventy-one participants filled out questionnaires at the first and last session of the course, and returned follow-up questionnaires by mail 3 months later. In order to obtain clinical data, medical charts were reviewed for the periods 1 year before and 1 year after the course. Questionnaire data included a Medical Symptoms Checklist, the Brief Symptom Inventory, the SF-36, a course satisfaction form, and visits to the health care site. After PHIP, participants reported decreases in emotional and physical distress, increases in functional status, and high levels of satisfaction. Patient improvement was also reflected in decreased use of medical resources after a long-standing pattern of high utilization. These data suggest that by addressing physical complaints that are resistant to biomedical treatment alone, PHIP has practical utility, promoting increased quality of care, increased patient satisfaction, and better allocation of health care resources. PMID- 10168116 TI - The Continuous Health Improvement Program: research in an HMO delivery system. PMID- 10168117 TI - Establishing and achieving team-based organization performance measures. PMID- 10168118 TI - Patient surveys motivate unit staff to improve service. PMID- 10168119 TI - Review of JCAHO standards highlights weaknesses. PMID- 10168120 TI - A look behind the rapid growth in healthcare IS. PMID- 10168121 TI - Healthcare IS industry top 100. HBOC tops out 100. AB - The Healthcare Informatics Top 100 ranks the leading information system software providers to the healthcare industry by revenues. Due to the limited focus of the healthcare IS industry, many Top 100 companies serve other markets in addition to IS or healthcare. Thus, to most accurately compare companies, we asked cross industry companies and companies with non-IS specific offerings to separate out those revenues specific to healthcare information systems. For some companies this proved an impossible task. In such cases, we relied on estimated revenues provided by professional sources throughout the industry. (Such companies are marked by an asterisk on the Top 100 list). According to industry analyst Sheldon I. Dorenfest of Sheldon I. Dorenfest & Associates, Chicago, the healthcare information systems marketplace can be divided into three parts: sales of computer and networking equipment account for 62 percent of revenue, software and software associated management services account for 33 percent, and consultation and other management services account for 5 percent. The Healthcare Informatics Top 100 features companies offering software and software associated management services as primary source of revenue (this includes resales of hardware and networking equipment). Companies not eligible for the Top 100 include investment companies, and companies for which consulting, non-software management services, or hardware or medical equipment is the primary source of revenue. PMID- 10168122 TI - Contract management. Providers take control. PMID- 10168123 TI - Instant, trackable remittance processing. PMID- 10168124 TI - Cut your losses. Choose the right claims processing system. PMID- 10168125 TI - Spotlight on claims systems. PMID- 10168126 TI - Beware "return on investment". PMID- 10168127 TI - Market politics. Playing the game at hospitals' expense. PMID- 10168128 TI - How healthy are firewalls? Rating their resistance. PMID- 10168129 TI - Rating the firewall products. PMID- 10168130 TI - Integration consternation. The IDS faces an uncertain future. AB - Many healthcare providers across the country are finding themselves in reactive mode: New York City is a case in point. After years of bureaucratic indolence and excess in which the city trailed the rest of the country in reform initiatives, managed care is now taking the entire state by storm. With the passage of the New York Healthcare Reform Act of 1996, the state is in the process of moving from a highly-regulated, prospective payment system to a competitive system of negotiated rates for non-Medicare payors of inpatient care. PMID- 10168131 TI - Financial applications. Will yours stand the test of time? PMID- 10168132 TI - OSHA cuts red tape on injury/illness reporting. PMID- 10168133 TI - Career moves. Start planning now for your next step. PMID- 10168134 TI - On the move: long-term plans. PMID- 10168135 TI - Leave with wings or on your tail. PMID- 10168136 TI - If you're miserable, you'll love this. PMID- 10168137 TI - Know your scopes. AB - How much do you know about the endoscopes you buy? If you're anything like most of your colleagues in purchasing, the answer probably is, "Not enough." Endoscopes are incredibly complex instruments. They're also very expensive (but you already knew that). So it makes sense to know something about them when making purchase decisions. Endoscope expert Patricia Holland, R.N., marketing and clinical consultant for FiberTech Medical, often provides education on the structure and operation of endoscopes, as well as criteria for selecting them. The following discussion of flexible endoscopes was adapted from her presentation at a recent conference sponsored by the Society of Gastroenterology Nurses and Associates, of which she is a past president. Material provided by FiberTech, an endoscope repair company based in Baltimore, was also incorporated. PMID- 10168138 TI - High-tech boosts costs of clinical engineering. PMID- 10168139 TI - Eager beavers build state-of-the-art CS. PMID- 10168140 TI - 'Pumpathon' puts IV devices to the test. PMID- 10168141 TI - Stats. Communication system decisions: who has a voice? PMID- 10168142 TI - The mind/body connection: improving health through nontraditional approaches. Interview by Mary Jane Gore. AB - Sound, touch and other stimulants to the senses can trigger a visceral response that aids-or impedes-the healing process. At mind/body centers like the one at Mid-Columbia Medical Center, patients work with nontraditional forms of therapy that help them deal with their physical and mental health problems. PMID- 10168143 TI - Gaining staff buy-in for Planetree: answers, involvement, ownership. PMID- 10168144 TI - Quality leaders differ on accountability measures. AB - Leaders of the National Committee for Quality Assurance, Joint Commission on Accreditation of Healthcare Organizations and the Foundation for Accountability agree that performance and outcomes measures need to be standardized-but they disagree on how. PMID- 10168145 TI - Designing for patient-centered care--making it happen in today's marketplace. AB - It's more than just "muffins and massage," Laura Gilpin says of the Planetree program. It's a new level of awareness of patients' concerns and needs. That level of awareness is carried to the patients' surroundings, calm, home-like and friendly to visitors. Caregivers at Griffin Hospital in Derby, Conn.; Mid Columbia Medical Center in The Dalles, Ore.; and Bergan Mercy Medical Center in Omaha, Neb., tell of their experiences and their commitment to this more humanistic approach to patient care. And the cost can be little more than the cost of traditional care. PMID- 10168146 TI - The health care commission has promising substance. PMID- 10168148 TI - What's up on the web. PMID- 10168147 TI - Patients, profits and health system change. Panel discussion. PMID- 10168149 TI - Labor and managed care: an uneasy alliance. PMID- 10168150 TI - And baby makes three. PMID- 10168151 TI - Insomnia: costs to lose sleep over. PMID- 10168152 TI - How much is enough? PMID- 10168154 TI - Data watch. On the Net: what a difference a year makes. PMID- 10168153 TI - Data watch. Cardiologist or gatekeeper: who does it better? PMID- 10168155 TI - Data watch. Workers' comp costs: divergent views. PMID- 10168156 TI - Battlefield Pittsburgh. PMID- 10168157 TI - Today's CIO: catalyst for managed care change. AB - As the impact of managed care increases and capitation becomes all pervasive, healthcare providers' attention to cost control will intensify. For integrated delivery networks (IDNs) to be competitive, today's CIO must leverage managed care as a catalyst for change, and use a sophisticated information system toolset as the means to an integrated end. An area many CIOs target for fast results and maximum cost savings in resource management. This article reviews how Dick Escue, chief information officer at Baptist Memorial Health Care Corporation (Memphis, TN), uses electronic information management systems to integrate and conserve the resources of Baptist's widespread healthcare organization. PMID- 10168158 TI - The modern CIO: forging a new role in the managed care era. AB - The advent of managed care has helped forge new roles for healthcare professionals. Competitive pressures, the profile of the member community, and provider network design drive healthcare delivery via the managed care model. Careful analysis and design of the managed care model charts the success or failure of the health care delivery system--usually an integrated delivery system (IDS). Therefore, those healthcare organizations that have chosen to get on the managed care bandwagon must re-invent themselves, both culturally and technologically. The chief information officer (CIO) leads this technological revolution. To work effectively, the technological infrastructure of the IDS must be closely in line with enterprise goals and objectives. In the managed care environment the old information system (IS) approach of supporting the operational needs of individual departments simply will not work. The CIO's new role will be to master the concept of managed care to ensure that enterprise-wide needs for operational, clinical, and financial information are met, and that IS and enterprise goals are aligned. CIOs who have an intuitive grasp of the managed care environment--although their numbers are growing as managed care mushrooms- make up a minority group. They are a special breed with clearly definable qualities such as business savvy and an affinity for big-picture thinking. To an IDS, a CIO with these qualities is a rare gem indeed. This article introduces Don Winschel, the associate administrator and CIO of Johnson City Medical Center (Johnson City, TN) as an example of one such modern CIO. PMID- 10168159 TI - Wound healing management: enhancing patient outcomes and reducing costs. AB - Biomedical technology as applied to wound healing management allows specific evaluations of the oxygen-related pathophysiology of non-healing wounds. In many of these cases the use of transcutaneous oxygen mapping of the skin and hyperbaric oxygen (HBO) therapy as an adjunctive treatment for non-healing wounds speeds the healing process. While HBO treatment has remained a covered service for hospital-based care, only recently have treatment algorithms for its application in an outpatient setting been available. This technological advancement has also been a factor in the development of cost effective wound healing centers (WHC) in community hospitals. Better outcomes for many chronic wounds are achieved by combining a multidisciplinary team approach using advanced technologies. In this article the case of a soft-tissue radiation necrosis ulceration of the leg successfully treated with adjunctive HBO is presented. In this example, a reduction in patient charges of greater than 30% was achieved as compared to costs associated with traditional surgical/hospital management of the condition. PMID- 10168160 TI - Building healthcare confidence. PMID- 10168161 TI - Measuring and improving outcomes in managed care. PMID- 10168162 TI - From the Internet to the Intranet: Part I. PMID- 10168163 TI - More than a question of loyalty. PMID- 10168164 TI - Symposium: Issues in AIDS services delivery. PMID- 10168165 TI - Issues in AIDS services delivery: a symposium. Introduction. PMID- 10168166 TI - A tale of two health care delivery systems. PMID- 10168167 TI - AIDS services in Florida: who's doing what, and who's paying for it? AB - The rapid growth of AIDS in the 1980s was paralleled by a rapid growth in AIDS Service Organizations (ASOs) throughout the United States. This article examines one state, Florida, and the 52 ASOs to determine each ASOs organizational affiliation, major types of service offered, sources of funding, and geographic dispersion in the state. Based on the results of this examination, several research and policy implications are discussed. PMID- 10168168 TI - Medicaid AIDS waivers: seeking cost effective financing of AIDS care. AB - The epidemic of Acquired Immunodeficiency Syndrome (AIDS) emerged at a time of transition in American health care and health care policy. The waiver of traditional Medicaid limitations on home and community-based health care services for persons with AIDS has been utilized by several states attempting to demonstrate models of care where quality of life as well as financial concerns are addressed. The Medicaid AIDS Waiver programs in New Jersey and Florida note promising results in the cost-effectiveness of such programs when compared with traditional Medicaid. Variations in patient participation by geographic area and demographic characteristics indicate areas for future improvement in program accessibility. PMID- 10168169 TI - Volunteer burnout and dropout: issues in AIDS service organizations. PMID- 10168170 TI - An analysis of employees' job involvement in a community-based AIDS service organization. AB - This study analyzes employees' job involvement in a community-based AIDS Service Organization (ASO). The study reveals that these employees have a relatively high level of job involvement and that three job-related factors are significantly correlated to the job involvement. The three factors are: employees' perceived job security, attitude toward their organization, and the conflict between job and family. The study further explains the importance of these findings to the management of ASOs. PMID- 10168171 TI - Nonuse of local hospitals by rural Medicare beneficiaries. AB - Previous studies of hospital utilization by rural residents suggest that local hospitals were often bypassed for treatment in larger, urban hospitals. This study examines hospital utilization by aged rural Medicare beneficiaries in Minnesota and Kentucky residing in zip codes that have local hospitals using FY 1987 Medicare discharge data. Most of these beneficiaries were hospitalized locally. Beneficiaries not using hospitals likely did so because cardiovascular surgical procedures were required and were often only performed in large urban teaching hospitals. Bypassing appears to be due to regionalization of care rather than dissatisfaction with local hospitals. PMID- 10168172 TI - National health care reform and a single-payer system: messiah or pariah? AB - U.S. health care spending consumed about 14% of the GDP in 1992 and current trends threaten to boost this figure to 18% by the year 2000 (CBO, 1992). Our health care delivery system needs an overhaul but there is evidently little consensus on what format a new system should follow. Persuasive befuddling, and frequently contradictory, suggestions have ranged from the federal government's active involvement in a single-payer national health care plan to enactment of a nationwide mandate compelling (taxing?) employers to provide a minimum health benefit package to all workers. There were two common objectives shared by the major, recently contending health care reform proposals: first, to provide universal access to health care with assurances that coverage is maintained when economic circumstances change or when someone experiences poor health; second, to stunt the growth rate of health care spending nationally. Single-payer alternatives, previously introduced by Congressman McDermott and others, would have required a heavy federal subsidy, regulation, and blocking directing each state to establish and administer a health care system covering its entire population. Currently, the single-payer system has become a fading contender in a dissolving list of health care reform options that previously included a new, widely publicized option embracing managed care and so-called "managed competition." Most recently, however, the single-payer proposals have apparently gone nowhere, seriously sustaining sound political defeat. Divergent views of proponents and detractors of a single-payer plan, its funding and operation, are presented. It has become extremely difficult to get Congress to advance any particular proposal because of dire, unsubstantiated socioeconomic impact hypothesizing and the unrestrained politicizing of the health policy formulation process. On February 10th, 1994, the prestigious American College of Surgeons literally stunned the national health care community by its surprise public declaration of conceptual support for the still highly controversial legislative health care reform long-shot, the Single Payer Health Plan (Mcllarth, 1994). As individual physicians weighed the contentious single-payer health care issue against alternatives (O'Heany and Berry, 1994), many health care provider groups even now remain adamantly opposed to a single-payer system (Mitka, 1994), not unexpectedly including the vocally conservative leadership of the American Medical Association (Culhane, 1994; Cotton, 1994). As spokesman for the American College of Surgeons (ACS). Chairman David Murray MD, indicated that the 60,000 member group acted out of frustration with current insurer-run managed care plans and a desire to bring out reforms that permit patients to choose the physician or surgeon. At the time, Murray emphasized that the college had not endorsed any specific single-payer bills that were pending then in Congress and had a number of significant differences with the former leading contenders which had been sponsored by Rep. Jim McDermott MD (D. Wash.) and Sen. Paul Wellstone (D. Minn) (Mcllarth, 1994). However, testifying subsequently before the House Committee on Education and Labor, Dr. Murray said that single-payer approaches probably present the best assurances that patients could seek care from any physician they choose and that single-payer approaches could probably be made more simple and administratively workable (Cotton, 1994). Again, that time, Dr. Murray expressed concern about the extensive power that would have been granted to health insurance purchasing under the now defunct Clinton administration's "managed competition" health care reform package, HR 3600 (Ibid.). These concerns were shared by others (Geisel, 1993; Wagner, 1993). (ABSTRACT TRUNCATED) PMID- 10168173 TI - Strategies of the treatment of type II diabetes mellitus. AB - In Type Diabetes mellitus (DM), the two primary defects that occur are insulin resistance and impaired insulin secretion. Currently, no data exist showing improved outcomes or reduced macrovascular complications with tight glycemic control in Type II DM, and only minimal data shows a reduction of microvascular complications. Still, the current standard of practice is to attempt to attain glycemic goals in patients with Type II DM. As an attempt to resolve this issue, the United Kingdom Prospective Diabetes Study (UKPDS) was initiated. This 11-year study is comparing conventional therapy to intensive therapy in patients with Type II DM. The American Diabetes Association's (ADA) guidelines state that either sulfonylureas, metformin, acarbose, or insulin can be used as first-line treatment for Type II DM; however, oral agents can be attempted first in most patients. Until results from the ongoing UKPDS trials are available, the guidelines for glycemic control from the ADA should be followed. PMID- 10168174 TI - Important aspects of self-management education in patients with diabetes. AB - The Diabetes Control and Complications Trial has shown that the long-term complication of diabetes can be decreased with intensive glycemic control. However, comprehensive patient education is required to provide the patient with the self-management skills necessary to achieve this level of glycemic control. Epidemiologic data indicate that large numbers of patients do not receive the proper care or education necessary to develop such self-management abilities. In order to convey the importance of patient education, the American Diabetes Association (ADA) has labeled self-management education as a cornerstone of therapy for patients with diabetes. Standards of care have also been defined by the ADA. Within the current U.S. health care system, however, limitations are present that may affect the quality of care and ability to provide adequate patient education. Therefore, it is the responsibility of the health care provider to improve the education process in an attempt to maintain standards of care outlined by the ADA. When developing a diabetes self-management training program, the ADA national standards can be used as a guideline. PMID- 10168175 TI - Approach to the treatment of diabetic nephropathy. AB - Renal failure is a common long-term complication of diabetes mellitus. Stages of diabetic nephropathy have been described that characterize its clinical course. Diabetic nephropathy develops secondary to long-standing hyperglycemia and hemodynamic changes that damage the glomerulus. Therapy that focuses on the control of glomerular pressures and systemic hypertension can slow the progression of proteinuria and deterioration of renal function. Angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers have been demonstrated to be effective in the management of diabetic nephropathy. A systematic approach to the patient with diabetes with annual screening for proteinuria will help identify those individuals early in the course of disease when proper therapy may be most helpful. PMID- 10168176 TI - Managing the care of the diabetic transplant patient. AB - Care of the diabetic transplant patient presents many challenges for therapeutic management. Complications of diabetes such as retinopathy, neuropathy, hyperglycemia, and hypertension add to the already difficult management of nondiabetic transplant patients. The role of the pharmacist as an educator, counselor, and interaction and profile manager is an essential part of a successful transplant program. Understanding the purpose of the medications and their side effects is vital for the patient to comply with a demanding medication regimen. This depth of understanding cannot be conveyed without repetitive educational efforts that are reinforced by all of the health care practitioners and supportive family members. Although kidney transplantation offers freedom from dialysis, it does not offer freedom from insulin dependence. Kidney pancreas, pancreas, or islet cell transplantation may provide insulin independence and are the only curative interventions available. Evaluation of the research literature compares the advantages and complications of these surgical modalities. Early intervention with transplantation may offer insulin-dependent diabetics a new opportunity to improve their quality of life; however, intensive educational efforts and assurance of compliance are essential for successful outcomes. PMID- 10168177 TI - Applying the principles of pharmaceutical care to the patient with diabetes. AB - Current medical care for patients with diabetes neither meets the guidelines from the American Diabetes Association (ADA) nor approaches the levels of intensive care in the Diabetes Control and Complications Trial (DCCT). The drug-use process for patients with diabetes could be enhanced by improving the way in which drug therapy is monitored and managed. The concept of pharmaceutical care strategically redefines the drug-use process into a pharmaceutical care system in which the pharmacist takes responsibility for monitoring the effects of drugs and acts to resolve drug-related problems before they become a drug-related morbidity. A method for implementing a pharmaceutical care service using practice guidelines to help a pharmacist provide consistent care to all patients with diabetes is discussed. PMID- 10168178 TI - The role of the clinical specialist in reengineered pharmacy departments. PMID- 10168179 TI - The impact of scheduling patients for refills on the process of providing pharmaceutical care and prescription revenue. PMID- 10168180 TI - The impact of methodological and drug development issues on the use of economic data generated by clinical trials. PMID- 10168181 TI - PPS would be disastrous for subacute providers unless changes made, warn industry leaders. PMID- 10168182 TI - Subacute industry preparing for battle over budget. PMID- 10168183 TI - HCFA not in favor of replacing survey and certification procedures. PMID- 10168184 TI - OIG issues model compliance plan for clinical laboratories. PMID- 10168185 TI - Tax-exempt bonds, Internal Revenue Service releases, Revenue Procedure 97-13. PMID- 10168186 TI - Can patients understand their consent forms? PMID- 10168187 TI - Lab redesign project brings massive cost cuts, improves care quality. PMID- 10168188 TI - Redesign team had to fight resistance from all sides. PMID- 10168189 TI - 'Room service' food delivery brings big savings. PMID- 10168190 TI - Should 'hospitalists' be part of your PFC redesign? PMID- 10168191 TI - Six ways to stunt your growth. PMID- 10168192 TI - Recognizing your forgotten donors. PMID- 10168193 TI - Should governments subsidize the use of insecticide-impregnated mosquito nets in Africa? Implications of a cost-effectiveness analysis. AB - Recent large-scale field trials show that mosquito nets impregnated with insecticide can substantially reduce all-cause mortality in children in malaria endemic areas in Africa. This paper considers the cost-effectiveness of impregnated nets, initially from the perspective of a government programme which would distribute nets free of charge and organize and fund re-impregnation on an annual basis. The calculations show that with the reductions in all-cause mortality observed in the trials, complete government subsidy of nets through a vertical programme would represent an efficient use of scarce resources for most combinations of assumptions. However, alternative ways of financing and organizing the use of impregnated nets are also possible and may be more cost effective than vertical delivery. Distribution of nets and insecticide might be less costly than required for a vertical programme by integrating delivery with other types of government health programmes, with private sector delivery systems for other types of products, or with government systems developed for other sectors such as agriculture. Further, not all the costs need to be met by governments, as costs could be shared with donors, NGOs and the beneficiaries. The major conclusion is that impregnated nets would save a large number of lives in malaria endemic areas, they are an efficient use of scare resources, and ways of encouraging their use need to be developed and tested. PMID- 10168194 TI - Cost-effective treatment for severely malnourished children: what is the best approach? AB - In urban Bangladesh, 437 children with severe malnutrition aged 12-60 months were sequentially allocated to treat either as i) inpatients, ii) day care, or iii) domiciliary care after one week of day care. Average institutional cost (US$) to achieve 80% weight-for-height were respectively $156, $59 and $29/child. As a proportion of the overall costs, staff salaries were the largest component, followed by laboratory tests. Parental costs were highest for domiciliary care, as no food supplements were provided. Nevertheless it was the option most preferred by parents and when the institutional and parental costs were combined, domiciliary care was 1.6 times more cost-effective than day care, and 4.1 times more cost-effective than inpatient care. CONCLUSION: With careful training and an efficient referral system, domiciliary care preceded by one week of day care is the most cost-effective treatment option for severe malnutrition in this setting. PMID- 10168196 TI - Health status during the transition in Central and Eastern Europe: development in reverse? AB - This paper reports on a study of the cross-national trends in health status during the economic transition and associated health sector reforms in Central and Eastern Europe (CEE). The central premise is that before long-run gains in health status are realized, the transition towards a market economy and adoption of democratic forms of government should lead to short-run deterioration as a result of: (i) reduction in real income and widening income disparities; (ii) stress and stress-related behaviour; (iii) lax regulation of environmental and occupational risks; and (iv) breakdown in basic health services. Analysis focused on three broad indicators of health status: life expectancy at birth, infant mortality rate and the probability of dying between the ages of 15 and 65 years, shown by the notation '50q15'. The study revealed significant new information about health status and the health sector which could not have been obtained without a proper cross-national study. Infant mortality rates in former socialist economies (FSE) follow the global trend, declining as per capita income rises. However, rates are lower than would be predicted given their income levels. Despite declining infant mortality, life expectancy at birth in the former socialist economies decreases as per capita income rises, in marked contrast to global trends. This is because rising income level is associated with greater probability of death between the ages of 15 and 65: the wealthier the society, the less healthy is its population, particularly for its males. Causes of death in the FSE follow global trends: higher death rates due to infectious and parasitic diseases in poorer countries, and higher death rates due to chronic diseases in wealthier countries. However, age-standardized death rates for chronic diseases generally associated with unhealthy lifestyles and environmental risk factors are very high when compared with wealthier established market economies (EME). Policies and procedures which alter the effectiveness of health services have had a demonstrable but mixed impact on health status during the early phase of transition. Effective preventive health strategies must be formulated and implemented to reverse the adverse trends observed in Central and Eastern Europe. PMID- 10168195 TI - Dirt and diarrhoea: formative research in hygiene promotion programmes. AB - Investment in the promotion of better hygiene for the prevention of diarrhoeal diseases and as a component of water and sanitation programmes is increasing. Before designing programmes capable of sustainably modifying hygiene behaviour in large populations, valid answers to a number of basic questions concerning the site and the intended beneficiaries have to be obtained. Such questions include 'what practices favour the transmission of enteric pathogens?', 'what advantages will be perceived by those who adopt safe practices?' and 'what channels of communication are currently employed by the target population?' A study of hygiene and diarrhoea in Bobo-Dioulasso, Burkina Faso, used a mixture of methods to address such questions. This paper draws on that experience to propose a plan of preliminary research using a variety of techniques which could be implemented over a period of a few months by planners of hygiene promotion programmes. The techniques discussed include structured observation, focus group discussions and behavioural trials. Modest investment in such systematic formative research with clear and limited goals is likely to be repaid many times over in the increased effectiveness of hygiene promotion programmes. PMID- 10168197 TI - Challenges in implementing a budget-holding programme for primary care clinics. AB - In 1990, Kupat Holim Clalit (KHC), Israel's largest sick fund, initiated a demonstration programme for transforming a number of primary care clinics in the Negev district of southern Israel into autonomous budget-holding units. Four programme components were implemented in the nine participating clinics: allocation of a fixed budget; expansion of day-to-day decision-making authority; establishment of a computerized information system to produce monthly reports on expenditure; and provision of incentives for budgetary control. The research findings are based on a four-year evaluation of the programme, which involved a longitudinal case study conducted with multiple research tools: in-depth interviews, a staff survey, and analysis of relevant documents. This article analyzes the challenges involved in implementing the demonstration programme. It examines clinic staff evaluation of the implementation process (e.g. overall staff had a positive attitude toward it); assesses staff satisfaction with clinic participation in the programme (while only 33% were satisfied, only 21% said they would like the clinic to revert to the pre-programme model) and factors influencing this satisfaction (among them intrinsic benefits, perception of the programme as fair and age); and discusses the lessons to be learnt from the programme regarding effective implementation of organizational change. The main lessons indicate the importance of certain factors in implementing such programmes: (a) long-term management commitment to the programme; (b) appointment of agents of change/programme administrators; (c) establishment of a formal agreement between the parties involved; (d) establishment of communication channels between the parties involved; (e) intrinsic benefits for staff, perceived as incentives to economize; (f) reliable data, perceived to be reliable by the parties involved; (g) staff participation in the process of change; and (h) involvement of the participating unit as a single entity. PMID- 10168198 TI - Reducing perinatal mortality in developing countries. AB - The perinatal mortality rate (PNMR) is a key health status indicator. It is multifactorial in aetiology and is significantly influenced by the quality of health care. While there is an ethical imperative to act to improve quality of care when deficiencies are apparent, the lack of controls--when an interventions is applied to an entire service--makes it difficult to infer a causal relationship between the intervention and any subsequent change in PNMR. However, by specifically measuring avoidable perinatal deaths (those due to error or omission on the part of the health service), this limitation is partially overcome, and the impact of the intervention can be more rigorously evaluated. This paper reports the impact of perinatal audit in a rural African health district between 1991 and 1995. A total of 21,112 consecutive births were studied: the average number of deliveries increased by 31% from 325 to 424 per month. The PNMR (birth weight > or = 1000g) in 1991 was 27/1000, increased to 42/1000 in 1992, and fell steadily to 26/1000 in 1995 (40% reduction; p = 0.002). The proportion of avoidable deaths fell from 19% in 1991 to zero in the second half of 1995 (p = 0.0008). While factors associated with perinatal mortality are many, complex, and interrelated, this report suggests that mortality can be reduced significantly in resource-poor settings by improving quality of health care. Including the measurement of avoidable deaths in perinatal audit allows the impact of interventions to be more rigorously assessed than by simple measuring the PNMR. PMID- 10168199 TI - The effect of type of hospital and health insurance on hospital length of stay in Irbid, North Jordan. AB - The study aimed at examining the effects of type of hospital and health insurance status on hospital length of stay for three identified medical and surgical conditions. Medical records of 520 patients for the year 1991 were reviewed in one public and one private hospital. Comparison of hospital length of stay for the private (n = 185) versus public sector patients (n = 335) was carried out. The effect of presence of health insurance (n = 189) and the lack of it (n = 325) was also studied. It was found that the average length of stay in the public hospital was significantly longer than the private one (3.3 versus 2.7 days). In addition, insured patients had significantly longer hospital length of stay (3.3 versus 3.0 days). The results of the multi-variate analysis showed that after socioeconomic factors and clinical conditions of patients were adjusted for, the influence of hospital type and health insurance on hospital length of stay was about one day. The paper also discusses the need to base hospital cost containment strategies on studies of hospital behaviour and performance. PMID- 10168200 TI - Getting sensitive information on sensitive issues: gynaecological morbidity. PMID- 10168201 TI - Pesticides and immunosuppression: the risks to public health. AB - There is substantial experimental, epidemiological and other evidence that many pesticides in widespread use around the world are immunosuppressive. This poses a potentially serious health risk in populations highly exposed to infectious and parasitic diseases, subject to malnutrition, and inadequately serve by curative health programmes. An expanded programme of research is needed to investigate this potential risk and to design precautionary measures. PMID- 10168202 TI - Managed care resurrects 'dumping' fears. PMID- 10168203 TI - Deal with latex allergy now--it's not going away. PMID- 10168204 TI - Spotting alcohol-dependent patients improves care. PMID- 10168205 TI - New discharge, UR process reduces Medicare losses, cuts LOS. PMID- 10168206 TI - Hospital Santa Engracia, Monterrey, Nuevo Leon, Mexico. PMID- 10168207 TI - Clinical directors. Beyond the call of duty. PMID- 10168208 TI - Emergency admissions. The wrong side of bed. PMID- 10168209 TI - Mental health. Cross purposes. PMID- 10168210 TI - Data briefing. Promises, promises. PMID- 10168211 TI - Communications. Talking heads. PMID- 10168212 TI - Mental health. Over the rainbow. PMID- 10168213 TI - Career profile. Nurse managers--doing their own thing. PMID- 10168214 TI - Mental incapacity and consent to treatment. Who gives the go-ahead? PMID- 10168215 TI - Minors and the right to refuse treatment. Major problems with minors. PMID- 10168216 TI - Personnel policy. Relative values. PMID- 10168217 TI - Personnel policy. Juggling act. PMID- 10168218 TI - Has anyone paid the tax yet? Will anyone pay the tax? PMID- 10168219 TI - Pacemaker prices holding firm. PMID- 10168220 TI - Hospitals scramble to define latex issues in glove policies. PMID- 10168221 TI - Rotational therapy beds: are they worth the cost? PMID- 10168222 TI - Managing hospital equipment, step by step. PMID- 10168223 TI - Roping down managed care. PMID- 10168224 TI - If you don't befriend your patients, your competitors will. PMID- 10168225 TI - Multispecialty groups: still the provider of choice for HMOs. PMID- 10168226 TI - They kiss babies, don't they? So why can't Congress pass children's health insurance? PMID- 10168227 TI - A doctor goes to prison for his medical judgment. PMID- 10168228 TI - Go East, young doctor. PMID- 10168229 TI - Quality: your new pay yardstick. PMID- 10168231 TI - It's getting easier for employers to sue you. PMID- 10168230 TI - What's a doctor doing selling Amway? PMID- 10168232 TI - Mandatory POS (point-of-service). Idaho law forces HMOs to pay for non-network care. PMID- 10168233 TI - Staying not-for-profit. Michigan hospital drops talks with Columbia. PMID- 10168234 TI - Back in business. Suit against N.Y. merger shows feds' antitrust concern. PMID- 10168235 TI - Skilled-nursing PPS plan draws fire. PMID- 10168236 TI - Tax bout, round 3. Hospital sectors sparring again over Medicare compensation measure. PMID- 10168237 TI - To freeze or not to freeze. Debate over Medicare inpatient pay gets emotional, silly as AHA digs in heels. PMID- 10168239 TI - Seeking real partnership. Ohio hospital, physician practice form 50-50 venture. PMID- 10168238 TI - Senior services. Hospitals around the country have seen the future and it is gray. AB - Hospitals across the country are busy adding services and making investments in new facilities and renovations to serve the exploding senior-services market, which has estimated annual revenues of more than $124 billion when the assisted living, skilled-nursing and home-care industries are combined. MODERN HEALTHCARE looks at what providers in three diverse major markets are doing to stay competitive. PMID- 10168240 TI - Taking charge of quality. Institute teaches caregivers to set achievable improvement goals. PMID- 10168241 TI - The 'lost profit' world. Payment recovery firms target lucrative healthcare industry. PMID- 10168242 TI - Getting specific. Committees dicker over balanced-budget plan details. PMID- 10168243 TI - Have radiology administrators given up? PMID- 10168244 TI - From technologist to manager. PMID- 10168245 TI - Triage: a refocused concept. PMID- 10168246 TI - AHRA survey. Nuclear medicine operations. PMID- 10168247 TI - AHRA survey. Assessment of technologist education. PMID- 10168248 TI - Avoid stress and burnout! PMID- 10168249 TI - Breaking down professional silos: the potential of integrated management. AB - The "change" train is headed down the track. You can be on board the train, be under it, or be left at the station, but this train will continue with or without you. Patients, families and healthcare professionals believe that healthcare is delivered in a fragmented fashion. Our silos--our departments, the facilities we are associated with, our professions and professional associations--are under attack and must respond. Schools are educating students to practice in a place that just isn't there anymore. Many educators have been away from the healthcare arena too long. Critical factors for an organization's success, in business and in healthcare, include having a seamless, aligned and simplified operation that offers high value. The successful healthcare organization must be financially viable. It must harness technology's potential, particularly in information systems, to improve the work we do. Change must be lead or driven from the top. Concepts must be sold to staff, family members and patients so each group believes its best interests are served. PMID- 10168250 TI - Project planning in the diagnostic imaging department. AB - Certain common steps in the planning process are necessary to ensure the success of any construction project in a diagnostic imaging department. Determining the need for the project, analyzing requirements for equipment, space and personnel, and budgeting for the project are necessary steps. They are followed by scheduling and designing the various aspects of the project. Engineering the construction phase and implementation with follow-up are the last steps. Determining whether a proposed project is necessary is the essential first step. Doing a cost-benefit analysis and determining if the return on the investment will be positive are important for a project's success. Good planning and communication with key staff members of the healthcare institution and the members of the design and construction team will help ensure successful implementation of any project. The role of the facility engineer is often critical in the early planning stages of a project to determine what utilities may be needed, any need for plumbing or electric work, power sources, building code requirements, the need for medical gasses and suction and so forth. Analysis of a potential project's equipment, space and personnel needs is also critical. Gathering the necessary information from various sources within the healthcare institution is essential. The steps for scheduling and designing an entire project should include finalizing the design and developing a schedule for its implementation. Keeping accurate minutes and documenting action items from all project meetings can serve to protect the budget. By following the steps outlined, budgeting time efficiently and delegating some tasks to others, the radiology administrator can continue to perform tasks involved in the day-to-day management of a radiology department. PMID- 10168251 TI - Call a medical physicist: a guide to troubleshooting. AB - A catastrophic problem may occur when an imaging system suddenly fails. In most cases, however, a problem comes on gradually until the imaging quality is so far degraded it becomes clinically unacceptable. In that circumstance, pressure is put on the technologist to do something quickly to improve the quality of the images. There are several guidelines to follow when a similar situation occurs in your workplace. First, any correction should be made rationally using the data at hand. Don't rush to change a lot of things all at once or you'll never know what did work. Putting in a call to a physicist may be in your best interest as the second step to follow. A qualified diagnostic medical physicist has an overview of the principals and applied technology of the imaging process. Both the radiologic technologist and the technical representative from film or x-ray and film processor companies have training in all areas of x-ray technology. It is the physicists' many years of training in the application of scientific methods to medical imaging problems that provide an edge in diagnosing technical problems. Their strength is that they are good with scientific concepts and numbers. Don't let the physicist leave until the problem has been shown to be solved. Bring in the service engineer to run a control strip to show that the remedy has indeed had the desired effect with no undesirable side-effects. Document the problem and the solution is the fourth rule, while rule five is to use the physicist to coordinate the process, objectively measure and assess the results of any change. You'll be back on line more quickly and will know what went wrong. PMID- 10168252 TI - Should technologists tell everything they know? AB - Students and staff technologists used to be taught to give no information to patients, an easy stance but hardly justifiable. Today's technologists are professional practicing in advanced settings; today's patients want and often demand information. How do we ensure that the pendulum of providing healthcare information does not swing from telling patients nothing to telling patients everything? Only recently have patient-care texts begun to recognize this as a dilemma, with the unanswered question remaining: how much do we tell them when they ask? The desire to look like an expert may lead technologists, particularly those who are newly graduated and enthusiastic, into providing information to a patient before evaluating its appropriateness. Technologists working with anxious or worried patients may also give out information to ease both their own and the patient's feelings of anxiety. Many patients are really looking for reasonable reassurance about their tests and illness, not detailed information. There are three types of technologists: the revealer, the hider and the expert. The latter has learned to evaluate information for its appropriateness for patients to hear and their ability to receive it. As part of the ongoing learning process, technologists need to consider how to evaluate a patient's motive for asking a question, to decide the answer's effect on the patient, determining who is the most appropriate person to answer the question, and finally, judging how much information is best for the patient to hear. For the most apprehensive patient, distraction may be a useful technique. PMID- 10168253 TI - Vendor agreements offer cost savings for cardiac catheterization. AB - Hospitals continue to search for ways to save money at the same time they provide their physicians and clinical staffs with the variety and quality of supplies needed to do their jobs. St. Joseph's Medical Center in Stockton, Calif. watched expenditures for its cath lab increase while its activity stabilized. They looked at their high-volume use of balloon catheters, says Gary Boyd, service director. At a cost of $600 to $700 apiece, it made sense to carefully manage their supply. Choosing a prime vendor was the first step in controlling inventory. Materials management, which had previously had a hands-off policy in the cath lab, took an active role in determining choices for this product. Through a lengthy selection process, medical center management and physicians reached a consensus for a single vendor. Having a prime vendor policy may increase the vendor's commitment to the hospital and provide added advantages. For St. Joseph's, selecting a prime vendor has better positioned the hospital to arrange for inventory to be stocked on consignment: the vendor owns the shelved supplies, which the hospital pays for only as they are used. However, some vendors may reduce their discounts when they enter into a consignment agreement. The best way is to get the maximum discount on the invoice price first, and then work with the vendor to manage inventories at the lowest level possible. Smaller facilities have less leverage and less flexibility, but they can often piggy-back onto large bargaining agreements by partnering with a larger institution. PMID- 10168254 TI - Become your own mentor. PMID- 10168255 TI - Managing as a team. PMID- 10168256 TI - The Health Enhancement Research Organization (HERO). PMID- 10168257 TI - Application of Karasek's demand/control model a Canadian occupational setting including shift workers during a period of reorganization and downsizing. AB - PURPOSE: To apply Karasek's Job Content Model to an analysis of the relationships between job type and perceived stress and stress behaviors in a large company during a period of reorganization and downsizing. DESIGN: Cross-sectional mail out, mail-back survey. SETTING: A large Canadian telephone/telecommunications company. SUBJECTS: Stratified random sample (stratified by job category) of 2200 out of 13,000 employees with a response rate of 48.8%. MEASURES: Responses to 25 of Karasek's core questions were utilized to define four job types: low-demand and high control = "relaxed"; high demand and high control = "active"; low demand and low control = "passive", and high demand and low control = "high strain." These job types were compared against self-reported stress levels, perceived general level of health, absenteeism, alcohol use, exercise level, and use of medications and drugs. Similar analyses were performed to assess the influence of shift work. RESULTS: Employees with "passive" or "high strain" job types reported higher levels of stress (trend test p < .0001); poorer health (trend test P = .006); and higher levels of absenteeism (trend test p < .0001). More shift workers reported themselves in poor or fair health (chi-square p = .018) and reported high levels of stress at home (chi-square p = .002) than nonshift workers. The relationships between job type and levels of stress, health and absenteeism, however, held for nonshift workers as well. CONCLUSIONS: Job types with high demand and low control were associated with increased stress, increased absenteeism, and poorer self-concept of health. The demand/control model of Karasek and Theorell was validated in this setting with respect to stress and some stress-associated attitudes and behaviors. PMID- 10168258 TI - Measuring job stress: some comments on potential pitfalls. PMID- 10168259 TI - Short- and long-term outcomes of a health promotion program in a small rural community. PMID- 10168260 TI - Private sector-funded community health promotion. PMID- 10168261 TI - Related effectiveness of continued, lapsed, and delayed smoking prevention intervention in senior high school students. AB - The relative effectiveness of continued, lapsed, and delayed smoking prevention intervention was tested with senior high school students. The original intervention was conducted during Grades 7 through 9, with significantly fewer intervention students reporting smoking than control students. The intervention was reintroduced in the 11th grade to one-half of intervention students (continued intervention), was withdrawn from the other half (lapsed intervention), and was initiated with one-half control students (delayed intervention). The 11th-grade smoking rates of these groups were compared to those of a fourth group, a continued control group. Results showed that continued control students reported significantly less smoking than continued control students and lapsed intervention students. Additionally, the delayed intervention group exhibited smoking rates lower than the lapsed intervention and continued control groups. This finding underscores the importance of continuing smoking prevention activities, as well as initiating these activities, in senior high school years. PMID- 10168262 TI - Evaluation of a supermarket intervention to increase consumption of fruits and vegetables. AB - PURPOSE: The purpose of this study was to evaluate whether a supermarket point-of purchase intervention could increase shoppers' consumption of fruits and vegetables. METHODS: Eight supermarkets in rural Iowa were randomized to receive either an 8-month intervention or no intervention. The intervention consisted of: (1) one-page supermarket flyers that identified fruits and vegetables on sale, gave receipts and menu ideas for using sale foods, and gave a store coupon worth 50 cents toward the purchase of any fruit or vegetable; (2) store signage to identify fruits and vegetables featured on the flyer; and (3) consciousness raising activities such as food demonstrations and nutrition related signage. Evaluation was based on exit interviews and take-home surveys, completed by random samples of 120 shoppers from each store at baseline and approximately 1 year post randomization. RESULTS: At follow-up, 42.9% of intervention store shoppers and 6.5% of control shoppers recalled seeing the intervention flyer. Thirty-six percent of intervention shoppers had used a 50-cent coupon and 18% had used a recipe. Approximately 70% of all shoppers had purchased fruits or vegetables on the day they were interviewed, which did not differ between intervention and control stores. Compared to change in control shoppers, there was a borderline statistically significant 8.4 percentage point increase (p < .07) in the percentage of intervention store shoppers in the action or maintenance stages of dietary change, but there was no corresponding increase in fruit or vegetable consumption. DISCUSSION: Studies to test point-of-purchase interventions are difficult to design, implement, and evaluate. More powerful interventions are probably necessary to induce shoppers to purchase and consume more fruits and vegetables. PMID- 10168264 TI - Community coalitions: a self-assessment tool. PMID- 10168263 TI - The relative effects of a health-based versus an appearance-based intervention designed to increase sunscreen use. PMID- 10168265 TI - Steering Committee enhancements on health promotion program delivery. PMID- 10168266 TI - Anesthesia and preoperative and postoperative medications. AB - Retrobulbar blocks, although widely used, still have potentially serious complications. Topical anesthesia presents less risk of injury to the globe and less pain but requires careful usage and an experienced surgeon. New techniques, however, allow for an increase in the percentage of patients able to have topical anesthesia. Preoperatively, 2.5% phenylephrine is found to be just as effective as 10% phenylephrine, and, when compared with wound closure and surgeon's experience, the effect of prophylactic medications was found to be negated. Postoperatively, diclofenac is found to be as effective an anti-inflammatory agent as prednisolone. Also, the addition of 10% phenylephrine to 4% pilocarpine drops enhances the effectiveness of pharmacologic treatment of postoperative iridocorneal adhesions. In addition, ophthalmologists should be aware of emerging antibiotic resistance. PMID- 10168267 TI - Evolving trends in cataract surgery techniques and timing. AB - Evolution in cataract surgery developed along two fronts: technique and timing. New cannulae with very wide aspiration ports permit nucleosuction; a manual small incision method that fractionates and aspirates the nucleus. Phacoemulsification is made easier and safer with phaco sweep. Posterior capsule polishing is gentle if the only vacuum is generated by the infusion passing through the system and the aspiration tubing is not used. Fibrin glue may make long corneal incisions as stable as short ones. Several studies challenge our conventional thoughts simultaneous bilateral cataract surgery and whether patients need to be examined on the first postoperative day. PMID- 10168268 TI - Multifocal intraocular lenses. AB - It has been 10 years since I implanted the first multifocal intraocular lens (IOL). Unfortunately, there has been a gradual lessening of commitment to this modality by the ophthalmic community. The most important single factor for this lack of interest despite the more than adequate available clinical data is the repeated moving of "goal posts" by the American FDA when a multifocal lens style nears premarket approval. The refractive multifocal lens styles of iolab (Claremont, CA), Stortz Ophthalmics (St. Louis, MO), Domilens (Lyon, France), and Amo with the diffractive multifocals of 3M (St. Louis, MO), and Pharmacia (Kalamazoo, MI) and their recent modifications are reviewed. Reports show that they generally give excellent visual results depending on whether a near or distance dominant lens is indicated. The foldable Amo Array SA40N provides a good distance dominant foldable lens for the surgeon performing small incisions and has a small but dedicated surgical following. Loss of contrast sensitivity at low light levels remains a source of concern in certain professions and with certain lifestyles, and a report suggesting that many monofocal and multifocal patients do not achieve the standards set for night driving by the German Ophthalmic Society warrants further consideration. Development of a new accommodative IOL for small incision surgery is the only really new concept, and it will be interesting to see the results of independent reports. Spectacle dependence is considerably reduced with all the current multifocals when compared to monofocals, and for patients there are ample multifocal lens styles from which to choose. It is the author's opinion that more than 60% of the cataract population is currently suitable for multifocals if small incision surgery is performed. More multifocals would be used if price disparity with monofocals was reduced. PMID- 10168270 TI - Perioperative antibiotic, steroid, and nonsteroidal anti-inflammatory agents in cataract intraocular lens surgery. AB - Ophthalmologists continue to choose topical antibiotics and corticosteroids more frequently than injectable agents for their current cataract surgical techniques. The preoperative use of povidone-iodine 5% and the postoperative use of impregnated soft contact lenses have helped augment our therapeutic armamentarium. NSAIDs play an important role in decreasing postoperative convalescence with fewer side effects. The intracameral administration of heparin and antibiotic solutions is discussed. PMID- 10168269 TI - Corneal topography in cataract surgery. AB - Keratometry and videokeratography are the most important means of evaluating induced corneal changes after surgery and have comparable sensitivities in the paracentral region of the cornea. When cataract surgery is planned, corneal topography can be used preoperatively in the calculation of IOL power, particularly in difficult cases, such as in patients who have undergone corneal refractive surgery or penetrating keratoplasty. A study published in the past year suggests that the mean power in ring 3 of the Tomey TMS-1 videokeratoscope (Cambridge, MA) appears to give the most accurate estimate of corneal power for the calculation of IOL power after radial keratotomy. In the case of PRK, traditional methods of determining the corneal power can lead to great amounts of anisometropia. Further research is needed to develop more accurate methods of calculating IOL power after PRK. Videokeratography can also be used before cataract surgery in planning the location and size of the incision. In general, smaller temporal incisions result in less astigmatism than do larger superior incisions. Postoperatively, videokeratography can be used to detect tight sutures, torsion of the wound, internal wound gape, and irregular astigmatism, as well as to guide suture removal or in cases where best-corrected visual acuity is not adequate and there are no other obvious causes for poor vision to determine if corneal irregularities are present. PMID- 10168271 TI - The cornea in cataract and intraocular lens surgery. AB - Corneal complications following cataract surgery and intraocular lens implantation continue to be more unusual because of advances in our surgical techniques. Complications can still occur, however, and can include mechanical or toxic injury of the endothelium, stripped Descemet's membrane, epithelial toxicity and disruption, infectious keratitis, and epithelial ingrowth. Endothelial cell survival after cataract extraction and lens implantation are still major concerns. Healing of the cornea following clear corneal incisions has become more important as this technique is more frequently used, and several studies are looking at the results of clear corneal incisions performed for cataract surgery. Patients with ocular surface disease still require extra lubrication and management of blepharitis to prevent epithelial toxicity at the time of surgery as well as postoperatively. As incisions move back to the cornea from the distant limbus, careful observation for complications involving the cornea will be needed. Still, modern day cataract extraction and lens implantation are extremely gentle on the cornea. PMID- 10168272 TI - Surgical management of coincident cataract and glaucoma. AB - Surgical management of coincident cataract and glaucoma has become very common for ophthalmic surgeons. As the medical options continue to improve, many patients with glaucoma do not require surgical intervention until the time of cataract extraction. Therefore, combined glaucoma procedures are becoming increasingly common. With the advent of small-incision phacoemulsification and trabeculectomy with releasable sutures and antimetabolites, techniques have improved considerably in the recent decade. This article discusses many of the important topics as they relate to this subject. It is not a comprehensive review, but rather discusses the literature over the scanning period of this periodical. PMID- 10168273 TI - Recent studies of risk factors and protective factors for cataract. AB - The multifactorial nature of cataractogenesis has been further exposed in recent epidemiologic studies, most efficiently by four case-control studies. The factors found include various plasma constituents, steroids, alcohol, diabetes, hypertension, hyperlipidemia, and obesity. Further examination of dietary factors leaves confusion as to their role in the prevention of cataract. PMID- 10168274 TI - Pediatric cataracts. AB - Posterior chamber intraocular lenses are a well-accepted treatment of aphakia in children 2 years of age and older, with many now considering them as the treatment of choice. Infants, however, are usually treated with contact lens, rather than intraocular lens implantation, as the infant eye undergoes significant axial elongation. The use of intraocular lenses in children with cataracts associated with juvenile rheumatoid arthritis remains controversial, but a recent article [9] describes good results in these patients, who historically have a poor prognosis. The management of amblyopia associated with unilateral congenital cataracts is evolving. In the 1970s and 1980s, full-time occlusion of the sound eye was advocated for infants with unilateral congenital cataracts. It was also taught that binocular fusion was impossible to obtain, and children with unilateral cataracts inevitably develop strabismus. Recent studies have shown that part-time occlusion may in fact yield better results, allowing the development of binocular vision and stereopsis and reducing the incidence of strabismus. PMID- 10168275 TI - Lensectomy-vitrectomy indications and techniques in cataract surgery. AB - Lensectomy-vitrectomy is the removal of the crystalline lens through a transscleral retrociliary incision (usually the pars plana) under clinical conditions in which the vitreous gel has to be partially or totally removed. It was designed in the early 1970s at the onset of modern vitreous surgery. The vitreous cutter was used to remove the lens and the vitreous (lensectomy as vitrectomy). With the development of small incision cataract surgery, foldable IOL, the term lensectomy-vitrectomy also applies to separate incisions in one procedure combining lens and vitreous surgery. With this in mind, it covers several very different situations from neonatal congenital cataracts to adult or senile-associated diseases. This type of surgery is widely accepted, and the main controversy is about the consequences of neonatal surgery and the age of IOL implantation in uni- or bilateral congenital cataracts. My personal work with laser flare and cellmetry demonstrates that pars plana vitrectomy alone creates very little trauma to the blood-aqueous barrier, as can be checked by the anterior chamber level of proteins (ie, flare). The postoperative flare in pars plana vitrectomy alone is very close to the preoperative level. Therefore, the association of pars plana vitrectomy and lens surgery should not be more traumatizing to the eye than lens surgery alone. This review will first report the consequences of neonatal lensectomy-vitrectomy to the eye. Subsequent indications for surgery and implantation will be discussed as well as special indications and complications in congenital cataracts, dislocated nucleus in cataract operation, cataract and associated vitreoretinal disorders in diabetes, and giant retinal tears and removal of the lens during vitrectomy. PMID- 10168276 TI - Cataract surgery in patients with uveitis. AB - Although cataract surgery for senile cataract is routine and easily performed, the decision to remove the cataract in a patient with a history of uveitis is considerably more complex and usually involves multiple considerations, related not only to the cause of the uveitis but also to the appropriate surgical procedures. The problems confronting the ophthalmologist caring for the patient with uveitis begin with the first visit. Establishing a diagnosis and controlling the inflammation are the critical elements in the treatment of the patient; these two factors will determine the incidence of cataract formation and other complications, the appropriate time for cataract removal, and the surgical strategy, as well as determine the visual outcome long before surgery occurs. Diagnosis, control of inflammation, preoperative management, particularities of the surgical techniques, and postoperative complications in patients with a history of uveitis have been reviewed previously in this section. Our aims in this article are to review the literature on this subject over the past year and to reemphasize the idea of a model of zero tolerance for inflammation to minimize the incidence of cataract and irreversible damage of ocular structures essential to good vision. PMID- 10168278 TI - Telespirometry: novel system for home monitoring of asthmatic patients. AB - OBJECTIVES: To describe a newly developed telespirometry system consisting of a portable spirometer that transmits the lung ventilatory values by telephone from the patient's home to a remote monitoring center and to assess the ability of the telespirometry system to detect early signs of asthmatic deterioration. METHODS: Thirty-nine patients with moderate to severe asthma were monitored with the telespirometry system. The lung function testing and transmission of the spirometric data by telephone from the patient's home to a remote monitoring center were performed according to the patient's judgment. All previous transmissions of the spirometric data were analyzed retrospectively to detect early signs of asthmatic deterioration, which resulted in dispatch of the mobile intensive care unit (MICU) to the patient's home. RESULTS: In 19 patients (49%), analysis of the spirometric data detected early signs of asthmatic deterioration. Analysis of the spirometric data correlated with decisions to dispatch the MICU in 22 of 39 (56%) patients. In patients with severe asthma, the decision was made during oral communication between the patient and the operator and was based on clinical impression rather than functional results. CONCLUSION: Home monitoring of asthmatic patients with the telespirometry system may improve the management of the disease and the quality of life and reduce costly hospitalizations. PMID- 10168279 TI - Utilization and cost savings of a wide-area computer network for neurosurgical consultation. AB - BACKGROUND AND OBJECTIVE: Telemedicine systems offer many potential advantages for health care delivery. Most reports have centered on the delivery of primary and medical subspecialty care rather than on its impact on patient care and the potential for cost savings. In 1993, we implemented NeuroLink, a wide-area teleradiology network for delivery of specialty care in neurologic surgery at Allegheny General Hospital (AGH). This study was designed to determine the potential cost savings of such a network. METHODS: We prospectively reviewed 100 consecutive telemedicine neurosurgical consultations from 20 western Pennsylvania community hospitals participating in the NeuroLink network. Data related to referring hospital, diagnosis, disposition of the patient, and mode of transportation were reviewed. To determine the potential cost savings, the differential of hospital-based charges between AGH and western Pennsylvania primary hospitals was calculated based on an average length of stay (LOS), patient bed costs, and transportation charges. RESULTS: Of the 100 patients, 33 did not require transfer to a tertiary facility but were instead managed at the community hospital as a direct result of the remote diagnosis and image review disclosing that neurosurgical procedures or intensive care were not required. Cost analysis, comparing the average LOS at AGH with that of the average community hospital, including transportation, showed savings of $502,638. CONCLUSION: Our neurosurgical wide-area computer network has led to more appropriate transfer of patients to a tertiary facility and significant estimated cost savings. PMID- 10168280 TI - Reliability of telemedicine examination. AB - OBJECTIVES: To assess the reliability of telemedicine examination and identify the issues to be addressed if the conduct of physical examination and the reading of images and tracings by telemedicine are to be as reliable as conventional examination and reading. METHODS: Patients were examined both conventionally and by telemedicine in 12 clinics, and the results were compared. There were 1826 matched pairs of observations. Cardiac auscultation, echocardiography, electrocardiography, electroencephalography, obstetric ultrasonography, ophthalmologic examination, physical therapy assessment, pulmonary auscultation, and the reading of chest radiographs with telemedicine cameras and monitors were studied. The main outcome measure was agreement between the telemedicine findings and a criterion standard. RESULTS: For ophthalmology, physical therapy, and cardiac auscultation, 91.2% of the conventional findings and 86.5% of the telemedicine findings were identical or similar to the criterion standard. The kappa coefficient on matched-pair analysis was 0.66. For pulmonary auscultation and reading of chest films with a telemedicine camera and monitor abnormalities were suppressed at default settings but subsequently revealed with extensive manipulation of system settings. For tracings and images, both conventional and telemedicine findings showed 92% reliability, with a kappa coefficient of 0.87. CONCLUSIONS: On the basis of these observations and the methods used, reliability varied with the type of examination, clinician experience with telemedicine, and participant knowledge of system limitations. Clinicians without experience or knowledge of system limitations missed findings of clinical importance. Improvements in equipment since the clinics were conducted in 1994 may have resolved some of these problems. Our findings raise doubts about the reliability of occasional telemedicine consultations by clinicians inexperienced in the technology. PMID- 10168281 TI - Public knowledge, perception, and expressed choice of telemedicine in rural West Virginia. AB - OBJECTIVE: It is doubtful that any new health care delivery system that requires as much adjustment as telemedicine does will be sustained if its users do not fully support it. We sought to determine the familiarity with, perceptions of, and attitudes toward telemedicine among rural adults in West Virginia. METHODS: Data were collected in a statewide telephone survey of 461 non-institutionalized rural adults. The survey contained questions about familiarity with telemedicine, perceptions about its attributes and benefits, and willingness to use it for routine, specialty, and emergency care. Responses were examined in relation to the subjects' age, sex, socioeconomic status, access to care, and insurance coverage. RESULTS: Despite mass media coverage of the subject, only one third of the respondents had heard of telemedicine. Nearly two thirds thought patients would find it less satisfactory than seeing a physician in person. Male subjects, younger subjects, and those with higher incomes were more likely to think telemedicine would be as satisfactory as a face-to-face meeting. There was a general consensus on the benefits of telemedicine, such as greater convenience and easier contact with specialists. For chronic conditions, 47% of the respondents would use telemedicine if no physician was available locally, whereas 27% would go out of town to see another physician in person, and 25% would wait for their own physician. For emergency care, these figures were 41%, 58%, and 0. Three fourths of the respondents were somewhat or very willing to use telemedicine for routine or specialist care. CONCLUSION: More work needs to be done to demonstrate the efficacy of telemedicine and disseminate this knowledge to the public. PMID- 10168282 TI - Plea for standardization in teledermatology: a worm's eye view. AB - Like any clinical interaction, teledermatology requires accurate, timely, and relevant information. The need to provide reliable, representative, diagnostic quality images to the consultant is obvious. Predetermined patient views for a given clinical presentation and optimal hands on techniques to acquire them are not standardized. As a result, the training provided to those who take the images is inconsistent. Anecdotal evidence from the author's telemedicine practice is employed to support this contention. A formal collaboration between the telemedicine and medical photography communities is proposed to generate such standards and a relevant curriculum. PMID- 10168283 TI - Telemedicine: a useful tool for the pediatric cardiologist. AB - OBJECTIVE: To determine if the Georgia Statewide Academic and Medical System Telemedicine Network can deliver subspecialty pediatric care to rural areas of Georgia. MATERIALS AND METHODS: A retrospective review was conducted of a clinical experience, over a 30-month period from November 1993 through June 1996, involving 13 pediatric cardiology-related encounters in seven male and six female patients. Patients' ages ranged from 5 days to 16 years. Eleven encounters were initiated because of a suspicion of congenital heart disease (CHD); two encounters involved postoperative evaluations in patients who had recently undergone cardiac surgery at the Medical College of Georgia (MCG). RESULTS: Of the 11 patients suspected to have CHD, five had CHD documented during the telemedicine evaluation, of whom two were transferred to MCG for further invasive evaluation and surgical correction. Three others with CHD, and the remaining six patients who required no further subspecialty follow-up, were followed in their home communities by their primary care physicians. CONCLUSIONS: Telemedicine is a useful tool for the evaluation of infants and children with suspected CHD. PMID- 10168284 TI - AirLifeLine. PMID- 10168285 TI - UNMC (University of Nebraska Medical Center) laboratory system cuts errors and labor costs. PMID- 10168286 TI - Privacy Act of 1974; system of records--HCFA. AB - HCFA is proposing to revise the systems notice for the "Medicare Physician Identification and Eligibility System (MPIES)," System No. 09-70-0525. The following alterations will be made to this system of records: 1. The purpose statement for the system will be revised to better reflect the system's expanded function. The new purpose of this system of records will read as follows: "to maintain unique identification of each physician, practitioner, and medical group practice requesting and/or receiving Medicare reimbursement." 2. The name of the system will be changed from the "Medicare Physician Identification and Eligibility System (MPIES)," to the "Unique Physician/Practitioner Identification Number (UPIN) System." 3. The name of the "Unique Physician Identification Number (UPIN)" will be changed to the "Unique Physician/Practitioner Identification Number." Despite this amendment, the acronym UPIN will not be changed because Federal and state agencies and private and public insurance entities are familiar with the use of this acronym. 4. The structure of the UPIN identifier is being changed from a 6-digit identifier to a 10-digit identifier so as to uniquely identify all physicians, practitioners and medical group practices, and to rectify current problems with existing individualized identification systems. 5. Tax identification numbers will be collected and added to the data fields maintained on all physicians, practitioners, and medical group practices in this system. 6. HCFA is also proposing to add a new routine use (number 10) to this system notice for the release of data to other Federal and state agencies. PMID- 10168287 TI - Medical devices; current good manufacturing practice (CGMP) final fule; quality system regulation--FDA. Final rule. AB - The Food and Drug Administration (FDA) is revising the current good manufacturing practice (CGMP) requirements for medical devices and incorporating them into a quality system regulation. The quality system regulation includes requirements related to the methods used in, and the facilities and controls used for, designing, manufacturing, packaging, labeling, storing, installing, and servicing of medical devices intended for human use. This action is necessary to add preproduction design controls and to achieve consistency with quality system requirements worldwide. This regulation sets forth the framework for device manufacturers to follow and gives them greater flexibility in achieving quality requirements. PMID- 10168289 TI - Clinical protocols using gene therapy for HIV infection. PMID- 10168288 TI - In the know on EtO. PMID- 10168290 TI - Colony-stimulating factor priming for collection of peripheral blood stem cells. AB - This article is an executive summary of the Blue Cross Blue Shield Technology Evaluation Center (TEC) Assessment "Colony-Stimulating Factor Priming for Collection of Peripheral Blood Stem Cells," Volume 9, No. 21, 1994. The complete assessment, which includes background information, methods, formulation of the assessment, review of evidence, conclusions, and references are available to Blue Cross Blue Shield TEC Program subscribers only. For subscription information, contact the program at (312) 440-6080. PMID- 10168291 TI - Colony-stimulating factors for drug-induced neutropenia (other than antineoplastic- or HIV-associated). AB - This article is an executive summary of the Blue Cross Blue Shield Technology Evaluation Center (TEC) Assessment "Colony-Stimulating Factors for Drug-Induced Neutropenia (Other than Antineoplastic- or HIV-Associated)" Volume 9, No. 23, 1994. The complete assessment, which includes background information, methods, formulation of the assessment, review of evidence, conclusions, and references are available to Blue Cross Blue Shield TEC Program subscribers only. For subscription information, contact the program at (312) 440-6080. PMID- 10168292 TI - Intravenous immune globulin for multiple sclerosis. AB - This article is an executive summary of the Blue Cross Blue Shield Technology Evaluation Center (TEC) Assessment "Intravenous Immune Globulin for Multiple Sclerosis" Volume 9, No. 26, 1994. The complete assessment, which includes background information, methods, formulation of the assessment, review of evidence, conclusions, and references are available to Blue Cross Blue Shield TEC Program subscribers only. For subscription information, contact the program at (312) 440-6080. PMID- 10168293 TI - Stereotactic radiosurgery: a double interview. PMID- 10168294 TI - Stereotactic radiosurgery for high-grade gliomas. PMID- 10168295 TI - Stereotactic radiosurgery for meningiomas. PMID- 10168296 TI - Stereotactic radiosurgery for multiple or recurrent brain metastases. PMID- 10168297 TI - A new look at an old surgery for Parkinson's disease. PMID- 10168298 TI - Fetal mesencephalic transplantation for the treatment of Parkinson's disease. PMID- 10168299 TI - Stereotactic radiofrequency pallidotomy without microelectrode mapping for the treatment of Parkinson's disease. PMID- 10168300 TI - Problems in assessing technology. PMID- 10168301 TI - The diagnosis is depression. PMID- 10168302 TI - Phototherapy for the treatment of seasonal affective disorder. PMID- 10168303 TI - Radioactive seed implantation for prostate cancer. PMID- 10168304 TI - Ultrasound accelerated fracture healing. PMID- 10168305 TI - The right to bear children. PMID- 10168306 TI - Intravenous immune globulin for recurrent fetal loss. PMID- 10168307 TI - Paternal or fetal antigen immunotherapy for recurrent fetal loss. PMID- 10168308 TI - Integrating alternative approaches. PMID- 10168309 TI - Biofeedback. PMID- 10168310 TI - Orthoptic training for the treatment of learning disabilities. PMID- 10168311 TI - Lobar lung transplantation for end-stage pulmonary disease in children and adolescents. PMID- 10168312 TI - MD TV. PMID- 10168313 TI - Transplants involving the small bowel. PMID- 10168314 TI - Surgical procedures for the treatment of obstructive sleep apnea syndrome. PMID- 10168315 TI - Finding the keys to HIV-1 immunity. PMID- 10168316 TI - Dynamic posturography in the assessment of vestibular dysfunction. PMID- 10168317 TI - Stereotactic radiofrequency pallidotomy with microelectrode mapping for treatment of Parkinson's disease. PMID- 10168318 TI - Breathtaking diseases. PMID- 10168319 TI - Lung volume reduction surgery for severe emphysema. PMID- 10168320 TI - Thoracoscopic laser ablation of emphysematous pulmonary bullae. PMID- 10168321 TI - Looking at gender differences. PMID- 10168322 TI - Brachytherapy in breast-conserving initial treatment of stage I or II breast cancer. PMID- 10168323 TI - Management of nonpalpable breast lesions: biopsy techniques. PMID- 10168325 TI - How good is your health plan? PMID- 10168327 TI - If the condom breaks. A morning-after treatment for exposure to HIV might protect you from AIDS. But don't count on it. PMID- 10168326 TI - Economics, values, and health care reform. PMID- 10168328 TI - How to live to 100. PMID- 10168329 TI - Naked before the world. Will your medical secrets be safe in a new national databank? PMID- 10168330 TI - The struggle over retiree medical benefits: who's on top? AB - Over the past decade, there has been an explosion of litigation addressing an employer's right to unilaterally amend or terminate medical benefits provided to retirees. The sheer volume of these cases and the variety of facts and legal theories have combined to obscure the patterns and trends that actually are emerging from this litigation. This article will describe the context of the struggle over retiree benefits and discuss those leading decisions in which the federal courts of appeals have established their rules for deciding retiree benefits cases. PMID- 10168331 TI - Managing workers' compensation medical costs: a state-by-state guide. PMID- 10168332 TI - Putting your company's whole brain to work. AB - Innovate or fall behind: the competitive imperative for virtually all businesses today is that simple. Responding to that command is difficult, however, because innovation takes place when different ideas, perceptions, and ways of processing and judging information collide. And it often requires collaboration among players who see the world differently. As a result, the conflict that should take place constructively among ideas all too often ends up taking place unproductively among people. Disputes become personal, and the creative process breaks down. The manager successful at fostering innovation figures out how to get different approaches to grate against one another in a productive process the authors call creative abrasion. The authors have worked with a number of organizations over the years and have observed many managers who know how to make creative abrasion work for them. Those managers understand that different people have different thinking styles: analytical or intuitive, conceptual or experiential, social or independent, logical or values driven. They deliberately design a full spectrum of approaches and perspectives into their organizations and understand that cognitively diverse people must respect other thinking styles. They set ground rules for working together to discipline the creative process. Above all, managers who want to encourage innovation need to examine what they do to promote or inhibit creative abrasion. PMID- 10168333 TI - Discovering new points of differentiation. AB - Most profitable strategies are built on differentiation: offering customers something they value that competitors don't have. But most companies concentrate only on their products or services. In fact, a company can differentiate itself every point where it comes in contact with its customers--from the moment customers realize they need a product or service to the time when they dispose of it. The authors believe that if companies open up their thinking to their customer's entire experience with a product or service--the consumption chain- they can uncover opportunities to position their offerings in ways that neither they nor their competitors though possible. The authors show how even a mundane product such as candles can be successfully differentiated. By analyzing its customers' experiences and exploring various options, Blyth Industries, for example, has grown from a $2 million U.S. candle manufacturer into a global candle and accessory business with nearly $500 million in sales and a market value of $1.2 billion. Finding ways to differentiate one's company is a skill that can be nurtured, the authors contend. In this Manager's Tool Kit, they have designed a two-part approach that can help companies continually identify new points of differentiation and develop the ability to generate successful differentiation strategies. "Mapping the Consumption Chain" captures the customer's total experience with a product or service. "Analyzing Your Customer's Experience" shows managers how directed brainstorming about each step in the consumption chain can elicit numerous ways to differentiate any offering. PMID- 10168334 TI - Can patients drive the future of health care? AB - As the traditional system of health care in the United States gives way to a regime run increasingly by the private sector, a powerful force is emerging: the patient. According to Harvard Business School professor Regina Herzlinger, health care is much like other service industries. Providers that hope to survive must cater to increasingly demanding and well-educated consumers. In a review of Herzlinger's book Market-Driven Health Care: Who Wins, Who Loses in the Transformation of America's Largest Service Industry, Alexandra Wyke, managing editor at the Economist Intelligence Unit, argues that the path to consumerism in medicine will be longer and bumpier than Herzlinger suggests. Consumers of medicine don't simply want health care to be more convenient; they want cures for all ills. How can providers gratify this appetite for ever better medicine? Furthermore, patients are not always capable of making sound decisions about their medical care. And health care professionals, who emphasize the complex nature of decision making in medicine, are doing their best to keep patients from holding the health care steering wheel. Herzlinger has written a bullish book on the virtues of market-driven health care, but, Wyke contends, she has overlooked the far-reaching effects that emerging technology could have in shaping medicine- especially in reducing the need for specialists. She also has given short shrift to the young managed-care industry, which has succeeded in controlling costs and is now under competitive pressure to meet patients' needs better. PMID- 10168335 TI - When your star performer can't manage. AB - Vic, the CEO of a sporting goods company in this fictional case study, is pleased with the numbers. For several years now, they've gone steadily in one direction: up. But there's trouble in paradise Hidden from the public's view of industry dominating winners--from the coolest snowboards to the hottest in-line skates- lies a product development department that may be ready to shatter like cheap fiberglass. There's one reason in particular for the dark rumblings that periodically reach Vic, and his name is Linus Carver. Carver, the company's chief of product development, is the workaholic mad genius who is responsible for most- he might say all--of the company's successful products. At the same time, he has managed to alienate the rest of his staff, including the two whizkid Generation Xers he brought in. He has been charged with everything from stealing ideas to squashing the initiative of the rest of the team. From his perch as CEO, Vic preaches "team". And he's even made a few stabs at reining Carver in--his latest move has been to recommend that his mercurial star get some coaching. But Vic also knows who butters his bread. In short, he's bewildered. Four commentators suggest how Vic can keep the company's product-development group intact and it sales growth strong. PMID- 10168336 TI - The path of kyosei. AB - Many global companies believe they have a moral duty to respond to the world's problems but are unsure how to do that and still pursue a reasonable profit for their shareholders. Ryuzaburo Kaku, honorary chairman of Canon, the Japanese technology company, suggests that companies consider kyosei, a business credo that he defines as a "spirit of cooperation" in which individuals and organizations work together for the common good. Kyosei, Kaku claims, has helped Canon make a significant and positive impact on many world problems as the company has grown to become one of the world's preeminent innovators and manufacturers of technology. The implementation of kyosei can be divided into five stages, with each stage building on the preceding one. In the first stage, companies must work to secure a predictable stream of profits and to establish strong market positions. From this foundation, they move on to the second stage, in which managers and workers resolve to cooperate with each other, recognizing that both groups are vital to the company's success. In the third stage, this sense of cooperation is extended beyond the company to encompass customers, suppliers, community groups, and even competitors. At the fourth stage, a company takes the cooperative spirit beyond national boundaries and addresses some of the global imbalances that plague the world. In the fifth stage, which companies rarely achieve, a company urges its national government to work toward rectifying global imbalances. For each stage, Kaku provides detailed examples from Cannon's own experience in putting the ideas of kyosei into practice. PMID- 10168337 TI - Fair process: managing in the knowledge economy. AB - Unlike the traditional factors of production--land, labor, and capital--knowledge is a resource that can't be forced out of people. But creating and sharing knowledge is essential to fostering innovation, the key challenge of the knowledge-based economy. To create a climate in which employees volunteer their creativity and expertise, managers need to look beyond the traditional tools at their disposal. They need to build trust. The authors have studied the links between trust, idea sharing, and corporate performance for more than a decade. They have explored the question of why managers of local subsidiaries so often fail to share information with executives at headquarters. They have studied the dynamics of idea sharing in product development teams, joint ventures, supplier partnerships, and corporate transformations. They offer an explanation for why people resist change even when it would benefit them directly. In every case, the decisive factor was what the authors call fair process--fairness in the way a company makes and executes decisions. The elements of fair process are simple: Engage people's input in decisions that directly affect them. Explain why decisions are made the way they are. Make clear what will be expected of employees after the changes are made. Fair process may sound like a soft issue, but it is crucial to building trust and unlocking ideas. Without it, people are apt to withhold their full cooperation and their creativity. The results are costly: ideas that never see daylight and initiatives that are never seized. PMID- 10168338 TI - How management teams can have a good fight. AB - Top-level managers know that conflict over issues is natural and even necessary. Management teams that challenge one another's thinking develop a more complete understanding of their choices, create a richer range of options, and make better decisions. But the challenge--familiar to anyone who has ever been part of a management team--is to keep constructive conflict over issues from degenerating into interpersonal conflict. From their research on the interplay of conflict, politics, and speed in the decision--making process of management teams, the authors have distilled a set of six tactics characteristic of high-performing teams: They work with more, rather than less, information. They develop multiple alternatives to enrich debate. The establish common goals. They make an effort to inject humor into the workplace. They maintain a balanced corporate power structure. They resolve issues without forcing a consensus. These tactics work because they keep conflict focused on issues; foster collaborative, rather than competitive, relations among team members; and create a sense of fairness in the decision-making process. Without conflict, groups lose their effectiveness. Managers often become withdrawn and only superficially harmonious. The alternative to conflict is not usually agreement but rather apathy and disengagement, which open the doors to a primary cause of major corporate debacles: groupthink. PMID- 10168339 TI - Managing our way to higher service-sector productivity. AB - In the two decades following World War II, U.S. productivity grew at an annual rate of 3%. But since the beginning of the 1970s, it has grown at only about 1%. Had the earlier rate been sustained, the gross domestic product would now be about $11 trillion instead of about $6.5 trillion. That extra $4.5 trillion per year in economic output would have had a profound impact on a wide range of social and economic problems. What is preventing a productivity revival in the U.S. economy? Clearly not the manufacturing sector, which has rebounded since the early 1980s. The service sector, on the other hand, has seen productivity growth rates stagnate during the same period. Why? Michael van Biema and Bruce Greenwald believe that the usual explanations are incomplete and have resulted in some serious misconceptions. The authors point out the limitations of those explanations and offer one of their own. They lay the blame in two places: the ineffectiveness of many service-sector managers at improving productivity and the inherent complexity of the sector itself. The authors argue that the problem is not a lack of resources; rather, it is that service sector companies operate below their potential. If managers focused on putting the existing technologies, labor force, and capital stock to work, rapid productivity growth would follow. Although the service sector is complex, the authors believe that managers would do well to apply the same tools, techniques, and policies that have been so effective in manufacturing sector. Doing so would help them keep their eye on the ball - the efficiency of basic operations. PMID- 10168340 TI - How to write a great business plan. AB - Every seasoned investor knows that detailed financial projections for a new company are an act of imagination. Nevertheless, most business plans pour far too much ink on the numbers - and far too little on the information that really matters. Why? William Sahlman suggests that a great business plan is one that focuses on a series of questions. These questions relate to the four factors critical to the success of every new venture: the people, the opportunity, the context, and the possibilities for both risk and reward. The questions about people revolve around three issues: What do they know? Whom do they know? and How well are they known? As for opportunity, the plan should focus on two questions: Is the market for the venture's product or service large or rapidly growing (or preferably both)? and Is the industry structurally attractive? Then, in addition to demonstrating an understanding of the context in which their venture will operate, entrepreneurs should make clear how they will respond when that context inevitably changes. Finally, the plan should look unflinchingly at the risks the new venture faces, giving would-be backers a realistic idea of what magnitude of reward they can expect and when they can expect it. A great business plan is not easy to compose, Sahlman acknowledges, largely because most entrepreneurs are wild-eyed optimists. But one that asks the right questions is a powerful tool. A better deal, not to mention a better shot at success, awaits entrepreneurs who use it. PMID- 10168341 TI - Health statistics sources on the Internet. AB - The Internet is expanding the options for locating health statistics. Electronic versions of print resources and access to searchable databases provide new avenues to statistical data. This article identifies and describes major Internet sites which provide free public access to health statistics. Covered are sites for United States federal and state data, international statistics, as well as subject specific sites for AIDS, aging, and substance abuse. PMID- 10168342 TI - A new role for the clinical librarian as educator. AB - The Clinical Medical Librarian (CML) Program of the Tompkins-McCaw Library is a special instructional initiative to teach third-year medical students the use of information resources in the clinical setting. Librarians spend one week with selected internal medicine teams participating in work rounds and instructing team members in the use of the medical literature. The librarian assists team members to identify and retrieve relevant information through computer workstations located in the hospital. Photocopies of journal articles are made available to team members through the CML document delivery program. PMID- 10168343 TI - Active learning: its role in health sciences libraries. AB - Active learning is a method of instruction which involves the students/attendees in the learning process by having them participate and reflect on that experience. It is a process which has received much publicity in the educational literature and is being incorporated in many fields within the health sciences. Health sciences librarians are beginning to incorporate active learning into instruction sessions, and a number of techniques being used in other settings could also be adopted. Examples are offered for using active learning in teaching the use of indexes, end-user database searching, Internet navigation, and problem based learning. PMID- 10168344 TI - Reactions and corrections of journal articles: implications and management in hospital libraries. PMID- 10168345 TI - Using electronic mail to teach MELVYL MEDLINE. PMID- 10168346 TI - A magic Medicare moment. PMID- 10168347 TI - Clean lungs at a price. Do smoking-related deaths save the nation money? PMID- 10168349 TI - Cataract surgery and lens implantation. PMID- 10168348 TI - Ephedrine's deadly edge. PMID- 10168350 TI - Glaucoma. PMID- 10168351 TI - Molecular genetics of open-angle glaucoma, moving from gene localization to predictive testing. AB - It has long been suspected that genetic factors play a role in open-angle glaucoma. Only recently, however, has the molecular basis of such factors begun to be established, with the primary localization of the GLC1A locus for juvenile onset and early-onset autosomal dominant open-angle glaucoma on chromosome 1q. These findings are clinically significant in that they allow familial screening of individuals at risk for glaucoma before the onset of irreversible visual impairment. A physical map of the GLC1A genomic region is now available, and the actual GLC1A gene might be identified in the near future. Nevertheless, open angle glaucoma is a genetically heterogeneous entity, and additional loci have been mapped or proposed. Identification of open-angle glaucoma genes should provide invaluable clues to the disorder's pathophysiology. It could also aid in conceiving novel therapeutic agents and broadening the screening of at-risk subjects. PMID- 10168352 TI - The cellular basis of aqueous outflow regulation. AB - This review begins with an introduction to the concept of the cellular regulation of aqueous outflow, current methods used for its study, and the cell types that are known to participate in this process. Current research in the field is divided into work on cell properties, cell products and extracellular matrix, cytoskeletal and structural changes, and drug interactions. PMID- 10168353 TI - Topical carbonic anhydrase inhibitors. AB - Dorzolamide, a topically active carbonic anhydrase inhibitor, is an effective new glaucoma medication that creates a decrease in intraocular pressure similar to that produced by beta-blockers. When beta-blockers are contraindicated, dorzolamide may be used as a first-line therapy. It has excellent additivity with other topical ocular hypotensive medications, including beta-blockers and pilocarpine. Systemic side effects are minimal, particularly compared with those of oral carbonic anhydrase inhibitors. However, local side effects, including corneal edema in patients with borderline endothelial function, may occur. Decreased visual acuity and allergic reactions, which occur frequently, may curtail the use of dorzolamide in some patients. PMID- 10168354 TI - Glaucoma, apoptosis, and neuroprotection. AB - The demise of the retinal ganglion cell represents the final common pathway of glaucomatous vision loss. Various studies demonstrate that ganglion cells die by the mechanism of apoptosis in conditions such as experimental animal models of glaucoma and optic nerve transection, and in human glaucoma. Apoptosis is a basic cell death mechanism noted in a number of neurodegenerative conditions. It constitutes a genetically coded "suicide" program activated when cells are no longer needed or have been seriously damaged, and is typified by rapid phagocytosis without inflammation. These cells demonstrate characteristic morphological changes on electron microscopy: nuclear chromatin condensation, compaction of cytoplasmic organelles, and membrane blebbing. Neurotrophin withdrawal and excitotoxic neurotransmitters have been implicated in apoptosis in ganglion cells damaged by glaucoma. Understanding the cellular and molecular biological events involved in ganglion cell death may lead to novel approaches to the treatment of glaucoma. PMID- 10168355 TI - New definitions of glaucoma. AB - At this time, there is no comprehensive and specific definition of glaucoma. Diagnostic tests such as retinal nerve fiber layer observation, scanning laser polarimetry, and confocal scanning laser tomography may improve the diagnosis and detection of glaucoma. Also, new functional tests, including short-wave-length automated perimetry, may provide better detection of glaucoma. PMID- 10168356 TI - The role of alpha-agonists in glaucoma therapy. AB - alpha-Agonists are a relatively old class of medications, the topical use of which lowers eye pressure. Clonidine was introduced for this use in 1966, brimonidine in 1974, and apraclonidine in 1978. Initial short-term attempts to use clonidine were complicated by problems with systemic hypotension. Apraclonidine is more polar and less lipophilic than clonidine. This probably allows less penetration into both the posterior segment of the eye and systemic circulation, allowing for an excellent therapeutic index. The prophylactic use of apraclonidine (1% and 0.5%) has dramatically changed the safety profile for many anterior segment laser procedures, cataract surgery, and vitrectomy. The role of alpha-agonists in the chronic treatment of glaucoma is still uncertain. Potential benefits of additional lowering of intraocular pressure must be weighed against the following potential disadvantages: tachyphalaxsis, posterior segment vasoconstriction, psychologic depression and fatigue, syncope and systemic hypotension, and a topical allergy-like syndrome. PMID- 10168357 TI - Methods to objectify reversibility of glaucomatous cupping. AB - Lowering intraocular pressure in adults with glaucoma may be associated with an improvement in appearance of the optic nerve head. The stage of disease, the amount of intraocular pressure reduction, and the age of the patient probably influence the occurrence of this event. The clinical relevance of "reversal" has not been established with certainty. The reversibility of glaucomatous cupping can be detected by subjective and qualitative means (examination of the patient or of fundus photographs) or by quantitative techniques such as photogrammetry, computerized image analysis, and scanning laser tomography. Clinical and experimental studies are providing new information about the behavior of the optic nerve head tissues in response to changes in intraocular pressure. PMID- 10168358 TI - The potential systemic effect of topically applied beta-blockers in glaucoma therapy. AB - Although topical beta-blockers are generally tolerated, they can produce significant systemic side effects. The systemic side effects of nonselective beta blockers (eg, timolol, carteolol) are primarily related to the cardiovascular (beta 1-adrenergic) and respiratory (beta 2-adrenergic) systems. Carteolol has intrinsic sympathomimetic activity, which theoretically reduces the risk of adverse effects through beta blockade. It has been reported that topical timolol and carteolol unfavorably alter the lipid profile and that the effects of carteolol are less pronounced than those of timolol. Topical beta-blockers are associated with systemic events, not only acting by themselves, but also interacting with other drugs (eg, quinidine) administered orally or intravenously. To reduce systemic absorption and adverse effects, new preparations of beta-blockers, such as timolol gellan, have been developed. We should always bear in mind the potential systemic effects of topically applied beta-blockers in glaucoma therapy. PMID- 10168359 TI - The logic of prevention of glaucomatous damage progression. AB - Glaucoma is an optic nerve head neuropathy for which there is presently no curative treatment. However, as glaucoma is known to be statistically associated with some risk factors, the logic of glaucomatous damage prevention consists of identifying those risk factors for which a potential therapy is available. PMID- 10168360 TI - Criteria for success of surgical treatment of glaucoma. AB - Outcome measures for studies of the surgical treatment of glaucoma include intraocular pressure, functional status (usually with visual field measurements), and structural status of the optic nerve or nerve fiber layer. Older studies relied heavily and almost solely on intraocular pressure as a surrogate measure for expected glaucomatous damage, but the situation is improving. It is clear that functional outcomes must be used in the evaluation of surgical therapy (indeed, of all therapy) for glaucoma whenever feasible. Measurements of structural damage are also important in patients with early or suspected damage. Structural evaluations probably do not provide information beyond that derived from visual field measurements in patients with advanced glaucomatous damage. This paper surveys the criteria and methods used to determine success in recent studies of glaucoma surgery and makes recommendations about the most appropriate outcome measures for surgical studies of glaucoma treatment. PMID- 10168361 TI - Laser scanning tomography and angiography of the optic nerve head for the diagnosis and follow-up of glaucoma. AB - New imaging technologies allow us to detect and follow very subtle changes of the structure and perfusion of the optic nerve head. Two of these technologies, confocal scanning laser ophthalmoscopy and confocal tomographic angiography are reviewed, focusing on new data and advances reported in the past year. These and other technologies (eg, nerve fiber layer polarimetry, optical coherent topography, and laser doppler flowmetry) will enhance the ability to diagnose and monitor glaucomatous disc damage. PMID- 10168362 TI - Antiglaucomatous trabecular surgery. AB - In contrast to conventional filtering procedures, microtrabecular surgery is intended to selectively combat the diseased structure in the pathogenesis of chronic open-angle glaucoma, thereby reducing potential risks during and after transscleral drainage operations. This overview considers new techniques in trabecular surgery, with special emphasis on the description of each novel technique, its instrumentation, its presumed mechanism of action, and its clinical results. Trabecular aspiration is evaluated as a method of clearing extracellular debris from intertrabecular spaces in pseudoexfoliation glaucoma or goniocurretage, and laser trabecular ablation for the treatment of absolute glaucomas is discussed. Although preliminary results are promising, most of these procedures are still experimental and under careful clinical evaluation, leaving plenty of room for refinements and further developments. PMID- 10168363 TI - Perspectives. Sub-acute care gets prospective payment--in four flavors. PMID- 10168364 TI - Beyond the credentialing and privileging controversy surrounding image-guided breast biopsy. The rationale for a national registry for quantifying outcomes. PMID- 10168365 TI - Virtual integration, less costly than vertical integration, allows organizations to focus on core competencies. Case study. PMID- 10168366 TI - Revitalizing hospital culture by questioning assumptions about employee/management relations. PMID- 10168367 TI - Building knowledge of health care as a system. AB - A system is a functionally related group of interacting, interrelated, or interdependent elements forming a complex whole with a common aim. This article presents a method--a 10-step exercise--for building knowledge of the elements of an interdependent system of health care. Those who seek to improve the work of a system can use this exercise for designing and relating new improvement efforts to the general work of the organization. PMID- 10168368 TI - Formulating the mess: lessons from "Building Knowledge of Health Care as a System". AB - This article describes the experiences of a group of health administration educators, a group of medical educators, and a group of nursing educators in applying the lessons of the exercise "Building Knowledge of Health Care as a System" to the organization of health professions education. PMID- 10168369 TI - Managing conflicts over limited resources. AB - Many conflicts in health care, such as disputes over physician compensation or plan coverage decisions, recur frequently and can be viewed as processes of production. This article proposes a model of the negotiation process and suggests an approach to the management and improvement of common conflicts over limited resources. PMID- 10168370 TI - Transforming patient feedback into strategic action plans. AB - Patients' perceptions provide valuable insight into areas for improvement and opportunities for strategic planning. Using both quantitative and qualitative research methods, the topics of what drives patient satisfaction, what delights patients, and what disappoints patients were examined. A case study approach was used to develop strategic recommendations for two market segments. For primary care patients, recommendations revolve around "provider caring" and "choice." For specialty patients, recommendations concentrate on "provider caring," "provider competence," and "office wait time." PMID- 10168372 TI - Clinical process cost analysis: a promising tool for clinical improvement. AB - In today's environment, health care organizations are expected to provide the best possible care at the lowest possible cost. Neither aspect can be considered independently, but correlating the two with traditional systems of cost analysis is very difficult. This article presents a new method for linking costs to the process of care that also promises to be a powerful tool for clinical improvement and redesign. PMID- 10168371 TI - Continually improving the health and value of health care for a population of patients: the panel management process. AB - Today's primary care provider faces the challenge of caring for individual patients as well as caring for populations of patients. This article offers a model--the panel management process--for understanding and managing these activities and relationships. The model integrates some of the lessons learned during the past decade as we have worked to gain an understanding of the continual improvement of health care after we have understood that care as a process and system. PMID- 10168373 TI - Satisfaction of residents and families in long-term care: III. Dissemination of results. AB - Dissemination of new information to caregivers in ways that enhance the care they deliver is central to quality improvement in health care. This article describes several strategies that have been employed in one long-term care setting and discusses evidence of their success. PMID- 10168374 TI - Learning through simulation: the next dimension in quality improvement. AB - Simulation modeling offers several distinct gains in learning opportunities beyond traditional quality improvement tools. A simulation model captures complex, multivariate system components and replicates system operation in compressed time. The visual aspect enables workers to "see" the effect of proposed changes and thus eliminates much of the fear of failure typically associated with change. Most important, simulation permits design of a total solution, addressing interactions of all system components. PMID- 10168375 TI - Matters of life and death. PMID- 10168376 TI - Drive-through deliveries: in support of federal legislation to mandate insurer coverage of medically sound minimum lengths of postpartum stay for mothers and newborns. AB - President Clinton signed the Newborns' and Mothers' Health Protection Act of 1996 into law on September 26, 1996. The Act requires insurers that provide maternity benefits to cover medically sound minimum lengths of inpatient, postpartum stays according to the joint guidelines of the American Academy of Pediatrics and the American College of Obstetrics and Gynecology. This Note discusses the historical context in which the necessity for passage of protective legislation arose, the interplay between state and federal statutes that created the need for federal legislation to provide desired protections for postpartum patients, and examines the provisions of the Act. This Note endorses the Newborns' and Mothers' Health Protection Act of 1996 as federal legislation necessary to protect postpartum patients from medically inappropriate insurer mandates while still allowing medical providers and their patients flexibility in medical decision making in the postpartum period. PMID- 10168377 TI - Elders Share the Arts: transforming memories into art. PMID- 10168378 TI - Physician-assisted suicide: a brief historical and legal overview. PMID- 10168379 TI - Home Health Management Services, Inc. cluster care program: an update. PMID- 10168380 TI - Issues concerning end-of-life care. PMID- 10168381 TI - Long-term care for the Korean American elderly: an exploration for a better way of services. PMID- 10168382 TI - Cultural clash between providers of majority culture and patients of Chinese culture. PMID- 10168383 TI - Ethnic differences regarding life and death in the care of the frail elderly: a West Indian perspective. PMID- 10168384 TI - Provider due process amidst growing reimbursement complexity. PMID- 10168385 TI - The elements of risk for the institutionalized elderly. PMID- 10168387 TI - Hospitals and primary health care. AB - This paper addresses the pre-eminent role, as has finally been acknowledged internationally, Primary Health Care plays with regards to meeting the health needs of the population of nations at the community level. The paper argues that for this primary health care strategy to be successfully implemented and bring about an improvement in the general level of health of people in communities cooperative, co-ordinated and organised action must be taken by all those in the health care field, public and Social Services and the people themselves at the community level. The paper acknowledges that although hospitals have traditionally been accorded a leadership position in the total health care effort, in their current make-up, however, they are ill-equipped and unfocused to undertake alone the task which will be involved in implementing the proposed PHC strategy. The major areas of commitment demanded by Primary Health Care programmes and the core functions for hospitals in support of PHC are identified. By these, the author argues that the insular character of hospitals, which has always proved a major stumbling block to the effective and successful implementation of PHC programmes, will begin to undergo a welcomed and overdue process of change. PMID- 10168386 TI - An era of change and reform in health and social security in Mexico. AB - As with many countries who try to provide their population with public health, social security programs and benefits, Mexico, for the past decade, has been striving in trying to allocate the proper means and solutions to the nation's medical and economic problems, with great difficulty. Being regarded as a developing country, many are the constraints affecting our financial and administrative attempted solutions (big internal and external debt, high inflation, unemployment, excess bureaucracy, constant mismanagement, overlapping health systems and in some spheres, even corruptions). In response to the above and in trying to maintain at least the current sustained level of care and attention built in the past through great effort and sacrifice by many, our country has taken the decision to search for new ways and solutions to promote change and public benefits. In a broad sense, this article then explains the transformation our health system is experiencing. PMID- 10168388 TI - The new market in health care: prospects for managed care in Australia. AB - Most developed countries are experiencing, or moving at full speed, to implement new forms of health delivery based in part on capitation arrangements and stronger accountability of health service providers. Proposals for introduction of capitation or managed care have been advanced in Australia but have attracted strong opposition from the medical profession. This paper reviews the policy issues surrounding the introduction of managed care, including how Australia's current institutional forms may evolve into managed care provision. PMID- 10168389 TI - MHRP, a model for hospital resource planning. AB - This paper describes and illustrates the use of the Model for Hospital Resource Planning (MHRP), a system designed as a tool to assist hospital planners. As Master Planning should serve the overall objectives of Hospital Strategic Planning, the MHRP links them by including hospital objectives and strategies in the forecasting of facility requirements for the future. By integrating projections and trends with all relevant opinions and judgements in each phase of the process, MHRP permits to adapt future facilities to short term and long term hospital decisions for the future, being proactive rather than reactive. The main benefit of MHRP system is that discussions about possible policies or strategies of the hospital in the context of the overall hospital environment are automatically directed to considerations of their implications for future resource requirements of the centre. PMID- 10168390 TI - Implementation of non-smoking policies in hospitals--Tom Hurst Memorial Lecture. AB - The paper draws upon the experience of the Preston Acute Hospitals NHS Trust in being a member of the European Network of Health Promoting Hospitals and, in so doing, places the health promoting activities of the Trust in its widest context. There is a discussion on the advice issued by the Department of Health towards making hospitals smoke free, which concludes that the advice is not helpful. It is suggested that successful attempts to eradicate smoking in hospitals must be part of a wider health promoting strategy. This, in turn, can be linked to the changing role of hospitals where there is an increasing emphasis on primary care services and a push towards rationalisation of district general hospitals. PMID- 10168392 TI - HCFA to extend "hospital within a hospital" regulations to more facilities. PMID- 10168391 TI - Subacute care industry urges adjustments to proposed salary equivalency guidelines for therapists. PMID- 10168393 TI - Staffing to acuity can help subacute providers improve efficiency and quality. PMID- 10168394 TI - Contracting guidance: physician-hospital employment contracting. PMID- 10168395 TI - What is employee participation and how does it work? PMID- 10168397 TI - Are we having fun yet? PMID- 10168396 TI - Anxiety among mammography patients. AB - Anxiety levels appear to act as a barrier to screening mammography, perhaps as serious a barrier as cultural beliefs and economics. Future research on how to reduce anxiety around screening needs to be done. Such research requires we consider women in various age groups, of various income and education levels, and various racial and ethnic backgrounds if we are to overcome this serious barrier and increase screening participation. PMID- 10168399 TI - The miracle on 8th Street. PMID- 10168398 TI - From history to morality. PMID- 10168400 TI - AMA marks 150 years of caring. PMID- 10168401 TI - Counseling overweight patients. PMID- 10168402 TI - Rehab facility overcomes scarcity of models to make benchmarking pay. AB - LOCATION: Bryn Mawr Rehab, a 141-bed rehabilitation facility in Malvern, PA. PROBLEM: Scarcity of benchmarkable models. The facility wanted to benchmark an integrated caregiving model that melded the disciplines of therapy and nursing into work teams reporting to the same supervisor. SOLUTION: It did not find a complete model but did glean valuable information from two facilities that had changed parts of the overall organizational structure. PMID- 10168403 TI - Rehab center develops unique caregiving model. AB - Benchmarking does not have to involve expensive consultants to be successful, but it does require careful attention to training and motivation. The best results come from teams who understand their mission, its contribution to the hospital's goals, and the basics of data gathering and manipulation. Managers must assume leadership of teams and be willing to train other team members. PMID- 10168404 TI - How to get your data message across. Charts and graphs can bring reports to life. AB - LOCATION: Phoenix Baptist Hospital and Medical Center. PROBLEM: Board members could not understand data contained in voluminous narrative reports. Reports went unread and unused. SOLUTION: Reports were reformatted into a graphical presentation, incorporating benchmark data to give measurement meaning. PMID- 10168405 TI - Automaker's fast-track process shows hospitals how to improve. AB - WHERE: Cleveland Clinic Foundation. PROBLEM: Discharge of patients took up to eight hours. Satisfaction scores reflected patients' ire. SOLUTION: Quality Choice Project for best discharge practices, plus a fast-track improvement process borrowed from General Motors. PMID- 10168406 TI - ED's paradigm shift cuts costs, improves quality. AB - WHERE: The emergency department of Parkview Memorial Hospital, a 519-bed, VHA affiliated acute care facility in Ft. Wayne, IN. PROBLEM: The need to shorten waiting time, improve patient satisfaction, and reduce costs while maximizing the potential of a $9 million renovation. Also, the need to address emergent and urgent care with different processes and operations. SOLUTIONS: Through benchmarking, staff initiated bedside registration on laptop computers; cross trained and restructured to drastically reduce overtime and salary expenses while adding FTEs; and provided tools for training physicians and nurses to handle patients. RESULTS: Wait time to see a doctor has declined by two-thirds. Cost per visit has dropped 12%, saving the department more than $422,000 in 1996. Satisfaction scores have almost doubled to 86%. PMID- 10168407 TI - State sources for hospital benchmarking data. PMID- 10168408 TI - Internet sites offer shortcuts to research. PMID- 10168409 TI - HEDIS outcomes may not be the only ones you need to benchmark. AB - The Foundation for Accountability (FACCT), a coalition of employers, is leading a trend away from process-oriented performance measures by generating patient centered data sets for a variety of disease states, including asthma, diabetes, and depression. Many large employers, dissatisfied with the National Center for Quality Assurance's focus on cost, are pressuring managed care organizations to use the FACCT measures, which largely rely on patient self-reports about the care they receive. Some plans are using the data sets voluntarily, as a tool to better assess the quality of services they provide and to evaluate physician groups. PMID- 10168410 TI - NCQA implements new outcomes audit standards. AB - Faulty data gathering and auditing techniques have put in question the comparability of HEDIS outcomes standards. The National Center for Quality Assurance has moved to shore up its data's credibility with new auditing standards. A new class of certified auditors must be trained. Until then, the Health Care Financing Administration will have Medicare managed care organizations audited by independent firms. PMID- 10168411 TI - 100 Top Hospitals list is a hot benchmark source. PMID- 10168412 TI - Special report: home health agencies. Take the leap from manual to on-line collection. AB - Home health agencies, like hospitals, soon will be required to report electronic outcomes to the Joint Commission on Accreditation of Healthcare Organizations. However, most agencies are not as advanced in data gathering and benchmarking efforts as are hospitals in general. The following two articles offer tips on conquering the electronic reporting beast and fashioning good benchmarking surveys. PMID- 10168413 TI - New team system speeds billing time. AB - PROBLEM: Fragmented, departmental approach to billing at UCLA Medical Center in Los Angeles had bills bogged down in a bureaucratic maze. SOLUTION: Patient administrative service teams based in nursing units combine functions of admissions, registration, utilization review, medical records, and patient accounting to cut billing cycle from 30 days to 12. PMID- 10168414 TI - Internal benchmarking paves way for medical transcription improvements. AB - Accurate, detailed data collection is essential to improving productivity in medical transcription departments. Transcription staff are best positioned to identify nonvalue-added duties and processes and should be involved in improvement planning. Even a small percentage of improvement in productivity can translate into huge dollar and time savings. PMID- 10168415 TI - Best supply practices revolve around patients. AB - Stanford Health Services has automated supply services for fast turnaround and recapture of lost charges. Satellite stock rooms on the units keep day-to-day supplies, which are ordered by procedure to eliminate unnecessary supplies. The four-year-old program has more than paid for itself, saving the system almost $15 million in labor and inventory costs. PMID- 10168416 TI - Retraining support staff has its ups and downs. PMID- 10168417 TI - Medical savings accounts (MSAs)--big benefits for small business. AB - The Health Insurance Portability and Accountability Act, passed by Congress last year, implemented a four-year pilot project that allows employees of small businesses to set up tax-free interest-bearing medical savings accounts. These accounts offer advantages for both employees and employers PMID- 10168418 TI - The looming retirement crisis. AB - A retirement crisis looms in the United States due to a number of recent and emerging trends that affect government retirement programs, employer- and union sponsored retirement benefits and personal savings arrangements. The crisis can be averted, but only with well-thought-out action on a number of issues, particularly Social Security and Medicare reform. PMID- 10168419 TI - Retiree health care: a new model for improving health and reducing costs. AB - Managing the use of prescription drugs in older adults is an area of particular concern because inappropriate medications so frequently trigger additional health care utilization and expenditures in this population. Pharmacists, as the crucial link in the treatment chain between physician and patient, are well positioned to play a key role in this effort. This article describes a new health management approach to coordinating prescription services for older adults. PMID- 10168420 TI - ERISA preemption of surety bond claims: the state's choice of weapon: plain old common sense. AB - One avenue that may be available to multiemployer funds in the collection of delinquent contributions from insolvent employers is to file suit on the state surety bond. However, such action may raise the issue of ERISA preemption. This article analyzes recent state and federal cases addressing the preemption of state surety bond claims and argues against a finding of ERISA preemption based on the underlying purpose of ERISA and appropriate deference to traditional areas of state regulation. PMID- 10168422 TI - Survey report: information technology usage on rise in healthcare facilities. PMID- 10168421 TI - Cost-effective health care: new data. AB - The key to health care programs that meet their goals is to integrate data, coordinate care and ensure a patient-centered not cost-centered, focus. Then the purchaser can achieve the desired decrease in cost of care, increase in quality of care, improvement in quality of life, improvement in job performance, decrease in disability and decrease in absenteeism. PMID- 10168423 TI - Coping with downsizing. PMID- 10168424 TI - The true cost of membership acquisition in Medicare risk. PMID- 10168425 TI - Repersonalizing health care by mass customizing it on a one-to-one basis. PMID- 10168426 TI - Keeping an ear to the ground: Georgia fitness center adapts to health care market changes. PMID- 10168427 TI - The dangers of putting patient care into the hands of patients. PMID- 10168428 TI - Digest finds 570 integrating systems. PMID- 10168429 TI - Data trends. Why hospitals lose money on physician practices. PMID- 10168430 TI - It can't happen here? PMID- 10168431 TI - Worrying about Medicare. PMID- 10168432 TI - Who's sorry now? Managed care under siege. PMID- 10168433 TI - Extending and enhancing existing information systems using Internet-based technologies. PMID- 10168434 TI - Medicare and Medicaid risk contracting opportunities for PSOs. AB - Legislation has been proposed in Congress to allow provider-sponsored organizations (PSOs) to negotiate risk contracts directly with the Medicare program and, possibly, with Medicaid programs. Initially, qualifying PSOs would not be required to be licensed as HMOS, but would be required to demonstrate fiscal solvency and meet quality assurance standards. The proposed solvency requirements, as well as requirements regarding the proportion of commercial to Medicare enrollees in a plan, would not be as rigorous for PSOs as they are for HMOs. The legislation's proponents argue that relaxing requirements for PSO risk contracting will allow Medicare and Medicaid beneficiaries more healthcare choices and better benefit packages. Opponents assert that PSOs would be given an unfair advantage in the marketplace and that consumers may be exposed to a greater risk of plan insolvency. While details of the legislation need to be reconciled, many observers predict that it will become law. PMID- 10168435 TI - FTC and DOJ modify efficiency provisions of merger guidelines. AB - Revisions to the Merger Guidelines issued by the Federal Trade Commission and Department of Justice may indicate some easing of Federal antitrust enforcement practices of the past. The revisions clarify how claims that mergers are likely to lower costs, improve quality, or otherwise achieve efficiencies are analyzed. The revisions provide guidance to potential merger partners about which efficiency claims might be scrutinized. The guidelines should be considered in their entirety when mergers are being considered; however, these revisions may indicate increased flexibility in the types of transactions that will be allowed. PMID- 10168436 TI - Managing demand using clinical decision support tools. AB - Managing patient and physician demand for resources is crucial to the cost effective delivery of high-quality patient care. This task is complicated by the expectations for better medical care that patients and physicians developed before prospective payment systems were instituted. The use of clinical decision support tools, which may combine appropriateness criteria with practice guidelines, can help manage demand rationally, control costs, and minimize concerns about overutilization and underutilization of healthcare services. PMID- 10168437 TI - State insurance regulation of provider-sponsored organizations. AB - Provider-sponsored organizations (PSOs) are health risk-bearing entities that assume risk either by contracting directly with individuals, employers, or other groups, or by entering into risk agreements with HMOs. Under the former arrangement, the PSO is generally subject to state insurance licensure requirements. Under the latter arrangement, the PSO is generally not directly regulated. The National Association of Insurance Commissioners (NAIC) has recommended that direct-contracting PSOs be subjected to the same requirements as HMOs, including minimum cash reserves. Arguments have been made that requiring such reserves of PSOs is burdensome and inappropriate. The NAIC has begun a Consolidated Licensure for Entities Assuming Risk (CLEAR) initiative to establish means by which states may regulate all organizations that perform managed care functions and assume health insurance risk. PMID- 10168438 TI - Using profiling for cost and quality management in the emergency department. AB - Overutilization and underutilization of resources are inappropriate and may result in unacceptable quality of care and increased morbidity. Current data are needed to monitor the use of clinical resources and help identify physicians with appropriate cost/quality outcomes and those who may have utilization or quality problems. Profiling is an analytical tool that uses epidemiological method to compare cost, service use, and quality of various physician practice patterns for a large number of patient encounters. To develop a profiling program, standards of care must be established and information systems must be instituted to measure resource utilization and care efficiency. Such a program can be especially valuable in the emergency department of hospitals, where wide variation in practice patterns may occur because of the episodic nature of patient encounters. A reduction in practice variations saves time and increase patient throughput in many cases. PMID- 10168439 TI - Intermediate tax sanctions: an overview. AB - New federal tax law applies intermediate tax sanctions when tax-exempt organizations enter into so-called excess benefit transactions with corporate insiders. The sanctions take the form of a two-tiered penalty excise tax, which is assessed not on the tax-exempt organization itself but on the insider who receives the excess benefit and the organizational managers and board members who knowingly participate in an improper transaction. The intermediate tax sanctions, therefore, present tax-planning challenges for tax-exempt hospitals and integrated delivery systems as well as for 501(c)(4) HMOs. Forthcoming treasury regulations are expected to add clarity to the new law. PMID- 10168440 TI - How intermediate sanctions change the dynamics of healthcare transactions. AB - The Taxpayer Bill of Rights 2 contains significant reforms relating to tax-exempt organizations, most notably the establishment of intermediate tax sanctions. These changes, which clarify tax rules applicable to tax-exempt HMOs, hospitals, and integrated delivery systems, are of particular interest to entities that are or will be involved in joint ventures or other business alliances with physicians and other for-profit partners, the officers and directors of such entities, and the physicians and for-profit partners in the ventures. For the first time, the legislation imposes monetary penalties on those engaging in transactions with tax exempt healthcare providers if impermissible private inurement is involved. PMID- 10168441 TI - Impact of tax sanctions on physician practice acquisitions and employment. AB - The intermediate tax sanctions create significant concerns for tax-exempt healthcare organizations that seek to integrate practicing physicians through practice acquisition or employment. The sanctions will force not-for-profit healthcare organizations to examine both the strategic and business implications of the dollars they have committed to practice acquisition and physician employment. The sanctions also should motivate organizations to reexamine their existing physician compensation arrangements, which may be creating negative incentives for practice productivity. PMID- 10168442 TI - Avoiding managed care pricing pitfalls. AB - Healthcare providers, concerned about competing as managed care proliferates, have attempted to negotiate as many contracts as possible to secure market share. Economic theory suggests that, in the short run, any contract that yields incremental revenues in excess of incremental costs is desirable. However, the marginal costs associated with managed care contracts can have serious financial consequences. Maimonides Medical Center (MMC), New York, New York, had negotiated a variety of payment terms and methods for inpatient healthcare services- including discounts off the Federal DRG rate, discounts off the state-regulated case-payment rate for managed care companies, global pricing, per-diem rates, and capitation--with more than 15 managed care companies. As market incentives changed, however, contract decisions that had been made either "on the margin" or in response to market-driven prices did not always improve financial performance over the long term. Some of the unexpected pitfalls MMC encountered were dual discounting and adverse risk selection. PMID- 10168444 TI - Reviewing practice expenses can improve profitability. AB - Many physician group practices--particularly practices that have been acquired by hospitals and integrated delivery systems--are experiencing expense increases and productivity decreases. Physician group practices can take steps to reverse these unfavorable trends by carefully reviewing and benchmarking practice costs related to physician compensation plans, support staff salaries and benefits, occupancy costs, clinical supply costs, and malpractice insurance. Group practices also can improve cost management and resource utilization by creating an operating budget based on historical expenditures and anticipated revenues and by comparing it with peer benchmarks. PMID- 10168443 TI - Controlling supply expenses through capitated supply contracting. AB - Some providers dealing with the financial challenges of managed care are attempting to control supply expenses through capitated supply contracting and similar risk/reward sharing arrangements. Under such arrangements, a supplier sells products and services to a provider for a fixed, prospective price in exchange for the provider's exclusive business. If expenses exceed the prospectively established amount, the supplier and provider share the loss. Conversely, if expenses are less than the fixed amount, they share the savings. For a capitated supply arrangement to be successful, providers must be able to identify and track supply expense drivers, such as clinical pathways, technology utilization, and product selection and utilization. Sophisticated information systems are needed to capture data, such as total and per-transaction product usage/volume; unit price per item; average and cost per item; average and total cost per transaction; and total cost per outcome. Providers also will need to establish mutually cooperative relationships with the suppliers with whom they contract. PMID- 10168445 TI - Negotiating a sound physician office lease. AB - Physician group practices that lease office space should consider several issues before signing a lease. These issues include whether to hire a broker to assist in the search for office space, negotiating lease provisions that pertain to compliance with the Americans with Disabilities Act; confidentiality of patient records; proper disposal of medical waste and other hazardous materials; compliance with occupational safety standards; quiet enjoyment; and utility use. In addition, physician group practices that lease office space from other healthcare providers must ensure that the lease terms conform with antifraud and abuse safe harbor regulations. PMID- 10168446 TI - Effective coding practices avoid penalties, control costs. PMID- 10168447 TI - Making better use of EDI purchase orders. PMID- 10168448 TI - CFO role models manage change effectively. PMID- 10168449 TI - Developing an RFP for outsourcing investment management. PMID- 10168450 TI - Tarrant County's hospital watch program: 10 years later. PMID- 10168451 TI - Installing and operating a fingerprint ID system for patients. PMID- 10168452 TI - Winners of hospital design awards cite security's role in planning. PMID- 10168453 TI - Hospital reduces injuries to ER personnel despite increase in incidents. PMID- 10168454 TI - Maximizing use of lighting, cameras in hospital parking areas. AB - Next to emergency rooms, a hospital's parking areas poses the greatest risk of crime and violence for staff, patients, and visitors. Critical to securing such areas (and creating an improved perception of safety) are the employment of lighting and the use of surveillance cameras. In this report, we'll give details of how one hospital used a lighting survey to trigger improvements in its parking security setup and we'll present tips from a leading camera manufacturer on the most effective use of cameras in conjunction with lighting in parking areas. PMID- 10168455 TI - Tracking incidents before they become lawsuits paying off for hospitals. PMID- 10168457 TI - Time out! When slowing down can be the quickest way. AB - Proxima, a leading manufacturer of desktop projection devices, formed a team to select and implement a new manufacturing resource planning II system. Although standard implementation methods were employed throughout the process, the implementation was plagued by software problems, systems operating problems, and team dysfunction and was halted after the first year. This article examines how and why the implementation effort failed, what the company learned from the experience, and what changes were made that allowed the company to succeed on its second attempt. PMID- 10168456 TI - Managing conflicts in systems development. AB - Conflict in systems development is nothing new. It can vary in intensity, but there will always be two possible outcomes--one constructive and the other destructive. The common approach to conflict management is to draw the battle lines and apply brute force. However, there are other ways to deal with conflict that are more effective and more people oriented. PMID- 10168459 TI - Five years and counting: the path to self-directed work teams. AB - In 1989, Roberts Express launched its first self-directed work team. Today it has more than 25 such teams, and they essentially have the responsibility of running operations. Those involved in the move to self-directed teams know it hasn't been easy. They have learned a number of important lessons along the way, some of which are described in this article. PMID- 10168458 TI - So you're the project leader: 10 roadblocks to watch out for. AB - Serving as project leader during the implementation of a manufacturing resource planning II system is exciting but can cause anxiety and concern, especially if you have to deal with some of the many typical roadblocks. Below is a description of 10 roadblocks to watch out for and suggested ways to deal with them. PMID- 10168460 TI - Play and learn team building. AB - In order to have a team function correctly, power must be distributed equally, with no team member having more perceived power than any other. It is this leveling of the playing field that allows the team to develop and to stimulate the creative juices of its members. This article discusses techniques that can help an organization break down the power barriers and permit its employees to become a cohesive unit--a team. PMID- 10168461 TI - Conquering internal process problems with the use of cross-functional self directed work teams. AB - The purpose of this article is to introduce a no-nonsense approach to motivating employees while reducing cycle time, improving quality, and creating a flexibly trained, self-directed work force. The article focuses on both the use of cross functional teams and the change in the role of management that must occur. PMID- 10168462 TI - Flexible forecasts: a key to better customer service. AB - Good customer service requires companies to keep their fingers on their customers' pulse and develop intelligent forecasts with their needs built in. As even the smallest factories today are placing at least some emphasis on lead time reductions to improve flexibility and the speed of response to customer requirements, the role of the forecast, now more than ever, is to provide at all times the best, most recent, and most accurate picture of what exactly will be required and when. PMID- 10168463 TI - Profiting from cycle time reductions. AB - Most U.S. companies have found themselves under immense pressure to reduce their costs, improve their quality, and reduce the cycle time of manufacturing current products and getting new products to market. Cycle time reduction is still fertile ground for gains in competitiveness, and this article describes the process that Eastman Kodak Company has used to achieve significant improvement, 50 percent or more in some areas. PMID- 10168464 TI - Maximizing the potential of your systems. AB - In the last two decades, manufacturing businesses throughout the United States have learned that an important factor affecting the productivity of their manufacturing systems when implementing manufacturing resource planning is the way they approach the implementation itself. Eighty percent of an implementation effort needs to be devoted to preparing people in the organization to use the system and only 20 percent should be devoted to purchasing the system. PMID- 10168465 TI - World-class materiel flexibility: one plant's victory over materiel-related downtime. AB - It is not uncommon for the materiel managers in a manufacturing company to be blamed for downtime and the consequent failure to meet production targets. To avoid downtime, materiel managers need to look at their role in solving materiel related downtime and to address the problems that cause downtime in the same way they would address other process quality problems. PMID- 10168466 TI - The evolution to electronic data interchange: are there benefits at all stages of implementation? AB - Many companies implement electronic data exchange (EDI) as part of their customer supplier partnerships. Both the customers and suppliers expect to gain operational and competitive benefits. This article describes why a midsize midwestern supplier company received only minimal benefits from its EDI installation. PMID- 10168467 TI - Effective performance measurements. AB - When your company is sluggish and information or products aren't moving like they should, do you know how to figure out why? This article will show you how measuring performance can identify the problems, and "root cause analysis" can help identify the solutions. In addition, the article will show you how to use performance measurements to constantly monitor the health of your company to prevent it from becoming sluggish in the first place. PMID- 10168468 TI - Inventory accuracy in 60 days! AB - Despite great advances in manufacturing technology and management science, thousands of organizations still don't have a handle on basic inventory accuracy. Many companies don't even measure it properly, or at all, and lack corrective action programs to improve it. This article offers an approach that has proven successful a number of times, when companies were quite serious about making improvements. Not only can it be implemented, but also it can likely be implemented within 60 days per area, if properly managed. The hardest part is selling people on the need to improve and then keeping them motivated. The net cost of such a program? Probably less than nothing, since the benefits gained usually far exceed the costs. Improved inventory accuracy can aid in enhancing customer service, determining purchasing and manufacturing priorities, reducing operating costs, and increasing the accuracy of financial records. This article also addresses the gap in contemporary literature regarding accuracy program features for repetitive, JIT, cellular, and process- and project-oriented environments. PMID- 10168469 TI - Don't force change--facilitate it. AB - Many projects are planned well but seem to fail in the implementation stage. We've all been in that situation to one degree or another, so we know that planning, in and of itself, does not dictate success. What is the link between planning and success that is missed so often? While a project with no plan is doomed to failure, a well-planned project can fail just as easily if you can't execute the plan. The ability to keep your team motivated and the project moving forward is critical, and most project leaders don't recognize some fundamentals that are prerequisites for success. PMID- 10168470 TI - The Genesis Enterprise: creating peak-to-peak performance. AB - Peak performance is often the beginning of failure. The process of continuously creating peak-to-peak performance defines the Genesis Enterprise. There will always be more problems than there are solutions. We need to install a process that anticipates and solves problems before they are problems and to continuously transform our organization into a championship organization that is nevertheless the underdog. PMID- 10168471 TI - The future role of materiel management. AB - The objectives of this article are to review Dean Amer's forecasts and offer my personal observations as to why the forecasts were not completely accurate, review current business pressures and trends that present unprecedented opportunities for professional experts with leadership skills, and share a personal forecast as to what role materiel management can and should play in the future in manufacturing enterprises. PMID- 10168472 TI - Eliminate (don't automate) inventory tracking. AB - Being competitive in today's global markets is not easy. As a result, most companies are investing heavily in upgrading their competitive posture through the implementation of advanced methodologies, which are now becoming affordable to even the smallest of companies. It is also true that technology is advancing too rapidly for most organizations to absorb and effectively implement new developments. We've learned that technology alone is insufficient to improve competitiveness... and when implemented improperly it adds cost, with very little advantage. We've further learned that the effective implementation of technology must be rooted in common sense, accompanied by fundamental shifts in thinking. A change in how we manage and track inventory is one of those fundamental shifts that must take place if we are to benefit from much of the new technology. This article discusses changing the inventory management and tracking mindset. PMID- 10168473 TI - Value-added forecasting. AB - Long ago, the emphasis shifted away from forecasting as a competitive weapon when it became apparent that forecast error could never be eliminated. Forecasts became a necessary evil that no one wanted to claim responsibility for. It's time to clear up some of the misconceptions about forecasts and to seize the opportunity inherent in the forecasting process. It is not forecast accuracy but rather improved understanding and use of forecasting as a tool for reducing both costs and lead times that will add real value to an enterprise and can improve the results from any and all other initiatives. PMID- 10168474 TI - Just get it right! Measure it and fix it: the only sure route to 98-percent inventory record integrity. AB - Call it what you want: Back to Basics, Do it Right the First Time, or simply Inventory Integrity. There is no escaping the fact that accurate inventory just may be the most important requisite for any successful business or any business improvement effort. Good decisions require good facts, not just a good imagination or high hopes. Inventory, which is often the largest asset on the books, forms the basis for major and far-reaching business decisions every single day. If it is not accurate, then just imagine how good the decisions will be. PMID- 10168475 TI - It's 8 a.m.: do you know where your paradigm is? AB - This article is one form of communication, but it is a one-way method. When we discuss communication problems, we usually refer to a breakdown in the process of sharing information with each other--two way communication. We ask questions such as, How do we establish communication? What do we need to do to maintain the process of communication? Why do the lines of communication break down? There are of course, many factors that either contribute to or block out communication. This article deals with one insidious factor that is absolutely necessary to establish and maintain communication and happens to also be one of the reasons for breakdowns in the process of communication. That factor is your own paradigm. In fact, your paradigm may be the number one problem that blocks communication. PMID- 10168476 TI - Lead, follow, or get out of the way. AB - The more we know about the individuals who work for us, the better understanding we will have of them and the better job we will do in motivating them. Regardless of whether you work in credit, production, accounting, sales, engineering, personnel, or purchasing, you will have one problem in common with all managers. The problem is people. They take up by far the greatest portion of our operating budget. People are difficult. They have their strengths and weaknesses, their ups and downs, their joys and sorrows; and you don't have to be managing people for long before you find out that people don't like change. PMID- 10168477 TI - Just-in-time in the infrastructure. AB - We know that just-in-time (JIT) manufacturing is a set of philosophies, not a set of techniques. These same philosophies are embraced by the total quality management (TQM) school. The most important element of this philosophy is that of continuous improvement--the acceptance of constantly changing objectives as a departure from reliance on standard requirements. This fundamental concept drives other philosophical aspects such as improving utilization of resources (employee involvement, reduction of waste) and long-term success (customer focus, vendor partnerships). Clearly, these philosophies are applicable to all organizations and functions. Perhaps some of these philosophies are manifest by certain JIT principles that we might consider when we design organizational routines and practices. Why not apply what has been proven in the factory to the seemingly bureaucratic behaviors in the office. PMID- 10168478 TI - The high cost of foreign sourcing. AB - Buyers in many industries have, for the past 30 years, sought lower purchased prices of materiel by sourcing with foreign suppliers. Few companies have fully assessed the actual cost of purchasing and using these foreign goods and comparing these costs with those of domestic producers. This is a reexamination of the actual costs, not foreign source "bashing." The results may surprise you. PMID- 10168479 TI - How to use benchmarking to reduce planning and purchasing costs. AB - Each year at budget time, the standard question asked of the materiel management group is "Why do you have so many people?" Our answer had been that we do not have enough people. With more people, we could lower total cost and manage inventories better. The inevitable standoff occurs with each side feeling that the other does not understand the need for materiel management services. In early 1993, we decided to be prepared to answer the famous question of Dr. W. Edwards Deming, "How do you know?" We wanted to show people we really did know our business and thus initiated a project to benchmark planning, purchasing, and scheduling services of other companies. This article shares not only the results of the benchmarking efforts, but also the techniques for getting started. PMID- 10168480 TI - Congregate care facility selection: a conjoint approach. PMID- 10168481 TI - Assessing the strategy-performance paradigm: implications for organizational adaptation in discontinuous environments for home health care providers. AB - Home health care agencies are on the brink of experiencing prospective payment systems which will prove to be a major environmental shift. What will be the best strategy to offset the effects of prospective payment systems? Longitudinal studies of hospitals facing similar pressures may offer the best solution. This paper offers an attempt to address whether proactive or low cost strategies will provide home health agencies with higher firm performance after prospective payment systems. PMID- 10168482 TI - The progressive impact of psychological climate: a prognosis of health care providers' subjective powerlessness in reform legislation. AB - This study explores the impact of psychological climate variables on the perceived powerlessness of health care providers with regard to their contribution in reform initiatives. It is proposed that perceptions of powerlessness in intra-organizational settings can and do extend to subjective powerlessness in the socio-political arena. A conceptual framework for the theoretical arguments is provided. The hypotheses were tested on survey data from health care providers employed in a major US primary metropolitan statistical area. Several highly significant relationships were observed. Since the actions of health care administrators are primarily responsible for shaping their institutions' psychological climate, recommendations regarding how administrators can foster psychological climates that induce more provider involvement in reform are offered. PMID- 10168483 TI - The impact of social norms and economic requirements on the strategic marketing of managed care organizations. AB - The trend in managed care is toward an increased emphasis on cost containment mechanisms. However, many people have begun to argue that cost controls are being implemented at the expense of the provision of appropriate care. By focusing on the impact of societal values on the performance of MCOs, it is argued that MCOs need to focus their marketing efforts on championing cost-cutting efforts in areas that do not impact the quality of care provided, while at the same time, implementing a marketing campaign aimed at promoting their conformity to prevailing social norms. PMID- 10168484 TI - Dental practice location: some aspects of the importance of selection of place. AB - In the past, dentists' decisions regarding location have been characterized as "irrational." With increasing competition, more thought and planning must accompany the dental practice location and development decision. The history of the community and site selection process by dentists is reviewed, and a call for is made for the application of atmospherics to dental site development. PMID- 10168485 TI - An investigative model evaluating how consumers process pictorial information on nonprescription medication labels. AB - Currently, marketed over-the-counter (OTC) medication labels were simulated and tested in a controlled environment to understand consumer evaluation of OTC label information. Two factors, consumers' age (younger and older adults) and label designs (picture-only, verbal-only, congruent picture-verbal, and noncongruent picture-verbal) were controlled and tested to evaluate consumer information processing. The effects exerted by the independent variables, namely, comprehension of label information (understanding) and product evaluations (satisfaction, certainty, and perceived confusion) were evaluated on the dependent variable purchase intention. Intention measured as purchase recommendation was significantly related to product evaluations and affected by the factor label design. Participants' level of perceived confusion was more important than actual understanding of information on OTC medication labels. A Label Evaluation Process Model was developed which could be used for future testing of OTC medication labels. PMID- 10168486 TI - Cigarettes and health: historical controversies and constraints--Part II. PMID- 10168487 TI - Major determinants of social networks in frail elderly community residents. AB - Although social networks has been extensively studied as independent, intervening, and moderating variables affecting health, little attention has been paid to social networks as dependent variables. The present research is a longitudinal study which focuses on social networks as the dependent variable. A sample of 3,559 poor, frail, elderly from California Multipurpose Senior Services Project (MSSP) were evaluated in six month intervals over an eighteen month period. The results indicate that life events, sex, ailments, mental functioning, and health habits are significant predictors of the elderly's social networks after six months, and that life events, sex, age, and health habits are significant predictors of the elderly's social networks after twelve months, as well as after eighteen months. Implications for intervention and for further research are discussed. PMID- 10168488 TI - Agency approaches to common quality problems in home care: a scenario study. AB - In a study of best practices in home care quality assurance (QA), a sample of 128 respondents from exemplary home care agencies were presented with 7 brief scenarios depicting common problems in home care quality. Agency respondents were asked to describe their likelihood of identifying the problem in each scenario, how they would identify the problem, and how they would correct it. We found that agencies expressed considerable confidence they would identify the problems, but were unlikely to view their QA efforts as contributing to detecting the problems. Identification was more often perceived to come from ordinary care, with considerable burden placed on paraprofessional staff or clients to bring the problem to the attention of the agency. Medically-oriented agencies were significantly more likely than socially-oriented to rely on formal QA to identify deteriorating patient conditions and depression. Across all agencies, a relationship existed between the type of problem in the scenario and the most frequent responses about detection and correction nodes. Once the problem was identified, agencies presented an appropriate and fairly wide range of corrective strategies. The implications for making QA more organically related to clinical care are discussed. PMID- 10168489 TI - The use of home care by cancer patients: a multivariate analysis. AB - The use of home care by cancer patients over the course of a year was analyzed using a two-part model that estimated: (1) the probability of any use, and (2) the quantity of visits given some use. The findings support the use of a two stage model for estimating home care over single equation approaches. We found that while HMO membership increased the probability of some home care for cancer, it resulted in a smaller number of visits given some use. Health care coverage was also found to have different effects on these two components of total use. Some implications of some of these findings for future policies are discussed. PMID- 10168490 TI - Self-direction in home care for older people: a consumer's perspective. AB - Interest among elder home care consumers in playing a stronger role in planning and supervising their own care was examined. Elder home care consumers were surveyed to determine their willingness to assume more responsibility for their home care such as in the hiring, paying, scheduling, supervising and/or firing of their home care worker. Telephone interviews were conducted of 883 home care clients in the Massachusetts Home Care Program which is administered through 27 local, private, non-profit Home Care Corporations (HCC) and which currently serves 33,000 clients. Respondents reported high levels of satisfaction with their home care services and home care worker. However, a substantial minority of respondents reported a willingness to assume more responsibility for their own home care services. A quarter to a third of the respondents indicated that they could take greater responsibility for supervising a home care worker and needed less assistance from a case manager. Multiple regression analyses revealed that prior experience in directing an in-home worker, greater length of receipt of home care services, greater current involvement in directing a home care worker, and lower levels of satisfaction with home care services were associated with a willingness to assume responsibility for directing a home care worker. Pilot projects are needed that develop and test options for older people with disabilities to exercise greater control over their own personal assistance. PMID- 10168491 TI - Psychiatric home care for the elderly. AB - This study summarizes descriptive information concerning an existing psychiatric home care service and lays the foundation for more sophisticated studies of elderly depressed persons who receive this type of long term care. Using existing medical record data, the demographic and clinical characteristics of the elderly patients using a multi-site home health care service are summarized, including: (1) their functional/psychiatric status, (2) their length of stay, (3) caregiver availability, (4) scope of multidisciplinary interventions provided, and (5) reasons for discharge. Prospective research of elderly persons receiving psychiatric home care is needed in the future. PMID- 10168492 TI - Unmet long-term care needs of elderly people in the community: a review of the literature. AB - The extent of unmet need, or the extent to which needed assistance is unavailable for insufficient, is an important issue in public policy and financing of health and support services. This article reviews the research of literature to assess how unmet method is measured, and the extent of unmet needs among elderly people in the community. Measurement difficulties include variable definitions and measures of need across studies, the relative dearth of studies which undertake to measure unmet needs, and varying methodologies used to estimate need and unmet need. In addition, some measures of status and need, such as cognitive impairment and care giver burden are excluded from many estimates. Estimates of unmet need range from around 2 percent to about 35 percent of community dwelling elders, depending on what is included or excluded from the definition. Unmet need is associated with higher disability levels and living alone. The literature suggests that estimates of future unmet need will be mitigated by declining disability levels and increased use of assistive devices among the elder population. PMID- 10168493 TI - Mergers. All mixed up. PMID- 10168494 TI - US healthcare. Emerging doubts. AB - Hundreds of US hospitals are being merged or closed. This trend is the focus of public opposition. Many hospitals are making increasing use of care assistants to cut costs. PMID- 10168495 TI - Mental health. Calls for help. PMID- 10168496 TI - Patient participation. Power to the people. PMID- 10168497 TI - Career profile. Senior managers--how to be ahead. PMID- 10168498 TI - Management maestro. New software for health facilities can help bring harmony to all operations. PMID- 10168499 TI - Asset test. Are you ready for the new generation of real estate asset management software? PMID- 10168500 TI - The big chill. Chiller integration puts the freeze on energy costs. PMID- 10168502 TI - High-tech housekeeping: don't get left in the dust. PMID- 10168501 TI - CAFM (computer-aided facility management) system tracks assets, monitors changes. PMID- 10168503 TI - Integrated delivery systems mean IT upgrades, increased spending, and staffing. PMID- 10168504 TI - From knowledge to wisdom. PMID- 10168505 TI - AHA calls for fraud-probe respite. PMID- 10168506 TI - Boyke resigns as AHA unit president. PMID- 10168507 TI - Turmoil in the boardroom. Former hospital trustee says Columbia broke promises. PMID- 10168508 TI - Ambulance wars. Columbia's planned lease of Ky. service prompts lawsuit. PMID- 10168509 TI - Hitting home care. Bills would repeal payment hike, cut further in 1998. PMID- 10168510 TI - FPA poised for growth. Acquisition, HMO contracts open New York market. PMID- 10168512 TI - Hospital lobbying blitz starts paying off. PMID- 10168511 TI - VHA's new data link. Deal is latest effort to serve members' information needs. PMID- 10168513 TI - A win for mergers. Federal court OKs Mich. hospital deal, but FTC may fight. PMID- 10168514 TI - Access or poor care? Suit alleges Kaiser booked four patients in one slot. PMID- 10168515 TI - Mayo managed care. Clinic's Arizona network forms its own HMO. PMID- 10168516 TI - New vistas for HMOs. Managed care makes inroads in northern Rockies states. PMID- 10168517 TI - Embattled doc turns to buying hospitals. PMID- 10168518 TI - N.J. study: senior health services must increase. PMID- 10168519 TI - Ga. group wants MSAs. State medical association pushing for pilot project. PMID- 10168520 TI - HMOs tighten own reins. In Minn., plans lead passage of patient protection law. PMID- 10168521 TI - Providers, insurers fight over PSO definition. PMID- 10168522 TI - Savings for states? Senate budget aims to reinstate Medicaid cost sharing. PMID- 10168523 TI - Hospitals out in the cold. Plan to freeze Medicare marketbasket update in 1998 is unfair and unnecessary. PMID- 10168524 TI - It pays to be the boss. Survey shows top hospital execs' pay hikes leave little for other managers in departments. AB - Modern Healthcare's annual survey of salary and compensation trends shows that it truly pays to be the boss. This year's data show the healthiest pay hikes in three years for hospital managers, directors and executives. The overall pay raise--defined as the increase in cash compensation--averaged 4.2% in this year's survey, up from 3.48% last year and 2.47% in 1995. See page 76 for a comprehensive list of the winners and losers. PMID- 10168525 TI - Cardiac relief. Stent prices could drop with FDA approvals ahead. PMID- 10168526 TI - Volume set on high. Tax-exempt bond sales climb 25% in the second quarter. PMID- 10168528 TI - Tools of the trade for cost-effective MRI. PMID- 10168527 TI - Clinic lays groundwork for a filmless future. PMID- 10168529 TI - Clinical MR: where it's been, where it's going. PMID- 10168530 TI - PPMs offer solutions to managed-care woes. PMID- 10168531 TI - The size distribution of droplets in the exhaled breath of healthy human subjects. AB - Droplets carried in exhaled breath may carry microorganisms capable of transmitting disease over both short and long distances. The size distribution of such droplets will influence the type of organisms that may be carried as well as strategies for controlling airborne infection. The aim of this study was to characterize the size distribution of droplets exhaled by healthy individuals. Exhaled droplets from human subjects performing four respiratory actions (mouth breathing, nose breathing, coughing, talking) were measured by both an optical particle counter (OPC) and an analytical transmission electron microscope (AEM). The OPC indicated a preponderance of particles less than 1 mu, although larger particles were also found. Measurements with the AEM confirmed the existence of larger sized droplets in the exhaled breath. In general, coughing produced the largest droplet concentrations and nose breathing the least, although considerable intersubject variability was observed. PMID- 10168532 TI - Aerosolized amiloride: dose effect on nasal bioelectric properties, pharmacokinetics, and effect on sputum expectoration in patients with cystic fibrosis. AB - Aerosolized amiloride normalizes the excessive sodium absorption cystic fibrosis (CF) respiratory epithelium. The aims of this study were to assess the dose effect relationship and the duration for which amiloride inhibits Na+ transport, to determine acute and chronic pharmacokinetics, and to test the effect of acute aerosolized amiloride on the amount of sputum expectorated. The effect of inhaled amiloride was assessed principally by nasal potential difference (PD) measurements. Amiloride serum levels were measured in 23 patients after inhalation of different doses of aerosolized amiloride. Twenty CF patients inhaled amiloride (10(-3)M) or a placebo in a double-blinded, randomized order, and sputum production was quantitated. The results of this study showed that maximal initial PD inhibition was achieved by 6 x 10(-3)M of amiloride. The duration of inhibition of PD (effective time until return to 50% delta PD [ET50] after nasal administration) was dose dependent (10(-3)M, 39 +/- 0.8 minutes; 10( 2)M; 133 +/- 14 minutes). Amiloride serum levels were below 2.5 ng/ml in 20 of 28 patients; levels were above 5 ng/ml only within 4 hours after high dose inhalation (10(-2)M). In the double-blinded, crossover study, more sputum was expectorated after amiloride inhalation as compared with that after a placebo (P < 0.05). In conclusion, the bioelectric effects of amiloride and serum levels after inhalation are dose dependent, and amiloride is effective at inducing sputum expectoration in CF. PMID- 10168533 TI - Single hospital experience with emergency cardiopulmonary bypass using the portable CPS (Bard) system. AB - One hundred four patients were placed emergently on the Bard CPS portable femoro femoral bypass system over a 4 year period. Thirty-two patients (31%) were discharged from the hospital. Seventy-six of these patients (73%) required emergency bypass following cardiac arrest, and twenty-eight patients (26%) were in cardiogenic shock or respiratory failure. In the arrest group, no one survived an unwitnessed arrest and those with cardiopulmonary resuscitation times less than 30 minutes had a better survival rate. The highest survival rate was in those patients who did not arrest prior to bypass. Fifty-two percent of these patients were released. The 74 patients receiving interventional therapy on bypass had a higher survival rate than those unable to be treated. Of the thirty patients receiving no intervention, only three (10%) were eventually discharged. For the 19 patients receiving treatment only in the cardiovascular laboratory, the discharge rate was 26%. Of the 55 patients taken to the operating room for surgical correction, 24 (44%) were discharged from the hospital. No patients placed on bypass at an outlying hospital or treated using CPS within 72 hours of a previous open heart procedure survived. PMID- 10168534 TI - Hemostatic assessment of patients undergoing intraaortic balloon pump therapy. AB - Patients undergoing intraaortic balloon pump (IABP) therapy are at risk for developing coagulopathies due to the adverse effects of prolonged exposure of the synthetic surface of the polyurethane balloon to blood components. Hemorrhagic risk has been attributed to a number of factors including thrombocytopenia, vascular injury, and/or platelet degranulation which increase the potential of receiving autogeneic blood transfusions. The present study is a prospective evaluation of coagulation using a viscoelastic monitor (Thrombelastograph--TEG) that measures functional aspects of clot development and stabilization in patients being treated with IABP therapy. Following Institutional Review Board approval, six patients undergoing IABP therapy for hemodynamic instability were enrolled in this study. Blood samples were taken prior to balloon insertion, at 8, 16, 24, 48, 72, and 96 hours on IABP therapy, and 24 hours following the removal of the balloon when applicable. Samples were incubated with heparinase to degrade heparin and TEG profiles were subsequently determined in duplicate. Measured parameters on the TEG included R-time, K-time, maximum amplitude, alpha angle, and lysis at 30 and 60 minutes with calculation of the TEG index. Mortality was 33% following IABP discontinuation. Transfusion of packed red blood cells occurred in 50% of the patients during their balloon pump therapy. Patients demonstrated a significant deviance in fibrinolytic potential from pre-IABP lysis (1.6% +/- 1.8) at both 24 hours (18.8% +/- 22.9) and 48 hours (21.9% +/- 28.5) of therapy (p < 0.05) which returned to baseline shortly after balloon removal. Activation of coagulation factors appeared evident by a steadily increasing alpha angle from pre-IABP data (3.1 +/- 9.2) throughout the duration of therapy and 24 hour recovery (53 +/- 14; p < .005), and by a steadily trending increase in the TEG index pre-IABP (.251 +/- 1.4) to post-IABP (2.6 +/- 1.7; p < 0.05). The results indicate that IABP therapy induces an increase in fibrinolytic potential at 24 to 48 hours of balloon pump therapy with a paradoxical trend toward increased coagulability, potentially predisposing the patient to hemorrhagic risk. PMID- 10168535 TI - Evaluation of the Hemochron 8000 Rx/Dx system for heparin management. AB - The Hemochron Rx/Dx uses an ACT and a heparin response tube to calculate the heparin dose to identify heparin sensitive/resistant patients. We evaluated the Rx/Dx system in 37 patients to determine if the ACT after the predicted heparin loading dose was adequate to initiate CPB. The mean heparin dose calculated by the Rx/Dx was 31,700 IU +/- 8,700 IU (370 IU/kg) with a mean post ACT of 463 +/- 124 sec. Our standard heparin dose (400 IU/kg) would have given an additional 2,800 IU over the Rx/Dx. Four patients (6.5%) were predicted to be heparin sensitive and all four achieved an ACT over 450 sec. Twenty-one patients (56.8%) were predicted to be resistant and yet failed to raise the ACT over 450 sec in 17 (81.0%). Twelve patients (32.4%) were predicted to have a normal heparin response, and four (33.3%) did not achieve an ACT over 450 sec. In all, 21 patients (56.8%) did not achieve an ACT greater than 450 sec. Each institution should evaluate their heparin loading dose and the resultant ACT. In this study, we found the number of times the Rx/Dx system did not raise the ACT over 450 sec too great to justify the additional expense. PMID- 10168536 TI - Determining when a clinical activity should be classified as research requiring Institutional Review Board Review. AB - The boundary between therapy and research may at times be difficult to distinguish, and it is, therefore, important for health care professionals to recognize when a clinical activity should be properly classified as research. Research may be subject to federal regulations which require advance review and approval by an Institutional Review Board (IRB) in order to protect the rights and welfare of patients who serve as human subjects. This paper will discuss the criteria health care professionals can use to distinguish between therapy, innovative therapy, and therapeutic or clinical research. PMID- 10168537 TI - Cracked acrylic ventricular assist devices after using a Doppler stethoscope and ultrasound transmission gel to predict impending pump failure: a case report. AB - At Saint Louis University Health Sciences Center, bi-ventricular assist devices were placed in a patient after failure to wean from bypass. These acrylic devices are known to be used for post cardiotomy failure. Acrylics and other plastics are used in extracorporeal circuitry. Plastics have been known to crack when exposed to certain chemicals and conditions. This case describes the use of ultrasound transmission gel as another ingredient that causes cracking of centrifugal assist devices made of acrylic plastic. PMID- 10168538 TI - Rapid pediatric cardiopulmonary support system. AB - Emergency cardiopulmonary support (CPS) systems for pediatric patients have not achieved widespread acceptance because they have been limited by extended setup times and large priming volumes requiring blood products. To address these limitations, we developed a miniaturized CPS system which can be rapidly assembled with a small bloodless priming volume. This system was successfully utilized in two infants with congenital heart disease in whom emergent cardiopulmonary support was instituted outside the operating room. The pediatric CPS system proved safe and effective in allowing the salvage of both patients. Further study of this system is warranted to evaluate potential future applications. PMID- 10168539 TI - Effective laser ablation of enamel and dentine without thermal side effects. AB - We present a feasibility study into laser treating dental materials by using femtosecond pulses generated by a titanium:sapphire laser system which consisted of an oscillator and a regenerative amplifier. The pulse duration was varied between 200 fs and 2 ps. The observed energy thresholds for the ablation process of dentine and enamel were clearly smaller than those observed when longer pulse durations were used. The consequence of this observation is a lower thermal load within the vicinity of the radiated area. Thus no thermal damage or mechanical damage, such as cracks, were produced during the laser treatment. Commercially available femtosecond laser systems can produce ablation rates in healthy and in vitro demineralized dental material 2 mm3 per min and 6-16 mm3 per min, respectively. These values are an order of magnitude larger than those produced by picosecond laser systems at the same time pulse energy and pulse repetition rate. The brightness of the plasma spark generated by the laser treatment depended on the dimineralization of the teeth. This may allow online control of the laser treatment. PMID- 10168540 TI - Prostatic stents for benign prostatic hyperplasia. AB - Treatment options for benign prostatic hyperplasia (BPH) have developed rapidly over the past several years. These options include surgical intervention, medical therapy, and minimally invasive modalities such as prostatic stents. Prostatectomy remains the treatment of choice for symptoms that are the result of bladder outflow obstruction, with success rates of 85-90%. Medical therapy with selective alpha-1 antagonists, 5 alpha-reductase inhibitors, LHRH antagonists, antiandrogens, and aromatase inhibitors have increased in popularity and are mainly used to treat patients with mild to moderate prostatic obstruction. Prostatic urethral stents have recently emerged as an alternative treatment for BPH throughout Europe and Asia, but few investigators have used prostatic stents in the United States because of strict regulatory forces and a debate concerning the indications for these devices. The possibility of providing a treatment option for BPH to patients who are frail and elderly, as well as to patients with multiple medical problems, has prompted enthusiasm toward prostatic stents in the urologic community. The focus of this review will be an up-to-date discussion of the types of prostatic stent available, including a review of recent clinical trials involving the use of each available stent. PMID- 10168541 TI - Design considerations in penile prostheses: the American Medical Systems product line. AB - Penile prostheses represent an important treatment modality for erectile dysfunction. A review of the design considerations for penile prostheses is presented, using the American Medical Systems, Inc., product line as a practical example. Current models include both inflatable hydraulic and solid malleable designs. The challenge for the future is to develop devices with improved durability while optimizing ease of use and cosmetic appearance. PMID- 10168542 TI - Artificial urinary sphincter: evolution and development. AB - The first hydraulic artificial urinary sphincter came into clinical use in 1972. The original prototype has undergone many modifications resulting from advances in mechanical design, applications of new technology, and clinical experience. This evolutionary process has culminated in the AS800, the most frequently used hydraulic artificial urinary sphincter in the U.S. today. Although the AS800 device most closely approximates the biological urinary sphincter, clinical demands for an ever more ideal urinary sphincter require the ongoing improvement of this device. PMID- 10168543 TI - Biocompatibility in transfusion medicine. AB - The first measurable event upon interaction of artificial surfaces with blood is adsorption of proteins within seconds or minutes. At a later stage, blood cells interact with the surfaces through the initially deposited protein layer. The chemical composition of the surface is only one criterion for differential deposition of various plasma proteins, with molecular motion (polymer chain ends, loops and their flexibility), and topography (roughness, porosity) of the surface decisively influencing the interactions as well. Initially incompatible surfaces, which may be dangerous to the patient, may be rendered compatible by physicochemical surface modifications. Modern methods to estimate biocompatibility have become so sensitive that they may detect biological modifications of the blood after contact with a surface, which has no consequence for the patient. In these cases it is often difficult to decide whether a material should be classified as biocompatible or non-biocompatible. This paper discusses some methods that we have used for the study of biocompatibility of extracorporeal circuitry. It seems to us that minute signs of laboratory evidence for bioincompatibility should not preclude usage of the material in a clinical setting. PMID- 10168544 TI - Modification of activation-dependent platelet antigens CD62p and CD63 during haemodialysis. AB - In particular, activated platelets are thought to be involved in the pathophysiology of thrombotic occlusions of vessels. In this study, we evaluated activation-dependent changes in platelet antigens during extracorporeal haemodialysis treatment. Flow cytometry was used in combination with monoclonal antibodies that bind to platelet glycoproteins CD62p (GMP-140) and CD63 (GP53). Maximum peaks of mean channel fluorescence intensity (MCFI) were reached after 60 min in 20/26 procedures in CD62p (P < 0.005) and in 15/25 treatments in CD63 (p < 0.002), respectively. An initial peak of CD62p and CD63 fluorescence expression could be detected in 21/25 and 23/25 treatments, respectively (CD62p within 15, CD63 within 30 min), indicating the early onset of activation. The structural antigen CD41a MCFI slightly decreased over time in all treatments, while CD42b expression did not change. From these results we conclude that haemodialysis contributes to platelet activation and secondary hypercoagulability. Analysis of platelet glycoproteins by flow cytometry may provide clinical information on patients at a higher risk for thrombosis and may help in further improvement of haemodialysis equipment. PMID- 10168545 TI - Clinical efficacy of haemorheological treatment using plasma exchange, selective adsorption and membrane differential filtration in maculopathy, retinal vein occlusion and uveal effusion syndrome. AB - The aim of the study was to test the clinical efficacy of haemorheological treatment with extracorporeal techniques in ocular diseases. We treated patients suffering from maculopathies of different origin: age-related (AMD, n = 17), uveitis-associated (n = 14) and myopia-associated maculopathy (n = 5). We also treated patients with uveal effusion syndrome (n = 3) and central retinal vein occlusion (n = 4) resistant to haemodilution or steroid therapy. The treatment consisted of plasma exchange, selective adsorption with a tryptophan polyvinylalcohol adsorber and membrane differential filtration. Maculopathy patients underwent two treatments while the other patients received between 1 and 7 treatments. Pulsatile ocular blood flow was measured in 10 patients before and after therapy. The main parameter for evaluating clinical outcome was the change in visual acuity. Severe side-effects did not occur. The rheological parameters including plasma viscosity, whole blood viscosity and erythrocyte aggregation were statistically significantly lowered. Of 36 patients suffering from maculopathy, 25 showed an improvement of at least 1 line of visual acuity after therapy, 7/17 patients in AMD, 6/14 in uveitis and 0/5 in myopia improved 3 lines or more. All patients suffering from retinal vein occlusion improved at least 1 line and two showed an improvement of 3 lines or more. In uveal effusion syndrome, an improvement of 3 lines or more was reached in all patients. Plasma exchange, selective adsorption and membrane differential filtration are effective rheological treatment approaches to improving visual acuity in patients suffering from maculopathy except myopia-associated maculopathy. Efficacy in patients suffering from central retinal vein occlusion and uveal effusion syndrome was proven, even when the patients were resistant to previous haemodilution or steroid therapy. We conclude that a rheological approach should be considered before invasive methods such as laser coagulation, radiation therapy or surgery are applied. PMID- 10168546 TI - Haemorheological changes in mixed cryoglobulinaemia during apheresis treatment. AB - Thirty-four patients affected by mixed cryoglobulinaemia have been submitted to treatment by apheresis (plasma exchange or double cascade filtration). The authors have monitored clinical, laboratory and, above all, haemorheological changes following therapy. The final results have shown mainly a reduction of plasma viscosity and consequently an improvement of the haemorheology of the affected organs. In conclusion, apheresis may be considered a successful therapy in patients with severe renal or neurological diseases due to mixed cryoglobulinaemia. PMID- 10168547 TI - Changes of haemorheological parameters when using plasma exchange, selective adsorption and membrane differential separation. AB - At present, conventional haemorheotherapy consists of changes in life-style, drug therapy and haemodilution. Extracorporeal therapy has been considered only for the treatment of hyperviscosity syndromes. However, a wide range of viscosity related syndromes may be amenable to rheological therapy if appropriate techniques were available. According to our data, plasma exchange, selective adsorption and membrane differential filtration may lead to an improvement of haemorheology and clinical conditions. For reasons of economy and feasability, membrane differential filtration is favoured over other techniques of differential separation therapy. PMID- 10168548 TI - Lipoprotein(a)-apheresis in the secondary prevention of coronary heart disease. AB - Lipoprotein(a) [Lp(a)] is one important cause of atherosclerosis. It consists of one molecule of low density lipoprotein and an additional molecule of apo(a) linked to apoB-100 by a disulfide bridge. Apo(a)s are partially homologous to plasminogen, with one kringle 5 and 10-40 repeats of kringle 4. As there is no drug therapy available, we treated three patients who had suffered from at least one myocardial infarction and had Lp(a) as the only risk factor for atherosclerosis. Since October 1992, 186 immunoadsorption treatments have been carried out weekly with Sepharose-coupled anti-Lp(a)-columns. To achieve a reduction in Lp(a) from 78-250 mg/dL before apheresis to below 25 mg/dL immediately after apheresis, patient plasma volume had to be treated two to three times. Treatments lasted 3-5 h. Immediately reversible side-effects such as flushing and tachycardia during the first treatment were seen in 9% of immunoadsorptions. Non-specific protein loss remained tolerable, if one takes into account that the patients received approximately 1 L of ACDB with heparin as anticoagulant and some of the column-rinsing buffer. One patient's clinical condition and exercise test improved dramatically as did coronary angiography after 2 years. Another patient had no change after 1 year, the third patient showed subjective improvement and has not yet had repeat angiography after 1 year of treatment. We conclude that Lp(a)-apheresis may retard progression of atherosclerosis in patients with selective Lp(a) elevation. Further studies to support this hypothesis are needed. PMID- 10168549 TI - Immunosorbent for IgG apheresis: an in vitro study. AB - We obtained anti-IgG Sepharose-an immunosorbent with sheep monospecific polyclonal antibodies against human IgG-for extracorporeal removal of human IgG. Appropriate conditions for effective usage of the immunosorbent were chosen. Binding capacity and selectivity of anti-IgG Sepharose were determined and compared with the corresponding properties of other sorbents for IgG apheresis; these properties appeared to be acceptable for immunoapheresis procedures. Methods for therapeutic application of anti-IgG Sepharose is expected to be effective when used in immunoapheresis procedures for treatment of autoimmune diseases and for preparation of patients for organ transplantation. PMID- 10168551 TI - Plateletpheresis: what's new? AB - 1995 has brought several novelties into the field of thrombocytapheresis. The most important is the presentation by Baxter of the Amicus CFC apparatus that, in a two-vein collection time of 51-53 min, collects 3.93-4.13 x 10(11) platelets contaminated by 0.2 x 10(6) white blood cells (WBC) with an efficiency of 72-74%. Similar results are obtained in 55 min, in single-needle procedures, with a collection efficiency of 70.7%, a total yield of 4.3 x 10(11) and a contamination of 0.9 x 10(6) WBC. Presently the machine cannot collect red blood cells (RBC), along with platelets, as does the DFC Haemonetics MCS3p. With this machine in mandatory single-needle procedures lasting 80-85 min, approximately 4.5 x 10(11) platelets can be collected with a WBC contamination of 3.1 x 10(6). Along with the platelet cells (PC), with the SDP PRC protocol at the end of each pass it is possible to collect aliquots of plasma red blood cells (PRBC) (10-50 mL) with a haematocrit of 65%. Depending on the number of passes and on the donor's body weight (BW), from 1 and 2 U/PRBC containing approximately 55 g of haemoglobin (Hb) each can be obtained. This method not only costs less but also immunological and viral risks for the patients are more efficiently addressed since it is possible to reduce the number of allogeneic exposures in the same transfusion event. PRBC can also be collected with the Fresenius AS104 and the Dideco Excel apparatuses. Dideco is presently using the "Genova" separation chamber, which can collect an average of 4.8 x 10(11) platelets contaminated with 0.5 x 10(6) WBC, in approximately 55 min. The ACD-A-to-blood ratio may be as low as 1/20 since the very last belts and lines are coated with non-thrombogenic substances. Therefore, there is no alteration of the quality of the platelets as evaluated with monoclonal antibodies (MoAbs) anti-CD 62, 63, 36 and 51, no extra haemorrhagic risk for the donors and citrate reactions and microaggregate formation are totally eliminated. In 1995 there has also been some rejuvenation of the older cell separators. The CS3000+ uses the TN6/PLT 30 combination of separation collection chambers. Platelets are collected in only 30 mL of plasma, and non plasma solutions containing acetate can be used for their resuspension. The Fresenius AS204 is ready for better-quality combined platelet collection, and RBC PC collection with Cobe Spectra is under evaluation along with the leucocyte reduction system that apparently brings leucocyte contamination down to 0.35 x 10(5). This interest in thrombocytapheresis is also the result of the challenge that thrombopoietin phase I and II trials have promoted. PMID- 10168552 TI - How can we improve platelet preparation and storage? AB - The use of platelet additive solutions to replace the major part of plasma as storage medium can improve storage through supply of fuel in platelet metabolism. It is important to avoid platelet activation, e.g. through optimal anticoagulation and gentle procedures at preparation. Leucodepletion of platelet concentrates (PCs) reduces HLA immunization and therapeutic refractoriness. Leucofiltration has become common to obtain leucocyte-depleted PCs, but frequently results in considerable platelet loss. Attempts at improvements must be validated, e.g. by testing post-transfusion increments and function in vivo. The in vitro bleeding-time test seems to be a valuable tool for the latter purpose. Bacterial contamination of PCs occur more commonly than so far believed, however, severe clinical complications seem to be relatively rare. Newly available methods for bacterial culture are sufficiently rapid and sensitive to be useful in PC testing. Bacterial decontamination, e.g. using psoralen-UVA, may be a future possibility for obtaining safer PCs. PMID- 10168550 TI - Treatment of graft versus host disease (GVHD) by photopheresis? AB - Graft versus host disease (GVHD), whether acute or chronic, is a frightening complication of bone marrow allografts-indeed in many cases it can be life threatening. In chronic GVHD, the symptoms are less serious, but they can nevertheless be alarming. The mechanism of this reaction is very complex and the pathogenesis of chronic GVHD seems to be slightly different from that of acute GVHD. However, there is no doubt about the immune mechanisms. The production of numerous cytokines plays an important part and has also been des-cribed. Until the use of photopheresis, the only treatments that were effective to any degree have been immunosuppressive treatments. Extracorporeal photopheresis (ECP), a technique recently proposed in chronic GVHD, is promising and is believed to attack the actual cause of the disease (the role of cytotoxic T lymphocytes is now recognized). ECP is believed to have a complex mechanism of action, the explanation of an anti-T lymphocyte action of ECP seems too simple. We report the results of three patients suffering from chronic GVHD, refractory to the usual treatments. The schedule for ECP was a cycle of two treatments every 2 weeks. We recorded a complete remission for patient No. 1 (grade 1) with no relapse for now 3 years. In patient No. 2 (grade 2-3) a progressive improvement was observed in the various symptoms with, however, several episodes of aggravation. In patient No. 3 (grade 2-3), the skin symptoms improved and the lichen planus lesions healed after only 15 months of treatment (interrupted by two infectious episodes during which ECP was stopped). Although the study population was small, we may be justified in thinking that ECP can cause an improvement in chronic GVHD refractory to immunosuppressive treatment. These results should be confirmed by a rigorously designed multicentre study. PMID- 10168553 TI - IVBT-documented platelet function correlates with flow cytometric data. AB - Thrombocytopenic patients with identical platelet counts often show different bleeding tendencies owing to significant differences in the platelet function. This could be demonstrated by the in vitro bleeding test (IVBT). Using flow cytometry, we tried to find characteristics of platelet antigen expression in order to explain these differences in function. Thirty patients with bone marrow hypoplasia receiving 65 platelet transfusions (mainly from a cell separator) were observed for 3 to 29 days. Size, granulation and fluorescence of platelet-rich plasma (n = 522 samples) were evaluated using monoclonal antibodies against GP IIIb (collagen receptor), GP IIb/IIIa (fibrinogen receptor) and GP Ib (thrombin receptor). We defined separate gates for each antibody using the results from 50 normals and by laying an orthograde cross over the gate to divide the gate into four equal quadrants. The platelet populations were divided into four different groups according to the occlusion time (OT) of the IVBT and the Simplate time (ST). The thrombocytes with the most impaired function (OT > or = 485 s/ST > 30 min) had significantly less platelet fluorescence when marked with antibodies against GP IIIb and GP Ib than those with short OT and ST (OT < 100 s/ST < 15 min). Similar results were obtained when evaluating the data relative to the bone marrow status: patients with < 1000 WBC/microliters showed significantly less platelet fluorescence when marked with anti-GP IIIb and anti-GP Ib than thrombocytopenic patients, who had a spontaneous platelet rise beyond 30,000 platelets/microliters a few days later. One day after platelet transfusion, significantly more platelets with high GP IIIb and Ib expression could be found. We were also able to document better transfusion efficacy of platelet concentrates with high GP IIIb and Ib expression. Finally, patients with high bleeding scores showed less GP Ib expression on the platelets than patients with low bleeding scores. In summary, the IVBT-documented platelet function clearly corresponded to an increased expression of the collagen receptor and the thrombin receptor of platelets. PMID- 10168554 TI - The storage quality of apheresis platelets--analysis of results from seven different cell separators. AB - Apheresis platelet concentrates (CAP) have been available for more than 20 years. Now, as a result of the use of, and progress in, automatic blood separation techniques, the quality of platelets is continually being improved so that we currently have access to purified concentrates which are not contaminated by red cells and contain only very few white cells. In view of the wide experience available to us, it was useful to monitor a number of qualitative parameters indicating platelet activation during storage. We monitored platelet aggregation, release of beta thromboglobulin, activation of complement and other basic parameters in seven platelet concentrates from seven cell separators (Cobe Spectra, MCS Haemonetics, CS3000+, Baxter, Excel Dideco, Autopheresis C Baxter, and V50 Haemonetics). We found that in the majority of cases aggregation was greatly reduced during storage. Release of beta thromboglobulin and activation of complement increased. pH remained within acceptable limits in some cases. However, in others (MCS, Excel), a decrease in pH < 6.0 was found. To conclude, although CAP, which are from a single donor, reduce the risks of transfusion, they are not protected from physical alteration and therefore from reduction in the clinical effects of transfusion. It is therefore necessary to improve the storage conditions of these cells in the future, for example by designing new plastics, or adding platelet storage media. Basic biological parameters should also be defined, within the framework of quality assurance, to evaluate platelet quality. PMID- 10168555 TI - State of the art in platelet transfusion therapy. AB - Platelet transfusions are established as effective treatment for thrombocytopenic bleeding, and are commonly used prophylactically to prevent bleeding in thrombocytopenic patients. However, many issues in platelet supportive care remain to be resolved, including the optimal methods for the preparation of platelet concentrates, the best means for the prevention of complications such as platelet refractoriness, transfusion reactions and the transmission of infection, and the precise clinical indications for their use. The demand for platelet concentrates continues to rise, mainly due to the increasing number of patients undergoing myeloablative therapy. This is leading to considerable interest in the coming availability of recombinant thrombopoietin for clinical use. PMID- 10168557 TI - Effect of storage conditions on the CD34+ counts in flow cytometric analysis after anticoagulation of samples with EDTA. AB - The transplantation of peripheral blood precursor cells (PBPC) is becoming of interest for autografting patients with a wide variety of haematological and other malignancies. For rapid quality control of PBPC apheresis products, flow cytometry is applied to quantify the number of CD34+ events. We studied the effect of different storage conditions on the number of CD34+ counts in EDTA anticoagulated aliquots of PBPC grafts. Within 24 h, CD34+ signals decreased when samples were stored at room temperature (RT, 20 +/- 2 degrees C) compared to the results obtained directly after cytapheresis. The signal rate equalled or exceeded the baseline values after 24 h when aliquots were deposited at room temperature and subjected to agitation. Storage at 4 degrees C revealed no significant changes. These data indicate that quality control of PBPC samples by flow cytometry significantly depends on storages time, temperature and other conditions like the agitation of the specimen. PMID- 10168556 TI - Integration of biological, procedural, apheresis principles of peripheral blood stem cell transplantation programs. AB - Collection and use of peripheral blood stem cells have rapidly replaced harvesting of pelvic bone marrow for transplant protocols. The mobilization of progenitor populations into the peripheral blood by chemotherapy and/or cytokine stimulation of marrow hematopoietic production has made it possible, in general, to collect larger quantities of progenitor populations than obtained in a single harvest of marrow. Technological advances through flow cytometry and generation of monoclonal antibodies to identify CD34 antigen expression on cells has provided a rapid means of assessing leukapheresis products for the presence of progenitor populations and has largely replaced the laborious 14 day culture assays' to measure colony forming units. Unlike apheresis platelet collection, where the yields are predictable through integration of donor biological variability, total volume of blood processed, and machine efficiency, CD34+ cell yields are not predictable. This has led to great diversity in stem cell collection procedures. Analyses of the same variables used to predict platelet yields, if applied to CD34+ cell collection, might lead to useful algorithms for development of standardized guidelines for stem cell collection. PMID- 10168558 TI - Factors influencing the timing of peripheral blood stem cell collection (PBSC). AB - High-dose conditioning regimens followed by autologous peripheral blood stem cell rescue are frequently used for the treatment of solid tumors and hematological malignancies. In 24 patients up to four peripheral stem cell collections (PBSC) were performed after priming with various chemotherapies and G-CSF (300 micrograms s.c. per day). In 16 patients (group A) more than 2 x 10(6) CD 34 positive cells per kg bodyweight could be collected; fewer were harvested in the remaining eight patients (group B). The amount of collected CD 34 positive cells correlated with the median number of these cells in the peripheral blood at the start of PBSC. The two groups differed both in recovery time after priming induced cytopenia (4 vs 6 days from nadir) and in the number of WBC (21 x 10(6) mL-1 vs 6.1 x 10(6) mL-1) and platelets (133 x 10(6) mL-1 vs 58 x 10(6) mL-1) reached at first day of PBSC. No difference between the two groups was seen according to age, duration of disease or disease status. However, the intensity of prior treatment was significantly greater in group B than in group A. These observations indicate that the toxicity of previous chemotherapy is the most important factor for the mobilization of sufficient CD 34 positive cells into the peripheral blood. PMID- 10168559 TI - Collection of peripheral blood stem cells (PBSC) after chemotherapy and administration of rhGM-CSF in children weighing less than 17 kg. AB - Peripheral blood stem cells (PBSC) were collected from six children weighing less than 17 kg. Stem cell pools had been expanded by chemotherapy and rhGM-CSF. Nineteen procedures were performed with a continuous-flow separator (CS 3000 plus) using central venous access. The extracorporeal line was primed with red blood cells and 5% albumin (HA). Acid-citrate-dextrose:- formulae A(ACD-A) was added in a median ratio 1:11 (range 1:9-1:15). A median number of 5.6 x 10(8) kg 1 NC (3.5-9.7) and 7.1 x 10(6) kg-1 CD34+ cells (2.1-26.1) were collected per patient. Four patients were transplanted with PBSC and showed normal haematopoietic recovery (leucocytes > 1000 microL-1 between days 11 and 12). The results show that successful PBSC collection and transplantation is possible even in small paediatric patients. Administration of growth factors results in a marked increase of peripheral white blood cells and in a higher yield of NC and CD34+ cells in PBSC collections. PMID- 10168560 TI - Stem cell separation in paediatric patients. AB - We performed 28 separations in 11 children weighing from 14 to 72 kg (median: 27 kg) using either the Cobe Spectra or the Fresenius AS 104 cell separator. For children under 20 kg, human albumin solution was used for the last 200 mL of the priming procedure instead of NaCl. Blood flow was reduced to 30-50 mL min-1 depending on the children's size and weight to prevent citrate reactions. Within 149-337 min we processed three times the patients' total blood volume and collected 309.7 x 10(6) (102.9-1140.0) mononuclear cells (MNC) and 2.01 x 10(6) (1.90-6.50) CD34+ cells per kg body weight. These results were comparable to the results we previously obtained in adults. We conclude from these initial results that peripherae blood stem cells (PBSC) separations, with both devices, can be adapted successfully to the needs of paediatric patients. PMID- 10168562 TI - PBSC collection from G-CSF primed donors. AB - Peripheral blood stems cells (PBSCs) have been used in autologous transplantation as an alternative to bone marrow-derived cells. Recently, PBSCs have been collected from healthy donors after priming with G-CSF and used for allogeneic transplantation. We have a comparatively large experience with PBSC collection in autologous and allogeneic settings. The five cell separators we employ are: the CS3000 plus, AS 104, Excel, Cobe Spectra and MCS 3p. These machines appear to have different efficacies but no studies have been carried out on this topic. In a prospective study we have randomly assigned donors to different cell separators to evaluate their efficiency. Twenty-five donors underwent the procedure and 50 leukaphereses were carried out. Donors were given 5 micrograms kg-1 d-1 of recombinant human G-CSF for 3 days and 10 micrograms kg-1 d-1 for 4 days subcutaneously. Leukaphereses were performed on days 6 and 7 of G-CSF administration. The results of our study show that a total value of CD34+ cells ranging from 48.44 x 10(6) to 270.37 x 10(6) can be collected from donors with a white cell count ranging from 40.50 x 10(3) microL-1 to 51.34 x 10(3) microL-1 and mononuclear cells ranging from 16.42 to 20.37%. The Excel and the MCS 3p seem to differ from the other machines in terms of higher CD34+ cell collection efficiency. The Excel appears to be even more efficient than the MCS 3p, but this may not reflect reality because the Excel processes 12 L of blood while the MCS 3p employs an 8 L procedure. All the machines showed satisfactory results in terms of yield and quality of the harvests. PMID- 10168561 TI - Technical and safety aspects of blood and marrow transplantation using G-CSF mobilized family donors. AB - An allogeneic transplantation programme using immunoselected blood progenitor and bone marrow CD34+ cells has been established. Thirteen healthy HLA-matched, MLC negative sibling donors received two doses of 5 micrograms kg-1 G-CSF (s.c. daily) for 5 days. On days 4 and 5, large-volume mononuclear cell aphereses were performed (COBE Spectra) and on day 5 one unit of autologous blood was obtained. Mononuclear cells were pooled and cryopreserved after CD34+ cell-immunoselection on day 5. Bone marrow (BM) of the same donors was procured under routine conditions 10-45 days later (median: 27 days). The final graft consisted of blood CD34+ cells with either complete BM (n = 5) or immunoselected BM CD34+ cells (n = 8). The present paper describes the progenitor cell mobilization and apheresis protocol and analyzes the cell loss by BM and peripheral blood progenitor cell (PBPC) donation. Considerably larger amounts of mononuclear cells (CD45+), T lymphocytes (CD3+) and platelets were lost by the apheresis as compared to bone marrow without apparent immediate clinical consequences for the donors. Owing to cross-cellular contamination of the apheresis concentrate, blood platelet count (PC) significantly decreased (mean PC after the second apheresis 116 x 10 microL 1); furthermore on average 3.04 x 10(10) CD3+ cells were removed by two apheresis sessions. This loss did not lead to long-term total lymphocyte count changes (2370 microL-1 versus 1889 microL-1) as observed during the long-term follow-up of 7/13 donors (mean 290 days). Subjectively, the PBPC collections were better accepted than BM donations in all but one family donor. PMID- 10168563 TI - Combined CD34 positive plus CD2 negative selection for effective T-cell depletion as GvHD-prophylaxis in HLA-nonidentical blood progenitor cell transplantation. AB - G-CSF mobilized, T-cell-depleted peripheral blood progenitor cells (PBPC) and T cell-depleted bone marrow (BM) were given to seven children (6 AL, 1 SCID) to prevent severe graft-versus-host-disease (GvHD) as well as graft rejection after transplantation from HLA-nonidentical parental donors. BM was T-cell-depleted by lectin agglutination and E-rosetting. For T-cell-depletion of the PBPC grafts a combination of CD34+ selection with the Ceprate SC immunoadsorption system and a subsequent depletion of CD2+ cells with immunomagnetic Dynabeads was used. The overall recovery was 0.3 (0.1-1.2)% for nucleated cells, 29 (18-45)% for CD3+ cells, respectively. The purity of CD34+ cells was 87 (68-97)% with a 0.3(0.05 0.7)% residual CD3+ T-cell contamination. In spite of the large T-cell number in the PBPC grafts the combination of CD34 positive and subsequent CD2 negative selection achieved a more than 4 log T-cell depletion and prevents severe GvHD even in HLA-nonidentical transplantation. In addition, if a high dose of progenitor cells ensures stable engraftment, this new approach could increase the possibility of wider use of HLA-mismatched family donors for transplantation. PMID- 10168564 TI - Improved lectin agglutination method for T-cell depletion of HLA-mismatched bone marrow grafts in children. AB - For T-cell depletion in HLA-nonidentical bone marrow transplantation of children with malignant diseases, we improved the original lectin/rosetting method described in 1981 by adding anti-CD2/3 coated donor red blood cells to the combination to achieve lectin agglutination in one step. Further improvements in handling led to a shortened and simplified method and better quality of the graft. Five bone marrow grafts prepared with this modified protocol contained a median number of 6 (0-28) x 10(4) T-cells per kg, corresponding to 0.02 (0-0.08)% CD3+ cells and 6 (3.7-10.5) x 10(6) CD34+ cells per kg at a median body-weight of 7 (5-38)kg. The overall recoveries after T-cell depletion were: NC 17 (10-44)%, CD34+ cells 61 (22-100)%, and CFU-GM 55 (29-212)%. PMID- 10168566 TI - Wheelchair seating. PMID- 10168565 TI - Development of tumor B-cell lymphocyte hybridoma (TBH) autovaccination. Results of a phase I-II clinical trial. AB - To improve patient immune recognition of autologous tumor cells, we have developed a tumor B-cell lymphocyte hybridoma (TBH) autovaccination protocol. This approach is based on immunization of a cancer patient with a hybridoma cell suspension derived from the fusion of autologous activated B-cells and autologous cancer cells. This hybrid allows the host immune system to recognize and destroy oncocytes with low toxicity and high specificity. Of 21 treated patients with very advanced diseases, six complete responses and four partial responses were achieved. Overall, survival was prolonged. Side-effects and combination therapies with IL2, IL6 and gamma I/FN are discussed in this paper. Breast and colon cancer seem to be sensitive to this therapy. PMID- 10168567 TI - Seating and mobility issues for polio survivors. PMID- 10168568 TI - Common arm neuropathies. PMID- 10168569 TI - Beyond the randomized controlled trial: a case for 'judicial review'. PMID- 10168570 TI - Perceived stress factors and coping mechanisms among mothers of children with sickle cell disease in western Nigeria. AB - While many studies have looked at the stressful effects of chronic illness of those who suffer such conditions, less is known about the effects on caregivers, especially in developing countries. Mothers in particular must bear the brunt of care and stress for children who have sickle cell disease (SCD). A sample of 200 mothers attending six SCD clinics in both public and private hospitals in the Ibadan-Ibarapa Health Zone of Oyo State, Nigeria, were interviewed. Stress levels were measured using an instrument comprised of stressors listed by mothers themselves in focus group discussions that preceded the survey. Higher levels of stress were associated with less educated and older women, as well as non-married women and those in polygamous households. Stress levels were also greater when there was more than one child with SCD in the family and when the index child was of school age. Coping mechanisms varied according to the category of stressor. Financial stress and disease factors were met with confrontation while family sources of stress were either complained about, accepted or avoided. Knowledge of the different types of mothers who experience more stress and of their preferred coping mechanisms can be useful in designing clinic-based counseling. PMID- 10168571 TI - Increasing compliance with colorectal cancer screening: the development of effective health education. AB - The ability of a health education leaflet to raise awareness of the frequency of colorectal cancer and its asymptomatic nature and to increase intention to participate in screening with faecal occult blood testing (FOBT) was investigated. One hundred subjects were interviewed before and after reading the leaflet. The number of men stating bowel cancer was 'very common' increased significantly from 20 to 60% (chi 2 = 16.7, P < 0.0001) and those understanding its asymptomatic nature form 64 to 92% (chi 2 = 11.4, P < 0.001). The leaflet significantly increased the percentage of women reporting bowel cancer as 'very common' from 30 to 70% (chi 2 = 16.0, P < 0.0001) and as being asymptomatic from 58 to 94% (chi 2 = 17.8, P < 0.0001). After reading the leaflet, 55% of men who initially declined screening reversed their decision (chi 2 16.5, P < 0.0001) and 50% of female non-adherers reversed their decision (chi 2 = 17.3, P < 0.0001). Reasons most frequently given for declining colorectal cancer screening were feeling well (77% of subjects declining), concern about further tests (38%), unpleasantness of FOBT (13%) and illness (6%). This leaflet successfully educates people about colorectal cancer and increased intention to participate in screening programmes. PMID- 10168572 TI - A process evaluation of the National Cancer Institute's Data-based Intervention Research program: a study of organizational capacity building. AB - This paper reports on a qualitative process evaluation of the Data-based Intervention Research (DBIR) program, that was funded by the National Cancer Institute (NCI) and operated in 21 states and the District of Columbia. The goal of DBIR was to build a foundation within state health agencies to ensure the translation of cancer control science into practice. NCI's objective reflected the readiness of cancer control research for public health application, the paucity of cancer control activity within public health settings and the recognition that state health agencies could play a critical role in the effective transfer of research results into public health practice. The qualitative process evaluation reported in this paper is based on one case study of four DBIR programs. The present study indicates that the four state health agencies executed the DBIR program with fidelity. Also, the four states offered a balanced assessment of NCI's role in enabling the state agency operation of DBIR, providing numerous citations illustrating how NCI successfully facilitated organizational capacity as compared to fewer mentions of ways NCI was less than successful. Thus, in funding the DBIR model, NCI was successful in raising state health agency capacity to implement cancer prevention and control programming. Implications for capacity building in state health departments are discussed. PMID- 10168573 TI - The impact of the National Cancer Institute's Data-based Intervention Research program on state health agencies. AB - To assist state health agencies adopt a new role in cancer prevention and control, the National Cancer Institute (NCI) initiated the Data-based Intervention Research (DBIR) program. The goal of DBIR was to stimulate data driven activities and to build capacity for ongoing programs within state health agencies to ensure the translation of cancer prevention and control science into practice across the US. Each state funded under the DBIR program was required to conduct four phases of activity: identifying and analyzing relevant data, using these data to develop a state cancer control plan, and implementing and evaluating prevention and control interventions at the local level. This paper presents the results of survey of the 22 states that participated in the DBIR program. The survey is intended as a supplement to the case study also reported in this issue of Health Education Research. Results indicated that states were able to implement the DBIR model and they show the process to be useful to their cancer prevention efforts. DBIR had a major impact on how states will use data in future planning for cancer prevention and control. States had a number of recommendations for how NCI could improve its working relationships with state health agencies. PMID- 10168574 TI - Provocative appeals in anti-smoking mass media campaigns targeting adolescents- the accumulated effect of multiple exposures. AB - This paper reports findings from a longitudinal study that evaluated the accumulated effect of three consecutive mass media campaigns using provocative and dissonance arousing appeals to prevent cigarette smoking by adolescents. In the spring of 1992, all eligible adolescents aged 14 and 15 in one intervention county (N = 4898) and one control county (N = 5439) in Norway were included in the study, and were followed until they were 17 and 18 years of age in 1995. Only students who completed questionnaires both in 1992 and 1995 were included in the analyses. Among the non-smokers at baseline, a significantly lower proportion of adolescents of both genders had started to smoke in the intervention county compared to the proportion in the control county. Among those who were smokers at baseline, significantly more girls in the intervention county had stopped smoking than in the control county, while no significant difference between the counties was detected among boys. Our findings suggest that provocative and dissonance arousing appeals that create affective reactions and lead to interpersonal communication should be given more attention in campaigns designed to influence adolescent smoking. However, such appeals may easily produce negative reactions and the normative context should be thoroughly considered when using such appeals in future interventions. PMID- 10168575 TI - Women's smoking behaviour--caught by a cigarette diary. AB - This study explores women's smoking behaviour in relation to mood, activity and social context. A particular aim was to design a 'cigarette diary', useful for research as well as for practical purposes. Fifty male nurses and secretaries kept a diary for one to three typical work days. Diaries consisted of a set of identical sheets, each of which related to one cigarette. Pre-smoking mood and the context of smoking were carefully noted. It was hypothesized that smoking is positively related to perceived stress. Results partly supported this hypothesis, but they also showed that a majority of the cigarettes were smoked in a state of happiness and relaxation. PMID- 10168576 TI - Evaluation of a smoking cessation intervention for pregnant women in an urban prenatal clinic. AB - A smoking cessation and relapse prevention intervention was tested in an urban, prenatal clinic serving predominantly low-income, African-American women. At their first prenatal visit, 391 smokers were randomly assigned to an experimental (E) group to receive usual clinic information plus a prenatal and postpartum intervention or to a control (C) group to receive only usual clinic information. The intervention consisted of individual skills instruction and counseling by a peer health counselor on the use of a self-help cessation guide and routine clinic reinforcement. Among the E group (n = 193), 6.2% were cotinine-confirmed quitters at third trimester and among the C group (n = 198) the quit rate was 5.6%. Quitters were light smokers at entry into prenatal care. Many had tried to quit smoking at least once prior to pregnancy. PMID- 10168577 TI - School and community influences on adolescent alcohol and drug use. AB - Social environment risk factors present in schools and communities have not been thoroughly investigated. This study cross-sectionally examined the social environments of schools and communities, and their influence on adolescent alcohol and drug use. Survey responses of eighth grade students (N = 2309), a random half of their parents (n = 943), community leaders (n = 118), school principals (n = 30), school counselors (n = 30) and chemical health providers (n = 14) were pooled to create indices of social environmental norms, role models, social support and opportunities for non-use of alcohol. Each index was examined for its association with prevalences from 30 schools of alcohol use onset, last month alcohol use, heavy alcohol use and last-year marijuana use in univariate and stepwise regression analyses. Increases in the levels of norms, role models and opportunities for non-use predicted decreases in alcohol use prevalences. The explanatory power of the examined constructs in multivariate analyses was acceptably high (R2: 38-53%). These findings further support the notion that community-wide efforts need to be launched to affect changes in the normative, role model and opportunity structures of adolescents' social environments in order to curb adolescent alcohol and drug use. PMID- 10168578 TI - The effects of a participative programme on Irish pupils' attitudes to HIV/AIDS. AB - The study is concerned with a general humanistic approach to health (lifeskills) education and its application to the specific issue of HIV/AIDS in the Republic of Ireland. A programme of five classroom sessions, structured to encourage active participation, was administered to an experimental group of 20 participants (10 male and 10 female). There was an equivalent control group. Attitudes towards 10 AIDS-related person concepts were measured before and after the programme using semantic differential rating scales. Highly significant differences were found between groups in post-programme attitudes to the concepts. There were no gender differences. It is concluded that this participative programme strongly influences AIDS-related attitudes, and, in particular, promotes compassion towards those with HIV/AIDS. PMID- 10168579 TI - Sexual behaviour in a fishing community on Lake Victoria, Uganda. AB - This study describes the sexual behaviour of men and women in a fishing village on the shores of Lake Victoria in southwest Uganda. The village is near a well known trading town-truckstop on the main trans-Africa highway with a high recorded prevalence of HIV infection. Data were obtained on the daily travel and sexual activities of 26 women and 54 men with particular attention paid to the rate of partner change and the proportion of sexual contacts with people outside the village. During a total of 587 person weeks the men made 1086 trips, mostly returning home the same day. They had a total of 1226 sexual contacts, most of which occurred either in their own village (83%) or a neighbouring fishing village (11%); 17 per cent of sexual contacts were with new partners. Fifteen of the women described themselves as married; 42 per cent of their sexual contacts were casual, paying partners. Of the eleven women who were single, between 80 and 100 per cent of contacts were with paying partners. Most of the women's partners were resident in the village. These data show a very high rate of sexual mixing within the village. Such communities should be targeted in future STD control programs. PMID- 10168580 TI - Socio-demographic correlates, HIV/AIDS-related cofactors, and measures of same sex sexual behaviour among northern Thai male soldiers. AB - We use data from an anonymous self-administered 1991 survey of military personnel in northern Thailand to estimate overall levels of and socio-demographic differentials in same-sex sexual behaviour in this population. Additionally, we examine the relationship between sexual experience with another male and a variety of outcomes relevant to HIV prevention and policy. Overall, 16.3 per cent of the sexually active soldiers report ever having had anal or oral sex with other males. Same-sex sexual behaviour in this sample is positively associated with several indicators of higher socio-economic status. All of the men who report having had sex with other men report having had vaginal intercourse with females as well. Comparison of our estimate of same-sex sexual behaviour with those obtained from two similar samples drawn in 1991 suggests that the lower estimates observed in the other two studies are largely due to differences in data collection methods. Regarding the HIV/AIDS-related outcomes we examined, men who have had sex with other men are significantly more likely than those who have not to have ever injected drugs, to personally know someone with HIV/AIDS, to have had sex with a female prostitute in the last six months, and to have had a sexually transmitted disease in the last six months. In this sample, men who have had sex with other men are also less knowledgeable about HIV/AIDS than are men who have not. These results are discussed in terms of their implications for HIV prevention policy in Thailand. PMID- 10168581 TI - Rationalizing health care in a changing world: the need to know. AB - The World Development Report 1993 announced that global life expectancy was then 65. Experience in the developed world suggests that the World Health Organization's dictum, 'health is a state of complete physical, mental and social well-being', is simply not attainable for the foreseeable future. As physical health has improved, mental problems have become more prominent and a sense of well-being has declined. Furthermore, as the population ages and medical technology improves, the cost of health care grows almost exponentially. Since the population of the developed world is continuing to age and aging is spreading rapidly throughout the developing world, knowledge is the principal way of dealing with this seemingly intractable problem: we must know, quantitatively, the age-specific causes of ill health, and we must know which means of prevention and treatment are effective. Finally, we must apply that knowledge rationally. PMID- 10168582 TI - Stretching the limits of health interventions in Burkina Faso. PMID- 10168583 TI - Telemedicine puts the bite on poisonous stings. PMID- 10168584 TI - Telediagnosis in pathology through the Internet. PMID- 10168585 TI - Home health agency benefits. PMID- 10168586 TI - Rising to the challenge. PMID- 10168587 TI - One voice: the GHAA/AMCRA merger. PMID- 10168588 TI - Quantity in health care is not always a substitute for quality. AB - Examines the outcomes of attempts to improve health services in the former Communist countries of Eastern Europe and in the West European democracies. Discovers that while the East Europeans focused their efforts on increasing the numbers of doctors and beds per patient, while keeping to relatively low levels of investment in technological advances, West European countries have taken the opposite approach, emphasizing quality of care, particularly advanced care, reducing the numbers of physicians and hospital beds, acquiring advanced technological systems for diagnosis and treatment and spending ten times as much per patient as in Eastern Europe. Concludes that the West European approach has led to far better results. PMID- 10168589 TI - Perspectives. CBO: changes, cuts would nip growth of Medicare HMO's. PMID- 10168590 TI - Perspectives. Disease management seeks to duck threat of "Balkanization". PMID- 10168591 TI - Marketplace. Can health plan report cards spur competition on quality? PMID- 10168592 TI - Perspectives. Plans follow employers in search of wellness dollars. PMID- 10168593 TI - Marketplace. Long-term HMO contracts promise better value for all. PMID- 10168594 TI - Perspectives. Fungibility factor looms large in DSH, child health decisions. PMID- 10168596 TI - NHS Regional Librarians Group evidence to the Functions and Manpower Review 1993 94. Management of library services in the proposed new structure. AB - The mission of the library and information service is to ensure that the knowledge base of health care is available and accessible to all providers, purchasers and consumers, and to promote and encourage its effective use. Access should be free at the point of use. Library services should be a national and regional responsibility. The close association with Postgraduate and Continuing Medical and Dental Education should continue. Clear terms of reference for library and information services should guarantee access to these services for all National Health Service (NHS) staff. There should be greater emphasis on quality aspects of information. Information Management and Technology (IM & T) strategy should take full account of the needs of library and information services so that the NHS investment in information networks can be fully realized. Good practice in library and information services should be identified, promoted and disseminated. National Health Service Management Executive (NHS-ME) initiatives which affect the library services of the NHS should be co-ordinated. A working party of users and librarians, working within the Functions and Manpower Review implementation process, should define a structure for the management and provision of NHS library services which gives the most value for money. PMID- 10168595 TI - Perspectives. The impact of managed care on behavioral providers. PMID- 10168597 TI - Libraries and the R&D strategy: a way forward. AB - As guest editor for the December 1994 issue of Health Libraries Review, I chose the theme of Evidence-Based Practice. In my editorial I suggested that Evidence based Practice offered tremendous opportunities for NHS librarians to demonstrate their skills in supporting a knowledge-based NHS, because many clinicians had complained that they did not have time, retrieval skills of knowledge of relevant information resources to be effective at finding scientific evidence. Librarians, on the other hand have advanced online searching skills, rapid document retrieval and delivery services, and up-to-date knowledge of the world's medical information resources and networks. These skills mean that librarians are not only well-placed to support clinicians in finding and sifting scientific evidence, but also in teaching clinicians how to search for and store information themselves. NHS librarians have not been slow to recognize these opportunities and innovative professional development programmes have appeared to help hone their skills, such as the Librarian of the 21st Century Programme in the Anglia and Oxford region. The success of NHS librarians in supporting evidence-based health care has led to their formal development in evidence-based medicine workshops for clinicians in a number of regions. In March 1996, as NHS Library Adviser. I was asked to prepare a paper for the R&D Board of the NHS Executive about how this library support could be formally integrated into the R&D Strategy. My paper was unanimously endorsed by the Board and later by the Central R&D Committee of the NHS Executive. It suggests principles of library provision in support of R&D and is reprinted below. PMID- 10168598 TI - Developing multidisciplinary library services in trust hospitals: a case study at the City Hospitals Sunderland NHS Trust. AB - The paper describes an example of good practice in the establishment of multidisciplinary library services at a Trust hospital. In 1995, City Hospitals Sunderland NHS Trust commissioned a survey to determine their needs for library services for all staff. The results of the survey and the recommendations are described. The Trust's further actions are briefly noted. This case study is set into the wider context of the need for well-resourced library and information services within the NHS. The constraints under which such developments operate are listed. PMID- 10168599 TI - Following the money. PMID- 10168600 TI - A work in progress. AB - The electronic medical patient record may be the linchpin for health management in the twenty-first century. But as this status report suggests, it has a long way to go. PMID- 10168601 TI - The other budget. AB - Medicare cuts are getting most of the attention as Congress crafts a deficit elimination plan. But Medicaid negotiations pose similarly difficult issues, and perhaps some good news. PMID- 10168602 TI - Think globally, manage locally. PMID- 10168603 TI - The layered look. PMID- 10168604 TI - Hometown hospitals, national resources. PMID- 10168606 TI - Building bridges. Managing a merger with transition liaisons. PMID- 10168605 TI - TB blues. An old threat poses new challenges in the health care workplace. PMID- 10168607 TI - Return to work. AB - Worker's compensation isn't just for hard hats anymore. Occupational health strategies may be a lucrative launch-pad for hospitals interested in forming deeper relationships with employers. PMID- 10168608 TI - Oxford man. Interview by Craig Havighurst. PMID- 10168609 TI - Data. Hospitals embarked on 169 mergers and acquisitions worth a record $18 billion in 1996. PMID- 10168610 TI - Latex allergy: how safe are your gloves? PMID- 10168611 TI - In Dresden. Reunited Germany has new medical school. PMID- 10168612 TI - Teaching microsurgery in developing countries. PMID- 10168613 TI - What Americans think. Health care fraud. American Association of Retired Persons. PMID- 10168614 TI - Medicine 2000: attitudes are rapidly changing. AB - Today, as we face the next millennium, the author sees several interesting realities for the practice of medicine. There is very little opportunity for the new independent practitioner or the small group practice. Without joining an established group practice, it is extremely difficult for an individual physician to build a practice. The competition is too great. PMID- 10168615 TI - Benefits of profit centers for cardiology medical groups. AB - This article describes the benefits that profit centers provide to cardiology medical groups in the areas of pricing strategy, cost management, and quality enhancement, plus shows how an annual profit objective can also be implemented to internally generate funds for making capital investments. PMID- 10168616 TI - What every manager should know about equipment upgrades. PMID- 10168617 TI - Too poor to treat. States are balking at paying for pricey AIDS drugs. PMID- 10168618 TI - When your HMO says no. How to fight for the treatment you need--and win. PMID- 10168619 TI - Computers, OBRA 90 and the pharmacist's duty to warn. PMID- 10168620 TI - Healthcare Foodservice 1997 buyers' guide. PMID- 10168621 TI - Thermometers: the key to unlocking food safety. PMID- 10168622 TI - Meatless diets: are they right for your menu plan? PMID- 10168623 TI - Computerized meal system produces fresh meals daily at Phoenix's Good Sam Regional Medical Center. PMID- 10168624 TI - Irradiation enhances food quality and safety. PMID- 10168625 TI - Barriers & breakthroughs in EDI. PMID- 10168626 TI - Merging high tech with quality care. AB - Concerns about preserving quality care and services for managed care members continues to grow with the ongoing development of information technologies. In this article, Mitchell Curtis highlights some of the latest innovations that can improve healthcare access and services for everyone. PMID- 10168627 TI - Remedy register. Utilization review/case management information systems update. PMID- 10168628 TI - Dialing for diagnosis. AB - From healthcare to self-care, technology is moving to a level where members have more information and more responsibility in areas relating to their health and well-being. In this article Barbara Hesselgrave explains how healthcare call centers, using data collection resources, can assist members with non-emergency medical matters over the telephone and lower the cost of doctor and emergency room visits. PMID- 10168629 TI - Consultants or contractors? How to find the right help. PMID- 10168631 TI - Managed care outlook. How regions differ in projected demand for primary care doctors in 2000. PMID- 10168630 TI - Supporting disease management programs. PMID- 10168632 TI - Compensation monitor. Financial incentives play a subordinate role in drawing doctors to a practice opportunity. PMID- 10168633 TI - The law that shields HMOs from the risk doctors face. PMID- 10168634 TI - Master the 'ABCs' of activity-based costing. PMID- 10168635 TI - Understanding change and diversity. A visit with consultant Peter Kongstvedt, M.D. PMID- 10168636 TI - Ten ways to save money on your office dictation. PMID- 10168637 TI - Hammurabi's managed health care--circa 1700 B.C. PMID- 10168638 TI - One physician's system for reporting test results. PMID- 10168639 TI - Utilization of generics: a managed care failure? PMID- 10168640 TI - New online benefits business features growing competition. PMID- 10168641 TI - Can doing the right business thing protect physicians from liability? PMID- 10168642 TI - New Stark II rules on referrals will further restrict medical practices. PMID- 10168643 TI - Newly hired auto workers will test 'try it, you'll like it' intro to HMOs. PMID- 10168644 TI - Compensation monitor. How capitation's prevalence varies with practice size. PMID- 10168645 TI - Is it now your job to change patient's life styles? PMID- 10168646 TI - Gain the 'quality' edge in competing for contracts. PMID- 10168647 TI - They're coaching your patients on what to demand from you. PMID- 10168648 TI - A visit with Mickey Herbert. PMID- 10168649 TI - Managed care hassles--a fact of life? PMID- 10168650 TI - Constructing disease management programs. PMID- 10168651 TI - Last year's health reform law may create federal 'speed traps'. PMID- 10168653 TI - Managed care outlook. HMO enrollment rising as a share of state populations. PMID- 10168652 TI - Why does managed care look and feel so unfair? PMID- 10168654 TI - The cost management organization: the next step for materiel management. AB - With Materiel Management's transition over the last decade from simple logistics to analysis and cost management, it has gained recognition as a key part of the management team responsible for supplies, equipment, standards, and associated processes to identify, purchase, store, distribute, issue, and dispose of supplies and equipment. The materiel manager's job consists of putting the right product in the right place at the right time and in the right quantity at the best total delivered cost. In this context, Materiel Management has made powerful impacts to lower costs associated with: Distribution--costs have been lowered by actively adopting advanced supply channel management techniques such as primary suppliers, JIT, stockless programs, case cart/custom kit/procedure based delivery systems, modified stockless programs as well as margin management through cost plus, flat fee, or margins paid per activity. Cost of goods--lowered through aggregated purchasing in the forms of regional and national purchasing alliances and local capitation or other gain/risk share programs. Internal process costs- lowered by out-sourcing and/or integrating supplier processes and personnel into operations via partnership approaches. We have also reduced transactional costs through EDI transaction sets and the emerging use of the inter and intranet/electronic commerce, procurement cards, and evaluated receipt settlement processes. De-layering--We have lowered the operating costs of Materiel Management overhead by re-design/re-engineering, resulting in reduced management and greater front line authority. Quality--We have learned to identify and respond to customer and supplier needs by using quality improvement tools and ongoing measurement and monitoring techniques. Through this we have identified the waste of non-beneficial products and services. We have adopted supplier certification measurers to ensure quality is built into processes and outcomes. With so much already accomplished, it should be easy to rest on these laurels and simply operate. However, we believe that this is just a beginning. A new generation of highly educated leaders are emerging and taking advantage of the contributions of pioneers who laid the ground work. These new leaders will have advanced management, statistics, and behavioral sciences skills. They will be analysts and organizational motivators. Their goal will be to improve financial and clinical performance measured by real time process and performance data. The new leaders will have information at their fingertips thanks to significant leaps forward in data collection, automated continuous replenishment processes, and software designed for better management of clinical and cost outcomes. This article documents significant Materiel management accomplishments and conceptualizes cost management processes. The cost management organization is the logical evolution in our efforts for better outcomes in healthcare Materiel management. PMID- 10168655 TI - Fast changes for tough times: employee suggestion programs. AB - In the midst of the current marketplace's turmoil, healthcare organizations (HCOs) lack two critical commodities: time and money. Today, time and money are all that stand between many HCOs current operations and their demise at the hands of healthcare reform; therefore, healthcare administrators cannot afford to spend either frivolously. Consultants have put forth an array of employee incentive programs designed to address cost containment and market positioning goals of various institutions. Many of these programs are well packaged and can be considered "politically correct" in terms of current philosophies on employee management relations. However, many programs focus on long-term goals and strategies and, therefore, are most appropriate for organizations not in immediate danger of demise. One long-term program espoused and implemented widely by organizations is the employee suggestion system. This article looks at employee suggestion programs. PMID- 10168656 TI - Seismic upgrades of healthcare facilities. AB - Before 1989 seismic upgrading of hospital structures was not a primary consideration among hospital owners. However, after extensive earthquake damage to hospital buildings at Loma Prieta in Northern California in 1989 and then at Northridge in Southern California in 1994, hospital owners, legislators, and design teams become concerned about the need for seismic upgrading of existing facilities. Because the damage hospital structures sustained in the earthquakes was so severe and far-reaching, California has enacted laws that mandate seismic upgrading for existing facilities. Now hospital owners will have to upgrade buildings that do not conform to statewide seismic adequacy laws. By 2030, California expects all of its hospital structures to be sufficiently seismic resistant. Slowly, regions in the Midwest and on the East Coast are following their example. This article outlines reasons and ways for seismic upgrading of existing facilities. PMID- 10168657 TI - Managing professionals: a clash of values. PMID- 10168658 TI - Reducing the appetite for federal spending. PMID- 10168659 TI - Facilitating medical staff involvement in the expense reduction process. PMID- 10168660 TI - Tithing ... a fundamental foundation for your healthy community. AB - What is one of the most important actions an organization can take to make a difference in improving the health of its community? Tithing, or intentionally setting aside financial resources, is the greatest accelerant you can do; it gives you the resources and commitment you can't get any other way. As soon as you do this, you're absolutely going to take off! PMID- 10168661 TI - Values in action. AB - St. John Health System, Detroit, is committed to the values of wisdom, compassion, service to the neighbor, stewardship and servant leadership. When a patient walks through any one of the six St. John Hospitals, they see these words displayed many times. But what do they mean to the employees? Patients? The community? According to Anthony R. Tersigni, EdD, St. John president and CEO, "The values remind us of who we are and what our responsibilities are to the communities we serve." PMID- 10168663 TI - Hold the strawberries, please. PMID- 10168662 TI - Taking benefits for granted. Community benefits and market-driven health care. AB - No one used to question the value of hospitals to their communities. Hospitals simply took good care of the residents of the cities in which they were located. They did the little things that endear an institution to its neighbors. Perhaps this was a luxury of hardier economic times, when the pressure to control health care costs was not so pronounced. Perhaps everyone took for granted the many benefits hospitals provide for communities. PMID- 10168664 TI - Michigan hospitals: helping where there's need. AB - The MHA received 24 nominations for the 1997 Ludwig Community Benefit Award, representing programs that range from addressing youth violence and teen pregnancy to multifaceted approaches to improve a community's overall health status. Five programs were chosen to receive Ludwig Awards this year, each of them representing an impressive collaborative effort to improve life in the communities they serve. A brief synopsis of each of these outstanding programs follows. PMID- 10168665 TI - If not you, then who? PMID- 10168666 TI - Are you in the big picture? AB - Carol Smith, an endoscopy nurse, is spending her two-week vacation as the camp nurse at the Boy Scouts Camporee. Staff from the Food and Nutrition Department volunteer to cook and serve meals at the Salvation Army soup kitchen. Linda Ward of the Distribution and Processing Department spends her vacation at Camp Quality, just one of many volunteers who brighten the faces of children who have cancer. PMID- 10168667 TI - Trustees expand their focus. AB - Paoli Memorial Hospital, a 180-bed community hospital in Philadelphia's western suburbs, has become increasingly involved in community health over the past several years. What spearheaded this involvement was the creation of a foundation and committee on community health whose mission is to: assess the needs of the community, provide financial ability to address those needs, and actively pursue the means to solve the problems identified. The work of the hospital foundation has received a strong, positive response from the hospital board, auxiliary and the community at large. PMID- 10168668 TI - How are hospitals beneficial? AB - Community benefit is defined as programs and services that address broad community health needs and provide measurable improvement in health access, health status and use of health care resources. How does the presence of hospitals and/or health systems in your community enhance community benefit? PMID- 10168669 TI - How to quantify the mission. Software to define and report community benefit activity. AB - More and more health care organizations are being approached to participate in efforts to report and financially quantify community services and charity care provided in their respective communities. It is apparent that a consistent format and more concise definitions are needed if data are to be useful in presenting a clear, industry-wide picture of the magnitude of contributions made to communities by health care organizations. PMID- 10168670 TI - Treasuring the memories. AB - Resident-focused care at The Detroit Medical Center Nursing Centers-West (DMCNC W) is home to 260 residents, all with varying conditions and diagnoses. Over the past two years we have developed a program of resident-focused care that greatly enhances the quality of life for all our residents. PMID- 10168671 TI - Physician recruitment incentives. PMID- 10168672 TI - Managing your call center: ways to optimize service. AB - Proper measurements and telecommunications technology can help you make the most positive impact on service to your many publics. When patients call a number (often an 800 number) for nurse triage, physician referral, a physician answering service, claims eligibility or customer assistance, chances are they are calling into a call center. No other industry is exploring and improving call center applications with more vigor than health care. PMID- 10168673 TI - Feelin' Good Mileage Club. AB - Like many other states, Michigan is experiencing a serious erosion of school physical education and community recreation programs. As a result, children's physical fitness levels are decreasing and body fat measurements are increasing. Nationally, about 25 percent of children are overweight; in Michigan the numbers are closer to 38 percent. PMID- 10168675 TI - Clinical pathways: a roadway for providers. AB - The steady growth of managed care, combined with advances in both medical and computer science, has begun to transform the way health care providers treat patients. The evolution and rapidly expanding use of clinical pathways has become an important component of the modern health care system. PMID- 10168674 TI - Popular programs are priceless. AB - So what do Disneyworld, fishing trips, bingo games, bus tours, breakfast, Detroit Tigers' games, and skating all have in common? They are all events offered to employees and volunteers through St. Luke's Hospital's WorkPerks program. WorkPerks is an employee-based program that provides opportunities for employees and their families to relax, mingle with co-workers, and have fun. PMID- 10168676 TI - Making a real difference. Beyond community service to community benefit. AB - Community benefits or community benefit? Plural or singular? In general, the "pluralists" come from a health insurance perspective and think about community benefits as elements, like benefits in health insurance contracts. The "singularists" come from a broader perspective, and think about community benefit like community service, as a broad direction and commitment related to mission. But there are important exceptions to this rule, of which the Michigan health & Hospital Association is an outstanding example. That organization clearly belongs in the camp of the singularists, but is currently with the pluralists, perhaps reflecting their strong commitment to a pluralistic health system. PMID- 10168677 TI - Good news about hospitals. AB - There's a seldom seen headline. For the last 10 years, hospitals have been a convenient scapegoat, a symbol of the problems of health care, an easy target for those with only a superficial understanding of health care delivery and financing. PMID- 10168678 TI - Tertiary care. The battle for the techno-medicine "high ground". PMID- 10168679 TI - Refinancing academic medicine. Ending the cross-subsidization of tertiary care. PMID- 10168680 TI - Keep lines of communication open between managers and staff. PMID- 10168681 TI - Coping with eight types of problem personnel. PMID- 10168682 TI - Eleven pitfalls to avoid when redesigning the ED. PMID- 10168683 TI - Breaking through hospital walls: case managers build bridge to primary care. AB - Some case managers, dissatisfied with the fragmented nature of the health care system, are attempting to eliminate obstacles between inpatient and outpatient care by positioning themselves at the front line; the physician's office. Getting physicians to accept and value case managers, however, requires a financial incentive. Capitation, which forces physicians to pay closer attention to costs, outcomes, and patient wellness, can do the trick. In areas with less managed care penetration, you can encourage physician acceptance of case management by helping reduce the hassle of caring for chronically ill patients. PMID- 10168684 TI - Continuum care is built on provider relationships. AB - One of the biggest obstacles to creating truly seamless continuity of care is the difficulty of creating an effective feedback loop from home health care agencies to hospital case managers. The problem is complicated by the number of home health agencies to which most hospitals refer, and by lack of external incentives. Case managers at Children's Hospital of Pittsburgh attempt to get around the feedback problem by communicating with the families of patients receiving high-tech home care, such as infusion therapy. Experts advise that it's easier to establish policies for sharing information and case management tools such as critical pathways when you enter into formal partnerships with high volume home care agencies. PMID- 10168685 TI - New asthma guidelines emphasize preventive care. AB - The National Heart, Lung, and Blood Institute has released the first revision in six years of its groundbreaking asthma guidelines. The guidelines heavily emphasize the inflammatory nature of asthma and stress the use of anti inflammatory drugs such as inhaled corticosteroids and cromolyn. Patients should receive aggressive treatment at first, and then cut back once their condition is under control, according to the guidelines. Changes from the previous edition include revised severity classifications, new guidelines for referral of patients, and renewed emphasis on patient education. PMID- 10168686 TI - Orthopedic pathways cover the continuum. PMID- 10168687 TI - Lap choly pathway leads to efficiency, savings. AB - Promina Gwinnett Health System's laparoscopic cholecystectomy pathway has allowed the system's surgery programs to standardize supplies, reduce time and paperwork, and cut costs by $200 per patient per day. Care coordinators at Promina recently implemented a perioperative pathway that will be used in conjunction with a number of outpatient surgical pathways, including lap choly. The perioperative pathway further addresses the issue of reducing paperwork. To gain acceptance for their pathways, case managers meet frequently with physicians one on one to discuss concerns. The also post a list of physicians who comply with the pathway as a means of applying peer pressure. PMID- 10168688 TI - CABG path yields savings, but proves 'user unfriendly'. AB - By reformatting their cardiac surgery pathways and soliciting greater staff participation in the development process, case managers at Bakersfield (CA) Memorial Hospital have boosted staff buy-in and streamlined documentation. Such an overhaul was made necessary last year when the percentage of cardiac patients being put on the pathway dropped sharply, from an initial high of 90% to less than 40%. Under the pathway, extubation times following surgery dropped from an average of 18 hours to 11 hours, with 60% of patients averaging between five and seven hours. PMID- 10168689 TI - Expansion of pay-for-performance will change the way payers compensate health systems. PMID- 10168690 TI - IDS survival strategies. PMID- 10168691 TI - New rules for recruiting physician executives with star power. PMID- 10168692 TI - Elder caregiving in the 21st century. AB - The need for high-quality elder care is on the increase because of the aging of the baby boomers, whose parents are living longer than any previous generation. This trend will demand that home care providers be prepared to meet the elder care needs of not only their clients but also of their own employees. PMID- 10168693 TI - Building professionalism in turbulent times. AB - Health care budgets are being slashed at the same time that the aging of the baby boomers will increase the need for in-home care delivery in the next few decades. New regulations will likely be introduced in conjunction with this caseload influx; to prepare to meet such demands, providers need to anticipate a program of national standards and upgrade the skills of their staff accordingly. PMID- 10168694 TI - Managing diabetes through home care. AB - Diabetes management will hold an increasingly larger place in home care services as the population ages. Advocate Home Health Services in Oakbrook, Illinois, has developed a diabetes management program to help people with diabetes live more easily with this chronic disease. PMID- 10168695 TI - Diabetes: working with the newly diagnosed patient. AB - Patients with diabetes must take responsibility of self-care, including glucose monitoring, exercise, and dietary planning. Although these self-care regimes eventually become second nature, the newly diagnosed patient needs extra support and information to lessen the shock of being forced to adapt to an altered lifestyle. At the onset of diabetes, home care providers can be an invaluable resource. PMID- 10168696 TI - Nursing student practicums in home care. AB - In the next decades home care will become the setting of choice for health care delivery. Because of this trend, nursing education must begin offering a home care component to nursing degree candidates. One such program strives to better prepare students for the unique care delivery that in-home care demands. PMID- 10168697 TI - Employee rights--a mission possible. AB - With the growing awareness of workplace rights, how can today's home care manager separate the vital few from the trivial many? What are the basic legal requirements that employers must maintain every day within the work environment? How do managers educate supervisors to comply with these rights? PMID- 10168698 TI - Respite care for family caregivers. PMID- 10168699 TI - Serving our communities. PMID- 10168700 TI - "I am not a crook!". PMID- 10168701 TI - Entitlements, spending reductions, and you: a new Medicare for the new millenium. PMID- 10168702 TI - Are independent contractor physicians really hospital employees? AB - Before entering into a contractual relationship with a physician, a provider organization must understand whether, according to the IRS, the physician will be considered an employee or an independent contractor. Correct assessment of this relationship is important to avoid penalties for failure to withhold and pay taxes and possible disqualification of employee retirement plans. The IRS's most recent rulings in this area, two technical advice memorandums issued in September 1995, appear to indicate a shift in the agency's approach when defining these relationships--it now seems more likely that contractual arrangements between hospitals and physicians that typically have been treated as independent contractor relationships will be considered employer-employee relationships. The issuance of these memorandums may indicate the IRS's intention to crack down on what it perceives to be abuses of the independent contractor status in the healthcare industry. PMID- 10168703 TI - Promoting physician productivity through a variable compensation system. AB - Integrated delivery systems must find ways to achieve optimal physician productivity and accountability, while fostering an entrepreneurial attitude among physicians. Lovelace Health Systems, Albuquerque, New Mexico, has implemented a variable compensation system designed for this purpose. An assessment of Lovelace's physician productivity had indicated performance well below national medians. To offer physicians a strong incentive to increase productivity, Lovelace developed a variable compensation system based on the resource-based relative value scale and relative value units. Lovelace also developed benchmark productivity targets. PMID- 10168704 TI - Improving financial and patient outcomes: the future of demand management. AB - Demand management has evolved from early managed care models that sought to curtail rising costs through demand-side utilization controls. The first generation of demand management relied heavily on financial incentives for consumers and physicians to demand fewer and less costly resources. The second generation of demand management complemented financial incentives with clinically focused strategies. Often, these strategies were implemented directly by the payer on through a primary care physician gatekeeper. The current and coming generation of demand management activities emphasizes informed consumer choice and active participation in preventative health care, resource utilization decisions, and customization of healthcare services. This personal health management aligns financial incentives, clinical care protocols, and consumer decision-support systems to balance outcomes and resource consumption. PMID- 10168705 TI - Degree of integration can influence organizational economic decisions. AB - When healthcare providers join to form contracting organizations to negotiate managed care contracts, the resulting organizations can be characterized by their degree of integration: tightly integrated (ie, a single bottom line) or loosely integrated (ie, economic independence of each affiliated entity is preserved). Tightly integrated organizations generally are more attractive to payers and better able to optimize returns on their managed care contracts. PMID- 10168706 TI - Direct contracting: a Minnesota case study. AB - During 1996, HealthEast Care, Inc., a healthcare provider-owned and governed direct-contracting company, successfully responded to a request for proposal from the metropolitan Minneapolis-St. Paul-based Buyers Health Care Action Group (BHCAG), a coalition of self-insured employers, to provide healthcare services to members of BHCAG's Choice Plus health plan. HealthEast Care developed a care system proposal for BHCAG that balanced consumer and purchaser expectations with historical healthcare costs. Providers are reimbursed for contracted healthcare services according to a unique fee-for-service, budget-based payment model. BHCAG chose to contract with HealthEast Care and 23 other care systems in the metropolitan Minneapolis-St. Paul area and other parts of Minnesota to serve more than 117,500 Choice Plus enrollees. PMID- 10168707 TI - Coding component important element of compliance plan. AB - In recent years the U.S. government has increased its fraud and abuse investigations in all sectors of the healthcare community. Healthcare providers that are successfully prosecuted may be excluded from the Medicare programs and are liable for monetary penalties. The best course of action is for providers to have a comprehensive compliance plan in place. An important element of such a plan is a component that will identify and address problematic coding issues. PMID- 10168708 TI - Opportunities in the international health services arena. AB - Fundamental changes in domestic healthcare delivery in the '90s have prompted many U.S. healthcare organizations to consider entering international markets. Opportunities available to U.S. organizations include investing in foreign organizations, controlling foreign facilities, and obtaining referrals from extraterritorial or cooperating foreign providers. Before entering into these arrangements, however, organizations must consider the benefits, risks, and constraints they may face, specifically with regard to reimbursement and cash flow, currency risk, regulation, and political risk. To succeed in international service delivery ventures, organizations also may need to make adjustments in the training of healthcare financial managers who will face the international marketplace. Being sensitive to the culture of the countries with which they will be dealing is just as important as knowing the currency and financial regulations. PMID- 10168709 TI - High-quality nutritional interventions reduce costs. AB - Numerous clinical studies have documented improved clinical outcomes and cost savings when patients at risk for malnutrition receive high-quality nutritional care. A survey of 19 hospitals found that patients who received high-quality nutritional care averaged 12.2 days in the hospital. Patients who received medium nutritional care averaged 14.0 days in the hospital. Patients who received low quality nutritional care were hospitalized an average of 14.4 days. The survey further revealed that only 7.5 percent of patients at risk for malnutrition actually received the type of nutritional care that was associated with the shortest average length of stay. If all patients in the at-risk population had received high-quality nutritional care, the estimated net savings potential would have been $1,064 per patient. Financial managers can determine the financial consequences of clinical nutritional policies and practices from information and analytical tools that are readily available. PMID- 10168710 TI - The future of physician practice management companies. AB - Physician practice management (PPM) companies are growing sector of the healthcare industry and have caught the attention of Wall Street, as evidenced by the number of initial public offerings of PPMs in the past three years. The cost of operating efficiencies, declining premiums, integration, oversupply of specialists, shift from a gatekeeper to a direct-access model, and cultural challenges are the emerging market forces that may affect PPM viability. The challenge for PPMs is to maintain earnings growth in the face of these market forces. PMID- 10168711 TI - Lease or buy: optimizing capital equipment procurement. AB - Many physician group practices struggle over whether to buy or lease equipment. While purchasing has been the traditional method of acquiring equipment, leasing often can be more cost-effective. Conducting a lease-versus-purchase analysis can help group practices arrive at the most cost-effective decision. Careful consideration of the alternatives can lead to the best use of the group's resources to meet its financial goals. PMID- 10168712 TI - Additional spending reductions necessary to save Medicare. PMID- 10168713 TI - Combating check fraud with EDI. PMID- 10168714 TI - Data trends. Key organizational performance indicators. PMID- 10168715 TI - Managerial roles in contemporary hospital departments. AB - The emergence of managed care and more integrated healthcare delivery systems brings new challenges to managers in hospital departments. Managers can effectively respond to these challenges by assuming three roles--those of strategist, designer, and leader--described in the following article. PMID- 10168716 TI - Job satisfaction of selected categories of Utah hospital managers. AB - In a survey of managers in Utah hospitals, 85 percent responded overall satisfaction with their jobs. Surprisingly, women in the survey reported significantly greater satisfaction with their jobs than other respondents. PMID- 10168717 TI - Beyond JCAHO: using competency models to improve healthcare organizations. Part I. AB - In 1996 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required hospitals to assess, prove, track, and improve the competence of all employees. Part 1 of this two-part series discusses competencies, their assessment, and the implications of meeting and going beyond JCAHO's requirements. Part 2, which will appear in the next issue of Hospital Topics, provides specific guidelines for the development of a competence assessment system and its practical application. PMID- 10168718 TI - The social responsibility of hospitals. PMID- 10168719 TI - Texas gears up for STAR + PLUS. PMID- 10168720 TI - Health authorities. Its all in the balance. PMID- 10168721 TI - Mental health. Information breakdown. PMID- 10168722 TI - Staff support. A matter of confidence. PMID- 10168723 TI - Communications. Managing the message. PMID- 10168724 TI - Successful procurement. A licence to spend money? PMID- 10168725 TI - Medical technology. A cut above. PMID- 10168726 TI - Supplies in demand. PMID- 10168727 TI - Relocation. Moving targets. PMID- 10168728 TI - Building design. Designs for living. PMID- 10168729 TI - Complaints. Industrious resolution. PMID- 10168731 TI - Bursary. Step up to success. PMID- 10168730 TI - Support for carers. Somebody cares. PMID- 10168733 TI - The changing face of risk management--one trust's experience. PMID- 10168732 TI - Data briefing. Statistics count. PMID- 10168734 TI - Choosing a risk information system. PMID- 10168735 TI - Integrated care management. PMID- 10168736 TI - Case study. Risk modification using closed claims analysis. PMID- 10168737 TI - The implications of risk for purchasers and providers. PMID- 10168738 TI - Primary care. Who's sorry now? AB - Almost two-thirds of health authorities believe their relationships with GPs have improved since the merger. Forty-four percent of LMCs think there has been no change, and 42 per cent report a deterioration. More than half the LMCs believe knowledge and understanding of GPs' contracts, and payments, have declined since the merger. PMID- 10168739 TI - Trust performance. Self examination. PMID- 10168740 TI - Long-term care. Theme and variations. AB - Health authorities' eligibility criteria for long-term care vary in scope. This small study suggests that while differences in access remain, they may be lessening. There is little evidence of radical changes in investment. PMID- 10168741 TI - Mental health. Nursing doubts. PMID- 10168742 TI - Chief executives' forum. Tackling tomorrow's challenges today. PMID- 10168743 TI - Healthcare planning. Making access a primary concern. PMID- 10168744 TI - Palliative care. Open all hours. PMID- 10168745 TI - IT update/PFI (Private Finance Initiative). A marriage of convenience. PMID- 10168746 TI - IT update/strategy. The road ahead. PMID- 10168747 TI - IT update/security. The secret agent. PMID- 10168748 TI - Fund raising. Too much appeal? PMID- 10168749 TI - Public health. Targeting neglect. AB - 40 per cent of health authorities responding accepted all the Health of the Nation targets. More than half of respondents rejected or modified some of the targets. This has implications for a national strategy. Lack of baseline data and difficulties in measuring progress were given as reasons for non-compliance. PMID- 10168750 TI - Litigation. In reduced circumstances. PMID- 10168751 TI - Health technology assessment: decentralized and fragmented in the US compared to other countries. AB - This paper presents the results of the first comprehensive international survey to catalogue health technology assessment (HTA) activities. By 1995, there were formal HTA programs in 24 countries established mostly in the late 1980s and early 1990s. European countries generally have one or two federal or provincial HTA programs each, Canada has an extensive network of federal and regional organizations coordinated by a central body and the US has 53 HTA organizations, the vast majority of which are in the private sector. While the commitment of the US government to HTA has been erratic, the private sector has been witness to an expansion of HTA activities by insurance companies, hospitals, medical/device manufacturers, consulting firms and health professional societies. In contrast to other developed countries, the current state of technology assessment in the US is decentralized, fragmented and duplicative. We conclude by discussing the importance of a US HTA agency at the national level. PMID- 10168752 TI - The role of economic evaluation in the pricing and reimbursement of medicines. AB - In most countries, governments or health insurers have taken initiatives to influence the price and utilization of medicines. One stated objective of these schemes is to encourage efficiency, or cost-effectiveness. In principle, economic evaluation should to be relevant to decisions about the pricing and reimbursement of health technologies, since it offers a way of estimating the additional value to society of a new intervention (e.g. medicine) relative to current therapy. However, the application of economic evaluation in drug pricing and reimbursement schemes is variable. Therefore, this paper reviews the actual and potential role of economic evaluation in different drug pricing and reimbursement schemes, such as 'free pricing' systems (United Kingdom, United States), two-stage administered systems (France), reference pricing systems (Germany, Netherlands, Sweden) and economic evaluation systems (Australia, Canada). It is concluded that, other than in the case of Australia and Canada, the potential role of economic evaluation could be greatly developed, especially in the case of new medicines, for which there is no close substitute. Comments are also given on the practical problems of using this approach. However, it is noted that economic evaluation alone cannot set a price for a medicine, since a decision has to be made about the proportion of added value going to society and the proportion going to the pharmaceutical company as a reward for innovation. PMID- 10168753 TI - Less fog on the Tyne? Programme budgeting in Newcastle and North Tyneside. AB - Programme Budgeting (PB) has been widely promoted as a model for the better conduct of the work of Health Authorities in the National Health Service in the United Kingdom. This paper reports on a project which looked at the development of PB in Newcastle and North Tyneside Health Authority (NNTHA), concentrating on the construction of a computerised tool for the compilation and analysis of programme budgets. The main activities carried out were a survey of user requirements for PB, a survey of data availability, the collection of data to construct programme budgets, and development of a relational database for storing and manipulating PB information. The main source of data was the Contract Minimum Data Set, which was supplemented by data from a number of other sources to give comprehensive information on spending in NNTHA. Costed activity data were produced, which could be aggregated in a large number of ways, such as by care setting (inpatient, outpatient, community, general practice, etc.), disease group (ICD9 chapter headings), case mix (Healthcare Resource Groups) and socio demographic variables (age/sex, locality of GPs practice). PMID- 10168754 TI - HIV prevention in Hungary. AB - Hungary is a country with relatively low HIV prevalence. Since 1989, a wide range of HIV prevention projects has been developed both by government agencies and by an increasingly active voluntary sector. While energy and resources continue to be invested in HIV information and education, some senior public health officials have argued that it is the country's compulsory HIV testing and compulsory reporting system which have enabled it to maintain its low seroprevalence levels. The testing and reporting system are soon to be reformed, however, in response to growing demands for better protection of personal privacy and confidentiality. Whether or not the forthcoming reforms will have an impact on HIV prevention, and what the nature of this impact will be, remain to be seen. PMID- 10168756 TI - The hunt for healthcare quality. PMID- 10168755 TI - Household income and health care expenditures in Mexico. AB - The purpose of this paper is to examine the determinants of household health expenditures in Mexico. Our analysis involves the estimation of household monetary health care expenditures, using the economic and demographic characteristics of the household as covariates. We pay particular attention to the impact of household income on health expenditures, estimating the elasticity of health care expenditures with respect to income for different income groups and according to health insurance status. For the empirical analysis, we use the Mexican National Survey of Income and Expenditures of 1989. Our principle findings show that monetary health expenditures by Mexican households are sensitive to changes in household income levels and that the group which is most responsive to changes in income levels in the lower-income uninsured group. This suggests that in times of economic crisis, these households reduce cash expenditures on health care by proportionately more than higher-income and insured households. PMID- 10168757 TI - Physician integration strategies. PMID- 10168758 TI - The personal touch pays off for Children's Mercy Hospital. PMID- 10168759 TI - Taking on organizational ethics. To do so, ethics committees must first prepare themselves. AB - Healthcare ethics committees which have focused almost entirely on clinical ethics, now need to prepare to deal with organizational ethics, a field that is attracting increasing attention. As they did with clinical ethics, ethics committees members must educate themselves in the demands of the newer field. As before, they must respect the perspectives of the actual decision makers while maintaining an independent framework for analyzing the issues at stake. They must ensure that management is properly represented on the committee if they need guidance from a professional ethicist they should seek one with a strong background in business ethics and social justice. Healthcare organizations are likely to need help with a wide range of ethical issues involving patient services (rationing of resources, for example), business and service plans (mergers and joint ventures, for example), business and professional integrity (conflicts of interest, for example), employee rights and responsibilities (downsizing, for example), and the organization's role in in the community (advocacy and lobbying, for example). To be helpful to the organization, the ethics committee must be prepared to say when cost factors trump other considerations and when they do not. An ethics committee will often be asked to give advice on specific occasions-a proposed new policy, for instance. The most important part of its response is its analysis of the issue. Finally, an ethics committee should view its organization as part of the larger social context. PMID- 10168760 TI - A question of value. What does ethics contribute to the life and work of an organization? AB - In faith-based healthcare, the scope of ethics reaches beyond clinical ethics which, up to now, has been its primary focus-to encompass the entire culture of the organization and all its relationships. Consequently, sustained attention to ethics contributes to the life of, and adds value to, the organization. Ethics' role is to articulate the beliefs and values that are to be embodied in the organization's culture, given its fundamental commitments. Ethics devises methods for shaping and nurturing the culture, and has a role in periodically assessing the state of the organization's relationships, both external-with other healthcare entities, the community, and society-and internal-with employees and patients. Further, ethics shapes the relationships the organization's associates have with each other and with the organization. Attention to ethics encourages improvement in the moral quality of the interactions within the organization; provides an opportunity for moral growth; creates a climate in which ethical issues are dealt with, not ignored; and, over time, creates a community of moral discourse. PMID- 10168761 TI - The virtuous manager. Renewing the experience of work. AB - In healthcare, as in any other field, work can become dehumanizing, meaningless drudgery. But good managers can transform their organizations and renew the experience of work. Good management demands not only good business skills, but character, rooted in truthfulness and vision. Three virtues are particularly important: prudence, justice and fortitude. The moral skill of prudence enables healthcare managers to know what is to be done; justice creates honest relationships; and fortitude enables managers to seek a good that is difficult to achieve--to do the right thing. Businesses must also explore their potential for sacramentality and find ways in which employees--and employers--can become better, holier people through their work. Organizations should strive to achieve subsidiarity and keep employees well-informed of their missions. Establishing a sense of connectedness is important, as is open and honest communication. Finally, managers-and healthcare organizations-must always work for the common good. PMID- 10168762 TI - Ensuring accountability in decision making. A step-by-step approach applies common sense to complex issues. AB - All institutions must routinely make decisions that may have a profound impact on their organizations and communities. The process used to reach those decisions defines an organization's commitment to its mission, values, and corporate ethics. At Sisters of Mercy Health System in St. Louis (SMHS), a corporate decision-making process was developed over the course of a year and introduced systemwide in 1994. The process establishes a disciplined and accountable technique for evaluating initiatives, discussing options, and arriving at clear, values-based decisions. The process begins with two questions: Is the proposed action compatible with the organization's mission? Will the proposed action advance the mission in any significant manner? Next, a step-by-step approach enables members of the decision-making group to consider the proposed action in light of the SMHS mission and values. Participants explore the implications of the decision from three perspectives: social vision, responsibility, and self interest. They also consider the potential consequences of the decision on all affected parties, particularly poor and powerless people. SMHS leaders have found the decision-making process brings clarity and comprehension to the task of making decisions. PMID- 10168764 TI - Community networks. Neighborhood Health Partnership, New Orleans. PMID- 10168763 TI - A voice against physician-assisted suicide. AB - In the early hours of November 14, 1996, Card. Joseph Bernardin died of pancreatic cancer. The Archbishop of Chicago approached death not in fear but as a "transition from earthly life to life eternal." One of his last public acts was writing a letter to the U.S. Supreme Court. He asked the justices to reject arguments that the dying have a right to physician-assisted suicide. In two powerful and poignant pages, the cardinal concisely summarizes the legal and policy arguments against legitimizing the purposeful facilitation of death by healthcare providers. CHA attached his letter to the amicus curiae brief it filed with the U.S. Supreme Court in Vacco v. Quill and Washington v. Glucksberg, the two physician-assisted suicide cases to be decided by the Court this term (see "CHA Amicus Curiae Brief on Physician-Assisted Suicide," p. 36). In this article we provide context for the thoughts expressed in Card. Bernardin's letter, excerpted below, and describe how this letter makes a persuasive legal argument against physician-assisted suicide. PMID- 10168765 TI - Community networks. Partnership, Trenton, NJ. PMID- 10168766 TI - Managed care with a mission. PMID- 10168767 TI - The benevolent dictator. A new breed of medical director. PMID- 10168768 TI - Medical director. The patient's best advocate. PMID- 10168769 TI - Medical director. Liability risks: fact or fiction? PMID- 10168770 TI - Medical director. Doc on the street: another view. PMID- 10168771 TI - Patients you know. PMID- 10168772 TI - Q&A with AMR CEO Paul Shirley. Interview by Lauren Simon Ostrow. PMID- 10168773 TI - Telling right from wrong is going to get a lot harder. PMID- 10168774 TI - Urgent-care centers don't worry me anymore. PMID- 10168775 TI - Too many primary-care doctors? It could happen. PMID- 10168776 TI - Will patients choose NPs over doctors? PMID- 10168777 TI - When a $155,000 offer is really $134,000 in disguise. PMID- 10168779 TI - Health-cost alert. '97 looks okay, but watch out for '98. PMID- 10168778 TI - The uninsured. It's not just kids falling through the cracks. PMID- 10168780 TI - Medicare's future is visible for all to see. PMID- 10168781 TI - Are you throwing away revenue? PMID- 10168782 TI - Where disease management is paying off. PMID- 10168783 TI - Adding profitable services that fit your practice. PMID- 10168784 TI - Selling your practice, Part I. Is that offer a trap? PMID- 10168785 TI - Selling your practice, Part II. Knowing what your practice is worth. PMID- 10168786 TI - Medicare. More and more, doctors are choosing to take assignment. PMID- 10168787 TI - Health insurance. For employers, quality joins cost as a decision-maker. PMID- 10168788 TI - How's Oregon's bold rationing program doing? PMID- 10168789 TI - "Some doctors have done very well". PMID- 10168790 TI - This group's motto: don't duck capitation. Embrace it. PMID- 10168791 TI - FTC's secret Texas deal. 'Early clearance' of Lubbock merger followed long probe. PMID- 10168793 TI - Major Nashville not-for-profits plan link. PMID- 10168792 TI - Vatican taking closer look. Rejected N.J. alliance shows deals face intensified scrutiny. PMID- 10168794 TI - Exemption challenged. Petition claims S.C. merger OK ignored lack of local benefit from deal. PMID- 10168795 TI - It's everyone for himself in budget showdown. An urban grab. PMID- 10168796 TI - Close, but no deal. Kenosha, Wis., hospitals call off partnership. PMID- 10168797 TI - It's everyone for himself in budget showdown. Public hospitals, AHA in Medicaid tiff. PMID- 10168798 TI - Going country. Bills seek to lure Medicare HMOs into rural markets. PMID- 10168799 TI - Making HMOs credible. PMID- 10168800 TI - Take this job and ... this job ... and that job. HMOs farm out responsibilities to physicians. PMID- 10168801 TI - AHA shakes up exec jobs. Vice presidents may have to reapply for their positions. PMID- 10168802 TI - Low-key branding. No Columbia, Tenet pushes local hospitals' names. PMID- 10168803 TI - VHA's new network. 60 organizations have signed up for Internet-style system. PMID- 10168804 TI - Better data. Premier's new service will let systems compare themselves against specific foes. PMID- 10168805 TI - Threat to tax-exempt debt. House proposal could hike healthcare financing costs. PMID- 10168806 TI - VA adds clinics. Pennsylvania, home state of key senator, is a big winner. PMID- 10168807 TI - Off the hook. HHS drops 16 PATH audits, cites unclear billing guidance. PMID- 10168808 TI - Funding hit for HCFA? House panel votes to kill budget for billing system. PMID- 10168809 TI - Hospital lobbies line up to fight new capital rule. PMID- 10168810 TI - Fighting for Part A. Vulnerable doctors go after hospital Medicare funds. PMID- 10168811 TI - Foiled again. Phoenix's Samaritan is finding life as a suitor tough. PMID- 10168812 TI - Union cries foul on hospital's talks with Tenet. PMID- 10168813 TI - Columbia probe widens. Federal raid in 7 states targets lab, home-care records. AB - Federal agencies bellowed no to hospitals' pleas for leniency on fraud investigations. FBI agents served warrants at current and former Columbia/HCA Healthcare Corp. facilities in seven states last week regarding Medicare billing for laboratory and home-care services. More search warrants are ahead for the investor-owned giant as the probe continues. And a new report put Medicare losses due to billing errors at $20 billion last year. PMID- 10168814 TI - Disney gets 2nd CON denial for Fla. hospital. PMID- 10168815 TI - The pesky enemy within. Threat of Medicare spending cuts turns hospitals' Unity Coalition into war zone. PMID- 10168816 TI - Been there, done that. An old pro at change, California hospital stays positive. PMID- 10168817 TI - Prescribed cutback. HMOs shift risk to doc groups to curb drug utilization. PMID- 10168818 TI - Look out for Stage 3. How hospitals can survive as markets move toward managed care dominance. PMID- 10168819 TI - The CFO squeeze. As mergers trigger job cuts, finance execs must adapt. PMID- 10168820 TI - Strikes at Kaiser, Sutter Health. PMID- 10168821 TI - JCAHO's bright finances. PMID- 10168822 TI - Playing the ace. Michigan hospitals go to Congress to stop FTC suit. PMID- 10168823 TI - War on networks. Pittsburgh's Highmark vows only single-hospital pacts. PMID- 10168824 TI - New Boston-area system. Four community hospitals plan to merge assets. PMID- 10168825 TI - Columbia's top execs resign; is Tenet deal next? Vice Chair Frist steps in to redirect company's course. AB - Richard Scott (left), resigned as chairman and chief executive officer of Columbia/HCA Healthcare Corp. and was replaced by industry icon Thomas Frist Jr., M.D. (right), a major Columbia shareholder. Another top Columbia executive, David Vandewater, resigned as controversy around the company grew. Reports surfaced of merger negotiations between Columbia and Tenet Healthcare Corp. PMID- 10168826 TI - New Catholic powerhouse. Providers near deal to form system in Western N.Y. PMID- 10168827 TI - Catholic buying group takes shape. PMID- 10168828 TI - Doc 'down payment'? Primary-care fee hike likely to be smaller than expected. PMID- 10168829 TI - Medicare HMO demos may resurface. PMID- 10168830 TI - Money, medicine and ethics. The doctor-patient relationship must be shielded from influence of market forces. PMID- 10168831 TI - Post-acute care. Investment builders. Real estate development firms help hospitals get out of bricks-and-mortar business. PMID- 10168832 TI - ABCs of distribution. VHA to implement 'activity-based costing' approach. PMID- 10168833 TI - Incinerator closing likely under EPA rules. PMID- 10168834 TI - Bond champ. Sisters of Mercy is 1st not-for-profit with Moody's Aa1 rating. PMID- 10168835 TI - The great bed debate. LAC-USC rebuild gets tied up on the right type of capacity. PMID- 10168836 TI - AHA members getting ownership guidelines. PMID- 10168837 TI - Budget includes freeze. Hospitals lose on Medicare pay; mixed bag on PSOs. PMID- 10168838 TI - Post-acute transfer provision lives on. PMID- 10168839 TI - How far up will it go? 'First phase' of Columbia probe nets 3 indictments. AB - In the wake of last week's criminal indictments of three Columbia/HCA Healthcare Corp. executives, the question on everyone's mind is: How far up the chain of command will the investigation go? Some observers say the feds are looking toward the top. Meanwhile, Thomas Frist Jr., M.D., Columbia's new chief executive officer, in an interview with Modern Healthcare, vowed to build a new value system and corporate culture to turn the company around. PMID- 10168840 TI - Cashing in on connections. N.Y.C. hospitals' funding deal angers upstate rivals. PMID- 10168841 TI - Crusader or gold digger? California attorney in the thick of governance lawsuits. PMID- 10168842 TI - Not so fast, VA. Congress seeks more input on restructuring plan. PMID- 10168843 TI - Board games. Suit accuses Columbia directors, execs of insider trading. PMID- 10168844 TI - Leader of the pack. PMID- 10168845 TI - Rural opportunities. East Texas system finds profit where others have failed. PMID- 10168846 TI - The price of progress. Providers seek to control high cost of computer upgrades. PMID- 10168847 TI - Healthy bonds. Rating upgrades reflect industry's successful restructuring. PMID- 10168848 TI - Budget bill a mixed bag. Providers criticize spending cuts, back Medicare reforms. PMID- 10168849 TI - Provider 1997 LTC buyer's guide. The directory of long-term care products & services. PMID- 10168850 TI - Classifying patients by episodes of care. PMID- 10168852 TI - Top contract rehab therapy providers to nursing facilities. PMID- 10168851 TI - The new rehab market stretches ... beyond seniors. PMID- 10168853 TI - Staffing the assisted living explosion. PMID- 10168854 TI - Responding to search and seizure threats. PMID- 10168855 TI - The greening of financing. PMID- 10168856 TI - Better quality through better measurement. PMID- 10168857 TI - 'I love my work.'. PMID- 10168858 TI - Take two ginseng and call me in the morning. Alternative therapy and traditional medicine shake hands and make up. AB - Consumers have been using alternative therapies for years--they spent $13.2 billion on them in 1990--and many mainstream physicians are finally taking such treatments seriously. Oxford Health Plan is offering an alternative medicine program through its network, and research conducted at universities and teaching hospitals is validating the mind/body connection. In Oklahoma City, Integris Health has discovered the power of a good belly laugh and is making it work for patients. PMID- 10168859 TI - Board games. 10 transitions. A conversation with James E Orlikoff. PMID- 10168860 TI - Dying well. Montana town takes a community approach to the end of life. PMID- 10168861 TI - These are challenging times for not-for profit boards. PMID- 10168862 TI - Governing performance. Reexamining the board's role in executive compensation. AB - If you want a successful organization and you want to keep the IRS off your back, try linking executive performance to compensation. The first step is to develop a philosophy that defines and measures performance in terms of strategic actions. From there, find out how the board should execute what may be its most important responsibility. PMID- 10168863 TI - Program helps family caregivers. PMID- 10168864 TI - The battle for teen health: what works--and what that tells us. PMID- 10168865 TI - Gang violence: ain't no denying it. PMID- 10168866 TI - National coalition will advance dream of healthy communities. PMID- 10168867 TI - Made for each other. Mentor programs help teens and hospitals focus on their futures. PMID- 10168868 TI - Local providers stem migrant apple pickers' health problems. PMID- 10168869 TI - The health care volunteer: needed now, more than ever. PMID- 10168870 TI - Taking kids on a health adventure. PMID- 10168871 TI - Retired docs aid uninsured workers. PMID- 10168872 TI - Internet, telematics and health. PMID- 10168873 TI - CT and mini-CT 2D-image analysis for the quantitation of vertebral trabecular architecture. PMID- 10168874 TI - Scanning Acoustic Microscopy of human and canine cortical bone microstructure at high frequencies. AB - An Olympus UH3 Scanning Acoustic Microscope (Tokyo, Japan) has been used in the burst mode at 400 and 600 MHz to study the elastic properties of osteons and osteonic lamellae in both canine and human compact cortical bone. The nominal resolution at each frequency is within the width of an individual lamella. Three important new observations have been made regarding the acoustic properties of individual lamellae. Firstly, the acoustic impedance, as measured by shade of gray levels, of the outer most lamellae of adjacent osteons interdigitate (blend) although the structures, as determined by backscatter scanning electron microscopy, are seen to be quite separate. Secondly, in almost every osteon observed in this study, the shade of gray level for individual lamellae appear to alternate-dark, light etc.-translating to alternating compliant, stiff lamellar units respectively. Thirdly, the outermost lamella of each osteon appears to be the most compliant (darkest gray level). A preliminary SAM study of sheep femoral trabecular bone has shown the some alternation of lamellar gray levels as observed in osteonic lamellae. PMID- 10168875 TI - Ultrasonic wave propagation in porous media: determination of acoustic parameters and high frequency limit of the classical models. AB - Results on the ultrasonic wave propagation in porous materials are presented with emphasis on the measurement of acoustic parameters and on the discrepancy between experimental results and theoretical predictions for the attenuation at high frequencies. This discrepancy can be observed in Biomedical Engineering where the propagation in different sorts of bones is studied as well as in the fields of Geophysics and Material Science. In the present study, the slow wave propagation in polyurethane foams saturated by different gases is investigated in a frequency range of [70-800 kHz]. Methods are presented to determine the tortuosity and the viscous and thermal characteristic lengths. The experimental results, obtained using standard ultrasonic and vacuum equipments, show that an excess attenuation occurs when the wavelength is not sufficiently large compared to the lateral dimensions of the fibers. This effect constitutes a limit of the classical models of equivalent phases. It is evaluated with the help of a model of ultrasonic scattering. A numerical simulation of osteoporosis using Biot's model is also presented. PMID- 10168876 TI - Anatomical variation of human cancellous bone mechanical properties in vitro. AB - The aim of the study was to assess mechanical properties of human cancellous bone in vitro. Six hundred cubic specimens of cancellous bone were obtained from the tibia, femur, patella, lumbar spine and humerus of eight subjects. The elastic properties were assessed using an ultrasonic transmission technique developed and validated by Ashman (1). The results showed that differences exist between subjects significantly (p < 0.05) and that the mechanical properties vary along the length and the periphery (about a factor 3 to 5). Cancellous bone should be considered heterogeneous and as orthotropic materials exhibiting degrees of anisotropy varying from 2 to 4. Linear and power fit elationships for cancellous bone were found approximately equal. Powers vary from 1.3 to 1.7 for axial modulus versus density and 1.3 and 2.3 for strength versus density. Finally, these results suggest the use of appropriate mechanical properties upon the type of bone for finite element analysis. PMID- 10168877 TI - Diaphyseal bone growth and adaptation: models and data. AB - The cross-sectional growth and development of the long bone diaphysis is strongly influenced by in vivo mechanical loading. An analytical approach was developed to model these mechanobiologic influences. First, human growth under normal loading conditions was modeled. Our model predictions were validated by comparison to human data obtained during adolescence. Next, skeletal adaptation during growth under altered loading conditions was examined using an animal model. Rat hindlimb suspension experiments were performed and femoral adaptation to reduced loading during growth was measured and compared to normal controls. Then our model predictions of adaptation during growth were compared directly to our experimental data. PMID- 10168879 TI - In vivo and in vitro measurement of ultrasound velocity in cortical bone. AB - The measurement of ultrasound velocity is gaining increasing interest in clinical and biomedical research. Its applications are mostly in the quantitative assessment of fracture healing, and in the study of the effect of osteoporosis on the bone mechanical properties. We will give an overview of the studies that have been made in the past, aiming at the development of a reliable measurement technique. Further the concept and importance of the wavepath analysis will be discussed and finally we will report on the results obtained so far in clinical trials. PMID- 10168878 TI - The in vitro measurement of ultrasound in cancellous bone. AB - This paper describes our recent findings on the relationships between ultrasonic measurements (velocity and broadband ultrasonic attenuation) and some physical properties of human and bovine cancellous bone (density, trabecular orientation and Young's modulus of elasticity). We have found velocity to be an extremely effective measure of Young's modulus (R2 approximately 95%). When velocity is combined with a measure of apparent density R2 improves to approximately 97%. We demonstrate that this is due to the ability of ultrasound velocity to measure structural anisotropy in the tissue. The findings for broadband ultrasonic attenuation (BUA) are more complex. In the same specimens BUA is not as good as velocity at predicting Young's modulus (R2 approximately 62%). We demonstrate that this is due to a non-linear relationship between BUA and tissue density (porosity). However there is a strong indication that BUA is also affected by variation in cancellous structure. PMID- 10168880 TI - Prospects of computer models for the prediction of osteoporotic bone fracture risk. AB - Bone fractures are major problems for osteoporosis patients. To avoid such fractures, more information is needed about the factors that determine the bone fracture risk. In this chapter, it is discussed how recently developed finite element computer models that can represent the trabecular architecture in full detail can provide such information. It is concluded that a computer modeling approach to this problem is feasible, required and promising. It is expected that, eventually, such models can be used as a basis for an accurate diagnosis of the bone fracture risk. PMID- 10168881 TI - Validation of adaptive bone-remodeling simulation models. AB - Using computer models based on Finite Element Analysis (FEA), Wolff's paradigm of mechanically-controlled adaptive bone remodeling can be simulated. These simulation models use empirical mathematical rules that describe the assumed relationships between local bone loads and bone mass. These models are particularly valuable for preclinical testing of orthopaedic implants, relative to their bone-maintaining capacities. In this Chapter the question of validity of these models for these purposes is considered. Furthermore, an overview is presented of validation studies that were performed by the research group of the author. PMID- 10168882 TI - The significance of histology in relation to non-invasive techniques in the evaluation of bone tissue. PMID- 10168883 TI - Micro-tomographic imaging for the nondestructive evaluation of trabecular bone architecture. AB - The structural properties of trabecular bone have been shown to vary significantly with age, anatomic location, and metabolic condition. Micro computed tomography (microCT) is an emerging technique for the nondestructive assessment and analysis of the three-dimensional trabecular bone architecture. Within the framework of the European Union BIOMED I project "Assessment of Bone Quality in Osteoporosis," a total of 350 bone biopsies from five different anatomical locations were harvested post mortem from 70 donors (aged 23 to 92 years). These biopsies were measured using a newly devised compact micro tomographic system, also referred to as desk-top microCT. Samples with a diameter from a few millimeters to a maximum of 18 mm and a length of up to 55 mm can be measured. For this study fresh, untreated bone biopsies with a diameter of 8 mm were measured micro-tomographically with a nominal isotropic resolution of 14 microns. For all samples, the volumes of interest (4 x 4 x 4 mm3) were binarized using a uniform threshold. Subsequently, standard structural indices such as bone volume density (BV/TV), bone surface density (BS/BV), trabecular plate number (Tb.N), trabecular thickness (Tb.Th), trabecular separation (Tb.Sp) and the degree of anisotropy (DA) were computed for all specimens incorporating mean intercept length (MIL) measurements. Regression analysis was used to estimate the correlations of single structural parameters with age or with a second parameter and also among different measurement sites. The nondestructive microCT measurements allowed not only to perform quantitative bone morphometry but also to assess other important microstructural features in the determination of the mechanical integrity of trabecular bone such as the incidence and prevalence of microcallus formations. The findings from the BIOMED I study are expected to improve our understanding of the relative importance of bone architecture, damage accumulation, and bone mineralization in the characterization of bone quality in the progress of age- and disease-related bone loss. PMID- 10168884 TI - Assessment of trabecular structure using high resolution magnetic resonance imaging. AB - Although bone mineral density is one of the most important contributing factors to bone strength and risk of fracture, studies have shown that changes in bone quality and structure independent of bone mineral density, influence both bone strength and individual risk of fracture. The influence of these other factors is thought to explain at least partially the observed overlap in bone mineral measurements between patients with and without osteoporotic fractures, irrespective of measurement site or technique. Thus, several new emerging techniques have been aimed at quantifying trabecular bone structure in addition to bone density. With recent hardware and software advances magnetic resonance (MR) images with spatial resolutions of 80-150 microns and slice thickness of 300 700 microns which resolve the trabecular structure have been obtained both in vitro and in vivo. Both modified spin-echo and gradient echo based imaging sequences have been used to obtain these images, and although the technical parameters and the sequence specific mechanisms affect the depiction of trabecular bone. In conjunction with three dimensional image processing and an understanding of the mechanisms of image formation, these high resolution images may be used to quantify trabecular bone architecture. In addition to obtaining standard stereological measures such as trabecular bone volume, mean trabecular width, mean trabecular spacing, mean intercept length as a function of angle, parameters such as three dimensional connectivity as measured by the Euler number, fabric tensor in three dimensions and texture related parameters such as fractal dimension may be derived from such images. Quantitative measures of trabecular architecture derived from such images have been compared with those obtained from higher resolution 18 microns images, and with biomechanical properties. In vivo studies in the radius and calcaneus have been performed and differences between osteoporotic and normal subjects are distinguishable. Thus, MR imaging techniques coupled with computerized image analysis may potentially be very useful for studying osteoporosis and quantifying trabecular bone architecture and may provide information in addition to bone density. PMID- 10168886 TI - The effect of CLIA '88 and managed care on the medical lab market. Its impact on POLs, hospital labs, and reference labs. PMID- 10168887 TI - Something for every facility in changes to NFPA 101. PMID- 10168885 TI - The quality of trabecular bone evaluated with micro-computed tomography, FEA and mechanical testing. AB - Most standard methods to predict bone quality are merely based on apparent density measurements. However, apparent density alone does neither explain all variation of the mechanical properties nor does it account for the structural anisotropy of trabecular bone. Thus, apparent density alone might not be sufficient to accurately predict the quality of bone. This study investigates if a new approach based on microstructural computer models can provide additional and relevant information on bone quality. 58 human trabecular bone samples from the femoral head were measured with a 3-D micro-Computed Tomography (micro-CT) system providing a voxel representation of the bone microarchitecture with a resolution of 28 microns. Based on such representations, the orthotropic stiffness matrices and the principal directions were computed for 5 mm cubes with microstructural Finite Element Analysis (FEA). For a subset of six samples the moduli were then validated with tri-axial mechanical compression tests. The results show that on average 15% of the variation of the elastic properties are not explained by bone volume fraction. Differences of elastic properties between samples with the same bone volume fraction range up to 53%. The variation of the degree of anisotropy is unrelated to that of the bone volume fraction. Finally, the direction-dependent stiffness of the trabecular bone differs by a factor of four, indicating that one single (isotropic) modulus as predicted from apparent density measurements might not be adequat. It is concluded that micro-CT-based FEA provides new and additional information about anisotropy and mechanical properties in a direct and non-destructive way, and thus will be important in the future for advanced failure risk prediction. An extension to patient examinations using high-resolution CT or MRI techniques is envisaged. PMID- 10168888 TI - Topical carbonic anhydrase inhibitors. PMID- 10168889 TI - Golf-related ocular injuries. AB - Golf-related ocular injuries have been reported since the early 1900s. Although this type of ocular injury is fortunately a relatively rare occurrence, the effects are usually devastating. The purpose of this article is to review the mechanism of golf injuries, the prognosis for different types of golf-related injuries, and how such injuries might be prevented. PMID- 10168890 TI - Clinical implications of vascular growth factors in proliferative retinopathies. AB - Angiogenesis is a fundamental component of normal development and pathologic processes within the eye. Complications due to abnormal ocular neovascularization remain the leading cause of visual loss throughout the world today. Neovascularization and the associated increase in vascular permeability are the underlying threats to vision in such diverse conditions as diabetic retinopathy, retinal vein occlusion, retinopathy of prematurity, exudative age-related macular degeneration, sickle cell retinopathy, radiation retinopathy, and numerous others. Although it has been appreciated for nearly one-half century that the clinical findings associated with ocular neovascularization suggest an etiology involving the elaboration of growth factors, the exact molecules involved and their mechanisms of action have remained incompletely understood. Recent developments in this rapidly evolving field have begun to elucidate the major factors responsible for modulating the neovascularization common to these conditions and have significant theoretic implications for the development of novel, nondestructive, pharmacologic treatment modalities. PMID- 10168891 TI - Retinal arterial occlusions in the young. AB - Retinal arterial occlusions occur secondary to a multitude of mechanisms. The evaluation and workup of a patient with a retinal arterial occlusion depends on many factors, including the age and the systemic health status of the patient. Retinal arterial occlusions in the young typically occur by somewhat different mechanisms than do arterial occlusions in older adults. This article reviews the recent literature related to the etiology and diagnostic evaluation of retinal arterial occlusions in young people as well as potential new managements. PMID- 10168892 TI - Endophthalmitis after penetrating ocular trauma. AB - Endophthalmitis following penetrating eye injuries has a relatively poor prognosis due to the underlying eye trauma and the frequency of more virulent organisms such as Bacillus species. Risk factors for infection include 1) retained intraocular foreign body, 2) a rural injury setting, 3) delay in primary wound closure, and 4) disruption of the crystalline lens. Although endophthalmitis is difficult to distinguish from traumatic changes, recognition of early clinical signs of endophthalmitis, such as hypopyon, vitritis, or retinal periphlebitis, is important and early treatment is recommended. Comprehensive prophylactic antibiotic treatment at the time of injury repair combined with timely diagnostic vitrectomy and injection of intravitreal antibiotics when infection is suspected may significantly improve visual acuity outcomes following penetrating injuries. Treatment includes intravitreal, periocular, and systemic antibiotics. Intravitreal and periocular corticosteroids are also recommended. Recent and past literature supporting these recommendations, as well as the authors' specific prevention and treatment protocols for post-traumatic endophthalmitis, is included in this review. PMID- 10168893 TI - Cataract extraction after retinal detachment. AB - Cataract surgery is a known risk factor for retinal detachment. The risk for retinal redetachment after cataract surgery in eyes that have previously undergone retinal detachment repair is not well documented but has recently been investigated. Eyes that have undergone previous scleral buckling surgery have good potential for positive visual outcome after cataract surgery, with a low rate of intraoperative complications and a low risk for recurrent retinal detachment. Eyes with complicated retinal detachments that have undergone vitrectomy as part of surgical repair may have a higher rate of intraoperative complications, including difficulty with nuclear expression during planned extracapsular cataract extraction and capsular tears during irrigation and aspiration. The risk for recurrent retinal detachment in these eyes is not known. PMID- 10168894 TI - Cytomegalovirus optic neuritis. AB - Cytomegalovirus (CMV) optic neuritis is a rapidly blinding disease. Untreated eyes have a final visual acuity of no light perception. Treated eyes maintain visual acuity of approximately 20/100. Relapse occurs often in subjects maintained on single-dose ganciclovir and is controlled by double-dose ganciclovir. Central visual field testing is indicated to detect indolent cases of optic neuritis, because relapse can be silent with stable visual acuity and fundus appearance. Survival of patients with CMV optic neuritis is comparable to that of a matched group having CMV retinitis alone. Early recognition and therapy of CMV papillitis protect against irreversible visual loss. CMV papillitis does not carry a worse prognosis for survival than CMV retinitis alone. PMID- 10168896 TI - Visual acuity in children with colobomatous defects. AB - Examining a child with a colobomatous defect can be challenging. The most important predictor of visual outcome is identification of normal foveal anatomy. The clinician should first evaluate the child for the associated systemic conditions. The next step is to identify the presence of normal foveal structures in the involved eye(s). If present, a trial of amblyopia treatment should be initiated. Anisometropic amblyopia is common and should be addressed. Retinal detachments are common and add uncertainty to predicting visual acuity. PMID- 10168895 TI - Diabetic retinopathy and lipid abnormalities. AB - The relationship of serum lipid levels and diabetic retinopathy has interested clinicians for several decades. Data from both a population-based study of diabetic retinopathy and a controlled, randomized trial of laser photocoagulation and aspirin treatment in diabetic retinopathy have provided further information regarding the importance of the role of serum lipids in patients with elevated serum lipid levels and diabetic retinopathy. Retinal hard exudate, which is accompanied by macular edema, is associated with elevated serum lipid levels. Although the data are observational, visual loss is likely to be associated with retinal hard exudate and serum lipid abnormalities. These relationships are evaluated in the analyses of the data from the Early Treatment Diabetic Retinopathy Study. PMID- 10168897 TI - Retinal vasculitis. AB - Inflammation of the retinal vasculature may occur as a manifestation of an infectious disease, as part of a systemic inflammatory disease, or as part of an isolated retinal disease, and can result in severe and permanent visual loss. The search for a cause in patients with retinal vasculitis requires appropriate systemic evaluation and testing. Discrimination between the infectious or noninfectious etiology of retinal vasculitis is important because the treatment is different. PMID- 10168899 TI - Surgical management of retinoschisis. AB - Most cases of X-linked juvenile retinoschisis and degenerative retinoschisis never require any type of surgical intervention. However, on rare occasions, associated problems such as retinal detachment come about and threaten the visual prognosis. Both conditions have in common the adherence of cortical vitreous to the inner layer of peripheral schisis cavities, which can make the secondary complications technically difficult to manage. Although good surgical results can often be obtained, it is not unusual to require relatively advanced vitreoretinal techniques to achieve long-term surgical success. PMID- 10168898 TI - Treatment of cytomegalovirus retinitis with the intraocular ganciclovir implant. AB - The treatment of cytomegalovirus retinitis (CMV-R) has improved considerably in the past two years. Local ocular therapy has proved to be effective and provides significant advantages over systemic therapy with regards to better control, preventing progression, avoiding bone marrow and renal toxicity. Direct intraocular injections of anti-CMV drugs and the sustained-release ganciclovir device are the mainstay of local therapy. The ganciclovir intraocular device has undergone rigorous testing and has recently been approved for clinical use. This review describes the surgical procedure, recommendations for use, and exchange and management of associated retinal detachment. In addition, the results of the initial studies and the multicenter, randomized clinical trial are discussed. Current data available from the Study for the Ocular Complications of AIDS (SOCA) and AIDS Clinical Trials Group (ACTG) studies are summarized in the context of CMV-R management. PMID- 10168900 TI - Pathogenesis of idiopathic macular holes. AB - An improvement in our understanding of the pathogenesis and natural history of idiopathic macular holes over the last 10 years has led to a more optimistic and interventionist approach to the surgical management of this vitreoretinal disorder. This article reviews the theories postulated for the pathogenesis of this condition and looks at recent work that has investigated the role of the vitreous, internal limiting membrane, and posterior vitreous detachment in the natural history of macular holes. PMID- 10168901 TI - Internet-based marketing strategies. PMID- 10168902 TI - PSOs at center stage. PMID- 10168903 TI - Comparative analysis software and its utility in managed care decision making. PMID- 10168904 TI - Software systems integration achieves cost-effective, clinically defensible, market-sensitive solutions. PMID- 10168906 TI - Virtual reality (VR) techniques in orthopaedic research and practice. AB - Modeling the musculoskeletal joint system using biomechanical analysis and computer graphics techniques allows us to visualize normal, diseased and reconstructed joint function. This model can be used to study the loading of bones and joints under theoretical and simulated activities. In this study, intact cadavers were imaged using MRI, CT scanning and cryo-sectioning techniques. Using sequential pixel information of bone and soft tissue boundaries collected from digital camera images, MRI and CT scans, the volumetric models of the musculoskeletal joint system are reconstructed. "Descriptive geometry" techniques which treat bones as rigid bodies and cartilage, ligament and muscles as deformable bodies were used to construct the model. Joint resultant forces and moments were determined using an inverse dynamics formulation, while ligament tension, joint contact pressure, and bone stresses are solved through a simplified Rigid Body Spring Modeling technique and the Finite Element Method. The results under static and dynamic loading activities can be visualized using interactive computer graphics. The advantages of such a model are the elimination of the need for large numbers of intact cadaveric specimens, and the unprecedented capability to study joint loading responses under normal, abnormal and surgically reconstructed states. Such a model and its analytical capability are ideal for pre-operative planning and computer-assisted orthopaedic surgery. This Visual, Interactive, Computational, and Anatomic Model(VICAM) and its associated analysis capability represent the next generation of technology which will have an enormous impact in orthopaedic research, education and patient care. PMID- 10168905 TI - Trends in provider termination from managed care plans. PMID- 10168907 TI - Psychiatric therapeutic applications of virtual reality technology (VRT): research prospectus and phenomenological critique. AB - There is theoretical and empirical research supporting the hypothesis that virtual reality technology (VRT) can be efficaciously applied to attenuate the symptoms of mental disorders (Baer, 1996; Rothbaum et al, 1995a, 1995b; Rothbaum et al, 1996.) Yet there is also research suggesting psychiatric therapeutic applications of VRT may induce noxious or unexpected psychological consequences (Kolasinski, 1996; Muscott & Gifford, 1994; Regan & Price, 1994; Regan & Ramsey, 1996; Strickland, 1995.) A prudent conclusion would be to advocate ever more sophisticated studies on psychiatric therapeutic applications of VRT concerning (1) increasing the overall socioadaptiveness of patients, (2) the robustness of moderating, modifying, or other intermediary variables effecting or affecting VRT therapeutic efficacy, and (3) variables, processes, and hypotheses generated from VRT applications in non-psychiatric fields. PMID- 10168908 TI - TeleInViVo: a collaborative volume visualization application. AB - Converging technologies in the areas of networks, volume visualization algorithms, and computer performance have made possible the development of a new tool for collaboration, which extends the reach of health professionals, and other consumers of volumetric data around the world. TeleInViVo(tm) is a three dimensional (3D) collaborative volume visualization tool for medical applications. It extends the capabilities of InViVo(tm), a fast volume visualization tool developed at the Fraunhofer IGD, Darmstadt, Germany [1-3], with efficient and intuitive network collaboration features for remote consultation and new modes of interaction. The software runs on both UNIX and Windows NT platforms. TeleInViVo provides a high degree of interactivity for the medical professional when interacting with the patient data, facilitates explanation and communication between field personnel and medical experts located far from the field, and permits viewing of the data in a multitude of ways designed to support rapid and accurate diagnosis. Current efforts involve architectural enhancements to support multiuser, distributed telemedical scenarios. The application includes the following features: Volume and subvolume data transmission at user specified resolution, Synchronization cues, Integration of Immersion Probe(tm), a 6 degree-of-freedom input device, for ergonomic 3D data exploration, Tools for measuring distances, Tools for planning instrument path, Arbitrary cutting planes in real time, Interactive segmentation tools, Virtual video recorder and playback (cine loops), 3D stereo mode. TeleInViVo is an essential part of the MUSTPAC-1 portable 3D ultrasound system developed by Battelle Pacific Northwest Labs, Richland, WA. PMID- 10168909 TI - Simulation of soft-tissue tumor excisions: a multimodal interactive approach. AB - Total 3-D reconstruction of the tumor size, shape, and relations with surrounding structures using CT, MRI, sonography, and angiography images can make simulated radical resection of soft-tissue sarcomas possible, thus sparing normal tissues. With our approach, starting from three MR images for a given patient, a new single image representation of all three parameters is generated by using two different techniques on a workstation in a standard UNIX and X-11 environment. The first one is a transformation linking together the MR parameters and the RGB (red, green, blue) color components. The second one is an unsupervised segmentation method based on a number of neural and fuzzy models. We can dinamically render and update a stereo display using field sequential presentation of left and right eye views on the monitor, with Cristal Eyes LCD shutter eyewear (StereoGraphics Inc., San Rafael, CA) to view it. As 3D locating tool, a 3D locating control system based on low-frequency magnetic fields (Polhemus Fastrak) has been chosen. Simulations of soft-tissues excisions may be performed in this interactive environment with augmented-reality modalities. All this, in our experience, has greatly facilitated the simulation of soft-tissue sarcoma excisions. PMID- 10168910 TI - New interface metaphors for complex information space visualization: an ECG monitor object prototype. AB - Wearable augmented reality medical (WARM) interfaces could provide ubiquitous point-of-care decision support and enhance the quality and efficiency of clinicians' efforts. Creation of such systems involves the design and evaluation of new information displays that leverage the representational and presentational capabilities of three-dimensional AR environments. We describe our first efforts in this process: the implementation of interface objects for display of real-time electrocardiographic monitoring information and an evaluation methodology using a simulated clinical environment. Our pilot data confirm the utility of presentation modes that place simultaneous information tasks in close proximity, and highlight issues encountered in designing new representations of medical information. PMID- 10168911 TI - Computerized hand diagnostic/rehabilitation system using a force feedback glove. AB - This paper describes recent results of a unified computerized system for hand diagnosis and rehabilitation. Automatic diagnosis data collection and Virtual Reality rehabilitation exercises are the main characteristics of the system. The diagnosis subsystem includes a tactile sensing glove in addition to standard devices such as electronic dynamometer, pinchmeter and goniometer. Three standard rehabilitation exercises were simulated in a Virtual Reality environment, using the WorldToolKit graphics library. The first two exercises (ball squeezing and DigiKey) allow measurement of finger forces exerted during the rehabilitation routine. The third exercise (Peg board) involves the patient's visual-motor coordination. The rehabilitation subsystem uses a VPL DataGlove retrofitted with Rutgers Master (RM-I) and its interface. The exercises involve manipulation of objects with different stiffnesses and geometry. Grasping forces were modeled and fed back using the Rutgers Master worn on patient's hand. Data is gathered in real time from both diagnosis and rehabilitation subsystems. Finger specific forces recorded during rehabilitation exercises allow better diagnosis of the patient impairment. An ORACLE database is used to store and manipulate patients' records. Proof of concept trials were performed in a clinical environment. Some results of patient records analysis are presented in this paper. A new version of the system using an RM II haptic interface is presently under consideration. PMID- 10168912 TI - Virtual cancer image data warehouse. AB - We previously developed a system with which we have created more than 100 virtual cancer images from CT or MR data of individual patients with cancer (Cancer Edutainment Virtual Reality Theater: CEVRT). These images can be used to help explain procedures, findings, etc. to the patient, to obtain informed consent, to simulate surgery, and to estimate cancer invasion to surrounding organs. We recently developed a web-based object-oriented database both to access these cancer images and to register medical images at international research sites via the Internet. In this report, we introduce an international medical VR data warehouse created using an object-oriented database. PMID- 10168913 TI - More real-time visual and haptic interaction with anatomical data. AB - The University of Colorado's Center for Human Simulation has developed fundamental algorithms for real-time visual and haptic interaction with polygonal and voxel base data sets, including those derived from the Visible Human Dataset. These algorithms are currently being used to create prototype simulators for surgery, needle insertion (anesthesiology, radiology, and rheumatology), dentistry, and ophthalmology. This paper briefly discusses our segmentation and classification effort as well as our ability to create texture-mapped polygonal models directly from the data: both are fundamental to the creation of anatomically based simulators. PMID- 10168914 TI - Virtual reality and the neuropsychological assessment of persons with neurologically based cognitive impairments. PMID- 10168915 TI - Building a virtual reality temporal bone dissection simulator. AB - The temporal bone is one of seven bones that comprise the human skull, and has an intimate relationship with many vital structures. Anatomically, its three dimensional relationships make it one of the most challenging areas for surgeons to understand and master. In addition, the temporal bone contains minute structures that are among the most sophisticated and delicate in the human body. These structures include the cochlea and vestibular organs, which are responsible for hearing and balance; the middle ear, including the ossicles, which conduct acoustic energy to the cochlea; and the facial nerve, which is responsible for controlling the muscles of facial expression, and contributes to the sensation of taste. Additionally, the temporal bone forms a major portion of the skull base, and has intimate relationships to vital structures including the carotid artery, jugular vein, cerebral cortex, brainstem, and cranial nerves. Surgical procedures performed on the temporal bone include: procedures to eradicate chronic and acute infections; procedures to remove malignant and benign tumors within the temporal bone, from the skull base, or from the posterior cranial fossa; procedures to restore the hearing mechanism; procedures to eliminate balance disorders; and procedures to correct congenital anomalies. For surgeons-in-training, and even surgeons-in-practice, mastery of the anatomy of the temporal bone and the many complex approaches necessary to treat patients takes years of focused endeavor. This is typically accomplished through the dissection of human cadaver temporal bones, which are scarce, and require a dedicated laboratory facility. Efforts are currently underway to develop a realistic simulator for temporal bone procedures. Users immersed in the simulator will interact with a three-dimensional temporal bone, derived from patient-specific data, using a haptic interface to simulate traditional surgical procedures. Feedback from experts in otologic surgery will be built into the system for additional instruction. This presentation will include an overview of the application being developed, a report of its current state of development, and plans for the future. PMID- 10168916 TI - Micro-telerobotic surgical system for microsurgery. AB - Modern surgical methods which utilize microscopes have allowed medical professionals to visualize the surgical field on the order of microns. This new found visual capacity has created a performance gap between a surgeon's visual skills and manipulative skills that surgical robotics have the capability to remedy. Robotics can be used as an aid to the surgeon to help correct natural human dexterity problems such as tremor and resolution of motion. Devices that would benefit surgical dexterity at the micron scale are in development at Sandia National Laboratories. A six degree-of-freedom (DOF) force reflecting telerobotic manipulator has been designed and developed for use in microsurgical applications. The system utilizes a unique mechanical platform, actuation schemes, and controller that provides high positional precision while maintaining high frequency response for implementation of force feedback. Thus, the same device is used to form a master-slave telerobotic arrangement to assist the surgeon. This makes the system very intuitive to the surgeon and easier to implement for the engineer. The system utilizes high performance Digital Signal Processors (DSP) for control of both the master and slave platforms. Six dimensional force information is obtained from transducers located at the end effectors of both the master and slave. Two distinctly different types of motors are currently being evaluated, as well as several types of control algorithms. Position scaling, force scaling, and tremor filtering are being implemented in the DSP control software. Control parameters are based upon system frequency response testing. Results from our system identification and performance testing will be discussed. PMID- 10168917 TI - The status of virtual reality for the cognitive rehabilitation of persons with neurological disorders and acquired brain injury. PMID- 10168918 TI - An "augmented-reality" aid for plastic and reconstructive surgeons. AB - Starting from MR and CT images for a given patient, a new single image representation of all parameters has been generated by using false-color techniques in a standard UNIX and X-11 environment. A transformation linking together the MR, CT parameters and the RGB (red, green, blue) color components has been used. Moreover an unsupervised segmentation method based on a number of neural and fuzzy models may directly produce segmented image volumes. Each image of the various sequences has been interactively displayed by using a specifically designed application. The resulting images have been displayed on a stereo monitor allowing the three-dimensional rendering of visual data through LCD shuttered glasses. Moreover, a 3-D control system based on low frequency magnetic fields has been used, while a bandheld Polhemus stylus could be used as an electronic knife for dissecting the 3-D data set and for defining flaps and grafts. Bone or soft-tissue contour can be analyzed, and sections can be removed from the model to allow a view of the underlying structures. Flaps and grafts obtained utilizing the above-reported techniques can be fitted exactly, without repeated removal and recarving. Nuances of depth, tapering, and arc are carved directly into the bone, while chances of asymmetry are markedly diminished. In this way, moreover, anesthetic times are reduced by more efficient utilization of operative time, which usually offsets the increased cost of imaging. PMID- 10168919 TI - Possibilities for peacekeeping: the role of telemedicine in international initiatives. PMID- 10168920 TI - MERMAID 1996--report on the implementation of a European Project on "medical emergency aid through telematics". AB - MERMAID is a project that intends to provide multilingual medical emergency services to seaborne vessels around the world. MERMAID uses two-way transmission of live images in marine medical teleconsultation, greatly improving services that up to now depended on short-wave and VHF radio alone. Transmission of high resolution still pictures is also possible, so that the teleconsulting physician may closely (visually) examine his patient, along with transmission of biological signals and patient anamnesis details. Telemedical interventions are critically dependent on local paramedics. Merchant marine officers are trained in first-aid procedures and basic medical transactions. In practice, however, this training is often inadequate. For this reason MERMAID uses a multimedia medical guide that covers the absolutely necessary basics to handle medical emergencies and common medical problems on board. This application is based on the WHO "Medical guide for ships" and EU Council Directive 92/29. The delivery of medical and mental health care to distant populations has never been easy. In addition, the progress of technology has widened the disparity between the quality of care available to the urban citizen and that available to the rural or remote location resident. The only viable solution to the problem seems to come from telecommunications technologies. Indeed, ISDN is the first widely available public network that supports integrated services and can serve as a reliable backbone for telemedical services. Communications satellites provide a means of expanding ISDN network to geographically remote locations. Against this background, MERMAID combines mobile satellite technologies, VSAT technologies and ISDN protocols in order to realise a Global Telemedicine System that is reliable, exhibits, continuity, is seamlessly connected, has low cost and is downward compatible. PMID- 10168921 TI - Hyper Hospital on the satellite multi-media network. AB - We have been developing the Hyper Hospital, a network based VR mediated medical care system. The Hyper Hospital is composed of two seamlessly integrated environments, that is, the virtual and the real worlds. Of them, its virtual environment expands the conventional medical care system using the virtual reality technology as a principal human interface and a collaboration tool, in the present study, an attempt to extend the Hyper Hospital system to various modalities of communication network is reported. A satellite communication based multi-media network using Internet protocols with the WWW interface is used. Data transmission rate and other performances were measured under various conditions and the satellite network was shown to be suitable to the Hyper Hospital network. PMID- 10168922 TI - Telehealth in Africa. AB - This paper deals with the developments of the project "Telehealth in Africa", to establish a link between more European reference Hospital Centers and some African Hospital Centers, connected with Peripheral Units of Assistance, to transmit and receive health diagnostic images, etc. The project has been developed by the European Collaboration Group for Telemedicine in developing countries which was created in collaboration with ITU (International Telecommunication Union). A demonstration of telehealth from Milan (Italy), Toulouse (France), to Abidjan (Ivory Coast, Africa) and Midrand (South Africa) proves that it is possible for a diverse group of intergovernmental organizations, non-governmental organizations and the private sector to work together for the benefit of all participants and, most of all, for developing countries. PMID- 10168923 TI - An augmented reality system for health care provision via telematics support. AB - We are developing a prototype portable health care support device for Emergency Telemedicine. This device can telematically "bring" a specialist doctor at the site of a medical emergency, allow him to evaluate patient data and issue directions to the emergency personnel on treatment procedures until the patient is brought to hospital. The portable device is carried by a paramedic technician in "wearable" form, allowing the technician to perform his normal duties while communicating with the specialist at the hospital site. This augmented reality system allows for maximum utilisation of available resources and offers a complete, practical solution for increasing survival rates before and during the transportation of accident victims to hospital. PMID- 10168924 TI - High-performance clinical patient data review and consultation system. AB - Primary care physicians rely on specialists. Specialists are too expensive to be located at every clinical site requiring a practical means for specialists to help without requiring patients or specialists to travel for consultation. To address the challenge of providing primary care physician access to specialists, we are developing a clinical prototype system for the high-speed access and transfer of patient data and images within Radiology Departments, Medical Centers and Health Care Networks. The key components of the system are: a high-bandwidth network (100 Mbit/s upgradeable to ATM); an image server system with a 30-60 day patient image on-line archive ( < 10 sec. recall) coupled with a long term archive; viewing consoles matching existing film display paradigms located within the medical center and clinics providing rapid access to patient data and diagnostic images for house staff (OR/ER/ICU); clinician access to the image archive on a consultation basis in office computers; and image review applications which closely follow the established paradigms used by clinicians. Using our system primary care physicians can rapidly review patient data locally obtaining additional consultation from tertiary sites while the patient is present. Clinics and outlying medical centers gain rapid access to specialists with physicians in different cities discussing patient diagnostic and management issues in a shared environment leading to instantaneous data analysis and diagnosis further reducing health care costs and enhancing patient care. PMID- 10168925 TI - Transeuropean network for the provision of added-VAlue Services in Telemedicine- (VAST-Net). AB - Populations most likely to use telemedicine are usually located far away from ISDN networks in contrast to providers of telemedical services who normally dwell in urban centers. VAST-Net is a consortium that aspires to reach such populations by introducing added-value ISDN-based telemedical services across Europe, through networking a small number of selected, strategically distributed, points-of-care and by focusing on a series of well defined health care provision scenaria. This will be achieved by relying on: (1) the Euro-ISDN infrastructure, (2) satellite based ISDN medical networks (e.g. the INMARSAT/VSAT based MERMAID network), (3) private ISDN networks. The VAST-Net telemedical network will be initially operated on a small but transnational scale in order to assess: (1) the acceptance of telemedical services by end users, (2) the economic viability of the telemedical sector, especially in an international context (3) the legal implications of telemedical practice (4) the regulatory framework within which telemedicine will be developed in the E.U. Based on this assessment the VAST-Net Consortium will proceed to develop appropriate business plans that will allow PTTs and other Telecom operators, medical groups, insurance companies and public health authorities to offer transnationally ISDN-based telemedical services. Potential forms of cooperation may include: (1) "Framework agreements" between PTTs, telemedical service providers (e.g. doctors, hospitals etc.) and "bulk users" (insurance companies, public health authorities), (2) PTT provision of "telecommunications backbones" over which competing telemedical networks can be organised, (3) organisation of a European Economic Interest Group (EEIG), modeled upon international companies such as INMARSAT, that will undertake the operation of VAST-Net. PMID- 10168926 TI - Using the World-Wide Web for peer-to-peer patient support. PMID- 10168927 TI - Applications of virtual reality technology in pathology. AB - TelePath(SM) a telerobotic system utilizing virtual microscope concepts based on high quality still digital imaging and aimed at real-time support for surgery by remote diagnosis of frozen sections. Many hospitals and clinics have an application for the remote practice of pathology, particularly in the area of reading frozen sections in support of surgery, commonly called anatomic pathology. The goal is to project the expertise of the pathologist into the remote setting by giving the pathologist access to the microscope slides with an image quality and human interface comparable to what the pathologist would experience at a real rather than a virtual microscope. A working prototype of a virtual microscope has been defined and constructed which has the needed performance in both the image quality and human interface areas for a pathologist to work remotely. This is accomplished through the use of telerobotics and an image quality which provides the virtual microscope the same diagnostic capabilities as a real microscope. The examination of frozen sections is performed a two-dimensional world. The remote pathologist is in a virtual world with the same capabilities as a "real" microscope, but response times may be slower depending on the specific computing and telecommunication environments. The TelePath system has capabilities far beyond a normal biological microscope, such as the ability to create a low power image of the entire sample using multiple images digitally matched together; the ability to digitally retrace a viewing trajectory; and the ability to archive images using CD ROM and other mass storage devices. PMID- 10168928 TI - Medical electronic link (MEL): providing telemedicine on the World Wide Web. AB - Many tertiary care centers in the USA have attempted to implement interactive television (IATV) or dynamic telemedicine systems. The advantage these systems provide is real-time interaction. The biggest disadvantage is cost: expensive hardware, band-width and personnel. An alternative to IATV is Medical Electronic Link (MEL); a low cost, store-forward, internet-based physician consultation system. MEL allows physicians in remote locations to consult physicians at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire by using the World Wide Web. The Benefits of MEL are low hardware and band-width costs, accessibility, a self-explanatory interface, convenience, and its use of the case record. This system has been implemented at a family practice clinic in Manchester, NH and at the Tribhuvan University Teaching Hospital in Kathmandu, Nepal. PMID- 10168929 TI - Towards a novel augmented-reality tool to visualize dynamic 3-D anatomy. AB - Using augmented reality (AR) to teach dynamic 3-D anatomy may impart better understanding of bone dynamics during body movement. We are currently developing an AR tool that will allow superimposition and registration of bone structures on real anatomical counterparts of a human subject. This article describes the application, the problems to be solved, and reports on preliminary developmental studies of a first prototype of the tool. Specifically, studies test approaches to simulating real-time dynamic anatomy, and the feasibility in achieving registration of 3-D anatomical bones on their real counterparts. Such a tool will offer several unique advantages over traditional teaching methods and overcome many of their current limitations. PMID- 10168930 TI - Virtual reality environments for psycho-neuro-physiological assessment and rehabilitation. AB - Virtual Reality Environments for Psychoneurophysiological Assessment and Rehabilitation-is an European Community funded project (Telematics for health-HC 1053 http:/(/)www.etho.be/ht_projects/vrepar/) whose aim is: to develop a PC based virtual reality system (PC-VRS) for the medical market that can be marketed at a price which is accessible to its possible end-users (hospitals, universities and research centres) and which would have the modular, connectability and interoperability characteristics that the existing systems lack; to develop three hardware/software modules for the application of the PC VRS in psychoneurophysiological assessment and rehabilitation. The chosen development areas are eating disorders (bulimia, anorexia and obesity), movement disorders (Parkinson's disease and torsion dystonia) and stroke disorders (unilateral neglect and hemiparesis). This paper presents the rationale of the different approaches and the methodology used. PMID- 10168931 TI - Display of coregistered cross-modality images using time-weighted alternation method. AB - Cross-modality coregistration of functional and anatomical images has rapidly grown as the aid for the interpretation of functional images. Various methods have been previously investigated so that the coregistered images can be easily interpreted and realistically visualized. We used the time/intensity-weighted alternation method to display the coregistered images simultaneously. Stereotactic registration was done with two methods. We realized the automated method of alignment using the boundary of head scalp extracted from the sinogram of a PET emission scan and surface-matching algorithm in brain, and the semi automated method using a paired point-matching algorithm in the chest and abdomen. For the simultaneous display of the stereotactically registered images, rapid switching of the screens were applied on which both images were written with independent color scales. Rapid alternate display of two images, that is synchronized using the monitor scanning process, could induce the fusion of images in the human visual perception system. Also, intensification of an interesting image is possible by weighting the displaying time or global intensities of images with the degree of interest. These techniques could be useful for the interpretation and visualization of the coregistered images. PMID- 10168932 TI - Tactile sensor method for thoracoscopic detection of intrapulmonary nodules. AB - We have developed a tactile sensor which can be used to quantify the hardness of objects and applied it to thoracoscopic surgery for the localization of small invisible nodules in the lung. The hardness properties of objects can be obtained as changes in the resonance frequency of the tactile sensor (delta f). When the sensor probe is moved over the lung surface, a delta f curve is depicted on the computer screen. When the sensor tip passes the area just above a target nodule, a spike is evoked in the delta f curve. In thoracoscopic surgery, tactile sensor was employed to detect a total or 42 nodules, 32 indeterminate and 10 metastatic, in 37 patients. All except two of these detected nodules, had been preoperatively demonstrated with computed tomography. Each nodule was detected successfully by recognizing the spot on the pleura, at which the spike of delta f curve was evoked, and resected thoracoscopically. All of the indeterminate nodules were diagnosed intraoperatively; 28 benign tumors and 4 primary carcinomas. In conclusion, our tactile sensor method can be a viable alternative for thoracoscopic detection of small and invisible pulmonary nodules. PMID- 10168933 TI - Deformable models and the analysis of medical images. AB - Deformable models are a popular and vigorously researched model-based approach to computer-assisted medical image analysis. The widely recognized efficacy of deformable models stem from their ability to segment, match and track images of anatomic structures by exploiting (bottom-up) constraints derived from the image data together with (top-down) a priori knowledge about the location, size and shape of structures of interest. Deformable models are capable of accommodating the often significant variability of biological structures over time and across different individuals. Furthermore, they support highly intuitive interaction mechanisms that allow medical scientists and practitioners to bring their expertise to bear on the model-based image interpretation task as necessary. In this paper we will review deformable models and present some recent developments in the methodology, including topologically adaptable deformable models, an approach that permits segmentation and reconstruction of topologically complex anatomical structures. PMID- 10168934 TI - Cubby. A medical virtual environment based on multiscreen movement parallax. AB - In this paper a desktop virtual reality system named Cubby is described. Cubby is based on self-induced, head-coupled movement parallax on three orthogonal screens. It is argued that this system is better suited to medical practice than Immersive VR solutions or single screen Desktop VR systems. Whilst Cubby is currently limited to visualisation it opens up possibilities of direct instrumental manipulation and as such could prove useful as a medical simulator. PMID- 10168935 TI - Simulation of jaw-movements for the musculoskeletal diagnoses. AB - Simulations of static and dynamic aspects of the functionality of the human body are getting more important as the complexity of operations increases. The preoperative planning of maxillofacial operations like the repositioning of the jaw is an example for such operation. Here, but also in other medical fields, simulation can help to estimate the results of a procedure or can facilitate the diagnosis through a better view of the anatomy and pathology of the patient. A virtual view on the pathology and the possibility of simulating the postoperative results simplifies and improves the preoperative planning. The goal of our research is the development of a graphical simulation of the human mastication system to give the surgeon an impression on the inner anatomy of his patient. This simulation allows him to predict the aesthetic and functional outcome of his operation. The main focus of this paper is the introduction of a kinematic model of the temporomandibular joint. This kinematic model describes the geometrical and analytical movement of the jaw by specially defined axes. It is the basis for an animated simulation of the mandible movement. Through integration of the muscles and muscle forces, we come to a realistic dynamic simulation of the whole mastication system. PMID- 10168936 TI - Telepresence in neurosurgery: the integrated remote neurosurgical system. AB - This paper describes the Integrated Remote Neurosurgical System (IRNS), a remotely-operated neurosurgical microscope with high-speed communications and a surgeon-accessible user interface. The IRNS will allow high quality bidirectional mentoring in the neurosurgical suite. The research goals of this effort are twofold: to develop a clinical system allowing a remote neurosurgeon to lend expertise to the OR-based neurosurgical team and to provide an integrated training environment. The IRNS incorporates a generic microscope/transport model, Called SuMIT (Surgical Manipulator Interface Translator). Our system is currently under test using the Zeiss MKM surgical transport. A SuMIT interface is also being constructed for the Robotics Research 1607. The IRNS Remote Planning and Navigation Workstation incorporates surgical planning capabilities, real-time, 30 fps video from the microscope and overhead video camera. The remote workstation includes a force reflecting handcontroller which gives the remote surgeon an intuitive way to position the microscope head. Bidirectional audio, video whiteboarding, and image archiving are also supported by the remote workstation. A simulation mode permits pre-surgical simulation, post-surgical critique, and training for surgeons without access to an actual microscope transport system. The components of the IRNS are integrated using ATM switching to provide low latency data transfer. The research, along with the more sophisticated systems that will follow, will serve as a foundation and test-bed for extending the surgeon's skills without regard to time zone or geographic boundaries. PMID- 10168937 TI - Virtual cutting in medical data. AB - In this paper we present a method for virtual 3D cutting operations in 3D tomographic data. When cutting interactively the user specifies a series of 3D cutting points and corresponding cut depths on the surface of the object. Each pair of succeeding cutting points then defines a freeform shape of the incision. A 3D meshing algorithm constructs a Finite Element mesh formed by tetrahedrons, representing the surgical intervention. PMID- 10168938 TI - 3-D surface reconstruction of patient specific anatomic data using a pre specified number of polygons. AB - Virtual reality environments provide highly interactive, natural control of the visualization process, significantly enhancing the scientific value of the data produced by medical imaging systems. Due to the computational and real time display update requirements of virtual reality interfaces, however, the complexity of organ and tissue surfaces which can be displayed is limited. In this paper, we present a new algorithm for the production of a polygonal surface containing a pre-specified number of polygons from patient or subject specific volumetric image data. The advantage of this new algorithm is that it effectively tiles complex structures with a specified number of polygons selected to optimize the trade-off between surface detail and real-time display rates. PMID- 10168939 TI - The use of a robotic device for gait training and rehabilitation. AB - This study was aimed at investigating normal subjects walking with support using a robotic device (REHABOT) intended for gait training and rehabilitation of physically disabled individuals. Ground reaction forces, knee joint kinematics, temporal factors of gait, and oxygen cost were measured on fourteen healthy subjects. The apparatus was to support 0%, 20%, 40% and 60% of each subject's body weight through an upper torso harness connected to the robotic device. Each subject was then asked to walk on a 10 meter circular pathway. Temporal factors of gait, ground reaction forces and knee kinematic measurements showed little change from 0% to 40%, but a significant alteration in these gait parameters was noticed when 60% of the subject's body weight was supported. Oxygen cost decreased significantly (P < 0.05) from 0% to 40%, but increased at 60%. These results suggest that body weight support up to 40% reduces energy demands without significantly altering gait patterns. Consequently the REHABOT can be considered as a gait training device for patients with weight-bearing difficulties. This apparatus may also be used as an exercise machine for certain patients who cannot walk un-assisted. PMID- 10168940 TI - A flexible and extensible object-oriented 3D architecture: application in the development of virtual anatomy lessons. AB - "Anatomic VisualizeR" represents the first application to be developed using a 3D architectural framework created at the University of California, San Diego, School of Medicine. This application combines 3D anatomic models (based on the Visible Human dataset) with supporting 2D media (e.g., diagnostic imagery, surgical videos, etc.) to establish a comprehensive learning environment for anatomy. "Guided lessons" are being created to address complex curricular and learning objectives. Faculty expertise is represented in these preconfigured lessons, in part through the specification of appropriate content and the incorporation of activities to enhance visualization. These lessons are an intellectual framework which ensures that clinically-relevant issues and ancillary learning opportunities are available. The curricular exercises are non sequential and can be interrupted at any time; users are encouraged to freely explore the environment. At the core of Anatomic VisualizeR's object-oriented architecture is the ability to identify, access, view, and manipulate heterogeneous content. The capacity to query a database gateway to retrieve specified resources has been built into the application. Encapsulation of individual elements to form 3D display objects ("blocks") enables Anatomic VisualizeR to efficiently manage 3D models, 2D images, text, sound, and video. The "block" paradigm also allows Anatomic VisualizeR to associate contextually appropriate display characteristics and behaviors with the various content elements. For example, the anatomic model block provides the capability to "link" and "unlink" the anatomic models and to alter their transparencies. The anatomic models can be displayed concurrently with other blocks to facilitate structural comparisons. Anatomic VisualizeR marks a major milestone in our developmental efforts. While lessons and database content are still not complete, we are confident that it will become the first tangible realization of our vision. PMID- 10168941 TI - Teaching and assessing clinical skills using virtual reality. AB - The need to improve the teaching and assessing of students' procedural skills has been well 0 encounters, often with little or no supervision. Assessment of these skills has depended on rudimentary physical models, or standardized patients. The limitations of these methods also are well known. A new technology known as "Virtual Reality" has tremendous potential to assist medical educators in teaching and assessing clinical skills of students, residents and physicians in practice. Virtual Reality consists of a computer-generated three-dimensional simulation in which the user both views and manipulates the contents of the environment. Various degrees of immersion may be experienced that may include elements such as vision, touch or sound. It can provide an environment that so closely represents an actual clinical situation that skills learned will transfer to patients. Many variations in anatomy or other complications can be presented, and trainees can practice hundreds of times until their skills are perfected. This paper describes current activities in this area in the Dalhousie Faculty of Medicine and elsewhere. Various forms of Virtual Reality are described and their application to particular clinical areas are described. PMID- 10168942 TI - A distributed virtual environment prototype for emergency medical procedures training. AB - Because of the increasing complexity of emergency medical care, medical staffs require increasingly sophisticated training systems. Virtual environments offer a low cost means to achieve a widely usable yet sophisticated training capability. We describe the Virtual Emergency Room (VER) project, a simulation system designed to enable emergency department personnel within level I and II emergency rooms to practice emergency medical procedures and protocols. Because emergency rooms are manned by a wide variety of medical professionals, we are developing a simulation facility that uses a distributed virtual environment architecture to enable real-time, multi-participant simulations. The potential advantages of this system include the ability to evaluate and refine treatment skills, and the ability to provide scenario-specific training for mobile military field hospital teams. These advantages will ultimately improve the readiness of emergency department staffs for a wide variety of trauma situations. This paper describes the VER and the major components of its distributed virtual environment. The current capabilities of our system are described followed by a discussion of recommended follow-on work. PMID- 10168943 TI - Simulated casualties and medics for emergency training. AB - The MediSim system extends virtual environment technology to allow medical personnel to interact with and train on simulated casualties. The casualty model employs a three-dimensional animated human body that displays appropriate physical and behavioral responses to injury and/or treatment. Medical corpsmen behaviors were developed to allow the actions of simulated medical personnel to conform to both military practice and medical protocols during patient assessment and stabilization. A trainee may initiate medic actions through a mouse and menu interface; a VR interface has also been created by Stansfield's research group at Sandia National Labs. PMID- 10168944 TI - Assisting maxillofacial surgery by using multimedia VR techniques. AB - Multimedia and VR technologies are examined as regards their potentiality for medicine, specifically for maxillofacial surgery. The goal is to achieve a surgical procedure of better quality as well as a more interesting way of imparting medical knowledge. Close cooperation with the Maxillofacial and Plastic Surgery Department of the University Hospital Benjamin Franklin (UKBF) ensures the suitability of the material for the user. Doctors give regular feedback on the 3D human-computer interface, graphics and interaction devices because they are crucial for the implementation of multimedia and VR systems in medicine. Before implementing a VR or multimedia application, the technical possibilities should be explored in depth. Therefore, a VR tested for 3D input and output devices has been established at the Technical University of Berlin to assess the advantages and technical restrictions of commercially available and self-made devices. Parts of the VR tested are currently being transferred to the Medical Informatics Department of the UKBF, where the usefulness of various 3D input and output devices for different medical applications in a real clinical environment will be evaluated. PMID- 10168945 TI - The BRAIN project: an interactive learning tool using desktop virtual reality on personal computers. AB - The BRAIN-project is an endeavor in using computer aided learning to improve the understanding of the human brain anatomy. The project consists of four parts, each based on modular packages: BRAINIMAGES: Brain atlas consisting of horizontal and frontal brain slices spaced I mm apart enabling the identification of structures and areas of the brain. The software also contains views of the brain's outer surface with all pertinent structures marked. BRAINRADIOLOGY: Visualisation of the brain using CT, MRI and angiography. The different imaging techniques enable the user to explore the brain from several angles and also view the major blood vessels of the brain. NEUROHISTOLOGY: Cells of the brain using histologically stained sections. The program emphasizes the organization of cells in layers and the interaction of different cell types. 3D-BRAIN: Three dimensional reconstructions based on physical slices of a human brain. The reconstructed brain views are made interactive using a simple form of desktop virtual reality: QuickTime VR technology. The user can rotate the different views in all directions producing a 3D effect. The different views are designed to highlight important structures and their organization within the outlined (and semi transparent) brain surface. Contrary to similar applications, the actual three dimensional objects are not based on MRI or CT scans (with comparatively poor resolution), but on tracings made on high resolution images of photographs of actual sections of a postmortem brain. N.B., this approach produces 3D renderings in a more detailed and reliable way. The BRAIN project is designed as a support package for students in preclinical education by supplying additional means for gathering information pertinent to the curriculum. By cross linking, the students can switch from a three dimensional object to a corresponding slice, and then to the relevant histological sample and son on. The software components are based on a modular design enabling easy modification of the various parts and the entire project is designed to run on both Apple Macintosh and MS Windows based PCs. PMID- 10168946 TI - Virtual reality: from the development laboratory to the classroom. AB - In conclusion, in order for virtual reality simulations to move from the R & D laboratory to the teaching classroom on a large scale basis, there are four conditions which must be met: faculty involvement, student cooperation, affordable equipment and administrative support. 1. Faculty must understand the advantages of using VR simulations and be committed to developing the procedures and teaching modules and evaluating their effectiveness. They must understand that the simulations are another teaching tool and not a substitute for the teacher. 2. Students must be guided in the use of VR simulations to develop the level of skill required. Students must be willing to accept new ways of learning and must be able to see their individual learning progress in skill development. 3. Equipment-Must be realistic, affordable, available and clearly demonstrate advantages over traditional methods of teaching. 4. Administrative Support Initially the cost of instituting VR simulations may be more than using other traditional teaching tools, thus ongoing financial support is very important. I believe that the faculty of the Nursing Department at the State University of New York at Plattsburgh is showing the way in incorporating VR simulations into a traditional undergraduate nursing program and as a result they are changing forever the way we will prepare health professionals for the future. PMID- 10168947 TI - Blind persons navigate in virtual reality (VR); hearing and feeling communicates "reality". AB - Can Virtual Reality (VR) developments in audio navigation for blind persons support therapies for all? Working with Crystal River Engineering we are developing navigable Virtual Reality worlds for blind users, using spatialized audio [1], [2]. All persons, however, use specialized channels, such as: visual, aural, and kinetic learning senses. Predominantly visual VR worlds and health informatics models from World Wide Webs, may be downloaded, tailored, augmented, and delivered to each of these learning senses using VR. We are also testing a proof of concept system with Boston Dynamics which downloads 3-dimensional, satellite-derived map models from the World Wide Web, and makes them navigable by "feeling" the terrain using haptic (tactual or force feedback to your hand) robotic interfaces. Ultimately, these multi-sensory VR access methods: sight, localization by audio, and "feeling" of data sets could open up the World Wide Web to individuals with sight impairments. This could also, however, benefit government, businesses, universities, and (elementary) education. It could contribute more powerful communications, education, and medical simulation applications on the World Wide Web. This work is part of government technology transfer to telemedicine, (elementary) education, disabilities access to the Web, and new Internet access and productivity efforts under Vice President Gore's National Performance Review. PMID- 10168949 TI - Integrating medical informatics into the medical undergraduate curriculum. AB - The advent of healthcare reform and the rapid application of new technologies have resulted in a paradigm shift in medical practice. Integrating medical Informatics into the full spectrum of medical education is a viral step toward implementing this new instructional model, a step required for the understanding and practice of modern medicine. We have developed an informatics curriculum, a new educational paradigm, and an intranet-based teaching module which are designed to enhance adult-learning principles, life-long self education, and evidence-based critical thinking. Thirty two, fourth year medical students have participated in a one month, full time, independent study focused on but not limited to four topics: mastering the windows-based environment, understanding hospital based information management systems, developing competence in using the internet/intranet and world wide web/HTML, and experiencing distance communication and TeleVideo networks. Each student has completed a clinically relevant independent study project utilizing technology mastered during the course. This initial curriculum offering was developed in conjunction with faculty from the College of Medicine, College of Engineering, College of Education, College of Business, College of Public Health. Florida Center of Instructional Technology, James A. Haley Veterans Hospital, Moffitt Cancer Center, Tampa General Hospital, GTE, Westshore Walk-in Clinic (paperless office), and the Florida Engineering Education Delivery System. Our second step toward the distributive integration process was the introduction of Medical Informatics to first, second and third year medical students. To date, these efforts have focused on undergraduate medical education. Our next step is to offer workshops in Informatics to college of medicine faculty, to residents in post graduate training programs (GME), and ultimately as a method of distance learning in continuing medical education (CME). PMID- 10168948 TI - Preparing our future physicians: integrating medical informatics into the undergraduate medical education curriculum. AB - This paper describes how two medical schools have integrated "medical informatics" into their undergraduate medical education programs with the aim of preparing their students for future practice. It describes the components or elements of the informatics programs, how learning opportunities have been integrated into the curricula, how the informatics programs have evolved, and future directions. The medical schools approached the task of introducing informatics in a parallel way. Following needs identification, similar topic areas, goals, and specific informatics learning objectives were developed. These were used as a basis for implementation and evaluation. In general, the topic areas selected are: computer literacy, communications, information retrieval and management, computer-aided learning, patient management, office practice management, and hospital information systems. Learning opportunities in informatics were integrated for the above goals, in accordance with how the curriculum was organized in each school. These opportunities, and the support activities provided will be described. PMID- 10168950 TI - The props-based interface for neurosurgical visualization. AB - We describe a three-dimensional human-computer interface for neurosurgical visualization. The interface is based on the two-handed physical manipulation of hand-held tools, or "props", in free space. These user interface "props" facilitate transfer of the user's skills for manipulating tools with two hands to the operation of a user interface for visualizing 3D medical images, without need for training. The interface allows neurosurgeons to explore a 3D MRI scan of a patient's brain during presurgical planning. From the surgeon's perspective, the interface is analogous to holding a miniature head in one hand which can be "sliced open" or "pointed to" using a cross-sectioning plane or a stylus tool, respectively, held in the other hand. Cross-sectioning a 3D volume, for example, simply requires the surgeon to hold a plastic plate (held in the preferred hand) up to the miniature head (held in the nonpreferred hand) to demonstrate the desired cross-section. PMID- 10168951 TI - The tradeoffs of successful simulation. AB - This presentation will discuss the decision process we followed to develop an ultrasound simulator. The development of an advanced technology medical device always requires tradeoffs and compromises between what is desired, and what can be realistically achieved. The medical applications of computer based education are increasingly important to the process of medical education. Product developers will be required to address these concerns. Some tradeoffs result from technical, scientific, and engineering factors; while others are the result of marketing, financial, or competitive constraints. All of these factors will influence the design and production of simulation tools. A manager, scientist, or engineer who is involved in development of this kind of innovative product may be helped by considering the impact of some of these decisions earlier in the process. Forewarned is fore-armed. The most basic design issue we faced was the conflict between the requirements we envisioned for the ultrasound simulator, and the limitations of realistic simulation. Our goal was to achieve a product which would be affordable to the academic institutions who would be using it. Simulation will be defined and presented with examples from our experience. PMID- 10168952 TI - Productivity and quality improvements in health care through airboss mobile messaging services. AB - The US health care industry is in the midst of revolutionary changes. Under tremendous pressures from third-party payers and managed care programs to control costs while providing high quality medical services, health care entities are now looking at information technologies to help them achieve their goals. These goals typically include improved productivity, efficiency and decision-making capabilities among staff members. Moreover, hospitals and other health care facilities that provide a broad and integrated range of inpatient and outpatient care, wellness and home care services are in the best position to offer comprehensive packages to managed care and private insurers. Many health care providers and administrators are considered mobile employees. This mobility can range from intra-building and intra-campus to multi-site and metropolitan areas. This group often relies on a variety of information technologies such as personal computers, communicating laptops, pagers, cellular phones, wireline phones, cordless phones and fax machines to stay in touch and handle information needs. These health care professionals require mobile information access and messaging tools to improve communications, control accessibility and enhance decision making capabilities. AirBoss mobile messaging services could address the health care industry's need for improved messaging capabilities for its mobile employees. The AirBoss family of services supports integrated voice services, data messaging, mobile facsimile and customized information delivery. This paper describes overview of the current mobile data networking capability, the AirBoss architecture, the health care-related applications it addresses and long-term benefits. In addition, a prototype application for mobile home health care workers is illustrated. This prototype application provides integrated e-mail, information services, web access, real-time access and update of patient records from wireline or wireless networks, and cross media delivery and notification. It provides seamless wide area access to patient data in a secure environment, thus providing a continuity of care from the hospital to home. PMID- 10168953 TI - Internet image database: development and implementation. AB - The widespread acceptance of World Wide Web (WWW) hypermedia protocols allows rapid cross-platform development of database interfaces. Using the WWW as the interface promotes easy integration of databases with other publicly available Internet resources. We present our experience with an image database search program (IDBS) developed on the PC platform using freely available UNIX development tools. The database routines were written in PERL. The image database program provides a familiar user interface to a collection of clinical images stored in digital form, either on local media or on the Internet. The design goals of the project and the strategies used to meet them are presented. The source code and a demonstration database are available on the Internet at http:/(/)www.webmedix.com/idbs. PMID- 10168954 TI - Virtual reality support system in palliative medicine. AB - We have been examining the potential value of a VR system for the palliative care of cancer. We recently developed palliative care system which consists of a 100 inch-wide screen, HMD (Head-mounted display) and 8-mm video or a PC. Our goal is to use VR techniques to help alleviate a patient's stress and concern regarding their cancer during hospitalization. We can use this system to present (1) personal video movies, (2) video letters from friends and family, (3) personal video instruction about medical examinations, and (4) interactive information about their cancer using a PC-based VR system. Our preliminary results indicate that interesting VR presentations are useful for reducing stress. PMID- 10168955 TI - Patient specific color texture mapping of CT-based anatomical surface models utilizing cryosection data. AB - In traditional medical imaging modalities, color and texture information can add considerable information for diagnostics. Presently, multimodal images of a patient are unregistered and referenced independent of each other, or registered and fused into a single hybrid volume. Doctors and other medical professionals need to be able to visualize and interrogate, on a per-patient basis, a wide variety of 2D and 3D data representations that can be created from non-invasive imaging modalities, such as MRI and CT. In addition, any colorization that may be applied to the image data is strictly based on tissue density, radiation emission, or magnetic signature, and not on any physiological foundation. In order for "true-to-life" color information to be incorporated with non-invasive imaging techniques, and for it to be of consistent quality across the entire body, a single whole-body cryosection specimen with associated medical image data is needed. The National Library of Medicine's Visible Human Project offers just such a specimen. Using the full-body medical image data along with the cryosection images of the Visible Human subject, a set of color lookup tables for all visually well defined structures and organs can be created. As a result, patient-specific colorization based on real tissue color and characteristics can be incorporated into traditional intensity-based imaging modalities. The primary goal of this work has been to create CT color lookup tables for all visually well defined structures in the Visible Human male cryosection data set. The subsequent goal has been to develop a method for stripping textures from a volumetric data set for polygonal models and non-uniform rational B-spline (NURBS) models, also generated from the volumetric data. PMID- 10168957 TI - Patient safety and efficacy as measured by clinical trials and regulatory policy. AB - Virtual Reality and other technological innovations in medicine provide new challenges to the regulatory framework of the premarket review process for medical devices. By reinventing the government-academia-industry partnership, clinical trial data necessary for a medical device to enter the market can be more efficiently obtained. PMID- 10168956 TI - Computer assisted therapy for multiple sclerosis and spinal cord injury patients application of virtual reality. AB - For patients with multiple sclerosis and spinal cord injury, virtual reality systems provide new methods of assistance with dysmetria, tremor, spasticity, and weakness. Robust mechanisms exist within the central nervous system to produce neuroplastic adaptive responses operative in retraining motor activities. Haptic systems cued by the patient's visual environment can produce force corridors to guide a patient's wrist and hand in the performance of specific tasks. Such haptic application can substantially reduce motor instability and improve performance. Preliminary clinical approaches, using video tremor tracking and manual force application, indicate the extent of the expected improvements attainable with this approach. Refinement of these techniques is proceeding to development of VR systems that will allow more extensive application to the problems of dysmetria, more general instances of tremor, spasticity, and weakness. PMID- 10168958 TI - High definition 3D ultrasound imaging. AB - We have demonstrated high definition and improved resolution using a novel scanning system integrated with a commercial ultrasound machine. The result is a volumetric 3D ultrasound data set that can be visualized using standard techniques. Unlike other 3D ultrasound images, image quality is improved from standard 2D data. Image definition and bandwidth is improved using patent pending techniques. The system can be used to image patients or wounded soldiers for general imaging of anatomy such as abdominal organs, extremities, and the neck. Although the risks associated with x-ray carcinogenesis are relatively low at diagnostic dose levels, concerns remain for individuals in high risk categories. In addition, cost and portability of CT and MRI machines can be prohibitive. In comparison, ultrasound can provide portable, low-cost, non-ionizing imaging. Previous clinical trials comparing ultrasound to CT were used to demonstrate qualitative and quantitative improvements of ultrasound using the Sandia technologies. Transverse leg images demonstrated much higher clarity and lower noise than is seen in traditional ultrasound images. An x-ray CT scan was provided of the same cross-section for comparison. The results of our most recent trials demonstrate the advantages of 3D ultrasound and motion compensation compared with 2D ultrasound. Metal objects can also be observed within the anatomy. PMID- 10168959 TI - Visualization of compression neuropathies through volume deformation. AB - This paper describes an interdisciplinary effort to simulate and visualize the mechanisms involved in compression neuropathies, specifically tissue deformation occurring during vaginal delivery. These neuropathies often evolve into chronic pelvic pain. We present our methodologies of using high resolution magnetic resonance acquisitions from submillimeter pulse sequences to develop interactive computer simulations based on physically plausible volume models to drive 3D simulations of childbirth. This effort will elucidate tissue movements and mechanics involved in pain disorders and better explain the etiology of these disorders. PMID- 10168960 TI - Matching services to needs in the health care of elderly people. AB - This paper is based on the results of a postal enquiry to health care professionals working in the care of elderly people in a Scottish Health Board. Responses fall into three main categories. The first refers to issues of process, where lack of information or delays in response create problems. Second, there are problems of scarcity, with both lack of provision and pressures on existing provision. Third, the responses relate to the impact of constrained choices, which are the consequences of that scarcity: either people are sent to existing services because of a lack of alternatives, or people cannot be referred on appropriately because of the lack of alternatives. The process of referral is, then, affected directly by the options that are available. In the process, compromises have to be made, and this produces mismatches between needs and services. PMID- 10168961 TI - Cohort, gender and practice organization: examining the bounds of collaborative medicine among newly established female and male family physicians in Ontario. AB - This paper analyzes data from a 1993 survey of 395 newly established female and male family physicians in Ontario, Canada, to examine the relationship between practice organization and gender. Previous research suggests that younger physicians, particularly women, tend to enter group practice. Compared to solo practice, groups may offer more predictable incomes, more manageable workloads, peer collaboration and review, and economies of scale. Further, female physicians in groups may develop distinctive styles of collaborative medicine. The results show that a majority of physicians in our cohort are in private community-based group practice. However, while many groups share premises, staff and expenses, and many have common charts and practice guidelines, only a minority incorporate regular meetings to discuss business or patient care, have shared care of hospitalized patients, or audits of physicians' practices. Few gender differences are observed in private group practice: although women physicians attract larger proportions of female patients than do their male colleagues, women and men organize their groups in similar ways and have similarity strong patient-centered attitudes. PMID- 10168962 TI - Promoting a quality of service culture in health care: review of a Scottish initiative. AB - This paper is a review of a quality of service initiative which was carried out as a PICKUP Quality Project within the Scottish Health Service. This Quality Initiative took place between 1989 and 1990: before the emergence of The Patient's Charter. The aim of the review was to provide answers to a number of important questions which examined the perceptions of staff who took part in the Quality of Service initiative, identified parts of the process which were in need of substantial revision, and reported on the reactions of participants to the overall process. The methodology employed involved questionnaires and interview techniques. A number of problems were identified and, after examination, these were taken to indicate learning pointers for the future. It was evident that good quality of service training can be delivered, but only if it is clearly and appropriately tailored to the audience. It is also of fundamental importance to be familiar with the environment in which the organization is operating. In this instance, as is often the case for health care, there were considerable financial limitations in force at the time. These limitations heightened the general business sensitivity and showed that carrying through quality of service improvements involved the demonstration of commitment and the provision of resources. PMID- 10168964 TI - Organizational power and conflict regarding the hospital-physician relationship: symbolic or substantive? AB - The purpose of this paper is to provide a critical review of organizational power and conflict regarding the hospital-physician relationship. The issue of power being symbolic and/or substantive is discussed. The classification (Mintzberg Model) of organizations as simple structures, machine bureaucracies, professional bureaucracies, divisionalized forms and adhocracies are reviewed. Also, the issue of whether the perceived autonomy that professional employees enjoy increases the likelihood that an executive level manager in a professional bureaucracy (hospital entity) will devote substantial attention to influencing symbolic outcomes as opposed to substantive outcomes in a machine bureaucracy is discussed. In conclusion, conflicts between hospitals and physicians can be resolved in two ways: (1) by avoiding controversial decisions that might threaten the powers and prerogatives of professional groups; and (2) by agreeing to decisions that hold something for everyone involved in the hospital-physician power relationship. PMID- 10168963 TI - Application of the Mantel-Haenszel odds ratio in validation of hospital episode statistics data. AB - The National Health Service reforms have led to a growing need to determine the efficiency and cost effectiveness of health care provision. Resource utilization and the factors that influence it form a vital part of the information procured by commissioners of health care. Currently the most comprehensive source of routinely collected data is the Hospital Episode Statistics database. This database provides the most complete coverage of all areas of hospital inpatient services; these services account for up to 70% of the health care budget. Several studies have investigated the integrity of these data, but they have been concerned only with a subset of the data or with particular hospitals. This paper derives a method of data validation that can be applied either regionally or nationally to two key fields within the database: in this instance, consultant specialty and principal diagnosis. The process uses the Mantel-Haenszel odds ratio estimate to reveal large anomalies within either specialty of diagnostic coding. Within the West Midlands, it was generally observed that diagnosis codes are coded more consistently than consultant codes. However, problems occur due to incomplete or incorrect diagnostic entries and these anomalies are irregular across provider units. In contrast, anomalies within Korner specialty codes are associated predominantly with maternity, obstetrics, geriatric and general medicine. A large number of these anomalies are well understood within the context of local practice variation. Nevertheless, many anomalies remain within a wide range of other specialties where further investigation is warranted. Where systematic error is found, provider units should be notified in order to improve data consistency and enhance quality for future data users and health care planners. PMID- 10168965 TI - Tips on structuring a telemedicine program. AB - This article is the first in a two-part series on telemedicine programs. In this issue, the technological aspects of telemedicine and its advantages and disadvantages are presented. Part II, in the September issue, will focus on the legal issues of telemedicine. PMID- 10168966 TI - Case management finds success in a university hospital. PMID- 10168967 TI - Perspectives. Risky business: Maryland's new Medicaid program. PMID- 10168968 TI - Marketplace. Utah and Maryland pioneer new look in HMO report cards. PMID- 10168969 TI - Promoting library services to qualified nurses: towards a market-led approach. AB - This article summarizes a research project carried out with the nursing staff of South Buckinghamshire NHS Trust. A 'community profile' looked at nurses' use of library and information services for patient care purposes and found that only a small portion of all categories of qualified staff were library users. A postal questionnaire was used to investigate why nurses sought information, what they used it for, where they obtained it from and how valuable they perceived it to be. The results shown that personal and departmental collections were used quite frequently and the information was widely disseminated by the nurses to patients and their families, to colleagues and to students. The overall message from the survey was that the information obtained is valued highly and is used for various important purposes in health care delivery, such as educating patients and their families and revising treatment plans. However, nurses have difficulty in accessing libraries, which are judged to contain the most accurate, reliable and up-to-date information. The data from the community profile and questionnaire were further analysed using soft systems methodology, in order to identify problems in the traditional model of information delivery to nurses via conventional library and information service. These were then investigated further and a series of recommendations for action drawn up. PMID- 10168970 TI - EVINCE: The value of information in developing nursing knowledge and competence. AB - The aims of the EVINCE research project included examination of the impact of information on the clinical knowledge and practice of nurses, midwives and health visitors. EVINCE (Establishing the Value of Information to Nursing Continuing Education) was funded by the British Library R&D Department for 1 year, from 1 November 1995 to 31 October 1996. The methods employed (based on those used in the Value project) included a critical incident type study to establish patterns of information need and use among a random sample of nursing professionals. The nature of the impact of information obtained on present and future competencies was assessed from a survey of the searches and requests presented to library and information services. Nurses, midwives and health visitors did value the information (96% of respondents agreed that there was, or would be an effect on future practice through enhanced competence in one or more areas). The impact findings can be used to guide a more precise assessment of information needs. PMID- 10168971 TI - From vision to reality--managing change in the provision of library and information services to nurses, midwives, health visitors and PAMs: (professions allied to medicine) a case study of the North Thames experience with the Inner London Consortium. AB - One of the North Thames' pioneering consortia, the Inner London Consortium (ILC) is a complex body which includes NHS Trusts with teaching hospital university connections, community-based Trusts and general hospital acute Trusts. Within the consortium there are 12,000 trained nurses, midwives, health visitors and other professional staff working in the professions allied to medicine (PAMs), all of whom require access to and provision of appropriate library information services. In 1994, taking into account experiences elsewhere in the Region and nationally, it became clear that library issues were complex and would become acute with the move of nursing libraries from ILC Trust sites over a very short timescale. A report on the issues commissioned by the Consortium recommended that a library project, which built on existing NHS Trust PGMDE funded library resources and moved these to a multidisciplinary base to serve the consortium membership, be implemented. The objective of providing access to library information services for nurses and PAMs was achieved. Successes that emerged from the implementation included: The registration in Trust libraries of almost 12 000 new members within the initial 6-month monitoring period. The development of service level agreements and standards for the delivery of services to these new user groups. This paper describes the processes behind these significant and complex changes. PMID- 10168972 TI - Information for trained nurses in remote areas: do electronically networked resources provide an answer? AB - This paper reports on a research project which examined the potential of the Internet, and other networked information resources, to improve access to information for trained nurses working in remote areas. This paper provides a review of current literature in the field. It describes the research carried out, presents a summary of the research findings and discusses the implications of these findings. The paper concludes that the Internet and networked resources do have considerable potential to improve access to information for nurses working in remote and rural areas. However, information skills, along with professional guidance, are also required. PMID- 10168973 TI - Implementing access management strategies. PMID- 10168974 TI - The hospital evolution to discharge planning automation. AB - An automated discharge planning system generates significant productivity benefits to hospitals committing to the process. It also allows full interactive communication to track patients at any level in the continuum of care. Not every hospital today is capable of operating in a network environment. In addition, many ECOs are not currently equipped to participate in the discharge planning process using personal computers. Capital investment costs present an obstacle to some providers contemplating participation in the process of interactive discharge patient information exchange through the continuum. Yet external pressures continue to mount for improved healthcare process productivity. As a result, both hospitals and extended care organizations seem likely to increasingly rely on automation of the discharge planning process in order to operate and compete effectively as the healthcare industry continues its evolution. PMID- 10168975 TI - Reducing appointment no-shows and same-day cancellations. PMID- 10168976 TI - American Health Information Management Association. Issue: Quality healthcare data and information. PMID- 10168977 TI - Practice brief. Issue: Master Patient (Person) Index (MPI)--recommended core data elements. American Health Information Management Association. PMID- 10168978 TI - Managing clinical data: a cancer registries update. PMID- 10168979 TI - Overview of trauma registries in the United States. PMID- 10168980 TI - Implementing a data management education program. PMID- 10168981 TI - Implementing the wireless computerized patient record. Interview by Harry Rhodes. PMID- 10168982 TI - FORE resource update: clinical data management. PMID- 10168983 TI - AHIMA provides testimony on coding/classification issues pertaining to HIPAA (Health Insurance Portability and Accountability Act of 1996) implementation. AB - In summary, AHIMA has identified the following key issues: Uniformity and consistency must be required of all health-care organization, payers, and other data users. A central authority, comprised of representatives from the public and private sector, should be created to ensure compliance with and enforcement of coding system rules and official coding guidelines. A realistic implementation plan for the introduction of any new coding system, including migration to a single procedural classification system, must be established. Since data quality is based on the data source, clinical vocabulary, and classification system, it is important not to focus on only one component. A standard data set must be established. It is important to maintain data comparability with other nations in order to conduct global research studies. AHIMA has had a long-standing relationship working with the department on coding and classification issues and is committed to providing assistance to carry out out the requirements of the law. PMID- 10168984 TI - Collaboration: a framework for clinical quality improvement. AB - Healthcare organizations are being challenged to find ways to leverage improvement efforts. Collaboration offers an avenue for working together toward a common goal. Healthcare leaders can initiate collaborative projects to analyze common clinical problems and to share best practices. This article describes how a Catholic healthcare system successfully initiated a systemwide collaborative clinical quality improvement project to deal with patient falls. PMID- 10168985 TI - The road to commendation by the Joint Commission. AB - Undergoing a survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is an arduous and grueling task. In many healthcare settings, there is more emphasis than ever before on achieving commendation status, which is the highest rating possible from JCAHO. This article chronicles one hospital's journey toward receiving accreditation with commendation and is applicable to any hospital preparing for its own survey. PMID- 10168986 TI - Performance improvement through self-paced learning. AB - Organizations are facing the economic challenges of managed care while employees are facing the domino effect. Both are having an arduous time with changes in healthcare delivery. Employees don't automatically fall into line with strategic plans for organizational change. They need current information and assistance into obtaining the necessary training related to their jobs. How does a medical center help employees to integrate the organization's mission, vision, and values into all work processes in ways that meet their needs? Adult learners need to know why they need to grasp the concept of managed care and how they can apply it on the job. PMID- 10168987 TI - Transferring management technology: healthcare quality improvement education in central and eastern Europe. AB - The newly independent nations of the former Soviet Union continue to restructure and refine their political and economic environments. Competition for scarce of dwindling economic resources within these nations and between the nations of an expanding global community necessitates that they adopt more efficient and effective management methods to provide essential public services. As a result, organizational management concepts developed and used in the West (i.e., in the United States and the countries of the European Union) are eagerly sought for incorporation into new administrative systems. This is an opportune time for healthcare service management educators to develop and present total quality management (TQM) programs, stressing continuous quality improvement (CQI) methods specifically targeted and adapted to the organizational needs of these countries, as they restructure their societies from centrally planned to market-driven economies. In general, educators in healthcare service management, acting as information consultants, can play a pivotal role in guiding strategies for healthcare organizational change and in helping to stabilize transitional organizational processes, by providing guidelines that can improve utilization of healthcare resources and monitoring of healthcare service outcomes. Most of the observations and recommendations presented in this article are derived from the author's experiences in conducting healthcare management improvement projects in Bulgaria in 1993 and in Lithuania since 1991. PMID- 10168988 TI - Value-based cost management: the foundation of a balanced performance measurement system. AB - Healthcare organizations need critical performance measures if they are to lead, manage, and operate effectively. Traditional financial measures or report cards on patient satisfaction and clinical outcomes are insufficient, however. Value based cost management directly links cost accounting, processes, clinical outcomes, and patient and employee satisfaction through organizational, work environment, and financial relations measures. These measures address three levels of performance: strategic, diagnostic, and operational. Their linkages identify value in three areas: business-related financial and operational measures; employee-related measures such as those related to satisfaction and well-being; and learning and patient-related measures linked to clinical outcomes, satisfaction, and population. PMID- 10168989 TI - Evolution of computer-based information systems and networks to support integrated health care delivery systems. AB - As health care delivery systems become more integrated with an emphasis on community wellness and prevention, well-developed information infrastructures will be needed to support their activities. The article introduces several previously published independent models for the evolution of integrated delivery systems, computer-based patient records (CPRs), and health information networks as well as a summary model that illustrates the relationship among these entities and their somewhat parallel development. PMID- 10168990 TI - Models for evolving community health information networks. AB - Community stakeholders, from hospital systems to independent physicians, from self-insured employers to managed health plans, from government agencies to consumers, require access to health information across the continuum of care. As the information highways for organizations and communities, health information networks and community health information networks have become the vehicles to address this growing health information imperative. Research identified more than 500 health information networks in all 50 states and most metropolitan markets. Health information networks vary widely in their definition, strategy, and operational status. Despite tumultuous change with both successes and failures, health information networks are indeed affecting health care delivery within enterprises and local communities, across regions, and on a national scale. PMID- 10168991 TI - Developing a health information network within an integrated delivery system: a case study. AB - Changes in the health care environment, such as the growth of integrated delivery systems and the proliferation of managed care, are having a profound impact on the way in which health care organizations manage both clinical and financial information. Health information networks (HINs) are emerging to support the goals and internal needs of integrated delivery systems. In this environment, health care managers must assume a leadership role in planning for the development of HINs. The article provides an overview of the principal issues that should be addressed in an organization's information systems plan when a HIN is being developed and includes a case study that illustrates the key points discussed. PMID- 10168992 TI - Facilitating linkage through universal patient identifiers: a difficult endeavor. AB - The article discusses the creation and use of universal patient identifiers to facilitate the linkage of patient records from all the components of the health care delivery system. The benefits and disadvantages of using a national health identifier that uses the Social Security number are discussed. A number of universal patient identifier proposals are presented to illustrate the complexity of the issue. The article concludes with a discussion of what health information managers can currently do in their own facilities to facilitate access to integrated information. PMID- 10168994 TI - Legal review: protecting the confidentiality and integrity of patient records. AB - Computerized patient records, like paper-based records, are subject to a number of security threats. In the context of health care networks, such as integrated delivery networks, special precautions are required to protect both the confidentiality and the integrity of patient records. The article discusses the principle threats to networked patient data and recommends practical steps to reduce the inherent risks. PMID- 10168993 TI - Internet policy and procedures for health care organizations: the approach of Partners Healthcare System, Inc. AB - The internet, and in particular the World Wide Web, are becoming significant elements of health care organization's strategic information technology plans. The Internet, although having great potential, also poses risks to the organization, and its use must be managed. The article discusses the Internet policies and procedures developed by Partners Healthcare System, with emphasis on the philosophies behind and the major components of the policies and procedures. PMID- 10168995 TI - State regulation of capitated reimbursement for physician-hospital organizations. PMID- 10168996 TI - The Boren Amendment and data envelopment analysis. PMID- 10168997 TI - Healthcare organizations and 501(C)(3): uncertainty in the post-Geisinger world. PMID- 10168998 TI - Nonprofit hospitals and the federal tax exemption: a fresh prescription. PMID- 10168999 TI - The role of placental examination and its pathology in obstetric risk management. AB - The placenta is a marker of biologic events that occur during pregnancy. Placental pathologic examination gives insight to pregnancy-related insults, which affect the newborn at and after birth. Clinicians and risk managers can use this information to identify the cause of newborn complications in cases suggested to be birth-related injuries. PMID- 10169000 TI - The impact of inefficient clinical diagnosis on the cost of managing low back pain. AB - The clinical examination remains the pivotal factor in evaluating low back pain (LBP) for decisions concerning compensation and rehabilitation. Many practitioners believe it to be highly reliable, even though existing literature does not support this belief. Not only are there no data supporting the efficacy of clinical diagnosis for LBP, but also published data underscore its many inherent weaknesses. Healthcare risk managers need accurate clinical information to make decisions. If current clinical information is unreliable, then healthcare risk management strategies for LBP must be revised. This article reviews the work of many researchers in their attempts to unravel the problem of diagnosing LBP. The following conclusions were reached: The problem is significant and continues to increase. The problem is rooted in the clinician's strong dependency on reported pain, which may not always be a reliable source of objective information. Quantification of the impact of the objectivity of reported pain on clinical performance demonstrates the need for a independent source of functional data that can improve the diagnosis. Technology exists to complement the clinical examination, improve clinical performance, and thus reduce the cost associated with LBP management. The research results presented in this article unveil disturbing findings for healthcare risk managers. The strong bias clinicians reserve for reported pain may lead them to overrate pathology, treat patients inappropriately, prescribe unnecessary imaging tests, and generate unfounded medical opinions that are responsible for many disputes. Data are presented to demonstrate the financial benefits that result from the introduction of systematic objective controls via technology. These sound management principles allow the risk manager to determine the validity of claims and treatment proposals. Risk managers can then make informed decisions on contentious claims and regulate the large number of clinician-supported disability cases--decisions that represent significant savings. PMID- 10169001 TI - Managed care physician organizations: next generation of healthcare reform. AB - This article focuses on the evolution of physician-sponsored organizations in the managed care continuum. Given the amount of influence that physicians have on the overall level of healthcare expenditures within the U.S. economy, physician commitment to the managed care process is critical to truly drive the next round of managed care initiatives. The capital markers have recognized this and have contributed significant amounts of capital to fuel the development of for-profit models called physician practice management companies. PMID- 10169002 TI - Nursing home may be guilty of "dumping" patient. Haleyville Health Care Center v. Winston County Hospital Board. PMID- 10169003 TI - Allegations of sexual misconduct: a risk management perspective. AB - Increasingly, patients are making complaints to state licensing boards and filing lawsuits against healthcare providers alleging sexual misconduct. This article addresses the risk management implications of patient allegations of sexual misconduct involving inappropriate touching by healthcare providers during an examination or treatment. From a risk management standpoint, techniques can be implemented before and after these incidents that can help reduce the facility's exposure. PMID- 10169004 TI - Reducing the need for authorization and referral management. PMID- 10169005 TI - Facts and figures. Infant health in the United States. PMID- 10169006 TI - Health care systems reach out over the Internet: Part I. PMID- 10169007 TI - A case study in earnings: the Coventry story. PMID- 10169008 TI - Homeopathy within alternative and orthodox care. AB - The increasing demand for treatment by alternative care practitioners has resulted in MCOs marketing networks of acupuncturists, herbalists, massage therapists, and others to their members. However, before an alternative provider network is considered, one must understand the comparisons and contrasts between conventional biomedical-based therapy and alternative care techniques. In the conclusion of a two-part article, the author delves into the practice of homeopathy. PMID- 10169009 TI - Can managed care put genetic testing to good use? PMID- 10169010 TI - Primary care guidelines. PMID- 10169011 TI - Pharmacologically rich clinical decision support provides extra measure for managed care success. AB - Gatekeepers are currently being asked to do more, including managing referrals to specialists. When a physician appropriately continues care at the primary level in order to pursue a more conservative course of treatment, prescription drugs often play an important role. According to the author, physicians can easily turn to utilization management, not disease management programs, for clinical guidance. Adding a pharmaceutical component with clear indications for drug use to the clinical decision support criteria or guidelines used by physicians helps them to decide when a trial of first-line pharmaceutical management is warranted and at what point to switch to an alternative drug therapy or to refer. PMID- 10169012 TI - Challenges for disease management: balancing technology and touch. PMID- 10169013 TI - Telecommunications and disease management in the home environment: new strategies to improve outcomes. AB - This article provides an overview of the issues and effects of principle-centered health care within organized systems of care; portrays a comprehensive disease management framework for home health care; and offers virtual health management, telecommunications, and mobile computing strategies to enable health management enterprises to achieve health and outcomes maximization accountability demands in managed care. PMID- 10169015 TI - AHA's Rick Pollack: President's plan avoids needed Medicare fix. PMID- 10169014 TI - Leave requirements under the Family and Medical Leave Act: a trap for the unwary. AB - The old adage "ignorance of the law is no defense," is certainly true when dealing with the Family Medical leave Act. That is, lack of knowledge does not excuse the failure of the employer to properly designate the leave. Therefore, as an employer, one must be sure to know and follow the Family Medical Leave Act requirements. Not doing so may be a costly mistake. PMID- 10169016 TI - IRS revenue ruling guides recruitment of physicians. PMID- 10169017 TI - Medicare reductions could cost Georgia hospitals more than $1 billion. Is time running out on Medicare? PMID- 10169018 TI - Medicare program; description of the Health Care Financing Administration's evaluation methodology for the Peer Review Organization 5th Scope of Work contracts--HCFA. General notice with comment period. AB - This notice describes how HCFA intends to evaluate the Peer Review Organizations (PROs) for quality improvement activities, under their 5th Scope of Work (SOW) contracts, for efficiency and effectiveness in accordance with the Social Security Act. In accordance with the provisions of the Government Performance and Results Act of 1993, the 5th SOW contracts with the PROs are performance-based contracts. PMID- 10169019 TI - Approval of information collection requirements for the joint interim rules for health insurance portability for group health plans, and the individual market health insurance reform: portability from group to individual coverage; federal rules for access in the individual market; state alternative mechanisms to federal rules--IRS, DOL, HCFA. Interim rules with request for comments; approval of information collection requirements. AB - On April 8, 1997, the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services (Departments) published joint interim rules governing the access, portability and renewability requirements for group health plans and issuers offering group health insurance coverage in connection with a group health plan. The rules implemented changes made to certain provisions of the Internal Revenue Code of 1986 (Code), the Employee Retirement Income Security Act of 1974 (ERISA), and the Public Health Service Act (PHS Act) enacted as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In the April 8 publication, the Departments submitted the group market information collection requirements, for, among other things, establishing creditable coverage, notice of special enrollment rights, and notice of pre existing condition exclusion periods, to be Office of Management and Budget (OMB) for emergency review under the Paperwork Reduction Act of 1995 (PRA 95). In addition, on April 8, 1997 the Department of Health and Human Services submitted the HIPAA individual market information collection requirements to OMB for emergency review under the PRA 1995. This document amends the April 8 Federal Register documents to properly display the OMB control numbers. PMID- 10169020 TI - Children's crusade. AB - There's at least $16 billion available to help more children get health care. But on Capitol Hill, there's a bitter dispute over how the money should be spent. Give the states the money, some say, and let them bolster novel health care programs such as Florida's Healthy Kids. Others want to expand Medicaid. PMID- 10169021 TI - Backing away from Medicare's future. PMID- 10169022 TI - Government Web sites facilitate access to a wealth of medical information. PMID- 10169023 TI - Which MEDLINE? The search for good, fast, cheap access. PMID- 10169024 TI - Gore launches free MEDLINE from NLM. PMID- 10169025 TI - Big savings, better patient care are results of energy saving program. PMID- 10169026 TI - ED redesign puts all patients on fast-track. PMID- 10169027 TI - Re-engineered discharge, UM process cut LOS. PMID- 10169028 TI - Aides critical link in patient satisfaction chain. PMID- 10169029 TI - Before the service encounter. Referral variables influence patient perceptions of a specialist's service quality. AB - Relationships with referring providers are important to specialists for more than just ensuring a supply of incoming patients. They also offer an opportunity to influence the service referral variables, which unfortunately are not under the direct control of the specialist. Target providers must try to "manage" the service referral variables whenever possible. Patients are not objective in their evaluations of service quality, basing decisions solely on the actual service provided. For the endodontists in this study, almost 9% of the variance in service quality scores can be explained by factors related to the referral process alone. Consequently, the evaluation of the service is dependent to a significant degree on what happens before the patient arrives at the office. All of the service referral variables studied--perceived choice, amount of information, and attitude toward being referred to another provider--had at least as much influence on perceived service quality as waiting time did. And, two of the referral variables--perceived choice and attitude toward the referral--were as influential on patients' behavioral intentions as was the perceived cost of the service. PMID- 10169030 TI - Managing perceptions of hospital quality. Negative emotional evaluations can undermine even the best clinical quality. AB - Patients use more than 500 criteria to evaluate a hospital's quality. The authors synthesized these criteria into 14 dimensions to provide the foundation of a new instrument for measuring service quality in health care. Patients use emotional criteria to evaluate technical quality. Therefore, hospitals must not neglect the emotional aspects of cure. Developed around three theoretical components- structure, process, and outcome--the quality dimensions should help hospital marketers pinpoint what is important to patients and how they perceive the service encounter. PMID- 10169031 TI - Preventive maintenance. 'Problem recognition style' can be used to segment the market and promote healthier lifestyles. AB - Problem recognition styles--desired state types (DSTs) and actual state types (ASTs)--have an effect on preventive health care decision making. Segmenting the market along these lines can help marketers position products and services to educate and attract people who will not see a doctor unless there is something wrong with them. Both groups expect the same benefits from preventive health care actions, but ASTs fail to act on those expectations. Therefore, marketing strategy touting the benefits of preventive health care might be futile. Educational promotional campaigns aimed at both DSTs and ASTs also are wasteful because DSTs already possess much health knowledge, lead wellness-oriented lifestyles, and practice preventive health behaviors. PMID- 10169032 TI - Databases put the direct in direct marketing. PMID- 10169033 TI - Using Baldrige criteria for self-assessment. PMID- 10169034 TI - Marketers can counter managed care bashing. PMID- 10169035 TI - Negotiation: bringing more to the table than demands. PMID- 10169036 TI - Targeting Medicare consumers. Managed care providers can make inroads by understanding preference and cost-sensitivity issues. AB - The authors' conjoint study provided valuable information on the preferences of the hugh Medicare-eligible and soon-to-be-eligible markets. Leading the list were hospitalization coverage, skilled nursing facilities, and out-of-area coverage. The task of defining choice sets was made easier and more meaningful by selecting the top six attributes for each respondent. Asking respondents to rank levels within each attribute and assessing the importance of the various levels provided a more robust estimate of consumer preferences. Using an innovative price sensitivity method preserved the integrity of the data. The method minimized respondent fatigue and enabled the authors to gather price-sensitivity data from respondents who were not actually paying for their health services. Respondents preferred Supplemental F and Medicare products even though they placed more value on the qualities of alternative health care products. This suggests that managed care providers need to change consumer perceptions about their products. PMID- 10169037 TI - Positioning PCNs (primary care networks): understand what MCOs really want. PMID- 10169038 TI - HCFA clamping down on long-term acute care "hospitals within hospitals". PMID- 10169039 TI - A population-based approach to managing risk, access and care in a managed care market. PMID- 10169040 TI - Rationally assembled and configured assets enable truly integrated delivery. PMID- 10169041 TI - MCOs won't drive many docs out of medicine. PMID- 10169042 TI - Health promotion. Feelgood factors. AB - Half the targets in The Health of the Nation have already been, or are set to be, achieved by the specified date. Deaths from strokes, smoking, fat consumption, and accidents among elderly people are all falling-but not fast enough to meet targets. Obesity, drinking, skin cancer and smoking among 11 to 15-year-olds are all increasing. PMID- 10169043 TI - Accident and emergency. A godsend for the East End. AB - A primary care unit established in an A&E department is well attended and has cut waiting times. Nurse practitioners running the unit have powers to prescribe and refer to specialists. The unit reflects growing recognition that A&E departments must serve patients previously considered the responsibility of GPs. PMID- 10169044 TI - Mental health. Changing of the old guard. AB - Government policy requiring community mental health nurses to target services to patients with severe mental health problems demands considerable change. The proposed ways of working have implications for other parts of the mental health services and those referring patients to them. A service review should involve and inform all those affected. PMID- 10169045 TI - Medical education. Early learning centres. PMID- 10169046 TI - Locality commissioning. Local heroes. PMID- 10169047 TI - Out-of-hours care. Night and day. PMID- 10169048 TI - Data briefing. No smoke without fire. PMID- 10169049 TI - NHS charges. Light on the charge brigade. AB - Patients charges form a very small part of NHS income. Governments have often used charges to emphasise their commitment to austerity. Knowledge of the effect of charges on public health, equity and eliminating waste is limited. Both Conservative and Labour health ministers have made attempts to abolish charges. PMID- 10169050 TI - Smoke and dust. PMID- 10169051 TI - Primary care. Defining role. AB - There is no nationally agreed definition of nurse practitioners or of the training required. The extent of the need for nurses to take on doctors' work needs to be established. A clear training framework is required. PMID- 10169052 TI - Developing a diversity program. PMID- 10169053 TI - More than art, less than science. The realities of effective post-merger leadership. PMID- 10169054 TI - Medical staff education. PMID- 10169055 TI - Medicare payment for practice expenses. PMID- 10169056 TI - Addressing ethics accusations. PMID- 10169057 TI - American College of Healthcare Executives. Ethical Policy Statement. Ethical Decision making for healthcare executives. August 1993, February 1997 (revised). PMID- 10169058 TI - Finding healthcare information. PMID- 10169059 TI - The human side of change. Managing employee morale and expectations. PMID- 10169060 TI - Structured pluralism: towards an innovative model for health system reform in Latin America. AB - Health systems throughout the world are searching for better ways of responding to present and future challenges. Latin America is no exception in this innovative process. Health systems in this region have to face a dual challenge: on the one hand, they must deal with a backlog of accumulated problems characteristic of underdeveloped societies; on the other hand, they are already facing a set of emerging problems characteristic of industrialized countries. This paper aims at analyzing the performance of current health systems in Latin America, while proposing an innovative model to promote equity, quality, and efficiency. We first develop a conceptualization of health systems in terms of the relationships between populations and institutions. In order to meet population needs, health systems must perform four basic functions. Two of these financing and delivery-are conventional functions performed by every health system. The other two have often been carried out only in an implicit way or not at all. These neglected functions are 'modulation' (a broader concept than regulation, which involves setting transparent and fair rules of the game) and 'articulation' (which makes it possible to organize and manage a series of transactions among members of the population, financing agencies, and providers so that resources can flow into the production and consumption of services). Based on this conceptual framework, the paper offers a classification of current health system models in Latin America. The most frequent one, the segmented model, is criticized because it segregates the different social groups into three segments: the ministry of health, the social security institute(s), and the private sector. Each of these is vertically integrated, so that it performs all functions but only for a particular group. As an alternative, we propose a model of 'structured pluralism', which would turn the current system around by organizing it according to functions rather than social groups. In this model, modulation would become the central mission of the ministry of health, which would move out of the direct provision of personal health services. Financing would be the main function of social security institutes, which would be gradually extended to protect the entire population. The articulation function would be made explicit by fostering the establishment of 'organizations for health services articulation', which would perform a series of crucial activities, including the competitive enrollment of populations into health plans in exchange for a risk-adjusted capitation, the specification of explicit packages of benefits or interventions, the organization of networks of providers so as to structure consumer choices, the design and implementation of incentives to providers through payment mechanisms, and the management of quality of care. Finally, the delivery function would be open to pluralism that would be adapted to differential needs of urban and rural populations. After examining the convergence of various reform initiatives towards elements of the structured pluralism model, the paper reviews both the technical instruments and the political strategies for implementing changes. The worldwide health reform movement needs to sustain a systematic sharing of the unique learning opportunity that each reform experience represents. PMID- 10169061 TI - Principal-agent problems in health care systems: an international perspective. AB - A central feature of all health care systems is the flow of finances from the population, via a variety of agencies, to the providers of health care. Each transfer of funds within the system involves a principal-agent problem, in the sense that a principal is entrusting funds to an agent with the intention that some desired aspect of health care delivery can be secured. This paper examines within the context of a principal-agent model three key elements of the health care system: the raising of finance, the transfer of funds to hospitals, and spending by hospitals. At each of these stages there is a danger that the objectives of society for the health care system are lost. In order to illustrate the issues involved, five mature systems of health care are examined: Austria, Germany, the United Kingdom, the Netherlands and the United States of America. The paper concludes that three aspects of the flow of funds are crucial to securing adequate control: the means of controlling patient entry to hospitals; the mechanism for remunerating hospitals for additional patients; and the control of physicians by hospital management. PMID- 10169062 TI - Economic evaluations of drug therapy: attitudes of primary care prescribing advisers in Great Britain. AB - All health authorities in Great Britain have both medically or pharmaceutical qualified staff to advise both the authority and the local primary care medical practitioners about drug use and prescribing. This study used a piloted postal questionnaire to assess the attitudes of these advisers to economic evaluations of drug therapy, and their perceptions of the barriers to achieving cost effective prescribing by use of these evaluations. There was a 65% response rate to the questionnaire. Economic issues were rated by advisers to be less important than clinical issues, but were considered at most meetings between advisers and primary care medical practitioners. Advisers wished to consider true cost effective prescribing but often felt obliged to consider drug acquisition costs and risks of budgetary overspends. The perceived inflexibility of existing structures within the British National Health Service and the lack of credibility of the evaluations (often perceived as pharmaceutical industry marketing) were the major barriers to the application of the evaluations. The paper concludes that advisers were keen to use economic evaluations to promote cost effective prescribing but were impeded by the perceived bias of existing studies and by rigid current NHS structures. PMID- 10169063 TI - Biotechnology: a special case for health technology assessment? AB - Many substances produced naturally in a wide range of living organisms have been identified to be of benefit in the treatment of human disease. Current health biotechnologies recreate DNA-recombinant cellular processes in laboratory settings to produce 'natural' therapeutics: these are potentially a step forward from traditional pharmacology which has developed synthetic analogues or sought to extract products from donor material. However, with increasing financial pressures, decision makers require evidence that the benefits of biotechnologies justify their costs. The challenges experienced when evaluating the cost effectiveness of biotechnologies are explored with reference to three examples: HA-1A human monoclonal antibody, erythropoietin and DNase. Difficulties in economic evaluation are similar to those experienced with conventional pharmaceuticals: use of short-term clinical endpoints rather than meaningful health outcomes, the artificial nature of clinical trial protocols, and uncertainty about the applicability of economic data. However, early clinical and economic assessments are required by decision-makers, particularly where biotechnology products fill major gaps in therapy. The financial structure of biotechnology companies may limit movement towards adequate clinical and economic research for health technology assessment. Governments should negotiate with the industry to promote more relevant studies, and develop policies for the managed introduction of products as evidence on effectiveness and cost expands. New technologies often present additional costs requiring reallocation of existing resources. Careful resource planning is required so that cost-effective innovation are not denied to patients. PMID- 10169064 TI - Babies and moms get treated in grand style at Swedish Medical Center. PMID- 10169065 TI - Robbing the cradle. Hospitals have learned the hard way that one baby stolen is one too many. PMID- 10169066 TI - Keeping the peace. PMID- 10169067 TI - Cleanteam. PMID- 10169068 TI - Nuts and volts: searching for ways to zap EMI effects. PMID- 10169069 TI - The dirt on disinfectants--do labels tell the truth? PMID- 10169070 TI - NIOSH alert: preventing allergic reactions to natural rubber latex in the workplace. PMID- 10169071 TI - Computer-based patient records support organizational redesign. PMID- 10169072 TI - Are physicians failing CHF patients? PMID- 10169073 TI - Chest pain protocol passes tests for sensitivity, patient satisfaction. PMID- 10169074 TI - From decision making to choice making: Part 1. PMID- 10169076 TI - How Zantac became the best-selling drug in history. AB - Glaxo's Zantac began its dominance of the acid/peptic marketplace with a launch strategy, taking advantage of the established Roche sales force to rapidly promote the product. Educational symposia for physicians were instrumental in disseminating both disease and product information to primary care physicians and specialists. This technique not only pleased physicians (more referrals), but also increased public awareness of gastrointestinal disease, further expanding the patient market. Several novel marketing strategies contributed to Zantac's success, including the public-service announcements, celebrity media tours, and consumer-awareness bulletins, which brought the drug to the lay public and encouraged individuals to seek advice from their physicians. PMID- 10169075 TI - Happy employees lead to loyal patients. Survey of nurses and patients shows a strong link between employee satisfaction and patient loyalty. AB - A strong relationship exists between employee satisfaction and patients' perceptions of the quality of their care, measured in terms of their intent to return and to recommend the hospital to others. Employee dissatisfaction can negatively affect quality of care and have an adverse effect on patient loyalty and, thus hospital profitability. Therefore, health care marketers should regularly measure employee satisfaction as one way to monitor service quality. Health care marketers must work more closely with their human-resource departments to understand and influence employees' work environment and maintain a high level of job satisfaction. Marketers also should place an increased emphasis on both employee and patient perceptions of satisfaction when developing internal and external strategic marketing plans and formulating future research. PMID- 10169077 TI - A quality tool for health insurers. A new scale measures "quality orientation" from the customer's point of view. AB - This study defines a company's quality orientation as "all process-related activities that can be discerned by customers." This even includes certain processes internal to the company that can be seen and evaluated by customers. One significant contribution this study provides is scale development centered on customer rather than employee perceptions. To generate scale items, input was gathered from experts involved in the study, senior managers employed with the target company, focus groups of employees working on the front line with customers, and users of the services. Because the sale measures customer perceptions of quality in comparison with the firm's closest competitor, it provides managers with information for benchmarking performance relative to others in the marketplace. PMID- 10169078 TI - Partnerships: the prescription for healthier communities. PMID- 10169079 TI - Researching high-risk groups. PMID- 10169080 TI - Hospital marketing and the Internet. PMID- 10169082 TI - Joint Commission and CARF (Commission on Accreditation of Rehabilitation Facilities) establish combined survey process for rehabilitation hospitals. PMID- 10169081 TI - Clinton, health care, and the crystal ball. With the Democrats back in power, where do we go from here? AB - Although Clinton's Health Security Act was unsuccessful, the President's first term did see considerable headway in health care policy, including the Health Insurance Reform Act, the Family and Medical leave Act, and improvements to both Medicare and Medicaid programs. Whether the result of a federal reform plan or free-market forces, efforts to control health care costs hinge on continued growth of managed care. Capitation is the wave of the future, according to some experts. America's aging population is rapidly overwhelming the Medicare Hospital Insurance Trust Fund. Clinton's balanced-budget proposal would keep Medicare solvent until 2006, while a bipartisan committee devises a long-term plan. Options for relief, however, are limited to increasing revenues by raising premiums and copayments or by decreasing spending. PMID- 10169083 TI - Standards for advance directives clarified. PMID- 10169084 TI - Pharmacies providing respiratory medications to patients in their home now eligible for accreditation. PMID- 10169085 TI - Striving for better compliance: tips on 10 most challenging behavioral health care standards. PMID- 10169086 TI - Approaches to reducing medication errors. PMID- 10169087 TI - Future of long-term care service continuum explored. PMID- 10169088 TI - The Sentinel Event Policy: a work in progress. PMID- 10169089 TI - Hospital introduces practical approach to interactive patient education. PMID- 10169090 TI - Revised Sentinel Event Policy features Accreditation Watch provision. PMID- 10169091 TI - Medical insurance and the use of health care services by the elderly. AB - The objective of this paper is to find how health insurance influences the use of health care services by the elderly. On the basis of the first wave of the Asset and Health Dynamics Survey, we find that those who are the most heavily insured use the most health care services. Because our data show little relationship between observable health measures and either the propensity to hold or to purchase private insurance, we interpret this as an effect of the incentives embodied in the insurance, rather than as the result of adverse selection in the purchase of insurance. PMID- 10169092 TI - Standard gamble, time trade-off and rating scale: experimental results on the ranking properties of QALYs. AB - This paper compares the relative performance of quality adjusted life years (QALYs) based on quality weights elicited by rating scale (RS), time trade-off (TTO) and standard gamble (SG). The standard against which relative performance is assessed is individual preference elicited by direct ranking. The correlation between predicted and direct ranking is significantly higher for TTO-QALYs than for RS-QALYs and SG-QALYs. This holds both based on mean Spearman rank correlation coefficients calculated per individual and based on two social choice rules: the method of majority voting and the Borda rule. Undiscounted TTO-QALYs are more consistent with direct ranking than discounted TTO-QALYs. PMID- 10169093 TI - Medicare's disproportionate share adjustment and the cost of low-income patients. AB - We investigated whether or not hospitals have higher costs for inpatient care provided low-income Medicare patients, after controlling for other cost differences already accounted for by Medicare payments. We estimated differences in Prospective Payment System-adjusted costs and outlier-adjusted length of stay for low-income patients relative to matching non-low-income cases from the same hospital in 85 high-volume diagnosis-related groups (N = 1,247,670). Low-income Medicare patients do not have costlier hospital stays, although their stays are 2.5% longer. We conclude that disproportionate share payments are not justified on grounds of higher treatment costs. PMID- 10169094 TI - HMOs, moral hazard and cost shifting in workers' compensation. AB - Previous research has shown that workers respond to the economic incentives provided in workers' compensation. In particular, claim frequency rises with increased benefits, and claim duration, on net, seems to increase. Here we provide additional evidence of another incidence of behavioral responses to incentives. We find that doctors in health maintenance organizations (HMOs) have a greater tendency to classify claims as compensable under workers' compensation than do other physicians. Our evidence suggests that the rapid expansion of HMOs over the 1980-1990 period resulted in a significant increase in workers' compensation claim frequency. PMID- 10169095 TI - Is health care really a luxury? AB - Much of the work which has led to a widely held view that the income elasticity of health care spending exceeds one has been based on international cross-section data, or on pooled cross-sections and time series. In this paper we re-examine this view in the context of long-run equilibrium relationships between non stationary time series, possibly including autonomous trends. Our results cast doubt upon the usefulness of pooling and upon the notion of an elasticity above one. PMID- 10169096 TI - The effect of price on switching among health plans. AB - A recent policy change by the University of California (UC) provides a unique natural experiment for investigating the sensitivity of consumers to health plan premiums. When the UC moved to a policy of limiting its contribution to the cost of the least expensive plan, out-of-pocket premiums increased for roughly one third of UC employees. We examine the extent to which UC employees switched plans in response to this change in premiums. Our results indicate a strong response. Individuals facing premium increases of less than $10 were roughly 5 times as likely to switch plans as those whose premiums remained constant. PMID- 10169097 TI - The effect of a private sector on the waiting time in national health service. AB - This article examines the effect of a private sector on the waiting time associated with treatment in a public hospital. Without rationing of waiting-list admissions, a private sector is shown to result in a longer waiting time if the demand for a public treatment is sufficiently elastic with respect to the waiting time. When waiting-list admissions are rationed, the waiting time is shown to increase if the public sector consultants are permitted to work in the private sector in their spare time. PMID- 10169098 TI - Altruism or moral hazard: the impact of hospital uncompensated care pools. AB - Empirical evidence from New Jersey supports theories of hospitals altruism. From 1987 to 1992, New Jersey reimbursed hospitals for uncompensated care through the Uncompensated Care Trust Fund. The Trust Fund reduced the shadow price of charity care, inducing hospitals to increase their provision of uncompensated care. Hospitals increased inpatient uncompensated care by an average of 14.8% and statewide uncompensated care increased by $360 million during 1987-1990. Empirical evidence suggests that the state effectively addressed the moral hazard problem created by the Trust Fund by auditing uncompensated care and regulating hospital collection procedures. PMID- 10169099 TI - Hospital-insurer bargaining: an empirical investigation of appendectomy pricing. AB - Employers' increased sensitivity to health care costs has forced insurers to seek ways to lower costs through effective bargaining with providers. What factors determine the prices negotiated between hospitals and insurers? The hospital insurer interaction is captured in the context of a bargaining model, in which the gains from bargaining are explicitly defined. Appendectomy was chosen because it is a well-defined procedure with little clinical variation. Our results show that certain hospital institutional arrangements (e.g. hospital affiliations), HMO penetration, and greater hospital concentration improve hospitals' bargaining position. Furthermore, hospitals' bargaining effectiveness has diminished over time and varies across states. PMID- 10169100 TI - Genetic information and investment in human capital. AB - In a game of incomplete information we analyze the consequences of giving an employer access to imperfect genetic information about his employees. The employer chooses whether to invest in the employee and the employee chooses a life style. We derive the condition for markets of information services to exist and the conditions for when it is beneficial to the various parties. In one specification of the game, the mere introduction of the information service may change the employee's choice of health behavior, which means that the value of genetic information may be negative to the employer. PMID- 10169101 TI - The effect of HMOs on fee-for-service health care expenditures: evidence from Medicare. AB - This paper examines the relationship between HMO market share and fee-for-service health care expenditures using 1986-1990 county- and metropolitan statistical area-level data on Medicare expenditures and HMO market share. Fixed-effects estimates imply that fee-for-service expenditures are concave and decreasing in market share. Increases in market share from 20% to 30% are associated with 3-7% expenditure reductions. Instrumental variable estimates that exploit cross sectional variation in HMO activity also indicate a concave relationship, with expenditures declining in market share for market shares above 15-18%, but imply larger expenditure responses to market share changes. PMID- 10169102 TI - Too many for too few? Efficiency among dentists working in private practice in Norway. PMID- 10169103 TI - How my practice profile almost got me fired. PMID- 10169105 TI - 'You're no longer a doctor: you're a damn administrator". PMID- 10169104 TI - Making doctors' lives easier--and patients happier. PMID- 10169106 TI - Luring seniors into managed care. PMID- 10169107 TI - The second-generation IPA: will it save independent practice? PMID- 10169108 TI - Don't let that high starting salary fool you. PMID- 10169109 TI - Medical practice. Has managed care really hurt it? Even doctors can't agree. PMID- 10169110 TI - Physician recruitment. Is the drive to build primary-care networks slowing down? PMID- 10169111 TI - Can Washington make medical records private again? PMID- 10169112 TI - The best way to improve your staff's efficiency. PMID- 10169113 TI - Marketing moves that backfire. PMID- 10169114 TI - Informed consent will require more informing. PMID- 10169115 TI - Worrying about Medicare. PMID- 10169116 TI - Provider affiliations in managed care. PMID- 10169117 TI - Opportunities in Medicare for federally qualified health centers. AB - Competition for Medicaid managed care recipients has cut into the resources traditionally available to safety net providers. At the same time, a lack of primary care providers in many rural areas has increased the demand for federally funded community health centers to serve senior citizens. To meet the needs of the communities they serve and to maintain revenue streams, community health centers are increasingly serving the Medicare population. PMID- 10169118 TI - Physician motivation, satisfaction and survival. AB - Physicians are working harder today and enjoying it less. What has happened to create such dissatisfaction among those in one of the most autonomous professions? What can be done to address the anger, fear and unhappiness? This article is an analysis of the factors influencing human motivation. Maslow's hierarchy of needs--physiological, safety/security, social/affiliation, esteem and self-actualization--is used to suggest ways physicians can satisfy their needs in turbulent financial and professional times. PMID- 10169119 TI - Managing resources. Directing patients to appropriate specialist care. AB - Patients and physicians are wary that managed care will unnecessarily limit access to specialists. At the same time, there is a recognized need to control medical costs. Clinical decision support criteria can help group practices achieve balance between clinical protocol and cost management. They help protect against over- and underutilization of resources, including specialist care. They also help physicians justify care decisions to the patient and to the health plan providing payment. PMID- 10169120 TI - Reimbursement comes of age. EMPOWER: a management information system. AB - A management information (MI) system for general and academic medical practices is imperative in a changing environment. Funded by a grant from the MGMA Academic Practice Assembly, EMPOWER is relevant to all types of medical practice. The software package supports financial/time allocation models, income/expense models and incentive cost center approaches. PMID- 10169121 TI - Have your capitations been HIPAA'd? Health Insurance Portability and Accountability Act. PMID- 10169122 TI - On the road with MGMA (Medical Group Management Association). AB - Preparing for the annual conference, members of the 1996 Annual Conference Committee traveled the country interviewing members. They discovered innovative work in rural and urban settings, multispecialty practice and physician-directed insurance companies. Richard Hansen presents his snapshots from the trip. PMID- 10169123 TI - An emerging niche market opportunity. Part I. AB - Society is split between a desire for access to quality health care and a reluctance, by some, to pay for it. Looking at this cost/access dichotomy historically enables one to recognize an emerging niche market--discriminating, affluent consumers willing to pay for better health care. PMID- 10169125 TI - Budget-battle aftermath. AHA criticized for failing in patient-transfer payment fight. PMID- 10169124 TI - The physician manager. Practice management education in the 21st century. AB - Are physicians prepared to operate competitively for the 21st century? Not according to a recent survey completed by the Society of Physicians in Administration's (SPA) membership. In fact, as far back as the 1980s, physician surveys indicated that third-year physician residents and recent graduates felt their training in practice management was inadequate. Understanding practice management issues would improve a physician's chances for success. According to the SPA survey, however, most medical schools and residency training programs don't offer courses in management. PMID- 10169126 TI - Cost reports next weapon in fraud war. PMID- 10169127 TI - Back to basics. Reform plan sees Columbia shifting operational focus. PMID- 10169128 TI - More HMO backlash. Ariz. case applies malpractice to medical directors. PMID- 10169129 TI - Sharing the burden. Mass. law makes payers give $100 million to indigent fund. PMID- 10169130 TI - New Medicare options in budget law. PMID- 10169131 TI - Repeal of 'Boren amendment' raises fears. PMID- 10169132 TI - Focus report. CON survival struggle. Certificate of need: gone in many states but not dead yet. PMID- 10169133 TI - Bubbling over again. Property-tax issues heat up in Idaho, Pennsylvania. PMID- 10169134 TI - AHA plan to sell old HQ gets lift. PMID- 10169135 TI - The feud continues. Physician groups at odds over failed Medicare maneuver. PMID- 10169136 TI - Weaving a new net. Web browser technology holds promise to become all-purpose information tool. AB - Healthcare systems are adapting the "browser" technology that simplified use of the Internet to weave new webs--known as "intranets"--among their provider and facility networks. Browsers eventually will be tapped to deliver information at the point of care, making them an all-purpose tool to reshape clinical practice by providing just the right data at just the right time for a diagnosis or treatment decision. PMID- 10169137 TI - Going mainstream. Consumers opening minds, wallets to alternative care. PMID- 10169138 TI - Quicker fix for back pain. Device speeds healing, but docs crave competition. PMID- 10169139 TI - What's right, wrong? Calif. task force taking a close-up look at managed care. PMID- 10169140 TI - Switching to a 401(k). Post-merger conversion of retirement plans can be tricky. PMID- 10169141 TI - Feds' fraud cases boom in '90s. PMID- 10169142 TI - Blues HMO in limbo. Mass. Medicare plan, stuck in probe, loses key provider. PMID- 10169143 TI - Medicare, plus choice. Addition of MSAs, PSOs, other options complicate enrollment with new deadlines. PMID- 10169144 TI - No honor students. Healthcare lobbyists earned barely passing grades in latest federal budget debate. PMID- 10169145 TI - Home health heats up. Survey finds massive change at industry's door. AB - Modern Healthcare's annual Home Care and Durable Medical Equipment Providers survey found massive change at the industry's door. Intensified government scrutiny has Columbia/HCA Healthcare Corp. putting its $1 billion home-care division on the selling block, and continuing anti-fraud efforts may prompt other hospital systems to step back from the home-care business, too. PMID- 10169146 TI - More execs depart as Columbia's troubles mount. PMID- 10169147 TI - End-of-life training. N.Y. med schools to join on improving palliative care. PMID- 10169148 TI - Ties that bind. BJC sees outcomes efforts as drivers of integration. PMID- 10169149 TI - By the numbers. Medicare cost reports yield wealth of data, frequent disputes. PMID- 10169150 TI - Quid pro quo? Senate panel probes nursing home donations to Democrats. PMID- 10169151 TI - Home court advantage? Judge in Long Island antitrust case has N.Y. hospital ties. PMID- 10169152 TI - Appropriate data tools improve claim processing. PMID- 10169153 TI - Lighting the path to a safe workplace. PMID- 10169154 TI - Financial services suppliers. PMID- 10169155 TI - Being picky about partners. The success of a network depends on the selection of quality participants. PMID- 10169156 TI - Soliciting feds' good opinion. PMID- 10169157 TI - Taking the fast track to low-cost loans. PMID- 10169158 TI - Turning numbers into pictures of health. Spreadsheet graphics can help track resident health conditions. PMID- 10169159 TI - Recognizing signs of alcohol abuse. PMID- 10169160 TI - Solving problems by asking 'Why'. PMID- 10169161 TI - We can do it! Despite the hard work, trustees embrace the challenge of governance. AB - Being a trustee of a health care organization if hard work. So why do busy professionals give so generously of their time and energy? See what drives your peers to sacrifice their time for the health and well-being of their communities. And don't forget to complete the fax pool at the end of the article! PMID- 10169162 TI - Getting down to basics. Providers reach out to strengthen families. AB - According to two health care execs, a healthy family unit is crucial to the health of a community. Recognizing the impact that divorce and other family stresses can have on health, several providers have decided to reach out to strengthen families before those tensions cause permanent damage. PMID- 10169163 TI - Smart shoppers. What happens when the board, staff, and community work together on a hospital sale? AB - Many communities are protesting the sale of their hospitals to for-profit chains without stopping to consider all the ramifications. But when the board, staff and community work together on a hospital sale, everyone ends up a winner. PMID- 10169164 TI - Does your board have V.A.L.U.E.? PMID- 10169165 TI - New relationships with physicians: an overview for trustees. AB - As resources become increasingly scarce and tightly controlled, health care organizations must integrate their services with those of other providers in order to use those resources more efficiently and to reduce costs relentlessly. One of the most critical and difficult aspects of this integration is with physicians. To effect the level of integration that is needed, new relationships and partnerships between providers and physicians must be created--even as the old models are destroyed. Why is integration with doctors so critical to the success of the health care organization as well as the physicians? The answer comes from a core principle of business economics that states that the fundamental means of production must be controlled by the business. This is absolutely essential if the business has any chance of controlling costs and thriving in a more efficient market. PMID- 10169166 TI - Perspectives. With regulations still unclear, PSOs prepare for Medicare. PMID- 10169167 TI - Ratio analysis for the development office of health care institutions. PMID- 10169168 TI - Surfing the Web: getting our feet wet. PMID- 10169169 TI - How United HealthCare and two contracting hospitals address cost and quality in era of hyper-competition. Case study. AB - Boston Regional Medical Center and Children's Hospital, Columbus, OH, offer models for working with a large managed care organization. PMID- 10169170 TI - "New pay" deployed to advance organizational goals at three California hospitals. PMID- 10169171 TI - A bitter prescription. Faced with several federal probes into its practices, Columbia/HCA Healthcare ousts its dynamic CEO. PMID- 10169172 TI - Beyond cholesterol. PMID- 10169173 TI - A problem-solving approach to depression treatment in primary care. AB - Pharmacotherapy coupled with supportive behavioral change therapy is "the most promising treatment" for managing depression in the primary care setting, according to a psychologist at Group Health Cooperative of Puget Sound. GHC offers solution-oriented therapy and interactive educational materials to help patients identify and manage lifestyle issues that contribute to their depression. PMID- 10169174 TI - New guidelines will identify two million more diabetics. PMID- 10169175 TI - A self-rating tool for patients suspected to be suffering from depression. PMID- 10169176 TI - Identifying and caring for depressed patients: healthcare organizations try new approaches. AB - Depression is one of the most common and most expensive illnesses facing our society. Yet mounting evidence suggests that patients suffering from depression are seriously undertreated. To better control costs and improve patient outcomes, healthcare organizations are rolling out new depression initiatives as part of their long-term strategic quality plans. The most effective treatment models focus on educating primary care practitioners to recognize the many--and often subtle--symptoms of depression and involving behavioral health specialists, when needed. PMID- 10169177 TI - Helicopter dispatch: a time study. AB - PURPOSE: To quantitate request to liftoff (R/L) and dispatch to liftoff (D/L) times and reasons for delay in an active air medical transport program. METHOD: This was a prospective observational study blinded to crew and pilots. Data were collected by the communications department during a 4-week period on 197 consecutive missions. RESULTS: The air medical helicopter program services 25,000 square miles with four BK 117 helicopter each staffed by nurse/paramedic crew. During the study period, R/L and D/L averaged 10.9 and 6.8 minutes, respectively. One hundred and twenty-two flights had an R/L of 10 minutes or less for an average R/L of 7.2 minutes and D/L of 5.9 minutes. Seventy-five flights had an R/L greater than 10 minutes, for which reasons included weather check--21; standby by requestor--27; all ships in flight--5; receiving facility delay--4; mechanical problems--4; original ship diverted--2; additional fuel needed--1; airport clearance--1; and no specific reason given--10. CONCLUSION: Most variance occurred in R/L rather than D/L. Evaluating R/L time not only provides a better indication of program activity but also identifies most delays. It appears reasons for delay are limited, which should allow development of a concise plan to overcome them. PMID- 10169178 TI - Reduced emergency department stabilization time before cranial computed tomography in patients undergoing air medical transport. AB - INTRODUCTION: Advanced patient stabilization skills provided by air medical providers were hypothesized to result in streamlined emergency department (ED) stabilization of patients with head injuries requiring urgent cranial computed tomography (CCT). The goal of this study was to compare initial ED stabilization times between air- and ground-transported patients requiring urgent CCT and emergency neurosurgical hematoma evacuation. SETTING: Academic Level trauma center (annual ED census 60,000) receiving patients from ground EMS and a nurse/paramedic air medical transport team. METHODS: This retrospective study identified, from a database of 15 months of ED visits, consecutive group of adults who had CCT performed within 60 minutes of ED arrival and underwent emergent craniotomy for intracranial hematoma. Demographics, hemodynamic status, patient acuity, and time intervals between ED and CCT suite arrivals were compared between air and ground patients using chi-square, Fisher's exact, and t tests (p = 0.05). RESULTS: Eleven air- and 39 ground-transported patients were eligible. All patient acuity data were similar between groups. Air patients were more likely to be intubated (100% versus 71.8%, p = .04) and had shorter mean ED stabilization times (29 versus 40 minutes, p = .02) than the ground. CONCLUSION: This study suggests that advanced patient stabilization offered by air medical transport may result in reduced ED stabilization time for patients requiring urgent craniotomy. PMID- 10169179 TI - Anxiety in adult fixed-wing air transport patients. AB - INTRODUCTION: Critically ill patients may experience anxiety because of the method of transport, possibly having an impact on both patients and their health care providers. The purpose of this research was to study the presence and degree of anxiety in fixed-wing air transport patients. METHODS: Subjects were 41 patients 25 to 79 years of age. Self-ratings of anxiety were obtained and vital signs were recorded at five predesignated points before, during, and after the flight. Additional questions addressed current and previous experiences and perceptions of flying. RESULTS: Anxiety ratings were generally low, averaging approximately 1.9 on a 1 ("worry-free") to 10 ("completely terrified") scale. Anxiety was greatest in anticipation of the flight. Fourteen percent of patients had never flown before; patients with little or no flight experience had significantly higher anxiety ratings. However, in all cases anxiety declined steadily as the flight progressed. Most patients (82%) reported greater worry about their medical condition than about the flight. CONCLUSION: Anxiety is generally low among adult fixed-wing air transport patients and decreases further over time. This decrease was true even for patients who initially reported high levels of anxiety before the flight. The data suggest that previous flight experience can be used to predict anxiety during air medical transport. PMID- 10169180 TI - Are drive-through deliveries so bad? Shorter hospital stays may not endanger infants. PMID- 10169181 TI - Evaluation of prescription-writing quality in a French university hospital. AB - OBJECTIVE: To evaluate the quality of prescription writing at a university hospital in France. DESIGN/PATIENTS: Each of the 42 medical, surgical, and intensive-care departments were invited to participate in the study. The initial medication orders were reviewed for 866 patients, resulting in 3,254 medications prescribed. One prescription per patient was reviewed for a total of 866 patients, presenting 3,254 medications. RESULTS: Of the 866 prescriptions reviewed, 95.5% were dated. Patient identification was complete in 35.3%. The prescriber was identified properly by both full name and signature in 7.5% of prescriptions. Medication information was complete in only 24% of cases. CONCLUSION: This study showed that prescriptions were not written correctly. Results of this study have been disseminated, and education has begun on proper prescription practice. PMID- 10169182 TI - A trend for reduced 15-day wound infection and 6 months' mortality in laparoscopic relative to open cholecystectomy: the Israeli Study of Surgical Infections. AB - OBJECTIVE: To utilize a naturally occurring "experiment," when introduction to laparoscopic cholecystectomy occurred in Israel; to compare the concurrent outcomes (wound infection and mortality) of laparoscopic versus open cholecystectomy; to adjust for patients' characteristics and procedural factors while making the comparisons. DESIGN: Multicenter prospective follow up, including patients' interviews prior to the operation, daily information on postoperative care, a summary of the operation report and postdischarge telephone interview 15 days after surgery. SETTINGS: A sample of 100 consecutive cholecystectomy patients from all 20 acute-care hospitals in the country, where such operations were performed. PATIENTS: 1,785 consecutive patients during 1991 and 1992; 1,184 had open cholecystectomy, and 601 had laparoscopic cholecystectomy. RESULTS: Crude wound infection rates at 15 days were 2.3% for laparoscopic cholecystectomy and 6.3% for open cholecystectomy (odds ratio [OR], 2.8; P < .001). Crude mortality rates at 6 months were 0.17% and 3.0% for laparoscopic and open procedures, respectively (OR, 18.5; P < .004). Logistic models for infection and mortality were used to adjust for case-mix and procedural factors in the comparisons between the two operations. Adjusted ORs for open versus laparoscopic cholecystectomy were 1.9 (P = .06) for wound infection and 4.3 (P = .17) for mortality. Stratification of patients on the basis of the models into high- and low-risk strata indicated that the protective effect of laparoscopic cholecystectomy was mainly evident in the high-risk group: 1.8% versus 8.3% (P < .001) for 15-day infections and 0.6% versus 4.4% (P = .017) for 6 months mortality. CONCLUSION: We conclude that, although the P values for the adjusted comparisons were of borderline significance (due to the small number of deaths in the laparoscopic group), our results suggest advantageous outcomes for laparoscopic cholecystectomy, especially among the high-risk patients. PMID- 10169183 TI - Quality in managed care: developments and considerations. AB - With the rapid movement of both individuals and groups away from fee-for-service health care into managed care, concerns have been expressed appropriately that the quality of care may be affected adversely. Over the past several years, a number of developments have taken place to respond to these concerns. This quality movement in managed care has not been without some issues and considerations, however. This article first describes the National Committee for Quality Assurance (NCQA) and the prominent role it has played in this movement. Next, quality improvement study design is addressed in the context of assuring quality, controlling costs, and achieving NCQA accreditation. The effect that capitation, as a payment strategy for providers, has on data quality is then described. Fourth, the value of partnering is explored. Finally, the newest version of NCQA's performance measurement template is discussed: the Health Plan Employer Data and Information Set, version 3.0. PMID- 10169184 TI - A methodology model for quality management in a general hospital. AB - A reappraisal is made of the relevance of industrial modes of quality management to the issues of medical care. Analysis of the nature of medical care, which differentiates it from the supplier-client relationships of industry, presents the main intrinsic characteristics, which create problems in application of the industrial quality management approaches to medical care. Several examples are the complexity of the relationship between the medical action and the result obtained, the client's nonacceptance of economic profitability as a value in his medical care, and customer satisfaction biased by variable standards of knowledge. The real problems unique to hospitals are addressed, and a methodology model for their quality management is offered. Included is a sample of indicator vectors, measurements of quality care, cost of medical care, quality of service, and human resources. These are based on the trilogy of planning quality, quality control, and improving quality. The conclusions confirm the inadequacy of industrial quality management approaches for medical institutions and recommend investment in formulation of appropriate concepts. PMID- 10169185 TI - Informatics, imaging, and healthcare quality management: imaging quality improvement opportunities and lessons learned form HCFA's Health Care Quality Improvement Program. AB - This article examines the use of population-based healthcare data at the interface among radiology, healthcare informatics, and health services research for the purposes of healthcare quality management. To illustrate these concepts, we draw on experience with Health Care Financing Administration's Medicare Health Care Quality Improvement Program (HCQIP). We present two HCQIP efforts that have identified opportunities to improve the delivery of imaging services, specifically studies of the diagnosis and management of congestive heart failure and cerebrovascular disease. The examples demonstrate from a population-level perspective that there are opportunities to enhance the quality of imaging practice by reducing the magnitude of imaging practice variability, implementing evidence-based guidelines, and optimizing the communication of imaging study findings to physicians who are responsible for subsequent diagnostic and therapeutic decisions. Additional research is required in specific clinical domains of radiology to determine if implementation of evidence-based imaging guidelines and enhanced clarity in the interpretation and communication of diagnostic imaging will improve health outcomes. PMID- 10169186 TI - Establishing physician networks within evolving antitrust guidelines. AB - Rapid changes in health care are being driven by the growth of managed care. Health plans have become more aggressive in negotiating with physicians, and providers have increasingly chosen to establish networks in response. Because these provider networks frequently represent horizontal forms of integration between competitors, antitrust issues have become increasingly important. This article addresses current antitrust law as it relates to physician networks. In particular, it reviews the most recent statements of antitrust enforcement policy of the Department of Justice and the Federal Trade Commission concerning physician networks. Procompetitive activities by physician networks are central to the latest rulings. PMID- 10169187 TI - Beware! Reengineering has arrived in health care. AB - This latest management fad can bring dramatic cost savings, but the savings often are through reduction in head count. Experience in other industries shows that the damage too much downsizing can cause occurs in short-term benefits, as well as over the long run. Readers are advised to participate actively in reengineering rather than to be content with others doing it for them. Research now underway in a number of New York City hospitals is exploring the effects of greater labor-force participation as a cost-effective and humane alternative to downsizing. PMID- 10169188 TI - Methods for analysis of the occurrence of abscess in patients with pancreatitis. AB - OBJECTIVE: Standard survival analysis methods are useful for data involving censored cases when cures do not generally occur. If the object is to study, for instance, the development of a complication in the progress of an infectious disease, some people may be cured before complications develop. In this article, we provide methods for the analysis of data when cures do occur. An example is a study of prognostic factors for pancreatic abscess in patients with pancreatitis, some of whom leave the risk set because the pancreatitis clears. DESIGN: We present methods for estimating the survival curves and comparing hazard function for two objectives: (1) the occurrence of an abscess, irrespective of whether the patients are cured or not, and (2) the occurrence of an abscess for patients who, at that stage, have not been cured. PATIENTS: We illustrate the applications of the methods using a sample of 50 patients with severe pancreatitis. RESULTS: To study the occurrence of an abscess, regardless of whether the patients are cured or not, we show that the appropriate strategy is to assign to the cured patients an infinite time to the appearance of an abscess. If the cured were considered censored at the moment the pancreatitis cleared, this would result in an overestimation of the hazard of presenting an abscess. On the other hand, if the objective is to compare the occurrence of abscess according to an exposure for patients who have not been cured, one needs to censor the cured patients at the time they are cured. CONCLUSIONS: For the analysis of survival data in the context of infectious diseases when cure is possible, it is important to use a censoring strategy that is pertinent to the specific aims of the study. Considering cures as censored at the time of cure is not always appropriate. PMID- 10169189 TI - Uniform requirements for manuscripts submitted to biomedical journals. International Committee of Medical Journal Editors. PMID- 10169190 TI - Medicare, Medicaid, and CLIA programs; Clinical Laboratory Improvement Amendments of 1988 continuance of exemption of laboratories licensed by the State of Washington--HCFA. Notice. AB - This notice announces that laboratories located in the State of Washington that possess a valid license under the Medical Test Site Licensure Law, Chapter 70.40 of the Revised Code of Washington (RCW), continue to be exempt from the requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA) until April 30, 2001. PMID- 10169191 TI - Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after July 1, 1997--HCFA. Notice with comment period. AB - This notice sets fort a revised schedule of limits on home health agency costs that may be paid under the Medicare program for cost reporting periods beginning on or after July 1, 1997. These limits replace the per visit limits that were set forth in our July 1, 1996 notice with comment period (61 FR 34344). This notice also responds to comments on the July 1, 1996 notice. PMID- 10169192 TI - Interim rules for amending ERISA disclosure requirements for group health plans; approval of information collection requirements--DoL. Interim rules; approval of information collection requirements. AB - On April 8, 1997, the Department of Labor published interim final rules governing disclosure requirements for private sector group health plans (62 FR 16979). The rules implemented changes to made to certain provisions of the Employee Retirement Income Security Act of 1974 (ERISA), enacted as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Newborns' and Mothers' Health Protection Act of 1996 (NMHPA). In the April 8 publication, the Department submitted its revision of the currently approved collection regarding Summary Plan Description requirements under ERISA to the Office of Management and Budget (OMB) for emergency review under the Paperwork Reduction Act of 1965 (PRA 95). This document amends the April 8 Federal Register document to properly display the OMB control number, 1210-0039. PMID- 10169193 TI - Medicare program: special payment limits for home oxygen--HCFA. Proposed notice. AB - This notice would establish special payment limits for home oxygen. Currently, payment under the Medicare program for home oxygen and other items of durable medical equipment is equal to 80 percent of the lesser of the actual charge for the item or the fee schedule amount for the item. Based on our experience and after consulting with representative of home oxygen suppliers, we have determined that the Medicare fee schedule amounts for home oxygen are grossly excessive and are not inherently reasonable because they are excessively high relative to the payment and amount for similar services by the Department of Veterans Affairs which uses a true competitive payment methodology. This notice would replace the use of fee schedule amount and proposes that payment for home oxygen be equal to 80 percent of the lesser of the actual charge or a special payment limit set by HCFA, which would vary by locality. It is intended to prevent continuation of excessive payment. The special limit would be based on the average payment amount for home oxygen services by the Department of Veterans Affairs. PMID- 10169194 TI - Payment for non-VA physician services associated with either outpatient or inpatient care provided at non-VA facilities--VA. Proposed rule. AB - This document proposes to amend Department of Veterans Affairs (VA) medical regulations concerning payment for non-VA physician services that are associated with either outpatient or inpatient care provided to eligible VA beneficiaries at non-VA facilities. We propose that when a service specific reimbursement amount has been calculated under Medicare's Participating Physician Fee Schedule, VA would pay the lesser of the actual billed charge or the calculated amount. We also propose that when an amount has not been calculated, VA would pay the amount calculated under a 75th percentile formula or, in certain limited circumstances, VA would pay the usual and customary rate. In our view, adoption of this proposal would establish reimbursement consistency among federal health benefits programs, would ensure that amounts paid to physicians better represent the relative resource inputs used to furnish a service, and, would, as reflected by a recent VA Office of Inspector General (OIG) audit of the VA fee-basis program, achieve program cost reductions. Further, consistent with statutory requirements, the regulations would continue to specify that VA payment constitutes payment in full. PMID- 10169195 TI - Medicare crooks. AB - Medicare is racked with more waste, fraud and abuse than anyone had imagined. Ending overpayments would keep the program from going bankrupt in 2001. But can the government hunt down all the swindlers? Don't count on it. PMID- 10169196 TI - Five minutes with Bruce Vladeck. Interview by Elise Nakhnikian. PMID- 10169197 TI - Senior housing. Getting creative with capital investment. PMID- 10169198 TI - Surviving the survey. Zen and the art of earning zero deficiencies. PMID- 10169199 TI - No place like home. PMID- 10169200 TI - Mop up on dirt. PMID- 10169201 TI - Dysfunctional duos. Having a hard time with your admin? Here are some tips that may help. PMID- 10169202 TI - Wound care. Pressure ulcers: stop don't yield. PMID- 10169203 TI - Rewriting the rules for end of life. PMID- 10169204 TI - Training, training, and more training. PMID- 10169205 TI - Five minutes with Robert Butler. Interview by Doug Brunk. PMID- 10169206 TI - Pressure ulcer prevention and the bottom line. PMID- 10169207 TI - Assisted living. The selling never stops. PMID- 10169208 TI - Two can play the payroll audit game. PMID- 10169209 TI - The doctor is out--and the extender is in. PMID- 10169210 TI - Random acts of violence. PMID- 10169211 TI - Is this food safe? PMID- 10169212 TI - Of hope and hospice. PMID- 10169213 TI - Leaders can't afford to be computer-illiterate. PMID- 10169214 TI - Caregivers make slow gains in treating pains. PMID- 10169216 TI - Contemporary Long-Term Care's 1997 software showcase. PMID- 10169215 TI - Taking stock of the IPOs. PMID- 10169217 TI - Does managed care jeopardize quality? PMID- 10169218 TI - Horizontal accounting. A new method takes quality into account. PMID- 10169219 TI - Food purchasing: yesterday, today, tomorrow. PMID- 10169220 TI - Largest survey of hospital patient satisfaction. PMID- 10169221 TI - Intermountain Health Care shapes Utah market with financial prudence. AB - Intermountain Health Care dominates its market like few other health systems. The sprawling nonprofit system manages to stay well ahead of the competition by: selecting physicians who deliver both quality and financially efficient care; offering employers varying levels of choice and price in insurance plans; leading the way in information technology advances. PMID- 10169222 TI - Providers squeezed as costs increase over profits. But low premiums could bring more into HMOs. PMID- 10169223 TI - Good or bad: payer's financial health is linked to yours. PMID- 10169224 TI - Tracking capitation: necessary for success. AB - Eugene Hoekendorf's column explores the range of new information-gathering needs a PHO, IPA, or medical group must consider under capitation and what kinds of internal systems need to be put in place to manage the contract. This is the second of two parts. The first part, which discussed core competencies, ran in the July issue. PMID- 10169225 TI - NCQA 'seal of approval' spreads to doctors. PMID- 10169226 TI - CHA (Canadian Healthcare Association) transformed. PMID- 10169227 TI - The federal decision to proceed with cuts to the CHST (Canada Health and Social Transfer) will endanger medicare. Canadian Healthcare Association. PMID- 10169228 TI - The conundrum of patient records. AB - Examines issues and concerns surrounding the management of patient information in the form of health records, such as accessibility, privacy, security, confidentiality, ownership and eventual disposal. Discusses the effects of health reform on the management of patient information, especially regionalization in Saskatchewan, and advances in technology. Concludes that it is incumbent on health-care professionals to show leadership and set guidelines since technology will outstrip legislation. PMID- 10169229 TI - Health policy or intellectual property policy? The fight over Bill C-91. Canadian Healthcare Association. AB - Adapted from the Canadian Healthcare Association's submission to the House of Commons Standing Committee on Industry currently reviewing Bill C-91, an Act to amend the Patent Act. Discusses the controversy surrounding this legislation, which extended patent protection to brand-name drug manufacturers to 20 years before generic copies of pharmaceuticals can be introduced on to the market. PMID- 10169230 TI - Non-medical predictors of quality of care of hypertension in elderly patients. AB - Describes a study designed to develop instruments for examining the quality of routine care of hypertension among the elderly and, using non-medical predictors of quality--such as elderly patient and doctor variables and doctor-patient interaction variables--to explain the variance in the quality of care. The study population comprised 352 elderly people (92 per cent) in one Jerusalem neighborhood who were members of Israel's largest sick fund. Interviews, screening, observation and examination of records were the sources of information. Multivariate analysis was performed. The findings indicated a plethora of deficiencies in the quality of routine care, mostly in the quality of surveillance and the control of hypertension. It was found that the outcome of care is primarily a result of the physician-patient interaction, rather than of a lack of patient compliance. Proposes a national programme using the instruments developed. PMID- 10169231 TI - Measuring technical efficiency of output quality in intensive care units. AB - Presents some examples of the implications derived from imposing the objective of maximizing social welfare, subject to limited resources, on ethical care patients management in respect of quality performance of health services. Conventional knowledge of health economics points out that critically ill patients are responsible for increased use of technological resources and that they receive a high proportion of health care resources. Attempts to answer, from the point of view of microeconomics, the question: how do we measure comparative efficiency in the management of intensive care units? Analyses this question through data from an international empirical study using micro-economic measures of productive efficiency in public services (data envelopment analysis). Results show a 28.8 per cent level of technical inefficiency processing data from 25 intensive care units in the USA. PMID- 10169232 TI - Costs of the treatment of leg ulcers: initiating a quality assurance process. AB - Reports on a study which aimed to initiate a quality assurance process among health care personnel in Sweden. An epidemiological survey concerning treatment of leg ulcers in a defined region in Sweden was conducted and the costs of treating leg ulcers at different levels of care were analysed. The epidemiological survey provided the data necessary to calculate the socio economic costs for the treatment of leg ulcers. The weekly cost was found to be about 24 times higher for hospital inpatients than it was for patients treated at home. The quality assurance process has continued through an interdisciplinary regional consensus conference and the establishment of a consensus programme in the region, with targets and general suggestions for the care and treatment of leg ulcers. To maintain high quality in leg ulcer treatment in the region, an interdisciplinary reference group has been established with members from different clinics at the hospital and members from the primary health care. PMID- 10169233 TI - The role of expectations in the perception of health care quality: developing a conceptual model. AB - Proposes a conceptual model of quality which incorporates an expectation framework. The model was prompted by a related empirical study examining effectiveness in a health care setting which highlighted the importance of quality measures in a contracting environment. The model attempts to understand the relationships between perceived service quality and patient expectations, experience and satisfaction. Makes recommendations which are considered to be relevant to NHS policy makers. PMID- 10169234 TI - Annotated bibliography: integrated approaches to quality improvement in health care: Part IV. PMID- 10169235 TI - A clinical view of pathways of care in disease management. AB - Pathways of care define in detail the individual components of treatment for a group of patients. A well written pathway can give rise to consistent care or the highest quality. There are both educational and audit advantages to the approach. Details the means by which groups are selected and the care pathways written. Gives an example of the benefits that can accrue, based on the authors' experience at Ashford Hospital, UK of running a pathway for patients having prostate surgery. The pathways are appreciated by patients, nurses, doctors and managers. Care is improved and costs contained. PMID- 10169236 TI - GP referral letters to a community mental health team: an analysis of the quality and quantity of information. AB - Presents the results of a study which investigated whether the quality of information provided by GP referral letters to a community mental health team (CMHT) was sufficient to determine an appropriate response and the allocation of professional resources. A random sample of GP referral letters received over a six month period was analysed. The presenting problem, diagnosis and the indication of severity of symptoms were rated. Perusal of the CMHT members' replies to the GP's allowed a rough analysis of the extent of agreement with the GP's diagnoses, description of presenting problems and severity of symptoms. Discusses the results of the study with regard to the implications of GP fundholding and the employment of GP-based counsellors. PMID- 10169237 TI - Disease management: from sand table exercise to local achievement. AB - Presents an outline of a local pilot project on disease management in Ollerton, Nottinghamshire, UK. Disease management has been a staff college exercise at a national level: the alliance for health in Ollerton involved a purchaser, an acute trust and a practice. Secondary care expertise was used earlier in the disease process to identify patients and to treat them with a more continuous care programme. Disease management began with gastric illness--in examination, review and treatment for H Pylori eradication; extensions are planned to glaucoma and epilepsy. The project involved co-ordinated investment in building extensions, staff skills and records. PMID- 10169238 TI - Reviewing the value of clinical audit: is now the time for a change? AB - Many different activities have been defined for the effective use of clinical audit. Proposes a method of linking the practice and outcome of audit with the Trust business people, setting out criteria methodology and background following a two-year research study. PMID- 10169239 TI - A critique of the concept of quality of life. AB - Taking a philosophical approach, ancient Greek philosophers and Christians began to investigate the concept of quality of life. Later, such philisophical pursuit was replaced by the school of positivism, which indicated that science was and still is the only valid form of enquiry. Through such positivistic science, the metaphysical nature of the concept of quality of life is thought to be uncovered. However, the later Wittgensteinian philosophical thoughts demonstrated that there is no metaphysical understanding of any concepts but there is only knowledge of playing language games. In the light of this philosophy, prior to any scientific investigations, researchers have already understood and agreed on the concept of quality of life by playing language games. From the above philosophical analyses, outlines some implications for health care research. PMID- 10169240 TI - Annotated bibliography: integrated approaches to quality improvement in health care: Part III. PMID- 10169241 TI - The nature and value of small and community hospital accreditation. AB - Discusses the characteristics of health care accreditation schemes, especially the implications of their voluntary status. Singles out the Trent small hospital accreditation scheme (TSHAS) for detailed and systematic evaluation. Describes the quantitative and qualitative evaluation methods, which involved a meta analysis of the literature, interviews with key staff and questionnaires completed by other participants in TSHAS. The main findings, divided into ten themes, confirm much of the published work on accreditation. The findings also provide new insights into the nature and value of health care accreditation, notably about the direction in which accreditation needs to go if both community and larger hospital accreditation is to survive. PMID- 10169242 TI - Bridging the gap between managed care and academic medicine: an innovative fellowship. AB - Numerous challenges face academic medicine in the era of managed care. This environment is stimulating the development of innovative educational programs that can adapt to changes in the healthcare system. The U.S. Quality Algorithms Managed Care Fellowship at Jefferson Medical College is one response to these challenges. Two postresidency physicians are chosen as fellows each year. The 1 year curriculum is organized into four 3-month modules covering such subjects as biostatistics and epidemiology, medical informatics, the theory and practice of managed care, managed care finance, integrated healthcare systems, quality assessment and improvement, clinical parameters and guidelines, utilization management, and risk management. The fellowship may serve as a possible prototype for future post-graduate education. PMID- 10169243 TI - Cost-effectiveness of sumatriptan in a managed care population. AB - We conducted an open-labeled study to determine whether sumatriptan is more cost effective than other therapies used to treat migraine headache. We contacted by phone 220 sumatriptan users enrolled in QualMed, a health maintenance organization (HMO) in Spokane, Washington. Of these, 203 met the inclusion criteria and 164 (81%) completed our telephone survey. The main outcome measures were healthcare costs to the HMO and number of days free of migraine-related disability before and after sumatriptan treatment. Before sumatriptan treatment, 89% of patients reported severe migraine, compared with 63% after sumatriptan treatment. The number of monthly migraine disability days decreased from 6.5 days per month before sumatriptan to 3.9 days per month after sumatriptan. Healthcare utilization rates (ie, number of hospitalizations, emergency department visits) and costs were lower after the patients began taking sumatriptan. The number of different over-the-counter medicines and prescription medications (other than sumatriptan) taken for migraine disabilities decreased. Although total drug expenditures per month increased, the total migraine healthcare expenditure was 41% lower after sumatriptan was initiated. The cost-effectiveness ratio was 47% more favorable after patients started taking sumatriptan. Overall, patients reported fewer migraine-related disabilities, had lower migraine severity scores, and used fewer healthcare resources when taking sumatriptan. These changes resulted in a better cost-effectiveness ratio for migraine treatment. PMID- 10169244 TI - A cost-effective approach to the use of selective serotonin reuptake inhibitors in a Veterans Affairs Medical Center. AB - In light of the tremendous expansion in the number of selective serotonin reuptake inhibitors available to the clinician, the Pharmacy and Therapeutics Committee of the Denver Veterans Affairs Medical Center considered the advantages and disadvantages of fluoxethine, paroxetine, and sertraline, to determine which agent or agents would be carried on the formulary. The committed recommended sertraline as the preferred agent for the treatment of depression, panic disorders, and obsessive-compulsive disorders. The purpose of this retrospective study was to assess the economic outcome of that decision. The study population consisted of patients at the medical center who were receiving selective serotonin reuptake inhibitors during January through March of 1994 and those were receiving these agents between September 1995 and January 1996. The expanded collection period in 1995-96 was due to a relatively new medical center policy to offer 90-day fills on medication to reduce costs. The extended collection period assured a 100% sample of patients receiving these agents. The 1994 fluoxetine to sertraline dosage equivalency ratio was 20 mg:55.6 mg, based on average daily doses of fluoxetine and sertraline of 32.7 and 90.9 mg, respectively. The cost to the medical center for an average daily dose of fluoxetine was $1.86; sertraline cost $1.22 per day. The 1996 fluoxetine to sertraline dosage equivalency ratio (20 mg:51.3 mg) had not changed significantly since 1994, indicating that the dose of 20 mg of fluoxetine remained very close to a 50-mg dose of sertraline. The average daily doses of fluoxetine and sertraline (34.9 mg and 89.7 mg, respectively) were not significantly different than the 1994 doses. Only 33 patients had been prescribed paroxetine (average daily dose, 32.4 mg). On the basis of these values, the average daily cost of fluoxetine to the medical center was $2.01, compared with $1.18 for sertraline and $1.24 for paroxetine. This $0.83 per patient per day drug acquisition cost difference between fluoxetine and sertraline results in a drug cost reduction of $302,674 per year. PMID- 10169245 TI - An innovative approach to reducing medical care utilization and expenditures. AB - In a retrospective study, we assessed the impact on medical utilization and expenditures of a multicomponent prevention program, the Maharishi Vedic Approach to Health (MVAH). We compared archival data from Blue Cross/Blue Shield Iowa for MVAH (n = 693) with statewide norms for 1985 through 1995 (n = 600,000) and with a demographically matched control group (n = 4,148) for 1990, 1991, 1994, and 1995. We found that the 4-year total medical expenditures per person in the MVAH group were 59% and 57% lower than those in the norm and control groups, respectively; the 11-year mean was 63% lower than the norm. The MVAH group had lower utilization and expenditures across all age groups and for all disease categories. Hospital admission rates in the control group were 11.4 times higher than those in the MVAH group for cardiovascular disease, 3.3 times higher for cancer, and 6.7 times higher for mental health and substance abuse. The greatest savings were seen among MVAH patients older than age 45, who had 88% fewer total patients days compared with control patients. Our results confirm previous research supporting the effectiveness of MVAH for preventing disease. Our evaluation suggests that MVAH can be safely used as a cost-effective treatment regimen in the managed care setting. PMID- 10169246 TI - The relationship and tensions between vertical integrated delivery systems and horizontal specialty networks. AB - This activity is designated for physicians, medical directors, and healthcare policy makers. GOAL: To clarify the issues involved with the integration of single-specialty networks into vertical integrated healthcare delivery systems. OBJECTIVES: 1. Recognize the advantages that single-specialty networks offer under capitated medical care. 2. Understand the self-interests and tensions involved in integrating these networks into vertical networks of primary care physicians, hospitals, and associated specialists. 3. Understand the rationale of "stacking" horizontal networks within a vertical system. PMID- 10169247 TI - Managed care organizations should not disclose their physicians' financial incentives. PMID- 10169248 TI - To tell the truth: disclosing the incentives and limits of managed care. AB - As managed care becomes more prevalent in the United States, concerns have arisen over the business practices of managed care companies. A particular concern is whether patients should be made aware of the financial incentives and treatment limits of their healthcare plan. At present, managed care organizations are not legally required to make such disclosures. However, such disclosures would be advisable for reasons of ethical fidelity, contractual clarity, and practical prudence. Physicians themselves may also have a fiduciary responsibility to discuss incentives and limits with their patients. Once the decision to disclose has been made, the managed care organization must draft a document that explains, clearly and honestly, limits of care in the plan and physician incentives that might restrict the care a patient receives. PMID- 10169249 TI - The impact of physician economic incentives on admission rates of patients with ambulatory sensitive conditions: an analysis comparing two managed care structures and indemnity insurance. AB - The utilization of financial incentives to limit the use of health resources by primary care physicians represents a common reimbursement strategy by managed care organizations. These arrangements are virtually nonexistent with indemnity insurance. This analysis compares the hospitalization rates of patients with low acuity medical conditions--ambulatory sensitive conditions (ASCs)--among three groups receiving care from primary care physicians. The physicians were compensated under different reimbursement mechanisms, in which incentives for reduced resource utilization varied. The groups can be described as follows: (1) a capitated for-profit group practice in which the physician partners have a relatively high economic incentive for lower utilization (group I); (2) physicians providing care under the auspices of three separate independent practice associations, in which the associations are capitated but the physicians are paid on a discounted fee-for-service basis (the associations also were included in this group) (group II); and (3) physicians who service patients whose care continues to be paid for by traditional indemnity insurance (group III). Financial incentives in the third group cohort were believed to be low to intermediate, and the physicians were assumed to have had no economic incentives to restrain their use of healthcare resources. Additional data analysis examined the role of emergency department utilization among patients in the groups. Group I patients ages 25 to 44 were admitted for ambulatory sensitive conditions at a significantly lower rate than were patients in groups II or III--0.8/1,000, 2.7/1,000, and 2.9/1,000, respectively. No difference was apparent in admission rates between patients in groups II and III. Overall emergency department utilization rates were lowest in the group I capitated panel (70/1,000), much higher in the group II independent practice association panel (363/1,000) and highest in the group III indemnity panel (466/1,000). Each of these rates was significantly different from the other. Both the ED utilization rate and ambulatory sensitive condition admission rate may have been affected by differences in socioeconomic status among the patient panels in the three groups. The overall effect of this variable on the two admission rates could not be isolated. PMID- 10169250 TI - Medical liability risk avoidance: a case for adopting the International Normalized Ratio (INR) system. AB - Since bleeding is a common adverse effect associated with the oral anticoagulant warfarin, maximizing the therapeutic potential of this drug requires close laboratory monitoring. The International Normalized Ratio (INR) is a system that has been developed to improve and standardize the assessment of the intensity of oral anticoagulation therapy. Clinical information and medicolegal arguments supporting the adoption of this system are reviewed. The potential for improvement in patient outcomes and minimization of medical liability favors the adoption of the INR system. PMID- 10169251 TI - Theoretical framework for implementing a managed care curriculum for continuing medical education--Part I. AB - Healthcare reform has created a new working environment for practicing physicians, as economic issues have become inseparably intertwined with clinical practice. Although physicians have recognized this change, and some are returning to school for formal education in business and healthcare administration, formal education may not be practical or desirable for the majority of practicing physicians. Other curriculum models to meet the needs of these professionals should be considered, particularly given the growing interest in continuing education for physicians in the areas of managed care and related aspects of practice management. Currently, no theory-based models for implementing a managed care curriculum specifically for working physicians have been developed. This paper will integrate diffusion theory, instructional systems design theory, and learning theory as they apply to the implementation of a managed care curriculum for continuing medical education. Through integration of theory with practical application, a CME curriculum for practicing physicians can be both innovative as well as effective. This integration offers the benefit of educational programs within the context of realistic situations that physicians can apply to their own work settings. PMID- 10169252 TI - Application of the problem-based learning model for continuing professional education: a continuing medical education program on managed care issues--Part II. AB - Physicians must incorporate concepts of practice management and knowledge of managed care into their practices. Managed care presents an immediate and challenging opportunity to providers of continuing medical education to offer effective educational programs for physicians on managed care issues. In this exploratory research, the problem-based learning model was used to develop a continuing medical education program that would offer an interactive and effective method for teaching physicians about managed care. Problem-based learning is a departure from the traditional lecture format of continuing medical education programs because it is designed for small groups of self-directed learners who are guided by a faculty facilitator. Although only a small number of participants participated in this program, the findings offer important considerations for providers of continuing medical education. For example, participants reported increased confidence in their knowledge about managed care issues. Participants also clearly indicated a preference for the small group, interactive format of the problem-based learning model. PMID- 10169253 TI - Patterns of anti-inflammatory therapy in the post-guidelines era: a retrospective claims analysis of managed care members. AB - Published and widely disseminated guidelines for the care and management of asthma characterize asthma as a chronic, inflammatory disease and propose specific recommendations for therapy with inhaled anti-inflammatory medications. In a retrospective analysis of medical and pharmacy claims data of approximately 28,000 asthmatic members from five managed care settings, the dominant pattern of pharmacologic therapy that emerged was the use of bronchodilators without inhaled anti-inflammatory drug therapy. In addition, a significant proportion of asthmatic patients received no prescription drug therapy for asthma. Less than one third of asthmatic patients received any anti-inflammatory therapy and the majority of these received one or two prescriptions per year. Specialist physicians were two to three times more likely than non-specialists during a study period of 1 year to prescribe an anti-inflammatory medication, and were half as likely to have their asthmatic patients experience an emergency department or hospital event. This database analysis suggests that greater conformity with guidelines and/or access to specialist physician care for asthmatic members will lead to improved patient outcomes. PMID- 10169254 TI - Implications of managed care denials for pediatric inpatient care. AB - With the growing penetration of managed care into the healthcare market, providers continue to experience increasing cost constraints. In this environment, it is important to track reimbursement denials and understand the managed care organization's rationale for refusal of payment. This is especially critical for providers of pediatric care, as children justifiably have unique healthcare needs and utilization patterns. We developed a system for tracking and documenting denials in our institution and found that health maintenance organizations denied claims primarily for one of three reasons: medically unnecessary care, care provided as a response to social (rather than medical) need, and provider inefficiencies. Health maintenance organization denials are also growing annually at our institutions. This knowledge can not only help providers of pediatric care more effectively negotiate future contracts, but provides an opportunity to differentiate the health needs of the pediatric patient from those of the adult. This information can be used as a basis for education, pediatric outcome studies, and guideline development--all tools that can help providers receive reasonable reimbursement for pediatric services and enable them to meet the complex health needs of children. Recommendations for action are discussed. PMID- 10169255 TI - A successful tobacco cessation program led by primary care nurses in a managed care setting. AB - We conducted a descriptive study of a tobacco cessation program sponsored by a health maintenance organization (HMO) and led by primary care nurses. The tobacco cessation program was conducted at 20 primary care clinics in northeastern and central Pennsylvania. We gauged the successfulness of the program by the patients' self-reported quit rates at 1 year. We also examined the association between quit rates and compliance with scheduled counseling visits, the impact of the availability of an HMO pharmacy benefit that supported the costs of nicotine replacement therapy, and the quit rates among patients with HMO insurance versus those with insurance other than managed care. Of 1,695 patients enrolled in the program from July 1993 to March 1996, 1,140 completed 1 year of follow-up. Of these, 348 (30.5%) reported they had quit using tobacco. Among the 810 HMO enrollees who participated in the program, the quit rate was 280 (34.6%); among the 330 non-HMO participants, the quit rate was 69 (20.9%), a statistically significant difference (P < 0.001). For all patients, keeping more than four visits with the program nurse was associated with a significantly higher likelihood of quitting (317/751 [42.2%] versus 32/389 [8.2%]; P < 0.001). Non-HMO patients were less likely than HMO enrollees to keep four or more visits (165 [50%] versus 586 [72.3%]; P < 0.001). We were unable to detect a difference in quit rates among those with and those without a pharmacy benefit (196/577 [34%] versus 84/233 [36.1%]). These data are limited by their descriptive nature and the lack of information about other factors important in determining the quit rate among program participants. Nevertheless, they suggest that HMOs can successfully sponsor nurse-led tobacco cessation programs in multiple primary care settings and achieve 1-year quit rates significantly higher than the 15% quit rate reported in the medical literature. In addition, successfully quitting tobacco use appeared to be associated with use of counseling visits but not with use of a pharmacy benefit to pay for nicotine replacement therapy. Even though tobacco cessation programs have the best chance of benefitting HMO enrollees, patients not enrolled in managed care plans also appear to benefit significantly. This finding has important implications for developing future strategies- including the role of managed care organizations, the need to defray the costs of nicotine replacement therapy, and the best approach to provide counseling to patients--to meet the Healthy People 2000 goal of reducing tobacco smoking. PMID- 10169256 TI - The influence of day of life in predicting the inpatient costs for providing care to very low birth weight infants. AB - The purpose of this study was to test, refine, and extend a statistical model that adjusts neonatal intensive care costs for a very low birth weight infant's day of life and birth weight category. Subjects were 62 infants with birth weights below 1,501 g who were born and cared for in a university hospital until discharged home alive. Subjects were stratified into 250-g birth weight categories. Clinical and actual daily room and ancillary-resource costs for each day of care of each infant were tabulated. Data were analyzed by using a nonlinear regression procedure specifying two separate for modeling. The modeling was performed with data sets that both included and excluded room costs. The former set of data were used for generating a model applicable for comparing interhospital performances and the latter for comparing interphysician performances. The results confirm the existence of a strong statistical relationship between an infant's day of life and both total hospital costs and the isolated costs for ancillary-resource alone (P < 0.0001). A refined series of statistical models have been generated that are applicable to the assessment of either interhospital or interphysician costs associated with providing inpatient care to very low birth weight infants. PMID- 10169257 TI - The three dimensions of managed care pharmacy practice. AB - Our goal is to provide a framework for pharmacy in an evolving healthcare marketplace by identifying and discussing the three dimensions of pharmacy practice: (1) pharmacy practice across the continuum of care; (2) the major elements of pharmacy practice; and (3) the evolution of pharmacy during the five stages of the development of managed care. The framework was devised under the proposition that there is a substantial consistency in what patients need or should expect from pharmacists. As integrated health systems develop, pharmacists must apply their skills and knowledge across the continuum of care to ensure that they play an integral part in the systems. In a managed care environment characterized by change and the development of integrated health systems, pharmacists have opportunities to become involved directly in patient care in such areas as disease prevention, home healthcare, primary care, and subacute care. Information systems, hospital drug distribution, clinical pharmacy, and the fiscal environment comprise the major elements of pharmacy practice within an integrated health system, and the way in which each of these elements evolves as the healthcare market adapts to managed care is critical to pharmacy practice. If the pharmacy profession can demonstrate its ability to manage disease and health, improve outcomes, and reduce costs within the evolving healthcare system, pharmacists will play a vital role in the managed healthcare market in the approaching new millennium. PMID- 10169258 TI - Alternative insurance arrangements and the treatment of depression: what are the facts? AB - Using insurance claims data from nine large self-insured employers offering 26 alternative health benefit plans, we examine empirically how the composition and utilization for the treatment of depression vary under alternative organizational forms of insurance (indemnity, preferred provider organization networks, and mental health carve-outs), and variations in patient cost-sharing (copayments for psychotherapy and for prescription drugs). Although total outpatient mental health and substance abuse expenditures per treated individual do not vary significantly across insurance forms, the depressed outpatient is more likely to receive anti-depressant drug medications is preferred provider organizations and carve-outs than when covered by indemnity insurance. Those individuals facing higher copayments for psychotherapy are more likely to receive anti-depressant drug medications. For those receiving treatment, increases in prescription drug copayments tend to increase the share of anti-depressant drug medication costs accounted for by the newest (and more costly) generation of drugs, the selective serotonin reuptake inhibitors. PMID- 10169259 TI - Use of PRISM scores in triage of pediatric patients with diabetic ketoacidosis. AB - Triage guidelines are needed to help in the decision process of intensive care unit (ICU) versus non-ICU admission for patients with diabetic ketoacidosis (DKA). Pediatric risk of mortality (PRISM) scores have long been used to assess mortality risk. This study assess the usefulness of the traditional PRISM score and adaptation of that score (PRISM-ED, which uses presentation data only) in predicting hospital stay in pediatric patients with DKA. PRISM and PRISM-ED were tested for correlation with length of stay and length of ICU stay. A medical record review was conducted for patients admitted to The Children's Hospital of Alabama with DKA during an 18-month period (n = 79). Two scores were calculated for each study entrant: PRISM using the worst recorded values over the first 24 hours and PRISM-ED using arrival values. Median scores, median test, and Spearman rank correlations were determined for both tests. Median PRISM scores were PRISM = 11 and PRISM-ED = 12; Median PRISM and PRISM-ED scores for patients admitted to the ICU were less than median scores among floor-admitted patients: [table: see text] Spearman rank correlations were significant for both scores versus total stay: PRISM, rs = 0.29; P = 0.009; PRISM-ED, rs = 0.60, P < 0.001. Also, correlations were significant for both scores versus ICU stay: PRISM rs = 0.22, P = 0.05; PRISM-ED, rs = 0.41, P < 0.001. Triage guidelines for ICU versus floor admission for DKA patients could have significant economic impact (mean ICU charge = $11,417; mean charge for floor admission = $4,447). PRISM scores may be an important variable to include in a multiple regression model used to predict the need for ICU monitoring. PMID- 10169260 TI - Short-term continuous infusion thrombolytic therapy for occluded central nervous venous dialysis catheters. AB - The necessity of maintaining a strict schedule of dialysis treatments in patients with chronic renal failure dictates that occluded access catheters be restored to full function in a timely and cost-effective manner. The records of 22 consecutive patients receiving outpatient treatment for occluded hemodialysis catheters at Osteopathic Medical Center of Texas were reviewed by the authors. Each patient had 100,000 units of urokinase in 50 ml normal saline instilled over 30 minutes through the occluded catheter. In most instances the dose was divided to allow 35 ml to the proximal port and 15 ml to the distal port. The maximum sustained blood flow rate on dialysis was recorded for each patient. The mean maximum sustained blood flow rate improved from 150 ml/min +/- 79 ml to 261 ml/min +/- 62 ml. Following infusion, improvement was obtained in 19 of 22 patients, with 14 catheters delivering blood flow greater than 250 ml/min. The total cost per treatment was $316. No adverse events were experienced. Thrombotic occlusion of extended use hemodialysis catheters can be rapidly and safely relieved in a cost-effective manner with little delay in scheduled dialysis treatments. PMID- 10169261 TI - Outcomes of routine testing of liver enzymes in institutionalized geriatric patients. AB - This study sought to identify any benefit of routine liver function tests (LFTs) in chronically ill, geriatric patients and to assess which patients require evaluation for abnormal LFT levels. A retrospective chart review was carried out on 268 consecutive patients (M:F = 1.2, mean age 77 years, range 61-98 years) presenting for acute care from a long-term care facility. All were without jaundice, right upper quadrant pain, pruritus, bruising, or signs of chronic liver disease. The degree of LFT abnormality (aspartate aminotransferase, alanine aminotransferase, total bilirubin, or alkaline phosphatase) during admission was compared to the clinical diagnosis at the time of discharge. The most common diagnoses were pneumonia, urinary tract infection, and peripheral or coronary disease in 186 (60%). Thirty-seven patients (14%) had elevated LFT levels on admission. The levels normalized within 2 days in 26 of these patients, 25 of whom had a history of vascular disease (96%). Of the 11 remaining patients, 4 had coexistent vascular disease (36%), and 5 had LFT levels twice normal (none with vascular disease) and underwent abdominal ultrasound. One patient had a common bile duct stone successfully extracted. Enzyme abnormalities were due to hepatitis B or medication use in 10 of 11 patients. No patient had liver biopsy. All but one of the 268 patients were discharged without further evaluation. Over one year of follow up, no patient returned for a liver-related problem. Based on these findings, only those patients with LFT levels that are twice normal and which do not normalize within 2 days warrant further evaluation. Transient LFT abnormalities may be due to decreased liver perfusion. PMID- 10169262 TI - Prepaid capitation versus fee-for-service reimbursement in a Medicaid population. AB - Utilization of health resources by 37,444 Medicaid recipients enrolled in a capitated health maintenance organization was compared with that of 227,242 Medicaid recipients enrolled in a traditional fee-for-service system over a 1 year period (1983-1984) in the state of Kentucky. Primary care providers in the capitated program had financial incentives to reduce downstream costs like specialist referral, emergency room use, and hospitalizations. The average number of physician visits was similar for both groups (4.47/year in the capitated program; 5.09/year in the fee-for-service system). However, the average number of prescriptions (1.9 versus 4.9 per year), average number of hospital admissions per recipient (0.11 versus 0.22 per year), and average number of hospital days per 1,000 recipients (461 versus 909 per year) were 5% to 60% lower in the capitated group than in the fee-for-service group. The Citicare capitated program resulted in a dramatic reduction in healthcare resource utilization compared with the concurrent fee-for-service system for statewide Medicaid recipients. PMID- 10169263 TI - Primary gonadotropin-releasing hormone agonist therapy for suspected endometriosis: a nonsurgical approach to the diagnosis and treatment of chronic pelvic pain. AB - Chronic pelvic pain is a condition that affects one in seven women of reproductive age in the United States. Direct and indirect medical costs associated with this condition are estimated to be more than $3 billion annually before factoring in the costs of diagnostic testing. At many medical centers, endometriosis is the most common single cause of chronic pelvic pain; other causes include intra-abdominal adhesions, chronic pelvic inflammatory disease, ovarian cysts, and adenomyosis. The current approach to diagnosis and treatment of chronic pelvic pain is a two-step approach, with medical history, physical examination, laboratory testing, and empiric therapy (nonsteroidal anti inflammatory drugs, oral contraceptives, and/or antibiotics) comprising Step 1 and surgical diagnosis with laparoscopy as Step 2. At many centers, the most common diagnosis at the time of laparoscopy for chronic pelvic pain is endometriosis, typically minimal to mild disease that can be effectively treated with hormonal therapy. Therefore, a rational alternative approach is a 3-month empiric course of therapy with a gonadotropin-releasing hormone agonist before laparoscopy. The advantages of this approach are the high rate of pain relief in women, the possibility of avoiding an invasive procedure (laparoscopy), the ability to extend therapy, if pain is relieved, to the full 6-month therapeutic course of endometriosis, and a potentially lower cost relative to laparoscopy. PMID- 10169264 TI - Hospitals and managed care: catching up with the networks. AB - Although the growth of managed care is having a significant impact on hospitals, organizational response to managed care remains fragmented. We conducted a survey of 83 hospitals nationwide that indicated that most hospitals now have at least one person devoted to managed care initiatives. These individuals, however, often spend most of their time on current issues, such as contracting with managed care organizations and physician relations. Concerns for the future, such as network development and marketing, although important, receive less immediate attention form these individuals. Hospital managed care executives must take a more proactive role in long range managed care planning by collaborating with managed care organizations and pharmaceutical companies. PMID- 10169265 TI - Managed care clinical corner: a case of congestive heart failure--the managed care perspective. PMID- 10169266 TI - Effectiveness and economic impact of antidepressant medications: a review. AB - This article reviews the existing literature on the pharmacoeconomics and effectiveness of antidepressant medications. Although selective serotonin reuptake inhibitors (SSRIs) have not proved to be more efficacious than the older tricyclics, and their prescription costs are significantly higher, they provide superior effectiveness; ie, patients are less likely to discontinue taking them or switch antidepressants. Pharmacoeconomic studies consistently demonstrate a relationship between this superior effectiveness and reductions in overall treatment costs, often through decreased utilization of medical and hospital services. The most conservative study found a cost offset that more than negated the extra cost of drugs, although the cost savings were not statistically significant. Other studies found statistically significant lowering of utilization costs by using SSRIs rather than tricyclics. Studies comparing SSRIs with each other present conflicting findings, although fluoxetine appears to have an edge over sertraline and paroxetine with regards to effectiveness and pharmacoeconomics. More studies employing a prospective outcome design and naturalistic study setting need to be conducted with SSRIs and other new antidepressants. PMID- 10169267 TI - Should managed care organizations pay for nicotine replacement therapy? PMID- 10169268 TI - Exceptional CHF program is built on best practices, benchmarks. AB - Advocate Health Care in Oak Brook, IL, has built an exceptionally successful congestive heart failure (CHF) program based on best practices. Advocate's 90-day readmission rate for CHF patients is half the national average. A new part of the program, transitional care, has a readmission rate of just 4%. It is based on telephone follow-up and ongoing patient education. Advocate managers are building an internal database for their program, which will allow emergency department staff to access patients' latest labs, EKGs, blood serums, and other information. PMID- 10169269 TI - Don't fret if you can't find your benchmarking mate. AB - Some satisfaction issues are universal. Almost every industry surveys its customers on issues similar to those examined by health care. Health care providers are not restricted to benchmarking against other providers. There are viable partners in other industries to benchmark against. If your facility's surveys are always 100%, have a low response rate, or show problem areas, it's probably time to benchmark patient satisfaction. PMID- 10169270 TI - New information system can lend competitive edge. AB - Information technology provides more than just the means to collect data on best practices and outcomes. It can also give your facility an edge in competing for managed care contracts. Good data systems facilitate communication across the continuum of care and drastically reduce the time and labor needed to gather data and make outcomes comparisons. Managers from quality control, utilization, and other areas tasked with data monitoring should have input into designing and buying information systems. PMID- 10169272 TI - Design a mistake-proof preprinted order form. PMID- 10169271 TI - Hand washing soars after IC posse hits the wards. PMID- 10169273 TI - On-site police substation helps make hospital, neighborhood safer. PMID- 10169274 TI - An interview with: Earl Williams on investigating workers' injuries and illnesses. PMID- 10169275 TI - Training dialysis staff, security to deal with disruptive patients. PMID- 10169276 TI - Security fax system helps hospitals guard against theft, abduction. PMID- 10169277 TI - Meeting the security challenges of wealthy foreign patients: how hospitals in one city are faring. AB - Seattle, WA, hospitals are among the many seeking to attract foreign patients. Seattle is conveniently located, relatively speaking to dozens of Pacific Rim countries with residents who have economic means to seek out first-class health care when they need it. Patients at Seattle hospitals now include Russians in large numbers, as well as significant numbers from Korea, Hong Kong, Japan, the Philippines, Vietnam. Cambodia, Saudi Arabia, and neighboring North African nations. Treating foreign VIPs, however, can bring new challenges to hospital security departments. Many patients, along with their families and entourages, frequently have cultural expectations that differ from those held by many Americans. In one "worstcase" scenario, a hospital official cites behavior of some people who come from places "where it is all right to goose a woman or to pursue her openly." That kind of situation can escalate quickly, the official says. However, "we've had very good success sitting someone down and explaining in a good way that it is not OK to do that here and you can't do it again. Usually we have really good results, but if you go in like gangbusters, it could be a disaster." In this report, we'll describe some other security problems that can come with foreign patients and give details on how Seattle hospitals are meeting them. PMID- 10169278 TI - National campaign pushes hospital use of safer needlestick devices. PMID- 10169279 TI - Ridding hospitals of roaches and rats: how one service does it. PMID- 10169280 TI - Inspecting the inspectors: could JCAHO's deemed status face a threat? PMID- 10169281 TI - What if you don't make the grade? PMID- 10169282 TI - What's important--and not--in QM. PMID- 10169283 TI - The CPHQ (Certified Professional in Healthcare Quality) credential: changing with the field. PMID- 10169284 TI - Managers as patients. Sickness benefit. PMID- 10169285 TI - Contracting. Quality commitment. AB - Almost half of health authorities would accept a reduction in activity levels for demonstrable improvements in quality. A fifth of acute trusts reported poor working relationships with purchasers. Almost two-thirds of acute trusts thought they could improve quality if activity levels were reduced. PMID- 10169286 TI - Communications. Jaw games. PMID- 10169287 TI - Communications. Don't look back in anger. PMID- 10169288 TI - Data briefing. The comprehensive spending review. PMID- 10169289 TI - The veterans healthcare system: preparing for the twenty-first century. AB - Since its establishment in 1946, the veterans healthcare system has greatly expanded in both size and responsibility. It is now the largest integrated healthcare system in the United States, the nation's largest provider of graduate medical and other health professionals training, and one of the largest research enterprises in America. It is also the nation's largest provider of services to homeless persons, an essential provider in the public healthcare safety net, and an increasingly important element in the federal response to disasters and national emergencies. Patterned after what was considered the best in American healthcare, for most of the past 50 years the Department of Veterans Affairs (VA) healthcare has focused primarily on acute inpatient care, high technology, and medical specialization. Now, in response to societal and industrywide forces, the Veterans Health Administration (VHA) is reengineering the veterans healthcare system, changing the operational and management structure from individual hospitals to 22 integrated service networks and transitioning the system to one that is grounded in ambulatory and primary care. This article briefly describes the history and functions of the veterans healthcare system, its service population, and key aspects of its restructuring. PMID- 10169290 TI - Best practices in managing organized delivery systems. AB - The U.S. Department of Veterans Affairs (VA), a large public-sector healthcare delivery system, is following the lead of the private sector in seeking a more integrated approach to providing patient care. The belief is that new entities known as organized delivery systems (ODSs) will produce better, more cost effective care. Toward this end, VA has reorganized its facilities into 22 networks. The purpose of this paper is to provide VA policymakers and managers with information about building and managing an integrated delivery system for the nation's veterans based on findings from the Health Systems Integration Study (HSIS). PMID- 10169291 TI - Transferring managed care principles to VA. AB - The Under Secretary for Health asked the Health Services Research and Development (HSR&D) service to identify the managed care principles that would enable The Department of Veterans Affairs (VA) to most improve its efficiency and effectiveness while retaining its unique mission. In response to this request, HSR&D's Management Decision & Research Center (MDRC) prepared this article. This article represents the initial work done by the MDRC to determine the extent to which readily available published evidence on implementing managed care principles meets the Under Secretary's information needs and to outline potential areas for further work. It provides an overview and synthesis of existing literature. The document was prepared by the MDRC Technology Assessment Program, which took responsibility because of its expertise in systematic reviews and syntheses of the literature, with contributions from the MDRC's programs in information dissemination and management research. PMID- 10169292 TI - Organizational culture: the critical link between strategy and results. AB - The U.S. Department of Veterans Affairs (VA) is undertaking a massive reorganization to transform itself into a more efficient, patient-focused healthcare system. It has developed a new strategy and structure. But if it is to achieve the rapid, sustainable transformation needed to succeed in today's environment, it must also change its culture. The rigid, functionally focused, command-and-control culture that has long been a hallmark of VA must be replaced by one that values speed, flexibility, and the processes for delivering high quality, cost-effective patient care. Such a change will not come easily. In addition to the normal hurdles, several barriers are unique to VA. They include ingrained bureaucratic traditions and behaviors, constraints imposed by the federal government, close scrutiny by powerful service organizations, and a Civil Service employee base that makes the hiring, promoting, and removing of employees a slow, unwieldy, and procedurally complex exercise. In a climate that does not encourage change, successful transformation must be well orchestrated. To drive the change, the leadership must be mobilized as a team, new work processes must be developed, and a full range of human resource processes must be established. PMID- 10169293 TI - Visionary leadership and the future of VA health system. AB - As the U.S. Department of Veterans Affairs (VA) makes the change over to Veterans Integrated Service Network (VISNs) the need for new and better leadership is warranted if VA wants to not only survive, but thrive in the emerging twenty first century healthcare system. VA can prepare for the future and meet the challenges facing them by adopting a system of visionary leadership. The use of scenarios and vision techniques are explained as they relate to VA's efforts to move toward their new system of VISNs. The four scenarios provide snapshots of possible futures for the U.S. healthcare system as well as the possible future role and mission of VA--from VA disappearing to its becoming a premier virtual organization. PMID- 10169294 TI - Strategic alliances in healthcare: opportunities for the Veterans Affairs healthcare system. AB - Strategic alliances are proving to be effective strategies for responding and adapting to changing environments, and as such they offer the U.S. Department of Veterans Affairs (VA) healthcare system valuable opportunities for accomplishing the goals of its major reorganization effort. This article begins with an examination of basic strategic-alliance structures that are employed across many different types of industries. Next, consideration is given to the ways in which these basic alliance structures may be adapted to the unique organizations and individuals that serve as providers, purchasers, and consumers of health services. Finally, this article explores how models of strategic alliance in healthcare can be tailored to the specific needs and constraints of the VA healthcare system through an examination of existing and potential alliance opportunities. PMID- 10169295 TI - Organization design of integrated delivery systems. AB - Healthcare integrated delivery systems (IDSs) evolve through four observed stages of development, with each successive stage having greater levels of interdependence among facilities and between facilities and physicians. The cottage industry stage is characterized by competition among hospitals and little interdependence. Healthcare organizations in the next stage, horizontally integrated systems, have pooled interdependencies, and in the third stage, vertically integrated systems, have predominately sequential interdependence with reciprocal interdependence between physicians and hospitals. In the fourth stage, community healthcare, community systems have reciprocal interdependence among their facilities and other organizations providing services along the continuum of care. This reciprocal interdependence is characteristic of the level of integration that must be addressed for system effectiveness. Greater levels of interdependence require stronger organizational integrating mechanisms and processes. "Integrative management" or "service-line management" is one vehicle for providing this integration. Although few empirical studies are available, this article relates the available empirical and conceptual literature to analyze the interdependencies at each level of IDS development, as well as the organizational design characteristics to address those interdependencies. It then examines the organization of the Veterans Health Administration (VHA) in terms of the four stages of IDS evolution, and suggests organization designs to address VHA's increased needs for integration. PMID- 10169296 TI - Managing the human side of change in VA's transformation. AB - Transformational change interventions often fail or short fall of their intended impact on organizations and systems. One main reason is that these interventions frequently do not strategically address the complex human dynamics of change. This happens despite awareness of and commitment to intervening at this level by top management and change leaders. The wisdom that "systems don't change; people change" is widely acknowledged but inadequately applied. These are exactly the conditions the U.S. Department of Veterans Affairs (VA) faces in deploying its new Veterans Integrated Services Networks (VISNs). Applying validated behavioral science strategies that address the human side of change will help VA implement VISNs effectively. Six strategies derived from many years of study and practice in the public and private sectors are discussed, along with suggestions for VISN managers about how to implement them. PMID- 10169297 TI - The cost-effectiveness of a cardiovascular risk reduction program in general practice. AB - An economic evaluation was conducted alongside a randomised controlled trial of two lifestyle interventions and a routine care (control) group to assess the cost effectiveness of a general practice-based lifestyle change program for patients with risk factors for cardiovascular disease. Routine care was the base case comparator because it represents 'current therapy' for cardiovascular disease (CVD). A 'no care' control group was not considered a clinically acceptable alternative to lifestyle interventions. The interventions consisted of an education guide and video for GPs to assess individual patient risk factors and plan a program for risk factor behavior change. Each patient received a risk factor assessment, education materials, a series of videos to watch on lifestyle behaviors and some patients received a self-help booklet. Eighty-two general practitioners were randomised from 75 general practices in Sydney's Western Metropolitan Region to (i) routine care (n = 25), (ii) video group (n = 29) or (iii) video + self help group (n = 28). GPs enrolled patients into the trial who met selection criteria for being at risk of CVD. There were 255 patients in the routine care (control) group, 270 in the video (intervention) group and 232 in the video + self help (intervention) group enrolled in the trial. Outcome measures included patient risk factor status: blood pressure, body mass index, cholesterol and smoking status at entry to trial and after 1 year. Changes in risk factors were used to estimate quality adjusted life years (QALYs) gained. One hundred and thirty patients in the routine care group, 199 in the video group and 155 in the video + self help group remained in the trial at the 12-month review and had complete data. The cost per QALY for males ranged from $AUD152,000 to 204,000. Further analysis suggests that a program targeted at 'high risk' males would cost approximately $30,000 per QALY. The lifestyle interventions had no significant effect on cardiovascular risk factors when compared to routine patient care. There remains insufficient evidence that lifestyle programs conducted in general practices are effective. Resources for general practice based lifestyle programs may be better spent on high risk patients who are contemplating changes in risk factor behaviours. PMID- 10169298 TI - Reform of primary health care: the case of Spain. AB - Different approaches to health reform are proposed in many countries to overcome inefficiencies in care delivery. This paper assesses an incremental reform initiated in Spain 10 years ago, which sought to improve the efficiency of the entire health system through changes in the organization and delivery of primary care. In this study, aspects of accessibility, comprehensiveness, longitudinality and technical quality of reformed versus unreformed care were assessed for respondents to a household interview survey conducted in the Basque Region of Spain in 1992. According to this study, aspects of care such as longitudinality and technical quality seemed improved with the reform, whereas other aspects such as accessibility and comprehensiveness remained unchanged. The authors conclude that system related characteristics (more associated with access and comprehensiveness) may be impeding the achievement of the goals of the reform and argue that attempts to encourage more autonomy of care delivery may be required. PMID- 10169299 TI - Physician participation in a Medicaid managed care program, the Kansas Primary Care Network. AB - This study was designed to identify the factors that enhance and impede physician participation in a Medicaid managed care program, the Kansas Primary Care Network (PCN). The data for the study were collected in the summer of 1993 through a mail survey of primary care physicians in the PCN service area. Logistic regression and cross tabular analytic techniques were employed for data analysis. The results indicate that physicians who are not receptive to capitation-based reimbursement practices, those who practice in the higher per capita income counties, those who do not compare the PCN reimbursement rates favorably with private insurance rates, and physicians who think that untimely payment and the requirement to document patient referrals for specialty treatment pose problems for them are less likely to participate in the PCN program. Further, the study shows that institutional physicians have larger Medicaid caseloads than solo practitioners, who have larger Medicaid caseloads than single-specialty and multi specialty group practitioners. Since most of the variables that attain statistical significance in explaining physician participation in the PCN program have to do with money, the study reaffirms the two market theory of the United States' health care delivery system. PMID- 10169300 TI - New Zealand policy strategies concerning the funding of general practitioner care. AB - The evolution of New Zealand health policy concerning general practitioner care suggests six major goals: (1) providing GP services universally at zero or very low user charges, (2) increasing the proportion of GPs in rural and sparsely populated areas, (3) increasing the proportion of primary care going to low income populations, (4) increasing the effectiveness of primary care in promoting health, (5) lowering the cost of primary care provision, and (6) giving patient consumers (with particular emphasis on Maori) more control over the environments in which primary services are provided. Policy packages have lacked analytical coherence, however, with the consequence that only some of the goals have been effectively promoted at any point in time. The particular policies promoted have varied over time depending on the political party in power, and on the international climate of opinion concerning the prioritising of goals. The current view is that the most significant shift in New Zealand health policy orientation occurred during 1992-1994, with the emphasis on managed competition strategies and increased reliance on user charges. The 1992-1994 policy reforms also reflect a long-standing orientation in New Zealand of attempting to separate the care of the poor from that of everyone else, and of providing care for the poor by the state in a paternalistic context, and the care for the non-poor in market arrangements that reflect the preferences of patients. PMID- 10169301 TI - Testing the HMO competitive strategy: an analysis of its impact on medical resources. AB - Competitive approaches to health care reform, including managed competition, are hypothesized to reduce health care expenditures and the resources devoted to medical care. Empirical evidence has been limited. The short- and long-run effects of an experiment closely resembling managed competition are analyzed. We examine effects on hospitals, technology diffusion, physicians, and health insurance premiums. The strategy reduces capital in hospitals, has minor effects on physicians and technology, and has only initial effects on average premiums. PMID- 10169303 TI - Optimal non-linear health insurance. AB - Most theoretical and empirical work on efficient health insurance has been based on models with linear insurance schedules (a constant co-insurance parameter). In this paper, dynamic optimization techniques are used to analyse the properties of optimal non-linear insurance schedules in a model similar to one originally considered by Spence and Zeckhauser (American Economic Review, 1971, 61, 380-387) and reminiscent of those that have been used in the literature on optimal income taxation. The results of a preliminary numerical example suggest that the welfare losses from the implicit subsidy to employer-financed health insurance under US tax law may be a good deal smaller than previously estimated using linear models. PMID- 10169302 TI - Taxation, smuggling and demand for cigarettes in Canada: evidence from time series data. AB - This study analyzes Canadian cigarette consumption and taxation between 1980 and 1994, a period in which there have been large price rises and declines, and a dramatic increase in the consumption of contraband tobacco products. We examine elasticities of legal cigarette sales and total sales (including contraband) with respect to the price of legal cigarettes and various other factors. The growth of the contraband market since 1987 appears to have created two classes of cigarette -taxed and untaxed--with responses to changes in the legal price that are respectively higher, and lower, than was previously the case. The sensitivity of total cigarette sales to the taxation instrument is much lower than it would appear from sales of taxed cigarettes alone. PMID- 10169304 TI - Do fee descriptors influence treatment choices in general practice? A multilevel discrete choice model. AB - Before 1990 Australian general practitioners (GPs) were remunerated according to consultation length. This was assumed to encourage GPs to prescribe more, counsel less and provide fewer treatments than were 'appropriate'. In an attempt to change this behaviour, the remuneration system was altered to reflect the content of consultations. This paper analyses, through the use of multilevel modelling, the effect of content-based descriptors on the discrete choice behaviour of GPs while controlling for patient, GP and practice characteristics. GPs who used content-based descriptors were just as likely to prescribe, counsel and treat compared to GPs who used time-based descriptors. PMID- 10169305 TI - Willingness to pay for poison control centers. AB - We used the willingness-to-pay (WTP) method to value the benefits of poison control centers when direct access was blocked, comparing WTP among: (1) blocked callers (n = 396), (2) callers after access was restored (n = 418), and (3) the general population (n = 119). Mean monthly WTP was $6.70 (blocked callers), $6.11 (non-blocked callers), and $2.55 (general population). Blocked and non-blocked callers had a significantly higher WTP than general population respondents (p < 0.001). We conclude that the WTP method measured benefits that are difficult to quantify; however, WTP surveys need to be carefully conducted to minimize bias. We discuss how this approach could be useful for other health care services. PMID- 10169306 TI - Price, tobacco control policies and smoking among young adults. PMID- 10169307 TI - Worker demand for health insurance in the non-group market: a note on the calculation of welfare loss. PMID- 10169308 TI - My hospital has a robot! PMID- 10169309 TI - Making the most and making sense: ethnographic research on spirituality in palliative care. AB - Presents ethnographic research on spirituality in palliative care. Reviews the literature and interviews palliative care staff along with their patients. Discovers two dominant themes in the literature and interviews with staff and patients around spirituality: making the most of it now and making sense. Discusses findings and suggests implications for the practice of spiritual care. PMID- 10169310 TI - Grafting clinical pastoral education: teaching competencies for the new spiritual care work. AB - Proposes that preparing chaplains for integrated system spiritual care will involve acknowledging the need for new learnings and identifying competencies that will be useful in emerging health care structures. Provides a sketch designed to achieve these objectives and shares specific instruments to aid in facilitating movement toward appropriate competencies. PMID- 10169311 TI - Pastoral care of the premature baby. AB - A chaplain shares his learning in his attempts to deliver meaningful pastoral care to premature babies in a Neonatal Intensive Care Unit of a hospital. Explicates some of the parallels between pastoral communication with adults and with babies, noting especially the necessity of recognizing the need for creative modification of adult modes of care. PMID- 10169312 TI - The letting loose of hope: where psychology of religion and pastoral care converge. AB - Argues that William James's pragmatic method of truth provides a bridge over which the fields of psychology of religion and pastoral care might together pass. Proposes that this method enables us to see that psychology of religion understands hope to be the core of genuine religious experience and that pastoral care is fundamentally about enabling individuals (singly or collectively) to have, and recognize that they have had, religious experiences of hope. PMID- 10169313 TI - The religiosity variable and personal empowerment in pastoral counseling. AB - Claims that therapeutic fuzziness and unexplored assumptions contribute to an all too-ready devaluing or dismissal of what is important to religious clients. Argues that sorting out the client's religiosity components into facets of religion, spirituality, and theology to reflect respectively the process, capacity, and product of meaning-making serves to shed light on why consideration of religiosity is important in therapy. Notes that such processes of discernment provide a bridge between the sciences (e.g. psychology) and humanitarian (e.g. religiosity) endeavors in that both engage in the same meta-process of meaning making in their search for empowerment, although they do so from different perspectives and different initial suppositions. Concludes that the art of psychotherapy can draw on the content of both science and religiosity to facilitate well-being in clients and in therapists alike. PMID- 10169314 TI - The applicability of selected rational-emotive therapy principles for pastoral counseling. AB - Examines the compatibility and possibility of communication between pastoral counseling and Rational-Emotive Therapy (RET). Uses a Delphi technique to determine whether a randomly selected group of pastoral counselors (N = 15) believe that the basic principles of RET can be used without surrendering theological tenets foundational to pastoral counseling. Concludes that some RET principles may be applicable for pastoral counseling. PMID- 10169316 TI - "Hear a just cause, O Lord, attend to my cry": organ donation and pastoral care. AB - Reports the findings of a survey of hospital chaplains, congregational clergy, and seminary students on the subject of organ donation. Points out the need for additional education and theological discussion focused on the donation of organs. PMID- 10169315 TI - Quantitative and qualitative outcome research on a regional basic supervised SPE (supervised pastoral education) program. AB - Discusses issues in the evaluation of supervised pastoral education (SPE) programs. Explains four ways of applying triangulation in developing an accurate evaluation of SPE and presents a case study of an SPE program evaluated through triangulation Offers suggestions about the use of triangulation on SPE program evaluation. PMID- 10169317 TI - Effects of physician outreach programs on rural-urban differences in breast cancer management. AB - In 1986 to 1987, urban-rural differences in several breast cancer management practices were noted in Illinois data. Several intervention programs for physicians were initiated to improve rural patients' access to state-of-the-art breast cancer management to reduce these differences. This report compares an intensive rural oncology outreach intervention program with a lower intensity physician education program. Medical records from 1986 to 1991 were reviewed on 2,277 breast cancer patients in a 12-county study area. The care received by urban patients was compared with three groups of rural patients: those managed in rural hospitals with intensive oncology outreach programs beginning in 1988 (Rural group 1), and in those rural hospitals with less intensive interventions using an audit with feedback strategy beginning in 1989 (Rural group 2). Rural patients who traveled to one of the urban facilities also were included in the analysis because the less intensive interventions also took place in these facilities, and these patients showed unique patterns of care in the baseline analysis (Rural Group 3). The years 1986 to 1987 constituted the baseline, and 1990 to 1991 constituted the final evaluation period. Chi square and multivariate analyses were conducted to compare the effect of the two types of interventions on changing breast cancer management practices and reducing the urban-rural differences. By the final evaluation period, the high intensity intervention was not more successful in reducing or eliminating the urban-rural differences than the low intensity intervention for many practices. However, often the frequency estimates were higher in Rural Group 1, which received the high intensity intervention. The changes noted in Rural Group 3 were not always the same as in Rural Group 2, even though both received the same low intensity interventions, lending evidence to the observation that travel distance and other nonmedical factors affect the choices of management modalities for these patients. Finally, given the nonrandomized study design, other explanations for the changes could not be ruled out. PMID- 10169318 TI - Rural-urban comparisons of age and health at the time of nursing home admission. AB - This study re-examines the contention that rural elders admitted to nursing homes are younger and healthier than their counterparts who enter urban facilities. The analysis uses interview data gathered in both urban and rural nursing homes. Residents were interviewed at or near the time of admission regarding their health and circumstances immediately prior to entering the nursing home. The findings indicate few and modest differences between urban and rural residents. In those instances where differences are observed, there is ambiguity--some measures indicate lower health status in the case of rural residents, while others suggest that urban residents are more likely to report health impairments. The divergence of these findings from earlier research may be due to differences in the study populations, measurement differences, or, more likely, that policies and processes have changed over time. PMID- 10169319 TI - How rural physicians compare on cost and quality measures for Medicaid ambulatory care episodes. AB - This study compares the costs and quality of episodes of care for two common childhood illnesses, urinary tract infections (UTI) and otitis media (OM), across providers practicing in rural, small town, and urban counties in Alabama in 1992. The data source is Medicaid claims data for children under age 8 who were treated for these conditions. The study found that episodes cared for by rural providers were less expensive than episodes cared for in other locations, both because fewer rural episodes included outpatient facility charges and because fewer ancillary services were provided in rural settings. Researchers also found that, even controlling for physician characteristics and patient demographic and utilization factors, rural episodes were significantly less likely to include two process measures of quality of care: fewer rural UTI episodes included urine cultures, and fewer rural OM episodes included follow-up visits. This study suggest that, as a group, rural physicians may have a favorable cost profile but a potentially unfavorable care content profile, compared with other physicians. Both practice profile data and explicit care recommendations need to be available to physicians so thy can monitor, defend, or alter their clinical practices. PMID- 10169320 TI - Rural radiology: who is producing images and who is reading them? AB - The purpose of this study is to identify the local availability and trends in local availability of imaging technology and interpretation services in rural hospitals in the northwestern United States during the period between 1991 to 1994. Another objective is to describe hospital and community factors associated with the diffusion of image production and interpretation services. The information for this study was gathered through telephone surveys of rural hospital administrators in eight northwestern states in 1991 and 1994. The availability of magnetic resonance imaging (MRI) equipment, computed tomography (CT) scanners, ultrasonography equipment, and dedicated mammography equipment increased between 1991 and 1994. The increases in MRI units were primarily in mobile equipment, while ultrasonography and mammography equipment increases were primarily fixed hospital-based units. In 1994, image interpretation in the rural hospitals was provided by both primary care and radiology physicians. Forty-six (11.5%) of the rural hospitals had no on-site radiology services and only 73 (18%) had daily radiology services. Between 1991 and 1994, 12 hospitals gained at least once-a-week radiology services, but 24 lost all radiology services. Teleradiology availability more than doubled during the three years. Radiology technology has diffused widely into rural communities in this region of the United States at differing rates for large and small hospitals. Radiologists are available to these hospitals only 46 percent of the days each year, with more days of availability in the larger hospitals and fewer days in the smaller hospitals. Teleradiology capability is increasing more rapidly in the larger hospitals that have radiologists more readily available. PMID- 10169321 TI - Importing employer-based managed care initiatives to rural areas: the experience of the South Dakota state employees group. AB - In urban areas, employers are frequently in the forefront of efforts to implement managed care initiatives at the community level, either individually or through coalitions. While employer-driven managed care initiatives also exist in rural areas, they are less common and much less is known about them. This article describes and analyzes the early experience of a large rural employer--the state of South Dakota--in its attempt to develop and implement a managed care initiative. Several aspects of that experience suggest that employer-driven managed care models in urban sites may require reexamination and redefinition for implementation in rural areas. PMID- 10169322 TI - Conditions affecting rural hospital specialization, conversion, and closure: a case-based analysis of threat and change. AB - The purpose of this analysis is to increase understanding of how and why rural hospitals change, with an eye toward the relevance of these questions to overall access and quality in the rural community. This study reports the threats that precipitated three major classes of organizational change (specialization, conversion, and closure) in 16 rural hospital cases. The authors identify the types and levels of threat faced by the case hospitals and examine how different threat situations may lead toward different classes of change. Conversions and closures typically seem to result from moderate- or high-threat situations. Specializations seem to result from low- or moderate-threat situations. PMID- 10169323 TI - The role of race and residence in determining stage at diagnosis of breast cancer. AB - Breast cancer kills more than 46,000 women each year. Previous research has found that minorities and those who reside in geographically remote settings are particularly vulnerable. However, virtually no research has been done on the potential "double jeopardy" faced by rural minority women. This research examines (1) the extent to which racial and residential differences contribute to differences in stage at diagnosis; (2) the existence of an interaction between race and residence, which may place black rural women at greater risk; and (3) the influence of both individual and structural characteristics on racial and residential differences. The findings indicate that rural black women are diagnosed with breast cancer much later than are black urban women or whites of either residence. A number of individual and structural variables were influential in predicting stage at diagnosis, yet none of these accounted entirely for racial differences. PMID- 10169324 TI - MSAs: is there demand? New IRS figures show experiment goes slowly, but supporters say just wait. PMID- 10169325 TI - AHA's million-dollar man. Davidson's pay rising as his association keeps shrinking. PMID- 10169326 TI - The patient or the wallet. N.H. hospitals battle over open-heart surgery CONs. PMID- 10169327 TI - A healthcare Baldridge? Congress considers funding quality award for providers. PMID- 10169328 TI - N.C. deal may signal antitrust policy shift. PMID- 10169330 TI - Mergers hit another field. Medical malpractice insurers vie to expand markets. PMID- 10169329 TI - Organizing specialists. More than 600 physicians have signed up for Oxford 'teams' in N.Y.C. area. PMID- 10169331 TI - Seniors on patrol. HHS trains retired professionals to find Medicare fraud. PMID- 10169332 TI - Keep it simple. HMOs' image will improve when the complexity imposed on patients is removed. PMID- 10169333 TI - Which is the real Kaiser? AB - Fans of Kaiser Permanente, the nation's oldest and largest HMO, consider the company a cost-effective healthcare delivery system that supports its patients, caregivers and the practice of high-quality medicine. Its detractors see Kaiser as an evil HMO empire that hoards money, mistreats doctors and skimps on care. The dichotomy shows that Kaiser is like a giant mirror, reflecting the struggles and uncertainties of the evolving U.S. healthcare system. PMID- 10169334 TI - On call. Foundation Health Systems' sophisticated telephone triage center gains popularity with patients and physicians. PMID- 10169335 TI - We blew it, AMA admits. But Sunbeam may try to hold group to endorsement deal. PMID- 10169336 TI - Psyched up. Hospitals rush to add geriatric mental health services. PMID- 10169337 TI - Scrubbing emissions. EPA toughens rules on incinerators; many may close. PMID- 10169338 TI - UPS strike slowed supply stream. PMID- 10169339 TI - Hospital forecast: unsettled. Urban areas, Northeast may be not-for-profit trouble spots. PMID- 10169340 TI - House and Senate approve budget reconciliation bills. PMID- 10169341 TI - Practice expense payment changes will be phased in. PMID- 10169342 TI - Redesigning the business services department. PMID- 10169343 TI - Marketing and the medical specialist in the managed care environment. AB - Marketing means more than just communicating or advertising to potential patients; marketing means identifying your customers and working to meet or exceed their expectations. There are five key areas of a marketing plan: (1) Establish the foundation, beginning with your mission statement; (2) Assess your marketing environment by internal and external research; (3) Target your efforts, looking at image and perception; (4) Develop your particular mix of product, price, place of distribution, and promotion; and (5) implement and evaluate your marketing process. This article discusses the importance of a marketing plan for the medical specialist and highlights the features unique to a practice working in a system of capitated reimbursement. Applying these principles will help to demonstrate added value, protect the fundamental role of the patient-physician relationship, ensure that our efforts are aligned with professional missions and goals, and ultimately increase profitability and professional success. PMID- 10169344 TI - New thinking for health care leaders. AB - What is the difference between strategic management and a typical strategic plan? It is simply not enough today to restate and refine current organizational strategy, when the environment is demanding innovation and the rules of the game are rapidly changing. What are the consequences for hospital administrators and boards that still believe that catering to medical specialists and inpatient facility improvement will suffice when the future will be driven by greater needs for outpatient and primary care provider services? Developing a plan based on outdated operations or assumptions may speed the organization's decline. Strategic management involves a process of thinking through a "vision" of what sort of organization you want and asking extremely difficult questions. PMID- 10169345 TI - The coming globalization of health care. AB - In Phase One of the global economy, international marketing of goods was paramount. In Phase Two, the marketing of services is becoming an increasingly important force. And one of the industries best positioned to profit from the globalization of services is U.S. health care. For years, a small number of providers with international reputations has catered to foreign patients. But the competition for this potentially lucrative market is on the verge of exploding. It's been estimated that the number of foreign patients visiting the U.S. for health care will quadruple in the next few years. How is this new global phenomenon unfolding, who are the potential players in the market, and what obstacles and opportunities exist? Is it so preposterous to imagine Egyptians undergoing heart bypasses in Boston? The fact is, it's already starting to happen. PMID- 10169346 TI - Assess your quality of care quotient. AB - The upsurge of large, single/multi-specialty group practices in contemporary health care has precipitated a corresponding surge in marketing strategies aimed at promoting group speed, efficiency, and/or productivity. Subsequently, the quality of care is often overlooked or redefined in financial terms. However, assessing quality of care--above and beyond strictly economic factors--can provide crucial information for executives concerned with making informed managerial decisions. This article explores one prototypical physician group's quest to assess their "quality care quotient," and explicates the process by which they obtained important data from patients, as well as how they used the assessment to improve their practice. The process may serve as an exemplar to physician groups concerned with conducting such analyses. PMID- 10169347 TI - Why activity-based costing works. AB - With advancing technology and the quest for delineating the true cost of a procedure or diagnostic test, cost accounting techniques are being re-explored in the health care setting. Activity-based costing (ABC), adopted from other businesses, is one such example that has applications in the health industry. The purpose of this paper is to enhance the understanding of health care costs among physician providers, emphasizing a new approach--activity-based costing. PMID- 10169348 TI - Health care futures. Part 2: The future of physician executives? Panel discussion. AB - What is the future of health care in America? This is Part 2 of The Physician Executive panel discussion that explores the future of health care in America. To narrow this ambitious focus somewhat, the future is defined as five to 10 years hence. In Part 1, which was published in the May/June issue, Russell C. Coile, Jr., Barbara LeTourneau, MD, MBA, FACPE, James Reinertsen, MD, Uwe Reinhardt, PhD, Marshall Ruffin, MD, MPH, MBA, FACPE, and David Vogel, MS, shared their opinions about what the future holds in managed care, information technology, and biotechnology. In Part 2, Susan Cejka, Barbara LeTourneau, MD, MBA, FACPE, John Henry Pfifferling, PhD, Uwe Reinhardt, PhD, and James Todd, MD, share their views on the future of medical education and physician executives. PMID- 10169349 TI - Forming physician organizations. Part 2: The underlying reason a PO succeeds: an offense, not defense. AB - How has Community Health Partners been able to move the ball down the field toward the goal of a preferred network in its community? What are the specific offensive strategies CHP has implemented to bring about its vision? Part 1 of this series explored five reasons for CHP's progress: (1) A working, knowledgeable board of respected physicians, (2) A board that moves ahead on simultaneous tracks, (3) a willingness to affiliate with any hospital or payer that really knows how to partner with physicians, (4) developing quick wins and communicating the progress, and (5) educating physicians about the new ground rules for capitation. Here are six more reasons for CHP's success in forming a PO. PMID- 10169350 TI - Spinning the future. AB - You may not be able to predict the future, but you can create scenarios to help you think about the future proactively. Instead of attempting to tell the future, tell stories about it. Here are eight steps to help you zero in on the future- they are designed to take you through the process of spinning scenarios in order to make decision-making, long-term planning, and thinking about the future more fruitful. Spinning scenarios is a highly sophisticated, singularly useful, and imminently practical way to think about the future. Yet, it is simple enough that you can do it yourself. PMID- 10169351 TI - What kind of feedback are you soliciting? AB - How can you assess how well you're performing? From benchmarking to finding a mentor, here are some suggestions to help you solicit meaningful feedback to improve your performance. The feedback that's most beneficial isn't an opinion- even the CEO's, although it's important--because it's often the opposite of fact. You need standards against which to measure yourself that aren't tightly linked to your organization's culture, so you'll need to research what's going on with your competitor's employees and network with other professionals. PMID- 10169352 TI - The three R's of writing: reading, "riting," and risking. AB - The mere thought of writing an article can be intimidating. But, even if you have the desire, despite the fear, to write an article, how do you get started? How can you produce satisfying work? Is there a way to begin writing, get your ideas down, and save judgments and editing for alter? Here are some steps--Reading, "Riting," and Risking--to help you write that article you've been thinking about. By separating the process into two stages, creativity or freewriting, and then criticism or editing, you'll find writing much easier. PMID- 10169353 TI - Strategic positioning. Part 1: The sources of value under managed care. AB - Part 1 of this series organizes and discusses the sources of value against a background of an evolving managed care market. Part 2 will present, in more detail, the marketing and financial challenges to organizational positioning and performance across the four stages of managed care. What are the basic principles or tenets of value and how do they apply to the health care industry? Why is strategic positioning so important to health care organizations struggling in a managed care environment and what are the sources of value? Service motivated employees and the systems that educate them represent a stronger competitive advantage than having assets and technology that are available to anyone. As the health care marketplace evolves, organizations must develop a strategic position that will provide such value and for which the customer will be willing to pay. PMID- 10169354 TI - Putting "teeth" in your resume. AB - How can physician executives get the kind of management experience they need to move to the next level? Is the MBA the end all or can significant management experience and top assignments impress recruiters and CEOs? Here are some important questions to ask yourself about each job you have held as you prepare to move forward in your career: How did I improve the organization? How did I contribute to greater efficiency? How did I affect productivity? How did my work increase the bottom line? Thinking about these questions can help you put teeth in your resume and get you where you want to go. When you can answer those questions from your own experience, you will have created a powerful career track record that is likely to impress the next CEO whose staff you want to join. PMID- 10169355 TI - Providing children with health care. AB - Introducing a new column on health policy issues of relevance to physician executives. What are the legislative options to provide children with health care coverage? Federal health initiatives for children have become the next frontier in health care reform. This column defines the problem in the U.S., describes voters' support for a federal initiative, and provides discussion of the options available to federal legislators. PMID- 10169356 TI - Who is the victim? Ordinary families bending the rules, not just crooked docs, are fueling the explosion in home care cost. PMID- 10169357 TI - Code blue at Columbia/HCA. Why the for-profit hospital chain needs to clean up after former CEO Rick Scott. PMID- 10169358 TI - Shaping up for the sixth round. PMID- 10169359 TI - Australian registered nurses describe the health care workplace and its responsiveness to sexual harassment: an empirical study. AB - This report is a summary of findings from a 1995 study of Australian registered nurses and their perceptions of their health care workplaces, especially as it relates to sexual harassment. There is little Australian-based empirical research available to guide hospitals and health care facilities in developing appropriate policies regarding sexual harassment. Additionally, hospitals have few assessment tools at their disposal to determine if policies and procedures are well known and effective. As the major employer of registered nurses, hospitals and health care facilities need to be concerned about employees' perceptions of the workplace. PMID- 10169360 TI - Spirituality and discourse: a postmodern approach to hospice research. AB - In modern western society, because of the dominance of secular modernist ideas of rationalism and positivistic science, notions of spirituality have been at best marginalised, at worst excluded from our discourse on health care. Research into spirituality has been limited by modernist epistemological assumptions concerning 'objective' proof and measurements. This discussion seeks to help reverse such a direction by offering an example of research on an Australian hospice service (Karuna Hospice Service) which is inclusive of the notion of spirituality. This research indicates that a spiritual discourse was not only important in the genesis of this organisation, but is also a significant factor in energising and guiding the ongoing democratic, holistic, compassionate praxis of this hospice service. PMID- 10169361 TI - Australian nursing and pharmacy labour force data available. PMID- 10169362 TI - To market, to market: corporatisation, privatisation and hospital costs. AB - The Australian political arena echoes with calls for the privatisation of health care institutions, the contracting-out of health care services and the introduction of various marketing strategies into hospital management. These calls are justified by asserting that the market, rather than the public sector, can provide better services, greater productivity and increased efficiency. The National Health Strategy (1991, p 17) provides a good example. Noting that Australia is copying American investment trends for hospital 'chains' rather than for independent small establishments, the strategy dismisses any concern over changes in ownership, pointing instead to a 'process of rationalisation' that is to be 'welcomed'. Using evidence from the United States, United Kingdom and Australian hospital sectors, this paper examines claims for the greater efficiency of market processes. PMID- 10169364 TI - Automated coding of cause of death. PMID- 10169363 TI - Heart disease and stroke: recent mortality trends. PMID- 10169365 TI - Classifying sub-acute and non-acute patients: results of the New South Wales Casemix Area Network study. AB - In 1994 the New South Wales Casemix Area Network initiated a study to develop a classification and funding model for sub-acute and non-acute care. Thirty-five rehabilitation, geriatric, psychogeriatric and palliative care services were recruited into the study throughout eight area health services. The aim of the first phase, summarised here, was to capture and analyse a sufficiently large quantity of data to select those variables most likely to predict resource utilisation, for subsequent use in a detailed costing study. It is known that acute care diagnosis related groups are not predictive of costs in sub-acute care. This phase of the project confirmed that, in New South Wales, the most predictive variables were case type, functional status measures, impairment type for rehabilitation, phase for palliative care and severity of symptoms for palliative care. The resultant Phase 1 casemix classification, which has built on recent United States experience and studies in other Australian States, has been termed the New South Wales Sub-Acute and Non-Acute Patient (SNAP) Version 1 classification. PMID- 10169367 TI - Post acute care: can hospitals do better with less? AB - Judging by reports in medical magazines and journals, 'early discharge schemes', better termed 'post acute care', are not popular with doctors. However, government policy encourages earlier discharge from hospital, so that the choice facing clinicians is to discharge patients early with support, or early without support, or deal with the consequences of length of stay overruns. Fortunately, government funding for post acute care is increasing. There is a strong rationale for post acute care based on better patient outcomes and cost-effectiveness, but these desirable results will only be achieved if scrupulous attention is paid to detail, as embodied in the 10 principles of post acute care. To function optimally, post acute care should be coordinated by the hospital which provided the acute care. PMID- 10169366 TI - Recruitment of medical practitioners to rural areas: a practical approach from the coalface. AB - The successful recruitment of medical staff to country areas is a difficult process. This paper outlines strategies designed to increase the probability of a successful recruitment program. Strategies include determining if the position is truly required, designing an advertising campaign that reaches the target audience and addressing the significant regional and medical factors influencing the attractiveness of positions. Other areas discussed include the role of local hospitals, factors unique to individual medical practitioners, contracts and two possible long-term solutions--familiarising medical students with rural practice and recruiting overseas doctors. PMID- 10169368 TI - The home based rehabilitation service: rationale, operation and outcomes. AB - The Home Based Rehabilitation Service was established as an allied health early discharge and outreach service from a major metropolitan post-acute teaching hospital. Two hundred and eighty-two patients were discharged to the service according to established criteria from the following specialities: neurology, neurosurgery, rheumatology, amputation, orthopaedic and spinal. Inpatient length of stay was reduced by 19 days on average (the range was 3-75 days). Inpatient throughput was increased equivalent to 10 extra beds on an annual basis. The cost of home-based services was 11 per cent of the cost of the inpatient services they replaced. There were low rates of hospital readmissions, and users registered high levels of satisfaction with the service. PMID- 10169369 TI - Adult intensive care in an environment of resource restriction: how should the unit director respond? AB - Adult intensive care touches the lives of very few while consuming a disproportionately high level of resources. To survive in the future environment of resource restriction and accountability, the unit director must rapidly acquire a wide range of professional management skills. The intensive care unit director must be able to demonstrate to colleagues, health managers and the community that the large amount of resources provided to intensive care, and the remarkable freedom given to intensivists to use those resources, are justified in terms of compassionate evidenced-based care, efficiency, efficacy and appropriateness. While many outcomes may be subjected to audit, intensive care units must publish minimal performance data indexed to severity of illness and including their mortality, hospital mortality and length of stay and an overall indicator of patient acuity to identify patients at low risk who need not be admitted to an expensive intensive care bed. PMID- 10169370 TI - Corporate management and clinical autonomy: the ethical dilemma in mental health. AB - Funding constraints and management practices are increasing pressure on clinical autonomy within Australian mental health services. The introduction of total quality management, output-based funding and changes to public mental health policy have promoted business-like efficiency and increased control of resources. It is argued that such moves significantly circumscribe the discretionary authority that mental health professionals have previously enjoyed. This paper attempts to highlight the ethical and moral tension inherent with a corporate management approach, and calls for mental health services to acknowledge the value of intellectual capital, creativity and innovation. PMID- 10169372 TI - Display challenges hold up move to telemammography. PMID- 10169371 TI - A partnership of care: an approach to the management of adults with cystic fibrosis. AB - Several factors occurring more or less simultaneously have led to a major change in the management of adults with cystic fibrosis at The Prince Charles Hospital, Brisbane. Less than 50 years ago, 80 per cent of infants born with cystic fibrosis did not survive the first two years of life. In Australia today, the median survival is around 30 years of age, with many surviving into their fourth decade (Landau & Ryan 1991, p 4). Recent developments in the management and treatment of cystic fibrosis provide an exciting and promising foundation for further development and a changing focus in cystic fibrosis management. Increased longevity has significant implications for the management of adults with cystic fibrosis. Until recently, most people with cystic fibrosis were managed within the paediatric setting, with the expectation that life expectancy would not exceed adolescence. In reality, there has been a dramatic increase in the number transferring from children's hospitals to adult facilities, and a subsequent need to provide optimal care to a group of patients coming to terms with their own perceptions of being adolescents with a life-shortening condition. From an organisational perspective, the increased demand for resources has generated the need to consider alternative methods of providing care. Such options include home intravenous therapy, day admission, alternative accommodation and education of staff in remote health centres. Home intravenous therapy has proven to be a popular alternative to hospital treatment and has significant implications for reducing lengths of stay and occupied bed-days. Within the current focus on best practice, developing strategies for providing optimal health care in the hospital setting are paramount. A multidisciplinary team focus based on a 'partnership of care' philosophy underpinned by best practice principles describes the approach adopted by the cystic fibrosis team at The Prince Charles Hospital that has led to successful outcomes in meeting challenges inherent in the care of young adults with cystic fibrosis. PMID- 10169374 TI - Remote ultrasound reading earns its keep in Seattle. Suburban patients avoid travel to downtown hospitals. PMID- 10169373 TI - Ultrasound given shakedown for evaluating venous clots. Negative results too common for lower extremity scans. PMID- 10169375 TI - Digital revolution ready to sweep x-ray imaging. PMID- 10169376 TI - Mass customization can cut costs, enhance quality. PMID- 10169377 TI - Lessons learned from CT provide guide for the '90s. PMID- 10169378 TI - Computer vision. Exploiting the processing power of advanced imaging workstations. PMID- 10169379 TI - Tc-99m sestamibi exam finds niche in breast Dx. PMID- 10169380 TI - X-ray and CT top choices in refurbished market. PMID- 10169381 TI - GE finds national stage for digital mammography. PMID- 10169382 TI - MR finds structural changes before cartilage degenerates. Microenvironment of water gives up secrets. PMID- 10169383 TI - Drug policy in China. Transformations, current status and future prospects. AB - The pharmaceutical sector in China developed rapidly with the implementation of the market-oriented economic reforms, which began at the end of the 1970s. From 1980 to 1988 the production of drugs quadrupled, subsequently increasing at an annual rate of 20%, and consumption of drugs correspondingly increased. The increase in drug production was largely a result of the increase in the number of pharmaceutical companies, particularly the number of private joint ventures, of which there were none in 1980 and 1900 in 1994, accounting for 37% of the total number of pharmaceutical companies. With the transformation of the Chinese pharmaceutical market, some new problems have appeared. The low efficiency of pharmaceutical companies, poor-quality drugs, unfair competition and misuse of drugs have been of great concern to the Chinese government. Some countermeasures have been taken, but the problems remain. Increases in the age of the Chinese population, increases in income and changes in disease patterns, together with membership of the World Trade Organization will promote the development of the pharmaceutical market. However, health-insurance reform, an essential drug list, the separation of drugs from services, and controls on the increases in hospital revenue will reduce the demand for drugs. Pharmaceutical companies in China face both opportunities and challenges. The trend in development of the pharmaceutical market depends on the outcome of the interaction between the factors that increase, and those that decrease, the demand for drugs. While the general trend is towards an increase in the demand for drugs and the expansion of the pharmaceutical market, downward fluctuation is inevitable if effective health reforms of cost control are introduced nationwide. PMID- 10169384 TI - Publication bias in clinical trials and economic analyses. AB - Publication bias is an established notion in the clinical literature; essentially, large studies or positive results are more likely to find their way into the public domain than small studies or negative results. Meta-analysis presents a focus for the problems of publication bias, seeking to summarise the evidence in a particular therapeutic area by retrieving and analysing all available clinical studies. Economic analyses are also vulnerable to publication bias, and at 3 levels: first, in the health-outcomes data available for modelling (resulting from publication bias in the clinical literature); second, in the motivations for conducting an economic analysis; and third, in repeating the process of seeking publication. PMID- 10169385 TI - Cost effectiveness of the prevention and treatment of deep vein thrombosis and pulmonary embolism. AB - The purpose of this article is to review and critically appraise the cost effectiveness analyses that have compared various modalities for the prevention and treatment of deep vein thrombosis (DVT) and pulmonary embolism. Studies were identified by MEDLINE search and review of bibliographies of retrieved articles. Original economic analyses for the prevention or treatment of venous thromboembolism published in the English language literature were included in the analysis. In addition to collecting clinical and economic data, the methodological quality of the studies was evaluated using predefined criteria. Separate analyses were performed for studies of the prevention, and of the treatment, of venous thromboembolism following general surgery and following total hip arthroplasty. Fourteen cost-effectiveness analyses involving thromboembolic prophylaxis following total hip arthroplasty and 7 following general surgery met the eligibility criteria for this analysis. Each of the total hip arthroplasty studies containing a 'no intervention arm' determined that effective forms of prophylaxis not only reduced the rates of venous thromboembolic complications, but were less costly than a strategy of not providing venous thromboembolic prophylaxis. Six of 7 studies found low-molecular weight (LMW) heparin to be more effective, and 4 of 7 found it to be less costly, than either unfractionated heparin or warfarin for the prevention of venous thrombosis following total hip arthroplasty. Following general surgical procedures, 6 of 7 studies found prophylaxis to be both more effective and less costly than no prophylaxis. Two studies also concluded that LMW heparin was more effective and less costly than unfractionated heparin for the prevention of DVT after general surgery. In general, the studies included in this overview were of high methodological quality with 11 of 15 studies fulfilling 4 or more of the 6 criteria for sound cost-effectiveness analyses. Effective venous thromboembolic prophylaxis results in fewer complications and is less costly than no prophylaxis following general surgery and total hip arthroplasty. LMW heparin was reported to be more efficacious and cost effective than unfractionated heparin following general surgery, and unfractionated heparin and warfarin following total hip arthroplasty. However, these findings must be regarded with caution in view of recent clinical trials and a meta-analysis reporting that the efficacy of LMW heparin and unfractionated heparin are similar following general surgery, and the efficacy of LMW heparin and warfarin are similar following total hip arthroplasty. Conclusions about the most cost-effective treatment for DVT await the publication of cost analyses from clinical trials comparing outpatient subcutaneous LMW heparin with inpatient therapy with intravenous unfractionated heparin. PMID- 10169386 TI - Economics of thromboprophylaxis in total hip replacement surgery. AB - In 1997, 50,000 hip replacements will be performed in the UK, and over 1 million worldwide. Venous thromboembolism is the most frequent serious complication following joint replacement; its effective and economic management is essential. Antithrombotic prophylaxis can be used to reduce the incidence of venous thromboembolic disease, which presents as either deep vein thrombosis or pulmonary embolism. A number of published studies have shown that prophylaxis against venous thromboembolism is financially beneficial in terms of reduced diagnostic and treatment costs. Cost-effectiveness studies have provided a comparison of the costs and consequences resulting from alternative prophylactic programmes. This article reviews the epidemiology of venous thromboembolism after total hip replacement, prophylaxis against it and a model for cost-effectiveness analysis. Its aim is to highlight inadequacies in the available data and areas of uncertainty within the model that require further research. Pharmacoeconomic studies published to date have all used a similar framework to allow prophylactic options to be compared. However, assumptions made about the frequency of clinical disease have varied widely between studies. This degree of uncertainty calls into question the validity of reported incremental cost savings between treatments. Some studies have also failed to address the cost of complications resulting from the prophylactic method under consideration. Future studies must carefully consider the validity of their models, understand the limitations on current knowledge of outcome rates, and carefully consider all outcomes (both beneficial and detrimental) that result from the intervention. PMID- 10169387 TI - Modelling the cost effectiveness of lamivudine/zidovudine combination therapy in HIV infection. AB - The use of combination antiretroviral therapy is supported by clinical evidence for its superiority over monotherapy. Lamivudine (3TC) has been studied in combination with zidovudine (ZDV) and is recommended for use specifically in combination therapy. With the associated increase in drug acquisition cost, the economics of combination therapy versus monotherapy warrant study. An economic evaluation was undertaken to compare 3TC/ZDV combination therapy with ZDV monotherapy, taking a UK public finance perspective. The cost effectiveness of each of the 2 treatments was estimated using a Markov model of progression through 3 HIV-positive disease states: (i) CD4 cells > 200 and < 500 cells/mm3; (ii) CD4 < 200 cells/mm3, non-AIDS; and (iii) AIDS to eventual death. Progression probabilities and life expectancy were derived from a cohort treated at Chelsea and Westminster Hospital in London, using data for 1987 to 1995, along with cost data for a ZDV intent-to-treat population for 1994 and 1995. The relative risk of progression for 3TC/ZDV compared with ZDV monotherapy was estimated from meta analysis of 4 completed comparative trials. To predict the effect of 3TC/ZDV on life expectancy and lifetime costs, progression probabilities were adjusted by the relative risk statistic for the duration of treatment with 3TC/ZDV. On the basis of an estimated relative risk of progression of 0.509 (95% CI 0.365 to 0.710), treatment with 3TC/ZDV is predicted to yield an incremental cost effectiveness ratio of Pounds 6276 (95% CI Pounds 5337 to Pounds 9075) per life year saved (discounted at 6% per year). Extensive sensitivity analyses were performed to test the effects of varying values of input parameters on the model results. Under reasonable assumptions, the predicted cost effectiveness of 3TC/ZDV combination therapy compares favourably with previously reported economic analyses of various HIV treatments. PMID- 10169388 TI - Economic evaluation of ACE inhibitor treatment of nephropathy in patients with insulin-dependent diabetes mellitus in Italy. AB - Diabetic nephropathy is one of the major complications of insulin-dependent diabetes mellitus (IDDM), with proteinuria being the main clinical manifestation of diabetic nephropathy. Most patients who develop overt proteinuria progress to end-stage renal disease (ESRD), usually within 5 to 7 years; ESRD necessitates dialysis or renal transplantation. Although a relationship between blood pressure reduction and delaying of ESRD has been assumed for a long time, only recently has a controlled randomised clinical trial shown that the treatment of diabetic nephropathy with an ACE inhibitor can significantly delay the loss of renal function and, therefore, ESRD. Consistent with the clinical trial on which this economic evaluation was based, the costs and consequences of 2 alternatives were considered: (i) patients subject to blood pressure control with only antihypertensive medication, but without an ACE inhibitor (placebo group) and (ii) patients given ACE inhibitor therapy (captopril group) with similar blood pressure control to the placebo group. This cost-effectiveness analysis was performed from the perspective of the Italian National Health Service [Servizio Sanitario Nazionale (SSN)]. Accordingly, only direct costs related to publicly funded healthcare services were included. The number of dialysis-years avoided (DYA) was the clinical end-point. A 10-year time horizon was considered for the economic evaluation. Captopril therapy was dominant, being at the same time more effective and less costly. The total cost for the captopril alternative during the 10-year period was 21,901,625 Italian lire (L; 1993 values) per patient, while total cost for the placebo alternative was L30,352,590 per patient. Compared with placebo, 20.01 DYA per 100 patients treated were estimated with captopril therapy during the trial period, equivalent to 2.4 months per patient. The robustness of this result was confirmed by sensitivity analysis: for both extremes, captopril remained dominant. This economic evaluation, requested by the Italian Ministry of Health, demonstrated savings in healthcare expenditure with the use of an ACE inhibitor in patients with proteinuria. PMID- 10169389 TI - Analysis of the costs of NSAID-associated gastropathy. Experience in a US health maintenance organisation. AB - Clinicians recognise nonsteroidal anti-inflammatory drugs (NSAIDs) as valuable first-line agents in the treatment of rheumatic disorders and as dangerous irritants to the gastrointestinal tract. This has led to questions about the economic impact of NSAID-induced gastropathy in populations. This study estimated the 1992 costs of NSAID-associated gastropathy episodes, and calculated an iatrogenic cost factor for NSAID-associated gastropathy among elderly members of a health maintenance organisation (HMO), the Northwest Region of Kaiser Permanente. Using data retrieved from automated databases and from medical records, NSAID and antiulcer drug costs were calculated, and estimates were made of the incidence rates of inpatient and outpatient NSAID-associated gastropathies, the services provided to treat them, and the cost of those services. Kaiser Permanente Northwest spent $US0.35 for each $US1.00 spent on NSAID therapy for the elderly, an iatrogenic cost factor of 1.35. The estimated average treatment per NSAID-associated gastropathy episode was $US2172. The average outpatient pharmacy cost per elderly NSAID user was $US80 and estimated average NSAID-associated treatment cost per elderly NSAID user was $US43. Although the findings were specific to the HMO because of the databases used, the methodology employed and the drug formulary influence on NSAID selection, they show that a substantial amount of resources were used to treat NSAID-induced gastropathies in the elderly, underscoring the risk of prescribing NSAIDs and reinforcing the need for their prudent use in elderly patients. PMID- 10169391 TI - $520 million spent on telemedicine worldwide in 1996. Most sales in Europe, North America, Pacific Rim. PMID- 10169392 TI - New VA facility creates telemedicine-friendly atmosphere. PMID- 10169390 TI - Cost-utility analysis of melphalan plus prednisone with or without interferon alpha 2b in newly diagnosed multiple myeloma. Results from a randomised controlled trial. AB - This study evaluated the cost utility of adding interferon-alpha 2b to conventional treatment in patients with multiple myeloma. It also provides a methodology for transforming complex quality-of-life profiles into a single index value on the conventional 0 to 1 quality-adjusted life-year scale (QALY). From 1990 to 1992, 583 patients with newly diagnosed, symptomatic multiple myeloma were enrolled in a randomised, multicentre, phase III study to evaluate the addition of interferon-alpha 2b to treatment with melphalan and prednisone. Addition of interferon-alpha 2b yielded a 12% increase in median survival time, at the expense of a slight reduction in quality of life during the first year of treatment. The gain in survival time was not large enough to reach statistical significance. Patients receiving interferon-alpha 2b also had a 5- to 6-month prolongation of the plateau phase. Cost per QALY gained by adding interferon alpha 2b was conservatively estimated at $US110,000. Potentially better cost effectiveness may be found in different treatment regimens or in certain patient subgroups. PMID- 10169393 TI - Dubai Hospital gets second opinions via links to U.S. institutes. PMID- 10169394 TI - Uzbekistan health officials seek telemedicine products. PMID- 10169395 TI - Georgia Baptist doctors linked to Vienna, Paris Cancer Conferences. PMID- 10169396 TI - MERMAID helps sailors injured at sea. PMID- 10169398 TI - New Zealand health reforms. PMID- 10169397 TI - A cost-utility analysis of second-line chemotherapy in metastatic breast cancer. Docetaxel versus paclitaxel versus vinorelbine. AB - The aim of this study was to determine the incremental effectiveness, the incremental health-related quality of life (differences in quality-adjusted progression-free survival between treatments), the incremental cost and the incremental cost-effectiveness and cost-utility ratios, for docetaxel, paclitaxel and vinorelbine, when these drugs were used as second-line treatment in patients with metastatic breast cancer. In the absence of comparative direct evidence of the relative efficacy of docetaxel, paclitaxel and vinorelbine in this setting, a model was designed to determine the effects of the 3 interventions on health outcome and cost. A Markov process model, based on 53 disease states, was thus constructed to evaluate the socioeconomics of the 3 treatment regimens. The model allows assessments from the start of second-line chemotherapy until death. Costs were evaluated from the combined view of the healthcare system and the patient. Direct nonmedical and indirect costs were excluded. Consumption per episode of care was estimated by retrospective analysis of 153 medical reports from 5 different hospitals. Hospital costs were allocated values from the national accounting costs by diagnosis-related group (DRG). The content of the health states was based on the multiattribute health states classification system (MASH). Preference values were assigned by application of a standard reference lottery using 20 oncological nurses as proxies for the patients. The health related quality-of-life score was used as a quality adjustment weighting factor to calculate quality-adjusted progression-free survival associated with the 3 different regimens. Docetaxel reduces the time spent in progression, decreases the number of complications due to progressive disease and thereby provides better quality of life. It provides a benefit of 57 disease- and discomfort-free days compared with vinorelbine and 22 days compared with paclitaxel. Docetaxel may be thought of as self-financing as a result of savings in hospital admissions, providing net savings of 6800 French francs (FF; 1993 values) compared with expenditure associated with vinorelbine treatment and FF700 compared with the equivalent figures for paclitaxel. PMID- 10169399 TI - Key factors in choosing a healthcare communication system. PMID- 10169400 TI - Ordnance Survey outlines ways to manage health estates. PMID- 10169401 TI - Reform of the public health sector in the Republic of Mauritius. PMID- 10169402 TI - The private finance initiative--developers view. PMID- 10169403 TI - Developing a European professional record of achievement in engineering: towards portable qualifications. AB - This paper describes a Leonardo da Vinci pilot project the aim of which is to establish a Professional Record of Achievement within the engineering industry for developing and recording career development plans and the resulting requirements for learning and for personal and professional development. recording learning achievements and professional development, and the accumulation of credit towards relevant qualifications. The project will draw upon recent experiences and developments in different countries. A survey of some previous work in the area of portfolios or records of achievement in Europe is presented. PMID- 10169404 TI - Working together--an approach to PFI. Mowlem Facilities Management Ltd. PMID- 10169405 TI - Risk management. PMID- 10169406 TI - Thermal imaging for electrical distribution systems. PMID- 10169407 TI - Growth in roof gardens. PMID- 10169408 TI - Protection against electromagnetic interference (EMI) for sensitive medical devices. PMID- 10169409 TI - Dry processing system puts enhanced diagnostic imaging at the forefront of Bristol's needs. PMID- 10169410 TI - Cost-effective management of Legionella risks in buildings using computer software. PMID- 10169411 TI - Cutting the cost of water. PMID- 10169412 TI - Biofilm treatment for free. PMID- 10169413 TI - Ionisation water treatment for hot and cold water services. PMID- 10169414 TI - The 1995/96 financial performance of NHS Trusts. PMID- 10169415 TI - Silver/copper ionisation treatment of water to reduce the risk of Legionella in NHS healthcare premises. Water Quality Working Group-4. PMID- 10169416 TI - Legionnaires': a prescription for prevention. PMID- 10169417 TI - Major paging order to keep Royal London Hospital staff in-touch across five sites. PMID- 10169418 TI - Changes to structural timber codes. PMID- 10169419 TI - Timber treatments. The Pesticides Trust. PMID- 10169420 TI - TTL research to test lifetime performance of smoke seals. PMID- 10169421 TI - Control of Legionella--a summary of practical advice. PMID- 10169422 TI - Legionella control in hot water. PMID- 10169423 TI - Water temperature and flow monitoring as part of Legionellosis risk minimisation. PMID- 10169424 TI - A low energy green hospital. AB - This paper describes a unique project to monitor and evaluate a range of energy saving techniques and measures installed in a hospital in the North East of England. The aims of the project were: to test theoretical studies that had identified measures that could achieve savings in energy usage in hospitals to test the economic viability of the energy saving measures and determine whether they are suitable for replication in new, as well as existing hospitals to provide experience of energy saving techniques and measures in an operational hospital to provide a comprehensive database of information on how energy is used in hospitals The results from the project show that it is possible to significantly reduce the energy consumption in hospitals. Over the three year monitoring period, it is calculated that the hospital used an average of 39% less energy per annum than a comparable, conventional hospital. This energy saving also represents a reduction in CO2 emissions of 1900 tonnes per annum. The project has provided reliable data and information that has contributed to a much better understanding of how energy is used in hospitals. PMID- 10169425 TI - When the 'big one' hits. PMID- 10169426 TI - Core values bring a mission to life. PMID- 10169427 TI - A foundation for success in rural communities. PMID- 10169428 TI - Communicating charitable estate planning to older adults. PMID- 10169429 TI - The steps to planned giving success. PMID- 10169431 TI - 1997: the challenges ahead for health care philanthropy. PMID- 10169430 TI - A tale of two ideas. Reaching others, reaching ourselves. PMID- 10169432 TI - 'A' is for attitude. PMID- 10169433 TI - Employee campaigns in the midst of change. PMID- 10169434 TI - Bad practices. The federal probe of Columbia/HCA is just part of a broad assault on health-care fraud. PMID- 10169436 TI - Georgia gets ready for: Medicaid. PMID- 10169435 TI - The heart attackers. PMID- 10169437 TI - Association announces new name: GHA: An Association of Hospitals and Health Systems. PMID- 10169438 TI - Of the right to healthcare. PMID- 10169439 TI - Medical compliance plan spells out duties of laboratories. PMID- 10169440 TI - Annotated bibliography. Data quality. PMID- 10169441 TI - Comparison of ICD-9-CM and ICD-10-AM. Australian modifications; ICD-10 changes. PMID- 10169442 TI - Creation of a clinical classification. International statistical classification of diseases and related health problems--10th revision, Australian modification (ICD-10-AM). PMID- 10169443 TI - But who's driving? A quality manager's look at the role of executive staff in creating a quality-driven organisation. PMID- 10169444 TI - Approaching EQuIP (Evaluation and Quality Improvement Program)--from the inside. PMID- 10169445 TI - Casemix and ethics. PMID- 10169446 TI - Challenges of a regional health information advisory service. PMID- 10169447 TI - Looking to CQI for improvements in clinical documentation and coding. AB - The following paper examines how the philosophy of Continuous Quality Improvement (CQI) can be used to improve the quality of clinical documentation and coding. The philosophical basis of CQI and its application in the healthcare environment is outlined. Health information managers need to explore inventive ways of solving the problem of inadequate clinical documentation and high coding error rates, particularly in light of the current casemix-based funding environment. PMID- 10169448 TI - Health care expenditure and hospital management. AB - The article briefly describes the health financing system of Japan and then proceeds to analyse expenditure. The focus, however, of the paper is to express concern at the poor level of management in the hospital systems in Japan. The author urges hospital directors to engage in a much more pro-active management approach. PMID- 10169449 TI - The impact of China's health sector reform on county hospitals. AB - The article describes the impact of China's health sector reform on relatively small hospitals in rural counties. It uses one county hospital to illustrate how pressures to increase revenue, combined with distortionary pricing policies, have led to cost increases. It argues that the introduction of hospital insurance could accelerate the cost increases unless measures are taken to control costs. These measures will include improvements to hospital management and changes to mechanisms of payment for hospital services. Government will have to play an active role to ensure that county hospitals serve the needs of rural people. PMID- 10169450 TI - Management in the Ministry of Health: what are the vital signs? AB - Effective and efficient management of health services is becoming more and more important in all countries and in all organizations whether profit or non-profit. Management practices and attitudes which may have been accepted in previous years are no longer appropriate. A study was conducted in the Ministry of Health, State of Bahrain to determine the current status of management skills and attitudes. Participants were asked to identify the best and the worst practices of managers. Eight key areas of concern were identified: participative vs. non-participative style, communication, motivation, delegation, human relations skills, style of supervision, goal-oriented behavior, and use of supervisory power. In each of these management-related skill areas, examples of best and worst practices are provided in order to aid the manager/leader in self-assessing his/her abilities as a first step toward improving management. PMID- 10169451 TI - No health for all without better trained management. AB - This article notes that existing health professionals and managers constitute the first 'generation' working in a world where Health for All is a practical possibility because, if founded on community-based public and primary health care with hospitals in support and good intersectoral help, we now have the appropriate technology, access to finance and adequate numbers of health workers. What we still lack are sufficient health professionals, at all levels, with the managerial skills and experience to apply the technology, generate the funding and motivate the staff; making full use of community involvement, the co operation of other sectors and good relationships with local and central government. Management can be learned both at the workplace and in the training room, and from the managers a few of them will emerge as leaders, with the vision to secure the willing support of others in reaching worthwhile health goals. A very useful publication is the Training Manual on Management of Human Resources for Health, WHO/EDUC/93.201 from World Health Organisation, Geneva, Switzerland. The paper closes with examples illustrating four principles for health management development: finding key points of entry; reaching large numbers; accelerating national self-sufficiency; and international. PMID- 10169452 TI - The outpatient hospital: a hospital without beds. AB - A radical reordering of the hospital building looms on the horizon. By the advent of the new millennium just a few years away, the outpatient hospital--a hospital without beds--will be the new healthcare model. The outpatient premise is that a wellness system is fundamentally different from a medical care system. The patient is no longer forced to distinguish between his ongoing health maintenance needs and his intermittent medical intervention needs. The barrier between the public health system and the acute care system disintegrates, and the two merge into one entity. Thus, hospitals evolve into outpatient wellness centers where the building's physical structure is a single entity in terms of service points. PMID- 10169453 TI - Medicare program; revisions to payment policies under the physician fee for schedule, other Part B payment policies, and establishment of the clinical psychologist fee schedule for calendar year 1998--HCFA. Proposed rule. AB - This proposed rule discusses several policy changes affecting Medicare Part B payment. The changes related to physician services, including resource-based practice expense relative value units and geographic practice cost index changes, clinical psychologist services, supervision of diagnostic tests, the methodology used to develop reasonable compensation equivalent limits, payment to participating and nonparticipating suppliers, global surgical services, caloric vestibular testing, clinical consultations, and payments based on actual charges. Under the law, we are required to develop a resource-based system for determining practice expense relative value units effective January 1, 1998. In addition, since we established the physician fee schedule on January 1, 1992, our experience indicates that some of our Part B payment policies need to be reconsidered. This proposed rule is intended to correct inequities in physician payment and solicits public comments on specific proposed policy changes. PMID- 10169454 TI - Mental health parity and newborns' and mothers' health protection--HCFA. Solicitation of comments. AB - This document is a request for comments regarding issues under the Mental Health Parity Act of 1996 (MHPA) and the Newborns' and Mothers' Health Protection Act of 1996 (NMHPA). The Department of Labor and the Department of Health and Human Services (collectively, the Departments) have received comments from the public on a number of issues arising under both MHPA and NMHPA. Further comments from the public are welcome. PMID- 10169455 TI - Who's entitled? AB - For the first time, serious consideration has been given to whether well-off seniors should pay higher Medicare premiums. Fans and foes alike say that means testing throws open for debate the very nature of the federal government's vast entitlement programs. PMID- 10169456 TI - Doctoring Medicare. PMID- 10169457 TI - Child and family focus. Systems of care. PMID- 10169458 TI - Twelve partnerships. The National Leadership Council: a unique collaboration. PMID- 10169459 TI - From paper to computers. How to train clinical staff for an effective transition. PMID- 10169460 TI - High demand, low-control jobs reduce productivity and increase workplace disability costs. AB - Workplace behavioral risk management methods build on EAP core technologies to help employers improve productivity and reduce direct and indirect costs of behavioral conditions. Current research suggests that restructuring high-demand, low-control jobs may enhance productivity and reduce disability costs. The author suggests that the use of appropriate social supports and coping-skills training will further offset the damaging consequences of high-demand, low-control jobs. PMID- 10169461 TI - Dialogue. Quality and the bottom line. How can shareholder interests be prevented from interfering with quality care? AB - Market-driven, for-profit behavioral health systems put patients and investors in the same financial equation. Do shareholder profits depend on preventing patients from receiving appropriate care? Does investor greed directly increase consumer pain and suffering? Or, does the marketplace work the way one hopes: providing profits to investors in proportion to improvements in healthcare quality and affordability? Well-intentioned providers find themselves walking right through the middle of this high-stakes minefield. Should the government and the marketplace allow clinicians--and their standards of ethics and social values--to be swept away in the name of efficiency? Or does the marketplace for behavioral healthcare require government intervention through legislation and regulation to protect the interests of both patients and providers? This debate is far from over. Every reader of this journal has a vital stake in the outcome. In the following dialogue, leaders representing employers, clinicians, and managed care plans argue different positions in this debate and propose compelling solutions. PMID- 10169462 TI - Deciding what services to provide. Behavioral healthcare product planning and market research. PMID- 10169463 TI - ERISA preemption and its impact on behavioral health services. AB - Recently, mental health parity provisions were passed and incorporated retroactively into the Health Insurance Portability and Accountability Act (PL 104-191). Although limited, these provisions were instrumental in focusing national attention and debate on people's need for and right to behavioral health services. A handful of states have also passed parity provisions, but their full impact on the insurance market cannot be assessed. This is because a majority of plans are preempted from compliance with many state insurance mandates by the Employee Retirement Income Security Act of 1974 (ERISA). ERISA is the primary obstacle to state behavioral health mandates, and it threatens the inclusion of behavioral health providers and settings in managed care plans integrating public and private healthcare systems. This article provides basic information on ERISA, its preemption clauses, and its impact on behavioral healthcare services. PMID- 10169464 TI - One experience with outcomes data. Belmont Behavioral Health. PMID- 10169465 TI - Quality assessment and improvement standards for behavioral group practices. AB - Behavioral group practices have agreed on performance indicators and have established national benchmarking standards. Collaborative study, led by the Institute for Behavioral Healthcare's Council of Behavioral Group Practices (CBGP), facilitates practice pattern evaluation, trend analysis, and clinical quality improvement. The study reports the benchmarking standards for quality assessment and improvement standards in behavioral group practices in the comprehensive 1995 and 1996 CBGP Performance Indicator Reports. PMID- 10169467 TI - Managed behavioral healthcare today and tomorrow. PMID- 10169466 TI - Cost containment versus quality of care. PMID- 10169468 TI - Lifting the global burden of mental disorders. Services policy and planning using epidemiology and disability measurement. PMID- 10169469 TI - Mental health parity compliance. Legal requirements and benefit design options. AB - Employers considering a response strategy to federal parity legislation may go as far as eliminating healthcare and mental health benefits altogether. Complying, however, could have higher payoff potential in performance results and in enhanced employee morale and relations. Reexamination of the value of behavioral health benefits should be considered in an organization's overall strategic plan. Our writer, a consultant to Wm. Mercer, Inc., defines plans which are potentially exempt from new mental health legislation, and examines the risks of "opting out," as well as the benefits of complying. PMID- 10169470 TI - Satisfaction ratings: meaningful or meaningless? AB - The measurement of consumer satisfaction with behavioral healthcare services in increasing with market and regulatory requirements. Some organizations refer to the results of their measures as "outcomes." Some confusion and debate has consequently arisen as to the meaning of consumer satisfaction and its relationship to other types of outcomes. In this article, Lunnen and Ogles refer to existing research to clarify these meanings and relationships. PMID- 10169471 TI - Dialogue. Resource allocation: to those in the greatest need or those who will benefit most? AB - The behavioral healthcare community seeks universal coverage for mental health and addiction treatment services at parity with coverage for other medical conditions. To achieve this goal, our field must accept and work within realistic financial limits. The time has come to establish a framework for "rational rationing" of behavioral healthcare resources. What are the priorities? How should resources be equitably shared? Should we sacrifice people with mild and moderate disabilities and illness in order to spend most of our dollars on people who are severely impaired? Our first writer, Dr. Daniels, warns us that there are no moral tenets upon which we can easily or comfortably hang our hats, as he shares the current perspective of medical bio-ethics. Dr. Sabin is a practicing psychiatrist at Harvard Pilgrim Health Care. He highlights the Oregon health Plan as one example of political fortitude and wisdom in resolving healthcare resource allocation challenges. Mac Crawford, chairman of the board and chief operating officer of Magellan Health Services, is in one of the most influential positions in private sector integrated behavioral services delivery. He stresses the importance of managed care and clinical process standardization as fundamental requirements for the rational allocation of resources. One additional note: The lack of a consumer voice in this Dialogue is an unfortunate consequence of the mismatch between submissions received and our publication deadlines. It was our intention to present the perspective of a prominent individual from the growing field of consumer and family advocacy. We apologize for the lack of this perspective, which may have extended this discussion to the practical implications of this abstract question of resource allocation. PMID- 10169472 TI - The five Cs of choice. Outcome measures for individuals with severe and persistent mental illness. AB - In a time when mental health service providers are cutting costs and services, stakeholders need adequate information in the form of outcome measures to evaluate services based on quality. Outcome measures are particularly important for high-risk populations, where severe and persistent mental illness results in serious functional impairment of daily life. A client-oriented method of gauging rehabilitation of real-world behavior over the long-term, as well as the short term, and which allows for comparison with other programs, must be developed. Lack of agreement on the domains to be measured, however, has hindered the development of common standards, making it difficult to track accountability and service effectiveness. Four authors provide a framework to help organizations choose and develop appropriate outcome measures, as well as core data suggested to measure longitudinal changes in rehabilitation. PMID- 10169473 TI - Employee assistance programs: a worldwide perspective. AB - Once limited to U.S. corporations, employee assistance programs (EAPs) are now spreading around the world. The authors review global EAP trends and identify similarities and differences among EAPs in North America, Europe, Central and South America, the Asia-Pacific region, and the Caribbean. Through affiliations between international professional associations and services to multinational corporations, the EAP field is quietly creating globalized behavioral health services. PMID- 10169474 TI - CIO survey confirms growth in information technology budgets. PMID- 10169475 TI - Internet/Intranets. Capitalizing on a trend. PMID- 10169476 TI - Physician pushes for the use of technology. Interview by Tyler L. Chin. PMID- 10169477 TI - Managed care. Remote control education. PMID- 10169478 TI - Enterprise network. Anticipating explosive growth. AB - Columbia/HCA designed its information network around a central mainframe linked to regional data centers. That approach has been a key in handling rapid expansion. PMID- 10169479 TI - Electronic records. Meeting outpatient needs first. PMID- 10169480 TI - Telemedicine. Providing proof to payers. PMID- 10169481 TI - Managed care. A pragmatic application of the Internet. PMID- 10169482 TI - Three tier architecture. What role will the most advanced form of client/server play in health care? PMID- 10169483 TI - Using automation to reduce medication errors. PMID- 10169484 TI - Software becomes a strategic tool for human resources departments. PMID- 10169485 TI - A chief security officer charts new territory. PMID- 10169486 TI - Health care's workplace revolution. Management, morale, and motivation in the era of "future work". PMID- 10169487 TI - Guiding change in the ED: teamwork, communication are key. PMID- 10169488 TI - Ten leadership mistakes ED managers should avoid. PMID- 10169489 TI - Update on the Access to Emergency Medical Services Act of 1997. PMID- 10169490 TI - Battling burnout in the ED. PMID- 10169491 TI - Long-term care: concept and reality. AB - Despite increasing demand and numerous problems associated with its delivery, long-term care has been largely ignored in the recent debates over health care reform. The gap between concept and reality is explored in detail, along with possible approaches to the creation of a system that is humane, fair, and equitable. PMID- 10169492 TI - Financing long-term care in Canada. AB - Financial policies relating to long-term care in Canada are changing rapidly in response to demands for health care reform. This chapter focuses on the financial structure of institutional care, primarily nursing homes, in the western provinces of Alberta and British Columbia. Community-based long-term care is discussed briefly. PMID- 10169493 TI - Long-term care in the British National Health Service: a problem of funding. PMID- 10169494 TI - Long-term care in Canada. AB - Problems associated with long-term care in Canada include the growing number of elderly citizens, inconsistencies in social policy and legislative initiatives among provinces, effective quality assurance, and cost containment. Deinstitutionalization and independent living have shifted the focus to community participation. PMID- 10169495 TI - The long-term care system in Israel. AB - The long-term system in Israel is not a centralized entity but rather a fragmented conglomerate of services for the elderly. Many of its problems are common to the long-term care system in the United States. Three major trends have emerged in recent years: (1) privatization, (2) shift to community-based services, and (3) gradual development of mechanisms for quality assurance. PMID- 10169496 TI - Long-term care in the Danish health care system. AB - Because of a declining birth rate and increased life expectancy, emphasis in the Danish health care system has shifted from child care to care of the elderly. The author examines the social, medical, governmental, and financial implications of this shift, focusing on an experimental scheme in the rural community of Skaevinge. By shifting from institutional to community-based services, the Skaevinge project created a new interdisciplinary structure that turned a nursing home into apartments and introduced 24-hour services for the entire community. PMID- 10169497 TI - Long-term care: the Australian experience. AB - Mainly because of migration of young people, the Australian population is young in comparison with the population of other economically developed countries. Fragmentation and excessive reliance on institutions of care of handicapped and elderly people have led to efforts at coordination of services, quality assurance, and a balance between institutional and community-based services. PMID- 10169498 TI - The Italian model for long-term care. AB - During the past decade in Italy, delivery of long-term care has undergone many changes, with introduction of the nursing homes as the central force. High quality residential and outpatient services have become available in new community-oriented services. Among the benefits are reduction of inappropriate admissions, improved quality of life for residents and outpatients, decreased dependence on private resources, growth of voluntary services, and creation of new occupational opportunities. PMID- 10169499 TI - Glossary of terms for long-term care. PMID- 10169500 TI - Emphasizing patient participation: the key to determining appropriate end-of-life care? AB - Traditional approaches to end-of-life care have been criticized for both their high cost and their assumption that the physicians knows what is best for the patient. Both fiscal and ethical concerns can be addressed by increased patient participation in treatment choices during end-of-life care. PMID- 10169501 TI - Managing for quality in a nursing home: a resident-directed approach. AB - As the population ages, the need for nursing care services will increase. Consumer focus on quality of life as well as reduction of expenditures poses a major challenge to the traditional nursing home, which often reinforces dependent resident behavior. The authors propose various strategies for improving life satisfaction and functional status of residents as well as efficiency and productivity of staff. PMID- 10169502 TI - Quality improvement in nursing homes. AB - Regulation, competition, and cost containment have focused attention on quality improvement in nursing homes. Definition, measurement, and monitoring of quality are essential components of any program designed for quality assurance or continuous quality improvement. PMID- 10169503 TI - Role of nursing in long-term care. AB - Nursing services are an essential component of long-term care, whether it is based in the community and home or traditional nursing facilities. The author reviews the various demands of each type of care in terms of nursing education and specific skills as well as resident characteristics, survey findings, and staffing recommendations. Innovative nursing models in long-term care and areas for future research are also addressed. PMID- 10169504 TI - Patient management and use of medication in long-term care. AB - The pharmacotherapeutic approach to patient management in long-term care is fraught with uncertainties and perils, including overprescription, overmedication, and adverse drug events as well as escalating costs. The author argues for alternative protocols that emphasize behavior modification, exercise, supervised hydration, and well-monitored nutrition. PMID- 10169505 TI - Legal and policy issues in long-term care. AB - Law and legislation are changing to reflect the growing needs of the long-term care constituency, Governmental protections include mandates for increased access for physically challenged people, changes in estate and trust laws, modification of Social Security benefits and categories of disability, increased research funding, and even changes in criteria to determine the point of death. PMID- 10169506 TI - Specialization and diversification in the nursing home industry. AB - Recent increases in the types of services offered by nursing facilities and in the formation of specialized care units have resulted in the emergence of two distinct but broadly defined types of services: subacute and long-term care. The authors examine the market, regulatory, and structural incentives behind diversification and specialization and speculate how these trends will affect the future of the nursing home industry. PMID- 10169507 TI - Interdisciplinary teams ensure guideline compliance. PMID- 10169508 TI - Disease management: how soon to take the leap? AB - Managed care has driven development and use of disease management programs, but now these programs are cropping up in fee-for-service hospitals interested in more effectively managing their high-volume chronically ill patient populations. Unlike case management, with its focus on lowering inpatient costs, disease management stresses reducing the number of hospital and emergency department admissions, which puts these hospitals in the troubling position of curbing their income from admissions. Although disease management can be a tough sell in fee for-service markets, experts stress that developing these programs can give your hospital a leg up on the competition when it comes time to bid for managed care contracts. PMID- 10169509 TI - A new approach to disease management for seniors. AB - Faced with the challenge of caring for a growing elderly population, case managers at Margaret R. Pardee Memorial Hospital secured a grant to develop a comprehensive data collection system to help them keep track of elderly patients and more effectively share information with other local health care providers. They developed a standardized information system, using a relational database, to collect patient-centered information while eliminating the redundant documentation that had characterized their previous system. Pardee is expanding the program to include local primary care and home health agencies, who will be able to access the patient database by modem. PMID- 10169510 TI - MS pathway encourages physician buy-in. AB - Case managers at Shepherd Center in Atlanta were satisfied with their procedures regarding inpatient i.v. therapy for multiple sclerosis patients, but they saw an opportunity to further reduce length of stay by implementing a current-practice pathway for MS. Case managers say one reason they were able to secure physician support for the pathway was that they based the path on the center's own best practices. They also formed pathway authorship groups around physician champions. Following a patient's stay at Shepherd, inpatient case managers coordinate care with the center's outpatient clinic as well as with the patient's primary care physician and local hospital. PMID- 10169512 TI - Stroke path slashes LOS by three days. PMID- 10169511 TI - Computerized deep vein thrombosis path allows patient management, not data management. PMID- 10169513 TI - Inspecting the inspectors: feds target JCAHO. AB - From now through October, inspectors from the federal Office of the Inspector General (OIG), the agency that performs Medicare oversight, will be conducting an examination of accreditation practices of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). As part of their examination, OIG investigators will observe JCAHO surveyors at a minimum of four hospital surveys. Although representatives from JCAHO claim not to be worried, they concede that they aren't sure of OIG's intentions. Although the OIG investigators will be observing the surveyors, not the hospitals being surveyed, some experts suggest that their presence could mean tougher surveys across the board, at least in the short term. PMID- 10169514 TI - Misconceptions about diagnostic radiology & specialization. PMID- 10169515 TI - Ask the doc: a novel method of determining treatment energy. PMID- 10169516 TI - ACR MRI site accreditation. What will its impact be? PMID- 10169517 TI - Rural teleradiology: a snapshot. AB - A national survey was conducted among rural hospitals active in teleradiology and their affiliated health care providers to delineate the current status of rural telemedicine. 109 telemedicine programs were identified that use teleradiology as well as other telemedicine applications, and 340 programs were identified that use only teleradiology. Programs that use only teleradiology have been in operation longer than programs that combine teleradiology with other telemedicine services. Most teleradiology facilities are adjacent to small metropolitan areas or in more rural counties with a population of at least 2500. Only 22% of the teleradiology-only facilities spend more than $60,000 on initial equipment, and annual transmission costs average less than $4,000 for most facilities. Ordinary copper telephone lines are the transmission medium most commonly used for transfer of radiology images. Radiographs and CT scans are the types of studies most commonly transmitted, followed by MRI and nuclear medicine studies. PMID- 10169518 TI - Leadership: energy vs power. PMID- 10169519 TI - The political economy of capitated managed care. AB - Despite the fact that billions of dollars are being invested in capitated managed care, it has yet to be subjected to the rigors of robust microeconomic modeling; hence, the seemingly intuitive assumptions driving managed care orthodoxy continue to gain acceptance with almost no theoretical examination or debate. The research in this paper finds the standard unidimensional model of risk generally used to analyze capitation--i.e., that risk is homogenous in nature, organizationally fungible, and linear in amplitude--to be inadequate. Therefore, the paper proposes to introduce a multidimensional model based on the assumption that phenomenologically unrelated species of risk result from non-homogenous types of socioeconomic activity in the medical marketplace. The multidimensional analysis proceeds to concentrate on two species of risk: probability risk and technical risk. A two-dimensional risk matrix reveals that capitation, far from being a market-oriented solution, actually prevents the formation of a dynamic price system necessary to optimize marketplace trades of medical goods and services. The analysis concludes that a universal attempt to purchase healthcare through capitation or any other insurance mechanism would render the reasonable attainment of social efficiency highly problematic. While in reality there are other identifiable species of risk (such as cost-utility risk), the analysis proceeds to hypothesize what a market-oriented managed care approach might look like within a two-dimensional risk matrix. PMID- 10169520 TI - Development of a heart failure center: a medical center and cardiology practice join forces to improve care and reduce costs . AB - Congestive heart failure (CHF) is a rapidly growing and expensive cardiovascular disorder. Conventional care for CHF is ineffective and results in a cycle of "crisis management" that includes repeated emergency department visits, hospitalizations, and physician visits. Recently, a number of outpatient coronary care centers that provide consistent, aggressive outpatient therapies and extensive patient education have emerged and are successfully breaking this cycle of dependence on hospital services. One such effort is the Heart Institute's Heart Failure Center, the result of a partnership between a private-practice cardiology group and our tertiary-care medical center. Our program includes not only patient education and outpatient infusions of inotropic agents, but an electronic linkage to the emergency department and home healthcare services. Preliminary data show that 16 months after the program was initiated, hospital admissions decreased by 30%, hospital days by 42% and average length of stay by 17%. An effective outpatient heart failure program can alleviate the economic burden of CHF and improve the quality of patient care. PMID- 10169521 TI - Course of antidepressant treatment with tricyclic versus selective serotonin reuptake inhibitor agents: a comparison in managed care and fee-for-service environments. AB - We compared course of treatment with tricyclic antidepressant drugs (TCADs) and selective serotonin reuptake inhibitors (SSRIs) to assess interactive effects of antidepressant type with payer type and patient characteristics. A nationwide sampling of adults (n = 4,252) from approximately equal numbers of health maintenance organization (HMO) and indemnity enrollees were prescribed no antidepressants for 9 months, and thereafter prescribed a TCAD or SSRI. Using a retrospective analysis of prescription claims, these cohorts of TCAD and SSRI utilizers were followed for 13 to 16 months after their initial antidepressant prescription. Outcome measures included (1) termination of antidepressant treatment before 1 month; and (2) failure to receive at least one therapeutic dose during treatment lasting 3 months or more. Rates of premature termination and subtherapeutic dosing were significantly higher for TCAD-treated than SSRI treated patients, and for HMO than indemnity enrollees. The interaction of HMO enrollment and TCAD use was associated with particularly high rates. Excluding patients terminating in the first month, the proportions of TCAD and SSRI utilizers remaining in treatment over time were not significantly different. We conclude that SSRIs may provide advantages in treatment adherence and therapeutic dosing, particularly in environments with limited prescriber time. The first month of treatment may be especially critical in determining compliance. PMID- 10169522 TI - Using a multidisciplinary automated discharge summary process to improve information management across the system. AB - We developed and implemented an automated discharge summary process in a regional integrated managed health system. This multidisciplinary effort was initiated to correct deficits in patients' medical record documentation involving discharge instructions, follow-up care, discharge medications, and patient education. The results of our team effort included an automated summary that compiles data entered via computer pathways during a patient's hospitalization. All information regarding admission medications, patient education, follow-up care, referral at discharge activities, diagnosis, and other pertinent medical events are formulated into the discharge summary, discharge orders, patient discharge instructions, and transfer information as applicable. This communication process has tremendously enhanced information management across the system and helps us maintain complete and thorough documentation in patient records. PMID- 10169523 TI - Managing asthma care. AB - This activity is designed for physicians, medical directors, and healthcare policy makers. GOAL: To provide the reader with the tools needed to monitor and manage the care of all enrollees with asthma. OBJECTIVES: 1. Become familiar with a health maintenance organization (HMO)-wide data collection system. 2. Learn the essential elements of asthma care for patients. 3. Learn how to track the implementation of these elements in various HMO settings. PMID- 10169524 TI - Differences in physician compensation for cardiovascular services by age, sex, and race. AB - The purpose was to determine whether physicians receive substantially less compensation from patient groups (women, older patients, and nonwhite patients) that are reported to have low rates of utilization of cardiovascular services. Over an 18-month period we collected information on payments to physicians by 3,194 consecutive patients who underwent stress testing an 833 consecutive patients who underwent percutaneous coronary angioplasty at the Yale University Cardiology Practice. Although the charges for procedures were not related to patient characteristics, there were large and significant differences in payment to physicians based on age, sex, and race. For example, physicians who performed percutaneous transluminal coronary angioplasty received at least $2,500 from, or on behalf of, 72% of the patients 40 to 64 years old, 22% of the patients 65 to 74 years old, and 3% of the patients 75 years and older (P < 0.001); from 49% of the men and 28% of the women (P < 0.001); and 42% of the whites and 31% of the nonwhites (P < 0.001). Similar differences were observed for stress testing. These associations were largely explained by differences in insurance status. PMID- 10169525 TI - Use of ineffective or unsafe medications among members of a Medicare HMO compared to individuals in a Medicare fee-for-service program. AB - Adverse drug reactions and inappropriate prescribing practices are an important cause of hospitalization, morbidity, and mortality in the elderly. This study compares prescribing practices within a Medicare risk contract health maintenance organization (HMO) in 1993 and 1994 with prescribing practices for two nationally representative samples of elderly individuals predominantly receiving medical care within the Medicare fee-for-service sector. Information on prescriptions in the fee-for-service sector came from the 1987 National Medical Expenditures Survey (NMES) and the 1992 Medicare Current Beneficiary Survey (MCBS). A total of 20 drugs were studied; these drugs were deemed inappropriate for the elderly because their risk of causing adverse events exceeded their health benefits, according to a consensus panel of experts in geriatrics and pharmacology. One or more of the 20 potentially inappropriate drugs was prescribed to 11.53% of the Medicare HMO members in 1994. These medications were prescribed significantly less often to HMO members in 1994 than to individuals in the fee-for-service sector, based on information from both the 1987 NMES and the 1992 MCBS. Utilization of unsafe or ineffective medications actually decreased with increasing age in the HMO sample, with lowest rates in individuals over the age of 85. However, no relationship between age and medication use was seen in the NMES study, except for individuals over the age of 90 years. The study data support the conclusion that ineffective or unsafe medications were prescribed less often in the Medicare HMO than in national comparison groups. In fact, for the very old, who are most at risk, the use of these medications was much lower in the Medicare HMO than in the Medicare fee-for-service sector. Nevertheless, in 1994, approximately one of every nine members of this Medicare HMO received at least one such medication. Continued efforts and innovative strategies to further reduce the use of unsafe and ineffective drugs among elderly Medicare HMO members are needed. PMID- 10169526 TI - Issues in the measurement of satisfaction with treatment. AB - Patients satisfaction with treatments is a growing area of research that has tremendous potential to provide outcome measures for clinical trials and disease management programs. It also has applications in marketing and product development, especially for the treatment of chronic diseases. The objective of this review is to demonstrate that treatment satisfaction is a distinct area of research that has produced some important initial results. We define treatment satisfaction and provide a conceptual framework that clarifies the role of treatment expectations, preferences, and satisfaction in the context of healthcare in general. Nineteen articles were selected from more than 1,400 abstracts and were reviewed for the following information: (1) topics covered; (2) method used to design the measure; (3) descriptive statistics; (4) assessment with respect to the attributes in the Instrument Review Criteria of the Medical Outcome Trust's Scientific Advisory Committee; and (5) covariates. We conclude that some important initial results about treatment satisfaction have been obtained, but that much work remains to be performed. We recommend that future research devote more attention to qualitative research with patients, assessment of the measures, and the covariates presented in the conceptual model. We also recommend that decision makers insist on measures that meet these criteria. PMID- 10169527 TI - Improving clinician acceptance and use of computerized documentation of coded diagnosis. AB - After the Northwest Division of Kaiser Permanente implemented EpicCare, a comprehensive electronic medical record, clinicians were required to directly document orders and diagnoses on this computerized system, a task they found difficult and time consuming. We analyzed the sources of this problem to improve the process and increase its acceptance by clinicians. One problem was the use of the International Classification of Diseases (ICD-9) as our coding scheme, even though ICD-9 is not a complete nomenclature of diseases and using it as such creates difficulties. In addition, the synonym list we used had some inaccurate associations, contributing to clinician frustration. Furthermore, the initial software program contained no adequate mechanism for adding qualifying comments or preferred terminology. We sought to address all these issues. Strategies included adjusting the available coding choices and descriptions and modifying the medical record software. In addition, the software vendor developed a utility that allows clinicians to replace the ICD-9 description with their own preferred terminology while preserving the ICD-9 code. We present an evaluation of this utility. PMID- 10169528 TI - HMOs and the efficiency of healthcare delivery. AB - HMOs and other forms of managed care continue to grow rapidly and remain the centerpiece of this nation's policies for health system reform. Despite a growing public and legislative backlash at managed care, there is no comprehensive theory of HMOs to guide policymakers and analysts. It is not yet clear whether managed care improves society's allocation of resources to and within the health sector. After examining HMOs within the context of Coase's theory of the firm, I argue that HMOs share characteristics with collective goods. This framework, and the expanded agency role of physicians under managed care, is used to evaluate the equity and efficiency characteristics of a system of competing HMOs. Other concerns that are increasingly associated with managed care also are addressed. PMID- 10169529 TI - Managed care resource directory. PMID- 10169530 TI - Considerations in pharmaceutical conversion: focus on antihistamines. AB - The practice of pharmaceutical conversion, which encompasses three types of drug interchange (generic, brand, and therapeutic substitution), is increasing in managed care settings. Pharmaceutical conversion has numerous implications for managed care organizations, their healthcare providers, and their customers. Although drug cost may be a driving consideration in pharmaceutical conversion, a number of other considerations are of equal or greater importance in the decision making process may affect the overall cost of patient care. Among these considerations are clinical, psychosocial, and safety issues; patient adherence; patient satisfaction; and legal implications of pharmaceutical conversion. Patient-centered care must always remain central to decisions about pharmaceutical conversion. This article discusses the issues related to, and implications of, pharmaceutical conversion utilizing the antihistamines class of drugs as the case situation. PMID- 10169531 TI - Randomized trial of zileuton in patients with moderate asthma: effect of reduced dosing frequency and amounts on pulmonary function and asthma symptoms. Zileuton Study Group. AB - This 6-month, randomized, multicenter study was designed to determine whether patients who had been treated with the leukotriene pathway inhibitor zileuton 600 mg four times daily (QID) for 2 months could be maintained at the same level of pulmonary function, symptom control, and beta-agonist use with less frequent dosing--first 600 or 800 mg three times daily (TID) and then twice daily (BID). A total of 278 patients with chronic asthma, ages 16 to 70, participated at 25 US centers. All had a 1-second forced expiratory volume (FEV1) of 35%-75%, reversible airway disease, and a nonsmoking history of 1 year. An 8-week open label period (zileuton 600 mg QID) was followed by a 16-week double-blind period, in which patients who responded to the QID treatment were randomized to receive zileuton 600 or 800 mg TID for 8 weeks and then rerandomized to receive zileuton 600 or 800 mg BID for another 8 weeks. Primary outcomes were FEV1 and asthma symptom scores; secondary outcomes were peak expiratory flow rate, beta-agonist use, and asthma exacerbations requiring steroid rescue. Patients who showed improvements in lung function when treated with zileuton 600 mg QID demonstrated minimal decreases in FEV1 and comparable peak expiratory flow rates, symptom control, beta-agonist use, and systemic corticosteroid rescue when being treated with lower doses and/or less frequent doses of zileuton. Patients who demonstrate improved asthma control with zileuton 600 mg QID may be able to reduce their daily dosage and/or frequency while still maintaining the same level of symptom control. PMID- 10169532 TI - Managed care clinical corner: abdominal aortic aneurysm. PMID- 10169533 TI - Reducing malpractice risk through more effective communication. AB - This activity is designed for physicians, health plan administrators, and other providers. GOAL: To help physicians, health plan administrators, and other providers learn more about the relationship between provider communication behaviors and subsequent negligence litigation and learn how to reduce malpractice risk through improving communication behaviors. OBJECTIVES: 1. To describe research findings concerning the relationship between provider communication behaviors and subsequent claims of negligence. 2. To describe the major interviewing deficiencies that have been identified as precipitants of malpractice litigation. 3. To describe three functions of effective interviewing. 4. To describe training and learning methods that can improve provider-patient relationships, leading to improved clinical outcomes and decreased malpractice risk. PMID- 10169534 TI - Improving the quality of the NCQA (National Committee for Quality Assurance) Annual Member Health Care Survey Version 1.0. AB - The National Committee for Quality Assurance (NCQA) developed a standardized survey instrument in 1995 designed to measure enrollee satisfaction with the care and services received from health plans across the United States. After the survey was administered for a large number of health plans and thousands of responses were received, some areas for survey improvement have emerged. The objective of this research was to evaluate the NCQA Annual Member Health Care Survey Version 1.0 (the standard form) relative to an alternate survey form created in cooperation with the HMO Group, Maritz Marketing Research, Inc., and Healthcare Research Systems, Ltd. The alternate form of the NCQA survey was constructed to test several theories of measurement improvement via rewording of items, reordering of items, deletion of items, and addition of items. The most important findings of the research project are reported herein. Ten geographically dispersed member health maintenance organizations (HMOs) of The HMO Group took part in the project. A split-half design was used to test the standard and alternate survey forms concurrently. Surveys were administered by using the NCQA-recommended mail methodology of survey and cover letter, reminder card, and second survey. Assuming a 50% response rate, a target of 400 responses (200 for each survey form) per HMO was planned. The window for responding was allowed to remain open 4 weeks beyond the mailing of the second survey to achieve the desired response rate. A total of 4,056 responses were collected (2,022 for the standard form and 2,034 for the alternate form). It was found that the addition of "No Experience" and "No Opinion" response options to the majority of satisfaction items reduced the random error associated with informed responses and produced statistically significant higher correlations with the global satisfaction items relative to the standard form items. Only four of the eight Short Form 12 summary scales, General Health, Reported Health Transition, Mental Health, and Social Functioning, were useful for adjusting data (covariation). The entire set of comorbidities (chronic disease checklist) could be eliminated without losing significant data adjustment capability. The multiple linear regression models generated by using the global satisfaction items on the alternate form had higher adjusted R2 values than the standard-form models. The alternate-form item Overall Value correlated highly with cost items and general satisfaction item, making it a useful global satisfaction variable for predictive modeling. PMID- 10169535 TI - The diagnostic and treatment approach to two common conditions by the physician members of a community health maintenance organization. AB - We retrospectively collected data from one community managed care organization on all ambulatory care patients initially diagnosed with pneumonia or acute bronchitis from October, 1, 1992, to March 31, 1993, and from November 1, 1993, to January 31, 1994. We considered treatment to be successful when patients did not return for any related service within 15 days of initial diagnosis. We identified 2,490 episodes of illness, 85.7% which were acute bronchitis and 14.3% which were pneumonia. Overwhelmingly, physicians approached these conditions empirically (no diagnostic test); just 8.6% of patients had a diagnostic test during the 15-day episode of illness. Two-hundred twenty-nine of the episodes (9.2%) were apparently related to initial diagnoses, as they occurred during the 15-day period. More branded prescriptions (vs. generic) were dispensed during these related episodes. One patient was hospitalized and 19 patients used the emergency room either for first or subsequent visits. Empiric treatment is associated with effective diagnosis and therapy in ambulatory care patients with acute bronchitis and pneumonia. It remains unclear, however, if this strategy is the most cost-effective or if it leads to the most effective utilization of services. PMID- 10169536 TI - Economic winners and losers after introduction of an effective new therapy depend on the type of payment system. AB - An effective therapy for a costly illness has economic consequences. There may also be differences between provider costs and payer costs and initial versus long-term costs; costs may also vary with the reimbursement scheme. Consider the case of an effective therapy to prevent restenosis after coronary angioplasty. Assume that the initial provider cost of angioplasty is $12,000 and that restenosis within 6 months results in repeat angioplasty in 20% of cases, with a follow-up cost of $2,400, or $14,400 total. Assume that a therapy costs $1,000 per angioplasty and decreases restenosis by 50%, resulting in repeat angioplasty in 10% of cases. This will result in an initial cost of $13,000 and a follow-up cost of $1,300, or $14,300 total. The total societal costs will be -$100, a slight savings. Thus, the $1,100 cost of therapy is offset by reduced costs associated with restenosis, and the societal costs are almost neutral. Assume that under fee for service providers charge costs plus 10% and that without the new therapy either a package price or a capitated system is revenue neutral. Changes in costs resulting from therapy to prevent restenosis are as follows (plus sign indicates cost or loss; minus sign indicates savings or profit): [table: see text] Under fee for service, the payer takes the risks, and the economic consequences to providers are minimal. The situation is reversed under capitation. For whoever takes the risk, there is an initial loss to pay for the therapy, but a long-term gain due to less restenosis. Under package pricing, the providers lose because of the cost of therapy and fewer procedures, while the payers gain. A new therapy, even if it is revenue neutral to society overall, may have considerable economic consequences, which vary with time and with the different perspectives of providers and payers. PMID- 10169537 TI - Health outcomes and managed care: discussing the hidden issues. AB - Too often the debate over health outcomes and managed care has glossed over a series of complex social, political, and ethical issues. Exciting advances in outcomes research have raised hopes for logical medical reform. However, science alone will not optimize our patients' health, since value judgements are necessary and integral parts of attempts to improve health outcomes within managed care organizations. Therefore, to form healthcare policy that is both fair and efficient, we must examine the fundamental values and ethical concerns that are imbedded in our efforts to shape care. We must openly discuss the hidden issues including: (1) trade-offs between standardization of care and provider patient autonomy; (2) effects of financial incentives on physicians' professionalism; (3) opportunity costs inherent in the design of insurance plans; (4) responsibilities of managed care plans for the health of the public; (5) judicious and valid uses of data systems; and (6) the politics of uncertainty. PMID- 10169538 TI - Resource utilization and work or school loss reported by patients with diabetes: experience in diabetes training programs. AB - Diabetes exerts a major economic impact on healthcare in the United States both in terms of direct and indirect costs. Diabetes management and education programs designed to assist patients in achieving more optimal glycemic control represent a potential mechanism for reducing the morbidity and costs associated with diabetes. The relationship between HbA1c and patient hospitalizations and between HbA1c and days lost from work or school related to diabetes within the past year were evaluated. A cohort of 2359 patients with diabetes (188 type I, 2171 type II) referred to a comprehensive diabetes self-management training program was included in the analyses. Overall, 350 (14.8%) patients reported hospitalization, and 212 (9.0%) reported days lost from work or school. Patients with type I diabetes reported more hospitalizations (26.1% vs 13.9% and days lost (19.2% vs 8.1%) than type II patients. For the hospitalization outcome, the multivariate analyses indicated that younger age, the number of co-morbidities, and the duration of diabetes exerted a greater influence on the reported numbers of hospitalization than glycemic control. For the days lost outcome, the multivariate analyses indicated that there was a marginally significant association between patients with poor glycemic control and reported work or school loss related to diabetes (odds ratio = 1.5; 95% confidence interval, 1.0 2.2). These data suggest that interventions that improve glycemic control may decrease indirect costs related to diabetes. PMID- 10169539 TI - Diagnosis and treatment of chronic renal failure in children. AB - This activity is designed for primary care and specialist physicians. GOAL: To provide an overview of the unique features and treatment of chronic renal failure in children. OBJECTIVES: 1. Describe the diagnosis of chronic renal failure in children. 2. Discuss the medical treatment of chronic renal failure in children. 3. Understand the treatment of end-stage renal disease in children. 4. Discuss the financial impact of caring for a child with chronic renal failure. PMID- 10169540 TI - Competency, board certification, credentialing, and specialization: who benefits? AB - Pharmacists are concerned with the rapid changes in the healthcare system and what the requirements will be for a pharmacist in the near future. The emergence of board certification, credentialing, and other certification programs for pharmacists are causing significant concern among pharmacists. Pharmacists must assess certification programs and decide on the value of certification to their careers and to the patients they serve. Employers of pharmacists and those paying for healthcare and pharmacy services must also evaluate the value of pharmacists certification. Perhaps the most direct and significant benefit of pharmacist certification lies in the ability of the pharmacist to provide better and more comprehensive care to patients or selected groups of patients (eg, diabetic patients). Better and more comprehensive care provided by a pharmacist benefits the patient, other healthcare professionals, the healthcare system generally, and payers of healthcare and pharmacy services. Demonstrated competence of the pharmacist to provide pharmaceutical care is essential to achieving this benefit. Board certification of pharmacists in current board-recognized specialty areas of nutrition support pharmacy, pharmacotherapy, psychiatric pharmacy, nuclear pharmacy, and oncology pharmacy totaled 2075 board certified pharmacists in the United States as of January 1997. PMID- 10169541 TI - Economic change does not justify a "new" ethic. PMID- 10169542 TI - It's all relative. A veteran paramedic and his rookie son share their experiences as EMS professionals in Los Angeles. PMID- 10169543 TI - Dispatch and confidentiality. PMID- 10169544 TI - Termination of field resuscitation. AB - Termination of field resuscitation programs allow the base-station physician to pronounce a patient dead through the eyes and ears of the paramedic. Despite the controversy of changing the way we treat cardiac arrest victims in the field, there are several benefits to having these programs. For many agencies, the benefits and strengths will far outweigh the weakness. Commitment, education and patience on the part of the entire department are required to make this type of program work. The emergency medical service community as a whole must work diligently to overcome society's concept that everyone who is treated by EMS gets transported to the hospital and everyone survives. While advances in emergency cardiac care are being studied every day, the fact remains that the national save rate is still very low. In many cases, discontinuing efforts in the field might be a feasible option. PMID- 10169545 TI - 1996-1997 generation gap. PMID- 10169546 TI - An American in Lithuania. Making the best of a new situation. PMID- 10169547 TI - Hanging out with the neighbors. PMID- 10169548 TI - Managed care: the next generation. AB - Managed care today affects most Americans. Of the 160 million Americans receiving employee coverage, 120 million are in a managed care setting. HMO development to date has been driven by the desire to reduce health benefit costs for employers. Employees, the real consumers, perceive a clash between "good care and good profits." Health plans have generated profits by reducing utilization and keeping a portion of the savings. In the future, market conditions will force plans to develop new ways of maintaining profitability. Also, plans will survive by focusing on factors that matter most to consumers-such as overall care quality and access. Care systems that combine the benefits of open-access systems with the benefits of point-of-service products represent the next generation of consumer-driven healthcare. PMID- 10169549 TI - In managed care, putting patients first is more important than choosing one model over another. PMID- 10169550 TI - Two points of anecdotal evidence do not make a trend. PMID- 10169551 TI - Consumer-oriented managed care: oxymoron or new direction? PMID- 10169552 TI - US medical education. Young doctors. AB - Opinions diverge on how medical education in the US should develop. Most students graduate with substantial debts which deter them from entering lower-paying branches of medicine. Attempts to broaden the intake of medical schools have not been very successful. PMID- 10169553 TI - Family planning services. Capital control. AB - Commissioning of contraception and abortion services is underdeveloped. Access to family planning clinics varies greatly between health authorities. The proportion of abortions funded by the NHS varies between health authorities from 42 per cent to 72 per cent. PMID- 10169554 TI - Healthcare information. Slow to learn. AB - Access to information in the NHS is in need of huge improvements. In 1992 more than half of all staff had no access to a library service geared to their requirements. NHS libraries are now expected to serve patients and managers as well as clinical staff. PMID- 10169555 TI - On the evidence. Mental health promotion in high-risk groups. PMID- 10169556 TI - Career profile. Primary care managers--teaming with ideas. PMID- 10169557 TI - The rise and fall of medical paradigms. PMID- 10169558 TI - Second thoughts: can managed care be ethical? PMID- 10169559 TI - Clinical care with a retail flavor: Twin Cities employer group tries a bold new experiment. AB - In this revolutionary new healthcare purchasing model, individual consumers- employees, not employers--make healthcare buying decisions. Providers, in turn, are directly accountable to consumers and design their networks to compete for consumer market share. PMID- 10169560 TI - One size doesn't fit all--the right way to integrate. PMID- 10169561 TI - Trouble in the boardroom. The seven deadly sins of ineffective governance. PMID- 10169562 TI - International emerging leaders 1997. AB - Each of the young executives selected for this year's International Emerging Leaders in Healthcare Award has demonstrated an extraordinary ability to rise to the challenge of the healthcare marketplace of the Nineties. Whether battling with far-larger, health plans for market share in California's brutal managed care arena, trying to create health for the residents of its surrounding West Baltimore neighborhood, looking for a new ways to partner in an effort to keep an academic medical center financially vibrant, or creating customer loyalty by asking consumers what they want--an almost unheard-of concept in healthcare, all four of this year's award winners have achieved things, and envisioned things, that distinguish them from their colleagues. And all of them, at 40 or younger, have made a huge impact at an early age. In recognition of that, and of the likelihood that they will continue to perform at a high level, no matter what they encounter as the face of healthcare changes, Korn/Ferry International and The Healthcare Forum are proud to honor Jane Durney Crowley, Tim Parris, Kenneth Prewit-Wood, and David Strand. PMID- 10169563 TI - Log on. A continuing guide to the online world for healthcare executives, managers, clinicians & patients. PMID- 10169564 TI - Stress. Creating an environment to prevent burnout. PMID- 10169565 TI - Imitating the enemy. PMID- 10169566 TI - The effects of teamwork on staff perception of empowerment and job satisfaction. AB - Rosabeth Moss Kanter's model of organizational empowerment was used to examine the effects of a multidisciplinary teamwork project initiated in preparation for a 1995 Canadian Council on Health Services Accreditation survey. Kanter maintains that work structures such as teams foster opportunities to learn and grow, provide access to information, support and resources, empower employees, and result in increased work satisfaction and effectiveness. Staff who participated on multidisciplinary teams to prepare for the accreditation survey (n = 210) and a random sample of staff who did not participate on the teams (n = 348) were surveyed to ascertain their perceptions of work-related empowerment and job satisfaction. Consistent with Kanter's propositions, members participating on teams had higher empowerment scores and perceived access to empowerment structures to be more important than members not participating on these teams. Overall, perceived access to empowerment structures was found to be significantly lower than perceived importance of access to the empowerment structures. The results of this study support the use of multidisciplinary teams as one work redesign strategy for enhancing work effectiveness in the health care environment. PMID- 10169567 TI - The role of consumers in health care decision making. AB - This paper focuses on the results of a survey of chief executive officers and consumer board members of Ontario hospitals and community health centres regarding the role of consumers in health care decision making. The opinions of both the chief executive officer and consumer board member respondents were elicited regarding the value of consumer input in decision making for the organizations studied. Results indicate that consumer board members feel that their input into organizational decision making is valued, chief executive officers value the input of consumers, and consumer involvement in decision making is increasing. More women are now involved on boards of the organizations studied, but visible minority representation remains low on hospital boards. Consumer board members feel that their decision making is influenced by providers on the board. PMID- 10169568 TI - Planning for complex change: insights from the Metro Toronto District Health Council Hospital restructuring project. AB - Restructuring and large-scale organizational change have become facts of life in Ontario's health care sector in recent years. Nearly every jurisdiction in Ontario has undergone systemwide hospital restructuring studies, and individual hospitals have increasingly turned to large scale re-engineering processes to improve efficiency and effectiveness. One example of planning for significant change was a hospital restructuring study undertaken by the Metropolitan Toronto District Health Council between 1993 and 1995. This article provides an overview of key insights gleaned from the project, including an analysis of the effectiveness and utility of some of the major planning strategies and tactics employed to realize project objectives. Given the organizational, process and communications issues faced by the study, many of the insights provide will be relevant to other groups engaged in planning for large-scale change processes, who face tough decision making in similarly complex environments. PMID- 10169569 TI - The challenge of evaluating programs in a large health sciences centre. AB - This article illustrates how the logic model and a course on program evaluation at a large health sciences centre were instrumental in preparing staff to evaluate their own programs. Staff and physicians need basic skills in program evaluation. The logic model is a simple yet useful tool in helping to identify key measurables. A short course to teach the theory and practice of logic models, evaluation design, choice and design of measures, and data analysis has been shown to be a practical solution in preparing staff and physicians to evaluate their own programs. PMID- 10169570 TI - Whither professionalization--how will we be judged? PMID- 10169571 TI - Structuring the design and implementation of leadership and teamwork for program management. AB - Health care providers throughout Canada are aspiring to improve how they manage their resources, while maintaining or improving the quality of patient care through more patient-focused, team-based approaches. Many of the current program management models being implemented in the field are designed to realize these aspirations. Yet they are actually opposing them because of a lack of clarity about accountability and authority. Working relationships (teamwork) within clinical teams, and between clinical teams, physicians, support functions and the senior management committee, have been vague. This lack of clarity in role relationships has created many problems. This article demonstrates how we attempted to solve some of these problems at the Royal Ottawa Health Care Group. PMID- 10169572 TI - Networking: the essential ingredient in career management. PMID- 10169573 TI - No formulas or management models allowed. Interview by Matthew D. Pavelich. PMID- 10169574 TI - The etiquette of Chevron: was the court serving escargot or the main course? PMID- 10169575 TI - Making sense of the federal sentencing guidelines: how health care corporations can manage risk by adopting corporate compliance programs. PMID- 10169577 TI - Taxpayers' Bill of Rights 2: making sense of the sanctions. PMID- 10169576 TI - Race, ethnicity & hospital care: the need for racial and ethnic data. PMID- 10169578 TI - IRS guidance on physician recruitment: from the seeds of Hermann Hospital to the proposed and final ruling and beyond. PMID- 10169579 TI - Because judges went to law school, not medical school: restrictive covenants in the practices of law and medicine. PMID- 10169580 TI - A pioneering spirit on the Great Plains. Creating a rural EMS system. PMID- 10169581 TI - Readin', ritin', and respondin'. EMS on college campuses. PMID- 10169582 TI - An FP wins a harrowing battle in the obstetrics turf war. PMID- 10169583 TI - Academic practice. Income growth: the big winners are family physicians. PMID- 10169584 TI - What HHS's war on fraud and abuse means for you. PMID- 10169585 TI - Get ready for the IRS's newest doctor shakedown. PMID- 10169586 TI - Expanding the hospice time frame. PMID- 10169587 TI - Recruiting a staffer? Watch for land mines. PMID- 10169588 TI - Curbing HMO treatment denials: is a trend tacking hold? PMID- 10169589 TI - Mercy Health System-Northeast. "Caring for our community". PMID- 10169590 TI - The University of Chicago Hospitals. "Gifts we share". PMID- 10169591 TI - Eisenhower Medical Center. 25th anniversary annual report. PMID- 10169592 TI - St. Mary's Health Network. "The art, the poetry of caring". PMID- 10169593 TI - Daniel Freeman Hospitals. "Strengthening Ties". PMID- 10169594 TI - Johnson City Medical Center. "Reflections". PMID- 10169595 TI - Best hospitals 1997. Taking charge. Slowly, patients have the won the right to dictate terms--to refuse treatment, to be pain free. Hospitals are still digesting what this means. PMID- 10169596 TI - Why we rank America's hospitals. PMID- 10169598 TI - Three cheers for volunteers! PMID- 10169597 TI - Best hospitals 1997. Inside the rankings. We evaluated hospital care in 17 specialties. Here's how. PMID- 10169600 TI - Bronx mission: making a neighborhood whole again. PMID- 10169599 TI - The empowerment zone. Clinic helps women with HIV recover--or discover--self esteem. PMID- 10169601 TI - A friend in deed. Health Connection eases the isolation of chronically ill patients. PMID- 10169602 TI - Naturally interested. A Seattle trustee uses political advocacy to bring natural medicine to public health. PMID- 10169603 TI - Miracle workers. Medical center wins converts--one believer at a time. PMID- 10169604 TI - Targeting minorities. Community volunteers are key to success. PMID- 10169605 TI - Healthy kids a priority in Florida. PMID- 10169606 TI - Volunteers patch clinic's safety net. PMID- 10169608 TI - United we stand. Leaders share strategies for strengthening communities. PMID- 10169607 TI - A call to service. Summit to forge bold plan for mobilizing volunteers. PMID- 10169609 TI - All the comforts. Hospital redesign redefines patient-focused care. PMID- 10169610 TI - Safe and healthy. Families in Charleston, SC, get more than just a free car seat. PMID- 10169611 TI - Gifts of HOPE. Holmes Regional Medical Center gives the needy a chance for better health--and a better life. PMID- 10169612 TI - Getting people involved. Four principles for building commitment. PMID- 10169613 TI - Taking care of the uninsured. PMID- 10169614 TI - The power of one. Every healthy community needs a champion. PMID- 10169615 TI - Microscopy for the biological and clinical laboratory: Part 2. PMID- 10169616 TI - Development of an updated method for fecal bile acid and neutral steroid analysis. PMID- 10169617 TI - Model compliance plan for clinical laboratories. PMID- 10169618 TI - Characterization of spermatozoa by planar morphometry. AB - OBJECTIVE: To define the morphometric characteristics of normal sperm heads, and compare them to sperm head measurements used to define normal morphology using strict criteria. DESIGN: Computerized image analysis of selected normal and abnormal seminal fluid specimens collected for routine male fertility studies. SETTING: Research laboratory at the Department of Medical Technology, Bowling Green State University, Bowling Green, OH. PATIENTS: Sixty adult male patients who submitted semen samples for routine analysis. Fifty percent had normal seminal fluid analysis results. The remaining 50% demonstrated abnormal sperm morphology. CRITERION STANDARD: Microscopic evaluation of sperm head morphology. Sperm fitting the criteria of normal as defined by WHO (1987 and 1992) and Kruger (1988) were classified as normal. Sperm with a post nuclear area of less than 40% were classified as acrosomal deficient. MAIN OUTCOME MEASURES: Measurements made from stained seminal fluid smears included sperm head area, perimeter, acrosomal area, percent acrosome, Ferret's diameters, aspect ratio, shape factor, and specific length. Normal sperm heads (NL group) were compared to sperm heads demonstrating an acrosomal deficiency (AD group) for statistically significant differences using multivariate analysis of variance (MANOVA) and analysis of variance (ANOVA). Stepwise discriminant analysis was used to remove duplicating variables. Discriminant analysis was used to classify the sperm heads into NL and AD groups. Receiver-operating characteristic (ROC) curves were applied to the 2 most influential variables in order to identify a cutoff that best distinguishes normal from acrosomal deficient sperm heads. RESULTS: MANOVA and ANOVA showed all 10 variables to be statistically significant (p < .002). Discriminant analysis correctly assigned 98.7% of the normal sperm heads to the NL group and 99.0% of sperm with acrosomal deficiency to the AD group. The percent acrosome and acrosomal area were determined to be the 2 most influential variables. ROC analysis identified a cutoff of 3.6 mu2 for acrosomal area as having the highest sensitivity and specificity (99.7% and 88.0%, respectively). Similarly, a cutoff of 44% for percent acrosome gave a sensitivity of 92.3% and a specificity of 88.7%. The coefficient of variation (CV) for each of the 10 variables determined from 20 day-to-day replicates of a normal semen smear ranged from 2.6% to 8.4%. CONCLUSION: Computerized image analysis is able to define a reference range for sperm head area, percent acrosome, and acrosomal area that may be used to differentiate normal form abnormal sperm heads. Maximum and minimum Ferret's diameters measure sperm head length and width, respectively. Mean maximum Ferret's diameter, minimum Ferret's diameter, and maximum-minimum Ferret's diameter ratio correspond closely to the WHO (1987) midpoint for normal sperm head length, width, and length-width ratio. The average percent acrosome of normal sperm heads determined by morphometry closely correlate to the WHO (1992) and Kruger (1988) midpoints for percent acrosome. PMID- 10169619 TI - Importance and emphasis of mycobacteriology competencies as perceived by educators. AB - OBJECTIVE: To compile a list of mycobacteriology competencies and to investigate the importance and emphasis of these competencies as perceived by clinical laboratory educators of three program types. DESIGN: Use of a survey instrument, which included 97 competency statements with Likert-type scales for the quantitative study of importance and emphasis of competencies. STUDY SELECTION: Randomly selected sample from all accredited college/university-based clinical laboratory science programs, hospital-based clinical laboratory science programs, and associate-degree clinical laboratory technician programs. DATA SYNTHESIS: For analysis, the competencies were divided into eight sub-categories. Means for each competency and each sub-category were calculated. Analysis of variance was used to determine any difference among the three program types for each sub-category of competencies. Chi-square analysis was used to determine significant differences for competencies requiring dichotomous responses. CONCLUSION: With the significant increase in tuberculosis and other mycobacterioses, the mycobacteriology experience for clinical laboratory students must be validated for relevance. PMID- 10169620 TI - Fibrinolysis inhibitors. AB - The fibrinolytic system involves a series of enzymatic reactions that results in the conversion of the proenzyme, plasminogen, into the trypsin-like lytic enzyme, plasmin. The major physiologic target of plasmin is fibrin. Free plasmin in plasma is a nonspecific lytic enzyme that will degrade other proteins such as fibrinogen and coagulation factors V and VIII. Plasmin and activators of plasminogen also play a role in ovulation, embryo implantation, tissue remodeling, and inflammation. PMID- 10169621 TI - Resistance to activated protein C: a major cause of inherited thrombophilia. AB - Blood coagulation proteins play a major role in the development of pathological venous and arterial thrombosis. Inherited disorders of thrombosis are due to deficiencies of the anticoagulant proteins antithrombin, protein C, and protein S in 10% to 15% of individuals that present with venous thrombosis. A recently described cause of venous thrombosis is characterized by a poor response to activated protein C. In 90% of cases the activated protein C resistance is attributable to a mutation in the factor V gene (factor V Leiden). Activated protein C resistance is found in up to 7% of the Caucasian population but essentially unseen in other races. Activated protein C resistance is associated with a 5 to 10X increased risk of venous thrombosis in individuals that are heterozygous for the defect and a 50 to 100X increased risk in those individuals that are homozygous for factor V Leiden. Activated protein C resistance can be detected in the laboratory by modifications of the activated partial thromboplastin time assay. This assay is easy to perform and can be automated for a variety of instruments. Confirmation of the mutation of the factor V gene is accomplished through polymerase chain reactions that require DNA extraction from the patient's blood sample. Global assays that reflect the functionality of the protein C pathway have recently been introduced to the marketplace. PMID- 10169622 TI - Lupus anticoagulants: diagnostic dilemma and clinical challenge. AB - Lupus anticoagulants (LAs) are immunoglobulins which prolong 1 or more of the in vitro phospholipid-dependent tests of coagulation (e.g., activated partial thromboplastin time [APTT], dilute Russell viper venom time [dRVVT], kaolin clotting time [KCT], and textarin time [TT]). Paradoxically, patients with LAs rarely experience hemorrhagic problems. Approximately 1/3 of individuals with LAs experience thromboembolic complications such as stroke, deep vein thrombosis, and pulmonary emboli. LAs are members of the antiphospholipid antibody (APA) family. The APA family includes: LAs, anticardiolipin antibodies (ACAs), and reagin (the antibody responsible for the positive serologic test for syphilis). In approximately 60% of the patients, a LA and an ACA will both be present. The diagnosis of LAs requires an organized approach. Careful preparation of platelet poor plasma (PPP) is essential to assure maximum detection of LA. In order to rule out LAs, it is necessary to perform at least 2 screening tests (e.g., APTT, dRVVT). Additional steps in the diagnosis of LAs include mixing studies to identify the presence of an inhibitor and confirmatory procedures to demonstrate phospholipid-dependence of the inhibitor. It is also important to rule out any other potential coagulopathies which may account for the prolonged screening studies. PMID- 10169623 TI - An international standard for terminally sterilized medical device packaging. AB - Manufacturers of terminally sterilized medical devices must ensure that packaging protects the device from damage, allows it to be sterilized, and provides an effective barrier against microbiological contamination. The previous article in this column discussed quality system requirements for packaging. Recently, an international standard concerning sterile packaging has been developed and this article provides an overview of the standard. PMID- 10169624 TI - Validating radiation sterilization. AB - There are three aspects that manufacturers must address when validating radiation sterilization. These are the minimum dose that ensures sterility, the maximum dose at which radiation affects the functionality of the device, and the dose distribution throughout the product. This article defines a validation protocol that satisfies current radiation sterilization standards. PMID- 10169625 TI - Sterilization using pulsed white light. AB - Pulsed light is a non-thermal sterilization method that uses brief intense pulses or flashes of white light to kill micro-organisms. This article discusses tests performed on blow/fill/seal containers. The results suggest that pulsed light has potential as a terminal sterilization method for filled and sealed transmissive products and packages. It also examines the effectiveness of pulsed light in eliminating water-borne pathogenic organisms. PMID- 10169626 TI - Industrial low-temperature gas plasma sterilization. AB - The search continues for alternative low-temperature sterilization technologies that do not exhibit adverse toxicological or environmental effects. Low temperature plasma sterilization is one technology that is under investigation as an alternative to ethylene oxide and formaldehyde. This article examines the process and reports on the current status of the technology. PMID- 10169627 TI - Long-term survival experience of patients with multiple sclerosis. AB - BACKGROUND: Long-term survival of patients with multiple sclerosis is not well characterized because this disorder is relatively uncommon and subjects must be followed for decades after onset of symptoms. This paper reports comparative mortality experience of the world's largest series on an unselected cohort with multiple sclerosis. RESULTS: Excess mortality varied with age, gender, duration since onset and diagnosis, calender year of onset, and clinical severity. CONCLUSIONS: Compared to the general population in Denmark, patients with multiple sclerosis had less favorable survival experience during long-term follow up. PMID- 10169628 TI - Selected transactions of the International Underwriting Congress 1997. Medical underwriting in the genetics era. PMID- 10169629 TI - Diastolic dysfunction of the left ventricle. A review of the physiology, causes, diagnosis, treatment and implications. AB - Diastolic dysfunction of the left ventricle frequently occurs in people with left ventricular hypertrophy and coronary artery disease. It is a common cause of congestive heart failure, especially in the elderly. The mechanism of diastolic dysfunction, its causes, diagnosis and treatment, are reviewed. These are important factors to a Medical Director who must assess the results of non invasive studies. Alerted by the possibility of diastolic dysfunction, the Medical Director can be more sensitive to other signs and symptoms that may represent early signs of congestive heart failure or ischemia. PMID- 10169630 TI - Detecting alcohol abuse: the value of carbohydrate deficient transferrin. AB - The author, an advocate of CDT testing for insurance applicants, senses considerable uncertainty among medical directors concerning the value of the test. This review of CDT literature and the history of CDT testing in insurance laboratories is an attempt to mitigate that confusion. Two principle problems are identified: 1) the expected sensitivity of the CDT test in insurance applicants will be 50% at most, usually considerably less. 2) adapting CDT testing to commercial laboratories has been, and still is, an unsolved problem for there remains an important disparity between the method used at Clinical Reference Laboratories and LabOne. Other important issues are also reviewed: gender differences, ethnicity, LFT's and CDT, and technical facts. PMID- 10169631 TI - Monoclonal gammopathy of undetermined significance. AB - Monoclonal gammopathy of undetermined significance is not a benign condition. There is a significant increase in mortality associated with the risk of development of multiple myeloma and related disorders. PMID- 10169632 TI - Experiences in CDT testing. PMID- 10169633 TI - Effect of age on mortality experience in patients with hypertrophic cardiomyopathy. PMID- 10169634 TI - The discipline of insurance medicine. PMID- 10169635 TI - Randomized trial of carvedilol in treatment of congestive heart failure. AB - BACKGROUND: Members of the U.S. Cardevivol Study Group at Lovelace Scientific Resources, Albuquerque, NM, designed and carried out a large multicenter randomized clinical trial of Cardevilol vs placebo in patients with clinical heart failure and ejection fraction < 0.35. RESULTS: Derived exposure and death data at 50-day intervals to 400 days were used to construct tables of comparative mortality, all ages, both sexes and all durations to 400 days combined, in the Carvedilol and the placebo groups Derivation of expected mortality is explained in detail. CONCLUSIONS: Excess mortality, measured as mortality ratio or excess death rate, was much higher in the placebo than in the Cardevilol-treated group. PMID- 10169636 TI - Mortality analysis of complete right and left bundle branch block in a selected community population. AB - A twenty year follow up of a selected, community population with complete right and left bundle branch block is reviewed by comparative mortality analysis. In this population, where cases and controls were free of hypertension and heart disease at entry, the presence of complete right bundle branch block does not have excess mortality. Complete left bundle branch block exhibits excess total and cardiac mortality. PMID- 10169637 TI - AIDS morbidity and the role of the family in patient care in Uganda. AB - Extended families and clans in African societies have extensive systems of treatment and patient management which can be used with AIDS sufferers. This paper used data from a baseline survey of six districts to study patient care in Uganda. The levels of AIDS illness are high, and highest in the sexually active age groups of 20-49 years. Of the nuclear family, parents, siblings, spouses and children are the dominant AIDS patients' primary carers in that order. Other relatives in the extended family also contribute much primary care. The contribution of neighbours and friends to primary caring and of other relatives as secondary carers is small. This is perhaps because of the financial burden of caring for the patients. However, there are indications that households and families are coping with the effects of the disease. PMID- 10169638 TI - Screening for HIV I through the regional blood transfusion service in southwest Uganda: the Mbarara experience. AB - Antibody screening for HIV has reduced transmission of AIDS by blood transfusion. Of the 12,768 units of blood donated to the Mbarara Regional Blood Bank between January 1992 and December 1994, 577 were found to be HIVI-positive using the ELISA technique. Percentage of positivity decreased from 5.4 in 1992 to 3.9 in 1994. Replacement donors had a higher positivity rate than volunteer donors. The females had more positives than the males. Distribution of the blood groups O and AB was similar between the Ugandan and English samples. There were differences in the blood groups A and B. The AB blood group which was only 4 per cent of the total had a higher percentage of HIV I positives. This preliminary finding should be confirmed by a more organized study. PMID- 10169639 TI - The psychological effect of orphanhood: a study of orphans in Rakai district. AB - This paper examines the psychological effect of orphanhood in a case study of 193 children in Rakai district of Uganda. Studies on orphaned children have not examined the psychological impact. Adopting parents and schools have not provided the emotional support these children often need. Most adopting parents lack information on the problem and are therefore unable to offer emotional support; and school teachers do not know how to identify psychological and social problems and consequently fail to offer individual and group attention. The concept of the locus of control is used to show the relationship between the environment and individuals' assessment of their ability to deal with it and to adjust behaviour. Most orphans risk powerful cumulative and often negative effects as a result of parents' death, thus becoming vulnerable and predisposed to physical and psychological risks. The children were capable of distinguishing between their quality of life when their parents were alive and well, when they became sick, and when they eventually died. Most children lost hope when it became clear that their parents were sick, they also felt sad and helpless. When they were adopted, many of them felt angry and depressed. Children living with widowed fathers and those living on their own were significantly more depressed. These children were also more externally oriented than those who lived with their widowed mothers. Teachers need to be retrained in diagnosing psycho-social problems and given skills to deal with them. Short courses should be organized for guardians and community development workers in problem identification and counselling. PMID- 10169640 TI - Widowhood, remarriage and migration during the HIV/AIDS epidemic in Uganda. AB - Recently the levels of widowhood have increased in countries of sub-Saharan Africa that are afflicted by the HIV/AIDS epidemic. This paper reviews the cultures of several societies in Uganda in relation to the treatment of widows. Using a data set based on a sample of 1797 households covering east, south and western Uganda, the study finds higher proportions of widows than widowers. Over half of widowers compared to one quarter of widows remarry. Reasons for remarriages of widowers and widows are discussed. While younger widows migrated from their late spouses' homes more than the older ones, the pattern of the widowers shows that those in age 20-34 migrated most. Deeper analysis indicates that widowed people who moved away from their deceased spouses' homes did so for reasons other than the death of their spouses. The widowers were more likely to move than the widows and the unhealthy ones migrated more than the healthy ones. PMID- 10169641 TI - Fertility levels and trends in the face of the AIDS epidemic in Uganda. AB - The paper uses data on ever-married women interviewed in 1992 and 1995 surveys in six districts of Uganda. Total fertility rates declined during the inter-survey period from 7.3 to 6.0. Women in households that experienced AIDS-related deaths had lower fertility levels than women in non-AIDS-affected households in both 1992 and 1995. This pattern was true of women at older ages, in polygamous unions, the widowed and separated, and among the highly educated and the uneducated. PMID- 10169642 TI - HIV/AIDS, change in sexual behaviour and community attitudes in Uganda. AB - The spread of HIV/AIDS is mostly through sexual intercourse and is largely influenced by behaviour and attitude. Data based on a sample of 1797 households are used to study changes in sexual behaviour and attitudes sickness and death in Ugandan communities, which were due to the realization that too many deaths were occurring in the community. Positive behaviour and attitudes include willingness to use condoms and go for HIV tests. Reasons for willingness and reluctance to test for HIV status are discussed. Changes of behaviour and attitude are significantly related to age, sex, education, ethnic group and number of AIDS patients and deaths known to a respondent. PMID- 10169643 TI - Socio-economic determinants of HIV serostatus: a study of Rakai District, Uganda. AB - The objective of the study was to establish the extent to which socio-economic status affects the acquisition of HIV. Data were collected in 1992 from 1784 respondents in Rakai district by the Rakai Project, with results for HIV serology and information on demographic, socio-economic and some behavioural variables. Level of education and urban residence were positively significantly related to HIV status both at bivariate and multivariate levels. Household wealth status was positively associated with HIV status at the bivariate level, but negatively related with HIV status at the multivariate level though not statistically significantly. Occupation was significantly associated with HIV status at the bivariate level and for one model at the multivariate level, but when occupation of the partner, travel destinations of partner and respondent, condom use and number of sexual partners in the previous year were introduced in a second model, occupation was not significantly related to HIV status. PMID- 10169644 TI - The AIDS epidemic and infant and child mortality in six districts of Uganda. AB - Several studies in sub-Saharan Africa have associated infant and child mortality with the AIDS epidemic in the region. The paper uses retrospective survey data of six districts in the east, south and west of Uganda to study infant and child mortality, which increased in the 1980s probably because of the AIDS epidemic and started declining in the early 1990s, a period when the epidemic was reported to be subsiding. Deeper analysis of data indicates that children whose parents are polygamous, educated, formally employed and in business are at a higher risk of death from AIDS and related illness. Although AIDS as a direct cause of death is the fourth leading killer of children, other serious diseases such as diarrhoea, respiratory infection and measles are associated with AIDS. PMID- 10169645 TI - AIDS mortality in Uganda: circumstances, factors and impact of death. AB - HIV/AIDS is a serious problem in sub-Saharan Africa. The disease affects the most sexually active adults of the population, who belong to the most productive age groups, and some of whom are breadwinners. The paper uses data from a baseline survey of six districts of Uganda to study the circumstances, factors and impact of death due to AIDS. While high proportions of patients of AIDS or related diseases use health facilities, most deaths occur at home. Deaths due to AIDS or related diseases are associated with sex, age, marital status, type of marriage, education, occupation and ethnicity. The worst effect of AIDS deaths on the household is lack of finance. PMID- 10169646 TI - Livelihood and the risk of HIV/AIDS infection in Ghana: the case of female itinerant traders. AB - Itinerant trading is the second major economic activity for women who constitute an important chain in the distribution of goods in West Africa. Historically they have played important roles in the political economy of Ghana. With the outbreak of AIDS these women, some of whom move far away from home sometimes for days for even weeks, stand the risk of being infected with HIV through their activities. Using a combination of methods including a survey, focus-group discussions and conversations with key informants; we examine how the trade is organized, the characteristics of the traders, and the risk factors that are likely to predispose them to contracting the AIDS virus. Itinerant women traders appear highly vulnerable, as women and as highly mobile people. This state of affairs, occasioned by the extremely difficult conditions in which the women work, is exploited for the sexual gratification of the men with whom they come into contact. The attempt to reduce the spread of AIDs through education has to target itinerant women traders at the points of transaction. PMID- 10169647 TI - Effect of AIDS on children: the problem of orphans in Uganda. AB - The problem of orphans is serious in sub-Saharan Africa and has been increasing with the deaths of both parents from AIDS. A study of six districts of Uganda conducted in 1992 investigated the problem. Almost all the orphans are cared for by their extended family members who made the decisions to do so. It is recommended that more assistance be given to the family to enhance its capacity to cope with increased orphans expected in the future. PMID- 10169648 TI - Health-seeking behaviour of persons with HIV/AIDS in Ghana. AB - Historically, diseases whose aetiology could not be readily explained have been given supernatural explanations among the various ethnic groups in Ghana. Now HIV infection, with no known cure and origin, has been given a supernatural explanation. Such an explanation of disease causation influences people's attitude to the disease and to infected persons, and influences the health seeking behaviour of infected persons. Data from a study on the Social Dimensions of HIV/AIDS Infections in Ghana are used to examine the health-seeking behaviour of some persons with AIDS interviewed in 1992. The paper examines the health care outlets used by infected persons and the reasons for using those outlets. Some HIV-infected persons in Ghana felt that they had been bewitched and, therefore, used multiple health care outlets, either serially or simultaneously, hoping that one of them might provide a cure or relief as well as explain the source of the infection. This is in spite of the continuing educational campaign stating that the disease has no cure. Such attitudes towards the disease and health-seeking behaviour should be considered in the design of programs for infected persons. PMID- 10169649 TI - Postpartum sexual abstinence in the era of AIDS in Ghana: prospects for change. AB - Postpartum sexual abstinence for females has been identified as one of the socio cultural factors with the potential for creating conditions for the sexual spread of HIV in areas where it is practised. In general, women are expected to abstain from sex after childbirth in order to ensure the survival of the mother and child. Men are not similarly expected to abstain and that has been used to rationalize polygyny. With changes in socio-economic conditions making it more difficult now than before to maintain two or more wives, particularly in urban areas, some men will abstain like their wives for fear of HIV infection; but such men may press their wives to resume sex early. Some women, on the other hand, may give in to the demands of their husbands by reducing the prescribed duration of postpartum abstinence. If this happens without the use of effective modern contraception, fertility may be affected. Some may also enter short or long-term relationship outside marriage, hoping that they will be safe from sexually transmitted infection. Using data from the Ghana segment of the Social Dimensions of AIDS Infection Survey, the study examines the responses of women who reported postpartum sexual abstinence and that of their partners. Both men and women reported abstaining, but some women were aware that their partners did not abstain as they did. Some of the women knew the sexual partners of their partners. Mostly it was men who made the first move to resume sex. For any behavioural change to occur, attitudes towards socially-constructed practices such as postpartum sexual abstinence will need to be changed by intensive education of both men and women and also through community support. PMID- 10169650 TI - Attitudes to and management of HIV/AIDS among health workers in Ghana: the case of Cape Coast municipality. AB - Health Care Workers as key players in the prevention and management of diseases and important opinion and community leaders have become targets for studies, more so with the outbreak of HIV. Their perceptions, attitudes and practices have implications for the management of diseases in both health centres and communities. This study reports some of the results of in-depth interviews with Health Care Workers in the Cape Coast municipality (Ghana) on their perception of risk of exposure to HIV, attitudes to known persons with HIV/AIDS, counselling and confidentiality. Results indicate a general fear of infection given the working environment and conditions such as the insufficient supply of basic items, and inadequate information on the sero-status of some patients. Although aware of the basic precautions needed to avoid infection, some health workers did not follow them. There was also a lack of consensus among them on the issues of confidentiality and responsibility towards a discordant partner. The main arguments were those of the general debate between safeguarding individual rights and protecting the common good. It is important for the medical establishment to debate the issue so that the rights of some individuals are not compromised. PMID- 10169651 TI - Vulnerability to sexually transmitted disease: street children in Accra. PMID- 10169652 TI - Health-seeking behaviour of STD patients in an urban area of southwest Nigeria: an exploratory study. AB - Sexually transmitted disease patients of health institutions in Ado-Ekiti responded to questionnaires on the quality of STDs treatment; four-fifths of the institutions are privately owned. Gonorrhoea and syphilis are the major STDs reported by the respondents and treated by the health-care providers. Other types are candida, dysuria, lymphogranuloma venereum, chancroid, trichomoniasis and STD related problems. The symptoms noticed by the respondents are pain, burning sensation, discharges, itching and open sores. Most sought treatment within seven days of noticing the symptoms. Most sought treatment from other health providers before coming to the health institutions where they were interviewed. Respondents were attended by modern doctors during their search for a cure, but in most cases, only by physical examination because laboratory facilities were non existent or inadequate. Treatment was mainly chemotherapy, involving antibiotics and analgesics. In addition to chemotherapy, the health providers counselled the patients. Most respondents reported that they were satisfied with the quality of treatment. Results are discussed and recommendations are made. PMID- 10169653 TI - Men's sexual behaviour in urban and rural southwest Nigeria: its cultural, social and attitudinal context. PMID- 10169654 TI - Women's role in reproductive health decision making and vulnerability to STD and HIV/AIDS in Ekiti, Nigeria. AB - An exploratory study of women's role in reproductive decision making in Ekiti shows that women in the state are increasingly taking active decisions on matters affecting their daily lives. More women than ever before believed that they could take decisions on family size, when to have a baby and choice of spacing period. The cultural barrier against short postpartum abstinence appeared to have diminished and sex during lactation was not considered a major cultural and religious taboo. Knowledge of contraception has become universal in recent years, and the majority of women take decisions on the method and timing of family planning. All women who used family planning considered their decision in this regard very important. The ability of women to take decisions on these issues may not only enhance their bargaining power but also reduce their vulnerability to STDs including AIDS from diseased or high-risk partners. PMID- 10169655 TI - 'Main' girlfriends, girlfriends, marriage, and money: the social context of HIV risk behaviour in sub-Saharan Africa. AB - Research on African societies documents the magnitude of the AIDS epidemic, and shows that at younger ages women are more likely to be affected than men. Young African women are particularly vulnerable to HIV infection because sexual relations with men are an important means to achieve social and economic status, and for some women they are necessary for survival. Many African adolescents and young adults engage in premarital sexual relationships, either sequentially or simultaneously. Unmarried African males commonly have a 'main' girlfriend whom they expect to marry, and one or more other girlfriends, for whom there are no such expectations; some females have similar strategies. This study uses focus group data from Cameroun to describe popular types of premarital sexual relationships, and to examine gender differentials in the motivations for engaging in such relationships and in perceptions of the factors that affect the marriage prospects of these premarital relationships. Economic need leads many young women to use premarital sexual relations for economic support, despite high levels of HIV infection. These findings help inform policy-makers and program managers in Africa about gender differentials in the motivations for engaging in premarital sexual unions, which in turn can help improve the design and implementation of social and health policies and programs. PMID- 10169656 TI - Men, women and the trouble with condoms: problems associated with condom use by migrant workers in rural Zambia. AB - Understanding cultural attitudes to condoms is of the utmost importance in promoting their use as a means of protection against HIV transmission. This article examines condom use in relation to what people see as the purpose of sex, what good sex entails and how this relates to ideas of being a proper woman or man. It seems that the underlying and pervasive ideal is that sex is essentially a procreative act, since an emphasis on male potency and male and female fertility often overrides anxieties about contracting HIV and other sexually transmitted diseases. Hence condom use is usually only negotiated within some short-term relationships and then not consistently. Whilst both men and women have negative attitudes to condoms, women because of their economic and ideological dependence on men are in a much weaker position to negotiate condom use. PMID- 10169657 TI - Using rapid research to develop a national strategy to assist families affected by AIDS in Tanzania. AB - Although information on African family adaptation to the AIDS epidemic is critical to planning and managing government, donor and NGO programs of assistance, current knowledge is limited to a small number of research studies. An AIDS prevention project in Tanzania undertook a rapid national assessment to identify the major problems for families in Tanzania in adapting to the epidemic. The methodology used for the work was distinct from prior studies: the research covered a wide cross-section of Tanzanian population groups to gauge the extent of ethnic, urban-rural and regional variation; it was rapid and qualitative, to gather data on broad trends in a short time; and it was designed in co-operation with policy-makers so they could understand the approach being used and were receptive to the findings. The study identified common problems in AIDS care, counselling and survivor assistance. Many of the problems for families with AIDS have their origin in poverty and changes in African family structures over the past 20 years, which African demographers are just beginning to describe. Stresses arising from these changes are now being aggravated by AIDS, but families with sufficient resources, whether female or male-headed, are coping better than those without. PMID- 10169658 TI - Awareness and knowledge of AIDS among Indian women: evidence from 13 states. AB - Over 30,000 ever-married women in 13 (out of 25) Indian states where HIV is thought to be highly prevalent-Maharashtra, West Bengal, Tamil Nadu, and ten other less populous states-were surveyed about their awareness and knowledge of AIDS. Only one in six women had heard of AIDS. Among those, knowledge about transmission and prevention is poor. Multivariate analyses reveal that rural, poorly educated, and poor women are the least likely to be AIDS-aware and if aware, have the poorest understanding of the syndrome. Despite low levels of awareness and knowledge, we find a strong positive association between AIDS awareness and knowledge and condom use. PMID- 10169659 TI - Determinants of extramarital sex in the Philippines. AB - Understanding the factors associated with sexual behaviour is critical in slowing the spread of HIV in the Philippines, where sexual transmission accounts for most HIV infections, with the majority from heterosexual activity. Further, unprotected sex is common, as is sex with prostitutes. These factors increase the risks associated with extramarital sex. From an analysis of a nationally representative sample of women, we found that a number of factors were related to women's reports of their husbands' sexual activity outside their current relationship: women report that partners who are more educated, have been in the current relationship longer, and who had sex before marriage are more likely to be engaging in sex outside the marriage. Further, men who are older, who are farmers, who live at home, and who have more educated wives, were believed to be less likely to be having extramarital sex. PMID- 10169660 TI - What do school children and teachers in rural Maharashtra think of AIDS and sex? AB - This paper discusses findings on issues related to sex and AIDS based on focus group discussions conducted among students and teachers in the rural areas of Maharashtra. Most students were not sure whether AIDS could affect them, or how it could be contracted; some standard IX girl students stated the need for sex education at early ages. Most teachers did not want to talk about sex or student sexual behaviour; they stressed moral issues. PMID- 10169661 TI - Serial marriages and AIDS in Masaka District. AB - In the process of studying the functioning of households under the conditions of the AIDS epidemic in the districts of Masaka, Kabarole and Rukungiri, information was collected on the marital history of persons aged 12 years and above who had ever been involved in a regular union or marriage. That information allows the discussion of the pattern of marital mobility and the exploration of the possible links between serial marriages and the dynamics of the current epidemic. Serial marriages can be defined as the participation in a sequence of regular partnerships or unions. By this definition, males in polygamous unions are involved in the practice of serial marriages in that they go through the formation of regular unions more than once in their lifetime and are often involved in more than one such union at a time. In the case of females, serial marriage takes the form of transition from first to second and subsequent unions within a monogamous or polygamous framework. This paper describes the pattern of these serial marriages, the causes of the dissolution of unions, and the relationship between the observed patterns and selected social and demographic factors such as sex, residence, education and the household-level experience of a previous HIV/AIDS related illness or death. Particular attention is paid to the role of death of spouse and especially of death from AIDS in the dissolution of unions. Apart from the use of basic descriptive statistics, a hierarchical log linear regression is carried out and the tests of partial association between the fact of serial marriage and selected variables are presented. PMID- 10169662 TI - The role of the environment in the sexual activity of school students in Tororo and Pallisa Districts of Uganda. AB - Several models of adolescent sexual activity have previously been published and most of them suggest two basic components, biological and sociological. This article highlights important environmental factors in shaping the sexual behaviour of the school-going youth in Uganda. Students in education levels Senior 1 to 6 participated in the study. Information was collected from self response structured questionnaires, focus-group discussions, and discussions with teachers. Student respondents were randomly selected. PMID- 10169663 TI - Underlying factors in female sexual partner instability in Kampala. AB - Divorced or separated persons are more likely to be infected with HIV than those in marital unions: sexual partner instability appears to have significant implications in STD/HIV transmission. While this appears empirically true, most current STD/HIV preventive strategies do not seem to address partner instability as an important underlying factor in STD/HIV transmission and control. This paper describes reasons why young females may be motivated to change sexual partners or have more than one sexual partner. The problems appear to be dissatisfaction due to infidelity of the male partner, fear of getting STD from current partner, drunken or unattractive male partner, economic problems, lack of leisure time together, male partner's children with other women, and male partner's relatives' influence. STD/AIDS Control Programs should note that dissatisfaction with partner may be an underlying factor in HIV transmission. PMID- 10169664 TI - Cost considerations in patient-controlled analgesia. AB - Patient-controlled analgesia (PCA) is the use of a portable infusion pump activated by the patient to inject an analgesic drug intravenously, subcutaneously or epidurally. PCA permits a patient to deliver a small bolus of opioid to achieve prompt relief without over sedation. Use of PCA for pain management is increasing in hospitals and home settings, largely because it can provide equivalent or better analgesia than conventional methods, and patients are more satisfied with its use. This article reports on studies published between January 1984 and December 1995 which considered cost aspects of PCA. Most studies compared the direct costs of administering PCA with the cost of other forms of drug delivery, usually intramuscular injections. A few studies have included indirect costs such as length of stay and adverse effects associated with the use of PCA. The research on cost considerations of PCA is dominated by case reports, descriptive studies and poorly designed quasi-experimental studies. The most complete and well conducted studies usually have included only drug, equipment and labour costs. Only 6 randomised controlled trials were reported, all of which were conducted on postoperative patients. The cost effectiveness of PCA for pain management is an unresolved question because of the variability in methods used to determine costs and expenses, the different settings and patient populations in which PCA is applied, the different means to organise its management and the fact that it is a rapidly evolving technology during an era of changing reimbursement practices. There is substantial variation in the cost of drugs used in PCA and in the devices themselves, which influences the comparison of costs across studies. Also, researchers do not include the full scope of costs associated with the use of PCA in comparison with conventional drug delivery methods and some do not measure the level of pain relief achieved. Of the few complete and well designed published studies found, PCA was reported to produce superior analgesia at a higher cost than conventional intramuscular therapy in 3 studies, but to be more costly and produce less pain relief than intramuscular therapy in 1 study. There is a pressing need for cost-effectiveness, cost-utility and cost-benefit analyses to determine the appropriate clinical and cost circumstances for the use of PCA. PMID- 10169665 TI - The use of consensus methods and expert panels in pharmacoeconomic studies. Practical applications and methodological shortcomings. AB - The use of expert opinion in pharmacoeconomic studies is widespread. A review of the relevant literature has shown that expert opinion is frequently used in decision analysis, Markov models and disease management, with estimates of potential values derived from Delphi panels, modified Delphi panels and expert round tables. These consensus-gathering methods are often applied as if potential drawbacks to their application were absent. This article reviews and summarises the use of these techniques in pharmacoeconomic research and evaluates the potential shortcomings of the methodology employed. In particular, several areas of concern are noted: the provision of baseline information or seed algorithms to panellists, the high attrition rate of panels, the criteria for selecting experts and the definition of consensus. This article offers recommendations for the future application of these techniques and concludes that expert opinion can still play a valuable role in pharmacoeconomic research. PMID- 10169666 TI - Cost-related information to be provided by computerised drug-prescription systems to promote cost-effective prescribing. AB - Drug prescriptions are a source of steadily increasing healthcare expenditure in most developed countries. As the use of Computerised Drug Prescription Systems (CDPS) increase both in hospital and community-care settings, the potential of such systems to promote cost-effective prescribing and help contain prescription costs should be considered. This article describes the cost-related information that could be provided by a CDPS, namely decision-support information to be provided on-line during the prescription entry, and retrospective information made available by processing stored prescription records. The review also describes design and specification requirements for building a cost-information module that can be used in various health-delivery systems. These are: (i) adequate and well-organised data; (ii) pertinent background knowledge of the domain; and (iii) algorithms that allow adaptation to site-specific features. The propositions expounded in this article result from a part of the work performed during the Optimisation of Drug Prescription using Advanced Informatics (OPADE) European project. PMID- 10169668 TI - The cost effectiveness of pneumococcal vaccination strategies. AB - Pneumonia and influenza, combined, are the sixth leading causes of death in the US. The age-adjusted mortality rate for these diseases increased by 20% between 1979 and 1993, perhaps as a result of the emergence of multi-drug-resistant and penicillin-resistant strains of bacteria that cause pneumonia. Of the approximately $US23 billion annual cost of community-acquired pneumonia, pneumococcal pneumonia is currently estimated to account for up to $US18 billion. Considering the clinical and economic consequences of pneumococcal disease, vaccination appears to be a valuable preventive strategy. However, despite Medicare coverage and the recommendations of the Advisory Committee on Immunisation Practices (ACIP), only 28% of elderly and high-risk patients received the pneumococcal vaccine in 1993. This article reviews the epidemiology and economic factors that determine the cost effectiveness of pneumococcal vaccination strategies. The strategies are taken from a review of 10 published economic analyses of the pneumococcal vaccine. Cost savings and favourable cost effectiveness ratios are associated with key factors that increase vaccination programme benefits by maximising averted direct medical costs as well as reducing vaccination programme costs, such as through public vaccination campaigns. PMID- 10169669 TI - Economic impact of digoxin toxicity. AB - The costs of digoxin toxicity to the US healthcare system have not been previously reported. Therefore, the 1994 database of US University Health-System Consortium (UHC) was searched for cases of digoxin toxicity using the International Classification of Diseases (9th edition) [ICD-9] codes. In addition, the medical records of 17 patients admitted to the University of Illinois Hospital from September 1994 to July 1995 with a diagnosis of digoxin toxicity were also reviewed. Of the 17 patients, 14 were admitted with a primary diagnosis of digoxin toxicity. Causes of digoxin toxicity were worsening renal function (6 patients), excessive dosage prescribed (4 patients), excessive dosage self-administered (2 patients), multiple prescriptions (2 patients), accidental ingestion (1 patient), drug-drug interaction (1 patient) and unknown (1 patient). Digoxin toxicity could have been prevented in 9 (53%) of the 17 patients. The mean length of stay in the hospital as a result of digoxin toxicity was 3.3 +/- 1.2 days. The mean laboratory cost associated with digoxin toxicity was $US275.54 +/- $US106.57 and the mean hospital bed cost was $US3781.92 +/- $US2572.22. The mean overall cost associated with digoxin toxicity was $US4087.05 +/- $US2659.76. There was a significant correlation between the total cost associated with digoxin toxicity and the serum digoxin concentration on admission (r = 0.73, p < 0.01). From the UHC database, a total of 836 cases of digoxin toxicity in 56 hospitals were identified. This represented the occurrence of digoxin toxicity in 0.07% of all patients admitted to these US academic hospitals. Digoxin toxicity results in considerable costs to the healthcare system. Most cases can be considered readily preventable with proper patient counselling and education. PMID- 10169667 TI - A review of quality of life in chronic renal failure. AB - The quality of life of patients with end-stage renal disease (ESRD) has become an area of intensive investigation because of the high costs of renal-replacement therapy (dialysis or renal transplantation) and the rising prevalence of renal failure. Studies comparing quality of life of patients using different forms of renal-replacement therapy are flawed by deficiencies in study design, such as lack of randomisation. Nevertheless, in both retrospective and prospective studies, transplantation has been shown to offer the highest levels of functional ability, employment and subjective quality of life. After case-mix adjustment, there is little difference between peritoneal dialysis and haemodialysis in terms of quality-of-life (QOL) outcomes. Vocational rehabilitation is an important aim of therapy; for patients below retirement age, pre-dialysis education and counselling are important in maintaining employment. The elderly comprise the fastest-growing group of dialysis recipients; multiple comorbidities add to functional impairment in these patients. Subjective quality of life remains surprisingly high in many elderly patients, despite poor objective quality of life. The quality of life of patients with diabetes mellitus and ESRD is lower than that of nondiabetic patients with ESRD. For selected patients with insulin dependent diabetes mellitus, combined renal and pancreatic transplantation offers the advantage of freedom from insulin injections. Unfortunately, available evidence suggests only small improvements in quality of life with combined transplantation versus kidney-only transplantation, probably because many patients have developed multiple diabetic complications by the time of transplantation. Epoetin alfa (erythropoietin) has been shown to improve quality of life in a number of trials. The optimal target haematocrit is a subject of controversy, but on current evidence, a target of 34 to 37% is reasonable. The degree of improvement in quality of life must be balanced against the additional costs of achieving a higher haematocrit. Further study is necessary to clarify the optimal target haematocrit for epoetin alfa therapy, as well as the possible effects of nutritional support, growth hormone in paediatric patients, and combined renal and pancreatic transplantation in improving quality of life. PMID- 10169670 TI - An economic analysis of the Survival and Ventricular Enlargement (SAVE) Study. Application to the United Kingdom. AB - Recent studies have shown that ACE inhibitors reduce morbidity and mortality after myocardial infarction (MI). While these trials have obvious clinical implications, the widespread introduction of a new treatment for a condition as common as MI also has clear cost implications. The results of the post-MI studies with ACE inhibitors suggest that restricted use of treatment-in high-risk patients-is likely to be most cost effective, whereas treatment of all MI survivors, many of whom are at low risk, will be least cost effective. An approach somewhere in between may maximise clinical benefit at an acceptable cost. Economic analysis may help in deciding how these drugs might be best used after MI. We have conducted a cost-effectiveness and cost-utility analysis of the Survival and Ventricular Enlargement (SAVE) study, which reported the benefit of ACE inhibitors in intermediate-risk patients. Assuming all MI survivors require measurement of left ventricular function before selection for treatment (the approach used in the SAVE study), the incremental cost per life-year gained (LYG), over 4 years, using prophylactic captopril is approximately 10000 pounds sterling (Pounds) [1994 to 1995 values]. The cost per quality-adjusted life-year (QALY) is similar. These incremental cost per LYG and cost per QALY ratios compare favourably with other commonly used symptomatic and prophylactic treatments, and argue for extending post-MI use of ACE inhibitors to intermediate as well as high-risk patients. PMID- 10169671 TI - Prednicarbate versus fluocortin for inflammatory dermatoses. A cost-effectiveness study. AB - The purpose of this study was to compare, from a societal perspective, the cost effectiveness of topical prednicarbate 0.25% and fluocortin 0.75% in the treatment of inflammatory dermatoses, such as dermatitis and eczema, in Spain. Effectiveness and tolerability were determined by means of a meta-analysis of 17 randomised double-blind controlled clinical trials, using a MEDLINE search and a second-level reference search. The data were obtained on the basis of a per protocol assessment system, and the Mantel-Haenszel method (as modified by Peto) was used to make the statistical analysis. In terms of economic assessment, a model was developed in which the expected total cost was determined by the cost of the medicine (adjusted to the recommended dosage) plus the costs derived from the ineffectiveness and/or adverse effects associated with the different treatments. A sensitivity analysis was carried out on the basis of changes in: (i) clinical effectiveness; (ii) price of prednicarbate; (iii) incidence of adverse reactions; (iv) costs associated with ineffectiveness and/or adverse effects; and (v) the regimen under which prednicarbate was administered. The meta analysis showed that there was a statistically significant difference between the 2 alternatives (p = 0.001). The value of a combined odds ratio [and 95% confidence interval (95% CI)] for the combined studies of prednicarbate was 1.54 (95% CI 1.10 to 2.15), compared with 0.73 (95% CI 0.60 to 0.89) for fluocortin relative to moderate or moderate-to-high potency corticosteroids. Effectiveness was 84.9% for prednicarbate and 69.7% for fluocortin, while frequency of adverse effects was 3.5% for prednicarbate and 4.9% for fluocortin. The total expected cost per patient treated was found to be 4600 Spanish pesetas (Pta) [$US37.10; 1996 values] for prednicarbate and Pta5778 ($US46.60; 1996 values) for fluocortin. The total expected cost per patient successfully treated was Pta5608 ($US45.20) for prednicarbate and Pta8680 ($US70) for fluocortin. Prednicarbate has been shown to have a favourable cost-effectiveness ratio, when compared with fluocortin, for the treatment of dermatitis and eczema in Spain. Additional pharmacoeconomic studies on topical corticosteroids are required, including the use of new variables, long term analysis and/or the measurements of the effect of the drug on patients' quality of life. PMID- 10169672 TI - Ganciclovir. A pharmacoeconomic review of its use as intravenous or oral maintenance therapy in the management of cytomegalovirus retinitis in patients with AIDS. AB - Cytomegalovirus retinitis, an opportunistic infection caused by the herpesvirus cytomegalovirus, is a major cause of illness in patients with advanced AIDS. As infected patients require long term drug treatment to delay disease progression and minimise loss of vision, the disease is associated with substantial treatment costs which considerably increase overall expenditure on AIDS-related health care. During the last decade, intravenous ganciclovir has been a mainstay of treatment for patients with cytomegalovirus retinitis. However, notwithstanding its demonstrated efficacy as maintenance therapy for this condition, long term intravenous drug administration is both inconvenient and uncomfortable for many patients. Moreover, neutropenia and catheter-related infections have been reported commonly in patients receiving ganciclovir via the intravenous route. To overcome the limitations of intravenous ganciclovir, an oral formulation of the drug has been developed for use as maintenance therapy. In comparative clinical trials, both intravenous and oral ganciclovir maintenance therapy slowed disease progression and preserved visual acuity in patients with stabilised cytomegalo virus retinitis, although there was evidence that the intravenous formulation was more effective in terms of delaying recurrence of active disease. This suggests that oral ganciclovir use should be limited to the treatment of patients without evidence of immediately sight-threatening cytomegalovirus retinitis. Three published cost analyses, which were based on efficacy and tolerability data derived from 2 randomised, comparative clinical trials, have shown that oral ganciclovir maintenance therapy offers cost advantages over intravenous maintenance therapy, despite the higher acquisition cost of the oral formulation. The higher overall costs of intravenous maintenance treatment, compared with oral therapy, were attributed to higher drug administration and adverse event treatment costs. In one analysis, estimated lifetime treatment costs of oral maintenance therapy were 25.2% lower than those of intravenous maintenance treatment. As yet, no formal cost-effectiveness evaluations of oral and intravenous ganciclovir have been published. Few published data are available regarding the relative effects of intravenous and oral ganciclovir on quality of life. However, in a health state utility analysis, there was a large overall preference among HIV-infected individuals for oral over intravenous maintenance treatment. In conclusion, oral ganciclovir appears to be a cost-saving and patient-preferred alternative to its intravenous counterpart for the maintenance therapy of AIDS patients with stabilised cytomegalovirus retinitis in whom there is no evidence of sight-threatening disease. PMID- 10169673 TI - Comments on economic evaluation of chemotherapy. PMID- 10169674 TI - NeuroLink. Implementation of a wide-area neurosurgical consultation service. PMID- 10169675 TI - 4th annual telemedicine program survey. Part 1. Canada. PMID- 10169676 TI - Looking for acquaintances in the obituaries. PMID- 10169677 TI - How not to develop telemedicine systems. AB - The history of telemedicine is characterized by many systems that have failed, or have only lasted a short period of time. Some of the reasons for these failures are discussed. Presented here is a set of six simple rules that have been developed from evidence in the literature, and from personal telemedicine experience, about how to assure the failure of a project. These rules are unfortunately still frequently adhered to and lead to the failure, or the less effective functioning, of telemedicine systems. PMID- 10169678 TI - A time for communication and coordination. PMID- 10169679 TI - AHA move data misreported. PMID- 10169680 TI - Mortality in Medicare patients on dialysis for end-stage renal disease (ESRD), 1982-1987. PMID- 10169681 TI - Early predictors of sepsis in the motor-vehicle crash trauma victim. AB - INTRODUCTION: Sepsis is a major cause of late morbidity and mortality in the victim of trauma. Currently, there is no method that is clinically practical and accurate for predicting the occurrence of sepsis in trauma victims. METHODS: Data were collected on 3,759 motor-vehicle crash victims from 16 hospitals during a 4 1/2 year period. Retrospective analysis was done to examine the relationship of patient and injury factors known within the first 24 hours of admission on the development of sepsis. RESULTS: Sepsis developed in 154 patients (4.1%) who had a mortality rate of 17.5%. Significant early predictors of sepsis included: 1) certain pre-existing conditions; 2) blood transfusion required; 3) seven or more injuries; 4) Glasgow Coma Scale score <10 and hypotension [corrected]; 5) major blood vessel injury; 6) head trauma; 7) internal injury of the chest or abdomen; 8) spinal-cord injury; and 9) certain fracture types. CONCLUSIONS: These predictors might help target high-risk patients and, thus, promote earlier and more effective treatment for those patients. PMID- 10169683 TI - Employer involvement in eldercare: an organizational adaptation perspective. AB - Social and demographic changes represent an important environmental challenge to organizations. Recent demographic changes in the United States have increased the potential importance of "eldercare" benefits in the workplace. In this research, I elaborate a number of important organizational and environmental determinants that influence the recognition and interpretation of eldercare issues and relate these considerations to the level of employer involvement in the care of elderly dependents, or eldercare. PMID- 10169682 TI - Expertise at the end of life. PMID- 10169684 TI - Responses to health and safety risk in the work environment. AB - The subjective experience of workplace health and safety risk among exposed individuals is little understood. Health and safety risks are associated with multifaceted subjective interpretations different from those associated with other elements of the work environment and more directly influential on work attitudes and behavior than actual risk. This article conceptually and operationally defines these interpretations and evidences the influence of chronic risk exposure on job satisfaction, stress, and distraction from work tasks. PMID- 10169685 TI - Can HMOs wield market power? Assessing antitrust liability in the imperfect market for health care financing. PMID- 10169686 TI - Death by textualism: the NLRB's "incidental to patient care" supervisory status test for charge nurses. PMID- 10169687 TI - Death personification in the Kevorkian era. AB - Have death personifications changed over the past quarter of a century? A 1971 study explored the death personifications of college students, student nurses, nurses, and mortuary science students. The present study focused on 123 students of nursing and 324 students enrolled in general study courses at a large university in the American Southwest. The study also explored the possibility that Dr. Jack Kevorkian may have emerged as a contemporary image of death. Respondents were asked to imagine death as a character in the movies and to indicate the nature of this character through fixed-choice alternatives. Respondents were also asked to identify the sources or models for their personifications of death. It was found that male personifications of death still predominate, but that female personifications occur with greater frequency than in the earlier study, especially among female respondents. Although the "Gentle Comforter" is most often seen as an elderly person, overall the relationship between age and death personification appears to have weakened. There is now a larger divergence between the sexes in type of death personification selected most frequently. Females most often select "kind and gentle" imagery; males now are more likely to see death as a "cold, remote" person. Grim and terrifying images of death occur with some frequency, but are the least often selected by respondents of either sex. There was no evidence to support the emergence of a Kevorkian-type death personification, although he was identified correctly by almost all respondents and was viewed favorably by a majority. PMID- 10169688 TI - Personality constructs and perceived presence of deceased loved ones. AB - For a study of personality constructs associated with the experience of perceiving the presence of deceased loved ones, 20 male and 67 female bereaved participants completed Eysenck's Personality Questionnaire, Rotter's Locus of Control Scale, and a questionnaire related to the personal sensing experience. As hypothesized, perceivers exhibited higher scores on neuroticism and externalized control; contrary to expectations, perceivers demonstrated more extraversive than introversive tendencies. Perceived presence was not mediated by the quality of support available to the perceiver, was not generally correlated with specific demographic factors, and was most often characterized as comforting. Results are discussed in relation to current theories of grieving. PMID- 10169689 TI - The deceased child in the psychic and social worlds of bereaved parents during the resolution of grief. AB - A core dynamic by which grief is resolved by parents in Bereaved Parents, a self help group, is a series of transformations of the inner representation of the dead child in the parent's inner world and in the parent's social world. As the reality of the child's death as well as the reality of the parent's continuing bond with the child are made part of the socially shared reality, the inner representation of the child can be transformed in the parent's psychic life. The end of grief is not severing the bond with the dead child, but integrating the child into the parent's life in a different way than when the child was alive. This article traces the course of the inner representation of the child in the parent's inner life and social world as the parent progresses through Bereaved Parents. It concludes with some comments on the differences that should be maintained between scholarly and popular understandings of phenomena in the continuing bonds survivors maintain with the dead. PMID- 10169690 TI - An international survey of death education trends in faculties of nursing and medicine. AB - The purpose of this study was to identify and describe the availability of death education, including teaching and evaluation methods, specific content areas, issues being addressed, and the background and expertise of the faculty members involved in teaching death and dying content. A questionnaire was developed based on the current literature and sent to 80 faculties of nursing and 36 faculties of medicine in Canada and the United Kingdom. The majority of nursing and medical schools that responded to the survey included death education, an integrated approach, through all years of their programs. Despite recent criticisms of Kubler-Ross's model of grieving, the majority of programs reported using her theory most frequently. The findings identify the current status of death education for health professionals in Canada and the United Kingdom, and implications for curriculum changes are discussed. PMID- 10169691 TI - State health reform: effects on labor markets and economic activity. AB - Individual states are actively weighing health care reform proposals and their potential impacts on many levels, including states' own economies. This article considers the effects on state economies of two instruments of health reform: employer mandates and cost containment. The literature suggests that an employer mandate will reduce employees' wages in the long run. In the short run, however, to compensate for the costs associated with mandated health care insurance for their employees, firms may raise their prices to consumers, reduce the number of employees, or allow a drop in profit margins. By increasing health care spending and the number of insured persons, mandates would also increase states' levels of economic activity. Though cost containment may dampen the stimulative effects of expanded coverage, resources not spent on health care as a result of effective cost containment might be redistributed to other sectors in a state's economy. PMID- 10169692 TI - Medicaid participation among the eligible elderly. AB - This study uses data from the Survey of Income and Program Participation to address three issues: (1) what were the 1987 rates of Medicaid participation and private insurance coverage among elderly predicted to be categorically eligible and medically needy?; (2) how did these rates change between 1987 and 1992?; and (3) which factors influence insurance choices among persons who are categorically eligible for Medicaid? The 1987 Medicaid participation rates were 64 percent for the categorically eligible, but only 11 percent among the medically needy. Participation among the categorically eligible declined to 59 percent by 1992, but the difference was insignificant. In both years, about 23 percent of all categorically eligible persons had private insurance, but among those who do not participate in Medicaid, the rate rises to 48 percent. PMID- 10169693 TI - Grief and the sexual relationship of couples who have experienced a child's death. AB - In an interview study of the sexual relationship of bereaved parents, 16 of 24 heterosexual couples interviewed after the death of a child reported a break or decline in sexual intercourse. Consistent with social constructivist perspectives, the meanings couples gave to sexual intercourse, the death, and their grief were central in their understanding of the break or decline--e.g., the belief that intercourse was too painful because it was how the child had been made. Meanings were also linked to the continuation or resumption of the intercourse--e.g., that intercourse was life-affirming. Touching, which was defined as sexual by many people interviewed, had consistent meanings across couples--connection, support, and comfort--although couples differed in whether touching increased, decreased, or did not increase enough to satisfy one partner following the death. The meanings that couples used in discussing touching and the decline or break in sexual intercourse were also used in talking about extramarital affairs and grieving during intercourse. PMID- 10169694 TI - Evolving meanings of death during early, middle, and later adolescence. AB - The relationships among death conceptions, death experiences, patterns of parent and peer attachment, and risk-taking behaviors in adolescents were examined in an effort to construct a revised notion of the meaning of death at different points in adolescent development. Students (N = 95) from middle schools, a high school, and a university were assessed with the Inventory of Parent and Peer Attachment, a 10-item open-ended death conception questionnaire, and a demographic and death attitude survey. Results indicated that death experiences, discussions about death, belief in noncorporeal continuation (some form of life or energy after physical death), and parent attachments appear to increase during the course of adolescence. Parent attachment was found to be inversely associated with death experiences, conversations about death, and risk-taking behavior. Other findings are discussed with regard to the dialectical tensions of this phase of development; portraits of the early, middle, and later years of adolescence; and the notion of reconceptualizing the ideas of adolescents as cognitive death schema. PMID- 10169695 TI - Measuring parental grief after childhood cancer: potential use of the SCL-90R. AB - To contribute to a better understanding of the utility of the Symptom Checklist 90-Revised (SCL-90R; L. Derogatis, 1983) with bereaved samples, an exploratory factor analysis was conducted on SCL-90R responses of 97 parents 2 years after the death of their child from cancer. The factor analysis revealed one significant factor that accounted for 30% of the variance in this administration. This factor included many items that reflected the theme of somatic complaints. PMID- 10169696 TI - Older adults' attitudes toward suicide: are there race and gender differences? AB - Suicide among older persons in the United States is a major problem that has increased dramatically during the past decade. Little is known about older nonsuicidal adults' attitudes toward suicide. The purpose of this study was to identify attitudes of older persons toward suicide and to explore the relationship of race and gender to attitudes toward suicide. The Suicide Attitude Vignette Experiences for the Elderly (SAVE-L) scale, which consists of 16 vignettes, was used to measure empathy toward suicidal people and agreement with suicidal actions as portrayed in 16 vignettes. The sample consisted of 54 low-income, inner city residents, aged 65 or older. Participants reported a moderate level of empathy with suicidal behavior (M = 2.82 on a 5-point scale) and a low level of agreement with suicidal actions (M = 1.31 on a 5-point scale). There were no differences in empathy toward suicidal people nor in agreement with suicidal people's actions based on race (African American or White) or gender; nor was there a significant interactional effect of race and gender on attitudes toward suicide. PMID- 10169697 TI - The Gerasim model of caregiving: reflections on Tolstoy's novella, The Death of Ivan Ilyich. AB - Count Leo Tolstoy's classic novella The Death of Ivan Ilyich (1886/1981) is examined from the perspective of a health care professional for its portrayal of a helping relationship between the central character and his servant Gerasim. The purpose of the article is to extrapolate helping behaviors depicted in the story and construct a caregiving model. Tolstoy's work, literary critiques of the novel, biographies of Tolstoy, and principles from feminist ethics are used as sources. The model will be of assistance to those who care for the terminally ill. PMID- 10169698 TI - Frozen life's dominion: extending reproductive autonomy rights to in vitro fertilization. AB - Lawyers and judges faced with a contemporary constitutional issue must try to construct a coherent, principled, and persuasive interpretation of the text of particular clauses, the structure of the Constitution as a whole, and our history under the Constitution--an interpretation that both unifies these distinct sources, so far as this is possible, and directs future adjudication. They must seek, that is, constitutional integrity. PMID- 10169699 TI - Parent bereavement stress and preventive intervention following the violent deaths of adolescent or young adult children. AB - It is currently believed that effective intervention programs can reduce the negative consequences of stressful life events. The purpose of this paper is to describe a three-step process used to develop a theory-based preventive intervention for parents whose 12- to 28-year-old children had died 2 to 7 months previously by accident, homicide, or suicide. Assumptive world, family life cycle, victimization, and social support theories form the basis for "matching" parent bereavement stress with selected intervention strategies. PMID- 10169700 TI - Parents' evaluation of a preventive intervention following the sudden, violent deaths of their children. AB - A preventive intervention for 156 bereaved parents whose 12- to 28-year-old children died by accident, homicide, or suicide was tested using a multisite longitudinal cohort pretest/posttest experimental design. Reported here are bereaved parents' evaluations of the two-dimensional support program. Problem focused support was rated by parents' perceptions of readiness, relevance, timing, and understanding of the information and skills presented. Emotion focused support was rated by the identification of I. Yalom's (1985) therapeutic group factors and group leader/clinician support. Over 70% of all the person/session responses showed that both support dimensions were rated at 6 or 7 on a 7-point scale (e.g., 0 = not at all relevant, 7 = very relevant.) Additional exploratory analyses examined the extent to which 5 participant and treatment characteristics influenced parents' evaluations. Clinical implications and future research directions are suggested. PMID- 10169701 TI - Communal and individual mourning dynamics within traditional Jewish law. AB - This paper discusses how various details of traditional Jewish law (Halakha) reflect human dynamics of mourning, drawing heavily on the approach of the late Joseph B. Soloveitchik, one of the major philosophers of Judaism of this century. PMID- 10169702 TI - Family environment, attitudes toward life and death, depression, and suicidality in elementary-school children. AB - This study examines whether perception of family environment, attitudes toward life and death, and depression predict suicidality in elementary-school children. Seventy-eight participants ages 8 to 13 recruited through an elementary school and a university were assessed for attitudes toward life and death, depression, suicidality, and family environment. A regression equation indicated that depression and attraction to life were the only variables accounting for variance in suicidality (49%). Family environment variables were moderately correlated with depression, indicating that family environment may play a role in the development and maintenance of depression, of which suicidality is a symptom. Concurrent treatment of family issues may not only ameliorate children's symptoms, but also provide a critical sense of support that may decrease the likelihood that these children will become suicidal in the future. PMID- 10169704 TI - The right to choose how to die: a constitutional analysis of state laws prohibiting physician-assisted suicide. PMID- 10169703 TI - Elderly suicide, mental health professionals, and the clergy: a need for clinical collaboration, training, and research. AB - This article addresses the need for improved clergy-mental health professional collaboration in the assessment and treatment of elderly suicide. Millions of older adults with personal problems seek the counsel of clergy. A recent Gallup survey found that elders are more willing to turn to their clergy than their medical doctor or a mental health specialist for help when a friend is contemplating suicide (Gallup Organization, 1992). Elder suicide prevention presents the mental health and religious communities with unique opportunities to work together in the best interests of those they serve. PMID- 10169705 TI - Beyond bereavement support group meetings: exploring outside social contacts among the members. AB - This article examines the extent to which bereavement support group participants engage in social interaction with fellow group members outside of the meetings, demographic influences on outside contact, and the relationship between this social interaction and bereavement outcomes. Data are presented from a longitudinal study that included 144 recently bereaved spouses between the ages of 51 and 89 who participated in a support group intervention. During the course of the study the majority of the participants had contact with other group members in addition to the scheduled meetings even though the group leaders did not encourage outside contact. Although the frequency of the interaction was only moderate, the support group participants reported feeling relatively close to their fellow group members. Men were as likely as women to have outside contact but they delayed in doing so. Those who engaged in outside contact were slightly more depressed, experienced more stress, and were more lonely at the time of the contact relative to others. Those who maintained some kind of interaction by Time 3 (1 year bereaved), however, reported less loneliness by the end of the study (Time 4). Findings are discussed in terms of the frequency and duration of support group interventions, the gender composition of the groups, and the need to incorporate into future studies a more systematic examination of outside interaction among support group participants. PMID- 10169707 TI - Structure of the Collett-Lester Fear of Death and Dying Scale. AB - The study examined the factor and cluster structures and internal consistency reliabilities of the Collett-Lester Fear of Death Scale. Data were reanalyzed from an earlier study of 88 subjects who completed the scale under neutral conditions. The four subscales showed only weak recovery in the four-factor solution and gender loaded on the factor reflecting the Fear of Death of Others subscale. The two-factor solution showed that items reflecting the death and dying of "self" tended to load on the first factor whereas items concerning "others" loaded on the second factor. A Ward's cluster analysis yielded five meaningful clusters of items. Not surprisingly, the four subscales showed only moderate internal consistency reliabilities whereas the overall scale was acceptable. Comments are presented for improving the scale as well as for using the scale in applied settings. PMID- 10169706 TI - Working with the bereaved: U.S. Army experiences with nontraditional families. AB - This paper uses a postmodern family perspective to examine the interaction between Army Casualty Assistance Officers (CAOs) and the families of deceased soldiers. The data we examine are open-ended survey responses of CAOs (N = 188) who assisted bereaved families of soldiers killed in three unrelated air disasters. Five themes emerged from our analysis of the qualitative responses: postmodern family structures, contested definitions of "significant other," language, diversity, and emotion. These themes appear to be related to the difficult demands associated with bereavement work. We argue that the experiences of the CAO are comparable to the experiences of others who may work with the bereaved (e.g., police officers, medical workers, and disaster workers) when working in similar familial contexts. PMID- 10169708 TI - Attitudes of college students about physician-assisted suicide: the influence of life experiences, religiosity, and belief in autonomy. AB - This study describes attitudes of college students about physician-assisted suicide, analyzes key factors that predict attitudes on this issue, and compares these attitudes with those regarding other forms of end-of-life actions. Data were collected via personal interviews with 200 randomly selected students at a 4 year college. A majority of respondents believe that a physician should be able to assist in the suicide of a terminally ill person who requests help, though larger percentages support the withholding or withdrawing of life-sustaining technology and the right of a terminally ill person to end his or her own life. Results of multiple regression analysis determine that the key predictors of this attitude are student's level of religiosity (students higher in religiosity are more likely to disapprove) and belief in autonomy as a philosophical principle (students placing more value on autonomy are more likely to approve). Respondent's sex, cumulative grade point average, and amount of exposure to these issues are not significant predictors. PMID- 10169709 TI - Suicidality, hopelessness, and attitudes toward life and death in clinical and nonclinical adolescents. AB - To see if hopelessness and four attitudes (attraction to life and death and repulsion by life and death) account for the development of suicidality in children, 15 adolescent psychiatric inpatients and 84 middle and high school students, average age 15.2 years, took a four-item version of the Suicidal Behaviors Questionnaire, the Hopelessness Scale for Children (HSC), and the Multi Attitude Suicide Tendency Scale for Adolescents (MAST-A). Profiles on the four attitudes differentiated adolescents at risk for suicide from those not at risk. Suicidality was negatively related to Attraction to Death and positively related to Repulsion by Life, Attraction to Death, Repulsion by Death, and hopelessness. Hopelessness was negatively related to Attraction to Life, and positively related to Repulsion by Life and Repulsion by Death. The best predictors of suicidality were hopelessness and Repulsion by Life. Results imply that reducing feelings of rejection by their families might lessen suicidality in adolescents. PMID- 10169710 TI - The impact of Medicaid managed care on the uninsured. PMID- 10169711 TI - Protecting the physician in HIV misdiagnosis cases. PMID- 10169712 TI - Fear of personal death in adulthood: the impact of early and recent losses. AB - This study examines the association between the loss of significant others and fear of personal death in adulthood. The sample consisted of a group of 86 Israeli adults who had experienced a significant loss in childhood or adolescence and a matched group of 86 subjects who had not experienced any early loss. Participants in each group were further divided according to the experience of a significant loss during the previous 2 years and completed a multidimensional scale measuring fear of personal death. Whereas early loss was positively related to the interpersonal component of fear of death, recent loss was positively related to the intrapersonal and transpersonal components of this fear. These associations were found to be moderated by the identity of the lost person, the age of the subject at the time of the early loss, and the subject's gender. The discussion emphasizes the complexity of the meanings and antecedents of fear of death in adulthood. PMID- 10169713 TI - Twenty suicide assessment instruments: evaluation and recommendations. AB - Twenty relatively new suicide assessment instruments can be grouped into the following categories: (a) clinician-rated suicide instruments, (b) self-rated suicide instruments, (c) self-rated buffers against suicide, (d) instruments focused on children and adolescents, and (e) special purpose scales. The present review describes these instruments, giving the potential clinician or researcher information about their psychometric properties, strengths, and weaknesses. They vary in length and the age group for which they are designed, but most are reliable and have some psychometric evidence of validity. Of the 20, most highly recommended are Beck's Scale for Suicide Ideation series, Linehan's Reasons for Living Inventory, and Cole's self-administered adaptation of Linehan's structured interview called the Suicidal Behaviors Questionnaire. PMID- 10169714 TI - The Suicide Intervention Response Inventory: a revision and validation. AB - The Suicide Intervention Response Inventory (SIRI) was developed by Neimeyer and MacInnes (1981) to assess the ability of paraprofessional counselors to recognize appropriate responses to suicidal clients. Although several studies have supported the validity of the scale, concerns have been raised about its ceiling effect when administered to more highly trained counselors. Psychometric improvements were therefore attempted, and the original dichotomous scoring system was replaced with a Likert scale format, in the SIRI-2. Because respondents were required to make more subtle judgments concerning the appropriateness of each response as defined by a criterion group of highly expert suicidologists, the ceiling effect that limited the use of the original measure was eliminated. Construct and discriminant validity were demonstrated in both versions of the instrument. Internal consistency and test-retest reliability showed improvement with the SIRI-2. Overall, the SIRI-2 shows promise as an index of suicide counseling effectiveness, especially among more skilled counselors. PMID- 10169715 TI - When welfare reforms promote abortion: "personal responsibility," "family values," and the right to choose. PMID- 10169716 TI - Overview of the Veterans Health Administration: organizational structure and function. PMID- 10169717 TI - Clinical ethics in the Veterans Health Administration. PMID- 10169718 TI - The evolving role of ethics advisory committees in VHA. PMID- 10169719 TI - Salt Lake City VA Medical Center's first 150 ethics committee case consultations: what we have learned (so far). PMID- 10169720 TI - VHA policy-related clinical ethical issues. PMID- 10169721 TI - End-of-life decisionmaking in the Veterans Health Administration. PMID- 10169722 TI - VHA's mission: institutional integrity, non-abandonment and VHA special emphasis programs. PMID- 10169723 TI - Perspectives. Caution mixes with courage in sweeping health care bill. PMID- 10169724 TI - Marketplace. What fills the gap as employers drop health care coverage for pre Medicare retirees? PMID- 10169725 TI - New rules in the risk game. PMID- 10169727 TI - From bill-payer to purchaser: Medicare in transition. PMID- 10169726 TI - The system works. PMID- 10169728 TI - The Blues' new colors. PMID- 10169730 TI - Taking a rural route. Three new hospital companies have a similar aim: revive small, distressed hospitals with a dose of integration. PMID- 10169729 TI - The spirit of St. Louis. Merging organizational culture and decision making at BJC Health System. PMID- 10169731 TI - Looking homeward. Managing care across the post-acute continuum. PMID- 10169732 TI - Under new management. PMID- 10169733 TI - All terrain vehicle. AB - MSOs (management service organizations) offer health systems and physicians a flexible, resilient vehicle for integration. But they work much better when providers tailor them carefully to their markets and give them a clear mission. PMID- 10169734 TI - El Nino. PMID- 10169735 TI - Data ... 10 million uninsured children. PMID- 10169736 TI - Meeting the need for speed--Columbia style. PMID- 10169737 TI - Free ride for workers enhances the community. PMID- 10169738 TI - Class act. Materials managers add capital equipment to their repertoire. PMID- 10169739 TI - Places in the heart. A project Perfect World diary. PMID- 10169740 TI - Closing the loop. Hospitals prepare for EHCR (efficient healthcare consumer response). PMID- 10169741 TI - Plugged in. Here's how to do business electronically. PMID- 10169742 TI - Supply pricing update. Dips and spikes. PMID- 10169743 TI - Positively productive. Turn around your down-at-the-mouth employees. PMID- 10169744 TI - Racks, stacks or carousels? Networks lead to massive reconfiguration of storage space. PMID- 10169745 TI - And the survey says ... what's going on in today's CS departments. PMID- 10169746 TI - Leading with your heart. Redefining "the patient". PMID- 10169747 TI - Maximizing internal opportunities for healthcare facilities facing a managed-care environment. AB - The primary theme of this article concerns the pressures on healthcare facilities to become efficient utilizers of their existing resources. This acute need for efficiency has been extremely obvious since the changing reimbursement patterns of managed care have proliferated across the nation. PMID- 10169748 TI - Quality-adjusted life years: cost-effective medical decision-making. AB - It is well-documented that the resources available to meet the healthcare needs of Americans are limited. Consequently, it is inevitable that limits will have to be set regarding how much can be spent. While such a proposal is obviously controversial, limits are already in place in many areas of healthcare. The problem is determining how to allocate healthcare dollars in order to get the most benefit. PMID- 10169749 TI - Uninsured kids: overestimating the numbers. PMID- 10169750 TI - Communicating choices for cost-effective care. PMID- 10169751 TI - Patients, profits and health system change. Panel discussion. PMID- 10169752 TI - Don't get stung by a sweet outsourcing deal. PMID- 10169753 TI - When workers fight flab. PMID- 10169754 TI - The prostate's economic squeeze. PMID- 10169755 TI - Managing care under the Big Sky. PMID- 10169756 TI - Data watch. Financial health with fewer workers. PMID- 10169757 TI - Integrating clinical and support process design for effective health services. AB - With increased capitation and managed care competition, health care systems must demonstrate effective health services with predictable costs, timing, transitions, and health outcomes. By involving patients, payers, and multiple providers, a health care system can design integrated clinical and support processes across the continuum for defined populations. The goals are lower costs, increased payer and patient satisfaction, and improved health status. This article shares examples and experiences from four health care systems that teamed with Premier, Inc., to design an integrated services sequence for defined populations. PMID- 10169758 TI - How do states buy health insurance for their own employees? AB - State governments play many roles in local health insurance markets. This paper focuses on the role of states as employers. As managed care and health care costs continue to grow, state governments engage in a variety of health insurance purchasing practices that influence the structure of health benefits offered to state employees. Descriptive analysis shows that many states have adopted managed competition to some degree, as well as traditional cost-reducing measures such as utilization review and self insurance. The experience of state governments can provide a benchmark for other public and private employers. PMID- 10169759 TI - Effectiveness of a teen pregnancy clinic in a managed care setting. AB - We retrospectively examined the effectiveness of a teen pregnancy clinic at a large multispecialty group between 1991 and 1994 using measurements of statistical differences in intervention and outcome variables. The 72 teens in the intervention group attended significantly more prenatal visits, more postpartum visits and gained more weight than the 33 controls. Other outcome variables such as fetal birth weight, Apgar scores, and neonatal intensive care unit admission showed trends toward improvement, but were not significantly different. We conclude that a teen pregnancy clinic in a managed care setting can be a cost-effective intervention in improving mental and neonatal outcome. PMID- 10169760 TI - The cognitively limited severely mentally ill: concerns for managed care. AB - The managed care needs of cognitively impaired severely mentally ill inpatients have not been estimated. The aims of the study were to estimate and describe the demographic and clinical characteristics of cognitively impaired patients in an urban inpatient sample. By doing so, we hoped to identify areas that need further study and treatment modification in planning capitated contracts. PMID- 10169761 TI - The early experience of a voluntary small group insurance program utilizing managed care plans. AB - HealthCare Group of Arizona (HCGA), a state-sponsored, voluntary health insurance purchasing program offering prepaid health plans to small businesses, became operational in 1988. This article summarizes the results from a wide-ranging evaluation of that program and discusses their implications. In general, enrollees were satisfied with their experience in their plans. HCGA did not appear to attract an adverse mix of health risks, and service utilization rates were consistent with HMO industry averages. However, these findings varied across health plans and the marketing approaches they adopted. Enrollment growth in HCGA has been steady, but premium subsidies may be necessary if HCGA is to substantially increase its enrollment of low-wage, uninsured workers. PMID- 10169762 TI - HealthEast Care: a direct contracting company. AB - HealthEast Care has contracted directly with large self-funded Minnesota employers, including 3M, since 1992. These innovative direct contracting arrangements continue to demonstrate how collaborative efforts between health care purchasers and providers can be of advantage to those enrolled in self funded and noninsured health plans. Insured HMO enrollment in Minnesota has been flat since 1991, while enrollment in self-funded plans and in noninsured public health plans has doubled during the same period. Minnesota is a bellwether state on the threshold of reform that will shift the power race for health care change from HMOs to purchasers and providers responding to consumer needs. PMID- 10169763 TI - Allina Health System's approach to high tech and high touch. AB - All health care providers, regardless of their integration status, must meet customer expectations to maintain market share and viability. The balance between high tech and high touch customer interactions is not a fad or trend. For integrated health systems with the full continuum of medical care, additional challenges are presented by the organization's competing health care delivery and financing components. Allina Health System describes its integrated health system approach to satisfying customer high tech and high touch needs. PMID- 10169764 TI - The Buyers Health Care Action Group: creating a competitive care system model. AB - The Buyers Health Care Action Group, BHCAG, representing 26 large self-funded employers, has developed a new approach to the health care marketplace. On January 1, 1997 these companies implemented their plan to promote consumer driven competition at the care system rather than the plan level around clinical quality, service quality and cost. This new approach features increased provider autonomy and accountability, while empowering consumers with information to choose care systems based on their own values. Results to date include availability of 90-95% of community primary care physicians (with almost twice the delivery sites as previous offerings), extensive consumer information about providers and the care systems in which they participate, and a 1997 cost reduction of 9% against expected claims. PMID- 10169765 TI - HealthSystem Minnesota: a leader in the Minnesota marketplace. AB - HealthSystem Minnesota is an integrated, patient-centered, care delivery system located in the Twin Cities. In the early 1990's, as pressure built for health care providers to cut costs and increased value, Park Nicollet Clinic, Methodist Hospital, Primary Physician Network, and our other member organizations merged to form HealthSystem Minnesota. Our organization has strong relationships with several major payers, but we have chosen to remain purely a physician-led, professionally managed care delivery system. This structure allows us to focus on our patients as our first priority. This article illustrates the role HealthSystem Minnesota plays in the highly competitive Twin Cities market. PMID- 10169766 TI - Facing market changes: a health care cooperative in rural Minnesota. AB - The Minnesota Health Care Cooperative Act, enacted as an article of the Minnesota Health Care Act of 1994, allows the creation of "health care provider cooperatives," corporations where members are licensed health care providers. Organized under Minnesota Statutes 62R, health care provider cooperatives (referred to hereafter as cooperatives) market their services to health care purchasers, including licensed health plan companies, health maintenance organizations (HMOs), and government plans on a "substantially capitated or similar risk sharing basis." Solvency and reserve standards do not apply to cooperatives because they are not engaged in the business of insurance. PMID- 10169767 TI - Changing notice and appeal rights for Medicare contracting HMOs. PMID- 10169768 TI - Key information system functions for managed care. PMID- 10169769 TI - Point/counterpoint. Centers of excellence. Ranae Dahlberg vs. David Plocher. AB - This issue's Point/Counterpoint considers the pros and cons of centers of excellence. On the pro side of the debate is Ranae Dahlberg, RN, BSN, Director, Quality Management, United Resource Networks (URN), a Minneapolis-based transplant management company owned by United HealthCare. URN, which began operating in 1990, has a network client base 337 customers. Ms. Dahlberg argues that though expensive, well-managed organ transplant programs have demonstrably improved outcomes. Dissenting is David Plocher, MD, a physician and consultant with Ernst & Young LLP, Minneapolis. He argues that outcomes data often are misleading depending on the criteria used to evaluate patient results and promised cost savings also may be illusory. PMID- 10169770 TI - Outcomes measurement across the continuum of care. AB - Outcomes management can only be truly achieved if it is conducted using data obtained from every possible care delivery site--the entire continuum of care. The author emphasizes that designing the most appropriate information infrastructure for an integrated health system requires a thorough understanding of the needs of the organization as reflected in its strategic business goals and objectives. PMID- 10169771 TI - Medicaid marketing: what do beneficiaries most want to know about managed care plans. PMID- 10169772 TI - Health care commerce on the net: the revolution begins. PMID- 10169773 TI - Low back pain. PMID- 10169774 TI - The anatomy of one trading week. PMID- 10169775 TI - Electronic formulary control. AB - Although pharmacy program managers have used numerous strategies to ensure conformance with the drug formulary, most are activated after the prescription of a nonformulary drug has been written. The ultimate goal being pursued by a variety of MCOs is to educate the physician at the point of care and present formulary alternatives at the time the prescription pad is out and the pen is in hand. PMID- 10169776 TI - Opportunities and challenges of electronic physician prescribing technology. AB - The results of a six-month pilot with electronic prescribing used by 17 Health Alliance Plan (HAP) physicians are reported. All 17 practice in an IPA setting in southeastern Michigan. This critical evaluation reveals the many opportunities and various challenges that this new technology brings to the managed health care environment. PMID- 10169777 TI - Why don't we have "better" diabetes care? PMID- 10169778 TI - Diabetes management: improving care in HMO and community settings. AB - Developing an effective, quality-driven disease management program for the treatment of patients with diabetes has become essential for MCOs, which cover the majority of American individuals suffering from this condition. At Cedars Sinai Medical Center in Los Angeles, the Diabetes Managed Care Program was developed and implemented in an effort to provide a model for similar diabetes management initiatives in both managed health care plans and community settings. PMID- 10169779 TI - HIPAA (Health Insurance Portability and Accountability Act) rules: federal and state enforcement. AB - Title I of the Health Insurance Portability and Accountability Act (HIPAA), signed into law in August 1996, pertains to "health care access, portability, and renewability," and affects the Employment Retirement Income Security Act, the Public Health Service Act, and the Internal Revenue Code. In this article, the author examines the regulations that will implement Title I of HIPAA on both the state and federal levels. PMID- 10169780 TI - Changing physician behavior: the Maine Medical Assessment Foundation. AB - Methods to produce change in physician practice patterns are of increasing importance to payers and regulators as well as to physicians themselves. Because some of the strategies being adopted occur without physician input and participation, they have aroused concern in the medical community. We describe the methods used and results achieved by the Maine Medical Assessment Foundation, a nonprofit education and research organization, that has been active in practice pattern analysis since the late 1970s. The foundation has successfully engaged clinicians in a program of systematic assessment of medical care provided to residents of Maine. Significant change in practice patterns has been documented. Physicians have become active participants in the process of voluntary self assessment, education, and quality improvement. PMID- 10169781 TI - Quality improvement activity directed at the national level: examples from the Health Care Financing Administration. AB - Quality improvement projects coordinated by the Health Care Financing Administration (HCFA) are currently underway to improve the care provided to Medicare beneficiaries. We describe five national quality improvement projects, the End Stage Renal Disease Core Indicators Project, the National Anemia Cooperative Project, the Ambulatory Care Quality Improvement Project, and the Cooperative Cardiovascular Project. We outline the types of intervention strategies employed and compare the approaches used for fee-for-service sites and for managed care plans. PMID- 10169782 TI - Rapid retrieval of neonatal outcomes data: the Kaiser Permanente Neonatal Minimum Data Set. AB - Although neonatal intensive care units are known to be expensive, much of what happens inside such units in managed care organizations is not known. One reason for this lack of knowledge is that existing database systems were not designed to capture information in modern critical care units. This article describes the development of a dedicated outcomes database and wide area network linking six level III intensive care nurseries in the Kaiser Permanente Medical Care Program's Northern California Region. This database can be considered a hybrid, in that it combines attributes of research and operational systems. PMID- 10169783 TI - Use of National Practitioner Data Bank disclosure information for decision making. AB - Hospital, state licensing boards, and managed care organizations query the National Practitioner Data Bank to receive malpractice payment and adverse licensure or clinical privileges reports concerning licensed health care practitioners. The results of a national survey of queriers strongly suggest that Data Bank reports impart valuable information that affects licensing and credentialing decisions. Thus, the Data Bank is fulfilling the role lawmakers intended in improving the quality of health care. PMID- 10169784 TI - The principles of quality-associated costing: derivation from clinical transfusion practice. AB - As clinical transfusion practice works towards achieving cost-effectiveness, prescribers of blood and its derivatives must be certain that the prices of such products are based on real manufacturing costs and not market forces. Using clinical cost-benefit analysis as the context for the costing and pricing of blood products, this article identifies the following two principles: (1) the product price must equal the product cost (the "price = cost" rule) and (2) the product cost must equal the real cost of product manufacture. In addition, the article describes a new method of blood product costing, quality-associated costing (QAC), that will enable valid cost-benefit analysis of blood products. PMID- 10169785 TI - The practice of quality-associated costing: application to transfusion manufacturing processes. AB - This article applies the new method of quality-associated costing (QAC) to the mixture of processes that create red cell and plasma products from whole blood donations. The article compares QAC with two commonly encountered but arbitrary models and illustrates the invalidity of clinical cost-benefit analysis based on these models. The first, an "isolated" cost model, seeks to allocate each whole process cost to only one product class. The other is a "shared" cost model, and it seeks to allocate an approximately equal share of all process costs to all associated products. PMID- 10169786 TI - Inpatient and ambulatory patient satisfaction with nursing care. AB - This study reports on the development and psychometric testing of inpatient and ambulatory patient satisfaction scales designed to measure patient satisfaction using the standards of nursing practice within a medical center. The surveys were administered to patients 4-6 weeks after discharge from the hospital or following a clinic visit. A total of 619 inpatient and 955 ambulatory patient questionnaires were analyzed. Factor analyses suggest there exist four scales for inpatient satisfaction anf five scales for outpatient satisfaction with high reliability and reasonable validity. PMID- 10169787 TI - Focused quality improvement in health care: the quality, satisfaction, performance technique applied in internal medicine. AB - Service quality assessments are dominated by simple analysis of questionnaire data. Such methods generally lack validity and reliability. Moreover, they do not have a target side defining what actions patient satisfaction should lead to from a management point of view. The quality, satisfaction, performance method, a technique with high validity, was applied in an internal medicine setting. The method appears to offer a unique way to relate desired results of care to different processes and structures in the clinic as well as incentives to intervene to improve the quality of care. PMID- 10169788 TI - Expanding health insurance for children: examining the alternatives. AB - This Issue Brief examines the issue of uninsured children. The budget reconciliation legislation currently under congressional consideration earmarks $16 billion for new initiatives to provide health insurance coverage to approximately 5 million of the 10 million uninsured children during the next five years. Proposals to expand coverage among children include the use of tax credits, subsidies, vouchers, Medicaid program expansion, and expansion of state programs. However, these proposals do not address the decline in employment-based health insurance coverage--the underlying cause of the lack of coverage, to the extent that a cause can be identified. What is worse, some proposals to expand health insurance among children may discourage employers from offering coverage. Between 1987 and 1995, the percentage of children with employment-based health insurance declined from 66.7 percent to 58.6 percent. Despite this trend, the percentage of children without any form of health insurance coverage barely increased. In 1987, 13.1 percent were uninsured, compared with 13.8 percent in 1995. Medicaid program expansions helped to alleviate the effects of the decline in employment-based health insurance coverage among children and the potential increase in the number of uninsured children. Between 1987 and 1995, the percentage of children enrolled in the Medicaid program increased from 15.5 percent to 23.2 percent. Some questions to consider in assessing approaches to improving children's health insurance coverage include the following: If the government intervenes, should it do so through a compulsory mechanism or a voluntary system? Is the employment-based system "worth saving" for children? In other words, are the market interventions necessary to keep this system functioning for children too regulatory, too intrusive, and too cumbersome to be practical? In addition to reforming the employment-based system, what reforms are necessary in order to reach those families who have no coverage through the work place? Which approaches are both efficient and politically acceptable? Employment based coverage of children will likely continue. The challenge for lawmakers is to find a way to cover more uninsured children without eroding employment-based coverage. Several current legislative proposals attempt to avoid this problem by excluding children who have access to employment-based coverage. Without such a requirement, the opportunity to purchase coverage at a discount would create incentives for some low-income employees to drop dependent/family coverage, which in turn could lead some employers to drop their health plans. PMID- 10169789 TI - Enterprise integration. Can network computers be your best friends? PMID- 10169790 TI - Intranets: communication for the international universe. PMID- 10169791 TI - What works. Ambulatory medical record shares information throughout the health system. PMID- 10169792 TI - What works. Client-server managed care solution targets productivity, competitiveness. PMID- 10169793 TI - What works. New VA facility uses paperless medical records systems to compete. PMID- 10169794 TI - What works. Rehab facility saves $300,000 a year, reduces FTEs, with scheduling system. PMID- 10169795 TI - Right on schedule? Demand for enterprise-wide scheduling solutions grows. AB - Driven by the need to get the most from staff and equipment, and to move patients efficiently through the care delivery system, enterprise-wide scheduling software is a hot commodity. Analysts say competition among vendors is heating up, too. PMID- 10169796 TI - Hotlist. Wireless systems and hardware. PMID- 10169797 TI - Integrating knowledge bases at the point of care. PMID- 10169799 TI - AI and matters of clinical and financial life or death. PMID- 10169798 TI - Working with vendors on your Year 2000 solution. PMID- 10169800 TI - Enterprise integration. The CIO tapes. Roundtable discussion. PMID- 10169801 TI - Getting connected without getting wired. PMID- 10169802 TI - EDI and the Internet: making new connections. PMID- 10169803 TI - Finding value in EMRs (electronic medical records). PMID- 10169804 TI - What works. Small Utah clinic gets big benefits from tailored financial package. PMID- 10169805 TI - What works. Fledgling HMO uses document imaging to differentiate itself. PMID- 10169807 TI - Hotlist. Health care IT consultants. PMID- 10169806 TI - What works. Handheld PCs, CPR software help clinic cuts costs, enhance service. PMID- 10169808 TI - Changing times and the business case for "telestuff". PMID- 10169809 TI - Technology-enabled clinical guidelines and EMRs (electronic medical records). PMID- 10169811 TI - Behavioral health and the transition to integrated information systems. PMID- 10169810 TI - Fast-forward at Fallon. PMID- 10169812 TI - What works. Automatic coding software identifies overlooked Medicaid APG reimbursements. PMID- 10169813 TI - What works. AIDS application enhances case managers' productivity and proactivity. PMID- 10169814 TI - What works. Imaging system: $50,000 annual savings, pays for itself in 18 months. PMID- 10169815 TI - What works. Computerized patient record cuts redundant documentation, improves charting. PMID- 10169816 TI - Boosting bandwidth. AB - The good news is that newer, faster technology is opening up new horizons for networked applications. The bad news? Figuring out how much bandwidth to install to meet future demands, without overbuilding and suffering a poor ROI. PMID- 10169817 TI - Information systems help redesign traditional utilization management processes. PMID- 10169819 TI - Hotlist. Laboratory systems. PMID- 10169818 TI - Establishing an electronic enrollment system. PMID- 10169820 TI - Health care consolidation: look before you commit. PMID- 10169822 TI - Engineering department physical plant staffing requirements. AB - There is a considerable effort in the health care arena to establish credible engineering manpower yardsticks that are universally applicable as a benchmark. This document was created by using one facility's own benchmark criteria that can be used to help develop either internal or competitive benchmarking comparisons. PMID- 10169821 TI - EMC(electromagnetic compatibility): how to manage the challenge. AB - The significant changes in health care and telecommunications has produced an emergence of new and exciting technologies. Clinical engineers must continue to safeguard patient safety by adequately refurbishing their arsenal of technical knowledge of electromagnetic compatibility (EMC). This document examines the methodology and the tools for managing the technical changes in the telecommunications and biomedical equipment areas. PMID- 10169823 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1998 rates--HCFA. Proposed rule. AB - We are proposing to revise the Medicare hospital inpatient prospective payment systems for operating costs to implement necessary changes arising from our continuing experience with the systems. In addition, in the addendum to this proposed rule, we are describing proposed changes in the amounts and factors necessary to determine prospective payment rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes would be applicable to discharges occurring on or after October 1, 1997. We are also setting forth proposed rate-of-increase limits as well as proposing changes for hospitals and hospital units excluded from the prospective payment systems. PMID- 10169824 TI - Interim rules for health insurance portability for group health plans--HCFA. Correction. PMID- 10169825 TI - Interim rules for health insurance portability for group health plans; correction -HCFA. Correction to interim rules. AB - This document contains corrections to interim rules which were published in the Federal Register on Tuesday, April 8, 1997 (62 FR 16894). The interim rules govern the access, portability and renewability requirements for group health plans and issuers of health insurance coverage offered in connection with a group health plan under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). PMID- 10169826 TI - Individual market health insurance reform: portability from group to individual coverage; federal rules for access in the individual market; state alternative mechanism to federal rules; correction--HCFA. Interim final rule; correction. AB - This document corrects an interim rule and a previous correction to the interim rule published in the Federal Register of April 8, 1997 that implement the health insurance portability, availability, and renewability provisions of the Health Insurance Portability and Accountability Act of 1996 in the individual health insurance market. PMID- 10169827 TI - Distance learning and telemedicine loan and grant program--Rural Utilities Service, USDA. Final rule. AB - The Rural Utilities Service (RUS) is amending its regulation concerning the Distance Learning and Telemedicine Grant Program. This final rule promulgates regulations for a new loan program that provides both loans and grants for distance learning and telemedicine projects benefiting rural areas. The regulation is necessary to implement a new loan program mandated by the Federal Agriculture Improvement and Reform Act of 1996. The regulation establishes, among other things, RUS' policy, the method of selecting projects to receive loans and grants and allocating the available funds, and the requirements for submitting an application for financial assistance. PMID- 10169828 TI - Investigational new drug application; exception from informed consent; technical amendment--FDA. Final rule. AB - The Food and Drug Administration (FDA) is amending its investigational new drug application (IND) regulations to clarify that, within 30 days after the receipt of an IND for any clinical investigation involving an exception from informed consent, FDA will provide a written determination as to whether the investigation may begin. This action is intended to clarify a recent amendment to the IND regulations for clinical investigations involving an exception from informed consent that states that FDA will provide a written authorization within 30 days of receipt of the IND. PMID- 10169829 TI - Medicare program; ambulance services--HCFA. Proposed rule. AB - This proposed rule would update and revise HCFA's policy on coverage of ambulance services. It would base Medicare coverage and payment for ambulance services on the level of medical services needed to treat the beneficiary's condition. It also clarifies Medicare policy on coverage of non-emergency ambulance services for Medicare beneficiaries. PMID- 10169830 TI - License term for medical use licenses--NRC. Proposed rule. AB - The U.S. Nuclear Regulatory Commission is proposing to amend 10 CFR part 35 to eliminate the five-year term limit for medical use licenses in 10 CFR 35.18. License terms for licenses issued pursuant to part 35 would be set, by policy up to ten years, as are the license terms for other materials licenses. The NRC would issue some licenses for shorter terms, if warranted by the individual circumstances of license applicants. The amendment would reduce the administrative burden of license renewals for both NRC and licensees, and would support NRC's goal of streamlining the licensing process. PMID- 10169831 TI - Accessibility to new drugs for use in military and civilian exigencies when traditional human efficacy studies are not feasible; determination under the interim rule that informed consent is not feasible for military exigencies; request for comments--FDA. Request for comments. AB - The Food and Drug Administration (FDA) is requesting written comments related to the advisability of revoking or amending the interim final rule that permitted the Commissioner of Food and Drugs (the Commissioner) to determine that obtaining informed consent from military personnel for the use of an investigational drug or biologic is not feasible in certain situations related to military combat. The agency is also soliciting written comments identifying the evidence needed to demonstrate safety and effectiveness for such investigational drugs that cannot ethically be tested on humans for purposes of determining their efficacy. FDA is seeking written comments from all interested groups, including, but not limited to: Consumers, patient groups, veterans and veteran groups, active-duty military personnel, organizations and departments, ethicists, scientists, researchers with particular expertise in this area, and health care professionals. The written comments are intended to provide FDA with information to help the agency in making policy decisions on the use of investigational products during military exigencies and the appropriate evidence needed to demonstrate safety and effectiveness for drug and biological products used in military or other exigencies when traditional human efficacy studies are not feasible. PMID- 10169832 TI - Content and format of labeling for human prescription drugs; pregnancy labeling; public hearing--FDA. Notice of public hearing; request for comments. AB - The Food and Drug Administration (FDA) is announcing a public hearing regarding requirements for the content and format of the pregnancy subsection of labeling for human prescription drugs. The public hearing will focus on the requirement that each drug product be classified in one of five pregnancy categories intended to aid clinicians and patients with decisions about drug therapy. Public comments and FDA's prelimintary review of the pregnancy category designations for marketed drugs suggest that the categories may be misleading and confusing, may not accurately reflect reproductive and developmental risk, and may be used inappropriately by clinicians in making decisions about drug therapy in pregnant women and women of childbearing potential and also in making decisions about how to respond to inadvertent fetal exposure. The hearing is intended to elicit comments on the practical utility, effects, and limitations of the current pregnancy labeling categories in order to help the agency identify the range of problems associated with the categories and to identify and evaluate options that might address identified problems, and to hear the views of groups most affected. PMID- 10169833 TI - Program exclusions: June 1997--Office of Inspector General, HHS. Notice of program exclusions. PMID- 10169834 TI - Miscellaneous amendments--HHS. Final rule. AB - This final rule will remove appendixes I and J, which contain the test of Office Management and Budget (OMB) Circulars A-128 and A-133, from 45 CFR part 74. It will also update several items to conform them to the Federal Acquisition Streamlining Act of 1994 and correct a confusing statement which resulted from two typographical errors in that portion of OMB Circular A-110 upon which this statement is based. PMID- 10169835 TI - Medical use of byproduct material: issues and request for public input--NRC. Request for public input on rule development. AB - The U.S. Nuclear Regulatory Commission (NRC) has developed a program for revising the regulations governing the medical use of byproduct material. The decision to revise this regulation resulted from the NRC Strategic Assessment and Rebaselining Initiative (SA), a process involving identification of the direction setting issues and associated options for the future of NRC activities. This notice describes the NRC's program for revising the medical use regulation; notifies the public of the availability of documents associated with this action on the NRC Technical Conference Forum and through the NRC Public Document Room; and solicits informal public input on development of proposed rule language and associated documents. The Commission plans to formally propose specific rulemaking text for public comment during summer of 1998. PMID- 10169836 TI - Medicare program; hospice wage index--HCFA. Final rule. AB - This final rule establishes a methodology to update the wage index used to adjust Medicare payment rates for hospice care. It also includes the new wage index, to be effective October 1, 1997. The wage index is used to reflect local differences in wage levels. A new wage index is needed because the index currently applied is based on 1981 wage and employment data and has not been updated since 1983. The methodology is based on the recommendations of a negotiated rulemaking advisory committee comprised of persons who represent interests affected by the hospice rules. PMID- 10169837 TI - Medicare program; end-stage renal disease (ESRD) payment exception requests and organ procurement costs--HCFA. Final rule. AB - These final regulations specify the criteria HCFA uses to determine if a facility that furnished dialysis services to Medicare patients with end-stage renal disease (ESRD) qualifies for a higher payment under an exception to its prospectively determined payment rate and the procedures HCFA uses to evaluate ESRD payment exception requests. These regulations also revise the way HCFA computes acquisition costs for organs that are transplanted into Medicare beneficiaries. PMID- 10169838 TI - Medicare and Medicaid programs: effective dates of provider agreements and supplier approvals--HCFA. Final rule. AB - This rule establishes uniform criteria for determining the effective dates of Medicare and Medicaid provider agreements and of the approval of Medicare suppliers when the provider or supplier is subject to survey and certification as a basis for determining participation in those programs. It also establishes appeal rights and procedures for entities that are dissatisfied with effective date determinations. PMID- 10169839 TI - Medicare program; revisions to payment policies under the physician fee schedule, other Part B payment policies, and establishment of the clinical psychologist fee schedule for calendar year 1998; correction--HCFA. Correction of proposed rule. AB - This document corrects technical errors that appeared in the proposed rule published in the Federal Register on June 18, 1997 entitled "Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Other Part B Payment Policies, and Establishment of the Clinical Psychologist Fee Schedule for Calendar Year 1998." PMID- 10169840 TI - Revision of Department of Justice Freedom of Information Act and Privacy Act Regulations and Implementation of Electronic Freedom of Information Act Amendments of 1996--DoJ. Proposed Rule. AB - This document sets forth proposed revision of the Department's regulations under both the Freedom of Information Act (FOIA) and the Privacy Act of 1974. The FOIA and Privacy Act regulations have been streamlined and condensed, in accordance with the principles of the National Performance Reviews. With more "user friendly" language wherever possible. These revisions also reflect the principles established by President Clinton and Attorney General Reno in their FOIA Policy Memoranda of October 4, 1993. The new statement of discretionary disclosure policy will supercede the existing regulation regarding discretionary access to records of historical interest. Additionally, the regulations have been updated to reflect developments in the case law and to include updated cost figures to be used in calculating and charging fees. These proposed revisions also contain new provisions implementing the Electronic Freedom of Information Act Amendments of 1996. PMID- 10169841 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); exception of the CHAMPUS dual compensation/conflict of interest provisions--DoD. Proposed Rule. AB - This proposed rule provides an exception to the CHAMPUS dual compensation/conflict of interest provisions. This exception is for part-time physician employees of government agencies. PMID- 10169842 TI - Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA); interpretation of "federal means-tested public benefit"--HHS. Notice with comment period. AB - This notice with comment period interprets the term "Federal means-tested public benefit[s]" as used in Title IV of the Personal Responsibility and work Opportunity Reconciliation Act of 1996 (PRWORA), Pub. L. 104-193, to include only mandatory spending programs of the Federal Government in which eligibility for the program's benefits, or the amount of such benefits or both, are determined on the basis of income or resources of the eligibility unit seeking the benefit. At HHS, the benefit programs that fall within this definition (and are not explicitly excerted from the definition by Section 403 (c)) are Medicaid and Temporary Assistance for Needy Families (TANF). PMID- 10169843 TI - Agency information collection activities: proposed collection; comment request- HCFA. PMID- 10169844 TI - CLIA program; fee schedule revision--HCFA. General notice with comment period. AB - This notice updates the certificate fees for laboratories established under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) consistent with the methodology set forth in 42 CFR part 493. Section 353 (m) of the Public health Service Act requires that fees be collected to recoup costs of general administration of the CLIA Program. By economizing at every opportunity, the CLIA program has managed to maintain the fees established in 1992 and has absorbed all increases in costs. Revisions to the fees are necessary because the current fees are no longer sufficient to support the administration of the CLIA program. This restructuring of fees will move equitably distribute fees across all sizes and complexity of laboratories. For purposes of simplification, this notice announces a flat fee of $100 for a certificate of registration. PMID- 10169845 TI - Notice regarding section 602 of the Veterans Health Care Act of 1992 rebate option--HRSA. Notice. AB - Section 602 of Pub. L. 102-585, the "Veterans Health Care Act of 1992", enacted section 340B of the Public Health Service (PHS) Act, "Limitation on Prices of Drugs Purchased by Covered Entities." Section 340B provides that a manufacturer who sells covered outpatient drugs to eligible entities must sign a pharmaceutical pricing agreement with the Secretary of HHS in which the manufacturer agrees to charge a price for covered outpatient drugs that will not exceed that amount determined under a statutory formula. The purpose of this notice is to request comments on the proposal of a rebate option for State AIDS Drug Assistance Programs (ADAPs) receiving funds under Title XXVI of the PHS Act. PMID- 10169847 TI - Block grant programs: implementation of OMB Circular A-133--HHS. Interim final rule with request for comments. AB - This interim final rule implements Office of Management and Budget (OMB) Circular A-133 for Department of Health and Human Services (HHS) block programs. PMID- 10169846 TI - Grants and cooperative agreements to state and local governments, universities, hospitals, and other non-profit organizations--USDA. Interim final rule. AB - This interim final rule amendment is issued to implement the Single Audit Act Amendments of 1996 (Public Law 104-156, 110 Stat. 1396) and the June 24, 1997, revision of OMB Circular A-133, "Audits of States, Local Governments, and Non Profit Organizations" and to replace the existing audit requirements that are superseded by Public Law 104-156 and the revised A-133. PMID- 10169848 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1998 rates--HCFA. Final rule with comment period. AB - We are revising the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes resulting from the Balanced Budget Act of 1997, Pub. L. 105-33, and changes arising from our continuing experience with the systems. In the addendum to this final rule with comment period, we describe changes in the amounts and factors necessary to determine prospective payment rates for Medicare hospital inpatient services for operating costs and capital-related costs. Generally, these changes are applicable to discharges occurring on or after October 1, 1997. We also set forth rate-of-increase limits and changes for hospitals and hospital units excluded from the prospective payment systems. PMID- 10169849 TI - Procedures for disclosure or production of information under the Freedom of Information Act; amendments--Consumer Product Safety Commission. Final Rule. AB - The Electronic Freedom of Information Act Amendments of 1996, which amend the Freedom of Information Act, are designed to make government documents more accessible to the public in electronic form. The amendments are also intended to expedite and streamline the process by which agencies disclose information generally. In this notice, the Commission amends its Freedom of Information Act regulations to comply with the requirements of the new statute. PMID- 10169850 TI - Federal employees health benefits program; medically underserved areas for 1998- OPM. Notice of medically underserved areas for 1998. AB - The Office of Personnel Management (OPM) has completed its annual calculation of the States that qualify as Medically Underserved Areas under the Federal Employees Health Benefits (FEHB) Program for the calendar year 1998. This is necessary to comply with a provision of FEHB law that mandates special consideration for enrollees of certain FEHB plans who receive covered health services in states with critical shortages of primary care physicians. Accordingly, for calendar year 1998, OPM's calculations show that the following States are Medically Underserved Areas under the FEHB Program: Alabama, Louisiana, Mississippi, New Mexico, South Carolina, South Dakota, West Virginia, and Wyoming. North Dakota has been removed from that list, with no new additions for 1998. PMID- 10169851 TI - Negotiating preferred vendor contracts. PMID- 10169852 TI - Designing facilities to deliver patient-focused care around service lines. PMID- 10169853 TI - Meadville Medical Center and Crawford Health Plan beat the odds. PMID- 10169854 TI - Employer group intent on using the Dartmouth Atlas to drive change in healthcare delivery systems. PMID- 10169855 TI - The economics of managing healthcare delivery systems by service lines. AB - In their continuing quest for greater efficiency and lower costs without compromising quality of care (and preferably while improving quality), some health system leaders have adopted what is called the "service line" or "product line" approach to healthcare delivery. PMID- 10169856 TI - Waste not--want not. AB - The waste budget rarely gets the attention it requires. After all, c'mon it's garbage. We produce it and it costs money to get rid of it. There's nothing we can do about it. Sound familiar? We feel as if we have a handle on it when we negotiate to receive the lowest bid, but our efforts can not stop there. Do we really know what we-re getting for our money? Do we really need everything that is being suggested by the hauler? Are we investigating every avenue that involves waste or are we wasting valuable dollars? With the ever increasing need to find savings, let's look for in in our waste. The following overview of current waste issues is Part One of a guide for the review of practices and potential opportunities. The second part will appear next month. PMID- 10169857 TI - Capitation: strategies for success with managed care contracts. AB - With enrollments in HMOs increasing at double digit rates, independent practice associations, integrated medical groups, hospitals and specialty networks are experiencing a substantial increase in the share of their business paid for through capitation. Experience has shown that once one contract is signed, many are sure to follow. Providers must make sure each contract signed is financially sound for the organization. Then they must be able to manage and monitor contracts long after the ink is dry. This column provides a brief overview ad list of pointers for organizations moving into the managed care arena. PMID- 10169859 TI - Uniform standards are basic building blocks for Electronic Data Interchange. Healthcare EDI Coalition. PMID- 10169858 TI - Panel's dilemma: will new regulations hamper affordable quality? PMID- 10169860 TI - The reality of litigation in managed care. PMID- 10169861 TI - Technologies' impact on healthcare facilities. AB - Technologies common to other industries are gradually being utilized in healthcare. Heavily led by information technology, providers are using technology to increase efficiency, improve customer service and better integrate and streamline business and clinical processes. These changes are gradually making many hospitals' physical facilities obsolete, requiring substantial changes or upgrades. Eight examples are illustrated where technology is changing the requirements in facility utilization, design and construction. PMID- 10169862 TI - Physician employment contracting: an overview of hospital concerns. PMID- 10169863 TI - Selling interests in ambulatory surgery centers: a legal primer. PMID- 10169864 TI - IRS clarifies physician recruiting rules for charitable hospitals. PMID- 10169865 TI - GME cuts seek to staunch new physician pipeline. PMID- 10169866 TI - Education incentives are a smart choice. PMID- 10169867 TI - How much should patients know about their doctors? PMID- 10169868 TI - Getting into the information business. What doctors think their patients should know. PMID- 10169869 TI - 'Better late than never' doesn't wing high marks. Getting to the patient on time. PMID- 10169870 TI - Specialty nursing improves home care. AB - With shorter hospital stays, patients arrive home sicker and consequently require specialized equipment and complex nursing procedures. To provide care efficiently to such patients, nurses need expert knowledge and skills. The specialty nurse is best prepared to managed complex cases in home care. The cost of specialty training is well worth the results: better care at a lower cost. PMID- 10169871 TI - Clinical nurse specialists: a market advantage. PMID- 10169872 TI - Assessment--patients, chronic heart failure, and home care. AB - Congestive heart failure is the most common hospital discharge diagnosis in the United States. Increasing hospital readmission rates for this patient population translate into spiraling health care costs. One agency decided to measure the outcomes of patients enrolled in a specialized cardiac home care program that focuses on teaching and monitoring this patient population using cardiac-trained nurses. The findings suggest that patients enrolled in a cardiac specialty program may have improved outcomes, which translates into significant cost savings for payors. PMID- 10169873 TI - Renal transplant care in the home. AB - As transplantation continues to grow as a medical field, shorter hospital stays have become the norm for transplant recipients. From the pretransplant visit to life after surgery, patients need nursing staff who have both transplant care clinical skills and teaching ability. Pretransplant home intervention allows staff to assess and educate transplant recipients much earlier in the patient's disease process. A well-educated home care team ensures continuity and quality of care for transplant recipients. PMID- 10169874 TI - Development of a psychiatric home care program. AB - Psychiatric home care is a valuable service that addresses both acute and chronic psychiatric conditions; it fills a gap in the mental health continuum of care by providing an adjunct to outpatient treatment. How can home care agencies begin psychiatric programs of their own? One home care agency in Colorado has set up a psychiatric program to address these particular needs. PMID- 10169875 TI - The value of clinical pathways in home care. AB - Providing cost-effective, high-quality care can pose a challenge in this era of managed care. One agency successfully established and implemented multidisciplinary teams to organize and optimize care. Two case studies compare the nursing process of traditional versus well-managed care and show that clinical pathways can be effective tools to enhance the nursing process in home care. PMID- 10169876 TI - Standards--setting rules in the game. AB - In negotiations for managed care contracts, payors have the stronger position; care providers need their business and often make promises that may later cause them problems. Payors don't known the minimum needs or maximum limits for care- if providers don't establish these baseline standards for care, and all agree to abide by them, some providers will continue to try to provide more with less and may compromise quality of care as a result. PMID- 10169877 TI - HCFA proposed CoP (conditions of participation) revisions. PMID- 10169878 TI - A global perspective: technology in home care. Discussion. AB - Technological advances are changing the way the world shares information and conducts daily business, CARING asked home care colleagues around the world to respond to a question about technology's role in home care delivery. Although the degree of technology's involvement differs from country to country, each country is aware of the possibilities and is looking toward the future. PMID- 10169879 TI - Licensing and liability: crossing borders with telemedicine. AB - Anticipating the rapid growth of telemedicine in health care delivery, various segments of the industry are debating the opportunities and challenges that these new technologies present. Nurses and physicians face a host of legal issues as they contemplate providing telehome health services. PMID- 10169881 TI - Canada's emerging home infusion market. PMID- 10169882 TI - Aerospace technology comes home. AB - Science is expanding the options for homebound patients. Many of the new technologies coming into the home care industry are the result of aerospace innovations. What are these new technologies, and what can the home care industry expect to see in the future. PMID- 10169880 TI - Community-based rehabilitation programs in five countries. AB - A hallmark of the current era is the shrinking of the world, which will remain a persistent and aggressive trend well into the 21st century. That is good news for businesses, including home care providers. Providers will be able to more easily learn from other countries how to get the job done better--such as how to most effectively care for people with disabilities. PMID- 10169883 TI - Telecare for HIV/AIDS patients. AB - Telecare--or health care services delivered via telecommunications--can be a valuable adjunct to conventional home care service delivery, particularly to chronic care patients. Technological advances have made it possible for providers to deliver cost-effective telecare to the in-home HIV/AIDS patient. PMID- 10169884 TI - Healthy talk: a telecommunication model for health promotion. AB - The growth of managed care has led to a greater emphasis on health promotion- disease prevention (HP/DP) as a primary component of health care delivery. New technology is simplifying the HP/DP process. One agency used a disease management monitoring system to track clients' general health status. PMID- 10169885 TI - Caring for the home ventilator-dependent patient: a case management model. AB - As home care services become more specialized, nurses can meet the complex needs of ventilator-dependent patients in the comfort and privacy of their own homes. The case management model can help providers deliver cost-effective, high-quality home care to these vulnerable patients. PMID- 10169886 TI - The Intensity of Home Care Acuity Scale. Part one. AB - Competition and consumer demand for lower-cost health services are affecting how patients receive home care. To help support field staff, one agency created an quantitative tool--Intensity of Home Care Acuity Scale. PMID- 10169887 TI - When employees can't afford health insurance: the self-funding approach. AB - As job opportunities for home care workers increase--particularly for aides- providers need to offer attractive benefits packages to reduce staff turnover. Through self-funded health benefits plans, home care organizations can offer more affordable coverage for their employees. PMID- 10169888 TI - Improving maternal and child outcomes of hard-to-reach populations. AB - One county health department has created an innovative program to provide pre- and postnatal health care to Hispanic women and children. This case study demonstrates the importance of finding new ways to meet the needs of a rapidly changing population, understanding different cultural beliefs, and establishing a level of trust to achieve positive outcomes within this hard-to-reach population. PMID- 10169889 TI - Me and the Mayo. PMID- 10169890 TI - Sexual harassment in health care: a major productivity problem. AB - Sexual harassment in health care is a problem because of exorbitant legal costs, lost productivity, poor morale, and nonproductive absenteeism or turnover. Sexual harassment is more prevalent in health care. Health care organizations often do little to prevent it and do not respond properly when it occurs. In this article, legal precedents are reviewed, and a model of sexual harassment is developed to illustrate the phenomenon and identify interventions. Harassing and stereotyping behavior can be changed. Victims' responses and willingness to report incidents can be changed. Policies, sanctions, accountability, training, the type of investigations, and changed organizational culture help reduce sexual harassment. It is argued that reduction of sexual harassment in health care is important because it is a major productivity issue. PMID- 10169891 TI - Resolving conflict through managing relationships in health care institutions. AB - To managers of health care institutions, intraorganizational conflict represents an unpleasant but essentially unavoidable prospect. Conflict arises naturally whenever one party believes its interests are being opposed or negatively affected by another, and such "circumstances" frequently arise within health care institutions. Negotiation represents a key by which conflict may be successfully resolved within such settings. The means by which health care managers may successfully negotiate conflict resolutions by managing relationships with and between their employees are discussed in this article. In particular, practical guidelines are developed that illustrate how conflicted health care parties may successfully create and then claim value through relationship-oriented negotiation processes. PMID- 10169892 TI - Workplace violence: the responsibility of employers and supervisors. AB - Violence in medical institutions is escalating and is not limited to emergency departments and psychiatric units. Employers, administrators, and supervisors share responsibility for controlling these assaults. Preventive measures are expensive, but not as expensive as the lack of safety control. Nor can safety be measured only in terms of dollars. This article offers a practical strategy for protecting employees, patients, and others from being assaulted. PMID- 10169893 TI - Mastering the APG grouping process. AB - This case history details one company's success in using coding software to handle the requirements of the new ambulatory patient group (APG) system following the implementation of this complex new payment mechanism for outpatient care. Providers and payers are looking to coding software for help in billing and paying for outpatient services. Since the APG system "consolidates," "packages," and "discounts" a facility's payment for outpatient services, the new coding software helps ensure adequate reimbursement. PMID- 10169894 TI - Irritability in work relationships. AB - Irritability is a word that is not commonly found in management textbooks. However, it is a phenomenon that the manager may frequently encounter and should be understood if correct intervention is to occur. This paper explores the phenomenon of irritability as it relates to emotions, behavior, and physiology, in order to provide information for the manager to use in recognizing, understanding, and detecting irritability in one's self, peers, boss, or employees. PMID- 10169895 TI - Responsibilities of health care supervisors and employees: seven recommended tenets. AB - This article proposes seven tenets of responsibility for health care managers and the employees under their supervision. The damaging consequences of workplace misbehavior are chronicled, and the importance of establishing forthright supervisor/employee relationships is documented. Seven recommended tenets of responsibility are proposed as guideposts for managers and employees alike. PMID- 10169896 TI - Rumors and gossip: a guide for the health care supervisor. AB - Rumor and gossip are long-standing means of communication among humans and are prevalent in health care settings in part due to the nature of the organization. Rumor and gossip may be negative or positive, and health care supervisors should monitor the grapevine and consider themselves personally responsible for transmitting accurate information whenever possible to ensure that rumor and gossip do not have a negative effect on the department or institution. PMID- 10169897 TI - When your employee forgets who the boss is. AB - Managers confront many types of behavior in the workplace. One interpersonal problem that presents an unusual challenge to the manager is the employee who appears to "forget who the boss is." This article addresses this unusual employee manager problem by first describing the characteristics and dynamics of the behavior and then providing guidelines for responding to this problematic behavior. PMID- 10169898 TI - Effective employee counseling for the first-line supervisor. AB - Counseling is an important supervisory skill applied for a number of purposes. Although the need for counseling is as constant as any need facing the supervisor, a number of commonly encountered barriers often prevent effective counseling. In most instances counseling is a necessary step preceding disciplinary action, and it is always an important step in improving employee performance. Although the supervisor may not come to the job with expertise in counseling, counseling can nevertheless be learned through practice and the conscientious application of a few simple guidelines. PMID- 10169899 TI - 1997 survey of salaries & responsibilities for hospital biomedical clinical engineering & technology personnel. AB - The Journal of Clinical Engineering conducted its twelfth annual survey of the salaries paid to biomedical/clinical engineering and technology personnel in U.S. hospitals. This paper reports the salary and work responsibility data obtained from 276 professionals in relationship to: region of the U.S.; teaching versus nonteaching facilities; years of experience; education; certification; union membership; and gender. Data are included on wage increases and job responsibilities as of 12/31/96, and are compared with data as of 12/31/95. The average BMET I has 2.9 years of experience and earns $26,126 +/- $5,800 (nationwide mean +/- standard deviation). The average BMET II has 8.29 years of experience and ears $34,687 +/- $6,300. The average BMET III has 12.7 years of experience and earns $40,960 +/- $6,900. The average BMET Specialist has 16.7 years of experience and earns $46,131 +/- $9,100. The average BMET Supervisor has 15.0 years of experience and ears $44,248 +/- 47,700. The average Clinical Engineer has 13.6 years of experience and earns $44,839 +/- $10,000. CE Supervisors have an average of 21.6 years of experience and an average salary of $59,789 +/- $13,100. The overall group or department Director or Manager has 17.5 years of experience and earns $55,325 +/- $16,200 on average. PMID- 10169900 TI - Establishment of a clinical engineering department in a Venezuelan national reference hospital. AB - Since 1976, Clinical Engineering (CE) has been studied at the Simon Bolivar University (USB) as part of the Bioengineering Studies program developed at that University. However, it was not until 1996 that Clinical Engineering activities were established in a Venezuelan hospital. This paper describes how the USB, using its own human resources, has achieved the establishment of a Clinical Engineering Department in a national reference hospital for the first time. PMID- 10169901 TI - Directory of CE and biomedical organizations. PMID- 10169902 TI - Organizational change: decentralization in hospitals. AB - Decentralization may be defined as the spread of power from higher to lower levels in a hierarchy. For hospitals, decentralization is an organizational change of special importance. Decentralization in hospitals may be accomplished through decentralization to departments; more general changes in organizational structure (reduction in the number of hierarchical levels and divisionalization); and, delegation of tasks. A framework for an analysis of decentralization status in hospitals is proposed in four main points; its starting point; the need for change in decentralization status; decentralization solutions; and, the need for review before a decentralization proposal is put into practice. Positive effects of decentralization may be obtained; but, to date, empirical investigations on the impact of decentralization in hospitals are few. PMID- 10169903 TI - Merging managed care with the German model. AB - Since public officials in the United States may lack the courage and political will to significantly raise payroll taxes or the contain Social Security, Medicare and Medicaid benefits, Americans can anticipate that; (a) future generations increasingly will pay for these entitlements; (b) additional cutbacks to providers in Medicare, Medicaid and health maintenance organization reimbursement will hasten the current thrust of hospitals, physicians and insurers in forming huge health networks with their powerful managed care plans; and, (c) many of these new alliances will function as virtual monopolies- eventually resulting in the public proposing that state health services commissions be established. This article then suggests that future modifications in how the United States health delivery system be organized and financed preferably should be along the lines of the German multi-player, multi-tier, self governing, decentralized, quasi-private, quasi-public model; and, also patterned after experiences of the State of Arizona's Medicaid program. It concludes that what America needs most is a hybrid of the European global budgetary targets to constrain total health expenditures, and the competitive managed care concept to curtail use patterns and to enhance quality. PMID- 10169904 TI - The Philippines' National Health Insurance Act: a German perspective. AB - Through the recent National Health Insurance Act (NHIA), the Philippines have committed themselves to introducing a social health insurance with universal coverage within 15 years. Germany was the first country to introduce a social health insurance system more than 100 years ago. Its system is based on the principles of corporatism, federalism and a mandate for equity. Based on a long term German experience with equity, quality, cost and efficiency issues, the Philippines' NHIA is analysed concerning the entitlement to benefits and the benefit package, the organization of the health insurance programme, health insurance financing, and provider payment mechanisms. It is suggested that the Philippines could profit from including preventive and promotive services as well as pharmaceuticals in the benefits package. The organization of the health insurance system could be decentralized using the 13 regions as its principal units. To achieve financial equity between regions and health funds, a contribution compensation scheme is proposed. To prevent over-utilization in over served areas and to promote utilization in under-served areas, a relative value scale for fee-for-service payments seem advisable. PMID- 10169905 TI - A note on co-ordinating the AIDS crisis: issues for policy management and research. PMID- 10169906 TI - Local cost sharing in Bamako Initiative systems in Benin and Guinea: assuring the financial viability of primary health care. AB - The fourth in a series of five, this article presents and analyses data on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea since 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in the two national scale programmes is also described. In Benin and Guinea, a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker salaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in decision making, strategy definition and quality control. In Benin in 1993, community financing revenue amounted to about US$0.6 per capita per year and generally covered all local recurrent non salary costs except vaccines and left a surplus. Although total costs and revenues were slightly lower in Guinea for the same period, over-all user fee revenue (around US$0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and revenue between regions and individual health centres revealed important differences in cost recovery ratios. In Benin, some centres recovered more than twice the local costs targeted for community financing. Twenty-five per cent of centres in Guinea did not manage to cover their designated local recurrent costs. The longitudinal analysis showed that the level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better understand the most important characteristics affecting cost recovery levels, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed that the size of the target population of the health centre is a key determinant of cost-recovery in both countries. In addition, in Guinea the utilization of curative care linked to geographical access and in Benin the average revenue per case linked to the number of deliveries proved to be additional factors of importance. In best performing centres, financial viability improved over time in both countries between 1990 and 1993. Finally, the implications of these conclusions for the planning of health centre revitalization in West Africa are discussed. PMID- 10169907 TI - Health seeking behaviour and household health expenditures in Benin and Guinea: the equity implications of the Bamako Initiative. AB - Curative and preventive care utilization in Bamako Initiative health centres in Guinea and Benin increased significantly. Service based data and household survey results are compared and interpreted to evaluate the equity aspects of the Bamako Initiative programmes in these settings. Improvements in the use of preventive services are shared by the richer and poorer groups of the population. Inequities are more apparent regarding curative area. An important part of the population is not using Bamako Initiative Health Centres for financial reasons. However, the poor were found to use these Health Centres relatively more than richer socio economic groups. Challenges of the future are identified and recommendations made as to how to tackle the problem of true indigence. PMID- 10169908 TI - Sustainability of primary health care including expanded program of immunizations in Bamako Initiative programs in West Africa: an assessment of 5 years' field experience in Benin and Guinea. PMID- 10169909 TI - Where will OR staff of the future come from? PMID- 10169910 TI - Boomers and busters: ways to bridge the gap. PMID- 10169911 TI - What's your role in a surveillance system? PMID- 10169912 TI - What infection rates do--and don't--mean. PMID- 10169913 TI - Reporting of infection rates stirring debate. PMID- 10169914 TI - Independent thinking critical to decision making. PMID- 10169915 TI - For-profits, not-for-profits boast of benefits. PMID- 10169916 TI - Links among people is managers' best hope. PMID- 10169917 TI - One-to-one approach catches on. Proven in other industries, now popular in healthcare marketing. PMID- 10169918 TI - Stalking the wily senior. Elderly hard to pin down, but booming market makes it worth effort. JWT Specialized Communications (Dallas, TX). PMID- 10169919 TI - Weeding out the "real" kids' hospital. Reinforcing old message of specialization, commitment. Miami Children's Hospital (Miami, FL). PMID- 10169920 TI - Changing times, changing names. Hospital keeps image in step with rapidly shifting demographics. NorthEast Medical Center, Concord, N.C. PMID- 10169921 TI - Vans offer convenience, outreach, advertising. Cleveland hospital makes rolling investment in community. Parma Community General Hospital, Cleveland, OH. PMID- 10169922 TI - Reaching out to kids in trouble. Center helps parents, kids without scaring them too much first. KidsPeace National Hospital for Kids in Crisis (Orefield, PA). PMID- 10169923 TI - National Hospital Ambulatory Medical Care Survey: 1995 outpatient department summary. AB - OBJECTIVE: This report describes outpatient department visits in the United States in 1995. Statistics are presented on selected patient and visit characteristics. METHODS: The data presented in this report were collected from the 1995 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey, which measures health care utilization across various types of providers. NHAMCS is a national probability survey of visits to outpatient departments and emergency departments of non-Federal, short-stay and general hospitals in the United States. Sample data were weighted to produce annual estimates. RESULTS: During 1995, an estimated 67.2 million visits were made to hospital outpatient departments in the United States, an overall rate of 25.7 visits per 100 persons. Overall, visit rates did not vary by age. Females and black persons had higher rates of visits than males and whites, respectively. There were an estimated 7.3 million injury-related outpatient department visits in 1995. PMID- 10169924 TI - National Ambulatory Medical Care Survey: 1995 summary. AB - OBJECTIVE: This report describes ambulatory care visits made to physician offices within the United States. Statistics are presented on selected physician patient, and visit characteristics for aggregated ambulatory care visits. METHODS: The data presented in this report were collected from the 1995 National Ambulatory Medical Care Survey (NAMCS). NAMCS is part of the ambulatory care component of the National Health Care Survey, which measures health care utilization across various types of providers. NAMCS is a national probability survey of visits to office-based physicians in the United States. Sample data were weighted to produce annual estimates. RESULTS: During 1995, an estimated 697.1 million visits were made to physician offices in the United States, an overall rate of 2.7 visits per person. One quarter of the NAMCS visits were made to general and family physicians, which was significantly higher than the other 13 specialties. Persons 75 years of age and over had the highest rate of physician office visits 5.9 visits per person. Females had a significantly higher rate of visits to physician offices than males did overall, as did white persons compared with black persons. Of all visits made to these offices in 1995, 86% were covered by some form of insurance, and 11 percent were paid "out-of-pocket." There were an estimated 81.6 million injury-related visits during 1995, or 31.2 visits per 100 persons. A significantly higher proportion of injury visits were made by white persons compared with black persons. Over two-thirds of all injury visits were for unintentional injuries. PMID- 10169925 TI - Addressing legal concerns is key to structuring a successful telemedicine program. PMID- 10169926 TI - Perspectives. Informed consumer choice still a distant and difficult goal. PMID- 10169927 TI - Marketplace. Will medical liability outlays boost total health care costs? PMID- 10169929 TI - Perspectives. Practice-based research targets nuances of everyday care. PMID- 10169928 TI - Perspectives. States exploring new roles as catalysts in GME restructuring. PMID- 10169930 TI - Marketplace. Tough times for home care may benefit for-profit chains. PMID- 10169931 TI - Patient heal thyself. PMID- 10169932 TI - Small hospital gets big on EDI. PMID- 10169933 TI - Globe plotting. U.S. healthcare organizations & IT companies go boldly into uncharted world markets. PMID- 10169934 TI - How to overcome four big scheduling hurdles. PMID- 10169935 TI - Today's CDRs (clinical data repositories). The elusive "complete" solution. PMID- 10169936 TI - The Internet access breakthrough. Bringing healthcare home. PMID- 10169937 TI - HL7 Reference Information Model. More robust and stable standards. PMID- 10169938 TI - Service and support. Missing in action? PMID- 10169939 TI - Global opportunities in managed care. PMID- 10169940 TI - Out with the old, in with The New York Hospital. PMID- 10169941 TI - When people talk, PCs listen. PMID- 10169942 TI - Surfing the ICU. PMID- 10169943 TI - Patient informatics in growing. PMID- 10169944 TI - Hold that line--get ready for telemedicine. PMID- 10169945 TI - The power of one. Interview by Terry Monahan. PMID- 10169946 TI - Manufacturing healthcare. Columbia/HCA strives toward common systems. AB - Of any one organization in the healthcare industry, Columbia HCA/Healthcare Corp. has become a symbol for the mass-market commercialization of healthcare. Since its humble beginnings in 1987 as a two-hospital organization in El Paso, Texas, the cunning of its founder and CEO Richard Scott had catapulted the hospital chain start-up, through an aggressive strategy of mergers and acquisitions, to its current position as the nation's largest provider of healthcare services. PMID- 10169947 TI - Living in a materials world. How to choose a materials management system. PMID- 10169948 TI - Spotlight on laboratory information systems. The emergence of the Internet. PMID- 10169949 TI - Perhaps pigs do fly! PMID- 10169951 TI - Economic, social and racial justice: the survival of the African-American family. PMID- 10169950 TI - Race, ethnicity, and access to health care, Rhode Island, 1990. AB - Differences in access to health care by race and ethnicity have been examined using data obtained from a statewide health interview survey conducted by Rhode Island Department of Health in 1990 (N = 6,536 individuals in 2,586 households), in which ethnic minorities were oversampled. Compared to White non-Hispanic (WNH) respondents, White Hispanics (WH) were more likely to lack a regular source of medical care at some time in the past twelve months (14.0% vs. 9.8%) and were much more likely to lack health insurance coverage (22.7% vs. 7.5%). Black respondents were more likely to lack regular source of care (10.4%) and health insurance coverage (17.4%). Asian respondents also had a high proportion without insurance (13.5%). Multivariate analysis has been employed to identify significant social, economic, and demographic determinants of inadequate access to care, including variables for race/ethnicity, age, sex, income, education, and employment status, and to quantify their independent contributions as predictors of level of access. PMID- 10169952 TI - Medicare revenue in large medical groups. AB - The aged are the heaviest users of physician services. A ageing population and escalation in medical costs have pressured Medicare budgets, which have increased fastest in Part B physician reimbursement. Policy responses include adoption of the Resource Based Relative Value Scale (RBRVS) for physician payment. This paper considers receipt of Medicare revenues by large medical groups and expectations of how groups will fare under RBRVS. In a 73-percent sample of U.S. large group practices, Medicare coverage accounted for one-fourth of clients, Medicare related revenues for slightly more than one-fourth of revenues, suggesting a slightly higher revenue intensity for Medicare clients, but showing no evidence of truly disproportionate revenues from Medicare users. Medicare shares of revenues are explained by factors related to Medicare clientele and geriatric service provision. Overly-strict Medicare assignment policy may control costs by limiting access to needed care, rather than by limiting overpayments to physicians. Expectations as to how groups will fare under RBRVS are not found to be related to reliance on Medicare, rather to group auspices and ability to contain costs under Medicare payment. The findings are important not only to physician payment under RBRVS but also under health care reform. PMID- 10169953 TI - A macro approach to the explanation of physician distribution in Canada. AB - Physician distribution is influenced by complex factors. It is generally argued that the probability of physician increase will be greater in areas that have more to offer in the way of social and economic advantages, This study examines the effects of selected demographic, socioeconomic, and environmental factors (e.g., population size, percent university educated, and hospital bed/population ratio) on the spatial distribution of physicians, using data for "active" civilian physicians obtained from Health and Welfare Canada. The findings indicate that the variable "percentage university educated" is the most important factor influencing physician distribution, once demographic and environmental factors are controlled. The higher the educational level of the population, the higher the physician/population ratio and the higher the proportion of children under age 5, the lower the physician/population ratio. Findings provide evidence of a concentration of physicians in high-status areas. A pattern of larger relative dispersion was also observed for physician/population ratios across areas for suburban dwellers. PMID- 10169954 TI - The impact of transfer patients on Medicare inpatient cost per discharge. AB - The cost of inpatient transfer cases has concerned hospitals as well as rate setters. Reform of transfer payment in Medicare's Prospective Payment System has been suggested to ensure access and adequate treatment for these cases in a period where inpatient revenue has been declining. This analysis indicates that both transfer cases received and cases transferred to other hospitals have above average costs per case but their impact on Medicare inpatient cost per discharge is smaller than that of variables such as case-mix, area wages and resident/bed ratio which are used directly in PPS payment. Evidence is provided indicating the desirability of reform of PPS payment methods for transfer cases. PMID- 10169955 TI - Charges and charge coverage in the treatment of HIV/AIDS patients in a rural southern state. AB - In Mississippi it was not known where Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Disease Syndrome (AIDS) persons receive care, what type of care is available to them, and how care is financed. To ascertain inpatient treatment charges of HIV/AIDS patients, a medical record review was conducted at 10 priority hospitals distributed across Mississippi. One-hundred fifty-six (156) patient records were randomly selected from a population of persons with HIV/AIDS. A total of 3,865 patient days was recorded for all hospitals. Available overall hospital charges per paid day ranged from +401.63 to +1,261.34, with an average charge of +741.65 per day. Average length of stay was 25 days. Average charge per hospitalization per patient totaled +18,541. Concerning source of payment, 44.8% of the patients had private insurance, 29.9% listed Medicaid as their payment source, 7.8% were on Medicare, 1.3% had supplemental insurance, and 16.2% of patients reviewed had no payment source. Based on this review, it is evident that the number of AIDS patients covered by private health insurance will continue to decline and the payment responsibilities will continue to shift to public supported programs. Acquired immunodeficiency syndrome brings attention to the weakness of Mississippi's health care financing system and will continue to force consideration of alternative financing mechanisms. PMID- 10169957 TI - Medicare CACs (Carrier Advisory Committees) and the surgical community: why surgeons should get involved. PMID- 10169956 TI - Fires in the operating room. PMID- 10169958 TI - Hands-on approach to patient grievances: an interview with Charles R. Hatcher, Jr., MD, FACS. Interview by Karen Sandrick. PMID- 10169959 TI - Baptist Health's team-centered efforts in population-based planning design a system based less on beds, more on health. Case study. PMID- 10169960 TI - Restructuring care. Danbury Health System realigns structures to improve care while preparing for risk-bearing demands. PMID- 10169961 TI - Using SPC (statistical process control) to analyze quality indicators in a healthcare organization. AB - A tool of statistical process control (SPC) called a P Chart is introduced as a process-based approach for analyzing quality indicators in healthcare. The underlying methodology of a P Chart is described using card-playing examples. A discussion on the implementation of SPC in healthcare follows, along with examples using Maryland Project quality indicators. PMID- 10169962 TI - Patient relations for modern times. AB - A well-organized patient relations program can improve the quality of care while reducing risk to the organization. Patient relations is also a matter of the organization's survival in a competitive marketplace. The consumer's choice for healthcare will be made based on how the organization id differentiated from other organizations with otherwise common attributes. These distinct attributes set a product or organization apart from its competitors by creating a "personality" in the marketplace. A selected program, such as patient relations, can build a marketing plan that creates an identifiable market personality with opportunity for good financial returns and stability. PMID- 10169963 TI - Telemedicine: new technology = new questions = new exposures. AB - Cyberspace, telemetry, and virtual reality all refer to mankind's evolving ability to be in two places at once, without ever leaving one location. Now this ability has expanded into the world of medicine, with increased awareness of risk management concerns, and questions about where we go from here. PMID- 10169964 TI - Planning for a bomb threat. AB - A bomb threat must always be taken seriously. It is important to have specific response plans in place, especially in a healthcare facility, where patients may be particularly vulnerable both to danger and to the threat of danger. Also, the facility may be judged in the community by how it responds to a threat. A prudent risk manager will plan in advance, setting up a chain of command and specific procedures, and familiarizing all who take on bomb threat duties not only with their responsibilities, but also with one another. There should be a familiar and easy relationship among those required to work together in stressful situations. PMID- 10169965 TI - A risk management plan for your career. PMID- 10169966 TI - Agency not liable for actions of nurse supplied by agency. Hansen v. Caring Professionals, Inc. PMID- 10169967 TI - Sexual harassment may be insidious and may continue after termination. Smith v. St. Louis University. PMID- 10169968 TI - Professional liability loss control in the vertically integrated healthcare system: managing from a helicopter. AB - As the prevalence of integrated healthcare organizations increases, the opportunities and threats confronting the risk manager increase as well. It is important that risk managers recognize not only the type of organizational configuration in which they work, but also the proper loss prevention techniques applicable to that system. PMID- 10169970 TI - Physician organizations. PMID- 10169969 TI - PPM (physician practice management company) growth strategies. Part I. PMID- 10169971 TI - Facts & figures. Long-term care driven by chronic diseases. PMID- 10169972 TI - Managed care stock index. West Coast story. PMID- 10169973 TI - Health care systems reach out over the Internet: Part II. PMID- 10169974 TI - The dew of Jerusalem: the Israeli health care system. AB - The Israeli health care system is more advanced than the American system in its universal coverage, its financing mechanism, and in its implementation of a managed competition process. Yet, it trails American developments in management of inpatient and outpatient services and in the creative design of provider reimbursements. An MCO executive provides his observations from a trade/study mission to this Middle Eastern country. PMID- 10169975 TI - Enhancing member retention, satisfaction, and compliance. AB - The authors discuss a health care communications skills training workshop to teach providers how to enhance patient satisfaction, compliance, and loyalty. Participants are taught the characteristics and communication needs of the four basic behavioral styles. This knowledge can make for more beneficial provider patient encounter and better outcomes. PMID- 10169976 TI - Measuring the success of disease management programs: research design and selection of comparison groups. PMID- 10169977 TI - Improving asthma care in the outpatient setting. AB - Asthma is a chronic and costly disease that affects 5% of the U.S. population and accounts for more than 450,000 primary admissions each year. Blue Cross and Blue Shield of Massachusetts attempted to identify patients with asthma and develop a comprehensive asthma management program in the outpatient setting. The program has focused on one-to-one nursing education, increased utilization of anti inflammatory inhalers, and actively engaging patients in a customized asthma care program. PMID- 10169978 TI - Shortchanging the psyche. Will your HMO be there if you need therapy? PMID- 10169979 TI - Brave new world. AB - The new budget bill means big changes in Medicare. The elderly are expected to help save the program by switching to less costly health care options. But some experts warn seniors that more choice means more risk. PMID- 10169980 TI - Medstat promises satisfaction reports that are free of suspicion of bias. PMID- 10169981 TI - Compensation monitor. Family physicians prosper as managed care spreads. PMID- 10169982 TI - You and your HMO: the marriage that didn't happen. PMID- 10169983 TI - Pioneer not-for-profit plans struggle to remain leaders. PMID- 10169984 TI - An interview with Scott Weingarten, M.D. PMID- 10169985 TI - Diary of the birth of an HMO. PMID- 10169986 TI - Use a 'SWAT' team to collect old receivables. PMID- 10169987 TI - Projecting a leaner managed Medicare. PMID- 10169988 TI - Get help fighting fraud investigation, but don't shoot yourself in the foot. PMID- 10169989 TI - Anticipating managed care in the year of Lindbergh. PMID- 10169990 TI - Managed care outlook. When HMOs contract with organized delivery systems. PMID- 10169991 TI - Electronic claims growth slows. PMID- 10169992 TI - Reaching out to the elderly. PMID- 10169993 TI - Providing the proof. PMID- 10169994 TI - A new conduit for claims. PMID- 10169995 TI - Climbing up the career ladder. Interview by Tyler L Chin. PMID- 10169996 TI - Breaking new ground. PMID- 10169997 TI - Health data security: a new priority. AB - As more health care information is computerized, concerns about the security of on-line data are growing. Some well-publicized health data security breaches illustrate the potentially devastating impact of confidentiality violations. This package of stories offers and in-depth look at the state of health data security. It includes a "roundtable discussion" by five prominent chief security officers, as well as articles on data encryption, biometrics, legislation and other topics. PMID- 10169998 TI - Health care security chiefs share their predictions, tips. Interview by Bill Siwicki. PMID- 10169999 TI - Encryption grows in importance to physicians. PMID- 10170000 TI - Health care starts to eye biometrics technology. PMID- 10170001 TI - Fate of federal privacy legislation far from certain. PMID- 10170002 TI - Intranets: the latest trend in the development of broad health networks. AB - Frustrated by high costs, many organizers of community health information networks are tuning to low-cost, easy-to-implement Internet technologies and protocols. Of the 22 broad network initiatives still under way, about half are either planning to build intranets or incorporating Internet technologies on some form. PMID- 10170003 TI - ActiveX vs. Java. What roles will these technologies play? AB - ActiveX and Java capitalize on distributed object computing and have great potential for making information systems truly interoperable. But a battle for market dominance between their developers--Microsoft Corp. and Sun Microsystems Inc., respectively--could cause confusion. And it's unclear what role these two important new technologies will play in health care. For now, a number of pioneering organizations are experimenting with using the technology to improve data flow and access. PMID- 10170004 TI - Automation comes to the aid of credentialing efforts. AB - Virtually every hospital and managed care plan performs credentialing for every physician, and it can be a labor-intensive--and redundant--effort. But administrative software tools are being developed and expanded to better gather and keep track of vital information about physicians. Some providers and health plans are also working together to centralize the process by electronically sharing the information. PMID- 10170005 TI - Psychosocial high-risk screening: enhancing patient care through rapid social work engagement. PMID- 10170006 TI - Home care critical pathways: tools for managed care contracting. PMID- 10170007 TI - Program profile: the "Friendly Caller" Program. PMID- 10170008 TI - Taking on Goliath: responding to practice management company advances. PMID- 10170009 TI - CEO survey reveals trends for the year 2000. PMID- 10170010 TI - Philadelphia academic medical center evolves through a partnering strategy. PMID- 10170011 TI - Risk-based managed care contracting. PMID- 10170012 TI - Survey shows demand increasing for specialty and solo physicians. PMID- 10170013 TI - House, Senate prepare to hammer out budget differences. PMID- 10170014 TI - HCFA revises application process for new providers. PMID- 10170015 TI - GAO blasts HCFA's antifraud and abuse efforts. PMID- 10170016 TI - Study finds nursing facilities have high rate of lost work days due to job related injuries. PMID- 10170017 TI - Five minutes with Andrew Turner. Interview by Elise Nakhnikian. PMID- 10170018 TI - An appeal for better Medicare appeals. PMID- 10170019 TI - More than just paper compliance. PMID- 10170020 TI - These may be the good old days. PMID- 10170021 TI - Looking good. Order of Excellence 1997 awards. PMID- 10170022 TI - Unusual suspects. PMID- 10170023 TI - Germ warfare. MRSA has infiltrated one in four health care facilities. How can you keep it at bay? PMID- 10170024 TI - Some reassurance on quality assurance privilege. PMID- 10170025 TI - Using technology to simplify your processes. PMID- 10170027 TI - Will your PHO kill your hospital? Give MDs power to lead. PMID- 10170026 TI - Detailed coding keeps rehab from slipping away. PMID- 10170028 TI - PHOs place second to large MD groups. PMID- 10170029 TI - What's wrong? Lawyer helps MDs leave PHOs. PMID- 10170030 TI - Creating a physician network can pay off--with the right tools. AB - Putting together a physician practice group and then creating the management and administrative structure for that practice to financially succeed is one of the greatest challenges health systems face today. The marriage can work, experts tell Managed Care Strategies, but only with innovation and careful attention to details such as physician compensation design, governance issues, and methods for resolving conflict resolution. PMID- 10170031 TI - Sensitivity issues top patient satisfaction list. PMID- 10170032 TI - Proving your way to success: outcomes data can win contracts. PMID- 10170034 TI - Physician recruitment guidelines help nonprofits. PMID- 10170033 TI - JCAHO implements quality indicator measurements. PMID- 10170035 TI - Five ways to overcome common PHO (physician-hospital organization) mistakes. PMID- 10170036 TI - Recognition can help promote CME. Part 2. PMID- 10170037 TI - Physician pay formula shifts aren't painless. PMID- 10170038 TI - Help residents make informed career choices. PMID- 10170039 TI - Better efficiency without the fuss. PMID- 10170040 TI - Part-time program improves physicians' quality of life. PMID- 10170041 TI - AMA defines physician quality: what's your status? PMID- 10170042 TI - Hospital-intensive physicians balk at practice expense proposal. PMID- 10170043 TI - New site-of-service rates empty surgeons' wallets. PMID- 10170044 TI - Joint data collection system saves hospital system $3.6 million. AB - Knee and hip joint replacement costs at HealthEast in St. Paul, MN, were 33% too high, according to national benchmark data. However, before managers could lower costs, they had to gather their data. After a drawn-out manual compilation, healthEast piloted an automated system for tracking joint replacement data. That software is now available nationwide. By collecting the data, measuring cost and utilization, HealthEast has lowered its total knee and hip replacement costs by $3.6 million. PMID- 10170045 TI - Patient education proves best practice in DVT. PMID- 10170046 TI - Eliminating, consolidating forms save $750,000. AB - Sometimes a baseline can be hard to find. When the BJC Health System in St. Louis wanted to establish a benchmark for the number of forms the newly merged system should have, the improvement team embarked on a two-year journey. Along the way, the team learned a lot about best practices in standardizing forms, coordinating automation, and the tremendous waste companies indulge in when it comes to buying forms. The team also saved about $750,000 and negotiated a contract with a forms supplier that will save them even more. PMID- 10170047 TI - Make sure your patient education is effective. PMID- 10170048 TI - Continuous benchmarking improves best practices. PMID- 10170049 TI - Lowering cost: another look. PMID- 10170050 TI - Action steps to prepare for the new managed care. AB - Remaining competitive under a managed care system requires skills and talents that were not necessarily important in home care until recent years. And as we get used to it, the current managed care model will undergo even more disruptions in the near future. Providers that want to succeed in the 21st century must learn to adapt and re-adapt to the managed care of tomorrow. PMID- 10170051 TI - Hospice. Can it work within managed care? AB - Managed care organizations often are unaware of the services that are unique to hospice--for example, the contribution of volunteers, the need to enroll patients at an appropriate stage in their illness, and the potential cost savings of dying at home rather than in the hospital. Hospices need to undertake educational campaigns to help ensure their inclusion in a managed care system. PMID- 10170052 TI - Increasing rehab utilization. A CQI approach. AB - As managed care stresses the bottom line, home care providers feel the pressure to achieve the best, most cost-effective outcomes possible. One provider in Colorado found a way to educate its staff on when it is appropriate to refer patients to rehabilitation specialists so they can recover more quickly and effectively. PMID- 10170054 TI - Functional visual problems: training home care aides to identify early signs. AB - Home care aids are a primary source of direct care to frail elders, for whom vision loss is a key factor in their declining health. Together, a vision rehabilitation service and a home care aid service agency developed a training program to increase aides' awareness and sensitivity to the issues of visual impairment and to develop a referral system for appropriate eye care and vision rehabilitative services for their clients. PMID- 10170053 TI - Using OASIS (Outcomes and Assessment Information Set) to reach OBQI (outcome based quality improvement). AB - The Health Care Financing Administration (HCFA) has proposed new regulations that require home care providers to report outcome results. The Outcomes and Assessment Information Set will be the vehicle by which home care providers reach outcomes-based quality improvement--the ultimate goal for the industry and HCFA. PMID- 10170056 TI - Self education and professional growth. PMID- 10170055 TI - Emergency Medical Services. Silver Book. PMID- 10170057 TI - EMS and HIV: understanding the CDC's provisional guidelines for HIV post-exposure prophylaxis. PMID- 10170058 TI - Injury control: the cure for trauma. PMID- 10170059 TI - Talk to the animals. Learning how to handle our furry friends on a call. PMID- 10170060 TI - Don't mess with Darla. Interview by Patricia Sellers. PMID- 10170062 TI - Ontario Advocacy Commission rights advice delivery system. PMID- 10170061 TI - The Consent to Treatment Act in a team or multi-facility environment. AB - The Consent to Treatment Act is intended to uphold and protect the right of informed choice for all persons in Ontario. Operationalizing the Act and ensuring the greatest benefit for patients will require collaboration and communication among professionals, the public, agencies and institutions. PMID- 10170063 TI - Sacrificing patient autonomy? PMID- 10170064 TI - Access to service: threats and opportunities/the role of the private sector in Alberta's new health system. PMID- 10170066 TI - Fitness to stand trial: a study of a change in the law concerning pre-trial psychiatric remands. PMID- 10170065 TI - Advance directive fallacies. PMID- 10170067 TI - "Under the knife": an examination of the Oregon Basic Health Act, the Clinton Health Security Plan and their impact on ethical health care rationing in Canada. PMID- 10170068 TI - Consolidating customer services in central unit: how one program works. PMID- 10170069 TI - Report growing use of high-tech systems for infant abduction, switching. PMID- 10170070 TI - Gangs and hospitals: guarding against inside and outside threats. PMID- 10170071 TI - New FBI reporting system could improve hospital crime statistics. PMID- 10170072 TI - User-friendly customer service: an expanded role for hospital security. PMID- 10170074 TI - The press, VIPs, and oddballs: how hospital protected the Shabazz family. PMID- 10170073 TI - Handling patients who are victims of domestic abuse: what hospital personnel should know. AB - Greater participation by hospital employees, including security officers, in collecting and documenting evidence in cases of domestic violence is advocated by experts concerned with the problem, but some express certain reservations. In recent years, they report, healthcare providers have become more actively involved. To date, however, nurses and doctors in the obstetrics and gynecology, maternity, and emergency departments are often the first to see and offer assistance to victims of domestic abuse. In this report, we'll provide details on how one hospital handles domestic violence cases, resources for security officers who want to familiarize themselves with those areas, and some pros and cons expressed by victim advocates about participation of hospital security in investigating domestic violence. PMID- 10170075 TI - How hospital survived flood that forced it to close for three weeks. PMID- 10170076 TI - American College of Healthcare Executives. Key industry facts. PMID- 10170077 TI - From hospital to health system governance. The changing characteristics of boards. PMID- 10170078 TI - 25 pitfalls of strategic planning. AB - Strategic planning has often been viewed as a panacea, a means of addressing and solving all of an organization's issues and problems. Unfortunately, that is not often the case. Strategic planning is merely a tool. And it is only effective when used well. To help you make the most of your planning efforts, Healthcare Executive talked with several healthcare consultants who specialize in healthcare strategic planning. They identified the following 25 pitfalls you can avoid to make strategic planning a stronger tool for your organization. PMID- 10170079 TI - ACHE support services for affiliated groups. PMID- 10170080 TI - Governance team education. PMID- 10170081 TI - How to put life into an old job. PMID- 10170082 TI - Managing physician group practices. PMID- 10170083 TI - CEOs influencing hiring decisions. PMID- 10170084 TI - Congress adopts Medicare reforms. PMID- 10170085 TI - Pull vs. push technology. PMID- 10170086 TI - The new governance. Time for the tough to get going. PMID- 10170087 TI - A note on prevention versus cure. AB - The aim of this study is to test if the general Swedish population prefers saving lives through prevention or acute care. A trade-off question of a choice between saving lives through prevention or acute care was administered in a Swedish population sample. Based on the answers we estimate the median number of lives saved in acute care that is judged equivalent to saving one life through prevention. According to the results 1.2-1.4 lives saved in acute care is judged equivalent to saving one life through prevention. Thus our results indicate that lives saved through prevention and cure are given about the same value by the median respondent. Individuals seem to focus on the size of the health benefits rather than whether the health benefits are achieved through prevention or cure. PMID- 10170088 TI - Is it cost effective to introduce screening programmes for colorectal cancer? Illustrating the principles of optimal resource allocation. AB - This paper seeks to shed light on the relative cost effectiveness of colorectal cancer by comparing the cost effectiveness of this programme with the economics of another screening programme which is widely implemented: cervical cancer screening. The paper illustrates the principles of optimal resource allocation, and discusses the limitations and strengths of the analysis presented. The paper concludes that colorectal cancer is a cost effective option relative to cervical cancer screening when health is seen as the only outcome of the screening programmes. However, further insight into consumer preferences and inclusion of intangible costs and benefits is necessary in order to guarantee optimal resource allocation. PMID- 10170089 TI - A second opinion. Cost-utility analysis and varying preferences for health. PMID- 10170090 TI - International assistance and health care reform in Poland: barriers to project development and implementation. AB - The restoration of democracy in Poland initiated a major system transformation including reform of the health sector. The international community were quick to respond to the need for assistance. Polish proposals were supported by international experts and projects were developed together with international development agencies and donors. Donors had no experience of central and eastern Europe, these countries had never been beneficiaries of aid and neither side had experience working together. Progress and absorption of funds was slow. Comparative experience from developing countries was used to analyze the barriers encountered in project development and implementation in Poland. The conditions necessary for implementation were not satisfied. Insufficient attention was paid to the project process. Barriers originate on the side of both donors and recipients and additionally from programme characteristics. The most serious problems experience in Poland were lack of government commitment to health care reform leading to failure to provide counterpart funds and low capacity for absorption of aid. Rent seeking attitudes were important. Donor paternalistic attitudes, complex procedures and lack of innovative approach were also present. Poor coordination was a problem on both sides. Multi-lateral projects were too complex and it was not always possible to integrate project activities with routine ones. External consultants played an excessive role in project development and implementation, absorbing a large portion of funds. The barriers have been operationalised to create a checklist which requires validation elsewhere and may be useful for those working in this field. PMID- 10170091 TI - The cost-effectiveness of permethrin impregnated bednets in preventing child mortality in Kassena-Nankana district of Northern Ghana. AB - Permethrin impregnated bednets are now being widely promoted as an effective means of protecting African children against malaria, but there is little evidence of their cost-effectiveness. The impact on child mortality of introducing permethrin impregnated bednets was evaluated in a rural district of northern Ghana in a controlled trial. The cost-effectiveness of the intervention is reported in this paper. The total cost of the intervention over the 2 years of follow-up was US $148,245. Cost per impregnated bednet per year and per person protected per year was US $2.4 and 1.2, respectively. Approximately 16,800 child years were protected and 74 child deaths averted at an estimated cost of US $8.8 per child year protected and US $2003 per death averted. In this rural community, where life expectancy at the mean age of death of trial children was 57.5 years, the estimated cost per discounted healthy life-year gained was US $73.5. Sensitivity analysis suggested that this cost-effectiveness ratio might be reduced substantially by feasible changes in programme implementation. This study supports the argument that the cost-effectiveness of bednet impregnation is sufficiently attractive to make it part of a package of high priority interventions for children. Issues of how to finance the provision of nets and insecticide, and especially the relative contribution of governments, households and donors, need urgently to be addressed. PMID- 10170092 TI - Health policy versus industrial policy in the pharmaceutical sector: the case of Canada. AB - This paper analyses the trade-off between health policy and industrial policy objectives in the field of pharmaceuticals in the Canadian policy setting. In Canada pharmaceutical regulation is organized in two tiers. The federal government is responsible for the conduct of industrial policy for the pharmaceutical sector, including the patenting of new molecular entities, the registration and approval of pharmaceutical products, and the pricing of new products. At the province level, policy-makers are responsible for the reimbursement of the cost of medicines; the methodologies implemented for this purpose may be geared towards meeting the objective of cost containment within tight health budgets rather than addressing industrial policy objectives and, thereby, supporting the pharmaceutical industry. The reimbursement methodologies implemented may also be related with the strength of pharmaceutical presence in each province. The paper provides evidence from two such provinces, British Columbia and Ontario, and contrasts pharmaceutical policy-making at the provincial level with that at the federal level. PMID- 10170093 TI - New children's hospital is a family affair. PMID- 10170094 TI - Salad daze. Food service could be added to your menu. Get ready. PMID- 10170095 TI - Show and tell. Time to teach your ES staff how to shine in the JCAHO's new survey process. PMID- 10170096 TI - Water torture. There are ways to protect paint jobs from the ravages of moisture. PMID- 10170098 TI - Get your food service wast (and costs) out of the garbage. PMID- 10170097 TI - Lamp latest: energy savings on the rise, mercury falling. PMID- 10170099 TI - Real estate manager 2000: show me the money flow. PMID- 10170100 TI - Foley advances not showing up in prices. PMID- 10170101 TI - Prime targets: major GPOs eye regionals for mergers. PMID- 10170102 TI - When assessing supply costs, don't forget case volume. PMID- 10170103 TI - Emory tackles costs with more data, less inventory. PMID- 10170104 TI - Guidelines recommended for all contracts. PMID- 10170105 TI - Rightsizing the right way. PMID- 10170106 TI - You don't have to miss out on a valuable profit center. Case studies and success stories of thriving POLs. PMID- 10170107 TI - Inventive strategies for laboratory recruitment. PMID- 10170108 TI - A quality approach to referral lab contracting. What to look for, what to avoid when contracting with a referral laboratory. PMID- 10170109 TI - Understanding cost behavior in the lab. The key to financial success. PMID- 10170111 TI - Secrets of power negotiating. PMID- 10170110 TI - The role of community values in setting healthcare priorities. Ethically and financially viable, or merely a "modest proposal?". PMID- 10170112 TI - MLO's National Salary Survey. Part 1. PMID- 10170113 TI - Answering the call to customer service. PMID- 10170114 TI - Efficiency gains with bar coding and interfaced instruments. AB - This study of immunology and hematology testing at two hospital laboratories shows a reduction of as high as 47% in labor requirements by using bar coding and interfaces at the instrument level. PMID- 10170115 TI - Caught in the Web. Combating work stress in the information age. AB - The computer, the fax, the cell phone, the pager--all the trappings of the information age--cause much stress in the workplace. Mastering these gadgets- knowing how and when to use them and dealing with the barrage of messages generated by them--is essential to maintaining workplace sanity. PMID- 10170116 TI - How to neutralize manipulators. PMID- 10170117 TI - Exempt from caps? Language in budget law may open Medicare loophole. PMID- 10170118 TI - Another Kaiser picket line. Historic pact with AFL-CIO fails to stop Oregon strike. PMID- 10170119 TI - Providers lead in earnings gains. PMID- 10170120 TI - Profits soar 20% at Colo. hospitals. PMID- 10170121 TI - Boon for rural hospitals. Revived program may mean higher Medicare payments. PMID- 10170122 TI - Medicare to pay docs who use telemedicine. PMID- 10170123 TI - Phoenix or buzzard? Will Columbia really end its predatory ways? If so, what will Wall Street think? PMID- 10170124 TI - The rise and fall. AB - By the time the government raided Columbia/HCA Healthcare Corp. facilities this summer, colleagues had been trying for years to warn the company's then-top executive, Richard Scott, about the unnerving arrogance from the executive suite in Nashville. Modern Healthcare explores key events in the rise and fall of Scott and the company he built. PMID- 10170125 TI - More hospitals settle. CFOs taking pre-emptive action in outpatient billing probe. PMID- 10170127 TI - How many FTEs? No one method for tracking labor productivity for the OR. PMID- 10170126 TI - The ownership care. Tenet plays its tax-paying status against S.C. rival. PMID- 10170128 TI - Infection experts ready protocols as superbug looms. PMID- 10170129 TI - NIOSH alert recommends the use of powder-free gloves. PMID- 10170130 TI - Before you buy: looking into limited reuse. PMID- 10170131 TI - Team wins award for ending "waiting game". PMID- 10170132 TI - Fail-safe discharge: patients with no ride home. PMID- 10170133 TI - 24-hour videotaping in OR raises questions. PMID- 10170134 TI - Arthroscopy study zeros in on infections. PMID- 10170135 TI - Speaking up: tips for delivering bad news. PMID- 10170136 TI - Patient loses bid for hospital infection rates. PMID- 10170137 TI - White House views hospice connection. PMID- 10170138 TI - Sleuthing for clues. Providers use satisfaction surveys to uncover activities and services residents need and want. PMID- 10170139 TI - States look for due diligence in staffing. PMID- 10170140 TI - Medicare covers multiple physician visits. PMID- 10170141 TI - Education, consultation decrease restraint use. PMID- 10170142 TI - More med students train in long-term care. PMID- 10170143 TI - Business planning basics. PMID- 10170144 TI - Barbarian behavior. PMID- 10170145 TI - Benchmarking and innovative adaptation. PMID- 10170146 TI - Seven stars in the healthcare system: a lesson in trajectories. AB - Massive reorganization in the healthcare industry has created a new series of high-level, multi-talented managers. Many have risen from the ashes of change, taking new positions and shifting from positions with a single focus to managing complex administrative matrices. Seven who have been through the reorganization process comment on where they have come from and what they learned from their experience. Their distilled advice: take advantage of further schooling, OJT, hospital association seminars and workshops. Delegate; communicate; don't be afraid to admit you don't have all the technical knowledge at your fingertips. Above all, remember you are to direct the work, not do the work itself. PMID- 10170147 TI - Developing radiology procedure cost standards. AB - Containing costs is at the forefront of healthcare management, particularly as managed care replaces fee-for-service care. The first step in costs is to gain an understanding of the "building blocks" or components of procedure costs. The department of radiology at Duke University Medical Center and Health System, in conjunction with the department of management engineering, developed labor and supply standards to predict direct procedure costs throughout the radiology department, where 285,000 procedures are performed annually. This team concept resulted in a consistent approach to building procedure standards that predict direct costs across all sections. Step by step instructions are given for the following standards. Variable labor standards represent the average amount of staff time required for each procedure. Variable supply standards represent the average amount of consumable supply resources required per procedure. Fixed labor time standards predict the amount of fixed time resources necessary to operate the department of radiology at Duke University hospital. Cost per procedure uses the standards developed in the other sections. These basic steps will help readers determine their own direct costs per procedure for most radiology procedures (excluding capital and indirect costs). When these standards and costs are identified, the next step is to identify the areas to reduce such costs without affecting the quality of patient care. PMID- 10170148 TI - AHRA survey: radiology nursing. PMID- 10170149 TI - Little baby steps. PMID- 10170150 TI - New Columbia boss orders radical surgery. PMID- 10170151 TI - Cutting-edge sonography obviates breast biopsy. PMID- 10170152 TI - Do benefits of contrast outweigh its costs? PMID- 10170154 TI - Teleradiology: sideshow or part of the solution? PMID- 10170153 TI - CR, flat-panel radiography to compete and likely coexist. PMID- 10170155 TI - Teleradiology sales tilt toward higher end units. PMID- 10170157 TI - Keep eye on telerad's evolving legal climate. PMID- 10170156 TI - Calculate film costs before going electronic. PMID- 10170158 TI - A radiologist's guide to new management models. PMID- 10170159 TI - Breast cancer, politics make unhappy bedfellows. PMID- 10170160 TI - Job-hunting radiologists face downsized future. PMID- 10170161 TI - Who's leading radiology--and where is it headed? PMID- 10170162 TI - Vertebroplasty relieves osteoporosis pain. PMID- 10170163 TI - CR matches screen-film in breast imaging exams. PMID- 10170164 TI - In situ hybridization versus immunohistochemistry: what's the difference? PMID- 10170165 TI - Lipids and atherosclerosis: an impossible causal relationship. PMID- 10170166 TI - HMO family physicians: men and women differ in their work. AB - OBJECTIVE: The goal was to identify differences in the type of work and amount of work performed by male and female family HMO physicians. DESIGN: Data were collected by self-administered physician surveys, retrospective analysis of encounter forms, ambulatory care group (ACG) analysis of physicians' patient panels, and participant observation. SETTING: A large HMO-based clinical facility. PARTICIPANTS. Family practitioners (n = 21) at one HMO clinic. MAIN OUTCOME MEASURES: Measures included patient encounters/day, self-assessed and encounter-form-based workload, ambulatory care group panel evaluation and qualitative observation of practice patterns and team functioning. RESULTS: These data show that the kind of work male and female physicians did at this site differed, when compared on the basis of encounter-form-based diagnoses, ambulatory care group panel assessments and participant observation. However, the amount of work performed by each gender did not appear to different when evaluated by age-sex-adjusted panel size, patient encounters per unit time, a subjective magnitude estimation workload questionnaire and an encounter-form based workload assessment. CONCLUSION: In this study, multiple measures for evaluating physician workload revealed distinct differences in the kind of clinical work performed by male and female HMO family physicians. These findings have implications for clinicians, managers, planners, researchers and educators. PMID- 10170167 TI - Developing a system for automated monitoring of psychiatric outpatients: a first step to improve quality. AB - OBJECTIVE: To evaluate an automated system of quality monitoring for psychiatric outpatients. DESIGN: Cross-sectional study. SETTING: Large outpatient psychiatry clinic in Kaiser Permanente--Northern California. PARTICIPANTS: Approximately 1500 new psychiatric patients and 20 clinicians. INTERVENTIONS: This system gave clinicians data on new patients from validated instruments before their intake interviews, measured outcomes for the depressed and panic-disordered patients, and monitored the clinic's case-mix. MAIN OUTCOME MEASURES: Clinic case-mix: Axis II disorders (Personality Disorder Questionnaire--Revised); emotional, social and physical functioning (Health Status Questionnaire 2.0); Axis I symptoms (Symptom Checklist-90); depression and panic disorder (Health Outcomes Institute Modules). Clinician reaction to system (telephone interview). RESULTS: The study population was 62.4% female; 73.9% Caucasian; 70% employed; 15.9% had evidence of personality disorder; 63% reduced daily activities because of emotional problems; 18% had depression; 7% had panic disorder. Over 75% of clinicians used the data reports and found them helpful; criticism focused on questionnaire length, inadequate training, numerous false-positives, and insufficient administrative support. CONCLUSION: An automated patient monitoring system can be implemented; clinician involvement needs to be significant; more research is needed to establish the usefulness of standardized data and outcomes management. PMID- 10170168 TI - Identifying depressive symptoms among elderly Medicare HMO enrollees. AB - Increasing attention has been devoted to the urgent need for identifying depressive symptomatology at the primary care point of contact for older individuals to prevent more serious disease and potential negative behavioral outcomes. Delivering medical care services in a system that is sensitive to the symptoms of depression may lead to greater cost-effectiveness and improved quality of life. This paper examines the correlates of depression in a random sample of 1800 Medicare beneficiaries enrolled in a risk-sharing HMO. Ten percent of the total sample reported a high degree of depressive symptoms, as measured by the CES-D score. The prevalence of depressive symptoms was significantly higher for those who were not married, reported less well-developed social support networks, had low perceived ability to control future health, or had poorer health status. Depressive symptoms were also associated with a greater number of physician office visits and higher ambulatory charges, although no significant relationship was found for inpatient use or total charges. Practical approaches to monitoring depressive symptomatology at the primary care level in an HMO are suggested. PMID- 10170169 TI - Case management programs: investment in the future. AB - A well-planned, proactive case management program that focuses on the identification and management of high-risk/high/cost patients can prove to be a valuable investment. FHP, Inc., implemented a pilot Patient Care Management program in the Long Beach/Orange County, California region. The program produced an estimated cost savings of nearly 4 million dollars in its first full year of operation. Results also included improved patient satisfaction, increased quality of care and decreased medical-legal risks. The program is currently expanding to all states where FHP has staff model operations. This article examines the steps utilized in the development of the program, and identifies keys to success. PMID- 10170170 TI - Beyond the benefit package. PMID- 10170171 TI - Computerized patient records: the patients' response. AB - A large primary care HMO health care center in Chandler, Ariz, has utilized a comprehensive computerized patient record for the past 2 years. The patient flow through the center is described in detail. Patients (n = 126) completing an automated medical record office visit were surveyed at random to determine their response to the computerized record. Results indicate patients are convinced that our use of the automated record helps us be more familiar with their medical history, providing a strong mandate to continue the project. The patients expressed some concerns about confidentiality of automated records, and about computer-related distractions that may occur during a visit. PMID- 10170172 TI - The interwined roles of primary care physicians and specialists. PMID- 10170173 TI - Innovations in primary care: encouraging research by clinical staff. PMID- 10170174 TI - Bioethics in the clinical laboratory: the value of values. Tools for analyzing ethical issues and making good moral judgments. PMID- 10170175 TI - Point-of-care testing: managing people and technology. A win-win approach to successful point-of-care test management. AB - The objective of this article is to provide a step-by-step approach to evaluating the need for a point-of-care testing program. It also describes a process for writing a proposal for the implementation of the program, getting the program accepted by all stake-holder groups, and managing it after it has been established. More importantly, the actions described will help assure that the program design: 1. fits the information needs of the patient care area where it will be implemented 2. meshes with the resources available in the organization 3. takes advantage of the state-of-the-art in laboratory technology. PMID- 10170176 TI - Will your laboratory be ready for the future? PMID- 10170177 TI - Low cost, high payoff solutions! PMID- 10170178 TI - The manager's financial handbook. Cost concepts and breakeven analysis. AB - As the health-care environment becomes more competitive, laboratory managers need to become skillful in using and controlling their resources. Controlling resources usually means managing cost. By analyzing cost and understanding its different components, the laboratory manager can make rational decisions. This article describes and analyzes different categories within which cost can be characterized and shows how breakeven analysis can be used when dealing with fixed-price payers or multiple payment purchases of health-care services. PMID- 10170180 TI - As we see it. What is the point of point-of-care testing? PMID- 10170179 TI - Is the tail wagging the dog? PMID- 10170181 TI - Measuring and improving quality and performance in an evolving health-care sector. AB - How can the challenges of quality measurement, assurance, and improvement be met at the national, state, and community levels? Can we sustain high levels of quality of care in an evolving health sector that wants to control costs and needs to extend access to millions of people? Can we find new ways to measure clinical practice performance and improve quality that will work more effectively in both the private and public sectors? All these questions demand answers in the context of contemporary circumstances. PMID- 10170182 TI - Physician practice information systems. Company directory. PMID- 10170183 TI - Physician practice information systems. Product functions. PMID- 10170184 TI - Uniting practice management and the CPR. PMID- 10170185 TI - Practice management systems: coming of age. PMID- 10170186 TI - Net commerce development grows. PMID- 10170187 TI - Up and ATM? PMID- 10170188 TI - Married to the mainframe. AB - Despite the growth of client/server technologies, many healthcare organizations remain committed to their mainframe systems. But will mainframes remain good partners for years to come? PMID- 10170189 TI - Destination: quality care and cost management. PMID- 10170190 TI - Case management vendors. PMID- 10170191 TI - The ubiquitous, yet invisible security system. PMID- 10170192 TI - Some faces of compassion. PMID- 10170193 TI - Staying on target. AB - In the area of market research, it's critical to be accurate and accumulate useful information, but it's also important to be cost-effective. Sometimes, a lot of planning and a little innovation can be the answer to obtaining the right information at the right price. PMID- 10170194 TI - Bedside manner. AB - The hospital setting can be a place of healing and hope for the future. Unfortunately, it can also be a site filled with pain and grief. How hospitals deal emotionally with patients, and others who experience trauma is an important aspect of overall care. The following is a look at the importance of compassionate care and how some Alabama hospitals tend to the emotional, psychological and spiritual needs of patients and their loved ones. PMID- 10170195 TI - Capitation survival kit: how to fashion provider excess coverage. PMID- 10170196 TI - Documentation issues in electronic fetal monitoring. PMID- 10170197 TI - Don't wait for new OSHA standard to protect against TB. PMID- 10170198 TI - Process maps point the way to new solutions. People power. PMID- 10170199 TI - Staff ideas net hefty savings--and cash awards. PMID- 10170200 TI - Dry and dirty. Only 30 minutes after use, it's harder to clean a scope. PMID- 10170201 TI - Stats. Pack-to-pack. There's no clear winner in the face-off between custom and standard packs. PMID- 10170202 TI - Invasion of privacy. PMID- 10170203 TI - The children's crusade. PMID- 10170204 TI - Doctors' dilemma. PMID- 10170206 TI - Use technology assessment forms to gain input from several perspectives. AB - As healthcare organizations tackle the problem of effective selection and appropriate use of new medical and diagnostic technologies, four major questions must be asked: How does this technology affect patients; is it needed to compete in the marketplace; will it be used appropriately; and is there enough information available for making a decision to buy? To ensure that all viewpoints are considered, the Healthcare Association of New York State in Albany developed forms for gathering pertinent information from the perspectives of the provider, community, facility, vendor and finance department. Here are two HANYS forms- Medical Assessment and Community Assessment--for use in gathering information needed for making a decision. PMID- 10170205 TI - Lessons from formulary decisionmaking. PMID- 10170207 TI - Managed care, academic health centers declare truce, join in partnerships for quality education. PMID- 10170208 TI - Taking a critical look at technology: smarter purchasers make smarter users. AB - That new technology being lauded in today's medical journals may not be just what the doctor ordered for your healthcare organization. The decision to use it, the experts say, should rely on a thorough assessment of cost, quality and, especially, patient outcomes. PMID- 10170209 TI - How we keep health costs under a grand. Case study. AB - To some, this Florida hoteller's rock-bottom employee health costs attest to his revolutionary vision. Others point to exclusions in coverage and say the price is too high. PMID- 10170210 TI - What's behind those satisfaction surveys? AB - Health plans eagerly collect and disseminate evidence of contented enrollees, but what do member satisfaction surveys really reveal? Unless methodology is reported along with results, the answer is, Not Much. PMID- 10170211 TI - Crushing your health plan's legal protection. AB - Enacted in the pre-managed care days, ERISA has shielded health plans from liability in a way the nation's lawmakers may never have intended. The business community watches warily as this blanket protection erodes. PMID- 10170212 TI - The high cost of anxiety. PMID- 10170213 TI - Are you prepared for a medical emergency? PMID- 10170214 TI - Data watch. Managed care: enrollment increases, costs decreases. PMID- 10170215 TI - Chaos theory. PMID- 10170216 TI - Store more: data storage trends. PMID- 10170217 TI - Creating Web windows may leave doors to data unsecured. PMID- 10170218 TI - What works. Surgeons generate "clean bills" from the point of care. PMID- 10170219 TI - What works. Paperless organ transplant system helps reduce staff, enhance quality. PMID- 10170220 TI - What works. Telemedicine links specialists with rural Iowans. PMID- 10170221 TI - What works. Outsourcing cuts operating costs 20 percent, saves $1.5 million in capital investment. PMID- 10170223 TI - Hotlist. Patient data repositories. PMID- 10170222 TI - Integrated vs. interfaced practice management systems. PMID- 10170224 TI - Enhancing productivity and satisfaction with patient education software. Interview by Jim Evans. PMID- 10170225 TI - Value management: new challenges for health care informatics. PMID- 10170226 TI - Socialism and the British National Health Service. AB - This paper examines some of the key characteristics of a socialist health care system using the example of the British National Health Service (NHS). It has been claimed that the NHS has socialist principles, and represents an island of socialism in a capitalist sea. However, using historical analysis, this paper argues that while the NHS claims some socialist ends, they could never be fully achieved because of the lack of socialist means. The socialist mechanisms which were associated with earlier plans for a national health service such as salaried service, health centres, elected health authorities and divorcing private practice from the public service were discarded in negotiation. Moreover, even these would have achieved socialism merely in the sense of distributing health care, without any deeper transformation associated with doctor-patient relationships and prevention. In short, the NHS is more correctly seen as nationalised rather than socialised medicine, achieving the first three levels of a socialist health service identified here. It can be said to have socialist principles in the limited distributional sense and has some socialist means to achieve these. However, it lacks the stronger means to fully achieve its distributional goals, and is very distant from the third level of a radical transformation of health care. PMID- 10170227 TI - What would a socialist health care system look like? A sketch. AB - In this paper I argue that, since institutions must reflect the societies in which they are placed, a socialist health-care system cannot be understood unless democratic socialism--which would assure all of basic necessities of existence, full education and health-care to all members of the community--is not incompatible with a flourishing market for other products. In contrasting single with multiple tiered health care systems, I suggest that a single tiered system in which all have equal access to health care and none can buy more, is most consistent with the ideals of democratic socialism. PMID- 10170228 TI - Necessary conditions for a socialist health service. AB - A socialist health service in a non-socialist society may be forced to stress care and rescue rather than prevention, health maintenance or the promotion of better health and more equal health status. A socialist health service ought to be 'integrated'. A socialist health service ought to provide universal and comprehensive care. PMID- 10170229 TI - What would a socialist health service look like? AB - A socialist health service cannot be a socialist island in a sea of capitalism, as the record of the British National Health Service shows. Nonetheless, since health is a basic need, it can be a key component of the advocacy of socialism. I propose two central socialist principles. On the basis of these I suggest that a socialist health system would emphasise care rather than service; insist on democratic structures and control of resources; and require the prohibition of private medicine. PMID- 10170230 TI - Capable people: empowering the patient in the assessment of capacity. PMID- 10170231 TI - A social market in health care faces reform: the Seehofer Plan for the German health system. PMID- 10170232 TI - To the uninformed: managed care means damaged ethics. PMID- 10170233 TI - The ethics of teaching nursing ethics. PMID- 10170234 TI - Health records issues. The case of the missing notes. PMID- 10170235 TI - Institute of Health Record Information and Management. Regulations for diploma award, effective from May 1997. PMID- 10170236 TI - Centers for Disease Control and Prevention; statement of organization, functions, and delegations of authority. PMID- 10170237 TI - Field report--capitation. Sharp Rees-Stealy Medical Group, San Diego, Calif. Making the transition from productivity compensation to capitation. PMID- 10170238 TI - Do managed care practices hamper clinical research? PMID- 10170239 TI - Better patient communications mean lower liability exposure. PMID- 10170240 TI - Physician-assisted suicide, managed care: unhappy bedfellows, a match made in hell. PMID- 10170241 TI - HIPAA extends Big Brother's reach. PMID- 10170242 TI - Managed care outlook. Formularies get stricter. PMID- 10170243 TI - Compensation monitor. Family physicians vs. internists: a state-by-state salary comparison. PMID- 10170244 TI - Do managed care plans reward the best doctors? PMID- 10170245 TI - Disease management gains a degree of respectability. PMID- 10170246 TI - Cut pharmaceutical costs, but mind the legal dangers. PMID- 10170247 TI - Managed Medicare's rapid expansion. PMID- 10170248 TI - Comprehensive management of depression arrives slowly. PMID- 10170249 TI - An interview with Alan Hillman, M.D., M.B.A. PMID- 10170250 TI - Field report--capitation. How capitation turned red ink to black at Harris Methodist Health Systems. PMID- 10170251 TI - Field report--capitation. Pacific Communities Management Services Organization, Harbor City, Calif. Capitation is for specialists, not for primary care physicians. PMID- 10170252 TI - Point-counterpoint. Not-for-profits vs. for-profits: is one better for patient care? Valuable societal functions for which there is no economic market. PMID- 10170253 TI - Point-counterpoint. Not-for-profits vs. for profits: is one better for patient care? Developing a spectrum of innovative partnerships. PMID- 10170254 TI - Mercy Medical: developing an acute and subacute care continuum. Case study. AB - Managed care has yet to make the inroads in Alabama that it has in other states, but this religious system is bracing for change. Its near-term plans include expanding services and affiliating with local acute care facilities. PMID- 10170255 TI - Physician acquisitions: beating the competition in a dog-eat-dog world. PMID- 10170256 TI - Independent healthcare organizations band together to keep unwanted suitors at bay: are these alliances working? AB - Competitive pressures are forcing a growing number of independent health-care organizations to consider allying with local rivals to create a market presence capable of keeping mega for-profit competitors at bay. Such moves, however, do not reflect "just a for-profit versus not-for-profit thing," says one consultant. "This is life and death." PMID- 10170257 TI - Internet/intranets. Providing easier access to clinical data. AB - The Regenstrief Institute has helped to create electronic records on millions of patients. Now, a developing intranet holds the promise of giving easy access to valuable clinical data. PMID- 10170258 TI - CIO of the Year. Thriving on the challenge of change. AB - To manage the change that confronts Harris Methodist Health System, Larry Blevins uses his technical knowledge, management and interpersonal skills, and business savvy. In 14 years with the Arlington, Texas-based health care system, Blevins has unified its information systems approach and given in the automation infrastructure to thrive. "If you're not changing, then you're either dead or stagnant," Blevins says. "While that is the challenge, that's part of the fun. Change should be fun." PMID- 10170259 TI - Telemedicine. Progress on the payment issue. PMID- 10170260 TI - Coping with capitation. AB - Capitation is spreading as a payment mechanism as managed care plans and employers look for ways to hold down costs and make them more predictable. More provider organizations are using information technology to measure their costs, forecast risks and carefully analyze capitated contracts before signing them. They're also turning to information systems to fairly divvy up the capitated payments to physicians and other clinicians. PMID- 10170261 TI - Outsourcing. Health care organizations are considering strategic goals in making outsourcing decisions. AB - More health care organizations are outsourcing the management of some or all of their information systems. Executives at many organizations that have tried outsourcing say it enables them to focus on core competencies, better allocate resources, get more information technology at less cost, share risks of implementing information technology with outsourcers and guarantee access to skilled labor. But the information technology outsourcing market remains relatively small in health care because many CIOs still are wary of turning over control of important functions to outsiders. PMID- 10170262 TI - Long-term care facilities tackle clinical automation. AB - Long-term care facilities building automation strategies face many challenges. In a market dominated by software for hospitals and clinics, they must make sure that the software they acquire meets the specific needs of the long-term care niche. For example, they need software that can collect data required by the federal government and that can be used to keep good nutritional records. PMID- 10170263 TI - Provider automation. Building rather than buying. PMID- 10170264 TI - Managed care. Image control. PMID- 10170265 TI - Dominant health care organizations. Ten strategies for becoming "indispensable" provider-sponsored networks. PMID- 10170266 TI - The scapegoat archetype: who's right vs what's right. PMID- 10170267 TI - Laser printers in digital mammography. PMID- 10170269 TI - Standardizing MR image quality: if not ACR, then who? PMID- 10170268 TI - Using continuous quality improvement (CQI) to improve the care of patients with breast cancer. PMID- 10170270 TI - The role of computed tomography in community-acquired pneumonia. PMID- 10170271 TI - Zen and technology. PMID- 10170272 TI - Looking above to aviation leadership. PMID- 10170273 TI - Change management--organizational culture as change factor. PMID- 10170274 TI - Knowledge is power. Comparative analysis software is a powerful tool for healthcare. PMID- 10170275 TI - The new magnetic resonance techniques of diffusion and perfusion imaging. PMID- 10170276 TI - Bioelectromagnetics & the future of medicine. PMID- 10170277 TI - Managerial guidelines for implementing teleradiology. AB - How should the manager of a healthcare organization approach this new and quickly changing technology? How should the technology be diffused within the medical organization's structure? How can unnecessary costs be avoided? PMID- 10170278 TI - Making it through the mental health maze. PMID- 10170279 TI - Assisted living. Finding new ways to pay. PMID- 10170280 TI - Reimbursement. Striking the right balance with assisted living. PMID- 10170281 TI - Subacute seal of approval. ACHCA exam certifies subacute care administrators. PMID- 10170282 TI - Assisted living special section. Caution: growth ahead. PMID- 10170283 TI - Performance-oriented: toward a successful strategy. AB - Changes in the health care industry have profoundly affected hospital management and have caused severe declines in hospital profitability. In 1993, Health Care Management Review reported that the average operating profit margin, around 2% in 1984, had declined to a 0.2% loss by 1990. In the past, hospitals were buffered by entry regulations and cost reimbursement; thus, they rarely dealt with traditional market pressures. But the changed terrain means that competitive factors now underscore all strategic decisions. This study examines the strategic significance of market orientation in the health care industry. The authors identified forms of market orientation by emphasizing different components, and discovered that hospitals fell into four distinct clusters or groups. They also found a critical relationship between market orientation and performance scores on a number of criteria. Finally, the authors suggest that different forms of market orientation should be employed to target specific performance measures. PMID- 10170284 TI - Charting patient satisfaction. AB - The importance of maintaining high levels of patient satisfaction has been well researched and thoroughly documented. Patient satisfaction can be measured, changed, controlled, and managed effectively to aid in improvement quality. Nevertheless, little research has been conducted to determine how patient satisfaction affects quality or how satisfaction strategies affect patients' perceptions. The authors of this study view patient satisfaction as a value-added component. They present a statistical process control-chart method that can help implement and evaluate a CQI strategy for improving patient satisfaction. The study illustrates how to measure patient satisfaction, create control charts, interpret the results, and develop administrative applications aimed at fulfilling a CQI strategy. PMID- 10170285 TI - Improving marketing strategies for wellness. AB - The authors address the following questions in a research study and propose six hypotheses: Does the desire for exuberant well-being, perceived threat to health, or a combination of both best explain wellness behavior? Threat is the stronger motivation for wellness behavior, followed closely by the desire for exuberant well-being. The authors present a thorough discussion of the implications of such findings for health care organization managers and marketers. PMID- 10170286 TI - What's next for managed care? Panel discussion. AB - Change continues to be health care's only constant in the United States. As enrollment in managed care organizations skyrockets, the glare of public scrutiny intensifies. Success is no longer as simple as undercutting traditional fee-for service providers; MCOs have to become more responsive to consumer needs as they compete with one another. Whether substantial set of values or mere buzzword, quality is the lingua franca of the MCO arena. Although MCO executives attribute the concept's ubiquity to many factors, the common denominator is staying competitive in a high-growth industry. Along with the elimination of the gatekeeper, a major trend to watch for is the rise of industry oversight provided by standardized practice guidelines. MCO executives recognized that implementing such measures will streamline operations and make MCOs more user-friendly. PMID- 10170287 TI - Columbia: siting an online opportunity. PMID- 10170288 TI - Do physicians need relief from antitrust laws? PMID- 10170289 TI - Building sensible segmentation strategies in managed care settings. PMID- 10170290 TI - The importance of outcomes data in health care decision making and purchasing. PMID- 10170291 TI - Economic advantages of breast-feeding in an HMO: setting a pilot study. AB - We performed a pilot study on newborns randomly chosen from term singleton deliveries born to mothers in an HMO group between September 1992 and August 1993. Breast-fed infants were breast-feeding at 6 months (n = 41), whereas bottle fed infants were bottle-fed from birth (n = 107), Medical care and costs for the first 12 months were retrospectively analyzed, including office visits, drug prescriptions, and hospitalizations. Both groups had similar numbers of office visits and pharmacy costs. Breast-fed infants had fewer inpatient admissions (0.13 vs. 0.20 discharges per 1,000 babies), and their average total medical costs were $200 less than those of bottle-fed infants. Extrapolating to the total number of deliveries during this period, an increase in breast-feeding from the current rate (17%) to the Healthy People 2000 goal (50%) could save up to $140,000 annually. PMID- 10170292 TI - Cost of illness studies for schizophrenia: components, benefits, results, and implications. AB - Although schizophrenia affects only about 1% of the worldwide population, it is costly to patients, their families, community care centers, hospitals, and society. International cost of illness studies show a wide variation, with annual costs ranging from Australia's $139 million US dollars (1975) to the cost in the United States of $65.2 billion US dollars (1991). Since methodology and assumptions vary widely from study to study and country to country, it is a challenge to directly compare the results of these studies. Nevertheless, the published COI studies reveal several consistent trends. Inpatient care may be the largest cost driver for direct costs, suggesting that relapse prevention is key to reducing healthcare costs. Indirect costs resulting from the patient's and caregiver's inability to fully participate in the work force is extensive due to the debilitating nature of the disease and its early onset. Lastly, when prescription drug costs were reported, they represented no more than 3% of direct cost. PMID- 10170293 TI - Asthma treatment costs using inhaled corticosteroids. AB - Asthma is a chronic inflammatory disorder of the airways that affects 10 to 17.5 million people and leads to more than $5 billion in treatment costs in the Unites States annually. This retrospective study is an initial step in understanding the beneficial economic outcomes of inhaled corticosteroid therapy by determining whether differences exist in healthcare utilization expenditures for three inhaled corticosteroids available for use in the United States: (1) beclomethasone dipropionate (Vanceril/Schering and Beclovent/Allan & Hanburys); (2) flunisolide (Aerobid/Forest); and (3) and triamcinolone acetonide (Azmacort/Rhone-Poulenc Rorer). This study was based on an analysis of 4,441 patients with at least one pharmaceutical claim for one of the study drugs, using inpatient, outpatient, and prescription drug claims data obtained from The MEDSTAT Group's MarketScan database for calendar years 1990 through 1993. We tested a null hypothesis for no differences in total asthma treatment costs, when drugs were excluded, using multivariate linear regression modeling controlling for patient demographic and clinical characteristics that might affect the study outcome. We found that, after excluding study drug payments and controlling for other contributing factors, total asthma healthcare expenditures to triamcinolone acetonide (Azmacort) users were higher than those for beclomethasone dipropionate (Vanceril and Beclovent) and flunisolide (Aerobid) users. When study drug costs were included in the expenditure measure, both triamcinolone acetonide (Azmacort) and flunisolide (Aerobid) users had higher expenditures than did beclomethasone dipropionate (Vanceril and Beclovent) users. No significant differences in expenditures were detected between Vanceril and Beclovent patients, a finding consistent with the fact that these drugs are the same type of inhaled corticosteroid. Other factors contributing to differences in total asthma healthcare costs included patient age, patterns of switching among and continuing with study drugs, prestudy asthma utilization or drug proxy severity, and comorbidities of precipitating illnesses. PMID- 10170294 TI - The challenge of integrating monoclonal antibodies into the current healthcare system. AB - Although there are few monoclonal antibody (MoAb) products on the market, the biotechnology industry has made considerable progress over the last decade. The industry has developed new technology to address the primary hurdles facing the development of MoAbs--including the immune response to murine-derived antibodies as well as lack of tumor specificity. As the techniques for development become more refined, more products will be approved by the Food and Drug Administration. Integrating these products into the existing healthcare system will be a challenge, given their high acquisition costs. Recent pharmacoeconomic examples outlined in this paper confirm that MoAb products will need to be supported with proven clinical and economic profiles. As long as a global clinical and economic perspective is taken and patient care benefits can be demonstrated, the place of MoAbs in the future of healthcare will be assured. PMID- 10170295 TI - Costs, true costs, and whose costs in economic analyses in medicine? AB - Cost-effectiveness analyses of clinical practices are becoming more common in the development of health policy. However, such analyses can be based on misconceptions and flawed assumptions, leading to flawed policies. We argue that such is the case with the recent recommendations for routine measurement of umbilical cord gases at delivery, a policy based on the assumption that this clinical strategy will pay for itself by reduced malpractice awards. As we demonstrate, this argument reflects the physician's perspective, not that of society or of patients. It also ignores the fact that malpractice awards are largely transfer payments, not cost of healthcare. PMID- 10170296 TI - Breast reconstruction after mastectomy. AB - This activity is designed for primary care physicians. GOAL: To appreciate the significant advances and current techniques in breast reconstruction after mastectomy and realize the positive physical and emotional benefits to the patient. OBJECTIVES: 1. Understand basic and anatomic principles of breast reconstruction. 2. Discuss the options for breast reconstruction: a) immediate versus delayed; b) autologous tissue versus implant; and c) stages of reconstruction and ancillary procedures. 3. Provide a comprehensive overview of the risks and benefits of, as well as the alternatives to, each approach so primary care physicians can counsel patients effectively. PMID- 10170297 TI - Exploring self-care and wellness: a model for pharmacist compensation by managed care organizations. AB - Self-care and wellness are rapidly becoming mainstays of practice for many pharmacists. Consumer confidence and trust in pharmacists provides continuing opportunities for pharmacists to create products and services to satisfy consumer demands related to disease prevention and healthcare delivery. We outline two pharmacy wellness programs designed to meet consumer needs, and offer them as models for pharmacists. Issues related to the program and extent of involvement by pharmacists are raised, including the role of the pharmacists in behavior modification efforts; selecting areas of focus (e.g., smoking cessation); working with physicians for referrals; enlightening community business leaders and managed care organizations to the economic benefits of the program; and developing strategies for fair purchase of services to achieve program goals and provide adequate compensation in return. PMID- 10170298 TI - Breast-feeding and managed care. PMID- 10170299 TI - Impact of managed care on quality of healthcare: theory and evidence. AB - Each strategy for managing healthcare risk has important and unique implications for the patient-provider relationship and for quality of care. Not only are different incentive structures created by different risk-sharing arrangements, but these incentives differ from those in a fee-for-service environment. With fee for-service and traditional indemnity insurance, physicians have incentives to provide healthcare services of marginal value to the patient; under managed care, physicians have fewer incentives to provide marginally beneficial services. However, the impact of financial arrangements on quality of care remains ambiguous, because it depends on the strategic behavior of physicians with regard to their informational advantage over their patients. Using the framework of an agency theory model, we surveyed the current scientific literature to assess the impact of managed care on quality of care. We considered three different dimensions of quality of care: patient satisfaction, clinical process and outcomes of care measures, and resource utilization. Although we found no systematic differences in patient satisfaction and clinical process and outcomes between managed care and fee-for-service plans, resource utilization appears to be decreased under managed care arrangements. Given the strengths and weaknesses of fee-for-service and managed care, it is unlikely that either will displace the other as the exclusive mechanism for arranging health insurance contracts. Policy makers may be able to take advantage of the strengths of both fee-for-service and managed care financial arrangements. PMID- 10170300 TI - Patient health management: a promising paradigm in Canadian healthcare. AB - Disease management, or the focused application of resources to achieve desired health outcomes, began in Canada in 1971 with the introduction of a universal healthcare program and a single government payor. Although relatively unfocused and nonrestrictive by contemporary standards, this program was successful in terms of outcomes. However, it is expensive, and Canada's rapidly aging population is fueling a growing demand for more efficacious medical therapies. As a result, isolated services are being restricted in an effort to reduce costs. As a result of these changes and low prescription and patient compliance rates for efficacious therapies, total system costs have risen, there is a growing concern about deterioration of health outcomes, and stakeholders are dissatisfied. To optimize healthcare outcomes and reduce costs, a new paradigm--patient health management (PHM)--has emerged. With PHM, clinical and cost outcomes are continually measured and communicated to providers in an attempt to promote more efficacious care. PHM also seeks to avoid restrictive practices that are now associated with detrimental health outcomes and increased costs. PHM has proved successful when applied to acute and chronic cardiac disease treatment. It remains untested for most other diseases, but available data suggest that the comprehensive, evidence-based disease and systems management that characterizes PHM is likely to achieve the best health outcomes for the most people at the lowest possible costs. PMID- 10170301 TI - The effects of clonazepam on quality of life and work productivity in panic disorder. AB - Although panic disorder has been associated with impaired quality of life (QOL) and financial dependence, no prior study has examined whether a clinical intervention will improve these outcomes. This study examines the effects of clinically titrated doses of clonazepam versus placebo on QOL and work productivity (WP) in patients with panic disorder. QOL and WP were measured in conjunction with a randomized, double-blind, placebo-controlled trial. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and Work Productivity and Impairment questionnaire were used to assess QOL and WP, respectively. Baseline assessments were obtained before randomizing patients to receive clinically titrated doses of clonazepam or placebo. Follow-up assessments were obtained after 6 weeks of therapy with the test drug or at premature termination from the study. Improvement on the SF-36 Mental Health Component Summary scale was more than twice as great with clonazepam than with placebo (P = 0.03). Clonazepam patients improved (P < 0.05) on all five measures of mental health-related QOL, and both measures of physical health-related QOL, and both measures of WP. Placebo patients improved on three of five measures of mental health-related QOL, but on no other measures. Patients with marked improvements on clinical measures of panic disorder severity, especially avoidance and fear of the main phobia, showed the greatest gains on the SF-36 Mental Health Component Summary scale. Clinically titrated doses of clonazepam significantly improved mental health-related QOL and WP in panic disorder patients. Lesser improvements were obtained with placebo. PMID- 10170302 TI - Epidemiology and screening for prostate cancer. AB - This activity is designed for primary care physicians, internists, and general audiences. GOAL: To provide the reader with a basic understanding of the controversy surrounding population-based prostate cancer screening and of the tools needed to conduct early detection programs for prostate cancer among enrollees. OBJECTIVES: 1. Become familiar with the national debate regarding population-based prostate cancer screening. 2. Learn the essential elements of prostate specific antigen testing for patients. 3. Understand the cost effectiveness and medico-legal/informed consent issues surrounding prostate cancer detection and screening. PMID- 10170303 TI - Identifying and managing patients with hyperlipidemia. AB - Cardiovascular disease related to hyperlipidemia is a significant cause of morbidity and mortality in the United States. The benefit of lowering lipid levels in patients with and without cardiovascular disease has been demonstrated in numerous clinical trials. The results of these trials prompted the National Heart, Blood, and Lung Institute to form the Nation Cholesterol Education Panel (NCEP). This panel developed guidelines for identifying and treating lipid disorders. Before starting antilipemic therapy, patients should be evaluated for secondary causes of hyperlipidemia, including disease states and medications. Risk factors for cardiovascular disease should be identified and used to determine the patient's goal low-density lipoprotein level. Regardless of the drug therapy used, the cornerstone treatment for hyperlipidemia is dietary changes. The NCEP recommendation for dietary modification follows a two-step plan to reduce intake of cholesterol and dietary fats. Other nonpharmacologic treatments for hyperlipidemia include exercise, weight reduction for obese patients, reduction of excessive alcohol use, and smoking cessation . Drug therapy should be considered in patients who do not respond to an adequate trial of dietary modifications and lifestyle changes. The principal lipid-lowering agents currently used are the bile acid sequestrants, nicotinic acid, 3-hydroxy-3 methylglutaryl coenzyme A (HMG CoA) reductase inhibitors, and fibric acid derivatives. Estrogen, fish oil, and alcohol also can decrease the risk of developing heart disease. In pharmacoeconomic studies, lipid-lowering drug therapy has been shown to decrease the number of procedures, hospitalizations, and other medical interventions required by patients with cardiovascular disease. PMID- 10170304 TI - Quality improvement and clinical research: an important partnership. PMID- 10170305 TI - Providers should deliver value when managing demand. PMID- 10170306 TI - Out with the old and in with the new at Columbia/HCA Healthcare Corp. PMID- 10170307 TI - Congress throws "a Medicare managed care party" with balanced budget act. PMID- 10170308 TI - Community effort in Minneapolis produces school-based clinic and many challenges. PMID- 10170309 TI - Columbia case prompts strategic questions. PMID- 10170310 TI - Focusing on our patients. PMID- 10170311 TI - Your personal compliance plan. PMID- 10170312 TI - When opposites attract: will Americans accept for-profit/not-for-profit mergers? PMID- 10170313 TI - Intranets promise value, but careful planning still necessary. PMID- 10170314 TI - Using a supply usage relational database to reduce costs. AB - Relational database applications are valuable tools for tracking supply utilization patterns. This information can be used to standardize supplies and reduce utilization, thereby reducing costs and improving consistency. A supply usage database can generate comprehensive reports in a fraction of the time required to produce similar reports by other means. The reports can provide data sorted by patient, surgeon, procedure, product, or any other data field the user specifies, and the comprehensive data are a persuasive means for suggesting changes to supply utilization patterns to physicians. PMID- 10170315 TI - Evaluating integrated healthcare trends: an interview with Dean Coddington. PMID- 10170316 TI - Evolving HMO business practices can threaten tax-exempt status. AB - HMOs are developing new lines of business and fashioning changes to operations that enable them to compete and react to market demands. Executives of tax-exempt HMOs should be aware that some of these new functions could pose a threat to their organization's tax-exempt status or create a Federal income tax liability. Activities that resemble indemnity insurance operations, barriers to eligibility for individuals or groups, and even the composition of its board of directors can affect an HMO's tax-exempt status. PMID- 10170317 TI - Assessing the impact of open-access HMOs on providers. AB - Open-access model HMOs, in which HMO members may seek specialty care without having to be referred by a primary care physician, have been hailed as the next major growth area for the managed care industry. This model is attractive to HMO members because it offers greater freedom in selecting and accessing providers. Payment mechanisms, though, tend to differ from those used by traditional gatekeeper model HMOs. The preferred method of payment in most open-access HMOs is to reimburse primary care physicians on a fee-for-service basis and capitate specialists. Open-access HMOs may lead to more restrictions for providers however, and their continued growth could lead to less desirable payment arrangements and weaker market positions. What types of payment and care delivery systems will ultimately result from open-access HMOs remain to be seen. PMID- 10170318 TI - Federal government expands compliance initiatives. AB - In 1995, the Federal government initiated Operation Restore Trust to increase enforcement of fraud and abuse regulations in Medicare and Medicaid programs. With the success of the original initiative, the government is expanding the project to additional states and program areas. The initial scrutiny of home health agencies, nursing homes, hospice care, and durable medical equipment is being expanded to managed care plans and acute care hospitals with an eye toward DRG creep. To manage this increased enforcement activity, healthcare organizations should institute comprehensive corporate compliance programs. Such programs should provide a framework that delineates responsibilities and provides a systematic means to resolve issues in a timely manner. PMID- 10170319 TI - Building an effective corporate compliance plan. AB - Corporate compliance plans are essential for healthcare organizations to cope with, and perhaps even stave off, investigations arising from allegations of illegal business practices. Initial development and implementation of a corporate compliance plan can be facilitated through four steps: determining the content of the code of conduct, determining how the code will be distributed, assigning responsibility for implementing the plan, and appointing a compliance task force to guide the implementation process. Special attention should be paid to education requirements of the United States Sentencing Guidelines to see that all employees understand and can apply provisions of the plan. PMID- 10170320 TI - What is a board's liability for not adopting a compliance program? AB - A key element of the 1991 United States Sentencing Commission's guidelines, used in sentencing corporations and business convicted of Federal crimes, is the provision of leniency for organizations that adopt effective corporate compliance programs. Given the increased scrutiny of healthcare organizations by Federal Investigators, the incentive to adopt corporate compliance programs has never been greater. Directors or trustees of healthcare organizations should be especially interested in adopting such programs, since recent case law suggests that they may be held personally liable for damages or losses resulting from a finding of fraud and abuse at their facilities. PMID- 10170321 TI - Computerized patient records benefit physician offices. AB - The use of computerized patient record systems in ambulatory settings is still a relatively new concept; however, such systems offer a variety of benefits to physician practices. Computerized patient record systems can help improve the quality of care provided, for example, by providing real-time patient status reports, test results as soon as they are available, and graphs and flowsheets of test trends. They can help reduce costs by eliminating many manual functions and the supply and staff expenses associated with these functions. Finally, they can provide practices the data necessary to attract and negotiate favorable managed care contracts. Because computerized patient record technology is still new, substantive empirical evidence upon which to base payback calculations is scarce. Time and motion studies were conducted at a model five-physician, primary care clinic to determine where efficiencies and cost savings could be realized through the use of a computerized patient record system. In addition, actual and anecdotal information from several clinics of comparable size that have such systems was used to reach some preliminary conclusions. Findings suggest that computerized patient record systems may return productivity gains and help physicians attain their patient care and financial goals. PMID- 10170322 TI - Can earning prompt-payment discounts really save money? AB - Healthcare financial managers should determine whether to take advantage of the discounts vendors offer for prompt payment of invoices. Prompt-payment discounts offered by vendors can result in substantial savings, but this benefit may be offset by the costs of acquiring the funds necessary for faster payment. The best results are achieved when the cost of funds is less than the discount savings that can be achieved, vendor discounts are available for a high percentage of the provider's purchase base, the provider is able to negotiate with vendors to increase discount levels, and the provider has an efficient system for processing invoices. PMID- 10170323 TI - Correct fair market value calculation needed to avoid regulatory challenges. AB - In valuing a physician practice for acquisition, it is important for buyers and sellers to distinguish between fair market value and strategic value. Although many buyers would willingly pay for the strategic value of a practice, tax-exempt buyers are required by law to consider only the fair market value in setting a bid price. Valuators must adjust group earnings to exclude items that do not apply to any willing seller and include items that do apply to any willing seller to arrive at the fair market value of the practice. In addition, the weighted average cost of capital (WACC), which becomes the discount rate in the valuation model, is critical to the measure of value of the practice. Small medical practices are assumed to have few hard assets and little long-term debt, and the WACC is calculated on the basis of those assumptions. When a small practice has considerable debt, however, this calculated WACC may be inappropriate for valuing the practice. In every case, evidence that shows that a transaction has been negotiated "at arm's length" should stave off any regulatory challenge. PMID- 10170324 TI - Matching physician compensation plans to capitation levels. AB - As managed care penetration increases, physician compensation plans need to reflect the current transition from fee-for-service to capitated payment. In choosing the compensation structure that will be most beneficial to the success of the group practice and secure physician buy-in, practices need to assess their mission, goals, and corporate culture. They also need to assess their percentage of capitation to total revenues and develop, when necessary, new compensation pools that reward physicians for a variety of behaviors, such as increased productivity and utilization control. Compensation plans should be fair, flexible, and simple to understand and administer. PMID- 10170325 TI - CFO leaders focus on relationship building. PMID- 10170326 TI - EDI invoices save money. PMID- 10170327 TI - Developing products on Internet time. AB - The rise of the World Wide Web has provided one of the most challenging environments for product development in recent history. The market needs that a product is meant to satisfy and the technologies required to satisfy them can change radically--even as the product is under development. In response to such factors, companies have had to modify the traditional product-development process, in which design implementation begins only once a product's concept has been determined in its entirety. In place of that traditional approach, they have pioneered a flexible product-development process that allows designers to continue to define and shape products even after implementation has begun. This innovation enables Internet companies to incorporate rapidly evolving customer requirements and changing technologies into their designs until the last possible moment before a product is introduced to the market. Flexible product development has been most fully realized in the Internet environment because of the turbulence found there, but the foundations for it exist in a wide range of industries where the need for responsiveness is paramount. When technology, product features, and competitive conditions are predictable or evolve slowly, a traditional development process works well. But when new competitors and technologies appear overnight, when standards and regulations are in flux, and when a company's entire customer base can easily switch to other suppliers, businesses don't need a development process that resists change--they need one that embraces it. PMID- 10170328 TI - Should you take your brand to where the action is? AB - When markets turn hostile, it's no surprise that managers are tempted to extend their brands vertically--that is, to take their brands into a seemingly attractive market above or below their current positions. And for companies chasing growth, the urge to move into booming premium or value segments also can be hard to resist. The draw is indeed strong; and in some instances, a vertical move is not merely justified but actually essential to survival--even for top brands, which have the advantages of economies of scale, brand equity, and retail clout. But beware: leveraging a brand to access upscale or downscale markets is more dangerous than it first appears. Before making a move, then, managers should ascertain whether the rewards will be worth the risks. In general, David Aaker recommends that managers avoid vertical extensions whenever possible. There is an inherent contradiction in the very concept because brand equity is built in large part on image and perceived worth, and a vertical move can easily distort those qualities. Still, certain situations demand vertical extensions, and Aaker examines both the winners and the losers in the game. Managers may find themselves facing a situation that presents both an emerging opportunity and a strategic threat, and alternatives to vertical extensions may have even higher risks and costs. Furthermore, a number of brands have been extended vertically with complete success. If after assessing the risks and rewards you conclude that a vertical extension is on the horizon, proceed with caution. And keep in mind that your challenge will be to leverage and protect the original brand while taking advantage of the new opportunity. PMID- 10170329 TI - Unleashing the power of learning: an interview with British Petroleum's John Browne. Interview by Steven E. Prokesch. PMID- 10170330 TI - How to make experience your company's best teacher. AB - In our personal life, experience is often the best teacher. Not so in corporate life. After a major event--a product failure, a downsizing crisis, or a merger- many companies stumble along, oblivious to the lessons of the past. Mistakes get repeated, but smart decisions do not. Most important, the old ways of thinking are never discussed, so they are still in place to spawn new mishaps. Individuals will often tell you that they understand what went wrong (or right). Yet their insights are rarely shared openly. And they are analyzed and internalized by the company even less frequently. Why? Because managers have few tools with which to capture institutional experience, disseminate its lessons, and translate them into effective action. In an effort to solve this problem, a group of social scientists, business managers, and journalists at MIT have developed and tested a tool called the learning history. It is a written narrative of a company's recent critical event, nearly all of it presented in two columns. In one column, relevant episodes are described by the people who took part in them, were affected by them, or observed them. In the other, learning historians--trained outsiders and knowledgeable insiders--identify recurrent themes in the narrative, pose questions, and raise "undiscussable" issues. The learning history forms the basis for group discussions, both for those involved in the event and for others who also might learn from it. The authors believe that this tool--based on the ancient practice of community storytelling--can build trust, raise important issues, transfer knowledge from one part of a company to another, and help build a body of generalizable knowledge about management. PMID- 10170332 TI - Strategy and the new economics of information. AB - We are in the midst of a fundamental shift in the economics of information--a shift that will precipitate changes in the structure of entire industries and in the ways companies compete. This shift is made possible by the widespread adoption of Internet technologies, but it is less about technology than about the fact that a new behavior is reaching critical mass. Millions of people are communicating at home and at work in an explosion of connectivity that threatens to undermine the established value chains for businesses in many sectors of the economy. What will happen, for instance, to dominant retailers such as Toys "R" Us and Home Depot when a search through the Internet gives consumers more choice than any store? What will be the point of cultivating a long-standing supplier relationship with General Electric when it posts its purchasing requirements on an Internet bulletin board and entertains bids from anybody inclined to respond? The authors present a conceptual framework for approaching such questions--for understanding the relationship of information to the physical components of the value chain and how the Internet's ability to separate the two will lead to the reconfiguration of the value proposition in many industries. In any business where the physical value chain has been compromised for the sake of delivering information, there will be an opportunity to create a separate information business and a need to streamline the physical one. Executives must mentally deconstruct their businesses to see the real value of what they have. If they don't, the authors warn, someone else will. PMID- 10170331 TI - Looking ahead: implications of the present. AB - On its seventy-fifth anniversary, HBR asked five of the business world's most insightful thinkers to comment on the challenges taking shape for executives as they move into the next century. In "The Future That Has Already Happened," Peter Drucker examines the effects of the increasing underpopulation of the world's developed countries. With growing imbalances in labor resources worldwide, he writes, executives in the developed countries will need to improve the productivity of knowledge and of knowledge workers to maintain a competitive advantage. Esther Dyson's article "Mirror, Mirror on the Wall" reveals the mind shift executives will need to make in a networked world, where companies will be known for what they do rather than for what they say. Executives will have to respond openly and intelligently to feedback about their organizations. The old language of property and ownership no longer serves executives, writes Charles Handy in "The Citizen Corporation." The corporation should be thought of no longer as property but as a community, where members are regarded as citizens. Technology has given executives more information than today's machines can help them understand, explains Paul Saffo in "Are You Machine Wise?" Machine-wise executives will know when to turn their computers off and take their own counsel, he writes. Peter Senge's article "Communities of Leaders and Learners" urges executives to reject the myth of leaders as isolated heroes and instead to build a community of leaders. Sustained institutional learning, he writes, requires organizations to reintegrate their typically fragmented learning processes. PMID- 10170333 TI - Managing in an age of modularity. AB - Modularity is a familiar principle in the computer industry. Different companies can independently design and produce components, suck as disk drives or operating software, and those modules will fit together into a complex and smoothly functioning product because the module makers obey a given set of design rules. Modularity in manufacturing is already common in many companies. But now a number of them are beginning to extend the approach into the design of their products and services. Modularity in design should tremendously boost the rate of innovation in many industries as it did in the computer industry. As businesses as diverse as auto manufacturing and financial services move toward modular designs, the authors say, competitive dynamics will change enormously. No longer will assemblers control the final product: suppliers of key modules will gain leverage and even take on responsibility for design rules. Companies will compete either by specifying the dominant design rules (as Microsoft does) or by producing excellent modules (as disk drive maker Quantum does). Leaders in a modular industry will control less, so they will have to watch the competitive environment closely for opportunities to link up with other module makers. They will also need to know more: engineering details that seemed trivial at the corporate level may now play a large part in strategic decisions. Leaders will also become knowledge managers internally because they will need to coordinate the efforts of development groups in order to keep them focused on the modular strategies the company is pursuing. PMID- 10170334 TI - Needed: a new system of intellectual property rights. AB - The world's current system of intellectual property rights has in recent years become unworkable and ineffective. Designed more than 100 years ago to meet the needs of an industrial era, it is inadequate to handle the ownership and distribution of intellectual property generated by the brainpower industries that have come to dominate the world's economy. The prevailing wisdom is that minor tweaking can remedy the problem. But MIT economist Lester Thurow challenges such thinking and calls instead for a new system--one redesigned from the ground up. In making his case for why the old system doesn't work anymore, Thurow lays out the challenges the new system must meet. It must offer incentives to inventors that are strong enough to offset the decline in publicly funded research. At the same time, it must protect the public interest by keeping some intellectual property--basic scientific knowledge, for example--in the public domain. The new system must be flexible enough to deal with the fact that new technologies have created new potential forms of intellectual property rights (Can pieces of a human being be patented?) and have made old rights unenforceable (When books can be downloaded from an electronic library, what does a copyright mean?). And in an increasingly global economy, a new system must meet the needs of both "catch-up" states and "keep-ahead" states. A system that ignores the lesson of history--that every country that has caught up has done so by copying--will be an unenforceable one. PMID- 10170335 TI - Avoiding fire disaster: sprinklers, training, fire dept cooperation. PMID- 10170337 TI - Security for new hospital garages that replace parking lots. PMID- 10170336 TI - Sextuplets: security and public affairs team up to keep press happy. PMID- 10170338 TI - New EAS systems expanded to track wandering patients off-premises. PMID- 10170339 TI - 'Fun' and accessibility win employee participation in safety training. PMID- 10170340 TI - Disaster planning: meeting the challenge of 'killer' tornadoes. AB - In many areas of the country, tornadoes represent a major concern for hospitals in preparing disaster plans. Like all such plans, the hope is that they will not have to be put to use. But last spring, in areas of Arkansas and Texas, damage and casualties from twisters made national headlines and put the disaster plans of a number of hospitals to the test. For example, as part of the country's worst tornado outbreak since March 1994, twisters that tore through Arkansas from southwest to northeast on the afternoon of Saturday, March 1, killed 25 and injured hundreds. The tornadoes left a path of damaged buildings and downed trees more than 200 miles long. Three persons died in the Little Rock suburb of College Station. Warning sirens and TV and radio broadcasts a few minutes before the tornadoes hit were able to give area residents time to take cover, reducing the number of casualties. On May 27, tornadoes that hit three central Texas counties killed 32 people and left hundreds homeless. The small town of Jarrell was flattened by winds of up to 270 mph. In Cedar Park, about 20 miles south of Jarrell, a grocery store was demolished and a nearby shopping center had roofs torn off. Fortunately, there were relatively few injuries. In the area immediately around Jarrell, hospitals reported 33 casualties treated. The small number of injuries may have been the result of a large number of deaths, one official speculated. In this report, we'll give details on how nine hospitals in the affected areas dealt with tornado emergencies and how their disaster plans were carried out. PMID- 10170341 TI - Should your hospital spring for a mock survey? PMID- 10170342 TI - JCAHO-QHR (Quality Healthcare Resources)-client form a triangle. PMID- 10170343 TI - VBAC trend put in reverse. PMID- 10170344 TI - Solutions for adverse selection in behavioral health care. AB - Health plans have incentives to discourage high-cost enrollees (such as persons with mental illness) from joining. Public policy to counter incentives created by adverse selection is difficult when managed care controls cost through methods that are largely beyond the grasp of direct regulation. In this article, the authors evaluate three approaches to dealing with selection incentives: risk adjustment, the carving out of benefits, and cost- or risk-sharing between the payer and the plan. Adverse selection is a serious problem in the context of managed care. Risk adjustment is not likely to help much, but carving out the benefit and cost-sharing are promising directions for policy. PMID- 10170345 TI - Health insurance coverage at midlife: characteristics, costs, and dynamics. AB - Recent data from the first two waves of the Health and Retirement Study are analyzed to evaluate prevalence of different types of health insurance, characteristics of different plan types, and change sin coverage as individuals approach retirement age. Although overall rates of coverage are quite high among the middle-aged, the risk of noncoverage is high within many disadvantaged groups, including Hispanics, low-wage earners, and the recently disabled. Sixty percent of individuals with health benefits are enrolled in health maintenance organizations (HMOs) or preferred provider organizations (PPOs). In addition, one fourth of enrollees in fee-for-service (FFS) plans report restrictions in their access to specialists. PMID- 10170346 TI - Managing access: extending Medicaid to children through school-based HMO coverage. AB - This study explores how a health maintenance organization's (HMO) capacity and incentives to manage care might be used to improve access. In the early 1990s, the Florida Healthy Kids (FHK) demonstration extended Medicaid-like HMO coverage to indigent children in the public schools of Volusia County, Florida. The study finds that uninsured student months in area public schools were likely reduced by one-half. Utilization and cost levels for these indigent enrollees proved to be indistinguishable from commercial clients; and measures of access, utilization, and satisfaction for enrollees were in line with (and in some cases, superior to) non-enrollees with private insurance. Overall, these results suggest the value of using schools as a medium for providing coverage, and the importance of taking deliberate steps to manage access to reduce non-financial barriers to care. PMID- 10170347 TI - Medicare Part A utilization and expenditures for psychiatric services: 1995. AB - This study provides an overview of Medicare's current coverage and payment policies regarding hospitalization for psychiatric disorders, and presents new information on demographic, diagnostic, utilization, and expenditure characteristics associated with inpatient psychiatric care among 1995 Medicare beneficiaries. Results suggest that utilization and expenditure patterns for Medicare beneficiaries hospitalized for psychiatric illness in 1995 differ across demographic (e.g., age, sex, race) and diagnostic categories. The implications of these findings for current management of the Medicare program as well as the evolution of Medicare managed care systems for behavioral health services are discussed. PMID- 10170349 TI - Business, households, and government: health care spending, 1995. AB - For the period 1990-95, we will present data on health care spending by business, households, and government. In addition, we will measure the relative impact of these expenditures on each sector's ability to pay. In 1994 and 1995, health care costs experienced the slowest growth in 3 decades. Combined with healthy revenue growth, slow cost growth helped ease or stabilize the financing burden faced by business, households and government. PMID- 10170348 TI - Trends in Medicare Part B mental health utilization and expenditures: 1987-92. AB - This article examines the impact of expanding Medicare Part B coverage of mental health services, based on analysis of 6 years of Medicare Part B claims data (1987-92). Inflation-adjusted per capita spending more than doubled (from $9.91 to $21.63) following the elimination of the annual outpatient treatment limit and extension of direct reimbursement to clinical psychologists and social workers. There was a 73-percent increase in the user rate (from 23.25 to 40.20 per 1,000 Medicare beneficiaries), and a 27-percent increase in the average number of services per user (from 8.9 to 11.3). Mental health spending increased from 1 percent to 2 percent of expenditures for Part B professional services. Ongoing monitoring of mental health utilization is desirable to ensure that recent access gains are not eroded with the increasing shift to managed care and implementation of gatekeeper mechanisms. PMID- 10170350 TI - Matching MCBS (Medicare Current Beneficiary Survey) and Medicare data: the best of both worlds. AB - Survey reports from the Medicare Current Beneficiary Survey (MCBS) were matched to Medicare administrative files to create the 1992 MCBS Cost and Use file. This file improves on previous MCBS Access-to-Care user files by representing the entire (ever enrolled) Medicare population and including services not covered by Medicare such as outpatient prescription drugs and long-term facility care. The matching and reconciliation process improved the accuracy and completeness of health care use and cost. For example, Medicare billing data corrected 22 percent of survey reports that did not record Medicare as a payer and 39 percent in which the amount was missing. PMID- 10170351 TI - Hospital, employment, and price indicators for the health care industry: third quarter 1996. PMID- 10170352 TI - Medicare Home Health Initiative: current activities and future directions. AB - This article describes the Medicare home health benefit and summarizes the growth and change in the use of the benefit and in the industry providing home health care. The article details the progress the Home Health Initiative has achieved in the key areas of quality assurance, administration and operations, and policy. It concludes with a discussion of future directions for reforming Medicare's home health benefit. PMID- 10170353 TI - Report to Congress. Evaluation of the Grant Program for Rural Health Care Transition: 1997 annual progress report. PMID- 10170354 TI - A resident-based reimbursement system for intermediate care facilities for the mentally retarded. AB - In this article, the authors present a resident-based reimbursement system for intermediate care facilities for the mentally retarded (ICFs-MR), which represent a large and growing proportion of the medicaid budget. The statistical relationship between resident disability level and the expected cost of caring for the individual is estimated, allowing for the prediction of expected resource use across the population of ICF-MR residents. The system incorporates an indirect cost rate, a base direct care rate (constant across all providers), and an individual-specific direct care rate, based on the expected cost of care. PMID- 10170356 TI - Cost shifting in a mental health carve-out for the AFDC population. AB - This study tests whether the managed care vendor shifted costs to Medicaid reimbursed medical care after the start of the mental health carve-out for the Aid to Families with Dependent Children (AFDC) population in Massachusetts. We used claims data over a 4-year period to estimate expenditures for four types of health services, two of which were paid for by the managed care vendor and two by Medicaid. Total per person public expenditures declined by only about 3 percent. Inpatient psychiatric services were replaced by outpatient psychiatric services and some pharmaceuticals, but overall there was little or no evidence of cost shifting to the medical sector. These results are in contrast to what was found in a sample of Medicaid beneficiaries eligible due to a mental health disability. PMID- 10170355 TI - Expenditures for mental health services in the Utah Prepaid Mental Health Plan. AB - This article examines the effect of a mental health carve-out, the Utah Prepaid Mental Health Plan (UPMHP), on expenditures for mental health treatment and utilization of mental health services for Medicaid beneficiaries from July 1991 through December 1994. Three Community Mental Health Centers (CMHCs) provided mental health services to Medicaid beneficiaries in their catchment areas in return for capitated payments. The analysis uses data from Medicaid claims as well as "shadow claims" for UPMHP contracting sites. The analysis is a pre/post comparison of expenditures and utilization rates, with a contemporaneous control group in the Utah catchment areas not in the UPMHP. The results indicate that the UPMHP reduced acute inpatient mental health expenditures and admissions for Medicaid beneficiaries during the first 2 1/2 years of the UPMHP. In contrast, the UPMHP had no statistically significant effect on outpatient mental health expenditures or visits. There was no significant effect of the UPMHP on overall mental health expenditures. PMID- 10170357 TI - The human side of re-engineering. PMID- 10170358 TI - Focused factories. Giving consumers what they want. Interview by Mark Hagland. PMID- 10170359 TI - The empowered consumer. New demands for access, information and services are changing the face of healthcare delivery. PMID- 10170360 TI - The accountability crisis in healthcare. PMID- 10170361 TI - Log on. Technology decision-making. PMID- 10170362 TI - Where are the clones? PMID- 10170363 TI - Is altruism killing prevention? When health systems take on the role of public health provider. PMID- 10170364 TI - Managing the customer portfolio of healthcare enterprises. Data driven marketing. PMID- 10170365 TI - The third alternative: extended enterprise alliances. Healthcare imitates the high tech industry. PMID- 10170366 TI - Is the war between investor-owned institutions and not-for-profits over? PMID- 10170367 TI - Renegotiating the contract. PMID- 10170368 TI - Big fish in a small pond: advantages and disadvantages of a first-mover strategy. AB - The case of a free-standing psychiatric hospital moving into a small rural market as the sole provider of hospital-based psychiatric services is examined as an example of a first-mover strategy. The theoretical bases for a first mover advantage are considered together with an analysis of the situational factors necessary to the strategy's success. The case study illustrates some of the potential consequences of success, namely the attraction of a new competitor with a broader scope of services. The case also illustrates other lessons for market niche competitors in enhancing their likelihood of survival and success in their selected market. PMID- 10170369 TI - Attribute correlates of hospital outpatient satisfaction. AB - Customer satisfaction (patient satisfaction) with hospital outpatient or ambulatory services is an important factor in influencing patient patronage and loyalty. Based on an empirical study, this article examines the attributes of the ambulatory care experience which were significantly associated with the level of satisfaction resulting from the most recent hospital ambulatory visit. This study focuses on identifying attributes of ambulatory services. This article brings to the health care marketing literature information on ambulatory satisfaction comparable to that which has been contributed to the literature regarding satisfaction with physician and hospital experiences. PMID- 10170370 TI - Factors associated with emergency room choice among Medicare patients. AB - Changing macroenvironmental factors have caused hospital administrators to reassess their positions across all service lines and market segments. This pilot study explores relationships among the service experience, satisfaction and future patronage decisions among 368 Medicare patients, an often overlooked segment, who were recent users of a hospital emergency room. Results show widespread dissatisfaction with aspects of care. Many of these patients report that they do not intend to return to the same emergency room and would discourage others from choosing it. PMID- 10170371 TI - The role of "free" mammograms in motivating first-time screening: a community experiment. AB - Despite the fact that many women understand the value of preventive screenings in the early detection of breast cancer, and despite the fact that some women "know" the recommended guidelines for timing and frequency of screenings over a woman's life, less than 2/3 of the eligible women have ever had a mammogram. Among several factors that may inhibit women's adherence to recommended screening regimens, the cost of such screenings is often cited as a major problem, especially for low-income women and women from ethnic minorities. This study reports the results of a survey conducted with women who received a "Gift Certificate" for a no-cost mammogram at a hospital-based breast care center or its affiliated mobile mammography van. Data point to some important--both positive and negative--"side effects" of a no-cost screening. Implications for communications encouraging women to receive mammograms, for pricing and incentives, and for insurance reform are discussed. PMID- 10170372 TI - The use of contextual cues for improving pharmacist consultation services. AB - The objective of this study was to assess the proportion of patients who initiate consultation or ask questions during consultation with their pharmacist depending upon whether or not they viewed a programmable electronic display (message box) in a community pharmacy environment. Using observation and exit interviews within a modified separate-sample pretest-posttest design, data were collected from a random sample of 192 patients who purchased prescriptions at the study sites. Six months after the message box was installed, patients who reportedly had viewed it were more aggressive seekers of information from their pharmacist. PMID- 10170373 TI - The uninsured consumer and hospital choice: an assessment of emergency department utilization. AB - The term "choice" has played an important role in the ongoing debate over health care reform in the United States. One of the major assumptions underlying reform efforts is that affordability drives consumers' choice of health care providers, particularly for the uninsured. In the state of Maryland, the issue of affordability is addressed by an "all-payor" system. In such a scenario, where enhanced choice opportunities are available for the uninsured, such consumers seem to be making choices which lead to the use of hospitals other than those which would be predicted based upon convenience or closeness of location alone. PMID- 10170374 TI - The relative importance of information sources in consumers' choice of hospitals. AB - The research presented focuses on an examination of the relative importance of word-of-mouth, expert opinion, external communication, and past experience in the context of hospital choice. Past research has examined the effect of each individually and various combinations of the four sources, but not all four simultaneously. Results of the present study suggest that past experience plays a greater role in hospital choice than other information sources, including expert opinion. The strength of word-of-mouth as a source of information is also verified. The implications of this research include the following: (1) health care researchers need to incorporate word-of-mouth when investigating informations sources, and (2) local hospitals need to be aware of "negative perceptions" and strive for consumer satisfaction. Health care delivery systems incorporating consumer-based choice render these findings especially valuable as researchers and practitioners address the challenges that these evolving systems will bring. PMID- 10170375 TI - Report rips hospitals' home-care referrals. PMID- 10170376 TI - Tougher stance on fraud. Columbia probe hits harder than '92 not-for-profit audits. PMID- 10170377 TI - Everybody gets a shot. Law extends pilot that pays hospitals to cut students. PMID- 10170378 TI - Specialists keep fighting. Practice-expense war continues despite budget deal. PMID- 10170379 TI - Columbia's woes foil more deals. PMID- 10170380 TI - Unafraid of Medicaid. Catholic-sponsored HMO buys for-profit rival, expanding New York network. PMID- 10170381 TI - Building for seniors. Housing for the elderly, long-term care show strength. PMID- 10170382 TI - Peer review still in game. Budget law lets PROs scrutinize private Medicare plans. PMID- 10170383 TI - Here come the docs. With managed care on the run, physicians are regaining control of healthcare. PMID- 10170384 TI - Outsourcing boom. Survey shows more hospitals turning to outside firms for a broad range of services. AB - Our annual survey of contract management companies shows their business is booming, as more and more healthcare executives turn to outsiders to provide a broad range of services once provided by hospital staffs. Even the largest companies reported double- and triple-digit increases in contracts. For many healthcare facilities, cutting costs is the main reason to outsource, the survey found. PMID- 10170385 TI - HCFA readies for PSO solvency debate. PMID- 10170386 TI - The reluctant doctor. Survey finds luring physicians into systems is tough. PMID- 10170387 TI - Arbitration under attack. System's pros, cons debated in Calif. courts, legislature. PMID- 10170388 TI - Who needs paper? Hospital cooperative moves data to Internet, easing access. PMID- 10170389 TI - Doing endorsements right. ADA's 67-year-old approval program offers a model. PMID- 10170390 TI - Capital faucet wide-open. Firms' healthcare-related investments up 16% in first half. PMID- 10170391 TI - Hospitals, look within. HHS memo recommends in-house anti-fraud programs. PMID- 10170392 TI - Centers tapped to evaluate technology. PMID- 10170393 TI - The big questions. Clinton's quality panel faces a daunting challenge. PMID- 10170394 TI - Electronic name tags. Identifiers are first step toward standardized claims system. PMID- 10170395 TI - Three AMA execs lose jobs in wake of Sunbeam scandal. PMID- 10170396 TI - Medicare meal ticket. HCFA tests combined doc-hospital inpatient payment. PMID- 10170397 TI - Leave the market alone. Providers complain HMOs take too long to pay, but the culprit is supply and demand. PMID- 10170398 TI - 1997 group purchasing survey. AB - As integrated delivery networks mature, many are questioning whether purchasing groups are as relevant as they used to be. Sure, the groups promise purchasing muscle, but many systems already have enough buying heft to extract concessions from suppliers. And many systems can afford to hire their own purchasing experts or get what they need from consultants. As a results, the purchasing group isn't the automatic decision it once was. PMID- 10170399 TI - Change on horizon for D.C. hospitals. Entrance of for-profit Universal and coming of managed care set stage for merger-and-acquisition frenzy in Washington. PMID- 10170400 TI - Davidson, IG plan meeting to discuss fraud crackdown. PMID- 10170401 TI - Turf war in Maryland. Assisted-living, nursing home operators fight over rules. PMID- 10170402 TI - Eyeing the reprocessors. Makers of disposable devices push for controls on reuse. PMID- 10170403 TI - Investor anxiety. Columbia's troubles draw mixed reaction on Wall Street. PMID- 10170404 TI - McEntee to leave AHA. Resignation adds to power shift from Chicago to Washington. PMID- 10170405 TI - WHO's first assisting? ORs turn to non-MDs but reimbursement lags. PMID- 10170406 TI - WHO's first assisting? Personnel used as FAs: are they qualified? PMID- 10170407 TI - WHO's first assisting? A patchwork of payment for first assistants. PMID- 10170408 TI - Trauma pathways improve care, bottom line. PMID- 10170409 TI - Case managers help map paths through OR. PMID- 10170410 TI - Hepatitis C. New guidelines on precautions, follow-up. AB - An OR team has a greater chance of operating on a patient infected with hepatitis C than on a patient with HIV or hepatitis B. Many patients with HCV aren't critically ill, and the team may not know a patient is infected. HCV is more common than many think--an estimated 3.5 million people in the US are infected. The consequences are grave. For most, infection is lifelong. At least 85% become chronically infected. Chronically infected individuals are at risk for cirrhosis and liver cancer. Unfortunately, not much can be done to prevent transmission. There is no vaccine and not much in the way of treatment. In recent weeks, the Centers for Disease Control and Prevention (CDC) and professional societies have tried to address workers' concerns with new recommendations that, although they don't provide easy answers, offer added guidance. PMID- 10170411 TI - A new ambulatory center for the Big Apple. PMID- 10170412 TI - Service lines. They're back, but do they work in the OR? PMID- 10170413 TI - Budget bill addresses Medicaid managed care, beneficiary issues. PMID- 10170414 TI - Institutional providers hit hard by budget reconciliation bill. PMID- 10170415 TI - Maximizing collections for care provided to federal employees. PMID- 10170416 TI - Community health assessment: diagnosis and prescription. AB - Community health assessments are ideally a joint effort by all the major health care providers in the community, working in concert with local government, business, and concerned community groups. A noble activity, no doubt, but clearly a lot of trouble. Physicians, whose potential to contribute to community assessments is obvious, frequently avoid them. Whether in management or clinical practice, they ask: Is this really worth my time? Will it make any difference? Isn't there a better way? But, rightly or wrongly, physicians often have a disproportionate amount of influence on the community assessment process. That influence, whether you attribute it to respect, credibility, or power, adds value to the process. The most important quality the physician brings to the process is genuine concern for his or her patients that generalizes to the health of the entire community. PMID- 10170417 TI - Population health--a new discipline. AB - A new discipline--population health--has emerged with the potential to profoundly impact the U.S. health care system. Multiple forces stimulating the new population health concept include: (1) the increasing dominance of managed care and critical scrutiny of its development; (2) the continued refinement of clinical effectiveness and outcomes assessment research; (3) increasing public policy emphasis on cost-effectiveness accountability for health care services; and (4) a new focus on the importance of collaboration between the medicine and public health enterprises in this country. The need for sophisticated analysis of population health determinants has never been greater in history. New programs, like the University of Wisconsin-Madison's interdisciplinary Graduate Program in Population Health, address the need for analysis, dissemination, and application of information about the many factors affecting the health of populations. PMID- 10170418 TI - The role of public health in population health. AB - The role of public health is central in population health. What distinguishes public health from clinical medicine is that it's focus is on the entire population--not the individual patient. To achieve the goal of population health, healthy communities, or Healthy People 2000 requires physician leadership in medicine and public health at all levels--local, state, and national. The challenge is formidable, but the goals are attainable through strategies that focus on the goal of the common good and through collaboration of public health, medicine, and the community. PMID- 10170419 TI - The shape of public health policy: the Australian experience. AB - Public health policy is shaped by many factors. A brief historical reflection is given on policy development in Australia to illustrate the various influences on health policy. Medical technology; ethical trade-offs; environmental, social, and political imperatives; popular movements; and changing patterns of disease; as well as market forces have helped to shape Australian contemporary public health policy. These multiple and often competing forces, however, can work against individual consumer choice in health care decisions. This article demonstrates through the eyes of history the factors that shape public health policy. As Australia has a short history compared to most industrialized democratic societies and can be viewed as a microcosm, it is used as the exemplar. PMID- 10170420 TI - Managing population health. AB - As experience with managing the health of populations is gained, resources will have to be set aside for rewarding improvements in Health Adjusted Life Expectancy (HALE). Financial incentives and rewards will need to be aligned with improved outcomes, instead of the traditional fee-for-service structure. This article describes how a uniform health outcomes measurement such as HALE could be incorporated by public and private purchasers of medical care and those responsible for the nonmedical determinants of health sectors and services. Three phases of potential development and implementation are outlined: (1) Phase One (1997-2000): Debate, acceptance, and, research; (2) Phase Two (2001-2010): Outcome-based payment for integrated health delivery systems; and (3) Phase Three (2011-2020): incorporating the non-medical determinants and sector. PMID- 10170421 TI - Meet the mandate to measure clinical quality. AB - The mandate for health care organizations to be accountable for quality, as well as price, is now unavoidable. The Joint Commission's ORYX project is requiring every hospital to measure clinical outcomes of a majority of its patients within the next three years. This mandate can be met best with systems of clinical outcomes measurement that provide valid, reliable risk adjustment; yield meaningful information about many different diseases and procedures; and measure more than mortality or cost--all using primarily billing data. New outcomes measurement tools with all of these capabilities are available and have already enabled quality improvement in dozens of hospitals across the U.S. PMID- 10170422 TI - Coming out. AB - Self-knowledge is the beginning of integrity, of coming out of the closet, and is a prerequisite for dealing well with change. Integrity is not just about not lying. Integrity means as on the inside, so on the outside. The Latin roots of integrity refer to touch. To have integrity is to be untouched, undivided, whole, integrated, integral. There is a tight relationship between integrity and the ability to change, because integrity is about knowing yourself, about being transparent. Integrity allows you to move with tremendous speed when the time comes to move. An organization that wants to learn to dance with change must come to know itself and its environment thoroughly. To do this, it must make use of all the knowledge of every member--and all of their learning capability. It must be built into the culture that new information and different points of view are powerful, are welcomed. PMID- 10170423 TI - Targeted searches: a double-edged sword. AB - Besides being discriminatory, there are short- and long-term problems inherent in targeted searches. What are the issues rarely considered by companies looking for a quick diversity fix? (1) Internal candidates will bolt when they figure out what's going on. (2) Most top candidates hate targeted searches. (3) Many search firms don't like targeted searches, and some won't even participate in them. (4) Targeted searches can set up new hires for failure. These issues are useful to consider when you begin the search process for your next star. PMID- 10170424 TI - Confronting the disruptive physician. AB - Ignoring disruptive behavior is no longer an option in today's changing health care environment. Competition and managed care have caused more organizations to deal with the disruptive physician, rather than look the other way as many did in years past. But it's not an easy task, possibly the toughest of your management career. How should you confront a disruptive physician? By having clearly stated expectations for physician behavior and policies in place for dealing with problem physicians, organizations have a context from which to address the situation. PMID- 10170425 TI - Acing the 'chemistry' test. AB - With the right boss, you can go far and learn much. The wrong boss could actually slow or even stall your executive career. When you interview for a job, you're also interviewing for a boss--and it's in your own interest to try to find the individual who is the best possible fit with your own management style. This is a matching process--not quite a courtship, but with some of the same characteristics. What can you do to ensure a good match with your new boss? (1) Do your homework; (2) Make your interview a dialog; (3) Use subtle strategies, too, such as watching for body language; (4) Ask the employer for references; and (5) Know yourself. PMID- 10170426 TI - Standardizing medical data. AB - Congress passed The Health Insurance Portability and Accountability Act of 1996 in the doldrums of last Summer, and promptly charged the National Committee on Vital and Health Statistics to begin working on the regulations that will help providers, payers, and all members of the public adhere to the spirit of the law. What does this legislation portend for the health care industry? Standardization of information systems will play a large role in assuring the portability of health care insurance from one employer and payer to another in this legislation. Accountability, too, will depend on those same data standards to allow comparisons of processes and outcomes of care across health plans, providers, communities, states, and regions. In fact, without standardized data describing patients and their treatments, there can be no comparisons of their outcomes of care, or the processes used to treat them. PMID- 10170427 TI - A Medicare reform primer. AB - The use of the federal budget process to change Medicare policy is of importance to physician executives because of its impact on the health care delivery system. In particular, changes in Medicare policy, driven by the need to shore up the solvency of a politically popular program, will create changes for other public and private purchasers of health care. Reforming Medicare through the budget process is not new. Physician fees have been frozen, reduced, and selectively increased as a result. In 1983, the hospital reimbursement methodology was changed to prospective payment through this process. The budget process will continue to be used to make policy changes because of the large amount that Medicare occupies of the federal budget. Given the profound impact changes in Medicare can have in other health care sectors, the lack of consensus for a long term solution would mean those in the health care arena will have to be prepared for significant annual policy changes through the reconciliation process. PMID- 10170428 TI - Misinterpretations and misapplications of the transtheoretical model. PMID- 10170429 TI - Changing unhealthy lifestyle: who's ready ... who's not?: an argument in support of the stages of change component of the transtheoretical model. PMID- 10170431 TI - The relationship between self-efficacy, attitudes, intake compared to others, consumption, and stages of change related to fruit and vegetables. AB - PURPOSE: This study examined whether eating practices and psychosocial factors differed across stages of change for fruit and vegetables. DESIGN: Data were collected using a self-administered written survey among a convenience sample of 739 Dutch adults. Response rate was 92%. SETTING: Data were collected as part of the baseline assessment for a nutrition intervention study. MEASURES: Fruit and vegetable intake was measured as self-reported consumption with a validated eight item food frequency questionnaire. Psychosocial variables were measured with six items on bipolar seven-point scales and stage-of-change classifications were based on separate four-item algorithms for fruits and vegetables. Differences in psychosocial factors and consumption were analyzed using one-way analysis of variance with Scheffe's multiple-comparison test. RESULTS: Significant differences were found between stages of change in dietary intake, attitudes, self-efficacy, and judgment of one's own intake compared to others. Attitudes were most positive in preparation and action and least positive in precontemplation. Intake and self-efficacy were more positive in action/maintenance than in pre-action stages. CONCLUSIONS: The findings suggest that nutrition education aimed at encouraging higher intake of fruits and vegetables might be most effective if it is stage-tailored. Messages to influence attitudes about fruits and vegetables are likely to affect people in precontemplation, and self-efficacy information to increase confidence in overcoming barriers to consumption is likely to be effective with persons in contemplation and preparation stages. PMID- 10170430 TI - Impact of a longitudinal community HIV intervention targeting injecting drug users' stage of change for condom and bleach use. AB - PURPOSE: To evaluate the impact of the Long Beach AIDS Community Demonstration Project, a community-based HIV-prevention intervention incorporating principles from the Transtheoretical model in its design and evaluation. DESIGN: Repeated cross-sectional sampling with matched intervention and comparison communities. SETTING: Neighborhoods in Long Beach, California, having a high prevalence of drug abuse and prostitution. SUBJECTS: 3081 injecting drug users who were sexually active and/or shared injection equipment. INTERVENTION: Trained peer volunteers distributed fliers featuring role model stories targeted to the population's stage of change. Fliers were packaged with bleaching kits and/or condoms. MEASURES: Primary outcome measures were exposure to the intervention, condom carrying, and stage of change for disinfecting injection equipment with bleach and for using condoms with main and other partners. RESULTS: Toward the end of the study, 77% of injection drug users in the intervention area reported being exposed to the intervention. In the intervention area, rates of condom carrying increased from 10 to 27% (p < .001), and there was an increase from 2.32 to 3.11 in mean stage of change for using condoms with other partners, while stage of change decreased in the comparison area (p < .01). Mean stage of change for using condoms with a main partner also increased in the intervention area, but the difference was not significant after controlling for change in the comparison area. Subjects with recent project exposure had higher stage-of-change scores for using condoms with a main partner (p < .05) and other partners (p < .01) and for cleaning injection equipment with bleach (p < .05). CONCLUSIONS: The results demonstrate the effectiveness of the AIDS Community Demonstration Project intervention for reaching injecting drug users in the community and for motivating the adoption of risk-reducing practices. PMID- 10170432 TI - A stage-matched smoking cessation program for pregnant smokers. PMID- 10170433 TI - Expanding the stages of change: a program matched to the stages of alcohol acquisition. PMID- 10170434 TI - The transtheoretical model of health behavior change. AB - The transtheoretical model posits that health behavior change involves progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change have been identified for producing progress along with decisional balance, self-efficacy, and temptations. Basic research has generated a rule of thumb for at-risk populations: 40% in precontemplation, 40% in contemplation, and 20% in preparation. Across 12 health behaviors, consistent patterns have been found between the pros and cons of changing and the stages of change. Applied research has demonstrated dramatic improvements in recruitment, retention, and progress using stage-matched interventions and proactive recruitment procedures. The most promising outcomes to data have been found with computer-based individualized and interactive interventions. The most promising enhancement to the computer-based programs are personalized counselors. One of the most striking results to date for stage-matched programs is the similarity between participants reactively recruited who reached us for help and those proactively recruited who we reached out to help. If results with stage-matched interventions continue to be replicated, health promotion programs will be able to produce unprecedented impacts on entire at-risk populations. PMID- 10170435 TI - Stages of change, decisional balance, and self-efficacy across four health behaviors in a worksite environment. AB - PURPOSE: This study examined differences in decisional balance and self-efficacy scores across the five stages of change and across four health behaviors (exercise, protection from sun exposure, smoking, and dietary fat consumption), and explored the relationship between the frequency of subjects at each stage across four health behaviors. DESIGN: Data for this study were collected as part of a health behavior survey of employees. SETTING: The study was conducted in a municipal government worksite in Arizona. SUBJECTS: A total of 393 employees completed the survey. The sample was predominantly white (84.9%) and male (64.4%), with an average age of 42.2 years and a median annual household income of between $40,000 and $59,999. MEASURES: Previously validated questions to measure stages of change, decisional balance, and self-efficacy were administered, along with questions about demographic variables. RESULTS: Significant differences were found for decisional balance and self-efficacy scores across the five stages of change, but they were not significantly different between the four health behaviors. A minority of subjects (18.6%) were in the same stage of change for all four health behaviors. CONCLUSIONS: This study provides preliminary evidence that there is considerable stage specificity across multiple health behaviors. Because employees at each stage of change possess differences in terms of their pros, cons, and self-efficacy, wellness programs need to focus on stage-specific interventions. PMID- 10170436 TI - What makes a good staging algorithm: examples from regular exercise. AB - PURPOSE: This study retrospectively compared subjects from three unrelated studies using eight algorithms to stage exercise behavior. SUBJECTS AND SETTINGS: Study One included 936 employees involved in a smoking cessation study at four worksites--a medical center, retail store, manufacturing firm, and a government agency. Study Two included 19,212 members of a New England HMO; and Study Three included a convenience sample of 327 adult New Englanders. MEASURES: The eight algorithms used different descriptions of stages based on the transtheoretical model, as well as different definitions of exercise and response formats. RESULTS: Algorithms using longer, more precise definitions of exercise resulted in larger numbers of subjects being staged in precontemplation and contemplation in comparison to algorithms using shorter definitions, which tended to stage subjects in preparation and action. Maintenance was the most and preparation the least consistently described stage across algorithms. CONCLUSIONS: Alteration of the descriptions of stage and the definition of exercise has consequences for the staging of subjects. Definitions need to be explicit, stating all parameters needed to meet criterion, and subjects must be able to assess themselves. Either a 5-Choice or a true/false response format is effective in assessing stage. PMID- 10170437 TI - Construct validity of stages of change for exercise behavior. AB - PURPOSE: Previous research examining the transtheoretical model of behavior change within the exercise domain has been limited by use of self-report measures exclusively and inconsistent practices with regard to stage of exercise assessment. The present study was designed to partially circumvent these limitations and extend the current literature by determining the degree of association among stage of exercise and body mass index, cardiorespiratory fitness, exercise behavior, relapse, barriers, and self-efficacy, after controlling for several potential confounders. DESIGN: A descriptive, cross sectional study. SUBJECTS: Two hundred thirty-five adults (M age = 34.7 years) volunteered to participate. MEASURES: Participants were classified by stage of exercise and compared on two behavioral, two biometrical, and three psychological variables while statistically controlling for social desirability and demographic differences. RESULTS: Significant between-stage differences were found for the overall set of dependent variables (p < .0001) and for each dependent variable separately (p < .01). The proportion of variance accounted for by the dependent variables ranged from .06 to .53. CONCLUSIONS: This study offers objective support for the stage-of-change model within the exercise domain. By acknowledging and accurately assessing stage of exercise, researchers and clinicians may be able to improve physical activity promotion efforts. PMID- 10170438 TI - The anatomy of stages of change. PMID- 10170439 TI - Bibliography current world literature. PMID- 10170440 TI - Corneal and conjunctival infections. AB - Recent advances in the field of infectious conjunctivitis and keratitis include new diagnostic methods, the identification of new pathogens, and novel therapeutic agents. Tandem confocal microscopy has been used to diagnose Acanthamoeba keratitis, and polymerase chain reaction has proven to be a rapid and sensitive technique for detecting specific viral antigens, particularly in cases where cultures yield no growth. Two new antiviral agents, ganciclovir and carbocyclic oxetanocin G, have been shown to be as effective as acyclovir in treating herpetic epithelial disease. The fluoroquinolones, especially ofloxacin, have become the antimicrobial agents of choice in the initial management of selected cases of bacterial keratitis. PMID- 10170441 TI - Allergic diseases of the lids, conjunctiva, and cornea. AB - Allergic ocular diseases are frequently encountered in the ophthalmologic practice. The term covers a wide array of severity, ranging from seasonal allergic conjunctivitis to the sight-threatening variant of atopic keratoconjunctivitis. The pathophysiology of these diseases is complex. Recent studies showed that nerve growth factor and interleukin IV, seem to play a role in these mechanisms. PMID- 10170442 TI - Storage, surgery, outcome, complications, and new developments in corneal and conjunctival grafts. AB - This review covers last year's literature on corneal, limbal, and conjunctival transplantation including tissue storage and eye banking. In this area, the main themes were related to a better evaluation of tissue viability and the exclusion of disease transmission. An analysis of the changing indications for penetrating keratoplasty shows the differences between American and European series. Most efforts in relation to surgical techniques are oriented toward obtaining better refractive results, whereas the study of large series sheds new light on the risk factors for graft failure and other complications. Limbal transplants have acquired the status of a new field in the surgical treatment of ocular surface disease, particularly in relation to corneal stem cell deficiencies. PMID- 10170443 TI - Dry eye syndrome, tear film, pharmacology of eye drops, and toxicity. AB - Over the past years, the main parameters used for the diagnosis of dry eye have been outlined: there is now substantial effort to bring them into correlation with each other, resulting in easier diagnosis of the diseases that appear to cause dry eye. Although increasing awareness of the plethora of dry eye diseases makes the differential diagnosis and the treatment difficult, the increased availability of optimized artificial tears and tear substitutes, especially viscoelastics, does allow easier relief of the most serious symptoms of dry eye disease. Improved topical treatment, in turn, allows various treatments, such as excimer laser treatment, to be performed, even in dry eyes. This, together with the identification of tear substitutes as a major research target and a better understanding for the psychological tasks of chronic dry eye diseases, offers a good basis toward further improvements. PMID- 10170444 TI - Stem cells, wound healing, growth factors, and angiogenesis in the cornea. AB - The integrity of the corneal epithelium is, among other factors, dependent on the function of corneal stem cells which serve as proliferative reserve. The concept that corneal stem cells are located in the basal limbal epithelium has been further strengthened by experimental evidence. Furthermore, the usefulness of surgical treatment for bilateral stem cell malfunction by means of limbal allograft transplantation has been confirmed. The field of growth factor interactions has further been expanded by the meaning such factors have for the paracrine cross-signaling between the various corneal cell populations, especially epithelium and stroma. This review focuses on the progress that has been made in the field of corneal cell biology in the context of stem cells, wound healing, and corneal angiogenesis. PMID- 10170445 TI - Tumors of the cornea and conjunctiva. AB - This article reviews the literature published in 1996 regarding conjunctival and corneal tumors. There is an increased incidence of squamous cell carcinoma of the conjunctiva in patients with HIV infection, especially in young individuals and Africans. Presumed causative factors for conjunctival squamous cell carcinoma include ultraviolet light, HIV infection, human papillomavirus and other unknown factors. Metastatic tumors to the conjunctiva appear at an advanced stage of the disease, and metastases to the conjunctiva are a poor prognostic sign for survival. Reviews of premalignant lesions of the conjunctiva, including diagnosis, treatment, and recurrence, are discussed. Spindle cell and mucoepidermoid variants of squamous cell carcinoma of the conjunctiva have a worse prognosis for intraocular extension compared with usual conjunctival squamous cell carcinoma. PMID- 10170446 TI - Indications, techniques, results, limits, and complications of laser in situ keratomileusis. AB - In this article we describe the state of the art of laser in situ keratomileusis (LASIK) through a presentation of the principles, the advantages, the disadvantages, the indications, the techniques, and the main complications. LASIK, as it is known today, involves the creation of a corneal flap using a keratome; this is followed by the in situ photoablation of the exposed stromal bed with an excimer laser. The flap thickness is about 160 mm with a circumference of about 300 degrees, the idea being to leave a portion of tissue attached, thus creating a corneal hinge. The in situ stromal bed exposed by the lamellar cut is then photoablated and the flap is repositioned without sutures. Functional recovery and anatomical healing are rapid. The operation is painless, and it is performed under topical anesthesia in an outpatient environment. PMID- 10170447 TI - Contact lenses and corneal shields. AB - This article reviews literature regarding contact lenses and corneal shields published between February 1996 and January 1997 that will help the ophthalmologist to better understand some of the clinical effects of contact lenses and corneal shields. Progress has been made in understanding the interaction between contact lenses and the eye, and this may improve fitting. However, fitting presbyopic patients with contact lenses still remains a challenge. There is new insight in the pathomechanism of serious corneal infections caused by Acanthamoeba species and Pseudomonas aeruginosa, which may lead to decreases in these complications. Furthermore, in the era of different wear modalities and replacement schedules and the advent of daily disposable lenses, an update of contact lens terminology is provided. PMID- 10170448 TI - Corneal topography. AB - In the review period, limitations of individual Placido disk-based topography systems have been studied and new principles, such as raster photogrammetry, pancorneal slit topography, laser holographic interferometry, and confocal laser scanning topography, have been introduced for laboratory or clinical work. Both Fourier analysis and Zernike decomposition of topographic height data seem to be powerful new tools for cross-sectional analysis of complex topographic corneal images, such as after cataract surgery, penetrating keratoplasty, and refractive surgery, as well as for longitudinal studies of corneal changes, such as in schoolchildren. Subdividing into rational optical components may improve consistency and standardization of topography data from different systems. Topography-based flying-spot-mode excimer laser photoablation after Zernike decomposition of topography height data has been proposed for correction of irregular corneal astigmatism. Topography-based central power measurements are of increasing value for intraocular lens power calculation before cataract surgery in eyes with irregular corneal surfaces, such as in keratoconus or after refractive surgery procedures. Quantitative and qualitative classification of corneal topography maps after corneal transplantation following conventional mechanical and nonmechanical trephination or after refractive surgery may lead to a better understanding of impaired visual acuity despite a clear graft or despite significantly reduced ametropia or corneal astigmatism. PMID- 10170450 TI - Cost effectiveness in the treatment of heart failure with ramipril. A Swedish substudy of the AIRE study. Acute Infarction Ramipril Efficacy. AB - We estimated the cost effectiveness of adding the ACE inhibitor ramipril to conventional treatment in patients with heart failure after acute myocardial infarction. These estimates were based on the Acute Infarction Ramipril Efficacy (AIRE) study and on complementary Swedish healthcare resource use data for a subset of patients. The average follow-up period was 15 months (minimum 6 months, maximum 3.8 years). The perspective of the analysis was that of the county councils (third-party payers), and we focused on the cost of drugs and hospitalisation. The marginal cost effectiveness of the treatment was estimated over 3 treatment periods: 1, 2 and 3.8 years. The cost-effectiveness ratios varied between SEK14,148 and SEK33,033 per life-year gained ($US1 = SEK7.70. Pounds 1 = SEK12.40) for the 3 treatment periods. Adding ramipril to conventional treatment for heart failure after acute myocardial infarction is therefore cost effective, and compares favourably with the cost effectiveness of other common medical therapies in the cardiovascular field. PMID- 10170449 TI - A cost analysis of alfentanil+propofol vs morphine+midazolam for the sedation of critically ill patients. AB - Morphine + midazolam and alfentanil + propofol are regimens offering well tolerated and effective sedation for critically ill patients. However, morphine + midazolam is associated with accumulation in these patients, resulting in prolonged recovery characteristics. Alfentanil+propofol, although more expensive, has a shorter elimination half-life, is not associated with accumulation problems and results in a rapid recovery. This study compared sedation quality, patient recovery characteristics and the cost of alfentanil + propofol and morphine + midazolam for sedating critically ill patients in the intensive care setting. 26 patients were randomly allocated to receive sedation with alfentanil + propofol (n = 17) or morphine + midazolam (n = 9). Outcome measures were the times until extubation, intensive care unit (ICU) transfer and final hospital discharge. Cost analysis assessed both drug-related costs, including drug acquisition and administration, and non-drug-related costs, including bed occupancy. Age, gender, diagnosis, Acute Physiological and Chronic Health Evaluation (APACHE) II scores and sedation quality did not differ significantly between groups. The times to extubation and until patients were fit for transfer from ICU were significantly shorter for patients sedated with alfentanil + propofol than for those sedated with morphine + midazolam. The total costs (at the time of the study Pounds 1 was equivalent to $US1.59) for ICU hospital stay per patient for alfentanil + propofol and morphine + midazolam were 3063 Pounds and 9511 Pounds, respectively, because the shorter recovery characteristics of alfentanil + propofol led to a reduction in ICU stay. Corresponding costss for total hospital stay were 6063 Pounds and 13735 Pounds, respectively. In conclusion, alfentanil + propofol has a better pharmacoeconomic profile than morphine + midazolam for sedating critically ill patients in the ICU setting. PMID- 10170451 TI - Cost-effectiveness analysis of a dry powder inhaler (Turbuhaler) versus a pressurised metered dose inhaler in patients with asthma. AB - In an open randomised parallel-group study, 1004 patients with asthma in 7 countries were randomised to receive asthma treatment via 2 different kinds of inhalers: an aerosol pressurised metered dose inhaler (pMDI) and a dry powder inhaler (Turbuhaler). The patients were treated for 52 weeks with inhaled corticosteroids and/or inhaled beta 2-agonists. All patients were considered adequately treated with inhaled corticosteroids and/or inhaled beta 2-agonists via pMDI before inclusion in the study. Healthcare utilisation variables were attached to the case record forms of the patients, thus making an economic analysis possible. Because of the difficulty of comparing costs between countries, each country was analysed separately. Canadian patients constituted the largest subpopulation (445 patients) and were therefore used in this analysis. From the analysis, we concluded that the effectiveness of treatment (measured as the number of exacerbations and days with exacerbation) was significantly better for patients treated via Turbuhaler than via a pMDI (p = 0.03). Furthermore, the total annual costs of treatment were, on average, $Can331 less (p < 0.01) for patients using Turbuhaler than for those using a pMDI (mainly due to lower costs for hospitalisation and medication). The cost differences between inhaled corticosteroids and inhaled beta 2-agonists were significantly in favour of treatment via Turbuhaler (p < 0.01). Thus, the results of this study suggest that treatment via Turbuhaler is a cost-effective strategy in patients with asthma in Canada. PMID- 10170452 TI - Cost effectiveness of treatment to National Cholesterol Education Panel (NCEP) targets with HMG-CoA reductase inhibitors. Trial design. AB - HMG-CoA reductase inhibitors effectively reduce cholesterol levels, and this is associated with a lower rate of cardiovascular events. Some HMG-CoA reductase inhibitors are more effective than others in reducing low density lipoprotein (LDL) cholesterol, and such drugs should help patients achieve LDL cholesterol targets prescribed by the National Cholesterol Education Panel (NCEP). This paper describes the design of a trial comparing the clinical efficacy and cost effectiveness of four HMG-CoA reductase inhibitors in reducing LDL cholesterol to specified targets. This trial is being conducted in 30 physicians' practices in the USA. Its primary aim is to assess the resource use required to achieve and maintain NCEP targets by all patients randomised and followed up for one year. PMID- 10170453 TI - Pharmacoeconomic analysis of venlafaxine in the treatment of major depressive disorder. AB - We conducted a cost-effectiveness analysis of acute major depressive disorder (MDD) using serotonin-norepinephrine reuptake inhibitors (SNRIs; venlafaxine), selective serotonin reuptake inhibitors (SSRIs; fluoxetine, fluvoxamine, sertraline, paroxetine), or tricyclic antidepressants (TCAs; amitriptyline, imipramine, desipramine, nortriptyline). A decision-tree model over 6 months was constructed using an expert panel. The analytic perspective was that of the Ontario Ministry of Health as payor for all direct costs, which were derived from standard lists and included the cost of the drug as well as those for medical care, laboratory services, hospitalisation and managing adverse events. Success and dropout rates were determined from a meta-analysis of published randomised controlled trials. Medline, Embase, and International Pharmaceutical Abstracts were searched from 1984 to 1996, as were references from retrieved articles and reviews. Inpatients and outpatients were analysed separately. SSRIs were used as backup therapy for patients receiving venlafaxine and TCAs, and SNRIs were used as backup therapy for patients receiving SSRIs. Pharmacoeconomic outcomes were expected cost per success, expected cost per symptom free day (SFD), and incremental cost per success and per SFD. The meta-analysis identified 56 treatment arms from 36 randomised controlled trials involving 2953 patients (2380 outpatients and 573 inpatients). SNRIs had the highest success rates. The respective costs (in 1996 $Can; $Can1 = $US0.74) for outpatients and inpatients are given below. The expected costs per success were $6044 and $17,234 for venlafaxine, $6634 and $20,874 for SSRIs, and $9035 and $20,459 for TCAs in outpatients and inpatients, respectively. The respective expected costs per SFD were $45.92 and $127.31 for venlafaxine, $51.64 and $157.04 for SSRIs, and $70.71 and $152.43 for TCAs. Venlafaxine was dominant for all incremental pharmacoeconomic analyses. Sensitivity analyses indicated that the results were robust for outpatients but somewhat sensitive for inpatients. In conclusion, venlafaxine is a cost-effective drug for the treatment of MDD in adult outpatients and inpatients. PMID- 10170454 TI - Why training is the key to successful guideline implementation. AB - The market for pharmacoeconomic analysis is rapidly expanding. Demand for experienced investigators seems to have outpaced the capacity of both the academic community and industry to train qualified practitioners. The result is that many professionals charged with producing and using cost-effectiveness and other drug-related economic evaluation studies may lack the basic skills required to carry out their duties. This, in turn, raises concerns regarding the credibility and integrity of the field as a whole. In our opinion, the adoption of self-imposed practice guidelines is a necessary first step in confronting these issues. However, the power of guidelines to promote responsible practice will be limited by the technical preparation of the analysts charged with adhering to them. A long term solution requires a collaborative commitment, on the part of both the academic community and the private sector, to targeted graduate training in pharmacoeconomic methods, and to the provision of ample opportunities for continuing professional education. PMID- 10170455 TI - The economic potential of tamoxifen prophylaxis in breast cancer. PMID- 10170456 TI - Strategies to improve the cost effectiveness of general practitioner prescribing. An international perspective. AB - Prescribing costs are rising in all developed countries. The positive reasons for this are improved screening for diseases, aging populations and better drugs. The negative reason is prescribers' failure to use drugs cost effectively, i.e. in a scientifically and economically rational manner. It is for the latter reason that health administrators and managers, faced with cutbacks of other essential health provisions such as elective surgery, have found it necessary to intervene to attempt modification of general practitioner prescribing. This article describes the range of interventions in 3 continents, from the extreme of an essential drugs list to financial incentives and/or penalties for the patient and/or physician, to independent academic, educational interventions. The impact of hospital-initiated prescribing on general practice is briefly considered, as is the need to educate patients not to expect a prescription except when absolutely necessary. Finally, the inadequacy of medical school training in pharmacology and therapeutics is described, together with the need for formal postgraduate education in these topics for all prescribers, both general practitioner and hospital specialist. PMID- 10170457 TI - The US orphan drug programme 1983-1995. AB - The Orphan Drug Act has become a staple of food and drug law in the US. The experience with the US programme continues to serve as a useful reference point as interest in orphan drug incentive programmes expands globally. This article first reviews details of the legislation and orphan drug regulations, and then provides a 13-year overview (1983-1995) of orphan drug activity in the US, including descriptive data on the designated and approved orphan drugs, their indications and sponsors. In light of a recent challenge to the Food and Drug Administration's (FDA's) authority under the Act, we also examine the interplay between the exclusivity provision of the Act and the orphan drug regulations that define when 2 drugs will be considered the 'same' for the purposes of the Act. A recent court decision affirming the FDA's interpretation of the clinical superiority provisions of the regulations suggests that orphan exclusivity may be less predictable and less certain than it has been in the past. Finally, we consider the usefulness to orphan drug sponsors of other initiatives such as FDA's early access and fast-track approval programmes, and the extent to which the FDA's discretion to waive, defer and reduce prescription drug user fees has worked to the benefit of orphan drug sponsors. Over the 13-year analysis period, the FDA granted 631 orphan designations involving 450 different drugs, for which 121 FDA marketing approvals have been granted. Those with both treatment investigational drug designation and fast-track approval status appeared to benefit substantially from shorter development times. The indications targeted by the orphan drugs fall into 8 categories, with 40% of all orphan indications involving cancer and genetic diseases. Evident in the latter part of the analysis period is the increasing share of orphan activity attributable to biotechnology firms. Even though the Prescription Drug User Fee Act of 1992 did not recognise orphan status for the purpose of waiving or reducing the amount of fees payable, almost one-third (32%) of the $US 8,531,550 in user fee revenue foregone through waivers and reductions was attributable to orphan drugs. PMID- 10170458 TI - Economics of home parenteral nutrition. AB - The past 30 years have seen long term parenteral nutrition evolve from a novel technique to an accepted intervention for gastrointestinal failure. The development of home parenteral nutrition (HPN) has parallelled a shift in resources from hospital to community care and has been driven by technological advances, the growth of commercial home care companies and patient choice. Costs for HPN per patient year have been estimated to range from $US 150,000 to $US 250,000 in the US, and are around 55,000 pounds in the UK, perhaps only 25 to 50% of in-hospital costs. In the absence of any alternative treatment for many patients with gastrointestinal disease, parenteral nutrition is life saving and offers the prospect of maintaining a good quality of life. The cost of 1 quality adjusted life-year for HPN has been estimated as 69,000 pounds in the UK (1995 values), and $Can 14,600 in Canada (1984 values), making HPN relatively cost effective compared with other ways of spending money to improve health. HPN is also given to patients in whom life expectancy is unlikely to be influenced, such as those with cancer or AIDS. Although there is considerable heterogeneity between countries in the proportion of HPN patients with a particular disease, malignancy is now the single most common indication. HPN can be expected to improve quality of life over a short period of terminal care, and whilst a strong case can be made for use of HPN in some of these patients, its use has not been subjected to detailed medical or economic appraisal. PMID- 10170459 TI - Drug rationing in the UK National Health Service. Current status and future prospects. AB - There are major problems in attempting to ration drug use in the UK. These include the large indigenous pharmaceutical industry, the nature of funding of drugs within the National Health Service (NHS) and the political sensitivities of rationing. Rationing of services within the NHS has therefore usually been implicit rather than explicit, and there is little public debate about rationing of health services. In relation to drug therapy, prescribing in primary care technically can only be rationed by encouraging the general practitioner (GP) to contain his or her own costs-effectively moving the difficult decision to the GP. Direct incentives to the GP, in the form of incentive payments or by fundholding seem to have some success in containing costs, largely by simple generic substitution. There are established systems in hospitals to control the costs of drugs, including formularies and drug management committees. Hospitals commonly try to transfer drug costs to the GP budget. While in part this is clinically appropriate, it can lead to tensions. Health authorities and GP fundholders now include prescribing, particularly at this interface, in their contracts with hospitals. Economic evaluations currently play little part in aiding decisions about choice of drug. These decisions tend to be dominated by the need for short term cost containment in the UK. Recent reforms of the NHS have moved responsibility for the rationing of services to the local authorities or purchasers; this might in time create an additional, local hurdle for pharmaceutical companies trying to market new drugs. A proposal to introduce a national limited formulary in which drugs will be selected partly on the basis of an economic evaluation seems impractical, although similar ideas might be further developed. PMID- 10170460 TI - Treatment costs and quality of life with granulocyte-macrophage colony stimulating factor in patients with antineoplastic therapy-related febrile neutropenia. Results of a randomised placebo-controlled trial. AB - This study examined the costs of treatment of, and quality of life in, patients with antineoplastic therapy-induced neutropenic fever who were treated with antibacterials, with or without granulocyte-macrophage colony-stimulating factor (GM-CSF). Patients with haematological malignancies (n = 47) or solid tumours (n = 87) who had severe neutropenia (neutrophil count < 0.5 x 10(9)/L) and fever (> 38.5 degrees C once, or > 38 degrees C twice, in a 12-hour observation period) were randomised to receive subcutaneous GM-CSF 5 micrograms/kg/day (n = 65) or placebo (n = 69) in conjunction with broad-spectrum antibacterials. GM-CSF enhanced neutrophil recovery compared with placebo. Median neutrophil counts at day 4 were 2.9 (range 0 to 25) x 10(9)/L in the GM-CSF arm and 1.3 (range 0 to 9) x 10(9)/L in the placebo group (p < 0.001). No significant difference was observed with regard to median days with neutrophil count < or = 1.0 x 10(9)/L or in time to resolution of fever. Quality-of-life scores in 90 patients demonstrated significant differences in favour of the placebo group. The results for the oncology and haematology patients were similar to the results for the total group. Patients in the GM-CSF and placebo groups had a mean hospital stay of 7.25 and 8.33 days, respectively. Hospital costs were higher for the GM-CSF treated patients when GM-CSF was included in the price [mean costs: GM-CSF arm $US 5177 vs placebo arm $US 4178 (p < 0.05; 1992 values)]. The haematology patients stayed longer in hospital than the oncology patients, resulting in higher total costs for the former group. These results indicate that GM-CSF does not affect the number of days required for resolution of fever of the hospitalisation period for this patient group, and does not provide a cost effective contribution to the treatment of these patients. Sensitivity analyses indicate that GM-CSF would produce savings if the duration of hospitalisation with GM-CSF was < or = 76.5% of that in the placebo group. PMID- 10170461 TI - Cost effectiveness of hepatitis A virus immunisation in Spain. AB - The aim of this study was to evaluate, in economic terms, the recently launched hepatitis A vaccine in comparison with the use of nonspecific immune globulin, for the prevention of hepatitis A. A cost-effectiveness analysis was performed, comparing mass and selective strategies for both active and passive immunisation in children, adolescents and the high-risk adult population. Direct costs of diagnosis, treatment and immunisation, and travelling expenses of the individuals, were considered. The alternative of mass vaccination for children and adolescents cost 2679 to 6394 European Currency Units (ECU) [$US 3040 to $US 8312; 1994 values] per case prevented. Selective vaccination of high-risk individuals cost ECU205 per case prevented for young adults (those aged about 20 years) when the annual risk of contracting the disease was 0.7%, while there were net savings for all age groups when there was a 2 to 3% risk. The most sensitive variables affecting the cost of mass-vaccination strategies were incidence of hepatitis A, vaccine coverage and vaccine cost; for the various high-risk groups, these were vaccine cost, incidence of hepatitis A and costs of treating infection. Selective vaccination, depending on the age of high-risk patients [mainly travellers to endemic areas for periods of over 6 months, or those under 'precarious' conditions (e.g. backpackers, even for short periods)], is the most efficient alternative; in fact, the cost-effectiveness ratio has not been calculated, since there were net savings. For occasional travellers (as above, and those travelling for periods of under 6 months in 10 years), passive immunisation is more efficient. Selective vaccination for package-tour, short stay travellers (infection risk around 0.3%) and strategies for mass vaccination of children and adolescents are not justified from an efficiency point of view. PMID- 10170462 TI - Cost-effective treatment of uncomplicated gonorrhoea including co-infection with Chlamydia trachomatis. AB - We evaluated the cost effectiveness of treating uncomplicated gonorrhoea in a theoretical cohort of 1000 adults (nonpregnant women of reproductive age, or men) with either intramuscular ceftriaxone 125 mg or a single oral dose of cefixime 400 mg, ofloxacin 400 mg or ciprofloxacin 500 mg. We assumed that all patients were also empirically treated for uncomplicated chlamydial infection, with either a single oral dose of azithromycin 1 g, or oral doxycycline 100 mg twice daily for 7 days. Treatment of gonorrhoea with intramuscular ceftriaxone was found to be the most cost-effective alternative. This was followed by treatment with the either of the fluoroquinolones (ofloxacin or ciprofloxacin), then cefixime. For empirical treatment of uncomplicated chlamydial infection, doxycycline was more cost effective than azithromycin when approximately more than 80% of the patients were assumed to comply with the doxycycline regimen. When patients' compliance was poor with the doxycycline regimen, the azithromycin therapy became more cost effective from a societal viewpoint. Nevertheless, its relatively high cost to the individual patient with limited financial resources might prevent him or her from filling prescriptions. Any decrease in patients' compliance with the azithromycin therapy would favour treatment with doxycycline. PMID- 10170465 TI - Telehealth Center gets foundation support. PMID- 10170466 TI - New Alaska telemedicine project to let patients control appointments. PMID- 10170464 TI - Dornase alfa. A review of pharmacoeconomic and quality-of-life aspects of its use in cystic fibrosis. AB - Cystic fibrosis (CF) is a fatal hereditary disease; patients with CF have an average lifespan of 30 years. By cleaving neutrophil-derived DNA, dornase alfa (recombinant human deoxyribonuclease I) decreases the adhesiveness and visco elasticity of sputum in the infected lungs of patients with CF. As a result, respiratory function is improved in patients with all degrees of disease severity, and the relative risk of pulmonary exacerbations is reduced in patients with mild to moderate disease. Resource utilisation (days spent in hospital or receiving parenteral antibiotics) in patients with mild to moderate disease is also reduced by dornase alfa, as evidenced by a placebo-controlled trial in > 900 patients. Cost savings generated by these reductions in resource use during 24 weeks of dornase alfa therapy offset about 17 to 37.5% of the acquisition cost of the drug, depending on local cost data for various countries. Reductions in resource utilisation with dornase alfa have not been observed in patients with severe disease. Available cost-effectiveness and cost-utility analyses are not fully published. One analysis estimated that the incremental cost of avoiding one hospitalisation was about $Can 15,000 relative to standard therapy after 1 year of treatment. Informal analysis in the UK suggests a cost per quality-adjusted life-year of 25,000 Pounds for dornase alfa. Some quality-of-life (QOL) domains (mainly cough frequency and chest congestion) have shown modest improvement in patients treated with dornase alfa, mainly those with mild CF. Persuasive evidence of QOL benefit is lacking in those with more severe disease. Identifying patients most likely to benefit from dornase alfa therapy is essential to maximise clinical and cost benefits. The lack of a demonstrated reduction in resource utilisation in patients with severe CF makes its use more difficult to justify economically in this group than in those with less severe disease. However, in the absence of other treatments for this group, economic considerations must be weighed against clinical benefits. In conclusion, the acquisition cost of dornase alfa is partially offset by savings gained by reducing resource utilisation in patients with mild to moderate CF, and the drug appears to improve quality of life in some patients, mostly those with less severe disease. However, in the absence of guidance from definitive cost effectiveness analyses, individual healthcare providers must make their own decisions about how best to provide dornase alfa to patients with CF in a rational and cost-justifiable manner. PMID- 10170463 TI - A predictive model of the health benefits and cost effectiveness of celiprolol and atenolol in primary prevention of cardiovascular disease in hypertensive patients. AB - This study compares the antihypertensive and lipid modifying effects of treatment of mild to moderate hypertension with celiprolol or atenolol. It also models the 5-year cardiovascular risk reduction and the cost effectiveness of monotherapy from a partial societal perspective. The effects of celiprolol and atenolol on systolic blood pressure (SBP), total serum cholesterol (TC) and high density lipoprotein cholesterol (HDL-C) were obtained from a pooled analysis of published studies. Although celiprolol and atenolol had similar effects on SBP, celiprolol reduced the ratio of TC to HDL-C by 10.2% [95% confidence intervals (95% CI) 16.4%, -4.0%) but atenolol increased the ratio by 7.7% (95% CI of 3.4%, 12.0%). The 5-year absolute risks of an initial coronary or cerebrovascular event or cardiovascular death were computed for cohorts of patients treated with either agent or remaining untreated, using an accelerated failure time (AFT) model, based on Framingham Heart Study data. Inputs to the model were age, gender, smoking status, SBP, TC and HDL-C. The change in absolute risk was estimated using the changes in SBP and TC: HDL-C obtained from the pooled analysis. Average life-months gained by therapy were computed as differences between the Kaplan Meier survival curves estimated from the model plus differences in 5-year cardiovascular death rates multiplied by average life expectancy obtained from life tables. Direct medical costs included drug treatment, and the costs of acute care for initial coronary and cerebrovascular events deferred by therapy over the 5-year treatment period. The model shows that in the lowest-risk base case (60 year-old men who are nondiabetic and nonsmokers with SBP of 160 mm Hg and a 5 year absolute cardiovascular risk of 12%), celiprolol (271 mg/day) is 2-fold more effective than atenolol (77.4 mg/day) in reducing coronary event risk, and equally effective in reducing cerebrovascular event risk. The number of individuals that would have to be treated for 5 years to avoid 1 coronary event is about 30 for celiprolol versus 70 for atenolol. Therapy with celiprolol yields more life-months and at current prices, the cost per life-year gained by therapy is significantly lower. Both drugs are cost effective by international standards in the treatment of patients with 5-year absolute cardiovascular risk greater than 10%, and are more cost effective in those patients at higher levels of absolute cardiovascular risk. The direct medical costs of treatment for 5 years with celiprolol are the same or slightly less than treatment with atenolol at the dosages used in the clinical trials, despite a 19% higher tablet price. Both drugs are more cost effective in patients at higher levels of absolute cardiovascular risk. These findings are sensitive to the drug dosages, tablet prices and the discount rate. Based on epidemiological and clinical data, replacing atenolol with celiprolol in patients with mild to moderate hypertension, but without overt cardiovascular disease, is predicted to have similar effects on stroke risk, but to be substantially more effective in reducing the risk of coronary events at no additional direct medical cost over a 5-year treatment period. PMID- 10170467 TI - New York doctor goes on the 'Net to save a baby in Argentina. PMID- 10170469 TI - Abu Dhabi Hospital links to WorldCare Gulf. PMID- 10170468 TI - Teledermatology solves a nasty skin problem at the bottom of the world. PMID- 10170470 TI - Appalachia telemedicine projects show cost savings. PMID- 10170471 TI - Telemedicine reimbursement approved by Congress. PMID- 10170472 TI - Mars mission shows how far telemedicine can go. PMID- 10170473 TI - FCC urges companies to standardize telemedicine equipment. PMID- 10170474 TI - Licensure barriers to the interstate use of telemedicine. PMID- 10170475 TI - Telemedicine--implications for patient confidentiality and privacy. PMID- 10170476 TI - The copyrightability of factual compilations such as databases containing medical records. PMID- 10170477 TI - Death and dying in four Asian American cultures: a descriptive study. AB - Among ethnic minorities, the Asian and Pacific Islander (API) American group is the fastest growing, and, as a whole, is quite longevous. Although there is a significant literature on the history and religious traditions of API cultures, little has been published on death rituals and beliefs of the American descendants of these groups. The purpose of this study was to begin to explore cultural variations in response to the process of dying and grieving among four Asian American populations--Chinese, Japanese, Vietnamese, and Filipino. To this end, key informants and focus group interviews were conducted with members of these ethnic groups, and significant differences among, and within, groups were found. The small size and Hawaiian base of the sample preclude generalization of findings to the United States as a whole. However, this study provides health care workers with information that can increase their awareness of and sensitivity to Asian American approaches to death and dying. PMID- 10170478 TI - Suicide among the elderly in Israel. AB - This comparative analysis examines the data on attempted and completed suicides among the aged population (65+) in Israel to assess what changes have occurred in recent years. The sources of the data used in this review were statistics reported by the Israeli Ministry of Health and the Israeli Central Bureau of Statistics for two decades, 1962-1971 and 1977-1986, with additional data provided for previous years. Analysis of these data shows a rise in both attempted and completed suicides among the elderly in Israel over the last decade. However, a comparison with selected European and Western countries reveals that these rates are still lower than those of other Western countries. These findings are discussed within the framework of family care, religious tradition, and social policy. In light of the fact that suicide rates are shown to rise with increasing age both in Israel and in other countries, the need to understand suicide among the elderly is becoming even more urgent and should generate more research. PMID- 10170479 TI - Tibetan Buddhism and the resolution of grief: the Bardo-thodol for the dying and the grieving. AB - This article is a contribution to the cross-cultural study of grief. The Bardo thodol (sometimes translated the Tibetan Book of the Dead) and the ritual associated with it provides a way to understand how Buddhism in Tibetan culture manages the issues associated with what is called grief in Western psychology. The resolution of grief in the survivors is intertwined with the journey to rebirth of the deceased. The present article describes (a) the progression of the deceased, (b) the rituals by which survivors separate from the physical incarnation of the deceased, (c) how, by channeling the feelings of grief to support the progress of the deceased, grief is brought to a positive resolution, and (d) the continuing bond survivors maintain with the dead even though the dead has moved on to the next life. PMID- 10170480 TI - Death as a stimulus to improving the African environment for more healthful living. AB - In D. Leviton's (1991) conception of horrendous death, a poorly managed environment can contribute to widespread mortality, and the deaths so caused can further create an environment for subsequent death. The African environment in particular is characterized by a number of "deathogenic" factors that must be understood and confronted by health educators committed to minimizing or eliminating the impact of horrendous death on the African continent. In this comment, the author argues that attention to characteristic but preventable forms of death in the African context can lead to greater public advocacy among African health educators, contributing to the physical and psychological well-being of the populations they serve. PMID- 10170481 TI - May I ask you a personal question? The right to privacy and HIV testing in the European Community and the United States. PMID- 10170483 TI - Cost-effectiveness analysis as a measure of value. PMID- 10170482 TI - Justice Joseph Story and death in early 19th-century America. AB - Justice Joseph Story, associate justice of the United States Supreme Court from 1811 until his death in 1845, suffered many losses during his lifetime. His first wife died a little more than one-half year after their marriage, and her death was followed a few months later by the death of Story's father. Five of his 7 children died. Other family members, friends, and colleagues died. Story was insightful and articulate in describing these losses. Thus a study of his reactions to, and coping mechanisms for, these deaths provides an excellent perspective on how death was dealt with in early 19th-century America. PMID- 10170484 TI - PET myocardial perfusion imaging for the detection of coronary artery disease- clinical assessment, vol. 10, no. 21, 1995. PMID- 10170485 TI - The impact of traumatic brain injury. PMID- 10170487 TI - Dynamic posturography in the assessment of vestibular dysfunction (Executive Summary File--vol.11, no.11, 1996). PMID- 10170486 TI - Botulinum-A toxin for treatment of chronic spasticity (Executive Summary File- vol.11, no.6, 1996). PMID- 10170488 TI - Globalization of biotechnology and the public health challenges accompanying it. PMID- 10170489 TI - Cost effectiveness and allocation of therapies in a treating population. PMID- 10170490 TI - Extra. 245 "overvalued" procedures targeted for FY 90 cuts. PMID- 10170491 TI - A supervisor's role in workplace drug abuse. AB - On-the-job drug abuse has become a major concern throughout business, industry, and the professions. Health care supervisors interact daily with their employees and are responsible for work production and performance standards. Likewise, they are usually first to detect changes in these standards and changes in their personnel. The supervisor plays a pivotal role in any drug abuse policy. The supervisor should create an atmosphere of intolerance with regard to drug abuse and recognize that the employer's most persistent personnel problems are usually rooted in the personal problems of its employees. The employer's overall goal should be improving the work environment and maintaining high levels of job performance and productivity while restoring and maintaining the employee's self image and the employer's reputation in the community. PMID- 10170492 TI - Should your lab perform tumor immunology? PMID- 10170493 TI - Planning marketing strategies for ambulatory surgery units. PMID- 10170494 TI - The $100 billion hangover. PMID- 10170495 TI - Model criteria for adolescent chemical dependency inpatient treatment. Chemical Dependency Treatment Committee, Hospital Council of Southern California. PMID- 10170496 TI - Death needs no assistance. PMID- 10170497 TI - Utilization review takes toll on mental health units. PMID- 10170498 TI - Hospitals feeling trauma of violence. Emergency departments suffer as drug related injuries soar. PMID- 10170499 TI - Ambulatory surgery pay rates issued. PMID- 10170500 TI - Designing chemical dependency programs in HMOs. AB - This article is a description of an existing chemical dependency treatment program in an HMO, Group Health Cooperative of Puget Sound, a consumer-owned and governed staff model organization. It presents the various issues that were considered before deciding to develop an in-house program and the variety of different services offered. The Alcohol and Drug Abuse Program of Treatment (ADAPT) is a comprehensive model offering both inpatient and outpatient detoxification and rehabilitation services to an enrollment base of approximately 350,000 subscribers. This article, written from a practical "nuts and bolts" perspective, should benefit other HMO providers who are considering development of their own in-house program. PMID- 10170501 TI - Medicare reimbursement for "overvalued" procedures to be reduced in 1990. PMID- 10170502 TI - The Committee on Alternate Health Care Delivery Systems. PMID- 10170503 TI - Medicare program; revision of ambulatory surgical center payment rate methodology -HCFA. Final notice of payment rates. AB - This final notice sets forth the revised payment rates for ambulatory surgical center services. We are refining the methodology used to determine the payment rates and have based the rates on the most recent survey data collected from participating ambulatory surgical centers. In addition, we have computed the payment rates using the HCFA hospital wage index. We are also incorporating the payment for intraocular lens inserted during cataract surgery into the facility rate as required by section 4063(b) of the Omnibus Budget Reconciliation Act of 1987. Finally, we are changing the payment policy for surgical procedures that are terminated due to medical complications that increase the surgical risk to the patient. As a result of the refinements to our ratesetting methodology, this final notice establishes eight payment groups rather than the six proposed groups. Of these eight groups, two groups (Group 6 and Group 8) contain only cataract procedures. PMID- 10170504 TI - Integration of formulary systems with centralized pharmaceutical procurement. AB - The integration of formularies with pharmaceutical group purchasing and supply systems for multiple hospitals and ambulatory health centers in the Indian Health Service of the US Public Health Service is described. Two models by which these systems have been integrated are presented. The approach of one group of facilities for maintaining high-quality therapeutics in a cost-effective manner was to maintain separate P & T Committees and formularies for each facility, with one centralized drug procurement center. The other group developed a central P & T Committee and formulary to serve all area facilities, as well as continued to maintain a separate P & T Committee at each facility that could act between meetings of the central committee. These models of centralized procurement have provided both decreased drug costs and increased information on drug use within the multifacility systems. In both models, staff have reached consensus on drugs that will provide quality therapeutics in a cost-conscious environment. PMID- 10170505 TI - Bundling can work for instrument acquisition. PMID- 10170506 TI - Disabilities Act could spell big changes for providers. PMID- 10170507 TI - Model criteria for adult inpatient and intensive outpatient alcohol and chemical dependency treatment. Chemical Dependency Treatment Committee, Hospital Council of Southern California. PMID- 10170508 TI - Hospitalization of children for surgery: the parents' view. AB - A qualitative study based on interviews with nine families was implemented to explore the parental experience when a child is hospitalized for surgery. Participant observation during the stress points identified in the literature and interviews with parents both in the hospital and in the home after the child was discharged were the major sources of data. Sources of parental stress, parental roles during the child's hospitalization, coping strategies used by parents, and parents' suggestions for health care professionals, particularly nursing staff, were explored. The need for health care professionals to make themselves available to parents and to negotiate roles with parents were key findings. PMID- 10170509 TI - Quality assurance through adverse drug reaction reporting: improving hypnotic prescribing. AB - While adverse drug reactions (ADRs) contribute to excessive health care costs through increased patient morbidity and mortality, most hospital ADR reporting programs are ineffective in documenting the adverse reactions to drugs that occur in their institutions. Furthermore, the ADR reporting programs have an untapped potential as a quality assurance (QA) tool; ADR reports provide a means of identifying potential problems in patient care. If 10-20% of hospitalized patients develop adverse effects while taking medications and over 50% of the iatrogenic events are avoidable, educational strategies and prospective monitoring could reduce this significant cause of patient morbidity. At Memorial Hospital (Ormond Beach, FL), routine QA screening detected a potential problem with the use of Halcion (triazolam). A plan of action, which included a drug use evaluation (DUE), educational efforts, and hypnotic prescribing guidelines was developed to address and resolve the concerns raised by initial ADR reports. PMID- 10170510 TI - The evolution of free-standing ambulatory surgical care. PMID- 10170511 TI - Ambulatory surgery in the 1990s. PMID- 10170512 TI - Medicare's prudent approach to paying for ambulatory surgery services. PMID- 10170513 TI - The case mix of ambulatory surgery as measured by ambulatory visit groups. PMID- 10170514 TI - Outpatient surgery for injured workers. PMID- 10170515 TI - The classification of resource use in ambulatory surgery: the products of ambulatory surgery. PMID- 10170516 TI - Ambulatory care of elderly surgical patients. PMID- 10170517 TI - Ambulatory surgery: critical management indicators. PMID- 10170518 TI - Unbundling could be costing you a bundle. AB - Here's what you need to know about the mysterious world of code manipulation. Consultants and payers claim it's responsible for physician charges increasing at an alarming rate. PMID- 10170519 TI - Medicare program; Medicare secondary payer for disabled active individuals--HCFA. Proposed rule. AB - This proposal sets forth the rules that limit Medicare payment for services furnished to disabled "active individuals" who are covered under a large group health plan (LGHP), and prohibit discrimination by an LGHP against such individuals. These rules are necessary to implement section 1862(b)(1)(B) of the Social Security Act (the Act), and related provisions, which make Medicare benefits secondary to LGHP benefits. PMID- 10170520 TI - The first of earthly blessings, independence. Development of a service for the severely physically disabled. AB - Over the past six or seven years Basingstoke and North Hampshire HA has invested considerable effort in pioneering a particular approach to the provision of care and support to the extremely physically disabled. Charles Kaye describes the development of the service and pursuit of quality assurance. PMID- 10170521 TI - Nursing home aides experience increase in serious injuries. AB - Physically impaired and socially isolated, many residents of nursing homes greatly depend on nursing aides and other employees; in providing care the workers themselves incur disabling injuries, often to the back. PMID- 10170522 TI - Cost of maternal drug abuse drawing notice. PMID- 10170523 TI - Federal contractors to maintain drug-free workplace. PMID- 10170524 TI - Cosmetic surgery: a specialty worth exploring. PMID- 10170525 TI - Perinatal substance abuse--an overview. PMID- 10170526 TI - Cost containment through outpatient substance abuse services. PMID- 10170527 TI - Feminine values engage women. PMID- 10170528 TI - Who's the real victim of substance abuse? PMID- 10170529 TI - Perioperative documentation. PMID- 10170530 TI - Cooperative agreements for communications programs for the prevention of illegal drug use or the illegal use or abuse of alcohol--ADAMHA. PMID- 10170531 TI - Addiction. Help employees who help themselves. AB - Employers are helping their employees overcome difficult times due to substance abuse. Find out how companies are dealing with substance abuse in the workplace, and what programs have been successful for their employees. PMID- 10170532 TI - Cocaine babies. PMID- 10170533 TI - HMM price watch. PMID- 10170534 TI - Sicker psych patients could help hospitals. PMID- 10170535 TI - Alzheimer's facility set to open soon in Colorado. PMID- 10170536 TI - Hospitals urged to provide drug-abuse treatment. PMID- 10170537 TI - HCFA sets ambulatory surgery rates. PMID- 10170539 TI - The health-insurance factor. Picking the wrong plan now could mean no choice of hospital later. PMID- 10170538 TI - Is booming demand dooming emergency department? PMID- 10170540 TI - Anguish and opportunity. AB - Alzheimer's, once considered a rare affliction, is now billed as one of the nation's leading killers. Its rapid rise to public and political prominence is the result in part of a carefully crafted public relations strategy. PMID- 10170541 TI - A city comes of age. PMID- 10170542 TI - Creating a healing environment. AB - To regain some of the principles of personalized care that were part of the foundation of nursing, Carondelet St. Mary's Health Center in Tucson, AZ, instituted a nurse case manager program in 1985. The program assigns a nurse case manager to coordinate patient and family care from an array of nursing services. Its special characteristic is a focus on home care after discharge. The basis for the program is a belief in holistic care, beginning during the hospital stay and continuing after discharge. Because the psychosocial and spiritual impact of the illness might not be felt until the client returns home, the nurse case manager concentrates on preventing or alleviating distress through a program of care, education, and service. In 1988 the center was asked to apply its program to a high-risk adolescent obstetrical group enrolled in a local health maintenance organization. The challenges for the nurses included poor nutritional status, substance abuse, unemployment, low self-esteem, and other factors precipitated by the group's socioeconomic status. By direct intervention the nurses were able to set patterns for positive adult behavior, and by the end of the program most of the clients had made considerable changes toward more successful life-styles. PMID- 10170543 TI - Is there a role for the small rural hospital? AB - Rural hospitals represent almost half of all short-stay nonfederal general hospitals in the United States, but have been more severely affected than their urban counterparts by changes in reimbursement, regulation, and technology. Two hundred and six rural community hospitals closed during the first nine years of the 1980s, and the rate of closure is accelerating. Using secondary data sources to examine the structure, role, and content of rural hospitals, small rural hospitals are described and compared to larger and nonrural hospitals. Rural hospitals differ systematically from other hospitals in the United States, with smaller daily censuses, lower occupation rates, shorter lengths of stay, and disproportionately high shares of Medicare patients. They are dominated by very small institutions, with more than 1,000 rural hospitals having fewer than 50 beds. Small rural hospitals offer a core of basic services to the populations they serve. Emergency, obstetric, and newborn services are virtually ubiquitous in rural hospitals of all sizes, and they are also more likely to offer long-term nursing and home care services than urban hospitals of similar size. The inpatient diagnostic and procedural mix of these institutions demonstrates that they provide care for common medical and surgical conditions of low complexity. Rural hospitals are also relatively inexpensive, representing only 6 percent of total expenditures for hospital care. Given their central role in supporting the provision of health services to rural areas, the apparent appropriateness of the conditions they treat, and their relatively modest cost, it would seem reasonable to use federal policy to stabilize our previous investment in these institutions. PMID- 10170544 TI - Medicare program; definition of surgical services--HCFA. Notice of definition of surgical services for physician volume performance standard rates for increase with comment. AB - This notice announces the definition of surgical services for purposes of the performance standard rates of increase for expenditures and volume of physician services and the appropriate fee schedule updates under the Medicare Supplementary Medical Insurance (Part B) program as required by section 6102 of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239). Surgical services are defined as follows: All services currently classified as type of service "surgery" in the Medicare payment record that are performed by surgical specialists, including podiatrists and oral surgeons. All services currently classified as type of service "assistant at surgery" in Medicare payment records. This definition includes procedures recognized in the surgical section of Current Procedural Terminology published by the American Medical Association and certain other invasive procedures. This definition would not lead to payment differentials by physician specialty. Any differential in annual updates because of separate performance standard rates would be procedure-specific without regard to specialty. PMID- 10170545 TI - Hospital obligations toward recovering addicted employees. PMID- 10170546 TI - Researching needs: young people with physical disabilities. AB - In many places services for the younger physically disabled are unsatisfactory. Often the first need is to discover what services are actually available, what young disabled people and their carers know about them and what use they make of them. Hilary Priestman and Alan Crawshaw describe such an exercise in North Humberside. PMID- 10170547 TI - Physician substance abuse: prevention through reeducation. AB - Physicians may be far more likely than other professionals and the general public to experience problems with drug and alcohol dependence. The availability of drugs, difficulty of detection, reluctance to confront addictive behaviors, unwillingness to admit weakness, and the lack of ways to detect and manage impaired physicians exacerbate the complexities of preventing and treating the problem. This literature review explores the complicating factors and suggests that prevention can be enhanced through medical education, candid disclosure of facts, acceptance, and understanding of substance abuse as a medical disorder. PMID- 10170548 TI - Multiple delivery methods for an interdisciplinary audience: assessing effectiveness. AB - Recent federal legislation has provided guidelines for intervention services for infants and toddlers with handicaps, birth to age three, and their families. Many disciplines, including nursing, will be involved in providing these services. Serving on an interdisciplinary team or acting as a consultant requires appropriate preparation. Many professionals are not comfortable with their roles in serving this new population, due in part to the limited emphasis on the handicapped infant and toddler in most basic preservice professional education programs. The project described here was useful in helping an interdisciplinary audience develop knowledge and skills needed for intervention services for infants and toddlers. PMID- 10170549 TI - Challenging the paraprofessional: developing an in-home activities program for the demented home care client. AB - Individuals with Alzheimer's disease or other forms of dementia frequently require little more than custodial care, which can often be performed by a family caregiver. As a result, homemaker-home health aides, engaged primarily for respite care, enter situations where there is little to do in terms of traditional homemaker-home health aide duties. In an effort to increase job satisfaction for employees and provide a benefit for clients, AL-C*A*R*E has developed an in-home therapeutic activities program for demented clients that is conducted in each client's home by the homemaker-home health aide. PMID- 10170550 TI - Establishment of national datasets for mental health and substance abuse treatment services. AB - Congress has recognized the importance of having complete and uniform data available from the states in order to determine the need for additional funding for services within the mental health and substance abuse service delivery system. Congress also needs data to determine the effectiveness of available services and to evaluate the typology of clients served. In order to ensure that the necessary data are available for Congress, grant funds have been allocated to many states in order to 1) implement a uniform dataset for substance abusers which will ultimately lead to a national database, and 2) promote the adoption of the Mental Health Statistics Improvement Program to allow the National Institute of Mental Health to receive uniform data upon request. Collection of the data needed by Congress will have to begin at the facility level. Therefore medical record professionals working or consulting in mental health and substance abuse facilities need to be aware of the national data sets and must be prepared for changes in data reporting requirements to their state mental health and substance abuse agencies. PMID- 10170551 TI - A customized instrumentation stand for patient transport. AB - A customized instrumentation stand is described for use during transport of cardiothoracic or major surgery patients between the OR and a critical care area. The stand attaches to a patient bed and is equipped with a pulse oximeter, ECG/BP monitor, defibrillator/monitor and support module, oxygen tank, supplies, and medications. The design allows maximum visibility and accessibility, easy movement, and quick attachment to and disconnection from a bed. A similar apparatus may benefit surgical programs facing comparable transport needs. PMID- 10170552 TI - "Trade-off" between medical cost controls and quality of care? Maybe, maybe not! Part II. AB - In Part I of this article, published in the last issue of the JQA (February/March 1990, Vol. 12, No. 1), Majors Varney and Schroeder reviewed the issues surrounding the impact of the Medicare prospective pricing system (PPS). After defining "quality health care" and discussing indicators of quality, the authors presented several arguments by anti-cost containment advocates. In Part II, research is presented on the effects of cost containment on access to health care, substance abuse programs, improved care, severity indexing, alternative care, and utilization review programs. PMID- 10170553 TI - Another Pandora's Box? Parental participation in anesthetic induction. PMID- 10170554 TI - A simple workload recording system that your entire staff can use. PMID- 10170555 TI - Estimating the financial savings from maintaining the level of acute services with fewer hospital beds. AB - All district health authorities are obliged to use resources most efficiently. One approach to increasing efficiency is to identify measures which allow service levels, in terms of patients treated and standards of care, to be maintained at a lower cost. This could be achieved by maintaining service levels with fewer hospital beds. Reducing lengths of stay by removing organizational delays and expansions of day-case care, are policies which can increase patient caseload per bed. This paper puts forward an approach for estimating the resources released by such policies and assesses the savings achieved by realizing efficiency gains identified in a previous study by Beech et al. (1987). That study identified significant potential for maintaining services with fewer beds, with the expansion of day-case care being a key mechanism. However this paper concludes that when services are maintained with fewer beds, the vast majority of hospital costs remain fixed. It also reaches the alarming conclusion that as a vehicle for reducing costs, day-case care is much less effective than previous studies have implied. However, increasing hospital throughput per bed does release capacity to treat more patients. The proposed reforms of the NHS (Secretaries of State, 1989) envisage an internal market for health care, allowing hospitals to enter into contracts with purchasers of health care. The approach to costing described in this paper is applicable to assessing the increased costs associated with such developments. These extra costs can then be compared with expected income. PMID- 10170556 TI - Sierra Tucson treatment center profits from patients, high profile. AB - An Arizona dependency treatment center is building a high profile and high profits by attracting private-pay patients and very private clientele such as Ringo Starr and Rob Lowe. An initial public offering last year has gained more than 50% in value, and expansion is in the works. PMID- 10170557 TI - Patient attitudes in day surgery a "breakthrough". PMID- 10170558 TI - Back away from strains and sprains. PMID- 10170559 TI - Helping the addicted nurse. PMID- 10170560 TI - Will the disabilities bill disable your group practice? PMID- 10170561 TI - Antibiotic prophylaxis in cardiothoracic surgery: results of a second survey. AB - The use of prophylactic antimicrobials in cardiothoracic surgery has become an accepted medical practice. The choice of drug and the duration of therapy varies among institutions. In 1985, we conducted a telephone survey to determine the choice of prophylactic antimicrobials in cardiothoracic surgery programs across the U.S. We recently conducted this survey for a second time. In our 1988 survey, 51 hospitals responded, with 34 (67%) having a standard antimicrobial regimen. Of all hospitals surveyed, first-generation cephalosporins were the most commonly used agents. First-generation cephalosporins were employed in 33 (48.4%) hospitals, cefamandole in 13 (19.1%), cefuroxime in nine (13.2%), vancomycin in three (4.4%), and vancomycin plus gentamicin in two (2.9%). A variety of other agents were employed by one of the remaining hospitals. Fourteen (27%) hospitals had automatic stop orders for antimicrobial prophylaxis in this indication. Ten (19.6%) institutions had changed the antimicrobial agent(s) used for prophylaxis in the last year. The results of this survey indicate that most hospitals continue to use first-generation cephalosporins for antimicrobial prophylaxis in cardiothoracic surgery, but there is considerable variation among institutions. PMID- 10170562 TI - Hospitals and AIDS discrimination: applicability of federal discrimination laws to HCWs (health care workers) and staff physicians. PMID- 10170563 TI - United States Commission on Civil Rights--medical discrimination against children with disabilities: an abstract. PMID- 10170564 TI - Hospital labs' cost pressures to continue, but right strategy can test positive for profits. PMID- 10170565 TI - National Health Service census on ethnicity and disability. PMID- 10170567 TI - Dr. Death's suicide machine. PMID- 10170566 TI - Individual versus team case management in optimizing community care for chronically ill patients with dementia. AB - Secondary analyses of a randomized trial comparing two models of case management of community residing chronically ill elderly showed that the greatest cost savings of the more intensive neighborhood-based team model, as opposed to the centralized individual model, were in the group with dementia. Estimated costs of health care in the team group were 41% lower than costs for the control group. No differences in survivorship, functional and care need status, or in caregiver satisfaction were found, suggesting no negative effect of reduction in use. Team case managers had much smaller caseloads, made many more home visits, (with much more counseling for family support), and made more referrals for medical evaluation, respite, and day care than did case managers for the control group. PMID- 10170568 TI - Corporate America's response to substance abuse. PMID- 10170569 TI - HMM price watch. Purchasing managers' index still on upward climb from 50.2 in April to 50.7 in May. PMID- 10170570 TI - Megatrends 2000: strategic implications for health care. PMID- 10170571 TI - 1988 summary: National Hospital Discharge Survey. PMID- 10170572 TI - Dementia and the elderly: facilitating care in the home and community. Proceedings of the Eighth Annual PRIDE Institute Conference, October 12, 1989. PMID- 10170573 TI - Modifying the home environment or community setting for people with cognitive impairments. AB - We need a great deal of work on household and day care environmental design. Systematic research, linked to the degree of impairment and to individual lifestyles, is appropriate. I have only scratched the surface of environmental considerations, with some attention to distinguishing the issues of home, community, and institutional environments. It is important that we identify some of the unique priorities in each of these settings. To draw conclusions from institutional settings and apply them to the home is to miss some of the strengths inherent in the home. We have come a long way. Once, it was pretty well accepted that older people with dementia were oblivious to their environments. Now, through observation and improvisation, we have come to understand that there are both individual reactions and patterns of responsiveness. In the future, we need to identify environmental design issues appropriate to mild, moderate, and severe levels of impairment; to different types of contexts (urban versus rural or suburban); and to different subcultures and economic groups. PMID- 10170574 TI - Developing a community services model: home care, day care, and residential services. PMID- 10170575 TI - Linking persons with dementia to appropriate services: summary of an OTA study. PMID- 10170576 TI - Health abuse marketing. AB - The Health Care Industry is being challenged by diverse needs and demands from the population at large. A growing market is the chemically dependent and the variety of situations that each individual and substance brings. As the public awareness and education increases, organizations, hospitals and groups are responding. This paper will discuss the behaviors around cigarettes, food, alcohol, co-dependency and drugs along with programs and approaches established to address these issues. PMID- 10170578 TI - Recent changes in service use patterns of disabled Medicare beneficiaries. AB - An analysis was made of the pre- and post-patterns of Medicare Part A service use using the samples of the 1982 and 1984 National Long-Term Care Surveys linked to the Medicare Part A bill files and mortality reports. The analysis was conducted both for the total elderly Medicare beneficiary population and for the community resident disabled population--a group felt to be particularly vulnerable to any adverse effect of the prospective payment system's induced change in service use. The expected changes in Medicare service patterns were identified, but there was no evidence of adverse changes in outcome--even for select vulnerable populations. PMID- 10170577 TI - Outcomes of surgery under Medicaid. AB - In this study, health outcomes during the 6-month period following surgery are examined for all Medicaid recipients in Michigan and Georgia who underwent selected surgical procedures between July 1, 1981, and June 30, 1982. Readmissions were somewhat more prevalent in both States for hysterectomy, cholecystectomy, appendectomy, and myringotomy. On almost all measures in both States, levels of post-surgical utilization, expenditure, and complications were higher among females, older patients, Supplemental Security Income enrollees, and those with higher levels of presurgical utilization and longer and more costly surgical stays. The results further demonstrate the utility of claims data in monitoring outcomes of surgery. PMID- 10170579 TI - Toward a prospective payment system for ambulatory surgery. AB - In this article, ambulatory surgery among the aged Medicare population in 1985 is examined. Total hospital facility charges for ambulatory surgery in that year were estimated at $1.8 billion, with about one-half of that amount involving cataract surgery. The possibility of using diagnosis-related groups for a prospective payment system for ambulatory surgery was examined and was rejected for two reasons: (1) about 20 percent of the dollar volume of hospital-based ambulatory surgery fell into medical diagnosis-related groups and (2) the ratio of inpatient diagnosis-related group weight to outpatient billed charges for the ambulatory procedures falling into a given diagnosis-related group varied more than tenfold, making diagnosis-related group weights impossible to use in a consistent manner. A newly developed version of ambulatory visit groups and the even newer ambulatory patient groups were then considered as an alternative for a prospective payment system. These are briefly described. PMID- 10170580 TI - The role of guidelines in achieving rational health care management. PMID- 10170581 TI - Labs take the strain. PMID- 10170582 TI - Drug interaction microcomputer software evaluation: Drug Therapy Screening System (DTSS). AB - Drug Therapy Screening System (DTSS) was evaluated using general and specific criteria. The installation process, ease of learning and use, the user documentation, and the technical support were rated excellent. The scope of coverage, the quality of the clinical documentation, and overall clinical performance were also excellent. The frequency of updates is good. The program is one of the best microcomputer drug interaction software packages evaluated by the authors thus far, because of its comprehensiveness, simplicity in use, and quality of its drug interaction information. The relatively high annual cost may limit its attractiveness. PMID- 10170583 TI - The interdisciplinary team approach to long-term care of the dementia patient. PMID- 10170584 TI - Hospital sees payback from back testing. PMID- 10170585 TI - Revision of ambulatory surgical center payment rate methodology; Medicare program -HCFA. Correction of final notice. AB - This document corrects technical errors to the final notice published in the February 1, 1990 issue of the Federal Register (90-2669), beginning on page 4526. PMID- 10170586 TI - Medicare program; payment for outpatient surgery at eye specialty hospitals and eye and ear specialty hospitals--HCFA. Final rule. AB - In accordance with section 4068(a) of the Omnibus Budget Reconciliation Act of 1987, this final rule revises the payment provisions concerning outpatient hospital services furnished in connection with ambulatory surgical procedures for certain qualified eye specialty hospitals and eye and ear specialty hospitals. It establishes that, for cost reporting periods beginning on or after October 1, 1988 and before October 1, 1990, the blended payment amount applicable to these hospitals remains at 75 percent of the hospital-specific amount and 25 percent of the ambulatory surgical center amount. PMID- 10170587 TI - Medicaid program; eligibility of qualified severely impaired individuals who work -HCFA. Final rule with comment period. AB - This rule amends the Medicaid regulations to specify, for Medicaid coverage, a permanent eligibility group of qualified individuals who, although severely impaired, work and demonstrate ability to perform substantial gainful activity and who are considered to be Supplemental Security Income (SSI) recipients. It also specifies how SSI payments made to certain institutionalized individuals are to be disregarded as income under Medicaid for a limited period. The amendments conform the regulations to provisions of the Omnibus Budget Reconciliation Act of 1986 and the Employment Opportunities for Disabled Americans Act. PMID- 10170588 TI - When saving lives is a specialty. PMID- 10170589 TI - Two designs for Alzheimer's patients. PMID- 10170590 TI - Summary suspension of physician after conviction for drug-related felony upheld. PMID- 10170591 TI - Ways to make EAPs more cost effective. PMID- 10170592 TI - Current list of laboratories which meet minimum standards to engage in urine drug testing for federal agencies--ADAMHA. Notice. AB - The Department of Health and Human Services notifies Federal agencies of the laboratories currently certified to meet standards of subpart C of Mandatory Guidelines for Federal Workplace Drug Testing Programs (53 FR 11986). Starting this month, a similar notice listing all currently certified laboratories will be published monthly, and updated to include laboratories which subsequently apply and complete the certification process. If any listed laboratory fails to maintain its certification, it will be omitted from updated lists until such time as it is restored to full certification under the Guidelines. PMID- 10170594 TI - Dual Alzheimer's unit sensitively carved out of X-shaped floor plan. PMID- 10170593 TI - Drug interaction microcomputer software evaluation: PDR's drug interactions and side effects diskettes. AB - The PDR's Drug Interactions and Side Effects System was evaluated using general and specific criteria. The installation process, ease of learning, and ease of use were rated excellent. The user documentation and technical support were good. The quality of the clinical documentation was fair. The scope of coverage and overall clinical performance were fair. The frequency of updates is good. The primary advantage of the program is its citation of drug interactions and side effects listed in the official product labeling of numerous brand name products. The major disadvantages are that it lacks evaluative interaction information, may not include current information, and only contains brand names listed in one of the PDR compendia. PMID- 10170595 TI - 'Outpatient care putting elderly at risk'. PMID- 10170597 TI - Focusing on ambulatory surgery. American Hospital Association's Society for Ambulatory Care Professionals. PMID- 10170596 TI - Psychiatric hospitals softening tone and content of advertising messages. AB - Hospitals that offer chemical-dependency treatment are moving away from the grim messages of death that once characterized their marketing and advertising efforts. They're relying more on positive messages to persuade people to get help or motivate loved ones to step in. PMID- 10170598 TI - Guiding HCFA through payment reform. Interview by Roxanne Bolinger. PMID- 10170599 TI - Operation theatre. PMID- 10170600 TI - NCEPOD (National Confidential Enquiry into Perioperative Deaths) PMID- 10170601 TI - A new era in the European marketplace. AB - While many American healthcare supply companies already do business in a global market, the European Community's impending switch to a single-market system and the radical changes in Eastern European countries in recent months should spell increased opportunities overseas. However, as European trade barriers come down, the level of competition is likely to go up, both at home and abroad. PMID- 10170602 TI - Disabled adults learn the laundry business. PMID- 10170603 TI - Remembering the forgotten. OBRA demands attention for Alzheimer's patients. PMID- 10170604 TI - Special report on labor and employment. Substance abuse in the workplace: considerations in adopting a substance abuse policy. PMID- 10170605 TI - The Disabilities Act and its effect on life safety. PMID- 10170606 TI - Medical center not guilty of discrimination. PMID- 10170607 TI - Method for quality control of laboratory tests using histograms of daily patient data. AB - A method for controlling the quality of laboratory tests is proposed. Histograms of patients' daily results which fall within reference ranges of healthy individuals are used for estimating accuracy and precision of measurements. For the determination of accuracy, three methods are evaluated; computing an average of patients' results; determining the location of the peak of the histogram; approximating the histogram by an Erland distribution and determining the peak of the distribution. For precision control, standard deviations are calculated from patient data. We applied these methods to serum aspartate aminotransferase (AST or SGOT) and total cholesterol of patients in a general hospital. Averages, peaks of approximated Erland distribution, and standard deviations were found to be useful to daily quality control in laboratories of large hospitals. PMID- 10170608 TI - Pet therapy for Alzheimer's patients: a survey. PMID- 10170609 TI - A case mix procedure for matching the clinical characteristics of patients with dual disorders to planned treatment and treatment costs. AB - A procedure for matching the clinical characteristics of patients with a dual substance abuse psychiatric disorder to planned treatment resource consumption is described. The procedure uses current standards and practices within the mental health literature on dual diagnosed patients, providing an empirical basis for quality assurance, utilization review, and program evaluation. These procedures permit an empirical linking of clinical service performance to the costs of clinical resources, thereby providing a means of: (a) evaluating program costs in terms of the specific clinical characteristics of patients and (b) planning budgets based on the patients' clinical needs. The methods are sufficiently flexible so that as new clinical research recommend changes in assessment and treatment, the case mix definitions and evaluation procedures can be easily modified. PMID- 10170610 TI - Identification of patients with coexisting alcohol and cocaine disorders at a community mental health center. AB - To measure the prevalence of cocaine abuse at a community mental health center's inpatient alcohol unit, a 20 item document was used to obtain information from the medical records of 162 patients admitted from January 1988 through July 1988. The data collected were analyzed to evaluate the assessment, diagnosis, treatment and referral of patients with coexisting alcohol and cocaine disorders. Of the 162 patients in the sample, 154 (95%) had a diagnosis of alcohol abuse/withdrawal and five (3%) had a diagnosis of cocaine abuse. Fifty-five patients had used cocaine for at least one year and 39 (24%) of the patients had a positive laboratory test for the drug upon admission. Eighty-six patients, over 53 percent of the sample, met the DSM III-R criteria for cocaine abuse, but only five (3%) of the patients were referred to substance abuse clinics or support groups upon discharge. These findings highlight the inadequate diagnosis, treatment and follow-up of patients with coexisting alcohol and cocaine disorders. PMID- 10170611 TI - The mentally ill substance abuser: challenges for the administrator. AB - Despite a high incidence of dual diagnosis among substance abusers and among the mentally ill, few programs provide the comprehensive services needed to address both problems simultaneously. Dual diagnosis presents a series of challenges for administrators: Which problem should be addressed first? Should admission criteria be altered to exclude such clients? Can more comprehensive services be offered within existing funding? Differences between the two domains of treatment exacerbate their inability to work together. Substance abuse programs often employ "recovering" individuals as treatment staff and offer relatively brief inpatient programs, often using confrontational approaches. Self-help groups are frequent adjuncts to treatment but disdain the use of prescribed medications. In contrast, programs for the chronic mentally ill usually do not employ former clients, have longer lengths of stay, include use of medications to alter behavior, and are more supportive and educational. Overcoming barriers to treatment must involve change in policies related to funding, staff training, admission criteria and differences in philosophy of treatment. PMID- 10170612 TI - Cardiac services find a new home in community hospitals. AB - Community hospitals increasingly are entering the cardiac-care business, with hopes of enhancing their public image, increasing revenues and winning managed care contracts. But some question whether advanced services such as cardiac catheterization and open-heart surgery are profitable for smaller hospitals, or even medically appropriate. PMID- 10170613 TI - Cardiac catheterization moves out. PMID- 10170614 TI - What's up, doc? Huggable scrubs, that's what! PMID- 10170615 TI - Cocaine: the right place at the right time. PMID- 10170616 TI - Establishing drug use questionnaire concurrent validity: methodological considerations. AB - The recent call for comprehensive drug education programs has provided a multitude of opportunities for health education specialists. Unfortunately, not all drug education programs are effective. Because of their lack of effectiveness, there is a need for comprehensive evaluation of existing programs. In order to conduct high quality evaluations, valid data collection procedures must be used. Probably the most common method of collecting data in drug use studies is the self-report questionnaire. One method of establishing the validity of these questionnaires is through urinalysis-based concurrent validity studies. Despite results similar to laboratory tests, investigators may have increased confidence in the results obtained from their questionnaires. PMID- 10170617 TI - 'The point is to save lives.' Needle exchange in Hawaii. PMID- 10170618 TI - A thousand points ... needle exchange around the country. AB - Needle exchange in the United States is a part of the AIDS direct action movement. Activists around the country, refusing to wait for health officials to create AIDS interventions for drug users, have taken the task upon themselves. Prevention Point in San Francisco, the National AIDS Brigade in Boston, and ACT UP/New York all run illegal programs in their locales, and member of all three groups have been arrested for their work. Tacoma, Seattle, and New Haven now have authorized programs, but only after Dave Purchase in Tacoma, ACT UP Seattle, and the National AIDS Brigade and ACES in New Haven demonstrated that needle exchange was a viable and necessary public health intervention. Health/PAC here presents some of the stories from this citizen's health action movement. PMID- 10170619 TI - Drug use and AIDS in New York City. Health policy for the '90s--discussion. PMID- 10170620 TI - Drug policy in the age of AIDS: the philosophy of 'harm reduction'. PMID- 10170621 TI - Hospital emergency rooms: an endangered species? PMID- 10170622 TI - The Americans with Disabilities Act of 1990: health care aspects. PMID- 10170623 TI - A skeptical approach to new technology--a cost control strategy. PMID- 10170624 TI - Refined DRGs: an add-on system identifying groups of patients with similar resource usage profiles. PMID- 10170625 TI - Costs of alcohol, drugs and mental illness. PMID- 10170626 TI - Disabilities discrimination: a map through the maze. Part 1: Employment issues. PMID- 10170627 TI - Overcoming to help others. AB - Drew Batavia has known the plight of the disabled ever since an automobile accident left him paralyzed from the neck down 17 years ago. Now as a White House Fellow he's using the first-hand knowledge to help others by translating the Americans with Disabilities Act into rules employers must follow in the work place. PMID- 10170628 TI - Method to assess quality of cardiac care developed. PMID- 10170629 TI - Managers grapple with decisions about lap cholies. PMID- 10170630 TI - Hospices services for the terminal Alzheimer's patient. AB - Alzheimer's patients and their families have dealt with the physical and emotional burdens of this debilitating disease for many years. By the time Alzheimer's advances into its terminal phases the patient needs additional care and the caregiver--often frail and elderly--needs respite. Visiting Nurse/Hospice Atlanta combines home care and hospice so that Alzheimer's patients can spend their last days at home, with their families. PMID- 10170631 TI - Drug cost review: January-June 1990. PMID- 10170632 TI - IMS updates HMM's pharmacy indexes. PMID- 10170633 TI - Hiring-bias charge tied to AIDS. PMID- 10170634 TI - A mathematical model for scheduling screening tests for progressive diseases. AB - In this paper, a mathematical model describing the stochastic process underlying the etiology of noncontagious, curable, progressive diseases is developed. In our previous study of progressive diseases, the reliabilities of screening tests were assumed to be constants, independent of how long the individual has had the disease. The purpose of this study is to develop more insight into modeling the disease process, and the interaction of screening tests with the natural behavior of the disease. To accomplish this task, more realistic screening parameters are selected, and optimum policies for mass screening programs under different reliabilities of screening tests are developed. These modifications make the model general enough to be applicable to a larger class of progressive diseases that includes breast cancer. Solutions to two simplified versions of the model for childhood neuroblastoma illustrate the use of our proposed procedure. PMID- 10170635 TI - The shadows lurking behind Dr. Death. PMID- 10170636 TI - Nutrition, hydration, and the demented elderly. PMID- 10170637 TI - Nurse diversion program helps addicted nurses. PMID- 10170638 TI - One nurse's recovery from drug addiction. PMID- 10170639 TI - N.J. hospitals battle appeal of CON denial. PMID- 10170640 TI - Disabilities Act to influence hiring practices of providers. PMID- 10170641 TI - Women's health and rights gain media's and medicine's attention. PMID- 10170642 TI - Kevorkian murder charge dropped but not forgotten. PMID- 10170643 TI - Chemical dependency program: monitoring & evaluation. PMID- 10170644 TI - Enforcement of nondiscrimination on the basis of handicap in federally assisted programs. Final rule. AB - This common rule amends the regulations issued by the agencies listed above for enforcement of section 504 of the Rehabilitation Act of 1973, as amended, in federally assisted programs or activities to include a cross-reference to the Uniform Federal Accessibility Standards (UFAS). Because some facilities subject to new construction or alteration requirements under section 504 are also subject to the Architectural Barriers Act, government wide reference to UFAS will diminish the possibility that recipients of Federal financial assistance would face conflicting enforcement standards. In addition, reference to UFAS by all Federal funding agencies will reduce potential conflicts when a building is subject to the section 504 regulations of more than one Federal agency. PMID- 10170646 TI - How willing are general practitioners to manage narcotic misuse? AB - In 1989 a self-administered questionnaire concerning current management of, attitudes to, and knowledge of, narcotic misuse was completed by 206 Inner London general practitioners. Results showed that whilst over three quarters were prepared to offer patients supportive interviews, few were willing to prescribe for them, most preferring to refer to specialist facilities. Only 33 respondents had received adequate training in the management of narcotic misuse, but over a quarter expressed an interest in small group training to improve their skills. These findings are discussed in relation to Department of Health guidelines concerning the management of narcotic misuse. PMID- 10170645 TI - Position paper on the role of occupational therapy in adult physical dysfunction. The Canadian Association of Occupational Therapists. AB - When an adult suffers from trauma or a condition that results in physical impairment or dysfunction, independence in daily living tasks may be affected. The occupational therapist's perspective and expertise lies in the assessment and treatment of the individual's function/dysfunction in the occupational performance areas of self-care, productivity and leisure. Assessment and treatment is carried out within the context of the individual's lifestage and environment. The occupational therapist facilitates the individual to assume a reasonable degree of responsibility for the rehabilitation process. Through the use of specific treatment approaches and techniques, occupational therapy intervention assists adults with physical dysfunction to restore function, develop new skills, develop adapted techniques, and maintain existing skills. PMID- 10170647 TI - Initiation and evaluation of a pilot scheme for minor surgery in general practice. AB - This study evaluated minor surgery in seven general practices in Stockport during the last six months of 1988. Information was collected from general practitioners followed by a survey on patient and doctor satisfaction with the scheme. A total of 361 minor surgery procedures were undertaken with no serious consequences of intervention; the post-operative infection rate was less than 1%. Financial implications were identified, including the effect on the District histology services. The results suggest high doctor/patient satisfaction rates, and support the hypothesis that minor surgery in general practice presents a practical alternative to hospital provision. PMID- 10170648 TI - An evaluation of a respite care unit for elderly people with dementia: framework and some results. AB - This paper offers a comprehensive framework for service evaluation relevant to a new respite care unit, and reports some results of its application. On existing evidence the planning assumption of a preventive effect of respite care, in avoiding admission to institutional care, is argued to be unjustifiable. The results indicate that this unit had a high non-attendance and fall-out rate, and no incentives to co-operate with alternative services or to operate efficiently. Broad estimates of cost parities revealed that attenders at the unit sacrificed considerable amounts of alternative forms of care. PMID- 10170649 TI - The new lab law. How will group practices fare? The 1990 AGPA laboratory survey. AB - The cost of doing business will increase due to the fact that hospital and reference labs charges will be higher than the cost of performing tests on-site. These higher costs will be reflected in higher charges to patients. Patients will lose the ability to have face-to-face discussion with physicians regarding lab results. PMID- 10170650 TI - Nursing homes report patients' mental problems. PMID- 10170651 TI - Use and cost of short-stay hospital inpatient services under Medicare, 1988. AB - In this article, data are presented on trends in the use of and program payments for inpatient short-stay hospital services to Medicare beneficiaries. The data on the services used by aged and disabled Medicare beneficiaries are presented for the years 1972 through 1988. The discussion is focused on trends in utilization and program payments resulting from the implementation of the Medicare prospective payment system. The State data for 1988 consist of utilization and program payment statistics by the residence of the beneficiaries in urban and rural areas. This is the first time that inpatient hospital data have been presented in this manner. PMID- 10170652 TI - Guidelines for managing ambulatory surgery programs in the 1990s. PMID- 10170653 TI - Costs of ambulatory care: implications for outpatient prospective payment systems. PMID- 10170654 TI - Critical issues surrounding the evolution of ambulatory surgery. PMID- 10170655 TI - Study tracks costs of treating employees' drug problems. PMID- 10170656 TI - Orthopedic implants swing toward group contracts. PMID- 10170657 TI - Dealing with the impaired supervisor. AB - As professional impairment issues have gained increasing recognition, a multitude of resources have been established for dealing with them. The most common source of impairment is chemical dependence-especially involving alcohol. The PA working with an impaired supervisor should understand the disease process associated with chemical dependence, come to terms with his or her own personal views on impairment, and seek support from colleagues. Every state has some form of physician impairment mechanism. With increasing availability of support systems, the prospects are good for successful rehabilitation of impaired professionals. PMID- 10170658 TI - The sole source: the Library of Congress National Library Service for the Blind and Physically Handicapped. AB - The Library of Congress National Library Service for the Blind and Physically Handicapped leads a co-operative network of specialized libraries and ancillary agencies that are delivering a successful programme of reading and informational services to blind, visually impaired and handicapped users. Its unique position within the Library of Congress and the benefits which emanate from this relationship are described. This current review outlines and discusses the development, role and functioning of the National Library Service. PMID- 10170660 TI - An effective method of handling PRN orders to reduce labor and improve efficiency. AB - Rex Hospital, Raleigh, NC, found its method of PRN (unit dose) medication delivery to be time consuming, labor intensive, and repetitive. Thus, it was decided to evaluate this system and to find a more efficient method of PRN delivery. A 24 hour supply of unit dose medication is delivered daily using a cart exchange system at this hospital. Three approaches were used to reduce the handling of PRN medications: (1) Removing all PRN orders of Milk of Magnesia, cascara, and mineral oil from the patient drawer. These three medications are now floor stock items at each nursing station; (2) Removing all PRN orders of 325 mg aspirin and acetaminophen tablets, 600 mg aspirin, and 650 mg acetaminophen suppositories. These items are now kept at the nurses station as a "no charge" floor stock item; and (3) Using zip-lock bags for all other non-controlled PRN medication orders. A 48 hour supply of medication is sent upon receipt of the original order, and not filled again until the empty bag is returned to the pharmacy. The plastic bag is identified by a computer generated label containing the patient's name, room number, and medication identification. The patient medication drawer is divided into two areas, one for storing standing medication orders and one for PRN orders. A time study showed a 40% improvement in cart filling time. The 48 hour supply of PRN medications rarely need refilling. Milk of Magnesia, cascara, and mineral oil PRN orders are often ordered, but seldom used. Thus, floor stocking these items has not been a problem. Floor stocking aspirin and acetaminophen as no charge items has been very successful. All medication orders, including aspirin, acetaminophen, Milk of Magnesia, and so forth are entered onto the patient's medication profile even though they are not sent from the pharmacy. Drug allergies or drug-drug interactions can be detected by reviewing the patient profile when the original order is entered onto the profile. Nursing is very pleased with the divided patient medication drawers and has had no problem with turn around time using PRN bags. PMID- 10170659 TI - Anatomy of the Alzheimer's Respite Care Program (ARCP). AB - The Alzheimer's Respite Care Program is an innovative project designed to serve caregivers of Alzheimer's clients. This unique model offers both in-home and institutionally based respite care. Two community organizations which offer Adult Day Care respite forged a partnership to coordinate and expand their continuum of care, bringing many of the benefits of a day care setting into the home. This paper compares the original project conceptualization with its current design today. Factors affecting this evolution are explored together with program modifications incorporated to more appropriately respond to local needs. Key marketing strategies are discussed coupled with a presentation of program successes and recommendations for the future. PMID- 10170661 TI - Instituting a multiple-site urinalysis QC program. PMID- 10170662 TI - Creative ways to employ people with disabilities. PMID- 10170663 TI - What's new in surgery for 1991? Colon & rectal surgery. PMID- 10170664 TI - What's new in surgery for 1991? Critical care & metabolism. PMID- 10170665 TI - What's new in surgery for 1991? Gastrointestinal & biliary conditions. PMID- 10170666 TI - What's new in surgery for 1991? Gynecology & obstetrics. PMID- 10170667 TI - What's new in surgery for 1991? Neurological surgery. PMID- 10170668 TI - What's new in surgery for 1991? Surgical oncology. PMID- 10170669 TI - What's new in surgery for 1991? Orthopaedic surgery. PMID- 10170670 TI - What's new in surgery for 1991? Otorhinolaryngology. PMID- 10170671 TI - What's new in surgery for 1991? Pediatric surgery. PMID- 10170672 TI - What's new in surgery for 1991? Plastic surgery. PMID- 10170673 TI - What's new in surgery for 1991? Trauma & burns. PMID- 10170674 TI - What's new in surgery for 1991? Urology. PMID- 10170675 TI - What's new in surgery for 1991? Peripheral vascular surgery. PMID- 10170676 TI - What's new in surgery for 1991? Cardiac surgery. PMID- 10170677 TI - HIV/AIDS prevention: problems and approaches to establishing needle exchange programs in rural areas. AB - Needle and Syringe Exchange Programs (NSEP) were established to prevent the spread of HIV/AIDS amongst intravenous drug users (IVDU). The first rural NSEP in Australia was developed in the North Coast Region of NSW. The aims and objectives of the NSW NSEP are outlined. The problems and approaches faced by health services managers in developing a needle exchange program in a conservative rural area are presented with the emphasis on 4 major groups: intravenous drug users; the media; the general community and the public health system. A brief description of the North Coast NSEP, which is a combination of fixed outlets and outreach work, is presented. During 1989, there were 4,000 direct client contacts with 65,000 needles/syringes dispensed and 45,000 collected (69% return rate) for contaminated waste disposal. PMID- 10170678 TI - Laboratory reports issued on or after discharge date. AB - The authors of this article discuss the problem of ensuring that physicians are informed of bacteriology test results in a timely manner, a study they undertook, and the steps taken to solve the problem. PMID- 10170679 TI - Dealing with substance abuse in the workplace. AB - Substance abuse within the workplace affects both the employer and the employee. A decrease in morale and an increase in accidents and sick calls can contribute to significant financial losses for an institution. This article discusses ethical and legal considerations in developing substance abuse policies and employee assistance programs. A proactive approach intended to prevent substance abuse and exert greater control over the problem with resulting decreases in the waste of valuable human resources is presented. PMID- 10170680 TI - The evolution of the Oregon program for impaired physicians. PMID- 10170681 TI - Monitoring recovering physicians: the New Mexico experience. PMID- 10170683 TI - Medical device regulation: silicone breast implant dangers. PMID- 10170682 TI - Access to Medicaid and Medicare by the low-income disabled. AB - The most pervasive eligibility-related problems encountered by low-income disabled persons in gaining access to Medicaid and Medicare are reviewed in this article. A series of options for restructuring program eligibility requirements are presented, with particular attention to improving the plight of the low income disabled worker during the 24-month waiting period for Medicare. Options for Medicaid involve nationwide income eligibility levels at 100 percent of poverty and mandatory buy-in provisions to Medicaid in all States. For Medicare, the reforms range from altering the waiting period for Medicare by the disabled who are expected to die within 24 months after benefit award to eliminating the waiting period altogether. PMID- 10170684 TI - Health issue advertising. AB - "Americans say that the battle against drugs is the chief issue facing the nation" (McQueen and Shribman, 1989). The Wall Street Journal/NBC poll conducted by Peter Hart and Robert Teeter shows a public willingness to experiment with a wide variety of anti-drug efforts. "No single issue has so riveted the nation's attention since the 1982 recession," Messers. Hart and Teeter say in their analysis of the poll. They add that respondents seem willing to try almost anything to solve the drug problem (ibid). How can and does marketing affect this process? This paper will examine some of the methods and effectiveness of advertising in regard to this very timely health issue and societal challenge. For the purposes of this paper, drug discussions refer to alcohol as well. Social marketing in general will be addressed. PMID- 10170685 TI - Hospital unit to treat Alzheimer's. PMID- 10170686 TI - Putting EAP (employee assistance programs) in the driver's seat. PMID- 10170687 TI - The Pepper Report. A legislative proposal for long-term care. AB - The Pepper Commission, charged by Congress to recommend legislation that would ensure all Americans coverage from health care and long-term care, released its final report in 1990. Excerpted in this issue are sections of the report specifically addressing the issues of long-term care, and home care in particular. PMID- 10170688 TI - Myths & realities: why most of what everybody knows about long-term care is wrong. PMID- 10170689 TI - EMS drug tests: passing results? PMID- 10170690 TI - A comparison of hospital-integrated and freestanding ambulatory-surgery programs. Their uses of selected procedures. AB - For a variety of good reasons, the use of ambulatory surgery in the U.S. grew significantly during the 1980s. Both hospital-integrated and freestanding outpatient programs were developed, although a general lack of research on ambulatory surgery has not confirmed either approach's impact. Using the programs of Syracuse, New York, the author compares the two programs' volumes of procedures performed and each program's standing within the entire ambulatory surgery community. PMID- 10170691 TI - Day surgery. PMID- 10170692 TI - When duplicate testing leads to different results. PMID- 10170693 TI - An autologous transfusion program helped this small rural hospital. PMID- 10170694 TI - Civilian heart venture begins. PMID- 10170696 TI - HMM pricing index/price watch. PMID- 10170695 TI - A second look at second surgical opinions. PMID- 10170697 TI - Outpatient managers try new staffing ideas. PMID- 10170698 TI - The Alzheimer's Association dementia specialist training program. PMID- 10170699 TI - Respite care and dementia services program for central New York. PMID- 10170700 TI - The physician and the use of computers. Interview by Bill W. Childs. PMID- 10170701 TI - Substance abuse and dependence in the hospital workplace: detection and handling. AB - A hospital can take many avenues in dealing with an employee or professional who is impaired by substance abuse or dependence. The most difficult aspect of dealing with the problem is detection. Fortunately, increasing public awareness and concern regarding workplace substance abuse is forcing legislators to address the issue and expose the problem. The legislative response appears to be geared toward treatment and education rather than punishment, which in the opinion of this author is a desirable approach. The pharmacy department can be a valuable asset to the hospital risk manager in detecting diversion of controlled substances and educating employees as to the clinical signs and symptoms of impairment. PMID- 10170702 TI - Feds war on drugs in the workplace. PMID- 10170703 TI - "Reasonable accommodation" under the Americans with Disabilities Act--what does it mean? AB - The Americans with Disabilities Act (ADA) imposes on employers the duty to afford qualified disabled applicants and employees "reasonable accommodation," but provides minimal guidance as to the range of actions necessary to fulfill this duty. Under the statutory scheme, required accommodations will vary from employer to employer, from worksite to worksite for the same employer, and perhaps even from employee to employee at the same worksite. Personnel managers will be required to make very fact-specific decisions in each case as to whether to offer particular accommodations, with any decision declining to provide the accommodation subject to attack in litigation. Based on an analysis of how similar reasonable accommodation requirements have been interpreted under other statutes, this article analyzes the likely parameters of the duty to afford reasonable accommodation under the ADA and offers specific suggestions for employers to minimize their risk of liability. PMID- 10170704 TI - Required reading. Federal Disabilities Act increases litigation risks for providers. AB - The Americans with Disabilities Act of 1990 (ADA) is considered the most sweeping civil rights legislation since the Civil Rights Act of 1964. The two parts of the ADA that apply most directly to healthcare providers are the prohibitions on employment discrimination and the requirements for provision of services to persons with disabilities. The ADA states that a person's disability should not be an adverse factor in employment decisions. Employers must make "reasonable accommodations" to the qualified person's known impairment so that person can perform his or her job more easily. The ADA also prohibits private entities from discriminating against persons with disabilities in the full and equal enjoyment of services (i.e., "public accommodations"). Providers will have an affirmative duty to remove (in existing buildings) architectural elements proven to be barriers to persons with disabilities. Public access requirements apply to new building construction as well. Healthcare providers must also install wheelchair lifts in shuttle bus systems they operate. Healthcare providers, both as employers and providers of public services, now have just a matter of months in which to respond to these new requirements. Planning efforts to ensure compliance should begin immediately. PMID- 10170705 TI - The impaired nurse: assisting treatment to achieve continued employment. PMID- 10170706 TI - Benign moral hazard and the cost-effectiveness analysis of insurance coverage. AB - When a medical intervention is found to be cost effective, what level of insurance coverage should apply to it? The optimal level of coverage may be less than or greater than full coverage of medical care costs; a finding of cost effectiveness for a service does not necessarily imply v full coverage or coverage at the same rate as other services. If there is some imperfection in the ability to translate higher insurance benefits into higher insurer revenues, the optimal level of coverage will be greater the higher the degree of moral hazard applying to the service. PMID- 10170707 TI - Americans with Disabilities Act: overview of the employment provisions. AB - The Americans with Disabilities Act, when fully implemented, will affect almost every person in this country. The Act covers employment, public accommodations, transportation, and telecommunications. It will affect the employment, training, promotion, compensation, and termination policies of every employer having 15 or more employees. It also will affect the provision of goods and services by both private and public entities. This article examines the requirements included in Titles I and V of the Act pertaining to employment. PMID- 10170708 TI - Disabilities Act poses legal hurdles. PMID- 10170709 TI - Use of selected medical device implants in the United States, 1988. PMID- 10170710 TI - Voluntary drug testing for high school students. PMID- 10170711 TI - Rehabilitating workers hooked on drugs. PMID- 10170713 TI - How health care employers can prepare for the Americans with Disabilities Act. PMID- 10170712 TI - Eye hospitals diversify to stay afloat. AB - A special reimbursement deal from the government may not be enough to keep the nation's 18 eye specialty hospitals financially healthy. Many hospitals have been forced to diversify in the face of competition from freestanding surgery centers, which have chomped off much of the cataract surgery market. Also, the hospitals fear that peer review organizations soon may adopt a policy that would eliminate much of what's left of eye hospitals' remaining inpatient business. PMID- 10170714 TI - Getting orthopods to help in implant cost containment. PMID- 10170715 TI - Innovative Alzheimer's program helps patients, staff and family caregivers. PMID- 10170716 TI - Satellite registration program: a decentralized system to meet customer needs. AB - In summary, if you want to meet your patient, physician and ancillary service needs, then consider registration as a necessary transitional activity and then go about making it secondary to the reason the patient came for healthcare service. The complexities of data collection are for us to be concerned with, not the patient! Also, the physicians will appreciate your efforts on behalf of their patients. You, too, can have an effective Satellite Registration Program if you remember that flexibility, creativity and administrative support are essential to success! Good Luck! PMID- 10170717 TI - Computing. Not standard practice. PMID- 10170718 TI - 1992 and all that. PMID- 10170719 TI - Special needs dementia units: the next generation. PMID- 10170720 TI - Special needs dementia units: developing their true mission. PMID- 10170721 TI - The emergence of special care units. PMID- 10170722 TI - Meeting the needs of persons with Alzheimer's disease. PMID- 10170723 TI - Physical aspects of Alzheimer/dementia units: a national survey. PMID- 10170725 TI - Violent, drug-related crime contributes to closures of trauma units--report. PMID- 10170724 TI - Dual diagnosis among older adults: a new array of policy and planning problems. AB - Case finding and successfully engaging and treating older adults with substance abuse disorders continue to be enigmatic processes. Because of the adverse consequences on health of substance abuse among the elderly, substance abuse has serious implications not only for the well-being of the elderly but also for the future costs and resources of the mental health and health care systems for older adults. However, older adults with concurrent mental and substance abuse disorders are appearing in the public gerontological mental health system. This system is both unprepared and ill-equipped to manage and treat these often difficult clients. Further complicating the situation is the seeming lack of knowledge about "dual diagnosis" among the elderly. Policy and planning issues necessary to address this newly discovered array of problems are discussed. PMID- 10170726 TI - Surgery centers continue pattern of growth. AB - The number of outpatient surgery centers grew at an 11% clip in 1990, fueled by the continued shift of patients and procedures to the outpatient setting, according to a recent survey by SMG Marketing Group, a Chicago-based healthcare consulting and market research firm. But while figures project continued growth, competition and government regulation could limit future expansion. PMID- 10170727 TI - Dunedin Hospital's day surgery unit. PMID- 10170728 TI - Criminalization of pregnant substance abusers: a health care perspective. PMID- 10170729 TI - Drug exposed newborns: alternatives to punitive sanction of the mother--a coordinated response. PMID- 10170730 TI - Urban hospitals: society's last safety net. PMID- 10170731 TI - Medicare lab payments too high--GAO study. PMID- 10170732 TI - Disabilities Act proposed rules clarify facility obligations. PMID- 10170733 TI - Health-care professionals with AIDS: the risk of transmission balanced against the interests of professionals and institutions. PMID- 10170734 TI - Parent's presence eases children's fears. PMID- 10170735 TI - Second opinions and cost-effectiveness: the questions continue. AB - For nearly 20 years, second surgical opinion programs have been promoted as a means of containing health care costs. Since their introduction, debate has continued over their cost-effectiveness. This article provides a historical perspective of second surgical opinion programs, with a particular emphasis on the federal government's past and current involvement in these programs. Also included are a summary of recent reports on employers' and insurers' involvement in these programs and the College's views on second surgical opinion programs. PMID- 10170736 TI - Medicare program; withdrawal of coverage of certain investigational intraocular lenses.--HCFA. Final notice. AB - This notice announces the withdrawal of Medicare coverage for certain investigational intraocular lenses (IOLs). Medicare coverage of IOLs that have received approval by the Food and Drug Administration (FDA) will continue to be covered by Medicare, as well as certain other IOLs that are awaiting FDA approval. PMID- 10170737 TI - Nutrition & specialized care. AB - We live in a time of specialized medical care. Now, patients can find myriad healthcare centers that offer state-of-the-art treatment for their particular ailments & disabilities. As therapy regimens have become more sophisticated, so has the role food & nutrition programs play in patient care. Featured on the following pages are five programs that are tailored to patients living with chemical dependencies, eating disorders, cardiovascular disease, cancer & mental illness. In each, directors & dietitians are working actively with other healthcare professionals to provide the kind of nutritional support patients need to regain their health or, in some cases, even to survive. PMID- 10170738 TI - Special report on labor and employment. Provider obligations under the Drug-Free Workplace Act. AB - In view of the sanctions that may be taken by government agencies against employers, all providers should take their obligations under the Act seriously. The first step for each provider is to determine if it is subject to the Act or to any analogous state statutes. If so, the provider should take steps, if it has not already done so, to comply with the Act or applicable state legislation. While the Act has been criticized as a matter of social policy for not going further to prevent substance abuse in the workplace--by, for example, mandating drug testing or requiring sanctions against employees without the prerequisite of a criminal conviction--there is no question that the penalties it authorizes against employers do go far enough to warrant careful compliance with the Act's provisions. PMID- 10170739 TI - Issues for comparability of DRG statistics in Europe. Results from EURODRG. AB - DRG use has spread through most European countries thus offering an opportunity for improving hospital data bases at the European level. An EEC Concerted Action 'Use of DRGs to support Hospital Sector Management in the European Community' was approved by the Committee of Health Services Research of the EEC. A general overview of the project is presented as well as a detailed description of the results of the work on aspects related to DRG data production. These aspects (MBDS implementation and variables definition; coding systems and updating; mapping systems; data auditing; trimming methods; and DRG grouper versions) have been analyzed with the objective of increasing opportunities for valid international comparisons of DRG statistics between European countries. PMID- 10170740 TI - The impact of different coding systems on DRG assignment and data. AB - The Diagnosis Related Group (DRG) classification system is widely used to describe the casemix of acute care hospitals, making it possible to compare the casemix of hospitals from different countries. However, in order to fully understand these comparisons, it is necessary to clarify the impact which the different coding systems used in various countries may have had on the results. The DRG system is based on codes from the International Classification of Diseases 9th Revision Clinical Modification (ICD9CM). Countries which use other coding systems convert, i.e. map, their codes into the nearest ICD9CM equivalent before allocating the DRGs. The impact of mapping on both medical and surgical DRGs is discussed and new titles are given for the affected DRGs. As far as possible, problems caused by mapping are distinguished from those caused by differences in coding practices. Based on the analysis of the classification systems, the mapping tables and the resulting DRG data, it is concluded that using mapped data does not have a great impact on the DRGs. Only 37 DRGs (7.8%), 15 medical and 22 surgical classes, are affected by mapping problems. However, while the scale of these problems is not large, given the large number of different surgical classification systems currently in use in Europe, the introduction of a standard surgical classification system for Europe is recommended. PMID- 10170741 TI - DRGs: the state of the art, circa 1990. AB - The history, up to 1990, of operational DRG systems in the United States is described from the viewpoint of changes to the patient classification system. Uses of DRGs, the DRG assignment process and the clinical verification steps are also described. The DRG classification process has become more precise over the last decade in both detail and structure. The annual revision process used in the U.S. is outlined with a detailed summary of historical changes. Recent improvements to DRGs have been directed towards a higher degree of precision as regards patient severity and related resource intensity. Recent research into modifying DRGs to better account for complexity or severity is presented with some scenarios for future developments. PMID- 10170743 TI - Disabilities discrimination: a map through the maze: Part 2: Public accommodations and services. PMID- 10170742 TI - Antitrust policy in the Dutch health care system and the relevance of EEC competition policy and U.S. antitrust practice. AB - Dutch health care policy is undergoing a radical shift from a planning-oriented towards a market-oriented approach. A fundamental restructuring of the health care financing system should bring about workable competition among providers and among health insurers. As the result of both government regulation and anticompetitive self-regulation strong cartels and dominant positions are deeply rooted in the present Dutch health care system. In order to be successful structural reforms should be supported by an effective antitrust policy. However, present Dutch antitrust policy is too lenient to fulfil this necessary condition. EEC competition policy is far more stringent, but for several reasons its relevance will be limited. For an effective enforcement of national antitrust policy in health care, the so far unique American experience in this field provides some useful lessons. PMID- 10170744 TI - Substance abuse coverage provided by employer medical plans. AB - In summary, substance abuse is a serious problem in America. In fact, a Gallup poll ranked drug use as the Nation's number one problem. As a rapidly accelerating component of health care costs, charges for alcohol and drug abuse treatment are helping to drive up medical care expenses. The substance abuse crisis is also affecting employers, both public and private, who are struggling to provide needed health benefits while controlling spiraling plan costs. Despite the upward pressure on health costs, the problem is so serious that there has been a steady increase in the incidence of coverage for substance abuse treatment in employer-provided medical care plans, to the point that virtually all plans now provide some benefits. Nevertheless, health plans typically cover substance abuse treatment on a more restrictive basis than other illnesses. This may change, however, as the interest in, and the need for, comprehensive substance abuse treatment benefits grows. PMID- 10170745 TI - Hospitals grapple with HCFA's rules for clinical labs. PMID- 10170746 TI - No more knives. PMID- 10170747 TI - 1989 summary: National Hospital Discharge Survey. PMID- 10170748 TI - Investing in a drug-free workplace. PMID- 10170749 TI - Prioritising waiting lists. AB - The 'top 22' patient conditions on the general surgical waiting list at Guy's Hospital were rated independently by five general surgeons. Each surgeon estimated the peri-operative mortality rates associated with each treatment; the proportion of patients who failed to benefit; the effect of successful treatment on life expectancy and on the patients' quality of life. the mean values were used to estimate the expected net benefits (in terms of quality-adjusted life years) from treatment one year earlier than might otherwise have been the case. These benefits were then related to the operating times and length of stay associated with each treatment; this identified which treatments offered the greatest benefit per unit of each constrained resource. Of all conditions examined anal fissures where shown to be the least resource intensive in relation to the benefits generated, whilst varicose veins and epigastric hernias proved otherwise. For the full potential of this approach to be realised it needs to be repeated in other places and in other specialties. It nevertheless offers a more rational basis for interpreting waiting list data than presently exists and by using the short-cut methods is a relatively cheap way of generating much useful data. PMID- 10170750 TI - The cost of day surgery. AB - Recently there has been an expansion of day surgery in Britain. However, it is difficult to prove that surgical treatment on a day case basis actually saves money. This paper discusses the development of a new costing strategy which suggests that costs could be reduced by a planned programme of day surgery. These results have obvious significance for the National Health Service. PMID- 10170751 TI - D-FY-IT (Drug Free Youth in Texas): an anti-drug program that works. PMID- 10170752 TI - Final ADA regulations to be issued this month. PMID- 10170753 TI - Management issues in an AIDS era. PMID- 10170754 TI - A 24-hour ordering system for clinical examinations. AB - We have developed a 24-hour ordering system for clinical examinations, making use of the features of multi-function workstation (IBM5550) which performs two functions both in an on-line terminal and in a personal computer. It is used as an on-line terminal for the host computer (IBM4381) in day time. At night or on holiday, it is used as a stand-alone type personal computer to order clinical examinations. For this purpose, basic information of the inpatients (patient number, name, sex, date of birth, clinic, ward) are transferred from the host computer to the disket in the workstation in the evening when host computer finished on-line service. A physician can input the patient number followed by examination items using the touch panel according to the dialogue type guides written in Chinese character. Then, specimen label, list of ordered tests and an order form are printed out instantly. The date (patient number, examination items, identification number of the specimen, etc.) stored in the disket in the workstation at night are transferred from workstation to the host computer next morning. The host computer merges the information ordered in day time and at night and supplies working documents for examination (worksheets, master log, etc.) to technicians. Thus physicians can order examinations all day long using workstation, which make it possible to spare the time. PMID- 10170755 TI - Mistakes to avoid in CPT coding and billing. PMID- 10170756 TI - Using referral labs efficiently. Part II: Tips on evaluating and monitoring quality. PMID- 10170757 TI - New surgical techniques will improve outcomes, decrease costs. PMID- 10170758 TI - Disability and health: characteristics of persons by limitation of activity and assessed health status, United States, 1984-88. PMID- 10170759 TI - Comorbidity, age, and hospital use among elderly Medicare patients. AB - This article reports the findings of a retrospective study of elderly Medicare patients (N = 8,915) discharged from New York City hospitals prior to the implementation of the Medicare Prospective Payment System in New York State. Its purpose was to investigate physical comorbidity, mental comorbidity, age, and other factors for their relationship with hospital use. Study findings suggest that age, as used in the diagnosis-related group (DRG) classification scheme, is less powerful than comorbidity as a predictor of hospital use. Dementia, which is not recognized as a valid comorbid condition by the DRG system, was also found to be positively associated with use. PMID- 10170760 TI - Medicaid: providing health care to (some of) America's poor. AB - Although Medicaid has done much to relieve the health care burdens of the poor and the elderly, it is still widely viewed as falling short of its charge to provide the poor and indigent with access to quality health care. The most frequently discussed problems with the program relate to its structure of eligibility, benefits, and payment policy--which vary from state to state. Reforms are desperately needed if Medicaid is to realize its original goal--to provide care for those who would not have access to it otherwise. PMID- 10170761 TI - Equalizing reimbursement for outpatient surgery could save Medicare $118 million, report says. PMID- 10170762 TI - Fighting drug abuse in operating rooms. AB - A growing problem of drug addicts working in operating rooms is mobilizing hospitals to make it more difficult for staff members to steal drugs for their own use or for sale to others. Monitoring devices and tighter drug distribution security are among measures being used to deter theft by anesthesiologists, technicians or nurses who are addicted to one of many potent narcotics readily available to them. PMID- 10170763 TI - 1991 Gallup California health care poll. Californians want resolution to health access problems. PMID- 10170764 TI - Program dispels myths about disabled workers. PMID- 10170765 TI - Hospital outpatient payment policy: aiming for the target. PMID- 10170766 TI - Life-saving compulsory surgical intervention: a duty or a discretion? and the admissibility of evidence so obtained--the Israeli approach. PMID- 10170767 TI - Treatment for the patient with acute behavioral-emotional and chemical dependency problems: an analysis of outcome in an intensive residential program. AB - Data were collected from a study of 28 patients in 1988 and 18 patients in 1989 admitted into Camelback Vista Treatment Center. Camelback Vista is a free standing 64-bed residential center under Camelback Behavioral Health Services in Phoenix, Arizona. The tool used in this study was the Camelback Vista Self Assessment and Management Scale. This scale was specifically designed to provide a monitoring tool for a more acute patient population than has been treated in residential settings in the past. The 1988 study cited improvement in 72% of the patients studied. The 1989 study cited improvement in 78%. Both studies monitored four areas: personal skills, social skills, financial skills, and emotional skills. PMID- 10170769 TI - Chest image quality: film-screen vs. computed radiography. AB - Chest image quality is of three types: image attractiveness, physical measurement, and diagnostic yield measurement. Each is important, but it is the Georgetown group's opinion that it is the improvements in diagnostic yield that can result from the reconstruction of a single set of digital information with different image algorithms, each selected as best for a particular suspected disease, that will drive the conversion from conventional film radiography to storage phosphor plate radiography and that it is a combination of the need for the dissemination of images within hospitals and the desire to view several different reconstructions of chest digital data that will lead to chest radiographic images being interpreted on workstations. In its current form CR has been shown to be equivalent in diagnostic yield to FR. As better reconstruction algorithms are tested and proved, they are expected to demonstrate better diagnostic yield than FR. PMID- 10170768 TI - Does partial hospitalization for children with emotional disorders mean partial education? AB - In this keynote address, Dr. Zimet discusses two issues. She reviews the accomplishments and future efforts of the Child and Adolescent Special Interest Group in AAPH. And she presents research findings that attempt to answer the question posed in the title. PMID- 10170770 TI - Former drug addicts, family members talk about disease in hospital video. PMID- 10170771 TI - Testing health care workers for drugs: developing and implementing a program. PMID- 10170772 TI - Packaging a better brand of mental health. AB - Applying managed care procedures to mental health and substance abuse benefits has been the right recipe for Hunt-Wesson. PMID- 10170773 TI - Americans with Disabilities Act (ADA) accessibility guidelines for buildings and facilities. Architectural and Transportation Barriers Compliance Board. Final guidelines. AB - The Architectural and Transportation Barriers Compliance Board is issuing final guidelines to assist the Department of Justice to establish accessibility standards for new construction and alterations in places of public accommodation and commercial facilities, as required by title III the Americans with Disabilities Act (ADA) of 1990. The guidelines will ensure that newly constructed and altered portions of buildings and facilities covered by title III of the ADA are readily accessible to and usable by individuals with disabilities in terms of architecture and design, and communication. The Department of Justice has proposed to adopt the guidelines as the accessibility standards for new construction and alterations in places of public accommodation and commercial facilities for purposes of title III of the ADA. PMID- 10170774 TI - Nondiscrimination on the basis of disability by public accommodations and in commercial facilities--Department of Justice. Final rule. AB - This rule implements title III of the Americans with Disabilities Act, Public Law 101-336, which prohibits discrimination on the basis of disability by private entities in places of public accommodation, requires that all new places of public accommodation and commercial facilities be designed and constructed so as to be readily accessible to and usable by persons with disabilities, and requires that examinations or courses related to licensing or certification for professional and trade purposes be accessible to persons with disabilities. PMID- 10170775 TI - Nondiscrimination on the basis of disability in state and local government services--Department of Justice. Final rule. AB - This rule implements subtitle A of title II of the Americans with Disabilities Act, Public Law 101-336, which prohibits discrimination on the basis of disability by public entities. Subtitle A protects qualified individuals with disabilities from discrimination on the basis of disability in the services, programs, or activities of all State and local governments. It extends the prohibition of discrimination in federally assisted programs established by section 504 of the Rehabilitation Act of 1973 to all activities of State and local governments, including those that do not receive Federal financial assistance, and incorporates specific prohibitions of discrimination on the basis of disability from titles I, III, and V of the Americans with Disabilities Act. This rule, therefore, adopts the general prohibitions of discrimination established under section 504, as well as the requirements for making programs accessible to individuals with disabilities and for providing equally effective communications. It also sets forth standards for what constitutes discrimination on the basis of mental or physical disability, provides a definition of disability and qualified individual with a disability, and establishes a complaint mechanism for resolving allegations of discrimination. PMID- 10170776 TI - Equal employment opportunity for individuals with disabilities--EEOC. Final rule. AB - On July 26, 1990, the Americans With Disabilities Act (ADA) was signed into law. Section 106 of the ADA requires that the Equal Employment Opportunity Commission (EEOC) issue substantive regulations implementing title I (Employment) within one year of the date of enactment of the Act. Pursuant to this mandate, the Commission is publishing a new part 1630 to its regulations to implement title I and sections 3(2), 3(3), 501, 503, 506(e), 508, 510, and 511 of the ADA as those sections pertain to employment. New part 1630 prohibits discrimination against qualified individuals with disabilities in all aspects of employment. PMID- 10170778 TI - Hospitals need coordinated approach to deal with drug-addicted patients. PMID- 10170777 TI - Recordkeeping and reporting under Title VII and the ADA--EEOC. Final rule. AB - This final rule is based on two separate Notices of Proposed Rulemaking (NPRM) published on February 13, 1989 (54 FR 6551), and March 5, 1991 (56 FR 9185). This final rule amends 29 CFR part 1602, EEOC's regulations on Recordkeeping and Reporting under title VII of the Civil Rights Act of 1964 (title VII), to add recordkeeping requirements under the Americans with Disabilities Act of 1990 (ADA). It increases the records retention period required in part 1602 for title VII and the ADA from 6 months to one year. The Commission also is adding a new subpart R to part 1602, 29 CFR 1602.56, that will clarify that the Commission has the authority to investigate persons to determine whether they comply with the reporting or recordkeeping requirements of part 1602. In addition, the Commission is making several minor changes to sections 1602.7 and 1602.10. The Commission also is deleting section 1602.14(b) of its title VII recordkeeping regulations, which provides that the section 1602 recordkeeping requirements do not apply to temporary or seasonal positions. Information regarding such employees now must be reported on Standard Form 100 on September 30 of each year, in the same fashion as information regarding permanent employees is reported. Similarly, the Commission is deleting sections 1627.3(b) and 1627.4(a)(2) of the Age Discrimination in Employment Act recordkeeping regulations, which provide for a 90-day retention period for temporary positions, and is clarifying the mandatory nature of such recordkeeping. The Commission is not issuing a final rule on proposed section 1602.57 at this time. PMID- 10170779 TI - Guidelines for minimal standards in cardiac surgery. American College of Surgeons. PMID- 10170780 TI - Let there be life: an approach to worship with Alzheimer's patients and their families. AB - Describes a novel approach to providing a meaningful worship service for Alzheimer's patients in which greater stress is placed upon familiar scripture, music, prayers, and other right-brain functions, rather than on sermon or homily. PMID- 10170781 TI - CLR (Clinical Laboratory Reference) 1991-92. Clinical and professional reference guides; product information section. PMID- 10170782 TI - Follow-up care increases recovery rates, study finds. PMID- 10170783 TI - ASCs may face growth hazard as outpatient surgery matures. PMID- 10170784 TI - Using referral labs efficiently. Part III. How to get the best service from a referral laboratory. AB - Providing appropriate information, abiding by shipping specifications, and keeping communication open will help your referral lab do the top-notch work you want. Series conclusion. PMID- 10170785 TI - ABLEDATA: a database of products for the disabled. AB - ABLEDATA (ABLE), a database funded by the National Institute on Disability and Rehabilitation Research (NIDRR) of the U.S. Department of Education and produced by the Adaptive Equipment Center of Newington Children's Hospital, Newington, Connecticut, provides information on more than 17,000 rehabilitation products from over 2,000 manufacturers in the U.S. and Canada. ABLE, which is available through BRS Search Service, BRS Colleague, and BRS After Dark, is a useful resource for rehabilitation professionals and others who wish to locate appropriate assistive devices for all categories of disabled persons. PMID- 10170786 TI - Alzheimer's disease: the patient. PMID- 10170787 TI - Suicide and homicide. PMID- 10170788 TI - Alzheimer's disease's other victims. PMID- 10170789 TI - Legal planning after Alzheimer's diagnosis. PMID- 10170790 TI - Alzheimer's disease, a nurse's perspective. PMID- 10170791 TI - Kentucky program helps memory-impaired wanderers. PMID- 10170792 TI - The undead, the forgotten. PMID- 10170793 TI - Budget extra. Congress passes scores of Medicare changes for '91. PMID- 10170794 TI - A gentle place to live and die. PMID- 10170795 TI - Day-to-day image problem. PMID- 10170796 TI - Relationship between inappropriate admissions and days of care: implications for utilization management. AB - A critical issue for utilization management programs is how much of the hospitalization should be reviewed and whether information relative to the admission provides information about the subsequent days of stay. This study evaluates the relationship between the appropriateness (defined as overutilization of acute, inpatient services) of admissions and all days of stay in a probability sample of 6,063 hospitalizations from 50 Department of Veterans Affairs medical centers (VAMCs). Results suggest that preadmission reviews in hospital-based utilization management programs may eliminate not only unnecessary admissions but also, in most cases, completely inappropriate hospitalizations. In addition, except where inpatient-appropriate surgeries are not performed in a timely manner, review of the rest of the stay may not be an efficient use of time and resources. PMID- 10170797 TI - Disability discrimination in the 1990s: an overview of the employment provisions of the Americans with Disabilities Act. PMID- 10170798 TI - Fighting drug abuse at the local level. PMID- 10170799 TI - What you should know about the ADA (Americans with Disabilities Act). PMID- 10170800 TI - U.S. hospital chains retreat from Europe. AB - With trade barriers expected to be lifted in Europe next year, many American companies have been beating a path overseas to position themselves for expansion. But not U.S. hospital chains. While pharmaceutical and hospital supply firms have made significant inroads overseas, hospital companies are choosing to divest their foreign facilities, citing obstacles to market penetration. PMID- 10170801 TI - Civil rights extended to disabled. AB - Largely unnoticed for more than a quarter century, disabilities groups have waged a fight to extend equal rights and opportunities protection to an estimated 43 million Americans with disabilities. On July 26, 1990, President Bush signed landmark legislation dear to the disabled into law. To ensure an easier and smoother transition and compliance for their organizations, physician executives should have a general understanding of the law and its ramifications. PMID- 10170802 TI - Testimonials make powerful messages. PMID- 10170803 TI - The Medicare Alzheimer's Project in Portland, Oregon. PMID- 10170804 TI - Adolescent chemical dependency treatment in an HMO. AB - HMOs are under increasing pressure to expand benefits and services for treatment of adolescents who abuse alcohol and drugs. Little information exists, however, on these programs. This article describes a comprehensive adolescent chemical dependency treatment program within an HMO and presents data on use, costs, and results. Characteristics of clients were similar to adolescents seen in community treatment programs. Less than 1% of the HMO adolescent population sought treatment, and the mean number of outpatient treatment visits was 9.7. The median was between two and three visits, and the mode was one visit. Thirty-four percent of the adolescents required residential treatment, and 65% of the adolescents completed the recommended 28-day stay. The additional premium cost per member per month for adolescent chemical dependency treatment was approximately $0.28. A telephone follow-up survey of a random sample of treated adolescents found that most adolescents had reduced their use of alcohol and drugs and had made improvements in other areas of their lives. Few adolescents, however, met the program's goal of total abstinence. PMID- 10170805 TI - Medicare and Medicaid; eligibility for premium hospital insurance; state buy-in agreements--HCFA. Final rule with comment period. AB - These rules-- 1. Set forth the requirements and procedures for certain individuals under age 65 to enroll and become entitled to Medicare Part A benefits through payment of monthly premiums; 2. Revise the rules on State buy-in for Medicare benefits to provide that-- After 1988, a State may, at any time, request a buy-in agreement or a modification of an existing agreement, including a modification under which the State may enroll a pay Part B premiums on behalf of a new buy-in coverage group--Qualified Medicare Beneficiaries (QMBs); and After 1989, a State may request and obtain a modification of an existing agreement, under which the State may also enroll QMB's in Part A and pay Part A premiums on their behalf. These amendments are necessary to conform HCFA rules to changes made by section 9010 of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), section 301 of the Medicare Catastrophic Coverage Act of 1988 (MCCA), and sections 6012 and 6013 of the Omnibus Budget Reconciliation Act of 1989 (OBRA '89). The purposes of the amendments are-- 1. To make it possible for certain disabled individuals to become entitled to Medicare Part A benefits that require payment of a monthly premium. The provisions apply to an individual under age 65 who loses entitlement to Medicare Part A without premiums because his or her earnings exceed the limit imposed for entitlement to social security disability benefits, on which Medicare Part A entitlement was based; and 2. To make available to States, for payment of premiums for QMBs, the administrative and cost efficiencies of the State buy-in procedures. PMID- 10170807 TI - Measuring input prices for physicians: the revised Medicare Economic Index. AB - Medicare payments for physician services under Part B were historically restrained by capping prevailing charges using the Medicare Economic Index (MEI). The MEI, an input price index for physician services that incorporates an adjustment for economywide labor productivity, has not undergone a major revision since 1975. The MEI is an important determinant of the annual volume performance standard that will be used to set aggregate increases in the revised system for paying physicians under Medicare beginning in 1992. The MEI will also be used in establishing the annual changes to the payment conversion factors under the new payment system. PMID- 10170808 TI - Perspectives. Disabilities Act could cost billions. PMID- 10170806 TI - Health insurance coverage among disabled Medicare enrollees. AB - In this article, we use the Survey of Income and Program Participation to identify patterns of non-Medicare insurance coverage among disabled Medicare enrollees. Compared with the aged, the disabled are less likely to have private insurance coverage and more likely to have Medicaid. Probit analysis of the determinants of private insurance for disabled Medicare enrollees shows that income, education, marital status, sex, and having an employed family member are positively related to the likelihood of having private health insurance, whereas age and the probability of Medicaid enrollment are negatively related to this likelihood. PMID- 10170809 TI - Supplemental security income for the aged, blind, and disabled; federal administration of State supplementary payments to individuals in Medicaid facilities--SSA. Final rule. AB - These final regulations reflect section 12201(b) of Public Law 99-272 (the Consolidated Omnibus Budget Reconciliation Act of 1985, enacted April 7, 1986). Section 12201(b) permits Federal administration of optional State supplementary payments to individuals in medical facilities that receive little XIX (Medicaid) funds at a level exceeding 50 percent of the cost of their care (Medicaid facilities). Currently, the regulations prohibit Federal administration of optional State supplementary payments to a person who, throughout any month, is in a Medicaid facility. Under these regulations States will have the option of having the Social Security Administration (SSA) administer optional State supplementary payments to these individuals. States will be limited to one State supplementary payment level variation for residents of Medicaid facilities (Federal living arrangement "D"). PMID- 10170810 TI - Preventing mental health problems in children with chronic illness or disability. AB - Children with special health needs have an added risk for mental health problems. These problems may be preventable in many cases by focusing on the development of competence in children and their family members in adapting to the chronic condition demands. Five strategies for developing competence are discussed: (a) encourage normal life experience, (b)increase coping skills, (c) increase use of social support, (d) coordinate the delivery of care, and (e) empower families. Examples of programs employing these strategies that have been evaluated are presented. PMID- 10170811 TI - The growth of networks in mental health and substance abuse care: the recent California experience. PMID- 10170812 TI - Outpatient chemical dependency treatment and the managed care system: an unrealized symbiosis. PMID- 10170813 TI - Small area variations: a critical review of propositions, methods, and evidence. PMID- 10170814 TI - Rehab hospitals share in athletes' victories. AB - More rehabilitation hospitals are becoming sponsors of sports programs and competitive events for people with disabilities, and the facilities are sharing in the athletes' victories in a variety of ways. This week, hospitals nationwide are celebrating National Rehabilitation Week, which is designed to promote rehabilitative medicine and the independence of people with disabilities. PMID- 10170815 TI - Prospective payment likely for OP services. PMID- 10170816 TI - Computer applications in quality assurance. AB - To tackle the present and future demands of the health care system, a coordinated effort of science and technology is necessary. The information age is upon us, and the medical community desperately needs the assistance of the new tools technology has provided. The application of personal computers and information databases holds much promise for health care. PMID- 10170817 TI - Europe and hospitals--strengths and requirements. AB - Hospitals all over Europe must get ready to face the important challenge of 1993 at all levels: micro-economic, macro-economic, local, regional and European. Despite the liberalization trends which will inevitably appear with the increased freedom of exchange and movement, hospitals must strive to remain havens of peace to patients. PMID- 10170818 TI - Sources of stress for family caregivers of institutionalized dementia patients. AB - Although many caregivers place their relative in a nursing home in an attempt to reduce their own burden, caregiving stress often continues after institutionalization. This research examined sources of stress for 66 caregivers who cared for their impaired relative at home and later placed that individual in a nursing home. We hypothesized that although these caregivers no longer had primary responsibility for direct care, they would continue to experience distress because of the stressors associated with the nursing home. Results ran counter to our expectations. Although many caregivers reported stressors related to nursing home care, stressors stemming from the patient's Alzheimer's disease (AD) symptoms accounted for more variance in caregivers' levels of anxiety and depression, and in the quality of their interpersonal relations. Even though caregivers were assisted in their caregiving responsibilities by the nursing home staff, their relative's AD symptoms continued to prompt distress. PMID- 10170819 TI - Comparative health systems. The Federal Republic of Germany. PMID- 10170820 TI - Suspension of DNR orders during the perioperative period: the Johns Hopkins policy. PMID- 10170821 TI - Anti-drug program for personnel engaged in specified aviation activities--Federal Aviation Administration. Final rule. AB - On November 14, 1988, the FAA issued a final rule requiring specified aviation employers and operators to submit and implement anti-drug programs for personnel performing sensitive safety- and security-related functions. This final rule modifies that rule by excluding most entities conducting operations that do not require a part 121 or 135 certificate. Entities conducting sightseeing flights in an airplane or rotorcraft for compensation or hire will continue to be covered by the rule. PMID- 10170822 TI - Adopting AIDS-related employment policies. PMID- 10170823 TI - Minimally invasive therapy. AB - A rapid change is taking place in the development of less invasive surgical and radiological techniques. The consequences of these changes may have considerable implications for clinical work patterns and institutional design in the next decade. Surgeons, radiologists and health economists must be prepared to recognise and react rapidly to these radical shifts in technology which are aimed at the reduction of patient morbidity and mortality. PMID- 10170824 TI - The new ADA (Americans with Disabilities Act): what it means to you. PMID- 10170825 TI - Effects of a surgical case review handbook on chart documentation. AB - The study results demonstrated statistically significant improvement in chart documentation after handbook distribution for the residents (t = 5.67, p.05). Improvement was made in the attending group after distribution of the handbook relative to documentation, but it was not statistically significant. The attending physicians showed a reduction of 1.2 percent in the mean percentage of documentation errors per month after use of the handbook, whereas the residents showed a reduction of 5.0 percent. The new residents (first-year) reached levels of chart documentation comparable to the more senior residents (second- and third year) within three months after handbook distribution. During the study period, no interventions or efforts were made other than distribution of the handbook. Therefore, it can be concluded that the handbook produced an improvement in chart documentation compliance for all physicians, with a statistically significant effect for the resident physicians. The results indicate a high potential benefit for the first-year residents in particular. PMID- 10170826 TI - Accessible health care in Texas. PMID- 10170827 TI - Assessing the role of vocational rehabilitation in disability policy. AB - Since 1975, vocational rehabilitation has represented a small and declining component of federal disability policy. This trend is perhaps reflective of the relatively crude assessment techniques that have been applied to the program in the past. Using the Virginia Vocational Rehabilitation (VR) program as a prototype, we outline how the data and methods of assessment can be improved for purposes of directing public policy. The key issues include identifying an appropriate comparison group for VR, analysis of longitudinal earnings data, and methods for refining measures of program cost. The analysis provides "fixed effects" estimates of net earnings impacts for each of three postprogram years stratified by disability classification and gender. These treatment impacts are compared to total and service-specific costs. In general, this analysis suggests that evaluation of VR can be substantially improved and that these improvements can be attained at relatively modest analytic cost. PMID- 10170829 TI - The role of the laboratorian on the critical care team. PMID- 10170828 TI - Meeting the special needs of the open heart surgery patient. PMID- 10170830 TI - Why testing is being moved to the site of patient care. PMID- 10170831 TI - Point-of-care testing. A laboratory guide to meeting changing demands. PMID- 10170832 TI - Monitoring versus testing technologies: present and future. PMID- 10170833 TI - Technology's answer to labor and resource constraints. PMID- 10170834 TI - A respiratory care view of point-of-care blood gas and electrolyte testing. PMID- 10170835 TI - A risk management perspective on point-of-care testing. PMID- 10170836 TI - How accelerated regulation will affect point-of-care testing. PMID- 10170837 TI - The evolving needs of critical care. PMID- 10170839 TI - Homeless and runaway youth. PMID- 10170838 TI - Public health in Spain. Aspects relevant to the last few years. PMID- 10170840 TI - Social policy and runaways. AB - This paper examines the relationship between social policy and the phenomenon of runaways and their health. Through an exploration of the literature and reference to empirical studies, including the author's own work, it provides background and establishes the relationship between being in care and running. Assumptions which guide social policy as well as the service delivery itself provide an explanation for the runaway--child welfare connection. The paper concludes with discussion of the implications and recommendations for a policy shift with respect to services for adolescents. PMID- 10170841 TI - Developing policies for runaways: insights from the literature. AB - This article examines the literature on runaways from an historical perspective. It argues that societal responses to runaways have been structured by the prevailing assumptions about the nature and meaning of runaway behaviour. The recurring theme of detachment and connection is highlighted and its implication for policy development is examined. PMID- 10170842 TI - A sample of homeless and runaway youth in New Jersey and their health status. AB - In this study of homeless and runaway young people served by youth shelters in New Jersey mental health problems were predominant. They include anxiety, depression, suicide attempts, drug and alcohol abuse. The sample exhibited high levels of general behavioral problems and school and/or peer problems. One quarter of the sample had had trouble with the law. About two thirds of the sample were homeless rather than runaway. For a similar proportion of the sample this was a repeat experience and/or had lasted a week or more. Only one third were able to be reunited with their families after being served. The prognosis for these youth is poor without specific programs to protect them and their physical and mental health. PMID- 10170843 TI - Structural problems in institutional care for youth. AB - In examining the relationship of emotional responsiveness and authoritarianism to the success of child welfare institutions as measured by running away behavior structural factors relating to both are discussed. The emotional deficit of the care giving situation seems to be a factor related to running away. Authoritarianism was not a related factor. Though both runaways and nonrunaways rated the institutional experience to be less emotionally responsive than their families, workers and runaways rated runaways experience as the least emotionally responsive. This is thought to relate to both runaways history and the consistency and continuity of caregivers. This further points to a pressing need for child welfare programs to greatly increase continuity of care and positive emotional contact between youth and caregivers. Individuation of youth in group living situations and foster care is crucial to their benefitting from such programs. PMID- 10170844 TI - Silicone gel-filled breast prostheses; silicone inflatable breast prostheses: patient risk information--FDA. Notice. AB - The Food and Drug Administration (FDA) is issuing a notice to promote the dissemination of information on risks associated with silicone gel-filled breast prostheses and silicone inflatable ("saline-filled") breast prostheses to women considering having the devices implanted. This notice addresses an important public health issue presented by the continued marketing and implantation of these unapproved devices. FDA has identified significant deficiencies in premarket approval applications for silicone gel-filled breast prostheses. FDA will regard breast prostheses as misbranded under the Federal Food, Drug, and Cosmetic Act (the act) if their labeling does not provide adequate written information to patients on the risks associated with these devices. Such information should be written so as to be easily comprehensible to most patients and should be provided to patients prior to scheduling implantation, so that patients have sufficient time to review the information and discuss it with their physicians. To satisfy the requirements of the act, such patient risk information must set out the known, suspected, and potential risks associated with implantation of these devices. This notice includes suggested patient risk information sheets as guidance. PMID- 10170845 TI - An analysis of substance abuse patterns, medical expenses and effectiveness of treatment in the workplace. AB - This article examines the effectiveness of substance abuse treatment offered by the Members Assistance Program of a self-insured union welfare fund. The authors find that medical costs decreased dramatically for participants who were under treatment for at least one year. PMID- 10170846 TI - Seeking sane solutions: managing mental health and chemical dependency costs. AB - Plan design holds the key to managing mental health and substance abuse costs, Ms. Pflaum points out. She explains that utilization review, EAPs, HMOs and PPOs, and carve-outs can be useful in the process. PMID- 10170847 TI - Special report on reimbursement. HCFA publishes proposed rule establishing new payment system for physicians. AB - Whether any or all of these effects actually occur is presently a matter of conjecture. Over the long term, however, it is likely that RBRVS will lead to new opportunities to structure relationships between hospitals and physicians. In practical effect, DRG payments to hospitals, coupled with RBRVS fee schedules, are designed to promote patient care in outpatient settings. This means there will be new opportunities for joint ventures and practice/management arrangements between hospitals and physicians. As these new arrangements come to fruition, both hospitals and physicians must be aware of the financial implications of the new RBRVS codes. PMID- 10170848 TI - A strategy for the cost containment of surgical implant purchases. AB - Although the experience of the Hospital for Joint Diseases is unique in terms of size of market controlled, the cost-containment techniques described above are applicable to almost any hospital. A crucial factor in any such process is enlisting the active participation of the surgical staff at every stage. On the basis of the success, this cost-containment procedure is being applied to other components of the medical device purchases. PMID- 10170849 TI - Materiel management and reimbursement in the American Association of Eye and Ear Hospitals. AB - Simply stated, understanding how hospitals receive money enables materiel managers to save money. Reimbursement in the health care industry is a complex phenomenon, and the rules and regulations change annually, so that it is sometimes difficult to budget appropriately and estimate the hospital's bottom line accurately. The savvy materiel managers who can utilize the reimbursement concepts effectively will be highly regarded within their institutions. PMID- 10170851 TI - New Deal. Katherine Stephen's multi-function room provides self-sufficiency and dignity for FDR's spiritual heirs. PMID- 10170850 TI - Testing the limits: special treatment procedures for child and adolescent partial hospitalization. AB - How does a child and/or adolescent partial hospitalization program structure care for patients who are suicidal, assaultive, or combative or using drugs? Special treatment procedures designed for use in child and adolescent partial hospitalization programs must adequately address the issue of safety and involve the family and the community, while maintaining the patient in the least restrictive environment. This paper deals with management of child and adolescent partial hospitalization patients whose behavior and level of impulsivity have escalated to the point where they require special programs. Special treatment procedures for dealing with patients displaying aggressive, acting-out behaviors, noncompliance with program rules, suicidal or runaway ideation, and drug usage are described. PMID- 10170852 TI - Independence and dignity for homeless women. PMID- 10170853 TI - Interpretations ... adverse drug reactions. AB - The Standards Interpretation Committee recently approved the following interpretations concerning the definition and review of adverse drug reactions, as well as the review of surgical and other invasive procedures. The latter interpretation is based on standards revisions that appear in the Accreditation Manual for Hospitals (AMH), Volume I, 1992 edition. PMID- 10170854 TI - The impact of low birthweight on special education costs. AB - We investigate the relationship between low birthweight, enrollment in special education and special education costs in the U.S. We use a sample of approximately 8,000 children aged 6 to 15 who are in school, calculating the probability of attending special education, holding constant individual, family and regional variables. Children who weighed less than 2,500 grams at birth are almost fifty percent more likely to be enrolled in any type of special education than children who were of normal weight at birth. This results in an incremental cost of special education of $370.8 million (1989-1990) per year due to low birthweight. PMID- 10170855 TI - How the ADA will affect your employment practices. AB - On July 26, 1992, federal legislation known as the Americans with Disabilities Act (ADA) will take effect, opening an era of potentially dramatic changes for American businesses, including hospitals and other health care providers. The ADA will forbid discrimination against disabled persons in four broad areas: employment, public services (especially public transportation), public accommodations, and access to telecommunications. The following information, focusing on employment practices under the ADA, is the second of Michigan Hospitals' three-part series on the effects this new law will have on health care providers. The last installment will deal with public accommodation practices under the ADA. PMID- 10170856 TI - Doc data release raises concerns. PMID- 10170857 TI - Americans with Disabilities Act: hospitals must comply. PMID- 10170858 TI - Instituting a concurrent process for monitoring the clinical risk of physicians' practice. AB - By implementing a more concurrent program for identifying and responding to situations that put patients at risk, such as the approach described in this article, hospital quality assurance and risk management professionals, as well as the medical staff and administration, may finally achieve the complementary goals of increasing the quality of clinical care while simultaneously reducing claims and suits against the hospital and its physicians. PMID- 10170859 TI - Recent court decisions show wide range of rulings on futility. PMID- 10170860 TI - Blood exposure in the operating room: reducing the risk. AB - Blood must be considered a toxic substance in the operating room. Members of the operating room team must exercise greater caution to prevent blood contact. Increased attention to the adequacy of barriers and avoidance of certain operating room behavior is important. All surgical team members must be vaccinated against hepatitis B. The frequency of operating room transmission of HIV infection is clearly less than has been the case with hepatitis B. Because of documented cases of occupationally acquired HIV following hollow needle exposures, it is clear that the risk is not zero. While no case of operating room transmission of HIV has yet been documented, it has no doubt occurred and will certainly be documented in the future. It is the responsibility of each member of the surgical team to be an advocate for his or her own protection in the operating room. A heightened awareness of our general behavior and particular attention to our use of sharp instruments and needles in the operating room will be our best line of defense. PMID- 10170861 TI - ADA's parking requirements pose big challenge. PMID- 10170862 TI - 1991 Muriel Driver lecture. The environment: a focus for occupational therapy. AB - Individuals in Canada with a disability encounter environmental constraints that limit their active participation in the daily life of our communities. Fundamental inequities in participation and integration continue to exist and there is a need for a concerted effort to eliminate these disabling environments. Several factors, including the built environment, societal production of space, classification of individuals based on norms, the perception of disability as deviance, the power of health disciplines and bureaucracy are examined to determine their contribution to the creation of these disabling environments. Recent modifications to occupational therapy theory and practice, while meaningful, have not fully explored ways in which disabling environments limit occupation. Prevailing ideas about occupation and the environment are examined for their contribution to solving these environmental problems. Principles which can assist occupational therapy intervention directed at changing disabling environments are described. The intent is to define methods of changing disabling environments, based on the desires and active participation of people with disabilities PMID- 10170863 TI - Post-occupancy evaluation: an environment-behaviour technique for assessing the built environment. AB - This paper reviews the development, structure and process of post-occupancy evaluation (POE) as an environment-behaviour approach to assessing built environments of all sizes and types. It illustrates the use of POEs with three examples from the Health Care sector: The Canadian Hospital Evaluation Program, the Weiss Institute, and 18 independent-living apartment units. A comparison is made between POEs and the approach currently used by occupational therapy (OT) for environmental assessments. Recommendations suggest that OT's approach could be extended and strengthened through 1) incorporating POE methods and existing data from environment-behaviour studies; 2) the use of standard assessment procedures and well-validated measures; and 3) the development of a data bank on OT environmental assessments. PMID- 10170864 TI - Medicaid support of alcohol, drug abuse, and mental health services. AB - Medicaid expenditures for alcohol, drug abuse, and mental health (ADM) services in 1984 were examined for the States of California and Michigan. Persons receiving such services constituted 9 to 10 percent of the total Medicaid population in the two States and accounted for 22 to 23 percent of total Medicaid expenditures. ADM expenditures were 11 to 12 percent of the total. Although the two States had similar proportions of overall expenditures for these services, Michigan appeared to emphasize inpatient psychiatric care, while California emphasized ambulatory and nursing home care. Based on the experience of the two States, national Medicaid expenditures for ADM services exclusive of long-term care were estimated to be $3.5 to $4.9 billion in 1984, two to three times the level suggested by earlier estimates. PMID- 10170866 TI - Definitive job descriptions are key to ADA compliance. PMID- 10170865 TI - I'm HIV-positive, but I won't give up being a doctor. PMID- 10170867 TI - A need not to know. PMID- 10170868 TI - Providing public accommodations under the ADA. Part III. AB - On July 26, 1992, federal legislation known as the Americans with Disabilities Act (ADA) will take effect, opening an era of potentially dramatic changes for American businesses, including hospitals and other health care providers. The ADA will forbid discrimination against disabled persons in four areas: employment, public services (especially public transportation), public accommodations, and access to telecommunications. The following information focuses on the public accommodation aspects of the Act, and is the last in our three-part series on the effects this new law will have on health care providers. PMID- 10170869 TI - Hiring employees under the Disabilities Act. PMID- 10170870 TI - IL Monarch System--Instrumentation Laboratories. PMID- 10170871 TI - The benefits of alternative care. PMID- 10170872 TI - Health maintenance organizations and the treatment of substance abuse. AB - The deterioration of substance abusers to the point where they need to be hospitalized generally happens slowly, over a period of years if not decades. During this time, most of their medical care takes place in an ambulatory setting. Primary care physicians are thus in an ideal position to identify and help patients in relatively early stages of the problem. The HMO, with its ability to practice patient-oriented case management and its access to all aspects of the medical care delivery system without additional financial burden to the patient, is particularly suited to provide effective and efficient care. The next challenge for HMOs is to reach patients at much earlier stages of their disease. PMID- 10170873 TI - Helping health care professionals confront substance abuse. PMID- 10170874 TI - Payment for assistants at surgery reinstated for selected procedures. PMID- 10170875 TI - Profit from perfecting image relies on program parameters. PMID- 10170876 TI - Drug programs. Position available: drug test required. PMID- 10170877 TI - Special report. HCFA hikes conversion factor to $31.001, adopts 77 other pay policies for RVS era. AB - This Health Policy Week Special Report summarizes provisions of the final Medicare resource-based relative value fee schedule, slated for publication in the Nov. 25 Federal Register. The fee schedule applies to virtually all 500,000 private practice physicians in the U.S. The Health Care Financing Administration (HCFA) issued the fee schedule after reviewing 95,000 comments on the proposed version (HPW 6/10/91). PMID- 10170878 TI - Special report. HCFA hikes conversion factor to $31.001; adopts 77 other pay policies for RVS era. AB - This Part B News Special Report summarizes provisions of the final Medicare resource-based relative value fee schedule, slated for publication in the Nov. 25 Federal Register. The fee schedule applies to virtually all 500,000 private practice physicians in the U.S. The Health Care Financing Administration (HCFA) issued the fee schedule after reviewing 95,000 comments on the proposed version (PBN 6/10/91). PMID- 10170879 TI - Hiring under the ADA. PMID- 10170880 TI - Special report. HCFA hikes conversion factor to $31.001, adopts 77 other pay policies for RVS era. AB - This Hospital Revenue Report Special Report summarizes provisions of the final Medicare resource-based relative value fee schedule, slated for publication in the Nov. 25 Federal Register. The fee schedule applies to virtually all 500,000 private practice physicians in the U.S. The Health Care Financing Administration (HCFA) issued the fee schedule after reviewing 95,000 comments on the June 5 proposed version. PMID- 10170881 TI - A parent's perspective. Family-centered care. AB - In summary, although I feel that family-centered care has progressed in the last several years, much remains to be done. With improvement in research and technology come new challenges for medical professionals and also new liabilities. I have found individuals who were not interested in working with my son because of the risk in decision making and liability his medical conditions pose. I would like to see the next generation of medical personnel be trained to accept the challenge of multihandicapped and medically fragile children. While our current system puts pressure on physicians and hospitals to protect their business interests, I would like to see this change to allow for more sensitized and comprehensive care for all patients. My child's medical needs will be ongoing, and I know that many more doctors will come and go throughout his lifetime. What I would like to see for him (and others) is a more personalized continuum of quality care. I want him to feel, at whatever his ability to understand, that the medical professionals caring for him want him to thrive, be healthy, and feel food about himself. PMID- 10170882 TI - The Family Caregiver Support Act. PMID- 10170883 TI - Enabling caregivers to care for Alzheimer's patients at home. AB - The VNA of Louisville has developed a teaching manual to help caregivers of Alzheimer's disease patients better understand the effect the disease has on both the patient and the caregiver. PMID- 10170884 TI - Aiding the Alzheimer's dementia patient to live in safety and security. AB - Alzheimer's is truly a "family" disease, affecting not only the patient but the entire family. The patient's emotional/psychological safety and security are as important as his or her physical condition, and therefore must be addressed. Families should be encouraged to use every resource that is available. The nurse/caregiver is in an excellent position to offer support and suggest resources. The key is understanding the course of the disease and measures that can be employed to maintain the patient in optimal safety and security. PMID- 10170885 TI - Alzheimer's disease. Getting on the federal agenda. AB - Eleven years ago, a handful of family caregivers started a grassroots movement that has raised the nation's awareness of Alzheimer's disease and captured the attention of government policymakers. PMID- 10170886 TI - Dignity--the cornerstone of care. AB - At the Alzheimer's Day Center in Columbia, South Carolina, staff, families, and volunteers comprise the A-team. The team offers persons with Alzheimer's disease a homelike environment full of laughter and love, while providing respite for family caregivers. PMID- 10170887 TI - Hospitalization of the person with Alzheimer's disease. AB - Providing consistency in care and avoiding change whenever possible are important principles to consider when caring for the Alzheimer's disease patient. Hospitalization, a major disruption of care, requires planning and communication on the part of the caregiver. PMID- 10170888 TI - Mental competency and planning for disability. AB - When the Alzheimer's disease patient is no longer mentally competent to handle his or her legal and personal affairs, a guardianship is the most common solution. PMID- 10170889 TI - Medicare program; fee schedule for physicians' services--HCFA. Final rule. AB - This final rule sets forth a fee schedule for payment for physicians' services beginning January 1, 1992. Establishment of this fee schedule is required by section 6102(a) of the Omnibus Budget Reconciliation Act of 1989, as amended by the Omnibus Budget Reconciliation Act of 1990. This final rule explains which services will be included in the fee schedule and sets forth the formula for computing payment amounts. Application of transition rules during 1992 through 1995 is also described, as well as other adjustments to fee schedule payment amounts. PMID- 10170890 TI - CDC pushes ahead for exposure-prone procedures listing. PMID- 10170891 TI - RBRVS--resource-based relative value scale. Physicians will push for OR productivity. PMID- 10170892 TI - Joint venture gets IRS nod. PMID- 10170893 TI - New views define appropriate resuscitation circumstances. PMID- 10170894 TI - How home heals. AB - In a stunning transformation of a sober house in Gloucester, Payette Associates write a new page for health care history. PMID- 10170895 TI - Warts and all. AB - If the government wishes to promote minor surgery in general practice as an alternative to hospital care, it must demonstrate a much greater commitment to the task, argue Chris Smaje, Sean Boyle and Rosemary Beardow. PMID- 10170896 TI - Stat testing in the new CLIA era. PMID- 10170897 TI - Hospitals act to accommodate Americans with Disabilities Act. AB - The ramifications of the Americans with Disabilities Act are many, and the nation's hospitals may be ill-prepared to comply with all the law's facets, say administrators, attorneys and consultants. The law, which takes effect this week, will force hospitals to take steps to end discrimination against patients, employees and employee candidates who have disabilities. PMID- 10170898 TI - Tooling up for ADA. PMID- 10170899 TI - Pre-employment back injury screening. The employer's crystal ball. AB - A properly designed pre-employment screening process can prevent unnecessary headaches for the EMS provider and service alike. This article describes various back-screening processes that can help determine whether an EMS responder is at risk of injury. PMID- 10170900 TI - Overcoming obstacles. Three inspirational paramedics. PMID- 10170901 TI - The new Medicare fee schedule--Part I. PMID- 10170902 TI - Medicare program; update of ambulatory surgical center payment rates and additions to and deletions from the current list of covered surgical procedures- HCFA. Notice with comment period. AB - This notice implements section 1833(i)(2)(A) of the Social Security Act, which requires that the payment rates for ambulatory surgical center (ASC) services be reviewed and updated annually, and responds to the public comment we received concerning the ambulatory surgical center payment rate update notice with comment period published on July 5, 1990 (55 FR 27690). It also implements section 1833(i)(1) of the Social Security Act, which requires, in part, that the list of covered ambulatory surgical center procedures be reviewed and updated at least every 2 years. This notice announces additions to and deletions from the list of surgical procedures for which facility services are covered when the procedures are performed in an ASC. This notice also announces the assignment of payment groups for each procedure and responds to public comments received in response to the notice proposing additions to and deletions from the list of covered surgical procedures that was published on December 7, 1990. PMID- 10170903 TI - A guide to the EEOC's final regulations on the Americans with Disabilities Act. AB - The Equal Employment Opportunity Commission (EEOC) recently issued its final regulations on the Americans with Disabilities Act (ADA). Although the regulations offer some guidance for employers on how to comply with the Act, they fail to provide specific answers to the many complicated compliance questions that will surely arise. Further, the regulations are almost totally silent on certain critical issues related to insurance, workers' compensation, and potential conflicts between ADA obligations and terms of collective bargaining agreements. The EEOC has essentially left the resolution of many important ADA questions to case-by-case determination and the litigation process. PMID- 10170905 TI - Why bad doctors aren't kicked out of medicine. PMID- 10170904 TI - How the ADA will affect health care signage. PMID- 10170906 TI - Confidentiality of health care information: some notable concerns. PMID- 10170907 TI - Title III of the Americans with Disabilities Act: new rights for the disabled to public accommodations. PMID- 10170908 TI - Special report: the value of pharmaceuticals. An "expensive" drug may be the most cost effective. AB - The pharmaceutical's impact on the utilization of all health resources, including hospitalization and surgery, must be assessed. Higher-priced drugs may also be more cost effective if they have greater efficacy, wider therapeutic range, and are less costly to prepare and administer. PMID- 10170909 TI - Issues in the practice of cosmetic surgery: consumers' use of information and perceptions of service quality. AB - The information sources consumers use and consumers' perceptions of the quality of services they receive are examined in the context of breast augmentation surgery. Consumers who received breast implants for reconstructive purposes (i.e., after a mastectomy) were compared with those who received them solely for cosmetic purposes. Implications for health care marketers at a time of federal scrutiny are discussed. PMID- 10170910 TI - A comparison of two methodologies for assessing human service needs and an assessment of the impacts of methodological choices on identified needs. PMID- 10170911 TI - A ban on silicone. PMID- 10170912 TI - Laboratory safety--problems of energy supply and their solution. PMID- 10170913 TI - Conceptual framework for estimating the social cost of drug abuse. AB - Drug abuse imposes costs on individuals and society. Researchers have produced several studies on a subset of tangible costs of drug abuse and other illnesses, but key tangible costs sometimes have been overlooked and, even when recognized, rarely have been estimated. An assortment of intangible costs also have received very little research attention. This study outlines a comprehensive conceptual framework for estimating the social cost of drug abuse. We address both the tangible and intangible costs for the drug-abusing and non-drug-abusing population. Our conceptual framework is based on critical reviews of new and traditional methods for estimating the costs of illness and disease including cost-of-illness methods, averting behavior methods, and utility valuation techniques. We show how the proposed methods can be combined with existing data to estimate the total social cost of drug abuse. Using social cost estimates will enable policymakers to more accurately assess the total burden of drug abuse and related problems on society. PMID- 10170914 TI - Suspension of DNR orders in the OR being questioned. PMID- 10170915 TI - Cocaine use: implications for intervention with childbearing women and their infants. AB - This paper summarizes the literature on the effects of maternal cocaine use, drawing implications from the literature for the development of early intervention programs. It is suggested that intervention must be focused on maternal cocaine use among childbearing women as well as perinatal cocaine exposure among infants. Emphasis is placed on interventions that promote a reduction in drug use by potential childbearing women as well as expectant mothers and that focus on promotion of optimum parent-child interaction and parenting skills as well as maternal self-sufficiency. PMID- 10170916 TI - The Civil Rights Act of 1991. PMID- 10170917 TI - Buyers taking silicon-gel breast implant ruling in stride. PMID- 10170919 TI - Legal ramifications of the ADA (Americans with Disabilities Act). PMID- 10170918 TI - Accessibility takes effect. PMID- 10170920 TI - The Americans with Disabilities Act: new challenges for hospitals. PMID- 10170921 TI - Calculating your Medicare fees. PMID- 10170922 TI - Medicare Part B spending. AB - In its continuing effort to identify and examine the trends in Medicare spending for surgical services, the College obtained copies of the Medicare procedure code files for the years 1986 through 1989. The results from analysis of these data files were presented in a report entitled Trends in Medicare Part B Spending 1986 1989, issued by the College in September 1991. This article describes the federal activity that prompted the College to commission the report, and presents some of the significant results of the analysis. PMID- 10170923 TI - A new challenge for home care agencies. AB - The Americans with Disabilities Act will change the employment practices of all home care agencies by prohibiting employers from discriminating against individuals on the basis of a disability. While the act requires an employer to reasonably accommodate all applicants and employees must be reasonably accommodated, home care agencies face a particular challenge in employing and accommodating individuals with a disability who are homemaker-home health aides, nurses, or therapists. PMID- 10170924 TI - Health care in the EC member states. PMID- 10170926 TI - Aspects of the Children Act--a medical perspective. PMID- 10170925 TI - In-home respite care: a comparison of volunteers and paid workers. AB - Descriptive data using an administered questionnaire were obtained from fifteen in-home respite volunteers and from fifteen paid in-home respite workers. From each group, five volunteers and five paid workers and the families they served, were interviewed in depth. Independent t tests showed volunteers to be older, have more education, spend less time in respite and more time in the confidant role than paid workers. Volunteers were characterized as a family surrogate motivated by altruistic and substitutive needs. They were shown to be reliable, competent, creative, and nurturant. Paid workers were found to be motivated by a liking for people and financial need. Though their services were also shown to be reliable, competent and nurturant, paid workers were characterized more as an extension of the family care-giver. PMID- 10170927 TI - Focused psychiatric review: impacts on expense and utilization. AB - Focused Psychiatric Review, Aetna's inpatient mental health utilization review program, reduces length of stay and stabilizes admission rates and, as a consequence, reduces expenses, according to the study reported in this article. The program has greater impact on psychiatric than on substance abuse treatments. The best estimate of annual net program savings is $34.90 per covered employee, a return of $12.60 saved for each program dollar spent. PMID- 10170928 TI - Managing mental health care. AB - Managed mental health has evolved from company-run employee assistance programs and a few specialty utilization review firms to a mind-boggling array of specialists. New developments portend a more comprehensive, measurable and aggressively interventionist industry in the making. PMID- 10170929 TI - The Americans With Disabilities Act: preparing your health care facility to achieve compliance. AB - The article discusses the Americans With Disabilities Act, signed into law by President Bush on July 26, 1990, and its potential effects on the health care industry. The author offers advice on how health care facilities can insure compliance with this sweeping legislation. PMID- 10170930 TI - Enforcing handicapped parking laws. PMID- 10170931 TI - ER drug visits resumed upward climb in '91 following dip in 1990. PMID- 10170932 TI - Managing risk. A priority in the health service. PMID- 10170933 TI - Healthcare in Europe--Ireland. Change and tradition. AB - Community spirit and top-quality professionals have given Ireland a health status that belies its relative lack of wealth. But it is time to find a better management system, says Marie Brady. PMID- 10170934 TI - Medicare fee schedule: revisions to the relative work values. PMID- 10170935 TI - Birth-related neurological injury compensation funds: solution or stopgap? PMID- 10170936 TI - A deadly return. Tuberculosis. AB - Fueled by poverty, homelessness and AIDS, a disease we almost wiped out is back in a dangerous new form. Its resurgence is neither fluke nor mystery, but a tragic social failure. PMID- 10170937 TI - Medicare, Medicaid and CLIA programs; regulations implementing the Clinical Laboratory Improvement Amendments of 1988 (CLIA)--HCFA. Final rule with comment period. AB - This final rule revises regulations applicable to laboratories and implements provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA), Public Law 100-578. The regulation applies to laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. They specify the performance requirements, based on 19 test complexity and risk factors related to erroneous test results, that apply to laboratories that are subject to CLIA. They also list requirements for laboratories performing certain limited testing to be eligible for a certificate of waiver. These laboratories will not be inspected routinely, nor will they be required to meet certain other CLIA requirements. PMID- 10170938 TI - Clinical Laboratory Improvement Act program fee collection--HCFA. Final rule with comment. AB - This rule implements provisions of section 353 of Public Health Service Act (as amended by the Clinical Laboratory Improvement Amendments of 1988). Those provisions require laboratories to pay fees for issuance of registration certificates, certificates of waiver, certificates of accreditation, or certificates and to fund activities to determine compliance with the requirements established by the Department of Health and Human Services for laboratory testing. It also establishes the policy that laboratories licensed by and located in States with licensure programs approved by HHS may be exempt from the requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA). This rule also establishes the methodology used to determine the amount of the fees charged for certificates of waiver, registration certificates, certificates of accreditation, or certificates and activities to establish application procedures and determine compliance with applicable certification requirements. PMID- 10170939 TI - Specific list for categorization of laboratory test systems, assays and examinations by complexity--PHS. Notice with comment period. AB - The Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, requires that the Secretary provide for the categorization of specific laboratory test systems, assays and examinations by level of complexity. 42 CFR 493.17, published elsewhere in this issue of the Federal Register, establishes criteria for such categorization. It is the Department's intention to complete the categorization of all currently available clinical laboratory test systems, assays and examinations prior to the effective date of the amendments to 42 CFR Part 493 (September 1, 1992). This Notice announces the first of a series of lists containing specific clinical laboratory test systems, assays and examinations, categorized by complexity. Additional lists of test systems, assays and examinations will be published periodically. On or before September 1, 1992, a complete list of all laboratory test systems, assays and examinations, categorized by complexity, will be published in the form of a compilation of these Notices. Any clinical laboratory test system, assay or examination that is not on that final list will be considered high complexity, until categorized otherwise, as provided under 42 CFR 493.17. After publication of the compilation, applications will be taken to categorize (or recategorize) other laboratory test systems, assays and examinations following the procedures delineated in 42 CFR 493.17(d). Notices will be published periodically in the Federal Register to announce any additional test system, assay or examination that has been categorized (or re-categorize) during the preceding interval. PMID- 10170940 TI - The challenges of providing proper drug therapy. PMID- 10170941 TI - The federal refocusing on long-term care. AB - Widespread public support for a federally funded long-term care program coupled with election-year politics have prompted the introduction of numerous legislative proposals to help the millions of Americans who suffer from disability and chronic illness of long-term duration. PMID- 10170942 TI - Supported living services for survivors of brain injury. PMID- 10170943 TI - The right to know and the right to privacy: HIV testing and health care management. AB - Balancing the rights of suspected or actual HIV-infected individuals versus the preferences of patients, customers, coworkers, and others requires a delicate balancing of individual rights and responsibilities in light of medical and epidemiological facts. It is undoubtedly the quintessential ethical and legal problem of our time for health care management to confront. The dilemmas and the ensuing debate will be intensifying in the nineties as the number of diagnosed AIDS cases and of HIV-positive individuals rapidly expands. Much of the literature in the management field, and unfortunately some in the area of AIDS, consists of writing that ends with such concepts as prescriptions, guidelines, battleplans, etc. for dealing with the problem being discussed. Certainly, excellent articles and books abound in this vein. There is an ever present desire, however, for deductive reasoning whereby, because the topic is management, the problem, whatever it may be, can be managed in the classical scientific method, with one best way to handle the situation. The typical conclusion to an article such as this would be a section subtitled the antithesis of reality, that is, something like "AIDS Made Easy" or "Ten Steps to Effectively Deal with AIDS For Health Care Providers." The foregoing review presents issues that are too complex to be reduced to simplistic action plans for health care management and providers. The legal and ethical problems of the use of HIV testing of health care providers are but one part of the myriad of difficulties brought on by the epidemic--among these being the complex social issues brought on by AIDS and the ramifications in the areas of hospital and health care service reimbursement, cost, capacity, and adequacy. The legal status and propriety of HIV testing will continue to be under debate and in flux for some time, as all available precedent and guidelines in this area are based on current epidemiological and medical knowledge. This is, of course, subject to change and reinterpretation as more is learned about AIDS and as the prevalence of HIV infection, ARC, and AIDS increases. Certainly, it is not an issue that has been resolved by Leckelt and Glover, but these cases have brought more insight into the proper role of HIV testing of health care workers in light of current medical and legal knowledge.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10170944 TI - Achieving cost control in the hospital outpatient department. AB - The rapid growth in outpatient expenditures and the congressional mandate for development of a prospective payment system (PPS) for these expenditures are discussed. Extension of diagnosis-related groups to outpatient care is shown to be infeasible. Alternative patient classification schemes and options for defining the unit of payment and establishing weights and rates are discussed. A PPS primarily controls price and can only address volume by defining a broad unit of payment, such as an episode of care. Therefore, adoption of a volume performance standard approach could be effective. Outpatient payment policies must be integrated with those of other ambulatory care providers. PMID- 10170945 TI - Don't let safety happen by accident. AB - Get ready to update and improve your company's safety program. On pages 24-38, you'll find a comprehensive guide to safe industry practices to enhance your operation and help you stay in compliance with OSHA regulations such as the General Duty Clause and the Right-to-Know law. Achieving a safe, healthy, productive, and profitable business doesn't happen by accident. It takes upper management commitment to improve equipment, procedures, and employee training. Managers have a personal and a legal responsibility for employees' safety on the job. Don't delay safety improvements! PMID- 10170946 TI - Regulatory era for physician office labs comes with $1/test price tag. PMID- 10170947 TI - Understanding the forces that drive mental health and chemical dependency utilization. AB - Economic and social forces combined with imprecise treatment standards are creating a virtual explosion in employer costs attributable to mental and chemical dependency disorders. To develop appropriate programs for managing these costs, the forces that drive utilization must be understood. PMID- 10170948 TI - Cash in hand. PMID- 10170949 TI - Keep in touch. PMID- 10170950 TI - Florida court set to break legal ground on denial of physician privileges for economic reasons. PMID- 10170951 TI - Suit charges Calif. clinic violated Disabilities Act. PMID- 10170952 TI - The effects of the ADA on group practice. AB - In this article, James Frierson, J.D., outlines the requirements for group practices under the Americans with Disabilities Act (ADA). Rules concerning required changes take effect in January of 1993 (and sooner for some groups), making it imperative that group practices be aware of the new law. PMID- 10170953 TI - A QA plan to monitor charted lab results. PMID- 10170954 TI - Voluntary proficiency testing: a step toward excellence. PMID- 10170955 TI - Physiotherapy with alcohol and drug dependent patients: implications for general settings. AB - This article focuses on some of the problems presented by alcohol and drug dependent patients and how physiotherapists can respond to them. Approaches used on the Medical Ward of the Clinical Institute of the Addiction Research Foundation (ARF) are presented. The attitude of the physiotherapist toward addictions is important, both in the rehabilitation of the patient's physical problem and in the treatment of his/her alcohol or drug problem. Questions about drug or alcohol use in a physiotherapy assessment can reveal important information about how the patient manages pain and add to understanding of other psycho-social considerations. A brief overview of the types of patient conditions commonly seen on the Medical Ward is given. This is followed by an outline of the ways in which withdrawal from drugs and alcohol is managed. Information is included about pathology related to alcohol abuse. Evidence that many alcohol related neurological conditions are often reversible suggests that physiotherapists should be optimistic in their expectations about successful alcohol and drug treatment outcomes and should convey this optimism to their patients. PMID- 10170956 TI - A therapeutic approach to physical disability. PMID- 10170957 TI - Diagnosis and disability in Geriatric Assessment Team clients: a pilot study. AB - This study presents the results of a pilot study examining the diagnosis and disability levels of a sample of clients seen by four Victorian Regional Geriatric Assessment Teams (GATs). It identifies a clear relationship between the client disability profile and the resultant recommended care plan. As expected, clients recommended for nursing home care are the most disabled, although clients recommended for inpatient treatment/rehabilitation also have very high levels of physical disability. Recipients of hostel or Special Accommodation Home (SAH) recommendations, however, exhibit levels of physical disability comparable to those of clients with community care recommendations. The distinguishing factor here is the presence of cognitive disability, which substantially reduces the likelihood of retention in the community. PMID- 10170958 TI - Health jobs you might not know about. PMID- 10170959 TI - The effect of the Americans With Disabilities Act upon medical insurance and employee benefits. AB - The Americans With Disabilities Act will have a significant impact upon plan sponsors and the administration of an employee benefit plan. Prior to the July 26, 1992 effective date, a plan sponsor or trustee should meet with the plan's attorney, provider and other insurance advisers and review the effect ADA will have upon the plan. The EEOC will be issuing additional interpretive rules before the effective date of ADA, and there will be numerous court challenges after the effective date. Plan sponsors and trustees should keep abreast of the developments as they occur. Before a benefit change or premium adjustment is made, it should be reviewed with legal counsel to assure that it conforms to ADA's insurance exemption. Plan sponsors and trustees should have legal counsel, the provider and the plan's insurance advisers develop the documentation that will enable the plan to establish ADA's insurance exemption to defend any legal challenge. PMID- 10170960 TI - Creating puree artistry. PMID- 10170961 TI - Out of pocket expenditures by family caregivers of dementia patients residing in the community. AB - Out of pocket expenditures by families (N = 182) of relatives with dementia residing in the community were examined. Average expenditures for a three month period were $1,149. The relationship between illness variables, income, insurance coverage and total expenditures is described. PMID- 10170962 TI - Over the obstacles. PMID- 10170963 TI - Outpatient surgeries pull ahead of inpatient. PMID- 10170964 TI - Recommendations for flash sterilizing implants differ. PMID- 10170965 TI - Computers bring cost accounting within OR's reach. PMID- 10170966 TI - Paediatric cardiology in a sub-regional cardiothoracic unit. AB - The aim of this study was to examine the pattern of referrals the number of admissions, cardiac catheterisations and surgical procedures-including outcome-in infants and children referred to a sub-regional cardiothoracic unit during a 6 year period. The unit is served by one paediatric cardiologist and four general cardiothoracic surgeons, two of whom undertake paediatric surgery. Referrals were received from within the Trent Regional Health Authority, and from three other health Regions. During the study period 2,097 infants and children were admitted to the unit with cardiac disease, and 730 underwent cardiac surgery. The proportion of admissions undergoing surgery increased significantly with time, as did the neonatal and infant surgical procedures and infant surgical procedures. Overall, the surgical mortality did not alter with time, and was comparable to the national average. The results show an increase in the demand for cardiac investigations and surgery, and this was most evident in infants, particularly for open procedures. This unit serves a large population with proven needs, and the number of children treated falls within the range of existing supra-regional centres. The combination of available expertise, and a cost-effective patient outcome measure, should place such units in a category of high priority for resource allocation. PMID- 10170967 TI - Patient goal setting as a method for program improvement/development in partial hospitalization programs. AB - Data were collected from a study of 49 patients in 1990 and 106 patients in 1991 admitted into Country View Treatment Center and Green Country Counseling Center. Country View is a 30-bed chemical dependency residential center operating under St. John Medical Center in Tulsa, Oklahoma. Green Country is an evening partial hospital chemical dependency program operating under St. John Medical Center in Tulsa, Oklahoma, The tools used in this study were the Country View Patient Self Reporting Questionnaire, the global Rating Scale, and the Model of Recovering Alcoholics Behavior Stages and Goal Setting (Wing, 1990). These assessments were specifically designed to measure the patient's perceptions of goal setting and the patient's perspective on treatment outcome. The study outcome resulted in program improvement (Green Country evening partial hospital program) and the development of the Country View Substance Abuse Intermediate Link (SAIL) Program (day partial hospital). PMID- 10170968 TI - New lab testing rules. American Society of Internal Medicine. PMID- 10170969 TI - Clonazepam for psychiatric disorders? A look at its use in an inpatient psychiatric facility. AB - A retrospective study of clonazepam usage was conducted at the Medical University of South Carolina because it was observed that this agent was being prescribed with increasing frequency. The results of this study are presented below. PMID- 10170970 TI - The effects of cocaine abuse on infants and their implications for social workers. AB - The growth in the number of children and infants born exposed to cocaine is a relatively recent phenomenon that has taxed the already overburdened child welfare system's ability to carry out its social mandate. Despite the emergence of this social problem there is a paucity of published research on this subject in the social work literature. This paper addresses that gap by using the Social Research and Development method to review the empirical literature from a variety of fields for the purpose of identifying generalizations with empirical support on the effects of cocaine abuse on infants. These generalizations identify the effects of pre- and perinatal usage of cocaine by mothers on children, the effects on attachment behavior, and identifies the characteristics of the cocaine using mother. The paper concludes by identifying intervention guidelines that flow from the empirical findings. PMID- 10170971 TI - The politics of prevention: changing definitions of substance use/abuse. AB - Over the past decade there has been a significant shift in the language used by the Reagan and Bush administrations in the fight against youthful drug abuse. We believe this shift reflects a change both in the "moral climate" regarding drug use as well as a reconceptualization of the appropriate way to confront the issue -the "just say no" philosophy. This paper will first provide a brief sociological overview of the emergence of adolescent drug use as a major social problem. We will then document, through an examination of government-sponsored literature on drug use produced over the past 10 years, the changes in conceptual focus that have occurred and consider some of the potential negative consequences of these changes for education. PMID- 10170972 TI - Alzheimer's units: the next frontier for regulators. PMID- 10170973 TI - ADA essentials. What coverage does the Americans with Disabilities Act extend to medics? PMID- 10170974 TI - Market forecast indicators. No. of all-listed procedures for inpatients discharged from short-stay hospitals, by procedure category, sex, and age: U.S. 1990. PMID- 10170975 TI - AIDS and drug abuse in rural America. AB - This paper reviews the nature and extent of drug abuse-related HIV disease services in the rural United States. Issues concerning the delivery of HIV disease and substance abuse health care services in rural settings are outlined and discussed. PMID- 10170976 TI - Underground medicine. A quest for state-of-the-art treatments is turning thousands of ordinary Americans into activists--and sometimes outlaws. PMID- 10170977 TI - Independent living and the physical environment: aspects that matter to residents. AB - Field interviews were conducted with seven clients with disabilities for the purpose of developing design guidelines for apartments suitable for independent living. Analysis of these data generated six factors that were highly valued and felt to contribute to the success of these individuals' venture into community living. Control appears to be the central construct and to subsume the other concepts: safety/security, accessibility/mobility, function, flexibility and privacy. These findings are presented and discussed here as a working model of environmental control. These ideas are suggested as hypotheses which would need to be tested and refined further before being used as a model to guide clinical interventions. PMID- 10170978 TI - Multi-unit providers surgery centers survey 1992. Surgicenters cut further into market. PMID- 10170979 TI - Trauma center relief hits snag in Congress. PMID- 10170980 TI - Surgeon payments to rise more in '93 under RBRVS adjustment. PMID- 10170981 TI - Caring with dignity: Alzheimer's and long term care. PMID- 10170982 TI - Insurance options under ADA (Americans with Disabilities Act). PMID- 10170983 TI - Hands-on answers to hidden health costs. PMID- 10170984 TI - Wanted: the disadvantaged with a dream. Program trains unemployed to be Alzheimer's aides. PMID- 10170985 TI - To care but never to prolong? AB - What levels of life-prolonging medical interventions, if any, are appropriate for moderately and severely demented older people? This opinion piece includes a recent study of physicians' attitudes, which helps focus the controversy and examine the varied opinions that exist both internationally and within particular countries. PMID- 10170987 TI - Hospital pharmacists seek to control sales rep activities. PMID- 10170986 TI - Antibiotic prophylaxis in cardiothoracic surgery 1990: results of a third survey. AB - The use of prophylactic antibiotics for cardiothoracic surgery has become an accepted medical practice. The choice of drug and duration of therapy is controversial, however. In 1985 and 1988 the authors conducted telephone surveys of cardiothoracic surgery programs to determine the most frequently used agents. The survey was repeated in in 1990. In the 1990 telephone survey, all 51 hospitals contacted in 1988 responded. Of the hospitals responding, 31 (61%) had standard regimens used for all patients and 19 (37%) used automatic stop orders for these regimens. In institutions with standard regimens, 18 (58%) used first generation cephalosporins, 8 (26%) cefuroxime and 4 (13%) cefamandole. First generation cephalosporins were included in 33 (48%) of the 69 regimens reported to be used in all hospitals surveyed. Cefuroxime, cefamandole, ceftriaxone, and vancomycin were all used in multiple hospitals. Eight (16%) hospitals changed regimen in the last 12 months, with three of these changing to cefuroxime. The data obtained in this most recent survey are similar to the data obtained in the 1985 and 1988 reports. The results of this survey indicated that most hospitals continue to use first-generation cephalosporins for antibiotic prophylaxis in cardiothoracic surgery, but there is considerable variation among institutions. PMID- 10170988 TI - Expanding the role of long-term care. The nursing home and beyond. PMID- 10170989 TI - Filling the gaps. Systems offer two models of care management: community outreach and inpatient care. AB - The growing number of vulnerable people, such as the elderly and people with long term disabilities, calls for healthcare providers to offer more programs to ensure a continuum of care. Client-focused care management programs offer access to such a continuum. Care managers understand services and reimbursement and can pull it all together for the client. The Sisters of Charity Health Care Systems, Cincinnati, have two models of care management. St. Joseph Coordinated Care provides extensive outreach to a large, culturally diverse New Mexico community, serving urban and rural clients. Penrose-St. Francis Healthcare System offers inpatient medical care management in Colorado. Coordinated Care at St. Joseph Healthcare System in Albuquerque is comprehensive, covering a wide spectrum of client needs--medical, social, and psychological. The program's central goal is to help individuals remain safely at home. Persistence and devotion to the client are the hallmarks of effective care management and the foundation of the new geriatric care management program at Penrose-St. Francis Healthcare System in Colorado Springs, CO. The program's goals are to improve inpatient geriatric care, smooth the patient's transition to alternative care settings, and ensure efficient and effective resource use during the patient's hospital stay. PMID- 10170990 TI - Funding of new ambulatory initiatives: Canada and the United States. PMID- 10170991 TI - Move to outpatient settings may boost medical hotels. AB - The shift of surgeries to outpatient settings could be healthy for medical hotels, those amenity-equipped facilities originally developed to ease patients out of costly acute-care beds. Because fewer hospitals have a pressing need to use such alternative lodging, some medical hotels are hoping to hitch their fortunes to the outpatient trade, keeping patients overnight after surgeries that don't require hospital admission. PMID- 10170992 TI - The accessible restaurant. Part II: Employee accommodation. PMID- 10170994 TI - Health care financing: how much reform is needed? PMID- 10170993 TI - Efforts to help impaired MDs improving. PMID- 10170995 TI - CLIA '88 rules go final, HCFA details sweeping changes. PMID- 10170996 TI - The Americans with Disabilities Act of 1990: implications for managers. AB - What happens if an applicant for a job in your firm has a disability--is blind or infected with HIV or epileptic? Will you know how to treat that applicant without discrimination? The Americans with Disabilities Act was passed to make sure that the 15 million disabled people not already covered by antidiscrimination legislation would be assessed for jobs on their skills and abilities, not on their disabilities. This article will help you begin to plan for the day that applicant walks in your door. PMID- 10170997 TI - College responds to HCFA's final Medicare fee schedule. AB - On March 24, 1992, the American College of Surgeons submitted its official comments on the relative value units published in the final rule to implement the new Medicare fee schedule to the Health Care Financing Administration (HCFA). The following article provides background information on the Medicare fee schedule, describes the process the College used in developing its comments, and summarizes the comments themselves. PMID- 10170998 TI - Tapping new revenues. How to bill Medicare Part-B directly for prosthetics and orthotics products. PMID- 10170999 TI - Push for Alzheimer's patients intensifies. 50% increase in capacity anticipated. PMID- 10171000 TI - Things go better with COLA (Commission on Office Laboratory Assessment). PMID- 10171002 TI - The nuts and bolts of complying with CLIA '88. PMID- 10171001 TI - CLIA's effect on physician labs. A round table discussion. PMID- 10171003 TI - Establishing a substance abuse treatment program: considerations for the administrator. AB - More health care facilities are involved in the delivery of substance abuse treatment today than ever before. A program or health care facility administrator needs to be well informed before attempting to establish a treatment program. A knowledge of both the illness and the available treatment options is necessary to evaluate effectively the fiscal and community benefits of providing alcohol and chemical abuse and dependence treatment. The most successful long-term benefits are seen when community services are coordinated and persons seeking treatment are referred to the treatment program that best suits their individual needs. Education--of both hospital personnel and the community--is the foundation of any treatment program. Prevention and early intervention are the cornerstones of treatment. A broad view of the problems related to substance abuse will aid the administrator in a careful assessment of the needs of the community. Only then can the administrator benefit the institution and the entire community. PMID- 10171004 TI - Shining light on ADA. PMID- 10171005 TI - Millions to benefit from the Safe Medical Devices Act (SMDA) of 1990. AB - The need and desire for quality improvements in patient care, coupled with consumer desire to assume increasing responsibility for their own healthcare, signals a strong future for services like the International Implant Registry. PMID- 10171006 TI - Coding notes: significance of clinical laboratory values. PMID- 10171007 TI - Coding's the key to resource based relative value system. PMID- 10171008 TI - When love is exhausted. PMID- 10171009 TI - The Americans with Disabilities Act. PMID- 10171010 TI - Tips for meeting the tough new cytology regulations. PMID- 10171011 TI - 1990 summary: National Hospital Discharge Survey. PMID- 10171014 TI - Responding to the codependent employee. AB - Codependence is an important human disorder that is disturbingly prevalent. When codependence is viewed as a psychological concept, it offers a useful framework for evaluating and responding to problematic behavior. While nursing the addicted and codependent patient and family is an emerging specialty that is helping address the national health care problem of addictions, until now the nursing literature has provided little assistance with the need to recognize codependency from a broad perspective in nursing management. This field offers important and unexplored terrain for the creative and scholarly nurse to assist in developing nursing knowledge. This article has summarized key information about the general problem of codependency and suggests how to apply this information to the setting of the nurse manager. When a nurse manager responds to codependent behavior with understanding and firm control, feelings of security for codependent individuals can be increased and optimum performance will be facilitated. PMID- 10171012 TI - Alternate-site testing. PMID- 10171015 TI - HCFA issues long-anticipated, controversial final clinical laboratory rules. PMID- 10171013 TI - Medical devices; device tracking--FDA. Final rule; notification of status under the Safe Medical Devices Act; confirmation of effective date. AB - The Food and Drug Administration (FDA) is issuing a final rule to establish a device tracking requirement for certain categories of medical devices as required by the Safe Medical Devices Act of 1990 (the SMDA). In a proposed rule issued on May 27, 1992, and published elsewhere in this issue of the Federal Register, FDA discussed the agency's initial review of certain comments received in response to an earlier proposed rule that published in the Federal Register of March 27, 1992 (57 FR 10702), that has been withdrawn. In issuing this final rule, FDA is providing notice that the proposed rule published elsewhere in this issue of the Federal Register now has the status of a final rule by operation of section 3(c)(2) of the SMDA. FDA is also confirming that the effective date of this rule is March 1, 1993. This rule applies to all devices subject to tracking under the SMDA that are initially introduced into interstate commerce or presented for importation into the United States on or after March 1, 1993. In the proposed rule published elsewhere in this issue of the Federal Register, FDA requests comments on that proposal. Upon closure of the comment period for that proposed rule and consideration of comments responding to both the original March 27, 1992, proposed rule and the new proposed rule, FDA will, if necessary, take further actions to revise the rule. PMID- 10171016 TI - Developing hospital policy on impaired practitioners. PMID- 10171017 TI - Caregivers' perceptions of case management and community-based services: barriers to service use. AB - This study explored the use of case-managed services for dementia patients and their families. Forty-six primary caregivers, recruited from five case-managed programs and from independent sources, participated in a structured interview. The findings suggest ways in which case-managed services might be structured more effectively for caregivers to dementia patients. Specifically, families seek greater flexibility and increased family input into the service package. Further, caregivers emphasize the need for more information about service eligibility and availability, and the importance of finding a sympathetic person within the system. PMID- 10171018 TI - Dutch library services to disadvantaged persons. AB - Hospital libraries in the Netherlands provide a variety of services. In this paper two well-equipped hospital libraries, staffed by professionally qualified librarians, are described. Some hospital libraries rely on volunteers, supervised by professional librarians, while in others volunteers work completely on their own. Special services for elderly people are focused on persons who cannot visit the library by themselves. These services vary from visiting house-bound people to placing a small library in residential homes. Of special interest is the library work for aphasics in the Netherlands. The Section of Library Work for the Elderly, Sick and Handicapped Persons, a section of the Dutch Centre for Public Libraries and Literature (NBLC) is described. PMID- 10171019 TI - The legal impact of the Americans with Disabilities Act (ADA) on health information managers. PMID- 10171020 TI - Implementation of the National Healthcare Billing Audit Guidelines. PMID- 10171021 TI - Medicare payments for assistants at surgery. PMID- 10171022 TI - Should employers review mortality data? PMID- 10171023 TI - Thoughts on the Americans with Disabilities Act. PMID- 10171024 TI - Legal Qs & As ... Americans with Disabilities Act. AB - The questions and answers in this column have been drawn from Legal Memorandum Number Fifteen, The Americans with Disabilities Act: A Practical Guide for Hospitals, prepared by the ADA Task Force of the American Hospital Association's Labor Relations Advisory Committee and published by AHA's Office of Legal and Regulatory Affairs. This material has been included for information only; it should not be viewed as legal advice or used as such. PMID- 10171025 TI - Rehabilitation institutions and the ADA. PMID- 10171026 TI - AIDS: an ADA-covered condition. PMID- 10171027 TI - What health care institutions need to know about the ADA. PMID- 10171028 TI - Effective handling of health-related leaves of absence. AB - This article will address the legal obligations of employers in non-union settings toward employees who request pregnancy leave, parental or medical leave, workers' compensation leave, and other forms of disability leave. Specifically, this article will address the legal standards set forth under the Pregnancy Discrimination Act, various state pregnancy and family leave acts, workers' compensation retaliatory discharge authority, and the Americans With Disabilities Act of 1990. In addition, this article will provide practical guidance for employers in formulating effective leave policies that provide the maximum amount of operational flexibility while at the same time minimizing the risk of costly and excessive litigation. PMID- 10171029 TI - Smoking in the workplace: a management perspective. AB - Caution is warranted when undertaking smoking measures that go beyond those required by state or local laws and do not accommodate the interests of all employees. Twenty states and the District of Columbia have enacted laws regulating smoking in the private workplace. In contrast, twenty-two states recently have enacted laws that protect persons who smoke outside the workplace from being subjected to adverse employment actions. Although these laws vary widely in their language and specifics, most pose practical and compliance problems for employers. The following article updates the author's more comprehensive examination in 1988 of judicial, legislative, and employer responses to the workplace smoking issue published in 14 Employee Relations Law Journal 359 (1988). PMID- 10171030 TI - Preparing for Medicare outpatient payment reform. AB - Orthopedic hospitals, institutions with a high volume of surgeries, and hospitals with high Medicare populations should learn from the experiences of eye and ear hospitals, some of which could have been put out of business by Medicare outpatient payment reforms proposed in 1986 and partially implemented since then. As the reforms are refined, hospitals should analyze their vulnerability to the proposed changes using the matrix proposed in this article. They should also take steps to counter any negative impact on revenues and try to influence the nature and scope of the reforms. PMID- 10171031 TI - Harm reduction. A new approach to drug services. PMID- 10171032 TI - Norway's pivotal role in regulatory health economics and pharmaceutical cost containment--what can other countries learn? AB - With an increasing trend in health care consumption--together with the introduction of an increasing number of new medical technologies-- governments, insurance companies and other third party payers seek new ways of limiting increases in consumption, as well as limiting the use of new medical technologies to the most efficient ones (clinically, economically). One particular area of focus in this context is the pharmaceutical sector, where the innovational rate of new technologies (drugs) has been high. One of the forerunners in the areas of health care cost containment and regulatory health economics is Norway. This country has succeeded in keeping drug prices and drug consumption at moderate levels, as well as keeping the number of new drugs to a relatively modest level. This study describes the Norwegian drug regulatory process, the Norwegian drug market, the Norwegian cost-containment policies and future regulatory perspectives. For many European countries and in North America, where stricter price and reimbursement regulations are considered, the Norwegian drug regulatory process presents an interesting example of how a strict regulatory environment may affect the availability of drugs, as well as drug prices, drug reimbursement and drug consumption. PMID- 10171033 TI - Substance abuse treatment services: an introduction. PMID- 10171034 TI - Substance abuse day treatment and managed health care. AB - Day treatment for substance abusers has been viewed by many as a viable treatment modality, particularly in light of the success of psychiatric day treatment programs. The available research also supports the efficacy of day treatment versus inpatient treatment for substance abusers. Nevertheless, day treatment programs for substance abusers have had difficulty gaining acceptance with treatment providers and patients alike. This paper offers several explanations for this lack of acceptance and proposes that managed care settings are ideally suited to pioneer substance abuse day treatment programs. Practical suggestions will also be offered to help market this treatment modality and minimize patient resistance. PMID- 10171035 TI - New directions in substance abuse services: programmatic innovations in the Veterans Administration. AB - The purpose of this paper to describe the Department of Veterans Affairs' (VA) recent expansion and enhancement of its substance abuse treatment services. Several treatment innovations are considered from both clinical and administrative perspectives. These services include extended care programs for multiply impaired patients, programs for substance abuse patients with comorbid psychiatry conditions and services designed to improve continuity of care and community re-entry. Emergent themes include a broadening of services to meet the needs of a changing substance abuse population and an emphasis on providing more cost-efficient treatment. PMID- 10171036 TI - Substance abuse treatment management information systems: balancing federal, state, and service provider needs. AB - There is increased interest in documenting the characteristics and treatment outcomes of clients served with Alcohol, Drug Abuse, and Mental Health Block Grant funds. The evolution of federal client-based management systems for substance abuse treatment services demonstrates that data collection systems are important but require continued support. A review of the Massachusetts substance abuse management information system illustrates the utility of a client-based data set. The development and implementation of a comprehensive information system require overcoming organizational barriers and project delays, fostering collaborative efforts among staff from diverse agencies, and employing considerable resources. In addition, the need to develop mechanisms for increasing the reliability of the data and ongoing training for the users is presented. Finally, three applications of the management information system's role in shaping policy are reviewed: developing services for special populations (communities of color, women, and pregnant substance abusers, and injection drug users), utilizing MIS data for evaluation purposes, and determining funding allocations. PMID- 10171037 TI - Referral and screening for substance abuse treatment in jails. AB - As jails and prisons have become filled to capacity with inmates arrested and convicted for drug-related offenses, efforts have intensified to reduce subsequent drug use, drug-related crime, and recidivism among this population. Faced with the drug abuse epidemic; treatment resources in the community have expanded more quickly than in detention and corrections facilities. Many large jails and prisons do not presently have a substance abuse treatment program despite clear evidence of widespread drug and alcohol dependence problems among inmate populations. Where substance abuse treatment resources are available, administrators face difficult choices in determining which inmates will receive services. This paper provides a discussion of issues related to referral and screening procedures for in-jail substance abuse treatment programs. Referral and screening systems implemented in several jails across the country are reviewed. PMID- 10171038 TI - Treating the drug-abusing offender. AB - The association between drug abuse treatment and criminal justice control is examined in this article. A framework is presented for mental health administrators and policy-makers to examine and appreciate the use of authority derived from the criminal justice system for drug abusers involved in community treatment. In addition, an overview of relevant literature is provided to encapsulate the literature related to the drug-abusing criminal offender which is most useful for mental health administrators and policy-makers. PMID- 10171039 TI - Substance abuse and family illness: evidence from health care utilization and cost-offset research. AB - Although the substance abuse treatment community recognizes that physical and psychological problems are common among families with a substance-abusing member, third-party funding for comprehensive treatment of the families of substance abusers is limited. Failure to provide treatment for these collateral effects of substance abuse on the family is thought to reduce the efficacy of substance abuse treatment, increase the risk of relapse, and leave untreated secondary pathology among family members. This article presents a review of health care utilization and cost-offset studies of the collateral effects of substance abuse on the family to aid administrators and planners in documenting the economic advantages of comprehensive treatment for the families of substance abusers. PMID- 10171041 TI - Breast implants, Hippocrates, and burden of proof. AB - The author argues that the burden of proof for the safety and efficacy of some medical devices properly lies with the manufacturers of the devices and with the providers who use them. The controversy over breast implants is used as a case for this shift in the burden of proof of safety and effectiveness. PMID- 10171040 TI - A survey of state insurance mandates covering alcohol and other drug treatment. AB - This article reports the results of a survey of health insurance mandate legislation for alcohol and other drug treatment in the 50 states through spring 1991. A total of 23 states (including the District of Columbia) requires insurance carriers to provide coverage for alcohol and other drug treatment. This paper compares the provisions in these states at the present time and contrasts these provisions with those in effect in 1981. The paper concludes with a discussion of the policy objectives states pursue through enactment of such legislation and the outcomes brought about by the mandates. PMID- 10171042 TI - Waiving the rules. PMID- 10171043 TI - AHA report outlines challenges facing nation's urban hospitals. PMID- 10171044 TI - What is value? The discounted cash flow approach. PMID- 10171045 TI - Reducing the physical and fiscal pain of back injury. AB - In the British Columbia health care industry from 1988 to 1990 occupational back injury accounted for 37 per cent of the time lost to injuries and 47 per cent of costs associated with wage loss. In 1988, the Royal Inland Hospital in Kamloops, British Columbia, implemented an early-intervention and occupational rehabilitation program. By 1990, this program had reduced the hospital's average time lost to back injury by 43 per cent. This article describes the procedures and benefits of the program. PMID- 10171046 TI - Medicare program; carrier jurisdiction for claims for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) and other issues involving suppliers, and criteria and standards for evaluating regional DMEPOS carriers- HCFA. Final rule with comment period. AB - This final rule Modifies regulations to provide that claims for durable medical equipment, prosthetics, orthotics and certain other items covered under part B of Medicare be processed by designated carriers. Specifies the jurisdictions each designated carrier will serve. Changes the method by which claims for these items are allocated among the carriers from "point of sale" to "beneficiary residence." Establishes certain minimum standards for suppliers for purposes of submitting the above claims. Incorporates in regulations certain supplier disclosure requirements imposed under section 4164 of the Omnibus Budget Reconciliation Act of 1990, as part of the process for issuing and renewing a supplier's billing number. Describes the criteria and standards to be used beginning October 1, 1993 for evaluating the performance of designated carriers processing claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) in the administration of the Medicare program. Section 1842(b)(2) of the Social Security Act requires us to publish criteria and standards against which we evaluate Medicare carriers for public comment in the Federal Register. We expect the above changes to lead to more efficient and economical administration of the Medicare program. PMID- 10171049 TI - Hospitals may not discriminate against AIDS-infected health care workers. PMID- 10171047 TI - Social problems that escalate America's health care costs. PMID- 10171048 TI - The reshaping of healthcare. Part 2. AB - Powerful new tools produced by the biotechnology revolution--predictive genetics (and ultimately genetic therapy) and immunotherapy--will eventually make obsolete much of our current armada of crude "halfway" technologies, and enable us to prevent most illness altogether. These advances were discussed in the May/June issue of the Journal. This article addresses their likely impact on healthcare delivery. PMID- 10171050 TI - La Nina de Genesis. PMID- 10171051 TI - Day surgery. AB - Costing half as much as inpatient treatment, with good results and advantages to patients, day surgery might be expected to be more widespread than it is. Purchasers may be those who push for more by specifying targets for day surgery for certain procedures. How can managers respond? PMID- 10171052 TI - A guide to NIDA certification for workplace drug testing. PMID- 10171053 TI - Gains in productivity, technology keeping lid on cost of lab tests. PMID- 10171054 TI - Perspectives. Anatomy of a waiver: Oregon plan stumbles. PMID- 10171055 TI - Special report. Drug usage by employees: an update. AB - A declining number of American workers are testing positive for drugs, according to one of the leading substance abuse testing companies in the United States. Smith-Kline Beecham Clinical Laboratories, King of Prussia, PA, conducts urinalysis for corporate clients and has tested more than six million people for drugs since 1987. In 1991, for the fifth consecutive year, it found a declining percentage of Americans on drugs at work. What is behind this apparent decline? Is it becoming easier to "beat" drug tests? What drugs are most used? Who is most likely to be on drugs? In this report, we'll present some of the conclusions about drugs in the workplace that have emerged after several years of testing and treatment experience. PMID- 10171057 TI - The ADA: new directions for the disabled--and hospitals. AB - Federal ADA experts emphasize that hospitals will be judged by higher standards than others. The author offers a comprehensive overview that is a guide for management to deal with the issue and with the new regulations. PMID- 10171058 TI - Building bridges with ADA. PMID- 10171056 TI - Sterilizing talcum powder used in surgery. PMID- 10171059 TI - The "Overcoming Challenges" program at NME. PMID- 10171060 TI - An evolutionary process: applying CQI techniques to quality assurance issues. AB - Evolving from a traditional quality assurance to a continuous quality improvement mindset is both challenging and frustrating. How to phase out the old and embrace the new is not always clear. Approaching the shift as an evolutionary process by applying CQI techniques to issues identified through traditional QA methods can be effective. It helps to validate the significance of past efforts and provide tangible evidence of process improvement. PMID- 10171061 TI - Community support for young physically handicapped people. AB - This study examined the cost of home and hospital care for individuals who are severely physically handicapped and who may have many years to live. In addition to quantifying the overall level of these services and their costs, factors which might influence the level of service were identified and their use related to the diagnosis, duration and severity of disability, and number of unpaid carers. Costs of health and social service community support increased with severity of disability, and were mostly incurred by individuals with a Barthel score of less than 50 (more severe handicap). Costs, except for those individuals with cerebral palsy, were independent of the number of careers, and for those of school and university age the costs of special educational facilities were significant. PMID- 10171062 TI - Cancellation in elective orthopaedic surgery. AB - The management of operating theatre time is a crucial element in the size of surgical waiting lists, and this paper reports a survey of causes of the cancellation of operations for orthopaedic surgery. The results show that, although the majority of cancellations were due to medical causes, others were the result of extended theatre schedules. These findings suggest that closer co operation between surgical staff, general practitioners and theatre staff could help to reduce this problem. PMID- 10171063 TI - Avoidable causes of cancellation in elective orthopaedic surgery. AB - As part of an audit of clinical practice in an orthopaedic unit for elective surgery, a study was made of the causes of cancellation of operations. Despite careful liaison with general practitioners, and a booked admission policy, over 6% of patients were cancelled as unsuitable. The results of this study suggest that the number of cancellations on medical grounds would be reduced by closer liaison with general practitioners, and the establishment of preadmission clinics. Ensuring that only consultants book patients for surgery would also reduce the number of cancellations due to incorrect indications for surgery. PMID- 10171064 TI - Day care surgery for the correction of hallux valgus. AB - This paper reports the experience of performing Wilson's osteotomy on a day care basis, and explores the potential and pragmatism of day surgery in orthopaedic practice. Fifty one patients (58 feet) were treated by a Wilson's osteotomy for the correction of hallux valgus. The results show an overall success with day care surgery and compare favourably with other series. PMID- 10171065 TI - CLIA heralds a new system affecting almost all clinical labs. PMID- 10171066 TI - Hospitals ask about the ADA (Americans with Disabilities Act). PMID- 10171067 TI - Surgical waiting lists I: Definition, desired characteristics and uses. AB - In the first of this two-part series, the authors define waiting lists, review the waiting list situation in Canada, discuss factors affecting such lists, outline their desired characteristics and describe the analysis and use of waiting list data. The manner in which lists are compiled results in significant differences which makes the meaning of waiting lists difficult to determine. From the literature reviewed and interviews with various health service executives, the authors show that waiting lists, as compiled today, are not a valid and reliable measure of the extent of unmet demands for hospital care. In Part II, which will be published in the next issue of FORUM, the authors will present the results of an exploratory survey done to determine how waiting lists and times are presently being compiled and used in secondary and tertiary hospitals. These findings will be summarized and compared to the desired characteristics and uses of a waiting list as presented in Part I. PMID- 10171068 TI - The importance of exterior environment for Alzheimer residents: effective care and risk management. AB - Evidence shows that environments especially designed for cognitively impaired seniors can maintain or increase their level of functioning. Little emphasis has so far been placed on the prosthetic role that may be played by exterior environments. This study attempted to determine the value that specially designed exterior spaces may have in reducing undesired behaviours, thereby minimizing risks to the patients and potential liability to the institution. The researchers tested that (a) poor environments increase residents' frustrations and can precipitate catastrophic behaviour and (b) freedom of movement and opportunities to avoid crowding, noise and excess stimulation minimize the frequency of aggressive behaviour. The researchers found that the use of exterior environments reduced incidents of aggressive behaviour, and contributed significantly to a risk management program. PMID- 10171069 TI - The role of a development lab in a hospital setting. PMID- 10171070 TI - Specific list for categorization of laboratory test systems, assays and examinations by complexity--PHS. Notice with comment period. AB - The Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, requires that the Secretary provide for the categorization of specific laboratory test systems, assays and examinations by level of complexity. 42 CFR 493.17, published in the Federal Register on February 28, 1992 established criteria for such categorization. It is the Department's intention to complete the categorization of all currently available clinical laboratory test systems, assays and examinations prior to the effective date of 42 CFR 493 (September 1, 1992). This notice announces the second of a series of lists containing specific clinical laboratory test systems, assays and examinations, categorized by complexity. This notice also includes deletions and corrections to the list of test systems, assays and examinations published on February 28, 1992. Additional lists of test systems, assays and examinations as well as deletions and corrections will be published periodically. On or before September 1, 1992, a complete list of all laboratory test systems, assays and examinations, categorized by complexity, will be published in the form of a compilation of these Notices. Any clinical laboratory test system, assay or examination that is not on that final list will be considered high complexity, until categorized otherwise as provided under 42 CFR 493.17. After publication of the compilation, applications will be taken to categorize (or recategorize) other laboratory test systems, assays and examinations following the procedures delineated in 42 CFR 493.17(d). After September 1, 1992, notices will be published periodically in the Federal Register to announce any additional test system, assay or examination that has been categorized (or re-categorized) during the preceding interval. PMID- 10171071 TI - Ready or not, here it is. The Americans with Disabilities Act. PMID- 10171072 TI - Episodic crises: does dementia make a difference? AB - Preventing episodic crises in residents with and without dementia is possible when staff learns how to identify "signaling events": changes in behavior or life status, physiological symptoms, or other complaints. PMID- 10171073 TI - Predicting crises: residents with dementia. PMID- 10171074 TI - Ballard Health Care Residence: a SWAT team in action. PMID- 10171075 TI - Inglis House: a wheelchair community. AB - Long-term care facilities with younger residents may find it difficult to meet this unique group's needs. Inglis House is one special community designed especially for a younger population. PMID- 10171076 TI - Nation's governors seek more control over Medicaid funds. PMID- 10171077 TI - Innovations in managing difficult behaviors. AB - Caring for people with difficult behaviors is among the greatest challenges for nursing facility providers. This month, Provider looks at successful techniques in caring for people with dementias and other difficult-to-manage behaviors. PMID- 10171079 TI - Disabilities Act to alter lives of both employers and employees. PMID- 10171078 TI - New data useful for AIDS policies. PMID- 10171080 TI - A fifty-question self-audit on ADA (American with Disabilities Act) compliance. AB - Three converging trends should cause employers to go beyond the minimum requirements of the ADA in recruiting, hiring, retaining, and promoting disabled workers. 1. The number of entry-level employees, ages eighteen to twenty-five, is decreasing to the extent that many businesses are finding it difficult to fill open, entry-level job positions. Hiring disabled people can help fill these positions. 2. The Education for the Handicapped Act of 1975 that requires mainstreaming disabled students is responsible for ensuring full educational benefits for all individuals with disabilities. 3. As we become more of an informational society, employees' brainpower becomes more important than their physical abilities. Therefore, effective compliance not only with the letter of the ADA, but also with the spirit of this law is simply good business. PMID- 10171081 TI - Making reasonable accommodations under the ADA (Americans with Disabilities Act). PMID- 10171082 TI - The law and HIV-/HBV-infected workers: protection or punishment? PMID- 10171083 TI - Greater accessibility for the disabled costing hospitals billions. PMID- 10171084 TI - Community integration for persons with disabilities: working together to make it happen. AB - In summary, the common themes for therapists working in these three areas are very evident. The content of each paper seemed relevant to all of the client populations. The current trends toward integration and increased consumer control are impacting on occupational therapy practice with all three groups. These trends have significant implications for service delivery and all health care professionals. Occupational therapy has already begun to recognize and value these trends (Canadian Association of Occupational Therapists, 1991; Law et al., 1991). Occupational therapists need to work together and align their efforts to promote the establishment of a comprehensive community service system that enables people to receive the support that they require in their home communities. Service approaches must be designed for empowerment and the full participation of persons with disabilities in all aspects of community living. Treatments that focus solely on minimizing an individual's disabilities will not be successful in achieving this stated goal. There is a need for approaches that creatively adapt environments and reallocate resources so as to enhance the formation of relationships and participation in typical community activities. Service providers must be prepared to respond with the assistance that individuals need to achieve their goals. This is only made possible by the participation of persons with disabilities in the decision making process and in the development of services to meet their needs. Such efforts are supported by government initiatives and strategic plans. The realization of full community participation of persons with disabilities is dependent on the quality of the partnerships that are formed between the community, the service providers, and (ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171085 TI - New barrier-free law challenges designers. PMID- 10171086 TI - Incarceration in parents of day hospital youth: relationship to parental substance abuse and suspected child abuse/maltreatment. AB - The number of individuals incarcerated in penal institutions in the United States has increased dramatically in recent years. Children of incarcerated parents have been studied infrequently. They appear to be at high risk for present and future behavioral disorders, although their rate of utilization of mental health services is not known. This study compares a group of behaviorally disturbed children in day hospital treatment who have had incarcerated parents with a group of children without this history who were treated in the same facility at the same time. Children with histories of incarcerated parents account for almost 40% of those treated. They are more likely than their peers without histories of having had an incarcerated parent to have had substance abusing parents and to have been involved in at least one report of suspected child abuse/maltreatment. These variables together are taken as signs of severe family disorganization or dysfunction. In previous studies they have also been associated with poor outcome in mental health treatment. Clinical and social implications of these findings are discussed. PMID- 10171087 TI - Coping with CLIA, Part I. How to obtain a CLIA certificate without getting stuck in the details. AB - Welcome to the sticky world of HCFA's form 109. Prepare it with clinically strict accuracy. Believe it or not, the future of your laboratory depends on how well you fill out this form. PMID- 10171088 TI - Selecting instruments with an eye to CLIA. PMID- 10171089 TI - Open your doors to the disabled--it's the law. PMID- 10171090 TI - Grass-roots reflections on substance abuse. A community dialogue approach. AB - The Greater Cleveland Dialogue brings together people from all walks of life to express their sufferings and opinions. Professional ethicists have a role to play in this process, but chiefly as listeners and interpreters rather than as theoreticians. The ethics that arises from this process is at least as useful as the conclusions that descend deductively from the many rival "first principles" of a more theory-driven approach. If community dialogues provide a partial answer to questions of ethics and health care, they do so because they include the public. Policies related to health care affect the public and must be in tune with public sentiment if they are to be effective. Moreover, a different style of health care ethics emerges from the dialogue process. My view is that a truly public bioethics is ultimately necessary, since the policies our society develops in the area of health care can be meaningful only if they are grounded in the general will. We need to work harder at widening the umbrella of bioethics to include the public, for the sake of the community and for our own education as professionals. Certainly major questions for the future surround the nature of consensus and the process of achieving it. PMID- 10171091 TI - To ration or not to ration? PMID- 10171092 TI - Monitored anesthesia care for laparoscopies in oncology patients. AB - A retrospective chart review was conducted on 241 oncology patients who received monitored anesthesia care for laparoscopy. A review of perioperative analgesic and sedative requirements, and perioperative complications is included. The authors conclude that laparoscopy for diagnostic and staging purposes can be accomplished successfully with monitored anesthesia care. PMID- 10171093 TI - Thoracic imaging in the intensive care unit. PMID- 10171094 TI - Saliva alcohol reagent strips in altered response protocols. AB - The prehospital care provider has been limited in his or her initial assessment of patients due to having available only a limited number of simple diagnostic tests. There has not been an accurate field test available to rule out significant ethanol intoxication. We designed a prospective trial for the prehospital setting to test the utility of a rapid, semi-quantitative, saliva alcohol reagent strip for patients with an altered level of consciousness. We found that these strips were useful in ruling out significant ethanol intoxication as a cause of an altered level of consciousness with a sensitivity of 85.7% and a specificity of 94.4%, but were not useful in accurately predicting the blood alcohol level. We conclude that these reagent strips are useful in the prehospital setting to provide information about patients with an altered level of consciousness. PMID- 10171095 TI - Guidelines for transcutaneous p O2 and p CO2 measurement. AB - This document provides guidelines in the terminology, methodology, and in the interpretation of data obtained from the use of skin (transcutaneous) p O2 and p CO2 electrodes. The transcutaneous technique has found special application for newborn infants. The causes of analytical bias with respect to arterial blood gas values and imprecision obtained with transcutaneous p O2 and p CO2 electrodes are reviewed. Electrode temperatures above 44 degrees C should not be used routinely, and, at a measuring temperature of 44 degrees C, the measuring site should be changed at least every 4 h to avoid skin burning. PMID- 10171096 TI - Laser vascular tissue fusion: development, current status, and future perspectives. AB - Tissue fusion has a number of vascular applications such as making sutureless blood vessel anastomoses and for securing the end points of endarterectomies and dissection planes. Precision of tissue apposition at the time of fusion has been found to be a critical parameter, affecting the rate of healing and tensile strength of tissue welds. Several laser wavelengths can be used to accomplish vascular and other soft tissue fusions. Potential advantages of laser fusion over suture techniques may include healing without foreign body reaction related to sutures and preserved mechanical properties at anastomoses. While preliminary experimental and clinical data are very promising, additional work is needed. This would include determining the mechanism and optimal laser parameters and wavelengths required for vascular tissue fusion. In addition, the characteristics needed to seal uniformly large-diameter arteries and to fashion welds that withstand systemic arterial pressures must be identified. Follow-ups of approximately three years suggest that strong initial primary seals will eliminate significant adverse effects. PMID- 10171097 TI - Development and application of modern devices in vascular surgery including comment on modern antithrombotic and lytic drug therapy. AB - Since modern vascular surgery started with the discovery of heparin and the development of modern vascular grafts including autogenous saphenous vein, the speciality has been technologically driven. At the outset, vascular surgery depended almost entirely on the development of specialized clamps, instruments, and tools to permit decisive attack on the problems of occlusion. No less important was the development of insight into the basis of atherosclerosis, the discovery that atherogenesis with thrombosis is electrochemically identical to corrosion in pipes and therefore subject to chemical forces, which have not yet been delineated, as well as mechanical forces which have been delineated and permit one to attack the atheroma directly. Thus, classic replumbing techniques including bypass and endarterectomy have long been a part of the fundamental firmament of vascular surgery. Most recently, modern techniques in cleaning out blood vessels, removing occlusive processes, and modern thrombus-dissolving enzymes have all come to the forefront. Frequently multiple techniques are used simultaneously. This article is an attempt to summarize various aspects of this activity and describe several of the patents which have been seminal in the ultimate application of the techniques in both experimental animals and man. This should be the first of a series of efforts to summarize this area. The process of change has never been more kinetic than now. PMID- 10171098 TI - Long-term delivery of testosterone by ALCAP ceramic implants in rats. AB - The capability of ALCAP ceramic drug-delivery implantable devices to release testosterone for 12 months was investigated. A total of 120 Sprague-Dawley male albino rats were distributed equally into three groups. Two ALCAP capsules, one nonimpregnated and the other impregnated with polylactic acid (PLA) were implanted into each rat in Groups I and II. Capsules implanted into Group I rats were loaded with 40 mg testosterone (T) each. Group II rats were implanted with two empty capsules (sham group), and Group III animals served as unimplanted controls. Eight rats from each group were euthanized at the end of 1, 3, 6, 9, and 12 months following the implantation of the ceramics. No significant changes in the weights of vital organs of rats were observed between any of the three different groups. Vas deferens and epididymal fluid were devoid of normal spermatozoa within 3 months of implanting the steroid-containing ceramics. Testes and epididymis weights decreased significantly in the rats implanted with ALCAP ceramics containing steroid, and the seminiferous tubules became oligospermic after 1 month and azoospermic after 3 months. Circulating levels of both LH and FSH hormones were suppressed in experimental rats. Serum T level was lower than the control but showed no significant difference in comparison to control rats. The data collected in this study suggest that: (a) ALCAP ceramic capsules are capable of delivering T in a sustained manner for 12 months; (b) T delivered by ALCAP capsules can be used effectively to regulate spermatogenesis in rats. PMID- 10171099 TI - Preliminary development of a hydroxyapatite-backed strain gauge. AB - Long-term in vivo strain sensing would provide information about deformation changes adjacent to implants during bone remodeling. Biodegradation of the cyanoacrylate adhesive commonly used to attach strain gauges to bone has generally limited in vivo strain sensing to time periods less than one month. Hydroxyapatite (HA) which has been used to attach implants to bone in vivo, was attached to strain gauges using a solvent-thinned polysulfone solution. Three HA polysulfone surface morphologies were tested in a preliminary bench-top test. The single layer pressed surface morphology, which responded most accurately during bench-top testing, was modified slightly and applied to two gauges which were implanted on the femur of a greyhound. Strain measurements from the HA backed gauges in place for four months in vivo were compared to strains measured from the contralateral femur. Comparison of the results indicated these gauges were well-bonded and that they were sensing strain accurately. After embedding in PMMA, the femur having the HA-backed gauge and the control femur were sectioned at the level of one of the HA-backed gauges. Microradiographs of these sections indicated no adverse tissue response to the HA-backed gauge on the endosteal or periosteal surface. PMID- 10171100 TI - A poly-HEMA based aqueous humor draining device. AB - An aqueous humor draining device, with size comparable to that of the Krupin tube, was constructed by using poly-HEMA material. Deposits were found on the surface of poly-HEMA when contacted in vitro with the aqueous humor of the rabbit's eye. A fibrous structure, probably composed of proteins and other macromolecules, developed on poly-HEMA surface in 15 days after the draining device was implanted into the rabbit's eye. The draining device was still in function 250 days after its implantation. SEM analysis of the retrieved poly HEMA draining device indicated that the poly-HEMA tube opening was not blocked by any substance. These results suggest that poly-HEMA could be used as a biomaterial for construction of the aqueous humor draining device to relieve the intraocular pressure of glaucoma patients. Its long-term application awaits further investigation. PMID- 10171101 TI - Clinical accuracy of continuous hemoglobin oxygen saturation monitoring devices. AB - Three devices used to measure hemoglobin oxygen saturation in the extracorporeal circuit were studied and compared to a control. The Baxter Bentley OxySat, Oximetrix Accusat, and Radiometer ABL4 blood gas monitor were compared to a control, the IL 282 Co-Oximeter. Fifty-one sample points were obtained during all phases of cardiopulmonary bypass with results as follows: table: see text. The Accusat was found to be a statistically more accurate means of monitoring hemoglobin oxygen saturations during cardiopulmonary bypass than the ABL4 and the OxySat. All devices had significant correlation with the control and with each other. PMID- 10171102 TI - Aortic valve replacement. PMID- 10171103 TI - Reperfusion modification with a simplified blood cardioplegia system compared with oxygenated crystalloid cardioplegia. AB - A simplified system was developed for administration of blood cardioplegia with reperfusion modification. This system utilizes a single pass stainless steel coil to eliminate the need for a separate heat exchanger circuit. This system was compared with an oxygenated crystalloid cardioplegia system which was utilized in a manner which allowed warm blood perfusion of the heart for the last three minutes of the crossclamp interval. Both of these systems were compared with regard to mortality, spontaneous defibrillation, myocardial temperature, blood usage and peak CK-MB levels. In this series of patients, no significant advantage of either system could be identified. PMID- 10171104 TI - Interlaboratory cholesterol standardization: a model project. PMID- 10171106 TI - Technology assessment and the evaluation of implanted medical devices. AB - Technology assessment is attracting new attention and funding as concern about costs and effectiveness of health care grows. This article provides a general overview of technology assessment and relates recent trends and future prospects specifically to the use and evaluation of implanted medical devices. In the next decade we may expect to see renewed interest in technology assessment as pressure to control health care costs continues and as a different focus of evaluation emerges that emphasizes patient preferences and quality of life in addition to traditional measures of safety, efficacy, and cost-effectiveness. These pressures and forces will act to increase the visibility and importance of proper assessment of medical technology, and the field may more nearly achieve its early promise as a tool to make medical care more rational. PMID- 10171105 TI - New approaches to nucleated RBC correction of WBC counts. PMID- 10171107 TI - Osteoinductive biomaterials for medical implantation. AB - The search for the ideal implant material continues since presently available implants all have significant drawbacks. This paper reviews three studies that we recently completed with bone-inducing implants. Long-term clinical follow-up of 75 allogeneic demineralized bone implants showed an average degree of resorption of 49%. Implants used for dorsal nasal augmentation showed an average degree of resorption of 50.7%, increasing to 82.5% after a 24-month follow-up. The efficacy of demineralized bone implants is dependent on many factors including site of implantation, method of preparation, etc. Transforming growth factor-beta 1 (TGF-beta 1) is a regulator of bone formation. We combined recombinant TGF-beta 1 with demineralized bone powder in a rabbit facial augmentation model. At 6 weeks, there was evidence of increased bone formation in the implants containing TGF-beta 1. Even though TGF-beta 1 can increase bone formation in demineralized bone implants, the overall bone-inducing activity in these implants seems to be suboptimal. Osteoinductive factor extract (OFE) is a partially purified bone factor preparation that has been shown to form bone when implanted into rats. Using a collagen/ceramic carrier, we implanted OFE into a rabbit facial augmentation model. At 21 d, histomorphometry revealed numerous osteoblasts and bone formation in the OFE implants. The bone-inducing activity of many partially purified osteoinductive preparations such as OFE is probably due to Bone Morphogenetic Protein-2A (BMP-2A), which has been shown to induce bone formation in its recombinant form. Recombinant DNA methodology provides the technology necessary to produce these molecules in their homogeneous form, permitting evaluation of bone-inducing activity in a preparation free of contaminants. Finally, the ideal carrier must be devised to permit safe and effective delivery of recombinant bone-inducing factors. PMID- 10171108 TI - The clinical use of aluminium oxide bioceramic implants for mandibular condyle replacement: a six year report. AB - In a 6-year period, six bilateral and five unilateral compact aluminium oxide ceramic condyle fixed with titanium screws were implanted. During the years following the operation, it was not necessary to remove any ceramic condyle. In only one case (rheumatic polyarthritis) was it necessary to reoperate on the patient because of bilateral reankylosis. Ceramics can be recommended in a wide field application because of the simplicity, uniformity, durability, and good tissue-enduring ability. The danger of postoperative ankylosis occurs only in patients suffering from rheumatoid arthritis. PMID- 10171109 TI - Biostability of materials and implants. AB - The purpose of this paper is to discuss some important parameters that are involved in the biostability of materials and implants aimed at the eventual development of improved in vitro testing and evaluation procedures. In view of the fact that certain terms have been the subject of misunderstandings, definitions are offered for the terms "biomaterials", "bioerosion", "biostability", and "bioresorption". Following brief descriptions of various classes of materials used in biomedical applications, the in vitro and in vivo degradations of selected materials are discussed. The main conclusions are as follows: (1) most synthetic polymers degrade in vivo by nonenzymatic hydrolysis. Hence, it is recommended that initial, in vitro testing schemes of most synthetic polymers and implants omit the use of enzyme solutions. The use of enzyme solutions is appropriate in the case of natural biopolymers as well as synthetic biodegradable polymers that contain peptidic-, glycosidic-, or phosphatidic bonds. (2) The biostability of materials and implants may be greatly affected by the simultaneous presence of stresses and active components in the physiologic environment that may lead to environmental stress cracking. (3) The biostability of polymeric materials is influenced not only by adsorption but also by the absorption of components in the physiologic environment. PMID- 10171110 TI - Anterior cruciate ligament replacement: a review. AB - The anterior cruciate ligament (ACL) is the major intra-articular mechanical element that limits motion of the tibia with respect to the femur. It is a multi fasciculated structure composed of crimped aligned collagen fibers. The purpose of this paper is to review the literature on ACL structure and mechanical properties in an effort to stimulate the development of a new generation of more effective replacement devices. Replacement of the ACL is achieved using biologic and synthetic grafts. Biologic grafts include illiotibial band, semitendinosus and gracilis tendons, patellar tendon, and meniscus. Bone-patellar-bone complexes used to replace the ACL are revascularized and ultimately replaced by neo-ligament. Synthetic implants including the Integraft, Leads-Keio ligament, Gore-Tex? ligament and Kennedy Ligament Augmentation Device (LAD) have either not been approved or approved by the FDA for limited use as a replacement for the ACL. The Kennedy LAD has been found to increase the strength of autogenous tissue during revascularization. Based on the success of autografts and the Kennedy LAD, we conclude that the next generation of ACL replacement devices will consist of a scaffold and a biodegradable augmentation device. The scaffold will have a structure that mimics the normal ACL as well as stimulates revascularization and healing. A biodegradable augmentation device will be employed to mechanically reinforce the scaffold without stress shielding the neo ligament. By combining the advantages of autografts and a biodegradable augmentation device, a new generation of ACL replacements will be achieved. PMID- 10171111 TI - Molecular impact surface textured implants (MISTI) alter beneficially breast capsule formation at 36 months. AB - Since the development of smooth silicone breast implants in 1962, over two million women throughout the world have opted for breast augmentation surgery. While initially successful, smooth implants are prone to developing surrounding scar capsules that may harden and contract--resulting in discomfort, weakening of the shell with rupture, unsightliness, and patient dissatisfaction. This phenomenon has been shown to occur in as much as 70% of implanted patients over time. Our work on the texturing of implantable prosthesis material (published in 1968), and subsequent discoveries, has led us to the development of textured silicone breast implants. Because the host interface is altered by the texture, collagen fibrils select a formation that is multiplanar which results in thinner, more pliable capsules that are more resilient and less likely to contract. At 18 months (August, 1989), with 116 implants, all remain soft, after an additional 18 months follow-up, for a total of 36 months maximum and 18 months minimum. The long-term performance of these implants must await the availability of further clinical data. PMID- 10171112 TI - Hydroxyapatite-coated orthopedic implants. AB - Hydroxyapatite (HA)-coated metal implants were developed in order to capitalize on the excellent biological properties of HA, and minimize the potential for mechanical failure of the HA in vivo. Results of implantation studies suggest that synthetic HA is osteoconductive (enhances local bone healing) and becomes osteointegrated (forms an intimate bond with bone). HA-coated prostheses are currently being evaluated for use in cementless total joint arthroplasty. The purpose of this article is to review the experimental studies leading to the development of HA-coated orthopedic devices, and to summarize the current status of clinical studies. Finally, the concerns and future directions for HA-coated implants are addressed. PMID- 10171114 TI - Breast implants under siege: an historical commentary. AB - Despite 3 decades of rapidly expanding application of polydimethylsiloxane as a relatively safe implantable biomaterial, the American public is being told by a vocal minority that its use in the breast implant may be dangerous. Most of the furor has been generated by consumer advocates with support of a handful of scientists who have expressed opinions, not well supported by facts, about the risks of these devices. These anxieties have been fueled in the public's mind by a media more interested in sensationalism than disciplined reporting. The controversy has complicated the regulatory process and has become politicized in the halls of State Legislatures and Congress. Remarkably, this controversy has not involved the many other biomedical applications of silicone. How has this controversy gathered momentum? What role has the government played and how have the professional, scientific, corporate, and patient communities responded to public concern? This discussion places the breast implant battle into an historical perspective. PMID- 10171113 TI - The political and social context of silicone breast implant use in the United States. AB - Silicone breast implants have been used for breast enlargement and reconstruction after mastectomy since 1963. It is estimated that they have been implanted in over 2 million women in the U.S. The U.S. Food and Drug Administration (FDA) has required manufacturers of the implants to submit evidence of their safety and effectiveness. The implants have been shown to benefit women in psychological studies. Physical risks include capsular contracture (affecting up to half of wearers), impaired mammographic results, implant rupture, and possibly connective tissue disease. Human studies would benefit from improved research design, including controls and long-term follow-up. Professional societies of plastic surgeons, whose members benefit commercially from breast augmentation and reconstruction, have campaigned forcefully for the continued and increased use of breast implants by women. PMID- 10171115 TI - Augmentation mammaplasty--a further review of 20 years using the polyurethane covered prosthesis. AB - Augmentation mammaplasty continues to attract much attention. So far, it seems to be an operation with an indefinite endpoint regarding the longevity of results. It is also a procedure that has wide monetary implications and would often seem to be inappropriately used. With the advent of the latest polyurethane-covered prostheses, marketed under various trade names such as Meme, Replicon, and Optimam, a more predictable result can be obtained, at least for the first 6 years. Much controversy still exists, and in view of this, the authors have revised their long-term results and comments on important current aspects. PMID- 10171116 TI - Breast implants: renewed polyurethane controversy or confusion? PMID- 10171117 TI - The inhibition of bacterial adhesion to a tobramycin-impregnated polymethylmethacrylate substratum. AB - Tobramycin sulfate powder (1.2 g) was mixed with Palacos polymethylmethacrylate (PMMA) bone cement (40 g) to produce 100 discs containing 5.9 mg tobramycin per disc. These discs were used to evaluate the inhibition of bacterial adhesion to an antibiotic-laden biomaterial. Tobramycin-impregnated PMMA discs and control discs containing no tobramycin were exposed in vitro to Staphylococcus epidermidis. Colonization was quantitated using plate count techniques and electron microscopy. Tobramycin-impregnated surfaces reduced adhesive bacteria colonization by 1 log relative to control discs. These observations suggest that tobramycin-impregnated PMMA may not be significantly effective in preventing colonization of the biomaterial substratum and PMMA may be a poor choice as a drug delivery vehicle in biomaterial and compromised tissue-centered infections. PMID- 10171118 TI - Tissue compatibility of tyrosine-derived polycarbonates and polyiminocarbonates: an initial evaluation. AB - Compression-molded disks of two tyrosine-derived polymers [poly(desaminotyrosyl tyrosine-hexyl ester carbonate) and poly(desaminotyrosyl-tyrosine hexyl ester iminocarbonate)], two polymers derived from Bisphenol A [poly(Bisphenol A iminocarbonate) and poly(Bisphenol A N-phenyliminocarbonate)], and two clinically used standard materials [poly(D,L-lactic acid) and high-density polyethylene] were implanted subcutaneously in the back of Sprague-Dawley rats. The tissue response elicited by these materials was evaluated histologically at 7, 30, and 120 days postimplantation, based on the total cell density (including fibroblasts, monocytes, giant cells, and macrophages) at the implantation site. The tissue response observed for the two tyrosine-derived polymers was mild, comparable to the two standard materials, medical-grade poly(L-lactic acid) and high density polyethylene. The two Bisphenol A-containing polymers elicited significantly more severe tissue responses. These results indicate that the use of derivatives of the natural amino acid L-tyrosine in the synthesis of degradable implant materials improved the tissue compatibility of these materials relative to chemically related polymers that contain Bisphenol A, an industrial diphenol. The tyrosine-derived polyiminocarbonate and polycarbonate are therefore promising candidates for a detailed evaluation of their biocompatibility, including long-term implantation studies in higher mammals. PMID- 10171119 TI - A fluidics-based 8-channel STAT analyzer. PMID- 10171120 TI - The Sentinel-4 evoked potential/electroencephalographic analyzer. PMID- 10171121 TI - Poly(vinyl alcohol) hydrogel as an artificial articular cartilage: evaluation of biocompatibility. AB - We have developed a new poly(vinyl alcohol) hydrogel (PVA-H) of increased physical strength through a new manufacturing process. Its mechanical properties have been found to be preferable as a substitute for articular cartilage. To evaluate its biocompatibility as an artificial articular cartilage, a series of in vivo tests within the intraarticular, as well as the intramuscular, environment were conducted. Tissue reactions of cartilage, bone, synovium, and muscle to PVA-H were studied histologically. In the experimental group, in which PVA-H was implanted, inflammatory reactions of all of these tissues were very slight. In the control group, in which ultra-high molecular weight polyethylene (UHMWPE) was implanted, although tissue reactions of bone and muscle were as slight as in the experimental group, those of cartilage and synovium were somewhat more conspicuous. By way of these findings, the better biocompatibility of PVA-H was documented. PMID- 10171122 TI - Orthopedic implant devices: prevalence and sociodemographic findings from the 1988 National Health Interview Survey. AB - National population-based estimates on the magnitude and distribution of orthopedic implant devices in the United States have not been available to date. The Food and Drug Administration's Center for Devices and Radiological Health (FDA/CDRH) collaborated with the Centers for Disease Control's National Center for Health Statistics (CDC/NCHS) in the design and conduct of a nationwide medical device implant survey to generate the first national population-based prevalence estimates of orthopedic implant devices. A Medical Device Implant Supplement to the 1988 National Health Interview Survey was administered in personal household interviews to a national sample of 47,485 households, which included 122,310 individuals. An estimated 6.5 million orthopedic implants were in use in the general US population in 1988, including 1.6 million artificial joints and 4.9 million fixation devices. As a group, orthopedic implants comprised nearly half of all medical device implants in use, 43.4%. The majority of artificial joint recipients were 65 years of age or older, white, and male. The majority of fixation device recipients were less than 45 years of age, white, and male. The limitations and strengths of these population-based estimates are discussed. PMID- 10171123 TI - Laser-drilled cardiovascular surgical needles. AB - Surgical sutures that are directly attached to the surgical needle ends are called swaged sutures. A forming tool has been used to split one-half of the wire diameter of cardiovascular needles that forms a channel or receptacle for the suture. With the advent of lasers, uniform holes can now be produced in the ends of small-diameter cardiovascular needles. An advantage of the laser produced hole is that its outer circumference is smooth; the channel swage has a linear slit that interrupts its smooth outer circumference. A standardized reproducible test has been developed that quantitates the force required to pull the needle end through a synthetic membrane that simulates vascular tissue. A swage produced by a laser encountered significantly less drag forces than that noted with a comparable size channel swage of cardiovascular needles. PMID- 10171124 TI - An innovative conveyor belt system for a clinical laboratory. PMID- 10171125 TI - An investigation of skin deformation around percutaneous devices. AB - According to the literature one of the primary failure models of percutaneous devices (PDs) in soft tissue implantation sites is that of mechanically induced trauma along the implant/tissue interface. In order to avoid such avulsion, subcutaneous flanges have been incorporated into PD designs to provide a better distribution of stresses along the implant/tissue interface. Tissue necrosis and inflammation were then observed to be most pronounced around the rim of the subcutaneous flange. It was the goal of this study to develop and test PDs with subcutaneous flanges of varying stiffnesses in order to allow the flange to distribute stresses into the surrounding tissues more evenly, thereby reducing the likelihood of failure due to avulsion. PDs were tested with flanges of constant thickness or varying linearly, reducing toward the flange rim. They were evaluated using an in-vitro testing method which was designed to simulate the situation of an implanted PD subjected to external loading. The results indicated that the stiffness characteristics of the subcutaneous flange had a substantial effect on the behavior of the devices under loading. A PD having a radial stiffness decrease would improve the likelihood of implant survival in the clinical situation due to the reduction of mechanically induced trauma along the implant/tissue interface. PMID- 10171126 TI - Intravascular ultrasound as a guiding modality for mechanical atherectomy and laser ablation. AB - One of the most compelling practical applications for intravascular ultrasound imaging is in enhancing the safety and efficacy of the second-generation catheter devices designed to ablate or remove plaque. Initial studies have shown that intravascular ultrasound is well suited to demonstrate the amount of atheroma present in a vessel, and the distribution within the vessel wall at any given point. Further clinical studies are required to determine whether more complete debulking of atheroma, guided by ultrasound imaging, has a favorable impact in reducing the rates of acute closure and restenosis following the procedure. PMID- 10171127 TI - Transvascular and intracardiac two-dimensional echocardiography. AB - Recent developments in transesophageal and catheter-based ultrasound instrumentation have allowed invasive ultrasound imaging. This experimental study presents a new application of invasive ultrasound, transvascular and intracardiac ultrasound imaging. In six pigs, we introduced a 7-mm, 5-MHz esophageal ultrasound probe into both the abdominal aorta and inferior vena cava and explored the imaging potential of this approach. Transvascular imaging from the aorta allowed visualization of the various cardiac structures, the neural canal and interspaces, and peritoneal anatomy. Advancement of the transducer to the level of the aortic valve or into the left ventricle yielded images of the cardiac valves and chambers. With transvascular imaging from the inferior and superior vena cava, the aorta, neural canal, pancreas, and liver were well visualized. Intracardiac imaging from the inferior venae cavae and various regions of the right heart, the left heart structures could be visualized. This in vivo feasibility study demonstrates the potential application of transducer tipped catheters for transvascular and intracardiac imaging. PMID- 10171128 TI - Directions for the use of intracardiac high-frequency ultrasound scanning for monitoring pediatric interventional catheterization procedures. AB - Intravascular and intracardiac ultrasound imaging using high-frequency ultrasound catheters has a number of potential applications in pediatric cardiology. This article reviews the current difficulties associated with interventional procedures for congenital heart lesions, the feasibility of intravascular ultrasound imaging in children, and its potential applications. PMID- 10171129 TI - Intravascular ultrasound cross-sectional arterial imaging. AB - In this paper we review the current status of intravascular ultrasound. Data from qualitative and quantitative studies is presented. Our experimental findings and those of other investigators are reviewed. Intravascular ultrasound has been shown to delineate normal and abnormal arterial morphology as well as to identify and differentiate fibrous, lipid-rich, calcified plaques and complicated plaques. Quantitative studies show strong correlations between ultrasound and histology for lumen area, wall thickness, and plaque area. In vivo studies from our experimental work and clinical laboratory as well as the work of other researchers is presented. This data supports the potential of ultrasound imaging for guidance of intravascular intervention. The potential advantages and limitations of this new technology are discussed. This methodology shows promise for the assessment of the extent and severity of atherosclerosis, monitoring its progression and regression and guiding intravascular plaque ablation technologies. PMID- 10171131 TI - Intraoperative echocardiographic assessment of global and regional myocardial function. AB - Intraoperative echocardiography is gaining increasing importance to the anesthesiologist and the surgeon in the management of high-risk patients undergoing cardiac and major noncardiac surgery. It can provide for the noninvasive, immediate assessment of global left ventricular function, and its determinants; preload, afterload, and myocardial contractility. In addition, abnormalities of regional myocardial function, as a marker of myocardial ischemia, can be easily identified. With the advent of transesophageal echocardiography, this imaging technique can be more widely applied without interfering with the surgical procedure, not only increasing our ability to adequately monitor the patient, but also guiding our therapy and providing additional insights into the physiological and pathophysiological processes affecting the heart during surgery. PMID- 10171132 TI - Assessment of chest pain by nuclear cardiology techniques. AB - This article reviews the nuclear cardiology techniques which can be used to assess chest pain. Nuclear techniques can potentially give valuable information on the location and extent of myocardial perfusion abnormalities, the assessment of myocardial viability, and/or presence of myocardial necrosis and the effects, both regional and global, of myocardial ischemia on myocardial function. The article reviews specific tests available and their indications and indicates the usefulness of these techniques for the clinician managing myocardial ischemia. PMID- 10171130 TI - Intraoperative monitoring of regional wall motion abnormalities for detecting myocardial ischemia by transesophageal echocardiography. AB - Transesophageal two-dimensional echocardiography has been used for intraoperative monitoring of regional wall motion of the left ventricle. Regional wall motion abnormality is a sensitive indicator of myocardial ischemia and the use of two dimensional transesophageal echocardiography may have a substantial advantage for early detection of myocardial infarction and thus for initiating timely and appropriate therapy in preventing postoperative myocardial ischemia. With an expected increase in the use of intraoperative transesophageal echocardiography for monitoring regional wall motion, we described the practical aspects of transesophageal echocardiography: (1) insertion technique of transesophageal echocardiographic probe; (2) the technique for obtaining an optimal short-axis view of the left ventricle; and (3) the method for evaluating regional wall motion abnormality and myocardial ischemia. Regional wall motion abnormality is best monitored at the mid-papillary muscle level where all three coronary arteries meet. In obtaining this view, the transesophageal echocardiographic probe was found to be predominantly located in the stomach. Failure in obtaining short-axis view of the left ventricle at this level occurred in patients with left ventricular dilatation or obesity. Because of the anatomical reason, the echocardiographic transducer cannot reach a proper plane. In anesthetized patients, air can be pushed into the stomach during induction and may disturb the visualization. The pitfalls in examining regional wall motion abnormalities include: (1) shifting of the center of left ventricular contraction; (2) inadequate direction of the scanning plane; and (3) paradoxical septal movement. Three cases are presented to demonstrate the usefulness of transesophageal echocardiography in managing coronary artery surgical patients. PMID- 10171134 TI - Recent developments in the surgical treatment of glaucoma. AB - Surgical treatment of the glaucomas continues to evolve with the advent of new techniques and adjunct therapies. The modulation of wound healing with antimetabolites has increased the success and predictability of filtration surgery. Silicone tube shunts continue to be developed and improved for use in refractory glaucoma. Preoperative factors, such as long-term topical medications, may contribute to the success or failure of filtration surgery. Early recognition of postoperative complications and effective management of these complications may also enhance the success of filtration surgery. The debate over combined surgical procedures for glaucoma and cataract persists. This article reviews recent developments in the surgical treatment of glaucoma. PMID- 10171133 TI - New aspects in the surgical treatment of glaucoma. AB - With modern techniques and advances in materials and instruments, the outcome of glaucoma surgery has been improved. Early filtering surgery has become a definite option in open angle glaucoma, particularly as the complications of such surgery are minimal. Refractory cases of glaucoma are always problematic, but modifications to the routine surgical options such as silicone-tube implants, partial-thickness procedures, 5-fluorouracil, and cyclocryotherapy, have improved the outcome. This article reviews some of the current trends in glaucoma surgery. PMID- 10171135 TI - Surgical treatment of cardiac arrhythmias. PMID- 10171136 TI - Implantable defibrillators. PMID- 10171137 TI - Transesophageal echocardiography: clinical applications and prospects. PMID- 10171138 TI - Prediction of cardiac risk in patients undergoing vascular surgery. PMID- 10171139 TI - Basic and clinical progress in implantable devices for control of ventricular tachyarrhythmias and prevention of sudden death. PMID- 10171140 TI - Laser surgery benefits from guidance by MR. PMID- 10171141 TI - Investigators explore new world of angioscopy. PMID- 10171142 TI - Chest radiographs boast superior anatomic detail. PMID- 10171143 TI - Implants for site-specific drug delivery. PMID- 10171144 TI - An investigation of bioactive glass powders by sol-gel processing. AB - Bioactive glass powders, with a composition of SiO 2-CaO-P 2O 5, have been successfully synthesized via a sol-gel process at considerably lower temperatures than required for conventional melting methods. Bioactive glass powders made via conventional methods form an interfacial bond with bone when they are implanted. Bonding is correlated with the formation of a surface hydroxyapatite layer. This study examined the formation of a hydroxyapatite layer in Tris-buffered solution as a function of SiO 2 content of sol-gel derived powders. A FT-IRRS technique was used to monitor the formation of the hydroxyapatite on the surface of the powders. X-ray diffraction analysis and BET were also used to characterize the chemical and physical properties of the sol-gel derived bioactive powders. It was discovered that: (a) the rate of hydroxyapatite formation decreased with increasing SiO 2 content for powders whose SiO 2 content was less than 90 mol%; (b) a hydroxyapatite film does not form for the powders whose SiO 2 content is more than 90 mol%; (c) the SiO 2 limit, beyond which the powders lost their bioactivity, was much higher for bioactive glass powders made through sol-gel process (90%) than those made by conventional melting methods (60%). These results indicate that it is possible to significantly expand the bioactive composition range through microstructural control made possible by sol-gel processing techniques. PMID- 10171145 TI - Alteration in pericardial adhesion formation following pretreatment with fibrin glue. PMID- 10171146 TI - Comparison of the deformation response of synthetic and cadaveric femora during simulated one-legged stance. PMID- 10171148 TI - Permeation enhancers compatible with transdermal drug delivery systems. Part I: selection and formulation considerations. AB - Part I of this article reviews the classification, chemistry, properties, selection, and use of skin permeation enhancers in transdermal drug delivery systems and dermal patches. The authors discuss ideal properties of enhancers and describe various enhancers' actions on the skin. Part II will describe interactions between permeation enhancers and other transdermal delivery system components, such as backing materials, pressure-sensitive adhesives, membranes, and release liners. Adhesive properties critical to the optimization of a transdermal formulation will be discussed. PMID- 10171147 TI - Procedural overview of molecular genetics technology in the clinical laboratory. AB - Basic concepts of molecular technology and diagnostic applications in the clinical laboratory are discussed. Advances in molecular biology have led to an increased number of clinical laboratories providing diagnostic support at the genetic level. The clinical applications of such a technology at present is broad, perhaps limited only by the regions mapped on the human genome. As the rapid discovery of new genes ignites a chain reaction of opportunities, the clinical laboratory scientist should be kept informed of the exciting technologic advances in the diagnosis of infectious diseases, genetic-related diseases, and leukemia and lymphomas. Many future diagnostic applications are now being researched. PMID- 10171149 TI - Permeation enhancers compatible with transdermal drug delivery systems: part II: system design considerations. AB - Part I of this article reviewed the classification, chemistry, properties, selection, and use of skin permeation enhancers in transdermal drug delivery systems and dermal patches. In Part II, the authors discuss ideal properties of enhancers and describe various enhancers' actions on the skin, as well as interaction among permeation enhancers and other transdermal delivery system components, such as backing materials, pressure-sensitive adhesives, membranes, and release liners. Adhesive properties critical to the optimization of a transdermal formulation are discussed. PMID- 10171151 TI - Objectivity in the evaluation of biological safety of medical devices and biomaterials. AB - This article attempts to present the current situation with respect to the evaluation of biological safety and biocompatibility where imitations in the methodology and validity are apparent. The introduction of procedures that facilitate the quantitative determination of the parameters of the biological performance of materials, and their objective analysis, should considerably enhance our ability to specify safety and describe biocompatibility. PMID- 10171150 TI - Current trends in the development of synthetic materials for medical applications. AB - During the last 30 years, advances in material science have led to the development of a number of synthetic materials that have unique properties for medical applications. To date, most of these synthetic materials are nondegradable and accordingly have found limited applications. This article discusses synthetic biomaterials and explores their uses, suggesting that in future, implants will find more routine applications and that degradable implants will be refined, leading to wider applications. PMID- 10171153 TI - Defining the problem and finding the cure--the state of the diagnostics industry in Europe. A statement issued by the Verband der Diagnostica Industrie, e.V. AB - This article charts the development of the diagnostics industry with special reference to the situation in Germany, and describes its vital role in health care and sickness prevention. The industry has suffered a recent leveling out in growth; the author assesses the reasons for this, outlining measures that have impeded its development and discouraged the medical profession from making the most of the opportunities offered by laboratory diagnostics. Remedies are suggested that will allow the industry to achieve its maximum potential to the benefit of all. PMID- 10171154 TI - Laser hemorrhoidectomy in an outpatient setting: a cost analysis. PMID- 10171152 TI - Considerations when using ethylene oxide for the sterilization of medical devices. AB - Of all the alternative sterilization methods available, it is ethylene oxide (EtO) sterilization that arouses most concern. EtO, whether used on its own or mixed with CFCs, has potentially harmful effects both to the environment and the body. However, with adequate attention to the standards that will control EtO sterilization, its future should be relatively certain for a good few years to come. PMID- 10171155 TI - Supportive angioplasty utilizing the Bard cardiopulmonary support device. AB - Bearing in mind that one case does not make a study, we would briefly like to elaborate on our exposure to cardiopulmonary support (CPS) at Milwaukee Heart Surgery Associates. CPS, in our opinion, is something that we will have to deal with whether we share the same cardiological philosophy or not. In order to provide the same standard of care to patients in the catheterization laboratory as we do for patients in surgery, it is incumbent upon us as perfusionists to be as knowledgeable and skilled as possible. A good rapport with the cardiologist and surgeon is essential in developing a workable protocol so as to avoid abuse of the technique. Direct visualization, with respect to cannulation and surgeon participation, is an ideal situation and is the standard of care in our practice. The cardiologist cannot perform supportive angioplasty utilizing CPS without consulting a surgeon, thereby minimizing some of the vascular complications that can arise as a result of nonsurgeon participation. PMID- 10171156 TI - Vortex pumping for routine cardiac surgery: a comparative study. AB - Vortex pumping has become popular for mechanical assist applications, but has only recently received serious consideration for use as the arterial pump of choice for routine open-heart surgery. We report on a prospective randomized study designed to evaluate this pump in routine use. Sixteen patients undergoing routine coronary artery surgery were randomized into two groups in which the only difference in equipment and technique was the use of a Stockert roller pump in group S and a Biomedicus vortex pump in group B. The groups were compared with respect to haematology, perioperative fluid balance, transfusion requirements, complement activation, haemolysis and microbubble transmission. The groups were reasonably well matched, with slightly longer mean bypass and ischaemic times in group S (94.8 vs 105.5 minutes and 75.7 and 83.8 minutes respectively). Group B patients showed significant improvements over group S patients with respect to preservation of platelet numbers, decreased complement activation and reduced microbubble transmission. The afterload sensitivity of the vortex pump did not present the perfusionist with any practical problems although a different technique is required for initiating and terminating bypass. We conclude that vortex pumping would seem to offer better blood handling for routine use. More extensive testing is required to establish whether or not this would be reflected in clinically measurable improved patient outcome. PMID- 10171157 TI - Blood transfusion in cardiac surgery. PMID- 10171158 TI - Centrifugal blood pumps--a brief analysis: development of new designs. AB - Analysis of 350 different sources of information from leading countries of the world enabled us to determine the availability of 20 different designs of centrifugal and rotary blood pumps. Most of them are for extracorporeal applications with radial pumping wheels of disc or vane type. The prospect of improving these designs was suggested by a combination of these two types. Five new designs based on the Biomedicus have been produced. Basic calculations are given for one of these with respect to limitations for shear stresses. It is proposed that the suggested designs will allow reductions in thrombosis and haemolysis which are the main problems for these pump designs. PMID- 10171159 TI - Percutaneous cardiopulmonary bypass in the cardiac catheterization laboratory. PMID- 10171160 TI - Portable cardiopulmonary bypass for heart-lung donor transplants. AB - In 1985 a portable cardiopulmonary bypass machine was devised in order that heart lung donors from hospitals that were some distance away from our own institution could be procured. The distance of these hospitals ranged from the far north of Scotland to the Greek city of Athens. This paper will show how the portable bypass machine was developed and how it is used for the procurement of donor organs. As an offshoot of this, the device has been used for two emergency bypass procedures at noncardiac units where the transfer of the patient was impossible. PMID- 10171161 TI - Clinical application of heparin-coated perfusion equipment with special emphasis on patients refusing homologous transfusions. AB - Clinical application of heparin-coated cardiopulmonary bypass equipment during perfusion with low systemic heparinization is reported with special emphasis on patients refusing any transfusion of homologous blood or blood products. Using the described technique, coronary artery revascularization was successfully performed in three Jehovah's witnesses. During perfusion, the activated clotting time (ACT) was maintained above 180 seconds. Prebypass haematocrit was 38 +/- 3% and dropped to 22 +/- 1% after seven days. Hence, cardiopulmonary bypass with low systemic heparinization may further reduce bypass induced morbidity and improve the final outcome in selected patients. PMID- 10171163 TI - Pneumatic retinopexy: an overview. PMID- 10171162 TI - Comparison of the standard roller pump and a pulsatile centrifugal pump for extracorporeal circulation during routine coronary artery bypass grafting. AB - The present prospective study compared the standard nonpulsatile twin roller pump with the Sarns centrifugal pump, in the pulsatile mode, as arterial pumps for extracorporeal circulation during coronary artery bypass grafting (CABG). The study was conducted in two consecutive groups of 25 patients receiving a standard anaesthetic and surgical protocol. The investigated parameters included haemodynamic profiles, oxygen exchange, blood gas and acid-base homeostasis, haematology, coagulation and complement consumption. With comparable settings for pump flow, gas flow and delivered oxygen concentrations, there was no difference between the groups in the main haemodynamic parameters during cardiopulmonary bypass (CPB). However, a tenfold lower dose of sodium nitroprusside was required to keep systemic vascular resistance within physiologic limits during CPB in the centrifugal group (C group) compared with the roller group (R group). During rewarming oxygen extraction was higher in the C group than in the R group. During the first eight hours after CPB no differences in haemodynamics, oxygenation parameters and pulmonary shunt between the groups were observed. During, as well as after, CPB there was no significant difference in blood gas and acid-base homeostasis between either group. Average postoperative blood loss via chest tubes, total transfusions of blood products, haemoglobin and coagulation did not differ between the two groups. However, the white blood cell count, corrected for changes in haematocrit, decreased during the early phase of CPB in the R group, but not in the C group.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171164 TI - Posterior tube shunt implants for glaucoma surgery. PMID- 10171165 TI - Biocompatibility of extracorporeal circuits in heart surgery. PMID- 10171166 TI - Revival of the Ugandan Blood Transfusion System 1989: an example of international cooperation. AB - 10 yr of civil war in Uganda had destroyed the Blood Transfusion Service when the government came to power in 1986. AIDS had become recognized as a problem of severe proportion. In 1987, the E.E.C. pledged to rehabilitate the central blood bank. This paper describes the first year of operation from December 1988. Over 5000 units of blood, largely from volunteer donors, were delivered to 19 hospitals. The overall incidence of HIV-1 seropositivity was 14.6% and Hepatitis B surface antigen was 5.5%. The cost was 21.5 ECU (US $25) for each unit of HIV negative, H.B.s.Ag. negative, blood. PMID- 10171167 TI - Translumbar inferior vena cava catheters: experience with 58 catheters in peripheral stem cell collection and transplantation. AB - Most patients who need peripheral stem cell transplantation do not have peripheral venous access to allow apheresis for stem cell collection. Subclavian apheresis catheters have an unacceptably high incidence of thrombosis-related access failure. We have used a technique for translumbar insertion of permanent, subcutaneously tunnelled silicone rubber apheresis catheters into the inferior vena to place 58 catheters in 54 patients for stem cell collection. 37 catheters have been left in place for venous access during the transplantation procedures. These catheters had a very low rate of apheresis-related complications (3.6%). Access failure occurred due to thrombosis in 14 catheters (24%) and mechanical complications in 8 (14%) but these responded to standard therapy in all except 3 cases. Catheters functioned well as venous access devices during transplantation with only rare complications during this time. Withdrawal venograms at time of removal of 20 catheters showed a fibrin sheath in 17 cases but caval occlusion in none. There was no clinical or CT scan evidence of bleeding after placement or removal of the catheters. Percutaneously placed translumbar inferior vena cava apheresis catheters are an effective route for peripheral stem cell collection and can be left in place for venous access during transplantation. PMID- 10171168 TI - Catheter ablation. AB - Catheter ablation is gaining increasing interest for the therapy of symptomatic, sustained arrhythmias of various origins. The scope of this review is to give an overview of the biophysical aspects and major characteristics of some of the most widely used energy sources in catheter ablation, e.g., the discharge of conventional defibrillators, modified defibrillators, laser light, and radiofrequency current application. Results from animal studies are considered to explain the basic mechanisms of catheter ablation. The recent achievements with the use of radiofrequency current to modify or ablate cardiac conduction properties are outlined in more detail. PMID- 10171169 TI - Implantable cardioverter-defibrillators: the second decade. AB - Implantable cardioverter-defibrillators (ICD) have advanced from a hypothetical device (1970s), to the first human trials (1980s), to the current and future models capable of differentiating ventricular tachyarrhythmias and bradyarrhythmias and of applying selective electrical therapy. The device is successful in decreasing the expected high risk of sudden cardiac death in implantees from approximately 30% to approximately 2% at 1 year. However, because of the major surgical procedure required for implantation and cost of therapy, controversy remains regarding the specific selection of patients to whom the device should be offered. Technologic advances have expanded the potential applicability of this therapy but may simultaneously diminish the survival benefit because of the complexity and sophistication of programming. In this review, we discuss the current status of ICD use, controversies that have yet to be settled, and the direction of future devices based on recently available information. PMID- 10171170 TI - Pediatric cardiac electrophysiology. AB - Over the past year, many advances have been made in the management of cardiac arrhythmias in the pediatric patient. It has become evident that the new surgical procedures for congenital cardiac disease can result in arrhythmia associated morbidity and mortality. New pharmacologic agents such as adenosine have been shown to be efficacious in treating supraventricular tachycardias, and other agents such as flecainide, beta-blockers, and amiodarone are also of significant value in young patients with acute and chronic arrhythmias. Along with advances in the use of pharmacologic agents, pacing catheter techniques for the diagnosis and treatment of cardiac arrhythmias have also significantly progressed. Transcatheter ablation is safe and effective in our patient population, and an understanding of various pacemaker modalities and the physiologic parameters for optimum use have been defined. This review outlines the advances in all modes of treatment of cardiac arrhythmias. PMID- 10171172 TI - Surgery. PMID- 10171171 TI - Pediatric cardiac surgery. AB - The treatment of many forms of congenital heart disease has continued to advance, and numerous reports have appeared in the last year to document these improvements. Increased information regarding the "natural history" of repaired congenital heart disease has also been reported. Based both on improving results of surgical treatment and on the problems with delayed reparative operations, there has been continued interest in primary early repair of an increasing number of defects, including atrioventricular canal, tetralogy of Fallot, pulmonary atresia with intact ventricular septum, transposition of the great arteries, and truncus arteriosus. Advances have also been reported in transplantation for complex congenital heart disease and in the "physiologic correction" of various forms of single ventricle by the Fontan approach. A number of experimental reports on the protection of both the heart and the brain during ischemia point out areas where knowledge is incomplete and where further research is needed. These developments suggest that the overall outlook for the patient with congenital heart disease has continued to improve. PMID- 10171173 TI - Cardiopulmonary bypass. AB - There has been a recent renewed interest in certain aspects of cardiopulmonary bypass employing extracorporeal circulation. Several areas have received special attention. Among these is the institution of extracorporeal circulation using a percutaneous technique for circulatory assistance during high-risk percutaneous transluminal coronary angioplasty. A national registry has been established to review and monitor results using this percutaneous technique. Several recent developments in the delivery of cardioplegia during ischemic arrest have stimulated investigative efforts. In particular, the delivery of cardioplegia in a retrograde manner through the coronary sinus has proved an effective and useful adjunct to myocardial protection during cardiopulmonary bypass with extracorporeal circulation. A newer investigative technique employing only warm cardioplegia delivered primarily through the retrograde coronary sinus route seems to offer some promise in providing optimal myocardial protection while minimizing hemorrhagic complications and other cold-induced myocardial injury. Because of concerns regarding blood transfusion-related communicable disease (eg, acquired immune deficiency syndrome and non-A, non-B hepatitis), there has been increasing research effort into postoperative hemorrhage related to cardiopulmonary bypass with extracorporeal circulation. Specifically, various drugs that may serve as hemostatic adjuncts have been investigated extensively. These drugs include aprotinin and desmopressin acetate. Likewise, several studies have evaluated other drugs (mainly aspirin) that have a negative influence on postoperative hemostasis. Additionally, there has been continued research interest in the activation of the inflammatory system during cardiopulmonary bypass.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171174 TI - Angioscopy. AB - Over the last year, research using flexible, ultrathin fiberoptics for vascular imaging (angioscopy) has continued to demonstrate its clinical potential. Vascular surgeons, thus far angioscopy's strongest advocates, have repeatedly demonstrated that the use of this procedure during peripheral vascular bypass surgery can improve graft patency rates. Although it is doubtful that angioscopy could ever replace angiography, the qualitative details of a vessel's surface disclosed by angioscopy are significant and not available by other means, including intravascular ultrasound. Investigators have used angioscopy to evaluate the burgeoning number of new, catheter-based vascular technologies. A combination of angioscopy and laser or atherectomy, however appealing, will require major technologic advances. One such advance has been the balloon-tipped catheter for blood-free imaging, which circumvents the need for potentially hazardous saline flush. Such an imaging system has provided new insights into the diseased myocardium of living patients. PMID- 10171175 TI - Dacron collateral ligament reconstruction with proximal interphalangeal joint arthroplasty. AB - A porous Dacron (Phoenix Bioengineering, Bridgeport, PA) tendon is described for collateral ligament reconstruction and augumentation with proximal interphalangeal joint implant arthroplasty. Eight cases with a minimum follow-up of 15 months are reviewed. Diagnoses include posttraumatic arthritis and osteoarthritis, as well as rheumatoid arthritis. The porous Dacron tendon is constructed as a collagen-like weave. It has been useful in patients who have insufficient local tissue to achieve lateral proximal interphalangeal joint stability. In selected cases, it can obviate the need for a tendon graft and provide an alternative to arthrodesis. PMID- 10171176 TI - Enhanced bone ingrowth and fixation strength with hydroxyapatite-coated porous implants. AB - The effect of a hydroxyapatite (HA) coating on the interface attachment strength, rate of development of attachment strength, and degree of bone ingrowth of porous implants was investigated. Implants with ideal surgical fits and those having interface gap spaces were evaluated using femoral transcortical and intramedullary models. The application of a thin HA coating to porous implants significantly enhanced both interface attachment strength and bone ingrowth. The rate of development of interface strength and bone ingrowth was also more rapid with the HA-coated system. There was no evidence of any disruption, loss, or resorption of the HA coating. PMID- 10171177 TI - Evaluation of a new cervical immobilization/extrication device. AB - A new cervical immobilization device (the Philadelphia Red E.M. Collar with Head Immobilizer/Stabilizer), has been introduced as an adjunct in extricating potentially neck-injured patients. This study compared the efficacy of immobilization using the collar to that of a short spine board. In addition, experienced EMS personnel rated the collar in simulated field situations. METHODS: In Part I of the study, the collar and a short spine board were applied to 25 adult volunteers in a sitting position, using standard methods. Each subject then exerted maximal force in flexion, extension, rotation, and abduction. Degrees of head motion from neutral position were measured in each direction. Mean values were compared using Student's t-test. For Part II, 10 EMS personnel were asked to apply the collar to volunteers. Each rated the performance of the collar on a scale of 1 (poor) to 4 (excellent) regarding: ease of application (sitting and supine), ease of extrication (lifting, logrolling, transfer), access to patient (chest auscultation, CPR, airway management), storage, and overall utility. RESULTS: The collar was significantly better than the short spine board in both lateral and rotational immobilization (p less than 0.001). There was no significant difference for flexion or extension (p greater than 0.05). The Red E.M. limited motion to a mean of 15 degrees or less in any direction. Ratings by EMS personnel for the device (mean+/- standard error) were: ease of application (sitting) 3.5+/-0.2, (supine) 2.7+/-0.2; ease of extrication 3.1+/-0.2; access to patient 3.4+/-0.2; storage 3.1+/-0.3; and overall utility 3.1+/-0.2.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171178 TI - Diagnostic and surgical approaches to orbital fractures. PMID- 10171179 TI - Endosurgery enhances treatment of AVMs. PMID- 10171180 TI - Surgical treatment of glaucoma. PMID- 10171181 TI - Laser excisional conization in an office environment. AB - Use of the laser as an excisional tool in the treatment of cervical disease is an established technique. A study was constructed to determine whether laser excisional conization could be done safely and effectively in an office environment. The subjects of the study were 104 sequential patients who underwent laser excisional cone in an office environment. The average cone size was 16.5 mm by 12.5 mm. The average operating time was 15 minutes. Margins of the cone specimen were adequate for interpretation in 100 patients (96%). Of patients available for complete posttherapy follow-up, 96/98 (98%) achieved initial cure of their lesion. Complications included bleeding requiring revisit in 7.7%, relocation of the SCJ out of colposcopic view in 7%, and cervical stenosis/occlusion in 2 patients. Four pregnancies have occurred and have either been delivered or are progressing satisfactorily. We believe that laser excisional conization may safely and effectively be moved out of the operating room environment. PMID- 10171182 TI - Carbon dioxide laser therapy for benign cervical tumors. AB - Eight patients underwent carbon dioxide (CO 2) laser excision of benign cervical tumors during a 5-year period. Six patients had symptoms of abnormal vaginal bleeding, and 2 had asymptomatic cervical masses. All but one procedure was performed as outpatient surgery. Blood loss was minimal in 7 patients and less than 50 ml in the other patient. There were no cases of morbidity, and long-term follow-up showed excellent results. The technique to perform CO 2 laser excision of large benign cervical tumors is described. PMID- 10171183 TI - Forces and torques produced by a 640-gauss permanent magnet of ferromagnetic objects. AB - Magnetic forces and torques were measured in a 640-G permanent magnet. The forces on external objects were directed in such a way and of such a strength that the likelihood of injury from unsupported ferromagnetic objects was very small. The forces and torques on ferromagnetic objects within the subject were comparable to those produced by gravitational and inertial efforts in daily living. PMID- 10171184 TI - Office use of Nd:YAG laser has clear benefits, cost advantages. PMID- 10171185 TI - MRI, laser fiberoptic teamed for advances in endoscopic surgery. PMID- 10171186 TI - Invasive and noninvasive cardiovascular imaging in the child and fetus. AB - The imaging technologies available for evaluating congenital cardiac disorders continue to evolve. In noninvasive areas such as color Doppler echocardiography, more sophisticated questions are being asked of the techniques: investigators want not just diagnostic information about the fetus or newborn, but fundamental predictors of prognosis. An improved understanding of the tradeoffs between magnetic resonance imaging and echocardiography for pediatric patients has evolved, and ultrasound technology has invaded invasive areas such as the operating room (with transesophageal echoscopes) and the catheterization laboratory, where it is used to guide therapeutic catheterizations; and angiography. Lastly, the newest technique, intravascular imaging, now appears applicable for pediatric patients and may yield new insights about interventional catheterization procedures, as well as about changes in the circulatory system in preoperative or postoperative congenital heart disease patients. PMID- 10171187 TI - Pediatric cardiac surgery. AB - The surgical literature continues to report numerous successful series of neonatal correction for a variety of complex cardiac defects. Infant repair of defects, such as those of the atrioventricular canal, tetralogy of Fallot (with or without pulmonary atresia), truncus arteriosus, and transposition of the great arteries, is now considered routine, and in most instances, the results of infant correction surpass those of staged procedures. The use of palliative bands and shunts is consequently receiving less attention in the literature, although the selection of these procedures remains an important option for certain uncorrectable defects. The success of Norwood's operation for hypoplastic left heart syndrome has encouraged application of major staging procedures as an appropriate therapeutic modality for certain complex defects as a stage towards eventual performance of the Fontan procedure. The Fontan procedure itself seems to show improved results with caval-pulmonary anastomoses, and the use of a bidirectional Glenn shunt or a hemi-Fontan procedure as a stage towards total Fontan physiology is gaining increased popularity. Aortic and pulmonary homografts have changed the technical options for patients with aortic valve disease as well as for infants with truncus arteriosus and tetralogy of Fallot with pulmonary atresia. Although surgeons continue to focus on optimal methods of neonatal myocardial protection, more attention is being given to perfusion techniques that protect the brain and organism as a whole. The use of intraoperative echocardiography has enhanced the standard of evaluation of operative repair so that fewer patients now leave the operating room with poor outcome. The outlook for patients born with congenital heart defects in 1992 continues to improve with enhanced applications of technology and operative technique. PMID- 10171188 TI - Programmed electrical stimulation, the signal-averaged electrocardiogram, and the implantable cardioverter-defibrillator in ventricular arrhythmias. AB - In the last year the technique of programmed electrical stimulation has been further developed and more fully evaluated when used for the assessment of an individual's risk from ventricular arrhythmias. The method of recording and analyzing signal-averaged electrocardiograms has recently undergone considerable technical development, especially in the frequency and spectrotemporal domains. The importance of late potentials as a risk factor for arrhythmic events in the convalescent period following acute myocardial infarction is less clear in patients who have received thrombolytic therapy. The implantable cardioverter defibrillator is now fitted to over 10,000 new patients each year, yet its true value has not yet been prospectively assessed. However, it is known that fitting the device is associated with a considerable operative mortality, and the device does not completely eradicate sudden death. Furthermore, the cost of this form of therapy is very high and its prophylactic use has not been established. PMID- 10171189 TI - Cardiopulmonary bypass surgery. AB - New information on cardiopulmonary bypass continues to be produced by investigators from many disciplines. Investigations are related to problems and complications resulting from use of the heart-lung machine. The relationship of perfusion and pressure during bypass in brain, kidney, and other organs is the subject of several reports. The studies confirm that low flow and pressure are safe with hemodilution and hypothermia. Investigations related to the pH stat and alpha stat blood gas schemes are sometimes inconclusive, but significant observations favor the use of the alpha stat blood gas scheme. The complications of choreoathetosis in pediatric patients appears to be related to low levels of hypothermia. Studies continue to show the many adverse effects of cardiopulmonary bypass on platelets, leukocytes, and the complement system. The minimum acceptable activated clotting time during cardiopulmonary bypass may be less than 400 seconds. Other authors address the complications of protamine infusion and heparin-induced thrombocytopenia. PMID- 10171190 TI - Benefits and limitations of database analysis for outcome prediction in cardiac surgery. AB - Large databases are being used for outcome prediction analysis with increasing frequency. This review examines four separate databases used to provide risk analysis in the cardiac surgery population. Populations in the databases range in size from 3500 to over 116,000 patients. All of the databases were applied on the clinical, and in one instance, institutional level. Outcome prediction from databases is not without its limitations. Data collection, model bias, and methodologic variation all contribute to weaknesses in the application of databases for outcome prediction. PMID- 10171191 TI - Clinical usefulness of biplane transesophageal echocardiography. AB - The clinical usefulness of biplane color Doppler transesophageal echocardiography is illustrated by the results obtained in 300 successive examinations. The additional contribution of the newer longitudinal plane was judged significant or major in 64% of the cases. The method was useful mainly for intraoperative examinations, assessment of native valvular disease, prosthetic valve evaluation, search for tumors, and assessment of endocarditis, congenital heart disease, and aortic disease. In contrast, the longitudinal plane option was not contributory in 68% of the cases of thromboembolism. Typically, the technique aided in the evaluation of mitral valve insufficiency and the detection of paraprosthetic leaks. Lesions located at the level of the ascending aorta, the left and right ventricular outflow tracts, and the interatrial septum were also visualized best. The limitations of the method were negligible and the duration of the examination was not significantly increased in comparison to the monoplane method. When available, biplane transesophageal echocardiography seems to be preferred in most clinical settings. PMID- 10171192 TI - Advances in the non-pharmacologic treatment of atrial fibrillation. PMID- 10171193 TI - HTR polymer and sinus elevation: a human histologic evaluation. AB - HTR (hard tissue replacement) polymer was used in a second session to perform 26 sinus floor elevations in 16 patients with dental implantation (Flexiroot, U.S.A.). A period of 6, 8, 10, or 12 months elapsed between the two operations, making it impossible to examine the tissular integration of HTR from both clinical and human histologic aspects. Following the sinus elevation, neither prolonged wound healing nor a rejection reaction was observed in any of the cases. During an 8 to 10 month period, sufficient new bone and fibrous connective tissue had grown between the HTR granules to ensure appropriate supporting tissue for the implantation. Subsequently (12 months), the HTR and the new bone became clinically increasingly harder, forming a union that was difficult to shape. HTR may be stated to be a material suitable for purposes of sinus elevation. In three cases in which the alveolar bone was originally very thin (2 to 3 mm), the resorption of this bone was observed, as a consequence of this the implantation was not performed. The resorption is explained by the inadequate blood supply that developed for surgical-technical reasons, and is not connected with the nature of the material used for the sinus elevation. PMID- 10171194 TI - Cell growth on collagen: a review of tissue engineering using scaffolds containing extracellular matrix. AB - Collagen has been used as a substrate for growth of cells derived from skin and cardiovascular tissue. Experimental results reported in the literature suggest that cell differentiation and orientation is enhanced in the presence of collagen. Extensive progress in cultivation of autogenous and allogeneic cells in vitro on collagen has led to advances in the transplantation of cultured materials. The purpose of this paper is to review the literature regarding cell culture on collagen substrates and to analyze the state of knowledge concerning the long-term effects. In the area of skin, long-term replacement of tissue has been studied extensively. Progress in this area has led to the development of technologies that will be used in the future for producing replacements for a wide variety of tissues and organs. PMID- 10171195 TI - Issues concerning possible cobalt-chromium carcinogenicity: a literature review and discussion. AB - Recently, questions have been raised concerning the stability and biocompatibility of metallic orthopaedic implants. Concerns have been expressed regarding cobalt-based alloys and the possibility of a future realization of a gross carcinogenic reaction from chrome-cobalt alloy implants. In this report, selected issues are reviewed and categorized for independent analysis to stimulate more comprehensive future research and theory formulation. Issues examined include those relating to metallic corrosion and potential local and systemic carcinogenic effects. The ionic valences of constituent materials, the electrochemical properties of the implant, and the proposed pathophysiological pathway of ions reportedly released from implants are traced. Tables listing 20 cases of primary neoplasia associated with total joint arthroplasty and seven cases reported in a 1975 study are discussed, compared, and contrasted. Finally, a selected bibliography is provided as a foundation for future study and research. In the author's opinion, the 50-year clinical experience and history of the use of cobalt-chromium as an implant material in orthopaedics, dentistry, and plastic surgery more than adequately establish its safety and effectiveness. PMID- 10171196 TI - SEM study of surface alterations of bioactive glasses and glass--ceramics in a bony implantation bed. AB - Back scattered electron (BSE) images of glasses and glass-ceramics with different degrees of bone-bonding behaviour have been investigated. After the implantation of probes in the femur of rats changes of the surface material, induced by leaching and corrosion (material response) and of the tissue in the drill hole (host response), were studied. The results demonstrate advantages of using BSE images and give further information for understanding the sequential changes in the implant material which occur mainly in bone-bonding materials. The density of the leached zone was not homogeneous and it therefore might be possible that preferential leaching of the glass matrix contributes to the mineralization of extracellular matrix. These findings could be of use for further development of surface reactive materials. PMID- 10171197 TI - Physico-chemical considerations of titanium as a biomaterial. AB - Physico-chemical properties of titanium are discussed. Special attention is paid to those of amorphous TiO 2 that contact tissues in vivo. In aqueous environments TiO 2. (aq) has low ion-formation tendency and low reactivity with macromolecules. This is accompanied by low toxicity. Titanium does not facilitate reactive oxygen radical generation during inflammatory conditions as observed in in-vitro experiments. The outermost layers of the oxide are in the Ti(IV) oxidation state, although using electron spin resonance (ESR) techniques, formation of Ti(III) is observed at atmospheric conditions. The impact of similarities between water and TiO 2 is speculated upon, and the physico-chemical properties of titanium are tentatively linked to some in-vivo consequences. PMID- 10171198 TI - Clinical use of injectable bovine collagen: a decade of experience. AB - Bovine collagen has long been recognized as a safe, highly biocompatible material. In 1981 and 1985, two injectable fibrillar suspensions of purified bovine dermal collagen, Zyderm and Zyplast collagen implant, were commercially launched in the USA for use in soft tissue contour irregularities. Since that time more than 750 000 patients have been treated with Zyderm and/or Zyplast collagen implants internationally. Adverse reactions to bovine collagen implants occur in a small percentage of treated patients. The most prevalent adverse reaction is localized hypersensitivity at treatment sites, occurring in 3% of skin tested patients and 1 to 2% of the treated patients. These reactions resolve with time as the implant material is resorbed by the host. Circulating antibodies to bovine collagen can be demonstrated in the sera of a majority of patients (90-100%) with local hypersensitivity. These antibodies are specific for bovine collagen and do not cross react with human type I, II or III collagen. Although the presence of a humoral immune response to bovine collagen can be associated with localized symptoms of hypersensitivity, antibodies to bovine collagen can also be demonstrated in the absence of any clinical manifestation. PMID- 10171199 TI - Biodegradable implants in orthopaedic surgery. PMID- 10171200 TI - New insights on the degradation of bioresorbable polymeric devices based on lactic and glycolic acids. AB - This contribution recalls some recent advances in the understanding of the mechanisms of degradation of bioresorbable polymers of the poly(beta-hydroxy acid) type derived from lactic and glycolic acids, which are receiving increasing interest for their potential for osteosynthesis. First, the various polymers are introduced and the field of applications is delimited. It is confirmed that degradation proceeds faster in amorphous domains than in crystallites. It is also shown that degradation proceeds faster in the center than at the surface, although this feature is not predominant in the case of semicrystalline lactic acid stereocopolymers. Of special interest are the findings that quenched compounds can crystallize at body temperature during degradation and that highly crystalline degradation residues can remain in situ for several years. Data show that osteosynthesis with bioresorbable plastics might become a reality for reasonably loaded bones, provided the peculiarities of polymers are taken into account by surgeons. PMID- 10171201 TI - Mechanisms of biodegradation of implantable polymers. AB - This paper is concerned with the mechanisms by which polymers degrade following implantation in the body. The possibility that enzymes, free radicals and other active species are involved in this degradation is discussed. PMID- 10171202 TI - Mechanical characterization of biodegradable implants. AB - The mechanical properties of degradable implant materials are low in comparison to metals used in orthopaedic surgery. There are possibilities to improve the strength of degradable implants by self-fibre-reinforcement, high molecular weight or special manufacturing processes. However, the moduli of the materials cannot be increased significantly by these techniques. Comparison of the mechanical properties of the most important materials are shown. Creep and relaxation are characteristic properties of degradable materials and limit the use of load-carrying implants. The rate of degradation in vitro and in vivo shows larger differences between the various materials and range from a few weeks up to 3 years. PMID- 10171203 TI - Injection moulding of biodegradable implants. AB - In medical engineering, degradable polymers represent an attractive alternative for conventional materials to be used as implants in the body. They are used as drug deliveries or as plates and screws to fix broken bones. Since they are completely broken down by the human body, the second operation, which is generally required, can be avoided. A central problem is the processing of these polymers, because no stabilisers are allowed. This causes a partially relevant loss in molecular weight, which correlates directly with the mechanical properties. Tests carried out on an injection moulding machine and on a conical plate rheometer show the influence of temperature, shear, residence time and moisture on molecular weight reduction and mechanical properties. PMID- 10171204 TI - Resorbable polyesters: composition, properties, applications. AB - Synthetic polymers, in particular polyesters based on lactic acid, glycolic acid and other raw materials are described for medical and technical applications. Their main advantages are compatibility and safety. As they are degradable in the human body they are particularly suitable for implants needed only temporarily for the healing process. Resorbable polyesters are produced by direct polycondensation or ring opening polymerization resulting in a broad range of polymers with different features. The main properties such as degradation (hydrolytic and thermal), crystallinity and mechanical strengths are discussed. These polyesters, which can be processed like other thermo-plastic polymers by extrusion and injection moulding, are used mainly for wound closure products (sutures, staples, clips), fracture fixation devices (nails, screws, plates) and parenteral depot systems for the sustained release of drugs. Possibilities for polymer and process improvement to develop better implants and additional applications are presented. PMID- 10171205 TI - Legal requirements for the preclinical toxicological evaluation of biomaterials. AB - Biomaterials intended for use in humans must, by law, be tested preclinically before the products can be placed on the market. Such preclinical studies should be guided by the recommendations for testing proprietary medical products. The biomaterial employed should in most cases be tested or evaluated at three levels: (1) toxicity tests with the various ingredients used to manufacture the basic biomaterial; (2) toxicity tests with the final biomaterial; and (3) toxicity tests with the final device. This article discusses the legal requirements and preclinical studies for biomaterials, suggesting that the type of test conducted, its design, and the extent of testing should depend upon the risks associated with that biomaterial. PMID- 10171206 TI - Biodegradable implants in orthopaedic surgery--a review on the state-of-the-art. AB - Until recently, internal fixation of fractured bones and joints has been managed by metal implants. Certain disadvantages of the metal implants are: the properties of the materials are stiffer than those of cortical bone and removal of the implants requires a second operation. About 40 different biodegradable polymers, copolymers and composites have been developed in order to substitute the metal implants for internal fracture fixation. First experimental and clinical results demonstrate the limitations of these new methods. The main problem of the material is the loss of mechanical strength within a time interval not long enough to guarantee bone healing. The development of sterile sinus at the site of implantation is also a problem reported by various groups. Despite some drawbacks, there are indications for the isolated or the adjuvant implantation of biodegradable materials. PMID- 10171207 TI - Interactions between osteoclastic cells and biodegradable polymers in vitro. AB - The use of implants to stabilize fractured diaphyseal bone, to handle difficult bone damage and to perform augmentation or replacement procedures in bone has become a common method in bone surgery. In most cases metal implants were used. Biodegradability of implant materials offers new perspectives. Restoration of the physiological status in the implant site becomes possible. Allergic reaction and second operations to remove the implants can be avoided and transitional aid in wound healing by the use of biomaterials can be achieved. An in-vitro system was established to investigate the interactions between osteoclasts and biomaterials, since it is the osteoclasts which are potentially able to resorb or degrade implants. The cell's resorption capabilities as well as its morphological behavior were documented. Two biodegradable and four nonbiodegradable materials were tested. The non-degradable materials provoked specific cell behaviour patterns but were not resorbed. Fibrin tissue adhesive sealant, however, displayed resorption lacunae mediated by osteoclasts, whereas polydioxanone (PDS) showed no resorption sites but normal cellular morphology when compared to the standard control (cells on hydrophilic coated teflon dishes). Both materials appeared to be well accepted by osteoclasts. This test system was established for the valuation of biodegradable implant materials and can be used to characterize new materials concerning their resorbability and biocompatibility without superposition by other cell systems. PMID- 10171208 TI - A primer of drug safety surveillance: an industry perspective. Part II: Product labeling and product knowledge. AB - OBJECTIVE: To place the fundamentals of clinical drug safety surveillance in a conceptual framework that will facilitate understanding and application of adverse drug event data to protect the health of the public and support a market for pharmaceutical manufacturers' products. Part II of this series discusses specific issues regarding product labeling, such as developing the labeling, changing the labeling, and the legal as well as commercial ramifications of the contents of the labeling. An adverse event report scenario is further analyzed and suggestions are offered for maintaining the product labeling as an accurate reflection of the drug safety surveillance data. This article also emphasizes the necessity of product knowledge in adverse event database management. Both scientific and proprietary knowledge are required. Acquiring product knowledge is a part of the day-to-day activities of drug safety surveillance. A knowledge of the history of the product may forestall adverse publicity, as shown in the illustration. DATA SOURCES: This review uses primary sources from the federal laws (regulations), commentaries, and summaries. Very complex topics are briefly summarized in the text. Secondary sources, ranging from newspaper articles to judicial summaries, illustrate the interpretation of adverse drug events and opportunities for drug safety surveillance intervention. STUDY SELECTION: The reference materials used were articles theoretically or practically applicable in the day-to-day practice of drug safety surveillance. DATA SYNTHESIS: The role of clinical drug safety surveillance in product monitoring and drug development is described. The process of drug safety surveillance is defined by the Food and Drug Administration regulations, product labeling, product knowledge, and database management. Database management is subdivided into the functions of receipt, retention, retrieval, and review of adverse event reports. Emphasis is placed on the dynamic interaction of the components of the process. Suggestions are offered to facilitate communication of a review of adverse event data for various audiences. CONCLUSIONS: Careful drug safety surveillance is beneficial to the health of the public and the commercial well-being of the manufacturer. Attention to the basic principles is essential and, as illustrated, may be sufficient to resolve some problems. PMID- 10171209 TI - Why is European healthcare embracing object-oriented technology? PMID- 10171210 TI - Oregon contemplates next step after Feds reject reform plan. PMID- 10171211 TI - Is the ADA a tough act to follow? AB - The Americans With Disabilities Act is sparking significant changes in the employment and public accommodation standards for many facilities across the country. But hospitals are finding that trying to enact the ADA is open to some interpretation. PMID- 10171212 TI - CLIA regulations. PMID- 10171213 TI - Computer simulation streamlines ambulatory surgery patient flow and increases capacity at Bay Medical Center. PMID- 10171214 TI - Oregon continues to push its health care reform plan. PMID- 10171215 TI - Specific list for categorization of laboratory test systems, assays and examinations by complexity--PHS. Notice with comment period. AB - The Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, requires that the Secretary provide for the categorization of specific laboratory test systems, assays and examinations by level of complexity. 42 CFR 493.17, published in the Federal Register on February 28, 1992 established criteria for such categorization. It is the Department's intention to complete the categorization of all currently available clinical laboratory test systems, assays and examinations prior to the effective date of 42 CFR 493 (September 1, 1992). This notice announces the third of a series of lists containing specific clinical laboratory test systems, assays and examinations, categorized by complexity. Additional lists of test systems, assays and examinations by complexity will be published periodically. A complete list of all laboratory test systems, assays and examinations, categorized by complexity, will be published in the form of a compilation of these Notices. Any clinical laboratory test system, assay or examination that is not on the compilation list will be considered high complexity, until categorized otherwise as provided under 42 CFR 493.17. After publication of the compilation list, categorization or recategorization of laboratory test systems, assays and examinations will follow the procedures delineated in 42 CFR 493.17(c). After the effective date of 42 CFR 493, notices will be published periodically in the Federal Register to announce any additional test system, assay or examination that has been categorized (or re-categorized) during the preceding interval. PMID- 10171216 TI - Specific list for categorization of laboratory test systems, assays and examinations by complexity--PHS. Notice with comment period. AB - The Clinical Laboratory Improvement Amendments of 1988, Public Law 100-578, requires that the Secretary provide for the categorization of specific laboratory test systems, assays and examinations by level of complexity. 42 CFR 493.17, published in the Federal Register on February 28, 1992, established criteria for such categorization. It is the Department's intention to complete the categorization of all currently available clinical laboratory test systems, assays and examinations prior to the effective date of 42 CFR part 493. This notice announces the fourth of a series of lists containing specific clinical laboratory test systems, assays and examinations, categorized by complexity. This notice also includes deletions and corrections to the list of test systems, assays and examinations published on February 28, 1992. After publication and close of comment period on the published partial lists, a complete list of all laboratory test systems, assays and examinations, categorized by complexity, and responses to public comments received on the partial lists will be published in the form of a compilation of these Notices. Any clinical laboratory test system, assay or examination that is not on the compilation will be considered high complexity, until categorized otherwise as provided under 42 CFR 493.17. After publication of the compilation, applications will be taken to categorize (or re categorize) other laboratory test systems, assays and examinations following the procedures delineated in 42 CFR 493.17(d). After the effective date of 42 CFR part 493, notices will be published periodically in the Federal Register to announce any additional test system, assay or examination that has been categorized (or re-categorized) during the preceding interval. PMID- 10171217 TI - Charting a new course in Alzheimer's care. PMID- 10171218 TI - Americans with Disabilities Act under way. PMID- 10171219 TI - Community options for community care in Australia. AB - Australia's trial community options projects help meet those individual needs of the aged, the disabled, and others trying to avoid institutionalization that are beyond the capacity of home and community agencies. The next step is to spread the good news. PMID- 10171220 TI - Preparing for expansion in Canadian home care. AB - Through its universal health care system, Canada has conducted three care assessment studies in Canadian provinces. Although covering divergent topics, all point to a national need: more training for paraprofessionals to provide high quality care. PMID- 10171221 TI - Second opinion programs: continued savings from nonconfirmed surgeries. AB - A second opinion program for elective surgery was one of the first tools utilized by employers to "manage" health care costs. These authors argue that second opinion programs continue to demonstrate their usefulness as part of overall health care cost-management effort. PMID- 10171222 TI - Special report on health care delivery systems. Final regulations implement Clinical Laboratory Improvement Amendments of 1988. AB - The primary purpose of CLIA and the Regulations is to strengthen federal oversight of clinical laboratories to ensure that test results are accurate and reliable. The new law and the Regulations create a national unified certification and enforcement system that affects virtually every laboratory in the country. Thus, all laboratories and health care providers with laboratory components that may be affected should carefully review the Regulations and prepare to comply with them well in advance of their September 1, 1992 implementation date. PMID- 10171223 TI - How ADA (Americans with Disabilities Act) applies to the physician's office. PMID- 10171224 TI - Women and children last. Barriers to drug treatment for women. PMID- 10171225 TI - Developing a pharmaceutical purchasing strategy. AB - The process commonly used by group purchasing organizations to contract for multisource pharmaceuticals and a strategic approach for the director of pharmacy in working with the purchasing group and the P & T Committee is described. The pharmacist should be knowledgeable concerning the group's contract commitment requirements, product specifications, terms and conditions and procedures for vendor selection, product award, contract implementation, and performance monitoring. To ensure results that meet the needs of the medical staff, it is important that the P & T Committee actively participate. The P & T Committee should understand the reasons for selecting a particular purchasing group, understand the necessary steps in obtaining the most favorable economic advantage, review products with potential brand interchange concerns, recommend product specifications, and reaffirm formulary procedures regarding the principle of current consent. PMID- 10171226 TI - Use of demand surveys to support budget requests. AB - Like pharmacy staff members at many hospitals, pharmacy personnel at Deborah Heart and Lung Center have been affected by new programs or increased activities undertaken by their organization and/or other departments requiring pharmacy support. At Deborah, these programs and activities were initiated after department budgets for the year were already approved. For the past 2 years the pharmacy department has employed a method of planning that effectively eliminated this problem as well as supported budget requests for increased services. PMID- 10171227 TI - Bibliography and reference. PMID- 10171228 TI - Testing healthcare workers for AIDS is costly, ineffective. PMID- 10171229 TI - Minimally invasive therapy. AB - Minimally invasive therapy is a new and important development in medicine. With minimal disruption to the patient's body or way of life, outcomes are at least as effective and procedures are safer than conventional surgery. But there are clear implications for management on costs, and organisational and strategic issues. PMID- 10171230 TI - What your colleagues are charging. PMID- 10171231 TI - The hybrid laboratory: shifting the focus to the point of care. PMID- 10171232 TI - Joining the technological evolution in health care. PMID- 10171233 TI - Using cost-effectiveness analysis to weigh testing decisions. PMID- 10171234 TI - A collaborative approach to managing risk. PMID- 10171235 TI - Controlling error in laboratory testing. PMID- 10171236 TI - Striving for efficiency in orthopedic programs. Managing implant inventory answer to skyrocketing costs. PMID- 10171237 TI - Striving for efficiency in orthopedic programs. Standardization of implants cuts costs, boosts efficiency. PMID- 10171238 TI - Ambulatory surgery faces regulatory hurdles. PMID- 10171239 TI - Communication promotes dignity for residents with Alzheimer's. PMID- 10171240 TI - Sponsor program helps families adjust to facility placement. PMID- 10171241 TI - Assisted living Alzheimer's units provide specialized services. PMID- 10171242 TI - Danger: implants. AB - The superheated debate over breast implants awakened a sleeping giant of an issue clouding "medical devices"--the government's clumsy nomenclature for any medical product that is not a drug, from breast implants and artificial hips to X-ray machines and surgical thread. Some 130 categories of high-risk devices are in use with little or no proof of safety, reliability or effectiveness. All appeared before 1976, the year that the Food and Drug Administration got the authority to regulate such products. Under activist chief David Kessler and with added clout from a 1990 law, the FDA plans to scrutinize the entire 130-item list. Five will get special attention starting early next year: saline-filled breast implants, inflatable penile implants, testicular implants, heart-bypass pumps and cranial stimulators. U.S. News has looked at all five devices, using FDA data obtained through the Freedom of Information Act. In-depth computer analysis suggested that penile implants deserve closer examination. Why is clear from the following report. PMID- 10171243 TI - Professor Dr Hermann Hoffmann. Interview by Peter Ossen. PMID- 10171244 TI - Using HIS data for health care research. AB - The importance of measuring healthcare performance and outcome rapidly grows around the world. As hospital information systems (HIS) become more commonplace, their use as clinical research tools can be easily developed. This is demonstrated in the article by two examples of clinical outcomes research undertaken on the world's largest HIS database. The research studies described in the article were on: (1) The effect of hospital 'experience' on inpatient mortality rates for patients with HIV-related pneumocystis carinii pneumonia, and (2) The effect of streptokinase and tPA on post-acute myocardial infarction survival rates. PMID- 10171245 TI - Trends in reported disability in the Australian aged population: interpretation of preliminary ABS survey findings. AB - The 1981 and 1988 Australian Bureau of Statistics Disability Surveys provide the basis for gaining insight into changes in disability prevalence in the older Australian population. Between 1981 and 1988, self-reported disability rates increased 52% and 78% for the 65-84 and 85+ cohorts, respectively. Through cross referencing with other data bases, it is possible to attribute between one-third and one-half of this increase to population growth, much of which can be ascribed to disproportionate growth in the 65-84 and 85+ cohorts. Much of the remainder appears to be related to an increase in self-reported prevalence of chronic diseases at older ages, with a concomitant rise in disability, and a residual reporting effect. In conclusion, some issues of data collection and analysis for planning both long term care and health promotion interventions are raised. PMID- 10171246 TI - Hospital tries focused approach to treating pregnant addicts, program eyed as possible national model. PMID- 10171247 TI - U.S. turns down Oregon plan to rank, ration Medicaid services. PMID- 10171248 TI - The emerging role of the clinical reimbursement coordinator. PMID- 10171249 TI - Homelessness. Why nothing has worked--and what will. PMID- 10171250 TI - Medicare program; update of ambulatory surgical center payment rates--HCFA. Notice with comment period. AB - This notice implements section 1833(i)(2)(A) of the Social Security Act, which requires that the payment rates for ambulatory surgical center (ASC) services be reviewed and updated annually, and responds to the public comments we received concerning the ASC payment rate update notice with comment published on December 31, 1991 (56 FR 67666), except for those concerning payment amounts for lithotripsy, which will be addressed in another Federal Register document. DATES: Effective date: The payment rates contained in this notice are effective for services furnished on or after October 1, 1992. Comments date: Comments will be considered if we receive them at the appropriate address, as provided below, by 5 p.m. on November 30, 1992. PMID- 10171251 TI - Quality assurance and the resource crunch: issues in downsizing. PMID- 10171252 TI - A post-discharge study on the use of assistive devices. AB - Through this study of a heterogeneous patient population, the prescription and distribution of assistive devices was found to be a beneficial occupational therapy intervention. Although 97% of patients were satisfied with the education provided during occupational therapy intervention, it was discovered that more time is required to practice tub transfers, as well as to fully explain to patients the benefits of sock-aids. The need for further longitudinally based research in the use of assistive devices is recognized. PMID- 10171253 TI - Taking the right track. Regulation of Alzheimer's units at a crossroads. PMID- 10171254 TI - Outcome measures in speech therapy: impairment, disability, handicap and distress. AB - Recent changes in health service policies have led to renewed attention to the problem of measuring and relating outcome to health care provision. This has meant an increased focus on effectiveness itself, and a link with value for money. The effects of treatment have often defied measurement, and outputs, therefore, have replaced measures; the output of a service is important, but it should not be confused with outcome. This paper describes a simple method of measuring outcome reflecting the complex efforts of rehabilitation. PMID- 10171255 TI - Health clinics for problem drug misusers. AB - This paper reports the results of an evaluation of two community based 'walk-in' health clinics for drug misusers, primarily for those injecting drugs. In 1989, these clinics were established as a means of improving the availability of health care facilities to a group of individuals known to have high morbidity. The factors leading to the establishment of this service are identified, and the first year of the service is described together with suggestions for further expansion of this service. PMID- 10171256 TI - The ADA (American with Disabilities Act) and medical staff relations. PMID- 10171257 TI - The littlest victims. PMID- 10171258 TI - ADA's (Americans with Disabilities Act) signage rules: significant, strict, specific. PMID- 10171259 TI - Home is where the healthcare is. PMID- 10171260 TI - Constraints on innovatory practice: the case of day surgery in the NHS. AB - Rates of adoption of new technology or innovatory practices depend upon their inherent managerial and clinical incentives. Rates will be highest where these incentives coincide and lowest where both are weak. Within this framework we examine the current low rate of adoption of day surgery in the National Health Service (NHS) of the United Kingdom (UK). We assess the current managerial incentives for the introduction of day surgery in terms of its potential either to achieve financial savings or to allow expansions in overall hospital caseload. These are both shown to have been low within the context of the traditional method of funding health care in the NHS. Clinical attitudes and their perceptions of the barriers to day surgery are examined based on data from a survey of 240 consultant surgeons. A high proportion of surgeons regard day surgery as clinically acceptable for a wide range of procedures, but the limited clinical appeal of day surgery procedures and the lack of day facilities have further limited its adoption. These findings are considered in the context of the revised methods of funding hospital services in NHS, introduced from April 1991. Priorities may change with managerial incentives playing a greater role in the introduction of new technologies and innovatory practices. PMID- 10171261 TI - A laboratory automation platform: the next robotic step. PMID- 10171262 TI - How to read the Federal Register and other CLIA-related documents. PMID- 10171263 TI - Final CLIA regulations released. PMID- 10171264 TI - The personnel touch in mapping strategies. AB - Human resources departments are playing an increasingly important role in planning their hospitals' long-term competitive strategies, according to this year's MODERN HEALTHCARE survey of employee benefits and human resources issues. A human resources executive is a member of the strategic planning team at 52% of the hospitals that responded to the survey, and the human resources department assists in planning at half of the other hospitals. PMID- 10171265 TI - Special units aim at dementia. AB - Nursing home providers, especially the large chains, are responding to calls for improved services for people with Alzheimer's disease and other dementia-related disorders by developing special-care units. While Alzheimer's programs have been in existence since the mid-1980s, the rising number of seniors who have the disease and their families' demands for quality long-term-care programs have resulted in rapid growth. PMID- 10171266 TI - VA's heart surgery mortality rates drop. PMID- 10171267 TI - ADA compliance to be costly for docs--study. PMID- 10171268 TI - ORs reorganizing services for endoscopic surgery. PMID- 10171269 TI - Applications for laparoscopic surgery growing. PMID- 10171270 TI - Credentialing addressing concerns about laparoscopy. PMID- 10171271 TI - Pushing the emotional hot button. Outpatient ad campaign shies away from technology to deliver 'feelings'. River Oaks Hospital, Jackson, MS. PMID- 10171272 TI - Providers optimize benefits by becoming Part B suppliers. PMID- 10171273 TI - Laboratories increase nursing efficiency, resident service. PMID- 10171274 TI - Slow down the SCU (special care units) regulatory bandwagon. State regulation threatens innovation. PMID- 10171275 TI - Effects of a surgical pre-operative assessment clinic on patient care. AB - Surgery makes many demands of both hospitals and patients. For the hospital, there are many procedural aspects: admission, health assessment, and patient education; the actual operation; and the post-surgical recovery period, a time when patients are susceptible to complications and nosocomial infections. For the patient, surgery means physical pain and emotional anxiety. A pre-operative assessment clinic (POAC), however, can assist both hospital and patients by streamlining their admission, assessment, and education, by decreasing the time they spend in the hospital recovering from surgery, and by easing their anxiety. In this article, the authors describe a study of a POAC at a Canadian hospital. PMID- 10171276 TI - Why do some caregivers of disabled and frail elderly quit? AB - In this study, the authors examine the extent to which the characteristics of caregivers or recipients determine the probability that caregivers stop being caregivers. We find that caregivers' characteristics such as working outside their homes, raising children, or having their own health problems do not increase this probability. Nor does the emotional distress of caregiving increase the probability of quitting. However, caregivers are more likely to quit when recipients have six to seven disabilities in activities of daily living and need help on demand around the clock. This study also determines that assistive equipment, home modifications, and attendance at senior centers do not reduce the probability that caregivers quit. PMID- 10171277 TI - Economic grand rounds: a forum for cost consciousness. AB - This article analyzes the implementation of a traditional Economic Grand Rounds (EGR) program in a teaching hospital. The conclusions are that the original concepts of EGR--presentations of treatment costs by clinicians in a grand rounds setting, reinforcement of agreed changes in practice patterns, and subsequent evaluation and participation--are still valid but are inadequate to ensure a successful program. Other factors must be added if EGR is to attain its goals. These factors are administrative and nursing involvement, a provision to make policy changes, and incentives for the medical staff. This article also outlines areas of potential savings achieved through an EGR program in laboratory testing, preoperative laboratory testing, and intravenous therapy with antibiotics. PMID- 10171278 TI - A case management system for infants with chronic illnesses and developmental disabilities. AB - Continuity of care has been identified as a priority goal for infants with developmental disabilities or chronic illnesses who are faced with long-term or frequent hospitalizations. This goal was accomplished by Project Continuity, a family-centered intervention and care coordination system in which the family plays an integral role in the planning and implementation of the care plan. Procedures borrowed from diverse traditions including job analysis from industrial psychology and quality assurance from health care were used to describe, monitor, and assess the complex professional behaviors and outcomes of care coordination. PMID- 10171279 TI - Employee Assistance Program utilization for substance abuse problems and organizational climate as perceived by supervisory personnel. PMID- 10171280 TI - Sullivan made the right choice in rejecting the Oregon plan. PMID- 10171281 TI - Partial hospitalization: when less is more. PMID- 10171282 TI - The Treaty of Maastricht and public health. PMID- 10171283 TI - European Community Medical Device Directives. PMID- 10171284 TI - Readmission to Fremantle Hospital: who comes back, when and why? PMID- 10171285 TI - The Oregon Plan's impact on the future of healthcare reform. PMID- 10171286 TI - Free to run and play. PMID- 10171287 TI - The consequences and costs of maternal substance abuse in New York City. A pooled time-series, cross-section analysis. AB - We use a pooled time-series cross-section of live births in New York City between 1980 and 1989 to investigate the dramatic rise in low birthweight, especially among Blacks, that occurred in the mid 1980s. After controlling for other risk factors, we estimate that the number of excess low birthweight births attributable to illicit substance abuse over this period ranged from approximately 1,482 to 3,359. The increase represents between 3.2 and 7.3% of all LBW over the period resulting in excess neonatal admission costs of between $18 and $41 million. PMID- 10171288 TI - Implementing ergonomic approach promotes workplace safety. PMID- 10171289 TI - Fairness, training help avoid ADA discrimination claims. PMID- 10171290 TI - Outpatient surgery is now the norm. PMID- 10171291 TI - Assistive technology devices and home accessibility features: prevalence, payment, need, and trends. PMID- 10171292 TI - Special report on medical staff relationships. An open question: does the Americans with Disabilities Act apply to medical staff decisions? Part I. PMID- 10171293 TI - Employee lawsuit insurance covers possible liability under new laws. AB - Employers faced with increased liability under recently enacted federal legislation can now turn to insurance companies for protection against suits involving personnel practices. At least two insurance companies are now offering policies that protect companies against litigation for wrongful dismissal, sexual harassment, and/or discriminatory employment practices and procedures. PMID- 10171294 TI - With an eye to an ear. PMID- 10171295 TI - Travail sans frontieres. PMID- 10171296 TI - Genetic testing: should clinical laboratory regs cover DNA analyses? PMID- 10171297 TI - The Americans with Disabilities Act says 'No' to the Oregon Medicaid demonstration project. PMID- 10171298 TI - American College of Healthcare Executives Public Policy Statement. Strengthening healthcare employment opportunities for persons with disabilities. PMID- 10171299 TI - Laboratory non-salary expenses per billable test. PMID- 10171300 TI - Measuring physician activity accurately. PMID- 10171301 TI - What physicians need to know about the ADA (Americans with Disabilities Act). AB - The Americans with Disabilities Act (ADA) has raised a lot of questions and concerns from physicians and medical groups regarding their responsibilities in meeting the public accommodation portions of the act. Rebecca Burke and Peter Thomas answer the most commonly asked questions concerning the ADA. PMID- 10171302 TI - Characteristics of dementia-specific day programs. AB - Adult day programs are a rapidly growing alternative for community-based care for the elderly, but there are few descriptions of dementia-specific programs in the gerontologic literature. We present the first overview of such efforts in the United States with a national scope, using information provided by a pool of 283 applicants to the Robert Wood Johnson Foundation Dementia Care and Respite Services Program. Results show program consistency in hours of operation and use of professional staff, and variability in sources of funding and size of the community served. On the average, participant fees accounted for less than 25 percent of total revenues. PMID- 10171303 TI - Routine low-cost pathology tests: measuring the value in use of bacteriology tests in hospital and primary care. AB - The introduction of a managed market in health care in the NHS will encourage managers and clinicians to examine clinical services, such as pathology, more closely. However, simple cost-minimization may not be sufficient; the recent Audit Commission report on pathology emphasises a need to measure and monitor cost-effectiveness of clinical services such as pathology. This paper presents the findings of a study to measure the cost-effectiveness of one routine pathology test; the culture and antibiotic susceptibility test performed by all microbiology laboratories. Over 2,900 requests were examined and test results tracked in hospitals and general practices served by three laboratories. The findings show that, although average test costs are low for the three main user groups (4.3-5.9 pounds), the cost of producing an effect on patient management (change to therapy) is high at 54-67 pounds. In addition to therapy changes, the one major effect recorded was that of clinician reassurance. If all measured effects are weighted by their reported clinical utility, cost-utility ratios of 27.0 pounds +/- 1.0 pounds, 45.5 pounds +/- 4.5 pounds and 44.5 pounds +/- 3.5 pounds per patient management effect are calculated for general practitioner, outpatient and inpatient use respectively. A theoretical model is presented which will allow the comparative cost-effectiveness of a range of routine diagnostic tests to be measured through the use of a test-utility index, similar to the health index which is currently used to measure the outcome of medical interventions (QALYs). PMID- 10171304 TI - Design of institutions: cognitive functioning and social interactions of the aged resident. AB - Older people experience sensory, cognitive, and social deficits that adversely affect their interaction with the environment. Design of institutions for the elderly resident should be prosthetic to ensure that environments optimally accommodate the functioning of the residents. The sensory and cognitive state of the residents should be considered in every facility. This review discusses how sensory and cognitive changes in aging affect orientation and wayfinding as well as how the physical aspects of the environment can accommodate these changes to reduce confusion and disorientation. Environmental features that promote social interaction are reviewed. Because the environmental needs and unique characteristics of the cognitively impaired resident differs from that of the nonimpaired resident, special issues in the design of facilities for demented residents are reviewed. Conclusions are offered with regard to research needs and applied problems. PMID- 10171305 TI - CPR (computerized patient records) and the law: plan now. PMID- 10171306 TI - Total quality management at Bethesda, Inc. AB - This article describes 4 years of TQM implementation at Bethesda, Inc., a private not-for-profit diversified healthcare organization. Bethesda has used a comprehensive implementation strategy involving the use of process improvement teams, hoshin planning, daily management of critical processes, and quality function deployment. The article includes four process improvement case studies demonstrating the use of the seven quality control tools and a nine-step process improvement model. Factors contributing to processes as well as obstacles are described. PMID- 10171307 TI - Medicare program; fee schedule for physicians' services for calendar year 1993- HCFA. Final notice with comment period. AB - This final notice with comment period announces the final relative value units (RVUs) for Medicare payment for existing procedure codes under the physician fee schedule and interim RVUs for new and revised codes. Section 6102(a) of the Omnibus Budget Reconciliation Act of 1989, as amended by section 4118 of the Omnibus Budget Reconciliation Act of 1990, requires establishment of the physician fee schedule and periodic review and adjustment of the RVUs. PMID- 10171308 TI - Physician performance standard rates of increase for federal fiscal year 1993 and physician fee schedule update for calendar year 1993--HCFA. Final notice with comment period. AB - This notice announces the calendar year (CY) 1993 updates to the Medicare physician fee schedule and the Federal fiscal year (FY) 1993 performance standard rates of increase for expenditures and volume of physician services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848(d) and (f), respectively, of the Social Security Act. It also sets forth an "initial" procedure-specific list of surgical and nonsurgical services to be used in applying the CY 1993 updates. These surgical and nonsurgical designations are subject to public comment. The physician performance standard rates of increase for Federal FY 1993 are 10.0 percent for all physician services, 8.4 percent for surgical services, and 10.8 percent for nonsurgical services. The fee schedule update for CY 1993 is 3.1 percent for surgical services and 0.8 percent for nonsurgical services. PMID- 10171309 TI - Incentive regulation of nursing homes. AB - A social experiment was conducted in San Diego to test the effectiveness of monetary incentives in improving the health of nursing home residents and lowering Medicaid expenditures. Use of a Markov model to represent the resulting health changes of nursing home residents shows that the monetary incentives had beneficial effects on both the quality and the cost of nursing home care. Moreover, the nursing homes admitted more people with severe disabilities, and the average length of their stays was shortened. If implemented, this kind of incentive program would save Medicaid substantial amounts of money, but not through lowering nursing home payments. Instead, the more efficient use of nursing homes would transfer more people out of hospitals and thereby save unnecessary hospital reimbursement. PMID- 10171310 TI - The relationship between physician fees and the utilization of medical services in Ontario. PMID- 10171311 TI - Employer obligations under Title I of the Americans with Disabilities Act. PMID- 10171312 TI - Public accommodations provisions--Title III. Americans with Disabilities Act. PMID- 10171313 TI - A differently-abled administrator. PMID- 10171314 TI - Nurse. Athlete. Competitor. Quadriplegic. PMID- 10171315 TI - Americans with disabilities. The mission meets the law. PMID- 10171316 TI - Security systems keep tabs on patients, guard against abduction, aid rehab and heighten peace of mind among caregivers. PMID- 10171317 TI - Medicare program; payment for durable medical equipment and orthotic, and prosthetic devices--HCFA. Interim final rule with comment period. AB - This interim final rule implements section 4062(b) of the Omnibus Budget Reconciliation Act of 1987 which specifies that payment under the Medicare program for durable medical equipment, orthotics, and prosthetics furnished on or after January 1, 1989 is limited to the lower of the actual charge for the equipment or the fee schedule established by the carrier. We are setting forth the methods for computing fee schedules for six classes of these items. We are also describing how the fee schedules are updated in subsequent years. PMID- 10171318 TI - Order of excellence. The Fountains at La Cholla; Kachina Point Retirement Village; Jewish Home & Hospital for Aged; Heartland of Boynton Beach. PMID- 10171319 TI - Special report on medical staff relationships. An open question: does the Americans with Disabilities Act apply to medical staff decisions? Part II. PMID- 10171320 TI - Coping with CLIA, Part 5. How to prepare for a proficiency testing event (and survive a failure). PMID- 10171321 TI - Internal proficiency testing for hematology. PMID- 10171322 TI - Will QALYs be target of Americans with Disabilities Act? AB - The rejection of Oregon's health care rationing plan on the basis that its quality-of-life criteria inherently devalued the life of persons with disabilities raises the fundamental question of whether any fair and practical rationing plan can be devised without reference, at least implicitly, to quality of life. The following articles describe Oregon's revised plan and recent work on quality-adjusted-life-years, or QALYs (pronounced QUAL-eez). PMID- 10171323 TI - American Health Information Management Association. Position statement. Issue: Physicians' Current Procedural Terminology (CPT): its application in the hospital setting and use by payers. PMID- 10171324 TI - Patient education in the ambulatory care setting. PMID- 10171325 TI - Disabilities Act can affect medical staff appointment process. PMID- 10171326 TI - Breast MRI. The potentials and dangers: are you informed? AB - Breast MRI is a field that is rapidly emerging. The approaches to breast MRI technology and clinical utilization are highly variable. The viability of any selected technology should be fully understood before it is advocated as a solution for any clinical role. It is my opinion that all breast MR methods currently in use should undergo more clinical trials before they are employed for routine breast diagnosis. Before purchasing special breast imaging hardware, you should be shown proof of clinical capability that includes well controlled clinical trials, not just a pretty picture. The use of MRI for breast diagnosis is far different from other clinical applications. If MRI misses the meniscal tear, the patient will return with continued symptoms and eventually have appropriate treatment. If MRI falsely calls a meniscal tear, then the worst thing that will happen is a diagnostic arthroscopy which would have occurred if the patient had never had the MRI. If breast MRI detects an enhancing mass that cannot be confirmed by biopsy or any other imaging examination, there are two potential disastrous consequences: 1) Overzealous treatment could result in needless and permanent deformity. 2) The results of the MRI positive lesion are ignored and the patient may lose the opportunity for cure in a lesion confined to the breast. Until MRI directed biopsy capability is available, the clinical value of this examination is questionable. MRI may be used for the evaluation of possible free silicone from implant leaks. The ultimate role of MRI in this evaluation compared with sonography is uncertain.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171327 TI - The role of imaging in the operating room of the future. PMID- 10171328 TI - Utilization of laboratory services: issues, opportunities and risks. PMID- 10171329 TI - ADA and health facilities: some progress, problems. PMID- 10171330 TI - The Americans with Disabilities Act: the responsibilities of health care providers, insurers and managed care organizations. PMID- 10171331 TI - Duties under the Americans with Disabilities Act: is a surgeon required to perform elective surgery on an HIV positive patient? PMID- 10171332 TI - Ethnic patterns in drug abuse treatment utilization. AB - This study describes utilization of drug abuse treatment and related perceptions among African American, Hispanic, and Anglo drug-using arrestees in Los Angeles. The study extends prior research by, first, describing ethnic variation in treatment utilization through analyses that control for nonethnic demographic factors and by, second, exploring the degree to which ethnicity is related to two predisposing factors (attitude toward treatment and perceived need) and two enabling factors (perceived cost and availability). After nonethnic demographic factors and past drug dependence are controlled, African American and Hispanic drug users in Los Angeles are less likely to report having been in drug abuse treatment. Hispanic drug users are more likely than Anglos to say that they have not sought treatment because they do not need it. African American drug users are more likely than Anglos to hold unfavorable views of treatment. PMID- 10171333 TI - Cross-training prepares ASC nursing staff for flexibility. PMID- 10171334 TI - Methadone in maintenance treatment of narcotic addicts; joint revision of conditions for use; interim maintenance treatment; human immunodeficiency virus disease counseling--FDA and SAMHSA. Final rule. AB - The Food and Drug Administration (FDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) formerly the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) are revising the conditions for the use of methadone in the maintenance treatment of narcotic addicts. The final rule allows, contingent on FDA and State approval, public and nonprofit private narcotic treatment programs to provide interim maintenance treatment to patients awaiting placement in comprehensive maintenance treatment and to require all narcotic treatment programs to provide counseling on preventing exposure to, and the transmission of, human immunodeficiency virus (HIV) disease. PMID- 10171335 TI - Reduction of health plan benefits payable to catastrophically ill employees. PMID- 10171336 TI - Introduction. Minimally invasive therapy in five European countries: diffusion, effectiveness and cost-effectiveness. AB - Minimally invasive therapy (MIT) is a field that has gained a great deal of attention since the mid-1980s. MIT is a new and rapidly growing area of medical treatment based on developments in endoscopy, vascular catheters, imaging devices, and related technologies. Although endoscopes have been in use for more than 100 years, it is relatively new to use them for therapeutic purposes. Now practically every organ system in the body can be approached by these technologies. The resulting revolution in health care is the subject of this issue of the journal. PMID- 10171337 TI - Hysteroscopy: an evolving case of minimally invasive therapy in gynaecology. AB - Hysteroscopy is an endoscopic technique, allowing inspection of the intrauterine cavity. Diagnostic applications of the technique began to develop in the 1970s. Although it is often claimed that diagnosis under direct visualization is better than standard dilatation and curettage, it has not yet been proved that hysteroscopic diagnosis has better results than curettage. The clinical application of therapeutic hysteroscopy, mainly in the field of the treatment of abnormal uterine bleeding, started in the 1980s. Two thousand patients have been treated with either hysteroscopic myomectomy, endometrial resection, or endometrial laser ablation, according to the literature. No randomized trials have been conducted. The first clinical results of hysteroscopic treatment seem satisfactory, with average success rates of 85%. There is some evidence that the therapy is cost saving, because hysteroscopic procedures only require one or two nights in hospital. The technique is not yet widely diffused, mainly because of technical difficulties and lack of definite evidence on its effectiveness. PMID- 10171338 TI - Diffusion of minimally invasive therapy in Europe. AB - This paper considers the diffusion of the 10 cases presented in this issue. Most of the cases have diffused relatively slowly. This slow diffusion can be explained by a number of factors, including budgetary restraints, financial incentives, physician conservatism, and lack of appropriate training. A consistent thread in the cases is the argument that evidence of effectiveness is not convincing. The article considers whether further diffusion of each innovation can be justified from existing evidence. This information is important for policy purposes. Policies might be developed to encourage or to discourage any potentially important innovation. PMID- 10171339 TI - The cost-effectiveness of 10 selected applications in minimally invasive therapy. AB - In this article, evidence of effectiveness and cost-effectiveness of the following procedures is reviewed: (1) laser treatment of bladder tumors; (2) extracorporeal shock-wave lithotripsy and percutaneous nephrolithotomy; (3) laparoscopic treatment of endometriosis; (4) laparoscopic removal of ovarian cysts; (5) laparoscopic cholecystectomy; (6) laparoscopic appendectomy; (7) catheter treatment of coronary artery disease; (8) palliation of colon cancer by endoscopic intervention; (9) treatment of upper gastrointestinal (UGI) bleeding by endoscopic intervention; and (10) arthroscopic knee surgery. Despite considerable potential to be effective and cost-effective, evidence is disappointingly limited in these cases. The lack of evidence hampers decision making in this new field. PMID- 10171340 TI - The dynamics of innovation in minimally invasive therapy. AB - The emergence of minimally invasive therapy (MIT), which provides alternatives to major open-surgery procedures, is affecting all aspects of medical care delivery. In the present environment of resource and cost constraint in health services, an uncommon consensus among patients, physicians, providers, and payers has evolved regarding the rapid acceptance of this area of medical intervention, an acceptance that, in turn, is stimulating further innovation. This paper discusses the dynamics of medical innovation and analyzes these forces in the context of three minimally invasive therapies: percutaneous transluminal coronary angioplasty, extracorporeal shock wave lithotripsy, and laparoscopic cholecystectomy. The different experiences of the United States and Europe are used to illustrate how scientific, medical, economic, and regulatory factors affect both the rate and direction of technological change in minimally invasive therapy. PMID- 10171341 TI - Implications of minimally invasive therapy. AB - The field of minimally invasive therapy (MIT) raises many important issues for the future of health care. It seems inevitable that MIT will replace much conventional surgery. This trend is good for society and good for patients. The health care system, however, may find the change disruptive. The need for hospital beds will shrink. Day surgery and community care will grow. Physicians will have to have special training in doing the new procedures. New organizational forms of care will evolve. Quality assurance procedures will be needed to assure that out-of-hospital care is safe and effective. One negative consequence of MIT is that the indications broaden, so that many 'preventive' procedures may be carried out. Societies are doing little to face up to these changes. The potential of MIT could be enhanced by active policy interventions, including evaluation and attention to the organization and financing of health care. PMID- 10171342 TI - Minimally invasive therapy in Denmark. AB - Minimally invasive therapy (MIT) is beginning to have impacts on health care in Denmark, although diffusion has been delayed compared to diffusion in other European countries. Now policy makers are beginning to appreciate the potential advantages in terms of closing hospitals and shifting treatment to the out patient setting, and diffusion will probably go faster in the future. Denmark does not have a system for technology assessment, neither central nor regional, and there is no early warning mechanism to survey international developments. This implies lack of possibilities for the planning of diffusion, training, and criteria for treatment. PMID- 10171343 TI - Minimally invasive therapy: the French case study. AB - The diffusion in France of the 10 selected technologies is quite different, depending on the technology. Some are 'ancient', widely diffused and stabilized techniques, such as arthroscopy for knee surgery and lithotripsy for bladder stones. Others are very new but quickly disseminating technologies, such as laparoscopic cholecystectomy, and others, especially those based on lasers, have only a restricted diffusion related in some cases to a lasting skepticism of most physicians. It is therefore not possible to draw a common sketch that would apply to 'minimally invasive surgery in France' as a whole. Nevertheless, it is possible to stress some common points which characterize the dissemination of innovation in the French health care system since the 1980s. These include the lack of methods available to health authorities to control medical innovation; the organizational and financial constraints on health care institutions, restricting their ability to adapt to changing circumstances; a limited judicial response in the face of potentially dangerous technologies; the high degree of freedom that medical practitioners have in adopting innovations; the weakness of French industry; and the important and sometimes destructive role the media play in diffusion of health care innovations. PMID- 10171344 TI - Minimally invasive surgery in the Federal Republic of Germany. AB - In the Federal Republic of Germany 67 experts were questioned concerning the diffusion of 10 procedures in minimally invasive surgery (MIS). Most of the ten procedures have potential economic advantages and benefits for the patient. Informants state that more randomized controlled trials are needed. Extra corporeal shock wave lithotripsy, percutaneous transluminal coronary balloon angioplasty, sclerosing of sites of upper gastrointestinal bleeding (including esophageal varices), and arthroscopic meniscectomy are well-established; laparoscopic cholecystectomy made a breakthrough in 1990. The diffusion process of the others is promising. Main obstacles to further diffusion are high investment and maintenance costs, long delivery time for special instruments, lack of systematic training in MIS, performance regulations, and conservatism. Investigations into total costs are necessary. Since the present financing of hospital services through per diem payment is detrimental to the diffusion of MIS, lump-sum payments could remove barriers to diffusion. New methods of interlinking hospital and out-patient care should be tested. PMID- 10171345 TI - Diffusion of minimally invasive therapy in The Netherlands. AB - In the context of the European project, the diffusion of 10 selected cases of minimally invasive therapy (MIT) in the Dutch health care system was documented and analyzed. In each case the diffusion pattern resulting from the balance of stimulating and impeding factors is described, and summarized in a matrix framework. Budgetary pressures, lack of evidence on effectiveness and physician conservatism are the most important factors impeding diffusion of MIT. Patient demand, media reporting and presence of medical innovators are important diffusion-stimulating factors. Finally, a judgment is made on the policy implications of these findings, based on a comparison of the extent and speed of the diffusion of each case, the quality of evidence on effectiveness and cost effectiveness and, in a few cases, existing policies. In most cases, more active policy making, either stimulating or otherwise guiding diffusion, would be desirable. PMID- 10171346 TI - An introduction to minimally invasive therapy. AB - Minimally invasive therapy (MIT) has as its basic premise the reduction of iatrogenic trauma to the patient by surgeon, physician or radiologist. This approach must also imply that the therapeutic procedure succeeds in its aim of cure in a manner no less effective than is currently achievable by established methods of treatment. Acceptance of this principal has many identifiable sequelae, including profound changes in hospital design, increasingly expensive technological instrumentation, more sophisticated teaching and learning patterns, and a massive redirection of health care financial resources. These changes cannot be contemplated at leisure, because they are dynamically imperative and progressing with relentless rapidity, being directly driven by the consumer. It is vital that this shift in clinical emphasis should be appreciated so that future planning can be undertaken with some rationality. PMID- 10171347 TI - The development of minimally invasive therapy in the United Kingdom. AB - The diffusion of minimally invasive therapy (MIT) must be understood against the background of sweeping changes in the organisation and funding of the National Health Service (NHS) in the UK. The separation of purchasers from providers of health care makes national policy, in theory, less important, as local developments are supposed to drive the process of needs assessment and resource allocation. Within this climate new technologies increasingly have to prove their cost-effectiveness. Yet the country case study illustrates that such studies lack established methodologies and wide application. One of the key barriers to diffusion lies within the profession itself, where resistance to paradigmatic change is the strongest force against innovation. The partnership between innovative clinicians and forward-looking managers is important if diffusion of new procedures is to be secured. The discussion of the 10 examples will highlight some of these important issues. PMID- 10171348 TI - Risk reduction in prenatal care: interventions for healthier children. PMID- 10171349 TI - Laboratory testing under the microscope: the Clinical Laboratory Improvement Amendments of 1988. PMID- 10171350 TI - HIV antibody testing: legal considerations and sound hospital policy. PMID- 10171351 TI - Coping with CLIA. Part 6: How to follow the rules for patient test management. PMID- 10171352 TI - Structuring group medical practices: labor and employment issues. AB - This article is the third in a series addressing the general representation factors involved in structuring group medical practices. In this article, selected labor and employment issues frequently encountered by counsel and managers of group medical practices are reviewed, and the impact of various legal restrictions--including the Americans with Disabilities Act--is discussed. PMID- 10171353 TI - Bloodless surgery meets patient needs for alternatives. PMID- 10171354 TI - Europe takes AIM (Advanced Informatics in Medicine) on high-impact HITs (healthcare information technology). PMID- 10171355 TI - Medicaid program; eligibility and coverage requirements--HCFA. Final rule with comment period. AB - These regulations amend the requirements for coverage of certain groups of individuals under Medicaid and the requirements for determining Medicaid eligibility. The regulations relate to coverage of individuals in optional categorically needy groups; aged, blind and disabled individuals in States that use more restrictive requirements for Medicaid than those under the Supplemental Security Income (SSI) program; individuals receiving optional State supplementary payments; individuals under age 21 who are not receiving AFDC; individuals who are ineligible for cash assistance under the Social Security Act because of requirements that do not apply under Medicaid; and medically needy groups. In addition, the regulations revise the methodologies for determining income and resource eligibility under Medicaid, including financial responsibility of relatives, and for determining financial eligibility of medically needy groups, including determining medically needy income levels. These regulations interpret provisions of the Tax Equity and Fiscal Responsibility Act of 1982, as amended by several acts, including, most recently, the Omnibus Budget Reconciliation Act of 1987, the Medicare Catastrophic Coverage Act of 1988, the Family Support Act of 1988, the Omnibus Budget Reconciliation Act of 1989, and the Omnibus Budget Reconciliation Act of 1990. We are also making some administrative changes to achieve more efficient operation of the Medicaid Program. PMID- 10171356 TI - Medicare, Medicaid and CLIA programs; regulations implementing the Clinical Laboratory Improvement Amendments of 1988 (CLIA) and Clinical Laboratory Improvement Act Program fee collection--HCFA. Final rule with comment period. AB - In the February 28, 1992, issue of the Federal Register (57 FR 7002), the Department of Health and Human Services established rules that set forth the test performance requirements for laboratories that are subject to the CLIA requirements. This rule corrects both typographical and technical errors made in that document as well as provides some additional clarification after a limited review of the comments we received after the publication of the rule. PMID- 10171357 TI - Addiction medicine in the '90s: a case study. PMID- 10171358 TI - The quiet epidemic. AB - While the incidence of mental health and substance abuse problems in our society is dramatically high, perhaps even more shocking is the low percentage of those who receive treatment. And though there has been much debate over the cost of providing mental health coverage, attention must be given to the burdens created by not providing necessary care. PMID- 10171359 TI - Medicare payments for assistants at surgery. PMID- 10171360 TI - Minimal invasive surgery--operating through the abdominal keyhole. PMID- 10171361 TI - Wellness programs: complying with the Americans with Disabilities Act (ADA). AB - Employers that offer wellness programs must be careful to comply with the guidelines of ADA. As the dollar amounts involved in these programs and the number of participants increase, so does the risk of lawsuits. PMID- 10171362 TI - Point-of-care testing. PMID- 10171364 TI - HIV and the surgical team--an update. PMID- 10171363 TI - A practical guide to the Americans with Disabilities Act. AB - The employment provisions of the Americans with Disabilities Act (ADA) became effective on July 26, 1992 for many employers. This article is intended to provide practical guidance for compliance with ADA from the combined perspectives of the labor attorney and the industrial psychologist. The article addresses the legal requirements of the ADA and points out the tasks required of employers in order to comply. It is designed to help employers identify and meet their obligations and be prepared to defend their actions if challenged. PMID- 10171365 TI - Alzheimer's care centers. PMID- 10171366 TI - Design prescriptions for the disabled. PMID- 10171367 TI - Design for dementia. PMID- 10171368 TI - Serving two masters: the interaction between Family and Medical Leave Acts and the ADA. AB - The complex interaction between family leave acts and the new Americans with Disabilities Act (ADA) is just coming to light as employers begin to analyze how to comply with both laws. Specifically, the ADA implicates the procedures set forth in most family leave acts for verifying an employee's need for a leave through mandatory medical examinations and doctor's certificates. Many employees who are entitled to a leave of absence under state law are defined as "disabled" under the ADA. The ADA protects these employees with disabilities by regulating medical examinations and inquiries, and protecting the confidentiality of information obtained in such inquiries. This article offers some practical guidance for employers in providing leaves of absence under state family leave acts, while verifying the need for leaves in compliance with the ADA. PMID- 10171369 TI - Ophthalmic day case surgery: the role of a dedicated day case unit. AB - A study was undertaken to examine all cases admitted to a new ophthalmic surgical day case unit during its first six months of operation. This paper describes the experience gained in establishing the unit, including operational management, and outlines the factors contributing to the unit's success. A quarter of the patients usually admitted as inpatients have been treated in the day unit, and day case surgery rarely results in unplanned inpatient admission, or subsequent readmission. Provided strict admission criteria are followed, the results show that this facility can accommodate a wide range of common ophthalmological procedures, and that general anaesthesia is compatible with day case management. PMID- 10171370 TI - Cataract extraction: patient characteristics and preferences. AB - This paper reports the results of a comparative study of inpatient and day case patients undergoing a cataract extraction with intraocular lens implant. An assessment was made of their home circumstances, and included questions about their health and hobbies before and after surgery. The results show that patients were generally optimistic about their capabilities after the operation, and that most were pleased to have been randomly allocated to their particular group. There were no statistically significant differences between day cases and inpatients, suggesting a possibility of choice for patients within available resources. PMID- 10171371 TI - Coping with CLIA, Part 7. Walking the straight and narrow on quality control. PMID- 10171372 TI - The application of quality filters in searching the clinical literature: some possible heuristics. AB - Experienced searchers can help their patrons find the "best" by employing any of several techniques which might filter search results. Using a sample search on Alzheimer's Disease, this article describes and illustrates the following five objective indicators which might be considered signs of quality: methodological rigor, document attributes, peer review, journal reputation, and filtering at input. Sample techniques and results are presented for six databases: MEDLINE, CINAHL, EMBASE, SAMM, CCML, and JWAT. Understanding of the patron's need and knowledge of the structure and contents of the database will determine when each should be applied to search results. PMID- 10171373 TI - Countdown to community care. Cold turkey. PMID- 10171374 TI - Outpatient surgery: helping to contain health care costs. PMID- 10171375 TI - Legal actions brought against AIDS discrimination. PMID- 10171376 TI - Mismanagement of dual disorders. PMID- 10171377 TI - Two collaborative organizations improve care delivery. PMID- 10171378 TI - Many general surgery work values increased. PMID- 10171379 TI - New England Deaconess Hospital reduces lengths of stay and enhances patient satisfaction in a tertiary-care environment. PMID- 10171381 TI - Americans with Disabilities Act compatible with Joint Commission standards. PMID- 10171380 TI - Analysis of underwriting factors for AAPCC (adjusted average per capita cost). AB - The adjusted average per capita cost (AAPCC) formula is used to determine payment to health maintenance organizations (HMOs) by Medicare. The four original underwriting factors (i.e., age, sex, institutional status, and welfare status) for the AAPCC were calibrated from the Current Medicare Surveys for 1974-76. Those factors have been updated by various actuarial adjustments. Revised calculations of the AAPCC underwriting factors are presented using survey data from the 1984 National Long-Term Care Survey and expenditure data from the Medicare Part A and Part B bill files. Also examined is the effect on the underwriting factors of chronic functional disability, defined as having one or more chronic limitations in activities of daily living. Comparison of alternative underwriting factors is conducted by simulating the dollar impact on payment to HMOs for select enrollee populations. PMID- 10171382 TI - Hazards of electrosurgery in laparoscopy overlooked. PMID- 10171383 TI - 'Fast track' center streamlines processes. PMID- 10171384 TI - 1993 prices for orthopedic implants up 5.7%. PMID- 10171385 TI - Stark introduces new anti-referral legislation. PMID- 10171386 TI - Laparoscopic surgery: emerging risks and liability concerns. PMID- 10171387 TI - Make sure your office layout is legal. PMID- 10171388 TI - Urologists: busier--and more prosperous--than ever. PMID- 10171389 TI - Defensive medicine is worthless--on two counts. PMID- 10171391 TI - Using critical limits to improve patient outcome. PMID- 10171390 TI - Dealing with substance abuse in the medical workplace. AB - Medical facilities are a potential breeding ground for the promotion of alcohol and drug abuse among employees, writes Edward E. Arshem, FACMGA. Thus, group practice managers must learn how to recognize and treat these problems because the ultimate loser if these things are ignored is the patient. PMID- 10171392 TI - Identifying and providing for today's long term care resident. AB - Nursing facility residents today are more diverse than ever before. This month's cover story identifies today's LTC residents, and how providers are responding to meet their changing needs. PMID- 10171393 TI - Rural bus service provides valuable community resource. PMID- 10171394 TI - Untraditional facilities extend care to young residents. PMID- 10171395 TI - How the Americans with Disabilities Act will affect physicians' offices. PMID- 10171396 TI - Risk-assessment interviewing for HIV. AB - Halting the spread of AIDS and HIV infection has become the top priority for clinicians and public health officials. The majority of HIV infection transmission occurs as a result of specific behaviors. A thorough discussion of the individual history is necessary to learn about a patient's lifestyle and formulate an HIV risk assessment. This article examines the two principal behaviors responsible for HIV transmission--injection drug use and high-risk sexual activity--and discusses in detail how to conduct risk-assessment interviews. PMID- 10171397 TI - Bioethics and anti-bioethics in light of Nazi medicine: what must we remember? AB - Only recently have historians explored in depth the role of the medical profession in Nazi Germany. Several recent works reveal that physicians joined the Nazi party in disproportionate numbers and lent both their efforts and their authority to Nazi eugenic and racist programs. While the crimes of the physician Mengele and a few others are well known, recent research points to a much broader involvement by the profession, even in its everyday clinical work. Analogous activities existed in the German legal and industrial communities; disruption of the medical ethic thus sprang from the broader social contexts of Nazi Germany. The new United States Holocaust Memorial Museum, now opening on the Mall in Washington, D.C., will have an opportunity to educate the public about both the great crimes at Auschwitz and other camps, and the gradual but thorough degradation of ethics in the German medical profession. From this presentation, contemporary bioethics can ponder the proper use of the Nazi analogy in bioethical debate. PMID- 10171398 TI - Access to surgical care in the inner cities: one provider's perspective. PMID- 10171399 TI - Cultivating common ground. Women with disabilities. PMID- 10171400 TI - Uncivil disobedience: the troublesome cripples of Orlando. PMID- 10171401 TI - The inside story. PMID- 10171402 TI - Countdown to community care. Three for all. PMID- 10171403 TI - Ophthalmology. AB - Three main conditions cause blindness and loss of sight, affecting significant numbers of-mainly elderly-patients. Advances in technology mean that many may now be treated as day cases though this trend-and achievement of treatment and prevention targets like those set in the rest of Europe and the USA-is not yet widespread. PMID- 10171404 TI - National Health Laboratories settlement raises unresolved legal issues. AB - The government's prosecution of National Health Laboratories indicates that clinical laboratories may be held legally accountable for billing for unnecessary services when the lack of medical necessity is known. A laboratory's legal risk increases significantly when the laboratory induces physicians to order unnecessary tests. Clinical laboratories must scrutinize their marketing activities--particularly those related to custom profiles--to ensure they do not mislead physicians into ordering tests that are not required. PMID- 10171405 TI - Action steps for effectively managing ambulatory surgery under outpatient prospective payment. AB - This article reviewed common problems faced by managers in effectively using resources in ambulatory surgery. The article also recommended action steps for programs to consider to gain better control over the resources used in surgery. As reimbursement for outpatient surgery shifts to more resource use-based approaches, the importance of examining patterns of surgery and identifying opportunities for more efficient use of resources will grow in order to maintain financial and clinical performance. PMID- 10171406 TI - Ambulatory care prospective payment: the effect on clinical practice patterns. AB - Prospective payment for ambulatory surgical services offers the opportunity to achieve a number of operational efficiencies in the health care delivery system by incorporating incentives for both physicians and facilities to reorganize care. The risk associated with this opportunity is the creation of additional bureaucratic infrastructure. PMID- 10171407 TI - Utilization and costs of substance abuse services within The HMO Group. AB - This paper describes the organizational characteristics, benefit coverage, referral pathways, utilization rates, and costs of substance abuse services within 17 HMOs belonging to The HMO Group in 1990. All 17 health plans responded to the questionnaire. Responses to the survey reflected the complexity of HMO substance abuse services. Overall, The HMO Group members provided substance abuse service coverage partly dependent upon state mandates, employer group priorities, and local competitive benefit structures. The HMOs reported that service utilization rates and the productivity of their substance abuse providers were critical information needs currently not fully reported. Overall, the survey responses reflected the need for improvement of clinical information systems and expansion of the aggregate substance abuse database. PMID- 10171408 TI - Europe AIMs (Advanced Informatics in Medicine) at telemedicine. PMID- 10171409 TI - Volume and outcome in hospital care: evidence, explanations and implications. AB - The relationship between the volume of work undertaken in a hospital and the outcome of care has assumed increasing importance in recent years. A review of the literature reveals that most studies have been carried out in the USA and have largely been confined to six specific areas of health care. There is evidence that better outcomes are obtained at higher volumes for several surgical operations, cardiac catheterisation and care of the severely injured. As yet there is no clear association for coronary, neo-natal and burn care. There are two competing hypotheses to explain any association -- 'practice-makes-perfect' and 'selective referral'. These are discussed and implications for the future provision of hospital services considered. PMID- 10171410 TI - An analysis of the Americans with Disabilities Act of 1990. AB - This paper presents the basic philosophies that have influenced the development of social policy affecting the disabled. These philosophies include utilitarianism, humanitarianism, and human rights. It is suggested that the Americans With Disabilities Act (ADA) of 1990 is grounded in the human rights philosophy. Under the Act, disabled individuals are treated as an oppressed group who have been denied basic constitutional rights. The Americans With Disabilities Act is considered to be the "emancipation proclamation for the disabled." PMID- 10171411 TI - Nondiscrimination on the basis of disability by public accommodations and in commercial facilities; Americans With Disabilities Act accessibility guidelines for buildings and facilities--Department of Justice. Final rule: technical amendment. AB - This document contains technical amendments to the regulations on nondiscrimination on the basis of disability by public accommodations and in commercial facilities, which implement title III of the Americans with Disabilities Act (ADA) and to appendix A to those regulations. This final rule makes some technical corrections to the regulations and amends the regulations to reference an Office and Management and Budget control number in compliance with the Paperwork Reduction Act of 1980, as amended. PMID- 10171412 TI - Through the keyhole. AB - Surgically speaking, history is likely to dub the 1990s as 'the laparoscopic years', as changes in surgical practice cause one of the biggest revolutions in our hospitals since the arrival of general anaesthesia. As a result, surgeons are having to re-examine their skills and training, while managers need to update their infrastructure for budgets and funding. Both purchasers and providers of surgical services need to ensure that they are not tied down to 'historic' contracts. PMID- 10171413 TI - Needle exchange programs and social policy. AB - The specter of AIDS will continue to dominate the concerns of clinicians, policy makers, and social scientists into the next century. In addition to being a biological issue, HIV disease is a political issue. As a result of this, interest groups have mobilized to restrict certain interventions aimed at stopping the spread of HIV. Among those restricted interventions is the exchange of sterile needles and syringes for "dirty" needles and syringes with injection drug users (IDUs). Increasing the availability of clean equipment by removing the laws restricting their availability, and/or by funding needle exchange programs, would appear to be a much needed and rational public health policy. However, needle exchange programs have been viewed as fostering drug addiction or enabling drug addicts, thus marginalizing it as an early stage of treatment for addicts and as a demonstrated public health intervention. There is no empirical evidence to support this conclusion. In the absence of better knowledge about how to prevent the use of illicit injection drugs and how to effectively treat IDUs, we believe that needle exchange programs (NEPs) need to be implemented for several key reasons. First, they can help slow the spread of HIV infection. Second, they can be cost-effective when compared to the higher health care costs that result without needle exchange programs. Third, they can act as a precursor to treatment, or recovery, for addicts. PMID- 10171414 TI - Court OKs economic credentialing. Rosenblum v. Tallahassee Memorial Regional Medical Center. PMID- 10171415 TI - Controlling characteristics of group insureds: risk rating. AB - Employers seek to manage risk in their group health and life insurance plans through wellness programs and certain hiring practices. In both cases, the Americans with Disabilities Act may ultimately affect the use of these forms of risk rating on the grounds that they are discriminatory. PMID- 10171416 TI - How 'top performers' manage materials in ambulatory surgery. PMID- 10171417 TI - Standardizing implants: how to break the barrier. PMID- 10171418 TI - Clinicians: new surgical techniques require new buying skills. PMID- 10171419 TI - Outpatient payment reform: hospitals brace for an uncertain future. PMID- 10171420 TI - CLIA '88 and purchasing for the lab: operating, labor costs add up. PMID- 10171421 TI - Buying lab equipment: comparative analysis reveals operating costs. PMID- 10171422 TI - Stats ... ambulatory surgery centers. PMID- 10171423 TI - Matching patient needs, price, quality, helps to cut implant costs. PMID- 10171424 TI - Reusables may slow rising tide of laparoscopic surgery costs. PMID- 10171425 TI - Ensuring that preoperative test results are available at the time of surgery--a quality improvement project at Strong Memorial Hospital. AB - PROJECT: Improving the hospital's record for having preoperative electrocardiogram interpretations and laboratory results available for surgeons at the time of surgery. Principals: Representatives of management and supervisory staff from the Admitting Office, Laboratory Medicine, Medical Records, Heart Station, Surgical Support Services, Surgical Nursing, as well as representatives of the physician staff and quality assurance staff. Process Improvement Method: Modified Juran model. Timeline: Begun: Fall 1989. RESULTS reported here: September 1989-May 1991. KEY FINDINGS: Because of problems with the procedures for ordering preoperative tests, performing and interpreting the tests, and transmitting and filing results, 36 percent of inpatient EKGs and of inpatient laboratory reports, 8 percent of same-day admission EKGs, and 19 percent of same day admission laboratory reports were not available at the time of surgery. RESULTS: At the time of this report, 91 percent of the tests ordered were in the medical record when the patient reached the operating room. Data indicate that once further improvements recommended by the team are implemented by other QI teams and committees, 95 percent of EKGs and lab test results will be in the medical record by the time of surgery. PMID- 10171426 TI - The Oregon health care proposal and the Americans with Disabilities Act. PMID- 10171427 TI - Psychiatry of old age. AB - Some 25% of those over 80 suffer from dementia -- just one of the mental health problems that affect elderly people. Their care is compounded by physical difficulties and ill health and, often, by the lack of relatives to assist in their care. PMID- 10171428 TI - Alzheimer's disease: the burden of the illness in England. AB - This paper reports the findings of a study that estimated the socioeconomic costs, both direct and indirect, of Alzheimer's Disease in England by using a 'burden of illness' framework. The burden of illness was calculated for all main areas of provision: hospital and residential care, general practice, day care, home care and informal care, including the calculations of costs by age-group and by service provider. The results show that the cost of this care amounted to around 1,039m pounds in 1990/91, establishing that spending associated with Alzheimer's Disease is a major area of care expenditure. Such burden of illness data should help those involved with health care decision-making, planning and priority setting, especially for health districts and social services establishing base plans for care in the community. PMID- 10171429 TI - A comparison of diagnosis related groups and ambulatory visit groups in day-case surgery. AB - Case-mix measurement is a basic requirement of clinical and resource management systems within health care organisations, and offers a potentially useful tool for the setting and monitoring of contracts. Ambulatory care has particular problems in the construction of appropriate case-mix measures, and day-case surgery provides an opportunity to test two existing measures, one inpatient (Diagnostic Related Groups) and one ambulatory (Ambulatory Visit Groups). These grouping systems were applies to the same data to compare the case-mix patterns that they produce. The findings show that the ambulatory visit group appear to have advantages over the diagnostic group with respect to their underlying assumptions and labelling of the groups; in particular, they assign greater weight to procedures. However, diagnostic groups are more developed, easier to use, more familiar and allow direct comparisons with inpatient care. Nevertheless, a proper evaluation of these issues requires further data collection and analysis, together with a fundamental examination of the uses of ambulatory case-mix. PMID- 10171430 TI - A measure of perceived burden among caregivers. AB - This report describes an easily administered scale for measuring perceived burden among caregivers of family members with dementia. During home interviews conducted in 1991, 82 caregivers rated their family member with dementia on several items related to functional ability, the type of care provided, and associated stress. The resulting measure of perceived burden, based on 15 internally consistent items (alpha = 0.87), is significantly correlated with depressive symptomatology (r = 0.38, p = 0.0004). This measure is useful in assessing perceived stress associated with specific caregiving responsibilities. It can be used, along with other measures of patient functional status, to assess overall caregiver burden and to target intervention strategies. PMID- 10171431 TI - Power pack. AB - Disabled people need unbiased information on equipment. But who controls this information, and who pays for it? Ginny Jenkins unravels the issues. PMID- 10171432 TI - Consumer reaction to hospital mortality data respecting heart surgery. PMID- 10171433 TI - Myth and reality in general surgery. PMID- 10171434 TI - The NHS and the law. Bit of a quagmire. PMID- 10171435 TI - Over the obstacles. AB - Although recognised as a good thing, day surgery still has barriers to overcome if it is to become a first-rate service, argue Caron Grainger and Rod Griffiths. PMID- 10171436 TI - Hurricane Iniki--providing hospital pharmacy services. PMID- 10171437 TI - Coping with CLIA, Part 9. CLIA's quality assurance: a study in total devotion. PMID- 10171438 TI - Tuberculosis alert: an old killer returns. AB - Health officials predicted tuberculosis would be completely eradicated in the U.S. by the year 2010. They were wrong. Here's how to gear up the lab for its return. PMID- 10171439 TI - Bedside testing, Part 2. Bedside testing: beyond glucose. PMID- 10171440 TI - Managing risk under CLIA (Clinical Laboratory Improvement Amendments). AB - By now, physician groups that perform any laboratory testing should have either registered under the Clinical Laboratory Improvement Amendments (CLIA) or applied for a certificate of waiver. Rebecca Burke, in her article, discusses some of the risks associated with CLIA that group practices need to be aware of and how, in some cases, those risks can be reduced. PMID- 10171441 TI - Looking at bans in a different light. Efforts to end self-referrals are more turf battles than altruistic crusades. PMID- 10171442 TI - AARC clinical practice guideline. In-vitro pH and blood gas analysis and hemoximetry. American Association for Respiratory Care. PMID- 10171443 TI - Ambulatory care: growing pains? PMID- 10171444 TI - Alzheimer's activities. Residents set their own pace. PMID- 10171445 TI - Regulating Alzheimer's special care units. PMID- 10171446 TI - Organizing and financing PRS by a health insurance fund. PMID- 10171447 TI - The Swedish model of social alarm systems for the care of the elderly. PMID- 10171448 TI - Scoring guidelines addressing smoking policy for the MHM, (Accreditation Manual for Mental Health, Chemical Dependency, and Mental Retardation/Developmental Disabilities Services). Volume II. Joint Commission on Accreditation of Healthcare Organizations. PMID- 10171449 TI - Workplace drug abuse policy. AB - An estimated 70 percent of illicit drug users are in the workforce. This paper studies workplace policies relating to drug abuse treatment and testing in a labor market with asymmetric information about worker proclivities to abuse drugs and to incur costs of workplace accidents. Drug abuse has a moral hazard component related to worker choice of treatment or other deterrent activities, and a selection component related to drug testing. We characterize the type and frequency of workers treated and tested in labor market equilibrium. Labor market incentives will generally lead to too little treatment and too much testing. PMID- 10171450 TI - Regulation in review. Payment reform likely to continue for clinical laboratory services. AB - Payment for clinical laboratory services has been at the forefront of Medicare payment reform. Significant changes are likely to continue. These changes may eliminate the well-established practice of selling laboratory services to physicians at discount prices and may require laboratories to compete for the opportunity to participate in managed-care arrangements that result from federal health-care reform. Laboratories should restructure, as necessary, to ensure that they can provide testing at the lowest possible cost and to otherwise prepare for health policy changes. PMID- 10171451 TI - Breast implants and the FDA: past, present and future. PMID- 10171452 TI - Form for reporting serious adverse events and product problems with human drug and biological products and devices; availability--FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing the availability of a new form for reporting adverse events and product problems with human drug products, biologic products, medical devices (including in-vitro diagnostics), special nutritional products (dietary supplements, medical foods, infant formulas), and other products regulated by FDA. There are two versions of the form. One version of the form (FDA Form 3500) is available for use by health professionals for voluntary reporting; the other version of the form (FDA Form 3500A) is to be used by user facilities, distributors, and manufacturers for reporting that is required by statute or FDA regulations. The new form will simplify and consolidate the reporting of adverse events and product problems and will enhance agency-wide consistency in the collection of postmarketing data. This notice also responds to written comments the agency received on proposed versions of this form. Copies of both versions of the new form appear at the end of this document. PMID- 10171453 TI - Adaptive computer education--more than "high-tech". AB - Advances in technology have greatly broadened the range of occupational opportunities available to persons with disabilities. While technical devices help in making participation in computer-based work functions possible, a variety of strategies are required to help individuals with special needs prepare for, acquire, and maintain employment. The experience of the Centre for Adaptive Computer Education, a vocational training programme for adults with disabilities, highlights several strategies that have proven effective in helping persons with disabilities to access work training and employment. Techniques used to embrace a number of structural and behavioural approaches to training, including extended training time, individualized curricula, individual tutoring, stress management training, behaviour management, supportive counselling, and promotion in the workplace. PMID- 10171454 TI - Managing AIDS in the workplace. AB - Because of the AIDS epidemic and the protections afforded individuals with AIDS under the Americans with Disabilities Act (ADA), employers are well advised to ensure compliance under applicable law to reduce exposure to employee claims of discrimination and to efficiently manage workplace issues associated with AIDS. Employers should implement AIDS policies and programs designed to educate their workforce to reduce the spread of AIDS and to clear up any misunderstandings about the disease which could wreak havoc in the workplace. This article summarizes suggested action steps for employers and outside resources to consult for guidance. PMID- 10171455 TI - Benefit plan limitations after the Americans with Disabilities Act. AB - Virtually all company welfare benefit plans contain one or more disability specific benefit limitations. The Americans with Disabilities Act casts doubt on the lawfulness of these limitations. The legislative history of the ADA is confusing, and the EEOC's failure to offer meaningful guidance on this issue further clouds the situation. Based on the Supreme Court's prior interpretation of language similar to that used in the ADA, we believe all disability-specific limitations adopted prior to the ADA are entitled to a "safe harbor"; disability specific limitations adopted after Congress passed the ADA are still lawful unless the limitations are intentionally used to discriminate in a nonbenefit aspect of employment. PMID- 10171456 TI - Measuring opportunities to expand ambulatory surgery in Canada. AB - Enhancement of comparative ambulatory care information reporting systems will expand the ability of health care managers to assess accurately the opportunities and relative benefits and costs of substituting ambulatory care for traditional inpatient services without jeopardizing the five basic principles of Canada's health care system: universality, accessibility, portability, comprehensiveness, and public administration. In the long run, this will improve Canada's ability to provide high-quality and cost-effective health care within the constrained resources now available. PMID- 10171457 TI - New initiatives in ambulatory care funding in Alberta. PMID- 10171458 TI - Funding in-hospital same-day surgery in Canada. AB - The significant advantage of replacing global (i.e., cost-based) ambulatory funding with the same dollar value of case mix (i.e., input-based) ambulatory funding is that the fundamental basis for funding has been altered. First of all, it is widely believed that case mix-based funding establishes even more compelling incentives for hospitals to control resource utilization and costs without reducing service volumes than global systems. Case mix also represents a more precise policy instrument for ministries of health because incentives (e.g., different funding rates for various types of day surgery) can easily be incorporated to direct the composition of services rather than merely limit total hospital day surgery expenditures, as is currently done. Using the hybrid global/case mix day surgery funding system described above, funding policies can be designed to control both total cost and case mix composition while at the same time introducing incentives toward increasing ambulatory services. Although historical funding inequities remain unrectified, further inequities as ambulatory surgery volumes or case mixes change can be avoided. PMID- 10171459 TI - Hospitals seek bigger cut of outpatient surgeries. PMID- 10171460 TI - Liability concerns about implanted material may hurt device availability. PMID- 10171461 TI - Glucose testing of diabetics can prevent chronic complications. PMID- 10171462 TI - Streamlined waiver applications will bolster state participation. PMID- 10171463 TI - The Americans with Disabilities Act: the impact on radiologic technologists and managers. AB - On July 26, 1990, President Bush signed the Americans With Disabilities Act (ADA) which prohibits discrimination on the basis of disability. The act is being cited as one of the most extensive changes in personnel law since the Civil Rights Act of 1964. The law will impact hiring, promotion, and retention practices in the U.S. work force. Popular press reports have focused on the hiring of disabled workers, but the author argues that retaining healthy workers who become disabled will be the major impact for radiology managers. This article discusses the ADA with a specific emphasis on the retention of disabled radiologic technologists. PMID- 10171464 TI - Applying the Americans with Disabilities Act to radiology. AB - In this second article on the Americans With Disabilities Act (ADA), Mr. Aribisala outlines the essentials of the law and then describes how his department handled the case of a radiologic technologist who was diagnosed with Lupus and fibromyalgia. For radiology administrators who want to learn about key court rulings that have shaped the ADA, the article includes an abridged summary of the legal precedence for Title I of the act. PMID- 10171465 TI - Comparing surgical efficiency in independent practice association HMOS and traditional insurance programs. AB - This study examines the effect of Independent Practice Association (IPA) HMO membership on hospital total charges, ancillary charges and length of stay (LOS) for surgical patients. Intrahospital comparisons of IPA and traditional insurance patients are made after adjusting for surgical procedure, admission severity of illness, age, sex and year of admission. Our multiple regression model indicates that IPA patients undergoing 12 frequently occurring surgical procedures have lower resource use. Eight (80%) of the 10 study hospitals exhibit a negative IPA beta coefficient for total charges, ancillary charges and LOS. Five (50%) hospitals have statistically significant (p < 0.05) negative coefficients for total charges, while one (10%) hospital has a significant positive coefficient. IPA patients exhibit adjusted total charges that are 6% lower than traditional insurance, ancillary charges that are 4.3% lower, and LOS that is 10% shorter. PMID- 10171466 TI - A physician incentive compensation program in a staff model HMO. AB - A physician incentive program was developed at an established staff model HMO. Differential compensation, which augments a salary scale that reflects years of experience and service, is based on productivity and utilization of laboratory and x-ray services. Productivity is objectively measured on a relative-value scale for time utilized for a range of types of visits. Laboratory and x-ray utilization is measured against recent historical practice patterns. A case mix adjustment stratifies for age in the adult patient encounters. PMID- 10171468 TI - Limits on AIDS coverage are challenged under ADA. PMID- 10171469 TI - Hospital care and medical services in non-VA facilities--VA. Final rule and regulation. AB - Department of Veterans Affairs (VA) is amending regulations which pertain to the authorization for contract non-VA hospital care and medical services for veterans. The Veterans Health Care Act of 1992 provides that veterans with a total disability permanent in nature from a service-connected disability may be authorized contract non-VA hospital care and medical services. Contract care may be authorized only if the VA facility is not capable of furnishing the care required, or is not capable of furnishing economical care or services because of geographical inaccessibility. This amendment will make the regulations consistent with the law. PMID- 10171467 TI - Outpatient cardiac catheterization: its role in managed care. AB - Cardiac catheterization, as developed by Dr. Sones, has revolutionized the practice of ischemic heart disease. I personally appreciate his support on behalf of the development of outpatient cardiac catheterization, as he counseled me over the years in regards to this methodology. I believe its appropriate use, both in certified ambulatory facilities as well as in expanded hospital programs, would lower the death rate in those who experience sudden death as well as myocardial infarction. Cardiovascular administrators must now position themselves in the outpatient area in order to coordinate not only outpatient catheterization, but also noninvasive assessment. They also must provide support for managed care, which utilizes low-cost programs such as: outpatient cardiac rehabilitation for drug selection, assessment of ischemia, appropriate management (rather than relying on sudden death and myocardial infarction as a satisfactory method of identifying patients with heart disease). PMID- 10171470 TI - Freestanding ambulatory surgery: cost-containment winner? AB - In many states, freestanding, ambulatory surgery centers (ASCs) are being permitted to provide overnight, postoperative recovery and observation services. As a result, ASCs are now able to perform surgical procedures that were once the exclusive province of hospital-based outpatient surgery departments. As an analysis of data gathered in Florida and North Carolina illustrates, freestanding ASCs usually have lower charges than their hospital-based counterparts. This finding suggests that hospitals will have to take steps to control their ambulatory surgery costs if they want to compete successfully in the race for ambulatory surgery dollars. PMID- 10171471 TI - Physician office laboratory regulation: proven strategies to meet the demands of the CLIA (Clinical Laboratory Improvement Amendments). AB - This article outlines the requirements of the Clinical Laboratory Improvement Amendments, as implemented by regulations that became effective in late 1992. Background information about the statute and a description of the laboratory director's role are provided, and proven strategies for meeting the regulations' quality assurance requirements are discussed in detail. PMID- 10171472 TI - The hospital/medical staff relationship: does Title I of the Americans with Disabilities Act apply? PMID- 10171473 TI - High-risk preterm infants at 3 years of age: parental response to the presence of developmental problems. AB - In this article we describe developmental status at 3 years and family utilization of early intervention services of 24 children who were born prematurely and weighed less than 1,500 g or who required mechanical ventilation at birth. Findings indicated (a) a low rate of major disabling conditions; (b) a high rate of developmental, mild cognitive, and behavioral concerns; and (c) a lack of family follow-through on referrals for early intervention services for potentially responsive children, even though the concerns put the children at risk for school difficulties. PMID- 10171474 TI - Caregivers of children with disabilities: a comparison of those managing "OK" and those needing more help. AB - A survey was mailed to caregivers of children with disabilities to ascertain how they were managing caregiving. Caregivers reporting they were managing "OK" were compared to those who reported they needed more help or could not manage much longer ("not OK"). Results showed the not OK group of caregivers had children who were more severely impaired and functionally dependent. Their mothers were in poorer physical and mental health, had greater demands placed on their time and finances, and received less emotional support from friends and family. Special programs provided some assistance but not enough to meet their needs. PMID- 10171475 TI - Disabled newborn infants and the quality of life. PMID- 10171476 TI - Tairawhiti Board's visiting neurodevelopmental therapy service. PMID- 10171477 TI - Perspectives. Good-bye, Hawaii: changes ahead in corporate-backed CME. PMID- 10171479 TI - Labor pains. Getting a grip on the Americans With Disabilities Act. AB - This month the Americans With Disabilities Act goes into final effect, requiring employers with 15 or more employees to comply with nondiscriminatory policies for employment accommodation and hiring. How can home care agencies or hospices defend or challenge a claim? PMID- 10171478 TI - Reality ignored: health reform and people with disabilities. AB - The current health system reform debate largely has omitted the impact of different proposals on people with disabilities. Yet this population has a profound impact on the health care system and vice versa. The perspective of people with disabilities is different from that of other consumers and should be included in any health reform plan. PMID- 10171480 TI - 20% of Medicaid's hospital-care costs traced to substance abuse. PMID- 10171481 TI - The exceptional environment--preparing for dementia care. PMID- 10171483 TI - Glucose monitoring--from fingersticks to Star Trek. PMID- 10171482 TI - Economics of outreach testing in the hospital laboratory: Part I. AB - Hospital laboratories are faced with the dilemma of needing to maintain a baseline of testing and staffing to meet patient and physician needs while facing personnel shortages, declining reimbursement, and excess personnel and equipment capacity. Because cost cannot be reduced past some basic minimum, laboratories must find ways to increase test volumes to use the excess capacity intrinsic in the system. One solution to this dilemma is to increase the number of outpatient tests performed by developing an outreach program. If carefully managed, this solution can improve productivity, allow laboratories to operate with a lower inpatient reimbursement infrastructure, and begin to balance the uneven economic equation faced by many laboratories. This two-part article presents three case studies that illustrate decision points and results in developing a hospital outreach program. In Part I, a case study for a 300-bed hospital in a rural community is presented. PMID- 10171484 TI - Building better backs. Back safety programs and the roles and responsibilities of employers and employees. AB - Back injuries are among the most common and expensive problems in the work setting today. Not only that, the healthcare setting is one of high risk for the possibility of back problems. How do employers and employees avoid costly back injuries? This article seeks to answer this question. PMID- 10171485 TI - Nursing administrators' responses to physically, mentally, and substance-impaired nurses. AB - Impaired nurses--whether the impairment is physical, mental, or substance use- can be a potential hazard in a healthcare setting, both to themselves and to patients. It is therefore imperative that nursing administrators identify such nurses in order to take the proper actions. But just how do administrators react toward nurses with impairments? The authors of this article present the results of a survey in an attempt to answer this question. PMID- 10171486 TI - Does you don't have access? PMID- 10171487 TI - CLR (clinical laboratory reference) 1993-94. Index of tests, equipment, services; product information; reference laboratories for rare tests; directory of diagnostic marketers. PMID- 10171488 TI - Coping with CLIA, Part 11. Proving performance under CLIA '88. PMID- 10171489 TI - Medicare hospital outpatient services and costs: implications for prospective payment. AB - Medicare expenditures of hospital outpatient department (HOPD) services are growing rapidly, prompting congressional interest in a prospective payment system. In this article, the authors identify frequently provided services and examine service volume and charges in the HOPD. Relatively few services drive Medicare HOPD spending, and volume is dominated by visits, imaging and laboratory tests, whereas surgery accounts for a large proportion of charges. Hospital-level variations in charges, costs, case mix, and outliers are also explored. There is substantial variation in charges and costs across hospital types. However, after case-mix adjustment, all hospital types have average costs within 6 percent of the national average. PMID- 10171490 TI - Ambulatory surgery. PMID- 10171491 TI - Barely auditable? PMID- 10171492 TI - Now you're talking. PMID- 10171493 TI - Waits and measures. PMID- 10171494 TI - Managing HIV-infected employees in the OR. PMID- 10171496 TI - Reducing pathology test misuse. AB - Our laboratory serves a 450-bed acute care hospital in the rapidly growing Gold Coast region. The problem facing the department comprised an almost 10 per cent yearly increase in patient numbers in the face of budgetary constraints and pressure to increase efficiency. In January and February 1992 a vigorous effort was made to reduce pathology test numbers without compromising quality of patient care. The approach adopted involved targeting 'unnecessary' tests, defined as those investigations that would not affect a clinician's management of the patient. A team effort by laboratory scientific staff and heads of clinical departments was aimed at scrutinizing the ordering patterns of junior medical staff, who generate most of the test requests. The result was a 'test per patient' figure of 8.2 for both months, calculated as the number of tests on each request form received. In comparison, for January and February of the preceding four years, 1988 to 1991, the number of tests per patient fluctuated between 9.9 and 11.8. Patterns of unnecessary ordering that emerged included duplicate ordering of identical tests due to poor communication between house-staff, too frequent repeats of tests (for example, daily liver function tests), crossmatch where low transfusion likelihood would make group-and-hold appropriate, tests generated by nursing staff, and numerous others where the result would not affect management (or indeed even be looked at!). The nearly 20 per cent drop in tests does not include those instances where all tests on a request form were disallowed and the encounter therefore not included as a 'patient' statistic.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171495 TI - What managers should know about the ADA. PMID- 10171497 TI - A spreadsheet program measuring laboratory productivity in several ways: an application of College of American Pathology scores and other data to assess the overall economics of clinical laboratories. AB - A spreadsheet has been designed that measures the productivity of hospital or other clinical laboratories using several methods, one of which, used as a yardstick, is based on College of American Pathology (CAP) workload test scores with some departures from CAP conventions. In this method the CAP-assessed proportion of a laboratory's time utilised in performing pathology or other tests is compared with the time allocated to non-testing departmental activities as a group. A premise in the approach is that variation in the time allocated to these latter activities, in addition to variation in the efficiency of testing, also contributes significantly to the productivity and economics of hospital laboratories. The workload measure of productivity used in the study is referred to as total staff-paid-productivity (TSPP)--allied to paid-productivity of the CAP Manual 1991--and it is suggested that it be used together with several other result parameters to assess laboratories. However, there are two differences from CAP in the TSPP parameter: the salaries and hours of all staff whether medical, technical or scientific are included; and the professional component (time necessary for test interpretation) is also included where applicable. Necessary data include the goods and services costs, the total test-generated income, the total number of full-time staff equivalents and their hours in each unit or work group, the numbers of tests and raw CAP scores and in addition, an estimation of the professional/interpretive component of each test until the generation of a report. The method is illustrated with examples from six different departments with total staff-paid-productivities covering a wide range beyond the typical values of 65 per cent to 75 per cent. When the data for the laboratories are compared, it is observed that the various admixtures of non-testing activities are a stronger influence on differences in total staff-paid-productivity than the interpretative components of tests, although the latter vary markedly from discipline to discipline. When the interpretative components are included in workload measurements, it enables the productivity of different laboratories to be compared across disciplines. It is suggested that for laboratories to generate ongoing productivity they should be staffed at a rate that produces approximately a maximum total staff-paid-productivity of about 75 per cent. PMID- 10171498 TI - Medicare, Medicaid and CLIA programs; regulations implementing the Clinical Laboratory Improvement Amendments of 1988--HCFA. Final rule; correction. AB - On January 19, 1993, we updated the rules originally published on February 28, 1992, concerning requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA). We have identified a number of typographical errors and we are correcting them in this notice. We also add regulatory text that was inadvertently omitted on January 19, 1993 relating to quality control requirements for cytology testing and qualifications for general supervision. PMID- 10171499 TI - Ergonomics and back injury. PMID- 10171500 TI - Capping comp costs. Back injuries send 80% of us for medical help. PMID- 10171501 TI - Access all areas. PMID- 10171503 TI - PCR (polymerase chain reaction) and the future of molecular testing. AB - Molecular testing is no longer exotic, distant, or complex. It's moving into your lab and revolutionizing the rapid diagnosis of pathogenic organisms as well as your role as a laboratorian. PMID- 10171502 TI - Incidence and type of disability insurance benefits, 1958-90. PMID- 10171504 TI - Making sense of the revised CPT codes. AB - This year's CPT code revisions were supposed to eliminate problems resulting from codes not keeping pace with lab technology, but errors in the revisions have provided new thorns equally capable of drawing blood. Here's how not to get stuck. PMID- 10171505 TI - Report on waiting lists sparks debate. PMID- 10171507 TI - ADA (Americans with Disabilities Act) guidance issued for employers. PMID- 10171506 TI - Flight nurse interpretations of chest radiographs. AB - The authors conducted a study to determine whether basic instruction in reading chest radiographs could enable flight nurses to interpret radiographs accurately. Flight nurses were taught 10 trauma-related chest roentgenographic patterns. The chest radiographs of 40 transported trauma patients were chosen randomly over a 14-month period for interpretation by a flight nurse and a referring physician. Flight nurses correctly identified 47 out of 55 patterns (85%). Referring physicians correctly identified 37 out of 55 (67%). Flight nurses also correctly identified 13 patterns that the referring physicians missed. The results indicate that emergency radiologists can advance and improve the radiological aspects of emergent patient care by providing flight nurses with minimal training in interpreting radiographs. When a flight nurse and a physician in an outlying area -where trauma is less commonly encountered--work as a team, more accurate and earlier diagnoses can be made, and therapy can be instituted earlier. PMID- 10171508 TI - Medical devices; illustrative and designated lists for device tracking--FDA. Final rule and request for comments. AB - The Food and Drug Administration (FDA) is amending the medical device tracking regulations to add the temporo-mandibular joint prostheses to the illustrative list of devices and the penile inflatable implant to the list of devices designated for tracking. These devices are being added to the illustrative and designated device lists based on the significance of the risk to health posed by their use. This action requires manufacturers to track these devices after distribution so that they can be located in the event of a recall or patient notification action. FDA requests comments on these changes. Elsewhere in this issue of the Federal Register, the agency is announcing notification of the change of status of the device tracking regulations and is suspending the effective date of the regulations until August 29, 1993. PMID- 10171509 TI - Impact of the Americans with Disabilities Act on employee plans. PMID- 10171510 TI - Epidural, intrathecal, and patient-controlled analgesic use in a university medical center. AB - OBJECTIVE: To determine the number and profile of surgical patients receiving epidural, intrathecal, and patient-controlled analgesia. DESIGN: Two-month audit of epidural, intrathecal, and patient-controlled analgesia. SETTING: A 300-bed, tertiary care, university medical center. PATIENTS: All patients undergoing surgery and receiving epidural, intrathecal, or patient-controlled analgesia. RESULTS: Of 1123 operations performed during the two-month audit, 185 patients (16 percent) received one of the three forms of analgesia studied. Sixty-three percent of the 185 patients received patient-controlled analgesia and 33 percent received epidural injections for pain control. The most common types of surgery associated with the use of these specialized pain-control techniques were obstetric/gynecologic, orthopedic, general, urologic, and cardiothoracic. CONCLUSIONS: Specialized forms of analgesia are becoming increasingly common. Our audit defined the number of patients receiving such therapies according to type of surgery. Collection of such information by other institutions should allow for targeted evaluations of cost-effectiveness (e.g., drug use evaluations). PMID- 10171511 TI - Transfusion medicine and surgical practice. AB - When contemplating the transfusion of blood products (that is, red cells, platelets, and plasma proteins), the surgeon must always analyze the patient's clinical condition and not be influenced solely by laboratory tests. Risks associated with allogeneic blood products must be weighed, and alternatives such as autologous blood products and crystalloid and colloid solutions should be considered. Autologous blood can be collected weeks or months prior to elective surgery, immediately prior to surgery, intraoperatively, or postoperatively. The important things to remember about transfusion therapy are that: (a) the patient's clinical condition should dictate what blood product to transfuse and in what quantity; (b) temperature is a very important factor in transfusion therapy; and (c) washed filtered shed blood is safer than nonwashed filtered shed blood, although nonwashed filtered shed blood can be reinfused safely but in a smaller quantity. PMID- 10171512 TI - Medicare volume performance standards and Part B spending. PMID- 10171513 TI - Surgery: mechanical or healing art? PMID- 10171514 TI - Statement on laparoscopic and thoracoscopic procedures. American College of Surgeons. PMID- 10171515 TI - MDs, administrators team up to standardize, cut ortho implant costs. PMID- 10171516 TI - Possible reforms for financing long-term care. PMID- 10171517 TI - The role of economic evaluation in setting priorities for elective surgery. AB - Problems with waiting lists have long affected the National Health Service. The priority given by clinicians to the elective surgery conditions usually found on waiting lists is low, but the publicity surrounding the waiting lists ensures that the priority accorded elective surgery in the political arena is much higher. Waiting list initiatives have provided additional resources for the purpose of reducing the number of patients waiting for elective surgery. It is suggested that economic evaluation should form one of a package of tools used by those setting priorities within elective surgery, but that the evidence provided by previously conducted economic evaluations of elective surgery is not of sufficient quality for purchasing authorities to use as a basis for priority setting. PMID- 10171518 TI - Dementia protocol to become part of long term care survey. PMID- 10171519 TI - Patient's comprehension of the medical informations presented before the invasive procedures. AB - The requirement of an informed consent has become a major issue even in the rural area of Japan. Particular interests were focussed on understanding of the information and the effect of pre-existing anxiety on that understanding. Nineteen neurological patients who were going to have either surgeries or invasive diagnostic procedures, agreed to cooperate with the study. Results of the study revealed the followings; (1) comprehension of medical disclosure varied widely from one patient to another, (2) assistance from co-medical staff (a registered nurse in the study) could not facilitate greater comprehension, and (3) the more anxious patients comprehended more. It seemed to remain a question as to how much adults of sound mind actually comprehended it even when the medical disclosure was presented fully and in a simple style. PMID- 10171520 TI - The patients nobody wants. PMID- 10171521 TI - Two lab chains pay $39.8 million to settle Medicare fraud charges. PMID- 10171522 TI - Michigan groups battle for better heart care. PMID- 10171523 TI - Lab tests: a choice between buying a Rolls or fixing the roof. Interview by Donalee Moulton. PMID- 10171524 TI - Night & day ... day surgery. PMID- 10171525 TI - Mental health and substance abuse services in the era of health care reform. AB - In the face of the cost crisis in the U.S. health care delivery system and in the era of reform, mental health and substance abuse services are in jeopardy. As the Clinton health reform plan is being debated during the months ahead, however, advocates for mental health and substance abuse care can play an important role in preserving benefits. To do so, they must press on with research into the effectiveness and cost-effectiveness of all aspects of mental health and substance abuse treatment; they must focus energies on working with managed care companies to ensure the provision of only necessary care at the appropriate level and intensity; and they must strive toward understanding the reforms being proposed and the implications for mental health and substance abuse services. Successful integration of the full array of mental health and substance abuse services into a generic benefits package remains a realistic goal, but the challenge is formidable. PMID- 10171526 TI - Serving the dually diagnosed homeless: program development and interventions. AB - In this paper the authors present the specific characteristics of the dually diagnosed (severely mentally ill and substance abusers) population and describe a hybridized program and interventions which have been empirically shown to be effective in working with these multiply impaired individuals. The article is based upon a three-year federally funded demonstration project. The following interventions were found to be effective: engagement, care and nurturing, structure, limit setting and the development of responsibility, positive reinforcement, and self esteem. The authors describe these interventions and highlight their impact in both staff management and working with funding sources. PMID- 10171527 TI - A demonstration program for homeless male alcohol and other drug abusers. AB - The National Institute on Alcohol Abuse and Alcoholism, in consultation with the National Institute on Drug Abuse, awarded nine demonstration grants in 1988 for community-based programs addressing issues of the homeless alcohol and other drug (AOD) abusers. Project Connect in Louisville, Kentucky, was one of the nine demonstration grants. The three-year project was designed to address a multitude of needs of the homeless male AOD abuser, including housing, medical, employment/economic, and social support, in addition to treatment for AOD abuse. The present article details the evolution and implementation of Project Connect and describes characteristics of the target population. In addition, the article presents issues and problems that surfaced during program implementation in order to assist other communities that are considering similar programs for their homeless populations. PMID- 10171528 TI - The use of shelters as substance abuse stabilization sites. AB - The feasibility of providing postdetoxification residential substance abuse programming (stabilization) in large emergency shelters was examined as part of a demonstration project funded by the National Institute on Alcohol Abuse and Alcoholism under Section 613 of the Stewart B. McKinney Act (Public Law 100-71). The program completion rates of 773 homeless/near-homeless substance-abusing individuals assigned to two large shelters (71% and 62%) and two traditional substance abuse treatment agencies (68% and 54%) were comparable. These data support the expansion of shelter services to include substance abuse programming and intervention. Shelters represent windows of opportunity into the lives of homeless substance-abusing men and women, and full advantage of this opportunity should be taken to impact this subgroup of the homeless. PMID- 10171529 TI - A residential recovery program for homeless alcoholics: differences in program recruitment and retention. AB - This paper describes the Sober Transitional Housing and Employment Project (STHEP), a long-term residential recovery program in Los Angeles for homeless alcoholics. This NIAAA community demonstration project aimed to reintegrate homeless alcoholics into the urban environment and to increase levels of sobriety, housing, and employment. Participants first completed a 90-day program in a rural location and then transferred to a downtown recovery home for an additional 120 days. Services included enhanced vocational and housing assistance and specialized group activities. The evaluation examined patterns of recruitment and program retention, in comparison to a control group which received only the first phase, without enhanced services. Whites, women, and younger residents were less likely to sign up for the project waiting list and to accept entry into the project when randomized. STHEP participants were more likely to complete the first phase, particularly black males, compared to the control group. Upon completion of the second phase, whites were more likely to discharge to a rental situation, blacks to a sober group living facility, and women to live with others. Differences in program recruitment and completion may be explained by employment history, economic status, and gender, race, and age differences in subsistence patterns while homeless. The findings suggest the need for program planners to take into consideration the diverse backgrounds and needs of homeless alcoholics and to match individual needs to services. PMID- 10171530 TI - Health care plans covering outpatient x-rays and lab tests. PMID- 10171531 TI - Challenges in medical staff credentialing. AB - This article addresses the challenges faced by medical staffs in conducting their medical staff appointment and reappointment activities, including credentialing, privileging, establishing criteria for new procedures, crossover privileging, and creating credentialing systems for new facilities. In order to satisfy legal scrutiny, the cornerstone of all these activities must be quality patient care. PMID- 10171532 TI - Pap smear furor may derail Clinton changes. PMID- 10171533 TI - Disabled protest AHCA approach in lobbying for reform. PMID- 10171534 TI - Implications of outpatient surgery growth. PMID- 10171535 TI - A comparative cost analysis of alternative models of adult day care. AB - An analysis of the component costs of adult day care (ADC) programs in the Commonwealth of Pennsylvania indicates widely varying experiences in terms of fiscal and contractual administrative arrangements. Medical model ADC, program funded services, and those agencies performing their own client assessments reported higher client per diems than the social model, slot-funded, and non-ADC assessed programs. For-profits displayed cost characteristics similar to their not-for-profit counterparts. Medical and slot-funded programs more frequently turned to multiple sources for budget supplementation. All program types tended to depend on voluntary client contribution methods as compared to means-tested approaches when determining fee-for-service. PMID- 10171536 TI - Aluminium release as a new factor in the estimation of alumina bioceramic implants. AB - Aluminium release from an alumina bioceramic was investigated parallel to standardized biocompatibility testing in an animal experiment. Alumina implants were introduced into both femurs of male rats and into the mandible of male guinea-pigs. After a period of 6 or 8 months animals were sacrificed. The bone surrounding the implant was examined by utilizing standard histological procedure. The material was well tolerated both in the rat and in the guinea pig. The surface of the removed implants was examined in the SEM. No changes were observed. In both femurs of the 10 experimental and six control rats the aluminium content was determined by utilizing the atomic absorption spectroscopy method (AAS). It was found that the level of aluminium was essentially higher in the bones of the experimental animals. Therefore the safety of alumina introduction into human organisms for a long period becomes open to doubt, in spite of the favourable results of the short-term biocompatibility tests. PMID- 10171537 TI - Biological behavior of cellulosic materials after bone implantation: preliminary results. AB - The biological behaviour of cellulosic material was examined after intermedullary implantation in femoral shafts of rabbits. The examination of rabbits' femurs occurred at 3, 9, 12 and 34 weeks by X-ray, microscopic and macroscopic examinations. They showed a perfect bone-implant adaptation without macroscopic or X-ray modification of the bone and without any cortical secondary weakness. In spite of the difficulties arising from the retraction of dehydrated cellulose before methylmethacrylate embedding, microscopic aspects show, at the end of the implantation, a very low inflammatory reaction with bone intra-spongious regeneration of cells and the integration of the cellulosic implants. These results are encouraging for success in new applications of cellulose in orthopaedic surgery. PMID- 10171538 TI - Corrosion protection of metal implants by hard biocompatible ceramic coatings deposited by radio-frequency sputtering. AB - Most metals used for orthopaedic and stomatology implants and prostheses belong to the families of titanium or nickel-based and cobalt-based superalloys designed for advanced technology industries (e.g. space, aeronautic and nuclear industries). Ideal materials should be as insoluble and biologically compatible as possible. In the present paper the corrosion behaviour of Ni-Cr and Co-Cr alloys in biological media is evaluated through potentiodynamic polarization tests. It is shown that these metals exhibit some minor release of the component elements and degradation products, which may induce cytotoxic and allergic effects. The corrosion resistance of these alloys can be strongly enhanced by hard ceramic coatings deposited by radio-frequency sputtering. The biocompatibility of coated and uncoated metals is compared from differentiated human cell cultures. PMID- 10171539 TI - Bacterial adhesion to medical polymers--use of radiation techniques for the prevention of materials-associated infections. AB - The basic principles of the adhesion of bacteria to polymer surfaces are discussed, as the first important step in the pathogenesis of foreign-body infections. Strategies for the prevention of foreign-body infections by polymer modification with ionizing radiation are presented. These include the modification of polymer surfaces by radiation or glow discharge techniques to obtain antiadhesive or antimicrobial surfaces, as well as the fixation or incorporation of antibiotic drugs to or into the polymer. PMID- 10171540 TI - Development of an artificial articular cartilage. AB - We have attempted to develop an artificial articular cartilage on the basis of a new viewpoint of joint biomechanics in which lubrication and load-bearing mechanisms of natural and artificial joints are compared. We investigated poly(vinyl alcohol)-hydrogel (PVA-H) which has been recognized as a rubber-like gel and have improved the mechanical properties of this gel through a new synthetic process. In this article we report the biocompatibility and various mechanical properties of the new, improved PVA-H from the aspect of its usefulness as artificial articular cartilage. As regards the lubrication, we measured the change of thickness and fluid pressure of the gap formed between a glass plate and the specimen under loading and found that the PVA-H had a thicker fluid film under higher pressure than polyethylene (PE). The momentary stress transmitted through the specimen revealed that PVA-H had a lower peak stress and a longer duration of sustained stress than PE, suggesting a better damping effect. The wear factor of PVA-H was approximately five times as large as that of PE. Histological findings of the articular cartilage and synovial membranes around the PVA-H implanted for 8-52 weeks showed neither inflammatory nor degenerative changes. The PVA-H artificial articular cartilage could be attached to the underlying bone using an osteochondral composite material. Although there remain still some problems to solve, PVA-H seems to be a very interesting and promising material which meets the requirements of artificial articular cartilage. PMID- 10171541 TI - Early tPA treatment and aeromedical transport of patients with acute myocardial infarction. AB - Over a 2-year period 192 patients with acute myocardial infarction (AMI) were transported by helicopter and treated with recombinant tissue-plasminogen activator (tPA). All patients were entered into the Thrombolysis in Myocardial Infarction-Phase II (TIMI II) trial. Eighty-two of these patients were treated with tPA after aeromedical transport to a tertiary care center. One hundred ten patients had tPA treatment initiated by the flight crew prior to transport. The flight crews initiated therapy 28 +/- 11 minutes after arrival at the sending hospital. The post-flight treated patients received the tPA bolus 82 +/- 20 minutes after arrival at the sending hospital (P less than .0001), and 41 +/- 18 minutes after arrival at the receiving hospital (P less than .0001). Based on enzyme and electrocardiographic changes, all patients in the study had a confirmed diagnosis of AMI before discharge. Patients with inferior myocardial infarction (MI) treated with tPA in-flight were more likely to suffer from bradycardia and hypotension requiring atropine injection during transport than the post-flight treated patients or in-flight treated patients with anterior MI. There was no in-flight mortality in either group. Our experience indicates that patients with AMI can be transported safely during tPA therapy. Also, a trained team whose sole responsibility is the early evaluation and initiation of therapy in a patient with AMI can function as accurately and significantly more rapidly than tertiary care emergency department and ICU personnel following identical protocols. PMID- 10171542 TI - A review of practices among information resource programs on assistive technology. AB - There is presently a growing need for timely information on assistive technology products and services. Some exemplary assistive technology information resource programs exist, while others are just now being developed. A survey was used to review the practices of 24 information resource programs. The results, obtained from 15 responding programs, provide guidelines for those considering setting up such services of their own. Among the significant findings, 60% of the programs receive between 10 and 100 requests per month; over two-thirds of these come by telephone, but over one-half must be answered by mail; the average time spent per request is 33 minutes; over one-half of all requests are for product literature, and over one-half of all requests come from service providers. Some critical issues related to information delivery are presented for further investigation. PMID- 10171543 TI - Intraoperative contrast echocardiography. PMID- 10171544 TI - Examination of vascular anastomoses during liver transplantation by intraoperative Doppler duplex scanning. AB - Intraoperative examination of the arterial and portal vein anastomoses was performed in 16 liver transplant patients using duplex scanning. Two major defects and three minor defects were found in 5 arterial anastomoses. Major defects were defined as those associated with an audibly abnormal Doppler signal, a defect greater than 3 mm in length or greater than 50% luminal narrowing. Minor defects were defects visible by ultrasound but not meeting the above criteria. The major defects were repaired and scans following repair were without evidence of defects. The three minor defects were ignored. A nearly occluding thrombus was found in the portal vein of one patient. A thrombectomy was performed successfully. All patients have done well postoperatively. This report suggests that intraoperative duplex scanning may be of value in detecting technical imperfections in the vascular anastomoses during liver transplantation. Detection of a major defect intraoperatively allows immediate repair. PMID- 10171545 TI - The CBM-3000 tonometric blood pressure monitor. PMID- 10171546 TI - Monitoring neuromuscular function. PMID- 10171547 TI - The anesthetic machine in the 1990s. PMID- 10171548 TI - A review of the detection and treatment of venous air embolism. AB - Venous air embolism is a common potential complication of several surgical procedures and should be understood by anesthesiologists. The first part of this article, which appeared in a previous issue (Sept/Oct 1991;18(5):29-37), reviewed the pathophysiologic aspects. This concluding segment discusses the detection of venous air embolism and its prevention and treatment. PMID- 10171549 TI - Laboratory evaluation of the Pall LG6 leukocyte depleting arterial line filter. AB - The Pall LG6 arterial line filter has been designed to remove free circulating leukocytes from the arterial line of the extracorporeal circuit employed in openheart surgery. The filter was evaluated and compared to a control filter (Pall Stat-Prime) in terms of its general blood handling characteristics, particularly with regard to the associated level of leukocyte removal. The gross air handling characteristics of the filters were also assessed together with pressure drop. It was found that the filters differed little in terms of all factors studied other than the level of leukocyte depletion. The LG6 filter was associated with substantial levels of leukocyte depletion, particularly the depletion of neutrophils. Over the 90 minute perfusion period the LG6 filter was found to be associated with a neutrophil depletion rate of around 70% while preferentially sparing lymphocytes. This compared to a 10-20% depletion rate in the control filter. This was achieved without apparently compromising the performance of the filter in terms of the other factors studied. PMID- 10171550 TI - What's new in monitoring the coronary surgery patient? AB - Monitoring has been extensively reviewed in most textbooks of cardiothoracic surgery and anaesthesia, particularly in the recent textbooks on monitoring edited by Carol L Lake 1 and Casey D Blitt 2 and in the Journal of Clinical Monitoring. Although monitoring properly includes both pre- and postoperative periods, this review will concentrate exclusively on the operative period. I will also concentrate on new approaches or information which relate to more traditional approaches to monitoring. The emphasis in this review will not be on what we can monitor, but rather on what we should monitor. In this regard, I will analyse accuracy and identify sources of error and try to answer the following questions. Does the device or parameter measure (monitor) what we want to know? Does it improve patient outcome and safety? Is it cost-effective? Unfortunately, data are not always available to answer all these questions at present, but hopefully the discussions will make us aware of what we do and do not know, and what we should look for in the near future. PMID- 10171551 TI - Histologic analysis of a retrieved expanded polytetrafluoroethylene posterior cruciate ligament. AB - An expanded polytetrafluoroethylene (PTFE) prosthesis used to reconstruct the posterior cruciate ligament in a 37-year-old Caucasian male was retrieved and histologically examined in this study. Backscattered electron (BSE) microscopy, utilized to observe the mineralized tissue ingrowth into the retrieved specimen, revealed an absence of bony ingrowth within the graft. Light microscopy demonstrated an exuberant foreign body giant cell response surrounding and invading the substance of the graft, and also revealed evidence of graft degradation. These observations indicate that PTFE may not be as favorable a material for reconstruction of ligamentous tissues as previously reported. PMID- 10171552 TI - Stability of a cyclically loaded hydroxyapatite coating: effect of substrate material, surface preparation, and testing environment. AB - Cyclic loading of Ti-6-4 and Co-Cr-Mo (cast) test samples with grit-blasted or waffle-textured surfaces coated with a plasma-sprayed 50-mum HA layer was performed in air, Ringer's solution (5% dextrose), 0.9% NaCl (Tris buffer, pH 7.40), and balanced Hank's solution. Maximum interfacial stresses in bending of 40 ksi (280 MPa) and 20 ksi (140 MPa) were utilized, and the specimens tested to 10 6 cycles at 5 Hz with a MTS servohydraulic machine. Tested samples were examined by optical microscopy to determine coating integrity and thickness and by scanning electron microscopy (electron backscatter mode and EDAX) to determine surface morphology and chemical changes. The following observations were made: (1) Samples cyclically tested in solutions showed a general thinning of the coating, accentuated in the higher-stressed regions. (2) Samples tested with an equivalent static load in the solutions did not show this centralization. (3) Bare metal interface surfaces were noted on most of the edges of highly stressed central specimen regions, in several entire central regions, and on the upper surfaces of some of the waffled samples. (4) The specimens tested in Ringer's solution (pH 4.70 initially) demonstrated the most dramatic coating deterioration. (5) The coatings on titanium appeared more stable than these on Co-Cr as tested in all solution environments for both surface types. The HA coating evaluated in this experiment demonstrated increased instability when cyclically loaded in in vitro solutions of lowered pH and depleted cations (Ca 2+) at stress levels of 280 MPa.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171553 TI - Biocompatibility tests on a novel glass-ceramic system. AB - The aim of this study was to look at the bone bonding potential of six formulations of a novel glass-ceramic system. Cylinders of the ceramics were implanted in rabbit tibiae for 4 and 7 weeks. Histological tests, both quantitative and qualitative, as well as push-out tests, were carried out during the bonding assessment. Bone growth was quite prolific, even at 4 weeks, as evidenced by growth up to and along the implant surfaces. The interfacial shear strengths compared well with other biomaterials in use as endosseous implants. Therefore it seems pertinent to pursue further long-term experimentation with this material. PMID- 10171554 TI - Mammary implants. PMID- 10171555 TI - Basics of flow cytometry. AB - The basics of flow cytometry are described. Cytometry is the measurement of cells; the flow cytometer performs this measurement quickly and reproducibly. Single cells in suspension are presented to a light source through hydrodynamic focusing. The resultant scattered light and fluorescence are collected and converted to electrical pulses, which are digitized for computer analysis. Frequency distributions can be viewed as single- or multiple-variable histograms for evaluating cell measurements. The versatility of flow cytometry is demonstrated by the types of samples it can analyze, characteristics it can measure, and applications in multiple laboratory sciences. Flow cytometry has been adapted easily and rapidly from a research tool to a clinically important procedure. PMID- 10171556 TI - HIV infection: immunobiology and laboratory diagnosis. AB - The immunobiology of human immunodeficiency virus (HIV) and the role of laboratory testing in the diagnosis and management of HIV infection are reviewed. HIV is one of a family of RNA viruses called retroviruses. HIV has three structural genes (one of which codes for reverse transcriptase) and six regulatory and maturation genes. Upon infection in humans, HIV commandeers the immune system by infecting and lysing T-helper lymphocytes. Since these cells are key to directing the body's immune defenses, the person becomes susceptible to a variety of opportunistic infections, neoplasias, and neurologic disorders. Laboratory tests for HIV are used for three purposes: screening of large populations (such blood donors), diagnosis of current or latent infection, and monitoring of disease progression. Diagnosis of HIV infection relies on HIV antibody detection, viral cultures, antigen detection, or polymerase chain reaction viral genome detection. Disease progression can be estimated using immunophenotyping with flow cytometry or using other immunologic markers. The immunologic variables associated with HIV infection disclose a growing spectrum of immune deficits. New tests for diagnosing and monitoring patients infected with HIV have been quickly incorporated into clinical practice. PMID- 10171557 TI - An orthopaedic and prosthetic program in Mozambique. PMID- 10171558 TI - Arterial imaging. AB - Angioscopy, magnetic resonance angiography, computed tomography, and nuclear medicine are assuming an increasingly important role in arterial imaging. This review discusses recent advances in these modalities. Angioscopy has proven valuable in monitoring intraoperative surgical procedures as well as percutaneous interventions. Carotid artery magnetic resonance angiography is gaining increasing acceptance in clinical practice. Magnetic resonance angiography of the peripheral arteries is limited by spatial resolution and signal loss distal to the stenosis. The role of computed tomography in limiting the number of aortograms performed in evaluating aortic laceration remains controversial; however, several recent papers indicate its usefulness in evaluating clinically stable patients with abnormal chest radiographs. Computed tomography of abdominal aortic aneurysms may obviate the need for preoperative aortography in the majority of cases. Nuclear imaging for deep venous thrombosis using 111In labeled antifibrin monoclonal antibodies was shown highly sensitive in its initial report. PMID- 10171559 TI - New micro-endoscopic techniques reduce scars, recuperation time. PMID- 10171560 TI - Effects of biostability and morphology on host response of polyurethane-based soft tissue implants. AB - Polyurethane has been found to be one of the most successful polymers for soft tissue applications. We have investigated the effect of material biostability and morphology on the host response of polyurethane-based soft tissue implants in rabbits. The polyurethane containing allophanate linkage was prepared by using hexamethylene diisocyanate, polypropylene glycol (400) and 1,4-butane diol. Biuret-based biostable polyurethanes were prepared by using hexamethylene diisocyanate, polytetramethylene glycol and trimethylol propane and water. Samples of circular button and rectangular specimens were implanted subcutaneously in rabbits in the paravertebral region for a post-implantation period of 9 months. Relatively larger polyurethane samples with different morphology elicit a varied tissue response with our candidate polyurethane materials. A favorable tissue response was observed with rectangularly shaped thin polyurethane. Giant cell reaction, absence of fibrous tissue encapsulation and degradation were noticed for the rectangular smooth samples at the end of post-implantation period of 9 months. No malignant changes were noticed in any of these samples. PMID- 10171561 TI - The transcranial Doppler. PMID- 10171562 TI - Transcranial Doppler sonography: trend monitor of cerebral hemodynamics? PMID- 10171563 TI - Monitoring during carotid surgery: somatosensory evoked potentials vs. carotid stump pressure. AB - In the following prospective study of 125 carotid endarterectomies, we compared monitoring of somatosensory evoked potentials (SEPs) with carotid stump pressure (CSP) measurement in order to determine the efficacy of both methods in reliably predicting cerebral ischemia caused by cross-clamping of the carotid artery. A complete flattening of the cortical SEP was the sole criterion for selective shunting. Two patients suffered from transitory neurological deficits in the postoperative period. Both experienced complete disappearance of postcentral SEP components after carotid cross-clamping. In a further 10 cases, an intraoperative loss of SEP amplitudes occurred, but could be reversed by the insertion of a shunt or by induced hypertension. All of these patients showed a normal neurological examination postoperatively as did all of the patients with identifiable SEPs after cross-clamping. In all of the 12 patients with complete flattening of the cortical waveform, we found CSP levels less than 50 mm Hg. A further 61 patients had a CSP less than 50 mm Hg, but neither an intraoperative loss of SEP amplitudes nor postoperative neurological deficits were detected in any of these patients. We conclude that, in contrast to CSP, SEPs not only help to identify patients with insufficient collateral blood flow who benefit from specific cerebral protection, but also to avoid improper and hazardous application of these measures in patients with sufficient cerebral perfusion. PMID- 10171564 TI - Thrombolytic treatment of an acute anterior myocardial infarction based upon echocardiography and in the absence of electrocardiographic criteria. AB - Tissue plasminogen activator was administered intravenously to a patient with clinical features of, but without electrocardiographic criteria for, an acute myocardial infarction. The ultimate treatment decision was based upon echocardiographic findings diagnostic for an anteroseptal myocardial infarction. Subsequent coronary angiography demonstrated a severe proximal, but patent left anterior descending stenosis. The patient is now asymptomatic 3 months following thrombolytic therapy and coronary angioplasty. PMID- 10171565 TI - Extracorporeal shock wave lithotripsy of midureteral stones using the Dornier HM 3. AB - Fifty-three patients were treated in the prone position for stones located in the pre-sacral ureter. Cases were performed at the Orange County Kidney Stone Center by 28 urologists from March 1988-November 1989. A Dornier HM-3 Lithotripter with the original generator, 15.6-cm ellipse, and computerized gantry was used. No repeat treatment was utilized in this series and three failures resulted. PMID- 10171566 TI - Psychology intervention and cost containment. PMID- 10171567 TI - New findings in mood and anxiety disorders are important for health insurers. PMID- 10171568 TI - DNA analysis for human identification using the polymerase chain reaction. PMID- 10171569 TI - The intraoperative role of transesophageal echocardiography: the anesthesiologist's perspective. PMID- 10171570 TI - STIR sequences detect breast implant rupture. PMID- 10171571 TI - MRI powerful adjunct to CT in imaging thorax. PMID- 10171572 TI - Image guidance assists needle biopsy of thorax. PMID- 10171573 TI - Technology in the trenches. PMID- 10171574 TI - Clinical evaluation of a new saturation/hematocrit monitor. AB - The purpose of this study was to evaluate the utility of the Cobe SAT/HCT Monitor, an in-line device which continuously displays hematocrit and venous oxygen saturation. A fiber optic cable was used to connect the monitor to a "window" on the blood inlet of a venous reservoir (Cobe CML). Sixty venous blood samples were drawn from 20 patients undergoing cardiopulmonary bypass. Statistical correlations were performed comparing monitor readings with controls measured by an IL 482 co-oximeter and a TRIAC centrifuge. Results showed a high degree of correlation between the monitor and control values for both venous saturation (r = .96) and for hematocrit (r = .94). Although this device has some minor deficiencies, it is a useful tool which enables the perfusionist to monitor two important components of oxygen consumption. PMID- 10171575 TI - Transesophageal echocardiography. AB - Transesophageal echocardiography has provided a new acoustic window to the heart, the great vessels, and the mediastinum. It provides anatomical, functional hemodynamic, and blood flow information. High-quality visualization of left atrial appendage, thoracic aorta, atrial septum, and mitral valvular apparatus can be obtained readily. We discuss historical and technical aspects of transesophageal echocardiography, anatomical views, and major clinical indications for this procedure. These indications include intracardiac masses, thoracic aortic dissection, endocarditis, prosthetic and native cardiac valve function assessment, as well as its value in the detection of intracardiac source of systemic emboli. Furthermore, the role of transesophageal echocardiography in the assessment of coronary artery and congenital heart disease and as an intraoperative diagnostic and monitoring technique is discussed. PMID- 10171576 TI - Temperature monitoring should be routine during general anesthesia. PMID- 10171578 TI - Laparoscopically assisted vaginal hysterectomy and laparoscopic hysterectomy: two procedures utilizing lasers. PMID- 10171577 TI - Medial temporal atrophy as a magnetic resonance imaging marker for Alzheimer's disease. AB - Medial temporal lobe atrophy (MTLA) on brain magnetic resonance imaging (MRI) may help differentiate Alzheimer's disease (AD) from multiinfarct dementia (MID) and other dementias. MTLA was seen in 6 of 11 patients with clinically diagnosed AD, 16 of 20 with mixed dementia (with both AD and MID), 1 of 5 with psychiatric disease, and in none of 32 with MID or 8 with other dementias (p less than 0.0001). Increased patchy periventricular signal, or "unidentified bright objects" were seen in 2 of 11 patients with AD, 10 of 20 patients with AD and MID, and 26 of 32 patients with MID. A larger series with autopsy correlation may verify that MTLA is a reasonably specific marker for AD, and unidentified bright objects are a sensitive, but not specific, marker for vascular dementias. PMID- 10171579 TI - Operative laparoscopy (minimally invasive surgery): state of the art. AB - In any body cavity, endoscopic surgery is possible and usually preferable. Advantages include better exposure, magnification, and operating very close to the affected tissue. We demonstrate some of the past, present, and future of laparoscopy. PMID- 10171580 TI - Breaking new ground or just digging a hole? An evaluation of gynecologic operative laparoscopy. AB - The gynecological surgical procedures that may be accomplished via operative laparoscopy have dramatically increased in the past decade. Ideally, strong evidence of advantages over traditional surgical approaches should be presented for each surgical procedure before widespread use occurs. Such evidence is generally lacking. This review of recent publications concludes that laparoscopic operations for tubal ectopic pregnancy have been demonstrated generally to be preferable to laparotomy. Although evidence is very suggestive, clear superiority of laparoscopy has not been proven for endometriosis, ovarian cystectomy, oophorectomy, distal salpingostomy, or adhesiolysis for infertility. There is not adequate evidence to reach a conclusion on the use of laparoscopic myomectomy for fertility. When appropriately indicated, vaginal hysterectomy seems preferable to abdominal or laparoscopic hysterectomy, and preliminary evidence suggests that laparoscopic hysterectomy may have some advantages over abdominal hysterectomy. There is no evidence that laparoscopic tubal sterilization is better than minilaparotomy tubal sterilization. Much more scientific study of operative laparoscopic procedures is needed before universal change to these procedures can be fully endorsed. PMID- 10171581 TI - Medium technology in health care. AB - The health care industry relies on technological innovation to provide solutions to the ever increasing range of medical problems in the modern world. No industry can survive without financial investment, and some areas of the health care industry have encountered difficulties when trying to attract finance. In this article, the author outlines specific areas that are likely to attract investment funding and the elements that make up an attractive proposition for potential investors. PMID- 10171582 TI - How to get started in cardiovascular MR. PMID- 10171583 TI - Tricalcium phosphate as a bone graft substitute. AB - A clinical trial is reported that was conducted in an attempt to establish a timeframe for replacement of tricalcium phosphate by bone. In 20 cases, an 8.5mm by 3mm disc of tricalcium phosphate was implanted into the cut surface of the tibia at the time of total knee replacement. When followed radiographically, the disc of tricalcium phosphate generally could not be identified at six months. At two years, no untoward effects have occurred and no vestigial shadows remain, indicating that the block has fully incorporated and largely been absorbed and replaced by host bone. The experience in this series of cases indicates that tricalcium phosphate is a useful resorbable bone filler material. PMID- 10171584 TI - Solving electromagnetic compatibility problems in medical equipment. AB - The Electromagnetic Compatibility (EMC) Directive came into force on 1 January 1992, bringing with it an increased awareness of the importance of EMC in electromedical equipment. In this article, the author advocates that EMC should be considered early in the design stage of product development, when solutions to EMC problems and compliance with the requirements can often be introduced for very little cost. The author discusses a number of methods for tackling EMC problems, which will lead to enhanced product reliability, and therefore increased safety, as well as benefits in other areas of product quality. PMID- 10171585 TI - The health industry bar code in Europe. AB - As information systems in the health care industry become more widely used and increasingly sophisticated, the source data used to make decisions must become more accurate and speedily available to improve the decision-making process. A proven technique for the fast and accurate capture of data by computers is bar coding. This article examines health industry bar coding and some of its many potential benefits, focusing in particular on the Health Industry Bar Code in Europe. PMID- 10171586 TI - Biostable polyurethane elastomers. AB - The generic term polyurethane represents the most versatile family of synthetic polymers. The unsurpassed physical and chemical properties of polyurethanes, coupled with their biocompatibility, have led to their use in a wide range of biomedical applications. Although polyurethanes have been shown to be stable in vitro for many years, they can undergo rapid microcracking when implanted. These microcracks not only weaken the polymer but also serve as nucleation sites for thrombus formation and lead to catastrophic failure. In this article, the authors report on the development and testing of a new ether-free polyurethane that does not exhibit surface microcracking under accelerated in vivo condition. PMID- 10171587 TI - Sterilization equipment and services: a medical device technology survey. AB - Most medical device manufacturers use sterilization procedures at some point in their production processes. Many factors affect the choice of sterilization method and whether manufacturers sterilize products in-house or subcontract their sterilization requirements. Underlying trends are apparent, and this article summarizes these trends from the results of a survey recently conducted among European medical device, diagnostic, and pharmaceutical manufacturers. PMID- 10171588 TI - Gamma processing: the state of the art. AB - Some materials undergo undesirable changes after sterilization by gamma irradiation, principally related to changes in colour and material properties. However, it is argued that there are ways to overcome these problems; solutions can involve using the most appropriate polymer or reducing the dose that is applied to the product. The new approach to dose setting has led to the view that providing certain conditions are met, a product treated with less than 25 kGy can be sterile without a sterilization test being necessary, which consequently, increases the advantages of this method. PMID- 10171589 TI - Improving the ethylene oxide sterilization process. AB - Although ethylene oxide (EtO) sterilization is commonly used in the manufacture of sterile medical devices, concern about residues of the sterilant in the sterilized products has led to an increase in the use of alternative methods; however, these methods, in turn, have significant drawbacks. The authors have tackled the issue by looking into the possibility of reducing EtO residuals. After conducting a series of investigative experiments, it has been proved that EtO residuals may be reduced by decreasing the amount of EtO used in the sterilization process. This can be achieved without lowering the safe sterility level and there are additional benefits for safety, cost, and the environment. PMID- 10171590 TI - Steam sterilization: a suitable alternative? AB - Extracorporeal blood-circuit devices can be sterilized by ethylene oxide (EtO), irradiation, or steam. The majority of these devices are sterilized by the first two processes, and the use of steam sterilization seems to be limited. This article compares the different processes, discusses their advantages and disadvantages, and makes a case for sterilizing these products by steam. PMID- 10171591 TI - Electron-beam accelerators: a technology adapted for the sterilization of medical devices. AB - Developments in electron-beam technology have led to its increased use in the sterilization of medicosurgical equipment. The author asserts that this method is fast, flexible, and precise. In his description of a 10-MeV electron-beam sterilization unit, this claim is substantiated by reference to tests and experiments carried out by the company. The high dose rate and short exposure time involved in the process are seen as particularly advantageous for the sterilization of polymers. PMID- 10171592 TI - Polyurethanes in medical devices. AB - Because of their biocompatible qualities, polyurethanes have found many uses in the medical device field. This article describes several of the better-known polyurethanes and discusses their suitability for use in medical applications such as artificial heart systems, catheters, mammary implants, semiocclusive dressings, and drug delivery systems. The adoption and use of these materials by the medical community is likely to increase as new formulations are developed. PMID- 10171593 TI - Biomedical applications of NASA technology. AB - Through the active transfer of technology, the Technology Utilization (TU) Program of the National Aeronautics and Space Administration (NASA) assists private companies, associations, and government agencies in using NASA's technological resources effectively to improve U.S. economic competitiveness and to provide societal benefit. This article discusses several examples of how aerospace technology has been adapted to solve health care problems. PMID- 10171594 TI - Glass-ceramic implant in acetabular bone defect: an experimental study. AB - Extensive acetabular defects produced surgically in 25 dogs were repaired using A W glass-ceramic blocks. No dislocation of the femoral head, and no displacement or breakdown of the blocks was seen 1 year after surgery. All dogs were able to run normally shortly after surgery, except for one that limped for a short time. The failure load between the blocks and the bone had increased markedly 2 months after implantation. The failure load/unit area was 33.2 kgw/cm 2 1 year after implantation. We conclude that glass-ceramic supplementation of the acetabulum is successful experimentally, and that this may be a promising method for repair of large acetabular bone defects. PMID- 10171595 TI - The effect of a TCP-collagen implant on the healing of articular cartilage defects in the rabbit knee joint. AB - Osteochondral defects in the rabbit knee were filled with a TCP-collagen mixture. In the femoral condyles a fibrous tissue was formed in the defects similar to that seen in control defects. In the tibial plateau defects were made with penetration of the underlying epiphysis. Repair tissue was formed resembling articular cartilage. PMID- 10171596 TI - Osteoconduction of bioceramics in normal and osteopenic rats: comparison between bioactive and bioinert ceramics. AB - Rats with experimental osteopenia, which was induced by resecting both ovaries and sciatic nerves (OVX + NX), were used to evaluate osteoconduction of an apatite and wollastonite-containing glass-ceramic (designated A-W.GC) and an alumina ceramic. The bone mineral densities (BMDs) of the femurs were measured by dural energy X-ray absorptiometry (DEXA) and determination of the ash weight. Twelve weeks after the first operation, when the BMDs in the OVX + NX groups were about 20% less than that in the sham-treated groups (Sham), the bioceramics were implanted into the proximal tibiae. The bone mineral masses around the implants in the proximal tibiae were evaluated by histological examination of undecalcified specimens and DEXA. Both types of implants in the OVX + NX groups showed less reactive bone than those in the Sham groups. However, a histomorphological study revealed that the direct contact area between bone and implant was larger with bioactive ceramic A-W.GC than with the bioinert alumina ceramic even under osteopenic conditions while two types of ceramic made no difference on the bone at distance from the implant. The direct contact area with A-W.GC did not show any difference between the Sham and the osteopenic OVX + NX groups. The bioactive ceramic A-W.GC appears to have good osteoconductivity solely on its surface even under osteopenic conditions. PMID- 10171597 TI - Considerations in the use of biologic grafts and alloplastic implants in facial plastic and reconstructive surgery. AB - Surgical changes in the contour of soft tissue and bone of the craniomaxillofacial structures may require use of a biologic graft or alloplastic implant. Autologous materials are preferred; however, the harvesting procedure, donor site, and its associated morbidity are the disadvantages of using autografts. There are numerous types of alloplastic implants and they all differ in how they interact with host tissues. Factors such as implant texture, ability to integrate with host tissues, and rate of resorption all influence the overall success of different implants. In this article, we discuss some considerations in the use of biologic grafts and alloplastic implants in facial plastic and reconstructive surgery. PMID- 10171598 TI - Upper extremity applications of functional neuromuscular stimulation. AB - Functional electrical stimulation (FES) has been used for increasing muscle strength, decreasing spasticity, and controlling movement of limbs for many years. Most of this work, however, has been done in a research setting. Over the past decade, FES has moved slowly from the laboratory to the clinical world through feasibility studies in groups of patients with spinal cord injuries and strokes. Electrical stimulation has been shown to decrease spastic tone both during and after the stimulation, allowing for better limb positioning, decrease in contracture formation, and in some cases, improvement of voluntary movement. Electrical stimulation as a motor prosthesis is now being provided to small groups of spinal cord-injured patients (primarily C4, C5 and C6 levels) to assist with hand positioning and to produce hand grasp. In these settings, patients have attained greater independence in activities of daily living and in work related tasks. Distribution of this technology to multiple centers is continuing through a technology transfer program. PMID- 10171599 TI - Opportunities and challenges for the clinical utilization of functional electrical stimulation. AB - Clinical applications of electrical stimulation for effecting change in the damaged or disabled nervous system are in their infancy. This technique is extremely powerful, because any neural structure that is electrically excitable can potentially be affected. Although early attempts to apply electrical stimulation were limited by insufficient physiological knowledge and undeveloped technology, developments over the past two decades now provide a strong base for clinical applications. Clinical systems for bladder control and respiration have been in use for many years. Some applications of FES to restore hand function and walking are in multicenter testing, whereas many others are being studied for clinical feasibility at single sites. Applications are focusing on safety and efficacy, as well as on clinical outcome measures to address the issues posed by the regulatory and reimbursement processes. As clinical systems become more routine, issues of multiple system applications will need to be addressed. Present and future applications of functional electrical stimulation may be expected to significantly enhance independence and improve the quality of life for individuals with central nervous system dysfunction. PMID- 10171600 TI - Skeletal reconstruction with allograft segments following bone tumor resection. AB - The successful treatment of malignant neoplasms of bone requires surgical removal of the primary tumor. Limb salvage as an alternative to amputation requires surgical resection of the neoplasm with a wide margin and reconstruction of the segmental defect that is created. Transplantation of an allograft bone segment, with or without articular cartilage, is one option for reconstruction. The types of defects created and the types of reconstruction using segmental allografts are classified. Specific technical details involved in allograft reconstruction are discussed. PMID- 10171601 TI - Self-guided instructional materials in the physician office laboratory. AB - The effectiveness of systematically designed print-based materials in teaching (a) knowledge of laboratory tests and (b) laboratory test skills to laboratory staff in small office practices was measured. Self-guided packets on Gram stain performance and interpretation, rapid streptococcal testing, and vaginal wet preparations were developed by a multidisciplinary team. A total of 21 staff members (14 treatment, 7 control) in 12 family practice offices with three or fewer physicians participated in the study. A posttest-only control group design was used to determine the effects of using the self-guided instructional packets. The treatment group, in relation to the control, scored significantly higher on tests of knowledge for all packets, demonstrated no difference in scores for Gram stain or streptococcal test skills, and scored significantly higher for identification of elements in photographs of vaginal wet preparations. Results affirmed both the usefulness and limitations of print-based instruction for knowledge level outcomes. For developing laboratory test skills additional forms of instruction are needed. PMID- 10171602 TI - Temperature monitoring need not be done routinely during general anesthesia. PMID- 10171603 TI - Brief therapy in addictions: one answer to the mental health benefit gatekeeper. PMID- 10171604 TI - The use of transesophageal echocardiography to evaluate the effectiveness of patent ductus arteriosus ligation. AB - The ligation of patent ductus arteriosus (PDA) is a comparatively easy operation, but some complications are possible. The most common complication is incomplete ligation of the PDA; others include inadvertent ligation of the descending aorta or left pulmonary artery, transient rise in systemic blood pressure and increased left ventricular afterload, and acute right heart failure due to pulmonary hypertension. The completeness of the PDA ligation is usually determined only by the operating physician's experience, including the use of an esophageal stethoscope or a finger on the lesion to feel for vibration. These methods sometimes fail to detect an incomplete ligation. With transesophageal echocardiography (TEE), we have monitored the entire course of the PDA ligation directly without interrupting the surgical procedure, and precisely determined the completeness of the ligation. We also expect that TEE will enable us to avoid other complications as well. PMID- 10171605 TI - The assessment of cerebral function during paediatric cardiopulmonary bypass. PMID- 10171606 TI - Oxygenation design: a global approach. PMID- 10171607 TI - Transesophageal echocardiography: expanding indications for ICU use. How TEE can complement--or surpass--transthoracic techniques. AB - Transesophageal echocardiography (TEE) is a Doppler technique that uses the esophagus as an acoustic window. In critically ill patients (particularly ventilated patients), TEE may be used to assess left ventricular function, valvular disease, endocarditis, and prosthetic valve dysfunction. It is also helpful in elucidating the cause of hypotension after cardiac surgery, and can detect chronic aortic dissection and transection, valve rupture, and myocardial contusion in trauma victims. TEE is superior to transthoracic echocardiography in evaluating a cardiac source of embolism. Contraindications to TEE include esophageal disorders and an uncorrected bleeding diathesis; a large hiatal hernia may cause suboptimal transgastric images. PMID- 10171608 TI - Working for play. Toys & assistive technology for children with disabilities. PMID- 10171609 TI - Outcomes measurement in medical rehabilitation. PMID- 10171610 TI - Spotlighting rehab technology. PMID- 10171611 TI - Funding assistive technology. PMID- 10171612 TI - Development and potential of fetal pulse oximetry. PMID- 10171613 TI - Sensible laboratory testing for suspected Lyme disease. PMID- 10171614 TI - A logical approach to the patient with jaundice. PMID- 10171615 TI - Ultrafast CT makes bid in chest, body imaging. PMID- 10171616 TI - Ultrasound lights path for invasive therapies. PMID- 10171617 TI - Implant retrieval, analysis, and database: a challenge for the medical devices industry. AB - Despite the widespread use of various medical implant devices since the 1960s, there has not been any systematic effort developed for implant retrieval, analysis, and data banking. Most medical implants fail prematurely because of selection of wrong materials and/or processing conditions, selection of wrong in vitro testing methods, inappropriate extrapolation to in vivo conditions, and/or ignorance of the state of the art. Inasmuch as another federal effort is unlikely to deal effectively with these problems, it is proposed that the medical devices industry establish an independent Institute for Medical Implant Retrieval and Analysis using a small percentage of the profits gained from the sale of implants. In addition to carrying out in-house work, this Institute would support appropriate projects in selected academic institutions, with appropriate feedback to regulatory agencies internationally. PMID- 10171618 TI - In vitro evaluation of the calcification behavior of polyurethane biomaterials for cardiovascular applications. AB - Scope of the study is the calcification behavior of medical grade polyurethanes for cardiovascular devices. Within these applications, implant material calcification is a serious complication. The calcification behavior of these materials is investigated with a dynamic in vitro testing method for evaluating the influence of dynamic mechanical strain and parameters of the solubility of calcium salts. PMID- 10171619 TI - Analysis of mammalian connective tissue: relationship between hierarchical structures and mechanical properties. AB - It is widely accepted that the mechanical properties of implants must match those of the surrounding connective tissue to prevent stress concentration and premature failure. The purpose of this paper is to review the structure mechanical property relationships that exist for connective tissue. The mechanical properties of connective tissue depend on the content of collagen, elastic tissue, and proteoglycans, as well as the geometric arrangement of the fibrous components, age, and location of the specimen. To a first approximation the geometry and loading pattern of the collagen networks in these tissues dominate the mechanical response at high strains. The behavior of the elastic fiber networks dominate the low-strain mechanical response in tissues where energy and shape recovery are critical. Proteoglycans are involved in resisting tissue compressive forces. Since the stiffness of connective tissue increases with age, it is necessary to attempt to match this property by designing implants that have similar behaviors to insure that stress concentration does not occur at the interface between the implant and host. PMID- 10171620 TI - Non-invasive magnetic resonance imaging of the soft tissue response to a biomaterial. AB - Magnetic resonance imaging (MRI) has been employed to visualize the tissue response to hydrogel implants in rats. High contrast MR images of the implant site were obtained. Distinct tissue variations in the MR images have been observed. These can be attributed to either the surgical procedure or the application of a tissue irritant to produce inflammation and have been verified histologically. This study demonstrates that MRI is potentially a useful tool for the non-invasive in-vivo evaluation of biomaterials. PMID- 10171621 TI - Diffusion of fibroblast growth factor from a plaster of Paris carrier. AB - Fibroblast growth factor (FGF) is a polypeptide that has been shown to have a stimulatory effect on osseous tissues in vitro. This study characterized the release of FGF from plaster of Paris (PLP) and measured the dissolution of PLP in various solutions with the aim of developing a reliable carrier system for the release of FGF in vivo. The study consisted of five experiments: (I) FGF diffusion from PLP pellets, (II) FGF diffusion from PLP discs, (III) PLP dissolution in saline, (IV) PLP dissolution in serum, and (V) FGF adsorption by commercially pure titanium. FGF was observed to be released at a rate directly proportional to the rate of dissolution of the PLP carrier, suggesting that either the FGF binds to the PLP; or, alternatively, the FGF may be entrapped by the PLP. Dissolution rate, and thus release rate, could be varied by varying the mass of the carrier. Greater diffusion of FGF was observed in larger, more slowly dissolving PLP carriers. Dissolution of PLP was observed to be slower in serum than in saline, apparently due to stabilization by factors in the serum but not due to a concentration gradient effect. Titanium coupons did not adsorb significant amounts of FGF. These results indicate that PLP, which has been shown in the past neither to aggravate inflammatory response nor to interfere with bone ingrowth, may serve as delivery vehicle for FGF to osseous tissues in vivo. PMID- 10171622 TI - On the use of primary reference grade polydimethylsiloxane. AB - There has been an increase in the use of primary reference material as a standard for identifying the cellular response to biomaterials. One such material is NHLBI-DTB polydimethylsiloxane (PDMS). The PDMS was developed for blood contacting studies and is composed of PDMS backed on one side with mylar. The results of implantation studies of two different publications are discussed in light of the different materials and different surface topographies of each of the materials. The appropriateness of in vivo studies using this reference material is questioned. PMID- 10171623 TI - Biomechanical performance of new vascular sutures and needles for use in polytetrafluoroethylene grafts. AB - Two new cardiovascular monofilament sutures attached to taper point needles have been developed for use in expanded polytetrafluoroethylene (PTFE) grafts. One monofilament suture made of PTFE has a microporous structure that allows it to be channel swaged to a needle that closely approximates its suture diameter. The other suture is a monofilament polypropylene suture that has been extruded to produce a tapered swage end, which was significantly smaller than that of the remainder of the suture in order to be channel swaged to smaller diameter needles. On the basis of comprehensive biomechanical performances, the performance of the new needle suture products with needle/suture diameter ratios approaching 1:1 was superior to needle suture products with 2:1 needle/suture diameter ratios for use in PTFE vascular grafts, regardless of the suture material. PMID- 10171624 TI - In "biocompatibility tests on a novel glass-ceramic system" [JAB 3:217-224; 1992], by L.A. Wolfe et al., the introduction and the discussion in the article invited us to make some comments and objections. PMID- 10171625 TI - Medical devices in dentistry. AB - Medical devices in dentistry have a long history of standardization at national, European, and international levels. Testing and certification programmes are established in many countries. The challenge for dentistry today is to upgrade and integrate the current systems to the requirements of the EC Directive for medical devices. PMID- 10171626 TI - The most expensive hysterectomy. PMID- 10171627 TI - Laparoscopic surgery with a new tuned high-energy pulsed CO 2 laser. AB - Although CO 2 lasers have gained popularity in operative laparoscopy, it has been suggested that they do not deliver sufficiently high power density at the distal end of a laparoscope. Heating of the insufflation gas inside the laparoscope by absorption of some of the laser power causes the gas density to change and creates distortion and defocusing, resulting in lower power density at the tissue as the laser power is increased. A new laser uses the carbon-13 isotope in the laser gas mix instead of the carbon-12 isotope, which is used in both conventional lasers and CO 2 insufflation gas. The new laser was found to have no noticeable effect on tissue attributed to distortion or power loss from absorption in the insufflation gas, and it allowed the surgeon to work with minimal thermal side effects, such as the formation of charred tissue. The laser was fitted with separate controls for adjusting pulse energy and average power, allowing the surgeon to control the laser-tissue response at different operating speeds. PMID- 10171628 TI - Disinfection and sterilization of reusable endoscopic instruments. PMID- 10171629 TI - Bone accretion around polymethylmethacrylate and polyethylene implanted in the rabbit tibia. AB - This study examines the accretion rate of bone surrounding orthopaedic polymeric implants in different physical forms. Forty mature, female, New Zealand white rabbits were used in the study. Bilateral 6mm drill holes were made in the anteromedial tibias, 1cm from the joint line. The right tibia received a polymeric implant and the left tibia functioned as a prepared but nonimplanted control. The animals were allocated as follows: Group 1--bulk, preformed cooled polymethylmethacrylate (PMMA) plug; Group 2--bulk, doughy PMMA implant; Group 3- cement polymer powder; Group 4--bulk ultra-high-molecular-weight polyethylene (UHMWP) plug; Group 5--UHMWP particles averaging 67.29 mum; Group 6--UHMWP particles averaging 15.68 mum. All animals received the same volume of PMMA or UHMWP. The animals were killed after four months by barbiturate overdose. Beginning four weeks prior to sacrifice, the animals were given tetracycline injections at two-weekly intervals for two consecutive days. The upper tibias were harvested bilaterally and the specimens were processed undecalcified. Using a fluorescent microscope, the distance between successive tetracycline bands was assessed. Doughy PMMA tended to suppress bone formation compared to the control side, whereas preformed PMMA plugs and particulate PMMA polymer did not. This may be due to the heat of polymerization or to the presence of residual monomer in the doughy group. Polyethylene tended to facilitate bone accretion whether in bulk or particulate form when compared to the control side or to doughy cement. This effect was less marked when the cement was in particulate form.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171630 TI - How to make the most of the laparoscopic preoperative period. PMID- 10171631 TI - Imaging methods augment liver malignancy ablation. PMID- 10171632 TI - Echocardiography in valvular heart disease. AB - Clinical applications of echocardiography continue to grow and be refined with the development of newer technology and the resultant increase in clinical studies. The reliability of echocardiography applied to patients with valvular heart disease has been very well established in determining pressure gradient, stenotic valve area, right-sided cardiac pressure, and ventricular responses (dimension and global systolic function) to pressure and volume overload. Less well established are the determination of regurgitation severity, the role of echocardiography in endocarditis, and the use of the echocardiographic information in clinical decision-making. These issues have been dealt with extensively in the most recent literature. Through superb visualization of the native and prosthetic valvular apparatus by transesophageal echocardiography, new morphologic and functional observations continue to be made. PMID- 10171633 TI - Surgery for congenital heart disease. AB - Surgery for congenital heart disease has reached two important milestones. Intermediate and long-term results are available for the arterial switch operation and the modified Fontan procedure which allow us to assess their efficacy. New techniques and changes in the timing of operations have forced us to rethink older approaches and dicta. Finally, longstanding controversies continue to inspire argument as well as insightful investigation. This review highlights many of these topics. PMID- 10171634 TI - Myocardial protection and cardioplegia. AB - Over the past year there has been a tremendous enthusiasm for the novel technique of warm heart surgery. In contradistinction to hypothermic myocardial preservation, warm cardiac surgery provides for operative repair in a nonischemic heart. Warm cardioplegia can be administered in an antegrade or retrograde manner, continuously, and perhaps even intermittently. It may have beneficial effects on systemic perfusion and may be a useful adjunct in the setting of acute cardiac ischemia. There likewise has been a burgeoning enthusiasm for the retrograde cardioplegic delivery route. Many reviews of clinical work using both warm and cold retrograde cardioplegia have identified the advantage of this technique, particularly in the setting of valve replacement and reoperation for coronary revascularization. Finally, new avenues of investigation in ischemia and reperfusion including inquiry into the role of neutrophils in reperfusion injury and modification of the reduced thiol pool to modulate the postischemic burst of oxygen-free radical production. PMID- 10171635 TI - Echocardiographic detection of acute myocardial ischemia during percutaneous transluminal coronary angioplasty. AB - The usefulness of echocardiography and Doppler for the detection of acute myocardial ischemia was evaluated during right coronary artery occlusion in 20 patients. The echocardiographic findings were compared with the occurrence of chest pain, and to electrocardiographic and hemodynamic changes obtained during percutaneous transluminal coronary angioplasty. Our results confirm that, even in the case of small segmental myocardial ischemia, two-dimensional echocardiography is superior to all other measured parameters. In contrast, Doppler examination of transmitral flow is not sensitive enough for the detection of such small segmental myocardial ischemia induced by right coronary artery occlusion. PMID- 10171636 TI - Pitfalls in the echocardiographic diagnosis of intracardiac and extracardiac masses. AB - Transthoracic and transesophageal two-dimensional (2-D) echocardiography remain the procedures of choice for evaluating cardiac mass lesions. Potential errors in diagnosis can be made, however, if the mass lesion's size, shape, mobility, and attachment to other cardiac structures are not clearly delineated. Usually a left atrial myxoma arises from the interatrial septum at the level of the fossa ovalis. Pitfalls in diagnosis occur when the tumor size is very small, or its attachment site is atypical or ill-defined. Atrial thrombi classically reside in an atrial appendage, but can also form in the body of the left atrium. The presence of atrial fibrillation rhythm, enlarged atrial chamber, prosthetic mitral/tricuspid valves, stenotic mitral/tricuspid valves, low cardiac output state, and spontaneous atrial contrast echoes are all features that favor the mass in question being a thrombus. Ventricular thrombi usually occur with poorly functioning ventricles. The diagnosis of ventricular thrombus should be made with great caution if the systolic function is normal, or if the mass has a band or thread-like appearance. A thorough knowledge of normal anatomical variants that can mimic pathological lesions is also important for reaching a correct diagnosis. Last but not least, as in all testing modalities, the patient's clinical picture should be correlated with the echocardiographic findings. PMID- 10171637 TI - An overview of the patency and stroke rates following thrombolysis with streptokinase, alteplase, and anistreplase used to treat an acute myocardial infarction. AB - The results of an overview of early (90-240 min) and late (24 hours or more) patency and of stroke rates for each of the three commercially available thrombolytic agents, streptokinase, alteplase, and anistreplase are presented. Studies included in this analysis are all those published between 1985 and March 1992 and focus on the licensed dosage regimens of each agent. The rates of early and late patency for streptokinase were 64.7% and 80.8%; for alteplase, 66.6% and 73.7%; and for anistreplase, 72.1% and 84.5%. The rates of total and hemorrhagic stroke for streptokinase were 0.69% and 0.17%; for alteplase, 1.27% and 0.50%; and for anistreplase 0.91% and 0.38%. These results provided evidence that the rates of early and late patency appeared to be greatest for anistreplase and that the rates of stroke are within "acceptable" ranges for all three thrombolytic agents with streptokinase affording the lowest rate. PMID- 10171638 TI - The mass spectrometer in the clinical practice of anaesthesia. PMID- 10171639 TI - Human motor pathways: electrical and electromagnetic stimulation. PMID- 10171640 TI - Validity and reliability of an ultrasound device for detecting carotid emboli. AB - Cardioembolic mechanisms cause 15 to 20% of all strokes and may account for the high incidence of neurological dysfunction associated with cardiopulmonary bypass. Accurate identification of high-risk subjects and/or surgical techniques would allow more effective testing and implementation of preventive or therapeutic measures to help reduce morbidity and mortality. This article reports on validity and reliability testing of a new emboli detection device that allows continuous monitoring of the common carotid artery. The instrument appears to be capable of detecting accurately particles of 193 mu or less in diameter and is highly reliable both within and between observers. In preliminary clinical use, the instrument also detected embolic signals in all patients monitored during cardiopulmonary bypass, while none were detected in healthy control subjects. These results establish the validity and reliability of a new emboli detection device and suggest its potential application to emboli detection monitoring during cardiopulmonary bypass. PMID- 10171641 TI - Volumetric scans change perceptions in thoracic CT. PMID- 10171642 TI - Employment follow-up after initial drug screening. PMID- 10171643 TI - Underwriting Alzheimer's dementia. PMID- 10171644 TI - Improving disability management in the workplace. Insurance implications. PMID- 10171645 TI - The system for expanding potentials. An interdisciplinary approach to the treatment of disability. PMID- 10171646 TI - Survival in Alzheimer's disease and vascular dementias. PMID- 10171647 TI - Underwriting left ventricular hypertrophy--a review of the medical literature with an emphasis on mortality and morbidity. PMID- 10171648 TI - Morbidity and disability. PMID- 10171649 TI - The Americans with Disabilities Act. Implications for health and accident insurance. PMID- 10171650 TI - Disability income insurance: an odyssey. PMID- 10171651 TI - Bioluminescence-enhanced immunoassays: an ultrasensitive method. AB - Ultrasensitive bioluminescence immunoassays for the determination of peptides and proteins are illustrated in this paper with the enzyme immunological determination of total IgE in human serum. The usable range of standard curves is from 5 pg to 5000 pg per liter. The intra- and interassay coefficients of variation of this test are in the same range as obtained for chromogenic enzyme immunoassays. PMID- 10171652 TI - French homologation for medical devices: past and future. AB - The French approval procedure for medical devices, known as homologation, is considered to be one of the most complicated national approval processes in Europe. This article outlines some of the key elements of homologation and the major changes that have been introduced since 1991. In addition, homologation will not survive in its present form when the EC Directives come into force. The author outlines current expectations. PMID- 10171653 TI - Experience with osseous implants for bone and biomaterials research. AB - A Cancellous Access Port (CAP) osseous implant for repeated sampling of cancellous tissue was developed and tested for experimental studies of bone, marrow, and materials biocompatibility. The CAP and associated methods were shown in a series of studies to allow the repeated biopsy of unstrained cancellous tissue with little morbidity and no mortality when used in baboons, rhesus, sheep, and horses. CAP infusion, material testing, and biopsy core assemblies were developed and tested for the administration and assessment of the effects of pharmaceuticals and biologics; the placement and retrieval of a biomaterial with the surrounding tissue; and studies of cancellous bone healing and remodeling. PMID- 10171654 TI - National survey of self-reported breast implants: 1988 estimates. AB - This report provides the first population-based national estimates of the prevalence of adult women with breast implants in the U.S. These findings are based on the Medical Device Implant Supplement to the 1988 National Health Interview Survey. The overall prevalence was 33 implant recipients (95% confidence limits [CL]: 26 to 40) per 10,000 women. Almost three-fourths had two implants: prevalence peaked at 85 (59 to 100) per 10,000 for women aged 35 to 44 years. Implant prevalence was statistically significantly greater among women who were white, residents of the south and west, had higher family income, and had more education, who worked, or were slim. Among current implants, 87% were original. Complications were reported for 24% of the implants. PMID- 10171655 TI - Hematological assessment of patients undergoing plasmapheresis during cardiac surgery. AB - Methods of reducing patient exposure to homologous blood transfusions include the technique of intraoperative plasmapheresis for the production of platelet rich plasma (PRP). The present study was designed to determine the patient benefits of PRP by examining hemostatic changes in coagulation screens and viscoelastic whole blood monitoring (Thrombelastography, [TEG]). One hundred fifteen patients undergoing elective cardiac surgery were prospectively randomized into a blinded study. Sixty-three patients had 20 percent of the circulating plasma volume sequestered prior to heparinization and pheresed into PRP, which was reinfused 10 minutes following heparin reversal with protamine. The control (CTR) group of 52 patients were exposed to no sequestration procedure. Patients were followed to discharge and 112 parameters, including anthropometric, operative, and postoperative factors, were measured. There were no significant differences between patient groups in preoperative, cardiopulmonary bypass (CPB), or surgical parameters. Average PRP volume was 600+/-100 ml with a total platelet yield of 1.1 billion platelets per patient. TEG indices were determined at four distinct times during the surgical procedure. The CTR group had significantly higher pre CPB TEG indices of 2.3+/-1.2 and 2.1+/-1.2 (mean+/-SD), vs. 1.8+/-1.5 and 1.4+/ 1.7 in the PRP group (p less than .04). Following heparin reversal, pre-PRP reinfusion TEG values were similar between groups, although both groups had significantly decreased indices when compared to pre-CPB values. Thirty minutes post-PRP infusion the treatment group had significantly improved TEG recovery when compared to the CTR group, 1.0+/-1.2 vs. 0.3+/-1.7 (p less than .05).(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171656 TI - Logistical hurdles loom for stroke intervention. PMID- 10171657 TI - The assistive technology outlook. PMID- 10171658 TI - Use of a physician survey to identify opportunities for quality improvement. PMID- 10171659 TI - A survey of activation importance of individual secondary controls in modified vehicles. AB - The results of a new survey of members of the Society of Automotive Engineers Adaptive Devices Standards Committee are presented. These findings identify priorities for secondary controls when adapting vehicle controls for drivers who are physically disabled. Previous surveys conducted in this area are cited in conjunction with the results from the current survey. The results identify the secondary controls that should be considered to have the greatest and least importance when designing the driver's compartment. A summary of additional comments made by those surveyed is also presented. PMID- 10171660 TI - Applying robotic technology to aid people with severe disabilities. AB - Researchers at Rice University and the Baylor College of Medicine in Houston have developed a prototype robotic aid for people with severe disabilities, with emphasis on low cost, versatility, and ease of use. Using custom software written for the Macintosh? line of personal computers and a custom input device that emulates a mouse, a user can command a modified HERO 2000? robot to perform simple fetch and carry tasks in a structured indoor environment. Further interaction with the environment is possible using a household appliance controller that is also interfaced to the computer. PMID- 10171661 TI - Hydroxyapatite-coated strain gauges for long-term in vivo bone strain measurements. AB - The aim of this study was to examine the bonding process between hydroxyapatite coated strain gauges and bone in order to continue development of a long term in vivo strain measurement device. Two types of commercially available hydroxyapatite (HA) particles were applied to the sensing surface of uniaxial strain gauges using a polysulfone solution as an adhesive. Characterization by scanning electron microscopy and x-ray diffraction (XRD) was used to determine materials property differences between the two powders. Interfacial strengths between the HA coatings and the strain gauges were tested and found comparable to interfacial strength obtained by a plasma sprayed HA coating on the surface of a titanium implant. Gauges were surgically placed on the periosteal surface of greyhound femora. Three groups of dogs were implanted with gauges for periods of 3, 6, and 12 weeks using cyanoacrylate, resorbable sutures, and cable ties to initially hold the gauge against the surface of the bone. Following euthanasia, the femora of the dogs were explanted and subjected to cantilever loading. Response of the implanted HA-coated gauges were compared to a control set that had been freshly glued onto the contralateral femur. Full response, that is, 100% of the strain measurement with respect to the control, was obtained after 12 weeks in vivo. Attachment of HA-coated gauges with circumferential suture showed bonding, while HA-coated gauges attached with cyanoacrylate did not bond to bone. After mechanical testing, femora were embedded in polymethylmethacrylate, cut, ground, and polished. Sections were stained using mineralized bone stain (MIBS) and optical microscopy was performed using transmitted and fluorescent light to allow analysis of remodeling occurring in the region of the strain gauges. Bone formation occurred at the HA surface of sutured gauges, and a fibrous tissue layer developed between the bone and HA coating when the tissue adhesive was used to initially bond the gauge. Fluorescence microscopy indicated an increase in the number of areas of bone remodeling adjacent to the gauge but a normal rate of remodeling of 0.93 +/- 0.07 mum/day was observed. No gross bone remodeling due to strain gauge placement was observed. Backscattered electron imaging (BSE) indicated new bone apposition at all time periods. PMID- 10171662 TI - Evaluating managed mental health programs. PMID- 10171663 TI - NIDRR plans for the future. AB - For over 5 years now, the National Institute on Disability and Rehabilitation Research (NIDRR) has not had a well-defined, written long-range plan. A new plan is needed to establish a research agenda for NIDRR. This article outlines steps taken in the development of the long-range plan. As well, it describes outcome areas, goals, and objectives underlying the plan's overall focus: empowering persons with disabilities to achieve maximum freedom and independence. Dissemination connects research and empowerment. The use of disseminated knowledge is a key factor in the long-range plan's elements. NIDRR and its grantees employ four basic dissemination strategies: spread, choice, exchange, and implementation. These strategies, with examples of their application, are briefly discussed. The article also defines "participatory research," a practice in which those who will benefit from the research are deeply involved throughout the process. As well, the article defines participatory research's importance in the long-range plan. PMID- 10171664 TI - Predictors of assistive technology abandonment. AB - Technology abandonment may have serious repercussions for individuals with disabilities and for society. The purpose of this study was to determine how technology users decide to accept or reject assistive devices. Two hundred twenty-seven adults with various disabilities responded to a survey on device selection, acquisition, performance, and use. Results showed that 29.3% of all devices were completely abandoned. Mobility aids were more frequently abandoned than other categories of devices, and abandonment rates were highest during the first year and after 5 years of use. Four factors were significantly related to abandonment--lack of consideration of user opinion in selection, easy device procurement, poor device performance, and change in user needs or priorities. These findings suggest that technology-related policies and services need to emphasize consumer involvement and long-term needs of consumers to reduce device abandonment and enhance consumer satisfaction. PMID- 10171665 TI - Comparative studies of the toxicity of standard reference materials in various cytotoxicity tests and in vivo implantation tests. AB - Polyurethane films that contained various amounts of zinc diethyldithiocarbamate (ZDEC) and zinc dibutyldithiocarbamate (ZDBC) were prepared as standard reference materials (SRM). Using three cell lines of V79, L929, and Balb/3T3 cells, the cytotoxicity of the dithiocarbamates and the SRM films were compared by agar diffusion assay, filter diffusion assay, neutral red assay, cell growth assay, and colony assay. Among these in vitro cytotoxicity tests, colony assay was found to be the most sensitive method for detecting the cytotoxicity. The cytotoxic potentials of extracts from SRM films correlated well with the concentrations of ZDEC or ZDBC involved in SRM. When various rubber materials including SRM and surgical rubber latex materials were tested, cytotoxic potentials of these extracts were also correlated with the inflammatory tissue capsule thickness in short-term implantation tests. On the basis of these results, the SRM is judged to be useful for validating test sensitivity, and comparing the correlation between in vitro and in vivo responses. PMID- 10171666 TI - The influence of flange compliance and mechanical loading on the tissue response to percutaneous devices. AB - The failure of most percutaneous devices (PD) is caused by infection initiated by a lack of a tight seal at the skin-device interface. This interface can be disrupted by both extrinsic and intrinsic forces. Many stress reduction methods have been proposed, the most common being the application of a subcutaneous flange. It is widely believed that the bending compliance of the flange plays a significant role in the success or failure of a PD. A study was conducted to observe the effect of flange compliance on local host response in both a functional and nonfunctional setting. Two PDs having flanges with different bending rigidities were implanted percutaneously in goats (n = 8). After a healing period of 2 weeks, half of these devices were externally stimulated with a random load. All the implants were retrieved after 4 weeks and evaluated histologically. The tissue capsule was significantly thicker and the incidence of severe fibrosis and/or necrosis was higher at the flange rim of the functional implants, irrespective of flange compliance. The more compliant devices were encapsulated with a thick fibrous capsule more frequently than the less compliant ones, irrespective of functional status. The more compliant devices also had a greater incidence of foreign body giant cells in the corner region and elicited severe acute inflammation at the corner and top of the flange more frequently than the less compliant implants.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171667 TI - Technology development from the perspective of industry. PMID- 10171668 TI - Development of a scale to measure barriers to health promotion activities among persons with disabilities. AB - Subjectively-defined barriers to engaging in health promoting activities are one of the most important, yet least well operationalized, components in our models of health promotion. This article describes the development of a tool to measure barriers to health promotion among persons with disabilities. The Barriers to Health Activities among Disabled Persons scale (BHADP) is comprised of 16 items reflecting barriers to taking care of one's health identified from previous barriers literature and interviews with disabled persons. In a study of 135 disabled adults living in two southwestern cities, the BHADP yielded a Cronbach Alpha of .82 as a measure of internal consistency reliability. In addition, t test analyses demonstrated a significant difference in scores between the disabled sample and a comparison group of 144 nondisabled adults, suggesting the BHADP discriminate between these groups. The BHADP may be useful in sensitizing health care providers to the wide range of barriers experienced by persons with disabilities, thereby enabling them to work more effectively with this special population. PMID- 10171669 TI - The relationship of physical activity and cardiovascular fitness to absenteeism and medical care claims among law enforcement officers. AB - BACKGROUND: Previous research has shown an inverse relationship between cardiovascular fitness and both absenteeism and health care costs. The documentation of these relationships with law enforcement officers will support the usefulness of providing health promotion programs for this population. METHODS: Data were collected over a one-year period to examine the relationship of physical activity and cardiovascular fitness to absenteeism and medical care claims among law enforcement officers (N = 734). RESULTS: Analysis of covariance indicated that sedentary officers were absent significantly more often than active officers; also, female officers were absent significantly more than male officers. Although proportionally more female officers than males scored above the 50th percentile on fitness (based on Cooper's norms), increased fitness for females was not related to decreased absenteeism. Increased fitness for male officers was related to decreased absenteeism. Medical care claims for a sub sample of male officers (N = 363) were lower for more fit and more active officers, although this relationship was nonsignificant. DISCUSSION: These observational data strengthen the hypothesis that absenteeism levels of physically active officers are lower than those of sedentary officers. For females, the relationship of absenteeism to family issues associated with child care and pregnancy leave in the workplace appears worthy of examination. PMID- 10171670 TI - Using guiding-idea theories of the person to develop educational campaigns against drug abuse and other health-threatening behavior. AB - Educational campaigns against health-threatening behaviors such as drug abuse may lose effectiveness because they tend to be narrow, atheoretical and to stress negative effects. As a corrective, it is proposed that health campaigns take into account the broad range of human needs and consider how the health threatening behavior may be gratifying to each need. This allows taking into consideration not just the bad effects (which tend to be obvious) of such behaviors as drug abuse, but also the gratifications they provide to a variety of human needs, by their associated lifestyles as well as by their pharmaceutical effects. In this way anti-drug campaigns can be made to cope more relevantly with the attractions of such health-threatening behaviors. We sketch 16 theorized human needs, widely contrasting in their assumption of what instigates human action and what terminates it, each of which theories has proven provocative in guiding basic research. From each of the 16 theories some implications are drawn regarding the attractions of drug abuse and regarding the design of educational campaigns against such health-threatening behaviors. PMID- 10171671 TI - A review and assessment of non-governmental organization-based STD/AIDS education and prevention projects for marginalized groups. AB - A review of projects run by non-governmental organizations (NGOs) in primarily developing countries, which have aimed to provide STD/AIDS education and prevention skills to various marginalized groups, reveals that past quantitative and formative research has failed to identify key programmatic factors which lead to more successful project implementation and sustainability. In observations, interviews with field staff, visits to program sites and information drawn from the literature, a variety of methods to reach a wide range of groups such as men who have sex with men, prostitutes, clients of prostitutes, prisoners, street children, migrant workers and refugees are explored. Factors found to facilitate project success include the following: at least one full-time committed staff member; respectful treatment and appropriate motivation of the target group; suitable and sufficient equipment and supplies (particularly condoms); planning ahead for the participation of HIV-positive individuals and ways to meet their needs; focusing on qualitative rather than quantitative evaluation; planning in advance beyond a 9 or 12 month 'model'. Despite some evidence that marginalized groups can be successfully motivated to practise safer sex through prevention education, long-term behaviour change still presents major challenges--even when specific conditions are met. PMID- 10171672 TI - School-based substance abuse prevention: a review of the state of the art in curriculum, 1980-1990. AB - Substance use prevention studies published between 1980 and 1990 are reviewed for content, methodology and behavioral outcomes. Studies were classified based on the inclusion of 12 content areas: Information, Decision Making, Pledges, Values Clarification, Goal Setting, Stress Management, Self-Esteem, Resistance Skills Training, Life Skills Training, Norm Setting, Assistance and Alternatives. Six groups of programs (Information/Values Clarification, Affective Education, Social Influence, Comprehensive, Alternatives and Incomplete programs) are identified. Reports are analyzed for two major threats to validity, selection bias and statistical power. Program groups generally have similar selection biases but have important differences in statistical power. Comprehensive and Social Influence programs are found to be most successful in preventing the onset of substance use. PMID- 10171673 TI - Tips for monitoring the position of a central venous catheter. How placement can go awry--even when the anatomy is normal. AB - Malpositioning of a central venous catheter can cause potentially life threatening complications. Knowledge of thoracic anatomy and close attention to proper insertion technique increase the likelihood of, but do not ensure, proper placement. Selection of a right-sided venous entry site reduces the risk of malpositioning. The return of nonpulsatile, dark-colored blood is a strong, but not infallible, indication of venous placement. Do not assume that venous system valves preclude malpositioning. Use chest films to confirm accurate insertion. When these are equivocal, take simultaneous blood samples from a peripheral artery and the central line; the samples will have markedly different blood gas levels if the catheter is in a vein. PMID- 10171674 TI - Angioscopy in peripheral vascular disease: current status and future prospective. PMID- 10171675 TI - The effect of dissolution on plasma sprayed hydroxylapatite coatings on titanium. AB - Plasma sprayed hydroxylapatite (HA) coated titanium specimens were immersed into Ca-free Hank's balanced salt solution for periods of 1, 2, 4, and 6 weeks. At each of the respective time intervals the HA coatings were analyzed with X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FTIR), and Raman spectroscopy to determine the effect of dissolution on the structure and composition of the coatings. At the 2- and 6-week intervals, additional samples were removed from solution and shear tested to evaluate the effect of dissolution on the coating-to-substrate interfacial bond strength. XRD results revealed that the plasma sprayed coatings retained their basic apatitic structure throughout the 6-week period in solution. There was, however, a trend towards a more definitive baseline, suggesting a loss of amorphous material by dissolution. FTIR and Raman analyses of the as-sprayed and dissolution specimens showed that the phosphate groups were not lost during the time in solution; however, there was a decrease in hydroxyl content as a result of dissolution mechanisms. FTIR also revealed an increase in carbonate content within the coating during immersion in the simulated physiological balanced salt solution. The average shear bond strengths for the as-sprayed, 2-, and 6-week dissolution specimens were 14.82+/-3.52 MPa, 12.51+/-3.41 MPa, and 12.54+/-2.02 MPa, respectively. Duncan's multiple range test confirmed that the shear bond strength was not significantly reduced after 6 weeks in solution, but there was evidence that suggested a decrease in interfacial bond strength as a result of dissolution mechanisms. PMID- 10171676 TI - Ambiguity persists over uses for MR of breast. PMID- 10171677 TI - Nuclear medicine aids clinical war on drugs. PMID- 10171678 TI - The drug-device interface. AB - The difference between a drug and a device appears clear, but there are instances when the distinction between a product being a drug or a device is blurred. By making reference to the EC Directives for medicinal products and medical devices, this article seeks to clarify the definition of a medical device that incorporates or administers a drug. PMID- 10171679 TI - Through the labyrinth. PMID- 10171680 TI - A scramble for facts. PMID- 10171681 TI - Beyond the ADA. PMID- 10171682 TI - Criminal justice and the drug-abusing offender: policy issues of coerced treatment. AB - Criminal justice populations, including arrestees, probationers, inmates and parolees, have become increasingly involved with drugs of abuse. These numbers have seriously impacted the criminal justice system from enforcement to the courts, corrections, and subsequent legal supervision agencies. Prevalence of substance abuse in these populations is reported, as well as the effectiveness of community-based and corrections-based treatment in effecting behavioral changes to reduce drug demand. The characteristics of successful intervention programs are described and an ideal model proposed for better integrating community treatment and criminal justice intervention efforts. PMID- 10171683 TI - Medicalizing the drug war. AB - Recent findings in the field of psychopharmacology pertain to the abuse of drugs and alcohol among criminal offenders and have implications for new management techniques. Drugs of abuse exert their effects on areas of the brain responsible for pleasure, providing a powerful reinforcement for drug usage. Furthermore, there is a prevalence of psychological, psychiatric and social dysfunctions that antedate drug use which are identifiable at an early age. It is suggested that drugs of abuse differentially influence users via these biological, psychological and social mechanisms, reinforcing the development of serious and chronic abuse in a vulnerable subgroup. Studies of drug abuse specially indicate that within this subgroup, antisocial behavior precedes and exacerbates drug abuse, and multiple risk factors contribute to the concomitant development of criminality and drug abuse. Early detection and comprehensive treatment of underlying disorders that may both precipitate and result from drug abuse promise to improve possibilities for prevention and reducing relapse rates. Furthermore, the inclusion of pharmacologic treatments may further enhance the success of conventional drug treatments. This article proposes that incorporating scientific data and medicalizing our approach to drug abuse is essential to win the war against drugs. PMID- 10171685 TI - Comparison of blood gas and electrolyte test results from the Gem-Stat and CDI 300 versus a conventional laboratory analyzer. AB - Continuous blood gas monitoring devices have been an aid to the perfusionist since the introduction of the oxygen saturation meters of the early 1980s. Since that time, the perfusionist has had to decide between continuous versus intermittent sampling, and on-line (an analyzer that can automatically sample either at prescribed intervals and/or on demand) versus in-line devices (monitors that continuously sample and display results). This report compares the continuous, in-line CDI-300 blood gas monitor and the Mallinckrodt Gem-Stat blood gas analyzer using intermittent sampling with the Corning 278 blood gas analyzer and 2500 Co-Oximeter. Thirty samples were taken, one per 30 patients, for comparison. Five samples were disqualified from the study. When comparing the remaining 25, the Gem-Stat results to the Corning 278 blood gas analyzer results, all measured values (arterial pH, pCO 2, pO 2, venous pO 2, Na, K and Hct) correlated greater than 0.5000 with a p value of less than 0.001. The exception was the ionized calcium value which had a correlation of 0.2473 with a p value of less than 0.232. When comparing the CDI-300 results to the Corning 278 blood gas machine results, all measured values (pH, pO 2, pCO 2, and venous pO 2) correlated greater than 0.5000 with a p value of less than 0.003 or better. When comparing the Gem-Stat results to the CDI results, all measured values (pH, pCO 2, pO 2 and venous pO 2) correlated greater than 0.5000 with a p value of less than 0.002 or better. PMID- 10171684 TI - Use of a new malleable implant as a bone substitute in maxillofacial surgery. AB - Biocompatible osteoconductive polymer (BOP) has been used since 1979 as a substitute for bone in orthopedic surgery and neurosurgery. To date, in maxillofacial surgery, loss of bone volume as a result of either trauma or osteoporosis has been compensated for by autologous bone onlay graft or subperiosteal apposition grafts of synthetic materials. Neither of these solutions is entirely satisfactory. Autologous bone is subject to reabsorption, requiring initial overcorrection and multiple reoperations to achieve an acceptable result. Preshaped implants of Proplast, Vicryl, Gore-Tex, or silicone do not offer much flexibility, and coral granules and hydroxyapatite are difficult to handle. Finally, all foreign materials can elicit problems with tolerability. In its SP (solution/powder) form, BOP is a paste that can be molded precisely to the required shape, making it ideal for maxillofacial surgery. This study examined the long-term tolerability and facial alterations after implants of BOP in 11 patients who underwent post-trauma and cosmetic surgery. PMID- 10171686 TI - Tracking and surveillance of patients with medical devices and implants. AB - The United States Congress and FDA recently proposed modifications to the regulation for the tracking of certain medical devices and implants that will place significant demands on the manufacturers and importers of those products. The regulation, which comes into effect in August this year, will require the industry to carry out not only tracking of those devices or implants to the end user, but also continued observation of the device user or implant recipient throughout the life of the patient or the device. In this article, the author outlines FDA requirements and advises how best to meet those demands. The important elements for setting up a patient-tracking programme are discussed; these include the use of a Patient Registry as a basis for tracking and the importance of confidentiality throughout the tracking process. PMID- 10171687 TI - Ceramics for human clinical use. PMID- 10171688 TI - In-vitro evaluation of the cytocompatibility of wear particles generated by UHMWPE/zirconia friction. AB - Cytotoxicity of wear products generated by UHMWPE/yttria partially stabilized zirconia (YPSZ) friction and UHMWPE/surface-nitrided Ti-6Al-4V friction in pseudo extracellular fluid (PECF) at 37 degrees C was evaluated. Though the amount of abraded UHMWPE against YPSZ was almost the same as that against nitrided Ti-6Al 4V, the wear products generated by UHMWPE/YPZ friction significantly inhibited cell growth while those by UHMWPE/nitrided Ti-6Al-4V friction showed no growth inhibition. Dissolved Zr and Y ions were at least 70 times less than the amount causing growth inhibition. The cytotoxicity was caused mainly by the particles less than 0.22 mum in size. Amorphous zirconium-containing particles (5-20 nm) found in the PECF, formed presumably by stress corrosion, would be a responsible factor for the cytotoxicity. PMID- 10171689 TI - Ceramic composites for biomedical applications. AB - Ceramics have been successfully used for more than twenty years for orthopaedic prostheses, as articulating bearing surfaces against ceramic or polymer components. In both cases, ceramics are characterized by low friction coefficient and low wear rate, compared to metallic materials (stainless steels, titanium and chromium-cobalt alloys). However, their brittleness is much higher than that of metals and presently restricts the use of ceramics for hip joint balls or knee condyles. In the material science field, it is very well known that the association of two different materials can lead to new materials, often called 'composites'. Their properties can be higher than the same properties of each of the individual materials, when taken separately. Nevertheless, the word 'composites' is not universally used with the same meaning. For this reason, we will first give a few definitions in order to clearly understand what can be called 'composite' for ceramic materials. Dispersed phases increase the fracture toughness and high temperature mechanical behaviour of ceramics. In this paper, devoted to medical applications, only mechanical properties at the low (body or room) temperature are analysed. Particular attention is given to the alumina zirconia system, because aluminium and zirconium oxides are currently accepted as biomaterials for joint prostheses. Finally, a highlight is given on the difficulties in the technological processes to obtain improved ceramic composites. PMID- 10171690 TI - Use of a modified nominal group process for improving laboratory performance in human immunodeficiency virus type 1 antibody testing. Reaching consensus on three questions concerning HIV-1 testing. AB - Using expert panels of medical technologists and public health microbiologists, a modified nominal group process was used to reach a consensus on three questions concerning current human immunodeficiency virus type 1 (HIV-1) testing methods. The questions related to important sources of error, improving the testing process, and improving proficiency testing. The modified nominal group process proved to be effective in developing lists of errors in laboratory testing; it provided a fast, economic means of identifying possible areas for improving laboratory quality assurance and training programs. For the HIV testing model, the focus group panelists indicated laboratory pipetting errors, labeling, and specimen identification as the most important sources of error. To improve the quality of this testing, the panel recommended standardizing test interpretation and restricting testing to laboratories licensed to perform HIV-1 testing. To improve proficiency testing, the use of blind specimens and establishing minimum standards of performance were suggested. PMID- 10171692 TI - Long-term care design: emerging trends. PMID- 10171691 TI - Laboratory apprenticeships: a look back in history or a new paradigm? AB - The reality of the world and the workplace is changing rapidly, and continuing the "old" ways will not provide the solutions needed to address the problems the health-care industry faces today. "The organization of the laboratory, as we now know it, will change. An environment in which every instrument is run by highly trained medical technologists is not likely to be the norm. Instead, laboratories will be staffed by lesser trained technicians under the direction of a limited number of medical technologists.... Licensing and regulatory trends for laboratories will support the downgrading of the average level of laboratory expertise required to perform tests". Similarly, in 1993 a regional director of the National Labor Relations Board (NLRB) ruled that many medical technologists do not meet the NLRB definition of professional because they perform highly automated and routine work that does not require the consistent exercise of discretion and judgment. Does the laboratory industry need to have all of its work done by highly trained medical technologists? A look at current laboratories would seem to answer that question as "no." On the other hand, do we need highly trained medical technologists in the laboratories? The answer is yes, but it is apparent that medical technologists of the future need to prepare themselves in new ways to address future demands on the profession.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171693 TI - Long-term care design: blazing new territory--code reform & beyond. PMID- 10171694 TI - Beware of spinal implants' hidden costs: 'loaners' at a premium price. PMID- 10171695 TI - Medicare, Medicaid and CLIA programs; regulations implementing the Clinical Laboratory Improvement Amendments of 1988--HCFA. Final rule; correction. AB - In the January 19, 1993 issue of the Federal Register (FR Doc. 93-1169) (58 FR 5215), we updated the rules concerning requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA). We have identified an error in the text of the regulations and we are correcting it in this notice. PMID- 10171696 TI - Robots in the operating room. PMID- 10171697 TI - Two new studies released by Wyeth-Ayerst and Marion Merrell Dow benefit planners. AB - The 1993 editions of the Wyeth-Ayerst Compendium of Hospital Economics and the Marion Merrell Dow Inc. Managed Care Digest, HMO Edition will provide new data for hospital strategists. Several planners offer their recommendations on how to interpret secondary data resources. PMID- 10171698 TI - Are you ready for a CLIA inspection? AB - Despite talk within the Clinton administration of watering down the Clinical Laboratory Improvement Amendments (CLIA) of 1988, currently CLIA is the law of the land. Federal officials say that physicians shouldn't expect any significant changes in the law until 1995 at the earliest. Already, surveyors have begun inspecting physician office laboratories across the country. This article, written by staff from ASIM's Medical Laboratory Evaluation (MLE) program, explains how to prepare your lab for inspection. The article originally appeared in "Focus On ... Physician Office Laboratories," a newsletter for MLE participants. More information on MLE is available by calling (202) 835-2746, ext. 274. PMID- 10171699 TI - Proficiency testing requirements under CLIA '88. American Society of Internal Medicine. PMID- 10171700 TI - The personal and the political. Medical attitudes toward disability. PMID- 10171701 TI - An update on ready-to-use intravenous delivery systems. AB - The advent of ready-to-use intravenous (IV) delivery systems, particularly small volume parenterals less than 250 mL has contributed greatly to pharmacy and patient care. Since their introduction in the late 1970s, the availability and variety of systems have increased. The purpose of this article is to update practitioners on small-volume parenterals systems that have a large product availability requiring little manipulation to make the system patient-specific. Additional benefits such as extended stability, potential for decreasing waste of products, as well improved end-quality are also discussed. With the benefits described that these systems have over the traditional method of preparing small volume parenterals, there is still hesitation to fully utilize these systems. The primary reason for this seems to be the issue of cost. With various rebate incentive programs offered by manufacturers as well as the benefits that the systems provide, ready-to-use IV delivery systems are comparable in price to the traditional method of preparing small-volume parenteral agents. PMID- 10171702 TI - Employer health insurance plans and the ADA: new EEOC guidelines will cause collision. PMID- 10171703 TI - Needs assessment: developing an economic approach. AB - Health authorities and health boards in the UK are required under the provisions of the NHS Act, 1990, to assess the needs of their resident populations for health care and, through contracting, to act as purchasers of services informed by those needs. This paper presents an economic approach to informing the purchaser on priority setting for contracting. For illustrative purposes, the technique is applied to services for elderly people with dementia. The paper demonstrates that an economic approach to needs assessment is both desirable and practicable. PMID- 10171704 TI - Standards for histories, physical exams revised for consistency. PMID- 10171705 TI - The ventricular assist device patient. AB - This article provides an overview of ventricular assist devices, which are mechanical pumps that circulate blood within the body. At the present time, these devices are used to provide a "bridge to transplantation" of the heart or to maintain adequate circulation while the heart recovers from injury. Permanent implantation of these devices may soon become a reality. Use of this technology can tremendously impact the recipient's life and adaptation to their circumstances may be difficult. Topics related to the process of adjustment are presented. These include quality of life issues such as optimization of patient care, dealing with the occurrence of complications, limitations in mobility, and possible termination of support. Facing these issues requires great courage and will likely affect personal growth and deepen relationships. Caregivers can be instrumental in helping to meet the basic physical, emotional and spiritual needs of these patients. PMID- 10171706 TI - Transplantation: a team approach. The chaplain's role: a cardiac surgeon's view. PMID- 10171707 TI - Do you know how much to charge? PMID- 10171708 TI - Giving patients a bigger say in choosing treatment. Interview by Berkeley Rice. PMID- 10171709 TI - Outpatient surgery moving out of hospitals. PMID- 10171710 TI - Minimally invasive surgery: a payer's point of view. AB - For insurers, the decision to provide coverage for a new technology sets in motion a series of events that can cause real dilemmas. Ordinarily, a new technology, once covered as a benefit, expands in utilization, sometimes dramatically. The trick for the insurer is too determine how much of this new utilization is appropriate and how much is not. Failure to gain control of the technology can contribute to further cost increases. PMID- 10171711 TI - Injuries cut with lift use in ergonomics demonstration project. AB - Over the years, many types of programs have been instituted in attempts to reduce the incidence of back injuries in the long term care industry. However, incidence rates continue to climb. PMID- 10171712 TI - A new approach to nursing home layout and work patterns. PMID- 10171713 TI - Physician self-referral: empirical evidence and policy implications. AB - Ownership of health care businesses to which physicians refer patients but at which they do not directly provide services, has become commonplace in recent years. Perhaps these self-referral arrangements, known as "joint ventures," have proliferated because they are lucrative investments whereby physicians can earn legalized kickbacks for patient referrals. This article reviews existing empirical studies documenting the effects of physician self-referral arrangements. The general concensus of the empirical evidence on physician self referral reveals that the financial incentives inherent in such arrangements are associated with increased utilization of services and higher costs to patients. None of the studies to date, however, has been able to determine whether the increased utilization that accompanies the practice of physician self-referral represents inappropriate or unwarranted services. Policy options which address the problem of physician self-referral are also discussed. PMID- 10171714 TI - Estimating the effect of new technology on Medicare Part B expenditure and volume growth: do related procedures matter? AB - The new Medicare Part B physician reimbursement system requires the Health Care Financing Administration to consider how medical technology contributes to growth in service volume. One estimate of this effect has been made by the Physician Payment Review Commission (PPRC), which estimated how individual new technologies have influenced volume growth. This paper extends the PPRC analysis to include both new technology services and those services that are complementary, or related to, the new technology services. The results show that adjusting for related procedures can increase the estimated cost of new technology by as much as 50 percent. In addition, related procedures can increase the estimated share of volume growth attributable to new technology by as much as 42 percent. This implies that both new and related procedures should be used when implementing physician payment reforms. PMID- 10171715 TI - Core Services Committee recommendations. National Advisory Committee on Core Health and Disability Support Services. PMID- 10171716 TI - Predictors of in-home and out-of-home service use by family caregivers of Alzheimer's disease patients. AB - Few studies have examined whether the use of different types of services is predicted by different characteristics of elderly care recipients and primary kin caregivers. Most research aggregates services into a single category, thereby assuming that different services have the same predictors. This investigation differs from the aggregation approach by comparing four groups of elderly care recipients: in-home service of users, out-of-home service users, users of both in and out-of-home services, and those who do not use services. Data come from personal interviews with 171 family caregivers of mild to moderate dementia patients who reside in the community. Using the modified Andersen framework and multiple group discriminant analysis, results show that care recipients who do not use services and those using only in-home services have inadequate informal supports, more emotionally strained caregivers, and more functionally impaired care recipients compared with users of out-of-home or both in- and out-of-home services. PMID- 10171717 TI - Managing quality on an orthopedic service: ileus in the lumbar spinal fusion patient. AB - As healthcare providers, nurses in an acute care setting have the opportunity to review and evaluate the impact of their care delivery. The orthopedic nursing staff at a not-for-profit tertiary care community hospital in Michigan decided to undertake this challenge when they began to pursue a quality management (QM) review of patients admitted to their unit. The QM study targeted the elective surgical candidate admitted for a lumbar decompression with spinal fusion. The quality care issue focused on the complication known as an abdominal ileus. Two basic questions helped the staff to establish the indicators within this project: (1) what common variables could be measured within the high-risk patient population, and (2) by assessing these variables within the plan of care, could a link or association be made to reduce the incidence of the ileus complication? PMID- 10171718 TI - Substance abuse: one anesthesiologist's perspective. PMID- 10171719 TI - A close-up look at laparoscopic instrument costs. AB - Clearly, the choice between single-use and reusable laparoscopic instruments encompasses a number of complex issues. We found that hospitals in this study could replace existing reusable instruments with disposables--without meaningful impact on total costs. Such change would also have important benefits not quantified in this study. These include reduced risk of postoperative infection and transfer of blood-borne pathogens resulting from improper cleaning and sterilization, improved instrument performance, and reduced risk of employee injury. Given the importance of the single-use versus reusable decision, each hospital needs to analyze its own, specific situation. With input from surgeons, administrators, and OR, infection control and sterile processing staff, each institution can make an informed decision consistent with its cost and patient care objectives. PMID- 10171720 TI - Cost-containment strategies for centers offering open heart product lines: one conceptual model. AB - Those hospitals currently offering cardiovascular service lines must look carefully at cost and outcome criteria. Certain considerations, such as the aging population, declining reimbursement rates, more critically ill patients and advances in healthcare technology, may be cause for many hospital administrators to rethink the viability of offering open heart services. The sometimes brutal competition in healthcare threatens the existence of many smaller programs. Some may argue that the corporate culture of healthcare is fast becoming more and more bottom-line oriented. True, the bottom line is important, but at what point is quality affected? The concept of managed care and capitated fees has, in effect, sent third-party payers into a "feeding frenzy" with respect to contract negotiations. This often results in the pitting of one hospital or doctor against another in what could be argued to be a calculated effort to drive down cost. Health-service organizations performing open heart surgery must understand a multitude of political and economic factors in order to provide cost-effective care. At the top of the priority list must be quality of care. Programs which experience low mortality/morbidity rates will be those facilities that consumers and payers choose. In fact, adjusted mortality/morbidity reports are already a reality in some states. Successful heart programs will be those known in the community (and, perhaps more importantly, to payers) as "centers of excellence," which offer customers high-tech and cost-conscious healthcare. Paramount to successful heart programs will be variables such as favorable managed-care contracts, program size, peer review and proactive case management.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171721 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); reimbursement of providers, claims filing, and participating provider program- DoD. Correction to final rule. AB - This document contains corrections to the final rule which was published Friday October 1, 1993 (58 FR 51227). The final rule publication omitted two attachments to the preamble: first, a report on analysis conducted to support agency consideration of public comments and, second, a list of ambulatory surgical procedures subject to the reimbursement rules in section 199.14(d). Also, the supplementary section of the final rule stated, in error that new ambulatory surgery reimbursement procedures would be implemented January 1, 1994. This document supplies the missing attachments, and corrects the implementation date for the new ambulatory surgery reimbursement procedures. PMID- 10171722 TI - Sexual behavior in residents with dementia. Guidelines explain how to respond. PMID- 10171723 TI - Alzheimer's care heads for a new destination. PMID- 10171724 TI - Preadmission discharge planning shortens LOS (length of stay) for elective orthopedic surgery. PMID- 10171725 TI - European regions come of age. PMID- 10171726 TI - Don't phlunk that physical. PMID- 10171728 TI - Spreadsheet templates for calculating precision according to NCCLS (National Committee for Clinical Laboratory Standards) guidelines. PMID- 10171727 TI - Do elderly Medicaid patients experience reduced access to nursing home care? AB - This paper uses data from the National Long-Term Care Survey and the Area Resources File to analyze the problem of diminished access to nursing home care for elderly Medicaid patients. Using a proxy for the length of time on a waiting list before nursing home entry as my measure of access, I find evidence suggesting that nursing home operators in some areas preferentially admit private patients. Waitlisting of Medicaid patients appears to be a problem mainly in counties in which a high proportion of potential nursing home patients are private and counties in which bed supply is low. PMID- 10171729 TI - Michigan hospital sues state over rival's open-heart CON; detractors question numbers. PMID- 10171730 TI - Judge says Mich. hospital can't sue state to protest its rival's open-heart CON. PMID- 10171731 TI - Nursing turnover times examined by specialty. Part 2. PMID- 10171732 TI - Staying competitive in minimally invasive surgery. PMID- 10171733 TI - Laparoscopic surgery costs, demand up. PMID- 10171734 TI - Robots for health care. PMID- 10171735 TI - Collaborative patient care protocols: a development process. AB - Computerization of these protocols is in progress. This project is funded for one year with projected completion in January 1994. This study will form a framework in which further research can be completed. Utilizing protocols will allow the measurement of nursing decision making by testing relationships between parameters and interventions and by identifying rules for decision making. For example, questions that may be answered include which physiologic parameters do clinicians treat and in what order or priority, as well as what is the impact on patient outcomes in regard to cost of care and complications. Computerized patient care protocols can be further developed to meet patient-specific needs. A computerized data base will facilitate managing large amounts of patient data and tailoring instructions to these patients. One of the goals of this project was to measure the feasibility of developing computerized patient care protocols and implementing them in a critical care setting. Eventually, this experience will facilitate implementing computerized protocols at other sites. An additional benefit is the ability to implement continuous quality improvement strategies in a prospective manner rather than by retrospective review. PMID- 10171736 TI - Is hospice care appropriate for Alzheimer patients? AB - Hospice care can benefit late-stage Alzheimer's patients, but caregivers and families must first be aware of the complications and treatment difficulties that often accompany Alzheimer's disease. From this awareness they can determine whether and when hospice care is appropriate for their patients or loved ones. PMID- 10171737 TI - Benchmarking hospital laboratory financial and operational performance. AB - The movement toward more integrated delivery systems requires hospital administrators, medical staffs, and health care network organizations to consider strategies that will meet the future challenges facing laboratory services. Many health care experts predict that the number of hospital inpatient days, staffed acute care beds, and length of stay will continue their precipitous decline, and then stabilize during the next four to five years. Hospitals should carefully evaluate how their laboratories might be affected as a result of the decline in inpatient services and the integration of health care services at all levels. Hospital executive management must find a way to manage staffing levels and technical resources in order to maintain quality patient services in the face of declining test volume. This Special Report discusses relevant benchmarks intended to help hospital administrators and laboratory directors identify "best practices" in hospital laboratories so that comparisons of patterns of care and financial operations can be made. Benchmarking the relative financial and operational performance of hospital laboratories allows health care planners to design the most appropriate laboratory services delivery system for future hospital inpatient and outpatient market demands. Factors influencing financial and operation performance will be investigated, including utilization, testing costs, staffing mix, productivity, and organizational structure. This will be followed by a discussion on the future of laboratories and the trend toward regional laboratories owned by hospital consortiums. PMID- 10171738 TI - Medicare program; Part A premium for 1994 for the uninsured aged and for certain disabled individuals who have exhausted other entitlement--HCFA. Notice. AB - This notice announces the hospital insurance premium for calendar year 1994 under Medicare's hospital insurance program (Part A) for the uninsured aged and for certain disabled individuals who have exhausted other entitlement. The monthly Medicare Part A premium for the 12 months beginning January 1, 1994 for these individuals is $245. The reduced premium for certain other individuals as described in this notice is $184. Section 1818(d) of the Social Security Act specifies the method to be used to determine these amounts. PMID- 10171739 TI - Genetic discrimination. PMID- 10171740 TI - The medication errors that get doctors sued. PMID- 10171741 TI - American Health Information Management Association. Position Statement. Issue: disclosure of health information relating to alcohol and drug abuse. PMID- 10171742 TI - Are you at risk under the ADA? AB - The Americans with Disabilities Act may have more impact on your benefits plan than you think. PMID- 10171743 TI - Medicare program; carrier jurisdiction for claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)--HCFA. Final rule. AB - This final rule would address the provisions of section 1834(a)(12) of the Social Security Act that authorizes us to designate one carrier for one or more regions to process all claims within that region. It incorporates in regulations the four designated carriers that will process claims for durable medical equipment, prosthetics, orthotics, supplies and certain other items covered under Part B of Medicare. We expect the above changes to lead to more efficient and economical administration of the Medicare program. PMID- 10171744 TI - An analysis of substance abuse patterns, medical expenses and effectiveness of treatment in the workplace: long-term followup. AB - This study of workplace substance abuse programs indicates that they are effective for many participants and also shows that these programs can significantly lower medical expenses for those who successfully complete them. PMID- 10171745 TI - Title I of the Americans with Disabilities Act and workers' compensation: a call for discussion. AB - The Americans with Disabilities Act may have a great impact on state workers' compensation systems if it serves as a catalyst that encourages them to expand their focus and become more actively involved in helping injured workers return to the workforce. PMID- 10171746 TI - Managing the disability process. PMID- 10171747 TI - Cooperative vendor selection saves money, helps improve care. AB - A cooperative effort between physicians and facility administrators with respect to purchase of materials and services can reduce costs dramatically and provide clinical benefits, as well. At Hamot Medical Center in Erie, Pa., orthopaedic physicians and hospital administrators developed a process for selecting a single source of implants used in total joint replacement procedures. As a result, the medical center was able to enter into a volume purchasing contract anticipated to save the medical center about $630,000 over the two-year period of the contract. PMID- 10171748 TI - The Icarus effect. PMID- 10171749 TI - Deaths after surgery. PMID- 10171750 TI - Hazardous materials management and control in clinical laboratories of small hospitals. AB - Rising fears of health hazards associated with exposure to chemical and biological wastes have focused attention on controlling clinical laboratory wastes. Governmental regulation of management and disposal practices has created special concerns for small clinical laboratories. Responses to a questionnaire sent to managers of clinical laboratories in small hospitals are reported. These responses indicate concern about maintaining compliance with government regulations that affect managing hazardous materials. Laboratory managers consider these regulations as necessary but have difficulty keeping abreast of constant changes. They also view the rising costs related to these regulations as a major problem for future laboratory operations. PMID- 10171751 TI - Hospitalized teens. Ambulatory care utilization patterns. AB - Twelve- to eighteen-year-olds enrolled in a federally qualified HMO in Central Massachusetts who had an admission to a hospital with a diagnosis of trauma or mental health problems were identified. Routine and episodic health care utilization for a 24-month period of each study case was determined and compared with the same for a comparison group matched for age, sex and length of enrollment. Although information on health habits and lifestyle was often missing from the charts, it was determined that the study cases were less likely to be in school and living with their parents and used episodic care more frequently, especially in the 6 months prior to admission. Both hospitalized and non hospitalized youth had a higher average number of visits to office-based providers than their national counterparts. The study suggests that (1) greater awareness of morbidity and health care utilization patterns and risk behaviors may enhance prevention efforts; (2) use of instruments to capture more information on health habits and lifestyle may facilitate preventive interventions; (3) collaborations among pediatric primary care providers, the Information Services (IS) and Quality Management (QM) departments may facilitate this type of research in a managed care setting. PMID- 10171752 TI - Evaluation of day care surgery in orthopaedics. PMID- 10171753 TI - Reverberations from the Sounding Board ... Waiting Your Turn. AB - In the July/August 1993 Sounding Board, Leadership presented four commentaries on Waiting Your Turn: Hospital Waiting Lists in Canada (third edition), prepared by the Fraser Institute's Joanna Miyake and Michael Walker. Waiting Your Turn, released in May 1993, surveyed 2,147 physicians in late 1992 and, based on the results, compares access to common surgical procedures in all 10 provinces. Commenting on the report for Leadership were Charles W. McDougall, executive vice president and COO of Montreal's Royal Victoria Hospital; Liza Kallstrom, manager of the health policy department at the British Columbia Health Association; Carol Gabanna, executive director of the Hospital Association of Prince Edward Island; and Dr. Hugh E. Scully of The Toronto Hospital. In this issue, Michael Walker responds. PMID- 10171754 TI - Medicare program; revisions to payment policies and adjustments to the relative value units under the physician fee schedule for calendar year 1994--HCFA. Final rule with comment period. AB - This final rule revises the payment policy for specific physician services and supplies, revises the relative value units (RVUs) assigned to certain existing procedure codes, and establishes interim RVUs for new and revised procedure codes. Section 6102(a) of the Omnibus Budget Reconciliation Act of 1989, as amended by section 4118 of the Omnibus Budget Reconciliation Act of 1990, requires establishment of the physician fee schedule and periodic review and adjustment of the RVUs. Further changes concerning payment for certain physician services are required by sections 13513 through 13517 of the Omnibus Budget Reconciliation Act of 1993. PMID- 10171755 TI - The clinical laboratory of the 2000s--a peek into the future. PMID- 10171756 TI - Accidental diets. Weight loss in Alzheimer's patients is the result of behavior, not disease. PMID- 10171757 TI - Ordinary people become heroes. AB - One home care nurse went beyond the expected during the floods of the Midwest by taking her charge to her home to care for him there. PMID- 10171758 TI - A comparison of diagnosis related groups and ambulatory visit groups in day-case surgery. AB - Case-mix measurement is a basic requirement of clinical and resource management systems within health care organisations, and offers a potentially useful tool for the setting and monitoring of contracts. Ambulatory care has particular problems in the construction of appropriate case-mix measures, and day-case surgery provides an opportunity to test two existing measures, one inpatient (Diagnosis Related Groups) and one ambulatory (Ambulatory Visit Groups). These grouping systems were applied to the same data to compare the case-mix patterns that they produce. The findings show that Ambulatory Visit Groups appear to have advantages over the Diagnosis Related Groups with respect to their underlying assumptions and labelling of the groups; in particular, they assign greater weight to procedures. However, Diagnosis Related Groups are more developed, easier to use, more familiar and allow direct comparisons with inpatient care. Nevertheless, a proper evaluation of these issues requires further data collection and analysis, together with a fundamental examination of the uses of ambulatory case-mix. PMID- 10171759 TI - Sitting in the lab. AB - Concerns about ADA compliance in the growing business of laboratories are generating adjustable equipment. PMID- 10171760 TI - Expanding adult day care successfully. AB - Expanding adult day care services successfully by strengthening recruitment and retention, quality assurance, programming, scheduling and financial management requires strong program leadership. Since the vast majority of day care program directors are educated as registered nurses, social workers and recreation therapists, cultivation of effective leadership skills must be achieved through a combination of additional formal education in management, extensive seminar/workshop attendance, outside readings and on the job guidance and experience. The administrator, to whom the program director reports, should devote considerable time and effort toward the director's management development through instruction, counseling and support. Conflicts may arise in areas such as staff and overtime expenses, and marginally efficient equipment purchases, where the director's clinical background may overshadow an objective cost/benefit analysis. Learning to delegate responsibility for basic programming and clinical services to staff, thus developing their skills, is a significant area for director and program growth. A well-trained and motivated nurse's aide can be quite capable of leading discussion and activity groups, perhaps assisted by volunteers. Social work students, with supervision, do a fine job of cofacilitating caregiver support groups and with additional experience, intake assessments. PMID- 10171761 TI - A study of inventory analysis in Forward Medical Stores Depot. AB - A study was conducted in Forward Medical Stores Depot with a view to determine the scope of its utility, efficacy and to educate staff working in the depot regarding techniques of inventory analysis system. 292 drugs were selected and were studied for one year from 01 Apr 91 to 31 Mar 92. The expenditure on 01 section (drugs) without application of inventory analysis during 90-91 was Rs. 60, 82,926.70. The expenditure was Rs. 51,61,589.08 after application of the techniques. A significant statistical reduction in the consumption pattern and expenditure was noticed by Rs. 9,21,3773.62. An uninterrupted supply of vital and essential drugs was ensured upto great extent. PMID- 10171762 TI - Social policy issues in narcotics abuse. AB - Social Policy in regard to drug abuse is presently the subject of intense controversy in this country. This paper examines the relationships between various policies with major emphasis on Treatment and Law enforcement. Specifically, it is recommended that greater use be made of civil commitment programs that give heroin and cocaine addicts a clear choice, that is, personal freedom is made contingent on drug-free, responsible behavior. PMID- 10171763 TI - Inpatient and outpatient outcomes in Missouri's alcohol and drug treatment programs. AB - A comparison of the effectiveness of inpatient and outpatient services for alcohol and drug clients is presented. Controls for program completion and severity of substance use on entry to treatment are included. While inpatients do only as well as outpatients overall, inpatient services show significant advantage for particular classes of clients. Results, though preliminary, suggest that the recent call for a cutback in inpatient services is premature. PMID- 10171764 TI - Increasing the adjustment success of the disabled African American. AB - Adjustment to a physically disabling condition is a challenge for any patient who confronts a future of severe impairment and limited mobility. The emotional trauma is usually devastating at least until the initial shock of the disability dissipates. For the disabled African-American patient, the physical and psychic pain are compounded by personal and social factors not experienced in similar intensity by other disabled patients. A conceptual framework for better understanding the nature of the forces that impinge on the ability of the disabled African-American patient to adjust and an understanding of the impact of multi-level systems on the life of the disabled African-American is provided. The influence of racism, be it intentional or unintentional, is explained as it relates to the services and the attitudes of health care systems. The family as a significant and vital system is discussed as the major contributor to the successful adjustment of African-American disabled persons. PMID- 10171765 TI - Assessment of process quality in Tanzanian primary care. AB - Process quality is the commonly used operational definition of health care quality. Its key components are technical and inter-personal skills, but most assessments undertaken in developing countries focus only on technical skills. This study from Tanzania used explicit observation checklists to review the process of providing antenatal, curative and nursing care in primary health units, assessing both technical and inter-personal skills. The study findings emphasize the weaknesses in available care, particularly in the attitudes of health staff but also in aspects of technical care. Differences in performance between health units appear to be influenced by factors such as workloads, structure and staff allocations. Differences between cadres were also identified and may underlie some of the inter-unit differences. The policy actions required to address the problems must reflect the diversity of the underlying influences, seeking to raise both technical and inter-personal quality, as the two are mutually reinforcing. PMID- 10171766 TI - Assessing quality in nursing home dementia special care units: a pilot test of the Joint Commission protocol. AB - Dementia is a serious and growing public health problem in the United States. Nearly 60% of nursing home residents are estimated to be cognitively impaired. Currently about 10% of nursing homes have special care units for residents with serious dementia including Alzheimer's disease. This research evaluates a protocol developed by the Joint Commission on Accrediation of Healthcare Organizations to assess the capability of special care units to provide quality care. The protocol was pilot tested through the use of two separate evaluations of diverse special care units in metropolitan Chicago. In comparing the two separate surveys from each site, data analysis revealed a high rate of correlation between these two evaluations at three distinct levels. The standards used, their intent, and the survey process were considered sound by those who tested the protocol and by those who were evaluated by it. PMID- 10171767 TI - Recommendations of the Little Rock Working Group on Mental and Substance Abuse Disorders in Health-Care Reform. PMID- 10171768 TI - The use of treatment progress scales in client monitoring and evaluation. AB - This article describes a multiple-use patient monitoring and evaluation system, the Treatment Progress Scales (TPS), which has been used for the last six years on 4,600 psychiatric and chemically dependent patients in a state-operated mental health facility. The system has been used for patient monitoring, management information, and program evaluation purposes. The article summarizes these and offers a brief overview of the TPS, its psychometric properties, and its advantages and disadvantages. PMID- 10171769 TI - The emerging epidemiology of rural AIDS. AB - The incidence of AIDS in rural areas is increasing rapidly. However, historically it has been overshadowed by AIDS in the epicenters. From 1991-1992 the increased percentage of cases was higher in nonmetropolitan areas than in any other areas of residence. The rate per 100,000 also increased at almost the same rate in rural areas as in the largest metropolitan areas, defined by the Centers for Disease Control (CDC) as having a population of more than 500,000, and in other metropolitan areas of 50,000 to 500,000 population, as designated by CDC. To date, the epidemiology of AIDS in rural areas has not been defined. This information is necessary to developing effective policies and programs. The research presented here reviews the literature on AIDS in specific areas and populations at risk as a basis for generating hypotheses for further study. The first wave of the epidemic, primarily affecting homosexual or bisexual men, is strongly evident in many rural locations. The second wave of the epidemic is strongly evident in the South and can be seen among high-risk groups such as black women, adolescents, migrant and seasonal farm workers, people who abuse alcohol, intravenous drug users, and users of crack cocaine, including those who trade sex for drugs. Poverty is a common characteristic of the second-wave population. Proximity to interstate highways as well as metropolitan areas may also be associated. A national study of the epidemiology of AIDS in rural America is imperative. PMID- 10171770 TI - Children with special health care needs program: urban/rural comparisons. AB - The purposes of this study were to: (1) describe both the urban and rural clients who received services from the Indiana Children with Special Health Care Needs program (CSHCN) including both demographic and clinical characteristics; (2) conduct a health care needs assessment of the CSHCN program clients in both urban and rural areas; and (3) measure the perceived quality and adequacy of the CSHCN program services. A survey instrument was developed and mailed to all 6,459 families who participated in the Indiana CSHCN program from July 1, 1990 to June 30, 1991. Of the 2,722 questionnaires used in the analysis, 1,624 clients (59.7%) resided in urban counties and 1,098 (40.3%) resided in rural counties. The most frequently noted conditions for program eligibility were asthma, ear infections, hearing impairments, heart defects, and convulsions and seizures. Asthma had greater prevalence among the urban clients while cleft lip/palate, epilepsy, and heart defects were more common among the rural clients. The majority of program clients perceived their medical needs as being met. However, significant numbers of clients perceived unmet needs for mental health services, support groups, information about community services, resources to pay for uncovered medical expenses, and respite care. Of the 23 listed services, five were reported at significantly lower rates by rural clients as not being met: regular medical care, recreation, child care/day care, parent support group services, and speech therapy. Quality of medical services was generally perceived as being "excellent or good," while services related to information about community programs, child's rights in school, resources available to pay for uncovered medical expenses, as well as communication between the treatment center and the child's school were more often rated as "fair or poor." A smaller proportion of rural clients rated physician care and availability of staff nurses as fair or poor. A larger percentage of the rural group reported that access to treatment center location was fair or poor, compared to the urban group. Overall, the evaluation of the Indiana CSHCN program has shown that the non-medical care component seems to be in need of change, especially in the area of information and communication. Attention needs to be focused on providing more family support such as respite or child care and support groups, better information and communications, and improved availability of mental health services to better enable the CSHCN program to meet its objectives. PMID- 10171771 TI - Robotic assistant for laparoscopic surgery. PMID- 10171772 TI - Mother-and-child reunion. AB - Big-city hospitals have developed inventive programs to solve the tragedy of abandoned babies. PMID- 10171773 TI - The EC's need for a common currency in health care quality assurance. AB - Argues that the economic integration of the EC's 12 member nations into a single community and the elimination of barriers to free trade will not result in a single health-care system. However, the closer relationships among the member nations and the members' individual desires for competitive advantage in the new marketplace will, inevitably, lead to an interest in comparing health-care systems along cost and quality dimensions. Without a common currency for quality assurance, such comparisons will be time consuming, costly and of questionable validity. Consensus must be achieved on the following: the essential elements in a database for health care quality assurance; common classification systems for key elements in the QA database; standardized conventions for coding practices to ensure data validity and reliability. Suggests an assessment of current practices in health data collection in the member nations; a pilot project to assess the feasibility of developing a common currency for quality assurance, and an EC-wide symposium to discuss data comparability issues as next steps. PMID- 10171774 TI - Day surgery; development of a questionnaire for eliciting patients' experiences. AB - OBJECTIVE: To develop a single, short, acceptable, and validated postal questionnaire for assessing patients' experiences of the process and outcome of day surgery. DESIGN: Interviews and review of existing questionnaires; piloting and field testing of draft questionnaires; consistency and validity checks. SETTING: Four hospitals, in Coventry (two), Swindon, and Milton Keynes. PATIENTS: 373 patients undergoing day surgery in 1990. MAIN MEASURES: Postoperative symptoms, complications, health and functional status, general satisfaction, and satisfaction with specific aspects of care. RESULTS: Response rates of 50% were obtained on field testing draft questionnaires preoperatively and one week and one month after surgery. 28% of initial non-responders replied on receiving a postal reminder, regardless of whether or not a duplicate questionnaire was sent; a second reminder had little impact. Many patients who expressed overall satisfaction with their care were nevertheless dissatisfied with some specific aspects. Outcome and satisfaction were related to three aspects of case mix; patient's age, sex, and type of operative procedure. The final questionnaire produced as a result of this work included 28 questions with precoded answers plus opportunities to provide qualitative comments. Several factors (only one, shorter questionnaire to complete, fewer categories of nonresponders, and administration locally) suggested that a response rate of at least 65% (with one postal reminder) could be expected. CONCLUSION: A validated questionnaire for day surgery was developed, which will be used to establish a national comparative database. PMID- 10171776 TI - Oversight in California law turns HFMA member into 'lobbyist'. PMID- 10171775 TI - Day surgery: development of a national comparative audit service. AB - OBJECTIVES: To develop software for hospitals to analyse their own survey data on patients' experiences of day surgery and to create and test the feasibility of a national comparative audit service. DESIGN: Software development and testing; database analysis. SETTING: Eleven general hospitals in England. PATIENTS: 1741 day surgery patients undergoing procedures during 1991-2. MAIN MEASURES: Postoperative symptoms, complications, health and functional status, general satisfaction, and satisfaction with specific aspects of care. RESULTS: Software for data entry and analysis by hospitals was successfully used at the pilot sites. The overall response rate for the 11 hospitals using the questionnaire was 60%, ranging from 33% to 90% depending on the way the survey was managed. Data from all 11 hospitals were included in the national comparative audit database. Hospitals showed little variation in measures of patients' overall satisfaction (around 85%), but significant differences were apparent for specific aspects such as receiving adequate written information before admission (range 50%-89%), provision of adequate parking facilities (14%-92%) and experiencing a significant amount of postoperative pain (8%-42%). The proportion of day case patients undergoing procedures that could have been performed in outpatient departments varied from 0 to 27% between hospitals. Further comparisons of outcome, in particular measures of effectiveness, must await the development of validated case mix adjustment methods. CONCLUSION: Establishing a comparative audit database is feasible but several methodological problems remain to be resolved. PMID- 10171777 TI - The disability community as litmus test. Toward a unified strategy for surmounting the dilemmas in health care reform. PMID- 10171778 TI - Toward a client-centered understanding of drug treatment. AB - This article reports some of the results of a study of the content of drug treatment in New York City that is being conducted by Health/PAC's Drug Treatment Policy Project and funded by the Robert Wood Johnson Foundation. The research is led by a steering committee made up of clients of drug treatment services, providers and administrators of drug treatment programs, and legal and financial advocates for drug users. This article reflects 20 months of meetings and discussions by the steering committee; over 50 interviews with drug users, advocates, drug treatment providers, and program administrators about the experience, structure, and policies of drug treatment in New York City; and an analysis of the major evaluations of drug treatment services in New York City, supplemented by informal telephone surveys of facilities by staff. The Drug Treatment Policy Project has found services in New York City as a whole to be less than enlightened or adequate. But, in the course of the research, many programs were found to be both helpful and effective, mostly as a result of the efforts and personal risks taken by individuals who filled in gaps or by programs that, because they were community based, went to extraordinary efforts on behalf of their clients to make sure that a variety of options and services were available. We hope to outline these successes in another article. PMID- 10171779 TI - Looking for help...the experience of residential drug treatment. PMID- 10171780 TI - Pharmacy-related standards in the 1994 AMH; drug samples; and adverse drug reaction requirements. PMID- 10171781 TI - Pa. hospitals show consistent performance on heart surgeries. PMID- 10171782 TI - Residential living. Linking service to standards. PMID- 10171783 TI - Patients' experience of surgical accidents. AB - OBJECTIVE: To examine the psychological impact of surgical accidents and assess the adequacy of explanations given to the patients involved. DESIGN: Postal questionnaire survey. SETTING: Subjects were selected from files held Action for Victims of Medical Accidents. PATIENTS: 154 surgical patients who had been injured by their treatment, who considered that their treatment had fallen below acceptable standards. MAIN MEASURES: Adequacy of explanations given to patients and responses to standard questionnaires assessing pain, distress, psychiatric morbidity, and psychosocial adjustment (general health questionnaire, impact of events scale, McGill pain questionnaire, and psychosocial adjustment to illness scale). RESULTS: 101 patients completed the questionnaires (69 women, 32 men; mean age 44 (median 41.5) years. Mean scores on the questionnaires indicated that these injured patients were more distressed than people who had suffered serious accidents or bereavements; their levels of pain were comparable, over a year after surgery, to untreated postoperative pain; and their psychosocial adjustment was considerably worse than in patients with serious illnesses. They were extremely unsatisfied with the explanations given about their accident, which they perceived as lacking in information, unclear, inaccurate, and given unsympathetically. Poor explanations were associated with higher levels of disturbing memories and poorer adjustment. CONCLUSIONS: Surgical accidents have a major adverse psychological impact on patients, and poor communication after the accident may increase patients' distress. IMPLICATIONS: Communication skills in dealing with such patients should be improved to ensure the clear and comprehensive explanations that they need. Many patients will also require psychological treatment to help their recovery. PMID- 10171784 TI - The big story. AB - When a mega-policy issue--health care reform--runs up against the Information Age, the result is likely to be increased earnings and career-making opportunities for journalists. PMID- 10171785 TI - Medicare enrollment. PMID- 10171786 TI - Medicare supplementary medical insurance benefit for hospital outpatient services. PMID- 10171787 TI - A description of Medicaid eligibility. PMID- 10171788 TI - Trends in Medicaid payments and users of covered services, 1975-91. PMID- 10171789 TI - Medicaid recipients, services, utilization, and program payments. PMID- 10171790 TI - Easing the pain of Alzheimer's with sign language. AB - Arizona State University researchers spent four weeks teaching Alzheimer's patients at Hearthstone of Mesa sign language with surprizing results. PMID- 10171791 TI - Establishing and evaluating QC acceptability criteria. PMID- 10171792 TI - A program for assessing statistical QC procedures. PMID- 10171793 TI - Concerns raised about quality of banked bone. PMID- 10171794 TI - Managed care to level off surgery volume. PMID- 10171795 TI - Surgery's black hole: is it consuming your practice? PMID- 10171796 TI - At what price? AB - The Clinton Administration has proposed a capped entitlement program to expand home- and community-based services for the disabled. This program's impact on nursing facilities is yet to be interpreted. PMID- 10171797 TI - Quality--a regulatory view. PMID- 10171798 TI - Ergonomics for the laboratory. A guide for developing appropriate procedures. AB - In Section 5(a)(1) "General Duty Clause," The Occupational Safety and Health Administration enforces the guidelines that assist employers in preventing ergonomic disorders through sound safety and health programs. These guidelines are advisory in nature and are intended to be adapted to the needs and resources of each laboratory facility to reduce unnecessary workman's compensation claims. The Clinical Laboratory Management Association (CLMA) prepared this guide to assist employers in developing appropriate procedures in their laboratories. Although the information in this article is compiled from sources and documents believed to be reliable, its accuracy is not guaranteed nor is any responsibility assumed or implied for any damage or loss resulting from inaccuracies or omissions. CLMA and the author are not engaged in rendering legal advice. Any legal questions should be discussed with an attorney. PMID- 10171800 TI - Refusal of surgery in an insured population. AB - Among 195 people who did not have recommended elective surgery in which a second opinion was required, virtually all indicated they were not going to have the operation and did not want a second opinion. The extent to which this decision adversely affected their health status and well-being and the extent to which alternate treatments were tried are examined. The findings also highlight the discretionary nature of patient and physician decision making. PMID- 10171799 TI - Comparison of NHS and private patients undergoing elective transurethral resection of the prostate for benign prostatic hypertrophy. AB - OBJECTIVES: To compare the operative thresholds and clinical management of men undergoing elective transurethral resection of the prostate for benign prostatic hypertrophy in the NHS and privately. DESIGN: Cohort study of patients recruited by 25 surgeons during 1988. SETTING: Hospitals in Oxford and North West Thames regions. PATIENTS: Of 400 consecutive patients, 129 were excluded because of open surgery (nine), lack of surgeons' information (three), and emergency admission (117) and three failed to give information, leaving 268 patients, 214 NHS patients and 54 private patients. MAIN MEASURES: Sociodemographic factors, prevalence and severity of symptoms, comorbidity, general health (Nottingham health profile) obtained from patient questionnaire preoperatively and reasons for operating, and operative management obtained from surgeons perioperatively. RESULTS: NHS and private patients were similar in severity of symptoms and prevalence of urinary tract abnormalities. They differed in four respects: NHS patients' general health was poorer as a consequence of more comorbid conditions (49, 23% v 7, 13% in severe category); the condition had a greater detrimental effect on their lives (36, 17% v 2, 4% severely affected; p < 0.01); private patients received more personalised care more quickly and were investigated more before surgery, (29, 54% v 60, 20% receiving ultrasonography of the urinary tract); and NHS patients stayed in hospital longer (57, 27% v 3, 6% more than seven days; p < 0.001). CONCLUSIONS: Private patients' need for surgery, judged by symptom severity, was as great as that of NHS patients, and there was no evidence of different operative thresholds in the two sectors, but, judged by impact on lifestyle, NHS patients' need was greater. PMID- 10171801 TI - Utilizing cardiovascular data bases to guide the balance of cost and quality. AB - Cardiovascular administrators are being asked to focus on quality, cost-efficient operations of their service lines, to market that service, to secure business through managed-care contracting and to increase direct referral volume. PMID- 10171802 TI - Guidelines for using standardized outcome measures following addictions treatment. AB - Increasingly, program managers are incorporating existing standardized tests as part of outcome evaluation. This article identifies guidelines for selecting and using standardized measures following addictions treatment. The principles identified in this context, however, are not only applicable to addictions treatment evaluation but also to the use of standardized measures in outcome evaluation of health programs generally. These guidelines cover eight basic criteria for selecting outcome measures: validity, sensitivity to measuring change, suitability for type of clients in the program, acceptability, clinical usefulness, ease of administration, scoring, and low cost. The article also discusses uses of outcome data, comparison of monitoring client outcomes to other forms of evaluation, and some practical issues related to using standardized outcome measures, including selecting what to measure and interpreting results. PMID- 10171803 TI - Intake/discharge unit ups clinic's efficiency as well as its comfort. New York Eye and Ear Infirmary. PMID- 10171804 TI - Bundled outpatient charges give competitive edge. PMID- 10171805 TI - 1991 summary: National Hospital Discharge Survey. PMID- 10171806 TI - Negative moods as correlates of smoking and heavier drinking: implications for health promotion. PMID- 10171807 TI - Operative reports and reimbursement. PMID- 10171808 TI - Adverse drug reactions: the San Juan Department of Veterans Affairs Medical Center experience. AB - The San Juan Department of Veterans Affairs Medical Center's adverse drug reactions (ADRs) reporting and monitoring program is described. ADRs for the first 2 years of the program are discussed. These were mainly hypersensitivity (29.3%), drug intoxications (19.9%), cardiovascular (15.9%), hematologic (7.6%), neurologic (4.9%), and gastrointestinal (4.7%) ADRs. Drugs most frequently involved were antibiotics (28.7%), cardiovascular agents (21.2%), anticonvulsants (10.2%), psychotropics (9.4%), and theophylline (5.1%). Preventive interventions include the development of a clinical pharmacist-run anticoagulation clinic, a drug utilization evaluation of phenytoin, development of a dosing algorithm for theophylline, and the possible future initiation of a pharmacokinetic consult service. The success of the ADR program is evidenced by a 750% increase in ADR reports over the 2-year period. This was possible by the establishment of a clear definition of an ADR, the creation of a simple reporting method, and an ongoing educational campaign. PMID- 10171809 TI - Patient-specific platinum intracranial electrodes as a diagnostic tool in the surgical treatment of the epilepsies. AB - A popular method of signal acquisition in the surgical treatment of the epilepsies is through the utilization of intracranial electrodes. These electrodes can be placed either epidurally or subdurally. By fabricating these intracranial electrodes on-site, a great deal of flexibility is gained because each electrode is designed to ensure an exact fit for each patient. With the use of intracranial electrodes fabricated on-site, there are none of the usual delays or limitations associated with the acquisition of commercially available electrodes, and significant cost savings are also seen. PMID- 10171810 TI - Enhancing options. AB - According to a study, ALFs (assisted living facilities) can offer a cost effective model of care for the disabled due to the environment's flexible staffing patterns and a slower rate of spend-down to Medicaid. PMID- 10171811 TI - Accurate information for the incineration debate. PMID- 10171813 TI - Communities respond to common disease of aging. PMID- 10171812 TI - Satisfaction with health-related educational workshops: the role of environmental and logistical factors. AB - The present study examined correlates of the perceived quality of four educational conferences. Specifically, the study examined the relationships of ratings of subjective overall conference quality with environmental and logistical aspects of the conferences. The results showed that ratings of room quality as well as ratings of meeting structure were significantly related to ratings of overall conference quality. Follow-up coverall conference ratings, measured up to one year after the conferences, were predicted by initial ratings of food quality. PMID- 10171814 TI - The social re-engagement model for treating Alzheimer's disease. AB - By creating a completely new social structure shaped in response to the Alzheimer resident's perceived reality, nursing homes can provide an environment in which the individual can develop a new sense of identity. PMID- 10171816 TI - Day shift. PMID- 10171817 TI - Day surgery. Home comforts. PMID- 10171815 TI - The changing face of long-term care. AB - In this article, we present population estimates of individuals with disabilities and discuss the manner in which the composition of this population is changing. We then highlight aspects of service delivery systems that are evolving in response to the changing long-term care (LTC) population. Following a summary of financing issues, we discuss several cross-cutting issues related to the organization of service delivery, quality assurance (QA), and financing. Current and future Health Care Financing Administration (HCFA) research and demonstrations emerging from these issues are then described. PMID- 10171818 TI - Dependency policies for Europe. PMID- 10171819 TI - Liability exposure shifting to outpatient care. PMID- 10171820 TI - Medical device review at the Food and Drug Administration: lessons from magnetic resonance spectroscopy and biliary lithotripsy. AB - Medical devices marketed in the United States must satisfy FDA standards of safety and effectiveness. Many observers have criticized the FDA medical device review process as both time consuming and unpredictable. In this note, Lawrence Makow examines the Agency's treatment of two novel medical technologies, magnetic resonance spectroscopy and biliary extracorporeal shockwave lithotripsy. He concludes that the outcomes of these cases exemplify the mismatch between clinical utility and FDA approval status that has prompted concerns about lack of predictability. Mr. Makow asserts that this mismatch results from the FDA's implementation of the medical device statute rather than from the statute itself. He proposes an asymmetric standard for evaluating the safety and efficacy of new medical devices. While the safety showing would always require a high burden of proof, the efficacy standard would vary depending on the relationship between the device's safety and efficacy. Under this asymmetric standard, the FDA could better manage its workload and achieve more predictable results without sacrificing the public interest in avoiding injury from unproven medical devices. PMID- 10171821 TI - Social Security and Medicare adjudications at HHS: two approaches to administrative justice in an ever-expanding bureaucracy. PMID- 10171822 TI - The criminalization of perinatal AIDS transmission. PMID- 10171823 TI - 1993 drug dollar volume leaders in hospital pharmacies. PMID- 10171824 TI - Bringing focus to the mind of dementia. PMID- 10171825 TI - Back-to-work remedies. PMID- 10171826 TI - Guaranteeing fair housing. PMID- 10171827 TI - A prospective dosage adjustment program in a geriatric population. AB - This article describes the successful implementation of a prospective drug dosage adjustment program that has achieved cost-containment, improved quality of patient care, and optimum usage of clinical pharmacy services. It has significantly reduced the number of unnecessary doses administered and lowered the possibility of adverse drug reactions. PMID- 10171828 TI - Restricted activity days and other problems associated with use of marijuana or cocaine among persons 18-44 years of age: United States, 1991. PMID- 10171829 TI - 'Putting words into action.' The Individuals with Disabilities Education Act and the poor. PMID- 10171830 TI - Managed care as health care rationing. AB - This article is based on the author's presentations to the New York State Governor's Health Care Advisory Board's Task Force on the President's Health Care Plan, November 22, 1993, and to a hearing of the New York State Attorney General on the experience of consumers with health insurers and health maintenance organizations, September 20, 1993. His comments deal with the effects of the Clinton health care reform proposal and other forms of managed care on those most in need of care. Particularly interesting are his suggestions for protecting the rights of health care consumers. PMID- 10171831 TI - A community response to the needs of drug users. Stand Up Harlem. AB - In our first article reporting the results of a study by Health/PAC's Drug Treatment Policy Project, "Toward a Client-Centered Understanding of Drug Treatment" (Fall 1993 issue), we discussed the general inadequacy of public drug treatment services in New York City and the myriad obstacles that exist to obtaining treatment. This article maintains the client-centered perspective in examining an alternative approach that has been successful in helping drug users. PMID- 10171832 TI - Chest imaging in critically ill patients: analysis of clinical value. PMID- 10171833 TI - A successful strategy for handling substance abuse. PMID- 10171834 TI - State Medicaid health maintenance organization policies and special-needs children. AB - Little research has been done to ascertain what enrollment in a health maintenance organization (HMO) may mean for the care of Medicaid recipients who regularly require specialty health services. This article presents the results of a survey of all State Medicaid agencies regarding their policies for enrolling and serving special-needs children in HMOs. The survey revealed that many States have implemented one or more strategies to protect special-needs Medicaid recipients enrolled in HMOs. The survey results suggest, however, that such strategies are too limited in scope to ensure appropriate access to specialty services for all children with special health needs. PMID- 10171835 TI - Why home health services are provided to Alzheimer's disease patients in California's Alzheimer's disease program: an exploration. AB - Logistic regression is used to examine why formal home health service recommendations are made to Alzheimer's disease patients (N = 822) by staff at each of six Alzheimer's Disease Diagnostic and Treatment Centers (ADDTCs) in California. Patients are selected on the basis of their having Alzheimer's disease, and not having any physical co-morbid health problems noted at the time of their clinical assessment. Using Medicare Part A to pay for care, previous home health use, having regular access to and prior use of a primary care physician, prior hospitalization, client agitation and apathy, and family's social isolation were significant predictors of the latent propensity to recommend formal home health services to members of this sample. PMID- 10171836 TI - SSM Rehabilitation Institute. Electronic bulletin board links the disabled community. PMID- 10171837 TI - Near-patient testing: the management issues. PMID- 10171838 TI - Surgery moving to clinics to save on costs. PMID- 10171839 TI - Audit of cost and clinical outcome of cataract surgery. AB - An audit of routine cataract surgery in our hospital was carried out by examining records of 340 adult patients who underwent such surgery during October 1990. The category of intended accommodation (day case or inpatient), operative details, post-operative course and management were recorded, along with the outcome measures of visual acuity (unaided and corrected) and refractive error (spherical equivalent and cylinder). The costs of treatment, including post-operative management, were calculated for each patient. The results indicate that day case surgery under local anaesthesia was the most cost-effective method of cataract surgery, with no detrimental effect on clinical outcome. PMID- 10171840 TI - Surgical scars. PMID- 10171841 TI - Managed care: two rival doctors, two rival reactions. PMID- 10171842 TI - Forging partnerships that work: a strategy for near-patient testing. AB - Near-patient testing systems, which bring innovative technologies to the site of patient care, also offer management challenges to effectively integrate clinical and laboratory services. A two-tiered committee structure--composed of an umbrella "advisory" organization supported by several subcommittees operating as the "working arms" of the program--offers a viable strategy to address issues involved in implementing and monitoring near-patient testing systems. PMID- 10171843 TI - Equitable service provision: a feasibility study of the common waiting lists model. AB - Long waiting lists are of concern to policy makers, professionals and patients, and despite major initiatives to address the issue the problem remains. Suggests that one partial solution may be chronologically maintained common waiting lists for high-volume routine surgical procedures at the departmental level rather than by individual consultants. Since case severity differences between the various surgeons in a team may mitigate against such a model a pilot study of two procedures: arthroscopic examination of knee and repair of inguinal hernia was undertaken. Describes the study. Little statistically significant difference was found in case severity between the patients belonging to the different general and orthopaedic surgeons in South Tees Health district, and a significant proportion of operations was undertaken by middle grade doctors. At present waiting times vary considerably depending on which consultant the patient is referred to by their general practitioner, thus creating inequity. The problem has been further exacerbated by the NHS reforms with fund-holding general practitioners receiving preferential treatment, thus creating a two-tiered service. Common waiting lists will ensure equitable provisions and may increase efficiency, and hence need serious consideration. PMID- 10171844 TI - Workers' compensation proves the brain and body are connected: lessons for managed care. AB - Workers' compensation is not only the last frontier for managed care, but also it is the area where somatization is the most apparent to the trained clinician. Because with workers' compensation laws the presumption is always with the injured employee, the incentive can be to see disability as the solution to psychological, social, and economic problems. In many workers' compensation cases, behavioral health issues are more important than the physical injury. PMID- 10171845 TI - The legacy of Dr. Alzheimer. Nearly a century after the disease got its name, the spotlight on care burns brighter than ever. PMID- 10171846 TI - Special care. Do Alzheimer's units make sense--or just dollars? Advocates tout better care and quality of life. PMID- 10171847 TI - CLIA national survey, Part 1. CLIA after year 1: no help to patients, and a hindrance to labs. PMID- 10171848 TI - INR (International Normalized Ratio) reporting of prothrombin time. PMID- 10171849 TI - Home surgical recovery program proves value. AB - The evidence is overwhelming that sharp reductions in health care costs can be achieved by reducing or eliminating reliance on expensive hospital care. In surgery, this is not always possible. However, significant savings can be achieved through reducing the length of time that a surgery patient must spend in the hospital. In outpatient surgery, the hospital stay is reduced to a single day. In this article, the authors describe a home surgical recovery program that has had great success in reducing hospital stays for even more complicated surgical procedures, frequently matching the achievements of outpatient surgery programs. PMID- 10171850 TI - An approach to the impaired physician. AB - The 1988 California Administrative Code requiring all acute care medical staffs to provide assistance to impaired physicians has not resulted in an increase in the annual census in the Medical Board of California Diversion Program. In part, this lack of an increase is due to the failure of some hospitals to form physician aid committees and to the poor functioning of such committees in other hospitals. The common reasons for these deficiencies are that the medical staff leadership does not think there are any impaired physicians on staff and that they don't know what the committee would do if it were formed. This attitude demonstrates a lack of appreciation for the prevalence of impaired physicians and the tremendous amount of work required (establishing policies and procedures) to identify and help them. This article discusses the prevalence of the impaired physician, the types of impaired physicians, a "cookbook" approach to managing these physicians, and the success of intervention. PMID- 10171851 TI - Developing strategies for providing services to the mentally ill chemically abusing population. PMID- 10171852 TI - Employer-sponsored health plans and experimental medical treatments: life and death cost/benefit decisions. AB - The process of determining whether--and how--to limit coverage for certain expensive, experimental medical treatments is complex and involves social, legal and economic considerations. However, employers do have several options for responsibly containing their health plan costs while meeting their employees' basic health care needs. PMID- 10171853 TI - Disability. Open to question. PMID- 10171854 TI - Using hospital pharmacy technicians to check unit dose carts. AB - This study was undertaken to evaluate the accuracy of technicians checking unit dose carts as compared with pharmacists checking unit dose carts. The final (after check) fill in both arms of the study was evaluated for accuracy on the same five criteria: 1) correct drug, 2) correct dose, 3) correct dosage form, 4) correct quantity, and 5) expiration date. In the technician arm, 7571 doses were checked with 10 errors, giving a 99.76% (1 error in 420) accuracy. In the pharmacist arm of the study, 3116 doses were checked with 34 total errors, giving a 98.91% (1 error in 92) accuracy. The results of this study indicate that technicians would have as high if not a higher accuracy rate than pharmacists. Using pharmacy technicians in this role should continue the same level of care by maintaining a high accuracy in medication dispensing and provide greater economic benefit to the organization by using technical rather than professional personnel. PMID- 10171855 TI - Health care reform--the rhetoric versus the reality. PMID- 10171856 TI - Design for dementia care. PMID- 10171857 TI - Sexual victimization and substance abuse in psychiatrically hospitalized adolescents. AB - This article investigates the relationship between substance abuse and sexual abuse in a population of 260 psychiatrically hospitalized adolescents. Seven hypotheses are set forth to test a model that uses parental alcohol abuse, sexual abuse status, and gender as exogenous variables, perceived benefit of alcohol or drugs as an endogenous mediating variable, and substance abuse as the dependent variable. Using these variables, a path model was constructed and revised based on empirical testing. The revised model achieved an adjusted R2 of .38, thus explaining 38 percent of the variance in this sample's abuse of alcohol or drugs. The model suggests that within clinical populations, sexually abused adolescents should be screened for substance abuse, and attention should be given to parental alcohol abuse as well as the degree to which adolescents perceive benefits from their alcohol or drug use. PMID- 10171858 TI - Mistakes in health care: the learning experience in cardiac surgery. PMID- 10171859 TI - Telepresence lets surgeons operate from remote site. PMID- 10171860 TI - Hospital develops orthopedic product formulary. PMID- 10171861 TI - Human fibrin makes effective tissue adhesive. PMID- 10171862 TI - Americans with Disabilities Act: meeting the needs of hearing-impaired patients. AB - To comply with Title III of the Americans With Disabilities Act of 1990, radiology managers must take responsibility for providing special assistance for hearing-impaired patients. That includes training staff members in techniques that can help them communicate more effectively with hearing-impaired patients. This article describes difficulties some hearing-impaired patients experience during radiology exams, and suggests measures radiologic technologists can use to assist them. PMID- 10171863 TI - Questions and answers on ADA compliance for medical buildings. PMID- 10171864 TI - The distribution of pharmaceuticals in Europe--current and future trends in wholesaling. AB - As of January 1, 1993 a huge market, encompassing more than 325 million people, has been established with the unification of the 12 member states in the European Community. During the last 10 years, the pharmaceutical wholesaling sector has therefore been involved in an intense restructuring process. But, there is a considerable scientific gap in the knowledge of pharmaceutical wholesaling. In view of the uncertain situation and the scarcity of structured information, the purpose of this article is to examine current and future trends in the European pharmaceutical wholesaling sector. We reviewed the literature and identified three major areas of interest; general threats to traditional full-line wholesaling, wholesalers' response to these threats, and the new Glaxo distribution scheme. The current and expected importance of these areas were assessed with the help of a survey, encompassing 20 experts in this field. Based on the review and the survey, we conclude that there are many serious threats to traditional wholesaling, the major ones being governmental pressures to lower the already relatively low gross margins, manufacturers contemplating taking over the drug distribution process themselves and increasing international competition. The major responses to these threats are to become a truly international player (via mergers, acquisitions and joint ventures), or being able to provide the customers with detailed management information through computerised networks. In order to survive the next 5-10 years, companies have to be very alert to the changing competitive situation. PMID- 10171865 TI - Managing orthopedics and neurosciences costs through standard treatment protocols. AB - High-cost, high-volume specialty programs such as orthopedics and neurosciences find themselves in a position of evaluating the costs and in some cases the appropriateness of medical practices in response to payer scrutiny and provider selection processes. Orthopedics and neurosciences programs are at a stage of development analogous to that of cardiovascular care several years ago. Many of the same trends have come into play, such as payer "carve-outs" for orthopedic services, payer selection of centers of excellence based on cost and quality, reduction of Medicare reimbursement, greater use of high-cost technology, the decline of profitability due to "older, sicker, and tougher" patients, and the recent emergence of national orthopedic specialty networks oriented to national contracts for care. In an era in which payers demand value on both sides of the cost-plus-quality equation, programs are challenged to maximize the return on a patient population rife with "no-win" situations. In the orthopedic service line these include a high proportion of Medicare patients and chronic conditions such as workers' compensation medical back cases or repetitive motion injuries, which can be elusive to diagnose and expensive to treat. Many hospitals continue to lose money on joint replacement surgeries, the largest-volume orthopedic inpatient service, primarily because of the high Medicare population and the cost of implants. Neuroservices, while still relatively well reimbursed, face a rising proportion of Medicare payments as patients live longer and develop chronic, degenerative conditions. Inpatient days are decreasing due to payer pressures to limit hospital stays and to shift inpatient care to outpatient services. Some hospitals "have lost interest in (the orthopedic) service line during the last five years because of recent trends in orthopedic-related inpatient volume and payment." But by managing costs strategically, both the neurosciences and orthopedics service lines can provide substantial revenue as well as the opportunity to achieve a "center of excellence" competitive position in a managed care environment. This Special Report outlines the process and advantages of managing costs and quality of care strategically, that is, in a manner which helps these programs meet internal cost and clinical goals while responding to market situations. The hospital, physicians, and patients all benefit as costs are reduced, quality is enhanced, and the service line's competitive position is strengthened. PMID- 10171866 TI - Total cost reduction in the laboratory: a team effort. AB - The laboratory has been seen as a revenue source and its product a commodity. In fact, good laboratories have always provided more of a service. As health care strives to reduce the cost of an episode of care, the laboratory may, ironically, incur additional costs to provide testing that contributes to earlier diagnosis and decreased length of stay. Laboratorians working with physicians and the institution must design processes to reduce cost through decreased utilization and improved decision making. Although materiel managers will continue to perform their traditional functions, they will become more involved in helping to select clinically relevant, cost-effective technologies through the technology assessment process. In order to evaluate new methods and equipment, laboratory expenses must be refined to include workload recording of individual tests and cost accounting of supplies, equipment, facilities and reagents. PMID- 10171867 TI - Virtual reality. Computer magic & modern medicine. PMID- 10171868 TI - Market memo: endoscopic surgery requires capital and commitment. PMID- 10171869 TI - Waiting lists in the post-review NHS. AB - Waiting lists for hospital inpatient treatment have existed since the foundation of the NHS. There have been many theories put forward to explain them and a wide range of proposals have been advanced to reduce or eliminate them. The effect of the recent changes in the NHS, coupled with the renewed political focus on waiting lists, is explored. It is concluded that access to waiting lists may be restricted, either by explicit rationing or as a result of contractual specifications. Further, the introduction of GP Fundholding, together with the purchaser-provider split, could result in a two-tier service, at least for non urgent patients. These conclusions are illustrated by the findings from a simple simulation model. PMID- 10171870 TI - Ensuring universal access to quality laboratory services: CLMA White Paper. National Affairs Committee, Clinical Laboratory Management Association. AB - As part of its National Affairs Plan, approved in 1991, CLMA committed to publishing periodic position, or "white," papers to explore contemporary public policy issues in laboratory services administration. As CLMA's first white paper, this article is an in-depth analysis of the historical and economic background to today's clinical laboratory industry in the United States. It provides the logic and rationale behind CLMA's position statement on Health-Care Reform and the Clinical Laboratory. The statement has been formally adopted by consensus and has been widely circulated to both Congress and our membership. It will help form the policy basis for the development of the Association's legislative agenda on health-care reform. The principles are intended to be universal and apply not only to U.S. reform efforts at the national level, but also to states and other nations. PMID- 10171871 TI - Preparing children for day surgery. AB - This study measured the effect of a group preoperative teaching program on the level of children's emotional distress during day surgery. The sample consisted of 30 children, ages 3 through 10, scheduled for elective surgery. One group attended a structured program and received procedural and sensory information within 2 weeks of their surgery. The other group did not receive this intervention. A t test identified significant differences between the groups. Children who attended the preoperative teaching program demonstrated less emotional distress than children who did not receive this intervention. These findings reinforce the positive outcomes of preoperative teaching programs that provide procedural and sensory information to children as preparation for day surgery. PMID- 10171872 TI - Information-seeking coping and anxiety in school-age children anticipating surgery. AB - This study examined the relation between coping behavior and anxiety among school age children anticipating an elective tonsillectomy and/or adenoidectomy. The demographic variables of age, gender, previous hospitalization, and birth order were also studied in relation to both coping and anxiety. Interview methods were utilized to measure information-seeking and information-limiting coping behaviors and feelings of anxiety. The results of this study indicate that children who used primarily information-seeking or information-limiting strategies were successful (as measured by low anxiety levels) in managing the stress of anticipated hospitalization. Children using information-seeking strategies for some, but not all, aspects of the hospitalization experience reported the greatest anxiety. The demographic variables were not related to either anxiety or coping. PMID- 10171873 TI - After the intensive care nursery experience: families' perceptions of their well being. AB - This article describes family well being after a child's intensive care nursery experience. Thirty families of children who were graduates of intensive care nurseries participated in the study. Fifteen families of children with identifiable disabilities and 15 families of children with no identifiable disabilities were interviewed and completed standardized questionnaires. A comparison of family well being was done across three dimensions: the child's characteristics and caregiving needs, the family's support resources and needs, and the family's values and beliefs regarding their child's hospitalization and resulting special needs. Both groups of families had realized a renewed sense of meaning concerning family, children, and life itself due to their child's medical crises or disability. Families of children with disabilities, however, noted their financial concerns, burdens with their child's caregiving, and their difficulty in locating services for their child. These families' experiences underscore the need for a coordinated transition from the hospital to the community for the family and child. PMID- 10171874 TI - Stalled on the road to health care reform: an analysis of the initial impediments to the Oregon demonstration project. PMID- 10171875 TI - Capital Cost Health's back-care programme. PMID- 10171876 TI - NZ first for an Auckland hospital. PMID- 10171877 TI - The CPT system and related College activities. PMID- 10171878 TI - Drug misuse--high anxiety. PMID- 10171879 TI - Ambulatory case mix funding systems in Canada. AB - The implementation of inpatient case mix funding in Alberta and Ontario does not allow for adequate incentives to shift resources to an outpatient basis, where appropriate, or to provide outpatient care efficiently. This paper explores the prospects and problems of further extending case mix tools into this area. The availability of tools to characterize output for day surgery, special clinics and emergency care is surveyed. We conclude that case mix funding is desirable and feasible for ambulatory surgery; however, it is questionable for emergency care and special clinics. However, developments in this area in the United States will continue, and this will likely maintain an interest in Canada. PMID- 10171880 TI - The regionalization of laboratory services. Part 1. PMID- 10171881 TI - Point-of-care testing: the JCAHO perspective. PMID- 10171882 TI - Conservation of blood in cardiac surgery. AB - The rising costs of surgical care and decreasing third-party reimbursement mandate conservation of surgical resources and supplies whenever possible. One such resource is autologous blood. Its conservation has the added benefit of protecting the patient from the potential dangers of homologous blood and its products. This article presents conservation techniques found to be feasible in open-heart surgery. PMID- 10171883 TI - Emerging approaches to hospital care and hospital architecture. AB - One cannot speak about emerging approaches to hospitals and hospital design without taking into consideration the ever-increasing changes in the structure of all aspects of today's society: cultural, economic, educational, scientific, social and technological. The design of health care is interwoven with all of these changes. Health facilities design is an outcome of a collective effort of all those involved in both the design and execution of projects. Success in laying down the features of new approaches to hospitals and their design depends to a large extent on our ability to confer and co-operate with each other, to learn from the past, to anticipate the needs of the future and to influence the direction of all developments, based on the strength of knowledge and creativity. In this article, both authors give their views on these issues. PMID- 10171884 TI - An evaluation of the Taxi Subsidy Scheme for the Disabled. AB - This paper reports on an evaluation of the Taxi Subsidy Scheme for the Disabled (TSSD). The evaluation focused on members of the TSSD in terms of their eligibility for Home and Community Care (HACC) Program Services. Using a probability sample in the Brisbane metropolitan area, the project found evidence that at least 79 per cent of TSSD members (under the relevant category) were entitled to such membership, as they also fulfil the requirements prescribed under the Home and Community Care Act 1985. However, the evaluation also found evidence that current utilisation of HACC Program Services does not truly reflect the need for these services within the community. PMID- 10171885 TI - Finding a balance: client choice vs public protection. AB - Choice should be a basic part of health care, yet questions arise when untrained individuals take on the responsibility of supervising their own care--questions of safety and appropriateness. PMID- 10171886 TI - A disability perspective on home care. AB - As the disabled community continues to find its voice, advocates are trying to change the way our society defines disabled persons and the way our health care system defines the services they need. Home- and community-based care can offer the disabled the independence and community access they want--home care agencies should be aware of the special needs of this growing population. PMID- 10171887 TI - How the customer sees it. Which personal care model is best? AB - Jason Tweed and his father conducted a session at the Home Care Aide Association of America Conference in April 1994. In that session and this article, Jason and his father present the perspective of a disabled man and his father--enabling professional caregivers to understand what is most important to this population of patients. PMID- 10171888 TI - Independent provider programs. At what price choice? AB - Independent provider programs may work well for those who are willing and able to find, screen, and dismiss their own providers, but agency-directed care must be an option for those who will not or cannot oversee every step of their own care. PMID- 10171889 TI - The changing role of the rehabilitation nurse. AB - As traditional medical treatment gives way to nontraditional and home-based care, rehabilitation nurses in home care are ideally positioned to assist more and more disabled clients in adjusting to their homes and communities. This article examines the rehabilitation nurse's role and the issues involved in providing this assistance. PMID- 10171890 TI - The ADA & the health professional--a close relationship. An introduction to what health professionals need to know. President's Committee on Employment of People with Disabilities. PMID- 10171891 TI - Proficiency testing: error prevention and correction. PMID- 10171892 TI - Wis. program aids Medicaid disabled. PMID- 10171893 TI - Perspectives. The chronically ill and reform: a minefield of opportunities. PMID- 10171894 TI - More health plan requirements under ADA. PMID- 10171895 TI - Direct contracts for substance abuse benefits. PMID- 10171896 TI - The Medicare secondary payer program: Part I. AB - In order to apprise managed care organizations of their potential exposure under the Medicare Secondary Payer laws, this two-part article examines many of the lessons learned from litigation related to the program. PMID- 10171897 TI - Systemic problems in Medicare: an overview of eight critical issues. PMID- 10171898 TI - Trends in length of stay for Medicare patients: 1979-87. AB - Hospital length of stay (LOS) declined steadily during the 1970s, then rapidly during the early years of the Medicare prospective payment system (PPS). In this article, the authors examine trends in hospital LOS for Medicare patients from 1979 through 1987 for all cases combined, for medical and surgical cases separately, and for different geographic regions. The increase in LOS for surgical cases from 1985 through 1987 represented two offsetting trends. Continuing declines in LOS for most procedures were offset by an increased shift toward complex, long LOS procedures. PMID- 10171899 TI - A patient-based analysis of drug disorder diagnoses in the Medicare population. AB - This article utilizes the Part A Medicare provider analysis and review (MEDPAR) file for fiscal year (FY) 1987. The discharge records were organized into a patient-based record that included alcohol, drug, and mental (ADM) disorder diagnoses as well as measures of resource use. The authors find that there are substantially higher costs of health care incurred by the drug disorder diagnosed population. Those of the Medicare population diagnosed with drug disorders had longer lengths of stay (LOSs), higher hospital charges, and more discharges. Costs increased monotonically as the number of drug diagnoses increased. Overlap of mental and alcohol problems is presented for the drug disorder diagnosed population. PMID- 10171900 TI - Competition keeps LIS (less invasive surgery) prices in check. PMID- 10171901 TI - Non-salary expenses in the laboratory. PMID- 10171902 TI - '93 saw 10% growth in surgery centers. PMID- 10171903 TI - Care paths cut length of stay, reduce charges. PMID- 10171904 TI - Perioperative case managers redesign processes. PMID- 10171905 TI - Americans with Disabilities Act prohibits limiting healthcare coverage. AB - With the enormous increase in the cost of healthcare, especially for catastrophic illnesses, employers have begun to modify their healthcare insurance plans to limit the amount of coverage an employee can receive for treatment of a particular illness, such as AIDS and its related illnesses. The passage of the Americans with Disabilities Act in 1990, however, prohibits an employer from discriminating against disabled individuals with respect to healthcare benefits even if the employer's healthcare plan is not administered by the employer. Thus, it is important for healthcare providers to actively investigate healthcare claims prior to a patient's admission to a hospital to determine whether adequate coverage exists--and to what extent it exists--for treatment of the patient's illness and how and from whom the hospital will be compensated. PMID- 10171906 TI - The Philadelphia story--a landmark case for EMS and the ADA. PMID- 10171907 TI - Reaping maximum benefits from minimally invasive surgery. AB - A study conducted by Deloitte & Touche examined the use of minimally invasive surgery (MIS)--specifically laparoscopic cholecystectomy, laparoscopically assisted vaginal hysterectomy laparoscopic inguinal hernia repair and thoracoscopic wedge resection--at nine U.S. hospitals. From a total hospital cost perspective, two procedures studied reduce hospital costs, one is a breakeven and one increases hospital costs. In addition, with MIS there is a major shift in resource consumption from nursing care units to the operating room. Best practices, defined as most efficient staffing levels, operative times, lengths of hospital stay and other treatment characteristics practiced at the study hospitals, were also identified. Hospitals can maximize their return on MIS by providing ample training to surgical and processing staff, standardizing on equipment, wisely choosing when to use custom kits, block scheduling for MIS and incorporating MIS into the hospital's strategic plan. PMID- 10171908 TI - Special section: minimally invasive surgery. AB - The minimally invasive surgical revolution has brought great benefits to patients and healthcare providers alike. Along with the successes have come some challenges, particularly for those who must clean and reprocess the reusable parts of scopes of all types. We have put together this special section to highlight some of the ways manufacturers of scopes, instruments, cleaning equipment and solutions have endeavored to make processing easier. This section is not all-inclusive, but it should give those facilities with continuing scope reprocessing problems a helping hand. PMID- 10171909 TI - Hospice lends a hand. PMID- 10171910 TI - Small area analysis: descriptive epidemiology in health services research. AB - Small area analysis is descriptive epidemiology applied to health care events. Several methodological issues complicate such studies. Nevertheless, it is possible to derive several conclusions about the determinants of regional variation in medical care use from the small area analysis literature. Most of these conclusions are specific to the procedures, times, and places studied. Changes in technology, economic incentives, and epidemiological factors may invalidate study findings. Nevertheless, small area analysis studies are useful management tools if performed periodically rather than as one-time events. Small area analysis can contribute to our understanding and control of costs, quality, and the accessibility of care, and thus have relevance for both management and policy. PMID- 10171911 TI - Application of a statistics-based expert system to provide automated second opinions prior to elective surgery. AB - Second opinions now are mandated by many funding agencies prior to elective surgery to provide an opportunity to evaluate the indications for surgery and allow an evaluation of the risks of surgery. One difficulty with second opinion programs is the observation that 80% to 95% of all surgical recommendations confirm the need for surgery and the number of patients requiring second opinions represents a significant health care cost. The interactive statistical package (ISP) is a statistics-based decision support system currently used to teach residents medical decision processes. Training an ISP is relatively simple because experts need only define the patient parameters and the allowed values of each parameter. Each expert then sets up a decision tree to represent his or her decision process. The system will then present a series of randomly generated cases to the expert and observe the expert's action. Through Bayesian statistics the system identifies the parameter values that significantly affect the expert's judgment and the direction that they exert on the decision. A decision support system used to evaluate patients with prostate cancer reproduces an expert's treatment selection with an accuracy of 94% on a log rank test when selecting among six treatment options including three different surgical procedures, two different radiation regimens, and palliative therapy. The entire system was trained and validated over 3 weeks, and the accuracy of the system is comparable to the consistency of the expert (90%). Because several experts can review the same patient material and make decisions independently, multiple systems can be created and validated, and operated in parallel.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171913 TI - CLR 1994-1995. Clinical and professional reference guides. PMID- 10171912 TI - CLR 1994-1995. Product information section. PMID- 10171914 TI - Lab regionalization: structural options for the age of managed competition. Part 2. PMID- 10171915 TI - Employee stress pinches hospitals on the bottom line. PMID- 10171916 TI - 1993 changes in drug cost for inpatient services. AB - This article reviews changes taking place in reference to drug cost during the year 1993. It presents indices used for tracking the changes taking place on a monthly basis, classified by different therapeutic class and overall cost factors. PMID- 10171917 TI - New England Medical Center launches program to hire disabled employees. PMID- 10171918 TI - ADA still demands employer vigilance on job descriptions and interview protocol. PMID- 10171919 TI - Lutheran General uses the great outdoors to build teams year round. PMID- 10171920 TI - Letter to the editor ... management of STAT testing. PMID- 10171921 TI - The Joint Commission's indicator measurement system: implications for information systems. PMID- 10171922 TI - Americans with Disabilities Act (ADA) gives rise to workers' compensation claims. PMID- 10171923 TI - ERISA preemption and its effects on capping the health benefits of individuals with AIDS: a demonstration of why the United States health and insurance systems require substantial reform. PMID- 10171924 TI - Medicare program; Medicare Secondary Payer (MSP) amendments--HCFA. General notice. AB - This notice--1. Describes the changes made to the MSP for the disabled provision by sections 13561(b) and 13561(e) of the Omnibus Budget Reconciliation Act of 1993, Public Law 103-66, hereafter referred to as OBRA '93; and 2. Provides guidance for employers and employer health plans so that they can provide to Medicare contractors and beneficiaries the information necessary to implement these changes. Section 13561(b) changes the sunset date of the MSP for the disabled provision from October 1, 1995 to October 1, 1998. Section 13561(e) modifies the MSP for the disabled provision to conform to the MSP for the working aged provision, so that for both groups, the MSP provision applies (and the group health plan is primary payer) only when coverage under the plan is based on "current employment status with an employer." PMID- 10171925 TI - Alzheimer's disease--the long goodbye. AB - Alzheimer's disease affects one in 10 families in the United States; unless an intervention is found, millions more will be afflicted. Research is beginning to unveil the way the disease works and what causes it, leading to a glimmer of hope for future treatments. But understanding must come first. PMID- 10171926 TI - Policy issues surrounding special care units. AB - What is specialized care for Alzheimer's patients? Is it really specialized, or could that word simply be a marketing ploy? Home care agencies that care for patients with Alzheimer's disease will face these questions with their patients and undergo the same questions that the nursing home industry faces. PMID- 10171927 TI - Effects of an intervention program on dementia patients & their caregivers. AB - Caregivers of Alzheimer's patients often feel frustration, anger, and depression, which cannot help but affect their wards. Would better caregiver training lead to positive outcomes for both caregivers and their patients? PMID- 10171928 TI - Alzheimer's disease. Research turned into reality. AB - A needs assessment revealed that a majority of home care workers feel the need for more education on Alzheimer's disease if they are taking care of such individuals. One program in Canada addressed this hole in the home care basket with a seven-module training course, which prepares its workers for the difficult task of caring for persons with AD when no one else is there. PMID- 10171929 TI - Heroes of health care: a window on caregiver burden. AB - On Wednesday, March 23, 51 older Americans came to Washington, DC, to deliver their unique messages concerning the need for long-term care and a health care system responsive to the needs of older Americans. HealthRIGHT, a coalition created to capture Americans' views on the health care system and what needs to be done to improve it, orchestrated the event. In an extraordinary briefing session in the Rayburn House Office Building, First Lady Hillary Rodham Clinton was present with congressional leaders to hear these stories. Several of the witnesses focused on Alzheimer's patients or their caregivers. CARING is pleased to include their stories here, as testimony to the major effect this terrible disease can have on a family. PMID- 10171930 TI - Dealing with depression & anger: reactions of family caregivers. AB - Family caregivers are the second victims of Alzheimer's disease, often bearing physical, financial, and emotional burdens of which their loved one cannot conceive. These burdens naturally lead to anger, guilt, loneliness, and depression for caregivers. Professional caregivers are in a position to support the families and ease their anxieties. PMID- 10171931 TI - Patience is a virtue. AB - Family members learn a lot about intervention while caring for Alzheimer's patients. Nutrition and safety are two aspects of Alzheimer's care that family caregivers can influence on their own, day to day. PMID- 10171932 TI - Networks for home care support: the ComputerLink project. AB - Family caregivers of Alzheimer's patients often feel isolated by the restrictions placed on them by their role. The ComputerLink project was established to provide these caregivers with the information and support they need to make informed decisions about plans of care and to feel connected to others in similar circumstances. PMID- 10171933 TI - Nursing role in advance proxy planning for Alzheimer patients. AB - Patients with Alzheimer's disease or other types of dementia become unable to make decisions regarding their care. Advance proxy planning provides a mechanism for protecting these patients' self-determination. PMID- 10171934 TI - Costs and outcomes of inpatient versus outpatient hernia repair. AB - This study sought to compare treatment costs and outcomes for a large number of Medicare patients undergoing inpatient versus outpatient hernia repair around the country. Medicare physician and hospital claims were obtained for all Medicare enrollees residing in eleven states in 1987 and 1988, in order to take advantage of geographic variation in treatment location. All patients undergoing uncomplicated inguinal hernia repair were identified from the surgeon's bill; the location of surgery was then validated by the facility bill (n = 27,036). Over one-third of all hernia repairs in our sample were performed on an ambulatory basis, but with tremendous variation across states, ranging from 89.9% of cases in Washington in outpatient settings to almost none (6.3%) in Georgia. Treatment costs were 56% higher for hernias repaired on an inpatient basis, $2341 versus $1505 for those performed in outpatient settings. There were no detectable differences between inpatients and outpatients along such outcomes as complication rates, deaths and hernia recurrence, but readmission rates were higher for inpatients. The dramatic differences in costs, along with the apparent absence of adverse outcomes, suggests that Medicare should actively encourage surgeons to perform more hernia repairs on an outpatient basis. PMID- 10171935 TI - Disability transitions in an area-based system of long-term care for the elderly and disabled. AB - OBJECTIVE: To describe patterns of individual disability development and mortality in an area-based system for long-term care of the elderly and disabled. DATA SOURCES AND STUDY SETTING: Yearly surveys according to the ASIM system from 1985 to 1991 of all citizens of Solna, Sweden, receiving long-term care services from the municipality and/or the county council. STUDY DESIGN: Linkage of individual assessments concerning disability and level of care from one survey to the next, using national registration numbers. DATA COLLECTION: Registrations according to the ASIM system concerning services actually provided, assessed need of services, social environment and disability were collected by the staff responsible for the services provided. PRINCIPAL FINDINGS: Mortality was shown to be strongly connected to disability. Disability transitions occurred in both directions for all age groups, but the average rate of disability increase rose with advancing age. Rapid disability development was shown in a multivariate analysis to be connected to institutional care and change in the level of care between surveys. CONCLUSIONS: Data describing disability development can be used for planning purposes, either directly or with the help of a simulation model. More research seems to be needed with regard to the influence of the level of care and of transfers on disability development. PMID- 10171936 TI - Cost containment and health care reform: a study of the European Union. AB - This article gives a short summary of the organisation and financing of health services of the 12 Member States of the European Union. It then describes the latest developments in cost containment in each of the countries. The third section describes the new initiatives for reform in Spain, Italy, the Netherlands, Portugal and the United Kingdom. Finally, it gives a summary of the cost containment measures in the 12 countries, listing them under a set of headings. They are classified as budget control, alternatives to hospital care, cost sharing, influencing authorizing behaviour and limits on supply. The article shows the considerable convergence of policies which is developing. Overall budget control in some form is to be found in 8 of the countries. Where providers are paid by a number of different insurers, budgets are nevertheless applied to hospitals in three countries and in another only to public hospitals. Both Germany and France have used budgets to control other items of expenditure. Profits or the prices of drug companies are controlled in 8 countries and in one indirectly. Three have adopted reference price systems for drugs and another has taken powers to do so. Two have adopted or are moving towards provider markets. PMID- 10171937 TI - Ambulatory surgery marketing to primary care physicians. AB - The leaders of health care organizations across the country are facing significant pressure to improve the quality of their services, reduce operating costs, and adjust to decreases in reimbursement. Survival of a surgery center is achieved when physicians work together to decrease their vulnerability to outside forces and increase their ability to reach desired objectives. Improved communication, operational efficiency, and cost effectiveness are the strategic imperatives. As competition for patient referrals increases among providers, in the midst of a national trend, a surgery center marketing program must be well organized and carefully designed to meet the needs of all its customers. A surgery center that can strategically place itself as a critical link between the surgical specialist and the gatekeeper will survive and prosper in the current health care world. PMID- 10171938 TI - Focus on quality: profiling physicians' practice patterns. AB - This article presents a physician practice profiling system developed using Medicare data to evaluate the quality of care provided by primary care physicians. We discuss four attributes to physicians' practice profiles that make them useful for quality improvement: flexibility, user involvement in developing profiles, explicit plans for evaluation, and fairness to groups of providers. This system serves as a model for physician profiling with a focus on quality of care measurement. PMID- 10171939 TI - Where the Supreme Court feared to tread: closing the loopholes in ERISA section 510. PMID- 10171941 TI - Comment: informed consent, obligation or opportunity? PMID- 10171940 TI - Current topics in medical staff development and credentialing. PMID- 10171942 TI - Substance abuse and the Health Security Act: a case study of a benefit under the Clinton health plan. PMID- 10171943 TI - Medical futility: when is enough, enough? PMID- 10171944 TI - Preparedness a must for compliance. PMID- 10171945 TI - The long-term benefits of employing the disabled. PMID- 10171946 TI - When interviewing the disabled, focus on their abilities. AB - Thanks to the ADA, employers can capitalize on the abilities of disabled persons, rather than create barriers to employment. This article explains some common myths that have shaped hiring practices in the past and provides practical interviewing tips. PMID- 10171947 TI - Approaching architectural challenges under the ADA. PMID- 10171948 TI - Training key to job satisfaction. PMID- 10171949 TI - Employing people with disabilities. AB - By July 26, 1994, employers with 15 or more employees must comply with the Americans with Disabilities Act. By understanding the ADA regulations, you can recruit qualified, dedicated employees from a virtually untapped segment of the population. PMID- 10171950 TI - Critical pathways. Pathways guide care at St Luke's, Houston. PMID- 10171951 TI - Critical pathways. Hospital shortens cataract stays, boosts satisfaction. PMID- 10171952 TI - Two-thirds of surgeries outpatient by 1995. PMID- 10171953 TI - Technical considerations of bariatric surgery in the superobese. PMID- 10171954 TI - Disabilities Act demands prompt action. PMID- 10171955 TI - Measuring handicap: the London Handicap Scale, a new outcome measure for chronic disease. AB - OBJECTIVE: To develop a handicap measurement scale in a self completion questionnaire format, with scale weights allowing quantification of handicap at an interval level of measurement. DESIGN: Adaptation of the International Classification of Impairments, Disabilities and handicaps into a practical questionnaire incorporating the dimensions of handicap mobility, occupation, physical independence, social integration, orientation, and economic self sufficiency and scale weights derived from interviews with a general population sample, with the technique of conjoint analysis. SETTING: Two general practices in different areas of London. SUBJECTS: 240 adults aged 55-74 years randomly selected from the practices, 101 (42%) of whom agreed to be interviewed, and 79 (78%) of whom completed the exercise. MAIN MEASURES: Rating of severity of handicap associated with 30 hypothetical health scenarios on a visual analogue scale, from which was derived a matrix of scale weights ("part utilities") relating to different levels of disadvantage on each dimension, with a formula for combining them into an overall handicap score. Severity scores measured directly for five scenarios not used to derive the scale weights were compared with those calculated from the formula to validate the model. RESULTS: The part utilities obtained conformed with the expected hierarchy for each dimension, confirming the validity of the method. The measured severities and those calculated from the formula for the five scenarios used to validate the model agreed closely (Pearson's r = 0.98, p = 0.0009; Kendall's tau = 1.00, p = 0.007). CONCLUSIONS: This interval level handicap measurement scale will be useful in assessing both specific therapies and health services, in clinical trials, in analyses of cost effectiveness, and in assessments of quality assurance. PMID- 10171956 TI - Effects of a computerised protocol management system on ordering of clinical tests. AB - OBJECTIVE: To assess the effects of a computerised protocol management system on the number, cost, and appropriateness of laboratory investigations requested. DESIGN: A before and after intervention. SETTING: A supraregional liver unit in a teaching hospital. PATIENTS: 1487 consecutive patients admitted during 1990 and 1991 (one year before and one year after introduction of the system). INTERVENTION: Introduction of a computerised protocol management system on 1 January 1991. MAIN MEASURES: The number and cost of clinical chemistry tests requested per patient day. RESULTS: The total number of clinical chemistry tests requested per patient day by the unit declined 17% (p < 0.001, Student's t test) and of out of hours tests requested per patient day from 0.31 to 0.16, 48% (p < 0.001; Mann-Whitney U test), resulting in a 28% reduction (p < 0.001) in direct laboratory expenditure per patient-day. Overall, the number of tests per admission decreased by 24% (p < 0.001; Mann-Whitney U test). CONCLUSION: Use of the computerised protocol management system resulted in closer compliance with the protocols and a significant reduction in the overall level of requesting. IMPLICATIONS: Although similar systems need to be tested in other clinical settings, computerised protocol management systems may be important in providing appropriate and cost effective health care. PMID- 10171957 TI - Measuring handicap: motives, methods, and a model. PMID- 10171958 TI - Integrating quality assurance with continuous quality improvement. Case 4. PMID- 10171959 TI - EMEA (European Medicines Evaluation Agency) and the new pharmaceutical procedures for Europe. AB - Regulation of medicines in the United Kingdom has changed considerably since the establishment of the Medicines Control Agency in 1989, and other changes will take place throughout the European Community (EC) over the next few years. 1995 will see the introduction of a centralised procedure, applicable to a small number of innovative drugs, and a decentralised procedure, based on mutual recognition of licences granted by existing control authorities in other EC countries. PMID- 10171960 TI - Breast implants: is there an association with connective tissue disease? AB - Following concern over a suggested link between the implantation of silicone gel and connective tissue disease, the Medical Devices Directorate (MDD) of the Department of Health reviewed all available data for submission to a specially convened Expert Advisory Group. Animal studies indicated that silicones are unlikely to stimulate a specific antibody response or cell-mediated immunity, that they have no adverse effect on resistance to infection, and produce minimal effects in the presence of potent adjuvants but can act as adjuvants themselves. The connective tissue disease most commonly claimed to be associated with breast implants is scleroderma. Although one series of patients showed a significantly higher prevalence of this disease than expected, there is no clear indication that the incidence of scleroderma in women with breast implants is any higher than in the general population. PMID- 10171961 TI - The use of aspirin in children under 12 years old attending a paediatric dentistry department in a dental hospital. AB - For several years it has been recommended that aspirin should be avoided in children under the age of 12 years because of the risk of Reye's Syndrome. In this study we investigated the reported use of analgesics among children who attended the Children's Department of the Dental Hospital in Newcastle upon Tyne. In addition the study also investigated the complaints that led to use of analgesics, the dose and frequency of administration of the analgesic, and past and current contact with medical services. Of 179 children investigated, 129 were under 12 years-old; of these 129 children under 12 years-of-age, 72 (56%) had taken an analgesic within the previous six months, 12 (17%) of whom took aspirin. Three of these children who had taken aspirin were reported to have had a serious illness in their lives, and would therefore have had significant contact with medical services. One-quarter of all children who had taken an analgesic did so for toothache. Inappropriate use of aspirin in children under 12 years-of-age indicates that health education about the possible risks of Reye's Syndrome needs to be improved. PMID- 10171962 TI - Drug misuse. Casing the joint. PMID- 10171963 TI - The contribution of treatment outcome research to the reform of children's mental health services: multisystemic therapy as an example. AB - Service system reforms of the past decade have yielded innovations in type, accessibility, and cost of services provided for some children and families with serious problems, but few of the treatments delivered have been empirically evaluated. Rigorous tests of well-conceived treatments are needed to provide a solid foundation for continued reform. Multisystemic therapy has demonstrated efficacy in treating serious clinical problems in adolescents and their multineed families and is an example of the successful blending of rigorous treatment outcome research and service system innovation. PMID- 10171965 TI - Urethral strictures treatment with neodymium:YAG laser. AB - A total of 14 patients with stricture of the urethra underwent treatment with Nd:YAG (neodymium:YAG) laser irradiation. A new 800-micron hemispherical optical quartz fiber was used in contact technique to produce linear incisions in the scarred tissue. Within 11.2 months, median of follow up, there was improvement in the obstructive voiding symptoms in all the patients. One patient who still had mild stricture in the first follow-up cystoscopy was managed successfully with second treatment. Endoscopic application of laser energy in the contact mode facilitates the immediate vaporization and disintegration of the fibrous area and secondary reepithelization of the urethra without scarring. PMID- 10171964 TI - Cost-effectiveness of substance disorder interventions for people with severe mental illness. AB - This study examines the cost effectiveness of three intervention strategies for people with severe mental illness who are dually diagnosed clients in terms of service use and costs. The interventions represent three primary approaches to treating these disorders: 12-step recovery, case management, and behavioral skills training. Interim findings from the study indicate that all three approaches are reducing acute and subacute service use and increasing involvement with outpatient and case management treatments. However, both the case management and behavioral skills approaches reduce costs more than the 12-step recovery approach, although not to a statistically significant degree in the data collected thus far. Overall, the societal costs for these clients are reduced by 43% without increasing the burden on client families or on the criminal justice system. PMID- 10171966 TI - Imaging in neuro-otology. AB - Imaging the disorders of the auditory pathways is best achieved by magnetic resonance imaging (MRI), especially with contrast enhancement. Computerized tomography (CT) still has an important role for disorders of the middle ear as well as congenital, traumatic and other osseous abnormalities of the petrous temporal bone. PMID- 10171967 TI - Ocular therapy with silicone oils. AB - It has been 30 years since the first reported use of intraocular liquid silicones for retinal reattachment. During this time, there have been many notable advances in surgical techniques and instrumentation together with an improved understanding of the pathogenic mechanisms of complex retinal detachment associated with proliferative vitreoretinopathy. More recent attention has also been focused on improving the quality of the previously used commercial silicone oils. Enhanced surgical results combined with refined high-viscosity oils have led to a dramatic decrease in complications previously associated with and ascribed to the use of liquid silicone. This article reviews the literature regarding ocular use of silicone oils as an instrument and as a tamponade. PMID- 10171968 TI - Imaging helps guide Nintendo surgeons. PMID- 10171969 TI - Once more with GUSTO. PMID- 10171970 TI - The development of a novel implant: induction of a non-rigid and self-renewing anchorage of artificial implants to bone. AB - Artificial implants currently used in orthopaedic surgery and dentistry are anchored to the surrounding bone by rigid mechanical fixation. Long-term studies indicate that the rate of implant failure due to loosening increases steeply after 10 years of function. The loosening is attributed to the micro-movements occurring at the bone implant interface. Non-rigid, self-renewing ligamentous anchorage is nature's solution to the problem of micro-movements. An excellent example of this type of anchorage is the tooth-bone system, where the tooth is anchored to the bone by a fibrous connective tissue. A novel artificial implant, bearing on its surface a unique biological substrate (BS), was designed to induce a ligamentous anchorage of implant to bone. The implant consists of a metallic core to which the BS is bound. The BS is a composite of plastic material and a collagen mesh which is partly incorporated into the plastic material and partly freely extended from its outer surface as artificial Sharpey's fibers. BS fabrication did not affect the capacity of the collagen to withstand non-specific degradation in vitro. Non-weight-bearing implants implanted into the femoral bone of rats induced and maintained a ligament-like tissue up to 4 months. The collagen fibers of the ligament-like tissue were spliced with the artificial BS Sharpey's fibers and were also anchored as Sharpey's fibers into the surrounding bone. Examination of control plastic implants (without the BS) revealed bone formation in close approximation to the implant surface.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171971 TI - A comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy. AB - The goal of this study was to compare laparoscopically assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH). We performed a prospective comparison of the hospital courses of 30 women, 15 undergoing LAVH and 15 undergoing TAH, in a teaching hospital setting. Analysis of variance (ANOVA) was used, with statistical evaluation of differences by Student's t-test for normally distributed data and Kruskal-Wallis for data with dissimilar variances. Fourteen of fifteen patients scheduled for LAVH had their surgery completed without need of a laparotomy. In the LAVH group, (1) mean surgical time was 50 minutes longer, (2) blood loss, complications, and hospital costs were not statistically different, (3) hospital days averaged 1 1/2 less, and (4) postoperative pain ratings and medication requirements were significantly decreased, compared with the TAH group. In many cases, LAVH may be reasonably performed instead of an indicated TAH. PMID- 10171972 TI - Laparoscopic supracervical (subtotal) hysterectomy (LASH). AB - The use of laparoscopically assisted vaginal hysterectomy with or without annexectomy has been widely discussed. We report the technique of laparoscopic supracervical (subtotal) hysterectomy (LASH), which was first performed in 1990. Laparoscopic supracervical hysterectomy was carried out in a series of 36 women. The duration time was 60 min in experienced hands. There were no major complications. The feasibility and low morbidity rate of this laparoscopic approach led us to propose LASH in certain indications, particularly in cases of a uterus with multiple submucosal myomas where hysteroscopic therapy is less successful. PMID- 10171973 TI - Laparoscopic myolysis with the Nd:YAG laser. AB - Laparoscopic myomectomy can be carried out in cases of subserosal and intramural fibroids. Laparoscopic myolysis can be proposed as an alternative to laparoscopic myomectomy in cases of large or multiple intramural fibroids in women aged over 40 or not desiring to bear more children but wishing to avoid a future hysterectomy. The authors report the technique and the long-term results in a series of 48 women with fibroids treated by myolysis. Because of the risk of bowel adhesions, further studies with another type of laser fiber are required. PMID- 10171974 TI - Laparoscopic radical hysterectomy and laparoscopically assisted vaginal radical hysterectomy with pelvic and paraaortic node dissection. AB - Nineteen women underwent laparoscopic radical hysterectomy or laparoscopically assisted vaginal radical hysterectomy, with pelvic node dissection and paraaortic node dissection when indicated. One procedure was converted to laparotomy due to equipment failure (at The University of Puerto Rico). There were two minor postoperative complications. The first, febrile morbidity resulting from a urinary tract infection, responded to medical therapy. The second was incisional bleeding, which was controlled with sutures applied using a local anesthetic. No major postoperative complications were noted, there have been no incidents of recurrence, and the follow-up results are encouraging. PMID- 10171975 TI - Intraoperative echocardiography by a new miniaturized epicardial probe: preliminary findings. AB - Miniaturized probes constitute recent progress in the field of epicardial echocardiography. We recently used a new miniaturized probe, derived from a standard transesophageal probe, in a series of 12 adult patients who underwent cardiac surgery in order to test the possibility of obtaining new views for epicardial imaging. This study demonstrates the feasibility and safety of performing intraoperative echocardiography when using a miniaturized epicardial probe. This probe may be placed on a broader epicardial and vascular area, thus overcoming the size limitations of the commonly used epicardial probes. The major limitation found with the miniaturized probe, however, was the inability to obtain a true four-chamber view from the ventricular apex, due to the difficulty of holding the probe motionless between the apex and the diaphragm while the heart is beating. Although extensive experience with larger groups of patients and different pathologies will be required to define the full potential of this new probe, the advent of the miniaturized probe may further expand the applicability of epicardial echocardiography in pediatric patients during surgery for congenital heart disease. PMID- 10171976 TI - Preliminary experience with a percutaneous cardiopulmonary support system. AB - Percutaneous cardiopulmonary bypass has been introduced to support circulation in critical patients. In our preliminary experience we resuscitated two patients who sustained a prolonged cardiac arrest (52 min. and 31 min.) after coronary angiography and elective cardiac surgery, respectively. Cannulation was achieved percutaneously within 10 min. in both cases. Pump flow ranged from 2 to 31/m. Total support lasted from 52 min. to 180 min.. Both patients were successfully weaned. Patient 1 was declared brain dead and expired 17 days later. Patient 2 was discharged from the hospital and is doing well. Cannulation was attempted in a third patient after 30 min. of cardiac arrest. Despite surgical cut down of the femoral vessels, it was impossible to advance the arterial cannula because of bilateral occlusive disease. We conclude that PCPS is a powerful technique in selected patients to recover a stable cardiac function after prolonged cardiac arrest. PMID- 10171977 TI - Heparin removal in three intraoperative blood savers in cardiac surgery. AB - The aim of the study was to compare the residual heparin in the composition of autologous blood retransfusion units harvested during cardiac surgery under extra corporeal circulation with three different intraoperative autologous blood savers. In this institutionally approved study, thirty patients undergoing CABG were randomly assigned to three groups according to the intraoperative blood saver used during the procedure: {HAEMONETICS Cell Saver IV (n=10)- DIDECO/SHILEY STAT (n=11)--BRAT 250 (n=9)}. Anaesthesia and conduct of bypass were identical for all patients. The initial heparin dose was 300IU-kg -1 and was supplemented to maintain an activated coagulation time over 480s. The harvested blood was processed according to the procedure defined by each equipment manufacturer. The biological study was performed on the first blood sediments sampled before administering protamine to the patient. Blood cell count, residual heparinemia assessed by its anti-Xa activity using an amidolytic method {STACHROM HEPARIN--DIAGNOSTICA STAGO}, and weight of the blood sediment proteins were determined. Demographic data did not differ between groups. Despite a slight but significant difference between groups, the three devices provided virtual elimination of heparin. The total protein content was significantly higher in the BRAT 250 group. There was a highly significant positive correlation between the anti-Xa activity and total protein content. Haematologic data were within clinically acceptable ranges. PMID- 10171978 TI - Histological and histomorphometrical evaluation of the bone reaction to three different titanium alloy and hydroxyapatite coated implants. AB - The aim of this study was to investigate the bone response to three different types of titanium (Ti) alloys and hydroxyapatite (HA) coated titanium alloy by histological and histomorphometrical analysis. Therefore, implants made of these materials were inserted into the tibia of rabbits. Implantation times were 6 and 16 weeks. The histological evaluation included measurement of the amount of bone apposition and analysis of the bone reaction and interface characteristics around the implants. The results demonstrated no marked differences in bony reaction to the different implant materials. In addition, the HA coatings showed loss of thickness. PMID- 10171979 TI - A comparison of peripheral nerve repair using an absorbable tubulization device and conventional suture in primates. AB - Median nerve regeneration was studied in 30 adult primates after repair by microsurgical suture or tubulization with a nonwoven, bioabsorbable, polyglycolic acid device. The two methods were compared electrophysiologically and histologically 6 and 12 months after repair. The electrophysiology included recording of electrically evoked compound action potentials and subsequent determination of threshold, conduction velocity, amplitude, and area above the baseline for each component. Measurements were obtained before nerve transection and at the time of biopsy by stimulating both proximal and distal to the transection site. Analysis of all electrophysiological parameters revealed no statistically significant differences (p less than 0.05) between the two repair techniques. Histopathology included examination of cross sections proximal and distal to the repair sites and longitudinal sections through the coaptation site. End organs (Meissner's and Pacinian corpuscles and muscle) were sectioned to determine the degree of reinnervation. No significant differences between the repair techniques were observed by histological analysis of these sections. These evaluations indicated that the tubulization repair technique produced results comparable to that of the suture technique. PMID- 10171980 TI - Cost effectiveness and efficiency in assistive technology service delivery. AB - In order to develop and maintain a viable service delivery program, the realities of cost effectiveness and cost efficiency in providing assistive technology must be addressed. Cost effectiveness relates to value of the outcome compared to the expenditures. Cost efficiency analyzes how a provider uses available resources to supply goods and services. This paper describes how basic business principles of benefit/cost analysis can be used to determine cost effectiveness. In addition, basic accounting principles are used to illustrate methods of evaluating a program's cost efficiency. Service providers are encouraged to measure their own program's effectiveness and efficiency (and potential viability) in light of current trends. This paper is meant to serve as a catalyst for continued dialogue on this topic. PMID- 10171981 TI - Comments on Warren's "cost effectiveness and efficiency in assistive technology service delivery" . PMID- 10171982 TI - Technology for people with disabilities: a survey of needs. AB - A good understanding of the needs, desires, and capabilities of individuals with disabilities is critical if rehabilitation workers are to promote optimum quality of life. This survey was undertaken to determine the needs of a population of adults with disabilities as a result of neurological trauma or disease. We looked at communication, seating, mobility, environmental control, education, and leisure. Consideration of assistive technology's role in meeting these needs was achieved by an experienced Technology Access Team comprising a physiotherapist, occupational therapist, and speech pathologist in screening consenting residents. The initial needs survey identified that 37% of clients in the study had problems with verbal communication, 62% with cognition, and 52% with seating. Assessments for electric wheelchairs were required by 21.5% of clients while 30.7% had problems with hand function for accessing. Further assessment for equipment and/or training was recommended in 123 (70%) of the 163 participants. These findings have implications for management, including raising awareness of technology's benefits. There are also implications regarding staff knowledge and specialist skills required to identify needs and technological solutions. Preliminary recommendations await validation as individual's requirements are further investigated. PMID- 10171983 TI - Ligating varicoceles through the laparoscope. PMID- 10171984 TI - Research perspectives for a European clinical trials network. Report from an EC study group. PMID- 10171985 TI - Image-guided therapy tackles prostate cancer. PMID- 10171986 TI - Confidentiality of medical information from the perspective of the life insurance business. PMID- 10171987 TI - Perspectives on myocardial protection: warm heart surgery. AB - Continuous normothermic blood cardioplegia (CNBC), was recently introduced into clinical cardiac surgery and has generated great interest. CNBC represents the evolution of concepts which were initially described in the 1950s but which were forgotten as hypothermia became the main ingredient in all cardioplegic techniques and in heart surgery in general. The historical background to the development of CNBC is presented, as well as a review of the current state of knowledge about normothermic heart surgery. The limitations and pitfalls of the method are highlighted, along with future developments and perspectives. PMID- 10171988 TI - Monitoring of CO2 exchange during cardiopulmonary bypass: the effect of oxygenator design on the applicability of capnometry. AB - The correlation between pCO2 values in blood and in exhaust gas from the oxygenators was examined during cardiopulmonary bypass (CPB) using one bubble oxygenator and three membrane oxygenators. Forty-seven CPBs were performed, 17 with Compactflow (Dideco, Italy), 10 with Maxima (Medtronic Inc., USA), 10 with Cobe CML (Cobe Laboratories, USA) membrane oxygenators and 10 with Hi-Flex (Dideco, Italy) bubble oxygenators. Blood samples were taken both from arterial and venous lines of the oxygenator. A capnometer was connected to the oxygenator gas exhaust port and CO2 fraction was measured at the time of drawing blood samples. CO2 pressure in the gas phase was calculated from the product of the CO2 fraction and water vapour-corrected barometric pressure. Blood gases were measured at 37 degrees C and the pCO2 value was corrected to the temperature of the arterial line. The correlation between blood and exhaust gas pCO2 was good in all the oxygenators examined, ranging from 0.921 to 0.976. The standard error of estimate (SEE) was in the range of about +/- 2 mmHg for all the oxygenators. The systematic error (slope and intercept of the correlation line) varied depending on the construction of the oxygenator, with countercurrent design having the best overall correspondence. Based on the results of this study it can be concluded that arterial or venous CO2 pressure can be monitored with a capnometry device coupled to the oxygenator gas outlet port.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10171989 TI - Assessing gravimetric estimation of intraoperative blood loss. AB - Our objective was to assess the accuracy of gravimetric estimation of intraoperative blood loss using the colorimetric method. Forty laparotomy sponges were selected randomly from general gynecology cases during a 2 month period. The blood contained on each sponge had been assessed by the OR staff by weighing the sponges. The hemoglobin contained in the sponges was then converted to alkali hematin and measured in a Beckman spectrophotometer at 465 nm. Using the patient's preoperative hemoglobin measurement, the amount of blood present in the sponges was determined. The gravimetric and colorimetric measurements were compared statistically. We found no statistically significant correlation between the amount of blood loss estimated by the gravimetric method and the actual blood loss as measured by the colorimetric method (P = 0.074). The gravimetric method of assessing intraoperative blood loss is neither precise nor accurate. PMID- 10171990 TI - The role for laparoscopic presacral neurectomy. AB - This study was carried out to determine the efficacy of laparoscopic presacral neurectomy (LPSN) and to define its role in modern gynecology using a prospective consecutive cohort. One hundred three patients underwent LPSN, and 87 were included in this study. After LPSN, 91% of these 87 patients experienced some decrease in pelvic pain, and a majority of patients had 50% or greater reduction in pain score. There was a highly significant difference among the preoperative and postoperative pain levels (p less than 0.0001). Patients with pain of endometriosis (72), primary dysmenorrhea (5), and chronic pelvic inflammatory disease (10) responded with a decrease in pain score to this procedure. Complications included 1 patient with intraoperative bleeding, 2 with postoperative vaginal dryness, and 1 with constipation. We conclude that LPSN is as effective as that performed by laparotomy and should be offered to patients undergoing operative laparoscopy for central dysmenorrhea and pelvic pain. This procedure should be performed only by expert endoscopists experienced in the anatomy of this region. PMID- 10171991 TI - Laparoscopic presacral neurectomy vs neurotomy: use of the argon beam coagulator compared to conventional technique. AB - Presacral neurectomy is effective treatment for dysmenorrhea and midline pelvic pain. Conventional laparoscopic techniques describe retroperitoneal dissection to excise retroperitoneal nerve tissue. The argon beam coagulator (ABC) can be used laparoscopically to hemostatically ablate and thus separate the presacral tissues down to the periosteum without dissecting or excising tissue. In 32 patients undergoing laparoscopic presacral neurectomy, 17 were performed with conventional methods, and 15 patients underwent ABC neurotomy only, without dissection or excision. Postoperative pain reduction was the same in both groups (73% vs 75%), with average anesthesia time 64 min for ABC neurotomy vs 92 min with conventional techniques. One major vascular complication requiring immediate laparotomy occurred in the ABC group. When properly applied laparoscopically, the ABC is an effective tool to rapidly coagulate and separate the presacral nerves with minimal smoke, excellent visualization, and no retroperitoneal dissection. PMID- 10171992 TI - Video-monitored TURP: variation on a standard. PMID- 10171993 TI - Can lasers deliver a sutureless anastomosis to urology? PMID- 10171994 TI - What you should know about perioperative protection from infectious agents. PMID- 10171995 TI - Lasers add a glow to the search for BPH therapies. PMID- 10171996 TI - Porous implants for knee joint meniscus reconstruction: a preliminary study on the role of pore sizes in ingrowth and differentiation of fibrocartilage. AB - Implants with four different macropore sizes were implanted in the meniscus of 29 rabbits for assessment of ingrowth and differentiation of fibrocartilage. Implant macropores were 50-90, 90-150, 150-250 and 250-500 mum, the vol.% macropores was 48-55 and total pore volume 84-86 vol.%. Ingrowth was optimal in the two large pore implants whereas the small pore implants partially remained empty up to 1 year post-operative. Capsule formation and the foreign body reaction was severe for the small pore implants whereas this occurred to a lesser extent in the two large pore implants. Fibrocartilage formation, as assessed by morphology and antibody labelling for type I and type II collagen, was observed in a similar way in all implant types. It is concluded that for optimal ingrowth and incorporation of partial or total meniscal prosthesis, macropore sizes must be in the range of 150-500 mum. PMID- 10171997 TI - The effect of ion implantation on cellular adhesion. AB - As there are only a finite number of materials suitable for orthopaedic reconstruction, considerable effort has been devoted recently to investigating ways of altering the surface chemistry of prosthetic materials without altering their bulk properties. Ion beam implantation is one such technique which is appropriate for orthopaedic reconstructive materials. This paper investigates the early effect of ion beam modification on cellular attachment of bone derived cells using a prototype device which measures the strength of attachment of individual cells to a silicon substratum. The results point to several conclusions. (1) There is no evidence that ion beam implantation with nitrogen, phosphorus, manganese or magnesium produces increased adhesion of human bone derived cells. (2) Surface etching with hydrofluoric acid, electron bombardment and thermal oxidation increases the strength of attachment between cells and substrata. (3) There is a correlation between wettability and rate of cellular attachment to oxygen implanted substrata during the first 2 h after cellular seeding. However, the increase in cellular attachment cannot be entirely explained by the change in critical surface tension or via increased fibronectin attachment to the substrata. PMID- 10171998 TI - Biodegradation and bioresorption of calcium phosphate ceramics. AB - The use of several calcium phosphate (Ca-P) materials for bone repair, augmentation, substitution and as coatings on metal implants has gained clinical acceptance in many dental and medical applications. These Ca-P materials may be of synthetic or natural origin, available in different physical forms (dense or macroporous, particles or blocks) and are used in bulk as coatings for metallic and non-metallic substrates or as components in composites, cements and bioactive glasses. Biodegradation or bioresorption of calcium phosphate materials implies cell-mediated degradation in vitro or in vivo. Cellular activity during biodegradation or bioresorption occurs in acid media; thus the factors affecting the solubility or the extent of dissolution (which in turn depends on the physico chemical properties) of the Ca-P materials are important. Enrichment of the microenvironment due to the release of calcium and phosphate ions from the dissolving Ca-P materials affects the proliferation and activities of the cells. The increase in the concentrations of the calcium and phosphate ions promotes the formation of carbonate apatite which are similar to the bone apatite. The purpose of this invited paper is to discuss the processes of biodegradation or bioresorption of Ca-P materials in terms of the physico-chemical properties of these materials and the phenomena involved including the formation of carbonate apatite on the surfaces and in the vicinity of these materials. This phenomenon appears to be related to the bioactivity of the material and the ability of such materials to directly attach to bone and to form a uniquely strong material-bone interface. PMID- 10171999 TI - Echocardiographic assessment of adults with tetralogy of Fallot. AB - Advances in medical and surgical management of congenital heart disease in the last three decades have resulted in a great many survivors to adulthood. Proper care requires intimate knowledge of the basic malformations and their surgical anatomy and results. Tetralogy of Fallot, the most common cyanotic malformation in adults, represents a spectrum from mild right ventricular outflow tract obstruction to complete pulmonary atresia. Evaluation of surgical residua and sequelae includes imaging of aortic-to-pulmonary arterial palliative shunts, detection of residual ventricular septal defect patch leaks or right ventricular outflow tract obstruction, definition of extracardiac conduit patency, and quantitation of ventricular function and valvular regurgitation. Refined echocardiographic imaging and hemodynamic definition is a mainstay in precise segmental anatomical and hemodynamic assessment. Transesophageal echocardiography is particularly important for intraoperative evaluation of surgical results. PMID- 10172000 TI - Retrospective estimate of the nursing cost of autonomy impairment and cost benefit in clinical trials: feasibility and application of piracetam in demented elderly patients. AB - The aims of this study were to determine whether the nursing costs of functional disability could be assessed retrospectively and, if so, whether this method was sensitive enough to show the influence of a treatment on economic costs. Four studies were available for this purpose: three randomized, double-blind, placebo controlled, clinical trials measuring, among others, the influence of piracetam on activities of daily living (ADL) of elderly demented patients in Italy, Austria, and Belgium, and one large population-based survey measuring the costs of providing basic nursing, hygienic, and therapeutic needs to 6000 elderly according to ADL scores. The items on the different ADL scales used in each trial were recoded to a common denominator, and an overall dependency score was calculated for each patient. The survey data showed a highly significant linear correlation between ADL status and nursing expenses. Nursing costs of noninstitutionalized patients were calculated by assigning each patient the average nursing cost of all persons from the survey who matched by sex, age, and dependency score. Retrospective economic assessment was possible for ambulatory patients when there were functional assessments and a survey with nursing costs gauged according to those functional assessments. Objective classification criteria for hospital or retirement home patients are needed for the level of reimbursement of nursing costs. Piracetam treatment decreased dependency, compared with placebo. The economic improvement continued over the entire duration of all three clinical trials, lasting up to 6 months in the Italian trial in both ambulatory and residential settings. The decrease in nursing costs remained stable during the same period for patients treated with piracetam, whereas nursing costs of placebo patients steadily increased. After 6 months this difference increased a monthly average of 820 Belgian francs (BF {35 BF = 1 US $}) for ambulatory patients in favor of piracetam, 1650 BF for residential patients, and 2580 BF for hospitalized individuals. PMID- 10172001 TI - Spiral CT refines imaging of temporal bone disorders. PMID- 10172002 TI - Plastics processing: statistics, current practices, and evaluation. AB - The health care industry uses a huge quantity of plastic materials each year. Much of the machinery currently used, or supplied, for plastics processing is unsuitable for use in a clean environment. In this article, the author outlines the reasons for the current situation and urges companies to re-examine their plastic-processing methods, whether performed in-house or subcontracted out. Some of the factors that should be considered when evaluating plastics-processing equipment are outlined to assist companies in remaining competitive and complying with impending EC regulations on clean room standards for manufacturing areas. PMID- 10172003 TI - Regulation: threat or opportunity? AB - There are those in the medical device manufacturing industry who consider the new regulatory system in Europe to be a burden that will reduce profitability. In this article, the author makes a case for the benefits that can be gained by implementing the new procedures, particularly for the many small companies that make up the European medical device industry. By using implementation of the new system as an opportunity to take a fresh look at product development and manufacturing processes, profitability can be increased. PMID- 10172004 TI - Anesthesia for coronary artery surgery. AB - Anesthesia for coronary artery bypass graft surgery continues to evolve in concert with changing epidemiology, advances in technology and pharmacology, and refinement in technique. The profile of the cardiac surgical patient is increasingly characterized by factors such as advanced age, reoperation, combination procedures, complications of acute intervention, and more complex disease. Preoperative risk factor assessment offers a means of strategic planning and intervention. Choice of anesthetic agents, muscle relaxants, and anti ischemic medications affects both perioperative management and long-term outcome. Transesophageal echocardiography and ST segment monitoring are being applied more broadly. Advances have been made in managing postoperative blood loss. As in other areas of medicine, economic issues have become important considerations in anesthesia for the cardiac surgical patient. PMID- 10172005 TI - X-ray computed tomography and magnetic resonance imaging of the cardiovascular system. AB - Both electron beam (or ultrafast) x-ray computed tomography and magnetic resonance imaging are developing cardiovascular imaging modalities that can provide high temporal and spatial resolution images of the beating heart and the great vessels in the outpatient setting. The three-dimensional registration of these images has facilitated numerous studies, showing that these devices are capable of quantitating cardiovascular anatomy, function, and blood flow. Continued research employing these methodologies has examined both applications that are complementary to more traditional noninvasive cardiology tools, such as two-dimensional echocardiography and radionuclide and perfusion imaging, as well as applications unique to computed tomography or magnetic resonance imaging. This review discusses progress made in x-ray computed tomography, focusing on the application of electron beam computed tomography and new applications of magnetic resonance imaging within the past 2 years. Specific comments are made regarding these applications, as well as the limitations of both with regard to general clinical applications. PMID- 10172006 TI - A new bioactive glass--ceramic as a coating material on titanium alloy. AB - Apatite--wollastonite-containing glass--ceramic (A--W . GC) has a strong ability to bond to bone and relatively high mechanical strength. Therefore, as a bulk material it has recently been applied clinically even in load-bearing sites. In this study, we modified A--W . GC by altering its composition ratio with the removal of CaF 2 and the addition of B 2O 3, and examined the potential use of the resulting new glass--ceramic as a material for coating on a titanium (Ti) alloy. The bioactivity of this new coating (NC) material and its bonding ability to bone were investigated mechanically and histologically. After implantation of the Ti alloy plate coated with this material into the tibiae of rabbits for 2, 3, 4, 8, and 25 weeks, a detaching test was performed. The detaching failure load of the NC plates was compared with those of A--W . GC plates, hydroxyapatite (HA) plates, and uncoated Ti alloy plates implanted in the same way. The failure load of NC was as high as that of A--W . GC for all periods, whereas it was significantly higher at 3 and 4 weeks than that of HA. Uncoated Ti alloy showed lower failure loads for all periods, differing significantly from the other materials. There was no breakage or detachment of the coating layer observed after the detaching test. Histological examinations by CMR, Giemsa surface staining, and SEM-EPMA showed that NC bonded directly to bone without any intervening soft tissue layer. A calcium--phosphorus-rich layer (apatite layer) was observed within the coating layer, as is the case in A--W . GC. These results indicate that this new glass--ceramic has earlier bone-bonding ability and high mechanical strength, making it a promising coating material. PMID- 10172007 TI - Biomaterials availability: development of a characterization strategy for interchanging silicone polymers in implantable medical devices. PMID- 10172008 TI - Community attitudes and mental health law. PMID- 10172009 TI - The bladder prosthesis: part of urology's future? PMID- 10172010 TI - Cardiac outcome of major noncardiac surgery in patients undergoing preoperative coronary angioplasty. AB - Patients with significant coronary artery disease are at increased risk for myocardial infarction and death when undergoing major noncardiac surgery, particularly vascular, thoracic and upper abdominal procedures. Revascularization with coronary bypass surgery has shown to be effective in reducing perioperative coronary events in such patients. Little data is available on the role of preoperative coronary angioplasty in this setting. The objective of this study was to determine the perioperative cardiac outcome in patients undergoing coronary angioplasty within six weeks of major noncardiac surgery. We analyzed our experience with 108 consecutive patients (85 males) with a mean age of 68 years (range 41-83) who underwent coronary angioplasty within 42 days of a major operative procedure, which was defined as either a vascular, thoracic or upper abdominal procedure. Multivessel disease was present in 48% of patients. Angioplasty success rate was 97% with 33 (31%) patients having more than one lesion dilated. Angioplasty complications included 1 stroke and 4 non-Q wave myocardial infarctions. The mean time from angioplasty to operative procedure was 14.5 days (range 0-41 days). Ninety six (91%) of the patients underwent vascular surgery--including 42 abdominal aneurysm repairs, 29 carotid endarterectomies, 21 lower extremity bypass operations and four renal artery bypass procedures. Eight patients had major abdominal surgery and one patient had a thoracic procedure. Postoperative cardiac complications included three non Q wave myocardial infarctions and one Q-wave myocardial infarction which resulted in the only cardiac death (0.9%). There were no sustained ventricular arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10172011 TI - Clinical comparisons of continuous venous oxygen saturation and hematocrit monitors in pediatric surgery. AB - Continuous venous oxygen saturation and hematocrit values are important parameters in assessing patient status while on cardiopulmonary bypass. Two devices used to measure continuous venous oxygen saturation while on cardiopulmonary bypass were compared to a control. The Bentley Oxysat meter and the Medtronic MX2 Oxygen Saturation and Hematocrit System were compared to the ABL500 blood gas monitor. The continuous hematocrit readings from the MX2 system were compared to spun hematocrits. Twenty-nine pediatric patients ranging from 2.3kg-43.3kg were randomly selected. In-line optical transmission cells used were 1/4" or 3/8" depending upon the patient's blood flow requirements. A total of 163 data points were analyzed at different blood flow rates, temperatures, and hematocrits. The venous oxygen saturation values obtained from the Oxysat and the MX2 devices correlated well with the ABL500 over the entire range of blood flows, temperatures, and hematocrits. All correlation coefficients were greater than 0.89. The correlation between the MX2 device and the spun hematocrit varied with temperature ranges. The correlation coefficient tended to decrease with decreasing temperature. We conclude that these devices are important adjuncts to bypass as long as their limitations are understood. PMID- 10172012 TI - Report of the Policy Conference of NASPE on device/lead performance and the development of a postmarket surveillance database. North American Society of Pacing and Electrophysiology. PMID- 10172013 TI - Carbohydrate deficient transferrin in alcoholism. PMID- 10172014 TI - A program of instruction in operative laparoscopy in a residency in obstetrics and gynecology. AB - Operative laparoscopy has found an increasingly innovative role in contemporary gynecologic practice. Residency programs must now formulate protocols for training in laparoscopic surgery on which subsequent credentialling may be safely recommended. This report describes a program of instruction in operative laparoscopy and the number of procedures required to develop technical skills at each year level of a 4-year residency. The objective of the program was to develop clinical judgment and technical skills in operative laparoscopy during the first 3 resident years. The main outcome measurement was the safe performance of complicated operative laparoscopy during the fourth resident year. This program emphasized progressive, graded responsibility in operative laparoscopy to develop skills in both the principles and practice of laparoscopic surgery. Principles were taught through didactic sessions in laparoscopic instruments and techniques, assignment of reading lists for each year level, and a review of videotapes to assist in decision making for each procedure. Skills in technique and development of manual dexterity were taught over 4 years as follows. Postgraduate year (PGY) 1: restricted to diagnostic procedures emphasizing the development of basic eye-hand coordination using a video monitor system; PGY2: incorporation of principles of laparoscopic hemostasis and laparoscopic tubal ligation; PGY3: operative laparoscopy using multiple puncture sites, sharp dissection, and suture techniques; PGY4: progressively more complicated procedures to include salpingectomy, salpingostomy, and segmental resection for ectopic pregnancies; oophorectomy for benign disease, appendectomy, and adhesiolysis.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10172015 TI - Laparoscopic myomectomy using the argon beam coagulator. AB - Fourteen patients with symptomatic uterine fibroids underwent laparoscopic myomectomy using the argon beam coagulator (ABC). The ABC provides conventional unipolar coagulating current in a nontouch technique, which aids in dissection of the myoma in a hemostatic fashion. Minimal smoke production yields excellent visualization. Fibroids ranged from 2 cm to 6 cm, and eight of the patients had multiple fibroids removed. There were no intraoperative complications and there was minimal operative blood loss. The ABC is a safe and effective tool for laparoscopic removal of symptomatic uterine fibroids. PMID- 10172016 TI - A comparison of laparoscopically assisted vaginal hysterectomy vs traditional total abdominal and vaginal hysterectomies. AB - The objective of this work was to compare laparoscopically assisted vaginal hysterectomy to traditional total abdominal and vaginal hysterectomies in seven critical areas: anesthesia time, surgery time, hospital stay, operative blood loss, total analgesic use, time required to return to work, and total cost of each of these procedures. The first 25 unscreened, consecutive laparoscopically assisted vaginal hysterectomies performed by the senior author were compared with 25 randomly selected traditional total abdominal and 25 randomly selected vaginal hysterectomies performed by the senior author's professional corporation. Laparoscopically assisted vaginal hysterectomy compared favorably to abdominal and vaginal hysterectomy in three areas and was superior to both total abdominal hysterectomy and vaginal hysterectomy in the remaining four areas. Although the use of the endoscopic stapling device and laser made the laparoscopically assisted vaginal hysterectomy a more expensive procedure than traditional vaginal hysterectomy, the expense was not significant and was justified by the decreased surgery time. The results of this comparative study suggest that laparoscopically assisted vaginal hysterectomy is superior or comparable to total abdominal hysterectomy and vaginal hysterectomy, especially for patients who may not have been candidates for vaginal hysterectomy. This procedure has allowed the gynecologic endoscopic surgeon to convert abdominal to vaginal procedures. Laparoscopically assisted vaginal hysterectomy provides an overall cost savings to the patient, has a low complication rate, adapts well to the outpatient setting, causes less patient discomfort, and allows the patient to return rapidly to home and workplace. PMID- 10172017 TI - Preventing adolescent drug abuse and high school dropout through an intensive school-based social network development program. AB - Purpose. The hypothesis tested was that experimental subjects, relative to controls, would demonstrate significant increases in school performance and decreases in drug involvement at program exit (5 months) and at follow-up (10 months). Design. A two-group, repeated-measures, intervention trial was the design used. Setting. The study involved four urban Northwest high schools. Subjects. Participants included 259 youth at high risk of potential school dropout, 101 in the experimental group and 158 in the control group. Intervention. The Personal Growth Class experimental condition was a one semester, five-month elective course taken as one of five or six regular classes. It had a 1:12 teacher-student ratio, and integrated group support and life skills training interventions. The control condition included a regular school schedule. Measures. School performance measures (semester GPA, class absences) came from school records. Drug use progression, drug control, and adverse consequences were measured by the Drug Involvement Scale for Adolescents. Self esteem, school bonding, and deviant peer bonding were measured using the High School Questionnaire: Inventory of Experiences. All multi-item scales had acceptable reliability and validity. Results. As predicted, trend analyses revealed significantly different patterns of change over time between groups in drug control problems and consequences; in GPA (but not attendance); and in self esteem, deviant peer bonding, and school bonding. The program appeared to stem the progression of drug use, but group differences only approached significance. Conclusion. Program efficacy was demonstrated particularly for decreasing drug control problems and consequences; increasing GPA and school bonding; and desired changes in self-esteem and deviant peer bonding. Program effects on progression of drug use were less definitive. PMID- 10172018 TI - Clinical use of the Relaxograph NMT-100. PMID- 10172019 TI - Prosthetic replacement of the anterior cruciate ligament: a challenge. AB - Replacing the chronic deficient anterior cruciate ligament (ACL) has been demonstrated to be a challenging surgical procedure. ACL anatomy and structure as well as its biomechanics have been extensively studied in order to understand its properties and improve its reconstruction. Currently the ACL may be replaced by different means. Autogenous grafts, allografts (augmented or not) and prosthetic devices are available. Each method exhibits inherent advantages and drawbacks which are critically reviewed. If one considers the method of choice as the use of the middle third of the patellar tendon, there is no good evidence that prosthetic augmentation of autogenous grafts offers any advantage over autogenous grafts by themselves. The currently available prosthetic ligaments break and generate debris which are responsible for synovitis. Further development of new devices more closely duplicating the biomechanical features of ACL is necessary. PMID- 10172020 TI - Comparative investigation on the biomechanical properties of ligament replacement in the sheep knee using six different ligament prostheses. AB - Six different ligament prostheses were implanted in 40 sheep to replace the anterior cruciate and medial collateral ligament of the right knee. After one year the explanted knee joints were tested for stability by measurement of the anterior drawer. Tensile tests on the ligament replacements were performed to determine the stiffness and rupture force of the replacement. Gross inspection of the knee joint showed abrasion and partial ruptures for all types of prostheses after one year. Depending on the type of prosthesis total rupture rates between 0 and 66% of all implants could be seen. The anterior drawer for the operated knee was 3-4 times higher than for the non-operated contralateral side. Neither the stiffness nor the rupture strength of the replacements reached the biomechanical properties of the normal ligaments. PMID- 10172021 TI - Biomechanics of synthetic augmentation of ligament reconstructions. AB - Synthetic augmentation of an anterior cruciate ligament reconstruction is intended to provide stress protection to the biological graft during the early healing period when the graft tissue is weak. It is hypothesized that the ligament augmentation device carries the majority of the load during the early post-operative period, and as the graft tissue heals the load is gradually transferred from the ligament augmentation device to the biological graft. This transfer of load to the biological graft occurs as the stiffness of the remodeling graft tissue increases. Cadaver studies of biological grafts augmented with the Kennedy LAD? demonstrated that the LAD carried 28% of the load with a high-stiffness bone-patellar tendon-bone graft and 45% of the load with a lower-stiffness semitendinosus/gracilis graft, which supports the hypothesis that load sharing is dependent on the stiffness of the graft tissue. Cadaver studies have also demonstrated high fixation strength with the Kennedy LAD?. A new bioabsorbable LAD with long-term strength retention has been developed to avoid potential complications caused by the implant material. PMID- 10172022 TI - In vivo evaluation of collagen-coated Dacron fiber in bone. AB - To evaluate the influence of type I collagen and hydroxyapatite coatings on the ability of Dacron fiber to achieve biologic fixation to bone, tows with the following coatings were evaluated in vivo: avian collagen (A); an avian collagen/hydroxyapatite composite (AH); bovine tendon collagen (B); a bovine tendon collagen/hydroxyapatite composite (BH); and plain (uncoated) Dacron tow (C). The Dacron tows were placed unstressed in the cancellous bone of both lateral femoral condyles of rabbits. Tissue reaction to each kind of Dacron tow was evaluated histopathologically, histomorphometrically and biomechanically. Inflammatory reaction was apparent around the AH and BH Dacron fibers at 2 weeks. There was no such reaction in the A, B, and C specimens, thus implicating the hydroxyapatite particles as the cause. At later time periods specimens A, B, and C all induced new bone formation. Direct contact between the Dacron fibers and trabecular bone was apparent in A and B. The pull-out strength of the B fibers was higher than the controls at a statistically significant level, but there was no significant difference between any of the other specimens and C (controls). There was no significant difference between any coating and controls at 8 or 16 weeks. Dacron fibers coated with bovine tendon collagen exhibited the best biocompatibility to bone and improved the anchoring to bone in the early time intervals by maintaining direct contact between Dacron fibers and trabecular bone.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10172023 TI - Development of the Apex polyester fibre cruciate ligament implant. AB - This paper describes the work done in developing the Apex polyester fibre cruciate ligament implant. A series of animal experiments showed that the material was the basis for good collagenous tissue ingrowth at the calcaneal tendon and within the knee joint. The rate of increase of strength of ingrowth at the calcaneal tendon was investigated. The slow maturation led to the development of a stainless steel screw and grommet anchorage system, which was also tested in vitro. A long-term animal study of the clinical implant and anchor system showed the implant fibres spaced apart by prolific ingrowth, while no implant particles were found, and there was no evidence of synovitis. The tissue reactions in human use have been found to be the same as in the animals, while ultrastructural study of retrieved specimens has given evidence of long term collagen maturation. PMID- 10172024 TI - Studies on a novel anterior cruciate ligament polyethylene fiber prosthesis: the histomorphological pattern of organization and bony anchorage of a polyethylene fiber prosthesis in the stifle of the goat. AB - The anterior cruciate ligament of goats was substituted by a high-tensile polyethylene fiber prosthesis. The animals were sacrificed after 6-12 months. Histologically, the implants were separated from a newly formed bony shell by a thick fibrous interface membrane, which was anchored to the bone by Sharpey-like fibers. Within the joint cavity, the implants were enclosed in thick fibrous sheaths, which were continuous with the intra-osseous interface membranes. While the inner granulomatous layer of the interface membrane extended in between the polyethylene fibrils for a short distance, the bulk of the prosthesis was poorly organized. A thick central fibrous band accompanied the intra-osseous and intra articular portions of the implants throughout their entire lengths. Oblique fibrous tracks linked the interface membranes with the central fibrous bands. The intra-osseous tunnels were considerably expanded when compared to the initially drilled tunnels. PMID- 10172025 TI - Functional evaluation of polyarylamide fibers for use in a prosthesis for anterior cruciate ligament replacement in the sheep. AB - In order to evaluate the potential use of polyarylamide fibers as a prosthetic material for ligament replacement, resected sheep anterior cruciate ligaments were replaced by braided devices routed through a tibial tunnel and over the top of the lateral femoral condyle. Twelve sheep were used and sacrificed between 3 and 12 months. The tissue response to the implant was evaluated histologically. Morphologic features of the fibers and the abraded particles were measured by image analysis. Simultaneously, the tensile properties as well as the creep and fatigue properties of non-implanted prostheses were measured under laboratory conditions. It was shown that the polyarylamide fibers exhibited high strength, a high modulus, but low fatigue abrasion properties. At autopsy, 1 prosthesis was broken, 6 had frayed and 5 were intact. There was no adverse tissue response to the intact fibers. Inflammation was always linked to the presence of polymeric particles. A large bony ingrowth in the tibial tunnel through the prostheses strands was observed. There was no material resorption throughout the experiment. Polyarylamide fibers appear to be a suitable material for ligament replacement provided that abrasion against bone can be avoided. PMID- 10172026 TI - Intra-operative assessment of myocardial ischaemia during general surgery by transoesophageal echocardiography: present state and future perspectives. AB - This paper reviews the present state and future perspectives of the peri operative application of Transoesophageal Echocardiography (TEE) for early detection of myocardial ischaemia during general surgery. The increasing clinical relevance of this problem parallels the progressively higher frequency of surgery performed in patients at relatively high cardiovascular risk, due to a longer life-span and improved anaesthetic techniques. TEE potentially provides a powerful method for detailed cardiac monitoring in patients undergoing general surgery. The detection of a new regional asynergy during echocardiographic monitoring represents an early and reliable marker of myocardial ischaemia. The sensitivity, specificity and feasibility of TEE monitoring of intraoperative myocardial function and ischaemia will be outlined and compared with those of ECG and invasive monitoring. Problems related to the interpretation of intra operative findings, with special reference to possible non-ischaemic mechanisms responsible for intra-operative regional asynergies--which can decrease the specificity of this method--are considered. Though still under investigation, the potential contribution of ultrasonic tissue characterisation of the asynergic ventricular wall as an additional, or even alternative, marker of myocardial ischaemia, is discussed. Finally, educational problems related to the new tasks facing the anaesthesiologist involved in intra-operative echo-Doppler evaluation of cardiac function are also foreseen. PMID- 10172027 TI - Detachable balloon technique for transvenous closure of patent ductus arteriosus. PMID- 10172028 TI - Diagnostic applications of repetitive DNA sequences. AB - Different diagnostic applications are discussed for various categories of repetitive DNA sequences. Since all eukaryotes are characterized by genomic redundancy, these sensitive, rapid, and comparatively simple techniques are revolutionizing many fields in clinical and experimental diagnostics. In addition to individuality testing in humans and animals, for example, eukaryotic infectious agents can be identified and tumors classified with respect to genomic changes. The forensic as well as animal and plant breeding sciences have already adopted the DNA technology involving repetitive sequence tools. PMID- 10172029 TI - Risk assessment and management as related to evaluation of medical devices: a view from the FDA. AB - The regulatory management by the FDA of medical products should be thought of as a form of risk assessment and risk management. This is a new approach, a new way of thinking about product review and postmarket management processes. This paper outlines several aspects of risk assessment and management that have recently been incorporated into the FDA processes that will simplify reviews and lower the risks involved with the use of medical devices. These aspects include development of a new process for selecting the appropriate resources to dedicate to individual device applications, an increased emphasis on good experimental design for clinical studies, and continued development of a biomaterials database. PMID- 10172030 TI - Chin augmentation with porous hydroxyapatite blocks. AB - The results of chin augmentation by porous hydroxyapatite blocks were evaluated clinically and radiographically in nine patients. Recovery of a satisfactory facial profile was achieved by the procedure, and all patients but one, with removal of the implant because of infection, were satisfied with the results of the surgery. Radiographically, the implants were incorporated into the bony structure of the mandible by deposition of bone at and around the bone-implant interface and ingrowth of bone into pores. Cephalometrically, the procedure was found to provide very stable results, with little change in the position of the implants and no appreciable resorption of the implants and bone. Despite heavy chemotherapy, histologic examination of the removed hydroxyapatite showed the presence of areas with numerous inflammatory cell infiltration and no bone formation. Thus, the procedure is quite useful for chin augmentation, but utmost care should be taken to avoid infection. PMID- 10172031 TI - Freirian praxis in health education: research results from an adolescent prevention program. AB - This article illustrates how Paulo Freire's social change theory can be integrated with a cognitive and behavior change theory to develop a comprehensive health education program directed at both individual- and community-level change. Through discussion of ASAP, an alcohol and substance abuse prevention program for youth from high-risk communities in New Mexico, this article presents an interweaving of Freirian theory and protection-motivation cognitive change theory. Qualitative research data are provided on the processes of change, the interplay of personal and societal factors, and the potential outcomes as a result of using this integrated approach. Programmatic and evaluation implications for health education programs are discussed. PMID- 10172032 TI - Glaucoma drainage implants. AB - Glaucoma drainage implants provide a useful option in the management of complicated glaucomas for which the risk of failure of conventional filtering surgery is high. The basic design of these devices is similar; a silicone tube shunts aqueous humor from the anterior chamber to a fibrous capsule surrounding a synthetic plate or band positioned at the equatorial region of the globe. The capsule serves as a reservoir for aqueous drainage. Drainage implants have been used in the treatment of various refractory glaucomas, including those associated with aphakia and pseudophakia, prior unsuccessful filtering surgery, anterior segment neovascularization, trauma, youth, uveitis, epithelial downgrowth, iridocorneal endothelial syndrome, vitreoretinal disorders, and penetrating keratoplasty. Modifications in implant design and surgical technique have been developed to limit the occurrence of postoperative complications such as hypotony and its related sequelae, and strabismus. PMID- 10172033 TI - Minimally invasive surgery: shortcut to recovery. PMID- 10172034 TI - Clinical utility of body fluid analyses: an overview. AB - OBJECTIVE: To assess new laboratory procedures for testing body cavity fluids from minor sites such as amniotic fluid, saliva, and synovial fluids, as well as major sites such as pleural, pericardial, peritoneal, and cerebrospinal fluids. DATA SOURCES: Recent professional literature. STUDY SELECTION: Not specified. DATA EXTRACTION: Survey of literature. DATA SYNTHESIS: Normal values for fluids in major body sites are given; causes of abnormalities include inflammation, infection, and neoplastic conditions. Clinical value of newer amniotic fluid tests for fetal lung material and other ancillary tests using synovial fluid, saliva, and cerebrospinal fluid in the diagnosis of metabolic disorders is assessed. CONCLUSION: Clinical laboratories will require a clear demonstration of that value before putting the tests into widespread use; data must show that tests are less expensive, more informative, and safer than the old ones. PMID- 10172035 TI - Laboratory analysis of cerebrospinal fluid. AB - OBJECTIVE: To review the physiology of cerebrospinal fluid (CSF), normal laboratory reference values, and key aspects of CSF sample collection, gross and microscopic examination, microbiologic testing, and chemical analysis. DATA SOURCES: Recent professional literature. STUDY SELECTION: Selected manually by the authors. DATA EXTRACTION: Articles manually by the authors. DATA SYNTHESIS: CSF is formed by a combined process of plasma ultrafiltration and active secretion. Mechanical and osmotic barriers exist between plasma and CSF and between CSF and brain. Lumbar puncture is the preferred technique for CSF sampling. Normal CSF should be clear, colorless, and free of clotted material. CSF can be examined for presence of microbes using stains. Additionally, the chemical composition of CSF can be examined; tests of interest include glucose, protein, lactate, enzymes, glutamine, specific amino acids, biogenic amines, and various drugs. CONCLUSION: Visual, microscopic, and chemical examination of CSF is essential to the clinical management of patients with CNS disease. PMID- 10172036 TI - Saliva testing--a nontraditional diagnostic tool. AB - OBJECTIVE: To demonstrate the advantages of saliva testing over more common methods of determining concentrations of hormones, drugs, and viral antibodies in blood. DATA SOURCES: Recent professional journals, product literature, bibliographies, and conference proceedings. STUDY SELECTION: Not applicable. DATA EXTRACTION: Survey of literature. DATA SYNTHESIS: In the past 10 years, saliva has been used increasingly to determine concentrations of steroid hormones, HIV antibodies, drugs of abuse, and therapeutic drugs in blood. Benefits of using saliva rather than blood or urine for diagnostic testing include convenience and economy of specimen collection, ease of multiple sampling, and low risk of exposing laboratorians to hazardous samples. CONCLUSION: Saliva testing is possible with currently available laboratory technologies. If benefits of saliva testing are to be fully realized, laboratorians must provide physicians with data showing correlations of analyte concentrations in saliva, blood, and urine. PMID- 10172037 TI - When it's right, when it's not. PMID- 10172038 TI - Image guidance lowers costs, risks of surgery. PMID- 10172039 TI - Healthful behaviors: do they protect African-American, urban preadolescents from abusable substance use? AB - PURPOSE: Relationships between positive health behaviors and abusable substance use in preadolescent, urban, African-American schoolchildren were investigated. DESIGN: Personal interviews and classroom surveys were used to assess health behavior and abusable substance use cross-sectionally. SETTING: All respondents resided in the District of Columbia and attended the public school system. SUBJECTS: The sample consisted of 303 urban, African-American fourth and fifth graders (151 boys, 152 girls). MEASURES: Classroom surveys assessed drinking, drinking without parental knowledge, smoking, use of other abusable substances, friends' use, self-esteem, and academic performance. Personal interviews assessed children's diet, exercise, overall health behavior, and socioeconomic status. RESULTS: Logistic regressions showed that children who engaged in more health behaviors (exercise and proper nutrition) were one-third less likely to have smoked (OR=0.66) or to have drunk alcohol (OR=0.63) than those who engaged in fewer healthful activities. However, when gender, socioeconomic status, self esteem, academic performance, personal use, and friends' use of other abusable substances were controlled, relationships were no longer statistically significant. CONCLUSIONS: These findings suggest that although positive health behaviors appear to be inversely related to abusable substance use in urban, African-American preadolescents, the relationship may be spurious. PMID- 10172040 TI - A multi-component stage model for matching drug prevention strategies and messages to youth stage of use. AB - The purpose of this paper was to describe the development of a comprehensive, stage-based model for the prevention of drug use titled the multi-component motivational stages (McMOS) model. The McMOS model is proposed as a multi element, integrative theoretical framework for the development of prevention strategies and content which are matched to the developmental stages of drug use among youth, based on previous work by Prochaska and DiClemente. The major components of the McMOS drug prevention model include: (1) a stage-based framework which permits the matching of prevention strategies and messages to youths' stage of development in the change process; (2) the delineation of a continuum of stages ranging from the acquisition of drug use through the successful modification of drug use; (3) a two-level prevention schema for targeting a broader range of youth for intervention, including those regularly using drugs as well as those not yet regularly using drugs; (4) a drug specific emphasis for proposing prevention strategies targeting the most prevalently used drugs, based on epidemiologic research; (5) the delineation of major theoretical constructs influencing the movement of youth through the stages, based on three prominent behavioral theories; and (6) a framework for selecting a range of prevention delivery modes for youth at all stages and levels of behavioral change. PMID- 10172041 TI - The clinical utility of angioscopy during intracoronary stent implantation. AB - Angiographic evidence of thrombus may have important implications during coronary stent deployment procedures. The periprocedural presence of thrombus has been shown to increase the risk of subsequent stent thrombosis. Coronary angioscopy is a new technology that may prove more accurate for the detection of coronary thrombus. Angiographic filling defects suspicious for thrombus were observed in 15 (22%) of 64 patients undergoing coronary angioscopy during stent implantation procedures. Angioscopy confirmed the presence of thrombus in 9 (60%) of these 15 patients. Protruding thrombus was found in four cases and only mural thrombus in five. In six cases (40%) thrombus was not visualized and angioscopy provided an alternative explanation for the angiographic filling defect. Bulky atherosclerotic plaque was seen protruding into the lumen in two cases, disection with protruding fronds of tissue was found in three cases and a ruptured venus valve was found in one final case. Thrombolytic therapy was administered in all four cases containing protruding thrombus, in only two of the five cases containing mural thrombus, and in none of the cases where thrombus was not visualized. Angioscopy was more accurate than angiography for the diagnosis of thrombus and allowed more precise tailoring of the intervention to the underlying anatomical substraight. This resulted in an excellent clinical outcome, with no episodes of stent thrombosis and limitation of the risks associated with thrombolytic therapy to only those patients at increased risk of a thrombotic complication. PMID- 10172042 TI - A public health approach to reducing harm from drug use. PMID- 10172043 TI - Plasticization of biodegradable polymers for use in controlled release. AB - The design of a plasticized, biodegradable polymeric material, suitable for application as a controlled-release system, was attempted. A poly(DL-lactic acid) oligomer was plasticized with 1,2-propylene glycol and glycerol. The latter plasticizer showed poor compatibility whereas 1,2-propylene glycol was compatible with the polymer up to high concentrations. The mixtures prepared displayed considerable depression of processing temperature and enhanced delivery of salicylic acid, in the early stages of release. It seemed, therefore, feasible to produce systems which allow easy and safe processing and can be injected into a body cavity, without the need for surgical retrieval after completion of the release. Furthermore, the differential rate of drug delivery might be of profound interest for cases where elevated drug doses are necessary in the beginning of treatment. PMID- 10172044 TI - A procedure for the visualization of bone with hydroxyl-apatite coated implants. AB - A procedure for the histological visualization of the interface between implants coated with hydroxyl-apatite (HA) and bone, and the reaction of bones to the implants, has been developed. Thick sections of bones with HA-coated stainless steel implants, were investigated with the implant still in situ with routine and (confocal) fluorescence microscopy. The prosthesis-HA-bone interface, bone cells, necrotic and vascularised bone, bone-ingrowth and bone remodelling could be visualised. After removal of the implant from the sections alternative sections were further processed for routine light microscopy, microradiography and detailed fluorescence studies. It appeared that the HA coating was still intact and the integrity of the HA-bone bond was very well preserved. The HA coating layer had the same appearance as after the first inspection with surface microscopy. However, more details were visible. Prosthesis-related and time related changes in the appearance of the HA layer were detected. The advantage of the procedure is that observations can be made of bone reactions with the prosthesis still in situ, without previous embedding in plastics, and laborous sectioning and/or grinding procedures. Thereafter, sections can be processed for different histological techniques, e.g. immunocytochemistry, routine histology, microradiography, fluorescence microscopy, apparently without imparing the HA coating layer. PMID- 10172045 TI - Economics of mandatory HIV and hepatitis B virus testing for healthcare workers performing surgical procedures. PMID- 10172046 TI - The transparency directive--is it working? AB - The origins and nature of the Transparency Directive of the European Community (EC) are described. The Directive attempts to make the member nations of the EC clearly identify the methods they use to control pharmaceutical prices, to provide the reasons for official decisions in this area, and to set definite timetables for arriving at such decisions. These matters have long been a point of contention between national administrations and the international pharmaceutical industry. The Directive, which is legally binding, has been in force since January 1991. This discussion concludes that the Directive has been generally effective in reducing the time taken to approve drug prices, but less so in its other aims. It is stressed that much depends on the way in which rules are applied in practice. Moreover, the onus is on a company that feels it has been unfairly treated to take legal action, a step that may take time and have an uncertain outcome. Recent developments in national and Community approaches to the control of pharmaceutical expenditure are reviewed. Discontent with current arrangements is widespread and novel initiatives may be favourably received. PMID- 10172047 TI - Is parallel trade in medicines compatible with the single European market? AB - For many years the varying methods of price control of medicines by national governments in the European Community (and elsewhere) have resulted in wide variations in prices. Parallel traders buy products in low pricing Community countries and sell them, generally relabelled or repackaged, in high pricing Community countries. This practice diverts sales revenue and profits from the manufacturers to the traders, distributors, pharmacists and, in some measure, to the sickness funds and to some patients. While parallel trade appeals to those who gain financially, its basis is a market distortion that poses a significant threat to the future of the research-based pharmaceutical industry. PMID- 10172048 TI - A comparison of the safety, timing and cost-effectiveness of administering antibiotics by intravenous bolus (push) versus intravenous piggyback (slow infusion) in surgical prophylaxis. AB - This study was carried out to evaluate the safety, timing and cost-effectiveness of administering perioperative antimicrobial prophylaxis with cefmetazole via intravenous (IV) bolus, or 'push', compared with the more common method of IV 'piggyback' administration. A total of 60 patients were studied, 30 in each group. No major adverse reactions were noted in either group. Phlebitis did not occur with either method of administration. Loss of patency was noted in 2 patients in the IV bolus group at the time of catheter removal. While no overall difference in timing of antibiotic administration in relation to the surgical procedure was noted, 2 patients in the IV piggyback group did not receive their preoperative dose until after surgery had started. Both pharmacy preparation time and nursing administration time were shorter with the IV push method, resulting in a cost avoidance of $US0.60 per dose. Material cost avoidance, primarily due to elimination of the minibag and IV tubing with bolus administration, was $US3.25 per dose. Extrapolated cost avoidance for our institution, for both prophylaxis and treatment, is $US184 000 per year. Administration of selected antibiotics by IV push is safe, allows optimal timing of administration, minimises preparation and administration time, and is cost effective. Hospitals and outpatient care facilities should consider this alternative method of antibiotic administration. PMID- 10172049 TI - Pharmacoeconomic aspects of treatment of acute myocardial infarction with thrombolytic agents. AB - Thrombolytic therapy reduces early mortality, preserves left ventricular function and improves long term prognosis of acute myocardial infarction. However it is relatively expensive and increasing use will have considerable financial consequences. With competing demand for health resources, information on economic evaluation of this revolutionary therapeutic modality is much needed. Economic evaluation of thrombolytic therapy of acute myocardial infarction entails the assessment of all resources consumed (costs) directly and indirectly in relation to the administration of thrombolytic drugs, versus the beneficial effects (outcome) on health preservation of the patients. To save 1 year of life, the costs of thrombolytic therapy using intravenous streptokinase, alteplase (recombinant tissue plasminogen activator; rt-PA) or anistreplase (anisoylated plasminogen streptokinase activator complex) under standard restricted indication criteria, vary from 1000 pounds British sterling to 1700 pounds British sterling in the UK, SEK3090 to 9660 in Scandinavia and $US35 000 to 800 000 in the US, depending on time delay in starting treatment after pain onset, size of infarct, thrombolytic agents used, study methodology, lists of clinical events considered in cost counting and the discount rate. Cost-utility analyses revealed that the costs of thrombolytic treatment are similar to those of many other treatments for cardiac or other diseases, but methods for evaluating quality of life and utility require further refinement and validation. Economic assessments confirm that thrombolytic treatment of the elderly ( greater than 70 years) is as cost-effective as treatment of younger patients and that both early and late thrombolytic therapy (given 6 to 12 hours after infarction) are beneficial and cost-effective. There are major logistical problems with prehospital thrombolysis, which despite great initial enthusiasm, is unlikely to be cost-effective in saving lives unless savings in time are greater than 1 hour. Cost-effectiveness/utility value of one drug determined from one study cannot be directly compared with that found in other studies using different drugs. More direct prospective comparative trials will be needed in respect of relative benefits and costs with different agents and adjunctive therapies. PMID- 10172050 TI - Economic aspects of general anaesthesia. AB - Proper economic evaluation involves comparative analysis of alternative courses of action in terms of both costs and outcome. This is difficult for general anaesthesia as there are few alternatives and measurement of outcome is difficult to define. All that is generally available is a cost description of different anaesthetic techniques. This article outlines the choice of drugs, breathing systems and ventilatory pattern available to the anaesthetist, and compares regional with general anaesthesia. For each technique the cost and advantages/disadvantages are outlined. There is a discussion of some wider issues involved together with their implications: the abandonment of cyclopropane and nitrous oxide; equipment costs and recommendations by the Association of Anaesthetists of Great Britain and Ireland; staffing levels; legal aspects and the increase in day surgery. The limitation of cost-effectiveness analysis of general anaesthesia is outlined. PMID- 10172051 TI - Patent term restoration in non-drug-developing nations. PMID- 10172052 TI - Overview of international pharmacy pricing. PMID- 10172054 TI - Medication, quality of life and compliance: the role of the pharmacist. PMID- 10172055 TI - Economic costs of adverse drug reactions. PMID- 10172056 TI - Economic evaluation of pharmaceuticals. PMID- 10172057 TI - Pharmacoeconomics of genetically engineered drugs. AB - Biotechnology is a rapidly developing area of drug development which has great growth potential. Development of genetically engineered drugs is very expensive and as these products become available the impact on healthcare costs could be vast. The cost-benefit ratio of biotechnology products needs to be established, but few relevant pharmacoeconomic studies are available. Issues in pharmacoeconomic analysis of genetically engineered drugs can be exemplified by the data available for alteplase, epoetin and interferon alpha-2b. One study concluded that thrombolysis with streptokinase rather than alteplase would substantially reduce the percentage of total hospital costs that were not reimbursed. However, differences in efficacy were not accounted for. Based on the superior efficacy of alteplase, a more extensive pharmacoeconomic analysis found that alteplase was more cost-effective than streptokinase when the agents were combined with aggressive reocclusion management. However, this conclusion may be altered by the finding of a more recent study that streptokinase may be at least as effective as alteplase. Economic factors involved in epoetin treatment of anaemia associated with chronic renal disease have been studied thoroughly. However, cost-effectiveness or cost-benefit analysis was not attempted, and improvement in quality of life with epoetin therapy also needs to be considered, to facilitate cost-utility analysis. Compared with chlorambucil, the use of interferon alpha-2b for hairy cell leukaemia resulted in significant direct and indirect cost savings, in a retrospective cost-benefit analysis.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10172058 TI - New detector material enhances digital x-rays. PMID- 10172053 TI - Cost-effective intervention in stroke. AB - A rigorous assessment of current practice in all branches of medicine is necessary to ensure that we are minimising the costs and maximising the effectiveness of management and treatment. This is especially important in cerebrovascular disease which imposes a large burden of death; it is the third commonest cause of death after cancer and heart disease in most developed countries, and the commonest cause of long term disability on society. Stroke consumes up to 5% of healthcare expenditure in developed countries, and costs can be expected to remain static or increase with an increase in the proportion of elderly (who are at high risk of stroke) in the community over coming decades. This article reviews the epidemiology of stroke (risk factors, incidence, prevalence and the burden of disability and handicap), the various studies dealing with the community and individual costs of stroke, and the cost effectiveness of interventions to prevent stroke such as control of hypertension, reduction in cigarette intake, encouragement of a healthy lifestyle, antiplatelet or anticoagulant therapy, and carotid endarterectomy. Acute treatment of stroke remains an area of major potential therapeutic benefit, but no widely applicable therapy currently exists, although many treatments are being investigated. Rehabilitation after stroke is costly, but may result in significant reduction in disability and handicap with reduced need for long term institutional care. The clinical implications of these studies and the potential for future research are also discussed. PMID- 10172059 TI - A critical analysis of laparoscopic assisted vaginal hysterectomies compared with vaginal hysterectomies unassisted by laparoscopy and transabdominal hysterectomies. AB - The first 115 laparoscopically assisted vaginal hysterectomies (LAVH) done by our faculty surgeons were compared with 220 vaginal hysterectomies (VH) and 194 abdominal hysterectomies (AH) done in our affiliated hospitals over the same period of time. Logistic regression analysis indicates that LAVHs were done for cases that would significantly be more likely selected for AH than for VH (p less than 0.0001). Matched case control studies with 28 LAVH/VH and 34 LAVH/AH pairs and bivariate analyses demonstrated that LAVH can be accomplished with low morbidity, short lengths of stay, and little, if any, increase in operating times compared with VH and AH. The LAVH procedure can be expected to replace many AHs in the future. PMID- 10172060 TI - The benefits of using the loop ligature (Endoloop) laparoscopic sterilization procedure in a residency program. AB - This study was conducted to determine the impact of the addition of the loop ligation (Endoloop) technique on choice of sterilization surgery in our residency teaching program and to investigate significant differences between this technique and other methods performed at our hospital. A retrospective study of all patients undergoing interval tubal sterilization at Tampa General Hospital in 1989 and 1991 was undertaken. Data were analyzed to determine the frequency of sterilization methods and differences between the loop ligation method and the other procedures performed; p values of less than 0.05 were considered significant. Sixty-one patients in 1989 and 75 in 1991 qualified for the study. Five methods of interval sterilization were performed: loop ligation, minilaparotomy, colpotomy, laparoscopic bipolar fulguration, and Silastic ring application. The frequency of the loop ligature technique increased from 0% in 1989 to 40% in 1991. There were no significant differences in operative time and complication rate among the loop method and other procedures. The loop ligature (Endoloop) method of laparoscopic sterilization does not significantly change the length of surgery, blood loss, or complication rate compared to the other laparoscopic techniques used in our residency program. This method provides a definitive tissue diagnosis, eliminates the risk of thermal injury, theoretically provides an opportunity of later tubal reanastomosis, and subjectively helps develop laparoscopic skills. PMID- 10172061 TI - A new device and method for extracorporeal knot tying in laparoscopic surgery. AB - Advances in laparoscopic suturing will be facilitated by the ability to tie knots rapidly and effectively. A new device is presented that enhances extracorporeal laparoscopic knot tying, using familiar surgeon's or square knots in any size or type of suture material. It speeds knot formation and allows precise control of knot placement in a wide variety of applications. PMID- 10172062 TI - A follow-up study of severely disabled patients with mental retardation. PMID- 10172064 TI - The cost of institutional care in Alzheimer's disease. PMID- 10172065 TI - Is alteplase (t-PA) more cost-effective than streptokinase? PMID- 10172066 TI - Who uses streptokinase vs alteplase (t-PA), and why? PMID- 10172068 TI - The laparoscopic route to standard pelvic lymph node dissection. PMID- 10172067 TI - Extracorporeal life support of neonates with congenital cardiac defects: techniques used during cardiac catheterization and surgery. AB - Neonatal patients with congenital cardiac defects require proper diagnosis often by cardiac catheterization before surgical repair. In our institution, patients whose echocardiograms reveal surgically correctable lesions, but who are severely decompensated, have been placed on Extracorporeal Life Support (ECLS) prior to catheterization or surgery. Subsequent management of ECLS and cardiopulmonary bypass (CPB) are dictated by the surgical procedure. Hypothermia can be utilized while on ECLS to facilitate low-flow CPB, or circulatory arrest. Total extracorporeal circulation may be performed with the ECLS circuit, or the patient may be transferred to a conventional CPB circuit during the procedure. If required, post surgical ECLS can be facilitated through prior cannulation. We have found pre-operative institution of ECLS, in the neonate with severe congenital cardiac defects, provides immediate control of hemodynamic and respiratory problems, lowers the risk of cardiac catheterization, and reduces the usage of blood products during surgery. PMID- 10172069 TI - Laser pilonidal cystectomy: superior to conventional surgery. PMID- 10172070 TI - Development of a glucose sensor for glucose monitoring in man: the disposable implant concept. AB - This paper describes the issues related to glucose sensing in the framework of the concept of disposable implants. The possibility of providing a diabetic patient with a continuous access to his blood glucose concentration and of detecting nocturnal hypoglycaemia would be a major breakthrough in diabetes therapy. To this end, our laboratories have developed a miniaturized, subcutaneous glucose sensor for glucose monitoring. It is based on the enzymatic, amperometric detection of glucose. This glucose sensor has been extensively evaluated in rats, dogs and more recently in human volunteers. Under experimental conditions, a controlled increase in blood glucose concentration is followed by an increase in the current delivered by the sensor. It is then possible to transform this current into an estimation of the glucose concentration. Experiments in rats have shown that the glucose sensor functions for up to 10 days when implanted in the subcutaneous tissue. Experiments in conscious dogs have shown that it works in a subcutaneous tissue closer to the human one. More recently, the glucose sensor was investigated in non-diabetic volunteers. These studies have demonstrated that this subcutaneous glucose sensor is able to provide a reliable estimation of blood glucose concentration in man, making it suitable for blood glucose monitoring. Biocompatibility of the glucose sensor, and particularly long-term tolerance, remains to be demonstrated. PMID- 10172071 TI - Materials and design concepts for an intervertebral disc spacer. I. fiber reinforced composite design. AB - The intervertebral disc is a complex joint anatomically and functionally. It may be displaced or damaged due to trauma or a disease process. To alleviate this condition, it may be necessary to remove the involved disc surgically and fuse the two adjacent vertebrae. Fusion is one option; however, replacing the damaged disc (or part thereof) with a suitable synthetic equivalent to allow near normal joint motion is more desirable. Unfortunately, the complex mechanical properties of the lumbar disc cannot be duplicated with homogeneous synthetic materials (polymers). To overcome this fundamental problem we have developed rational designs utilizing biocompatible thermoplastic elastomers of various stiffnesses (durometers) with and without fiber reinforcements. Our design consisted of three components analogous to the natural end plates, annulus, and nucleus. In this study only the fiber-reinforced design is considered. The variables examined in the present study included orientation of the fiber layers, number of fiber layers, and order of the reinforcing layers. The results of mechanical testing of the fiber reinforced disc spacer indicate that the range of compressive and torsional properties can be achieved. The results further demonstrate that properly developed, this design results in properties similar to the natural disc. Designs developed provided adequate compression and compression torsion properties for a synthetic spine disc spacer. PMID- 10172072 TI - Processing and characterization of absorbable polylactide polymers for use in surgical implants. AB - Absorbable fibers of linear poly-alpha-hydroxy acids have been used successfully in providing temporary scaffolds for tissue regeneration. In some surgical applications, degradation rates for poly(glycolide) (PGA) are too high, but implants of poly(L-lactide) (PLLA) fibers may degrade too slowly for optimal function. Polymers produced by copolymerization of L-lactide with varying amounts of D-lactide may offer an alternative choice for absorbable fiber based implants. Poly(L/D-lactide) stereocopolymers with L/D lactide molar ratios of 95/5, 90/10, and 85/15 were considered. Melt-spun/hot-drawn fibers with L/D molar ratios of 90/10 and 85/15 and draw ratios ranging from 3.0 to 8.9 were further evaluated by mechanical testing, differential scanning calorimetry, birefringence, x-ray diffraction, and in vitro exposure to pH 7.4 phosphate buffered saline at 37 degrees C. Fabrication was reproducible and results indicated that tensile strength, modulus, an birefringence all increased with increasing draw ratio up to a draw ratio of 6.7 and declined thereafter; elongation to failure decreased for the entire range studied. For fibers with a draw ratio of 6.7, there was a 10% relative difference in crystallinity between the 90/10 and 85/15 lactide fibers (90/10 was higher). Wet strength retention after 12 weeks in vitro exposure was approximately 10% for the 90/10 fibers and 30% for the 85/15 fibers. The intermediate wet strength retention of lactide stereocopolymer fibers when compared to reported values for PGA and PLLA fibers, suggests these materials may be useful in absorbable surgical implants for tissue repair and regeneration. PMID- 10172073 TI - Stimulation of bone healing by transforming growth factor-beta 1 released from polymeric or ceramic implants. AB - The ability to transforming growth factor-beta 1 (TGF-beta 1), to stimulate bone healing was evaluated in a rat critical calvarial defect model. Both a low dose and a high dose of TGF-beta 1 were incorporated into two different types of implants: one made from a composite of poly(lactic-co-glycolic acid) (PLPG) (50:50) and demineralized bone matrix (DBM), and the other from calcium sulfate (CaSO 4). Scanning electron microscopy showed that the CaSO 4 implants were more porous than the PLPG/DBM samples. Both types of implants released biologically active TGF-beta 1 for over 300 h in vitro. The samples were implanted in a 9-mm diameter rat calvarial defect for 6 weeks along with contralateral control implants containing no TGF-beta 1. Microradiography and histological analysis were used to assess the bone healing in the defects. Microradiography revealed that the greatest amount of calcified bone (67.5%) was present in in the CaSO 4 implants containing a high dose of TGF-beta 1 while minimal new bone formation occurred in the PLPG/DBM implants. Histologically, the PLPG/DBM implants exhibited an inflammatory response with little mineralization or bone formation. The defects containing the PLPG/DBM implants consisted of a connective tissue stroma with large void spaces. Giant cells and numerous polymorphonuclear leukocytes were present throughout the implants. In contrast, the CaSO 4 implants had only a few inflammatory cells and the presence of mineralization and true bone was a more consistent feature. These preliminary studies show that TGF beta 1 is capable of inducing new bone formation. Furthermore, the materials used to deliver the growth factor can play a significant role in the bone healing process. PMID- 10172074 TI - Deception among quit smoking lottery entrants. PMID- 10172075 TI - Cell culture methods for testing biocompatibility. AB - Cell culture systems may be of value in testing the biocompatibility of prosthetic materials before they are introduced into clinical use. In recent years, in vitro methods for assaying biomaterials have gained in importance owing to the growing concern over the use of animals for biomaterials testing. Significant effort is therefore being focused toward developing predictive and quantitative, but also simple and reliable, methods of testing using cultured cells. At present, a number of methods for measuring both the cytotoxicity and the specific cytocompatibility of different materials are available. The usefulness of these systems is no longer confined to screening new materials; they can be used to study the mechanisms of action of various materials during tissue/material interaction. This paper reviews the published literature on the use of cell culture models in evaluating biocompatibility and reports on the personal experience of the authors, who have been using cell culture systems for many years and for different purposes. PMID- 10172076 TI - Sterilisation of implantable devices. AB - The pathogenesis and rates of infection associated with the use of a wide variety of implantable devices are described. The multi-factorial nature of post operative periprosthetic infection is outlined and the role of sterilisation of devices is explained. The resistance of bacterial spores is highlighted as a problem and a full description is given of the processes of sterilisation by heat, steam, ethylene oxide, low temperature steam and formaldehyde, ionising radiation and liquid glutaraldehyde. Sterility assurance and validation are discussed in the context of biological indicators and physical/chemical indicators. Adverse effects upon the material composition of devices and problems of process control are listed. Finally, possible optimisations of the ethylene oxide process and their potential significance to the field of sterilisation of implants is explored. PMID- 10172077 TI - Medical care: courtesy of the Department of Motor Vehicles. PMID- 10172078 TI - Integrating control of multiple assistive devices: a retrospective review. AB - Advances in technology now allow individuals to operate multiple assistive devices through a single, integrated control. A retrospective review of clients at the Center for Applied Rehabilitation Technology (CART) was conducted to determine the factors that support the recommendation of integrated controls. A total of 290 client charts were reviewed; data from 87 clients met the study criteria and were included in the review. For each individual, information was obtained on available access sites, types of assistive technology controlled, and types of input devices used. Meetings were held with CART therapists to determine reasons for recommending specific access configurations for each individual. Twelve reasons falling into four general categories (i.e., performance, functional abilities, subjective, and external) were identified and used to code responses. The findings indicated that integrated controls may be useful in the following cases: 1) when an individual has a single, reliable access site; 2) when the optimum access method for each assistive device is the same; and 3) when the individual prefers integrated control for personal reasons (e.g., aesthetics). Integrated controls may not be appropriate in the following cases: 1) when performance on one or more assistive devices is severely compromised by integrating control; 2) when the individual wishes to operate an assistive device from a position other than from a powered wheelchair; 3) when physical, cognitive, or visual/perceptual limitations preclude integrating; 4) when it is the individual's personal preference to use separate controls; and 5) when external factors such as cost or technical limitations preclude the use of integrated controls. PMID- 10172079 TI - Obesity and insurance risk: the insurance industry's viewpoint. AB - Obesity is regarded by insurance companies as a substantial risk for both life and disability policies. This risk increases proportionally with the degree of obesity. Mortality statistics for life insurance were the earliest indicator that the cost of obesity to the individual was a decreased life span and increased illness, particularly that affecting the cardiovascular and musculoskeletal systems. The prevalence of coronary heart disease rises with increases in the body mass index in both men and women. Cigarette smoking greatly augments these risks in both sexes. Hypertension and diabetes are very common in obese persons and add further to the risks of vascular disease. Abdominal obesity (when the abdominal girth measured round the umbilicus exceeds the maximum measurement round the hips) is correlated with the risk of cardiac disease and stroke, independently of bodyweight. Insurance companies consider abdominal obesity as unfavourable and rate it accordingly. Obesity (even that of moderate degree) greatly increases the chances of disability due to cardiovascular disease or musculoskeletal illness. In one study of 51 522 adult Finns, 25% of disability pensions in women were found to result directly from obesity. Obesity causes increased health expenditure, decreased life span and productivity, and premature retirement. Insurance companies are compelled to build these risks into their policies. However, because the excess mortality occurs late in mild to moderate obesity, some companies may minimise this risk for life policies that mature early. PMID- 10172080 TI - Challenges for health promotion in the 1990s: social inequities, empowerment, negative consequences, and the common good. PMID- 10172081 TI - Intracorneal implants. PMID- 10172082 TI - Mechanical methods in refractive corneal surgery. AB - Over the past decade, keratorefractive surgery has moved into the mainstream of ophthalmology as improved instrumentation and newer techniques have evolved. These new aspects increase the safety and effectiveness of the various keratorefractive procedures. The introduction of new techniques and knife designs has led to improved results with radial keratotomy. The newly developed arcuate keratome purportedly offers the possibility of improving the predictability of arcuate keratotomy. Keratomileusis and epikeratoplasty have been successful for some difficult refractive states, such as aphakia and high myopia. Intracorneal lenses are showing promise in correcting high refractive errors and may offer an alternative to the more technically challenging lamellar procedures performed for correcting these conditions. Intrastromal ring implants are early in their clinical testing, but may provide an alternative to radial keratotomy for correcting myopia. The predictability, effectiveness, safety, and stability are far from perfect for current procedures, but recent results are encouraging. PMID- 10172083 TI - Recombinant human granulocyte-macrophage colony-stimulating factor after autologous bone marrow transplantation for lymphoid cancer: an economic analysis of a randomised, double-blind, placebo-controlled trial. AB - In a blinded retrospective economic evaluation of a double-blind, randomised, placebo-controlled clinical trial, total utilisation and charges for lymphoid cancer patients who received recombinant human granulocyte-macrophage colony stimulating factor (rhGM-CSF) or placebo were compared following autologous bone marrow transplantation. The 40 patients enrolled (22 rhGM-CSF, 18 placebo) could have acute lymphoblastic leukaemia, non-Hodgkins lymphoma or Hodgkin's disease, be of any age, and were undergoing autologous bone marrow transplantation in a metropolitan cancer research centre. Main outcome measures consisted of initial hospital lengths of stay (LOS), total and department charges, rehospitalisation rates and charges, and outpatient charges, all inclusive of the first 100 days following bone marrow infusion. The perspective of the study is that of the third party payer. Initial hospitalisation charges were $US54 100 for patients who received rhGM-CSF and $US68 600 for patients who received placebo (p = 0.05). The difference of $US14 500 was 21% less in patients who received rhGM-CSF, mainly due to lower average LOS with rhGM-CSF (24.2 days) compared with placebo (30.8 days). Outpatient charges were $US9500 (rhGM-CSF) and $US6800 (placebo) {p = 0.18}. Total charges, including readmission (10 per group) were $US12 200 lower in the rhGM-CSF group ($US70 300 vs $US82 500, p = 0.19). The use of rhGM-CSF after autologous bone marrow transplantation was shown to result in substantial cost savings during the initial hospitalisation. When comparing total inpatient and outpatient medical charges within the first 100 days following bone marrow infusion, we found no evidence that these savings were negated. PMID- 10172084 TI - Enhancing the efficacy of preoperative autologous blood donation by erythropoietin. AB - A double-blind, randomized and placebo-controlled study was performed with 62 patients undergoing orthopedic hip surgery. Mean hemoglobin levels at surgery, after four weekly blood-donations were 12.3, 12.7 and 13.9 g/dL for the patients receiving placebo, 100 and 200 IU/kg r-hu EPO respectively, via the subcutaneous route. The groups receiving r-hu EPO were operated on without any homologous blood supply. The endogenous erythropoietin levels remained stable throughout the observation period in the treatment groups, whereas they increased in the placebo group. The study confirms the known efficacy of erythropoietin in preoperative autologous blood-donation, but the ideal dose for each individual patient remains to be defined. PMID- 10172085 TI - Where have all the implants gone? The need for surveillance and tracking. AB - This article examines the issues involved in the recent, widely publicized failures of some implants. It is important that the health care industry and patients have realistic expectations of implants. The limitations as well as the benefits of current technology and practices must be acknowledged, so that the industry can continue to be innovative and sustain the confidence of patients. The author suggests that an important element in achieving this is for the industry to take the initiative in formulating an effective tracking and assessment system. PMID- 10172086 TI - The impact of reagent standardization on the quality of diagnostic devices. AB - Global quality is becoming a major concern for the medical device and diagnostics industry. Good Manufacturing Practice (GMP) regulations aim to guarantee that effective and safe products are produced. However, the overall quality of a device depends on the quality of its components, which are frequently not manufactured by the manufacturer of the final product. The quality of components, such as reagents can be controlled by setting acceptance criteria, but the standardization of reagents would result in improved quality of the final product. This article briefly reviews the role of GMP regulations with regard to product quality and provides examples of how the application of modern technologies can, and in some cases has, contributed to the realization of standardizable reagents. PMID- 10172087 TI - Software validation: requirements for programmable electronic medical systems, how to comply with the essential requirements of the EC Directives, part II. AB - In the second part of this two-part article, the author reviews existing standards and current international and European standardization work, which serves to highlight the need for harmonized standards for medical devices that incorporate software. The new concepts of essential performance, and safety integrity, severity, and risk levels are examined, and these present a new basis for the revision of safety standards to make them relevant to the EC Directives. PMID- 10172088 TI - Vigilance systems in the EU and the US: a short comparison. AB - This article compares the approaches to vigilance systems taken in the European Union and the United States. It details the type of information that must be collected following an adverse incident relating to the use of a medical device, and contrasts the time frames for reporting these details to the regulatory authorities. The differences highlight the need for standardization of the procedures, particularly when companies have to comply with both systems. PMID- 10172089 TI - 151 endoprosthetic reconstructions for patients with primary tumors involving bone. AB - As part of the UCLA limb salvage program, 151 patients received 151 endoprostheses for primary tumors involving bone. Follow-up of all patients was to death (56), revision (21), or a minimum two years for the 74 additional survivors (range: 24-114 months; mean: 52 months). Endoprosthetic replacements were of the distal femur (81), proximal femur (19), proximal humerus (13), proximal tibia (11), scapula (11), total femur (8), total humerus (4), intercalary prostheses (2), and one each of the distal humerus and the pelvis. There were three soft tissue sarcomas, five benign bone lesions, and 143 primary malignant tumors of bone. MSTS function was good-excellent in 78%. There were 64 local complications in 55 patients (36%). Mechanical failure occurred in 24 patients (15.9%), local recurrence occurred in ten (6.6%), minor wound healing problems in nine (5.9%), and infection in eight (5.3%). Few systemic complications were reported. Function appeared to be location dependent. All of the 29 patients with benign or low grade malignant tumors (parosteal, IA, IB) have survived. Of the 116 patients with stage IIA and IIB disease, 59% survived three years, and a Kaplan-Meier analysis projects that 56% are expected to survive at five years. Only 17 (11%) of these 151 endoprostheses have been revised; an additional four (3%) eventually came to amputation. The Kaplan-Meier analysis revealed that 91% of the prostheses survived three years and 83% survived five years. The Cox Proportional Hazards model revealed that for patients with stage IIA and IIB disease, the risk of death is four times the risk of the need for revision at five years. Although endoprosthetic reconstructions have their own unique complications, they have proven durable in this series of patients. Local problems usually can be managed without amputation, and patient satisfaction is high. PMID- 10172090 TI - Trauma radiology: part II. Diagnostic imaging of thoracic trauma: review and update. AB - Frontal chest radiographs are the principal diagnostic imaging study to detect, verify, or exclude acute thoracic injury after trauma, and they should be obtained as quickly as possible without compromising clinical assessment and resuscitation. Chest radiographs provide important information about potentially life-threatening conditions, such as tension pneumothorax, major hemothorax, and major arterial injury. In many patients, chest radiographs also provide helpful clues to the presence of such conditions as diaphragmatic rupture, pulmonary contusion/laceration, and tracheobronchial injury. In selected patients, computed tomography scans can supplement information provided by radiography, particularly for detection of mediastinal hemorrhage, aortic pseudoaneurysm, subtle pneumothorax, and delineation of complex pleuroparenchymal processes. On occasion, magnetic resonance imaging can be used to assess integrity of the hemidiaphragms and visceral herniation when other diagnostic studies are equivocal. We consider typical imaging findings associated with a variety of acute thoracic injuries, as well as the most appropriate use of available imaging techniques in different clinical scenarios. PMID- 10172091 TI - Endopyelotomy, guided by meticulous anatomy. PMID- 10172092 TI - Preliminary assessment of the Con-Bio laser in vivo. AB - A variety of lasers are available for the treatment of pigmented and vascular lesions. This paper presents our preliminary evaluation of the Q-switched 532 nm Con-Bio laser (Continuum Biomedical, Livermore, CA) in a murine model. Mice were anesthetized with intraperitoneal pentobarbital. Laser impacts (10 nsec, 150 mJ max.) were created on the ears at fluences of 1.5, 2, 3, 4, 5, and 6 J/cm 2. Acute study animals were sacrificed 15 min postinjury. Tissues were fixed in formalin and examined via light microscopy. Chronic study animals were allowed to heal for 3 weeks postoperatively. Parameters analyzed included the presence or absence of blistering, hemorrhage, visual assessment of thermal injury, microscopic evidence of vascular coagulation, or disruption and cosmesis. Acute vascular disruption and coagulation were present in all samples. Healing and cosmesis were good at all fluences tested. Tests of the laser in a prefocused mode produced a tissue cavitation effect with a depth of coagulation of 0.73 +/- 0.44 mm and hemorrhage of 0.68 +/- 0.41 mm. A chronic study of the vascular effect on larger vessels (1-2 mm) was conducted on a rabbit ear. Acute disruption was observed, however, all vessels were recanalized when examined grossly and histologically at 3 weeks. These preliminary results suggest that this new laser may be useful for the treatment of cutaneous vascular lesions. Further studies and clinical trials are warranted. PMID- 10172093 TI - Financing pharmaceuticals in Africa. PMID- 10172094 TI - Progress in the treatment of posterior segment trauma. AB - Ocular trauma remains a common cause of vision loss worldwide. Progress appears to have been made in the treatment of intraocular foreign bodies and traumatic endophthalmitis particularly with the use of early vitrectomy and intravitreal antibiotics. Recent work increasingly supports the benefit of vitrectomy in conjunction with other modern surgical techniques for the treatment of other injuries of the posterior segment. This review highlights much of the literature on ocular trauma from the previous year and discusses the merits of current and future approaches to surgical intervention. PMID- 10172095 TI - Diabetic vitrectomy. AB - Proliferative diabetic retinopathy is one of the leading causes of permanent vision loss. Vitrectomy for the complications of proliferative changes has resulted in preservation of vision. Recent studies have focused on the cellular and structural changes in patients with proliferative changes. Data obtained from the early Treatment of Diabetic Retinopathy Study show that the rate of vitrectomy is reduced in eyes that have early-scatter photocoagulation in comparison with those that have deferral of treatment. The efficacy and complications of silicone oil tamponade have been more carefully evaluated with respect to complex detachments associated with proliferative diabetic retinopathy. PMID- 10172096 TI - Outpatient treatment of sleep apnea syndrome with CO 2 laser, LAUP: laser assisted UPPP results on 46 patients. AB - The pharyngeal airway obstruction during sleep in the obstructive sleep apnea syndrome (OSAS) can be improved after treatment by laser-assisted uvulopalatoplasty (LAUP), a new technique performed under local anesthesia. It permits surgery to be performed without hospitalization or general anesthetic. LAUP has many advantages over the traditional uvulopalatopharyngoplasty (UPPP). It is simple, reliable, hemostatic, sterilizing, and relatively painless. Our experience with LAUP in sleep apnea syndrome is described in 46 patients from December 1988 to May 1993. Among 40 patients classified as successful responders, the respiratory disturbance index (RDI) was reduced more than 50%. Among the 46 patients, in 43.5% of cases (20 patient) there was healing of snoring and sleep apnea syndrome. In 43.5% of cases (20 patients) there was an important reduction of length and number of apneas and a significant improvement in nocturnal oxygen saturation. Thirteen percent (6 patients) were relative failures, with a diminution of snoring, but no reduction in sleep apnea syndrome. There were no important complications reported. PMID- 10172097 TI - The use of a staff training model for implementing fitness programming to prevent substance abuse with at-risk youth. PMID- 10172098 TI - Point-of-care testing goes with the flow. PMID- 10172099 TI - Using California outcome data to your advantage. PMID- 10172100 TI - Patient information provision: its effect on patient anxiety and the role of health information services and libraries. AB - This article is concerned with the importance of communicating information to patients as an aid to recovery by decreasing anxiety. Recent research suggests that pre-operative information helps to decrease post-operative stress and leads to a quicker recovery. The health belief model has proven to be an effective predictor of individuals' responses towards health-related matters. It is described as a useful theoretical framework for medical professionals in deciding the content and quantity of information that each patient should receive. A study for further research is suggested, exploring the hypothesis that reading about illness significantly helps to reduce anxiety when the patient has added emotional support from a health professional. The existing problem of who is ultimately responsible for giving information to patients is highlighted in the general practice, hospital and public settings. Recommendations are made for the improvement of patient information provision in these three areas. Librarians are seen as being in a good position to liaise with medical professionals to provide the most effective health information service possible for patients and the consumer in general. PMID- 10172101 TI - Team approach solves mobility devices problems. PMID- 10172102 TI - Redesigning the pre-anesthesia clinic at Providence Hospital & Medical Center. AB - Using the critical incident technique, a team at Providence Hospital & Medical Center found that patients' greatest source of dissatisfaction with out-patient surgical services was the waiting they experienced in the pre-anesthesia clinic. After analyzing the process, the team discovered that patients spent an average of 32 minutes waiting. The team reconceptualized the process so that individual patient appointments are now made, and anesthesiologists scrutinize each preoperative test ordered. RESULTS: Average patient throughput time dropped from 58 minutes to 36.5 minutes. Routine preoperative tests dramatically decreased (eg, 35 percent drop in complete blood counts and urinalyses). Patient waiting time was completely eliminated unless appointment and arrival times differed significantly. Patient satisfaction with the entire outpatient surgical experience rose from 85 percent to 96 percent. PMID- 10172103 TI - Feedback on quality: patients' experience of surgical care. AB - There is a growing consensus within the NHS of the importance of obtaining feedback from patients in order to improve the quality of health care; consequently, many patient satisfaction surveys are now undertaken. However, much research is based on provider-held assumptions about service quality. This study focuses on patient satisfaction with coronary bypass surgery, starting with the concerns expressed by patients and using these as a basis for evaluating different aspects of care. The paired comparison technique was employed to produce a ranked list of aspects of care that were perceived to be in greatest need of improvement. Some difficulties were encountered in administering the ranking technique to patients in a highly specialized health-care setting; however, results were obtained and validated for follow-up patients. The item of most concern to these patients was a lack of sensitivity about when patients felt ready for discharge. PMID- 10172104 TI - Prospective audit comparing ambulatory day surgery with inpatient surgery for treating cataracts. AB - OBJECTIVES: To compare the cost effectiveness and safety of inpatient cataract surgery (with one night in hospital postoperatively) with ambulatory day case surgery under local anaesthesia. DESIGN: Prospective study of patients receiving inpatient (group 1) or day case (group 2) surgery. SETTING: One ophthalmic surgical firm. PATIENTS: 100 patients in each group, excluding those with coexisting ocular conditions, contraindications to local or request for general anaesthesia, ill health, or lack of agreed minimum social care; four patients died during follow up. INTERVENTIONS: Envelope method and implantation of the posterior chamber lens into the capsular sac in both groups. MAIN MEASURES: Perioperative complications, operating and turnover times, visual outcome at three to six days and 10 weeks to six months after operation, patient satisfaction (according to self administered questionnaire) at three to six days, and total costs (1989 salaries) for both groups. RESULTS: Patients in both groups did not differ significantly in age or sex, perioperative complications, visual outcome (6/9 or better in 78 patients in group 1 and 75 in group 2 at one month after operation and 6/12 or better in 92/98 in group 1, 90/98 in group 2 at final follow up), or patient satisfaction. The mean total cost per patient for group 1 patients was 365.99 pounds and for group 2, 221.62 pounds. CONCLUSIONS: Day case surgery for cataract is safe and more cost effective. IMPLICATIONS: Day case surgery should be recommended to increase availability of cataract surgery and thereby improve quality of life for more patients. PMID- 10172105 TI - Measuring patient satisfaction: a test of construct validity. AB - OBJECTIVE: To establish the validity of two patient satisfaction questionnaires (surgery satisfaction questionnaire (SSQ) and consultation satisfaction questionnaire (CSQ)) developed for use in general practice. DESIGN: Prospective study of performance of SSQ and CSQ in patients selected for their predicted levels of satisfaction. SETTING: Avon Family Health Services Authority (FHSA); general practices in Bristol (practice A) and in Cheltenham (practice B). PATIENTS: 400 patients selected by Avon FHSA who had changed practices but not their home address and whose original practice had not changed its services (group 1); 869 randomly selected patients (221 from practice A, 648 from practice B) (group 2). MAIN MEASURES: Median difference in satisfaction scores for each questionnaire between groups 1 and 2 and between subgroups of group 2 patients according to assessed level in continuity of care (< 50%, > or = 50%) in the past 12 consultations. RESULTS: 272 (68.0%) patients in group 1 completed the SSQ and CSQ. 711 (81.2%) patients in group 2 (178/221 (80.5%) in practice A, 533/648(82.3%) in practice B) completed the SSQ and 374(88/106(83.0%), 286/335(85.4%)) completed the CSQ. Both questionnaires classified patients in groups 1 and 2 according to the construct of satisfaction; thus the difference in median scores for every component of satisfaction in each questionnaire was significant and occurred in the direction predicted by the construct. Each questionnaire also discriminated between patients grouped according to their assessed level of continuity of care. CONCLUSION: SSQ and CSQ are valid measures of satisfaction for these types of patients. IMPLICATIONS: Valid measures of patient satisfaction can be developed; untested instruments should no longer be used. PMID- 10172106 TI - Jennifer's ear: airing the issues. PMID- 10172108 TI - Assistive technology in the home. AB - Emerging technologies for home use may ease long-term costs for patients. More important, they may be applied to home care to improve patient quality of life and outcomes. What will the increasing role of physicians be in this arena? PMID- 10172107 TI - Surgical interventions for glue ear: what form will a quality service take? PMID- 10172109 TI - The pursuit of illness for secondary gain. AB - Secondary gain is defined as the advantage that occurs secondary to stated or real illness. Transition into the sick role may have some incidental secondary gains for patients. Types of secondary gain include using illness for personal advantage, exaggerating symptoms, consciously using symptoms for gain, and unconsciously presenting symptoms with no physiological basis. These symptoms may contribute to the social breakdown syndrome and the patient's choice to remain in the sick role. PMID- 10172110 TI - Humanity by design. Industrial designer Patricia Moore's products focus on the rehabilitation needs of elders and of the "differently-abled". PMID- 10172111 TI - Disability support services and the reforms. AB - Features of disability support service provision in New Zealand are examined. Factors influencing the restructuring of the disability support services are identified in the context of international comparisons. Reference is made to the debate on the health/welfare interface, policy trends that have favoured a shift from institutional to community care and the need to contain escalating public health service expenditure. Changes to the disability support services under the new Regional Health Authority structure are outlined. Thereafter, the influence of the reforms in redressing the problems inherent in the long-term care services is analysed, as well as the possible consequences of the changes. PMID- 10172112 TI - Sensory assistance to improve your hospital. PMID- 10172114 TI - Point-of-care lab services will be surveyed. PMID- 10172113 TI - Cost-effectiveness of chemotherapy for sputum smear-positive pulmonary tuberculosis in Malawi, Mozambique and Tanzania. AB - The cost-effectiveness of chemotherapy for pulmonary sputum smear-positive tuberculosis was examined in the national tuberculosis control programmes of Malawi, Mozambique and Tanzania. In these three programmes, routine cure rates have exceeded 80 per cent. Average, average incremental and marginal unit costs for standard, short-course and retreatment regimens with and without hospitalization have been measured. The average incremental cost per year of life saved through chemotherapy ranged from US $0.90-3.10. In all conditions, short course chemotherapy is preferable to standard 12-month chemotherapy. When hospitalization during the intensive phase of chemotherapy increases the cure rate by 10-15 percentage points, it can be relatively cost-effective. Analysing the cost-effectiveness of short-course and standard chemotherapy, where the depth of the margin of benefit is different, illustrates some of the dangers of simplistic use of cost-effectiveness ratios. PMID- 10172115 TI - Aortic aneurysm repair made less invasive. PMID- 10172116 TI - Alcohol- and drug-related visits to hospital emergency departments: 1992 National Hospital Ambulatory Medical Care Survey. PMID- 10172117 TI - National Ambulatory Medical Care Survey: 1992 summary. PMID- 10172119 TI - A more rational basis for funding services. PMID- 10172118 TI - Changing disease patterns, shifting demographics: effects on laboratory services. AB - Laboratory services of the early 21st century will be heavily influenced by significant demographic redistributions and shifts in the incidence and prevalence of disease. A persistent influx of immigrants literally will change the face of the U.S. population. Persons born between 1946 and 1964 will reach middle and old age and will require testing for arthritis, diabetes, cardiac dysfunction, Alzheimer's disease, and stroke. Efforts to combat infertility will expand. Tuberculosis, wrongly assumed to be under control, will continue to proliferate. Testing will be needed for the millions of people living with AIDS and for the millions more infected or suspected to be infected with HIV. Cancer screening and information from genetic markers will widen. Public screenings will be routinely offered in assorted sites. As the national focus shifts from curing illness to promoting health, laboratory tests will assess healthy persons to a greater degree than ever. PMID- 10172120 TI - Technology aids the disabled. PMID- 10172121 TI - Public procurement. PMID- 10172122 TI - The reform lobby and an update on alcohol and drug abuse patient records. PMID- 10172123 TI - Guidelines for office-based surgery: quality assurance. ACS Board of Governors' Committee on Ambulatory Surgical Care. PMID- 10172124 TI - Frequently asked questions on the College's coding hotline. PMID- 10172125 TI - Outpatient cholecystectomy: implications for hospital utilization. AB - One hundred consecutive outpatient cholecystectomies were reviewed to determine hospital utilization. Operative time was 43 minutes and total hospital time eight hours. Fifty patients required parenteral analgesia in the recovery room and five in day surgery. Eight patients were admitted postoperatively for an average hospital stay of 2.5 days. There was one readmission, no major complications and high patient satisfaction. Outpatient cholecystectomy may be possible for 90 percent of all elective patients. PMID- 10172126 TI - Long-term care design: Woodside Place--the role of environmental design in quality of life for residents with dementia. PMID- 10172127 TI - Q&A: 'Reasonable accommodation' under disability law includes a 'right of transfer'. PMID- 10172128 TI - Q&A: disability law and workplace tests require sensitivity, caution on HR's part. PMID- 10172129 TI - Assessment of the structures and functions of Fife core dementia teams. AB - A research partnership was formed between Fife Regional Council's Social Work Department, Fife Health Board and the Dementia Services Development Centre and Social Work Research Centre of Stirling University, to investigate the multi disciplinary dementia teams which operate in Fife. The primary method of data collection was a series of group interviews with the six dementia teams: the teams were autonomous coalitions of professionals from various agencies and organizations who met together voluntarily. The informal nature of the teams has permitted them to operate without a defined set of purposes or objectives, enabling the participants to work together with a degree of pragmatism according to professional values and agency policies. There was wide agreement within the teams that the coordination of multi-agency services to clients was much improved and inter-personal relations between different professionals had become much better developed since the operation of teams. PMID- 10172130 TI - Potential effect of tacrine on expenditures for Alzheimer's disease. AB - Tacrine is the first drug approved for the treatment of mild or moderate Alzheimer's disease (AD). The present study evaluates the potential ramifications of tacrine on AD costs. An economic model was specified to link cognitive changes observed in a 30-week clinical trial of tacrine with estimates of the cost of AD, drug therapy, monitoring, time in a nursing home, and survival from diagnosis. Two groups were evaluated: (1) 367 patients receiving varying doses of tacrine, including treatment failures, and (2) 67 patients able to tolerate the high dose of 160 mg/day. Based on a literature review, a patient with AD survives a mean 4.4 years from diagnosis and incurs lifetime treatment costs of $57,169 (1993 dollars). Patients taking doses of 80-160 mg/day, showed an improvement in Mini Mental State Exam (MMSE) of 1.0 point, which resulted in 9.5 months of predicted community and institutional care avoided, for annual savings of $2,243/patient (range, $-109 to $3,342). Patients able to tolerate the 160-mg dose improved 2.0 points on the MMSE, resulting in a prediction of 12.1 months of reduced community and nursing home care, for annual savings of $4,052/patient. Tacrine therapy could generate savings up to 17% of the current costs of AD, or a total of $3.6 billion annually for the estimated 1.6 million persons with mild-to-moderate AD. PMID- 10172131 TI - Management of HIV infection and AIDS in the workplace. PMID- 10172132 TI - Developments in total quality management in the United States: the Intermountain Health Care perspective. AB - In summary our purpose has been to evaluate quality in the following terms. Best process of care--narrowing the variation of care decisions, working towards the best method. Best clinical outcome--decreased morbidity ond mortality. Best patient satisfaction--both for clinical outcome and the process of care. Best value--best value at the lowest cost. At Intermountain Health Care we believe that the best way to achieve the best quality improvement in a health care system is to involve all of the participants--patients, providers, and systems--in employing the principles of total quality management. Patient involvement--in prevention; participating in best care process through education and utilisation; in evaluating functional status before, during, and after intervention; in satisfaction; in clinical outcome and follow up with providers. Provider involvement--in planning, implementing, analysing, and educating; in defining guidelines; in reassessing and defining guidelines; in reassessing and continually modifying the care map, always striving for "best care." System involvement--in providing structure and mechanisms, support staff, and information systems and being willing to focus on quality as a part of its mission. An American philosopher, George Santayana, once said: "What we call the contagious force of an idea is really the force of the people who have embraced it." It will be up to all of us collectively to become the force behind moving quality management principles into the forefront of patient care methodology and ensuring that quality remains as the guiding principle of health care delivery in the future. PMID- 10172133 TI - Computerized physician order entry and quality of care. AB - In automated physician order entry systems, physicians enter orders directly on the computer. Compared with manual systems, advantages are that orders are legible, transcription is eliminated, the writer can be identified, and orders can rapidly be routed to their destinations. But most importantly, physician order entry allows order checking and provision of decision support to the orderer in real time. Disadvantages are that systems developed to date have been slower than pen and paper and they represent a major process change so that implementation is time-consuming and requires patience both on the part of the users and the developers. PMID- 10172134 TI - Dance/movement therapy with the frail elderly. PMID- 10172135 TI - Medical Project OSVITA. PMID- 10172136 TI - Computerization in clinical laboratories and health care facilities: making decisions in transition. Part II: Understanding user friendliness, computer assisted physician ordering, patient informational needs. PMID- 10172137 TI - The cardiac care step-down unit at home. AB - Clinical pathways have proven to be the key to shortening hospital stays for cardiac patients, allowing them to move out of the hospital and back home sooner. These pathways have truly facilitated the paradigm shift from institutional to home care. PMID- 10172138 TI - Bringing the lab home with near-patient testing. AB - Near-patient testing has been shown to decrease costs while improving the quality of patient care. Technological advances are making this cost-effective element of caring more accessible. PMID- 10172139 TI - Incidence of adverse drug reactions in adult medical inpatients. AB - This study was a prospective observational study of ADR occurrence and evaluation in adult internal medicine inpatients conducted over a 120-day period. Clinical pharmacists screened for ADRs at a county hospital in Indianapolis, IN. Patient information was reviewed on admission, every four days during hospitalization, and at discharge. ADRs occurring after hospital admission were assessed for causality, severity, pharmacological type (i.e., augmented pharmacology versus idiosyncratic reaction) and affected organ system. Nurse and pharmacist reports, incident reports, physician consults, patient transfers to critical care units, and serum drug concentration reports were additional means of ADR identification. Overall, 23.1% of patients experienced an ADR while 2.6% of the 11,702 drug exposures resulted in an ADR. Patients aged greater than 65 years (29.6% vs. 20.5% for younger patients) and females (26.2% vs. 20% for males) were at higher risk for ADR development (p < 0.05). Length of hospital stay was longer (13.3 days vs. 6.7 days; p < 0.05) and drug exposures more frequent for patients experiencing ADRs (p < 0.001). Furosemide elicited the most ADRs with 36 in 244 patient exposures (14.7%). Diltiazem, enalapril, heparin, trimterene/hydrochlorothiazide combination and captopril were also frequently implicated. ADRs were classified as mild (35.9%), moderate (52.6%), and severe (10.2%). Organ systems most commonly affected were the metabolic/hematologic (32.9%), gastrointestinal (17.8%), genitourinary (11.8%), and cardiovascular (10.5%). Over 30% of events were idiosyncratic reactions. ADR incidence was consistent with previous literature. Many frequently implicated medications were newer agents and the severity of events was less than previously reported. PMID- 10172140 TI - Fitness to drive: updated guidelines for cardiovascular fitness in vocational drivers. Honorary Advisory Panel on Driving and Disorders of the Cardiovascular System. PMID- 10172141 TI - The labour market for qualified orthotists/prosthetists. AB - The United Kingdom Health Departments have recently encouraged increased intakes to degree-level training courses leading to a dual qualification in prosthetics/orthotics. Surveys of qualified orthotists and prosthetists and of their employers were undertaken to examine the dynamics of this labour market, and a model was used to project potential requirements for newly qualified orthotists and prosthetists. The model indicates that: current policy on student numbers is broadly appropriate for maintaining the present working population; any expansion in service provision would require significant growth in student places; and even a small decline in demand could shortly lead to an over-supply of such specialist services. PMID- 10172142 TI - "Refusal to treat" cases involving HIV-infected persons under the Americans with Disabilities Act. PMID- 10172143 TI - Estimating the cost of a Medicare outpatient prescription drug benefit. AB - People enrolled in Medicare account for more than one-third of all outpatient prescription drug expenditures in the United States. That being the case, a proposed prescription drug benefit under the Medicare program would insure a substantial part of the market and would create the largest expansion of the program in the past 20 years. This article explains how the cost of a drug benefit was estimated as part of the Clinton Administration's health reform initiative. PMID- 10172144 TI - Hospice: a comprehensive program. AB - Having begun operations in 1991 with six employees, four volunteers, and three patients, the St. Louis-based Incarnate Word Family and Alzheimer's Hospice today boasts 44 professional employees, 6 clerical staff, and more than 100 volunteers. The hospice offers a medically supervised home care program in which staff work closely with patients and families throughout the illness and bereavement period. Using a palliative rather than curative approach, the Incarnate Word Family and Alzheimer's Hospice focuses on enhancing the remaining life of the patient. Patients are enrolled based on their need for care, not on their ability to pay for services. To meet the unique needs of certain patients, the hospice offers a variety of specialized services, including pediatric, Alzheimer's, and AIDS care. Collaborative efforts with local agencies include cross-training, continuing education, client referrals, and support services. In 1993 Incarnate Word introduced hospice services to area residential care facilities (RCFs). The program enables RCF residents who develop life-limiting illnesses to remain in the place that they have come to know as home. In March 1994 Incarnate Word Family and Alzheimer's Hospice opened a branch office in north St. Louis. The new location enables the hospice to serve more people and creates an additional resource for physicians treating terminally ill patients. Volunteers provide rest breaks for care givers, help with meal preparation and simple housekeeping, run errands, comfort patients and family, and listen when others may find their story too overwhelming. PMID- 10172145 TI - Preparing for the real world. Program helps rehabilitation patients perform everyday tasks. AB - St. Francis Health Care Centre in Green Springs, OH, decided in 1991 to enlist local merchants in a program in rehabilitative medicine. The program, named for Green Springs's main street, is "Broadway: A Route Home." Broadway is a program for persons who, because of severe illness or injury, require extended rehabilitation. Along with care for continuing physical or cognitive problems, such patients often need help in performing tasks--buying groceries, cashing a check, renting a video--that most people take for granted. Under the Broadway program patients can practice these tasks safely in shops, restaurants, and theaters in Green Springs and other nearby communities. Later, escorted by therapists, some patients journey to larger cities and, finally, to their own communities, to exercise everyday skills. PMID- 10172146 TI - Is there a relation between waiting-list length and surgery rate? AB - The aim of this study was to investigate whether the differences in waiting-list lengths between hospitals can result from differences in demand for surgery. We compared waiting-list lengths for seven surgical procedures to the rates of these procedures. The numbers of procedures were obtained from the 1987 Finnish Hospital Discharge Register, and the numbers of patients on the waiting lists were obtained from an inquiry made to Finnish hospitals in 1987. Correlation coefficients were calculated between population-based waiting-list lengths and procedure rates. Significant, positive correlations were found between population based waiting-list lengths and rates for operations on hallux valgus, for herniorrhaphy and for hysterectomy. Rates for cholecystectomy and haemorrhoidectomy were also positively correlated with waiting-list lengths, but these correlations were not statistically significant. There was no correlation for varicose-vein operations, and a negative correlation for cataract extraction. These results suggest that insufficient resources are not the only reason for long waiting lists; but, both long waiting lists and a high rate of surgery can result from a high demand for surgery, influenced by physicians' decisions. If the waiting list is long because surgical treatment is preferred, the answer is not necessarily to increase resources, but to examine critically the indications for surgery. PMID- 10172147 TI - TB testing: methods and time targets. PMID- 10172148 TI - Predicting the risk of failure in proficiency testing. PMID- 10172149 TI - Court's rulings in two cases could carry a big price tag. PMID- 10172150 TI - Buying groups bid for docs' hearts. PMID- 10172151 TI - Working in the OR is tough on your back. PMID- 10172152 TI - Project Open Heart brings hope, supplies to Kazakhstan. PMID- 10172153 TI - Aboriginal and Torres Strait Islander health: current status and recent initiatives. Health and Community Development Branch, Aboriginal and Torres Strait Islander Commission. AB - Against a background of the appalling health problems experienced by indigenous Australians, the following discussion details the current status of health services for Aboriginal and Torres Strait Islander peoples and recent government and non-government initiatives to address these problems. In many localities, health services are overwhelmed by the tasks confronting them. State and Territory governments, having primary responsibility for the health of all citizens, must act in close cooperation with local communities, the Aboriginal and Torres Strait Islander Commission (ATSIC), regional councils and Aboriginal health services to ensure inequalities are addressed in health service provision to Australia's indigenous people. The Federal government, through ATSIC and the Department of Human Services and Health, has implemented a range of initiatives in order to make a significant contribution to indigenous health and welfare. A primary task remains to implement broader scale changes relevant to Aboriginal and Torres Strait Islander people within the mainstream health services. Mainstream services have the primary responsibility, and are funded on behalf of the whole population, to address health problems in a working partnership with the communities they serve. The Australian Hospital Association and its membership can help to improve the health of indigenous peoples by actively and sensitively working with them in the localities where they live, and through advocacy in the policies and plans that shape the whole of our health system. PMID- 10172154 TI - The Americans with Disabilities Act and the corpus of anti-discrimination law: a force for change in the future of public health regulation. PMID- 10172155 TI - Patterns of Medicaid expenditures after AIDS diagnosis. AB - This article examines average monthly Medicaid expenditures after diagnosis of acquired immunodeficiency syndrome (AIDS) for the diagnosis, mid-illness, and death intervals, as well as Kaplan-Meier estimates of expenditures from AIDS diagnosis to death. A clinical severity measure (the Severity Index for Adults with AIDS [SIAA]) designed to be predictive of patient survival was applied to a population of continuously enrolled New York State Medicaid patients who survived at least 6 months after being diagnosed with AIDS. Our findings suggest that groups of more seriously ill patients who appear to have more intense demand for health care services, especially over the diagnosis and mid-illness intervals, can be identified using the SIAA. PMID- 10172156 TI - Disabled workers' risk of hospitalization and death. AB - Data from the 1982 New Beneficiary Survey (NBS) were matched with 5 years (1984 88) of Social Security and Medicare data to analyze disabled workers' probability of death and inpatient care. Fifteen percent of the disabled workers died within 18-24 months of initial eligibility; 34 percent died within 5 years. Older disabled workers had higher probabilities of death and hospitalization. Males were two times as likely to die as females, but no more likely to be hospitalized. Black persons also had a higher risk of death but no greater risk of hospitalization than other races. Additional health insurance had no influence on survival, but was differentially associated with inpatient care. Married males were more likely to survive. Physical functioning capacity had no influence on survival or hospitalization. Respiratory, circulatory, and digestive disorders increased the probability of hospitalization and mortality. PMID- 10172158 TI - Let's improve the flagging of abnormal hematology specimens. PMID- 10172157 TI - Differences by race in the rates of procedures performed in hospitals for Medicare beneficiaries. AB - This study analyzes administrative data from the Medicare program to compare differences by race in the use of 17 major procedures performed in the hospital. In both 1986 and 1992, black beneficiaries were less likely than white beneficiaries to have received these procedures while hospitalized. The largest differences were seen for "referral-sensitive surgeries" such as percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, total knee replacement, and total hip replacement. These differences by race suggest that there are barriers to these services. In contrast, black beneficiaries were found to have substantially higher rates than white beneficiaries in the use of four procedures performed in the hospital: amputation of part of the lower limb, surgical debridement, arteriovenostomy, and bilateral orchiectomy. The types of procedures for which black beneficiaries have higher rates raise questions about whether there is a need for more comprehensive and continuous ambulatory care for the underlying health conditions associated with these procedures. PMID- 10172159 TI - How total error can save time and money for the lab. PMID- 10172160 TI - Violence and abuse education: toward changes to physiotherapy curricula. PMID- 10172161 TI - Characteristics of health data: structure and relationships. AB - The characteristics of health data are diverse and vary by discipline. Health data can be viewed from three perspectives. They can be examined at a basic level of different variable types and database constructions. At an intermediate level, the way data are structured in a facility is a model of how an organization works. A computerized information system is a model of how work is performed. An understanding of facility data architecture and data structure is essential for adapting both manual and computerized systems to the rapid changes occurring in health care today. Lastly from the highest-level perspective, for communication and exchange of health data to be possible across all components of the health care delivery system, standards for data must be adopted by all institutions and individuals involved in the development of health data information systems. To expedite such exchange, the American Medical Informatics Association (AMIA) has recommended standards for patient, provider, and site-of-care identifiers; computerized message exchanges; and medical record content and structure. AMIA has also recommended the use of the universal medical language system as the basis for future developments in a universal medical language. PMID- 10172162 TI - Reducing orthopedic implant costs. A physician-driven approach at Mt. Sinai Medical Center, Cleveland. AB - Faced with the closing of its service, the Orthopaedics Department at Mt. Sinai Medical Center, working with Materials Management, began a program to become profitable. Through standardization, appropriate utilization, pre-planning of cases and the development of critical pathways, the service has realized about 40% savings in materials and dropped their average product costs to $2,700 per joint and reduced length of stay by five to six days. The keys have been physician input from the start, teamwork and continuous training. PMID- 10172163 TI - America's other drug problem. PMID- 10172164 TI - Some considerations for identifying quality measures of surgical outcome. PMID- 10172165 TI - Conversion to day surgery unit in listed building achieved in 16 weeks. PMID- 10172166 TI - Medicare program; monthly actuarial rates and monthly supplementary medical insurance premium rates beginning January 1, 1995--HCFA. Notice. AB - As required by section 1839 of the Social Security Act, this notice announces the monthly actuarial rates for aged (age 65 or over) and disabled (under age 65) enrollees in the Medicare Supplementary Medical Insurance (SMI) program for calendar year 1995. It also announces the monthly SMI premium rate to be paid by all enrollees during calendar year 1995. The monthly actuarial rates for 1995 are $73.10 for aged enrollees and $105.80 for disabled enrollees. The monthly SMI premium rate for 1995 is $46.10. PMID- 10172167 TI - Obtaining endoscopic surgery data requires planners to become database sleuths. PMID- 10172168 TI - Challenges in preventing suicide. AB - The success of traditional suicide prevention efforts is evaluated and found wanting. Some encouraging recent developments are noted, and it is suggested that suicidologists might also profitably consider the strategies used by professionals dealing with other public health and social problems, such as drug abuse and delinquency. PMID- 10172169 TI - Use of the Threat Index with family members waiting during surgery. AB - We describe the use of the 40-item Threat Index (TI) with family members (N = 206) of surgical patients who also completed Templer's (1970) Death Anxiety Scale, the Death-of-Self and Dying-of-Self subscales of the Collett-Lester (1969) Fear of Death Scale, and the Death Acceptance subscale of Reker and Peacock's (1992) Life Attitude Profile-Revised. Word sets from the 40-item TI that are part of the 25- and 7-item versions of the TI produced strong alphas and correlations to their parent instrument. Regression analyses indicated that self/ideal-self scores and previous experience as a hospital patient were significantly associated with TI scores. We conclude that if the time available for completion and scoring of the TI is limited, the shorter versions can be used, although their alpha strengths are slightly lower than that of the full TI and the respondent's age influences the scores. PMID- 10172170 TI - Primer on blood salvage: implications for the hospital pharmacist. AB - With a basic understanding of intraoperative and postoperative blood salvage procedures, pharmacists can use their expertise in pharmacology and pharmacokinetics to answer questions regarding drug disposition during blood salvage. The methods and equipment, as well as the indications for its use are described. Pharmacological considerations include the patient's drug regimen, agents used in the surgical field including irrigation solutions, hemostats, and the anticoagulant used in the salvage system. In addition to providing drug information, the pharmacist should be involved in the admixing of the anticoagulant solutions used in the salvage system. A basic bibliography for the subject is provided. PMID- 10172171 TI - Workplace drug abuse policy. PMID- 10172172 TI - Four words that could ruin your disability protection. PMID- 10172173 TI - Laparoscopic surgery--it's relevance to Indian urology with cost effectiveness. PMID- 10172174 TI - The interview: a potential mine field. PMID- 10172175 TI - Caring for children with special health care needs. AB - With approximately 20 million children in the United States living with some type of chronic illness, home care's opportunity and responsibilities are clear. Home care services are a crucial part of this population's health care continuum, from chronic clinical care to familial and social support. PMID- 10172176 TI - Roadblocks to home care. AB - Inadequate or lack of Medicaid or private insurance reimbursement for needed services, lack of social and emotional support for families in certain communities, poor teaching, lack of continuity of treatment at home and communication breakdowns between key providers are just a few of the problems pointed out by discharge planners and pediatric home care nurses when transferring medically fragile children to the home. Although many children are successfully transferred and cared for in the home, problems continue to revolve around money, resources, and time, which stand in the way of an optimal success rate. PMID- 10172177 TI - Support for families & children with special needs. AB - One home care agency's staff identified community needs and developed three pediatric programs to address those needs. The programs include case management, a respite program, and parent education to prevent child abuse or neglect. All programs strengthen the families and thus the community this agency serves. PMID- 10172178 TI - Surgery guidelines become part of chapter on care of patients. PMID- 10172179 TI - Surgery center aims for low-cost procedures. Central Maryland Surgery Center. PMID- 10172180 TI - Protect your organization from ADA-compliance scams. PMID- 10172181 TI - Recycling program finds value in people society might have pushed aside. PMID- 10172182 TI - An expert system for the interpretation of flow cytometric immunophenotyping data. AB - The development of high-grade non-Hodgkin's lymphomas in HIV-positive patients and patients with acquired immune deficiency syndrome (AIDS) is a well known phenomenon. The proper classification of these neoplasms often requires a multiparameter approach, including the interpretation of a large panel of immunologic markers analyzed by flow cytometry. The availability of individuals with the required expertise to properly interpret these marker studies is limited. For this reason, we have designed an expert system to automate the analysis of immunophenotyping panels in both HIV-related and non-HIV-related hematopoietic neoplasms. The expert system, which we call "Professor Fidelio", runs on IBM-compatible computers under Windows 3.0. The system is designed to accept any number of markers studied from a repertoire of 35 markers. Professor Fidelio functions on the basis of heuristic classification of defined diagnostic patterns. Nine specific patterns (Stem Cell, Myeloid and/or Monocytic, Erythroid, Megakaryocytic, Immature B-cell, Immature T-cell, Mature B-cell, Mature T-cell, and Plasma cell) and one "non-specific" pattern have been agreed upon. Fidelio's knowledge base contains the definitions of each of these patterns and the heuristics for excluding patterns when an incomplete panel of markers is performed. The inference engine interprets the findings (including the age of the patient) and reports the patterns which are matched, the differential diagnosis, the suggested diagnosis from the list of differentials if the marker studies are specific, and recommendations for additional tests which may be valuable in establishing the diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10172183 TI - The impact of informal care giving on labor force participation by rural farming and nonfarming families. AB - Using data from the National Survey of Families and Households, 1987, this study contrasts urban versus rural, and farm versus rural nonfarm informal care givers of the elderly and disabled to illustrate the conflicts that each group experiences when combining work and care giving. Women are the primary care givers in both rural and urban areas. Rural care givers spent more time providing care than urban care givers, whether the dependent resided in the care giver's home or elsewhere in the community. A moderate difference existed in the number of hours care givers spent at work, although the rural care giver's spouses worked significantly more hours than urban spouses. Rural nonfarm care givers spent more hours caring for individuals residing in their communities, while farm care givers spent the most time in household-related activities when caring for someone in their homes. In-home activity decreased the number of hours spent at work, while community care giving did not. PMID- 10172184 TI - New dimensions in behavioral health/primary care integration. AB - The case is made for the integration of primary care and behavioral health services in the HMO. Key features of a successfully integrated behavioral health service are offered, along with brief reports of integration efforts at a number of HMOs across the United States. The author believes that better value and cost efficiencies result from integration. PMID- 10172185 TI - Perspectives. Medicare: should it--can it--be reformed? PMID- 10172186 TI - Withdrawing or withholding medical care from premature infants: who should decide, and how? PMID- 10172187 TI - Medical devices; classification of temporomandibular joint implants--FDA. Final rule. AB - The Food and Drug Administration (FDA) is classifying four temporomandibular joint (TMJ) implants, the total temporomandibular joint prosthesis, the glenoid fossa prosthesis, the mandibular condyle prosthesis, and the interarticular disc prosthesis (interpositional implant), into class III (premarket approval). These actions are being taken under the Federal Food, Drug, and Cosmetic Act (the act), as amended by the Medical Device Amendments of 1976 (the 1976 amendments) and the Safe Medical Devices Act of 1990 (the SMDA). PMID- 10172188 TI - Minimal access surgery. Through the keyhole. PMID- 10172189 TI - Friend or fraud? PMID- 10172190 TI - Need expert help with the ADA? Look no further than your institution's own staff. PMID- 10172191 TI - Shelter services: mutual aid and self-help for elderly and disabled persons. PMID- 10172192 TI - Intensive case management in Alzheimer's disease home care: an interim report on the Cincinnati (Ohio) Medicare Alzheimer's Project. PMID- 10172193 TI - Virtual reality in surgery and medicine. AB - This report documents the state of development of enhanced and virtual reality based systems in medicine. Virtual reality systems seek to simulate a surgical procedure in a computer-generated world in order to improve training. Enhanced reality systems seek to augment or enhance reality by providing improved imaging alternatives for specific patient data. Virtual reality represents a paradigm shift in the way we teach and evaluate the skills of medical personnel. Driving the development of virtual reality-based simulators is laparoscopic abdominal surgery, where there is a perceived need for better training techniques; within a year, systems will be fielded for second-year residency students. Further refinements over perhaps the next five years should allow surgeons to evaluate and practice new techniques in a simulator before using them on patients. Technical developments are rapidly improving the realism of these machines to an amazing degree, as well as bringing the price down to affordable levels. In the next five years, many new anatomical models, procedures, and skills are likely to become available on simulators. Enhanced reality systems are generally being developed to improve visualization of specific patient data. Three-dimensional (3 D) stereovision systems for endoscopic applications, head-mounted displays, and stereotactic image navigation systems are being fielded now, with neurosurgery and laparoscopic surgery being major driving influences. Over perhaps the next five years, enhanced and virtual reality systems are likely to merge. This will permit patient-specific images to be used on virtual reality simulators or computer-generated landscapes to be input into surgical visualization instruments. Percolating all around these activities are developments in robotics and telesurgery. An advanced information infrastructure eventually will permit remote physicians to share video, audio, medical records, and imaging data with local physicians in real time. Surgical robots are likely to be deployed for specific tasks in the operating room (OR) and to support telesurgery applications. Technical developments in robotics and motion control are key components of many virtual reality systems. Since almost all of the virtual reality and enhanced reality systems will be digitally based, they are also capable of being put "on-line" for tele-training, consulting, and even surgery. Advancements in virtual and enhanced reality systems will be driven in part by consumer applications of this technology. Many of the companies that will supply systems for medical applications are also working on commercial products. A big consumer hit can benefit the entire industry by increasing volumes and bringing down costs.(ABSTRACT TRUNCATED AT 400 WORDS) PMID- 10172194 TI - The management of health services in Tanzania: a plea for health sector reform. AB - There are essentially four main approaches used in attempts to strengthen the management of health services in developing countries. These are: information system development; management training; use of planning and evaluation methodologies; and, health sector reform. As part of a collaborative research project based in Kisarawe District, Tanzania, we tested the hypothesis that a combination of the first three of these approaches would be sufficient to ensure that decisions and actions were taken to bring about major improvements in the management of health services. It was assumed that the decentralization, which took place as part of the 1982 reorganization of local government responsibilities, had provided managers with sufficient decision-making autonomy to allow them to bring about improvement in health service performance, provided that the other conditions were met. In fact, it was found that despite being presented with clear evidence of serious inefficiencies and inequities in the allocation of health resources, managers were often highly reluctant to decide upon actions which would alleviate the problems in situations where there were potential losers as well as winners, even if the benefits greatly outweighed the costs. This article argues that interventions based solely on training, information systems, or planning and evaluation protocols will make only marginal improvements to health service management, and that changes to the system as a whole are needed in order to provide managers and health professionals with incentives to rectify performance failings. Some ideas for health sector reform, to give managers power and incentives for improving efficiency and quality of care, are put forward. Since it is likely that the systemic problems of the health sector in Tanzania are shared by many other developing countries, the lessons drawn from this study probably have more general applicability. PMID- 10172195 TI - Managing information from bedside testing. PMID- 10172196 TI - Ahead ... robots, digital surgeons, and virtual reality. PMID- 10172197 TI - New anesthetics have fewer side effects. PMID- 10172198 TI - OR technology: microrobots, computer aids, tissue welding. PMID- 10172199 TI - What's special about special care? Con. PMID- 10172200 TI - What's special about special care? Pro. PMID- 10172201 TI - Pharmacoeconomics and the formulary decision-making process. AB - What is pharmacoeconomics and why is there growing interest in this concept by those who work in or serve the medical community? This article provides a brief explanation of this concept and its importance from an institutional perspective. Additionally, the tasks typically associated with the position of a pharmacoeconomist in the hospital setting are defined. Also described are the types of cost analyses that can be used, the relationship between pharmaceutical care and pharmacoeconomics, and finally, two examples of how pharmacoeconomic principles are actually being used in the formulary decision-making process at a major tertiary care center--The Cleveland Clinic Foundation. PMID- 10172202 TI - Balancing residents' rights. PMID- 10172203 TI - More health dollars to buy more operations. PMID- 10172204 TI - Transport and accommodation policy outlined. PMID- 10172205 TI - Risk management tips for video technology. AB - Proper management of the videotaping of medical procedures begins with identifying the purpose of the video; determining whether it is educational, diagnostic-related, or for "public relations" purposes; and obtaining a clearly defined consent that addresses an understanding of all risks and expectations involved. Although an exception to the policy may become necessary in some instances, addressing the key issues in policies and procedures before taping is the key to minimizing risks. Videotapes are useful as a teaching tool, but they also can easily become a part of the discovery process in a malpractice suit. Given the current nature of discovery in most states, many courts would require disclosure of the videotape. Although this may be disturbing to many health care providers, it should also be considered that the videotape could contain a valid record that the procedure was performed correctly, clearing the physician or facility involved of charges of negligence. With video cameras in such common use today, a positive, proactive position on the benefits involved in videotaping should be taken to minimize the potential negative ramifications that could occur. PMID- 10172206 TI - Identifying reasonable accommodations under the Americans with Disabilities Act. PMID- 10172207 TI - Ambulatory care and healthcare reform. AB - The escalating costs of inpatient care have resulted in the increased utilization of outpatient facilities and home care. As the sites of care proliferate, the system of healthcare delivery must be integrated so that healthcare provision is both cost-effective and safe. PMID- 10172208 TI - Medicare program; additions to and deletions from the current list of covered surgical procedures for ambulatory surgical centers--HCFA. Final notice with comment period. AB - This final notice with comment period implements section 1833(i)(1) of the Social Security Act, which requires, in part, that the list of covered ambulatory surgical center (ASC) procedures be reviewed and updated at least every 2 years. This notice announces the specific additions to and deletions from the list of surgical procedures for which facility services are covered when the procedures are performed in a Medicare-participating ASC, as well as the assigned payment groups for each addition. The notice also announces a change in our criteria for deleting procedures from the ASC list. This notice also responds to public comments received in response to our proposed notice published December 14, 1993 (58 FR 65357). In that notice, we requested comments on the proposed additions to and deletions from the list of covered surgical procedures for ASCs; the proposed quantitative change in our deletion criteria; the development of alternatives to the proposed quantitative deletion criteria; and the assignment of payment groups for each addition. Finally, this notice solicits public comment on certain additions to and deletions from the ASC list that had not been suggested in our December 1993 proposed notice. It also solicits public comment on the assignment of payment groups for certain new procedure codes. PMID- 10172209 TI - The back track. Ergonomics training programs are cutting costs and employee back injury rates. AB - Back injuries account for 52 percent of all workers' compensation claims in nursing homes. To keep their workers and their bottom lines healthy--and in anticipation of impending OSHA regulations--many facilities are developing innovative ergonomic programs. PMID- 10172210 TI - Making your liability coverage work. PMID- 10172211 TI - International models. Home care in Europe and The Netherlands. AB - The Netherlands and other countries in Europe have well-established systems of home care that may show the US industry to be still developing. However, all home care systems seem to have areas of concern. PMID- 10172212 TI - Financial toll of substance abuse studied. PMID- 10172213 TI - Injury-related visits to hospital emergency departments: United States, 1992. PMID- 10172214 TI - A stitch in time: case for assessing the burden of delayed surgery. PMID- 10172215 TI - Is being HIV-positive a disability under the Americans with Disabilities Act? PMID- 10172216 TI - The American College of Surgeons' CPT and RUC activities. Part I. PMID- 10172217 TI - An update on healthcare reform in the states. Mental health and substance abuse coverage. PMID- 10172218 TI - A new order in Washington: implications for mental health and substance abuse. PMID- 10172219 TI - Capital costs of supporting young disabled people at home. AB - The quality of life of disabled people depends partly on resources accessible to them. In this study, the capital costs of disability are defined and quantified for disabled people aged 16-64 years, inrelation to: their families, the state, the level of disability, medical diagnosis, and income, for 173 people in the Harrow area on Social Services registers of very severe and appreciable handicap. The mean cost of capital equipment and adaptations was 5,700 pounds (inter quartile range 200 pounds to 6,600 pounds) to individuals and their families, and 4,500 pounds (inter-quartile range 100 pounds to 6,900 pounds) to statutory bodies (1993 prices, based on a 1988 survey). Two-thirds of this was spent on structural alterations, and one-third on aids and equipment, and costs to the individual were not apparently related to income from employment or state allowances. Capital costs of disability acquired in later life were partly ameliorated for some by accrued pensions, and for those disabled earlier in life, costs were often borne by carers and family. High capital outlay, often borne by the family, was reported for those with congenital disorders. The study indicates the need for financial support, and the need to increase suitable available accommodation for disabled people; regular review may help to identify individual requirements and changing needs. PMID- 10172220 TI - Substance use of medical students: a nationwide survey. AB - Medical students from 13 medical schools in England, Scotland and Wales were asked about their use of tobacco, alcohol and other drugs. Data from 1,278 students (68% response rate) are presented here. 10% of the respondents were current smokers, 10% ex-smokers. In a typical week 17% of the respondents exceeded the recommended limits for sensible drinking. Other drugs besides tobacco or alcohol had been used by 37% of the respondents. Most of the students who had used drugs had done so on no more than 10 occasions. 9% were current users. Although the majority of medical students neither smoke nor drink heavily nor take drugs, a significant minority either persist in or develop potentially harmful substance use behaviour during their studies. The scope for preventive efforts is considerable. PMID- 10172221 TI - Ambulatory care planning for a hospital. PMID- 10172222 TI - Hospital packages endoscopic surgeries. PMID- 10172223 TI - RoboDocs and mousecalls. PMID- 10172224 TI - What is long-term care? PMID- 10172225 TI - Drugs education. Peer pressure. PMID- 10172226 TI - More operations for people most in need. PMID- 10172227 TI - Health and disability service ethics. PMID- 10172228 TI - The American College of Surgeons' CPT and RUC activities. Part II. PMID- 10172229 TI - Life care plans as a managed care tool. AB - Life care plans, standardized catastrophic plan-of-care formats, have been successfully used for case management purposes for more than 10 years. Standardizing the format and procedures provides an easy-to-understand road map of care to professionals, family, and insurance companies. This article reviews the history of this plan-of-care format and offers a checklist to be covered by the catastrophic care provider. PMID- 10172230 TI - The triple diagnosed. AB - The triple diagnosed are AIDS patients who are also substance abusers and mentally ill. Such a combination raises roadblocks to care that any of the conditions alone would not cause. A team approach throughout the home care community, however, seems to overcome the obstacles. PMID- 10172231 TI - Second in a series. Personal factors contributing to back injury in home care. AB - A healthy back is necessary for every activity a person undertakes--whether at work, home, or anywhere else. Preventing back problems is more effective than treating them after they happen. If a person gets a back injury, it may not be caused just by a single activity, but by many activities and lifestyle choices that have added up over time. PMID- 10172232 TI - TQM tools strike rich vein. PMID- 10172233 TI - The Philadelphia story. Should you assume teen trauma victims are stoned? PMID- 10172234 TI - Technology, medicine & health, Part 4. Technological cancer: its causes & treatment. PMID- 10172235 TI - Guidelines. Encountering the disabled with knowledge and understanding. PMID- 10172236 TI - What will fixed payments mean for surgical providers, volume? PMID- 10172237 TI - Study tests RN monitoring for eye surgery. PMID- 10172238 TI - The total costs of illness: a metric for health care reform. AB - Systems thinking is a fundamental element of quality management and should be a fundamental element of health care reform. An implication of systems thinking is that one aim of health care should be to minimize the total costs of illness, not simply the direct medical expenditures. If we are to continue to improve health care over time, we should measure its impact on the total costs of illness to the patient, family, employer, and society. Thus a system of measurement is needed that quantifies total costs of illness and also suggests how these constituencies can collaborate to improve processes and reduce total costs. This article introduces the total costs of illness concept, contrasts it with societal costs of illness, describes a measurement system we developed to quantify it, and describes a case study examining the total costs of back injury illness to employers. We found that medical expenditures accounted for less than half of the total costs of illness, the average total costs of illness varied by over 350 percent among employers, and a simple metric (days off work) explained 62.5 percent of the variance in total costs of illness. PMID- 10172239 TI - Rehabilitation medicine: need for an integral approach. PMID- 10172241 TI - Breaking with tradition and redefining the disability equation: the Southern Californian Edison experience. AB - Southern California Edison formed a single, new disability prevention and management organization: Employee Services. This department aggregated the formerly scattered programs dealing with the entire disability continuum from injury prevention through claims and rehabilitation to Occupational Safety and Health Administration (OSHA) compliance and occupation research. PMID- 10172240 TI - Day care urology in a hospital based setting. AB - From January 1, 1991 to December 31, 1992, 3078 operations were performed on day care basis and 1185 operations on in-patient basis. Surgery performed on day care basis included ureteric stone basketing, ureteroenoscopic stone retrieval, JJ stenting, cystolithotripsy, TUR-BT, TUR-P and internal urethrotomy. Failure of complication rate was 0.97%. Most of the complications (26/29) could be detected early and managed by conversion of short admission into a regular one. Only 3 patients (0.1%) were admitted later on through the emergency. There was no mortality. In conclusion, we recommend urologic operative procedures on carefully selected patients on day-care basis to achieve two of the government's primary goals a) the provision of high quality services and b) the reduction of health care costs. Simultaneously a word of caution that it is unique challenge to be handled with care. PMID- 10172242 TI - Integrating an outcomes information system into managed care for substance abuse. AB - The following paper describes a program launched recently to combine the efforts of two very different sectors of the outcomes management field--a managed behavioral healthcare company and a research-oriented academic center--and to pragmatically integrate outcomes data collection into routine clinical assessment and treatment processes in the substance abuse treatment field. This program has important implications not only for the behavioral healthcare industry's ability to satisfy external demands for outcomes data, but also as a foundation for better internal management and quality improvement processes. PMID- 10172243 TI - Automation is at the heart of this cost-control effort. PMID- 10172244 TI - Mental disabilities under the ADA: a management rights approach. AB - While numerous sources have focused on employee rights and employer obligations under the Americans with Disabilities Act, this article will emphasize employer rights with respect to mental disabilities under the ADA. Specifically, it addresses the ADA's definition of "mental disability," the right of employers to screen job applicants in spite of the ADA, the conditions under which an employer may require an employee to undergo a "fitness for duty" examination, and the limits of the duty to "reasonably accommodate" an employee with a mental disability. PMID- 10172245 TI - Expanding ADA coverage to employee benefit plans: recent judicial and administrative developments. AB - The Americans with Disabilities Act has been heralded as the Emancipation Proclamation for persons with disabilities. The purpose of the law is to provide nothing less than a "clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities." Precisely how the nondiscrimination principles of the ADA will be applied to an employer's provision of health benefits to its employees has been the subject of much debate since the Act's passage in 1990. Although the statutory language and the legislative history support a limited application of the ADA to benefits issues, recent court decisions and enforcement actions by the Equal Employment Opportunity Commission indicate that the ADA may have a much more profound impact in the area of benefits plan design and administration. Moreover, as benefits administrators take a much more active role in managing health care decisions, the ADA may become a vehicle for legal challenges to those decisions that affect the disabled. PMID- 10172246 TI - Comprehensive drug and alcohol treatment programming: a bold new approach. AB - We have witnessed, in the latter half of the 20th century, significant revisions in the manner in which medical, psychiatric, and forensic services are delivered. Specifically, it appears that a wide range of treatment services are moving from modes of intervention that are dominated by primary institutional arrangements towards decentralized, community-based models of care. Missouri's CSTAR program represents a similar shift in alcohol and drug treatment. The CSTAR program provides an array of intensive community services that replaces hospital and residential services. In addition, community-based case management services promote social as well as medically based interventions. Parallels between the CSTAR model and the development of Community Support Services in psychiatric care are offered. PMID- 10172247 TI - Addiction treatment in the mid-1990s. AB - The rapid and dramatic changes now transforming the American healthcare system are also being felt in the addiction treatment field. How this change will be manifested in the structure, content and financing of substance abuse treatment over the next three to five years is described in the following article. PMID- 10172248 TI - Mental health and substance abuse services: common concerns in healthcare reform. PMID- 10172249 TI - On drug diversion in health care. AB - David Sells Jr. is director of security services at Presbyterian Health Services Corporation, Charlotte, NC, a multi-campus facility with four hospitals providing about 1,000 beds and approximately 90 medical buildings. He consults nationally on the subject of drug diversion and is author of the book Drug Diversions: An Investigative for the Health Care Professional. In this interview, Sells talks about this growing problem and the role of the hospital security director. PMID- 10172250 TI - Special report. A new look at security and parking booths: What's available? How much will it cost? AB - As users increasingly look to pre-fabricated security control booths--with units coming either completely pre-assembled including wiring or shipped in modular wall sections--they also are requesting a wide array of security features to meet their needs and comply with requirements of the Americans with Disabilities Act (ADA). These requirements cover such areas as ground and floor space, floor surfaces, turning radius within the booth, door clearance and threshold heights, counter and transaction windows, ceiling heights, and ramps. Costs of security, parking, and cashier booths vary greatly depending on the options selected. In this report, we will examine new developments in pre-fabricated booths and how manufacturers are employing security devices based on requests from users. PMID- 10172251 TI - Day surgery. Gains and pains. PMID- 10172252 TI - Day surgery. Daylight savings. PMID- 10172253 TI - Day surgery. Welcome words. PMID- 10172254 TI - Disability as a part of diversity. AB - One out of every seven people in this country has a disability, 19.1% of our population. Of all people with disabilities 66% are unemployed; 79% of them want to be engaged in meaningful work. It is apparent that there is a huge untapped resource for those seeking volunteers. This article explores barriers to and strategies for incorporating people with physical disabilities into a volunteer pool. It is based on the experience Courage Centers (a rehabilitation facility) has had in working with people with physical disabilities as volunteers and on a presentation made at the Association for Volunteer Administration International Conference in October, 1992. PMID- 10172255 TI - The impact of managed behavorial healthcare on the costs of psychiatric and chemical dependency treatment. AB - As Congress debates the Health Security Act, a key issue centers on whether and how to include mental health and substance abuse benefits and how to contain costs if and when these benefits are paid at parity with general healthcare. Previous studies estimating the average annual cost of providing behavioral healthcare services have shown considerable divergence, depending on the nature of the defined population and the inclusion of various benefit categories, out-of pocket expense and administrative costs. Experience from 14 members of the American Managed Behavioral Healthcare Association (AMBHA) is used to define the key features of managed behavioral healthcare, and to demonstrate that a properly managed behavioral healthcare benefit can be significantly less costly than the current reform debate would admit. AMBHA companies (which have many years of experience and presently manage the cost and quality of care for over 65 million people in the United States) [See Table 3, page 28], have shown that a specialty managed care approach can achieve not only significant savings to healthcare providers, payers and society, but also improve quality and access to care. Traditional attempts at reducing mental illness benefit coverage costs have entailed limitations on the availability or access to care. These approaches, however, ignored the larger implications to society of untreated mental illness and chemical dependency. When traditional coverages have offered more extensive benefits, they have primarily favored inpatient treatment, thus increasing costs by overemphasizing care of patients at expensive inpatient settings. AMBHA's proposed principles of healthcare reform and recommended benefit packages for behavioral healthcare can be found on page 80 of this magazine. PMID- 10172256 TI - The unintended consequences of healthcare reform for children's mental health services. PMID- 10172257 TI - ADA: employment protection of mental impairments. PMID- 10172258 TI - Seven principles of healthcare reform. American Managed Behavioral Healthcare Association. AB - The American Managed Behavioral Healthcare Association (AMBHA), is comprised of 15 of the country's leading managed behavioral healthcare companies. In January of 1994, AMBHA issued the following statement of "Principles of Healthcare Reform," as well as proposing an alternative basic benefit package for mental illness and substance abuse coverage under managed care. These documents represent an important effort in defining and describing appropriate behavioral healthcare coverage within the larger national debate on healthcare reform. Please also see the report on the cost impact of managed behavioral healthcare, prepared by AMBHA's Actuarial Subcommittee, on page 18 of this issue of Behavioral Healthcare Tomorrow. PMID- 10172259 TI - Data briefing. The top 10. PMID- 10172260 TI - Employer-sponsored health benefit plan may be subject to liability under ADA for limiting coverage for AIDS-related illnesses. PMID- 10172261 TI - Senate bill seeks Medicaid deal. PMID- 10172262 TI - Important trends to watch in surgical technology. PMID- 10172263 TI - Case series: No. 3 ... Home IV for drug users. PMID- 10172264 TI - Biological performance of tantalum. AB - A detailed literature search was carried out to define the current knowledge about the biological performance of tantalum. The pure metal appears, to a great degree, to be inert both in vivo and in vitro. Both the pure metal and its principle oxide possess low solubility and toxicity; however, halide compounds are more biologically active. Local host response is benign, characterized by vital encapsulation in soft tissue and frequent osteointegration, reminiscent of titanium, in hard tissue. Tantalum has been in clinical use since before 1940 and has found a wide range of diagnostic and implant applications, with apparently overall excellent results. In some applications, such as for radiographic bone markers and cranial closure, tantalum may well be the current material of choice. In summary, metallic tantalum is a promising biomaterial whose applications have been limited by technical rather than biological performance considerations. PMID- 10172265 TI - Protocol for the Multicenter Acute Stroke Trial--thrombolysis study. AB - The rationale for the Multicenter Acute Stroke Trial (MAST) is presented in a companion article appearing in this issue. Acute ischaemic stroke is the third major cause of death in developed countries, and a major cause of disability. Despite a very poor prognosis, no treatment has demonstrated an efficacy in lowering the mortality and disability resulting from stroke events. Thrombolysis has been proven to reduce mortality in myocardial infarction, and it has been shown able to induce recanalisation when administered to acute stroke patients. A recent meta analysis of small-sized studies suggests that thrombolysis could offer some benefit to stroke patients, by reducing the mortality and severe invalidity by 56%; these results need to be confirmed in adequately designed and sized studies. PMID- 10172266 TI - Rationale for testing thrombolysis in acute ischaemic stroke. MAST Group. AB - Stroke is an important health problem in developed countries, being a common cause of death and disability. Prognosis is poor for hospitalised stroke patients, with a 30-day mortality rate of 20-30%, and 30% of the survivors remaining severely disabled. Based on results from experimental animal studies it is thought that early intervention will improve the patients' prognosis. Thrombolytic therapy has been shown to reduce mortality in patients with acute myocardial infarction, and several trials aim to assess its efficacy in patients with acute cerebral infarction. Although many clinical trials have been performed to address this problem, none have provided a clear answer, either because the sample size was insufficient, or by modern standards, the methodology used was not adequate. The Multicenter Acute Stroke Trials (MAST) has been designed to assess the safety and efficacy of thrombolytic therapy with streptokinase for this indication. PMID- 10172267 TI - Whether a genetic defect is a disability under the Americans With Disabilities Act: preventing genetic discrimination by employers. AB - The Americans with Disabilities Act will not protect all forms of discrimination based upon one's genetic make up. Legislation is needed to prevent genetic discrimination. PMID- 10172268 TI - AIDS in the healthcare workplace: rights and responsibilities. AB - With the increasing spread of AIDS and HIV, courts are confronted with the task of balancing the need of public disclosure of a healthcare worker's HIV status against that individual's right to privacy. PMID- 10172269 TI - Rethinking long-term care: a personal journey. PMID- 10172270 TI - How to start a care management program. PMID- 10172271 TI - Going the way of fewer, larger labs. PMID- 10172272 TI - Recycling hazardous chemical waste--and proud of it. PMID- 10172273 TI - Essential drugs for ration kits in developing countries. AB - Since the early 1980s drug ration kits have been used to improve the supply of essential drugs to rural health facilities in developing countries. This paper evaluates some of the experiences with kit systems in Angola, Bhutan, Democratic Yemen, Guinea-Conakry, Kenya, Mozambique, Sudan, Tanzania, Uganda and Zambia in relation to the selection of drugs for the kits and their quantities and cost. Data were collected through a review of published papers, annual reports and programme evaluations, by questionnaires among field staff and interviews with key experts. In comparing the 10 programmes, 21 drugs can be identified that are used in at least two-thirds of all kits. This list may be useful for evaluation and planning purposes. Six drugs (ORS, chloroquine and 4 antibiotics) usually account for over 60% of the cost of the kit. Careful monitoring of the price and quantities of these 6 drugs can therefore be very cost-effective. In the absence of reliable data on morbidity and drug needs in the initial phases of a kit system, the median drug quantities in kits from these 10 countries may serve as a starting point. Accumulating surpluses are sometimes perceived as a serious disadvantage of kit systems, ORS, benzylbenzoate solution and iron tablets are the three drugs that have most frequently accumulated. These drugs are relatively cheap and usually have a long shelf-life; in most programmes they have been successfully redistributed to other health facilities while the kit content was being adapted. The overall financial loss due to accumulation of surpluses is therefore limited. Most programmes have reached a stable kit content within two years. PMID- 10172274 TI - Helping homeless men begin a new life. A program on Chicago's West Side provides substance abuse rehabilitation and job training. AB - The MARSEPH program, named for the two principal program collaborators--the Marillac Social Center and Saint Joseph Health Centers and Hospital--provides life and work skills to homeless men who visit a day shelter operated by the Marillac Social Center. Participants gain work experience at Saint Joseph. One of the most important aspects of the MARSEPH program is the removal of obstacles to the newly employed. Each MARSEPH participant receives housing assistance, a uniform, transportation to Saint Joseph Health Centers and Hospital, and a meal pass to the hospital's cafeteria. Through this assistance, the men can get off the streets, get to their jobs, be nourished, and look presentable. The MARSEPH program carefully monitors each participant's progress, to ensure his success. Case workers meet weekly with the men to discuss problems and concerns. Every week case workers also visit each participant's residence to monitor his living conditions and offer emotional support. At the end of the six-month training program, MARSEPH helps graduates find employment. PMID- 10172275 TI - Freedom and safety. A Colorado center cares for Alzheimer's patients. AB - Namaste Alzheimer Center, in Colorado Springs, CO, was founded in 1990 as a free standing special care facility for persons suffering from Alzheimer's disease. We do not physically restrain our residents and make only minimal use of psychotropic drugs. We want our residents to be as free of restrictions as possible--and also as safe as possible. Sometimes these goals conflict. As our census climbed, the number of resident falls seemed to be climbing as well. We responded to this by charting the falls. The graphs showed us which residents had the most falls, which building wings most falls occurred in, and the times of day falls were most likely to occur. Armed with this information, our staff deployed themselves in a way to help prevent falls. Namaste had 35 resident falls in October 1992. In February 1993 we had only nine. We not only reduced the number of falls; by furnishing the wings with beanbag chairs and futons instead of the usual furniture, we made falls less dangerous. We are now in the process of sharing what we have learned with the three acute care facilities that, with Namaste, are owned and operated by Penrose-St. Francis Health Care System. PMID- 10172276 TI - Medicine 2001. A technologic framework. PMID- 10172277 TI - Glassy carbon implant as a bone graft substitute: an experimental study on rabbits. AB - The purpose of this experimental investigation was to study the incorporation of porous glassy carbon in bone. Cylinders of porous glassy carbon were implanted in drill holes in diaphyses and metaphyses of rabbits tibia for 1, 3, 6, 12 and 24 weeks. Bone ingrowth into the glassy carbon implants was examined by radiographic, histologic, fluorocrome and microradiographic methods. The material caused no pathological reaction. Tissue ingrowth into pores was seen by all examination methods. The amount of bone in the pores increases with time. The ingrowth was most distinctive in those areas where the implant was in close contact with cortical bone or trabeculae of the cancellous bone. Porous glassy carbon can be used as bone substitute, although the small size of implant available is at the present a limitation for its clinical use. PMID- 10172278 TI - NPO after midnight before elective surgery is no longer common practice for the majority of anesthesiologists. AB - One thousand three hundred thirty-seven anesthesiologists randomly selected from the current American Society of Anesthesiologists' directory were surveyed to discover if their attitudes toward the policy of allowing preoperative patients nothing by mouth (NPO) have changed. One thousand forty surveys were returned. For each response to a survey question, the percentage of respondents giving that response was calculated. The 95% confidence intervals for these percentages were calculated by using the normal approximation of a binomial distribution. Chi square analyses were used to explore possible relationships between demographic factors and NPO orders. Nearly all anesthesiologists surveyed used less than an 8 hour fast for elective pediatric surgery. At least 50% of the anesthesiologists surveyed no longer use NPO after midnight as an order for elective surgery for adults. Of the demographic variables, only geography and the question of whether or not a hospital was a teaching institution were statistically related to NPO practice. PMID- 10172279 TI - Effect of patient-controlled sedation on recovery from ambulatory monitored anesthesia care. AB - Patient-controlled sedation (PCS) with propofol has been shown to be an effective means of conscious sedation during monitored anesthesia care. The purpose of this study was to assess both the intraoperative conduct and postoperative recovery of patients receiving propofol for conscious sedation, randomized to either PCS or anesthetist-controlled sedation (ACS). Forty-three patients scheduled for outpatient procedures requiring monitored anesthesia care were randomized to PCS or ACS. Both groups received an initial bolus of propofol 0.5 mg/kg and fentanyl 1 microgram/kg i.v., followed by an identical background infusion of propofol 50 micrograms/kg per minute. Subsequent doses of propofol 30 mg i.v. were either self-administered (PCS) or administered at the discretion of the anesthetist (ACS). Variables measuring hemodynamics, ventilation, saturation, and level of sedation were measured at baseline, after initial bolus of propofol and fentanyl, after skin incision, at last stitch, at admission to recovery, and 1 hour later. More propofol was used by the PCS group (P < 0.05). Finger-tapping was slower and responsiveness scores were lower in the PCS group at the end of the procedure (P < 0.05). More patients in the PCS group required oxygen supplementation (saturation < 90%) on admission to recovery (P < 0.05). At 1 hour after recovery admission, however, there were no differences between groups. These results indicate that when patients determine their own sedation, they are more sedated at the end of a procedure than when the anesthetist determines the level of sedation. PMID- 10172280 TI - The CLASS program: self-directed care. AB - Many issues surround self-directed care, and individuals who need habilitation services have brought those issues to the fore in recent years. The Visiting Nurse Association of Texas participates in a program with the state of Texas that allows individuals with disabilities to direct their own care while it also ensures that safety measures are addressed. The program is a success on many fronts. PMID- 10172281 TI - Ergonomic factors contributing to back injury. Third in a series. AB - The last two articles in this series pointed out that back injuries do not occur overnight unless acute trauma occurs. Rather, they are the result of cumulative trauma--they develop gradually over a period of time. Even though back injuries appear to be related to a single event (i.e., "While lifting the patient up I felt my back pop."), they are actually related to repeated events that predispose a person's body to the final breakdown event. PMID- 10172282 TI - Addiction. A matter of substance. PMID- 10172283 TI - Hot deals on orthopedic implants lure hospitals to resale market. PMID- 10172284 TI - Are you covered by FMLA (Family and Medical Leave Act)? PMID- 10172285 TI - Symposium: the use of silicone implants in orthopaedic surgery. PMID- 10172286 TI - New developments in perioperative cardiovascular monitoring. AB - Substantial technological progress has been made recently in the area of perioperative cardiovascular monitoring. Specialized monitoring may be performed for problems identified by preoperative evaluation. New technologies have been developed for monitoring the blood pressure continuously and non-invasively. Electrocardiographic monitoring of perioperative ischemia has been characterized. Newer techniques in echocardiography such as the use of contrast, and tissue characterization allowed improved monitoring of ischemia as well as ventricular function. Continuous monitoring of cardiac output can be performed by impedance cardiography and Doppler ultrasound and by continuous thermodilution. Improved rules for the differentiation of ventricular from supraventricular tachycardia have been developed. Detection of MI has been facilitated by new scintigraphic and enzymatic techniques. In critically ill patients, multi-system monitoring may be required to adequately assess the cardiovascular system. PMID- 10172287 TI - Propofol reduces prolonged outpatient PACU stay. An analysis according to surgical procedure. AB - This study compared the effects of propofol anesthesia and nonpropofol general anesthetics on duration of stay in the postanesthesia care unit (PACU) for prolonged drowsiness or nausea and vomiting following various surgical procedures. A group of 512 patients undergoing general anesthesia for a variety of outpatient surgical procedures over a 6-month period received general anesthesia with nitrous oxide, with or without propofol. Data collected from PACU records included type of surgical procedure and duration in the PACU of more than 2 hours owing to drowsiness or nausea and vomiting. Overall, patients who received propofol with nitrous oxide experienced less frequent drowsiness, nausea, or vomiting compared with patients who received nonpropofol anesthetic agents (drowsiness 12% vs 31%; nausea/vomiting 3% vs 25%). For patients undergoing gynecologic surgery, propofol anesthesia yielded an 8% incidence of prolonged PACU stay, compared with 41% for nonpropofol techniques. Similar results occurred for orthopedic surgery (15% vs 35%); for ear, nose, or throat procedures (30% vs 75%); and for ophthalmic surgery (18% vs 71%), but not for oral surgery (44% vs 64%). Most same-day surgery patients benefit from administration of propofol for induction and maintenance of anesthesia. Advantages include a decreased likelihood of a prolonged stay in the PACU as a result of drowsiness or nausea and vomiting. PMID- 10172288 TI - Reducing perioperative pain and anxiety. AB - As outpatient surgery becomes the norm, pediatricians are increasingly involved in preparing children--and their families--for the experience. This anesthesiologist's approach can help you guide your patients toward a smooth recovery. PMID- 10172289 TI - Patient satisfaction: an indicator of quality in disablement services centres. AB - OBJECTIVES: To develop a patient satisfaction system for disablement services centres and to report on how the initial findings have been used in audit to improve their quality of care and services. DESIGN: Interview survey of randomly selected users attending in three centres: Birmingham (centre X), Oxford (centre Y), and Cambridge (centre Z) to establish core topics for developing a patient satisfaction questionnaire with incorporation into a computer patient satisfaction system (PATSAT) to enable collation of responses to the questionnaire. A pilot of the questionnaire was undertaken in the centres to assess the sensitivity of the questionnaire, which was subsequently used as part of clinical audit process during June 1991 and April 1992 in centre X and the patient satisfaction system used to monitor changes in routine practice. PATIENTS: 123 amputees in the development phase, selected by cluster sampling, and 1103 amputees in the pilot study. MAIN MEASURES: Satisfaction scores for components of the service. RESULTS: The questionnaire included 16 core topics contributing to quality of care and services, including comfort of limbs, appointments, interpersonal aspects of care, a system of support and counselling, and organisation. The pilot survey demonstrated high satisfaction scores for aspects of interpersonal care, organisation, and physical surroundings of the centres and lower satisfaction for counselling services, comfort of the limb and the number of alterations made before the limb was considered acceptable. During the audit in centre X these results prompted changes to care and services which produced significant improvements in satisfaction. CONCLUSIONS: The early results suggest that the questionnaire, coupled with PATSAT software system, enable users' views to be expressed, collated, and fed back to staff; the information provided has already prompted change, and the system is sufficiently sensitive to measure changes in satisfaction with the service. PMID- 10172290 TI - A case study. The challenges of serving mental health and addictions recovery patients. PMID- 10172291 TI - Developing conceptions of chronic disease: a comparison of disease experience. AB - We predicted that children's conceptions of various self-care behaviors and social relations would be related to their degree of experience with insulin dependent diabetes mellitus (IDDM). A total of 55 children were recruited for this study in three experience groups: children with IDDM (high experience), children having a sibling with IDDM (low experience), and normal healthy children (no experience). In line with our model, children with IDDM had a more developed and sophisticated understanding of concepts associated with disease management than did either siblings of children with diabetes or the comparison group; surprisingly, experience with the disease (children with IDDM) was associated with more complex conceptions of social relations as well. PMID- 10172292 TI - Opportunities for older children and adolescents with disabilities through the Supplemental Security Income Program. AB - The revitalization of the Supplemental Security Income Program for low-income children with disabilities has important implications for state Title V programs for children with special health care needs. Historically, this program has focused primarily on recipients under the age of 7. The files of children between the ages of 7 and 16 referred to Children's Special Health Services, North Carolina's Title V children with special health care needs program from July to August 1991 were analyzed to determine whether there was documentation that children in this age group were receiving recommended services. Reports in the files indicated that most (n = 214, 77%) of the children's needs for specific services were being met. The utility of information that currently exists on older children and adolescents eligible for SSI for assisting Title V children with special health care needs programs in coordinating care is discussed. PMID- 10172293 TI - Relationship between cigarette smoking and other unhealthy behaviors among our nation's youth: United States, 1992. PMID- 10172294 TI - The blunt truth about sharps injuries in the OR. PMID- 10172295 TI - Tread carefully when dealing with personal problems of employees. PMID- 10172296 TI - Backs to the drawing board. PMID- 10172297 TI - Diagnosis: work pain. Rx: practical job redesign. PMID- 10172298 TI - CLIA program; categorization of tests and personnel modifications--HCFA. Final rule with comment period. AB - In this rule we are responding to some of the comments on categorization of tests and personnel requirements received in response to rules published on February 28, 1992 and January 19, 1993. (In a future rule, we will be responding to the remaining comments.) We are revising our regulations to: Allow dentists and midlevel practitioners to perform tests in the "physician-performed" microscopy (PPM) subcategory of moderate complexity procedures (we now call the subcategory "provider-performed"); include three additional tests in PPM; and expand provisions relating to general supervisor and high complexity testing personnel. PMID- 10172299 TI - Physician reaction to price changes: an episode-of-care analysis. AB - Physicians may respond to fee reductions in a variety of ways. This episode-of care analysis examines the impact of surgical fee reductions (mandated by the Omnibus Budget Reconciliation Acts [OBRAs] of 1986-87) on the overall pattern and cost of health care services provided in association with the surgical procedure itself. The study focuses on six procedure groups: cataract extractions; total hip replacement; total knee replacement; coronary artery bypass graft (CABG) surgery; upper gastrointestinal (GI) endoscopy; and prostatectomy. Only two of these procedures give significant evidence for the existence of a service volume offset to the fee reductions. PMID- 10172300 TI - Specialty board certification and federal civil rights statutes. PMID- 10172302 TI - When caregivers are abused. PMID- 10172301 TI - Applicability of ADA non-discrimination principles to self-insured health plans: do "AIDS caps" violate the law? PMID- 10172303 TI - The obsolescence of surgical operations: causes and effects. PMID- 10172304 TI - [Evaluation of objectives and implementation of services of a combined program for prevention and health promotion]. PMID- 10172305 TI - Current diagnostic guidelines for Alzheimer's disease. AB - The pointers outlined recommend specific steps for the neurologic examination, assessment instruments for detecting physical and cognitive dysfunction and mood alteration, and relevant laboratory tests. When to use imaging studies is highlighted. PMID- 10172306 TI - Needed: a new philosophy for treatment of the greatest sufferers. PMID- 10172307 TI - Rehabilitation of disability benefit claimants other than dependency. AB - Canadian sponsors of successful rehabilitation programs have found they offer impressive benefits for participants in long-term disability plans, as well as for employers and insurers. However, multiemployer plans frequently are not able to capitalize on these benefits. PMID- 10172308 TI - Causes of Medicaid expenditure growth. AB - Expenditures for the Medicaid program grew at the alarming and unexpected average annual rate of nearly 20 percent from 1989 ($58 billion) to 1992 ($113 billion). These statistics raise a critical question: What caused spending to grow so dramatically? Using State-level data from 1984-92, this analysis examines the determinants of Medicaid expenditure growth. The results indicate that Medicaid enrollment, Federal Medicaid policy, and State policy are significantly related to Medicaid expenditure growth. The analysis also finds the prevalence of acquired immunodeficiency syndrome (AIDS) to be significantly related to Medicaid expenditures. PMID- 10172309 TI - Day surgery. What a difference a day makes. PMID- 10172310 TI - Group contracts tempering LIS (laparoscopic instruments and supplies) prices. PMID- 10172311 TI - Management of nonunion below proximal humeral prosthesis. AB - Fractures below proximal humeral prostheses are rare and their successful management presents technical difficulties. Closed treatment usually results in nonunion. A case illustrating this disabling complication is reported and a literature review is presented that summarizes the classification, treatment options, and complications of these uncommon fractures. PMID- 10172313 TI - "Gotcha" journalism and the fate of health reform. PMID- 10172312 TI - The use of explanatory models to enhance surgical outcome. AB - A case is reported that demonstrates the impact of psychological variables on a patient's reaction to stressful medical procedures. The evaluation and management of psychological variables that might have an effect on treatment outcome is discussed. PMID- 10172314 TI - Tuned in to "To Your Health". PMID- 10172315 TI - Channel surfing through health reform. PMID- 10172316 TI - Are Alzheimer's special care units effective? PMID- 10172317 TI - Requirements of ADA create challenges for providers. PMID- 10172318 TI - Price increases for orthopedic implants continue to slow. PMID- 10172319 TI - Two surgeons in the operating room: how do you code? PMID- 10172320 TI - Near patient testing. Recommended guidelines for hospitals--August 1992. New Zealand Institute of Medical Laboratory Science. PMID- 10172321 TI - Point-of-care laboratory testing. Position statement. Canadian Society of Laboratory Technologists. PMID- 10172322 TI - Laboratory services in the context of health care in the 1990's. AB - Third in a series of articles on the Clinical Laboratory of the Future, this paper explores the trends affecting the human dimension of laboratory services. The role of the medical laboratory technologist will change along a number of predictable trends over the next five years. Each of these trends is discussed in light of the adjustments to be made over the next five years. PMID- 10172323 TI - American College of Healthcare Executives. Ethical policy statement. Impaired healthcare executives. March 1995 (revised). PMID- 10172324 TI - CLIA's effect on POLs (physicians' office laboratories). PMID- 10172325 TI - A pain-free inauguration of point-of-care testing. PMID- 10172326 TI - Molecular pathology, Part 2. QA initiatives for the DNA lab. PMID- 10172327 TI - Allied's regional effort now a nationwide celebration. Allied Services, Scranton, PA. PMID- 10172328 TI - Greater Baltimore cuts to the chase. Greater Baltimore Medical Center, MD. PMID- 10172329 TI - Case studies in ethics. A substance-abusing manager. PMID- 10172330 TI - Molecular diagnostics: from the research bench to the clinical bench. PMID- 10172332 TI - Establishing a capitation policy for mental health and substance abuse services in healthcare reform. AB - In healthcare reform the evolution toward capitated payment systems raises many questions that are unique to behavioral healthcare providers. These issues include how to structure risk contracts, how to set appropriate prices and how to price and cover the severely mentally ill and uninsured. Two possible solutions to the pricing dilemma are described in this article: using prior-use experience for setting prices, with a DRG-type classification formula, and using a combination of past-use formulas and current utilization data. PMID- 10172331 TI - But doctor, it's my hip!: the fate of failed medical devices. AB - It is difficult to study failed medical devices because of a lack of data. Routine device retrieval and analysis (DRA) is essential to performance evaluation, which, in turn, is essential to good patient care. We argue for the development of a national DRA program and medical device database and discuss the major ethical and policy issues associated with this proposal. PMID- 10172333 TI - TennCare: mental health advocates move to solidify services. PMID- 10172335 TI - The Disabilities Act and injured workers. PMID- 10172334 TI - Residential Living. An alternative for Alzheimer's residents. PMID- 10172336 TI - Safety characteristics of the conically sculpted Nd:YAG laser fiber for operative laparoscopy. AB - The objective of this study was to define the effects and safety margins of available Nd:YAG laser fibers with flat and conically sculpted tips for operative laparoscopy. An in vitro agar base model was designed to define the effect of the conically sculpted fiber at distances of 5 and 10 mm beyond the fiber tip, and an in vivo rat model was used to assess similar effects in the contact mode, as well as at 1, 3, 5, and 10 mm beyond the tip. The beam divergence emitted through conically sculpted tips demonstrated significant reduction in power density at 3 5 mm beyond the tip, which is suggestive of minimal risk of undesired effects. Threshold energy levels required for thermal effects are lower for darker organs than for light-colored objects. The Nd:YAG laser cutting effect is satisfactory when the conically sculpted tips are in contact with soft tissue, and subjacent organs are relatively more protected when compared to the flat tips. The potential advantages of this tool over other laser and conventional accessories for operative laparoscopy has yet to be determined. PMID- 10172337 TI - Operative laparoscopy for the treatment of localized chronic pelvic-abdominal pain caused by postoperative adhesions. AB - One hundred fifty-six patients with chronic abdominal pain associated with postoperative adhesions were treated with laser laparoscopy. Eighty-eight percent of these patients had complete relief, 9% had satisfactory relief, and 3% required a second laparoscopy to lyse recurrent adhesions. It is concluded that chronic abdominal pain associated with adhesions can be treated successfully with laser laparoscopy. PMID- 10172338 TI - The effect of CO2 laser laparoscopy for treatment of pelvic endometriosis on serum concentrations of antiendometrial antibodies. AB - This study uses antiendometrial antibodies as an indicator for follow-up of patients with endometriosis after surgical treatment. This is a prospective study of 32 patients with endometriosis. The patients were used as their own controls. Serum samples were obtained before surgery and 1 month, 3 months, and 6-9 months following surgery. All patients were treated with CO2 laser laparoscopy. Serum concentrations of antiendometrial antibodies decreased significantly at 1 month, 3 months, and 6-9 months following treatment in each group. There was no correlation between baseline concentration of antibodies and stage of the disease. This study confirms the value of using antiendometrial antibodies as an indicator for follow-up of endometriosis patients. Surgical treatment with CO2 laser laparoscopy is effective in lowering the antigenic effect of the disease in these patients. This beneficial effect is maintained for up to 9 months after treatment. PMID- 10172339 TI - Laparoscopic assisted vaginal hysterectomy: one group's experience. AB - Laparoscopic assisted vaginal hysterectomy (LAVH) has been reported worldwide. We report our experience with LAVH in 51 patients, 23 with the laparoscopic stapling device, 12 with a combination of stapler and bipolar coagulation, and 16 by bipolar coagulation exclusively. No operations were converted to laparotomy, and there were few minor complications. Average operating time was 1 h and 38 min. Hospital stay averaged 2.2 days. Average hospital costs were greater for the stapling devices ($7815.00) compared with bipolar coagulation ($7150.00). Postoperative patient satisfaction was high (96%), with high resolution of the symptoms (94%). We conclude that LAVH is a safe, effective operation in selected cases and may be a valid alternative to abdominal hysterectomy. PMID- 10172341 TI - Minimizing bias in self-reports of health beliefs and behaviours. AB - Bias in self-reports is one of the key problems which confronts researchers interested in using qualitative research techniques to understand individuals' cognitive and conceptual models of health behaviours. This is a problem that is especially apparent, for example, in research around addictive behaviours, where the fundamental trustworthiness of respondents' accounts may be in doubt. This research note discusses the problems associated with using conventional qualitative methods in health research and suggests a means of avoiding these. PMID- 10172342 TI - Integrating behavioral health care into a full-service system. PMID- 10172343 TI - Sonography guides biopsy and therapy in the neck. AB - Sonography is a powerful imaging method that can be used in the evaluation of patients with thyroid and parathyroid disease. The role of sonography in visualizing normal superficial neck structures and detecting small pathologic neck masses is being enhanced and expanded by its ability to accurately characterize suspected pathologic processes through precise percutaneous needle biopsy under real-time visualization. PMID- 10172344 TI - Cost-benefit analysis of transesophageal echocardiography in cardiac surgery. AB - This article evaluates the costs and outcomes associated with TEE during and after cardiac surgery. The costs include the direct and indirect costs--the complications of TEE. The outcomes include the positive consequences or the benefits: money and lives saved. The article uses liberal (high) estimates of the direct and indirect costs of TEE and conservative (low) estimates of the benefits. The exact cost or benefit depends on the number of cases performed. The analysis shows that patients having surgery for congenital heart disease derive the greatest overall benefit: around $600 per case studied. Patients having valvular repair surgery derive the next greatest benefit: around $450 per case studied. In contrast patients having valve replacement have an overall cost of around $150 per case studied. Patients having surgery for coronary artery disease also derive an overall benefit: around $100-$300 per case studied, depending upon assumptions regarding TEE's role in prevention of intraoperative strokes. This analysis indicates that the financial benefits of TEE are substantial and frequently outweigh costs in patients requiring cardiac surgery. PMID- 10172346 TI - Endometrial ablation vs laparoscopic hysterectomy. Pro laparoscopic hysterectomy. PMID- 10172345 TI - Endometrial ablation vs laparoscopic hysterectomy. Pro endometrial ablation. PMID- 10172347 TI - Lysis of uterine adhesions with the four-channel hysteroscope. AB - Hysteroscopy with direct visualization of the uterine cavity has made intrauterine surgery easier and safer. Most hysteroscopes have one operating channel. This report illustrates the four-channel Baggish-Weck hysteroscope, which allows simultaneous clearing of the surgical field and lysis of adhesions. PMID- 10172348 TI - Hearts, knees or hips: where to focus OR savings efforts. PMID- 10172349 TI - Dentists' responses to drug misusers. AB - A survey among a sample of illicit drug misusers in 1993 indicated under-use of dental services, in spite of a high prevalence of dental problems, whilst a survey of dentists revealed reluctance to treat such patients. Most dentists use additional infection control procedures when they detect 'at-risk' patients, but their screening procedures are unlikely to be effective. Most dentists in the survey would welcome extra training focused on drug misuse. PMID- 10172350 TI - Maternity services for drug misusers in England and Wales: a national survey. AB - A postal questionnaire was sent to the 213 National Health Service maternity units in England and Wales to identify their current involvement with drug misusers. The response rate was 89.5%. Data indicated that only 29% had formal links with their local drug agency. Child protection case conferences were automatically convened in 52%, and 57% routinely admitted babies to high dependency areas. Twenty-seven per cent of the units did not offer hepatitis B screening to pregnant women, and 32% did not offer hepatitis B prophylaxis to babies whose mothers were infected. Local Health purchasing authorities should ensure that their providers are offering appropriate services to pregnant drug misusers in order to encourage such women to seek help without fear of discrimination. Liaison between health care agencies should be encouraged and areas with low levels of drug misuse should receive help with formulating policies, and training, from units with more experience. PMID- 10172351 TI - Sale of drugs and health care utilization in a health care district in Zaire. AB - Health centres of Idjwi district (Zaire) have been self-financed through the selling of drugs since 1985. Medical care is expensive and its use is low (24 visits per year per 100 inhabitants). In 1989 the medical team tried to reduce the cost of visits by changing the prices of drugs and prescriptions. A limited control was set up to assess this intervention. The study showed that although prescribed drug costs were stabilized compared to inflation, there was no increase in the use of medical care. Moreover, the reduction of drug profit margins for health centres seriously affected the health care institution by causing a drop in income. Six months after the intervention the monthly accounts showed a deficit in 6 centres out of 8. The need for health care centres to be self-financing is a major limiting factor in the use of health care in Idjwi district. There are no easy solutions for health centre managers that satisfy both low-cost access to care and health care self-financing. Some minimal financial participation from the state is required. Only then can the concept of financing health care through the selling of drugs be operational. PMID- 10172352 TI - Aging: laboratory testing and theories. AB - OBJECTIVE: To review theories of aging and the changes in laboratory test results that occur because of physical changes in the normal elderly patient. DATA SOURCES: Books on aging, laboratory test interpretation, and nutrition as well as published articles on aging, vitamins, and nutrition. STUDY SELECTION: Elderly people. DATA EXTRACTION: Survey of the literature. DATA SYNTHESIS: Aging theories may present possible aspects of the effects of aging on health in the elderly. Normal aging may lead to physical changes that alter laboratory test results without causing disease. Treatment of these "abnormal" results in the elderly may be detrimental to their health. CONCLUSION: As the elderly population increases, laboratorians will encounter an increasing number of elderly patients. Discriminating between truly abnormal test results and those caused by aging will require laboratory reevaluation of adult reference ranges. PMID- 10172353 TI - Outcome of open-heart surgery in octogenarians. PMID- 10172354 TI - Drug advisory committees. Getting outside advice for close calls. PMID- 10172355 TI - New ways to foil heart attacks. PMID- 10172356 TI - Using EDI to exchange clinical information. PMID- 10172357 TI - Just another day at the office. PMID- 10172358 TI - Indirect costs of disease; an international comparison. AB - Results of economic evaluations are often strongly influenced by estimates of indirect costs. International comparability of these estimates may contribute to rational decision-making in health care policy. Hence, estimates should be international comparable. Comparability of these results between countries may be hampered due to variation in methodology, data sources, valuation of production losses, and social security arrangements. Furthermore differences in epidemiology, demography and economic environment may cause variation in the level and the distribution by diagnosis of indirect costs. In this study indirect costs of disease for the Netherlands are compared with estimates for Sweden and the United States. We found large differences: both in the share of indirect costs in GDP as in the constituting elements, absence from work, disability and mortality. The level of indirect costs due to absence from work and the distribution according to diagnosis are quite similar for the two European countries. The costs of disability are particularly high for the Netherlands. Comparison of disability costs between the three countries is hampered due to lack of quantitative information on the influence of social insurance arrangements on the level of indirect costs and the distribution by diagnosis. The large number of deaths at young age in the U.S. is responsible for the higher mortality costs compared to the two European countries. PMID- 10172359 TI - The reimbursement of the expenses for medical treatment received by 'transnational' patients in EU-countries. AB - The number of 'transnational' EU-patients, i.e. EU-citizens receiving medical treatment in another country than their working state--where they contribute for social security--is growing steadily. This article describes the EU and member states' rules governing the reimbursement of the expenses for medical treatment received abroad, for the case where patients travel abroad with the sole purpose of medical care in the framework of the national health insurance (treatment authorised by E112-form). It is illustrated that some countries' national rules comply with the EU-rules, a number of countries apply stricter rules, while other EU-members have established legislation that is more favourable for their citizens, than the EU-rules. Furthermore, the financial burden of treatment abroad also differs widely, since some countries reimburse travel and living expenses for the patient, and sometimes also for an accompanying person, while other countries do not provide such reimbursements. The article concludes with some policy implications. PMID- 10172360 TI - Tread carefully when dealing with troubled employees. PMID- 10172361 TI - Workers at risk. What industry and government are doing about the problem. PMID- 10172362 TI - New drugs may help treat psychoses. PMID- 10172363 TI - Behavioral journalism: beyond the marketing model for health communication. PMID- 10172364 TI - Safety standards and the Medical Devices Regulations 1994. PMID- 10172365 TI - Haemodynamic effects of pressure-controlled ventilation versus volume-controlled ventilation in patients submitted to cardiac surgery. AB - OBJECTIVE: To compare the haemodynamic effects of pressure-controlled ventilation (PCV) with volume-controlled ventilation (VCV) in patients after cardiac surgery. DESIGN: Prospective clinical study. SETTING: Post-operative cardiac surgical ICU. SUBJECTS: Twenty sequential elective adult patients with no previous chronic lung disease and aged less than 70 years old. INTERVENTIONS: One hour after ICU admission and receiving mechanical ventilation utilising sinusoidal flow, patients were divided into two groups according to cardiac index (CI): group I: CI > 2.5 l/min/M2 and group II: CI < 2.5 l/min/M2. They were submitted randomly to 15 minutes' PC or VC mode, a 30-minute wash-out period of mechanical ventilation with a sinusoidal flow pattern, and then alternate PC or VC mode for 15 more minutes. Data were statistically compared using analysis of variance (ANOVA) with a significance level of 5%. Sedatives and muscle relaxants were given as necessary. ENDPOINTS: Data were obtained at the end of 15 minutes under each ventilatory mode, observing a 30-minute interval between each. MEASUREMENTS: Standard cardiorespiratory parameters were measured or calculated using conventional monitoring (including cardiac output), Qs/Qt, A-aDO2 alveolar arterial oxygen difference, peak inspiratory pressure, mean airway pressure and dynamic compliance (C). RESULTS: No significant differences between PCV and VCV modes, or between groups, were seen in MPAP, MAP, PCWP, RAP, heart rate, O2ER, VO2I, Paw, C, A-aDO2 and Qs/Qt. However, DO2I (p = 0.0063), LVSWI, (p = 0.0001) and RVSWI (p = 0.0053) showed a statistically significant difference between groups I and II. No influence of VCV or PCV on these parameters was seen. There was a slight significant difference between groups for PVR (p = 0.0205). In contrast, CI (p = 0.0001) and SVR (p = 0.0062) showed significant differences among groups, but also a significantly favourable effect of PCV over VCV (p = 0.0239 and p = 0.0318 respectively). Finally, a significant reduction (p = 0.0001) in peak inspiratory pressure with PCV was observed. CONCLUSION: PC and VC ventilatory modes had comparable effects on patients with preserved or depressed cardiac output. Patients ventilated with PCV showed significantly higher values for cardiac index, a decreased SVR, as well as significantly lower values for inspiratory pressure when compared with VCV patients. PMID- 10172366 TI - Myocardial temperatures during in vivo endocardial Nd:YAG laser irradiation. AB - To determine safety and efficacy of neodymium:YAG laser irradiation of the endocardium, temperatures at both the epicardium and the endocardium were recorded for thermal damage evaluation. A total of 48 coagulation lesions were created at power settings of 20 and 30 W in 20 open chest dogs by transcatheter endocardial laser irradiation. Tissue temperatures were monitored by epicardial thermography (Tepi), and by endocardial thermocouples at the catheter tip (Tprox) and 4 mm below the endocardial surface (Tdist). In group I the optical fiber extended 1 mm from the catheter and irradiation times ranged from 3 to 60 sec. Tepi reached > or = 57 degrees after a weighted average of 5 sec of laser irradiation (n = 44). In group II the fiber was retracted 1 mm from the catheter tip, and irradiation times were 100 to 150 sec. Tepi reached > or = 57 degrees C after a weighted average of 30 sec (n = 4). Blood vessels were recognized as heat sinks until coagulation occurred. Lesion volume showed a proportional increase with total delivered energy. From the observed timeframes in epicardial temperature rise it is suggested that total direct light absorption at the epicardium was the main contribution to Tepi, and the Nd:YAG laser can efficiently create transmural lesions. The epicardial temperatures remained below 80 degrees C in combination with the constant movement of the epicardial wall suggested safety from thermal damage to the ambient organs. PMID- 10172367 TI - Characterization of drug-related problems in elderly patients on admission to a medical ward. AB - The incidence, types, avoidability and risk factors associated with drug-related problems (DRPs) in geriatric patients on admission to a medical ward of the Toronto Hospital were assessed. The admission note and laboratory data of 150 consecutive admissions were reviewed for the presence of an adverse drug reaction, inappropriate dose, non-compliance, drug interaction, or lack of required medication. The avoidability (avoidable, possibly avoidable, or unavoidable) and contribution to hospitalization (major reason, contributing or non contributing) of each DRP was characterized. On admission, 41% of patients had a DRP identified, of which most were potentially avoidable (96.8%) and involved commonly prescribed drugs. The DRP was the major or contributing reason for admission in 31% of cases. Polypharmacy was a statistically significant risk factor for a DRP, particularly for male patients (p = 0.0010). In this elderly population, DRPs were not statistically correlated to age greater than 65 years, gender, renal function, native language, or duration of hospital stay. The incidence of DRPs and hospitalizations in the elderly can potentially be reduced by improving medication use. Enhanced communication, particularly between hospital and community pharmacists and their patients, may be a key mechanism. PMID- 10172368 TI - Study deems single-use instruments more cost-effective than reusable in lap choly procedures. PMID- 10172369 TI - CLR 1995-1996 reference laboratories for rare tests. PMID- 10172370 TI - CLR 1995-1996 clinical laboratory reference. Index of tests, equipment, services. PMID- 10172371 TI - A decade of progress in OR management. PMID- 10172372 TI - ASCs fight for market share in managed care. PMID- 10172373 TI - Same-day hysterectomy beneficial for some patients. PMID- 10172374 TI - Advances in Alzheimer's disease. AB - Investigations linking this disorder to numerous factors, such as neurotransmitters and apolipoprotein E, are leading to future drug therapy. Current patient care must be focused on finding and alleviating the causes of immediate behavioral concerns. PMID- 10172375 TI - Medicare program; payment for durable medical equipment and orthotic and prosthetic devices--HCFA. Final rule. AB - This final rule addresses comments received on an interim final rule with comment period published on December 7, 1992. The interim final rule implemented section 4062(b) of the Omnibus Budget Reconciliation Act of 1987. It specified that payment under the Medicare program for durable medical equipment (DME), prosthetics, and orthotics furnished on or after January 1, 1989 is limited to the lower of the actual charge for the equipment or the fee schedule amount established by the carrier. This final rule describes amendments to the methods for computing fee schedules covering the six classes of DME and how they are updated in subsequent years in accordance with sections 13542 through 13546 of the Omnibus Budget Reconciliation Act of 1993. PMID- 10172376 TI - In closing ... cost containment efforts. PMID- 10172377 TI - An interview with Jerome H. Stone, founder and honorary chairman of the Alzheimer's Association. Interview by Jill Sherer. PMID- 10172378 TI - Bladder injuries during total laparoscopic hysterectomy: diagnosis, management, and prevention. AB - Based on a series of 150 total hysterectomies carried out via laparoscopy between January 1993 and December 1994, we observed 2 bladder complications: 1 bladder injury and 1 vesicovaginal fistula. These two accidents form the basis of discussion on the risk factors for these complications, their diagnosis, treatment, and prevention. PMID- 10172379 TI - New directions for care of Alzheimer's disease and dementia. AB - A consortium of home care agencies has created a training program that not only ensures low staff turnover but greatly enhances care for patients with Alzheimer's disease and dementia. Using specialized training and an emphasis on knowledge-based care, this program proves that self-esteem is the key to success- for home care aides as well as patients. PMID- 10172380 TI - Why medicine is driving doctors crazy. PMID- 10172381 TI - Laboratory automation, Part 1. Total laboratory automation: a view of the 21st century. PMID- 10172382 TI - Cost-per-test analysis for the small lab. PMID- 10172383 TI - They're the best at keeping a lid on costs. AB - Hospital executives like to talk about the importance of cutting costs, but how many really practice what they preach? A survey of hospitals and hospital markets shows who's out in front of the pack. Some hospitals on the list at first blush might seem like unlikely candidates. PMID- 10172384 TI - Benchmarking critical pathways--a method for achieving best practice. AB - This article outlines the processes for the development and implementation of critical pathways to achieve best practice by two health organisations funded under the Commonwealth Government's Best Practice in the Health Sector Program. Each organisation is using a slightly different approach to using benchmarking as a tool to ensure best practice is achieved, however, they are similar in that they each demonstrate customer focus and a multidisciplinary, participative change management style. PMID- 10172385 TI - The status of laparoscopic surgery in Australia. AB - Laparoscopic surgery continues to evolve and to offer major potential for achieving benefits to patients and to health care providers because of decreased morbidity. Laparoscopic cholecystectomy has diffused rapidly and widely. However, the spread of other minimal access surgery methods has been more gradual, reflecting uncertainties as to the degree of benefit and rate of change of technology. Firm evidence of efficacy and costs of the new methods is still limited, and a number of organisational issues continue to demand attention. PMID- 10172386 TI - Factors to consider in assessing adult litigants' complaints of childhood sexual abuse. AB - Based on limited research, clinical and forensic experience and observations, factors hypothesized to be potentially useful in forensic evaluation of claims of decades-delayed discovery of childhood sexual abuse are delineated. Factors considered include: (1) alleged victim factors, (2) memory factors, (3) therapist/examiner factors, (4) external influences on the abuse account, (5) evidential patterns. Differences among a limited sample of cases seen by the author are described. Present knowledge does not provide a basis for reliable determination of whether a specific recollection is true or false, based only upon the claimant's account. At this time, there is no empirically validated method for discriminating valid from invalid cases. Experts testifying for either side must exercise caution and restraint as it may be premature and even unethical in many cases to propound opinions about the validity or invalidity of the memories. PMID- 10172387 TI - Healthcare's greatest challenge: providing services for people with severe mental illness in managed care. AB - The delivery of services for people with severe mental illness (SMI) is described as healthcare's most difficult challenge because SMI patients suffer from the combined effects of conditions that have 1) a chronic course, 2) disabling consequences, and 3) a high risk of poverty. The fundamental advantages of managed care for persons with chronic, disabling conditions are discussed along with an examination of how well these assumptions hold in actual practice for persons with SMI. The legal risks assumed by clinicians in managed care are reviewed, including the inherent risk of discriminating against high cost enrollees, such as patients with SMI. Finally, recommendations are made regarding the measures that might be taken to increase the "match" between the principles of managed care and the specialized needs of people with severe mental illness. PMID- 10172388 TI - Wayfinding--looking for the right signs. PMID- 10172389 TI - Landmark Columbia/HCA deal standardizes implant supplies. PMID- 10172390 TI - Measuring program performance in methadone treatment using in-treatment outcomes: an illustration. AB - Quality measurement and quality assurance in substance abuse treatment have, over the past few years, become a major policy issue. In addition, there is interest in the degree to which client outcomes can play a role in measuring treatment program performance. This article discusses the movement toward outcome-based performance measurement in substance abuse treatment. Examples of the products that such a performance measurement system might produce are provided. Why outcomes must be case-mix adjusted is discussed. In addition, using data from 18 methadone programs and more than 2,000 methadone clients from the Treatment Outcome Prospective Study, an illustration of case-mix-adjusted performance measurement is provided. PMID- 10172391 TI - Predictors of homeless veterans' irregular discharge status from a domiciliary care program. AB - This study addresses the relationship of homeless veterans' discharge status from a domiciliary care program to biopsychosocial characteristics presented at admission into the program. Hypotheses were that younger age, less education, and substance abuse or psychiatric disorder would predict an irregular discharge. Research participants were 367 homeless male veterans who had been admitted to a domiciliary care program at the West Los Angeles Veterans Affairs Medical Center for treatment of medical, psychiatric, or substance disorders. Status of veterans' program discharge (regular or irregular) served as the outcome measure. Logistic regression analysis revealed that irregular discharge from the program was more likely among veterans who were black, who had poor employment histories, or who had problems with alcohol. Results are discussed in light of the need to maintain homeless veterans in treatment programs so that they can achieve maximum benefit from available programs. PMID- 10172392 TI - Alcohol and drug use in the workplace: a survey of Alberta workers. PMID- 10172393 TI - Evaluation of five in-line hematocrit monitors. AB - Monitoring the hematocrit is essential during cardiopulmonary bypass for efficacious administration of blood products. The purpose of this study was to evaluate five cardiopulmonary bypass in-line monitors designed to display continuous hematocrit or hemoglobin values. The devices were evaluated for accuracy using an in vitro circuit primed with human blood while randomizing hematocrit, blood flow rate, and temperature. Hematocrits correlated significantly with the error in all the devices (p < 0.01). Over evaluation time, the error of the CDI, Gish, IBC, and MX2 increased significantly (p < 0.05). Temperature correlated significantly with the error of the Gish device (r = 0.49, p < 0.01). Blood flow correlated significantly with the Gish error (r = 0.24, p < 0.01). The Cobe device had a significantly smaller overall error than the other devices (p < 0.001). Device evaluation, based on a low mean error, a low percent error, a high correlation with the actual hematocrit, low correlations between mean error, blood flow, and temperature, and insignificant correlation between time and error, suggests that the Cobe device is more accurate for the continuous monitoring of hematocrit during cardiopulmonary bypass. PMID- 10172394 TI - Analgesia after inguinal herniorrhaphy with laparoscopic inspection of the peritoneum in children. Caudal block versus ilioinguinal/iliohypogastric block. AB - The authors prospectively evaluated the efficacy of caudal epidural block versus local infiltration combined with ilioinguinal/iliohypogastric block for analgesia after inguinal herniorrhaphy with laparoscopic inspection of the peritoneum. During standardized anesthetic care, 24 children were randomized to Group I (caudal epidural block with 1.2 mL/kg of 0.25% bupivacaine) or to Group II (local infiltration with an ilioinguinal/iliohypogastric block). Postoperative pain scores were significantly lower at all four evaluation points in Group I than in Group II. Patients in Group I had a significantly decreased requirement for supplemental intravenous fentanyl. Intra-operative requirements for isoflurane were decreased in Group I. The expired concentration of isoflurane was 0.4 +/- 0.1 (mean +/- SEM) in Group I and 1.5 +/- 0.3 in Group II. Time to extubation was 3.8 +/- 0.5 minutes in Group I and 8.2 +/- 1.1 minutes in Group II. The time from arrival in the postanesthesia care unit until discharge home was 113 +/- 3 minutes in Group I and 152 +/- 11 minutes in Group II. Caudal epidural block was more effective than local infiltration in controlling pain after herniorrhaphy with laparoscopy in children and resulted in earlier discharge home. PMID- 10172395 TI - Challenge: how to improve the nutritional status of Alzheimer's patients. PMID- 10172396 TI - Fostering a drug-free workplace. AB - Drug abuse costs American industry and the public an estimated $100 billion a year. As a result, workplace drug testing programs have become a serious option for many companies. Federal guidelines regarding testing and laboratories are in place. An overview of the current components necessary in designing a corporate drug testing program that complies with these guidelines is presented. Essential features of a corporate workplace drug testing program, that is, the policy, the testing process, and the laboratory contracted to test employees, are detailed from designs suggested in the current literature and in compliance with federal guidelines. Developing a cost-effective corporate program that meets federal guidelines, stands up to court scrutiny, and is universally accepted by employees is the objective of a drug testing program. The challenge can be met by building consensus, spelling out policy, maintaining high testing standards, and above all making rehabilitation of employees who test positive the ultimate goal of a drug free workforce/workplace. PMID- 10172397 TI - Monitoring of low flow anesthesia: the United States perspective. PMID- 10172398 TI - Medicaid eligibility groups and Medicaid expenditures, 1975-1993. PMID- 10172399 TI - Trends in outpatient surgery. PMID- 10172400 TI - Utilizing road drawings as a therapeutic metaphor in art therapy. PMID- 10172401 TI - Are surgeons too creative? PMID- 10172402 TI - Preventing HIV/AIDS in drug-abusing incarcerated women through skills building and social support enhancement: preliminary outcomes. PMID- 10172404 TI - Michigan's substance abuse services: readiness for managed care. PMID- 10172403 TI - The cost of depression in the workplace. AB - Depressive disorders in employees and their dependents pose a major occupational health challenge, with implications for productivity, competitiveness, disability program utilization and medical care costs. The following article shows just how big an impact depression has had on the benefit programs of a major Midwestern employer--generating over half of all mental healthcare diagnoses and claims and even more days of disability and 12-month recidivism than chronic physical complaints such as heart disease, diabetes, high blood pressure and low back pain. PMID- 10172405 TI - Assessing audiences from a cultural perspective: targeting the medical marketplace. PMID- 10172406 TI - New POCT (point-of-care testing) guide establishes testing uniformity. PMID- 10172407 TI - Disability support services for Maori. PMID- 10172408 TI - Congenital and acquired anophthalmia. AB - Anophthalmia is an absence of ocular tissue in the orbit. Important aspects in the diagnosis, evaluation, and treatment of both congenital and acquired anophthalmic patients are reviewed. Congenital and acquired anophthalmia differ in etiology, but many concepts of management can apply to either category. Specific steps in the evaluation and treatment including the proper timing for medical and surgical intervention will be discussed. The major goals for the ophthalmologist are to optimize motility and symmetry of the eyelids and orbit and coordinate efforts with other medical specialties. PMID- 10172409 TI - Ocular toxicology. AB - This review of recent articles on ocular toxicology concentrates on undesirable effects on the eye induced by systemically used xenobiotics. These effects include the corticosteroid-induced glaucoma and cataracts (especially in children), chloroquine-induced heart block and retinopathy, its possible protection by platelet aggregating factor antagonists, oculopathy after intracarotid chemotherapy with nitrosyl-urea or cisplatin, ketoconazole-induced papilledema, cytarabine-induced photophobia, ethambutol HCl-induced visual deficits, psychotherapeutic-agent overdose-induced ocular bobbing, amiodarone induced cataracts, and imipramine HCl-induced angle-closure glaucoma. Also reviewed are the role of hormone levels in diabetic retinopathy, the therapeutic use of clonidine for perioperative intraocular pressure spikes, the increase in ocular blood flow by pentoxifylline, and decrease by nicotine, the potential for the reduction in drop size of mydriatic medications, a theory for sulfonamide induced myopia, and guidelines for animal models of ocular toxicity. No drug achieves ultimate efficacy or ultimate safety. Thus, the decision to employ a given therapy involves a physician's evaluation of its therapeutic index, the ratio between efficacy and toxicity. PMID- 10172410 TI - Ophthalmological aspects of Alzheimer's disease. AB - Patients with Alzheimer's disease may present to the ophthalmologist with visual symptoms that precede or overshadow the features of dementia. This visual variant of Alzheimer's disease has been recognized only recently and typically appears in late middle age as progressive visuospatial and reading dysfunction, with normal visual acuity and fields. Common features include simultanagnosia and the other features of Balint's syndrome, and variable hemispatial neglect and hemianopia. The neuroimaging and neuropathological findings in this Alzheimer's variant are distinct and suggest disruption of occipitoparietal visual projections. The identification of the visually symptomatic patient who is destined to develop other signs of Alzheimer's disease depends on the use of appropriate screening tests, including text reading, figure-ground discrimination, and other bedside tests of visuospatial attention and perception. PMID- 10172411 TI - Silicone oil in vitreoretinal surgery. AB - Silicone oil has been in use as a vitreoretinal surgical adjunct for more than 30 years. The literature from late 1993 through 1994 is dominated by reports from the Silicone Study, which addresses outcome differences after primary versus repeat vitrectomy, combined retinotomy and retinectomy, and silicone oil removal, as well as the problem of postoperative intraocular pressure abnormalities. Contemporary retrospective series reporting on the use of silicone oil for pediatric, cytomegalovirus retinitis-related, and diabetic retinal detachments are also reviewed. PMID- 10172412 TI - Tumors of the cornea and conjunctiva. AB - This article reviews literature regarding corneal and conjunctival tumors and explores some of the causative factors, prognostic factors, and treatment options for melanocytic, neoplastic, and lymphoid tumors. A review of epibulbar choristomas and associated syndromes is also included. Newer treatments including excimer laser phototherapeutic keratectomy and topical mitomycin C for corneal intraepithelial neoplasia, microscopic control of tissue margins with sequential surgery for squamous cell carcinoma and cryotherapy for lymphoma are reviewed and compared with traditional therapy. Conjunctival mucosal-associated lymphoid tissue (MALT) lymphoma is probably more common than previously realized. Recent findings of MALT lymphoma and the origin of conjunctival MALT is discussed. PMID- 10172413 TI - An overview of 711 general surgery liability cases. The anatomy of surgical malpractice claims. PMID- 10172414 TI - Managed care in a niche population. Networking health services for children with special needs. PMID- 10172415 TI - Easter Seals transforms the telethon. PMID- 10172416 TI - Establishing benchmarks for ambulatory surgery costs. AB - The acceleration of managed care activity has made benchmark data on performance especially important. To date, benchmark data on financial and clinical performance in ambulatory surgery have been lacking in both hospital-based and independent, freestanding ambulatory surgery centers. This article discusses tools, empirical data, and strategies to assist financial (and clinical) managers in healthcare organizations critically examine the efficiency of their ambulatory surgery services. PMID- 10172417 TI - RWJ (Robert Wood Johnson) study: sick patients in managed care have more difficulty. PMID- 10172418 TI - Quality of Life Award. Havenwood-Heritage Heights. PMID- 10172419 TI - Complications of laparoscopy and thoracoscopy. AB - Laparoscopy was first performed at the turn of the century, but it was not until the introduction of laparoscopic cholecystectomy that the procedure became widely adopted by general surgeons. Since then, traditional open procedures, including cholecystectomy, exploratory laparotomy, colectomy, hernia repair, and appendectomy, are being widely performed laparoscopically. The advantages of laparoscopic surgery, including less postoperative pain due to smaller surgical incisions, shorter hospital stay, quicker return to preoperative activity, and superior cosmesis, resulted in widespread popularity with both surgeons and patients. In certain situations, the traditional method may be superior to the laparoscopic approach, as may be the case with laparoscopic hernia repair. It is difficult to justify converting a local, extraperitoneal, 45-minute, outpatient inguinal hernia repair in a virgin groin into a general anesthetic, transperitoneal, 2-hour plus, possibly inpatient laparoscopic procedure with the implantation of mesh. However, data may indicate that this operation does indeed have benefits. We must, therefore, carefully study such new operations. With the advent of a new surgical procedure, both surgeons and anesthesiologists must be familiar with the various complications unique to this technique. If recognized early, potentially life-threatening complications, including gas embolization and tension pneumothorax, can be corrected. PMID- 10172420 TI - Medical therapy of acute myocardial infarction: Part I. Role of thrombolytic and antithrombotic therapy. AB - Thrombolytic therapy has been established as a safe and effective therapeutic strategy in acute myocardial infarction (MI). Its efficacy is improved with early administration, although modest benefits can be demonstrated for up to 12 hours. Tissue plasminogen activator (TPA) appears to offer benefits over streptokinase when administered to patients who present within 4 hours, those with an anterior MI, and who are less than 75 years old. Age alone is not a contraindication for thrombolysis because the risk of bleeding complications in the elderly is outweighed by a significant improvement in mortality. One of the major limitations of thrombolytic therapy in acute MI is reocclusion. Use of adjunctive antithrombotic therapy can reduce the rate of reocclusion following successful thrombolysis. The beneficial role of aspirin is well established. Use of intravenous heparin in conjunction with streptokinase offers no clinical benefit. The efficacy of heparin when administered with other thrombolytic agents remains to be established. These issues and the role of newer antiplatelet and antithrombin agents are being examined in ongoing clinical trials. The objective of this review is to provide the information needed for careful and appropriate judgment in the use of thrombolytic agents and antithrombotic therapy. General principles are emphasized, and specific recommendations are included as guidelines. PMID- 10172422 TI - Application of statistical inference techniques in health information management. AB - We have demonstrated that objective comparisons can be made using accepted statistical techniques. We have also shown that you can apply tests which don't meet the basic assumptions and still obtain valid results, in most cases. This robustness of statistics tests is particularly helpful with the type of data and analysis that health information management professionals typically deal with, where exactness of the results is not crucial. You can perform a quick analysis using simple statistical tools and obtain a P value that is fairly close to what it would be if you selected the tests more stringently. The examples of inferential statistics in this article demonstrate how to select tests based on characteristics of the data and how to interpret the results. The kinds of statistical analysis that can be performed in health information management are numerous. Below are some other ideas on how to use inferential statistics in HIM practice. 1. Set up an ordinal scale to evaluate coding accuracy to evaluate coders: Score 1 means the correct code was assigned for the principal diagnosis and only minor errors in coding among secondary diagnoses. Score 2 means the correct code was assigned for the principal diagnosis, but there are omissions or major errors among secondary diagnoses. Score 3 means a minor error in coding the principal diagnosis and only minor errors in secondary diagnoses. Score 4 means a minor error in coding the principal diagnosis and major errors or omissions in secondary diagnoses.(ABSTRACT TRUNCATED AT 250 WORDS) PMID- 10172421 TI - Calcium administration for cardiovascular support in critically ill patients: when is it indicated? AB - Calcium has a fundamental role in the maintenance of myocardial function and vascular tone. The ionized form of calcium is the most important physiologically, and this form needs to be measured to assess physiologically active calcium levels. Ionized hypocalcemia can occur as a result of various pathophysiological disturbances, and it is seen frequently in critically ill patients. Several investigators have observed a poorer prognosis in those patients with ionized hypocalcemia. It is unclear whether calcium supplementation is beneficial in these patients. It may improve cardiovascular performance, but, in contrast, it may contribute to cellular damage (especially during hypoxia following cardiopulmonary resuscitation). In sepsis, there may be an increased cellular influx of calcium, which may be deleterious to cellular function; indeed, calcium entry blockers in this situation may be protective. We review the role of calcium as an inotropic agent, its interaction with other inotropic agents, and its use during blood transfusion and during cardiopulmonary resuscitation. PMID- 10172423 TI - Stereotactic breast biopsy revisited. PMID- 10172424 TI - Spotting patients who want illicit drugs. PMID- 10172425 TI - Alternative medicine comes to the OR. PMID- 10172426 TI - Regional variation in the rate of common surgical and orthopaedic procedures among Medicare beneficiaries. PMID- 10172427 TI - Statement on issues to be considered before new surgical technology is applied to the care of patients. Committee on Emerging Surgical Technology and Education, American College of Surgeons. PMID- 10172428 TI - Medicare program; update of ambulatory surgical center (ASC) payment rates effective for services on or after October 1, 1995-HCFA. Notice. AB - This notice implements section 1833(i)(2)(C) of the Social Security Act, which mandates an automatic inflation adjustment to Medicare payment amounts for ambulatory surgical center (ASC) facility services during the years when the payment amounts are not updated based on a survey of the actual audited costs incurred by ASCs. PMID- 10172430 TI - Endoscopic cardiac bypass could reshape surgery. PMID- 10172429 TI - APGs for outpatient surgery are controversial. PMID- 10172431 TI - Home is where the heart is for elders with cognitive impairment. Interview by Aileen Leo. PMID- 10172432 TI - Case costing's contribution to utilization review activities: a review of a laparoscopic cholecystectomy patient population. AB - The Ottawa General Hospital is one of 13 Ontario hospitals participating in the Ontario Case Cost Project. The hospital has been collecting clinical and financial information based on the patient-specific use of products and services since April 1, 1993. The resulting decision-support database that is evolving enhances the traditional utilization review process. The author presents the analysis and conclusions regarding laparoscopic cholecystectomy patients as an example of the hospital's use of the data in utilization review activities. PMID- 10172433 TI - The dirt on bath design. PMID- 10172434 TI - Medical patents: how far can they go? PMID- 10172435 TI - Beyond the ADA. Rancho Los Amigos Medical Center, Downey, CA. PMID- 10172437 TI - HIV and AIDS--employers grapple with difficult issues. AB - HIV infection and AIDS pose special challenges to employers. Myriad laws affect how the employer must respond when an applicant or employee is infected with HIV or is ill due to AIDS. An overall compliance strategy should include thorough knowledge of those laws and a policy on HIV and AIDS, put in place before a crisis occurs. PMID- 10172436 TI - Disabling job injuries among urban EMS providers. AB - OBJECTIVE: Nationwide data were collected concerning serious, disabling injuries requiring hospitalization (SDIH) or deaths among urban emergency medical services (EMS) providers. DESIGN AND SETTING: A mail survey of EMS systems was conducted among the 200 most populated U.S. cities. PARTICIPANTS: Participants were training and operations officers of urban EMS systems. MEASUREMENTS AND MAIN RESULTS: Ninety forms (45%) were returned with 88 evaluable (44%). There were 81 SDIHs for a rate of one in 31,616 dispatches. No deaths were reported. Body parts most frequently injured were the hand (22%), head (19%), foot (16%), and eye (14%). Although 90% of fire-based EMS systems (fire-EMS) provided helmets, eye protection, safety shoes, and gloves, less than half (45%) of nonfire-EMS did so. Three (4%) SDIHs resulted from acts of violence. CONCLUSION: Occupational injuries of EMS personnel are at a serious level. Fire-based EMS systems experienced a higher rate of hand SDIHs despite the provision of protective equipment. Few nonfire-EMS staff are provided with safety equipment, which may have resulted in a relatively high number of head and hand SDIHs. Fire-EMS medical directors need to take an active role in verifying that protective equipment is adequate and appropriate to allow the performance of field EMS duties without being too cumbersome. Medical directors of nonfire-EMS must be advocates for the provision of basic protective equipment aimed at mitigating SDIHs of EMS staff. PMID- 10172438 TI - The future of disability management is ... integration. AB - The synergy that results from the integration of disability and health care innovations can significantly improve both productivity and profitability, recent experience shows. Such integration also links employees and employers in a way that achieves continuous improvement of work life, further enhancing individual and corporate performance. PMID- 10172439 TI - Incorporating drugs and devices into emergency medical services systems. AB - The proliferation of new medical technology and pharmacology forces the medical community to ensure the efficacy and safety of new drugs and devices before their use in patient care. Although traditional medical practices have a fairly consistent means to achieve this end, prehospital medical practice often does not. In addition, it often appears that the emergency medical services marketplace does not always follow conventional supply/demand and cost/quality paradigms. This article describes a process implemented in Pennsylvania to standardize the mechanism by which new drugs and devices are introduced into prehospital medical practice. PMID- 10172440 TI - Interventional cardiology: an Indian perspective. PMID- 10172441 TI - Interventional cardiology in Australia. PMID- 10172442 TI - ADA plaintiffs get their day in court. PMID- 10172443 TI - Risk analysis: a standard approach? (Part I). AB - The European Medical Device Directive (MDD) requires risk analysis to be conducted for all classes of devices. Many companies lack experience in conducting formal risk-analysis studies. To assist companies in complying with the Directive, a European standard on risk analysis is being developed. Part I of this two-part article will discuss the MDD requirements for risk analysis, the approach taken by the draft standard, and some alternative methods that some companies are using to generate risk-analysis data and information. Part II will discuss the contents of the draft standard in more detail. PMID- 10172444 TI - The use of silicone as a biomaterial. AB - The availability of silicone biomaterials has severely declined. This has been caused by the departure of many suppliers because of product liability concerns and the increase in litigation, particularly in the United States. This article discusses the current and future problems facing the health care industry. PMID- 10172445 TI - EMS providers do not accurately note motor-vehicle crash patients with positive serum alcohol concentrations. AB - INTRODUCTION: Alcohol use is associated with many motor-vehicle crashes and may increase the severity of injury. Because alcohol use also may mask injury, prehospital emergency care providers (PHECPs) may make inaccurate assessments. To assess and triage crash victims accurately, PHECPs must identify recent alcohol use. STUDY OBJECTIVE: This study examines the accuracy of PHECPs in identifying motor-vehicle crash victims who had positive serum alcohol concentrations. DESIGN: Retrospective cohort study. POPULATION: Included in the study were motor vehicle crash victims more than 17 years of age who were conveyed directly to a university medical center emergency department by ground ambulance (n = 372). TIME PERIOD: 15 July 1990 to 15 July 1991. METHODS: Data sources included ambulance report forms and hospital records. Variables that were abstracted included the Revised Trauma Score (RTS), the PHECPs' impression of alcohol use, and serum alcohol concentrations. Sensitivity, specificity, predictive-value positive, predictive-value negative, and 0.95 confidence intervals (0.95 CI) were calculated for the PHECPs' ability to identify patients with a serum alcohol concentration > 0. The relationship between the RTS and the impressions of alcohol use was analyzed with chi-square testing: a p-value of < 0.05 was considered statistically significant. CONCLUSION: This study suggests that PHECPs cannot accurately identify crash victims with positive serum alcohol concentrations. Selection bias and retrospective design are significant limitations of this study. Future studies should develop and evaluate methods to improve PHECPs' accuracy in assessing alcohol use in motor-vehicle crash victims. PMID- 10172446 TI - Directional coronary atherectomy for the diagnosis and treatment of radiation induced coronary artery stenosis. AB - While radiation therapy has been known to cause myocardial and pericardial damage, its role in accentuating coronary artery disease in the absence of traditional cardiovascular risk factors has been controversial. As younger patients with treatable cancers are being treated with mediastinal radiation, coronary artery disease as a cause for severe chest pain should be entertained as a possible diagnosis. We describe a 25-year-old male who presented with an inferior wall myocardial infarction 6 years after receiving mediastinal radiation and chemotherapy for Hodgkin's disease. He was subsequently treated by directional atherectomy to a 95% lesion in the right coronary artery. Histological examination of the atherectomy specimen revealed evidence of radiation-induced endothelial damage that had resulted in plaque formation and subsequent ischemia. Possible mechanisms for radiation-induced coronary artery disease and treatment options are discussed. PMID- 10172447 TI - A profile of therapeutic opioid dependent persons in Queensland. AB - This paper describes the philosophy and practice of the Drugs of Dependence Unit, Queensland Health, with regard to the collection and evaluation of dangerous drug prescription data. Using patient information extracted from the Monitoring of Dangerous Drugs Computer System and patient files at the unit, the paper presents a profile of 335 therapeutic opioid dependent persons who constituted the entire therapeutic caseload of the unit as at June 1992. The data include medical history, drug details, initial and final diagnosis, an escalation factor, and prognosis. Profile findings detail the prescribing patterns of medical practitioners and highlight the importance of continuous monitoring and review in the care and management of therapeutic opioid dependent persons. PMID- 10172448 TI - Using shape-memory alloys. AB - Design considerations and material selection play important roles in the development of surgical instruments for minimally-invasive procedures. Substituting shape-memory or superelastic metals or alloys for conventional materials can lead to a significant improvement in the overall performance of those instruments. In addition, simplicity of design, a reduced number of parts, and ease of assembly and disassembly result in cost reductions. PMID- 10172449 TI - Special report. Some new approaches to hospital parking security. AB - A hospital's parking facilities--garages and parking lots--can be a major source of revenue, but parking areas also account for a substantial percentage of hospital crime incidents. In the most recent IAHSS hospital crime survey (1993), some 15% of sexual assaults, 31% of robberies, 39% of burglaries, and 54% of vandalism were reported to have occurred in parking lots or structures. Some 87% of reported auto thefts also occurred in parking facilities (with most of the rest taking place on public streets or elswhere on hospital grounds). The IAHSS survey also reported that employees were the victims of the above crimes in hospital parking facilities between 40% and 60% of the time, underscoring the need for securing employee parking areas. In this report, we'll bring you up-to date on two new access control systems that are being used to secure employee and patient parking areas. We'll give you details on a patrolling technique for large parking areas that is growing in popularity. And we'll tell you how a leading rehabilitation hospital has designed its parking garage to meet the needs of its handicapped patients and their vehicles. PMID- 10172450 TI - Program characteristics and readmission among older substance abuse patients: comparisons with middle-aged and younger patients. AB - Older substance abuse patients were compared to middle-aged and younger patients before, during, and after an index episode of inpatient care in 1 of 88 substance abuse treatment programs. Associations between program characteristics and readmission rates adjusted for key differences in the types of patients in different programs varied by age group. Among older patients, more structured program policies, more flexible rules about discharge, more comprehensive assessment, and more outpatient mental health aftercare were associated with lower casemix-adjusted readmission rates. More intensive treatment was associated with higher-than-predicted readmission. By contrast, among younger patients, more family involvement in assessment and treatment, community consultation, and treatment emphasizing the development of social and work skills were associated with lower casemix-adjusted readmission rates. The findings suggest that intensive, directed treatment may be more effective for younger substance abuse patients, whereas a more supportive treatment regimen in a well-organized program and prompt outpatient aftercare may be especially helpful for older patients. PMID- 10172451 TI - Service needs, receipt, and outcomes for types of clients with serious and persistent mental illness. AB - Classifying clients with serious and persistent mental illness (SPMI) into groups with differential demographic and clinical characteristics that relate directly to the need and receipt of services and changes in functioning provides a strong foundation on which to build program- or system-level planning, development, and evaluation efforts. In this study, clinician-generated problem data and cluster analytic techniques were used to develop a four-group typology for a sample of 293 clients with SPMI. Each of the types--extremely disabled, young adult, personally distressed, and adapted--was profiled demographically and clinically in terms of human service needs, prognosis, and treatment outcomes. Each of the four types evidenced a unique pattern of needs and outcomes that was consistent with its clinical profiles. The typology, associated service needs, and outcomes provide valuable information for use in service planning and program development for clients with SPMI. PMID- 10172452 TI - Emotional disturbance and substance abuse in youth placed in residential group homes. AB - Residential group homes are increasingly important components of the system of mental health care for children and adolescents. However, they often do not have sufficient resources to provide active therapeutic programs as a result of their usual missions in serving abandoned or runaway youth. The authors studied 299 youth, ages 12 to 17 years, in five large residential group home programs in South Carolina. The instruments administered were (1) the Center for Epidemiological Survey-Depression Scale (CES-D), (2) a brief substance abuse questionnaire, and (3) questions about socioeconomic status, previous placements, and family relationship variables. A significant percentage scored above conservative clinical cut-off scores for the CES-D (51.7% scored 16 or above and 33.6% scored 23 or above). The youth also had significant levels of substance abuse problems. However, these variables were not predictive of previous multiple out-of-home placements (runaway behavior was predictive). These findings support the importance of addressing the clinical needs of youth in these programs. PMID- 10172453 TI - Flash: OR sheds light on a sterilization dilemma. PMID- 10172454 TI - Determinants of patient satisfaction with outpatient surgery. AB - To help understand the determinants of patient satisfaction following outpatient surgery, the authors developed a written survey instrument and administered it to more than 200 patients. The significant predictors of overall satisfaction were the courtesy of the staff and clinical quality. Overall satisfaction was also found to be a significant predictor of intent to recommend. PMID- 10172455 TI - Application of health-related quality of life to hospital pharmacy practice. PMID- 10172456 TI - Children find hope and help. PMID- 10172457 TI - Screening restricted by Disabilities Act. PMID- 10172458 TI - Stimulating activities enhance lives. Creative activities bring about small successes that lead to big rewards for residents with Alzheimer's disease. PMID- 10172459 TI - Tacrine for Alzheimer's disease. Costs and benefits. PMID- 10172460 TI - The cost effectiveness of amoxicillin/clavulanic acid as antibacterial prophylaxis in abdominal and gynaecological surgery. AB - The objective of this study was to compare the cost effectiveness of amoxicillin/clavulanic acid with other antibacterial regimens for prophylaxis of infection after elective abdominal or gynaecological surgery. Data from 21 previously published comparative clinical trials were used to calculate statistical confidence intervals for differences in postoperative wound infection rate. A simple model was used to produce a tabular sensitivity analysis of cost effectiveness over a wide range of costs of wound infection and potential differences in efficacy. For more expensive comparator regimens, including combination regimens utilising gentamicin and metronidazole, amoxicillin/clavulanic acid was either likely to be more cost effective or equally cost effective. For example, in trials of colonic surgery the comparators were on average 11.39 pounds more expensive than amoxicillin/clavulanic acid, which was > 95% likely to be more cost effective unless the cost of wound infection was estimated to be > 1519 pounds. Amoxicillin/clavulanic acid was more expensive than only 2 of the 21 comparators. Furthermore, in one of these 2 trials it was also significantly more effective than the comparator. In this trial, amoxicillin/clavulanic acid was > 95% likely to be more cost effective as prophylaxis in hysterectomy than rectal metronidazole, provided that the cost of wound infection was estimated to be > 179 pounds. In conclusion, this analysis shows that amoxicillin/clavulanic acid, given as monotherapy, is likely to be equally or more cost effective than a wide range of comparator regimens for prophylaxis of elective abdominal or gynaecological surgery. PMID- 10172462 TI - Neopterin: biochemistry and clinical usefulness. AB - Neopterin is a marker for activation of the immune system. Serum or urine neopterin can increase in infection, transplant rejection, or in other disturbances of the immune system. Measurement of neopterin concentrations in body fluids offers a way to monitor the patient's immune system in some disorders. However, the nonspecificity of this biochemical marker for particular diseases raises problems in the interpretation of the results. This paper discusses the effects of disease and other factors on the levels of neopterin in biological fluids. PMID- 10172461 TI - Budesonide. An appraisal of the basis of its pharmacoeconomic and quality-of-life benefits in asthma. AB - Budesonide is an inhaled corticosteroid that is used prophylactically to reduce the underlying inflammation and consequent airways narrowing associated with asthma. Widespread clinical experience has shown that inhaled budesonide is effective and well tolerated, and its use is well established in the management of adult and childhood asthma. In developed countries, asthma is a major health problem and consumes a large proportion of healthcare resources. Both the prevalence and severity of asthma appear to be increasing. Additionally, asthma related mortality has been reported to have gradually increased since the mid- to late-1970s in many countries, possibly due to undertreatment and/or suboptimal management of the disease. Current guidelines recommend a shift away from initial treatment with oral bronchodilators, such as theophylline, or regular use of beta 2-agonist inhalers, toward the earlier use of more expensive inhalers containing corticosteroids. Inhaled bronchodilators are still used as indicated for treatment of acute attacks. Data suggest that the acquisition cost of budesonide is more than offset by decreased morbidity and reductions in costs associated with acute asthma exacerbations. Both once-daily administration and its administration in dry powder form via Turbuhaler appear to be well accepted by patients; these factors may potentially improve patient compliance with therapy. Budesonide appears to have positive effects on some quality-of-life indices, although studies using validated quality-of-life instruments are needed to confirm these conclusions. Modelling studies would be helpful in order to assess the possible economic benefits to society through reduction of the considerable direct and indirect costs of asthma and cost-effectiveness comparisons with other inhaled corticosteroids are needed to clarify its relative positioning in this regard. Until then, the available data provide an encouraging pharmacoeconomic rationale for budesonide as first-line asthma therapy, and a good basis for future pharmacoeconomic analysis of asthma management. PMID- 10172463 TI - Management of giant retinal tears. PMID- 10172464 TI - Management of the exposed scleral explant. PMID- 10172465 TI - Intraoperative hemodilution and autologous platelet rich plasma collection: two techniques for collecting fresh autologous blood. AB - Intraoperative hemodilution (IH) and autologous platelet rich plasma (APRP) collection are two techniques used to obtain autologous blood in the operating room. They have been used to reduce allogeneic blood exposure in patients undergoing both cardiac and non-cardiac surgery. Both components have the advantage of providing fresh blood not subject to the storage lesion. Whole blood (IH) or platelet rich plasma is removed from the patient as anesthesia is induced and replaced with acellular fluid. The blood is transfused back after bypass or major bleeding has ceased. Although used commonly, the data supporting the use of either technique are controversial. Methodologic problems which have confounded studies evaluating their utility include: poorly defined transfusion criteria, concommitant use of other blood conservation techniques (i.e. cell salvage, pharmacologic agents, hypothermia, controlled hypotension) and changing transfusion practices with greater tolerance of normovolemic anemia. Randomized controlled studies with well defined up to date transfusion criteria are needed to identify patients likely to benefit from these techniques. PMID- 10172466 TI - Warming devices pay off for surgical patients--and the budget. PMID- 10172467 TI - Rough waters. Attention to residents' individual needs. PMID- 10172468 TI - Employee assistance plans in Canada. AB - In Canada as in the United States, employee assistance plans have evolved from their early concentration on employees' alcohol-related problems to a much more comprehensive concern with employees' total well-being. Studies have documented the effectiveness of this approach. PMID- 10172469 TI - Healing process of vascular cutting edge using an Nd:YAG laser bipolar dissector. AB - The wound healing process was histopathologically investigated in a rabbit femoral artery (n = 48) after transection using a laser bipolar dissector (LBD, 1064nm the Nd:YAG bipolar contact laser) with laser power of 13W in 0.5-sec pulses. The cutting edges were harvested immediately (n = 6) and at 1 (n = 6), 4 (n = 6), and 7 (n = 6) days, 2 (n = 6), 3 (n = 6), and 4 (n = 6) weeks, and 6 months (n = 6), and evaluated by light microscopy. During the postoperative period, no perforation was seen in the 48 transected sites with the LBD. The healing process after LBD transection was accomplished within 2 weeks by organization of the intraluminal thrombus and by the formation of granulation tissue outside the adventitia of vessels. Characteristic morphological changes after LBD transection were recognized in the tapering area, i.e., cartilage and bone formation. Cartilaginous foci (n = 6) were observed in the media at 4 weeks after transection, and osseous foci (n = 3) in subendothelial space at 6 months. These observations may suggest that the heterotopic cartilaginous and osseous metaplasia of a vessel wall may be a result of the biostimulative effects of the Nd:YAG laser. PMID- 10172470 TI - Current pharmacoeconomic issues in Japanese healthcare. PMID- 10172471 TI - A comparative analysis of the pharmaceutical market in four European countries. PMID- 10172472 TI - AmeriHealth brings anti-drug message to New Jersey schools. AB - He's robotic, he's interactive, he's entertaining. And he's got a message. He's The Caring Coach, currently assisting AmeriHealth in New Jersey communicate antisubstance abuse messages to elementary school kids. PMID- 10172473 TI - Medicare beneficiaries rate their medical care: new data from the MCBS (Medicare Current Beneficiary Survey). AB - The Medicare Current Beneficiary Survey (MCBS) contains a wealth of information about the people whose care is financed by the program. This article examines their satisfaction with medical care received and explores the relationship of these attitudes with the characteristics of subgroups of the enrolled population. Satisfaction with medical care among Medicare beneficiaries is found to be generally high (80-90 percent). Disabled Medicare beneficiaries are less satisfied than the aged, and health maintenance organization (HMO) enrollees less satisfied than fee-for-service (FFS) patients. Others with lower-than-average satisfaction are people with poorer health status, those covered by Medicaid, and those without supplementary insurance. PMID- 10172474 TI - Legal issues relevant to clinical laboratory education program admissions. AB - OBJECTIVE: To address the basic legal requirements for admissions, admissions standards, student and applicant records, and discrimination in admissions for clinical laboratory science (CLS) and clinical laboratory technician (CLT) educational programs. DATA SOURCES: Recent academic literature and legal precedents. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: CLS and CLT educational programs typically practice selective admissions. Program directors and faculty need to be aware of the issues relating to student selection that may have legal implications. Admissions practices should be guided by three basic legal requirements: that the selection process not be arbitrary or capricious, that the program adhere to its published admissions standards and honor admissions decisions, and that the program not have admissions policies that discriminate on the basis of race, gender, age, disability, or citizenship. Specific guidelines are offered for applying these legal requirements to the admissions practices typically used by CLS and CLT programs, including published admission policies and standards, application forms, interviews, rating of noncognitive attributes, and communication with applicants. CONCLUSION: Admissions practices in CLS and CLT programs need to be guided by the three basic legal requirements. PMID- 10172475 TI - Clinical comparison of patient-side fibrinogen assay and common laboratory analyzer in pediatric cardiopulmonary bypass. AB - The coagulation status of infant and pediatric patients can be severely compromised during the course of cardiopulmonary bypass due primarily to hemodilution and hypothermia. Fibrinogen level is one source of information necessary to assess the coagulation status of a patient. An accurate and expedient method to determine the fibrinogen level would allow for earlier initiation of coagulation therapy to prevent excessive postoperative bleeding. The purpose of this study was to compare two methods of determining fibrinogen level: a patient-side assay and a common laboratory analyzer. The patient-side test utilized the HemoChron Fibrinogen Assay and was performed in the operating room. The MLA 1000C was the laboratory method utilized in the hospital's coagulation laboratory. Simultaneous testing was conducted prebypass and intraoperatively on 26 infant and pediatric patients undergoing cardiopulmonary bypass for palliation and correction of congenital heart defects. The resulting values were compared using paired t-test, regression and correlation analysis, and descriptive analysis. The values obtained by the two methods were significantly different (p < .05) at each collection time. Further analysis revealed that other variables, such as hematocrit and platelet count, affected the differences between the results of the methods. The HemoChron Fibrinogen Assay may not be a viable tool for the assessment of fibrinogen level on infant and pediatric patients undergoing cardiopulmonary bypass surgery. Further studies should be done in this patient population incorporating other confounding variables. PMID- 10172476 TI - Accuracy of in-line venous saturation and hematocrit monitors in pediatric perfusion. AB - Cardiopulmonary bypass (CPB) in neonates and infants routinely employs lower blood flow rates (BFR), temperatures, and hematocrits (Hct) than those typically observed in adult CPB. The purpose of this study was to evaluate the accuracy of three devices available for continuous in-line measurement of venous oxygen saturation (SvO2) and Hct during pediatric CPB. Venous blood samples were obtained over a range of BFR, temperatures, and Hct and analyzed on a Corning 2500 Co-Oximeter and HematoStat C-70 centrifuge. These values were then compared to those measured by the Bentley OxySat SM-0200, the Gish StatSat, and the 3M CDI 100 in-line monitors. Seventy samples were obtained and analyzed using linear regression, paired t-test and residual analysis to establish the reliability and accuracy of each device. The results demonstrate the CDI to be more statistically accurate (p > 0.05) than the Gish and Bentley devices for measuring SvO2 in nearly all circumstances, though all correlated well with the control (r > 0.70). When comparing spun Hct to the CDI and Gish values, the CDI in-line monitor demonstrated a greater reliability to predict actual patient Hct (r > 0.90) than the Gish StatSat (r > 0.60). Residual analysis revealed that even though the Gish StatSat had higher calculated p values (p > 0.05) than the CDI 100 for interpreting Hct, it was shown to display more inconsistent and sporadic values over the ranges of BFR and temperature studied. It is concluded that the CDI 100 proved to be more accurate, reliable, and consistent than the Gish StatSat and the Bentley Oxysat devices in determining SvO2 and Hct over all evaluated parameters in this study. PMID- 10172478 TI - Never again. History seems to be losing its credibility with the public. PMID- 10172477 TI - How should an unconscious person with a suspected neck injury be positioned? AB - INTRODUCTION: Awareness of the risk of spinal-cord damage in moving an unconscious person with a suspected neck injury into the "lateral recovery position," coupled with the even greater risk of inadequate airway management if the person is not moved, has resulted in a suggested modification to the lateral recovery position for use in this circumstance. HYPOTHESIS: It is proposed that the modification to the lateral recovery position reduces movement of the neck. In this modification, one of the patient's arms is raised above the head (in full abduction) to support the head and neck. The position is called the "HAINES modified recovery position." HAINES is an acronym for High Arm IN Endangered Spine. METHODS: Neck movements in two healthy volunteers were measured by the use of video-image analysis and radiographic studies when the volunteers were rolled from the supine position to both the lateral recovery position and the HAINES modified recovery position. RESULTS: For both subjects, the total degree of lateral flexion of the cervical spine in the HAINES modified recovery position was less than half of that measured during use of the lateral recovery position (while an open airway was maintained in each). CONCLUSION: An unconscious person with a suspected neck injury should be positioned in the HAINES modified recovery position. There is less neck movement (and less degree of lateral angulation) than when the lateral recovery position is used, and, therefore, HAINES use carries less risk of spinal-cord damage. PMID- 10172479 TI - Medicare program; Part A premium for 1996 for the uninsured aged and for certain disabled individuals who have exhausted other entitlement--HCFA. Notice. AB - This notice announces the hospital insurance premium for calendar year 1996 under Medicare's hospital insurance program (Part A) for the uninsured aged and for certain disabled individuals who have exhausted other entitlement. The monthly Medicare Part A premium for the 12 months beginning January 1, 1996 for these individuals is $289. The reduced premium for certain other individuals as described in this notice is $188. Section 1818(d) of the Social Security Act specifies the method to be used to determine these amounts. PMID- 10172480 TI - Major technology issues in surgical data collection. AB - Surgical scheduling and data collection is a field that has a long history as well as a bright future. Historically, surgical cases have always involved some amount of data collection. Surgical cases are scheduled and then reviewed. The classic method, that large black surgical log, actually still exists in many hospitals. In fact, there is nothing new about the recording or reporting of surgical cases. If we only needed to record the information and produce a variety of reports on the data, then modern electronic technology would function as a glorified fast index card box--or, in computer database terms, a simple flat file database. But, this is not the future of technology in surgical case management. This article makes the general case for integrating surgical data systems. Instead of reviewing specific software, it essentially addresses the issues of strategic planning related to this important aspect of medical information systems. PMID- 10172481 TI - Public policy trends in drug pricing and reimbursement in the European Community. AB - In the European Community, the key issue of cost containment in healthcare (including pharmaceuticals) is dominated by three main background influences: The principle of 'solidarity' (society's responsibility for those who cannot afford to pay the full cost of healthcare); 'subsidiarity' (doing nationally what is best done nationally rather than at the Community level); and the 'pharmapolitics' of balancing the drug budget with the demands of patients in their capacity as voters. Pharmaceutical expenditure generally exceeded the rate of inflation during the 1980s despite legislation to contain costs. In the 1990s, more intensive efforts are being applied to oblige doctors to prescribe rationally and economically whilst putting even greater pressure on the pharmaceutical industry. Again with an eye on electoral repercussions, only limited attempts to make patients pay a higher proportion of total costs have so far been made. PMID- 10172482 TI - Pricing and reimbursement of pharmaceuticals in Sweden. AB - Significant changes in the Swedish reimbursement system for drugs were introduced on January 1, 1993. A reference price system was introduced and price control became the responsibility of the National Social Insurance Board (NSIB). If a drug is to be reimbursed when prescribed, the price must be approved by the NSIB. The prices for drugs included in the reference price system do not have to be approved by the NSIB, as the reimbursement level is fixed at 10% above the price of the cheapest generic. Several pricing strategies were developed by pharmaceutical companies after these changes. For original products within the reference price system, the price, with few exceptions, was dropped to the reimbursement price. Total sales for compounds with reference prices decreased in value and the market share for generic products increased. Some products and package sizes, mainly with regard to hospital drugs, were withdrawn from reimbursement and the prices increased. The total sales of drugs for human use increased by about 6.5% during the first 6 months of 1993 when compared with the same period the previous year. There was a slight decrease (1.6%) in total expenditure for the reimbursement scheme (NSIB), but an increase of 14% for patient copayments during the first 3 months compared with the same period the year before. Cost containment has become a major priority for all publically financed programmes. However, the changes in the Swedish drug reimbursement system have not produced significant savings in public expenditure and further changes may be expected. PMID- 10172483 TI - Balancing costs, efficacy, and side effects. AB - Drug approval processes in most developed countries generally do not provide the comparative information necessary for clinicians, patients or policymakers to make informed choices between similar agents, balancing efficacy and toxicity. These questions have been made exponentially more complex with the addition of cost as a third dimension to consider in making therapeutic choices. Application of cost-containment pressure in the absence of adequate data provides a poor foundation for optimal decision making. A systematic, disciplined process is needed for the comparison of similar drugs along each of the three dimensions of efficacy, safety, and cost. Such an inquiry will require use of several methodologies, from conventional randomised controlled trials, to pharmacoepidemiological studies and cost-effectiveness analyses. Such information need not form the basis for drug registration, but instead would be made available to practitioners, patients, and payers to inform their therapeutic choices. The cost of such an ambitious research endeavour would be more than offset by the opportunity for enormously greater efficiencies in the rational use of cost-effective drug therapy. PMID- 10172485 TI - Economic evaluation of drugs and its potential uses in policy making. AB - Interest in the economic evaluation of drug treatments is steadily increasing, but the impact of such evaluations on decisions concerning the use of drugs is unclear. In this article I examine different decision and policy situations where economic evaluations of drug treatments could potentially be used. Economic evaluations may be used as an aid to the development of treatment guidelines, decisions within healthcare organisations, and decisions relating to approval, reimbursement and pricing. Economic evaluations appear to be most useful in the development of treatment guidelines and as an aid to reimbursement decisions. The incentive to use economic evaluations embodied in the healthcare system is also important. It is argued that it is too early to introduce regulations that require the use economic evaluations in, for example, reimbursement decisions. A more cautious approach might be preferred, where economic evaluations are used more selectively until the methodology and the field have developed further. PMID- 10172484 TI - Economic analysis of lenograstim in the correction of neutropenia following chemotherapy for non-Hodgkin's lymphoma. AB - A prospective economic analysis of lenograstim and placebo was performed as part of a randomised double-blind trial in 162 patients receiving chemotherapy for non Hodgkin's lymphoma (NHL). The primary clinical end-point was the percentage of patients experiencing > or = 1 documented infection in each treatment group. The cost of hospitalisation and the cost of medical services used were the primary economic end-points. Economic analysis was based on the French Hospital perspective. Over the 56-day study period, patients in the placebo group received more days of inpatient intravenous (8.9 vs 5.3 days; p < 0.01) and oral (5.3 vs 4.2 days) antibiotic therapy than those in the lenograstim group. This difference was due to a higher rate of documented infection in the placebo group. Patients treated with placebo also spent more days in hospital for reasons other than administration of chemotherapy (18.5 vs 14.4; p < 0.05). The number of days of chemotherapy was significantly greater in the lenograstim group than in the placebo group (19.4 vs 17.5; p < 0.001) because of shorter delays between chemotherapy cycles in the lenograstim group. The use of lenograstim to prevent chemotherapy-induced neutropenia in patients with NHL was associated with a reduction in total direct medical costs (excluding the cost of lenograstim) of FF7297 as a result of reduced patient morbidity. Furthermore, the higher rate of completion of chemotherapy in the lenograstim group may lead to better long term survival; this observation deserves further clinical investigation. PMID- 10172486 TI - The effects of lactic acid on PGE2 production by macrophages and human synovial fibroblasts: a possible explanation for problems associated with the degradation of poly(lactide) implants? AB - The aim of this study was to investigate the effects of lactic acid on cells found at the bone-implant interface in order to try to discover more about the effects of degradation of implants manufactured from poly(lactide). This study shows that human synovial fibroblasts and murine macrophages release prostaglandin E2 (PGE2) a bone resorbing and inflammatory mediator, into the surrounding medium when exposed to lactic acid. The production of PGE2 in response to lactate may help to explain isolated cases of inflammation and discomfort seen some time after fracture fixation with poly(lactide) implants. PMID- 10172487 TI - Bone formation and remodeling around implanted materials under load-bearing conditions. AB - Bone formation and remodeling around implanted materials are influenced by the load-bearing conditions. In this study, three types of material were implanted into dog femoral condyles and bone formation and remodeling were observed for 24 weeks thereafter. Even thickening of lamellar bone was observed around bead coated alumina implants, whereas thick fibrous tissue surrounded by corticalized bone formed around those made of smooth alumina. With an implant made of an artificial osteo-chondral composite material, abundant bone ingrowth into the titanium fibers was observed 8 weeks after the operation and this ingrowth resulted in firm attachment of this composite material to the host bone site. The tibial joint surface against the polyvinyl alcohol (PVA)-hydrogel articular surface of this implant remained intact, which suggests this artificial osteochondral composite material is a very promising joint prosthetic material. PMID- 10172488 TI - Early effects of the self-reinforced PGA implant on a growing bone: an experimental study on growing rats. AB - The purpose of the study was to investigate the immediate/early effects of a bioabsorbable implant on a growing bone and monitor the strength retention. Fifty eight rats were used as experimental animals. In 29 animals a 1.1 mm self reinforced (SR-PGA) polyglycolic acid implant was placed through a transphyseal drill channel up to the diaphysis of the femur. In another 29 rats similar implants were placed in both femora and in the dorsal subcutis. After a follow-up time of 1-28 days a histologic and a roentgenographic analysis of the femora was undertaken and the shear and bending strengths of the removed implants in the other group were measured. The implant was broken at the plane of the growth plate by 21 days. No permanent growth disturbance occurred in the operated femora compared to the control side. The SR-PGA implants lost a substantial part of their mechanical strength in 2 weeks. PMID- 10172489 TI - Beginning, growth, and transition. AB - This is what has happened and is happening. For those offended along the way, I apologize--but try us now. Prehospital and Disaster Medicine no longer is an experiment to see if a Journal of this ilk can be a success. It is. The experiment is over. Prehospital and Disaster Medicine is here to stay. Clearly, it meets many of the needs of a broadly based audience, and could meet needs of those who still are not participating in this exciting and enriching endeavor. I am grateful for the support of each of you, for that of the sponsoring organizations, and to the advertisers and publisher. A new phase has begun. The state of the Journal is dynamic, and it will continue to improve. It only can better meet your needs if you participate with us in its evolution. As always, your input is requested. Our aim is to provide you with the very best, and only with your continued input and support can we continue to build the medical disciplines of prehospital and disaster medicine. PMID- 10172490 TI - Laser vision correction spawns industry. PMID- 10172491 TI - Surgery. Operational tactics. PMID- 10172492 TI - There's no fat left to cut in Medicare or Medicaid. PMID- 10172493 TI - On-site apartment mimics life after discharge. PMID- 10172494 TI - Mechanisms to reduce stress and provide staff support. PMID- 10172495 TI - Remove the barriers that hinder performance. PMID- 10172496 TI - A pooled cross-section analysis of the health care expenditures of the OECD countries. AB - This paper has two purposes. The first, empirical purpose is to estimate and evaluate the effects of aggregate income, institutional and socio-demographic factors on health care expenditures in the OECD countries. The second purpose is methodological, and comprises assessment of temporal instability, the choice of functional form, and misspecification of the estimated relationships. Data compiled over three years (1974, 1980 and 1987) from 19 OECD countries are used in a pooled cross-section regression analysis. Like previous studies, this one concludes that aggregate income measured by Gross Domestic Product per capita is the statistically most important factor in cross-national variation in health care expenditures, and that the aggregate income elasticity exceeds one. However, the data analyzed in this study also show some evidence that public financing of health care services is associated with lower expenditures per capita, and that countries with fee for service as the dominant form of remuneration have higher expenditures. The examined relationships appear to be temporally stable over the three years except for upward shifts, and there is no indication of statistical misspecification. This does not necessarily imply a correct specification, and we do note the presence of measurement errors in some of the variables. Moreover, the selected log-linear functional form appears to be non-optimal according to a likelihood criterion, and is rejected against a quadratic form. Based on the analyses from this study the results do not appear to be sensitive to use of the quadratic form specification. PMID- 10172497 TI - Is there a Sisyphus syndrome in health care? PMID- 10172498 TI - The Health Security Act of 1993 and health care for persons with disabilities. AB - Persons with disabilities are an important and potentially vulnerable subgroup of the American public. This article discusses both the progress and the promise of health care reform in terms of benefits and impact on persons with physical and/or mental impairments. The author investigates the possibilities implied in the Clinton reform proposals for opportunities to include health promotion, prevention, and early intervention strategies, designed specifically for persons with disabilities. The author also examines the extent to which the reform plan may change the traditional, medically oriented approach to disability. PMID- 10172499 TI - The significance of long-term care in health reform. AB - The American Association of Homes and Services for the Aging, long-term care institutions, and housing providers applaud the proposed state entitlement program in the President's plan, because it is consistent with the belief that individuals should have autonomy and should be able to live as independently as possible for as long as possible. The author presents a convincing argument that elderly and disabled people prefer home and community-based care delivered at home or in home-like settings (aging in place) over the far more expensive nursing facility care, which is now perceived as care of the "last resort." PMID- 10172500 TI - Perspectives. Managed care for disabled: big hole in Medicaid plan. PMID- 10172501 TI - Malpractice coverage for health professionals with physical, mental, or substance abuse impairments. How do insurance companies make their decisions? AB - How do insurance companies decide whether or not to provide malpractice insurance to health professionals? What information do they gather on applicants and renewing policyholders? Who has the responsibility to determine if health professionals are suffering from physical, mental, or substance-abuse impairments that make them unfit to care for patients? The authors conducted a survey to find the answers to these questions. PMID- 10172502 TI - Special report. Twin Cities hospital breaks down ambulatory care, overcomes fears of outpatient care. AB - With payers pushing for shorter hospital stays and outpatient services generating growing shares of hospitals' revenues, experts everywhere are projecting the end of the traditional inpatient-oriented hospital. Those predictions have triggered a scramble by many hospital managers to adapt their organizations and empty beds to the expected predominance of same-day services. One Minnesota facility that surveyed the outpatient trend, however, found that its strategic options weren't limited to becoming a jumbo-sized outpatient clinic, explain David Allen, a partner with The Chancellor Group, Bloomington, Minn., and Daniel Weber, vice president of Fairview Southdale Hospital, Edina, Minn., in this special report. By understanding the multidimensional nature of ambulatory services and focusing its efforts on becoming a regional hub of healthcare services, Fairview Southdale has carved its own niche in a changing provider market. PMID- 10172503 TI - Journal club provides answers to post-op nausea. PMID- 10172504 TI - Managed care and ambulatory surgery: a seemingly perfect match that is not. PMID- 10172505 TI - Don't expect a consensus on hernia repair. AB - Hernia surgery, a bread and butter operation for many hospitals, seems a likely candidate for streamlining, standardization, and package pricing. But there's no consensus on the best way to do hernia repairs. Surgeons differ vehemently on which approach is preferable. The mesh plug attracted attention this summer when its advocate, Ira Rutkow, MD, appeared on TV. But the patch, traditional open repair, and laparoscopy also have their advocates. Here's a look at the techniques and why you're unlikely to see consensus soon. PMID- 10172506 TI - Hospital wins back its cataract business. PMID- 10172507 TI - How can you be prepared for outpatient APGs? PMID- 10172508 TI - A randomized trial comparing intravenous immunoglobulin and plasma exchange in Guillain-Barre syndrome. PMID- 10172509 TI - Politics and personal pursuits: the experience of mothers of children with severe disabilities. AB - This study concerns the political nature of the work of mothers of children with disabilities who extended their caregiving responsibilities to social action in the public domain. Conversations were held with twenty-one women to determine, from the women's personal points of view, the meaning of their politically oriented work. The women who participated in the study were actively engaged in developing educational programs, initiating parent support groups, educating professionals in health, education, and social services and serving on various committees and boards of directors. The research adopted a feminist frame of reference to understand the women's experience of political activism. As such, the research recognized the integrative aspects of women's lives: commonplace and routine tasks of caregiving took on political aspects as the women sought assistance and services for their children with disabilities and their families. Their work often occurred spontaneously and without prior planning due to the urgency of their family's personal needs. In fact, many of the women did not consider their work political at all for it simply coincided with the job of caring for their children. The women's achievements could be attributed in part to the intensity of their personal missions and their remarkable abilities to persuade influential officials and administrators. PMID- 10172510 TI - The provision of high levels of personal assistance services in the U.S. AB - State programs which provide personal assistance services (PAS) were surveyed to determine how many offer 24-hours of PAS per day if necessary. A total of 103 programs in 44 states were contacted and of these 23 (22.3%) in 7 states said that they offered 24-hour PAS in at least some circumstances. Persons with significant levels of disability who do not have extensive informal supports and live in states which do not offer 24-hour PAS may be placed in nursing homes or other institutions. The research highlights problems in defining 24-hour PAS and determining who needs this level of service. The economic and policy implications of 24-hour PAS are discussed and specific research is recommended on the cost of different models of service provision. PMID- 10172511 TI - Rethinking disability policy: equity in the ADA era and the meaning of specialized services for people with disabilities. AB - An analysis of disability policy suggests that policy-makers have pursued two strategies to treat people with disabilities equally. In one approach, categories of people with disabilities were identified and provided with specialized services. In the second, categories of services were provided to people with disabilities on a specialized basis. In both cases, the implication is that people with disabilities are so different a class of people that society should not be required to adapt to their presence. In this article, the authors suggest that the new equity standard established by the Americans with Disabilities Act makes such specialized services inappropriate and suggests a general three-prong strategy for including the needs of people with disabilities in mainstream policy making. This strategy addresses education and training needs, health care reform, and civil rights enforcement. PMID- 10172512 TI - New disability rights require organizational change and leadership. AB - On July 26, 1990, President George Bush signed the Americans with Disabilities Act (ADA). This legislation has been referred to as the "emancipation proclamation for the disabled" because of its great importance to persons with disabilities in our society. The ADA will not be implemented in a substantive way, however, without truly transformative leadership. Because of their traditional role in this area, health care professionals are in a unique position to provide that leadership and to help effect the necessary organizational changes. Passage of the ADA is only the beginning; the true test of its success will be in its implementation. PMID- 10172513 TI - Management considerations for a heterozygous protein C deficient patient undergoing open heart surgery with cardiopulmonary bypass. PMID- 10172514 TI - The ADA's impact on health care providers. PMID- 10172515 TI - Judge rules for chain in ergonomics case. PMID- 10172516 TI - Gray marketing of pharmaceuticals. AB - Pharmaceutical marketers in the European Union are constrained by regulated prices, opening up opportunities for gray marketers. The authors investigate the legal framework that regulates gray markets by summarizing and analyzing relevant European Court of Justice decisions that favor gray marketers and actually foster parallel trade. Before marketing managers can develop effective strategies in this marketplace, they must first understand the precedents of the legal system in which they will be operating. PMID- 10172517 TI - The Trent Regional Day Case Commission. An initiative to investigate the constraints to the extension of the use of day surgery. AB - In 1989, Trent Regional Health Authority set up a Commission to enquire into the organization of day case surgery and encourage its use. Improved methods for measuring and comparing day surgical activity were developed using routine data sources. These revealed even greater variation between hospitals and specialties in the amount of day surgery performed than did the usual analyses. Arrangements for day surgery differed considerably between specialties. Few theatres, beds, or surgeons' sessions were dedicated to day surgery, but general surgery and gynaecology used dedicated facilities more than other specialties such as ENT and ophthalmology. The Commission visited each hospital and found that day case facilities, organization and resources were poor in many of them. It was able to make specific recommendations for improvements. Day case surgery increased substantially over the period that the Commission operated, most hospitals reported that it had influenced changes in day surgery and that it had been useful, especially for local managers. Schemes to increase day surgery were funded. Highlights two elements for managing change: the need for good information about a problem, and the need to extend ownership of the issue throughout the organization. PMID- 10172519 TI - Quantitative virtual reality enhances stereotactic neurosurgery. PMID- 10172518 TI - Reductions in unwanted complications and lengths of inpatient stay by use of "dynamic guidelines". AB - A literature survey was used to identify pre-operative risks that commonly result in unwanted post-operative complications in the elderly. By adapting these risk conditions into a pre-operative survey, seniors who might have these complications were identified. Practitioners were notified of these risk factors. Elective surgery was postponed, when necessary, to have patients stop smoking and to gain training in pulmonary toilet. When in the inpatient setting, the patients were followed by both the surgeon and the appropriate specialist to reduce complications rates. By developing and employing this approach, a 25 percent decrease in unwanted complications was experienced, mostly due to reduction in pulmonary events. This resulted in an associated 58 percent drop in unwanted length-of-stay days in the hospital per 1,000 senior patients. Outcomes were improved, while inpatient utilization was reduced. PMID- 10172520 TI - What if you opted out of workers' comp? PMID- 10172521 TI - Comparative costs for substitutable services: inpatient and day surgery episodes of care. AB - The authors analyze the differences in costs between inpatient and outpatient elective surgery, by case mix group*, using the University of Alberta Hospitals Patient Resource Consumption Profile database (PRCP), supplemented with additional data from other agencies. PRCP measures costs for both inpatient and outpatient cases and is linked to the hospital's medical records, so that individual case-costing and detailed cost comparisons can be made. The focus of the comparison is on cost per case, measured in terms of the entire episode of outpatient surgery. PMID- 10172522 TI - Careful management keeps general surgery costs low. PMID- 10172523 TI - Outpatient TURP (transurethral resection of the prostate) is routine at Florida ASC. PMID- 10172524 TI - Where it may really hurt. PMID- 10172525 TI - A tale of two states. Arizona and Tennessee reinvent Medicaid, but not without pain and perils. PMID- 10172526 TI - Long-term care. Age of uncertainty. PMID- 10172527 TI - CHIPS (Center for Healthcare Industry Performance Studies) reports examine hospital indicators. PMID- 10172528 TI - Are your elevator phones ready for the ADA? PMID- 10172529 TI - The impact of religious faith and practice on patients suffering from a major affective disorder: a cost analysis. AB - Presents empirical data showing the relationship between religious beliefs and practices and lengths of stay in the hospital for patients suffering from one form of mental illness. Includes a spiritual injury scale which measures guilt, anger or resentment, sadness/grief, lack of meaning, feeling God/life has treated one unfairly, religious doubt, and fear of death. Shows in statistical form the relationship between these spiritual injuries and length of stay in the hospital. Indicates that spiritual injury issues are positively associated with longer lengths of hospital stay and that an inverse relationship exists between religious faith as measured by church attendance and cost for health care. PMID- 10172530 TI - Establishing and maintaining a back injury prevention program. PMID- 10172531 TI - Ability OnLine: children in hospital now in touch with the world. AB - Health prevention seeks to avoid the onset of disease or symptoms by eliminating or at least minimizing environmental factors that increase the risk of illness. This article describes Ability OnLine, an innovative program designed to reduce the isolation young people can experience in a healthcare facility or when confined to their home. The electronic bulletin board is a friendly platform for disabled and chronically ill children to easily communicate with their peers and adult and teen mentors. PMID- 10172532 TI - Members divulge repeat rates and secrets for success. PMID- 10172533 TI - Late orbital reconstruction. PMID- 10172534 TI - The role of appropriate medical technology procurement and user maintenance instructions in developing countries. AB - Reports bear witness that a significant proportion of all healthcare equipment in developing countries is not in use. There are many and varied reasons this, including inappropriateness or a lack of basic maintenance. This report addresses these issues, including guidelines for procurement staff and end-users and a bibliography. Examples of the considerations involved are given in the specialties of therapy oxygenation, laboratory tests and solar-powered equipment. PMID- 10172535 TI - Junk journalism and Medicare reform. PMID- 10172536 TI - Confidentiality of certain medical records--VA. Final rule. AB - This document establishes Department of Veterans Affairs (VA) regulations to implement specific provisions of the Veterans Omnibus Health Care Act of 1976 and the Veterans' Benefits and Services Act of 1988 concerning the confidentiality of certain medical records. These regulations protect the confidentiality of VA records pertaining to drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus (HIV), and sickle cell anemia. PMID- 10172537 TI - When does an employer act in good faith? A step-by-step approach to providing a reasonable accommodation under the Americans with Disabilities Act. PMID- 10172538 TI - Computers put surgical sites in the crosshairs. PMID- 10172539 TI - Prosthetics procurement. Taking stock. PMID- 10172540 TI - Setting the stage for safe resident transfers. PMID- 10172541 TI - Knowing risk areas can help avoid them in the ED. PMID- 10172542 TI - Alzheimer disease and the "then" self. AB - The authority of the intact self over the future severely demented self is based on notions of integrity and precedent autonomy. Despite criticism of this authority, the principle of precedent autonomy in the care of people with Alzheimer disease or other progressive and irreversible dementias retains its moral significance. PMID- 10172543 TI - Seven steps to a capitated contract for orthopedic implants. PMID- 10172544 TI - Integrating primary care and specialty pharmacy practice to improve ambulatory patient care services. AB - This article describes the evolution of clinical pharmacy services in an outpatient setting over a 20-year period. An historical overview of the initiation of services, the state of current practices, and the development of a new clinical service--the medication management service (MMS)--to provide care for general medical patients is presented. Four case studies of recent patients managed by the MMS are given to illustrate the interrelationship between this service and the pharmacist-managed specialty clinics. PMID- 10172545 TI - Effect of a drug supply and cost sharing system on prescribing and utilization: a controlled trial from Nepal. AB - The effect on prescribing habits of a drug supply and cost sharing system was studied in a hill district in Nepal. In this district the inadequate yearly supply of drugs from the government was supplemented by an extra supply from the project. Drugs were sold at a fixed prescription charge which covered all drugs for one episode of illness. The prescribing pattern in this district was compared to a control district with only the yearly government drug supply and no drug scheme. Drugs prescribed were also compared to theoretical needs based on the recorded diagnoses of the same patients and recommended treatment guidelines. Attendance figures were studied before and after the introduction of the drug scheme in the test district. A 25% sample of prescriptions was taken from all health posts in both districts, over a one year period. This was in total 11,772 prescriptions from 22 health posts. The results show that in the drug scheme district health workers prescribed essential drugs excessively. However, the doses that were prescribed were somewhat better than in the control district. Utilization of health facilities dropped by 18% in the drug scheme district and then increased in the second year. A supply of essential drugs does not necessarily improve the quality of care, or increase attendance levels. The WHO indicators designed to assess the quality of drug use at health facilities can give a misleading picture, as they do not include information on dosages. The effect on quality of care of supply and financing mechanisms needs further study. PMID- 10172546 TI - Quality as the driving force for cost-effective psychiatric managed care. AB - The mental health profession is plagued by the perception that it is a vague, ambiguous, and sometimes ineffective field. A confluence of worldwide megatrends is affecting the mental health and substance abuse delivery system. Two different methods of providing psychiatric clinical care are addressed. PMID- 10172547 TI - Pump up your PT IQ. PMID- 10172548 TI - In whose voice? Composing an ethics case as a song of life. PMID- 10172549 TI - Disabling conditions among children and adults under age 65. PMID- 10172550 TI - Waiting times. Signs of the times. PMID- 10172551 TI - Addiction services. Shooting home. PMID- 10172552 TI - The issue of substance abuse in the health care industry. A preliminary survey of managerial thinking. AB - Substance abuse in the workplace has been a growing concern in recent years and ways to detect employees and applicants who use drugs has been the subject of much debate. In this article, the results of a survey on the attitudes of medical practice human resource managers on drug testing of both employees and applicants are given. For this study, 273 human resource managers were sent questionnaires detailing various attitude statements and were asked for their level of agreement. Categories of questions included the administrators' general philosophy of drug testing, their attitudes toward the organizational impact of drug testing, their attitudes toward the implementation of drug testing and their attitudes toward specific issues pertinent to drug testing in medical groups. PMID- 10172553 TI - On the state of the public health. PMID- 10172554 TI - 1996 CPT revisions. PMID- 10172555 TI - Planning creative outdoor spaces. PMID- 10172556 TI - Faded memories. PMID- 10172557 TI - Orthopedics one of easiest product lines to integrate. PMID- 10172558 TI - Managing CHAMPUS mental health care with public-private partnerships. AB - When faced with skyrocketing costs and utilization of mental health and substance abuse services covered by the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), the Department of Defense (DoD) turned to a managed care approach to seek improvements. This article provides brief background information on CHAMPUS and its experience in the area of mental health services, describes DoD's partnerships with private sector mental health care firms, and highlights the most successful features of each. PMID- 10172559 TI - Special report: How to figure Medicare risk PMPMs (per-member per-month capitation payments). PMID- 10172560 TI - Rehab centers run dry. PMID- 10172561 TI - Techniques for noninvasive diagnosis of lower respiratory tract infections. Which tests to order, when to consider invasive procedures. AB - Although sputum culture and Gram's staining have been the traditional methods for determining the cause of lower respiratory tract infections, oropharyngeal contamination and improper sputum collection can limit their usefulness. Nevertheless, these noninvasive techniques remain a rapid means of gathering diagnostic clues. Alternative approaches include acid-fast sputum stains, direct immunofluorescence examination, enzyme immunoassays, DNA probes, and serologic testing. However, for critically ill patients, invasive procedures (such as bronchoscopy and thoracentesis) can provide more definitive diagnoses to guide selection of antimicrobial therapy. PMID- 10172562 TI - Learning disabilities. Hidden depths. PMID- 10172563 TI - Some tough questions for surgeons. Interview by Mark Crane. PMID- 10172564 TI - Increasing patient satisfaction through outpatient breast surgery. PMID- 10172565 TI - Positioning an unconscious patient with suspected neck injury. PMID- 10172566 TI - Clay as a therapeutic tool in group processing with the elderly. AB - Geriatric rehabilitation includes medical treatment, physical therapy, and therapy in both the psycho-social field and the activities of daily living (ADL). Its objective is to return the individual to independent functioning. This may be achieved through art therapy, which enables verbal and non-verbal communication; the expression of personal feelings; and physical, sensorimotor, and cognitive therapy. Group work with hospitalized elderly people is general limited, and art therapy using clay is particularly so. Yet it can stimulate feelings of fellowship and evoke a sense of cooperation and support. This article reviews group work with clay as an additional form of therapy with a group of 8 patients with Cerebrovascular Accident (CVA), or stroke, and femur neck fractures. The objective of the therapy was to combine bilateral sensorimotor activities of the upper limbs with social interaction directed towards future leisure-time activity. The subject of the clay work was "the home," which is central in the life of the elderly person. The article describes initial group activity with two groups of patients. Analysis of the activity was through retrospective observation--examining videotapes, photographs, and questionnaires at the end of each session. PMID- 10172567 TI - Medics dealing with use of t-Pa in strokes. PMID- 10172568 TI - Remote surgery and virtual endoscopy on the horizon. PMID- 10172569 TI - Office surgery is gaining outpatient market share. PMID- 10172570 TI - Surgeons operate across miles with remote system. PMID- 10172571 TI - New wave of minimally invasive surgery. PMID- 10172572 TI - Surgical decision making and elderly patients. PMID- 10172573 TI - Predicting effects of minimal invasive therapy. AB - OBJECTIVE: To estimate expected effects of minimal invasive therapy (MIT). DESIGN: We developed a structured questionnaire and sent it to 35 mainly senior academic surgeons considered leaders in MIT in the UK, USA, and Canada. We asked their opinions on which specific operations would be done by minimal invasive technique and the effects of this change on hospitals over the next 5 years. We used these responses to predict effects on hospitals of MIT. We also compared predictions against published data 2 years later. RESULTS: Respondents predicted 34 specific operations would be performed using MIT, and that 53% of the patients undergoing these operations would receive MIT procedure. This transformation would lead, in their opinion, to a decline of 10 million inpatient hospital days, a 62% decline of average length of stay for operations predicted amenable to MIT, and a resultant savings of $4.5 billion in the U.S. Comparable effects could be expected to occur in other countries. CONCLUSION: Many of the trends predicted by respondents are being borne out. If these trends continue, MIT will have profound effects on patients (clinical, quality of life function), providers (hospital utilization and financing, physician training), and payers (expenditures) in all countries if respondents' predictions about MIT and its impact are even reasonable accurate. Attention should be directed first to the hospital sector, given expected effects of changes of clinical service mix, revenues, and the need for different, and differently trained, personnel. PMID- 10172574 TI - What if your hospital corners the medical market? PMID- 10172575 TI - The creation of economic efficiencies in hospital mergers. AB - Antitrust evaluation of proposed mergers requires the assessment of merger created efficiencies, the beneficial effects of which may swamp any competitively adverse effects of higher market concentration. There are many potential sources of such efficiencies, and this paper investigates one that has been largely overlooked. Because merger often makes it possible to consolidate two small clinical departments into one larger unit, it can reduce the relative variability - the "peak load problem" - of daily patient census. This in turn makes it possible to reduce the costs of staffing adequately for random periods of high demand. Based upon a sample of two years of daily admissions data for several merging hospitals, and confirmed with data averaged over all U.S. hospitals, the efficiency effects of such clinical consolidation are estimated to be a substantial percentage of affected operating costs. PMID- 10172576 TI - An ergonomics system aimed at preventing back injuries in health care. PMID- 10172577 TI - Assistive devices give residents a lift. PMID- 10172578 TI - HealthSouth posts healthy 4th-qtr. earnings. PMID- 10172579 TI - Lights! Camera! Scalpel! PMID- 10172580 TI - The politics of health sector reform in developing countries: three cases of pharmaceutical policy. AB - This paper examines the political dynamics of health sector reform in poor countries, through a comparative study of pharmaceutical policy reform in Sri Lanka, Bangladesh, and the Philippines. The paper first reviews five reasons why policy reform is political. It then presents three political economic models of the policy reform process: the political will, political factions, and political survival models. Next, the paper describes the three cases of national pharmaceutical policy reform, and identifies common conditions that made these reforms politically feasible. The paper's analysis suggests that health sector reform is feasible at certain definable, and perhaps predictable, political moments, especially in the early periods of new regimes. The most important and manipulable political factors are: political timing, which provides opportunities for policy entrepreneurs to introduce their ideas into public debate, and political management of group competition, which allows leaders to control the political effects of distributional consequences and protect the regime's stability. A strong and narrow political coalition improves the capacity of political leaders to resist the pressures of concentrated economic costs (both inside and outside national boundaries). The paper argues that for reform to succeed, policy-makers need effective methods to analyze relevant political conditions and shape key political factors in favor of policy reform. The method of Political Mapping is briefly introduced as a technique that can help policy makers in analyzing and managing the political dimensions of policy reform and in improving the political feasibility of reform. PMID- 10172581 TI - Back breaks. A network of trainers are teaching workers how to take the pain and strain out of lifting. PMID- 10172582 TI - Episode treatment groups: an illness classification and episode building system- Part I. PMID- 10172583 TI - Off to see the wizard. PMID- 10172584 TI - A separate unit for Alzheimer's patients: impact on discharge planning. PMID- 10172585 TI - Beating hearts. PMID- 10172586 TI - ADA compliance in the admissions process. PMID- 10172587 TI - Feeding frenzy. PMID- 10172588 TI - Solving the perioperative path dilemma. PMID- 10172589 TI - Pricing a capitated laboratory contract: 7 steps to the poor farm? PMID- 10172590 TI - 1996 Health Care Hall of Fame. Michael E. DeBakey, M.D. PMID- 10172591 TI - Minimally invasive surgery gains ground. PMID- 10172592 TI - Privileging: physicians are protected by the Americans with Disabilities Act. PMID- 10172593 TI - Despite all odds: how do we continue to practice good medicine? PMID- 10172594 TI - Transfer of DNA tests from research to routine laboratories: some lessons from the French experience in the case of Duchenne muscular dystrophy. AB - In the last few years, the activity of research laboratories has led to the emergence of new DNA diagnostic tests in France. They permit the origin of genetic diseases to be identified and provide an answer concerning the detection of carriers and prevention. Nevertheless, given this, new actors have emerged on the health care scene: the research workers who developed the tests and who work in public research laboratories. The economic question of the transfer of the test practice from research to hospital laboratories is the main topic of this paper, taking Duchenne Muscular Dystrophy (DMD) DNA diagnostic tests as the example. After a presentation of the complexity of DNA tests for DMD, the fact that financial and human constraints do not allow the actors to continue to produce the DNA tests is discussed. The financial role of the non-profit-making associations is then explained and leads to the conclusion that a more global policy on DNA tests, such as carried out in the UK and the Netherlands, should be adopted in France by the Social Security if it wants DNA testing activity to be pursued. PMID- 10172595 TI - Medical mall: one-stop shopping for outpatients. PMID- 10172596 TI - Use of New York Medicaid PASs (Products of Ambulatory Surgery) with emergency surgical episodes. AB - The New York Products of Ambulatory Surgery (PAS) patient classification system was implemented by the state of New York for reimbursement of Medicaid ambulatory surgery claims. Using a national claims based database, the PAS system was evaluated for use with emergency department-generated surgical episodes. The PAS system performed well, but would benefit from the inclusion of age, comorbidity, and presence of multiple surgical procedures. Further, model power increased significantly when focused on total episode versus surgical charges alone. The study indicated the high degree to which emergency department-generated charges are closely tied to other charges in any overall care delivery system. PMID- 10172597 TI - Applying the value-of-information paradigm to laboratory management. AB - This paper argues that some sort of utility analysis must be applied for managers to modify laboratory testing services, e.g., volume, precision, timeliness, in the direction of necessarily improved patient services. A familiar laboratory performance measure, diagnostic efficiency, applied without utility analysis can be misleading and can lead to decision criteria that do more harm than good. The method used to demonstrate this contention is a case-specific theoretical analysis, and empirical verification would be needed before using these results in any actual patient care situations. However, this paper suggests that managers need to better understand and quantify the benefits of clinical laboratory testing if they are to protect the beneficial services they provide from the emerging cost consciousness in the medical services industry. This paper illustrates how the long established concept of the clinical utility of laboratory information can be applied. PMID- 10172598 TI - Using patient outcomes to screen for clinical laboratory errors. AB - How to measure the quality of laboratory testing has long been a challenging problem for laboratory managers and accrediting agencies. Traditionally, laboratory quality has been assessed by direct inspection, proficiency testing, and the credentials of staff. None of these methods is entirely satisfactory at answering a fundamental question: does the laboratory give technically accurate and clinically meaningful information for each patient that it tests? This paper discusses how information on patient outcomes can be used to screen for laboratories that may be making frequent random or systematic errors. This approach is called downstream event monitoring (DEM). The basic idea is to look at what happens to a laboratory's patients in a critical window of time after they have been tested. The approach carries out a basic adage of quality management: follow up with your customers to see if your product has met their needs. The main idea of DEM is that if a laboratory has not conveyed accurate information, the clinician may take actions that fail to help, or maybe even harm, the patient. If a laboratory's patients have an unusually high rate of adverse events that happen within a window of time when the laboratory test would have played a critical role, the laboratory should be further examined to see if it is the cause of the problem. Right now, DEM is a technique under development. It needs a clinical logic to relate a patient's outcomes back to a laboratory test, and it needs good data to compare laboratories. This paper discusses how the prothrombin time test and the serum digoxin test have been examined for Medicare patients to see if certain laboratory characteristics are associated with unusually high occurrences of adverse events after testing. The need for future validation studies is also discussed. PMID- 10172599 TI - An actuarial model approach to assessing the impact of serial testing for prostate cancer using the Tandem PSA assay. AB - This article summarizes an analytical approach to modeling prostate cancer detection scenarios that health-care plans, i.e., managed care organizations, can use to assist them in making early detection policy decisions. The actuarial modeling approach incorporates current variations in clinical practice with costs for the purpose of generating per member per month outputs. The intent of this approach is to provide laboratories with a tool to provide a value-added service to their managed care customers. The model can be tailored to an array of managed care plans and payer financial arrangements. Included here is a summary of an oral presentation from the Outcomes Conference at the CLMA meeting in Minneapolis, Minnesota in August of 1995. This material was presented by Robert Parson. PMID- 10172600 TI - Improving outcomes in therapeutic drug monitoring--a case history. AB - A case history describes quality improvement initiatives undertaken by the Laboratory, the Pharmacy, and the Department of Nursing at Children's Medical Center in Dallas, Texas, a 266-bed pediatric teaching hospital affiliated with the University of Texas Southwestern Medical School. The initial purpose of the study was to correct problems identified by a retrospective review of randomly selected patient charts. The problems included laboratory schedules for drug assays, the timing and documenting of blood collections, the reporting of toxic results to physicians, and the interpreting of serum drug concentrations. The major changes in the program included increased frequency of testing in the laboratory, educating nurses as to sample collection guidelines, introducing a clinical pharmacy consultation service, daily reporting of all drug levels to the pharmacy from the laboratory computer, and reporting toxic levels to the clinical pharmacist who then notified the physician and offered a consult. The study then began to focus on attempting to monitor the service related to outcome indicators. Outcome data included a comparison of test volumes (15.7% decrease), tests per adjusted patient day (15.4% decrease), and tests per patient day of therapy for aminoglycosides (gentamicin decreased 6.8%) before and after the changes were implemented. Data also included aminoglycoside tests reported as therapeutic and as toxic. Plans for further improvement have been identified and include differentiating peak and trough serum drug concentrations for aminoglycosides, possibly developing protocols for vancomycin and cyclosporine monitoring, continuing to educate laboratory technologists and nurses, and continuing to monitor usage and outcome indicators. PMID- 10172601 TI - Comparison of four methods (L/S ratio, TDx FLM, lamellar bodies, PG) for fetal lung maturity using meta-analysis. AB - Multiple factors in the past encouraged physicians to order laboratory tests excessively and perhaps even abusively. The shift in the financing of health care to managed care and capitation will create an environment where physicians will be more receptive to laboratory efforts to influence their test ordering behavior toward cost-effectiveness. Various strategies to modify physicians' test-ordering behavior have met with only mixed success due to lack of data to support the desired result: reducing laboratory tests that are not specifically indicated for a particular patient. The current dynamics in the health care industry in general and in the clinical laboratory in particular place increasing value on information about the overall process of health-care delivery. This information can be derived from data from what were formerly considered discrete, transactional events, i.e., specific publications. Combining data from articles dealing with the same subject (meta-analysis) is increasingly being used to assess the value of the overall process of delivery (the outcome). Although considered ?arm chair? research, meta-analysis is an important tool in evaluating the worth of a method in patient care. We chose to evaluate, given the current literature, which laboratory test--lecithin/ sphingomyelin ratio, surfactant/albumin ratio, lamellar bodies, or phosphatidylglycerol--is the best and most cost effective method to screen for fetal lung maturity. We identified all pertinent literature from 1966 to the present using a search of Medline. PMID- 10172602 TI - Research ethics and new diagnostic technologies. PMID- 10172603 TI - Waimate's health and disability services strategic plan to the year 2000: a model of rural health development? PMID- 10172604 TI - Queen Mary Centre sweeps 13th Annual International MARKIE Awards. PMID- 10172605 TI - The use of priority criteria to help decide access to health and disability services--no clash with Human Rights Act. PMID- 10172606 TI - Access to primary health care among persons with disabilities in rural areas: a summary of the literature. AB - Despite the prevalence of disabilities among persons living in rural areas, scarce data exist on their health care needs. While rural residents generally experience barriers to access to primary health care, these problems are further exacerbated for people with disabilities. This article summarizes findings from the published literature on access to primary health care among people with disabilities living in rural locations. A comprehensive computerized literature search turned up 86 articles meeting the study criteria, focused on the following rural populations affected by disabilities: children and adolescents, working-age adults, the elderly the mentally ill, and people with AIDS. For each of these populations, substantial problems in accessing appropriate health care have been documented. The literature consistently emphasizes the failure of local health care systems in nonmetropolitan areas to adequately address the complex medical and related needs of individuals with disabilities. In the absence of specialized expertise, facilities, and primary care providers trained specifically to care for disabled persons, local programs rely heavily on the use of indigenous paraprofessionals and alternative models of care. Further research is needed to identify and test the efficacy of innovative service delivery strategies to improve health care access for this population. PMID- 10172607 TI - Federal financial participation in state assistance expenditures; federal matching shares for Aid to Families with Dependent Children, Medicaid, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 1996 through September 20, 1997--HHS. Notice. PMID- 10172608 TI - Dialogue. Provider licensing: a requirement in public/private partnerships. PMID- 10172609 TI - Factors to consider in special care unit start-ups. PMID- 10172610 TI - The magic of three-dimensional interactive art. PMID- 10172611 TI - American College of Healthcare Executives public policy statement. Strengthening healthcare employment opportunities for persons with disabilities. May 1995 (revised). PMID- 10172612 TI - ED managers: head off drug seekers and the multiple risks they can pose. PMID- 10172613 TI - A JIT-type stocking system for hospital pharmacies: the stockless method. AB - During the past few years, hospitals have been actively evaluating the use of newer-type stocking systems for their pharmacies. While "stockless," a just-in time (JIT) variation, appears to be emerging as perhaps the most promising method, it is far from being accepted as the industry standard. Because of growing concern for health care reform, with its cost containment component, it may well be anticipated that both the pace and profoundness of these efforts will continue to intensify. PMID- 10172614 TI - Access and satisfaction within the disabled Medicare population. AB - Little is known about variations in the levels of access and satisfaction within the disabled Medicare population. Based on the Medicare Current Beneficiary Survey (MCBS), beneficiaries under 65 years of age were classified by original reason for disability (mental versus physical). Those with a mental disability were less likely to have a private physician as a usual source; were less satisfied with the overall quality of care, availability of after-hours care, followup care, and coordination of care; and were more likely to report unmet need, owing in large part to supply barriers. Implications for the current delivery system and for design of managed care programs are discussed. PMID- 10172615 TI - Access to care under physician payment reform: a physician-based analysis. AB - This article reports physician-based measures of access to care during the 3 years surrounding the 1989 physician payment reforms. Analysis was facilitated by a new system of physician identifiers in Medicare claims. Access measures include caseload per physician and related measures of the demographic composition of physicians' clientele, the proportion of physicians performing surgical and other procedures, and the assignment rate. The caseload and assignment measures were stable or improving over time, suggesting that reforms did not harm access. Procedure performance rates tended to decline between 1992 and 1993, but reductions were inversely related to the estimated fee changes, and several may be explainable by other factors. PMID- 10172617 TI - Substance abuse treatment: outcomes of managed care techniques. PMID- 10172616 TI - The Community Medical Alliance: an integrated system of care in Greater Boston for people with severe disability and AIDS. AB - The Community Medical Alliance in Boston has adapted principles of prepaid managed care to redesign service delivery for people with severe physical disability and with late-stage AIDS. Experience to date suggests that the flexibility of capitation can be used to substantially shift care from its usual hospital focus to clinicians in home and community settings, especially nurse practitioners, with a high degree of patient satisfaction and without apparent compromise in quality. Instead of limiting access, managed care can use prepayment to support early interventions, coordination, and the development of services specifically designed to meet the needs of the target population. PMID- 10172618 TI - Are you stealing from other doctors? PMID- 10172619 TI - Day surgery. Day for night. PMID- 10172620 TI - Ambulatory surgery centers: harbinger of managed care shift. AB - Since the late 1960s, elective surgery in the US has been shifting from traditional hospitals to freestanding, independent, corporate or hospital-owned ambulatory surgery centers (ASCs). At present, over three million surgeries are performed yearly in some 2,100 ASCs across the nation. Many underlying forces have been at work influencing this change in the surgical environment. For example, technological advances in minimally invasive procedures have gained acceptance by physicians and patients alike. And these new surgical developments are used in ASCs. Patients have chosen convenience over the institutional approach. And finally, managed care has demanded the lower overhead costs and the efficiencies that ASCs provide. This article examines the growth of ASCs. It also looks specifically at how Columbia/HCA's 130 ambulatory surgery centers purchase products and services. PMID- 10172621 TI - New shades of Alzheimer's research: finding cure will take time. PMID- 10172622 TI - Day versus inpatient treatment for cocaine dependence: an experimental comparison. AB - This study was designed to explore the question of whether day treatment is a viable alternative to inpatient treatment for cocaine-dependent patients. Inpatient subjects were compared with day treatment subjects in a randomized, prospective study design. Treatment outcome was evaluated at three and six months posttreatment. At three months posttreatment, the inpatient group had a statistically significant higher rate of total abstinence than the day-treatment group, but the difference at six months was not statistically significant. The two groups also were statistically comparable at six months posttreatment in terms of ?current? abstinence and in terms of other measures. Average costs for day-treatment subjects was 48-61% of the cost for inpatient subjects. The results of this study support the use of day treatment as a clinically and economically effective alternative to inpatient treatment for many cocaine-dependent patients, especially when steps are taken to minimize drop out. PMID- 10172623 TI - Deliberate self-harm and substance dependence: the management of patients seen in the general hospital. AB - The aim of this study was to examine management decisions made at the time of assessment of an episode of deliberate self-harm seen in the general hospital and examine the extent of referral to a specialized addiction unit. Factors involved in making a clinical decision regarding the appropriate management of self-harm cases when alcohol factors were identified are reviewed. Simply referring to a specialized addiction unit was found to be an unsatisfactory method of providing a comprehensive response to the problem of substance misuse and deliberate self harm. It is suggested that services should be developed using active posthospital discharge community follow-up. Motivational interviewing used in such a setting may increase the number of patients who will go on to accept specialist care. PMID- 10172624 TI - Proportion of mortality caused by severe hospital-acquired infection in open heart surgery. AB - OBJECTIVE: To investigate severe hospital-acquired infection as an independent risk factor for in-hospital mortality and the proportion of mortality caused by severe hospital-acquired infections in patients under going open-heart surgery. SETTING: A 1,300-bed teaching hospital in Spain. METHODS: A retrospective cohort study of 702 patients who underwent open-heart surgery procedures between January 1989 and December 1991. The mean age was 57 years, and 68% of the subjects were men. Of the 702 patients, 42% underwent a valve operation, 41% had coronary artery bypass grafting, 4% had both a valve operation and coronary artery bypass grafting, 5% underwent repair of congenital heart disease, and 8% had other surgical procedures. RESULTS: The cumulative incidence of severe hospital infection was 16.8%. The overall mortality rate was 5.4%. The mortality risk was 5.15 times higher in nosocomially infected patients than in uninfected patients. In addition, univariate analysis revealed up to 18 perioperative variables associated with in-hospital mortality. By multiple logistic regression, we identified four factors that independently predicted increased risk of mortality: preoperative New York Heart Association functional class level IV; long duration of cardiopulmonary bypass; low cardiac output syndrome; and severe hospital acquired infection. The proportion of mortality caused by severe hospital acquired infection in the cohort was 31.1%. CONCLUSIONS: Severe hospital-acquired infection is a principal factor in in-hospital mortality. One third of all deaths are caused by infection. Major efforts should be devoted to the prevention and control of severe nosocomial infections in open-heart surgery patients to prevent mortality. PMID- 10172625 TI - Staphylococcus cohnii: a case report on an unusual pathogen. AB - Coagulase-negative staphylococci have become increasingly important causes of infection in predisposed hosts. such as patients receiving immunosuppressive therapy and broad-spectrum antimicrobial drugs, patients who have prosthetic devices, or those who have prolonged hospital or intensive care unit stays. However, human infections caused by Staphylococcus cohnii rarely have been reported in the literature. In this report, we review the current literature and describe a 38 year-old immunosuppressed woman who developed catheter-related S. cohnii bacteremia. The case illustrates why microbiology laboratories under certain circumstances should identify coagulase-negative staphylococci to the species level. This information may be critical because it may allow clinicians to identify the source of the infecting organism and to choose appropriate antibiotics. Yet in this era of cost containment many laboratories may decrease costs by decreasing services, including species identification. PMID- 10172626 TI - Global pricing calls for a proactive approach. PMID- 10172627 TI - Global pricing streamlines open-heart service. PMID- 10172628 TI - The blunder years. PMID- 10172629 TI - Maximum waiting-time guarantee--an attempt to reduce waiting lists in Sweden. AB - In Sweden, as in most countries with publicly financed health services, long waiting lists for some surgical procedures have been a serious quality problem on the health policy agenda. To reduce waiting lists, the Swedish Government and the Federation of County Council agreed on an initiative to offer a maximum waiting time guarantee for 12 procedures during 1992. Patients awaiting procedures are guaranteed a waiting time no longer than 3 months from the physician's decision to treat/operate. The initial agreement was to be in force for 1 year, and a grant of 500 million SEK (USD 70 million) was appropriated for the initiative. The guarantee has been prolonged by annual decisions to be in force 1993 through 1995. However, no extra resources were set aside for these years. This article describes the background and the introduction of the guarantee. and discusses some of the major results during the first 2 years. Generally, waiting lists decreased substantially during 1991 and 1992. By the end of 1992 only a few departments were unable to serve patients within 3 months. During 1993 the reduction in the waiting lists ceased, and waiting lists for some procedures showed a tendency to increase by the end of the year. The overall successful result, in terms of waiting lists and waiting times, seems to have been achieved mainly by increased production, improved administration of the waiting lists, and a change in attitudes toward waiting lists. The expectation that the guarantee would lead to a more even use of resources across the country has not been realised since it appears that hospital departments chose to expand their own activities rather than use the new opportunity offered by the guarantee to refer patients to other hospitals. PMID- 10172631 TI - Res-Care latest target in SEIU campaign for industry scrutiny. PMID- 10172630 TI - Accounting for the transition from inpatient to outpatient surgery. AB - This article reports on some of the factors that have advanced and impeded hospital progress in moving from inpatient to outpatient surgery. Early on, patients, physicians, and hospital administrators all agreed that outpatient surgery had an intuitive appeal. Patients liked it because they didn't have to go in the hospital. Physicians liked it because they could get in and out of the outpatient surgery center more easily than the main hospital operating room. Administrators recognized the inherent appeal of outpatient procedures but were unable or unwilling to switch services from inpatient to outpatient for a variety of reasons. First, empty hospital beds and diminished scope of inpatient operations are a threat to the power of administrators. Moving surgery from inpatient to outpatient settings reduces inhouse operations. Second, reimbursement incentives were definitely in favor of continued inpatient care long after technology was in place for outpatient care. The third and most critical reason was that cost data on outpatient operations were just not available for making decisions on when to move into the outpatient setting. This review of the literature was intended to document the lack of relevant cost-based accounting. Instead, many other factors that more directly slowed progress were encountered. More than anything, this illustrates the erratic course of progress in health care reform. PMID- 10172632 TI - Last among equals. PMID- 10172633 TI - Legal considerations for the hiring process. PMID- 10172634 TI - Co-operatives--the third path? CRAME (Central Regional d'Approvisionnement en Medicaments Essentiels): a case-study from Central African Republic. PMID- 10172635 TI - The insurance industry's use of genetic information: legal and ethical concerns. PMID- 10172636 TI - Dilemmas of providers treating pregnant mothers who use drugs: patient confidentiality versus the duty to report drug use. PMID- 10172637 TI - Suicide by persons with disabilities disguised as the refusal of life-sustaining treatment. PMID- 10172638 TI - When worlds collide: disability rights and medical prerogatives in matters of life and death. PMID- 10172639 TI - Changing to a client-focused quality service through more effective team work. AB - The Mary Marlborough Disability Service, a specialist NHS unit providing non acute support which enables people with physical disabilities to lead independent lives, established an inter-disciplinary team which addresses any problem of relevance to an individual which might affect their daily existence, social life, work, education or leisure pursuits. Identifies three areas of change: the style of service; its effectiveness; its efficiency. Finds, although the unit perceived itself to be working as a team, there were major operational difficulties which led to lack of cohesion and communication. As the unit was resistant to change, a clinical co-ordinator experienced in the field of disability was seconded to to the unit to guide the necessary changes, and a number of lessons were learned. PMID- 10172640 TI - OR management. AB - Market forces throughout the US, especially in specific geographic areas, have brought about profound changes in health care delivery. One of the most significant is the move to managed and capitated care with the resulting impact on hospital reimbursement. As these forces gain momentum, continually moving further from fee for-service, the hospital portion of the healthcare dollar continues to contract. In response, healthcare delivery organizations are developing innovative strategies to ensure the continual provision of cost effective care. Emphasis is placed upon keeping resources close to the point-of care delivery. Necessary savings, reductions, and efficiencies must come from structural change, reengineering, best practice development, and more cost effective care delivery with highly standardized use of resources. Healthcare is in a transitionary stage. The transition has been from providing acute inpatient care to managing the continuum of care, from treating illness in individuals to providing education and maintaining wellness in the defined population. Revenue centers are no longer recognized; rather, in this increasingly capitated market, all, including operating rooms, are cost centers. The focus is no longer on filling beds, ORs, radiology suites, etc. The challenge is to find effective methods to minimize the needed resources to deliver high quality, cost effective care while maintaining and increasing patient and physician satisfaction. This article focuses on surgery in a large integrated system, Sharp Health care (San Diego, CA), a network of organizations providing, or arranging to provide, a coordinated continuum of services to a defined population. PMID- 10172642 TI - Aerosol particle generation from dry powder inhalers: can they equal pressurized metered dose inhalers? AB - In comparison with pressurized metered dose inhalers (pMDIs), dry powder inhalers (DPIs) emit a semi-stable aerosol cloud and are inspiratory flow actuated and inspiratory flow driven. In vitro studies show that different DPIs vary in their efficiency as delivery systems of fine drug particles (aerodynamic diameter < 5 microns). The efficiency of DPIs may vary according to the inspiratory force used to generate the aerosol. In comparison with other DPIs, Turbuhaler has been shown to be an efficient fine particle generator at weak, moderate and strong inspiratory forces. Deposition studies using human throat casts have shown that the throat has a minor influence on the deposition of drugs delivered from DPIs, whereas the throat has a major influence on the deposition of drug delivered from pMDIs. The fine particle dose able to penetrate the human throat casts was considerably higher for budesonide Turbuhaler than for budesonide pMDI, whereas for fluticasone propionate the fine particle dose was considerably higher from the pMDI than from Diskhaler. Thus, whether the fine particle dose and the deposition pattern of a drug generated from DPIs can equal that generated from pMDIs depends on the drug, the formulation and the patient. PMID- 10172641 TI - Transesophageal echocardiography in myocardial ischemia: a review. AB - This article reviews established as well as emerging fields in the application of transesophageal echocardiography (TEE) in the investigation of myocardial ischemia. TEE already has a well defined and established role in stress echocardiography in patients with poor transthoracic acoustic window, and in the detection of intraoperative myocardial ischemia in cardiac and noncardiac surgery. The evaluation of right ventricular ischemia and infarction and the assessment of coronary flow reserve (CFR) are relatively new fields in the application of TEE and the potential of this technique has not yet been fully evaluated. The evidence collected and reviewed in this article is still preliminary but it presupposes a significant role of TEE in the diagnosis and pathophysiological assessment of myocardial ischemia. PMID- 10172643 TI - Implications of airway retention for radiation doses from inhaled radionuclides. AB - A slow phase of bronchial and bronchiolar clearance ('airway retention') has been included in the revised dosimetric model for the human respiratory tract recently adopted by the International Commission on Radiological Protection (ICRP), based primarily on the results of the bolus clearance experiments conducted by Stahlhofen et al. The treatment of airway retention in the new ICRP model is described. An analysis was carried out of the sensitivity of the equivalent lung dose, and the effective dose, to assumptions made in the new model about the extent of airway retention. It was shown that inclusion of airway retention of material deposited in the bronchial tree does have a significant effect on both end-points (of the order of 10-50%) for a wide range of radionuclides. In some cases, notably moderately soluble forms of long-lived alpha-emitters, its inclusion increases these doses by up to a factor of three, so that it makes the dominant contribution to the calculated dose. The model assumes that material in transit through the bronchial tree, having initially deposited in the alveolar region, is not subject to airway retention. Including retention of this material would typically increase doses by a further factor similar to that resulting from the airway retention of the bronchial deposit. PMID- 10172644 TI - Regulating healthcare technologies and medical supplies in the European Economic Area. AB - A complex relationship exists among EU regulations, current national practices and rules, institutional capacities to implement regulatory adjustments and the legacy of past health and regulatory policy and traditions. However, there is little empirical information on medical devices policy, the medical devices industry, and the assurance of medical device safety and usage. Drawing on a review of the secondary literature and on-going field work, the evidence suggests that the current mix of state-centric and self-regulatory traditions will be as important in determining the implementation and final outcomes of EU-rules as the new rules themselves. EU directives redesign rules, but they do not necessarily lead to institutional change, create manpower, skills and institutional capacities, or alter governance and administrative practices in the short term. Neither EU directives nor national regulatory adjustments determine the 'man machine/skills-experience' interface which is shaped and influenced by local medical traditions and the acceptance of these traditions by local publics. PMID- 10172645 TI - State update. The long and winding road. PMID- 10172646 TI - The plaintiff's two-sided mouth: defeating ADA claims based on inconsistent positions taken by the plaintiff on other claims. AB - In the typical ADA claim, the plaintiff will claim that he or she has a disability but is nevertheless able to perform the essential functions of his or her job. This position is often in direct conflict with other non-ADA claims that the plaintiff has made or is making, where the plaintiff is claiming total disability and/or that he or she is unable to work. This article examines these phenomena, reviews the numerous recent cases that have found for employers based on these inconsistent positions of the plaintiff, and explains how employers can be develop and present this defense. PMID- 10172647 TI - Frontiers in laparoscopy: current techniques. PMID- 10172648 TI - UPJ obstruction: assessing minimally invasive therapies. PMID- 10172649 TI - Unclear visions for the future. PMID- 10172650 TI - Screening's payoffs coming into focus. PMID- 10172652 TI - Advances in gynecologic care: the effect on an HMO. AB - The introduction of four endoscopic surgical procedures into the gynecology department at Fallon Community Health Plan (FCHP) is discussed. The use of these endoscopic procedures reduced average length of stay (ALOS), hospital days/1OOO members, and rate of postoperative complications compared to the open (laparotomy) method. These minimally invasive procedures are popular with patients and physicians, and their use has the potential to decrease an HMO's overall operational costs. PMID- 10172651 TI - Correlation of ACT as measured with three commercially available devices with circulating heparin level during cardiac surgery. AB - Automated activated clotting time (ACT) is utilized as the primary means of assessing anticoagulation status for cardiopulmonary bypass (CPB) procedures. Influences on the clotting cascade during CPB such as hypothermia, hemodilution, and platelet dysfunction are known to affect ACT. The recently introduced Thrombolytic Assessment System (TAS) has been reported to be less sensitive to changes in hemodilution and hypothermia during CPB than more conventional ACT devices. This study evaluated the ability of TAS, and two other commercially available automated ACT systems, the HemoTec and Hemochron, to correlate with circulating heparin levels. Reference standards for circulating heparin were determined by inactivation of factor Xa assay. Nineteen patients undergoing moderate hypothermic CPB served as subjects for this investigation. Blood samples were obtained for study at four time periods: 1) baseline (control), 2) post heparin administration (300-400 U/kg) prior to CPB, 3) during CPB, and 4) post protamine. Study results demonstrated a high correlation between the HemoTec and Hemochron (r = 0.99), increased heparin dose response on CPB compared to pre-CPB activity (p < 0.05), and a significant (p < 0.05) negative correlation between devices and patient hematocrit during CPB. Additionally, device correlation with anti-Xa assay during collection periods 2 and 3 showed negative correlations in each of the three devices evaluated. We conclude that all automated devices tested demonstrated an inability to predict circulating heparin at levels necessary for CPB, and that these discrepancies become magnified during CPB procedures. PMID- 10172653 TI - Trying to reach the pregnant substance-abuser: learning from failure. PMID- 10172654 TI - Enhancing motivation in substance abusers. PMID- 10172655 TI - Minnesota pioneers managed care for chemical dependency clients. PMID- 10172656 TI - Community care. Health, housing, hiatus. PMID- 10172657 TI - Equal opportunities. Equal to the occasion. PMID- 10172658 TI - Policy relevance of the health expectancy indicator; an inventory in European Union countries. AB - Due to epidemiological transitions in population health both an increase in life expectancy and in chronic morbidity and disability have been observed in many countries. Consequently the tension between 'living longer' on the one hand and the 'quality of life' on the other have become a central health policy problem. The introduction of the indicator 'health expectancy' (HE), a measurement that combines mortality data with morbidity and disability data, was a logical reaction to these changes and to the growing need of a present-day yardstick to estimate this problem. The HE indicator is still under development, a process being furthered by the international network of researchers, REVES. A European project, called Euro-REVES, aims to promote and harmonize future HE calculations in Europe. To begin this project and to gain more insight into the indicator's policy relevance, an inventory has been carried out among policy makers, National Statistical Institutes and researchers in countries of the European Union (EU). This paper presents the results of the inventory, attempts to place these within a provisional classification system of HE types, and discusses the consequences of the findings for further conceptual harmonization and development of the indicator. Already 11 of the 15 ER member states have HE results available. The actual use of such results for policy making is increasing. Notwithstanding a great diversity in sources and questions used for the calculations, there seems to be enough simularity to give the harmonization effort a good perspective. PMID- 10172659 TI - The 1990 GP contract--meeting needs? AB - This paper reviews the empirical evidence about the effects of the 1990 general practitioner (GP) contract on the provision of medical services in the United Kingdom. A brief outline of the major changes instigated by the 1990 GP contract is given. Studies of the implementation of the changes tend to focus on either trend analysis, cost-effectiveness or medical practice variation. These studies are reviewed and the implications for the efficiency of primary health care are discussed. PMID- 10172660 TI - Opening the debate on DALYs (disability-adjusted life years). AB - The 1993 World Development Report is proving to be an influential document for the development of the health sector policies in developing countries. One important aspect of the Report concerns its proposals for Disability Adjusted Life Years as a measure of health change and hence effectiveness of interventions. This article comments on the use of such measures in the health policy arena. PMID- 10172661 TI - Art therapy: a passage into patients' pasts. PMID- 10172662 TI - Private medicine and socioeconomic differences in the rates of common surgical procedures in Finland. AB - The aim of the study was to evaluate socioeconomic equity in access to surgical services in Finland and to explore the contribution of private sector procedures to any inequities. Data on nine common surgical procedures performed on patients aged 25 and over were obtained from the 1987-88 Finnish Hospital Discharge Register. Socioeconomic indicators were linked to the procedure data by personal identity numbers from the 1987 population census, which was also used to derive the data on population at risk. The study revealed marked differences in rates across socioeconomic categories for several procedures. Some of these disparities are probably explained by variations in need for surgery across socioeconomic groups. However, for cataract operations and hip replacements due to arthrosis or deformity, the surgery rates favoured the better-off, despite low social status being considered a risk factor for these disorders. The correlation or disposable family income with hysterectomy and prostatectomy rates, and the low surgery rates for many procedures in the lowest income quintile also suggested socioeconomic disparities in access to services. The specific effect of private sector seems to have contributed to the socioeconomic differences in rates for, at least, hysterectomy, prostatectomy, and cataract operations. Although the Finnish health care system operates universal coverage without formal barriers to equal access, systematic socioeconomic inequity in the use of individual surgical treatments prevail. Part of these inequities is evidently due to private sector services. PMID- 10172663 TI - From universalism to selectivity: is 'appropriateness' the answer? AB - As health expenditures continue to consume increasingly large proportions of national budgets, ways must be found to assure that money spent on health is used for effective services. Only a small proportion of medical decisions are based on scientific evidence about their outcomes, thus it is not surprising that wide variations exist in clinical practice. In recent years, questions have been raised about how medical decisions are made and the proportion of medical procedures and services that are performed for appropriate reasons. One method that has been developed to quantify the amount of inappropriate use is the so called 'RAND appropriateness method,' which is based on a structured review of the scientific literature and the collective judgement of an expert panel. Measured by this method, a number of procedures have been shown to have high rates of inappropriate or uncertain use. The challenge is to find ways to eliminate ineffective services and procedures to free resources for those that have been proven effective. Further research is needed to improve the method and to find acceptable ways its findings can be used to promote effective care. PMID- 10172664 TI - MIS techniques could transform heart surgery. PMID- 10172665 TI - Diagnostic risk adjustment for Medicaid: the disability payment system. AB - This article describes a system of diagnostic categories that Medicaid programs can use for adjusting capitation payments to health plans that enroll people with disability. Medicaid claims from Colorado, Michigan, Missouri, New York, and Ohio are analyzed to demonstrate that the greater predictability of costs among people with disabilities makes risk adjustment more feasible than for a general population and more critical to creating health systems for people with disability. The application of our diagnostic categories to State claims data is described, including estimated effects on subsequent-year costs of various diagnoses. The challenges of implementing adjustment by diagnosis are explored. PMID- 10172667 TI - Characteristics of children living in group homes. PMID- 10172666 TI - Diagnosis-based risk adjustment for Medicare capitation payments. AB - Using 1991-92 data for a 5-percent Medicare sample, we develop, estimate, and evaluate risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees. Hierarchical coexisting conditions (HCC) models achieve greater explanatory power than diagnostic cost group (DCG) models by taking account of multiple coexisting medical conditions. Prospective models predict average costs of individuals with chronic conditions nearly as well as concurrent models. All models predict medical costs far more accurately than the current health maintenance organization (HMO) payment formula. PMID- 10172668 TI - Disability. Waiting for more than two ticks. PMID- 10172671 TI - Perspectives. Substance abuse treatment not a priority for most health plans. PMID- 10172670 TI - Conflict and quality-of-life concerns in the nursing home. PMID- 10172672 TI - Born in the USA. The medicalization of social problems. AB - As the debate over health care reform intensified a few years ago, Americans questioned their delivery system and pointed to Canada, Great Britain, and other countries as potential models for reform. NHA conducted its own examination of these models and concluded: the United States, and Michigan in particular, will have difficulty improving the health status of its citizens and controlling health care expenditures unless we more effectively deal with a uniquely American phenomenon--the medicalization of social problems. PMID- 10172669 TI - Alteplase: a pharmacoeconomic evaluation of its use in the management of myocardial infarction. AB - Alteplase (recombinant tissue plasminogen activator; rt-PA) is a thrombolytic agent that when given in an accelerated regimen with intravenous heparin has survival advantages compared with streptokinase in the treatment of acute myocardial infarction, as shown by the results of the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial. Although alteplase is more fibrin-specific than streptokinase, alteplase therapy is associated with a small relative increase in the incidence of haemorrhagic stroke, but appears to cause a small relative decrease in the incidence of major bleeding. Because alteplase has a higher acquisition cost than alternative thrombolytic agents, analyses have been undertaken to assess whether administration of alteplase after myocardial infarction is a cost-effective use of healthcare resources. In retrospective analyses undertaken before completion of the GUSTO trial, it was generally assumed, on the basis of better 90-minute patency rates, that alteplase would provide survival advantages compared with streptokinase or conventional nonthrombolytic therapy. Alteplase had acceptable cost-effectiveness ratios compared with conventional therapy and streptokinase therapy from both third-party payer and hospital perspectives. Subgroup analyses demonstrated that alteplase was more cost effective when given early after symptom onset and when given to patients with large infarcts. Prospective evaluations of the cost effectiveness of alteplase in 3-hour and accelerated regimens have similarly demonstrated that alteplase therapy after myocardial infarction improves survival at an 'acceptable' cost. The largest prospective evaluation undertaken to date was performed in conjunction with the GUSTO trial. Primary analysis, on the basis of the clinical findings of the GUSTO trial and prospective collection of cost data from US patients, revealed that the cost effectiveness ratio for accelerated alteplase therapy compared with streptokinase was $US32,687 (1993 dollars) per year of life saved (YLS). This value is most relevant for US patients and lies within the definition of 'cost effective' if $US50,000/YLS is the benchmark for acceptable use of resources. The cost effectiveness ratio for alteplase was most sensitive to assumptions regarding long term survival and cost differences after the first year following treatment. In subgroup analyses, alteplase was a cost-effective treatment option for all elderly patients (> 60 years of age) and all patients > 40 years of age with anterior infarction. Alteplase therapy appears to have in-hospital costs/charges similar to those for primary percutaneous transluminal coronary angioplasty (PTCA), mainly because PTCA appears to have a favourable effect on duration of hospitalisation. Given the technical expertise and facilities required for PTCA, it is likely that thrombolytic therapy will remain the management option of choice in most centres. In conclusion, under the conditions of the GUSTO study, accelerated alteplase in combination with intravenous heparin confers survival advantages compared with streptokinase therapy. While decision-makers must choose how best to use their available healthcare resources, pharmacoeconomic evaluations have confirmed that, on the basis of accepted benchmark values, alteplase therapy is a cost-effective therapeutic option for the treatment of acute myocardial infarction, especially in elderly patients with either anterior or inferior infarcts and nearly all patients with anterior myocardial infarction. Thus, on the basis of clinical and economic data, predominantly provided by the GUSTO trial, alteplase is a cost-effective first-line management option for acute myocardial infarction. PMID- 10172674 TI - Top cardiac centers ranked according to 1995 open-heart volume. PMID- 10172673 TI - What does it mean to be poor in America? PMID- 10172675 TI - Talking among colleagues. Union Memorial Hospital, Baltimore, MD. PMID- 10172676 TI - Service coordination: program development and initial findings. PMID- 10172677 TI - Just say no. Strict policies can help supervisors keep on-the-job drug abuse in check. PMID- 10172678 TI - An issue of equity. Properly valuing the evaluation and management component of the surgical global period. PMID- 10172679 TI - Using patient feedback for creating and improving innovative programs. AB - There are two goals that should be of paramount concern to clinicians today. With the current emphasis on cost control in healthcare, it has become necessary to search for ways to (a) decrease the total burden of illness for costly conditions and (b) compile outcomes data to measure effectiveness and efficiency. This article describes an experimental work therapy program that seeks to address the needs of early-stage Alzheimer's disease and other dementia patients. Feedback from patients and caregivers was used to validate the benefits of the program activities in reducing the total burden of illness. These data also were used as a basis for improving program components. Once the program was well defined, patient and caregiver feedback measures were used to ensure that the program continued to meet their needs. PMID- 10172680 TI - Play it safe in long-term care facilities. AB - Instead of caring for patients, nurses and other healthcare workers at long term facilities are increasingly becoming patients themselves. Over the past decade, the injury rate among nursing home workers jumped by 55%, with more than 200,000 of these workers injured annually. This article discusses the types of injuries suffered and how they can be prevented. PMID- 10172681 TI - Cost containment through pharmaceutical procurement: a Caribbean case study. AB - This article discusses the potential for health sector cost containment in developing countries through improved pharmaceutical procurement. By describing the specific example of the Eastern Caribbean Drug Service (ECDS), which provides a pooled procurement service to nine ministries of health in the small island nations of the Caribbean, it examines the elements of the procurement operation that allowed ECDS to reduce unit costs for pharmaceuticals by over 50 per cent during its first procurement cycle. The analysis of ECDS considers: (1) political will, institutional alliances, and the creation of a public sector monopsony; (2) pooling demand; (3) restricted international tendering and the pharmaceutical industry; (4) estimating demand and supplier guarantees; (5) reducing variety and increasing volume through standardizing pack sizes, dosage forms and strengths; (6) generic bidding and therapeutic alternative bidding; (7) mode of transport from foreign suppliers; (8) financing mechanisms, including choice of currency, foreign exchange, and terms of payment; (9) market conditions and crafting and enforcing supplier contracts; and, (10) the adjudication process, including consideration of suppliers' past performance, precision requirements in the manufacturing process, number of products awarded to suppliers, and issues of judgment. The authors consider the relevance of this agency's experience to other developing countries by providing a blueprint that can be adopted or modified to suit other situations. PMID- 10172682 TI - Mission accomplished: RhIG protocol streamlined. PMID- 10172683 TI - New and emerging pathogens. Part 5. Those crazy cocci: more virulent and resistant to antibiotics than ever. PMID- 10172684 TI - Correlates of functioning in a population with dual diagnoses: an examination of diagnosis and problem history. AB - This study examines the relationship between diagnosis and life functioning using the Addiction Severity Index (ASI) with 467 hospitalized individuals with mental illness and substance abuse problems. Persons diagnosed with schizophrenia were the best functioning group across most of the ASI domains except employment and psychiatric functioning. More robust relationships were found between problem history (i.e., prior symptomatology or treatment) and current functioning. Respondents with histories of drug treatment, prior experience of anxiety and depression, self-injurious behavior, or violence control problems experienced more severe medical, drug, alcohol, psychiatric, legal, and family/social problems at the time of hospitalization. Violence control problems were related to drug use and criminal involvement, whereas self-injurious behavior was more often related to alcohol use and psychiatric distress. These findings suggest that problem history may be a stronger predictor of treatment need at the time of hospital entry than are more commonly used indexes, such as diagnosis. PMID- 10172685 TI - Social model treatment and individuals with dual diagnoses: an ethnographic analysis of therapeutic practice. AB - Concurrent substance and psychiatric problems have been shown to significantly reduce the probability of successful treatment outcomes while increasing vulnerability to a range of troubles including homelessness, incarceration, physical health problems, and criminal victimization. This article presents an ethnographic analysis of treatment processes in a residential social model treatment program specifically designed for individuals with dual diagnoses in an effort to inform current debates with empirically grounded knowledge regarding therapeutic practice itself. The article focuses on four fundamental themes bearing on therapeutic practice in this residential program: social model treatment; the formulation of clinical identities; recovery, personal responsibility, and authority; and the measurement of therapeutic success. In conclusion, the article suggests that the central role played by program residents in the therapeutic process deserves particular attention and makes recommendations regarding mental health services delivery that, if followed, might invigorate treatment efficacy. PMID- 10172686 TI - Program development and integrated treatment across systems for dual diagnosis: mental illness, drug addiction, and alcoholism (MIDAA). AB - Numerous bureaus of mental health, drug addiction, and alcoholism are designated to provide service to persons who have discrete singular disorders of mental illness, drug addiction, or alcoholism. Mental health and substance abuse programs (nationally and internationally) have evolved with this singular limited service capacity. Contrasting incompatible philosophies and treatment methods across the systems have resulted in minimal services for persons with dual diagnoses. The project the authors have outlined is an example of the development of a dual/multiple-disorder program that integrates these diverse systems and provides comprehensive services within each of the programs of each delivery system. These programs are cost-effective, use existing facilities, train and cross-train existing staff, correct the issues of incompatible treatment interventions, and end the dilemma of gaps in services systems and limited referral resources. As a result, the availability and quality of care for persons with dual diagnoses is greatly improved. PMID- 10172688 TI - Private sector coverage of people with dual diagnoses. AB - In general, people with dual diagnoses account for a significant proportion of both the mental health and substance abuse populations. Most published information on dual diagnosis comes from research on selected treatment programs that are largely funded from public sources. This analysis uses private health insurance claims and eligibility files for 1989 to 1991 for three large firms to identify individuals with both substance abuse and mental health claims and to examine their characteristics, charges, and utilization. More than half of people with dual diagnoses incurred significant charges over three years in both mental health and substance abuse. These individuals with high mental health charges were more likely to be male than were patients with mental health claims alone; they were less likely to be male than were patients with claims for substance abuse and no mental health services. They were also significantly younger than were patients with substance abuse or mental health utilization only for two of the firms. The average charges for people with dual diagnoses were higher than those for patients with substance abuse or mental health claims only. PMID- 10172687 TI - Exploring the diversity of dual diagnosis: utility of cluster analysis for program planning. AB - This study demonstrates the utility of using cluster analysis to explore the heterogeneity of dual diagnosis populations so as to facilitate planning and implementation of individualized treatment programs. A sample of 467 persons admitted to a state psychiatric hospital with DSM-III-R psychiatric diagnoses and substance abuse problems were interviewed on the Addiction Severity Index (ASI) and other measures to assess psychological, social, and community functioning. Scores on seven ASI severity ratings (medical, employment, alcohol, drug, legal, family, and psychiatric functioning) were used to group patients into seven homogeneous subgroups using cluster analysis: best functioning, unhealthy alcohol abuse, functioning alcohol abuse, drug abuse, functioning polyabuse, criminal polyabuse, and unhealthy polyabuse. Cluster reliability and validity were demonstrated using split-half tests as well as cross-sectional and longitudinal analyses. Results illustrate the extreme heterogeneity of dual diagnosis and are suggestive of how individualized treatment programs can be matched to the particular needs of patients with dual diagnoses. PMID- 10172689 TI - Toward cost-effective care for persons with dual diagnoses. AB - Implementing services that control costs and improve client functioning for persons with both severe psychiatric and substance disorders is paramount in a managed care environment. In this clinical trial, standard mental health care augmented by the behavioral skills intervention was more effective than two other approaches (case management and modified 12-step recovery) in interventions with persons with dual diagnoses across indicators of psychosocial adjustment, psychiatric and substance abuse symptoms, and mental health service costs. These findings reinforce the need to address mental health and substance disorders concomitantly; to provide skill-building interventions as the primary ingredient of active treatment to address various instrumental, coping, and social skill deficits that clients with dual diagnoses have; and to monitor the effectiveness of the services and client progress every six months on multiple adjustment and symptomatology dimensions. PMID- 10172690 TI - The role of health care organizations in integrating care for persons with special health care needs. AB - Health care organizations must use research, evaluation, and enhanced management and communication strategies to effectively provide high quality care for special populations. Activities that focus on provider education, enhanced data applications, and consensus building inside and outside the organization are only some of the means by which health plans can achieve improved outcomes for persons with special health care needs. PMID- 10172691 TI - Enhancing preventive and primary care for children with chronic or disabling conditions served in health maintenance organizations. AB - Health maintenance organizations serve an estimated 20 percent of the child population, approximately 12 million children, many of whom have chronic conditions or disabling conditions. These children consume a disproportionate share of health resources and represent an important challenge in terms of care management. As HMOs increasingly enroll children with private insurance and Medicaid who have various physical, developmental, behavioral, and emotional disorders, they must find new and innovative ways to provide their care. Almost one third of children are affected by chronic conditions, and a smaller percentage (6 percent) suffer from chronic disabling conditions. Seven design elements for enhancing preventive and primary care for children with chronic conditions are presented in this article with illustrative examples from HMOs and state Medicaid programs. PMID- 10172692 TI - Caring for children with special needs in HMOs: the consumer's perspective. AB - HMOs should design and include in their services case management systems and health plan policies that meet the special needs of children with chronic illness and their families. Information provided by the plan on case management support and access to specialty care services is critical in helping families choose HMOs that can best serve their child. A child advocate illustrates certain steps, including partnership roles, that health plans can take to assist families with children with special needs. PMID- 10172693 TI - A Medicaid mental health carveout program: the Massachusetts experience. AB - Private sector contracts with Medicaid mental health programs have the potential to help states offer quality improvements and cost savings for chronically mentally ill populations. A Massachusetts experience illustrates how state agencies, community providers, and a private, mental health management firm collaborated to reduce rising Medicaid mental health and substance abuse costs and improve access and quality of care for Medicaid recipients. PMID- 10172694 TI - How to organize and implement health care ergonomics teams. AB - Using a systems approach to safety and health management through a comprehensive ergonomic program addresses workplace processes, operations and conditions as interdependent systems in order to identify and eliminate or reduce all types of ergonomic hazards to employees. This document examines the way one health care facility improved its ergonomic program using this approach, from early data collection to implementation of the new plan. By creating several teams with different areas of concern, they set out to reduce ergonomic-related injuries in their facility by 10 percent. PMID- 10172695 TI - The cost of Alzheimer's disease. Will drug treatment ease the burden? PMID- 10172696 TI - The 4S study and its pharmacoeconomic implications. PMID- 10172698 TI - Cost pressures to fall mainly on hospitals, other providers. PMID- 10172697 TI - Propofol. A pharmacoeconomic appraisal of its use in day case surgery. AB - Propofol is an intravenous anaesthetic agent that has become widely used in day case surgery. It induces anaesthesia rapidly and 'smoothly', is associated with a quick recovery and has a lower incidence of postoperative nausea and vomiting (PONV) than other agents. In studies comparing propofol with other intravenous anaesthetics (most commonly thiopental sodium) in day case surgery, the use of propofol as induction and/or maintenance anaesthesia was associated with a shorter time to intermediate recovery (street fitness or time to discharge), although the mean time difference was generally less than 1 hour. However, when compared with volatile anaesthetics (particularly desflurane), the differences in time to discharge were smaller. Propofol is also associated with less PONV than barbiturates, volatile anaesthetics or barbiturate/volatile anaesthetic combinations in the immediate postoperative period. The faster recovery time and the decreased incidence of PONV have potential pharmacoeconomic implications. Delayed recovery can increase the use of hospital resources and decrease patient throughput and PONV can incur costs due to an increase in adjunctive medications usage (e.g. antiemetics), nursing time or unintended admissions. The pharmacoeconomic significance of these properties of propofol requires formal evaluation. Pharmacoeconomic investigations, such as cost-effectiveness, cost benefit and cost-minimisation studies, which include clinical outcome parameters are difficult to conduct in anaesthesia since there are no objective measures of equipotency between anaesthetic agents and because there is no specific health outcome associated with the delivery of anaesthesia. At present, cost-utility studies are not possible because there are no validated instruments for measuring utility in the provision of anaesthesia. To date, pharmacoeconomic analyses of propofol (and other anaesthetic agents) in day case surgery have been restricted to partial cost analyses. Only 2 of these have included the cost of drug wastage, an important consideration since propofol contains no preservative. With 1 exception, these studies have only included drug acquisition costs and propofol was reported to be approximately 1- to 3-fold as costly as other intravenous/inhalational agents. However, these limited analyses have little applicability since they do not include all relevant costs. In addition to drug acquisition costs, pharmacoeconomic studies should also include other direct costs such as the cost of adjunctive medications (including treatment necessary for adverse events), equipment and staff time, indirect costs such as loss of productivity and/or wages and intangible costs such as patient satisfaction and quality of life. A few studies have attempted to quantify some of these factors. Based on differences in recovery time, 2 studies have estimated a decreased demand for nursing staff time associated with the use of propofol compared with thiopental sodium/isoflurane. In addition, informal patient satisfaction assessments show propofol to be equal to or better than other anaesthetic agents. With these broader considerations, it thus remains for future studies to quantify the intangible and indirect costs associated with propofol anaesthesia, to determine whether differences in recovery between propofol and other agents (especially the newer inhalational anaesthetics) are of economic importance, and to identify those instances where propofol use provides the greatest value for available funds. PMID- 10172699 TI - Medicare program: special enrollment periods and waiting period--HCFA. Final rules with comment period. PMID- 10172700 TI - Cut adverse drug reactions with clinical decision support. PMID- 10172701 TI - The acute hospital sector in selected OECD countries: an analysis of expenditure and utilization. AB - As the costliness of the acute hospital sector is of critical importance to the demands on the health sector as a whole, this paper presents an assessment of the trends in expenditure and utilization of this service area for selected OECD countries since the early 1980's. This analysis shows that despite reductions in bed availability and lengths of stay, admission rates and expenditures have generally been increasing over the period. As the continuing rise in expenditure levels is cause for growing concern at the individual country level, the reform of the financing of the acute hospital sector has become a more urgent priority. PMID- 10172702 TI - The use of phones by elders with disabilities: problems, interventions, costs. AB - Recognizing the important role the telephone plays in the life of frail elders, this study sought to gain a better understanding of the problems these elders encounter in using their phones to meet their needs. Starting with a sample of 354 frail elders, it was determined that 35, or just under 10%, were having some difficulty in the use of their phones. Twenty-two of these 35 subjects were randomly selected for an assessment of their impairments and phone setups in their homes. Interventions were provided to 19 of the 22 subjects, with two subjects refusing an intervention. At a 6-week follow-up call, all subjects were satisfied with the new phone or phone-related equipment. At a 6-month follow-up, 95% of subjects expressed satisfaction with the intervention. Phone usage increased by 50% for subjects provided a phone intervention. Average cost of equipment was $70.45; cost of personnel time was significantly higher. Recommendations are made for addressing the phone-related problems of frail elders. PMID- 10172703 TI - People with mobility impairments in the United States today and in 2010. AB - This article presents a study undertaken to develop a population profile of people with mobility impairments in the U.S.A. today and to estimate the profile of people with mobility impairments in the year 2010. The profile was developed under contract to the U.S. Architectural and Transportation Barriers Compliance Board (Access Board) as part of a project to examine technical requirements for ramp slope and length. The profile was used to establish a representative (both today and in the future) sampling frame for human subjects in the current project, as well as to guide the Access Board in developing accessibility guidelines in the future. The present article highlights findings concerning mobility impairments in the population today and trends likely to influence the future prevalence of such impairments. The findings have implications for accessibility requirements and disability policy in general. PMID- 10172704 TI - The effects of oligomers content and surface morphology on foreign-body tumorigenesis with polyetherurethanes: two years subcutaneous implantation study in rats. AB - Three polyurethane materials were prepared by removing and adding the leachable oligomers from and to the same polyetherurethane (PEU). The three PEU materials were dissolved in tetrahydrofuran (THF) and dimethyformamide (DMF) and the solutions were cast on a glass plate to make films of smooth and foamed surfaces, respectively. These six materials and polydimethylsioxane (silicone) were implanted into subcutaneous pocket of rats for 2 years to evaluate the long-term effects around the implant. Among the smooth surface implants, PEU materials induced a higher incidence of tissue responses, including tumor formation than silicone. However, no relationship between the oligomer content and the tissue responses was found. Changing surface morphology from a smooth to a foamed one prolonged the latent period of tumor development and decreased the total tumor incidence. PMID- 10172706 TI - Frontiers in laparoscopy: economic issues and future perspectives. AB - A little over 5 years ago, laparoscopy was introduced into the field of urology via the pioneering work of William Schuessler, and later Howard Winfield, in the realm of laparoscopic pelvic lymph node dissection. Since then, much has happened in this area and in reconstructive laparoscopic surgery. For urologists pursuing laparoscopic training, lymph node dissection remains the primary setting in which to learn the technique. In the first part of this roundtable, our panelists discussed applications of laparoscopy. Here, they examine economic issues related to the technology and give us a glimpse of what the future holds. PMID- 10172705 TI - Treating myocardial infarction in the post-GUSTO era. A US perspective. PMID- 10172707 TI - Progress in interventional cardiology. PMID- 10172708 TI - Alloplastic materials for orbital surgery. AB - Alloplastic materials are used as an adjunct to many types of ophthalmic surgery. This article reviews recent advancements in the use of alloplastic materials for orbital surgery, with emphasis on anophthalmic socket and bony orbital reconstruction. Several new porous materials and resorbable implants offer exciting prospects in the management of anophthalmos and orbital fractures. PMID- 10172709 TI - Orbital trauma and reconstruction. AB - This article reviews the most recent topics of investigation concerning orbital trauma and reconstruction. During the past year there have been many articles of interest regarding management of the sequelae to orbital trauma, pathophysiologic process in orbital injury, diagnostic techniques, as well as operative methods, materials, and complications. Recent research has focused on the pathophysiology of traumatic optic neuropathy and visual compromise in orbital hemorrhage. Theories regarding the etiology of atraumatic spontaneous enophthalmos are described. In the realm of orbital reconstruction, rigid fixation systems have ben extensively investigated for use in orbital and facial trauma. Investigators have begun to address the question of potential complications from rigid fixation in children. PMID- 10172710 TI - Equally efficacious asthma management with budesonide 800 micrograms administered by Turbuhaler or with beclomethasone dipropionate > or = 1500 micrograms given through a pressurized metered-dose inhaler with spacer. The French Budesonide Trial Group. AB - To avoid the side effects associated with long-term administration of high doses of inhaled glucocorticosteroids, they should be used at the lowest effective dose. This study compared the clinical efficacy of budesonide given via a dry powder, inspiratory flow-driven device (Turbuhaler), at a daily dose of 800 micrograms, with beclomethasone dipropionate (BDP) 1500 to 2000 micrograms given via pressurized metered-dose inhaler (pMDI) with spacer to adults requiring the latter dose of BDP to control their asthma. The study was performed as a 2-week run-in, 8-week open, randomized, multicenter, parallel-group design. Adult asthmatics with a forced expiratory volume in 1 second 55% or more of predicted normal and receiving BDP 1500 to 2000 micrograms daily entered the study. After a 2-week run-in, one group continued with BDP and the other was switched to budesonide through the Turbuhaler. After 8 weeks, morning peak expiratory flow (PEF) had increased by 5.9 L/min from a mean of 390 L/min in the budesonide group and by 1.9 L/min from a mean of 402 L/min in the BDP group. No clinically or statistically significant differences between groups were evident with regard to the change in this primary variable. Similarly, only small changes in evening PEF and secondary variables of lung function were seen, with no statistically significant difference between groups. The authors concluded that both treatments were equivalent in managing asthma in adult patients with stable asthma. PMID- 10172712 TI - Ocular toxicology. AB - In this review of recent articles on ocular toxicology, the author concentrates on undesirable effects on the eye induced by systemically used xenobiotics. These effects include increased tear flow elicited by systemic cyclosporine; uveitis associated with inactivated influenza vaccine, intravenous immunoglobulins, or skin tattoos; iritis associated with intravenous streptokinase; corneal epithelial erosion associated with the use of an alcohol-based antimisting spray; decreased color vision associated with workplace exposure to perchloroethylene, or to digoxin; myocardial ischemia induced by topical atropine; and systemic exposure to cyclopentolate after topical instillation. Ocular irritation associated with systemic use of 5-fluorouracil may be attenuated with prophylactic ice packs. At doses evaluated for treatment of choroidal neovascularization, systemic alpha interferon leads to toxicity in multiple organ systems. Promethazine precipitates when injected into intravenous lines with fluorescein. No drug achieves ultimate efficacy or ultimate safety. Thus, the decision to employ a given therapy involves a physician's evaluation of its therapeutic index-the ratio between efficacy and toxicity. PMID- 10172711 TI - Toward a social ecology of community coalitions. AB - This article is guided by several premises. First, community coalitions fit with a social ecology perspective of health promotion because they work with multiple domains and promote community change. Second, the community context affects the functioning of coalitions. Third, key leaders are an important part of the social fabric of a community and influence the social ecology of a community; therefore a coalition should include key leaders and influence them and their organizations. The purpose of this article is to advance an understanding of the social ecology of coalitions by describing concepts, variables and results from two national studies and by providing anecdotal evidence and a measure of key leaders from our own work. After briefly defining and describing community coalitions, we: (1) review literature on contextual variables and community coalitions, (2) provide examples of contextual variables influencing community coalition development, and (3) discuss the relationship of key leaders in multiple domains and community coalitions. The article concludes with a discussion of the need for a framework of contextual variables and a promising next step. PMID- 10172713 TI - Symptom heterogeneity in comorbid alcohol disorder. AB - The heterogeneity of signs and symptoms of alcohol disorder was examined in a community sample of 1,955 persons with either alcohol disorder alone or alcohol disorder plus one of four categories of major mental disorder (antisocial personality disorder, schizophrenia, affective disorder, anxiety disorder). When all diagnostic categories were combined, persons with comorbid mental and alcohol disorders showed evidence of more severe alcohol-related symptoms than did persons with alcohol disorder alone. Distinct symptom patterns distinguished the four diagnostic groups, reflecting heterogeneity in the manifestation of comorbid alcohol disorder. Most notably, comorbid antisocial personality disorder and schizophrenia were associated with higher levels of alcohol consumption and more severe social consequences of alcohol use. These findings substantiate the need for development of specialized dual diagnosis programs and suggest that additional specialization may be required to address diagnostic group differences in the characteristics of comorbid alcohol disorder. PMID- 10172714 TI - Residential alternatives to hospitalization for patients with severe and persistent mental illness: should patients with comorbid substance abuse be excluded? AB - Residential alternatives to hospitalization for adults with severe mental illness in crisis were not designed for, and often exclude, persons with coexisting substance abuse disorders. Given high comorbidity rates, however, it is important to know whether residential alternatives can be effective for patients with dual diagnoses. To explore the impact of comorbidity on treatment outcomes, structured interviews were conducted at admission and discharge with 92 consecutive admissions to a residential alternative. Using the Structured Clinical Interview for DSM-III-R, two groups were identified: 24 patients with and 68 patients without comorbid substance abuse disorders. At admission, the two groups were similar in demographic and clinical characteristics. The treatment was effective independent of comorbidity; at discharge, treatment success, symptom improvement, and patient satisfaction were similar for both groups. Persons with coexisting substance abuse disorders remained in residence a week longer, but the difference was not statistically significant. Residential alternatives appear suitable for patients with dual diagnoses. PMID- 10172715 TI - Practice brief. Issue: Protecting patient information after a closure. American Health Information Management Association. PMID- 10172717 TI - Hospital's vertical expansion of garage complex adds efficiency, safety. PMID- 10172716 TI - Smart tips for tackling the pesky no-show problem. PMID- 10172718 TI - Error budgets for quality management--practical tools for planning and assuring the analytical quality of laboratory testing processes. AB - Analytical quality is often assumed, rather than being assured or guaranteed. Given that it is still essential that laboratories produce reliable test results, managers must continue to improve their skills in analytical quality management. This paper shows managers how to use error budgets and charts of operating specifications (?OPSpecs? charts) to select appropriate control rules and numbers of control measurements, taking into account the analytical or clinical quality required for a test and the imprecision and inaccuracy observed for a method. With currently available tools and a little practice, quality control (QC) procedures can be selected quickly and easily, in just 1 minute or less. Future technology is expected to automate the QC selection process and provide dynamic quality control. PMID- 10172719 TI - The ethics of billing. PMID- 10172720 TI - Autologous blood donation in cardiac patients. AB - Despite the advantages of autologous blood transfusion, doubt still remains about its safety in cardiac patients. We report our experience with 439 cardiac patients who donated a total of 1692 units of blood before coronary, valvular, or congenital cardiac operations. During the collections, patients were continuously monitored with ECG, blood pressure, and heart rate. In 22 collections we observed vasovagal reactions, which represents an incidence of 1.3% of the total number of collections. The patients recovered quickly and only in 3 cases was volume replacement with saline needed. There were no other complications which could be related to the preoperative autologous donation program. We feel that, with careful selection of the patients and of the circumstances surrounding the collection of blood, autologous blood donation in cardiac patients is a safe and beneficial experience. PMID- 10172721 TI - Gas exchange in the airways. AB - The primary function of the lungs is to exchange the respiratory gases, O2 and CO2, between the atmosphere and the blood. Our overall understanding of the lungs as a gas-exchanging organ has improved considerably over the past four decades. We now know that the dynamics of gas exchange depend on the blood solubility (beta b, ml gas ml blood-1 atm-1) of the gas. While the major focus of research has rightly been on the respiratory gases, the lungs exchange a wide spectrum of gases ranging from very low solubility gases such as SF6 or helium (beta b = 0.01) to water vapor (beta b = 20,000). O2 (beta b = 0.7) and CO2 (beta b = 3.0) exchange primarily in the alveolar region of the lung and their exchange is limited by the rate of ventilation and perfusion. In contrast, highly soluble gases (beta b > 100) are likely to exchange primarily in the airways of the lung. We have used exhaled ethanol (beta b = 1756) profiles for humans, steady-state exchange of six inert gases (0.01 < beta b < 300) in an in situ dog trachea, and a mathematical model to analyze the dynamics of airway gas exchange. We make the following conclusion: (1) ethanol exchanges entirely within the airways, and (2) the magnitude of perfusion- and diffusion-related resistance to airway gas exchange is the same. PMID- 10172722 TI - Sterile by any other name. AB - Will manufacturers of CE-marked medical devices produced under aseptic conditions be able to label their products with the harmonized symbol for sterile? Perhaps not. This is because there are differences of opinion concerning the sterility assurance level that a European harmonized symbol for sterile should represent. This article will discuss the current proposed criteria for labelling a medical device with the European harmonized symbol for sterile, a more stringent approach, and some factors that should be taken into consideration before reaching any final decisions. PMID- 10172723 TI - Amendments to the medical device directive. AB - Variations in the transposition of the Medical Device Directive (MDD) by some countries has led to problems of interpretation and compliance, and there is still some way to go to achieve harmonization throughout Europe. This article suggests amendments to the MDD that should be introduced through the mechanism of the In Vitro Diagnostics Directive. PMID- 10172725 TI - Using health insurance claims data to analyze substance abuse charges and utilization. PMID- 10172724 TI - AIDS and the ADA: physician liability for discriminatory nontreatment or referral of AIDS patients. PMID- 10172726 TI - Pain management and psychosocial issues in HIV and AIDS. PMID- 10172727 TI - Trials of the European Working Party on streptokinase and of the European Cooperative Study Group on alteplase in patients with acute myocardial infarction. European Investigators. PMID- 10172728 TI - Empirical study of the Americans with Disabilities Act: employment issues from 1990 to 1994. AB - The Americans with Disabilities Act (ADA) of 1990 is the most comprehensive federal civil rights law addressing discrimination against one-fifth of the American population. This article is meant to contribute to the emerging dialogue on ADA implementation by presenting information from a longitudinal investigation of employment integration and economic opportunity under the employment provisions of the ADA, set forth in Title I of the act. The broader relevance of the investigation to emerging questions under Title I law is described. Thereafter, the investigation's seven core findings are presented, and then the implications for future investigation of the ADA are examined. PMID- 10172729 TI - Cell adhesion to biomaterials: correlations between surface charge, surface roughness, adsorbed protein, and cell morphology. AB - Adhesion of cells to a biomaterial surface can be a major factor mediating its biocompatibility. In this investigation, jet impingement techniques were used to quantify strength of cellular adhesion to various material surfaces. The metals tested: HS25 (a cobalt-based alloy similar to F75), 316L stainless steel, Ti-6Al 4V, and commercially pure tantalum, exhibited nearly a fivefold increase in adhesion strength above that characteristic of the polymeric materials tested (PTFE, silicone rubber, and HDPE). The present study examines physical and biological factors that might influence fibroblast adhesion to the biomaterial surface. The relation between surface charge and cellular adhesion was investigated in a controlled manner by measuring adhesion strength over a range of charge densities. The cells showed charge and electrical potential-dependent adhesion maxima, suggesting that surface alloying for optimum adherence may be possible. In a preliminary series of experiments adsorbed serum protein layers on a series of materials of differing adherence were investigated using gel electrophoresis to assess protein composition. Analysis of adsorbed proteins revealed little difference in relative abundance or total adsorption quantity. SEM micrographs of cells on Ti-6Al-4V and silicone rubber (high and low adhesion materials, respectively) demonstrated differences in cell morphology and cell density. PMID- 10172730 TI - Economic outcomes for the treatment of allergic rhinitis. AB - The purpose of this article is to review the literature related to economic outcomes associated with treating allergic rhinitis. A literature review was conducted using 'Medline' and the in-house database of the publishers of this journal for articles published between January 1991 and January 1996. Only 3 cost outcome analyses that compared alternative treatments for allergic rhinitis were found. Given the limited number of full economic evaluations, much of this article focuses on issues related to direct and indirect costs and outcome measures that should be considered when performing an economic evaluation of allergic rhinitis. We conclude that more comprehensive analyses using a wide array of costs and outcomes are needed. At present, it is not possible to draw general conclusions regarding the economic value of alternative treatments for allergic rhinitis. PMID- 10172731 TI - Prosthetic design considerations in total shoulder arthroplasty. AB - Total shoulder replacements should, as far as possible, be designed after normal anatomy. A small mismatch in curvature between the humeral head and glenoid surfaces may reduce edge loading when the humerus translates on the glenoid, but may increase contact stresses caused by point loading. Modularity increases sizing options but decreases head size for a given soft-tissue space and introduces the risk of component dissociation. Releases and soft-tissue balancing at surgery, and rehabilitation afterwards, are more important than the type of glenohumeral prosthesis implanted. PMID- 10172732 TI - Emergency postpartum hysterectomy. AB - Twenty-two deliveries were followed by emergency postpartum hysterectomy among 109,842 deliveries in the last 10 years, an incidence of 1 in 4992 deliveries (20/100,000). The leading causes of emergency postpartum hysterectomy were uterine rupture in 8 (36.3%), uterine atony in 7 (31.8%), and abnormally adherent placenta in 6 (27.3%) patients. Five of the uterine rupture cases followed previous cesarean births, whereas the other 3 followed dystocia. Of the 7 patients with uterine atony, 4 were after vaginal delivery and 3 were after cesarean birth. Of the 6 patients with adherent placenta, 4 had repeat cesarean deliveries and the other 2 were subjected to cesarean section for postterm pregnancies. The maternal mortality rate was found to be 4.5% (1/22). The perioperative morbidity included blood transfusion in 72.2%, febrile morbidity in 40.9%, and wound infection in 13.6% of the patients. Fetal mortality rate was 45.4%. PMID- 10172733 TI - Comparative study of laparoscopy vs. laparotomy for adnexal surgery: efficacy, safety, and cyst rupture. AB - Operative laparoscopy is becoming routine in gynecologic surgery. This study was designed to compare the safety and efficacy of laparoscopy and laparotomy for ovarian cystectomy and adnexectomy. The medical records of 32 patients who underwent operative laparoscopy for adnexal masses (group L) were reviewed and compared with those of 32 patients who underwent surgical laparotomy (group S) for similar indications. All patients sustained either an ovarian cystectomy or adnexectomy. The group were matched for age, weight, and history of previous laparotomy. Median operating time for group L was 90 min and for group S was 85 min. Blood loss was significantly less in group L (33.4 +/- 22 mL) than in group S (84.6 +/- 22.2 mL), p < 0.0001. There were two intraoperative complications in group L and one in group S. Significantly less patients in group L had postoperative fevers (16%) as compared with those in group S (69%), p < 0.0001. There was a higher incidence of cyst rupture when cystectomy was performed in patients from group L (7 of 21) as compared with patients from group S (2 of 17). No such difference in cyst rupture was noted when an adnexectomy was affected in group L (1 of 11) and group S (1 of 15). Patients in group L remained in the hospital a shorter time period, 1.5 +/- 0.8 days, than patients in group S, 4.7 +/- 0.9 days, p < 0.0001. Patients in group L required a shorter postoperative recovery time before resuming normal activities, 9.1 +/- 6.6 days, than patients in group L, 27.5 +/- 9.2 days, p < 0.0001. Similarly, patients in group L required less time to become pain free, 10.1 +/- 7.4 days, than patients in group L, 17.7 +/- 6.1 days, p < 0.0005. This study demonstrates a statistically significant decrease in postoperative morbidity and faster recovery in patients undergoing laparoscopy for adnexal surgery as compared with patients undergoing laparotomy for the same procedure. When cystectomy is performed via the laparoscope, there is a higher incidence of cyst rupture than with laparotomy. PMID- 10172734 TI - Laparoscopic silastic band sterilization failures. AB - Silastic band laparoscopic sterilization was introduced in the early 1970s as an alternative to unipolar cautery laparoscopy. Banding eliminates burn injury and reduces tubal destruction. However, in comparison with other methods, the success of Silastic banding may depend more on tubal morphology. This case-control study of 70 banding failures and 140 controls matched for age, gravidity, and date of procedure reveals that morphologic abnormalities of pelvic organs (adhesions or tubal thickening) or a history of a disease known to cause such abnormalities (pelvic inflammatory disease) increases the risk of sterilization failure. The risk of failure is further increased if the procedure is performed immediately postpartum or postabortion rather than as an interval procedure. PMID- 10172735 TI - Don't get suckered into missing an MI. PMID- 10172736 TI - Essential requirements for clinical laboratory science. AB - OBJECTIVE: To present a sample list of essential requirements for clinical laboratory science (CLS) education that support the requirements of the Americans with Disabilities Act (ADA). The essential requirements provide a basis for student admission and academic progress measurement. DATA SOURCES: Over 700 articles have appeared in various professional and trade journals on the impact of the ADA since it was signed in 1990. DATA EXTRACTION: Literature review. DATA SYNTHESIS: The ADA prohibits discrimination against academically qualified program applicants with disabilities, and requires a list of essential requirements, distinct from academic requirements and distinct from essential functions of jobs, for each academic program. Essential requirements, also called technical standards or functional expectations, are task and attribute-based criteria that define their educational program. Applicants and students must possess or be able to achieve the essential requirements directly or through reasonable accommodations. CONCLUSION: By July 1994, all educators must have been prepared with defensible essential and academic requirements that reflect the needs of their programs, and with appropriate processes for managing applications, academic progress, and program completion that promote equal educational opportunity for qualified individuals with disabilities. PMID- 10172737 TI - Computer programs that teach the interpretation of image-based laboratory tests. AB - OBJECTIVE: To review the effort of the University of Washington (UW) Department of Laboratory Medicine to develop and use personal computer programs to teach the interpretation of image-based clinical laboratory tests to medical technologists and other health care workers. DATA SOURCES: Professional journals and books; Software owned by and licensed by the University of Washington. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: We have been developing interactive personal computer (PC) programs for teaching image-based laboratory tests to medical technologists and other health care workers. The programs, called "Laboratory Tutors," are useful for teaching microscope-based tests and tests based on electrophoresis. Our programs include ANA-Tutor, which teaches the immunofluorescence assay for anti-nuclear antibodies; Gram Stain Tutor, which teaches the direct Gram stain; Electrophoresis-Tutor, which teaches the interpretation of agarose gel protein electrophoretic patterns; Urinalysis Tutor, which teaches the microscopic examination of urine sediment; in addition to other programs. The tutorials are all based on high-quality digital images that were acquired and processed using digital imaging systems. They require minimal computer literacy and have a number of advantages over standard approaches to teaching image-based laboratory tests. The computer tutorials are used in UW's medical technology and medical school curriculum, where they are used as supplements to traditional instruction. CONCLUSION: Laboratory tutors are computer programs that use high resolution digital images to teach the interpretation of image-based laboratory tests. We plan to continue to develop these programs, study their educational effectiveness, and update them periodically. PMID- 10172738 TI - Laser safety programs in general surgery. AB - General surgery represents a speciality where, while any procedure can be performed with lasers, there are no procedures for which the laser is the sine quo non. The general surgeon may perform a variety of procedures with a multitude of laser wavelengths and technologies. Laser safety in general surgery requires a multidisciplinary approach. Effective laser safety requires the oversight of the hospital's "laser usage committee" and "laser safety officer" while providing a workable framework for daily laser use in a variety of clinical scenarios simultaneously. This framework must be user-friendly rather than oppressive. This presentation will describe laser safety at the Rochester General Hospital, a tertiary care, community-based teaching hospital. The safety program incorporates the following components: input to physician credentialing and training, education and in-servicing of nursing and technical personnel, equipment purchase and maintenance, quality assurance, and safety monitoring. The University of Rochester general surgery residency training program mandates laser training during the PGY-2 year. This program stresses the safe use of lasers and provides the basis for graded hands-on experience during the surgical residency. The greatest challenge for laser safety in general surgery centers on the burgeoning field of minimally invasive surgery. Safety assurance must be balanced so as to maintain a safe operating-room environment while ensuring patient safety and the ability to permit the surgery to proceed efficiently. Safety measures for laparoscopic procedures must be sensitive to the needs of the surgical team while not providing confusing signals for the "gallery" observers. This task is critical for the safe operation of lasers in general surgery. Effective laser safety in general surgery requires constant vigilance tempered with sensitivity to the needs of the surgeon and the patient as laser technology and its applications continue to evolve. PMID- 10172739 TI - User desires for wheelchairs. RERC-TET study shows manufacturers would do well to listen to consumers. Rehabilitation Engineering Research Center on Technology Evaluation and Transfer. PMID- 10172740 TI - Marketing or management: which way the future? PMID- 10172741 TI - Bringing order to test orders: one lab's story. PMID- 10172743 TI - POC vs. lab: both may be best in blood gas analysis. PMID- 10172742 TI - For some, it's efficiency through practice guidelines. PMID- 10172744 TI - CAP offers recommendations on selecting surgical specimens for examination. PMID- 10172745 TI - Is consulting an opportunity suited to you? PMID- 10172746 TI - Perioperative services reach into community. PMID- 10172747 TI - The utilisation of public and private hospitals in Victoria: an issue of access? AB - Consumers regard access to hospital services as one of the key components of quality in health care delivery. A mixed public/private system operates in Victoria, but a morbidity collection from private hospitals was commenced only relatively recently. In 1993-94 the collection covered 82 per cent of private hospital separations, and it was considered timely to examine the utilisation patterns in the private system and compare them with those in the public system. Medical and surgical emergencies and other complex conditions and procedures are serviced largely in the public sector, whereas private hospitals are utilised for elective and less complex surgery and non-urgent conditions. Occupancy rates are around 79 per cent in public hospitals and 67 per cent in private hospitals. Elective surgery waiting list data suggest that while urgent cases are treated within a month, significant proportions wait six months or more for non-urgent surgery. Private health insurance is the main factor in determining access to and the utilisation private hospitals. The current Medicare Agreement and the move to separate the role of purchaser and provider may allow the maximal utilisation of private hospitals and diminish the burden of chronic illness. PMID- 10172748 TI - Stroke. Damage control. PMID- 10172749 TI - Aging. Older, longer. PMID- 10172750 TI - Medicare HMOs develop plan for future of Alzheimer's programming. PMID- 10172751 TI - Disease management programs--guidelines for employers. AB - The new disease management programs hold a promise of successful drug maintenance and lower health care costs for participants with certain chronic medical conditions. These programs can benefit both employees and employers, but employers adopting them should take all the steps necessary to bring them under ERISA and to carefully monitor their operation. PMID- 10172752 TI - Programs train healthcare workers in avoiding back injuries. PMID- 10172753 TI - A method evaluation decision chart (MEDx chart) for judging method performance. AB - OBJECTIVE: To introduce a new graphical tool that improves the process of making decisions about method performance. DATA SOURCES: Scientific literature, mathematical models, and the author's experience. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Relationship to charts of operating specifications (OPSpecs charts) provides guidance for classification of performance as poor, marginal, good, or excellent. CONCLUSION: Objective decisions on the performance of methods can be made quickly and easily with the aid of a Method Evaluation Decision Chart. PMID- 10172754 TI - Alcohol and other drugs of abuse in pregnancy. AB - This paper presents an overview of the Mother-Baby Chemical Health Program (MBCHP), which was designed to decrease preterm births among pregnant women who use and abuse drugs. Three hundred and fifty-two patients enrolled in the program between January 1990 and December 1992 were followed. More than 90% of the women involved in the MBCHP did not use substances during their pregnancies. Approximately 93% of the participants delivered at 37 or more weeks gestation, and over 91% of the infants weighed 2500 grams or more. PMID- 10172755 TI - Battling drug use in pregnancy. AB - Holy Spirit Hospital, Camp Hill, PA, established the Capital Region Maternal Assistance Program (MAP) to reduce the incidence of substance abuse in pregnant women and new mothers by creating a bridge between perinatal and substance abuse services in the community. Two nurses at Holy Spirit developed the idea of setting up a program in the community and obtained permission from the hospital administrators to pursue the project. They drew in staff from an inner-city obstetrical clinic in nearby Harrisburg, PA, and formed a work group to plan and build a consortium of agencies. Another hospital joined the consortium within a year. With several grants, the team hired an MAP coordinator, who in turn hired care managers, leased vans, and started the MAP in an office on the campus of Holy Spirit Hospital. The program focuses on case management (facilitating access to available community (resources) as opposed to direct service delivery. Referrals come from a variety of healthcare providers, county courts, probation and parole offices, and Children and Youth Services. Care managers visit clients weekly in their homes; coordinate services provided by multiple hospitals, clinics, and agencies; help clients set goals and become self-reliant; and address problems with transportation and babysitting. PMID- 10172756 TI - Increase in health care costs due to technological diffusion in diagnostic tests and diagnostic imaging. PMID- 10172757 TI - Cost-effective standardization of urine sediment analysis. PMID- 10172758 TI - EN 552: validating 25 kGy as a sterilization dose. AB - EN 552 and ISO 11137 present challenges to the historically accepted dose of 25 kGy for sterilizing medical devices. New demands are being made of manufacturers who must now supply experimental evidence to substantiate the effectiveness of 25 kGy. This article explains those demands and provides guidance on meeting them. Some of the shortcomings of the standards and, in particular, the alarming cost issues are examined. PMID- 10172759 TI - European standards and the In Vitro Diagnostic Directive: current status. AB - The role of harmonized standards to support the proposed In Vitro Diagnostic Directive is examined in this article. EDMA is undertaking a number of activities to aid the standards work. These projects include guidelines on how to construct a technical file and how to conduct risk analysis. These and other initiatives will ensure the active participation of the IVD industry in the formulation of the standards. PMID- 10172760 TI - Dose setting and auditing. AB - How have the new standards for dose setting and dose auditing been received by manufacturers and how are they responding to the challenges? From the view-point of a UK provider of contract sterilization services, this article comments on the situation faced by the different-sized companies in the industry. PMID- 10172761 TI - Medical device technology 1996 sterilization survey. PMID- 10172762 TI - Are national drug expenditure control policies compatible with a single European market? AB - Turning a set of independent national markets into a single market is by no means an easy undertaking, especially when the original situation is characterised by a high level of public intervention, as is the case in the drug markets. This article describes the recent trends and the present situation with regard to public intervention in the Spanish drug market, and the conflicts faced in the process of integration into the single European market. The main conclusion is that building a single market should not only mean the elimination of trade barriers among the countries concerned, but that it also necessitates addressing the problems derived from the regulatory policies applied by the national authorities of member states, which may conflict with the working of a single market. PMID- 10172763 TI - Group living for elderly patients with dementia--a cost analysis. AB - The average labour cost of group living for elderly people suffering from senile dementia amounted to just over SEK 230,000 per patient and year, or SEK 639 per patient and day (24h), in 1992 prices. These figures emerge from our study of 106 group-living units in 46 municipalities in southern Sweden. The average staff density, that is the number of full-time employees on a yearly basis, was 1.06 per patient. The study also shows that the labour cost per patient decreases when the number of patients in a unit increases. Units that form part of other types of residence for the elderly have lower labour costs than detached group-living units (everything else being equal). If individual flats or apartments are large (at least two rooms), a higher staff density was observed. A high degree of functional disability in the individual entails higher staff density and consequently higher labour costs as well. However, in comparison with other forms of caring for the elderly, such disabilities have a less marked effect on labour costs. Everything else being equal, comparatively young residents entail higher labour costs than older ones. The average cost per patient in group-living units amounted to SEK 986 per day. This cost includes the cost of care (labour cost adjusted for flexible salary increments), as well as of capital, operation and maintenance, and food (raw materials). The cost of care amounts to approx. 80% of the estimated cost per patient. The average cost per patient is higher in group living units than in old people's homes; but as regards dementia sufferers with some degree of functional disability, the cost of care is probably about the same in both types of accommodation. PMID- 10172764 TI - Practice brief. PMID- 10172765 TI - Overcoming barriers to integration of primary care and behavioral healthcare: focus on knowledge and skills. PMID- 10172766 TI - Third parties keep on chopping fees. PMID- 10172767 TI - Attitudes about Alzheimer's. PMID- 10172768 TI - The lady in white. Patients on cocaine can behave unpredictably. PMID- 10172769 TI - Cardiac paths: a 'ballet' that keeps OR in step. PMID- 10172770 TI - Pharmacoeconomic evaluation of anesthesia in ambulatory surgery: comparison of desflurane to isoflurane and propofol. PMID- 10172771 TI - Biocompatibility testing for medical implant materials: the activities of F04.16 on biocompatibility test methods. PMID- 10172772 TI - Standardization in orthopaedics: the growth and activities of ASTM's arthroplasty subcommittee. PMID- 10172773 TI - Public policies and private anti-health behavior. PMID- 10172774 TI - Wages, workers' compensation benefits, and drug use: indirect evidence of the effect of drugs on workplace accidents. PMID- 10172775 TI - Do (more and better) drugs keep people out of hospitals? PMID- 10172776 TI - Predictors of attitudes toward three target groups of elderly persons: the well, the physically ill, and patients with Alzheimer's disease. AB - This research compared attitudes of 143 nursing home employees toward three hypothetical target groups of older adults: well elderly persons, physically ill elderly persons, and elderly persons with Alzheimer's disease. Staff provided successively less positive evaluations of physically ill elderly persons and elderly persons with Alzheimer's disease compared to well elderly persons. Age, education, and contact with grandparents differentially predicted positive evaluations toward well and physically ill older adults. Self-efficacy was a significant predictor of positive evaluations across all target groups. Findings suggest that interventions designed to increase staff members' feelings of self efficacy may lead to more positive evaluations of elderly clients and, ultimately, improved quality of care. PMID- 10172777 TI - Alzheimer's disease. The unpaid burden of caring. AB - This study presents detailed estimates of the hours and cost of informal care provided to Alzheimer's disease patients in Northern California. Data were collected over 12 months from 93 community-residing patients and their caregivers and from 94 institutionalized patients and their caregivers. Patients residing in the community received an average of 286 hours per month of unpaid care, whereas institutionalized patients received 36 hours per month. Alternative methods of imputing informal costs are described. The annual value of informal care (in 1990 dollars) is $34,517 for the noninstitutionalized sample and $5,542 for the institutionalized sample. The determinants of informal caregiving were examined and compared in the two settings. The more cognitively impaired the individual, the higher the informal costs no matter what the residential setting. In an institutional setting, the younger the patient and caregiver, the higher the costs. If a caregiver is not a spouse, higher informal care costs were also found. PMID- 10172778 TI - Changes in functional competency in the oldest old. A longitudinal study. AB - Changes in everyday functioning and cognitive abilities are studied longitudinally in a representative sample of the oldest old. Respondents were selected by using census records from all people aged 84, 86, 88, and 90 years old living in an area of South Central Sweden, and then were assessed at 2-year intervals. The findings show high base rates for disabilities and high incidence of cognitive and functional deficits among survivors. Mortality is associated with higher rates of disability at the previous time of assessment. Because of this increased mortality rate among disabled individuals, prevalence does not rise as much as would be expected from the high incidence. Instead, new cases of disabled are partly replacing disabled individuals who died since the previous evaluation. PMID- 10172779 TI - Mental and physical health of male caregivers of a spouse with Alzheimer's disease. AB - Fifty-two male spouse caregivers of patients with Alzheimer's disease and 53 demographically equated controls completed multidimensional assessments of mental and physical health. Results indicate that compared with noncaregiving men, male spouse caregivers have poorer mental and physical health, but only within limited domains of health outcomes. In particular, caregiving men showed higher levels of depression, respiratory system symptoms, and poorer levels of health habits, but did not differ from noncaregiving men on other indexes of physical and mental health. The importance of focusing on understudied specific subgroups of caregivers, such as male spouses, as well as using multidimensional instead of summary measures of mental and physical health are emphasized. PMID- 10172780 TI - Reactions to stigmas. The effect of targets' age and controllability of stigmas. AB - Reactions toward older adults have been widely researched, but the question of whether such reactions are due to age per se or due to the presence of other stigmas (e.g., physical disabilities) has received little attention. This study was designed to investigate emotional reactions and willingness to help older versus younger adults who exhibited a wide range of stigmas, including AIDS, leg amputation, depression, and so on. Guided by attribution theory, the cause of the stigmas was further ascribed to either uncontrollable or controllable factors. Older adults evoked less anger than younger individuals, particularly in the case of blindness, depression, leg amputation, lung cancer, and unemployment. Subjects were also more willing to help an older than a younger amputee. Moreover, stigmas ascribed to uncontrollable factors generally produced less anger, more pity, and greater willingness to help than stigmas described as due to controllable causes. These results provide little support for the notion of ageism, at least within an age range of up to 65 years, but suggest that responses to older adults with stigmas may be subject to positive stereotyping. PMID- 10172781 TI - The condition of American health care. PMID- 10172782 TI - An experience in general surgery: Zambia, Africa. PMID- 10172783 TI - The quest: preventing adverse drug events. PMID- 10172784 TI - Early return-to-work shows promise. PMID- 10172786 TI - Special report. Drug theft from hospital pharmacies: lessons from the 'Syracuse scam'. AB - Theft and drug diversion by employees from hospital pharmacies pose increasing security concerns for institutions as evidenced by the indictment in May 1996 by an Onondaga County, Syracuse, NY, grand jury of four men--one an associate hospital pharmacy director--on charges relating to the theft and resale of more than $3 million in prescription drugs from two Syracuse hospitals over an eight year period. The drugs were used to treat cancer patients. In this report, we'll give you in-depth details of what was stolen and how it was stolen. We'll present some advice from experts on how to prevent your hospital from becoming vulnerable to such large-scale losses. And we'll give you insight into a vast black market that may indicate that what took place at the two Syracuse hospitals may not be an isolated occurrence. PMID- 10172785 TI - Management of cataract. PMID- 10172787 TI - The remote location of an air medical service to the 1995 Special Olympic World Games. PMID- 10172788 TI - Live on the Internet: surgery. AB - A Massachusetts hospital uses live surgical scenes, an interactive survey and other measures to build interest in its Web site. It's also using Internet technology for its growing intranet. PMID- 10172789 TI - Exploring imaging options in lung volume reduction surgery. PMID- 10172790 TI - Risk factors in dental implant failure. AB - The goal of this study was to assess risk factors for dental implant failure. Eighty-three implants were placed in thirty patients who were followed for three years using digital subtraction radiography. The following putative risk factors for implant failure were employed in the model: age, sex, implant length, implant position, implant surface coating, smoking habit, and presence of infection. Implant failure was defined as progressive bone loss compromising the implant. We found that the presence of infection (P < 0.001) and absence of HA coating (P < 0.001) were the primary factors associated with early implant failure. PMID- 10172791 TI - Achieving systematic compliance with the Medical Device Directive. AB - This article outlines key issues that will aid successful compliance with the requirements of the Medical Device Directive through ISO 9000/EN 46000. A well constructed quality system that complies with these standards will also act as a good basis for ensuring compliance with many other global regulatory requirements. PMID- 10172792 TI - Cost saving of 5-day therapy with cefpodoxime proxetil versus standard 10-day beta-lactam therapy for recurrent pharyngotonsillitis in adults. A prospective general practice study. AB - A prospective economic evaluation was undertaken as part of a randomised clinical trial conducted in French general practice. Its aim was to compare the costs and therapeutic outcomes of a 5-day course of cefpodoxime proxetil 100 mg twice daily with 10-day courses of phenoxymethylpenicillin (penicillin V) 1 MIU 3 times daily and amoxicillin-clavulanic acid 500/125 mg 3 times daily for the treatment of recurrent pharyngotonsillitis in 575 adults. Over the 6-month study period, the total cost to society per patient treated with cefpodoxime proxetil was 123 French francs (FF; 1993 values) lower than that for patients treated with phenoxymethylpenicillin and FF227 lower than that for patients treated with amoxicillin-clavulanic acid. This cost saving was primarily attributable to a lower initial drug acquisition cost, and a reduction in the cost associated with lost productivity and general practitioner consultations. Furthermore, as a consequence of a lower relapse rate, the cost-saving ratio for cefpodoxime proxetil, expressed as FF per month free of recurrence, was FF50 less than for phenoxymethylpenicillin and FF60 less than for amoxicillin-clavulanic acid. Thus, a 5-day course of cefpodoxime proxetil is likely to be less costly for treatment of pharyngotonsillitis in the general practice setting than standard 10-day courses of phenoxymethylpenicillin and amoxicillin-clavulanic acid. PMID- 10172793 TI - Methadone programmes. The costs and benefits to society and the individual. PMID- 10172794 TI - Health-related quality of life in inflammatory bowel disease. AB - Inflammatory bowel disease (IBD) is characterised by a chronic, but frequently remitting, clinical course involving significant morbidity. As medical and surgical advances have occurred, focus has shifted from merely reducing mortality to efforts on decreasing morbidity and improving health status. With this paradigm shift has come the need for qualitative and quantitative assessment of outcomes important to the individual patient. Existing disease activity measures fall short in this area. Health-related quality of life encompasses the areas of physical function, somatic sensation, psychological state and social interactions that are affected by one's health status. Instruments have recently been developed for both generic and disease-specific health states, such as IBD. These psychometric measures have proven to be useful tools for patient assessment. Both medical and surgical trials have incorporated these measures as salient outcomes. An additional outcome that has come under closer scrutiny is the cost of medical interventions. The literature on the cost of IBD is sparse but is likely to increase logarithmically in the future. Quality of life and cost issues are becoming central to the study of not just IBD but all of medicine. PMID- 10172795 TI - Drug treatment takes a hit. As substance abuse has surged among teens, coverage for care has been curtailed. PMID- 10172796 TI - Behavioral medicine in the 21st century. Future trends for mental health and drug dependency services. PMID- 10172797 TI - The Rochester Consortium. AB - The laboratories of the six hospitals in Rochester, New York worked together to bid on laboratory services for local managed-care contracts. Their primary goal was to keep shrinking health-care dollars in the Rochester community while providing quality laboratory services for managed-care payers. The six laboratory providers formed a cooperative Consortium that enabled them to compete successfully with national commercial laboratories for referral laboratory testing for outpatients and nonpatients. In 1995, the Consortium was approached by a Rochester-based health maintenance organization (HMO) offering an exclusive contract opportunity based on requirements that included cost reduction and a switch from a fee schedule to a capitated payment method. The Rochester laboratories each agreed to contract terms with the HMO, then followed this success by working with a second, significantly larger HMO, agreeing to provide exclusive laboratory services under a similar, capitated arrangement. The formation and work of the Consortium may provide other hospitals facing daunting competition from large commercial laboratory enterprises with a cooperative arrangement model to provide community-wide laboratory services. PMID- 10172798 TI - The move to community care and the impact of long-term disability on health service provision: some implications for library services. AB - This paper describes the epidemiological and demographic trends underpinning the current shift to primary health care heralded by the Community Care Act. It suggests that the health service is increasingly treating people suffering from long-term disability. Hospitals no longer provide an appropriate setting for the management of long-term disability as hospital-based practitioners cannot integrate treatment modalities into the everyday life experiences of the patient. Community care introduces a social dimension to the traditional medical model of health. The paper examines the information needs generated by both the social model and the medical model of health and considers the types of information required by each model. It concludes by discussing the potential for librarians to influence health care provision via the type of information they make available to practitioners. PMID- 10172799 TI - Report cards: are they passing or failing? One New Yorker says they're passing. PMID- 10172800 TI - Report cards: are they passing or failing? Another New Yorker says they're failing. PMID- 10172801 TI - Contract program for veterans with alcohol and drug dependence disorders--VA. Final rule. AB - This document amends 38 CFR part 17 by adopting as a final rule the proposal to modify eligibility criteria for veterans participating by contract in the Department of Veterans Affairs' programs of alcohol and drug dependence or abuse treatment and rehabilitation in residential and nonresidential facilities. Previous regulations stipulated that, prior to participation in contract care under this programs, veterans were to be provided hospital care in facilities over which the Secretary has direct jurisdiction. It was proposed to change the regulations to stipulate that, prior to participation in contract care, veterans must have been or must be receiving care (regardless of whether it was or is hospital care) by professional staff over whom the Secretary has jurisdiction (regardless of whether it is direct jurisdiction). The elimination of the requirement of "hospital care" is necessary to address changed clinical practices and continue the intended program. In the past, substance abuse treatment generally was provided in a hospital setting. Now, much substance abuse treatment also is provided in an ambulatory care or residential setting. Further, this document changes "direct jurisdiction of the Secretary" to "jurisdiction of the Secretary" to allow for continuation of any cases in which the VA has had involvement (including, among other things, fee basic care) and thereby help ensure that a complete course of treatment is provided. PMID- 10172802 TI - Prison healthcare. Banged up, shooting up, messed up. PMID- 10172803 TI - Global fees for minimally invasive surgeries. PMID- 10172804 TI - Who will be paying those lab bills? PMID- 10172805 TI - Medicare program; Part A premium for 1997 for the uninsured aged and for certain disabled individuals who have exhausted other entitlement--HCFA. Notice. AB - This notice announces the hospital insurance premium for calendar year 1997 under Medicare's hospital insurance program (Part A) for the uninsured aged and for certain disabled individuals who have exhausted other entitlement. The monthly Medicare Part A premium for the 12 months beginning January 1, 1997 for these individuals is $311. The reduced premium for certain other individuals as described in this notice is $187. Section 1818(d) of the Social Security Act specifies the method to be used to determine these amounts. PMID- 10172806 TI - Substance abuse. When the systems fails. PMID- 10172807 TI - Managing employment risks in home health care agencies. PMID- 10172808 TI - Comprehensive medical rehabilitation in the 1990s: the community integration rehabilitation model. AB - The development of new models of understanding the disabling process, the changing system of financing health care in the United States, and the increasing incidence of disability is challenging rehabilitation to define new models of care delivery. Current models of comprehensive medical rehabilitation include multidisciplinary therapy in inpatient, outpatient, home and community settings. Managed care and the development of capitated funding systems for health care financing will challenge rehabilitation to prevent disability in a population. This article proposes a model system for comprehensive rehabilitation in managed care: the Community Integration Rehabilitation Model. This system advocates the development of a continuum of services including a strong community-based rehabilitation system, that is, a shift in emphasis to expanding opportunities for independent and productive community living as well as management of disease and impairment for individuals with disabilities, and the forging of partnerships between institution-based rehabilitation and its community. Comprehensive rehabilitation is redefined as a continuum of disability prevention and treatment across the lifespan of a population. PMID- 10172809 TI - Establishing the boundaries of ethically permissible research with special populations. PMID- 10172811 TI - Counting instruments is still the best policy. PMID- 10172810 TI - Trocar talk. PMID- 10172812 TI - Data watch. Divergent views on the pervasiveness of worker pain. PMID- 10172813 TI - Easing the costs of pain. PMID- 10172814 TI - Building an express lane back to work. PMID- 10172815 TI - A survey of legal issues and gaps in legal coverage in the EC. PMID- 10172816 TI - The six safety first principles of health information systems: a programme of implementation. Part 2. The environment, convenience and legal issues. PMID- 10172817 TI - The six safety first principles of health information systems. Progress report. PMID- 10172818 TI - Practical aspects of handling data protection and data security. AB - Looking at practical applications of health care information systems, we must conclude that in the field of data protection there still is too large a gap between what is feasible and necessary on one hand, and what is achieved in actual realizations on the other. To illustrate this point, we sketch the actual data protection measures in a large hospital information system, and describe the effects of changes affecting the system, such as increasing use of personal computers, and growing intensity of use of the system. Trends in the development of new and additional systems are indicated, and a summary of possible weak points and gaps in the security is given, some suggestions for improvement are made. PMID- 10172819 TI - Case-based quality management system for surgery, a bottom up approach. AB - Quality control has become a familiar concept in health care in The Netherlands in the last ten years, as it has elsewhere in the Western world. To achieve the goals of total quality, medical audit plays a central role in the process. An important issue for medical audit is to collect consistent and coherent data on the medical performance. As no widespread tradition exists to do this routinely using common widely accepted protocols and information technology, examples of routine quality control of medical services are scarce. In this paper a report is given of the process of collecting routine data on the surgical treatments and its complications in a Dutch general hospital. Based on the results of this and other local initiatives to control and improve the quality of surgical procedures the Dutch Association of Surgeons has recently adopted a policy document, which promotes to enhance quality Management. This paper presents also the increasing need among health care professionals to compare the results of treatment of similar patients. The role of Information Technology to achieve these goals is growing at an impressive pace. A more complete documentation of the care process will increasingly support a case based approach, which will be essential for a comprehensive analysis and Management of the care provided to patients. The paper supports a systematic collection of data documenting structure, process and outcome. PMID- 10172820 TI - Recommendations for European health data protection legislation. AB - In year 1 of the SEISMED project, the Katholieke Universiteit Leuven coordinated the inventory and analysis of medical personal data protection legislation in Europe. A report on legal issues of medical data protection legislation in Europe was written by the Vrije Universiteit Amsterdam, the Centre National pour la Recherche Scientifique (Paris) and the University College Dublin. This report served as a basis for a second important legal deliverable, i.e. the Health Informatics Deontology Code. In this third and final report, we take into account the results of the other two legal reports and we formulate recommendations for the national and European legislator. This report analyses critically the upcoming privacy directive. We propose several recommendations which should be taken into account by the European and national legislator. We focused quite extensively on the use of medical data for research purposes. We had several reasons to do this. One of them is the fact that the use of medical data for research purposes is very popular, in particular now the health care sector is becoming more and more 'standardized' by using computers, networksystems and telematics. Legislation is therefore needed. Moreover, the use of medical data for research purposes involves the transfer of data from one Member State to another. Therefore, a harmonized legislation is really needed. We hope that the recommendations we propose, will be taken into consideration by the European legislator. PMID- 10172821 TI - The State of the European Union Directive on Data Protection presented on 11th July 1994. PMID- 10172822 TI - The Data Protection Commissioner's point of view. PMID- 10172823 TI - Directive 95/EC of the European Parliament and of the Council of on the protection of individuals with regard to the processing of personal data and on the free movement of such data. The European Parliament and the Council of the European Union. PMID- 10172824 TI - Developing the security culture at the SEISMED Reference Centres. AB - The paper gives a brief summary of the SEISMED project and the particular role played by the Reference Centres. Details are given of the hardware and application systems in use in the Royal Hospitals (NHS) Trust (RHT), one of the SEISMED Reference Centres. It proposes, without verification, a definition of a Security Culture based on three criteria. These are suggested to be the "Awareness" the "Acceptance" and the "Actions" of the management and staff to improve Information Systems Security throughout the RHT. The way that "Awareness" was increased is shown by the specific initiatives commenced as a result of a CRAMM Risk Analysis and the management and staff training programmes. The specific initiatives mentioned include, an Information Systems Security Policy, a contingency and disaster recovery plan, improvements in the physical protection of equipment and changes to the method of access control. The "Acceptance" by the staff of these measures is considered and the success or failure of "Developing A Security Culture" examined. The role of SEISMED in this process is assessed. PMID- 10172825 TI - The European legislation on medical devices. AB - The protection of health and safety of patients and users, is the main objective of the comprehensive, harmonised legislation created in the EU, in the area of medical devices. In this paper, a brief description of the legislative programme is presented,-giving details on the three medical device directives, as well as their transposition. A detailed analysis of the directives context follows, with the steps and actions that all involved parties have followed or need to follow to ensure their uniform application. PMID- 10172827 TI - The Australian Medical Device Vigilance System. AB - Since its inception, in 1986, the Australian Vigilance System has had voluntary and compulsory components. The voluntary component is the Therapeutic Device Problem Reporting Scheme and the compulsory one is requirements on sponsors to report as a condition of entry on the Australian Register of Therapeutic Goods. In addition, reports produced worldwide are actively monitored for their applicability to Australia. PMID- 10172826 TI - Medical devices vigilance: the European approach. AB - Post market procedures have been foreseen within the medical device directives. This in turn, led to the preparation of the guidelines on a medical device vigilance system, which is actually the establishment of a recommended procedure to deal with reported adverse incidents. The medical device vigilance system provided a most valuable service to enhance safety of medical devices in the EU. However, a number of potential problems can arise during its implementation. Proper use of the vigilance system improves the protection of health, by reducing the likelihood of repeating the same type of incident. PMID- 10172828 TI - Medical device accident reporting: does it improve patient safety? AB - A significant number of patient injuries and deaths are associated with the use of medical devices. After several decades of experience in device evaluation and accident investigation, ECRI believes that many of these adverse effects could not be predicted in advance, even with the most sophisticated design validation techniques. Reporting networks with investigational capability that identify problem devices and provide feedback about adverse effects to manufacturers and medical device users are essential to meet the health communities obligation to provide safe and effective products and patient care. PMID- 10172829 TI - Requirements specification for a harmonized medical device vigilance information exchange system. AB - Effective and efficient medical device vigilance information exchange requires addressing several organizational and technical issues in a harmonized way. This paper describes a conceptual data model that has been derived within the scope of the EUROMEDIES project and accepted by project participants as a meaningful representation of data requirements on medical device vigilance. A possible scenario of a distributed implementation of the model is also discussed. PMID- 10172830 TI - Security aspects for medical device vigilance information exchange. AB - The implementation of appropriate security mechanisms for an effective and efficient medical device vigilance information exchange is very important, as the system handles sensitive information. These mechanisms have to be designed in such a way that they maintain confidentiality, integrity and availability of the data of medical devices. In this paper the security aspects of the information exchange on medical device vigilance is examined in detail. PMID- 10172831 TI - The EUROMEDIES EDI prototype system. AB - EDI is expected to be the dominant form of business communication between organisations moving to the Electronic Commerce era of 2000. The healthcare sector is already using EDI in the hospital supply function as well as in the clinical area and the reimbursement process. In this paper, we examine the use of EDI in the healthcare administration sector and move specifically its application to the Medical Devices Vigilance System. At a first place, the potential of this approach is examined, after an initial brief presentation of the EDI concept and its application in healthcare. This presentation is followed by an overall description of the EDI prototype system, which was developed in the context of the EUROMEDIES Concerted Action, in order to facilitate the requirements definition phase. PMID- 10172832 TI - Data exchange in metrology. AB - The adoption of the directives 71/316/EEC on measuring instruments and 90/384/EEC on non-automatic weighing instruments has resulted in a considerable quantity of certificates to be exchanged between the Central Metrological Authorities and the Local Metrological Authorities, in the member states. This requirement to exchange data, prompted the setting up of the WELMEC working group, to explore how computerisation could help the member states perform their tasks. PMID- 10172833 TI - Notified body needs of information exchange. PMID- 10172834 TI - National handling of medical devices vigilance reports and the use of registers. AB - A compulsory incident reporting is operating in Norway, as part of the implementation of the medical devices directives (MDD). Incidents are being handled locally by the quality councils and only if they prove of importance they are entered into the central database. As for the MDD Vigilance, exchange of information concerning investigation and follow up of incidents is forming a different part of the reporting system. The different possibilities of use of registers, in Norway and accordingly in the European Union, is analysed further in this paper. PMID- 10172835 TI - The EUROMEDIES concerted action outcomes. PMID- 10172836 TI - Two- and three-dimensional imaging for interventional MRI and CT guidance. AB - Minimally invasive techniques using endoscopes for image guided therapy are common in the surgical field and in internal medicine. Interventional procedures in the past were performed with either fluoroscopic, sonographic or CT-guidance, but now MRI-guided interventional procedures are being developed. Combining these technologies will improve surgical access and reduce complications. Today, tomographic 2 D and 3 D imaging (CT, EBT, MRI) can be used for precise and transparent guidance of endoscopes and surgical instruments inside the body for the field of minimally invasive therapy. 3 D imaging is helpful for anatomical, but not for morphological understanding. It has to be used interactively with actual cross sectional imaging for instrument guidance. This will offer a safe and effective access into the body, especially in high risk areas and lead to the new field of "Surgical Tomography". PMID- 10172837 TI - MRI-and CT-scopic microsurgery and drug installation for outpatient treatments. PMID- 10172838 TI - An interactive visual man-patient interface for semimmersive endoscopic surgery. AB - Endoscopy, a we know it today, is far from perfect. In an attempt to make the interventions as little invasive as possible, the ergonomics of the procedure, for the surgeon, are often not dealt with at all. In an attempt to improve the surgeon-patient interface during endoscopic procedures, a new concept is presented to allow the surgeon a much more natural visual interaction with the inside of the patient. It is made possible for the surgeon to look around into the cavity, with a stereo endoscope, mounted on a robot arm. This robot arm is directed by the motion of the head of the surgeon. PMID- 10172840 TI - Virtual endoscopy of the head and neck. Diagnosis using three-dimensional visualization and virtual representation. AB - BACKGROUND: Although flexible endoscopy is only 25 years old, a new technology may soon be used to provide the same view of internal organs without inserting an instrument. This is virtual endoscopy. METHODS: By acquiring patient specific high resolution digital images with a helical CT scan or MRI, individual organs can be graphically isolated or "segmented" into fully interactive 3-D reconstructions on a computer monitor. Applying sophisticated flight-tracking programs from military pilots, the organs can be "flown through", giving a view identical to endoscopy. CONCLUSIONS: In the future we will fly through data instead of inserting endoscopic instruments for gastrointestinal endoscopic diagnosis. PMID- 10172839 TI - Interactive operation planning and control with VIRIM. PMID- 10172841 TI - Virtual reality surgical simulation in endoscopic urologic surgery. PMID- 10172842 TI - Remote-guided surgical navigation in ENT surgery. PMID- 10172843 TI - Teleproctoring laparoscopic operations with off-the-shelf technology. AB - Teleproctoring may be a viable approach to training surgeons in the near future. It may also be a superior form of instruction, providing for instantaneous visual and audio feed back to the participant. Conventional proctors are sometimes tempted to reach in and "help", thus infringing on the learning process of the participant. This is a problem that is averted by use of a teleproctoring system. Teleproctoring thereby challenges the proctor to expand the means by which he teaches. As new technologies mature teleproctoring may become the gold standard for teaching new surgical techniques. PMID- 10172844 TI - Medical reality and virtual reality. PMID- 10172845 TI - The teleos virtual environment toolkit for simulation-based surgical education. AB - In the past, surgical simulations have largely been created through the development of dedicated applications that require considerable programming and computer graphics skills. Advances in simulation-based surgical education have been limited by this dependence on computer graphics programming expertise. To lower barriers to the adoption of simulation-based training, we are developing tools based on Teleos, software technology that allows a wide variety of medical content developers to author surgical training simulations without programming. PMID- 10172846 TI - A haptic interface for virtual simulation of endoscopic surgery. AB - Virtual reality can be described as a convincingly realistic and naturally interactive simulation in which the user is given a first person illusion of being immersed within a computer generated environment While virtual reality systems offer great potential to reduce the cost and increase the quality of medical training, many technical challenges must be overcome before such simulation platforms offer effective alternatives to more traditional training means. A primary challenge in developing effective virtual reality systems is designing the human interface hardware which allows rich sensory information to be presented to users in natural ways. When simulating a given manual procedure, task specific human interface requirements dictate task specific human interface hardware. The following paper explores the design of human interface hardware that satisfies the task specific requirements of virtual reality simulation of Endoscopic surgical procedures. Design parameters were derived through direct cadaver studies and interviews with surgeons. Final hardware design is presented. PMID- 10172847 TI - Robotic arm enhancement to accommodate improved efficiency and decreased resource utilization in complex minimally invasive surgical procedures. AB - Resource allocation, including manpower and other expenses, have limited the evolution of minimally invasive surgical procedures to provide humanism and to improve surgical care for patients. Robotic enhancement has been proposed as a mechanism to improve the cost-benefit relationship for patients. To this end, we have used the robotic arm enhancement to minimize resource and personnel utilization during minimally invasive procedures. Phase I of our study has included the use of the robotic arm in 24 laparoscopic hernia repairs, cholecystectomies, and nissen fundoplications with the surgeon as a solo surgeon, i.e., the primary surgeon is the only participant in the operative sterile field. The scrub nurse did not participate in the procedures. During this study, there were no technical mishaps, no complications related to the solo surgeon-robotic arm concept, and the operative times were statistically similar to equivalent procedures utilizing multiple personnel. The hernia repair is least complex and most amenable to solo surgery due to the use of only three access ports; cholecystectomy occasionally requires four access ports increasing its complexity to a measurable degree. Nissen fundoplication, however, requires five access ports and proved to be the most complex of the procedures to adapt successfully to solo surgery utilizing robotic arm enhancement. Phase II of our study has involved the use of a combination of technologically complex and sophisticated technology to improve outcomes in complex laparoscopic procedures. The head mounted display, the robotic arm, and the harmonic scalpel have been used in 140 complex minimally invasive procedures; the procedures were laparoscopic spine surgery (24 cases), laparoscopic gastric surgery (28 cases), and laparoscopic colon resection (88 cases). The use of these sophisticated technologies added safety, improved versatility, and did not increase the length of the operative procedures. The use of multiple technologies had an additive effect on the benefits. There were no experiences in which the technologies contributed to a technical complication or an adverse result for the patients. However, the successful use of these technologies requires an in depth educational experience for the surgeon and for the operating room team. In a further effort to improve efficiency and control of the visual fields during minimally invasive surgery, we have implemented a prototype voice activation, head-directed control, and instrument tracking by robotic arm enhancement in order to control the visual field through computer programming. Prototype voice activation and deactivation also allows instruments to be used in the visual field for the surgical procedure while not being used for tracking of the visual field. Tracking with the instrument utilizing a color-coded tracking system, and the head-directed control system have both been 100% effective in our hands, have not induced errors in technical performance of procedures, and have shortened the time required for performance of specific procedural tasks. Further, this process improves versatility for the surgeon, increases concentration, reduces fatigue and does not interfere with the position of the surgeon. Areas for improvement which have been observed utilizing these techniques are (1) the use of appropriate and consistent voice activation terminology, (2) the proper positioning of the instrument tracking unit in the most appropriate locations on the video screen and on the instrument within the visual field, and (3) the appropriate use of head-directed control of the robotic arm. We have concluded from these experiences that the robotic technology will continue to reduce costs and minimize risk for patients undergoing minimally invasive surgical procedures; moreover, safety, versatility, and diminished use of resources will accrue utilizing the additive benefit of sequential sophisticated technologies requiring a simultaneous educational PMID- 10172848 TI - The influence of LCD shutter glasses on spatial perception in stereoscopic visualization. AB - For a general establishment of stereoscopic visualisation systems in clinical routine a fundamental analysis of the influence of technical, optical and physiological parameters onto visual spatial perception seems to be necessary to achieve an optimisation of the existing devices. As one important component of these systems we perform studies on the influence of LCD Shutter glasses on the individual binocular perception. The developed shutter system, the initial experiments and their results are presented. PMID- 10172849 TI - Using human factor analysis and VR simulation techniques for the optimization of the surgical worksystem. AB - The introduction of minimal invasive operating techniques into the conventional surgical worksystem, requires a fundamental analysis of the resulting problems. Based on ergonomic investigations, concerning working postures, static holding work and task sequence analysis, bottlenecks of workplace design can be demonstrated. As a contribution to the optimization of workplace design, the development of a CAD-based VR simulation environment with an integrated anthropometric man-model, as a very useful tool for anthropometric system design is presented. PMID- 10172850 TI - Force feedback for virtual reality based minimally invasive surgery simulator. AB - This paper presents ongoing research towards an endoscopic surgery simulation system. Our specific application of interest is laparoscopic surgery. The goal is to conceive an endoscopic surgical training tool which allows to realistically simulate the interactions between one or several surgical instruments and the gastrointestinal organs in a virtual reality based environment. An artificial patient is being developed into which endoscopic surgical instruments can be inserted to operate upon virtual organs displayed on a video monitor. In order to achieve a faithful and precise simulation, not only a realistic graphical representation of the organic tissue and its behavior is needed, but also the forces and moments on the surgical instruments encountered during an operation are required to be simulated. The laparoscopic surgery simulator must therefore provide force feedback through the endoscopic instruments manipulated by the surgeon. This paper details the mechanical design of the force feedback mechanisms and addresses some of the technical challenges of this project. PMID- 10172851 TI - The expert surgical assistant. An intelligent virtual environment with multimodal input. AB - Virtual Reality has made computer interfaces more intuitive but not more intelligent. This paper shows how an expert system can be coupled with multimodal input in a virtual environment to provide an intelligent simulation tool or surgical assistant. This is accomplished in three steps. First, voice and gestural input is interpreted and represented in a common semantic form. Second, a rule-based expert system is used to infer context and user actions from this semantic representation. Finally, the inferred user actions are matched against steps in a surgical procedure to monitor the user's progress and provide automatic feedback. In addition, the system can respond immediately to multimodal commands for navigational assistance and/or identification of critical anatomical structures. To show how these methods are used we present a prototype sinus surgery interface. The approach described here may easily be extended to a wide variety of medical and non-medical training applications by making simple changes to the expert system database and virtual environment models. Successful implementation of an expert system in both simulated and real surgery has enormous potential for the surgeon both in training and clinical practice. PMID- 10172852 TI - Tactile optical sensor for use in minimal invasive surgery. AB - In minimal invasive surgery high sensory palpation of the organs is largely lost. It is the purpose of this work to recover tactile sensing for the surgeon. To achieve this goal, a new tactile optical pressure sensor has been developed which allows to display 64 measuring points on a 0.64 cm2 surface area with a digital resolution of 12 bits. The sensor has been conceived for application in laparoscopic grasping forceps and can also be integrated into a sensing rod, both 15 mm in outside diameter. This optical sensor allows us to display graphically indurations spread in the tissue. Furthermore, the measured values serve to activate a vibrotactile display unit for tactile feedback onto the surgeon's fingertip. In order to obtain further information about the requirements for an analog tactile display, an actuatorarray with 144 pins on a 4 cm2 surface area was built. The array allows various test objects to be recognized in a true scale presentation by exploratory movements of the fingers. PMID- 10172853 TI - Three-dimensional versus two-dimensional video endoscopy. A clinical field study in laparoscopic application. AB - Stereoscopic visualisation systems are available for the medical application in clinical routine, especially in the field of endoscopic or minimal invasive surgery. As we have shown in laboratory studies in 1991 the use of stereoscopic visualisation systems leads to a significant improvement of endoscopic manipulation. A broader diffusion of these systems in clinical routine will be based on quantitative evaluation of the influence of stereoscopic visualisation systems on the intervention. As a first approach we performed a clinical field study to compare 2D and 3D video endoscopy in laparoscopic interventions in urological surgery. PMID- 10172854 TI - Structure for classification and coding of surgical procedures. AB - PT002s of TC251 of CEN has been established in order to identify structural elements for classification and coding of surgical procedures. This project team identified 10 types of characteristics that could describe any surgical procedure. These characteristics were grouped in three classes: objects (topography/e.g. body system and body site, pathology, side, material); actions (procedure, extent, numeral) and methods (instrument, material, topography). Syntax rules are proposed as well as references to existing lexicons. This structure is mainly addressed to developers of classifications of procedures. It allows retrieval of monoaxial classifications through a multiaxial representation, logical rules for updating, as well as a method to compare existing classification systems. It is still in development and discussion. PMID- 10172855 TI - Medicare program; revisions to payment policies and five-year review of and adjustments to the relative value units under the physician fee schedule for calendar year 1997--HCFA. Final rule with comment period. AB - This final rule makes several policy changes affecting Medicare payment for physician services, including payment for diagnostic services and transportation in connection with furnishing diagnostic tests. The final rule also makes changes in geographic payment areas (localities) and changes in the procedure status codes for a variety of services. Since we established the physician fee schedule on January 1, 1992, our experience indicates that some of our policies may need to be reconsidered. This final rule is intended to correct several inequities in physician payment. This final rule also makes changes to work relative value units (RVUs) affecting payment for physician services. Section 1848(c)(2)(B)(i) of the Social Security Act requires that we review all work RVUs no less often than every 5 years. Since we implemented the physician fee schedule effective for services furnished beginning January 1, 1992, we have completed the 5-year review of work RVUs that will be effective for services furnished beginning January 1, 1997. In addition, we are finalizing the 1996 interim RVUs and are issuing interim RVUs for new and revised procedure codes for 1997. PMID- 10172856 TI - Medicare program; physician fee schedule update for calendar year 1997 and physician volume performance standard rates of increase for Federal fiscal year 1997--HCFA. Final notice. AB - This final notice announces the calendar year 1997 updates to the Medicare physician fee schedule and the Federal fiscal year 1997 volume performance standard rates of increase for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and, (f), respectively, of the Social Security Act. The fee schedule updates for calendar year 1997 are 1.9 percent for surgical services, 2.5 percent for primary care services, and -0.8 percent for other nonsurgical services. While it does not affect payment for any particular service, there was a 0.6 percent increase in the update for all physicians' services for 1997. The physician volume performance standard rates of increase for Federal fiscal year 1997 are 3.7 percent for surgical services, 4.5 percent for primary care services, -0.5 percent for other nonsurgical services, and a weighted average of -0.3 percent for all physicians' services. PMID- 10172857 TI - Diffusion of six surgical endoscopic procedures in the Netherlands. Stimulating and restraining factors. AB - The diffusion of six surgical endoscopic procedures in the Netherlands was investigated. Questionnaires were sent to 138 laparoscopic surgeons. They were asked which of the following laparoscopic procedures they had adopted in their hospital: cholecystectomy, appendicectomy, Nissen fundoplication, inguinal hernia repair, large bowel resection and thoracoscopic procedures. Furthermore, they were asked to indicate the influence of 13 pre-defined factors: "budget', "competition', "conference', "extra benefit', "media', "nature of the technology', "patient demand', "planning/logistics', "reimbursement', "service industry', "support industry', "surgical technique' and "training/course' on the adoption of those procedures. The adoption rates for the procedures were: 100%, 69%, 19%, 43%, 19% and 52%, respectively. In general, factors were assessed more positively by adopters than by non-adopters. Significant differences were mainly found for "extra benefit', "nature of the technology', "surgical technique' and "conference'. The surgeon's perception of the additional benefits of an endoscopic technique and, to a lesser degree, of its technical aspects were the most important factors in deciding whether or not to adopt a procedure. In an ideal diffusion model, a description is given of when and how the 13 factors can influence the diffusion of an endoscopic procedure in the desired direction. In this model, the extra benefit of a new procedure must be proven before other factors are allowed to influence the diffusion. PMID- 10172858 TI - The Americans with Disabilities Act: prescription for tax relief. AB - As employers, healthcare organizations must comply with Title I of the Americans with Disabilities Act of 1990-Employment Discrimination by Private Entities-which covers virtually all aspects of employment and prohibits employers from discriminating against otherwise qualified job applicants and workers who have disabilities or who become disabled. Further, healthcare organizations must comply with the provisions of Title III of the act-Nondiscrimination on the Basis of Disability by Public Accommodations and in Commercial Facilities-which requires places of public accommodations and commercial facilities to be designed, constructed, and altered in compliance with the accessibility standards of the act. While compliance with the ADA can be costly, four specific sections of the Internal Revenue Code offer tax relief to organizations that meet the guidelines of Titles I and III. PMID- 10172859 TI - Can wounded HMOs avoid Feds' knives? PMID- 10172860 TI - PRO-CITE as a bibliographic management tool. AB - Despite experiencing some difficulties, (and who hasn't when dealing with unfamiliar software), I find Pro-Cite to be both useful and user-friendly. It is easy enough for the one-professional library to implement, and has enough flexibility to meet a wide variety of patrons' needs for bibliographic information. PMID- 10172861 TI - Mini-CABGs are taking off with training, devices. PMID- 10172862 TI - OR med mix-up likely cause of boy's death. PMID- 10172863 TI - Community residential care program and contract program for veterans with alcohol and drug dependence disorders--VA. Final rule. AB - This document updates the Department of Veterans Affairs (VA) regulations concerning the Community Residential Care Program and the Contract Program for Veterans with Alcohol and Drug Dependence Disorders by incorporating by reference relevant portions of the latest editions of the National Fire Protection Association Life Safety Code entitled "NFPA 101, Life Safety Code" and "NFPA 101A, Guide on Alternative Approaches to life Safety." This is intended to ensure that buildings used for treatment and residential services for veterans meet appropriate fire and safety standards. Also, this document amends the regulations for such programs by delegating authority to each of the Veterans Integrated Service Network (VISN) Directors of the Veterans Health Administration to grant certain equivalencies or variances to building standards of the Life Safety Code. Further, this final rule does not adopt the portion of the proposed rule concerning the Adult Day Health Care Program since the Adult Day Health Care Program and the corresponding regulations are no longer in existence. PMID- 10172864 TI - Planning future hospital laboratory services: using benchmarks to evaluate laboratory operational and organizational strategies. PMID- 10172865 TI - Morbidity and mortality associated with stroke. PMID- 10172866 TI - Prognostic features of menopausal and postmenopausal applicants for life insurance. AB - The increasing proportion of the aged in the population is posing significant new challenges to politics, society and medicine as well. Gerontology and geriatrics are playing a role in all areas of preventive and curative medicine. Since the life expectancy of women is approximately eight years longer than that of men, gynecology draws special significance from the fact that the greater part of an aging society will primarily be comprise of women. The medical treatment and care of women in climacteric and postmenopause in the past is seriously inadequate by today's standards. The attitude in earlier years of not making any great investment of cost or personnel in patients over 75 can, in view of the vitality of modern-day senior citizens, no longer be justified or maintained. The necessity of establishing old-age gynecology becomes more and more clear and urgent. The decrease of ovarian function in menopause is without doubt an important turning point in the life of a woman. The first signs of aging are inescapable. Following these years a woman still has more than one third of life expectancy ahead of her which she would like to and should spend in good mental, spiritual and physical health. The principle of postmenopausal hormone replacement has shown itself to be amazingly successful in treating climacteric disorders and their effects on the entire organism. Treatment over many years with as board a spectrum as possible of preventive hormones to combat the long term consequences of hormone deficiency, like osteoporosis-related fractures, heart attacks, or strokes, is one of the great medical advances of our time. Furthermore, the significance of preventing a number of genital concern manifestations through hormone replacement therapy cannot be overestimated. Gynecology has taken a remarkable step toward its goal of enabling aging women to spend the third part of their lives free of unnecessary diseases and suffering. In 1994, after consultation with representatives of European countries during the World Congress of the International Menopause Society, a statement was published by the menopause society of German-speaking countries. In this consensus paper, a stand was taken on hormone replacement therapy in postmenopause. The purpose of this paper was to serve as an aid in formulating and interpreting the text in the package inserts that are enclosed with hormone preparations. The most important passages were to once again summarize the present status of knowledge on hormone replacement therapy and its risks and benefits: (Estradiol is the estrogen normally produced by a woman's ovaries that exercises all functions of the natural follicle hormone. It is used to treat all symptoms of estrogen deficiency). Estrogen eliminates, or mitigates, all typical symptoms of estrogen deficiency in menopause, including hot flashes, night sweats and other complaints frequently observed like nervousness, sleep disturbance and depression, with great reliability. Estrogen stimulates the cell division of an aging organism, of mucous membranes, of supportive and connective tissue. It improves the blood circulation and the salt and water content. Furthermore, estrogen prevents or eliminates deterioration in the urogenital area and the disorders that result from such deterioration. Estrogen prevents or retards bone deterioration, osteoporosis and spinal, lower arm and femur fractures. By positively influencing HDL- and LDL-cholesterol, blood vessels and circulation, long-term estrogen replacement inhibits the development of arteriosclerosis and nearly halves the frequency of heart attacks and strokes. The mortality rate of women over 50 is therefore decreased significantly and life expectancy increased. (Benefits to the blood vessels of such preventive treatment can already be seen after five years of estrogen therapy and their benefits continue for several years after treatment is stopped. PMID- 10172867 TI - Older age applicants: medical directors' perspective. PMID- 10172868 TI - A practical guide for calculating indirect costs of disease. AB - There may be some discussion about whether indirect costs should be taken into account at all in an economic appraisal, but there is certainly considerable debate about the proper way of estimating these costs. This reviews offers a practical guide for quantifying and valuing these indirect costs of disease, both at an aggregated level of general cost of illness studies, and in an economic appraisal of specific healthcare programmes. Two methods of calculating these costs are considered: the traditional human capital approach, and the more recently developed friction cost method. The former method estimates the potential value of lost production as a result of disease, whereas the latter method intends to derive more realistic estimates of indirect costs, taking into account the degree of scarcity of labour in the economy. All necessary steps in the estimation procedure and the data required at various points will be described and discussed in detail. PMID- 10172869 TI - German health economic cost evaluation on oral ganciclovir in treating cytomegalovirus retinitis. AB - The purpose of this study was to discuss the cost of oral ganciclovir in comparison with its intravenous formulation in treating CMV retinitis. A cost cost evaluation was carried out to compare the costs of oral and intravenous treatment with ganciclovir. Costs were calculated by employing the usual prices charged to sickness funds (German social health insurers). The costs of induction and maintenance therapy depend on the period of time the therapy takes, the site of administration (e.g. hospital, physician's office, patient's home) and the charges for the services. Different treatment scenarios were created in order to calculate the costs of the treatment alternatives and in a sensitivity analysis the robustness of the results was tested. Different probabilities for adverse effects were used. The study results showed that total costs of treating CMV retinitis with oral ganciclovir were substantially lower than the costs of intravenous treatment. PMID- 10172870 TI - The health of the aged in India. AB - Because of declining fertility, the proportion of the aged in the Indian population has risen. Although the rise has been modest, as shown by an increase in the population over 60 years of age from 5.5 to 7.0 per cent between 1951 and 1995, by the latter date, India's experience with 65 million people of this age is unusual. The paper employs data on persons 65+ years of age drawn from the 42nd Round of the National Sample Survey, and for the analysis subdivides them into three age groups, 60-64, 65-69 and 70+. It is shown that, among population over 60 years of age, 10 per cent suffer from impaired physical mobility and 10 per cent are hospitalized at any given time, both proportions rising with increasing age. Of the population over 70 years of age, more than 50 per cent suffer from one or more chronic conditions. The very limited support provided to the old by government is brought out by the fact that even in Karnataka, one of the states with the most generous provision, only 15 per cent of persons over 65 years of age receive any type of pension. PMID- 10172871 TI - Rationalizing health care in a changing world: the need to know. AB - The World Development Report 1993 announced that global life expectancy was then 65. Experience in the developed world suggests that the World Health Organization's dictum, "health is a state of complete physical, mental and social well-being', is simply not attainable for the foreseeable future. As physical health has improved, mental problems have become more prominent and a sense of well-being has declined. Furthermore, as the population ages and medical technology improves, the cost of health care grows almost exponentially. Since the population of the developed world is continuing to age and aging is spreading rapidly throughout the developing world, knowledge is the principal way of dealing with this seemingly intractable problem: we must know, quantitatively, the age-specific causes of ill health, and we must know which means of prevention and treatment are effective. Finally, we must apply that knowledge rationally. PMID- 10172872 TI - Dementing illnesses in rural populations: the need for research and challenges confronting investigators. AB - Expansion of the world's elderly populations has increased concerns about aging related medical disorders like Alzheimer's disease and other dementias. In the United States, one fourth of those older than age 65 and at greatest risk for developing dementia live in rural environments that may influence its manifestation. The objectives of this study were to determine the need for and potential benefits of further epidemiological research concerning dementia and similar disorders in rural U.S. populations and to identify pertinent methodological issues related to rural dementia research. This study employed a National Library of Medicine (MEDLINE) document search based on the key words "cognitive disorders," "dementia," "Alzheimer's disease," and "rural," followed by recovery of literature resources references in the bibliographies of selected articles. Nineteen studies focusing on dementia or related disorders in rural settings have been reported from around the world. While four of these were conducted in the United States, only one rural dementia prevalence study has been undertaken in this country. Because of methodological variability, comparisons of prevalence estimates between these rural studies, as well as with those from urban investigations, is difficult. Nonetheless, there is reason to believe that certain potentially dementing illnesses are more common in rural populations. There is also evidence to suggest that the screening instruments commonly used in such studies tend to misclassify rural elders as "false positive" dementia cases. Information regarding dementing disorders, particularly Alzheimer's disease, in rural populations is scarce. Preliminary observations that dementia may be more common in rural settings and that rural families are more likely to maintain their dementing elders in the community imply that further rural dementia research could yield important insights into the risk factors for these illnesses, the variables influencing their course, and the methods by which they can be more effectively managed. A determination of the reliability and validity of commonly used dementia screening instruments in rural populations would represent an important advancement in this area of research. PMID- 10172873 TI - Medical records: information gathering and confidentiality. AB - This article focuses on protecting the confidentiality and privacy of workplace medical records. All employers should be concerned about the potential legal liability for unauthorized and improper disclosure of confidential employee medical data. Employers should adapt and follow a corporate policy governing the use and maintenance of confidential employee hiring, benefits, personnel and medical information. If there is any question concerning the confidentiality of records, employers should consult with legal counsel or other outside advisers. PMID- 10172874 TI - Integration of mental health and chemical dependency care with primary care. PMID- 10172875 TI - Medicare risk programs and pharmacy benefits managers. AB - With 80% of all Medicare risk programs offering some type of prescription benefit, the management of that prescription benefit plays an important role in the success of the Medicare managed care plan. This article examines the issues and success factors involved in designing and managing prescription benefits program for seniors. PMID- 10172876 TI - Enhance productivity and reduce turnover with worksite safety and disability management. PMID- 10172877 TI - Do you always make sure patients get test results? PMID- 10172878 TI - Enhancing laboratory detection of disease. Part I: The concept of syndromic classification. AB - Syndromic classifications differ from other taxonomies because they build on an ideal theoretical information standard to amplify information. This ideal standard, a truth table with requisite variety, h, equal to or greater than the generated symbols or system it seeks to control, preserves all of the information about the disease state available in the database. Such a system, interestingly enough, theoretically has no beta errors (diagnostic misses) because all possible alternative disease hypotheses are created by the proper-sized truth table that controls the diagnostic system. Subsequent articles will examine the process in more detail. PMID- 10172879 TI - Outcomes measurement of assistive technologies: an institutional case study. AB - The assistive technology (AT) community has been challenged to effectively measure the outcomes of AT services. There has been much discussion recently in the literature about how to conceptualize and respond to this challenge. In this paper, we suggest that these objectives are best accomplished when AT services are understood within the contexts of the total rehabilitation of AT users and the institutional culture in which services are delivered. We provide examples of outcome priorities we have identified and the tools and approaches we have used. These include projects in the areas of clinical, functional, and psychosocial outcomes assessment of ATs. PMID- 10172880 TI - Apolipoprotein E and its association with Alzheimer's disease. PMID- 10172881 TI - Assistive technology. Stuck in a funding quagmire. PMID- 10172882 TI - Centralized credential verification for mental health and substance abuse. PMID- 10172883 TI - HCFA's new demonstration project: questions and answers. PMID- 10172884 TI - Home care and the Alzheimer's disease patient: an educational imperative. AB - Alzheimer's disease has no specific treatment; care often must be directed to patient behavior. That is why education--of professional and family caregivers- is essential. The more caregivers know, the easier it is to ensure the Alzheimer's patient is comfortable and secure. The pointers in this article are therefore valuable to both professional and lay caregivers. PMID- 10172885 TI - An international comparison of trends in disability-free life expectancy. PMID- 10172886 TI - Possibilities and problems in a cross-country comparative analysis of long-term care systems. PMID- 10172887 TI - Almost optimal social insurance for long-term care. PMID- 10172888 TI - Improve AMI (acute myocardial infarction) therapy by working with ICU, ED. PMID- 10172889 TI - A glimpse at the surgery of the next century. PMID- 10172891 TI - Medicaid program: redeterminations of Medicaid eligibility due to welfare reform- HCFA. Final rule with comment period. AB - The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 and the Contract with America Advancement Act of 1996 created changes in Federal law affecting the eligibility of large numbers of Medicaid recipients. These changes include revisions to the definition of disability for children and to the eligibility requirements of non-U.S. citizens and individuals receiving disability cash assistance based on a finding of alcoholism and drug addiction. This final rule with comment period protects Federal financial participation (FFP) in State Medicaid expenditures for states with unusual volumes of eligibility redeterminations caused by these recent changes in the law. We are making changes to the regulations to provide for additional time for States to process these redeterminations and provide services pending the redeterminations. PMID- 10172890 TI - How to face surgery. PMID- 10172892 TI - When the alarm goes on, the gloves come off--but is it worth the cost? PMID- 10172893 TI - AHCPR releases last guidelines: diagnosing early Alzheimer's. PMID- 10172894 TI - An exploratory analysis of communication sources: targeting high risk behavior among injection drug users. AB - Currently, most AIDS education and prevention programs attempt to change the high risk behavior of injection drug users (IDU's) (e.g., sharing needles and engaging in unsafe sex) through the implementation of two distinct strategies. First, empirical-rational strategies suggest that people maximize their rational self interest. Second, normative re-education strategies suggest that people change their individual behavior when they believe that there has been change in the sociocultural norms, values, and habits around them. Both of these strategies make assumptions about how communication changes IDU's beliefs and behavior. An empirical-rational strategy emphasizes non-personal mass communications (e.g., television, radio, newspaper); while normative re-education strategies make use of personal communications (e.g. friends, family, educational outreach workers, and group discussion). The purpose of this paper is to compare these strategies by examining the impact of AIDS communication sources on the beliefs and behaviors of IDU's. PMID- 10172895 TI - Targeting substance abuse. PMID- 10172896 TI - Design for assisted living. Familiar surroundings and activities are key for residents with dementia. PMID- 10172897 TI - 10 ways to defuse tense situations before they explode. PMID- 10172898 TI - Biomedical warfare. AB - A bruising battle for scarce research dollars is being waged among competing advocacy groups that seek cures for dread diseases. Many activists are unwilling to leave decisions to the scientists. They want Congress to decide which diseases deserve the most bucks. PMID- 10172899 TI - The economic burden of affective disorders. PMID- 10172900 TI - State mandates, self-insurance, and employer demand for substance abuse and mental health insurance coverage. PMID- 10172901 TI - ADA--revealing the legal impact, shaping employer tactics. PMID- 10172902 TI - European healthcare. Foreign exchange. AB - The European Union offers sources of funding, skills and experience, so why are health organisations not tapping into them? Carol Ludvigsen and Janet Allen recount one trust's experiences. PMID- 10172903 TI - Mental health. Without these walls. AB - Many prisoners have mental health problems and need support after their release. A project in Winchester sets up community services when they leave. Rachel Lart and Barbara Swyer report. PMID- 10172904 TI - Psychiatric and substance abuse disorder diagnoses as predictors of length of hospital stay. AB - The mental health and substance abuse components of AN-DRG 3 were examined using data from all inpatient separations in two Australian States over a two-year period. Assignment to a mental health or a substance abuse diagnosis related group (DRG) predicted about 20 per cent of the variability in average length of stay of patients treated for such conditions. Assignment to a substance abuse DRG was a much less robust predictor of length of hospital stay than assignment to a mental health DRG. There was little variation between years or States. Day-only intent patients were excluded, as were long-stay outliers identified using an inter-quartile range trimming process. Psychiatric DRGs are similar to a number of other non-surgically focused diagnosis related groups in their capacity to predict length of hospital stay. They are likely to remain an important component of casemix classification systems. PMID- 10172905 TI - Hepatitis: an overview of important issues. PMID- 10172906 TI - Ethical considerations in perioperative care. PMID- 10172907 TI - Guidelines for standards in cardiac surgery. Advisory Council for Cardiothoracic Surgery, American College of Surgeons. PMID- 10172908 TI - Clinical pathways. CareMaps used in perioperative patient care. PMID- 10172909 TI - Clinical pathways. OR sees its pathway role as standardization. PMID- 10172910 TI - When to offer workers light duty positions. PMID- 10172911 TI - Improving service in Alzheimer's care units. PMID- 10172912 TI - What you need to know about 1997 Medicare payment changes. PMID- 10172913 TI - Costs of employee assistance programs: findings from a national survey. PMID- 10172914 TI - Healthcare resource consumption in terminal care. AB - Recent developments in healthcare have raised important ethical challenges. One of the trends is the increasing attention to patient autonomy for medical decision making. Patients are exercising greater authority to refuse medical treatment and to seek medical treatment that may end life. Another important trend is that end of life medical care has become increasingly expensive. Further, changes in reimbursement for medical care may create incentives for providers to deny heroic treatment. This article reviews issues relevant to these developments. We consider the issue of medical futility, the role of advance directives, and the international movement toward the legalisation of euthanasia. We suggest that futile medical treatment should not be offered and that advance directives should he used. However, review of the literature suggests that advance directives may not reduce medical costs. The effect of managed care upon advance directives, denial of heroic care and euthanasia is not known at this time. PMID- 10172915 TI - Measurement of quality of life in patients with chronic obstructive pulmonary disease. AB - In measuring quality of life in chronic obstructive pulmonary disease (COPD) we have to make a distinction between using quality-of-life (QOL) instruments for research or for patient care purposes. For research purposes, these instruments have proven their value. However, for healthcare, the value of these instruments has not yet been established. It is clear that quality of life is important to both the patient and the physician. For the patient, experienced health is quite probably the most important aspect of healthcare. For the time being, however, it is difficult to include this aspect of the primary care of patients with COPD in a proper and well balanced way, because we do not know exactly what value we must attach to a changed quality of life and what consequences this has for medical care. Moreover, in COPD it might be possible that only severely obstructed patients have a detectably impaired quality of life as assessed by QOL instruments, which obviously makes these instruments less suitable for healthcare. PMID- 10172916 TI - Quality-of-life measures as providers of information on value-for-money of health interventions. Comparison and recommendations for practice. AB - Three different approaches to measuring quality of life have been developed. Global scales (e.g. time trade-off, visual analogue), multi-attribute utility scales and multidimensional scales (which may be generic or disease-specific). Each of these approaches to measurement provides different kinds of information about quality of life and each can be used to provide information to healthcare purchasers concerning the relative value-for-money of health interventions. The value-for-money of health interventions, in terms of quality of life, can be demonstrated in 2 ways: a formula-driven approach based on cost-utility analysis, which uses scales generating the unit of a quality-adjusted life-year (i.e. global and multi-attribute utility); and a non-formula-driven approach, which uses scales generating multidimensional profiles of quality of life (i.e. multi attribute utility and multidimensional). Analysis shows that no single approach is sufficient, and that healthcare purchasers should use a variety of types of information in their decision-making, including both cost-utility and informal approaches. Healthcare resource allocation is inevitably a value-dependent activity. PMID- 10172917 TI - Measuring quality of life in patients with schizophrenia. AB - Schizophrenia is a chronic disabling illness that affects about 1% of the population. It is a heterogenous disorder with variable aetiological, prognostic and treatment response patterns. Its course is generally long term, with acute psychotic exacerbations that may require hospitalisation. The cornerstone of clinical management is the use of antipsychotic (neuroleptic) medications. Although these are effective, they can cause adverse effects that may impact negatively on the functional status of the individual. Early studies of quality of life in schizophrenia were mainly concerned with the development of techniques to identify patients' needs in the community. Difficulties encountered in these studies included: lack of agreement on definition of quality of life; lack of appropriate integrative conceptual models; concerns about reliability of patients' self-reports about their quality of life; and the lack of standardised quality-of-life measures appropriate for schizophrenia. A number of disease specific or generic scales have subsequently been used for measurement of quality of life in schizophrenia. The list of disease-specific scales is extensive; unfortunately, many of them were used only in a single study or their psychometric properties were not specified. Generic scales can be applied across various types and severity of illness, as well as in different health interventions across demographic and cultural groups. Medication costs in schizophrenia represent only a small fraction of the total cost of the illness. However, pharmacoeconomic studies have attracted much interest as a result of the high cost of newly introduced medications and of concern about the limitations of antipsychotic medications, particularly their adverse effects, as exemplified by the reintroduction of clozapine for the treatment of refractory schizophrenia. Few studies have combined quality-of-life measures with cost analysis in schizophrenia; a number of these have methodological shortcomings. Many studies are retrospective in nature, and in most the number and length of hospitalisations has been used as the parameter for cost analysis, which can introduce bias depending on the varying approaches to hospitalisation. We conclude that the following factors are important in choosing or developing a quality-of-life measure for schizophrenia: quality of life is a multidimensional concept that has to be reflected in its measurement; the scale has to be appropriate for the purpose as well as the population studied; measurement has to include patients' self-reports about their quality of life; measures should include only items that are relevant and expected to change; single-item global measures are useful only when combined with multidimensional measures; in developing new scales, psychometric properties have to be established as well as being field-tested. PMID- 10172919 TI - Orbital implants. AB - Several aspects of orbital implants are reviewed. Hydroxyapatite has become one of the most commonly used implants for anophthalmic patients and has many of the characteristics desirable in an implant, although reports of significant complication rates are noted. Recent editorials acknowledge the advancement that hydroxyapatite has given in treating anophthalmic patients but add a note of caution in its extensive use. It may be reasonable to limit the use of hydroxyapatite to patients who are highly motivated. Other recent advances in surgical technique, evaluation, and treatment of complications from hydroxyapatite are discussed. In addition, recent trends in treating orbital fractures are reviewed. PMID- 10172920 TI - Current concepts in lacrimal drainage surgery. AB - Dacryocystorhinostomy remains the mainstay of treatment of acquired primary and secondary obstructions of the lacrimal drainage system. The advent of the endoscope has prompted renewed interest in the intranasal or endonasal approach to fistulae formation. As results of the intranasal approach are reported, they are compared with the time-tested and effective external approach, bringing controversy to the once staid subject of lacrimal drainage surgery. Debate continues regarding the optimal timing of intervention in the treatment of congenital nasolacrimal duct obstruction. Clinical outcome analysis suggests that early office-based lacrimal probing is more cost-effective than a hospital-based procedure. Others warn that when other factors are included in the decision process, the recommended course of intervention may be different. If dacryocystorhinostomy is required in a child with congenital nasolacrimal duct obstruction, the results by an experienced surgeon are comparable with those in an adult operated on for primary acquired lacrimal obstruction. PMID- 10172921 TI - Medical experts take chest imaging to task. PMID- 10172918 TI - Simvastatin. A reappraisal of its cost effectiveness in dyslipidaemia and coronary heart disease. AB - The Scandinavian Simvastatin Survival Study (4S) has confirmed the link between the cholesterol-reducing effects of simvastatin and improved survival in patients with hypercholesterolaemia and pre-existing coronary heart disease (CHD). Pharmacoeconomic analyses of the 4S trial, using prospectively collected data for cost-generating events, demonstrate that the cost per year of life saved for simvastatin in such patients falls within the range considered cost effective. Reductions in resource utilisation costs (numbers of hospitalisations and revascularisation procedures) largely offset the acquisition cost of long term simvastatin treatment in the US. Models of primary prevention incorporating epidemiological data to predict CHD events generally suffer from deficiencies in the methods and assumptions used, and no firm conclusions can be made at present regarding relative cost effectiveness of the drugs studied, including simvastatin. It is generally agreed that cost effectiveness will improve in patients with higher absolute risk of CHD. In summary, simvastatin has been shown in a major clinical trial and its companion economic analyses to reduce mortality and to be cost effective in patients with hypercholesterolaemia and existing CHD. As is the case for others of its class, its cost-effectiveness ratio in primary prevention remains to be ascertained. This issue aside, simvastatin is a rational choice of cholesterol-lowering agent in secondary prevention whose use can be justified on an economic basis. PMID- 10172922 TI - Video conferencing in surgery: an evolving tool for education and preceptorships. AB - The advent of advanced laparoscopic procedures has provided unquestioned patient benefits but has also engendered some significant concerns about whether surgical team members are able to stay current in this everchanging arena. The interactive video conferencing program at Doctors Hospital in Columbus, Ohio, was developed to improve the education and preceptoring of surgical teams. This article describes the evolution of the program and its basic technology and connectivity. Physicians and other health care professionals began to accept this teaching alternative as usage increased. Based on this initial experience, video conferencing in surgery appears to be a valuable and exciting method of enhancing the educational process and augmenting the preceptorship experience. Further studies need to be conducted to determine the actual cost-effectiveness of this teaching method. PMID- 10172924 TI - Data trends. Potential cost and patient day savings for inpatient surgical procedures. PMID- 10172923 TI - Regionalization of tertiary care: impact of safe cardiovascular volumes in Iowa. AB - The outcomes of cardiovascular care for individual patients are known to be better when treatment is provided in hospitals where the volume of such care is greater. We examined the impact of establishing safe volume thresholds on hospitals now performing such procedures in the state of Iowa by analysing the relationship between various volume thresholds and the number of hospitals that would continue to provide the service if the thresholds were enforced. Four procedures performed in hospitals in Iowa in 1990 were studied: coronary artery bypass graft surgery, vascular surgery, cardiac valve surgery, and cardiac catheterization. The analysis was conducted assuming current per capita procedure rates and repeated assuming reduced procedure rates. The study finds that the 12 hospitals now performing coronary artery bypass graft surgery in Iowa could be reduced to two, providers of vascular surgery could be reduced to as low as four from the current 33, the 10 providers of cardiac valve surgery might be reduced to one, and catheterization could be provided at two rather than 22 hospitals. PMID- 10172926 TI - A gentler approach to heart surgery. PMID- 10172925 TI - The impact of prospective payment on Medicare patients. PMID- 10172927 TI - Telesurgery in cyberspace. AB - Imagine surfing the Internet and coming across somebody's gallbladder, liver, appendix or any other organ you might want to see. Or how about watching a surgical procedure on your screen while it is being conducted in another part of the world. PMID- 10172928 TI - With a wink of the eye. AB - Imagine being able to turn on lights, open doors and operate your radio and television set by merely moving your eyebrows up and down. Assistive technology is described as any device that empowers an individual to perform a certain activity that he or she could not perform or would have difficulty performing. It is changing the quality of life for persons with disabilities, enabling them to participate in gainful employment, enjoy recreational activities, return to school, and engage in other activities of independent daily living. PMID- 10172929 TI - Profile of persons with disabilities in Medicare and Medicaid. AB - This DataView presents descriptive information on beneficiaries with disabilities in Medicare and Medicaid. Medicare data show that persons with disabilities have more functional limitations, poorer health status, lower incomes, and experience more barriers to health care than aged Medicare beneficiaries. Medicaid data reveal that significant growth in the Medicaid disabled population has led to the disabled outnumbering the Medicaid-eligible elderly. Additionally, Medicaid serves an increasingly younger disabled population and more persons with mental impairments. PMID- 10172930 TI - Reporting panic values in the middle of the night. PMID- 10172931 TI - Developing a budget for the laboratory. AB - Cost accounting is the basic "tool" for identifying the expenses associated with laboratory operations. A budget is a planning tool that allows the director and manager to visualize the evolution of expenses, assets, liabilities, and revenues over a period of time. It is a quantitative annual plan of activities and programs that helps an organization measure the progress toward its financial goals on a periodic basis. A knowledge of how to develop and understand a budget is essential for every director and manager. PMID- 10172932 TI - Rethinking prevention for people with disabilities. Part I: A conceptual model for promoting health. PMID- 10172933 TI - Rethinking prevention for people with disabilities. Part II: A framework for designing interventions. PMID- 10172934 TI - Economic evaluation techniques in healthcare. Reinventing the wheel? AB - Application of the technique of economic evaluation has increased markedly in the past 5 years. Literature on the techniques of economic evaluation is over 30 year old, and the principal architect of such techniques in Britain is Professor Alan Williams of the University of York. In 1974 he wrote a 'checklist of questions' to apply to economic studies. These questions have since been elaborated by Mike Drummond and colleagues, and by the end of the 1980s guidelines were well articulated. Since this time there have been substantial investments in 'gilding the lily', leading to marginal improvements. This investment in 'reinventing the wheel' could more usefully be applied to resolution of contentious areas where there is still a lack of consensus. It is time to stop going around in circles with guideline reiteration and quasi-consensus statements, and instead target resources where they give the greatest return to knowledge. PMID- 10172935 TI - Guidelines for pharmacoeconomic studies. Recommendations from the panel on cost effectiveness in health and medicine. Panel on cost Effectiveness in Health and Medicine. AB - This article reports the recommendations of the Panel on Cost Effectiveness in Health and Medicine, sponsored by the US Public Health Service, on standardised methods for conducting cost-effectiveness analyses. Although not expressly directed at analyses of pharmaceutical agents, the Panel's recommendations are relevant to pharmacoeconomic studies. The Panel outlines a 'Reference Case' set of methodological practices to improve quality and comparability of analyses. Designed for studies that inform resource-allocation decisions, the Reference Case includes recommendations for study framing and scope, components of the numerator and denominator of cost-effectiveness ratios, discounting, handling uncertainty and reporting. The Reference Case analysis is conducted from the societal perspective, and includes all effects of interventions on resource use and health. Resource use includes 'time' resources, such as for caregiving or undergoing an intervention. The quality-adjusted life-year (QALY) is the common measure of health effect across Reference Case studies. Although the Panel does not endorse a measure for obtaining quality-of-life weights, several recommendations address the QALY. The Panel recommends a 3% discount rate for costs and health effects. Pharmacoeconomic studies have burgeoned in recent years. The Reference Case analysis will improve study quality and usability, and permit comparison of pharmaceuticals with other health interventions. PMID- 10172936 TI - Differences in the methodology and data of economic evaluations of a health programme. The case of hepatitis B vaccination programmes in Spain. AB - Economic evaluations of hepatitis B vaccination programmes in Spain or particular regions of Spain were identified and analysed, and their methodologies and data were compared. The results revealed important differences in methodology and the way in which different parameters, such as duration of immunity, costs and sources of cost data, were defined and measured. Some of these variations could be justified by the need to adapt studies to specific contexts, while others appeared arbitrary. Although it is understandable that there should be a substantial amount of heterogeneity between studies, greater efforts need to be made to reduce unnecessary variations in the way in which different parameters are measured. Increasing standardisation in methodology, which nevertheless takes into account inevitable variations due to changing circumstances and perspectives, will help to make economic evaluation a more attractive proposition for decision makers. PMID- 10172937 TI - Outcomes and assistive technology. PMID- 10172938 TI - The costs of behavioral health care coverage. AB - Psychiatric and chemical dependency conditions can have significant financial implication for plan sponsors, but a variety of mechanisms are available to control these costs. The application of appropriately designed and implemented benefit designs in combination with managed behavioral health care protocols can have a significant return on investment for the plan sponsor. PMID- 10172939 TI - New approaches to Alzheimer's disease. PMID- 10172941 TI - An awkward position: restraints and sudden death. PMID- 10172940 TI - Barriers to prenatal care among Medicaid managed care enrollees: patient and provider perceptions. AB - To identify what patients and providers perceive as barriers to prenatal care among women enrolled in a Medicaid managed care plan, focus group discussions of: 1) women, 13 to 45 years of age, enrolled in a Medicaid managed care plan and 2) providers (physicians, nurse practitioners, nurses, and medical assistants) that serve this population were conducted at a location in the community by professional facilitators. Forty-two enrolled women and 22 providers participated. Based on an interpretive analysis of comments regarding perceived barriers towards receiving prenatal care by patients and providers, we found some perceived barriers that were similar for both groups. Both groups of respondents thought that problems with transportation, knowledge of TennCare, and substance abuse were barriers to receiving prenatal care. Providers mentioned lack of enrollee's education, need for child care, and limited hours of operation; and patients mentioned treatment by office personnel, lack of rapport with health providers and lack of recognition of pregnancy as additional barriers. Understanding both patient and provider perspectives of the barriers to receiving care is the first step towards meeting the needs of the target population. Health plans that serve the historically underserved population must take a specialized approach that adapts to the population's distinct needs. PMID- 10172942 TI - Successful aging in America, Part I. Nutrition, the elderly, and the laboratory. AB - Laboratory testing should be integral to nutrition-related services, including screening, assessment, and monitoring for both inpatient and outpatient geriatric populations. Find out how the laboratory can contribute to the improved health of seniors and reduce overall healthcare costs through nutritional status assessment and monitoring. PMID- 10172943 TI - Corrective actions: what to do when control results are out of control. PMID- 10172944 TI - Ambulatory surgery in the United States, 1994. AB - OBJECTIVES: This report presents estimates of surgical and nonsurgical procedures done on an ambulatory basis in hospitals and freestanding ambulatory surgery centers in the United States during 1994. Data are presented by types of facilities, age, sex, geographic region, and disposition for ambulatory surgery visits. Major categories of procedures and diagnoses are shown by age, sex, and region. METHODS: The estimates are based on data collected from the national Survey of Ambulatory Surgery, conducted for the first time in 1994 by the national Center for Health Statistics. The 1994 data were abstracted from 118,000 medical records in 494 hospitals and freestanding ambulatory surgery centers. PMID- 10172945 TI - Legal issues in securing Medicaid home care services in New York. PMID- 10172946 TI - An economically rational method of managing early-stage endometriosis. AB - Endometriosis is a common gynecologic disease among women of reproductive age. The lesions of early endometriosis may be missed during laparoscopy, which has been considered to be the definitive means of both diagnosis and treatment. Moreover, laparoscopic treatment of minimal-to-mild (stage 1 to 2) endometriosis does not always resolve associated chronic pelvic pain in many women. Instead, medical therapy with gonadotropin-releasing hormone (GnRH) agonists may be more effective in providing long-lasting pain relief in patients with similar disease stages. The author outlines the cost effectiveness of a trial course of GnRH agonists in women presenting with chronic pelvic pain. PMID- 10172947 TI - Hospitals--East meets West--reflections on international hospital co-operation. AB - On the European scene, particularly in the Member States of the European Union, the social system and the healthcare system as essential part of it are under demographic and economic pression and in full change. Hospitals being important partners in the healthcare network are rethinking their role and re-orienting their mission. Co-operation is a key issue both within the hospital with its multiple interprofessional relationships around the patients and outside the hospital with the variety of partners of the local healthcare network, with the general public and with the competent authorities. Change and co-operation are the keywords in the HOPE operation which the HCEC started in synergy with WHO Europe within a year after the Wall in Berlin was broken down in November 1989. Whatever the importance of East-West Co-operation between hospitals may be, it can not separate the paneuropean hospitals from the rest of the world. Hospitals and their national and international associations could play an exemplary role in the real active management of the changes at world level and in the prevention of poverty and violence. PMID- 10172948 TI - Outpatient mastectomy. Plan for breast cancer surgery to avoid 'drive-through' label. PMID- 10172949 TI - Surgery is slowing, outpatient shift continues. PMID- 10172950 TI - Managed care and special populations: key marketing and enrollment issues. AB - If managed care is to reach handicapped patients and people with special needs, including Medicaid recipients and ethnic minorities, special attention must be paid to issues of outreach and cultural diversity. The authors discuss barriers that hinder such efforts and suggest methods for dealing with them. PMID- 10172951 TI - Americans with Disabilities Act accommodation issues may apply to environmental illness. PMID- 10172952 TI - MidCentral Health plans major upgrading of hospital facilities. PMID- 10172953 TI - How to forestall antidiscrimination suits. PMID- 10172954 TI - The special care touch. PMID- 10172955 TI - Focus on caregiving. Teaching staff how to interpret difficult behavior. PMID- 10172956 TI - Central RHA sets interim booking system thresholds. PMID- 10172957 TI - Don't rely on hospitals to report test results. PMID- 10172959 TI - Enhancing laboratory detection of disease. Part 2: Amplifying information and requisite variety. PMID- 10172958 TI - Use of utilization management methods in State Medicaid programs. AB - This article describes the use of utilization management (UM) methods by State Medicaid programs. The use of optional UM methods range from zero in one State to eight in four States, with a median of five. A majority of States have programs for ambulatory surgery, preadmission certification, lock-in, primary-care case management, and targeted case management. Overall, no UM method was judged by States to have an adverse effect on access of quality of care. For UM methods mandated by the Medicaid program, more than one-third of the States rated physician certification as minimally effective. PMID- 10172960 TI - Federally regulated testing for alcohol in the workplace. PMID- 10172961 TI - When it pays to test for wellness. PMID- 10172962 TI - Legal and ethical issues of patient access to laboratory results. PMID- 10172963 TI - Psychosocial correlates of health compromising behaviors among adolescents. AB - The objective of the present study was to examine psychosocial correlates of diverse health-compromising behaviors among adolescents of different ages. The study population included 123,132 adolescents in sixth, ninth and 12th grades. Psychosocial correlates of substance abuse, delinquency, suicide risk, sexual activity and unhealthy weight loss behaviors were examined. Risk-taking disposition was significantly associated with nearly every behavior across age and gender groups. Other consistent correlates included sexual abuse and family connectedness. Correlates of health-compromising behaviors tended to be consistent across age groups. However, stronger associations were noted between sexual abuse and substance use for younger adolescents, and risk-taking disposition and school achievement were stronger correlates for older youth. The results suggest the presence of both common and unique etiological factors for different health-compromising behaviors among youth. The results emphasize the importance of focusing on positive 'risk-taking' experiences for youth in prevention programs; being sensitive to possible sexual abuse experiences among both female and male adolescents in health-care consultations; integrating strategies for improved family connectedness into health promotion efforts; and making school relevant for all adolescents. PMID- 10172964 TI - A novel method to identify migration of small implantable devices. AB - A histologic method has been developed to assess the migration of chronically implanted intramuscular devices. Bullet-shaped glass devices with varying tip configurations and glass-encapsulated microstimulators of a similar size were loaded with the fluorescent tracer Procion Yellow dissolved in molten glucose. Dissolution of the hardened glucose soon after contact with body fluids released the Procion Yellow, which binds irreversibly to local tissues, thereby marking the initial site of implantation with a localized fluorescent spot. After survival times of 2-7 weeks, histologic analysis usually showed a close physical relationship between the fluorescent spot and the connective-tissue capsule from which the device was extracted. In one case, migration of a sharply pointed device from the deep surface of an implanted muscle was recognized by differences in the location of the dye spot and the site of explantation from nearby fascia. Results suggested that this method could measure migratory distances as small as 5-10 mm. PMID- 10172965 TI - Japan's aging population. Implications for healthcare. AB - In the early years of the next century, the Japanese population may well become the oldest in the world. The Japanese government's concentration on post-World War II economic expansion meant that the government only fully woke up to the financial implications of having a large elderly population when oil prices were raised in the 1970s, highlighting Japan's economic dependence on global markets. This article explains the process by which policy regarding Japan's elderly developed both before and after these oil price increases. The measures of healthcare cost containment that the government introduced in response to the increased financial pressure are described, with a particular focus on pharmaceuticals. This article shows that the government has achieved a degree of success in terms of containing pharmaceutical costs, but that future effects on the quality of healthcare are uncertain. Ultimately, a wider application of a per diem fee in place of the prevalent fee-for-service system, and the realisation of plans to improve the social service infrastructure, would be the best path for policy to follow. PMID- 10172966 TI - Healthcare technology assessment and the challenge to pharmacoeconomics in Japan. AB - Faced with rapidly rising healthcare costs, aging populations and healthcare technology growth, coupled with a decline in economic growth, all developed countries have introduced reforms to their healthcare systems. Since Japan's healthcare system is thought to achieve good health at low cost, the evaluation of present issues and efforts involved in healthcare reform in Japan will offer a unique lesson for other countries. While Japan's healthcare system has achieved accessibility and equity of healthcare, the most serious problem it faces is unassured quality of healthcare. In Japan, a large number of healthcare technologies have been introduced and utilised uncritically. Several systematic assessments have been carried out, and shed light on the present situation of quality of healthcare. However, the Japanese government has no explicit health policy to comprehensively evaluate effectiveness and efficiency of healthcare technologies and their use. To cope with this issue under limited healthcare expenditures, a systematic approach to healthcare evaluation such as healthcare technology assessment is urgently needed. The highest priority will be placed on pharmacoeconomic evaluation in Japan, and this will serve as a typical model for healthcare evaluation in Japan. The Japanese government is required to make clear its objectives and strategies in using systematic evaluations for health policy making. PMID- 10172968 TI - The CQI pathway. AB - The use of CQI to identify issues, processes, and methods of quality management was a favorable learning experience for the Botsford General rehabilitation staff. They experienced improved interdepartmental communication and enhanced understanding of the roles and responsibilities of other disciplines, as well as the overall CQI process. The use of the CQI process accomplished the objective of decreasing the length of stay of patients with amputations by 6 to 8 days, thereby reducing costs. Use of flowcharting to outline a typical patient stay from admission to discharge helped to clarify potential problems, eliminate unnecessary steps, and reduce documentation time. Although rehabilitation services are currently exempt from diagnosis-related group application, in order to maintain cost efficiency and service effectiveness, it behooves us to continually track and stay in line with the competition. In light of anticipated health care reforms, the rehabilitation industry must be proactive in its management of service delivery with an emphasis on functional outcomes. Botsford General's success with using a critical pathway for the amputee program as part of a program evaluation system will lead to the development of critical pathways for additional diagnoses. PMID- 10172967 TI - The flight from Rwanda in 1994: what were (are) the priorities? AB - EXTENT OF THE CATASTROPHE: More than 2 million refugees, 2-3 million displaced persons internally, thousands of unaccompanied children, and a total number of reported fatalities of 48,347 in Goma, Zaire. PRIORITIES FOR INTERNATIONAL RELIEF: International relief support started with coordination provided by the United Nations High Commissioner for Refugees (UNHCR). In the first phase, availability of potable water was the highest priority. Current priorities are to intensify repatriation of Rwandan refugees under conditions that will guarantee human rights and allow for dignified daily living. CONCLUSIONS: Education beginning at childhood, to overcome conflicts, social inequality, and overpopulation should be promoted by assisting governments, instead of pursuing policies aimed largely at forwarding their own national interests. PMID- 10172969 TI - Geriatric fitness. PMID- 10172970 TI - Reentry begins at home. PMID- 10172971 TI - Physiatrists as primary care physicians. PMID- 10172972 TI - Therapeutic recreation in the continuum of care. PMID- 10172973 TI - What's the outcome? Multiple variables complicate the measurement of assistive technology outcomes. PMID- 10172974 TI - Use of telepathology for routine surgical pathology review in a test bed in the Department of Veterans Affairs. AB - BACKGROUND: Routine surgical pathology review by telepathology could be an important service component of multi-institutional pathology laboratory systems. Such service networks would increase access for rural hospitals without on-site pathologists to a broader range of pathology services on a daily basis. METHODS: In this clinical trial, we analyzed the diagnostic accuracy, deferral rates, and viewing times of two generalist pathologists using a hybrid dynamic/store-and forward (HDSF) telepathology (TP) system to render diagnoses in real time on 200 consecutive surgical cases. The objective was to assess the efficacy of TP in providing diagnostic surgical pathology services to a remote hospital without an onsite pathologist. Surgical pathology specimens underwent gross preparation by specially trained personnel. When appropriate, this was done under the video supervision of a telepathologist. For TP, glass slides were placed on the stage of a robotic microscope at the Iron Mountain (MI) Department of Veterans Affairs Medical Center (VAMC) (remote site); control of the motorized microscope was then transferred to a pathologist located 220 miles away at the Milwaukee VAMC (host site). For each case, the telepathologist had the option of rendering a diagnosis or deferring the case for later analysis by conventional light microscopy (LM). After the slides were read by TP and a surgical pathology report had been generated, the slides were transported to Milwaukee, where they were reexamined by the telepathologist using LM and then by the pathology group practice or, when there was no consensus, by an outside consultant to establish a "truth" diagnosis. RESULTS: Compared with the consensus ("truth") diagnosis, clinically important and overall concordance were 99.0% and 97.4%, respectively, by TP, and clinically important and overall concordance were 100.0% and 98.5%, respectively, by LM. The deferral rate was 2.5%. Examining glass slides by HDSF telepathology took an average of 4.43 minutes per slide and 12.09 minutes per case. CONCLUSION: The high diagnostic accuracy and low rate of case deferral support the proposal that an offsite pathologist using HDSF telepathology can substitute effectively for an onsite pathologist as a service provider. PMID- 10172975 TI - Disability. All systems go. PMID- 10172976 TI - Accreditation for behavioral healthcare 1997. New initiatives relevant to your organization. PMID- 10172978 TI - Perspectives. Long road ahead to integration of primary and behavioral care. PMID- 10172977 TI - The physician exodus from hospitals. AB - Physicians are spending increasingly less of their work week in the hospital. This is true of surgeons because they are performing more ambulatory surgery, often off the hospital premises, and for primary care physicians because they are delegating hospital care of their patients to others. What are the effects of this physician exodus on hospitals, patients, physicians, and medical education? Some of these consequences are explored, from disruptions in the continuity of care, to increase in practice productivity, to preparing undergraduates for the realities of medical practice. PMID- 10172979 TI - Teacher offers lessons in power of technology. Interview by Bill Siwicki. PMID- 10172980 TI - The physicians' view of the lab, Part 1. Clinicians examine the lab, and they like what they see. PMID- 10172981 TI - Successful aging in America--Part 2. The impact of an aging population on the clinical laboratory. PMID- 10172982 TI - Dutch drug policy: a model for America? AB - While debates over drug policy in America have focused on choices between demand reduction and supply reduction, the Dutch have pioneered the alternative strategy of harm reduction. The Dutch have built their policy around the principles of separation of markets, low threshold treatment, and normalization of treatment. These policies are worthy of examination as a possible model for drug policy reform in America. PMID- 10172983 TI - The case for morphine. PMID- 10172984 TI - Utilization of LDH isoenzymes in the diagnosis of myocardial infarction. AB - With the arrival of managed care, increased pressure is being placed on the health-care system to reduce the use of laboratory services. When evaluating less expensive methods to measure CK-MB to help reduce costs of triaging patients suspected of having myocardial infarction (MI), we also had an opportunity to evaluate the ordering pattern of LDH isoenzymes for these same patients. We found that LDH isoenzymes were continuously ordered as a routine test at least 14% of the time. We worked with the Division of Cardiology to reduce the use of LDH isoenzymes in two ways: 1) by changing the protocol of triaging suspected MI patients and 2) by reporting the test result only after director approval. This article summarizes our approach to reducing the use of LDH isoenzymes, an expensive test in terms of reagent cost and technician time. PMID- 10172985 TI - Re-engineering surgical services in a community teaching hospital. AB - The Grace Hospital Surgical Services redesign project began in December 1995 and concluded in November 1996. It was led by the Chief of Surgery, the Surgical/Anesthesia Services Director, and the Associate Director of Critical Care/Trauma. The project was undertaken in order to radically redesign the delivery of surgical services in the Detroit Medical Center (DMC) Northwest Region. It encompassed the Grace Hospital Main Operating Room (10 operating theatres) and Post-Anesthesia Recovery Unit, and a satellite Ambulatory Surgery Center in Southfield, Michigan. The four areas of focus were materials management, case scheduling, patient flow/staffing, and business planning. The guiding objectives of the project were to improve upon the quality of surgical services for patients and physicians, to substantially reduce costs, and to increase case volume. Because the Grace Surgical Services redesign project was conducted in a markedly open communicative, and inclusive fashion and drew participation from a broad range of medical professionals, support staff, and management, it created positive ripple effects across the institution by raising staff cost-consciousness, satisfaction, and morale. Other important accomplishments of the project included: Introduction of block scheduling in the ORs, which improved room utilization and turnaround efficiencies, and greatly smoothed the boarding process for physicians. Centralization of all surgical boarding, upgrading of computer equipment to implement "one call" surgery scheduling, and enlarging the capacity for archiving, managing and retrieving OR data. Installation of a 23-hour, overnight recovery unit and provision of physician assistants at the Ambulatory Surgery Center, opening the doors to an expanded number of surgical procedures, and enabling higher quality care for patients. Reduction of FTE positions by 27 percent at the Ambulatory Surgery Center. This yielded a total cost reduction of +1.5 million per annum in the annual budget of +10.3 million; Recruited 10 new podiatrists and increased the volume of cases brought to Northwest Region facilities by surgical specialists. This added 100 cases in 1996, and is projected to add 500 cases in 1997. A 14.5 percent reduction in the cost of operating the Surgical Services was achieved. This was accompanied by enhanced staff morale, physician satisfaction and a higher quality of patient care. PMID- 10172986 TI - New residence design helps Alzheimer's patients find their way. PMID- 10172987 TI - Heavy duties? On-the-job back injuries are a bigger--and costlier--pain than you think. PMID- 10172988 TI - Teaming up for ergonomics? This facility shows you how. PMID- 10172990 TI - A solid future for savvy subacute administrators. PMID- 10172989 TI - Total quality management: an application in a biomedical laboratory. PMID- 10172991 TI - More states enrolling elderly and disabled persons in risk-based Medicaid managed care plans. PMID- 10172992 TI - Examples of CHE (Crown Health Enterprises) initiatives over the past three years. Crown Company Monitoring Advisory Unit. PMID- 10172993 TI - Notice of specific list for categorization of laboratory test systems, assays, and examinations by complexity--CDC. Notice with comment period. AB - Regulations codified at 42 CFR 493.17, implementing the Clinical Laboratory Improvement Amendments of 1988 (CLIA), Public Law 100-578, require that the Secretary provide for the categorization of specific laboratory test systems, assays, and examinations by level of complexity. The criteria for such categorizations also are set forth in those regulations. This Notice announces the addition of approximately 1,300 test systems, assays, and examinations that have been categorized and notified between June 7, 1996 and December 31, 1996. These categorizations were effective on the issue date of the notification letter sent to the manufacturer and are subject to the 30 day comment period for this Notice. PMID- 10172994 TI - Equipment planning for toxicology laboratory. PMID- 10172995 TI - Walking through walls. AB - By watching out for the community's most vulnerable people, Santa Fe's unique multiagency Crisis Response Task Force averts medical emergencies and unnecessary costs. They didn't know how to fix the turf issues, so they just started meeting. PMID- 10172996 TI - Pain and opiophobia. PMID- 10172997 TI - 1997 CPT revisions. PMID- 10172998 TI - The battle for teen health: what's worked and what it tells us. PMID- 10172999 TI - European solutions to home care challenges. AB - Countries all over the world are facing an increasing demand for home care services. Home Care in Europe: A Country-Specific Guide to Its Organization and Financing assesses European countries' home care in terms of funding, staffing, and organization and covers both home nursing and home helps and how the two work together to provide home care in Europe. PMID- 10173000 TI - National snapshot of ambulatory surgery now available. PMID- 10173001 TI - Saddleback Memorial issues annual "Quality Report Card" to grade itself in private--and in public. PMID- 10173003 TI - No more steps: redesign considers disabilities. PMID- 10173002 TI - Back to basics. PMID- 10173004 TI - The transplant trap: the impact of health policy on employment status following renal transplantation. AB - This study examined the relationship between concern for health insurance coverage and employment status following renal transplantation. The sample consisted of 293 individuals who underwent renal transplantation at The Ohio State University Medical Center. The study found fewer individuals reported employment during the past year (58%) than indicated they were able to work (72%). Although 72% of the sample indicated the physical ability to work 41% reported receiving a monthly disability check. Regression analysis revealed that receipt of a monthly disability check and employment status one day prior to transplant were the two most significant predictor variables for employment activity during the year prior to participation in this study. Intervention that is coordinated on a psychosocial level from the time of diagnosis of ESRD throughout the post-transplant period is critical to supporting individuals in pursuing their goals. Research findings should be utilized to advise policy makers and advocate for system changes that support employment for individuals with ESRD. PMID- 10173005 TI - Innovations in cardiac surgery: providing care in Third World countries. PMID- 10173006 TI - Should patenting of surgical procedures and other medical techniques by physicians be banned? PMID- 10173007 TI - Medicaid and long-term care. PMID- 10173008 TI - Calculating hospital activity. Measure for measure. PMID- 10173009 TI - They're not calling me an outlier anymore. PMID- 10173010 TI - Why I called in the state police. PMID- 10173011 TI - Donald E. Bogardus on dangerous new trends in drug diversion. PMID- 10173012 TI - Comfort and care. Nursing homes find new ways to help those with Alzheimer's. PMID- 10173013 TI - Premier unit to test alliance's clout. PMID- 10173014 TI - Improving the benchmark. Makers of a better, more costly Pap test face a tough sell. PMID- 10173015 TI - Medicare, Medicaid, and CLIA programs; clinical laboratory requirements- extension of certain effective dates for clinical laboratory requirements under CLIA--CDC, HCFA. Final rule with comment period. AB - This final rule extends certain effective dates for clinical laboratory requirements in regulations published on February 28, 1992, and subsequently revised December 6, 1994, that implemented provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA). This rule extends the phase-in date of the quality control requirements applicable to moderate and high complexity tests and extends the date by which an individual with a doctoral degree must possess board certification to qualify as a director of a laboratory that performs high complexity testing. These effective dates are extended to allow the Department additional time to issue revised quality control requirements and to ensure laboratory directors are able to complete certification requirements. These effective date extensions do not reduce the current requirements for quality test performance. PMID- 10173016 TI - Laparoscopic instruments good outsourcing candidates. PMID- 10173017 TI - Using surgical outcomes data. AB - The measurement of expanded outcomes data is continuing. As managed care continues to spread through the United States and competition increases, an increased emphasis will be placed on the importance of collecting and analyzing outcomes data as a way to assess and ensure quality of care. Surgeons must familiarize themselves with the concepts behind the measurement of outcomes data and involve themselves in the development of outcomes indicators for surgery in order to ensure a continuing high level of surgical care is provided to their patients. PMID- 10173018 TI - Searching for the right "keyhole" in heart surgery. PMID- 10173019 TI - The latest thing. Minimally invasive heart surgery is all the rage. But it may not always be the right thing to do. AB - Laman Gray Jr., M.D., of Jewish Hospital in Louisville, KY., is among the surgeons at the forefront of new minimally invasive heart surgery techniques. While patients around the country are seeking out surgeons to perform the new techniques, some experts question whether minimally invasive heart surgery is as effective as standard procedure for most patients. PMID- 10173020 TI - Medicare, Medicaid and people with disability. PMID- 10173021 TI - Thirty years of Medicare: impact on the covered population. PMID- 10173022 TI - The controlled clinical trial, single-case research, and the clinical laboratory. PMID- 10173023 TI - An automated hematology workstation. PMID- 10173024 TI - Enhancing laboratory detection of disease. Part 3: Detecting a hantavirus disease event: a case study. AB - A purposive syndromic classification diagnostic system, with known means to ends, has been developed that extracts bits of structural information from endogenous laboratory data. An edifice of structural information for organization, regulation, and decision-making was built for determining future pathophysiological events by asking the fewest questions to define the next event uniquely. The structural information is based on laboratory ordering patterns of physicians for patient populations they serve. Patient history and a physical examination may be included as hardware and software evolves for linking more aspects of the medical record. PMID- 10173025 TI - Reimbursing side effects of pharmaceutical drugs--a Scandinavian speciality. AB - Pharmaceutical insurance applies to drugs which are approved by Swedish licensing authorities and are marketing in Sweden. This paper reviews the pharmaceutical insurance. PMID- 10173026 TI - Mutual recognition and global harmonization. PMID- 10173027 TI - The regulatory situation in central and eastern Europe. AB - The countries of central and eastern Europe, as part of their integration into the European Community, are required to adopt Community regulatory systems for medical devices. This article discusses the challenges faced by these countries during the transition, and support the Community itself can provide to assist their integration. The views expressed in this article are those of the author and do not necessarily represent those of the European Commission. PMID- 10173028 TI - Controls on clinical investigations in Europe: national differences. AB - Clinical investigations in Europe of non-CE-marked medical devices are subject to the controls imposed by the European Directives. At the national level, this creates problems for manufacturers primarily because of country-to-country differences in transposing the Directives into national laws. This article will illustrate some of these differences using two case studies. PMID- 10173029 TI - Implementing the packaging and packaging waste directive. AB - Some Member States have already established systems to meet the recovery and recycling targets for packaging waste. This article reviews their differences and similarities. PMID- 10173030 TI - Cost-benefit analysis of prophylactic granulocyte colony-stimulating factor during CHOP antineoplastic therapy for non-Hodgkin's lymphoma. AB - Several randomised comparative trials have shown that granulocyte colony stimulating factor (G-CSF) reduces the duration of neutropenia, hospitalisation and intravenous antibacterial use in patients with cancer who are receiving high dosage antineoplastic therapy. However, one area that has received less attention is the role of G-CSF in standard-dosage antineoplastic regimens. One such treatment that is considered to have a low potential for inducing fever and neutropenia is the CHOP regimen (cyclophosphamide, doxorubicin, vincristine and prednisone) for non-Hodgkin's lymphoma. We conducted a cost-benefit analysis from a societal perspective in order to estimate the net cost or benefit of prophylactic G-CSF in this patient population. This included direct costs for hospitalisation with antibacterial support, as well as indirect societal costs, such as time off work and antineoplastic therapy delays secondary to neutropenia. The findings were then tested by a comprehensive sensitivity analysis. The administration of G-CSF at a dosage of 5 micrograms/kg/day for 11 doses following CHOP resulted in an overall net cost of $Can1257. In the sensitivity analysis, lowering the G-CSF dosage to 2 micrograms/kg/day generated a net benefit of $Can6564, indicating a situation that was cost saving to society. The results of the current study suggest that the use of G-CSF in patients receiving CHOP antineoplastic therapy produces a situation that is close to achieving cost neutrality. However, low-dosage (2 micrograms/kg/day) G-CSF is an economically attractive treatment strategy because it may result in overall savings to society. PMID- 10173031 TI - Incremental cost-effectiveness ratio of alteplase in patients with acute myocardial infarction in the French setting. AB - On the basis of data collected from general hospital centres in France on 704 patients initially presenting with acute myocardial infarction, the mean 1-year cost of treatment was calculated to be 52,160 French francs (F) per patient (1994 values). This was independent of whether the patient received thrombolysis, and included all costs associated with initial hospitalisation including a stay in intensive care, cardiology or medical units, as well as rehospitalisations, revascularisation procedures and any drugs prescribed. When only those patients who survived the initial hospitalisation were considered, the mean cost of treatment was F58,184 per patient. Among patients who received thrombolysis during their initial hospitalisation, the respective mean 1-year costs were F74,684 per patient for those treated with alteplase and F64,866 per patient for those treated with streptokinase (p = 0.09). This nonsignificant difference can be explained by the higher cost of alteplase relative to that of streptokinase, the lower mortality rate associated with alteplase during the initial hospitalisation period (9.2% versus 10.6%) and the difference in the percentage of additional revascularisations required in the 2 treatment groups (32.8% versus 42.3%). Combining the pharmacoeconomic data collected in the French general hospital setting with incremental patient survival data stemming from the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial showed that the incremental cost-effectiveness ratio of alteplase versus streptokinase amounted to F70128 per life-year saved for the total group, and F52035 per life-year saved for those patients who survived the initial period of hospitalisation. PMID- 10173032 TI - Pre-hospital thrombolysis. PMID- 10173033 TI - Options for paramedic supply storage. PMID- 10173034 TI - Answering your question on blood film reviews. PMID- 10173035 TI - The physicians' view of the lab, Part 2. Doctors speak their minds on lab profiles and problems. PMID- 10173036 TI - Quality control practices and preferences in today's clinical laboratory. A report for government regulators, decision makers, and advisors. PMID- 10173037 TI - Materials used in urological devices. AB - The most commonly used materials in the manufacture of urological devices are discussed with respect to their application to urinary catheters, penile implants, testicular implants, artificial urinary sphincters, and urological stents. The manufacturing, physical properties, and general chemical and biological behavior of there materials are reviewed. Attention is paid to future research trends and the general condition of the field of urological device materials. PMID- 10173038 TI - Silicone manufacturing for long-term implants. AB - The manufacture of silicone materials, particularly silicone elastomers, is described. Chemistry, typical formulations, ingredients, and manufacturing procedures and problems are discussed. Sources and testing for contamination and extractables are reviewed. PMID- 10173040 TI - Carpet: making the appropriate choice. Carpet and Rug Institute. AB - The visual beauty and comfortable atmosphere that carpet adds continues to make carpet an excellent floor covering choice for over 70 percent of floor surfaces in the United States. Choosing the appropriate carpet and rugs for homes, offices, institutions, or public facilities should be based on a knowledge of carpet construction, proper installation, and maintenance. The Carpet and Rug Institute can help with informational tools for the specifier and building manager. PMID- 10173039 TI - Testicular implants. AB - Testicular implants have been in use for more than 50 years with an excellent record of safety and efficacy. The controversy concerning the use of silicone prosthetics in breast implants also affected testicular implants. There is no conclusive evidence associating connective tissue disorders, autoimmunity, or malignancy with silicone implants. Studies show silicone leakage from these implants, but long-term follow-up is required to identify the significance of this finding. Saline-filled silastic shell testicular prostheses will be implanted as part of an ongoing study to monitor various safety parameters, as required by the Food and Drug Administration. PMID- 10173041 TI - A modest proposal: patient underwear in OR. PMID- 10173042 TI - An argument for human consideration. PMID- 10173043 TI - Morphology of glaucoma drainage implantation. AB - Implantation of glaucoma drainage devices has become a standard procedure in various forms of intractable glaucoma. Indications include extensive conjunctival scanning at the upper limbal area, neovascular glaucoma (in addition to pars plana vitrectomy and endolasercoagulation), and secondary glaucoma due to uveitis or trauma. Implanting a glaucoma drainage device is an alternative to trabeculectomy with antimetabolites in young patients in whom delayed complications such as bleb-related endophthalmitis are more likely to occur. Intermediate-term success rates ranging from 70% to 90% are encouraging; however, long-term rates are substantially lower (< or = 50%). Major complications after glaucoma drainage device implantation include hypotony with suprachoroidal hemorrhage and shallowing of the anterior chamber, tube obstruction by fibrin clot, and long-term failure caused by bleb fibrosis. Various glaucoma drainage devices are commercially available; however, none of the designs has proved to be superior to the others. PMID- 10173044 TI - Primus Corp-CLC 385 Automated Glycohemoglobin by HPLC. PMID- 10173045 TI - As we see it. Prudent use of technology. PMID- 10173047 TI - Time bombs in American health care. PMID- 10173046 TI - When the vessel is bad, lowering cholesterol may save the ship. PMID- 10173048 TI - The Americans with Disabilities Act: accommodating guests who have disabilities. PMID- 10173049 TI - ADA and floor care: raising safety consciousness. PMID- 10173050 TI - The impact of anticipatory grief on caregivers of persons with Alzheimer's disease. AB - Caregivers of persons with Alzheimer's disease (AD) and other dementias are known to experience many physical and emotional problems. However, research has consistently shown that the relationship between the demands of caregiving and the effects on the caregiver is not strong. Despite considerable research, a full understanding of how the demands of caregiving uniquely impact the individual has not been established. The present study examines anticipatory grief, an emotion that has not been studied to date for its possible impact on the current functioning of caregivers. Structured interviews, consisting primarily on standardized measures, were conducted with 100 caregivers. Results of the study show that physical and emotional problems and the expectation to place the patient out of the home were more likely to occur among those caregivers who expressed the most intense grief and those feelings of remorse and anger characteristic of the anger and guilt stages of grief. PMID- 10173051 TI - Is screening as good as it looks? PMID- 10173052 TI - Perfusion during coronary and mitral valve surgery utilizing minimally invasive Port-Access technology. AB - Minimally invasive surgery has been used in the treatment of some cardiovascular diseases. Port-Access surgery is a new minimally invasive technique that utilizes cardiopulmonary by-pass and a specialized catheter system that provides cardiopulmonary support and myocardial preservation. Extrathoracic cardiopulmonary support is established with femero-femoral bypass with kinetic assisted venous drainage. An endovascular catheter system allows for all the benefits of mechanical support as well as myocardial preservation. This catheter system includes an endoaortic balloon catheter which functions as an aortic cross clamp and antegrade cardioplegia delivery catheter, endopulmonary vent, and endocoronary sinus catheter used for administration of retrograde cardioplegia. An initial cohort of 20 patients was treated by the Port-Access surgical approach with cardiopulmonary bypass. Ten patients had coronary artery surgery and 10 patients had mitral valve surgery. The average bypass times were 94.4 min (coronary artery) and 152.8 min (mitral valve). The mean aortic occlusion times were 49.7 min (coronary artery) and 112.6 min (mitral valve). All patients were weaned from bypass. This initial patient series demonstrated that Port-Access surgery was feasible in selected patients. PMID- 10173053 TI - Image guided surgery and its potential. AB - The use of higher technology in medicine promises improved outcomes and enhanced productivity. That is, successful techniques will lead to lower cost, higher quality care for a larger population. In surgery, these changes range from the more efficient use of skilled medical practitioners, through improvements to conventional practice (a recent example is the shift to endoscopic surgery in the abdomen), to the creation of new procedures which capitalize on the availability of information in new forms._Image Guided Surgery may be defined as the use of advanced technology to help the surgeon see with 1) Better resolution 2) Orientation and context setting 3) Higher contrast, and 4) Vision inside "solid objects", including the elimination of occlusion by the surgeon's tools or other external items. We describe here the current imaging processes and their limitations with regard to direct guidance of therapy. The physical properties of real time image acquisition systems are described along with the mechanisms for inherent and enhanced contrast. Examples of the use with surgical instruments or other interventional devices for image-monitored and guided procedures are then discussed, and future prospects elucidated. PMID- 10173054 TI - Surgical planning system for soft tissues using virtual reality. PMID- 10173055 TI - A volumetric approach to virtual simulation of functional endoscopic sinus surgery. AB - Advanced display technologies have made the virtual exploration of relatively complex models feasible in many applications. Unfortunately, only a few human interfaces allow natural interaction with the environment. Moreover, in surgical applications, such realistic interaction requires real-time rendering of volumetric data-placing an overwhelming performance burden on the system. We report on a collaboration of an interdisciplinary group developing a virtual reality system that provides intuitive interaction with volume data by employing real-time volume rendering and force feedback (haptic) sensations. We describe our rendering methods and the haptic devices and explain its utility of this system in the real-world application of Endoscopic Sinus Surgery (ESS) simulation. PMID- 10173056 TI - Use of the virtual instrumentation laboratory for the assessment of human factors in surgery and anesthesia. AB - There is a growing consensus that human factors issues for anesthesiologists, surgeons, and other operating room personnel require serious attention. We have established a program of collaboration between the University of California Davis Medical Center Departments of Anesthesiology and Surgery and the California State University Sacramento Biomedical Engineering Program to address ergonomic problems in anesthesiology and surgery using a Virtual Instrumentation Laboratory. A 17-workstation Virtual Instrument Laboratory using LabVIEW software on Power Macintosh platforms permits rapid prototyping of medical monitor displays as well as rapid development of data acquisition and processing circuits for physiologic data collection. The Virtual Instrument Lab has been used for three Master's thesis projects and a BME course titled Human Factors in the Design of Medical and Assistive Technology. Course projects have included: 1) The design of novel physiologic data displays for potential use in anesthesia workstations, and 2) The measurement of surface electromyographic signals and heart rate variability to investigate the physical and mental workload of performing laparoscopic surgery. The Virtual Instrument Lab allows BME students to investigate relatively complex human factors issues in anesthesiology and surgery in a short time span. PMID- 10173057 TI - Virtual endoscopy: evaluation using the visible human datasets and comparison with real endoscopy in patients. PMID- 10173058 TI - Basic technology of simulation system for laparoscopic surgery in virtual environment with force display. AB - A basic simulation system for laparoscopic surgery was constructed. The system consists of force display in a virtual environment construction system. Recently, laparoscopic surgery has become popular around the world. However, this operation strategy requires very high dexterity, so that only some medical doctors can use it. Doctors can see the human organs in a three-dimensional environment in the case of ordinary operations. On the other hand, in the case of laparoscopic surgery, doctors can only see a narrow space in a two-dimensional environment on a CRT monitor and tactile information is decreased during operation procedures. We therefore developed a basic technology of surgical simulator for laparoscopic surgery. The focus of our research is the presentation of resistance from virtual organs. PMID- 10173059 TI - Virtual reality in the operating room of the future. AB - In cooperation with the Max-Delbruck-Centrum/Robert-Rossle-Klinik (MDC/RRK) in Berlin, the Fraunhofer Institute for Computer Graphics is currently designing and developing a scenario for the operating room of the future. The goal of this project is to integrate new analysis, visualization and interaction tools in order to optimize and refine tumor diagnostics and therapy in combination with laser technology and remote stereoscopic video transfer. Hence, a human 3-D reference model is reconstructed using CT, MR, and anatomical cryosection images from the National Library of Medicine's Visible Human Project. Applying segmentation algorithms and surface-polygonization methods a 3-D representation is obtained. In addition, a "fly-through" the virtual patient is realized using 3 D input devices (data glove, tracking system, 6-DOF mouse). In this way, the surgeon can experience really new perspectives of the human anatomy. Moreover, using a virtual cutting plane any cut of the CT volume can be interactively placed and visualized in realtime. In conclusion, this project delivers visions for the application of effective visualization and VR systems. Commonly known as Virtual Prototyping and applied by the automotive industry long ago, this project shows, that the use of VR techniques can also prototype an operating room. After evaluating design and functionality of the virtual operating room, MDC plans to build real ORs in the near future. The use of VR techniques provides a more natural interface for the surgeon in the OR (e.g., controlling interactions by voice input). Besides preoperative planning future work will focus on supporting the surgeon in performing surgical interventions. An optimal synthesis of real and synthetic data, and the inclusion of visual, aural, and tactile senses in virtual environments can meet these requirements. This Augmented Reality could represent the environment for the surgeons of tomorrow. PMID- 10173060 TI - Virtual reality in endonasal surgery. AB - Virtual environments provide a new dimension of graphic simulation. The interaction between the human and the computer is now intuitive for the user. The use of virtual reality (VR) gives the user the feeling of participating in a (computer generated) scenario very much like reality. This feeling is an essential requirement for simulation of surgical interventions using digital data. Especially in the fields of sinus and skull-base surgery, computer assisted simulation could present a valuable and effective alternative method for honing endoscopic skills. Traditionally, surgeons gain experience through anatomic preparation and education by more experienced colleagues. Landmarks like skull base, carotid arteria or optical nerve have to be identified intraoperatively in order to orientate in this critical region. Highly sensitive structures can be damaged most easily. The quality of surgical skills can be characterized as the sum of knowledge, individual experience and manual dexterity. It is conceivable that a surgeon's level of training and experience could be significantly increased by use of VR. With this in mind, a VR-based simulator for procedures in sinus surgery will improve most of these parts. To provide the virtual environment, a realistic representation of the region of interest with all relevant anatomical structures is required. Based on data from tomographic imaging studies, a three-dimensional representation of the paranasal sinuses is semiautomatically reconstructed. Textures derived from endoscopic images are superimposed on the virtual anatomic structures and provide better realism. Two main components of the VR interface can be distinguished: the 3-D interaction to guide the surgical instruments and the 2-D graphical user interface for visual feedback and control of the session. Moreover, the 3-D interaction has to be realized by means of Virtual Reality techniques providing a simulation of an endoscope and an intuitive handling of other surgical instruments. PMID- 10173061 TI - Virtual reality in surgical practice in vitro and in vivo evaluations. AB - This paper describes a method for the acquisition and integrative processing of laparoscopic and endoluminal ultrasound images. We used a stepping motor attached to a stabilizing rig, interfaced to the laparoscope, or the ultrasound probe. 360 degrees laparoscopic scenes were constructed during minimally invasive surgery, and three-dimensional reconstructions were made of related ultrasound data. Integration of 360 degrees panoramas with geometric ultrasound models could be displayed as interactive scenes. This resulted in a better demonstration of the surgical field and topographic anatomy. In conclusion, this type of visualizations may be used in virtual reality simulations for documentation, education and in operative planning. PMID- 10173062 TI - Force sensor for laparoscopic Babcock. AB - GENERAL: A force sensor has been designed and fabricated that will fit to existing laparoscopic grasping forceps (Babcocks) from Ethicon Endosurgery Inc. The goal of the sensor development is to provide tool-tissue force information to the surgeons so that surgeons can regain the sense of touch that has been lost through laparoscopy. Eventually, force sensing will provide feedback for robotic laparoscopic surgical platforms. OBJECTIVE: We have developed a prototype force sensor system with ATI Industrial Automation. This tool is provided as an in-line transducer with six degrees of freedom that can retrofit current Babcocks. The sensor is currently being used in clinical trials with animals to determine the benefits. The sensor system utilizes industry proven technology in combination with a custom transducer and user interface. A GUI is part of the system and provides resolved force magnitude data in a graphical format for case of interpretation. Sterilization, size, and ease of use are addressed by the current design. Operating room reliability and safety are currently being investigated. CLINICAL TRIAL: A three phase experimental trial using a porcine model is being completed that will test the hypothesis that force information can be used to minimize tissue trauma during laparoscopic surgery. RESULTS: Based on our research, there is strong evidence that surgeons would benefit from information regarding the levels of force applied to tissues. In the future, robotic surgery will require force sensing. Surgical simulators could provide force feedback during simulated surgical procedures by using a sensor platform such as this. In addition, tool tip design in the future will benefit from the application of this technology and data base. PMID- 10173063 TI - Spatial perception during laparoscopy: implementing action-perception coupling. AB - Laparoscopy is a telepresence task since the surgeon has no direct contract with the patient. Performance of the surgeon will increase if his sense of telepresence is improved. This can be achieved by restoring the hampered action perception coupling. With respect to visual perception this means that the surgeon should be informed about the spatial lay-out of the environment; depth information and information about the location of observation. Both types of information can be provided by allowing the surgeon to explore. This paper describes our work on restoring the action perception coupling with respect to visual perception. It provides an overview of different technical solutions which balance between what information should be provided from an perceptual stand point and what information can be provided from a technical viewpoint. PMID- 10173064 TI - Fast finite elements for surgery simulation. AB - This paper discusses volumetric deformable models for modeling human body parts and organs in surgery simulation systems. These models are built using finite element models of linear elastic materials. To achieve real-time response condensation has been applied to the system stiffness matrix, and selective matrix vector multiplication has been used to minimize the computational cost. PMID- 10173065 TI - Surgical navigation using audio feedback. AB - Current medical visualization technology intended for positional guidance in surgical applications may only ever have limited utility in the operating room due to the preexisting visual requirements of surgical practice. Additionally, visual systems impose limits as a result of their high latency, poor image resolution, problems with stereopsis and physical strain upon the user. Audio technology is relatively unexamined in the broad range of available methodologies for medical devices. The potential to translate surgical instrument position into audio feedback presents a novel solution to the human factors and engineering problems faced by visual display technology because audio technology employs a rich and as yet unburdened sensory modality. We describe an experimental system we have developed for investigating this new interface design approach using commercially available hardware. PMID- 10173066 TI - Computer-based training for surgeons: evolution or revolution? PMID- 10173067 TI - Telerobotic surgery: applications on human patients and training with virtual reality. AB - This paper deals with the developed researches and applications on telerobotic surgery, devoted to human patients and with training by virtual reality. The researches have been developed in cooperation between Telerobotics Laboratory, Department of Mechanics, Politecnico di Milano, Italy, and Automation and Control Section, Jet Propulsion Laboratory, Pasadena, USA. The researches carried to a telesurgery robotic operation on a dummy on 7th July 1993, by means of satellites communications, to a prostatic biopsy on a human patient on 1st September 1995 with optical fibers, to results on time delay effects, to results on virtual reality applications for training on laparoscopy and surgery. The search implied time delay when the control input originated in Politecnico di Milano, Italy. The results were satisfactory, but also pointed out the need for specific new control transformations to ease the operator's or surgeon's visual/mental workload for hand-eye coordination. In the same research, dummy force commands from JPL to Milan were sent, and were echoed immediately back to JPL, measuring the round trip time of the command signal. This, to some degree, simulates a contact force feedback situation. The results were very surprising; despite the fact that the ISDN calls are closed and "private" calls, the round-trip time exhibited great variations not only between calls but also within the same call. The results proved that telerobotics and telecontrol may be applied to surgery. Time latency variations are caused by features of communication network, of sending and receiving end computer software. The problem and its solution is also an architectural issue, and considerable improvements are possible. Virtual reality in the application of the research is a strong support to training on virtual objects and not on living beings. PMID- 10173068 TI - ENT endoscopic surgical training simulator. AB - This paper describes work in progress on the design and development of a prototype simulator for minimally invasive otolaryngology surgical training. The anatomy of the paranasal sinuses is geometrically complex and dangerously close to the brain and orbits, making this procedure challenging to practice and difficult to learn. We discuss the potential role of computer simulation to enhance and accelerate acquisition of surgical skills. The design goals of the prototype include high-fidelity simulation of the endoscopic imagery and haptic cues of surgical palpation. The prototype enables endoscopic navigation and limited interactive tissue manipulation and dissection tasks on a virtual patient using realistic replicas of surgical tools. We present an overview of the system architecture with a discussion of the technological challenges, design issues and current status of the efforts. PMID- 10173069 TI - Emerging robotics technology and its transformation of practices in healthcare. PMID- 10173070 TI - MIST VR. A laparoscopic surgery procedures trainer and evaluator. AB - The key bimanual instrument tasks involved in laparoscopic surgery have been abstracted for use in a virtual reality surgical skills evaluator and trainer. The trainer uses two laparoscopic instruments mounted on a frame with position sensors which provide instrument movement data that is translated into interactive real time graphics on a PC (P133, 16 Mb RAM, graphics acceleration card). An accurately scaled operating volume of 10 cm3 is represented by a 3D cube on the computer screen. "Camera" position and size of target objects can be varied for different skill levels. Targets appear randomly within the operating volume according to the skill task and can be grasped and manipulated with the instruments. Accuracy and errors during the tasks and time to completion are logged. Mist VR has tutorial, training, examination, analysis and configuration modes. Six tasks have been selected and include combinations of instrument approach, target acquisition, target manipulation and placement, transfer between instruments, target contact with optional diathermy, and controlled instrument withdrawal/replacement. Tasks can be configured for varying degrees of difficulty and the configurations saved to a library for reuse. Specific task configurations can be assigned to individual students. In the examination mode the supervisor can select the tasks, repetitions and order and save to a specific file for that trainee. Progress can be assessed and there is the option for playback of the training session or examination. Data analyses permit overall, including task, and right or left hand performances to be quantified. Mist VR represents a significant advance over the subjective assessment of training performances with existing "plastic box" basic trainers. PMID- 10173071 TI - Finite Element analyses to study periprosthetic bone adaptation. AB - Periprosthetic bone adaptation around orthopaedic implants can be studied with Finite Element models. It requires a comparison between the mechanical status of the bone in the operated (unnatural) situation and the natural situation. The difference between these two situations is the alteration in mechanical condition of the bone, which is assumed to be the driving force of the adaptation process. The time dependent bone adaptation process can be simulated with a computer algorithm by an iterative (time stepping) procedure. This study reviews some clinical and experimental issues, it addresses the value of computer models of periprosthetic bone adaptation and discusses a new development of voxel based models directly converted from CT scans. PMID- 10173072 TI - The "knack" of Alzheimer's care. AB - Some caregivers just seem to have a "knack" when it comes to dealing with people with Alzheimer's disease. But you don't have to be born with it--many coping techniques can be learned. PMID- 10173074 TI - The future of surgical oncology. PMID- 10173073 TI - Cost-effective management of diabetic foot ulcers. A review. AB - Foot lesions are common and serious complications in patients with diabetes mellitus. In recent years, several authors have, in addition to the medical aspects, focused on the high costs for treatment of this complication. However, few studies have performed a complete health-economic comparison and analysis of different treatments. This is probably related to the complexity of the problem and ethical difficulties in performing randomised clinical trials on these patients. Despite the lack of comparative health-economic studies, most authors conclude that amputations should be avoided if there is any possibility of saving the limb. This is not only because of the economic consequences-high costs for repeated hospitalisations, rehabilitation, home care and social-service support associated with amputations, but also the quality-of-life aspects. Alternative treatment options might seem costly in the short term, but most cost effectiveness analyses that also consider the long term perspective have concluded that treatment alternatives in which the limb is saved are more cost effective. Methodological aspects, such as the perspective of a study, may cause difficulties in comparing results between countries and settings. By using the societal perspective in economic studies, incentives to push costs from one sector to another might be avoided. PMID- 10173075 TI - Surgery on the edge of the desert. PMID- 10173076 TI - Outpatient laparoscopy: can we? Should we? How are we to know? PMID- 10173077 TI - Laparoscopic surgical procedures at the "recovery hotel". PMID- 10173078 TI - Same-day surgery has new benchmarking option. Patient survey offers national comparisons. AB - A new survey instrument developed by the Picker Institute in Boston uses highly specific questions to target same-day surgery successes and failures from the patients' perspectives. Hospitals and surgery centers can compare their performance with benchmarks from the academic institutions that are members of the University HealthSystem Consortium in Oak Brook, IL. Surveys will identify which specialty areas produce the most and least satisfied patients. PMID- 10173079 TI - Monitoring health care system performance in Iowa. AB - Monitoring the performance of the health care delivery system is a public health function that becomes more important as organized delivery systems begin to take control over larger portions of the medical care market. The study reported here illustrates how standard medical care epidemiology can be applied to analysis of health care system performance to aid governmental efforts to monitor new developments in the medical care market. In order to evaluate the efficiency of hospital care delivered in Iowa, age- and sex-adjusted population admission rates for five common procedures were generated for all 99 counties. The five common procedures were defined as follows: hernia, tonsillectomy, cesarean section, hysterectomy, and cholecystectomy. In addition, variations in 11 ambulatory care sensitive condition rates were analyzed. Residents of at least 15 counties were at significantly greater than average risk of receiving each of the common procedures (chi 2 test, P < 0.05). Counties that had a high rate for one procedure tended to have a high rate for at least one other procedure. Several counties had more than twice the mean rate. Even a 10% reduction, when added across all five common procedures. amounts to well over 2,000 hospitalizations avoided. It is assumed that reductions would be concentrated in high-rate counties. If a 50% reduction could be achieved in only part of the ambulatory care-sensitive procedures, more than 10,000 hospital admissions could be avoided. PMID- 10173080 TI - The friction cost method: a comment. AB - The friction cost method has been proposed as an alternative to the human-capital approach of estimating indirect costs. We argue that the friction cost method is based on implausible assumptions not supported by neoclassical economic theory. Furthermore consistently applying the friction cost method would mean that the method should also be applied in the estimation of direct costs, which would mean that the costs of health care programmes are substantially decreased. It is concluded that the friction cost method does not seem to be a useful alternative to the human-capital approach in the estimation of indirect costs. PMID- 10173081 TI - Vitrectomy for the management of recurrent retinal detachments. AB - Repair of rhegmatogenous retinal detachment is successful in approximately 90% of cases. Assuming all retinal breaks are identified and closed, the most common reason for eventual failure of surgery is the development of proliferative vitreoretinopathy, accounting for the failure of 7% to 10% of primary repairs and an increased proportion of secondary procedures. Recurrent retinal detachment complicated by proliferative vitreoretinopathy is now most frequently treated by pars plana vitrectomy with intraoperative peeling of membranes. During the 1990s, a better understanding of the nature of recurrent retinal detachment due to proliferative vitreoretinopathy has grown concomitantly with more experience using various vitreoretinal techniques to manage these complicated cases. This article reviews the latest developments in vitreous surgery to repair recurrent retinal detachments due to proliferative vitreoretinopathy, focusing on the most recent reports in the literature. PMID- 10173082 TI - Current concepts in the management of central retinal vein occlusion. AB - The results of the Central Vein Occlusion Study (CVOS) guide the management of macular edema and neovascularization. This study did not show that grid-pattern laser photocoagulation had a significant beneficial effect for the management of decreased visual acuity caused by perfused macular edema in eyes with central retinal vein occlusion (CRVO). Panretinal laser photocoagulation (PRP) was shown to be beneficial for eyes with at least 2 clock hours of iris neovascularization or any angle neovascularization. PRP has not been advocated as prophylaxis for ischemic eyes before the formation of neovascularization. Although treatment of the ocular consequences of CRVO may be guided by the CVOS data, management of the underlying cause of CRVO-the occluded vein itself-was not addressed in the study. Recently, several reports have suggested restoring venous outflow by 1) creating a laser-induced or surgically induced chorioretinal anastomosis, 2) administering recombinant tissue plasminogen activator (rt-PA), 3) cannulating the retinal vein transvitreally, or 4) transecting the posterior scleral ring. PMID- 10173083 TI - Addressing addiction. Groups fight one-size-fits-all substance-abuse coverage. PMID- 10173084 TI - The diagnosis, classification, and management of asthma according to severity. AB - This activity is designed for primary care and specialist physicians. GOAL: To provide prompt and appropriate treatment for asthma of all levels of severity resulting in improved level of activity and decreased need for urgent care and hospitalization with a possible reduction in the annual decline of lung function, degree of permanent airway damage, and mortality. OBJECTIVES: 1. To provide a framework on the basis of history, physical findings, and laboratory results for the diagnosis of asthma. 2. To improve the ability to classify asthma by degree of severity. 3. To describe an incremental therapeutic approach to asthma by degree of severity. 4. To provide a systematic approach with regard to periodic reevaluation of asthma severity and modification of the treatment plan. PMID- 10173085 TI - How one physician can make a difference. PMID- 10173086 TI - Dual diagnosis care for severe and persistent disorders. A comparison of three methods. AB - People with severe and persistent mental illnesses frequently suffer from addictive disorders as well. Managed care plans and at-risk providers who care for people with these conditions must understand, authorize, and provide evidence based and cost-effective care. The authors of this article evaluated three specialized interventions for treating people with co-occurring severe mental illness and substance abuse. Treatment of both disorders was found to be essential. In addition, a behavioral skills training was found to improve outcomes and reduce total healthcare costs when compared with intensive case management and 12-Step recovery interventions. Supplemental supportive services further increase the overall value of care. Implications for managed care and at risk providers are discussed. PMID- 10173087 TI - Foster Higgins National Survey: trends in behavioral benefits. AB - Most employer-sponsored health insurance plans provide some coverage for mental health and addiction treatment. However, analysis of over 3,000 employer benefit plans reveals wide variation in the level and scope of behavioral health benefits. Of all commercially insured employees and dependents, 77 percent are currently enrolled in health maintenance organizations (HMOs), preferred provider organizations (PPOs), or point-of-service (POS) managed care plans. This article documents the differences among behavioral health coverage packages in these three different types of managed care organizations (MCOs), and the lower levels of behavioral health coverage compared with coverage for other medical care. The author states that some employers are selecting single-specialty managed behavioral carve-out plans specifically to increase benefit levels and improve quality of care. PMID- 10173088 TI - Transforming the long-term care system: policy and managerial challenges. AB - As the need for long-term care of people with disabilities increases, the model of care faces crucial changes, including a shift from institutional to independent living, significant changeover in organizational auspices, and policies created by the Americans with Disabilities Act. Such systemic changes pose fiscal, technological, and social challenges to policymakers and managers of care delivery. PMID- 10173089 TI - Future trends in chronic disability and institutionalization: implications for long-term care needs. AB - Demographic changes (including a healthier and aging population), trends in chronic morbidity and disability, and changes in active life expectancy have affected trends in long-term care delivery in the United States. Managed care plans face particular challenges, including creation of mix-based reimbursements and better integration of geriatric and other specialty services. PMID- 10173090 TI - From the walls of the city: disabilities as culture. AB - Invites pastoral professionals to consider the disabled as a cross-cultural population who faces a crisis while searching for meaning in a larger culture that finds meaning in beauty, power, freedom from strife, and physical and emotional wholeness. Argues that the disabled merit the same informed and specific study as other persons who are "different." Urges pastoral professionals to examine what they know about disabilities and discusses the unconscious, unchallenged myths about the disabled and treatment implications of considering disability as culture. PMID- 10173091 TI - Unbundling outpatient laboratory charges: an investigation update. PMID- 10173092 TI - Hospital care for persons with AIDS in the European Union. AB - This study estimates the current and future hospital resources for AIDS patients in the European Union (EU), using multinational scenario analysis (EU Concerted Action BMH1-CT-941723). In collaboration with another EU-project ('Managing the Costs of HIV Infection'), six national European studies on the utilization of hospital care for AIDS have been selected to provide the data for our analysis. The selection criteria involve recentness, quality, comparability, accessibility and representativeness. Baseline hospital resource utilization is estimated for hospital inpatient days and outpatient contracts, using a standardized approach controlling for two severity stages of AIDS (chronic stage and late stage). The epidemiological part of the study is based on standard models for backcalculating HIV incidence and projecting AIDS incidence, prevalence and mortality. In the next step, baseline resource utilization is linked to epidemiological information in a mixed prevalence and mortality-based approach. Several scenarios render different future epidemiological developments and hospital resource needs. For the year 1999, hospital bed needs of 10,000-12,700 in the EU are indicated, representing an increase of 20-60% compared to the estimated current (1995) level. The projected range for 1999 corresponds to a maximum of 0.65% of all hospital beds available in the EU. The growth in the number of outpatient hospital contacts is projected to possibly exceed that of inpatient days up to 1.82 million in 1999. Our methodology illustrates that estimation of current and future hospital care for AIDS has to be controlled for severity stages, to prevent biases. Further application of the multinational approach is demonstrated through a 'what-if' analysis of the potential impact of combination triple therapy for HIV/AIDS. Estimation of the economic impact of other diseases could as well benefit from the severity-stages approach. PMID- 10173093 TI - Substance abuse treatment evolves. Case manager assumes new responsibilities. PMID- 10173094 TI - Employment law. Body armour. PMID- 10173095 TI - A cost/efficacy analysis of oral antifungals indicated for the treatment of onychomycosis: griseofulvin, itraconazole, and terbinafine. AB - This analysis was conducted at HIP Health plan of New Jersey (a Northeastern group model health maintenance organization) to determine the most cost-effective therapy among the three currently available oral antifungal drugs that are indicated for the treatment of onychomycosis: griseofulvin, itraconazole, and terbinafine. Costs of an appropriate and complete treatment regimen were calculated for each of the three drugs based on average wholesale price. Efficacy was determined by meta-analysis of the published literature for those studies where appropriate treatment regimens for onychomycosis were put to use. Efficacy outcome measures were limited to mycologic cure rates in the more recalcitrant cases of toenail onychomycosis. From these measures of cost and efficacy, a cost/efficacy ratio was calculated for each drug by dividing the cost per treatment by the weighted average mycological cure rate. This ratio represents the cost per mycologically cured infection. The final outcome measure (the cost per mycologically cured infection) was $2,721.28, $1,845.05, and $648.96, for griseofulvin, itraconazole, and terbinafine continuous therapies, respectively. For itraconazole and terbinafine pulse therapy, the costs were $855.88 and $388.50, respectively. For both continuous and pulse therapy, terbinafine is apparently the most cost-effective drug, followed by itraconazole and then by griseofulvin. Terbinafine has the fewest drug interactions and the highest treatment success rate. PMID- 10173096 TI - Trends and issues in parity for behavioral healthcare coverage. PMID- 10173097 TI - Professional associations and managed care. How four provider groups are helping their members. AB - Managed care is facilitating rapid change in the day-to-day practice of many addiction treatment and mental health professionals. It is only natural, therefore, that the associations representing the various disciplines in behavioral healthcare should seek to present short- and long-term plans, advice, and programs for their members. We have asked leaders from four prominent groups to present what their organizations are doing today to assist professionals in adapting to the new realities of the healthcare system. The comments below are by no means conclusive, and are representative of a few efforts and thoughts. It is our mission at Behavioral Healthcare Tomorrow to provide an independent platform for dialogue in the world of mental health and addiction treatment. It is our hope that the proposals and ideas published here stimulate even more planning amongst providers as managed care assertively enters public sector services. PMID- 10173098 TI - Laboratory considerations in the rapid determination of drugs in patient specimens. PMID- 10173099 TI - Aspects of male circumcision in sub-equatorial African culture history. AB - This paper describes the general cultural background of male circumcision for the Bantu speaking peoples of sub-equatorial Africa. Where the contemporary cultural context of male circumcision is now variable and often transformed amongst groups who continue the practice, traditional practices were commonly of a particular and rather narrow profile linked to the toughening, training and initiation of male adolescents into warrior status. For those groups the normal social context of circumcision was in the adolescent rites of passage typically called 'initiation schools' in the ethnographic literature. These in turn were highly associated with 'age-grades', age ranked male cohorts whose membership was defined by participation in the same initiation schools in the same year. Linguistic evidence suggests the schools and circumcision are very ancient and typological arguments suggest that those Bantu groups which do not circumcise males have abandoned a once more widespread practice. In the main, the Bantu groups which do not circumcise males belong to certain contiguous linguistic groups and their neighbours from amongst bordering Bantu subgroups. Almost all groups which have abandoned male circumcision have also abandoned initiation schools and age-grades. This constitutes a culture area in terms of those dimensions of those societies. Circumcising and non-circumcising groups are suggested to have their distribution due to diffusion of loss and it cannot be expected that differential risk behaviours in relation to HIV infection will be found to sort similarly amongst Bantu-speaking or other African peoples. But such mapping, for those who would do it, can now take place with the knowledge that a cluster of cultural traits typify the non-circumcising Bantu groups. PMID- 10173100 TI - The "sterile" debate: the effects of radiation sterilization on polymers. AB - All medical devices have to be sterilized, but the process of killing bacteria and other organisms can also have some deleterious effects on the devices themselves. This article discusses the mechanisms by which gamma irradiation can cause polymer damage and the potential consequences of this. PMID- 10173101 TI - Quality management systems: a reliable proof of conformity. AB - Doubts have been raised about whether proof of conformity via a certified full quality management system is appropriate for in vitro diagnostic products used for screening blood donations, for example, tests for HIV and hepatitis B and C. This article reviews all the arguments and finds in favour of the proposed system because it involves requirements that extend beyond the normal quality system standard. PMID- 10173102 TI - Telesurgery. Telepresence. Telementoring. Telerobotics. PMID- 10173103 TI - Best hospitals 1997. Little surgery, big plans. The heart is a hot target of minimally invasive procedures. PMID- 10173104 TI - Discrimination claims rejected by three federal district courts. PMID- 10173105 TI - Implementation of the Bamako Initiative: strategies in Benin and Guinea. AB - Two West African countries, Benin and Guinea, have been reorganizing their peripheral health systems since 1986, with the goal of improving access to primary health care (PHC). A comprehensive approach evolve, based on improving effectiveness, optimizing efficiency, ensuring financial variability and promoting equity. These strategies were launched as the Bamako Initiative by the World Health Organization's Regional Assembly in 1987. This is the first in a series of five articles on the Bamako Initiative in Benin and Guinea. The strategies implemented in these two countries are discussed. Subsequent articles discuss the improved health indicators, impact on service costs efficiency, and community empowerment through local cost recovery and equity implications. The health center is the basis for a revitalized primary care system. From here, an integrated minimum health care package is readily accessible to meet basic community health needs. Through the Bamako Initiative program, drugs and other essential resources are always available, regular contract between the community health service providers and communities has increased, and the quality of care has improved while also becoming more efficient. Community health resources are managed locally through joint microplanning and monitoring, involving health personnel and village committees. Community ownership, fostered by local budgeting and decision making, is an essential pillar for the success of the system. PMID- 10173106 TI - The Bamako Initiative in Benin and Guinea: improving the effectiveness of primary health care. AB - The objective of the health system revitalization undergone in Benin and Guinea since 1986 is to improve the effectiveness of primary health care at the periphery. Second in a series of five, this article presents the results of an analysis of data from the health centres involved in the Bamako Initiative in Benin and Guinea since 1988. Data for the expanded programme of immunization, antenatal care and curative care, form the core of the analysis which confirms the improved effectiveness of primary health care at the peripheral level over a period of six years. The last available national data show a DPT3 immunization coverage of 80% in 1996 in Benin and 73% in 1995 in Guinea. In the Bamako Initiative health centres included in our analysis, the average immunization coverage, as measured by the adequate coverage indicator, increased from 19% to 58% in Benin and from less than 5% to 63% in Guinea between 1989 to 1993. Average antenatal care coverage has increased from 5% in Benin and 3% in Guinea to 43% in Benin and 51% Guinea. Utilization of coverage with curative care has increased from less than 0.05 visit per capita per year to 0.34 in Guinea and from 0.09 visit per capita per year to 0.24 in Benin. Further analysis attempts to uncover the reasons which underlie the different levels of effectiveness obtained in individual health centres. Monitoring and microplanning through a problem-solving approach permit a dynamic process of adaptation of strategies leading to a step by step increase of coverage over time. However, the geographical location of centres represents a constraint in that certain districts in both countries face accessibility problems. Outreach activities are shown to play an especially positive role in Guinea, in improving both immunization and antenatal care coverage. PMID- 10173108 TI - CLR 1997-1998 clinical laboratory reference. PMID- 10173107 TI - Affordability, cost-effectiveness and efficiency of primary health care: the Bamako Initiative experience in Benin and Guinea. AB - Since 1986 two West African countries, Benin and Guinea, have been actively reorganizing their peripheral health systems according to strategies subsequently called the "Bamako Initiative". Two preceding articles described the strategies implemented and the increased effectiveness of primary health care (PHC) witnessed over a period of six years. This article presents an analysis of cost and coverage data from biannual monitoring sessions between 1988 and 1993 in approximately 200 health centres in Benin and 214 in Guinea. In order to assess affordability, the total and per capita recurrent costs for operational health centres are analysed and then compared. The cost analysis reveals a mean total cost per health centre per year of slightly over US+11,000 in Benin and nearly US+9,000 in Guinea. The median cost per capita per year is approximately US+1.0 in Benin and between US+0.60 and US+0.80 in Guinea. Comparisons of these costs between regions, health centres and over time (as coverage levels evolved) show very little variation in either country. Cost-effectiveness is estimated by allocating these costs to immunization, antenatal and curative care and comparing them to the coverage achieved with these interventions. First, the cost effectiveness of the Bamako Initiative (BI) system as a whole is analysed. The cost per fully vaccinated child is calculated at US+10.9 in Benin and US+8.8 in Guinea. The cost per woman receiving at least three antenatal visits is US+7 in Benin and US+4.7 in Guinea. For curative care, cost per full treatment is US+1.6 in Benin and half this amount in Guinea. Cost-effectiveness is variable between regions, health centres reveals that these differences in cost-effectiveness are mainly caused by the coverage levels achieved, since total costs are relatively stable. Finally the efficiency of drug management and prescriptions as well as of outreach for the expanded programme of immunizations (EPI) is estimated by relating specific drug and outreach activities costs to the number of beneficiaries. The average cost of drugs per treatment is around US+0.5 in Benin and around US+0.3 in Guinea. Cost analysis of outreach activities undertaken for EPI in Guinea revealed a similar average cost per child completely vaccinated for health centres with different intensities of outreach (approximately US+10) and an additional cost per child vaccinated attributable to outreach of US+1-2. PMID- 10173109 TI - Savings, patient demand push new techniques. PMID- 10173110 TI - Keyhole cardiac surgery. Patients' shorter stay has impact on nursing. PMID- 10173111 TI - When defibrillator patients come to surgery. PMID- 10173112 TI - Coding--Part 1 of 5. Get the highest coding you're entitled to. PMID- 10173113 TI - Preparing your facility for dementia care. PMID- 10173114 TI - Elderly pose unique oral care challenge. PMID- 10173115 TI - System for outcomes-based surgical report care developed by the Governor's Committee on Socioeconomic Issues. PMID- 10173116 TI - Providing high-quality care for children. AB - Because home care traditionally has served older patients under Medicare, some providers tend to treat in-home pediatric patients like "little adults." To offer children and their families the specialty care that they require and deserve, one agency limits its services exclusively to pediatrics. PMID- 10173117 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); program for persons with disabilities; basic program--DoD. Final rule. AB - This final rule simplifies the administration of benefits under the CHAMPUS Program for the Handicapped (PFTH) and changes the name of this benefit to Program for Persons with Disabilities (PFPWD); adds occupational therapists in independent practice to the list of authorized individual professional providers; provides criteria for cost-sharing certain procedures when data is transferred electronically from the patient's home to a medical practitioner; defines and limits plans recognized as supplemental insurance under CHAMPUS; and adopts the Federal Claims Collection Act and the Federal Claims Collection Standards by reference. PMID- 10173118 TI - Dissecting drug cost trends. PMID- 10173119 TI - Counseling patients can improve their outcomes. PMID- 10173120 TI - Peppermint prozac. PMID- 10173121 TI - Assessing the need, use, and developments in mental health/substance abuse care. AB - This overview presents an introduction to the articles published in this issue of the health care Financing Review, entitled "Mental Health Services and Vulnerable Populations." This article discusses the challenges the mental health and substance abuse (MH/SA) care system is confronted with in terms of equity and efficiency and how the system is responding to these challenges. It further addresses research issues in assessing the need and use of mental health services and summarizes recent activities in the research and evaluation of new delivery and payment systems. PMID- 10173122 TI - The drug abuse treatment gap: recent estimates. AB - There is a widely acknowledged problem of drug abuse in the United States, but there is no widely accepted estimate of the number who need treatment for drug abuse. In this article, the authors present new estimates of the numbers of persons in this country who need and receive treatment. These estimates are derived from improved definitions and statistical estimating methods applied to the national Household Survey on Drug Abuse (NHSDS). There are two separate estimates (based on severity) of people needing treatment, yielding a combined total of 7.1 million people. These new estimates are crucial to better resource planning and allocation. PMID- 10173123 TI - Provider specialty choice among Medicare beneficiaries treated for psychiatric disorders. AB - This study estimates the probability of mental health specialist use among elderly and disabled Medicare beneficiaries treated for a primary psychiatric diagnosis, based on the 1991 Medicare Current Beneficiary Survey (MCBS) and physician claims. Beneficiaries with psychotic and affective disorders or multiple psychiatric diagnoses had a higher probability of specialty use, as did beneficiaries in counties with greater psychiatrist density. Elderly in counties with greater general practitioner density and disabled in counties with greater psychologist density were less likely to see a specialist, suggesting possible provider substitution. Government programs to recruit and retain mental health professionals in underserved areas may change provider specialty choices among Medicare beneficiaries treated for psychiatric disorders. PMID- 10173125 TI - Data trends. Economies of scale in outpatient surgery. PMID- 10173124 TI - Mental health of Medicare beneficiaries: 1995. PMID- 10173126 TI - Cost effectiveness of micronised fenofibrate and simvastatin in the short-term treatment of type IIa and type IIb hyperlipidaemia. AB - The aim of this study was to compare the cost effectiveness of micronised fenofibrate 200 mg and simvastatin 20 mg in the treatment of type IIa and IIb hyperlipidaemia. In a retrospective analysis, data from 2 randomised controlled clinical trials were evaluated. The results show that micronised fenofibrate has a better short term cost effectiveness than simvastatin. The costs per successfully treated patient with hyperlipidaemia over a 12-week period were [in Deutschmarks (DM); DMI = $US0.66, April 1995] DM537 for fenofibrate and DM809 for simvastatin. When the data were analysed according to type of hyperlipidaemia (classification of Frederickson), there were only small differences between both test drugs (DM450 for fenofibrate, DM517 for simvastatin) in patients with type IIa because simvastatin had higher response rates which, in part, compensated for the higher acquisition cost. However, response rates in patients with type IIb hyperlipidaemia were higher for fenofibrate, which led to a substantial cost advantage for this agent (DM768 for fenofibrate, DM2080 for simvastatin). These results were confirmed by various sensitivity analyses, including the assessment of drug monitoring programmes (postmarketing surveillance) to validate response rates and the total costs of the therapy. In this study, we evaluated the total costs of a 12-week period of therapy, not the costs per day. The results are based on actual clinical data and not just on theoretical models. The study underlines the necessity to differentiate between the types of hyperlipidaemia when performing a pharmacoeconomic analysis of lipid-lowering treatments. PMID- 10173127 TI - Survey shows outpatients have high expectations. PMID- 10173128 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); Program for Persons with Disabilities; basic program--DoD. Final rule; administrative corrections. AB - The Department of Defense published a final rule concerning the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) on June 30, 1997 (62 FR 35086). There were incorrect amendments published to the Program for Persons with Disabilities section of the CHAMPUS rule. This document corrects the administrative error. PMID- 10173129 TI - Medicare program; adjustment in payment amounts for new technology intraocular lenses--HCFA. Proposed rule. AB - This proposed rule would establish in regulations a process under which interested parties may request, with respect to a class of new technology intraocular lenses (IOLs), a review of the appropriateness of the current payment amount for IOLs furnished by Medicare-participating ambulatory surgical centers. The rule implements section 141(b) of the Social Security Act Amendments of 1994, which requires us to develop and implement this process. PMID- 10173130 TI - How do you define the health of populations? AB - What are the perceptions of population health, and how do you define it to move forward on any common action agenda of policy, management, teaching, or research? The author asks a series of questions to clarify the ambiguities around the population health concept, beginning with defining "health" as more than the absence of disease, but less than the breadth of complete well-being. Such a framework requires an operational measure of population health outcome that goes beyond quantity of life (mortality) to add extra dimensions. In other words, the goal is not only to purchase life years, but life years at some level of quality. The article provides an argument for the importance of some aggregate measure of health outcome, such as Health Adjusted Life Expectancy (HALE), as a management tool for purchasing populations health. PMID- 10173131 TI - Continuous quality improvement decreases length of stay and adverse events: a case study in an interventional cardiology program. AB - A study was performed to assess the effectiveness of continuous quality improvement in achieving a better quality of care for patients undergoing coronary interventions. Increasing utilization of new coronary interventional devices has incurred a higher incidence of complications, prolonged hospital stay, and related costs. Using a clinical information system, we adopted continuous quality improvement to control the incidence of complications and postprocedural length of stay. Multiple regression analysis and a matched case control study were performed to detect complications related to postprocedural length of stay and their causes among 342 patients. The results led to the modification of the postprocedural heparin anticoagulation protocol, which was followed by the introduction of a ticlopidine-based poststent anticoagulation regimen. Two sequential groups of patients (n = 261, n = 266) were selected to compare postprocedural length of stay and frequency of complications with those for the first group. Adjustments were made for patients and procedural characteristics through stratification and multiple regression methods. Blood transfusion was the most important predictor of prolonged hospital stay (partial R2 = 0.26, P < 0.01). A high level of postprocedural anticoagulation and intracoronary stent use were significantly associated with blood transfusion (P = 0.01, P = 0.02, respectively). The comparison among the three groups showed that heparin protocol change reduced only postprocedural length of stay (P < 0.001) for patients without stents, whereas the stent change in anticoagulation protocol significantly reduced both transfusion and hospital stay for patients with stents (P < 0.001, P < 0.05, respectively). Continuous quality improvement based on clinical information is promising to control both complications and hospital costs. Physician involvement is necessary throughout the process. PMID- 10173132 TI - Treating panic disorder. PMID- 10173133 TI - No shades of gray. One out of ten long-term care residents is under 65, but most facilities are unprepared to handle them. PMID- 10173134 TI - One step at a time. Assisted living managers are learning the art of keeping wandering in check. PMID- 10173135 TI - Minds matter. Helping employees cope secures ADA compliance--and it's good business. PMID- 10173136 TI - Future European health care: cost containment, health care reform and scientific progress in drug research. AB - The cost of the development of a new pharmaceutical product from its conception and synthesis through to the regulatory approval process has more than quadrupled in the last 20 years. Both clinical and total development times have increased substantially. To amortize the costs incurred, the pharmaceutical industry has taken an international dimension. The incentives for pharmaceutical firms to discover and develop new drugs depend on the length of the development and regulatory review process plus the potential market size. Recent regulatory, economic and political changes may have significant implications for the future of new drug developments in Europe. The European Union industrial policy felt that there is a need for convergence in the area of pricing. It is recommended that the policy should aim to contain growth in pharmaceutical expenses by means specific to reimbursement rather than direct price controls. By encouraging doctors to prescribe and customers to use generics, competition is enhanced to bring down drug prices. More emphasis is being laid by government in educating customers to cost-awareness and cost-benefit ratios with regard to pharmaceuticals. Concerning clinical trials, European harmonization has been achieved by significant developments: the rights and integrity of the trial subjects are protected; the credibility of the data is established; and the ethical, scientific and technical quality of the trials has improved. Future European health care forecasts a whole change in the pharmaceutical business. Important issues in cost and outcome measurement should be carefully planned and considered in drug development. Due to important mergers and acquisitions, the pharmaceutical sector will consist mainly of important multinational corporations. In this way, valuable new products may be brought to the market. PMID- 10173137 TI - Massachusetts Risk Management Survey (MaRMS) of teaching hospital physicians. AB - OBJECTIVE: To assess and compare the risk management knowledge of physicians from Massachusetts teaching hospitals. DESIGN: A survey. SETTING: Participating Massachusetts teaching hospitals. PARTICIPANTS: 639 of some 2,000 staff physicians of participant hospitals who were sent surveys. An additional 174 postgraduate year 1 (PGY1) and PGY3 house officers also completed the survey. MAIN OUTCOME MEASURES: Percent of questions answered correctly, and comparisons between staff physicians and house officers. RESULTS: Staff physicians scored higher (87%) than PGY1s and PGY3s combined (81%), P<0.001. Scores among staff physicians did not differ according to field of medicine, age, proportion of time spent in clinical practice, or years in practice. PGY3s did not score significantly higher than PGY1s (82% vs. 80%). Some 40% of physicians said they ordered more tests than necessary because of malpractice worries; they indicated 72% of their colleagues do so as well. Physicians in obstetrics-gynecology and emergency medicine were more likely to respond yes to this question than physicians in other fields of medicine (P<0.001), as were physicians who had been defendants in a malpractice suit (88 P=0.013). CONCLUSIONS: Surveyed staff physicians have an adequate risk management knowledge. Training directors should encourage house officers to attend risk management programs to improve their knowledge. Physicians might overestimate the amount spent on defense medicine based on their perceptions of other physicians. PMID- 10173138 TI - Safety valve may reduce adverse events during open-heart surgery. PMID- 10173139 TI - Elective surgery, selective coverage. PMID- 10173140 TI - Substance abuse treatment evolves: a follow-up. PMID- 10173141 TI - Drug distribution dynamo. Cardinal Health, Bergen Brunswig propose mega-merger. PMID- 10173142 TI - What's up on the web. PMID- 10173144 TI - Analyzing hospital market share along product lines. AB - This article illustrates a method of analyzing market share based on product lines or specific hospital services, using 1990 data from a health service catchment area in South Carolina. Hospital discharges from two specific services: vascular and cardiac surgery; and obstetrics, were used to compute market rates of retention, discharge, escape, commitment, opening, and capture. The results confirm that as hospitals become more specialized, market share analysis based on total discharges is often misleading. Rather, discharges should be disaggregated and separate service areas with different boundaries constructed for different product lines. This method of market analysis can be performed easily and periodically by hospitals to monitor the market situation of their product lines. PMID- 10173143 TI - The role of drugs and alcohol in urban minority adolescent suicide attempts. AB - This study examined psychopathology and substance use in 15 African American adolescents who attempted suicide and 15 African American adolescents who did not attempt suicide (control group). Both groups of adolescents and their parents completed questionnaires that addressed depression, behavior problems, family functioning, and drug and alcohol use. On the basis of group means of the Children's Depression Inventory (Kovacs & Beck, 1977), the Youth Self-Report (Achenbach & Edelbrock, 1987), and the Child Behavior Checklist (Achenbach & Edelbrock, 1983), the suicidal youth were found to have a significant level of depression in addition to a variety of internalizing and externalizing behavior disorders. Similarly, on the Multigating Substance Use Evaluation System (Jurkovic & Bruce, 1991), the suicidal youth were at a high risk for alcohol and drug abuse. The suicidal group reported more alcohol and drug abuse than the control group. The results indicated that suicidal African American adolescents used significant amounts of drugs and alcohol, which may be associated with suicide attempts. PMID- 10173145 TI - Resource constraints and strategic change in a public hospital system. AB - It has been suggested that strategic management in public services tends to be oriented towards preserving and perpetuating current patterns of service provision, rather than changing priorities. However, faced with severe resource constraints combined with growing demand and rapidly developing technology, public hospitals in Canada have come under increasing pressure. Based on an empirical study of strategic management and change in 32 Montreal hospitals, this paper examines the relationship between financial adversity and the extent and nature of strategic change in these organizations. Strategic change indicators considered in the study include overall product mix, product diversity, product complexity, market demographics, efficiency, and revenue diversification. Results suggest that resource constraints have indeed stimulated changes within these organizations. In particular, hospitals suffering more severe financial difficulties have reduced their size and focused on a narrower range of services. Moreover, there is evidence that greater complementarity has been achieved among the entire sample of hospitals. PMID- 10173146 TI - Working together: differing perspectives and persuasions amongst health and social care authorities. PMID- 10173147 TI - Profiling primary care physicians for a new managed care network. AB - We developed methods for comparing physicians who would be selected to participate in a major employer's self-insurance program. These methods used insurance claims data to identify and profile physicians according to deviations from prevailing practice and outcome patterns, after considering differences in case-mix and severity of illness among the patients treated by those providers. The discussion notes the usefulness and limitations of claims data for this and other purposes. We also comment on policy implications and the relationships between our methods and health care reform strategies designed to influence overall health care costs. PMID- 10173148 TI - Cervical screening: the impact of the gender of the smear-taker on service uptake. PMID- 10173150 TI - Government go-ahead delights MidCentral Health. PMID- 10173149 TI - Managerial perceptions of the incentives inherent in National Health Service capital charging. AB - Capital charging was introduced into the National Health Service (NHS) in 1991 in order to stop capital being treated as a 'free' good and to encourage managers to use their assets more efficiently. This article seeks to examine the extent to which managerial thinking has been influenced. It uses as evidence interviews with NHS managers conducted in Scotland in 1994. The following uses of capital charges data are explored: capital programme; disposal programme; maintenance programme; contract pricing; and budgetary devolution. New capital programmes required more justification and capital charges were seen as relevant to estate rationalization. Less effect was found with regard to the maintenance programme, though this may have been due to a downgrading of the estates function in most Trusts. Although the capital charge costs included in contract prices affect the competitive position of providers, there was criticism of the lack of development of the purchasing function. Budgetary devolution was proceeding relatively slowly but, among those Trusts which had devolved capital charges, evidence was found that some clinicians were becoming aware of the full costs of equipment use. This article concludes, with cautious optimism, that capital charges are beginning to influence decisions and that, despite some incentives being dysfunctional, they will lead to a better managed NHS. PMID- 10173152 TI - New SuperClinic to meet health needs of South Aucklanders. PMID- 10173151 TI - Fleet manager creates win-win for clients. PMID- 10173154 TI - From science fiction to virtual reality. Waitemata Health is a leader in telemedicine in New Zealand. PMID- 10173153 TI - Health is about both services and values, says Minister. PMID- 10173156 TI - Two-year redesign of Waitemata Health surgical process ends 'crawl across desert' for patients. PMID- 10173155 TI - Dementia predicted to double in next 20 years--advice on Alzheimer's and other dementias. PMID- 10173157 TI - Who should fund support services for people with disabilities? PMID- 10173158 TI - Saving money in hospitals through a focus on capital expenditure strategy and management. PMID- 10173159 TI - Specialized databases can work for you--in more ways than one. PMID- 10173160 TI - How re-engineering affects hospital risk/quality managers. PMID- 10173161 TI - Strategies to prepare for the JCAHO survey. PMID- 10173162 TI - Patient capacity and judicial decisionmaking. PMID- 10173163 TI - A feminist model for clinical ethics consultation: increasing attention to context and narrative. PMID- 10173164 TI - A practical instrument to evaluate ethics consultations. PMID- 10173165 TI - Advance directives: a computer assisted approach to assuring patients' rights and compliance with PSDA (Patient Self-Determination Act) and JCAHO standards. PMID- 10173166 TI - Optimizing the quality of health care through better communication: case conferences. PMID- 10173167 TI - Assessing values: the neglected dimension in long-term care. PMID- 10173168 TI - Point and counterpoint. Therapeutic clinical ethics. PMID- 10173169 TI - Point and counterpoint. Is distance critical for clinical ethicists? A reply to Glenn McGee. PMID- 10173170 TI - Mergers and sterilization: ethics in the board room. PMID- 10173171 TI - Perspectives. Options vs. limits: drug cost strategies reconsidered. PMID- 10173172 TI - Perspectives. HIPAA boosts state reform, but glitches raise concern. PMID- 10173173 TI - Marketplace. Trend to looser managed care threatened by rising premiums. PMID- 10173174 TI - Perspectives. States mix and match options in new child health programs. PMID- 10173175 TI - Perspectives. Fawell bill returns; ERISA questions, HIPAA thicken plot. PMID- 10173176 TI - Marketplace. Florida CHPAs seek a way to live without state money. PMID- 10173177 TI - Designing a search strategy to identify and retrieve articles on evidence-based health care using MEDLINE. AB - The practice of evidence-based health care requires that information on methodology be identified from databases such as MEDLINE. Up until this year there have been no designated medical subject headings (MeSH) for evidence-based health care. 'EVIDENCE-BASED MEDICINE' appears as a MeSH term from 1997. The absence of designated MeSH for this concept prior to 1997 provides a challenge to the searcher. This paper describes the creation of a MEDLINE search strategy to retrieve articles on the methods of evidence-based health care published prior to the introduction of the new term, where an optimal combination of free-text and MeSH terms is required to identify relevant material. The study examines both free-text and subject heading searching and attempts an optimal balance of sensitivity and specificity. It begins by examining separate free-text and subject heading searches. Sensitivity of the subject heading search was 33% and specificity 80%, while the free-text search produced a sensitivity of 50% and a specificity of 67%. The final strategy, combining both approaches, was more successful with sensitivity reaching between 82 and 90% and specificity 83%. It is therefore possible to devise a search strategy to retrieve articles on the methods of evidence-based health care with relatively successful rates of sensitivity and specificity. The limitations of MEDLINE, however, necessitate the use of additional approaches in identifying articles on the methods of evidence based health care. PMID- 10173178 TI - Practice libraries: managing printed information and meeting the information needs of staff in general practice. AB - Librarians and GPs share an interest in exploring different approaches to providing information to general practice and improving information management within it. Describing the aims, policy, collections, enquiries and services of three Practice Libraries in the Aylesbury area, this paper demonstrates that an information professional can make a significant impact on the management of printed information whilst facilitating access to external sources. A wealth of opportunities lie ahead for those willing to apply information handling skills to general practice. Medical librarians will need to strike a careful balance between providing direct access to sources and the development of information services tailored to meet the needs of primary health care workers. PMID- 10173179 TI - Latex sensitivity: legal issues. PMID- 10173180 TI - For want of a spill kit, a department was lost. PMID- 10173181 TI - Latex sensitivity: current issues. PMID- 10173182 TI - The learning curve and the health care industry. AB - This article will examine the learning curve and its potential impact on the health care industry. Although the learning curve has traditionally been applied to the manufacturing industry, a labor-intensive industry like health care is a prime candidate for the benefits of the learning curve. Specifically, we will look at past research on the learning curve and discuss what effects learning might have on health care costs and outcomes in the current health care environment. PMID- 10173183 TI - Capital budgeting: evaluating competing projects with differing useful lifetimes. PMID- 10173185 TI - Software and systems 1997 guide. American Health Information Management Association. PMID- 10173184 TI - Enhanced ABC costing for hospitals: directed expense costing. AB - Space limitations do not allow a complete discussion of all the topics and many of the obvious questions that the preceding brief introduction to directed expense costing probably raised in the reader's mind. These include how errors in accounting practices like posting expenses to the wrong period are handled; and how the system automatically adjusts costs for expenses benefiting several periods but posted to the acquisition month. As was mentioned above, underlying this overtly simple costing method are a number of sophisticated and sometimes complex processes that are hidden from the normal user and designed to automatically protect the integrity and accuracy of the costing process. From a user's viewpoint, the system is straightforward, understandable, and easy to use and audit. From a software development perspective, it is not quite that effortless. By using a system that is understood by all users at all levels, these users can now communicate with each other in a new and effective way. This new communication channel only occurs after each user is satisfied as to the overall costing quality achieved by the process. However, not all managers or physicians are always happy that the institution is using this "understandable" cost accounting system. During one of the weekly meetings of a hospital's administrative council, complaints from several powerful department heads concerning the impact that the use of cost data was having on them were brought up for discussion. In defending the continued use of the system, one vice president stated to the group that cost accounting does not get any easier than this, or any less expensive, or any more accurate. The directed expense process works and works very well. Our department heads and physicians will have to come to grips with the accountably it provides us to assess their value to the hospital. PMID- 10173186 TI - Issue: Practice brief--Merging master patient (person) indexes (MPI). American Health Information Management Association. PMID- 10173187 TI - Project management--building a process. PMID- 10173188 TI - HHS and NCVHS issue recommendations. PMID- 10173189 TI - Benchmarking for process improvement: two approaches. PMID- 10173190 TI - Sampling best practices. Managing delinquent records. PMID- 10173191 TI - Sampling best practices. Collecting outcomes data for oncology patients in an acute care setting. PMID- 10173192 TI - Sampling best practices. Quality in action: improving the patient information highway. PMID- 10173193 TI - 1997 survey results: staffing issues. PMID- 10173194 TI - Is same-day surgery different than ambulatory care? PMID- 10173195 TI - Outcome Assessment Information Set (OASIS) for home care. PMID- 10173196 TI - Summary of ICD-9-CM Coordination and Maintenance Committee meeting. PMID- 10173197 TI - Hypertensive disorders of pregnancy. PMID- 10173198 TI - Practice brief. Issue: maintenance of master patient (person) index (MPI)--single site or enterprise. American Health Information Management Association. PMID- 10173199 TI - Breaking away from traditional roles can create new opportunities. PMID- 10173201 TI - Moving forward with integrated delivery systems. PMID- 10173200 TI - Privacy and confidentiality issues dominate federal legislative and regulatory agenda. PMID- 10173202 TI - Integrated healthcare delivery systems: an overview for health information managers. AB - As integrated healthcare delivery systems stake their claims for the future, it is rapidly becoming the health information manager's duty to integrate and manage healthcare data. Read on for a general outlook on the changes surrounding integration activities, from new trends to integration's impact on the profession. PMID- 10173203 TI - Turning a dream into reality: the evolution of a seamless electronic health record. AB - Growing competition in the healthcare industry has created a strong-demand for improvement in all areas. Learn how integrated delivery systems have been created and effectively utilized in order to change how the business side of healthcare is conducted and how provider organizations measure and achieve success. PMID- 10173204 TI - Staffing to volume in integrated delivery networks. AB - If yesterday's universal staffing standards are no longer valid in today's workplace, and new standards don't seem likely in the near future, how do HIM practitioners maintain a workable staff? By embracing a detailed methodology, the author shows how it is possible to benchmark HIM staff within integrated delivery networks. PMID- 10173205 TI - A physician office billing compliance program. PMID- 10173206 TI - Making a difference with HIM Week. PMID- 10173207 TI - Pulmonary aspergillosis. PMID- 10173208 TI - Triumph awards. American Health Information Management Association. PMID- 10173209 TI - Progress toward implementing the HIT and HIA curriculum models. AB - In addressing the changing needs of the healthcare industry, AHIMA recently produced curriculum models for associate and baccalaureate degree programs in health information management. Here's an update on the progress education programs are making toward implementing their models. PMID- 10173210 TI - Career trends in health information management: a look toward 2006, Part I. AB - The transformation taking place in health information management is causing a shift in the role of HIM professionals. This article examines the influence this shift has had on current trends in the workforce and what it means to HIM professionals. PMID- 10173211 TI - Case management: a strategy for resource management. AB - Many hospitals and integrated health networks are turning to case management as a means to control costs by more effectively managing resource utilization. The problem arises when an organization does not define the scope of case management or does not identify criteria specific to the needs of the organization and the population it serves. Integrating case management into the existing organizational structure and systems is key to its success. PMID- 10173212 TI - Evaluation of a critical pathway for pneumonia. AB - Pneumonia is the third most frequent admission diagnosis at Macomb Hospital Center. The average length of stay for this diagnosis (DRGs 89 and 90) was 9.07 days. After the initiation of a critical pathway that begins in the emergency department, the average length of stay decreased to 7.11 days. Quality of care also improved in two areas: the time elapsed before delivery of antibiotics and availability of X-ray reports. This article reviews the implementation and results of the critical pathway for pneumonia. PMID- 10173213 TI - Focus group feedback from breast cancer patients. AB - Wayne Memorial Hospital uses focus groups to elicit feedback from clients. One group involved 11 women with breast cancer. Aspects of interest included screening and detection, diagnostic evaluation, treatment, life after cancer, and general perceptions of cancer care. The findings revealed that participants felt the community offered high-quality progressive cancer care. Opportunities for improvement along the continuum were identified, including a need for personalized breast self-exam education, consideration of bed placement in the room following breast surgery, and additional support for breast cancer victims and their husbands. A multidisciplinary plan was developed to address the identified issues. PMID- 10173214 TI - Development of a social work case management guideline and model. AB - This article describes the process that a team of Department of Veterans Affairs social work service department heads went through as they developed national guidelines for social work case management. Many of the concepts and findings of this team apply to case managers in any profession. PMID- 10173216 TI - Stereotactic breast biopsy: an overview. PMID- 10173215 TI - Reengineering the emergency evaluation of chest pain. AB - This article presents strategies for enhancing the emergency department care delivered to patients with chest pain and suspected acute myocardial infarction. It also describes the planning and implementation of an emergency department reengineering project at a university medical center. The establishment of chest pain evaluation centers within emergency departments has been associated with improved clinical outcomes and cost control. Creating such a center requires careful revamping of diagnostic and treatment algorithms, a process that must be based on information from all departments affected by the changes. PMID- 10173217 TI - Information management systems in the OR: making a commitment. PMID- 10173218 TI - Surgical care in Kyrgyzstan. PMID- 10173219 TI - The correct coding initiative. PMID- 10173220 TI - Dust busters protect patients during construction. PMID- 10173221 TI - Think or swim. Here's how materials managers helped salvage their facilities from financial depths. PMID- 10173222 TI - Battle against bacteria. PMID- 10173223 TI - Enemy within. Basic weapons can foil VRE (vancomycin-resistant enterococcus). PMID- 10173224 TI - Antibiotic resistance = germicide resistance ... fiction or fact? PMID- 10173225 TI - What the heck do execs expect? See yourself as your bosses see you, in an updated CEO/CFO survey. PMID- 10173226 TI - Be sharp! Dull instruments just don't cut it. PMID- 10173227 TI - Germ warfare. A drug-resistant staph strain has doctors on edge. PMID- 10173229 TI - Older and sicker--and happier in an HMO. PMID- 10173228 TI - The immortality enzyme. A newly discovered gene may help scientists combat cancer and ailments linked to aging. PMID- 10173230 TI - Equating health and productivity. PMID- 10173231 TI - Marketing managed care to retirees. PMID- 10173232 TI - Do integrated delivery systems do it better? PMID- 10173233 TI - Benefits parity: what's a healthy mind worth? PMID- 10173234 TI - Health plan enrollment goes self-service. PMID- 10173235 TI - Osteoporosis: a cost (and bone) breakdown. PMID- 10173236 TI - The real cost of micromanagement. PMID- 10173237 TI - Shapes, sizes and purchasing needs. PMID- 10173238 TI - Data watch. Is this the way to manage pharmacy costs? PMID- 10173239 TI - PPM growth strategies. Part II. PMID- 10173240 TI - Problem solving: a comparison between medical and military art. AB - Compares the methodology of the medical decision-making process with that of the military. The key to both professions is reliable, efficient decision making. Effective decision makers use the hypothetical-deductive approach which utilizes intuition to generate ideas which are tested by the available evidence. Medicine is developing a holistic, conceptual and student-centred education process which compares with the more rigid, external system of military training. The military system has a better methodology for communication both verbally and in writing than medicine. Suggests that both professions may benefit from an examination of each professional culture. PMID- 10173241 TI - Explicit versus implicit rationing. PMID- 10173242 TI - Medicine and management: a conflict facing general practice? AB - Partners and practice managers are beginning to understand implications of management issues raised by recent reforms. Practices involved in this study agree the need for improvement, but partners and managers were often unable to define improvements needed. Demonstrates that effective management structure is vital to future success for general practice. To achieve this involves understanding new managerial challenges practices must meet and different organizational competences required. To change requires a radical restructure of many practice roles and several options are considered. Regardless of the chosen option the question of training remains. There is a need to involve consultants, managers, and doctors already advancing the boundaries of practice development, in a dialogue with institutions providing management training, to design suitable programmes. Academic institutions too often produce management programmes geared towards the old environment, whereas managerial skills which changes in the NHS demand from future practice managers are now required. PMID- 10173243 TI - Doctor in the process. The engagement of clinical directors in hospital management. AB - Aims to examine medical involvement in hospital management processes, and to consider the implications of current experience for the next generation of clinical directors. Doctors who move into a formal management role often find themselves unprepared for their new responsibilities. Research has thus concentrated on identifying the management competences which doctors lack, and with designing ways to remedy the deficit. Seeks to move beyond this deficit model by adopting a perspective which focuses on the engagement of doctors in the management process. Draws data from in-depth interviews with six clinical directors and 19 other members of the hospital management team at Leicester General Hospital NHS Trust (LGH). Content analysis of interviews suggest that the engagement of clinical directors in the hospital management process at this site can be described as reluctant, transient, service-driven, power-pulled and pressured. This negative portrayal of the role, however, must be set in the context of the "management expectation" held of clinical directors by other hospital managers and staff--an expectation that is not currently fulfilled. PMID- 10173245 TI - Myth-management in the NHS. AB - Reviews the role of clinical directors from outside the usual managerial framework to challenge the managerial myth applied to professionals who take on these roles. Defines management, managing, managerialism and leadership and develops an empirical framework to compare the roles of doctors and managers. Uses the framework to identify the cognitive map that clinical directors use and how they perceive their role. An emergent model illustrates how clinical directors combine a new cognitive map with their existing professional behaviours to undertake their role. Clinical directors both perceived and described their role in terms of leadership rather than management reinforcing the inappropriateness of using managerial frameworks. Instead clinical directors should be developed and evaluated as professional leaders. This raises wider questions of whether management and the language of management are either useful or appropriate for professionals in the NHS or whether their value is really a myth. PMID- 10173244 TI - Transforming the National Health Service. The challenge for career management. AB - Claims that, for the 1990s, images of careers are multidimensional and individualistic. Notes that employees are encouraged to take responsibility for their own self-development, incorporate horizontal as well as vertical moves and forge careers based on "employability", i.e. learning, networking and reputation. Bases its arguments on the findings of a study into senior executives in the NHS, and explores the consequences of organizational restructuring for the careers of clinical, general and functional managers. Suggests that organizational and professional barriers exist to undermine the notion of the multidimensional career. Argues that prescriptive approaches to career self-development need to take account of organizational context and that, to meet the challenges of careers in the 1990s, both the organization and the individual need to become more willing to take risks. PMID- 10173246 TI - Managerial effectiveness in the NHS. A possible framework for considering the effectiveness of the clinical director. AB - Examines managerial effectiveness in the NHS, in particular the effectiveness of the clinical director. Based on a qualitative study of an NHS Trust hospital case study, utilizes a social cognitive perspective to analyse the data and draw conclusions. Uses the data to suggest a possible framework for examining the effectiveness of individual directors. The framework may be relevant to other messages, particularly those in professional service organizations. It may also be used as a diagnostic tool to assess these managers. The framework is grounded in the perceptions of the interviewees at the Trust: both clinical directors and managers. PMID- 10173247 TI - Does medical audit lead to explicit standards? Experience with thrombolysis in four UK hospitals. AB - The setting of explicit standards against specific criteria is a recognized part of the medical audit cycle, but often in practice it has been neglected, implicit judgements being used instead. The conduct of a study to evaluate audit among physicians in four UK district general hospitals provided an opportunity to encourage the setting of explicit standards and observe the results. The subject chosen for audit by the participating physicians was the extent of use of intravenous thrombolysis in patients with suspected acute myocardial infarction (AMI). Standard setting was requested at initial peer review meetings held to review baseline results. This was followed up by a written request to lead consultants and subsequent telephone calls. Two out of the four participating hospitals set technical standards, which excluded patients with contra indications from the denominator. The other two hospitals set population standards as requested, one with considerable reluctance and scepticism. Each hospital set separate standards for definite AMIs and for probable AMIs. Six out of the eight standards set were achieved in at least one of four audits conducted in each hospital. Time trends were difficult to interpret because of small numbers. The amount of discussion between the lead consultant and colleagues about standards was highly variable, but there was no clear relationship between the process for agreeing standards in a particular hospital and subsequent attainment. PMID- 10173248 TI - The lights are bright? Debating the future of the permanent night shift. AB - Debates a controversial issue in healthcare management, that is, whether internal rotation (day-night) or permanent night shifts is an appropriate shift system for nursing staff. A multidisciplinary approach draws together international research from the fields of occupational psychology, management, ergonomics and medicine. Explores evidence on sleep, physical and mental health, job satisfaction, performance, absenteeism, and social and domestic disruption, all important factors in considering appropriate shift patterns. Suggests that both nurse choice (or non-choice) of shift and adjustment, or otherwise, of circadian rhythms are important causal factors influencing the debate. As no unequivocal picture emerges, recognizes some of the real and potential limitations of a paper of this kind; however, the balance of argument tends to favour the maintenance of permanent night shift nurses as opposed to the further extension of internal rotation systems. This is especially the case as many nurses will still be given a choice of shift pattern which may, in itself, negate some of the potential ill effects of night working. Decisions further to extend internal rotation may, in the light of the complex, ambiguous and equivocal evidence, be informed by partial knowledge and influenced by a managerial perspective. PMID- 10173249 TI - Administration to innovation: the evolving management challenge in primary care. AB - The concept of the primary health-care team involving an increasingly diverse range of health care professionals is widely recognized as central to the pursuit of a primary care-led health service in the UK. Although GPs are formally recognized as the team leaders, there is little by way of policy prescription as to how team roles and relationships should be developed, or evidence as to how their roles have in fact evolved. Thus the notion of the primary health-care team while commonly employed, is in reality lacking definition with the current contribution of practice managers to the operation of this team being poorly understood. Focusing on the career backgrounds of practice managers, their range of responsibilities, and their involvement in innovation in general practice, presents a preliminary account of a chief scientist office-funded project examining the role being played by practice managers in primary health-care innovation. More specifically, utilizing data gained from the ongoing study, contextualizes the role played by practice managers in the primary health-care team. By exploring the business environment surrounding the NHS general practice, the research seeks to understand the evolving world of the practice manager. Drawing on questionnaire data, reinforced by qualitative data from the current interview phase, describes the role played by practice managers in differing practice contexts. This facilitates a discussion of a set of ideal type general practice organizational and managerial structures. Discusses the relationships and skills required by practice managers in each of these organizational types with reference to data gathered to date in the research. PMID- 10173250 TI - Analysing the medicine-management interface in acute trusts. AB - The impact of the NHS reforms, and the resulting purchaser-provider split, has refocused attention on the relationship between management and medicine in acute hospitals. It is timely to assess the explanatory power of various theoretical models regarding the management-medicine interface. Argues that this interface is currently rather fluid and that a dynamic and adaptive model is best suited to understanding the way in which doctors and managers develop their relationship within the changing policy context. Two examples illustrate these shifting boundaries. PMID- 10173251 TI - Crossing boundaries: communication between professional groups. AB - The NHS reforms increased emphasis on a managerial culture. In primary care this raised questions about responsibility and philosophical approaches. Greater integration between agencies brings benefits, but creates tensions. Failure to bridge the gap may result in dysfunctional teams and compromised quality of patient care. The different orientations may manifest themselves in several ways but lead to frictions that can breed hostility and prevent effective teamwork. Explores issues involving social service and community nurse teams in Dorset to identify a new framework for working, by recognizing and respecting differences and by creating a climate of dialogue. The process involves three stages. First, mutual awareness by use of meta planning which revealed several important themes, different priorities, political dynamics and organizational constraints. Second, behavioural contracting facilitated by role reversal and third, the development of consensus working protocols as a bridge for professional gaps. PMID- 10173252 TI - Preventing unintended teenage pregnancies and reducing their adverse effects. PMID- 10173254 TI - Multiprofessional guidelines: can we move beyond tribal boundaries? PMID- 10173253 TI - Volume of clinical activity in hospitals and healthcare outcomes, costs, and patient access. PMID- 10173255 TI - Measuring quality in contraceptive services. PMID- 10173256 TI - Clinical guidelines: quantity without quality. PMID- 10173257 TI - Quality of contraceptive services in Finland. AB - OBJECTIVE: To investigate whether the quality of contraceptive services in Finland varies by the type of care provider. DESIGN: A cross sectional questionnaire survey. PARTICIPANTS: A random sample of 3000 Finnish women aged 18 44 years (response rate 74%) in 1994. RESULTS: Almost all women (94%) had used contraception at some time and 75% were current users. Although self care was common (29% had obtained their latest method outside the health services), 83% had sometimes used the health services for contraception. For their last visit, 55% of women had chosen a health centre (a publicly administered and funded health service), and 33% a private unit. In the health centre, the care provider was usually a general practitioner or a public health nurse, whereas in private care the providers were gynaecologists. Women who used private care were more likely to be from higher social classes and urban areas. After adjustment for a women's background, the two groups were similar for most indicators of the quality of care, but access to care and woman's experiences of treatment were better with private care. CONCLUSIONS: In terms of availability and choices the current system of contraceptive services in Finland is adequate. It is not always an integral part of municipal primary health care, and many women prefer private care for gynaecological services; this may case problems of comprehensiveness and equality of care. PMID- 10173258 TI - Adherence by midwives to the Dutch national guidelines on threatened miscarriage in general practice: a prospective study. AB - OBJECTIVE: To determine the feasibility for midwives to adhere to Dutch national guidelines on threatened miscarriage in general practice. DESIGN: Prospective recording of appointments by midwives who agreed to adhere to the guidelines on threatened miscarriage. Interviews with the midwives after they had recorded appointments for one year. SETTING: Midwifery practices in The Netherlands. SUBJECTS: 56 midwives who agreed to adhere to the guidelines; 43 midwives actually made records from 156 clients during a period of 12 months. MAIN OUTCOME MEASURES: Adherence to each recommendation and reasons for non-adherence. RESULTS: The recommendation that a physical examination should take place on the first and also on the follow up appointment was not always adhered to. Reasons for non-adherence were the midwives' criticism of this recommendation, their lack of knowledge or skills, and the specific client situation. Adherence to a follow up appointment after 10 days, a counselling consultation after six weeks, and not performing an ultrasound scan was low. Reasons for non-adherence were mainly based on the midwives' criticism of these recommendations and reluctance on the part of the client. Furthermore, many midwives did not give information and instructions to the client. It is noteworthy that in 13% of the cases the midwife's policy was overridden by the obstetrician taking control of the situation after the midwife had requested an ultrasound scan. CONCLUSIONS: Those recommendations in the guidelines on threatened miscarriage that are most often not adhered to should be reviewed. To reduce conflicts about ultrasound scans and referrals, agreement on the policy on threatened miscarriage should be mutually established between midwives and obstetricians. PMID- 10173259 TI - Practice guidelines in Finland: availability and quality. AB - OBJECTIVE: To describe the quantity, quality, and availability of practice guidelines currently used in Finland. DESIGN: Cross sectional survey. METHODS: Guidelines from 1989 to 1995 were collected through a database search, through hand searches of the two Finnish general medical journals, and through an inquiry into hospitals, health centres, and medical societies. The content and source of evidence for guidelines was assessed. RESULTS: 719 practice guidelines were found. 578 guidelines (80%) were retrieved by the inquiry, the database search identified 27 (4%) and hand searches 106 (15%). There were 150 guidelines (21%) developed nationally, 120 (17%) regionally, and 449 (62%) locally. The structure and quality of evidence supporting the guidelines was variable and only two guidelines were based on meta-analysis. The references were significantly more often (P < 0.001) documented in the national guidelines (n = 129, 86%) than in the regional or local guidelines (n = 65, 11%). CONCLUSIONS: There are many ways of disseminating guidelines and it may be difficult for end users to find the appropriate guidelines. Sources of evidence were seldom documented in the regional and local guidelines and even some national guidelines lacked all references. More attention should be paid to documenting the level of evidence, structuring the guidelines, and creating optimal strategies for development and dissemination of guidelines. PMID- 10173260 TI - The reliability of patients' judgements of care in general practice: how many questions and patients are needed? AB - OBJECTIVES: To estimate the number of questions and patients that are needed to achieve reliable measurements of patients' judgements of care in general practice. DESIGN: Sensitivity study, using generalisibility theory and real data from surveys of patients. SUBJECTS: 739 patients with chronic illness from 23 general practitioners in The Netherlands. MAIN MEASURES: The reliability coefficients of scores per patient and scores per general practitioner for patients' judgements of nine dimensions of care in general practice. RESULTS: For most dimensions the reliability per patient was 0.80 or higher if three questions were used, but for the evaluation of the "organisation of appointments" and "premises" five questions had to be used. To reach a reliability coefficient of 0.80 per general practitioner three questions and 90 patients, or five questions and 60 patients, were needed for most dimensions. Even more patients or questions were needed for the dimensions "availability for emergencies", premises, and "continuity". A reliability of 0.70 per general practitioner could be achieved if three questions and 60 patients were used, except for availability for emergencies and premises, for which more patients or questions were required. CONCLUSIONS: Surveys of patients can only provide reliable information if the samples of questions and patients are large enough. It is important to distinguish between the reliability of scores per patient and the reliability per care provider, as well as between different dimensions of care. The reliability per patient is good for most dimensions if three questions are used, but a good reliability per care provider requires more questions or patients. PMID- 10173261 TI - Incorporating patients' voices in the audit process. AB - Obtaining patients' views about their experiences of care should be an integral part of clinical audit. The importance of listening to patients as an aspect of quality can be attributed, in part, to the growth of consumerism in health care, and this in turn has led to the widespread use of satisfaction surveys to obtain patients' views. This paper raises some doubts about current methods for assessing patient satisfaction, and recommends the use of qualitative methods to capture patients' voices in audit. PMID- 10173262 TI - Purchasing good quality eye care: the provider's view. PMID- 10173263 TI - Quality health care: the hospital chief executive's role. PMID- 10173264 TI - The nursery's littlest victims. Hundreds of cases of 'crib death,' or SIDS, may in fact be infanticide. PMID- 10173265 TI - Caring from afar. PMID- 10173266 TI - Seeking safe harbor. You can find health coverage on your own. PMID- 10173267 TI - Why Ted gave it away. PMID- 10173268 TI - The land of the handout. PMID- 10173269 TI - Think before you give. PMID- 10173270 TI - After fen-phen. PMID- 10173271 TI - A deadly dance. PMID- 10173272 TI - Medicare for boomers. Congress is building the 21st-century system, but is this what you're going to want? PMID- 10173273 TI - The FDA defense: a prescription for easing the pain of punitive damage awards in medical products liability cases. PMID- 10173275 TI - Mixing oil and water: the government's mistaken use of the Medicare anti-kickback statute in False Claims Act prosecutions. AB - In 1996, billing integrity generated a great deal of debate and litigation in the health care arena. Significantly, the federal government views a violation of the Anti-Kickback Act as a basis for a False Claims Act action. While federal courts are split on the issue, the author strongly contends that using the False Claims Act to do what the Anti-Kickback Act was intended to do is inappropriate, given Congress' intention in enacting each legislation. PMID- 10173274 TI - Interpreting the 1996 federal antitrust guidelines for physician joint venture networks. AB - The Statements of Antitrust Enforcement Policy in Health Care, issued by the FTC and the DOJ, dramatically change how the agencies evaluate physician joint venture networks. This article analyzes the Statements, providing useful guidance to the health lawyer. PMID- 10173276 TI - The government's use of the Civil False Claims Act to enforce standards of quality of care: ingenuity or the heavy hand of the 800-pound gorilla. AB - Fraud and abuse issues abound in health care. A new, rather unique assertion is that submitting a bill for health care that is inadequate constitutes a violation of the Civil False Claims Act. The authors contend that there are more effective and appropriate ways to address poor quality of care, and that using the False Claims Act in this matter is like fitting a square peg in a round hole. PMID- 10173277 TI - The role of the federal government in ensuring quality of care in long-term care facilities. AB - Quality of care is a concept most important to our vulnerable populations, including the elderly. When the government pays for nursing care for the elderly, it expects that it is paying for quality care. When the quality is substandard, as it was with Tucker House II, the government can and will use the False Claims Act to recover monies paid. PMID- 10173278 TI - Directors' duty to obtain a fair price in the conversion of nonprofit hospitals. AB - Boards of Directors of tax-exempt hospitals are increasingly struggling with whether to convert their facilities to for-profit status. Other than the traditional duties of loyalty and fair dealings imposed upon directors, there is currently little guidance to assure that boards obtain a fair price for the hospital in such conversions. The author provides recommendations to assure proper valuation. PMID- 10173279 TI - To resuscitate or not ... in the operating room: the need for hospital policies for surgeons regarding DNR orders. AB - As more Americans have become aware of end-of-life planning, health care professionals are faced with more "Do Not Resuscitate" orders. A patient with a terminal condition who has signed such an order may enter the operating room for a surgical procedure; few hospitals have developed protocols to assist the medical staff. In most hospitals, it is unclear whether the medical staff should honor the "DNR" or follow the traditional resuscitation protocol of the operating room. PMID- 10173280 TI - The brave new world of health care compliance programs. AB - The need for corporate compliance programs in health care delivery systems is ever increasing. This article identifies the key items a good program should contain, and addresses issues raised by the existence of a program as well as its implementation. PMID- 10173281 TI - Health care fraud and abuse: new weapons, new penalties, and new fears for providers created by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). AB - The Health Insurance Portability and Accountability Act of 1996 may well be the most significant increase ever in the federal government's health care fraud and abuse enforcement authority. This new authority coupled with increased scrutiny of the health care industry generally creates a compelling incentive for health care facilities to develop corporate compliance programs. PMID- 10173282 TI - Evaluating the effectiveness of nursing home pre-admission review: a state example. PMID- 10173283 TI - Catholic sisters in health care: a focus on the frail aged. PMID- 10173284 TI - Risks of care at home for the frail aged. PMID- 10173285 TI - Death's challenges from the perspective of three generations of elderly. PMID- 10173286 TI - Disqualification of a clinical investigator--FDA. Final rule. AB - The Food and Drug Administration (FDA) is amending the investigational new drug regulation that provides for disqualification of clinical investigators who submit false information. The revision is intended to clarify the agency's authority to reach sponsor-investigators under the regulation. PMID- 10173287 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); health promotion and disease prevention visits and immunizations--DoD. Final rule. AB - This final rule expands well-baby visits and immunizations to dependents under the age of six and improves access to preventive benefits for dependents age six and above to include health promotion and disease prevention visits in connection with immunizations, Pap smears, mammograms, and colon and prostate cancer screenings. PMID- 10173288 TI - Let's get physical! AB - As part of Michigan's health care leadership team, people look to you to provide quality, health-related services to them and their families--a duty you do your best to fulfill. Unfortunately, you are so busy serving their health needs that you neglect your own. PMID- 10173289 TI - Your board: you ain't got a thing if they ain't in the swing? PMID- 10173290 TI - Healing with humor. Clowns on call bring hugs and happiness. AB - Each year tens of thousands of children visit The Detroit Medical Center's Children's Hospital of Michigan as patients. Hundreds of thousands of orders are processed and even more prescriptions are written. This year rare and different kinds of orders and prescriptions are being written ... orders for Clowns-on-Call and prescriptions for laughter. PMID- 10173291 TI - Managed care has taken root. AB - Managed care has taken root in Michigan. While its growth in rural areas of the state may occur at a slower pace, managed care--and capitated reimbursement--will ultimately replace fee-for-service health care in the Upper Peninsula for the same reasons it is doing so in Detroit. Both private and public payers want to increase the predictability of their outlays for health care. They want to contain cost growth, and receive demonstrable value for their investment. PMID- 10173292 TI - How to become politically savvy. AB - On the political frontier, unprecedented changes are sweeping across the country. In this industry, health care financing and Medicare funding are at the vanguard of political change. CEOs can choose to shape the policies of the future or watch from the sidelines at their own peril. PMID- 10173293 TI - A democratic decision. No constitutional support for assisted suicide. AB - While the issue of assisted suicide continues to receive mixed reviews in the Michigan courts, the United States Supreme Court recently held unanimously that state laws banning physician-assisted suicide are constitutional. Under the court's ruling, terminally ill adults do not have a constitutionally-protected right to obtain a physician's aid in dying. PMID- 10173294 TI - Health care at the crossroads. AB - The era of managed care is upon us, the result of a growing cost consciousness, an increasingly competitive marketplace and excesses on our parts as providers. Attention to the bottom line does not leave us much time to talk, connect and develop trust. If this trend continues, we are in danger of abandoning our basic commandment as healers, to act on behalf of our patients. PMID- 10173295 TI - Selecting board members. PMID- 10173296 TI - Educational services reinvented. AB - The Michigan Health Care Institute (MHCI), MHA's educational arm, has reinvented itself as the MHA Center for Health Resources. It's more than just a name change. It's a change of direction. PMID- 10173297 TI - Mediation: affordable justice. AB - Are you spending too much time and money on interrogatories, depositions and attorney fees, or having continuous disputes with your dealers or supplier network? Are people making unjustifiable demands you cannot meet? When the most effective procedures for dispute resolution aren't used, time, money and good will are wasted. PMID- 10173298 TI - Bridges link the world. AB - Organizations that use videoconferencing quickly discover how a video call connecting two sites can be a productive and cost effective way to hold meetings, offer remote diagnosis and participate in distance learning. But, administrative and education applications, in particular, are likely to require that multiple sites be networked at the same time. A simple solution is video bridging. PMID- 10173299 TI - Nursing: a caring connection. Nurses are essential to healthy leadership teams. AB - In 1996, the American Hospital Association and the Picker Institute, a national research firm, sponsored an extensive study, summarized in the report Eye on Patients. Focus groups and surveys explored public perceptions of health care and hospitals. The patients and their families reported relatively high rates of satisfaction when surveyed about their experiences, but they also reported serious concerns and worries, primarily with the way the "system" works (or fails to work) and with the changes taking place in health care. As the primary link between patients and a changing health care environment, nurses play a key role in affecting treatment outcomes and perception of the hospital experience. PMID- 10173300 TI - Men and women are different. AB - Examine your existing incentive programs. Study your incentives to make sure they aren't geared toward only male workers. Build in rewards for group achievements. Studies show that women are better at building consensus than their male counterparts. Help women workers map out a career plan. The glass ceiling still looms large at many organizations. Work with female employees to set goals and career paths. Put more emphasis on recognition. The history of corporate America's discrimination against women is still fresh in the minds of many and, because of that, women appear to value meaningful recognition more than some men. PMID- 10173301 TI - Do you have an IPS (investment policy statement)? AB - Academic studies have shown that over long-term time periods market timing is responsible for less than two percent of the variance of investment returns; security selection is responsible for less than five percent; while asset allocation policy (the desired mix of stocks and bonds) is responsible for almost 92 percent of the total return variation (see chart). This is yet another reason why it is critical to document the desired asset allocation policy and other guidelines for the portfolio in a written IPS. PMID- 10173302 TI - Sending up a smoke signal. AB - Tedious lectures about the dangers of smoking are a thing of the past for 10th graders in two Flint-are high schools. These students will learn to kick the habit this fall through an interactive high tech health class, created through a partnership between the schools, McLaren Health Care Corporation and Ameritech. PMID- 10173303 TI - Making a plan. Helping patients in end-of-life decision making. AB - Few medical legal issues are more complex or confusing than end-of-life decision making. Many people form definite views about what they would or would not want based on the case of a friend or relative, only to discover when their turn comes that the medical facts are very different, and their preconceived views are inapplicable. Others simply change their minds. PMID- 10173304 TI - Good news about hospitals. AB - Commitment to caring--whether in the hospital, the clinic or the community, caring is our trademark. We put patients first. In 1990, George Lundberg, editor of the Journal of the American Medical Association, said that health care "up to and into the next millennium, must be obviously in the public interest. It must ensure access to quality care for all, practice economic soundness, balance health fairly against all other societal needs, and most of all, require and demonstrate good will toward all people." PMID- 10173305 TI - Keeping your eye on the ball. PMID- 10173306 TI - Exploring the role of sulfonylureas in the treatment of non-insulin-dependent diabetes mellitus. AB - For the last 30 years, sulfonylureas have been the mainstay of treatment for patients with non-insulin-dependent diabetes mellitus (NIDDM). They offered patients an alternative to using insulin to lower their blood glucose. One of the advantages of these agents was that they could be taken orally as opposed to insulin, which required multiple daily injections. In addition, they are tolerable, with few side effects, and they cause less hypoglycemia than does insulin. In the past year, new agents (metformin and acarbose) have been introduced into the market and have offered practitioners an alternative to the traditional sulfonylureas. The sulfonylureas are still valuable agents in the treatment of NIDDM. Their efficacy is unsurpassed by any other oral medications. They possess the best tolerability profile of all oral agents on the market, and they possess very few contraindications or drug interactions. The sulfonylureas should still be considered first-line agents for NIDDM. Metformin and acarbose are agents that may benefit a specific patient population, but sulfonylureas are agents that can benefit most patients. PMID- 10173307 TI - New therapeutic options in the treatment of diabetes mellitus. AB - Although a number of compounds exist for the treatment of diabetes mellitus, euglycemia in many patients is still difficult or impossible to achieve. Many patients are insulin resistant, a condition that is not adequately remedied either by sulfonylureas or insulin, and usually worsens over time. In addition, there are patients that, although their fasting blood glucose is controlled, experience unacceptable postprandial glucose excursions. The newer compounds that are either approved or under development possess more novel mechanisms of action that may contribute to their efficacy in these patients. The agents reviewed in this article include those that attenuate postprandial glucose elevations by mechanisms such as delayed gastric emptying and enzyme inhibition, and those that directly increase insulin sensitivity. PMID- 10173309 TI - The importance of the pharmacist's expanding role on the diabetes team: reinforcing nutritional guidelines for improved glycemic control. AB - The role of the pharmacist on the diabetes care team is expanding due to the increasing number of patients diagnosed with diabetes, limited health care dollars, and the education related to and required for patients by managed care organizations and insurance companies. In the past, training of patients in diabetes self-management skills has been inadequate, and this continues to be the case. Clinical pharmacists, in cooperation with physicians, have increased opportunities to provide education about medications and may include instructions for patients regarding the interaction of food consumed with changes in blood glucose levels. Because of monthly refills on prescribed medications, a patient's interaction with the pharmacist in the setting of a commercial pharmacy is more frequent than with any other member of the diabetes team. This contact offers an ideal educational opportunity. The action and efficacy of medications that affect the pancreas, hepatic glucose production, the utilization of glucose by muscle cells, and the absorption of glucose from the intestines are influenced directly by the meal plan. Nutritional guidelines, meal planning for the Type I and Type II patient, use of the exchange system, carbohydrate counting, artificial sweeteners, alcoholic beverages, and suggestions for guiding patients to establish eating habits that lead to improved diabetes control are important issues for every member of the diabetes team to address. The reinforcement of dietary principles may occur in the educational setting of the hospital or the clinic or within the commercial pharmacy setting. When the team presents accurate and current information, continuity of care and improved patient understanding are achieved. PMID- 10173308 TI - Managing therapy and adverse effects with antihyperglycemic agents: a focus on metformin and acarbose. AB - Metformin and acarbose are novel antihyperglycemic agents indicated for the treatment of non-insulin-dependent diabetes mellitus. These agents offer new therapeutic options to control hyperglycemia that were previously unavailable. Common to both agents is a relatively high incidence of gastrointestinal adverse effects. Initiating therapy at a low dose and slowly titrating to therapeutic response may be the most effective way to minimize associated adverse effects. Recognition and proper management of these possible adverse effects can optimize therapy and maximize the potential for successful outcomes with these agents while limiting drug noncompliance. PMID- 10173310 TI - Treatment of hypertension in patients with diabetes. AB - Approximately 3 million Americans have the dual diagnosis of hypertension and diabetes. Both conditions are associated with and are risk factors for cardiovascular events, nephropathy, and retinopathy. When these conditions coexist, the prevalence, progression, and severity of these adverse outcomes are dramatically enhanced. For these reasons, hypertension should be treated aggressively and early in the diabetic patient to curtail the morbidity and mortality associated with these disease states. To this end, a number of consensus statements have been formulated and promulgated in an effort to increase the awareness of this condition and to provide guidelines by which optimal care may be afforded to patients. In addition, specific patient and drug related factors and conditions should be considered so patients can be committed to the optimal therapeutic plan. The outcome to attain optimal blood pressure should be mirrored by efforts to obtain glycemic and lipidemic control. By the implementation and optimization of effective therapeutic measures, which have the least amount of impact on the patient's concomitant disease states and body chemistry, positive differences in outcomes may be realized in this population. PMID- 10173311 TI - Issues in treating the geriatric patient with diabetes. AB - Diabetes, a disease commonly seen in the young, is more frequently seen in the geriatric age group (older than 65 years of age). This frequency has been estimated at 30 to 50 percent, although because of underdiagnosis, reported cases have approximately a 20 percent occurrence, the majority of which is Type II or non-insulin-dependent diabetes (NIDDM). Although the presentation in older adults is similar to that in younger patients, there are considerations for both evaluation and therapy that are unique to the geriatric patient. PMID- 10173312 TI - Systematic approach to the management of the Type II diabetic patient: case presentation. AB - Recently there has been a trend toward more aggressive management of people with diabetes. This stems from the conclusive clinical data that substantiate the benefit of tight glycemic control. It is clear that achieving near normoglycemia in people with diabetes will prevent and slow the progression of the microvascular complications and reduce the risk of the macrovascular complications. Clinicians now have multiple agents with differing mechanisms and sites of action allowing them to individualize the medication regimen and move toward normalizing the blood glucose levels. The following case is representative of a typical patient with Type II diabetes. This patient presents with multiple disease states and various treatment issues that must be addressed. An in-depth evaluation of the patient case is presented along with recommendations for drug therapy modifications. PMID- 10173313 TI - Improving health care with clinical practice guidelines and critical pathways: implications for pharmacists in ambulatory practice. PMID- 10173314 TI - Forget staffing formulas; it's the case management model that matters. PMID- 10173315 TI - Hospital program weds case, disease management. AB - To lower its readmission rates and inpatient length of stay for three high-volume chronic conditions, Memorial Hospital in Colorado Springs, CO, developed a program that combines clinical pathways with a cross-continuum disease management program. Community physicians refer patients to the program. Hospital-based care managers guide patients in the acute setting before handing them off to outpatient case managers, who coordinate the patient's transition to home care. Clinicians at Memorial sold administrators on the "care-case management" approach by arguing that increased inpatient efficiency would offset potential revenue shortfalls due to fewer admissions. PMID- 10173316 TI - Joint replacement path slashes LOS by eight days. PMID- 10173317 TI - Lumbar discectomy: practice analysis and care guide. PMID- 10173318 TI - Education improves treatment of depressed patients. PMID- 10173319 TI - Health system marketers must learn from past mistakes so history won't repeat itself. PMID- 10173320 TI - Physician-to-population ratios are key to setting staffing levels. PMID- 10173321 TI - As specialists regain control, how should they be paid? PMID- 10173322 TI - Specialist salaries rising, but not as fast as productivity. PMID- 10173323 TI - New SNF PPS seen as mixed bag; many details remain to be worked out. PMID- 10173324 TI - Industry looks to case-mix demonstration for answers on new SNF PPS. PMID- 10173325 TI - RUGS III rates from the Health Care Financing Administration's Nursing Home Case mix Payment and Quality Demonstration Project. PMID- 10173326 TI - Medical care. Antitrust laws emerging exemption. PMID- 10173327 TI - "Finger food menu" restores independence in dining. AB - Linda Jean is a senior nutrition service consultant for Vencor, Inc. She oversees nutrition care in 10 long-term care facilities in Massachusetts, and directly consults for three of them. Four years ago, she piloted a finger food menu for cognitively impaired residents and implemented a successful program that has worked to increase nutrient intake, decrease weight loss, and curtail the amount of high calorie and protein supplements that need to be provided. PMID- 10173328 TI - Checklist for monitoring dining room service. PMID- 10173329 TI - Population will be larger, older, more diverse. PMID- 10173330 TI - Osteopathic physicians in integrated networks help fill primary care void. AB - As demand for primary care physicians continues to grow, doctors of osteopathic medicine are helping fill the void and providing health systems and group practices with managed care-minded physicians. But as acceptance of these wellness-oriented practitioners increases, so does demand. PMID- 10173331 TI - Use these tips to secure physician practices. PMID- 10173332 TI - Risk-sharing contracts bring rewards for hospitals. PMID- 10173333 TI - PPMC boom brings growth opportunities for PHO industry. AB - As PHOs and other similar organizations grow and meet their initial goals, they often find themselves needing large amounts of capital in order to take the organization to the next level. Some of these systems are looking to get this capital by partnering with publicly traded physician practice management companies (PPMC). Finding the right PPMC to partner with is largely a matter of weighing strengths and weaknesses so that the PPMC's strengths fill in the PHO's weaknesses and vice versa. PMID- 10173335 TI - Americans trust physicians, not government, with medical info. PMID- 10173334 TI - Getting off to a good start with your physician panel. PMID- 10173336 TI - Creating a physician network can pay off--with the right tools. PMID- 10173337 TI - Will your PHO kill your hospital? Give MDs power. PMID- 10173338 TI - Cost analysis proves the value of better outcomes. PMID- 10173339 TI - Balance is hard for docs to find but vital for success. PMID- 10173340 TI - An increasingly attractive option in physician staffing. PMID- 10173341 TI - The revolution in inpatient care. How will hospitalists affect your institution? PMID- 10173342 TI - Managing costs may threaten managing care. PMID- 10173343 TI - Health care can learn a lesson from the airline industry. PMID- 10173344 TI - Developing a strategic plan for the nursing workforce. The California experience. PMID- 10173345 TI - Diagnostic certainty and hospital resource use. AB - OBJECTIVE: To determine whether the house staff's subjective probability estimates of their initial admitting diagnoses are independent predictors of in hospital resource consumption. DESIGN: Descriptive correlational study. SETTING: Academic medical center inpatient setting. PATIENTS: Patients admitted to general medicine wards. MEASUREMENTS: A visual analog scale with hash marks at 0, 25, 50, 75 and 100 was used to obtain a subjective probability estimate that the house staff's initial admitting diagnosis was a correct diagnosis. This provided the measure of diagnostic "certainty" at the time of admission. Patient demographic data, prior hospital stays, distance from hospital, MedisGroups scores, outlier status and vital status at discharge were obtained from administrative systems. Length of stay, total charges, cost estimates (total departmental), and number of consultations were obtained from the hospital-based transaction master database. RESULTS: House staff evaluated 1,778 admissions, 77.2% were assigned a diagnostic certainty rating of 75% or higher. In univariate analysis, the certainty rating did not vary with the MedisGroups score, outlier status or vital status at discharge. It varied with prior stays and measures of resource use. In multivariate analysis, the certainty rating was a significant factor accounting for variation in each of the measures of resource utilization with the exception of adjusted pharmacy charges. CONCLUSIONS: Even in a teaching hospital only a small proportion of patients had an "uncertain" diagnosis (22.8%). Nonetheless, the certainty variables were significantly related to measures of resource consumption including length of stay, total costs and number of consults obtained. PMID- 10173346 TI - On the record--the risky business of altering a medical record. PMID- 10173347 TI - Re-engineering the medical staff. Simplification is key. AB - Medical staffs are finding they must make do with less--less administrative support from financially strapped hospitals, and less volunteer physician member time from physicians who are distracted by managed care and by managing their changing practices. All too often the medical staff tries to do what they have always done, only faster, and with less help. This just frustrates those who were already working hard. The better alternative? Re-engineer the medical staff with the goal of simplifying operations. A critical look at the tasks undertaken by the medical staff often reveals that far too much time is spent doing unnecessary things. When asked, "Why do you do all this?" the answer is often, "because we are required to do it!" Yet scrutiny reveals that it is not required and that the task could be eliminated. Just because something "has always been done that way" does not mean it still must. It is time to look at the medical staff structure and procedures with a new set of questions: What is really required? What has great value for us? What can be jettisoned without affecting our operations? PMID- 10173348 TI - The benefit of intensivists. PMID- 10173349 TI - Specialty capitation methodology. Part 1. PMID- 10173350 TI - The leadership role of health services managers. PMID- 10173351 TI - Home care in Canada. AB - This is an overview of the home care sector's evolution in Canada, including current models and delivery structures, funding, eligibility criteria, and services provided. Cost escalations of the traditional healthcare system and a reduction in federal funding has driven health reform in Canada. This has been accompanied by a major but sporadic expansion of the home care sector across the country. For the home care sector to develop in a more rational, cost-effective and client-focused manner, the development of common standards, a common database and programme evaluation will be required. This will also be necessary for political, planning, and administrative officials to understand and justify the reallocation of resources from institutional to community health sectors. Addressing issues such as the impact of health reform, the role of the private sector, realignment of system incentives, and developing effective partnerships with hospitals is critical if home care is to be recognized as an essential, cost effective component in Canada's healthcare system. PMID- 10173352 TI - The challenges of assessing outcome in chronic pain. AB - Clinicians in chronic pain services are facing the need to develop meaningful and methodologically adequate measures, not only to evaluate the effectiveness of interventions and to assure quality, but also to support the continued funding and future development of such services. Explores the problems inherent in assessing outcomes in chronic pain. These include the complexity of the chronic pain syndrome itself, the multidimensional nature of interventions and the challenges of defining outcomes in the chronic illness syndrome. The complexity and challenges of assessing outcomes may lead to some reticence in facing the challenges but it is the responsibility of the clinicians to continue developing measures and to communicate to purchasers and other stake holders the complexity of assessing outcomes in chronic pain. PMID- 10173353 TI - Papers not patients?--unlocking resources, paying for quality. AB - Reviews the present contracting arrangements in general practice. Outlines recent Government White Papers, leading to a discussion of the future opportunities for general practice. Demonstrates the reality of primary-care-led NHS with quality of care plus cost containment. PMID- 10173354 TI - Implementation of a documentation management system for quality assurance in a university hospital. AB - Development and implementation of guidelines constitutes the basis of quality management systems for any organization. The authors have studied the internal documentation produced by professionals on 88 functional units of a university hospital. Reveals the existence of many documents concerning quality of care with an average of 102 available procedures or protocols per unit. However, this documentation is badly organized, making it difficult to consult and to put into practice. The results of this study were provided to other professionals at our hospital in order to make them aware of the necessity of rigorous document management. We have also written and sent recommendations for drawing up procedures and implementing an efficient documentary management system. This effort complements development of the hospital quality assurance plan. PMID- 10173355 TI - Measuring the outcomes of disease management. AB - Discusses measuring outcomes in the context of disease management and provides a single framework in the form of a key question checklist. Identifies key stakeholders. Outlines levels of outcome monitoring, measurement and date type and source. The development of an evaluative culture is essential to successful outcome measurements. PMID- 10173356 TI - Clwydian Community Care Trust: district nursing patients' questionnaire. AB - The aim of this project was to develop a reliable and valid consumer satisfaction questionnaire for users of the District Nursing Service in Clywd. During the qualitative phase 18 quality themes were identified. These were used to construct a draft questionnaire. Respondents were to rate their experience of the service (experience scale) as well as the importance to them of each service feature listed (importance scale). Following pilot testing and item analysis the importance scale was dropped. Factor analysis of the resulting 11-item questionnaire yielded four factors, similar to those identified in other studies. Makes some suggestions to improve the reliability and practical utility of the questionnaire, and describes its use in Clwyd. PMID- 10173357 TI - Annotated bibliography: integrated approaches to quality improvement in health care: Part V. PMID- 10173358 TI - The pressure for quality. PMID- 10173359 TI - Re-engineering hospital emergency rooms: an information system approach. AB - The efficiency and effectiveness of hospital emergency rooms depend on the effectiveness of the information and communication system as well as on the physical facility itself. Describes the role of information technology in the design of contemporary ER systems. A computerized information board is one system that can enhance the operation of an ER facility. Describes the structure of this system, as well as its integration with other computerized systems. Also describes design features that may help to reduce ER delays/frustration. Because many types of professionals are involved in the daily operations of an ER facility, their input to the design is essential. For this reason, also describes a group decision-making process. PMID- 10173360 TI - Quality rehabilitation--oasis or mirage? AB - Discusses the progress that has been made nationally with quality rehabilitation services for people with physical disabilities in terms of competence, respect, choice, accessibility and responsiveness. Finds implementation to be patchy, but gives examples of good practice. Suggests quality measures for hospital and community care components of rehabilitation services. PMID- 10173362 TI - Managing hospitals in dynamic environments. AB - Hospital environments have changed dramatically over the past two decades. Hospitals now have to contend with the dynamics of regulation, market forces, and quality and cost-conscious environments. The strategies proposed here emulate the changes pursued by much of US industry. Provides a framework for analysing hospital environments. Applies Deming's total quality management concepts to hospitals. Also suggests strategies to deal effectively with different types of hospital environments. PMID- 10173361 TI - Improving outpatient clinic efficiency using computer simulation. AB - To assess and plan alterations in outpatient clinic structure, produces a computer simulation of an outpatient clinic based on detailed time and role measurements from the authors' clinic. The stimulation which used an object oriented design method is able to indicate the impact of changes in clinic structure using patient and doctor waiting times in clinic as endpoint measures. The effects of changes in clinic size, consultation time, patient mix, appointment scheduling and non-attendance were examined. We found that patient waiting time could be shortened considerably by using an optimizing appointment scheduler to determine appointment intervals. Clinic mix influences patient waiting time, which was shorter with a 1 in 4 ratio of new to follow-up patients. In mixed clinics, new patients appointments are optimally spread throughout the clinic to reduce patient waiting time. In all new or all follow-up clinics, waiting time is improved if the appointment interval reflects the consultation time. Computer modelling can help in optimizing clinic management so improving the delivery of care in outpatient services. PMID- 10173363 TI - Achieving hospital operating objectives in the light of patient preferences. AB - Patient satisfaction is becoming increasingly important for the successful operation of private and public hospitals. The quality of the service provided can be improved if internal and external customers' opinions are taken into account during the definition of hospital operating objectives. This research presents a new methodology, called the simulation service quality system (SSQS), developed to improve operating performance measures in the light of customer preferences. The motivation for the development of the SSQS methodology arose from the need to achieve timeliness standards at United States Veterans' Hospitals. The Harry S. Truman Memorial Veterans' Hospital in Columbia Missouri served as the validation and initial application site for the SSQS methodology. Details one such project: the objective of reducing customer waiting times to 30 minutes or less at an outpatient treatment clinic. Through the identification of relationships and interactions, discrete-event simulation techniques are applied to model and experiment with the system to ultimately arrive at recommended changes in hospital operating policies which achieve the objective. PMID- 10173364 TI - Annotated bibliography: integrated approaches to quality improvement in health care: Part VI. PMID- 10173365 TI - Same-day surgery ileostomy closure? AB - Loop ileostomy is a common procedure for temporary fecal diversion. Length of stay for ileostomy closure in many series is 3 to 6 days. There is, however, increasing pressure on surgeons to discharge patients as soon as possible. With attention to surgical details and careful perioperative management, it is possible to perform ileostomy closure as a same-day-discharge operation. This technique was used to treat six patients who needed ileostomy closure. All patients were discharged the day after or the day of the surgical intervention. There was no morbidity. Loop ileostomy and same-day ileostomy closure are cost effective procedures for temporary fecal diversion. PMID- 10173366 TI - Managed care guidelines for the economic evaluation of pharmaceuticals. AB - Foundation Health Corporation, through its National Pharmacy and Therapeutics Committee, requires all pharmaceutical manufacturers and others who wish products to be considered for formulary listing to meet evidentiary and analytical standards in their submission documentation. This article details the evidentiary and analytical standards required from those making submissions and describes the methodological basis of the guidelines. This is the first time, as far as the authors are aware, that a managed care health system in the United States has required formulary submissions not only to meet clinical and economic evaluation standards, but also to take explicit account of the perspective of the managed care group in applying these techniques. Submissions are required to take what is described as a systems impact perspective. This approach is quite different, in both evidentiary and analytical terms, from standards required by health systems in other countries and standards for the economic evaluation of pharmaceuticals proposed by expert groups in the United States. PMID- 10173367 TI - Pharmacoeconomic analysis of selected antibiotics in lower respiratory tract infection. AB - An interactive pharmacoeconomic model was designed to evaluate the effects of clinical response and adverse drug events on the comparative cost and cost effectiveness of a relatively new antibiotic, clarithromycin, compared with those of six other antibiotics used to treat community-acquired lower respiratory tract infection. The cost and cost-effectiveness analyses were based don 12 randomized, double-blind, controlled clinical trials conducted between 1987 and 1992 in regionally distributed outpatient clinics in the United States. The trials enrolled a total of 2377 patients. Of the 2377, 1102 patients were treated for acute exacerbation of chronic bronchitis, 591 for pneumonia, and 201 for either of the two conditions. Safety data for one of the antibiotics was obtained from a trial of patients with sinusitis (N = 483). The antibiotics included in the analysis were amoxicillin/clavulanate, ampicillin, cefaclor, cefixime, cefuroxime, clarithromycin, and erythromycin. The main outcome measures were the costs of resources to achieve a clinical response, costs related to managing adverse drug events, and costs of antibiotic treatment from the perspective of managed care. The mean total cost per episode ranged from approximately $137 to $267. The drug acquisition cost typically contributed a small amount to the overall cost. For the cost-effectiveness analysis, in which complication-free cure was used as a proxy for patient satisfaction, the range of mean cost per complication-free cure varied from approximately $307 for clarithromycin to $612 for cefaclor. When ranked from most to least cost-effective, the order was as follows: clarithromycin, cefixime, amoxicillin/clavulanate, erythromycin, cefuroxime, ampicillin, and cefaclor. The costs associated with clinical management (including treatment failure) and managing adverse drug events significantly contribute to the total cost and cost-effectiveness of antibiotics in the outpatient setting. Cost-effectiveness analyses are valuable in analyzing the various costs associated with the treatment of lower respiratory tract infection (acute exacerbation of chronic bronchitis or pneumonia) and may be useful tools for physicians managing patients, members of pharmacy and therapeutics committees developing formularies, and medical staff implementing practice guidelines. PMID- 10173368 TI - Clinical improvement with bottom-line impact: custom care planning for patients with acute and chronic illnesses in a managed care setting. AB - 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. PMID- 10173369 TI - Comparison of intranasal triamcinolone acetonide with oral loratadine in the treatment of seasonal ragweed-induced allergic rhinitis. AB - A double-blind, randomized, multicenter, parallel-group controlled study compared the efficacy and safety of intranasal triamcinolone acetonide (220 micrograms/day) and oral loratadine (10 mg/day) in patients with at least two seasons of ragweed-induced seasonal allergic rhinitis. A 28-day screening period, including a 5-day baseline period, preceded a 4-week treatment period. Reduction in rhinitis symptom scores was evident in both groups as early as day 1, with no significant between-group differences during week 1. At weeks 2, 3, and 4, patients treated with triamcinolone acetonide were significantly (P < 0.05) more improved in total nasal score, nasal itch, nasal stuffiness, and sneezing than were patients treated with loratadine. At weeks 3 and 4, rhinorrhea and ocular symptoms were significantly (P < 0.05) more improved from baseline among triamcinolone acetonide patients compared with loratadine patients. There was no significant between-group difference in relief from postnasal drip at any time point. Physicians' global evaluations significantly (P = 0.002) favored triamcinolone acetonide at the final visit, with moderate to complete relief of symptoms attained by 68% of triamcinolone acetonide patients and 59% of loratadine patients. Over the 4-week treatment period, triamcinolone acetonide patients had significantly greater improvement in total nasal score, nasal itch, nasal stuffiness, sneezing, and ocular symptoms. Both treatments were well tolerated, with headache being the most frequently reported drug-related adverse effect in both the triamcinolone acetonide (15%) and loratadine (11%) groups. These results indicate that triamcinolone acetonide is more effective than oral loratadine in relieving the symptoms of ragweed-induced seasonal allergic rhinitis. PMID- 10173370 TI - Lyme disease: recognition, management, and prevention in the primary care setting. AB - This activity is designed for practitioners who see patients with tick bites, Lyme disease, or suspected Lyme disease in their practice, whether or not the practitioner is in an endemic area for Lyme disease. GOAL: To help primary care practitioners recognize and treat Lyme disease and provide preventive counseling. OBJECTIVES: 1. Be familiar with the terminology used for the causative agent of Lyme disease, its tick vector and reservoirs in nature, and where the disease is endemic. 2. Know the features of the common, characteristic clinical forms of Lyme disease. 3. Appreciate the uses and limitations of laboratory testing for this infection. 4. Understand early antibiotic treatment of Lyme disease, the management of a tick bite, and preventive measures. PMID- 10173371 TI - Osteoporosis: review of guidelines and consensus statements. AB - This activity is designed for physicians, pharmacists, nurses, health planners, directors of managed care organizations, and payers of health services. GOAL: To understand current guidelines and consensus statements regarding the prevention, diagnosis, and treatment of osteoporosis. OBJECTIVE: List four national or international organizations involved in the development of consensus statements regarding the prevention, diagnosis, and treatment of osteoporosis. 2. Discuss the significant differences among different countries regarding the prevention and treatment of osteoporosis. 3. List the major risk factors for osteoporosis. 4. Describe the differences in the application of bone mineral density scans, biochemical markers, and ultrasound in evaluating patients with suspected osteopenia and osteoporosis. 5. Distinguish between and briefly discuss therapeutic modalities used in primary prevention, secondary prevention, and treatment of osteoporosis. 6. Discuss the advantages and disadvantages of estrogen/hormone replacement therapy. 7. Describe alternatives to estrogen/hormone replacement therapy. PMID- 10173372 TI - Cardiovascular benchmarking saves hospital nearly $897,000. AB - When Chattanooga, TN-based Erlanger Medical Center wanted to implement care paths for cardiac patients, its benchmarking team found it had to treat its cardiovascular surgeons as one unit rather than as individual practitioners. Best practices emerged as a combination of internal benchmarking and study of care paths from top performing hospitals in the region and nationally. When incorporated in Erlanger's new care plans, these practices netted savings of $896,000 through reduced stays, utilization, and standardization of supplies and processes. PMID- 10173373 TI - Pathways incorporate best practices, shorten LOS. PMID- 10173374 TI - New antipsychotic drugs produce better outcomes. PMID- 10173375 TI - Study: CHF (congestive heart failure) education more than pays for itself. PMID- 10173376 TI - Here's how education saved $173,000. PMID- 10173377 TI - Experience gap linked to angio complications. PMID- 10173378 TI - ICUs called good target for anti-resistance efforts. PMID- 10173379 TI - Study: mergers mean changing physician roles. PMID- 10173381 TI - Health care, social justice and spirituality. PMID- 10173380 TI - Justice and the right to health care. Part I. AB - Michel Beaudin is a professor of political and socioeconomic ethics in the Faculty of Theology of the Universite de Montreal since 1985 and a specialist in the moral implications of market globalization. He has written extensively on the neo-liberal economy and the role of the Church, both in Quebec and elsewhere. He was also responsible for research on education program for Development and Peace, from 1974 to 1985. This article is a translation of an excerpt from the address that Mr. Beaudin gave at the annual convention of the Catholic Health Association of Canada. PMID- 10173382 TI - A health care spirituality rooted in Biblical justice. AB - This address was given by Father Walter Burghardt at the annual convention of the Catholic Health Association of Canada. It represents the distilled wisdom of more than four decades of immersion in theology and a career as one of the most outstanding preachers of our time. Fr. Burghardt is a senior fellow of the Woodstock Theological Center; a distinguished university professor and recipient of numerous honorary degrees; a widely acclaimed author and editor of the well known journal Theological Studies; and a past member of the first International Papal Theological Commission and interdenominational committees. In the past several years, Fr. Walter Burghardt has addressed the issues of medicine, health care, and health care ethics, seeking to articulate a practical and profound spirituality to guide health care professionals. PMID- 10173383 TI - Five traits of the ideal leader. PMID- 10173384 TI - Home care social workers: results of a national survey. AB - Home care social work as a practice specialty has not been well-researched. This study is the first of its kind and presents data that agency administrators can use to learn about the field and to use as a benchmark for their own social work lines of service. PMID- 10173385 TI - Medical social work's contribution. To home care. AB - A primary goal of managed care organizations is to reduce health care costs partly through an emphasis on outcomes and prevention. Medical social workers' unique skills can help ensure that improved patient care is not sacrificed to cost-reduction efforts. PMID- 10173386 TI - Operation Restore Trust. One agency's experience offers lessons for social work. PMID- 10173387 TI - Hand in hand: social work leads students to volunteerism. AB - Healthy individuals, healthy families, and healthy relationships are crucial to a healthy society and are our most precious and valuable resources. Home care providers can play a role in developing and maintaining these resources. PMID- 10173388 TI - Lessons from the OBQI (outcome-based quality improvement) demonstration sites. AB - The Outcomes and Assessment Information Set (OASIS)--a proposed mandate of the Health Care Financing Administration--can help agencies adapt to the data-driven health care system of the future. PMID- 10173389 TI - Diagnosing and treating depression and neurological problems in the elderly: a multidisciplinary approach. AB - Depression and neurological problems in the elderly often go undiagnosed. A multidisciplinary health care team can combine their expertise, accurately diagnose such problems, and often help the patient move in the direction of recovery. PMID- 10173390 TI - Humor therapy in home care. AB - Common sense tells everyone that laughter is good for the body. But what can professional caregivers do to bring laughter into the workplace and into patients' homes. PMID- 10173391 TI - CDC guidelines for infection precautions. AB - The Centers for Disease Control and Prevention (CDC) has revised its infection control recommendations for health care organizations and their staffs. Although the CDC guidelines are not home care specific, providers can use these precautions in most health care delivery sites, including in-home services. PMID- 10173393 TI - Morrison emphasizes central production; targets Florida market. PMID- 10173392 TI - Integration of services: the basic building blocks. PMID- 10173395 TI - The foodservice director as nutritionist. PMID- 10173394 TI - 1997 Silver Plate winner. Carol Sherman--New York University Medical Center. PMID- 10173396 TI - New structure, new revenues at Self Memorial Hospital. PMID- 10173397 TI - Coming to a health plan near you: yoga and belladonna. PMID- 10173398 TI - Finding new life in health stocks. PMID- 10173399 TI - Using perinatal audit to promote change: a review. AB - Close to half of all infant deaths world-wide now occur in the first week of life, almost all in developing countries, and the perinatal mortality rate (PNMR) is used as an indicator of the quality of health service delivery. Clinical audit aims to improve quality of care through the systematic assessment of practice against a defined standard, with a view to recommending and implementing measures to address specific deficiencies in care. Perinatal outcome audit evaluates crude or cause-specific PNMRs, reviewing secular trends over several years or comparing rates between similar institutions. However, the PNMR may not be a valid, reliable and sensitive indicator of quality of care at the institutional level in developing countries because of variations in the presenting case-mix, various confounding non-health service factors and the small number of deaths which occur. Process audit compares actual practice with standard (best) practice, based on the evidence of research or expert consensus. Databases reviewing the management of reproductive health problems in developing countries are currently being prepared so as to provide clinicians and health service managers with up-to date information to support the provision of evidence-based care. Standard practice should be adapted and defined in explicit management guidelines, taking into account local resources and circumstances. Forms of process audit include the review of care procedures in cases which have resulted in a pre-defined adverse outcome, know as 'sentinel event audit'; and the review of all cases where a particular care activity was received or indicated, known as 'topic audit'. These are complementary and each depends on the quality of recorded data. The forum for comparing observed practice with the standard may be external, utilising an 'expert committee', or internal, in which care providers audit their own activities. Local internal audit is more likely to result in improvements in care if it is conducted in a structured and culturally sensitive way, and if all levels of staff are involved in reviewing activities and in formulating recommendations. However, further research is needed to identify the factors which determine the effectiveness and sustainability of perinatal audit in different developing country settings. PMID- 10173400 TI - Viewpoint: public versus private health care delivery: beyond the slogans. AB - In most settings, a 'public' health service refers to a service which belongs to the state. The term 'private' is used when health care is delivered by individuals and/or institutions not administered by the state. In this paper it is argued that such a distinction, which is based on the institutional or administrative identity of the health care provider, is not adequate because it takes for granted that the nature of this identity automatically determines the nature of the service delivered to the population. A different frame of classification between public and private health services is proposed: one which is based on the purpose the health service pursues and on the outputs it yields. A set of five operational criteria to distinguish between health services guided by a public or private purpose is presented. This alternative classification is discussed in relation to a variety of existing situations in sub-Saharan Africa (Mali, Uganda, Zimbabwe). It is hoped that it can be used as a tool in the hands of the health planner in order to bring more rationality in the current altercation between the public and the private health care sector. PMID- 10173401 TI - Three countries' experience with Norplant introduction. AB - Despite international efforts to plan for Norplant introduction, the method has drawn the attention of critics of family planning programmes, and has raised several issues for debate since it was introduced into family planning programmes. The experiences of three countries with the introduction of Norplant highlight some of the unique features of the method that have affected its introduction. Indonesia, Bangladesh and the United States represent diverse cultural settings and systems of family planning provision. Experience in each country has highlighted the need to focus on quality of care for clients, most notably the need for good counselling and attention to removal as well as insertion. The cost of Norplant also has influenced its introduction in each country. Another issue includes the need to work with women's health advocacy groups, which is illustrated particularly in Bangladesh. Finally, the role of litigation in the United States, and its potential role in influencing Norplant introduction in other countries, is discussed. These three countries' experience illustrate the importance of understanding the programmatic context of contraceptive introduction. PMID- 10173402 TI - Infant mortality due to acute respiratory infections: the influence of primary care processes. AB - A population-based case control study was conducted to ascertain whether the process of primary care can be a determinant of infant mortality due to Acute Respiratory Infection (ARI). Cases were 118 infants who died from ARI, individually matched with 118 infants who suffered an ARI episode and recovered. Information was gathered through interviewing mothers. Study variables were assembled into five subsets: children's characteristics; mothers' characteristics; access to medical services; process of primary care, and; sociodemographic variables. An index per subset was built to analyze the independent influence of each on ARI death risk. The index was constructed upon the weighted sum of the adjusted odds ratios (OR) within each subset. Then, the values of each index were collapsed into high/low values with the 50 percentile as a cut-off value. Next, by means of a conditional logistic regression procedure, an explanatory model of ARI mortality was obtained. The final multivariate model included the indexes that showed an independent effect: I) Process of care (OR 9.68, CI 95% 3.59-26.1): inadequate referral, attention provided by more than one physician and being attended by a private physician; II) children's characteristics (OR 7.22, CI 95% 2.35-22.2): perinatal history, lack of breast-feeding and incomplete immunization scheme; III) access to medical services (OR 5.27, CI 95% 2.02-13.7): geographic and economic barriers, lack of confidence in public health services, and; IV) mothers' characteristics (OR 4.03, CI 95% 1.18-13.8), mainly represented by untimely care seeking. We conclude that the management of the disease is a key determinant in which factors relating to the mother and the health services are strongly related. Our study reveals untimely care seeking, difficult access and inadequate disease treatment as important factors which deserve careful attention in the future. We also confirm the importance of biological determinants previously described. A main strategy to reduce infant mortality due to ARI should be to encourage training of primary care physicians, including private practitioners, focused on providing effective case management and emphasizing the education to mothers. PMID- 10173403 TI - Primary health care in Turkey: a passing fashion? AB - The Alma-Ata Declaration has long been regarded as a watershed in the health policy arena. The global goal of the World Health Organization, 'Health for All by the Year 2000' through primary health care, has attracted many countries both in the developed and the developing world and commitments to this end have been made at every level. However, albeit this consensus on the paper, a common and explicit definition of the concept has not been reached yet. This paper aims at discussing various definitions of primary health care that emerged after the Declaration and also presenting a case study from Turkey, a country that advocates primary health care in her recent health policy reform attempts. After setting the conceptual framework for discussion the Turkish case is presented by using research carried out among Turkish policy-makers at different levels of the State apparatus. It has been concluded that application of primary health care principles as defined in the broad definition of the concept requires major changes or rather shake-ups in Turkey. These areas are outlined briefly at the end of the paper. PMID- 10173404 TI - Consequences of adult HIV infection for outpatient morbidity and treatment costs: a prospective study in a factory clinic in Tanzania. AB - Most studies of the medical costs of HIV infection focus on the terminal stage of this chronic illness when the patients have developed AIDS or severe HIV disease and in-patient care dominates. Data are also needed on the medical costs during the prolonged phase of HIV infection preceding severe terminal illness and the effects it may have on the provision of outpatient care. The study population was derived from a cohort study of factory workers and their spouses in Tanzania. Morbidity and outpatient health services utilization are estimated for 1832 adults who on average had been enrolled for two years and utilized the study clinic. Among those who had been enrolled at least 2 years, 50 cases (HIV+ since enrollment) and 150 control (HIV- until last visit) were selected, matched by age, sex and income level to estimate expenditure on drugs by HIV status. There was an increase in morbidity during HIV infection: the incidence of clinical diagnoses was 30% higher among HIV-positive than among HIV-negative adults (p < 0.001). HIV-infected adults also made more frequent use of the outpatient services (23% higher utilization). Estimates of essential drug costs among the subsample showed a 15% increase for HIV infected adults compared to HIV-negative adults, caused by higher use of antibiotics and other antimicrobial drugs. The overall increase in morbidity, outpatient care services utilization and essential drug use due to HIV infection was limited, as HIV prevalence in this adult population was 11%. For example, the net proportion of all illness episodes attributable to HIV infection was 3.2%. Possible biases are discussed and suggest that our findings are a minimum estimate of the effect of adult HIV infection on outpatient care costs. There is a need for more studies in different settings to assess the impact of HIV infection on outpatient care in developing countries. PMID- 10173405 TI - The impact of charging for insecticide on the Gambian National Impregnated Bednet Programme. AB - During the second year of the Gambian National Impregnated Bednet Programme (NIBP) charges for insecticide ($0.50 per net) were introduced into the half of the primary health care villages in the country where insecticide have been provided free of charge the previous year. Free insecticide was provided in the remaining villages that had acted as controls during the previous year. In villages where insecticide was provided free, 77% of nets were treated with insecticide. In contrast, in villages where charges were made coverage was only 14%. During the first year of the NIBP, mortality in children was significantly lower in villages where insecticide was provided free than in the control villages. Introduction of a charge for insecticide into the first group of villages and the provision of free insecticide in the latter abolished this difference. The cash income of rural Gambians is very limited and payment of even $2-3 for insecticide treatment for all the bednets in a household represents a substantial outlay. Further education on the benefits of treatment of nets and/or the provision of cheaper insecticide will be required before the full benefits of this powerful new malaria control measure can be fully realised in the Gambia. PMID- 10173406 TI - Understanding lay perspectives: care options for STD treatment in Lusaka, Zambia. AB - Understanding lay persons' perceptions of STD care is critical in the design and implementation of appropriate health services. Using 20 unstructured group interviews, 10 focus group discussions and 4 STD case simulations in selected sub populations in Lusaka, we investigated lay person perspectives of STD services. The study revealed a large diversity of care options for STD in the communities, including self-care, traditional healers, medicine sold in the markets and streets, injections administered in the compounds, private clinics, health centres and hospital. The factors identified as influencing care seeking behaviour are: lay referral mechanisms, social cost, availability of care options, economics, beliefs, stigma and quality of care as perceived by the users. PMID- 10173407 TI - Planning with PRA: HIV and STD in a Nepalese mountain community. AB - The application of Participatory Rural Appraisal methods (PRA) to the topic of sexual health enabled us to explore key factors concerning local people's perceptions regarding HIV/AIDS and STDs and to plan collectively to address the emerging issues. Conducting the process in a gender sensitive way enabled people to feel safe enough to express their own opinions, and having gained confidence in their peer groups, to share ideas later with the whole community in a joint planning exercise. Nevertheless one group was identified as difficult to reach and whose needs could not be met in a group for reasons of confidentiality. While the methodology itself clearly has great potential in planning around specific health issues, there are, nevertheless, limitations. Although the approach and the tools used are simple and accessible, the skills needed to analyze the information are more complex and demanding. The training given did not manage to equip facilitators adequately with these analytical skills and in the future will be more experience based and geared towards developing analysis and the ability to formulate questions. In addition, since the project is not permanently resident in the area, intensive support within the District is necessary to increase the chances of sustainability. PMID- 10173408 TI - Conducting a literature review on the effectiveness of health care interventions. AB - The dramatic increase in the volume of research based information means that effective policy makers must be able to conduct and interpret literature reviews. This article sets out the steps that should be followed in doing so. They are: explicitly defining the question; locating relevant literature; assessing the quality of studies and deciding whether they should be included; synthesizing and re-analyzing the results; and presenting them in a clear and concise manner. The article identifies the leading sources of information, including electronic databases and useful Internet addresses and describes briefly how each stage should be conducted, highlighting the strengths and weaknesses of different approaches and the ways in which bias may be introduced. PMID- 10173409 TI - Designing benefits that are good for employees and for business. AB - Hospital employers need to evaluate the true cost of their medical benefits program by comparing HMO benefits and premiums versus a self-funded plan's benefits and costs. Hospitals need to evaluate the cost of providing services at their own facility, then compare the capitation income derived from the HMO for providing these same services at their own facilities against the paid claims dollars that are returned to them when plan participants receive services at their own facilities. PMID- 10173410 TI - Hospitals reap the benefits of sharing risk with health maintenance organizations. PMID- 10173411 TI - Quorum launches employee ethics program. PMID- 10173412 TI - Paying for choice as health care in America continues to move into a market economy. PMID- 10173413 TI - Chicago hospital tries to save money and lives through violence prevention. PMID- 10173414 TI - Paying for the (alleged) sins of Columbia. PMID- 10173415 TI - Liability in the allocation of scarce health care resources. PMID- 10173416 TI - Class actions in breast implant litigation. PMID- 10173417 TI - The duty to warn third parties and AIDS in Canada. PMID- 10173418 TI - The ethics of deception in biomedical research. PMID- 10173419 TI - The missing piece of the long-term care reform puzzle: the Community Health Information Network. PMID- 10173420 TI - Teaching legal issues in university nursing programs. PMID- 10173421 TI - Hospital security: "a current look". AB - The results of a hospital security survey using a random sampling of hospital organizations in the AHA Membership Directory. The survey covered staffing, security attire and equipment, training, use of physical security, and bicycle patrols. No serious security staffing cutbacks have taken place in the past two years, according to survey respondents. PMID- 10173422 TI - K-9s in healthcare security: a reflection after five years. PMID- 10173423 TI - Preparing for healthcare security reductions and changes. AB - The author offers suggestions on how healthcare security can survive in this changing environment of downsizing. Be proactive and show how important security is, he says. PMID- 10173424 TI - Ethics and the security supervisor. AB - The article discusses ethical decisions, the decision-making process itself, dealing with errors in judgment, and creating everyday training. It is the security supervisor's effectiveness at incorporating ethical actions into everyday activities and thinking, says the author, that will determine a positive outcome. PMID- 10173425 TI - A team approach to the environment of care. AB - The author provides a step-by-step description of how his hospital used the team approach to comply with the Environment of Care standards of JCAHO. The end result--a high score with commendation--justifies the means, he says. PMID- 10173426 TI - Assessment tool assists in complying with many JCAHO standards. AB - How a Pennsylvania medical center found a unique and time-saving approach to satisfying compliance with JCAHO's Management of the Environment of Care standards. Several members of the Safety Committee and the Education Resources Department developed a 25-question quiz, the "Safety Challenge Assessment Tool," to see what employees really knew. PMID- 10173427 TI - Health care security: the emergency room view on violence. AB - The authors discuss why the emergency care environment is so volatile as well as how a secure and safe emergency department can be achieved. Security must be sensitive to the various needs of emergency room clients. PMID- 10173428 TI - Gangs in hospitals. AB - What occurs when a gang member presents himself or herself to a healthcare environment? What can the security and nursing departments do to respond to the potential danger and prevent a possible incident? Healthcare institutions, says the author, should adopt standards to reduce and prevent gang activity and make both the healthcare environment and society safer places. PMID- 10173429 TI - Security at a "model" psychiatric center. AB - The security problems faced by a recently opened psychiatric center located on the campus of a hospital--including staffing, fire safety, access control, patient restraints, and budget cuts--and how they are being dealt with. PMID- 10173430 TI - Principles for the use of mechanical restraints in a medical facility by staff and security officers. AB - The author discusses the use of restraints by a healthcare security force. Before restraints are used, have clear and documented policies and procedures on the proper application, he advises. When used properly, they help provide a safe and secure environment for staff, patients, and visitors. PMID- 10173431 TI - Elements of a violence prevention program for healthcare workers. U.S. Department of Labor, Occupational Safety and Health Administration. AB - For many years, healthcare and social service workers have faced a significant risk of work-related violence. In this article, OSHA's new violence prevention guidelines are presented, providing the agency's recommendations for reducing workplace violence. Through these guidelines, OSHA assists healthcare and social service employers and providers in preventing such violence and in providing a safe and healthful workplace through effective violence prevention programs. By adopting these practical measures, OSHA states, the serious threat to worker safety can be significantly reduced. PMID- 10173432 TI - The role of an investigator in healthcare protection. AB - The author discusses three types of investigations the healthcare security officer may be concerned with--employee theft, homicide and violent crimes, and fraud. He examines the role of the investigator as puzzle solver and the steps that need to be taken to put all the pieces of the puzzle in place. PMID- 10173433 TI - North Dakota hospital dramatically reduces security-related injuries. AB - The author discusses how his hospital was able to dramatically reduce its security-related injuries and why a Corrective Action Team is so important. Once an effective security program has been established, he says, review it periodically to maintain its effectiveness. PMID- 10173434 TI - Construction fire safety in a medical center environment. AB - The author describes how his medical center reduced repeated false alarms caused by construction, renovation, or maintenance work and improved fire construction safety. PMID- 10173435 TI - Training forensic staff. AB - The author provides a training package for forensic staff on how to handle prisoner patients who are being treated at a healthcare facility. She covers such topics as fire and evacuation plans, interim life safety measures, blood and bloodborne pathogens exposure, universal precautions, respiratory protection and TB, and voluntary medical immobilization and protection devices. PMID- 10173436 TI - Beyond JCAHO: using competency models to change healthcare organizations. Part 2: Developing competence assessment systems. AB - In 1996, JCAHO required hospitals to assess, prove, track, and improve the competence of all employees. This article is the second part of a review of the concept of competency assessment and the implications of meeting and exceeding the JCAHO standards. Part 1 (in the previous issue of Hospital Topics) provided the theory of competence assessment, the current situation in JCAHO surveys, and an overview of the problems inherent in competency assessment. This part puts competence assessment in the context of quality improvement and provides the details of developing competence assessment systems. PMID- 10173437 TI - Nursing compensation: a historical review. PMID- 10173438 TI - Clinical engineers: a vanishing hospital resource. PMID- 10173439 TI - Communication: the key to reducing malpractice claims. PMID- 10173440 TI - Stewardship. Sorting out the claims and obligations in managed care. PMID- 10173441 TI - Factors associated with achievement of goals for home health care. AB - With the introduction of Medicare's Prospective Payment System (PPS) and DRGs, the economic value of home health care services lies in its ability to reduce total patient care costs by the substitution of outpatient home care for inpatient hospital care. Analysis of service delivery patterns utilized by home health agencies in meeting goals for patient care will be an important ingredient in meeting these objectives. The purpose of this study was to determine if important patient characteristics known at the onset of home health care are predictive of utilization of home health services and/or the likelihood of meeting goals for home care established at the time of certification of care. Multivariate models were developed which predicted the odds of terminating with goals met based upon age, intensity of utilization, functional limitations, prognosis, presence of a caregiver, and type of patient condition. Results indicated that variability in likelihood of meeting goals for care is much better predicted by patient characteristics than by utilization of home care services. PMID- 10173442 TI - Assessing and balancing elder risk, safety and autonomy: decision-making practices of health care professionals. AB - Diverse professionals assess and manage risk with frail elderly yet no standard practice guidelines are used across the care continuum. This qualitative study provides new understanding of how eldercare workers conceptualize and assess risk with frail elderly clients. Fifteen professionals were interviewed using the Long Interview Method of McCracken (1988) and Crabtree and Miller (1991). Respondents included home care case managers, visiting nurses and hospital discharge social workers. This paper reports on two key decision-making styles identified through multidisciplinary analysis of transcripts: the "snap decision-makers" and the "agonizers." Labeling strategies are identified that may assist eldercare workers with the dissonance between professional training and the realities of practice. Variable thresholds for risk tolerance among diverse professionals were found. These findings suggest that risk assessment often reflects the values of the individual practitioner's profession and agency culture. Standardized training and ethical practice guidelines are needed to reduce extreme variability in professionals' judgments; and to better assist staff with assessing and balancing elder risk, safety and autonomy. PMID- 10173443 TI - Evaluating rehabilitation medicine: effects on survival, function, and home care. AB - The goal of this study was to measure the clinical impact of rehabilitation on adults diagnosed with a disabling disorder in four major diagnostic groups (nervous, circulatory, musculoskeletal, and injury). To summarize the current knowledge in this area, a meta-analysis of rehabilitation studies was also completed. Specific objectives of the clinical trial were to determine the effects of inpatient rehabilitation on: (1) survival, (2) function, (3) home care, and related variables such as family function and use of health care resources. Patients hospitalized for the first time with a disabling condition (n = 85) were randomly assigned to inpatient rehabilitation (n = 43) or to outpatient follow-up (n = 42) in which the usual medical services were provided but no scheduled rehabilitative therapies were offered. To compare the two groups, analyses of covariance were conducted for functional ability, health care use, survival, health status, personal adjustment and family function. The between subjects factor was inpatient rehabilitation versus the control group. The within subjects factor was time of assessment (index, six months, and 1 year). No significant treatment effect was found at six months or one year for any of the variables under study using analyses of covariance. There were also no differences between groups in their use of nursing homes, length of hospital stay, survival, or in the number of hospital readmissions or clinic visits during the first year after hospital discharge. Rehabilitation did cost significantly more than medical care, primarily due to the cost of inpatient services. Some clinical trials have noted a treatment effect on functional ability but not on mortality, need for skilled care, or mental health status. The current study is consistent with these previous findings except for the lack of impact on physical function. This exception may be due to the fact that prior studies looked only at homogeneous groups, whereas the current study utilized heterogeneous grouping across four major diagnostic categories. Any apparent benefit may not be detectable across disability groups and may require more specialized scrutiny, or even tailored rehabilitative care, to detect a difference. It is recommended that health care systems evaluate the benefits of subacute rehabilitative care and consider outpatient programs that can be provided at home for implementation. PMID- 10173445 TI - American Radiology Services, Inc., Baltimore, Maryland. PMID- 10173446 TI - Anchorage, Alaska. Alaska Native American Health Center. PMID- 10173447 TI - Peoria, Arizona. Sun Health Residence for Alzheimer's Care. PMID- 10173444 TI - Home care resource consumption and patient outcomes: what are the relationships? AB - This study examined empirical relationships between measures of home care resource consumption and patient outcome measures in a sample of 201 patients who began new episodes of home care with one of ten Medicare-certified home care agencies in Ohio. We found that, while the total volume of home care resource consumption (i.e., total visits and costs) was similar for patients whose episodes ended with discharge at home vs. hospitalization, patients discharged to hospitals consumed home care resources in a much shorter period of time. We also found that resource consumption patterns were very similar regardless of whether patients improved or declined in clinical and functional health during the episode of home care. Results suggest that home care agencies should carefully project both resource consumption and patient outcome targets when negotiating service contracts with managed care organizations, especially for Medicare patients. PMID- 10173448 TI - Managing death. A sad end? PMID- 10173449 TI - Managing death. Room to mourn. AB - More than a quarter of deaths occurred on wards which offered relatives and staff no privacy. In a fifth of cases no information was available on how to register a death. Almost half of the staff had received no training in bereavement. More than half of the staff wanted training or further training. PMID- 10173450 TI - Mortuary management. Cold comfort. PMID- 10173451 TI - NHS reforms. Counting the costs. AB - Localism predominates in purchaser-provider relationships, with markets strictly limited in practice. Block contracting predominates, largely to enable purchasers to bring pressure to bear on providers' costs and outputs. The administrative costs of operating the purchaser-provider split have led to a clear growth in the overall administrative costs within the NHS. Locality commissioning may conflict with the need to reorganise clinical services. PMID- 10173452 TI - Complaints. Had a nice day? PMID- 10173453 TI - Complaints. Now we're talking. PMID- 10173454 TI - Cancer care. Centre forward. PMID- 10173455 TI - New bids on the block. PMID- 10173456 TI - Integrated care. Primary dolours. AB - A primary care-led NHS has enjoyed gains, but at significant cost. The policy has failed to address public health issues, inequalities and problems in access to services. The policy has caused divisiveness and is seen as exacerbating deep rooted competitiveness between GPs and consultants. A new concept is needed to unite the aspirations of the whole NHS. PMID- 10173457 TI - Primary care. Ending in tiers. AB - Although there are many examples of fundholders' patients enjoying better access than those of non-fundholders, systematic studies comparing access between the two groups are lacking. An early end to two-tierism while the internal market exists, could have serious implications for the quality of existing services and the stability of trusts. Locality commissioning may be a way to ensure equity, while avoiding an over-centralised approach. PMID- 10173458 TI - Waiting times. Bones of contention. AB - A slot system allocating a set number of outpatient orthopaedic appointments to general practices in North West Anglia HA means all patients referred are seen in eight weeks. The system has provoked criticism from GPs on the grounds that the burden of waiting lists has shifted onto them, and it limits access to services. The scheme has improved communication between GPs and orthopaedic consultants. PMID- 10173460 TI - Racial issues. High culture. PMID- 10173459 TI - Cost of medicines. Kicking the habit. PMID- 10173461 TI - Handle with care. PMID- 10173462 TI - Primary care. Cracks in the edifice. AB - The cost-effectiveness of the shift towards primary care is unproven, despite studies claiming otherwise. Existing studies show serious methodological shortcomings. One fifth of studies failed to control for differences in case-mix and demographic make-up. Nearly half of studies made no attempt to measure outcomes. There is an urgent need for an improved evaluation agenda to cover both long- and short-term needs. PMID- 10173463 TI - Waiting lists. One EL of an idea. PMID- 10173464 TI - Security. Defence mechanisms. AB - Half of trust ambulance staff had been physically assaulted in the past three years, and 58 per cent seriously threatened. Managers had asked fewer than 10 per cent about the causes of the incident or how to stop a recurrence. Protective measures most requested by staff were identification of problem patients/locations, followed by police back-up Further research is needed on the effectiveness of protective measures for ambulance staff. PMID- 10173465 TI - Career profile. Independent sector managers. Finding your niche. PMID- 10173466 TI - Pain without gain. Say no to mergers. PMID- 10173467 TI - Mergers. Going with the flow. AB - A successful merger requires intense concentration on the people involved. Those affected are likely to show a grief reaction, including denial, resistance and eventual acceptance. You will never get it completely right, but good communication helps. PMID- 10173468 TI - Joint working. Local differences. AB - The interface between social care and primary healthcare remains underdeveloped. Where joint working is effective, it is the result of co-operation, trust and mutual respect. Successful local networks take account of professional autonomy. PMID- 10173469 TI - Total purchasing. Tracking down care. AB - Purchasers have a duty to monitor the quality of services purchased on patients' behalf; a purchasing general practice is best placed to do this effectively, especially by means of a tracker nurse. The tracker nurse should be diplomatic and experienced to earn the respect of professional staff in provider units, some of whom may see the process as threatening. The purchaser must introduce the concept of care monitoring gently but firmly, agreeing terms of confidentiality. Good practice should be highlighted and used as an example to others. Monitoring must follow the whole pathway of care, at the time and place it is given. PMID- 10173470 TI - Health promotion. Urban myths. AB - Homeless people are very aware of health messages. They worry about how to stay healthy, but feel disempowered. Progress is impeded by a lack of joint working between health services and homelessness agencies. PMID- 10173471 TI - Data briefing. Productivity. PMID- 10173472 TI - New uses for old hospitals. Phoenix from the ashes. PMID- 10173473 TI - Telecommunications. Calls to account. PMID- 10173474 TI - Community reprovision. Backyard blues. PMID- 10173475 TI - Repairs backlog. Assets or liabilities? PMID- 10173476 TI - Health policy. Time to turn the tide. AB - The government should not increase funding to the NHS until it can be demonstrated that this will improve population health and that the money cannot be made available from reducing current inefficiencies. The absence of an information base in the NHS is one of the greatest challenges. The new administration needs to acquire a deeper understanding of how resources are being used. New untested organisational structures and policy stunts should be avoided. Waiting lists should be prioritised according to urgency and ability to benefit. PMID- 10173477 TI - Evidence-based medicine. Literacy criticism. PMID- 10173478 TI - Mental health. Right approach. AB - The care programme approach for people with long-term mental illness appears to have been a key factor in increasing the average length of stay in psychiatric wards. In one trust the average length of stay has almost doubled since 1991. The need for complex care plans to be in place before patients are discharged, and the need for multidisciplinary meetings, can slow up discharge. A new model drawn up by the trust aims to cut down on delays by involving community services at the time of admission and using a care plan which is common both to the hospital and community. PMID- 10173479 TI - Career profile. Human resources. Power to the people. PMID- 10173480 TI - Mixed-sex wards. Mixed is no match. PMID- 10173481 TI - Resettlement. Home at last. AB - A three-year resettlement programme was hampered by opposition from local communities, with the result that many residents had to be moved in the last few months before the hospital closure. The idea of resettlement provoked anxiety among residents' relatives as some residents had been in the hospital all their lives. The cost of the programme was higher than first envisaged partly due to property prices. PMID- 10173482 TI - Mental health. Making the right links. AB - Intensive care management has not been widely adopted, partly because of the initial costs involved. Control of inpatient beds is crucial to successful initiatives. Implementing this approach in part of Newport, including appointing a link nurse who liaises with acute and community teams, has led to reduced bed use. PMID- 10173483 TI - Public health. Leading questions. AB - The arguments in favour of the public health director being a doctor remain powerful. It is difficult to imagine someone without a medical qualification being accepted by junior doctors, consultants and GPs. However, other disciplines may have a better understanding of social and economic determinants of health, and more skills in working with communities. Given current prevailing attitudes, it is unlikely that a professional other than a doctor could gain the confidence of the range of groups that a public health director must work with. But attitudes could and possibly should, change. PMID- 10173484 TI - Public health. When patients are a virtue. AB - A survey of doctors in public health revealed that less than a fifth were involved in clinical practice. But 72 per cent thought it would be appropriate for public health consultants to see patients. Responses revealed concerns that those not seeing patients might lack credibility with doctors in practice and could lose touch. Encouraging clinical involvement could enhance public health and the quality of patient care. PMID- 10173485 TI - Primary care. Running on empty. AB - There has been a management vacuum in primary care since the beginning of the NHS, but it has been disguised by the stability of the area and the dominance of the acute sector in the public's mind. Health authorities are now responsible for implementing a highly ambitious policy in a field where they have little power few skills and no extra resources. To be successful, a primary care policy requires greater management capacity on the part of health authorities support from GPs and merged general medical services and hospital and community health services budgets. PMID- 10173486 TI - Mental health. Nought for their comfort. AB - The development of resource centres works against mental health users being seen in GPs' surgeries. The community mental health team needs to be linked to inpatient services. Measuring activity is not a valid way of assessing service quality. Mental health inquiries are useless as learning exercises. The money and time they absorb would be better spent on remedying well-known problems in mental health services. PMID- 10173487 TI - Mental health. Careering around. AB - An orientation exercise provided a structured, supervised induction for practice based community psychiatric nurses. The exercise also provided community perspectives on need. The same process could be used for other new primary healthcare workers. PMID- 10173488 TI - Data briefing. Charging for GP visits. PMID- 10173489 TI - Transaction costs economics as a conceptual framework for the analysis of barriers to the diffusion of telemedicine. AB - Telemedecine has been talked about for more than 20 years, without it entering daily use with any success. Based on transaction costs economics, the present analysis of the exchange relationships between health care producers highlights certain characteristics of the current technical and legislative context, which leads to transaction costs. It also demonstrates that the introduction of telemedicine shifts the costs associated with agents' opportunism from patients to health-care producers themselves. All these costs may be considered nowadays to thwart the use of telemedicine. It is argued here that the Public Authorities and professionals of health care could act upon telemedicine in two fields: (1) intervention in the institutional environment aims notably at better defining the property rights of telemedicine, and so constitutes an unavoidable means of encouraging health-care producers to invest in new technology; and (2) implementation of organisational forms and mechanisms susceptible to regulating such telemedical relationships between health care producers-given the present institutional environment-constitutes an essential means for overcoming the immediate barriers blocking the diffusion of telemedicine. PMID- 10173490 TI - Waiting for coronary revascularization: a comparison between New York State, The Netherlands and Sweden. AB - OBJECTIVE: To compare waiting times for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery in New York State, the Netherlands and Sweden and to determine whether queuing adversely affects patients' health. METHODS: We reviewed the medical records of 4487 chronic stable angina patients who underwent PTCA or CABG in one of 15 New York State hospitals (n = 1021) or were referred for PTCA or CABG to one of ten hospitals in the Netherlands (n = 1980) or to one of seven hospitals in Sweden (n = 1486). We measured the median waiting time between coronary angiography and PTCA or CABG. RESULTS: The median waiting time for PTCA in New York was 13 days compared with 35 and 42 days, respectively, in the Netherlands and Sweden (P < 0.001). For CABG, New York patients waited 17 days, while Dutch and Swedish patients waited 72 and 59 days, respectively (P < 0.001). The Swedish and Dutch waiting list mortality rate was 0.8% for CABG candidates and 0.15% for PTCA candidates. CONCLUSIONS: There were large variations in waiting time for coronary revascularization among these three sites. Patients waiting for CABG were at greatest risk of experiencing an adverse event. In both the Netherlands and Sweden, the capacity to perform coronary revascularization has been expanded since this study began. Further international cooperation may identify other areas where quality of care can be improved. PMID- 10173491 TI - General practice fundholders' prescribing savings in one region of the United Kingdom, 1991-1994. AB - Since 1991, fundholding general practitioners in the UK have had a financial incentive to contain prescribing costs. Research has confirmed that fundholding practices have contained their prescribing costs more effectively than non fundholding practices, but how much fundholders have actually saved by changing their prescribing is difficult to quantify. Fundholders are allocated a prescribing budget, and the underspend on this budget has been taken to represent savings produced by changing prescribing behaviour. However, this assumes accuracy of budget setting, which has been questioned. The objective of this study was to estimate the true savings in prescribing made by fundholders during the first 3 years of fundholding, without making assumptions about the accuracy of budget setting. We compare this to underspends on prescribing budgets. The results suggest that budget setting did not give fundholders over-generous budgets and that budget underspends are justified by the true savings in prescribing. PMID- 10173492 TI - Costs and financial consequences of the changing epidemiological profile in Mexico. AB - This article presents an analysis of health-care costs and financial consequences of changes in the epidemiological profile in Mexico. Four tracer diseases were selected to conduct this study: two non-communicable diseases (arterial hypertension and diabetes) and two communicable ones (diarrhea and pneumonia). Costs involved in disease case-management, both in economic and planning terms, predict the internal competition for resources to finance health services for each tracer disease. In addition, the change in the number of cases expected during the study period highlights the process of internal competition and adds an element of intrinsic competition in the management of ambulatory and hospitalized cases for each disease. Study results support the conclusion that if preventive programs remain unchanged, the increasing demands for curative health care may cause great financial and organizational challenges to the health care system of middle-income countries like Mexico. PMID- 10173493 TI - Priority setting in health care: learning from international experience. AB - Priority setting in health care is not new but it is an issue of growing importance. In publicly financed health care systems, the combination of constrained resources and increasing demands has led policy makers to address this issue more directly than in the past. This is exemplified by experience in Oregon, the Netherlands, New Zealand, Sweden and the UK. In each of these systems, policy makers have taken the initiative to set priorities on a more explicit basis. This paper compares and contrasts experience in these systems and identifies a number of emerging themes. The work done so far can be likened to an exercise in policy learning in which policy makers have tried out a range of approaches and have adjusted course several times in the process. Priority setting is not amenable to once and for all solutions and the issues involved must be kept under continuous review. PMID- 10173494 TI - Effect of panel composition on physician ratings of appropriateness of abdominal aortic aneurysm surgery: elucidating differences between multispecialty panel results and specialty society recommendations. AB - OBJECTIVE: To investigate how the composition of multispecialty physician panels is associated with both the summary ratings assigned by such panels and the agreement of such panels with the recommendations of specialty societies. DATA SOURCES/STUDY SETTING: We examined the final ratings assigned by a nine-member multispecialty RAND Corporation physician panel regarding indications for abdominal aortic aneurysm surgery and the recommendations of a specialty society representing vascular surgeons who perform the same surgery. STUDY DESIGN: The panel was retrospectively divided into two sub-panels, one composed of the three vascular surgeons on the panel and the other composed of the six remaining physicians. We analyzed the two sub-panels' rating patterns with respect to each other and with respect to concurrent guidelines generated by the Joint Council of the Society of Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. PRINCIPAL FINDINGS: Of the 782 indications considered by the panel for appropriateness, the vascular surgeons had an average of mean ratings for appropriateness of 5.1, significantly higher than the 4.5 average of the other physicians. Across the 221 indications considered by the panel for necessity, the vascular surgeons had an average of mean necessity ratings of 6.8, significantly higher than the 5.8 average of the other physicians. The vascular surgeons' rankings of agreement with the guidelines of the Joint Council were significantly higher than those of the physician panelists from other specialties. CONCLUSIONS: statements of clinical appropriateness and necessity produced by summarizing ratings assigned to indications by expert panel members may disguise marked underlying disagreements among well-defined groups of practitioners within these panels. In the case of abdominal aortic aneurysm management, these disagreements within the RAND panel explain the marked discrepancy between the RAND multidisciplinary panel ratings and the recommendations issued by vascular surgeon professional societies. PMID- 10173495 TI - Marketers don't wear plaid: marketing and health care administration in the Canadian context. AB - Marketing has a bad reputation among Canadian health managers, even though marketing solutions may address many of their problems. This article provides an overview of current understandings of marketing and how they may be applied to health care situations. Marketing should be considered an ongoing process. This is particularly helpful if we understand the root task of health managers as creating and promoting exchanges--with governments, physicians, nurses, other health workers and client groups. Exchanges that are desirable to the health care community will more likely occur if the true costs and benefits of health services are analyzed, understood and imaginatively communicated. The public constantly evaluates the health system. Constant evaluation implies a need for marketing directed internally at staff and those within the health system, and externally at constituents outside the system. Properly understood and practiced, marketing can be part of the innovative solutions health care managers develop and apply as they deal with the difficult challenges facing them in Canada's current health care environment. PMID- 10173496 TI - Healthy hospital: toward a better tomorrow. A demonstration project to promote culture change through participatory decision making. AB - The three-year "Healthy Hospital" project was designed to increase participatory decision making, thereby decreasing job stress and increasing job satisfaction. Evaluation methods included employee surveys, focus groups and key informant interviews. Overall stress levels, job satisfaction and self-esteem generally improved. The diverse types of evaluation converge on a conclusion that the project achieved modest but significant gains throughout the organization. Lessons for future research and applications are discussed. PMID- 10173498 TI - The SMARTT (Sunnybrook Memory Assessment Research Treatment and Training) Program: planning for dementia care. AB - Dementia is being recognized as a major public health challenge. Caring for those with dementia poses a unique problem for family and health care providers in community and institutional settings. This article describes the development of the Sunnybrook Memory Assessment Research Treatment and Training (SMARTT) Program at an academic health science centre. This program serves as a model for an integrated health system to meet the needs of dementia patients and their families. PMID- 10173497 TI - Organizational restructuring in health care: a successful approach. AB - The process of redesigning the internal organization structure of the Hamilton Civic Hospitals provides a successful example of this type of transformation. Based on a strategic approach to change, this multiphased process used a modified delphi technique to allow maximum participation in a total redesign of the structure during a four-month time frame. Implementation, which followed over the next year, resulted in a 40 percent reduction in management positions and the integration of the two sites of the hospital. PMID- 10173499 TI - Devolution to whom? PMID- 10173500 TI - Public-private management partnerships in the Canadian environment: options for medical imaging. AB - Health services restructuring demands that hospitals consider innovative ways of providing patient care, including services within the clinical support departments such as medical imaging, diagnostic laboratories and pharmacy. This Brief Report describes the result of work carried out a St. Michael's Hospital to explore options for public-private management partnerships within the Department of Medical Imaging. Various partnership models and opportunities for cost containment, revenue generation and strategic positioning are discussed. PMID- 10173501 TI - Partnerships between self-help networks and health care facilities: the case of the Bayview Support Network. AB - This article discusses the role of patients and their families as peer support providers to other patients, and as decision makers within organizations. We use as a model the Bayview Support Network, a self-help network at the Toronto Sunnybrook Regional Cancer Centre. We review the benefits of partnership, costs, limitations and risks. A list of features that contribute to effective partnership is also provided. PMID- 10173502 TI - Five ways to jump start your career. PMID- 10173503 TI - Learning to live with uncertainty. Interview by Matthew D. Pavelich. PMID- 10173504 TI - Build it and they will come: far north facility shines as community focal point. PMID- 10173505 TI - Putting on the real estate management hat. Can you meet the challenge? PMID- 10173506 TI - Finding your way through ADA. Make your facility accessible to everyone. PMID- 10173507 TI - The look before the leap. How to assess your facility and equipment for integration or consolidation. PMID- 10173508 TI - T-square or cookie cutter? Is the single design approach right for multiple outpatient facilities? PMID- 10173509 TI - Where's the fire? Nowhere, if you know the code. PMID- 10173510 TI - Top 10 trends--and how to make them work for you. PMID- 10173511 TI - Turn sourpuss staffers into positive performers. PMID- 10173512 TI - Health care fraud alert: beware of suspect enforcement activities. PMID- 10173513 TI - Leadership of a cultural change process. AB - Explores the successful role of leadership in initiating and sustaining a major process of change. The findings build on the work of others who have so ably demonstrated the influence of powerful leaders. Research is based on qualitative data from an ethnographic study which immersed itself in the minutiae of organizational life. Outlines the processes that have unfolded in the wider context of NHS change. Discusses the findings and debates supporting evidence. The resultant model of change indicates that successful leadership of cultural change requires leaders to think culturally, to be guided by a cognitive model of change and to employ the cultural tools of symbolism while actively focusing on the politics of acceptance. Hard systems and structural changes can be implemented in parallel with soft symbolic and political activity. A highly receptive context, either real or created, assists by providing a trigger for change. PMID- 10173514 TI - The importance of being earnest: reflections on an attempt to create an information-led organizational culture in the NHS. AB - Presents a study of organizational culture in a community health-care Trust in the UK. The Trust has been involved in attempting to create what was described as an information-led culture and is concurrent with the implementation of a new information system. Describes some of the recent management initiatives which were intended to improve communications within the Trust and to provide employees with a better understanding of the changes which have been taking place. Identifies findings which suggest that there was some distance between the perceptions of management and those of employees. While the senior management team appear to have been in earnest in attempting to ensure that staff have the information and understanding they need, the results of an organizational culture survey suggest that these efforts may have been ineffective. PMID- 10173515 TI - Contested terrain: the incomplete closure of managerialism in the health service. AB - Focuses on feelings about culture and change in the health service and the impact of management development programmes on the change process. The issues raised in a series of semistructured interviews are taken forward to a case study, a medium sized hospital Trust. The researcher "hangs around and listens into" a management development programme aimed at middle managers with a nursing background. The theme of ideological conflict comes into central focus. Analysis of outcomes suggests that the managerial assumptions on which the programme is based result in resistance from participants. They resist the attempts of facilitators to provide "closure" whereby managerial ways of doing things are suggested as the "obvious way ahead". Advocates that management education particularly in the health service should have a pluralistic orientation. As part of such pluralism, more critical approaches should be considered beyond conventional and problematic conceptions of knowledge relating to management. These are reductionist in considering a manager as "having a set of technical competences" rather than exhibiting "a way of being". PMID- 10173516 TI - Successful implementation of process review in ophthalmology services. AB - Explains that considerable recent publicity has been given to the claim that around 70 per cent of business process re-engineering exercises are unsuccessful, mainly because of failure to take human factors into account. Outlines the work undertaken in a single specialist surgical service, within an acute services National Health Service Trust, and the outcomes achieved. Suggests that there are points arising from the project to be learned both by the Trust and by other health-care employers contemplating similar exercises: in particular, deciding objectives; the preparation undertaken prior to the project; and detailed post implementation benefit analysis. PMID- 10173517 TI - The challenge of education commissioning--Part 3: Management development. AB - The new education commissioning system in England is designed to deal with the "big numbers" of professional education, yet also applies to management development. Reviews national advice in this field. Suggests that management development is unlikely to feature highly on the education commissioning agenda. Proposes that changes in higher education and among NHS employers are likely to lead to greater flexibility in management education, but that opportunities will only be taken if both parties show initiative and imagination. PMID- 10173518 TI - Occupational stress in the ambulance service: a diagnostic study. AB - The Occupational Stress Indicator (OSI) was used to investigate job stress in an ambulance service in the northwest of England. Seven different aspects of the stress-strain relationship were assessed and the findings compared with those from the fire service. Ambulance service employees were found to be experiencing major stress outcomes of low job satisfaction and poor mental and physical health. Fire service employees revealed significantly poorer physical health. Assesses the sources of job stress, type A behaviour, locus of control and coping styles and discusses them in the light of change in the public services. PMID- 10173519 TI - Counting nurses: interpreting nursing workforce statistics. AB - Discusses the interpretation of nursing statistics, the problem of counting how many nurses there are in the workforce, and the need to be aware of how statistics are compiled when presenting numerical data to support arguments relating to nursing and the nursing workforce. Argues that NHS workforce statistics provide considerable evidence for claiming that there is a significant decline in the number of nursing staff doing the work of nursing in the NHS. Explains that although there was an increase in the number of qualified nurses working in the NHS throughout the 1980s (over a ten-year period the number of qualified nurses increased by 22 per cent), the increase in qualified nursing staff has not compensated for the loss of student learners in the workforce. Emphasizes that during the last three years for which figures are available, however, these gains have been wiped out, and the number of qualified nurses has declined to pre-Project 2000 levels. PMID- 10173520 TI - Surveying technologists: a novel method for establishing productivity standards in a clinical haematology laboratory. AB - Personnel costs comprise the largest clinical laboratory expense. Yet standards to judge the productivity of personnel have not been established. A survey of the authors' own personnel was conducted to derive productivity standards in the Clinical Hematology Laboratory at the Massachusetts General Hospital, Boston, Massachusetts, USA. Technologists were asked how many white blood cell differentials they could perform in an eight-hour shift. Differential productivity was tracked before and after the survey. Of the respondents, 100 per cent failed to meet their own expectations of productivity. Nine technologists were tracked both before and after the survey was mailed and manifested a significant increase in productivity. These results suggest that technologists are objective in their assessment of their own productivity, that their opinions might be a resource for establishing productivity standards within the laboratory, and that such surveys may serve as motivational tools to augment productivity. PMID- 10173521 TI - Competitive tendering in NHS catering: a suitable policy? AB - Seeks to evaluate the policy of competitive tendering for ancillary services in the National Health Service, by reference to a number of case studies of catering services. Argues that the success of the policy was dependent on certain assumptions being met about the extent of competitive pressure and the potential for savings, largely labour cost savings, to be made. Shows by case studies that these conditions frequently did not occur and hence the policy was flawed. Furthermore, even where these conditions did occur, the evidence shows that a range of other factors influenced the extent to which labour cost savings could be made. PMID- 10173522 TI - Understanding business processes. AB - Presents a background to process understanding which offers potential benefits to the NHS. Considers the various business processes found in health care organizations, noting that the management of cross-functional processes is an area in which improvements can be made. Outlines the kind of problems which can result from mismanagement of such processes and the potential benefits of process improvement. PMID- 10173523 TI - Process improvement and information management. AB - Notes the importance of continuous improvement as a concept to guide management and that this concept requires numerous components to make it work. Picks out the role of information management as a key area, citing factors such as the creation of an "information culture" as being of major importance. Looks at the path followed by some Trusts in pursuit of this "information culture" wherein staff gained an improved insight into the use of information as a management tool. PMID- 10173524 TI - What chance a caring management culture? AB - Management of the NHS is necessary and vital to effective delivery of health services. It is not a process that can be avoided, whoever does it. New Labour needs effective managers in the NHS if they are to bring about the changes they want to see. Manager bashing, which New Labour is showing signs of continuing, is counter productive and encourages a climate of threat for managers which subsequently translates into bad management practice with its inevitable consequences for service quality and productivity. The NHS badly needs a positive long-term strategy of serious investment in individual and organizational development. It is a question of balanced investment between the long-term management capability of the NHS and immediate patient care. The major issues of rationing, priorities and the balance between health and health services will always be part of the difficult national and local management task. Some move by politicians in the direction of open recognition of these difficulties and the burden they place on the skill, will and courage of managers could go a long way to building a caring management culture. PMID- 10173525 TI - Medicare reform without fireworks. PMID- 10173526 TI - Preserving the Catholic vision of care. Ministry leaders must not be intimidated by managed care or market pressures. PMID- 10173527 TI - Catholic health ministry will succeed. PMID- 10173528 TI - Community networks. Neighborhood-Based Senior Care National Initiative will provide a model of community care. PMID- 10173529 TI - Tradition, mission, and the market. Faith in ultimate purposefulness makes Catholic healthcare different. PMID- 10173530 TI - Teaching the hungry to fish. Group helps inner-city neighborhood help itself. PMID- 10173531 TI - Success in the desert. PMID- 10173532 TI - Catholic Health Association's 1997-98 strategic plan. Working for the common good of the Catholic health ministry. PMID- 10173533 TI - Continuing the vital mission. PMID- 10173534 TI - Expanding coverage for children. PMID- 10173535 TI - After the downsizing. How to build loyalty and productivity in the wake of restructuring. AB - The restructuring forced on many healthcare organizations today increases employees' stress and threatens their loyalty and productivity. To restore trust and improve morale, and maintain hope, healthcare leaders can implement six strategies: Clearly communicate decisions that affect employees, using verbal and written methods, and show compassion to displaced workers and acknowledge their contributions. Support remaining employees. Tell them why they survived and provide them with new challenges. Allow employees to participate in developing a shared vision of the organization's future. Empower employees by rewarding their accomplishments appropriately. Workers perform better when they develop their "personal power" and believe they are part of a team facing new challenges. Focus on learning and professional growth. New knowledge sparks workers' imaginations and helps them find better ways to accomplish their goals. Ask employees to reflect on their professional legacies-what they wish to be remembered for. PMID- 10173536 TI - Finishing big by starting small. Continuous improvement is the key to enhancing community health. AB - Although healthcare organizations increasingly seek involvement in community health improvement, they are often unprepared to do so because of their inexperience in disease and injury prevention. In recent years, however, continuous improvement (Cl) methodology has produced insights that are useful in such projects. An organization considering a community health improvement project should, from the start, test it through "Plan, Do, Study, Act" (PDSA) cycles. The project's leaders should begin by selecting an issue to work on. They must accurately define the community and involve its members in the project, because health improvement work is most effective when the people who care most strongly about a problem help solve it. Leaders should clearly define the project's aim, perhaps through analyzing hospital records and other databases. In forming a collaborative group to work on the project, leaders should begin with a "core team," perhaps adding other members later. This team should track data using three kinds of measurement--global, intermediate, and process--building data evaluation into its daily practices. The team would do well to get the guidance of someone familiar with Cl methodology. It should also use a process involving regular meetings, time lines, a means of communicating with experts outside the area, and a format that enables it to document progress and capture lessons learned. PMID- 10173537 TI - Collaboration requires special skills. Groups tackle health problems that have social, economic, and cultural aspects. PMID- 10173538 TI - Consensus creates effective programs. "Quick response service" project reveals importance of stakeholders' input. AB - In the Hamilton-Wentworth area of Ontario, Canada, three acute care hospitals and a home care program joined together to try to reduce local senior citizens' admissions to hospitals and visits to emergency rooms. They hoped to achieve this by providing seniors with care in their homes. Realizing that the project would have to employ collaborative decision making, its cosponsors selected participants from both the hospitals (for example, administrators and physicians) and the community (for example, consumers and family physicians). The cosponsors chose cochairpersons from the hospital sector and the community sector. The project was complex because it involved so many stakeholders, but the cochairpersons gave it both its stability and its driving force. Decision making was done through consensus, a process that can be tedious and frustrating, especially when based on systemic evaluation, a process in which a group analyzes a full range of advantages and disadvantages to a course of action. Nevertheless, the cosponsors found the process vital to the project's success. By the end of the project, 342 hospital admissions and 70 emergency room visits had been averted. The cosponsors had discovered that because collaborative decision making can facilitate efficiency and "buy-in," it saves both money and time in the long run. PMID- 10173539 TI - Cosponsorship preserves healthcare ministry. Unification cuts region's excess capacity. PMID- 10173541 TI - Six keys to successful fund-raising. PMID- 10173540 TI - Mentoring mission leaders of the future. Program prepares laity for ministry leadership. AB - As religious sponsors increasingly relinquished their CEO positions throughout the 1980s and early 1990s, they established mission integration positions-staffed primarily by women religious-to help ensure the Catholic identity of their facilities. Now that role, too, is undergoing change as sponsors seek to empower the laity in their organizations with responsibility for carrying on the Church's healing mission. At St. Vincent Hospitals and Health Services in Indianapolis, the Daughters of Charity of St. Vincent de Paul, the organization's sponsor, has developed a mentoring program to train the laity in the roles and responsibilities involved in mission. The year-long program has 11 modules that present theory on such topics as ethics, spirituality, the sponsor's history and charism, and the relationship of the healthcare organization to the Church. Participants also attend committee meetings, complete a mission integration project, and gain practical experience in mission-related activities. PMID- 10173542 TI - An exhortation to sponsors. PMID- 10173543 TI - You got to read 'em to treat 'em. PMID- 10173544 TI - Cultural diversity: essential education. PMID- 10173545 TI - Minimum pediatric equipment lists. PMID- 10173546 TI - Paramedic prep 101. How to gain admission to a paramedic program. PMID- 10173547 TI - Not the S.A.M.E.S. (Specialist in Adult Medical Education and Safety Inc.) old job. PMID- 10173548 TI - Online job hunting goes mainstream. PMID- 10173549 TI - Bill Brown's career advice. PMID- 10173550 TI - From frostbite to bison gorings: EMS in Yellowstone. PMID- 10173551 TI - Slam on the brakes. How EMS providers can prevent motor vehicle injuries. PMID- 10173552 TI - Federal EMS legislation. PMID- 10173553 TI - Why things go clunk in your back. PMID- 10173554 TI - Mommy (and Daddy) medic. PMID- 10173555 TI - How benchmarking can improve your ambulance service. Capture the competitive edge. PMID- 10173556 TI - Balancing on two wheels. How to start a bike medic program. PMID- 10173557 TI - Can't find what you need? Here's help. PMID- 10173558 TI - Watch out. Munchausen patients have found the computer. PMID- 10173559 TI - These young doctors make job-sharing work. PMID- 10173560 TI - Why the FTC gave these doctors a hard time. PMID- 10173561 TI - Do insurers really stand behind preventive care? PMID- 10173562 TI - A hospital's physician group goes under. PMID- 10173563 TI - GM wants to tune up your practice. PMID- 10173564 TI - Three clubs you should join. PMID- 10173565 TI - Cover story, Part I. Are boom times over for primary care? PMID- 10173566 TI - Cover story, Part II. One doctor's life: working harder, making less. PMID- 10173567 TI - Medicare HMOs. Making a hit with the senior set? PMID- 10173568 TI - Managed care. Even lawmakers can't stem the HMO tide. PMID- 10173569 TI - Will Congress buy the economic argument for tort reform? PMID- 10173570 TI - Are you losing money to a silent PPO? PMID- 10173571 TI - How to say no to a managed-care patient. PMID- 10173572 TI - "Integrated medicine" could boost your income. PMID- 10173573 TI - What you should tell patients about alternative medicine. PMID- 10173574 TI - A legal tight spot isn't a hopeless situation. PMID- 10173575 TI - Getting peanuts. PMID- 10173576 TI - Tort reform. How one state's law has discouraged suits against physicians. PMID- 10173577 TI - Professional satisfaction. Despite everything, you enjoy what you do. PMID- 10173578 TI - Managed care is hurting your reputation. PMID- 10173579 TI - 10 mistakes to avoid when you apply to a managed-care plan. PMID- 10173580 TI - Managed care shook this group to its core. Friendly Hills Medical Group. PMID- 10173581 TI - Why you should welcome the new assertive patient. Interview by Wayne J. Guglielmo. PMID- 10173582 TI - National battle erupts over state provider tax. PMID- 10173583 TI - JCAHO and COLA collaboration and CLIA 1997 heading for committees. PMID- 10173584 TI - Is the phlebotomist obsolete? PMID- 10173585 TI - Strategic competency assessment. A plan to minimize extra work in conducting employee reviews. PMID- 10173586 TI - The community-based comprehensive laboratory system. A promising future for anatomic and clinical pathology. PMID- 10173588 TI - AAMC STAT: a brief description. AB - AAMC STAT is a new, weekly electronic newsletter produced by the American Association of Medical Colleges. It provides coverage of national news related to academic medicine. This article briefly reviews the electronic publication and gives directions for subscribing to AAMC STAT. PMID- 10173587 TI - Outreach services: issues and challenges. AB - Tompkins-McCaw Library of Virginia Commonwealth University has planned and implemented four one-year outreach service projects during the past two years. These projects were funded by the National Library of Medicine and the National Network of Libraries of Medicine Southeastern/Atlantic Region. The projects focus on information access for public health nurses, HIV/AIDS information access, and circuit librarian services in rural Southern Virginia. This article documents issues and challenges which have been identified from these projects and suggests ways to resolve them. PMID- 10173589 TI - A trial of three commercial document delivery suppliers with strong holdings in biomedicine. AB - The University of Vermont's Medical Library evaluated the services of three commercial document delivery suppliers with significant holdings in biomedicine. The purpose of the trial was to determine whether journal articles could be procured in less time than routine interlibrary loan without greatly increasing costs. Each supplier offered a quick delivery method employing modern technology at a standard fee. The need to pay copyright royalties at times and a desire to test the possibility of substituting "access" for "collection" also prompted the trial. Results reported include: mean and median delivery times, percentages of requested titles held, and average price per transaction, including copyright fee. The Medical Library continues to use commercial services to augment interlibrary loan. PMID- 10173590 TI - Getting comfortable with STN: search tips. PMID- 10173591 TI - Human genetic databases on the Internet: a webliography. PMID- 10173592 TI - Teaching medical computing skills to internal medicine residents. PMID- 10173593 TI - Consumer health information services in the hospital setting. AB - Before planning for provision of Consumer Health Information Services, the librarian and administration must anticipate the problems encountered in sharing funds, personnel, space, and materials with an existing medical or patient education library. Establishing new space within or outside the hospital, or participating in community projects which meet consumer health information needs, are important considerations for planners. This article sets forth the place of some CHI services in the hospital setting, and how they relate to other library services. Differences between hospital library support for Patient Education and for Consumer Health Information services are discussed. PMID- 10173594 TI - Librarians as liaisons to college curriculum committees. PMID- 10173595 TI - UnCover on the Web: search hints and applications in library environments. AB - Among the huge maze of resources available on the Internet, UnCoverWeb stands out as a valuable tool for medical libraries. This up-to-date, free-access, multidisciplinary database of periodical references is searched through an easy to-learn graphical user interface that is a welcome improvement over the telnet version. This article reviews the basic and advanced search techniques for UnCoverWeb, as well as providing information on the document delivery functions and table of contents alerting service called Reveal. UnCover's currency is evaluated and compared with other current awareness resources. System deficiencies are discussed, with the conclusion that although UnCoverWeb lacks the sophisticated features of many commercial database search services, it is nonetheless a useful addition to the repertoire of information sources available in a library. PMID- 10173596 TI - Horizontal wires replace the vertical files. AB - Traditionally, clippings of newspaper articles, pictures from magazines, pamphlets, charts, graphs, posters, proceedings, or copies thereof, and other miscellaneous information sources have been stored in vertical files in libraries. The practice of creating and maintaining vertical files is extremely time consuming. In a medical library, in particular, old information about diagnosis, treatment, and prognosis can quickly become incorrect, misleading, and possibly harmful. Adequately tending to the vertical files can require a librarian to create a balancing act between properly maintaining vertical files and meeting the needs of the users in other areas of the library. The maintenance of vertical files is, by nature, highly consumptive of paper and space consuming. A reasonable alternative to the traditional vertical files is the World-Wide Web. Search engines exist for locating specific information, and bookmarks and/or links which point users to particularly useful sites can be set in search software. Some methods for searching are discussed, and a variety of World-Wide Web information sources are offered. PMID- 10173597 TI - Journal searching in non-MEDLINE resources on Internet Web sites. AB - Internet access to the medical journal literature is absorbing the attention of all relevant parties, i.e., publishers, journal vendors, librarians, commercial providers, government agencies, and end users. Journal content on the Web sites spans the range from advertising and ordering information for the print version, to table of contents and abstracts, to downloadable full text and graphics of articles. The searching parameters for systems other than MEDLINE also differ extensively with a wide variety of features and resulting retrieval. This discussion reviews a selection of providers of medical information (particularly the journal literature) on the Internet, making a comparison of what is available on Web sites and how it can be searched. PMID- 10173598 TI - MeSH chemical headings and pharmacologic action. PMID- 10173599 TI - Information connection: telehealth, telemedicine, and the virtual health sciences librarian. PMID- 10173600 TI - JCAHO process attacked. Patient death at Las Vegas hospital prompts probes, feeds union's complaints. PMID- 10173601 TI - The AHA seal of approval. Hospital group touts its own brand of product deal. PMID- 10173602 TI - Close, but no cigar. Rural Medicare payment hikes not enough, groups say. PMID- 10173603 TI - AMA-Sunbeam dispute heads to court. PMID- 10173605 TI - Putting it on the books. New HFMA statement offers guidance on healthcare deals. PMID- 10173604 TI - 1997 up and comers. AB - Leadership is both singular and diverse, subtle and bold. It moves others, transcends the obvious and stretches the boundaries of achievement. And it's always passionate about what it does. Being a leader in today's complex, evolving healthcare industry is an especially challenging task. Modern Healthcare salutes this year's "Up & Comers," 13 young executives, all 40 or under, who already have made their marks and will help shape the future of healthcare. PMID- 10173606 TI - Gauging satisfaction. S. Calif. docs beaten by N. Californians in new survey. PMID- 10173607 TI - Great flap in Montana. CON lawsuit latest weapon in Great Falls' turf battle. PMID- 10173608 TI - AMA prepares report. Local chapters seek further investigation into Sunbeam deal. PMID- 10173609 TI - AMA fiasco leaves docs with mixed reactions. PMID- 10173610 TI - VNAA image update. Home-care group restructures amid industry backlash. PMID- 10173611 TI - ProPAC: PPS margin still high. PMID- 10173612 TI - Joining the crowd. Foe of provider networks agrees to sell his Boston hospital. PMID- 10173613 TI - Rolling out the red carpet. AB - Legions of lawyers, consultants and accountants are pulling in the big bucks helping providers stay on the right side of government regulations. Compliance is the trendiest buzzword in healthcare today, and it's creating some lucrative business opportunities. Compliance officers, like Roy Snell (left) of University of Wisconsin Medical Foundation, ride herd to make sure healthcare companies stay within the lines. PMID- 10173614 TI - Columbia hospitals begin name-dropping. PMID- 10173615 TI - Picking their pockets. Insurance a bigger burden for employees at small firms. PMID- 10173616 TI - Staying strong. Hospital-affiliated fitness centers post healthy growth, return on investment. PMID- 10173617 TI - Patient-protection rift. Kaiser group calls for federally enforced HMO standards. PMID- 10173618 TI - Renewed cry for leniency. Not-for-profits ask for different antitrust standards. PMID- 10173619 TI - Ochsner at top in outpatient billing settlements. PMID- 10173620 TI - Phoenix rising. Despite managed-care growth and flat profit margins, area hospitals keep a tight grip on their independence. PMID- 10173621 TI - Daughters loosens reins. Catholic giant takes steps to make partnerships easier. PMID- 10173622 TI - Drawing top dollar. Managed-care skills earning executives premium pay. PMID- 10173623 TI - Making it easier to share. NYU Affiliates uses new network, increasing access to data. PMID- 10173624 TI - Thriving in the Bronx. Cost-control vigilance paying off at St. Barnabas. PMID- 10173625 TI - Church, hospital clash. Court OKs sale of Kansas City's Bethany to Columbia; next up, who gets the money? PMID- 10173626 TI - Speaking from experience. Fraud compliance group's members settled charges. PMID- 10173627 TI - Not-for-profits get new advocate. PMID- 10173628 TI - Challenging Highmark. Physicians in Pa. who opposed Blues merger are likely to get new hearing. PMID- 10173629 TI - Reporting on HMO quality. Plans receive high marks, but performance varies widely. PMID- 10173630 TI - AHA training society to fold. PMID- 10173631 TI - VHA chooses partners. Alliance endorses 3 doc practice software vendors. PMID- 10173632 TI - Rumblings in Nashville. Saint Thomas' moves raise talk of purchase, not merger. PMID- 10173633 TI - Growing pains. Defense Department finds adapting to managed care tougher than expected. PMID- 10173634 TI - What's it worth? Savings in UCSF-Stanford merger vary with auditor. PMID- 10173635 TI - Mutual benefit. Study boosts hospital links with assisted-living firms. PMID- 10173636 TI - The care is getting there. Data show U.S. system is making people healthier. PMID- 10173637 TI - Device battle continues. L.A. case sent back for statute of limitations ruling. PMID- 10173638 TI - Looking for the union label. SEIU launches campaign to boost unionized healthcare. PMID- 10173639 TI - A different game plan. L.A. County votes against privatizing prized rehab facility. PMID- 10173640 TI - Yes, Virginia, there is no gag clause. PMID- 10173642 TI - Whither reform? Kassebaum-Kennedy law may fall short of lofty goals. PMID- 10173641 TI - Virtual success. Pennsylvania network growing without ownership. PMID- 10173643 TI - A criminal's dream. Automated payment systems, designed for honest providers, are easy targets for fraud. PMID- 10173644 TI - Physicians find power in unions. AB - A growing number of physicians are using organized labor to gain economic leverage. Hospital downsizing and autocratic managed-care plans have prompted more doctors to join the ranks of other professionals who carry union cards. While not a sweeping trend, interest in unions is growing--even among private practice physicians who can't bargain collectively because of antitrust laws. PMID- 10173645 TI - New HHS probe ongoing. Feds apply False Claims Act despite industry pleas. PMID- 10173646 TI - Charity vs. profit debate splits Catholic healthcare community. PMID- 10173647 TI - Capitated solution. GAO says VA system may ease regional disparities. PMID- 10173648 TI - Panel readying modest 'patient bill of rights'. PMID- 10173649 TI - Medicare+choice+pay up. Feds force managed-care plans to foot bill for marketing information programs. PMID- 10173650 TI - 1997 Design Awards. AB - One word sums up the winners of this year's healthcare design awards: simplicity. Of the 11 winners in the competition sponsored by Modern Healthcare and the American Institute of Architects' Academy of Architecture for Health, at least half were chosen, in part, because the projects provide simple integration of a complex set of diverse functions. Many winners also were chosen for their simple, noninstitutional interiors. PMID- 10173651 TI - Report card given an 'F'. Groups dispute study critical of managed behavioral care. PMID- 10173652 TI - Closing in on a record. Healthcare bond volume remains robust in third quarter. PMID- 10173653 TI - Digital radiology's leap. Finally, X-ray makers may be ready to go commercial. PMID- 10173654 TI - AMA, HCFA release new documentation guidelines for E&M (evaluation and management) services. PMID- 10173655 TI - The new front desk improves practice revenues. PMID- 10173656 TI - Federal funds supplement assisted living. PMID- 10173657 TI - Assisted living's delicate balance. Operators face new challenges as they offer more nursing care. PMID- 10173658 TI - Wanderer/security supplier survey. PMID- 10173659 TI - Rounding the managed care bend. PMID- 10173660 TI - Ads must pass fair housing standard. PMID- 10173661 TI - A model of affordable assisted living. PMID- 10173662 TI - Mapping out markets. PMID- 10173663 TI - Managing what the doctor ordered. PMID- 10173664 TI - Congress tightens fraud and abuse laws. PMID- 10173665 TI - Psychotherapy gets new Medicare codes. PMID- 10173666 TI - Marking progress through data tracking. AB - In July 1997, Provider ran an overview of the foundation for continuous quality improvement (CQI). The following CQI principles were discussed: listening to customers; focusing on the processes that produce outcomes for customers; and using data to make decisions. The July article covered the first two aspects of CQI. In this article, the third principle, using data to make decisions, will be explored in further detail. PMID- 10173667 TI - Relieving the pain of cancer. PMID- 10173668 TI - Simplifying care plans. PMID- 10173669 TI - Reform bill to speed drugs to residents. PMID- 10173670 TI - Pharmacy giants shake market. PMID- 10173671 TI - Gaining JCAHO pharmacy accreditation. PMID- 10173672 TI - Tracking drug use to improve care. PMID- 10173673 TI - 1997 AHCA Quality Award winners. PMID- 10173674 TI - Wound/skin/continence survey. PMID- 10173675 TI - Independence, security under one roof. PMID- 10173676 TI - "Access with honor". PMID- 10173677 TI - Too closed for comfort. Trustees get a grip on excess capacity. PMID- 10173678 TI - Get yourself a dog: a strategy for avoiding acquisition. PMID- 10173679 TI - Clinical chairmen: new needs, new breeds. PMID- 10173680 TI - How does your CEO spell "relief"? Leadership survey shows how execs are dealing with change. AB - As a health care trustee, you volunteer your time, exhaust yourself trying to keep up with the ins and outs of the industry and do your best to provide an objective sounding board for the chief executive. But your job might make more sense and be a lot more valuable if you could put yourself in your CEO's shoes and understand what gets him up in the morning and keeps him awake at night. And how does that differ among leaders of hospitals, HMOs, and medical group practices? To give you the insights you need, here are the results from a Hospitals & Health Networks leadership survey (see "Who, What, Where, How, When?" page 10). PMID- 10173681 TI - School hunch. Could school-based health care be children's future? AB - Pairing kids--whether they live in rural or urban areas--with health care services is a tricky business. Lack of insurance is only one of the many variables that can prevent kids from getting the care they need. When that care is provided at school, they can get it when they need it, without long waits or fears that their privacy will be violated. PMID- 10173682 TI - Worshipping at the corporate alter. Risks and opportunities. AB - Corporate boards caught napping when bad executive decisions are made have raised controversial issues about governance. But health care trustees can learn some lessons from their corporate cousins--not only from the ones who make mistakes, but from those who take their jobs seriously and govern successfully. PMID- 10173683 TI - Keeping the community's trust during a hospital sale or merger. PMID- 10173684 TI - The internal investigation: when it's the right call. PMID- 10173685 TI - Medical renaissance. PMID- 10173687 TI - Health in the valley. Volunteer program improves lives. PMID- 10173686 TI - Up close and personal. Taking a community plunge puts you in touch with real people, real needs. AB - Taking a "plunge" into the community puts trustees in touch with the real people affected by decisions made in the boardroom. It's an education that goes beyond facts, figures, and policies. Trustees and execs at Memorial Health System in South Bend, Ind., have used this method for several years to put a face on social issues that influence their community's health. PMID- 10173688 TI - Mending a torn life. Or, how to turn a garage into a lifeboat. PMID- 10173689 TI - Setting the pace. Long-term care project holds hope for future programs. PMID- 10173690 TI - Care where it's needed most. Iredell Memorial Hospital brings medical services to public housing. PMID- 10173691 TI - AHA volunteers restructure. PMID- 10173692 TI - Strangers among us. Hospitals reach out to those isolated by language and culture. PMID- 10173693 TI - Getting down to family basics. PMID- 10173694 TI - Defining an episode of care: a study of five case types. AB - This is the first study in Australia to test definitions of various types of 'episodes of care'. The definitions reported here are those used in the 1996 National Sub-Acute and Non-Acute Patient (SNAP) Casemix Classification Study. The study collected data on a total of 683 patients at 10 hospitals and 2 community health services providing a range of rehabilitation, aged care and community care services. The kappa statistic (kappa) was used to determine the significance of the level of agreement between raters. The value of kappa was 0.838 with a 95 per cent confidence interval of 0.801 to 0.975. The results of this study are encouraging and support the use of the five Case Types - Palliative Care, Rehabilitation, Psychogeriatric, Geriatric Evaluation and Management, and Maintenance Care. All five Case Types proved to have good interrater reliability, there was a good fit for most patients, and staff found the definitions easy to use. PMID- 10173695 TI - A literature review of rehabilitative intervention for chronic obstructive pulmonary disease patients. AB - Pulmonary rehabilitation programs contribute to physical and psychological well being and improved quality of life. Pulmonary rehabilitation reduces fear and depression, and increases self-esteem; it improves feelings of well-being and lowers levels of mood disturbance, but does not seem to change lung function and perfusion. Patients with chronic conditions are reported to have problems complying with rehabilitation programs, especially when these programs require lifestyle modification. Community-based programs are therefore attractive for reasons such as addressing the specific needs of the population, cost-benefit and flexibility in delivery. PMID- 10173696 TI - Towards equity in long-term care. AB - There are considerable similarities and overlap in the levels of disability and dependency between those who receive home-based-long-term care and those who receive long-term care on a residential basis. These similarities are demonstrated from analysis of clients of the Western Domiciliary Care and Rehabilitation Service. When services are costed, it is shown that there is a very large discrepancy in the levels of government support that clients of home based care agencies attract compared to residents in subsidised hostels and nursing homes. This paper discusses the need for parity of funding to care providers and recognition of the economic value of the contributions of carers. It considers principles for the development of a casemix model for home-based care analogous to the Care Aggregated Module/Standard Aggregated Module (CAM)/(SAM) model applying to nursing home care. PMID- 10173697 TI - The hospital financing system in Germany. AB - In common with other western coutries, German health expenditure had been increasing at a rapid rate in recent years, especially in the hospital sector. This paper describes the reaction of the German legislator and summarises what has happened over the last few years following the introduction of the extensive Legal Reform Act. The paper puts the main emphasis on a new differentiated benefit system for hospitals, which is a requirement from 1996 onwards, after a transitional period. It shows the single components and the modalities of the new system and the possibilities of combining the new types of payment. PMID- 10173698 TI - Why a traditional health outcomes approach will fail in health care and a possible solution. AB - This paper challenges the assumption that improved knowledge of health outcomes and their causation will lead to more rational decision-making, resulting in improved care at lower costs. The assumption implies that the health system completely controls all those functions, factors and initiatives that can affect the implementation of the standard. These include policies, procedures, applications of techniques, skill mix of staff, inter-team interaction, communication systems, education, and so on. Changes in policy do not automatically mean a change in practice. Implementation is often approached in a manner that is perceived by staff as punitive, focusing on changing the individual rather than the system in which they work. Not only is this approach opposite to basic total quality management principles, but it also fails to acknowledge that most of the improvements arising from the health outcomes approach are a result of staff being prepared to continuously work harder, often ignoring the 'system', to maintain their high standard. However, continuing deterioration in the system in which they work sets the scene for an accident or incident to occur. The answer lies in revisiting the traditional quality assurance cycle and acknowledging that health care has never been able to effectively 'close the feedback loop', that is, the health system is continuously increasing the sophistication of data collection techniques without giving equal consideration to what needs to be done to ensure effective implementation and evaluation. This paper outlines how Campbelltown Health Service directly addressed this issue through its process of achieving international certification to ISO 9002:1994. PMID- 10173699 TI - Problems in counting and paying for multidisciplinary outpatient clinics. AB - Policy-makers have always found it problematic to formulate fair and consistent counting rules for public hospital outpatient activities. In the context of output-based funding, such rules have consequences which can affect patient care. This paper reviews the rationale for organising multidisciplinary clinics and reports on a series of focus groups convened in four Melbourne teaching hospitals to consider funding policy for such clinics. It discusses issues of targeting outpatient services, along with implications for payment policy. It evaluates counting rules in terms of intended and unintended consequences in the context of Victoria's introduction of output-based funding for outpatient services. PMID- 10173700 TI - Increasing general practitioner skills with patients with serious mental illness. AB - This report describes a clinical training program designed to increase general practitioner involvement with a public mental health service. The program involved one half-day clinical session per week and one two-hour formal training seminar per month, over a six-month period. Prior to training, participants demonstrated major clinical and theoretical skill deficits when assessing patients with serious mental illnesses. While specific knowledge of psychiatry increased by the end of the training program, little change in clinical interview skills was evident. Current initiatives to enhance general practitioner involvement in mental health care may be hampered if these skill deficits are not directly addressed in relevant shared care programs. PMID- 10173701 TI - Evaluating health information systems: an assessment of frameworks. AB - The rapid increase in investments for computerised systems is a major concern for all health organisations. Questions about these investments arise as information technology is only one of the areas that are competing for a finite amount of resources. There is also some concern that some of the failures of information technology would have been detected if proper evaluation of information systems were conducted. The state of the art of evaluating information systems shows changes from a very positivist approach to more comprehensive approaches that would incorporate multiple methods. This paper presents an assessment of the techniques and methods for information systems evaluation, followed by an application to a case study in community health to illustrate the value of the contextualist approach to evaluation. The paper argues for the use of longitudinal, contextualist approaches to information systems evaluation if decision-makers seek to improve the situation of information systems in the health industry. PMID- 10173702 TI - Corporate information systems in health organisations. AB - This paper presents an overview of the nature of corporate information systems and their applications in health organisations. It emphasises the importance of financial and human resource information in the creation of a corporate data model. The paper summarises the main features of finance and human resource systems as they are used in health organisations. It looks at a series of case studies carried out in health organisations, which were selected on the basis of their representation of different aspects of service delivery. It also discusses the theoretical and practical perspectives of the systems themselves, their roles in information management, executive and decision support, and in planning and forecasting. PMID- 10173703 TI - Controlling claims expenses through the use of defense counsel guidelines. PMID- 10173704 TI - How to protect your data during managed care contracting. PMID- 10173705 TI - Redesigning risk management. PMID- 10173706 TI - Re-engineering the ICU using TQM principles. PMID- 10173707 TI - Perspectives. End-of-life movement targets care shortcomings. PMID- 10173708 TI - Marketplace. How the stock market fall hits health care firms. PMID- 10173709 TI - Making the grade: a status report on hospital report cards. AB - Hospital report cards that document patients' medical outcomes are attracting increasing attention for their role in guiding health care decisions by employers, consumers and providers. Significant questions remain, however, regarding the validity and utility of this information. This Issue Brief is based on a seminar held by the Center for Studying Health System Change at which two expert panels discussed whether report cards make the grade. The first panel approached this subject through a Socratic dialogue that focused on the release of a hypothetical community hospital report card. The second panel weighed in on two research presentations related to report cards. The panelists agreed that efforts to collect and report clinical outcomes data are flawed. Even so, release of the data can help improve clinical quality and foster an environment in which health care quality information ultimately has an impact on health care decision making. PMID- 10173710 TI - David and Goliath make a deal. PMID- 10173711 TI - New directions; new visions. Interview by Craig Havighurst. PMID- 10173712 TI - That pioneer spirit: implementing clinical episodes of care in an imperfect world. AB - Managing care in integrated settings requires new frames of reference for assessing the cost and quality of care delivered. One approach, tracking episodes of care, has been discussed for decades, but it's been stymied by insufficient data. Now, the authors argue, the time has come for providers to develop episode based protocols and outcomes measures that compensate for data liabilities. PMID- 10173713 TI - Riding the waiver. California carves a path for provider-sponsored organizations. PMID- 10173714 TI - And a doctor shall lead them.... AB - With managed care reshaping every aspect of health care, physicians need to assume leadership roles more than ever before. This requires skills they don't teach in medical school. PMID- 10173715 TI - Cases closed. Glucksberg and Vacco explained. PMID- 10173716 TI - Care for the dying: a state of the union report. PMID- 10173717 TI - Rediscovering where our loyalties lie. PMID- 10173718 TI - The ties that bind. PMID- 10173719 TI - Data ... the physician practices they so eagerly acquire generally lose money. PMID- 10173720 TI - Unsolved mysteries of the budget. PMID- 10173721 TI - Taking safety to a new level. PMID- 10173722 TI - Getting out. An NFPA fire investigation re-ignites Life Safety Code discussions about protecting people in board-and-care homes in the United States and Canada. PMID- 10173723 TI - 1996 U.S. fire loss. PMID- 10173724 TI - Practice brief. Issue: Patient anonymity. American Health Information Management Association. PMID- 10173725 TI - Taking the lead in a changing world. PMID- 10173726 TI - Secretary of HHS releases recommendations regarding confidentiality of individually identifiable information. PMID- 10173727 TI - Career management: a continuing path. PMID- 10173728 TI - Professional development: designing a road map to 2006. PMID- 10173729 TI - Enhancing your career through self-assessment. PMID- 10173730 TI - The full circle: using 360-degree evaluations. PMID- 10173731 TI - Developing and improving project management skills. PMID- 10173732 TI - Revisions to the Joint Commission on Accreditation of Healthcare Organizations' IM Standards. PMID- 10173733 TI - Future of reimbursement for post-acute care--will prospective payment become a reality? PMID- 10173734 TI - ICD-9-CM revisions (effective 10/1/97). PMID- 10173735 TI - Perspectives: how to stay on top of your career. Interview by Sue Telingator. PMID- 10173736 TI - Career trends in health information management: a look toward 2006, Part II. PMID- 10173737 TI - 1940-1984: two lifetimes of medical adventure. PMID- 10173738 TI - The graying of America: major Social Security and Medicare battles are just beginning. PMID- 10173739 TI - The Balanced Budget Act of 1997. PMID- 10173740 TI - The role of the home health nurse. PMID- 10173741 TI - The technology and tactics of physician integration. PMID- 10173742 TI - The pharmacist and clinical intervention. PMID- 10173743 TI - Identifying nursing roles, responsibilities, and practices in telehealth/telemedicine. AB - The intent of this study was to describe the roles, responsibilities, and practices of telehealth/telemedicine nurses and to identify and validate that nurses are working in telemedicine. This brief report about nurses employed in telehealth/telemedicine proves that nurses are actively involved in the delivery of health care via telemedicine. Broad roles, responsibilities, and practices of telemedicine nurses were identified and a baseline was established for future research in telenursing. As health care continues its transformation through technology into the next century, telemedicine will continue to affect nurses. Whether these effects will create more collaborative or autonomous roles is yet to be determined. PMID- 10173744 TI - The changing role of the caregiver. PMID- 10173745 TI - Improving health care through clinical documentation. PMID- 10173746 TI - Trends and changing roles in emergency medicine. PMID- 10173747 TI - The changing role of the primary care practitioner: clinical enterprise management and information technology. AB - The Steeplechase Family Physicians Clinic, and Dr. Tom Landholt in particular, represent a prototype for enterprise primary care practice. The role transition heavily relies on the EMR and other technology as tools in addition to general management principles, processes, and tools that span the functions and staff of Steeplechase. He adapted principles that drive service delivery across industries to create the clinician enterprise manager role and life style. The role comprises a paradigm shift in primary care practice delivery and associated professional training which indicates potential for clinicians adapting to and adoption of enterprise health care delivery. PMID- 10173748 TI - The continuum concept comes of age. AB - The ideal of integrating long-term care with acute, community-based services and home care can be best realized by adopting a new paradigm of aging and a vision of integrated networks that focus on wellness, prevention, geriatric education and research, and integrated care delivery systems. The continuum of care concept should no longer be seen as provider offering an array of services. Rather, the continuum should be viewed as a lifetime care plan for each individual, prepared and managed by a primary care physician and a team of health caregivers appropriate to the individual's ever-changing health care needs and desires. Long term care organizations are challenged to accept this new paradigm and vision by integrating themselves with other health care organizations and developing information systems that support integration and improved care outcomes. PMID- 10173749 TI - An information infrastructure for long-term care. AB - Emerging trends promise to alter the way long-term care is practiced. These include: changing regulation of the nursing home industry with emphasis on outcome and assessment, a trend in medical informatics away from expert systems and toward on-line decision support and reminder systems, and the application of industrial statistical quality management techniques to the realm of human services. Emerging standards such as the Arden Syntax and Unified Medical Language Systems and technologies such as Rapid Application Development Tools will facilitate the use of modern computing to mold and implement these converging trends. PMID- 10173750 TI - Development of a pilot quality assessment tool for long-term care facilities. AB - Recently the demand to provide exceptional health care services has become of paramount importance. Facilities are competing with each other to provide to the public data which illustrates why one facility is superior to another. One area that has become important is demonstrating the performance of quality of care. The problem with proving the quality of services provided arises from the fact that defining quality as a single entity is difficult. Realizing this factor has created the need to define and measure quality of care in concrete ways. The intent of this research was to facilitate a technique to measure quality of care in long-term care facilities (LTCFs). This research resulted in the development of a pilot quality assessment tool to measure areas of care in LTCFs. PMID- 10173751 TI - Quality variables for documentation in long-term care. AB - Documentation in long-term care clinical records continues to pose many challenges as the industry adjusts to a period of significant change. This article will look at some of the forces impacting documentation resulting from the first major federal rewrite in 15 years for long-term care facilities participating in Medicare and Medicaid. A short synopsis of the federal regulatory environment that reshaped the core content of the long-term care clinical record will be presented, as well as a discussion of related medicolegal issues, information technology issues, and similar topics affecting long-term care will have a better understanding of the multifaceted forces impacting documentation in the clinical record and thus recognize the importance of documentation as a key quality improvement opportunity for long-term care facilities. PMID- 10173752 TI - Geriatric assessment, coordinated case management, and information systems: an integrated model for delivery of services to nursing home residents. AB - Several interventions have been developed to minimize the effects of a fragmented health care system and improve services to older adults in long-term care settings. In the context of scarce specialized resources and expertise, this article describes Comprehensive Geriatric Assessment, Minimum Data Set, and Resident Assessment Protocols, the integration of which offers promise for effective evaluation and case management. The model's significance and potential benefits for targeting services to residents at risk for adverse outcomes are explored as components of an integrated information system for enhancing the care of nursing home residents. PMID- 10173754 TI - Ethics and long-term care: some reflections on information management. AB - The ethical questions created by rapidly changing long-term care systems are demanding a much more intimate involvement of the information management professional. No longer is confidentiality one of the prime considerations. The ethical principles of justice, autonomy, dignity of person, beneficence, truth telling, and utility are becoming a daily part of the information task in long term care. The informal character of the long-term care facility requires a larger role for the information specialist. The result is that the information management role is being greatly expanded into the arena of ethical oversight of the information stream in long-term care facilities. PMID- 10173755 TI - The changing flow of management information systems in long-term care facilities. AB - Over the past three decades, the long-term care community has seen continual increases in the complexity and sophistication of management information systems. These changes have been brought about by the ever-increasing demands on owners and managers to provide accurate and timely data to both regulators and financial investors. The evolution of these systems has increased rapidly in recent years as the nation attempts to reinvent the funding mechanisms for long-term care. PMID- 10173753 TI - Consortium to establish a registry for Alzheimer's disease: development, database structure, and selected findings. AB - The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) was funded in 1986 by the National Institute on Aging to develop standardized assessments for patients with Alzheimer's disease (AD). Since that time, CERAD has developed and evaluated clinical and neuropsychological test batteries, a neuroimaging protocol, and an assessment of the neuropathological findings of the brains of these patients at autopsy. Approximately 1,200 carefully screened patients with AD and 450 control subjects were evaluated using these instruments at 24 major medical centers around the United States. Annual follow-up observations of these subjects were made for up to eight years. Autopsy examinations of the brain were done in over half of the deceased cases and the clinical diagnosis of AD was confirmed in 85 percent of them. This article outlines the procedures used for identifying the clinical sites, the entry and annual evaluations of patients and control subjects, the collection and analysis of data at a central Methodology and Data Management Center, and evaluation of the CERAD measures. We also present selected data from the 50 or so peer-reviewed papers published to date, with particular emphasis on findings from African-American patients with AD, and related policy implications. PMID- 10173756 TI - A survey of nursing home administrators' and ombudsmen's perceptions of elderly abuse in Pennsylvania. AB - The topic of elder abuse has been a source of growing concern and research over the past decade. Nationally, it is believed that about four percent of our elders (people over 60 years of age) are abused, even though every state currently has laws protecting abuse of elders. Therefore, health care professionals and the general public should be educated in order to ensure detection and reporting of elder abuse so that the victims receive appropriate care and protection. To the authors' knowledge, little or no published research has been done to assess the perceptions of nursing home administrators (NHAs) and ombudsmen with respect to elder abuse. This study explored Pennsylvania NHAs' and ombudsmen's knowledge of detecting, reporting, and managing elder abuse cases. Also, data were collected regarding the perceptions of Pennsylvania NHAs and ombudsmen about the knowledge of their nursing facility personnel in the areas of detection, legislation, and regulation of elder abuse. PMID- 10173757 TI - Establishing need for and designing information systems supporting decentralized services for the elderly: the case of Allegheny County, Pennsylvania. AB - Leaders of senior social services in Allegheny County, Pennsylvania, have reevaluated home-delivered meals (HDM) for the elderly in light of demographic and economic changes. A recommendation was the establishment of an integrated information system aiding policy and provider-level users in coordinating and planning numerous services, including HDM. The first step is the establishment of computerized geographic information and decision support systems. Further integration of a unified client database would enhance the capabilities of this information system in coordinating services for seniors. These possibilities, along with value-based and administrative challenges to constructing a countywide information system, are discussed. PMID- 10173758 TI - The "hospitalist"--a rapidly growing role for delivering inpatient care--comes in several configurations. PMID- 10173760 TI - A heart and a kidney. PMID- 10173759 TI - Disappointed by reengineering alone, Rush-Copley fast-tracks performance improvement efforts. PMID- 10173761 TI - What's up, doc? It's every surgery patient's nightmare: you're awake enough to feel the knife but not enough to scream. PMID- 10173762 TI - Use of restraints in air medical transport: a survey. AB - Although the practice of restraining combative patients is commonplace, restraint has been neither uniform nor scrutinized in the air medical transport environment. The objective of this study was to identify and characterize the use of physical and chemical restraining methods in air medical and critical care transport settings. A retrospective study was performed through faxed questionnaires to 92 medical directors who were members of the Air Medical Physician Association (AMFA). Neither program size nor program type correlated with the use of a particular restraint method. Cloth, including gauze, was the most common physical restraint (73%); both benzodiazepines and paralytics were the most common chemical restraints (53%). Injury to crew members was not widespread. This study of air transport services reported a lower incidence of injury to personnel (17%) than is reported in studies from emergency departments (EDs) (60%). This study also indicated that air transport services possess protocols governing actions toward violent patients (65%) more often than has been reported in studies on EDs (50%). Protocols varied in nature and extent. Consensus protocols should be established and implemented with the aid of detailed data acquisition to standardize personnel education in managing violent patients. PMID- 10173763 TI - Air medical transfers: are you COBRA compliant? PMID- 10173764 TI - Basics of research (Part 10): The grant application process. PMID- 10173765 TI - Data watch. The smoke clears on the real costs of cigarettes. PMID- 10173766 TI - What cigarettes do to American business. PMID- 10173767 TI - Quality in nursing home care: whose responsibility? PMID- 10173768 TI - Outcome measures for routine use in dementia services: some practical considerations. AB - OBJECTIVES: To work with specialist community teams to assess the practicality and acceptability of identified outcome measures for routine use in dementia services. SETTING: Seven specialist dementia services: four multidisciplinary teams, a specialist service for carers, a community psychiatric nurse team, and a day hospital. SUBJECTS: 20 members of staff from the specialist dementia services including psychiatry, community psychiatric nursing, social work, occupational therapy, Admiral nursing, ward management, geriatric nursing. MAIN MEASURE: A questionnaire designed to assess staff views on the use of six outcome measures in routine practice in terms of practicality, relevance, acceptability, and use in improving care. RESULTS: Each of the outcome measures took 15 to 30 minutes to administer. All were rated as easy to use and as relevant to dementia services and to carers. Staff commented that the measures could be useful in routine practice for structured assessment and service evaluation, but highlighted the need for sensitive use of measures with carers. CONCLUSIONS: These measures consider the main domains of functioning for people with dementia and their carers. The measures are suitable for use in routine practice in dementia services and are acceptable to staff and carers. The project underlined the need for management support, staff ownership of measures, and training in using outcome measures. Staff concerns about service evaluation need to be acknowledged. PMID- 10173769 TI - Longer term quality of life and outcome in stroke patients: is the Barthel index alone an adequate measure of outcome? AB - OBJECTIVES: To consider whether the Barthel Index alone provides sufficient information about the long term outcome of stroke. DESIGN: Cross sectional follow up study with a structured interview questionnaire and measures of impairment, disability, handicap, and general health. The scales used were the hospital anxiety and depression scale, mini mental state examination, Barthel index, modified Rankin scale, London handicap scale, Frenchay activities index, SF36, Nottingham health profile, life satisfaction index, and the caregiver strain index. SETTING: South east London. SUBJECTS: People, and their identified carers, resident in south east London in 1989-90 when they had their first in a life-time stroke aged under 75 years. INTERVENTIONS: Observational study. MAIN OUTCOME MEASURES: Comparison and correlation of the individual Barthel index scores with the scores on other outcome measures. RESULTS: One hundred and twenty three (42%) people were known to be alive, of whom 106 (86%) were interviewed. The median age was 71 years (range 34-79). The mean interval between the stroke and follow up was 4.9 years. The rank correlation coefficients between the Barthel and the different dimensions of the SF36 ranged from r = 0.217 (with the role emotional dimension) to r = 0.810 (with the physical functioning dimension); with the Nottingham health profile the range was r = -0.189 (with the sleep dimension, NS) to r = -0.840 (with the physical mobility dimension); with the hospital and anxiety scale depression component the coefficient was r = -0.563, with the life satisfaction index r = 0.361, with the London handicap scale r = 0.726 and with the Frenchay activities index r = 0.826. CONCLUSIONS: The place of the Barthel index as the standard outcome measure for populations of stroke patients is still justified for long term follow up, and may be a proxy for different outcome measures intended for the assessment of other domains. PMID- 10173770 TI - Risks and benefits of coronary angioplasty: the patients perspective: a preliminary study. AB - OBJECTIVES: To describe what cardiac patients in Northern Ireland understand to be the benefits of coronary angioplasty and assess the extent to which they have been able to make informed choices about their treatment. DESIGN: An interview based questionnaire survey completed after the patients had undergone coronary angiography, within hours of treatment counselling. SUBJECTS: 150 patients consecutively recruited from two regional cardiology centres in Belfast, Northern Ireland. MAIN OUTCOME MEASURES: The perceived complication rate and the perceived gain in life expectancy from coronary angioplasty. RESULTS: Although most subjects had asked the consultant questions, 70% (n = 104) thought that they contributed negligibly or not at all to the treatment decision. Although 75% (n = 112) recalled discussing the complication rate from the procedure, only 27% accurately estimated this rate (as between 0.5 and 1.5%). Eighty eight per cent (n = 131) thought that their mortality risks would be substantially or greatly reduced by having the procedure. The patients anticipated a gain in life expectancy of some 10 years (median) and this was significantly in excess of the potential gain in life expectancy which dietary prudence to lower blood cholesterol, not smoking, and taking more exercise might produce (median 5 years respectively; P < 0.0001, Wilcoxon matched pairs signed rank test). CONCLUSIONS: Patients vastly overrate the capacity of angioplasty to control their disease: angioplasty is seen as more effective than risk factor modification. PMID- 10173771 TI - Satisfaction with telephone advice from an accident and emergency department: identifying areas for service improvement. AB - OBJECTIVES: Members of the public often telephone general practice, accident and emergency departments, and other health services for advice. However, satisfaction related to telephone consultation has received relatively little attention. This study aimed to describe the views of callers to an accident and emergency department who expressed any element of dissatisfaction about their telephone consultation. This was part of a larger study intended to help identify areas for service improvement. METHODS: A telephone consultation record form was used to document details of advice calls made to the accident and emergency department over a three month period. Callers who provided a telephone number were followed up within 72 hours. The interviews were tape recorded, transcribed, and explored using content analysis for emerging themes related to dissatisfaction. RESULTS: 203 callers were contacted within 72 hours of their call, of which 197 (97%) agreed to participate. 11 (5.6%) expressed global dissatisfaction, and a further 34 (17%) callers expressed at least one element of dissatisfaction at some point during the interview. Sources of dissatisfaction fell into four broad categories, each of which included more specific aspects of dissatisfaction: 36 (80%) callers were dissatisfied with advice issues, 31 (69%) with process aspects, such as the interpersonal skills of the staff member who took the call, 23 (51%) due to lack of acknowledgement of physical or emotional needs, and 11 (24%) due to access problems. CONCLUSIONS: This study supports the findings of other work and identifies three issues for particular consideration in improving the practice of telephone consultation: (a) training of health professionals at both undergraduate and specialist levels should cover telephone communication skills, (b) specific attention needs to be given to ensuring that the information and advice given over the phone is reliable and consistent, and (c) organisational change is required, including the introduction of departmental policies for telephone advice which should become the subject of regular audit. PMID- 10173773 TI - Introducing quality assurance into long-term care for elderly people: a difficult and worthwhile process? PMID- 10173772 TI - Alzheimer's disease in the United Kingdom: developing patient and carer support strategies to encourage care in the community. AB - Alzheimer's disease is a growing challenge for care providers and purchasers. With the shift away from the provision of long term institutional care in most developed countries, there is a growing tendency for patients with Alzheimer's disease to be cared for at home. In the United Kingdom, this change of direction contrasts with the policies of the 1980s and 90s which focused more attention on controlling costs than on assessment of the needs of the patient and carer and patient management. In recent years, the resources available for management of Alzheimer's disease have focused on institutional care, coupled with drug treatment to control difficult behaviour as the disease progresses. For these reasons, the current system has led to crisis management rather than preventive support--that is, long term care for a few rather than assistance in the home before the crises occur and institutional care is needed. Despite recent innovations in the care of patients with Alzheimer's disease, the nature of the support that patients and carers receive is poorly defined and sometimes inadequate. As a result of the shift towards care in the community, the informal carer occupies an increasingly central role in the care of these patients and the issue of how the best quality of care may be defined and delivered is an issue which is now ripe for review. The objective of this paper is to redefine the type of support that patients and carers should receive so that the disease can be managed more effectively in the community. The needs of patients with Alzheimer's disease and their carers are many and this should be taken into account in defining the quality and structure of healthcare support. This paper shows how new initiatives, combined with recently available symptomatic drug treatment, can allow patients with Alzheimer's disease to be maintained at home for longer. This will have the dual impact of raising the quality of care for patients and improving the quality of life for their carers. Moreover, maintaining patients in a home environment will tend to limit public and private expenditure on institutional care due to a possible delay in the need for it. PMID- 10173774 TI - Improving the quality of long-term care for older people: lessons from the CARE (continuous assessment review and evaluation) scheme. PMID- 10173775 TI - Strategies to improve the quality of oral health care for frail and dependent older people. AB - The dental profile of the population of most industrialised countries is changing. For the first time in at least a century most elderly people in the United Kingdom will soon have some of their own natural teeth. This could be beneficial for the frail and dependent elderly, as natural teeth are associated with greater dietary freedom of choice and good nutrition. There may also be problems including high levels of dental disease associated with poor hygiene and diet. New data from a national oral health survey in Great Britain is presented. The few dentate elderly people in institutions at the moment have poor hygiene and high levels of dental decay. If these problems persist as dentate younger generations get older, the burden of care will be substantial. Many dental problems in elderly people are preventable or would benefit from early intervention. Strategies to approach these problems are presented. PMID- 10173777 TI - Medicare on life support: will it survive? AB - This Issue Brief discusses Medicare reform. The Balanced Budget Act of 1997 reduces spending in the Medicare program by $115 billion between 1998 and 2002. Most of the reduction in spending comes from reducing payments to providers, and most of the savings (36 percent) occur in 2002. By 2007, the Part A trust fund is expected to be insolvent, four years before the baby-boom generation reaches the current Medicare eligibility age of 65. Congress is likely to revisit Medicare reform in the near future. A number of reforms received a significant amount of attention during the Medicare reform debate, but were not included in the final legislation. The Senate-passed legislation would have increased the Medicare eligibility age from 65 to 67, imposed means testing on Medicare Part B, and imposed a Part B home health copayment of $5. While these provisions were not included in the Balanced Budget Act of 1997, they may be the focal point of future Medicare reform. Many changes to the Medicare program are likely to significantly affect employment-based health plans for both active and retired workers. Raising the Medicare eligibility age would undoubtedly affect both workers and retirees. Unless workers are willing to work until age 67, their likelihood of becoming uninsured would increase. In 1995, 15.8 percent of retirees ages 55-64 were uninsured, compared with 11.5 percent of workers in the same age group. Early retirees might also find themselves unable to afford health insurance in the private market. An Employee Benefit Research Institute/Gallup poll indicates a direct link between the availability of retiree health benefits and a worker's decision to retire early. In 1993, 61 percent of workers reported that they would not retire before becoming eligible for Medicare if their employer did not provide retiree health benefits. If workers responded to an increase in the retirement age by working longer, employment-based health plans would probably experience an increase in costs, because older workers are the most costly to cover. Some employers might respond to an increase in the Medicare eligibility age by dropping coverage altogether. The message for future beneficiaries is becoming very clear: expect less from Medicare at later ages and higher premiums. As was true prior to the enactment of Medicare in 1965, workers will increasingly need to include retiree health insurance as an expected expense as they plan and save for retirement. PMID- 10173778 TI - 21st century imaging for hospitals and health care systems of the future. AB - Medical technology is not only rapid, it is constantly changing. Architecture, however, is a slower and more deliberate process. This document discusses the awareness and understanding needed of the two fields for anyone involved in health care architecture. PMID- 10173776 TI - Effective management of obesity. PMID- 10173779 TI - Medical facility life cycle investment strategy. AB - This document discusses a health care investment strategy developed by the military. It is based from a survey conducted of both private and military facilities. The document provides techniques to help determine a medical facility's life cycle cost. PMID- 10173780 TI - Organizational performance improvement through the development of a team-based facilities group. AB - The support services division at Pennsylvania Hospital in Philadelphia developed and implemented a service concept to improve organizational effectiveness and service. The design of the new concept has five major elements: implementation of a team-based organization, establishment of individual performance criteria or standards, development of performance goals and objectives for the teams, individual staff development and a recognition program. This document discusses the elements of team design and implementation, stages of growth and the role that the other four components (performance standards, goals, staff development and recognition) play in achieving improved organizational performances. This case study is intended to show general management techniques that can be adopted into a facility's management plan. PMID- 10173781 TI - Lighting test partnership: Southern California/Kaiser Permanente lighting study. AB - Energy-reduction conservation efforts are in the interest of any well-run health care facility. Energy-efficient lighting and lighting systems can deliver significant energy savings while maintaining optimum lighting levels. This document is a result of a lighting study conducted by Southern California Edison's Customer Solution's Group and Kaiser Permanente to help resolve some issues relating to future lighting projects. In particular, specular reflectors as an issue was addressed. PMID- 10173782 TI - A new day for ... data. Georgia hospitals meet challenge of state's new data reporting law. PMID- 10173783 TI - "Operation Restore Trust" comes to Georgia. PMID- 10173784 TI - Validating a statewide data collection: differences in information technology resources between hospitals. AB - The Victorian Perinatal Data Collection Unit (VPDCU) is a statewide data collection established to collect information on the health of mothers and their babies. A Perinatal Morbidity Statistics Form is required to be completed for every birth, then forwarded to the VPDCU. Many medical record departments are responsible for both forwarding the forms to the VPDCU and responding to queries on data accuracy. In 1996 we undertook to determine if we were receiving a perinatal form for every birth occurring at every hospital in the State with obstetric beds. Health information managers were requested to supply a listing of all babies born at their hospitals in 1995-129 hospitals responded. Overall 62,759 births were validated. The VPDCU had received a perinatal form for 99.6 per cent of these births, with 251 missing forms. Reasons why the VPDCU had not received the forms were investigated. PMID- 10173785 TI - A new continuous quality improvement model for the coding process. AB - The following paper describes the development and evaluation of a Continuous Quality Improvement Model (CQIM) applied to the coding process of a public metropolitan teaching hospital. The evaluation was carried out by measuring changes to the accuracy, timeliness and quantity of the outputs of the coding process before and after the CQIM was implemented. For all three indicators of quality and productivity, improvements were observed after the CQIM was implemented. Continuous Quality Improvement methods are one strategy which health information managers can use to improve the quality of the coding process to support the provision of accurate coded data in a timely manner. PMID- 10173786 TI - An evaluation of the Postgraduate Diploma of Applied Science in Health Information Management. AB - Thirty-six students have graduated with a Graduate Diploma of Applied Science (Health Information Management) from the University of Sydney since the course was introduced in 1992. A survey of graduates was conducted to examine the extent to which they believed the course had provided them with sufficient knowledge and skills to become effective health information management practitioners. Options for changes to the course were also explored in the questionnaire. The results demonstrated that graduates strongly supported the existing curriculum. Increased opportunities for practical experience were suggested by many respondents. There was not strong support for an option to increase the length of the course. However, the option to commence study in January and undertake some classes in the inter-semester break was viewed positively by 68% of the graduates. PMID- 10173788 TI - Trendstar at Flinders Medical Centre. AB - Trendstar provides Flinders Medical Centre with a reliable management tool that facilitates appropriate resource allocation and ensures that those resources are utilised efficiently. The system supports our aim to provide high quality, cost effective care for our clients. PMID- 10173787 TI - Establishing electronic patient record standards using paper-based record functions and standards. AB - The South Australian Health Commission has embarked on a long term project to establish an Electronic Patient Record (EPR) for South Australia. The process requires extensive evaluation at the conclusion of each phase of development using a range of existing and purpose-developed evaluation tools. This paper describes a purpose-developed evaluation tool that uses the functional aspects of, and existing standards for, paper-based medical records in hospitals as its basis. The resulting EPR Standards are a tool which can be used to establish a benchmark against which to evaluate the efficiency and effectiveness of an electronic patient record. PMID- 10173789 TI - Senate committee inquiry into access to medical records. PMID- 10173790 TI - Recruitment and retention--a "top end" experience. PMID- 10173791 TI - Health care programs: fraud and abuse; revised OIG exclusion authorities resulting from Public Law 104-191--HHS. Notice of proposed rulemaking. AB - This rulemaking addresses proposed revisions to the OIG's sanction authorities in conjunction with sections 211, 212 and 213 of the Health Insurance Portability and Accountability Act of 1996, along with other technical and conforming changes to the OIG exclusion authorities set forth in 42 CFR parts 1000, 1001, 1002 and 1005. These proposed revisions are specifically designed to expand the protection of certain basic fraud authorities, and revise and strengthen the current legal authorities pertaining to exclusions from the Medicare and State health care programs. PMID- 10173792 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1998 rates--HCFA. Correction. PMID- 10173793 TI - Claims procedures for employee benefit plans--Pension and Welfare Benefits Administration, Department of Labor. Request for information. AB - This document requests information from the public concerning the advisability of amending the existing regulation under the Employee Retirement Income Security Act of 1974 (ERISA) that establishes minimum requirements for employee benefit plan claims procedures. The term "claims procedure" refers to the process that employee benefit plans must provide for participants and beneficiaries who seek to obtain pension or welfare plan benefits, including requests for medical treatment or services, consideration of claims, and review of denials of claims by plans. The primary purpose of this notice is to obtain information to assist the Department of Labor (the Department) in evaluating (1) the extent to which the current claims procedure regulation assures that group health plan participants and beneficiaries are provided with effective and timely means to file and resolve claims for health care benefits, and (1) whether and in what way the existing minimum requirements should be amended with respect to group health plans covered by ERISA. The furnished information also will assist the Department in determining whether the regulation should be amended with respect to pension plans covered by ERISA and in developing legislative proposals to address any identified deficiencies relating to the claims procedures that cannot be addressed by amending the current regulation. PMID- 10173794 TI - Draft guideline for infection control in health care personnel, 1997--CDC. Notice. AB - This notice is a request for review of and comment on the Draft Guideline for Infection Control in Health Care Personnel, 1997. The guideline consists of two parts: Part 1. "Infection Control Issues for Health Care Personnel, an Overview" and Part 2. "Recommendations for Prevention of Infections in Health Care Personnel", and was prepared by the Hospital Infection Control Practices Advisory Committee (HICPAC), the National Center for Infectious Diseases (NCID), the National Immunizations Program, and the National Institute of Occupational Safety and Health (NIOSH), CDC. PMID- 10173795 TI - Proposed information collection; Indian Health Service, community health representative activity reporting sample--IHS. PMID- 10173796 TI - Medicaid program; coverage of personal care services--HCFA. Final rule. AB - This final rule specifies the revised requirements for Medicaid coverage of personal care services furnished in a home or other location as an optional benefit, effective for services furnished on or after October 1, 1994. In particular, this final rule specifies that personal care services may be furnished in a home or other location by any individual who is qualified to do so. This rule conforms the Medicaid regulations to the provisions of section 13601(a)(5) of the Omnibus Budget Reconciliation Act of 1993, which added section 1905(a)(24) to the Social Security Act. Additionally, we are making two minor changes to the Medicaid regulations concerning home health services. PMID- 10173797 TI - Medicaid program: final limitations on aggregate payments to disproportionate share hospitals: federal fiscal year 1997--HCFA. Notice. AB - This notice announces the final Federal fiscal year (FFY) 1997 national target and individual State allotments for Medicaid payment adjustments made to hospitals that serve a disproportionate number of Medicaid recipients and low income patients with special needs. We are publishing this notice in accordance with the provisions of section 1923 (f)(1)(C) of the Social Security Act and implementing regulations at 42 CFR 447.297 through 447.299. The final FFY 1997 State disproportionate share hospital (DSH) allotments published in this notice supersede the preliminary FFY 1997 DSH allotments that were published in the Federal Register on January 31, 1997. PMID- 10173798 TI - Agency information collection activities: proposed collection: comment request- HRSA. PMID- 10173799 TI - Standards of performance for new stationary sources and emission guidelines for existing sources: hospital/medical/infectious waste incinerators--EPA. Final rule. AB - This action promulgates new source performance standards (NSPS or standards) and emission guidelines (EG or guidelines) to reduce air emissions from hospital/medical/infectious waste incinerator(s) (HMIWI) by adding subpart Ec, standards of performance for new HMIWI, and subpart Ce, emission guidelines for existing HMIWI, to 40 CFR part 60. The standards and guidelines implement sections 111 and 129 of the Clean Air Act (CAA) as amended in 1990. The standards and guidelines apply to units whose primary purpose is the combustion of hospital waste and/or medical/infectious waste. Sources are required to achieve emission levels reflecting the maximum degree of reduction in emissions of air pollutants that the Administrator has determined is achievable, taking into consideration the cost of achieving such emission reduction, any nonair-quality health and environmental impacts, and energy requirements. The promulgated standards and guidelines establish emission limits for particulate matter (PM), opacity, sulfur dioxide (SO2), hydrogen chloride (HCl), oxides of nitrogen (NOx), carbon monoxide (CO), lead (Pb), cadmium (Cd), mercury (Hg), dioxins and dibenzofurans (dioxins/ furans), and fugitive ash emissions. Some of the pollutants being regulated are considered to be carcinogens and at sufficient concentrations can cause toxic effects following exposure. The standards and guidelines also establish requirements for HMIWI operator training/qualification, waste management plans, and testing/monitoring of pollutants and operating parameters. Additionally, the guidelines for existing HMIWI contain equipment inspection requirements and the standards for new HMIWI include sitting requirements. PMID- 10173800 TI - Medicare program; solvency standards for provider-sponsored organizations; intent to form negotiated rulemaking committee--HCFA. Intent to form negotiated rulemaking committee and notice of meetings. AB - The Balanced Budget Act of 1997 requires the Secretary to establish a Negotiated Rulemaking Committee under the Federal Advisory Committee Act (FACA). The Committee's purpose will be to negotiate the solvency standards for provider sponsored organizations under part C of the Medicare program. The Committee will consist of representatives of interests that are likely to be significantly affected by the solvency rule. The Committee will be assisted by a neutral facilitator. We request public comment on whether--We have identified the key solvency issues to be negotiated by the Committee; We have identified the interests that will be affected by key issues listed below; The party we are proposing to serve as the neutral facilitator is acceptable. Additionally, comments are sought on several key definitions related to the negotiated rulemaking and the forthcoming rulemaking for Medicare+Choice organizations. PMID- 10173801 TI - Revised precautionary measures to reduce the possible transmission of Creutzfeldt Jakob disease (CJD) by blood and blood products; guidance document; availability- FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing the availability of a guidance document entitled "Revised Precautionary Measures to Reduce the Possible Transmission of Creutzfeldt-Jakob Disease (CJD) by Blood and Blood Products," dated December 11, 1996. The guidance document is intended to provide recommendations to the blood industry and may include information useful to other interested persons. PMID- 10173802 TI - Interim recommendations for deferral of donors at increased risk for HIV-1 Group O infection; guidance document; availability--FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing the availability of a guidance document entitled "Interim Recommendations for Deferral of Donors at Increased Risk for HIV-1 Group O Infection," dated December 11, 1996. The guidance document, which discusses the appearance in 1996 of two cases of HIV-1 Group O infection in the United States, is intended to provide interim measures to reduce the risk of HIV-1 Group O transmission by blood and blood products pending the licensure of test kits specifically labeled for detection of antibodies to HIV-1 Group O viruses. The guidance document recommends adding three questions to screening questionnaires used to exclude donors at high risk of HIV-1 infection. PMID- 10173803 TI - Health care continuation coverage--Pension and Welfare Benefits Administration- Department of Labor. Request for information. AB - This document is a request for information to assist the Department of Labor (the Department) in assessing the need for a regulation clarifying certain statutory notice requirements set forth in section 606 of Title I of the Employee Retirement Income Security Act (ERISA) and in section 4980B of the Internal Revenue Code (the Code). These statutory notice requirements were enacted as part of the continuation coverage provisions included in the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). The continuation coverage provisions, commonly referred to as the COBRA provisions, generally require group health plans to provide participants and beneficiaries who under certain circumstances would otherwise lose coverage (qualified beneficiaries) with the opportunity to elect to continue coverage under the plan at group rates for a limited period of time. The Department anticipates that information and views provided by plan sponsors, plan fiduciaries, service providers to plans, plan participants and beneficiaries, and other interested persons will aid it in assessing the need for issuing a regulation to explicate the notice requirements of the COBRA provisions and the appropriate scope and content of any such regulation. A regulation on the notice requirements of the COBRA provisions would affect participants and beneficiaries (including qualified beneficiaries) of certain group health plans, as well as the sponsors and fiduciaries of such plans. PMID- 10173804 TI - Panel makeup is key for fix to Medicare. PMID- 10173805 TI - Dr. Satcher: too partisan a portfolio? PMID- 10173806 TI - New Yorkers still sore over veto. PMID- 10173807 TI - Quality is the house specialty. PMID- 10173808 TI - Innovations breathe energy into healthcare market. PMID- 10173809 TI - Checking on docs: can high tech help? PMID- 10173810 TI - That was then, this is now: new ways to collect the data. AB - Although the task of surveying managed care members remains highly untechnical, advances in technology offer health plan officials alternatives and assistance with the traditional telephone and mail systems. Three of the largest HMOs in Minnesota tackle member satisfaction surveying with traditional methods. But in different ways, each organization depends on technology for collecting, sorting or disseminating the data. PMID- 10173811 TI - Marching on with managed care. AB - In a matter of months, officials with Tricare--the military's answer to managed care--hope to have the operations and information systems in Region 1 up and running. Military officials plan to increase the use of technology in this region by connecting military healthcare facilities not only with each other, but eventually with civilian managed care organizations. Tricare administrators could be creating an ideal role model for the integration needs within the civilian sector. PMID- 10173812 TI - Integrated health systems: building the perfect IT beast. AB - The evolution of managed care, from strictly paying for to actually providing care, has shifted the focus of information technology in this industry as well. Today, the perfect managed care information system requires functionality beyond claims processing and back-end HMO operations. The IT goal for integrated health system (IHS) executives should be a hybrid of both payor- and provider-based functionalities. PMID- 10173813 TI - Measuring outcomes. The search for answers. AB - Outcomes are among the most precious gems in healthcare right now. Finding the necessary data and using it to save both money and lives, however, can be a challenge. The National Committee on Quality Assurance (NCQA) has released a set of guidelines for collecting and measuring outcomes. But even officials with NCQA insist that information technology is the only realistic way to find this valuable resource. PMID- 10173814 TI - The outsourcing alternative. PMID- 10173815 TI - Implications of budget deal continue to mesmerize health care community. PMID- 10173816 TI - Should medical ethics be part of public relations? PMID- 10173818 TI - Managed care outlook. When hospitals share risk with HMOs. PMID- 10173819 TI - Compensation monitor. Growth in primary care pay outstrips increases in specialist compensation. PMID- 10173817 TI - You can protect the analysis, but not the underlying data. PMID- 10173820 TI - Taking back the power? How doctors can reclaim control of medical care. PMID- 10173821 TI - Taking back the power? They made the right choice when the money ran low. PMID- 10173822 TI - Taking back the power? Making 'HMO' a synonym for 'insurance company'. PMID- 10173823 TI - Taking back the power? Greater freedom through winning HMOs' trust. PMID- 10173824 TI - Taking back the power? Life can be simpler with a cash-rich partner. PMID- 10173825 TI - Taking back the power? The answers are different for different physicians. PMID- 10173826 TI - A day spent learning how to satisfy patients. PMID- 10173827 TI - A news reporter explains his 'HMO horror stories'. PMID- 10173828 TI - An interview with David Nash, M.D., M.B.A. PMID- 10173829 TI - Provider-sponsored organizations: the next generation of managed care? PMID- 10173830 TI - Selecting an HMO: what matters to patients? PMID- 10173831 TI - Ten practical pointers for tracking HEDIS data. PMID- 10173832 TI - Innovation + incentives + HEDIS = high immunization rates. PMID- 10173833 TI - Building effective boards by focusing on the system. AB - Seasoned board members from two dynamic health systems--Centura Health and Crozer Keystone Health System--point to the CEO's commitment to the system and its mission as the critical element in keeping the board focused. PMID- 10173834 TI - Tools of high-performance governance. PMID- 10173835 TI - Sisters of Mercy Health System: extending reach, managing growth. Case study. AB - The first not-for profit healthcare organization to win Moody's Aa1 bond rating, this healthcare system grew patient revenue by 85% in three years. It will continue to expand, leaders say, concentrating on growth that complements, not hinders, the entire system. PMID- 10173836 TI - Experts predict government scrutiny of Columbia's physician equity program will have little effect on industry practices. AB - Regulators are uneasy about possible Columbia/HCA violations of Stark prohibitions on self-referral. Health system leaders planning to offer physician incentives may want to wait until the government's course of action is clear. PMID- 10173837 TI - 10 pathways to high-performance boards in integrated health systems. AB - A "business-as-usual" attitude among board members won't do, says governance consultant Barry Bader. A system board must provide leadership through uncertain times by establishing and articulating clear strategic goals and core values. Mr. Bader identifies the 10 pathways that will lead to high performance--by the board and by the system. PMID- 10173838 TI - Down a road less traveled. PMID- 10173839 TI - Ethical implications of competition. PMID- 10173840 TI - Connecting the dots: grounding quality improvement and cost cutting initiatives in strategic planning. AB - Discuss cost management and performance improvement with any manager at an acute care hospital and you will hear several consistent themes: Quality improvement (QI) has not produced the anticipated results on a timely basis; Focused cost reduction efforts have at best provided short-term benefits; and The organization needs to be more nimble, more responsive to the marketplace. If your hospital is wrestling with these issues, take some comfort in knowing that you are not alone. In general, the same problems are being experienced by long-term care facilities, group practices, practice plans, and most other provider organizations. However, all is not doom and gloom. A common-sense, easy-to-understand solution to the cost control problem can be implemented if an organization is disciplined and can exercise patience and diligence in implementation. Business Process Redesign (BPR), a performance improvement strategy and tactic that has been successfully deployed throughout private industry, can solve the problem. If undertaken correctly, BPR links the best concepts and principles of quality improvement, operations analysis, and focused cost reduction with an organization's strategic planning efforts. BPR results in the establishment of cost management initiatives that are consistent with the organization's long term goals. This article takes a closer look at the merits of BPR in a changing healthcare environment. PMID- 10173841 TI - Using a value chain approach for effective decision making. AB - Effectively managing costs in a healthcare environment may require taking a new look at how those costs are evaluated. The price of a product is not necessarily the most effective or efficient way of determining the actual cost. Using a value chain approach takes into consideration the functional costs of using a product as well, including both the "process" and "downstream" costs to an organization. In this article, Associate Professor Neil A. Wilner examines the differences between price and cost using a typical purchase in a healthcare environment. PMID- 10173842 TI - All those confusing numbers in the healthcare supply chain. PMID- 10173843 TI - Waste abatement: recycling, disposal practices can cut costs. AB - On average, most healthcare facilities are doing less than they should in the areas of source reduction and recycling, and will likely do so until mandated by law. The main reasons for this are ever-tightening healthcare budgets, limited staffing, and the cost of operating recycling programs compared to the cost of general solid waste disposal. Poor record keeping also may also be hampering the final decision to recycle. This article, Part II on waste abatement practices in healthcare organizations, examines what factors facilities should consider in establishing a recycling program, and analyzes cost-effective collection and disposal practices. PMID- 10173844 TI - Encounter data: what's ahead?. Interview by Randall K. Spoeri. PMID- 10173845 TI - Watch the soft dollars. PMID- 10173846 TI - Who should govern an HMO? AB - Enactment of the federal Health Maintenance Act in 1973 set the stage for broad consumer protection and participation in health plan governance. HMO boards today are concerned with a much broader range of issues than in past years, such as the strategic direction of the company; its fiscal soundness; the morale and satisfaction of employees, members, and providers; the composition of its provider network; the methods of reimbursement to its providers; and issues related to cost, access, service and quality. PMID- 10173847 TI - Handle with care. Avoiding the perils of the RFP process. AB - Beginning a year ago, with the issuance of the first RFP to service recipients in five southeast Michigan counties, Michigan has sought to control the rising cost of providing health care services to Medicaid recipients through the use of managed care contracting. PMID- 10173848 TI - In the pink ... doctors have been noted for illegible handwriting. PMID- 10173850 TI - Michigan HMOS--member enrollment (1990-1996) PMID- 10173849 TI - May I help you? The importance of customer service. PMID- 10173851 TI - The modern doctor. AB - How satisfied are physicians with the current health care environment? The "next wave" of health--particularly the steady growth of managed care--has ushered in new realities that in many cases has strained the traditional physician-hospital relationship, while at the same time created unprecedented opportunities for collaboration. For hospitals and other providers, it is critical to understand the sources of dissatisfaction--as well as the motivation--of physicians in their community. PMID- 10173853 TI - Michigan HMOs--all plan types--inpatient days (1993-1996) PMID- 10173852 TI - Creating a healthy you. PMID- 10173854 TI - Generation X employees: teach me, point me and get out of my way. PMID- 10173855 TI - Combating billing problems. Regulatory compliance programs offer many benefits. PMID- 10173856 TI - Falling outside the umbrella. PMID- 10173858 TI - Hospital tax-exempt status: a real community benefit! PMID- 10173857 TI - Managing technical functions: is it your line of business? AB - Food, laundry, valet and transportation services are areas that have been contracted out by hospitals for many years. Technical services are another area that may make sense to outsource, providing the company can pass the following tests: 1. Quality of service--can they do it better than your own employees? 2. Timeliness of service--usually the objective is speedier service. 3. Cost effectiveness--is the service a good value? PMID- 10173859 TI - Quantum leaps: from today to tomorrow. PMID- 10173860 TI - Changing roles in case management: some reflections. PMID- 10173861 TI - On Lok: community-based long term care. PMID- 10173862 TI - The Balanced Budget Act of 1997 and the continuum. PMID- 10173864 TI - Occupational health clinics can be an added service in the ED. PMID- 10173863 TI - Program profile: continuum of care committee eases network merger pains. PMID- 10173865 TI - When religious beliefs conflict with care: 'Seek understanding first'. PMID- 10173866 TI - Physicians disagree about mandatory blood-alcohol reporting measures. PMID- 10173867 TI - Urgent care centers help EDs provide cost-effective care. PMID- 10173868 TI - ORYX is right around the corner; is your department ready? PMID- 10173869 TI - COPD pathway cuts costs per case by $900. AB - Mobile (AL) Infirmary Medical Center's clinical pathway for chronic obstructive pulmonary disease (COPD) has cut length of stay from 7.8 days to 5.6 days, and cut costs per case from $4,050 to $3,170, resulting in an annual profit of more than $300,000. One reason for the pathway's high degree of physician buy-in has been case managers' willingness to make changes to the pathway with a minimum of red tape. One early revision to the COPD pathway was the development of specific patient goals for each day of the path. Other revisions included making the pathway a permanent part of the medical record and attaching relevant protocols to the pathway, such as a protocol for oxygen therapy. PMID- 10173870 TI - Medication errors could lead to high variance rates. AB - Medication errors could be contributing to high variance rates and treatment costs for patients placed on your clinical pathways, and you might not even know it, experts say. The problem is potentially severe. One recent study found a 9% error rate in admixtures overall and potentially catastrophic 34.4% to 56.7% error rates for potassium chloride mixtures. However, experts claim that hospitals could go a long way toward solving their admixture error problems by simply switching to ready-to-use products and having nurses record actual medications per day on clinical pathways. Meanwhile, HCFA is about to make official a new ceiling for errors: 2%, vs. the old 5% rate. This could pose serious problems for hospitals dependent on Medicare and Medicaid reimbursements. PMID- 10173871 TI - Measuring effectiveness of mental health care. AB - Because they lack the objective data available to other caregivers, mental health care providers must arrange for close follow-up of patients in order to adequately assess the effectiveness of case management efforts. Measures of case management performance should combine patient-specific measures, which evaluate how well the case manager is meeting the needs of the patient, with system oriented measures. To maintain quality while optimizing resource utilization, the entire treatment team must be actively involved in providing effective services. PMID- 10173872 TI - Pathways and protocols alone aren't enough. PMID- 10173873 TI - HMO stirs debate with outpatient mastectomy push. AB - The public furor over outpatient mastectomies may have quieted for the moment, but same-day surgery managers have been left with lingering concerns. Congress currently is considering two bills addressing outpatient mastectomies. One would ensure a minimum length of stay for the procedure, while the other leaves that decision to the physician and patient. Some professionals say outpatient mastectomies fail to provide crucial emotional and psychological support. Patients of one breast center suggested routine outpatient mastectomies with preadmission educational components. PMID- 10173874 TI - Outpatient mastectomies: what makes them work? PMID- 10173875 TI - SNF per diem PPS to begin in 1998; transition period blends facility, national rates. PMID- 10173876 TI - Congress passes budget; SNFs get $9.5 billion hit. PMID- 10173877 TI - IG audit highlights improper payments to SNFs. PMID- 10173878 TI - Innocent errors can lead to Medicare fraud and abuse charges; careful, proper documentation helps shield providers. PMID- 10173879 TI - Expanded Medicare managed care options viewed as good news for subacute providers. PMID- 10173880 TI - How the coming Medicare therapy reimbursement changes will effect subacute providers. PMID- 10173881 TI - Quarterly financial results of post acute/subacute companies. PMID- 10173882 TI - Budget Act favors swing-bed hospitals over other subacute providers, industry groups warn. PMID- 10173883 TI - HCFA modifies "hospital within a hospital" proposal. PMID- 10173884 TI - HCFA releases 1998 payment rates to managed care organizations. PMID- 10173885 TI - Implementation of evidence-based clinical protocols can improve outcomes, but significant barriers must first be overcome. PMID- 10173886 TI - Internal Revenue Service releases. Revenue Ruling 97-21 provides guidance on physician recruitment incentives. PMID- 10173887 TI - Physician managed care compensation: methodologies and contract terms. PMID- 10173888 TI - Current approaches to physician compensation. AB - Physician compensation plays a critical importance in the delivery of health care and the financial health of practices and payors. The choice of compensation methodologies impacts the use of health care resources, the splitting of revenues amongst groups, the incentive to provide more or less care and a variety of other medico-business behaviors. The health care industry overwhelmingly has concluded that the method of payment plays a major role in the types and amounts of services provided. From a counselor's perspective, it is critical to understand the pros and cons and the purposes of different compensation methods. Because the country is likely to end up with a mix of payment systems, it is also likely that practices and payors will continue to employ a mix of systems. In general, there one absolute right system exits. Rather, each practice should thoughtfully develop a system aimed at achieving the goals it desires. PMID- 10173889 TI - Are cardiac-catheterization services Stark designated health services? PMID- 10173890 TI - Disease management contracting: a sample regulatory review. PMID- 10173891 TI - MSO/IPA credentialling and peer review activities. PMID- 10173892 TI - Hire midlevel practitioners to lower costs in EDs. PMID- 10173893 TI - Young patients help design pediatric unit. PMID- 10173894 TI - Pediatric treatment model is a family affair. PMID- 10173895 TI - Same-day surgery patients have high expectations. PMID- 10173896 TI - Doing 'what makes sense' changes plan to decentralize administration. PMID- 10173897 TI - Boost satisfaction: combine ED, urgent care. PMID- 10173898 TI - Continuous improvement in health professions education. PMID- 10173899 TI - Continuous improvement in nursing education. PMID- 10173900 TI - Continuous improvement in physician education. PMID- 10173901 TI - Health administration education for the future. PMID- 10173902 TI - Improvement in health care continuing education. PMID- 10173903 TI - A community-based model for educating health professionals. PMID- 10173904 TI - Building relationships with physicians. Internal marketing efforts help strengthen organizational bonds at a rural health care clinic. AB - Physician turnover is costly for health care organizations, especially for rural organizations. One approach management can take to reduce turnover is to promote physician loyalty by treating them as an important customer segment. The authors develop an information--oriented framework for generating physician loyalty and illustrate how this framework has helped to eliminate physician turnover at a rural health care clinic. Rural health care organizations must develop a more internal marketing orientation in their approach to establishing strong relationship bonds with physicians. PMID- 10173905 TI - Promoting physician referral services. Prospective users are not necessarily the best advertising target. AB - Providers of physician referral services (PRSs) often focus advertising toward consumers who are least aware that such services exist. However, focusing advertising toward a more aware audience might be more useful. A recent study found that consumers most familiar with health care services are most likely to remember the concept of a PRS. Since these consumers may discuss PRSs with others, there appears to be value in promoting PRSs to more aware consumers as intermediaries to diffuse information to less aware consumers. PMID- 10173906 TI - The ethics of managed care. An initial look at physicians' perspectives. AB - The need for medical care in the United States had exceeded the financial resources required to pay for that care. To address this problem, managed care health insurance programs have become commonplace. With managed care programs, however, physicians are facing increasing ethical pressures. This article reviews the ethical dilemmas physicians face under a managed care system and conducts a national random sample of general practitioners and surgeons regarding four major ethical dilemmas: under treatment of patients due to overt pressures or financial incentives, breaches of patient confidentiality by the physician that are required by the managed care plan, lack of disclosure to the patient of the financial incentives or overt pressures under which the physician functions, and overuse of practice guidelines. The results of this survey suggest that physicians are more likely to compromise patients' confidentiality and not discuss financial arrangements with patients than they are to compromise actual patient care. Those physicians with more than 30 percent of their patient load coming from managed care are more likely to have faced the scenarios presented by the survey. There is, however, no statistically significant difference in the physicians' responses to these scenarios based on the percentage of the physicians' patient load coming from managed care. PMID- 10173907 TI - Health care marketing may resemble retail as patients gain consumer savvy. PMID- 10173908 TI - Outshopping: the battle between rural and urban medical services. PMID- 10173909 TI - Fostering a better health care market. Case study. PMID- 10173910 TI - The Fortune 500 on health care. Most top executives want to set the market free. AB - The nature of the American health care marketplace is in a state of flux and refinement. The recent attempt by the federal government to change the health care system has brought these issues to the forefront of public and private discourse. This research endeavor examines if these discussions influenced health care decisions by some of the nation's most influential decision makers. PMID- 10173911 TI - Health care marketing and the Internet. PMID- 10173912 TI - Physicians team with home care for new formula in care. PMID- 10173913 TI - Cleveland IDS forms division to slash costs for its 9 member hospitals and systems. PMID- 10173914 TI - Massive redesign, continuous stretching at Shands Hospital result in big savings annually. PMID- 10173915 TI - New clinical paths often need process redesign to finish the cost-saving/CQI job. PMID- 10173916 TI - Costly systems upgrades can't be ignored forever. PMID- 10173917 TI - Heart failure management program improves outcomes, saves millions at UCLA. AB - At UCLA Medical Center's heart failure center, a comprehensive management program is showing startling results in slashing costly hospital readmissions and dramatically improving clinical outcomes. Learn how the basic components at most large hospitals can be brought together to create the synergies and successes that UCLA is crowing about. PMID- 10173918 TI - Lovelace simplifies, saves big with single-source imaging equipment service contract. AB - Lovelace Health System traded in its disorganized mess of service contracts for imaging and cardiology equipment for one umbrella contract--and is now saving more than $200,000 a year as a result. Find out how to achieve similar savings. PMID- 10173919 TI - MGMA cost survey offers benchmarks for physician practice performance analysis. AB - Read this first: A new cost survey from the MGMA offers great details on the costs involved in running a physician group practice. Check out the data to measure how the group practice you are considering buying stacks up to benchmarks. PMID- 10173920 TI - Don't let dollars go up in smoke with onsite incinerator. PMID- 10173921 TI - Patient fingerprinting speeds up registration, cuts medical records backlog, mistakes. AB - La Porte (IN) Hospital is using cool new fingerprint scanners in its patient registration areas to speed up sign-in for patients and reduce backlogs of duplicate medical records. Once the hospital stores an electronic copy of a patient's fingerprint on file, future admissions take as little as a minute. The hospital was the first in the country to employ the potentially money-saving technology, and it's drawing lots of interest. PMID- 10173922 TI - Hospital's aggressive screening efforts save money in long run. AB - A Toronto hospital is winning the battle against VRE and MRSA, two potentially dangerous hospital bacteria, with an infection control program that involves aggressive screening of every patient who walks in the door. Learn how their bold efforts can be employed at your organization before these infections spread out of control. Plus, here's the hospital's official screening protocol. PMID- 10173923 TI - Average hospital charges for asthma treatment vary dramatically by region and state. AB - Asthma is one of the most frequent causes of hospitalization among children and adults and it's a costly chronic condition. But treatment costs and utilization vary geographically. Here's the data developed by a group health insurance company, which surveyed total charges for its asthma patients across 50 states and came up with broad variations in costs. PMID- 10173924 TI - Love--the most important medicine. PMID- 10173926 TI - Customer service excellence: do or die. PMID- 10173925 TI - Diabetes home care--teach your patients well. PMID- 10173927 TI - A global perspective: traditional and nontraditional care. AB - With the National Association for Home Care's 16th Annual Meeting coinciding with the World Congress on Homecare and Hospice this month, CARING turns its focus to medicine around the world, in particular to what different cultures consider "traditional" medicine versus alternative medicine. Home care colleagues around the world responded to a survey on this question, revealing vast differences as well as surprising similarities between systems. PMID- 10173928 TI - US-Hungarian partnership: strengthening home care's stand. AB - A partnership established between a US home care provider and a hospital in Hungary dedicated itself to reducing the length of hospital stays by strengthening home care in Vac, Hungary. With other similar ventures, the accomplishments of the partnership can be disseminated throughout other parts of Hungary and central and eastern Europe. PMID- 10173929 TI - Home care in the Republic of Suriname: a work in progress. AB - Because of lack of resources with the current delivery of health care, the organizations that provide care through clinics and a few small village hospitals face considerable funding and staffing shortages. Civilians in Suriname have started the Suriname Home Care Foundation, a pilot program to develop a viable and sustainable system for professional home care, especially in the Amerindian and Maroon communities. PMID- 10173930 TI - Building bridges in the Dutch health care system. AB - Recent reforms in the Dutch health care system have dramatically changed the role of and relationship between hospitals and home care organizations. These changes have fostered a more active role for hospitals in the delivery of home care services. PMID- 10173931 TI - Psychiatric home care in Austria. AB - As in many parts of the world, mental health care in Austria is growing more progressive and multidisciplinary in scope, moving from an "alternative" to an established treatment. One region in Austria has established a counseling center that provides comprehensive in-home patient services to complement inpatient care and to keep individuals stabilized in society. PMID- 10173932 TI - Designing a discharge planning program that fits. AB - With formal home care services increasing in prominence all over the world, the need for discharge planning becomes more apparent. No matter what type of plan providers use, beginning with the basics and allowing for options will ensure that patients get the services they need, no matter where on the globe they live. PMID- 10173933 TI - Nurse complementary therapists. A return to healing. AB - As chronically ill patients take more responsibility for their own health and well-being, they are requesting information about complementary and alternative treatment options. Through training in complementary care techniques, nurses can better serve such clients. PMID- 10173934 TI - Mental health home care aide program. Enhancing services all around. AB - Home care aides are a vital link in the home care continuum. One agency realized that specialty training for home care aides would not only make them even more valuable to the agency but also provide a career ladder for aides. One of the agency's first areas of specialty training was mental health. PMID- 10173935 TI - Meeting the needs of patients and staff in an era of change. AB - One home care agency has challenged itself to be innovative in its strategic planning to better serve its patients and staff. By surveying staff on patient characteristics and needs and then analyzing the results, agency administrators now have a greater understanding of the implications of a changing health care system for the patient and are better equipped to thrive in this new environment. PMID- 10173936 TI - Assisted living: opportunities for partnerships in caring. AB - Throughout the United States, a variety of state government bodies license or certify assisted-living facilities. States have taken a variety of approaches in setting standards and protecting consumers. Consumers will respond to innovative solutions that enable elders to remain independent while assuring peace of mind of their adult children. PMID- 10173937 TI - Frank E. Moss: standing tall in public service. PMID- 10173938 TI - In-home oral anticoagulation therapy: a specialized program. AB - Recent years have seen an increase in the use of warfarin therapy to treat patients with atrial fibrillation and mechanical heart valves. Cardiovascular Home Care in Fort Worth, Texas, developed an in-home oral anticoagulation therapy program to improve patient outcomes, prevent adverse effects of therapy, and reduce cost and resource utilization. PMID- 10173939 TI - HIPAA certification requirements. PMID- 10173941 TI - Claim audits: a relic of the indemnity age? AB - Traditional claim audits offering quick fixes to specific problems or to recover overpayments will not provide benefit managers with the data and action plan they need to make informed decisions about cost-effective benefit administration. Today's benefits environment calls for a comprehensive review of claim administration, incorporating traditional audit techniques into a quality improvement audit process. PMID- 10173940 TI - EEOC guidance on psychiatric disabilities: many problems, few workable solutions. AB - The EEOC recently issued "Enforcement Guidance" on psychiatric disabilities under the Americans with Disabilities Act. Although the Guidance provides clarification of a few issues involving mental disabilities under the ADA, in most respects the Guidance is problematic. For example, the Guidance suggests that the inability to get along with a supervisor or coworkers may constitute a disability under the ADA, that an employer may have to "accommodate" a disabled employee's misconduct, that an employer cannot require an employee to follow doctor's orders as a condition of employment, and that an employer may be obligated to modify work rules and procedures to accommodate a mentally disabled employee but is prohibited from explaining to coworkers why it is making such modifications. As the EEOC's Guidance exceeds or conflicts with the ADA in some respects and is largely unworkable in many respects, it remains to be seen how many courts will actually follow it. PMID- 10173942 TI - An analysis of the regulations interpreting and applying the Health Insurance Portability and Accountability Act of 1996. AB - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes a number of provisions that significantly affect health care plans. This article outlines key aspects of these changes, which apply to all health care plans, including those covering multiemployer, governmental and church groups. PMID- 10173943 TI - Saving our lives: questions of suffering. PMID- 10173944 TI - Balancing stress in work and at home. PMID- 10173945 TI - EMS communications: the difference between men and women. PMID- 10173946 TI - Just a routine. Private ambulance crews perform a critical role in patient care- one that many of us take for granted. PMID- 10173947 TI - Healthcare re-visits the commissary concept. AB - Commissary production can cost more in the early stages because of investments in equipment and training. But these systems often deliver improved quality, better control, greater efficiency and more meals per man hour. PMID- 10173948 TI - Challenge: how to increase satisfaction in an Alzheimer's center. PMID- 10173949 TI - Benchmarking: how do you measure up? PMID- 10173950 TI - What's your candidate's food safety IQ? PMID- 10173951 TI - Efficiency, objectivity and the departmental review. PMID- 10173952 TI - Opportunities, but not guarantees, for rural hospitals in federal budget act. PMID- 10173953 TI - Self-management education is the key to helping Medicaid patients with diabetes. PMID- 10173954 TI - PAVE-ing (Program Against Violent Events) the way to violence prevention: community, hospital develop peer mentoring. PMID- 10173955 TI - Medical group cultures pose big challenges. PMID- 10173956 TI - Data trends. Key organizational performance indicators. PMID- 10173957 TI - Principles and Practices Board, Statement No. 20: Healthcare mergers, acquisitions, and collaborations. Healthcare Financial Management Association. PMID- 10173958 TI - You don't bring me flowers anymore. PMID- 10173959 TI - Medicaid managed care enrollment--20 states/territories with the largest increase in enrollees. PMID- 10173960 TI - Medicare+Choice or Medicare experimentation? PMID- 10173961 TI - Not-for-profit status facilitates hospital merger. AB - Not-for-profit status may become an advantage for hospitals seeking to increase market share through a merger. On July 8, 1997, the Court of Appeals for the Sixth Circuit upheld the District Court's denial of a request by the Federal Trade Commission (FTC) to halt a proposed merger between two not-for-profit hospitals, Butterworth Hospital and Blodgett Memorial Medical Center, both in Grand Rapids, Michigan. The FTC had requested the District Court to enjoin the merger until the agency could determine whether it was in violation of Federal antitrust laws. The District Court was persuaded that mergers of not-for-profit hospitals do not generally lead to price increases, and may, in fact, lead to price reductions. Moreover, because the Michigan not-for-profit hospitals' boards included community representatives who were purchasers of the hospitals' services, the court found that "there would be no rational economic incentive for such an organization to raise its prices." PMID- 10173962 TI - Risk sharing in an integrated delivery system. AB - Development of an effective risk-sharing plan within an integrated delivery system (IDS) involves a complex decision-making process, in which the IDS should carefully assess its options to determine which will best suit its needs. In general, an IDS needs to consider four basic issues: how centralized the financial control of the risk-sharing plan should be; how the plan should be structured (eg, the number and size of budgets, interim provider payment, and the method for allocating surpluses and deficits to provider groups and individual providers); what risk-sharing strategies should be pursued; and how to avoid potentially catastrophic risk. PMID- 10173963 TI - Customer service: the new battlefield for market share. AB - In a survey conducted by the authors of the following article, it was determined that more than 50 percent of employers and managed care companies dropped providers who failed customer service standards. Many employers stated that they changed health plans according to their employees' preferences. Managed care organizations reported that they use the data from customer service surveys to choose providers, facilitate contract negotiations, and determine provider bonuses. Healthcare financial professionals can gain competitive advantages and help secure their organizations' financial future by focusing their resources and attention toward customer service issues. PMID- 10173964 TI - Is the Medicare SELECT program a stepping-stone to managed care? AB - Under the Omnibus Budget Reconciliation Act of 1990, Medicare SELECT programs and standardized Medigap policies were made available to senior citizens. Medigap policies offer coverage to supplement Medicare benefits, and the SELECT program offers a PPO-like product that offers reduced premiums if the beneficiaries agree to enroll in a preferred network. HCFA's recent evaluation of the SELECT program indicated a variable success rate in enrollment and cost-effectiveness. Providers will need to develop a strategic position concerning their participation in the Medicare SELECT program, which should include knowledge of SELECT program incentives, economics of the SELECT contract, and Medicare market position. In addition, providers should assess whether the SELECT program is consistent with strategies to transition Medicare populations into managed care. PMID- 10173965 TI - Protecting payment levels under Medicare risk-based contracting. AB - More than 3.4 million Medicare beneficiaries are enrolled in risk-based HMOs, and the enrollment rate is expected to double in the next five to seven years. In addition, the Balanced Budget Act of 1997 has directed HCFA to contract with other plans, including PPOs, provider service organizations, and traditional insurance companies. HCFA's payment determinations, therefore, will have an increasing impact on HMOs and other insurers in the future. The Medicare Act requires that HCFA's payment to a plan under a risk-based contract reflect the adjusted average per capita cost of the services typically furnished to Medicare patients in the geographic area. HCFA, however, sometimes errs in calculating this payment, resulting in underpayment to HMOs. In many instances, the errors occur because HCFA calculates payments by using a Medicare enrollee's Social Security mailing address rather than the geographic area serviced by the HMO. To avoid underpayment, risk-based HMOs should monitor Medicare payments for HCFA and challenge payment rates they feel are inadequate. PMID- 10173966 TI - Internal compliance investigations can reduce government sanctions. AB - An effective corporate compliance program is facilitated by three essential elements: a well-qualified compliance officer; a policy of immediate investigation of every report of potential fraud and abuse; and clearly defined roles for both corporate and outside counsel in conducting the investigations. A government agency is less likely to exercise the full extent of its powers when these elements are in place and three is evidence of a sincere compliance effort. PMID- 10173967 TI - Is contingency-fee consulting an endangered species? AB - Consulting firms that assist hospitals in optimizing Medicare and Medicaid reimbursement sometimes charge contingency fees for their services. These fees are based on a percentage of the increased revenue they can help a hospital capture. Although contingency-fee arrangements are not considered unethical, they can result in illegal billing practices because consulting firms may be tempted to up-code to increase their fees. The 1994 investigation of Metzinger Associates, Voorhees, New Jersey, a consulting firm providing services to 200 hospitals in 17 states, found evidence of illegal billing practices and resulted in a complaint filed by the United States Attorney's Office. Several hospitals were named as defendants. A Fraud Alert issued by the HHS's Office of the Inspector General earlier this year indicates the government intends to target consulting firms that charge contingency fees. Before engaging consulting firms that charge contingency fees, hospitals should carefully evaluate each firms to determine whether its recommended billing submissions will be accurate, credible, and defensible. PMID- 10173968 TI - Specialist capitation improves specialty and primary care physician relationships. AB - Physicians involved in managed care contracting serve as gatekeepers to manage their patients' care and receive payments through capitation arrangements. In serving as gatekeepers, primary care physicians assume financial risk for patients' care. A growing number of specialists, however, are entering into specialist capitation contracts, thereby sharing financial risk and patient care responsibilities. Primary care and specialist physicians should understand the terms of capitation contracts and develop positive working relationships to coordinate efficient, cost-effective patient care. Capitation contracts should define roles and responsibilities of primary care physicians and specialists and should delineate capitated payment rates. When primary care physicians and specialists share financial risk and divide responsibilities, patient care can be managed to the satisfaction of providers, payers, and patients. PMID- 10173969 TI - RVU costing in a medical group practice. AB - As risk-and-reward reimbursement arrangements proliferate, medical group practices should use cost accounting to measure costs of services delivered by physicians. The resource-based relative value scale (RBRVS) is a method of determining physicians' fees on the basis of the various resources used to provide procedures or services. Two cost-per-procedure methods can be used in RBRVS cost accounting. One method uses relative value units (RVUs), and the other uses component RVUs, which comprise work, practice, and malpractice costs. Though the two methods produce different calculated costs, using both together can produce a cost range medical practice administrators can use to ensure that the costs of delivering services are reimbursed adequately. PMID- 10173970 TI - Medicare audits and the importance of documentation. PMID- 10173971 TI - EDI enrollment provides economic benefits. PMID- 10173972 TI - Leadership essentials for the patient financial services professional. PMID- 10173973 TI - Is your compliance officer in place? PMID- 10173974 TI - Anticipate a for-cause, unannounced survey. PMID- 10173975 TI - Fraud costs $23 billion each year. PMID- 10173976 TI - Coding in the anti-fraud era. Skirt the upcoding spotlight. PMID- 10173977 TI - A prudent CP can minimize your risk. PMID- 10173978 TI - Pending discharge checklist improves care, scheduling. PMID- 10173979 TI - More patients get follow-up under new discharge. PMID- 10173980 TI - Make your CP the project of the year. PMID- 10173982 TI - 1997 salary survey results. PMID- 10173981 TI - Revitalize your quality council. PMID- 10173983 TI - Model compliance plan due soon from HHS; consortium readies itself. PMID- 10173984 TI - Surfing the Web can shorten quality search. PMID- 10173985 TI - Web has vast resources--and potential for waste. PMID- 10173986 TI - Reduce cost and length of ventilation. PMID- 10173987 TI - Beware pitfalls of fraud and abuse program. PMID- 10173988 TI - Dig for sentinel causes; create effective fixes. PMID- 10173989 TI - Team-based organization: the fruits of employee empowerment. AB - Tennalum, a division of Kaiser Aluminum, received the 1995 Shingo Prize for Excellence in Manufacturing. The plant also received the 1995 Tennessee Quality Achievement Award, the criteria for which are based on the Malcolm Baldridge National Quality Award. In 1994, Tennalum received the Clemson University's 21st Century Organizational Excellence Award, 33 Metal Producing Magazine's T.O.P. Award, and the Tennessee Quality Interest Award, and it was a finalist in Industry Week magazine's Top 10 Plants in America. Tennalum also earned ISO-9002 certification during that year. This article explains how Tennalum's people work together as self-directed work teams in an atmosphere of empowerment, involvement, and continuous improvement that translates into outstanding performance results. PMID- 10173990 TI - An innovative appraisal/reward strategy for high-performance teams. AB - Competitive pressures require today's corporate leaders to maximize productivity. And to achieve long-term bottom line results, they've found that it is necessary to create a culture in which company members want to be their best and work at peak efficiency levels. But what is the formula for success? Perhaps, as suggested by this article, it involves the creation of high-performance teams. PMID- 10173991 TI - Why our negotiations aren't more successful--and how to fix them. AB - Negotiation involves planning, execution, performance measurement, and review. Like any process, it can be perfected through practice. This article focuses on the planning stage of negotiations, although it gives suggestions for improving negotiating performance generally. PMID- 10173992 TI - You're always on stage, but do you know how to act? AB - Making presentations creates fear in most people. If at all possible, they avoid having to get up in front of an audience. But how many people think about the fact that we are constantly making informal presentations and that many of the same skills can be applied? Every team meeting, every discussion with peers, and every interaction between supervisor and subordinate is a potential presentation. Everyone can greatly enhance his or her effectiveness by applying many of the formal presentation and training techniques to these informal situations. This article explores some of the formal techniques that can be beneficially used. PMID- 10173993 TI - The ABCs of effective communication. AB - Communication is affected by the aim of the communicators, their bias, and the climate in which they are communicating. It is also affected by their attitudes, their behaviors, and their self-concepts. Finally, before communicating, they should assess the communication situation, create a blueprint for the communication, and choose a communication style. In other words, they should practice the ABCs of communication. PMID- 10173994 TI - Conflict and the dynamic organization. AB - Competition in today's world is fierce. Organizations are restructuring, re engineering, acquiring, merging, tightening their belts, downsizing, transforming their cultures, and raising their expectations. Those organizations that refuse to change or change too slowly will not survive. Thus, both organizations and employees need to be well prepared to handle the stress and conflict that accompany the change process. One necessary step in becoming prepared is to identify the sources and types of conflict likely to occur. PMID- 10173995 TI - Building the dream team: don't make it a nightmare. AB - This article covers the often overlooked area of team management concepts through a discussion of what many companies have done to implement these new concepts successfully. It describes the basics of how to and also explains why people resist the process of implementation. The main topics are (1) team formation, (2) pitfalls to avoid, and (3) team measurement. PMID- 10173996 TI - Personal strategies for maximizing your value in an uncertain future. AB - Because of the trend toward downsizing and the increase in job insecurity, managers need to consider strategies to ensure that they are not among those who will be laid off in the coming years. This article presents a set of such strategies, which mostly fall into the two categories of skill enhancement and management style adaptation. PMID- 10173997 TI - The resilient worker: employees who can cope with change. AB - Companies are getting serious about change. They recognize the need to not only make change happen but also to do it well--quickly and cheaply, yet with a strong emphasis on the needs of people and the problems people have with change. This commitment to managed change is having results. Faster and more effective change is happening, while the personal and collective pain of the change process is being minimized. PMID- 10173998 TI - Time-phased order points. AB - Many software packages designed for material management in health care unfortunately only offer the option of fixed or historically calculated re-order points for inventory planning. This article describes a technique called the time phased order point that is appropriate for industries, such as health care, in which materiel usage cannot be tied to a production plan or other schedule of events. It also provides numerous examples of the use of this technique as an aid in understanding how it works. PMID- 10173999 TI - Adjusting to not being "on top": making effective use of transitions. AB - In today's health care environment, it is possible even for the successful health care manager to be fired or demoted. To ensure continued success, the manager must view a termination or demotion as a normal transition of life and find ways to "move on". Given today's volatile environment, anticipatory planning for job loss or job change, which includes attention to continued professional training, visioning changes in health care, and maintaining strong professional contacts, is an imperative. PMID- 10174000 TI - Breaking down silos and building teamwork. AB - The purpose of this article is to explain how successful companies break down old functional silos and build teamwork. It describes techniques that foster teamwork across functional departments within a company as well as methods that can be used to cut across company lines and break down barriers between organizations. PMID- 10174001 TI - Setting new standards in the NHS. The impact of Alzheimer's disease on the health service. PMID- 10174002 TI - Consumer information. Dr who? AB - There is no systematic way to get reliable information about consultants' expertise and experience. A telephone survey of all acute trusts in one region revealed that half provided no information at all on their consultants, either for GPs or patients. The current situation flies in the face of rhetoric about informed patient choice and openness. PMID- 10174003 TI - Consumer information. You've been 'ad. PMID- 10174004 TI - Equal opportunities. Just the job. PMID- 10174006 TI - Nursing. Leading roles. PMID- 10174005 TI - Mental health. Sending in the paras. AB - Community support workers have become a common feature of mental health services. They work mainly with people with severe mental illness and offer intense support. Their need for training should be considered. PMID- 10174007 TI - Radiology. Light touch. PMID- 10174008 TI - Time to fix the price fix. AB - There is no evidence that the UK's pharmaceutical price regulation scheme is working. Arguments for abolishing it are that it is seriously flawed and inappropriate to today's health service, and that there are better alternatives. A regional drugs committee which makes evidence-based recommendations to GPs, could be a suitable alternative. The government should look to the experience of other countries and consult with healthcare professionals and the public before making any changes. PMID- 10174009 TI - Prescribing. Saving graces. AB - If fundholding is to be dismantled, consideration must be given to fundholders' prescribing budgets. One possibility would be budgeting by consent--involving GPs in setting budgets. More research is needed on prescribing budgets before they are abandoned. PMID- 10174010 TI - Public health. Capital gains. AB - Private investors should be encouraged to support initiatives other than hospitals. Primary care in inner cities should be strengthened and reorganised. The potential of the ambulance service needs to be harnessed. PMID- 10174011 TI - Mental health. Heads and tales. AB - Interviews conducted by other users can be a successful means of capturing mental health users' views on services. In this study, more than a third of those with severe mental health problems considered themselves over-medicated, and many wanted more 'talking therapies'. More than three-quarters were satisfied with their community psychiatric nurse but under half were satisfied with their consultant. A fifth did not know how to get help in a crisis. PMID- 10174012 TI - PFI's (private finance initiative) great white hope. PMID- 10174013 TI - Reappraising PFI (private finance initiative). Lateral thinking. PMID- 10174014 TI - First-wave schemes. New wave of ideas. PMID- 10174015 TI - Central Middlesex. Ahead of its time. PMID- 10174016 TI - Arranging finance. Banking on the future. PMID- 10174017 TI - Trusts. Larger than strife. AB - Effective working in a large trust depends on devolving responsibility. The model adopted at United Leeds Teaching Hospitals trust has saved 650,000 pounds on management costs. Management innovation is far more critical in organisational effectiveness than the question of size. PMID- 10174018 TI - Catering services. Measuring the wasteline. AB - The study found that overall almost half (46 per cent) of the food served in the hospitals surveyed was wasted. Waste was higher where meals were put onto plates in wards (57 per cent) than where meals were plated in the hospital kitchen (35 per cent). The researchers observed that meals often arrived late and were not well presented. PMID- 10174019 TI - Cancer services. Minding body and soul. AB - The psychosocial impact of cancer on patients' families and carers, as well as patients themselves, needs to be considered at all stages of diagnosis and treatment. The Calman-Hine report specified this principle but did not state how it should be put into action. Everyone who comes into contact with people with cancer should have the confidence to ask: 'How do you feel?' Standards should be incorporated into contracts. PMID- 10174020 TI - Patient compliance. Paid to comply. PMID- 10174021 TI - Trust accountability. Going public. PMID- 10174022 TI - Data briefing. Terminations. PMID- 10174023 TI - All the right moves. Four executives show how they made them. Interview by Jill L. Sherer. PMID- 10174024 TI - It takes a team. Building relationships and achieving results. PMID- 10174025 TI - Beyond the margin. PMID- 10174026 TI - Staying motivated in a long-term job search. PMID- 10174027 TI - The Volunteer Protection Act. PMID- 10174028 TI - Primary vs. specialty care roles. PMID- 10174029 TI - They really don't like us. PMID- 10174030 TI - Multi-skilled workforces. PMID- 10174031 TI - Building your management team. PMID- 10174032 TI - Finding a job on the Internet. PMID- 10174033 TI - Changes in the healthcare field are leading some executives to ask ... is healthcare still right for me? PMID- 10174034 TI - VHA, UHC purchasing combo puts savings ahead of styles. PMID- 10174035 TI - Protection level key to gown prices. PMID- 10174036 TI - UPN code standards may be the next issue. PMID- 10174037 TI - How much did that Band-Aid cost, really? PMID- 10174038 TI - Standardization: not always worth the effort. PMID- 10174039 TI - FASA (Federal Acquisition Streamlining Act of 1994) impact still debated as price list stays on hold. PMID- 10174040 TI - Push is on to standardize hip implants. PMID- 10174041 TI - Materials managers respond to UPS strike. PMID- 10174042 TI - Implant demand matching includes total knees. PMID- 10174043 TI - From decision making to choice making: Part 2. PMID- 10174044 TI - Controversial issues surrounding the case of HIV infections and AIDS through the use of unheated commercial blood products. AB - It has been reported in the recent years that not a small number of Japanese patients, including 1,792 hemophiliacs, have contracted HIV infections through the use of commercially available unheated blood products, such as factor VIII or IX concentrates. Many of them subsequently developed AIDS, and died shortly thereafter. It was later found that this tragedy was caused by misconducts and/or negligence of at least several persons responsible for the safety of the aforementioned blood products. Subsequently, a former chief of the Office of Biologics at the Ministry of Health and Welfare was arrested and indicted for the failure to prevent the spread of HIV infections throughout the country. His negligence allegedly killed two patients. No other person in the government, however, was indicted. There are controversies for and against the legal action. It has been questioned whether only one former senior medical officer of the government should and/or can assume full responsibility for the entire spectrum of the fiasco. It has also been claimed that the tragedy was caused by unfortunate combination of various factors in the government, industries, and medical communities, and that indictment of only one former senior medical officer is nothing but oversimplification of this very complicated issue. In order to increase the safety of blood products as well as to prevent the recurrence of the aforementioned tragedy, thorough investigation as well as adequate discussion on this case is highly desirable. Reformation of the current system should be made mandatory. PMID- 10174045 TI - Quality control in the health care in Japan--why CQI does not take root in Japan? AB - In the above, I have discussed the reasons why the Japanese hospitals failed to systematically improve health care quality from historical and cultural viewpoints with reference to the Japanese health care system. However, young physicians who are also the administrators of their own hospitals have become aware of the importance of the health care quality improvement and of the hospital management assessment by a third party, and they have been making positive efforts to solve the problems in their 30s who work at hospitals are also breaking the past image of conservative and stiff-necked doctor. Though there still remains much to be improved, the idea of informed consent is gradually taking root. The number of patients who insist on "the rights of patient" and "the right to make own decision" is on the increase. The system to have a third party assess the hospital administration is also under way. Under such circumstances, the leadership taken by physician, cooperation between various specialists as a team and the management capability of clerical staff are expected to play important role in the continuous quality improvement activities participated by the whole personnel of hospitals. Japanese industries are famous for their abundant experience and know-how of the management. If the health care industry will seriously tackle with quality improvement through good team work by participation of all the staff without any boundary between the jobs, the Japanese health care level is expected to improve and to satisfy the patients. In the past, boundary between the jobs also existed in Japanese corporations, but this obstacle was removed by taking the customer-oriented stance. It has now become obligatory in the factories to check the product whether it satisfies customers or not in final stage of manufacturing. There is no reason why hospitals cannot learn from these examples. It is now necessary for specialist organizations including hospital associations and Japan Medical Association to seriously address themselves to the task of continuous improvement of health care quality. Strange to say, there is no organization for secretary-generals of hospitals in Japan, but improvement of the quality and position of clerical staff is another key to raising the quality of health care. By raising the level of clerical staff, we may avoid such criticism as "Japan's medcine is first grade but health care is third grade". PMID- 10174046 TI - Is regulating the number of beds effective in controlling national medical expenditure? PMID- 10174047 TI - Features and problems of Japan's fee schedule for health care services. PMID- 10174048 TI - Trends in the shift of the outpatient population--a study from the statistics from the past 15 years. PMID- 10174049 TI - Analysis of structural changes in Japan's health care expenditure. PMID- 10174050 TI - Towards shortening the hospital stay of elderly patients. PMID- 10174051 TI - Economic analysis of preventive medicine in Japan--based on two empirical studies. PMID- 10174052 TI - A study on patient characteristics in neonatal intensive care unit. PMID- 10174053 TI - The frontier of nursing in the age of multimedia. PMID- 10174054 TI - Policy for containment of health care costs in developed countries--tasks and measures in health care supply. PMID- 10174055 TI - Hire a pro to survey your patients. PMID- 10174056 TI - One small town, six Dr. Rossi's. PMID- 10174057 TI - Male patients want one thing, women another. Interview by Neil Chesanow. PMID- 10174058 TI - Your practice brochure can get you in trouble. PMID- 10174059 TI - How fast are doctors' managed care revenues rising? PMID- 10174061 TI - Future doctors. What draws them to medicine? PMID- 10174060 TI - The misdirected search for malpractice reform. PMID- 10174062 TI - Congress sets Medicare on a whole new course. AB - You know it as the Balanced Budget Act. It could be called the Medicare Transformation Act, since it changes everything from doctors' fees to seniors' enrollment options. PMID- 10174063 TI - Should plaintiffs' experts get contingency fees? PMID- 10174064 TI - You can be an eight-minute Marcus Welby. PMID- 10174065 TI - These ob/gyns merged--and then jumped ship. PMID- 10174066 TI - How would you handle these ethical dilemmas? PMID- 10174067 TI - Get your dictation typed up right. PMID- 10174068 TI - What it costs to run a practice. PMID- 10174069 TI - The best thing I could do for Dad: stop being his doctor. PMID- 10174070 TI - Physician executives. Demand grows for doctors with management skills. PMID- 10174071 TI - Getting Medicare ready for the baby boomers. PMID- 10174072 TI - What to do when an HMO doesn't pay on time. PMID- 10174073 TI - Speed up payments with electronic transmissions. PMID- 10174074 TI - How to make direct contracting work. PMID- 10174075 TI - Quality counts--right in your wallet. PMID- 10174076 TI - An erroneous computer file jeopardized my career. PMID- 10174077 TI - What if you're downsized? PMID- 10174078 TI - Multidisciplinary approach improves patient care. PMID- 10174079 TI - What's all this noise about compliance? PMID- 10174080 TI - Know the consequences of your contract: a Bountiful lesson. PMID- 10174081 TI - The state of integration, 1997/1998. AB - Integration has been around long enough to assess its successes and failures. Of the three main types of integration--between physician groups, between hospitals and medical groups and through physician practice management companies--hospital physician group mergers have been the least impressive. Hospitals tend to throw money at situations, rather than try to understand group practice. Physician practice management companies, on the other hand, have made great strides by respecting the particularities of group practice and adding value to the practices they buy. PMID- 10174082 TI - Getting ready for professional-risk capitation. AB - California has long stood as the harbinger for things to come to the rest of the health care nation. Based on research in the state, Maurice Penner warns physician group managers to begin developing a geographically-diverse and credentialed network of physicians to attract the coming hoards of managed care plans. Compensation under capitation, he adds, is worth some advance planning. PMID- 10174083 TI - Medical group practices today and tomorrow. Key challenges and opportunities. Roundtable discussion. AB - McManis Associates, a nationally known health care consulting firm, and MGMA sponsored a round table for executives from leading medical groups across the country in May 1997. The purpose of the session was to share thoughts and insights related to creating successful medical groups, with a special focus on how medical groups approach partnerships and what makes those partnerships successes or failures. This article briefly profiles the round table participants and their organizations, summarizes the highlights of the discussion that took place and synthesizes the information into lessons learned that may be applicable to others. PMID- 10174084 TI - Successful physician search process for health care organizations. AB - Finding a physician is no simple process. Managers need to carefully identify their specific needs, be able to explain the opportunity clearly, use various sources to announce the position and be prepared to act professionally throughout. A 10-step checklist may help. PMID- 10174085 TI - Ethics of managed care. Implications for group practice. AB - The advent of managed care and the impact of an increasingly pluralistic, postmodern society need not mean abandoning standards of medical ethics embraced since Hippocrates. The time-honored relationship between patients and physicians remains of paramount importance. Ethical issues surrounding "universal" access and financial models that directly incentivize practices to withhold care are both addressed from a historical perspective. PMID- 10174086 TI - Merging primary care practices with MSOs. AB - Primary care group practices need to merge to provide the community-wide access demanded by managed care companies. Unfortunately, merger costs are high; according to some estimates, creating large-scale access can demand $1 million in start-up costs alone. Creating and using a management service organization can make the process less trying by pooling resources and talent in a common organizational structure. It's important, though, also to recognize the personal and financial burdens of such a plan. PMID- 10174087 TI - Assessing a practice management company's deal. PMID- 10174088 TI - Point-of-care testing technology. Is quality control still relevant? PMID- 10174089 TI - Blood gas testing in the laboratory and at the point of care. Finding the right mix. PMID- 10174090 TI - Information management's key role in today's critical care environment. PMID- 10174091 TI - Benchmarking for a competitive edge. PMID- 10174092 TI - Point-of-care testing and managed care--beneficial partners. PMID- 10174093 TI - The industry's response to managed care. PMID- 10174094 TI - Push is on to exempt POLs from the burdens of CLIA. PMID- 10174095 TI - Open your laboratory to the Internet. AB - The Internet can open many opportunities for laboratories. A wide variety of information resources are available via the Web, which can be researched more quickly and efficiently with a search engine. A laboratory can pursue marketing and advertising of its services on the Web as well. Consultation and collaboration can be accomplished via e-mail, listservs, and newsgroups. An Intranet can be created on a local area network to share electronic data within an organization. In addition, the rapid technological advances make the possibilities for tomorrow's communications limitless. PMID- 10174096 TI - A creative approach to documenting patient education. PMID- 10174097 TI - Empowerment. The latest motivational strategy. PMID- 10174098 TI - Beyond traditional quality control. How to check costs and quality of point-of care testing. PMID- 10174099 TI - Salary survey, Part 2. Overall package of wages and benefits has improved slightly. PMID- 10174100 TI - How to organize continuing education workshops and seminars. AB - Although required in only four states at present, continuing education for lab professionals is necessary for job survival. With this growing need for CE events, here's how one lab uses these seminars to establish a leadership position in the lab community and reaps numerous professional benefits for its employees. PMID- 10174101 TI - AMA faults Sunbeam in response to lawsuit. PMID- 10174102 TI - Lab probe hits 6 Minn. hospitals. PMID- 10174103 TI - System slashes jobs, pay. AHERF (Allegheny Health, Education and Research Foundation) blames 'trifecta' of financial pressures. PMID- 10174104 TI - Merger takes big bite. Sodexho-Marriott link to create giant in outsourcing of hospital food service. PMID- 10174105 TI - HMO picture unclear. New managed-care studies present contradictory data. PMID- 10174106 TI - Provider capacity drives healthcare spending--study. PMID- 10174107 TI - Volunteer Trustees reaps publicity, profits. PMID- 10174108 TI - Disney's dream. AB - In many ways, Walt Disney's dream for the town of Celebration is finally coming true. The model community in Osceola County, Fla, which broke ground in 1994, already has more than 1,200 residents. But one piece of the dream, a healthcare facility offering a full spectrum of services and top-of-the-line technology, hasn't come to fruition. While it's set to open next month, inpatient care won't be offered. Regulators cite an overbedded market and say the services just aren't needed. PMID- 10174109 TI - Gaps in doc pay. GAO finds big variance in federal physicians' income. PMID- 10174110 TI - AHA takes care to Hill ... false claims probes need legislative remedy, it says ... but House, Senate disagree on details. PMID- 10174111 TI - Neb. doc buys hospital. Tough law doesn't deter sale of struggling not-for profit. PMID- 10174112 TI - Keep the money local. Calif. AG tells new charitable trust to revise plans. PMID- 10174114 TI - PPM (physician practice management) percentages hit. Fla. ruling could force rewrite of hundreds of doc deals. PMID- 10174113 TI - Laboring against a merger. Stanford deal on track, but unions continue their fight. PMID- 10174115 TI - Practice run for APGs. Mass. uses Medicaid to prep for Medicare change. PMID- 10174116 TI - 4th hospital antitrust win. Court clears Long Island merger; cites not-for-profit status. PMID- 10174117 TI - Integration gap. Systems not really geared to managed care--survey. PMID- 10174118 TI - A boomer scare. Supplementary coverage for retirees declines--survey. PMID- 10174120 TI - Lobbying on rise. Budget plan leads healthcare groups to use checkbooks. PMID- 10174119 TI - For sale: hospitals at bargain prices. PMID- 10174121 TI - VA can keep the third-party money it can find. PMID- 10174122 TI - Facts, not myths. Study shows for-profit hospital conversions help communities by injecting capital. PMID- 10174123 TI - The expanding reach of risk management. AB - Although risk management is an industry that came into vogue 20 years ago because of a malpractice crisis, it has evolved beyond the singular concern of professional liability. That's evidenced by the entries for the seventh annual Excellence in Healthcare Risk Management Award competition. Each of this year's winners put a nontraditional twist on risk management. PMID- 10174124 TI - Mass. consulting firm gains strength. PMID- 10174125 TI - Safety gauntlet. Dangerous allergic reactions challenge hospitals' use of latex gloves. PMID- 10174126 TI - Institute rehabbed. New top exec joins Chicago facility in wake of change. PMID- 10174127 TI - Selling wellness. Company offers providers an added source of revenues. Gordian Health Solutions Inc. PMID- 10174128 TI - Banc One buys stake in Cain Bros. PMID- 10174129 TI - Mass. system on rebound. Neponset in search of new deal after Columbia jilts it. PMID- 10174130 TI - Private vs. public. In Australia, health insurance companies compete with the country's free, high-quality Medicare program. PMID- 10174131 TI - The new world of managed care. PMID- 10174132 TI - Hurdling a great wall. U.S. company opens China's first foreign-run hospital after four years' effort. PMID- 10174133 TI - Emerging markets. Developing countries offer burgeoning opportunities for private sector investment. PMID- 10174134 TI - Global direction. Longtime leader addresses future of International Hospital Federation. PMID- 10174135 TI - Setting standards. JCAHO consults with foreign countries on healthcare performance rules. PMID- 10174136 TI - Russian revolution. Cash-starved healthcare system struggles to emerge from legacy of Soviet rule. PMID- 10174137 TI - Made in America. U.S.-style healthcare and foreign cultures can make a poor mix. PMID- 10174138 TI - Investing in health reform. Fund manager sees global opportunity to make money on cost containment, outcomes improvement. PMID- 10174139 TI - Window to the future. Because of regulatory differences, Europe is often first to use U.S. innovations. PMID- 10174140 TI - FTC has good timing. OK comes just as HealthSouth-Horizon/CMS deal closes. PMID- 10174141 TI - AHA takes up gauntlet. Association vows to idemnify hospital that fights feds. PMID- 10174142 TI - Antitrust warning. Court: dental association's advertising limits restrict trade. PMID- 10174144 TI - Breaking apart. Some nurses depart ANA affiliates for SEIU, et al. PMID- 10174143 TI - Soros' new mission. Russian health project only the beginning, he says. AB - Since 1979 billionaire financier and philanthropist George Soros (left) has contributed millions of dollars of his personal wealth to some of the world's poorest nations. Now the Hungarian-born money manager is giving his largest gift ever. Soros will spend $500 million over three years in Russia, roughly $100 million of which will be invested in public health projects. PMID- 10174145 TI - AHA seeks to rein in personal member groups. PMID- 10174146 TI - An SEIU victory. A year after union's alert, JCAHO downgrades hospital. PMID- 10174147 TI - Docs cite care-vs.-money conflict. PMID- 10174148 TI - Reversal of fortune. RFP signals big changes are ahead for UniHealth. PMID- 10174149 TI - Hawaii pullout. Blues drops out of joint venture; motives questioned. PMID- 10174150 TI - Hospitals sue to temper PATH (physicians at teaching hospitals) probe. PMID- 10174151 TI - PPMs play big card. MedPartners, PhyCor merger to pool 6% of doctors. PMID- 10174152 TI - More healthcare credits rated AA. PMID- 10174153 TI - First 100 days busy for Frist: what comes next? PMID- 10174154 TI - More AHA restructuring. Latest effort an early retirement package for employees. PMID- 10174155 TI - They've gotta have art. More hospitals are acquiring artwork to build patient friendly collections. PMID- 10174156 TI - Relatively effective. Medicare's physician payment system keeps costs in line. PMID- 10174157 TI - Raising their voice. Group's message: managed care means more than HMOs. PMID- 10174158 TI - PET makes progress. New endorsements move device closer to mainstream. PMID- 10174159 TI - Payment past due. HMOs, hospitals often slow to settle their accounts. PMID- 10174160 TI - AHA trims to grow. Chicago belt-tightening may mean D.C. expansion. PMID- 10174161 TI - Being not-for-profit helps. In antitrust cases, judges have been giving hospitals credit for tax-exempt status. PMID- 10174162 TI - Making promises. Time will tell whether merged hospitals keep vows. PMID- 10174163 TI - Price hikes to HMOs preceded merger of Michigan hospitals. PMID- 10174164 TI - A favorable report. GAO finds little to fault in for-profit hospital conversions. PMID- 10174165 TI - Not so fast. Community input forces Md. hospitals to slow integration. PMID- 10174166 TI - Diversity institute faces changing times. Institute for Diversity in Health Management. PMID- 10174167 TI - Backlash continues. Survey finds managed care is still the bad guy in many Americans' eyes. PMID- 10174168 TI - Good works, good business. Not-for-profit nursing home giant prepares for hard times. PMID- 10174169 TI - IG: many hospice patients not terminally ill. PMID- 10174171 TI - Exporting equity models. U.K. docs targeted for investments in surgery centers. PMID- 10174170 TI - Unwelcome spotlight. Home-care industry protests its loss of good image. PMID- 10174172 TI - Nursing relief. In answer to hospital shortages, bill would allow some foreign nurses to work in U.S. PMID- 10174173 TI - IRS hints at future. A joint venture's tax status may depend on control. PMID- 10174174 TI - Political football. Managed-care reform lost amid partisan squabbling. PMID- 10174175 TI - CEOs, remember who hired you. PMID- 10174176 TI - Strategic divestitures. Healthcare companies are finding cash for new investments by selling noncore assets. AB - More and more healthcare companies are selling off noncore businesses to concentrate on what they do best. Hospitals are divesting radiology services, diagnostic businesses, home healthcare agencies and physician practices. The moves represent a pulling back from the vertical integration and massive system building favored in recent years. PMID- 10174177 TI - Time for rate regulation to go? Maryland's 20-year-old system under attack as state's hospitals begin to fall behind in cost control. PMID- 10174178 TI - Salary/career survey: hospitals. Raises on par; job scope is still expanding. PMID- 10174179 TI - What's getting you through times of change? PMID- 10174180 TI - The '97 OR Manager of Year wears many hats. PMID- 10174181 TI - Salary/career survey: ASCs. ASC managers see lower raises than in 1996. PMID- 10174182 TI - Salary/career survey. The big three challenges: cost, cost, cost. PMID- 10174183 TI - Carpal tunnel custom packs don't save time. PMID- 10174184 TI - Flash implants? What if there's no choice? PMID- 10174186 TI - Ideas for reducing waste volume in your OR. PMID- 10174185 TI - What's best way to dispose of suction waste? PMID- 10174187 TI - Broken incinerator forces new waste strategy. PMID- 10174188 TI - Execs want more attention paid to OR supply inventory. PMID- 10174189 TI - Staph with lower vancomycin resistance in US. PMID- 10174190 TI - America's top HMOs. Are HMOs the right prescription? PMID- 10174191 TI - America's top HMOs. Healing the great divide. How come doctors and patients ended up on opposite sides? PMID- 10174192 TI - America's top HMOs. Behind the HMO rankings. Our second set of ratings covers 223 plans in 46 states. PMID- 10174193 TI - America's top HMOs. State-by-state rankings. PMID- 10174194 TI - Throwing out good blood. Why the Red Cross cries 'crisis'--and tosses out so much. PMID- 10174195 TI - Safety and immunogenicity of a new inactivated hepatitis A vaccine in concurrent administration with a typhoid fever vaccine or a typhoid fever + yellow fever vaccine. AB - Two clinical studies were conducted to evaluate the safety and immunogenicity of concomitant administration of a new inactivated hepatitis A (HA) vaccine and either a typhoid fever (Vi) vaccine or a combination of Vi and yellow fever (YF) vaccines. In study 1, 62 healthy adults received HA+Vi into the deltoid muscle on contralateral sides. In study 2, 59 healthy adults received HA and a combined Vi/YF vaccine into the contralateral deltoid muscles. Reactogenicity was evaluated for 14 days following vaccination. Blood samples (for antibody titration) were obtained prior to vaccination on days 0 and 28 in study 1 and prior to vaccination on day 0 and on days 14 and 28 in study 2. The overall rate of local reactions was 19% at the HA injection site and 75% at the Vi injection site in study 1; the rate of systemic reactions was 41%. In study 2, local reactions occurred at 27% and 78% of the HA and Vi/YF injection sites; the rate of systemic reactions was 42%. All reactions were transient. Twenty-eight days after vaccination, the seroconversion rate was 100% for HA antibodies and 90% for the Vi vaccine in study 1. Rates of seroconversion in study 2 were 100% for the HA vaccine, 92% for the Vi vaccine, and 100% for the YF vaccine. Although this study was not comparative, both tested combinations were safe and immunogenic, and their routine use for persons at risk, such as travelers, can be recommended. PMID- 10174196 TI - Probing mechanical properties of living cells by magnetopneumography. AB - Magnetopneumography (MPG) has been used to study long-term particle clearance from human lungs as well as cellular motility of pulmonary macrophages (PMs). This study describes an extension of the method enabling the measurement of mechanical properties of PM cells in vivo. Ferromagnetic microparticles are inhaled and then retained in the alveolar region of the lungs, where they are phagocytized within hours by PMs. The magnetic particles can be rotated in weak magnetic fields, and the response to this twisting shear (force) is detected as a macroscopic magnetic field producing a measure of cytoskeletal mechanics. Cytoplasmic viscosity is very high compared with that of water and is strongly non-Newtonian. Under rotational stresses from 0.4 to 6.4 Pa, it acts like a pseudoplastic fluid showing a characteristic shear rate dependence. The viscosity as well as the stiffness of the cytoskeleton increases with increasing shear stress as seems typical for living tissue and evidence for an intact cytoskeletal matrix. The particle recoil as measured by the amount of recoverable strain following a short twisting force describes a cytoplasmic elasticity that depends on both level and duration of stress. These investigations on the mechanical properties of living human cells are promising and should lead to better understanding of cellular dysfunction in disease as well as pathways for drug administration. PMID- 10174197 TI - Complying with US and European complaint handling requirements. AB - The importance of customer complaints for providing valuable information on the use of medical devices is clearly reflected in United States (US) and European quality system requirements for handling complaints. However, there are significant differences in US and European complaint handling requirements. This article will discuss those differences and methods for ensuring compliance. PMID- 10174198 TI - Achieving the CE mark: getting it right first time. AB - Manufacturers are often unable to place the CE mark on all their medical devices immediately following an audit by a Notified Body because of deficiencies in documentation or procedures. In this article, the author uses the audit experience of a Notified Body to highlight some of the common problem areas. Manufacturers will be able to use this information as a checklist for their own system and significantly reduce the chance of delays in their CE-marking schedule. PMID- 10174199 TI - Anti-adhesive surfaces through hyaluronan coatings. AB - The ability to resist adhesion of proteins, bacteria, cells and tissue is an important requirement for the surfaces of medical devices. This article describes a surface-modification process that imparts anti-adhesive properties to the surfaces of biomedical materials through the covalent binding of hyaluronan. It can be applied to a wide range of materials to yield anti-adhesive surfaces on plastics, metals and ceramics. PMID- 10174200 TI - Promoting innovation. AB - An organization devoted to the support of small-to-medium-sized companies in the medical technology sector has recently been established in the United Kingdom. Medilink is a non-profit-making association that assists manufacturers in product development and marketing. This article discusses how it can generate new business opportunities for companies and the importance it places on establishing links. PMID- 10174201 TI - Doing business in France: short-term strategies. PMID- 10174202 TI - The engineering of polysaccharides. AB - Hyaluronan is a widely distributed and very important biological molecule of the polysaccharide family. Many of the functional characteristics of this substance can be retained when hyaluronan is transformed from a water-soluble substance into a structural biomaterial. This article highlights the potential applications of these materials in the regeneration of injured tissue. PMID- 10174203 TI - Response to Mitchell and Radford's rethinking research relationships in qualitative research: further thoughts and suggested training strategies. AB - This paper expands an important discussion initiated in an earlier publication of this journal (Mitchell & Radford, 1996). These authors point to a discrepancy between the ability of qualitative interviewers to elicit disclosures of personal information and the corresponding training of interviewers to respond appropriately to such disclosures. They suggest that high levels of disclosure may be attributable to the nature and duration of the qualitative research relationship. We propose that additional factors may be at play including, for example, the fact that research participants are sometimes paid for their participation. Based on our experience, we suggest strategies for training qualitative researchers. PMID- 10174204 TI - Outcomes and accreditation. PMID- 10174205 TI - Medicare mayhem. PMID- 10174206 TI - Documenting results is as important as effective therapy. PMID- 10174207 TI - The best staffing mix. PMID- 10174208 TI - Pediatric pain management. PMID- 10174209 TI - The nonreimbursed patient. PMID- 10174210 TI - Rehab gets wired. PMID- 10174211 TI - Rehabilitation following hand arthroplasty. PMID- 10174212 TI - MS & lifelong rehab. PMID- 10174213 TI - Survival strategies under managed care. PMID- 10174214 TI - Collecting and analyzing organizational level data for health behavior research. PMID- 10174215 TI - AIDS information needs: conceptual and content analyses of questions asked of AIDS information hotlines. AB - Dissemination of accurate information about HIV is an essential element of national AIDS prevention strategies and AIDS telephone hotlines serve a vital function in providing such information. In this study, questions asked of two AIDS information hotlines were collected and examined to determine the AIDS information needs of the general public. Questions asked of local AIDS lines in Houston and Milwaukee (N = 1611) were independently classified into 30 content areas, with two independent raters achieving 94% agreement. The content areas were organized for analysis into 11 broader information domains. Questions about HIV antibody testing were the most frequently asked (27%), followed by questions about sexual transmission of HIV (16%), HIV-related symptoms (16%) and situations that do not confer risk for HIV infection (14%). Content analyses suggested that individuals were motivated to call hotlines by fears of contracting HIV from actual risk behaviors or to dismiss concerns about contracting HIV through casual modes. Many individuals had information needs related to their own personal experiences that could not be addressed through media campaigns or other means of mass public health education. Results suggest that HIV information dissemination to the public through hotlines and other means of direct health education serves both preventive and destigmatizing functions. PMID- 10174216 TI - Do local inhabitants want to participate in community injury prevention?: a focus on the significance of local identities for community participation. AB - During the 1980s the community became the object of new interest and enthusiasm among many health promotion practitioners and researchers, and the principle of community participation was put on the research agenda. However, recent evaluations of major community health promotion programs have questioned the value of community interventions. This paper argues that the community level need not be of less importance in future health promotion initiatives. It is discussed whether the cultural dimension and the significance of local identities, neglected in most community health promotion programs, should receive more attention when local inhabitants are invited to participate in health promotion or disease prevention activities. Results from a study of injury prevention projects in small Norwegian municipalities indicate that the inhabitants' identification with local spatial subarenas might play an important role when they decide to become involved in injury prevention. Contemporary sociological approaches to the community, focusing on developments of local identities in processes of globalization, have formed a theoretical frame of reference in this study. PMID- 10174217 TI - Is peer tutoring beneficial in the context of school resuscitation training? AB - First year pupils at a Cardiff comprehensive school were trained in cardiopulmonary resuscitation, 106 by the teacher only and 137 by the teacher assisted by older pupils (peer tutoring). Scores in a multiple choice theory test and in practical skill assessment showed no significant difference between instruction methods, but boys taught by the teacher assisted by older pupils expressed less willingness to resuscitate in an emergency than girls instructed by either method (P < 0.01). Girls had higher scores in the multiple choice paper (P < 0.025) and in the skills assessment (P < 0.01). Those pupils who reported some prior knowledge of resuscitation techniques performed better during skill assessment than novice trainees (P < 0.025). PMID- 10174218 TI - Parental perceptions of barriers to childhood immunization: results of focus groups conducted in an urban population. AB - The current US immunization rates for 2 year olds are approximately half of the goal set for the year 2000. Research studies have focused primarily on the perception of health care providers in the identification of barriers and benefits to childhood immunization. While health care providers are an important part of the immunization delivery process, the perceptions of parents are also important. In this study, qualitative methods were used to explore perceived parental barriers to childhood immunization delivery. Twelve focus groups comprising White, African-American, Hispanic, urban and non-urban people were conducted at a variety of sites, including clinics, churches, schools and work sites. The results indicated that time off from work, access to well-child care and difficulty understanding the complexity of the immunization schedule were seen as barriers to adhering to an immunization schedule. Participants emphasized problems in taking time off from work to get immunizations, sometimes without pay, and expressed fears that doing so would jeopardize promotions and raises. While some of the parental perceptions were similar to those identified in studies of health care providers in the literature, many were not. This study emphasizes the importance of gathering information from parents as well as from health care providers. PMID- 10174219 TI - Physical exercise habit: on the conceptualization and formation of habitual health behaviours. AB - An observation one can make when reviewing the literature on physical activity is that health-enhancing exercise habits tend to wear off as soon as individuals enter adolescence. Therefore, exercise habits should be promoted and preserved early in life. This article focuses on the formation of physical exercise habits. First, the literature on motivational determinants of habitual exercise and related behaviours is discussed, and the concept of habit is further explored. Based on this literature, a theoretical model of exercise habit formation is proposed. More specifically, expanding on the idea that habits are the result of automated cognitive processes, it is argued that physical exercise habits are capable of being automatically activated by the situational features that normally precede these behaviours. These habits may enhance health as a result of consistent performance over a long period of time. Subsequently, obstacles to the formation of exercise habits are discussed and interventions that may anticipate these obstacles are presented. Finally, implications for theory and practice are briefly discussed. PMID- 10174220 TI - Effects of photographs and written descriptors on melanoma detection. AB - Two studies are reported on the effects of photographic and written information on performance in an experimental melanoma detection task. Subjects were shown slides of four types of skin lesions, including melanoma, and were asked what they would do if the lesion was on their skin. Four response options were provided from seeing a doctor immediately to doing nothing. In Experiment 1, no clear differences in performance were found as a function of prior instruction using four, eight or 16 photographs of each of the four lesion types. In Experiment 2, the effects of written and photographic instructional material were compared. The written material contained descriptions of each lesion type and details of the ABCD criteria for melanoma detection. Eight photographs were provided for each lesion type. Photographic information resulted in superior performance (P < 0.001) for seborrhoeic keratoses and a combination of both types of information was superior (P < 0.05) for melanoma. The two kinds of instructional material produced different effects, suggesting that a brochure offering a combination of photographs and written information is likely to be most useful in helping members of the public identify early melanoma as suspicious. PMID- 10174221 TI - Indicators of socioeconomic status for adolescents: the WHO Health Behaviour in School-aged Children Survey. AB - Many indicators of socioeconomic status used for adults are inappropriate for use in research on adolescents. In a school-based survey of 4079 Scottish schoolchildren using a self-completion questionnaire, over 20% of 11-15 year olds were unable to provide a substantive response on father's occupation. In contrast, indicators derived to construct a family affluence scale, which included car ownership, telephone ownership and the child having their own unshared bedroom, resulted in a 98% response rate; and 92% of children responded to a question on their weekly spending money. The intercorrelations between the conventional indicator of father's occupation and each family affluence and spending money were examined, and their associations with a range of health indicators and health behaviour measures compared. Father's occupational status and family affluence were moderately correlated and showed broadly similar patterns of association with the selected health measures although there were also some distinct differences. Child's spending money was only weakly correlated with father's occupation and showed rather different patterns of association with health measures. A case is made for the use of multiple indicators of socioeconomic status in adolescent health surveys, and it is argued that that the family affluence scale provides a useful and easily applied additional indicator to father's occupation or an alternative measure of socioeconomic background where occupational data are unavailable. PMID- 10174222 TI - Making better use of blood in bypass surgery. PMID- 10174223 TI - Pap smear liability: do computer-assisted rescreening devices affect the standard of care? PMID- 10174224 TI - Malignant tumors and bone. PMID- 10174225 TI - Polishing thyroid testing practices. PMID- 10174227 TI - Too early to solve Pap device puzzle. PMID- 10174228 TI - For labs, outcomes research may lead to catbird seat. PMID- 10174226 TI - Selling point-of-care pathology. PMID- 10174229 TI - Three approaches to improved screening. PMID- 10174230 TI - Clarifying the risk of cardiac crisis. PMID- 10174231 TI - Hepatitis outbreak, testing, and vaccines. PMID- 10174232 TI - PT self-test devices approved, but some are wary. PMID- 10174233 TI - New autoimmune tests seek acceptance. PMID- 10174234 TI - Study: too many stool tests. PMID- 10174235 TI - Out-of-hospital transfusions. PMID- 10174236 TI - PPO accreditation: who's in the driver's seat? PMID- 10174237 TI - Automated patient monitoring using interactive voice response technology. PMID- 10174238 TI - Cyberspace teamwork results in Medicare reimbursement. Nurses use the Internet to support bill. PMID- 10174240 TI - Prosolvia and University of Minnesota to create a virtual reality medical competence center. PMID- 10174239 TI - Texas gears up for telemedicine explosion. PMID- 10174241 TI - Allegheny General Hospital teams with hospital in Brazil to improve health care services. PMID- 10174242 TI - Psychotherapy on the Net--not yet. PMID- 10174243 TI - Kaiser Permanente Medical Center's pilot Tele-Home Health Project. AB - This is an interim report of a Kaiser Home Health Department study of the use of telemedicine technology in the home care setting. We present our study design and some early findings from the first six months of the project. Preliminary findings indicate the technology is dependable, and that average telehealth video visits are cost-effective and are about 60% shorter (18 minutes vs. 45 minutes) than on-site visits, with no decrease in patient satisfaction. The study will be completed in September of 1997. This study was initiated in 1996 to explore improving access to health services while maintaining quality of care, and to demonstrate the cost effectiveness of remote consultation technology in the home health setting. The the study, which began in May 1996, employs a randomized design approved by the Institutional Review Board and will be completed in approximately one year. This project was titled Tele-Home Health to acknowledge that a multi-disciplinary team would be composed mainly of nurse case managers, but would also include physical therapists, speech therapists, occupational therapists, home health aides, licensed PMID- 10174244 TI - A POTS-based tele-hospice project in Missouri. PMID- 10174245 TI - Another kind of tele-home health: medical call centers. PMID- 10174246 TI - Can tele-otolaryngology help in screening for head and neck cancer? PMID- 10174247 TI - 4th annual telemedicine program review. Part 2: United States. PMID- 10174249 TI - Strabismus. PMID- 10174250 TI - Oculoplastic and orbital surgery. PMID- 10174248 TI - Budget bill tackles telemedicine reimbursement. PMID- 10174251 TI - Detection, prevention, and rehabilitation of amblyopia. AB - The necessity of visual preschool screening for reducing the prevalence of amblyopia is widely accepted. The beneficial results of large-scale screening programs conducted in Scandinavia are reported. Screening monocular visual acuity at 3.5 to 4 years of age appears to be an excellent basis for detecting and treating amblyopia and an acceptable compromise between the pitfalls encountered in screening younger children and the cost-to-benefit ratio. In this respect, several preschoolers' visual acuity charts have been evaluated. New recently developed small-target random stereotests and binocular suppression tests have also been developed with the aim of correcting the many false negatives (anisometropic amblyopia or bilateral high ametropia) induced by the usual stereotests. Longitudinal studies demonstrate that correction of high refractive errors decreases the risk of amblyopia and does not impede emmetropization. The validity of various photoscreening and videoscreening procedures for detecting refractive errors in infants prior to the onset of strabismus or amblyopia, as well as alternatives to conventional occlusion therapy, is discussed. PMID- 10174252 TI - Comitant strabismus. AB - This article reviews 14 of the past year's important published works on comitant strabismus, referring to the most interesting developments related to subjects such as epidemiology of comitant strabismus and prevalence of esotropia and exotropia in pathologic conditions like cerebral palsy, Down syndrome, and prematurity-factors influencing the surgical success in strabismus and functional outcomes of early surgery in essential infantile esotropia. Relevant anatomic and physiologic findings on extraocular muscle function are also discussed, which may contribute to our knowledge on the pathophysiology of congenital strabismus. PMID- 10174253 TI - Paralytic and incomitant strabismus. AB - In the year under review, published work has concentrated on two main topics. The first is the etiology, pathophysiology, and natural history of paralytic and incomitant strabismus. No major studies were published but some interesting findings are discussed. The second is surgical results, largely assessed by uncontrolled retrospective data analysis. Also, a number of useful tips for patient management have emerged. PMID- 10174254 TI - Brain pathology, eye movement disorders, and basic science of ocular movement. AB - Diagnosis of eye movement disorders is an important step in evaluation of patients with developmental or acquired brain lesions. A better understanding of the various pathologies requires both a detailed clinical examination and the analysis of eye movement recordings (nystagmus of various types, saccade, and pursuit anomalies). Basic science studies help to interpret these eye movement disorders. PMID- 10174255 TI - Development of refraction and strabismus. AB - The goal of current research on the development of refraction is not to establish whether refraction is either genetically programmed or environmentally influenced, but to assess how heredity and environment interact in the genesis of refractive error. The continuing problem in strabismus research is one of cause and effect. Do binocular deficiencies induce strabismus, or is it the other way around? The papers highlighted in this article address these critical issues. The new findings have the potential to influence the treatment and clinical care of patients with refractive errors and strabismus. PMID- 10174256 TI - Neuro-ophthalmologic manifestations of systemic disease and neurologic disease. AB - Neuro-ophthalmology is a difficult and challenging field for both ophthalmologists and neurologists. Unfortunately, signs and symptoms of these patients can be very subtle and easily overlooked. Although neuro-ophthalmologic cases are rare in the practice of a general ophthalmologist, missing the diagnosis can have a severe impact on the patient's health. This paper reviews the past year's publications of neuro-ophthalmologic manifestations of systemic and neurologic disease. PMID- 10174257 TI - Visual impairment and dyslexia in childhood. AB - Although visual screening programs seem to be more and more effective, we face new problems with visual dysfunction that are not always detected in the visual screening programs. Many children born prematurely develop cerebral visual impairment. These children suffer from a cognitive visual impairment, causing them to have problems with orientation and visual perception. Brain impairment also seems to be relevant for the dyslexia syndrome, which continues to fascinate and puzzle many researchers. New findings in visual brain function cast light on these questions and might ultimately answer a few of the mysterious findings in dyslexia. PMID- 10174259 TI - Tumors of the orbit. AB - Orbital tumors may present with abrupt or insidious visual loss, proptosis, and disturbance of ocular motility. The treatment of many tumors of the orbit remains elusive. Recent contributions to the literature concerning the diagnosis and management of primary and secondary tumors of the orbit, including the intraorbital optic nerve, are reviewed. PMID- 10174258 TI - Current concepts in brow lift surgery. AB - During the past decade, surgeons have increasingly recognized that brow ptosis is an important contributor to dermatochalasis and ptosis of the upper eyelid. Surgical elevation of the ptotic brow improves eyelid esthetics; conversely, failure to appreciate and to alleviate brow abnormalities frequently compromises the results of upper eyelid surgery. Improved understanding of eyebrow anatomy and of the pathophysiology of the aging face, combined with advances in small incision surgery, have culminated in a unified approach to correction of the ptotic brow. Despite improvements in surgical techniques, the surgical outcome can deviate from the perceived eyelid-brow ideal. Both the surgical management and objectives of eyebrow surgery continue to evolve. PMID- 10174260 TI - Oculoplastic and orbital applications of porous high-density polyethylene implants. AB - Porous high-density polyethylene implants have become well accepted for the repair of orbital wall fractures, delayed orbital reconstruction, orbital rim and malar bony onlay augmentation, and volume replacement as orbital spherical implants for the treatment of anophthalmos. Medpor (Porex Surgical, Inc. College Park, GA) is a commercially available porous high-density polyethylene product available in sheets, blocks, Flexblocks, several onlay contour shapes, spheres, and custom implants. Recently, the motility coupling post was introduced to provide an integrated Medpor spherical implant with enhanced prosthetic motility. Medpor implants possess several advantages over hydroxyapatite implants. PMID- 10174261 TI - Orbital trauma. AB - This article is a review of recent advances in the evaluation and treatment of orbital and periorbital trauma. We present the pertinent literature from the past year dealing with orbital injuries, orbital imaging, assessment and management of orbital fractures, and traumatic optic neuropathy. Managing orbital trauma can utilize different approaches to achieve the same final goal: the restoration of normal orbital and craniofacial anatomy and the return of function. We provide the perspective of our orbital and ophthalmic plastic and reconstructive practice and relate the recent literature to our current treatment of orbital trauma. We find that often a multidisciplinary effort is advantageous for managing complex orbital and craniofacial injury. PMID- 10174262 TI - Improved clinical laboratory service and cost reduction through process analysis. PMID- 10174263 TI - A clinical laboratory automation system for drugs-of-abuse monitoring. PMID- 10174264 TI - Evaluation of a new generation cardioplegia administration system. AB - The delivery of cardioplegia has traditionally been constrained by the physical limitations of the mechanical devices in use, yet myocardial protective strategies may vary both according to patient condition and operative requirements. The need for a cardioplegia administration device that allows flexibility and safety is evident. The purpose of this study was to evaluate the performance of the Quest Myocardial Protection System (MPS) during clinically simulated conditions. The MPS was evaluated in an in vitro setting under the following conditions: blood to crystalloid ratios (1:1, 4:1, 8:1, all blood), potassium concentrations ([K+]) of 10 and 25 mmol/L, calcium concentrations ([Ca++]) of 1.4 and 2.8 mmol/L, and at flow rates of 100 and 300 ml/min. Predicted values from the MPS were compared with measured values, with statistically significance accepted at p < .05 level. Significant differences were seen between measured and MPS cardioplegia delivery volumes at the 4:1, 8:1 and all blood ratios with a flow rate of 300 ml/min. There were no significant differences seen between measured and expected [K+] and [Ca++] delivery values across all combination of flow rates and ratios. Differences between delivery pressures of the MPS and measured values for flow rates of 100, 250 and 500 ml/min were 0.4, 1.2 and 7.6 mmHg respectively. The mean cardioplegia cooling time from 37 degrees C to 9 degrees C was 37 +/- 4.5 seconds, while rewarming from 7 degrees C to 37 degrees C, took 53 +/- 10.4 seconds. In conclusion, the Myocardial Protection System performance characteristics were precise in ratio delivery, concentrations of potassium agents, additive agent concentration, temperature, and pressure across all experimental conditions, with the exception of delivery volume. PMID- 10174265 TI - An in vitro evaluation of an automatic clamp for use with centrifugal pumps. AB - The risk of air emboli is a concern for all perfusionists. A new clamping device for use with centrifugal pumps is designed to clamp both the arterial and venous lines at the first indication of air or retrograde flow, thereby allowing the perfusionist to evaluate the situation and correct the problem before entraining air into the arterial pump head. After evaluating this device in our lab, we conclude that this new safety device should be added to the heart lung machine by all perfusionists using centrifugal pumps. PMID- 10174266 TI - Laser safety analysis of a retinal scanning display system. AB - The Virtual Retinal Display (VRD) is a visual display that scans modulated laser light on to the retina of the viewer's eye to create an image. Maximum permissible exposures (MPE) have been calculated for the VRD in both normal viewing and possible failure modes. The MPE power levels are compared to the measured power that enters the eye while viewing images with the VRD. The power levels indicate that the VRD is safe in both normal operating mode and in failure modes. PMID- 10174267 TI - Current and future directions of biomedical materials research. AB - Biomedical materials and implants are not synonymous. Materials per se are not implanted--after configuring, processing, and finishing operations, they constitute parts of implants and other devices. The U.S. Food and Drug Administration currently does not "approve" biomaterials; rather, it approves medical devices, biologicals, and drugs. There have been important advances during the past 40 years in the clinical uses of medical implants and other devices, especially in ophthalmology, cardiology, orthopaedics, surgery and dialysis. In the 21st Century, there will be increased emphasis on curing and preventing major genetic diseases. There will be many nontraditional clinical applications of biomaterials, such as viral- and nonviral-mediated delivery agents in gene therapy, synthetic biomaterials with pharmacologic effects, and biomaterials that can integrate with the biological system to form a long-term, living, renewable interface with prosthetic implants. Therefore, those working in the field of biomaterials must become familiar with new molecular biological techniques and be able to collaborate effectively with molecular biologists. PMID- 10174268 TI - A long-term clinical study on drawn poly-L-lactide implants in orthopaedic surgery. AB - We have developed an ultra-high-strength drawn poly (L-lactide) (PLLA) with a bending strength of 240 MPa. Seventy-four patients (80 cases) who were treated with this PLLA implant were enrolled in this study. Their ages ranged from 14 to 78 years, and the follow-up period ranged from 4 to 9 years (mean: 5.3 years). Bony union was obtained in all cases. Osteolytic changes were observed in 12 cases (15%) but no late aseptic swelling was noted. Both MRI and roentgenographic findings indicated that the spaces where the PLLA implants were located had not been replaced with bony tissue. PMID- 10174269 TI - Peritoneal healing with adhesion formation: current comment. AB - Intra-abdominal adhesions are fibrotic structures, which lie in the form of a string or attachment between the abdominal organs and connect these together. They are responsible for serious clinical complications that include intestinal obstruction, infertility, and pelvic pain. During the last century, surgeons' comprehensive understanding of the biology of peritoneal healing and wound repair has allowed them to identify a variety of new therapeutic techniques that limit the development of adhesion formation. New drugs, dextran 70 and poloxamer 407, have been developed to prevent adhesion formation. In addition, three new biomaterials (oxidized regenerated cellulose, hyaluronate membrane, and polytetrafluoroethylene) are synthetic barriers being used to prevent adhesions. PMID- 10174270 TI - Complying with US and European change control requirements, Part I. AB - The successful operation of medical device companies is significantly affected by their ability to continually improve their products and operations. Also, from time to time, problems need to be resolved. These activities are often associated with changes that must be made and effectively managed. Part I of this two-part article will discuss United States and European quality system requirements for controlling changes to products, processes and documentation. Part II will discuss change control procedures and regulatory notification issues. PMID- 10174271 TI - Polymer suppliers and medical plastics: problems and opportunities. AB - Strong supplier-customer relationships are essential to the development of polymer materials that are suitable for manufacture. This is especially true in the medical device field. Issues such as understanding the customer's material specification, simple medical compatibility assessments, communicating polymer developments and changes and a co-development business strategy are addressed in this article. The subject is dealt with from the viewpoint of a medium-to-large volume injection moulder of plastic components for the medical device industry. PMID- 10174272 TI - The facts about PVC. AB - Poly(vinyl chloride) (PVC) continually arouses debate, but it remains the most widely used polymer in the industry. Important decisions about the use of materials should be based on scientific fact. This article provides the latest data on the use of PVC and describes how Denmark, the most environmentally radical country in Europe, is handling the issues. PMID- 10174273 TI - Validating the packaging process using factorial designs. AB - The development of an effective process requires a comprehensive understanding of two factors: the variables that can affect the process and the ability of the process to control those variables. This article examines the application of factorial designs in the qualification and validation of packaging systems. Using a case study to illustrate the concept, it describes a three-step approach that allows a reduction in the quantity of sampling compared with other experimental methods. PMID- 10174274 TI - Purchasing raw materials. PMID- 10174275 TI - Ceramics transformed: manipulating crystal structures to toughen bioceramics. AB - Ceramics have tremendous potential as engineering materials for the construction of medical devices but are inhibited by their inherent brittleness. This article discusses how this problem has been addressed by the development of the process of transformation toughening and places this in the broader context of the new generation of "smart" materials. PMID- 10174276 TI - Cytokines in platelet concentrates: a comparison of apheresis platelet (haemonetics) and filtered and unfiltered pooled buffy-coat derived platelet concentrates. AB - Variable degrees of platelet activation, shape changes, microvesiculation and fragmentation may occur during collection, processing and storage of platelet concentrates (PCs), contributing to different rate of platelet storage lesion. Leukocytes contribute to both the frequency of transfusion reactions and the acceleration of the rate of platelet storage lesion hence leukocyte removal of platelet concentrates has been introduced to overcome these problems. However transfusion reaction can still occur with the use of leuko-reduced products and it is not fully elucidated that the rate of storage lesion is equivalent for filtered and unfiltered counter parts. This issue has been addressed in this manuscript comparing the generation of cytokines during storage in PCs derived from pooled buffy coat with the standard apheresis products, with a similar level of leukocyte contamination. The EDTA-induced shape change in platelet was used as an index of platelet functional integrity. In addition IL-8 and TGF beta were used as indicators of filtration process-inducing stimulation of cytokines. Our results clearly indicate that a rapid disc/spheric conversion occurs during storage of buffy-coat derived PC, and while prestorage filtration reduces both IL 8 content immediately after filtration and at the end of platelet shelf life but such a process may lead to slight enhancement of the rate of TGF beta generation indicating that any additional process may have some bearing in stimulation of TGF beta release. PMID- 10174277 TI - Effect of pH and buffering condition on dMPV of three types of platelet concentrates. AB - Normal platelets display a log normal size distribution pattern when analysed by an automated cell counter. Considerable changes in the platelet size distribution occurs during collection, processing and storage. This is easily monitored by the variation seen in the cellular indices or size distribution patterns. Platelet activation leads to a shift to the right whereas discoid/spheric conversion and microvesiculation/fragmentation are associated to shift to the left. Therefore changes in cellular indices are of value in assessing the dynamic shape changes and aggregation/disaggregation that platelet undergo during storage. We describe here an objective method for measuring platelet functional integrity based on cell counting. Our procedure is simple and based on the measurement of difference (d) of MPV before and after the addition of platelet samples to EDTA (4 ml dry dipotassium EDTA tube), incubating at 22 degrees C for a period of 1 h (for optimisation of shape changes and disaggregation) before counting. Since the platelet functional activity/aggregation states are pH-dependent we have investigated the effect of buffering condition on the functional integrity measured by dMPV. Both the standard and buffered EDTA exposure procedures appear to be suited for monitoring platelet functional integrity/aggregation and activation states but the standard EDTA protocol eliminates the need for pH determination hence is our preferred diagnostic tool, for platelet functional integrity and aggregation states. PMID- 10174279 TI - Cytokines to reduce platelet transfusions: non-TPO cytokines. AB - Although thrombopoietin (TPO) has now been cloned, many pretenders have auditioned for the role. It is clear that interleukin-3, interleukin-6, interleukin-11, stem cell factor, leukaemia inhibitory factor and oncostatin-M all influence the proliferation and maturation of megakaryocytes. This review details the nature of these non-TPO cytokines, giving their genetic identity, molecular structure, receptor, mode of action and range of activities. Their effect on platelet production in preclinical and clinical studies is reported and their potential as agents for thrombopoietic support is discussed. PMID- 10174278 TI - The quality of clinical FFP, cryoprecipitate and cryosupernatant derived from single donor apheresis procedures and random donations collected in a BAT system: assessment of the activity states of FVIII, contact activation, microvesicle content and cytokines. AB - In establishing the best practice and/or evaluating any new process or procedures it is essential that apart from the compliance to specification, provided by the Guidelines (i.e. AABB or UK-BTS/ NIBSC), the changes that might occur in the activation states, and other regulatory mechanisms should be considered. Of particular relevance are the changes in the levels of FVIII in relation to its carrier protein and stabiliser von Willebrand factor; the levels of contact activation and serine proteases and the level of cellular fragmentation/microvesiculation due to shear induced stress in the cellular contents of blood and the development of cytokines. This brief original report compares the above parameters for three types of FFP, cryoprecipitate and the cryosupernatant in respect to same new in house quality monitoring criteria of acceptability. PMID- 10174280 TI - Thrombopoietin. AB - The term "thrombopoietin" (TPO) was first coined in 1958 but, despite several cytokines having thrombopoietic effects, the major megakaryocytic growth and development factor was not cloned until 1994. Wendling and colleagues (Virol, 1986; 149: 242-246) recognised a novel murine viral oncogene, v-mpl, responsible for a myeloproliferative syndrome. The corresponding human proto-oncogene, c-mpl, codes for a member of the haemopoietic cytokine receptor family. Its ligand is TPO. The structure and function of TPO, together with its action in stimulating proliferation and maturation of megakaryocytes, are discussed in detail in this review which also details the pre-clinical usage and clinical potential of TPO as a platelet sparing agent in haemato-oncological practice. PMID- 10174281 TI - The impact of peripheral blood stem cell transplants (PBSCT) on platelet usage. AB - Peripheral blood stem cells (PBSC) are rapidly replacing bone marrow cells for autologous transplantation. This introduction, largely without randomized prospective trials, has occurred because of the ease of PBSC collection and the associated rapid haematological recovery with its lower costs and reduced blood product exposure. The administration of haematopoietic growth factors during recovery from high-dose chemotherapy increases the number of circulating haematopoietic progenitor cells to levels 1000-fold greater than levels normally found in blood. The CD34+ cell number, CFU-GM and CFU-Meg are commonly employed parameters used to assess the quality of PBSC harvests. This review examines the impact that PBSCT has had on haematological practice and patient care illustrated by our local practice in Cardiff. PMID- 10174282 TI - Blood centres: the effect of cytokine therapy on transfusion medicine. AB - Platelet concentrates (PCs) are transfused mainly to patients with haematological disease. World-wide, the use of platelets is still increasing due, in part, to more intensive treatment schedules for such patients. Patients transplanted with cytokine mobilised peripheral blood stem cells (PBSC) have a shortened duration of thrombocytopenia and require fewer platelet transfusions. The principal thrombopoietic cytokine--megakaryocyte growth and differentiation factor (MGDF)- has been identified and is now being evaluated in clinical trials. MGDF treatment is likely to be widely used in patients with haematological malignancies to shorten thrombocytopenia resulting from marrow failure. Platelet transfusions will still be required in patients with malignant disease pre- and early post treatment before MGDF is effective, and in patients with thrombocytopenia caused by massive blood loss or following major surgery. MGDF will, however, reduce the overall requirement for platelets. Transfusion of blood components is associated with a number of adverse effects including viral transmission. Novel strategies such as photodynamic treatment of blood components may maximise the safety of PCs. Erythropoietin (EPO) is clinically indicated for correction of anaemia in a minority of patients and will not significantly affect the requirement for red cell transfusions. PMID- 10174283 TI - Platelet production methods in the United Kingdom. AB - Platelets had traditionally been produced in the United Kingdom (U.K.) either from random donor blood by centrifugation of the platelet rich plasma or by plateletpheresis using various apheresis machines. The proportions of apheresis versus non-apheresis derived platelets varying from centre to centre depending on local policy. The production of platelets from random donor blood is labour intensive and in the late 1980s and early 1990s, biotechnology manufacturers developed newer automated techniques to derive platelets from buffy coats aiming to produce a more standard product and reduce the labour intensity of platelet production. At the same time, apheresis technology has continued to develop with the aim of maximising platelet yields from single donors by yielding 4-6 single unit equivalent of platelets per donor while eliminating the need for further laboratory processing. The trend in some European countries and in North America has been to move away from platelets recovered from whole blood either by buffy coat method or by centrifugation of platelet-rich plasma to plateletpheresis. Intense pressure is being put on blood centres to introduce newer technologies which are inevitably more expensive methods of platelet production. Since 1992, centres in the U.K. have gradually changed their method of platelet production and a survey was conducted to examine the status of platelet production within the U.K. This has shown that many centres are moving away from the production of random donor unit platelets derived by secondary centrifugation of platelet rich plasma (25%) towards buffy-coat derived platelets (45.3%) while plateletpheresis remains fairly static (29.7). PMID- 10174284 TI - Production of platelet concentrates in Switzerland. PMID- 10174285 TI - Platelet concentrates in Germany. PMID- 10174286 TI - Methods for platelet preparation in Italy in 1996. PMID- 10174287 TI - Current methods for the preparation of platelet concentrates: laboratory and clinical aspects. AB - Modern blood transfusion services are striving to attain the highest standards through continual quality improvement and ensure that a formalised quality system is in place in the organisation for time management and waste reduction. With respect to the production of platelet concentrates (PCs), semi-automated and automated procedures are now available which are convenient and allow the processing of multiple packs simultaneously or the production of multiple doses of PCs with low leucocyte content. Nevertheless, PCs are highly heterogeneous on the basis of cellular content and storage stability. Statistical process control (SPC) is essential to ensure that optimal quality is maintained. In the light of new developments in platelet production, their clinical effect should be reappraised. This article highlights some of the key features in the production of PCs, focusing on basic concepts and quality indicators which reflect in vivo functions. The potential for bacteriological contamination and future production strategies are briefly mentioned. PMID- 10174288 TI - International forum: Europe. Buffy-coat-derived platelet concentrates: Swedish experience. AB - The need for source material for plasma products such as factor VIII preparations and improving the quality of red cells for transfusion became determining factors in the choice of methods for blood components in the 1970s and 1980s in Sweden. The possibility to make platelet concentrates (PC) from buffy coats (BC-PC) instead of from platelet-rich plasma (PRP-PC), as first described in England and The Netherlands, using an additive solution as the major component of the platelet storage medium, as first described by Rock et al., has been shown to influence favourably the national supply of blood components and has become accepted as the normal standard procedure in the first half of the 1990s. Leucocyte-depleted PCs, produced from pools of 4-6 BCs, used in all multiple platelet transfusions to thrombocytopenic patients, have strongly reduced the demand for HLA compatible PCs. Nationwide, 79% of the demand of PCs is supplied as BC-PCs, mostly leuco-depleted which, so far, have compared favourably with apheresis-PCs for cost-effectiveness. PMID- 10174289 TI - A system for the supply of platelets suspended in a storage medium including buffy-coat-derived platelet concentrates in combination with "split" apheresis platelets. AB - Our objective was to create a system for the supply of platelet concentrates (PCs) based on leukocyte-filtered PCs suspended in a storage medium (PAS-II) including: (1) pooled buffy-coat-derived (BC) PCs and (2) "split" apheresis PCs. The same standards were intended for the two preparations with regard to composition and blood cell counts. In preliminary studies, similar in vitro data were found for leukocyte-filtered and non-filtered reference BC PCs. Slightly inferior in vitro results than for BC PCs restricted the shelf-life of apheresis PCs to 5 days compared to 7 days for BC PCs. With the present platelet supply system in use as a routine service for one year, the experience was very satisfactory, meeting the demands for PCs very efficiently and resulting in a low out-dating rate (5%). PMID- 10174290 TI - International forum: U.K. Consensus conference on unrelated donor BMT: its use in leukaemias and allied disorders. PMID- 10174291 TI - International forum: Saudi Arabia. Donor screening for HTLV-I in Saudi Arabia: is it cost effective? AB - After screening over 100,000 blood donations for the presence of anti-HTLV-I antibodies, a final prevalence of 0.0038% was established in a multinational donor population. Among 38,201 donations by Saudi Arabian donors, the prevalence was found to be 0.0052%. Fifty-eight donors were found to be repeat reactive in the EIA screen test, but only 6.9% of these (n = 4) were truly infected with HTLV I as judged by the Western blot result. These results indicate that Saudi Arabia is non-endemic for HTLV-I as well as HTLV-II. The cost effectiveness of screening for HTLV-I in healthy blood donors from this area is highly questionable. Calculations point to a final risk of a case of post-transfusion HTLV-I associated disease of approximately one per 100 years at the current level of activity. PMID- 10174292 TI - Hepatitis B core antigen antibody as an indicator of a low grade carrier state for hepatitis B virus in a Saudi Arabian blood donor population. AB - Blood donor screening for anti-hepatitis B core antigen (anti-HBc) was introduced as a surrogate marker of non-A, non-B hepatitis prior to the availability of a specific test for hepatitis C. In areas endemic for hepatitis B virus (HBV), such as Saudi Arabia, earlier studies indicated that up to 30% of blood donors might disqualify if screened for anti-HBc. The issue was readdressed in a study of 6035 consecutive first-time Saudi national blood donors in an attempt to identify a subgroup of anti-HBc positive donors who might be at high risk of being low grade carriers of HBV. An isolated anti-HBc of high titer in a donor with a low or absent anti-hepatitis B surface antigen (anti-HBsAg) was taken as an indicator of increased risk of a low grade carrier state. Using this algorithm, an additional 125 (2%) donors would disqualify. HBsAg immune complex assays and polymerase chain reaction of donor samples with an isolated anti-HBc identified two donors with immune complexes and two donors with HBV DNA. All four donor samples expressed over 90% neutralization in the anti-HBc supplementary testing, indicating high titer anti-HBc. These findings seem to support the suggested policy of donor exclusion based on the anti-HBc and anti-HBsAg serology as a means to eliminate low grade carriers of HBV in endemic areas without jeopardizing the blood supply. PMID- 10174293 TI - The influence of peri-operative blood transfusion during radical hysterectomy on the prognosis of uterine cervical cancer. AB - To evaluate the clinical implications of peri-operative transfusion in the surgical treatment of uterine cervical cancer, a detailed analysis of the cumulative survival rate was performed using clinical data from 145 patients with FIGO stage Ib cervical cancer of the squamous cell type acquired between 1982 and 1989 at the Center for Adult Diseases. The cumulative survival rate was statistically analyzed using the Kaplan Meier method. Of the 145 patients with stage Ib cancer, 103 were considered to have undergone complete excision and received no further treatment post-operatively, and 42 were considered to have undergone incomplete excision because of the involvement of lymph nodes or the lymphovascular space. Of the 79 patients in the former group who received peri operative transfusion, 69 received less than seven units (1400 mL) and 10 received more than eight units (1600 mL). The cumulative 5-year survival rate was 100% in the 24 patients who received no transfusions, 91.7% in those who received less than 1400 mL, and 90.0% in those who received more than 1600 mL. Similarly, of the 42 patients in the incomplete excision group, nine did not receive any peri-operative transfusion, 27 received less than 1400 mL, and six received more than 1600 mL. The 5-year survival rate in these groups was 88.9, 77.8 and 50.0%, respectively. The survival rate of our patients with stage Ib cervical cancer without peri-operative transfusion was significantly higher than that of those with transfusion, regardless of post-operative irradiation therapy status, indicating that peri-operative transfusion has an adverse influence on the prognosis in cervical cancer. PMID- 10174294 TI - Reliability of a new recombinant immunoblot assay (RIBA HIV-1/HIV-2 SIA) as a supplemental (confirmatory) test for HIV-1 and HIV-2 infections. AB - The diagnosis of HIV infection is usually determined using serological methods. Positive results in a screening test should be confirmed with more specific supplementary assays, and the Western blot (WB) is the most frequently used. However, problems of WB, particularly in regard to the significance of indeterminate results, still remain. We evaluate a new recombinant HIV-1/2 antigen-based immunoblot (RIBA) as confirmatory assay in a panel of 190 clinical samples. The RIBA was much more sensitive and specific than WB. In particular, the test allows for a significant reduction in the number of indeterminate results and for more accurate distinction between HIV-1 and/or HIV-2 infections. Thus, these results make tests such as the RIBA instead of WB particularly attractive for validating anti-HIV EIA reactivity. PMID- 10174295 TI - A survey of Canadian neonatal blood transfusion practices. AB - In 1990, the Pediatric Hemotherapy Committee of the American Association of Blood Banks developed and distributed a questionnaire addressing neonatal blood transfusion practices. The same questionnaire was subsequently sent to Canadian university-affiliated hospitals (n = 92). This report describes the results of the Canadian survey. Seventy-two percent (n = 66) of institutions contacted responded. Of these 42% (n = 28) had sufficient experience with neonatal transfusions and provided sufficient data for analysis. Although the majority of stated practices did follow published guidelines, several areas of variability and/or suboptimal practices were identified. With respect to component selection and preparation, suboptimal practices included excessive pretransfusion testing, unnecessary routine washing of RBC concentrates for small-volume transfusions, routine volume reduction of platelet concentrates and the use of suboptimal granulocyte preparations. With respect to transfusion practices, a disturbingly high percentage of respondents indicated that frozen plasma would be given in situations generally considered inappropriate. There was a great deal of variability in the provision of blood components at low risk for CMV, in the use of gamma irradiation and in the platelet count used for prophylactic platelet transfusions. The data collected in this survey provide information concerning practices that require improvement, identify areas where further research is desirable and provide a basis for comparison with current and future neonatal blood transfusion practices. PMID- 10174296 TI - Should cardiac disease prevent autologous blood donation? AB - AIDS has created considerable concern among the public regarding being transfused with potentially infectious blood. However, autologous blood donations are still not maximally provided nor utilized. Significant heart disease disqualifies all allogeneic and most autologous blood donors (American Association of Blood Banks (AABB) Standards 1994). Disqualification is based on the widespread belief that donating blood could possibly be detrimental to their health. However, this belief has not been sufficiently documented. Sixty-eight donors (ages 14-84 years), all with histories of significant cardiac diseases, donated 111 units of whole blood (1-3 units). Twenty-eight patients donated 1 unit, 37 donated 2 units, and three patients donated 3 units. Fifty-nine patients had ischemic heart disease, and nine had valvular heart disease (five with mitral stenosis and four with mitral valve prolapse). No patient received erythropoietin, and only one received equal volume replacement with normal saline during donation. All these patients eagerly wished to donate in spite of being informed of the possible complications. No patient wishing to donate has been refused, and none has experienced any adverse consequences from donating. Forty-four patients underwent total hip/knee replacements. Only 56 units (50%) were transfused to 37 patients (54%). Although our experience is limited, it appears that many patients with histories of well established cardiac diseases can easily tolerate donating blood without compromising their health. PMID- 10174297 TI - Prenatal determination of human platelet antigen type 4 by DNA amplification of amniotic fluid cells. AB - To predict a fetus at risk for neonatal alloimmune thrombocytopenia (NATP) caused by human platelet antigen (HPA)-4 incompatibility, we applied a sequence-specific polymerase chain reaction (PCR-SSP). We were able to determine the HPA-4 genotype of three infants at risk using amniotic fluid cells without the need for fetal blood sampling. The HPA-4 genotypes of amniotic fluid cells determined in this way were completely concordant with the genotype and phenotype of infants' venous blood samples obtained after delivery. Therefore, this technique is also convenient to a fetus at risk in the antenatal management of NATP induced by HPA 4 incompatibility. PMID- 10174298 TI - Cyclosporin and plasmapheresis in treatment of progressive systemic lupus erythematosus (pSLE). AB - The prognosis of patients suffering from progressive systemic lupus erythematosus (pSLE) is poor, despite treatment with intensive drug regimens with combinations of corticosteroids, azathioprine and cyclophosphamide. Side-effects such as infections and malignomas often occur. In the present trial, 21 patients (four male, 17 female, aged 37.9 +/- 12.8) suffering from pSLE for 9.4 +/- 2.6 years, were treated for 2.3 +/- 1.8 years with drug regimens as mentioned above. Then, over a period of 6.4 +/- 2.6 (range 1-8) years, in addition to conventional therapies, cyclosporin (2.5 +/- 0.6 mg/kg body wt/d) and, in active stages of the disease with extremely high concentrations of anti-ds-DNA-, anti-nuclear antibodies and circulating immunocomplexes, plasmapheresis (therapeutic plasma exchange (TPE)) have been applied. Compared with previous treatment modalities, significantly (P < 0.05) more effective and rapid reduction of antibodies was achieved. Clinical symptoms improved within 2 to 4 weeks. Under the new therapeutic regimen all patients reported increased performance and a better quality of life. After 5 to 48 (17.5 +/- 13.8) months, cyclosporin was established as mono-therapy for 8/21 patients. In] the other cases, corticosteroids, azathioprine and cyclophosphamide were reduced by 40 to 100%. No severe side-effects were seen. In acute stages of pSLE and in forms with persistently high antibody levels, the addition of TPE to conventional therapy was very effective, with regard to improving both clinical and laboratory parameters. PMID- 10174299 TI - Incidence of electrocardiographic changes during cytapheresis using an intermittent flow centrifuge, haemonetics V50 and a continuous flow centrifuge, AS104. AB - Electrocardiographic (ECG) monitoring was performed during cytapheresis and the incidence of ECG changes was compared between methods of intermittent flow centrifugation using the Haemonetics V50 with apheresis donors and continuous flow centrifugation with the AS104 for peripheral blood stem cell (PBSC) collection from patients. ST depression, inverted T wave and other ECG changes were found in 49 (14.3%) of the 342 cytaphereses carried out by the intermittent flow centrifugation method and in 8 (4.7%) of the 169 PBSC collections by the continuous flow centrifugation method. This difference was significant (P < 0.05). The hemodynamic changes in the procedure with the AS104 seem to be small. This is considered to be important for prevention of serious ST and T wave changes. PMID- 10174300 TI - The quake that rocked rehabilitation. The Balanced Budget Act of 1997: business implications and survival strategies. PMID- 10174301 TI - The association of rehabilitation nurses. PMID- 10174302 TI - Pediatric functional assessment. Choosing the right tools is the key to comparing outcomes. PMID- 10174303 TI - The use and efficacy of ultrasound. PMID- 10174304 TI - Managing urinary elimination with ultrasound. PMID- 10174305 TI - The returning worker. Improving injured workers' function through an interdisciplinary approach. PMID- 10174306 TI - Doing more with less. Reengineering a rehab hospital for cost-effectiveness entails a new way of thinking. PMID- 10174307 TI - Balance and acquired brain injury. PMID- 10174308 TI - The future of cardiopulmonary rehabilitation. PMID- 10174310 TI - Anaemia of prematurity. Epidemiology, management and costs. AB - Recombinant human erythropoietin (rHuEpo) has been increasingly used in preterm infants in the last 3 to 4 years. Recent studies have indicated a reduction in blood transfusion requirements in infants receiving rHuEpo. No significant adverse effects have emerged, apart from iron deficiency (if iron supplementation is inadequate), and the risk of transfusion-related infection is decreased. Nevertheless, rHuEpo is relatively expensive (a 6-week course costs approximately the same as 2 blood transfusions), so its use requires careful consideration; it is logical to target rHuEpo therapy to those babies who are most likely to be transfused. Using this strategy, 1 study involving stable growing preterm infants has shown that direct costs of blood transfusion and rHuEpo were similar, and the use of rHuEpo was recommended. In addition, use of high-dosage rHuEpo early in the course of management on the neonatal intensive care unit has been shown to reduce direct treatment costs in ill preterm infants. Further studies will continue to identify infants who are likely to benefit from rHuEpo therapy and to define its cost effectiveness in more detail. PMID- 10174309 TI - Treating myocardial infarction in the post-GUSTO era. A European perspective. AB - In recent years, thrombolysis has been established as the treatment of choice for patients with evolving myocardial infarction. Reperfusion of ischaemic myocardium through reopening of the occluded infarct-related vessel results in limitation of infarct size and reduction of morbidity and mortality. The landmark Global Utilisation of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries (GUSTO-I) study, published in 1994, has identified a patent infarct vessel as the key to success of treatment. Opening the infarct vessel by means of coronary angioplasty or percutaneous transluminal coronary angioplasty (PTCA) was believed to be dangerous, expensive and ineffective and was only considered as an alternative when contraindications for thrombolytic treatment were present. However, recent reports from centres with experience in performing coronary angioplasty demonstrated superior results of primary coronary angioplasty (without additional or concomitant thrombolytic therapy) with regard to survival, morbidity and cost effectiveness, when compared with thrombolytic therapy. In hospitals with interventional cardiology facilities throughout Europe, this has resulted in a different attitude towards the treatment of patients with myocardial infarction. In a rapidly increasing number of European heart centres, primary coronary angioplasty is applied to reopen infarct vessels. This article tries to summarise the rationale for this approach. PMID- 10174311 TI - The costs of epilepsy and cost-based evaluations of anticonvulsants. AB - The rapid increase in cost-related studies of epilepsy is a response to the need for information by healthcare organisations and providers who are being asked to include costs in their criteria for choosing among competing anticonvulsants. This article attempts to help non-economists to evaluate the results of research on the cost of epilepsy and cost-related evaluations of anticonvulsants. Selected articles are reviewed as examples of the types of information that they are likely to encounter. The review demonstrates that the most typical approach to the evaluation of anticonvulsants combines hypothetical patients and simulated treatments, based on expert opinions with cost data from different, noncomparable sources to estimate the costs and potential savings of competing drugs. The interpretation of the potential biases from the large array of data from different sources is extremely difficult and the comparison of different results is nearly impossible. The discussion suggests that the most important problem faced by potential consumers of cost-related research on epilepsy is the wide variance in the concepts and methods used to evaluate the cost effectiveness or cost-minimising effects of competing anticonvulsants. The importance of choices among competing anticonvulsants for costs and the well-being of patients make it imperative that researchers adopt concepts and methods that produce a much higher degree of comparability among studies than is now in practice. Some of the articles reviewed make important contributions to the achievement of that objective. PMID- 10174312 TI - An economic evaluation of tiludronic acid treatment in Paget's disease of bone. AB - The objective of this study was to evaluate the long term comparative outcome of intermittent courses of therapy with low-dosage tiludronic acid (400 mg/day) versus etidronic acid in patients with Paget's disease of bone. The long term outcome was evaluated by means of a model, as the number of complications avoided during a 5-year period. Only major complications were considered (fractures of long bones, spinal cord dysfunction, osteoarthritis of the hip), which can be cured by adequate medical intervention, and may thus be valued in terms of direct costs. Deafness was not considered and was not valued. The various additional direct costs incurred (treatment and follow-up) and avoided (complications avoided) were assessed using an extrapolation model, based on the results of a clinical study. A standard costing methodology was used, according to the patterns of care currently in use in France. Costs were calculated from a societal perspective, including social security and private insurance fund reimbursements, and out-of-pocket expenses. These were estimated in French francs (F: 1994 values). The estimated mean treatment cost per patient for the treatment of Paget's disease and its complications over a 5-year period was F34,198 with etidronic acid, and F30,754 to F36,422 with tiludronic acid, depending on whether an optimistic or a conservative view of the efficacy of tiludronic acid was assumed. Despite its higher acquisition cost, the use of tiludronic acid was less expensive in the treatment of Paget's disease and its complications, compared with the use of etidronic acid, when an optimistic view of the efficacy of tiludronic acid was assumed. PMID- 10174313 TI - Economic evaluation of the use of nadroparin calcium in the prophylaxis of deep vein thrombosis and pulmonary embolism in surgical patients in Italy. AB - The objective of this study was to compare the costs, from the perspective of the payer, of using nadroparin calcium, a low-molecular-weight heparin, instead of unfractionated heparin in the prophylaxis of venous thromboembolism in patients undergoing orthopaedic surgery or major general surgery in Italy. The methods used were based on a published meta-analysis and a survey of clinical practice. We constructed a model of the prophylaxis and management of venous thromboembolism in Italy. Resource use associated with individual events was estimated on the basis of the clinical survey. Unit costs, not available from published sources, were taken from charges made by hospitals and from direct observation. A sensitivity analysis was conducted to examine whether the results were robust to changes in key variables. In the base case, compared with unfractionated heparin, prophylaxis with nadroparin calcium reduced the expected costs of managing thromboembolism by 267,226 Italian lire (L, 1994 values; $US1 = L1600 approx.) per patient undergoing orthopaedic surgery, and by L45,588 per patient undergoing major general surgery. Therefore, switching from unfractionated heparin to nadroparin calcium in these patients offers the possibility of significant cost savings to the Italian healthcare system. PMID- 10174314 TI - The impact of Parkinson's disease on health status, health expenditures, and productivity. Estimates from the National Medical Expenditure Survey. AB - Parkinson's disease (PD) is a common disorder that leads to severe disability, despite pharmacological and surgical interventions. As PD progresses, patients and their families experience substantial health and economic burdens. Little research has been conducted into the economic consequences of PD or the impairment of health dimensions, such as social function and mental health, that may accompany the deterioration in economic resources and physical function. In the current study, the US National Medical Expenditure Survey (NMES) was examined as a source of population-based information about health-resource use, medical expenditures and health status. 43 patients with PD were identified, and each was matched with 3 individuals without PD to estimate the costs attributable to PD. Data from the NMES demonstrate the serious health and economic burdens of PD. The patients with PD were clearly shown to have decreased health status, increased health expenditures and lost productivity relative to controls. However, these estimates of the magnitude of disease burden must be used with caution. The small sample size appears to have inadequately represented patients in the earliest and the most advanced stages of PD. There was also considerable variability in case control groups, resulting in wide confidence intervals for the estimates. PMID- 10174315 TI - Interferon-beta in multiple sclerosis. Can we control its costs? PMID- 10174316 TI - Economic evaluation techniques in healthcare. Reinventing the wheel? PMID- 10174317 TI - Applied pharmacoeconomics. When can publication be legitimately withheld? AB - Pharmacoeconomic studies can help decision-makers choose the most efficient drug treatments in our internationally cost-constrained healthcare environment. However, perceptions of bias about the nature of many economic evaluations limit the usefulness of pharmacoeconomic data to decision-makers. In an effort to increase the credibility of pharmacoeconomic studies, several groups have developed methodological guidelines, and one has developed ethical guidelines for these evaluations. In this article, we evaluate issues related to the publication of the results of pharmacoeconomic studies. Pharmacoeconomics is a true science (and should be so treated), rather than a form of marketing. Pharmacoeconomic studies must undergo the same peer review process and be published in serious research journals, as are other types of scientific investigations. Investigators should attempt to publish the results of pharmacoeconomic studies, even (and, perhaps, especially) when the results are not favourable to the sponsor. However, there are acceptable reasons to withhold publication of 'negative' results. For example, when methodological problems plague a study, or when the study addresses an investigational drug not likely to be approved, then researchers are justified in giving up on publication, if they so choose. Similarly, feasibility studies to test methods of data collection or analyses conducted very early in the drug development process need not always be published. Nonetheless, access to all important investigations--regardless of whether the results are positive or negative--will become more important as healthcare becomes more evidence-based, as decisions have impact on large populations of people, and as those in charge of formularies actually begin to use cost-effectiveness analysis to help make choices among competing drugs. PMID- 10174318 TI - Current issues in German healthcare. AB - Germany has developed a model of social health insurance for financing healthcare. The basic characteristics of this model are compulsory membership, income-dependent contributions paid by employers and employees, a comprehensive package of healthcare entitlements, stringent government regulation and implementation by not-for-profit health insurers--the sickness funds--which operate under public law. Since the mid-1970s, when health care cost containment gradually evolved as a new issue in German healthcare policy-making, a long series of reform programmes have been initiated. Two recent development can be noted: the introduction of market competition in health insurance and the introduction of fixed budgets. Market competition in health insurance is now an explicit policy tool in Germany. This article analyses the German healthcare system, the history of healthcare reforms and the current healthcare acts. Special emphasis is given to the German drug market and its regulation. The paper describes the present cost-containment policy for pharmaceutical products, especially the global budget concept which was introduced for medicines and patients' copayments. PMID- 10174319 TI - Is aspirin underused in myocardial infarction? AB - This article reviews the relevant published literature in order to assess whether aspirin (acetylsalicylic acid; ASA) is underused in myocardial infarction (MI), taking into account: (i) the evidence of efficacy and safety from clinical trials; (ii) authoritative recommendations about its use; and (iii) published drug-utilisation studies. The use of low-dosage aspirin in the acute phase of MI, and as secondary prevention, should be recommended to all patients who do not have contraindications to the drug. This is a solid evidence-based recommendation with potential benefits that are, at least, similar to those obtained with other standard treatments. As this treatment is well tolerated and inexpensive, it is also assumed that net savings can be achieved. No conventionally used prophylactic aspirin regimen seems to be free from the risk of serious gastrointestinal toxicity. This is especially important in primary prevention, in which the benefits are small; there is, as yet, no clear evidence that aspirin is indicated for routine use in patients at low risk of occlusive vascular events. We have identified 21 published drug-utilisation studies, and the potential underuse of aspirin in MI was not properly assessed in most of them. In these studies, fairly high aspirin prescription rates were usually documented. However, it seems clear that there is room for improvement, and that a significant proportion of patients who could have benefited from aspirin did not receive it or received less well-studied and more costly drugs. The prescription rates for other drugs with proven efficacy have been lower, and the potential underuse greater, than those documented for aspirin. PMID- 10174320 TI - Health status assessment of the elderly. AB - The elderly are a heterogeneous population group who range from well and completely independent individuals to a smaller proportion who are frail, require help and are high users of the healthcare system. Since health is a state of well being which includes the domains of social, spiritual, psychological and physical function, each of these domains must be evaluated when we are measuring the health of older adults. In this article, we discuss some of the more important aspects of these domains. If we focus exclusively on the diseases which occur in older adults we will miss important aspects of their health status. We may miss the interactions of several different disease processes occurring in 1 individual, and the impact of those diseases on the individual's ability to live independently and his or her quality of life. In this article, we not only justify the measurement of function, cognition, affect and quality of life in the elderly but we also describe the necessary measurement qualities of instruments used to measure health-related quality of life in the elderly. We provide some examples of measurement approaches with which we as researchers and health workers are familiar. PMID- 10174322 TI - Measuring sensitivity in pharmacoeconomic studies. An integration of point sensitivity and range-sensitivity. AB - The level of uncertainty with regard to the outcomes of pharmacoeconomic studies cannot be completely covered by the statistical methods routinely employed to handle uncertainty in clinical research. Sensitivity analysis is the most common methodology to deal with the extra uncertainty associated with pharmacoeconomics, and has also been incorporated in recent guidelines on healthcare evaluation. However, the execution of a sensitivity analysis and the interpretation of its results have not yet been standardised, which may lead to subjectivity and consequently weaken the value of economic evaluations. This article presents a method of dealing more systematically with uncertainty and eliminating potential bias in sensitivity analysis, with regard to the measurement of sensitivity and the comparison of the degree of sensitivity between variables. An assessment of the disadvantages of using slope as a measure of sensitivity leads to 2 types of sensitivity analyses (point-sensitivity and range-sensitivity), which are integrated into one method for the measurement of sensitivity. PMID- 10174321 TI - Cost implications in the management of induction of labour. AB - For many years the standard treatment of induction of labour has been amniotomy followed by intravenous oxytocin. More recently prostaglandin E2 (PGE2; dinoprostone), in various preparations, has been used to both ripen the cervix before amniotomy and administration of oxytocin, and to induce labour on its own. Since the acquisition cost of PGE2 is approximately 15 times that of oxytocin, it is important to justify the use of PGE2. In this paper, literature from 1970 to 1996 has been reviewed and outcomes following the use of PGE2, plus amniotomy and oxytocin if necessary, have been compared with outcomes following the use of amniotomy plus oxytocin alone. No significant differences in the mode of delivery and no serious adverse effects in mothers or babies were detected. Three economic analyses of these approaches to induction of labour have been reviewed. While under certain conditions there may be some cost savings associated with the use of PGE2, neither of the studies reviewed showed substantial, reliable cost savings. Further research is required to identify the patients who would gain most benefit from the use of PGE2. PMID- 10174323 TI - Economic evaluation of oral sumatriptan compared with oral caffeine/ergotamine for migraine. AB - We conducted an economic comparison of oral sumatriptan with oral caffeine/ergotamine in the treatment of patients with migraine. Cost effectiveness, cost-utility and cost-benefit analyses were conducted from societal and health-departmental perspectives. A decision tree was used. Utilities were assigned to health states using the Quality of Well-Being Scale. Simple and probabilistic sensitivity analyses were also carried out. From a societal perspective, using sumatriptan instead of caffeine/ergotamine resulted in an incremental cost-effectiveness ratio of -25 Canadian dollars ($Can) per attack aborted, an incremental cost-utility ratio of -$Can7507 per quality adjusted life-year (QALY), and a net economic benefit of $Can42 per patient per year (1995 values). From the perspective of the health department, the incremental cost-effectiveness ratio was $Can98 per attack aborted, the incremental cost-utility ratio was $Can29,366 per QALY; the grade of recommendation based on past decisions regarding health technology for adoption into health insurance plans was 'moderate'. Sensitivity analysis showed that the results were robust to relatively large changes in the input variables. The incremental health benefits obtained from using oral sumatriptan rather than oral caffeine/ergotamine were achieved at moderately acceptable incremental costs, if past decisions on the adoption of other health technologies are used as a guide. PMID- 10174324 TI - Cost-benefit analysis of riluzole for the treatment of amyotrophic lateral sclerosis. AB - We conducted a cost-benefit analysis of riluzole therapy in patients with amyotrophic lateral sclerosis (ALS; motor neuron disease; Lou Gehrig's disease). The survival of patients with ALS increased by around 3 months as a result of riluzole therapy, from 3 to 3.25 years. A 3-month delay in hospitalisation was also expected as a result of riluzole therapy, resulting in a saving of $US40 per patient (1996 values). This gain was opposed by the additional costs per patient of bi-monthly serum ALT monitoring ($US234), 2 days of extra day-hospital observation ($US369) and other medical costs ($US79), as well as extra outpatient visits ($US26) and costs of medication other than riluzole ($US90), resulting from increased longevity. Using riluzole (at a cost of $US2247 per patient) resulted in an extra burden of $US757 on health services for the gain of an extra 3 months of life expectancy. Thus, health-service costs per life-year gained were $US12,013. Despite the increase in health-service costs as a result of increased longevity, the overall resource benefits to society from using riluzole amounted to $US2884 due to increased productivity benefits, giving a benefit: cost ratio of 1.28:1. Total benefits to society, including a valuation of 3 extra months of life ($US3599), amounted to $US6483, giving a benefit: cost ratio of 2.89:1. Therefore, from a societal perspective, the potential benefits of riluzole in patients with ALS clearly exceed costs. PMID- 10174325 TI - Quality-of-life outcomes and the use of antihistamines in a French national population-based sample of patients with perennial rhinitis. AB - Our primary objective in designing the first large-scale nationwide population based survey in France was to assess the impact of perennial rhinitis on quality of life. Our secondary objective was to describe the use of drug treatment, including histamine H1 antagonists, in that population. A pollbase of 20,000 households was screened for symptoms of rhinitis. 16,786 households responded, including 35,615 patients aged over 15 years, giving an overall response rate of 84%. Using an algorithm, 1367 patients with probable perennial rhinitis were selected for a cross-sectional collection of data about the history of their condition, comorbidity, use of medical resources, sick leave and nasal symptom related quality of life [according to the Medical Outcomes Study 36-Item Short Form Questionnaire (SF-36)]. Finally, multivariate regression techniques were used to describe the relationship between quality-of-life scores and treatment subgroups, controlling for some other confounding factors. The point prevalence of perennial rhinitis was estimated to be 4.1% [95% confidence interval (CI): 3.9 to 4.3%]. Association of perennial rhinitis with a history of asthma was highly significant (13.4% in those with perennial rhinitis vs 3.8% in those without; odds ratio 3.26; p < 0.001). 38% of the patients with perennial rhinitis reported having taken regular medication during the last 3 months. Antihistamine use was associated with use of decongestant or topical nasal products in about one-third of patients. Four SF-36 dimensions (physical functioning, role physical, bodily pain, social functioning) showed significantly higher mean scores (indicating better quality of life) in patients receiving non-anticholinergic histamine H1 antagonist therapy, relative to those receiving other treatments, a difference that was maintained after controlling for gender, age, level of nasal symptoms, medical history of asthma and number of general practitioner visits. These results established the long term impact of perennial rhinitis on quality of life (generic and specific), and raised questions about appropriate therapy, since a positive association between current use of non-anticholinergic antihistamines with improvements on some SF-36 dimensional scores in patients with perennial rhinitis was observed. PMID- 10174327 TI - ISBT 128 still not at starting gate. PMID- 10174326 TI - Azithromycin. A pharmacoeconomic review of its use as a single-dose regimen in the treatment of uncomplicated urogenital Chlamydia trachomatis infections in women. AB - In women, Chlamydia trachomatis infection often occurs in the urethra or cervix, with up to 70% of infections associated with few or no symptoms. Inadequate treatment may lead to infection of the upper genital tract and subsequent pelvic inflammatory disease (PID) in 10 to 40% of patients. PID causes an increased relative risk of ectopic pregnancy of 2.5 to 7.9 and PID may also lead to tubal infertility in about 17% of patients. 60% of infants born of mothers with C. trachomatis infection may become infected, leading to conjunctivitis in 23% and pneumonia in 21%. All of these sequelae of C. trachomatis infection may require in- or outpatient treatment. With > 4 million infections estimated to occur each year in the US, C. trachomatis is one of the most common and costly of the sexually transmitted pathogens. Treatment options for uncomplicated C. trachomatis infections in nonpregnant women include single-dose azithromycin 1000 mg or doxycycline 100 mg twice daily for 7 days orally. In clinical trials, the bacteriological cure rate of single dose azithromycin 1000 mg (95 to 100%) was similar to that of oral doxycycline 200 mg/day for 7 days (88 to 100%) in nonpregnant women. Azithromycin was at least as well tolerated as doxycycline and was associated with mainly mild gastrointestinal adverse effects including diarrhoea, nausea and abdominal pain. Pharmacoeconomic analyses have sought to determine if the 2.7- to 12-fold higher acquisition costs of azithromycin in comparison with doxycycline are offset by its simple single-dose regimen which is likely to aid patient compliance and so optimise drug efficacy. All analyses were retrospective cost-effectiveness decision-tree models and mainly considered direct costs. All models incorporated an estimate of noncompliance with doxycycline and its influence on efficacy. For the treatment of confirmed C. trachomatis infection, azithromycin saved around $US1200 per major outcome avoided (1993 values; third-party payer perspective in the US) or US$3502 per case of PID avoided (1993 values; US healthcare system perspective) compared with doxycycline. If infection was treated empirically, azithromycin was more costly than doxycycline by $US792 (1993 values), but the result was sensitive to changes of some parameters of the model. Azithromycin was more costly than doxycycline from the perspective of a public health clinic which paid for the treatment of initial infection and acute sequelae only. Thus, pharmacoeconomic data from the US support the use of azithromycin in the treatment of nonpregnant women with confirmed C. trachomatis urogenital infections from the perspective of the healthcare system or third-party payer; however, from the perspective of a public clinic, doxycycline is the less costly option. Decreases in doxycycline compliance or azithromycin acquisition cost are factors that favour azithromycin. PMID- 10174328 TI - Unraveling telepathology liability issues no easy matter. PMID- 10174329 TI - Trying to thrive despite daunting odds. PMID- 10174330 TI - CAP readies systems to accept alternative PT. PMID- 10174331 TI - What automation offers microbiology. PMID- 10174332 TI - Benefits of platelet crossmatching: a case in point. PMID- 10174333 TI - Standing out in the crowd of practice guidelines. PMID- 10174334 TI - Countdown to digital imaging. PMID- 10174335 TI - Combating transfusion tribulations. PMID- 10174336 TI - High aspirations. New guidelines offer uniform approach to breast FNA. PMID- 10174337 TI - Mobile telemedicine arrives. PMID- 10174338 TI - Teleradiology service providers. PMID- 10174339 TI - Considerations on time and use: teleradiology experiences from northern Norway. PMID- 10174341 TI - Software toolbox for telemedicine workflow. PMID- 10174340 TI - What's hot and what's not anticipating trends in technology. AB - Technology tends to progress over time in a step fashion. Changes in productivity associated with technology, when followed over time, often plot out as an S curve. Long quiescent periods are interrupted by rapid rises in technology advance and productivity. Anticipating this is important since it often enables us to plan for new technology. The lag in response to change often leads to bad planning or bad decisions. For example, I recently brought a new 166 Mhz laptop just a month before the new 233s came out, with a corresponding drop in the price of the 166 models ... so it clear I am not omniscient on the subject. In this column we will discuss important trends and identify what is hot and what is not in order to help you anticipate change in technology. I'll explore eight areas in depth. I will also touch on what you need to do to take advantage of the new technology if you have invested in older legacy technology. PMID- 10174342 TI - Program activity in the second year of the Rural Telemedicine Grant Program. Part 1. PMID- 10174343 TI - Technical dependability of obstetric ultrasound transmission via ISDN. AB - OBJECTIVE: To evaluate the dependability of a live telemedicine link for the transmission of obstetric ultrasonograms using a commercial telephone network. MATERIALS AND METHODS: We established an integrated services digital network (ISDN), consisting of three dedicated telephone lines from three satellite offices, to our central prenatal diagnostic center. All patients had a sonographic evaluation recorded on videotape by a trained sonographer. A live interactive video telemedicine link was then established, and a perinatologist directed the sonographer through the scan. A report was issued on the basis of the telemedicine examination. The number of calls required to obtain satisfactory real-time images was recorded, as were the reasons for suboptimal transmissions. The first 150 transmissions were excluded from this study. The results in the subsequent 100 patients who agreed to participate were analyzed. RESULTS: We were able to provide obstetric interpretations in all 100 patients scheduled to be examined using the telemedicine link. A single connection was required in 85 cases, two calls in 5 cases, three calls in 8 cases, four calls in 1 case, and five calls in another case. A repeat call was required in 20 cases because of poor image transmission; other repeat calls were caused by failure to connect (5 cases), calls disconnected (2 cases), and no image transmission (2 cases). CONCLUSIONS: The provision of telemedicine services for obstetric ultrasonography in the community is feasible, but the need for repeat connections because of technical failures needs to be incorporated into cost and time analyses in order to provide a measure of the system's efficiency. PMID- 10174344 TI - The Vermont Telemedicine Project: initial implementation phases. AB - OBJECTIVE: A comprehensive rural telemedicine system was implemented between Fletcher-Allen Health Care (FAHC) and a number of community hospitals in three distinct phases. We sought to describe each phase of its implementation to date and evaluate the technology and provider acceptance, as well as overall usage. PHASE I: A room-based video conferencing system with T-1 connections to two rural hospitals was initiated. The primary use of this system was telepathology, which underwent a rigorous evaluation. The system was well accepted by both referring and consulting pathologists, and the diagnostic accuracy was high, 91.2%. PHASE II: A desktop telemedicine system utilizing ISDN transmission at 384 kbps was implemented to six additional hospitals. Continuing medical education as well as consultative services for virtually every medical specialty were offered. Evaluation included tracking usage logs at each site, review of forms filled out for conferences, and (3) review of forms filled out by providers for medical consultations and clinical care delivered over the system. Technology failure represented the most frequent source of problems, particularly with multipoint calls. Usage increased steadily so that by 6 months, there was an average of one documented use per day. The principal use was for care delivered by pathology, surgery, nephrology, and obstetrics and gynecology. Video quality was judged excellent (62%) or satisfactory (15%) in most cases, while audio quality was excellent in 31% of cases and satisfactory in 46%. Overall, referring providers felt that the system improved patient care in 85% of cases, while 100% of the consultants felt this. PHASE III: Because of technology problems encountered in Phase II, a new system was designed and implemented. The network was expanded to additional sites, including physicians' offices. Evaluation is continuing. PHASE IV: Implementation of a regional information system, including video teleconferencing to every to provider's office in the region, is in the initial stages. CONCLUSIONS: Problems with video conferencing technology hamper use, but once providers utilize telemedicine as a clinical tool, use increases steadily. Clinical use across multiple specialties is possible in a manner that most providers feel improves patient care. PMID- 10174345 TI - Telemedicine in support of peacekeeping operations overseas: an audit. AB - BACKGROUND AND OBJECTIVE: Since 1993, the Department of Defense has augmented the medical support for Army units on peacekeeping operations in Macedonia through the medium of telemedicine. This project, known as Operation Primetime 1, was the first satellite-based telemedicine system deployed in support of remote primary care physician in the U.S. military. Its declared aims are: (1) to improve the standard of care; (2) to reduce evacuations; (3) to support junior physicians in the field; and (4) to improve the military effectiveness of the deployed units. This paper audits the success in attaining those goals for the period January 1994 to April 1995. METHODS: A log was collated from the referring units and questionnaires completed by both referring and consulting physicians. The referring physicians were interviewed on their return from Macedonia, and a more detailed study was undertaken of cases in which a change in outcome was noted. Follow-up interview of consultants was not possible. RESULTS: A total of 53 consults were undertaken on 47 patients. The use of telemedicine affected the decision to evacuate 13 times (13/47), with a net reduction of 9 evacuations. Management of individual cases was changed in 30 of the 47 cases in which telemedicine was used. Physician confidence and military effectiveness were also improved. The level of utilization of the system was largely dependent on a training and sustainment program. Units and General Medical Officers who were trained in the clinical use of telemedicine and the technical sustainment of the equipment used the system; those who were not, did not. Most patients (45/47) were treated satisfactorily with a single consult. Telemedicine under these circumstances seems to be cost effective. The deployed sites chose the referral centers that provided the best service. CONCLUSIONS: Telemedicine is a valuable tool capable of augmenting medical support to deployed military units. A successful deployed telemedicine project requires an integrated support package that includes adequate provision for training and equipment sustainment at both ends of the link. Experience with telemedicine in Operation Primetime indicates the potential for substantial cost savings as well as cost-effective medical care. Further application of telemedicine should be encouraged. Successful deployment of telemedicine projects may hinge on an integrated support package. PMID- 10174346 TI - Rural applications of telemedicine. AB - OBJECTIVES: To describe the status of telemedicine in rural America, the characteristics of health care facilities using telemedicine technologies to serve rural patients, the volume and scope of services delivered, the costs associated with this care, and the funding sources. METHODS: A screening survey was mailed to all 2472 nonfederal U.S. hospitals located outside metropolitan areas. Nonrespondents were interviewed by telephone. Those who reported some form of telemedicine capability, and all the telemedicine affiliates they named, became the sample for a detailed follow-up survey (N = 558) in January 1996. RESULTS: Ninety-six per cent of all rural hospitals responded to the screener survey, and 89% of the 558 identified telemedicine facilities responded to the detailed follow-up survey (total respondents = 499). In this cross-sectional study, two thirds of the telemedicine respondents (340) were using only teleradiology. Of the 159 telemedicine programs pursuing other clinical applications, 67% had been using telemedicine for 2 years or less. Telemedicine facilities have tried many clinical specialty applications, the most common being radiology, cardiology, and orthopedics. At this early stage of technology diffusion, reported utilization of the telemedicine systems for both clinical and nonclinical applications was very low, and the unit costs of equipment acquisition and operating expenses were corresponding high. Programs most commonly used hospital financial resources and federal grants and contracts for support. Telemedicine networks planned to grow from an average of nine facilities to an average of 13 facilities during 1996. CONCLUSIONS: Investment has been rapid in telemedicine, and the installed base reported in this survey was large, sophisticated, and growing rapidly. Nonclinical uses of the technology (e.g., meetings, training sessions, continuing medical education) were more common than clinical consultations, although the volumes of both were quite low. Investment and expansion to new sites were occurring in the absence of a favorable payor reimbursement environment and in spite of low volume at most operating sites, demonstrating optimism about the future of telemedicine and the potential for nonclinical applications. PMID- 10174347 TI - Telemedicine for dermatology care in rural patients. AB - BACKGROUND: Rural patients who develop dermatologic disorders often do not seek specialty care because of multiple logistical and economic factors. OBJECTIVE: To assess the effect of teledermatology consultations on the cost of care for a given episode of illness. METHODS: Telemedicine records were reviewed for 119 visits by 87 patients referred for teledermatology consultation over a 17-month period. RESULTS: Seven patients (8%) required follow-up in the dermatologist office for extended care, while 20 patients (23%) (52 visits) underwent follow-up teledermatology evaluation. The average duration of the dermatologic condition for each patient prior to the telemedical consultation was 17 months. The average of care for the diagnosed dermatologic condition, for all patients during an average period of 8 months prior to teledermatology was $294, compared with $141 for the 6 months after diagnosis by teledermatology. CONCLUSIONS: Telemedicine can be effective for dermatology consultation in new patients referred from rural communities. Our data indicate teledermatology can decrease the cost of care for the diagnosed condition. PMID- 10174348 TI - Four years with teleradiology: a technical description. AB - Since September 1992, Troms Military Hospital (Norway) has been connected to the larger University Hospital of Tromso by a teleradiology link transmitting about 6000 examinations annually. In the spring of 1995, the system was upgraded with a digital X-ray unit, thereby almost eliminating the scanning of analog radiographs. This article describes the technical development of the link. The discussion suggests ways of improving the teleradiology link, particularly in terms of integrating the radiology information system (RIS) and picture archiving and communication system (PACS). PMID- 10174349 TI - Telemedicine: extension to home care. AB - Although there are multiple challenges facing the use of telemedicine in home health care, it seems likely that they will be resolved. This analysis projects significant increases in productivity and savings to be realized by implementing a telemedicine system (such as the Tevital Home Care System) compared with traditional home care services. Additional savings are expected as a result of the reduction in the utilization of medical services other than home health care. At the same time, telemedicine offers conceivable benefits such as improved access for consumers, extended coverage capability by home health care agencies, decreased inefficiencies attributable to the complications associated with agency personnel travel, improved agency capacity for preventive care, and, ultimately, heightened consumer satisfaction and both physical and psychological well-being. Taken together, these benefits make adoption of telemedicine technology by home care providers highly desirable. PMID- 10174350 TI - Chicago downsizing. AHA's early retirement plan centers on Windy City office. PMID- 10174351 TI - Where are the savings? Study finds hospital alliances fail to achieve expected cost efficiencies. PMID- 10174352 TI - Va. merger slowed by monopoly concerns. PMID- 10174353 TI - 'I told you so.' For-profits laud GAO report; critics call it superficial. PMID- 10174354 TI - Whither Columbia? Healthcare giant to change its name next year. PMID- 10174355 TI - Change coming to FDA. Law should speed approvals, but critics say it's not enough. PMID- 10174356 TI - Full plate awaits new HCFA chief. PMID- 10174357 TI - The ghost of ClintonCare. In fight against managed-care regulation, Republications return to successful theme. PMID- 10174358 TI - As more and more doctors join physician groups, antitrust experts wonder whether hospitals and health plans will be ... outgunned. AB - To increase market leverage, more doctors are forming networks. That's setting off alarms among economists and antitrust experts who say such organizations are mushrooming without proven benefits for consumers. Some argue that more areas of the country could be saddled with monopolies that stifle competition. Hospitals and health plans fear physicians' new power could leave them outgunned. PMID- 10174359 TI - Are hospitals playing fair? Study says doc-practice buys may be aimed at referrals. PMID- 10174360 TI - Calculated move. S&P adds new ratios to gauge not-for-profits' strength. PMID- 10174361 TI - SuperClinic a masterpiece of modern healthcare. PMID- 10174362 TI - Northland Health living within its means and expanding health services. PMID- 10174363 TI - More procedures in the North Health region. PMID- 10174364 TI - The state of NZ's health services and how Labour would address the problems. AB - Controversy over the funding and provision of health services has escalated again in recent weeks. The following, an abridged version of an address by Labour leader Helen Clark on October 15 at the Dunedin School of Medicine, surveys present directions and sets out Labour's prescription for change. PMID- 10174365 TI - Education and development of health and disability workforce. PMID- 10174366 TI - Handling disabilities, chronic health impairments, and absences from work under federal law. PMID- 10174367 TI - Security measures for protecting confdential information on the Internet and Intranets. PMID- 10174368 TI - Measuring HR value-added from the outside in. PMID- 10174369 TI - Assessing the value of multisource feedback. PMID- 10174370 TI - An employer's guide to meeting the challenge of union organizing. PMID- 10174371 TI - Re-engineering hospital and healthcare processes. PMID- 10174372 TI - Medical gas pipeline installations. PMID- 10174373 TI - Spectrum of healthcare delivery from hospital to home in the United Kingdom. PMID- 10174374 TI - Designing for patients--redeveloping De Bijtjes Hospital. PMID- 10174375 TI - Assessment of methodological practices in the evaluation of alcohol and other drug (AOD) abuse prevention. AB - No authoritative consensus has been achieved on which substance abuse prevention activities are effective for given populations. One response to concern about "what works" took the form of a National Structured Evaluation (NSE), mandated by the Anti-Drug Abuse Act of 1988. The present paper describes the NSE's pivotal task of determining whether evaluation methodologies applied to substance abuse prevention were adequate to produce credible findings. The lessons learned from this evaluation experience, in turn, offer guidance on changes that must be made in the application of evaluation methodology prior to a conclusive demonstration of the value of prevention efforts. PMID- 10174376 TI - Patterns of service utilization for Mexican American majority students who use alcohol or other drugs. AB - A substance use and attitude survey was given to 436 students ranging in grades from fourth to twelfth in a Southwestern United States school district. Unique features of this district include a student body that is 90% Mexican American and the proximity to the Mexico border. The data revealed that eighth grade students were significantly more likely to seek a school counselor for help with drug use than tenth or twelfth grade students. PMID- 10174377 TI - Native Americans: a neglected health care crisis and a solution. PMID- 10174378 TI - Everybody into the pool! Medicare in the twenty-first century. AB - Both the President and now Republicans have proposed to slow the growth of Medicare costs by allowing seniors to join private managed care health insurance plans. In this article, the author demonstrates that a private market in health insurance will not function like a "normal" commercial insurance market, will constantly be undermined by adverse selection, and therefore is unlikely to achieve the objectives for which it is being created. This result follows from established principles of commercial insurance and our modern understanding of the pathophysiology of disease. PMID- 10174379 TI - Gender and support for mental health research in Ontario: 1992-94: a summary. AB - Based on early research by Stark-Adamec (1981), the question was explored as to whether current mental health funding appeared to be more relevant to male or female concerns, or to neither specifically. Three data sets, consisting of a total of 117 grants and 43 Fellowships awarded by the Ontario Mental Health Foundation from 1992-1994, were coded in terms of these concerns. For both Grants and Fellowships, a high proportion were coded as being primarily concerned with neither gender specifically. Some additional data, in terms of DSM III-R categories and grant committee memberships, were also explored, with, in general, similar findings. From one perspective, therefore, these findings do not support the notion of "gender bias." From another perspective, however, it does lend current support to Stark-Adamec's earlier findings that the mental health concerns of women remain poorly represented in mental health funding. Some discussion, as well as implications and limitations of the findings, are outlined. PMID- 10174380 TI - The effects of gender on primary care physician attitudes and practice orientations. AB - What gender-related differences are there among primary care physicians, and what are the implications of the similarities and differences among male and female physicians for health care reform? This study delineates the similarities and differences between male and female physicians. There is a statistically significant relationship between gender and physicians' ages, years in practice, medical practice organization, practice location, and concerns for professional autonomy and the paperwork demands of an alternative health care plan (AHP). There are no significant gender-related differences in physicians' concerns for reimbursement, support for the ongoing innovations in the health care delivery system, support for government involvement in health care delivery and financing, and in physicians' attitudes toward Medicaid beneficiaries. Although the majority of the female subjects of this study practice in public medical institutions, there are no statistically significant differences in male and female physicians' Medicaid caseloads, and in their participation in a government-sponsored alternative health care delivery plan for Medicaid beneficiaries. The study concludes by exploring the implications of the findings for health care reform. PMID- 10174381 TI - Organizational factors related to AIDS/HIV education in outpatient substance abuse treatment units. AB - The association of HIV and AIDS with intravenous drug use is well documented. Given this, substance abuse treatment providers must figure prominently in any effective national response to HIV/AIDS. The strategies employed by human service managers to address AIDS may be important in explaining how substance abuse treatment units implement policies and programs concerning AIDS-related prevention services. This paper utilizes data from the National Drug Abuse Treatment System Survey to examine how strategic activities concerning AIDS/HIV undertaken by outpatient substance abuse treatment unit managers impacted the provision of preventive AIDS-related services to clients. Results of multiple regression analysis indicate collaboration with other human service organizations and environmental scanning activities are important variables in explaining variation among substance abuse treatment units in the provision of AIDS prevention education to clients. Based on these findings, implications for future research and policy concerning AIDS prevention within the context of substance abuse treatment are made. PMID- 10174382 TI - Causal pathways to infant mortality: linking social variables to infant mortality through intermediate variables. AB - Using a conceptual model that integrates social and biomedical models of causation, this paper delineates the pathways through which social factors ultimately influence infant mortality in the African-American community. Two social factors, maternal education and marital status, are shown to influence the risk of infant death through the following intermediate variables: bio demographic (maternal age, birth order, birth interval and outcome of last pregnancy), health care (prenatal care utilization) and proximate infant health status at birth (preterm delivery and low birth weight). While the impact of maternal education is largely explained by the intermediate variables, marital status remains a significant, albeit a weak, predictor net of all other variables. PMID- 10174383 TI - The politics of Alzheimer's special care units: lessons to be learned from the demented? AB - The development of nursing home special care units for Alzheimer's Disease is linked to the political emergence of the disease in the past two decades. This article will explore the response of the nursing home industry to Alzheimer's Disease in the way of special care programs. Similarities and differences between the demented population and other groups served in nursing homes will be highlighted. Issues to be addressed before special care programs are developed for other populations will be suggested. PMID- 10174384 TI - The media and AIDS: health elite perspectives of coverage. AB - Most writers assessing AIDS have been critical of the media's coverage of this epidemic. To ascertain the views of key elites on media coverage of AIDS, the authors surveyed chief state public health officers, chairs of legislative health committees, and directors of hospital associations. In general, these groups tended to reject criticisms that media handling of AIDS is unbalanced. Conversely, however, they also generally rate the media as not doing a good job of educating the public about AIDS. The media's success in accurately communicating professional perspectives regarding AIDS might have accounted for their relative lack of independent influence in AIDS policymaking. The media exhibited a "guard dog" role-protecting the health professionals' positions instead of an agenda-setting role-dictating to the decision-makers what issues they should be addressing. PMID- 10174385 TI - The use of physical restraints in nursing homes: pre- and post-Nursing Home Reform Act. AB - The purposes of this paper are: (1) to determine resident risk factors for the use of physical restraints since the implementation of the Nursing Home Reform Act (NHRA) of 1987, (2) compare these results with resident risk factors for the use of physical restraints prior to the implementation of the NHRA, and (3) to identify facility characteristics associated with the use of physical restraints. The data used are from 4,215 nursing home residents in 268 facilities who were evaluated using the Minimum Data Set (MDS) in six month periods in both 1990 and 1993. Results indicate that the NHRA may have been successful in reducing the use of physical restraints; however, it would appear to have had less impact on the types of residents who are restrained. It is also shown that the use of physical restraints is associated with facility characteristics. PMID- 10174386 TI - The lowdown on high-rise fires. PMID- 10174387 TI - A practical approach to competency assessment. AB - Assessing clinical performance is difficult. Members of the Nursing Service Clinical Practice Committee at the Carl T. Hayden Veterans Affairs Medical Center in Phoenix developed a comprehensive program of competency assessment based on performance measures. This article describes the committee's process of developing and implementing the program and includes a blueprint for competency assessment and selected performance measures for all nursing staff who provide patient care. The approach to competency assessment includes performance measures specific to patients' ages. PMID- 10174388 TI - Exploring the formation of an employee injury team. AB - In May 1994, it was noted that lost work days due to employee injuries were out of control at MedCenter Hospital in Marion, OH. An employee injury team was commissioned by the continuous quality improvement steering committee to investigate and make recommendations to reduce lost workdays. An analysis of the situation required a data search that revealed several patterns and trends. This information was then examined and a decision was made to institute a "Back Care: Train the Trainer" program to reduce the major cause of employee injuries--back sprains and strains. The concept of teamwork is defined and the developmental process of a team is explored. PMID- 10174389 TI - Ethics and the healthcare quality professional. PMID- 10174390 TI - Redesign of a hospital's internal medicine service. AB - Hospital internal medicine and family practice care were redesigned in July 1995 at Kaiser Permanente of Colorado. The objectives were to provide for a full time dedicated inpatient team, improve continuity of care, and establish a two-tiered process of admission. Physicians were divided into four tracks that marked varying degrees of time in the hospital. A position of triage physician was created that screened all potential admissions to internal medicine. Hospital inpatient days per thousand members, unadjusted lengths of stay, patient readmission rates, and satisfaction questionnaires were obtained both before and after the change. The change achieved significant reductions in unadjusted average lengths of stay and days per thousand without diminishing quality of care, as reflected by hospital readmission rates and by patient satisfaction surveys. PMID- 10174391 TI - Continuous quality improvement efforts increase operating room efficiency. AB - The surgical service at the Philadelphia Department of Veterans Affairs Medical Center has been making a continuous effort toward improving efficiency in the operating room. A multidisciplinary task force was created in May 1994 to look at delays in operating room start times for the first case of the day. This article identifies problems that contributed to the delays and the changes implemented, along with a statistical analysis of the data collected. The team discovered that delays were related to system problems in the perioperative process and were not caused by any specific problem. Many of these problems proved correctable, as the statistical analysis shows, and the result was significant improvement in operating room efficiency. PMID- 10174392 TI - Provider profiling: severity-adjusted versus severity-based outcomes. AB - Providers will continue to experience increasing pressure to demonstrate cost effective, high-quality care. For relevant comparisons between providers, outcomes must be evaluated with respect to severity of illness and mortality risk. However, most hospitals use patient classification methods, such as Medicare and Health Care Financing Administration diagnosis-related groups (DRGs), which group together different levels of severity and mortality risk. The most common approach for developing severity-adjusted outcomes for groups of cases with dissimilar severity levels is to divide a statistic by a factor such as the Medicare case mix index, which was not designed or intended for that purpose. As an alternative, providers are increasingly using severity-based methods that classify patients as to severity levels within each diagnosis related group. The key to severity-based profiling is the classification of cases to similar patient groups and comparison to selected benchmarks for variance analysis at each severity level. Effective provider profiling requires that hospital staff and physicians work together toward the common goal of accurate and complete documentation and coding of all medical conditions. Through use of more accurate severity-based profiling, providers are better able to identify opportunities to improve performance and demonstrate cost-effectiveness and quality to buyers, beneficiaries, and third-party reviewers. PMID- 10174393 TI - Trends in specialty certification. AB - From 1980 to 1996, 334,597 certificates were issued by the 24 specialty boards. Of these certificates, 164,728 (49.2%) were issued in primary care specialties, 100,981 (30.2%) were certificates in the other medical specialties, and 68,888 (20.5%) were certificates in the surgical specialties. The figure above illustrates the changes that have occurred in the pool of board-certified physicians from 1980 to 1996. For the years reported, the number of certificates issued in the primary care specialties and in the other medical specialties has consistently exceeded those in the surgical specialties. It is clear that the pool of board-certified surgeons as a percentage of the total pool of board certified physicians has declined. In 1980, the total number of certificates issued by the 24 specialty boards was 16,034, with surgical specialty certificates accounting for 23.8 percent of that number. By 1996, surgical specialty certificates accounted for 16.7 percent of the 26,462 certificates issued by the 24 boards. In 1980, 1986, 1989, 1995, and 1996 primary care specialty certificates accounted for more than 50 percent of the total number of certificates issued by the 24 specialty boards in those years. Given the substantial growth in the number of certificates in the primary care and other medical specialties depicted in the figure, certificates in the surgical specialties as a percentage of the total number of certificates has remained stable. PMID- 10174394 TI - The day surgery was changed forever. PMID- 10174395 TI - The odds grow longer. Doctors had hoped by now to have eliminated the AIDS virus from some patients. No such luck. PMID- 10174396 TI - AIDS drugs fail a test. New studies show they don't eliminate all HIV. PMID- 10174397 TI - Gone today, hair tomorrow? PMID- 10174398 TI - MEDGuide and patient package inserts--again? AB - This article will trace the history and effects of the PPI from the time of its original concept by the FDA in the early 1970's to its current status. It will also address the response to this FDA initiative by the industry, medical community and consumer groups. Initiatives in other countries and future issues will also be discussed. PMID- 10174399 TI - Alternate method of acquisition for health care services; authorized by the federal acquisition regulations--IHS. General notice. AB - The Indian Health Service (IHS) issues this General Notice to inform the public that IHS has adopted the Rate Quotation as an alternate acquisition method to establish reimbursement rates for health care services purchased by its Contract Health Services Program. PMID- 10174400 TI - Availability of the HRSA competitive grants preview--HRSA. General notice. AB - HRSA announces the availability of the HRSA Competitive Grants Preview publication for Fall 1997. This edition of the Preview is a comprehensive review of HRSA's Fiscal Year 1998 programs. The purpose of the Preview is to provide the general public with a single source of program and application information related to the Agency's annual grant planning review. The Preview is designed to replace multiple Federal Register notices which traditionally advertised the availability of HRSA's discretionary funds for its various programs. In this edition of the Preview, HRSA's programs which provide funding for loan repayments and scholarships to individuals have been included in the section "Additional HRSA Programs." It should be noted that other program initiatives responsive to new or emerging issues in the health care area and unanticipated at the time of publication of the Preview, may be advertised through the Federal Register mechanism from time-to-time. Deadlines or other requirements appearing in the Federal Register are not changed by this notice. The Preview contains a description of competitive and additional programs scheduled for review in Fiscal Year 1998 and includes instructions on how to access the Agency for information and receive application kits for all programs announced. Specifically, the following information is included in the Preview: Program Title, Legislative Authority, Purpose, Eligibility, Estimated Amount of Competition, Estimated Number of Awards, Funding Priorities and/or Preferences, Projected Award Date, Application Deadline, Application Kit Availability, Catalog of Federal Domestic Assistance (CFDA) program identification number, and programmatic contact. PMID- 10174401 TI - Rehabilitation resources: a select list of journals. PMID- 10174402 TI - Get out of your library and learn what your customers need. PMID- 10174403 TI - Accessing Internet--tips for hospital librarians. PMID- 10174404 TI - A rose by any other name: defining the OPL (one-person library). PMID- 10174405 TI - Internet, Intranets offer opportunities to expand our influence. PMID- 10174406 TI - Space: the final frontier--maximizing space in the hospital library. PMID- 10174407 TI - A case for 'just in time:' could it be right for your hospital, too? AB - When people complain about the escalating cost of health care, malpractice suits are often blamed. But the reality is that hospitals' biggest problem may lie in the storeroom, rather than the courtroom. According to a recent study, hospitals spend about $83 billion per year on supplies--$11 billion of which could be reduced through more efficient supply chain practices. In fact, one leading consultant was recently quoted as saying the supply chain may be the number one area where hospitals can reduce cost. While these statements may be ambitious, the sad truth is that the healthcare industry has been slower than others to adopt money-saving logistics practices like just-in-time (JIT) and continuous replenishment, as well as supporting technology like bar coding and radio frequency. As a result, it has been missing out on some significant cost advantages. This article takes a look at how St. Luke's-Roosevelt Hospital Center in New York City implemented a customized JIT inventory system, saving more than $3 million per year. PMID- 10174408 TI - Capital equipment budgeting: changing an art to a science. AB - In today's integrated healthcare environment, one component of financial management remains antiquated in many facilities--the budgeting process for capital equipment. Many institutions budget for capital equipment based upon individual departmental wish lists and hopeful dreams. These highly inefficient practices are being replaced with automated systems that create departmental data exchanges, utilization analyses, life-cycle cost justifications and enterprise wide budget roll-ups. This article shows how automated capital budgeting systems help reduce capital spending by identifying utilization trends, providing for demand matching, and maintaining cost control data which enable the financial manager or asset steward to analyze and justify appropriate acquisitions. PMID- 10174409 TI - Models for virtual healthcare systems. AB - Historically, the healthcare industry has focused primarily on issues of quality. Today, cost is the primary concern of the public, politicians and healthcare providers. Healthcare providers are responding by questioning old assumptions about their roles in the industry. They are seeking new growth opportunities. Hospitals, for example, are taking on responsibilities once assumed by insurers and physicians. Healthcare providers also are developing strategies to consolidate resources, implement integrated information systems, and, in some cases, decentralize operations. This article uses examples from the experiences of the Baylor University Medical Center in Dallas to illustrate how healthcare systems are responding to the challenges of managed care by cutting costs while improving the quality of services. PMID- 10174410 TI - EDI is a business concept. PMID- 10174411 TI - Uniform patient data uses and challenges. PMID- 10174413 TI - Balanced budget bonanza. PMID- 10174412 TI - Get your CFO involved. PMID- 10174414 TI - Internet-based disease and demand management. PMID- 10174415 TI - Nonmigraine headaches. AB - The easiest-to-treat nonmigraine headaches for the 18-to-64 year old population have an average duration of 60 days. The most common diagnostic imaging test used is the computed tomography scan performed on the head or brain. Two out of 1,000 patients have a hospital admission. About 43% of the PTEs are treated without prescription. When a single prescription drug group is used, 56.7% of the prescriptions are for pain relief drugs. Nonsteroidal anti-inflammatory drugs are the most prescribed single drug group for this condition. PMID- 10174416 TI - Hospital occupancy rates: the effect of managed care on inpatient utilization. PMID- 10174417 TI - A conversation with David Eddy, MD, PhD. PMID- 10174418 TI - Electronic employee benefit management services. AB - Traditionally, employers were forced to accept the inefficiencies and costliness associated with the use of paper-based systems in the management and tracking of corporate health benefits. Advances in technology, however, are offering them new alternatives. Electronic employee benefit management systems are increasingly drawing employers' attention for their ability to provide simpler, more efficient processing of corporate benefits at reduced costs. PMID- 10174419 TI - Diffusing anti-managed care legislation. PMID- 10174420 TI - Putting patients first. PMID- 10174421 TI - What does the legislation mean for the future of managed care? PMID- 10174422 TI - Legislative challenges facing managed care pharmacy. PMID- 10174423 TI - The economic value of individualizing drug therapy. PMID- 10174424 TI - Scene safety: what does it really mean? PMID- 10174426 TI - EMS and vehicle safety. PMID- 10174425 TI - Rainy-day heroes. Meet the winners of the 1997 EMS Magazine/Braun Industries' EMT/Paramedic of the Year Award. PMID- 10174427 TI - Get a charge! PMID- 10174428 TI - Evidence preservation and collection: where does EMS fit in? PMID- 10174429 TI - EMS for children with special healthcare needs. PMID- 10174430 TI - Follow the signs. PMID- 10174431 TI - Unwarmed IVs and severe trauma: a dangerous combination. PMID- 10174432 TI - Anatomy of a fleet manager. PMID- 10174433 TI - Non-profits and the Internet. PMID- 10174434 TI - A question of community: at not-for-profit hospitals health is a local affair. AB - For-profit hospitals' entrepreneurial status, big business climate, and adherence to market discipline mandate that their services be considered akin to any other market commodity, to be bought and sold at the highest margin to the largest audience. Investor owned healthcare's primary allegiance must be a reasonable return to its stockholders and as a result it must avoid unprofitable services and unprofitable patients, by displacing their costly burdens onto the rest of the healthcare system. PMID- 10174435 TI - 1998 non-profit software guide. PMID- 10174436 TI - Physician practice management companies: implications for hospital-based integrated delivery systems. AB - Physician practice management companies (PPMCs) are one of the most visible entrants into the industry of managing physician practices, and anywhere from 100 150 are already in operation. Although PPMCs and hospital-based integrated delivery systems (IDSs) differ from each other in many ways, they share a number of common features, including the pursuit of capitation contracts from payors. As a result, PPMCs pose a growing, direct threat to hospital systems in competing for managed care contracts that cover physician service. PPMCs also provide an alternative to hospital-based IDSs at the local market level for physician group consolidation. This article looks at the structure, operation, and strategy of PPMCs and examines what implications their growth will have for hospital-based IDSs. PMID- 10174437 TI - Another perspective on practice management companies. PMID- 10174438 TI - Physician practice management companies: allure for physicians or added value to populations? PMID- 10174439 TI - Physician practice management companies: what do they offer physicians? PMID- 10174440 TI - Risk taking: a supervisory imperative. AB - Beset with job uncertainty and shifting responsibilities, today's health care supervisors are faced with frequent decisions that impact their careers and professional status. To stand pat and avoid change usually involve greater risk than taking chances and may result in job loss. To make bad decisions can also be detrimental. The goal of this article is to encourage one to accept accountability, to avoid the "victim complex," and to make decisions more effectively. PMID- 10174441 TI - When change is a must. AB - Change is a significant concept in health care. It is critical that health care professionals understand change dynamics and implement strategies to adapt to the changes in the modern workplace. PMID- 10174442 TI - The benefits of music in hospital waiting rooms. AB - This study investigated the impact of music on visitors in a hospital surgery/intensive care unit waiting room. The researchers controlled the presence/absence of music in the waiting area. Visitors' stress levels and perceptions of customer service were assessed through a questionnaire handed out by hospital volunteers. Results indicated that music reduced self-reported stress levels and that visitor stress levels were inversely related to perceptions of customer service. The implications of these findings for supervisors and other health care personnel are discussed. PMID- 10174443 TI - Reducing nurse aide turnover through the use of weighted applications blank procedure. AB - High turnover rates among hospital nurses demand rigorous and valid processes of research to determine the reasons motivating such attrition. This study was designed to determine whether use of a weighted application blank has the potential to improve the selection of employees in the nursing home industry. The use of weighted application blanks is, in essence, a proactive approach to reducing turnover. The initial results exhibit great potential to reduce high levels of turnover by reducing the number of poor candidates selected for employment. PMID- 10174444 TI - Management by enlightened self-interest: technique versus kindness. AB - The day of the pat answer is past. The day of the quick fix is over. Today we are looking beyond the quarterly report into the next century. We now speak of winning combinations, enduring values, and lasting corporate structures. This article examines the application of "enlightened self-interest" to the leadership functions in the highly competitive, hyperturbulent health care industry. Empirical evidence is offered that demonstrates that prosocial leadership behavior enhances the willingness of workers to sustain not only a high level of quality work performance but also an advanced degree of citizenship behavior in the workplace. PMID- 10174446 TI - Formula management: in search of magic solutions. AB - Formula management is the unjustified reliance on a set of rules or prescribed behaviors--a management formula, fad, or "flavor-of-the-month"--as the answer to an organization's needs. It is the manifestation of a tendency to believe that the essence of management can be proceduralized, that the art of management can be replaced with an expanding science of management. This tendency has been repeatedly demonstrated in the application of concepts such as management by objectives (MBO) and the variants of total quality management (TQM). All of management's "formulas" have their place; however, none of them provide all of management's needed answers. To view any of the specifically delineated "kinds of management"--all of which are highly susceptible to misapplication and resistance to change both blatant and subtle--as a cure-all is fully as inappropriate as denying their value out of hand. Formula or not, organizational results will continue to depend on the practice of the art, as well as the science, of management. PMID- 10174445 TI - Distance education for the health care supervisor. AB - Health care supervisors are being driven by the rapid changes in health care today. One demand is to complete their undergraduate degree or even a graduate degree. Few of us are able to devote the many hours required to attend on-campus classes full time. Now there is an alternative. Busy health care supervisors can now complete their undergraduate or graduate degrees from the comfort of their home--maintaining a job and family life. PMID- 10174447 TI - A supervisor asks: "Matters of attendance". PMID- 10174448 TI - Alternative dispute resolution: a conflict management tool in health care. AB - This article focuses on methods of resolving conflict either within or between health care organizations using an alternative dispute resolution (ADR) strategy. After identifying the principal sources of contemporary disagreements within health services settings, the authors describe the basis of ADR. This is followed by a discussion of some common obstacles to settling a dispute. The principal communication guidelines and stages of a mediation session are presented. An alternative dispute resolution framework is proposed that includes an Office of Dispute Resolution (ODR). Also provided is a series of attributes that together comprise the core of mediation as a discipline. PMID- 10174449 TI - Value innovation: the strategic logic of high growth. AB - Why are some companies able to sustain high growth in revenues and profits--and others are not? To answer that question, the authors, both of INSEAD, spent five years studying more than 30 companies around the world. They found that the difference between the high-growth companies and their less successful competitors was in each group's assumptions about strategy. Managers of the less successful companies followed conventional strategic logic. Managers of the high growth companies followed what the authors call the logic of value innovation. Conventional strategic logic and value innovation differ along the basic dimensions of strategy. Many companies take their industry's conditions as given; value innovators don't. Many companies let competitors set the parameters of their strategic thinking; value innovators do not use rivals as benchmarks. Rather than focus on the differences among customers, value innovators look for what customers value in common. Rather than view opportunities through the lens of existing assets and capabilities, value innovators ask, What if we start anew? The authors tell the story of the French hotelier Accor, which discarded the notion of what a hotel is supposed to look like in order to offer what most customers want: a good night's sleep at a low price. And Virgin Atlantic challenged industry conventions by eliminating first-class service and channeling savings into innovations for business-class passengers. Those companies didn't set out to build advantages over the competition, but they ended up achieving the greatest competitive advantages. PMID- 10174450 TI - The work of leadership. AB - More and more companies today are facing adaptive challenges: changes in societies, markets, and technology around the globe are forcing them to clarify their values, develop new strategies, and learn new ways of operating. And the most important task for leaders in the face of such challenges is mobilizing people throughout the organization to do adaptive work. Yet for many senior executives, providing such leadership is difficult. Why? One reason is that they are accustomed to solving problems themselves. Another is that adaptive change is distressing for the people going through it. They need to take on new roles, relationships, values, and approaches to work. Many employees are ambivalent about the sacrifices required of them and look to senior executives to take problems off their shoulders. But both sets of expectations have to be unlearned. Rather than providing answers, leaders have to ask tough questions. Rather than protecting people from outside threats, leaders should let the pinch of reality stimulate them to adapt. Instead of orienting people to their current roles, leaders must disorient them so that new relationships can develop. Instead of quelling conflict, leaders should draw the issues out. Instead of maintaining norms, leaders must challenge "the way we do business" and help others distinguish immutable values from the historical practices that have become obsolete. The authors offer six principles for leading adaptive work: "getting on the balcony," identifying the adaptive challenge, regulating distress, maintaining disciplined attention, giving the work back to people, and protecting voices of leadership from below. PMID- 10174451 TI - How Fidelity invests in service professionals. AB - If you're in the business of service delivery, investment in the training and development of your staff is one of the keys to your company's success. But what's the best way to design and implement your investment? In 1994, Fidelity Institutional Retirement Services Company (FIRSCo) needed to ensure that its rapidly expanding staff maintained the company's high levels of customer satisfaction. The solution, according to Ellyn McColgan, formerly an executive vice president of FIRSCo and now the president of Fidelity Investments Tax-Exempt Services Company, was to reach out to its service associates with a powerful new model for training and development called Service Delivery University. SDU is a virtual university with a content-based core curriculum and five colleges that focus on business concepts and skills. It is driven by three principles. First, all training must be directly aligned with the company's strategic and financial objectives and focused on customer needs. Second, service delivery is a profession and should be taught as such. And finally, professional development should be the primary responsibility of line managers rather than the human resources department. McColgan explains how FIRSCo overcame resistance to this sweeping change in employee education. (Time was one obstacle: each associate receives 80 hours of training per year.) In addition, the author discusses the fine art of measuring the success of a program like SDU. She finds that the company's investment has paid dividends to the staff, to the organization as a whole, and to FIRSCo's customers. PMID- 10174452 TI - When an executive defects. AB - The news that one of the company's senior managers is leaving comes as a complete surprise to Paul Simmonds, CEO of Kinsington Textiles, Inc. Ned Carpenter, KTI's vice president of operations for three years, writes in his resignation letter than he is leaving for a better opportunity. Simmonds soon learns that Carpenter's new job is at Daltex, one of KTI's main rivals in the intensely competitive carpet industry. Hiring Carpenter had helped Simmonds establish his reputation as a topnotch manager. Carpenter came to KTI with lots of ideas and put his enthusiasm to good use. Three years into a five-year change program, Carpenter had turned KTI's operations from one of the worst in the industry to one of the best. He also had helped develop and plan the upcoming launch of a new fiber coating--KTI's first breakthrough in years. In this fictitious case study, Simmonds, along with the company's counsel and vice president of human resources, must figure out how much and what sort of damage control they need. What are they going to tell the company's employees and the media? Should they immediately replace Carpenter with John Brady, the second-in-command of operations? What if Carpenter is taking KTI employees--and strategic information--with him to Daltex? Should Simmonds ask all his managers to sign noncompete agreements-something Carpenter was never asked to do? Should KTI sue Carpenter? Five experts offer advice about communicating with KTI's employees, the media, and Carpenter himself, and about protecting the company's confidential information. PMID- 10174453 TI - Building brands without mass media. AB - Costs, market fragmentation, and new media channels that let customers bypass advertisements seem to be in league against the old ways of marketing. Relying on mass media campaigns to build strong brands may be a thing of the past. Several companies in Europe, making a virtue of necessity, have come up with alternative brand-building approaches and are blazing a trail in the post-mass-media age. In England, Nestle's Buitoni brand grew through programs that taught the English how to cook Italian food. The Body Shop garnered loyalty with its support of environmental and social causes. Cadbury funded a theme park tied to its history in the chocolate business. Haagen-Dazs opened posh ice-cream parlors and got itself featured by name on the menus of fine restaurants. Hugo Boss and Swatch backed athletic or cultural events that became associated with their brands. The various campaigns shared characteristics that could serve as guidelines for any company hoping to build a successful brand: senior managers were closely involved with brand-building efforts; the companies recognized the importance of clarifying their core brand identity; and they made sure that all their efforts to gain visibility were tied to that core identity. Studying the methods of companies outside one's own industry and country can be instructive for managers. Pilot testing and the use of a single and continuous measure of brand equity also help managers get the most out of novel approaches in their ever more competitive world. PMID- 10174454 TI - The coming battle for customer information. AB - Companies collect information about customers to target valuable prospects more effectively, tailor their offerings to individual needs, improve customer satisfaction, and identify opportunities for new products or services. But managers' efforts to capture such information may soon be thwarted. The authors believe that consumers are going to take ownership of information about themselves and start demanding value in exchange for it. As a result, negotiating with customers for information will become costly and complex. How will that happen? Consumers are realizing that they get very little in exchange for the information they divulge so freely through their commercial transactions and survey responses. Now new technologies such as smart cards, World Wide Web browsers, and personal financial management software are allowing consumers to view comprehensive profiles of their commercial activities-- and to choose whether or not to release that information to companies. Their decision will hinge, in large part, on what vendors offer them in return for the data. Consumers will be unlikely to bargain with vendors on their own, however. The authors anticipate that companies they call infomediaries will broker information to businesses on consumers' behalf. In essence, infomediaries will be the catalyst for people to start demanding value in exchange for information about themselves. And most other companies will need to rethink how they obtain information and what they do with it if they want to find new customers and serve them better. PMID- 10174455 TI - The four faces of mass customization. AB - Virtually all executives today recognize the need to provide outstanding service to customers. Focusing on the customer, however, is both an imperative and a potential curse. In their desire to become customer driven, many companies have resorted to inventing new programs and procedures to meet every customer's request. But as customers and their needs grow increasingly diverse, such an approach has become a surefire way to add unnecessary cost and complexity to operations. Companies around the world have embraced mass customization in an attempt to avoid those pitfalls. Readily available information technology and flexible work processes permit them to customize goods or services for individual customers in high volumes at low cost. But many managers have discovered that mass customization itself can produce unnecessary cost and complexity. They are realizing that they did not examine thoroughly enough what kind of customization their customers would value before they plunged ahead. That is understandable. Until now, no framework has existed to help managers determine the type of customization they should pursue. James Gilmore and Joseph Pine provide managers with just such a framework. They have identified four distinct approaches to customization. When designing or redesigning a product, process, or business unit, managers should examine each approach for possible insights into how to serve their customers best. In some cases, a single approach will dominate the design. More often, however, managers will need a mix of some or all of the four approaches to serve their own particular set of customers. PMID- 10174456 TI - Still lives. AB - A remarkable photographic record of Bethlem Hospital patients of the mid-1850s, now on show in London, gives flesh and form to those who might otherwise have remained 'invisible'. Mark Crail took a look. PMID- 10174457 TI - Leadership. The personal touch. AB - The government is likely to move from a centralised corporatist form of governance to a more collaborative approach. This will require chief executives to rely on a style of leadership which derives more from personal influence than positional forms of power. It may be time to discuss the future of politically appointed chairs and whether the chief executive should be the sole local leader. The government's commitment to delegating power to regional tiers is likely to have a major impact on the nature of leadership in the NHS. PMID- 10174458 TI - Information services. Knowledge is power. AB - The drive for evidence-based care is placing new demands on NHS libraries. Wendy Lopatin offers a guide to sources of healthcare information, and Pauline Blagden describes overhauling library services in a community trust. PMID- 10174459 TI - Support services. Domestic bliss. AB - Healthcare assistants had to leave the patients' bedside to do routine housekeeping work. Replacing a healthcare assistant post with a housekeeper has improved the use of personnel, staff morale and patient care. Allowing healthcare assistants to manage the project has ensured ownership. PMID- 10174460 TI - Service-level agreements. Trading places. AB - Internal trading or service-level agreements can help trusts manage the interface between hospital consultants and support services. Previous attempts at introducing SLAs had increased the administrative burden on support departments without changing consultants' behaviour or improving budgetary control. Problems were resolved by simplifying and improving measuring and reporting systems to produce credible, user-friendly information that facilitates meaningful debate between clinical managers and support services. PMID- 10174461 TI - A unified health ministry in central Tennessee: eleven years of successful partnership. AB - Middle Tennessee Medical Center (MTMC) is a not-for-profit community hospital located in Murfreesboro, Tennessee. Eleven years ago, a large investor-owned hospital company presented the institution's board of trustees with a purchase offer. As an alternative, two church-related institutions in Nashville--Baptist Hospital and Saint Thomas Hospital, which is part of the Daughters of Charity National Health System--presented the board of trustees with a plan whereby a new not-for-profit holding company sponsored jointly by Baptist Hospital and Saint Thomas Hospital would become the corporate member of Middle Tennessee Medical Center. Funds contributed by Baptist and Saint Thomas Hospitals would be infused into the Christy-Houston Foundation, a not-for-profit entity devoted to identifying and serving community needs in Murfreesboro and the surrounding area. Their proposal was accepted, and the two church-related institutions became partners in jointly sponsoring and governing an important not-for-profit healthcare institution in central Tennessee. In 1996, The Lewin Group, a healthcare consulting firm based in Fairfax, Virginia, was commissioned by Baptist Hospital, Saint Thomas Hospital, and Daughters of Charity National Health System to conduct a retrospective assessment of the progress of this jointly sponsored ministry in relation to the original vision and goals. Historical and operational data were analyzed, and interviews were conducted with 24 people who were directly involved in conceiving, developing, or implementing this ministry. This article summarizes the principal findings and conclusions of this ten-year assessment. PMID- 10174462 TI - Is patient length of stay related to quality of care? AB - In this article, we investigate the relationship between hospital length-of-stay (LOS) and quality of care. We use hospital claims records from Medicare beneficiaries in Michigan to estimate condition-specific models for predicting patients' LOSs. With these models and a data set provided by Michigan Peer Review Organization, Inc. (MPRO), each patient's risk-adjusted LOS is then linked to a quality-of-care judgment (good care, poor care) from physician peer reviewers. LOS is a widely used indicator of hospital performance. Most commonly, it is viewed as an indicator of hospital efficiency and as a surrogate measure for costs, with hospitals having long average LOSs considered relatively inefficient in the use of resources and those with low LOSs considered to be efficient. Sometimes, however, LOS is assumed to relate to quality. For example, if hospitals were to respond to the financial incentives of prospective payment by attempting to lower costs by prematurely discharging patients, LOSs significantly lower than expected might be considered indicative of poor quality care. On the other hand, if poor quality of care causes complications, it would tend to extend LOSs. Under this assumption, longer than expected LOSs could be viewed as indicative of poor quality care. This article shows that in every one of the 13 clinical conditions examined, cases that received poor quality care had significantly longer risk-adjusted LOSs than cases whose care was of acceptable quality. PMID- 10174463 TI - Salaried physicians' intent to retain hospital membership: the effects of position and work attitudes. AB - This study examined the anticipation of salaried hospital physicians in Israel to retain hospital membership for a long term until their retirement. Examined are attitudinal and position factors, as well as hospital standing personal and situational factors that relate to this anticipation. The data collected from 195 full-time salaried physicians in Israeli hospitals indicated that about one-third of the physicians anticipate to retain hospital membership until retirement. It was found that factors reflecting the physician's standing within the hospital were the main predictors of this anticipation, whereas work-related attitudes had little or no effect on it. The implications of these finding to hospital physician integration strategies in the United States are discussed. PMID- 10174464 TI - Continuous quality improvement: a survey of American and Canadian healthcare executives. AB - The continuous quality improvement (CQI) movement, while experiencing great popularity years ago, has been declining in interest across other industries. This article studied American and Canadian hospital executives who have embraced the concept of CQI and will continue to be committed to CQI efforts in the future. Executives of CQI hospitals strongly believe that CQI is not a fad and is essential to their organizations' survival. The majority of the hospital executives in the sample have a good understanding of CQI. The drive to provide quality service to both internal and external customers is the primary motivation for being involved with CQI. Some unsuccessful CQI efforts can be attributed to a lack of CQI skills, poor planning, and insufficient staffing. Close to 90 percent of the respondents expected their involvement with CQI to increase significantly in the future. This result implies that CQI is still being considered and will maintain its role as an effective management tool in the healthcare sector. PMID- 10174465 TI - Protecting the public interest: the role of the state attorney general in regulating hospital conversions. AB - Increasingly, nonprofit hospital have been responding to market pressures by giving up their tax exemption and selling hospital assets to for-profit corporations. In 1995 alone, fifty-nine nonprofit hospital completed full-asset sales or joint ventures. Hospital managers and board members should understand the legal and regulatory environment surrounding hospital conversions. State attorneys general are taking a more active regulatory role. This discussion describes the application of laws governing charitable trusts and nonprofit corporations to hospital conversions, as well as the central role of the attorney general in the enforcement of such laws. The 1996 Michigan circuit court ruling in Kelley v. MAHSI provides an insightful case study, illustrating a strict application of the law to a joint-venture hospital conversion. The implications of this case will be discussed along with the larger implications of more aggressive state regulation of hospital conversions. PMID- 10174466 TI - Antitrust and affiliations among healthcare providers: the need for a level playing field. AB - Under pressure to remain competitive in the rapidly changing healthcare industry, policy leaders and healthcare administrators face the challenge of resolving antitrust matters arising from the creation of innovative healthcare provider affiliations. Although guidance from the Federal Trade Commission (FTC) is available, development of new affiliations is hindered due to contradictory rulings and ambiguous guidelines. Provider associations are further disadvantaged by a federal act granting insurance companies antitrust exemption, which enables insurance companies to affiliate more easily. Current antitrust regulations create unequal market powers, resulting in the development of inefficient systems. Softening antitrust laws in favor of provider-sponsored healthcare affiliations will provide for the flexibility necessary for effective healthcare reform. PMID- 10174467 TI - Comparative experience in home care and pharmaceutical policy. PMID- 10174468 TI - A study on decentralizing from acute care to home care settings in Germany. AB - Although it is generally accepted in Germany that decentralizing towards home care settings can improve the efficiency and effectiveness of health care, a coherent policy toward decentralization has not been developed yet. A variety of elements of the traditional German health care system have limited the opportunities for decentralizing. Separation between health care and social services, separation between acute care and medical rehabilitation and separation between ambulatory care and hospital care were rather strict, prohibiting development of a comprehensive infrastructure of professional support for home care as well as the hospital financing scheme. Recent reform measures in Germany in the field of health care policy and social policy partly have tackled these problems. The introduction of long-term care insurance might provide the chance for a better infrastructure and more comprehensive usage of professional support for home care, although it is not without risks, and integration of long-term care insurance in the health policy sector lacks coherence. While reforms of the hospital financing scheme and an entitlement of hospitals to provide one-day surgery and post-discharge treatment will decrease the likelihood that hospitals keep patients in order to fill their beds, the extent to which hospitals will make use of these new instruments remains doubtful at present. Increased competition between sickness funds could open opportunities for prudent 'managed care' as part of 'managed competition', and strengthening of home care might be part of managed care programs. At present it is not clear, however, whether sickness funds will be entitled to compete through usage of managed care mechanisms. Other elements of recent health care reforms were counterproductive as far as decentralizing towards home care is concerned. Especially global budgets on honorariums for office-based doctors and on volumes of prescribed drugs might create incentives for inefficient and ineffective referrals to hospitals. PMID- 10174469 TI - Decentralisation from acute to home care settings in Sweden. AB - Sweden has a regionally based, publicly operated and financed, national health care system. Implementation of policy and the provision of health care has been the responsibility of the county council. In 1992, the major responsibility and resources for care of the elderly was transferred to the municipalities. The start of this reform, unintentionally, coincided with an economic recession which caused additional difficulties for the financing of the present level of public services generally. This development, in combination with innovations in health care technology, resulted in a rapid decentralisation of certain elderly care services from acute care settings. PMID- 10174470 TI - Managed care for the elderly in the United States: outcomes to-date and potential for future growth. AB - With the growth in frail elderly populations, health providers and policymakers are exploring new models of caring for and financing the care of disabled elders. This paper reviews innovative care programs directed toward maintaining elders with dependency-producing physical and mental disabilities in home and community based programs, and toward minimizing the use of acute and long-term institutional care. These programs represent improvements over the traditional fragmented care and financing mechanisms by integrating patient management responsibilities into one provider organization. Some programs integrate only primary and acute care, while others integrate only the continuum of long-term care services. A third set of programs, the key focus of this paper, integrate the full continuum of care from primary through acute and long-term care services. Coupled with service integration is financial consolidation, with control over all sources of funds transferred to the managing provider along with some level of financial risk. Outcomes in terms of lowered acute care utilization and successful site duplication are described, and future prospects for program adoption on a national scale are addressed. PMID- 10174471 TI - Assessing cost and utilization in managed mental health care in the United States. AB - Mental health cost containment in the United States has evolved from fragmented utilization review and discounted pricing programs in the 1980s to comprehensive mental health managed care programs in the 1990s, in which the network managing the care takes on financial risks associated with price and utilization for all mental health services provided to an enrolled population. While the earlier programs did not control costs to any significant degree, the newer forms of managed mental health are showing substantial reductions in cost, primarily through the reduction in use of in-patient services. Based on these encouraging but very preliminary results, state Medicaid programs have increasingly embraced managed care for both medical and mental health services for eligible low-income populations. However, little has been systematically evaluated with respect to the effects of aggressive mental health care management upon quality of care, functional outcomes or patient satisfaction. In addition, substantial new investment in merged clinical and financial information systems raises the entry cost significantly for managed care providers. PMID- 10174472 TI - The management of the cost and utilisation of pharmaceuticals in the United Kingdom. AB - The British National Health Service (NHS) provide comprehensive health services, including prescription drugs, to the entire population. Thus pharmaceuticals are seen as part of the provision of health care, not as an isolated cost element. UK expenditures on pharmaceuticals has been relatively low by European and US standards. The basic dilemma facing pharmaceutical policymakers is the need to control public spending on drugs while encouraging a successful UK pharmaceutical industry. A highly centralised policymaking apparatus has historically permitted a fairly collaborative approach with the pharmaceutical industry. Prices are not controlled directly as in some other European countries; rather, producers negotiate an allowable rate of return on all sales to the NHS. This gives producers considerable discretion to set prices for new drugs without government interference. Thus, prices are somewhat higher than in comparable European countries, but utilisation rates are among the lowest. The credit for low utilisation (and high generic substitution rates) goes to the conservative nature and medical education of British general practitioners. A general conclusion is that pharmaceutical spending has been curbed with minimal damage to the UK pharmaceutical sector. PMID- 10174473 TI - Management of cost and utilization of pharmaceuticals in Germany. AB - The German health care system has had a series of reforms in its pharmaceutical sector, starting in 1988 with the introduction of a reference pricing scheme. A major new reform was introduced in 1993, which established a ceiling for all outpatient pharmaceutical expenditures along with substantial monetary sanctions for breeching that ceiling. A study of that reform, reported here, suggests that outpatient physicians may have responded to this ceiling by increasing their rate of patient referrals to hospitals. New health system reform measures should be constructed with an eye to their overall financial impact on the entire health system. PMID- 10174474 TI - Cost and utilisation of pharmaceuticals in Sweden. AB - Issues of efficiency, access, equity and cost have informed Swedish national policy toward pharmaceuticals for many years. While retail pharmacies have been owned and operated by a single state company since 1971, the manufacturing of pharmaceuticals has remained privately owned and operated. Costs to the health care system for pharmaceuticals have been rising 4-8% in the last several years, despite greater use of generic substitutes. Beyond price-reduction pressures created by the state retail monopoly, by reference pricing, by positive lists, and by an expanded system of capped patient copayments, the national government is considering plans to decentralise responsibility for all outpatients as well as inpatient drug expenditures to the 26 country councils. PMID- 10174475 TI - Pharmaceutical cost containment and innovation in the United States. AB - In the United States, government has played a limited role in containing the costs of pharmaceuticals. There are no price controls, no national drug formularies, no universal cost-sharing policies, and perhaps most important, no national coverage of prescription drugs. Rather, pharmaceutical cost containment was historically left to private insurers and managed care companies, while consumers paid out of pocket for close to 62% of all drug expenditures. US utilization has historically been relatively low and prices by far the highest of the four industrialized countries. The major change in pharmaceutical cost containment in the 1990s has been the consolidation of purchaser power at the level of the insurer and managed care companies. These 'whole sale' purchasers now represent 70% of direct manufacturer sales, and they are demanding and receiving deeper price discounts. Meanwhile these same players are implementing formulary policies, utilization controls, and disease management programs, the outcomes of which have not yet been systematically evaluated. Failure to pass on savings to consumers, cost shifting by manufacturers to vulnerable consumer groups, and potential under-utilization of cost-effective drugs remain of concern. PMID- 10174476 TI - The context for health reform in the United Kingdom, Sweden, Germany, and the United States. AB - The success of health policy initiatives can be strongly influenced by the political, social, and cultural context within which a health care system operates. This study explores the similarities and differences in the background context of the four countries considered in this supplement: Sweden, the United Kingdom, Germany, and the United States. It concludes that there are considerable differences in the background context among these four countries, which help to explain their differing structural and organizational approaches to issues of pharmaceutical and home care policy. PMID- 10174477 TI - Decentralisation from acute to home care settings in England. AB - The impact of technology and resource constraints on acute care, the concept of a 'primary-care led National Health Service' (NHS), and the emphasis on developing community-based alternatives to institutional care have contributed to a reshaping of the respective roles of acute and home care services over the past 10-15 years in the United Kingdom. In England, recent reforms are allowing GP Fundholders, District Health Authorities representing a specific geographic area, and local government social services departments to purchase both acute and community-based care. In addition, new constraints on further expansion of institutional long-term care are encouraging the substitution of home care for the elderly needing long term care services. The result has been a dramatic increase in use of home care services. However, resource and supply constraints impede further home care expansion. Other forces within the NHS continue to foster unnecessary post-acute institutionalization. The successful decentralization of acute services from hospitals to home care requires an integrated program across the continuum of health and social services. In practice, no such concerted program exists. PMID- 10174478 TI - Medicare reforms cut hospital payments, add PSO option. PMID- 10174479 TI - CHA's Website gets new name and a facelift. PMID- 10174481 TI - Building "neighborhoods of care." System's long-term care continuum anticipates future needs. PMID- 10174480 TI - Spirituality for lay leaders. System program stresses the motivation behind the ministry. AB - In 1989 the leaders of Daughters of Charity National Health System-East Central Region (DCNHS-EC) decided to explore their 10 facilities' underlying spirituality. A study group made up of top DCNHS-EC management and representatives of other DCNHS regions and ministries met quarterly for a year to discuss four topics: The distinction between "spirituality" and "religion". The difference between "human development" and "human formation". The primacy, in contemporary Western culture, of the "functional' dimension of human life over the "transcendent" dimension. The importance of "beholding the Mystery" of life, rather than trying to control or manipulate it. In 1990, at the end of their sessions, the group's participants published Spirituality and Spiritual Formation, a document summing up what they had learned. The leaders of each DCNHS EC facility were urged to understand and support the document; the vice presidents for mission services were especially encouraged to integrate spirituality and spiritual formation in their work. Over the past seven years, the DCNHS-EC facilities have integrated spirituality in the workplace by emphasizing such events and activities as spirituality committees, retreats, renewal days, and pilgrimages. In September, St. Vincent Hospitals and Health Services, Indianapolis, broke ground for a spirituality center for its associates, medical staff, volunteers, and benefactors and the members of their families. PMID- 10174482 TI - Catholic healthcare's future. Ten models for competition and capitation. AB - In the next five years, Catholic providers must select strategies that will involve affiliations, acquisitions, and consolidations with Catholic and non Catholic partners. At least 10 options are available to meet the long-term trends of managed care, competition, and capitation. Vertical integration allows comprehensive patient care. Multisponsor management can help religious institutes expand their market share. Systems and one-hospital sponsors can affiliate their facilities to form Catholic networks. Community-based not-for-profit networks can include both Catholic and non-Catholic organizations bound by contracts and joint ventures. Joint ventures provide the benefits of integration to Catholic providers, who must be willing to commit substantial capital to create HMOs and other networks with non-Catholic partners. Acquisition of facilities and regional and statewide expansion can strengthen a Catholic system's market position in the face of declining acute care hospital services. Catholic/non-Catholic mergers risk consolidating and closing facilities but need not erase Catholic identity. Cooperation between affiliation and merger, or "co-opetition," involves creating new legal territory for Catholic/non-Catholic consolidation. Divestiture may be an ultimate strategy, but Catholic sponsors must proceed with caution in their dealings with plentiful buyers. Catholic facilities and systems are joining with Catholic Charities, other providers, and local agencies to create networks. PMID- 10174483 TI - Healthy communities: good mission, good sense. Holistic approach is the key. AB - Catholic healthcare's mission is keeping people healthy, and providers must listen closely to determine their needs in these fast-paced, stressful times. In a society preoccupied with technology and acute care, which has the least overall impact on people's health, providers must implement more preventive strategies. The shift to promoting community health will require diverse, creative approaches. Catholic facilities must offer holistic healing, becoming community resources for children and the elderly. Religious institutes also must prepare for the laity's increasing role in the ministry. Providers must develop initiatives that define Catholic healthcare, such as the Welfare-to-Work Program in St. Louis, which offers women employment opportunities and benefits as a starting point to gain control of their lives. With increased school collaboration, nurses can help children develop good health habits. The guiding vision must be the health of the whole person and the community. Catholic providers must restore public trust and confidence by emphasizing person-centered healthcare. Only by becoming an integral part of the community can Catholic healthcare make a difference in people's lives. PMID- 10174484 TI - Reclaiming our moral tradition. Catholic teaching calls us to accept the limits of medical technology. AB - The success of science and medical technology has led to medical brinkmanship, pushing aggressive treatment as far as it can go. But medicine lacks the precision necessary for such brinkmanship to succeed, and the resulting cycle of expectation and disappointment in technology has, in part, led to an increasing acceptance of euthanasia and assisted suicide, linked closely with advocacy for patient autonomy. At the opposite extreme lies medical vitalism, which refers to attempts to preserve the patient's life in and of itself without any significant hope for recovery. The Catholic moral tradition offers a middle ground, well expressed in the 1994 Ethical and Religious Directives for Catholic Health Care Services. The tradition does not deny the good of technology or state that some lives are not worth living. Rather, it calls us to accept the fact that medical technology has limits. In reclaiming this tradition, we reclaim the naturalness of death. Reclaiming the tradition has practical consequences for the use of life prolonging technology at the end of life and for end-of-life decision making. These can be placed in three broad categories: the Christian understanding of care, the ambiguity inherent in end-of-life decision making, and the task of Christian formation. PMID- 10174485 TI - Opening new doors. A community health ministry evolves in New Orleans. PMID- 10174486 TI - New opportunities for mission leaders. CHA survey indicates emerging responsibilities, skills. PMID- 10174487 TI - California media campaigns work for healthy infants. PMID- 10174488 TI - Finding the center. PMID- 10174489 TI - Ministry of hospital chaplains: patient satisfaction. PMID- 10174490 TI - Current contents in pastoral care. PMID- 10174491 TI - 'Excellence' begets awareness. Long Island's Good Samaritan Hospital stresses areas of expertise. AB - Good samaritan Hospital Medical Center in West Islip, N.Y. has created a solid reputation as a community hospital noted for its compassionate care, especially as it relates to mother/baby wellness. But, in the increasingly competitive health care world, it's necessary to aggressively market services. Good Samaritan in the last decade built "institutes of excellence" as is telling the community about them in a coordinated multiplicity of strategies using nearly every facet of marketing communications and advertising. PMID- 10174493 TI - Coalition expands to help consumers. HealthPartners' Internet data provide hospital comparisons. PMID- 10174492 TI - Publisher moving onto Internet for hospital magazines. Electronic quarterly magazine will promote 'true wellness'. AB - McMurray Publishing Inc., Phoenix, Ariz., a publisher of customized hospital magazines, is rolling out another innovative magazine that will link online Internet users in January. PMID- 10174494 TI - Women's weekend in ninth year. PinnacleHealth, Harrisburg, PA. AB - For nine years, PinnacleHealth has lured busy women in the Harrisburg, Pa., area away for a weekend of pampering. It's a project of PinnacleHealth's WomanCare's Resource Center. The program began with 239 women, last year the event drew 400 participants. PMID- 10174495 TI - Top hospital designation rates ad series. South Carolina University Medical Center highlights its centers of excellence. AB - Medical University of South Carolina Medical Center last December was rated among the nation's 100 Top Hospitals. The designation prompted hospital officials to develop a newspaper ad campaign featuring 12 centers of excellence which boosted calls to its Health Connection line by 10%. PMID- 10174496 TI - Kids learn advertising hands on. Corbett HealthConnect teams with pre-teens to launch an education program. AB - Scott Cotherman, president and CEO of Corbett HealthConnect, Chicago, has found a better way to explain advertising to school children. He takes them out of the classroom into his offices and assigns them to create a public service awareness campaign to help improve the health of America's youth. Now, he's refining the program and thinking of offering it to his clients. PMID- 10174497 TI - Hospitals promote websites as 'ultimate' resource. Information key to luring online users to hospitals' websites. AB - Health care marketers are charting a rise in inquiries as a result of catchy, colorful and informative web sites. Information is the key to attracting online users to hospital web sites. PMID- 10174498 TI - The board-physician partnership: enhancing leadership potential. PMID- 10174499 TI - Going public. Do medicine and public health have a future together? PMID- 10174500 TI - Sizing up your board. Triage for governance growing pains. PMID- 10174501 TI - Oklahoma City. Voices of tragedy, voices of hope. PMID- 10174502 TI - What keeps you on the board? PMID- 10174503 TI - Psychosurgery redux. The 1990s version uses radiation and brain imaging. PMID- 10174504 TI - Joycelyn Elders is master of her domain. PMID- 10174505 TI - AIDS comes to small-town America. PMID- 10174506 TI - In Oregon, a political campaign to die for. Assisted suicide fight turns ugly. PMID- 10174507 TI - No more hard labor. High-tech and high-touch remedies for easing the pain of childbirth. PMID- 10174508 TI - How far should you go to stay fit? The battle between tough and tame. PMID- 10174509 TI - Mismanaged care? Wall Street takes the scalpel to HMO companies. PMID- 10174510 TI - Being a clinical director: first among equals or just a go-between? AB - This article explores doctors' experience of the role of clinical director in a large National Health Service (NHS) teaching Trust. The advent of doctors in management, as a relatively new phenomenon in the NHS, is reviewed to provide a contextual setting for the case study. The empirical findings are presented as a 'clinical diamond' which emerged as a form that captured the multifaceted nature of the role. The research demonstrates that, for a doctor, being a clinical director potentially threatens the professional identity, collegiality and autonomy of both the individual and the professional group the directorate represents. Moreover, stress that emanates from the structural tension inherent in the role is displaced into personal and professional stress. Clinical directors embody the tensions and conflicts of different managerial and professional cultures, whilst attempting to reconcile the demands of purchasers with the views of disparate and difficult professional colleagues. The argument concludes that there is an urgent need to recognize the demands being placed upon doctors who take on this role, and identifies the benefits and challenges that the role creates in leading health care. The final section identifies the issues that need to be considered to sustain this role in future and the recognition that it has substantially increased the power base of the medical profession, but often at a high price for the individuals involved. PMID- 10174511 TI - The cardiac waiting game: are patients prioritized on the basis of clinical need? AB - Waiting lists for coronary artery bypass grafting (CABG) have been a recurring problem for many hospitals, putting pressure on hospitals to manage waiting lists more effectively. In this study, we audited the records of 1594 patients who had coronary artery bypass surgery in 1992 and 1993 in three London hospitals, to assess their waiting time experience. Patients' actual waiting times were compared with an appropriate waiting time defined using an adapted version of a Canadian urgency scoring system. Influence of other factors (sex, age, smoking, hypertension, diabetes and obesity) on actual waiting time was assessed. A comparison of patients' actual waiting times with an appropriate waiting time, defined by the urgency score, showed that only 38% were treated within the appropriate period. Thirty-four per cent were treated earlier than their ischaemic risk indicated, and 28% with high ischaemic risk were delayed. Actual waiting time was associated with a patient's sex and smoking status but not with the other factors studied. The current system of prioritizing patients awaiting CABG is not concordant with a measure of appropriate waiting time. This could have arisen due to a number of factors, including the contracting process, waiting list initiatives, and methods of waiting list administration and patient pressures. The use of a standard method for prioritizing patients would enable a more appropriate use of resources. PMID- 10174512 TI - Improving general practitioner access to physiotherapy: a review of the economic evidence. AB - The provision of physiotherapy via general practitioner (GP) 'direct access' arrangements or in primary care itself has become increasingly common in the UK. Evidence on the economics and the cost-effectiveness of alternative methods of organizing access to physiotherapy services is reviewed, and the likely impacts of different organizational models are discussed. GP direct access physiotherapy and primary care provision appear to have a lower average cost than consultant access physiotherapy models, while GP direct access appears to minimize health care resource use per patient. Primary care physiotherapy provision appears to minimize the costs to patients of seeking care, and appears to generate a greater demand for service than other models. The extent to which physiotherapy provision in primary care can substitute for physiotherapy and other resources in the hospital sector is discussed, as is the extent to which patients may benefit from receiving physiotherapy in primary care. It is argued that continued expansion of access to physiotherapy should be critically appraised, and its ability to improve health status compared with that achievable in alternative patient groups who might benefit from physiotherapy in hospital or rehabilitation settings. PMID- 10174513 TI - Toward a systems quality paradigm: relating health outcomes, resource expenditures, and appropriateness of cholecystectomy patients. AB - This study addresses the question for cholecystectomy patients of whether there is an association among manifesting better health outcomes and the quantity of hospital resources consumed when the appropriateness of this surgery is also considered. 10,043 cholecystectomies performed by 218 surgeons in 43 Pennsylvanian hospitals are analysed using data from an administrative data set. Performance measures are adjusted for admission severity of illness and other patient variables. The results demonstrate a statistically significant positive association between adjusted hospital total charges and adjusted morbidity controlling for whether specified clinical criteria are met that validate the need for a cholecystectomy. This study illustrates a systems quality paradigm wherein performance is examined in terms of health outcomes, appropriateness and resource expenditures, as well as the relationships among these three dimensions. PMID- 10174514 TI - Partnerships in purchasing: development of consortium-based purchasing among GP fundholders. AB - In the last few years there have been considerable changes in the National Health Service (NHS) in the UK. Arguably the most significant of these has been the introduction of competition. Central to this development has been the introduction of general practice (GP) fundholding, whereby practices purchase health care for their patients directly from competing suppliers. Those practices which have become fundholders have faced considerable challenges in developing their purchasing function, given the complexities of contracting within the context of the NHS internal market. Although one of the original aims of GP fundholding was to facilitate locally responsive purchasing, such have been the complexities of contracting that many fundholding practices have attempted to reduce the managerial demands of purchasing through membership of purchasing consortia. Based on an in-depth study of GP fundholders across Scotland, this paper explores the development of consortium-based purchasing. Specifically, this paper seeks to address three issues central to the evolution of such consortium based purchasing. Firstly, the patterns of organizational structure and the operational dynamics of such consortia. Secondly, the impact of such consortia on the process of fundholder purchasing. Thirdly, the managerial implications of purchasing through such consortia for the participating practices. In addressing these issues, it will examine whether such patterns of purchaser development have impacted on the evolution of locally responsive purchasing. PMID- 10174515 TI - Programme budgeting revisited: special reference to people with learning disabilities. AB - The recent reorganization of community care in the UK removed many of the perverse incentives identified in the previous system. However, the organization of care for many people is still divided across several agencies in the public and independent sectors. As purchasing and providing agencies in both the National Health Service and local authority personal social services attempt to coordinate policy objectives and the means to achieve them, the total resources available and their allocation across different care groups and among people in the same care groups from a consistent focus of attention. The principles and practice of programme budgeting provide important lessons for planning and monitoring expenditure. This paper rehearses such principles in the specialized area of policies for people with learning disabilities and draws on the experience of mapping expenditure on relevant services in a survey over 10 local authorities in England. PMID- 10174516 TI - Healthcare pacts to replace contracting. PMID- 10174517 TI - How far will population-based medicine take us? PMID- 10174518 TI - Measuring pediatric immunization status in a managed care organization: agreement between medical charts and parent telephone interviews. AB - OBJECTIVE: To measure the agreement between pediatric immunization data obtained from medical charts and data provided by parents during telephone interviews and to assess the reliability of immunization information provided during parent telephone interviews. DESIGN: Medical charts reviews and telephone interviews with parents. SETTING: Prudential HealthCare. PARTICIPANTS: Children sampled for the 1993 HEDIS study and the parents of those children (n = 356). MAIN OUTCOME MEASURE: Overall agreement between immunization data obtained from medical charts and data provided by parents during telephone interviews. RESULTS: Agreement between immunization data obtained from medical charts and data provided in parent telephone interviews varies from poor to good if the parent refers to a shot record during the interview. Agreement between the two data sources is better with single dose vaccines (i.e., 1 MMR) than multiple dose vaccines (i.e., 4 DTP). Although parents tend to report fewer immunizations than are indicated in the child's medical chart, the medical charts in this study contained too many vaccine omissions to be considered reliable "gold standards" of vaccine receipt. Parents who refer to a shot record when providing information about pediatric immunizations provide reliable data (r = .8807-1.0). CONCLUSION: When measuring completion of the immunization series, especially among parents who do not have access to a shot record, medical chart reviews remain the better approach in the managed care setting. PMID- 10174519 TI - Attitudes about clinical practice guidelines in a mixed model HMO: the influence of physician and organizational characteristics. AB - OBJECTIVE: This study assesses physician attitudes toward clinical practice guidelines, in an organization where guidelines have long been incorporated into the clinical practice. Attitudes toward institutional guidelines and guidelines in general are explored, and are compared to a published study describing attitudes among a sample of American College of Physician (ACP) members. DESIGN: Descriptive study. SETTING: A large, mixed model HMO. SAMPLE: Two hundred and three internists and family practice physicians. MEASURES: Attitudes toward perceived compliance with clinical practice guidelines were assessed. Summary measures of attitudes and anticipated impact of guidelines were created. RESULTS: Overall, attitudes toward practice guidelines among HMO physicians were very positive. Differences were observed by gender, practice model, years in practice and residency training. HMO physicians on average held more favorable attitudes toward guidelines compared with published results of an ACP survey. While HMO physicians in independent group practices viewed the concept of guidelines less favorably than staff model physicians, they were more likely to view the impact of guidelines positively than were the ACP physicians. CONCLUSIONS: Exposure to practice guidelines in the context of clinical practice can lead to positive attitudes about those guidelines. While resentment toward a system which relies on practice supports such as guidelines may remain among some physicians, this need not be inconsistent with an appreciation of the potential value of guidelines for improving clinical quality. PMID- 10174520 TI - From Kaiser Permanente's Emergency Care Program to a collaboration with the American College of Emergency Physicians. PMID- 10174521 TI - A process IMPROVEment approach to preventive services: case studies of CQI demonstration projects in two primary care clinics. AB - The IMPROVE Project is a 4-year randomized controlled trial to test the hypothesis that HMOs can improve preventive services in their contracted primary clinics by assisting clinics to implement continuous quality improvement (CQI) and an organized system for preventive services. This paper describes findings from case studies of CQI teams in two demonstration sites where the CQI approach was tested. The case study analysis is based on interviews and observations conducted about 10 to 12 months after the CQI teams began. Initial responses of clinic staff to the IMPROVE Project included a mixture of interest in CQI, enthusiasm for prevention-oriented care, concern about the burden the project might impose, and skepticism. There were two formidable barriers to change: time and inertia. Environmental changes in the parent organizations also complicated and impeded the CQI process within the clinics. The thematic analysis identified four factors that appear to be important in implementing a CQI process in a clinic setting: awareness, momentum, ownership, and communication. PMID- 10174522 TI - Flexible sigmoidoscopy screening: patient acceptance. AB - Although compelling evidence is available that screening can reduce the risk of death from colon cancer, patient compliance with screening in the United States is poor. The objective of this study is to describe a program that uses patient education to improve patient acceptance of flexible sigmoidoscopy screening. Our program provides multiple opportunities for patients to ask questions and to receive information. Preliminary data show that this approach has resulted in a procedure acceptance rate of 81% of those referred in the first year of the program. Future research needs to focus on evaluating factors associated with noncompliance in colorectal cancer screening programs. PMID- 10174524 TI - Closing the gap in trust: to refer out or not? PMID- 10174523 TI - Aligning organizational strategic planning and research priorities: the Kaiser experience. AB - Kaiser Permanente, the largest nonprofit HMO in the country, is a prepaid group practice program which provides comprehensive health benefits coverage to more than 8 million Americans in 17 states and the District of Columbia. The Northern California region of Kaiser Permanente is the largest region with more than 2.6 million members. This article describes the creation of a research effort in the Northern California region to develop a long-range strategic research plan. This effort was initiated in order to align research priorities with organizational strategic planning. The plan's aim was to better guide the process of using research to help the region meet its mission, goals and objectives. Twenty-seven strategic research areas were identified organized into four major categories. The top six strategic research areas are discussed. PMID- 10174525 TI - Management of otitis media: the case for more judicious and targeted antibiotic use. PMID- 10174527 TI - Communication consultants. PMID- 10174526 TI - Improving the primary care evaluation of infertility. PMID- 10174528 TI - Provider-sponsored organizations: catching the first wave. PMID- 10174529 TI - Management and humanity. PMID- 10174530 TI - Cardiovascular leaders moving beyond logic: an active strategy for advancing cardiac services. AB - Cardiac leaders need to put forth cogent, well-articulated, conceptually sound reasons for pursuing issues that they consider to be significant to the future of their service. Logic, rationality, and quantification of issues are "givens"- they are the price of admission that one pays to have an issue contested in the organizational arena. Understanding the larger sphere in which CV issues reside by contextualizing logic and rationality in terms of organizational culture, power, politics, group dynamics, and ego improves the chance that the cardiac agenda will receive thoughtful consideration and support by organizational decision-makers. Clearly, optimal CV performance can only be attained through the process of sophisticated interdependence. Accordingly, by understanding and using the Iceberg in its entirety, CV leaders will manifest the power of it to bring about constructive change and market viability. The completed model appears in Figure 6. As your cardiovascular team advocates for the CV agenda, take care to "be as wary as snakes but as harmless as doves. PMID- 10174531 TI - Strategic planning: ensuring the future success of your cardiovascular program. PMID- 10174532 TI - The JCAHO survey of the cardiovascular laboratory: preparation strategies for managers. PMID- 10174533 TI - Changing management in health care. PMID- 10174534 TI - Managerialism and public attitudes towards UK NHS managers. AB - Presents the results of empirical work examining public attitudes towards UK NHS managers. The findings indicate a strong lack of sympathy for managers. Discusses possible explanations for these results. The preferred explanation is that NHS managers as a group tend to share an ideology about the nature of the NHS and the role of management within the NHS which is at odds with the beliefs held by most members of the public on these matters. Explores the origins and nature of managerial ideology (managerialism) in the NHS and discusses possible reasons why the ideology might tend to be unpopular with the public. Concludes by suggesting that the traditional core values of the NHS as perceived by the public could be being violated by managerialism. This violation may be the principal cause for the low public esteem in which NHS managers are currently held. PMID- 10174535 TI - Determining priorities for purchasers. The public response to rationing within the NHS. AB - There is currently great interest in how best to consult the public on purchasing priorities, but little information about the results of such activity. Based on health panels set up by Somerset Health Authority, intends to rectify this gap. The public were found to strongly favour universality of treatment, regardless of the cause of a condition, the age of the patient or the cost, although people should take some responsibility for their own health. There is a reluctance to purchase treatment for people who are not ill, although resources are well spent on health promotion and advice services. Argues that ordinary members of the public are capable of exploring complex funding priorities. A qualitative approach is essential to provide time for reflection, as the process of deliberation affects the decisions reached. PMID- 10174536 TI - Why are GP exercise schemes so successful (for those who attend)? Results from a pilot study. AB - Aims to explore and examine the meanings attached to two general practitioner prescribed exercise schemes in London. A total of 13 interviewees were recruited in two leisure centres in the borough of Lewisham and asked about their perceptions of the exercise scheme in which they were participating. The ages of the participants ranged from 30 years to 61, and all but two of the group were women. Finds that the perceptions and beliefs of people who have been referred play an important part in determining how the exercise is beneficial. One illustration of this is that, often, a functional component of their respective bodies is tangibly improved by the exercise, for example breathing. Thus, for groups who attend and exercise under supervised conditions there is clearly a "health-gain" however this is defined. Nevertheless, more comprehensive studies, perhaps using similar and complementary methodologies, are required in order to examine and clarify this further. General practitioners, the primary care team and commissioners of care need to be aware of the "qualitative" nature of the benefit which some scheme-participants report. PMID- 10174537 TI - User participation in service planning. A qualitative approach to gauging the impact of managerial attitudes. AB - It is often suggested that professional and managerial attitudes significantly delimit the impact of new structures for enhancing the role and influence of service users in health and social care planning. Considers the existence and clarity of such managerial attitudes in the context of one attempt to involve users in mental health care planning. The existence of latent and explicit managerial parameters to the role played by users in the planning of services was confirmed by the research at a very general level. Perhaps inevitably though, even in relation to a very specific user participation project, these parameters became less uniform as more detailed issues were considered. This suggests that an investigative focus on the "process" oriented attitudes and assumptions of managers and professionals, although important, should not be allowed to detract from a concern with gauging the demonstrable outcomes of user participation. PMID- 10174538 TI - Swedish physicians' perspectives on the introduction of the Stockholm model. AB - Reports findings on the perspectives of Swedish physicians since the introduction of the Stockholm model. Subjects were asked to describe their work, how long they had been working and whether they were familiar with the Stockholm model. Questions also focused on professional autonomy, use of diagnostic related groups (DRGs), quality of care and competition among health-care providers. Most of the physicians interviewed reported that the Stockholm model had the advantage of increasing efficiency and productivity, that economic incentives influenced their medical decisions, and medical treatment appears more patient-focused than before. Finally, primary care physicians report an enhanced status within the medical profession. PMID- 10174539 TI - Evolution in the relationship between industry and hospitals. PMID- 10174540 TI - The role of Northern NGOs (Non-Governmental Organisations) in rehabilitating the health sector in post-conflict settings: a need for a critical analysis. AB - The paper addresses issues of the health sector rehabilitation in post-conflict situation, and in particular the role of Northern Non-Governmental Organisations (NNGOs) in this process. While armed conflicts are regarded as public health issues for their negative implications on health and health systems, post conflict situation is considered, despite its complexity, as having both risks and opportunities for making the health system more equitable and sustainable. In this respect, NNGOs are believed to be able to play an efficient and effective role in rehabilitating the health system. The paper asserts that the assumed good qualities of the whole NNGOs sector in this specific context is not based on evidence and that a critical analysis is needed. Problems affecting NNGOs interventions are then highlighted. These include their political neutrality, technical accountability to policy, planning and quality development. These problems may have their roots at conceptual, operational and political levels. To avoid generalisations and unproved assumptions, research is therefore needed to distinguish NNGOs' characteristics, roles and motivations and to assess the extent to which NNGOs' interventions are effective in rehabilitating the health system in post-conflict settings as well as in strengthening local institutions. PMID- 10174541 TI - The Asklipieion's healing environment--learning from the past. AB - Asklipieia were the first hospitals (or, better, health care campuses) in Europe, which flourished in Hellas (Greece) for about 12 centuries, since about the 6th century B.C. A kind of holistic health care was offered in Asklipieia through the conception of illnesses as a result of interaction of physical, psychological, social and environmental factors. The study of Asklipleian health care will help us to complete our knowledge on the history of health care and can teach us a lesson deriving from the Hellenic philosophy and history that could form the prototypical base for a better understanding of the concept of healing environment. PMID- 10174542 TI - Health care's quality improvement imperative. AB - In health care, as quality improves, costs tend to decline. The goals of excellent care and affordable costs are not mutually exclusive. Borrowing quality improvement techniques from manufacturing industries, physicians and other health care professionals are achieving breakthroughs in improving the quality and reducing the cost of care. Quality improvement continues the tradition of scientific inquiry in medicine and places new emphasis on accountability to the customers of health care: patients and payers. By examining processes, clinicians look at the delivery of care across different treatment modalities and rely on the insights of employees involved at every stage of the processes. Intermountain Health Care is one American health care organization that has experienced significant success in improving quality and reducing cost through the use of quality improvement methods. PMID- 10174543 TI - Quality hospital care--global trends and future challenges. AB - This paper provides an international overview of trends and elements of quality services provision in hospitals. The factors reviewed are hospital accreditation, government quality intervention, resource review, clinical procedure standardisation, patient education, high technology, financial mechanisms, risk management and evidence based medicine as relates to quality. PMID- 10174544 TI - New horizon in quality care--Asian perspective. AB - The current status and directions for changes of issues related to quality care in health services in Asian countries--Malaysia, China, Singapore, Japan and Korea are overviewed. In countries with public sector dominated health care systems such as Malaysia. China and Singapore, governmental leadership in quality care is prominent along with legislative backup. Japan and Korea have private sector dominated health care systems and quality care activities are mainly carried out by non-governmental organisations. Hospital accreditation programs are in the developing stages in most countries, although China and Korea started in 1980. Most Asian countries are at the initial stages in quality care activities and focus has been placed on education and training. Asian countries are not exempted from efforts to enhance quality care activities and a new horizon in quality health care is emerging. PMID- 10174545 TI - An academic teaching hospital--the Japanese model. AB - The purpose of this paper is to give some ideas about the requirements for a truly academic hospital, presenting the status and significance of the teaching hospital in Japan. In the United States, medical schools and teaching hospitals are independent from each other, but both work together to achieve a mutual objective through clinical educational programmes. On the other hand, medical schools and teaching hospitals in Japan are more integrated, they do research and education as well as practice medicine in same environment. In the past, university hospitals have seen themselves as academic and the physicians in these hospitals have been considered as capable of conducting research. However, the field of research has become more expanded and profound in today's academic hospitals. Considering the difference in the capability of physicians, the number of problems to which clinical education and its orientation is unable to bring solutions is on the increase. It has now become very important to look for help in other academic fields when applying the results of research made to the field of medicine. The organization, therefore, with the necessary human and financial resources to provide training through contribution, to the benefit of patients and through liberal and continuous undertaking of research activities, challenging issues whose outcome are unpredictable, can be truly called an academic hospital. PMID- 10174546 TI - Costs and reimbursement of medical teaching and clinical research in Finland. AB - Alongside care and cure, hospitals produce teaching and research (T&R). In addition to the direct costs the T&R decrease productivity in patient care. An econometric model was used to estimate the effect of T&R. The variables in model were number of postgraduate medical students, on-the-job training weeks of nurses and the weighted number of articles published in scientific journals. Also service-mix (DRG), input mix and factor-prices were controlled. The average influence of teaching and research in costs of teaching hospitals was found to be 14.5 per cent. The cost of T&R in teaching hospitals varied between 10 and 16 per cent. The new reimbursement method based on the weighted numbers of physician examinations, dissertations and published articles in scientific journals was adopted. The total reimbursement was 700 million FIM per annum on which 50 per cent for the costs of research. PMID- 10174547 TI - The Georges Pompidou European Hospital, Paris. PMID- 10174548 TI - University teaching hospitals. An outline of some major issues. PMID- 10174549 TI - Compensation monitor. Has primary care earning growth peaked? PMID- 10174550 TI - What happens when politicians play doctor. PMID- 10174551 TI - Written tests can help you hire the best employees. PMID- 10174552 TI - One health system's approach to disease management. PMID- 10174553 TI - A conversation with Xerox's Helen Darling. PMID- 10174554 TI - Fraud and abuse find a home in managed care. PMID- 10174555 TI - Don't put off dealing with the 'Millennium Bug'. PMID- 10174556 TI - Managed care offers a new definition of 'doing good'. PMID- 10174557 TI - Legal privilege cannot shield routine business discussions. PMID- 10174558 TI - Fannie Mae's osteoporosis program blazes trail in women's health. PMID- 10174559 TI - Managed care outlook. Will managed care mimic fee-for-service? PMID- 10174560 TI - Managed care. Patient education at the crossroads. PMID- 10174561 TI - Internet/intranets. Netting clinical data. PMID- 10174562 TI - Self-care guru plugs information technology. Interview by John McCormack. PMID- 10174563 TI - Provider automation. Using the Internet to access records. PMID- 10174564 TI - Filling the data bucket. Trends in the development of repositories and warehouses. PMID- 10174565 TI - Measuring the benefits of telemedicine. PMID- 10174566 TI - Holding down the costs of delivering telemedicine. PMID- 10174567 TI - Health insurers turn to software for fraud busting. PMID- 10174568 TI - Web technology revitalizes efforts to eliminate radiology film. PMID- 10174569 TI - Managed care in the millennium. PMID- 10174570 TI - Reinventing managed care. PMID- 10174571 TI - Top ten trends for managed care: 1997-2000. PMID- 10174572 TI - AHA to push for repeal of patient transfer provision. PMID- 10174573 TI - Inspector General proposes rules on Medicare exclusions. PMID- 10174574 TI - Congress curtails OSHA's ergonomics activities. PMID- 10174575 TI - Managed care. Dealing with the dual eligible population. AB - This is the first of a two-part series reviewing the genesis of managed care programs for persons dually eligible for Medicare and Medicaid. Part two will profile several state programs, exploring their impact on long term care. PMID- 10174576 TI - Assisted living. Game plan for growth. How to turn four key challenges into opportunities. PMID- 10174577 TI - Subacute strategies. The sword of Damocles. How the new transfer policy will transform subacute care. PMID- 10174578 TI - Life after Boren. How can providers protect themselves and their residents if Medicaid rates start to fall? PMID- 10174579 TI - What admins earn. Contemporary Long Term Care's 1997 administrative salary survey. PMID- 10174580 TI - The day shift. More and more SNFs and ALFs are adding adult day to their mix of services. What's fueling the change? PMID- 10174581 TI - Medication mishaps. PMID- 10174583 TI - Sourcebook. The guide to long-term care products and services. PMID- 10174582 TI - Managing mental health madness. Interview by Edward M. Cherof. PMID- 10174584 TI - Pediatric asthma DM programs help kids breathe easier. PMID- 10174585 TI - Detroit health system steps up to the DM plate with health promotion center. AB - Detroit's Henry Ford Health System has opened the Center for Health Promotion and Disease Prevention in order to research prevention processes, encourage healthy lifestyle choices among its members, and assist its providers in incorporating prevention strategies into their delivery of services. Here is a profile of the center and the programs it is developing in pursuit of these goals. PMID- 10174586 TI - Institute seeks to close gap between knowledge and delivery in reducing C-section rates. AB - A Boston-based non-profit claims that improved clinical outcomes and cost-savings are compatible and realizable goals for providers and plans willing to incorporate known clinical improvement methods into their delivery systems. To prove it, the Institute for Healthcare Improvement has formed a number of collaboratives among plans and providers. Here is how one collaborative is seeking to reduce the rates of Cesarean sections. PMID- 10174587 TI - Disease assessment tool helps MCOs target DM resources. AB - Before embarking on disease management strategies, managed care plans and providers must determine where best to concentrate resources. Value Rx, a pharmacy benefit company that offers a variety of services including disease management assistance to its managed care customers, has developed an innovative assessment tool that takes a multitude of factors into account in identifying where to place disease management efforts. PMID- 10174588 TI - CHF costs yield to innovative DM programs. PMID- 10174589 TI - When it's all in their heads: managing the somatizing patient. AB - More than 50% of medical visits are undertaken by the "worried well," people who manifest physical symptoms without having any underlying physical malady. The Harvard Pilgrim Health Plan has created a program--being made available to other plans and provider groups--to curtail overutilization by these somatizing patients while providing them with the tools to find relief from their very real physical symptoms. PMID- 10174590 TI - Chemical abuse program targets special needs of pregnant women. AB - Health Partners' Mother-Baby Chemical Health Program, which incorporates drug and alcohol treatment, education, and social and community support, is helping pregnant women stay chemical-free so that they deliver healthy babies. The program is saving an average of $37,000 every time a woman delivers a baby full term. Here is how the inexpensive intervention works. PMID- 10174591 TI - Care for the terminally ill: a life-affirming paradigm. AB - By incorporating the core values of end-of-life patients and their families into care decisions, providers can offer compassionate care for the dying and avoid unnecessary and futile efforts that not only increase health care costs but often violate the spiritual, emotional, and cultural needs and wishes of the patients and their families. PMID- 10174592 TI - Prevent heart disease and osteoporosis at menopause. PMID- 10174593 TI - Manage rare and costly chronic disorders with specialized, comprehensive DM program. AB - A North Carolina-based disease management firm offers health plans and providers a way to introduce DM strategies for rare chronic diseases into their existing delivery systems. These tailored disease management programs are designed to reduce unnecessary costs and provide better care for patients by emphasizing patient-education, self-monitoring, and proactive clinical support. PMID- 10174594 TI - 'Dial-A-Doc' puts physicians on the line of 24-hour telephone info and triage system. AB - Around-the-clock physician advice is a phone call away. Dial-A-Doc is a physician staffed virtual call center being marketed directly to consumers, managed health plans, and employers. PMID- 10174595 TI - New computerized system combines disease management with Internet technology. AB - A new demand management system combines two of the hottest areas in health care today--disease management and Internet technology. SoftWatch Inc. has created downloadable, diary-based self-care programs that allow patients to enter, track, and share personal data with their providers to assist with the management of their diseases. PMID- 10174596 TI - Survival strategies for academic radiation oncology in a changing healthcare environment. PMID- 10174597 TI - Creating value-focused healthcare delivery systems: Part three--Core competencies. AB - Value is created through the delivery of high-quality, cost--effective healthcare services. The ability to create value from the providers' perspective is facilitated through the development and implementation of essential, customer focused core competencies. These core competencies include customer relationship management, payer/provider relationship management, disease management, outcomes management, financial/cost management, and information management. Customer relationship management is the foundation upon which all core competencies must be built. All of the core competencies must focus on the needs of the customers, both internal and external. Structuring all processes involved in the core competencies from the perspective of the customer will ensure that value is created throughout the system. Payer/provider relationship management will become a crucial pillar for healthcare providers in the future. As more vertical integration among providers occurs, the management of the relationships among providers and with payers will become more important. Many of the integration strategies being implemented across the country involve the integration of hospitals, physicians, and payers to form accountable health plans. The relationships must be organized to form "win/win" situations, where all parties are focused on a shared vision of creating value and none of the parties benefits at the expense of the others. Disease management in creating value requires that we begin examining the disease process along the entire continuum. Not only must providers be able to provide high-quality acute and chronic care, but they must also begin to focus more heavily on programs of prevention. Value is created throughout the system through reducing the prevalence and incidence of disease. Only through managing the full continuum of health will value be created throughout the healthcare delivery system. Outcomes management ensures that the outcomes are the highest quality at a cost-effective price. Outcomes must not only be compared to best practices, but to what is possible. Providers must constantly strive to enhance the quality of the services. Financial/cost management ensures that care is cost-effective and that a marginal profit is maintained to allow continued investment in new technology and continuing medical education to enhance the quality of care and lifestyles for all stakeholders. Information management is the binding element, or keystone, in providing value focused care. Through the collection, storing, transfer, manipulation, sorting, and reporting of data, more effective decision-making can occur. Integrated MIS allows information to be generated about the cost-effectiveness of treatment regimens, employee productivity, physician cost-effectiveness, supply utilization, and clinical outcomes, as well as patient information to be readily available throughout the healthcare system. Having this information available will allow providers to become more cost-effective in the delivery of care, which results in perceived higher value for the services. Customers demand value. Value is created by meeting the needs and demands of the customers through the delivery of cost-effective, high-quality healthcare services that are easily accessible and meet with high patient satisfaction. Providers who can demonstrate their ability to provide the services in this manner will create a competitive advantage in the marketplace and will be perceived as the value provider of choice by loyal customers. PMID- 10174598 TI - Marketing: a new role in a new healthcare system--implications for rural hospitals. PMID- 10174599 TI - Care maps, utilization, and outcomes: a viable solution. AB - Clearly, the changing healthcare environment and specific forces confronting cancer therapy today are necessitating collection and analysis of utilization, cost, and outcomes information. Manual tracking of information or tracking through multiple, disparate computer systems are cost--prohibitive alternatives to enabling cancer centers to efficiently and effectively manage these sophisticated information needs. However, the implementation of a cancer-therapy management system, which includes a disease-based process model of treatment and facilitates data-collection at the point of care, is now a strategic imperative for healthcare organizations. PMID- 10174600 TI - 1998 HFM resource guide. PMID- 10174601 TI - Building a sustainable, risk-bearing IPA. AB - HMOs are increasingly relying on risk-bearing IPAs to expand their networks. Physicians see IPAs as a way to access HMO patients without relinquishing their autonomy. To build a sustainable IPA to bear global risk for HMO enrollees, the IPA's organizers should select a provider panel that is committed to centralized medical management and dominated by primary care physicians, invest in talented managers, empower a strong governing board, and access a management information system that can perform the functions necessary to manage care. Additionally, the interests of any potential outside capital sources should be weighed carefully, and the financial incentives of all of the IPA's providers aligned with the IPA's goal of providing appropriate, cost-effective care. PMID- 10174602 TI - Succeeding under managed care using strategic cost reduction. AB - Under managed care, healthcare providers experience drops in utilization and the prices they can charge for services. Therefore, healthcare providers that achieve lower costs increase their chances for success. Operational improvements to control costs include reducing unit costs, reducing capacity, accelerating operational decision making, and developing new performance measures. Strategies to control costs include managing costs along the continuum of care, continuously managing costs, and refining assets. Specific cost-reduction strategies include building primary-care-driven networks, undertaking patient-focused care initiatives, reengineering patient flow, implementing managed variable costing, and developing a tight primary care operating environment. PMID- 10174603 TI - Intraoperative neurophysiological monitoring. Part 1: General overview. AB - Intraoperative electrophysiological recordings are gradually becoming part of standard medical practice, mainly because they offer an objective and effective way to assess the functional integrity of the nervous system of a patient during the course of an orthopedic, neurological, or vascular surgery. Continuous monitoring of spontaneous and triggered bioelectrical activity not only can avert damage of neurological structures that are at risk during certain surgical maneuvers, but also allows identification of specific neuronal structures and landmarks that cannot be easily recognized on anatomical grounds only. This series on neurophysiological monitoring will introduce various techniques of monitoring available today, the rationale for their intraoperative use, and the main principles on which they are based. Recommendations for proper implementation and troubleshooting will also be given. The present article gives a general overview of the procedures. PMID- 10174604 TI - Intraoperative neurophysiological monitoring. Part 2: Neurophysiological background. AB - Continuous intraoperative monitoring of neurophysiological signals provides a reliable way to determine the functional integrity of the nervous system during the course of neurological, orthopedic, or vascular surgery. To understand the use of electrophysiological recording in the operating room, the basic mechanisms that give rise to the recorded signals are briefly reviewed. Additionally, the equipment necessary for proper signal recording and presentation of the results is described. Finally, a short introduction to anesthesia management and some commonly induced neuroprotective conditions, such as hypothermia and hypotension, are provided, since these are the main factors affecting the signals, thus contributing to the difficulty of correct interpretation of the recordings during the course of an operation. PMID- 10174605 TI - Effective communication and supervision in the biomedical engineering department. AB - It is important for biomedical engineering supervisors to master the art of effective communication. Supervisors who have effective communication skills can successfully initiate creative programs and generate a harmonious working atmosphere. Using effective communication, they can promote good working conditions, such as high morale, worker initiative and loyalty to the department, which are almost impossible to measure but imperative for a successful department. However, effective communication tends to be neglected by supervisors who are either functional specialists or managerial generalists. This paper presents several cases of what effective communication truly is and discusses some potential factors that may lead to ineffective communication. PMID- 10174606 TI - A new model to estimate the appropriate staff for a clinical engineering department. AB - This study points out that the Clinical Engineering Department (CED) can provide expertise for the improvement of healthcare services if the size of the CED is appropriately determined; that is when the number of engineers, technicians and administrative staff is suitable for the activities that they are intended to carry out and for the amount of equipment they must manage. The paper presents a simple and flexible model where the staff is estimated according to the activities that need to be carried out by the CED and according to the amount of biomedical equipment being managed. Several examples of application and comparisons with the results provided by other models are reported and discussed. PMID- 10174607 TI - Development of a new Clinical Engineering Management Tool & Information System (CLE-MANTIS). AB - The evolution of the field of biomedical technology has led to the diffusion of an impressive number of medical devices into healthcare institutions. In this environment, Clinical Engineering Departments (CEDs) are expanding their role in healthcare technology management, by changing their structure and introducing quality systems in order to improve their services and monitor the outcomes. In the framework of the national project BIOTECHNET II, a software tool for the management of biomedical technology, named CLE-MANTIS, has been developed, with the aim to assist CEDs in their tasks. CLE-MANTIS functions include the upkeep of an inventory, the support and monitoring of scheduled maintenance, corrective maintenance, vigilance, equipment acquisition and replacement, service contract management and user training. The system offers clinical engineers the possibility to monitor and evaluate the quality and cost-effectiveness of their departments through the monitoring of quality and cost indicators. This paper presents the main features and functions of the system. PMID- 10174608 TI - Effects of second office and hospital consulting practices of physicians on rural communities. AB - This research examined the prevalence of second offices and hospital consulting practices of physicians in Missouri, the characteristics of physicians participating in such practices, the change in availability of services through these practices, the characteristics of counties and hospitals involved, and the practice organization of participating physicians. The assessment of the factors was conducted within the conceptual framework of community and physician characteristics, practice form and organization, and health system resources. In 1993, 64 of the 93 nonmetropolitan counties in Missouri gained, on average, 1.3 full-time equivalent physicians through second office and hospital consulting practices. Eighteen nonmetropolitan counties lost, on average, 0.4 full-time equivalent physicians through these practices; 11 nonmetropolitan counties were not affected. The majority of physicians engaged in these two types of practices are nonprimary care specialists. Consequently, in addition to the net contribution to total physician service availability, many nonmetropolitan counties gained access locally to a wider variety of specialty services. This change in availability of physician services, not generally incorporated in decisions, needs to be considered when policy efforts are undertaken to change the spatial and specialty distribution of physicians. PMID- 10174609 TI - The effects of physician in-migration to rural Colorado (1992 to 1995). AB - This paper reports the results of an analysis of the American Medical Association Masterfile. The purpose of this study was to examine changes in health care accessibility in rural Colorado from 1992 to 1995, and to describe the pattern of in-migration of physicians to nonmetropolitan statistical area counties of the state during that period. The number of direct patient care providers increased from 532 to 700 (31.6%) during the three-year period vs. a growth of 11.2 percent in the general population of nonmetropolitan statistical area counties. Of the 700 physicians serving residents of Colorado's 52 rural counties, 308 (44%) had been practicing in their community since 1992. The rate of departure from nonmetropolitan statistical area practice sites in 1992 was 26.4 percent (140 of 532). Physicians new to their rural practice locations were younger and proportionally more female, but they were similar in primary medical specialty to doctors who had remained in their 1992 sites. Population to physician and to primary care physician ratios were much more favorable for 1995 than for 1992. Accessibility to care was most improved in counties with fewer than 10,000 inhabitants. PMID- 10174610 TI - The attitudes of rural Minnesota family physicians toward nurse practitioners and physician assistants. AB - Increased use of nurse practitioners and physician assistants has been promoted as a possible solution to the shortage of primary care providers in rural locations. If the use of nonphysician providers is to be optimized in these areas, awareness and acceptance of their capabilities by rural family physicians is essential. This study surveyed the attitudes of rural Minnesota family physicians toward the use of physician assistants and nurse practitioners. Forty six percent of the 600 rural family physicians surveyed responded to the questionnaire. Approximately 90 percent of responding physicians indicated a high degree of confidence in the abilities of nonphysician providers in the areas of preventive and routine care; some concern was expressed about the proficiency of nonphysician providers taking call, covering the emergency room, and doing hospital rounds--activities that involve a broader base of clinical knowledge and diagnostic skills. Other concerns were an increased workload for physicians due to their assumed supervisory roles, an increase in complexity of cases seen by physicians, increased physician liability, job competition between nonphysician providers and physicians, and the lack of educational opportunities and supervisory guidelines for physicians regarding collaborative relationships. Appropriate roles for family physicians, nurse practitioners and physician assistants are not well-defined in the minds of respondents, and it appears future acceptance and practice patterns will depend on how these roles are established and accepted. PMID- 10174611 TI - Factors influencing exposure of children to major hazards on family farms. AB - On family farms, parents are usually knowledgeable of high-risk activities, yet they allow their children to be active participants in (or bystanders to) hazardous work for reasons not well-documented. A two-phase descriptive study, based on the theory of planned behavior and using mail survey research methods, was carried out to understand factors that influence parents' decisions to expose children to major hazards on family farms. A representative sample of 1,255 Wisconsin dairy farm fathers provided data about factors that influence their decisions to expose children younger than 14 years to risks of injury. Multivariate analyses revealed that attitudes, subjective norms, and perceived control accounted for up to three-fourths of the variance in fathers' behavioral intentions. Fathers' attitudes were stronger predictors of behavioral intentions than subjective norms (i.e., perceived social pressure) or perceived control. Grandparents and mothers exerted a limited influence. Other groups, such as health care providers, 4-H, Future Farmers of America, and insurers, exerted only a modest influence on fathers' feelings of social pressure. Few demographic characteristics of the family or farm were predictive of fathers' intentions to expose children to hazards. PMID- 10174612 TI - A typological approach to the study of rural HIV service delivery networks. AB - Despite the rapid growth of AIDS cases in nonmetropolitan areas, little is known about the characteristics and needs of HIV-positive rural residents or how rural areas are responding to the epidemic. This paper proposes a typology for distinguishing among rural environments and examining variations in HIV service networks. The typology identifies three dimensions that have a major effect on the development of rural HIV service networks: degree of rurality, the prevalence of AIDS, and the epidemiological and demographic characteristics of the infected populations. Data from four case studies are used to illustrate how variations in rural environments can affect the organization and delivery of HIV/AIDS care. The typology contributes to public policy discussions by identifying key attributes of rural environments that influence program planning and implementation and the transferability of service delivery models. PMID- 10174613 TI - Delivering care to rural HIV/AIDS patients. AB - With HIV/AIDS on the rise in rural areas, health care providers must find ways of delivering care with little or no increase in resource support. This paper examines the evolution of a rural HIV/AIDS alliance using a life cycle model to identify each stage of the alliance development and the specific issues associated with each stage. The data were collected through structured interviews and by review of background materials, including budgets, grant proposals, and program reports. The findings identify alliance strategies that can be used in other rural communities facing the challenge of serving an increasing number of HIV/AIDS patients with limited resources. Differing from other models, this rural HIV/AIDS alliance emerged from local government and community support into an independent, nonprofit organization operating through a network of interorganizational relationships. PMID- 10174614 TI - AIDS in rural America. PMID- 10174615 TI - HMO financial arrangements with rural physicians. AB - The growth of managed care in general suggests that a substantially larger number of rural primary care physicians will be asked to enter into risk-bearing contracts with Health Maintenance Organizations (HMOs) in the near future. This article describes the different types of payment and risk-sharing arrangements that exist between HMOs and primary care physicians and presents survey data relating to their prevalence in rural areas. Also, it describes in detail the payment arrangements used by four HMOs that contract with rural primary care physicians. The concluding discussion highlights policy issues regarding risk sharing arrangements that are especially pertinent in rural settings. PMID- 10174616 TI - What is rural? Issues and considerations. PMID- 10174617 TI - Researching on the World Wide Web/Internet. PMID- 10174618 TI - Evaluating the 1995 occupational employment projections. PMID- 10174619 TI - Evaluation of an automatic hematology analyzer in patients with nonhematologic conditions. AB - The Coulter STKS is a new automated hematology analyzer that provides complete blood counts (CBCs) and a five-part white blood cell (WBC) differential count. This study evaluated its performance and determined its value in reducing the extensive manual work required to obtain WBC differential counts from patients with nonhematologic conditions. The evaluations included precision, carryover, effects of storage duration and temperature, comparison of primary (automated) and secondary (manual) methods of aspiration, comparison with the Technicon H*1 machine, and WBC differential capability. Both primary and secondary methods provided CBC values that were precise, repeatable, and satisfactory. The WBC differential results also were accurate and comparable to those obtained manually. The Coulter STKS not only precisely analyzes CBCs but also screens blood samples without WBC abnormalities, as it has a 98% predictive value of negative test results. This instrument is suitable for use in nonhematology patients in large medical centers, teaching hospitals, and general hospitals. PMID- 10174620 TI - Successful treatment of acute subretinal hemorrhage in age-related macular degeneration by combined intravitreal injection of recombinant tissue plasminogen activator and gas. AB - Subretinal hemorrhage secondary to age-related macular degeneration (AMD) has a poor visual prognosis. Surgical drainage of the blood improves visual acuity only in selected patients. We report on two elderly patients with spontaneous subretinal hemorrhage from AMD. In one eye, recombinant tissue plasminogen activator (rTPA), combined with a long-acting gas (SF6), was injected into the vitreous cavity. The other eye was treated first by gas instillation followed 3 days later by rTPA injection. Both treatments led to nearly complete displacement of the subretinal hemorrhage from the macular region. In both eyes, an inferior exudative retinal detachment reabsorbed spontaneously within 2 weeks. Bilateral vitreous opacities after rTPA injection resolved without further treatment. Postoperative visual acuity increased to 0.3 and 0.4. The combined treatment is a valuable method for management of acute subretinal hemorrhage. Rapid displacement of this abnormality can minimize clot-induced damage of the highly sensitive macula and increase visual acuity. PMID- 10174621 TI - Immunoassay and other ligand assays: present status and future trends. AB - Immunoassay and other ligand assays have made a major impact on medical research and diagnosis since the first modern (radioisotopically-based) methods emerged. These ubiquitous microanalytic techniques are broadly classifiable as first generation (generally of "competitive" design, e.g., radioimmunoassay), and second generation (generally "noncompetitive," and relying on nonisotopic labels) these (often described as "ultrasensitive") being distinguished by dramatic improvements in sensitivity and performance time. A third generation is now in prospect (based on microarrays of antibody microspots) capable of ultrasensitive determination of hundreds of analytes in a drop of blood. Analogous technology (based on oligonucleotide arrays) is under intensive development for DNA analysis. Array technologies are likely to transform diagnostic medicine in the next decade. PMID- 10174622 TI - Importance of plasma phosphate determination. AB - Phosphate is an important component of all tissues and disorders of phosphate homeostasis are common in hospital populations. Hypophosphatemia, which is much more frequent than hyperphosphatemia, is commonly caused by infusion of carbohydrate or respiratory alkalosis. If hypophosphatemia is prolonged, severe consequences such as hemolysis, myopathy, and respiratory dysfunction may occur. In order to prevent these complications it is important to measure plasma phosphate concentration in a number of clinical situations. If severe hypophosphatemia is detected, phosphate supplements should be given to correct it. PMID- 10174623 TI - Prostate-specific antigen: update 1997. AB - Prostate-specific antigen (PSA) is the most important tumor marker for prostate cancer, although it is not a perfect marker as it is not cancer-specific. PSA, a member of the human kallikrein family, is present in two molecular forms in serum: free and complexed to protease inhibitors. PSA is now commonly measured on automated immunoassay systems employing monoclonal or polyclonal antibodies. Results from different assays can vary since some assays are not equimolar and react to the free and complexed forms differently. Utilization of the molecular forms of PSA is one approach to improve the sensitivity and specificity of the PSA assay. Patients with prostate cancer have a greater percentage of PSA bound to alpha1-antichymotripsin (ACT) than those without cancer. Measurement of the free to total PSA ratio in the diagnostic gray zone (usually 4-10 micrograms/liter of total PSA), where prostate cancer and benign prostatic hyperplasia (BPH) overlap, has been shown to eliminate between 16 and 79% of unnecessary biopsies. Free to total PSA cutoffs are influenced by the sensitivity and specificity values chosen, the reflex range for total PSA used, differences in free PSA assays, differences in populations studied, and factors such as total PSA concentrations, age, and prostate gland size. In addition to the molecular forms of PSA, age-specific reference ranges, rate of change of PSA concentrations (PSA velocity), ratio of serum PSA to prostate volume (PSA density), and neural network derived indices have been employed to improve the clinical utility of PSA measurements. PMID- 10174624 TI - Recent advances in the genetics of primary immunodeficiency disease. AB - Considerable advances have been made in our understanding of the genetics of primary immunodeficiencies over the last few years. The genetic defects underlying many forms of severe combined immunodeficiency, antibody deficiency, and neutrophil disorders are now known, raising the possibility of curative gene therapy for severe defects. These advances have also led to significant changes in our knowledge of basic mechanisms, not only of immunologic control but of cellular development and gene regulation. PMID- 10174625 TI - Complying with US and European change control requirements, Part II. AB - Part I of this two-part article discussed the United States (US) and European quality system requirements for controlling changes to products, processes and documentation. Part II will discuss some change control problems that can occur, the elements that should be included in change control procedures and records and the requirements for notifying regulatory authorities of changes. PMID- 10174626 TI - Economic considerations for device design and development. AB - The importance of the design and development process is often underestimated in the rush to get products to market. Studies have shown that sensible investment in this process will lead to manageable risk levels, consumer confidence and high levels of return. This article recommends procedures that manufacturers should follow to improve the quality and efficiency of their development endeavours, and thus maximize their product performance and market presence. PMID- 10174627 TI - Not long to go: the end of the transition period approaches. AB - There are only seven months left until the end of the transition period for the Medical Device Directive. Manufacturers who have already achieved compliance and the CE mark can, in theory, look forward to the free circulation of their products throughout the European Union. This article examines the situation for manufacturers who have not yet complied and discusses the status of non-CE-marked products on and after 14 June 1998. PMID- 10174628 TI - The device industry in Germany. AB - Germany is Europe's leading medical device market. Home to a number of large multi-national medical equipment manufacturing companies, the market is highly competitive and considered difficult to penetrate. In recent years, it has experienced constant growth, which despite problems with health-care funding, looks set to continue. PMID- 10174629 TI - Coping with cost constraints. PMID- 10174631 TI - The market: escalating demand. PMID- 10174630 TI - German law: the differences. AB - Medical device regulations in Germany are changing. The first amendment of the Medical Device Law, the MPG, is in preparation. Four decrees on medical devices are also being discussed by the Bundesrat, the Federal Council. This article summarizes what manufacturers, distributors and users should know about the German device regulations. PMID- 10174632 TI - Size and shape really matter: the influence of design on biocompatibility. AB - Biocompatibility is normally equated with the characteristics of degradation and toxicity. However, there are many more ways by which a medical device can affect the host, including the way in which devices distribute stress in the tissues. This in turn implies that the design of the device can be influential in determining the host response. PMID- 10174633 TI - Hawaiian Airlines flies with MedLink for round-the-clock medical assistance services. PMID- 10174634 TI - Researchers to test teleophthalmology on the reservation. PMID- 10174635 TI - Five years of telemedicine with the troops. PMID- 10174636 TI - Teledermatology demonstrates its potential in Oregon. PMID- 10174637 TI - Practicing telemedicine in midwestern winters. PMID- 10174638 TI - Defense Department gets its telemedicine Mobile Breast Care Center ready to travel. PMID- 10174639 TI - Hospitals to share scanner. PMID- 10174640 TI - Telesymposium on minimally invasive direct-access heart surgery viewed worldwide. PMID- 10174641 TI - WHO director-general highlights potential of telemedicine. PMID- 10174642 TI - Georgia Medical Center delivers home health care. PMID- 10174644 TI - Computer program allows virtual reality pre-surgery on eyes. PMID- 10174643 TI - Teleophthalmology clinics gets a workout. PMID- 10174645 TI - Army tests battlefield medical systems. PMID- 10174647 TI - National Library of Medicine grants provide telemedicine research from coast to coast. PMID- 10174646 TI - Doctors lag behind executives in using Email and the Internet. PMID- 10174648 TI - South Pacific islands team up to use satellite. PMID- 10174649 TI - U.S., Russia link for telemedicine. PMID- 10174651 TI - Hawaii uses telemedicine to link islands, Mainland, region. PMID- 10174650 TI - Greek, Chicago hospitals link cardiology services. PMID- 10174652 TI - Electronic medicine makes breathing easier for patients with asthma. PMID- 10174653 TI - The 12-step way to reduce overhead: staffing efficiencies. PMID- 10174654 TI - Making a difference with risk adjustment. PMID- 10174655 TI - A tool for training new employees. PMID- 10174656 TI - Fatal organizational flaws: let the physician beware. PMID- 10174657 TI - The 12-step way to reduce overhead: operational efficiencies. PMID- 10174658 TI - Managed care ethics committees make a difference. PMID- 10174659 TI - Keys to success in Medicaid managed care. PMID- 10174660 TI - A method for decreasing missed appointments. PMID- 10174661 TI - Primary, secondary, and tertiary prevention capabilities of selected HMOs: findings of an employer survey. AB - PURPOSE: To survey Health Maintenance Organizations (HMOs) of a major employer regarding the extent of their health promotion and disease prevention capabilities. DESIGN: A one-time cross-sectional survey. SETTING: The setting involved in this study was managed care organizations. SUBJECTS: The subjects were 22 HMOs located in the western part of the United States. MEASURES: The study involved completion of a survey grid on a fairly comprehensive range of primary, secondary, and tertiary prevention activities. RESULTS: Twenty-two HMOs were surveyed and 20 responded, providing a response rate of 90.9%. Analysis of distribution of responses and simple means were used. If a "perfect score" included addressing all 52 prevention targets across all 13 intervention modalities (minus inappropriate combinations) and that represented a score of 100%, the highest scoring HMO indicated that it provided or addressed 36.8% of all possible modalities and prevention target combinations. The composite average score for all three areas of prevention for all responding HMOs was slightly less than 13%. Additionally, five of the HMO respondents provided approximately 59% of all the prevention activity reported in the survey. Nonrepresentativeness of the HMOs in the sample represents the most significant study limitation. CONCLUSIONS: Results suggest that prevention capabilities among the HMOs surveyed are unevenly distributed and somewhat concentrated. PMID- 10174662 TI - Prevention capabilities among HMOs. PMID- 10174663 TI - Current trends in the integration and reimbursement of complementary and alternative medicine by managed care, insurance carriers, and hospital providers. AB - OBJECTIVES: To assess the status of managed care and insurance coverage of complementary and alternative medicine (CAM) and the integration of such services offered by hospitals. METHODS: A literature review and information search was conducted to determine which insurers had special policies for CAM and which hospitals were offering CAM. Telephone interviews were conducted with a definitive sample of 18 insurers and a representative subsample of seven hospitals. RESULTS: A majority of the insurers interviewed offered some coverage for the following: nutrition counseling, biofeedback, psychotherapy, acupuncture, preventive medicine, chiropractic, osteopathy, and physical therapy. Twelve insurers said that market demand was their primary motivation for covering CAM. Factors determining whether insurers would offer coverage for additional therapies included potential cost-effectiveness based on consumer interest, demonstrable clinical efficacy, and state mandates. Some hospitals are also responding to consumer interest in CAM, although hospitals can only offer CAM therapies for which local, licensed practitioners are available. Among the most common obstacles listed to incorporating CAM into mainstream health care were lack of research on efficacy, economics, ignorance about CAM, provider competition and division, and lack of standards of practice. CONCLUSIONS: Consumer demand for CAM is motivating more insurers and hospitals to assess the benefits of incorporating CAM. Outcomes studies for both allopathic and CAM therapies are needed to help create a health care system based upon treatments that work, whether they are mainstream, complementary, or alternative. PMID- 10174664 TI - Consumer focused or system focused? Choosing demand management interventions. PMID- 10174665 TI - Reaching the poor with health promotion through community free clinics. PMID- 10174666 TI - Physical activity, participation in team sports, and risk of suicidal behavior in adolescents. PMID- 10174667 TI - Differences in dietary intake between smokers and nonsmokers among Lumbee Indian women in North Carolina. PMID- 10174668 TI - Recruitment of managed care Medicare patients for a physical activity study. PMID- 10174669 TI - Consolidation for serum proteins. PMID- 10174670 TI - The high-tech war against TB. PMID- 10174671 TI - Hair testing for pharmaceuticals and drugs of abuse: forensic and clinical applications. PMID- 10174673 TI - Finding what you need on the internet. PMID- 10174672 TI - Improving the referral process: one group's experience with CQI. PMID- 10174674 TI - Re-engineering for managed care: a practice in transition. PMID- 10174675 TI - Re-engineering for managed care: a practice in transition. PMID- 10174676 TI - Nine ways to conduct more efficient office visits. PMID- 10174677 TI - Managed care: the fast lane to court? PMID- 10174678 TI - Exam documentation just got harder. PMID- 10174679 TI - Practical tips to boost your efficiency and cut practice costs. PMID- 10174680 TI - Blood transfusion in South Africa. AB - Sixty years of development have transformed previously small collection centres into major regional transfusion services. These organisations collect and process nearly 900,000 units of blood annually from a donor base of some 500,000 individuals with a male to female ratio of 5:3. Three quarters of the donations are from a regular pool of largely white people. The latter has both a cultural and socio-economic component that needs redress to meet expanding requests. The range of products and quality of newer technologies, including those that are centered on aphereses are commensurate with first world standards. Quality control is universally monitored and registration falls under prevailing legislation. The future of these vitally important services will need to accommodate changing priorities in South Africa. Specific challenges are a greater commitment to primary health care, the rapidly rising incidence of HIV positivity and centralisation of some facilities including plasma fractionation. PMID- 10174681 TI - HIV and blood transfusion in sub-Saharan Africa. AB - Blood transfusion services were poorly developed until the mid 1980s in most of sub-Saharan Africa, and were unable to provide adequate supplies of blood with acceptable safety. The pandemic of HIV was recognized seroepidemiologically from 1985 onwards. Blood transfusion was contributing from 10 to 15% to transmission in Africa. Groups at highest risk are children with malaria and anaemia, women with pregnancy-related haemorrhage or anaemia, victims of trauma and subjects with sickle-cell disease. Haemophiliacs are not a major risk group in comparison. Blood transfusion services have undoubtedly benefitted from the international, national and regional responses to the AIDS epidemic. Organizational structures have been established. There have been concerted moves to recruit voluntary unremunerated blood donors, selected from population groups with low seroprevalence. Serological screening for HIV, hepatitis viruses and syphilis has been introduced or strengthened. Standards for blood group serology, blood storage and handling have been improved. Guidelines for the appropriate use of blood have been formulated and adopted. There have been many training and retraining programmes. Much remains to be completed, however, using national and international resources, before the blood supply reaches acceptable standards of safety and is adequate in remote as well as in central areas of Africa. PMID- 10174682 TI - Cross-flow microfiltration of blood through an extracorporeal device: a study in parameterization. AB - This paper develops a new approach for the general description of membrane plasma separator performance by using dimensional analysis. Experiments involved cross flow microfiltration of goats' blood across flatsheet polyvinylidene fluoride durapore membranes of pore size 0.65, 0.45 and 0.22 microns in a thin-channel device. Certain non-dimensional numbers are evolved which represent the grouping of relevant filtration parameters and which contribute to the global characterization of membrane-based plasmapheresis devices. PMID- 10174683 TI - Normal saline versus heparin flush for maintaining central venous catheter patency during apheresis collection of peripheral blood stem cells (PBSC). AB - Thrombotic occlusion is frequently a complication of central venous catheters (CVCs). The original designers and producers of CVCs recommended heparin flush regimens to prevent thrombosis and maintain patency. This has become standard practice although no studies have demonstrated a relationship between heparin flushing and reduction of catheter thrombosis. Many consider the routine use of heparin flushing innocuous. However, serious complications including drug interactions and heparin induced thrombocytopenia and thrombosis syndrome (HITS) have been reported in association with heparin flushing. Numerous studies comparing heparin to saline flushing in peripheral devices suggest equal rates of thrombotic occlusions. The purpose of this study was to examine the incidence of thrombotic occlusions in CVCs using heparin compared to saline flushing. The study involved 78 cancer patients undergoing apheresis collection for peripheral blood stem cells; 29 received saline flushes and 49 received heparin (100 U/ml of saline) flushes. Study endpoints included slow apheresis flow rate (< 50 ml/min), urokinase use for thrombolysis, and radiographic evidence of catheter thrombosis. No significant differences were found for any endpoint between the two groups. These findings suggest saline may be as effective as heparin for maintaining patency of CVCs. PMID- 10174684 TI - Unexpected hemoglobin electrophoresis results following red cell exchange in a sickle cell anemia patient with acute chest syndrome. AB - Acute chest syndrome is a well described complication of sickle cell anemia. It is characterized by fever, pulmonary infiltrates, pleuritic chest pain and abnormal pulmonary auscultation. Transfusion therapy, either simple transfusion of red blood cells or a total red blood cell exchange, is a cornerstone therapy for these patients. Exchange transfusion is preferred when an acute reduction of the hemoglobin S (HbS) concentration is the therapeutic goal since it allows one to rapidly reduce the percent HbS without increasing blood viscosity or volume (Wayne, Kevy and Nathan, Blood 1993; 81:1109-1123). Hemoglobin electrophoresis may be used to monitor the effectiveness of the exchange in decreasing HbS. The post-exchange HbS electrophoresis results which were obtained in this case initially caused confusion. In this report we discuss the findings and the reasons why such results may be occasionally expected in future similar situations. PMID- 10174685 TI - Decreasing blood donor exposure in the neonates by using dedicated donor transfusions. AB - Critically ill infants receive frequent red cell transfusions for replacement of blood drawn for laboratory analysis and in treatment of symptomatic anemia. Since blood for multiple transfusions on a given day is typically obtained from one fresh RBC unit, each multiply transfused neonate is exposed to many donors increasing the risk of transfusion transmitted disease. We hypothesized that the number of donor exposures per infant would decrease by instituting DDTP and that more infants will be exposed to only a single donor. We started a Dedicated Donor Transfusion Program (DDTP) in our NICU. One unit of red cells is dedicated to each baby for the life of the unit (35 days). We compared the donor exposure in infants for one year, before and after DDTP. The infants were divided into three birth weight groups. Group I were infants < 1000 g; Group II infants were 1000 1500 g; Group III infants were > 1500g. The average number of transfusions per patient decreased significantly from 7.5 +/- 6.0 to 4.7 +/- 4.2 (P < 0.001) in Group I while it remained unchanged in Groups II and III. The Dedicated Donor Transfusion Program significantly reduced the donor exposure in NICU infants. The program also facilitated the reduction of the number of transfusions in the infants under 1000 g. PMID- 10174686 TI - Effect of long-term platelet donation on lymphocyte subsets and plasma protein concentrations. AB - Previous studies of changes in immune function in platelet donors have investigated subjects who were undergoing plateletpheresis using older equipment that is no longer in general use. Therefore, the purpose of this study was to determine the effect of long-term platelet donation on lymphocyte numbers and subsets and plasma protein concentrations in platelet donors using newer cell separators. Three groups included in the study were nondonor controls (n = 27), long-term whole blood donors (n = 29), and long-term platelet donors (n = 20). Using a cross-sectional analysis, lymphocyte numbers and subsets were determined and compared among the three groups. Plasma concentrations of total protein, globulin, albumin, and IgG were also compared. Among the three groups there were no significant differences in total white blood cell counts, percentage or absolute number of lymphocytes, or percentage or absolute number of lymphocyte subsets. Serum total protein, globulin, albumin, and IgG concentrations of platelet donors were within normal ranges. These data support the current Food and Drug Administration (FDA) and American Association of Blood Banks' standards for the frequency of platelet donation allowed and monitoring required for plateletpheresis donors. Furthermore, these data indicate that the FDA could eliminate the requirement for the warning in informed consents about lymphocyte depletion in platelet donors. PMID- 10174687 TI - Comparison of performance of six different cell separators in collecting peripheral blood mononuclear cells. AB - We compared the efficacy of six different cell separators in collecting peripheral mononuclear cells to be used for autologous or homologous peripheral stem cell transplantation. The product obtained with the Dideco Vivacell cell separator showed a low percentage of mononuclear cells (38%) in the final product and a high platelet efficiency (38%). The Baxter CS3000 Plus cell separator required the longest time to load and prime the kit (18 min), it showed a high MNC efficiency (68%), with the highest percentage of MNC in the final product, the highest platelet efficiency (45%), a low red blood cell contamination in the final product (2.7 mL), the highest extracorporeal volume (450 mL) and a high percentage of technical failures (15%). The product obtained with the Fresenius AS104 cell separator with P1Y kit showed the highest final volume (297 mL), the lowest platelet efficiency (12%) and the lowest extracorporeal volume (230 mL). The same cell separator with C4Y kit showed a lower MNC efficiency (52 vs 60%) and a higher percentage of MNC in final product (63 vs 41%). The platelet contamination in final product was the lowest (18 x 10(9)/100 mL). The Haemonetics MCS3p cell separator required the lowest time to load and prime the kit (5 min), it showed the highest MNC efficiency (71%). The blood volume processed per hour (1328 mL) and the percentage of MNC in final product was lowest (32%), the extracorporeal volume (450 mL) was the highest. The Cobe Spectra cell separator allowed to process the highest blood volume per hour (3383 mL) and the final product had the lowest red blood cell contamination (2.3 mL/100 mL). The Dideco Excel cell separator required the longest time to load and prime the kit (18 min), the lowest MNC efficiency (38%), the highest platelet contamination in final product. Furthermore this machine showed the highest percentage of technical failure (20%). None of the six instruments have all the required preconditions and the ideal cell separator for peripheral stem cell apheresis at present is not available on the market. PMID- 10174688 TI - Annexin V, a new marker of platelet storage lesion: correlation with dMPV. AB - Released annexin V, an intracellular platelets glycoprotein, was used to determine the cellular injury which occurred during storage of platelet concentrates. Twenty-eight units of leuco-reduced apheresis platelet concentrates, obtained without leucocyte filtration, were analysed. Released annexin V showed a significant correlation with EDTA-induced shape changes of platelet (r = 0.62, P < 0.01) while poor correlation was found between released annexin V and pH or MPV. The combination of released annexin V with dMPV provides excellent markers of the platelet storage lesion for quality monitoring, based on morphological/functional integrities and cellular injury, which are of direct relevance to clinical efficacy of platelet concentrates. PMID- 10174689 TI - Langerhans islet preparation in cell transplantation. AB - Islet cell transplantation is potentially one of the best techniques for the almost perfect symptomatic treatment of Type 1 diabetes mellitus. Thanks to the considerable progress achieved in isolating and purifying human islet cells, highly encouraging results have recently been reported. However, due to the need for immunosuppression treatment, the indications are presently as limited as those for transplantation of the vascularized pancreas, namely cotransplantation. The ultimate goal of transplantation is to allow long-term function of the grafted tissues using no or transitory host immunosuppression. When compared to solid organ grafts, cellular transplants are more amenable to creative strategies to accomplish this goal. We review the current status of islet transplantation in man and then the major steps before islet transplantation and their prospects. PMID- 10174690 TI - Monocyte/macrophages as effector cells in cancer immunotherapy. AB - Among the different strategies which have been developed for immunotherapy of cancer, adoptive immunotherapy uses leucocytes activated in vitro and reinfused into the patients. Five leucocytes subsets can be employed for this immunotherapy with activated autologous cells. Blood monocytes can be isolated in high purity and large numbers and under special culture conditions differentiated into macrophages for adoptive transfer. Once activated ex vivo, these cells display very high antibody dependent and independent specific cytotoxicity for tumour cells, are capable of phagocytosis of cancer cells and, as antigen presenting, cells are able to involve CTL in the anticancer response. As the understanding of this activation to cytotoxicity is only recent, the present paper first provides a literature review of the main points in the field. Our own results are then discussed in relation to the development of a clinical protocol for adoptive transfer of MAK (macrophage activated killer) cells, a therapeutic strategy having a pivotal role in the immunosurveillance of cancer. PMID- 10174691 TI - Methods of CD34+ cell separation: comparative analysis. AB - During the last decade, several technologies based on the recognition of CD34 antigen have been proposed to purify hematopoietic cells for clinical use. The following review describes the different approaches, including panning, high speed activated cell sorting, immunomagnetic selection and immunoadsorption column separation. Positive selection of hematopoietic stem cells is now an essential step in cellular therapy. Quantitative and qualitative aspects of each system will be discussed as well as technical progress in the clinical setting. PMID- 10174692 TI - Hematopoietic stem cell expansion. AB - This review addresses two issues: (1) cytokine-mediated expansion of functional end cells for the abrogation of short term neutropenia and thrombopenia following high dose chemotherapy and (2) cytokine-driven increase in absolute numbers of functional stem cells. The literature suggests that the short term exposure of CD34+ cells to cytokines produces mature progenitors which in turn give rise to functional neutrophils and platelets. The expansion of functional stem cells is a more complex issue, as primitive stem cells are quiescent and their growth requirements are less clearly defined. PMID- 10174693 TI - Gene therapy for AIDS. AB - The absence of effective treatments makes AIDS one obvious candidate among the infectious diseases which might be treated by somatic gene therapy. Since HIV1 predominantly infects cells of the haematopoietic system, multipotent stem cells or more mature CD4+ cells constitute potential targets for the introduction of a foreign antiviral gene that will inhibit HIV1 replication and/or spread. Reimplantation of the genetically-modified cells into HIV-infected patients should theoretically allow the repopulation of the host with HIV1-resistant CD4+ cells that might be able to control virus propagation in vivo. Alternatively, increased knowledge of the immunological mechanisms involved in the control of virus infection and propagation has led to the development of different strategies to augment host anti-HIV1 cytotoxic T lymphocyte responses in an effort to prevent virus spread and, hence, the onset of AIDS. While the therapeutic value of such approaches still remains unknown, these experimental treatments hold real promise that require thorough clinical evaluation. PMID- 10174694 TI - Gene transfer into human haematopoietic stem cells. AB - This review of gene transfer to the human haematopoietic system (1) describes the different vectors used to transduce genes into stem cells, emphasizing retroviruses that have already shown their efficiency and innocuousness; (2) analyses which human cells should be targeted to ensure long-lasting engraftment; (3) indicates the different means of infecting these targets ex vivo, underscoring the role of cytokines and stromal cells; (4) recollects the methods used to evaluate transduction efficiency; and (5) gathers the results of clinical trials recently performed using human stem cells. The major conclusions are that good practice can ensure safe gene delivery to human beings and that long lasting, multilineal precursors can be transduced using retroviral vectors of marker genes or genes of therapeutic interest. However, transduction rates appear to remain relatively low, which should stimulate ongoing research on both vector design and means of ex vivo gene transfer. PMID- 10174695 TI - Dendritic cells: therapeutic potentials. AB - Dendritic cells (DCs) are leukocytes that are specialized to capture antigens and initiate T-cell-mediated immune responses. After capture of antigens, DCs, then in an immature stage, leave their tissue of residence and migrate through the lymph/blood into secondary lymphoid organs where they differentiate into mature cells. Because DCs can prime animals in the absence of any other adjuvant, they have been termed 'nature's adjuvant'. Large numbers of DCs can now be generated from circulating monocytes or from CD34 hematopoietic progenitors in response to GM-CSF in combination with either IL4 or TNF alpha. In mice, tumor antigen loaded DCs have been shown to prevent the development of tumors and even to induce the regression of established tumors. DCs therapy represents a very promising approach to the treatment of cancer and infectious diseases. Early studies indicate the existence of DC populations that can induce tolerance and may prove useful in organ transplantation. PMID- 10174696 TI - Graft T-cell depletion as a prerequisite for the modulation of alloreactivity after haematopoietic stem cell transplantation. AB - The T-lymphocytes present in the graft, HLA compatibility, and the cytokine environment at the time of transplantation play a major role in alloreactivity. Increased knowledge of the on-going immunological interactions as well as the development of cellular therapy are required to permit further expansion of post transplantation alloreactivity as an important immunotherapy tool. By allowing successful GvHD prevention and various post-transplantation immunological interventions, T-cell depletion of the graft can be the starting point for a multistage "progressive" procedure transplantation process adapted to recipient disease, HLA compatibility, desired anti-tumour effects and observed alloreactivity. PMID- 10174697 TI - The efficient exam room. PMID- 10174698 TI - Open access plans: will family physicians be left behind? PMID- 10174699 TI - Building a solid employment agreement with a small group practice. PMID- 10174700 TI - The art of choosing the right practice consultant. PMID- 10174701 TI - What a patient advocate can do for your practice. PMID- 10174702 TI - Giving back to the community. PMID- 10174704 TI - Embracing the alternative. PMID- 10174703 TI - The case for computerized practice. PMID- 10174705 TI - Cash patients: an unexpected opportunity in managed care. PMID- 10174706 TI - Medicare update. Certifying home health care services requires extra caution. PMID- 10174707 TI - Improving your negotiating position with MCOs. PMID- 10174708 TI - Will hospitalists assume family physicians' inpatient care roles? PMID- 10174709 TI - The Academy's first survey of salaried family physicians. PMID- 10174710 TI - Mental health care: from carve-out to collaboration. PMID- 10174711 TI - Medical ethics. Recommended core educational guidelines for family practice residents. PMID- 10174712 TI - Avoiding fraud and abuse in Medicare claims: what FPs need to know. PMID- 10174713 TI - The proposed TB standard comes of age. PMID- 10174714 TI - American Health Information Management Association. Resolutions from the 1997 House of Delegates. PMID- 10174715 TI - Practice brief. Issue: Release of information for marketing purposes. American Health Information Management Association. PMID- 10174716 TI - The official position of American Health Information Management Association. Issue: Confidential health information and the Internet. PMID- 10174717 TI - Leading the quest for compliance. PMID- 10174718 TI - Healthcare compliance plans: good business practice for the new millennium. AB - Recent developments indicate that government scrutiny of healthcare providers will continue well into the next century. This article sheds light on the Federal False Claims Act and its recent interpretation by the Department of Health and Human Services' Office of the Inspector General and the United States Attorney's Office, the OIG's 1998 workplan, and current fraud and abuse initiatives. It also presents the fundamental elements of a compliance plan. PMID- 10174719 TI - Configuring compliance: a professional fit. AB - The development and implementation of compliance programs offer HIM professionals perfect opportunities to provide leadership and expertise. HIM professionals should be involved in these processes because the documentation of patient services is an essential part of the investigation and enforcement of compliance. This article outlines the guideposts for developing a compliance plan and highlights opportunities for growth, learning, and career advancement opportunities for HIM professionals. PMID- 10174720 TI - Compliance, medical records, and the FBI: preventing fraud and abuse. AB - The possibility of an investigation related to fraud and abuse is the last thing most people want to think about, but it's important to be prepared, just in case. The author gives some advice on how to react if your facility is the target of an investigation and points out some important steps to take to ensure compliance. PMID- 10174721 TI - Playing a part: the FBI's role in healthcare fraud investigations. PMID- 10174722 TI - HIM's impact on enhancing data quality and integrity in the home health setting. PMID- 10174723 TI - Coding compliance: practical strategies for success. PMID- 10174724 TI - Transforming a health care information management system. AB - The article presents results from a survey of 98 top executives at Baylor Health Care System (BHCS), a large, multifunction health care organization in Dallas, Texas. The survey assessed the executives' perceptions of current BHCS quality practices using the first survey developed for the health care industry based on the Malcolm Baldrige National Quality Award (MBNQA) criteria. Findings regarding the quality of BHCS internal and external data and information include the need for a $50 million information system transformation to achieve seven critical success factors for all business units and improved internal and external data and information for the business process redesign and quality transformation. Results highlight the need for further research investigating the information and analysis MBNQA criteria. PMID- 10174725 TI - Information for management--the extent of information management in the acute care hospital sector. AB - The article explores the contributions of information and information technology to health care management by means of a study into current information use in a small acute care hospital and the preparations for new general practitioner purchasing systems. The findings highlight the interdependency between manual and computer systems and key departments in the hospital. With increased emphasis on primary health care, there is a greater need for information sharing between the hospital and general practitioners. Provision of information itself becomes a factor in determining service quality. Information systems are therefore emerging as an element in gaining competitive advantage in hospitals in the United Kingdom. PMID- 10174726 TI - Standard generalized mark-up language: should it have a role in clinical records? AB - Standard generalized mark-up language (SGML) could have a role as one of the information management tools available to system developers and users because it has unique features that can help solve some of the current problems in clinical informatics. SGML allows the logical structure of multimedia documents to be described in a way that is independent of the hardware or software platform. This offers considerable advantages for purchasers of systems because it gives an opportunity to develop records that can be readily authored and read by a variety of systems, offering a route to effective communication of electronic clinical information. PMID- 10174727 TI - Surveillance by casualty attendance registers. AB - Health managers need trauma data, but appropriate information is often lacking. The challenge is to develop affordable and sustainable information systems. The article describes the development of a regional trauma database and an evaluation of a basic surveillance methodology. A comprehensive survey was conducted of first-time attenders with fatal and nonfatal trauma from both state and private sectors in metropolitan Cape Town, South Africa, and a hospital-based survey was conducted of nonfatal trauma in the surrounding rural areas. In four state hospitals, a standardized adaptation of casualty attendance registers was evaluated to determine whether such registers could be used to establish a trauma surveillance system. The two cross-sectional studies covered a population of 3.4 million and provided detailed data. The evaluation of the register highlighted problems and indicated how to establish a register-based trauma surveillance system. Although such surveys yield comprehensive local data, there is a need for salient regional and national surveillance data. Minor modifications of casualty attendance registers may provide this without much additional effort and expense. PMID- 10174728 TI - Copy management in a shared care environment using the Internet. AB - A new approach to sharing medical records using a demand-based database replication method and the Internet e-mail facility is proposed. The underlying model allows subscribed physicians to collect patient records from distant nodes and have local access to these records when needed. A system called the Internet Based Distributed Medical Information System has been developed and implemented in a shared care environment comprising outpatient clinics, independent practitioners, and diagnostic laboratories. This tool may be highly beneficial in improving coordination among health care professionals and reducing unnecessary repeat investigations. PMID- 10174729 TI - The use of case mix measures in the planning and provision of health care. AB - Recent changes in the management of U.K. health care have been directed toward the provision of cost-effective care appropriate to the health needs of the population. There are many initiatives to achieve this objective. In particular, the National Casemix Office has developed health care resource groups to categorize clinical activity for costing purposes and health benefit groups to categorize the population in terms of need for health care and ability to benefit from that care. The article describes the use of these two sets of groupings to develop a matrix that maps the major health needs in the population against the treatment and care required to meet those needs. The matrix provides a framework for the development of outcome measures and clinical guidelines. PMID- 10174730 TI - Assessing the impact of information on evidence-based nursing practice: the EVINCE (Establishing the Value of Information to Nursing Continuing Education) project. AB - One of the aims of the EVINCE study (Establishing the Value of Information to Nursing Continuing Education) was to assess the impact of information obtained from information and library services about nursing knowledge, competencies, and practice. Survey methods included a critical incident type survey of the patterns of information need and use among a random sample of more than 200 nursing, midwifery, and health visiting staff at five sites and a survey of 776 searches and requests presented to 13 different information services. Questionnaire surveys were followed by selected interviews. Results indicated that information seeking in practice was often prompted by a combination of purposes, with 41 percent of information-seeking incidents involving patient care purposes combined with informal or formal education. The profile of information requests seen by the information service differed, there being more emphasis on formal education and research. Nursing professionals value highly the information obtained from information and library services, and information that helps in evidence-based practice is a priority. Information skills are varied, suggesting that much support for critical appraisal is necessary. PMID- 10174731 TI - Assessing the impact of community health information networks: a multisite field study of the Wisconsin Health Information Network. AB - Community health information networks (CHINs) have emerged as a promising new technology to generate cost reductions and support change in the health care industry. The proliferation of CHINs has been thwarted, however, by a conspicuous lack of evidence to support the claims of enhanced efficiency and effectiveness from CHIN participation. A recent study of the Wisconsin Health Information Network, the nation's first fully functioning CHIN, documents the benefits of this emerging technology. The findings reveal the potential for significant cost savings via electronic transmission of patient clinical and administrative information as well as enhancement of the quality of patient care. PMID- 10174732 TI - A glimpse into the future: a survey of the expectations and ambitions of Australian health information management students. AB - The future of the health information management profession is largely dependent on the ability of educational programs to attract high-caliber students who have a clear understanding of their future career when entering their course and who aspire to become active members of the profession after graduation. A sample of Australian health information management students was surveyed to obtain information about satisfaction with their career choice, employment options, and intended involvement in professional and postgraduate education activities. The survey looked for differences between the responses of students at different stages of their courses and changes in student responses over time. The majority of students believed that they had made the correct career choice. There was a general preference for nontraditional health information management employment positions on graduation and a strong commitment to professional involvement and postgraduate education. Significant differences in some questionnaire responses were found among the student groups. Students' responses to questionnaire items about their future careers were less likely to change compared with other questionnaire items. Implications of the results for the health information management profession and educational institutions are discussed. PMID- 10174734 TI - Where does wireless work? PMID- 10174733 TI - PhyCor buys MedPartners. PMID- 10174735 TI - Confidence and confidentiality. PMID- 10174736 TI - The evolution of Ethernet. PMID- 10174737 TI - What works. CPR (computerized patient record) helps pediatrician add 2,000 patients, $200,000 revenue without more staff. PMID- 10174738 TI - What works. Monitoring system saves $1.4 million in first year. PMID- 10174739 TI - What works. Practice adds patients, reduces costs with electronic patient charting system. PMID- 10174740 TI - The Health Village pilot: tuning up an Internet solution. PMID- 10174741 TI - Hotlist. CPR/EMR. PMID- 10174742 TI - Mining for strategically significant financial information. PMID- 10174743 TI - Technology training: knowledge is power. PMID- 10174744 TI - Disease state management in diabetes care. AB - Diabetes affects over 16 million Americans. Caring for patients with diabetes requires extensive health care resources. Managed care organizations must utilize resources cost-effectively to survive in the health care industry. A disease state management program for diabetes may enable the managed care organization to meet its goal of providing cost-effective quality health care while meeting regulatory standards. The National Committee for Quality Assurance (NCQA) which accredits managed care organizations and provides information on performance, grants accreditation status to managed care organizations and reports favorable comparisons with competing managed care organizations. PMID- 10174745 TI - Economic evaluations and diabetes. AB - Diabetes and its treatment have significant economic implications for society, as evidenced by estimated health expenditures for diabetes and its complications in the range of $85-$105 billion in the United States in 1992. With constrained resources, health care professionals need to understand the burden of any illness, benefits and costs of alternative treatments, and the process of combining benefits and costs for the purpose of comparing alternatives. The economic evaluation approach seems best suited for this task. Full and partial economic evaluation techniques will be reviewed with descriptions that have appeared in the recent diabetes literature. PMID- 10174746 TI - The integration of quality assessment and a patient-specific intervention/outcomes program. AB - The clinical intervention program in place at the University of Iowa Hospitals and Clinics is based on the pharmacist's evaluation of the patient, the disease state, and the appropriateness of the selected therapy. The system was developed so that all pharmacists within our institution: staff pharmacists, clinical pharmacy specialists, clinical pharmacists, and pharmacy residents can easily and efficiently document all interactions with other health care providers. The recent introduction of the Medication Use Indicators process by the Joint Commission has provided many pharmacy departments with a series of outcome measurements which may prove useful in their attempts to maximize contributions to the medication use process. In this article, we describe how our department has begun to utilize the Joint Commission indicator data by integrating information from them into the daily practices of our staff, and how our department has utilized a formal interventions and outcomes program to evaluate such efforts. PMID- 10174747 TI - What's in there for me? The Internet for pharmacists. AB - Pharmacists and other professionals must develop a strategy to take the greatest advantage of information on the Internet. Healthcare providers must work effectively with increasingly demanding and well-educated consumers to survive the turbulent environment. We focus on describing Internet sites that can be of interest and assistance to individual pharmacists researching health and professional topics. It is important for health care practitioners to have an understanding of the content of Web sites so they may use their professional judgment to determine the authenticity of information. Utilizing the Internet to augment the pharmacist's knowledge base may solve the dilemma of the pharmacist's utility in the 21st century. The practicality of the Internet is underscored by its ability to link healthcare professionals worldwide in unique collaborative efforts unmatched by any individual's output, regardless of his singular genius. PMID- 10174748 TI - Hospital institutional review board committee: a pharmacist takes a seat. PMID- 10174749 TI - Incorporating individualized quality of life measures in the evaluation of pharmacy services: the IN*COMPASS framework. AB - Quality of life is a fascinating field to researchers and practitioners alike. To some researchers, quality of life is of interest because it offers untold challenges in constructing instruments and capturing data necessary to answer key questions about health, disease, and treatment. For such researchers, quality of life is about statistical relationships among questions and about using questions to define the physical, social, and emotional domains of health. To other researchers, this field is about finding practical applications in policy and treatment decision making for the information provided by quality of life assessments. To these researchers, the focus of quality of life is on ways to apply knowledge of quality of life differences between groups with and without specific diseases or ways to use knowledge about how treatments affect the quality of life of various patient populations. To practitioners, quality of life is about treatment outcomes that impact individual patients' daily lives. It is the practitioner that Funderburk, Pleil, and Pathak are considering in their paper in this issue of Pharmacy Practice Management Quarterly. These authors give several important messages to practitioners seeking to serve their patients by incorporating quality of life into their practices. The key message in the paper is that to better understand and determine the impact of treatment on a patient's quality of life, it is critical to start with a baseline or reference point relevant to that patient. From that baseline or reference point, treatment decisions can be made and progress, in quality of life terms, can be evaluated. Critical questions in their framework, which is called the IN*COMPASS (Individualized Client Oriented Method for Preferred Alleviation of Sickness States) Approach, are "How are you now?" and "How would you like to be?" The authors do not endorse particular quality of life tools in their approach; rather they prescribe certain critical questions that must be answered if information captured by any quality of life tool is to be useful at the patient level. Readers should not be put off by the fancy acronym used in this paper; nor must readers be keen students of quality of life to appreciate its message. The IN*COMPASS approach is fundamental to good patient care and can be applied by practitioners with any level of understanding of and appreciation for quality of life assessments. PMID- 10174750 TI - Creating a team approach to hospital and college of pharmacy relationships: a strategy to integrate missions to enhance education and patient care. AB - Academic medical centers continue to bear the burden of the additional costs of professional education. Such institutions and their affiliated colleges of pharmacy are challenged to sustain the degree of professional staffing required to deliver quality education and patient care services. Historically, these relationships have not always proven to be cooperative and mutually beneficial. As managers and deans attempt to maximize the productivity of their financial and human resources, they will need to creatively structure relationships that effectively meet those diverse professional missions that sometimes seem to exist in conflict or that each seem to be successful only at the expense of the other. Pharmacists who act as both faculty, delivering experiential education, and clinical staff providing patient care, are significantly stressed in their attempts to meet the sometimes conflicting objectives of these multiple missions. The survival of precepted experiential education in pharmacy and of pharmaceutical care in academic medical center hospitals will likely depend upon a model of cooperative relationship, such as the venture described by Jorgenson, et al. PMID- 10174751 TI - P&T Committee overview: Brigham and Women's Hospital. PMID- 10174752 TI - Are pharmacists and pharmaceutical care having an impact on diabetes? AB - This study sought to identify pharmacy services offered to patients with diabetes and demonstrate patients receiving pharmaceutical care services had better glucose control as measured by laboratory values and medication compliance. Two hundred randomly selected patients with diabetes were identified from a pharmacy benefits manager's database. Their pharmacists were mailed a survey requesting information concerning morbidity risk factors, concomitant disease states, concomitant medications, diabetes pharmacotherapy, blood glucose concentrations, and percent hemoglobin A1c values. Information concerning diabetes cognitive services offered was also requested. A statistically significant correlation between diabetes cognitive services and improved disease control was not demonstrated secondarily to the small number of responses returned with glucose control information. Our results indicate pharmacists must improve documentation of their services and the impact these interventions have on disease control in order to prepare for reimbursement for cognitive services. PMID- 10174753 TI - Conjunctivitis. PMID- 10174754 TI - Extranets: innovative on-line health care alliances. PMID- 10174755 TI - Stats & facts. Preventive care and quality in HMOs. PMID- 10174756 TI - How does HEDIS affect quality improvement strategies in an HMO? AB - To meet the demands of the marketplace, health plans devote considerable resources to comply with Health Plan Employer Data and Information Set (HEDIS) reporting standards and to improve performance along those measures. Given HEDIS's growing prominence, one might question whether it plays a major role in the formulation of an HMO's quality improvement strategies. The experience at NYLCare Health Plans, Inc., suggests that quality improvement strategies should focus on strengthening the ability of HMOs to meet the more general agenda of quality measurement and improvement, and not just requirements specific to HEDIS. PMID- 10174757 TI - Patient survey of a pharmacist-managed anticoagulation clinic. AB - The literature describing pharmacy involvement with anticoagulation services primarily does not include information about patients' perceptions of this involvement. A 22-question survey was developed and administered to 296 patients enrolled in the anticoagulation clinic at the VA Pittsburgh Health Care System. Excluded patients had fewer than four clinic visits or were followed outside of the anticoagulation clinic. The study period was nine weeks and any missed patients were telephoned. The median response to each question was determined. Similar questions were analyzed for acquiescent trends. Results indicate that, overall, patients are comfortable with pharmacists providing warfarin monitoring and dose adjustments. PMID- 10174758 TI - Selecting diseases for increased intervention. PMID- 10174759 TI - Patient care management programs: maximizing efficiency through the use of prevalence rates. AB - Providers are assuming more risk for patient management than ever before. This has led to more interest in managing patients with high-cost, chronic illnesses. In the following article, the authors discuss how accurate chronic disease prevalence rates can be used to better focus care management efforts, leading to a successful, cost-efficient program. PMID- 10174760 TI - The effect of panic disorder in the managed care setting. AB - Panic disorder is significantly overrepresented in the primary care setting, compared with the general population. Patients with panic disorder are expensive to treat because they tend to be high utilizers of health care and are more likely to suffer recurrent psychiatric and physical disorders, present with unexplained somatic symptoms, and attempt suicide. Most primary care physicians receive little training in accurately recognizing and effectively treating panic disorder. The overutilization of primary care services by, and frequent misdiagnosis of, patients with panic disorder indicates a need for managed care systems to develop guidelines for diagnosing and managing panic disorder. PMID- 10174761 TI - The use of pharmacoeconomic data in managed care: closing the credibility gap. AB - According to the author, MCOs rarely incorporate the findings of pharmacoeconomic studies in formulary decision making. As a result, managed care plans fail to examine the costs and cost savings of a new drug across the whole health care continuum, but see only how it directly affects their system. Credible pharmacoeconomic data can be valuable to formulary decision makers, offering them a broader perspective. However, what constitutes credible pharmacoeconomic data? PMID- 10174762 TI - Data trends. Why do system-affiliated hospitals earn high margins? PMID- 10174763 TI - The good news. PMID- 10174765 TI - 1996 medical expenses as a percentage of premium revenues for selected national health plans. PMID- 10174764 TI - Capitalizing medical practices. PMID- 10174766 TI - Administrative simplification and you (and me). PMID- 10174767 TI - (Intra)network-based patient records. PMID- 10174768 TI - Creating a table of authorization to empower staff. AB - Empowering frontline managers to make and accept accountability for decisions poses a significant challenge, especially for integrated delivery systems (IDSs) where multiple organizational layers and complex management structures can create confusion about roles and responsibilities. Without a clear set of guidelines for independent action, attempts to achieve staff empowerment are likely to fail. To achieve its empowerment goals, Overlook Hospital in Summit, New Jersey, a part of the Atlantic Health System, a New Jersey-based IDS, developed the "Table of Authorization for the Commitment or Expenditure of the System's Physical or Financial Resources." This management tool clarifies the degree to which frontline managers may make decisions and initiate actions without the need for senior management or board approval. The table provides an effective means of promoting a uniform basis for decision making across the system and encourages improved customer service vital in competitive markets. PMID- 10174769 TI - The virtual laboratory: regional clinical diagnostics for integrated delivery systems. AB - With the rise of integrated delivery systems (IDSs), hospital laboratories need to transform themselves to better serve these large regional systems. Four factors are driving this need for transformation: the decline in the customer base of hospital clinical laboratories, the expanding number of test options, the need to control costs, and the proliferation of new technologies. In the future, clinical diagnostic capabilities will be available via integrated regional laboratory systems, or "virtual laboratories". The virtual laboratories serving IDSs will consist of a control center to manage laboratory services across the system, a core laboratory to perform large-volume testing and all testing that does not require a rapid turnaround, satellite laboratories for quick-turnaround testing, and a range of point-of-care testing options. Developing these virtual laboratories will pose challenges, including a redeployment of resources and a reengineering of testing policies and procedures. Success in implementing a virtual laboratory also will depend on the development of effective information systems technology to link the laboratory's components. PMID- 10174770 TI - Effective managed care marketing strategies for evolving markets. AB - In a world of increased competition and changing consumer expectations, one of the keys to a fiscally sound health plan is having a dynamic marketing strategy that takes into account the shifting attitudes of consumers as managed care markets mature. The primary goal of any health plan marketing strategy should be the acquisition and retention of members. Providing cost-efficient and convenient service for enrollees, offering low or no deductibles, having convenient office locations, and minimizing paper-work are important elements of such a marketing strategy. Factors such as brand awareness and the perceived image of a health plan also are important considerations in acquiring and retaining market share. The relative importance of these consumer satisfaction criteria change as a managed care market evolves and matures. Financial and marketing managers, thus, should ascertain their market's stage of development and respond with appropriate marketing strategies. PMID- 10174771 TI - Contact capitation: an alternative for specialist capitation. AB - Because many specialists do not see capitation as a viable payment option, the most common strategy for paying specialists remains discounted fee-for-service. A transitional form of capitation for specialists, however, is growing in popularity--contact capitation. Unlike traditional capitation, which pays a per member-per-month amount based on utilization levels, contact capitation payments are made to physicians when they have the first "contact" with new patients. Many specialists find contact capitation attractive because of its similarity to fee for-service payment. But, unless some adjustments are made, contact capitation rates may underpay certain specialists. PMID- 10174773 TI - Acquiring capital equipment through shared-risk agreements. AB - The Medical Center at the University of California, San Francisco (UCSF) developed a shared-risk relationship with a vendor to manage the costs of infusion therapy. The relationship was centered on upgrading UCSF's aging stock of infusion pumps. Over the course of the 60-month agreement, the vendor agreed to provide the medical center with 750 new infusion pumps, upgrades on related software, a full warranty, full maintenance on the pumps, and assistance with ensuring appropriate utilization. Additional pumps were to be available if required to meet demand. In exchange, UCSF agreed to pay the vendor a fixed rate based on the number of admissions. If the number of pumps required exceeded 775 or fell below 730, the fixed rate could be reassessed. As a result of the agreement, UCSF has needed fewer infusion pumps and infusion sets. A slight increase in operating expenses has been more than offset by avoidance of the 7 to 10 percent interest the medical center would have had to pay if it had borrowed funds to purchase new pumps. PMID- 10174772 TI - Practice management companies improve practices' financial position. AB - To maintain control over healthcare delivery and financial decisions, as well as increase access to capital markets, some group practices are forming their own physician practice management companies. These companies should be organized to balance the expectations of physicians with the values of capital markets. This organization should include retained earnings, financial reporting in accordance with generally accepted accounting principles (GAAP), predictable earnings and cash flow, physician ownership and leadership, and incentives for high-quality management. Three large, primary care and multispecialty clinics that merged to form a new physician practice management company increased their access to capital markets and improved their overall financial position, which will help them achieve long-term survival. PMID- 10174774 TI - RVU costing applications. AB - Relative value unit (RVU) cost accounting which uses the resource-based relative value scale (RBRVS), can be used to determine the cost to produce given services and determine appropriate physician fees. The calculations derived from RVU costing have additional applications, such as analyzing fee schedules, evaluating the profitability of third-party payer reimbursement, calculating a floor capitation rate, and allocating capitation payments within the group. The ability to produce this information can help group practice administrators determine ways to manage the cost of providing services, set more realistic fees, and negotiate more profitable contracts. PMID- 10174775 TI - HCFA defines "actual charge" in proposed rule. PMID- 10174776 TI - Physician compensation and productivity trends surveyed. PMID- 10174777 TI - A few tips on cash investing. PMID- 10174778 TI - Promotion: a preparedness guide. PMID- 10174779 TI - Maintaining our charitable mission. PMID- 10174780 TI - The Feds discover home health care. PMID- 10174781 TI - Recycling pool provides innovative financing for an integrated system. AB - Not-for-profit integrated delivery systems require innovative financing mechanisms to compete effectively with expanding for-profit systems. The Massachusetts Health and Educational Facilities Authority (Mass HEFA), in collaboration with Partners HealthCare Systems, Inc., Boston, Massachusetts, developed such a mechanism--a capital asset recycling pool funded through a $150 million bond issue. The recycling pool gives Partners flexible access to tax exempt capital to fund routine capital expenses across the system and has enabled the system to centralize control of capital resources. Over the pool's 30-year life-span, Partners will be able to issue tax-exempt loans from the pool to any of its affiliates or, with Mass HEFA and insurer approval, transfer the funds to outside organizations. When the loans are repaid, the funds remain available and can be recycled at no additional cost to fund further capital projects. Creation of the pool was made possible by Partners' outstanding credit, strong market position, expanding primary care network, and substantial unrestricted net assets. PMID- 10174782 TI - Project administration departments improve information systems initiatives. AB - As integrated delivery systems evolve and grow, the information services organizations (ISOs) that serve them are increasingly called upon to undertake complex, high-cost, high-risk information systems projects. Because it is critical that such projects be managed efficiently and effectively, it is desirable to form a project administration department within the ISO to design and oversee a formal, consistent, and rigorous approach to project management. This department can assume responsibility for developing and implementing the processes, tools, functions, methodologies, and standards that ensure each project is performed consistently, on time, and within the established budget. The specific responsibilities of a project administration department will vary and evolve according to the needs of the healthcare system. PMID- 10174783 TI - Dispelling managed care myths. AB - A number of ideas regarding managed care and capitation are commonly accepted as truths. In reality, however, these ideas are half-truths or myths. Healthcare providers need to challenge some of these myths in order to respond proactively to change. Some of the traditional thinking about managed care that needs realignment includes the belief that PHOs essentially are transitional vehicles and not viable, long-term solutions; that the incentives under fee-for-service payment conflict totally with the incentives under capitation; that under global capitation, the best method for paying primary care physicians is capitation and the best way to pay specialists is discounted fee-for-service; and that small, exclusive physician panels are the most successful for managed care. PMID- 10174784 TI - Maximizing physician performance: a systems approach. AB - Managed care organizations are aware of the importance of managing the quality of care and controlling costs associated with the delivery of care. By utilizing physician-level performance reporting, an organization can help its physicians manage the organization's resources across the continuum of care. Physician participation can be obtained by developing a multicomponent program that includes opportunities for physician input regarding resource allocation and benefit packages; by articulating and documenting the organization's goals and priorities; by providing physicians with systemwide data related to indicators of their performance levels; and by offering financial incentives. PMID- 10174785 TI - Managing the strategic capital cycle. AB - A healthcare organization's financial strategy should be defined within the context of the capital cycle and provide for the management of three critical components that will ensure the expansion and renewal of capital capacity--the design and implementation of the financial plan, the design and implementation of an appropriate capital structure, and a means to strategically utilize capital and reinvest it in the organization. The capital cycle comprises two parts- strategic planning and implementation, and the development of the support infrastructure that includes financial planning, capital structure, and capital allocation. The financial plan positions an organization within an area of financial equilibrium and defines its organizational capabilities. The financial infrastructure gives integrity and momentum to the capital cycle. Capital structure addresses critical funding and financing questions and is best defined as the combination of debt and equity that funds the strategic plan. In regard to capital allocation, healthcare organizations should follow a corporate "best practices" approach for such areas as financial objectives and policies, project review, and the capital expenditures approval process. PMID- 10174786 TI - Avoiding state intervention in not-for-profit/for-profit affiliations. AB - States attorneys general recently have intervened in transactions involving not for-profit organizations that wish to convert to or transfer assets to for-profit status. These interventions are significant for two reasons: first, they reflect a tendency amount state attorneys general to involve states in the governance of not-for-profit healthcare organizations, and second, they demonstrate that attorneys general are paying renewed attention to the legal obligation of such organizations to provide a community health benefit, which imposes a charitable trust on not-for-profit healthcare organizations and the fiduciary duties of care and loyalty to that charitable trust on the organizations' officers and directors. To avoid state intervention in such transactions, officers and directors of not-for-profit organizations need to understand the circumstances under which attorneys general justify such intervention, which include the undervaluation of the organization's charitable assets; lack of a private letter ruling from the IRS; failure to adequately consider alternatives to the transaction; conflicts with the best interest of the organization; and inadequate responses to the attorney general's requests for information. PMID- 10174787 TI - Implications of the laboratory charges unbundling initiative. AB - Hospitals across the United States have began to receive demand letters as part of a joint anti-fraud and abuse effort between the HHS Office of the Inspector General and the Department of Justice regarding laboratory charges unbundling. The goal of this initiative is to recover erroneous payments. U.S. attorneys have been given the opportunity to implement initiatives in their own districts. Violations may be punishable by triple damages, additional $10,000 fines for each false claim filed, and exclusion from Federally funded healthcare programs. The initiative gives hospitals the option of limiting the damages to two times the alleged billing error or single damages if they agree to participate in a self auditing initiative. Through this initiative, hospitals agree to file an audit plan with the government and disclose the results. In order to limit damage exposure, it is important that hospitals have proof of their good-faith attempts to comply with antifraud and abuse laws by adopting compliance plans and installing software edits in their billing programs. PMID- 10174788 TI - Factors affecting the valuation of physician practices. AB - Valuation of physician practices provides physicians with a benchmark of their business success and helps purchasers negotiate a purchase price. The Center for Healthcare Industry Performance Studies (CHIPS) recently conducted a survey of physician practice acquisitions. The survey collected data on salaries and benefits paid to physicians after practice acquisition, historical profitability of the acquired practice, and specific values assigned to both tangible and intangible assets in the practice. Some of the survey's critical conclusions include: hospitals tend to acquire unprofitable practices, value is based on historical revenues rather than historical profits, the importance of valuation methodology and payer mix is underestimated, tangible assets represent a large part of the purchase price, and hospitals tend to pay higher physician compensation than do other purchasers. PMID- 10174789 TI - Understanding the business of physician practices. AB - Acquiring physician practices requires knowledge of the business of managing a group practice. Before establishing revenue expectations for the acquired practice, the purchaser should understand the nature of the product being sold, the change in cost behavior patterns brought about by the acquisition, components of physician compensation, and the accounting impact of writing off goodwill. PMID- 10174790 TI - Electronic commerce starts at home. PMID- 10174791 TI - Data trends. Key organizational performance indicators. PMID- 10174792 TI - Spark innovation through empathic design. AB - Companies are used to bringing in customers to participate in focus groups, usability laboratories, and market research surveys in order to help in the development of new products and services. And for improving products that customers know well, those tools are highly sophisticated. For example, knowledgeable customers are adept at identifying the specific scent of leather they expect in a luxury vehicle or at helping to tune the sound of a motorcycle engine to just the timbre that evokes feelings of power. But to go beyond improvements to the familiar, companies need to identify and meet needs that customers may not yet recognize. To accomplish that task, a set of techniques called empathic design can help. Rather than bring the customers to the company, empathic design calls for company representatives to watch customers using products and services in the context of their own environments. By doing so, managers can often identify unexpected uses for their products, just as the product manager of a cooking oil did when he observed a neighbor spraying the oil on the blades of a lawn mower to reduce grass buildup. They can also uncover problems that customers don't mention in surveys, as the president of Nissan Design did when he watched a couple struggling to remove the backseat of a competitor's minivan in order to transport a couch. The five-step process Dorothy Leonard and Jeffrey Rayport describe in detail is a relatively low-cost, low-risk way to identify customer needs, and it has the potential to redirect a company's existing technological capabilities toward entirely new businesses. PMID- 10174793 TI - Defining next-generation products: an inside look. AB - The continued success of technology-based companies depends on their proficiency in creating next-generation products and their derivatives. So getting such products out the door on schedule must be routine for such companies, right? Not quite. The authors recently engaged in a detailed study--in which they had access to sensitive internal information and to candid interviews with people at every level--of 28 next-generation product-development projects in 14 leading high-tech companies. They found that most of the companies were unable to complete such projects on schedule. And the companies also had difficulty developing the derivative products needed to fill the gaps in the market that their next generation products would create. The problem in every case, the authors discovered, was rooted in the product definition phase. And not coincidentally, the successful companies in the study had all learned how to handle the technical and marketplace uncertainties in their product definition processes. The authors have discerned from the actions of those companies a set of best practices that can measurably improve the definition phase of any company's product-development process. They have grouped the techniques into three categories and carefully lay out the steps that companies need to take as they work through each stage. The best practices revealed here are not a magic formula for rapid, successful new product definition. But they can help companies capture new markets without major delays. And that is good news for any manager facing the uncertainty that goes with developing products for a global marketplace. PMID- 10174794 TI - Changing the way we change. AB - More and more companies struggle with growing competition by introducing improvements into every aspect of performance. But the treadmill keeps moving faster, the companies keep working harder, and results improve slowly or not at all. The problem here is not the improvement programs. The problem is that the whole burden of change typically rests on so few people. Companies achieve real agility only when every function and process--when every person--is able and eager to rise to every challenge. This type and degree of fundamental change, commonly called revitalization or transformation, is what many companies seek but rarely achieve because they have never before identified the factors that produce sustained transformational change. The authors identify three interventions that will restore companies to vital agility and then keep them in good health: incorporating employees fully into the principal business challenges facing the company, leading the organization in a different way in order to sharpen and maintain incorporation and constructive stress, and instilling mental disciplines that will make people behave differently and then help them sustain their new behavior. The authors discovered these basic sources of revitalization by tracking the change efforts of Sears, Roebuck & Company, Royal Dutch Shell, and the United States Army. The organizations used these interventions to alter the way their people experienced their own power and identity, as well as the way they dealt with conflict and learning. As at Sears, Shell, and the U.S. Army, any major shift in those four elements will create a landmark shift in any organization's operating state or culture. PMID- 10174795 TI - Making strategy: learning by doing. AB - Companies find it difficult to change strategy for many reasons, but one stands out: strategic thinking is not a core managerial competence at most companies. Executives hone their capabilities by tackling problems over and over again. Changing strategy, however, is not usually a task that they face repeatedly. Once companies have found a strategy that works, they want to use it, not change it. Consequently, most managers do not develop a competence in strategic thinking. This Manager's Tool Kit presents a three-stage method executives can use to conceive and implement a creative and coherent strategy themselves. The first stage is to identify and map the driving forces that the company needs to address. The process of mapping provides strategy-making teams with visual representations of team members' assumptions, those pictures, in turn, enable managers to achieve consensus in determining the driving forces. Once a senior management team has formulated a new strategy, it must align the strategy with the company's resource-allocation process to make implementation possible. Senior management teams can translate their strategy into action by using aggregate project planning. And management teams that link strategy and innovation through that planning process will develop a competence in implementing strategic change. The author guides the reader through the three stages of strategy making by examining the case of a manufacturing company that was losing ground to competitors. After mapping the driving forces, the company's senior managers were able to devise a new strategy that allowed the business to maintain a competitive advantage in its industry. PMID- 10174796 TI - When consultants and clients clash. AB - This fictitious case study explores the issues that surround the relationships between consultants and their clients, as well as the dynamics of a newly merged organization. Susan Barlow, a senior consultant with the Statler Group, dreaded her upcoming status meeting. She had thought it a lucky break when she got assigned to the Kellogg-Champion project. Royce Kellogg, the CEO of the newly merged firm, had engaged the Statler Group for what seemed a simple project: to reconcile the policies and practices of the two former firms now that they had become one. But once on the job, Barlow realized that the issues were much more complex than they had seemed. The new firm needed help badly-but not the kind of help that the client had led Barlow to believe it needed. What would she and Jim Roussos, her partner on the assignment, tell Kellogg at the meeting? Kellogg, for his part, was not looking forward to the status meeting, either. From his point of view, the consultants had caused more problems than they had solved. What's more, he wasn't even dealing with the consultants he had hired. Where was George Gray, the senior partner he had met with originally? Maybe Barlow and Roussos were just too young and inexperienced. Kellogg felt he was getting a raw deal. How would he approach them in the morning? Should he fire them or make an attempt at damage control? Two experts advise the consultants and two advise the client on how to handle the status meeting. PMID- 10174797 TI - What's wrong with strategy? AB - Why is it that successful strategies are rarely developed as a result of formal planning processes? What is wrong with the way most companies go about developing strategy? Andrew Campbell and Marcus Alexander take a common sense look at why the planning frameworks managers use so often yield disappointing results. Companies often fail to distinguish between purpose (what an organization exists to do) and constraints (what an organization must do in order to survive), the authors say. Many executives mistakenly believe, for example, that satisfying stakeholders is an objective that drives thinking about strategy. In fact, it's a constraint, not an objective. Companies that don't win the loyalty of stakeholders will go out of business. Strategy is not about plans but about insights, the authors add. Strategy development is the process of discovering and understanding insights and should not be confused with planning, which is about turning insights into action. Furthermore, because executives develop most of their insights while actually doing the real work of running a business, it is important for companies not to separate strategy development from implementation. Is there a better way? The answer is not new planning processes or more effort. Instead, managers must understand two fundamental points: the benefit of having a well-articulated, stable purpose and the importance of discovering, understanding, documenting, and exploiting insights about how to create value. PMID- 10174798 TI - Strategy under uncertainty. AB - At the heart of the traditional approach to strategy lies the assumption that by applying a set of powerful analytic tools, executives can predict the future of any business accurately enough to allow them to choose a clear strategic direction. But what happens when the environment is so uncertain that no amount of analysis will allow us to predict the future? What makes for a good strategy in highly uncertain business environments? The authors, consultants at McKinsey & Company, argue that uncertainty requires a new way of thinking about strategy. All too often, they say, executives take a binary view: either they underestimate uncertainty to come up with the forecasts required by their companies' planning or capital-budging processes, or they overestimate it, abandon all analysis, and go with their gut instinct. The authors outline a new approach that begins by making a crucial distinction among four discrete levels of uncertainty that any company might face. They then explain how a set of generic strategies--shaping the market, adapting to it, or reserving the right to play at a later time--can be used in each of the four levels. And they illustrate how these strategies can be implemented through a combination of three basic types of actions: big bets, options, and no-regrets moves. The framework can help managers determine which analytic tools can inform decision making under uncertainty--and which cannot. At a broader level, it offers executives a discipline for thinking rigorously and systematically about uncertainty and its implications for strategy. PMID- 10174799 TI - The myth of the top management team. AB - Companies all across the economic spectrum are making use of teams. They go by a variety of names and can be found at all levels. In fact, you are likely to find the group at the very top of an organization professing to be a team. But even in the best of companies, a so-called top team seldom functions as a real team. Real teams must follow a well-defined discipline to achieve their performance potential. And performance is the key issue--not the fostering of "team values" such as empowerment, sensitivity, or involvement. In recent years, the focus on performance was lost in many companies. Even today, CEOs and senior executives often see few gains in performance from their attempts to become more teamlike. Nevertheless, a team effort at the top can be essential to capturing the highest performance results possible--when the conditions are right. Good leadership requires differentiating between team and nonteam opportunities, and then acting accordingly. Three litmus tests must be passed for a team at the top to be effective. First, the team must shape collective work-products--these are tangible performance results that the group can achieve working together that surpass what the team members could have achieved working on their own. Second, the leadership role must shift, depending on the task at hand. And third, the team's members must be mutually accountable for the group's results. When these criteria can be met, senior executives should come together to achieve real team performance. When the criteria cannot be met, they should rely on the individual leadership skills that they have honed over the years. PMID- 10174800 TI - To diversify or not to diversify. AB - One of the most challenging decisions a company can confront is whether to diversify. The rewards and risks are extraordinary. Success stories such as General Electric, Disney, and 3M abound, but so do stories of failure-consider Quaker Oats' entry into the fruit juice business with Snapple. What makes diversification such an unpredictable, high-stakes game? First, companies usually face the decision in an atmosphere that is not conducive to thoughtful deliberation. For example, an attractive company comes into play, and a competitor is interested in buying it. Or the board of directors urges expanding into new markets. Suddenly, senior managers must synthesize mountains of data under intense time pressure. To complicate matters, diversification as a corporate strategy regularly goes in and out of vogue. In short, there is little conventional wisdom to guide managers as they consider a move that could greatly increase shareholder value or seriously damage it. But diversification doesn't need to be quite such a roll of the dice, argues the author. His research suggests that if managers consider six questions, they can reduce the gamble of diversification. Answering the questions will not lead to an easy go-no-go decision, but by helping managers weigh risks and opportunities, it can help them assess the likelihood of success. The issues that the questions raise, and the discussion they provoke, are meant to be coupled with the detailed financial analysis usually conducted before a diversification decision is made. Together, these tools can turn a complex and often pressured decision into a more structured and well-reasoned one. PMID- 10174801 TI - Are you marketing your integrated delivery system? Maybe you shouldn't be. PMID- 10174802 TI - Coaching the entire team. Do you have what it takes to manage an integrated delivery system? PMID- 10174804 TI - Downsizing: confidentiality vs. disclosure. PMID- 10174803 TI - Integration challenges. What you can do to smooth the transition. AB - As the focus in healthcare delivery shifts to building a seamless continuum of care, many organizations are turning to integrated delivery systems as a way to provide high-quality healthcare while keeping costs down. Although these systems can take many forms, they often encounter similar roadblocks once the components are put into place. Healthcare Executive talked with several consultants and healthcare executives about some of the challenges you can address before and during integration to help you avoid those roadblocks later. PMID- 10174805 TI - Customer expectations in the new millennium. PMID- 10174807 TI - ACHE's peer review. PMID- 10174808 TI - Attracting and retaining the best physicians. PMID- 10174806 TI - Improving community health status. PMID- 10174809 TI - Is there an Intranet in your future? PMID- 10174810 TI - Private contracts under Medicare. PMID- 10174811 TI - American College of Healthcare Executives. Professional policy statement. Board certification in healthcare management. November 1997. PMID- 10174812 TI - Safety first: how to meet OSHA and JCAHO rules. PMID- 10174813 TI - With little room to grow--or park--this Texas facility chose an offbeat design. PMID- 10174815 TI - 'And now for my next trick....'. PMID- 10174814 TI - Salary survey. Payday '97. PMID- 10174816 TI - Spreading the word: grass-roots infection education. PMID- 10174817 TI - Mercury rising? Here's how you can control this hazard. PMID- 10174818 TI - ASHE advocacy on medical waste regs gets results. PMID- 10174819 TI - Latex allergy 'alert': what took NIOSH so long? PMID- 10174820 TI - OSHA plans to enforce TB safety standards. PMID- 10174821 TI - Getting lawmakers' attention. PMID- 10174822 TI - 1997 JEMS salary survey. Long hours, modest pay. AB - As in years past, the 1997 Jems salary survey tracks trends in compensation and career development in both the public and private sectors. This year, we've included some information about volunteer agencies as well. While the survey serves as a barometer for EMS wages and benefits, relying solely on the absolute numbers may create an incomplete picture because of changes in the number of respondents, organizational characteristics and other variables. However, combined with other industry data, the annual salary survey is a useful tool for comparing your pay with that of your peers. The survey should also prove useful to organizations and labor groups planning and preparing competitive compensation packages. PMID- 10174823 TI - Overtime pay. How the Fair Labor Standards Act affects you. PMID- 10174824 TI - Exposed! New protocols for post-HIV exposure. PMID- 10174826 TI - 1998 JEMS buyer's guide, company listings. PMID- 10174825 TI - Street people. Solutions to providing care for the 40 million uninsured. PMID- 10174827 TI - The player. Columbia is latest to enter for-profit buy-sell game. PMID- 10174828 TI - Small, less profitable get pitched in spinoff. PMID- 10174829 TI - Cool reception. Analysts question outcome of Columbia spinoff plans. AB - Columbia/HCA Healthcare Corp.'s long-awaited restructuring plan is leaving Wall Street unsatisfied and raising questions about what will happen to one-third of the nation's largest for-profit hospital chain. Under the plan, Columbia will be carved into five groups, with the company keeping its choicest hospitals. Three groups with a total of 108 facilities--which haven't performed as well overall- will be spun off. PMID- 10174831 TI - Throw it back. Hospitals Columbia plans to spin off. PMID- 10174830 TI - It's a keeper. Hospitals that will stay in the Columbia fold. PMID- 10174832 TI - AMA accreditation debut. Planners say Sunbeam flap won't keep N.J. docs out. PMID- 10174833 TI - Time to say, 'prove it!' Unsubstantiated allegations against Columbia have tarred the entire industry. PMID- 10174834 TI - For PSOs, it's ... ready, set, go! AB - With the signing of the federal balanced-budget act earlier this year, the long awaited era of the provider-sponsored organization is here. The legislation contained a provision giving the green light for Medicare PSOs, an option sought for years by hospitals and other providers. If the rhetoric about PSOs is to be believed, the organizations are the next generation of managed-care plans, ones that are locally controlled and operated by providers, not remote insurance companies. To many in the industry, this idea has become the last best hope for provider-directed healthcare. The government is scheduled to issue the rules for PSO financial solvency and operation this spring so providers can begin forming their organizations. But before they can accomplish anything, PSOs must be sold to consumers and to regulators. In this issue, we examine the marketing and financing of a new breed of healthcare organization. PMID- 10174835 TI - PSOs demand pricey launch. PMID- 10174836 TI - A hub for long-term care. Adult day centers strive to be post acute care's missing link. PMID- 10174837 TI - The deciding vote. Tenet gives clinicians final say in awarding contracts. PMID- 10174838 TI - Taking responsibility. More healthcare organizations insist on investments that match their mission. PMID- 10174839 TI - Crozer-Keystone settles. Deal is first under probe into Medicare pneumonia billing. PMID- 10174840 TI - Battle lines drawn as Clinton calls for patient legislation. PMID- 10174841 TI - Migrating to an electronic business office. PMID- 10174842 TI - Toward a global medical village. PMID- 10174843 TI - Robots hooked on drugs. Robotic automation expands pharmacy services. AB - Hospitals are not known for automating labor-intensive tasks but robots are just beginning to make inroads in health-care. The first--and still only--robot grew from a class assignment to use an established technology in a new growth industry. The established technology was bar coding; the industry health-care; and the result a robotic device for the hospital pharmacy. PMID- 10174844 TI - Change blows through the Windy City. PMID- 10174845 TI - PACS readiness assessment. Road map to digital imaging. PMID- 10174846 TI - Spotlight on radiology information systems. PMID- 10174847 TI - Government health information security standards. Beat the clock by developing security strategies now. PMID- 10174848 TI - "It's the capacity, stupid!" Building the next generation of executive decision support tools. PMID- 10174849 TI - More than just a bureaucratic chore. Data can tell a positive story about your organization. PMID- 10174850 TI - Five minutes with Gordon Bonnyman. Interview by Yvonne Parsons. PMID- 10174851 TI - Running the numbers for the new PPS. PMID- 10174852 TI - The Golden State learns the golden rule. PMID- 10174853 TI - Flexible pricing for CCRCs. PMID- 10174854 TI - The disappearing worker. PMID- 10174855 TI - Rehabilitation. Roadblocks to recovery. PMID- 10174856 TI - Merger mania magnified. PMID- 10174857 TI - Protection under the (new) law. The Budget Act alters funding--and legal rights. PMID- 10174858 TI - Reduce risk by screening, managing frail elderly. PMID- 10174859 TI - Medicare joint marketing efforts are good, cheap way to get noticed, but watch out! PMID- 10174860 TI - Watch out for Medicare HMO disenrollment as high as 42%. PMID- 10174861 TI - HCFA starts year with new rules affecting provider contracts, beefed-up agency oversight. PMID- 10174862 TI - Providers cut costs to succeed under Medicare demos. PMID- 10174863 TI - Baltimore provider steps up to the plate to score managed Medicaid home run. PMID- 10174864 TI - Tool gives patient information at a glance, helps reduce costs, increase profits in Medicare risk. PMID- 10174865 TI - Study helps predict Medicaid costs for disabled using diagnostic risk adjustment. PMID- 10174866 TI - Don't get burned by risky Medicare point-of-service. PMID- 10174867 TI - Provider tests no-premium Medicare POS, risk adjustment, rewards for healthy behavior. PMID- 10174868 TI - Providers share 4 solutions to calming the administrative Medicaid nightmare. PMID- 10174869 TI - Competition, quality, satisfaction top woes among managed Medicare, Medicaid execs. PMID- 10174870 TI - Senior volunteer programs give Medicare providers access to free social services. PMID- 10174872 TI - Education, communication are keys to preventing costly Medicaid disenrollments. PMID- 10174871 TI - Providers are key to preventing Medicare disenrollment. PMID- 10174873 TI - The difference between success and failure: NY plans, providers share Medicaid strategies. PMID- 10174874 TI - Medicare HMOs reveal unique contracting strategies for new ESRD risk demonstration. PMID- 10174875 TI - Case study finds 9 steps to managed Medicare success. PMID- 10174876 TI - Smart negotiating prevents disenrollment nightmares. PMID- 10174877 TI - Medicaid member retention begins at enrollment with plan, provider personal touch. PMID- 10174878 TI - New Jersey's Medicaid program finds success by keeping member materials simple. PMID- 10174879 TI - Providers should prepare now for Medicare open access. PMID- 10174880 TI - Studies find wide variation in service utilization among Medicare risk, FFS patients. PMID- 10174881 TI - Medical societies offer help, tips in negotiating Medicare, Medicaid risk contracts. PMID- 10174882 TI - Does your PSO have what it takes to direct-contract? PMID- 10174883 TI - Changes in Medicare and Medicaid payment, enrollment, consumer rights on horizon. PMID- 10174884 TI - Control of all Medicare dollars lures New Orleans provider into risky triple option demo. PMID- 10174885 TI - Provider's Medicaid plan offers popular benefits, risk assessment, customer service. PMID- 10174886 TI - Here's how to evaluate state Medicaid cap rates--before signing on the dotted line. PMID- 10174887 TI - Capitation survey offers detailed look at provider contracts under managed Medicare, Medicaid. PMID- 10174888 TI - MD-patient communication a vital link to DM success. PMID- 10174889 TI - How will the new federal asthma guidelines affect your disease management programs? AB - The National Asthma Education Program in Bethesda, MD, has come out with new federal guidelines on the treatment of asthma that recommend earlier, more aggressive treatment under a new "stepwise" approach. Here's what the new guidelines mean for your asthma disease management programs and strategies. PMID- 10174890 TI - DM nurse line creates 'win-win' scenario for point-of-service product. AB - A Philadelphia managed care company has set up a 24-hour demand management nurse line specifically designed for point-of-service programs. The nurse line not only helps triage patients and determine which level of care they need, but it also helps reduce out-of-network utilization. PMID- 10174891 TI - Ornish lifestyle modification program continues to produce impressive outcomes for CHD. AB - The Dean Ornish program for cardiac rehabilitation has been undergoing a national trial of patients with moderate to severe heart disease. Preliminary results indicate that the program can actually reverse coronary artery disease by lowering patients' cholesterol levels and reducing their blood pressure. Although the regimen requires a strict vegetarian diet, the program saves money over traditional therapies such as angioplasty and appears to be even more effective. PMID- 10174892 TI - Interests of disease management providers and purchasers not always aligned, survey finds. AB - A new survey reveals that purchasers of disease management services often want programs that are quite different than what providers are offering. The results may help you target your programs more effectively. PMID- 10174893 TI - Take the outbound approach to enhance your call center. PMID- 10174894 TI - Plug into home-based electronic monitoring devices to enhance your demand management efforts. AB - New telephone-based and computer monitoring devices offer health plans and providers the ability to keep tabs on patients' medication and clinical course without having to tie up call center staff or home health nurses, and the consistency of monitoring helps speed the detection of potential complications. PMID- 10174895 TI - What's new on the home-testing horizon for DM programs? PMID- 10174896 TI - Early Alzheimer's diagnosis can delay disease progression and help reduce costs, complications. AB - Are your clinicians correctly recognizing and diagnosing Alzheimer's disease? New guidelines suggest there are many types of dementia that can be incorrectly diagnosed as Alzheimer's. They also note that an earlier diagnosis can save dollars by allowing interventions that can delay symptoms. PMID- 10174897 TI - Use the Internet to reach more patients with your demand management programs. AB - Kaiser Permanente in Oakland, CA, is rolling out a new online Internet service for some of its members that provides educational information, support groups, and interactive question-and-answer bulletin boards between patients and their clinicians. Find out how this innovative service is reducing demand while enhancing the HMO's image with its members. PMID- 10174898 TI - Nurse practitioners to provide primary care in HMO project. AB - Oxford Health Plans is courting controversy--and hoping to reduce demand--with a pilot program that allows members to choose nurse practitioners as primary care providers. The HMO pays the NPs directly--at the same rates as it pays physicians. PMID- 10174899 TI - Nurse-driven CHF program cuts hospitalization by 87%. AB - Find out how a nurse-mediated, physician-directed, home-based disease management program called "Multifit" has reduced ED visits by 67% and cut hospital days by 87%. PMID- 10174900 TI - Specialists drive success of AIDS disease management. PMID- 10174901 TI - Slash cost of pneumonia, improve care by using risk classification system. AB - Federal researchers who have extensively studied community-acquired pneumonia have come up with recommendations on when to hospitalize patients so that those not at risk of poor outcomes can be safely and effectively treated on a less costly outpatient basis. PMID- 10174902 TI - Use this tool to identify best DM investments for your enrollee population. AB - Blue Cross Blue Shield of Georgia in Atlanta has worked with an outside data analysis company to identify the health plan's five most common and costliest diseases--coronary artery disease, diabetes, hypertension, pneumonia, and congestive heart failure--in an attempt to improve care and create more targeted interventions. PMID- 10174903 TI - Telephone support service helps keep schizophrenics on track. AB - A nationwide telephone counseling service for schizophrenic patients on the antipsychotic drug risperidone is proving helpful to patients, their families, friends, and providers, who otherwise would worry that patients aren't taking prescribed medications as ordered or are missing appointments with their mental health providers. PMID- 10174904 TI - Study suggests underuse of mental health specialists results in higher overall costs. PMID- 10174905 TI - HMOs aggressively developing disease management programs; cost reductions reported. AB - A new report documents the percentage of HMOs experiencing cost reductions, by type of health services, after implementing disease management initiatives--and the numbers are encouraging. PMID- 10174906 TI - New self-care program ties CHF patients to their doctors. PMID- 10174907 TI - Behavioral call centers help keep a lid on costly mental health claims. AB - A california managed care company is applying new technology to Medicare managed care patients with congestive heart failure. The program allows patients to monitor medications and daily vital signs--and it is resulting in fewer hospitalizations and a reduction in the need for other skilled care. PMID- 10174908 TI - Endocrinologists' group creates MD-patient contract to bolster diabetes self management. AB - Behavioral health call centers handle complex problems ranging from domestic violence to suicide intervention--and have impressive bottom-line benefits for payers and at-risk providers. Find out if this specialty call center concept can help your organization. PMID- 10174909 TI - Tap power of the mind to improve outcomes for high-risk diabetics. AB - Patients with chronic diseases like diabetes need encouragement to follow through on behavior and lifestyle changes, and simple patient education and self-care management strategies will not work unless monitored routinely. That's the conclusion of professional endocrinologists who are signing contracts with their patients and challenging other providers to follow their plan of care. PMID- 10174911 TI - Tap into patient data to bolster your DM programs. PMID- 10174910 TI - Little teddy bear brings big results to asthma DM program. AB - Find out how a little teddy bear combined with home health follow-up have produced dramatic reductions in utilization among pediatric asthma patients for an Ohio HMO. PMID- 10174912 TI - Zero in on depression as a major source of savings. PMID- 10174913 TI - Disease management programs target the high cost of epilepsy. AB - Epilepsy costs average as high as $17,000 per case, primarily because patients are on the wrong medication or they fail to follow their drug regimen properly. Several aggressive epilepsy management programs are determined to save costs and improve the quality of life for seizure patients. They are focusing on education, correct diagnosis, and correct medications--and their strategy is working. PMID- 10174914 TI - Web-based patient education becoming a powerful tool in demand management. AB - The doctor-patient relationship is taking on a whole new meaning with the advent of the Internet--from e-mail updates on blood pressure, to health risk appraisals on line, to huge collections of on-line health resources. It's all there, and still growing by leaps and bounds. Find out how and why you will want to jump on board the Internet bandwagon to support your demand management efforts. PMID- 10174915 TI - Consolidated purchasing power adds punch to outsourcing. AB - A new purchasing consortium is focusing on the disease management market, offering members a discount and a guarantee of quality from its selected vendors. PMID- 10174916 TI - Docs and delivery systems can work together to improve patient compliance. AB - Patients who don't comply with medication regimens or behavior modification recommendations are bound to give your DM programs a case of frustration. Two national efforts aimed at improving compliance will help you identify the barriers that keep patients from following instructions and show you ways to break them down. PMID- 10174917 TI - Get aggressive when negotiating risk contracts in '97. PMID- 10174918 TI - Survey reveals dramatic increase in capitation. PMID- 10174919 TI - Virtual integration aligns PCPs with other entities to increase profit, market share. PMID- 10174920 TI - Partner with behavioral health providers to boost your capitation surpluses. PMID- 10174921 TI - Establish careful criteria when selecting specialties to capitate. PMID- 10174922 TI - Redefining perspectives, processes, and performance in oncology services for the year 2000. AB - A central aspect of successfully redefining our approaches to service delivery is tapping the potential that exists within each member of an organization. How we relate within the organization and how we view the environment and markets in which our organization functions are critical issues. PMID- 10174923 TI - The impact of mergers/alliances on hospice care. AB - Since its inception, hospice care in the U.S. has transcended from a "movement" into the mainstream of healthcare. Hospice care consumes about $1.8 billion of the federal healthcare pie, making it one of the smallest providers. Yet hospice has been one of the most successful providers in terms of patient satisfaction and cost control. The Hospice Model as structured by Medicare provides cost savings primarily due to the substation of homecare for hospital stays in the last months of life. PMID- 10174924 TI - Hospice operations and perspectives: Part II. PMID- 10174925 TI - The equipment warranty: what's really in the fine print? PMID- 10174926 TI - Physicians challenge health-plan terminations. PMID- 10174927 TI - PPMCs on trial: the Barnett-MedPartners case. PMID- 10174928 TI - Preventing and managing the serious side effects of cancer chemotherapy. Consortium for the Prevention and Management of the Serious Side Effects of Cancer Chemotherapy. AB - This article is the result of a multiconstituency consortium's 18-month collaboration on the critical issue of quality of life for people undergoing chemotherapy for cancer and those who care for them. It is intended to supplement existing practice guidelines by establishing some easy-to-use guiding principles that can be understood by all concerned constituencies and that are practical to apply. PMID- 10174930 TI - IRS ruling offers guidance for physician recruitment by nonprofit hospitals. PMID- 10174929 TI - Hospice operations and perspectives: Part III. AB - As managed care and integration become increasingly important in healthcare, the hospice movement is struggling to find new ways to fit and survive within the changing system. PMID- 10174931 TI - Patient-physician communication: a selective literature review. AB - No longer are patients willing to accept the dictum of physicians as all-knowing experts solely capable of determining a patient's future. In fact, the "patient" label itself is often superseded by the concept of healthcare consumers, implying greater equality and patient participation in the patient-physician relationship. PMID- 10174932 TI - Creating value-focused healthcare delivery systems: Part one. AB - The healthcare environment is a dynamic environment and one of the most difficult environments in which to function--let alone prosper. Healthcare requires detailed attention to business disciplines. This article is part of a series discussing the need, components, and skills required to enhance the creation and perception of value in the healthcare arena. PMID- 10174933 TI - Working hours. Op around the clock. PMID- 10174935 TI - Abortion. Gin and despair. PMID- 10174934 TI - Winter admissions. All wrapped up? AB - Most initiatives to cope with increased winter workloads come from hospitals. The potential for co-operative efforts between hospitals and general practice is largely unexplored. One general practice, a total purchasing pilot site, plans to minimise the demand for emergency admissions by identifying patients at risk and having a nurse visit them in autumn to check their health. The practice estimates the project will be self-financing if it saves 12 admissions. PMID- 10174936 TI - Drug misuse services. No quick fixes. AB - The Department of Health's new funding formula for drug misuse services will reduce funding in districts with the highest demand for services. Some regions will receive up to four times more per reported episode of drug misuse than others. This is due, in part, to the inclusion of numbers in rented accommodation in the funding formula. PMID- 10174937 TI - Discharge planning. Oiling the wheels. AB - A liaison nurse can ensure effective discharge planning, enhance the services provided and introduce quality improvements. Employing a liaison nurse in a children's private patient directorate has reduced the length of patient stay, and stopped wards being used for outpatient sessions for children receiving follow-up treatment. Ward nurses have more time to spend with inpatients, so that children and their families benefit from a more comprehensive service and continuity of care is improved. PMID- 10174938 TI - Hospitals' bugbear. PMID- 10174940 TI - Under the strain. PMID- 10174939 TI - Tuberculosis. Rise of an old killer. PMID- 10174941 TI - Spreading costs. PMID- 10174943 TI - Patient's charter. NHS--keeping the customer satisfied. AB - Complaints to the College of Health suggest that the Patient's Charter standards on receiving care on the basis of clinical need, response to complaints, and information-giving are not being met in many cases. Patients must be involved in revising the Patient's Charter. A truly patient-focused service demands patient representatives on health authority and trust boards, spot checks and systematic reviews of health services. Acute trusts should be remodelled to mirror the patient's progress through the hospital and back to the community. PMID- 10174942 TI - MRSA. How to resist. PMID- 10174944 TI - Operating theatres. Funders keepers. AB - Recruiting and retaining operating theatre staff is a constant problem for many trusts. One trust has introduced a pay supplement of 1,500 Pounds for all operating theatre staff, and is now planning to implement a single pay spine for all categories of operating theatre staff. The long-standing staffing difficulties suggest it is time to reconsider skill mix in operating theatres. PMID- 10174945 TI - First person. Breakdown of trust. PMID- 10174946 TI - The management of stable angina. AB - Symptoms of chronic stable angina are easily identifiable and indicate that a patient is at increased risk of heart attack and death. In patients with less severe angina, medical treatments are as effective as more invasive treatments and produce better survival rates. There is little evidence that the main types of medical treatment differ in effectiveness. For patients at higher risk, invasive revascularisation procedures--coronary artery bypass grafting (CABG) and angioplasty--are more appropriate. CABG is slightly more effective than angioplasty. A high proportion of patients receiving angioplasty require re treatment. The risk of recurrence and coronary events is reduced if patients who receive invasive procedures also have long-term low dose aspirin and cholesterol lowering therapy. There is no clear evidence that intracoronary stents are more cost-effective than standard angioplasty. There is a need for evidence-based guidance to help determine referral thresholds for further investigation, and revascularisation procedures. There is evidence of inequality of access to testing and treatment, by gender, ethnic group and social class. Access should be monitored in order to promote equity. PMID- 10174947 TI - The voice of reason. PMID- 10174948 TI - Keeping ahead. PMID- 10174949 TI - Trials and errors. PMID- 10174950 TI - On the offensive. PMID- 10174951 TI - In the firing line. PMID- 10174952 TI - No cash, no chance? PMID- 10174953 TI - A tough brief. PMID- 10174954 TI - Transplants. The heart of the matter. AB - Thirty years after the world's first successful heart transplant, UK services are embroiled in a funding row. The country's eight units carried out more than 200 transplants last year, but after-care costs are rising as more people survive longer, and cardiologists fear the switch from central to regional funding will lead to cuts. Jenny Bryan looks at the past, present and future. PMID- 10174956 TI - Career profile. 'Moneybags' find the spotlight. PMID- 10174955 TI - Locality commissioning. The long and winding road. AB - It is unlikely that locality commissioning, as it stands, could respond to any future government policy that identifies it as the way forward. The size of localities should remain flexible. The government has indicated that it wishes to support pilots where localities have delegated budgetary responsibility, but it is unclear whether this will emerge as a preferred model. PMID- 10174957 TI - Basic training. Your clean team may know the drill--but does it practice the proper cleaning techniques? PMID- 10174958 TI - Outsource safety management? The ups and downs of bringing outsiders in. PMID- 10174959 TI - Remote control. Facility managers and engineers guide the move to telemedicine. PMID- 10174960 TI - Burning issue--med waste rules tough but flexible. PMID- 10174961 TI - Rating game: tips on how to assess your safety program. PMID- 10174962 TI - Health care in post-war Rwanda: re-establishing a national hospital using a mentor approach. AB - OBJECTIVES: To describe the rehabilitation of a large referral hospital amid the civil war in Rwanda, and to discuss the effectiveness of a mentor approach in re establishing the facility's administrative structure. DESIGN: A mentor administrative design was used to re-establish the hospital personnel structure. This approach linked Rwandan health workers with foreign medical consultants. Formal interviews to evaluate the acceptance and effectiveness of the mentor administration model were conducted with foreign and Rwandan administrative staff. Six month retrospective review of hospital demographics (August 1994 January 1995) was compared to 1993 pre-war data (January-December, 1993). SETTING: The Central Hospital of Kigali, a 600 bed facility in Rwanda, East Africa. PARTICIPANTS: Rwandan and foreign administrators, non-government relief organizations (NGOs), United Nations Military forces, and patients presenting to the Central Hospital. RESULTS: The hospital became fully functional in August of 1994. Both foreign and Rwandan administrators surveyed stated that the mentor program was effective but the hospital would ultimately require external financial support for sustainability. A total of 38,042 patients were treated at the hospital during the six month study period. Compared to 1993 pre-war data, there was a substantial increase in both the overall patient volume and the number of traumatic injuries. Despite this, the case fatality ratio during the post-war period was significantly lower. CONCLUSIONS: A mentor approach was utilized to re-establish the administrative structure of the Central Hospital of Kigali. The facility was able to successfully function despite a larger patient volume compared to the pre-war period. This collaborative effort between NGOs and Rwandan personnel resulted in the development of a sustainable administrative and medical program. The use of a mentor administration may serve as a model for future rehabilitative efforts abroad. PMID- 10174963 TI - Education for navigating "permanent white water:" establishing a bachelors program for Canadian health services managers. AB - A rapidly changing health services environment challenges educators to critically assess what they do, and what they should do, to prepare managers to survive and grow professionally and to contribute to clients, organizations and the health system. In this paper we describe the establishment of an undergraduate degree completion program in Health Services Management at Ryerson Polytechnic University in Toronto, Canada. In contrast to traditional programs which begin the process of education as the basis for later practice, this program, the first of its kind in a Canadian university, is designed to develop management skills and competencies on an existing base of professional experience and practice; it offers practitioners with 3-year diplomas in a health technology or allied health field the opportunity to complete an undergraduate degree on a part-time basis. Sections of the paper outline the multidisciplinary and multi-stage process of program development which took place outside of traditional departmental lines and involved a partnership of academics and practitioners; and the curriculum design, which integrates knowledge specific to the field of health administration, relevant knowledge from other professional fields, and liberal studies. In a final section we discuss the ongoing development of the program and factors contributing to its success. PMID- 10174964 TI - The 1997 Health Services Research Prize address. PMID- 10174965 TI - The 1997 Andrew Pattullo Lecture. Health management: curriculum with a soul. PMID- 10174966 TI - The academic elite in health services administration: linkages among top-ranked graduate programs. AB - The eleven top-ranked graduate programs in health services administration, based on a national survey of deans, top administrators, and senior faculty, were linked to one another by hiring one another's graduates. It is suggested that this linkage helps these programs maintain and enhance their prestige. PMID- 10174967 TI - Responding to health care reform: preparing tomorrow's practitioners. AB - At a time when all of healthcare is undergoing change and evolution, the healthcare education community has so far escaped intense public scrutiny. To remain valid, we must address the education and the reeducation of healthcare professionals. Baccalaureate health administration programs, in particular, can step in and respond to the changing needs of the industry, the market, and of healthcare professionals by creating articulation formats that provide flexible verti for associate degreed healthcare professionals. Such programs enable a diverse constellation of healthcare professionals to obtain the managerial and organizational skills that are cal and horizontal access key to career mobility in today's turbulent healthcare arena. PMID- 10174968 TI - Developing leaders in public health: the role of executive training programs. AB - The growing complexity of the nation's health care system is creating new challenges and opportunities for public health officials, and a renewed concern for leadership training among these officials. A focus group conducted with public health officials at local, state, and national levels reveals perceptions about the predominant trends effecting public health practice, the leadership skills required for effective public health practice, and the strategies that are needed for providing appropriate leadership training to public health executives. Officials indicate that public health practice is undergoing substantial changes in response to the growth of managed care and integrated delivery systems, changes in public health funding sources and levels, and efforts to privatize the delivery of public health services. The skills identified as critical for effective leadership in this environment include the ability to guide organizational behavior and cultivate interorganizational relationships; apply scientific knowledge to public health problems, and build and sustain community coalitions. In light of these skills, public health officials identify four essential components of an optimally effective executive training program in public health leadership: exposure to the core scientific disciplines within public health; exposure to organization theory and management science; training in community development and empowerment; and training in ethics and social justice. All of the officials agree with the need for distance learning programs for executives in public health leadership, and most officials also support the need for doctoral-level training in public health practice. PMID- 10174969 TI - Re-engineering unlikely in health care. PMID- 10174970 TI - Physicians welcome standardized feedback. PMID- 10174971 TI - Putting teeth into a compliance program. AB - Health care institutions across the country have implemented internal compliance review processes. Few, however, are consistent or powerful enough. With physician support, rigorous research and fair disciplinary action, internal reviews can be improved. A 12-step procedure can smooth issue resolution. PMID- 10174972 TI - Putting the process of care into practice. AB - "Putting the process of care into practice" provides an interactive, visual model of outpatient resources and processes. It illustrates an episode of care from a fee-for-service as well as managed care perspective. The Care Process Matrix can be used for planning and staffing, as well as retrospectively to assess appropriate resource use within a practice. It identifies effective strategies for reducing the cost per episode of care and optimizing quality while moving from managing costs to managing the care process. Because of an overbuilt health care system, including an oversupply of physicians, success in the future will require redesigning the process of care and a coherent customer service strategy. The growing complexities of practice will require physicians to focus on several key competencies while outsourcing other functions such as billing and contracting. PMID- 10174973 TI - Marketing medical services to the affluent. Part II of "An emerging niche market opportunity". AB - Society is split between a desire for access to quality health care and a reluctance, by some, to pay for it. Looking at this cost/access dichotomy historically enables one to recognize an emerging niche market--designer care delivered in a boutique setting. PMID- 10174975 TI - Understanding the uninsured dilemma. A necessity for managed care survival. AB - As we approach 2000, health care cost, quality and access continue to be highly debated issues within managed care and the health care delivery system. Of these, perhaps there is no single issue more contested among consumers than the average cost of health care. Factors affecting the cost of health care are many. However, the uninsured population is one of the most visible and difficult to predict. Leaders in managed care have extensively studied this problem for several years; however, there continues to be no consensus on the best way to capture the nearly 42 million uninsured, reprogram scarce health care resources or provide access into the health care delivery system for everyone while maintaining existing quality, cost containment measures and administration. This paper outlines the scope and impact of the uninsured in managed care and profiles initiatives in controlling the population. PMID- 10174974 TI - Medicare+Choice plans. Medicare risk contracting opportunities for provider sponsored organizations. AB - New federal legislation approves provider sponsored networks as direct contractors with Medicare. To date, financial, licensure and requirements differ, but providers should prepare to enter the new market. Niche physician groups, physician-hospital organizations and physician-HMO alliances are all configurations that should meet federal requirements. PMID- 10174976 TI - Physician leaders in integrated delivery. AB - It's common to hear the analogy comparing organizing physicians to "herding cats." Actual practice proves the adage false. Physicians are taking leadership roles in the formation of integrated systems across the country. Their input is proving invaluable. Based on case studies of integrated systems, the authors answer commonly asked questions about physician leaders, including: Should physician leaders be specilists? Should they continue to practice? and What will expensive physicians do to our administrative overhead? PMID- 10174977 TI - Exploring asset-based financing for physician practices. AB - Asset-based financing is an often overlooked option for financing acquistions. Two criteria for determining its applicability are the viability of the acquired entity and the liquid value of the borrowing base. Asset-based financing requires a lower initial investment than other forms of financing. However, overall costs may be higher than for traditional loans. PMID- 10174978 TI - Costs under capitation. AB - Physician practice costs can be categorized as either fixed (salaries, rent) or variable (office supplies, medical supplies, some labor costs). An optimal mix of these fixed ratio will change with fluctuations in patient volume and can be dramatically different in a capitated vs. a fee-for-service environment. The authors discuss techniques for calculating a practice's fixed and variable costs, the effect of volume changes on cost structures and ways to minimize negative financial consequences of declining patient loads. PMID- 10174979 TI - Is JAMA playing politics? Plan to publish attack on profits angers managed-care execs. PMID- 10174980 TI - AHA seeks change in Medicare profit data. PMID- 10174981 TI - Timeout. Ohio hospital group seeks halt to new hospitals as specialty facilities move in. PMID- 10174982 TI - Major PPM firms await regulators' response to deal. PMID- 10174983 TI - VA leads the way. Computerized patient data an example for private sector. PMID- 10174984 TI - Selling after settling. Post-acute firms ending litigation before wooing buyers. PMID- 10174985 TI - Columbia woes hit sector in survey. PMID- 10174986 TI - Welfare goes to work. Maine cuts costs by replacing FHS, training poor to handle Medicaid HMO enrollment. PMID- 10174987 TI - Maine Blues under fire. Insurer's for-profit joint ventures raise public concern. PMID- 10174989 TI - PacifiCare does an Oxford. Company forecasts loss, blames computers; stock tumbles. PMID- 10174988 TI - Trouble in Missouri. Squeezed insurers rebel against state employee health plan. PMID- 10174990 TI - Room for change? Mayo building plans test ties to Scottsdale system. PMID- 10174991 TI - The Tricare debate. Restructured financing of new military managed-care contracts raises questions. PMID- 10174992 TI - Pa. law provides tax shield for not-for-profits. PMID- 10174993 TI - Put competition into PPS. How Medicare can save money by allowing hospitals to offer DRG discounts. PMID- 10174994 TI - MRI renaissance. AB - A few years ago, magnetic resonance imaging was healthcare's version of a foreign sports car-flashy, expensive and impractical. Now, after years in the doldrums, sales of MRI systems are roaring back. An aging fleet of MRI scanners due for replacement and a hearty increase in doctors' use of the versatile imaging tools are combining to fuel the surge in demand, vendors and customers say. PMID- 10174995 TI - Speaking patients' languages. As the diversity of the U.S. population grows, providers struggle to break down the barriers to communication. PMID- 10174996 TI - Altered course. Capitation lag forces Chicago systems to change strategies. PMID- 10174997 TI - Connect the docs. Calif. medical group becomes guinea pig for tech firm. PMID- 10174998 TI - Using leverage. Healthcare market draws attention of LBO specialists. PMID- 10174999 TI - Hospitals thriving under managed care. PMID- 10175000 TI - Enrollees switching Medicare HMOs fast. PMID- 10175001 TI - Climbing the AHA's ladder. Harness, promoted again, will get some of McEntee's duties. PMID- 10175002 TI - A pause in consolidation. HealthEast rethinks plan to close downtown hospital. PMID- 10175003 TI - Seward departs AMA. Next question: will trustees survive Sunbeam debacle? PMID- 10175004 TI - Robbing Peter to pay pool. Massachusetts Blues cuts hospital fees to pay for free care. PMID- 10175005 TI - Vatican ups interest in healthcare issues. PMID- 10175006 TI - UniHealth may shed last hospitals. PMID- 10175007 TI - Hispanic connection. Two Chicago hospitals link to aid underserved group. PMID- 10175008 TI - First, give 'em the money. Study of healthcare political donations puts docs at top. PMID- 10175009 TI - Easing dispute resolution. When HMOs don't have a fair process for settling fights, it hurts quality at all levels. PMID- 10175010 TI - Nothing but blue skies? Not-for-profit health systems try to soar over a slipping Columbia. AB - With Columbia/HCA Healthcare Corp. sitting on the sidelines, a newly aggressive not-for-profit hospital sector is stepping up its merger and acquisition activity. Since Richard Scott resigned as Columbia's chief on July 25, the company hasn't announced a single acquisition. Meanwhile, during that span, 40 not-for-profit systems have announced deals involving 50 hospitals. PMID- 10175011 TI - Wanna buy an MRI? In one swoop, Premier becomes 10% of industry sales. PMID- 10175012 TI - Report traces healthcare's not-so-golden era. PMID- 10175013 TI - Spreading the word. Calif. insurer launches program to stop domestic violence. PMID- 10175014 TI - Industry getting a second UPREIT. PMID- 10175015 TI - Venture capitalists drawn to healthcare. PMID- 10175017 TI - Serving God, shareholders. PMID- 10175016 TI - Medicare panel fills up. Members include docs, payers, but not hospitals. PMID- 10175018 TI - N.Y. Catholic leaders, providers plan sprawling regional network. PMID- 10175019 TI - Real-time collections. Start-up has a computer solution for payment lag. PMID- 10175020 TI - Device truce in St. Louis. Hospitals must cooperate to get single gamma knife. PMID- 10175021 TI - The process begins. PSOs set to get application to join Medicare program. PMID- 10175023 TI - 1997 year in review. AB - From the fall from grace of Columbia/HCA Healthcare Corp. and the passage of a landmark federal balanced-budget act, 1997 was a year marked by turbulence in healthcare. We take a month-by-month look at the highlights. PMID- 10175022 TI - Cash squeeze ahead. AMA needs to go the way of 'Good Housekeeping' or lose its relevance. PMID- 10175024 TI - Too generous. MedPAC: Medicare overpaying hospitals for inpatient care. PMID- 10175025 TI - Whistleblowers. No easy job, but more workers vie for the title. PMID- 10175026 TI - The wedding is on. Catholic buying groups work out details of merger. PMID- 10175028 TI - Questions of community. Award winner details challenges facing coalition boards. PMID- 10175027 TI - Service awards ... fifth annual Marriott Service Excellence Awards. PMID- 10175029 TI - Taking stock of '97. Some healthcare sectors were hot, some not. PMID- 10175030 TI - Power challenge in N.C. Blues takes not-for-profit system to court over price hike. PMID- 10175031 TI - Perspectives. Managed care consumers' law requires renegotiating ERISA. PMID- 10175032 TI - The best defense.... PMID- 10175033 TI - Dealmaking. Back to basics. PMID- 10175034 TI - Taxes. Contract hits. PMID- 10175035 TI - Leader of the PAC. A conversation with new MedPAC Chair Gail Wilensky. Interview by Craig Havighurst. PMID- 10175036 TI - The States 1997 fifteenth policy survey. PMID- 10175037 TI - Louisiana--out of the swamp. PMID- 10175038 TI - Arkansas--going it alone. PMID- 10175039 TI - Texas--the new accountability. PMID- 10175040 TI - Redefining health care delivery through partnerships. PMID- 10175041 TI - Back to school. PMID- 10175042 TI - Up and coming carve outs. PMID- 10175043 TI - Data ... health care state rankings 1997. PMID- 10175044 TI - The sky isn't falling. PMID- 10175045 TI - Health care alliances--good medicine for an ailing health care industry, or antitrust illnesses to fence in? PMID- 10175046 TI - When staff members become substance abusers: identifying the drug-impaired clinician. PMID- 10175047 TI - Voluntary programs encourage impaired nurses to admit problem. PMID- 10175048 TI - Consider liability issues when managing drug-impaired staff. PMID- 10175049 TI - Telemedicine becoming a reality in today's ED. PMID- 10175050 TI - Coping with the new AMA/HCFA documentation requirements. PMID- 10175051 TI - Compliance programs as defense to civil damages. PMID- 10175052 TI - OIG issues advisory Opinion No. 97-5 relating to radiology joint venture. PMID- 10175054 TI - Aggressive staffing program speeds up patient care. PMID- 10175053 TI - Highlights of the Balanced Budget Act's revisions to Medicare. PMID- 10175055 TI - Telemedicine program saves health system money, offers relief to rural providers. AB - Allina Health System in Minneapolis set up an elaborate telemedicine program to offer big-city medicine and better coverage to rural hospitals in its regional network. Now, some rural hospitals are saving thousands of dollars and finding it easier to recruit and retain physicians. PMID- 10175056 TI - Automating clinical lab boosts quality and volume, allows more efficient use of labor. AB - The clinical lab at the University of Nebraska Medical Center has a robot of its own. And it's on the cutting edge of robotics with the recent addition of an automated vehicle that transports patient specimens to the lab's testing sites. The result? Staffing has been reduced and quality has gone up. Learn how UNMC was used as a test site to develop a state-of-the-art system that's already being snapped up by other organizations. PMID- 10175057 TI - Integration of behavioral medicine into general practice = better outcomes, lower costs. AB - Health care organizations save by looking beyond the basics of prescribing pills and taking to the operating table. Experts in behavioral medicine have developed six pathways to identify high-cost patients who may benefit from relaxation techniques and psychiatric counseling more than they can from biomedical care. Learn how to cut costs with formal behavioral medicine programs that are being instituted around the country. PMID- 10175058 TI - Risk-sharing deals emphasize savings, not low price. PMID- 10175059 TI - Conversion to computerized patient records streamlines ER process, saves money. AB - If your billing department can't read physician notes on ER patient records, you could be wasting valuable time and dollars getting bills out the door. Learn how a Boston hospital ER switched to a computerized patient record system, improved documentation, cut labor costs, and maximized reimbursement. PMID- 10175060 TI - Home-taught pediatric asthma program improves outcomes, cuts hospital, physician visits. AB - Providers, payers breathe easier, reduce per patient costs by at least $11,500 with home-taught pediatric asthma management program. Olsten Kimberly QualityCare reports terrific success in slashing hospital and physician costs by aggressive at-home training for children with asthma. See how registered nurse educators are teaching asthmatic children and their families to reduce the severity of attacks and need for hospital or physician visits. PMID- 10175061 TI - Study provides comparative targets to help reduce costs of surgical procedures. AB - Data Benchmarks: Cost and LOS benchmarks can help your organization target and reduce costs of surgical procedures. Setting up clinical pathways to improve quality and reduce costs requires good benchmarking data to zero in on the appropriate clinical services or procedures. This month's Data Benchmarks offers good comparative data on the most cost-intensive surgical procedures performed at U.S. hospitals. PMID- 10175062 TI - Fitness centers can be a first step to redesigning rehab services, but exercise caution. AB - Reengineering your rehab department. An Illinois hospital rejuvenated its rehab services with a combined fitness center, rehab, and physician office complex that's projected to net $1 million in revenues. But experts warn there are plenty of pitfalls when hospitals dabble in the fitness business, so heed the advice of these industry experts. PMID- 10175063 TI - Reduce LOS, boost reimbursement for chest pain cases. PMID- 10175064 TI - Don't let blood transfusion services bleed your budget dry. AB - Get control of blood services and save $558,000 or more. Health care facilities in several markets are tapping into new programs and centralized services offered by blood centers and the American Red Cross to rein in spiralling costs. Find out how shared blood services and computerized cross-matching are saving big bucks and cutting out wasted blood products. PMID- 10175065 TI - Laptops, wireless phones slash nursing time, improve patient satisfaction with care. AB - Slash hours of wasted nursing time with wireless phones and laptop computers. Part of a massive redesign, Regional Memorial Hospital in Hollywood, FL, found significant time saved and patient care substantially improved by reengineering how and where nurses place orders for medications, retrieve lab results, and make contact with physicians and other caregivers. PMID- 10175066 TI - Save $829,000 annually just by reengineering the way you receive products, supplies. AB - Data Benchmarks: Save $829,000 by reengineering the supply chain. A group has finally quantified how much money is spent unnecessarily in the hospital supply chain--and it's staggering. This month's column offers a close-up on specific segments of the supply chain where health care organizations are squandering most of their supply dollars, plus you'll find some best practices for getting the biggest bang for the buck. PMID- 10175067 TI - Health system ties executive pay to community's health. PMID- 10175068 TI - Cut wages and increase revenue by reducing wait times. PMID- 10175069 TI - Congestive heart failure doesn't have to be a money-loser; costs cut 78% at medical center. AB - $367,526 saved in 6 months with home health monitor. UIC Medical Center in Chicago is saving big dollars with a physician-invented home health monitor that has slashed readmissions among costly congestive heart failure patients. Now with FDA approval, the device can help other health care providers to offer an ounce of prevention--instead of a costly pound of cure. PMID- 10175070 TI - Hysterectomy debate focuses on cost efficiency, quality. AB - Watch that high-tech device: it might be more costly than you think. Recent studies find surgeons performing hysterectomies using laparoscopic devices are actually racking up higher costs, despite marketers' claims to the contrary. Greater Baltimore Medical Center found this high-tech procedure costs $1,000 to $2,000 more than traditional hysterectomy techniques, and a watchdog group offers guidelines to lower costs without sacrificing quality. PMID- 10175071 TI - Facilities could save as much as $18 million each with best practices identified in study. AB - Data Benchmarks: Learn how 30 hospitals that underwent redesign programs improved length-of-stay and lowered the dollars spent on direct caregivers' salaries. A recent study from Atlanta-based LUMEN reveals savings in 7 areas of care. PMID- 10175072 TI - Rx for cutting labor costs: add more registered nurses. PMID- 10175073 TI - Hospital takes customer service to new level, sees positive effect on bottom line. AB - Service with a smile boosts bottom line. Treating co-workers and patients like guests is the linchpin of a whole new philosophy at Bradley Memorial Hospital in Cleveland, TN. Administrators there insist a host of new customer service programs, from cap and gown graduation ceremonies to bunny bucks, has resulted in dramatic financial improvements and more satisfied patients and staff. PMID- 10175074 TI - Identifying low-risk pneumonia patients can avert unnecessary, costly hospital admissions. AB - New scoring system cuts costly pneumonia admissions. Massachusetts General Hospital in Boston recently completed a test-run of an innovative prediction rule scoring system that enables emergency physicians to determine if patients with pneumonia are at low risk for death. The information gleaned from the scoring system is helping physicians determine if patients can be sent home with confidence and antibiotics, instead of admitting them to the hospital. PMID- 10175075 TI - Reuse of single-use medical devices: study shows how to determine cost savings and limits. AB - How many times can providers reuse single-use medical devices before it's no longer cost-effective or safe? A recent industry report offers practical advice and mathematical equations to help managers compute savings and decide when to throw those devices away. PMID- 10175076 TI - Study finds providers have trouble tapping data for cost information. AB - A new study of health care executives finds a huge gap between the need for valuable, detailed cost data and the ability to access it in a timely, meaningful way. Here are the details, plus some data resources. PMID- 10175077 TI - More providers moving up in the Medicare 'food chain'. PMID- 10175078 TI - Plans, providers shift from short-term cost reduction to quality under managed Medicare. PMID- 10175079 TI - More, more, more: critical study could mean big changes at Medicaid contracting table. PMID- 10175080 TI - NY study confirms HMO and FFS Medicaid moms have more complicated, costly births. PMID- 10175081 TI - Medicare pharmacy risk a bitter pill for the unprepared. PMID- 10175082 TI - Medicaid pharmacy program becoming model for improved care, reduced costs. PMID- 10175083 TI - Once 'fat and happy,' pediatric ER reengineers operations to survive Medicaid risk market. PMID- 10175084 TI - Study finds utilization up among Medicaid risk members who don't understand managed care. PMID- 10175085 TI - Where it's at: Pennsylvania scores in Top 10 for Medicare risk enrollment, growth. PMID- 10175086 TI - Diabetes care targeted for improvement in Medicare risk. PMID- 10175087 TI - Dispute over rates, funding kills provider-sponsored Medicaid demo after 3-year negotiation. PMID- 10175088 TI - Understand plan benefits to avoid getting blind-sided by Medicare risk vision capitation. PMID- 10175089 TI - AIDS patients growing segment of Medicaid risk contracting, but specialized programs are few. PMID- 10175090 TI - Medicare specialty PMPM rates, staffing ratios good source of benchmarks for providers. PMID- 10175091 TI - Medical management magnified under Medicare risk. PMID- 10175092 TI - The tumor conference: an integral component of the oncology program. AB - This periodic meeting of individuals with oncologic expertise represents the best that modern medicine can be: a true multidisciplinary approach to patient care. Nowhere else in healthcare will you find a better example of combining different expertise for the express purpose of improving the delivery of care for an individual patient. PMID- 10175093 TI - Hospice operations and perspectives: Part I. AB - The American hospice movement is one of the most rapidly expanding healthcare phenomena of the past two decades. Over 300,000 terminally ill patients were served by America's hospices in 1994. In the past year alone, so many new hospices have emerged that the exact number at present is unknown. PMID- 10175094 TI - A conceptual model for assessing the internal environment of a healthcare organization. AB - By understanding the opportunities and threats in the external environment and relating them to the organization's internal strengths and weaknesses, strategic managers can determine the distinctive competence of the organization. Distinctive competence refers to the strengths that will give an organization a competitive advantage. PMID- 10175095 TI - Strategic decision-making processes in healthcare organizations. AB - Healthcare represents a promising area of research due to its uniqueness. In recent years, considerable progress has been made in strategic decision-making processes research, but not the study of healthcare-strategy research. This article reviews strategic decision-making in both context-free (generic) and context-specific (healthcare) domains. PMID- 10175096 TI - From product line to disease management--easing the transition. AB - Most facilities have captured the essence of product-line management, but what is the next step? The traditional reasons for product-line management are still more than valid, but forward-thinking organizations are moving to a disease-management focus. PMID- 10175097 TI - What you should know about patient billing. AB - Arming yourself with some knowledge of the billing process will help you understand what can be done to assist with self-pay and insurance claims. It will also provide you with some insight into how you can be part of the solution to this seemingly endless dilemma. PMID- 10175099 TI - The year 2000? No problem! PMID- 10175098 TI - Creating value-focused healthcare delivery systems: Part two--Value-focus traits and characteristics. AB - The healthcare arena is undergoing dramatic changes. These changes require new ways of thinking and doing. As Albert Einstein said, "We can't expect to solve problems utilizing the same level of thinking that created the problems in the first place." We must fundamentally change the way we think and do things if we want fundamental change to occur. The creation of value for all participants in the healthcare arena must become a major focus of the industry. As the healthcare industry has undergone fundamental change in the way services are provided and are reimbursed, successful healthcare providers and suppliers will create enhanced value through development and implementation of value-focus traits to include vision creation, leadership/communication, proactivity, anticipation, flexibility, innovation/creativity, knowledge, customized standardization, and service quality/accountability. The last part of this series will present the required administrative and management skills providers should possess and utilize to ensure that value is created in the delivery of care. PMID- 10175100 TI - At a glance. Percentage of Americans with commercial health insurance enrolled in HMOs in selected metropolitan areas. PMID- 10175101 TI - ClintonCare II: the revenge. PMID- 10175102 TI - Medical Intranets create virtual healthcare malls. PMID- 10175103 TI - Integrating the healthcare supply chain. AB - Today's integrated delivery systems (IDSs) require efficient supply chain processes to speed products to users at the lowest possible cost. Most excess costs within the supply chain are a result of inefficient and redundant processes involved in the transport and delivery of supplies from suppliers to healthcare providers. By integrating and assuming control of these supply chain processes, improving supply chain management practices, and organizing and implementing a disciplined redesign plan, IDSs can achieve substantial savings and better focus their organizations on their core patient care mission. PMID- 10175104 TI - Terminating physicians from managed care organizations. AB - Changes are under way regarding procedures for terminating physician contracts with managed care organizations. Recent legal and legislative developments at both the state and Federal levels have afforded physicians additional rights to hearings when managed care organizations seek their termination from the provider panel. As a result, the termination process will likely become more difficult and expensive. Managed care organizations should, therefore, monitor their states' legislative activity regarding termination requirements and reevaluate their existing termination standards in anticipation of changing standards concerning physician termination. PMID- 10175105 TI - Conducting a managed care contract review. AB - Healthcare providers traditionally focus on price when negotiating managed care contracts, but other important contract terms can affect the degree of legal, strategic, and financial risk a provider bears. In addition to having a review of all contracts by legal counsel, providers should conduct a separate business review of the contract terms, from making sure terminology and references are clearly defined or explained to assessing the details of the dispute resolution procedures. Providers should fully understand--and possibly refuse--requirements that could result in additional costs. PMID- 10175106 TI - Integrated health care: passing fad or lasting legacy? AB - The breakup of several integrated delivery systems (IDSs), and a continuing focus on the failures of many of these organizations to live up to expectations, suggests that integration may be a passing trend. Nonetheless, some systems, particularly those driven by multispecialty clinics, are achieving considerable marketplace success. Integrated systems that base their strategies on delivering value-added services to patients and healthcare purchasers still appear viable. Strategies typically used by IDSs include developing primary care networks, gainsharing with or owning health plans, reducing clinical variation, demonstrating high quality, cutting costs, and developing a seamless system of care. Primary care strategies are especially controversial given the fact that most hospital-affiliated primary care practices are losing money. However, research indicates that primary network development is one of the strategies that adds the most value for consumers and, thus, may be assumed to be of particular benefit to IDSs. Strategies aimed at reducing clinical variation can be expected to reap huge long-term benefits. PMID- 10175107 TI - Are your information systems ready for the year 2000? AB - With the approach of the year 2000, information systems professionals are analyzing potential problems associated with the century date. Because software programs use a two-digit number for the year portion of dates, current information systems will interpret 00 to be 1900 rather than year 2000, thereby causing massive disruptions in information processing. Healthcare information systems need to accurately transmit, retrieve, sort, and archive information by date in the next century to avoid adversely affecting patient care and financial operations. Although system vendors will help solve the problem by providing upgrades or conversion paths, healthcare organizations will need to make many of the required changes themselves. Healthcare organizations should understand the issues involved in the century date problem, define the solutions, make all necessary corrections, test all software and interfaces thoroughly, and implement and monitor all output. If they have not already done so, healthcare organizations should have plans in place soon to resolve information systems problems by early 1999. PMID- 10175108 TI - Designing an incentive compensation program that works. AB - To encourage innovation and improve departmental and organizational bottom lines, Winchester Hospital, Winchester, Massachusetts, developed and implemented a middle management and staff incentive compensation plan. Middle managers and staff who participate in projects that provide savings to the hospital are paid a share of the savings. The plan allows staff the option of designing "horizontal" projects, in which a project leader carries out a project individually or with peers, or "vertical" projects, in which a project leader directs a team of key individuals. Increasing numbers of vertical projects have been proposed since the plan's inception in 1994. In addition to increasing the hospital's operating income, the program provides cost-effective, variable compensation, which especially appeals to motivated, high-performing employees; motivates employees to overcome roadblocks; facilitates a team approach that bridges traditional departmental boundaries; and encourages a beneficial and collegial competitiveness among managers. PMID- 10175109 TI - Payers required to adopt standardized electronic claims processing. AB - The Health Insurance Portability and Accountability Act of 1996 requires most claims payers to support electronic claims processing and uniform national standards for code sets and identifiers to streamline healthcare administration. The law will penalize payers that do not support the standards and are not prepared to conduct business electronically by the year 2000. Many providers may qualify as claims payers and, thus, will be subject to penalties if they do not adopt EDI for the transactions required by the Act. Providers also will have greater opportunity to eliminate paper, speed claims payments, and cut administrative overhead. Both providers and payers will have new guidelines for privacy and confidentiality, and violation of these guidelines will result in significant penalties. Consequently, all providers should become familiar with the legislation and evaluate their EDI strategy in light of new opportunities and responsibilities. PMID- 10175110 TI - Eligibility and EDI create new opportunities. AB - A growing number of providers and payers are using EDI to automate the eligibility verification process. Some have integrated EDI eligibility verification into their patient scheduling routine. Others find it makes sense to integrate EDI eligibility into the patient registration process. Switching to electronic processing of eligibility information can make more information available faster to the many people involved in eligibility data processing. However, business office staff will have to be better trained to interpret eligibility data. PMID- 10175111 TI - EDI gains momentum, but still requires attention. PMID- 10175112 TI - Physician retention plans help reduce costs and optimize revenues. AB - Recruiting primary care physicians can cost a large practice millions of dollars in recruitment expenses and lost revenue. And competition among practices to attract physicians can cause a position to remain unfilled for a year or longer. Thus, the ability to retain physicians is critical to the financial well-being of a practice. Successful implementation of a physician retention plan can help reduce turnover, improve morale among the physicians, and foster a perception of a practice as a health services provider of choice. Penn State Geisinger Health System, Danville, Pennsylvania, developed a physician retention plan for its multispecialty group practice of nearly 1,000 physicians to reduce its costs associated with physician recruitment. The plan is organized into four phases of physician employment: recruitment, preemployment, employment, and postemployment. PMID- 10175113 TI - The physician equity option: an alternative to purchasing a practice. AB - Traditionally, a healthcare organization acquires a physician practice by purchasing the practice's assets and then acting as an employer to the physicians. Another acquisition strategy is for a healthcare organization's medical director to purchase equity in a practice and then direct the physician partners. An alternative to these traditional strategies is the physician equity option, by which a healthcare organization purchases an option to acquire a physician practice at a future date. This strategy enables a healthcare organization to meet its goal of developing relationships with physician groups without the cash outlay involved in purchasing 100 percent of a practice outright. PMID- 10175114 TI - RBRVS rule update expands procedural and documentation requirements. PMID- 10175115 TI - Data Trends. Regional physician coding differences. PMID- 10175116 TI - 1997 Celebration Health. The healing powers of community. PMID- 10175117 TI - Why some people get sick and others don't: a conversation with J. Fraser Mustard, M.D.. Interview by Joe Flower. PMID- 10175118 TI - Population-based design: the Baptist Health experience. PMID- 10175120 TI - Managing healthcare delivery costs by segmenting populations. PMID- 10175119 TI - A community approach to health. AB - Improving the health and well-being of a community may seem like a daunting task particularly when you consider the vast number of factors that can influence the quality of life of a neighborhood or a region. It's not impossible, however, as six widely different communities across the U.S. are discovering. The Accelerating Community Transformation (ACT) project--now underway by The Healthcare Forum through a five-year, $5 million grant from pharmaceutical joint venture Astra Merck Inc.--is an innovative attempt to create real-life learning laboratories in communities as diverse as an inner-city neighborhood on the west side of Chicago; the small southern town of Aiken, S.C.: the semi-desert city of San Bernardino, Calif.; a corner of America's heartland where Missouri, Kansas. Nebraska and Iowa meet; the new town of Celebration, Fla.; and St. Louis, Mo. The goals: to evaluate and accelerate community-wide efforts that result in healthier, more desirable places for people to live, work and play; to build community capacity; and to achieve measurable improved health and quality of life outcomes. PMID- 10175121 TI - Population health and HMOs: the Partners for Better Health experience. PMID- 10175122 TI - Forging a code of ethics for managed care. PMID- 10175123 TI - The beginning of the end for HMOs. Part 1: The awakening market. PMID- 10175124 TI - The monster code: biology and the computer sciences. PMID- 10175125 TI - Strategic information planning. PMID- 10175126 TI - Mavericks. PMID- 10175127 TI - Socioeconomic status and health-related outcomes: related--but how? PMID- 10175128 TI - Specialists stick closer to guidelines for treatment of CHF. PMID- 10175129 TI - Being analog. PMID- 10175130 TI - The (short) life and (tenuous) times of the hospital-sponsored MSO (management service organization). PMID- 10175131 TI - Sourcing as a function of strategic planning. PMID- 10175132 TI - The new faces of long-term care. PMID- 10175133 TI - Crossing over to PPS. Providers seek opportunities under new payment system. PMID- 10175134 TI - Laying new tracks. In the post-Boren era, providers must find a new perspective on payment security. PMID- 10175135 TI - Top 1997 nursing facility chains. PMID- 10175136 TI - Just say 'No'. Policies, procedures, and legal considerations for maintaining a drug-free work-place environment. PMID- 10175137 TI - Getting hospitals to drop your name. PMID- 10175138 TI - Securing FHA-insured loans. PMID- 10175139 TI - Implementing critical pathways. PMID- 10175140 TI - Reflecting residents' spiritual needs in care plans. PMID- 10175141 TI - Health care politics: the sequel. PMID- 10175142 TI - Royal College of Physicians of Edinburgh/Royal College of Obstetricians and Gynaecologists consensus conference on anti-D prophylaxis 7-8 April 1997. PMID- 10175143 TI - Perspective in platelet transfusion: current challenges and future trends. PMID- 10175144 TI - Platelet therapy: current opinions on laboratory and clinical aspects. AB - The rapid development in blood component technologies has lead to production of various types of platelet concentrates which are highly heterogenous in terms of cellular content, subpopulation of platelet and leucocytes and in vitro characteristics and storage stability. This emphasizes the need for a stringent in-process validation and statistical process control to ensure that optimal process efficiency and platelet functional integrity are continuously attained and maintained throughout the 5 days shelf life. Several unresolved issues such as development of cytokines and microparticles, some with immunomodulatory effects; fears of bacterial contamination of leucodepleted platelets, in particular in storage media; lack of progress in reduction of some unquantified risk of all types of transfusion transmitted infection (TTI), still remain the focus of current interest. While some processing results recently succeeded in killing both viruses and bacteria through a recently developed viral inactivation and filtration process, nevertheless much still remains to be elucidated in respect to long term effects of such treatments. Apart from development of purer products to reduce transfusion reactions, some complimentory alternatives to platelet transfusion are becoming available, which in the near future, may influence the demand for platelet support. PMID- 10175146 TI - Growth factors and thrombopoietin--impact on future patterns of platelet use. PMID- 10175145 TI - Clinician's overview of platelet support. AB - In a period of 2 years, 48 patients over age 55 were treated for acute myeloblastic leukaemia or myelodysplastic syndrome with greater than 10% blasts. 15 patients were treated with intestine chemotherapy, requiring a mean of 48 units of platelets per course. 33 patients were treated by supportive care alone of whom 19 required a mean of 380 units of platelets each. Long term supportive care is a feasible option in elderly leukaemia. Because of dysplasia some patients bleed at a higher threshold than younger patients. A further hazard is the use of i.v. hydrocortisone to suppress transfusion reactions. Such unintentional use of steroids in patients with dysplastic neutrophils and monocytes may predispose to fungal infections. PMID- 10175147 TI - Immunomodulation, autoimmunity and haemostatic dysfunctions. AB - Many links exist between the two major host defence mechanisms, haemostasis and immunity. Blood cells and endothelium are involved in these systems and their dysfunctions. The dual function of these cells is discussed. Once activated, cell cell interactions enhance the biological response and contribute to development of pathology. Furthermore, autoimmunity presents a special clinical relevance, and could be involved in many haemostatic disorders. A hypothesis is presented on how some auto-antibodies are generated and can trigger pathology, by targeting the immune response onto blood or endothelial cells, or to body's organs. PMID- 10175148 TI - Are cytokines in platelet concentrates responsible for febrile transfusion reactions? AB - In recent years, several studies have identified the leukocyte content and the age of the blood components as dominant factors in febrile transfusion reactions (FTRs). At present, extensive efforts are being made to reduce adverse effects by implementation and/or introduction of new methods for leuko-depletion of blood components and by studying the mechanisms responsible for these phenomena. A recent approach has been the evaluation of cytokines in platelet concentrates and this issue has been addressed with some detail in this review. Comparative data currently available on levels of cytokines in the different platelet concentrates is provided along with the functional role of the detected cytokines in including adverse reactions. PMID- 10175149 TI - Quality is a matter of mind: proposed quality improvement through the implementation of best practice. AB - In the past two decades, blood component, production and transfusion therapy have undergone considerable changes in terms of preparation of purer and safer products. This has led to a real improvement in their clinical effectiveness and prevention of untoward effects. With new developments in "tailor made" products it becomes imperative to establish a system of Quality Management in blood transfusion, similar to those of pharmaceutical manufacturers of blood products. Such a system must be comprehensive to embody all aspects of monitoring from donors to recipients, including validation processes using "state of the art" methodology and technology. To achieve overall acceptability, such a quality system must be simple, reliable and practical. We propose a quality improvement programme through the implementation of 6 pointers of quality which lend themselves to both harmonization and standardization programmes in all blood centres. PMID- 10175150 TI - Altruism and payment in blood donation. AB - Paid blood donation still has its defenders, who cite economic doctrines denying the existence of altruism per se, the inability of most countries with exclusively voluntary donations to achieve self-sufficiency and the supposedly successful use of selected groups of paid donors. This paper argues that blood donation is an example of genuine altruism where the altruistic behaviour is incorporated into the self as a role. Unpaid donation is proven to be much safer for receivers and supply problems can be attributed fundamentally to inefficiencies in the organization of transfusion services. Voluntary and non remunerated donation may be sufficient for a country/region to cover all its blood product needs, but requires an efficient organization and the elimination of "spurious altruism", nonmonetary forms of compensation that harm the social image of voluntary donation and obstruct its further development. PMID- 10175151 TI - Possible implication of sterile connecting device in contamination of pooled platelet concentrates. AB - Considering the possibility that a pooled random donor platelet concentrate could become contaminated by welding with a sterile connecting device, we undertook a study to determine the influence of pooling on the contamination rate. As a control group, apheresis platelets were examined. Bacteriological testing was done with a sensitive CO2 detecting culture system, the BacT/ Alert. Out of 1105 pooled platelet concentrates prepared by the buffy coat method, 15 (1.4%) were confirmed as contaminated, all with Staphylococcus epidermidis and two with a second bacterial species, i.e. Staphylococcus capitis and Propionibacterium acnes, respectively. Median detection time by the BacT/Alert was 23 h. Twelve pools of five units were contaminated, which is significantly more than the three contaminated pools of four units. On the other hand, the reuse of the welding wafers proved not be a risk factor for contamination. One welded tubing segment of a contaminated platelet concentrate failed the air leakage test, an incident which was 73 times more frequent than with the sterile platelet concentrates. We found five pooled platelet concentrates containing Staphylococci from which no bacteria could be grown from the individual buffy coats that had been pooled. We suggest the contamination here to have occurred after separation of the buffy coat from the whole blood, possibly during the welding process. Finally, none out of 378 apheresis platelet concentrates was contaminated. All our observations highlight the potential risk for contamination when making pooled platelet concentrates with a sterile connecting device. For this type of transfusion product, we advocate bacteriological screening of all units before release. The incubation time for the sterility test should, however, be limited to 36 h, if logistical problems with the availability of platelets are to be avoided. PMID- 10175152 TI - Differential reduction in lymphocyte and granulocyte content by removal of the buffy coat from fresh and overnight-stored blood. Comparison of manual and automated blood processing systems. AB - The efficiency of leukocyte removal was studied by the removal of the buffy coat layer from fresh and overnight-stored whole blood. Manual blood processing was compared with two types of automated separators: the T-ACE (Terumo) and the OPTI system (with the top-and-bottom bag, Baxter). The main characteristics of leukocyte removal were similar for the systems studied. The efficiency of leukocyte removal was consistently higher with overnight-stored blood. When the net red cell content of the buffy coat was 20-30 mL, the figures were: 70% (n = 103) vs 45% (n = 87, manual method), 78% (n = 6) vs 60% (n = 100, T-ACE) and 82% (n = 10) vs 71% (n = 20, OPTI system), respectively. The increase in the efficiency in leukocyte removal was due to a rapid increase in the efficiency of removal of granulocytes: 65% (n = 65) vs 45% (n = 57, manual method), 80% (n = 4) vs 46% (n = 83, T-ACE) and 74% (n = 9) vs 57% (n = 17, OPTI system), respectively. Processing of overnight stored blood may provide red cell concentrates with fewer contaminating leukocytes and granulocytes. PMID- 10175153 TI - Satisfactory recovery and viability of stem cells cryopreserved at high cell concentration. AB - Peripheral Blood Stem Cells (PBSC) are being extensively used in both oncology haematology and in solid tumor therapy schedules. The latest generation of cell separators allow the collection of greater numbers of nucleated cells (NC) than is usually obtained in bone marrow transplantation (BMT) settings. Thus, larger volumes of components would be stored if the same NC concentration employed in BMT is to be used. In order to reduce large volume DMSO-infusion related side effects and to avoid storage problems, we froze components from 23 PBSC collections at higher NC concentrations, from 40-200 x 10(6)/mL. After 2-12 months of storage, we thawed the samples and determined if the high NC concentration had a detrimental effect on NC viability and on stem cell clonogenicity. No statistically significant differences emerged in regard to CFU GM, CFU-GEMM and BFU-E percent recovery even at 200 x 10(6)/mL NC concentration. PMID- 10175154 TI - Evaluation of a new 5-log filter or packed red cells leucodepletion. PMID- 10175155 TI - Physiology and pathophysiology of blood volume regulation. AB - Adequate cardiac output and tissue perfusion is dependent on intravascular blood volume and its adequate return to the heart. Considering the overall functions of the cardiovascular system in ensuring appropriate flow to the peripheral microcirculation, it is not surprising that conflicts of interest may occur when an organism is exposed to stresses. Of particular importance are the stresses in which there are increased oxygen demands, decreased oxygen availability and concomitant requirements for thermoregulation. When there is depletion of intravascular blood volume, the splanchnic circulation is in effect an "autologous blood bank" for maintaining venous return until trans-capillary refill and haemodilution occurs. With the acute haematological stress response centralisation of blood, secondary contraction of the venous capacitance occurs, as seen with acute hypoxia. This results in overfilling of the heart, activation of atrial volume receptors, release of atrial natriuretic peptide and subsequent reduction of the plasma volume by rapid shifting of plasma into the lymphatic capacitance (via spleen) and transcapillary efflux throughout the circulation. In this overview the physiology and pathophysiology of blood volume, red cell mass and plasma volume regulation is reviewed. PMID- 10175156 TI - The physiology of oxygen transport. AB - Adequate organ function requires adequate provision of cells with oxygen (O2). The driving force for O2-diffusion from ambient air to its site of consumption in cell mitochondria is the oxygen partial pressure (pO2) gradient along this pathway. After uptake in the lungs, O2 transport in blood is achieved (1) through binding to haemoglobin and (2) through physical dissolution in plasma. While the sum of O2 in these two transport states defines total oxygen content of blood, the delivery of O2 to different organs is determined by cardiac output and arterial O2 content, being the product of both parameters. In the case of anaemia, intravascular volume and cardiac compensatory mechanisms determine the degree of O2 content reduction allowable prior tissue hypoxia and lactacidosis occur. When intravascular volume is preserved (e.g. normovolemic dilutional anaemia), reductions in O2 content are tolerated to a much higher degree than in hypovolemic anaemia (e.g. haemorrhagic shock). PMID- 10175157 TI - Clinical assessment and measurement of oxygen transport in the critical care setting. AB - Adequate delivery of oxygen to the tissues is an important factor both in the initial resuscitation of the shocked patient and subsequently in the development of multiple organ failure. The advent of the pulmonary artery catheter has facilitated the calculation of global measurements of oxygen transport at the bedside. Calculated oxygen delivery in fact represents arterial oxygen dispatch rather than actual oxygen delivery to the respiring tissues. Considerable controversy still surrounds the issue of resuscitation of critically ill patients to predetermined goals for oxygen delivery and consumption. More recently interest has arisen in other measures of oxygen transport, in particular regional techniques such as the gastric tonometer. PMID- 10175158 TI - The red cell storage lesion and its implication for transfusion. AB - Storage of red blood cells in preservative medium is associated with metabolic, biochemical and molecular changes to erythrocytes collectively referred to as the "storage lesion." In addition to corpuscular injury, bioreactive substances including cytokines and lipids accumulate in the medium during storage. We review evidence for those storage related changes and potential clinical implications for red blood cell transfusion. PMID- 10175160 TI - Red cell transfusion in specific circumstances. PMID- 10175159 TI - Red cell transfusion therapy in the critical care setting. AB - According to our own experience and published reports the frequency of red cell transfusion in intensive care units is in the range of 0.2 to 0.4 units per patient per day and is dependent upon the local strategy, the patients involved and the kind of surgery performed. The rationale for red cell transfusion is to maintain or restore the oxygen carrying capacity of the blood to avoid tissue hypoxia which occurs when oxygen delivery drops below a certain critical value. Besides bleeding, phlebotomy is also a significant source of blood loss in critically ill patients. According to several recent reviews and consensus articles there is no basis for a fixed indicator for transfusion, such as a haemoglobin concentration of < 100 gL-1. The decision to transfuse has to be made according to the patients individual status. The major adaptive mechanism in response to acute anaemia is an increase in cardiac output and hence blood flow to tissues. As a consequence even moderate degrees of acute anaemia may not be tolerated by patients with cardiac disease, whilst marked anaemia carries a considerable risk of ischaemia in patients with brain lesions or cerebral arterial stenoses. In critically ill patients it has been postulated that supply dependency of oxygen consumption occurs over a wide range of oxygen delivery, far above the critical values of oxygen delivery seen under normal conditions. Maximising oxygen delivery was therefore formulated as a goal in these patients. However, whether pathological supply dependency of oxygen delivery really exists in critically ill patients is still under discussion and recent studies found no benefit in maximising oxygen delivery to this patient group. However, individualised triggers for red blood cell transfusion are adequate for critically ill patients considering their co-morbidities and severity of disease. Finally, the decision to transfuse must also take into account the potential risks (infectious and non-infectious), as well as benefits for the individual patient. In the future, the level of transfusions may be reduced by using blood sparing techniques such as blood withdrawal in closed systems, bedside microchemistry, intravascular monitors, or autotransfusion of drainage blood in intensive care units. PMID- 10175162 TI - Frontiers of blood pressure and heart rate analysis. PMID- 10175161 TI - Potential Creutzfeldt-Jakob disease (CJD) exposure: to notify or not to notify. PMID- 10175163 TI - Maternal responses to the life and death of a child with a developmental disability: a story of hope. AB - Losing a child is probably the most devastating event that a mother can experience. When a child with a developmental disability dies, this painful loss may follow months or years of exhausting parenting. How do mothers of children with developmental disabilities respond to this dual loss (the loss of their ideal child and then the loss of their actual child)? This project used a semistructured interview and the Grief Experience Inventory to explore the bereavement experience of eight mothers who have lost such children. It explored variables that are associated with optimal or complicated bereavement. It was found that most of the mothers were very successful in using cognitive coping strategies to find meaning and benefit in the life and death of their children and were able to continue seeing the world as benevolent and purposeful. Exceptional cases are discussed, and implications for helping professionals are offered. The findings of this study fill a significant gap in the theory of parental coping and bereavement. PMID- 10175164 TI - Sibling bereavement: a concept analysis. AB - Investigators of sibling bereavement contend that the death of a sibling represents a unique and intense loss experience. The empirical literature, however, lacks conceptual clarity about the characteristics of sibling bereavement. Metaphors of siblingship are widely applied and may compromise the integrity of theory development specific to sibling bereavement, particularly as this knowledge base is broadened. There is an immediate need to extend the descriptive knowledge base for sibling bereavement beyond adolescence, in large part to prepare to address the needs of the great number of adults whose brothers and sisters have died as a result of AIDS. The purpose of this article is to examine the concept of sibling bereavement by reviewing the empirical literature and by applying the Wilsonian Method (1963) of concept analysis. A preliminary model addressing the factors of critical attributes and personal outcome variables for bereavement research specific to sibling loss is presented. PMID- 10175165 TI - Caregivers of persons with Alzheimer's disease: some neglected implications of the experience of personal loss and grief. AB - This article questions some traditional conceptualizations of caregivers of persons with Alzheimer's disease and related dementias (AD). The phenomenology of caregiving in rural and isolated regions of northern Canada is examined within a framework developed from the constructs of personal loss and grief. Sixty eight caregivers for persons with AD shared their thoughts and feelings about personal losses perceived to have occurred in their lives with the advent of the caregiving role. Four themes were identified suggesting a role perceived by caregivers as one in which they become subsumed to the needs of the person in care. Diminution of self in the caregiver role has been neglected in the literature. PMID- 10175166 TI - Genetic discrimination: Huntington's disease and the Americans with Disabilities Act. AB - This Note discusses the potential for genetic discrimination, current views as to whether genetic conditions will be covered by the Americans with Disabilities Act ("ADA"), and the specific issue of whether presymptomatic persons who test positive for Huntington's disease should be classified as persons with a "disability" within the meaning of the ADA. In considering whether presymptomatic Huntington's individuals have a disability under the ADA, an analogy is made between Huntington's disease and HIV-positive status. Inter alia, Huntington's disease and HIV-positive status are analogous in that, at the time of diagnosis, victims of both diseases may have no symptoms and may remain healthy for a number of years; but even though the exact time of onset of both diseases is unascertainable, death of both victims within a given range of years is highly likely. Further, both Huntington's disease and HIV are transmitted to offspring at a relatively high rate. Given these similarities, the author argues that Huntington's individuals should be afforded the protections of the ADA for the same reasons that HIV-positive persons are protected. PMID- 10175167 TI - It's a done deal: the changing role of traditional medicine. PMID- 10175168 TI - Managing human resources in a changing health-care environment. AB - Managing human resources in this era of precipitous change poses one of the most difficult challenges and opportunities for leaders in the clinical laboratory. Shifts in health systems integration, cost control, patient-focused managed care, and provider changes have led to trends which fundamentally alter the way in which clinical laboratory services are organized, provided, and funded. To be successful change agents, laboratory managers must understand the cycle of human resource development and how people adopt change. They must embrace a systems thinking perspective and develop strategic leadership skills to share a vision of what the laboratory of the future will be. These new, advanced human resource management skills can be acquired through a variety of formal and informal learning experience. PMID- 10175169 TI - Laboratory administration--visions into the future. Success in the future will require financially skilled laboratory leaders. AB - The health-care industry will continue to undergo dramatic changes aimed at reducing cost and improving quality. A high cost department like the clinical laboratory will be a prime candidate for restructuring, reengineering, or outsourcing. The new realities require the laboratory manager to have a working knowledge of financial issues facing both the laboratory and the entire organization. These skills coupled with formal education in medical technology will place the laboratory manager in a leadership position. PMID- 10175170 TI - Marketing skills for hospital-based laboratory managers in a managed care environment. AB - Managers of hospital-based laboratories have begun to realize the importance of a successful outreach program in protecting against declining inpatient activity. Succeeding in the highly competitive field of outpatient testing requires some new skills and techniques that may not have been apparent when addressing normal inpatient requirements. This article provides an overview of some very basic marketing concepts and attempts to show how they can assist the hospital-based laboratory manager in developing a successful outreach program. PMID- 10175171 TI - Using industrial models and strategic planning to improve customer service. AB - Years ago, the laboratory industry took a cue from what Demming taught the Japanese car industry to improve the way it approached quality assurance; now it's time to learn from an American car manufacturer to step into the future of customer service. The Saturn company has instituted a revolutionary way to relate to their customers. They have carefully identified every single point of contact with them and then made it their business to not just meet, but to exceed the expectations of clients and future clients at each and every interface. PMID- 10175172 TI - Multidisciplinary management--an opportunity for service integration. AB - The management team of the future will enter an environment requiring facilitation, participation, clinical, and empowerment skills. Those individuals who possess a clinical orientation as well as business expertise will be sought to manage multidisciplinary units. The rapid changes in the health-care environment have forced organizations to restructure their operations. To achieve quality care, customer satisfaction, cost-effectiveness, and efficiency, service integration across the organization will be required. As we approach the 21st century, this standard will evolve until "all levels are managing patient care." Some of the restructuring trends occurring in the health-care industry have been collaboration service integration, management consolidation, and job elimination. The emphasis for the multidisciplinary manager of the future will include integrating the professional and clinical services, managing information, building community partnerships, promoting physician collaboration, and managing the change process. A model organization in the next century will move toward a people-oriented system with inclusion and empowerment initiatives. Service integration will affect all organizations, but the disciplines within the Clinical Support System will be the most affected. Future opportunities of leadership will exist for pathologists, nurses, or medical technologists as the professional silos of managers and clinicians continue to crumble. PMID- 10175174 TI - Resource utilization and outcomes management: opportunities for the entrepreneurial pathologist. AB - Pathologists and laboratory managers are facing an increasingly uncertain place in the emerging managed care marketplace. Among the various opportunities available is outcomes management. The role of benchmarking in outcomes management and the initial steps in developing outcomes management programs are presented. PMID- 10175173 TI - The integrated delivery system: opportunities for leadership. AB - The re-engineering of health care by both government and private sector efforts is dramatically changing the appearance and function of medicine. Health providers are seeking partners, stimulated by the goals of managed care organizations (MCOs) to control cost and to increase market share through regionalization of their products. Ventures between even the most unlikely of providers are developing to gain potential savings by greater economies of scale, extending services and increased regional coverage. Because of the complex nature of this process, laboratory management faces a variety of developing models under which they must operate. Pathologists face the same change. The basic elements of pathology practice change associated with integration are similar to those for hospitals (1). Integration brings with it the opportunity for cost reduction, increased market share, standardization of methods and reports, broadened services, combined infrastructure, and a contracting advantage (2). The following is a discussion of integrated delivery systems and the impact on the laboratory operation. PMID- 10175175 TI - The role of technology in the clinical laboratory of the future. AB - Advances in automation and informatics will drive the implementation of new technology as we enter the 21st century. Five technologies which will have the greatest impact on the practice of laboratory medicine during the next decade include molecular diagnostics, near patient testing, image analysis, robotics, and information management. The list of molecular pathology tests with potential clinical utility expands daily. Some, such as tests for human immune deficiency virus (HIV) and hepatitis C virus, already are available as commercial kits. Quality assessment and proficiency testing programs still are evolving. DNA tests in oncology, such as T- and B-cell gene rearrangements and t(9;22) translocation, have proven useful in detecting small numbers of tumor cells and have demonstrated clinical utility in some circumstances. Tests for monogenetic diseases, such as sickle cell disease, are useful in planning antenatal management of mothers at risk. Screening tests for the genetic predisposition for certain forms of colon and breast cancer and Alzheimer's Disease are now possible. This suggests the potential for large scale screening of populations at risk. Continued improvements in biosensor technology and miniaturization will increase the ability to test for many analytes at or near the patient. The generally increased cost per test must be reconciled with the potential to decrease the overall cost of care by improved turnaround time. Computerized image analysis will radically change, and in some cases eliminate, manual clinical microscopy in urinalysis, hematology, immunohistochemistry, and cytology. Robotics will greatly decrease personnel requirements for repetitive tasks, such as specimen transport, processing, and aliquoting. We will process many specimens from start to finish without human intervention. Image management systems will allow archiving of diagnostic gross and microscopic images along with the traditional text descriptions and diagnosis. Telepathology will link smaller centers with expert consultants in tertiary centers. Voice recognition systems will obviate the need for transcriptionists. Modern database architectures will allow the clinical laboratory to measure performance effectiveness and clinical outcomes and will place laboratorians at the forefront of outcomes research. Hand held devices will allow physicians to conveniently order laboratory tests and retrieve results, further decreasing the functional turnaround time for laboratory testing. All of these technologies will be expensive to implement, but well-planned deployment will both decrease cost and improve the quality of medical care. PMID- 10175176 TI - Ethics and the future of health care. AB - Ethical values and beliefs will shape the decisions that shape the future of health care. This can be exemplified by reviewing some of the issues related to developing genetic testing. A good leader recognizes the ethical issues and addresses them explicitly. PMID- 10175177 TI - As we see it. Restructuring the laboratory: taking the "Ouch!" out of shrinking pains. PMID- 10175178 TI - A valued-based prototype for 21st century leadership. PMID- 10175179 TI - Complying with ORYX requirements: one hospital's plan to facilitate decision making. PMID- 10175180 TI - Markets in motion: are consumers satisfied with managed care? PMID- 10175182 TI - Ethics and cost accounting. PMID- 10175181 TI - Calculating the ORYX 20 percent requirement. PMID- 10175183 TI - Activity-based costing improves tracking costs for hospital professional recruiting. PMID- 10175184 TI - Fatal neglect. In possibly thousands of cases, nursing-home residents are dying from lack of food and water and the most basic level of hygiene. PMID- 10175185 TI - Developing a cardiovascular service line team: a process for humanizing clinicians and administrators. PMID- 10175186 TI - Information systems requirements for tracking cardiovascular costs and outcomes. AB - Despite much publicity, formal tracking of cardiovascular costs and outcomes remains a poorly understood and applied topic. Proper use of information systems is the primary way in which business models can be successfully applied to healthcare processes to achieve superior outcomes. Successful systems must meet certain conceptual, organizational, and implementation requirements. PMID- 10175188 TI - The price of state mandates. PMID- 10175189 TI - Bill and Hillary and Harry and Louise. PMID- 10175187 TI - Staff reductions for associated professionals in the near future? Implications of a major government reimbursement proposal. PMID- 10175190 TI - 10 tips for picking top health plans. PMID- 10175192 TI - Disenrollment. What it costs, how to stop it. PMID- 10175191 TI - Who's calling the health care shots? PMID- 10175193 TI - Still time for 24-hour coverage. PMID- 10175194 TI - Allergy's sting: it's partly economic. PMID- 10175195 TI - Do Rx drugs cost too much? Choices and consequences. PMID- 10175196 TI - Do Rx drugs cost too much? The market needs a peace treaty. PMID- 10175197 TI - Data watch. Sizing up women's health. PMID- 10175198 TI - CPRs: why some of the best work so well. PMID- 10175199 TI - Network managers: no longer nameless. PMID- 10175200 TI - Need for analysis drives data warehouse appeal. PMID- 10175201 TI - What works. Fax boards improve accuracy and reliability of peer review service. PMID- 10175202 TI - What works. HR/payroll system slashes transaction processing time. PMID- 10175203 TI - What works. Hospital cuts records staff and rent with electronic patient charting. PMID- 10175205 TI - Hotlist. Systems integration. PMID- 10175204 TI - The role of enterprise person directories. PMID- 10175206 TI - The evolution of a call center at Sarasota Memorial Hospital. PMID- 10175207 TI - Building cross-functional information systems is top health care IS issue, CSC study says. PMID- 10175208 TI - Home care systems: build or buy? AB - As recently as five years ago, home care providers who wanted to use information strategically had little choice but to build their own point-of-care applications. Today, as the number of home health agencies grows, so do the number of home health information systems. PMID- 10175209 TI - Systems integration: revving up the interface engines. AB - Best-of-breed applications can baffle health care IS professionals with a Babel like confusion of software tongues. Interface engines can provide some relief by acting as a computer interpreter which translates for multiple systems. PMID- 10175210 TI - EDI in rural and smaller capitated provider groups. PMID- 10175211 TI - Computers and radiology: stepping into the digital future. PMID- 10175212 TI - What works. Scheduling system turns two-day task into 3-to-4 hour job for radiology group. PMID- 10175213 TI - What works. EMR (electronic medical record) customized for pen input devices helps medical group manage messages. PMID- 10175214 TI - What works. Automated time and payroll system replaces paper time sheets. PMID- 10175215 TI - Hotlist. Materials management. PMID- 10175216 TI - An online approach to wellness. PMID- 10175217 TI - PACS users expect to buy more equipment. PMID- 10175218 TI - Natural rubber-containing medical devices; user labeling--FDA. Final rule. AB - The Food and Drug Administration (FDA) is issuing a final rule requiring labeling statements on medical devices, including device packaging containing natural rubber that contacts humans. The rule requires labeling of medical devices containing natural rubber latex that contacts humans to state: "Caution: This Product Contains Natural Rubber Latex Which May Cause Allergic Reactions."; labeling of medical devices containing dry natural rubber that contacts humans to state: "This Product Contains Dry Natural Rubber."; labeling of medical devices containing natural rubber latex in their packaging that contacts humans to state: "Caution: The Packaging of This Product Contains Natural Rubber Latex Which May Cause Allergic Reactions."; labeling of medical devices containing dry natural rubber in their packaging that contacts humans to state: "The Packaging of This Product Contains Dry Natural Rubber."; and that the claim of hypoallergenicity be removed from the labeling of medical devices that contain natural rubber. These requirements are being established in response to numerous reports of severe allergic reactions and deaths related to a wide range of medical devices containing natural rubber. PMID- 10175219 TI - Guidelines for the use of antiretroviral agents in pediatric HIV infection--HRSA. Request for comments. AB - The Health Resources and Services Administration (HRSA) is requesting comments from all interested parties on the following document: "Guidelines for Use of Antiretroviral Agents in Pediatric HIV Infection". The document was developed by specialists in the care of HIV-infected infants, children and adolescents, family members of HIV-infected children, and governmental agency representatives at a meeting on July 9 and 10, 1997, convened by the National Pediatric and Family HIV Resource Center (NPHRC) and HRSA. While the pathogenesis of HIV infection and the general virologic and immunologic principles underlying the use of antiretroviral therapy are similar for all HIV infected individuals, there are therapeutic and management considerations that are unique to HIV infected infants, children and adolescents. These include acquisition of infection through perinatal exposure for many infected children; in utero exposure to zidovudine (ZDV) and other antiretroviral medications in many perinatally-infected children; differences in diagnostic evaluation in perinatal infection; differences in immunologic markers (e.g. CD4+ lymphocyte count) in young children; changes in pharmacokinetic parameters with age due to the continuing development and maturation of organ systems involved in drug metabolism and clearance; differences in the clinical and virologic manifestations of perinatal HIV infection secondary to the occurrence of primary infection in a still-developing, immunologically naive individual; and special considerations related to treatment adherence in children and adolescents. This document addresses the pediatric-specific issues related to antiretroviral treatment and provides general guidelines to physicians caring for infected children and adolescents. PMID- 10175220 TI - Provision of health care to Vietnam veterans' children with spina bifida--VA. Final rule. AB - This document establishes regulations regarding Vietnam veterans' children with spina bifida. The regulations concern the provision of health care needed for the spina bifida or any disability that is associated with such condition. This action is necessary to establish a mechanism for providing health care to such children in accordance with recently enacted legislation. PMID- 10175221 TI - Provision of vocational training and rehabilitation to Vietnam veterans' children with spina bifida--VA. Final rule. AB - This document establishes Department of Veterans Affairs (VA) regulations for providing vocational training and rehabilitation to Vietnam veterans' children with spina bifida. This is necessary for providing vocational training and rehabilitation to these children under recently enacted legislation that authorizes this benefit. PMID- 10175222 TI - Medicare program; schedules of limits and prospectively determined payment rates for skilled nursing facility inpatient routine service costs--HCFA. Final notice with comment period. AB - This final notice with comment period sets forth an updated schedule of limits on skilled nursing facility (SNF) routine service costs for which payment may be made under the Medicare program and sets forth an updated schedule of payment rates for low Medicare volume SNFs that elect to receive prospectively determined payment rates for routine service costs. Section 1888(a) of the Social Security Act (the Act) requires that the Secretary update the per diem cost limits for SNF routine service costs for cost reporting periods beginning on or after October 1, 1995, and every 2 years thereafter. In addition, section 1888(d)(4) of the Act requires the Secretary to establish and publish prospectively determined payment rates at least 90 days prior to the beginning of the Federal fiscal year (FY) to which such rates are to be applied. PMID- 10175223 TI - Medicare program; adjustments to cost limits for skilled nursing facility inpatient routine service costs--HCFA. Proposed notice. AB - This notice proposes to eliminate an adjustment that we make to the Medicare cost limits for skilled nursing facility (SNF) routine services if the final rate of change in the market basket index for a calendar year that we use to set the limits differs from the estimated rate of change in the index by at least 0.3 percentage points. Elsewhere in this issue of the Federal Register is a separate final notice with comment period that explains the methodology we use to develop the cost limits and sets forth the cost limits applicable to cost reporting periods occurring on or after October 1, 1997. PMID- 10175224 TI - Unkind cuts for many of the elderly. PMID- 10175225 TI - Starting an international healthcare services program: a checklist for system leaders. PMID- 10175226 TI - Copley Health Systems: meeting the challenge of rural integration. PMID- 10175227 TI - Marketing healthcare globally: make it work for your organization. AB - Geographic location and good patient care alone will not guarantee a successful international program. Organizations attracting foreign patients talk about weighing the chances of successfully launching a program, making sure the system is ready to provide customized patient services and--instead of advertising their services--marketing one-on-one. PMID- 10175229 TI - Balanced budget deal leaves the details for states to hash out. PMID- 10175228 TI - Child and family focus. Working together to develop integrated systems of care. AB - We've all heard the jokes about the nature of committee work: "A camel is a horse designed by committee." Or, "A committee is a group of the unwilling unprepared to do the unnecessary." In the current case, nothing could be farther from the truth. Over the past year, we were very fortunate to be able to gather a group of experts who were more than willing, and prepared, to do the very necessary. Representing all areas of children's behavioral healthcare, these respected leaders of the field worked assiduously to produce a blueprint for how child mental health and welfare workers, public purchasers, families, managed care leaders, and other stake-holders can work together to create well-managed "systems of care." The article they coauthored reflects some of the best thinking on the problems of emerging multiple managed care systems and the specific actions urgently needed to protect children and their families. We are pleased to present their recommendations to you in this month's Child and Family Focus. We feel that the hard work that went into this collaboration, and the resulting consensus, demonstrates that integration can, does, and must work to create better systems of care. PMID- 10175230 TI - Quality monitors in primary care integration programs. PMID- 10175231 TI - Dialogue. What is the role of the PCP in addiction treatment? PMID- 10175232 TI - Cost and value of performance indicators. Results from IBH's (Institute for Behavioral Healthcare) National Leadership Council. AB - Consumer Reports style report cards are becoming commonplace in our industry and will emerge as a necessary component of 21st century behavioral healthcare. As a result, health plans and providers are increasingly required to invest in and maintain an infrastructure for comparative performance measurement and reporting. Policymakers and accrediting agencies must be careful to require reporting about the most cost-effective indicators in order to minimize the extra cost burden imposed upon health plans and providers by this effort. The Institute for Behavioral Healthcare's National Leadership Council evaluated "real life" performance indicators already in use in health plans, facility-based provider settings, community mental health centers, and behavioral group practices. This study shows which performance indicators are most worth measuring and those which are not, and why. Significant implications for policy and accrediting organizations, and for the behavioral healthcare field, are discussed. PMID- 10175233 TI - Beyond philosophy. Primary care & behavioral health integration. PMID- 10175234 TI - Creating a culture to support learning. Organizational redesign for quality. PMID- 10175235 TI - From psyche and soma to alliances and mergers. Consumers in the flood of integration. PMID- 10175236 TI - Excess hospital capacity. Recycling, retrofitting (or closure!). Alternatives for America's excess inpatient beds. PMID- 10175237 TI - Why aren't we closing those empty beds? PMID- 10175239 TI - Even 'safe' EDs need security. PMID- 10175238 TI - Safeguard the ED: act before violence strikes. PMID- 10175240 TI - Determine intent before following DNR orders. PMID- 10175241 TI - Benchmarking data may underestimate ED staffing needs, study reveals. PMID- 10175242 TI - Get 'wired'--up-to-date clinical information and valuable resources are available on the Internet. PMID- 10175243 TI - Five ways to battle 'computerphobia'. PMID- 10175244 TI - The intranet: it's coming to your ED. PMID- 10175245 TI - EDs struggling to save nurse educator programs. PMID- 10175247 TI - Newsletters improve morale, communication. PMID- 10175248 TI - Regional PPO network responds to market opportunity. PMID- 10175246 TI - Alternatives are essential in airway management. PMID- 10175249 TI - Patients rate physician organizations. PMID- 10175250 TI - Direct contracting: how providers can get onto employers' radar screen. PMID- 10175251 TI - Integrated delivery systems and workers' compensation issues. PMID- 10175252 TI - Hospitalists fill important new staffing niche. PMID- 10175253 TI - MedPAC may look at key subacute issues as part of Medicare review. PMID- 10175254 TI - Michigan nursing home group continues to pursue broad challenge of HCFA's survey procedures in federal court despite recent set-back. PMID- 10175255 TI - OSHA to target sites with high rates of injuries/illnesses; nursing facilities are on the hit list. PMID- 10175256 TI - Cost limit exemptions, exceptions aren't dead yet; file while you still can. PMID- 10175257 TI - Tips for improving patient education materials. The right readability level is one key to success. PMID- 10175258 TI - Quick 'n easy QI. Getting the most from the resources you already have. PMID- 10175259 TI - Applying HACCP (hazard analysis critical control points) to various food systems. PMID- 10175260 TI - Concerns about cook-chill systems: are they really safe? PMID- 10175261 TI - Assessing the readability of your patient education materials. There's more to it than simply applying a formula. PMID- 10175262 TI - Surviving the information explosion. PMID- 10175263 TI - The ORYX program: beginning a new era in performance measurement. PMID- 10175264 TI - Re-engineering food production tasks. PMID- 10175265 TI - Nine ways to shape up your sandwich plates. PMID- 10175266 TI - Telephone vs. mail surveys. Which is best for post-discharge data collection? PMID- 10175268 TI - The corporatization of American medicine. PMID- 10175267 TI - Improved accuracy of nutrition information in popular magazines. PMID- 10175269 TI - Trends in nutrition support. PMID- 10175270 TI - Keeping employees healthy. PMID- 10175271 TI - Documenting the competencies of your staff. PMID- 10175272 TI - Re-engineering food production tasks. Boost productivity by applying the principles of motion economy. Part 2. PMID- 10175273 TI - Community-based improvement: preventing motor vehicle injuries. PMID- 10175274 TI - Preventing motor vehicle injuries in San Miguel County, New Mexico, using a community-based model for improvement. PMID- 10175275 TI - Hospital benchmarks its way to 'best networked' health care system in U.S. PMID- 10175276 TI - Consortium benchmarks CHF, develops care path. PMID- 10175277 TI - Center improves X-ray wait, patient satisfaction. PMID- 10175278 TI - For benchmarking success choose right topics. PMID- 10175279 TI - Benchmarkers find keys to best wound care practices. AB - Forty-two Southeast hospitals benchmark to establish 54 "best practices" for improving outcomes in treating pressure ulcers. Nine factors critical to the success of a pressure ulcer program are identified: content, ease of use, patient satisfaction, staff education and awareness, efficacy, staff inclusion, tracking and use of information, physician involvement, and continuum of care. PMID- 10175280 TI - Consortium improves MCO, outpatient billing. AB - WHERE: University Health System Consortium, Oak Brook, IL, a group of 27 university hospitals nationwide. PROBLEM: Unscheduled outpatient visits represented 22% of gross revenues but accounted for 95% of claims processed. Simultaneously, numerous requirements by managed care organizations have resulted in billing and collection processes that are primarily manual. GOAL: The consortium wanted to balance the potential collection amounts with the costs of the resources used to collect them and reduce outstanding revenue days in accounts receivable. PMID- 10175281 TI - Imaging project highlights timeliness issues. AB - University Health System Consortium, Oak Brook, IL, sought to identify the best practices of members in processing imaging reports. Internal benchmarking found best practices include: reading images before patient leaves department; requiring radiologists to read all assigned cases before leaving each day; coordinating transcriptionists' schedules with radiologists' dictation patterns; and providing remote access to edit and sign off on transcribed reports. PMID- 10175282 TI - Electronic records pose new security challenges. AB - LOCATION: Sarasota (FL) Memorial Hospital. PROJECT: To effectively secure patient records as the hospital moves from paper records to electronic records system. GOAL: New fingerprint electronic security systems offer flexibility while restricting access to authorized individuals only. PMID- 10175283 TI - Automated patient surveys allow reliable follow-up. AB - PROBLEM: Getting fast and accurate patient feedback following a hospital stay is difficult, labor-intensive, and expensive. OPPORTUNITY: New automated patient survey systems offer flexibility in patient groups, timing of surveys, and survey content, while minimizing data collection burden to staff. PMID- 10175284 TI - When data were scarce, ED managers formed group. AB - Emergency department managers in the Midwest formed benchmarking group in 1996, when traditional data sources proved scarce. Group has established protocols and projects and is well on its way to comparing outcomes for initial projects. Internal benchmarking has already left its mark on members. PMID- 10175285 TI - Report shows trend toward capitation still growing. PMID- 10175286 TI - Clinical decision support helps link outcomes, practice patterns. PMID- 10175287 TI - MD payment plans continue to evolve under capitation. PMID- 10175288 TI - Health plan takes pro-physician approach to incentive system. PMID- 10175289 TI - PHO start-up provides lesson in planning for systems taking on risk. PMID- 10175290 TI - How to be a great teacher. Understanding the essentials of educational excellence in EMS courses. PMID- 10175291 TI - Twist of fate. PMID- 10175293 TI - No pain, no gain? no way! What to do when you're called to a health club. PMID- 10175292 TI - Know your public: the importance of the EMS provider in community and media relations. AB - In the hundreds, and even the thousands, of hours that are spent in EMS training, none of the time is dedicated to community relations and public information. You have learned how to provide a service, but not how to sell the product. We relate to stories about physicians who were unsuccessful because of a poor "bedside manner." The patient's perception of you has very little to do with your score on the final exam or the terminology used as you explain an illness. You are judged by the same rules by which store clerks, telephone operators, waitresses and all others in the field of public service are gauged everyday. You may never do great things, but you can do small things in a great way. Just calling 911 is not enough to save a life. The very idea that we can get everywhere in the nick of time to snatch victims from the jaws of death is a fallacy. You most be concerned with the training provided for the lay public as you are with your own continuing education. There is no better way to make your service more effective than to train your entire community to save lives. There are many reasons why you should know how to deal with the media. A strong relationship can be formed simply by knowing how to make their job easier. Following the golden rules for news releases and interviews help us all appear more professional. The career of an EMT is in metamorphosis. You have been accepted by the patients you served and your fellow members of the medical community. Now you must continue to evolve as practitioners; your skills must change to meet the demands of modern medicine, and your knowledge base must continue to increase as new information becomes available. The one thing that must remain the same is your total commitment to patient care. PMID- 10175294 TI - Survival techniques: put the pressure in perspective. PMID- 10175295 TI - Healthcare & eldercare. PMID- 10175296 TI - Better selection retrieval in the palm of your hand? PMID- 10175297 TI - St. Luke's Home in a Hurry program appeals to new parents. PMID- 10175298 TI - IOL prices level off after 3 years. PMID- 10175299 TI - Risk-sharing radiology pacts can streamline supply chain. PMID- 10175301 TI - Don't let blood products attract budget vampires. PMID- 10175300 TI - The hospital as business. How saving money can help save lives. AB - As hospitals and clinics merge into integrated delivery networks dependent for patients on health maintenance organizations, it is sometimes hard to remember who's on first. Instead of doctors, nurses, patients and hospitals, the world of health care now contains an alphabet soup of IDNs, HMOs, providers, consumers and payers. The changes extend deeply into the materials management department, where simply bargaining for the best price has been complicated by standardization, capitation, and a host of expense management strategies. Perhaps as a result of this ever-changing identity, most hospitals have yet to fully adopt the style and culture of the businesses they really are. Even purchasing managers, who are closer to the business end of the operation, are caught up in the traditional image. In the following comments, two experts in materials management explore the impact that this ambivalence has on a hospital's relationship with the outside world--including suppliers. Joseph Colonna is corporate vice president of the purchasing program at Shared Services Healthcare, Atlanta. Michael Garvin is an adjunct professor at the University of Iowa, and a researcher in medical supply purchasing practices. PMID- 10175302 TI - A reforming accountability: GPs and health reform in New Zealand. AB - Over the last ten years or so, many countries have undertaken public sector reforms. As a result of these changes, accounting has come to play a more important role. However, many of the studies have only discussed the reforms at a conceptual level and have failed to study how the reforms have been implemented and operated in practice. Based on the work of Lipsky (1980) and Gorz (1989), it can be argued that those affected by the reforms have a strong incentive to subvert the reforms. This prediction is explored via a case study of general practitioner (GP) response to the New Zealand health reforms. The creation of Independent Practice Associations (IPAs) allowed the State to impose contractual accountability and to cap their budget exposure for subsidies. From the GP's perspective, the IPAs absorbed the changes initiated by the State, and managed the contracting, accounting and budgetary administration responsibilities that were created. This allowed individual GPs to continue practising as before and provided some collective protection against the threat of state intrusion into GP autonomy. The creation of IPAs also provided a new way to manage the professional/financial tension, the contradiction between the professional motivation noted by Gorz (1989) and the need to earn a living. PMID- 10175303 TI - Health planning in Pakistan: a case study. AB - Health planning is an essential function of the state. For it to be successful, a number of conditions need to be satisfied. In particular it needs to be flexible, participative and integrated with other decision processes. Despite some strengths, the health planning system in Pakistan has generally failed to provide the framework to allow such an approach. Links between strategic and operational planning have been weak; decision-making has been very centralized; there has been a lack of functional clarity; the respective roles of bureaucrats and politicians have been unclear; and, links between capital and recurrent budgets and between planning and implementation have been weak. As a result, there is a number of imbalances in the allocation of resources. The introduction of a revised health planning system for Pakistan is discussed. The constraints on such a system and an initial assessment of its success are presented. PMID- 10175304 TI - A Delphi evaluation of the factors influencing length of stay in Australian hospitals. AB - Using a modified Delphi method, the factors influencing length of inpatient stay (LOS) were explored. Row/column effects loglinear modelling was used to compare ratings between the first and second rounds, and between the clinical and non clinical groups. Rating scale modelling was used to classify and determine the relative importance of each factor. Six important and 48 significant determinants of LOS were found, and four unimportant factors were identified. The relationship among these factors and the implications of this study are explored. PMID- 10175305 TI - Reforming health care in the Republic of Kazakstan. AB - Kazakstan, as in other former communist countries, is currently replacing the soviet system of health care financing for a model based on medical insurance. The main initial purpose has been to generate additional revenue for a sector suffering considerably from reductions in state funding induced by economic transition. Two key issues need to be addressed if the new system is to produce genuine reform. First, the rural areas have suffered disproportionately from the changes. There is an urgent need to adapt the existing system so that adequate funding goes to redress this imbalance. Second, although the fund has concentrated on raising revenue, it will only induce real reform if it begins to exercise its role as an independent purchaser of health care. There is a need for the future roles of both health ministry and insurance fund to be clearly defined to ensure that wide access to medical care is preserved. PMID- 10175306 TI - Volunteers in the middle of nowhere. PMID- 10175307 TI - From L.A. to country roads. Urban to rural. PMID- 10175308 TI - In search of grant money. PMID- 10175309 TI - Let benchmarking help you capture the competitive edge. Part two. PMID- 10175310 TI - Creating crew space. Ambulance modifications for medics. PMID- 10175311 TI - 1997 ambulance manufacturers directory. PMID- 10175312 TI - Building networks. A different leadership style is needed to drive networks. PMID- 10175313 TI - Bronchoscopes linked to two TB outbreaks. PMID- 10175314 TI - How many FTEs? Managers look at new ways to strengthen teams in OR. PMID- 10175315 TI - How many FTEs? Reports aid managers in tracking labor costs. PMID- 10175316 TI - Needlescopic surgery is painless and scarless. PMID- 10175317 TI - Building networks. OR nurses are allies in standardization effort. PMID- 10175318 TI - Building networks. Managing surgical services across a system. PMID- 10175319 TI - Carotid path breaks trail for other procedures. PMID- 10175320 TI - Budget deal has impact on surgical services. PMID- 10175321 TI - Greed is not good. PMID- 10175322 TI - E-mail: what's in and what's out? PMID- 10175323 TI - Clinical decision support criteria: key to managing managed care. PMID- 10175324 TI - Orchestrating a unified approach to information management. AB - Articles in both business and healthcare literature make frequent reference to the need for integration in healthcare organizations. In healthcare, the term horizontal integration can refer to the purchase of one hospital by another in the same geographical area, particularly where the hospitals' services overlap. Services might be consolidated in this example or one hospital may totally shut down the acquired one. Vertical integration refers to a hospital exercising control of its inputs or outputs. In one sense, patients referred to a hospital can be considered inputs. A hospital that purchases physician practices or integrated delivery systems is an example. Purchasing a nursing facility by an integrated delivery system (IDS) is another. This article focuses on organizational or holographic integration, where an organization is understood and embedded--like a hologram--in each of its smaller components, and each operating unit has knowledge about the whole system in which it is embedded. Conceptually, a hospital can achieve organizational integration relatively easily. One way is to assign administrative responsibility for two departments, radiology and pathology, for example, to one person who will handle billing, budgeting and human resources issues. Organizational integration breaks down turf barriers between distinct functional areas (often known as stovepipes or the silo mentality) because the result is less energy expended to solve problems. Organizational integration must include the merging of information technology (IT) into a single computer system that can report results across several departments, for example, in order entry, result reporting, resource scheduling or billing. At the University of Michigan Health System, technical and organizational integration are taking place across the information systems of the radiology and pathology departments. Deployment of an intranet-based architecture for ancillary information systems will provide the means to achieve high level integration across previously heterogeneous and non-integrated department-based clinical information systems. PMID- 10175325 TI - Developing a 360-degree, value-based performance review model. AB - In healthcare, competency assessment continues to be a concern. Even the JCAHO stresses its importance, along with ongoing education for employees. Many healthcare facilities have developed specific technical-competency requirements to ensure quality of service. The leadership at the University of Kansas Hospital (UKMC) wanted to develop a value-driven performance review process that focused on values and interpersonal skills for its employees. The current set of values lacked focus on key quality, behavior and service values, and it was felt employees had not committed to these values. A task force, made up of representatives from key hospital groups, was formed to create a process that would emphasize and assess key leadership skills and values. This team discussed various review mechanisms, including Micheli's 360-degree review process, which uses various sources (supervisors, colleagues and peers, for example) to give input that will be broader and more comprehensive of employee performance. The team incorporated such key leadership expectations as visioning, empowering, modeling, communication, stewardship and self-development into the tool. Called Leadership Enhancement And Development (LEAD), the tool could be completed by a peer, supervisor, direct report or even used for self-review. Results were kept confidential through the use of numbers and letters yet could be incorporated into a spreadsheet for analysis. Starting with managers and supervisors, the process has been piloted in a few larger departments at UKMC where it has been well received. Over time, the process will be used for all employees where it will continue to stress the importance of hospital values and commitment to patients and other employees. PMID- 10175326 TI - Physician unionization. AB - Typically, doctors have seemed unsuited for and uncomfortable with the idea of unions but with the current changes in practices and referral patterns, doctors are looking--at least warily--at unions. Two sets of laws apply to possible unionization of physicians; one, federal antitrust laws, the other, both federal and state labor laws as they apply to changes in the medical profession. Antitrust laws are designed to protect competition by prohibiting price fixing. Another typical antitrust issue that applies to healthcare is that of a group boycott or refusal to deal, where competitors try to coerce a third party to set prices where competitors want them set. Congress' earliest legislation to aide the labor movement involved exceptions to the antitrust laws. Some provisions of the laws are limited to workers who are employees, defined as someone who is employed by any person. Doctors are searching for solutions that provide the collective power of the labor laws without offending the antitrust laws. The question is whether doctors can form unions under these two conflicting forces. The first main issue is whether the doctor is or is not an employee. Although radiologic technologists, typically employees of hospitals or provider groups, have been unionized for years, doctors are usually not employees, at least not if they have their own practices. Although not employees, physicians may affiliate with a larger union to use that broader bargaining power, a purpose that is permissible under current law. Membership in a union does have its responsibilities and disadvantages. Some have suggested that the definition of employee be broadened to cover physician duties under managed care payer agreements, for example. Meanwhile, the Federal Trade Commission and the Justice Department are watching that non-employee physicians not use the union label to mask price fixing, boycotts or refusals to deal. PMID- 10175327 TI - Rumors and gossip in radiology. AB - Rumors and gossip have long been popular topics in literature. Social scientists have even studied the topic and defined four main types of rumor: wish rumors; fear or bogey rumors; wedge-driving or aggressive rumors; and anticipatory rumors. In general, people believe rumor and gossip are synonymous. Rumormongering--the spreading of rumors--occurs among all cultures and types of people. Both men and women gossip and women's gossip is not more vindicative than men's, as is often thought. With such new means of communication as the Internet, transmitting rumor is possible beyond the traditional oral and written forms. Rumor is spread in both the higher and lower levels of an organization. Typically, disproving a rumor is more difficult than proving a rumor. The financial impact of a rumor must be considered also. If people believe, for example, that a radiology department does not have its act together or offers poor customer service, the department may lose revenue because people have lost confidence in it. Originally, the word gossip had positive implications. It referred to a family friend or the woman who delivered a child and announced the event to the community. Because well-intentioned gossip often turns into a damaging story, various approaches for stopping rumors have been identified. They include analyzing the grapevine, identifying the habitual spreaders of rumor and keeping employees informed. In most cases, a person of authority who provides facts can stop or at least slow down rumors spreading at the employee level. PMID- 10175329 TI - Radiology Management: what do readers think? PMID- 10175328 TI - Speech-to-text: the next revelation for recording data. AB - There are numerous tools available for communicating and storing information. Administrators may want to consider speech-to-text-technology. Programs are available that are accurate, easy to use and easily integrated into existing hospital information systems. Computerized voice recognition systems that provide direct speech-to-text are available today and are often referred to as the "listening typewriter." You speak, the computer listens and then types out what it thinks it heard. Such a system has a vocabulary or collection of words that may be spoken by a user. The program analyzes the phonetic structure of words in the vocabulary. A database table compares sounds made by the voice to words in the vocabulary. Two types of recognition are available--realtime and deferred server-based. With realtime transcription, dictation appears on the workstation screen in front of the dictating radiologist. With the deferred system, the dictated session goes to a queue on a server and waits there to be processed, on operation often known as batch processing. Failure of the system can be prevented by clustering or having a redundant server that takes over for the primary server if it should fail. Options to consider for a speech transcription system include security for electronic signatures and a provision for quality assurance or editing professionals who will review documents for errors in recognition. Some software systems offer a program that examines the final document for new or misspelled words, while other systems require error correction to be completed within the last 10 dictated words. The distributed voice model contains a profile of users' pronunciations and allows the computer to recognize a voice that, associated with login ID, differentiates it from others. This model allows a physician to dictate from different locations. Although the cost of the hardware is impressive and requires a thorough cost benefit analysis, such a system can be an excellent solution for large institutions with several locations. PMID- 10175330 TI - Educating for collaborative practice. AB - OBJECTIVE: To describe a baccalaureate-level course which is designed to help allied health professions students develop an understanding of collaborative practice among interdisciplinary components of a health care system and to report on a survey which assessed the effectiveness of the course for clinical laboratory science graduates. SETTING: University of Kentucky, a large (24,000 students) state-assisted institution PRACTICE DESCRIPTION: Baccalaureate clinical laboratory science program PRACTICE INNOVATION: A college-wide course helps students develop an understanding of the linkages of the major components of a health care system and introduces the techniques necessary to function in an interdisciplinary team. MAIN OUTCOMES MEASURE: Perception of benefit from the course by clinical laboratory science graduates. RESULTS: Graduates report that the course helped them develop a larger perspective of health care delivery beyond that of their own discipline and aided in their understanding of group processes and group problem-solving. CONCLUSIONS: Clinical laboratory science curricula can benefit from the inclusion of a college wide course which introduces a broad perspective of health care delivery and group process concepts. PMID- 10175331 TI - Blood donor rejection rate: HemoCue hemoglobin analyzer vs. microhematocrit. AB - This study compared 2 different methodologies: hemoglobin by the HemoCue instrument and hematocrit by the microhematocrit method, to determine if there were any significant difference in the values that could affect donor rejection rates. Literature from the 1960s to 1990s reveals a variety of methods for hemoglobin and hematocrit determinations as well as discussions on fingerstick versus earlobe capillary samples. The HemoCue hemoglobin analyzer is a relatively new technology that tests capillary specimens. The copper sulfate method, although the method of choice for measuring prospective donor hemoglobin levels for many years, was not a part of the study. The microhematocrit method has historically been used as the method for measuring hematocrit alone or as a secondary procedure when donors failed the copper sulfate screening test. PMID- 10175332 TI - An alternative method for evaluating lipoprotein(a) excess in plasma. AB - OBJECTIVE: To estimate the stability and reliability of lipoprotein(a) cholesterol measurement, and explore the possibility to evaluate lipoprotein(a) excess in plasma by using lipoprotein(a)-cholesterol assay alternatively to assay lipoprotein(a). SETTING: Number 255 Hospital of PLA, Tangshan, Hebei, China. PRACTICE DESCRIPTION: A total of 396 plasma samples from 100 healthy people (control), 107 chronic renal failure patients, 114 coronary heart disease patients, and 75 cerebral infarction patients, respectively, were measured for lipoprotein(a) cholesterol and lipoprotein(a) mass; lipoprotein(a) cholesterol and lipoprotein(a) mass levels among control and diseased groups were compared; and lipoprotein(a) cholesterol levels and lipoprotein(a) mass values from the control group were subjected to linear regression analysis. MAIN OUTCOME MEASUREMENTS: The affinity between oligosaccharide contained in lipoprotein(a) and lectin wheat germ agglutinin to isolate lipoprotein(a) from other lipoproteins; lipoprotein(a) cholesterol and lipoprotein(a) mass detected by total cholesterol kits and enzyme linked immunosorbent assay kits, respectively. RESULTS: Both lipoprotein(a) cholesterol and lipoprotein(a) mass levels of the chronic renal failure, coronary heart disease, and cerebral infarction groups were significantly higher than those of the control (P < 0.05 or P < 0.01) whereas no difference was seen among the diseased groups at the 0.05 level. Regression analysis within the control group showed a very high correlation between lipoprotein(a) cholesterol and lipoprotein(a) (r = 0.9932). CONCLUSION: The results suggest that lipoprotein(a) cholesterol assay may be used in the place of lipoprotein(a) measurement for evaluating lipoprotein(a) excess for chronic renal failure, coronary heart disease, and cerebral infarction patients. Further studies about the mechanism of this association between lipoprotein(a) cholesterol and lipoprotein(a) levels are needed. PMID- 10175333 TI - Nonmalignant disorders of lymphocytes. AB - OBJECTIVE: To review the etiology, pathophysiology, clinical features, and laboratory findings in nonmalignant disorders of lymphocytes. DATA SOURCES: Current literature. STUDY SELECTION: Determined by author. DATA EXTRACTION: Determined by author. DATA SYNTHESIS: Assessing qualitative and quantitative changes in lymphocytes provides important information regarding immune reactions, disease conditions, and responses to therapy. Quantitative nonmalignant disorders encompass those conditions in which the total number of lymphocytes may be either increased (lymphocytosis) or decreased (lymphocytopenia). Frequently encountered disorders with a lymphocytosis include infectious mononucleosis and cytomegalovirus infection. Lymphocytopenia is not detected as often or as easily in the clinical laboratory, but may be induced by several causes such as stress, certain types of therapy, nutrient deficiencies, or premature destruction of lymphocytes as occurs in acquired immunodeficiency syndrome. Clinical and laboratory findings provide significant clues in defining the etiology of a nonmalignant disorder of lymphocytes. CONCLUSION: Disorders of lymphocytes include both benign and malignant quantitative and qualitative variations. A reactive lymphocytosis is commonly associated with many viral and certain bacterial infections. The clinical laboratory plays an important role in differentiating reactive and malignant lymphoproliferative processes. Benign lymphocytopenia, although not a frequent finding, must also be characterized by the laboratory. PMID- 10175334 TI - Federal regulations: compliance and implications. AB - The Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) are still an evolving process just as they were when formally launched in September 1992. In developing and guiding CLIA '88 programs, the Health and Human Services relied on 2 key agencies; the Health Care Financing Administration, and the Centers for Disease Control and Prevention within the Public Health Service. CLIA '88 established an important key position for laboratory personnel: the consultant with technical and scientific oversight of moderate complexity test performance, who also consults with laboratory clientele regarding diagnosis, treatment, and management of patient care, including the appropriateness of test(s) ordered. With these responsibilities, it is imperative for consultants and laboratory managers to thoroughly understand regulatory issues in consulting to determine the fine line between what is legal and what is not, and to ascertain any fraudulent and abusive over-utilization of laboratory services and claims under government health care programs. Current federal regulatory policies that clinical laboratory practitioners must be aware of and comply with will be discussed in this article. PMID- 10175335 TI - Virtual Reality in Neuro-Psycho-Physiology. Cognitive, clinical and methodological issues in assessment and rehabilitation. PMID- 10175336 TI - Virtual reality and cognitive assessment and rehabilitation: the state of the art. AB - VR offers the potential to develop human testing and training environments that allow for the precise control of complex stimulus presentations in which human cognitive and functional performance can be accurately assessed and rehabilitated. However, basic feasibility issues need to be addressed in order for this technology to be reasonably and efficiently applied to the neuropsychological assessment (NA) and cognitive rehabilitation (CR) of persons with acquired brain injury and neurological disorders. This chapter will provide an introduction to the basic concepts of neuropsychological assessment and cognitive rehabilitation along with rationales for virtual reality's applicability in these complimentary fields. We review the relevant literature regarding theoretical and pragmatic issues for these applications, and provide a description of our ongoing work developing a mental rotation/spatial skills cognitive assessment and training system. References are provided in each section for further reading in each area reviewed. PMID- 10175337 TI - Virtual environments in neuropsychological assessment and rehabilitation. AB - Brain damage constitutes a major problem for those affected, for their families and friends and for society as a whole. The need for effective rehabilitation strategies is clear. Yet, until the early 1960s, the brain was generally considered to be a somewhat fixed and inflexible organ. In consequence the impairments associated with brain damage were generally regarded as "incurable". Since that time neuroscientists have had reason to change their views dramatically. However, much remains to be done. Progress depends upon a co ordinated multidisciplinary approach within which assistive technology will be a key player. Within the area of assistive technology, one of the developments which holds particular promise for the field of neurological rehabilitation is the computer technology underlying virtual environments (commonly known as virtual reality). In this chapter we describe the new opportunities offered by virtual reality to pursue several aspects of the rehabilitation process. The value of the technology of virtual environments in this context is that it allows us to immerse people with brain damage in relatively realistic interactive environments which, because of their patterns of impairment, would otherwise be unavailable to them. PMID- 10175338 TI - Virtual environments for the rehabilitation of disorders of attention and movement. AB - The incidence of perceptual-motor disorders arising from stroke is steadily increasing in the population of Europe and USA. This chapter sought to define the role that virtual environments may have in designing remedial programmes for rehabilitation following stroke in the areas of attentional retraining and the reacquisition of perceptuo-motor skills. Principles for the structure of guided learning were identified and emphasis placed on the need to identify when and how virtual environments technology can introduce added value to the therapy situation. PMID- 10175339 TI - Virtual reality in the assessment of neuromotor diseases: measurement of time response in real and virtual environments. AB - This paper deals with the design and the development of an equipment, called DDI, as acronym for Disease Detector, developed for the quantitative analysis of neuromotor diseases. It measures the reaction of a person evaluating in the motion of one finger of the hand the time response, the velocity of phalanxes, the force exerted from the finger against a button. The condition of motion are ballistic motion, controlled motion guided by vision, controlled motion without vision, motion with a virtual reality modelization on the computer screen. The system performs also the requirements for medical applications and with its portability and accordance to European normative for safety and quality, represents a new step towards the possibility of quantitative analysis of the performances of the human hand both of mechanical phenomenon and electromyographic of neuromotor diseases, which provoke a decrease in upper and lower limbs action. PMID- 10175340 TI - Virtual reality therapy of multiple sclerosis and spinal cord injury: design consideration for a haptic-visual interface. AB - Multiple sclerosis and spinal cord injury patients can benefit by interaction with a haptic-visual system to increase the accuracy of movements in cases of spasticity, cerebellar tremor, and weakness. The device would apply a counterforce to constrain the upper extremity to a force corridor, a region of force/velocity space, designed to increase movement accuracy. Execution of movements with counterforce assistance under certain conditions improves accuracy and should enable patients to develop enhanced strategies for dealing with the movement disorders resulting from their neurologic deficits. Generation of appropriate force feedback requires dynamic adjustment of feedback plant characteristics and integration of visuospatial information in a virtual reality environment. Sensory augmentation, including compensation for visual and proprioceptive loss, can theoretically also be achieved with this approach. The underlying principles in the development of such a system are presented. PMID- 10175341 TI - Virtual reality for health care: a survey. AB - This report surveys the state of the art in applications of virtual environments and related technologies for health care. Applications of these technologies are being developed for health care in the following areas: surgical procedures (remote surgery or telepresence, augmented or enhanced surgery, and planning and simulation of procedures before surgery); medical therapy; preventive medicine and patient education; medical education and training; visualization of massive medical databases; skill enhancement and rehabilitation; and architectural design for health-care facilities. To date, such applications have improved the quality of health care, and in the future they will result in substantial cost savings. Tools that respond to the needs of present virtual environment systems are being refined or developed. However, additional large-scale research is necessary in the following areas: user studies, use of robots for telepresence procedures, enhanced system reality, and improved system functionality. PMID- 10175342 TI - Human factors consideration in clinical applications of virtual reality. AB - Virtual reality environments have many potential applications in medicine, including surgical training, tele-operated robotic surgery, assessment and rehabilitation of behavioural and neurological disorders and diagnosis, therapy and rehabilitation of physical disabilities. Although there is much potential for the use of immersive virtual reality environments in clinical applications, there are problems which could limit their ultimate usability. Some users have experienced side-effects during and after exposure to virtual reality environments. The symptoms include ocular problems, disorientation and balance disturbances, and nausea. Susceptibility to side-effects can be affected by age, ethnicity, experience, gender and physical fitness, as well as the characteristics of the display, the virtual environment and the tasks. The characteristics of the virtual reality system have also been shown to affect the ability of users to perform tasks in a virtual environment. Many of these effects can be attributed to delays between the sampling of head and limb positions and the presentation of an appropriate image on the display. The introduction of patients to virtual reality environments, for assessment, therapy or rehabilitation, raises particular safety and ethical issues. Patients exposed to virtual reality environments for assessment and rehabilitation may have disabilities which increase their susceptibility to certain side-effects. Special precautions therefore need to be taken to ensure the safety and effectiveness of such virtual reality applications. These precautions include minimisation of possible side-effects at the design stage. Factors are identified which are likely to affect the incidence of side-effects during and after exposures, and which need to be understood in order to minimise undesirable consequences. There is also a need for the establishment of protocols for monitoring and controlling exposures of patients to virtual reality environments. Issues are identified which need to be included in such protocols. PMID- 10175343 TI - Virtual reality therapy: an effective treatment for psychological disorders. AB - Behavioral therapy techniques for treating phobias often includes graded exposure of the patient to anxiety-producing stimuli (Systematic Desensitization). However, in utilizing systematic desensitization, research reviews demonstrate that many patients appear to have difficulty imaging the prescribed anxiety evoking scene. They also express strong aversion to experiencing real situations. This chapter describes the Virtual Reality Therapy (VRT), a new therapeutical approach that can be used to overcome some of the difficulties inherent in the traditional treatment of phobias. VRT, like current imaginal and in vivo modalities, can generate stimuli that could be utilized in desensitization therapy. Like systematic desensitization therapy, VRT can provide stimuli for patients who have difficulty in imagining scenes and/or are too phobic to experience real situations. Unlike in vivo systematic desensitization, VRT can be performed within the privacy of a room, thus avoiding public embarrassment and violation of patient confidentiality. VRT can generate stimuli of much greater magnitude than standard in vivo techniques. Since VRT is under patient control, it appears safer than in vivo desensitization and at the same time more realistic than imaginal desensitization. Finally, VRT adds the advantage of greater efficiency and economy in delivering the equivalent of in vivo systematic desensitization within the therapist's office. The chapter also describes how to use virtual reality in the treatment of specific phobias: fear of flying, fear of heights, fear of being in certain situations (such as a dark barn, an enclosed bridge over a river, and in the presence of an animal [a black cat] in a dark room), and fear of public speaking. PMID- 10175345 TI - Virtual reality for the palliative care of cancer. AB - We have been developing a VR system to provide patients with emotional support and to encourage them to assume an active life against cancer, since patients with an active lifestyle survive longer than those with a passive lifestyle. A possible explanation for this latter fact is that psychological stimulation may also activate the endocrine system and the immune system. Both systems may be able to rapidly repair tissue damaged by cancer and change the characteristics of the cancer itself. Although microelectrical analysis and molecular and genetic analyses are rapidly solving the riddles of the relationship between the brain and thought, we think that our VR research for palliative medicine may also play an important role in this area with regard to the development of new tools for treatment and support. This notion is based on the hypothesis that the brain can reorganize itself to compensate for irrationality or inappropriateness through pharmacological adaptation and/or anatomical regeneration of synapses. Another reason why VR research in palliative medicine is useful is that VR techniques represent not only an enhanced human-machine interface, but also an enhanced human communication technology. VR technology may also be used to help patients accept their disease. The mental state of a patient in the terminal stage of cancer changes step by step from denial of cancer, hope for a new treatment for cancer, suspicion of medical treatment, uneasiness regarding their future life, irritation, depression, and acceptance or despair. We plan to develop a new type of counseling system in medical cyberspace to provide mental care. It can also be used for group therapy or humor therapy to reduce loneliness. In summary, we conclude that VR technology can be applied to palliative medicine (1) to support communication between the patient and others, (2) to provide psychological support to treat neurosis and help to stabilize the patient's mental state, and (3) to actually treat cancer. PMID- 10175344 TI - Virtual reality as assessment tool in psychology. AB - Virtual environments (VEs), offering a new human-computer interaction paradigm, have attracted much attention, in clinical psychology, especially in the treatment of phobias. However, a possible new application of VR in psychology is as assessment tool: VEs can be considered as an highly sophisticated form of adaptive testing. This chapter describes the context of current psychological assessment and underlines possible advantages of a VR based assessment tool. The chapter also details the characteristics of BIVRS, Body Image Virtual Reality Scale, an assessment tool designed to assess cognitive and affective components of body image. It consists of a non-immersive 3D graphical interface through which the patient is able to choose between 9 figures of different size which vary in size from underweight to overweight. The software was developed in two architectures, the first (A) running on a single user desktop computer equipped with a standard virtual reality development software and the second (B) splitted into a server (B1) accessible via Internet and actually running the same virtual ambient as in (A) and a VRML client (B2) so that anyone can access the application. PMID- 10175346 TI - Virtual reality for the treatment of body image disturbances. AB - This chapter describes the characteristics and preliminary evaluation of The Virtual Environment for Body Image Modification (VEBIM), a set of tasks aimed at treating body image disturbances and body dissatisfaction associated with eating disorders. Two methods are commonly used to treat body image: (1) a cognitive/behavioural therapy to influence patients' feelings of dissatisfaction; (2) a visual/motorial therapy with the aim of influencing the level of bodily awareness. VEBIM tries to integrate these two therapeutic approaches within an immersive virtual environment. This choice would not only make it possible to intervene simultaneously on all of the forms of bodily representations, but also to use the psycho-physiological effects provoked on the body by the virtual experience for therapeutic purposes. The chapter, together with the description of the VEBIM theoretical approach, it also presents a study on two preliminary samples (71 normal subjects, uncontrolled study, 48 normal subjects, controlled study) to test its efficacy. PMID- 10175347 TI - Healthcare information systems architecture. AB - The integration and evolution of existing systems represents one of the most urgent priorities of healthcare information systems in order to allow the whole organisation to meet the increasing clinical organisational and managerial needs. This paper discusses how an open architecture, based on the introduction of a middleware of common healthcare-specific services not only reduces the effort necessary for allowing existing systems to interwork, but also automatically establishes a functional and information basis common to the whole organisation, on top of which also new applications can be rapidly developed, natively integrated with the rest of the system. Such architecture has been already formalised through the proposed European preStandard, defined by the CEN/TC251/PT1-013 "Standard Architecture for Healthcare Information Systems" [1]. Through the utilisation of the DHE middleware, the effectiveness and validity of this approach is also being demonstrated in practice by several hospitals and healthcare industries from 13 European countries, which collaborate in the Hansa project, presently running under the Telematics Application Programme of the Commission of the European Communities. PMID- 10175348 TI - Intranet technology in hospital information systems. AB - The clinical information system architecture at the Columbia-Presbyterian Medical Center in New York is being incorporated into an intranet using Internet and World Wide Web protocols. The result is an Enterprise-Wide Web which provides more flexibility for access to specific patient information and general medical knowledge. Critical aspects of the architecture include a central data repository and a vocabulary server. The new architecture provides ways of displaying patient information in summary, graphical, and multimedia forms. Using customized links called Infobuttons, we provide access to on-line information resources available on the World Wide Web. Our experience to date has raised a number of interesting issues about the use of this technology for health care systems. PMID- 10175349 TI - Open architecture for health care systems: the European RICHE experience. AB - Groupe RICHE is bringing to the market of health IT the Open Systems approach allowing a new generation of health information systems to arise with benefit for patients, health care professionals, hospital managers, agencies and citizens. Groupe RICHE is a forum for exchanging information, expertise around open systems in health care. It is open to any organisation interested by open systems in health care and wanting to participate and influence the work done by its user, marketing and technical committees. The Technical Committee is in charge of the maintenance of the architecture and impact the results of industrial experiences on new releases. Any Groupe RICHE member is entitled to participate to this process. This unique approach in Europe allows health care professionals to benefit from applications supporting their business processes, including providing a cooperative working environment, a shared electronic record, in an integrated system where the information is entered only once, customised according to the user needs and available to the administrative applications. This allows Hospital managers to satisfy their health care professionals, to smoothly migrate from their existing environment (protecting their investment), to choose products in a competitive environment, being able to mix and match system components and services from different suppliers, being free to change suppliers without having to replace their existing system (minimising risk), in line with national and regional strategies. For suppliers, this means being able to commercialise products well fitted to their field of competence in a large market, reducing investments and increasing returns. The RICHE approach also allows agencies to define a strategy, allowing to create a supporting infrastructure, organising the market leaving enough freedom to health care organisations and suppliers. Such an approach is based on the definition of an open standard architecture. The RICHE esprit project defined in 1993 the three layered architecture, with four main components and their services of which the main principles have recently been adopted by the CEN TC251 as a european pre standard. From this architecture specifications various implementations have been completed including the IMS DHE, the GESI DHE and the REFERENCE Kernel. However putting into practice this approach on a large scale is not so easy. Interesting lessons have been learned in the last years in different countries. PMID- 10175350 TI - Evolution of the Intranet in the University Hospital of Gent. AB - The explosive development of the internet in recent years has lead to the production of massive collections of web-based tools and development know-how. Implementing an Intranet solution within a health care environment offers tremendous advantages for internal information management, distribution and collaborative computing. Easy adaptability, scalability and the low development cost allow easy integration into existing health care structures. A key aspect of the UZ Gent Intranet is its transparent interaction with the currently implemented HIS thus providing an open gateway to the future. PMID- 10175351 TI - Clinical applications of Intranet-technology. AB - Several areas of HTML-applications using intranet-technology are presented, which are in routine use in our hospital: CBT for nurses and medical students, drug information, electronic literature retrieval systems and laboratory information systems. The basic concept is an integration of commercial databases and local information. All applications are hardware-independent with the same user interface and all use client-server-technology. By a central update it is ensured that everybody gets the most recent information. As a result of these efforts synergy has developed. The training of the medical staff is supported which helps to improve the care of the patients. PMID- 10175352 TI - Towards a component driven infrastructure for integrated healthcare systems. AB - A high level summarised description of the distributed clinical information system implemented in the hospital of the free university of Brussels (AZ-VUB) is described. It evolves towards a component based clinical distributed system that consists of a set of co-operating middelware software components running on a number of computers connected by a network that will foster the integration of applications, data servers and other resources in the medical field. This system is implemented in the University Hospital of Brussels (AZ-VUB) a full-service 800 bed university hospital that provides care for 23,000 inpatients, supports over 300,000 outpatient visits and receives 32,000 emergency patients a year. PMID- 10175353 TI - ORBIS OpenMed project: technical fundamentals. PMID- 10175354 TI - Rapid customizing to evolving HIS requirements due to an object oriented configuration architecture. PMID- 10175355 TI - First do no harm: a standard for electronic communication in healthcare. AB - This paper summarizes recent work on the application of document processing technology, specifically, Standard Generalized Markup Language (SGML) to the problems of electronic exchange of healthcare related information. It includes a short description of the HL7 SGML SIG and current work on SGML standards for healthcare information exchange. PMID- 10175356 TI - Communication standards: problems and future trends. AB - Communication standards are to facilitate the exchange of structured data and information between healthcare systems with different architectural concepts. Several national and international standard development organizations (SDO) are developing and maintaining standards, sometimes even for the same application. There is an increasing demand for a closer cooperation between SDO's and for a better harmonization of different standards going on. The current status of the most important standard application in healthcare is discussed and some further considerations for improving the harmonization process will be given. PMID- 10175357 TI - The role of communication servers in the architecture of healthcare information systems. AB - Communication between departmental subsystems within a hospital information system (HIS) is more and more supported by dedicated communication servers (CS). One of the main advantages is a centralized and standardized flow of information. Beside this "classic" approach a communication server may be embedded on at least two other hierarchical levels in the architecture of healthcare information systems: in an organizational unit within a hospital (subsystem) but also in large scale healthcare information systems covering aspects of communication between the involved external healthcare providers. PMID- 10175358 TI - The Erlangen Hospital Communication Hub: migration from proprietary to standardised communication. AB - The Erlangen communication hub allows medical subsystems to exchange data by two completely different methods. Since 1995 a communication data base, which is implemented using the relational data base system ADABAS D, contains data from the most important hospital systems. This data can be accessed by other medical systems. Thus, the communication data base allows subsystems which do not have a standardised interface to implement proprietary system interconnections via access based on SQL. The capabilities of this interconnection are dependent on both the implementation and the data which is made available by the communication data base. This contains mainly basic patient data and the results of tests performed by various laboratory systems. In addition to this proprietary communication system we have since the end of 1996 a communication server which can also handle standardised message formats such as HL7, EDIFACT, DICOM3. Future subsystems which possess standard interfaces will be connected via this server. The connection of the patient management system IS-H and the central laboratory system to the database has been proceeding since the beginning of 1997. PMID- 10175359 TI - Experiences with DCE: the pro7 communication server based on OSF-DCE functionality. AB - The pro7-communication server is a new approach to manage communication between different applications on different hardware platforms in a hospital environment. The most important features are the use of OSF/DCE for realising remote procedure calls between different platforms, the use of an SQL-92 compatible relational database and the design of a new software development tool (called protocol definition language compiler) for describing the interface of a new application, which is to integrate in a hospital environment. PMID- 10175360 TI - Open directory service for hospital information systems. PMID- 10175361 TI - Healthcare information system approaches based on middleware concepts. AB - To meet the challenges for efficient and high-level quality, health care systems must implement the "Shared Care" paradigm of distributed co-operating systems. To this end, both the newly developed and legacy applications must be fully integrated into the care process. These requirements can be fulfilled by information systems based on middleware concepts. In the paper, the middleware approaches HL7, DHE, and CORBA are described. The relevance of those approaches to the healthcare domain is documented. The description presented here is complemented through two other papers in this volume, concentrating on the evaluation of the approaches, and on their security threats and solutions. PMID- 10175362 TI - The DIFF project: an electronic patient record for the Hospital Princesse Marie Astrid in Differdange. PMID- 10175363 TI - From WING to MMSA: experiences with the implementation of a distributed HIS. AB - The following paper analyses the transition from a host centered to a client server based Hospital Information System (HIS) which takes place at the University Hospital of Giessen, Germany, since 1995. It focuses on the overall concept and practical realisation of the cornerstone within this transition, the Macintosh Mosaic Software Architecture (MMSA) which delivers now more than 90% of the clinical data which is entered on the wards and within the operating rooms. Besides the technical problems of the project, the paper also describes some aspects of the organisational challenges which took place within a typical German University Hospital during the last 4 Years and which mainly affect the daily management of a large HIS. PMID- 10175364 TI - Tutorial on the CEN/TC251 HISA standard: healthcare information systems architecture. PMID- 10175365 TI - Tutorial on communication standards in healthcare. PMID- 10175366 TI - Tutorial on the introduction to CORBA/CORBAmed. PMID- 10175367 TI - Tutorial on the DHE middleware: key aspects and practical utilisations. PMID- 10175368 TI - A federated schema-based middleware architecture for hospital information systems. AB - An important concern in distributed hospital information systems is the integration of information across heterogeneous subsystems. Consistent data replication is a central problem to be solved in this domain. The specific requirements and problems for integration of information within hospitals are discussed and a middleware architecture which has been designed according to these requirements is presented. Communication servers are often deployed in hospitals to connect heterogeneous subsystems. This paper discusses some problems with this approach and presents a federated schema-based middleware architecture as an alternative solution for propagation of information updates across heterogeneous subsystems within hospitals. PMID- 10175369 TI - Synapses in the context of healthcare information systems. AB - The Electronic Healthcare Record will increasingly lie at the heart of the Healthcare Information Systems of the future, and the ability to share safely and meaningfully patient records between Hospital Information Systems depends crucially on an agreed architecture for EHCR. This paper describes the approach to providing access to Federated Healthcare Records as proposed by Synapses, a pan-European project funded under the EU Health Telematics Programme, through the use of a record server. The positioning of this server within the Healthcare Information Systems Architecture is discussed together with some suitable candidate technologies for implementation. PMID- 10175370 TI - Comparison, evaluation, and possible harmonisation of the HL7, DHE, and CORBA middleware. AB - Regarding the need of change of both healthcare systems' structure and supporting information systems' architecture to the "Shared Care" paradigm, appropriate health information systems have to be distributed and interoperable, and will usually be based on middleware concepts. Structure and function of information systems meeting such requirements have been analysed in general. To describe, evaluate and combine distributed systems, a generic component model has been used. As a result, CORBA, DHE, and HL7 have been assessed systematically. A way to a common and harmonised middleware approach has been proposed. PMID- 10175371 TI - Hospital information system engineering using the PROMISE architecture. AB - This paper presents the novel Process Oriented Medical Information System Architecture (PROMISE) which has been developed in detail especially for the requirements of hospital information system engineering processes. The architecture is given in three columns and three layers along the following three dimensions: business process modeling, process specification and engineering. The heart of the architecture is a purpose-built framework for hospital information systems called PROSIGHT whose implementation can be used easily as a workbench. The single components can be customized according to detailed modeled hospital business processes which form in common a complete hospital information system. Any other framework can be used instead PROSIGHT if it can be used as a reference hospital information system in the same manner. Although the PROMISE architecture is presented in common with the given framework it can be seen as an open architecture. The hospital information system engineering process comprising the development as well as the adaptation process for a certain hospital will be skeched out. PMID- 10175372 TI - Component architecture in HIS: a drug order entry case study. AB - Historically, many healthcare information systems (HIS) have been designed around monolithic architectures that rely upon a single organization to provide most, if not all, of the system's business logic. Recent advances in distributed systems technology and healthcare standards make a component-based architecture feasible in building today's HIS. The First DataBank Drug Toolkit is used as a case study for the role of components in the design of a HIS. Several technical challenges associated with building truly plug and play components are discussed. PMID- 10175373 TI - Save medical personnel's time by improved user interfaces. AB - Common objectives in the industrial countries are the improvement of quality of care, clinical effectiveness, and cost control. Cost control, in particular, has been addressed through the introduction of case mix systems for reimbursement by social-security institutions. More data is required to enable quality improvement, increases in clinical effectiveness and for juridical reasons. At first glance, this documentation effort is contradictory to cost reduction. However, integrated services for resource management based on better documentation should help to reduce costs. The clerical effort for documentation should be decreased by providing a co-operative working environment for healthcare professionals applying sophisticated human-computer interface technology. Additional services, e.g., automatic report generation, increase the efficiency of healthcare personnel. Modelling the medical work flow forms an essential prerequisite for integrated resource management services and for co operative user interfaces. A user interface aware of the work flow provides intelligent assistance by offering the appropriate tools at the right moment. Nowadays there is a trend to client/server systems with relational databases or object-oriented databases as repository. The work flows used for controlling purposes and to steer the user interfaces must be represented in the repository. PMID- 10175374 TI - Security threats and solutions in distributed, interoperable health information systems using middleware. AB - Increasingly, distributed, interoperable healthcare information systems, which meet the shared care paradigm, work across the boundaries of policy, organisational, and technological domains and are based on middleware concepts. Especially in healthcare with its sensitive personal and medical data, such systems require advanced data security measures. In the paper, a common object oriented security model for middleware systems and advertisements for implementation are proposed, corresponding the security requirement of both the user and the application environment. PMID- 10175375 TI - Experiences with DHE: an order entry and result reporting case study. AB - Organization of hospital information systems that are currently in use is characterized by a multitude of simple, unfortunately less integrated components. For the integration of the already available as well as new components into a hospital information system, the "Committee European de Normalisation" (CEN) proposed a basic "Conceptual Architectural Framework". Based on the CEN proposal, in this paper we present first results of a case study in order to investigate the usability of the Distributed Healthcare Environment (DHE), as a standard architecture for hospital information systems. Another aim of this case study was to design an Order Entry and Result Reporting System and implement it by using DHE. PMID- 10175376 TI - The management of patients in a hospital information system based on a common middleware: a case-study for the Al-Amal Cancer Centre. PMID- 10175377 TI - Plug and play integration into a healthcare information system. AB - This paper discusses some experiences with the integration of a tumor documentation system into a distributed healthcare environment using a new European middleware technology. Although the middleware already offers a considerable support to the software engineer further facilities have been developed in order to accelerate integrations. Such facilities arised from the software engineering principle of separating reusable parts and non-reusable parts. PMID- 10175378 TI - Extending the standard architecture for healthcare units: the guideline server. AB - The main topic of our research is health care unit (HCU) reengineering. To this aim, a guideline oriented conceptual model of HCUs was developed. In order to map this conceptual model into an information system with a client-server architecture, a guideline server is needed. The guideline concept and its life cycle are introduced and the main functions of the guideline server are presented. PMID- 10175379 TI - Nursing Informatics '97. The Impact of Nursing Knowledge on Health Care Informatics. PMID- 10175380 TI - Improving nursing documentation to include outcomes of care in computerized information systems. AB - Often times when models of information systems are developed, outcomes are either left out or described as an end product of treatment alone. However, in research demonstrating outcomes, evaluating whether outcomes are achieved can best be accomplished when the outcomes are integrated into the entire care process. This paper describes a model for nursing to consider when integrating outcomes during several components of nursing care delivery, and several nursing domains for achieving outcome of care. PMID- 10175381 TI - Computer literacy: expected learning outcomes in nursing studies and the reality. AB - Information technology has been taught as part of nursing curricula for several years. With computer literacy now a basic requirement in clinical nursing practice, it is important to look more seriously at the standards and methods of teaching information technology at nursing colleges. In this study the objectives of teaching information technology and the content of information technology studies were evaluated by nurse educators (n = 162) and by an expert panel (n = 15). Nurse educators and the expert panel had more or less identical views on what those objectives should be. The quality and outcomes of information technology teaching in nurse education have never been measured in Finland before. In order to find out the consumers' point of view, student nurses were asked to assess their knowledge and skills in computer use. The student nurses (n = 373) felt that they had a reasonable command of the theoretical knowledge in information technology. However, their keyboard skills were confined to the use of word processors. PMID- 10175382 TI - Organizational diagnosis of computer and information learning needs: the process and product. AB - Organizational diagnosis views the organization as a single entity with problems and challenges that are unique to the organization as a whole. This paper describes the process of establishing organizational diagnoses related to computer and information learning needs within a clinical or academic health care institution. The assessment of a college within a state-owned university in the U.S.A. is used to demonstrate the process of organizational diagnosis. The diagnoses identified include the need to improve information seeking skills and the information presentation skills of faculty. PMID- 10175383 TI - The information age: the status of technology in nursing education programs in the United States. AB - The purpose of this research was to determine the status of technology in nursing education in the United States. The research design was a comparative descriptive survey of a stratified random sample of National League for Nursing accredited diploma, associate, baccalaureate and master programs. The instrument for data collection was developed by a panel of six experts in the area of educational technology. The survey, mailed to 347 randomly selected schools, identified four primary areas of investigation: 1) technology inventory, 2) technology applications and content, including education and clinical areas, 3) implementation plan, and 4) decision making including funding and staffing resources. Findings indicated there was a significant difference in available electronic resources among baccalaureate, associate and diploma programs. A majority of schools utilize computer applications to enhance teaching, but a very small percentage of schools addressed informatics in the curriculum. The project was funded by a grant from the Helene Fuld Health Trust Fund. PMID- 10175384 TI - The current status of nursing informatics in undergraduate nursing programs: comparative case studies between Sweden and Australia. AB - During the last ten years, the inclusion of education in health information systems has assumed an important role in graduate programs for health professionals. More recently, attention has focused on undergraduate programs. Throughout the world schools of nursing, organisations and associations are addressing the issue of educational offerings in nursing informatics. This paper reports on the status of nursing informatics at undergraduate level. Nurse academics from Gavle and Lund in Sweden, and from Melbourne and Sydney in Australia, took part in a survey of the respective nursing courses. The purpose of the study was to identify and describe examples of types of nursing informatics courses in Australia and Sweden. A convenient sample of academics were approached and interviewed. The results of the survey illustrate, in the schools surveyed, the slow emergence of nursing informatics into nursing curricula. PMID- 10175385 TI - An informatics education for improved nursing by introducing an easy data base system. AB - We began to explore the subject of nursing information systems nine years ago. Since then, we have advocated a system that is intended to be used by nurses for their own purposes. We have developed an easy database management system (Native Data Base Management System, called NDBS hereafter) that is feasible to operate in the nursing situation. We also have developed an educational training system for information technology, which is appropriate for nursing students as well as for experienced nurses. Both systems have helped to greatly improve nursing services. In fact, nurses have already created several beneficial databases which are tailored to their nursing needs. PMID- 10175386 TI - Education of clinical nurses in nursing documentation in accordance with the VIPS model. AB - The purpose of this study is to describe some effects on the clinical nursing documentation after registered nurses (RN) had participated in a three-day course in nursing documentation in accordance with the VIPS-model. Between November 1993 and December 1996, 4594 registered nurses participated in the course. In order to evaluate the effects of the course two questionnaires were sent out to 900 participants, one concerning the degree of development in their nursing documentation and another concerning what they perceived as inhibitors and facilitators to the development of nursing documentation. The result will be presented at the conference. PMID- 10175387 TI - Computerized education in a multi hospital university medical center. AB - The advantages of using authoring, instructional, and informational computer applications in a university-based multi-hospital medical teaching center are vast. Software applications are used by the staff development educators at The Presbyterian Hospital, Columbia University Medical Center (CPMC) for test construction and administration, information processing, instruction, assessment, and evaluation. The media formats include Windows and DOS based CAI programs, CD ROM, IVD, INTERNET sites, and other on-line resources. This presentation will focus on how nurse educators use the various types of software applications available on the CPMC network and in the multimedia center, and on the benefits experienced by learners, educators, and nursing management and administration. PMID- 10175388 TI - Evaluating standardized coding and classification systems for clinical practice: a critical review of the nursing literature in the United States. AB - Developers of healthcare information systems are challenged by the difficulty of meeting the simultaneous goals of 1) capturing and electronically representing the broad array of data related to healthcare with sufficient expressibility to provide adequate documentation of the patient encounter, and 2) utilizing standardized coding and classification systems to facilitate linkages among computer-based systems. The evaluation studies to date have primarily focused on matching actual clinical data with terms in the recognized classification systems. These studies have provided evidence that the classification systems are relatively domain complete for categorizing patient problems and nursing interventions. Although several of the published criteria for evaluation relate to structure, it is noteworthy that this has not yet been a major focus of study in nursing. There are several areas of critical need that must be addressed. First, additional work is needed to develop and refine a standardized set of atomic-level terms relevant to nursing, including those for assessments, problems, and activities. Second, knowledge representations must be developed to support the building of complex concepts from atomic-level data. PMID- 10175389 TI - Understanding surgery: multimedia comes to theatre. AB - Educational technology is well established within Schools of Nursing, however there are few computer based learning packages within the clinical environment. It was felt within the Operating Services Directorate, Royal Hallamshire Hospital, that the development of a multimedia package would enhance and complement existing teaching methods. This paper describes the theory behind the choice of a multimedia presentation and its development within the operating theatres. The package, concentrating on general surgery, has been developed by two experienced theatre nurses and a graphic designer. This has resulted in a structured but flexible, fun package which is relevant to all learners within the operating theatre environment and allied healthcare fields. The feedback obtained from users within the clinical area has reinforced the project team's original feeling that multimedia is a highly appropriate resource for clinical education. PMID- 10175390 TI - Nursing information in electronic patient records: criteria established in a Delphi study. AB - Nursing lacks an adequate tool to assist in determining the essential components of an information policy in health care institutions, and to outline the nursing component of the electronic patient record. The objective of this study was to determine the criteria to which a nursing information system, and its developmental process, should comply with, when such system is part of an electronic patient record system. Using the Delphi methodology, criteria for nursing information systems were determined by an international panel of 36 experts in three succeeding rounds. Most criteria gained consensus and are very useful for use in practice for those involved in nursing system development. Eventually the list of criteria will be included in a nursing information reference model. Nursing will benefit from the application of the reference instrument and criteria to express their information needs and to develop adequate information technology. PMID- 10175391 TI - System design challenges: the integration of controlled vocabulary use into daily practice. AB - System developers face the challenge of providing tools to improve health care productivity and quality. While progress is being made, clearly defined requirements, standards and development guidelines are not yet complete enough to provide the details needed to build such software. We have moved forward and created a clinical documentation system using a controlled vocabulary. Doctors and nurses use data entry tools such as browsers and templates to access the vocabulary for creating clinical notes. Our library of terms is mapped to SNOMED which is not complete enough to support clinical documentation. Therefore our libraries have been expanded beyond SNOMED. Overall we have found that clinicians will use a controlled vocabulary when it is intuitive, predictable, flexible, complete and fast to use. Other benefits have surfaced such as more complete and consistent documentation. Our experiences to date confirm that there is still much to explore, discover, invent and create. PMID- 10175392 TI - Using a revised model to identify information requirements for cardiac surgery patients operating mobile computing technology. AB - Information system selection and implementation continues to occupy the majority of informatics nurses' time in clinical settings. Despite the availability of more sophisticated guidance for system selection and implementation, some agencies continue to fail when attempting to automate their information processing. Such failures cost the agencies time and resources, two valuable commodities. In some cases information systems were selected and specifications developed without first identifying information needs within the agencies. The Model for Identifying Information System Requirements (MDISR) could be used to help agencies to identify information needing to be considered during the selection and implementation processes. PMID- 10175393 TI - The WISECARE Project and the impact of information technology on nursing knowledge. AB - The European Union retained the WISECARE project "Work flow Information Systems for European nursing CARE" for funding. The project focuses on the use of telematics technology for clinical and resource management in oncology care in hospitals. This paper outlines the impact of introducing this kind of advanced nursing informatics application on the management of nursing knowledge. Three shift in knowledge management that will get high attention in WISECARE, are identified. The first is the shift from knowledge dissemination to knowledge sharing. The second is the shift from individual knowledge to organisational knowledge. The third is the shift from deductive, prescriptive knowledge as seen in guidelines, protocols to more inductive, experience based knowledge. The paper emphasizes that the real impact of information technology is not in the automation of existing processes but on the discovery of new ways of organisation and living. PMID- 10175394 TI - Nursing informatics in nursing education. AB - Full integration of nursing informatics education at all levels at academic institutions and in practice is critical to nursing as the profession faces the 21st century. Nursing informatics, which encompasses computer hardware, software, and network systems, supports the profession's goals of achieving computer literacy by the year 2000. Strategies for successful integration of nursing informatics into curricula are identified, and specific tactics that promote desired outcomes suggested. The benefits that nursing informatics brings to education, administration, research, and practice are stated and the role of professional nursing organizations in promoting nursing informatics' status as a recognized nursing specialty is noted, and the specialty's role in promoting the profession's future development described. PMID- 10175395 TI - Nursing informatics in a registered nurse graduate program. AB - For many Registered Nurses the question is not whether to advance their education, but how to attain the requisite formal learning experiences given their professional and personal responsibilities. One innovative approach to facilitating the pathway to graduate education for a group of very experienced nurses lacking the BSN is the RN-MS Program at Northeastern University. This graduate-level curriculum provides an opportunity for selected Associate Degree and Diploma prepared nurses to integrate their basic nursing education, extensive clinical practice, professional leadership experience, and practical knowledge base within an extended (85 quarter hours) formal graduate program of study in a nursing specialization. The learning paradigm includes Nursing Informatics and computer competency. The intent of this work was to analyze the experience of RN applicants--students who participated in the faculty designed seminar and developed a typed portfolio using word processing software as part of the admission process in the RN to MS Program. The Nursing Informatics (computer competency component) and its integration throughout the curriculum will be evaluated. PMID- 10175396 TI - The role of nurse education in the integration of information in the health care environment. AB - The central theme of the paper is to explore the issues surrounding the development of European-wide knowledgeable nurse practitioners for effective and efficient patient care in an information intensive health care environment. Examination will be made of the role education needs to play to complement the new paradigm of health care. Where practicable, comparisons will be made between nurses' and other health care disciplines' approach to the introduction of information systems and how 'shared' approaches could be beneficial to all professions and the patients in care. The paper will conclude with a vision for the future and consideration will be given to where European nurses should position themselves to remain accountable and autonomous practitioners in health care. PMID- 10175397 TI - Keeping education in health informatics on the right track. AB - The programme in health informatics at Aalborg University has been running for three years and is about to be revised and extended to a full masters programme. In this paper the programme is presented and the systematic activities to obtain the basis for the revision are described. PMID- 10175398 TI - Benefits realisation in maternity information systems. AB - This paper describes the compilation of a monograph on benefits realisation of maternity information systems from maternity services around England and Wales. It was compiled to compliment a monograph produced in June 1995 on Nursing Information Systems. The paper summarises the structure of the monograph and outlines the concept of benefits realisation. The examples featured in the monograph are not "true" benefits realisation studies and many of the accounts are anecdotal in nature. However, the paper suggests that midwives do benefit from using a maternity information system particularly in the areas of auditing practice, effortless retrieval of statistics, less duplication of data entry, summaries of care and research purposes. Managers also benefit from some of these functions and those relating to estimating workload and allocation of resources. It is suggested that any benefits for staff and management should also benefit clients and improve the provision of the maternity services. PMID- 10175399 TI - An evaluation of the utility of the Home Health Care Classification for categorizing patient problems and nursing interventions from the hospital setting. AB - The purpose of this study is to evaluate the utility of the Home Health Care Classification for categorizing patient problems and nursing interventions from the hospital setting. The data set comprised 5,844 problem terms and 20,055 interventions terms. All terms could be categorized using the Nursing Components and Major Categories for Nursing Diagnoses and Interventions. A total of 1,767 (30.2%) patients problem terms could be placed into Major Nursing Diagnosis categories, but not subcategories even though there were subcategories related to the major category. All intervention terms whether they were classified at the Intervention Category or Subcategory could be coded according to Type of Nursing Action. These findings demonstrate that the Home Health Care Classification, at the level of Nursing Components and Major Categories, was domain complete for the data set. The fact that not all terms could be classified according to the existing subcategories suggests some areas for future development, but is also a reflection of the level of detail expressed in the data set itself. The results suggest that the Home Care Classification will be adequate and appropriate for categorizing problems and interventions across setting for the next phases of the research project. PMID- 10175400 TI - Partners in powersharing--the role of midwives in information technology. AB - The contribution which midwives can make to the successful implementation of information systems is described. Issues such as Change Management, Quality, Benefits Realisation, and Public Relations are discussed. Damage limitation in the information age is outlined. PMID- 10175401 TI - Evaluation of community nursing information systems. PMID- 10175402 TI - Using reengineering to improve "customer visit processes". AB - Much of informatics has been concerned with computer systems. Informatics took a broader view during the Fifth International Nursing Informatics Symposium Post Conference in Austin (1994) as Henry et al, captured the essence of informatics as being "imperative for assessing the quality of care provided and analyzing effectiveness of nursing interventions across settings and population". At York Central Hospital (YCH), Ontario, we realized the need to work differently, to keep what's good about what we do and still meet the changed needs of health care. We also realized it's about getting everyone close to the patient. We used a reengineering process to help us achieve that goal. This paper describes how models and techniques commonly used in reengineering can be used for assessing and analyzing the quality and effectiveness of the service provided to the client. PMID- 10175403 TI - Developing a generic health status measure for use in a computer-based outcomes infrastructure. AB - This descriptive, correlational study was designed to determine the sensitivity of a generic health status instrument to patient population and to time. The study sample included adult patients undergoing total joint replacement (TJR), adult patients in acute congestive heart failure (CHF), and pediatric patients receiving chemotherapy (PediOnc). A 2 x 3 (population x time) ANOVA for TJR and CHF demonstrated a significant main effect of time (F = 8.0, p = .0006) and a significant interaction effect between time and population (F = 14.4, p < .0001) for functional status. In the PediOnc subsample (HSOD child version), the highest scores for all HSOD factors with the exception of functional status were at Time 3. There was also a significant main effect of time on health care involvement, on the caregiver factor, and the family factor. These results support the sensitivity of the HSOD to patient population and to time. PMID- 10175404 TI - Description of a comprehensive research project to develop a reference model for nursing information systems. AB - This paper describes a comprehensive research project in progress that aims to develop a Nursing Information Reference Model. The study consists of several components. Together these components should lead to the production of the reference model. At the time of submission of this paper several components of the study are finished. After describing the scope of the study as a whole, individual components will be presented. An overview will also be offered of those parts that are still under development. PMID- 10175405 TI - Determining an appropriate clinical problem for expert system development in the neonatal intensive care unit. AB - The purpose of this pilot study was to demonstrate the use of the Nominal Group Technique (NGT) to identify a clinical problem for expert system (ES) development. NGT is a research method that allows individual judgments about a problem to be combined effectively. Problem identification is the necessary first step for the development of an expert system for use by neonatal nurse practitioners (NNPs) caring for neonates in the neonatal intensive care unit (NICU). Five NNPs identified 21 clinical problems encountered when caring for infants in the NICU and reduced these to the 5 most amenable to ES development. Of these 5 problems, fluid management in the very low birthweight (VLBW) infant was chosen for projected ES development. PMID- 10175406 TI - A collaborative international nursing informatics research project: predicting ARDS risk in critically ill patients. AB - An international nursing informatics research collaboration between Duke University Medical Center in Durham, North Carolina, USA and Allgemeine Krankenhaus Hospital in Vienna, Austria used data mining techniques called Knowledge Discovery in Databases (KDD) to explore the relationship between clinical data variables and adult respiratory distress syndrome (ARDS) in critically ill patients. Results of the study and logistics of international research collaboration will be presented at NI '97. The conceptual model, data mining methodology, and objectives for the collaboration are described here. PMID- 10175407 TI - Attention for security now more needed than ever. AB - Security is a major consideration for any computer system. Today the topic security is defined and divided in three different domains: confidentiality, integrity and availability. This paper deals with the topic availability and the fact that hospitals are getting more and more dependent of their computer systems In this contribution the different aspects of availability and non-availability are described and measures are mentioned to lower the risk of dysfunction in the hospital in case the system completely has collapsed for a longer period. PMID- 10175408 TI - Collection of nursing minimum data set (NMDS) could benefit from medical encoding experiences. AB - This paper describes the use by nurses of a semi-automatic, natural language oriented, encoder help tool currently in use in the medical sector. The use of a standard language in the daily activities of nurses is not acceptable therefore the use of an encoder will link nursing data collection with a classification system. PMID- 10175409 TI - A conception of a support system for optimising the organisation of nursing staff from the viewpoint of the nursing care needs structure. AB - Methods of allocating nursing staff in hospitals should be established that improve the "sufficiency rate" of existing care needs for nursing in patients. The conception of a support system for the optimisation of organising nursing staff was proposed so that the degree of meeting care needs could be maximised. In this study, the structure of care needs was defined by sampling information related to eight factors. A basic framework was developed for a support system for the optimisation of organising nursing staff by using data based on (1) rate of satisfying eight selected criteria, (2) condition factors that can affect this rate, and (3) organising nursing. The possible usage of this support system is also discussed in this paper. PMID- 10175410 TI - Exploring nursing knowledge by using digital photography. AB - Clinical decision making is in part, an interpretation of visual cues manifested by the patient. The colour of a patient's skin, his or her degree of mobility, or the posture adopted by the patient are examples. Clinicians compare presenting cues with previous representations of those cues to determine significant change. Literature suggests that the sources of data for this comparison are; the long term memory of the clinician, verbal interaction with colleagues and patient, and professional documentation. This paper describes findings of a study based on the assertion that contemporary documentation systems fail to provide sufficient information for nurses to make accurate comparisons between currently presenting visual cues and cues from the past. It is argued that interpretation of visual cues is primarily a visual/spatial activity (Gardiner, 1983) and, as current documentation systems rely on language they cater for linguistic rather than the visual/spatial activities. For example, subtle shades of red exhibited by the skin surrounding a surgical wound are reduced to the word "inflamed". Digital photography was explored as a documentation format that addressed this deficit. Forty nine nurse clinicians were asked to assess and plan management for one of four external sternotomy wound. Subjects were given access to a range of documentation formats including sequential daily wound photographs. Findings demonstrated that nurse clinicians are willing to use digital photographs and there is beginning evidence that photographic documentation may decrease the differences between novice and expert when comparing visual cues. PMID- 10175411 TI - 'Shared care' and computer assistance in glaucoma management. AB - Primary open angle glaucoma afflicts 1-2% of people over 50 years of age. The diagnosis relies on a number of examinations, many of them performed by ophthalmic nurses, and the care of glaucoma patients has become one of their main tasks. A knowledge-based system for decision support in glaucoma management has been developed and validated. The aim of the current study is to evaluate the influence of computerised decision support on a 'shared care' organisation for the management of glaucoma patients. PMID- 10175412 TI - A knowledge-based decision support system for prevention and treatment of pressure ulcers. AB - As part of a research project intended to provide problem-based knowledge to clinicians at the point of care, we have developed a system that supports the nurse's development of patient-specific, guideline-based treatment plans for patients who have pressure ulcers or are at risk for developing them. The system captures coded data about assessment, diagnosis and interventions using a point and-click interface. Knowledge is accessible to the user via: 1) hypertext links from the data entry screens; 2) explicit entry into an indexed version of the guideline; 3) imbedded knowledge-based rules that critique the diagnosis and offer guidance for treatment; and 4) explicit entry into interactive algorithms. The system has been implemented experimentally on one care unit at our hospital, where its impact will be assessed in comparison with a control unit. Data on 113 patients were entered during the 21-week experimental period. The system is being evaluated for its instructional adequacy, its impact on clinicians' decision making and knowledge, and on processes of care. Users' perceptions of the system are also being evaluated. Dissemination issues in the context of today's health care environment are addressed. PMID- 10175413 TI - Decision support for assessing patient preferences for geriatric care. AB - This paper describes a pilot study that tested the strategy and feasibility of a decision support system (DSS) that assists nurses in integrating patients' preferences for self-care functions in the assessment of elderly patients. 12 elderly clients and a clinical nurse specialist (CNS) participated in this study. The CNS reported the assessment strategy to be very helpful to learn about patients' strengths and weaknesses in self-care functioning. Clients reported that being asked about their preferences helped them clarify their goals, and created a shared understanding between nurse and patient. This pilot study also suggests that patients have a clear understanding of their predominant problems and can discriminate between their preferences. It further supports previous literature that there is a substantial difference in values patients place on clinical outcomes. This highlights the importance of an individual approach to patient care and the usefulness of DSS to assist nurses in eliciting patient preferences. PMID- 10175414 TI - Computerized decision support systems: implications for practice. AB - The informatics literature variously defines Computerized Decision Support (CDS) systems. These definitions are sometimes narrow and sometime broad, leading to occasional confusion in terminology. For purposes of this paper, a broad definition that enjoys some professional consensus has been adapted from Langston and colleagues: CDS systems encompass any computer software employing a knowledge base (facts and/or rules) designed for use by a clinician involved in patient care, as a direct aid to clinical decision-making. PMID- 10175415 TI - Thinking in nursing practice. AB - Despite the fairly extensive body of research describing nurses' thinking in practice, our understanding of this phenomenon remains incomplete. Until we have a full description of nurses' thinking, the component of our practice that is an exercise in clinical judgment will be less precise and scientific. This descriptive study utilized think aloud method to identify and describe the thinking strategies that nurses use in practice. Findings from this study improve our understanding of nurses' thinking in practice and provide information that can facilitate the development of decision support systems to assist nurses in their practice. PMID- 10175416 TI - Nursing documentation in the computer-based patient record. AB - This paper describes the INFORMM NIS (Information Network for On-line Retrieval & Medical Management Nursing Information System) charting system developed by the Departments of Nursing and Information Systems at the University of Iowa Hospitals and Clinics (UIHC). The documentation system features automated work lists, defaulted charting responses, decision support, automatic computations, chart forms and reports, and graphical displays of clinical data. The impact of the on-line charting system has been demonstrated by content standardization with Nursing Interventions Classification (NIC), improved standards compliance, increased efficiency, enhanced timeliness, expanded accessibility, and an augmented data archive. PMID- 10175417 TI - The patient care process: pathways in transition. AB - Developing patient care processes to include multiple activities of care, the continuum of care, primary diagnoses and co-morbid conditions, risk factors and outcomes of care improves patient care management in general. The Patient Care Process (PCP) is one initiative utilized to support standards of care and optimal resource utilization in our organization. This paper will focus on the issues and opportunities identified with the use of patient care plans, particularly the uniqueness of a new level of outcomes monitoring and evaluation. PMID- 10175418 TI - Nursing process redesign with the implementation of a computer based patient record in the ambulatory setting. AB - Increasingly, health care organizations are considering moving to Computer Based Patient Records (CPR), a trend driven by managed care and capitated payments. Central to the change is recognition of the need for community based and clinically relevant information systems that span the care continuum. Thus, Aurora Health Care chose to start their CPR effort in the ambulatory setting as the focus of health care delivery in the evolving paradigm. This paper describes computerization of the ambulatory record in a 45 physician clinic and associated workflow redesign. Months were spent in the processes of: current state documentation and analysis, future state design, detail system design, and workflow reengineering. There was substantial impact on nursing care delivery with computer system interaction at the point of care in the exam room. Access to clinically relevant longitudinal data was found key to the implementation and evaluation of Care Management strategies. PMID- 10175419 TI - Nursing process documentation--effects on workload and quality when using a computer program and a key word model for nursing documentation. AB - In 1993 the federation of County Councils commissioned Spri to carry out a broadly based study aimed at investigating individualised patient care as described in the notes kept at various care units using computers to support documentation of the nursing process. The wards involved in the study represented various disciplines such as surgery, obstetrics, internal medicine, geriatrics and psychiatry. During the study period certain measures designed to improve the documentation were implemented i.e. a special computer program and structured nursing documentation following the VIPS-model. Interviews with staff at the units confirm that the introduction of computers, in combination with the structure of the VIPS-model and training in nursing documentation, has made changes possible to working procedures and brought greater goal orientation to the activity of care. The overall examination of the nursing entries in the patients' notes showed that the language has improved. The entries were to a greater extent expressed clearly and distinctly. PMID- 10175420 TI - Functional requirements for IT support for nursing information systems integrated in electronic healthcare record systems (EHCRS). AB - This paper focuses on the functional requirements that support the activities performed by healthcare professionals, i.e. functions performed in the healthcare enterprise which result in requirements for IT support. The emphasis is on IT support for nursing activities as a part of general IT support for the whole care process realized through EHCRS. We argue that a standard for functionality (including user interface and functions supporting information security) would benefit manufacturers by giving them a well-defined target to aim for and give purchasers and users of EHCRS a foundation on which to base their specifications. Quality would be enhanced by ensuring that all EHCRS contained a standard core functionality and were compliant with basic structural requirements. To get a comprehensive list of requirements to ensure that EHCRS with IT support for nursing activities serve as an aid to the process of care it is essential that nurses get directly involved in the process of defining the requirements. In this paper we also give some examples of requirements that are candidates for standardisation. PMID- 10175421 TI - Monitoring and evaluating benefits of an automated patient care. AB - "Information Management", is key to the successful reengineering of our health care delivery system. There is a need to change the hospital system, in order to contain costs and find ways to constantly evaluate and improve the services that we provide to our customers. Information systems that support complete, integrated multidisciplinary care management, seem to be the tool that will support decision making in regards to future changes needed in the health care industry. The task of justifying information systems and information technology expenditures is an extremely complex process. At the Welland Hospital, we embarked on a formal benefits realization process with the assistance of an independent consultant company prior to the purchase and acquisition of CareVISION, an integrated electronic patient care record. PMID- 10175422 TI - Information technology in nursing: a project examining educational applications of the Internet and World Wide Web. AB - Developments in Information Technology are requiring nurses to not only access complex information but also manipulate it within an information rich environment to benefit patient care. Within such an environment, the role played by the Internet and more specifically, the World Wide Web (WWW or web), will become increasingly important to health care providers. Nurse academics within the School of Nursing, Monash University, have adopted an innovative and integrated approach to Internet technologies as part of information processing and inquiry in nursing. This approach is aimed at enhancing the teaching/learning process by lending additional richness to the learning environment. Initial feedback from this project supports the assumption that information technology has an important, and increasingly prominent, role to play within nursing education and clinical practice. Although very much at an embryonic stage, the project has been well received by students and staff alike. This descriptive paper will attempt to highlight some of the benefits of the project for nurse academics and students, provide an overview of Internet and WWW applications and suggest some practical applications of these technologies in nurse education. PMID- 10175423 TI - Using the Internet as a teaching strategy: informatics at work. AB - Development of the World Wide provides educators with an enormous library of teaching tools. The purpose of this presentation is to share the results of introducing over 60 graduate students to use e-mail, internet mailing lists, computer conferences, and the World Wide Web as teaching strategies. Data were collected from students through questions and Electronic Communication Logs. Response of the students was categorized into 6 phases: 1) fear and trepidation, 2) excitement, "this is great!", 3) "help, my mail box is full", 4) venturing forth independently, 5) this is easy, and 6) accepting the internet as a useful tool. Identification of these phases provided a basis for developing teaching strategies specific to internet uses. Feedback between students and instructor increased and was far more timely than occurs in the classroom setting. The student responses to these experiences were overwhelmingly positive. PMID- 10175424 TI - Self-study program on HTML browser--application to Clinical Nursing General Remarks Course. AB - We created a self-study program using HTML browser on the Clinical Nursing General Remarks Course, Eighty-three students each selected a published book on a personal history (written personal reflections from individuals who had undergone medical treatment and hospitalization), read it and submitted reports of their impressions of the histories. Their reports were arranged from a nursing perspective and entered on the home page of our college using HTML browser. We intended that the students would become more interested in reading of the personal histories, and that they would acquire new self-study skills and increase their interest in Internet through use of our program. In addition, we hoped that this program would encourage positive communication and mutual sharing of information. The students were able to easily refer to a personal history according to their interest from a nursing perspective. Therefore this program realized the mutual learning among students and other users. PMID- 10175425 TI - The Nightingale Tracker: information technology for community nursing education. AB - The international health care delivery system is evolving to include an increased emphasis on community care and automated clinical information and communication systems. These trends are dramatically affecting nursing education in the U.S. as faculty consider the strategies needed to communicate with their students at multiple clinical sites, and to educate students to fulfill their changing practice roles. In response to these changes, FITNE, Inc. is using triangulated research methods to develop an information technology system for use in community nursing education. Named the Nightingale Tracker, this system will: (1) facilitate real time voice and data distance communication between students at the point of care and their instructors, and (2) electronically process clinical data related to community nursing education visits. The Nightingale Tracker was pilot tested in 1996; findings will be used to plan a national beta test. Project completion is scheduled for late 1997. PMID- 10175426 TI - Innovation in nursing education: development of computer-assisted thinking. AB - In order to enhance students' active thinking, faculty members at International University of Health and Welfare developed the CAT (Computer Assisted Thinking) program. The CAT program is different from CAI (Computer Assisted Instruction), which mainly asks users to choose correct answers. Instead, the CAT program asks users to type in short sentences. There are two functions in the CAT program: one is to keep the students' action log each time they use the program and the other is to serve as medical dictionary. An analysis of the action log revealed that the students demonstrated little skill in inferential thinking. Their observations were very concrete. In order to help the students to develop their abstract thinking skills, we need to review our curriculum. PMID- 10175427 TI - Database issues in object-oriented clinical information systems design. AB - A clinical information system (CIS) prototype was created from an Object-Oriented (OO) design. We experienced considerable difficulties when implementing the OO data model in a relational database management system (RDBMS), including lack of semantic power and support for complex objects, inability to encapsulate object methods, and performance degradation due to extensive join operations. This paper reflects on the experiences of a CIS research project and explores issues related to the use of RDBMS and Object-Oriented Database Management Systems (OODBMS) in CIS design and development. PMID- 10175428 TI - Data mining: a strategy for knowledge development and structure in nursing practice. AB - Data mining is an emerging technique used more widely by the business world than the world of nursing and health care. However, this strategy can be helpful for improving the quality of decision making by clinicians and health care administrators. This paper addresses the concepts and techniques of data mining that could be useful for practicing nurses as well as nurse administrators. Data mining can be an important tool for the development of nursing knowledge and knowledge structures. An example of the use of the technique in an inpatient setting is provided and insights from the process are discussed. PMID- 10175429 TI - Facilitating higher order thinking skills in nurse education: a prototype database for teaching wound assessment and management skills. AB - The introduction of university based nurse education in Australia has nursing students spending more time in the classroom and less time in clinical settings. This decrease in clinical exposure may result in reduced opportunities for students to develop pertinent patient assessment and management skills. This is particularly true of skills required for effective wound assessment and management. Computerised databases offer an innovative method of teaching or refining these skills in a cost and time-effective manner without risk to patients or students. Such technology can also provide important grounding in data identification, hypothesis testing, problem solving and clinical decision making skills. This paper explores the underlying pedagogical principles of database use and describes the development of the prototype closed database, DECUBITUS. The prototype database included the following data fields; physical assessment, clinical diagnosis, risk assessment, wound assessment and treatment modality. The introduction of more sophisticated databases will permit the storage of visual images of actual wounds thus providing an additional dimension to the teaching of wound assessment and management. PMID- 10175430 TI - New challenges for nursing informatics. AB - Long a leader in health informatics, nursing faces new challenges. The full and effective use of technology requires an understanding of cognitive processes and organizational behavior. Nursing can play a key role in addressing aims supportive of a new vision of health informatics. The evolving paradigm for knowledge transfer will give rise to new educational models and new institutional entities which will nurture learning and relearning. PMID- 10175431 TI - Implementation of standardized nursing languages (NIC, NOC) in on-line care planning and documentation. AB - At the University of Iowa Hospitals and Clinics (UIHC), the Standardized Nursing Languages (SNLs) of Nursing Interventions Classification (NIC) and Nursing sensitive Outcomes Classification (NOC) are being implemented in on-line care planning and documentation. NIC and NOC are being integrated in the INFORMM NIS (Information Network For Retrieval & Medical Management Nursing Information System). The implementation process for SNLs includes six components: objectives, programming, database content, education, utilization, and evaluation. This process has been used successfully in NIC implementation and will be applied in NOC field testing. PMID- 10175432 TI - A comparative study of nursing diagnosis systems using neural networks and expert systems. AB - With the growing need in the field, the application of computers in nursing has been frequently studied with the aim of improving the quality of nursing care in Korea. However, the development of useful clinical programs has not received adequate attention. The aim of this study is to compare two Nursing Diagnosis Systems-one involving a Neural Network and one involving an Expert System. The simulated output of each Nursing Diagnosis System was compared with the judgement of the researcher and of two professors of nursing. The misdiagnosis rate of the Nursing Diagnosis System using the Neural Network was nine percent, while the Nursing Diagnosis System using Expert System showed consistency with the three experts in every aspect. The result of this study demonstrated the feasibility of the use of an expert system based Nursing Diagnosis System as another nursing tool. PMID- 10175433 TI - The learning collaboratory: a knowledge-building environment for nursing education. AB - As we approach the 21st century, higher education must face many challenges. One challenge is the transformation of education from a teacher-focused to a learner centered model. To accomplish this learner-centered model, several learning strategies are proposed to create socially relevant, distributed, and modular courses. This project creates a Learning Collaboratory whose overall goals are to build a knowledge-building environment for students to learn about nursing and to serve as a future global model for nursing education and interdisciplinary coursework. To begin this transformation, the research sequence for the graduate program was selected as the first pilot. This paper describes the analysis, redesign and implementation of the existing research courses during the 1996-1997 academic year. PMID- 10175434 TI - Training strategy for nursing staff in using computers in hospitals--a Malaysian viewpoint. AB - The ability of hospitals to fulfil their roles--of information processing and dissemination, and of quality patient care provider--is influenced by the availability of supporting information systems. Using computers in wards, which is a change process, introduces new working practices accompanied by attitudinal and knowledge alterations in the users. This paper suggests that as a practical approach users need to be consulted and assessed prior to the introduction of computers in their work places. A questionnaire survey, the main purpose of which was to determine the potential users' responses and to measure their computer competencies, was sent to 183 nursing staff in several hospitals. Results show that the respondents have slightly positive attitudes towards computers even though 85% of them were computer illiterate. A training strategy is needed to increase competencies and to develop more favourable attitudes, which can be monitored using four training indicators. PMID- 10175435 TI - Education and training in health informatics. The IT EDUCTRA Project. AB - In this contribution the AIM project EDUCTRA and the Telematics Applications Programme IT-EDUCTRA will be described. EDUCTRA has as its aim to investigate what gaps in knowledge health professionals have about health informatics and to provide educational material to fill these gaps. It was believed that a basic understanding of health informatics was present and that educational material should only cover the knowledge necessary for appreciating the products of the AIM programme. It appeared that the knowledge with respect to health informatics was deplorable. Guidelines for curricula were developed to change the situation. In IT-EDUCTRA the necessary course material will be developed. PMID- 10175436 TI - Expanding nursing informatics knowledge through cirriculum development: a collaborative faculty practice model. AB - In 1992 an informatics faculty practice model was implemented between a major teaching hospital and a Melbourne university. This arrangement was characterised by the provision of a mutually beneficial exchange of experiences and information between the participant clinician and academic. By using such a conjoint faculty practice model it has been found that many informatics problems can be addressed. Over the past three years the model has been evaluated through a longitudinal study. Investigations have included monitoring curriculum change, program evaluation and evaluation of participant professional outcomes. Survey results are presented and the specific elements that have made this model successful are described. PMID- 10175437 TI - Conquering technophobia: preparing faculty for today. AB - The constantly changing world of technology creates excitement and an obligation for faculty of schools of nursing to address computer literacy in the curricula at all levels. The initial step in the process of meeting the goals was to assist the faculty in becoming computer literate so that they could foster and encourage the same in the students. The implementation of The Cure for Technophobia included basic and advanced computer skills designed to assist the faculty in becoming comfortable and competent computer users. The applications addressed included: introduction to windows, electronic mail, word processing, presentation and database applications, library on-line searches of literature databases, introduction to internet browsers and a computerized testing program. Efforts were made to overcome barriers to computer literacy and promote the learning process. Familiar, competent, computer literate individuals were used to conduct the classes to accomplish this goal. PMID- 10175438 TI - Important considerations about nursing intelligence and information systems. AB - This discussion focuses on the importance of nursing intelligence to the organisation, and the nurses' role in gathering and utilising such intelligence. Deliberations with professional colleagues suggest that intelligence can only be utilised fully when the information systems are developed in such a way as to meet the needs of the people who manage and provide nursing care at the consumer level; that is, the activity of nursing itself. If accommodation is made for the recycling of nursing intelligence, there would be a support and furtherance of 'professional' intelligence. Two main issues emerge: how can nurses support the needs of management to optimise intelligence input? how can organisations optimise the contribution of nurses to its information processes and interpretation of intelligence? The expansion of this 'professional' intelligence would promote a generation of constantly reviewed data, offering a quality approach to nursing activities and an organisation's intelligence system. PMID- 10175439 TI - E-discourse and continuing professional education: the fusion of nursing knowledge and informatics to close the theory-practice gap. AB - Several modes of electronic discourse (e-discourse) are currently used by nurses, and have potential for meeting their formal and informal continuing professional education (CPE) needs. After defining e-discourse in relation to computer mediated communications (CMC), the author outlines some recent examples of it use. There follows discussion of the argument that, through e-discourse, nurses can reflect on their practice, incorporating and developing theory and meet their CPE needs. Some important constraining issues are presented, and the author suggests that, for many nurses, e-discourse will have more educational application than multimedia in the foreseeable future. The paper is set within the context of UK requirements, but the issues raised are pertinent to nurses around the world, particularly where CPE is incorporated within the re registration cycle. PMID- 10175440 TI - Nurses' MEDLINE usage and research utilization. AB - This exploratory study in the field of nursing informatics examined the usage of information technology, namely on-line access to MEDLINE in clinical setting, by a convenience sample of 121 nurses from a large university hospital. A descriptive correlational design was used. Guided by the conceptual frameword of Nurse-Computer Interaction and based on variables set forth in the Theory of Reasoned Action, the study tested hypotheses regarding attitudinal and normative influences on reported use of on-line bibliographic retrieval systems. It was also hypothesized that using MEDLINE coild increase and improve nurses' adoption of nursing research findings. Multiple regression analyses were conducted on nurses' responses to survey questions to test hypotheses-that those who register more favorable attitudes towards nursing research would have a higher reported use of the MEDLINE system. Findings were significant and supported the hypothesis that nurses' attitudes towards research influenced MEDLINE usage. Findings also indicated that MEDLINE usage was significantly related to nurses' research utilization. PMID- 10175441 TI - A comparison of network use by academic and clinical sites. PMID- 10175442 TI - Nurses' perceptions of the impact of a computerized information system on a critical care unit. AB - Critical care nurses work in complex environments and encounter a vast amount of information daily. To learn how a computerized information system (CIS) impacted nursing practice on a critical care unit, this foundational research was conducted before and after implementation of a CIS. Qualitative methods using interviews and open ended questions were employed. Results showed that nurses felt positive overall about the implementation of a bedside CIS. Nurses liked the readability of the information and having the CIS near the bedside. They disliked the periodic slowness or downtime. Broad themes of reflection, questioning and action emerged from the content analysis. The themes were in accord with the theoretical framework that guided the study. Recommendations for future research included exploring nursing medication documentation, use of hand held devices, and having resource databases within the CIS. PMID- 10175443 TI - Implementation of a patient management system in a children's hospital. AB - Implementing systems to the clinical areas within the hospital setting, is increasing as rapidly as technology is changing. This paper describes the requirements and problems identified during an implementation of a patient management system to a major Paediatric Hospital. The system implemented was developed within the I.S. Department of the hospital and provides a high degree of functionality and ease of use for clinical and clerical staff. It also offers case-based interfaces to clinical and business management systems outside the patient care setting. PMID- 10175444 TI - Advances in digital video for electronic media. AB - From media's early days of film strips and records, to today's multimedia CD ROMs, nurses have embraced educational tools. Today, the capabilities of these tools have placed a tremendous demand for providing information any time, any where. This has led to increasing digitization of sights and sounds. Once digitized, this information can travel over information highways made up of telephone lines, fiberoptic cables, microwaves and satellites, or it can be stored on magnetic and optical media. Technological advances have made it possible for computer users to create, store and retrieve high quality digital still and moving video and audio for inclusion in electronic media. Methods for digitizing include capturing and converting the information with cameras, scanners and capture boards. Digital video compression/decompression (codec) standards vary in quality. Potential uses of digital video abound including video on demand, videoconferencing, distance learning, telemedicine, on-line education and computer-based training. Examples illustrating the differences in digital video formats will be shown during the presentation. PMID- 10175445 TI - Video conferencing in group training of psychiatric nurses. AB - Video conferencing (VC) technology transfers synchronous audio and video signals via standard telecommunication lines. VC has become a useful communication device in the mental health care sector in Norway, particularly in the northern countries. Training and supervision is considered one of the areas where VC has great potential. This study followed a group of nurses who used VC in a training program every other week over a period of six months. The group consisted of seven nurses (two supervisors and five supervisees). Data was collected from four of the VC sessions. User satisfaction and judgements on the effect of VC on critical aspects of the supervision were evaluated through questionnaires. In addition, a closing group interview was held to sum up qualitative experiences and attitudes. Results indicate that VC may indeed be an acceptable tool in group supervision. Participants reported that they were able to establish a climate for communicating on an emotional and personal level, as well as provide necessary feedback and psychological support. PMID- 10175446 TI - Development of a CAI program entitled 'Introduction to Nursing Process'. Requirement for nursing education in Japan. AB - A new teaching strategy is required in nursing education in Japan. A multimedia CAI (Computer Assisted Instruction) program entitled "Introduction to Nursing Process." was developed. The aim of this study was to examine whether CAI could assist students' knowledge acquisition, and increase their motivation and readiness to learn clinical nursing practice. This study involved the process of developing CAI and a pilot study for measuring and evaluating the CAI program. Results demonstrate that CAI can increase students' understanding about the nursing process, enhance their motivation to learn, and provide realistic situations describing the concept of nursing the process. PMID- 10175447 TI - A simulation program that teaches clinical decision making in nursing. AB - The aim of this project is to produce a multimedia computer simulation program, to be used in the training of clinical decision making with nursing students in Swedish schools of nursing. The program is based on a number of clinical scenes filmed in a ward and dealing with the postoperative care of a patient who has undergone reconstruction of the crucial ligament. The student's task is to assess the need for care for a newly postoperative patient and to plan the care for the first 24 hours. Special emphasis is given to pain assessment, pain relief and drug administration. PMID- 10175448 TI - Transforming resource utilization data into information. AB - In view of increasing financial pressures, resource utilization management and review have become a primary focus for many healthcare organizations. Utilization strategies have been supported and enhanced by information technologies in many organizations. This paper describes the development and implementation of an on line application for resource utilization review. Developed for use by clinicians and case managers, access to on-line utilization data has markedly influenced strategic clinical and financial decisions. Recommendations for future use and revisions are provided. PMID- 10175449 TI - Effects of a nursing information system in 5 Dutch hospitals. AB - Two studies of the effects of components of the integrated Nursing Information System VISION, involving five Dutch hospitals, were concluded in 1996. This paper summarises these studies and their results. The studies assessed effects on workload, quality of co-ordination, job satisfaction, patient satisfaction and quality of information supply. In both studies a quasi-experimental approach was followed. The results show significant positive effects with respect to quality of co-ordination, nurses job satisfaction and patient satisfaction. Workload measurements revealed a shift in the nurses' activities, but no change in the amount of time spent on patient care. On the basis of the positive results, 4 of the 5 hospitals have decided to extend the use of the system. PMID- 10175450 TI - An information processing system for scheduling of nurse assignments by head nurses. AB - Implementation of the nurse scheduling task is a difficult problem for head nurses because it is a multi-period, multi-criteria decision-making problem with the condition that it meet the requirements of the patients, the hospital administration, and the staff nurses. There have been many research studies done using the following methods: cyclic method, mathematical modelling method, heuristic method and expert system approach. Without a theoretical review of head nurses' problem-solving processes, the limitations of inflexible computational modelling in comparison to the complex, real problem-solving process must be recognised. This research applies the cognitive scientific approach which uses protocol analysis and computer simulation. It will be used as basic data for a decision support system which will be constructed as a result of protocol analysis (collect data, analyse the head nurses' problem-solving process) and cognitive process simulation. Research in phase II will develop the following research lists: first; construction of databases including each nurse's major attributes as a data field, second; development of schedule optimising modules, and third; development of user interface for communication between head nurses and staff nurses using the system. PMID- 10175451 TI - Development of a computerized patient classification and staffing system. AB - Korean health care agencies are trying to find ways to survive amid strong competition within the health care industry and pressure to open health care market from abroad. One way to survive is to improve health care quality at present or reduced expenditure. Nursing is the largest manpower in health care agencies and plays an important role in determining quality of care through direct interaction with patients., thus, nursing manpower management is an essential part of survival strategies. If the nursing department can adapt to dynamic changes in the health care environment in terms of quality and quantity of service needed, health care agencies' quality and efficient management will be achieved at the same time. A computerized prototype patient classification and nursing staffing system was developed using Microsoft Visual Basic 3.0. This system allows a user to use GUI(Graphic User Interface) with an icon and a mouse. By applying this computerized system to clinical practice, nursing managers will receive accurate information regarding nursing manpower management at nursing unit level as well as departmental levels. Then nursing managers can achieve effective nursing manpower management, which will improve nursing care by allocating more nursing staff time to direct patient care. PMID- 10175452 TI - Workload measurement in the ICU. PMID- 10175453 TI - The ComputerLink projects: a decade of experience. AB - Telecommunications technology provides a pathway for nurses to reach patients and their family caregivers. The ComputerLink, an experimental computer network, enabled home-bound persons to access information, communications, and decision support services from their homes. Persons naive to computers can and will use telecommunications to maintain contact with peers and professionals. While participants in experimental networks used communication services most often, the access to relevant health information in a timely and convenient fashion may contribute more to the positive health benefits. Nursing interventions need to be tailored to capitalize on the unique features of computer network. The timing, cadence and content of interpersonal interactions must be modified to account for lags in the transmission of messages. Strategies for interpreting written text, which lacks the aural cues found in spoken speech, must be developed. PMID- 10175454 TI - Reducing nurses'. Workload using a computerized nursing support system linked to the hospital information system. AB - A computerised nursing support system (CNSS) linked to the hospital information system (HIS) was developed and has been in use for one year, in order to reduce the workload of nurses. CNSS consists of (1) a hand held computer for each nurse (2) desk-top computers in the nurses' station and doctors' rooms (3) a data server (4) an interface with the main hospital information system. Nurses enter vital signs, food intake and other information about the patients into the hand held computer at the bed-side. The information is then sent automatically to the CNSS data server, which also receives patients' details (prescribed medicines etc.) from the HIS. Nurses and doctors can see all the information on the desk top and hand held computers. This system was introduced in May 1995 into a university hospital ward with 40 beds. A questionnaire was completed by 23 nurses before and after the introduction of CNSS. The mean time required to post vital data was significantly reduced from 121 seconds to 54 seconds (p < 0.01). After three months 30% of nurses felt CNSS had reduced their workload, while 30% felt it had complicated their work; after five months 70% noted a reduction and 0% reported that CNSS had made their work more complex. The study therefore concludes that the interface between a computerised nursing support system and the hospital information system reduced the workload of nurses. PMID- 10175455 TI - Nursing informatics in Germany: hospitals on the track. PMID- 10175456 TI - The International Classification for Nursing Practice: a progress report. AB - This paper will review and report progress on the development of the International Classification for Nursing Practice. This project, begun in 1990 by the International Council of Nurses, aims to develop a standardised vocabulary and classification of nursing phenomena (nursing diagnoses), nursing interventions, and nursing outcomes which can be used in both electronic and paper records to describe and compare nursing practice across clinical settings. An Alpha Version of the Classification of Nursing Phenomena and Nursing Interventions was released for further development and field testing in 1996 and an outline for a Classification of Nursing Outcomes in 1997. Nurses around the world, and other classification experts, have been invited to participate in the development of the Beta Version which it is hoped will be ready for release in 1999. PMID- 10175457 TI - Developing informatics as a discipline. AB - Informatics is developing in all of the disciplines related to healthcare. There are many aspects to informatics development which frequently appear to be unrelated and to lack cohesion. This paper builds on the development of a model for nursing informatics and proposes how the components of that model can interact to provide an outline for the development of informatics as a discipline. A understanding of the disciple allows us to organize the existing research and more importantly to understand the areas where research is lacking as the discipline is evolving. PMID- 10175458 TI - Data extraction and archiving for nursing research using a bedside clinical information system. AB - Institution wide use of an intensive care bedside information system creates the opportunity to make available vast amounts of clinical data to support research and quality improvement activities. Acting on this opportunity has required the development of several innovative approaches to transform this raw data into usable information. The process described herein uses commercially available software and hardware tools to extract on a daily basis, process and archive data for 7 intensive care units. Once this procedure is complete, attention is turned to using individual and combinations of data elements to build a higher level of information that more directly relates to the kinds of inquiries that help to address questions of outcome, and care quality. PMID- 10175459 TI - Nursing intervention intensity and focus: indicators of process for outcomes studies. AB - Outcomes research has become increasingly important in the current health care environment and for informatics research efforts. Recent efforts in automating clinical data for use in outcomes studies has focused attention on the need to represent the processes of care in the classic structure-process-outcome models of care. This paper reports on use of the Nursing Intervention Lexicon and Taxonomy for classifying interventions to characterize two process of care variables: intervention intensity and intervention focus. Study results demonstrate that these variables are descriptive and provide promise for describing processes of nursing care for describing clinical care. PMID- 10175460 TI - Development of a computerized database for a nursing quality management program. AB - There has been little study on how nurse managers collect, store, process and retrieve quality management data, yet nearly every nursing department has an existing program to provide these functions. We investigated our current paper based system and found several deficiencies. Guided by structured interviews, task analysis, and focus groups we developed a networked computerized quality management database to provide more timely data reporting and consistency of analysis. This paper describes the development and implementation of the system with discussion on how it will be evaluated in the future. PMID- 10175461 TI - Design & implementation of an automated questionnaire. AB - This paper describes a system which allows the patient to answer a structured questionnaire in private, at their own speed and without pressure using a touch screen personal computer. A clinical report is generated immediately and used to help guide a clinician in a face to face consultation with the patient. Trials in a clinical setting have shown a positive response by both patients and clinicians. PMID- 10175462 TI - Patient outcomes and nurses' classification data. AB - The patient classifications done by nurses for all adult patients (n = 15,500) discharged from an urban teaching hospital in one year were retrieved and analyzed by discharge status. Classification results were summarized by physical functional, psychological-social, and dependence categories and were associated with discharge disposition; patients discharged home were less dependent than others discharged to nursing homes or those who died in the hospital. Diagnosis related group (DRG) payment weights were somewhat independent of the patient classification scores and were not associated with adverse outcomes. PMID- 10175463 TI - Health-related outcomes management: moving forward standing still. AB - In response to increasing economic and political pressures, administrators and other health-care professionals have become increasingly concerned with health related outcomes management. The categories of outcomes in health care have been identified within administrative, economic, and clinical realms. Great emphasis has been placed in the literature on the importance of measuring and using outcome data for decision making. Despite this emphasis, little progress has been made in either the science or the art of outcomes management. Furthermore, integrating the art and science into systematic processes for outcomes management has been done with limited success. This paper focuses on the state of outcome concepts, measurement, collection, and evaluation. Strategies will be offered to move the conceptualization and operationalization of outcomes management forward. PMID- 10175464 TI - Keys to success. Winning principles to guide you, your CEOs, and your board. PMID- 10175466 TI - CDOs and job stress. PMID- 10175465 TI - Riding the conversion wave. How one development officer helped his institution become a 'virtual hospital'. PMID- 10175467 TI - Lessons in H.O.P.E. Lessons, too, on how you can lead your organization's healthy community agenda. PMID- 10175468 TI - The strategic enlistment of board members. Finding volunteers who fit the new board model. PMID- 10175469 TI - AHP's strategic plan sets the stage. PMID- 10175470 TI - Ethical pressure points. PMID- 10175471 TI - Spreading the word. Grassroots infection education reaches out to workers. PMID- 10175472 TI - Smooth move. CS departments adapt to outbased customers. PMID- 10175473 TI - Firing line. How to terminate employees without landing in court. PMID- 10175474 TI - Quick scan ... bar codes deliver the goods. PMID- 10175475 TI - The 'perfect' pouch? It's not open and shut. PMID- 10175477 TI - Safety first. Take these actions to meet both OSHA and JCAHO rules. PMID- 10175476 TI - Nuts and volts. Searching for ways to zap EMI (electromagnetic interference) effects. PMID- 10175478 TI - Bringing patient preferences into decisionmaking. PMID- 10175479 TI - Graphing health status can help pinpoint patient problems. AB - Diagnosing the cause of a patient's complaints by reviewing physical symptoms alone may overlook indicators of psychological and emotional problems that need to be considered. A health status assessment (see "Health Status Assessment--A Vital Sign for Planning Patient Therapy," pages 2-9) using the Health Status Questionnaire enables a clinician to rapidly sort through the bases of presenting symptoms in physical and psychological terms. After a patient fills out the form, the data are input into a computer, which translates the results into a graph. The physician and patient then use the graph to review the results and develop a plan of therapy. The scenario below demonstrates use of the graph by Northfield, Minn., family practitioner Donald Lum, M.D., along with a standardized, scripted interpretation-and-questions process developed by Atlanta practitioner Dwana Bush, M.D., and Dr. Lum to plan patient therapy. PMID- 10175480 TI - Carve-out behavioral MCOs look to performance standards, accreditation to counter charges of poor quality. PMID- 10175481 TI - Health status assessment--a vital sign for planning patient therapy. AB - To better understand patient problems, some physicians are gathering and evaluating data on patients' perceptions of their health and emotional strengths. The tool--the SF-36 or Health Status Questionnaire--can be incorporated into practice with a small investment in technology and a few minutes with the patient. PMID- 10175482 TI - Medical errors: common and costly. PMID- 10175483 TI - Are gag clauses real? PMID- 10175484 TI - Health care woes are long-time companions. PMID- 10175485 TI - The power of words. Southern California Edison case study. PMID- 10175486 TI - Money is no obstacle to end-of-life care. PMID- 10175488 TI - The new quality teams. PMID- 10175487 TI - What's holding back MSAs (medical savings accounts)? PMID- 10175489 TI - Downsizing workplace stress. PMID- 10175490 TI - Adult immunization: shot in the (economic) arm. PMID- 10175491 TI - Blowing the whistle on health care fraud. PMID- 10175492 TI - Small group reform, public health, consumer laws. PMID- 10175493 TI - Data watch. Retiree coverage shrinks. PMID- 10175494 TI - Battle over regulation ahead. PMID- 10175495 TI - Case study: Southern Wine & Spirits. The employer as benefits connoisseur. PMID- 10175496 TI - Managed care's new ethics. PMID- 10175497 TI - What's up on the Web. PMID- 10175498 TI - Are employers missing the signs? Our 1997 executive opinion poll. PMID- 10175499 TI - When joints--and costs--become inflamed. PMID- 10175501 TI - Data watch. Gearing up for parity. PMID- 10175500 TI - Accountability begins with you. PMID- 10175502 TI - Miss America, AIDS warrior. PMID- 10175504 TI - How health plans stack up. PMID- 10175503 TI - How to choose an HMO. PMID- 10175505 TI - Sources of health insurance and characteristics of the uninsured: analysis of the March 1997 Current Population Survey. AB - This Issue Brief provides summary data on the insured and uninsured populations in the nation and in each state. It discusses the characteristics most closely related to individuals' health insurance status. Based on EBRI analysis of the March 1997 Current Population Survey, it represents 1996 data--the most recent data available. In 1996, 82.3 percent of nonelderly (under age 65) Americans had private or public health insurance. Seventy-one percent had private insurance, 64 percent through an employment-based plan. Sixteen percent had public health insurance. The percentage of uninsured Americans has been increasing since at least 1987. In 1987, 14.8 percent of the nonelderly population was uninsured, compared with 17.7 percent in 1996. However, the erosion of employment-based health benefits cannot fully explain this increase since 1993. Instead, the decline in public sources of health insurance would partly explain it. It may be that, while the percentage of individuals with employment-based coverage is rising, individuals previously covered by Medicaid and CHAMPUS/CHAMPVA are not being fully absorbed into the employment-based health insurance market. Between 1995 and 1996, the percentage of nonelderly Americans without health insurance coverage increased from 17.4 percent to 17.7 percent. Further examination indicates that children completely accounted for this increase. In 1995, 13.8 percent of children and 19 percent of persons ages 18-64 were uninsured, compared with 14.8 percent of children and 18.9 percent of persons ages 18-64 in 1996. With the recent passage of legislation designed to reduce the number of uninsured children, the next focal point for health care reform could be early retirees and unemployed persons. President Clinton and some members of Congress have expressed an interest in improving access to and affordability of coverage for these groups. Currently, health care cost inflation is at its lowest point in years, but there are signals indicating that it is about to rise above current levels. The federal government's recent announcement that health insurance premiums will rise for federal employees an average of 8.5 percent in 1998 may portend higher future health care costs. Similarly, disappointing earnings announcements from several large insurers because of higher medical costs and lower-than-expected revenues may indicate that health insurance plans will increase premiums. Employment and income play a dominant role in determining an individual's likelihood of having health insurance. Age, gender, firm size, work hours, and industry are also important determinants; however, these variables are also closely linked to employment status and income. Some of the widest variations involve factors that are not always looked at in traditional demographic assessments, such as citizenship. However, variations by race, ethnicity, and citizenship are also closely linked to employment status and income. PMID- 10175506 TI - Fast food finds a niche in healthcare. PMID- 10175507 TI - 30-year old hospital dining facility gets a facelift. PMID- 10175508 TI - Dietitians face unique problems when dealing with minority elders. PMID- 10175509 TI - An ounce of prevention is worth a pound of service. Keep your cooking equipment in peak operating condition. PMID- 10175510 TI - Are you sure that isn't rat poison? PMID- 10175511 TI - Reporting health care professionals to state licensing boards--VA. Proposed rule. PMID- 10175512 TI - National Committee on Vital and Health Statistics: publication of recommendations relating to HIPAA health data standards--HHS. Notice. AB - Section 1172 (f), Subtitle F of Pub. L. 104-191, the Health Insurance Portability and Accountability Act of 1996, requires the Secretary of Health and Human Services to publish in the Federal Register any recommendation of the National Committee on Vital and Health Statistics (NCVHS) regarding the adoption of a data standard under that law. On September 9, the NCVHS submitted recommendations to the Secretary relating to the unique identifier for payers, the unique identifier for individuals, and security standards. Accordingly, the full text of the NCVHS recommendations relating to HIPAA data standards is reproduced below. The text of the recommendations is also available on the NCVHS website: http@aspe.os.dhhs.gov/ncvhs/. PMID- 10175513 TI - Assessing the importance of report cards rating patient satisfaction. PMID- 10175514 TI - Baptist Health Systems of South Florida: building trust among providers and the community. AB - In just two years, this healthcare system has grown from a one-hospital system to be the largest in South Florida. Its strategy: partnering with physicians and employees in a commitment to quality care. PMID- 10175515 TI - Predictions for 1998: new expertise, infrastructure will be needed as capitation grows. PMID- 10175516 TI - Physician compensation strategies: one size does not fit all. PMID- 10175517 TI - The limits to health care and rehabilitation. AB - Customary in the field of health care and rehabilitation, a spirit of optimism pervades the work and attitudes held by most practitioners. Professionals have many reasons and excellent track records in working with individual clients to support optimistic beliefs. At the same time, substantial social, economic, and political limits determine what can be undertaken and accomplished. Some of these constraints are global in character; others are organizational. Definitions of these limits and awareness about their causes can lead to higher quality research and action on sociological, political, economic, and/or systems-level approaches. Eventually, this awareness and the responses to the limits may lead to greater resources and better outcomes. Such results would support rather than limit effective action at the individual level. New Zealand provides an interesting case study, given the prevailing economic hard times. PMID- 10175518 TI - Medical care reform: lessons from around the world. AB - Once again the United States is in a ferment of health policy reform. Proposals abound but sage observers remark that national health insurance has been "just around the corner" more than once in the last forty years. This time may be different, however. Proposals from all across the ideological spectrum are converging on the notion of "managed care" which is perhaps best known in its guise as a health maintenance organization (HMO). Other forms of managed care exist but they have neither the history nor the incentives found in traditional HMOs. The discussion on national health insurance (NHI) proposals has focused on financing issues to the virtual exclusion of public health concerns. In this article, the author addresses rural health and public hospitals in the United States; two problems that have been with us for a long time. Then articles examining the Canadian and English medical care systems are reviewed, illustrating some of the weaknesses of these approaches to national medical care. Research studies relating to Europe and the developing nations are next. Once again, these are intended to highlight public health problems found in differing medical care systems. Finally, the author examines utopian views of the United States medical care system of the future: the reform proposal offered by the National Association for Public Health Policy, the experimental policy in Washington State, and a vision of a planned system. The review is intended to draw together the lessons offered by public health policy research in other countries and the United States and apply them to the issue at hand: reforming the United States medical care system. PMID- 10175519 TI - Impact of socioeconomic status on health care utilization: factors influencing length of stay. AB - Using multivariate analysis, this study evaluates the relationship between socioeconomic status and hospital resource utilization as measured by length of stay for elderly Medicare patients, age 65 and older, within Shelby County, Tennessee. Variations in length of stay are compared across income groupings for seven different Diagnosis Related Groups (DRGs) and relative effects are measured for socioeconomic status, age, race, gender, discharge status, and severity of illness. Despite the lack of provider specific and patient specific information, the analysis does suggest that, once patients access the medical care system, socioeconomic status has a limited effect on discharge decisions. The results also indicate that the effect of administratively necessary days on length of stay needs further policy review. PMID- 10175520 TI - Health care organization and incentives under emerging models of elderly health care. AB - Health providers are rapidly establishing integrated delivery systems to prepare for managed care and capitation. However, acute and primary services for the elderly continue to be reimbursed through DRGs or fee-for-service (FFS) payments. Different incentives and care patterns are described for providers caring for elderly populations and younger, capitated groups. Pilot programs to provide Medicare services to the elderly may become models or foundations for a future, capitated health system for the elderly. Existing models of elderly health care that receive capitated payments are described in this article, including Social HMOs, TEFRA HMOs. and PACE programs. The potential significance of these programs for the synchrony of operational incentives, comprehensiveness of health care, volume of institutional services, and primary care orientation is analyzed. PMID- 10175521 TI - Improving access, efficacy, and cost effectiveness of alcohol rehabilitation for poor patients. AB - Numerous alcoholics and alcohol abusers unknown to other agencies enter hospitals for treatment of alcohol-related illnesses. Two well-constructed studies focusing on poor clients enrolled in alcohol rehabilitation programs do not duplicate the long-term medical cost savings typical for higher income populations. Study limitations are indicated. Alcohol rehabilitation might avert or reduce potentially even higher long-term costs for poor clients as well as a host of social costs. It is important to demonstrate and improve the accessibility, efficacy, and cost effectiveness of alcohol treatment programs for the poor, especially since the viability and stability of public programs may be threatened due to competition with private facilities for insured and self-pay clients to subsidize the costs of treating the poor. Theoretical and practice issues and advances are discussed. PMID- 10175522 TI - Burnout in Ghanaian hospitals: phase model findings in sub-Saharan Africa. AB - This replication shows the expected covariation of the phases of burnout with a set of 5 marker variables. As the phases progress I-->VIII, so do decreases or deficits occur on all the marker variables. All covariants far surpass usually accepted levels of statistical significance, although the magnitudes are not as great as in much other research with the phases. The Ghanaian incidence of the phases is also compared with several panels of populations. Those comparisons at once indicate a substantial Ghanaian incidence of advanced phases, as well as a distribution comparable to North American worksettings and more favorable than a panel of global worksettings. PMID- 10175524 TI - Intranets. Health care organizations are going beyond electronic publishing of documents to offer a broad range of functions on their new networks. PMID- 10175523 TI - Psychographic factors underlying satisfaction of senior adults with ambulatory health care provided by physicians: an exploratory study. PMID- 10175525 TI - Addressing the new network security challenges. PMID- 10175526 TI - Intranets case study. Mayo leading the way. PMID- 10175527 TI - Intranets case study. Improving care in rural areas. PMID- 10175528 TI - Intranets case study. Building a network on a low budget. PMID- 10175529 TI - Intranets case study. Breaking through red tape. PMID- 10175530 TI - New RUG categories unlikely for first year of SNF PPS. PMID- 10175531 TI - OIG to target therapy payments, "excessive" physician visits to SNFs in 1998. PMID- 10175532 TI - OSHA proposes mandatory TB standard; requirements vary according to risk of workplace exposure. PMID- 10175533 TI - Bill introduced to repeal patient transfer provision. PMID- 10175534 TI - Windows, Netscape, high-speed modem to be required for mandatory electronic submission of MDS (minimum data set) data. PMID- 10175535 TI - Department of labor targets nursing facilities; violations common. PMID- 10175536 TI - Congress approves fiscal 1998 funding for Medicare, Medicaid. PMID- 10175537 TI - HCFA plans to use MDS/RUGs as basis of PPS for rehab, long-term care hospitals. PMID- 10175538 TI - Building on residents' needs. What's good design? Ask your customers. PMID- 10175539 TI - Changing with the times. PMID- 10175540 TI - Coming to a market near you. Consumer demands are changing the look of long-term care. PMID- 10175541 TI - Creating affordable projects. PMID- 10175542 TI - Designing by market. AB - As competition heats up, facility owners and developers are creating new facilities and additions to answer market demands--and that means paying increasing heed to the needs of their buildings' end users: residents, their families, and long term care staff. Here's how a handful of architects responded to this diverse constituency in recent projects. PMID- 10175543 TI - Surfing the Web for innovation. PMID- 10175544 TI - The state of the nursing profession. PMID- 10175545 TI - The physician incentive plan rule: reevaluating physician compensation arrangements. PMID- 10175546 TI - Integrating alternative providers into managed care: a case study. AB - Alternative medical techniques have become extremely popular, particularly in the western United States. Washington State recently enacted a law requiring certain health plans to include alternative providers on their physician panels. The author describes the efforts of one MCO to comply. PMID- 10175547 TI - Managing risks. PMID- 10175548 TI - What to look for when contracting with a disease management vendor. PMID- 10175549 TI - Asthma. PMID- 10175550 TI - The Balanced Budget Act of 1997: Medicare implications. AB - Early last month, President Clinton signed into law the historic balanced Budget Act of 1997. The Act contains many sweeping changes, including provisions that authorize provider-sponsored organizations to contract directly with the Medicare program on a risk basis. PMID- 10175552 TI - Coordinated care model for developmentally disabled improves care, saves money. AB - Coordinated care model for developmentally disabled dramatically cuts inpatient LOS, costs. Learn how this hospital coordinates care for the developmentally disabled using specially trained nurse practitioners--and is cutting LOS and costs while assuring quality for this often-overlooked group. With the surge in managed Medicaid contracts, this approach should catch on with HMOs and providers. PMID- 10175551 TI - A cost-effectiveness analysis of breath-actuated metered-dose inhalers. AB - Managed care plans evaluate therapeutic alternatives to identify the most cost effective medications for asthma. Three hundred one patients with asthma were randomized to receive the beta-agonist pirbuterol from either a manually operated metered dose inhaler (MDI) or a breath-actuated inhaler (BAI). Cost effectiveness was evaluated by the cost of the beta-agonist medication used and patient reported outcomes. No significant differences between the two groups appeared in baseline or follow-up outcomes, which were assessed by self-reported health status and spirometry. However, patients receiving pirbuterol from BAIs used 23% less than those patients who received the drug from MDIs. PMID- 10175553 TI - Breast center's redesign improves outcomes, cuts costs, attracts MCOs. AB - Slashing breast cancer screening costs and improving outcomes: Implementing an innovative multidisciplinary approach to diagnosing breast cancer and narrowing its team to dedicated "breast specialists" has helped this community hospital's breast center win more MCO contracts--despite its location in the shadow of a world-renowned center. Here's how the new program works. PMID- 10175554 TI - Data shows hospital margins rising despite managed care; more efficient operations cited. AB - This month's column disputes hospital administrators' complaints that managed care is causing declining revenues. A recent analysis of hospital financial data shows a steady downward slope in average net operating revenue, but a surprising overall increase in average net operating margins. How does your facility compare? PMID- 10175555 TI - New generation of mid-priced ultrasound devices sparks interest among providers. AB - Mid-priced ultrasound devices have come a long way, and the newest equipment boasts a wide variety of high-quality features. U.S. health care providers are finding they can save tens of thousands of dollars by opting for the new generation of mid-range devices that cost much less than the best, but offer a terrific bang for the buck. PMID- 10175556 TI - Supplies on wheels a runaway hit for saving $3 million. PMID- 10175557 TI - New technology revamps telemetry unit, cuts costs. PMID- 10175558 TI - Oregon hospital saves big by dumping departments, creating patient-focused clusters. AB - Redesign of management structure, care delivery saves more than $600,000 annually. See how an Oregon hospital restructured its management to better reflect its newly-revamped delivery of care, and ended up dramatically cutting labor expenses, LOS, and patient care costs. Learn how this new cluster and council model was designed to see if it makes sense for your organization. PMID- 10175559 TI - Hospitals owning HMOs get shortchanged when it comes to controlling, reducing costs. AB - Data Benchmarks: HMO ownership a financial hindrance to hospitals? A new survey of hospitals owning HMOs vs. hospitals that don't surprisingly shows hospitals getting into the managed care business aren't faring as well as they hoped. Hospitals owning HMOs had 11.3% higher total costs per occupied bed than organizations that don't own HMOs. Here are the details, plus comparisons of other financial indicators between the two groups. PMID- 10175560 TI - Creation of older adult unit shortens LOS, trims costs. AB - Special attention to the elderly in a dedicated inpatient unit trims costs, makes hospital stay shorter and safer for older patients. St. Joseph Mercy Hospital in Ann Arbor, MI, created a specially-designed older adult unit that focuses on keeping elderly patients active and less confused. A new study finds the cost of caring for the unit's elderly is about $400 less per case compared with elderly patients in other parts of the hospital and LOS is lower as well. This new approach is so promising, St. Joseph has doubled the size of the unit. Find out why. PMID- 10175561 TI - Hospital labor force keeps declining; administration hard-hit. PMID- 10175562 TI - Contract direct as a PSO? Some providers say "No!". PMID- 10175563 TI - When HMO marketing doesn't bring new members, it's the provider to the rescue. AB - Provider marketing success story: St. Agnes Health Care in Baltimore has significantly boosted its managed Medicare population through a marketing program that motivates hospital employees and directs seniors to visit the in-hospital Medicare Information Center. PMID- 10175564 TI - Medicaid prenatal program reducing rates of low birth weight, infant mortality. AB - Medicaid prenatal program reduces low birth weight and infant mortality: Christiana Care Health System in Wilmington, DE, rejects the free baby stroller and gift certificate approach to motivating members and instead employs peer moms in the community to mentor pregnant Medicaid members and help them make life-long health improvements. PMID- 10175565 TI - Risk adjustment formulas being tested, but payment woes still plague Medicaid plans, providers. AB - Medicaid risk adjustment on the horizon? Some states are dabbling with new payment methodologies, but most plans and providers are still grappling with Medicaid rates based on traditional age, sex, and geographic bands. Here's an update, plus some sample state PMPM rates. PMID- 10175566 TI - Report finds Medicare HMO members are younger, healthier and lower cost than FFS seniors. AB - Data File: Are managed seniors healthier than those in fee for service? A recent study by the U.S. General Accounting Office looks at disenrollment rates and costs of chronically ill Medicare HMO members in California. The findings support the much-disputed theory that seniors enrolled in HMOs are younger, healthier, and lower cost. PMID- 10175567 TI - Breathe new life into your smoking cessation programs. PMID- 10175568 TI - Smoking cessation: AHCPR spells out strategies that work. PMID- 10175570 TI - One-source kidney stone DM approach cuts costs, eases burden for busy urologists. PMID- 10175569 TI - New ADA guidelines aim for earlier diagnosis; promise major cut in complications. PMID- 10175571 TI - Study maintains MCOs need redesign to meet challenge of managing chronic illness. PMID- 10175572 TI - Hospital's education center encourages self-care in style. PMID- 10175573 TI - HCFA launches new era of risk contracting regulation. PMID- 10175574 TI - Deflate the balloon in outpatient dollars as inpatient costs are cut. PMID- 10175575 TI - Using actuarial cost models to allocate global risk. PMID- 10175576 TI - Use these strategies to ease into capitation. PMID- 10175577 TI - Decision support: what do capitated providers need? PMID- 10175578 TI - 10 key questions to ask before buying decision support software. PMID- 10175579 TI - Does capitation make provider groups hotter investments? PMID- 10175580 TI - Severity-adjusted, referral-based distribution system improves efficiency of contact capitation. PMID- 10175581 TI - Scoring grid helps providers evaluate payers as partners. PMID- 10175582 TI - Capitation survives a round in court, but suits continue. PMID- 10175583 TI - Monitoring contract performance: are you flying blind? PMID- 10175584 TI - Calculate the impact of drug benefits when negotiating Medicare risk contracts. PMID- 10175585 TI - Financial benchmarks help providers evaluate soundness of their HMO partners. PMID- 10175586 TI - Rural systems need creative strategies to assume risk. PMID- 10175587 TI - Growth of open access clouds risk contracting market. PMID- 10175588 TI - Ten tips for managing unscheduled care through capitation of emergency care. PMID- 10175589 TI - Use this simple tool to help evaluate risk contracts. PMID- 10175590 TI - Use this statistical tool to analyze practice patterns and develop capitation rates. PMID- 10175591 TI - Decision support tools help you model, manage capitation. PMID- 10175593 TI - Ancillary providers gaining a healthy appetite for risk. PMID- 10175592 TI - How to make your stop loss policy work harder. PMID- 10175594 TI - Survey sheds light on how hospitals fit into risk-sharing. PMID- 10175595 TI - Develop an infrastructure to support primary care capitation. PMID- 10175596 TI - Perspectives. Information privacy: front burner issue in '98 session? PMID- 10175597 TI - Marketplace. The Internet: survival tool for providers, insurers. PMID- 10175598 TI - Perspectives. Medicaid managed care: is a national standard for quality reasonable? PMID- 10175599 TI - Marketplace. New COBRA rules may spur workers to keep coverage. PMID- 10175600 TI - Perspectives. Child health gains may hinge on aggressive outreach. PMID- 10175601 TI - Introduce cell phone detectors for enforcing hospital use restrictions. PMID- 10175602 TI - Move coordinator: security's role in hospital move is critical. PMID- 10175603 TI - Intern program gives students experience, employers capable officers. PMID- 10175604 TI - Train derailment taxes hospital's disaster plan; changes recommended. PMID- 10175605 TI - Proactive infant security: how New Jersey hospitals reacted to a kidnapping incident. AB - A number of hospitals in New Jersey have taken steps to tighten security procedures to prevent infant abductions, including the use of electronic technology and efforts to further restrict access to unauthorized persons in their maternity wards. Highlighting the need for increased attention to safety and security, hospital and security officials say, was an abduction at St. Joseph's Hospital and Medical Center, Paterson, NJ, on August 20, 1997, in which a 16-year-old female allegedly took a two-day-old baby from a room while the mother was showering and left the hospital. The mother and suspect, according to police reports, had engaged in friendly conversation for about an hour. The mother then asked the teenager to watch the baby while she showered. When she returned, both the teenager and child were missing from the room. The baby was found unharmed by Paterson police later that night and returned to the hospital. The teenage suspect was arrested. In this report, we'll present examples of what other New Jersey hospitals, some part of healthcare systems, are doing to prevent similar infant abduction incidents at their institutions. In nearly all cases, officials at these hospitals report there has never been an infant abduction, but say preventive action has been taken to be proactive and improve the safety consciousness of staff and patients. PMID- 10175606 TI - Patient commits suicide; hospital, nursing agencies settle for $700,000. PMID- 10175607 TI - Behavioral risk factor surveillance of aged Medicare beneficiaries, 1995. AB - The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing State-based telephone survey of adults, administered through State health departments. The survey estimates health status and the prevalence of various risk factors among respondents, who include both fee-for-service and managed care Medicare beneficiaries. In this article the authors present an overview of the BRFSS and report 1995 regional results among respondents who were 65 years of age or over and who had health insurance. The advantages and disadvantages of using the BRFSS as a tool to monitor beneficiary health status and risk factors are also discussed. PMID- 10175608 TI - Measuring the health status of Medicare beneficiaries: 1995. PMID- 10175609 TI - Hospital, employment, and price indicators for the health care industry: fourth quarter 1996 and annual data for 1988-96. PMID- 10175610 TI - Medicaid managed care policies affecting children with disabilities: 1995 and 1996. AB - The authors present findings from a study of State Medicaid managed care enrollment and benefit policies in 1995 and 1996 for children with disabilities. During this time the number of States serving children through fully capitated plans grew by more than one-third, and enrollment of children receiving Supplemental Security Income (SSI) payments and children in subsidized foster care increased. Most States required plans to provide all mandatory and most optional Medicaid services. Although States have begun to make noticeable improvements in their contract language concerning medical necessity and the early and periodic screening, diagnosis, and treatment (EPSDT) benefit, overall State guidance in these areas remains weak. PMID- 10175611 TI - Dialysis modality selection among patients attending freestanding dialysis facilities. AB - Persons with end stage renal disease (ESRD) are eligible to receive dialysis services under the Medicare program. An individual-level analysis was performed to determine the factors associated with the modality selected by patients; namely in-center hemodialysis, continuous ambulatory peritoneal dialysis (CAPD), continuous cycling peritoneal dialysis (CCPD), and home hemodialysis. Logistic regression equations were estimated using program data for 73,448 ESRD Medicare patients attending freestanding dialysis facilities. The results showed that CAPD, CCPD, and home hemodialysis were more likely to be selected by patients who were younger, had non-systemic precipitating causes of ESRD, had a shorter duration of ESRD, attended larger facilities, and were not ethnic minorities. There is no consistent evidence demonstrating the superiority of particular modalities. The policy goal should be to enable beneficiaries to use the modality for which they are best suited, which requires that the range of modalities be available to all ESRD beneficiaries. PMID- 10175612 TI - Predictors of functional health status of end stage renal disease patients. AB - Potential predictors of the functional health status of 125 end stage renal disease (ESRD) patients were studied cross-sectionally. When health status was assessed by the physician with the Karnofsky Index, younger patient age, lower ESRD severity of illness, lower comorbidity severity, and higher albumin levels were predictors of better health [R-square = 0.48]. When patients self-reported their health status with the Duke Health Profile, African-American race, higher family support, lower family stress, and lower ESRD severity were positive predictors [R-square = 0.23]. The importance of measuring functional status, severity of illness, and social support and stress of ESRD patients is supported by these findings. PMID- 10175614 TI - Measuring and improving the health status of end stage renal disease patients. AB - This highlight reports on recent efforts to develop and promote health status measurement instruments for use in dialysis units that treat end-stage renal disease (ESRD) patients, most of whom are covered for all medical services under Medicare. Readers interested in a more detailed discussion of instruments, including associated data collection and data processing aspects, should consult a recently published account, with its extensive references, of four instruments currently being used in dialysis units (Rettig et al., 1997). Those interested in early reports of the clinical utility of such instruments should consult the following references (Kurtin et al., 1992; Meyer et al., 1994; and DeOreo, 1997). PMID- 10175613 TI - Cost of care for cancer in a health maintenance organization. AB - The direct costs of medical care for cancer are examined at Kaiser Permanente (KP) in Northern California. Use data from July 1987 through June 1991 were obtained from KP automated files for all 21,977 KP patients in the Bay Area SEER registry with cancer at one of seven cancer sites. Medical charts were reviewed for a stratified sample of 886 patients. Costs were estimated for initial, continuing, and terminal care, and for all person time within 15 years of diagnosis, by stage at diagnosis. From diagnosis until death or 15 years, long term costs attributable to cancer were as follows: breast, $35,000; colon, $42,000; rectum, $51,000; lung, $33,000; ovarian, $64,000; prostate, $29,000; and Non-Hodgkin's Lymphoma (NHL), $48,000. The utilization and cost results reported here may be useful in assessing the cost-effectiveness of cancer prevention and control programs, in adjusting capitation rates and budgets, and in estimating the aggregate medical care costs attributable to cancer. PMID- 10175616 TI - Cuban deals. PMID- 10175615 TI - Medicaid home and community-based care waiver programs: providing services to people with AIDS. AB - The authors present the results of a survey demonstrating how Medicaid programs use the home and community-based waiver programs to provide services to people with acquired immunodeficiency syndrome (AIDS) and to other targeted groups. The survey identified a number of waiver services that are effective at meeting the care needs of people with AIDS, such as case management, personal care, respite care, home intravenous therapy, attendant care, hospice, and home-delivered meals. The study demonstrates that in addition to the AIDS-specific waiver program, State Medicaid programs use the home and community-based care waiver programs for the elderly and disabled to provide services to people with AIDS because of their disability status. PMID- 10175617 TI - Acute services. Time to strip the beds? AB - The health authority and trust proposals for Birmingham's health services, currently the subject of consultation, are radical, untested and uncosted. They assume that once emergency assessment and ambulatory care centres are operational, under half the current caseload will need inpatient stays. University Hospital Birmingham trust's proposal for a new hospital built and operated by the private sector assumes no growth in activity and a 17 per cent reduction in the present bed complement, at a time when emergency admissions in Birmingham are increasing by 5 per cent a year. Analysis of the proposals suggests they will destabilise an already precarious acute service in Birmingham. PMID- 10175618 TI - Primary care. Burden of proof. AB - Evidence that the shift of services from secondary to primary care is creating extra work for GPs is limited. A study showed that it is possible to quantify additional workload for GPs, but that certain aspects, such as measuring the time input, remain problematic. Future research needs to agree workload definitions, employ sensitive measures other than consultation rates, and distinguish between workload in practices and that of individual practitioners. PMID- 10175619 TI - Predictors of health care utilization in the chronically ill: a review of the literature. AB - The objective of this paper is to identify predictors of health care utilization in the chronically ill. This paper reviews 53 studies on hospitalizations and physician visits, published between 1966 and 1997 and identified by MEDLINE and ClinPSYCH databases. Studies with both univariate and multivariate analyses were included. On the basis of the Andersen-Newman model of health care utilization, the effects of predisposing, enabling and need variables are examined. Most studies reviewed indicate that predisposing factors such as age, sex, and marital status are not predictors of hospital utilization in the chronically ill. The enabling factors income, insurance and social support have not been shown to affect health care utilization, but characteristics of the hospitals could have an effect. Need factors such as disease severity, symptom severity and complications adversely affected health care utilization in the chronically ill, while disease duration and comorbidity do not have such an effect. Quality of life and perceived health might affect hospital utilization and physician use. Finally, depression and psychological distress proved to be among the strongest predictors of hospitalizations and physician visits. In conclusion, both disease severity and psychological well-being are most important in health care utilization. Intervention programs to support depressed or psychologically distressed patients should be considered. These could both help the patient and reduce health care utilization costs. PMID- 10175620 TI - The distribution of cataract surgery services in a public health eye care program in Nepal. AB - The cost-effectiveness of public health cataract programs in low-income countries has been well documented. Equity, another important dimension of program quality which has received less attention is analyzed here by comparisons of surgical coverage rates for major sub-groups within the intended beneficiary population of the Nepal blindness program (NBP). Substantial differences in surgical coverage were found between males and females and between different age groups of the same gender. Among the cataract blind, the surgical coverage of males was 70% higher than that of females. For both genders, the cataract blind over 55 received proportionately fewer services than younger people blind from cataract. Blind males aged 45-54 had a 500% higher rate of surgical coverage than blind males over 65. Blind females aged 35-44 had nearly a 600% higher rate of surgical coverage than blind females over 65. There was wide variation in overall surgical coverage between geographic zones, but little variation by terrain type, an indicator of the logistical difficulties in delivery of services. Members of the two highest caste groupings had somewhat lower surgical coverage than members of lower castes. Program managers should consider developing methods to increase services to women and to those over 65. Reaching these populations will become increasingly important as those most readily served receive surgery and members of the under-served groups form a growing portion of the remaining cataract backlog. PMID- 10175622 TI - The importance of lifestyle to self-assessed health. AB - Empirical research has revealed a causality between lifestyle and health, and lifestyle is seen as an important factor in explaining health differences among people. However, it is important to note the difference between the significance and the importance of a factor in explaining health differences, since the two concepts are commonly confused. Some research has suggested that lifestyle is not an important variable in explaining health differences, but just how important it is, is uncertain. This study measures the explanatory power of lifestyle for self assessed health. It is found that lifestyle has only a limited effect; 3-5% of the differences in self-assessed health are explained by lifestyle variables. PMID- 10175621 TI - Measuring the clinical consistency of panelists' appropriateness ratings: the case of coronary artery bypass surgery. AB - OBJECTIVE: To assess the clinical consistency of expert panelists' ratings of appropriateness for coronary artery bypass surgery. DESIGN: Quantitative analysis of panelists' ratings. PARTICIPANTS: Nine physicians (three cardiothoracic surgeons, four cardiologists, and two internists) convened by RAND to establish criteria for the appropriateness of coronary artery bypass surgery. MAIN OUTCOMES MEASURES: Percentage of indication-pairs given clinically inconsistent ratings (i.e. higher rating assigned to one member of an indication-pair when rating should have been equal or lower). RESULTS: In the final round of appropriateness ratings, among 1785 pairs of indications differing only on a single clinical factor (e.g., three-vessel vs. two-vessel stenosis), 6.6% were assigned clinically inconsistent ratings by individual panelists, but only 2.7% received inconsistent ratings from the panel as a whole (using the median panel rating as the criterion). Internists on the panel provided fewer inconsistent ratings (4.6%) than either cardiologists (7.8%) or cardiothoracic surgeons (6.3%) (p < 0.001). More inconsistencies were noted when the factor distinguishing otherwise identical indications was symptom severity (inconsistency rate, 13.2%) or intensity of medical therapy (13.2%) than when it was number of stenosed vessels (3.8%) or proximal left anterior descending (PLAD) involvement (1.9%). Contrary to expectations, panelists' inconsistency rates increased between the initial and final rounds of appropriateness ratings (from 3.9 to 6.6%, p < 0.001). Panelists' mean ratings across indications were only weakly correlated with individual inconsistency rates (r = 0.18, p = ns). CONCLUSIONS: The RAND/UCLA method for assessing the appropriateness of coronary revascularization generally produces criteria that are clinically consistent. However, research is needed to understand the sources of panelists' inconsistencies and to reduce inconsistency rates further. PMID- 10175623 TI - Association between attitudes toward health promotion and opinions regarding organ transplants in Japan. AB - Health promotion activities to educate the public about health lifestyles have been performed widely in industrialized countries where chronic adult diseases have become prevalent. According to a basic principle of health promotion activities, the symptoms of many diseases are regarded as the result of inadequate health behavior, curable by modifying health behavior. It is thus possible that an exposure to health promotion activities might instill negative attitudes towards organ transplants, because program participants may conclude that persons who need an organ transplant have become unhealthy as the result of their own poor health habits. In this study, two types of surveys were undertaken to test this hypothesis. The subjects of the first cross-sectional study were 712 male and female Japanese citizens, and those of the second case-control study were 240 female company employees in Japan. In the first study, a logistic regression analysis was used and the following findings were obtained. (1) Compared with the persons who felt that they did not have enough practical knowledge about individual health practices, those who felt that they had adequate knowledge were 0.66 times less likely to support organ transplants. (2) Compared with those who were not willing to spend money on healthful things, the persons who were willing to do so were 0.51 times less likely to support organ transplants. In the second case-control study, it was revealed that the subjects who had negative attitudes towards organ transplants had consistently healthier lifestyles than did those who had positive attitudes towards organ transplants. Based upon the present findings and the nature of the basic principles of health promotion activities, we infer that community health promotion activities have a negative influence upon citizens' opinions of organ transplants. Since these findings have health policy implications, more studies are necessary to conclusively evaluate the effects of health promotion activities upon attitudes toward organ transplants. PMID- 10175624 TI - Casting the screening net: separating big fish from little fish. AB - Screening tests are a rapidly growing part of medical practice. If we are going to make the best use of resources, screening tests need to be considered in terms of effectiveness, efficiency and equity. We present a framework as a way to think about screening programmes. The framework expands on existing literature that recognizes two categories of screening: universal and opportunistic. By adding the dimension of 'selectivity', we identify four categories of screening: active non-selective (universal or mass screening), active selective, opportunistic non selective and opportunistic selective. We illustrate the framework by categorizing screening recommendations for high serum cholesterol levels. We conclude there is no one ideal strategy for screening that simultaneously satisfies criteria of effectiveness, efficiency and equity. However, our framework allows a systematic consideration and balancing of these objectives in the development and assessment of screening programs. In this way, it may assist decision-makers by making this trade-off more explicit. PMID- 10175625 TI - Under-the-counter payments for health care: evidence from Bulgaria. AB - Against a background of falling revenues and increasing expectations, health care systems in central and eastern Europe are facing increasing budgetary gaps. There is extensive anecdotal evidence that these gaps are being filled by informal or 'under-the-table' payments. These are important because of their implications for estimates of future funding requirements, for equity, and for the possible perverse incentives they introduce for those providing and managing health services. There is, however, relatively little information on either their scale or how they are perceived in these countries. We report the results of a small survey from Bulgaria that begins to address these issues. Data were collected by means of an interviewer-administered household survey in which those who had used state-provided health services in the preceding 2 years were identified. The survey took place throughout Bulgaria in 1994. One thousand people were approached and 706 (70.6%) provided information suitable for analysis; 42.9% had paid for services that were officially free. Payments had been for a wide range of services and to differing groups, including medical, nursing and ancillary staff. Payments to individuals during consultations were between 3% and 14% of average monthly income but the average cost of an operation was 83% of mean monthly income. There were large differences in the amounts paid by individuals. Most people were in favour of both official user fees and health care reform, except among the old, the poor, and those in poor health. Despite certain limitations, this study gives some indication of the scale of informal payments in Bulgaria. Several possibilities exist to address them. Contrary to what is often argued, there seems to be a popular willingness for them to be converted into formal co-payments. Before this can be done, there is a need for more research on the impact that this would have on equity and affordability. PMID- 10175626 TI - Courts interpret open records and open meeting laws. PMID- 10175627 TI - Exclusions of problem physicians upheld in two cases. PMID- 10175628 TI - Progressivity, horizontal equity and reranking in health care finance: a decomposition analysis for The Netherlands. AB - This paper employs the method of Aronson et al. (1994) to decompose the redistributive effect of the Dutch health care financing system into three components: a progressivity component, a classical horizontal equity component and a reranking component. Results are presented for the health care financing system as a whole, as well as for its constituent parts. A final section sets out to uncover the relative importance (in terms of their effects on progressivity, horizontal equity and reranking) of the key institutional features of one component of the Dutch system-the AWBZ social insurance scheme. PMID- 10175629 TI - Contracts and purchaser-provider relationships in community care. AB - This paper considers the incentives embodied in contracts between purchasers and providers of residential care for frail elderly people. The paper begins with an assessment of current contractual arrangements. A theoretical inquiry generates propositions that some contracts create incentives for providers to misrepresent users' characteristics. These propositions are found to be supported by sample data. The paper then turns to a theoretical consideration of optimal governance structures and, in particular, the use of incentive contracts. These contracts, it is claimed, may go some way to curbing cost-exaggerating behaviour without providing strong incentives to cream-skim or shirk on quality. PMID- 10175630 TI - Adverse selection and the purchase of Medigap insurance by the elderly. AB - This study uses data on 8561 elderly respondents from the 1991 Medicare Current Beneficiary Survey to examine adverse selection in the supplemental private insurance market. Logit models of supplemental insurance choices provided modest but mixed evidence of self-selection on the basis of observable health status. Wealth had a strong influence on coverage. Two part models of Medicare utilization and expenditures showed that beneficiaries with individually purchased policies had higher total, part B and physician expenditures than those with employer-provided policies, even after controlling for observable differences, suggesting adverse selection. Results were similar for basic and more comprehensive policies. PMID- 10175631 TI - HYE (healthy years equivalent) and TTO (time trade-off): what is the difference? AB - This paper demonstrates that the HYE (healthy-years-equivalent) procedure not only has nothing more to offer than the TTO (time trade-off) method, but that it introduces a systematic bias that is not present using TTO. Diagrams are used to illustrate that the HYE yields health status values, not utilities as its creators suggest, and to show that the HYE and TTO techniques are theoretically identical. Then, empirical evidence concerning the standard gamble/certainty equivalence disparity noted elsewhere in the literature is shown to indicate that HYE responses are likely to contain systematic biases that will lead to HYE estimates exceeding TTO values. PMID- 10175632 TI - Contractual choice in the managed health care market. An empirical analysis. PMID- 10175633 TI - Is the valuation of a QALY gained independent of age? Some empirical evidence. PMID- 10175634 TI - QALYs and HYEs (healthy years equivalent). Spotting the differences. PMID- 10175635 TI - On the use of market prices to evaluate medical treatments. PMID- 10175636 TI - A clarificatory note on 'Valuing health states: a comparison of methods'. PMID- 10175637 TI - Medical costs in workers' compensation insurance: comment. AB - Professors Baker and Krueger ignore some costs associated with workers' compensation. Because of these costs, the contention that physicians willfully exploit the workers' compensation system for their own gain is questioned. PMID- 10175638 TI - The consolidated hospital laboratory network. An idea whose time has come. PMID- 10175639 TI - The Columbia/HCA scandal. How do you spell damage control? C-0-M-P-L-I-A-N-C-E. PMID- 10175640 TI - JCAHO recognizes COLA accreditation. PMID- 10175641 TI - Stamping out fraud. The model compliance program. PMID- 10175642 TI - Section reengineering to meet rapid volume growth. PMID- 10175643 TI - Quality assessment activities in Latin America and the Caribbean. AB - The Pan American Health Organization (PAHO) supports performance evaluation programs in clinical chemistry, Caribbean. Much more work remains to be done before many labs in this part of the world can be certified as providing accurate results, but PAHO has taken an important first step toward establishing benchmarks and rallying for labs to improve test quality. PMID- 10175644 TI - 1996-97 physician recruitment incentives reviewed. PMID- 10175645 TI - Using customer service data to develop process improvement initiatives. PMID- 10175646 TI - The way it was: radiology administrators remember. AB - Radiology Management wanted to understand what it was like to be a radiology administrator 24 years ago. What events were taking place in healthcare that inspired a small group of people to come together to form an organization for their mutual benefit? What role have changes in technology and the industry in general played over the years? Two roundtable discussions were held earlier this year as forums for AHRA members to come together and reminisce about the organization and the profession. One such discussion was held in Sudbury, Mass. where participants included Louise P. Broadley, FAHRA; Monte G. Clinton, FAHRA; Cecilie Godderidge, FAHRA; Chuck Mitchell, FAHRA; and Tammy Waldhauser. In addition, William W. Wheeler, FAHRA; David A. Stone, FAHRA; and Billy Wesson joined the conversation by telephone. The other roundtable was held during the Western Region's 25th anniversary meeting in San Diego in April, and included Lois A. Haas, FAHRA; Stephen J. Hage, FAHRA; Jack Healy; Merlin C. Heinselman, FAHRA; Martin T.J. Hilger, FAHRA; Brenda S. Holden, FAHRA; Sharon K. Johnson, FAHRA; Merle D. Meland, FAHRA; James Mom; Bobbie O'Boyle, FAHRA; Paula Osborn, representing Royce Osborn, FAHRA; Roland W. Rhynus, FAHRA; Mark Rutherford and Richard Steuve. As old friends will do when they get together after many years, these two groups on opposite sides of the country shared their stories with both humor and pathos. They reminisced about people they had known and hospitals where they had worked. They recalled some good times and some not so good, as they looked back at the beginning of an organization first called American Hospital Radiology Administrators. Mostly they talked of the many changes that have taken place over the years in healthcare and for the profession of radiology administration. Radiology Management is pleased to share some of those conversations here. PMID- 10175647 TI - Administrative and organizational ethics. PMID- 10175648 TI - The ethical importance of differences between managed care systems. PMID- 10175649 TI - Dimensions of time in managed care: metaphor or measure? PMID- 10175650 TI - Satisfaction, managed ethics, and the duty to design. PMID- 10175651 TI - Bioethics and the HMO. PMID- 10175652 TI - Managing the persistent patient with chronic pain. How can we help a patient with a psychiatric illness who persistently demands medical appointments? PMID- 10175653 TI - Part II. Ethics program evaluation: the Virginia Hospital Ethics Fellows example. PMID- 10175654 TI - Ethics committee consultation: a case. PMID- 10175655 TI - Regulating euthanasia in The Netherlands. Ethics committees for review of euthanasia? PMID- 10175656 TI - The evolving electronic patient record system. PMID- 10175657 TI - Digital medical image archive: the "A" in PACS is here. PMID- 10175658 TI - What healthcare really needs to know about managing electronic documents. PMID- 10175659 TI - Breaking away from paper. PMID- 10175660 TI - The journey to the electronic health record. PMID- 10175661 TI - Healthcare data capture: high quality & low cost. PMID- 10175662 TI - There's no place like home healthcare. PMID- 10175663 TI - Home healthcare IS products & services. PMID- 10175664 TI - Smooth operators. Medical call centers are bringing quality of healthcare home. PMID- 10175665 TI - No fool's gold. Guarantee riches from your data mine. PMID- 10175666 TI - Redesigning IS to serve the IDN. PMID- 10175667 TI - Knowledge-based software. Is your organization ready? PMID- 10175668 TI - HL7. A vendor-provider liaison. PMID- 10175669 TI - Should we have "supersecret" health records? PMID- 10175670 TI - University of Iowa webergizes its mainframe system. PMID- 10175671 TI - Reeling in the keepers. Strategies for healthcare execs to find, hook and land IT's best and brightest. PMID- 10175672 TI - New waves in patient care. Wireless standards drop one oar in the water. PMID- 10175673 TI - Breaking down the barriers. Improving physician buy-in of CPR systems. AB - The computer-based patient record (CPR) continues to gain recognition and notoriety as its potential benefits are paralleled by its potential problems. The benefits of an effective CPR system include increased efficiency, improved quality and cost savings. But potential problems may actually be decreased efficiency, lowered quality (rarely), and economic losses. Factors that effect these potential CPR outcomes include system quality, system expense and physician buy-in. But even though CPR systems are starting to show improved quality at more reasonable prices, the lack of physician buy-in may stop groups from pursuing CPR systems at this time. They realize that even a perfect CPR system will ultimately fail unless physicians understand the system and use it appropriately. PMID- 10175674 TI - Prospecting for the CPR. PMID- 10175675 TI - One doctor's wish list. Anesthesia services move into the computer world. PMID- 10175676 TI - Spotlight on perioperative anesthesia information systems. PMID- 10175677 TI - The data warehouse. New uses for old data. PMID- 10175678 TI - The benefits of a partnership approach to disability management. AB - Taking a partnership approach to disability management and fostering a return-to work culture can significantly reduce disability costs for employers and help disabled employees successfully return to work. Two rehabilitation case managers from ReliaStar Life Insurance Company share their perspective and experience, including three case studies that illustrate successful case management intervention and return-to-work strategies. PMID- 10175679 TI - Absence/lost time management: strategies to keep the workforce productive. AB - Managed disability is an effective tool to reduce the expense of disability claims. However, many employers have not realized the financial significance of lost time due to unexpected absence. This article discusses emerging trends that contribute to the need for absence/lost time management, quantifying the costs of lost time to the employer. Methods for tracking absence/ lost time are illustrated, as well as examples of lost time management. PMID- 10175680 TI - How employers can reduce the cost of their disability programs. AB - The rapid rate at which disability costs are rising is fueling the need to cut costs. This article details some strategies that employers can utilize to help keep disability costs under control. The authors discuss many difficult issues that need to be addressed to make productive changes to the existing status quo, which needs to be assessed for current strengths and weaknesses before changes can be made. Case studies are presented and many alternative plan designs are discussed that could involve varying cost savings depending upon the individual plan characteristics. PMID- 10175681 TI - The importance of subjective claims management. AB - This article discusses the causes and effects of "subjective disability" on today's workforce and employers. As employees feel out of control with both their careers and demands placed upon them, the number of claims characterized by self reported symptoms are increasing. Subjective disabilities include chronic syndrome, fibromyalgia, psychiatric claims and chronic pain. The author discusses creative strategies in case studies that have helped employers contain the costs of disability claims, while empowering the employee to take control of their own situation and return to work sooner. PMID- 10175682 TI - Linking health plan performance with disability outcomes. AB - Although the managed health care industry evolved and matured in the 1980s and 1990s, such initiatives to control disability costs failed to keep pace. As employers became aware of the costs of lost productivity, managed disability programs quickly evolved. This article discusses the trends, issues and assumptions in managed health and disability models, providing case studies to support the authors' hypothesis that health plans can have a direct impact on disability duration. PMID- 10175683 TI - Attacking the disability and absenteeism epidemic--behavioral health care solutions. AB - To remain competitive in a global economy, employers must implement effective programs to stem escalating disability claims and increased costly absenteeism. This article discusses methods to counter this latest workforce epidemic. The authors discuss employee attitudes, legal considerations and behavioral health care solutions. PMID- 10175684 TI - Managing disabilities in an integrated health environment: the experience of Aetna. AB - Disability-related outlays are increasing at a rate well above the medical inflation rate. This article discusses the experience of one company in its attempt to manage these skyrocketing costs, by developing a new program that integrates health and related benefits by combining the medical and human resources interventions into a unified program. The authors discuss the initiation, development and progress of the program, concluding with measured results revealing reduced lost work time, improved employee health and productivity, and reduced disability costs. PMID- 10175685 TI - The EEOC's new ADA mental disability guidelines: an EAP is a pretty reasonable accommodation. AB - The EEOC's enforcement guidelines for psychiatric disabilities may present a significant challenge for the small employer. The authors discuss the parameters of this challenge and consider the ADA mental disability guidelines in the context of an operational framework to assist employers. It is pointed out that an EAP or a managed behavioral health firm with knowledge of ADA can be useful in identifying cost-effective accommodations for employees claiming mental disabilities. PMID- 10175686 TI - Managed disability--past, present and future. AB - This article discusses the overall development of managed disability. First, it explores historical factors that have influenced managed disability programs, followed by important considerations in current programs, and finally discusses future issues to contemplate for successful evolution to occur. The authors conclude by pointing out the opportunity for insurers to develop innovative and responsive products and the opportunity for employers to have a direct impact on reshaping disability benefit programs. PMID- 10175687 TI - Patient privacy recommendations: what do they mean? PMID- 10175688 TI - Credo, conduct, and credibility. PMID- 10175689 TI - How to successfully implement medical education via the Internet. PMID- 10175690 TI - Health care management and the Internet: breaking the barriers of geography and time. PMID- 10175691 TI - Hacking the health system: using public key infrastructure to protect health information on the Internet. PMID- 10175692 TI - Caught in the Web by the killer app! PMID- 10175693 TI - Internet-enabled solutions for health care business problems. AB - Many health care delivery organizations have built, installed, or made use of Nets. As single entities merge with others, and independent institutions become part of much larger delivery networks, the need for collaboration is critical. With the formation of such partnerships, existing platforms will become increasingly available from which it will be possible to build disparate technologies that must somehow be part of a single working "system." Nets can enable this leveraging, allowing access from multiple technological platforms. The collaboration, distribution, application integration, and messaging possibilities with the Nets are unprecedented. We believe that meeting a health care delivery organization's needs without these benefits will soon be unthinkable. While Nets are not the answer to the challenges facing health care delivery today, they certainly are a large contributor to the solution. PMID- 10175694 TI - Linking providers and managed care organizations via the Internet. PMID- 10175695 TI - A guided tour of online career resources for health care information and management professionals. PMID- 10175696 TI - Enhancing quality and controlling costs: using Internet technology to apply workflow to health care. AB - The pressures associated with the competitive, quickly changing health care marketplace require the use of all available tools to deliver the highest quality care at the lowest cost. Workflow, as employed by other industries, delivers significant increases in both productivity and quality of services. Likewise, the application of automated workflow techniques to the health care industry offers measurable and immediate benefits. The very nature of a workflow product requires that it be available as widely as possible and be customized to fit the working patterns of the people who use it. To gain the advantages of customization and wide platform access, it is mandatory that the burgeoning technologies of the Internet be used in the creation of any modern networked computer application. Automated health care workflow provides the necessary information technology for caregivers to deliver efficient and effective high-quality care. PMID- 10175697 TI - A case study of a MUMPS intranet patient record. PMID- 10175698 TI - Design and evaluation of a World Wide Web site for rural health practitioners. PMID- 10175699 TI - A Boston anesthesiologist finds ingenious ways to alleviate youthful suffering by relating to a child's pain. PMID- 10175700 TI - Seeking answers in ancient rain-forest remedies is a life's work for the plant hunter. PMID- 10175701 TI - In search of sight. Physicians in Chicago use fetal cells to combat a degenerative eye disease afflicting millions. PMID- 10175702 TI - Linking an Amish hereditary disease with cerebral palsy, a pediatrician challenges a dark inheritance. PMID- 10175703 TI - In rural Brazil a surgeon uses a revolutionary and controversial method of repairing too big a heart. PMID- 10175704 TI - Genetic testing's growing ability to predict disease makes it vital to soften the shock of seeing the future. PMID- 10175706 TI - The global scourge of land mines left thousands limbless, and then two gifted Indians developed the $28 foot. PMID- 10175705 TI - A California brain surgeon wields formidable new weapons as he battles on the front lines of the tumor war. PMID- 10175707 TI - Fed up with the constant carnage he deals with in his emergency room, a doctor pleads with the nation's youth. Drop your guns! PMID- 10175708 TI - They share endless curiosity, a huge capacity for work and a willingness to defy convention. They are the heroes of medicine. PMID- 10175709 TI - With doctors scarce as skyscrapers in rural Kansas, two nurses are providing vital health care via the wired prairie. PMID- 10175710 TI - A New York hospital burn unit brings specialists together to treat pain-racked patients who have been to hell and back. PMID- 10175711 TI - By giving her bone marrow to a stranger, an Illinois mother went beyond the call. PMID- 10175712 TI - Fear of AIDS is only one reason some doctors are calling for bloodless surgery. PMID- 10175713 TI - In the thick of civil war a courageous doctor from Idaho beats back an epidemic by launching a rescue in Sudan. PMID- 10175714 TI - Physician, heal thyself. PMID- 10175715 TI - Code blue at Oxford. A computer glitch and a quarterly loss trigger bloodletting at what had been the healthiest HMO. PMID- 10175716 TI - The unfocused strategic vision. AB - Integrated delivery systems are often seen as the answer to the question of how to deliver high quality health services to a defined population at the lowest possible cost. This case examines the birth, growth, and ultimate demise of one such system. At first glance, all of the elements necessary for a successful integration were present including visionary leadership and a well defined strategic plan. However, the senior managers did not foresee the problems that would result from a clash of organizational cultures, significant mistrust between and among staff and physicians, and inability to manage the emotional cognitive landscape. PMID- 10175717 TI - Provider-based Medicare risk contracting and subcontracting: opportunities and risks for provider sponsored organizations. AB - Provider sponsored organizations (PSOs) are increasingly acquiring the risk for the management of Medicare Risk patients by accepting capitation directly from the Health Care Financing Administration (HCFA) or through contracts with HMOs or other organizations contracting with HCFA. The Medicare population and the requirements that the federal administration has put into place with respect to risk contracting are unique and demand specific responses on the part of the PSO for a contract to be successful. The PSO is cautioned to understand the actuarial risk, the clinical uniqueness of the Medicare beneficiary, Medicare reimbursement regulatory requirements, utilization management needs, and necessary reporting before entering into a contractual arrangement. This article attempts to describe some of the more common issues a provider organization must consider. PMID- 10175718 TI - Health promotion for seniors: what is over the horizon? AB - The health care industry is experiencing tremendous change in terms of health care delivery systems and fiscal pressure to provide high-quality health care at an affordable cost. A significant step forward in this change process will be the recognition of the value of comprehensive health promotion and disease prevention. The managed care model of health care is an excellent vehicle for a systematic health promotion program to flourish and succeed. This article surveys the literature on the topic of health promotion and its impact on the wellness of Medicare managed care beneficiaries and the senior population. The authors address issues, facilitators, benefits, and barriers within the context of health promotion and its potential to greatly impact both the quality and cost of health care for the rapidly growing senior population in the coming years. PMID- 10175719 TI - Strategic considerations for provider sponsored organizations entering the risk bearing Medicare market. AB - This article considers Michael Porter's five forces of industry competition as it relates to provider sponsored organizations and asks four important questions on marketing differentiation, quality, size of market, and product/service scope. PMID- 10175720 TI - Medicare managed care: a consumer perspective. AB - As managed care grows in the Medicare program, Congress must act to instill greater confidence among beneficiaries that the options offered will provide available and accessible, high-quality care. There must be an effective set of comprehensive standards, applicable to all Medicare contractors, that will ensure proper safeguards and beneficiary protections. These include strengthening quality improvement/assessment and the grievance and appeals process. Adequate levels of assistance should be provided for beneficiary counseling programs. Finally, the Health Care Financing Administration must be given sufficient resources to effectively oversee the managed care program. PMID- 10175721 TI - Employer-sponsored Medicare HMO strategies: common selection criteria. AB - Retiree health care costs have increased at an astronomical rate for employers. In order to gain control over these costs and reduce Financial Accounting Standards FAS 106 expense and liability, many employers have turned to Medicare HMOs as a solution. The Medicare HMO arena has exploded over the last few years. With the wide diversity of Medicare HMOs in the marketplace, the prospect of selecting Medicare HMOs can be daunting. However, as more and more employers offer Medicare HMOs to retirees, some common criteria to assist in the selection process have evolved. These criteria are in the categories of sufficient access, high quality care, generous benefit levels, at affordable cost. These are by no means the only criteria employers should consider; however, they should serve as a solid foundation from which a Medicare HMO strategy can be developed. PMID- 10175722 TI - Nashville: the Silicon Valley of health care? PMID- 10175723 TI - Provider sponsored organizations: opportunity or regulatory quagmire? PMID- 10175724 TI - The role of government in health care. Interview by Paul Kenkel. PMID- 10175725 TI - "Managing" demand: the wrong paradigm. AB - The "Managing" of demand practiced by managed care organizations has had some success in controlling health care expenditures, but only at great cost in terms of irate consumers, physicians, employers, media, lawyers and legislators. The spate of "HMO Bashing" can be attributed to the use of the wrong paradigm for dealing with consumer, i.e., management. Initiatives intended to avoid, replace and reform demand should use a marketing paradigm, emphasizing the delivering of value to customers. This article provides examples of the wide range of value adding benefits that well-designed and implemented demand improvement efforts can have for the wide range of customers affected. PMID- 10175726 TI - The AIDS predator. PMID- 10175727 TI - Body imaging. How doctors learned to peer beneath our skin to see what might be wrong without using surgery. PMID- 10175728 TI - Surgeon, drop that scalpel. PMID- 10175729 TI - Oh, yeah, the uninsured. PMID- 10175730 TI - Micromanaged care? PMID- 10175731 TI - The long road to home care automation. PMID- 10175732 TI - Privacy. Are there any guarantees? AB - Many health plan members worry that their medical records no longer are kept securely in paper medical files. Electronic data, they argue, is too easy to access. But healthcare administrators often need to use personal medical information to follow trends in outcomes, quality management and utilization review. Is there a balance? Kathleen O'Connor reports that Donna Shalala, secretary of the Department of Health and Human Services, recently provided some suggestions for safeguarding medical privacy in the information age. PMID- 10175733 TI - Realizing the promise of EDI. PMID- 10175734 TI - Feds stake a claim on standards. AB - One of the biggest challenges facing managed care organizations in the wake of The Health Insurance Portability and Accountability Act of 1996 is the lack of standards in the area of electronic claims. Administrative simplification--the federal government's plan to improve the transmission of medical data through the use of information technology--is putting pressure on payors, providers and vendors to come up with a standard set of rules before they begin to address other requirements of the new legislation. Article by Charlene Marietti. PMID- 10175735 TI - Remedy register. Claims management information systems update. PMID- 10175736 TI - Going global with information technology. Interview by Barbara Hesselgrave. PMID- 10175738 TI - Software helps cure patient scheduling headaches. AB - The popularity of scheduling software is growing as providers try to find new ways of improving efficiency. That's particularly true at integrated delivery systems, which are seeking to better coordinate care delivery across multiple sites. PMID- 10175737 TI - Planning for disaster recovery. AB - Planning for restoring information systems in the event of a disaster is rapidly changing and growing in importance. As health care organizations become more reliant on information technology, they're taking extra steps to safeguard their investments and to ensure reliable access to data. PMID- 10175739 TI - Overcoming physician resistance. PMID- 10175740 TI - Moving beyond billboards. PMID- 10175741 TI - Healtheon tries a different tack. PMID- 10175742 TI - Disney's city of the future. PMID- 10175743 TI - Tackling challenges following a merger. PMID- 10175744 TI - When will smaller medical groups discover computers? AB - Competitive pressures are leading many smaller group practices to take a long, hard look at investing more heavily in computer hardware and software, especially electronic patient records systems. These smaller group practices find it difficult to locate reliable information, identify someone to lead the automation effort and generate the cash to pay for the technology they need. PMID- 10175745 TI - Records standards: making sure everything fits perfectly. AB - Many organizations are working on setting standards for virtually every facet of electronic records, from medical vocabulary to clinical electronic data interchange. Standards for records ease the exchange of potentially life-saving information and facilitate research on what treatments work best. But some argue that the industry won't make any real progress in this area until the market for computer-based patient records software matures. PMID- 10175747 TI - Is speech recognition ready to roll? PMID- 10175746 TI - Practice management companies. Creating sound information technology strategies. AB - Practice management companies are becoming more prominent players in the health care industry. To improve the performance of the group practices that they acquire, these companies are striving to use updated information technologies. PMID- 10175748 TI - National scientists work to create 'virtual' patient record. PMID- 10175749 TI - Five minutes with Lori Porter. Interview by Doug Brunk. PMID- 10175750 TI - Benchmarking deserves a chance. PMID- 10175751 TI - When something just isn't kosher. PMID- 10175752 TI - Cost cutoff. Are you ready for Medicare's new PPS? AB - Medicare's new PPS will radically change the way skilled nursing facility managers think about acuity levels, therapies, and billing, among other key factors. How will it change the way you do your job, and what can you do to prepare for it? PMID- 10175753 TI - Map or maze? Confused about disease management? Here's how to make it work for you. AB - Disease management has some advantages over ad hoc, individualized care. But flexibility and a full understanding of the philosophy are essential to making standardized care plans work. PMID- 10175754 TI - Cover me. How can you get your share of positive media coverage? AB - Inch for inch, legitimate press coverage gives you far more credibility than direct mail, give-aways, or other marketing ploys--and it costs far less than an ad. Here's how can you get your share of media coverage. PMID- 10175755 TI - The Fair Housing Act: sword or shield? PMID- 10175756 TI - Getting the most out of your information system. PMID- 10175757 TI - Anxiety over ethics, contract disputes forces physicians to take a stand. PMID- 10175758 TI - Hospitalists can cut LOS, help get MCO contracts. PMID- 10175759 TI - Switching to a hospitalist model is simple. PMID- 10175761 TI - Internal audit prepares practice for surveys. PMID- 10175760 TI - What NASA probably can't tell you about expansion. PMID- 10175762 TI - And now what? A post-electoral commentary on the federal commitment to health care. AB - The former Federal Minister of Health and Welfare (1977-1984) and Dean of the Faculty of Health Sciences at the University of Ottawa brings a unique perspective to the recent federal election and the newly re-elected government's commitment to Canada's health care system and its future. PMID- 10175763 TI - A discharge scoring system for patients with total hip replacement. AB - Total hip replacement is a common and expensive procedure. Any attempt to shorten the length of hospital stay safely is desirable. Proposes a scoring system specifically designed for this patient population, to determine the optimal timing of safe discharge and postacute care placement. Discusses its implications for the quality of patient care. PMID- 10175764 TI - Patients' perceptions of outcomes of a Canadian hospitalization. AB - Notes that with health care reform moving at tremendous speed throughout Canada, a great deal of interest in outcomes research has been generated. States that the research team consisted of 17 professional practice leaders from eight disciplines. Proposes, through the research, to identify from the perspective of former patients what results they hoped to achieve prior to discharge from hospital and what facilitated and hindered them in achieving these results. Reports that a representative sample was selected for the study. Forty-one former patients each participated in up to two focus groups, with a total of 16 focus groups conducted. Hierarchical analysis revealed themes that fell within the framework of structure, process and outcomes. The findings will assist in ensuring that more appropriate and effective care is offered to patients by a variety of disciplines. PMID- 10175765 TI - Outpatient clinic's staffing: a case study. AB - Suggests that the traditional approach for establishing staffing levels in hospital systems is not feasible. Presents steps taken to study the staffing levels in an outpatient clinic of a central hospital. Puts forward recommendations for a periodic evaluation of staffing levels. PMID- 10175766 TI - Establishing and developing health promotion in an acute trust. AB - Outlines the integration of "Health of the Nation" and quality assurance into a health promotion strategy and reports on its implementation in a UK Health Trust. Presents and discusses strengths and weaknesses of such a health promotion strategy. PMID- 10175767 TI - Evidence-based clinical guidelines--implementation plans in Scotland. AB - Presents a study which investigates how it was planned to implement guidelines from the Scottish intercollegiate guidelines network (SIGN). The study aimed to describe the activity in planning the implementation of SIGN guidelines in Scottish Health Service Trusts in 1996, and to provide a baseline for evaluation. A postal questionnaire was sent to the Clinical Audit lead person in 46 Scottish Health Service Trusts. The response rate after two reminders ranged from 60-72 per cent across different categories of Trust. The questionnaire asked for plans to implement individual guidelines, adaptation, professions involved, timeframes, dissemination, and evaluation methods. Reveals that local consensus was the main factor in deciding priorities. Most Trusts wished to see other local versions of guidelines produced, and to evaluate implementation collaboratively. Most expected to have reviewed baseline practice before implementation. PMID- 10175768 TI - Annotated bibliography: integrated approaches to quality improvement in health care: Part VII. PMID- 10175769 TI - Quality assurance. PMID- 10175771 TI - Monitoring quality in the British health service--a case study and a theoretical critique. AB - Details the results of a monitoring exercise introduced in one local hospital to address the amount of time that patients spent waiting when attending outpatient departments in hospitals. Discusses whether a purely quantitative approach to quality can deliver the desired improvements. Argues that quality measures should incorporate more qualitative dimensions, including the tapping of patient perceptions of their experiences, before a claim can be made that reducing waiting times has improved overall quality. Also argues that the frequent use of the term customer in the quality literature receives critical attention when it is applied in the NHS. The fact that the term conflates the roles of consumer and purchaser makes analysis potentially difficult. Suggests that regarding patients as customers (in the manner of some traditional approaches to quality) is not a useful aid to analysis. PMID- 10175770 TI - Change-oriented patient questionnaires--testing a new method at three departments of ophthalmology. AB - The use of patient questionnaires has increased widely in recent years. Their purpose, to incorporate patient perspectives into the orientation and design of health care, is, of course, commendable. However, the survey methods themselves have been less adequate, both in terms of validity and reliability, and with respect to the potential for using the results to improve the quality of health care. Presents a pilot study at three departments of ophthalmology in Sweden, involving a new method which meets reasonable demands for validity and reliability, and is explicitly change-oriented. PMID- 10175772 TI - "I find the term customer offensive". AB - Explores the tensions between cost and quality, need and market, and the effects on patient care and service providers within today's NHS. Builds on research carried out in two hospitals during 1993 to 1995, focusing on perceptions of quality and its management in the context of the nursing discipline. Indicates a divergence of perspectives on "customer requirements" and the emergence of a cultural divide within the total care process. Identifies and illustrates the significant potential for cost savings in health care, which may be achievable while simultaneously improving quality, and suggests that the "prize" for bridging the cultural divide might include a substantial financial gain as well as improved standards of care. In the context of health care, need, expectation, and finite resources are inextricably linked. A shared understanding of the interdependence between the three, and of the balance to be struck, is essential in health care provision today and into the twenty-first century. Suggests that there is some way to go. PMID- 10175774 TI - Recent service evaluation research on people with learning difficulties. AB - Substantial research on the evaluation of residential services for people with learning difficulties emerged over the last ten years in the UK. Reviews some of the major findings (N = 14). Their measures on the effectiveness of services were based on three components: the reduction of clients' challenging behaviour; the level of engagement between staff and clients; and clients' community involvement. An overall impression showed inconsistency and controversy in the first two components but a negative trend in the third. Discusses some methodological issues and suggests other components for service evaluation research. PMID- 10175773 TI - Total partnership for primary health care provision: a proposed model: Part I. AB - Presents the first of a two part paper, based on a study which examined the dynamics of primary health care provision. The study examined 49 general practices in the Kirklees area, UK, through a detailed questionnaire mode. The response was 67 per cent covering the views of 106 doctors. To capture further input for the study, an in-depth seminar with nine doctors from a range of practices was conducted. Examines internal factors for managing general practices and the levels of competence in addressing financial, strategic, quality issues and whether general practices get involved in any external activities for new learning and benchmarking. Comprehensively covers common areas of concern and areas where expertise may be inadequate or lacking. PMID- 10175775 TI - Annotated bibliography: integrated approaches to quality improvement in health care: Part VIII. PMID- 10175776 TI - Children's hospitals benchmark through restricted Internet site. PMID- 10175777 TI - Benchmarking cuts lab utilization nearly in half. PMID- 10175778 TI - Path inventory facilitates benchmarking care paths. PMID- 10175779 TI - Study may produce new best practices. PMID- 10175780 TI - Here are highlights of pressure ulcer guideline. PMID- 10175781 TI - Is cholesterol education dangerously flawed? PMID- 10175782 TI - Follow these guidelines for resistant S. aureus. PMID- 10175783 TI - As drug costs rise, health plans shift the burden. PMID- 10175784 TI - Choosing the right criteria for carving out services. PMID- 10175786 TI - Variety of factors influence health plan selection. PMID- 10175785 TI - How HIPAA will affect your capitation experience. PMID- 10175787 TI - Neurology network develops successful capitation model. PMID- 10175788 TI - Use MD profiling to improve capitation performance. PMID- 10175790 TI - Texas malpractice law stings HMOs, threatens providers. PMID- 10175789 TI - Will ERISA law become a sword instead of a shield? PMID- 10175791 TI - Use these benchmarks to plan MD staffing under capitation. PMID- 10175792 TI - Multispecialty network offers doctors control, payers flexibility. PMID- 10175793 TI - Perspectives. Medicare buy-in: modest proposal kicks up big stir. PMID- 10175794 TI - Gold Book/Buyer's Guide. PMID- 10175795 TI - Marketing by means of the confidence factor. PMID- 10175796 TI - Clinton reignites health care battle with Consumer Bill of Rights and Responsibilities. PMID- 10175797 TI - A quick look at health care trends in 1998. PMID- 10175798 TI - Chicago hospitals form partnership that preserves their individual autonomy. PMID- 10175799 TI - Dana-Farber adopts new approach to women's cancer through new centers. PMID- 10175800 TI - The Health Care News Server reports business, political and managed care news at www.healthcarenewsserver.com. PMID- 10175801 TI - Are you ready to work in a managed care-dominated environment? PMID- 10175802 TI - Plans now require peer review. PMID- 10175803 TI - Medicare and Medicaid managed care over the top. PMID- 10175804 TI - Beware your staff whistle-blower. PMID- 10175805 TI - Ensure CP focuses on fraud opportunities. PMID- 10175806 TI - Manage sentinel events by fixing root causes. PMID- 10175807 TI - Should you consider ISO 9000? PMID- 10175808 TI - Weekly review of 'difficult discharges' reins in high-dollar cases. PMID- 10175809 TI - Don't stop with a written discharge plan. PMID- 10175810 TI - Mixing tech and touch saves $427 a month. PMID- 10175811 TI - One size of UM (utilization management) can't fit all. PMID- 10175812 TI - Don't rush your compliance plan. PMID- 10175813 TI - Beware the Y2K bug. PMID- 10175814 TI - Nerima Kings Garden. Nerima-ku, Tokyo, Japan. PMID- 10175815 TI - Health management awards. Picking winners. PMID- 10175816 TI - Primary care. Failure to achieve take-off. AB - The Primary Care Act, passed in April, allowed for experimentation with new forms of service delivery and enabled health authorities to commission GP services directly, suspending the national contract. It encouraged HAs, general practices and trusts to submit proposals for pilot projects to improve primary care. More than 500 proposals have been drawn up and the pilot projects are meant to go live on 1 April 1988. But progress has been sluggish. Many HAs are struggling to sustain enthusiasm for pilot projects, and GPs are divided. PMID- 10175817 TI - European community. Euro-cash dispensers. AB - Applications for funding should be well-targeted and must demonstrate a track record in the area of the proposed initiative. Applications not related to a trust's core business are unlikely to succeed. PMID- 10175818 TI - Waiting lists. Time for the hotel bar? PMID- 10175819 TI - The irrepressible computer. The brave new world of healthcare information technology. PMID- 10175820 TI - The frontier of ethics: a conversation with Alta Charo. Interview by Joe Flower. PMID- 10175821 TI - Older, sicker, smarter and redefining quality: the older consumer's quest for patient-driven service. PMID- 10175822 TI - Remapping healthcare: the move from insuring to ensuring health. PMID- 10175823 TI - Measures of quality: what can public reporting accomplish? PMID- 10175824 TI - One-to-one: knocking on healthcare's door. PMID- 10175825 TI - Making ethics an organizational priority. PMID- 10175826 TI - The uninsured: an old problem encounters new pressures. PMID- 10175827 TI - Lessons from the failed healthcare debate. PMID- 10175828 TI - The beginning of the end for HMOS. Part 2: Providers have more clout than they think. PMID- 10175829 TI - The most irrepressible force. PMID- 10175830 TI - It's a jungle out there. Some managers have learned how to hack through regulatory red tape. PMID- 10175831 TI - Air power. How to craft an IAQ program that will fly. PMID- 10175832 TI - Unfrozen assets. Some tips on tracking resources and equipment before integration. PMID- 10175833 TI - Does antibiotic resistance = germicide resistance? PMID- 10175834 TI - All fired up--receptacle testing rule sparks debate. PMID- 10175835 TI - HCFA extends survey cycle for home health agencies with deemed status. PMID- 10175836 TI - FDA issues alert of possible improper cleaning, disinfecting, and/or sterilizing of reusable medical devices. PMID- 10175837 TI - Top 10 most challenging laboratory standards: tips for future compliance. PMID- 10175838 TI - Credentialing and privileging in long term and subacute care: clarifying the issues. PMID- 10175839 TI - The future of managed care accountability. PMID- 10175840 TI - Customer service: the bridge between surveys. PMID- 10175841 TI - New Accreditation Participation Requirements chapters added to two manuals. PMID- 10175842 TI - Modifications to home care decision rules approved. PMID- 10175843 TI - How doctors spend their working hours. PMID- 10175844 TI - Managed care hurts quality for everyone. PMID- 10175845 TI - Patient satisfaction. These Medicare patients like HMOs. PMID- 10175846 TI - The Republicans' health-care agenda. PMID- 10175847 TI - Will telemedicine get you sued? PMID- 10175848 TI - Practicing medicine on the Net. PMID- 10175849 TI - The best ways to divide overhead. PMID- 10175850 TI - Kiss paperwork hassles goodbye. PMID- 10175851 TI - Coding, Part 2. Get the highest coding you're entitled to. PMID- 10175852 TI - "HMOs are good for doctors". Interview by David Azevedo. PMID- 10175853 TI - Doctors on the move. AB - We surveyed your colleagues to find out how they're responding to health-care turmoil. Our comprehensive findings show them selling, merging, relocating, or joining up. PMID- 10175854 TI - State health rankings. How are the tobacco fumes where you live? PMID- 10175856 TI - How to build clout when you work for a hospital. PMID- 10175855 TI - Confidentiality. Patients may have even more reason to worry. PMID- 10175857 TI - Coming soon: a public display of your performance record. PMID- 10175858 TI - Work fewer hours--but accomplish just as much. PMID- 10175859 TI - Don't handle money the way these practices did. PMID- 10175860 TI - Making a big group feel small. AB - Can a good-sized, well-established group reinvent itself? Recognizing a need for greater efficiency and more satisfied patients, this multispecialty clinic did. PMID- 10175862 TI - Treatment protocols. Groups prefer the homegrown variety. PMID- 10175861 TI - Turning over inpatients to a "hospitalist". PMID- 10175863 TI - Group compensation. For primary-care doctors, the brakes are on. PMID- 10175864 TI - Health-care executives. Job satisfaction comes at a heavy price. PMID- 10175865 TI - Hospital privileges under attack? Fight back--carefully. PMID- 10175866 TI - How to find--and use--a good accountant. PMID- 10175867 TI - Luring patients in for preventive care. PMID- 10175868 TI - Add fun and profits to your practice: do research. PMID- 10175870 TI - Sharp shootin'. Texas doctors put HMOs in the malpractice target zone. PMID- 10175869 TI - Clinical research: facing down the ethical dilemmas. PMID- 10175871 TI - Salary/benefits survey. Fringes: the wider the choices, the happier the staff. PMID- 10175872 TI - No-cause terminations: will they go up in flames? PMID- 10175873 TI - A court says No to doctor dumping. PMID- 10175874 TI - Washington '98: looming battles in the health-care war zone. PMID- 10175875 TI - Malpractice. Even when the claims go down, the news isn't always good. PMID- 10175876 TI - Quality of care. Groups rely on patients to tell them how they're doing. PMID- 10175877 TI - Will your malpractice insurer stifle your defense? PMID- 10175878 TI - How to deal with a stingy boss. PMID- 10175879 TI - 10 keys to running a good meeting. PMID- 10175880 TI - Salary/benefits survey. Are you paying your staff enough? PMID- 10175881 TI - Managed care is toughest on women doctors. PMID- 10175882 TI - Let's call a truce in the HMO referral war. PMID- 10175883 TI - Medicare's fee changes: how will you fare? PMID- 10175884 TI - Equal treatment for all patients? PMID- 10175885 TI - Suits vs. stethoscopes. Who's to blame when doctor-hospital mergers turn sour? PMID- 10175886 TI - These doctors pay their dues--to a union. PMID- 10175887 TI - Lack of insurance killed these patients. PMID- 10175888 TI - Managed care. Execs blame the press for MCOs' enrollment lag. PMID- 10175889 TI - Charlie the angel. Interview by Michael Pretzer. PMID- 10175890 TI - When fee-for-service is capitation in disguise. PMID- 10175891 TI - Things you do that nettle your staff. PMID- 10175892 TI - How much are groups paying doctors? PMID- 10175894 TI - A welcome delay. Small hospitals applaud JCAHO Oryx extension. PMID- 10175893 TI - Remember these dates. They give you easy ways to build patient--and staff- loyalty. PMID- 10175895 TI - For the Benefis of one. State lets Montana expand on local monopoly. PMID- 10175896 TI - Conflicting regs. Rural referrals hospitals lobby to alter HCFA rules. PMID- 10175897 TI - Embracing change. The only thing you can count on in healthcare is that nothing will stay the same. AB - From more woes for managed-care firms to continued hospital mergers, particularly among not-for-profits, the staff of Modern Healthcare makes its predictions for the healthcare industry in the new year. And--which should come as no surprise to seasoned executives--1998 should turn out to be memorable, possibly invigorating and most certainly full of change. PMID- 10175898 TI - A formula for shipshape management. Top 100 U.S. hospitals find quickest, best care routes. PMID- 10175899 TI - Long road in California. Panel finally set to make managed-care recommendations. PMID- 10175900 TI - Onward capitation. Doctors predict big growth in finance arrangements. PMID- 10175901 TI - All healthcare, all hours. New cable channel to pursue local hospital partners. PMID- 10175902 TI - Quality is in. Medicare will base participation on performance. PMID- 10175903 TI - A fat year for hospitals. Patient-care revenue growth fuels $21 billion profit in '96. PMID- 10175905 TI - Chapter 11 now a part of hospital prenuptials. PMID- 10175904 TI - Still trying to rein in feds. AHA letters to Congress question use of False Claims Act, seek legislative relief. PMID- 10175906 TI - Celebrating CON approval. After two denials, Florida hospital's bed transfer OK'd. PMID- 10175907 TI - '96 health spending rise smallest in 36 years. PMID- 10175909 TI - What's a PSO? HCFA previews its definition. PMID- 10175908 TI - Not a happy new year. Home-care agencies hit by lower reimbursements, new regulations. PMID- 10175910 TI - An off year for consolidation. 1997 hospital mergers, acquisitions, joint ventures and long-term leases. AB - Because of a significant drop in the number of major corporate mergers and acquisitions, total hospital consolidation in 1997 was well off the record setting pace of previous years. The number of hospitals involved in dealmaking dropped 18% to 627 compared with the previous year, according to Modern Healthcare's fourth annual roundup of consolidation activity. And there were only four corporate deals, compared with 11 in 1996. PMID- 10175911 TI - Stent wars. Guidant beats back market leader Johnson & Johnson with new device. PMID- 10175912 TI - Hospitals and hospitality. Meditrust REIT acquires hotel chain for $3 billion. PMID- 10175913 TI - N.J. smokers to finance charity care. PMID- 10175914 TI - Stark II spelled out. PMID- 10175915 TI - Widening Medicare. Critics rip Clinton proposal as expensive, ineffective. PMID- 10175916 TI - What downsizing? Hospitals adding nurses as part of work-force expansion. PMID- 10175917 TI - 5 plead guilty in nurse visa scheme. PMID- 10175918 TI - For-profit growth. Despite drop in deals, systems claim more hospitals. PMID- 10175919 TI - Hospital converts ahead of law. PMID- 10175920 TI - Docs strike back. Physicians are going to extremes to stop mergers. PMID- 10175921 TI - JCAHO policy altered. Controversial 'watch' program pushed down line. PMID- 10175922 TI - Stays still too long, firm says. PMID- 10175923 TI - Kaiser sets new grievance process. PMID- 10175924 TI - Election-year alert. Consumer pressure may drive reforms in healthcare fraud, managed care. PMID- 10175925 TI - Criminals, every one. When the Justice Department goes looking, there's no place for innocence. PMID- 10175926 TI - 1998 Trustees of the Year. N.Y. trustee nursed hospital back from brink. PMID- 10175927 TI - 1998 Trustees of the year. Iowa trustee made facility deliver on its name. PMID- 10175928 TI - Rising profits make pleading poor tough. PMID- 10175929 TI - Consolidation trend increases odds for conflicts of interest. PMID- 10175930 TI - Awards for technology innovation. Adding up savings. Hospital, docs reaps benefits of computer initiatives. PMID- 10175931 TI - Awards for technology innovation. Rx for efficiency. Medical center creatively combines pharmacy data system with robotics. PMID- 10175932 TI - Awards for technology innovation. Diagramming care. Burn center uses computers to better serve patients. PMID- 10175933 TI - Rules to play by. New accounting regs could have big impact on PPMs. PMID- 10175934 TI - Quality, schmality. Lack of marketplace demand causes Calif. doc group accreditor to go belly up. PMID- 10175935 TI - A voluminous year. Low interest rates likely to fuel bond sales momentum. PMID- 10175936 TI - Bad breakup. PPM, Catholic system nix partnership after power struggle. PMID- 10175937 TI - VHA readies ad campaign. Proposed plan would play up local hospitals' strengths. PMID- 10175938 TI - Tenet joins AHA inner circle. Committee appointment may enhance networking. PMID- 10175939 TI - AHA ponders backing tax hike. PMID- 10175940 TI - Consumers first. Industry trying but still not meeting demands--study. PMID- 10175941 TI - New threat to HMOs. Bill to amend ERISA would allow patients to sue. PMID- 10175942 TI - Small update from Medicare+Choice. PMID- 10175943 TI - The challenge ahead. With local partners, health systems take up the gauntlet against uninsurance. PMID- 10175944 TI - AHA 100th anniversary. Good Samaritan business. AB - In recognition of the American Hospital Association's centennial, we examine the AHA's long history, how it has evolved with the constantly changing healthcare industry and where the next century will take the nation's largest trade group. Our special section features interviews with AHA President Richard Davidson and two of his predecessors. We also look at the hospital's changing role in the community and the AHA's lobbying legacy. In addition, we've included highlights of the association's upcoming centennial membership meeting. PMID- 10175945 TI - AHA 100th anniversary. Celebrating change. AHA to toast centennial--and look ahead--at D.C. gala. PMID- 10175946 TI - AHA 100th anniversary. 100 years of service. PMID- 10175947 TI - AHA 100th anniversary. The view from the top. Interview by Deanna Bellandi. PMID- 10175948 TI - AHA 100th anniversary. McCarthy broke ground. Interview by Deanna Bellandi. PMID- 10175949 TI - The next reform fight. This time, healthcare groups are taking on GOP as well. PMID- 10175950 TI - AHA 100th anniversary. McMahon sought unity. Interview by Deanna Bellandi. PMID- 10175951 TI - AHA 100th anniversary. Lobbying legacy. AHA's D.C. office forever changed by Medicare PPS. PMID- 10175952 TI - AHA 100th anniversary. The next 100 years. AHA name a link to past as group looks toward future. PMID- 10175953 TI - Facing a test. IRS may reinstate old rules for not-for-profit 401(k)s. PMID- 10175954 TI - Outcomes studies: quest continues for validation. PMID- 10175955 TI - Competing in managed care with marketing skills and technology. PMID- 10175956 TI - Prospects for the evolution of automated hematology: one laboratory's experience. PMID- 10175957 TI - Reagents for measuring intracellular enzyme activity with flow cytometry. AB - The line of enzyme substrates described, together with the flow cytometer, bring a simplified method of measuring intracellular enzyme activity to the research laboratory. They are optimized for use in flow cytometry but can also be adapted to other fluorescent detection methods (e.g., spectrofluorometry, fluorescent microscopy, and image analysis) (Figure 5). The large number of enzymes that can be measured with the reagents (currently 37), together with the automation and multiparametric capabilities of flow cytometry, offer many advantages over conventional methods of cell characterization. They also expand the potential of functional assays for studying many normal physiological and disease processes. PMID- 10175958 TI - Hormone replacement therapy for men. PMID- 10175959 TI - Productivity evaluation of random access immunoassay platforms. PMID- 10175960 TI - Disease treatment or disease management? A misleading dichotomy. PMID- 10175961 TI - Scintigraphic assessment of drug delivery from the Ultrahaler dry powder inhaler. AB - A new dry powder inhaler, the Ultrahaler, has been developed to deliver nedocromil sodium for the prophylaxis of asthma. This study was performed to compare the lung deposition of nedocromil sodium inhaled from the Ultrahaler at two different inhaled flow rates with that from a pressurised metered dose inhaler (MDI). A scintigraphic study was conducted in 12 healthy volunteers. On each study day, volunteers received a single 4.2 mg dose of nedocromil sodium from the Ultrahaler, using either an optimal (fast) inhaled flow rate or a suboptimal (slow) inhaled flow rate, or two doses of 2 mg nedocromil sodium from an MDI using an optimal (slow) inhaled flow rate. Used optimally, the Ultrahaler deposited significantly more (p < 0.05) of the metered dose in the lungs than either the Ultrahaler used suboptimally or the MDI used optimally [mean (SD) lung deposition values of 13.3 (4.8)%, 9.8 (3.5)%, and 7.5 (2.9)%, respectively]. Oropharyngeal deposition averaged over 80% of the dose for all three treatment regimens. This scintigraphic study demonstrated in vivo proof of concept for the Ultrahaler dry powder inhaler, and provided quantitative data on the relationship in lung deposition between the Ultrahaler and MDI which differed from that predicted by the in vitro fine particle fraction. PMID- 10175962 TI - A comparative analysis of primate nasal airways using magnetic resonance imaging and nasal casts. AB - The nasal cavity is an intricate part of the respiratory tract. It is not only the site of olfaction, but also serves as a filter to protect the lower respiratory tract from inhaled pollutants. A substantial fraction of inhaled particles deposit in this region and may pose potential health risks. To predict possible sites of inhaled aerosol deposition and better understand health risks associated with inhaled aerosols in this region, it is necessary to examine the morphometry of the nasal passage. Magnetic resonance imaging (MRI) of the nose was done from the anterior to the posterior, in 3-mm sections, on five anesthetized rhesus monkeys and on two nasal casts (one human and one rhesus monkey). The MRI images were analyzed for perimeter and cross-sectional areas of each section. Results indicated that the left and right nasal passages were very symmetric for the five monkeys but not for the human cast. The cross-sectional area and, consequently, the volume varied greatly among monkeys in vivo. Measurements from the monkey cast exhibited 1.4-fold differences normalized body weight in cross-sectional areas, but with smaller differences in perimeter when compared to the MRI in vivo images. The human cast exhibited a volume three times greater than that of the monkey cast, while the surface area was approximately doubled. Results from this comparison showed many similarities in the structure of the monkey and human nose suggesting that the rhesus monkey would be a good human surrogate in aerosol deposition studies. PMID- 10175963 TI - In vitro performance testing of three small volume-holding chambers under conditions that correspond with use by infants and small children. AB - The in vitro behavior of three types of small volume-holding chambers intended for use by infants and small children (child AeroChamber, Vent-170 and Space Chamber) has been compared with two pMDI-delivered aerosol formulations (salbutamol: 100 micrograms unit dose and beclomethasone di-propionate (BDP): 50 micrograms unit dose) widely prescribed for this age group of patients. All devices were evaluated using a pediatric breathing simulator that created respiratory conditions likely to be encountered with infants and small children. The filter that collected aerosol delivered from the holding chamber on test was located at approximately the position that the patient's lips would be in the mask, by means of an annular support plate glued into the mask itself. At the lowest tidal volume (50 ml), no salbutamol or BDP was delivered by either the Vent-170 or Space Chamber, whereas the unit doses from the child AeroChamber were 39.7 +/- 1.6 micrograms and 11.8 +/- 1.2 micrograms, respectively. The Vent-170 and Space Chamber delivered measurable doses of both drugs when the tidal volume was increased to 100 ml and again to 200 ml, however, the corresponding doses available from the AeroChamber were always significantly greater. These findings emphasize the importance of designing in vitro tests that mimic use by the patient group for which the device is intended. In vitro measurements made at constant high flow rates in excess of 20 l/min do not reveal these differences in performance that are clinically significant, and may lead the physician to prescribe a device that under certain conditions may not deliver any drug to infants or small children. PMID- 10175964 TI - An experimental investigation of the spray issued from a pMDI using laser diagnostic techniques. AB - This research was concerned with the experimental investigation of the spray issued from a pressurised metered-dose inhaler (pMDI) using laser diagnostic techniques and has been motivated by the urgent need to find suitable replacements to the environmentally destructive CFC propellants currently used in the device. The experimental work was conducted using phase-Doppler particle analysis (PDPA), a single particle light scattering technique that provides the simultaneous measurement of drop size, velocity, and concentration, yielding the most detailed temporal and spatial analysis of the pMDI spray to date. Three formulations were studied to compare the performance of an "ozone-friendly" hydrofluoroalkane propellant against that of a traditional CFC propellant mixture and a commercially available CFC formulation containing drug and surfactant. The PDPA analysis was complemented by a visual investigation of the near-orifice flow field using copper laserstrobe microcinematography to obtain information on the primary atomization process of the pMDI. This work was conducted in parallel with the theoretical investigation of the spray issued from a pMDI. PMID- 10175965 TI - Building an interdisciplinary team. Strategies for leadership, consensus building, meetings, and performance reviews. PMID- 10175966 TI - A new approach to sports rehabilitation. Functional rehab program focuses on patients' individual needs. PMID- 10175967 TI - Preventing work site injuries. PMID- 10175968 TI - The future of physical therapy. PMID- 10175969 TI - Nutrition and rehabilitation. Medical nutrition therapy is recognized as an important element in complete rehabilitation. PMID- 10175970 TI - Introduction. Sexual networking, knowledge, and risk: contextual social research for confronting AIDS and STDs in eastern and southern Africa. PMID- 10175971 TI - Exploring partner communication and patterns of sexual networking: qualitative research to improve management of sexually transmitted diseases. AB - This ethnographic research among rural South African men and women seeking care for STDs explores constraints to communication among partners and defines predominant patterns of sexual networking. A series of fifteen open-ended interviews explored topics related to sexual networking and partner communication. Patterns of sexual networking showed clear gender variation, with men more likely to discuss multiple partners. Both men and women believed they should tell one partner about their STD, most often a steady partner. Strong distinctions were made between regular and casual partners, with an emphasis on the role of trust in a steady relationship. Men and women expressed anxiety about telling their partners of their illness, but women more often expressed fear whereas men felt embarrassed. Multi-partnered sexuality is common and is widely accepted for men. While the importance of regular partnerships is clear for both men and women, sexual relationships appear to be highly unstable. Communication among partners could be facilitated by stronger health promotion messages, such as the importance of telling a partner about an STD. Prevailing patterns of communication and sexual networking have profound implications for the STD epidemic. PMID- 10175972 TI - 'Between a rock and a hard place': applied anthropology and AIDS research on a commercial farm in Zambia. AB - Fieldwork on a commercial farm in southern Zambia, which was aimed at designing an HIV prevention program for farm workers, gradually exposed the nature of sexual liaisons between young girls, coming to work on the farm from the surrounding villages, and older migrant men workers. Before completing fieldwork, the anthropologist voiced her concern about the implications of these liaisons for the spread of STDs and HIV with the local rural community, farm management and farm workers. The immediate outcome of her intercessions was the decision by management to sack under-age workers. Although some members of the local community, including local research assistants, and some managers and workers welcomed this decision, others were angered by it. Caught between interest groups and conflicting guidelines, the anthropologist, it is argued, was in a no-win situation, 'between a rock and a hard place'. The paper proposes that the application of anthropological ethics in AIDS research needs some re-evaluation. PMID- 10175973 TI - HIV/AIDS and sexual behaviour among youth in Zambia. AB - This study was carried out in selected urban areas in Zambia; its objective was to examine the sexual networking and activities of urban youth in Zambia: specifically to determine how sexual behaviour among young people might influence the course of the AIDS epidemic and also to suggest policy interventions. Sexual behaviour among young people both in-school and out-of-school, aged between 12 and 25, may be vital in influencing the spread of AIDS in Zambia. The results indicate that sexual matters are discussed with close friends of the same sex and peer group, or with cousins who are of the same age. Sometimes grandmothers are consulted for advice by co-resident grand-daughters. Girls and boys engaged in sex or thought about engaging in sex at quite an early age. Girls discussed their intentions about sex with their close friends, many of whom appeared poorly informed about sex themselves. The general views of both sexes about STDs should be a source of concern. The youth do not seem to take STDs seriously basically because most of them, aside from AIDS, are curable. Many young people do not regard AIDS as a threat to their lives and do not even consider it as a hindrance to sexual relationships. A number of recommendations are made for information and education of young people, parents and teachers. PMID- 10175974 TI - Reassessing quality-of-life instruments in the evaluation of new drugs. AB - Investigators use 2 fundamental approaches to the measurement of health-related quality of life (HR-QOL). Generic instruments include health profiles that tap into the full range of HR-QOL issues and are widely applicable, but may lack responsiveness to small but important changes in HR-QOL. Utility measures summarise HR-QOL in a single number between 0 (death) and 1 (full health) and are useful for economic analysis, but may lack responsiveness. Accumulating data suggest the alternatives to generic measures, instruments that are specific to a function or a health problem, are more responsive than generic measures. While direct comparison of the validity and responsiveness of alternative approaches remains limited and should be extended, it is already clear that comprehensive assessment of HR-QOL requires more than 1 type of instrument. To be useful, HR QOL instruments must be interpretable. Investigators are beginning to elucidate what constitutes trivial, small but important, or large changes in HR-QOL. Approaches include both within- and between-patient global ratings, observing HR QOL scores in different patient populations, and observing the magnitude of change in HR-QOL with established interventions. PMID- 10175975 TI - The Danish approach to standards for economic evaluation methodologies. AB - Standards for economic evaluation have now been proposed in several countries. The background for this article is a report commissioned in 1994 by the Danish health authorities (the National Board of Health and the Danish Ministry of Health) on the state of the art of economic evaluation: are the methods ready to be used for systematic decision-making in the Danish healthcare sector? The themes of this article are the attitude towards economic evaluation of medical technologies and healthcare services in Denmark, the areas for application and the desirability and feasibility of a standard set of methods for conducting economic evaluations. In addition, the current state of methodologies in economic evaluation is briefly outlined. On the background of a roundtable discussion of interested parties, the Danish health authorities have decided to introduce economic evaluation of new pharmaceutical products, on a voluntary basis for 2 to 3 years, when application has been made for public reimbursement. PMID- 10175976 TI - Assessing antibacterial pharmacoeconomics in the intensive care unit. AB - Intensive care units (ICUs) represent areas of high use of antibacterials and other pharmacy goods and services. Many institutions view their ICUs as a target for drug-use surveillance and cost-containment programmes. Economic assessment of antibacterial interventions in the ICU should include all direct costs and patient outcomes. Nonetheless, many of these institutions focus their efforts at reducing antibacterial costs without considering the consequences of these actions. It is possible that devoting more resources to antibacterials can have an overall positive economic impact if more appropriate antibacterial use reduces length of stay, decreases bacterial resistance or lowers frequency of adverse complications. Two consequences of antibacterial use which can result in substantial economic burdens to institutions are drug-induced complications (toxicities and adverse events) and the development of antibacterial-resistant organisms. These events are logical targets for performing pharmacoeconomic studies to evaluate appropriate and inappropriate antibacterial use. Either of these problems can increase length of stay, which is the single most important variable influencing the overall cost of patient care. The primary goal of patient care is to hasten patients' clinical improvement. This will result in decreased antibacterial acquisition costs, decreased lengths of ICU and hospital stays, and ultimately decreased consumption of hospital resources. These can be accomplished by using strategies to guide antibacterial use in order to reduce failures, adverse events, toxicity and antimicrobial resistance. PMID- 10175978 TI - Application of the findings of the European Stroke Prevention Study 2 (ESPS-2) to a New Zealand ischaemic stroke cost analysis. AB - The aim of this study was to apply the findings of the European Stroke Prevention Study 2 (ESPS-2) to a paper that quantified and described the annual cost of ischaemic stroke in New Zealand, and to compare the cost of alternative drug regimens in the secondary prevention of ischaemic stroke. Comparisons were made between the costs of low-dosage aspirin (acetylsalicylic acid) monotherapy and a combination of modified-release dipyridamole and low-dosage aspirin. Differences in undiscounted costs were calculated over a 2-year period. The New Zealand cost per stroke event was multiplied by the ESPS-2 incremental reduction in stroke events to derive the cost of strokes avoided. As the focus of the paper was on direct medical costs, the primary perspective adopted was that of a healthcare provider or funder, but a societal perspective was also considered by evaluation of direct nonmedical and indirect costs. Compared with aspirin monotherapy, combination therapy generated incremental net direct costs of 18.22 New Zealand dollars ($NZ) per patient or $NZ18,223 per 1000 patients. However, individually, each treatment regimen resulted in direct cost savings when compared with placebo: combination therapy $NZ905.16 per patient; aspirin monotherapy $NZ923.39 per patient (a difference between the 2 regimens of $NZ18.22 per patient). Total direct and indirect incremental cost savings were $NZ40.96 per patient, and $NZ40,963 per 1000 patients, for the combination therapy. The analysis demonstrates that changing patients from low-dosage aspirin to a combination therapy of modified-release dipyridamole plus low-dosage aspirin would result in a small rise in incremental direct costs (using our conservative assumptions relating to hospital and continuing institutional care costs). If less conservative unit cost assumptions were adopted, a more likely outcome would be a saving in direct incremental costs of up to $NZ400 per patient treated. PMID- 10175977 TI - Do practice guidelines augment drug utilisation review? AB - Drug utilisation review (DUR) or drug use evaluation (DUE) studies or programmes are intended to detect and/or correct inappropriate drug use. Appropriateness can be assessed at 3 levels: (i) whether any medication is warranted, or whether either no therapy or nondrug therapy is preferred (level 1); (ii) assuming drug therapy is indicated, which of several alternative drugs is the preferred choice? (level 2); and (iii) appropriateness of the drug regimen, including dosage, duration, type and frequency of monitoring, and drug interactions (level 3). The traditional approach to DUR/DUE has been to begin the appropriateness evaluation after a drug is prescribed. However, changes in healthcare organisation provide the basis for a disease-management or health-maintenance approach to DUR/DUE, and practice guidelines afford a possible source for guiding such studies. We hypothesised that the latter approach to DUR/DUE would be more likely to result in evaluation of level 1 drug-therapy issues than the traditional DUR/DUE approach. We tested this hypothesis by reviewing 56 practice guidelines involving drug therapy and also reviewed research studies published from 1992 to 1996. We found that studies that used the traditional DUR/DUE approach were most likely to examine level 3 drug-therapy issues, never addressed level 1 issues, and typically evaluated adherence to provider- or study team-developed guidelines rather than published guidelines. In contrast, the disease- or health-management approach nearly always examined level 1 issues, seldom addressed level 3 issues, and almost always evaluated adherence to a published practice guideline. Regardless of the DUR/DUE approach, about 40% of studies evaluated level 2 issues. The guidelines themselves were much more likely to include recommendations about level 1 and level 2 issues than about level 3 issues; however, even when a guideline included level 2 or level 3 issues, studies of adherence to the guideline rarely assessed anything beyond level 1 issues. This suggests that guideline recommendations about level 2 and level 3 issues may be too imprecise for use in evaluative studies. The drug-information compendia, on the other hand, provide detailed recommendations about level 3 issues. Revision of drug compendia may be warranted to include recommendations about all levels of drug-therapy issues. The results of intervention studies to improve drug-therapy compliance with guidelines suggest that information provided at the time of prescribing, information presented by local health professionals and information provided with a large amount of provider contact may be more likely to demonstrate significant improvements in drug therapy. We conclude that practice guidelines are a useful resource for augmenting DUR/DUE but that challenges to optimising their use include whether they can be kept current, acceptable and accessible to providers. PMID- 10175979 TI - Measuring patient benefit from botulinum toxin in the treatment of dystonia. Feasibility of cost-utility analysis. AB - The dystonias are a group of movement disorders arising from CNS dysfunction and characterised by involuntary and prolonged spasms of muscle contraction. Recently there has been increasing demand for treatment with botulinum toxin (BT), a relatively expensive neurological paralytic agent. As there has been no systematic assessment of patient benefit from BT, this study was undertaken to develop and test a methodology for assessing the cost utility of BT therapy for patients with dystonias. A generic health status instrument, the EuroQOL, was completed at regular intervals over at least 6 months by 130 patients with a current diagnosis of dystonia. A general population tariff was used to calculate quality-adjusted life-year (QALY) gains from BT treatment, and relevant cost data were obtained from patients and medical records. The cost-per-QALY estimates ranged considerably, depending on the type of dystonia, the duration of BT treatment, type of health-related quality-of-life (HR-QOL) tariff used and baseline characteristics of participants. The study findings reflect the general clinical impression of BT: that it can benefit patients with dystonia, but the benefit may be small compared with many treatments for other diseases. The nature of the disease and its cyclical treatment caused practical difficulties in recruiting participants, administering questionnaires and in estimating QALY gains. PMID- 10175980 TI - Quality assessment of economic evaluations published in PharmacoEconomics. The first four years (1992 to 1995). AB - Our objective was to assess the quality of reporting of original economic research articles in PharmacoEconomics from inception to the end of 1995, in order to identify areas of strength and weakness, and analyse trends over time. Each regular issue of the journal was examined for original economic evaluations. Accepted articles were categorised by study type and by year of publication. A previously developed 13-item quality-scoring checklist was applied. The maximum possible score that an article could be assigned was 4.0. Quality scores were analysed over time and by study type. 54 articles were identified for analysis. Mean overall score (OS) ranged from a minimum of 1.80 to a maximum of 3.75, with a mean OS of 3.01 [standard deviation (SD) = 0.47]. The item with the highest mean score was the 'definition of study aim' (mean OS = 3.46, SD = 0.69). The item with the lowest score was 'ethical problems discussed and identified' (mean OS = 1.44, SD = 0.92). Only 4 items on the checklist had mean scores lower than 3.0. No significant time trend was apparent for OS (R2 = 0.002). Cost-benefit (mean OS = 3.25, SD = 0.85, n = 5), cost-effectiveness (mean OS = 3.11, SD = 0.97, n = 27), and cost-utility (mean OS = 3.29, SD = 0.93, n = 6) analyses had mean scores significantly higher than cost-analysis/cost-of-illness studies (mean OS = 2.51, SD = 1.14, n = 8). The mean OS for cost-minimisation studies was 2.74 (SD = 0.49, n = 8). Despite some weaknesses in particular aspects of economic evaluations published in PharmacoEconomics, we conclude that the journal has offered publications with acceptable overall quality and adequate methodology. PMID- 10175982 TI - How to calculate indirect costs in economic evaluations. AB - This article describes the components that should be included as indirect costs to be consistent with economic theory in studies conducted from a societal perspective. The recently proposed method of how to estimate indirect costs, the friction-cost approach, is shown to exclude many aspects of these indirect cost components. Furthermore, it is demonstrated that this approach rests on very strong assumptions about the individual's valuation of leisure and about the labour market. This approach does not, in most realistic circumstances, have a foundation in economic theory. It also shows that all indirect costs cannot be assumed to be included in the individual's reported utility weight for a health state [used to determine quality-adjusted life-year (QALY) values], as recently suggested by the US Panel for Cost-Effectiveness Analysis of Health and Medicine. Therefore, to be consistent with economic theory, neither the friction-cost approach nor the QALY approach can be recommended over the more commonly used human capital-cost approach for estimating the indirect costs of a disease in economic evaluations from a societal perspective. PMID- 10175981 TI - Costs of treating dystonias and hemifacial spasm with botulinum toxin A. AB - Botulinum toxin (BTX) has become a safe and effective therapeutic tool in the treatment of a variety of neurological disorders, especially dystonias. One major disadvantage, however, is the high cost of a single injection of BTX. In this study of 835 patients, we calculated the cost of treatment with BTX serotype A (BTX-A) for different dystonias and hemifacial spasm. The annual expenditure per patient for BTX-A injections in this cohort totalled (mean +/- standard deviation) 1030 Deutschmarks (DM) [1996 values] +/- DM610 [$US570 +/- $US340; 230 +/- 130 pounds sterling (Pound)] for blepharospasm (n = 158), DM1450 +/- DM1520 ($US800 +/- $US830; 310 Pounds +/- 280 Pounds) for craniocervical dystonia (n = 148), and DM1480 +/- DM780 ($US810 +/- $US430; 330 Pounds +/- 180 Pounds) for oromandibular dystonia (n = 16), while the treatment of cervical dystonia consumed DM4590 +/- DM2060 ($US2520 +/- $US1130; 960 Pounds +/- 420 Pounds) [n = 362] per patient. In order to alleviate symptoms in patients with hemifacial spasm (n = 151), DM510 +/- DM270 ($US280 +/- $US150; 110 Pounds +/- 60 Pounds) had to be spent annually. The expenses for surgical therapy for cervical dystonia were DM10,120 +/- DM1900 (n = 54). No major differences concerning expenditure could be found in this study between the 2 available preparations of BTX. However, there appeared to be a lower rate of adverse effects with the Botox formulation, compared with the Dysport formulation, of BTX-A (this difference was statistically significant, i.e. p < 0.001). Although the cost of an individual injection is high, other cost factors also substantially contribute to the societal costs of adult-onset dystonias. Some of these costs may be attenuated with the use of BTX. The subjective and objective relief of these socially devastating and sometimes painful conditions rewards the expenditure associated with the use of BTX-A. PMID- 10175983 TI - An outline for a cost-effectiveness analysis of a drug for patients with Alzheimer's disease. AB - This article provides an outline for a cost-effectiveness analysis of a drug that slows the consequences of Alzheimer's disease. Such an analysis cannot easily be performed for 2 main reasons. The first is that often relatives and friends, rather than professionals, take care of the patient. This means that informal care plays an important role in the analysis. However, consensus on how to value informal care is lacking. In this article, we have recommended the shadow-price method because this is an option that can be practically applied. The second reason is that the primary source of information on quality of life, the patients themselves, is unreliable because of cognitive disturbances. The solution is to ask 'significant others' to indicate quality of life instead of the patient. As well as measuring the patient's quality of life, the quality of life of the informal caregiver is also often measured. This is recommended here, but as a separate item in the analysis. In this way, double-counting in the final cost effectiveness ratio can be avoided. Several instruments for measuring a patient's and caregiver's quality of life are discussed and recommendations about suitable methods are made. PMID- 10175984 TI - Economic aspects of antibacterial adverse effects. AB - The economic impact of adverse effects is often understated. Increased hospitalisations attributed to adverse drug reactions alone account for billions of dollars each year within the US healthcare system. Although most classes of antibacterials are well tolerated, severe reactions do occur and can add significantly to the cost of care. Among hospitalised patients, antibacterial adverse effects account for nearly 25% of adverse drug reactions. Published pharmacoeconomic data on direct and indirect costs of antibacterial adverse effects are lacking. The importance of determining the most cost-effective treatment regimen is becoming more apparent due to limited resources available within the healthcare system. When considering the cost of new antibacterials, a simple comparison of acquisition costs may not accurately reflect the true costs of treatment. A drug with a lower acquisition cost may be more toxic and/or less effective, resulting in higher complication rates and/or treatment failures, thus leading to a higher overall treatment cost. In addition, nephrotoxic agents such as aminoglycosides and vancomycin often require close monitoring of serum drug concentrations and creatinine levels, which also contributes to the total cost of therapy. Indirect costs as a result of reduced quality of life or loss of productivity are certainly not reflected in the acquisition costs of antimicrobials. Institutions must evaluate a drug's potential for causing and adverse event, among various other factors, when considering drugs for inclusion on their formularies. Drugs with good safety profiles may minimise hospitalisation or facilitate early discharge. Thus, the adverse effect profile of an antimicrobial agent can contribute significantly to its overall direct costs, primarily as a result of higher monitoring costs and additional days of hospitalisation. For example, in the US, the cost associated with adverse effects, such as nephrotoxicity, observed with aminoglycosides and vancomycin, may add approximately $US2500 per patient with nephrotoxicity (1990 values). Indirect costs can also be substantial as a result of reduced productivity. Many adverse effects of antibacterial agents are predictable and may be minimised with appropriate monitoring and care. This article reviews the pharmacoeconomic aspects of adverse effects associated with some of the more important antibacterial classes such as the beta-lactams, aminoglycosides, vancomycin, macrolides and fluoroquinolones. PMID- 10175985 TI - Peripheral arterial obliterative disease. Cost of illness in France. AB - The main purpose of this study, carried out in 1995, was to determine, using available sources, the cost of peripheral arterial obliterative disease (PAOD) in France over a 1-year period. This cost-of-illness study was based on a retrospective analysis of the available literature and databases. It involved a description of epidemiological data and a cost estimate of the different medical resources consumed over 1 year. For this latter purpose, a payer perspective was chosen. Data were extracted from national representative surveys and databases with respect to morbidity and mortality [from the National Institute of Health and Medical Research (Institut National de la Sante et de la Recherche Medicale; INSERM) and the National Sickness Insurance Fund for Salaried People (Caisse Nationale d'Assurance Maladie des Travailleurs Salaries; CNAMTS)], consultations, examination tests and drug prescriptions [from the French Medical Audit conducted by Intercontinental Medical Statistics (IMS)], hospitalisations [from the Statistical Unit of the Department of Health-Service des Statistiques, des Etudes et des Systemes d'Information (SESI) and the National Public Research Centre in Health Economics (Centre de Recherche d'Etude et de Documentation en Economie de la Sante; CREDES)] and related health expenditure from CNAMTS. In France, the prevalence of stage II PAOD (Leriche and Fontaine classification) in 1992 was estimated to be 675,000; 53% of these patients had undergone vascular or bypass surgery. The total annual cost of healthcare (including consultations, drugs, laboratory tests, hospitalisation and hydrotherapy) for the management of patients with PAOD ranged from 3.9 billion French francs (F) to F4.6 billion (1995 values), depending on the type of hospital considered. 50% of this cost was related to hospitalisations and 75% was covered by the CNAMTS. Although this study was only a partial evaluation and did not take into account indirect costs or nonmedical direct costs, such as transport and care by healthcare assistants and paramedics, these results may help to establish public health priorities and modify clinical practice to favour an earlier diagnosis of PAOD. PMID- 10175986 TI - Cost implications of initial antidepressant selection in primary care. AB - While fluoxetine is considerably more expensive than tricyclic antidepressants (TCAs), some previous studies have suggested that general medical expenditures are lower among patients treated with fluoxetine. In this study, computerised pharmacy and cost-accounting records of a large health plan were used to examine overall treatment costs for 5169 primary-care patients beginning antidepressant treatment with fluoxetine or one of 2 TCAs, imipramine or desipramine. Comparison was based on initial medication prescribed, regardless of subsequent switches or discontinuation. Patients treated with fluoxetine were older, with a higher burden of medical illness and higher overall health-service costs before starting antidepressant treatment, compared with patients receiving the other 2 drugs. Initial choice of fluoxetine was associated with approximately $US140 higher mean antidepressant costs and approximately $US300 higher mean costs for all other health services (1995 costs). Alternative methods of accounting for baseline differences (age, medical comorbidity, prior costs) indicated that adjusted 'non antidepressant' costs (total costs minus costs of antidepressant therapy) in the fluoxetine group were $US75 to $US300 lower than in either of the TCA groups, but these differences were not statistically significant. Subgroup analyses suggested that the use of fluoxetine was associated with lower overall costs only among those incurring high costs in the pretreatment period. These findings support earlier studies suggesting that the use of fluoxetine as a first-line antidepressant in primary care will increase antidepressant drug costs, but will not significantly increase total treatment costs. PMID- 10175987 TI - Price indices of drugs and the switching to new drugs. Two empirical examples. AB - Standard price indices may not account for the price decrease that results when patients switch to pharmaceutical products for which their demand-reservation price exceeds the price of the new product. In a similar way, standard price indices may not account for the price increase that results when patients switch to pharmaceuticals for which the reservation price is below the price of the new drug. This study was designed to assess whether standard pharmaceutical price indices under- or overestimate the real price development resulting from new drug introductions. We illustrate that both situations may occur. In our first example, the switch from a branded to a generic drug, we showed that standard price indices recorded a price increase of about 16%, although the price actually decreased by about 5%. In our second example, the introduction of new formulation of a currently marketed drug, we showed that standard price indices recorded a price increase of about 6%, when the actual price increased by more than 65%. PMID- 10175988 TI - Cost effectiveness of a low-molecular-weight heparin in prolonged prophylaxis against deep vein thrombosis after total hip replacement. AB - The risk of late-occurring deep vein thrombosis and pulmonary embolism after total hip replacement persists for at least 3 weeks after hospital discharge. Recent clinical trials have demonstrated that prolonged prophylaxis with enoxaparin, a low-molecular-weight heparin (LMWH), significantly reduces this risk. We used a decision-analysis model to determine the incremental outcomes associated with the routine use of such prophylaxis, administered during hospitalisation for total hip replacement and for 3 weeks after discharge, instead of short term prophylaxis administered only during hospitalisation. For a hypothetical cohort of 100,000 patients undergoing hip surgery, prolonged LMWH prophylaxis saved between 601 and 783 additional lives compared with prophylaxis stopped at discharge. This was obtained at a net direct marginal cost ranging from 1118 to 1300 French francs (F) per patient. The cost-effectiveness ratio ranged from F11,158 to F34,591 per life-year saved and from F23,532 to F35,268 per venous thromboembolic event (routinely diagnosed and treated) avoided. Prolonged LMWH anticoagulant prophylaxis with enoxaparin is more effective in routine practice after elective hip surgery than conventional short term perioperative prophylaxis in terms of the number of deaths or thromboembolic events avoided. Such prophylaxis also appears to be clearly cost effective, using French cost data. PMID- 10175989 TI - Single European currency and Monetary Union. Macroeconomic implications for pharmaceutical spending. AB - This article examines the potential implications of introducing a single currency among the Member States of the European Union for national pharmaceutical prices and spending. In doing so, it provides a brief account of the direct effects of introducing a single currency on pharmaceutical business. These are static in nature and include the elimination of exchange rate volatility and transaction costs, increased price transparency and limited potential for parallel trade. It subsequently analyses the potential medium and long term macroeconomic policy choices facing the Member States and their impact on pharmaceutical spending following the introduction of a single currency. These include policy directions in order to meet the Maastricht convergence criteria in the run-up to forming an Economic and Monetary Union (EMU) and the implications of EMU on national macroeconomic policy thereafter. This article argues that the necessity for tight fiscal policies across the EU and, in particular, in those Member States facing high budget deficits and overall debt levels, will continue to exert considerable downward pressure on pharmaceutical spending. PMID- 10175990 TI - Cefotaxime. A pharmacoeconomic review of its use in the treatment of infections. AB - Cefotaxime is a parenterally administered third generation cephalosporin with a broad spectrum of antimicrobial activity. After more than a decade of use, cefotaxime continues to play an important role in the treatment of patients with serious infections, particularly those caused by Gram-negative bacteria. Clinical trials of cefotaxime have demonstrated clinical and/or bacteriological success rates usually between 75 and 100% in hospitalised patients with infections such as pneumonia, complicated urinary tract infections and bacteraemia. In general, comparative trials have shown that cefotaxime has equivalent clinical efficacy to ceftriaxone. Although cefotaxime was traditionally administered at 6- or 8-hourly intervals, evaluations of twice daily regimens have demonstrated the feasibility of using this extended dosage interval in selected patients. Like other parenterally administered cephalosporins, cefotaxime is well tolerated. Cefotaxime does not cause a significant incidence of coagulopathies, as observed with some cephalosporins (e.g., cefamandole and cefoperazone), nor is it associated with the development of pseudocholelithiasis as seen with ceftriaxone. Some hospitals have achieved significant cost savings by implementing programmes or policies involving replacement of prescriptions for ceftriaxone with those for cefotaxime; however, other institutions have shown cost savings when cefotaxime is replaced by ceftriaxone. Similarly, conflicting results were seen in studies that assessed only the drug acquisition and administration supply costs (with or without inclusion of labour costs), highlighting the difficulty in applying pharmacoeconomic data from one clinical setting to another. A limited number of detailed pharmacoeconomic analyses of cefotaxime have been conducted. One analysis, in patients with pneumonia or other serious infections, incorporated published clinical trial data as well as published or estimated cost data (from 1992 or earlier) for the US healthcare setting. Total treatment costs per patient day were $US25.21 for cefotaxime 1 g twice daily and $US37.23 for cefotaxime 1 g 3 times daily, compared with $US69.97 for ceftriaxone 2 g once daily and $US74.57 for ceftriaxone 1 g twice daily. Costs included those associated with drug acquisition, administration and preparation, laboratory monitoring and adverse events. A large retrospective analysis was conducted between 1989 and 1993 in a US hospital. Patients treated with cefotaxime twice daily had similar clinical outcomes, including duration of hospital stay (7.21 vs 7.24 days), to those receiving antimicrobials other than cefotaxime. However, when a model was applied to determine attributable differences, a trend was demonstrated towards reduced length of hospitalisation (mean reduction 0.5 days) and total cost of hospitalisation (mean reduction $US623 per patient) with cefotaxime. In a Canadian clinical decision-analysis model of initial empirical monotherapy for an average infectious disease state (costs for serious lower respiratory tract infection, urinary tract infection, sepsis, skin/soft tissue infection and febrile neutropenia were weighted according to the incidence of each infection and combined to give a single value), the average total cost per patient for cefotaxime was $Can4099 (1994 dollars). This was lower than that for ceftriaxone ($Can4257) but higher than that for cefepime ($Can3945), ciprofloxacin ($Can4008) and ceftazidime ($Can4086). Costs included those related to drug acquisition, preparation and administration, bacterial culture and sensitivity testing, hospitalisation and adverse events. An analysis conducted in France demonstrated that cefotaxime 1 g 3 times daily was associated with total treatment costs equal to or lower than those for ceftriaxone 2 g once daily. The study also evaluated total costs of cefotaxime 1 g twice daily and ceftazidime 1 g 3 times daily; treatment costs associated with cefotaxime were less than on PMID- 10175992 TI - Reaching for electronic records. PMID- 10175991 TI - For many, goal is fewer manual differentials. PMID- 10175993 TI - How subpar companies mar LIS marketplace. Clinical laboratory information systems. PMID- 10175994 TI - How we use LMIP in a multi-lab network. PMID- 10175995 TI - How viral load's role measures up. PMID- 10175996 TI - Responding to resistance. PMID- 10175998 TI - Survey of instruments: Automated CBC & 5-part differential hematology instruments. PMID- 10175997 TI - Gazing at tomorrow. PMID- 10175999 TI - How best to approach point-of-care testing. PMID- 10176000 TI - Outcome management: opportunities and objectives. PMID- 10176001 TI - Appropriate care--key to effective utilization management. PMID- 10176002 TI - Vision plans provide opportunity for farsighted providers and organizations. PMID- 10176003 TI - The PPO advantage. PMID- 10176004 TI - Provider sponsored organizations: balancing risks with rewards. PMID- 10176005 TI - Financial analysis of telemedicine in a prison system. AB - OBJECTIVE: To quantify the costs and benefits of medical care under a telemedicine agreement. METHODS: Two telemedicine contracts between the North Carolina Central Prison (NCCP) and the East Carolina University School of Medicine were analyzed, first from the point of view of the prison using break even analysis and second from the societal point of view examining whether the arrangements were positive for the taxpayers of North Carolina. RESULTS AND CONCLUSIONS: While the prison system never broke even with the first contract, the break-even was attainable, as it would have required an average of only one consultation per day. The prison system attained break-even status in the latest year of the second contract, and simple forecasts indicate a good chance that usage will grow beyond the break-even point. From the societal point of view, the contracts are merely transfers of funds from one state agency to another. Therefore, the differences in them are irrelevant. What is relevant is a measure of average fixed and variable spending for telemedicine and what this expenditure buys in terms of avoided costs. Thus, we examined the average full cost per visit, as determined from the actual or estimated expenditures, and concluded that the program paid back its cost during year 4. PMID- 10176006 TI - Rural Arkansas physicians and telemedicine technology: attitudes in communities receiving equipment. AB - OBJECTIVE: To assess physician attitudes toward the usefulness, effectiveness, and expected use of telemedicine, as well as interest in learning about the technology. METHODS: A survey instrument assessing attitudes toward each of the four objective domains was mailed to 46 physicians at six hospitals affiliated with the Rural Hospital Program of the University of Arkansas for Medical Sciences. Binomial probability methods were used to analyze the responses. RESULTS: The survey achieved a response rate of 59% (27/46). Physician responders agreed that telemedicine would be useful in improving patient care quality but would not be useful in improving the financial position of the hospital or in lowering patient-borne costs. Physicians were evenly split on the effectiveness and expected utilization of telemedicine for patient consults. There was significant interest in learning more about telemedicine applications. CONCLUSION: Barriers to utilization of telemedicine by physicians may remain even under a new reimbursement system unless referring physicians are convinced of the benefits to the community as well the clinical effectiveness of the technology. PMID- 10176007 TI - Telemedicine in trauma care: description of 100 trauma teleconsults. AB - OBJECTIVE: To study the role of telemedicine in the delivery of trauma care to rural providers on a telemedicine network. METHODS: A descriptive analysis of 100 trauma teleconsults over a private telemedicine network from February 1, 1995, through July 31, 1996. RESULTS: Of 354 clinical teleconsults during the study period, 100 (28%) concerned trauma. The largest number of trauma teleconsults (54) were provided by orthopedic surgeons. Emergency physicians provided 33 teleconsults, radiologists 8, and neurosurgeons 5. The most common reasons for trauma teleconsults (94%) were diagnosis and treatment of extremity and pelvic injuries. The document camera was used for all teleconsults, primarily to transmit radiographs. The mean age of the patients was 32.3 years. Sixty-one of the teleconsults were categorized as urgent, 32 were emergency, and 7 were scheduled. The mean duration of the emergency teleconsults was 4.3 minutes, and the overall mean duration of all teleconsults was 8.6 minutes. Ninety of the trauma teleconsults occurred during regular week days, Monday through Friday. Radiologists reviewed all hardcopy radiographs and computed tomography films, and hard-copy interpretations were compared with interpretations at the time of the teleconsult. No significant discrepancies between the two modes of interpretation were noted. Of the 100 patients involved in trauma teleconsults, 68 stayed in the rural community. No significant adverse outcomes were observed among patients involved in teleconsults. CONCLUSION: This analysis confirms the clinical effectiveness of telemedicine technology in the evaluation and treatment of extremity and pelvic injuries. PMID- 10176008 TI - Working with hospitalists. PMID- 10176009 TI - Computerized patient record systems: a survey of 28 vendors. PMID- 10176010 TI - More help with exam documentation. PMID- 10176011 TI - Managing the unmanageable: the disruptive physician. PMID- 10176012 TI - Back to the future: the telemedicine house call. PMID- 10176013 TI - Using loan abatement as a rural recruiting tool. PMID- 10176014 TI - Survey reveals current trends in hospital quality models. PMID- 10176015 TI - A look at Pap test accuracy and the duty to inform from a risk management perspective. PMID- 10176016 TI - Hospital develops methods for uncovering underlying causes of error in health care. PMID- 10176017 TI - Here's mud in your eye. PMID- 10176018 TI - Patient lifts: proper use and inspection. PMID- 10176019 TI - Alta Bates uses its own doctors as reengineering consultants for a share in the savings that result from four redesign initiatives. PMID- 10176020 TI - Alta Bates takes on "one of the last sacred places"--the OR and its traditions. PMID- 10176021 TI - 'Necessary inefficiency' in the physician-patient relationship. Interview by Sharon O'Malley. PMID- 10176022 TI - A checklist for accelerated quality improvement efforts. PMID- 10176023 TI - Definitions of cost, benefit divide breast cancer researchers. AB - The debate continues over the use of mammography to screen women ages 40-49 for breast cancer. The question: What determines appropriate healthcare--cost savings, lives saved or the most lives saved most cost-effectively. PMID- 10176024 TI - Total quality now! Putting QI on the fast track. AB - To keep up with today's constantly changing healthcare needs, organizations are looking for ways to expedite improvements to their systems. Some have adopted one of the nationally recognized methods--blitz improvement teams, the Breakthrough Series, PICOS or interactive accelerated replication. Other organizations are designing their own improvement programs, borrowing concepts from TQM and picking up the pace. Whatever the method used, they agree on 10 components that are essential for a successful effort. PMID- 10176025 TI - Severity adjustment for length of stay: is it always necessary? AB - OBJECTIVE: Severity adjustment is an oft-cited requirement when comparing physicians or medical delivery systems. Each application of severity adjustment, however, has to be tested to validate the need, the method, and its value. We examined the value of severity adjustment for identifying physician outliers when studying length of stay in the hospital. DESIGN: We compared the placement of physicians in an outlier category using a severity-adjusted average length of stay (SLOS) index with their placement using the unadjusted average length of stay (ALOS). Changes in placement of the list were validated by the utilization review coordinators. SETTING: A 614-bed tertiary-care university teaching hospital. SUBJECTS: We analyzed 11,146 discharges from 138 physicians in 1992. RESULTS: The mean ALOS +/- standard deviation was 9.05 + 4.50 days, and the SLOS Index was 7.56 +/- 3.06. There were 120 inliers, 6 high outliers, and 12 low outliers by the ALOS method. Using the SLOS index, 27 of 138 physicians had their categories changed from inlier to outlier or from outlier to inlier. The difference in group changes was more significant for those going from outlier to inlier status (8/120 vs 6/18; P < .001). The patients of the six physicians whose status changed from outlier to inlier status were sicker, as indicated by the comorbidity, complications, and manifestations of disease processes score. The utilization reviewers validated the status changes in 8 of 14 instances. CONCLUSIONS: Severity-adjusted length of stay by the SLOS index appears to provide a more accurate measure than the unadjusted ALOS. The changes, however, were small. It is not clear that the added effort is worthwhile. PMID- 10176026 TI - Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program. AB - OBJECTIVE: To evaluate changes in antimicrobial use and expenditures and the rates of selected nosocomial infections due to resistant organisms associated with implementation of an antimicrobial-prescribing improvement program. DESIGN: Before-after trial comparing 1992 (pre-program), 1993 (a transition year), and 1994 (after full implementation of the program). SETTING AND PARTICIPANTS: Academic medical center, all patients and physicians. INTERVENTION: An antimicrobial-prescribing improvement program with prior approval requirement for use of restricted agents. MAIN OUTCOME MEASURES: Antimicrobial use and expenditures, rates of selected nosocomial infection marker events. RESULTS: Between 1992 and 1994, there were substantial decreases in antimicrobial use, from 158,107 to 137,364 defined daily doses, and in expenditures from $2,486,902 ($24.01 per patient day) to $1,701,522 ($18.49 per patient day). After adjusting for changes in purchase prices and census days, we estimated savings attributable to the program of $279,573 in 1993 and $389,814 in 1994. In addition, we found significant decreases between 1992 and 1994 in the rates of enterococcal bacteremia (.34 vs .16 events per 1,000 patient days; P = .016), selected gram negative bacteremia (.26 vs .11; P = .015), methicillin-resistant Staphylococcus aureus colonization or infection (.66 vs .20; P < .0001), and Stenotrophomonas colonization or infection (.35 vs .17; P = .019). No significant change occurred in rates of nosocomial candidemia or Clostridium difficile toxin-positive diarrhea. Values for 1993 were intermediate between those of 1992 and 1994. CONCLUSION: Implementation of an antimicrobial-prescribing improvement program was associated with substantial savings in antimicrobial use and expenditures and significant decreases in rates of selected nosocomial infections due to resistant organisms. PMID- 10176028 TI - Evidence-based health care and the Cochrane Collaboration. AB - Evidence-based health care (EBHC) is a growing movement to integrate healthcare research with healthcare practice. A key element to EBHC is convenient access to relevant high-quality evidence. The Cochrane Collaboration is an international consortium of persons dedicated to producing and maintaining systematic reviews of healthcare practice and is an invaluable resource to the EBHC movement. This article will describe EBHC briefly and will highlight how the Cochrane Collaboration supports the EBHC perspective to create an efficient and effective healthcare system. PMID- 10176027 TI - Increased nursing-time requirements due to pressure sores in long-term-care residents in Quebec. AB - OBJECTIVE: To test the hypothesis that pressure sores significantly influence the nursing workload, after taking confounding factors into account, i.e., patients' characteristics simultaneously associated with the occurrence of pressure sores and the nursing-time requirements. DESIGN: Retrospective analysis of administrative data for a cohort of long-term-care residents (Planification Informatisee des Soins Infirmiers Requis database). Two methods were used to control for confounding factors: analysis of covariance and sample restriction. SETTING: Long-term-care institutions of Quebec, except exclusively psychiatric and private centers. PATIENTS: Data was available for the 13,555 residents aged 65 or more whose health status changed during the year 1993-1994. RESULTS: Prevalence of sores was 4.0% (544/13,555). Before any adjustments were made, residents with pressure sores needed, on average, 63 minutes more than the residents without pressure sores. Two confounding factors were identified: dependence in the activities of daily living and physical mobility. Analysis of covariance showed that the adjusted increase in daily nursing care was 19 minutes. In the second analysis, a restricted homogeneous sample for the confounding factors was used (5,849 patients, including 414 patients with pressure sores). According to this method, the adjusted increase in daily nursing care was 17 minutes. In both analyses, the increase was noticeable in the spheres of alimentation, mobilization, and treatments. CONCLUSIONS: The presence of pressure sores significantly influences the nursing workload, even after eliminating the influence of confounding factors. Because nursing time can be translated into cost, effective prevention strategies and strategies of reducing the costs of treating sores should be analyzed. PMID- 10176029 TI - The modification of physician practice patterns. AB - While physicians are directly responsible for only a small proportion of healthcare expenditures, their decisions influence the majority of medical costs. Because practice variations among physicians have been demonstrated abundantly, strategies to modify practice patterns have evolved. This article addresses the different factors that influence variations in patterns of practice, including physician characteristics, knowledge, beliefs, and attitudes. In designing programs to modify practice patterns, educational efforts, along with practice guidelines and feedback, all have been used. Although there are mixed results for each, the use of opinion leaders and the timing of interventions proximal to practice decisions are important. The costs and benefits of interventions are discussed as a method for assessing the utility of different programs to modify practice patterns. PMID- 10176030 TI - 1997 salary survey results. ED managers face more managed care: what's in the future? PMID- 10176031 TI - 'Prudent layperson' is here: watch out for managed care maneuvers. PMID- 10176032 TI - Teaching hospital uses staff to reverse satisfaction lows. PMID- 10176033 TI - New issues to watch in 1998. PMID- 10176034 TI - Charity in the ED boosts morale while helping the community. PMID- 10176035 TI - Critical care transport team can reduce risks, boost bottom line. PMID- 10176036 TI - Reduction in outpatient therapies payment goes into effect Jan. 1. PMID- 10176037 TI - Are LPNs (licensed practical nurses) employees or supervisors under federal labor law? Appeals courts give different answers. PMID- 10176038 TI - Look before you leap: assessing the need for subacute services. PMID- 10176039 TI - 1998 Joint Commission standards. Assuring staff competence is key to survey success. PMID- 10176040 TI - Tips for writing competency statements. Focus on infants. PMID- 10176041 TI - Teach your staff about adaptive equipment. PMID- 10176042 TI - Food and nutrition services for infants. First in a series on age-specific competencies. PMID- 10176043 TI - Can you prove your health care is good? Contracting swings toward quality. AB - Health care today is on the doorstep of an era where proving quality of care will be instrumental in attracting patients and contracting with payers. While the information systems that do this are still progressing, health systems that want to stay ahead of the curve should prepare to document the quality of their care. PMID- 10176044 TI - JCAHO is adding numbers to inspection criteria. AB - The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has begun phasing in new accreditation requirements that, for the first time, look at quality of care. Health systems are expected to have little or no difficulty meeting early reporting requirements. Over the next few years, however, the reporting requirements are expected to become more rigorous. Experts in the field expect such public reporting of outcomes to be commonplace in the future. PMID- 10176045 TI - Six ways to overcome common PHO mistakes. AB - Physician-hospital organizations (PHOs) are like people--they all make mistakes. Some PHOs recover from their errors and go on to become highly successful organizations. Others fall by the wayside. Success depends on some of the following methods: creating the PHO for the right reason; letting market forces shape the PHO instead of internal politics; mastering core competencies; communicating effectively and repeatedly; putting PHO interests before self interests; having primary care physician buy-in. PMID- 10176046 TI - Hone your management skills for risk sharing. AB - This article is the first of two regarding capitation contract management. In this installment, we examine the factors that affect financial performance under a capitation agreement and how technology can play an important role in improving profitability. In part two, we will explore the range of new information gathering needs a medical group, independent practice association, or physician hospital organization (PHO) must consider under capitation and what kinds of internal systems need to be put in place to manage the contract. PMID- 10176047 TI - Profiling moves from a defensive to an offensive stance for savvy practices. PMID- 10176048 TI - Re-engineering overhauls systems to make them work. PMID- 10176049 TI - What specialties are hot? PMID- 10176050 TI - Finding an end to the mighty pen (and paper). PMID- 10176051 TI - Helping practitioners usher in new physicians. PMID- 10176052 TI - Physician extenders are cost-effective approach. PMID- 10176053 TI - New system makes charting outcomes easier. PMID- 10176054 TI - Myths that trip you up: are you guilty of these benchmarking mistakes? PMID- 10176055 TI - Benchmarking outside the health care industry. PMID- 10176056 TI - Kaiser shares ambulatory surgery benchmarks. AB - The benchmark for utilization, or the amount of time the operating room is being used, is 85% in main ORs and 80% in ambulatory surgery unit, according to a study of Kaiser Foundation Hospitals of Southern California. Here are five ways to improve utilization: Use block scheduling and run at least some of your ORs through lunch. Schedule similar procedures after each other. Have your physicians standardize equipment and supplies as much as possible. Use certified registered nurse anesthetists. Reprocess and sterilize equipment on site. PMID- 10176057 TI - Psych home care is a quality alternative. PMID- 10176058 TI - PIECESS psychiatric home care model. PMID- 10176059 TI - Smart cards are set to revolutionize health care. PMID- 10176060 TI - Allocating scarce resources: a question of distributive justice. Part I. PMID- 10176061 TI - Justice and the right to health care. Part II. PMID- 10176062 TI - Challenges, changes and strategies. PMID- 10176063 TI - Don't flirt with disaster when it comes to stop loss. PMID- 10176064 TI - Safety net providers defend their niche in Medicaid market, enroll members in own health plans. AB - Safety net providers don't have to be cut out of managed Medicaid due to their high costs of caring for the poor and uninsured. See how Boston Medical Center and Cambridge Hospital got involved in the Massachusetts Medicaid waiver program and negotiated special rates and provisions. PMID- 10176065 TI - Meet your senior's online needs to compete in Medicare marketplace. AB - As more seniors turn to the Internet for health care information and services, is your organization prepared to meet their needs? Kaiser Permanente is reaching the cyber-senior market on the World Wide Web with interactive online services, including discussion groups with providers. PMID- 10176066 TI - Six senior care programs cut utilization, save millions for Medicare-savvy medical group. AB - Sound too good to be true? Here's the story of a Los Angeles medical group that has developed six senior care programs, from using hospital intensivists to home care. It's one of the most successful Medicare provider groups in the country. PMID- 10176067 TI - Medicare HMOs have fewer, but more expensive home visits. PMID- 10176069 TI - An interview with: Robert O. Murphy on security's role in today's healthcare environment. PMID- 10176068 TI - Hospital security: 'stay current' on HIV exposure treatment guidelines. PMID- 10176070 TI - Parking security plays key role in medical center's ADA compliance. PMID- 10176071 TI - Safety strategies for older patients: reports from leading multi-facility systems, researchers. AB - Falls and other accidents and patient wandering are two major safety and security concerns that are increasing as the population gets older and health systems face the challenge of the older patient, whether in hospitals or long-term care facilities. Recent research has shed new light on some of the problems being faced. Also described in this report are experiences of leading systems in protecting the elderly in their care. PMID- 10176072 TI - Lighting, environmental design seen keys to patrons' feeling of security. PMID- 10176073 TI - IT update/community health. The strain of repetitive record-keeping. PMID- 10176075 TI - IT update/supply industry. King of the castle. PMID- 10176074 TI - IT update/telemedicine. Telecomplications. PMID- 10176076 TI - Modern times? PMID- 10176077 TI - Health policy. Managed care--just ask US. AB - Managed care in the US reduces use of health services and hospital admissions. Concerns that cost control could jeopardize quality are widespread. But there is no significant evidence to suggest that this is the case. Managed care produces low patient satisfaction ratings. The US evidence on managed care has little direct relevance to the UK, but elements of it might be usefully tested here. PMID- 10176078 TI - Mental health. Focal points. AB - A pathways study looking at the process of acute care found the most vulnerable people admitted to hospital appeared to be the least likely to have received effective community care. Community services must be more systematically focused on those most in need. Day hospitals need to function as acute alternatives to inpatient care. Accommodation for newer service users must be considered. PMID- 10176079 TI - Managing admissions. Bed spreads. AB - A decrease in surgical beds left a trust insufficient flexibility to increase an already high throughput without affecting the quality of care. Changes in the management of surgical admissions, including the appointment of an admissions co ordinator, have improved co-ordination of elective and emergency admissions. Three years later maximum waiting times had fallen from 18 to 10 months. In the first nine months of the new booking system, the number of operations cancelled on the day because of bed nonavailability fell by half, while patients cancelled on the day of admission dropped by 36 per cent. PMID- 10176080 TI - Patient documentation. On the records. AB - Documentation of patient care is frequently the Achilles heel of clinical services. The use of a multidisciplinary, semi-structured healthcare record may achieve improvements, but it needs to be coupled with appropriate strategies to overcome professional and cultural barriers to unified documentation. When implementing changes, clinical staff may overestimate their clinical information needs while underestimating the problems of its routine collection. PMID- 10176081 TI - On the evidence. Improving outcomes in colorectal cancer. PMID- 10176082 TI - Weights and measures. Great Britons. PMID- 10176083 TI - NHS writers. My word. PMID- 10176084 TI - Literature for managers. Brought to book. PMID- 10176085 TI - Humour. Sick jokes. PMID- 10176086 TI - Medicare curbs hospital influence on choice of home health providers. PMID- 10176087 TI - New Jersey appellate court rules on hospital's internal procedures. Ende v. Cohen. PMID- 10176088 TI - Predicting the adoption and maintenance of exercise participation using self efficacy and previous exercise participation rates. AB - OBJECTIVES: To investigate the relationships among self-efficacy, changes in self efficacy, past exercise participation, future exercise adherence, and exercise program format. METHODS: Two-year randomized trial involving subjects (n = 63) participating in an aerobic exercise program. Subjects were randomly assigned to one of three exercise conditions: higher-intensity home-based exercise, higher intensity class-based exercise, or lower-intensity home-based exercise. RESULTS: Results indicated that baseline self-efficacy and exercise format had significant (p < .02), independent effects on adherence during the adoption and early maintenance phases of exercise behavior. In contrast, in predicting long-term exercise program maintenance, a significant (p < .05) self-efficacy x exercise format interaction indicated that self-efficacy predicted adherence only in the supervised home-based exercise conditions. Results also suggest that baseline self-efficacy, independent of the effect of past adherence, significantly (p < .03) predicted exercise adherence during the adoption phase, but not early maintenance phase, of exercise behavior. Finally, adherence change during the adoption phase of exercise behavior significantly (p < .04) predicted Year-one levels of self-efficacy even after adjusting for the effect of baseline self efficacy. CONCLUSIONS: These results suggest that exercise program format as well as an individual's initial cognitive and behavioral experiences in an exercise program play significant roles in determining exercise adherence. PMID- 10176089 TI - Adult consumption of fruit and vegetables and fat related practices by meal and day. PMID- 10176090 TI - Managing job strain: a randomized controlled trial of an intervention conducted by mail and telephone. PMID- 10176091 TI - Stages of change for physical activity, diet, and smoking among HMO members with chronic conditions. AB - PURPOSE: This paper investigated whether stage of change for health behaviors was associated with the presence of chronic conditions. DESIGN: A stratified cross sectional survey by mail with telephone follow-up. SETTINGS: This study was conducted at a mixed-model HMO with 650,000 members based in Minnesota. SUBJECTS: The sample consisted of a random sample of 8000 HMO members age 40 or over with systematic oversampling of members with hypertension, diabetes, dyslipidemia, or heart disease. MEASURES: In addition to demographics, readiness to change for physical activity, fat intake, fruit and vegetable intake, and smoking were assessed. RESULTS: The adjusted response rate was 82.4%. In a logistic regression analysis, members with one or more than one chronic condition had greater readiness to change for three out of four risk factors compared to members with no chronic conditions. CONCLUSIONS: The stage-of-change distribution of HMO members with chronic conditions suggests that members at highest risk of adverse health outcomes have the greatest readiness to change behavioral risk factors. Based on these observations, targeted, stage-specific efforts to support behavior change are likely to be both acceptable and effective in HMO members with chronic conditions. Improving stage of change for behavioral risk factors for members with diabetes may present special problems and opportunities. PMID- 10176092 TI - Prohibiting smoking in restaurants: effects on restaurant sales. AB - PURPOSE: The purpose of this study was to assess the impact of prohibiting smoking in restaurants on total restaurant sales in Flagstaff, Arizona. DESIGN: Flagstaff restaurant and retail sales data were collected for periods approximately 3.5 years prior to enactment of a no-smoking-in-restaurants ordinance and 1.5 years after enactment of the ordinance. Data were compared with six comparison areas utilizing four methods of analyses. SETTING: The city of Flagstaff, Arizona, was the community in this study that prohibited smoking in restaurants. SUBJECTS: Flagstaff restaurant and retail sales were compared to sales in two similar Arizona cities, three counties, and the entire state of Arizona. INTERVENTION: A city ordinance that prohibited smoking in all Flagstaff, Arizona, restaurants. MEASURES: Taxable restaurant sales were collected from Flagstaff and all comparison areas. Retail sales data were also collected to determine if changes occurred in the ratio of restaurant to retail sales. RESULTS: All analyses resulted in the same conclusions: prohibiting smoking in restaurants did not affect restaurant sales. CONCLUSIONS: Study findings indicate that prohibiting smoking in Flagstaff, Arizona, restaurants has had no effect on restaurant sales. PMID- 10176093 TI - Stages of change and psychosocial correlates of fruit and vegetable consumption among rural African-American church members. AB - PURPOSE: This study examined the relationship between stages of change, other psychosocial factors, and fruit and vegetable (F&V) consumption among rural African-Americans participating in a 5 a Day study. DESIGN: The cross-sectional design assessed associations between F&V intake, stage of change, self-efficacy, beliefs, barriers, and social support. SETTING: Participants were surveyed by telephone. SUBJECTS: Subjects were 3557 adult church members (response rate, 79.1%), aged 18 and over from 10 North Carolina counties. MEASURES: A seven-item food frequency measured F&V intake. Stage of change was measured using four items; other psychosocial variables were measured using Likert scales. Chi-square tests and analysis of variance were used in statistical analyses. RESULTS: The majority of participants (65%) were in the preparation stage of change. Individuals in action/maintenance consumed an average of 6.5 daily F&V servings compared to 3.3 to 3.5 servings for those in precontemplation, contemplation, and preparation. Self-efficacy, social support, and belief about how many daily F&V servings are needed, were positively associated with stage. Barriers were most prevalent among precontemplators. CONCLUSIONS: The findings support the applicability of the stages-of-change model to dietary change among rural African Americans. The relationship between stage, self-efficacy, social support, and barriers supports using a multicomponent intervention strategy. PMID- 10176094 TI - A stage-of-change classification system based on actions and beliefs regarding dietary fat and fiber. AB - PURPOSE: The objectives of this study were to develop a stage-of-change classification system and to determine the degree to which various adult subgroups have adopted the behavioral changes necessary to achieve a low-fat and/or high-fiber diet as recommended by the Dietary Guidelines for Americans. DESIGN: The study used a mail survey randomly sent to 7110 adults. SETTING: The survey was conducted in 11 states and the District of Columbia. SUBJECTS: The random sample included males and females over age 18. Of the eligible respondents, 3198 (51.5%) were included in this analysis, with 2004 and 2066 unambiguously classified into stages of change for fat and fiber, respectively. MEASURES: Stage of change was defined by an algorithm based on self-reported intent and behaviors to limit fat and/or increase fiber. RESULTS: 45% of the respondents were classified as being in action/maintenance for fat and 38% for fiber. Women, older adults, individuals with advanced education, persons with diet-related chronic disease, people with higher levels of relevant nutrition knowledge and attitudes, and persons who indicated that health concerns were a primary influence on their diet were more likely to be in action/maintenance than other respondents. CONCLUSIONS: The algorithm in this study presents a model that more closely reflects the proportions of the adult population that have achieved low-fat diets and classifies a greater proportion in the preparation stage than classification systems in previous studies. PMID- 10176096 TI - Neuro-ophthalmology. PMID- 10176095 TI - Obesity and absenteeism: an epidemiologic study of 10,825 employed adults. AB - PURPOSE: This study was conducted to determine the extent of the relationship between obesity and absenteeism due to illness. A secondary objective was to ascertain the extent to which age, gender, family income, length of workweek, and cigarette smoking influenced the obesity-absenteeism association. DESIGN: A cross sectional design was used. Data regarding obesity, absenteeism, and the potential confounding factors were collected during the same time period. SETTING: Data were collected within workplaces throughout the U.S., and at the headquarters of Health Advancement Services, Inc. (HAS). SUBJECTS: Subjects were 10,825 employed men and women who participated in an ongoing wellness screening program administered by HAS. MEASURES: The three-site skinfold technique was used to estimate body fat percentage. Absenteeism due to illness and the potential confounding variables were assessed using a structured paper-pencil questionnaire. RESULTS: Without controlling for any potential confounders, obese employees were more than twice as likely to experience high-level absenteeism (seven or more absences due to illness during the past 6 months), and 1.49 times more likely to suffer from moderate absenteeism (three to six absences due to illness during the last 6 months) than were lean employees. With all of the potential confounders controlled simultaneously, obese employees were 1.74 and 1.61 times more likely to experience high and moderate levels of absenteeism, respectively, than were lean individuals. CONCLUSIONS: Obese employees tend to be absent from work due to illness substantially more than their counterparts. PMID- 10176097 TI - Ocular manifestations of systemic disease. PMID- 10176098 TI - Carotid disease and the eye. AB - Patients with carotid artery disease may present with monocular, ipsilateral ocular symptoms, and signs that can herald a devastating stroke. Asymptomatic retinal emboli, transient monocular visual loss, and central retinal artery occlusion are the most common. Venous stasis retinopathy and ocular ischemic syndrome are associated with severe hypoperfusion of the eye and usually reflect severe carotid occlusive disease. Embolic ischemic optic neuropathies and compression of the intracranial optic nerve by supraclinoid carotid arteries remain debated. Third-order Horner's syndrome and eye pain are common in carotid artery disease, particularly carotid dissection; carotid artery disease, however, is an uncommon cause of ocular motor nerve palsy. Several recent publications have highlighted the prognosis and management of patients with carotid artery occlusive disease, and have emphasized the role of the ophthalmologist in early diagnosis and prevention of further cerebral and systemic complications. PMID- 10176099 TI - Neurology of the eyelids. AB - The role of eyelids is to provide maximal protection to the eyeball without interfering with vision. To accomplish this purpose, an intricate neural network coordinates the lid and eye movements. The lid-eye synkinesis is ultimately based on common innervation of the levator palpebrae superioris (LPS) and the superior rectus muscles. The LPS is variously affected in numerous neurologic disorders. Because the eyelids are readily accessible for inspection, and because they conform to the fundamental laws of neurophysiology, different syndromes of eyelid dysfunction are of great value in topologic diagnosis. PMID- 10176100 TI - Optic nerve disorders. AB - This review highlights recent advances related to diagnosis, clinical course, and management of nonglaucomatous optic neuropathies. Optic nerve disorders of particular interest and importance are emphasized, including ischemic optic neuropathy, optic neuritis, HIV-related infection, neoplastic disease, and pseudotumor cerebri. PMID- 10176101 TI - Neuro-ophthalmic genetics. AB - Mutations in nuclear or mitochondrial DNA may cause disorders of neuro-ophthalmic significance. These include disorders of the optic nerve, such as Leber's hereditary optic neuropathy and Kjer-type optic atrophy, and disorders of ocular motility, such as congenital nystagmus, autosomal dominant progressive external ophthalmoplegia, and oculopharyngeal muscular dystrophy. In addition to more accurate disease classification and diagnosis, identification of genetic loci, genes, and their mutations has stimulated investigation into factors influencing disease expression and penetrance. PMID- 10176102 TI - Orbital pseudotumor syndromes. AB - The disorder known as orbital pseudotumor and its related syndromes of myositis and dacryoadenitis continue to be a source of controversy in terms of histopathologic classification and approach to diagnosis and management. This review references recent papers regarding these issues. PMID- 10176103 TI - Third, fourth, and sixth cranial nerve palsies. AB - Clinical manifestations of ocular motor palsies may differ according to the type and the localization of the lesions involving the third, fourth, and sixth cranial nerves. Topical diagnosis of the third, fourth, and sixth nerve palsies is therefore required before imaging studies and workup are performed. The development of modern imaging techniques has significantly improved the diagnosis of the disorders affecting the ocular motor nerves. This review covers the most important aspects, in terms of clinical signs and symptoms and differential diagnoses, of these cranial nerve palsies. The more recently published articles have added new disorders to the differential diagnosis of ocular motor palsy. Moreover, magnetic resonance imaging (MRI) has been confirmed to be the most important diagnostic tool in most cases. Finally, recently developed MRI techniques were presented and demonstrated to be more sensitive than conventional MRI in several cases. PMID- 10176104 TI - Pathology techniques. AB - Pathology techniques developed over the past decade may be successfully applied to the diagnosis of orbital disease. Tissue specimens may be immunophenotyped by immunohistochemical staining and flow cytometry. Immunohistochemical staining provides a qualitative analysis of localization of antigenic determinants and flow cytometry provides a quantitative analysis. The molecular biologic technique of polymerase chain reaction enables detection of minute amounts of material by amplification from DNA primers. Fine-needle aspiration biopsy is an alternative to open biopsy in select cases. The most important concept regarding these techniques is communication with the ophthalmic pathologist regarding the collection and interpretation of the specimen. PMID- 10176105 TI - New discoveries in diabetes- and thyroid-related eye disease. AB - Although reports from Europe indicate a reduction in the incidence of diabetes related visual loss, diabetic retinopathy continues to be the leading cause of blindness. One agent, vascular endothelial growth factor (VEGF), has been found to stimulate angiogenesis and may be the cause of diabetic neovascularization and visual loss. New research implies that the manipulation of the VEGF pathway may be able to prevent diabetic visual loss. Type I (insulin-dependent) and type II (non-insulin-dependent) diabetes mellitus are different disease processes. There have been few attempts in the past to differentiate the retinopathy associated with these two distinct disorders. Recent reports indicate that these disorders have different responses to ocular therapy. Thyroid orbitopathy combined with ocular hypertension can produce true glaucoma. Nevertheless, this requires a prolonged duration of orbitopathy and most patients who have this combination will improve and not develop permanent glaucomatous changes. Similarly, the majority of Graves' disease patients develop improved function over time; however, the psychologic sequelae continue after the disease process is in remission, which warrants further studies. PMID- 10176107 TI - Ocular manifestations of systemic infections. AB - Awareness of atypical presentations and understanding the pathogenesis of uncommon systemic infections will make us better clinicians. Recent literature alerts the ophthalmologist to recent findings and treatment options regarding ocular manifestations of malaria, cysticercosis, histoplasmosis, mucormycosis, subacute sclerosing panencephalitis, and Acanthamoeba infection. PMID- 10176106 TI - Ocular manifestations of genetic and developmental diseases. AB - Ophthalmic genetics is a rapidly expanding field that includes both clinical and basic sciences. Clinical descriptions of syndromes and new diagnostic testing both reflect the increase in knowledge and technology of molecular biology. Technologic advances have resulted in old diseases being described in new ways and being attributed to new pathophysiologic mechanisms. This review is intended to update the past year's contributions in ophthalmic genetics. Discussion is by disease type, which is familiar to most clinicians. PMID- 10176108 TI - Ocular manifestations of immunologic and rheumatologic inflammatory disorders. AB - Our understanding of ocular manifestations in immunologic and rheumatologic inflammatory disorders has continued to expand over this past year. Studies that support the proposed immunologic pathogenesis of Vogt-Koyanagi-Harada disease are discussed. An article on the course of Behcet's disease is reviewed as well as another article discussing severe visual loss in patients with a familial occurrence of Behcet's disease. The prognostic factors for visual outcome in sarcoid uveitis are presented. An unusual case of giant cell arteritis and the most significant symptoms and diagnostic clues in helping make the diagnosis of giant cell arteritis are discussed. PMID- 10176109 TI - Ocular manifestations of various systemic diseases. AB - Diode laser therapy for retinopathy of prematurity appears superior to cryotherapy, because cryotherapy induces high myopia and macular coloboma-like changes. Plaque radiotherapy is highly effective in inducing regression of isolated uveal metastasis whether used as a primary therapy or when other modalities have failed. The nevus sebaceous syndrome is characterized by a yellowish discoloration of the posterior pole from intrascleral deposits of cartilage. Ultrasonic evidence of optic disc drusen helps in the diagnosis of Alagille syndrome in infants with intrahepatic cholestasis. PMID- 10176110 TI - Ocular toxicology. AB - This review of recent articles on ocular toxicology concentrates on undesirable effects on the eye induced by systemically used xenobiotics. These include color vision deficiencies or visual field deterioration related to antiepileptic drugs, elevated intraocular pressure associated with inhaled corticosteroids, retinal detachments associated with systemic corticosteroids, rifabutin-induced uveitis, cocaine-related retinal hemorrhagic lesions in utero, deferoxamine-related decreases in vision, ocular allergy to bovine-derived collagen, and a large case study of hydroxychloroquine retinotoxicity. Other publications reviewed include a controlled study showing that glucose levels do not seem to alter color vision, a report that intravenous methotrexate can reach clinically meaningful levels in the aqueous humor, and a study showing the effect of systemic pentoxifylline on ocular blood flow and diabetes. With respect to systemic effects of topical ocular medications, there was a case report of apparent systemic exposure to pilocarpine from an Ocusert (Alza Corp., Palo Alto, CA), generalized urticaria after a single application of 1% cyclopentolate, and asthma induced with topical ketorolac. Readers are reminded that no drug achieves ultimate efficacy or ultimate safety. Thus, the decision to employ a given therapy involves a physician's evaluation of its therapeutic index, that is, the ratio between efficacy and toxicity. PMID- 10176111 TI - Mechanisms of optic neuropathy. AB - Retinal ganglion cell death is the final common pathway of all human optic neuropathies. An understanding of how these cells die, either at the cell body or after axonal injury, may allow development of strategies for rescuing these cells and therefore ameliorating optic nerve disease. PMID- 10176112 TI - Cost accounting key to capitated contracts. PMID- 10176113 TI - Wavelets challenge JPEG in image compression. PMID- 10176114 TI - MQSA helps eliminate inferior mammography. PMID- 10176115 TI - Echo-planar MR enters routine clinical practice. PMID- 10176116 TI - Imaging assists appraisal of speech pathology. PMID- 10176117 TI - Strong governance gives groups competitive edge. PMID- 10176118 TI - What features to look for in a PACS workstation. PMID- 10176119 TI - Why Europe leads U.S. in interventional devices. PMID- 10176120 TI - How molecular medicine will impact radiology. PMID- 10176121 TI - Radiology helps manage clinical care resources. PMID- 10176122 TI - Groups grow larger in effort to stay afloat. PMID- 10176123 TI - Dedicated MR redefines scanning of extremities. PMID- 10176124 TI - Radiology's goal: quick and actionable diagnosis. PMID- 10176125 TI - Clinical comparison of pulsatile and nonpulsatile perfusion during cardiopulmonary bypass. AB - Controversy exists concerning the utilization of pulsatile flow during cardiopulmonary bypass (CPB) with regard to improved patient outcomes. The purpose of the present study was to evaluate pulsatile perfusion in patients undergoing CPB in a clinical setting. Seventy patients undergoing open heart surgery for repair of valvular or congenital heart disease were prospectively entered into the study and were randomly assigned to either pulsatile perfusion (PP, n = 35) or nonpulsatile perfusion (NP, n = 35) groups. All patients received identical surgical, perfusion, and postoperative care. Study parameters included: rate of spontaneous cardiac conversion, inotropic drug use, urine output, skin temperature, platelet count, fibrinogen concentration, and plasma free hemoglobin level. There were no statistically significant differences seen in either preoperative or operative parameters between groups. The PP group had a significantly higher rate of spontaneous cardiac conversion, less inotropic drug use, earlier recovery of skin temperature, and higher urine output during CPB (908.8 +/- 87.2 ml/hr vs. 606.1 +/- 57.5 ml/hr, p < .01). There were no significant differences in either platelet count or fibrinogen concentration between groups. There was a steady increase in plasma free hemoglobin during PP, which was not seen in the NP group (p < .01). We conclude that the use of pulsatile flow resulted in improved patient outcomes in maintaining better renal function and preserving cardiac function in the early post-bypass period. PMID- 10176126 TI - Extracorporeal circuit sterility after 168 hours. AB - One of the most important tasks of the perfusionist is the proper assembly of the extracorporeal circuit (ECC) prior to the initiation of cardiopulmonary bypass (CPB). The ECC is usually assembled, primed and debubbled 30 minutes to one hour prior to the patient entering the operating room. But there are occasions when the ECC may have been set up and the previously scheduled procedure cancelled. Perfusionists in this situation have found themselves in a quandary; dispose of the ECC because of required nursing compliance and the sterility question, or keep it and use it later because of the economic impact on the "bottom line". Some hospitals may have satisfactorily answered the question of ECC sterility after 24 hours without observation, but the few reported papers regarding this issue, and our desire to save these circuits, inspired us to find out if they were in fact sterile after having been open for a long period of time. The purpose of this study was to evaluate ECC sterility using an open reservoir oxygenator, over a time period of seven days. After obtaining 792 bacterial cultures from three sites within the ECC, the study was terminated. There were no positive bacterial cultures during the study period. Assuming there is no deliberate contamination, pump circuits assembled in an unused operating room can be maintained sterile for a period of seven days. PMID- 10176127 TI - An in vitro comparison of gas transfer and pressure drop of the Bentley Duraflo Coated Spiral Gold and the Medtronic Carmeda Coated Maxima hollow fiber membrane oxygenators. AB - Two models of heparin coated, hollow fiber membrane oxygenators were tested in vitro to compare gas transfer and transoxygenator pressure drop using an established protocol. Oxygen and carbon dioxide transfer rates were measured at blood flows of 2.5 and 5.0 liters per minute with gas flow: blood flow ratios of 1:1 and 2:1 at both blood flows. All testing was performed under normothermic conditions. The data shows that oxygen transfer increases as blood flow is increased in both oxygenators. Similarly, carbon dioxide transfer is increased by both increased blood and gas flows. Finally, the pressure drop was dependent on blood flow rate alone. This study demonstrated these two oxygenators to be comparable in both oxygen and carbon dioxide transfer and also in transoxygenator pressure drop. PMID- 10176128 TI - Laboratory evaluation of a new membrane oxygenator with a built-in hemoconcentrator. AB - In order to facilitate the handling of cardiopulmonary bypass (CPB) and simplify the circuit, we have developed a new membrane oxygenator with a hemofiltration function. The hollow fiber units for gas exchange and hemofiltration were combined in concentric circles in a cylindrical housing. The total priming volume was 190 ml. Because we used a silicon-coated hollow fiber membrane for gas exchange, this oxygenator was completely resistant to serum leakage. The gas exchange and hemofiltration sections both have a blood-outside flow configuration. All blood flows in a radial direction from around the central core to the surrounding hollow fiber units, first to the hemofiltration portion and then to the gas exchange section. Filtered fluid was easily collected through a stopcock mechanism. The oxygen transfer rate was 312 ml/min at a blood flow rate of 6 L/min, and the ultrafiltration rate was 3.5 L/hour at a blood flow rate of 4 L/min with 25% hematocrit and 200 mmHg transmembrane pressure in an in vitro study. The pressure drop was 62 mmHg at a blood flow rate of 4 L/min. We found no adverse effects in an in vivo study using a mongrel dog. In conclusion, this durable combined device could achieve excellent and simplified hemoconcentration by having all the blood in the unit flow through the hemofiltration portion, and may be useful not only in CPB during open heart surgery, but also in extracorporeal membrane oxygenation. PMID- 10176129 TI - The design and application of a pediatric centrifugal pump. AB - This centrifugal pump (CP) includes two parts: the blood pump and the driving apparatus. They are connected by six twin magnetic disc plates and driven by a magnetic DC motor (120W). The blood pump had six leaves deadlocked between two plastic discs. Six leaves were set at 30 degrees angles, separately. In the lower chamber of the CP, there was an inlay magnetic disc, which is connected with the disc leaves by an axis. This axis was sealed by silicon rubber and a ceramic ring. The priming volume of the blood chamber was 34 ml. In vitro testing showed that the free hemoglobin caused by the CP was much less than that caused by a roller pump after 180 min. The effect of this CP on blood cell damage was also studied in an animal model. Six goats were placed on cardiopulmonary bypass for 180 min. Perfusion flow rates were maintained between 1.5 and 2.5 L/min. The plasma free hemoglobin was lower in the CP group (6.04 mg/dL) than in the roller pump group (32.25 mg/dL), p < 0.01. The CP has been used in ten pediatric patients undergoing cardiopulmonary bypass surgery. The patients' ages were from three to five years, and body weights were from 15 to 20 kg. Perfusion flow rates were maintained between 1.8 and 2.5 L/min, and bypass times were from 30 to 50 min. The rotation speeds were from 2000 to 2500 rpm. All the patients recovered smoothly, and no hemoglobinuria occurred. PMID- 10176131 TI - Surgical glove hazards: a commentary. AB - Surgical contaminants of many kinds, including glove powder, cause granuloma formation. This is particularly well documented in the peritoneal cavity, but has been demonstrated in most anatomic sites. In addition, systemic manifestations result from the absorption of the latex protein antigens onto the starch powder on the surgical gloves, which is aerosolized when the gloves are donned or removed. PMID- 10176130 TI - Goal-directed research. AB - The current model of scientific research (basic research leading to applied research, followed by technological or clinical application) has served society and the scientific community well for over fifty years. Current societal changes suggest the need for a review and the addition of a new model: support for science and technology led by social and clinical needs. PMID- 10176132 TI - New developments in latex allergy. AB - There are several new developments in studies of latex allergy. It appears that many of the allergens to latex are defense proteins that the plant uses to respond to pathogens. Rubber elongation factor, hevein preprotein, hevamine, patatin, and glucanase have been identified as allergic proteins. In addition, processing and leaching of natural rubber latex devices results in a very low allergen content. Powdered rubber gloves appear to be a major contributor to airborne latex allergens. The replacement of low allergen-containing latex gloves for high allergen-containing gloves markedly reduces the levels of latex allergens in the clinical setting. By decreasing the inhalation and contact with latex allergens, we would expect a reduction in latex sensitization in the hospital. PMID- 10176133 TI - Endotoxin and particulate matter on surgical gloves. AB - Because of the continual need to protect of health care workers, gloves are increasingly used. Most gloves purchased are powdered. Besides having deleterious effects on wound healing, glove powder can act as a vehicle for latex allergens, endotoxin, and possibly bacteria. Few tested gloves had undetectable levels of endotoxin, and only one was free from particulate matter. Since powder particles can become airborne and are thus easily spread, concerns for health care professionals and patients arise. To reduce risks for exposure, glove-selection criteria must include low or undetectable levels of latex allergens, endotoxin, and particulate matter. PMID- 10176134 TI - Foreign bodies and intraperitoneal post-operative adhesions. AB - The presence of foreign bodies is one of the recognized causes of fibrous bands and intraperitoneal post-operative adhesions. The objective of this study was to identify foreign bodies actually present in fibrous bands and intraperitoneal post-operative adhesions. From a series of 211 consecutive patients re laparotomized by the same surgeon over a period of two years, 193 (91%) showed fibrous bands or adhesions; of these, 133 (69%) also showed reactions to foreign bodies. Comparison with a reference list established in animal work showed than in 127 (66%) of the cases the foreign bodies were of cellulose textile origin; in 3% of the cases, they were of diverse origin--starch powder, synthetic textiles, sutures, or unidentifiable particles. PMID- 10176135 TI - New developments in the use of fibrin sealant: a surgeon's perspective. AB - Fibrin sealant, a surgical tissue adhesive, has gained widespread use for its ability to achieve three major clinical goals: reducing hemorrhage, increasing tissue adherence, and allowing drug delivery. The object of this state-of-the-art review is to clarify the most recent developments in this field from a surgical perspective. The areas of greatest interest and progress relating to surgical uses for fibrin sealant--specifically, new methods of sealant production, new experimental or clinical uses, and new potential complications--are explored in this review. PMID- 10176136 TI - A technique for quantifying the performance of oscillating bone saw blades. AB - A new model has been developed to evaluate the performance of oscillating surgical saw blades used in medical-implant procedures. A test apparatus was constructed to maintain a constant cutting force between a blade driven by a pneumatic powered oscillating saw and the bone. Evaluations of saw-blade performance were determined using the following outcome measures: cutting time, volume of bone removal, and peak cutting temperature. Two popular, commercially available blades similar in size and tooth geometry were evaluated. This model identified differences in the performance of these two types of oscillating saw blades. PMID- 10176137 TI - Durability of oscillating bone saw blades. AB - The purpose of this study was to measure the durability of disposable saw blades using a standard bone-cutting experimental model that can be replicated in any laboratory. Using a constant cutting force, the bone-cutting efficiency was determined by recording the maximum cutting temperature and the rate of material removal. In this experimental study, porcine femurs as well as a synthetic bone substitute were used as the test samples for measuring cutting efficiency. Repeated cutting of these test materials did not significantly alter the performance of the disposable bone-cutting blades. PMID- 10176138 TI - Innovations in oscillating bone saw blades. AB - The purpose of this study was to identify some of the determinants of saw-blade design that influence bone-cutting performance. Using a reproducible experimental model, saw-blade performance was judged by measuring the blade temperature and the rate of bone removal. The results of this study demonstrated that the rake angle and blade swing radius had significant influence on saw-blade performance. PMID- 10176139 TI - Controlling the quality of raw materials. AB - Medical device manufacturers generally recognize the importance of selecting appropriate raw materials of high quality for the formulation and manufacture of their products. However, the documentation of raw material specifications and acceptance procedures is not always in complete compliance with quality system requirements. This article will discuss the activities and documentation needed to demonstrate conformity with United States and European requirements for controlling the quality of selected raw materials. PMID- 10176140 TI - Hydrogels: their future, Part I. AB - Hydrogels can be made from a wide variety of water-interactive or water-soluble polymers. They comprise a large family of materials with diverse properties, including some with "smart" responses to their environment. Part I of this two part article will address the range of biomaterial syntheses, properties and applications that can be obtained from one ubiquitous and biocompatible structure: poly(ethylene oxide). Part II will discuss the applications of a novel class of intelligent materials. PMID- 10176141 TI - New methods for surface modification and covalent attachment of heparin. AB - Research is continually under way to improve biocompatibility performance in biomaterials. This article discusses a technique for the covalent attachment of heparin and other drugs onto a variety of polymer and metal surfaces. It offers the potential to improve haemocompatibility and lubricity in a number of medical device applications as well as new drug-delivery systems. PMID- 10176142 TI - Surface plasmon resonance: a technique for characterizing biomaterial surfaces. AB - Surface plasmon resonance is an optical technique that allows the study of surface phenomena in real time, without preliminary labelling. The technique is useful in biomaterial science to determine affinity constants, concentrations, kinetics, film thickness and dielectric properties of material surfaces. This article examines the technology and some of its applications. PMID- 10176143 TI - Marketing medical devices in Japan. AB - The control of medical devices in Japan has recently undergone significant changes as the country brings its systems into line with those of the United States and Europe. This article discusses pre-market approval, quality system requirements and post-market surveillance. Many technical issues have been harmonized but language is likely to continue to be a barrier to trade. Details of information services that are available to foreign manufacturers and importers are supplied. PMID- 10176144 TI - When the balloon goes up: the materials technology of balloon catheters. AB - Balloons and catheters together form an increasingly important combination in diagnostic and therapeutic minimally invasive procedures. This article discusses how these simple devices have risen in stature over the last decade. PMID- 10176145 TI - Economic evaluation of desirudin vs heparin in deep vein thrombosis prevention after hip replacement surgery. AB - Deep vein thrombosis is a serious complication of orthopaedic surgery and can lead to pulmonary embolism and long term post-thrombotic syndrome. A simulation model based on both epidemiological data and data from clinical trials was used to compare the long term cost effectiveness of standard prophylaxis with subcutaneous unfractionated heparin with that of desirudin (recombinant hirudin), in patients undergoing elective hip replacement. The analysis, which was performed before the price of desirudin was set, showed that prophylactic treatment with desirudin saved 4.5 life-years per 100 patients treated, compared with unfractionated heparin. Desirudin prophylaxis was dominant up to a total drug cost of 4400 Swedish kronor (SEK) per treatment. The results were robust against changes in the parameters used in several sensitivity analyses. This study showed that prophylactic therapy with desirudin compared with unfractionated heparin was more cost effective and potentially cost saving under a wide range of assumptions concerning the future price of desirudin in preventing deep vein thrombosis following elective hip surgery. PMID- 10176146 TI - Using pharmacoeconomic analysis to make drug insurance coverage decisions. AB - Our objective was to institute a cost-effectiveness-based reimbursement eligibility and coverage scheme for drugs in the Canadian province of British Columbia. All applications from drug manufacturers requesting Pharmacare (British Columbia government-funded drug insurance plan) coverage were evaluated by the Pharmacoeconomic Initiative (PI) of British Columbia. PI recommendations are according to a majority decision reached by a multidisciplinary volunteer expert committee and are based on a critical evaluation of pharmacoeconomic studies submitted by manufacturers seeking reimbursement eligibility. Coverage for drugs is universal and completely free for the financially indigent. Others are charged a small copayment and/or a deductible. PI assessments are evidence-based. Published guidelines from the Canadian Coordinating Office of Health Technology Assessment (CCOHTA) and/or Ontario Ministry of Health guidelines for the economic evaluation of pharmaceuticals are recommended for preparing submissions to the PI. Between January 1996 and December 1996, the PI made recommendations on 21 submissions; 4 of these were cost-effectiveness or cost-utility analyses; 3 were cost-minimisation analyses; 6 were cost comparisons or cost-consequence analyses; and 8 were provincial formulary budget impact studies. Of the 21 PI recommendations, 18 were accepted by Pharmacare and decisions are pending for 2 others, thus providing a concordance rate of 95% (18/19; kappa = 0.89). A total of 7 of the 21 products were recommended for formulary inclusion by the PI; 4 were as per drug company requests (i.e. full-benefit status) and 3 were recommended under restricted use. Only 5 of 21 submissions, of which 4 had favourable reviews, complied with either the CCOHTA or the Ontario Ministry of Health guidelines. Most studies were conducted, not from a societal perspective, but from the perspective of the provincial healthcare system. Most of the analysis were short term and therefore discounting was not applied. Sensitivity analysis was not performed in more than half (52%) of the submissions, and 48% of applications used inappropriate comparators. Ontario is the only other Canadian province with a similar process, with cost-effectiveness criteria for reimbursement eligibility. However, analysis in that province during the same approximate time period demonstrated a low concordance between Ontario Drug Benefit and PI decisions (kappa = 0.07). Currently, the mandated or suggested use of technology assessments of pharmaceuticals with cost effectiveness as the primary end-point is a reality in several countries worldwide. Our results, based on actual experience from implementing such a programme, suggest that while industry is slow to adapt to the new reporting requirements it may also be sceptical about the importance of cost effectiveness and guideline compliance in decision-making. PMID- 10176147 TI - The effect of changes in treatment patterns on drug expenditure. AB - This paper investigates the effects of changes in drug therapy on drug expenditure in Sweden between 1990 and 1995. Analyses have been carried out for both the aggregate drug expenditure and for drug expenditure according to the main groups of the Anatomical Therapeutic Chemical (ATC) classification system. Changes in expenditure can be divided into 3 components: the price of drugs, the quantity of drugs consumed and a residual. The size of the residual is a measure of the effect of changes in drug treatment patterns on drug expenditure. The aggregate real drug expenditure increased by 50% between 1990 and 1995. The relative retail price index of drugs decreased by 9% and the quantity index measured in terms of defined daily doses increased by 27%. The remaining residual increased by 30%. This implies that, if the residual had been unchanged during the study period, the aggregate expenditure would have increased by only 15%. The results also show that the size of the residual varies substantially across different ATC groups. The increase in the residual was largest for drugs that affect the nervous system (ATC group N); the residual increased by 86%. From the observed changes in residual values, it can be concluded that the underlying factor responsible for the increase in drug expenditure in Sweden is changes in drug therapy from less expensive to more expensive drugs. PMID- 10176148 TI - Medico-economic analysis of diacerein with or without standard therapy in the treatment of osteoarthritis. AB - This 9-month pragmatic study compared 2 therapeutic regimens in the management of osteoarthritis of the hip and knee. Patients received either diacerein 100 mg/day plus standard osteoarthritic therapy for 6 months, followed by a 3-month monitoring period without diacerein, or standard therapy alone for the entire 9 month period. A total of 207 patients with osteoarthritis of the knee and hip were enrolled. Improvements in Lequense's functional index and quality-of-life scores (revised Arthritis Impact Measurement Scales Health Status Questionnaire and Nottingham Health Profile), and decreases in nonsteroidal anti-inflammatory drug and analgesic consumption were significantly greater with diacerein plus standard therapy than with standard therapy alone. The overall assessment of therapy by patients was good or excellent for 60% of those who received diacerein plus standard therapy, compared with 26% who received standard therapy alone. Medical and paramedical procedures carried out in addition to those stipulated in the protocol (medical consultations, physiotherapy, nursing, etc.), osteoarthritis-related, were fewer and less costly in the diacerein plus standard therapy group than in the standard therapy group. The average outpatient cost (in 1995 French francs) of osteoarthritis treatment in the standard therapy group was FF2272 compared with FF2360 in the diacerein plus standard therapy group. The cost-effectiveness ratios per point scored on Lequesne's index were FF1893 for the standard therapy group and FF1072 for the diacerein plus standard therapy group, leading to a saving of 43% with diacerein plus standard therapy. The marginal cost (additional cost corresponding to the clinical benefit obtained by adding diacerein to standard treatment) was FF88 per point scored on Lequesne's index. PMID- 10176149 TI - Economic evaluation of the Cardiac Insufficiency Bisoprolol Study for the Federal Republic of Germany. AB - The Cardiac Insufficiency Bisoprolol Study (CIBIS) demonstrates that, for patients with heart failure of different aetiologies, administration of the beta 1-adrenoceptor blocker bisoprolol as an adjuvant to the standard therapy leads to a significant avoidance of hospital admissions. A pharmacoeconomic analysis of the results of the CIBIS was conducted for the Federal Republic of Germany, and was restricted to direct costs only. The costs of bisoprolol medication and inpatient treatment of heart failure were considered, the latter forming the major part of costs incurred. Per 1000 patient-years, adjuvant bisoprolol therapy resulted in overall cost savings of Deutschmarks (DM)157,272. Statutory Health Insurance had a net saving of DM186,719 in 1000 patient-years, while patients experienced additional net expenses of DM17,760 over 1000 patient-years. The economic advantage of adjuvant bisoprolol treatment was also borne out in the sensitivity analysis. Adjuvant therapy with bisoprolol was not only clinically beneficial for the patient with heart failure but was also economically advantageous. PMID- 10176150 TI - The state of the industry. PMID- 10176152 TI - Automation: innovative and inevitable. A commentary. PMID- 10176151 TI - Automation: triumph or trap? AB - Automation, a hot topic in the laboratory world today, can be a very expensive option. Those who are considering implementing automation can save time and money by examining the issues from the standpoint of an industrial/manufacturing engineer. The engineer not only asks what problems will be solved by automation, but what problems will be created. This article discusses questions that must be asked and answered to ensure that automation efforts will yield real and substantial payoffs. PMID- 10176153 TI - Transferring inpatient specimen collection to nursing: the multidisciplinary path to success. AB - Declining reimbursement has been confronting all health-care providers over the last several years. Reactions are typically unique and cover many different aspects of clinical services. One of the more popular cost-saving ideas that has been adopted by many hospitals has been the transfer of inpatient specimen collection to nurses and their support personnel. This article will present the process used by a large academic medical center to eventually implement such a plan in 1995 to 1996. PMID- 10176154 TI - Competency assessment--an exploratory study. AB - CLIA '88 regulations require that laboratories evaluate and assure the competency of all personnel who perform laboratory tests. The study objective was to determine the interpretation of, compliance with, and implementation of these regulations by laboratories. Interviews were conducted with a stratified nonrandom sample of 20 laboratories including hospital, blood bank, commercial reference, physician office, group practice, and independent laboratories from 12 selected states. Information was collected about the history and development of their competency assessment programs and activities, their definition of competent staff, the interrelationship of competency assessment with performance appraisals, cost, benefits, and the assessment methods and tools used. Competence of laboratory personnel is a complex issue reflecting the dynamics and environment of each unique laboratory setting. This research found no consistent method of competency assessment implementation. This report provides a summary of methods and approaches. Learning what other laboratories are doing will assist managers in developing meaningful and cost-effective competency assessment programs. Documenting all competency assessment activities is important; it serves as a personnel performance management tool and satisfies inspectors. Used in the spirit of continuous quality improvement, the competency assessment program may point to ways of improving processes, personnel, and performance. PMID- 10176155 TI - A method for capitation rate calculation using financial data readily available to the laboratory manager. AB - The advent of managed care has expanded the universe of information needed by laboratory administration to properly manage a clinical laboratory. This article presents a method for calculating proposed capitation rates for laboratory services using financial information that is readily available to the laboratory manager. Having this information is essential before entering into negotiations with a managed care organization and also gives the manager information regarding the laboratory's competitive position in relation to market capitation rates. Once a cost-based capitation rate is determined, laboratory administration must assess whether or not to pursue the contract and how it can be consummated. This article briefly outlines questions to consider in determining whether and how to proceed in contracting with a managed care organization and the ongoing analysis that is required after the contract is won. PMID- 10176156 TI - Key performance indicators to assess laboratory operations. Benchmarking with the best. PMID- 10176157 TI - Profit or service. PMID- 10176158 TI - Overcome imperfection with ten simple management axioms: a laboratory can function smoothly--even in an imperfect world. PMID- 10176159 TI - Laboratory administration--capital budgeting. AB - The process of capital budgeting varies among different health-care institutions. Understanding the concept of present value of money, incremental cash flow statements, and the basic budgeting techniques will enable the laboratory manager to make the rational and logical decisions that are needed in today's competitive health-care environment. PMID- 10176160 TI - Product development: the making of the Abbott ARCHITECT. AB - Many laboratorians have a limited perspective on what is involved in developing an instrument and bringing it to market. This article traces the product development process used by Abbott Diagnostics Division that resulted in Abbott being named the 1996 Concurrent Engineering Company of the Year for the design of the ARCHITECT. PMID- 10176161 TI - Putting employees under the microscope. PMID- 10176162 TI - On-line project databases for construction projects. PMID- 10176163 TI - The National Blood Authority. PMID- 10176164 TI - The Healthcare Estate Management Awards--winners 1997. PMID- 10176165 TI - Service provision of the future. PMID- 10176166 TI - The Asklipieion's healing environment--learning from the past. PMID- 10176167 TI - Result-orientated cleaning contracts. PMID- 10176168 TI - Facilities management and the decision to outsource. PMID- 10176170 TI - Conducting a facility management audit. PMID- 10176169 TI - If medical gas testing is a minefield, can analysers lead us out of it? PMID- 10176171 TI - Ashes to ashes: the medical waste incinerator regulations. PMID- 10176172 TI - Alternative medical waste treatment technologies. PMID- 10176173 TI - Staying alive. Materials managers pitch in to save small hospitals. PMID- 10176175 TI - Supply prices slip. Supply pricing update. PMID- 10176174 TI - Fast friends. OR and CS were worlds apart--now they're inseparable. PMID- 10176176 TI - Unlock the budget approval process. PMID- 10176178 TI - Compensation monitor. Medicare changes favor office-based physicians. PMID- 10176177 TI - A cost-effective way of adding years to life. PMID- 10176179 TI - Are we unmanaging care? PMID- 10176180 TI - Needed: competition between accreditors? An interview with Dennis O'Leary, M.D. PMID- 10176181 TI - Will plans follow the new diabetes screening guidelines? PMID- 10176182 TI - HMOs' delicate balancing act: the art of setting copayments. PMID- 10176183 TI - Want fairness in managed care? Don't wait for the market to do it. PMID- 10176184 TI - A little careful housekeeping can prevent a lot of headaches. PMID- 10176185 TI - Managed care outlook. Employers, HMOs weigh in on PBM (pharmacy benefits managers) satisfaction. PMID- 10176186 TI - Healthcare resource management: integrating apples and oranges. AB - Over the past several years this journal has published numerous articles on the merits and benefits of effective resource management. Independently, these articles have supported the value of effective supply and materials management, management engineering and system restructuring, and clinical resource management in being able to save healthcare dollars by designing and injecting efficiencies into the healthcare delivery system. While most of these resource management activities have utilized very similar strategies (see Table 1 "Tools For Improvement"), much of the process revision and progress has remained within the walls of their own individual disciplines. Any widescale attempts to try to fully integrate all of these activities have been hampered by the intricacies of trying to mix apples and oranges. Despite these individual departmental gains, the challenge to conserve healthcare costs continues to permeate throughout all levels of the organization, and institutions are finally beginning to recognize the added value of merging these activities into a more centralized coordinated approach to resource management. Presented is a discussion on the potential value of developing a well-focused, integrated resource management program. PMID- 10176187 TI - The promise of object technology: what's in it for healthcare? AB - This article focuses on the application of a new business computing model- Objects. Although Object Technology is not new, its widespread use in healthcare information management executives struggle with the integration demands of the new enterprise, Object Technology will unleash the true power of desktop computing and lessen the many quandaries faced with the integration and aggregation of strategic enterprise data. As we move forward, the new healthcare business model will attempt to create the "virtual enterprise." This new enterprise, will be lean and nimble and allow the Integrated Delivery System (IDS) to deliver care to a broader population with fewer requirements for expensive and scarce resources. To do this, the IDS must possess the technology to share key data, with partners and providers, that will allow faster and more accurate decision making. This article presents the "natural fit" of Object Technology and its ability to solve the complex computing issues of the new healthcare enterprise. PMID- 10176188 TI - Designing today's hospital for the future. AB - About 8,000 visitors each day are treated to the serene beauty of a four-story, sky-lit atrium, decorated with maple and cherrywood walls, flowering plants, towering evergreens, two fountains, and river-patterned porcelain tile that flows along the entryway. This is the entrance to Genesys Regional Medical Center Health Park in Grand Blanc, Mich., often mistaken for a hotel. When designing the new 379-bed inpatient hospital, Genesys envisioned a facility that reflected a peaceful, comforting, homelike setting for patients and visitors. This vision, inspired by the spiritual values of the Sisters of St. Joseph, the Genesys sponsors, is now a reality. Having a vision and making it happen, however, was no small undertaking, says author Mark Harris of Genesys Health System. The labor intensive, evolutionary process took several years and thousands of people. In this article, Harris describes many of the building project considerations involved in designing a hospital of the future. PMID- 10176189 TI - Ten steps to implementing EDI. PMID- 10176190 TI - The role of benchmarking in quality management. PMID- 10176191 TI - Beware of that 15 percent! PMID- 10176192 TI - Sugar plums and a budget surplus. PMID- 10176193 TI - Teaching an old dog new tricks. PMID- 10176195 TI - The ADA ... putting teeth into employment discrimination protection. PMID- 10176194 TI - Corporate compliance: implications for trustees. AB - In this era of fraud and abuse enforcement efforts, hospital trustees are facing potential liability in the event that an investigation reveals the hospital has violated state or federal provisions pertaining to fraud and abuse. This liability can be minimized, or avoided, by ensuring that an effective compliance plan is in place prior to such an investigation. PMID- 10176196 TI - You gotta get ready ... ambulatory patient groups (APGs) will be implemented on Jan. 1, 1999. PMID- 10176197 TI - Making economic headlines. AB - There are several ways to assess the impact of hospitals on Michigan's state and local economies. One is to assess the role of hospitals within health care and the proportion of health care dollars and personal income spent on hospital services. Another is the role of the hospital as an economic entity, especially as an employer. A third is to consider the role of hospitals as an essential component of the infrastructure of a community. PMID- 10176198 TI - Look who's calling. PMID- 10176199 TI - Rightsizing for financial health. PMID- 10176200 TI - Getting the green light. How rural hospitals can form a cooperative. AB - As a result of a favorable ruling last fall by the Department of Justice's Antitrust Division, the Rural Wisconsin Health Cooperative (RWHC) is free to negotiate and administer HMO and other payer contracts on behalf of its members. This is a degree of provider collaboration that is desired but not previously seen as possible by many rural providers who are wary of possible antitrust sanctions. PMID- 10176201 TI - Determining our own fate. PMID- 10176202 TI - Health care fraud: guilty until proven innocent. AB - During the summer of 1994, the special prosecutor for health care fraud of the Department of Justice (DOJ), Washington, DC, paid a visit to each of the US Attorney's offices throughout major metropolitan cities in America. Representatives of the American Hospital Association and the American Medical Association in Chicago were invited by the DOJ to meet with the special prosecutor and his assistant to discuss the implications of the DOJ's recent reassignment of health care fraud from its number 11 to its number two priority, second only to violent crime. PMID- 10176203 TI - Kneading relationships. PMID- 10176204 TI - The conversion phenomenon. PMID- 10176205 TI - Disease management ... win/win for patients and the bottom line. PMID- 10176206 TI - Hope instead of homelessness. PMID- 10176208 TI - A square peg in a round hole. PMID- 10176207 TI - Seniors enjoy smoother access. PMID- 10176209 TI - Learning from others. Three key areas in hospital financing reporting. PMID- 10176210 TI - Medicare fraud probes increase in wake of Columbia/HCA problems. PMID- 10176211 TI - Subtle signs often signal federal investigation. PMID- 10176212 TI - Demand is strong for managed care executives. PMID- 10176213 TI - Get benefits of an MD-hospital merger without the grief. PMID- 10176215 TI - Growth rate of integrated systems shows huge rise in last two years. AB - The number of integrated health systems is increasing rapidly across the country as hospitals realize these are the key to their survival. Just how influential are these systems? Here are a few facts: The number of highly integrated health systems rose to 228 in 1997, a 20.6% increase from 1996. Integrated hospitals reported an average occupancy rate of 52.2%. Hospitals that are not integrated reported an average occupancy rate of 48.1%. PMID- 10176214 TI - How to set up a virtual integration model. PMID- 10176216 TI - Collaborative established as industry resource. PMID- 10176217 TI - Increase profits, MCO contracts with hospitalist model. PMID- 10176218 TI - It's simple to switch your PHO to a hospitalist model. PMID- 10176219 TI - HMOs now cover nearly 30% of insured Americans. PMID- 10176220 TI - The rising cost of health care publications. Why science is becoming a luxury purchase. PMID- 10176221 TI - Clinical appropriateness: the only real measure of quality. PMID- 10176222 TI - Strategies for provider reimbursement. Should physician pay exceed that of mid level practitioners? AB - It is clear that the bitter disputes over power and control in health care have been dysfunctional. The issue of reimbursement equity for nurse practitioners who provide primary care services is only one of many numerous, complex issues--each of which has many underlying and unresolved elements contributing to the dysfunctionality of the contemporary health care system. What is needed is a united effort and interdisciplinary collaboration to: a) address the maldistribution and excessive costs of health care, b) reevaluate all aspects of healthcare including who carries out what functions at what level of educational preparation and reimbursement, and c) redesign a system that is efficient, effective, and economical. It is imperative that individual nurses and physicians as well as organized medicine and nursing work with each other and with other health care providers, payors, regulators, suppliers, and most especially consumers to restructure health care and redefine roles. Doing so requires divestment of self-interests and a dispassionate focus on the mission and goals of the system. Using a conceptual model facilitates analysis of the literature, specific issues, and their impact on the system. However, resolution of the issues and improving the health care system's functionality requires commitment to the goal regardless of personal cost. This is the challenge confronting all of us. PMID- 10176223 TI - Metamorphosis of the standard of care and physician experts. PMID- 10176224 TI - Business should get out of the medical business. PMID- 10176225 TI - Post-Potvin depression. Termination of a managed care provider "without cause". PMID- 10176226 TI - Disease management: outsourcing for complex conditions. PMID- 10176227 TI - Leveling the playing field. A specialty PPM gives neurosurgeons the muscle they need to ensure that patients and physicians win in today's health care arena. PMID- 10176228 TI - Building an effective financial model for strategic planning. PMID- 10176229 TI - A comprehensive approach to analyzing capitated contracts. PMID- 10176230 TI - Show me the money. Part One. The anatomy and physiology of a medical malpractice action. PMID- 10176231 TI - Nosocomial pneumonia prevention utilizing a novel bed design. PMID- 10176232 TI - Applying economic analysis to the decision-making process. PMID- 10176233 TI - When it comes to information systems, too often the blind lead the blind. AB - A new survey of health care systems' chief information officers (CIOs) indicates that most are not able to collect the cost information they need to make decisions. Some 60% admit that they cannot calculate whether their managed care contracts are profitable or not. While 70% of these organizations benchmark other health care organizations, only 8% go outside the industry. Leading health system CIOs and benchmarking experts say systems managers must benchmark outside the health care industry if they want current and competitive information technology. PMID- 10176234 TI - Special report: America's best-designed hospital. Griffin's design, care make it a hot benchmark. AB - Griffin Hospital in Derby, CT, a 160-bed, not-for-profit hospital, has designed a beautiful and exceptionally functional facility around its patient-driven care model. More than 200 health care organizations have benchmarked Griffin. Griffin incorporated an extraordinary number of patient amenities, which are enhanced by the hospital system's architectural design, into its care model. Griffin, which operates firmly in the black, has found that it costs no more to provide hotel like accommodations. Meanwhile, its patient satisfaction scores have soared to mid-90 percentiles, while admissions are growing by 2% to 4% a year. PMID- 10176235 TI - Conducting a site visit: a step-by-step approach. PMID- 10176236 TI - JCAHO's ORYX could set national benchmarks. AB - New Joint Commission outcomes reporting requirements could prove a benchmarking boom in the long term, as a huge national database is created. The Joint Commission says it will coordinate the way outcomes are reported, which will bring desperately needed standardization to outcomes reporting. Short-term costs could be heavy as new systems and staffing strain already stretched budgets. PMID- 10176237 TI - Teams trained in-house can be extremely effective. AB - Benchmarking does not have to involve expensive consultants to be successful, but does require careful attention to training and motivation. The best results come from teams who understand their mission, its contribution to the hospital's goals, and the basics of data gathering and manipulation. Managers must assume leadership of teams and be willing to train other team members. PMID- 10176238 TI - Is law the prescription that can cure medicine? PMID- 10176239 TI - Ancient answers to modern questions: death, dying, and organ transplants--a Jewish law perspective. PMID- 10176240 TI - Essay: the challenge of providing adequate housing for the elderly ... along with everyone else. PMID- 10176241 TI - Responsibilities of employers toward mentally disabled persons under the Americans with Disabilities Act. PMID- 10176242 TI - A framework for analysis of ERISA preemption in suits against health plans and a call for reform. PMID- 10176243 TI - Intercountry adoption: a need for mandatory medical screening. PMID- 10176244 TI - Mandating coverage for maternity length of stays: certain problems with the good idea. PMID- 10176245 TI - Ridicule or recourse: parents falsely accused of past sexual abuse fight back. PMID- 10176246 TI - Therapists' liability to the falsely accused for inducing illusory memories of childhood sexual abuse--current remedies and a proposed statute. PMID- 10176247 TI - Perspectives. Incrementalism for the uninsured: kids health top '97 story. PMID- 10176248 TI - Marketplace. Long term care: how the leaders cope with HMOs. PMID- 10176249 TI - Perspectives. Medicaid HMOs: going gets tougher in new environment. PMID- 10176250 TI - The importance of celebration. PMID- 10176251 TI - Scheduling is universal: solutions in five countries. PMID- 10176252 TI - How information technology will change home care. AB - Home care organizations are accustomed to thinking along a paradigm of form following finance. But a new paradigm is coming: form follows information. And that information is in the hands of the client. PMID- 10176253 TI - The computerized patient record. AB - The computerized patient record (CPR) improves efficiency and enhances the availability of clinical information and creates comparative data. Although the CPR system offers many benefits, it also poses challenges to ensuring confidentiality and protecting information. PMID- 10176254 TI - The dynamics and details of acquisitions. AB - The acquisition process has its rewards, particularly for the small provider. But before engaging in an acquisition, providers must first understand the dynamics behind the consolidation trend and know the pitfalls to avoid. PMID- 10176255 TI - Software for the competitive edge. AB - In choosing computer software and hardware that will help their agencies run smoothly, providers face a sometimes overwhelming task. One agency shares its success in achieving a competitive edge using "off-the-shelf" software rather than spending money on more expensive, customized solutions. PMID- 10176256 TI - Selecting an electronic clinical data system. AB - Providers are now required to use documentation systems that include a full range of organizational and clinical information. To sort through the complex process of selecting an electronic clinical data system, clinical managers should use effective problemsolving techniques to evaluate and purchase such systems. PMID- 10176257 TI - Putting the Web to work. AB - Can home care agencies use the Internet to help them succeed in today's highly volatile, highly competitive market? You bet they can. The potential of Internet technology is limited only by an organization's own vision. The Internet is new ground, however, in an industry that for the most part has limited experience with even traditional communications media. PMID- 10176258 TI - Realizing the competitive advantage of the Internet. AB - Everyone's talking about the Internet; everyone's getting on the Internet, either with a home page or to gather information. How has this type of technology become so prevalent--and what if home care providers lag behind in jumping aboard? PMID- 10176259 TI - Industry information technology trends. AB - The coming year will be full of critical challenges for home care and hospice industry executives and senior managers. Information technology (IT), although posing its own challenges, will be a key solution to surviving and thriving through 1998 and beyond. These are the results of a ground-breaking survey conducted during the 16th Annual Meeting of the National Association for Home Care (NAHC) and the World Congress on Homecare and Hospice. PMID- 10176260 TI - The impact of information technology. AB - Although the past decade has seen dramatic changes in home care delivery, the next 10 years will bring profound societal and economic change that will alter the way all companies do business. Quantum leaps in information technology will usher in a new period of history--the networked era. PMID- 10176261 TI - Incompatible information systems: a simpler solution. AB - The day-to-day management of information is a major challenge for everyone in today's health care environment. Providers of all types are under pressure to find resources that address management issues and improve business operations and, at the same time, contribute to successful clinical outcomes--despite the confusing number of information systems that exist among providers. PMID- 10176262 TI - Body mechanics and transfers for health care providers. PMID- 10176263 TI - The lessons of user fee experience in Africa. AB - This paper reviews the experience of implementing user fees in Africa. It describes the two main approaches to implementing user fees that have been applied in African countries, the standard and the Bamako Initiative models, and their common objectives. It summarizes the evidence concerning the impact of fees on equity, efficiency and system sustainability (as opposed to financial sustainability), and the key bottlenecks to their effective implementation. On the basis of this evidence it then draws out three main sets of lessons, focusing on: where and when to implement fees; how to enhance the impact of fees on their objectives; and how to strengthen the process of implementation. If introduced by themselves, fees are unlikely to achieve equity, efficiency or sustainability objectives. They should, therefore, be seen as only one element in a broader health care financing package that should include some form of risk-sharing. This financing package is important in limiting the potential equity dangers clearly associated with fees. There is a greater potential role for fees within hospitals rather than primary facilities. Achievement of equity, efficiency and, in particular, sustainability will also require the implementation of complementary interventions to develop the skills, systems and mechanisms of accountability critical to ensure effective implementation. Finally, the process of policy development and implementation is itself an important influence over effective implementation. PMID- 10176264 TI - Health sector reform in central and eastern Europe: the professional dimension. AB - The success or failure of health sector reform in the countries of Central and Eastern Europe depends, to a large extent, on their health care staff. Commentators have focused on the structures to be put in place, such as mechanisms of financing or changes in ownership of facilities, but less attention has been paid to the role and status of the different groups working in health care services. This paper draws on a study of trends in staffing and working conditions throughout the region. It identifies several key issues including the traditionally lower status and pay of health sector workers compared to the West, the credibility crisis of trade unions, and the under-developed roles of professional associations. In order to implement health sector reforms and to address the deteriorating health status of the population, the health sector workforce has to be restructured and training programmes reoriented towards primary care. Finally, the paper identifies emerging issues such as the erosion of 'workplace welfare' and its adverse effects upon a predominantly female health care workforce. PMID- 10176265 TI - Reform follows failure: I. Unregulated private care in Lebanon. AB - This first of two papers on the health sector in Lebanon describes how unregulated development of private care quickly led to a crisis situation. Following the civil war the health care sector in Lebanon is characterized by (i) ambulatory care provided by private practitioners working as individual entrepreneurs, and, to a small extent, by NGO health centres; and (ii) by a fast increase in hi-tech private hospitals. The latter is fuelled by unregulated purchase of hospital care by the Ministry of Health and public insurance schemes. Health expenditure and financing patterns are described. The position of the public sector in this context is analyzed. In Lebanon unregulated private care has resulted in major inefficiencies, distortion of the health care system, the creation of a culture that is oriented to secondary care and technology, and a non-sustainable cost explosion. Between 1991 and 1995 this led to a financing and organizational crisis that is the background for growing pressure for reform. PMID- 10176267 TI - Health human resource development in rural China. AB - China has made significant progress in increasing the quantity of health workers in rural areas. Attention is shifting to improving the quality of health workers. This article documents several features of health workers in rural China. Many have not received formal training to a level implied by their rank and title, and there is no clear relationship between the skills of health workers and the functions they perform. Many better-qualified personnel have left lower level health facilities for more attractive employment in higher level and urban facilities. A system of professional licensing is currently being considered that will link educational requirements to employment and promotion. This article outlines some of the issues that should be taken into consideration in formulating this system. In particular, licensing may have unequal impacts on rich and poorer areas. This article argues that other regulatory measures will be necessary if licensing is to be an effective mechanism for controlling the quality of health workers, and contribute to the provision of affordable health services in both rich and poor areas. PMID- 10176266 TI - Reform follows failure: II. Pressure for change in the Lebanese health sector. AB - This paper describes how, against a background of growing financial crisis, pressure for reform is building up in the Lebanese health care system. It describes the various agendas and influences that played a role. The Ministry of Health, backed by some international organizations, has started taking the lead in a reform that addresses both the way care is delivered and the way it is financed. The paper describes the interventions made to prepare reform. The experience in Lebanon shows that this preparation is a process of muddling through, experimentation and alliance building, rather than the marketing of an overall coherent blueprint. PMID- 10176268 TI - Pharmaceutical regulation in context: the case of Lao People's Democratic Republic. AB - An explosive development of private pharmacies in the Lao People's Democratic Republic (Lao P.D.R.) has led to 80% of pharmaceuticals being provided by the private sector. In order to achieve the goal of access to good quality health care for all citizens, the Lao government is making an effort to regulate the private pharmaceutical sector using the emerging legal system of laws, decrees, and regulations. The aim of this paper is to describe and analyze the system of drug regulation in Lao P.D.R. in relation to the public social goals. Relevant official documents at the central, provincial and district levels have been reviewed, interviews were held with 30 key informants and 15 pharmacies were surveyed. The public social goals have been expressed in terms of equity and quality of care. However, total drug expenditure may be as low as US$1 per person per year which is far below any minimum standard and does not make it possible to achieve reasonable access to drugs for all. The regulatory system has so far been focused on entry into the pharmaceutical retail market and dealing with basic issues of product quality and conditions of sale. An enforcement system including sanctions is being developed; other policy instruments such as information and economic means are hardly being used at all. The government presently faces a trade-off between quality of pharmaceutical services and geographical equity of access. The study shows that regulation is strongly influenced by the general socioeconomic context. PMID- 10176269 TI - The potential role of risk-equalization mechanisms in health insurance: the case of South Africa. AB - International agencies such as the World Bank have widely advocated the use of health insurance as a way of improving health sector efficiency and equity in developing countries. However, in developing countries with well-established, multiple-player health insurance markets, such as South Africa, extension of insurance coverage is now inhibited by problems of moral hazard, and associated cost escalation and fragmentation of insurer risk-pools. Virtually no research has been done on the problem of risk selection in health insurance outside developed countries. This paper provides a brief overview of the problem of risk fragmentation as it has been studied in developed countries, and attempts to apply this to middle-income country settings, particularly that of South Africa. A number of possible remedial measures are discussed, with risk-equalization funds being given the most attention. An overview is given of the risk equalization approach, common misconceptions regarding its working and the processes that might be required to assess its suitability in different national settings. Where there is widespread public support for social risk pooling in health care, and government is willing and able to assume a regulatory role to achieve this, risk-equalization approaches may achieve significant efficiency and equity gains without destroying the positive features of private health care financing, such as revenue generation, competition and free choice of insurer. PMID- 10176270 TI - Eradicating guinea worm without wells: unrealized hopes of the Water Decade. AB - At the start of the United Nations International Drinking Water Supply and Sanitation Decade in the 1980s, guinea worm disease was targeted as the major indicator of the success of the Decade's efforts to promote safe water. By the late 1980s, most of the guinea worm endemic countries in Africa and South Asia had established guinea worm eradication programmes that included water supply as one of their main technical strategies. By surveying the water supply situation in Ifeloju Local Government Area (LGA) in Oyo State, Nigeria, in June 1996, as a case study, it was possible to determine the role that water supply has played in the eradication effort. Although two major agencies, the former Directorate for Food, Roads and Rural Infrastructure and UNICEF, provided hand dug and bore-hole wells respectively in many parts of the LGA, coverage of the smaller farm hamlets has been minor compared to efforts in the larger towns. This is ironic because the farm hamlets served as a reservoir for the disease in the 1980s, such that when the piped water system in the towns broke down, guinea worm was easily reintroduced into the towns. The survey of 188 ever-endemic hamlets with an estimated population of 23,556 found that 74.3% of the people still drink only pond water. Another 11.3% have wells that have become dysfunctional. Only 14.4% of this rural population has access' to functioning wells. Guinea worm was eliminated from 107 of the hamlets mainly by the use of cloth filters and chemical treatment of ponds. While this proves that it is possible to eradicate guinea worm, it fails to leave behind the legacy of reliable, safe water supplies that was the hope of the Water Decade. PMID- 10176271 TI - Impact of national immunization days on polio-related knowledge and practice of urban women in Bangladesh. AB - Bangladesh began to hold National Immunization Days (NIDs) from 1995 as part of the country's goal to eradicate poliomyelitis by the turn of the century. The NIDs brought together government agencies, the media, voluntary organisations and individual volunteers in social mobilization and service delivery activities. This paper assesses the impact of the first two polio NIDs in terms of the immunization coverage and change in knowledge about the disease among women living in Dhaka city, the capital of the country. Data were collected through pre and post-NID cross-sectional surveys in a sample of one area of Dhaka city which included slum and non-slum households. Knowledge data were collected from 525 women with at least one child aged less than five years. The oral polio vaccine (OPV) coverage during NIDs was obtained from 720 children. Knowledge of polio as a vaccine preventable disease increased after NIDs among both slum and non-slum women. The knowledge gap between the two groups was significantly reduced. Field workers, who regularly visit women at their homes to promote health and family planning services, were the main source of information for the slum women while television was cited as the most important source of information by non-slum women. The study revealed that 88% of children under five years received at least one dose of oral polio vaccine (OPV) during NIDs, and 67% received two stipulated doses with no significant differences between slum (65%) and non-slum (69%) groups. In addition, 68% of the children contacted during the NIDs were given vitamin A supplementation. The study suggests that strategies like NID can be effectively used to tap into community resources and to generate political commitments for health programmes. PMID- 10176272 TI - Comparing manual with software analysis in qualitative research: undressing Nud.ist. PMID- 10176273 TI - Rationalizing a diverse physician network integration. PMID- 10176274 TI - Revisiting the idea of an integrated health care delivery system. PMID- 10176275 TI - Shore Memorial targets mothers with maternity "bed-and-breakfast". PMID- 10176276 TI - HCFA refocuses "conditions of participation" from procedures to outcomes. PMID- 10176277 TI - Winning the consumers' hearts and minds: a health care branding strategy. PMID- 10176278 TI - More changes than usual for providers. PMID- 10176279 TI - HCIA, Mercer name top 100 hospitals, update benchmark practice patterns. PMID- 10176280 TI - How to ensure supplier quality from your supplier management program. AB - Companies are currently abandoning vertical integration in order to focus on their core competencies and capabilities. As a result, higher percentages of their products are being provided by suppliers. In today's global marketplace, customers can demand and receive products that possess excellent quality. In order to remain competitive, companies must be able to provide high-quality products at low prices. The quality of components purchased from suppliers influences product quality more than any other factor except design quality, and since purchased materiel make up such a large percentage of a company's product, ensuring supplier quality has become an economic imperative. PMID- 10176281 TI - How to attain supplier performance reliability. AB - Today's competitive and economic pressures have increased the expectations customers have regarding their suppliers. Increased quality, greater overall value, and excellent on-time delivery performance can only be achieved and sustained through long-term customer-supplier relationships. To support these relationships, operating personnel will be called upon to embrace new behaviors as well as new business processes. PMID- 10176282 TI - Creating win-win customer-supplier partnerships. AB - Today's global competition mandates that each customer-supplier combination achieve a balance between the supplier's manufacturing flexibility and the customer's schedule stability. Sharing valid schedules, working on quality together, reducing each other's costs, and streamlining communications allows a customer and supplier to become true enterprise partners. PMID- 10176283 TI - Is the customer always right? AB - This article begins with a brief review of the early days of production and inventory control (where it started), describes the present state of the art (what it is like today), and ends with a forecast of what the future looks like (where it is going). Recognizing the importance of the customer today, it focuses on the changes in supplier-customer relations in the past as well as those to come. PMID- 10176284 TI - Service: the next frontier. AB - There is a revolution taking place in the U.S. economy, a service revolution. Today, over 70 percent of the gross national product and 75 percent of all jobs can be attributed to the service sector. This monumental change is affecting not only service firms but also manufacturers. It is estimated that anywhere from 30 to 70 percent of the value added by a typical manufacturer is due to the service component. This article discusses the increased importance of services in our economy and on our shop floors. If manufacturers are to prosper in the coming decade, they will need to embrace this change and put services and service operations at the forefront of their strategic plans. PMID- 10176285 TI - Customer-focused service management: driving change up the hierarchy and outward. AB - The modern management revolution, which has quality and customer service at its core, is incomplete. The customer mindset is strongest in frontline operations and growing in support functions. Too often, however, the strategic hierarchy has been left out--still taking its marching orders from the skittish, myopic financial community centered in Wall Street, the City of London, and other meccas of money. Superior organizations, largely in manufacturing thus far, are taking steps toward correcting this deficiency. Their approach is to reorient using customer-focused principles that are attractive to all parties, including external partners. PMID- 10176286 TI - How to achieve customer service through short-cycle paperwork. AB - The ultimate goal of short-cycle paperwork is to satisfy customers by filling their orders as quickly as possible. Tools and techniques that can help achieve this goal include Just-in-Time paperwork elimination, process mapping, paper flow mapping, function/process mapping, work cells, and electronic kanban. Each of these is described briefly in the article. PMID- 10176287 TI - A compass for customer needs. AB - Baldor Electric uses a tool it calls the value formula to help teach its employees to look at their work through the eyes of the customer. In fact, the goal of the value improvement process is to focus everyone on customer value, and the employees, by going through five training courses, learn how improving quality and service and reducing cost and time lead to higher value for the customer. PMID- 10176288 TI - Foundations for a new tomorrow: how to bridge the gap in work force literacy. AB - U.S. companies face substantial challenges from abroad, and to meet these challenges they need workers who have the ability to learn on their own. Unfortunately, many workers lack the basic skills they must possess in order to respond to current and future changes. This article describes a new perspective on literacy in the workplace and presents a strategic approach to improving literacy. The approach includes determining what skills are truly needed, evaluating the current skill level of the work force, and tailoring education to meet the specific needs of particular groups of workers. PMID- 10176289 TI - Power learning: racing ahead of your competition. AB - Adhering to accepted practices, not wanting to rock the boat, and squelching dissenting opinions sentence organizations to a repetition of their mistakes. To be successful, organizations must continually learn. Organizations that learn are competitive. They are on the leading edge. They create their own futures instead of being created by their futures. The objective of this article is to present a new approach to learning that greatly enhances the quality of training and educational programs. The key subjects include learning styles, left and right brain processing, and the 4MAT System. In addition, two brief case studies are presented. PMID- 10176290 TI - Beyond education: winning hearts and minds. AB - Replacing an informal operating system, since it represents a substantial change, faces a typical obstacle: reluctance based on familiarity with the old way of doing things and fear of the new and unknown. Taking a logical approach to the change is not enough. The hearts and minds of the employees must be won over as well. This article presents a step-by-step process, along with a list of rules and a test of success, for motivating the necessary behavior change. The key is to focus not just on the technology needed for the new operating system but also on the people who will do the work. PMID- 10176291 TI - Stop wasting your training dollars! How to use integrative learning. AB - To succeed in today's competitive world, companies need to continually train their employees to do new jobs and to perform old jobs better. Unfortunately, most on-the-job education and training is wasted, since traditional methods do not get workers to retain what they have learned. This article describes a new method of education, integrative learning, that takes into account that each person has multiple kinds of intelligence and also has his or her own style of learning. By changing the learning environment and the way information is presented, processed, and used in the classroom, integrative learning produces substantially better results than traditional methods. PMID- 10176292 TI - Managing discharges. Honourable discharge. PMID- 10176293 TI - Discharges. Ready, steady, go. AB - Setting up a discharge lounge has proved popular with patients. Referrals from wards have increased but are still spasmodic. When under pressure some staff say they are too busy to transfer patients to the discharge lounge. The ambulance transport service has benefited from being able to pick up most patients awaiting discharge from a single area. PMID- 10176294 TI - Length of stay. Taking a day off. AB - A trust, comprising two hospitals, has reduced the mean length of stay for acute medical admissions from 11.1 to 10.5 days and the median from six to five days, despite an increase in the number of these admissions. Providing medical teams with unanonymised information on their length of stay profiles has helped achieve this. The information has been well accepted by consultants. In considering length of stay it is useful to look at the mode or peak, as well as the mean. This is because the mean is heavily influenced by the small number of patients who stay in hospital for a very long time. PMID- 10176295 TI - Hospitals. The regeneration game. AB - DGHs are faced with a choice between restricting their focus to intensive surgical and medical services or building up alliances with other agencies, including GPs. Their best hope for survival lies in robust relationships with GPs, local authorities, support groups and consumer organisations. Hospitals must pay more attention to discharge procedures. They must be prepared to manage demand in partnership with community providers. PMID- 10176296 TI - Working hours. Hardy annuals. AB - Employing nurses on annual-hours contracts which include on-call and stand-down duties has led to more efficient deployment of staff in relation to workload. The system has cut the use of agency nurses and bank staff and reduced staffing costs. The majority of staff who took part in the pilot scheme have chosen to remain on annual-hours contracts. PMID- 10176297 TI - Resettlement. A moving story. AB - The risk of death among elderly patients moved out of long-stay psychiatric hospitals can be minimised with careful preparation. A specialist team working with residents before the move, and visiting them for three months afterwards, helps provide continuity. In this group of 14 patients, aged 70 to 96, there were no deaths in the six months following the transition. PMID- 10176298 TI - Carers tell it like it is. AB - Carers want a great deal more medical and practical information than they are given at present. Their need for information may conflict with doctors' duty of confidentiality. Carers are often taking responsibility for day-to-day care while being kept in ignorance of many aspects of the patient's condition. Health professionals would not accept responsibility in these circumstances. Unless the availability of information, and its delivery, becomes more methodical, carers are likely to remain critical of health and social services. PMID- 10176299 TI - Mental health. Suitable cases for treatment? AB - Common misconceptions that people with severe personality disorders are 'undeserving and untreatable' often prevent them getting specialist treatment. A stay of at least six months in a specialist residential 'therapeutic community' can give significant improvements for 75 per cent of clients. Research has shown that treatment may pay for itself within two years and can result in a significant reduction in use of inpatient psychiatric beds. PMID- 10176300 TI - Comparative research and analysis methods for shared learning from health system reforms. AB - The pace and breadth of health reforms point to the need for a comparative methodology to support shared learning from country experiences. A common understanding of health reforms is a first prerequisite for comparative research. Dimensions characterising content, sequence, process, purpose and scope of policy change are identified on the basis of a literature review. Reforms can have a gradual build up, starting with piecemeal policy changes that can be eventually integrated to enhance their benefits. Comprehensive reforms can be defined as policy formulation and implementation that comprises the systemic, programmatic, organisational and instrumental policy levels through explicit strategies sustained in well-documented experiences and theories and implemented with the support of a specialised agency with consensus-building capacity. A minimum-data set is proposed on the basis of an extensive literature review to support the comparability of health reform case studies and descriptions. Its components are: the current health system, its background and context, the reform rationale, the specific proposals, political actors and processes, achievements and limitations, and lastly the reform's wider impact. Case studies can be compared historically, through particularistic comparisons, using ideal types and by means of exemplars. The advantages and limitation of each method are analysed as well as how they can be combined to frame the research questions and minimise resources. Finally, the International Clearinghouse for Health System Reform Initiatives is described as an instrument to disseminate comparative research and analysis in support of shared learning. PMID- 10176301 TI - Utilisation of medical technology assessment in health policy. AB - OBJECTIVE: To assess the contribution of medical technology assessment (MTA) to health policy decision making, the question has to be answered whether MTA is actually being used in decision-making processes and what factors are related to its utilisation. DESIGN: We investigated recent Dutch policy decision making concerning four cases, i.e., breast cancer screening, serum alphaprotein (AFP) screening, in vitro fertilisation (IVF) and lung transplantation. METHODS: A search of the international literature yielded 351 articles that reported MTA results concerning the four cases studied. Policy documents, advisory reports and parliamentary discussions were analysed to identify the utilisation of existing MTA knowledge in The Netherlands. Additionally, 23 structured interviews with experts in the field of MTA and/or policy decision-making were conducted. RESULTS: Numerous articles report results of MTA studies of breast cancer screening and in vitro fertilisation. In both cases the Dutch government commissioned MTA studies, but the outcomes of these studies did not substantially affect the decision-making process. MTA knowledge about AFP screening is more limited and studies dealing with lung transplantation are scarce. Nevertheless, policy decisions were made. CONCLUSION: Policy decisions concerning the introduction of (new) technologies in health care are not based on the results of MTA studies. Political arguments and interest groups decide the outcomes. At best, MTA results are used to implement (new) technologies more effectively. PMID- 10176302 TI - Willingness to pay for health insurance in a developing economy. A pilot study of the informal sector of Ghana using contingent valuation. AB - In the midst of high cost of health care both at the macro and micro levels, health insurance becomes a viable alternative for financing health care in Ghana. It is also a way of mobilising private funds for improving health care delivery at the macro level. This study uses a contingent valuation method to assess the willingness of households in the informal sector of Ghana to join and pay premiums for a proposed National Health Insurance scheme. Focus group discussions, in-depth and structured interviews were used to collect data for the study. There was a high degree of acceptance of health insurance in all the communities surveyed. Over 90% of the respondents agreed to participate in the scheme and up to 63.6% of the respondents were willing to pay a premium of 5000 cents or $3.03 a month for a household of five persons. Using an ordered probit model, the level of premiums households were willing to pay were found to be influenced by dependency ratio, income or whether a household has difficulty in paying for health care or not, sex, health care expenditures and education. As income increases, or the proportion of unemployed household members drop, people are willing to pay higher premiums for health insurance. PMID- 10176303 TI - Healthcare access and mobility between the UK and other European Union states: an 'implementation surplus'. AB - European Union (EU) policy on mobility requires ensuring healthcare access for EU residents who travel between EU states. This case-study investigates how this policy has been implemented in respect of EU visitors to the UK. EU visitors to the UK have similar access to 'immediately needed' National Health Service (NHS) healthcare to UK residents. For non-urgent healthcare, the NHS has official systems to discourage 'medical tourism' and divert such patients to the private sector or to reclaim the costs of NHS hospital treatment for EU visitors. Yet these official systems contrast with the flexibility and liberality of actual NHS practice towards EU visitors. Research on health policy implementation mostly examines reasons for 'implementation failure'. However, the present study indicates a health policy being implemented more fully than policy-makers may have anticipated. In the case of healthcare access for EU visitors to the UK, an implementation surplus is evident rather than an implementation deficit. PMID- 10176304 TI - Quality systems in Dutch health care institutions. AB - The implementation of quality systems in Dutch health care was supervised by a national committee during 1990-1995. To monitor the progress of implementation a large survey was conducted in the beginning of 1995. The survey enclosed all subsectors in health care. A postal questionnaire--derived from the European Quality Award--was sent to 1594 health care institutions; the response was 74%. The results showed that in 13% of the institutions a coherent quality system had been implemented. These institutions reported, among other effects, an increase in staff effort and job satisfaction despite the increased workload; 59% of the institutions had implemented parts of a quality system. It appeared that management pay more attention to human resource management compared to documentation of the quality system. The medical staff pay relatively more attention to protocol development than to quality-assurance procedures. Patients were hardly involved in these quality activities. The research has shown that it is possible to monitor the progress of implementation of quality systems on a national level in all subsectors of health care. The results play an important role in the discussions and policy on quality assurance in health care. PMID- 10176305 TI - Radiation: it's not just for cancer anymore. PMID- 10176306 TI - 'Less is more!' Jumping on the minimally invasive bandwagon. PMID- 10176307 TI - Emergency care for victims of violence, domestic and otherwise. PMID- 10176308 TI - Some interesting facts about injury prevention in the United States. PMID- 10176309 TI - Form follows technology. PMID- 10176310 TI - Contracting for health services when patient demand does not reflect quality. AB - This paper analyses contracts to keep down costs while maintaining quality of health services when patient demand does not reflect quality. There is then a natural role for forms of contract that have emerged during the reforms of the NHS in Britain that differ from pure fixed price or cost reimbursement contracts. The optimal form depends on whether the provider is entirely self-interested or benevolent in having genuine concern for patient welfare. With fully benevolent providers there are roles for block and cost and volume contracts. With partially benevolent providers, some degree of cost sharing is typically optimal. PMID- 10176311 TI - Do people shift their use of health services over time to take advantage of insurance? AB - This paper provides a test of the hypothesis that people shift their consumption of health services to time periods when they have more generous insurance coverage, in order to take advantage of third-party payment. We use data from the Survey of Income and Program Participation to compare utilization rates for people in transition between being insured and being uninsured to those of people who are continuously insured and continuously uninsured. We find little support for the hypothesis that people anticipate changes in their insurance status and arrange their health care consumption accordingly. PMID- 10176312 TI - Is there underinvestment in R&D about prevention? PMID- 10176313 TI - Price regulation of pharmaceuticals in Canada. AB - Patent holding pharmaceutical firms are modeled as price-discriminating international monopolies. In an unregulated world market, firms set monopoly prices in each national market. Three types of regulatory rules: (i) 'reasonable' relationship rule, (ii) international price comparison rule, and, (iii) therapeutic class comparison rule, are examined. While price regulation may lead to lower introductory prices for new drugs, the price of existing drugs may increase. Domestic price regulation may increase foreign prices. Canadian data supported the model's predictions. Policy makers should anticipate these responses that affects the entire vector of drug prices and not just those subject to specific regulations. PMID- 10176314 TI - The measurement of individual utility and social welfare. AB - It has been suggested by a number of economists that decisions about how to allocate scarce health care resources should be informed by the cost per quality adjusted life-years (QALYs) of the different alternatives. One of the criticisms of the QALY approach is that it is based on the measurement of individual utility; yet the values elicited are used to inform social choice. In this respect, it is argued that the QALY approach fails to take account of distributional issues that are known to be important in the context of health care. This paper addresses this issue and presents an approach grounded in microeconomic theory that is flexible enough to deal with a wide range of efficiency-equity trade-offs, while making the nature of the trade-off transparent. In addition, it is an approach that is relatively simple to investigate empirically, and the results of a preliminary study are presented as illustration of this. PMID- 10176315 TI - Alcohol use and wages: new results from the National Household Survey on Drug Abuse. AB - A recent study published in the Journal of Health Economics by French and Zarkin [French, M.T., Zarkin, G.A., 1995. Is moderate alcohol use related to wages? Evidence from four worksites, Journal of Health Economics 14, 319-344] found evidence of a positive, inverse-U-shaped relationship between wages and alcohol consumption for individuals at four worksites. In this paper, we attempted to replicate French and Zarkin's findings using a combined sample of prime-age workers from the 1991 and 1992 National Household Surveys on Drug Abuse (NHSDA). Whereas French and Zarkin found that individuals who consume approximately 1.5 to 2.5 drinks per day have higher wages than non-drinkers and heavy drinkers, we found no evidence of a turning point at this consumption level for either men or women. Our results do suggest that men who use alcohol have approximately 7% higher wages than men who do not drink, and this apparent wage premium is approximately the same over a wide range of alcohol consumption. For women, the estimated alcohol use premium is approximately half as large as for men and is statistically insignificant. PMID- 10176316 TI - Economies of scale in non-revenue producing cost centers: implications for hospital mergers. AB - This paper uses semiparametric methods to estimate the magnitude of economies of scale in 14 non-revenue producing cost centers in hospitals. There are substantial economies of scale in small hospitals, but economies are exhausted in hospitals with over 10,000 discharges annually. In recent hospital mergers challenged by federal antitrust agencies, one or both hospitals had over 10,000 discharges, suggesting that efficiency gains in non-revenue producing cost centers will be small, and could easily be offset by nominal price increases. PMID- 10176317 TI - The effects of low-pay and unemployment on psychological well-being: a logistic regression approach. AB - The paper explores the relationship between unemployment and mental distress. The analysis draws upon data from the 1992 British Household Panel Study (BHPS). Six different measures of mental distress are used. Controlling for a number of individual characteristics, unemployed individuals are found to suffer significantly higher odds of experiencing a marked rise in anxiety, depression and loss of confidence and a reduction in self-esteem and the level of general happiness even compared with individuals in low-paid employment. This finding highlights the involuntary nature of unemployment. The results also suggest that all six measures of psychological well-being are lower in middle age compared with younger and older age groups. In addition, women appear to be less affected by unemployment than men. PMID- 10176318 TI - How to finance a practice buy-in. PMID- 10176319 TI - I've become the perfect HMO provider! PMID- 10176320 TI - Destitute doctors? It happens. PMID- 10176321 TI - Physician executives. Specialists earn more in managerial jobs, too. PMID- 10176322 TI - When doctors lobby, will Congress listen? PMID- 10176323 TI - Will HMOs use specialists for "principal care"? PMID- 10176324 TI - Can new offices change a group's practice style? PMID- 10176325 TI - Who should design your medical building? PMID- 10176326 TI - Improving the PPI sample for prescription pharmaceuticals. PMID- 10176327 TI - Employment outlook: 1996-2006. Industry output and employment projections to 2006. PMID- 10176328 TI - Employment outlook: 1996-2006. Occupational employment projections to 2006. PMID- 10176329 TI - Employment outlook: 1996-2006. The U.S. economy to 2006. PMID- 10176330 TI - A one-year dip. Medicare inpatient spending to resume climb in '99. PMID- 10176331 TI - JCAHO firestorm. Hospitals, trade groups rebel on self-reporting policy. PMID- 10176332 TI - Deal deluge. Despite 4th-quarter slump, consolidations up 19%. PMID- 10176333 TI - Another doc group endorsing products. PMID- 10176334 TI - Recognizing quality. Disease management protocols at core of Pa. system's award winning approach. PMID- 10176335 TI - VA on the spot. Care quality, oversight to be probed by Congress. PMID- 10176336 TI - Balancing act. Cancer diagnosis a wake-up call to CEO struggling to juggle work, personal lives. PMID- 10176337 TI - Reaching for it. States struggle to gain new money for children's healthcare. AB - Last year's balanced-budget act authorized the creation of a state Children's Health Insurance Program and set aside federal funding for state children's healthcare plans. However, states can't get the feds' money unless they pony up some of their own dough. Not only are states worrying about how to come up with the money, they're also wondering how best to structure their children's healthcare plans. PMID- 10176338 TI - Change in Ohio's big small town. Tradition-bound Cincinnati goes with healthcare flow. PMID- 10176339 TI - Information systems. Surveying siteseers at HIMSS convention. PMID- 10176340 TI - Microsoft goes it alone, stages own show. PMID- 10176341 TI - Bragging rights. Report shows fraud probes are paying big dividends. PMID- 10176342 TI - Advice on how to stay afloat in swirling sea of priorities. PMID- 10176343 TI - Surgery teams make strides on OR delays. PMID- 10176344 TI - Effective technology planning needs an organizational focus. PMID- 10176345 TI - Do homework before starting on pathways. PMID- 10176346 TI - Build variance tracking into pathway program. PMID- 10176347 TI - Burnout: an occupational hazard for managers. PMID- 10176348 TI - 'Magnet' hospital reduces costs, keeps RNs. PMID- 10176349 TI - Machiavelli 'perfect fit' for managers of OR. PMID- 10176350 TI - Welfare reform benefits employers. PMID- 10176351 TI - Riding the bull market. After a breakthrough year, assisted living companies must find ways to sustain their growth. PMID- 10176352 TI - Top 30 assisted living chains. PMID- 10176353 TI - Fitting into a new role. Retrofitting a nursing facility to an assisted living residence is no easy task. PMID- 10176354 TI - The specter of violence in the work place. PMID- 10176355 TI - An OSHA inspection survival kit. PMID- 10176356 TI - Re-engineering therapy service delivery. PMID- 10176357 TI - Surveyors' perspective on weight-loss prevention. PMID- 10176358 TI - Intrapulpar temperature during continuous CO2 laser irradiation in human molars: an in vitro study. AB - To establish safety parameters, we in vitro studied the increase in intrapulpal temperature caused by the use of a cw CO2 laser. A thermistor was implanted in the inner part of the pulpal chamber of 25 human lower third molars to measure the intrapulpal temperature produced by laser powers between 2-10 W and exposure times of 0.5-25.0 s. The Pearson linear correlation factor applied to the measured values showed there is a direct relationship between the independent variable and the applied power. A variance analysis produced the linear regression equation: T = 1.10 + (0.127)E where T is the temperature and E the energy. The results showed that, with a power of 4 W and maximum exposure time of 2:5 s (10 J) and a power density of 12,738.85 W cm-2, there will be no damaging reactions affecting the pulpal tissues. PMID- 10176359 TI - Evolving issues in laser safety. AB - The approach to laser safety has come a long way since the 1960s when the first guidelines were issued by defense research organizations in the US and the UK, and then by the American Conference of Governmental Industrial Hygienists. Although the search for 'eye-safe' numbers continues in a few laboratories, this work is almost exclusively centered on deriving retinal thresholds for ultra short (sub-nanosecond) lasers. Setting limits in this temporal region has been difficult, since there are conflicting data sets and there is a limited amount of data to extrapolate to other spectral regions. In the standards arena, the concentrated efforts have been in terms of product classification and attempts to resolve the eternal question of 'how safe is safe?'. Recent efforts to revise safety standards have not always taken into account the historical rationale for the maximum permissible exposures and forget that safety factors were already factored into the limits and further safety factors are quite unnecessary. Finally, the study of accidents raises the question of whether our approach to eye protection and enclosures are adequate and whether separate standards and guidance is needed for different applications. PMID- 10176360 TI - Amendments to the Center for Devices and Radiological Health federal performance standard for laser products. AB - Federal law requires that all laser products that are imported into or introduced into commerce in the United States comply with the performance standard published in the Code of Federal Regulations (CRF), Title 21, Parts 1040.10 and 1040.11, administered by the Center for Devices and Radiological Health (CDRH), US Food and Drug Administration. Although it contains somewhat different requirements for hazard classification, engineering controls and labeling, the ANSI Z136.1 standard defers to the CDRH standard. The CDRH standard became effective in August, 1976 and was amended, in 1978 and also in 1985. In the early 1990s, US experts met to formulate an approach to bring the requirements of the CDRH standard and those of the International Electrotechnical Commission (IEC) standard, IEC 825, into closer agreement in order to lower barriers to international trade and to remove any excessive compliance burdens on manufacturers. In 1993, the CDRH published, formally in the Federal Register and informally, a Notice of Intent to amend the CDRH standard. Responses to those notices have now been analyzed and informal draft amendments were distributed in 1996. This draft is now being prepared for formal issuance as a Notice of Proposed Rulemaking. Meanwhile, the IEC standard was amended in 1993 and republished as IEC 825-1; these amendments created considerable controversy since they resulted in over classification of the hazard of many products, especially light emitting diodes (LEDs) that have a large divergence and increased source dimensions. Additional amendments are now being developed to correct this problem. The CDRH has carefully monitored developments in the IEC and actively participated in its proceedings as a guide in developing its own proposal. This paper describes the major changes that are being proposed for the CDRH standard and presents some rationale for the major changes. The more significant changes include expansion of applicability to include LEDs, reduced emission durations for classification, revised measurement for hazard classification, reduced performance requirements for lower power visible radiation products, and revised requirements for medical products. PMID- 10176361 TI - User reporting systems. AB - Under the European vigilance system, manufacturers are responsible for reporting serious incidents or near incidents concerning medical devices to the relevant Competent Authority. However, the European Directives do not require users to report incidents. As a result, user reporting requirements vary among Member States. This article examines the manner in which user reporting is addressed in the European Directives and European vigilance guidance document, some examples of national user reporting systems, and some important issues concerning user reporting. PMID- 10176362 TI - Using and controlling subcontractors. AB - The use of subcontractors for the provision of goods and services is an increasing fact of life in the medical device industry. Many specialist subcontractor companies do nothing but fulfil the needs of primary manufacturers. This article examines the quality system and compliance aspects of using subcontractors and makes reference to the recent recommendations from the European Notified Bodies Group on Medical Devices. PMID- 10176363 TI - Private-label manufacturing. AB - Private, or own-brand, labelling of products is an attractive proposition for manufacturers who may have unique products but lack access to particular markets, or distributors who may have a strong brand identity but lack a suitable product. However, care must be taken to ensure that private-labelled products comply with the Medical Device Directive and confusion may arise over who takes responsibility for compliance issues. This article looks at the alternative proposals for resolving this confusion and at some of the requirements for compliance. PMID- 10176364 TI - A new guide to EMC. AB - The European Commission has now finalized its new guide to the application of the Electromagnetic Compatibility Directive. The document makes significant changes in emphasis and substance to current thinking. This article describes the key changes relating to issues such as components, installations and systems, and the implications for suppliers of medical devices. PMID- 10176366 TI - The role of the medical director in a life insurance company. PMID- 10176365 TI - Engineering a concept: the creation of tissue engineering. AB - Tissue engineering is a fashionable phrase and a new concept. This article analyses what is meant by this term and discusses some of the products that may emerge from the translation of this concept into clinical reality. PMID- 10176367 TI - Comparative mortality in mentally retarded patients in California, with and without Down's syndrome, 1986-1991. AB - BACKGROUND: The large database of the California Department of Developmental Services provides a data source for mortality rates in persons with mental retardation by age, sex, severity, cause and associated conditions. RESULTS: Data for 1986-1991 were used to determine age-related mortality rates in cases with and without Down's Syndrome, in three severity levels of mental retardation. Distribution data for the data-base population are also given. CONCLUSION: In both Down's and non-Down's patient groups excess mortality increased with severity of mental retardation at all ages. In both groups excess mortality tended to decrease with advancing age to age 35-39 years, and to increase at the older ages. The age increase in excess death rate at age 40 years and up was steeper in the patients with Down's Syndrome. PMID- 10176368 TI - Effect of peripheral vascular disease on long-term mortality after coronary artery bypass graft surgery. AB - BACKGROUND: The Northern New England Cardiovascular Disease Study Group examined the effect of cerebrovascular disease (CVD) and lower extremity disease (LED) on long-term outcome following coronary artery bypass graft (CABG) surgery in patients with coronary heart disease (CHD). This article uses data provided by the authors to quantify the mortality implications of progressively more extensive atherosclerosis. RESULTS: After successful CABG surgery, mortality ratios for patients with CHD + CVD (107%), CHD + LED (171%), and CHD + CVD + LED (195%), respectively, were 1.6 times, 2.5 times, and 2.8 times higher than mortality ratios for patients with CHD only (69%). CONCLUSIONS: The extent of peripheral vascular disease predicted mortality experience even after successful myocardial revascularization. PMID- 10176370 TI - Supraventricular tachycardia vs. Marfan's syndrome. AB - Marfan's syndrome is one of several genetic connective tissue disorders that manifest cardiovascular abnormalities. Paroxysmal supraventricular tachycardia is not one of these manifestations. PMID- 10176369 TI - Adenocarcinoma of the prostate. AB - Prostate cancer presents a growing challenge for the medical director. Knowledge of prostate cancer statistics, risk factors, stage and grade of the tumors, screening, and treatment options is necessary for underwriting and claims evaluation. PMID- 10176371 TI - Environment, development and health: ideological metaphors of post-traditional societies? AB - Environment and health have become nearly interchangeable concepts in post traditional societies. We are able to observe almost an obsession with them, as if individual changes in ways of life--important for the individual and significant for the culture though they may be--possessed the power to overthrow a system of economic relations that aims at growth in numerical terms rather than at development, enabling society to sustain its specific modes of private and public interaction. PMID- 10176372 TI - Critical thinking: a central element in developing action competence in health and environmental education. AB - In the field of educational philosophy, health and environmental education share many common goals and challenges on the level of curriculum theorizing as well as the level of pedagogical practice. One of these challenges is to develop a radical philosophy of education which is critical and takes a controversial point of departure rather than the one of accommodation. It highlights, in other words, the socially critical role of education. From this point of view some key concepts are discussed in the paper in relation to health and environmental education: democracy as means and end, critical thinking, the critical orientation, and the action perspective. One of these concepts, critical thinking, is elaborated in particular as it is considered to be essential to pupils' development of action competence. A description is given how it can be seen from four perspectives: the epistemological, the transformative, the dialectical and the holistic. PMID- 10176374 TI - Lessons from a review of publications in three health promotion journals from 1989 to 1994. AB - A thematic analysis was undertaken of 72 editorials in three leading health promotion journals, Health Education Research: Theory & Practice, Health Education Quarterly and Health Promotion International, from 1989 to 1994. The three main themes which emerged were (1) the need to broaden health promotion interventions, (2) the need to promote rigour and professionalism in the discipline of health promotion, and (3) the need to respond to the information requirements of practitioners. Against this context, we conducted a content analysis of the journals, examining the nature of the 649 peer-reviewed publications in the same time period. Categories from the traditional bio-medical 'stages of research' models had to be adapted before full classification of articles published was feasible. The largest number of articles published could be termed descriptive research, followed by studies developing and validating health promotion measurement tools and health promotion theory. The proportion of program evaluations was small and the proportion of randomized controlled trials ('highest quality evidence' of effectiveness) decreased over time. Dissemination studies were also poorly represented in spite of this being identified in editorials as an important professional need. Ways to redress some of the imbalances observed are discussed. PMID- 10176373 TI - Global health promotion models: enlightenment or entrapment? AB - This paper suggests that there is a tendency for health promotion to be located within models that consider health to be a product of a range of forces, with practice itself assumed to comprise a similarly wide range of activities. This paper develops a critique of this tendency that is essentially accommodating, all embracing and 'neutral'. It is argued that this leads to the masking of tensions between the conflicting values contained within the different elements of the models. We suggest that for health promoters, this is neither conceptually appropriate nor practically sensible. These notions are developed in five main stages. We start by defining some of the key concepts in the piece, e.g. the nature of a 'model' and examples of 'global' models. We then examine some of the general reasons why global models are favoured, with respect to the emergence of the UK's strategy for health, The Health of the Nation. The third stage of the discussion identifies and considers, within the British context, professional and governmental factors perceived to have driven this choice. The fourth aspect of the paper will introduce a critique of the use of global modelling. The paper concludes by critically questioning this evolving relationship, and suggests that it will be essentially conservative and unproductive. We end by reviewing the implications for practice and suggesting a useful way forward. PMID- 10176375 TI - Self-administered interventions: a health education strategy for improving population health. AB - A case is presented for using self-administered interventions (SAIs) as a viable public health education/promotion option. SAIs are promulgated as a means to more fully participate in projected health care changes. One readily available opportunity is to incorporate SAIs into managed care organizations concerned about balancing costs and care, and responsible for the health care of the populations they serve. SAIs are both clinical and 'population-based' strategies that are viable alternatives to 'usual' care because SAIs offer a means to enhance reach, efficiency and efficacy when used independently or as part of a sequential, systematic series of interventions. SAIs also have other advantages such as being easily shared, disseminated, reusable and capable of including a valuable, inexpensive human resource, trained peer helpers or volunteers. The SAIs of minimal intervention and self-instruction have been widely used with a variety of lifestyle behaviors associated with cardiovascular disease. Research from the weight management literature is used as a heuristic illustration of the application of SAIs, and to describe the nature and potential of SAIs as public health strategies to meet health care challenges of the future related to service delivery. PMID- 10176376 TI - The effects of water supply on infant and childhood mortality: a review of historical evidence. AB - The provision of clean water is mentioned as an important factor in many studies dealing with the decline of mortality in Europe during the late nineteenth and early twentieth centuries. In developing countries too, improved water supply is assumed to have a strong impact on mortality. When studying the effect of water supply on public health, researchers are confronted with many methodological problems. Most of these also apply to historical studies of the subject. We review the evidence from this historical research, taking into account the methodological problems observed in contemporary impact evaluation studies, and we use more refined data from the Dutch city of Tilburg, enabling us to overcome many of these shortcomings. Finally, we discuss some factors which may explain why we failed to discover an effect of the availability of piped water on the level of childhood mortality. PMID- 10176377 TI - Maternal schooling and comprehension of child health information in urban Zambia: is literacy a missing link in the maternal schooling-child health relationship? AB - This paper examines the relationship between literacy skills and comprehension of health information by studying mothers of young children in a high-density urban area in Zambia. Both decontextualized language and print literacy skills were assessed for each woman and the resulting scores were related to her comprehension of both broadcast and printed health information. The results indicate that fluency in a language is not sufficient for full comprehension of broadcast messages in the decontextualized type of language used in bureaucratic communication, and that a woman's ability to use decontextualized language is associated with greater comprehension of such messages. Skill in using this type of language increases with years of schooling, even in the poorly equipped schools in Zambia, as does print literacy, even though the levels of comprehension achieved are well below their grade level on average for these women. Some implications of these findings for both health care providers and educators are then considered. PMID- 10176378 TI - Does maternal employment augment spending for children's health care? A test from Haryana, India. AB - Evidence that women's employment and earnings foster increased allocations of household resources to children's well-being have led to advocacy of investment in women's employment as a method for targeting the social benefits of enhanced economic opportunity. Work and associated earnings are hypothesized to empower women, who can then exercise their individual preferences for spending on child well-being as well as influence household spending patterns. This paper presents results from a small detailed household and community study of maternal employment and child health in northern India (one of six studies in a research network), which sought to show that such effects did indeed occur and that they could be linked to work characteristics. Careful analysis of employment and earnings showed that they are multidimensional and highly variable over occupations and seasons. Contrary to expectations, spending on health care for children's illness episodes was negatively associated with maternal employment and earnings variables in econometric analysis. The expected individual effects on women of work and earnings, if they did occur, were not sufficient to alter the general spending pattern. We conclude that the attributes of work as well as the social and cultural environment are important mediators of such effects, suggesting a confluence of 'individual' and 'collective' behavioural determinants meeting in the locus of the household. PMID- 10176380 TI - Self-test via Internet gives clues to alcoholism. PMID- 10176379 TI - Mothers' management of childhood diseases in Yorubaland: the influence of cultural beliefs. AB - Several studies have noted that, besides inadequate availability of health care services in many areas, especially the less developed countries, certain disease specific and non-disease-specific cultural beliefs may influence people's health seeking behaviour. It has even been noted that health services may be underutilized and several health and child care instructions may be ineffective or ignored in traditional and transitional societies where people's ideas and behavioural patterns conflict with the knowledge being passed to them (Feyisetan and Adeokun 1992; Feyisetan 1992). Feyisetan and Adeokun (1992) argued that non adoption of modern preventive and curative measures cannot be attributed to poverty alone since the costs of some preventive and curative measures are not exorbitant in several of these societies. Rather, they suggested that the gap between awareness of modern health measures and health seeking behaviour must be sought in the social and cultural determinants of behaviour in such matters as child care and disease management. Earlier studies have noted that children in Nigeria die mainly from malaria, diarrhoea, measles, neonatal tetanus, whooping cough, tuberculosis, and bronchopneumonia (Morley and MacWilliam 1961; Ogunlesi 1961; Morley, Woodland and Martin 1963, 1966; Baxter-Grillo and Leshi 1964; Animashaun 1977; Tomkins 1981). Because these diseases are preventable at low cost to the individual, there is a need to investigate why large percentages of children are still subjected to many episodes of these diseases. In this paper, we examine (1) the mothers' perceptions of the aetiology of the three most cited childhood diseases in our study areas, measles, diarrhoea and fever, and the effect of these perceptions on the mothers' suggested curative measures; and (2) the persistence of the belief in abiku and how this cultural belief can influence mothers' management of childhood diseases. Since, for most mothers, perceptions of the aetiology of the childhood diseases are rooted in cultural beliefs, a brief review of disease-specific cultural beliefs is undertaken. In order to determine the effect of socio-economic factors, the mothers' perceptions of the aetiology of the childhood diseases, their recommended curative measures and the belief in abiku are examined according to selected socio-economic variables. PMID- 10176381 TI - NASA launches Biocomputation Center at Stanford. PMID- 10176382 TI - National Library of Medicine grants for telemedicine research. PMID- 10176383 TI - Nova Scotia sets up province-wide network. PMID- 10176384 TI - Swedish hospitals field test telepathology. PMID- 10176385 TI - Twenty minutes in the life of a tele-home health nurse. PMID- 10176386 TI - An overview of state laws and approaches to minimize licensure barriers. AB - A tour de force of legal documentation. For a fully referenced version of this article, including tables, please go to: www. telemedtoday.com. The author's strongly worded closing comment, "An interstate or national licensure system would better serve individual physicians and the practice of medicine nationwide," is challenged by some pundits who fear that national licensure would not adequately protect patient interests. Let us know if you'd like to contribute your thoughts to the debate. PMID- 10176387 TI - Application and feasibility of video telecommunications in home healthcare. AB - The Capital Area Consortium on Aging and Disability (CACAD) of Albany, NY, partnered with NYNEX and the James A. Eddy Memorial Geriatric Center ("The Eddy"), a non-profit provider of services to the aged and disabled, to conduct a trial to investigate the use of video conferencing as a platform for providing health care services to the home. The trial, which took place from June to September of 1994 at The Eddy in Troy, New York had three goals: Determine what quality of video is needed to provide 2-way communication for home care applications. Develop a list of potential applications that could be supported by video communications. Identify "ease of use" and ergonomic issues associated with a video link for home health. PMID- 10176388 TI - Program activity in the second year of the Rural Telemedicine Grant Program Part 2. AB - Part 1, in our last issue, detailed the activity levels, number and types of consults, and transmission costs of the 13 telemedicine networks funded in 1994 by the Office of Rural Health Policy's Rural Telemedicine Grant Program. This concluding section presents the authors' conclusions drawn from the objective data in Part 1. PMID- 10176389 TI - Is telemedicine reimbursement a real barrier or a convenient straw man? PMID- 10176390 TI - Videotaping teleconsults: pros and cons. PMID- 10176392 TI - From plan to performance: implementing change. PMID- 10176391 TI - Practice brief. Issue: Managing multimedia medical records: a health information manager's role. American Health Information Management Association. PMID- 10176393 TI - Conscious transformational change in HIM services. PMID- 10176394 TI - Bridging the gaps: an assessment of culture in an integrated system. AB - After healthcare organizations merge, how do employees of different work cultures integrate? A study of four Colorado facilities in one delivery system reveals where employees reported similarities, differences, and problems--and the author tells how these issues were addressed. PMID- 10176395 TI - Organizational restructuring: one HIM team's approach. AB - Organizational restructuring offers a number of challenges--and opportunities--to employees. This article describes how members of one organization's HIM staff participated in a systemwide restructuring process, from planning to implementation to assessment of results. PMID- 10176396 TI - The future of HIM: an operational view. AB - What will HIM processes, departments, and the patient record look like 10 years from now? The author offers a view of HIM operations at an academic medical center with an eye for operational, organizational, and functional structure. PMID- 10176398 TI - ICD-10-CM update. PMID- 10176397 TI - Sentinel event procedures undergo scrutiny. PMID- 10176399 TI - At a glance. The hospital industry. PMID- 10176400 TI - Volunteer health care in Appalachia. PMID- 10176401 TI - Reduction of medical liability claim frequency: the Texas experience. PMID- 10176402 TI - Decreasing delays in surgery starting times. PMID- 10176403 TI - The 1998 Medicare fee schedule. PMID- 10176404 TI - Computer simulated cost effectiveness of care management strategies on reduction of long-term sequelae in patients with non-insulin dependent diabetes mellitus. AB - Systems dynamics and computer "microworlds" offer a window on the long-term benefit of investing in aggressive care management for patients with non-insulin dependent diabetes mellitus. This article describes how clinicians, planners, payment specialists, and patients collaborated to make the business case for aggressive management of this disease. PMID- 10176405 TI - Impact of a short stay unit on asthma patients admitted to a tertiary pediatric hospital. AB - A short stay unit (SSU) was opened at the Children's Hospital, Boston, with the aim of better fulfilling the needs of pediatric patients with straightforward diagnoses. Using historical and simultaneous comparison groups and controlling for disease severity, the opening of the SSU led to a decrease of between 16.5 and 28.4 percent in the mean length of stay for asthma patients without any increase in the rate of hospital readmission. PMID- 10176406 TI - Competency in health care management: a training model in epidemiologic methods for assessing and improving the quality of clinical practice through evidence based decision making. AB - This article describes a training model that focuses on health care management by applying epidemiologic methods to assess and improve the quality of clinical practice. The model's uniqueness is its focus on integrating clinical evidence based decision making with fundamental principles of resource management to achieve attainable, cost-effective, high-quality health outcomes. The target students are current and prospective clinical and administrative executives who must optimize decision making at the clinical and managerial levels of health care organizations. PMID- 10176407 TI - Reducing the need and demand for medical care: implications for quality management and outcome improvement. AB - Reduction in medical need (illness burden) and demand (variability in resource use) can improve health, reduce medical care costs, and move us toward the goal of becoming a healthy society. Health promotion, redefined, works to enhance individual autonomy. The underlying conceptual bases and the abundant empiric documentation of the effectiveness of need and demand reduction are summarized here. PMID- 10176408 TI - Improving clinical processes: one dialysis facility's experiences. AB - Northeast Louisiana Dialysis Center implemented continuous quality improvement (CQI) to improve the quality of care delivered to end stage renal disease (ESRD) patients treated by hemodialysis in their facility. The unit chose to address normalization of calcium and phosphorus and parathyroid hormone (PTH), anemia, nutrition, adequacy of dialysis and dialyzer reuse as well as performance benchmarks by the Health Care Financing Administration (HCFA) core indicators. This article presents the results obtained and the methodology used in this improvement effort. The article also presents nine principles the authors believe necessary for a successful CQI program. PMID- 10176409 TI - Measuring the quality of inpatient health care. AB - A validated case mix and severity adjusted performance measurement system and methodology are presented. Using this methodology in a user-friendly interactive interface, those who are interested in the performance of a hospital or providers within a hospital can easily identify areas for quality improvement. PMID- 10176411 TI - 1995 Fast Track: cost reduction and improvement. AB - To respond to a cost reduction crisis, Strong Memorial Hospital implemented an aggressively managed program of accelerated improvement teams. "Fast-track" teams combined the application of many management tools (total quality management, breakthrough thinking, reengineering, etc.) into one problem-solving process. Teams and managers were charged to work on specific cost reduction strategies. Teams were given additional instruction on interpersonal skills such as communication, teamwork, and leadership. Paradoxically, quality improvement in our hospital was advanced more through this effort at cost reduction than had previously been done in the name of quality itself. PMID- 10176410 TI - The importance of negative feedback and consequences of actions in the design of processes. AB - Like many organizations, Continental Rehabilitation Hospital of San Diego designs and communicates templates and targets for desired changes in behaviors and tracks results. It recognizes and celebrates successes and struggles with its failures. A recent case example demonstrates the importance of generating immediate feedback and consequences as a strategy for increasing effectiveness in changing behavioral patterns. PMID- 10176412 TI - Experimental medical treatments: who should decide coverage? PMID- 10176413 TI - Strategic planning for the millennium. PMID- 10176414 TI - Strategic planning is a bridge to an uncertain future. PMID- 10176415 TI - Modern methods for planning. PMID- 10176416 TI - Utilization review: another job for hospital case/business managers? PMID- 10176417 TI - Hospital cuts LOS in half for CHF (congestive heart failure) patients. PMID- 10176418 TI - CQI improves transition through the continuum. PMID- 10176419 TI - Burn rehab program cuts LOS by 12 days. PMID- 10176420 TI - Summary form helps discharge planners. PMID- 10176421 TI - CM is quality central at CA hospital. PMID- 10176422 TI - CMs have trouble adjusting to business mindset. PMID- 10176423 TI - Hospital system scales back its integration efforts. PMID- 10176424 TI - Cardiac surgery pathway cuts postoperative intubation time in half. PMID- 10176425 TI - Borrowed expertise leads to reengineering success. PMID- 10176426 TI - Wound care team nips costly bed sore problems, slashes hospital expenses. AB - Innovative wound care team combats bed sores and saves hundreds of thousands of dollars a year. A multidisciplinary team composed of plastic surgeons, nurses, nutritionists, and others pursue an aggressive risk assessment protocol to identify patients at risk for pressure ulcers. Avoiding this problem gets patients discharged sooner and they consume fewer resources during their hospital stay. PMID- 10176427 TI - Patient satisfaction scores don't have to be a casualty of reengineering efforts. AB - Do patient satisfaction scores have to nosedive during redesign projects, especially noisy construction? Not at Holy Cross Hospital in Chicago, where an elaborate plan to boost patient satisfaction paid off during an 18-month renovation project that's still underway. Learn how the hospital created a detailed plan and devised teams to focus on every element of patient satisfaction to make sure patients didn't get lost in the shuffle of reorganization. PMID- 10176428 TI - How does your emergency department measure up to these benchmarks? PMID- 10176429 TI - Focus on nutrition to improve chronic disease outcomes. PMID- 10176430 TI - Weight loss in cancer patients can be offset by aggressive nutritional therapy. AB - Patients with cancer or other debilitating diseases such as AIDS and COPD often have on and off interruptions in care because of cachexia, also known as wasting syndrome. However, managing these patients with "medical foods" can and does get them on their feet faster. Find out how and why some doctors are swearing by this not so well-known management tool. PMID- 10176431 TI - Treating weight problems in chronically ill patients a legal and economic imperative. AB - More than half of all Americans need to lose weight, and a growing number are becoming so severely overweight that, mixed with other chronic diseases, they represent a walking cocktail of costly morbidity and mortality. Obesity experts say taking the weight off is one of the first steps in managing a wide range of chronic diseases. PMID- 10176432 TI - Don't let disenrollment derail your DM programs. AB - Disenrollment is like kryptonite to disease and demand management programs, robbing them of their strength and keeping them from reaching their full potential for long-term cost savings. Rather than question the return on investment of DM programs when disenrollment levels are high, however, experts say 'stay the course' and use the added value of DM services to boost member retention. PMID- 10176433 TI - Pharmacist-led hypertension disease management program cuts utilization and costs. AB - Making sure your hypertensive patients are compliant with drug medications requires eyes and ears beyond the doctor's office. Pharmacists in one group practice in Beverly Hills are demonstrating that they can play a key role in keeping patients on track with drug regimens, and save a lot of money in the process. PMID- 10176434 TI - Great ideas to improve your negotiating power in 1998. PMID- 10176435 TI - Managing funds flow arrangements through risk-sharing groups. AB - When traditional risk-allocation methodologies don't bridge the gap between risk tolerant and risk-averse providers, risk-sharing groups can help a network to grow. PMID- 10176436 TI - Harness contracting clout by tracking physician productivity. AB - A multispecialty hospital system in Massachusetts has developed a provider productivity system based on Medicare's relative value scale to ease the transition from fee-for-service to capitation. PMID- 10176437 TI - Anesthesiologists beware: conversion factors, capitation rates show wide disparity. PMID- 10176438 TI - Should you prepare for a downturn in global cap rates? AB - A consulting actuary makes a strong case that, based on historic business cycles, capitated providers without sufficient reserves could go belly up if premiums and PMPM rates go south. PMID- 10176439 TI - Marketplace. State lawmakers consider keeping HMOs in line through malpractice suits. PMID- 10176440 TI - Perspectives. Research emphasis puts bipartisan face on Clinton budget. PMID- 10176441 TI - Perspectives. Medicare HMOs fear risk adjustment will cut their payments. PMID- 10176443 TI - At a glance. Demographic characteristics of uninsured Americans. PMID- 10176442 TI - Back to basics. PMID- 10176444 TI - Freedom or license? PMID- 10176445 TI - How healthcare organizations can achieve true integration. AB - Of the many organizations that have attempted to become integrated delivery systems (IDSs), only a few have actually achieved this goal. Achieving true integration requires commitment to an ongoing process that consists of a series of increasingly challenging phases: development of the organization's unifying concept and culture, specification of the organizational and administrative structure, integration of funds and other assets, development of synergistic operations, and ongoing commitment to ensuring organizational responsiveness to market forces. In addition, including physicians in the integration process is essential for achieving true integration. To effectively integrate physician practices into the larger organization, IDSs need to overcome physician resistance to losing perceived autonomy and control. Physicians are most likely to accept integration into an IDS if they recognize the advantages they gain from allowing the IDS to assume administrative control of their practices. PMID- 10176446 TI - Do IDSs really benefit from affiliating with managed care plans? AB - Integrated delivery systems (IDSs) affiliate with HMOs primarily to gain access to patients enrolled in managed care plans. Outright ownership of an HMO offers an IDS additional advantages, including opportunities to create a more seamless care process, improve patient outcomes, draw on the HMOs' experience in reducing costs, and administer health management and delivery at a significantly lower cost than the industry standard. The current trend toward IDS ownership of HMOs suggests that the line between providers and payers is blurring. Some states have encouraged this trend by enacting legislation that allows IDSs to act as insurers. Recent data indicate that IDSs with HMO components tend to be more vertically integrated than those without such components. These data suggest that close alignment with an HMO may be a key element in the effort to achieve vertical integration. PMID- 10176447 TI - Understanding managed care organizations' liability exposure. AB - Managed care organizations can minimize their liability exposures by staying informed about industry changes and by implementing a comprehensive risk management program. Typically, managed care organizations face three general exposure areas: directors and officers liability (e.g., exposures associated with nonclinical aspects of an organization); errors and omissions (e.g., exposures involving the day-to-day operations of managing the health care received by an organization's members); and financial loss, or provider excess (e.g., exposures that occur when certain catastrophic events expose the organization to financial peril). PMID- 10176448 TI - Combating silent PPOs. AB - A silent PPO is a contracting entity that negotiates discounts with providers but sells access to the discounts to other, nonrelated parties after services are provided to individuals covered by the nonrelated parties' insurance policies. Healthcare financial managers should be alert to the presence of silent PPOs when entering into contract negotiations. To combat silent PPOs, a two-pronged approach--prevention and detection--is advisable. Factors to consider include appropriate contract language stating that all clients with access to the discounts have a contract with the PPO, presence of the PPO's logo on a patient's insurance card, and the PPO's willingness to limit the number of providers in its network. Warning signs that indicate the presence of a silent PPO include a high volume of retroactive reclassifications, single employers taking discounts from multiple PPO networks, or payments for services provided to single individuals coming from multiple PPO networks. PMID- 10176449 TI - Ensuring adequate payment for the use of new technology. AB - To ensure that proper reimbursement is obtained for utilization of a new technology, providers should demonstrate to payers the long-term cost effectiveness of the new technology. Providers need to determine the incremental costs incurred in using the technology and various payers' payment rates for such use. If preliminary analysis shows that reimbursement for the technology may be insufficient, providers then should conduct a detailed analysis of the new technology. This analysis should assemble comparative data of internal and external performance benchmarks from various sources, including state, regional, and national databases. In addition, providers should assess the long-term savings achieved by using the new technology, such as reductions in hospital readmissions and repeated procedures. Managed care payers are likely to find such data persuasive in determining whether to increase payment rates for a new device or therapy. PMID- 10176450 TI - Data warehousing as a healthcare business solution. AB - Because of the trend toward consolidation in the healthcare field, many organizations have massive amounts of data stored in various information systems organizationwide, but access to the data by end users may be difficult. Healthcare organizations are being pressured to provide managers easy access to the data needed for critical decision making. One solution many organizations are turning to is implementing decision-support data warehouses. A data warehouse instantly delivers information directly to end users, freeing healthcare information systems staff for strategic operations. If designed appropriately, data warehouses can be a cost-effective tool for business analysis and decision support. PMID- 10176451 TI - Improving physician participation in billing compliance programs. AB - Billing compliance programs represent a challenge for all members of healthcare organizations. Despite the importance of such programs, many physicians often seem reluctant to embrace them. The solution to gaining physician buy-in to such programs lies in educating physicians, involving them in the programs' development and implementation, and making compliance as easy as possible. PMID- 10176452 TI - Utilization management in a mixed-payment environment. AB - Fee-for-service and capitation payment methods create different financial incentives for healthcare providers, and the objectives of utilization management differ under each payment method. These differences can be reconciled, however, by incorporating the strengths of utilization management programs associated with both methods into an overarching program that focuses on the continuum of care. Such a program should be focused on achieving the optimal outcomes for patients by identifying the appropriate level of care, who should provide it, and when and where it should be provided. Essential to this effort is access to comprehensive clinical and financial data through an integrated information system. In addition, financial incentives need to be aligned through such means as risk pools, compensation arrangements tied to achievement of medical management goals, and clearly defined policies and procedures. PMID- 10176454 TI - Opportunities for PSOs: an interview with Albert Holloway. AB - The Balanced Budget Act of 1997 authorizes provider-sponsored organizations (PSOs) to contract directly with Medicare as one of the new Medicare+Choice risk plan options for beneficiaries. The act allows HHS to waive state insurance licensure requirements in some circumstances and makes it easier for PSOs and other risk plans to operate. The act includes additional implications for PSOs. Recently, Albert Holloway, president and CEO, The IPA Association of America, Oakland, California, and a member of HFMA's Board of Directors, granted HFM the following interview to discuss opportunities the new PSO legislation affords hospitals and physicians. PMID- 10176453 TI - Survey finds physicians satisfied with practice acquisitions. AB - In 1995, Healthcare Financial Management and Physician Services of America conducted a national survey on practice acquisition to determine the types of practices hospitals were buying, the amount they were paying, and whether the hospitals' financial expectations of the practice were being met. A follow-up to this survey was recently completed to evaluate practice acquisition from the physician's perspective. Approximately 500 physicians who had sold their practices to hospitals were surveyed to determine their degree of satisfaction with the sale of their practices. Sixty-seven percent of the responding physicians indicated that they were somewhat satisfied or extremely satisfied with all aspects of the acquisition experience, 60 percent said they would recommend acquisition to a colleague, and 77 percent stated that they were satisfied with how the details of the acquisition process were handled. Of the respondents, 77 percent were primary care physicians. Most of the responding physicians had the characteristics of physicians whose practices are sought by hospitals--that is, they were nearing retirement or wanted to continue practicing for a number of years but were seeking relief from administrative duties and wanted to obtain the equity from their practices. PMID- 10176455 TI - How to optimize an MSO's financial performance. AB - Many hospitals and health systems create financial and strategic alignments with physicians to increase market share. One way to implement such an alignment is to form a management services organization (MSO). Forming an MSO, however, does not automatically guarantee success. To avoid financial losses, executives of hospitals and health systems need to diagnose potential problem areas in their MSOs and take control of problems before the organization and the physicians suffer financial losses. Among the areas that should be evaluated are the business scope of the MSO, the nature of practice acquisitions, physician compensation, governance, management skills, management information systems capabilities, organizational structure, and fee structure. Fee structures, in particular, can be used to align physician and MSO incentives. PMID- 10176456 TI - Medicare outpatient payment reforms are approaching. PMID- 10176457 TI - Assessing patient satisfaction with the revenue cycle. PMID- 10176458 TI - Is now the time for bar coding? PMID- 10176459 TI - Effective communications skills are career essentials. PMID- 10176460 TI - Data trends. Key organizational performance indicators. PMID- 10176461 TI - Junior doctors. Night vision. AB - By establishing separate timetables for senior house officers and registrars, an obstetrics and gynaecology department has been able to reduce out-of-hours work while offering training relevant to the doctors' proposed careers. Following the establishment of a daily, open-access gynaecology clinic, extending the role of midwives has reduced the out-of-hours workload of junior doctors. Emergency admissions, a major feature of out-of-hours work, have fallen by a quarter. PMID- 10176462 TI - Secure units. Safety measures. AB - More than 20 years after the publication of the Butler report which led to the establishment of medium-secure units, many of its recommendations have not been implemented. There is still a shortage of beds in medium-secure units. A survey of 18 of the 25 units in England and Wales has revealed wide variations in size as well as staffing ratios. National leadership and more coherent planning is needed. PMID- 10176464 TI - Information technology. Putting health on the cards. PMID- 10176463 TI - Care homes. Home truths. AB - Proposed joint inspectorates of care homes open the way for health input into residential care. An investigation into quality-of-care measures concluded that health professionals should be included in inspectorate teams, particularly in view of the increasing dependency of residents. No association was shown between cost and quality, but higher costs were associated with short-term car provision. When costing residential care, the impact on community and primary healthcare services may need to be taken into account. PMID- 10176465 TI - General practice. A tale of four cities. PMID- 10176467 TI - Joint working. Take your partners. AB - The white paper proposals for partnerships in the NHS of the future are much less developed than those for performance. It is unclear whether collaborative activities are discretionary or mandatory. Effective inter-agency co-operation will require central government to give joint working a higher priority. PMID- 10176466 TI - Funding. Adding to local divisions. AB - The white paper proposal to fund primary care groups according to a set formula is beset with difficulties. At present there appears to be no suitable formula for allocating funds at sub-district level. Applying to primary care the national formula now used to allocate funds to health authorities would change current spending considerably and could lead to greater inequities. PMID- 10176468 TI - Data briefing. Performance framework. PMID- 10176469 TI - Equal opportunities. Equal to the task. PMID- 10176470 TI - Mental health. A mind to change with the times. PMID- 10176471 TI - Health economics. The cost of ignorance. PMID- 10176472 TI - Information technology. Surfing options. PMID- 10176474 TI - MBAs. How to keep up. PMID- 10176473 TI - Career masters. PMID- 10176475 TI - Funding. Cash on delivery. PMID- 10176476 TI - Hospital pharmacy. A special dispensation. AB - A pilot scheme allowing hospital inpatients to take responsibility for administering their own drugs has been well received by patients and nurses. Requesting patients to bring in the drugs they are on at the time of admission has resulted in savings for the hospital. On admission, patients are issued with drugs for the whole of their expected hospital stay, and for two weeks after discharge. This has cut delays at the time of discharge. PMID- 10176477 TI - Patient information. In the clear. PMID- 10176478 TI - User groups. View finders. PMID- 10176479 TI - Basic i.v. solutions show price decline. PMID- 10176480 TI - Premier's challenge for '98: listen, communicate better. PMID- 10176481 TI - Most hospital supply prices headed upward in 1998. PMID- 10176482 TI - Buddy up with a lawyer, it's compliance program time. PMID- 10176483 TI - An emerging superbug. Staphylococcus aureus becomes less susceptible to vancomycin. AB - The name staphylococcus aureus comes from the Greek, staphyle (a bunch of grapes), kokkos (berry shaped), and aureus (golden). Morphologically, the pathogen resembles grapelike clusters of gram-positive cocci. The illustration here shows the bacteria infecting nasal epithelial tissue, and causing cell damage and inflammation. S. aureus has been knocking down our antibiotic defenses one by one, with some strains becoming dangerously less susceptible to vancomycin. Epidemiologists warn that these strains are coming soon to a hospital near you; be prepared by knowing how to identify the bug, notify infection control authorities, and use basic infection control procedures. PMID- 10176484 TI - MLO's national CLIA '88 survey, Part I: The self-assessment survey. PMID- 10176485 TI - Leveling the playing field. The economics of robotics in the hospital clinical lab. PMID- 10176486 TI - A principle-focused approach to lab management. AB - As in all healthcare fields, the clinical laboratory is under the stress of constant change. While planning for the financial implications is important, a more holistic approach to adaptation is for laboratorians to put the focus back where it belongs: on people, principles, and service. PMID- 10176487 TI - How to save time, money, and a precious resource via CQI. PMID- 10176488 TI - The laboratory's role in outcome assessment. AB - How does the laboratorian influence patient outcome, and how is this influence measured? The clinical laboratory gives vital support to decisions about diagnosis, treatment, and management. Outcome assessment must include a structured approach to performance improvement, proper test utilization, and defining best practices. PMID- 10176489 TI - A welcome to systems. Finally, AHA opens its doors to integrated networks. PMID- 10176490 TI - Blue vs. Blue. N.J. plan applies to enter New York City market. PMID- 10176491 TI - No plans to boost coverage. Uninsured numbers rise, but Congress not expected to act. PMID- 10176492 TI - AMA on Sunbeam cleanup mission. PMID- 10176493 TI - The unchanging of healthcare. Diversity still hard to find in top executive ranks. AB - Look around at the next conference of top-level healthcare executives. Chances are, the faces will appear mostly white. While there might be a few women, it's likely the number of blacks and Latinos will be minimal. Years of effort to increase the diversity has made some progress, but most in the industry agree there's a long way to go. Keith Brady (left), one of the few black CEOs who has made it in the private, for-profit sector, cites the influence of mentoring. PMID- 10176494 TI - Downsizing slows down. Hospitals predict fewer job cuts, redesigns, survey says. PMID- 10176495 TI - Benchmarking push. MGMA aims to create database of best doc practices. PMID- 10176496 TI - Most doc practices eschew outsourcing for billing, collections. PMID- 10176498 TI - Redefining health care for the 21st century. Keeping the promise. PMID- 10176497 TI - How does your foundation grow? With investment smarts, and community heart, and long-range planning goals all in a row. PMID- 10176499 TI - IT's now or never. Information technology may mean life or death for your system. PMID- 10176500 TI - Governance. Boards overboard, Part one. PMID- 10176501 TI - Community health. No man is an island. PMID- 10176502 TI - Communication: an essential chord in the merger waltz. PMID- 10176503 TI - When good people do bad things. PMID- 10176504 TI - Service integration: introduction. PMID- 10176505 TI - Launching a family-centered, neighborhood-based human services system: lessons from working the hallways and street corners. AB - The author describes Contra Costa County's efforts to implement Healthy Families 2000, the County's vision of neighborhood-based, family-centered, comprehensive integrated services in two of the county's unincorporated areas, North Richmond and Bay Point. Contra Costa County is one of six bay area counties, northeast of San Francisco. It has nearly 800,000 residents and is home to some of the wealthiest communities in the state as well as some of the poorest neighborhoods. This article provides a systematic review of the process and a discussion of the operating practices and principles guiding Contra Costa's significant effort to change its service delivery approach, anticipating that this experience might be helpful to others as they develop a neighborhood-based human services partnership with community leaders and residents. PMID- 10176507 TI - Applications of boundary theory to the concept of service integration in the human services. AB - Service integration (SI) is an aspect of theorizing about organizations and governance. To discover questions for future practice and theory-building, the analysis here reframes the SI concept in the human services from the typical starting point of fragmentation-integration to the imperatives of boundary theory. Extant SI discourse is a confused array of descriptive, normative, and explanatory theory. An action-reflection interplay with conflicting and missing values is revealed. Boundary spanning and boundarylessness, defined in five metaphors, illustrate boundary theory. Selected literature on SI in the human services is translated into boundary theory (e.g., types of SI boundaries, SI boundary values and roles) and a research agenda is posed. PMID- 10176506 TI - Assessing a family-centered neighborhood service agency: the Del Paso Heights model. AB - The author describes the Del Paso Model, a neighborhood-based integrated services effort underway in Sacramento County, California. Del Paso Heights is a community made up of African American, Asian, and white families on the northern side of the City of Sacramento. The County of Sacramento selected Del Paso Heights as a location to pilot a new family-centered holistic way to serve families under county human services programs in a Neighborhood Services Agency. The Del Paso Heights model demonstrates the power of the neighborhood as a focal point of integration of services and how the neighborhood can be used as a concept to overcome bureaucratic turf. Like many other community initiatives, measuring the outcomes of the Del Paso Heights Model remains an elusive goal. PMID- 10176508 TI - Organizational identity in a changing environment: when is a change a transformation? PMID- 10176509 TI - Reclaiming community: an integrative approach to human services. AB - Taking the community rather than the service system as its starting point, a community-centered approach to service integration seeks to interweave formal and informal systems of care. Working as part of a community--negotiating and building partnerships with families, social networks, and organizations to change problematic patterns and mobilize resources--requires not only collaboration among administrators, but teamwork among front line staff. Team members need to share work, knowledge, and resources, while building collaborative relationships with their counterparts in other organizations, service users, and other residents. Ensuring congruence between new, integrative methods of practice and the way they are introduced and managed may require substantial changes in management behavior. "Resistance" is best understood in this context as feedback to management about its need to change. PMID- 10176510 TI - Collaboration: a study of a children's initiative. AB - In times of shrinking resources within the social services, collaboration is being promoted as a more efficient way of meeting the needs of children and families. A study of a children's initiative collaborative developed to address the problems of children is reported. The authors present and use an evaluation framework which incorporated the dimensions of context, process, and outcomes of collaboration. The findings, based on the initial two years of collaborative effort, suggested the membership of the group and the process and structure governing the group's operations impacted the process and outcomes of the collaboration. PMID- 10176511 TI - Service integration: something old and something new. AB - The authors trace the definition and challenges of "service integration," variously known over time as "collaboration," "coordination," "human services integration," and "one-stop shopping." While the common use of service integration terminology currently may seem to indicate a consensus in favor of a broad systemic reform, motivations and expectations for service integration differ significantly among different players in the service system. The authors conclude that service integration cannot be defined by a particular service model or outcome, but instead should be conceived of as an ongoing reform process. This process, when well-designed and implemented with long-term vision, can reduce duplication, strengthen communities, and improve client outcomes. PMID- 10176512 TI - Patient medical records off the chart. PMID- 10176513 TI - In coagulation, a cascade of questions. PMID- 10176514 TI - Lawmakers likely to focus on patient protection in 1998. PMID- 10176515 TI - Sexual health of teens. PMID- 10176516 TI - Successful implementation of an evidence-based clinical practice guideline: acute dysuria/urgency in adult women. AB - This paper describes the development and successful implementation of an evidence based clinical practice guideline dealing with uncomplicated urinary tract infection in adult women (acute dysuria guideline). This guideline was based on an evaluation and synthesis of the medical literature using the best available evidence. Following guideline implementation, clinical practice changes recommended by the guideline were observed, including a significant decrease in laboratory testing and clinic visits for acute dysuria. Successful implementation of this guideline is attributed to the use of an explicit, evidence-based guideline development process, a combination of implementation strategies including decision support for providers, and a change in the roles of registered nurses. PMID- 10176517 TI - Managed occupational health care in an HMO. AB - This paper describes the efforts of an HMO to improve its delivery of occupational health services. Customer needs identification, occupational health structure, data systems, case management, clinical guidelines, and quality management are outlined. Our experience suggests that high-quality occupational health services can be integrated into managed care systems thereby offering cost effective care to large numbers of workers. Comparing 1991 to 1995, physician authorization of total disability days was reduced 17.9% per disability case (p < .0001). Based on July 1994 to June 1995 Oregon State Accident Insurance Fund (SAIF Corporation) data, HMO average total claim cost was $916/claim representing respectively, a 21% and a 20% reduced cost compared to two PPO model programs (MCO 00 and MCO 01). Patient satisfaction data indicated that 90% of patients were satisfied or very satisfied with the physician they saw. The savings appear to be due to cost-effective treatment and rapid return to work. PMID- 10176518 TI - ADA's (American Diabetes Association) provider recognition program. PMID- 10176519 TI - Managed care can improve pneumococcal and influenza vaccination levels. PMID- 10176520 TI - Preventing adolescent pregnancy. PMID- 10176521 TI - High hopes: better care for young families. PMID- 10176522 TI - Physician development initiative: small group CME. PMID- 10176523 TI - Cost-effective management of group A streptococcal pharyngitis. PMID- 10176524 TI - The latest word. PMID- 10176525 TI - Computer giants capitalize on intranets. PMID- 10176526 TI - The VA takes a stand. Adopted standards are the only standards. PMID- 10176527 TI - Imagine advanced medical techniques and technologies are on their way to a facility near you. PMID- 10176529 TI - By design. The National Healthcare Project is taking on the US healthcare system. Interview by Terry Monahan. PMID- 10176528 TI - Wiping the slate clean. Why network outsourcing is in. PMID- 10176530 TI - Contracting for competitiveness. PMID- 10176531 TI - Contracting out. PMID- 10176532 TI - Market strategy: how to decide what to market test. PMID- 10176533 TI - HTM 2022 revision: medical gas pipeline systems. PMID- 10176534 TI - An outsourcing experience. PMID- 10176535 TI - Implementation of outcomes measurement in performance improvement efforts. AB - The development of conceptual models is a necessary step in the implementation of outcomes-based statistical models in health information management departments. The article provides a step-by-step method of systematically implementing outcomes-based statistical process control methods in health information management departments. It is suggested that, to create an atmosphere conducive to the implementation of statistical process control techniques, health information management directors must be systematic in the application of these techniques, focus on personal and professional opportunities and not on the fear of numbers, provide training and resources, and celebrate success. PMID- 10176536 TI - Reengineering communication at the University of Mississippi Medical Center: the case for the campus dialogue. AB - One of the key concepts at the heart of the continuous improvement of processes and outcomes in health care is improved organizational communication. Complex organizations such as academic health centers often find that communication among internal customers is informal and ineffective. The article describes a successful effort for improving communication in an academic health center that was the product of reengineering a previous communication process. Implications of reengineering and lessons learned from implementation are presented. Reengineering is a beneficial concept for guiding some improvements in health care organizations. PMID- 10176537 TI - Employee satisfaction as it relates to customer service. AB - Employees are often the forgotten customer in health care organizations. Satisfied employees are productive employees, which leads to obtaining long-term satisfied customers. Negative employees can discourage customers and destroy the integrity of an organization's culture. Long-term customers are critical for the survival of health care organizations for the year 2000 and beyond. Excellent service will be the only differentiation between a good and an excellent health care company. The article describes the current status of employees satisfaction at Columbia Centennial Medical Center and steps to be taken toward increasing satisfaction in the future. PMID- 10176538 TI - Employee empowerment through team building and use of process control methods. AB - The article examines the use of statistical process control and performance improvement techniques in employee empowerment. The focus is how these techniques provide employees with information to improve their productivity and become involved in the decision-making process. Findings suggest that at one Mississippi hospital employee improvement has had a positive effect on employee productivity, morale, and quality of work. PMID- 10176539 TI - Creative employee scheduling in the health information management department. AB - What effect do schedules have on employees and department activities? Negative effects such as backlogs, poor employee morale, and absenteeism may be due to scheduling practices currently in place. The value of effective employee scheduling practices may be seen in areas of improved productivity. The process of developing schedules should include assessing department areas, understanding operational needs, choosing an option, and implementation. Finding a schedule that meets the needs of managers as well as those of the employees is rewarding. It is a win-win situation, and the benefits can yield increased productivity, decreased turnover, and higher morale. PMID- 10176540 TI - Clinical applications of computer-based health information. AB - Competitive health care systems are improving their clinical and cost efficiency by performing clinical practice analyses. Large numbers of severity-adjusted cases provide the most objective data for making clinical efficiency decisions. The most cost-effective way to perform these analyses is to utilize well-coded, computer-based health information. This requires consistent coding of patients' comorbidities and complications as well as an interactive working relationship between coders and clinicians providing the clinical practice analysis. The article describes one hospital's evolving clinical efficiency information needs, how its health information system met them, the clinical practice analysis procedure, and the outcomes of this clinical practice analysis. PMID- 10176541 TI - Theoretical foundations of TQM and CQI: or, does quality really have its own theory? AB - Total quality management and continuous quality improvement have been advocated as management salvation and anecdotally have been linked to improvements in operational effectiveness. The Joint Commission on Accreditation of Healthcare Organizations has adopted quality management as the organization improvement measure of the future and has mandated its application. The article explores the theoretical foundations of quality management and presents an integrated model dealing with this industry standard. An operational framework for managers is provided in an attempt to demystify the quality jargon that is so prevalent. The article also provides a prescriptive management overview incorporating quality management techniques into everyday operations. PMID- 10176542 TI - Implications of new organizational relationships and fiscal incentives on health information managers. AB - Whether the health field in the United States should be dominated by more competition or by more government regulation is now at the center of the public policy debate. After examining the market-driven and regulatory models to constrain cost, improve quality, and enhance access to care, the article argues that our current centrist political philosophy can be expected to continue on Capitol Hill and among the state legislatures. As a result, this will force health information managers to labor within a blended approach that is partially market driven and partially governed by regulations. How such a hybrid system will affect the future role of health information professionals, integrated information systems, and other related topics is also discussed. PMID- 10176543 TI - Descriptive and graphical strategies for assessing change: a case study of functional status in stroke patients. AB - A primary focus in the current context of the health care industry is the measurement of outcomes. Outcomes research, although inclusive of the use of advanced statistical analyses, can often be conducted using more easily understood analytical techniques such as descriptive analysis and graphical display of data. The article addresses the description and analysis of patient change scores on the Functional Independence Measure (FIM) from 745 stroke rehabilitation inpatients. Display and discussion of percentiles, cross tabulations, scatter plots, and side-by-side box plots are used in this case study of describing outcomes. PMID- 10176544 TI - Empowered teams transform systems at Children's Hospital and Health Center of San Diego to improve the use of resources. PMID- 10176545 TI - Cost-savings from operations disappoint integrated delivery systems, new research suggests. PMID- 10176546 TI - Survey of hospital systems and common serious medication errors. AB - The Institute for Safe Medication Practices and the University of Illinois at Chicago, College of Pharmacy, undertook a hospital survey of medical-surgical hospitals to determine systems-oriented factors that allow the highest level of medication safety. The study incorporated a peer-reviewed and pretested questionnaire, which focused on critical information necessary to yield quality data for comparison. Through analysis, it was shown that over one third of all medication errors reported in the survey involve just six categories--allergies, insulin, heparin, opiates, PCA devices, and potassium concentrates. PMID- 10176547 TI - Protection against employment claims. AB - Risk managers already deal with a great many issues in today's complex, managed care driven, healthcare environment. Now they must add expertise in handling ever more complicated employment issues. This article addresses areas risk managers need to both know and understand concerning this area of law, and some steps they can take to minimize loss or provide for insurance protection for any loss. PMID- 10176548 TI - Pharmaceutical risk management: special problems encountered in the hospital setting. AB - This article (1) reviews the types of adverse drug reactions that can occur, (2) discusses liability issues for hospitals and healthcare professionals who practice in a hospital or nursing home setting, and (3) presents risk management strategies for maximizing the quality of pharmaceutical care while minimizing exposure to risk. PMID- 10176549 TI - Using SPC (statistical process control) to analyze measurements in a healthcare organization. AB - This article presents a tutorial on statistical process control (SPC) for measurement data and the use of trial control charts. Examples from healthcare applications are used to illustrate one process in statistical control and two other processes not in statistical control. PMID- 10176551 TI - Unlicensed assistive personnel--risk management considerations. AB - Along with the restructuring and downsizing of healthcare organizations is the move toward further cost-reduction efforts, including the increased use of unlicensed assistive personnel for patient care activities. This can create new/increased risk exposures. Implications for healthcare risk managers are discussed and strategies for preventing and managing associated liability exposures are provided. PMID- 10176550 TI - The medicolegal risks of thermal injury during laparoscopic monopolar electrosurgery. AB - Medicolegal liability claims arising from minimally invasive surgeries are rapidly increasing. While the medical community appears aware of certain types of liability risks in this area, it often underappreciates the risks associated with monopolar laparoscopic electrosurgery. Jury verdicts and settlements help define this problem, which can lead to improved healthcare delivery and better outcomes for patients. PMID- 10176552 TI - Surrogate center may be liable for child abuse by biological father. Huddleston v. Infertility Center of America. PMID- 10176553 TI - National Centers of Excellence: moving ahead with the federal agenda. AB - The University of California at San Francisco stands as a model for integrated, comprehensive healthcare services for women--encouraged and supported by a grant from the U.S. Public Health Service Office on Women's Health. Meeting government criteria is not easy, says Manager Tracy Weitz--but satisfied customers make the effort worthwhile. PMID- 10176554 TI - Identifying goals and measures for women's health strategies. PMID- 10176555 TI - Performance measures high for managed care, but NCQA data show room for improvement. PMID- 10176556 TI - Integrating women's healthcare--serving the whole woman. AB - Health systems across the country are setting up centers to serve all the health needs of women. The driver for comprehensive care programs, they say, is expert intuition, not hard data, that integrated care will result in better outcomes than traditional fragmented care has produced. They point to women's preferences for "one-stop shopping" and government initiatives that encourage integration. And they offer six keys to successfully launching a comprehensive care program- insights gained in developing their programs. PMID- 10176557 TI - Development of prehospital medical classification criteria. AB - INTRODUCTION: A trauma classification system (TCS) is widely used by many prehospital personnel to provide advanced activation of trauma teams. Specific criteria serve to notify specialty departments and enhance communication between prehospital and emergency department (ED) personnel. Because the TCS has worked so well, a medical classification criteria tool (MCCT) was developed to consistently notify EDs of medical patients' acuity, enhance communication, and provide a smooth transfer of care. METHOD: MCCT development included establishment of tool validity by experts; retrospective chart review to determine consistency and accuracy of classification; and a pilot test of the MCCT at three hospitals. After the pilot, satisfaction surveys were distributed to receiving hospitals to determine tool effectiveness, ease of use, and enhanced transition of care. RESULTS: Of the receiving staff surveyed, 97% found the tool easy to understand; 82% thought the MCCT enabled them to effectively prepare for patients; 62% perceived consistency in classification by the helicopter staff. The flight crew had a 100% positive response regarding ease of MCCT use; 36% noted a positive change in preparation for medical patients' transfer of care. CONCLUSION: The MCCT enhances communication and is useful in preparation and transition of patient care from prehospital to the hospital environment. Advanced notification of patient illness severity may enhance care and affect overall outcome. PMID- 10176558 TI - Trauma triage: do AAMS transport guidelines do it effectively? AB - PURPOSE: Appropriateness of helicopter transport for trauma patient transfer is under closer scrutiny with the development of regionalized trauma systems and managed care. This study was conducted to determine the effectiveness of the 14 Association of Air Medical Services (AAMS) guidelines in triaging trauma patients. METHODS: The application of the trauma transport guidelines for 511 patients flown to our trauma center with hospital stays of fewer than 3 days were analyzed to ensure high sensitivity to overtriage. Injury severity score (ISS), revised trauma score (RTS), Glasgow coma scale (GCS), and mortality rates associated with each of the guidelines were analyzed. RESULTS: Each guideline was associated with mortality greater than or equal to 20%, except motor vehicle, falls, amputation, and degloving. All guidelines had significant ISS (> 14), RTS (< 10), and GCS (< 12), except falls (ISS-6.7, RTS-11, GCS-13.3) and amputations (ISS-6.3, RTS-11, GCS-13.5). Degloving, motor vehicle, spinal cord, airway, and extrication also had a significantly higher RTS (> 12). CONCLUSION: The AAMS transport guidelines for trauma patients accurately predict the potential for serious or life-threatening injury, with the exception of falls and amputations. The rapid access to highly skilled reimplantation teams required by patients with amputations justifies helicopter transport. However, falls greater than 20 feet do not appear to identify potential for life-threatening injury. PMID- 10176560 TI - Basics of research (Part 11): Compendium of research terms. PMID- 10176559 TI - CDC guidelines for occupational exposure to HIV. PMID- 10176561 TI - A 10-year experience in the use of air medical transport for medical scene calls. AB - OBJECTIVE: The objective of this retrospective descriptive study was to evaluate the use of air medical services in response to medical scene calls for transport to tertiary care in the rural setting. METHODS: This study is a retrospective descriptive review of all medical scene calls during a 10-year study period. The cases were analyzed for demographics, transport time, medical indication, procedures, role of ground EMS services, effects on community hospitals, and patient outcomes. A case-by-case review by emergency medicine (EM) physicians was conducted to determine necessity of air medical transport. RESULTS: A total of 8106 medical flights were conducted during the study period. Of these, 103 were scene calls for which 85 charts were available for review. The breakdown of medical scene calls is cardiac (29%), poisoning (17%), co poisoning (11%), neurologic (11%), and other (32%). Ground EMS was involved in 80% of the cases; ground advanced life support (ALS) was present in 58%. In 86% of the flights reviewed, an EM resident was aboard the helicopter. Of the 85 patients whose charts were available, 41 required admission to the ICU, five required hyperbaric oxygen (HBO) treatment, and 14 died before admission. CONCLUSION: Evacuation of the rural patient with a medical emergency accounts for an extremely small percentage of an air medical service's use. ALS services, including emergency procedures at the scene and rapid transport to a tertiary care, were provided. Seventy-one percent of the flights reviewed required transport to a tertiary care facility, indicating that air medical transport was appropriate. Physician guidelines to ensure effective and cost-efficient use of these services should be developed. Responding for victims in cardiopulmonary arrest appears to provide little benefit with respect to outcome. PMID- 10176562 TI - The high costs of hidden conditions. PMID- 10176563 TI - Transforming employer-sponsored health care. PMID- 10176564 TI - Is the gatekeeper a dying breed? PMID- 10176566 TI - Going entrepreneurial. PMID- 10176565 TI - Vision benefits are worth looking at. PMID- 10176567 TI - RSI (repetitive strain injuries) can strain the bottom line. PMID- 10176568 TI - Zeroing in on Medicare-risk disenrollment. PMID- 10176569 TI - Is a PSO in your future? PMID- 10176570 TI - The verdict on practice acquisitions. PMID- 10176571 TI - Recommendations of California's Managed Care Improvement Task Force. PMID- 10176572 TI - Assessing readiness for PSOs? PMID- 10176573 TI - MedPartners sale to PhyCor called off. PMID- 10176574 TI - Medicare program; monthly actuarial rates and monthly supplementary medical insurance premium rate beginning January 1, 1998--HCFA. Notice. AB - As required by section 1839 of the Social Security Act, this notice announces the monthly actuarial rates for aged (age 65 or over) and disabled (under age 65) enrollees in the Medicare Supplementary Medical Insurance (SMI) program for 1998. It also announces the monthly SMI premium rate to be paid by all enrollees during 1998. The monthly actuarial rates for 1998 are $87.90 for aged enrollees and $97.10 for disabled enrollees. The monthly SMI premium rate for 1998 is $3.80. PMID- 10176575 TI - Medicare program; home health agency physician certification regulations--HCFA. Decision to reexamine interpretations, with comment. AB - This document with comment period announces our decision to reexamine our recent interpretations of the Medicare regulations pertaining to indirect compensation arrangements between home health agencies (HHAs) and physicians who certify or recertify the need for home health services or establish or review the home health plan of care. We are withdrawing recent interpretations regarding indirect compensation arrangements where the physicians are salaried employees of, or have a contractual arrangement to provide services for, an entity that also owns the HHA. This will enable us to evaluate our recent interpretations of these regulations and related provisions of section 1877 of the Social Security Act to ensure consistent application of Medicare policy among providers of services. PMID- 10176576 TI - Exempt distribution of a radioactive drug containing one microcurie of carbon-14 urea--NRC. Final rule. AB - The Nuclear Regulatory Commission (NRC) is amending its regulations to permit NRC licensees to distribute a radioactive drug containing one microcurie of carbon-14 urea to any person for "in vivo" diagnostic use. The NRC has determined that the radioactive component of such a drug in capsule form presents an insignificant radiation risk and, therefore, regulatory control of the drug for radiation safety is not necessary. This amendment makes the drug more widely available and reduces costs to patients, insurers, and the health care industry. This action grants a petition for rulemaking (PRM-35-12) from Tri-Med Specialties, Inc. and completes action on the petition. PMID- 10176577 TI - Medicare+Choice program; collection of user fees from Medicare+Choice plans and risk-sharing contractors--HCFA. Interim final rule with request for comments. AB - This interim final rule with a request for comments establishes the methodology that will be employed to assess fees applicable to Medicare risk-sharing contractors for fiscal year (FY) 1998. Under section 4002 of the Balanced Budget Act of 1997, these contractors must contribute their pro rata share of costs relating to beneficiary enrollment, dissemination of information, and certain counseling and assistance programs. The Medicare+Choice regulation to be published in June of 1998 will implement this requirement for Medicare+Choice plans. PMID- 10176578 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); waiver of collection of payments due from certain persons unaware of loss of CHAMPUS eligibility--DoD. Proposed rule. AB - This proposed rule authorizes the waiver of collection of payments due from individuals who lost their CHAMPUS eligibility when they became eligible for Medicare Part A, due to disability or end stage renal disease. PMID- 10176579 TI - Guidelines for furnishing sensorineural aids (e.g., eyeglasses, contact lenses, hearing aids)--VA. Final rule. AB - This document affirms the Department of Veterans Affairs (VA) medical regulations concerning when VA will furnish veterans with sensori-neural aids (e.g., eyeglasses, contact lenses, hearing aids), which implement a requirement imposed in the Veteran's Health Care Eligibility Reform Act of 1996, Public Law 104-262. PMID- 10176581 TI - Diagnostic x-ray equipment performance standard; request for comments and information--FDA. Advance notice of proposed rulemaking. AB - The Food and Drug Administration (FDA) is announcing its intention to propose amendments to the performance standard for diagnostic x-ray systems and their major components. The agency is taking this action to address changes in the technology and use of radiographic and fluoroscopic systems. The agency is issuing this advance notice of proposed rulemaking (ANPRM) in accordance with its policy of early public disclosure of rulemaking activities. The FDA is soliciting comments and information from interested persons concerning the subject matter of the proposed amendments. PMID- 10176580 TI - Solicitation of new safe harbors and special fraud alerts--Office of Inspector General, HHS. Notice of intent to develop regulations. AB - In accordance with section 205 of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, this notice solicits proposals and recommendations for developing new and modifying existing safe harbor provisions under the Federal and State health care programs' anti-kickback statute, as well as developing new OIG Special Fraud Alerts. The purpose of developing these documents is to clarify OIG enforcement policy with regard to program fraud and abuse. PMID- 10176582 TI - Is this the year to sell to a PPM? PMID- 10176583 TI - PPMs. Are they beauties ... or are they beasts?. Interview by Timothy Kelly. PMID- 10176584 TI - Parity for behavioral health: will change be for the better? PMID- 10176585 TI - Promoting the purchasers' point of view. A conversation with Catherine Kunkle. Interview by Patrick Mullen. PMID- 10176586 TI - Patient autonomy in managed care: what are the choices for physicians? PMID- 10176587 TI - What you should know when you negotiate a managed care contract. PMID- 10176588 TI - Managed care outlook. Reality check: what members say about managed care and regulation. PMID- 10176589 TI - More red ink than black. PMID- 10176590 TI - Drug information resources for health professionals and consumers. PMID- 10176591 TI - Web slinkies, getting unkinked. PMID- 10176592 TI - Online catalogs for the smaller library. PMID- 10176593 TI - Telemedicine as a new role for the hospital library. PMID- 10176594 TI - Privacy and confidentiality. PMID- 10176595 TI - One system relies on partnering as a strategy to build a state network. PMID- 10176596 TI - Physician executives view communication skills as the key to their success as managers. PMID- 10176597 TI - MSOs: why they fail, and corrections to make. PMID- 10176598 TI - Intranets hold promise for linking widespread medical networks. PMID- 10176599 TI - Quality-based physician pay gets off to a slow start. PMID- 10176600 TI - Just because it's on the market doesn't mean it's smart to buy. PMID- 10176601 TI - Why and when just as important as how in moving physicians into incentive pay. PMID- 10176603 TI - HCFA publishes SNF routine cost limits for fiscal 1998. PMID- 10176602 TI - Physician exec pay highest in single-specialty groups, practice management firms. PMID- 10176604 TI - Departing HCFA chief Vladeck overturns PRRB prudent buyer ruling. PMID- 10176605 TI - Providers' experience under case-mix demonstration is mixed. PMID- 10176606 TI - How to gauge whether you are ready to accept risk-based managed care contracts. PMID- 10176607 TI - Court enjoins HCFA from enforcing non-coverage decision on electrical stimulation for wound care. PMID- 10176608 TI - HCFA publishes final rule on resident assessments, electronic submission of MDS (minimum data set). PMID- 10176609 TI - HCFA calculates Part B adjustment for SNF PPS rate; industry double-checking figures. PMID- 10176610 TI - New AHCA (American Health Care Association) sourcebook contains key subacute benchmarking data. PMID- 10176611 TI - Study estimates 12 popular health mandates raise premiums 30%. PMID- 10176612 TI - Hospitalist model can lower LOS, land contracts. PMID- 10176613 TI - What's in a name? Plenty--just ask this PHO. Ocoee Health Alliance has name that sells. PMID- 10176614 TI - Here's advice on mending your PHO relationship. PMID- 10176615 TI - Here's list of common headaches facing PHOs. PMID- 10176616 TI - Osteopathic physicians in integrated networks help fill primary care void. PMID- 10176617 TI - Physician salaries show small increase. PMID- 10176618 TI - What are you waiting for? You can end patient delays. PMID- 10176620 TI - Match staff to volume to fix your phone hang-ups. PMID- 10176619 TI - Why do patients love this doctor? PMID- 10176621 TI - Think outside the box when recruiting physicians. PMID- 10176622 TI - Thinking of selling or buying a practice? PMID- 10176623 TI - Cut pneumonia length of stay, costs, readmissions. PMID- 10176624 TI - Textile supply management program is no-risk, caps costs per adjusted patient day. AB - Western Reserve Care System put an end to escalating linen costs with a no-risk, cost management program that's already saved the Ohio provider more than $160,000. Learn how those savings were realized and how other providers can benefit as well. PMID- 10176625 TI - Handheld computers are key to improving homecare operations for Colorado provider. AB - Providers are finding great success at improving patient care and operations with hand-held computers that cut documentation time, reduce errors, and streamline operations. Here's how a Colorado medical center revamped its homecare operation and integrated wireless technology on the inpatient side, too. PMID- 10176626 TI - Despite homecare success, technology switch over inside hospital gets mixed reviews. PMID- 10176627 TI - Rethink outpatient surgery strategy? Study finds hospitals lose money on 56 procedures. AB - A new study reveals hospitals are losing an average of $268 on each Medicare patient who has outpatient surgery. Losses depend on procedures, ownership structure, and how often the particular type of surgery is performed. PMID- 10176628 TI - Fine-tune your strategies to beat the capitation blues. PMID- 10176629 TI - Improve referral management to reduce specialty utilization. AB - Referral management is perhaps the most important clinical imperative for capitated groups, but too many providers abdicate the role to non-clinical bureaucrats. Find out how to improve your referral management system, minimize unnecessary specialty care, and still maintain high quality and satisfaction. PMID- 10176630 TI - Careful accounting practices help keep your capitation performance on track. PMID- 10176631 TI - NAIC (National Association of Insurance Commissioners) risk-based formula may reshape risk contracting market. PMID- 10176632 TI - Perspectives. The AMA after Sunbeam: tremor in the house of medicine. PMID- 10176633 TI - Perspectives. Quality, output gains belie some health cost estimates. PMID- 10176634 TI - Marketplace. How hospital boards respond to market changes. PMID- 10176635 TI - Perspectives. By any measure, consumer satisfaction drives market results. PMID- 10176636 TI - World class customer service: do you have what it takes? PMID- 10176637 TI - Baptist Hospital of Miami. Total brand bundling. PMID- 10176638 TI - Health warning. PMID- 10176639 TI - Risk management. Safety slip-ups. PMID- 10176640 TI - Occupational stress. Taking the strain. PMID- 10176642 TI - Half a league onward. Not everyone welcomes government plans to compare hospitals' performance. PMID- 10176641 TI - Manual handling. Lifting the burden. PMID- 10176643 TI - Telephone services. Wired for sound. AB - There is some evidence that the British public would like to see an expansion of telephone advice lines. Exact demand is difficult to predict, but some research suggests that 500-1,000 nurses will be needed to staff a national service. The government's timetable for establishing a national service by 2000 is unrealistic. PMID- 10176644 TI - US healthcare. America on the line. AB - The growth of telephone advice lines has been partly driven by managed care schemes, keen to reduce use of health services. Some managed care companies are considering e-mail advice services, with nurses responding to descriptions of patients' symptoms. PMID- 10176645 TI - The MEDLINE experience at Yale: 1986-1996. AB - The Cushing/Whitney Medical Library began providing end-user access to MEDLINE in 1986 and switched to the OVID system in 1993. MEDLINE is a core service of the library, and the choice of delivery systems has had a significant impact throughout the Yale-New Haven Medical Center. This paper describes the user response to MEDLINE, discusses the effects of MEDLINE on other library services, and suggests ways in which technology, policy, and funding have influenced use. Yale's experience suggests that removing barriers in all three areas can dramatically expand the points of access, the number of users, and the amount of use with manageable effects on other library services. PMID- 10176646 TI - Sources of salary statistics for health care professionals. AB - Salary statistics for various health care professions are much in demand, yet finding them is not always an easy task. This article provides an annotated list of selected sources of salary statistics for medicine, dentistry, nursing, pharmacy, occupational therapy, and physical therapy. Emphasis is placed on sources which are published regularly. Strategies for finding additional sources of salary statistics are also discussed. PMID- 10176647 TI - A metastrategy for World-Wide Web information retrieval in clinical medicine. AB - The metastrategy for World-Wide Web information retrieval was presented as an integrated approach to end-user searching in clinical medicine, although its application may be made to any search for WWW information. Certain distinctions, such as between anticipated and unanticipated clinical information needs and between WWW catalogs for retrieving Web sites and WWW databases for retrieving Web pages, were made. These distinctions are important in the end-user strategy because they help maximize the productivity of the WWW for clinicians. PMID- 10176648 TI - Surviving reengineering: coping in today's health care environment. AB - Stress reactions during times of organizational change are only to be expected. In the volatile world of health care there are no exceptions. It has been said that the only constant is change. As a result, it is imperative that we develop effective methods to deal with the ever-changing world. The unspoken life-long employment contract no longer exists. Given that change is a constant--and that all change, even good change causes stress--how do we survive? Can we do better than survive? What about "surthriving"? It is possible to actually grow and develop during stressful times of change. PMID- 10176649 TI - The challenges of computer training in a small hospital. PMID- 10176650 TI - Premier unveils venture. Vendor-sponsored institute to push new technologies. PMID- 10176651 TI - From out of the rubble. S.C. systems build a future out of their broken merger. PMID- 10176652 TI - Budget battle looms. Clinton uses fraud fines, user fees to pay for programs. AB - President Clinton ignited a new money battle for providers last week as he proposed an activist healthcare agenda in his proposal to balance the federal budget in the next fiscal year. In his $1.733 trillion fiscal 1999 spending plan, Clinton proposed that providers and health plans pay $659.2 million in new user fees to fund expanded provider audits, certification surveys and a host of other HCFA activities. PMID- 10176653 TI - Forcing cooperation. VHA to create integrated computerization package. PMID- 10176654 TI - Health Care Hall of Fame. Teaching by example. The late James A. Hamilton was a pioneer in the field of healthcare management. PMID- 10176655 TI - Health Care Hall of Fame. A knack for achievement. Cutting-edge grad program, renowned hospital among Bernard J. Lachner's legacies. PMID- 10176657 TI - Health Care Hall of Fame past inductees. PMID- 10176656 TI - Health Care Hall of Fame. Man with a mission. Advancing public healthcare has been the career core of Elliott C. Roberts Sr. PMID- 10176658 TI - Alive on arrival. With his healthcare proposals, Clinton has GOP back on its heels. PMID- 10176659 TI - Feds clear PATH. 16 teaching hospital billing audits nixed. PMID- 10176661 TI - Managed care. In search of bias. Critics fault study showing 'neutral' media coverage. PMID- 10176660 TI - The horns of a dilemma. Public healthcare companies must decide: please investors or invest in future. PMID- 10176662 TI - Perfecting the picture. Contrast agents to make ultrasound clearer, pricier. PMID- 10176663 TI - Posting bond. New federal rule onerous for some home-care companies. PMID- 10176664 TI - Rules to follow. Hospitals given Medicare billing compliance model. PMID- 10176665 TI - Another hit for Columbia. Financial losses, unsealed affidavit add to its woes. PMID- 10176666 TI - Partners try two-step. FTC investigates second phase of N.Y. hospital deal. PMID- 10176667 TI - Case to decide, merger or scam? PMID- 10176669 TI - ACHE preview. Focus on doc leadership. PMID- 10176668 TI - Congress mulling substance abuse parity bill. PMID- 10176670 TI - ACHE preview. Stragegizing compliance. PMID- 10176671 TI - Double start-up troubles. PPM launches hit snags but stick to initial strategies. Interview by Mary Chris Jaklevic. PMID- 10176672 TI - ACHE preview. Capitation's effect on pricing, planning. PMID- 10176673 TI - ACHE preview. Promoting cultural understanding. PMID- 10176674 TI - ACHE preview. Good ethics, good business. PMID- 10176675 TI - ACHE preview. Principles of knowledge management. PMID- 10176676 TI - ACHE preview. Hospitals' assisted-living allies. PMID- 10176677 TI - ACHE preview. Is your hospital customer-friendly? PMID- 10176678 TI - ACHE preview. Looking for payoff from patient-focused care. PMID- 10176679 TI - A new player. HealthPlus execs aren't sold on network approach. PMID- 10176680 TI - Provider opposition. Premier joins fight against patient-protection bills. PMID- 10176681 TI - Is leadership born or made? AB - Is leadership born or made? By profiling three colleagues who made the transition from clinician to top-flight executive in a health care organization, the author provides case studies from which to discuss leadership issues. An evolutionary pattern has developed with respect to physicians changing careers: The first model was the medical director, followed by the vice president for medical affairs, and finally the move to managing the health care system, group practice, or managed care organization. Are physician executives fundamentally different from clinicians in terms of leadership characteristics? What are the essential qualities needed to lead health care organizations? These questions are explored in-depth. PMID- 10176682 TI - Changes in physician and non-physician relationships. AB - At the end of World War II, one-third of the nation's hospital administrators were physicians. During the 1950's through the mid-1980's a new breed of masters'level administrator, with well-honed coordinating skills, orchestrated a major expansion of new programs, services, and facilities. With the advent of the Medicare prospective payment system (PPS), more governing boards restructured their administrative staffs with corporate titles. Meanwhile, physicians sensed that trustees were becoming far more concerned with bottom line performance to repay a mounting debt that hospitals had incurred to remain technologically competitive. Since mergers and integrated health systems by themselves will be unable to generate significant operating efficiencies, governing boards will be forced to change direction and shift back to recruiting physicians as their CEOs or in other senior positions to assure themselves of the clinical leadership required to implement the managed care concepts of reducing utilization and cost, and simultaneously enhancing quality of patient care. PMID- 10176683 TI - Is there a physician union in your future? AB - Physician unions are in the news. Patient management and patient care decisions are increasingly being taken out of the hands of physicians and put into the hands of "The Suits." To take their case for a return to physician-driven patient care to the people, some physicians are joining unions. Some are even collectively bargaining for salary and other issues that are historically more closely associated with unions. The simple fact is that physician unions exist and the number of physicians joining them is expected to increase. What are the pros and cons of unionization? What motivates physicians to join unions, and what potential negative and positive factors are associated with physician unionization? This article reviews the pros and cons and the issues related to physician unions, for physicians attempting to answer the question, "Is there a union in my future?" PMID- 10176684 TI - The new breed. AB - Structural changes within the health system--particularly in the organization and financing of services--have made new and different opportunities available to physicians interested in management. What types of physicians are currently going into management? How do they compare to others who have been in management for a longer period of time and to the "traditional" portrait of the physician executive? The author profiles the emerging, contemporary physician executive and explores the implications for the viability of the field of medical management as a whole. PMID- 10176685 TI - Who will lead? AB - A recent survey conducted by the UCLA Center for Health Services Management and the Physician Executive Practice of Heidrick & Struggles, an executive search firm, sheds light on the emerging physician executive's role. The goal of the research was to identify success factors as a means of evaluating and developing effective industry leaders. Respondents were asked to look at specific skills in relation to nine categories: Communication, leadership, interpersonal skills, self-motivation/management, organizational knowledge, organizational strategy, administrative skills, and thinking. Communication, leadership, and self motivation/management emerged, in that order, as the three most important success factors for physician executives. An individual's general competencies, work styles, and ability to lead others through organizational restructuring defines his or her appropriateness for managerial positions in the health care industry. PMID- 10176686 TI - Why an MBA? AB - As physicians move into medical management, leaving clinical practice behind to play a major role in managing physician performance and clinical processes, they are having to deal in the business world. Physician executives are donning the pinstripe suit instead of the white coat, and adding a business acumen to their clinical skills. Many have opted to pursue executive MBA programs to learn the business competencies they need to manage health care organizations. This article summarizes the educational opportunities available in executive MBA programs and discusses the value of business training for aspiring physician executives. PMID- 10176687 TI - Strategic positioning. Part 2: Positioning challenges in an evolving health care marketplace. AB - Why is strategic positioning so important to health care organizations struggling in a managed care environment and what are the sources of value? In Part 1 of this article, entitled "The Sources of Value under Managed Care," the authors presented four sources of value relative to the evolution of the market from fee for-service to managed care. These value sources are: (1) assets, (2) price/performance, (3) distribution, and, ultimately, (4) capabilities and brand equity. In this article, the authors further elaborate on the sources of value as the market moves beyond the historical fee-for-service position to a managed care marketplace. Part 2 presents the marketing and financial challenges to organizational positioning and performance across the four stages of managed care. PMID- 10176688 TI - Breaking the trance. AB - The father of hypnotherapy, Milton Erickson, insisted that trance was a fairly common state for individuals, one that we drop into many times a day without any help at all--not at all the sensational image we think of with the magician hypnotizing the audience volunteer, or the psychiatrist the patient. Trances have a number of things in common--they: (1) are an altered state of consciousness; (2) feel autonomous; (3) come packaged with any of a number of "Deep Trance Phenomena"; (4) tend to repeat; (5) are universal. Organizations have trances, too. They have autonomous states of mind, ways of thinking that seem to come from nowhere, that seem impossible to change. They have automatic behaviors--ways of meeting, building of bureaucratic structures, interactions between departments. If organizations had knees, we might call them "knee-jerk reactions." Or communal habits. Or organizational trances. If the trance is a harmful one, how can you loosen its grip? By building up parallel realities. PMID- 10176689 TI - What's your financial set point? AB - Motivation is an important career issue, especially in the shrinking health care market. What inspires people to work hard today is often not the same thing that encouraged our parents' industriousness. What motivates you? What motivates your direct reports? Research suggests that people can't be motivated beyond their "financial set point"--the amount of money they need or want which will motivate them to work harder or smarter. The following motivators are explored: (1) Upward mobility; (2) limited goals; (3) need only; (4) revenge; (5) ego nourishment; and (6) time. PMID- 10176690 TI - Life after retirement. Interview by Barbara J. Linney. AB - Are you thinking about retirement? Here are interviews with four physician executives who have made the transition. Some are recently retired, while others have been retired for many years. The good news is that all of them are productive and exploring interests and hobbies that their careers had taken precedence over. All of them were asked the following: (1) How have you felt about retirement? (2) What are some interesting things you've done? (3) What advice would you give to others who are planning for it? PMID- 10176691 TI - Physician executive leadership. Leading the way. AB - Today's health care leaders are faced with tremendous pressures for change from diverse, powerful sources including payers, regulators, legislators, patients, and competitors. The leadership approaches of the past, designed to get things back under control, no longer work. In our turbulent times, leadership demands the creation of flexible, adaptive organizations with conscious, capable, and committed people who feel ownership and responsibility for their entire group. Critical components of this new leadership approach include: (1) Energizing the organization; (2) sharing responsibility for outcomes; and (3) resolving conflicts without command and control tactics. PMID- 10176692 TI - Diagnosis of a stalled career. AB - What should physician executives do to prepare for a career move? This is not a list of items to improve technical skills and knowledge, but information on how to accurately and clearly present your experience and gain credibility. A few of the basic career preparations that physician executives must make include: (1) Get your paperwork in order, both a resume and a curriculum vitae; (2) seek feedback and critical input; (3) refresh or establish your interviewing skills; and (4) focus on your communications techniques. Physicians executives cannot rest on their deserved laurels as strong practitioners when aspiring to a senior management role. It is critical to emphasize other skills--decisiveness, communication, and management experience in a range of health care organizations. PMID- 10176693 TI - Health data privacy. AB - How can the tradition of patient-provider confidentiality be preserved and still meet the changing information needs of insurers, employers, public health agencies, policy analysts, and researchers? As countries grapple with the issue of a patient's right to medical record privacy, actions that the U.S. takes in this area will set precedents and have implications for nearly every health care electronic transaction. The Health Insurance Portability and Accountability Act requires the Secretary of Health and Human Services (HHS) to recommend standards for electronic financial and administrative transactions. The HHS focused on the confidentially of patient's health care information, guided by five principles in developing recommendations: (1) Boundaries; (2) Security; (3) Consumer Control; (4) Accountability; and (5) Public Responsibility. PMID- 10176694 TI - Community representation and the effective board. PMID- 10176695 TI - Building healthy communities. Six steps for the board. AB - Many trustees believe that health care reform must begin in the communities that their organizations serve. To become the visionary leaders that health care needs, trustees must reexamine many long-held beliefs and values, adopt 21st century principles of governance, embrace the concept of a healthy community, and develop a systematic plan for change. Based on the collective knowledge of boards that have successfully led their organizations through change, the plan described here consists of a systematic six-step process. The process begins with techniques for creating awareness of the need to change and ends with techniques for measuring and sustaining gains (see figure 1 at right). PMID- 10176696 TI - A big man dissolves a big board. Restructuring requires visionary leadership. PMID- 10176697 TI - Strategic planning. Trick or treat? PMID- 10176698 TI - Governance. Advice from the trustee trenches. PMID- 10176700 TI - 1998 Resource Guide. PMID- 10176699 TI - The doctor is "in"! Physician "alignment" is health care's current mantra. PMID- 10176701 TI - Clinical waste disposal a change of direction. PMID- 10176702 TI - Hospital trip generation and parking. PMID- 10176703 TI - CHP as standby power in hospitals. Health Service Engineering Group. PMID- 10176704 TI - Reducing the environmental impact of clinical waste. PMID- 10176705 TI - Algorithms for the cost-effective installation of combined heat and power in a hospital environment. PMID- 10176706 TI - Incinerator and gas cleaning equipment overview. PMID- 10176707 TI - Alternative treatments for clinical waste. PMID- 10176708 TI - The Grand Forks disaster. PMID- 10176709 TI - Though aborted by some of its pioneers, patient focused care is still transforming organizations like 582-bed Ingalls in Harvey, IL. PMID- 10176710 TI - When did AIDS begin? A new study of the oldest known HIV suggests the virus jumped from animals to humans in the 1940s. PMID- 10176711 TI - Is direct contracting the next wave? PMID- 10176712 TI - Newborns' and Mothers' Health Protection Act: putting the brakes on drive-through deliveries. PMID- 10176713 TI - Ready for round two. AB - The next lobbying fight over health care is about to begin. This time, the key issue is quality of care. Democrats and even many Republicans say the system is broken. PMID- 10176714 TI - Abortion-rights groups look to 1998. PMID- 10176715 TI - A slant on cloning. AB - Human cloning may be the most difficult moral dilemma posed by science since splitting of the atom. But recent stories in The New York Times suggest the ethical debate is all but over. Now, along comes Dr. Seed. PMID- 10176716 TI - Conservatives push for health care privacy. PMID- 10176717 TI - Compensation monitor. Most physicians flourish under capitation, despite declining commercial payments. PMID- 10176718 TI - Hospitality giant builds its own workers' comp network in Florida. Marriott International Florida Workers' Comp. PMID- 10176719 TI - The march of capitation: reversed or just delayed? PMID- 10176720 TI - 'Contact capitation' and its cousins. PMID- 10176721 TI - Capitation won't rule, nor will it fade away. PMID- 10176722 TI - The Oregon experience. Must doctors lose money with managed Medicaid? PMID- 10176723 TI - New optimism from the 'Father of the HMO'. An interview with Paul Ellwood Jr., M.D. PMID- 10176724 TI - Medicare's transition to managed care. Panel discussion. PMID- 10176725 TI - Tough road ahead for the AMA's physician accreditation program. PMID- 10176726 TI - What a physician can learn in the role of family member. PMID- 10176727 TI - What you say can hurt you if said to the wrong person. PMID- 10176728 TI - Managed care outlook. Fewer employers sponsor retiree health benefits. PMID- 10176729 TI - 1997 salary survey results. Market demand high for hospital-based case managers. PMID- 10176730 TI - Feds go after discharge planners over improper home health referrals. PMID- 10176731 TI - Don't run afoul of these federal regulations. PMID- 10176732 TI - Restructuring: more hats for case managers. PMID- 10176733 TI - Carotid endarterectomy path cuts LOS below two days. PMID- 10176734 TI - New CABG procedure saves time, money. PMID- 10176735 TI - Maximize the efficiency of your patient pathways. PMID- 10176736 TI - Case management credentials: what you must know before taking the plunge. PMID- 10176737 TI - Problems plague ANCC's (American Nurses Credentialing Center) credentialing test. PMID- 10176738 TI - CM credentials: what employers want. PMID- 10176739 TI - What you need to know about CM credentials. PMID- 10176740 TI - Your role in JCAHO's continuity requirements. PMID- 10176741 TI - Care across the continuum: CHF demonstration project. Developing a regional model for disease management. PMID- 10176742 TI - Laminectomy path saves $180,000 annually. PMID- 10176743 TI - Applying information and technology management for successful care management. PMID- 10176744 TI - Stats & facts. Physician practice and managed care. PMID- 10176745 TI - Navigating out of the doldrums. PMID- 10176746 TI - Getting there is easier if you know where you are going. PMID- 10176747 TI - Developing a rural primary care practice network. AB - Establishing and managing a primary care practice in rural communities is particularly challenging. Many rural practices are closing, and relatively few new practices are initiated independently. The integrated health system can provide at least part of the solution to the lack of physicians in the rural setting. The following article describes the objectives, methods, and results of an integrated health system's development of a rural primary care provider network. PMID- 10176748 TI - The report card's role in health care decision making: Part I. AB - In the initial installment of a two-part article, the author suggests that report cards must evolve further before they can become truly useful measures of health plans or providers. They are a beginning, however, and some decisions can be made based on the claims data and process-based measures available today. PMID- 10176750 TI - Surviving the evolution of managed care ethics. PMID- 10176749 TI - Legal risks in the operation of referral and utilization review systems. PMID- 10176751 TI - Getting the most out of drug company DM programs. PMID- 10176752 TI - DM program tackles high costs of neonatal intensive care. PMID- 10176753 TI - Link prenatal and neonatal care to improve outcomes, cut costs. AB - The neonatal intensive care unit performs miracles on newborn babies but costs the health care system dearly in return. While most health care providers have been reluctant to challenge the assumption that all of the spending is necessary, one new neonatal disease management service has had the insight to take a different perspective, and the babies are the biggest winners. PMID- 10176754 TI - Use new diagnostic know-how to improve prevention, treatment of peptic ulcer disease. AB - The culprit behind peptic ulcer disease has finally been identified and caught. Now that providers know that a nasty bacterium, H Pylori, causes this painful and debilitating disease, and lurks in the bloodstream of at least half of the U.S. population including children, major health improvements and savings are on the horizon. PMID- 10176755 TI - Use DM strategies to reign in out-of-control workers' comp costs. AB - A medical director who manages a large national health plan's workers' comp cases claims appropriate standards of care are not applied to workplace injuries and costs are out of control as a result. But there is some good news: Managed care organizations could reap huge benefits if they applied disease management methods to workers' comp cases. PMID- 10176756 TI - Software program generates customized patient information. AB - A new computer software program personalizes disease management information for patients, provides doctors with a variety of drug treatment options, and generates a chart report. Doctors love the convenient help and patients love the personal touch. PMID- 10176757 TI - Do it now! PMID- 10176758 TI - The Home Care Coalition. Ensuring the future. PMID- 10176759 TI - Assistive technology for disabled clients. AB - Numerous resources exist for consumers who wish to explore the benefits of assistive technology. Consumers can tap into the knowledge base of rehabilitation technology suppliers, therapists, and physicians, and follow a step-by-step process to use new technologies to improve their daily lives. PMID- 10176760 TI - Home care 2000. Integration opportunities. AB - As integration and networks become the norm in the nation's health care system, home care is poised to be the lead player in the delivery of multiple and complex patient-centered services. Opportunities for integration will abound as the next century beckons. PMID- 10176761 TI - Creating a home care provider network. AB - Home care provider networks can help agencies serve more people more effectively. Before joining a health care provider network, however, agencies must analyze several factors and find partners who share the same business and health care philosophies. Using the guidelines in this article, agencies can be confident of better decisions for their businesses. PMID- 10176762 TI - The regulatory challenges of the 1997 Balanced Budget Act. PMID- 10176763 TI - Maintaining good media relations: what to say and how to say it. AB - Good media relations can help providers thrive in this era of intense scrutiny. By following a few simple pointers agency executives can foster positive relationships with the media and ensure fair and accurate reporting of agency activities. PMID- 10176764 TI - Managing Year 2000 risks within health care systems. AB - With every kind of health care provider turning to computers for efficiency and to enable smooth transactions with other providers, it is time--and beyond time- to ensure that these networks and tools will continue to function when the year 2000 rolls around. Much media attention has focused on this Year 2000 problem; what does it mean for home care providers? PMID- 10176765 TI - Health help on the Net. PMID- 10176766 TI - The no. 1 health-care company goes under the knife. PMID- 10176767 TI - The 100 best companies to work for in America. PMID- 10176768 TI - Now are you satisfied? The 1998 American Customer Satisfaction Index. PMID- 10176769 TI - Taking on the HMOs. PMID- 10176770 TI - Putting it all together: clinical performance improvement. PMID- 10176771 TI - Mutual fund, charge card companies could emerge as competitors to HMOs. PMID- 10176772 TI - Oxford Health Plan Inc. hopes to rebuild after Wall Street disaster. PMID- 10176773 TI - Columbia/HCA has a vision and a mission for its future, but no strategic plan. PMID- 10176774 TI - A retail analog for health care marketing. PMID- 10176775 TI - Should Columbia/HCA downsize? PMID- 10176776 TI - Theories of justice and their implications for priority setting in health care. AB - The paper aims to show how three theories of distributive justice; utilitarianism, egalitarianism and maximum, can provide a clearer understanding of the normative basis of different priority setting regimes in the health service. The paper starts with a brief presentation of the theories, followed by their prescriptions for distribution, as illustrated with their respective preferred points on a utility possibility frontier. After this general discussion, attention is shifted from utils to health. The paper discusses how the recent Norwegian guidelines for priority setting can be understood in the light of the theories. PMID- 10176777 TI - Valuing morbidity: an integration of the willingness-to-pay and health-status index literatures. AB - Placing dollar values on human health has long been a controversial aspect of policy analysis and remains difficult given the relatively small number of morbidity-valuation studies available. By combining both the economic and health literature, this paper offers an alternative approach to morbidity valuation and provides estimates for a wide range of short-term health conditions. PMID- 10176778 TI - Measurement of consumer-patient preferences using a hybrid contingent valuation method. AB - This study introduces a hybrid, two-stage, contingent valuation method applied to asthma treatment. Respondents are initially offered a choice between hypothetical medications, implying a tradeoff between safety and efficacy. Stage two elicits willingness to pay (WTP) for an improvement along a single risk dimension. Estimates of the value of asthma control based on the initial risk tradeoff stage range from approximately US$1400 to US$2100 per year, assuming a US $6 million value of life. Analysis of the second-stage WTP responses yield estimates for the value of a statistical life of approximately US$9 million and for asthma control of approximately US$2200 per year. PMID- 10176779 TI - Disability-adjusted life years: a critical review. AB - The disability-adjusted life year (DALY) has emerged in the international health policy lexicon as a new measure of the 'burden of disease'. We argue that the conceptual and technical basis for DALYs is flawed, and its assumptions and value judgements are open to serious question. In particular, the implications of age weighting and discounting are found to be unacceptable. Moreover, the proponents of DALYs do not distinguish between the exercises of measuring the burden of disease and of allocating resources. But the appropriate information sets for the two exercises are quite different. Allocating resources by aggregate DALY minimization is shown to be inequitable. PMID- 10176780 TI - Understanding DALYs (disability-adjusted life years). AB - The measurement unit disability-adjusted life years (DALYs), used in recent years to quantify the burden of diseases, injuries and risk factors on human populations, is grounded on cogent economic and ethical principles and can guide policies toward delivering more cost-effective and equitable health care. DALYs follow from a fairness principle that treats 'like as like' within an information set comprising the health conditions of individuals, differentiated solely by age and sex. The particular health state weights used to account for non-fatal health outcomes are derived through the application of various forms of the person trade off. PMID- 10176781 TI - The time trade-off: a note on the effect of lifetime reallocation of consumption and discounting. AB - This paper considers the extent to which responses to time trade-off (TTO) questions can provide unbiased estimates of ratios of individual marginal rates of substitution (MRS) of wealth for risk of various health state impairments relative to the corresponding MRS for risk of death. It is shown that if there is reallocation of lifetime consumption and/or discounting of future utilities, then a TTO response that is not adjusted for these effects will unambiguously overestimate the ratios of individual MRS. While the effect of reallocation is likely to be very small, discounting can lead to significant overestimation, the magnitude of which depends in part upon the severity of the health state impairment. PMID- 10176782 TI - A bootstrap approach to medical decision analysis. AB - In economic evaluations of health treatments, the sensitivity of a cost-benefit (CB), cost-effectiveness (CE) or cost-utility (CU) analysis to changes in modeling assumptions, variation in data, and sampling error is important. The typical approach to this problem is ad hoc experimentation; namely, a few parameters of particular interest are changed, either separately or in combination, over plausible ranges. The impact of random variation in the data is seldom explored beyond parametric tests of the statistical significance of estimated coefficients. This note suggests a systematic approach to sensitivity analysis. Bootstrap sampling is used to determine to what extent the patients' response to treatment and economic consequences might vary due to many replications of a clinical trial. PMID- 10176783 TI - On valuing morbidity, cost-effectiveness analysis, and being rude. PMID- 10176784 TI - OSHA TB proposal criticized by infection control experts. PMID- 10176785 TI - Surgeons decry OR layoffs of nurse managers. PMID- 10176786 TI - What managers need to know about Medicare fraud probes. PMID- 10176787 TI - Outpatient surgery is a money loser under Medicare. PMID- 10176788 TI - Joint commission. A restraint protocol for the postanesthesia unit. PMID- 10176789 TI - Case costing improves practice, bottom line. PMID- 10176790 TI - Sterilization & infection control. Are all your point-of-use processes in line? PMID- 10176791 TI - Abortions in America. So many women have them, so few talk about them. PMID- 10176792 TI - Who gets abortions and why. The effects on women are often surprising, even profound. PMID- 10176793 TI - When abortions come late in a pregnancy. Though rare, most aren't for medical reasons. PMID- 10176794 TI - 'I'll say I'm suicidal'. The mentally ill struggle through the maze of managed care. PMID- 10176795 TI - The new face of Medicare. PMID- 10176796 TI - The ICPD Programme of Action: pious hope or a workable guide? PMID- 10176797 TI - Addressing the demographic imperative through health, empowerment, and rights: ICPD implementation in Bangladesh. PMID- 10176798 TI - Reaching a stationary global population: what we have learnt, and what we must do. PMID- 10176799 TI - The new international population movement: a framework for a constructive critique. PMID- 10176800 TI - At a glance. The Medicare program. PMID- 10176801 TI - Martin Memorial Lecture: Operating outside the theater: new challenges for leadership. PMID- 10176802 TI - The National Practitioner Data Bank. What you need to know. PMID- 10176803 TI - Statement on the surgeon and HIV infection. American College of Surgeons. PMID- 10176804 TI - The Medicare Payment Advisory Commission. PMID- 10176806 TI - Revised documentation guidelines for E&M (evaluation and management) services: the physical exam. PMID- 10176805 TI - The MacPherson Triangulation Technique. PMID- 10176807 TI - Code blue 2000. Are you prepared for a medical device breakdown? PMID- 10176808 TI - Paywatch. Results from the 1997 Hay Hospital Compensation Survey. PMID- 10176809 TI - Fraud & abuse. Compliance countdown--take action now. PMID- 10176810 TI - Tube scoop. Insider's guide to cleaning lap instruments. PMID- 10176811 TI - Dress code--the right cath garb sparks IC success. PMID- 10176812 TI - Emergency! Stop spending time putting out fires. PMID- 10176813 TI - Docs open a new vein in standardization. PMID- 10176814 TI - Stats. Could outsourcing be all wet? PMID- 10176815 TI - Scrubs: uniform or IC garb? Answer spells big savings. PMID- 10176816 TI - Clearing the air. OSHA wants to protect health care workers against TB--but there are surprising dissenters. PMID- 10176817 TI - Parental perks at facilities help keep moms on the job. PMID- 10176818 TI - Software search: system borrows ideas from industry. PMID- 10176819 TI - Waste watchers dump high disposal costs. PMID- 10176820 TI - The British National Health Service. PMID- 10176821 TI - Accountability and the accounting regime in the public sector. Some messages from the NHS. AB - In the UK, the government is keen to introduce private sector procedures into the public sector. The latest stage of this process has been to suggest the adoption of accruals accounting by those parts of the public sector where it is not already operated. This approach to accounting was introduced into the NHS as part of the reforms which implemented a quasi-market to match the demands of purchasers of health care with its providers. Outlines the assumptions which underlie accruals accounting and considers whether the environment created for NHS Trusts is sufficiently like that of the private sector to justify its use. Shows that the initial ideas of the extent to which Trusts could mimic private sector organizations have not been fulfilled in practice, and concludes that it is not possible to justify the use of accruals accounting in the public sector simply on the grounds that as it is the technique used in the private sector it must be superior to the available alternatives. PMID- 10176822 TI - Opportunity 2000 in the National Health Service: a missed opportunity for women. AB - The NHS in 1991 launched an equality programme for women, setting eight goals to be achieved by 1994. Shows that at least some of the goals are not being met and suggests reasons falling into four categories. First is the NHS context, including trusts' autonomy which is incompatible with a national equality plan. Second, there is a failure of implementation. Third, the programme is inherently flawed: its business rationale is less than convincing to many health professionals who attach a high value to ethics, Fourth, the reasons for failure relate to all equality programmes for women, including a value system which sees the male career pattern as the norm. Concludes that movement towards equality for women in the NHS is only likely to be made if a different approach to goal setting is adopted. PMID- 10176823 TI - The impact of trust status on health care workers. AB - Reports the findings of a study which was undertaken to examine the effects of radical organizational changes, the move towards NHS trust status, on the health and wellbeing of health care workers within a large district hospital and community service. A prospective longitudinal design was adopted incorporating pre- and post-trust measures. A shortened version of the Occupational Stress Indicator (OSI) was supplemented by questions specific to the health care sector. The findings suggest that the transition towards trust status has not resulted in negative outcomes for the organization as a whole, as measured by levels of sickness absence. However, certain employees may be particularly vulnerable during the early stages of organizational change. PMID- 10176824 TI - Is the quality of health care changing? GPs' views. AB - Examines the debate on quality in health care in light of GP fundholding and the Patients' charter. Focuses on the development of quality issues in General Practice by carrying out research based on two stages: first, an exploratory stage aimed at the understanding of key issues; and second, a questionnaire made up primarily of attitude elements drawn from stage one. Concludes that, in the changing political and public environment, GPs are facing the challenges of managing service quality. PMID- 10176825 TI - Cultivating managers of the future. AB - The concrete experience of pupils and students, together with authentic and authoritative career information, are essential to allow for an educated career or vocational training choice. Such a choice is an essential part of the Government philosophy detailed in recent White Papers. The National Health Service, along with other public bodies, has lacked examples of structured student work placements to provide concrete experiences which have the potential to formally link with academic qualifications and hence provide an easing of access to further vocational development. The article charts the introduction application and evaluation of one such structured and practical scheme. The scheme is based on the "Young Manager" package produced by Henley Distance Learning Ltd and Cambridge Training and Development and piloted by the National Health Service Training Division. PMID- 10176826 TI - Market mechanisms and the management of health care. The UK model and experience. AB - Examines recent reforms of the UK's National Health Service (NHS), and explores the pressures for change in the pursuit of an efficient NHS and the conflicts which this causes in an organization which was based on the aim of equity. In particular, addresses the "false revolutions" of managerial change introduced after the Griffiths Report (1983) and the accounting changes introduced in the wake of the Griffiths proposals. Evidence shows that these intended revolutions were limited in impact. The result of these failures has been the introduction of the "real revolution"--the internal market in health care. This is a radical change in both the NHS management arrangements and in service delivery, with the division of the NHS into purchasers (health authorities and GP fund holders) and providers (hospital and community services, whether provided by private, voluntary or state-owned facilities. PMID- 10176827 TI - The audit society. PMID- 10176828 TI - Management education for undergraduate doctors. A survey of medical schools. AB - Explores the extent to, and ways in which, doctors are prepared for their future role in management through the undergraduate medical curriculum. Surveys the colleges across the UK offering undergraduate medical education using both prospectuses and questionnaires to establish both inclusion of healthcare management/policy in curricula and the subject content offered. Establishes that the majority of colleges offer some teaching of health care management/policy although the areas of study included vary considerably. The emphasis in most institutions appears to be on introducing the structure and organization of the NHS together with decision making in respect of resource allocation often located within a public health programme. This leads to the tentative conclusion that the management education needs of future public health physicians are reasonably well served while those of hospital doctors and general practitioners need further investigation. PMID- 10176829 TI - Doctors and change. AB - The introduction of clinical care pathways into one acute hospital trust provided the opportunity to investigate reasons why doctors behave the way they do, and to identify receptive and non-receptive factors for change. A multi-method research strategy was used to obtain primary data, both quantitative and qualitative material, namely responses to a questionnaire and interviews. The questionnaire was distributed to 70 consultants from a variety of medical and surgical specialties, and 42 questionnaires were returned (60 per cent response rate). Reports some of the findings and shows that consultant behaviour and the factors that influence that behaviour are affected by their own characteristics, specifically age and specialty, although all specialties agreed that non financial incentives would influence their behaviour. Characteristics of opinion leaders were also found to be specialty-specific in their degree of influence. Concludes that the multi-method research approach was effective in identifying factors which influence consultant behaviour, and further studies should be carried out in this area. PMID- 10176830 TI - Towards a new health care paradigm. Patient-focused care. The case of Kingston Hospital Trust. AB - Patient-focused care (PFC) and business process re-engineering (BPR) have been advocated in the academic literature as techniques to improve both quality of service and reduce costs. Seeks to separate and delineate the components of PFC and BPR and, using the case study method, describe the adoption and implementation process of PFC in medicine and maternity by one London NHS Trust Hospital. Reports the impact of this innovation on service delivery, staff reconfiguration and multi-skilling. Identifies preconditions and key success factors and indicates lessons for the future. PMID- 10176831 TI - Productive use of IT in support of FM (facilities management) solutions. AB - Drawing on the author's personal experience within the UK National Health Service, outlines at the macro level what information is needed, and why, in facilities management. Suggests that top-level data gathering is a priority, describes the processes required, and finally considers the advantages of sharing information with competitors and others. PMID- 10176832 TI - Medical devices; preemption of state product liability claims--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to amend its regulations regarding preemption of State and local requirements applicable to medical devices. This action is being taken to clarify and codify the agency's longstanding position that available legal remedies, including State common law tort claims, generally are not preempted under the Federal Food, Drug, and Cosmetic Act (the act). PMID- 10176833 TI - Application of HIPAA group market portability rules to health flexible spending arrangements--HCFA. Clarification of regulations. AB - This document clarifies that it is appropriate to treat benefits under certain health flexible spending arrangements as excepted benefits for purposes of the group market portability provisions added by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). PMID- 10176834 TI - Application of HIPAA group market rules to individuals who were denied coverage due to a health status-related factor--HCFA. Clarification of regulations. AB - This document addresses certain issues arising under the group market portability provisions added by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with respect to employees (or their dependents) who, until the effective date of the HIPAA nondiscrimination provisions, were denied coverage under a group health plan, including group health insurance coverage, because of a health status-related factor. PMID- 10176835 TI - Medicare program; schedule of limits on home health agency costs per visit for cost reporting periods beginning on or after October 1, 1997--HCFA. Notice with comment period. AB - This notice sets forth a revised schedule of limits on home health agency costs that may be paid under the Medicare program for cost reporting periods beginning on or after October 1, 1997. These limits replace the per visit limits that were set forth in our July 1, 1996 notice with comment period (61 FR 34344) and supersede those set forth in our July 1, 1997 notice with comment period (61 FR 35608). This notice also provides, in accordance with the Balanced Budget Act of 1997, that there be no changes in the home health per visit limits for cost reporting periods beginning on or after July 1, 1997 and before October 1, 1997 (that is, the cost limits set forth in our July 1, 1996 notice will apply to cost reporting periods beginning during this time period); that the establishment of the cost per visit limitations for cost reporting periods beginning on or after October 1, 1997 be based on 105 percent of the median of the labor-related and nonlabor per visit costs for freestanding home health agencies; that there be no updates in the home health costs limits (including no adjustments for changes in the wage index or other updates) for cost reporting periods beginning on or after July 1, 1994 and before July 1, 1996; and the wage index value that is applied to the labor portion of the per visit limitations be based on the geographic area in which the home health service is furnished. PMID- 10176836 TI - Aluminum in large and small volume parenterals used in total parenteral nutrition -FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to amend its regulations to add certain labeling requirements concerning aluminum in large volume parenterals (LVP's) and small volume parenterals (SVP's) used in total parenteral nutrition (TPN). FDA is also proposing to specify an upper limit of aluminum permitted in LVP's and to require applicants to develop and to submit to FDA for approval validated assay methods for determining aluminum content in parenteral drug products. The agency is proposing these requirements because of evidence linking the use of parenteral drug products containing aluminum to morbidity and mortality among patients on TPN therapy, especially premature infants and patients with impaired kidney function. PMID- 10176837 TI - Child support enforcement program; state plan requirements, standards for program operations, and federal financial participation--Office of Child Support Enforcement, HHS. Notice of proposed rulemaking. AB - This proposed rule would implement part of the paternity establishment provisions contained in section 331 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) and amended by section 5539 of Pub. L. 105 33, which impose new statutory requirements for a State's voluntary paternity acknowledgement process and require the Secretary to promulgate regulations governing voluntary paternity establishment services and identifying the types of entities other than hospitals and birth record agencies that may be allowed to offer voluntary paternity establishment services. States will be required to adopt laws and procedures that are in accordance with the statutory and regulatory provisions. These proposed regulations will address these procedures and related provisions. PMID- 10176838 TI - Medicare and Medicaid programs; surety bond and capitalization requirements for home health agencies--HCFA. Final rule with comment period. AB - The Balanced Budget Act of 1997-(BBA '97) requires each home health agency (HHA) to secure a surety bond in order to participate in the Medicare and Medicaid programs. This requirement applies to all participating Medicare and Medicaid HHAs, regardless of the date their participation began. This final rule with comment period requires that each HHA participating in Medicare must obtain from an acceptable authorized Surety a surety bond that is the greater of $50,000 or 15 percent of the annual amount paid to the HHA by the Medicare program, as reflected in the HHA's most recently accepted cost report. The BBA '97 also requires that provider agreements be amended to incorporate the surety bond requirement; this rule deems such agreements to be amended accordingly. The BBA '97 prohibits payment to a State for home health services under Medicaid unless the HHA has furnished the State with a surety bond that meets Medicare requirements. This final rule with comment period requires that, in order to participate in Medicaid, each HHA must obtain from an acceptable authorized Surety, a surety bond that is the greater of $50,000 or 15 percent of the annual Medicaid payments made to the HHA by the Medicaid agency for home health services for which Federal Financial Participation (FFP) is available. In addition to the surety bond requirement, an HHA entering the Medicare or Medicaid program on or after January 1, 1998 must demonstrate that it actually has available sufficient capital to start and operate the HHA for the first 3 months. Undercapitalized providers represent a threat to the quality of patient care. PMID- 10176840 TI - Supply usage data base helps set best practices. AB - As hospitals move more quickly toward managed care, the impact of industry changes is taking its toll. Networks and systems are rapidly being formed throughout the industry. One advantage of network formation is group purchasing and system-wide contract development. Bundling large volume contracts can produce lower prices for the individual hospitals. Now the challenge for individual hospitals is "where do we go from here?" In many cases, the "system" performs the contract function and the price of most product lines has already been reduced. This article looks at how Alta Bates Hospital in Berkley, CA, continues its efforts to reduce costs as an individual hospital within a larger system, using supply data base information. PMID- 10176839 TI - Make sure your imaging equipment goes the distance. AB - Today's hospitals have invested a substantial portion of their capital budgets on the purchase of high-tech equipment--diagnostic imaging machinery, clinical laboratory apparatus, biomedical devices--and yet only half have developed strategies for taking care of that equipment as it ages. When do you replace it? When is it obsolete? How do you determine whether it is cost effective? Kenneth Halverson examines the steps to take to develop and implement a successful asset management program that will enable you to keep your high-tech equipment going. PMID- 10176841 TI - Supplier certification modified for health care. AB - There have been numerous articles written in detail regarding industrial-based supplier certification programs. These programs generally concentrate on suppliers of raw materials. After reviewing them, it is difficult to visualize how these programs could support the ambulatory or inpatient operations of a healthcare institution. The University of Maryland Medical Center, a 747-bed teaching hospital in Baltimore, took on the challenge to adapt the supplier certification program to support its healthcare institution. After months of struggle, a program emerged by expanding the Medical Center's current process management philosophy, to include its suppliers. Documentation from the program developed by the Medical Center indicates the level of supplier support has increased. Through this certification program, the supplier is aware of the Medical Center's expectations and needs. In turn, the Medical Center has become aware of how its internal processes can hinder the supplier's operation. The supplier certification program has provided a valuable communication conduit. This article covers a brief summation of the industrial-based supplier certification program and how the University of Maryland Medical Center has adapted the program to support all its operations. PMID- 10176842 TI - Preparing for telemedicine and other future technologies. PMID- 10176843 TI - Let the market work. PMID- 10176844 TI - Benefits of EDI for health care. PMID- 10176845 TI - "I am not a crook". PMID- 10176846 TI - Distribution 2001: what will it look like? PMID- 10176847 TI - Medicine in the mail. PMID- 10176848 TI - More Mother's Days. AB - The American Cancer Society and AAHP will sponsor a Mother's Day educational campaign urging people to remind their moms to have regular Pap smears, mammograms, and other screening tests. PMID- 10176849 TI - Information technology. Ducks in a row. PMID- 10176850 TI - Lessons from school. Health plans are forming partnerships with local health departments to provide primary care to children through school-based initiatives. PMID- 10176851 TI - Exposing the silent thief. AB - Like a thief in the night, osteoporosis can sneak up on women and rob them of good health. But new strategies hold promise for prevention, early diagnosis, and better treatment. PMID- 10176852 TI - Health plans and research. Health plans are moving clinical, health services, and outcomes research in new directions. PMID- 10176853 TI - Patients taking control of diabetes. PMID- 10176854 TI - Inpatient management teams. Health plans are looking at new ways of coordinating care in the hospital. PMID- 10176855 TI - Mentoring: a management philosophy. PMID- 10176856 TI - Health plan liability. PMID- 10176857 TI - By the numbers. Managed care is increasingly popular among employees. PMID- 10176858 TI - By the numbers. A popular choice for Medicare beneficiaries. PMID- 10176859 TI - Breaking down the barriers. AB - The Prudential Center for Health Care Research is studying TennCare to identify barriers to early prenatal care. PMID- 10176860 TI - Streamlining referrals. PMID- 10176861 TI - Allina Foundation's Project DECIDE (Discussion of Evolving Choices in Dying and Ethics). PMID- 10176862 TI - Putting philosophy to work. The health plan community demonstrates its commitment to putting patients first. AB - I'm in good health today, but if I get sick tomorrow, will I have to worry about getting the care I need? Will somebody try to dictate what my doctor and I can talk about? If I need to go to the emergency room, will the plan refuse to pay? What if I need an experimental procedure or treatment--will the plan cover it? And if I'm in the hospital, will I have to go home before I'm ready? PMID- 10176863 TI - Unleashing the potential. Powerful changes are afoot as health plans use Internet technology for customer service. PMID- 10176864 TI - Women's health initiatives. Across the country, many health plans are focusing special attention on improving women's health. PMID- 10176865 TI - Making child safety no accident. PMID- 10176866 TI - Pioneers in patient care. AB - It's 1947, employer-sponsored health benefits are a rarity, and quality care is beyond the means of many Americans. But a small group of visionaries is convinced there is a better way to provide patient care. PMID- 10176867 TI - Measuring up. With the release of HEDIS 3.0, health plans are working to improve how they measure quality. PMID- 10176869 TI - Health plans tackle medical savings accounts. PMID- 10176868 TI - These eyes. A new practice model for eye care centers is improving patient satisfaction and lowering costs. PMID- 10176870 TI - Holding hands. AB - The winner of AAHP's National Exemplary Practice Program Award shares how it guides women through the complicated world of breast cancer detection and treatment. PMID- 10176871 TI - Finding top talent. AB - Two experts from a health care consulting/physician recruiting company provide a step-by-step approach to recruiting a medical director. PMID- 10176872 TI - Accreditation: more to come. PMID- 10176873 TI - The nuts & bolts of triage call centers. PMID- 10176874 TI - Keeping Medicare afloat. PMID- 10176875 TI - 'Breath mint'. Two words are the centerpiece of HealthPartners' successful anti tobacco campaign, the winner of AAHP's Community Leadership Award. PMID- 10176876 TI - Who needs to know? AB - Health plans need to collect data on mental health services to ensure quality and improve care. But can they do this and protect patient confidentiality at the same time? PMID- 10176877 TI - Providing support for cancer patients. PMID- 10176878 TI - Seven lessons of the ombudsman. PMID- 10176879 TI - The changing face of case management. PMID- 10176880 TI - By the numbers. Health plans generate savings for American families. PMID- 10176881 TI - Medical maverick. Interview by Mark Hagland. PMID- 10176882 TI - Measuring quality of life. PMID- 10176883 TI - Preventing medication errors. PMID- 10176884 TI - Goodbye to paperwork. PMID- 10176885 TI - Small businesses: the new frontier. PMID- 10176886 TI - Medicaid/Medicare dual eligibles. PMID- 10176887 TI - The new kid in town. PMID- 10176888 TI - Physician report cards. PMID- 10176889 TI - Giving yourself an edge. PMID- 10176890 TI - Consumers' choice. PMID- 10176891 TI - By the numbers. Vital statistics and health improving for Americans. PMID- 10176892 TI - Next generation Web sites. PMID- 10176893 TI - Eight principles for using data. PMID- 10176894 TI - Incorporating satisfaction measures into physician compensation. PMID- 10176895 TI - PEP (Personal Energy Plan) talk. PMID- 10176896 TI - Building an ethical framework. PMID- 10176897 TI - Beyond the basics: caring for patients with rare chronic diseases. PMID- 10176898 TI - Choices abound in the vast new world of Medicare: HMO, PPO, PSO, MSA. PMID- 10176899 TI - The year ahead: top policy priorities for 1998. PMID- 10176900 TI - The building blocks of a complementary medicine program. PMID- 10176901 TI - Children: the forgotten mourners. PMID- 10176902 TI - Tackling issues together. PMID- 10176903 TI - Marketplace. Why value-based purchasing lags in health care: Lansing's lessons. PMID- 10176904 TI - Perspectives. Consumer's desire for choice threatens cost gains of managed care. PMID- 10176905 TI - Perspectives. Regulation in the market: friend or foe of competition? PMID- 10176906 TI - Perspectives. States blend Medicaid, homegrown concepts in kidcare plans. PMID- 10176907 TI - Issues & trends affecting the nation's hospices. AB - As the hospice industry has grown and moved from isolation into the health care system, it necessarily faces new issues. Some are definite, such as budget considerations; others are more theoretical--for instance, physician-assisted suicide--and thus may remain up for debate as hospice matures into an as-yet unseen status. PMID- 10176908 TI - Clinical pathways for the terminally ill. AB - Clinical pathways help providers to enhance documentation, standardize care, and improve patient outcomes. One agency developed a clinical pathway that offers terminally ill patients comprehensive, accessible, and coordinated care. It prompts each team member to recognize positive outcomes and to conduct ongoing goal setting with the patient and family. PMID- 10176909 TI - Reassessing Oregon's Death With Dignity Act. AB - In 1994 the state of Oregon made people all over the country sit up and take notice when its citizens voted to enact the Death with Dignity Act. This year, after the Supreme Court of the United States declined to address the Act's constitutionality, citizens will again address the issue, deciding whether terminally ill patients will be able to ask their physicians to help them die. PMID- 10176910 TI - Volunteers providing bereavement support. AB - Bereavement programs can benefit from volunteers who have undergone the grieving process themselves. Torrance Memorial Home Health & Hospice has developed a program to train its volunteers in bereavement issues, thus enabling the program to reach out to the community, bringing a note of caring to those who need it most. PMID- 10176911 TI - Special care team: a welcome choice. AB - What happens when a patient isn't ready to accept hospice care? Or when curative rather than palliative care is needed? Some patients need the skills of a hospice nurse in a curative setting--which calls for a special care team. PMID- 10176912 TI - Volunteer hospices: exposing the myths. AB - Many all-volunteer hospices serve their communities without Medicare certification. They prefer to specialize exclusively in supportive services of a quality, quantity, and variety difficult to achieve in a setting affected by restrictions of third-party reimbursement and regulatory controls. PMID- 10176913 TI - Assessing home care aides with Palmore's Facts on Aging Quizzes. PMID- 10176914 TI - Can Oxford heal itself? AB - The fast-growing HMO was hammered on Wall Street after revealing its massive computer problems. Those foul-ups are being fixed, but now comes the hard part- reclaiming the trust of stunned shareholders and outraged doctors. PMID- 10176915 TI - A new mandate for human resources. AB - Should we do away with HR? In recent years, a number of people who study and write about business--along with many who run businesses--have been debating that question. The debate arises out of serious and widespread doubts about HR's contribution to organizational performance. Dave Ulrich acknowledges that HR, as it is configured today in many companies, is indeed ineffective, incompetent, and costly. But he contends that it has never been more necessary. The solution, he believes, is to create an entirely new role for the field that focuses it not on traditional HR activities, such as staffing and compensation, but on business results that enrich the company's value to customers, investors, and employees. Ulrich elaborates on four broad tasks for HR that would allow it to help deliver organizational excellence. First, HR should become a partner in strategy execution. Second, it should become an expert in the way work is organized and executed. Third, it should become a champion for employees. And fourth, it should become an agent of continual change. Fulfilling this agenda would mean that every one of HR's activities would in some concrete way help a company better serve its customers or otherwise increase shareholder value. Can HR transform itself on its own? Certainly not--in fact, the primary responsibility for transforming the role of HR, Ulrich says, belongs to the CEO and to every line manager who works with the HR staff. Competitive success is a function of organizational excellence, and senior managers must hold HR accountable for delivering it. PMID- 10176916 TI - Appraising boardroom performance. AB - Rare is the company that does not periodically review the performance of its staff, business units, and suppliers. But rare, as well, is the company that does such a review of one of its most important contributors--its board of directors. Reviewing a board's performance is not an easy proposition: it has to be done by the members themselves, people who generally have many other responsibilities and whose time is always at a premium. But done properly, appraisals can help boards become more effective by clarifying individual and collective responsibilities. They can help improve the working relationship between a company's board and its senior management. They can help ensure a healthy balance of power between the board and the CEO. And, once in place, an appraisal process is difficult to dismantle, making it harder for a new CEO to dominate a board or avoid being held accountable for poor performance. Done properly is the key here, though. Done incorrectly, board appraisals can degenerate into self-serving evaluations or unpleasant, time-wasting exercises. Worse, they can evolve into rigid mechanical processes that discourage innovation. In fact, all of the approaches the authors observed in two years of research were incomplete. The authors have therefore drawn on the strengths of several different approaches to synthesize a best practice process that is both rigorous and comprehensive. PMID- 10176917 TI - Making the deal real: how GE Capital integrates acquisitions. AB - Most companies view acquisitions and mergers as onetime events managed with heroic effort--anxiety-producing experiences that often result in lost jobs, restructured responsibilities, derailed careers, and diminished power. Little wonder, then, that most managers think about how to get them over with--not how to do them better. But even as the number of mergers and acquisitions rises in the United States, studies show the performance of the resulting companies falls below industry averages more often than not. To improve these statistics, executives need to view acquisition integration as a manageable process, not a unique event. One company that has done exactly that is GE Capital Services, which has assimilated more than 100 acquisitions in the past five years alone and, in the process, has developed a formal model for melding new acquisitions into the corporate fold. Drawing on their experiences working with the company to develop the model, consultants Ron Ashkenas and Suzanne Francis, together with GE Capital's Lawrence DeMonaco, offer four lessons from the company's successful run. First, begin the integration process before the deal is signed. Second, dedicate a full-time individual to managing the integration process. Third, implement any necessary restructuring sooner rather than later. And fourth, integrate not only the business operations but also the corporate cultures. These guidelines won't erase all of the discomfort that accompanies many mergers, but they can make the process more transparent and predictable for those involved. PMID- 10176918 TI - Preventing the premature death of relationship marketing. AB - Relationship marketing is in vogue. And why not? The new, increasingly efficient ways that companies have of understanding and responding to customers' needs and preferences seemingly allow them to build more meaningful connections with consumers than ever before. These connections promise to benefit the bottom line by reducing costs and increasing revenue. Unfortunately, a close look suggests that the relationships between companies and customers are troubled ones, at best. Companies may delight in learning more about their customers and in being able to provide features and services to please every possible palate. But customers delight in neither. In fact, customer satisfaction rates in the United States are at an all-time low, while complaints, boycotts, and other expressions of consumer discontent are on the rise. This mounting wave of unhappiness has yet to reach the bottom line. Sooner or later, however, corporate performance will suffer unless relationship marketing becomes what it is supposed to be--the epitome of customer orientation. Ironically, the very things that marketers are doing to build relationships with customers are often the things that are destroying those relationships. Relationship marketing is powerful in theory but troubled in practice. To prevent its premature death, marketers need to take the time to figure out how and why they are undermining their own best efforts, as well as how they can get things back on track. PMID- 10176919 TI - Enterprising nonprofits. AB - Faced with rising costs, more competition for fewer donations and grants, and increased rivalry from for-profit companies entering the social sector, nonprofits are turning to the commercial arena to leverage or replace their traditional sources of funding. The drive to become more businesslike, however, holds many dangers for nonprofits. In the best of circumstances, nonprofits face operational and cultural challenges in the pursuit of commercial funding. In the worst, commercial operations can undercut an organization's social mission. To explore the new possibilities of commercialization and to avoid its perils, nonprofit leaders need to craft their strategies carefully. A framework-what the author calls the social enterprise spectrum--can help such leaders understand and assess their options. Nonprofits first must identify potential sources of earned income; then they should set clear and realistic financial objectives. Commercial programs don't need to be profitable to be worthwhile. They can instead improve the efficiency and the effectiveness of organizations by reducing the need for donated funds; by providing a more reliable, diversified funding base; and by enhancing the quality of programs by instilling market discipline. In the end, commercial operations will not--and should not--drive out philanthropic initiatives. But thoughtful innovation in the social sector is essential if organizations are to leverage limited philanthropic resources. PMID- 10176920 TI - The competitive dynamics of network-based businesses. AB - Telecommunications carriers, transportation companies, and banks are among the many network-based businesses--companies that move people, goods, or information from various points to various other points. Managers have long assumed that customers valued all links in these networks equally. It was thought that banking customers, for example, sought access to all of the branches throughout the network or that shipping customers wanted to be able to send packages everywhere. Intuitively, managers thought that many of their customers' needs were, in reality, narrower, but they had no way of knowing which links were most important. New computing power and robust mapping software now make it possible to understand network customers better. In applying this technology, the authors, both consultants from McKinsey & Company, have uncovered three distinct usage patterns: one in which all links are, indeed, valued equally; another in which customers concentrate their use in particular zones; and a third in which customers value only individual links. Each of these patterns requires a different strategy to direct executives in making the decisions fundamental to managing any network-based business: whether to open or close outlets, whether to connect their network to others, and how to organize business units so that they reflect the network's structure. Those who don't spot the patterns or understand their strategic implications will find themselves on the losing end of the network battle. PMID- 10176921 TI - 1995 IAHSS salary, equipment, staffing and uniform survey. AB - This second part of the 1995 IAHSS annual Crime Survey provides information on security director salaries, security department staffing, and types of equipment and uniforms employed. Factors that may or may not affect salaries are explored- including the influence of hospital size and the differences between proprietary and contract status. Differences in the size of security staffs by bed size and the relative use of police officers in security are covered. The survey also reports on trends in the type of security equipment used by hospitals--including guns, stun guns, pepper spray, and Mace. New data on the use of police uniforms or blazers by security personnel are presented. Ten charts are included. PMID- 10176922 TI - A proactive response to workplace violence. AB - How to prevent workplace violence through the use of a proactive plan and implementation of a task force. Dealing with threats and terminated employees, as well as controlling employee access are discussed. PMID- 10176923 TI - Survey of newborn security in British Columbia hospitals. Review Committee on Newborn Security. Provincial Ministry of Health. AB - The abduction of a newborn from Kelowna General Hospital, Kelowna, BC, in September 1996 resulted in the formation of a newborn security review team by the province's Ministry of Health and the British Columbia Health Association. Part of the duties of the review team was the surveying of 87 hospitals in British Columbia that provide maternity services on current security protocols in each facility. Results of the survey are presented in this article, along with the subsequent recommendations of the review committee. PMID- 10176924 TI - Succeeding at the Joint Commission survey process. PMID- 10176925 TI - Security from the outside in. AB - Why good healthcare security starts at the perimeter of the facility, and that includes the parking lot. The author discusses his philosophy of security: "If I can control who or what comes into the building, then I can also control the problems that occur within it." PMID- 10176926 TI - Implementing the incident command system in the healthcare setting. AB - The author discusses a new requirement in NFPA 99 for healthcare facilities--the implementation of an Incident Command System in the event of a disaster. He offers suggestions on how facilities can change their disaster plans to meet this new standard. PMID- 10176927 TI - Communication issues during bomb threats. AB - How should healthcare security professionals handle a bomb threat? How can a large complex best be searched? The author discusses why he believes the judicial use of radios and cellular phones during emergencies can enhance security's ability to handle bomb threat situations, and offers guidelines to follow. PMID- 10176928 TI - Graduating to an integrated system: Yale University Medical School and Yale-New Haven Hospital coordinate security. AB - The authors, security directors at Yale University Medical School and Yale-New Haven Hospital respectively, discuss their decision to coordinate their efforts to procure compatible new security systems that would integrate such components as alarms, CCTV, and access control within and between the two campuses. The goal: improve safety and make alarm monitoring easier and more efficient by centralizing operations. THE RESULTS: an increase in security, a decline in security incidents, and a reduction in costs. PMID- 10176929 TI - Ethical and legal elements of private security in the modern health provision facility. PMID- 10176930 TI - JCAHO and the seven dwarfs. AB - The author describes the recently completed JCAHO survey at his hospital. He compares the months of preparation and the results to childbirth. PMID- 10176932 TI - Communication. Clarity begins at home. AB - The NHS's failure to use plain English is a long-standing and widely acknowledged problem. Most people get their information from tabloid newspapers, where sentences have 30 words or fewer. Patients should be involved in the preparation of patient information leaflets. The government's emphasis on involving the public in the NHS, and holding board meetings in public, will be meaningless unless briefing papers can be understood. PMID- 10176931 TI - Resolving the dilemma of educating and training professionals in security. AB - This article is excerpted from a Pinkerton Lecture Series paper, sponsored by Pinkerton Security and Investigation Services, that was presented at the 1997 Plenary Session of ASIS in June. The author presents his views on how best to educate and train the security professional in today's hightech environment. Among his suggestions: a more diverse curriculum broken into smaller packages, use of the Internet or other electronic media, and having security professionals teach courses and integrate security into the curriculum. PMID- 10176933 TI - Communication. Calling a bed a bed. PMID- 10176934 TI - Community services. The home team. AB - Reorganising a mental health service for elderly people to ensure most care can be given in the client's home has led to a dramatic decrease in admissions. Length of inpatient stay has not fallen, probably because those now admitted are more severely ill. The service is based on community mental health teams and places great reliance on healthcare assistants. PMID- 10176935 TI - Medical workforce planning. Spreading the load. AB - Medical workforce planning is a difficult and neglected area, but ignoring it will cost the NHS dear. Setting up collaborative mechanisms to deal with medical training and workforce issues is not easy, but has been shown by one health authority to be worthwhile. Plans for an 8 per cent increase in consultant posts will, if implemented, cost the HA 700,000 Pounds a year in salaries and on-costs alone, but better information has enabled the most beneficial to be prioritised. PMID- 10176936 TI - Data briefing. Our growing inequalities. PMID- 10176937 TI - Hospitals face new price pressures. PMID- 10176938 TI - Ongoing CHA project addresses lay sponsorship. PMID- 10176939 TI - RFRA (Religious Freedom Restoration Act): Catholic healthcare loses an arrow from its quiver. PMID- 10176940 TI - Growing needs blossom into innovative care management. PMID- 10176941 TI - New Web resource explores organizational integrity. PMID- 10176942 TI - The best of times, the worst of times. Interview by Judy Cassidy. PMID- 10176943 TI - Grassroots healthcare. System creates new division to improve community health status. PMID- 10176944 TI - System CEO predicts advocacy priorities. PMID- 10176945 TI - Mentoring physicians. Coalition is developing curriculum of end-of-life issues. PMID- 10176946 TI - Building healthier communities. A Mercy-sponsored initiative fosters broad collaborations. PMID- 10176947 TI - Unique governance for a national ministry. Catholic Health Initiatives' board structure empowers laity, supports mission. AB - The three original founding healthcare systems and 10 sponsoring religious institutes of Catholic Health Initiatives (CHI) have developed an unprecedented governance model to support their vision of a national Catholic health ministry in the twenty-first century. The new organization spans 22 states; annual revenues exceed $4.7 billion. Religious institutes choose either active or honorary status before consolidating with CHI, depending on their desired involvement in the organization. Currently, nine are active and two are honorary. CHI's civil corporation comprises one representative from each active congregation. These representatives approve major changes in mission or philosophical direction. They control board membership by appointing three to five congregation representatives as sponsorship trustees, who are responsible for approving the remaining members of the Board of Stewardship Trustees. This half-religious, half-lay governing board is responsible for leading CHI. CHI has only two levels of governance, a national board and boards of market-based organizations, for instance a network of facilities with one management structure, or a community board of an individual facility. This avoids multiple administrative layers and approval processes. The organization has a civil identity as CHI and a canonical identity as a public juridic person of pontifical right, called Catholic Health Care Federation (CHCF). The governing board members of CHI, as members of CHCF, serve as the religious sponsors for all CHI health facilities. Some facilities have already been "alienated" (turned over) to CHI by their religious institutes; others will be alienated in the future. CHI's recent consolidation with Sisters of Charity of Nazareth Health System added an 11th sponsor, a sixth geographic region, and two members--one religious and one lay- to the governing board. The governance model assists such growth through the appeal of an equal religious-lay partnership and a flexible sponsorship model. PMID- 10176948 TI - Survey helps system attain quality goals. Process tracks perceptions of patients, employees, and physicians. PMID- 10176949 TI - Bicycle safety programs save children's lives. PMID- 10176950 TI - Moving toward transformational leadership. PMID- 10176951 TI - 10 ways to stay happy in the age of corporate medicine. PMID- 10176952 TI - Retire? Not since I built the perfect practice. PMID- 10176953 TI - Dealing with know-it-all patients. PMID- 10176954 TI - What this man wants, you may get. Interview by Anne L. Finger. PMID- 10176955 TI - Are you sure you want to buy in as a partner? PMID- 10176956 TI - The latest malpractice risk: saving your patient's life. PMID- 10176958 TI - Capitation. It's still spreading where competition is hottest. PMID- 10176957 TI - I sold my soul to a PHO--and bought it back. PMID- 10176959 TI - Never mind "patient relations." Get ready for "consumer rights". PMID- 10176960 TI - Doctors win millions in a managed-care divorce. PMID- 10176961 TI - How one group builds market leadership. PMID- 10176962 TI - HealthSouth on target? Scrushy aims high with 'integrated service plaza' plan. PMID- 10176963 TI - Pharmacists get Rx. McKesson's robots relieve pill-counting drudgery. PMID- 10176964 TI - Ties that don't bind. Vencor's REIT doesn't plan to be 'captive' for long. PMID- 10176965 TI - Capstone to stay focused on healthcare. PMID- 10176966 TI - Enrollment albatross. Kaiser's 1997 loss shows downside of record growth. PMID- 10176967 TI - CEOs settle down. Turnover drops sharply as boards, CEOs sit tight. PMID- 10176969 TI - But hospital prices take a leap. PMID- 10176968 TI - Unsettled. Tobacco deal causes divisions in Congress, with states. PMID- 10176970 TI - AMA dodges union case. Group pushes for more house staff clout instead. PMID- 10176971 TI - New think tank links info tech execs. PMID- 10176972 TI - Boston system adds pieces. CareGroup, flagship facility strengthen ties with docs. PMID- 10176973 TI - Governance gap. Study: For-profits, not-for-profits run differently. PMID- 10176974 TI - Emeritus ends takeover. Attempt signals aggression in assisted-living industry. PMID- 10176975 TI - Awaiting word from IRS. 'Intermediate sanction' regulations still months off. PMID- 10176976 TI - Ready for rollout. Medicare+Choice marketing effort within budget. PMID- 10176977 TI - Power to the patient. The true consumer's emerging power means the end of traditional HMOs. PMID- 10176979 TI - Data systems' tangible benefits still a hard sell. PMID- 10176978 TI - Info system evangelists. AB - Top executives of healthcare organizations are recognizing the crucial role information systems play in realizing their strategies and fostering the productivity required for success. Modern Healthcare's eight annual survey of information system trends shows the boardroom and executive suite are becoming important checkpoints for clearance of information technology. PMID- 10176980 TI - Market profile. Seattle's choosy consumers. With HMO enrollment lagging, health plans turn to open networks to win consumers. PMID- 10176981 TI - Medical facts on line. VHA unit to help hospitals meet consumer demand. PMID- 10176982 TI - High-priced, hard-to-find. IS recruiters turn to finder's fees, signing bonuses. PMID- 10176983 TI - Going for-profit. St. Louis Catholic hospital gets OK for sale to Tenet. PMID- 10176984 TI - VA against the wall? Clinton's budget would strain system, critics warn. PMID- 10176985 TI - Limited-license rush is on. Some California systems apply to become like HMOs. PMID- 10176986 TI - PSO proposal exposes rift. Solvency standards separate the large from the small. PMID- 10176987 TI - Keep referrals coming. Hospitals shouldn't forget to feed their physicians in their frenzy over patients. PMID- 10176988 TI - Young Executive of the Year. ACHE award goes to executive of trade association for first time. AB - Fast-thinking, fast-acting fast-talking Lee Perlman is the consummate businessman. Luckily for hospitals in America's largest city, he has chosen to apply his talents serving them instead of Wall Street. Perlman, 39, executive vice president and chief financial officer of the Greater New York Hospital Association, has been chosen the 1998 Young Healthcare Executive of the Year. He's the first trade association exec to hold that honor. PMID- 10176989 TI - Comeback attempt. Can new leadership, funding resuscitate Oxford? PMID- 10176990 TI - JCAHO urges 'Do tell,' in sentinel event fight. Aviation's lesson: learn from experience. PMID- 10176991 TI - Seismic proportions. Calif. hospitals struggle to comply with retrofitting laws. PMID- 10176992 TI - Two giants link up. HIMSS and RSNA will showcase integration progress. PMID- 10176993 TI - Paint it blue. State Blues plans discover the power of branding. PMID- 10176995 TI - Diminishing business. Columbia's woes hurting home health unit's referrals. PMID- 10176994 TI - It comes in a box. More firms use off-balance-sheet financing technique. PMID- 10176996 TI - Columbia's new ethics policy could cost Texas hospital its accreditation. PMID- 10176997 TI - Fitness/wellness concept gaining. More hospitals creating affiliated centers. AB - Celebration Health is envisioned as the prototype for healthcare delivery and enhancement for the new town. While Celebration Health is associated with a hospital, neither sickness nor hospitalization is the focus of the facility. It's a center that encourages Celebration residents and those of neighboring communities--even tourists--to take charge of their physical, emotional and spiritual well-being. Other companies are taking another approach to wellness. Because of a growing interest among healthcare administrators across the country in hospital affiliated wellness and fitness center business, The Benfield Group of St. Louis, Mo., has produced a 10-page booklet to help care givers arrive at crucial decisions. While some groups are forming informational publications. Community Health Center Management, which debuted with a July-August 1997 edition, was created to provide a source of information for community health center directors and health care providers. PMID- 10176998 TI - Marketers target ethnic groups. Efforts reflect diversity, managed care growth. AB - Large health systems are slowly entering the ethnic markets to increase membership. Asians, Hispanics and other fast-growing ethnic minorities are a hot new market for HMOs. PMID- 10176999 TI - Insurance group reinvents name. Medical Mutual of Ohio restores historical image. PMID- 10177000 TI - The Health Care News Server reports business, political and managed care news at www.HealthCareNewsServer.com. PMID- 10177001 TI - Kansans hearing about Premier Blue. Media blitz aims at name recognition for HMO. PMID- 10177002 TI - Hospital appeals to decision makers. Focuses marketing efforts on female audience. New Britain General Hospital, Conn. PMID- 10177003 TI - ERs generate added patient care. System promotes emergency care as gateway to other services. Columbia North Florida Division. PMID- 10177004 TI - Women's health headed for the web. JAMA launching new information service. PMID- 10177005 TI - Dermatologists: attend to skin care. Three-year education campaign under way. PMID- 10177006 TI - The Benfield Group offers advice. Creating a successful hospital-affiliated fitness center. PMID- 10177007 TI - Advertising mix reflects market. Budgets key to selecting media that produce best return. AB - Healthcare advertisers are discovering different media mixes work for different targets. In addition, budget plays a big role in choosing the type of media that will return the best investments. PMID- 10177008 TI - Senior housing. A quiet revolution. PMID- 10177009 TI - Weinberg Terrace, Pittsburgh, Pennsylvania. PMID- 10177010 TI - Do the Dutch do it better? An aging population poses new challenges to a nation known for humanely housing all. PMID- 10177011 TI - Goddard House, Brookline, Massachusetts. PMID- 10177012 TI - Construction aims at a steady pace for '98. PMID- 10177013 TI - The role and application of the balanced scorecard in healthcare quality management. AB - To connect practices, outcomes, quality, value, and costs, healthcare organizations must start using a balanced scorecard. A balanced scorecard is a set of measures that reveals the interdependency of the organization, its employees, and its patients. It thus serves as a balanced perspective on the organization for senior management to use in designing, developing, deploying, and directing the strategic plan, consistent with total quality management principles. PMID- 10177014 TI - Reducing the incidence of ventilator-related pneumonia. AB - Ventilator-related pneumonia is costly not only in terms of treatment, equipment, and length of stay but also in terms of patient morbidity and mortality. From October 1995 through March 1996 an increase in ventilator-related pneumonia cases, of which 83% were caused by methicillin-resistant Staphylococcus aureus (MRSA), was noted at a Veterans Affairs medical center. A multidisciplinary team based on the TQI model and using TQI tools, methodology, and principles of problem solving was subsequently formed to look into ventilator-related pneumonia. The team's data collection and analysis efforts identified numerous opportunities for improvement. The primary outcome has been a decrease in the incidence of ventilator-related pneumonia that has resulted in substantial cost savings. PMID- 10177015 TI - Improving managed care through coding, monitoring, and trending quality-of-care concerns. AB - With the rise of managed care, purchasers and payers are increasingly demanding value in healthcare. Traditionally, patient satisfaction surveys and focus groups have been used to elicit information regarding customers' perspectives. This article explores the use of an inexpensive alternative methodology--that of monitoring quality-of-care concerns and complaints. A nomenclature and a process for tracking, trending, and reporting quality-of-care issues are detailed; they encompass both the patient's and the provider's perception of a specific care experience. This methodology promotes the use of quantifiable data to support strategic planning and compliance with National Committee for Quality Assurance accreditation standards. PMID- 10177017 TI - Internet Relay Chat: a window of opportunity for healthcare quality. AB - Internet Relay Chat (IRC) program is a medium that can provide low-cost interactive conferencing for healthcare organizations. This article analyzes IRC in the context of the many facets of the Internet, discusses some precautions regarding IRC use, and lists some sources of help for the user. IRC is an extremely powerful adjunct to other Internet programs. PMID- 10177016 TI - Mastering the Ambulatory Patient Groups system. AB - Providers and payers will need to implement the Ambulatory Patient Groups (APG) system, a complex new payment mechanism for outpatient care. Because the APG system consolidates, packages, and discounts a facility's payment for outpatient services, providers might receive decreased reimbursement for services, as compared to the reimbursement received under their present outpatient payment arrangements. APGs, like DRGs, will force providers to examine their coding practices carefully to ensure that they will receive reimbursement adequate to cover their costs. PMID- 10177018 TI - Redesigning a risk-management process for tracking injuries. AB - The changing responsibilities of registered nurses are challenging even the most dedicated professionals. To survive within her newly-defined roles, one nurse used a total quality improvement model to understand, analyze, and improve a medical center's system for tracking inpatient injuries. This process led to the drafting of an original software design that implemented a nursing informatics tracking system. It has resulted in significant savings of time and money and has far surpassed the accuracy, efficiency, and scope of the previous method. This article presents an overview of the design process. PMID- 10177020 TI - The trillion dollar health care tab. PMID- 10177019 TI - The Health Insurance Portability and Accountability Act: encouraging health care reform. PMID- 10177021 TI - Tangles in an expanded Medicare net. PMID- 10177022 TI - Purchasing lessons from the feds. PMID- 10177023 TI - A behind-the-numbers look at rising Rx costs. AB - Spending more on drugs saves health care dollars, by heading off complications of chronic disease. That was the conventional wisdom--until spiraling costs convinced cost-conscious employers to take a closer look at the pharmacy budget. PMID- 10177024 TI - Standouts in the benefits software parade. PMID- 10177025 TI - Zeroing in on costly chronic disease. PMID- 10177026 TI - Cardiac rehab: movement and medication. PMID- 10177027 TI - A health law score card. PMID- 10177028 TI - Data watch. The (flex) benefit not taken. PMID- 10177029 TI - Inhabiting different worlds: how can research relate to practice? PMID- 10177030 TI - Quality of care in developing countries: relevance and reality. PMID- 10177031 TI - Understanding the relation between research and clinical policy: a study of clinicians' views. AB - OBJECTIVES: To describe the relation between research evidence and local obstetric unit policy for specific areas of care and to explore clinicians' views about the reasons for any discrepancies identified. DESIGN: An independent evaluation of a project undertaken by a district maternity services liaison committee (MSLC) to promote evidence based maternity care in specific areas of care. The evaluation involved a combination of qualitative methodologies including documentary analysis, non-participant observation, semi-structured interviews, and self completed open ended questionnaires. SETTING: One English health district with three obstetric units. MAIN MEASURES: Congruence between unit policies and research evidence in specific areas of care. Views expressed by unit staff concerning the reasons for any discrepancies identified. Consistency between staff views within and between units. Unit attitudes to modification of discrepant policies and details of any subsequent changes made. RESULTS: Of the 12 unit policies considered, seven were consistent with the research evidence. In all cases in which unit policy did not reflect the evidence, provider unit staff thought that the differences were justified. In several cases there were substantive differences of view between staff in different units. No differences of view were expressed between staff in the same unit. There were three different types of concern about the research evidence and the problems of using it as a basis for deciding unit policy. These were: concerns about the adequacy or completeness of the evidence; concerns about the applicability of the evidence in the local setting; and concerns about local capacity to act on the evidence. At the time of the project, none of the units expressed any intention of modifying the policies under discussion. Subsequently, two of them did make changes of this sort. CONCLUSION: The results suggest the need for further research to ascertain what factors may produce such varying assessments of the validity and adequacy of particular sets of research findings as were found between clinicians in this study and to understand what considerations other than views about evidence may affect decisions to alter clinical policy. IMPLICATIONS: When clinicians have clear reasons for not following research evidence, two contrasting responses are possible. One is to take the view that the clinicians are mistaken, and seek to change their attitudes or persuade them to change their behaviour regardless of their views. An alternative response is to accept that the concerns they express may be legitimate and consider how their doubts may be addressed. The challenge is to recognise which response is preferable in any particular situation. PMID- 10177032 TI - What are hospitals doing about clinical guidelines? AB - OBJECTIVES: To assess the attitudes of senior hospital staff towards clinical guidelines, and to ascertain the perceived extent and benefits of their local use; to identify those hospitals with current or planned future written strategies for the systematic development of clinical guidelines, and the staff responsible for leading them; and to establish the essential elements of existing strategies, and the methods used to ensure the proper development, dissemination, implementation, and evaluation of local guidelines. DESIGN: Cross sectional survey. PARTICIPANTS: Senior staff of 270 acute hospitals in the United Kingdom (response rate 202/270 (75%)) in 1995. RESULTS: 197/199 (99%) of respondents thought that clinical guidelines were a good idea, and 176/196 (90%) were aware of some guideline activity occurring within their hospitals. The most important benefits of local guideline activity were increased healthcare efficiency and effectiveness, greater consistency of treatment, and team building. 174/194 (90%) of respondents were in favour of the development of a readily accessible national repository of evidence-based clinical guidelines. 38/201 (19%) of respondents had a clinical guidelines strategy and a further 91/201 (45%) said that they had plans to develop one in the near future. The need to improve clinical outcomes was most often reported as the reason for developing a strategy. Medical directors most commonly had formal responsibility to lead the strategy, but someone without formal responsibility ran the operation in half the hospitals. Only 18/36 (50%) of strategies gave advice on the development of guidelines; and only a few strategies made explicit statements on which clinical services to target for guideline development, or the methods to be used for their validation and promotion. Some strategies lacked explicit statements on methods to monitor adherence, routine review, and update of guidelines. Internal literature searches (29/31 (94%)), the use of national guidelines (29/32 (91%)), local consensus conferences (28/32 (88%)), and peer group review (21/24 (88%)) were the most popular methods of validation used in hospitals with a strategy. Methods used to promote the dissemination, implementation, and evaluation of clinical guidelines included clinical audit (31/32 (97%)), peer review (25/30 (83%)), continuing education (23/29 (79%)), targeting of opinion leaders (17/26 (65%)), use of structured case notes (14/31 (45%)), patient mediated interventions (9/26 (35%)), and patient specific reminders (8/26 (31%)). CONCLUSIONS: Most senior hospital staff have a favourable attitude towards clinical guidelines. Most hospitals are undertaking some guideline activity, but few seem to be doing so within a locally agreed hospital wide strategy in which guideline development, dissemination, implementation, and evaluation are systematically considered. Many of the current methods used to validate guidelines locally are inadequate. Evidence-based clinical guidelines should be developed nationally, leaving hospitals to focus their energies on the local adaptation, dissemination, implementation, and evaluation of such guidelines. Only in this way will local guidelines achieve their full potential to improve clinical care and patient outcomes. PMID- 10177033 TI - Evaluation of joint medical and nursing notes with preprinted prompts. AB - OBJECTIVE: To determine the views of doctors and nurses about two recent innovations in the structure of case notes: the use of preprinted prompts and the use of joint medical and nursing notes. DESIGN: Questionnaire survey of all doctors and nurses working on the children's wards. SETTING: Children's wards in a district general hospital. MAIN OUTCOME MEASURES: Whether or not respondents wanted to return to traditional notes; positive and negative aspects of the two innovations. RESULTS: There was an 81% response rate. 45 of 48 respondents (94%) did not want to return to traditional notes. Positive features of joint notes that were identified included: promotes team work (21/48 respondents), improves access to information (14/48), and reduces duplication (14/48). Negative features included uncertainty about identity of writer (8/48) and incompletely filled in sheets (7/48). Positive features of preprinted prompts included: less information omitted (29/48), easier to read and find information (28/48), and quicker to write (21/48). Negative features included: not enough space (19/48) and clerking too mechanical (16/48). CONCLUSION: Advantages of both innovations outweighed their disadvantages to the extent that only three out of 48 respondents wanted to return to writing traditional notes. PMID- 10177034 TI - Readmission rates are associated with differences in the process of care in acute asthma. AB - OBJECTIVE: To test the hypothesis that sustained differences in readmission rate for acute asthma were associated with variations in clinical practice. DESIGN: Data were collected by retrospective review of case notes, using the criteria recommended by the British Thoracic Society. SETTING: Two city National Health Service (NHS) hospitals that had recorded a sustained difference in readmission rate for acute asthma. SUBJECTS: A random sample of 50 from each hospital, selected from all 16-44 year old patients discharged in 1992 with acute asthma (ninth revision of the international classification of diseases (ICD-9) 493). RESULTS: Hospital A had a lower readmission rate than hospital B. The sample groups were similar for age, sex, deprivation of area of residence, and severity of episode. Systemic corticosteroids were given early more often (p = 0.02) and oral corticosteroids were prescribed at discharge more often (p = 0.04) in hospital A. When a short course of oral corticosteroids was prescribed the duration stated was longer (p = 0.02) and inhaled corticosteroids were started or the dose increased more often (p = 0.02) in hospital A. CONCLUSIONS: These results support the hypothesis that differences in readmission rates for acute asthma are associated with variations in clinical practice. Sustained variation in readmission rates is an outcome of health care, for acute asthma. The findings also support audit of the process of hospital asthma care as a proxy for outcome. PMID- 10177035 TI - Hospital beds and how to survive them. PMID- 10177036 TI - Pragmatic model of patient satisfaction in general practice: progress towards a theory. AB - A major problem in the measurement of patient satisfaction is the lack of an adequate theory to explain the meaning of satisfaction, and hence how it should be measured and how the findings are interpreted. Because of the lack of a fully developed theory, when developing patient satisfaction questionnaires for use in general practice, a simple model was used. This model was pragmatic in that it linked together empirical evidence about patient satisfaction without recourse to more general social or psychological theory of behaviour, other than to define satisfaction as an attitude. Several studies with the questionnaires confirm in general the components of the model. However, the importance of personal care had not been sufficiently emphasised, and therefore the model has been revised. It can now serve as a basis for future research into patient satisfaction, in particular as a stimulus for investigating the links between components of the model and underlying psychological or other behavioural theories. PMID- 10177037 TI - Healthy promotion: changing behaviour towards evidence-based health care. PMID- 10177038 TI - Putting continuous quality improvement into accreditation: improving approaches to quality assessment. AB - The accreditation systems of the United States, Canada, and Australia have been restructured to reflect the adoption by health services of the industrial model of continuous quality improvement. The industrial model of quality makes assumptions about management structures and the relation of process to outcome which are not readily transferable to the assessment of quality in health care. The accreditation systems have therefore had to adapt the principles of continuous quality improvement to reflect the complex nature of health service organisations and the often untested assumptions about the relation between process and outcome. PMID- 10177040 TI - Compression therapy for venous leg ulcers. PMID- 10177039 TI - Mental health promotion in high risk groups. PMID- 10177041 TI - The backlash against HMOS. PMID- 10177042 TI - When the fine print changes. What should you do if your HMO cuts back on benefits? PMID- 10177044 TI - Variations in healthcare measures by insurance status for patients receiving ventilator support. AB - OBJECTIVE: To examine differences in healthcare delivery by expected health insurance status for hospitalized patients in diagnosis-related group (DRG) 475, respiratory system diagnoses requiring intubation and continuous ventilator support. DESIGN: A survey, derived from the Healthcare Cost and Utilization Project interstate database, of the care delivered to 21,149 adult patients in DRG 475 and hospitalized in one of 718 acute-care hospitals in nine states. Multivariate analysis was performed, controlling for demographic and hospital factors. RESULTS: Patients insured by health maintenance organizations (HMOs) had significantly lower rates of inpatient mortality (odds ratio [OR], 0.84; 95% confidence interval [CI95], 0.73-0.96), 14.3 more procedures performed (CI95, 11.5-17.2), 7.0% shorter hospitalizations (CI95, 12.5-1.6), and 5.2% higher charges (CI95, 0.4-10.0) than those with traditional private insurance. In addition, patients insured by Medicaid had 3.5% more procedures performed (CI95, 1.6-5.4), 10.4% longer lengths of hospitalization (CI95, 6.7-14.0), and 13.8% higher charges (CI95, 10.6-17.0) than those with traditional private insurance. Finally, the uninsured had significantly lower rates of inpatient mortality (OR, 0.87; CI95, 0.77-0.99), 8.5% more procedures performed (CI95, 6.0-11.1), 16.5% shorter hospitalizations (CI95, 21.5-11.6), and 13.4% lower charges (CI95, 17.8 9.0) than those with traditional private insurance. CONCLUSION: Variations in healthcare measures by insurance status for this DRG emphasize the importance of more careful analyses of insurance categories as a determinant of healthcare access and outcomes. Expected insurance status was an independent predictor of cost. Private insurance and HMO populations differed significantly in outcome and cannot be considered equivalent. PMID- 10177043 TI - A clinical decision process model for evaluating vancomycin use with modified HICPAC guidelines. Hospital Infection Control Practice Advisory Committee. AB - OBJECTIVE: The objective of this study was to evaluate a clinical decision process model for the appropriateness of vancomycin use, using modified Hospital Infection Control Practice Advisory Committee (HICPAC) guidelines. DESIGN: All nondialysis vancomycin use was reviewed using the retrospective chart review method. The HICPAC guidelines were modified to distinguish between documented and suspected infections and appropriateness of vancomycin use initially and after 3 days of therapy. Data were collected on both vancomycin-use orders and vancomycin use days. SETTING: 446-bed health maintenance organization teaching hospital. RESULTS: 758 uses of vancomycin from 1993 through 1995 were evaluated using the modified HICPAC guidelines. Initial use was appropriate in 71% of the cases, with 26% used for documented infections and 74% for suspected infections. Of the 536 orders of initial appropriate use, 176 courses of treatment with vancomycin were discontinued appropriately within 3 days. Ongoing use evaluation after 3 days revealed appropriate use in 45%, inappropriate ongoing use in 25%, and empirical ongoing use in 30% of the cases. There were adequate clinical or laboratory data available in 70% of cases after 3 days to discontinue vancomycin or to reclassify from suspected to documented infections or indications. Vancomycin-use evaluation solely after 3 days would not have disclosed 537 initial inappropriate vancomycin use days, which were 44% of the total inappropriate use days. CONCLUSIONS: Comprehensive evaluation of vancomycin use with HICPAC guidelines should include a modification to encompass initial and 3-day reevaluation, because most initial use is for suspected, and not documented, infections. HICPAC guidelines do not address the issues of differentiating suspected from documented infection indications or ongoing empirical use. The clinical decision process model is a framework for documentation and data collection for use evaluation and addresses issues not covered in HICPAC vancomycin guidelines. This model could be used by other medical centers for evaluation of vancomycin or other antibiotics. PMID- 10177045 TI - The use of total quality improvement techniques to determine risk factors for back injuries in hospital workers. AB - OBJECTIVE: To identify the risk factors for back injuries among hospital employees using quality-management techniques. METHODS: Data from employee-health records were collected from 1993 to 1995 on a total of 100 back injuries. The data were reviewed retrospectively for risk factors using quality-management techniques. RESULTS: We identified two major categories of risk factors: administrative and environmental. The five most common causes of back injuries were as follows: inadequate or lack of proper training in body mechanics, not enough help in lifting, the load being lifted was too heavy, poor condition of the floor surface (slippery or uneven), and the patient was unable to help. The Workers' Compensation costs for the 100 back injuries was in excess of $600,000. CONCLUSION: Based on these findings, several preventive strategies are identified. PMID- 10177046 TI - Predictors of functional status in patients in a chronic-care facility. AB - OBJECTIVE: To identify those factors correlated with functional status levels (activities of daily living and mobility) in a chronically ill population in long term care. METHODS: Retrospective chart reviews were conducted over 3 months for information associated with functional status on all 220 patients in an urban extended-care facility. Independent variables included demographic variables, presence of selected medical conditions, current mental status, and baseline functional status on admission. Mean length of stay was 39 months. Multivariate analysis was performed to identify predictors of functional status. RESULTS: Factors correlated with functional status levels for 217 patients included total score on admission functional status and total score on current mental status (both P < .0001). There were no significant differences in mean scores of total functional status by medical problem, age, gender, length of stay, condition, level of care, presence of infection, or use of psychotropic drugs. PMID- 10177047 TI - Patient satisfaction--what's new? AB - The past decade has seen increased attention focused on patient satisfaction; however, there are no universally accepted means of measuring patient satisfaction. A review of recent studies reveals some interesting findings. Satisfaction has been shown to be related directly to patient expectations; however, intuitive physician judgments about patient expectations may not correlate with true expectations. Further, patient satisfaction may not correlate with the level of clinical outcome. Recent advances have changed our understanding of this complex field. PMID- 10177048 TI - Adverse selection at academic health centers. AB - Market influences are placing many academic health centers (AHCs) in financial distress. Competitive forces threaten the core missions of AHCs, principally because of selective contracting, which has introduced price competition to medical care. This manuscript discusses the issue of adverse selection for AHCs, the probability that patients with higher levels of illness severity seek care at, or are referred to, AHCs. AHCs are particularly vulnerable to adverse selection because of their prominence as referral centers, their specialty composition, research expertise, and the socioeconomic status of patients located proximal to their centers. The adverse selection of AHCs increases the likelihood that health plans will trim their networks to exclude them. Health plans may still contract with AHCs for tertiary care only, but this will only worsen the adverse selection at AHCs. PMID- 10177049 TI - Where's the evidence? How to find clinical-effectiveness information. AB - The National Health Service Centre for Reviews and Dissemination is the sibling organization to the UK Cochrane Centre, which is part of the Cochrane Collaboration. The two centers form part of a UK-government-funded initiative to provide information for research-based health care in a variety of ways, ranging from databases to printed publications. The new evidence-based culture in health care presents new challenges to healthcare professionals, who have discovered that systematic reviews and evidence-based guidelines are useful tools in the struggle to stay abreast of published research. However, the numbers of reviews and guidelines are increasing, and keeping track of them presents a new problem. Keeping up-to-data with research is a continuing issue because of constraints in time, resources, and poor search interfaces. There also are challenges in acquiring or developing skills, such as information retrieval to locate research, as well as critical appraisal abilities to evaluate research. However, there are many existing resources that can supply information on clinical effectiveness and many developing services that are trying to provide access to research information in timely and intuitive ways. PMID- 10177051 TI - CASPE accreditation--the day of reckoning. Aberdeen Royal Hospitals NHS Trust. PMID- 10177050 TI - Staphylococcus aureus bacteremia: the cost-effectiveness of long-term therapy associated with infectious diseases consultation. AB - OBJECTIVE: To investigate the cost-effectiveness of long-term therapy for Staphylococcus aureus bacteremia and to determine if an infectious diseases consultation affected the duration of therapy. METHODS: A decision analysis was performed based on data from the literature. To determine if consultation was related to therapy duration, a retrospective cohort study was performed using tightly matched pairs. RESULTS: The excess cost per life saved by long-term antibiotics was $500,000. The excess cost per life-year saved was $18,000. Nine pairs were matched. Patients who received consultation were more likely to receive long-term therapy than controls (median 41 days vs 15 days for controls, P = .04). CONCLUSIONS: The estimated cost per life-year saved by long-term therapy was similar to other accepted medical interventions. Infectious diseases consultation can encourage prolonged duration of antibiotic therapy for S aureus bacteremia. PMID- 10177053 TI - Sponsored patient information. PMID- 10177052 TI - Role of International Classification of Diseases in medical record management. AB - The Medical Record is the major source of Health information. Therefore, it is necessary to maintain good patient records by documenting all the required information, e.g. history, physical examination, progress notes, investigations, treatment including surgical procedures, complete diagnosis and end result, etc., as per the guidelines stated in the International Classification of Diseases published by World Health Organisation. If the documentation is accurate and complete, the health care information could be obtained and classified accurately and completely according to International Classification of Diseases published by WHO. Hence, International Classification of Diseases plays an important role in managing good medical records. PMID- 10177054 TI - The new NHS number. PMID- 10177055 TI - Mental health records in Scotland: some considerations associated with long-term retention. PMID- 10177056 TI - Medical devices; classification/reclassification; restricted devices; analyte specific reagents--FDA. Final rule. AB - The Food and Drug Administration (FDA) is issuing a final rule to classify/reclassify analyte specific reagents (ASR's) presenting a low risk to public health into class I (general controls), and to exempt these class I devices from the premarket notification (510(k)) requirements. FDA is classifying/reclassifying ASR's used in certain blood banking tests as class II (special controls) because general controls are insufficient to provide a reasonable assurance of safety and effectiveness. Finally, ASR's presenting a high risk are being classified or retained in class III (premarket approval). FDA is also designating all ASR's as restricted devices under the Federal Food, Drug and Cosmetic Act (the act), and establishing restrictions on their sale, distribution and use. The scope of products covered by this final rule includes both pre- 1976 devices, which have not been previously classified, as well as post- 1976 devices, which are statutorily classified into class III. The intent of this final rule is to regulate these pre- and post-1976 devices in a consistent fashion. This rulemaking does not affect requirements for reagents that are subject to licensure under the Public Health Service Act (the PHS Act). This rulemaking also does not affect reagents sold to nonclinical settings, including those reagents sold as components to manufacturers of cleared or approved in vitro diagnostic tests. PMID- 10177057 TI - Medicare and Medicaid programs; quarterly listing of program issuances--second quarter 1997--HCFA. Notice. AB - This notice lists HCFA manual instructions, substantive and interpretive regulations, and other Federal Register notices that were published during April, May, and June of 1997 that relate to the Medicare and Medicaid programs. It also identifies certain devices with investigational device exemption numbers approved by the Food and Drug Administration that may be potentially covered under Medicare. Section 1871(c) of the Social Security Act requires that we publish a list of Medicare issuances in the Federal Register at least every months. Although we are not mandated to do so by statute, for the sake of completeness of the listing, we are including all Medicaid issuances and Medicare and Medicaid substantive and interpretive regulations (proposed and final) published during this time frame. PMID- 10177058 TI - Respiratory protection--OSHA. Final rule; request for comment on paperwork requirements. AB - This final standard, which replaces the respiratory protection standards adopted by OSHA in 1971 (29 CFR 1910.134 and 29 CFR 1926.103), applies to general industry, construction, shipyard, longshoring, and marine terminal workplaces. The standard requires employers to establish or maintain a respiratory protection program to protect their respirator-wearing employees. The standard contains requirements for program administration; worksite-specific procedures; respiratory selection; employee training; fit testing; medical evaluation; respiratory use; respirator cleaning, maintenance, and repair; and other provisions. The final standard also simplifies respirator requirements for employers by deleting respiratory provisions in other OSHA health standards that duplicate those in the final standard and revising other respirator-related provisions to make them consistent. In addition, the standard addresses the use of respirators in Immediately Dangerous to Life or Health (IDLH) atmospheres, including interior structural firefighting. During interior structural firefighting (an IDLH atmosphere by definition), self-contained breathing apparatus is required, and two firefighters must be on standby to provide assistance or perform rescue when two firefighters are inside the burning building. Based on the record in this rulemaking and the Agency's own experience in enforcing its prior respiratory protection standards, OSHA has concluded that compliance with the final rule will assist employers in protecting the health of employees exposed in the course of their work to airborne contaminants, physical hazards, and biological agents, and that the standard is therefore necessary and appropriate. The final respiratory protection standard covers an estimated 5 million respirator wearers working in an estimated 1.3 million workplaces in the covered sectors. OSHA's benefits analysis predicts that the standard will prevent many deaths and illnesses among respirator-wearing employees every year by protecting them from exposure to acute and chronic health hazards. OSHA estimates that compliance with this standard will avert hundreds of deaths and thousands of illnesses annually. The annual costs of the standard are estimated to be $111 million, or an average of $22 per covered employee per year. PMID- 10177059 TI - Medicare program; limit on the valuation of a depreciable asset recognized as an allowance for depreciation and interest on capital indebtedness after a change of ownership--HCFA. Final rule with comment period. AB - This final rule with comment period revises the Medicare provider reimbursement regulations relative to allowable costs and sets a limit on the valuation of a depreciable asset that may be recognized in establishing an appropriate allowance for depreciation and for interest on capital indebtedness after a change of ownership that occurs on or after December 1, 1997. These provisions apply to providers that are reimbursed on the basis of reasonable costs. This change implements the mandate in section 4404 of the Balanced Budget Act of 1997 (Pub. L. 105-33). PMID- 10177060 TI - Indian Health Service. Statement of mission, organization, functions and delegation of authority. PMID- 10177061 TI - Medicare program; physicians' referrals; issuance of advisory opinions--HCFA. Final rule with comment period. AB - This final rule with comment period incorporates into HCFA's regulations the provisions of section 1877(g)(6) of the Social Security Act (the Act), as added by section 4314 of the Balanced Budget Act of 1997. Section 1877(g)(6) requires that the Secretary issue written advisory opinions to outside parties concerning whether the referral of a Medicare patient by a physician for certain designated health services (other than clinical laboratory services) is prohibited under the physician referral provisions in section 1877 of the Act. Section 1877 not only prohibits certain referrals under the Medicare program, but also affects Federal financial participation payments to States under the Medicaid program for medical assistance consisting of designated health services furnished as the result of certain physician referrals. This final rule sets forth the specific procedures HCFA will use to issue advisory opinions. PMID- 10177062 TI - Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships--HCFA. Proposed rule. AB - This proposed rule would incorporate into regulations the provisions of sections 1877 and 1903(s) of the Social Security Act. Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services under the Medicare program, unless certain exceptions apply. The following services are designated health services: Clinical laboratory services. Physical therapy services. Occupational therapy services. Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services. Radiation therapy services and supplies. Durable medical equipment and supplies. Parenteral and enteral nutrients, equipment, and supplies. Prosthetics, orthotics, and prosthetic devices and supplies. Home health services. Outpatient prescription drugs. Inpatient and outpatient hospital services. In addition, section 1877 provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for designated health services furnished under a prohibited referral, nor may the Secretary make payment for a designated health service furnished under a prohibited referral. Section 1903(s) of the Social Security Act extended aspects of the referral prohibition to the Medicaid program. It denies payment under the Medicaid program to a State for certain expenditures for designated health services. Payment would be denied if the services are furnished to an individual on the basis of a physician referral that would result in the denial of payment for the services under Medicare if Medicare covered the services to the same extent and under the same terms and conditions as under the State plan. This proposed rule incorporates these statutory provisions into the Medicare and Medicaid regulations and interprets certain aspects of the law. The proposed rule is based on the provisions of section 1903(s) and section 1877 of the Social Security Act, as amended by section 13562 of the Omnibus Budget Reconciliation Act of 1993, and by section 152 of the Social Security Act Amendments of 1994. PMID- 10177063 TI - Revised diphtheria, tetanus, and pertussis (DTP/DTaP/DT) vaccine information materials--CDC. Notice. AB - Under the National Childhood Vaccine Injury Act (42 U.S.C section 300aa-26), the CDC must develop vaccine information materials that health care providers, either public or private, are required to distribute to patients/parents prior to administration of each dose of specific vaccines. On September 13, 1996, CDC published a notice in the Federal Register (61 FR 48597) seeking public comment on proposed revision of the diphtheria, tetanus, and pertussis vaccine information materials to reflect Food and Drug Administration (FDA) licensure of acellular pertussis vaccine combined with diphtheria and tetanus toxoids (DTaP) for administration to infants as young as two months of age. The 60-day comment period ended on November 12, 1996. Following review of the comments submitted and consultation as required under the law, CDC has finalized the revised diphtheria, tetanus, and pertussis vaccine information materials. Those final materials are contained in this notice. PMID- 10177064 TI - Looking for a waiver. PMID- 10177065 TI - Buying a healthcare information system. AB - Replacing an antiquated computer system with state of the art equipment and software is a lengthy, at times frustrating, and never an easy decision. At Wesley Woods Center on Aging, Atlanta, an integrated provider of healthcare for the elderly affiliated with Emory University, the process consumed more than two and a half years. This article takes the reader through the entire process, from the initial decision to replace an existing system, through the final purchase and installation. It looks candidly at the problems that were encountered, including turnover among key personnel, difficulties with involving all of the user groups, changes in the technology and coordination with the University. The lessons Wesley Woods learned in its experience can be of benefit to any healthcare facility contemplating an information system change. PMID- 10177066 TI - Enterprise-wide automation in integrated health care delivery systems--has it finally turned the corner? AB - During the past decade, the healthcare industry has seen a marked expansion of networked delivery. The norm is no longer a stand-alone hospital, but an "Integrated Healthcare Delivery System," in which a healthcare provider may offer services from acute care, ambulatory, longterm and home health care. Along with the IHDS comes the need to integrate the vast amount of information necessary to operate the network and service the patients. This article looks at the findings of a survey of IHDS information usage and needs. PMID- 10177067 TI - Beware the 'slippery slope' of granting exceptions. PMID- 10177068 TI - Your Year 2000 compliance problem may be embedded in a patient. PMID- 10177069 TI - Total product information automation will let healthcare industry catch up. PMID- 10177070 TI - Backdoor reform. PMID- 10177071 TI - The future today: your mission, should you choose to accept it.... PMID- 10177072 TI - Isn't it time to reinvent materials management? PMID- 10177073 TI - Inova Fairfax Hospital goes wireless to improve services. AB - The advent of the wireless technology has brought new communications opportunities to healthcare facilities. A wireless phone system has allowed key employees to stay in touch at Inova Fairfax Hospital in Virginia, saving countless hours compared to traditional beeper systems, as well as saving money in reduced costs and improved efficiency. PMID- 10177074 TI - New insights into old theories: contracting relationships and the separation of powers. AB - The continual frustration expressed in the literature about contracting is usually placed in the frame of political economy, contract regimes or interorganizational behavior. This article proposes that two conceptual omissions in the literature, an understanding of the separation of powers and the acknowledgment of different types of contracting situations, can complement the contracting literature. The article describes the author's observation of the contracting process from a study of four federal contracting situations under the Circular A-76 process and compares these observations with examples of state contracting of social services. Recommendations include recognition of the value configurations surrounding governmental processes and types of contracting as an aid to improving contracting management techniques. PMID- 10177075 TI - Health care workers' AIDS attitudes and willingness to provide care--India. AB - Although AIDS is a world-wide pandemic, relatively little has been published on health care workers' attitudes and intentions to provide AIDS care outside of the U.S. This is a critical omission concerning countries such as India which is predicted to have tremendous increases in AIDS cases. Such information is important for health care administrators attempting to cope with disease transmission on a global level. The present research explored Indian health care workers' attitudes, knowledge, and willingness to provide AIDS care. A majority of those in the sample indicated a willingness to care for patients with AIDS. These intentions, however, were not predicted by health care workers' attitudes or knowledge of the disease. PMID- 10177076 TI - Adoption of a time-based competition paradigm into the health care industry. AB - Market and regulatory pressures are requiring health care organizations to find new ways to compete. This article introduces the concept of time-based competition, a strategy adopted by firms in the manufacturing sector to strengthen their competitive positions, as a new strategy for health care organizations. The Just-in-Time technique and set-up time reduction activities are used to demonstrate the adoption of this paradigm by health care organizations. A case study comparing the movement of elderly patient through the health care delivery system under traditional and time-based competition practices is used to illustrate gains from adopting the new paradigm. PMID- 10177077 TI - A nursing response to the needs of the elderly. AB - The aging phenomenon, a mark of contemporary society, has underscored the need to maintain and improve the health status of the elderly as well as their quality of life and to prevent their institutionalization. In a response to this need, the Foundation of the New York State Nurses Association has designed a unique and comprehensive health promotion program based on the cooperative efforts of volunteer nurses and consumers which is addressed to the well and frail elderly living in the community. This article discusses the various facets of the initial establishment of the process. More specifically, it focuses on the needs of the target population, the structure of the program, its curriculum, an evaluation comparing this effort with others, and the advantages accruing to the nursing profession. PMID- 10177078 TI - Improving service delivery: provider perspectives on building community-based systems of care. AB - This article examines the views of service providers toward different public policy efforts to improve service delivery to elders requiring multiple services from an array of organizations. The authors examine the relationship between provider assessments of the adequacy of their community-based systems of care and community resource levels, coordination strategies, and client characteristics. Findings, based on responses from managers of programs serving older adults (n = 250) to a mailed survey, were that two-thirds (69.4%) evaluated their service delivery systems as adequate or better. A regression model used to explain system adequacy indicated that 22% of the variance was accounted for by community resource level, information and service availability, attention to specific need clients, and percentage of minority clients served by the respondents' programs. Findings suggest that community resource level appears to be an important factor in respondents' evaluation of system adequacy. While respondents indicated that improved coordination could enhance their efforts to deliver services, this strategy was not one they favored in improving their community-based system of care. Instead, they preferred strategies which expanded or improved the services that were available. PMID- 10177079 TI - An empirical comparison of rural and urban safety-net hospitals. AB - This study compares the characteristics of rural hospitals with urban safety-net hospitals and with "other urban hospitals" (non-teaching, non-safety-net urban hospitals that provide mainstream care in the United States). The objective is to examine if there are similarities between rural and urban safety-net hospitals, both of which serve underserved populations. The authors also wish to study if there are areas in which rural and urban safety-net hospitals are closer together compared to "other" urban hospitals. Based on the results, some potential areas of cooperation between rural and urban safety-net hospitals are discussed. PMID- 10177081 TI - Employee job stress in the AIDS service organization: a study of personal and job factors. AB - This study examined employees' perceived job stress in a community-based AIDS service organization. The study reveals that: 1) these employees have a relatively low level of job stress and 2) their perceived job stress is correlated not to personal characteristics but to job-related factors, including job security, work/family conflict, and role ambiguity/conflict. Implications concerning the results of the study are discussed. PMID- 10177080 TI - Analyzing strategies for developing a prenatal health care outreach program to reduce social and cultural barriers. AB - Beginning in March, 1994, a multi-cultural, interdisciplinary team of health care providers at Rochester General Hospital in Rochester, New York, planned and implemented a prenatal outreach program in partnership with the Rochester YWCA. The purpose of the project is to increase access to obstetric and gynecological services for low-income African-Americans, Hispanic, and white women. The processes involved in developing an outreach intervention program, Opening Doors, are described and the conflicts that surfaced during the initial stages of program development are analyzed. The problems which occurred can be attributed to role boundary conflict and differences in philosophy regarding ethnicity and health behavior. Through interviews with the anthropologist on the management team and some changes in the overall structure of the program administration, resolution of the conflicts became possible. PMID- 10177082 TI - Laws, regulations will keep security pros busy. PMID- 10177083 TI - EDI. Dual deadlines challenge providers, payers. PMID- 10177084 TI - Managed care. Information systems get to the heart of the matter. PMID- 10177085 TI - Telemedicine. Lower costs could lead to a growth spurt. PMID- 10177087 TI - Standards groups. A guide to the leading organizations involved in setting standards for health care data. PMID- 10177086 TI - Associations. A guide to the major trade associations that deal with health care information technology issues. PMID- 10177088 TI - Health care information technology companies. PMID- 10177089 TI - Intranets grow, but need infrastructure to develop. PMID- 10177090 TI - Electronic records. Will doubters become believers in 1998? PMID- 10177091 TI - New data standards could ease integration efforts. PMID- 10177092 TI - Consumer Bill of Rights could force some major changes for MCOs. PMID- 10177093 TI - Big changes for diabetes management. Is your MCO missing the boat? PMID- 10177094 TI - How can an HMO make your customers happy? PMID- 10177095 TI - Ohio PHO succeeds in non-HMO market. PMID- 10177096 TI - Providers reap big savings with case management. PMID- 10177097 TI - Cancer center's unique case management program focuses on patients, payers; reduces LOS. AB - Case management--when every single one of your managed Medicare patients is high risk: Here's now the case management program at H. Lee Moffitt Cancer Center in Tampa, FL, controls utilization and improves outcomes using a unique model based on medical, financial, and psychosocial factors. PMID- 10177098 TI - Enrollment low? Disenrollment high? Just getting started? Focus group may help. AB - Low enrollment? High disenrollment? Patient complaints? Perhaps it's time to hold a focus group of your Medicaid or Medicare patients. Here are an industry expert's tips on using focus groups, plus a few success stories of providers and plans that have made important changes based on focus group comments. PMID- 10177099 TI - Capitation survey finds rising Medicare utilization, fluctuating payment rates for providers. AB - Data File: This month's column analyzes the results of the 1997 Capitation Survey conducted by the publisher of PSCR. While providers report ups and downs in Medicare PMPM rates from 1996 to 1997, utilization is clearly on the rise, signaling that providers need to beef up their medical management of resource intensive seniors. Here are the highlights, plus details on ordering the full report. PMID- 10177100 TI - Plans, providers experimenting with outbound call programs for Medicare risk seniors. AB - Putting a new spin on health care call centers: They've been used for commercial and Medicaid populations, but now plans and providers are testing the call center concept among their Medicare seniors. And while it may hold great promise for controlling utilization, there are big start-up costs and serious liability concerns. PMID- 10177101 TI - What are we going to do with all our surplus capacity? PMID- 10177102 TI - Health care organizations are listening to the newly-found voice of the consumer. PMID- 10177103 TI - Using wellness to gain market share. PMID- 10177104 TI - Evaluating the "emergency room in the chest". PMID- 10177105 TI - The future of hospital and health system governing boards depends on SUCCESS (Systems thinking, Understanding the environment, Customer focus, Communication, Effective decision making, Shared Values, Swift action). PMID- 10177106 TI - Who wants to be in the managed care business? PMID- 10177107 TI - Best healthcare project. Rehabilitation Institute of Chicago. Eva Maddox Associates. PMID- 10177108 TI - The heart of the matter. PMID- 10177109 TI - Fighting for his life. PMID- 10177110 TI - Teaching: the heart of leadership. PMID- 10177111 TI - The balanced CEO: a transformational leader and a capable manager. PMID- 10177112 TI - Leadership for a learning community. PMID- 10177113 TI - The emotionally competent leader. AB - Aristotle once challenged man "to be angry with the right person, to the right degree, at the right time, for the right purpose, and in the right way" (The Nicomachean Ethics). Daniel Goleman, Ph.D., a journalist for the New York Times, expands on this statement in his new book, "Emotional Intelligence." He defines emotional intelligence as the ability to rein in emotional impulses, to read another's innermost feelings and to handle relationships and conflict smoothly. This new model of intelligence puts emotions at the center of our aptitudes for living. Goleman asserts that these emotional aptitudes can preserve relationships, protect our health and improve our success at work. The following adaptation from "Emotional Intelligence" (Bantam Books, 1995) offers suggestions to managers and supervisors on how they can create a more cost-effective and healthier workplace for their employees by becoming more aware of their own emotional. intelligence. PMID- 10177114 TI - Learning leadership from history: a conversation with Doris Kearns Goodwin. Interview by Joe Flower. PMID- 10177115 TI - Power failure in management circuits. PMID- 10177116 TI - Navigating the rapids of collaborative governance. PMID- 10177117 TI - Improving professional satisfaction and effectiveness: a case study. PMID- 10177118 TI - Building on strength: how a Michigan community is increasing its "social capital". PMID- 10177119 TI - Organic strategy and the cellular organization. Part 1: Change has changed. PMID- 10177120 TI - Healthy chaos. PMID- 10177122 TI - Lessons in leadership. Keys to success from some of corporate America's best known leaders. AB - With the rapidity of change in the healthcare field, effective leadership is becoming increasingly important--for both the organizations and the people they serve. For insight on what makes a leader effective, Healthcare Executive looked to five well-known business leaders who have learned what it takes to lead and succeed in today's increasingly intricate business world. All agreed that good leadership is not the ability to analyze a balance sheet. Rather, it's the ability to manage the people side of the equation that makes a leader great and an enterprise successful. PMID- 10177121 TI - Leaders developing leaders at Wellmark. PMID- 10177123 TI - American College of Healthcare Executives. Professional policy statement. The role of the healthcare executive in a consolidation, merger, acquisition, or affiliation. November 1997. PMID- 10177125 TI - The mentor's cousin: the executive coach. PMID- 10177124 TI - Life in the middle. What it takes to succeed in middle management. AB - Under pressure from senior management to do more with less, middle managers are faced with the difficult task of reducing costs while improving processes and enhancing service. Meanwhile, as organizations flatten their hierarchies, many middle managers are assuming more responsibilities and supervising larger staffs with increasingly diverse needs and abilities. With demands from people both above and below them in the organization, middle managers would seem to be in a tough place. Yet many healthcare executives are finding success and career fulfillment as middle managers in today's healthcare environment. PMID- 10177126 TI - Physicians and compliance. PMID- 10177127 TI - The ethics of diversity. PMID- 10177128 TI - American College of Healthcare Executives. Ethics self-assessment. PMID- 10177129 TI - Provider-supplier partnerships. PMID- 10177130 TI - Benchmarking for success. PMID- 10177131 TI - Mission possible. You can create a strong post-merger culture. PMID- 10177132 TI - A struggle for control. Congress will consider regulation of health plans. PMID- 10177133 TI - Distance education. Advances in technology provide new--and sometimes better- ways to learn. PMID- 10177134 TI - Interview with ACHE's new chairman. Interview by Ann C. Bartling. PMID- 10177135 TI - Joint Commission on Accreditation of Healthcare Organizations. Corrections to the 1997-98 Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC). PMID- 10177136 TI - Managed behavioral health care accreditation program introduced. PMID- 10177137 TI - Standards revision permits some hospitals to have more than one medical staff. PMID- 10177138 TI - Sentinel events. In memory of Ben--a case study. PMID- 10177139 TI - Pennsylvania hospital continues to reduce seclusion and restraints. AB - Haverford State Hospital in Haverford, Penn, was one of three hospitals profiled in case studies of organizations that have made efforts to reduce their use of seclusion and restraints in the January/February 1996 issue of Perspectives. As a result of this article, the hospital received numerous requests for assistance and information about its practices from other health care organizations. Haverford State Hospital is a 300-bed inpatient care facility for the seriously and persistently mentally ill. During 1996, it continued its efforts to reduce the use of seclusion and restraints. In this On Site column, David W.P.Jones, assistant superintendent for quality assurance and risk management at Haverford State Hospital, shares information on the hospital's progress and provides some additional data. PMID- 10177140 TI - Quality oversight: a modest proposal. PMID- 10177141 TI - Evaluating credentials verification organizations: who is responsible? PMID- 10177142 TI - Joint Commission selects partners for Academy for Healthcare Quality. PMID- 10177143 TI - Most challenging long-term care standards: how to better comply. PMID- 10177144 TI - Missouri hospital establishes organizationwide approach to performance improvement. PMID- 10177145 TI - Long-term care resident and family responsibilities and rights. PMID- 10177146 TI - Putting health care's accountability pieces together. PMID- 10177147 TI - Revisions made to multi-hospital system survey process. PMID- 10177148 TI - Home care standard addresses competence assessment. PMID- 10177149 TI - The meaning of ambulatory care sensitive admissions: urban and rural perspectives. AB - Ambulatory care sensitive admission rates have been proposed as measures of access to health care. To test this, admissions for ambulatory care sensitive conditions (ACSC) were analyzed by multiple linear regression. The percentage of population below 200 percent of the federally defined poverty level, the percentage of black people, and the number of primary care providers per 1,000 population were found to be positively associated with ACSC admissions. Population density was negatively associated with ACSC admissions. There was no association between the location of the ZIP code in a health professional shortage area and ACSC admissions. Proximity to the hospital was found to be positively associated with ACSC admissions but was examined only in the most rural ZIP code group. The significant independent variables and the direction of their effects were the same across all ZIP code groups. The analysis suggests that high ACSC admissions may be a reflection of deficits in one or more of the following areas: primary care availability, accessibility, or appropriateness. In depth study is needed to determine the relative importance of these factors in a given geographical area. There also may be environmental and social factors external to the health care system that contribute to ACSC admissions. The findings suggest that ACSC should be used cautiously as a measure of primary care system needs, and in conjunction with other health, demographic, or service utilization data. PMID- 10177150 TI - Ambulatory care sensitive hospitalization rates in the aged Medicare population in Utah, 1990 to 1994: a rural-urban comparison. AB - The objective of this study is to compare the likelihood of hospitalization for conditions that are related to the adequacy and use of ambulatory health care services for Medicare beneficiaries residing in rural and urban regions in Utah. The Health Care Financing Administration's (HCFA) hospital discharge database (Utah hospitals: 1990 to 1994) was used to estimate hospitalization rates (with adjustment for out-of-state admissions) for ambulatory care sensitive conditions. Population estimates were obtained from HCFA beneficiary files. Regional hospitalization rates were obtained through ZIP code matching of the hospital discharge and beneficiary files. Medicare beneficiaries aged 65 and older residing in Utah during 1990 to 1994 are the subjects for the study. The main outcome measures include age and sex-adjusted hospitalization rates by region for the entire state and rate ratio estimates for nonurban regions. The results of the study show that Medicare beneficiaries residing in two rural-frontier regions were more likely than urban beneficiaries to be hospitalized for ambulatory care sensitive conditions. Rate ratio estimates were greater than 1.4 for both regions during the study period. These findings suggest a pattern of an increased burden of avoidable secondary complications and disease progression among Utah Medicare beneficiaries residing in some rural regions. This increased burden may be the result of limitations in the ambulatory care system, medical care provider supply, and/or beneficiary propensity to seek care. Variation in disease prevalence or hospital use patterns for these conditions also may be responsible for all or part of the observed variation in ambulatory care sensitive admission rates. PMID- 10177151 TI - Farm work is dangerous for teens: agricultural hazards and injuries among North Carolina teens. AB - Children who work in agriculture suffer more than 23,000 injuries and 300 fatalities on American farms every year. Using survey data collected from a random sample of working teens (ages 14 to 17) in North Carolina, the authors analyze the farm-based hazard exposure and injury experiences of teens who work on farms. The group of farmworking teens (N = 141) is 72 percent male, has a mean age of 16.6 years, and is, on average, in the 10th grade. The data show that teens working on farms in North Carolina are exposed to significant safety hazards throughout their farmworking careers. A majority of the respondents in this group of farmworkers reported exposure to tractors, large animals, all terrain vehicles, farm trucks, and rotary mowers, and more than one-third reported exposure to pesticides and tobacco harvesters. Common reported injuries include insect stings, cuts, burns, and falls. The researchers find that gender, age, and farmwork experiences are related to variations in types of hazards to which teens are exposed and in the types of injuries they suffer. These variables also are related to the overall complexity of the teens' farmwork experiences and the burden of injury endured by teens. PMID- 10177152 TI - The composition of rural hospital medical staffs: the influence of hospital neighbors. AB - The local supply of physicians has a strong influence on the availability and the quality of services provided by rural hospitals. Nevertheless, there are no published studies that describe the composition of rural hospital medical staffs and, in particular, the availability of specialists on these staffs. This study uses 1991 and 1994 survey data from rural hospitals located in eight states to describe the specialty composition and factors that influence the presence of specialists on rural hospital medical staffs. The results show a strong, positive association between the level of medical staff specialization in rural hospitals and the level of medical specialization of their closet rural neighbors, which suggests there is competition among rural hospitals based on the composition of the hospital medical staff. Analysis by specialty type, however, indicates that the degree of competition may differ for different types of specialists. PMID- 10177153 TI - Interdisciplinary student health teams: combining medical education and service in a rural community-based experience. AB - Several initiatives have been introduced over the years to address the maldistribution of health care professionals and to improve access to care for underserved rural populations. One of these is the sponsorship of community based, service-oriented teams comprised of students from various health disciplines. This study investigated extramural training as a complement to traditional hospital-based experiences. The specific objective of the study was to determine the extent to which the nation's medical schools combine training with a rural community-based experience in the form of an interdisciplinary student health team program. In the fall of 1994, a 32-item questionnaire was mailed to the chief academic or clinical affairs administrators of the nation's 126 allopathic medical schools. A total of 104 (82.5%) medical schools responded to the survey. Eighty-six of the respondents (82.7%) reported some type of rural training or public service activity; 22 (21.2%) acknowledged the sponsorship of an interdisciplinary student health team program. Small rural communities, those with populations of 5,000 or fewer, were the focus of 76 percent of the reporting programs. Nearly two-thirds of the reporting programs were located in the South, the region with the nation's lowest physician-to-population ratio. The nursing and medical professions were most frequently represented, although a wide range of disciplines were identified as participating on the student health teams. Activities of the teams included both ambulatory care and community outreach services. The majority of the programs used team-building exercises to enhance team effectiveness. Extramural training programs offer students a realistic examination of the social, cultural, economic, and political forces that influence both individual and community health. Rural community-based programs, such as interdisciplinary student health teams, should be valued because they can strengthen the link between the sponsoring institution's educational mission and its public service obligation. PMID- 10177154 TI - What is rural? A focus on urban influence codes. AB - Classification of U.S. counties into metropolitan and nonmetropolitan masks a high degree of variation in population size, density, and relationship between urban and rural areas. This article reviews the urban influence county coding system and illustrates how it applies to U.S. counties. The urban influence codes can be useful for analysis of rural health policy. PMID- 10177155 TI - Public-sector immunization coverage in 11 states: the status of rural areas. AB - This report uses county-level immunization data generated by state public health agencies to explore the rural-urban variation in the delivery of childhood immunizations in the public sector. Public health department-documented immunization coverage rates for 1995 were obtained from 882 counties in 11 states east of the Mississippi River. To assess the possible association between public health department immunization coverage rates and county rurality, descriptive statistics were calculated. A multiple regression model then was estimated. In all states except West Virginia, nonmetropolitan counties averaged higher completion rates than metropolitan counties. Consistent with the descriptive statistics, in the regression analysis nonmetropolitan counties had average immunization rates 2.47 percentage points higher than metropolitan counties, even when controlling for county socioeconomic characteristics. For the 11 states in the analysis, rural children immunized in the public sector had higher completion rates compared with urban children. These data reflect the dependence of rural families on the public health system and the potential for successful health care delivery through public clinics. As new health care systems are brought into rural areas, the success of this existing avenue for care must not be overlooked. PMID- 10177156 TI - Need cash for a new venture? Start here. PMID- 10177157 TI - The gravy train doesn't stop here anymore. PMID- 10177158 TI - Hey, HCFA, what'd you do with my money? PMID- 10177159 TI - Get your rookies to do more marketing. PMID- 10177160 TI - How I helped solve a baby's theft. PMID- 10177161 TI - Organized medicine's biggest fight--for survival. PMID- 10177162 TI - Hospitals. Managed care's trickle-down effect. PMID- 10177163 TI - Doctors' image. It's stronger, but pharmacists are still on top. PMID- 10177165 TI - A brochure that really sells your practice. PMID- 10177164 TI - How HMOs still gag doctors. PMID- 10177166 TI - Don't let a restrictive covenant send you to Siberia. PMID- 10177167 TI - History of medicine on the Internet: resources for librarians. AB - This paper offers an inventory of resources on the history of medicine on the Internet. Some sites are bibliographic; they supply book and journal citations. Some provide leads (or links) to more specific information, and some include full text articles or historical essays. Because this material is intended to furnish librarians with reference direction, more attention is given to bibliographic and "linked" sites. PMID- 10177168 TI - Addressing the health information needs of rural Missouri health care providers: an IAIMS assistant experience. AB - A one-year internship at the University of Missouri-Columbia offered an opportunity for a health sciences librarian to contribute to Integrated Advanced Information Management Systems (IAIMS) activities and take information management ideas back home. The IAIMS Assistant addressed information access issues. The Assistant helped to develop and administer a "Rural Provider Questionnaire" to assess the information needs of rural Missouri health care providers. The Health Sciences Library developed a Web page to bring together services and information resources in response to the perceived needs of health care providers associated with the Health Sciences Center. The article discusses the librarians' role in IAIMS initiatives. PMID- 10177169 TI - Training for the future (TF)2. PMID- 10177170 TI - Teaching health information Internet classes in the community: an opportunity for hospital library outreach and collaboration. PMID- 10177171 TI - Calling the feds. N.Y. partnership fingered by money-losing HMOs. PMID- 10177172 TI - Making the grade. U.S. to put foreign medical school graduates' skills to test. PMID- 10177174 TI - Protecting its interests. AMA may be backing off patients' rights legislation. PMID- 10177173 TI - CHA mulls dues update. Association might begin collecting from systems. PMID- 10177175 TI - PSO accord reached. Rules seek exclusion of weaker organizations. PMID- 10177176 TI - Do as they say ... AHA, AMA: disclosure needed for HMOs, not providers. PMID- 10177177 TI - Seating themselves. For-profit hospitals seek spot on JCAHO board. PMID- 10177178 TI - Formulary for trouble. Alliance, data firm in duel on drug-buying information. PMID- 10177179 TI - IRS rule might slow joint ventures. PMID- 10177180 TI - Balancing the scales. MedPAC urges Congress to look at Medicare fee variance. PMID- 10177181 TI - G-men. Federal resources are stacking up to tackle healthcare fraud. AB - Government fraud fighters are becoming as great a threat to providers as Treasury Agent Eliot Ness once was to mobster Al Capone. Federal agencies are packing heat with the False Claims Act in their fight against healthcare fraud and abuse. Last year the government collected more than $1 billion in fines and settlements. And observers say, for providers, the worst is yet to come. PMID- 10177182 TI - Top dollar incentives. CIOs retain top staff with generous salaries and perks. PMID- 10177183 TI - Entrepreneur's dream. Healthcare venture capital funding keeps record pace. PMID- 10177184 TI - ProxyMed wins financial services pact. PMID- 10177185 TI - Eyeing prospective payment parameters. PMID- 10177186 TI - Linking payment and quality. Quality measurement and prospective payment will hinge on electronic transmission of MDS data. PMID- 10177187 TI - Software supplier survey. PMID- 10177188 TI - Little greens for little green. From chip-and-putt to satellite dining: renovation projects on a limited budget. PMID- 10177189 TI - Going subacute. PMID- 10177190 TI - How satisfied are your residents? PMID- 10177192 TI - REITs (real estate investment trusts) may be the way to go. PMID- 10177191 TI - Effective strategies for lawful discipline. PMID- 10177193 TI - Don't be a D.R.I.P. PMID- 10177194 TI - Finding new strength. Exercising can help the frail elderly improve quality of life. PMID- 10177195 TI - www.ltc.pharmacy.com. Thanks to technology, pharmacists do more than just hand out drugs. PMID- 10177196 TI - You can take it with you. Wireless telephones promote efficiency and improved communication. PMID- 10177197 TI - What is the value of a voice? PMID- 10177198 TI - HMOs were the right Rx. Americans got lower medical costs--but also more worries. PMID- 10177199 TI - Using clinical laboratory specialists for in-service education: an important aspect of cross training. AB - Cross training of clinical laboratory professionals is on the rise because of hospital mergers and downsizing. Confusion and uncertainty during mergers, plus the added stress of cross training or learning a new "bench" can be overwhelming. Utilizing clinical laboratory specialists to provide continuing education as support for cross training laboratorians can be beneficial to both the laboratory employee and to management. This manuscript describes a model for continuing education support for laboratory personnel returning to the hematology "bench" after many years away from the high complexity level tests in this area of the clinical laboratory. The article addresses the cross-functioning role of laboratory specialists as educators as well as high-level bench technologists. This model for in-service education may serve several purposes, such as documentation for continuing education and personnel competency testing, while giving other laboratorians support for learning new tasks and enhancing their resume. PMID- 10177200 TI - Proactive detection of cryptosporidiosis by clinical laboratories. Working Group on Waterborne Cryptosporidiosis. AB - Laboratories can play a critical and preemptive role as a community's first line of surveillance in detecting waterborne outbreaks when they are aware of increased numbers of stool specimens and suspect or identify Cryptosporidium as the cause of illness. In addition, strong working relationships between clinical laboratories and local or state public health laboratories or agencies can facilitate a meaningful and rapid response related to potential outbreaks. Clinical and public health laboratories potentially play a key role in adding to the limited knowledge of the endemicity and ultimately the natural history of Cryptosporidium. This article addresses the early detection of waterborne outbreaks of cryptosporidiosis and some strategies that could be used to determine endemic levels of Cryptosporidium infections unrelated to outbreaks: to detect Cryptosporidium outbreaks by causes other than potable waterborne sources, e.g., food, surface or recreational waters, pets or farm animals, or sexual contact; or to determine outbreak or endemic levels of other infectious diseases. Strategies for clinical laboratories, which include proactive external and internal planning and a brief overview of laboratory methodologies as they relate to the detection of waterborne cryptosporidiosis, are included. PMID- 10177201 TI - Clinical laboratory employment and workload patterns. AB - Determining numbers and types of personnel to staff clinical laboratories is important to employers and educators. At 5-year intervals over the last 25 years, employment patterns among laboratory personnel have been examined in the 5 county Minneapolis-St. Paul (Twin Cities) area that includes 2.2 million persons, almost 50% of Minnesota's population. The 1995 survey was distributed to laboratory administrators of 28 major laboratories. All (100%) responded with information regarding personnel numbers and types. Data from 1995 were compared to that from 1970, 1980, and 1990. In 1970 there were 30 hospitals in the Twin Cities area with over 10,000 hospital beds; there were also 2 blood banks and 4 clinic laboratories. Altogether approximately 1300 laboratorians were employed. In 1980 there were still 10,000 hospital beds among 29 hospitals. However there were 8 other major employers of clinical laboratory personnel, including blood banks, clinics, and a reference laboratory. Between 1970 to 1980, the number of laboratory personnel almost doubled to 2500. The impact of managed care together with the Prospective Payment System, a government initiative of 1983, profoundly affected health care institutions and their personnel. By 1990 hospital mergers and closures reduced the number of Twin Cities hospitals to 20 with a total of 7500 beds. There were 11 blood banks, clinics, reference labs, and HMOs, including 3 reference (independent) laboratories. Laboratory employees increased slightly to 2600. By 1995, hospitals were reduced to 18 and hospital beds to fewer than 7000. The number of all personnel in the 28 laboratories surveyed rose to 2900. Between 1980 and 1995, 10 major hospitals closed or were converted to a different type of facility. Four hospitals merged to form 2 consolidated hospitals. Only 2 small suburban hospitals were built. However, despite the decrease in hospitals, laboratory personnel numbers increased after 1980, due largely to the emergence of 3 independent laboratories, as well as a result of an increase in overall testing volume. Seventy-five percent of the 28 administrators surveyed reported more laboratory testing in 1995 than in 1990. The number of laboratory personnel in the Minneapolis-St. Paul area has more than doubled in the past 25 years, despite the closure of 1/3 of the Twin Cities hospitals and efforts by the government to reduce laboratory testing. One reason for the expanded employment of laboratories and greater testing volume is the expansion of the laboratory itself--into new diagnostic technologies, as well as into new laboratory sites. PMID- 10177202 TI - Reproductive laboratory technology: an alternative career. AB - OBJECTIVES: Define the job description for reproductive laboratory technologist (RLT); describe the RLT laboratory setting; identify education level and certification of the respondents; establish level of job satisfaction and job security; determine if certification and position affect performance and job satisfaction; compare RLT job with any previous clinical laboratory position; and document education and training important for the position. SURVEY INSTRUMENT: A questionnaire was developed with questions targeted to answer objectives. SURVEY POPULATION: The questionnaire was mailed to a random sample of 300 non-physician members from the Reproductive Biology Professional Group and the Reproductive Laboratory Technology Group from membership lists provided by the American Society for Reproductive Medicine. STUDY POPULATION: 81 survey respondents. RESULTS: RLTs are mostly college-educated, certified and non-certified laboratory professionals, trained on the job for specialty work in andrology and assisted reproductive technology (ART). Position, but not certification, correlate with job performance and job satisfaction. Respondents describe the position of RLT as stressful, but very interesting, exciting, fulfilling, and secure. Respondents with previous clinical laboratory experience rated level of job satisfaction higher for the reproductive laboratory. The CLS curriculum is an excellent background for RLT. CONCLUSIONS: RLT is an exciting career alternative for CLSs. Newly formed laws and regulations, and the demand for more stringent regulation, will continue to increase the demand for certified CLSs for this position. Formal education and certification requirements are anticipated for RLT. The specialty is being incorporated in CLS training programs. PMID- 10177203 TI - Reverse transcriptase PCR and staging prostate cancer. AB - OBJECTIVE: To present a brief review of the diagnostic dilemma of staging prostate cancer and how a novel diagnostic technique, the reverse transcriptase polymerase chain reaction, is being used as an aid to better stage and manage the disease. DATA SOURCE: Research articles about prostate cancer and the reverse transcriptase polymerase chain reaction published in the last 5 years, as well as data gathered by the authors. STUDY SELECTION: Performed by the authors. DATA EXTRACTION: Performed by the authors. DATA SYNTHESIS: Prostate cancer is the most common cancer among men in the U.S. A wide variety of methods are used for the diagnosis; however, accurate staging of the disease to determine the most effective treatment is a problem. Because metastatic prostate cancer is routinely understaged, the reverse transcriptase polymerase chain reaction to identify prostate cancer cells in the circulatory system is becoming an important diagnostic aid for staging and monitoring the disease. It is analytically and clinically sensitive as well as specific. CONCLUSION: The reverse transcriptase polymerase chain reaction is a highly accurate aid in staging and monitoring prostate cancer. Its prognostic value, particularly when a small number of prostate cancer cells are detected in the circulatory system requires further long-term follow-up studies. PMID- 10177204 TI - Cryptosporidium and water: a public health handbook--1997. PMID- 10177205 TI - Emerging intestinal protozoa: a diagnostic dilemma. AB - Increasing isolation of Cryptosporidium, Cyclospora, and microsporidia from immunocompromised patients with severe diarrhea has prompted study of these organisms. Only recently recognized as human pathogens, they have also been associated with several waterborne outbreaks of diarrhea in immunocompetent individuals. Cryptosporidium and Cyclospora have been shown to be transmitted through fecally contaminated food and water. The mode of transmission for microsporidia is still unclear. While the life cycle and pathogenesis of Cryptosporidium are beginning to be understood, the microsporidia and Cyclospora are less well elucidated. The laboratory diagnosis of these protozoa is difficult. The routine ova and parasites screen does not include screening for them. Many microscopic methods, including wet mounts, modified acid-fast and trichrome stains, and immunofluorescence methods have been shown to be effective screening methods in the hands of experienced microscopists. Enzyme immunoassay and polymerase chain reaction methods also show promise. The proper identification of these pathogens rests with well-trained laboratory personnel. As appropriate treatment differs for each genus, communication between the laboratory and the physician is vital to the recovery of the patient. PMID- 10177206 TI - Still around and still dangerous: Giardia lamblia and Entamoeba histolytica. AB - The discovery of new infectious agents often overshadows the continuing impact and importance of well-established organisms. In the case of diarrheal disease, Entamoeba histolytica and its complications remain a major cause of morbidity and mortality in developing countries. Although it is also present in developing countries, Giardia lamblia is a primary cause of waterborne outbreaks of diarrhea in developed countries. Persons at risk of developing giardiasis in these countries include backpackers and campers who drink untreated stream water or persons who drink improperly treated municipal water containing infective cysts. Investigators have recently identified the mechanisms used by these organisms to colonize the intestinal tract and to cause disease. New methods of identification using immunologic principles have been added to the traditional microscopic methods of identification. PMID- 10177207 TI - Waterborne transmission of Cryptosporidium, Cyclospora and Giardia. AB - Waterborne transmission of Cryptosporidium, Cyclospora, and Giardia has been associated with numerous recent outbreaks of diarrheal disease. Epidemiologic evidence shows that many community-acquired infections originate from public water sources. Drinking water, even when chlorinated and filtered, has been implicated in several outbreaks. Cryptosporidium and Cyclospora are resistant to chlorine. Giardia cysts are not killed immediately by chlorine and are less susceptible than most other organisms. Swimming pools and other recreational waters have also been implicated as transmission sources. All 3 organisms pose a challenge to the water industry, as they are difficult to detect in water when small numbers of cysts or oocysts are present. Small numbers of these organisms can cause disease; therefore, the clinical laboratory must be vigilant in screening, identifying, and reporting outbreaks of illness due to these protozoa. PMID- 10177208 TI - Chinese CLS sister school relationship. AB - OBJECTIVE: Establish a relationship with a Chinese CLS Program to foster cross cultural diversity, provide for student and faculty cross-cultural exchange, scholarship, research, and improve the health care of both communities served by the colleges. DESIGN: Information needed to develop agreement strategy was gathered by literature review, personal interviews, and direct observation in China. Based upon literature review an original list of items for discussion was developed. Discussions were held between administrators of both schools and the teaching hospital. The Chief Laboratory Technologist of the associated Chinese teaching hospital was interviewed to establish the extent of CLS students' experiences. A form for the interview was developed and the results were used during the negotiation of the final agreement. SETTING/PARTICIPANTS: A CLS faculty team member from the U.S. traveled to the Jingmen School of Nursing and Allied Medical Sciences, Jingmen City, China, Hubei Province, P.R. China to establish an agreement. Tours of six cities in China, the School, and Jingmen hospitals provided for a better understanding of the Chinese culture and the Chinese CLS program. RESULTS/CONCLUSION: Three major concerns for success of the relationship (language barriers, communication vehicles, and socialization issues) were determined and addressed in a final agreement. The components of the agreement may provide some insight for others considering such a collaborative venture. Outcomes will be more fully addressed when exchanges begin. PMID- 10177209 TI - Latex sensitivity--a safety hazard. AB - Latex allergy is a significant safety issue for both healthcare workers and patients because of the widespread use of latex products and because of the severity of the sensitivity reactions that may occur in allergic individuals following exposure. Data shows that common, but often occult, immediate latex allergy merits more attention among healthcare workers. Because of this, each facility should have policies and procedures in place to address the issue of latex sensitivity. PMID- 10177210 TI - CLS advanced degrees and career enhancement. Part 1--Comparison of career data. AB - OBJECTIVE: Determine whether recipients of clinical laboratory science (CLS) advanced degrees (MS) experience greater career achievements than their baccalaureate level (BS) colleagues. DESIGN: Two similar questionnaires were used one for certified or licensed CLS professionals who had earned advanced CLS degrees (MS); the other for matched BS CLS colleagues. SETTING: Five academic programs that conduct both National Accrediting Agency for Clinical Laboratory Sciences accredited CLS education and CLS MS degree programs participated. PARTICIPANTS: The number of survey respondents was 220, 117 with advanced CLS degrees and 103 BS level controls. There were 99 matched pairs, i.e., 198 individuals were matched for gender, residence region, and years of experience. MAIN OUTCOME MEASURES: Careers of BS vs. MS respondents were statistically compared, e.g., fractions with managerial level jobs, relative earnings increases per year, numbers of publications and reports, and other professional contributions. RESULTS: Compared to their BS degree controls, MS degree respondents had more managerial level jobs (62% MS; 36% BS), a higher frequency of job change (once per 4.3 years MS; once per 5.9 years BS), and a higher increase per year of earnings (9.1% MS; 8.1% BS). A greater percentage of the MS degree graduates (77%) than the BS level controls (33%) had authored external publications; the responses related to authorship of institutional reports and procedures were less different-84% MS and 64% BS. Professional contributions to their institutions or profession were cited slightly more frequently by the MS graduates (65%) than by the BS level controls (55%). CONCLUSION: Compared to their matched BS level CLS colleagues, CLS MS degree recipients had greater job mobility, greater management authority, higher salary, and more numerous professional contributions. PMID- 10177211 TI - CLS advanced degrees and career enhancement. Part 2--A comparison of perceptions. AB - OBJECTIVE: To determine whether recipients of clinical laboratory science (CLS) advanced degrees (MS) perceive greater career enhancement value related to earning an advanced degree than is perceived by their baccalaureate level (BS) colleagues. DESIGN: Two questionnaires were used-one for certified or licensed CLS professionals who had earned MS CLS degrees; the other for matched BS CLS colleagues. SETTING: Five academic programs that conduct both National Accrediting Agency for Clinical Laboratory Sciences accredited CLS education and CLS MS degree programs participated. PARTICIPANTS: The number of survey respondents was 220 (117-MS; 103-BS level controls). The groups were matched for gender, residence region, and years of experience. MAIN OUTCOME MEASURES: The primary outcome measurements were the perceived benefits of having a CLS MS degree, the reasons for and against obtaining a CLS MS degree, and the overall evaluation of CLS degree programs at both levels. RESULTS: The highest perceived benefit of having a CLS MS degree was the same in both groups, "enhanced self esteem and confidence". The highest priority motivation of MS degree recipients for obtaining a CLS advanced degree was "personal satisfaction". The highest priority reason of the BS group for not obtaining a CLS advanced degree was "family obligation". In both levels of degree programs the subject most commonly cited as needing modification was laboratory management. CONCLUSION: The results indicate that CLS professionals who have CLS MS degrees perceive a greater career enhancement value of advanced CLS degrees than their BS level colleagues. PMID- 10177212 TI - The quest for professional recognition. AB - OBJECTIVES: To assess the progress clinical laboratory science has made toward achieving professional status. DATA SOURCES: Books, professional journals. STUDY SELECTION: Not applicable. DATA EXTRACTION: Survey of literature. DATA SYNTHESIS: Characteristics of clinical laboratory science as a profession were compared to a model of professionalization developed by Houle to assess the extent to which clinical laboratory science has acquired and refined selected attributes of a profession. CONCLUSION: Although clinical laboratory science has attained some of the characteristics associated with a profession, several critical issues must be addressed before it can achieve full professional status and recognition. PMID- 10177213 TI - Automated methods in urinalysis. AB - Automation has been an integral part of clinical laboratory testing for many years. In most moderate, or large laboratory settings, it is common to have a piece of equipment available to automate at least some, if not all portions of the urinalysis (UA). Examples range from the simple hand-held refractometer for the measurement of specific gravity, to a very sophisticated floor model instrument that performs the entire assay. PMID- 10177214 TI - Laboratory diagnosis of vaginal infections. AB - Vaginal discomfort and/or odor are a common complaint in primary care visits by female patients. This is especially true among sexually active women of childbearing age. Because treatment varies depending upon which syndrome is present, effective treatment depends upon accurate diagnosis. The microscopic exams for diagnosing vaginal complaints are most frequently done in primary care sites. Because of this, few clinical laboratory scientists (CLSs) have the opportunity to become familiar with microscopy on this specimen type. In addition, literature on the subject is only gradually becoming available. This paper will attempt to briefly review the clinical and microscopic features of the common syndromes associated with vaginal discomfort. PMID- 10177215 TI - Tracing our roots: origins of clinical laboratory science. AB - OBJECTIVE: To trace the roots of clinical laboratory science by explaining how women initially gained access to scientific work and to describe the emergence of clinical laboratories. DESIGN: A survey of literature on the history of clinical laboratory science was conducted. References consulted include various books and professional journals. CONCLUSION: The origin of the field of clinical laboratory science can be traced to the early 1900s. Between 1890 and 1910, women were able, for the first time, to pursue careers in scientific professions, clinical laboratories became established in hospitals, and the clinical utility of laboratory tests became more widely recognized by physicians. PMID- 10177216 TI - Clinical laboratory radioimmunoassay usage. AB - OBJECTIVES: To determine the extent of radioimmunoassay utilization in clinical laboratories in the state of Texas; to ascertain what methods have replaced it as an analytical tool; to identify trends and elicit comments regarding attitudes toward radioimmunoassay; and to ascertain the extent of instruction of radioimmunoassay principles required in clinical laboratory science curricula. DESIGN: Mailed, written survey designed by the authors. PARTICIPANTS: Laboratory managers or directors of 203 clinical pathology laboratories in Texas. MAIN OUTCOME MEASURE: Responses to seven forced-choice items, prompting information regarding laboratory type and size, extent of radioimmunoassay use, benefits or radioimmunoassay, and replacement technologies; a single item that elicited responses and opinions regarding general attitudes about radioimmunoassay and its place in clinical laboratory science curriculum. DATA SOURCE: Clinical laboratory managers or directors in the state of Texas. RESULTS: A total of 203 surveys were mailed within 127 respondents, yielding a response rate of 63%. The majority (77%) of clinical laboratories surveyed no longer use radioimmunoassay as a diagnostic tool with the predominant reason being the availability and affordability of automated enzyme immunoassays. Time-consuming recordkeeping was another common reason for abandoning the technique. Enzyme immunoassays were by far the most common method replacing radioimmunoassay. Comments reflected the general attitude that radioimmunoassay is a technique of the past in the clinical laboratory. A variety of views were elicited regarding the education of the principles of RIA to clinical laboratory science students. CONCLUSION: Radioimmunoassay, although a viable assay in some situations, has been abandoned as an analytical tool in most clinical laboratories in Texas. Current users are unhappy with the amount of paperwork that accompanies use of the technology, while non-users consider non-isotopic assays equivalent in sensitivity to RIA. In regard to information presented to clinical laboratory science students, the advent of molecular diagnostic techniques requires continued instruction in the principles of radioactivity, although not radioimmunoassay. PMID- 10177217 TI - Simulated lung transfection by nebulization of liposome cDNA complexes using a cascade impactor seeded with 2-CFSME0-cells. AB - The aim of this study was to devise a simulation aerosol system for quasirealistic gene transfection that could eventually be used to study the characteristics of aerosol delivery, stability, delivery efficiency, and expression efficacy of gene products. It consisted of (1) a PARI aerosol generator and PARI LL jet; (2) an Andersen cascade impactor with a calibrated vacuum pump, fitted with a glass "throat," nebulizer in which stages were seeded with pulmonary cells of interest (e.g., 2-CFSME0-); and (3) a hot room set to 37 degrees C and approximately 70% relative humidity. Cell viability remained at 95% to 99%. A prostaglandin G/H synthase (PGH)- and a human alpha 1-antitrypsin (AAT) expressing plasmid, respectively, driven by a cytomegalovirus promoter (pCMV4 PGH, pCMV4-AAT) and a heat-insensitive placental alkaline phosphatase (PAP) expressing plasmid driven by a Rous sarcoma virus promoter (pRSV-PAP) were employed; cationic liposomes consisted of N-[1-(2,3-dioleyloxy)propyl]-N,N,N trimethylammonium chloride/dioleoylphosphatidylethanolamine (DOTMA/DOPE) or 3 beta-[N-(N',N'-dimethylaminoethane)-carbamoyl]-cholesterol/DOPE (DC-Chol/ DOPE). The fluorescent dye Toto-1 was used to visualize aerosol distribution and to monitor cellular uptake. Alternatively, pCMV4-PGH deposited onto impactor stages covered with nitrocellulose membranes was hybridized with random primer-32P radiolabeled pCMV4-PGH and autoradiographed. The mass median aerodynamic diameter (MMAD) of the plasmid, liposomes, and liposome-plasmid complexes and their effect on the mass output were monitored. A majority of gene product was delivered to stages 1 through 5, corresponding to an area ranging from the pharynx to the terminal bronchi, excluding the alveolar space. A corresponding, although very low, transfection of cells with pRSV-PAP was found, with the majority of transfected cells on stages 4 and 5. The MMAD was significantly affected by the presence of the DNA constructs alone or by DNA constructs complexed with cationic liposomes; the control phosphate buffered saline (PBS) MMAD of 2.3 microns increased to 3.5 microns for DC-Chol liposomes and 4.5 microns for the DC Chol/PGH complex; DOTMA-based liposomes and liposome DNA complexes precipitated during aerosolization. Mass output was reduced for cationic liposomes from 0.61 g/min (PBS control) to 0.35 g/min. Large plasmid (pRSV-PAP, 10.1 kb) was more rapidly degraded by aerosolization than smaller plasmid (pCMV4-AAT, 6.2 kb) although complexation with cationic liposomes provided some protection in both cases. PMID- 10177218 TI - Reservoir design and dose availability with long-term metered dose inhaler corticosteroid use. AB - The effect of reservoir design and long-term use with inhaled metered dose inhaler (MDI) corticosteroids on aerosol dose availability was examined. Beclomethasone dipropionate (Vanceril) was delivered by MDI with three brands of available reservoir devices: the AeroChamber, the OptiHaler, and the Aerosol Cloud Enhancer (ACE). An in vitro lung model simulated inspiration. Long-term use was simulated by exhausting five MDI canisters of beclomethasone through each sample of reservoir tested. Each canister exhausted through a reservoir represented approximately 1 month of use with one drug. Total inhaled dose was collected at the reservoir mouthpiece and measured using a spectrophotometric assay. Dose delivery was measured before simulated use and after each MDI canister was exhausted through the reservoir. Three samples of each brand were tested with cleaning and three samples were tested without cleaning. With cleaning, the AeroChamber, OptiHaler, and ACE delivered significantly different average doses of 16.6, 10.3, and 8.7 micrograms per MDI actuation, respectively, (P = 0.0017) over time of use. Changes in dose delivery over time of use were not significant (P = 0.2011). Without cleaning, the same three brands averaged 21.1, 9.7, and 7.8 micrograms per MDI actuation, respectively, (P = 0.0019), and changes in dose delivery over time were not significant (P = 0.3265). Reservoir design can affect the delivery of an inhaled corticosteroid, although the delivery over 4 to 5 months remained stable. PMID- 10177219 TI - Aerosol bolus dispersion in patients with bronchiolitis obliterans after heart lung and double-lung transplantation. The Munich Lung Transplantation Group. AB - Bronchiolitis obliterans (BO) is one of the main late complications in patients after lung transplantation. Because BO is located in small airways, conventional lung function tests are supposed to be rather insensitive to detect early stages of this disease. In this study, the capability of the aerosol bolus dispersion test to detect BO was tested in 12 subjects with heart-lung and double-lung transplantation. Four of these patients had histological evidence of BO. The broadening (dispersion) of inhaled boluses consisting of monodispersed inert test particles during respiration was repeatedly measured in each subject. Additional measurements of spirometric and bodyplethysmographic measurements were performed. Patients with evidence of BO showed significantly increased aerosol bolus dispersion and significantly reduced maximal airflow parameters. Calculation of receiver operating characteristics (ROCs) revealed that from all lung function parameters under consideration, aerosol bolus dispersion divided by the maximum expiratory flow rate at 50% of vital capacity (MEF50) and MEI50 had the highest sensitivity and specificity for the detection of BO. Both parameters showed a sensitivity and specificity of 100%. Therefore, it may be speculated that even in early stages of disease, the combination of MEF50 measurement with aerosol bolus dispersion measurements may be a powerful tool for the detection of BO in patients with lung transplantation. PMID- 10177220 TI - Local versus total systemic bioavailability as a means to compare different inhaled formulations of the same substance. AB - For inhaled formulations of a drug substance, the balance between desired local activity and undesired systemic activity can be expressed with an L:T ratio, where L stands for the local bioavailability and T stands for the total systemic bioavailability. The L:T ratio depends not only on the ability of the different devices to divide the delivered dose between the lungs and the oropharynx but also on the inherent difference in gastrointestinal (GI) first-pass metabolism between different substances. The L:T ratio should therefore not be used to make comparisons across different drug substances but only to compare the same drug formulated in different inhalation systems. A high L:T ratio expresses a good targeting ability of the combination of substance and device or a low contribution from the GI tract. A high L:T ratio also reflects a more beneficial balance between wanted and unwanted effects. The L:T ratio was calculated from literature data for a number of salbutamol (albuterol) formulations and for two budesonide and two terbutaline formulations. For salbutamol, values ranged from 0.15 to 0.55 with different devices. For budesonide, the values ranged from 0.66 to 0.85, and for terbutaline, the values ranged from 0.59 to 0.79. The L:T ratio can thus be used to aid in the choice of inhaler. PMID- 10177221 TI - Excimer laser spectroscopy: influence of tissue ablation on vessel wall fluorescence. AB - Limited steerability and injury to the normal vessel wall are major drawbacks of laser coronary angioplasty. To overcome these limitations a new generation of laser systems has been developed which allows not only to eliminate the atherosclerotic plaque but to guide the laser beam by analyzing the laser induced tissue fluorescence (= spectroscopy) for the treatment of the atherosclerotic vessel. An excimer laser (MAX 10 LP, 308 nm, Technolas, Munich, Germany) was used with an emitting (phi 1070 microns) and a detecting (phi 130 microns) optical fiber to induce tissue fluorescence which was analyzed quantitatively by a computerized system. Specimens from the descending (thoracic) aorta were obtained from 24 patients (mean age 68.1 years, range 44-92). Tissue fluorescence was induced with ablating (26-30 mJ/mm2) and nonablating (3 mJ/cm2) laser activations. The emitted fluorescence (range 380-575 nm) was normalized to a wavelength of 380 nm; as a measure of tissue fluorescence the intensity ratio at 500 nm divided by 400 nm was calculated in normal (n = 78), mildly atherosclerotic (n = 40), and severely atherosclerotic (n = 48) tissue samples. Repeated laser activations were carried out and tissue fluorescence was checked until the fluorescence spectrum was normalized. All tissue samples were analyzed histologically by a semiquantitative score. Normal tissue samples showed the highest intensity ratios (5.9 +/- 3.4), whereas mildly (2.9 +/- 1.3) and severely atherosclerotic (2.1 +/- 1.0) samples elicited a significantly reduced fluorescence. Repeated tissue ablations were associated with a normalization of fluorescence intensity ratios in the mildly (7.0) as well as in the severely diseased (4.9) vessels. A curvilinear relationship between intensity ratio and the semiquantitative score was observed (r = 0.66) as well as between intensity ratio and intimal wall thickness (r = 0.62). No gender related differences were found but there was an inverse relationship between fluorescence intensity ratio and age (r = 0.56) as well as between intimal thickness and age (r = 0.41). Excimer laser spectroscopy allows reliable detection of atherosclerotic vessel alterations. Fluorescence intensity ratio is inversely proportional to the intimal wall thickness and the severity of the histologic alterations. There is an age dependency of fluorescence intensity ratio which can be explained by an increase in intimal wall thickness. Successful tissue ablation can be obtained by laser angioplasty and allows determination of the optimal point where complete tissue ablation is achieved by laser activation. Thus, excimer laser spectroscopy is an effective method for selective tissue ablation by laser angioplasty. PMID- 10177222 TI - Laboratory quality assurance at the international level: the role of nongovernmental organizations. AB - A wide range of nongovernmental organizations are involved in laboratory quality assurance at the international level. These organizations include for-profit organizations such as Murex or Randox, nonprofit organizations such as the Institute for Standardization and Documentation in Medical Laboratories (INSTAND), national professional organizations such as the National Committee for Clinical Laboratory Standards (NCCLS), regional organizations such as the Asian Pacific and Latin American Federation of Clinical Biochemists and International organizations such as the IFCC and WHO. The Interaction and roles of such organizations are discussed. PMID- 10177223 TI - Systematic reviewing in laboratory medicine. Position Paper from the IFCC Committee on Systematic Reviewing in Laboratory Medicine. AB - Each year a vast number of biomedical articles and books are published and based on the articles reviews are written. Such reviews should be performed in a systematic manner. Systematic reviewing is a new discipline with its own methods for locating, appraising, and summarizing primary studies. Such methods have also been developed for studies on diagnostic test evaluations. It is important for the laboratory disciplines to engage in this work. IFCC has established a Committee for Systematic Reviewing in Laboratory Medicine. This committee will work to promote the understanding, the use and the performance of systematic reviewing. PMID- 10177224 TI - Single-strand conformation polymorphism analysis with high throughput modifications, and its use in mutation detection in familial hypercholesterolemia. The IFCC Scientific Division: Committee on Molecular Biology Techniques. AB - The identification of the specific mutation causing an inherited disease in a patient is the framework for the development of a rationale for therapy and of DNA-based tests for screening relatives. We present here a review of the single strand conformational polymorphism (SSCP) method, which allows DNA fragments that have been amplified with specific primers and PCR to be scanned rapidly for any sequence variation. The general principles of the method are described, as are the major factors that must be considered in developing an optimal SSCP strategy, namely length of the PCR fragment and the temperature of the gel run. Options for sample denaturing gel characteristics and detection of DNA fragments are discussed. In addition, several modifications are presented that have been developed for high-throughput mutational analysis. The application of these techniques to screen for mutations in the LDL receptor gene in patients with familial hypercholesterolemia are described. PMID- 10177225 TI - Methods for detection of point mutations: performance and quality assessment. The IFCC Scientific Division, Committee on Molecular Biology Techniques. AB - We give an overview of current methods for the detection of point mutations as well as small insertions and deletions in clinical diagnostics. For each method, the following characteristics are specified: (a) principle, (b) major modifications, (c) maximum fragment size that can be analyzed, (d) ratio and type of mutations that can be detected (e) minimum ratio of mutant to wild-type alleles at which mutations can be detected, and (j) detection methods. Special attention is paid to the possibilities of quality assessment and the potential for standardization and automation. PMID- 10177226 TI - Monoclonal gammapathies. AB - The presence of a serum and/or urinary monoclonal immunoglobulin (monoclonal component, MC), or its subunits, heavy and light chains produced by a B cell clone in serum and/or urine characterizes a wide group of conditions called monoclonal gammapathies (MG). In most instances, the MG is clinically silent, and remains so throughout life. However, the clone may be, or will become, clinically overt because of its proliferation (i.e., multiple myeloma and its variants) and/or because the MC produces organ damage (i.e., kidney failure, amyloidotic cardiomyopathy, etc.). The clinical laboratorian greatly contributes to the diagnosis and management of these conditions mainly through detection and quantitation of the monoclonal immunoglobulin, which represents an ideal tumor marker. PMID- 10177227 TI - Looking ahead, Part II. PMID- 10177228 TI - How early is early? PMID- 10177229 TI - Fitness training for a healthy lifestyle. PMID- 10177230 TI - Neurorehab and TBI. PMID- 10177231 TI - Medicine or magic? PMID- 10177232 TI - Caring for stroke patients. PMID- 10177233 TI - Profitability in a capitated environment. PMID- 10177234 TI - Avoiding turf issues. PMID- 10177235 TI - HCFA issues. Health Care Financing Administration. PMID- 10177236 TI - Coming to grips with security gaps. PMID- 10177237 TI - The verdict on 'junk science'. PMID- 10177238 TI - Developing a disease management program to improve outcomes and efficiencies. PMID- 10177239 TI - The learning utilization management committee. PMID- 10177240 TI - The survival of top-quality, cost-effective patient prescription care. PMID- 10177242 TI - Rural health telemedicine use remains low. PMID- 10177243 TI - Teleradiology reduces errors in suspected heart attacks. PMID- 10177241 TI - Home care and clinical paths--steps toward more effective care. PMID- 10177244 TI - Patients use the 'net but don't tell health care providers. PMID- 10177246 TI - Kaiser Permanente uses computer technology to improve care for brain-damaged patients. PMID- 10177245 TI - HOST conference finds health care ready for Internet. Healthcare Open Systems & Trials. PMID- 10177247 TI - Britain to get GPs on the 'net. PMID- 10177248 TI - World Bank pursues telemedicine projects. PMID- 10177249 TI - TeleHealth providers urged to plan for applications. PMID- 10177250 TI - VA launches $4 million primary care expansion. PMID- 10177251 TI - Making patient care easier under multiple managed care plans. PMID- 10177252 TI - Strategies to protect health care facilities from costly latex allergy claims. PMID- 10177253 TI - How to tackle the year 2000 computer systems problem. PMID- 10177254 TI - Service level agreements. AB - Service level agreements provide clearer descriptions of the services to be provided and the objectives to be met. In many instances it is the first time that services have been defined allowing their performance to be suitably measured. They should be output based and not too prescriptive on how the services are to be delivered. The emphasis should be on establishing outputs and the arrangements for monitoring achievement. Customer expectations can exceed available resources and arbitration may become necessary if agreement cannot be reached on internal service level agreements. The main requirements of customers for change through service level agreements is usually improved communications on job status that includes notification of any delays and that agreed response times will be met. PMID- 10177255 TI - Looking for alternatives. PMID- 10177256 TI - Fire extinguishers. PMID- 10177257 TI - Total FM (facilities management)--a treatment not suitable for all. PMID- 10177258 TI - Effective use of health care information. PMID- 10177259 TI - How much should it cost? An introduction to management use of costing information. AB - With the introduction of the internal market the health service is changing rapidly and health libraries must change with it. Many libraries are requested to cost their services. The demand comes from external customers and from their own organizations. This paper discusses the various reasons for costing services and how costing information can influence our management decision making. The paper challenges librarians to move costing processes away from a mechanistic approach, towards a means of demonstrating the worth of a library resources unit in cost and qualitative terms. Using costing information for cost control purposes, comparison of cost with other providers, setting prices or determining future service delivery levels is discussed, as well as considering the question of external provision of library services. Use of information on fixed and variable costs and assessing break-even levels of service provision is illustrated as a helpful guide to library survival. PMID- 10177260 TI - Costing the library services. Cairns Library: a case study. AB - In the present climate libraries have to adopt a business approach to funding submissions; detailed management information must be produced in support of expenditure and to ensure that the services are cost-effective. In addition to the grant from its parent body (the Faculty of Clinical Medicine, University of Oxford), the Cairns Library obtains funding from five other bodies, including National Health Service Hospital Trusts. The Cairns Library has introduced an ongoing costing exercise covering the different services. The costs are divided into three categories: salary costs, other direct costs and indirect costs. Staff time has been identified from detailed time-sheets kept by each member of staff; the time recorded is assigned to the individual services. The direct costs and the indirect costs have been identified and allocated/apportioned similarly. The services are divided into five packages: core, current awareness, document delivery, enquiries and user education. The costs for each package have been apportioned to the funding bodies on the basis of the number of registered users from each body. PMID- 10177261 TI - Library and information services to support the education and development of nurses: the management of co-operation and change--a clash of two cultures? AB - This paper reports on the findings of research conducted by the Department of Information and Library Management and the Information Services Department at the University of Northumbria at Newcastle on behalf of the LINC Health Panel. It aims to investigate the organization and funding of library and information services to the nursing profession since the move of nurse education into higher education. The paper focuses on the lack of co-operation and communication between the National Health Service and higher education cultures in the provision of services to nurses. A brief review of the literature includes the views of experts in the field on library and information services and education for nurses as they are now, and ideas for possible developments for the future. This is followed by a description of the main research findings and the five key issues identified by information professionals in a questionnaire survey as vital for future consideration and action. Finally, the conclusions drawn from the findings have been developed into recommendations for the direction of the future discussion, research and action which is needed to further improve library and information services for all nurses. PMID- 10177262 TI - South and West Health Care Libraries Home Page: providing a local interface to health-related Internet resources. PMID- 10177263 TI - Legionella: a risk factors analysis. PMID- 10177264 TI - Protecting patients as costs are cut. AB - In today's managed healthcare era, cost-control measures that encourage underutilization of resources create fears that patients will receive less care than their conditions, injuries, or illnesses warrant. Patients need protection now that the rules have changed. Traditionally, patients have relied on direct caregivers to put their patients first. As individuals, caregivers want to be patient advocates; however, changes in the healthcare environment make it difficult for them to maintain their advocacy role. Clinical decision support criteria that are contained in a resource management program can help providers and payers maintain a balance between cost containment and healthcare quality. PMID- 10177265 TI - Quality: a driving force for healthcare in the United Kingdom. AB - Everyone has an opinion on healthcare delivery. When the subject is a national system for healthcare delivery, opinions can become very heated--for and against! This article outlines the British National Health Service (NHS). It discusses the history and background of the NHS and how those working within its system are endeavoring to follow the path of continuous quality improvement to enable it to meet the demands of the 21st century. PMID- 10177266 TI - Confidentiality: simply a buzzword? PMID- 10177267 TI - Overcoming 10 roadblocks to initiating clinical practice guidelines. AB - Canadian federal and provincial governments face relentless fiscal and societal pressures to reduce healthcare expenditures. A chief cause of this mounting stress is Canadians wanting to know how and why their healthcare dollars are being spent, as well as what evidence supports the use of new technology and alternative ways of treating specific medical conditions. One of the tools attracting attention and allowing this type of analysis is the clinical practice guideline. Physicians, who have come under increased scrutiny as the key players in health services delivery, are often asked to lead the clinical practice guideline process as project leaders. This article addresses some of the common roadblocks encountered as clinical practice guidelines are initiated, developed, and implemented in healthcare organizations. PMID- 10177268 TI - Applying the performance improvement team concept to the medication order process. AB - Healthcare literature suggests that most adverse drug events (ADEs) are the results of errors at the prescribing stage. These ADEs affect patients, physicians, pharmacists, nurses, and hospital administrators. Improving systems and providing education, rather than tracking the performance of individual prescribers, seem to be more effective in preventing and reducing ADEs. Pharmacists' participation on patient medical rounds and their presence in a satellite pharmacy increased their accessibility and their ability to share pertinent clinical information and thereby improved the medication order process and, ultimately, patient care. The pharmacy and medicine departments at one hospital took a proactive multidisciplinary approach that resulted in streamlining the medication order process, decreasing delays in initiating drug therapy, preventing ADEs, enhancing the knowledge of healthcare professionals, meeting the needs and expectations of patients and providers, and employing cost effective drug therapy. PMID- 10177269 TI - Continuous quality improvement techniques enhance HMO members' immunization rates. AB - To have a positive impact on the immunization rate of the 4,000 newborn infants it covers each year, Blue Care Network of Southeast Michigan (BCNSEM), a 240,000 member health maintenance organization that is based on an independent provider association model, convened a continuous quality improvement team. One of the results of this initiative was the development and implementation of an immunization registry, which is used as an internal tracking and reminder system for its members and providers. In recognition of its efforts, BCNSEM recently earned a Celebrating Innovation award from the American Association of Health Plans. PMID- 10177270 TI - Spotlight on the Internet. PMID- 10177271 TI - Evaluating performance outcomes measurement systems: concerns and considerations. AB - In today's managed care healthcare environment, there is a need for hospitals and physician groups alike to know the true quality and costs of healthcare services provided to patients. As the movement toward having providers accept risk via financial capitation escalates, quality improvement professionals involved in outcomes management are increasingly being asked to investigate information sources and systems that can prove helpful in managing effectively within these limitations. As a result, there is a high degree of interest in comparative performance outcomes measurement data based on risk-adjusted and severity adjusted data. This article explains the key features of performance outcomes measurement systems and notes concerns that should be considered when evaluating these software systems for selection. PMID- 10177272 TI - How computers-based records can improve healthcare. PMID- 10177273 TI - Information technology and work flow reengineering improves and revitalizes primary care. PMID- 10177274 TI - The use of problem knowledge couplers in a primary care practice. PMID- 10177275 TI - Clinical decision support: making the transition from the hospital to the community network. PMID- 10177276 TI - Clinical documentation that actually improves patient care. PMID- 10177277 TI - Benefits of an electronic clinical information system. PMID- 10177278 TI - The electronic medical record as a tool to improve patient care: hypothetical and practical opportunities. PMID- 10177279 TI - Knowledge management and business transformation: a new value proposition for the enterprise CPR. PMID- 10177280 TI - Care management: automating the care process to improve consumer service. AB - By implementing a care management system that is consumer-centric and service oriented, the goal of providing high-quality care, controlling costs, and providing excellent service can be achieved through every interaction with the consumer. Care management broadens the consumer's access to service while coordinating and managing care across this extended web of access. This can only be achieved by implementing a system with a clinical usage model that care providers will actually use in their practices. PMID- 10177281 TI - A methodology for improving the quality of healthcare in the physician's office. PMID- 10177282 TI - Ambulatory practice clinical information management: problems and prospects. PMID- 10177283 TI - Developing a public mental health report card: the Hoosier Assurance Plan Provider Profile Report Card. AB - In 1994, the Indiana General Assembly passed major legislation to reform the state's mental health system. This legislation, known as the Hoosier Assurance Plan, moves the old catchment area model into a system of managed competition. Included in the reform was a requirement that the Indiana Division of Mental Health is required to publish a provider profile. One response to that mandate is the Hoosier Assurance Plan Provider Profile Report Card. Development of a successful report card required a number of key steps. Indiana participated in the national dialogue on mental health report cards and borrowed heavily from the Mental Health Statistics Improvement Program prototype report card for indicators. The data in graphs was developed through a trial-and-error process and included broad provider and consumer input. The resulting report card is useful, and a review of the development process is informative to policy makers and others facing similar tasks. PMID- 10177284 TI - Internet-based patient information systems: what are they, why are they here, how will they be used, and will they work? AB - Web-based patient information systems are an emerging tool in the drive towards improving efficiency and effectiveness of health care. Providers and health plans may be able to achieve three key objectives with these systems: improve the health status of patients, improve marketing programs, and reduce costs. To discover what we know about these systems, we examine how they perform today, review the trends that are shaping their development, present a case study of a large East Coast HMO, and postulate future trends. PMID- 10177285 TI - The Internet in managed health care. AB - Blue Shield of California recognized it could realize business gains by implementing solutions that would streamline health care administration. It began looking for opportunities to apply the Internet to the core business and defining which of those services would benefit quickly from implementation. It selected Internet technology from Healtheon Corp., a Silicon Valley startup in Palo Alto, California. PMID- 10177286 TI - Using the Internet to educate consumers about health care choices. AB - Employers are increasingly using the internet to distribute comparative information to employees, dependents and retirees as it is often more cost effective and can be easily updated and customized to meet users' needs. Health Pages, a New York City-based consumer health information publisher, has been working with employers to distribute health education articles and comparative information nationwide. Working with employers such as General Motors, Boeing/McDonnell Douglas, US WEST and Southern California Edison, Health Pages has created customized websites providing a variety of benefit and comparative managed care plan/physician information via corporate intranets. To reach a broader audience, Health Pages also works with newspapers and magazines. Future activities in information dissemination will include aggregating performance information into simpler categories and allowing greater user interactivity. PMID- 10177287 TI - The gates are opening for HMO members but the tolls are rising for hospitals. PMID- 10177288 TI - Electronic commerce: is your health care organization safe? PMID- 10177289 TI - Assessing HMO centers of excellence programs: one employer's experience. AB - HMOs have sought to enhance the provision of organ and tissue transplantation services for their members through centers of excellence (COE) programs. Such programs initially assess and subsequently monitor the medical centers offered as part of such programs on the basis of procedure volumes and outcomes, as well as the experience of the transplantation surgeons. Purchasers rely on the presence of COE programs to assure their beneficiaries of access to appropriate care in the event that a need for transplantation arises, but little comparative literature exists on these HMO programs. One purchaser assessed the COE programs offered by 89 HMOs serving its beneficiaries, based on the criteria developed on its behalf by the medical directors of six different health systems and reviewed by HMO and academic medical center personnel. 57 (75 percent) met these criteria, and the implications for HMOs, medical centers, beneficiaries, and other purchasers are explored. PMID- 10177290 TI - Implications of ERISA for health benefits and the number of self-funded ERISA plans. AB - This Issue Brief provides an overview of the issues relating to the Employee Retirement Income Security Act of 1974 (ERISA) and health benefit plans, the major case law relating to ERISA and health plans, and the implications of the preemption of state regulations for health plan sponsors and participants. It also presents the latest data on the number of health plan participants in self funded ERISA plans. Finally, it presents a summary of current legislative proposals that would attempt to amend ERISA. Under the framework ERISA established for employee benefit plans, the regulation of employment-based health benefit plans has evolved into a two-tiered system in which both federal and state laws play important roles. The Supreme Court has interpreted ERISA's "savings" and "deemer" clauses to mean that insured plans are subject to regulations directly at the federal level and indirectly at the state level, while self-funded plans are regulated exclusively at the federal level. The ERISA statute and the courts' interpretations of the Act have created a sharp controversy over how employee health benefit plans are provided and administered, with state regulators and consumer advocates on one side of the debate and plan sponsors (e.g., employers and unions) on the other. State regulators and consumer advocates tend to favor more regulation, and in many instances greater regulation at the state level, which they argue would provide more protections for consumers. However, employers and unions (or any plan sponsors) think ERISA preemption is very important to their ability to provide innovative and cost effective health benefits for their employees, and assert that ERISA's present structure should be preserved. The U.S. General Accounting Office (GAO) found that 44 million individuals (39 percent of those in ERISA plans) were enrolled in self-funded ERISA plans in 1993, up from 39 million (33 percent of those in ERISA plans) in 1989. The Employee Benefit Research Institute (EBRI), using the same methodology as GAO with 1995 data, estimated that 48 million individuals (39 percent of those in ERISA plans) were enrolled in self-funded ERISA plans in 1995. When policymakers look to amend ERISA, they should consider whether the change to ERISA will produce a higher level of quality for consumers than is being provided under the present system and will continue to do so in the future. Policymakers must also decide whether quality of care is better enhanced by health plans' greater exposure to liability or by market forces. If policymakers decide that increased exposure to liability is the route to go, will consumers be able to enjoy any potential improvement in quality or will more individuals end up uninsured because of increased costs and not be able to get any care regardless of the quality? PMID- 10177291 TI - Health insurance portability: COBRA expansions and job mobility. AB - This Issue Brief discusses continuation-of-coverage mandates under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). It provides background information on health insurance portability and job mobility, data on the cost to employers of providing continuation of coverage to former employees, and a summary of empirical research on COBRA's effect on employee benefits and job mobility. COBRA coverage can be considered advantageous for most workers, as it allows continuation of the health insurance policy they had in place at work when they lose or leave a job. Although employees can be required to pay 102 percent of the premium for COBRA coverage, they can usually realize significant savings compared with the cost of purchasing the equivalent insurance policy in the private market. Many employers consider COBRA to be a costly mandate for three reasons. First, premiums collected from COBRA beneficiaries typically do not cover the costs of the health care services rendered. Second, COBRA imposes an additional administrative cost on employers. Third, many employers view the penalties for noncompliance as excessively large. According to a survey conducted by Charles D. Spencer & Associates, of the 10.2 percent of employees and dependents who were eligible for COBRA coverage in 1996, over 28 percent elected it. In addition, average employer claims costs for COBRA beneficiaries amounted to $5,591, compared with $3,332 for active employees in surveyed plans. According to Employee Benefit Research Institute estimates of the Survey of Income and Program Participation (SIPP), the COBRA population is much older than the general insured population. COBRA beneficiaries also have higher personal income than the general insured population, with this difference being almost entirely due to differences in retirement income. Any attempt to expand COBRA coverage, either through subsidies or by allowing workers to choose from plans with lower premiums, would likely result in increased employer health care costs. As a result, employers may consider various alternatives to reduce, shift, or eliminate the impact of this increased cost. One alternative would be to continue requiring active employees to share in the increased costs through higher employee contributions. A second alternative would be to reduce or eliminate health care benefits for active employees and/or future retirees and their families. A third alternative would be to reduce the size of the work force eligible for health insurance benefits. Finally, employers may pass additional costs on to workers or consumers. PMID- 10177292 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1998 rates; corrections--HCFA. Final rule with comment period; correction notice. AB - In the August 29, 1997, issue of the Federal Register (62 FR 45966), we published a final rule with comment period revising the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes resulting from the Balanced Budget Act of 1997, Pub. L. 105-33 and changes arising from our continuing experience with the system. This document corrects technical errors made in that document. PMID- 10177293 TI - Medicare program; hospice wage index; correction--HCFA. Correction notice. AB - This document corrects the final rule published August 8, 1997 (62 FR 42859), that established a methodology to update the wage index used to adjust Medicare payment rates for hospice care included in the new wage index, to be effective October 1, 1997. This notice corrects the wage index entry for Cherokee, GA. PMID- 10177294 TI - TRICARE formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); fiscal year 1998 mental health rate updates--DoD. Notice of updated mental health per diem rates. AB - This notice provides for the updating of hospital-specific per diem rates for high volume providers and regional per diem rates for low volume providers; the updated cap per diem for high volume providers; the beneficiary per diem cost share amount for low volume providers for FY 1998 under the TRICARE Mental Health Per Diem Payment System; and the updated per diem rates for both full-day and half-day TRICARE Partial Hospitalization Programs for fiscal year 1998. PMID- 10177295 TI - Agency information collection activities: proposed collection; comment request- AHCPR. Notice. AB - This notice announces the Agency for Health Care Policy and Research's. (AHCPR) intention to request the Office of Management and Budget (OMB) to allow a proposed information collection of the "Medical Expenditure Panel Survey- Insurance Component (MEPS-IC) for 1998 and 1999." In accordance with the Paperwork Reduction Act of 1995, Pub. L. 104-13 (44 U.S.C. 3506(c)(2)(A)), AHCPR invites the public to comment on this proposed information collection. PMID- 10177296 TI - Substance Abuse and Mental Health Services Administration; requirements applicable to protection and advocacy of individuals with mental illness; final rule--Center for Mental Health Services, SAMHSA. Final rule. AB - On December 14, 1994, the Department of Health and Human Services (Department or HHS) published a Notice of Proposed Rulemaking to comply with the requirements of section 116 of the Protection and Advocacy for Mentally III Individuals Act of 1986 (Act) (42 U.S.C. 10801 et seq.) which required that the Secretary promulgate regulations for the implementation of authorized activities of Protection and Advocacy (P&A) Systems to protect and advocate the rights of individuals with mental illness. The Department is issuing this final rule to implement Titles I and III of the Act. These regulations will govern activities carried out by the P&A systems under the Act. The rule includes: definitions: basic requirements regarding determination of, eligibility for and use of allotments, grant administration, eligibility for protection and advocacy services, annual and financial status reports, and remedial actions; and requirements regarding program administration, priorities, the conduct of P&A activities, access of the P&As to residents, facilities and records and confidentiality. DATES: Effective Date: This regulation is effective November 14, 1997 except for the information collection requirements in sections 51.8, 51.10, 51.23 and 51.25. These sections will become effective upon approval under the Paperwork Reduction Act. A notice of approval will appear in the Federal Register. PMID- 10177297 TI - Medicaid program; limitation on provider-related donations and health care related taxes; revision of waiver criteria for tax programs based exclusively on regional variations; correction--HCFA. Correcting amendment. AB - This document contains a correction to the final regulations that were published in the Federal Register on August 13, 1993 [58 FR 43156]. These regulations revised the Medicaid regulations relating to limitations on federal financial participation [FFP] in State medical assistance expenditures when States receive funds from provider-related donations and revenues generated by certain health care-related taxes. PMID- 10177298 TI - Informed consent for patient care--VA. Final rule. AB - This document amends VA medical regulations concerning informed consent for patient care. It describes the requirements for obtaining and documenting informed consent. It also describes the types of treatments or procedures for which the patient's or surrogate's signature on a VA-authorized form is required and establishes a list and priority of surrogates authorized to act on behalf of patients who lack decision-making capacity. Further, it establishes an internal decision-making process for patients who lack decision-making capacity and who have no authorized surrogate. This is intended to protect patient rights and ensure that the patient (or the patient's surrogate or representative) receives sufficient information to make an informed health-care decision. authorized form is required and establishes a list and priority of surrogates authorized to act on behalf of patients who lack decision-making capacity. Further, it establishes an internal decision-making process for patients who lack decision-making capacity and who have no authorized surrogate. This is intended to protect patients rights and ensure that the patient (or the patient's surrogate or representative) receives sufficient information to make an informed health-care decision. PMID- 10177299 TI - National Institute for Occupational Safety and Health; certification of respiratory devices used to protect workers in hazardous environments--NIOSH. Notice of priorities for rulemaking. AB - In response to public comments received from its May 16, 1996, request (61 FR 24740), NIOSH is announcing the intended priority order for the development of the next proposed rule amendments (modules) to the current NIOSH procedures for certifying respiratory devices used to protect workers in hazardous environments. The priority order is based on the comments and data in the public record. The priority order of the planned modules is provided to help the respirator community plan for potential changes. PMID- 10177300 TI - Occupational exposure to tuberculosis--OSHA. Proposed rule and notice of public hearing. AB - The Occupational Safety and Health Administration is proposing a health standard, to be promulgated under section 6(b) of the Occupational Safety and Health Act of 1970, 29 U.S.C. 655, to control occupational exposure to tuberculosis (TB). TB is a communicable, potentially lethal disease that afflicts the most vulnerable members of our society: the poor, the sick, the aged, and the homeless. As many as 13 million U.S. adults are presently believed to be infected with TB; over time, more than 1 million of these individuals may develop active TB disease and transmit the infection to others. TB remains a major health problem with 22,813 active cases reported in the U.S. in 1995. A number of outbreaks of this disease have occurred among workers in health care settings, as well as other work settings, in recent years. To add to the seriousness of the problem, some of these outbreaks have involved the transmission of multidrug-resistant strains of Mycobacterium tuberculosis, which are often fatal. Although it is the responsibility of the U.S. Public Health Service to address the problem of tuberculosis in the general U.S. population, OSHA is solely responsible for protecting the health of workers exposed to TB as a result of their job. OSHA estimates that more than 5 million U.S. workers are exposed to TB in the course of their work: in hospitals, homeless shelters, nursing homes, and other work settings. Because active TB is endemic in many U.S. populations, including groups in both urban and rural areas, workers who come into contact with diseased individuals are at risk of contracting the disease themselves. The risk confronting these workers as a result of their contact with TB-infected individuals may be as high as 10 times the risk to the general population. Although the number of reported cases of active TB has slowly begun to decline after a resurgence between 1985-1992, 16 states reported an increase in the number of TB cases in 1995, compared with 1994. Based on a review of the data, OSHA has preliminarily concluded that workers in hospitals, nursing homes, hospices, correctional facilities, homeless shelters, and certain other work settings are at significant risk of incurring TB infection while caring for their patients and clients or performing certain procedures. To reduce this occupational risk, OSHA is proposing a standard that would require employers to protect TB-exposed employees by means of infection prevention and control measures that have been demonstrated to be highly effective in reducing or eliminating job-related TB infections. These measures include the use of respirators when performing certain high hazard procedures on infectious individuals, procedures for the early identification and treatment of TB infection, isolation of individuals with infectious TB in rooms designed to protect those in the vicinity of the room from contact with the microorganisms causing TB, and medical follow-up for occupationally exposed workers who become infected. OSHA has preliminarily determined that the engineering, work practice, and administrative controls, respiratory protection, training, medical surveillance, and other provisions of the proposed standard are technologically and economically feasible for facilities in all affected industries. PMID- 10177301 TI - OCHAMPUS; state victims of crime compensation programs; voice prostheses--DoD. Interim final rule; request for comments. AB - This interim final rule establishes OCHAMPUS as primary payer to State Victims of Crime Compensation Programs and establishes voice prostheses as a CHAMPUS benefit. PMID- 10177302 TI - Medical and dental services fiscal year 1998--DoD. Notice. AB - Notice is hereby given that the Deputy Chief Financial Officer in a memorandum dated September 26, 1997 established the following reimbursement rates for inpatient and outpatient medical care to be provided in FY 1998. These rates are effective October 1, 1997. PMID- 10177303 TI - National Institute for Occupational Safety and Health; occupational exposure to inorganic lead: request for comments and information; republication--NIOSH. Request for comments and information relevant to occupational exposure to inorganic lead. AB - NIOSH is reviewing its recommendations contained in the document Criteria for a Recommended Standard.... Occupational Exposure to Inorganic Lead, Revised Criteria--1978 [NIOSH 1978]. The evaluation of recent literature indicates that the NIOSH recommended exposure limit [REL] of 100 micrograms/m3 as an 8-hour time weighted average [TWA] in that document does not sufficiently protect workers from the adverse effects of exposure to inorganic lead. NIOSH is requesting comments and information relevant to the evaluation of the potential health risks associated with occupational exposure to inorganic lead, as well as case reports or other data that demonstrate adverse health effects in workers exposed to inorganic lead at or below the OSHA permissible exposure limit [PEL] of 50 micrograms/m3 as an 8-hour TWA and any information pertinent to evaluating the technical feasibility of establishing a more protective REL for inorganic lead. NIOSH is also soliciting information on worker blood lead levels [BLLs] including data on methodologies used in measuring BLLs in the workplace and information that can be used for comparing airborne inorganic lead concentrations to observed BLLs. NIOSH intends to analyze the feasibility of developing preventive measures including an REL that would provide better protection for workers. In the interim, NIOSH plans to adopt the more protective current OSHA PEL as its REL. PMID- 10177304 TI - Criteria for implementing permissive exclusion authority under Section 1128(b)(7) of the Social Security Act--Office of Inspector General, HHS. Notice. AB - This notice sets forth a proposed policy statement, in the form of non-binding guidelines, to be used by the OIG in assessing whether to impose a permissive exclusion in accordance with section 1128(b)(7) of the Social Security Act. These guidelines identify specific factors with regard to whether an individual's or entity's continued participation in the Medicare and other Federal and State health care programs will pose a risk to the programs or program beneficiaries, and explain how these factors would be used by the OIG to assess a permissive exclusion decision. PMID- 10177305 TI - Office of inspector general; statement of organization, functions and delegations of authority--HHS. PMID- 10177306 TI - Quality mammography standards--FDA. Final rule. AB - The Food and Drug Administration (FDA) is amending its regulations governing mammography. Amendments are being made to the requirements for accreditation bodies; procedures for facility certification; and quality standards for mammography personnel, equipment and practices, including quality assurance. This action is being taken to provide increased assurance of adequate and consistent evaluation of mammography facilities on a nationwide level and compliance of the facilities with quality standards. It also carries out the intent of Congress that FDA replace the existing interim rules with more comprehensive final regulations. PMID- 10177307 TI - Medicare program; changes in provider agreement regulations related to federal employees health benefits--HCFA. Final rule. AB - This final rule makes two changes to Medicare's provider agreement regulations concerning payment for inpatient hospital services furnished to retired enrollees of fee-for-service Federal Employee Health Benefits (FEHB) plans who do not have Medicare Part A coverage. The first change specifies that payment for inpatient hospital services furnished to retired Federal workers age 65 or older who are enrolled in a fee-for-service FEHB plan but are not covered under Medicare Part A is limited to a payment amount that approximates the Medicare diagnosis-related group payment rates established under Medicare's inpatient hospital prospective payment system. The second change specifies that HCFA will consider termination or nonrenewal of a hospital's provider agreement with Medicare if a hospital knowingly and willfully fails to accept, on a repeated basis, the Medicare rate as payment in full for inpatient hospital services provided to a retired Federal worker who is enrolled in a fee-for-service FEHB plan and who does not have Medicare Part A coverage. This final rule implements section 7002(f) of the Omnibus Budget Reconciliation Act of 1990. PMID- 10177309 TI - Centers for Disease Control and Prevention; statement of organization, functions, and delegations of authority. PMID- 10177308 TI - Universal service--FCC. Final rule. AB - In this Order, we adopt a filing window period that begins on the date that the Schools and Libraries Corporation and the Health Care Corporation begin to receive applications for support. We also conclude that the administrative corporations will determine the length of the window and resolve other administrative issues necessary to implement our decision to adopt a window filing period consistent with our guidance set forth below. Therefore, we amend our rules to implement this change. In addition, we delegate authority to the Chief, Common Carrier Bureau to resolve unanticipated technical and operational issues relating to the new universal service mechanisms that may arise in the future. PMID- 10177310 TI - Unified agenda of federal regulatory and deregulatory actions--HHS. Semiannual regulatory agenda. AB - The President's September 30, 1993, Executive Order 12866 and the Regulatory Flexibility Act require that the Department semiannually publish an agenda summarizing all rulemaking under development and indicating those regulatory actions being analyzed for impact on small businesses. The Department published its last such agenda on April 25, 1997. PMID- 10177311 TI - Biomedical telemetry transmitters--FCC. Final rule. AB - By this Report and Order, the Commission amends its regulations regarding the unlicensed operation of biomedical telemetry transmitters in the 174-216 MHz (TV channels 7-13) and 470-668 MHz (TV channels 14-46) bands as proposed in the Notice of Proposed Rule Making ("Notice") in this proceeding, 61 FR 3367, January 31, 1996. These amendments will provide patients in health care facilities the ability to move about in a limited area while being continually monitored, speeding patient recovery times, shortening lengths of stay, and reducing health care costs. The standards being adopted for these devices should protect the licensed services operating in the TV bands. Further, a coordination procedure has been implemented to protect radio astronomy observatories from potential interference from biomedical telemetry systems operating on 608-614 MHz (TV channel 37). PMID- 10177312 TI - TRICARE/CHAMPUS; FY98 DRG updates--DoD. Notice of DRG revised rates. AB - This notice provides the updated adjusted standardized amounts, DRG relative weights, outlier thresholds, and beneficiary cost-share per diem rates to be used for FY98 under the TRICARE/CHAMPUS DRG-based payment system. It also describes the changes made to the TRICARE/ CHAMPUS DRG-based payment system in order to conform to changes made to the Medicare Prospective Payment System (PPS). PMID- 10177313 TI - Medicare program; revisions to payment policies and adjustments to the relative value units under the physician fee schedule, other Part B payment policies, and establishment of the clinical psychologist fee schedule for calendar year 1998- HCFA. Final rule with comment period. AB - This final rule makes several policy changes affecting Medicare Part B payment. The changes relate to physician services, including geographic practice cost index changes, clinical psychologist services, physician supervision of diagnostic tests, establishment of independent diagnostic testing facilities, the methodology used to develop reasonable compensation equivalent limits, payment to participating and nonparticipating suppliers, global surgical services, caloric vestibular testing, and clinical consultations. This rule also implements provisions in the Balanced Budget Act of 1997 relating to practice expense relative value units, screening mammography, colorectal cancer screening, screening pelvic examinations, and EKG transportation. In addition, we are finalizing the 1997 interim work relative value units and are issuing interim work relative value units for new and revised codes for 1998. PMID- 10177314 TI - Medicare program; physician fee schedule conversion factor for calendar year 1998 and sustainable growth rate for fiscal year 1998--HCFA. Final notice. AB - This final notice announces the calendar year 1998 Medicare physician fee schedule conversion factor and the fiscal year 1998 sustainable growth rate for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1846(d) and (f), respectively, of the Social Security Act. The 1998 Medicare physician fee schedule conversion factor is $36,6873. The sustainable growth rate for fiscal year 1998 is 1.5 percent. PMID- 10177315 TI - Medicare program; delay in implementing the adjustments to the practice expense relative value units under the physician fee schedule for calendar year 1998- HCFA. Notice of intent to regulate. AB - This notice identifies provisions in the Medicare physician fee schedule regulations that are affected by enactment of the Balanced Budget Act of 1997 (BBA 1997). Section 4505 of the BBA 1997 postpones implementation of a resource based practice expense relative value unit system until January 1, 1999 and provides for a 4-year transition. In addition, it provides for an adjustment for practice expense relative value units for 1998. It also requires publication of a new proposed rule for practice expense by May 1, 1998, thus requiring significant revision of our proposal contained in the proposed rule published June 18, 1997 (62 FR 33158). PMID- 10177316 TI - Termination of the Prospective Payment Assessment Commission and the Physician Payment Review Commission--GAO. Notice of termination of commissions. AB - The Balanced Budget Act of 1997 requires the Comptroller General, after the Medicare Payment Advisory Commission has been established, to provide for the termination of the Prospective Payment Assessment Commission and the Physician Payment Review Commission. This notice announces the termination of the two commissions. PMID- 10177317 TI - Medicare and Medicaid programs; quarterly listing of program issuances--first quarter 1997--HCFA. Notice. AB - This notice lists HCFA manual instructions, substantive and interpretive regulations, and other Federal Register notices that were published during January, February, and March of 1997 that relate to the Medicare and Medicaid programs. It also identifies certain devices with investigational device exemption numbers approved by the Food and Drug Administration that may be potentially covered under Medicare. Section 1871(c) of the Social Security Act requires that we publish a list of Medicare issuances in the Federal Register at least every 3 months. Although we are not mandated to do so by statute, for the sake of completeness of the listing, we are including all Medicaid issuances and Medicare and Medicaid substantive and interpretive regulations (proposed and final) published during this time frame. PMID- 10177318 TI - Medicare program; inpatient hospital deductible and hospital and extended care services coinsurance amounts for 1998--HCFA. Notice. AB - This notice announces the inpatient hospital deductible and the hospital and extended care services coinsurance amounts for services furnished in calendar year 1998 under Medicare's hospital insurance program (Medicare Part A). The Medicare statute specifies the formulae to be used to determine these amounts. The inpatient hospital deductible will be $764. The daily coinsurance amounts will be: (a) $191 for the 61st through 90th days of hospitalization in a benefit period; (b) $382 for lifetime reserve days; and (c) $95.50 for the 21st through 100th days of extended care services in a skilled nursing facility in a benefit period. PMID- 10177319 TI - Medicare program; Part A premium for 1998 for the uninsured aged and for certain disabled individuals who have exhausted other entitlement--HCFA. Notice. AB - This notice announces the hospital insurance premium for calendar year 1998 under Medicare's hospital insurance program (Part A) for the uninsured aged and for certain disabled individuals who have exhausted other entitlement. The monthly Medicare Part A premium for the 12 months beginning January 1, 1998 for these individuals is $309. The reduced premium for certain other individuals as described in this notice is $170. Section 1818(d) of the Social Security Act specifies the method to be used to determine these amounts. PMID- 10177320 TI - Quality mammography standards; correction--FDA. Final rule; correction. AB - The Food and Drug Administration (FDA) is correcting a document entitled "Quality Mammography Standards" that appeared in the Federal Register of October 28, 1997. The document was published with some inadvertent typographical errors and incorrect dates in the regulatory text. This document corrects those errors. FDA is also identifying with greater specificity those sections of the quality standards that will become effective October 28, 2002. For the convenience of the reader, FDA is republishing 21 CFR part 900 in its entirety with corrections. PMID- 10177321 TI - Grants to states for construction or acquisition of state home facilities--VA. final rule. AB - This document amends the "Medical" regulations regarding applications for grants to States for the construction or acquisition of State home facilities. VA awards grants based on a priority ranking system. Usually, the higher priority applications deplete the available funding to the extent that the lowest ranking application to be offered funding is offered only a partial grant. This final rule provides that if the lowest ranking grant application receives only a partial grant in a fiscal year and if such grant award is partial solely because VA has insufficient funds for a full grant, the application would be placed at the top of the list within its priority group for the next fiscal year. Often applicants are hesitant to accept a partial grant because of the uncertainty of receiving an additional grant the next fiscal year. This final rule will encourage States to accept a partial grant by creating the likelihood that the State would receive an additional grant in the subsequent fiscal year. Accordingly, this will help ensure that VA would be able to award grants to higher priority applicants that might otherwise reject partial funding. Also, this final rule provides that the applicant receiving partial funding and receiving priority as a proposed will not be required to submit a second application for additional funds in the subsequent fiscal year, but could be required to update information already submitted. The first application would normally be adequate because the grant award in the second fiscal year would be for the same project which received the partial grant award. Further, the final rule provides that the total amount awarded for the application may not exceed 65 percent of the total cost of the project as determined at the time of the second grant award for that grant application. This is consistent with the statutory requirement that limits grant awards to no more than 65 percent of the estimated cost construction or acquisition. PMID- 10177322 TI - Program exclusions: October 1997--Office of Inspector General, HHS. Notice of program exclusions. PMID- 10177324 TI - Medicare program; additional supplier standards--HCFA. Proposed rule. AB - This proposed rule would establish additional standards for an entity to qualify as a Medicare supplier for purposes of submitting claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). This proposed rule would establish additional standards that must be satisfied before a DMEPOS supplier could receive payment from the Medicare program. The Social Security Act Amendments of 1994 require that a DMEPOS supplier meet standards related to compliance with State and Federal licensure requirements, maintaining a physical facility on an appropriate site, proof of appropriate liability insurance, and other standards the Secretary may specify. PMID- 10177323 TI - Medicare program: request for public comments on implementation of the Medicare+Choice program, and notice of timeframes for submission of applications for contracts--HCFA. Notice of intent to regulate; solicitation of comments. AB - The Balanced Budget Act of 1997 (BBA) establishes a new Medicare+Choice program. Under this program, eligible individuals may elect to receive Medicare benefits through enrollment in one of an array of private health plans that contract with us. The BBA directs the Secretary to publish by June 1, 1998, regulations establishing standards for the Medicare+Choice program. We have already received comments and inquiries from the public on a number of issues associated with the Medicare+Choice program. This document solicits further public comments on issues related to implementation of the Medicare+Choice program. We intend to consider these comments as we develop an interim final rule to implement the Medicare+Choice program. This document also includes preliminary information regarding application procedures for organizations that intend to contract with us to participate in the Medicare+Choice program. This document also informs the public of a meeting to discuss the Medicare+Choice program. PMID- 10177325 TI - Health Resources and Service Administration; statement of delegation of authority. PMID- 10177326 TI - Draft guidance for industry; container and closure integrity testing in lieu of sterility testing as a component of the stability protocol for sterile products; availability--FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing the availability of the draft guidance entitled "Guidance for Industry: Container and Closure Integrity Testing in Lieu of Sterility Testing as a Component of the Stability Protocol for Sterile Products." The draft guidance is intended to provide recommendations and offer alternative methods for sterility testing to confirm the integrity of container and closure systems for sterile biological products, human and veterinary drugs, and medical devices. The draft guidance applies only to the replacement of the sterility test with an appropriate container and closure integrity test in the stability protocol, and it is not offered as a replacement for sterility testing for product release. PMID- 10177327 TI - Medtronic, Inc.; premarket approval of the Interstim Sacral Nerve Stimulation (SNS) System--FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing its approval of the application by Medtronic, Inc., Minneapolis, MN, for premarket approval, under the Federal Food, Drug, and Cosmetic Act (the act), of the Interstim Sacral Nerve Stimulation (SNS) System. After reviewing the recommendation of the Gastroenterology and Urology Devices Panel, FDA's Center for Devices and Radiological Health (CDRH) notified the applicant, by letter of September 29, 1997, of the approval of the application. PMID- 10177329 TI - National Practitioner Data Bank; change in user fee and elimination of diskette queries--HRSA. PMID- 10177328 TI - Emergency clearance: public information collection requirements submitted to the Office of Management and Budget (OMB)--HCFA. PMID- 10177330 TI - Medicare program; revisions to payment policies and adjustments to the relative value units under the physician fee schedule, other Part B payment policies, and establishment of the clinical psychologist fee schedule for calendar year 1998; correction--HCFA. Correction of final rule with comment period. AB - This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on October 31, 1997 entitled "Medicare Program; Revisions to Payment Policies and Adjustments to the Relative Value Units Under the Physician Fee Schedule, Other Part B Payment Policies, and Establishment of the Clinical Psychologist Fee Schedule for Calendar Year 1998. PMID- 10177331 TI - Medicare and Medicaid programs; salary equivalency guidelines for physical therapy, respiratory therapy, speech language pathology, and occupational therapy services--HCFA. Final rule. AB - This final rule sets forth revisions to the salary equivalency guidelines for Medicare payment for the reasonable costs of physical therapy and respiratory therapy services furnished under arrangements by an outside contractor. This final rule also sets forth new salary equivalency guidelines for Medicare payment for the reasonable costs of speech language pathology and occupational therapy services furnished under arrangements by an outside contractor. The guidelines do not apply to inpatient hospital services and hospice services. The guidelines will be used by Medicare fiscal intermediaries to determine the maximum allowable cost of those services. PMID- 10177332 TI - Financial disclosure by clinical investigators--FDA. Final rule. AB - The food and Drug Administration (FDA) is issuing regulations requiring the sponsor of any drug, including a biological product, or device marketing application (applicant), to submit certain information concerning the compensation to, and financial interests of any clinical investigator conducting certain clinical studies. This requirement will apply to any covered clinical study of a drug or device submitted in a marketing application that the applicant or FDA relies on to establish that the product is effective, including studies that show equivalence to an effective product, or that make a significant contribution to the demonstration of safety. This final rule requires applicants to certify to the absence of certain financial interests of clinical investigators and/or disclose those financial interests, as required, when covered clinical studies are submitted to FDA in support of product marketing. This regulation is intended to ensure that financial interests and arrangements of clinical investigators that could affect reliability of data submitted to FDA in support of product marketing are identified and disclosed by the sponsor of any drug, biological product, or device marketing application. If the applicant does not include certification or disclosure, or both, if required, or does not certify that it was not possible to obtain the information, the agency may refuse to file the application. FDA intends to propose to extend these requirements to submissions for marketing approval related to human foods, animal foods, and animal drugs in a subsequent issue of the Federal Register. PMID- 10177333 TI - Medical devices; exemptions from premarket notification and reserved devices; class I--FDA. Notice. AB - The Food and Drug Administration (FDA) is publishing a list of class I devices, subject to certain limitations, that will be exempt from premarket notification requirements on February 19, 1998. FDA is also publishing a list of those class I devices that FDA believes will remain subject to premarket notification requirements because they meet the new statutory criteria for premarket notification requirements. These lists do not include class I devices that have been previously exempted by regulation from the premarket notification requirements. FDA is taking this action in order to meet a requirement of the Food and Drug Administration Modernization Act of 1997 (the FDAMA). The agency requests comments on whether the list of class I devices that will remain subject to the premarket notification requirements should be modified. PMID- 10177334 TI - Current list of laboratories which meet minimum standards to engage in urine drug testing for federal agencies, and laboratories that have withdrawn from the program--SAMHSA. Notice. AB - The Department of Health and Human Services notifies Federal agencies of the laboratories currently certified to meet standards of Subpart C of Mandatory Guidelines for Federal Workplace Drug Testing Programs (59 FR 29916, 29925). A similar notice listing all currently certified laboratories will be published during the first week of each month, and updated to include laboratories which subsequently apply for and complete the certification process. If any listed laboratory's certification is totally suspended or revoked, the laboratory will be omitted from updated lists until such time as it is restored to full certification under the Guidelines. If any laboratory has withdrawn from the National Laboratory Certification Program during the past month, it will be identified as such at the end of the current list of certified laboratories, and will be omitted from the monthly listing thereafter. This Notice is now available on the internet at the following website: http://www.health.org. PMID- 10177335 TI - Medicare program; application of inherent reasonableness to all Medicare Part B services (other than physician services)--HCFA. Interim final rule with comment period. AB - This interim final rule implements section 4316 of the Balanced Budget Act of 1997. It revises the process for establishing a realistic and equitable payment amount for all Medicare Part B services (other than physician services) when the existing payment amounts are inherently unreasonable because they are either grossly excessive or deficient. This rule describes the factors HCFA (or its carrier) will consider and the procedures it will follow in establishing realistic and equitable payment amounts. PMID- 10177336 TI - Continuation coverage requirements of group health plans--IRS. Notice of proposed rulemaking. AB - This document contains proposed regulations that provide guidance under section 4980B of the Internal Revenue Code on certain changes made by the Health Insurance Portability and Accountability Act of 1996, the Omnibus Budget Reconciliation Act of 1989, and the Technical and Miscellaneous Revenue Act of 1988 relating to the continuation coverage requirements applicable to group health plans. The regulations will generally affect sponsors of and participants in group health plans, and they provide plan sponsors and plan administrators with guidance necessary to comply with the law. PMID- 10177337 TI - Medical devices; Mammography Quality Standards Act of 1992; inspection fees--FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing the new fees the agency will assess for inspections of mammography facilities starting on February 13, 1998. The Mammography Quality Standards Act of 1992 (the MQSA) requires FDA to assess and collect fees from mammography facilities to cover the costs of annual inspections required by the MQSA. Because these costs have increased since inspections began in 1995, FDA is raising the fees accordingly. This notice explains which facilities are subject to payment of inspection fees, provides information on the costs included in developing inspection fees, and provides information on the inspection, billing, and collection processes. This is the first increase in inspection fees under the MQSA since the initial fee was established in 1995. PMID- 10177338 TI - Managed care promises to dominate legislative landscape in 1998. PMID- 10177339 TI - A data platform for the consumer-oriented report card. PMID- 10177340 TI - COA's MIS and data collection requirements. Council on Accreditation of Services for Families and Children, Inc. PMID- 10177341 TI - CARF: the challenge for information systems. Commission for Accreditation of Rehabilitation Facilities. PMID- 10177342 TI - Clinical practice update. Incorporating mental health into primary care practice. PMID- 10177343 TI - Dialogue. Will online services for consumer self-help improve behavioral healthcare? PMID- 10177344 TI - NCQA's road map for information systems. National Committee for Quality Assurance. PMID- 10177345 TI - JCAHO standards and performance measurement systems. Joint Commission on Accreditation of Healthcare Organizations. PMID- 10177346 TI - The Dona Ana County experience: systems of care in a managed care environment. PMID- 10177347 TI - Visions, values, and our future. PMID- 10177348 TI - Network computing opens opportunity for connection. PMID- 10177349 TI - A comparison of satisfaction levels between traditional and managed care Medicare recipients. AB - The Spokane County health department conducted a survey of randomly selected households in the county. The survey combined several previously validated instruments. Since the purpose of this study was to compare satisfaction levels and access and communication issues of Medicare recipients in Health Maintenance Organizations (HMOs) to Medicare recipients using the traditional fee-for-service (FFS), a subpopulation was used. The results of this study did not support the findings of previous studies; HMO members were older and had no differences in health status from traditional FFS members. HMO members were more educated, had higher incomes, and were more satisfied with their care than the FFS group. The authors suggest that these differences from previous studies may be due to the fact that the majority of HMO respondents are in not-for-profit HMOs which return a fairly high proportion of the insurance premium to the patients in the form of medical care. They also suggest that not-for-profit HMOs may be different than for-profits due to the lack of pressure to return profits to the stockholders. PMID- 10177350 TI - Does dependency cause despondency? Welfare receipt and normative expectations among inner-city African-American youth. AB - This study attempts to isolate the effects of receipt of welfare on adolescents' expectations net of other coexisting factors such as family and household characteristics, neighborhood situational effects, and individual demographics. In addition, apart from the direct effect of these exogenous variables on expectations, mediating effects of peer association, maternal orientations, and academic attainment are also included in the analysis. The results indicate that time on welfare not only contributes directly to the non-normative expectations of adolescents but also indirectly by undermining mothers' expectations for the future well-being of their children. The results also indicate that family characteristics and neighborhood disadvantage have important implications for the prosocial development of youth. PMID- 10177351 TI - Welfare reform in the states: empirical investigations--a symposium. PMID- 10177352 TI - Cost neutrality and welfare reform. AB - Many states have chosen to reform welfare through the Social Security Act's Section 1115 waivers. When states choose this method, the Departments of Health and Human Services and Agriculture require the states to determine whether these initiatives are cost neutral to the federal government. States using this cost neutrality information as an ongoing piece of evaluation information must be careful in interpreting cost neutrality data. This article discusses two reasons for state and federal policy-makers to be cautious in using cost neutrality data as an indicator of welfare reform success. PMID- 10177353 TI - Paternalistic welfare reform: current perceptions and behavioral models. AB - Most of the current welfare reform incentives make assumptions about the behavior of AFDC clients. Among these assumptions are that clients will seek to maximize their financial resources; that they understand the requirements of the welfare reform; and that they can control the behaviors targeted by the welfare reform effort. Using survey data gathered from AFDC clients involved in Maryland's welfare reform initiative, the authors suggest that the assumptions underlying these welfare reform initiatives may be too simplistic. For welfare reform to be effective, the authors argue that these initiatives must reflect the complexity of the problems and concerns faced by the AFDC client. PMID- 10177354 TI - Do training programs help AFDC recipients leave the welfare rolls? An evaluation of New York City's BEGIN (Begin Employment Gain Independence Now) program. AB - Guided by the Federal Family Support Act of 1988 and the Job Opportunity and Basic Skills Program (JOBS), welfare reform initiatives on state and local levels were designed to foster employability among the public assistance population. Reform has focused on enhancing the supply of labor rather than the demand for labor as a route to labor force participation for the public assistance population. Program reforms assume that, by providing job training, educational services, and training-related expenses, labor market entry of the participating clientele would be facilitated while caseloads and public expenditures would decline. To date, analysis of similar programs in many states indicates that the impact of such programs in reducing public assistance caseloads is marginal. In New York City, despite the large investment of public funds in such programs, prior to this study the outcome of program implementation remained largely unknown. This study evaluates New York City's BEGIN program outcome target defined as the ability of the program to move welfare clients off public assistance and into the labor market. While the results of the study indicate that New York City's BEGIN program does not improve client's odds of leaving welfare, when compared to the odds of a non-participation client, there are several significant findings. The impact of program participation can be distinguished among distinct age groups. While older clients responded positively to BEGIN participation, access to day care was the only factor that significantly improved the probability that clients younger than 36 years of age would leave the welfare rolls within a two-year period. In response to the findings, the researchers suggest that future welfare reform efforts should grant localities broader flexibility to determine their own target population so that resources can be allocated to those groups that are most likely to benefit from specific programs. PMID- 10177355 TI - Redlands Surgical Services--"Bad facts make bad law". PMID- 10177356 TI - The growth in health care provider transactions and the impact on the health care lawyer. PMID- 10177357 TI - Assessing the health care needs of a rural community. AB - This article describes the methods used to complete a recent community health needs assessment study in a rural area. It illustrates the strategic marketing and management value of conducting this type of assessment by examining selected results from the study and discussing their implications for the local health care delivery system. PMID- 10177358 TI - The impact of public health media campaigns on drug users. AB - Evaluation of public health media campaigns to influence change in high-risk behavior often bemoans a lack of relevance to the target audiences as well as an absence of integrated interpersonal and mass-mediated communication channels. The assumption that illegal drug users are disconnected from mass-mediated communication may account for this absence of media interventions. However, the authors' HIV-prevention research project demonstrates that many out-of-treatment drug users are media consumers. Furthermore, it shows that participants who recalled seeing or hearing media interventions report greater levels of positive behavior change than participants who do not recall such messages. Results suggest strong coordination of human services messages that are relevant to out of-treatment drug users to facilitate changes in behavior. PMID- 10177359 TI - The health of the health care industry: a report card from American consumers. AB - This article reports on the public perceptions of the quality of health care services offered by three categories of provider professionals (physicians, dentists, and pharmacists) and three categories of hospitals (public, private, and those with religious affiliations). The authors examine quality along two dimensions: the quality of "cure" vs. the quality of "caring." Results show that, although the health care industry does a fairly decent job in delivering quality service, there is uneven performance across different providers. Data also show the quality of caring to be lagging the quality of cure; importantly, however, the former is more influential in earning patient loyalty. The role of the two types of quality in patient retention are presented, along with implications for health care industry managers. PMID- 10177360 TI - Market orientation in the hospital industry. AB - Using the more recent methodological developments in the assessment of the unidemensionality, reliability, and validity, the authors developed and examined a scale of market orientation for the hospital industry. The scale is based on a clear definition of the content of the construct of market orientation in the hospital industry. To this end, a national random sample of 237 hospital administrators was used. In addition to the support for the reliability and validity, the scale promises parsimony, pragmatism, and wide-ranging applicability. PMID- 10177361 TI - Applying a marketing perspective to health research organizations. AB - An excellent way for health research organizations to raise funds is by applying a well-executed marketing plan. Such a plan should include four steps: performing an environmental/internal audit, performing a services marketing audit, performing a relationship marketing audit, and developing a set of marketing strategies and tactics. PMID- 10177362 TI - A marketing research plan for mental health services. PMID- 10177363 TI - Questions of value in health care. PMID- 10177364 TI - A successful and necessary evolution to shared leadership: a hospital's story. AB - The success and adaptability of healthcare organizations will depend more and more on their ability to draw on the capabilities of their people. Tillsonburg District Memorial Hospital, a rural Ontario hospital, has evolved an organization and culture based on shared leadership and decision-making responsibility. Today this extends to front-line teams. This did not come about, however, without continuous effort. Successful transition takes preparation, guidance, much thought, commitment and patience. PMID- 10177365 TI - Community health centres in Canada. AB - In an increasing trend, clients are being moved from tertiary and secondary care to primary care. This "down-loading", accompanied by the increasingly complex needs of clients, has forced providers and policy makers to acknowledge the importance of primary care. In exploring options for the reorganization of primary care, the characteristics of community health centres are often promoted as the model with the best potential. This article outlines a descriptive overview of community health centres (CHCs) across Canada. PMID- 10177367 TI - Improving service quality in NHS Trust hospitals: lessons from the hotel sector. AB - This article looks to review recent practice undertaken within the UK hotel sector to improve customer service, and suggests ideals that could be implemented within National Health (NHS) Trust hospitals. At a time of increasing competition, hotel firms are using service enhancement as a means to gain competitive advantage, and therefore developing a range of techniques to measure levels of service quality improvement. With continued change in the health service, where greater focus now lies with patient satisfaction, so there is a requirement for managers to adapt techniques presently being offered in other service industries to improve levels of customer service and ensure patients are targeted to define their levels of satisfaction. PMID- 10177366 TI - Private and public medicine: a comparison of quality perceptions. AB - How do physicians and patients perceive the quality of medical services offered? Is this perception the same in the private and public sector? On the basis of a survey conducted in Greece on a 2 x 2 design with 20 respondents in each cell, several interesting characteristics were identified. Patients in the public sector attribute greater importance to resources of a medical and technical nature and do not seem particularly concerned about the contextual or environmental features of a hospital. Private patients are expecting a more holistic approach to their treatment and expect some attention to be directed to their emotional needs. Private surgeons are worried about the limited basic resources in private hospitals and their inability to satisfy the non-clinical needs of their patients. Important lessons may be drawn for policy makers in terms of priorities and resource allocation in. PMID- 10177368 TI - Attitude of laboratory personnel towards accreditation. AB - A multiple choice questionnaire was submitted to medical technologists in three medical laboratories, at varying times after obtaining an EN 45001 accreditation. A large majority (85-90 per cent) considered that their workload was increased by the accreditation process. In two laboratories, the technologists did not think that the accreditation process had improved the quality of the results. The major advantages were the fact that everything was traceable, that the technologists felt more sure about the procedures to follow, received more responsibilities and had a better knowledge of the tests they performed. The major disadvantages were the increased paperwork, discrepancies between the procedures and the reality, the fact that more attention is paid to the formalities than to the quality of the results and that the accreditation process decreased the adaptability. The number of advantages mentioned seemed to increase with the interval since the accreditation. A small majority of the technologists preferred working in an accredited laboratory than in a non accredited one. PMID- 10177369 TI - Practices of excellent companies in the managed health care industry. AB - The health care profession in the USA has traditionally attracted some of the best talent the country has to offer, with medical practitioners enjoying high incomes due to employer-paid medical indemnity insurance plans. There was no oversight process or quality standards governing the health care delivery process and no motivating factors to contain costs. Prior to the introduction of the Knox Keene Act in the 1970s requiring employers to offer managed care as an alternative indemnity coverage, the only known managed care company was the Kaiser Permanente Medical Plan. Until just over a decade ago, the concept of managed care was stereotyped as a low quality method of health care delivery. Criticisms from providers themselves suggested managed care systems meant withholding medical care for the sake of profit; "production line" medicine, and compromise in the delivery of quality health care. In order to refute that notion and grow as an industry, managed health care companies were required to take steps to prove their integrity, high quality of care, and cost-effective methods. Today the industry is fast growing, setting management practices that are becoming benchmark standards for other industries too. PMID- 10177370 TI - Total partnership for primary health care provision: a proposed model--Part II. AB - This is the second part in a paper which studied the dynamics of primary health care provision. This paper examines external factors related to the management of General Practices. The study revealed that there are major problems at GP/FHSA interfaces involving poor communications, needs evaluation and understanding, and the lack of teamwork. The paper argues that attempts by FHSAs in terms of initiatives are so far failing and have not effectively been able to build strong partnerships between the parties concerned. The paper concludes by proposing a Model of Total Partnership for effective primary health care provision. The model suggests that structures need to be modified in a horizontal way, focusing on patients and building a collaborative way between FHSAs and GPs in a seamless fashion. The model is based on Total Quality Management (TQM) principles and is represented by the building of a customer-supplier chain, the spirit of continuous improvement and synergy through teamwork with the ultimate goal of Total Patient Satisfaction. PMID- 10177371 TI - Take this Medicare risk readiness test for '98. PMID- 10177372 TI - Small PMPM rate hike may spell doom for benefit-rich, no-cost Medicare risk products. AB - Data File: Are generous--and free--Medicare benefits a thing of the past? Some experts think so, especially in light of low federal payment hikes. This month's column offers an interesting industry perspective on use of Medicare benefits, plan premiums, and trends in payment rates. PMID- 10177373 TI - Seeing 50% higher costs in depressed seniors, plan begins guideline to manage disorder. AB - Reduce the high cost of medical care for depressed seniors: Group Health Cooperative of Puget Sound found that up to 18% of its Medicare risk patients were depressed and their medical costs were 50% higher than non-depressed patients. Here are the details on this innovative provider's depression clinical guidelines and how they're working. PMID- 10177374 TI - Catholic providers in NY manage Medicaid special needs through innovative foster care pilot. AB - Care management for special-needs populations: Brooklyn-based Fidelis Care New York's unique pilot project managing foster children should help it prepare for managed Medicaid special-needs populations statewide. How the partners in the pilot structured their care management model can guide providers in developing their own programs. PMID- 10177375 TI - Minneapolis provider reveals the lowdown on long-term care under Medicare risk. AB - The lowdown on long-term care: Here's the story of a Minneapolis provider network that's successfully contracting for institutionalized Medicare risk and dual eligibles, as well as seniors in the community. The details on the network's global risk contract and how the group overcame obstacles in the long-term care market are enlightening. PMID- 10177376 TI - Take your organization's call center to a higher level. PMID- 10177378 TI - HMO's doctors teach each other to improve communication skills. AB - Do you really communicate effectively with your patients--and if so, how does this communication influence outcomes and adherence to therapy? A California health plan has trained physicians to become communication consultants to each other as part of a larger program of service to patients. It is winning praise from members and doctors alike. PMID- 10177377 TI - DM program attacks the high cost of osteoporosis. AB - Considering the huge costs and the painful debilitation associated with osteoporosis, some physicians are starting to ask why more attention is not paid to the healthy care and nurturing of good bones in younger women. PMID- 10177379 TI - Taking the fear out of colon cancer screening. AB - Colon cancer is the second leading cause of cancer death in the U.S., but few patients feel comfortable with the screening procedure and few PCPs recommend it. Find out how one health plan is training midlevel clinicians in a minimally painful screening procedure and eliciting good marks from many patients, who say they would agree to a repeat performance. PMID- 10177380 TI - CHF disease management programs produce dramatic shift away from hospitalization. AB - Nurse house calls and more aggressive drug therapy for congestive heart failure are keeping health plan costs down and creating healthier patients as well. Two health plans say these two factors must be added to any CHF disease management program to reach optimal effectiveness. PMID- 10177381 TI - Physicians and organizations: strange bedfellows or a marriage made in heaven? AB - Underscoring the importance of physician-organization alignment as a necessary condition for building and sustaining integrated healthcare systems, this article provides information regarding the nature of such alignment, the key influential factors, and the processes employed to make alignment a reality. Structural and strategic factors address the influence of environmental, market, and organizational characteristics on alignment. The strategic intent of organizations and physicians, and physician perspectives on the effects of integration, are explored. Key processes examined include building trust, placing physicians in management and governance, and developing physician leadership. Continuing issues and challenges are considered, and a set of principles to help guide the journey of physicians and organizations toward successful alignment is suggested. PMID- 10177382 TI - Examining social and organizational factors of physician integration. PMID- 10177383 TI - Successful physician partnering in a rapidly changing healthcare environment. PMID- 10177384 TI - Physicians and organizations: for whom the bell tolls. PMID- 10177385 TI - From technical professional to group leader. AB - Throughout the health care industry, technical and professional employees are moving into supervisory roles, usually without preparation for this major change. They often are frustrated during the transition period. This article discusses how to decide whether supervision is for you and how to prepare for the new role. Several tenets of leadership are offered in the health care setting. PMID- 10177386 TI - Managing crazy behavior in organizations. AB - Crazy behavior is an aspect of organizational life. This article examines the two sides of crazy behavior, positive and negative, and suggests guidelines for its management so that it does not become pathological or destructive to the competence of the organization. Crazy behavior is related to professional and ethical behavior, but the boundaries of craziness are often less clear than those for professional and ethical behavior. Therefore, crazy behavior is often tolerated, if not supported and encouraged, by the reactions of administrators. PMID- 10177387 TI - Validity of background data as a predictor of employee tenure among nursing aides in long-term care facilities. AB - Employee turnover and its associated costs continue to be an important concern for American industry. The purpose of this study was to determine whether differences exist in personal history data (biodata) of nurses aides who remained with the target nursing home corporation and those who either voluntarily or involuntarily separated employment. Results indicate that significant differences exist between the groups with respect to several important dimensions of personal history data. PMID- 10177388 TI - Toward understanding the patient's perception of quality. AB - Patients often don't have the technical competence to judge the quality of medical care. Therefore, they rely on different criteria than do professionals in assessing quality. They perceive quality as a gestalt of experiences influenced by such issues as empathy, integrity, and appearance of competency. Patients do not complain about service quality when it is appropriately provided. But to satisfy the consumer, providers must go beyond being reliable, polite, and honest. They must provide prompt services, be approachable, and provide individualized attention. To ultimately delight consumers, however, providers must meet the unarticulated needs of the patient. PMID- 10177389 TI - Managing health care organizations in an age of rapid change. AB - Health care managers find their work increasingly difficult, due in part to rapid environmental change that plagues organizational life. Management practices and attitudes that may have been appropriate in previous eras are ineffective today. A study was conducted among managers in the Ministry of Health, State of Bahrain, seeking information about current trends in the macro or external environment that affect the Ministry of Health, as well as internal environmental pressures that may be similar or different. This article provides a clear picture of the context in which managers perform their work and offers recommendations for coping with change in dynamic, complex organizations. PMID- 10177390 TI - The Joint Commission has provided a tool to change your work force: are you paying attention? AB - Most health care managers wonder how to change employee "attitudes" so that their staff will be more accountable for patient satisfaction, cost reduction, and quality of care. Employees were trained to function in an industry where the power players were the physician and the administrator and now it is exceedingly difficult to get them to switch their attention to the patient and the payer in a market-driven economy. For hospital managers, the answer may be right at their fingertips: The Joint Commission on Accreditation of Healthcare Organizations' standards demanding that employee competence be objectively measured, proven, tracked & trended, improved, and age specific. A comprehensive competence assessment system can save the health care manager enormous work in measuring fewer things, focusing performance assessment on the 20 percent of things that are true problems, and helping to specifically define certain competencies such as customer focus and cost consciousness so that coaching, training, and giving performance feedback is easier. Developing a comprehensive competence assessment system is a powerful tool to change the culture of organizations. Consequently, it is important that managers be aware of those possibilities before they embark on developing "competencies" or before their organizations get too carried away on redesigning systems to satisfy standards. PMID- 10177391 TI - Practical reward strategies available to supervisors. AB - Many health care organizations are cutting costs by eliminating or reducing their recognition and award systems. Salary increases and bonuses are harder to come by. To compensate for these losses at a time when morale is flagging and stress is increasing, it is imperative for supervisors and managers to fine-tune their recognition and reward skills. PMID- 10177392 TI - Employee involvement: motivation or manipulation? AB - Employee involvement is subject to a great deal of verbal tribute; there is hardly a manager at work today who will not praise the value of employee input. However, many employee involvement efforts leave employees feeling more manipulated than motivated. This occurs because supervisors and managers, while expecting employees to change the way they work, are themselves either unwilling to change or remain unconscious of the need to change. The result is that, although employee input is regularly solicited in a number of forms, it is often discounted, ignored, or altered to fit the manager's preconceptions. Often the employee is left feeling manipulated. Since the opportunity for involvement can be a strong motivator, it becomes the manager's task to learn how to provide involvement opportunity in manipulative fashion. This can be accomplished by providing involvement opportunity accompanied by clear outcome expectations and allowing employees the freedom to pursue those outcomes in their own way. PMID- 10177393 TI - It's never too early to plan for retirement. AB - There is a revolution today in the adult life cycle. People are leaving childhood sooner, but taking much longer to grow up and much longer to die. By the turn of the century, 1 in 5 persons will be over age 55. As people retire earlier and live to be older, extensive preparation needs to be made for retirement. This should be a priority for health professionals as well as for those they serve. PMID- 10177394 TI - Managing managed care: a battle for citizens' hearts and minds. PMID- 10177395 TI - Medical intranets: new technologies expose old problems. PMID- 10177396 TI - How should data be analyzed and reported in a risk-contracting environment? AB - Integrated delivery systems (IDSs) that enter into risk contracts with payers need sophisticated data analysis and reporting capabilities to ensure proper payment and to manage utilization. An IDS can develop these capabilities by following a six-step process: It should develop an IDS data management structure, obtain all requisite data, review and refine the data, consolidate the data, create a relational database, and develop a reporting structure. The reporting structure should consist of a set of standard reports and the ability to generate additional targeted reports that facilitate analysis of specific aspects of utilization and financial performance. PMID- 10177397 TI - New York court refuses to block merger of Long Island hospitals. AB - In October 1997, a New York court rejected an attempt by the U.S. Department of Justice (DOJ) to block the merger of two New York teaching hospitals. The DOJ's case was based, in part, on the premise that the consumers in the hospitals' market were managed care organizations, which needed prestigious teaching hospitals to "anchor" their healthcare delivery networks. In rejecting the DOJ's argument, the court found, in particular, that the merging hospitals were not sufficiently distinguishable from other area hospitals to constitute a separate product market of anchor hospitals and that the merging hospitals' faced competition for about 85 percent of their services. Moreover, the court recognized other significant consumers in the market. The decision may pave the way for metropolitan-area hospitals to pursue mergers. PMID- 10177398 TI - Capitating home health care. AB - Managed care is beginning to make inroads into home health care, and more home healthcare providers are signing capitation contracts. Unfortunately, a lack of home healthcare cost and utilization data has made it difficult to set reasonable capitation rates. In addition, home healthcare providers currently have little control over care management and, therefore, cannot effectively manage utilization under capitation. They also are unused to thinking in terms of controlling utilization and guaranteeing services for a predetermined population at a preset price. In the long run, however, home healthcare providers and payers that develop cooperative working relationships will find ways to collect and share the information they need to make these arrangements mutually successful. PMID- 10177399 TI - Medicare+Choice PSO formation: a step-by-step decision process. AB - The introduction of the Medicare + Choice program has opened up new opportunities for healthcare providers to contract directly with Medicare through provider sponsored organizations (PSOs). Because the time, resources, and risks inherent in forming and operating a Medicare + Choice PSO are substantial, providers should approach this new opportunity methodically. A seven-step process can take providers from assessment to contract application. PMID- 10177400 TI - Medicare+Choice creates opportunities for PSOs. AB - The Medicare + Choice program, a feature of the Balanced Budget Act of 1997, has far-reaching implications for healthcare providers, and for provider-sponsored organizations (PSOs), in particular. Under Medicare + Choice, PSOs will be able to contract with Medicare if they meet certain conditions. Most significantly, the PSO must be established, operated, and majority-owned by healthcare providers that directly furnish a substantial portion of the covered services. PSOs and other participants in the Medicare + Choice program will receive aggregate annual payments based on geographic location and demographic characteristics of enrollees. Medicare + Choice provider participants should understand the details of how these payments will be calculated. For instance, geographically based payments will gradually be modified to reflect a more uniform payment rate nationally. In addition, participants in Medicare + Choice will need to meet state solvency requirements or apply to HCFA for a three-year waiver of those requirements to participate in the program. The best time to form a PSO may be in the next three years, before HCFA's authority to grant such waivers expires. PMID- 10177401 TI - Estimating Medicare payment cuts for three outpatient services. AB - A change in the method used to determine Medicare outpatient payment to hospitals for outpatient ambulatory surgery, radiology, and other diagnostic procedures will lower payments to most U.S. hospitals. Using the equations provided in this article, healthcare financial managers can estimate Medicare payments under both the old and the new methods and determine the percentage payment reduction resulting from the new method. PMID- 10177402 TI - Preparing for full-risk capitation. AB - Full-risk capitation arrangements involve shared financial risk among all participants and place providers at risk not only for their own financial performance, but also for the performance of other providers in the network. Providers that wish to assume full risk must understand the types of risks they need to manage to ensure financial success for all network participants. They also must choose a method of paying network participants. The five principal physician payment models currently used in conjunction with full-risk capitation contracts are fee-for-service, salary, entrepreneurial, subcapitation, and hospital reimbursement. No matter which model is used, measurement and feedback systems should be established to increase the effectiveness of the payment systems. Such measurement and feedback systems should facilitate risk management, cost management, process management, revenue distribution, and contract renegotiation and follow-up monitoring. PMID- 10177403 TI - Specialty empowerment: a new trend in managed care. AB - The rise of the open-access managed care model has brought the concept of specialist empowerment to the forefront. Specialists are being asked to assume the gatekeeper role for specialty services throughout individual provider networks. A growing number of specialty practices are structuring to assume this role and manage the accompanying risk and capitation dollars. Many specialist practices are using this new structure to gain a competitive edge in the market. PMID- 10177404 TI - Consolidation guidelines for physician practices. AB - The trend of acquiring and consolidating physician practices is expected to continue for some time. The growth of physician practice management companies (PPMCs) has created accounting and financial reporting issues for these new physician organizations. The type of management arrangement ultimately affects the decision of whether or not to consolidate practices. In analyzing consolidation opportunities, PPMCs should consider the terms of the management agreement, which determine who controls the practice, and the advantages and disadvantages of consolidation. PMID- 10177405 TI - Cutting utility costs using EDI. PMID- 10177406 TI - Nontraditional job candidates provide competition for traditional CFOs. PMID- 10177407 TI - Data trends. The shift of care to outpatient settings. PMID- 10177408 TI - Legislation bars retaliatory action against health care personnel seeking to protect the quality of patient care. PMID- 10177409 TI - The transformation of healthcare in Central and Eastern Europe. PMID- 10177410 TI - Developing health management education in Central and Eastern Europe. PMID- 10177411 TI - Development of a graduate healthcare management program at Palacky University, Czech Republic. PMID- 10177412 TI - University partnership project in health services management education: the driving force behind the Czech Republic Educational Network. PMID- 10177413 TI - A case study: calculation of the break-even point of the Premature Children's Unit of the Children's Clinic at Jindrichuv Hradec Hospital, Czech Republic. PMID- 10177414 TI - An integrative role for a health policy course in the health services management graduate curriculum. PMID- 10177416 TI - Health system reform under the Russian health insurance legislation. AB - The Russian (1993 amended) health insurance legislation initiated a far-reaching reform in the financing, organization and management of the Russian health system. However, the implementation of the legislation has been slow and unstructured due to a lack of appropriate administrative and financial mechanisms: these concern entitlement, private-public mix, financial responsibilities of government at all levels, investment instruments, reimbursement and compensation systems, and a well-defined role of government. These issues are discussed in this article in the context of the Russian economy, the state of the health system, and the reform effort in the system. PMID- 10177415 TI - A cost analysis of family planning in Bangladesh. AB - This article presents a step-down cost analysis using secondary data sources from 26 Bangladesh non-government organizations (NGOs) providing family planning services under a US Agency for International Development-funded umbrella organization. The unit costs of the NGOs' Maternal-Child Health (MCH) clinics and community-based distribution (CBD) systems were calculated and found to be minimally different. Several simulations were conducted to investigate the impact of alternative cost-reduction measures. The more general financial analysis proved more insightful than the unit cost analysis in terms of identifying means by which to improve the efficiency of the family planning operations of these NGOs. The analysis revealed that 56 per cent of total expenditures in the two tiered umbrella's organizational structure are incurred in management operations and overheads. Of the remaining 44 per cent of project expenditures, 39 per cent is spent on the CBD program and 5 per cent on the MCH clinics. Within the CBD program, most resources are spent providing 4 million contacts (two-thirds of the annual total) which do not involve contraceptive re-supply. The clinics devote more resources to providing MCH services than to providing family planning services. The findings suggest that significant savings could be generated by containing administrative costs, improving operational efficiency, and reducing unnecessary or redundant fieldworker contacts. The magnitude of the potential savings raises a fundamental question about the continued viability and sustainability of this supply-driven CBD strategy. PMID- 10177417 TI - Demarketing dysfunctional demand in the UK National Health Service. AB - This article considers demarketing as a strategy to manage dysfunctional demand in the UK NHS. Demarketing seeks to persuade customers not to use a service which is provided. It appears in all four modes in the NHS as general, selective, ostensible and unintentional demarketing with an emphasis on supply-side applications. It is proposed that, as a demand-side strategy, it would allow purchasers of health care on behalf of communities, to discern values, attitudes and beliefs which predicate current behaviour through the use of the Theory of Planned Behaviour; and, subsequently, to develop appropriate demarketing alternatives to change these behaviours where they are dysfunctional for both consumer and provider. This approach is proposed for the significant behavioural changes required to manage the increases in the use of emergency services: in particular, general practitioner night calls, which are already developing evidence-based demand management strategies. Such alternative strategies need to demonstrate their acceptability to consumers rather than just the professionals. Such demand management strategies would be made more acceptable as they are drawn from both consumer and normative attitudes, values and beliefs. In this way demarketing could demonstrably provide a framework for intervention, collaboration, decentralization, explicitness and an ethical foundation to the key problem of demand management in health care. PMID- 10177419 TI - Hospital restocking may be illegal, feds warn. PMID- 10177418 TI - Economic and demographic consequences of AIDS in Namibia: rapid assessment of the costs. AB - Recent announcements by the Government of Namibia to provide financial support to people living with AIDS (and their family members) have received considerable media attention. However, given the fact that government budgets are already stretched, and the need for resources to devote the prevention efforts remains, there is an urgent need to assign some values to the support the government is considering within the context of an explosive epidemic. It is against this background that this study attempts to provide a rapid assessment of the economic costs of HIV/AIDS in Namibia over the next 5 years of the First National Development Plan. The estimates include the direct and indirect costs. The direct costs are costs to the economy for inpatient and outpatient medical services, as well as the costs of support payments to people living with AIDS, their families and children orphaned by AIDS. Government and donor expenditure on national prevention and control efforts are also included. The study concludes that no sector of the Namibian economy will escape the impact of AIDS. The epidemic will definitely tax hospital, public health, private and community resources, and these substantial burdens underscore the need for coordinated long-term planning. PMID- 10177420 TI - Presumptuous assumptions. PMID- 10177421 TI - New Year's Eve in Times Square. PMID- 10177423 TI - Lessons of the moment. PMID- 10177422 TI - Domestic violence. Recognize abuse and do something about it. PMID- 10177424 TI - Compassion. PMID- 10177425 TI - EMS 2000, Part II. Into the ED and the patient's home. PMID- 10177426 TI - 200 city survey. EMS in the nation's most-populous cities. PMID- 10177427 TI - Making our patients number one. PMID- 10177428 TI - The hidden risks and subtleties of capitation or, what you were never told when you agreed to accept capitated risk. AB - For your physician practice to be successful under a capitated contract, you must understand the subtleties of the arrangement that can impact the practice's level of risk exposure. This means you must know the key questions to ask when negotiating the contract and capitation amount, as well as what should be monitored to ensure the contract is implemented correctly. How the capitated rate is calculated and whether or not it appropriately covers the risk of each benefit plan the practice will be servicing will determine the financial viability of the contractual agreement. In addition, after the contract becomes effective, you should make sure that the practice is providing and billing for services consistent with its contractual obligations, and that the reimbursement received is correct based on the practice's membership mix. PMID- 10177429 TI - Using data in disease management. Opportunities and challenges. AB - Data collection is much talked about and little practiced. HealthPartners has a fully-developed data collection model that has successfully improved the quality and cost of health services, especially in women's health. This discussion of their system points out the complexities of data collections, the need for managed care plan and clinic cooperation and the clear benefits of the approach. Special attention is paid to developing data-based clinical practice guidelines, reminder systems, identification of at-risk patients and development of patient centered information about physicians. PMID- 10177430 TI - Improving marketability for joint ventures. AB - Many believe that by being in line with the revised Statements on Antitrust Enforcement Policy in Health Care, released by the Federal Trade Commission (FTC) and Department of Justice (DOJ) on August 28, 1996, they can regain control of their markets by being able to negotiate with employers, restore clinical autonomy to physicians, minimize the intrusion of health plans in the doctor patient relationship and compete more effectively with managed care plans. To really succeed, however, physician network joint ventures should exceed the antitrust guidelines. By doing so, the physician network joint venture will have the ability to define its worth and quality in terms and measurements to which purchasers and consumers understand and relate. PMID- 10177431 TI - Faculty practice and university hospital integration. AB - With a long history as unique providers of health care, academic medical centers have been exempt from many of the troubles plaguing less distinguished health care organizations. But with the increasing dominance of managed care, academic medical centers are facing fierce competition from aggressive and often better organized providers. Burdened with cumbersome and tradition-laden organization structures and volatile turf issues, many academic medical centers are still in the early stages of collaborating with physicians and other providers to develop the care continuums being demanded by payors. Few are operating as truly integrated delivery systems. As the stakes get higher, academic medical centers must accelerate development of health delivery systems by integrating faculty practice ambulatory services with university hospital patient services and those of network partners. Together these services can form the foundation of a system that ultimately provides a complete array of inpatient and outpatient services and is supportive of teaching, research and faculty and staff entrepreneurial activities. PMID- 10177432 TI - Cost control, quality begin with information at point-of-care. AB - Controlling costs under managed care usually means making existing procedures less expensive. This approach takes too isolated a view and starts too late. Effective cost control--that maintains or improves quality--begins from a comprehensive view of the totality of the health care process. Some procedures may be unnecessary all together. Some prescription drugs may seem too expensive at first, but in the long run, they so improve patient's health, they save money. In the end, decisions about cost control revert to the classic clinical-ethical question: "Are the services about to be presented necessary, appropriate and the best choice for this particular patient?" PMID- 10177433 TI - Zero-base budgeting can help group practices. PMID- 10177434 TI - Medical groups at the crossroads. AB - Medical groups and physicians have arrived at the crossroads of an uncertain future. The purpose of this paper is to explore how both can collaborate to win over the long-run. Evolving group practice imperatives are analyzed, including reinventing the group practice concept, achieving productivity from providers, intensifying medical management without raising costs and demonstrating the value of products and services. These imperatives define the deliverables required from medical groups and physicians in order to establish a promising fit with managed care plans. Responses to these imperatives enable medical groups to offer precisely the sort of distinctive competitiveness that managed care plans seek and that lead to long-run viability. PMID- 10177435 TI - Evolution in group practice management. An interview with new MGMA chair Mike Wilson. Interview by Pamela L. Moore. PMID- 10177436 TI - NCQA sets certification standards for physician organizations. PMID- 10177437 TI - Resolving payment disputes in small claims court. PMID- 10177438 TI - Improved processes optimize practice performance. PMID- 10177439 TI - The trouble with value and quality. PMID- 10177440 TI - The case for a quality manager. PMID- 10177441 TI - The human side of design: creating a new film library. AB - The use of continuous quality improvement may keep your film library processes running smoothly, but your staff may still struggle daily with its inadequate design. As the experts who work and live within the design, staff members deserve to play an active role in its improvement. When plans for a construction project that would include a larger film storage area were approved at Tampa General Healthcare, the administrative manager of the film library studied the first generation of blueprints. Encouraged to speak to the designer about her ideas, she presented sketches she had traced over blueprints to relocate the office entrance. Her design suggestions were welcomed. With the film library supervisors now wanting to involve staff members, the administrative manager created a wish list survey asking staff about positive and negative aspects of their work space, and for their suggestions on improving it, if given the chance. They responded with ideas for more soundproofing, better lighting and better storage space. Others recommended better ergonomic design for keyboard height, drawers and even the height of the sliding-glass window in the reception area. These suggestions did not account for the process delays the library experienced, however. Spending time in each of four work areas, the administrative manager found wasted movement, crowding of staff, film and equipment, and inadequate storage. This was the right time for change, she felt, an opportunity that shouldn't slip by. Various plans were created, not only to isolate office workers from noise and traffic, but to include items from the wish list. When it was time for the specifications, staff feedback became critical. The administrative manager consulted with staff members on various shifts and worked with staff ideas and sketches. The time the designer spent visiting the many work areas was critical to finalizing plans. The construction phase came next, after careful planning for carrying out work during the interim, a difficult period. A year later, the administrative manager recommends employee involvement in such projects. PMID- 10177442 TI - Performance improvement: how to get employee buy-in. AB - The radiology department at Northern Michigan Hospital in Petoskey, Mich. operated with little change under the same leadership for nearly 20 years. Its equipment was archaic and its operations production focused. Staff morale and both physician and patient satisfaction were low. Given a directive to measurably improve the service and quality offered by the department, the new director let her staff know she needed their support. She then set out to weave in performance expectations for both the organization and the department. Her goal was to create a relationship to both individual and organizational performance improvement, and in turn, to add value to the success of each individual, the department and the organization. Defining work processes was important for the definition of a common vision and core behaviour. The result was the F.A.S.T. concept (friendly, accurate, safe and timely) that put each general work process in a flowchart showing its steps. The next phase involved identifying the measurement for each critical point in the process and determining how to measure it. At each step, questions were defined, answered and translated into individual job descriptions and performance plans. Now, employees know how they and their departments are doing through quarterly reviews. Results are presented monthly at staff meetings, where report cards are posted to provide timely feedback. In some cases, individual report cards within a modality are shared. Successes are celebrated, both in staff meetings and on annual Quality Day, where departments present story boards showing how they have improved service or quality. PMID- 10177443 TI - Providing continuing education through a consortium. AB - A simple phone call was the impetus for a group of hospitals in northern New Jersey to create a consortium that would meet their collective need to supply continuing education credits for their RTs. Many of the seven original member hospitals had eliminated continuing education reimbursement and other resources were unavailable. Yet hospital RTs still needed to fulfill American Registry of Radiologic Technologists (ARRT) requirements. The mission of the consortium was to provide a variety of topics that would meet the criteria for continuing education credits, as mandated by the ARRT. The idea was so simple, the seven original hospital members wondered why they hadn't thought of it earlier. If each member hospital offered a three-credit seminar, collectively the consortium could offer 21 credits per year for their employees, more than enough to meet ARRT requirements. The group gave itself a name--Northern New Jersey Council for Continuing Education--and quickly began to create a policy and procedure manual. It came up with basic rules for attendance, voting privileges and a goal for expanding its membership. The newly created manual detailed member responsibilities and instructions for holding seminars. The manual outlined responsibilities for collecting fees, registration, attendance and certification. The consortium agreed on a consistent format for advertising, letterhead and certificates for seminars. Each member was required to submit a course outline for the consortium's approval, which allowed a variety of both technical and nontechnical topics. Some members organized their own seminars, after submitting an application to the ASRT for approval. Others worked with various vendors who were happy to provide a seminar to a group of customers, rather than to individual customers. After three years, the consortium has proved beneficial to all involved. Most of all, it has met the members' goal of providing continuing education with limited resources. PMID- 10177444 TI - Managing the film library: what to do until the panacea arrives. AB - Today's imaging departments are complex and often decentralized. Despite such growth, the film library is often overlooked and minimally planned for. The oversight may come from the anticipation of picture archiving and communications systems (PACS), considered by many to be the panacea for film management, but in reality, still only a concept, or at best, in its early stages. Since most departments do not anticipate going filmless for many years and others expect to continue hard copy imaging at a 20 to 30 percent rate, managing the film library remains an important issue. In general, film librarians' daily work remains labor intensive, despite attempts to automate some tasks. Yet when cutbacks are made, this support staff is often cut. One way to deal with service and expansion issues in the film library is to stop and evaluate the situation, assess the decline in the level of service, and determine what issues need improvement. Managers should gather information, analyze the data and listen to all interested parties to be sure they understand the overall problems, often best done by someone from outside the department. Analyzing and evaluating work processes, even observing the design of work areas, can be useful in understanding productivity inside the department. An invaluable way to gather data is to listen to those who carry out the daily tasks and those who use the services. Until their needs are understood by management, further changes will have minimal success. When a list of issues is assembled, managers should establish a team to review and prioritize them. Team members will need to understand departmental long-term plans before making recommendations. While every library's operations are unique, a key problem remains lost films. Policies and procedures for removing films must come from hospital senior administration, while managing film within the department is everyone's job. With the chaos under control, managers will be ready to face the challenge of electronic imaging. PMID- 10177445 TI - Construction and renovation guide for imaging facilities: ultrasound. PMID- 10177446 TI - Power and color Doppler assume adjunctive roles. PMID- 10177447 TI - Laparoscopic ultrasound invades the abdomen. PMID- 10177448 TI - Wheeled mobility device database for transportation safety research and standards. AB - To address the issue of safely accessing and securing wheeled mobility devices in motor vehicles, more information characterizing current-production devices was needed. In a recent effort, frame characteristics of wheeled mobility devices were defined and a database developed for recording characteristics relevant to access and securement. A representative number of devices have been surveyed to measure key characteristics, and these measures have been recorded in the database. This paper details the development of the database and frame characterization scheme, the methods used to survey currently available wheeled mobility devices, and some descriptive statistics resulting from an analysis of the data. A discussion of how this information is being used in research aimed at developing technology and safety standards to ensure vehicle access and safe transportation, as well as other potential uses, is also included. PMID- 10177449 TI - A guideline for the design of a four-wheeled walker. AB - More people use assistive technology devices to compensate for mobility impairments than for any other general type of impairment. Increasing numbers of people with mobility or balance problems use walkers with four wheels. Four wheeled walkers are often outfitted with seats to make it possible to travel longer distances with intermediate resting periods. The dangers of sitting on a parked walker are well known. Many physiotherapists tell walker users to park the walker against a wall to prevent injury in case the user forgets to apply the brakes or the brakes fail. To design a safer walker that can be used for sitting, the demands placed on it must be measured. With these data, three modes of walker instability must be considered: first, the brakes may hold but the wheels may slide along the ground; second, the entire walker may tip over; and third, the brakes may fail to hold the wheels in place, and they may begin to roll. Mathematical models can be constructed to simulate how different walker designs will perform. By this process, design improvements can be made for existing walkers, and future walker designs can also be proposed. PMID- 10177450 TI - The voice of the customer: consumers define the ideal battery charger. AB - The Rehabilitation Engineering Research Center on Technology Evaluation and Transfer is exploring how the users of assistive technology devices define the ideal device. This work is called the Consumer Ideal Product program. The results show what device characteristics are most and least important, indicating where to place the priority on product features and functions from the consumer's perspective. The "voice of the customer" can be used (1) to define the ideal characteristics of a product, (2) to make trade-offs in product design and function improvements based on their relative importance to the consumer, (3) to compare the characteristics of existing products against the characteristics of the ideal product, or (4) to generate a product checklist for consumers to use when making a purchase decision. This paper presents the results of consumers' defining the ideal battery charger. Four focus groups generated the survey's content, then 100 experienced users rated 159 characteristics organized under 11 general evaluation criteria. The consumers placed the highest importance on characteristics from the general evaluation criteria of product reliability, effectiveness, and physical security/safety. The findings should help manufacturers and vendors improve their products and services and help professionals and consumers make informed choices. PMID- 10177451 TI - Racial differences of frail elders in assistive technology. AB - This study compared differences in coping strategies, such as the use and ownership of assistive devices and home modifications, for 64 black and 441 white frail elders from the University at Buffalo Consumer Assessment Study. Controlling age, income, and education, there was no difference between black and white elders on health and functional status. Black elders on average own and use fewer assistive devices than white elders. There is no difference between the two groups in the number of home modifications, although black elders experience more home environmental problems than white elders. The majority of black elders rent their residence and thus lack the authority and ability to make the necessary adjustments to their home environmental problems. Predictor variables for assistive device use and environmental problems varied for black and white elders. PMID- 10177452 TI - An interdisciplinary problem-based learning project for assistive technology education. AB - The purpose of this paper is to describe the development, implementation, and outcomes of an extended problem-based learning project imbedded in an interdisciplinary assistive technology course. Students representing four health care disciplines worked together in small groups to address the complex needs of clients with significant issues regarding assistive technology (seating and mobility, augmentative communication, and computer access) and adaptive function. Problem-based learning was seen as a way to enhance the students' clinical reasoning and problem-solving skills and provide a "real life" treatment in a team experience. Formal and informal course evaluation results yielded qualitative data that reflected highly favorable impressions of the problem-based learning project, as well as suggestions for the future. PMID- 10177453 TI - Everest and Jennings Distinguished Lecture. Continue to be good. Aspire to be great. PMID- 10177454 TI - Colin McLaurin--a tribute to a quiet giant. PMID- 10177456 TI - Sheets, 3-D strands, trimensional (3-D) shapes, and sutures of either reinforced or nonreinforced expanded polytetrafluoroethylene for facial soft-tissue suspension, augmentation, and reconstruction. AB - Expanded polytetrafluoroethylene (e-PTFE) is an expanded, fibrillated polymer recently used in facial reconstruction. This material is produced in two compositions: pure e-PTFE, for sheets, 3-D strands, and sutures; and e-PTFE reinforced with fluorinated ethylene propylene (FEP) for sheets and trimensional (3-D) shapes. This material has been used for facial soft-tissue suspension, augmentation, and reconstruction and has demonstrated advantages over autologous grafts due to its optimal tissue incorporation, low infection risk, and biological inertness. PMID- 10177455 TI - Potential problems associated with use of speech recognition products. AB - Commercial speech recognition products are being used increasingly as alternate input devices for computers, particularly by persons with physical disabilities. These discrete speech dictation systems require the user to insert brief but distinct pauses after each spoken word. Anecdotal evidence suggests that some persons using these products experience moderate to severe problems with their voices, such as hoarseness, sore throats, and even complete loss of voice. This preliminary study, which includes data gathered from survey dissemination and clinical studies, indicates that persons with cumulative trauma disorder may be the most susceptible to these voice problems. Also, we hypothesized that in using these discrete speech recognition systems, there may be a tendency to maintain constant pitch, volume, and inflection, keeping the vocal tract musculature in a fixed position. Maintaining this fixed position for extended periods may result in muscle fatigue and, eventually, injury to the laryngeal musculature. Further studies are needed, however, to investigate the effects suggested here. In the meantime, we recommend that users become informed about the unnatural speech patterns used with discrete speech recognition systems; learn to use good vocal hygiene, such as performing warm-up and cool-down voice exercises; and use alternate methods of input along with the speech recognition product. PMID- 10177457 TI - High-density porous polyethylene for facial bone augmentation. AB - Medpor is a porous polyethylene biomaterial used in plastic and reconstructive surgery in the craniofacial skeleton. Its porous nature allows for substantial vascular and soft-tissue ingrowth. Medpor is available in a variety of implants including block, sheet, and preformed shapes. In vitro and in vivo studies have demonstrated that Medpor has been successfully used in the reconstruction of the orbital floor and external ear, and in augmentation of the chin, mandibular, nasal, and malar regions. PMID- 10177458 TI - Technical considerations in the use of polymethylmethacrylate in cranioplasty. AB - Polymethylmethacrylate (PMMA) is a self-curing acrylic resin that can be used in the repair of cranial defects. It is available in three forms: PMMA without mesh, PMMA reinforced with mesh, and PMMA preformed to fit a defect. In cranioplasty, the size and location of the defects provide the selection criteria for the use of PMMA. PMMA without mesh is ideal for small defects (5 cm2-15 cm2). PMMA reinforced with mesh is used for moderate sized defects (16 cm2-49 cm2). For very large defects (> or = 50 cm2), a CT scan guided mold is recommended because it provides the ideal contour and shape that simulates the normal skull. PMID- 10177459 TI - Polydimethylsiloxane for augmentation of the chin, malar, and nasal bones. AB - Polydimethylsiloxane (PDMS) is used for augmentation of the chin, malar and nasal bones and is available through three different manufacturers. PDMS has been widely accepted by surgeons for bone augmentation because of its variability in hardness, its ability to be easily molded and shaped, and its biological inertness. Wound repair around PDMS implants is achieved through capsule formation. Fibrous capsule formation can be interrupted by infection, immune reaction, implant migration, or extrusion. Recent studies have shown no correlation between silicone implants and connective tissue disease. PMID- 10177461 TI - University of Hawaii developing telehealth course. PMID- 10177460 TI - Anorganic bovine bone and analogs of bone mineral as implants for craniofacial surgery: a literature review. AB - Hydroxyapatite compounds and a new anorganic bovine bone mineral are materials that offer an alternative to autologous bone grafting. Ceramic hydroxyapatite implants are limited in their usefulness due to difficulty in contouring the cortical form and the tendency for the granular form to exist outside the reconstruction site. These limitations have been overcome by the advent of a hydroxyapatite cement paste exhibiting good biocompatibility, contour manipulation, implant stability and osseoinduction. Preliminary studies indicate that a new resorbable anorganic bovine bone mineral with a chemical composition and structure similar to human bone promotes initial bony healing more readily than its synthetic hydroxyapatite counterpart, and therefore may serve as an excellent alternative for craniofacial reconstruction. PMID- 10177462 TI - Kaiser patients accept telemedicine. PMID- 10177463 TI - Virtual world helps hospitalized children. PMID- 10177464 TI - Krug telemedicine system flies aboard space shuttle. PMID- 10177465 TI - Ultrasound to be aboard International Space Station. PMID- 10177466 TI - Navy uses telemedicine to save sailors, money. PMID- 10177467 TI - New guide discusses telemedicine for the home. PMID- 10177468 TI - Nortel equipment links Brazilian telemedicine network. PMID- 10177469 TI - World Bank calls for partnership in telehealth. PMID- 10177471 TI - Heather Hill Hospital launches website. PMID- 10177470 TI - Rural Montana uses telepsychiatry network. PMID- 10177472 TI - Subtle speech and language disorders identifiable through satellite transmission. PMID- 10177473 TI - Mobile BAT gets stroke victims to hospital. PMID- 10177474 TI - Providers must carefully evaluate risk in managed care contracts. A guide for contract negotiators. PMID- 10177475 TI - Getting started: quality improvement in an academic group practice. A university physicians' group measures results. PMID- 10177476 TI - Practice brief. Issue: A checklist to assess data quality management efforts. American Health Information Management Association. PMID- 10177477 TI - Taking chances, moving forward. PMID- 10177478 TI - HCFA publishes proposed rule on conditions of participation. PMID- 10177479 TI - American College of Healthcare Executives' Ethical Policy Statement: health information confidentiality. PMID- 10177480 TI - Ownership of health information in the information age. AB - The question "Who owns health information?" has no simple answer. The authors examine problems related to traditional ownership in the age of aggregated information and offer suggestions as to how some of these issues can be clarified and resolved. A sidebar examines the traditional view of provider and patient ownership and how these structures are changing. PMID- 10177481 TI - Protection of personal data--the European view. AB - A new series of laws are being passed to control the processing of personal information--including medical information--inside the European Commonwealth. The author gives an overview of the European view of personal information and examines the implications for healthcare professionals both here and abroad. PMID- 10177482 TI - New standards focus on information security. PMID- 10177483 TI - Securely implementing remote access within health information management. AB - As technology changes, our definition of the workplace expands, and we no longer are limited to working at our desk in an office. The authors describe technologies that enable us to work from home or on the road and examine security regulations and precautions. PMID- 10177484 TI - Reengineering medical records: the Dubois Regional Medical Center's experience. PMID- 10177485 TI - Stevens-Johnson syndrome. PMID- 10177486 TI - New Hanover Regional Medical Center in Wilmington, NC, does well by doing good. PMID- 10177487 TI - Globally priced episodes of care show promise of quality enhancement as deployed by Oxford Health Plans. PMID- 10177488 TI - Population-based chronic care and adverse risk selection: resolving the conflict. AB - Managed care prevention techniques can result in better management of the chronically ill--but higher costs for health plans. One physician consultant recommends blending risk management skills of insurers with care management skills of providers to develop the best possible care of these populations. PMID- 10177489 TI - Oregon collaboration standardizes ambulatory diabetes care. AB - When Oregon state officials recognized that differences among health plans' guidelines for treating diabetes resulted in less-than-adequate care, they brought the groups together to resolve the differences. Procedures were set up and adopted by the state's major health plans. PMID- 10177490 TI - Reducing variation in cataract surgery technique cuts complications. PMID- 10177491 TI - The population-based approach to chronic care. AB - Looking at the needs of a population rather than the episodes that land individuals in the hospital is one way to improve care. Find out the 10 steps to establishing population-based care programs, and learn some healthcare organizations' strategies for preventing acute episodes. PMID- 10177492 TI - Patients: why some press on while others give up. PMID- 10177493 TI - Employers: offering help along the way. PMID- 10177494 TI - Compliance a la carte. PMID- 10177495 TI - The worker's health: whose business is it? PMID- 10177496 TI - Data watch. The high cost of silent killers. PMID- 10177498 TI - 1998 market directory. PMID- 10177499 TI - Smoke and mirrors: Florida's tobacco-related Medicaid costs may turn out to be a mirage. PMID- 10177497 TI - Silent diseases: danger on the path to productivity. PMID- 10177500 TI - Child and Adult Care Food Program: improved targeting of day care home reimbursements--Food and Consumer Service, USDA. Final rule. AB - This final rule amends the Child and Adult Care Food Program regulations governing reimbursement for meals served in family day care homes by incorporating changes resulting from the Department's review of comments received on a January 7, 1997, interim rule. These changes and clarifications involve: The appropriate use of school and census data for making tier I day care home determinations; documentation requirements for tier I classifications; tier II day care home options for reimbursement, including use of child care vouchers; calculating claiming percentages/blended rates using attendance and enrollment lists; and procedures for verifying household applications of children enrolled in day care homes. This final rule also amends the National School Lunch Program regulations to facilitate tier I day care home determinations by requiring school food authorities to provide elementary school attendance area information to sponsoring organizations. These revisions implement in final form the provisions of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 to target higher CACFP reimbursements to low-income children and providers. PMID- 10177501 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE program; nonavailability statement requirements--DoD. Final rule. AB - This final rule revises certain requirements and procedures for the TRICARE Program, the purpose of which is to implement a comprehensive managed health care delivery system composed of military medical treatment facilities and CHAMPUS. Issues addressed in this rule include priority for access to care in military treatment facilities and requirements for payment of enrollment fees. This rule also includes provisions revising the requirement that certain beneficiaries obtain a non-availability statement from a military treatment facility commander prior to receiving certain health care services from civilian providers. PMID- 10177502 TI - Annual update of the HHS poverty guidelines--HHS. Notice. AB - This notice provides an update of the HHS poverty guidelines to account for last (calendar) year's increase in prices as measured by the Consumer Price Index. PMID- 10177503 TI - Reconsideration of denied claims--VA. Proposed rule. AB - This document proposes to amend the Department of Veterans Affairs' "Medical" regulations by adding a new section to set forth reconsideration procedures available if requested by an individual or entity who made a claim for benefits administered by the Veterans Health Administration and who disagrees with the initial decision denying the claim. It is anticipated that these procedures would not only allow for more reflective decisions at the local level but would also allow some disputes to be resolved without the need for further appeal to the Board of Veterans Appeals. PMID- 10177504 TI - Medical devices; device tracking; new orders to manufacturers--FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing that the agency has issued new orders to manufacturers of devices that were subject to tracking. These new orders became effective on February 19, 1998, and require manufacturers to continue tracking the devices under the revised tracking provisions of the recently enacted Food and Drug Administration Modernization Act of 1997 (FDAMA). FDAMA allows the agency discretion in issuing orders to manufacturers to track devices that meet certain criteria. FDA is soliciting comments on what factors should be considered in exercising its discretion in determining whether the agency should not track a particular device, even though it meets the statutory criteria. FDA specifically is requesting comments on whether there are factors that FDA should consider in exercising its discretion in releasing certain devices listed in this notice from tracking requirements. Elsewhere in this issue of the Federal Register, FDA is announcing the availability of a guidance that addresses device tracking under FDAMA, including the application of certain requirements under the current tracking regulations. PMID- 10177505 TI - FDA modernization act of 1997: guidance on medical device tracking; availability- FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing the availability of a guidance entitled "Guidance on Medical Device Tracking." This guidance is intended to provide guidelines to manufacturers and distributors about their responsibilities for medical device tracking under the Food, Drug and Cosmetic Act (the act), as amended by the Food and Drug Administration Modernization Act (FDAMA). This guidance addresses what statutory and regulatory tracking requirements have changed and what requirements remain the same under the FDAMA amendments. The agency requests comments on this guidance. Elsewhere, in this issue of the Federal Register, FDA is announcing new orders to manufacturers of devices that were subject to tracking. PMID- 10177506 TI - Medicare and Medicaid programs; surety bond requirements for home health agencies -HCFA. Final rule. AB - The Balanced Budget Act of 1997 (BBA'97) requires each home health agency (HHA), in order to participate in either the Medicare or the Medicaid program, to secure a surety bond. On January 5, 1998, we published a final rule with comment period that requires that each Medicare-participating HHA obtain from an acceptable authorized Surety a surety bond that is the greater of $50,000 or 15 percent of the annual amount paid to the HHA by the Medicare program, as reflected in the HHA's most recently accepted cost report. The rule also requires that an HHA participating in Medicaid must furnish a surety bond in an amount that is the greater of $50,000 or 15 percent of its Medicaid revenues to the Medicaid State agency in each State in which it operates. The rule also requires submittal of the initial bond to HCFA or the State Medicaid agency, or both--as applicable--by February 27, 1998. Because some HHAs have not been able to obtain a surety bond in time to meet the February 27 date, we are removing the date by which HHAs are required to submit the bonds to HCFA and/or the State Medicaid Agency. PMID- 10177507 TI - Medicare and Medicaid programs; surety bond requirements for home health agencies -HCFA. Notice of intent to amend regulations. AB - This document announces our present intent to make technical revisions to the surety bond and capitalization regulations for home health agencies (HHAs) published on January 5, 1998 (63 FR 292-355). These intended revisions include: generally limiting the Surety's liability on the bond to the term when it is determined that funds owed to Medicare and Medicaid have become "unpaid," regardless of when the payment, overpayment or other action causing such funds to be owed took place; establishing that a Surety will remain liable on a bond for an additional two years after the date an HHA leaves the Medicare or Medicaid program; and giving a Surety the right to appeal an overpayment, a civil money penalty, or an assessment if the HHA to which the bond has been issued fails to pursue its rights of appeal. These revisions should help smaller, reputable HHAs, such as non-profit visiting nurse associations, obtain surety bonds without weakening protections to Medicare and Medicaid inherent in the bond requirements. PMID- 10177508 TI - Compensation for certain undiagnosed illnesses--VA. Final rule. AB - This document adopts as a final rule the provisions of an interim final rule which amended the Department of Veterans Affairs (VA) adjudication regulations regarding compensation for disabilities resulting from undiagnosed illnesses suffered by Persian Gulf Veterans. This amendment is necessary to expand the period within which such disabilities must become manifest to a compensable degree in order for entitlement for compensation to be established. The intended effect of this amendment is to ensure that veterans with compensable disabilities due to undiagnosed illnesses that may be related to active service in the Southwest Asia theater of operations during the Persian Gulf War may qualify for benefits. PMID- 10177509 TI - Treatment of research-related injuries to human subjects--VA. Final rule. AB - This final rule amends the Department of Veterans Affairs (VA) medical regulations to provide (or to pay for the provision of) necessary medical treatment to certain human subjects injured as a result of participation in VA research. Under the final rule all participants in research approved by a VA Research and Development Committee (regardless of source of funding), and conducted under the supervision of one or more VA employees, are eligible for treatment unless injuries are due to noncompliance by a research subject with study procedures. VA will provide medical care in those circumstances where VA has some responsibility for the need for medical care. PMID- 10177510 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1998 rates; corrections--HCFA. Final rule with comment period; correction notice. AB - In the August 29, 1997, issue of the Federal Register (62 FR 45966), we published a final rule with comment period revising the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes resulting from the Balanced Budget Act of 1997, Pub. L. 105-33, and changes arising from our continuing experience with the system. This document corrects errors made in that document. PMID- 10177511 TI - New drugs for human use; clarification of requirements for patent holder notification--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to amend its regulations on notice of certification of invalidity or noninfringement of a patent to provide additional methods for new drug and abbreviated new drug applicants to provide notice to patent owners and new drug application (NDA) holders, without removing the existing means. These proposed amendments reflect current business practices and are intended to ensure that notice is provided to patent owners and NDA holders in a timely manner. FDA is also proposing to require certain applicants to submit to FDA a copy of the notice of certification. PMID- 10177512 TI - Outcomes needs bring innovations to home care. PMID- 10177513 TI - GIS: mapping the gap between providers and members. PMID- 10177514 TI - Worker's comp meets managed care. In the quest for lower costs, a new niche emerges. AB - Niche markets such as Medicare, Medicaid and behavioral healthcare are looking to managed care to control costs and increase the quality of care provided. Now workers' compensation officials are looking to managed care with the same goals in mind. As managed care organizations begin marketing to these special populations, the information glut is growing. Information technology can aid managed care officials in the collection, organization and dissemination of the data. PMID- 10177515 TI - How to enter the intranet era. PMID- 10177516 TI - Handling risk. Proactive risk management spans the spectrum of care delivery. AB - Risk management has changed in recent years. What once was a paper-pushing, claims issue has become a more involved process. Today, proactive risk management spans the spectrum of care. This article addresses the needs now facing risk managers and others involved in the care of patients and members, the data they need and how they can collect it. Financial and clinical data are discussed as they relate to the management of risk in today's managed care organization. This, certainly, is not an easy industry to get one's arms around. PMID- 10177517 TI - Risk management information systems update. PMID- 10177518 TI - Data security is everyone's job. PMID- 10177519 TI - Make ethical decisions known throughout the organization. PMID- 10177520 TI - Presbyterian Healthcare Services: New Mexico's managed care leader. AB - In 1997, PHS enhanced its presence in the managed care market by adding a large HMO to its health plan and snagging the largest part of state Medicaid managed care contracts. The health plan, once the source of only 15% of the system's revenue, is fast becoming the dominate component of the healthcare delivery system--a source of discontent for those who liked the old system. Find out the strategy behind these changes and plans for the future. PMID- 10177521 TI - California task force recommends managed care reform. PMID- 10177522 TI - Organizational ethics: it's your move. AB - As market forces have continued to push healthcare systems toward greater efficiency and lower costs, providers have begun asking for help in balancing ethical concerns. Several organizations are responding by establishing programs to provide guidelines for ethical decisionmaking. Health System Leader talked with these pioneers about their progress, the thinking that went into establishing these programs, and their recommendations for others beginning to tackle this need. PMID- 10177523 TI - There's no place like home. Genesys opens an outpatient detoxification program. AB - Genesys Health System's Center for Addiction Treatment in Flint has developed an outpatient detoxification treatment program that provides a desperately needed alternative to inpatient treatment and traditional outpatient therapy. Substance abusers who need daily medical monitoring, physician supervision, and a strong support system can benefit from the program--without inpatient treatment. PMID- 10177524 TI - Foot-in-mouth disease: condition stable, prognosis guarded. PMID- 10177525 TI - Legal issues in telemedicine. AB - The health care industry is in the process of addressing the problems that may arise from the development and implementation of telemedicine, including legal issues. Those issues include licensing of providers, confidentiality and privacy of patient information, and legal liability issues. The concerns expressed about licensing are addressed in legislation before the Michigan legislature. The technical aspects arising from concerns regarding privacy and confidentiality and legal liability issues have been recognized to exist as well. The following discussion will seek to highlight these issues to facilitate further analysis of them. PMID- 10177526 TI - Help for the rural provider. PMID- 10177527 TI - Life's little miracles. The Recuperation Center helps people heal. AB - "I see miracles happen here all the time." That's Dawn Brouwers' assessment of the Recuperation Center (TRC) in Grand Rapids, where she serves as executive director. Brouwers watches people come to TRC unable to walk, and later head for home under their own power. Patients arrive with no idea how they'll be able to live independently again, and leave with supportive systems established in their homes that allow them to be self-reliant. PMID- 10177528 TI - The wonderful world of Disney. A look at the future of health care? AB - What does the future hold for health care delivery? What will prove to be the most effective model for health services delivery in the next century? These are the questions that are foremost in the minds of health policy analysts across the country. While any discussion about the future of American health care typically centers around alternative payment methodologies or emerging physician-hospital integration models, one company believes it has a unique solution and is eager to share its vision for the future. That company is none other than Disney, and Celebration Health--with its grand opening on Nov. 23, 1997--is its latest venture. PMID- 10177529 TI - Raising the standard. Federal rules take aim at medical waste incinerators. PMID- 10177530 TI - Focus, focus, focus. Customer service strategies provide a competitive edge. PMID- 10177532 TI - Candor can be good news. PMID- 10177531 TI - Health care of the future. AB - Michigan Health & Hospitals magazine asked two member CEOs to answer the question what will health care delivery look like in the future? Judeth Javorek looked 50 years ahead, while Anthony Tersigni explored the near future. Following are their responses. PMID- 10177533 TI - Who will care for me? PMID- 10177534 TI - A family-friendly focus. AB - The cost of attracting and retaining qualified workers is difficult to quantify, but many human resource professionals adhere to the "factor of four" multiplier when considering turnover costs. For example, replacing a departing employee with an annual salary of $25,000 eventually will cost the company $100,000. This includes an employee's knowledge of the company, efficiency, and rapport and contacts established on the job. None of these can be replaced easily or inexpensively. PMID- 10177535 TI - Home, risky home. AB - Driven by increasing costs and decreasing reimbursement for inpatient care, home health care has been one of the fastest growing segments of the health care industry in recent years. While home care offers psychological and cost benefits to patients, there are increased liability exposures for the agency, hospital and health system. PMID- 10177536 TI - Going green by reducing red. New alternative medical waste treatment technologies. AB - The field of medical waste disposal is changing rapidly. Over the past decade, there has been increasing public health concern over health care's red bag waste. The health care industry must routinely contend with a complex set of regulations covering occupational safety, transportation and packaging, medical waste disposal management, and now environmental regulations for medical waste incinerators. PMID- 10177537 TI - Home care at a crossroad. AB - This decade's fastest growing segment of the health care industry, home health care, is facing a significant challenge as a result of changes in Medicare reimbursement included in the Balanced Budget Act of 1997. The implications could prove to substantially reshape the industry as well as many of its providers. PMID- 10177538 TI - A direct connection. Bringing health care and business together. PMID- 10177539 TI - The mecca of care. AB - Large regional medical centers have traditionally been viewed as a one way conduit of patients from outlying geographic areas to the metropolitan "mecca" of care. In reality, this perception is not far from the truth. The larger center saw smaller rural hospitals as "feeders" for referrals often resulting in resentment and strained relationships. PMID- 10177540 TI - Decision support considerations in the development and implementation of an electronic medical record. AB - The requirement for decision support capability has been a major force in the evolution of the electronic medical record (EMR). The EMR should deliver contextual information so that financial and clinical decision makers can efficiently, and with patient-centered understanding, deliver appropriate care. An organization's pursuit of the EMR is based in its need to overcome problems managing information and its analysis and to create a picture of the patient in terms of outcomes. This discussion is designed for use as a guide to how pharmacy management can support or lead an enterprise's EMR and decision support evolution. PMID- 10177541 TI - Issues of decision support in institutional pharmacy systems. AB - This article discusses the challenges of implementation and maintenance of a decision support system operating within an institutional pharmacy information system. The basic principles of database building and configuration are reviewed. Issues with the common alert systems, allergy, drug interactions, drug-food, and duplicate are discussed. The challenges within dose-ranging programs are also described. Pharmacists are encouraged to develop population-based decision support systems and systems which add value at the individual patient level. PMID- 10177542 TI - Assessing data quality for decision support--emphasis on secondary analysis. AB - In secondary analysis, the use of available data makes it possible for the researcher to bypass the most time-consuming and costly steps in the research process. However, there are some noteworthy pitfalls and problems in working with existing data, especially the uncertainty of data quality. If the integrity and quality of data are not assured, statistical analysis of the data will not be reliable, no matter what statistical procedure is used. If the analysis is not reliable, the information used for decision support will not be accurate. PMID- 10177543 TI - Developing a management planning and control system for ambulatory pharmacy resources. PMID- 10177544 TI - Improving the process of medication budget forecasting. PMID- 10177546 TI - Coping with consolidated billing. PMID- 10177545 TI - Disease management and business alliances. PMID- 10177547 TI - Assisted living. Back to basics in the new year. PMID- 10177548 TI - Year of the database. Software vendors are vying to help you put your data to work. PMID- 10177549 TI - Learning to lead. PMID- 10177550 TI - The federal factor. How government rules and regulations have shaped long-term care. PMID- 10177551 TI - Following restraining orders. PMID- 10177552 TI - Heading off system breakdown in the year 2000. PMID- 10177553 TI - Sometimes it pays to appeal survey findings. PMID- 10177554 TI - Five minutes with Dan Blazer. Interview by Doug Brunk. PMID- 10177555 TI - Meaningful data: ask the right questions at the right times. AB - "Garbage in equals garbage out" is never more true than when benchmarking with peers. Asking the right questions about your own operation as well as your benchmarking partner's takes some practice. Managers can be trained to interview, maximize the information gathered, and get pertinent facts. Experts say too rigid a focus on "apples to apples" comparisons will cause you to miss opportunities for improvements. PMID- 10177556 TI - Benchmarking develops buy-in for pathways. AB - Benchmarking needs to be an essential element of clinical pathways development to make sure highest-cost DRGs are prioritized. Data-driven internal and external comparisons not only help set best practices but appeal to physicians who must buy into paths. Nonetheless, physician champions are a necessary part of the mix because their leadership minimizes obstacles. PMID- 10177557 TI - Merging departments saves $400,000. AB - With hospital systems constantly pressured to cut costs, benchmarking can help managers make good decisions about where to focus attention. Once opportunities for improvement are identified, benchmarking provides data on how to improve. One children's hospital used benchmarking to bring a department's cost and efficiency in line with those of its peers. PMID- 10177558 TI - Psychological care can reduce cardiac costs. AB - Coronary artery disease patients show sure signs of benefiting from psychological counseling. At a time when HMOs have been "carving out" mental health benefits in an effort to control costs, an APA-Mayo model should help force the reintegration of the split. PMID- 10177559 TI - Panel defines essential infection control elements. PMID- 10177560 TI - You can safely skip the LDH and save thousands. AB - Walter Reed Army Medical Center ran a utilization review study on lactate dehydrogenase testing and concluded it's not needed to rule out myocardial infarction. Not performing 6,177 tests saved the hospital $47,000. Nearly 3/4 of hospitals perform unnecessary tests routinely. National guidelines have recommended against routine LDH testing since 1990. PMID- 10177561 TI - Written asthma plans cut hospitalizations in half. AB - A recent study found that children whose parents had written asthma management plans were half as likely to have a hospitalization or emergency department visit. A written plan is needed to help parents intervene at the first signs of deterioration so they can prevent their children from getting worse. The plan should teach parents how to recognize symptoms and how to respond quickly and appropriately. PMID- 10177562 TI - For best results, critically examine process behind benchmarking data. PMID- 10177563 TI - Pediatric facility links teamwork, OR productivity. PMID- 10177564 TI - Courting referrals with benchmarking data. PMID- 10177565 TI - Consortium benchmarks nonclinical outcomes. PMID- 10177566 TI - Are you spending your prenatal dollars wisely? PMID- 10177567 TI - Nurse partners are Medicare provider's secret weapon. PMID- 10177568 TI - Carle Clinic's risk screening tools identify, help manage at-risk senior patients. AB - Medicare risk screening tools: The Carle Clinic Association began identifying frail elderly years before Medicare risk was born, using a simple screening tool that could be used today. See how that screen evolved into a more sophisticated tool that's used today in screening new Medicare risk patients. PMID- 10177569 TI - Disease management program saves $850 PMPM for CHF seniors enrolled in Medicare risk. AB - Chf disease management saves medicare plan $850 pmpm: Humana Inc. has improved the care and outcomes of 1,900 seniors with congestive heart failure--plus slashed utilization and saved millions. Here are the details on how the program works and why monitoring CHF patients by phone is so important. PMID- 10177570 TI - Address low literacy issues to improve Medicaid risk member compliance, reduce costs. AB - Low literacy linked to higher costs among managed medicaid patients: The evidence is mounting that low literacy levels may be linked to poor Medicaid risk patient compliance and higher medical costs. Here are the details on an important new study, plus some tips from literacy experts on how to improve verbal and written communication skills. PMID- 10177571 TI - HMO study identifies leading cancers among seniors, offers cost and utilization benchmarks. AB - Data file: Research conducted at Kaiser Permanente in Northern California reveals the high prevalence of cancer rates among the plan's seniors and offers some valuable cost benchmarks. Among the findings of interest to plans and providers at full risk: the average costs of the disease can run double or more the typical Medicare PMPM rate. PMID- 10177572 TI - Marketplace. New York's hospital price-fixing suit spotlights troubles with joint operating agreements. PMID- 10177573 TI - Perspectives. Solution gap looms for financing baby boomers' future long-term care needs. PMID- 10177574 TI - Perspectives. Struggling choices demo full of warning signs for aspiring Medicare PSOs. PMID- 10177575 TI - Focus on quality assessment: the need for evaluation. AB - There is growing concern among purchasers and consumers of health care as well as among regulators that managed care has meant that quality has been sacrificed in the name of cost saving. Employers, as major purchasers, should demand that the managed care organizations they utilize demonstrate high-quality/low-cost care. PMID- 10177576 TI - Fiduciary responsibility and potential liabilities in health care cost management. AB - This article addresses the key legal issues facing ERISA welfare plan fiduciaries in health care cost management and explores the current status of a number of fiduciary obligations particularly relevant to welfare plan trustees. The authors discuss the fiduciary issues raised by the selection of a health care delivery system, plan design decision making and provider discount arrangements with health plans, and provide suggestion for administering reimbursements for health care costs from third party recoveries and addressing provider fraud. PMID- 10177577 TI - Disability management in Canada: rights and responsibilities. AB - As Canadian employers become more actively involved in disability management, they must be aware of the legislative and regulatory requirements that will affect their programs. Workers' compensation and occupational health and safety legislation are clearly important, but privacy legislation, privacy guidelines, employment standards requirements and common law principles may also be applicable. By addressing their legal obligations when they develop their disability management programs, employers can act in a manner that is both prudent and proactive. PMID- 10177578 TI - Recent developments in domestic partner benefits. AB - Domestic partner benefits have become increasingly common, particularly among large employers, as firms respond to stiff competition for highly skilled employees and also to equity issues. A lawsuit filed in response to the City of San Francisco's domestic partner amendment to an existing ordinance has drawn renewed attention to the subject in recent months. PMID- 10177580 TI - EMS Magazine website review. PMID- 10177581 TI - On event fund raising. Why have prices? PMID- 10177579 TI - Shockingly successful. How AEDs are expanding field treatment for victims of sudden cardiac arrest. PMID- 10177582 TI - Recruiting celebrities to tell your story. PMID- 10177583 TI - A recipe for non-profit success: managing the linkages and key elements of successful organizations. PMID- 10177584 TI - Everyone's scratching ... and it is contagious. AB - When implementing a fund-raising program or product, coordinators are faced with problems like quality, cost, and time involved. The Pennies to Dollars donation system was created to eliminate all of these worries, in addition to improving campaign implementation and profit potential. PMID- 10177585 TI - Septuplets! How hospital security handled the unprecedented media crush. PMID- 10177586 TI - An interview with: Russell F. Jones on what's ahead for IAHSS and hospital security professionals in today's changing healthcare environment. PMID- 10177587 TI - Violence hits home: murder of security supervisor by fired employee. PMID- 10177588 TI - The Birmingham abortion clinic bombing: preparing for an escalation of violence. AB - Reproductive healthcare clinics and hospitals that perform abortions are facing increased security concerns following the latest major incident of violence directed at such facilities--the January 29 bombing of a Birmingham, AL, abortion clinic that killed an off-duty police officer and seriously wounded a nurse. As of publication date, the FBI had issued an arrest warrant and was still searching for Eric Robert Rudolph, 31, as a suspect in the bombing, the first fatal one of an abortion clinic. A $100,000 reward is being offered to anyone providing information that leads to his arrest and conviction. This report will provide further details on abortion clinical violence and additional information on how such facilities--whether freestanding or hospital based--can better protect themselves. PMID- 10177589 TI - Hospital's new high-tech ventilation system reduces risk of infection. PMID- 10177591 TI - New COPs (conditions of participation) are on the way. PMID- 10177590 TI - Interaction of EAS systems with pacemakers. PMID- 10177592 TI - A credible CP (compliance program) is both sword and shield. PMID- 10177593 TI - Put head and heart into your CP (compliance program). PMID- 10177594 TI - ORYX: March 2 is breathing down your neck. PMID- 10177595 TI - New sentinel policy encourages self-reporting. PMID- 10177596 TI - JCAHO lightens its touch. PMID- 10177597 TI - Is your UR committee a dinosaur? PMID- 10177598 TI - No more secrets and lies. PMID- 10177599 TI - Community care. The afterpains of aftercare. PMID- 10177600 TI - Information technology. The bug stops here. AB - The millennium bug arises because up to the 1980s computers were programmed to represent years by the last two digits only. So, when the millennium arrives, programmes which represent the year 2000 as 00 will be unable to make the transition from 1999 into the 21st century. Such programs have been written into microchips, hardware and software. The problem is not restricted to computers, but extends to systems that rely on embedded chips, such as air conditioning, lifts, lighting, security and electro-medical equipment. The potential catastrophic consequences for patient care and administration are clear, and raise liability issues of which NHS managers need to be aware. PMID- 10177601 TI - Misuse of public office. Rogues' gallery. PMID- 10177602 TI - Mental Health. Lost in a no-man's land. PMID- 10177603 TI - Primary care groups. Trust worthiness. PMID- 10177604 TI - Nursing workforce. When the going gets tough. PMID- 10177605 TI - Primary care. Total Commitment. PMID- 10177606 TI - Winter admissions. Combination therapy. AB - Employing an extra social worker at a 600-bed acute hospital over three winter months (January to March 1997) and extending the opening hours of the medical assessment unit reduced delayed discharges. The time from a patient being allocated to a social worker to community care being provided fell from 16.6 to 13.8 days. The package of measures, which included employing a locum registrar in the medical assessment unit and extra nurses, released several hundred bed days. The project has been extended this winter. PMID- 10177608 TI - Health action zones. Trouble zones? PMID- 10177607 TI - On the evidence. Cholesterol and coronary heart disease screening & treatment. PMID- 10177609 TI - R&D. Failing the acid test. PMID- 10177610 TI - Management theory. More art than science? AB - Evidence-based medicine can draw on more clear-cut research than that available for management. But it is still desirable to practise evidence-based management. Managers should encourage a research culture and a questioning approach. Developing a research culture requires at least one senior manager to act as a role model. PMID- 10177611 TI - Care pathways. Paving the way. AB - Care pathways are most commonly used in acute trusts and private hospitals, according to a survey by the National Pathway Association. Orthopaedics is the specialty most likely to employ pathways, followed by surgery, medicine and care of elderly people. A third of respondents found the tool helped control costs, but a similar number found it did not. Setting and implementing standards of care and improving communication between staff are the most commonly reported benefits of using care pathways. PMID- 10177612 TI - Primary care. Associated benefits. AB - Results from an associate physician scheme for one region showed improved services for patients, benefits in organisation and management and high retention of doctors in inner cities. The scheme also caused early retirement of two poorly performing principals and uncovered instances of possible fraud. Success depended on the health authorities' commitment and support. PMID- 10177613 TI - The impact of the UK NHS purchaser-provider split on the 'rational' introduction of new medical technologies. AB - This article uses evidence from case studies of the introduction of three new medical technologies to explore the impact of the UK NHS purchaser--provider split on the diffusion of new medical technologies. A desirable policy objective is assumed to be the 'rational' diffusion of medical technologies according to evidence that they are clinically and cost effective. Theoretical mechanisms are identified through which diffusion could be controlled, and the case studies are used to explore the extent to which rational technology diffusion occurs in practice in the NHS. They illustrate the influence of purchasers and providers on the introduction and early use of new technologies and explore the extent to which research about clinical and cost effectiveness is used to inform decisions about technology adoption. The results demonstrate the limited influence of purchasers and the short term clinical and organisational objectives pursued by providers in relation to technology adoption. It is suggested that initiatives to promote rational technology diffusion might be most effective if they are focused on decision making in providers, and if they aim to balance the influence on decisions of administrative and financial information about the technologies with more systematic use of research about clinical and cost effectiveness. PMID- 10177614 TI - The role of priority programmes in the provision of health services in the state of Oaxaca, Mexico. AB - An assessment of the performance of five priority health programmes (basic sanitation, tuberculosis, vaccination, acute respiratory infections and acute diarrheal diseases) was carried out using ethnographic techniques in the region of La Canada in the state of Oaxaca, Mexico. The region presents a large percentage of Indian and peasant population living in extreme poverty and health care is mainly provided by the Ministry of Health. Both characteristics of the population and the health services are used to analyze the performance of the programmes. With access to abundant resources, vaccination and diarrheal disease programmes have been highly successful in involving the population and achieving their operative targets. Consequently this capacity to concentrate resources results in a lack of resources for other programmes. Despite partial successes, all programmes face serious operational difficulties demonstrating, in turn, the lack of capacity of health services to respond to the specific demands of local populations. The information presented is relevant for the discussion of selective versus comprehensive PHC. PMID- 10177615 TI - The role of geriatric intermediate care facilities in long-term care for the elderly in Japan. AB - Geriatric intermediate care facilities (GICFs) were first established in 1987 to help the hospitalized elderly return home within 3 months. Users of the GICFs are the elders who do not require hospitalization, but are mentally or physically impaired. Rather than providing unnecessary medical services, GICFs emphasize nursing care and rehabilitation so that users can carry out their daily tasks independently. Due to the limited supply of institutional and in-home services for the elderly in long-term care systems in Japan, only half of the discharged users were able to return home and a quarter stayed at GICFs for over 1 year, contrary to the initial purpose. This suggests that in addition to serving as an intermediate facility between institutions and private homes, GICFs should enlarge their role of home care supporting facilities in ways that would enable them to provide frail elderly patients at home with respite care and daycare services. PMID- 10177616 TI - Public/private financing in the Greek health care system: implications for equity. AB - The 1983 health reforms in Greece were indirectly aimed at increasing equity in financing through expansion of the role of the public sector and restriction of the private sector. However, the rigid application of certain measures, the failure to change health care financing mechanisms, as well as growing dissatisfaction with publicly provided services actually increased the private share of health care financing relative to that of the public share. The greatest portion of this increase involved out-of-pocket payments, which constitute the most regressive form of financing, and hence resulted in reduced equity. The growing share of private insurance financing, though as yet quite small, has also contributed to reducing equity. Within public funding, while a small shift has occurred in favor of tax financing, it is questionable whether this has contributed to increased equity in view of widespread tax evasion. On balance, it is most unlikely that the 1983 health care reforms have led to increased equity; it is rather more likely that the system in operation today is more inequitable from the point of view of financing than the highly inequitable system that was in place in the early 1980s. PMID- 10177617 TI - The German health care system and health care reform. AB - This article presents a structured survey of the German health care and health insurance system, and analyzes major developments of current German health policy. The German statutory health insurance system has been known as a system that provides all citizens with ready access to comprehensive high quality medical care at a cost the country considered socially acceptable. However, an increasing concern for rapidly rising health care expenditure led to a number of cost-containment measures since 1977. The aim was to bring the growth of health care expenditure in line with the growth of wages and salaries of the sickness fund members. The recent health care reforms of 1989 and 1993 yielded only short term reductions of health care expenditure, with increases in the subsequent years. 'Stability of the contribution rate' is the uppermost political objective of current health care reform initiatives. Options under discussion include reductions in the benefit package and increases of patients' co-payments. The article concludes with the possible consequences of the 1997 health care reform of which the major part became effective 1 July 1997. PMID- 10177618 TI - Managed care 1998: Medicare managed care. Partner with an HMO? There's more to it than money. PMID- 10177619 TI - Managed care 1998: Medicare managed care. The dos and don'ts of recruiting patients. PMID- 10177620 TI - Managed care 1998: Medicare managed care. Can your group handle full-professional risk? PMID- 10177621 TI - Managed care 1998: Medicare managed care. The verdict from colleagues who contract with HCFA. PMID- 10177622 TI - Managed care 1998: Medicare managed care. A quick guide to the lingo. PMID- 10177623 TI - When the fighting's over, will this practice still be standing? PMID- 10177624 TI - WWW: Can three little letters spell prosperity for your practice? PMID- 10177625 TI - Evelyn's prayer. When medicine can't help the dying, compassion can sometimes comfort the living. PMID- 10177627 TI - Reimbursement. Do health plans squeeze your pay to keep you in line? PMID- 10177626 TI - Are there gaps in your malpractice coverage? PMID- 10177628 TI - Patient relations. Do doctors need more training to build rapport? PMID- 10177629 TI - Do you need long-term-care insurance? PMID- 10177630 TI - Shining a little light on the self-referral ban. PMID- 10177631 TI - PPMs are taking over hospital networks. PMID- 10177632 TI - Managed care 1998. Medicare takes the spotlight. PMID- 10177633 TI - Managed care 1998: Medicare managed care. How you'll fare under new payment rules for senior HMOs. PMID- 10177634 TI - Managed care 1998: Medicare managed care. PSOs: success isn't guaranteed. PMID- 10177635 TI - Managed care 1998: Medicare managed care. Do this homework before taking on risk. PMID- 10177636 TI - Happy crisis tests hospitals' PR plan. Septuplets' arrival swamps Iowa hospitals with national, international media. Blank Children's Hospital, Iowa Methodist Medical Center, Des Moines. AB - The public relations staff believed the birth of healthy septuplets would become a human interest story for local media. But the staff was stunned at the outpouring of international and national media knocking at their front doors. The staff of both Iowa Methodist Medical Center and Blank Children's Hospital in Des Moines, Iowa, organized a communications plan for 14 official press conferences, constant updates to the media and a website to handle ongoing inquiries from the public. As a result, the story of the McCaughey septuplets was shown in more than 10,000 television stories around the world. The hospitals received more than 36,000 magazine and newspaper articles. The public relations staff not only fielded more than 2,000 phone calls in the days following the Nov. 19 birth, but more than 15 major networks parked their vehicles and satellite dishes in front of the hospital. PMID- 10177637 TI - North Carolina health network McGaw Prize winner. Attention to community service revives Bladen County Hospital. AB - Bladen County Hospital receives the prestigious 1997 Foster G. McGaw Prize for Excellence in Community Service. The county hospital funneled the $75,000 award money back to the community as seed money for the development of a wellness/fitness center. PMID- 10177638 TI - Hospital's comic book promotes benefits of good eating habits. Grocery chain joins campaign with "Cancer Day" promotion. Parkview Hospital, Fort Wayne, IN. AB - For the past seven years, Parkview Hospital has provided the educational component of Cancer Day. The hospital has distributed pamphlets that educate about different forms of cancer. Last year, the marketing department undertook the subject of colon cancer. PMID- 10177639 TI - Magazine addresses community health center issues. AB - Community HealthCenter Management was created to provide a source of information for community health center directors and health care providers. It is intended to provide an avenue for people in the industry to share their experiences and resources as well as offer advice on management, personnel issues and office equipment. PMID- 10177640 TI - Ohio healthcare center launches interactive website. Heather Hill Hospital demonstrates treatment, environments. AB - Heather Hill Hospital, Health and Care Center launched an interactive Internet website to share and demonstrate its treatment innovations, programs and environments with interested professionals, caregivers and individuals around the world, reaching more than 30 million people wired into the Internet. PMID- 10177641 TI - New York hospital group striving for brand recognition. HealthStar Network. AB - HealthStar Network established a new concept in its eastern market--a group of hospitals forming one association. Marketers of HealthStar are conducting a branding campaign to distinguish individual expertise under one umbrella company. PMID- 10177642 TI - Guide to raising safe kids finds hospital market. AB - An Illinois company is publishing a magazine designed to help parents raise their children in a safe environment. The glossy publication is distributed to approximately one million readers through pediatricians' offices, neonatal wards and emergency rooms. PMID- 10177643 TI - Alliance about to embark on national confidence building effort. VHA Inc., Irving, Texas. AB - VHA Alliance, a cooperative service network that represents more than 1,600 community and healthcare organizations, is mounting a nationwide confidence building campaign. PMID- 10177644 TI - Art and charity join hands during Christmas holiday season. PMID- 10177645 TI - Five cited for innovative community health programs. Hospitals, health systems form community partnerships. AB - The American Hospital Association awarded recognition to five of the nation's most innovative hospitals and health systems. See how the five hospitals created award-winning community service programs. PMID- 10177646 TI - Capitation: five steps for getting started. PMID- 10177647 TI - Breaking the mold. This system no longer takes a cookie-cutter approach to choosing board members. AB - When a system is formed from a hospital merger, the first board usually includes some from here and some from there. Eventually, the board or the CEO recognizes that this configuration undermines the system, and the board reinvents itself. But Clarian Health Partners started with a "nonrepresentational" board from the get-go, thus avoiding the usual turf issues and decision gridlock. PMID- 10177648 TI - Choosing a search consultant. PMID- 10177649 TI - See your way to a vision of community health. PMID- 10177650 TI - Boards overboard, Part two. PMID- 10177651 TI - What mystery shopping can do for you. PMID- 10177652 TI - Tithing: why now? PMID- 10177653 TI - Drug fighters coming by. Health system helps turn Atlantic City around. AB - AtlantiCare Health System knows firsthand the damage that drugs can do--both to the health and safety of its Atlantic City community and to its own bottom line. That's why it has spearheaded a collaborative effort among the police, residents, and community organizations to rid the city of drug dealers block by block. It's a long process, but one that's already having results. PMID- 10177654 TI - Key players in health care: the clients to know. PMID- 10177655 TI - Image-guided access enhances microtherapy. PMID- 10177656 TI - Multipurpose rooms expand imaging options. PMID- 10177657 TI - One-visit cancer consults streamline therapy decisions. PMID- 10177658 TI - In search of smart & simple PACS workstations. PMID- 10177659 TI - Future of IR in hands of primary-care docs. PMID- 10177660 TI - Stents match surgery in treating aortic aneurysms. PMID- 10177661 TI - Alzheimer's disease: unraveling the tangle. PMID- 10177662 TI - Chemiluminescence in immunoassays. PMID- 10177663 TI - A new challenge for risk managers: assessing risk within a specialty office practice. PMID- 10177664 TI - Cost of risk: a tool for measuring performance. PMID- 10177666 TI - Federal courts weigh impact of disability insurance applications on ADA claims. PMID- 10177665 TI - Program boosts healthy premature deliveries. PMID- 10177667 TI - Spotlight. Clinical data repositories. Filling the data bank. PMID- 10177668 TI - Standards bearers. The standardization of healthcare information gains momentum. PMID- 10177669 TI - Juggling act. Six IT strategies for managing the IDS into the next century. PMID- 10177670 TI - Gateways are coming. So much information exchange in healthcare requires a new approach to electronic communications. PMID- 10177671 TI - Shifting gears. The transition to client/server development. PMID- 10177672 TI - The human factor. Systems work better when designed for the people who use them. PMID- 10177673 TI - IVR (interactive voice response) me ASAP. Four hot applications of interactive voice response. PMID- 10177674 TI - Destination data. Data quality management key to organizing information. PMID- 10177675 TI - Bring in the ringer! Should your organization consider outsourcing IT? PMID- 10177676 TI - The standard intelligent interface. Smart interfaces help organizations absorb new patient populations. PMID- 10177677 TI - Taking a chance. Technology and training partnership delivers outcomes in record time. PMID- 10177678 TI - MARS (medical automated record system) attacks Cleveland. Award-winning system breaks through implementation barriers. PMID- 10177679 TI - The IT revolution. It's time to torture the data. PMID- 10177680 TI - Building the empire. CORBAmed focuses on goals of connectivity and interoperability. PMID- 10177681 TI - Digital Rx. PMID- 10177682 TI - The next wave of Medicare PPS. PMID- 10177683 TI - Limited access Webways. The reality of intranet and extranet business models. PMID- 10177684 TI - Technology survival guide for CFOs. PMID- 10177685 TI - Power shift. Interview by Polly Schneider. PMID- 10177686 TI - Partners in risk. Who pays when your systems don't? PMID- 10177687 TI - Technology ambassador. Interview by Polly Schneider. PMID- 10177688 TI - Middleware. The reality check for mobile healthcare. PMID- 10177689 TI - Serving the patient. IT benefits improve patient care quality and caregiver productivity. PMID- 10177690 TI - Writing to the rules. If you're looking at a clinical decision support system, it had better be Arden Syntax compliant. PMID- 10177691 TI - The urge to merge. PMID- 10177692 TI - Extensibility sensibility. Is XML the solution for electronic medical records data exchange? AB - Extensible Markup Language (XML), a subset of Structured General Markup Language (SGML), could be the key to unlocking medical record information scattered throughout the healthcare enterprise. PMID- 10177693 TI - Operations or outcomes? Clinical decision support systems come in two types. AB - Some organizations implement clinical decision support systems for use as retroactive repositories for strategic decision-making; others are implementing repositories with real-time and interactive clinical decision-making functionalities. PMID- 10177694 TI - How do you measure success? Healthcare looks to benchmarking to improve business processes. PMID- 10177695 TI - Report from down under. National center for healthcare IT. PMID- 10177696 TI - New informatics group in U.K. PMID- 10177697 TI - Better than a silver bullet. Five steps you can take now to save on technology maintenance and administration. PMID- 10177698 TI - Coming to terms. The key to standardizing clinical vocabulary is to build on what's already been done. PMID- 10177699 TI - Healthcare unplugged. Hospitals embrace mobile computing and wireless communications. PMID- 10177700 TI - Risky business. It takes a 'risk-balanced' team to implement a CPR. AB - University of Colorado Hospital: 393-bed inpatient facility and 30 clinics. PROBLEM: A breakdown of collecting and exchanging clinical information. SOLUTION: Create a computer-based patient record project development team to select and implement a CPR system. RESULTS: Eight clinics now participate in the system. KEYS TO SUCCESS: "Creating a risk-balanced team and a strong, honest vendor partnership." PMID- 10177701 TI - Image is everything. New York Hospital's institution-wide digital imaging lowers costs and improves care. AB - The New York Hospital-Cornell Medical Center, Manhattan: a 1,242-licensed bed voluntary non-profit hospital. PROBLEM: Conventional imaging technology created expensive logistical problems between the radiology facility and the Greenberg Pavilion, a new 850,000 square foot, 11-floor inpatient tower, located two city blocks away. SOLUTION: Use a picture archiving communications system (PACS) to transmit, store and archive digital images. RESULTS: Increased staff efficiencies, improved patient care and reduced costs. KEYS TO SUCCESS: "Many years of planning and a full commitment from the staff." PMID- 10177702 TI - Is a merger in your future? PMID- 10177703 TI - A review of ethical considerations in benefits planning. AB - The rising cost of employee benefits and ongoing pressure to improve existing benefits is forcing employers to make difficult decisions. Most employers are truly concerned about the welfare of their employees and attempt to make these decisions in an ethical manner. This article offers practical advice on maintaining an ethical perspective, which the authors contend is necessary to maintain when facing these challenging responsibilities. The article identifies the various stakeholders as well as the necessary steps to consider when attempting to make an ethically sound decision involving employee benefits. PMID- 10177704 TI - Ethical considerations in health care benefits administration. AB - Defining the scope of coverage and limitations in various health plans has become an increasingly difficult and confusing issue. The historical shift to managed care has fundamentally altered the limitations on health care benefits. Because of the existence of "benefits exclusions," confusing issues have emerged in managed care situations. Fundamental fear of health care rationing has raised the awareness of the general public to the ethics of this issue. This article discusses the definitions and examples of certain types of health benefit exclusions and the ethical considerations related to such exclusions. PMID- 10177705 TI - Employee contributions for dependent medical coverage: balancing cost, compensation and society. AB - This article explores the inception of the employee contribution concept to dependent medical coverage. The author discusses the developments that have occurred in the changing workforce as well as the effects of increasing medical costs. It considers the equity issues of unfair subsidies in medical benefit premiums for dependents. Finally, a potential solution is offered that would replace the multitiered structures available today. PMID- 10177706 TI - Ethical values: the real crisis in health care. AB - This author argues that the growth of apathy and greed and loss of ethical values in the current health care delivery system is due to the change in the foundation of the expectations between the consumer and the provider of health care. The agendas of the "third parties" involved with the provision of health care has caused confusion in the mind of the consumer and loss of autonomy for the health care provider. A historical perspective is provided that includes discussion of the issues of culpability for the current outcomes. Finally, the author discusses possible remedies to the current system. PMID- 10177707 TI - Total system costs and the case of the executive's hernia. AB - This article describes the advantages of taking a total system cost approach in the development of a benefits plan that improves employee health, productivity and profitability. It discusses the benefits and points out the possible pitfalls to the total system cost approach in providing employee health care. A research model is used to assess the value of certain medical procedures and technologies. To exemplify the point more clearly, the author uses a most interesting case study alluded to in the title of the article. PMID- 10177708 TI - Factors affecting pension and health benefits availability in small and large business. AB - Factors affecting the provision of fringe benefits are receiving more attention as fringe benefits have become an increasingly important component of total compensation. Despite the importance of trends in fringe benefits to businesses and the economy, the effects of factors--including firm size--on the provision of fringe benefits have received only limited systematic attention. Studies have examined either worker characteristics or firm/establishment/ industry characteristics, but few have combined both types of characteristics to study a more comprehensive set of determinants. The author addresses this limitation using new data from a nationally representative sample of almost 600 firms. The focus of this study is on the two most important fringe benefits--pension plans and health insurance. PMID- 10177709 TI - Ethics and employee benefits. AB - The following article attempts to bring to light the many questions and thoughts regarding ethical behavior as it relates to the employee benefits profession. Rather than dictating to the reader all the answers regarding ethics, the article demonstrates the different ways various situations can be interpreted. It leaves open the choices available to employee benefits professionals, while compelling us to confront the difficult decisions we must face when dealing with employees, employers and insurance companies. PMID- 10177710 TI - Burning issues. EPA's relaxed hospital incinerator rule has environmentalists fuming. PMID- 10177711 TI - Rocky road. The inside scoop on OR supply management. PMID- 10177712 TI - We took the politics out of capital equipment purchasing. PMID- 10177713 TI - Infusion confusion? Weigh your options carefully when choosing an i.v. pump. PMID- 10177714 TI - Year of living dangerously. 'Asian flu' spurs U.S. buyers to rethink 1998 budgets. PMID- 10177715 TI - Stats. Bottoms up! Good news for hospitals. PMID- 10177716 TI - Colorado health plans collaborate on single set of guidelines. AB - To eliminate the deluge of similar but competing guidelines facing physicians, healthcare organizations in Colorado are teaming up to produce a single set of guidelines. The first two address pediatric immunizations and adult diabetes. PMID- 10177717 TI - 12 ways to get physician buy-in to practice guidelines. PMID- 10177718 TI - Updating physicians without overwhelming them: how to balance best practice with autonomy. Interview by Matt Dembicki. PMID- 10177720 TI - Health benefits go global. PMID- 10177719 TI - Smoking and health: a perfect match? PMID- 10177721 TI - How provider fraud flattens corporate profits. AB - New laws are giving the private sector some real enforcement clout--and a better shot at recovering or preserving huge sums of money at a time when other dampers on costs are screwed down about as tight as they can get. PMID- 10177722 TI - Best practices that boost productivity. PMID- 10177724 TI - Mediplans move into managed care. PMID- 10177723 TI - Chiropractic: the new benefit staple. PMID- 10177725 TI - Outcomes-based buying goes direct. PMID- 10177727 TI - Strengthening the consumer voice. PMID- 10177726 TI - Treating back pain without breaking the bank. PMID- 10177728 TI - Data watch. Keeping cost hikes at bay--for the last time? PMID- 10177729 TI - Fighting for health care. 'Patients' rights' can curb unethical plans, but your coverage might still be chopped. PMID- 10177731 TI - Quality Guidelines No. 12. Confidentiality and disclosure of personal health information. Institute of Health Record Information and Management. PMID- 10177730 TI - Issues of quality and consumer rights in the health care market. AB - This Issue Brief describes how the structure of the health care market has changed in the recent years. It outlines the growth in managed care and the changes in the types of managed care plans available. In addition, it discusses the issue of quality in the health care market. It also includes an overview of the legislative topics and issues relating to quality and consumer rights that policymakers are currently considering. Growth in national health expenditures, the medical care price index, and employer health care costs has slowed significantly since 1990. This decreased growth has coincided with substantial increases in managed care plan enrollment. The percentage of employees enrolled in managed care plans increased from 48 percent to 85 percent from 1992 to 1997. Quality is a multidimensional concept. Although individuals may agree on its components, they may disagree on the relative importance of these components. Therefore, disagreement exists not only on how to measure quality but also on how it is defined. Consequently, policy decisions need to be based on an evaluation of a particular law's effect as opposed to its stated goal or intent. This distinction is important because a law that addresses access or consumer rights does not necessarily address the quality of care a consumer receives. Ultimately, whether an individual believes that a law truly addresses quality will depend in a large part on his or her subjective opinion of what quality entails. To date, comparison of the quality of managed care plans with that of fee-for-service plans has not produced results that uniformly differentiate between these two plan types in either a positive or a negative way. In addition, it is important to note that the current debate on the quality of care provided in the health care market is not new to the present managed care era. The regulations and mandates discussed in this report would not guarantee increased quality in the health care market, unless quality is defined as easier access for those with health insurance. However, if quality is defined as the success of the outcomes of health services provided, the effect of these regulations on quality is in need of further research. Yet, the regulations would have some impact on the costs of health benefits and insurance. This impact has been estimated to be relatively small to substantial, depending on the interpretation of the mandates and assumptions derived from that interpretation. Regardless of the magnitude of the estimated increases, some research has shown that these regulations could have serious implications for the likelihood of small businesses offering health benefits. While these health plan regulations effect on quality depends on one's definition of quality, costs would increase regardless of the definition one uses. Consequently, these regulations would come at a price. Thus, legislators must decide between: (a) imposing regulation that would increase access and consumer "rights" for those with insurance but would be of questionable value to the quality of outcomes, and (b) allowing existing market forces to improve quality through experimentation and competitive forces. PMID- 10177732 TI - Health records--why bother? PMID- 10177733 TI - Health action zones. PMID- 10177734 TI - Health Service Guidelines for 1997. Department of Health, UK. PMID- 10177735 TI - Medicaid program; state allotments for payment of Medicare Part B premiums for qualifying individuals: federal fiscal year 1998--HCFA. Notice with comment period. AB - Section 4732 of the Balanced Budget Act of 1997 (Public Law 105-33) amended the Social Security Act to provide for two additional eligibility groups of low income Medicare beneficiaries for whom Medicaid payment can be made for Medicare Part B premiums during the period beginning January 1998 and ending December 2002. This notice announces the Federal fiscal year 1998 State allotments that are available to pay Medicare Part B premiums for these two new eligibility groups and describes the methodology used to determine each State's allotment. PMID- 10177736 TI - Investigational new drug applications and new drug applications--FDA. Final rule. AB - The Food and Drug Administration (FDA) is amending its regulations pertaining to new drug applications (NDA's) to clearly define in the NDA format and content regulations the requirement to present effectiveness and safety data for important demographic subgroups, specifically gender, age, and racial subgroups. FDA also is amending its regulations pertaining to investigational new drug applications (IND's) to require sponsors to tabulate in their annual reports the numbers of subjects enrolled to date in clinical studies for drug and biological products according to age group, gender, and race. This action is intended to alert sponsors as early as possible to potential demographic deficiencies in enrollment that could lead to avoidable deficiencies later in the NDA submission. This rule does not address the requirements for the conduct of clinical studies and does not require sponsors to conduct additional studies or collect additional data. It also does not require the inclusion of a particular number of individuals from specific subgroups in any study or overall. The rule refers only to the presentation of data already collected. PMID- 10177738 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE prime balance billing--DOD. Interim final rule. AB - This interim final rule establishes financial protections for TRICARE Prime enrollees in limited circumstances when they receive covered services from a non network provider. This rule is being published to provide protection for TRICARE Prime enrollees. PMID- 10177737 TI - Medicare program; payment for preadmission services--HCFA. Final rule. AB - This final rule responds to public comments on the January 12, 1994, interim final rule with comment period that provided that inpatient hospital operating costs include certain preadmission services furnished by the hospital (or by an entity that is wholly owned or operated by the hospital) to the patient up to 3 days before the date of the patient's admission to that hospital. These provisions implement amendments made to section 1886(a)(4) of the Social Security Act by section 4003 of the Omnibus Budget Reconciliation Act of 1990. PMID- 10177739 TI - National Practitioner Data Bank; change in user fee and elimination of diskette queries--HRSA. Withdrawal. AB - National Practitioner Data Bank; Change in User Fee and Elimination of Diskette Queries notice, document 98-2637, pages 5811-5812, Volume 63, Number 23, in the issue of Wednesday, February 4, 1998, was published in error and is withdrawn from publication. The correct version of the notice was published on Thursday, January 29, 1998, Document No. 98-2116, Volume 63, Number 19, page 4460. PMID- 10177740 TI - Ophthalmic drug products for over-the-counter human use; proposed amendment of final monograph--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to amend the final monograph for over-the-counter (OTC) ophthalmic drug products. The amendment adds a new warning and revises an existing warning for ophthalmic vasoconstrictor drug products. These products contain the ingredients ephedrine hydrochloride, naphazoline hydrochloride, phenylephrine hydrochloride, or tetrahydrozoline hydrochloride; and they are used to relieve redness of the eye due to minor eye irritations. This proposal is part of the ongoing review of OTC drug products conducted by FDA. PMID- 10177741 TI - State offices of rural health grant program--HRSA. Notice of availability of funds. AB - The Office of Rural Health Policy, Health Resources and Services Administration (HRSA), announces that applications are being accepted for matching grants to States for the purpose of improving health care in rural areas through the continued operation of State Offices of Rural Health. This program is authorized by section 338J of the Public Health Service Act 42 U.S.C. 254r. Awards will be made from funds appropriated under Public Law 105-78 (HHS Appropriations Act for Fiscal Year 1998). Approximately $3.0 million will be available to support 50 grants in fiscal year (FY) 1998. PMID- 10177742 TI - Publication of the OIG compliance program guidance for hospitals--OIG. Notice. AB - This Federal Register notice sets forth the recently issued compliance program guidance for hospitals developed by the Office of Inspector General (OIG) in cooperation with, and with input from, several provider groups and industry representatives. Many providers and provider organizations have expressed an interest in better protecting their operations from fraud and abuse through the adoption of voluntary compliance programs. The first compliance guidance, addressing clinical laboratories, was prepared by the OIG and published in the Federal Register on March 3, 1997. We believe the development of this second program guidance, for hospitals, will continue as a positive step towards promoting a higher level of ethical and lawful conduct throughout the health care industry. PMID- 10177743 TI - Hematology and pathology devices; reclassification; restricted devices; OTC test sample collection systems for drugs of abuse testing--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to reclassify over-the counter (OTC) test sample collection systems for drugs of abuse testing from class III (premarket approval) into class I (general controls), and to exempt them from the premarket notification (510(k)) and current good manufacturing practice (CGMP) requirements. FDA is also proposing to designate OTC test sample collection systems for drugs of abuse testing as restricted devices under the Federal Food, Drug, and Cosmetic Act (the act), and to establish restrictions intended to assure consumers that: The underlying laboratory test(s) are accurate and reliable; the laboratory performing the test(s) has adequate expertise and competency; and the product has adequate labeling and methods of communicating test results to consumers. Finally, FDA is proposing a conforming amendment to the existing classification regulation for specimen transport and storage containers, to clarify that it does not apply to specimen transport and storage containers that are part of an OTC test sample collection system for the purpose of testing for the presence of drugs of abuse or their metabolites in a laboratory. PMID- 10177744 TI - Medicare program; HCFA market research for providers and other partners--HCFA. General notice with comment period. AB - This notice seeks public comments on information needs of Medicare risk contract health maintenance organizations (HMOs) and competitive medical plans (CMPs) and communication strategies that could improve the effectiveness and efficiency of the risk contract program. Under section 4002 of the Balanced Budget Act of 1997, and with the implementation of the Medicare + Choice program, all HMOs and CMPs will contract with HCFA under requirements of the Medicare + Choice program. The information sought in this notice will facilitate future changes in the contracting program, as well as improve information needs and communication strategies under the current risk program. Respondents should prioritize issues raised in the preliminary research and identify and additional areas of information needs and best communication strategies. This initiative is one component of our overall effort to develop a comprehensive communication strategy with Medicare providers and HMOs/CMPs and to develop innovative approaches that will assist all program participants to obtain and use information in the most accessible and effective manner. Preliminary research on the information needs of Medicare risk contract HMOs and CMPs and effective communication strategies has identified a number of areas in which we could provide additional information and potential strategies for communicating that information effectively. PMID- 10177745 TI - Collection from third party payers of reasonable costs of healthcare services- DoD. Final rule with request for comments. AB - This final rule implements, without embellishment or additional requirement, the recently enacted statutory authority to collect Social Security account numbers from all DoD beneficiaries as part of the program to identify third party payer situations. PMID- 10177746 TI - General hospital and personal use devices; classification of the Apgar timer, lice removal kit, and infusion stand--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to classify the Apgar timer, lice removal kit, and infusion stand into class I. FDA is also publishing the recommendations of the General Hospital and Personal Use Devices Panel (the panel) regarding the classification of the devices. After considering public comments on the proposed classification, FDA will publish a final regulation classifying the devices. This action is being taken under the Federal Food, Drug, and Cosmetic Act (the act), as amended by the Medical Device Amendments of 1976 (the amendments), the Safe Medical Devices Act of 1990 (the SMDA), and the Food and Drug Administration Modernization Act of 1997 (FDAMA). PMID- 10177747 TI - Collection from third party payers of reasonable costs of healthcare services- DoD. Proposed rule. AB - This proposed rule implements several recent statutory changes and makes other revisions to the Third Party Collection Program. The primary matter include implementation of new statutory authority to include workers' compensation programs under the Third Party Collection Program; the addition of special rules for collections from preferred provider organizations; and other program revisions. PMID- 10177748 TI - Medicare and Medicaid programs; announcement of additional application from hospital requesting waiver for organ procurement service area--HCFA. Notice with comment period. AB - This notice announces an additional application that HCFA has received from a hospital requesting waiver from dealing with its designated organ procurement organization (OPO) in accordance with section 1138(a)(2) of the Act. This notice requests comments from OPOs and the general public for our consideration in determining whether such a waiver should be granted. PMID- 10177749 TI - Revised medical criteria for determination of disability, endocrine system and related criteria--SSA. Proposed rule. AB - We are proposing to delete "Obesity," from the listing to adjudicate claims for disability under titles II and XVI of the Social Security Act (the Act) when we evaluate claims of individuals at step 3 of our sequential evaluation process. Current medical and vocational research demonstrates that, while many individuals with obesity are disabled, obesity, in and of itself, is not necessarily determinative of an individual's inability to engage in any gainful activity. Instead, individuals with obesity would have their cases reviewed under the listing for an affected body system(s) or, on a case-by-case basis, at the remaining steps of the sequential evaluation process. PMID- 10177750 TI - Medicare program; Medicare integrity program, intermediary and carrier functions, and conflict of interest requirements--HCFA. Proposed rule. AB - This proposed rule would implement section 1893 of the Social Security Act (the Act) by establishing the Medicare integrity program (MIP) to carry out Medicare program integrity activities that are funded from the Medicare Trust Funds. Section 1893 expands our contracting authority to allow us to contract with "eligible entities" to perform Medicare program integrity activities. These activities include review of provider and supplier activities, including medical, fraud, and utilization review: cost report audits; Medicare secondary payer determinations; education of providers, suppliers, beneficiaries, and other persons regarding payment integrity and benefit quality assurance issues; and developing and updating a list of durable medical equipment items that are subject to prior authorization. This proposed rule would set forth the definition of eligible entities, services to be procured, competitive requirements based on Federal acquisition regulations and exceptions (guidelines for automatic renewal), procedures for identification, evaluation, and resolution of conflicts of interest, and limitations on contractor liability. In addition, this proposed rule would bring certain sections of the Medicare regulations concerning fiscal intermediaries and carriers into conformity with the Act. The rule would distinguish between those functions that the statute requires be included in agreements with intermediaries and those that may be included in the agreements. It would also provide that some or all of the listed functions may be included in carrier contracts. Currently all these functions are mandatory for carrier contracts. These changes would give us the flexibility to transfer functions from one intermediary or carrier to another or to otherwise limit the functions an intermediary or carrier performs if we determine that to do so would result in more effective and efficient program administration. PMID- 10177751 TI - Medical devices; review and revision of compliance policy guides and regulatory requirements for refurbishers, rebuilders, reconditioners, servicers and "as is" remarketers of medical devices; request for comments and information; extension of comment period--FDA. Advance notice of proposed rulemaking; extension of comment period. AB - The Food and Drug Administration (FDA) is extending to June 29, 1998, the comment period for the advance notice of proposed rulemaking (ANPRM) that appeared in the Federal Register of December 23, 1997 (62 FR 67011). This advance notice announced FDA's intention to review and, as needed, to revise compliance policy guides, amend regulatory requirements and, as appropriate, exercise alternative regulatory approaches regarding the remarketing of used medical devices. The agency is taking this action in response to two requests for extensions. This extension of comment period is intended to allow interested persons additional time to submit comments on the ANPRM. PMID- 10177752 TI - Health care programs: fraud and abuse; revised OIG civil money penalties resulting from the Health Insurance Portability and Accountability Act of 1996- Office of Inspector General (OIG), HHS. Notice of proposed rulemaking. AB - This proposed rule would revise the OIG's civil money penalty (CMP) authorities, in conjunction with new and revised provisions set forth in the Health Insurance Portability and Accountability Act of 1996. Among other provisions, this proposed rulemaking would codify new CMPs for: Excluded individuals retaining ownership or control interest in an entity; upcoding and claims for medically unnecessary services; offering inducements to beneficiaries; and false certification of eligibility for home health services. This rule would also codify a number of technical and conforming changes consistent with the OIG's existing sanction authorities. PMID- 10177753 TI - Medicare program; "without fault" and waiver of recovery from an individual as it applies to Medicare overpayment liability--HCFA. Proposed rule. AB - This rule would amend the Medicare regulations governing liability for overpayments to eliminate application of certain regulations of the Social Security Administration and to replace them with HCFA regulations more specific to circumstances involving Medicare overpayments. The following specific changes are included in this rule. Explicit criteria and the circumstances under which a provider or supplier can be relieved of liability for an overpayment on the basis of being "without fault" with respect to the overpayment. Specific criteria and circumstances of the conditions under which a waiver of recovery for Medicare overpayments would apply to individuals. A provision to ordinarily consider it inequitable to recover an overpayment from a without-fault individual when an overpayment is made to a without-fault provider. Specific provisions that enable Medicare intermediaries and carriers to determine without fault in Medicare overpayments resulting from Medicare secondary payer conditional payments. Provisions that grant Peer Review Organizations the authority to make without fault determinations. Provisions for an administrative appeals process for providers and suppliers with regard to a "not-without-fault" determination. We expect this rule would prevent some providers and suppliers from claiming without fault status. This could reduce the number of overpayment liabilities passed on to individuals and result in a slight increase in the amount of money recovered. PMID- 10177754 TI - Expedited safety reporting requirements for human drug and biological products; correction--FDA. Final rule; correction. AB - The Food and Drug Administration (FDA) is correcting a document that appeared in the Federal Register of October 7, 1997 (62 FR 52237), to include some conforming amendments that were inadvertently omitted. The final rule amended the expedited safety reporting regulations for human drug and biological products. This action is being taken to ensure the accuracy and consistency of the regulations. PMID- 10177755 TI - Developmental disabilities: request for public comments on proposed developmental disabilities funding priorities for Projects of National Significance for Fiscal Year 1998--Administration on Developmental Disabilities, HHS. Notice of request for public comments on developmental disabilities tentative funding priority for Projects of National Significance for Fiscal Year 1998. AB - The Administration on Developmental Disabilities (ADD) announced that public comments are being requested on tentative funding priorities for Fiscal Year 1998 Projects of National Significance prior to being announced in its final form. We welcome comments and suggestions on this proposed announcement and funding priority which will assist in bringing about the increased independence, productivity, integration, and inclusion into the community of individuals with developmental disabilities. PMID- 10177756 TI - Social Security Ruling, SSR 98-1p; Title XVI: determining medical equivalence in childhood disability claims when a child has marked limitations in cognition and speech--SSA. Notice of Social Security Ruling. AB - In accordance with 20 CFR 402.35(b)(1), the Commissioner of Social Security gives notice of Social Security Ruling, SSR 98-1p. This Ruling results from the "top-to bottom" review of the implementation of changes to the Supplemental Security Income childhood disability program necessitated by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Pub. L. 104-193). It provides a policy interpretation that children who have a "marked" limitation in cognitive functioning and a "marked" limitation in speech have an impairment or combination of impairments that medically equals Listing 2.09. It also provides guidance for determining when a child has a "marked" or an "extreme" limitation in each of these areas. PMID- 10177757 TI - Medicare and Medicaid programs; salary equivalency guidelines for physical therapy, respiratory therapy, speech language pathology, and occupational therapy services; revised effective date and technical correction--HCFA. Final rule; delay of effective date and correction. AB - This document delays the effective date of the final rule on salary equivalency guidelines, published in the Federal Register (63 FR 5106) on January 30, 1998, from April 1, 1998 to April 10, 1998. In addition, we are making a technical correction in the preamble to the January 30, 1998 final rule. PMID- 10177758 TI - Medicare program; schedule of per-beneficiary limitations on home health agency costs for cost reporting periods beginning on or after October 1, 1997--HCFA. Final rule with comment period. AB - This final rule with comment period sets forth, in accordance with section 4602 of the Balanced Budget Act of 1997, a new schedule of limitations on home health agency costs that may be paid under the Medicare program for cost reporting periods beginning on or after October 1, 1997. These limitations are in addition to the per-visit limitations that were set forth in our January 2, 1998 notice with comment period. PMID- 10177759 TI - Electronic Freedom of Information Act; implementation--USIA. Proposed rule. AB - This rule establishes requirements and conditions necessary for the implementation of the new Electronic Freedom of Information Act (FOIA) Amendments of 1996, 5 U.S.C. 552, as amended by Pub. L. 104-231. This addition to the present regulation will establish criteria that will enable FOIA requesters to better understand how documents of the Agency are maintained and handled electronically. PMID- 10177760 TI - National Vaccine Injury Compensation Program: revised amount of the average cost of a health insurance policy--HRSA. PMID- 10177761 TI - Nursing recruitment program for Indians--IHS. Notice of competitive grant applications for the nursing recruitment program for Indians. PMID- 10177762 TI - Indian Health Service. Statement of mission, organization, functions and delegation of authority. PMID- 10177763 TI - Organ Procurement and Transplantation Network--HRSA. Final rule with comment period. AB - This document sets forth the final rule governing the operation of the Organ Procurement and Transplantation Network (OPTN), which performs a variety of functions related to organ transplantation under contract with HHS. The document also offers a 60 day period for additional public comment. The rule will become effective 30 days following the close of the comment period. If the Department believes that additional time is required to review the comments, we will consider delaying the effective date. In combination with a new National Organ and Tissue Donation Initiative, this rule is intended to improve the effectiveness and equity of the Nation's transplantation system and to further the purposes of the National Organ Transplant Act of 1984, as amended. These purposes include: encouraging organ donation; developing an organ allocation system that functions as much as technologically feasible on a nationwide basis; providing the bases for effective Federal oversight of the OPTN (as well as for implementing related provisions in the Social Security Act); and, providing better information about transplantation to patients, families and health care providers. PMID- 10177764 TI - Mutual Recognition of the Food and Drug Administration and European Community Member State Conformity Assessment Procedures; pharmaceutical GMP inspection reports, medical device quality system evaluation reports, and certain medical device premarket evaluation reports--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to amend its regulations pursuant to an international agreement that is expected to be concluded between the United States and the European Community (EC) (Ref. 1). Under the terms of that agreement, FDA may normally endorse good manufacturing practice (GMP) inspection reports for pharmaceuticals provided by equivalent EC Member State regulatory authorities and medical device quality system evaluation reports and certain medical device premarket evaluation reports provided by equivalent conformity assessment bodies. FDA is taking this action to enhance its ability to ensure the safety and efficacy of pharmaceuticals and medical devices through more efficient and effective utilization of its regulatory resources. The agency is requesting comments on the proposed rule. PMID- 10177765 TI - A new prescription. AB - With managed care plans discovering that it's difficult to control costs and give consumers what they want, some conservatives are saying it's time to revamp the health care system. PMID- 10177766 TI - Insuring early retirees. PMID- 10177767 TI - A new formula for VA health care. PMID- 10177768 TI - State Medicaid and MCO-CBO contracting. The George Washington University studies. AB - The web of contracts between purchasers, plans, and providers will ultimately shape the American healthcare system. Managed care contracts represent a marked departure from common law principles which allowed healthcare providers to decide when and under what circumstances they would enter into a provider/patient relationship. In two studies supported by the Substance Abuse and Mental Health and Services Administration (SAMHSA), contracts for behavioral healthcare services between Medicaid agencies and MCOs, and between MCOs and community-based mental health and substance abuse organizations were examined. Contracts typically cover both mental health and substance abuse treatment services, but state-to-state variation in procedures and specific services covered is the hallmark of behavioral healthcare contracts across the board. PMID- 10177769 TI - Dialogue. Building better bridges: avoiding litigation in public-private contracts. PMID- 10177770 TI - Privatization of the public trust: devolution or disaster? PMID- 10177771 TI - Enough already! Myths and realities of managed behavioral health care. PMID- 10177772 TI - The Maze Program. Clinical pathways in treatment for adolescents. PMID- 10177773 TI - Visionary leadership for behavioral healthcare. The Child Health Insurance Program--some lessons for the future. PMID- 10177774 TI - New forum for intranet builders. PMID- 10177775 TI - Going it alone. AB - A delivery system in Western New York has developed many of its own software programs, saving big bucks. Now, it's buying certain clinical programs and integrating them with the home-grown software. PMID- 10177776 TI - Charting new territory. Interview by Tyler L. Chin. PMID- 10177777 TI - Beyond the hype. Proven strategies for fixing the year 2000 problem. AB - Many health care organizations are developing effective strategies for coping with the year 2000 problem, assuring that computers with two-digit date fields will recognize that 00 signifies 2000. Clinics, hospitals and other sites are finding that in addition to fixing their core information systems, they also must carefully analyze the year-recognition capabilities of crucial medical devices- and even elevators. PMID- 10177778 TI - Claims on the Internet. A progress report on EDI developments. AB - While there's been a lot of talk about claims clearinghouses using the Internet as a conduit for receiving claims and related transactions from providers and employers, a major shift from conventional EDI has yet to materialize because of concerns about a number of issues, including security. In the meantime, some health care organizations are making plans to use the Internet and bypass clearinghouses. PMID- 10177779 TI - Crafting a good software contract requires some extra effort. PMID- 10177780 TI - Six-figure salaries common among health care CIOs. PMID- 10177781 TI - Managed care. Keeping tabs on childhood vaccines. PMID- 10177782 TI - Telemedicine. Let the vendors come to you. PMID- 10177783 TI - Assessing VHA's aggressive software endorsement effort. PMID- 10177784 TI - Call centers improve service, carry out managed care goals. PMID- 10177785 TI - Provider automation. Breaking new ground. PMID- 10177786 TI - Managed care. Learning a lesson the hard way. PMID- 10177787 TI - A new public health tool. More state agencies are disseminating and collecting data using Internet technologies. PMID- 10177788 TI - Banking on strategies from another industry. Interview by John McCormack. PMID- 10177789 TI - Data security. Where does a CSO begin? PMID- 10177790 TI - The role of smart cards in France. PMID- 10177792 TI - Systems integration. How will new standards help health care organizations tackle the challenge of easing the flow of data? PMID- 10177791 TI - Justifying where the dollars go. AB - Cost-conscious health care organizations are demanding that their investments in information technology generate a measurable return. For some applications, predicting a quick payoff is relatively easy. But for complex clinical systems, proving a tangible return can be difficult. PMID- 10177793 TI - Computer skills essential for medical records directors. PMID- 10177794 TI - Automating treatment protocols. PMID- 10177795 TI - Standard operating procedure. Interview by Fred Bazzoli. PMID- 10177796 TI - Beeping clinicians with vital information. PMID- 10177797 TI - Applying the Internet in health care. PMID- 10177798 TI - Bigger pipes. Health care organizations are building high-capacity communications networks to support strategic business goals. PMID- 10177799 TI - The role of document imaging in creating electronic records. PMID- 10177800 TI - Telemedicine. The turning point. PMID- 10177801 TI - Managed care. Database aids fight against cancer. PMID- 10177802 TI - Top 10 health care trends for 1998. Tomorrow's trends will be consumerism, cyberhealth, and co-opetition. PMID- 10177803 TI - Reviewing top 10 trends for 1997. Last year's predictions were 100 percent on target. PMID- 10177804 TI - ORYX PLUS: what you must know about JCAHO's 'accelerated option'. AB - Even though the deadline for participation in the Joint Commission's ORYX initiative has finally arrived, your hospital still has the option of participating in ORYX PLUS, the initiative's "accelerated option." But should it? Critics contend that the potential benefits of participation in ORYX PLUS are outweighed by its cost, labor requirements, disclosure requirements, and lack of relevance to smaller hospitals. The Joint Commission counters that because ORYX PLUS' performance measures and risk-adjusted methods are standard for all participating measurement systems, hospitals can be assured that they're participating in a valid and reliable database. PMID- 10177805 TI - Bone marrow path saves up to $100,000 per case. AB - The bone marrow transplantation pathway at Richland Memorial Hospital in Columbia, SC, has reduced length of stay by 8.6 days and cut costs per case by up to $100,000. The 44-day pathway, implemented in 1995, incorporated three major changes in the care of bone marrow transplant patients: beginning the inpatient stay with the first day of conditioning therapy; deleting some routine lab tests and rescheduling others; and giving medications orally rather than intravenously whenever possible. By using the pathway as an audit tool, case managers at Richland Memorial also improved documentation and helped staff better understand the bone marrow transplantation protocols. PMID- 10177806 TI - AMI team buckles down to improve outcomes. AB - Process improvements developed at Middletown (OH) Regional Hospital have cut length of stay by 1.6 days and reduced mortality by half for its acute myocardial infarction (AMI) patients. The hospital's initial efforts focused on educating the largely voluntary EMS squads on the latest technology and treatment protocols. As a result, "door-to-needle" time dropped from an average of 84 minutes to 22 minutes. Other areas of improvement included the emergency department's triage time, decision making for administering thrombolytic therapy, and the time used for repeat EKG. PMID- 10177807 TI - Middletown team refines its system. PMID- 10177809 TI - Care path for the mentally ill/chemically addicted. PMID- 10177808 TI - How to measure age-specific competencies. AB - According to standards issued by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, age-specific competencies must be defined for all caregivers who assess, treat, or provide care to patients of different ages. Case managers must know the principles of growth and development over the life span, be able to assess clinical data relative to patient age, and interpret information needed to identify patient needs relative to age-specific needs. With written standards and policies that reflect age-specific care, the organization has a means to measure case managers' performance and criteria that serve as a foundation for competency determinations. PMID- 10177810 TI - Nonprofit institute offers Rx for health care's year 2000 computer woes. PMID- 10177811 TI - Don't get caught with your password guard down. Hackers use hospitals as springboards. PMID- 10177812 TI - HCFA publishes final salary equivalency guidelines; rule takes effect April 1. PMID- 10177813 TI - Industry groups seek guidance on SNF PPS, consolidated billing; many questions remain. PMID- 10177814 TI - How to get the most information system for your money: Part I. Start with a plan. PMID- 10177816 TI - MedPAC delays SNF recommendations, proposes update adjustment for PPS-excluded providers. PMID- 10177815 TI - Industry groups protest Clinton's proposal to charge SNFs for surveys/other government activities. PMID- 10177817 TI - Accurate, timely completion of the MDS is critical to success under PPS. PMID- 10177819 TI - Practitioner licensure issues in telemedicine & disease management. PMID- 10177818 TI - New SNF start-ups can still make strategic sense under PPS. PMID- 10177820 TI - Physician compensation arrangements under Stark proposed rule. PMID- 10177821 TI - New York and Kentucky ease certificate of need restrictions. PMID- 10177822 TI - Assisted living contracts with home health agencies. PMID- 10177823 TI - Financing '98. The shape of things to come--roundtable discussion. PMID- 10177824 TI - Financing '98. Finding the funding. PMID- 10177825 TI - Financing '98. Tapping into the financing flow. PMID- 10177826 TI - Financing '98. Glossary. PMID- 10177827 TI - Financing '98. Industry trends that investors are eyeing. PMID- 10177828 TI - Five minutes with Bill St. John. Interview by Doug Brunk. PMID- 10177829 TI - How to make sure you're in their plans. PMID- 10177830 TI - Bridging the gap. Seniors with moderate incomes are vastly underserved. PMID- 10177831 TI - Ahead of the curve. Staying one step ahead of the market pays off for IHS. PMID- 10177832 TI - Breaking the language barrier. PMID- 10177833 TI - Look homeward. Slowly but surely, long-term care design is changing to fit consumer and provider needs. PMID- 10177834 TI - Higher acuity, higher risk. Med management looms larger in assisted living. Interview by Diana Reese. PMID- 10177835 TI - Stats & facts. Mental health benefits in managed care. PMID- 10177836 TI - Marketing pharmaceutical products on-line to consumers. PMID- 10177837 TI - Sinusitis. PMID- 10177838 TI - Emergency medicine in a managed care environment. AB - Managed care has changed the face of the health care system. Providers who schedule care have responded and modified their systems of delivery and provision of care. The focus has now turned to unscheduled care, such as urgent and emergency services. This market is much more difficult to control and reconstruct. This article discusses the role of emergency medicine within a managed care system and future opportunities. PMID- 10177839 TI - Managing pharmacy benefits through the Internet. PMID- 10177840 TI - Effective pricing in the age of managed care. AB - Global, or package, pricing represents an attractive alternative to capitation, particularly among specialists. In this article, the author outlines why MCOs are increasingly seeking package pricing deals in today's health care market. PMID- 10177841 TI - Chronic low back pain: new perspectives and treatment guidelines for primary care: Part I. AB - Low back pain is a leading cause of work-related disability and has important socioeconomic consequences. Although there is little evidence to determine the optimal treatment of chronic low back pain, treatment goals can be established. Primary care providers should focus on pain management, improvement of activity and functional level, and fostering a greater understanding of chronic low back pain. This two-part article summarizes consensus guidelines developed by practitioners with expertise in pain management, family medicine, internal medicine, physical therapy, rheumatology, and managed care, and provides direction for primary care providers on a multidisciplinary approach to the patient with chronic low back pain. PMID- 10177843 TI - Is the future of managed care in question? PMID- 10177842 TI - Paid claims analysis: a power tool for medical management. AB - The author describes a method of tracking medical services ordered by a plan's (or a capitated group's) doctors and analyzing the associated paid claims in order to identify physicians who are practicing inefficiently. It also identifies plan members who are overlooking the referral rules of their HMO plan. PMID- 10177844 TI - Liability issues in a managed care environment. PMID- 10177845 TI - The parabole of the three-legged stool. PMID- 10177846 TI - A unique approach to healthcare restructuring and reform. A case study. PMID- 10177847 TI - Allocating scarce resources: a question of distributive justice. Part II. PMID- 10177848 TI - Euthanasia by confusion. PMID- 10177849 TI - Don't get burned by emergency claim rejections. PMID- 10177850 TI - Simplified, one-on-one asthma education cuts Medicaid utilization up to 71%. AB - Medicaid asthma program slashes utilization, costs: After seeing hospital costs for asthma patients running as high as $500,000 a month, Hartford (CT) Hospital launched its own asthma education program for Medicaid members that's cut ER visits in half and hospital admissions by more than two-thirds. Learn why this person-to-person program works. PMID- 10177851 TI - Providers could find pot of gold by pursuing the right Medicare contracting alternative. AB - Develop a Medicare risk strategy based on your organization's strengths: If you think your only choice is to develop a PSO or remain a simple contractor, guess again. There are lots of strategic and contracting options for providers seeking to boost their profitability and gain more control over their Medicare lives. Learn how to evaluate your market position and strategies for contracting success. PMID- 10177852 TI - Affiliation, joint venture or PSO? Case studies show why provider strategies differ. AB - Joint venture, affiliation or PSO? Here are three case studies of providers who chose different paths under Medicare risk, plus some key questions you'll want to ask of your own provider organization. Learn from these examples so you'll make the best contracting decisions. PMID- 10177853 TI - Marketplace. Will others follow employers trying out direct contracting? PMID- 10177854 TI - Perspectives. Flap over what HIPAA doesn't do renews concern about individual market problems. PMID- 10177855 TI - Death, dying and grieving. Dealing with personal and work-related tragedies. PMID- 10177856 TI - EMS in 2000: what role will associations play? PMID- 10177857 TI - Hide & seek: encountering handguns on the streets. PMID- 10177858 TI - The ABCs of infectious disease. PMID- 10177859 TI - Ventilation revisited. PMID- 10177860 TI - The set-up-to-fail syndrome. AB - Why do some employees perform poorly? Most managers would answer that question by ticking off a list that includes weak skills, insufficient experience, inability to prioritize assignments, and lack of motivation. In other words, they would contend that poor performance is the employee's fault. But is it? Not always, according to the authors. Their research with hundreds of executives strongly suggests that it is the bosses themselves--albeit unintentionally--who are frequently responsible for an employee's subpar achievement. According to the authors, bosses and their perceived weak performers are often caught in a dynamic called the set-up-to-fail syndrome, which tends to play out as follows: A boss begins to worry when a subordinate's performance is not satisfactory. He then takes what seems like the obvious action by increasing the time and attention he focuses on the employee. But rather than improve the subordinate's performance, the increased supervision has the reverse effect. The subordinate, in perceiving the boss's lack of confidence in him, withdraws from his work and from the boss. And the relationship spirals downward. What is a boss to do? First, he must accept the possibility that his own behavior could be contributing to the problem. Second, he must plan a careful intervention with the subordinate that takes the form of one or several candid conversations meant to untangle the unhealthy dynamics in the relationship. The intervention is never easy, but the time and energy invested in it usually yields a high payback. PMID- 10177861 TI - The discipline of building character. AB - What is the difference between an ethical decision and what the author calls a defining moment? An ethical decision typically involves choosing between two options: one we know to be right and another we know to be wrong. A defining moment challenges us in a deeper way by asking us to choose between two or more ideals in which we deeply believe. Such decisions rarely have one "correct" response. Taken cumulatively over many years, they form the basis of an individual's character. Defining moments ask executives to dig below the busy surface of their lives and refocus on their core values and principles. Once uncovered, those values and principles renew their sense of purpose at the workplace and act as a springboard for shrewd, pragmatic, politically astute action. Three types of defining moments are particularly common in today's workplace. The first type is largely an issue of personal identity. It raises the question, Who am I? The second type concerns groups as well as individuals. It raises the question, Who are we? The third kind involves defining a company's role within society. It raises the question, Who is the company? By learning to identify each of those three situations, managers can learn to navigate right versus-right decisions successfully. The author asks a series of practical questions that will help managers take time out to examine their values and then transform their beliefs into action. By engaging in this process of self-inquiry, managers will be gaining the tools to tackle their most elusive, challenging, and essential business dilemmas. PMID- 10177862 TI - Making business sense of the Internet. AB - For managers in large, well-established businesses, the Internet is a tough nut to crack. It is very simple to set up a Web presence and very difficult to create a Web-based business model. Established businesses that over decades have carefully built brands and physical distribution relationships risk damaging all they have created when they pursue commerce through the Net. Still, managers can't avoid the impact of electronic commerce on their businesses. They need to understand the opportunities available to them and recognize how their companies may be vulnerable if rivals seize those opportunities first. Broadly speaking, the Internet presents four distinct types of opportunities. First, it links companies directly to customers, suppliers, and other interested parties. Second, it lets companies bypass other players in an industry's value chain. Third, it is a tool for developing and delivering new products and services to new customers. Fourth, it will enable certain companies to dominate the electronic channel of an entire industry or segment, control access to customers, and set business rules. As he elaborates on these four points, the author gives established companies a systematic way to sort through the risks and rewards of doing business in cyberspace. PMID- 10177863 TI - Even swaps: a rational method for making trade-offs. AB - Making wise trade-offs is one of the most important and difficult challenges in decision making. Needless to say, the more alternative you're considering and the more objectives you're pursuing, the more trade-offs you'll need to make. The sheer volume of trade-offs, however, is not what makes decision making so hard. It's the fact that each objective has its own basis of comparison, from precise numbers (34% versus 38%) to relationships (high versus low) to descriptive terms (red versus blue). You're not just trading off apples and oranges; you're trading off apples and oranges and elephants. How do you make trade-offs when comparing widely disparate things? In the past, decision makers have relied mostly on instinct, common sense, and guesswork. They've lacked a clear, rational, and easy to-use trade-off methodology. To help fill that gap, the authors have developed a system-which they call even swaps-that provides a practical way of making trade offs among a range of objectives across a range of alternatives. The even-swap method will not make complex decisions easy; you'll still have to make hard choices about the values you set and the trades you make. What it does provide is a reliable mechanisms for making trades and a coherent framework in which to make them. By simplifying and codifying the mechanical elements of trade-offs, the even-swap method lets you focus all your mental energy on the most important work of decision making: deciding the real value to your company of different courses of action. PMID- 10177864 TI - Why doesn't this HR department get any respect? AB - Since becoming managing partner of human resources at Loft Securities more than a year ago, Luke Robinson has tried everything he can think of to change his department's reputation as an administrative backwater. But he's swimming against the tide. Ever since the retirement of a charismatic CEO in 1995, the firm has suffered a slow bleed of good people. The new CEO doesn't have a flair for attracting and retaining talented people, and the HR department hasn't been able to pick up the slack. Robinson has done his best to turn things around. He's met with just about everyone, from senior executives to administrative assistants to external contacts. And, when he found out that recruiting wasn't Loft's only problem, he took a variety of concrete steps. Among other things, he established internal service standards and performance guarantees for his department. He created "listening posts" and implemented and "HR ambassador" program. And he drafted plans for a program to help educate all the company's employees about the role of HR--specifically, how it can contribute to creating and upholding the firm's strategy for success. But Robinson has run over some major speed bumps. Just before he joined the company, HR sullied its reputation by mishandling the investigation of a discrimination charge. And while on Robinson's watch, HR botched the issuance of year-end bonus checks for the managing directors and vice presidents. The frustrations are piling up, leading Robinson to entertain thoughts of bailing out. Five commentators on this fictional case study explain why he should avoid quitting and how he can help his department earn new respect. PMID- 10177865 TI - What is the best advice Rose can give to Robinson? Five commentators advise Robinson on how to upgrade HR's role at Loft Securities. PMID- 10177866 TI - How SmithKline Beecham makes better resource-allocation decisions. AB - Major resource-allocation decisions are never easy. For a pharmaceuticals company like SmithKline Beecham, the problem is this: How do you make good decisions in a high-risk, technically complex business when the information you need to make those decisions comes largely from the project champions who are competing against one another for resources? In 1993, the company experimented with ways of depoliticizing the process and improving the quality of decision making. In most resource-allocation processes, project advocates develop a single plan of action and present it as the only viable approach. In SB's new process, the company found an effective way to get around the all-or-nothing thinking that only reinforces the project-champion culture. Project teams were required--and helped- to create meaningful alternatives to current development plans. What would they do with more money? With less? With none at all? In another important departure from common practice, SB separated the discussion of project alternatives from their financial evaluations. In doing so, SB was able to avoid the premature evaluations that kill both creativity and the opportunity to improve decision making. The new process at SB has allowed the organization to spend less time arguing about how to value its R&D projects and more time figuring out how to make them more valuable. In the end, the company learned that by tackling the soft issues around resource allocation--such as information quality, credibility, and trust--it had also addressed the hard ones: how much to invest and where to invest it. PMID- 10177867 TI - Time pacing: competing in markets that won't stand still. AB - Most companies change in reaction to events such as moves by the competition, shifts in technology, or new customer demands. In fairly stable markets, "event pacing" is an effective way to deal with change. But successful companies in rapidly changing, intensely competitive industries take a different approach. They change proactively, through regular deadlines. The authors call this strategy time pacing. Like a metronome, time pacing creates a rhythm to which managers can synchronize the speed and intensity of their efforts. For example, 3M dictates that 25% of its revenues every year will come from new products, Netscape introduces a new product about every six months, and Intel adds a new fabrication facility to its operations approximately every nine months. Time pacing creates a relentless sense of urgency around meeting deadlines and concentrates people on a common set of goals. Its predictability also provides people with a sense of control in otherwise chaotic markets. The authors show how companies such as Banc One, Cisco Systems, Dell Computer, Emerson Electric, Gillette, Intel, Netscape, Shiseido, and Sony implement the two essentials of time pacing. The first is managing transitions--the shift, for example, from one new-product-development project to the next. The second is setting the right rhythm for change. Companies that march to the rhythm of time pacing build momentum, and companies that effectively manage transitions sustain that momentum without missing important beats. PMID- 10177868 TI - The power of virtual integration: an interview with Dell Computer's Michael Dell. Interview by Joan Magretta. AB - Michael Dell started his computer company in 1984 with a simple business insight. He could bypass the dealer channel through which personal computers were then being sold and sell directly to customers, building products to order. Dell's direct model eliminated the dealer's markup and the risks associated with carrying large inventories of finished goods. In this interview, Michael Dell provides a detailed description of how his company is pushing that business model one step further, toward what he calls virtual integration. Dell is using technology and information to blur the traditional boundaries in the value chain between suppliers, manufacturers, and customers. The individual pieces of Dell's strategy--customer focus, supplier partnerships, mass customization, just-in-time manufacturing--may be all be familiar. But Michael Dell's business insight into how to combine them is highly innovative. Direct relationships with customers create valuable information, which in turn allows the company to coordinate its entire value chain back through manufacturing to product design. Dell describes how his company has come to achieve this tight coordination without the "drag effect" of ownership. Dell reaps the advantages of being vertically integrated without incurring the costs, all the while achieving the focus, agility, and speed of a virtual organization. As envisioned by Michael Dell, virtual integration may well become a new organizational model for the information age. PMID- 10177869 TI - Interpretive management: what general managers can learn from design. AB - The past two decades have seen a dramatic acceleration in the pace of marketplace change. Companies have abandoned the old hierarchical model, with its clean functional divisions and clear lines of authority, and adopted flatter, less bureaucratic structures. But if most organizations have begun to adapt to the uncertainty of rapid change, most managers have not. They remain locked into the mechanical mind-set of the industrial age--that is, they assume that any management challenge can be translated into a clearly defined problem for which an optimal solution can be found. That approach works in stable markets and even in markets that change in predictable ways. Today's markets, however, are increasingly unstable and unpredictable. Managers can never know precisely what they're trying to achieve or how best to achieve it. They can't even define the problem, much less engineer a solution. The challenges facing the general manager in these circumstances, the authors argue, resemble those typically confronted by design managers. In the unpredictable world of research and design, neither the flow of the development process nor its end point can be defined at the outset. Rather than the traditional analytical approach to management, the design world requires an interpretive one. And that approach is equally well suited to rapidly changing, unpredictable markets. The authors describe how companies such as Levi Strauss & Company and Chiron Corporation have stayed at the top of their industries by adopting just such an interpretive approach to management. PMID- 10177870 TI - Hospital does 'more with less' via screening, training of new officers. PMID- 10177871 TI - Reducing visitor confusion and risk: the ABC's of hospital signage. PMID- 10177872 TI - Six car thefts in 27 years: how hospital secures its garage, 13 lots. PMID- 10177873 TI - Developing a program for dealing with violence in healthcare facilities. AB - The potential for violence is a growing concern in all healthcare facilities. Violent acts may be perpetrated by visitors, patients, employees, or outsiders. There are no simple answers to preventing or defusing such violence, but greater attention to the total climate for violence and a realistic approach to treating its different aspects are essential. In this report, Fredrick Roll, executive vice president, Hospital Shared Services, Denver, CO, which provides security services for more than 140 hospitals in six states, discusses the different aspects of violence that must be considered by all hospitals when setting up programs to deal with the problem. PMID- 10177874 TI - Expert warns of security pitfalls of long-term care facilities. PMID- 10177875 TI - How hospital security kept stay of famed Chinese dissident trouble-free. PMID- 10177876 TI - HCFA surveys the surveyors. PMID- 10177877 TI - Don't observe yourself out of business. PMID- 10177878 TI - Observation impact must balance revenue and cost. PMID- 10177879 TI - New CPTs carry fraud and abuse potential. Pay special attention to 99234, 99235, and 99236. PMID- 10177880 TI - Hospitals create strategies to implement new referral rules. PMID- 10177881 TI - Congress: home health choice must be offered. PMID- 10177882 TI - Observation means quality care. PMID- 10177883 TI - No observation unit? Here are tips for starting one. PMID- 10177884 TI - Add root-cause analysis to your PI armament. PMID- 10177885 TI - Patient surveys. There for the asking. AB - The government's proposal to survey 100,000 patients a year in order to improve services faces considerable organisational problems. We estimate it will cost 200,000 pounds a year. The simple opinion poll approach should be avoided in favour of a detailed questionnaire. A rolling programme of surveys in specific service areas might be more meaningful than a comprehensive annual survey. The aims of capturing patients' views and comparing performance across the country could prove incompatible. PMID- 10177886 TI - Primary care. From paper to practice. AB - The proposed size of primary care groups may prove problematic. Their creation will have bureaucratic consequences. Primary care groups' proposed accountability to three different organisations may lead to conflict. Their establishment will compound existing problems: increasing organisational complexity and conflicts between local discretion and central control. PMID- 10177887 TI - Managers. Bureaucracy: hit and myth. AB - The poor image of NHS management is largely undeserved. The greatest expansion in the number of managers took place before the introduction of the internal market. Many of the white paper proposals, including the establishment of primary care groups, suggest a substantial bureaucracy. PMID- 10177888 TI - Geriatric care. Remains of the day. PMID- 10177889 TI - NHS values. What are we here for? AB - Following more than a decade of change, the NHS is keen to explore the values driving its daily life. Consistency between values and behaviour are an important part of building an organisation's identity and confidence. It is likely that pluralistic values inform the NHS more now than was the case in the early years of the welfare state. PMID- 10177890 TI - Wards. Caring about sharing. AB - A small study of surgical patients in one hospital showed that most women preferred single-sex wards. But more than half the men had no preference. Most day-case patients wanted single-sex accommodation. Patients whose stay was seven days or longer showed greater tolerance of mixed-sex wards than others. PMID- 10177891 TI - Gurus assess health care progress. PMID- 10177892 TI - Caring for our own. Canada's Benevolent Society supports families of the fallen. PMID- 10177893 TI - Under pressure. The struggle for confidence when confronted with kid calls. PMID- 10177894 TI - The gentle art of pediatric assessment. Important steps you can utilize when evaluating your tiniest patients. PMID- 10177895 TI - A valuable resource instructors can use. Teaching TRIPP (Teaching Resource for Instructors in Prehospital Pediatrics). PMID- 10177896 TI - Education of prehospital providers in pediatrics. National Task Force studies EMS pediatric care. PMID- 10177897 TI - High-tech children. Interfacing EMS providers with children in the community. PMID- 10177898 TI - The cartoon world of Steve Berry. A portrait of the medic as an artist. PMID- 10177899 TI - OR, materials: stronger partnerships needed. PMID- 10177900 TI - FDA has plans to place limits on glove powder. PMID- 10177901 TI - VA studies patient outcomes and best practices in surgery. PMID- 10177902 TI - What's best method for warming patients? PMID- 10177903 TI - Supply issues not blocking OR efficiency. PMID- 10177904 TI - Materials coordinator brings value to ORs. PMID- 10177905 TI - About half of ORs have case carts. PMID- 10177906 TI - Building employee satisfaction: what works? PMID- 10177907 TI - Rewarding staff: it takes more than money. PMID- 10177908 TI - Preadmit packet makes for smoother process. PMID- 10177909 TI - Of AIDS and altruism. In theory, a new kind of vaccine could halt the epidemic. PMID- 10177910 TI - The redevelopment of Wimmera Base Hospital, Horsham, Victoria. PMID- 10177911 TI - Year 2000, or could be 1999. PMID- 10177912 TI - Authorised person (sterilizers)--training and registration. PMID- 10177913 TI - Year 2000--survival is not compulsory. PMID- 10177914 TI - The division and measurement of land in England. PMID- 10177915 TI - OIG releases compliance program guidance for hospitals. PMID- 10177916 TI - Practice brief. Issue: Recommended regulation and standard acquisition for specific healthcare settings (updated). American Health Information Management Association. PMID- 10177917 TI - Managed care: the dominant paradigm in US healthcare. AB - What does "managed care" really represent--and what effect has managed care had on the healthcare market? The author describes how managed care came to be a critical market force, offers a snapshot of its proliferation, and examines its effects on the traditional payment system. PMID- 10177918 TI - Choosing a managed care information system--what you need to know. AB - The new environment created by managed care has prompted providers to reconsider their information systems. An understanding of the market, the capabilities of various kinds of systems, and the needs of the organization can enable HIM professionals to aid their employers in making the right choices. PMID- 10177919 TI - Forging new relationships: HIM and managed care. AB - HIM professionals are blazing a trail in managed care in many roles. This article samples the perspectives of five practitioners, offering a glimpse of their work, their backgrounds, and the skills and experiences that have helped them manage their careers. PMID- 10177920 TI - Managing care, managing change, managing information. AB - Under managed care, information is often required on a longitudinal--not an episodic--basis. As a result, we need to rethink our approach to data storage and use. The author identifies ways to look at the demand for data in a managed care environment and shows how process assessment and benchmarking can help HIM professionals do their jobs more effectively. PMID- 10177921 TI - The evolving care continuum. PMID- 10177922 TI - Medicare managed care: risk adjustment and coding implications. PMID- 10177923 TI - A look at the balanced budget proposal. PMID- 10177924 TI - The Canadian Medical Protective Association. PMID- 10177925 TI - Health systems reform: 1997 state legislative wrap-up. PMID- 10177926 TI - Statement on the use of proprietary guidelines by managed care organizations. American College of Surgeons. PMID- 10177927 TI - Approval of courses in new skills. AB - The Committee on Emerging Surgical Technologies has previously published "Guidelines for Evaluation of Credentials of Individuals for the Purpose of Awarding Surgical Privileges in New Technologies." In that statement, which was approved by the American College of Surgeons' Board of Regents and published in 1994, the completion of a defined educational program in the technology, including didactic and practical elements, was recommended. The following statement, which was approved by the Board of Regents in October 1997, defines standards for courses in new technology that are designed to prepare the practicing surgeon to apply the technology to the care of patients. PMID- 10177928 TI - At a glance. Mortality data. PMID- 10177929 TI - The What Works awards. Three dramatically different solutions demonstrate creativity and effectiveness. PMID- 10177930 TI - Should you maintain that aging mainframe? PMID- 10177931 TI - Walking away from the paper chase. PMID- 10177932 TI - Telemedicine: a picture is worth.... PMID- 10177933 TI - TENN rates an 11: northern California telemedicine project saves $500,000. PMID- 10177934 TI - Voice/video/data telemedicine at INTEGRIS Health: how it fits into the overall telecommunications system. PMID- 10177935 TI - IT implications of the next generation of managed care. PMID- 10177936 TI - Reaching beyond the health care organization for expertise and a new perspective. PMID- 10177937 TI - Hotlist. Managed care systems. PMID- 10177938 TI - Creating a benchmark database. PMID- 10177939 TI - What's the difference between health care ethics, medical ethics and nursing ethics? PMID- 10177940 TI - From pharmaceuticals to alternative treatments for HIV/AIDS: what is the potential? AB - The current approach for dealing with the global AIDS pandemic focuses on technology, particularly pharmaceuticals. However, most of the world's PLWHA (people living with HIV/AIDS) have little or no access to these expensive treatments. Additionally, such technologies have not proven themselves adequate in addressing AIDS in global terms. When the health of communities is prioritized, rather than the interests of pharmaceutical companies and biomedicine, alternative strategies and policies can be considered. These strategies include seriously investigating traditional medicines in other cultures, rather than adopting an uncritical assumption that the biomedical approach is preferable. The limited research available suggests that some alternative treatments could indeed turn out to be useful in treating HIV/AIDS. However, without Western support for rigorous evaluation and development of local alternative therapies, the potential of these treatments for HIV/AIDS will continue to be dismissed. Additionally, the rights of communities to self determination, and PLWHA to the best possible primary health care, whether in rich or poorer nations, will also be diminished. PMID- 10177941 TI - The importance of care. AB - This paper is in three parts. In Part One we briefly explain that an unsophisticated form of utilitarianism--economic rationalism (ER)--has become dominant in many health systems. Its proponents argue that one of ER's most important effects is to increase consumer choice. However, evidence from New Zealand does not support this claim. Furthermore, the logic of ER requires the construction of systems which tend to restrict individual participation. In Part Two we argue that although some have advocated an 'ethic of care' in an attempt to counteract ER's utilitarianism, two decades of campaigning have had little influence on health policy. ER's pro-care adversaries have failed to make an impact because they have not developed a taxonomy of care--they have not established a language compatible with, or as powerful as, ER's. In Part Three, in an attempt to raise the conceptual and practical status of caring in contemporary health systems, we distinguish four different forms of care. In opposition to those who believe the 'ethic of care' can adequately direct health care practice, we demonstrate that care is a secondary notion. We show that in order for a carer to decide which form of care to adopt in different situations she requires a more powerful idea. We contend further that health care ought to be governed by a theory of health, and suggest that 'the foundations theory of health' should be adopted by planners searching for a more humane alternative to ER. We conclude that ER's dominance can and must be challenged. However, only those arguments which offer detailed theoretical analyses of health care, as well as meticulously derived practical policies, have any chance of success. PMID- 10177942 TI - Prescribers, patients and policy: the limits of technique. AB - What is good prescribing? In this paper we will look at the kinds of criteria which are relevant to evaluating prescribing. In particular we wish to challenge, or at least re-frame, the picture of prescribing as an essentially technical process. In so doing we hope to indicate something more general about the power, and limitations, of technical rationality in health care, and to contribute something to work in health care technology assessment. Finally we hope this discussion will act as a stimulus towards a much needed revision of the way 'good' prescribing is defined by current policies, guidelines and protocols. PMID- 10177943 TI - Can economics be bad for your health? AB - The increasing popularity of economic evaluation methods, especially cost effectiveness analysis, brings with it the danger of decisions being made on the basis of faulty criteria. This paper explores the underlying faults of orthodox economics, and offers tentatively an alternative means of decision appraisal via John Dewey's philosophy of instrumentalism and the methods of institutionalist economics. PMID- 10177944 TI - Creativity and sacrifice: two sides of the coin. A reply to David Seedhouse. PMID- 10177945 TI - The inescapable prejudice of health economics: a reply to Farrar, Donaldson, Macphee, Walker and Mapp. PMID- 10177946 TI - The defeat of reason. PMID- 10177947 TI - Occupational health services: the legal case for expansion. PMID- 10177949 TI - Agency for Health Care Policy and Research. General reorganization; statement of organization, functions, and delegations of authority. PMID- 10177948 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE program; reimbursement--DoD. Proposed rule. AB - This rule proposes to revise certain requirements and procedures for reimbursement under the TRICARE program, the purpose of which is to implement a comprehensive managed health care delivery system composed of military medical treatment facilities and CHAMPUS. Issues addressed in this proposed rule include: implementation of changes made to the Medicare Prospective Payment System (PPS) upon which the CHAMPUS DRG-based payment system is modeled and required by law to follow wherever practicable, along with changes to make our DRG-based payment system operate better; extension of the balance billing limitations currently in place for individual and professional providers to non-institutional, non professional providers; adjusting the CHAMPUS maximum allowable charge (CMAC) rate in the small number of cases where the CMAC rate is less than the Medicare rate; and implementing the government-wide debarment rule where any provider excluded or suspended from CHAMPUS shall be excluded from all other programs and activities involving Federal financial assistance, such as Medicare or Medicaid, and adding violations of our balance billing or claims filing requirements to the list of provider actions considered violations of the TRICARE/CHAMPUS program. PMID- 10177950 TI - Policy on 180-day marketing exclusivity for drugs marketed under abbreviated new drug applications; clarification--FDA. Clarification. AB - The Center for Drug Evaluation and Research (CDER) of the Food and Drug Administration (FDA) is publishing this document to clarify the status of its practices governing 180 days of marketing exclusivity for generic drugs and the approval of abbreviated new drug applications (ANDA's) subject to patent litigation. This document is being published due to recent court decisions interpreting provisions of the Drug Price Competition and Patent Term Restoration Act of 1984 (Pub. L. 98-417) (the 1984 amendments). PMID- 10177951 TI - Medical devices; reclassification and codification of suction lipoplasty system for aesthetic body contouring--FDA. Final rule. AB - The Food and Drug Administration (FDA) is announcing that it has issued an order in the form of a letter to the American Society for Aesthetic Plastic Surgery (ASAPS) reclassifying the suction lipoplasty system for use in aesthetic body contouring from class III (premarket approval) to class II (special controls). The reclassification is based on information regarding the device contained in a reclassification petition submitted by ASAPS and other publicly available information. Accordingly, the order is being codified in the Code of Federal Regulations. This action is taken under the Medical Device Amendments of 1976 (the 1976 amendments) as amended by the Safe Medical Devices Act of 190 (the SMDA). PMID- 10177952 TI - Medicare and Medicaid programs; hospital conditions of participation; provider agreements and supplier approval; extension of comment period--HCFA. Notice of extension of comment period for proposed rule. AB - This document extends the comment period for a proposed rule that generally would revise the hospital conditions of participation under Medicare and Medicaid, published in the Federal Register (62 FR 66726) on December 19, 1997. The comment period is extended 60 days for all provisions except the proposed new requirements relating to interactions between hospitals and organ procurement organizations, which are extended for an additional 14 days. PMID- 10177953 TI - National Practitioner Data Bank for adverse information on physicians and other health care practitioners: availability of and fee for public use data file- HRSA. PMID- 10177954 TI - Finding managed care's new fertile ground. PMID- 10177955 TI - Doctors with a plan's success at stake. PMID- 10177956 TI - Compensation monitor. For physician executives, that M.B.A. really pays off. PMID- 10177957 TI - Formularies tighten and physicians adapt. PMID- 10177958 TI - Why patients have little patience for report cards. PMID- 10177959 TI - Consumer protection in managed care: which way? A conversation with Ron Pollack. PMID- 10177960 TI - Keep peace in your practice. PMID- 10177961 TI - Competitive intelligence. Make public documents work for you. PMID- 10177962 TI - Respect for the patient has a future in the harried world of managed care. PMID- 10177963 TI - Determine a comfortable capitation to effectively negotiate contracts. PMID- 10177964 TI - Managed care outlook. See it now: the tube attracts members. PMID- 10177965 TI - Complementary medicine: mainstream health care accommodates alternative therapies, wellness, and holistic health. PMID- 10177966 TI - Catching the wave of the future: hospital and physician-sponsored complementary medicine clinics. PMID- 10177967 TI - Reinventing medicine: new models of care, disease management, and health promotion. PMID- 10177968 TI - Hard data drive physician buy-in for pathway development efforts. AB - Although getting physician buy-in for clinical pathway initiatives remains a challenge at many hospitals, there are things you can do to stack the odds in your favor, experts say. The first step is to lay the groundwork for physician support by winning over key physicians early. Target the chief of staff, a respected physician in a relevant field, or the physician you expect to be most resistant to pathway efforts. To maintain physicians' goodwill, you must manage to keep physicians involved in the pathway effort without making excessive demands on their time. Experts suggest incorporating pathway discussions into already-scheduled meetings, and shifting the burden of paperwork away from physicians. A third crucial component of buy-in is supplying physicians with valid, reliable data in a clear and concise manner. Build in a feedback loop, and let them know the data you collect won't be used against them. PMID- 10177969 TI - Physicians resist efforts to standardize care. PMID- 10177970 TI - Case management goes global. AB - As the global population ages and countries seek to privatize their national health systems, more and more hospitals overseas are turning to case management as a way to get a handle on health care costs. Even in advanced nations like Great Britain, however, the profession remains in a state of infancy. Cost data are often difficult to come by, and until recently, physicians and medical staff have not been held accountable for the quality of services they provide. Clinical pathways are also becoming popular abroad because they can serve as a means of identifying best practices and can help to reduce the fragmentation that has characterized health care overseas. PMID- 10177971 TI - Continuum-focused CHF path cuts LOS to four days. AB - Evanston (IL) Hospital's continuum-focused clinical pathway for congestive heart failure (CHF) has racked up some impressive numbers since its implementation in 1995: Length of stay has dropped from 6.2 days to four days--three less than the national average--while direct treatment costs have dropped by 60%. At the same time, the 30-day readmission rate has fallen from 19% to only 2.6%. Case managers at Evanston attribute much of the pathway's success to its ability to quickly mobilize team members and allow them efficient access to necessary resources. The drop in 30-day readmissions has resulted from Evanston's automated tele management program, which allows CHF patients to phone in their daily weights and answer questions related to their current health status. PMID- 10177972 TI - Beyond the first phases of a critical path system. PMID- 10177973 TI - CVA (cerebrovascular accident) pathway cuts across seven hospital units. AB - After discovering that stroke patients were receiving care on 18 different units within the hospital, St. Luke's Medical Center in Milwaukee developed its first cross-unit clinical pathway, targeted at cerebrovascular accident (CVA) patients. Implemented in October 1996, the five-day CVA pathway has cut length of stay by 1.6 days while maintaining a patient satisfaction rating of 94%. Nurse clinicians developed five key outcomes for the CVA pathway, including visits from speech therapy, a physiatry referral, a severity assessment, patient education, and patient consultation on the details of the discharge plan. PMID- 10177974 TI - Target individual needs to boost diabetic compliance. PMID- 10177975 TI - New case management credential announced. PMID- 10177976 TI - Tele-medical standards: the search for common ground. PMID- 10177977 TI - Managed care trends & emerging strategies. PMID- 10177978 TI - The altered dynamics of purchasing decision making. PMID- 10177979 TI - The irony of peak performance. PMID- 10177980 TI - The new management education front. PMID- 10177981 TI - The art of preparing for the SNF PPS. PMID- 10177982 TI - Minnesota pioneers dual-eligible managed care. PMID- 10177983 TI - The space race. More providers offer one-bedrooms in addition to studios. PMID- 10177984 TI - Why people hate long-term care. What's behind the industry's bad public image and what can providers do to improve it? PMID- 10177985 TI - OSHA casts a broader net for inspections. PMID- 10177986 TI - Beyond immunization. Broad-spectrum antibiotics help battle pneumonia. PMID- 10177987 TI - Five minutes with Dwayne Clark. Interview by Elise Nakhnikian. PMID- 10177988 TI - A culinary arts revival in dietetics. PMID- 10177989 TI - Tips for writing competency statements. Focus on children. PMID- 10177990 TI - Pay attention to Joint Commission's caps. PMID- 10177992 TI - Is your training program effective? PMID- 10177991 TI - Food and nutrition services for children. Second in a series on age-specific competencies. PMID- 10177993 TI - Despite cost and risk, ORYX PLUS offers benchmarking bonanza. AB - The Joint Commission's ORYX-PLUS option offers standardized measurement, risk adjustment, and reporting of outcomes not available in the less comprehensive ORYX program. This should create a wealth of truly comparable data against which to benchmark. There are additional costs: $2,500 to the Joint Commission, plus more expensive software and maintenance. This means the program is probably best suited for those systems that already have significant investments in information systems. As ORYX-PLUS eventually will issue performance report cards to the public on participants, there are the risks associated with disclosure. On the other hand, participating hospitals will be able to boast participation in a voluntary disclosure program aimed at excellence. PMID- 10177994 TI - Benchmarking data for home care are scarce. AB - There are few regional or national benchmarking sources for home care agencies, but two new accreditation requirements--ORYX and OASIS--will build vast national databases. OASIS, an outcomes measurement survey required by the Health Care Financing Administration, promises a standardized measurement and reporting set. However, the home care industry is well behind hospitals in collecting, compiling, and reporting outcomes. Don't expect a national database before the year 2000. PMID- 10177995 TI - Home agencies can benchmark internally. PMID- 10177996 TI - New initiative provides best practices for elderly. AB - Over the next 30 years, there will be a massive influx of geriatric baby boomers into the health care system, yet few facilities have programs for geriatric care. Nurses Improving Care to the Hospitalized Elderly is researching protocols, best practices, and benchmarks. Its survey for institutions helps systems evaluate their capabilities and zero in on improvements. PMID- 10177997 TI - National group surveys pediatric infection control. PMID- 10177998 TI - Capitated hospital cuts prematurity, saves big. AB - Because one premature infant can easily cost your health system $50,000, initiating management strategies for prematurity can save millions. Three factors -early identification of high-risk moms, education, and case management for those at high risk--can help cut your prematurity rate. Steroids given to develop a fetus' lungs are effective after 48 hours, so stopping labor for this amount of time is highly beneficial. One clinic's prematurity program cut days in neonatal intensive care by 75%. PMID- 10177999 TI - Improve retention rates (and quality of care) by showing nurses appreciation. PMID- 10178000 TI - Death of a subacute unit. PMID- 10178001 TI - Improve continuity of care through collaboration. The growth of assisted living provides opportunities for nursing homes. PMID- 10178002 TI - Tying the knot between resident care and quality of life. PMID- 10178003 TI - Are you in charge? Being a leader is more than just having a title. PMID- 10178004 TI - Caring by example builds your facility's business. PMID- 10178005 TI - The costs of depression in late life. PMID- 10178006 TI - Private duty companions are an untapped resource in your community. PMID- 10178007 TI - Home care takes massive hits in Balanced Budget Act. PMID- 10178008 TI - Use the luxury of time to build relationships with immigrant residents. PMID- 10178009 TI - Target high-cost areas for reducing utilization. PMID- 10178010 TI - Activity-based costing saves on supply distribution costs. AB - Activity-based costing is coming, but is your organization ready? A few pioneering hospitals are already reaping the operational and economic benefits of activity-based costing in their materials management, and now the VHA purchasing alliance is offering this costing option to its 1,200 hospital members. The concept is simple, so why aren't there more takers? Here are the details on this pragmatic pricing approach that could save your facility plenty. PMID- 10178011 TI - Physician order entry system cuts error rate, improves path compliance, tracks data. AB - Installing physician order entry systems goes a long way to reducing expensive adverse drug events. Brigham and Women's Hospital's automated physician order entry system identifies potential drug interaction problems and flags dosage errors--plus it enables data collection to track prescribing practices and encourages physicians to follow standardized pathways. Here are the details on BWH's system, its study on how adverse drug events waste health care dollars, and advice on minimizing adverse events at your institution. PMID- 10178012 TI - Data benchmarks. Purchasing physician practices: let the hospital buyer beware? AB - Data Benchmarks: Why are hospitals so eager to snap up physician practices when they're losing so much money in the process? This month's column provides the details from a new survey on physician practice acquisition, plus some insights on what hospitals can do differently to keep dollars from going down the drain. PMID- 10178013 TI - Controversy brews over cervical cancer screening. PMID- 10178014 TI - Reduce the pain and high costs associated with pressure ulcers. AB - For patients who suffer immobility or cognitive problems, institutionalization can bring on a whole new set of problems in the form of pressure ulcers. Pressure ulcers can be prevented using strict risk assessment measures, but many hospitals and skilled nursing facilities fail to use these strategies, resulting in extended lengths of stay. Find out how one provider collaborative attacked the problem, plus use their pressure ulcer prevention tool in your own facility. PMID- 10178015 TI - Doctor-patient partnerships key to successful asthma DM. AB - A majority of HMOs now have asthma DM programs, and although most are highly successful at achieving cost savings and better medical outcomes, researchers say new technologies and new methods can augment these efforts. Patients design an action plan with their doctor that takes into account new federal guidelines and new knowledge about medication use in this look at what's helping patients breathe easier. PMID- 10178016 TI - Study confirms impact of improper asthma drug therapy. PMID- 10178017 TI - Female-targeted drug therapies may propel migraine DM efforts. AB - Julius Caesar, Thomas Jefferson, and even Sigmund Freud had this ailment, and Alice is thought to have described it in Wonderland. But make no mistake, migraine headaches are not the stuff of fairy tales for the 45 million migraine sufferers of the disabling and costly disorder. Here are the disease management guidelines you need to reduce migraine-related expense and minimize your patient's pain. PMID- 10178018 TI - Contact capitation: the coming craze for specialists? PMID- 10178019 TI - Reinsurance coverage should evolve to meet your needs. PMID- 10178020 TI - Benchmark your PMPM costs against this specialty model. PMID- 10178021 TI - New reporting system provides cap rates, projects profitability. PMID- 10178022 TI - Consider these lessons from the front lines before investing in contact cap. AB - Why is contact capitation increasingly popular among specialists, and what situations are appropriate for its use? Each organization using this form of payment has a different tale to tell, but each is instructive. Here are three stories that reveal some of the advantages of contact cap and the steps needed to get there. PMID- 10178023 TI - As premiums rise, will capitation rates follow suit? PMID- 10178024 TI - AMA looks to protect members with standard capitation contract. AB - The American Medical Association has taken the bold step of developing a model managed care contract to serve as a governing document for arrangements between MCOs and physicians. How will it help at-risk providers? PMID- 10178025 TI - Lack of interest in accreditation for prepaid groups dooms TMQC (The Medical Quality Commission). AB - The Medical Quality Commission will cease operations on March 31, citing financial constraints and flat demand for medical group and IPA accreditation. What does the loss of this organization say about the importance of quality in capitated care? PMID- 10178026 TI - Can you meet these IPA performance benchmarks? PMID- 10178027 TI - Aggressive risk contracting demands full-time attention. AB - How does your organization manage the nuances of capitation? Some providers are creating capitation departments, which work side-by-side with financial and managed care staff to ensure an organization's fiscal integrity. PMID- 10178028 TI - Health system offers physicians variety of affiliation models to spur integration efforts. AB - A Kansas delivery system offers its physicians a choice of five levels of affiliation, each with its own compensation structure. The flexible approach is helping to position the system for capitation. PMID- 10178029 TI - Perspectives. Sub-acute payment changes hint at brave new world of outcomes. PMID- 10178030 TI - Lessons from the per-episode PPS demonstration. PMID- 10178031 TI - The Interim Payment System--frequently asked questions. PMID- 10178032 TI - Coping with the Interim Payment System: practical notes from the front lines. PMID- 10178033 TI - Advice from the experts. PMID- 10178034 TI - Managing in the IPS environment: new rules, new realities. PMID- 10178035 TI - Interim Payment System and risk management. AB - To stay afloat under the new Interim Payment System, agencies will need to be aware of the legal implications of the new changes. Agencies need to take deliberate steps to manage the risks that are sure to ensue under the new system of restricted payments. PMID- 10178036 TI - State associations weigh in on impact of IPS. PMID- 10178037 TI - IPS: what happens to beneficiaries? PMID- 10178038 TI - Toward more reasoned home health payment reform. Industry, legislative, and regulatory proposals to modify IPS. AB - The National Association for Home Care (NAHC), its members agencies, and affiliated state associations have launched an aggressive campaign to educate Congress and others about the harmful effects of Interim Payment System. One way is through NAHC's Blueprints for Action--NAHC's action plan for 1998. PMID- 10178039 TI - The impact of the Interim Payment System: agency expectations. AB - How agencies approach the IPS reductions will have a profound impact on the future of home health under Medicare. A recent survey provides some preliminary information about how home health agencies expect the reimbursement changes to affect them. PMID- 10178040 TI - Getting a grip on the future: managing the change process. AB - How will providers streamline existing administrative and clinical care systems to meet the new regulatory requirements? How will they reorganize to cope with outcome-based quality improvement? Success in this rollercoaster climate depends on providers' ability to manage the change process. PMID- 10178041 TI - Keeping our focus in a challenging time. PMID- 10178042 TI - Home care, the Balanced Budget Act of 1997, and IPS. AB - The evolution of policy leading up to IPS has been long and complicated. Since the early 1980s, policymakers have sought an alternative to the historic, cost based payment approach for home health care. PMID- 10178043 TI - Riverboat EMS: never a game of chance. PMID- 10178044 TI - Weapons check. Finding guns in surprising places. PMID- 10178045 TI - The spirit of caring at St. Joseph's Medical Center. Interview by Lisa M. Marinik. PMID- 10178046 TI - OSHA proposes TB standard. PMID- 10178047 TI - New medical waste rule will reduce on-site incineration. PMID- 10178048 TI - Promoting professionalism. Interview by Lisa M. Marinik. PMID- 10178049 TI - Can computers cure health care? PMID- 10178050 TI - Should providers pursue disease management? PMID- 10178051 TI - Using a limited HMO license strategy to pursue global capitation. PMID- 10178052 TI - Hospital-owned physician practices fail because hospitals fail to plan for them. PMID- 10178053 TI - The consolidated hospital laboratory network: the next step in clinical laboratories. PMID- 10178054 TI - Complex regulations are driving hospitals' corporate compliance efforts. PMID- 10178055 TI - Cooperating to improve community health. PMID- 10178057 TI - How to be an efficient in-house PFS consultant. PMID- 10178056 TI - Dropping Columbia brand & divisions is a mistake. PMID- 10178058 TI - EDI savvy software supports accounts payable and accounts receivable. PMID- 10178059 TI - Compliance culprits. PMID- 10178060 TI - Will expansion make Medicare go bust? PMID- 10178061 TI - How to save distressed IDS-physician marriages: a case study. AB - A hospital-driven IDS that encounters serious problems resulting from ownership of a physician practice should address those problems by focusing on three core areas: vision and leadership, effectiveness of operations, and physician compensation arrangements. If changes in these areas do not lead to improvements, the IDS may need to consider organizational restructuring. In one case study, a hospital-driven IDS faced the problem of owning a poorly performing MSO with a captive physician group. The IDS's governing board determined that the organization lacked effective communication with the physicians and that realization of the organization's vision would require greater physician involvement in organizational decision making. The organization is expected to undergo some corporate reorganization in which physicians will acquire an equity interest in the enterprise. PMID- 10178062 TI - Reconsidering integration strategies: an interview with Jeff C. Goldsmith. PMID- 10178063 TI - Tapping the potential of alternative medicine. AB - Interest in alternative medicine is growing among healthcare consumers. Health plans and healthcare organizations may be able to improve clinical outcomes and benefit financially by providing patients with access to alternative services. Organizations that can assess their communities' particular needs, draw on interested professional staff to help develop alternative medicine programs and protocols, and study quality outcomes will stand a better chance of making such programs successful. Educating medical staff, designing a credible program, and forging strategic alliances with respected partners can help organizations create a sharply focused brand identity in the community. PMID- 10178064 TI - Alternatives to traditional capitation in managed care agreements. AB - Risk arrangements typically fall into one of three categories: primary care capitation, professional services capitation, and global, or full-risk, capitation. Yet, in light of various disadvantages associated with these three methods, such as high administrative costs and inappropriate levels of risk assumed by providers, many healthcare payers and providers are experimenting with alternative payment plans. These alternatives include contact capitation arrangements, under which specialists receive a capitation payment on a per referral basis; open-access arrangements, under which patients do not need a gatekeeper referral to see specialists; and capitation arrangements with quality and hospital utilization bonuses, under which specialists and primary care physicians receive a capitation payment plus the potential for bonuses based on quality and utilization criteria. PMID- 10178065 TI - Applying new AICPA accounting rules on special reports. AB - Two new standards on agreed-upon procedures, issued by the American Institute of Certified Public Accountants, provide healthcare organizations and associated decision makers with new flexibility in acquiring professional accounting services. Effective January 1, 1996, these procedures allow organizations to target the type and volume of services performed by accountants and potentially avoid the time and expense involved in completing a full financial statement audit. As with any other accounting engagement, both the healthcare organization and the accounting firm need to establish what procedures will be conducted, who will be allowed to use the resulting report, and how the procedures will be conducted. PMID- 10178066 TI - Enhanced managed care opportunities of group practices. Attention to four key factors can improve a practice's contracting position. AB - As managed care penetration increases throughout the nation, group practices should evaluate their business composition and practices to make the most of the managed care arrangements into which they enter. By evaluating their practice in terms of its structure, organizational maturity, information collection capabilities, and financial position, a group practice will be able to make changes that will enhance its market position and improve its negotiating leverage. PMID- 10178067 TI - Fraud and abuse. Understanding the Stark II proposed regulations. AB - HCFA's recently published proposed regulations for implementing Stark II legislation have significant implications regarding Medicare and Medicaid payments for physician referrals, and likely will be the most extensive governmental guidance available on the Stark laws. While final regulations will not be issued for some time, the availability of the guidance provided by these expanded definitions increases the risk that the government will increase its antifraud and abuse activities, particularly with respect to those aspects of the statutes that were previously unclear. Physicians and hospitals should become familiar with the new definitions of designated health services for which self referrals are prohibited, particularly inpatient and outpatient hospital services, whose inclusion as designated health services significantly expands the scope of the Stark prohibitions to many common hospital/physician transactions. They also should begin to lay plans to ensure compliance with the new regulations and to map cut strategies for revising existing organizational structures and financial arrangements. PMID- 10178068 TI - Advisory opinions help clarify antifraud and abuse laws. AB - In 1997, the Office of the Inspector General published new procedures that allow requesters to obtain an advisory opinion as to whether a particular arrangement complies with the Federal anti-kickback statute. This process gives healthcare organizations a valuable new means by which to create individualized "safe harbors" for specific business arrangements. The advisory opinion process also may be integrated into a healthcare organization's corporate compliance program to help maintain the program's effectiveness. PMID- 10178069 TI - Fraud and abuse. Building an effective corporate compliance program. AB - In 1997, General Health System (GHS), a not-for-profit integrated delivery system headquartered in Baton Rouge, Louisiana, developed a formal corporate compliance program. A newly appointed corporate compliance officer worked with key GHS managers and employees to assess the organization's current fraud and abuse prevention practices and recommend changes to meet new regulatory and organizational requirements. Then a structure for implementing these changes was developed, with staff training at its core. The program required a significant initial outlay of financial and human resources. The benefits to the organization, however, including a greater ability to respond quickly and effectively to possible compliance problems and better organizational communications, were worth the investment. PMID- 10178070 TI - Approaching physician recruitment systematically. AB - Physician recruitment has become increasingly competitive. Organizations that recruit physicians need to establish a systematic recruitment approach that includes determining the organization's recruitment objectives, using various recruiting sources, assessing the skills and "fit" of all candidates, explaining the benefits to candidates early in the process, checking references carefully, and acting quickly to make an offer. Following a systematic physician recruitment plan can help healthcare organizations hire the best person for the job. PMID- 10178071 TI - Computerized patient records improve practice efficiency and patient care. AB - Paper patient records are proving increasingly inadequate to meet the modern information needs of group practices. Computerizing patient records can improve physician access to patient information and thereby also improve patient care and outcomes management. By investing in a computerized patient record system, practices can optimize revenues by saving labor costs associated with record retrieval, photocopying, filing, and other processes. Computerizing patient records requires careful planning and selection of a system that meets the practice's needs. PMID- 10178072 TI - Coping with Medicare and Medicaid regulatory delays. PMID- 10178073 TI - Asset allocation can enhance investment returns. PMID- 10178074 TI - The World Wide Web: as big as you want to be. PMID- 10178075 TI - Assessing the connection between information systems and hospital success: theory versus reality. PMID- 10178076 TI - Finding the right home care partner. PMID- 10178077 TI - Patient-focused primary care: a model. PMID- 10178078 TI - Recruitment of primary healthcare physicians in rural areas. PMID- 10178079 TI - Tattletales, culture, and quality of care. PMID- 10178080 TI - A Catholic healthcare advocacy agenda for 1998. PMID- 10178081 TI - When physicians perform abortions outside the Catholic hospital. PMID- 10178082 TI - Assessing spirituality. Healthcare organizations must address their employees' spiritual needs. AB - Catholic institutions need to respond to their managers, physicians, and other employees experiencing deep pain about the meaning and purpose of life. Initial approaches to people in spiritual distress include "tough love", codependence, and assistance programs, along with prayer and compassion. But a different approach that gives people the space and freedom to pursue their spiritual search and ask questions to discover deeper meaning in life may be more effective. It allows them to accept that they are where they need to be on their spiritual journey, even if that place is painful. Healthcare organizations can, through their structures and culture, create environments that promote this spiritual work. The entire organization must be spiritually grounded. Organizations can develop specific programs to address employees' spiritual yearnings, including: Private spiritual direction or companionship Formal mentoring Renewal days or retreats Spirituality programs for professionals Organizations must consider spirituality in recruiting, uphold policies on spirituality, and ensure physicians receive the same spiritual support as other employees. Resources should be allocated for expanded spiritual services, quiet places for reflection, meditation and related classes, traditional retreats, and qualified personnel. PMID- 10178083 TI - Weaving spirituality into organizational life. Suggestions for processes and programs. AB - Recent research has demonstrated a clear link between spirituality and health, but it remains a challenge for many organizations to weave spirituality into organizational life and make it an integral component of clinical care. Three dimensions of spirituality work together in healthcare: spiritual well-being of patients and families, spiritual well-being of workers, and spiritual well-being of the organization. To cultivate these dimensions in the life of healthcare organizations, several strategies may be employed. First, the definition of "spirituality" must be clear. Consider spirituality at the core of providing healthcare, instead of parallel to or part of clinical approaches. Separate spirituality from chaplaincy, since nurturing spiritual values is the responsibility of everyone in the organization. It is important to affirm what people already do spiritually, focus on what they have to offer instead of on deficiencies, and cultivate spirituality individual by individual. Organizational leaders must demonstrate spirituality in their personal and professional lives, and keep the organizational mission to the fore. When working to enhance organizational spirituality, create a vision within the organization of its spirituality and emphasize peer support and collaboration. Programs to help organizations inculcate spirituality include retreats or renewal programs for employees, forums to explore employees' spirituality, inclusion of spiritual issues in training and orientation programs, educational and development programs for working groups, regular review of spiritual well-being, training selected employees as spiritual facilitators, and supporting research on spirituality, health, and healthcare. PMID- 10178084 TI - The worker of the future. A system outlines the competencies its employees will need. AB - In 1993, Sisters of Mercy Health System-St. Louis (SMHS), having asked itself what kind of employees it would need in the twenty-first century, established a Worker of the Future Task Force to develop tentative answers. The task force began by making projections concerning healthcare, studying the strategic plans of SMHS's members, and surveying its employees. It learned that the system should help workers see how change could benefit them. Next, the task force studied the cultural history of the Sisters of Mercy, developing from it Six Guiding Principles for the evaluation of employee performance. From these principles, the task force derived Twelve Competencies that SMHS will seek in future workers. In 1995 the system's education leaders, with the aid of an internal training organization, decided to develop 17 training modules based on these guiding principles and competencies. Since then, more than 85 SMHS employees have been trained to help coworkers develop customer service skills and other competencies. SMHS has also incorporated the competencies in its job descriptions and performance evaluations, added the Worker of the Future curriculum to its orientation program for new employees, and is currently developing Worker of the Future training sessions for human resources personnel who interview prospective employees. PMID- 10178085 TI - After the UPS strike. Six lessons for healthcare organizations. PMID- 10178086 TI - Encouraging physician leadership. Catholic healthcare systems explore balanced relationships. PMID- 10178087 TI - Tools for physician-hospital partnerships. New company's services help system members and physicians. PMID- 10178088 TI - When hospitals hire physicians. Elements of the direct employment model. PMID- 10178089 TI - Renewing the idea of convalescence. New unit eases transition from hospital to home. PMID- 10178090 TI - The evolving nature of sponsorship. Recent decades have brought changes both in theory and practice. PMID- 10178091 TI - A framework for improving quality. Using project study teams, Providence Health System tackles problem areas. AB - To identify issues for quality improvement and monitoring, an organization first articulates its service mission and objectives. The organization uses internal measurements and self-examination with external accountability and benchmarks to select a manageable number of projects for study. Supported by collected evidence, published data, and broad-based approval, projects focus on the process or outcomes of care, frequency of services, or patient populations. An accountable leader selects team members from the affected disciplines, who review evidence, agree on what and how to measure, determine implementation strategies, and develop an evaluation plan. The team meets established targets to track the project's progress and shares results with other teams. Providence Health System (PHS) his integrated its continuum of care through quality study groups (e.g., CORE) and improved communication systems. The Guideline Evaluation and Redesign (GEAR) projects compare PHS performance against outside standards, studying eight patient conditions (e.g., geriatric depression, hysterectomy) to decrease hospital days without compromising care. Each team is encouraged to develop guidelines for admission, discharge, and hospital care in their specialty areas. These projects are balanced between surgical and nonsurgical conditions and across clinical programs to engage different staffs. The PHS Population Health Improvement (PHI) teams used feasibility studies of eight patient populations to identify ways to improve quality of care based on internal and external evidence. The high-risk pregnancy team has redesigned staffing and implemented case management, and the Medicare and Medicaid projects have developed risk screens for new patient members. PMID- 10178092 TI - Family resource center responds to community needs. PMID- 10178093 TI - Values-based programs for aging and chronically ill persons. PMID- 10178095 TI - Why preserve the not-for-profit tradition? PMID- 10178094 TI - Toward a common vision for the Catholic health ministry. PMID- 10178096 TI - Management competencies for medical practice executives: skills, knowledge and abilities required for the future. AB - The purpose of this study was to obtain a consensus of opinion from a large and diverse population of experienced ambulatory health care administrators regarding the essential ambulatory health care management competencies, and their related skills, knowledge and abilities (SKA) requirements, that will be required for successful management performance in ambulatory health care delivery settings in the next five years. A literature review suggests limited research in this essential and rapidly developing area for the health care community. The research design and methods employed the Delphi technique. Three hundred and twenty (320) Fellows of the American College of Medical Practice Executives (ACMPE) were asked to respond to two rounds of a Delphi mail survey. The results indicate that the essential ambulatory management competencies could be discretely grouped into six Management Domains, each with related SKAs. The respondents rated leadership and strategic management as the most important Management Domains. The highest rated SKA emphasized interpersonal skills with the next highest SKA relating to ethical and moral dimensions. Patient care management, as well as two SKAs relating to computer skills, were rated lowest. PMID- 10178097 TI - Customer survey activity in health administration education programs. PMID- 10178099 TI - Mastering health care executive education: creating transformational competence. AB - The effective health services executive needs to continue to develop analytical, technical and behavioral skills to anticipate and meet the changing requirements of the health care industry. Those leading the field of health administration will need to be competent in achieving transformations. Lifelong learning is a necessity. As the structure and knowledge of the field change, so must the ways of exchanging information about health and medical care. Distance learning is a strategy for lifelong learning that can be used to continue one's education. In order to be successful in positioning a health care organization in the competitive world, investment in continued education to update strategic thinking and the analytical competency of executives and managers is imperative. Academic programs able to respond to the educational needs of the health care industry have a dedicated faculty who understand corporate culture and competitiveness in the health care marketplace and are able to offer effective adult education using cutting-edge computer technology for distance learning. PMID- 10178098 TI - Graduate management education for nurses: a comparative study. AB - This paper examines graduate management education programs for nurses using two programs of one University as a case study. Historically, Schools of Nursing have provided educational programs for nurse executives. More recently, a combination of nursing and business programs have gained popularity. A survey of nurses with the Master of Science (MS) from a School of Nursing and the Master of Science in Health Administration (MSHA) from a Department of Health Administration was conducted to assess demographic variables and job characteristics. Differences in job characteristics of the alumni of the two programs are evaluated and discussed. PMID- 10178100 TI - Andrew Pattullo and "a strategy for building a profession". PMID- 10178101 TI - EMS 2000. Part I. High-tech triage. PMID- 10178103 TI - 1998 Almanac. Organizations; government agencies; calendar. PMID- 10178102 TI - Meth labs. PMID- 10178104 TI - Giant steps. PMID- 10178105 TI - Dual-eligible policy could fall short. PMID- 10178106 TI - Mapping out care. Pressure ulcer prevention and treatment path. PMID- 10178107 TI - Using family-friendly tools. PMID- 10178108 TI - Keeping an open-door policy. PMID- 10178109 TI - All roads lead to skilled nursing facilities. PMID- 10178110 TI - Bringing HIV expertise in-house. PMID- 10178111 TI - Keeping tuberculosis under control. PMID- 10178112 TI - Governing conversion foundations: a practical guide for trustees. PMID- 10178113 TI - By the bootstraps. 1998 Nova Award winners. PMID- 10178114 TI - Executive follow-up. Boards and CEOs get a line on succession--panel discussion. PMID- 10178115 TI - Strength in unity. PMID- 10178116 TI - Millennium meltdown: code blue 2000. PMID- 10178117 TI - Physician practice acquisition: a practical primer. PMID- 10178118 TI - A true tale of grassroots governance. PMID- 10178119 TI - Gen. Colin Powell salutes Health Adventures. PMID- 10178120 TI - Shared decision-making makes medical paternalism obsolete. So long, Marcus Welby. PMID- 10178121 TI - Going public: do medicine and public health have a future together? PMID- 10178122 TI - Take the AIDS awareness test. PMID- 10178123 TI - Finding your internal volunteer management team. PMID- 10178124 TI - The laughter factor: it's more than a rumor--humor is good for you! PMID- 10178125 TI - Impact of a management assessment centre in developing proficient health managers. AB - There is growing use of management assessment centres within parts of New South Wales Health. The present study examined outcome benefits from managers who participated in the Australasian Management Competencies Assessment Centre, some 123 staff from one rural and one metropolitan area health service. Results confirmed greater use of personal development plans and increased attendance at continuing professional development among participants compared with like managers who had not participated. The paper argues strongly in favour of widespread use of management competencies assessment centres as a way to implement planned cultural change. PMID- 10178126 TI - Rural, remote and metropolitan area health differentials: a summary of preliminary findings. PMID- 10178127 TI - Coordinating rural divisions: the workforce window. AB - Divisions of General Practice have been established to alleviate the professional isolation which general practitioners face by being excluded from involvement in other parts of the health care system. Divisions facilitate the development of local communication networks and cooperative activities which improve the integration of general practice with other elements of the health system. Coordination of communication is one of the strengths of divisions at the local level and Rural Divisions Co-ordinating Units at the State level. This strength is being effectively utilised to target general practice workface issues. Given the significant proportion of general practitioners in the medical workforce, particularly in rural and remote areas, this has implications for broader medical workforce issues. Australia faces a maldistribution in its general practitioner workforce, with an excess supply in urban areas and a significant shortfall in rural and remote areas. Since 1995-96, the General Practice Rural Incentives Program, which targets the recruitment and retention of rural doctors, has devolved funding to the Rural Divisions Co-ordination Units to coordinate the statewide provision of practical assistance to rural general practitioners, through their divisions, in relation to continuing medical education and the provision of locums. There is potential to build on the success of these initiatives and also to work with urban divisions through the state-based organisational structures which are currently being developed. PMID- 10178128 TI - Comparing patient satisfaction, outcomes and costs between cataract day surgery and inpatient surgery for elderly people. AB - The study reported in this paper examined the characteristics of elderly people undergoing cataract surgery and compared patient perspectives and satisfaction, outcome, costs, reported health problems and social circumstances of day surgery patients and hospital inpatients. The study sample was drawn from the client database of a health insurance fund and covered 291 people aged 60 years or more who had recently undergone cataract surgery. Overall, both day surgery patients and inpatients indicated a high level of satisfaction with their eye surgery (about 80 per cent for both groups). The majority of patients from both groups reported an improved level of vision, with vision outcome in the day surgery group being as good as in the inpatient group. Overall, inpatient treatment was more costly and involved higher out of pocket expenses. The study results indicate a potential to increase the number of patients undergoing cataract surgery as a day patient procedure. Pre-operative preparation contributed to patient satisfaction and the availability of family and/or social support was an important factor influencing day surgery admission. Whilst patients reporting health problems were less inclined to have cataract surgery than were day patients, this only accounted for one-fifth of the total inpatient group. Developing systematic and appropriate case selection criteria and effective case management will contribute to more efficient use of hospital resources, an increased use of day surgery facilities, and hence a more cost-effective overall cataract surgery service for elderly people. PMID- 10178130 TI - Total quality management in accredited New South Wales hospitals: a public/private comparison. AB - Analysis of data collected in a 1994-95 survey of accredited New South Wales hospitals examined the adoption of key elements of total quality management practice in the public and private sectors. In a number of areas of practice widely considered to be central to a hospital's total quality management efforts, there was no statistically significant difference between the two sectors. Where differences existed, total quality management practices more likely to be adopted by public hospitals were limited in their scope and likely to be explained by structural peculiarities. In contrast, private hospitals were more likely to adopt practices more critical to the successful implementation of total quality management. PMID- 10178129 TI - Managing potentially ischaemic chest pain and coronary care beds effectively. AB - One of the most common reasons why patients attend emergency departments in Australia is chest pain that is potentially due to coronary artery disease (myocardial infarction, unstable or stable angina pectoris). A number of models for the investigation and treatment of these patients have been employed over the last five to ten years. This paper describes the evolution of a model for managing ischaemic chest pain that aims to avoid potentially preventable deaths from undiagnosed myocardial infarction, to admit to hospital patients who could benefit from inpatient treatment, to admit to a coronary care unit patients at significant risk of complications, and to avoid inter-hospital transfer of patients. Introduction of the model has led to an increase in the appropriate hospital admission of patients with ischaemic chest pain, a marked reduction in inter-hospital transfers, and better utilisation of coronary care beds. Unmonitored, general ward management of low risk patients with clinical unstable angina has not resulted in compromised outcomes. PMID- 10178132 TI - Benchmarking in health care: a review of the literature. AB - This paper provides a review of the 10 significant publications related to benchmarking in health care. The discussion which follows is presented according to four headings: what the study did, how the study was conducted, what was learnt from the experience, and what the implications were for health care generally. The findings of this review are reassuring in that all studies provided valuable information, in terms of clinical practice and the health care service or the benchmarking process. They highlight the importance of the maintenance of quality health care, the reduction of health care costs and the need for improved efficiency and effectiveness in providing health care. PMID- 10178131 TI - Thoughts before whistling. AB - Whistleblowing is a public alert by an insider of an organisation to a practice or concerning potential they observe in the organisation. This paper proposes that the risk, values at stake, timeliness and manner of complaint be considered before a whistle is blown. It also notes education and monitoring mechanisms. PMID- 10178134 TI - A national clinical indicator database: issues of reliability and validity. AB - The introduction of performance (clinical) indicators into the accreditation process by the Australian Council on Healthcare Standards is in keeping with global trends and has enabled the establishment of a National Aggregate Database reflecting standards of care in acute health care organisations. The database contains both quantitative and qualitative information on the processes and outcomes of patient care and changes in practice induced through indicator monitoring. Of fundamental importance to the integrity of the database are the issues of indicator validity, responsiveness and reliability. This paper considers these issues, drawing parallels, as appropriate, to other performance indicator programs and studies. PMID- 10178133 TI - A pilot study of the utilisation and outcome of community orders: client, carer, case manager and Mental Health Review Tribunal perspective. AB - Mental health problems are a major public health concern due to their prevalence and impact at a personal, family, social and economic level. Compulsory community treatment is being utilised as a health care approach, despite much disagreement and lack of Australian research demonstrating its effectiveness. This pilot study investigated the utilisation and outcomes of community orders from the perspective of a client, carer, case manager and Mental Health Review Tribunal member. The findings indicate that compulsory community treatment had a positive impact upon hospital readmission rates and medication usage. All groups of respondents rated community orders as being of benefit in a number of areas. Further controlled studies are required. PMID- 10178135 TI - Searching for the hospital yardstick: a case study of private hospital productivity bargaining. AB - The decentralisation of Australia's centralised wage fixation system has been seen as providing opportunities for employers and trade unions to tailor working arrangements to suit the needs of the workplace and to provide better paid long term jobs. This paper details the productivity bargaining between the Private Hospitals' Association of Queensland and The Australian Workers' Union in 1995-97 in Queensland that led to the introduction of a number of productivity-based enterprise agreements. The case study shows that productivity bargaining in the private hospitals studied remains focused on 'bottom line' issues where cashable savings can readily be generated. The paper concludes with an examination of the lessons drawn from the productivity bargaining process. PMID- 10178136 TI - A rebuttal to Nancy Hewak's "The Ethical, Medical and Legal Implications of the Forcible Treatment Provisions of the Criminal Code". PMID- 10178137 TI - Telemedicine in support of peacekeeping operations. PMID- 10178138 TI - Relationships among death anxiety, communication apprehension with the dying, and empathy in those seeking occupations as nurses and physicians. AB - In light of the modern phenomenon of increased institutionalized deaths occurring in hospitals and in nursing homes, much of recent death attitude research has focused on health professionals. The present study explored possible relationships among measures of death anxiety, communication apprehension with the dying, and empathy in undergraduate nursing, premedical, and control subjects. Main effects for year in school indicated that seniors scored lower than freshmen on communication apprehension with the dying. The multivariate effects for field of study were also significant, with univariate results indicating that nursing students scored lower than controls on communication apprehension with the dying. PMID- 10178140 TI - Landfill tax and the opportunities for environmental bodies. PMID- 10178139 TI - Responsible management of contractors on gas installation projects. PMID- 10178141 TI - New Construction Act. PMID- 10178142 TI - When rabbis wrote the building regulations. PMID- 10178143 TI - Quality improvement in primary health care: a European perspective. PMID- 10178144 TI - Trauma emergency unit: long-term evaluation of a quality assurance programme. AB - OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme. PMID- 10178146 TI - Where does clinical audit fit in? PMID- 10178145 TI - Why is evaluation of the cost effectiveness of audit so difficult? The example of thrombolysis for suspected acute myocardial infarction. AB - BACKGROUND: Cost effectiveness analysis is an established technique for evaluation of delivery of health care, but its use to evaluate clinical audit is rarely reported. Thrombolysis for suspected acute myocardial infarction is a commonly used therapy of established effectiveness and an appropriate subject for audit in many healthcare settings. OBJECTIVE: To measure the cost effectiveness of audit of thrombolysis in some district general hospitals. MAIN OUTCOME MEASURE: Cost of audit per extra patient treated with thrombolysis (incremental cost effectiveness ratio). DESIGN: Prospective agreement with physicians to undertake repeated audits of a specific aspect of the management of patients with acute myocardial infarction. Baseline measurement of the proportion of these patients given thrombolysis in each hospital were made, as were three subsequent retrospective audits, giving time series of measurements. Costs were estimated from records of staff time and other resources used in each hospital; effectiveness was estimated by fitting the results to a model which assumed a uniform rate of increase over time in the proportion of eligible patients given thrombolysis which might be accelerated by regular audit. Upper and lower limits for main outcome measure were derived from sensitivity analysis of costs and logistic regression of time series data. SETTING: Five district general hospitals in North West Thames Regional Health Authority including one control hospital were used, starting in April 1991 when widespread medical audit was first introduced. RESULTS: Between the first and last audits, the proportion of patients with suspected acute myocardial infarctions receiving thrombolysis rose in three of the hospitals undertaking audit by 20% to 37% and fell by 6% in the fourth (although this hospital started with a rate in excess of 90%). The corresponding change in the control hospital was an increase of 15%. The differences between each of the auditing hospitals and control hospital were not significant, except in one case, where 51 extra treatments per year were attributable to audit (95% confidence intervals (95% CIs) 0.5 to 61 cases per year). Estimated overall costs in each hospital ranged from 3700 Pounds to 5200 Pounds for data collection, a series of four audit meetings, and subsequent actions. The central estimate of cost effectiveness in the three responsive hospitals ranged from 101 Pounds to 392 Pounds per extra case given thrombolysis, with very wide 95% CIs. In the fourth hospital audit had zero effectiveness as defined in this study. CONCLUSIONS: Methodological difficulties were encountered which need to be considered in future economic evaluations of clinical audit and related activities. These were: (a) adequate control for other factors influencing clinical behaviour; (b) uncertainties about the sustainability of changes in behaviour associated with audit; and (c) the relative infrequency in a single hospital of specific clinical events leading to small numbers for analysis. These difficulties constitute major challenges for the economic evaluation of clinical audit. They are most likely to be overcome in a large study which compares clinical audit with other interventions aiming for the same quality improvement, such as patient specific reminders or educational programmes. PMID- 10178147 TI - Nurses' participation in audit: a regional study. AB - OBJECTIVES: To find out to what extent nurses were perceived to be participating in audit, to identify factors thought to impede their involvement, and to assess progress towards multidisciplinary audit. RESEARCH DESIGN: Qualitative. METHODS: Focus groups and interviews. PARTICIPANTS: Chairs of audit groups and audit support staff in hospital, community and primary health care and audit leads in health authorities in the North West Region. RESULTS: In total 99 audit leads/support staff in the region participated representing 89% of the primary health care audit groups, 80% of acute hospitals, 73% of community health services, and 59% of purchasers. Many audit groups remain medically dominated despite recent changes to their structure and organisation. The quality of interprofessional relations, the leadership style of the audit chair, and nurses' level of seniority, audit knowledge, and experience influenced whether groups reflected a multidisciplinary, rather than a doctor centred approach. Nurses were perceived to be enthusiastic supporters of audit, although their active participation in the process was considered substantially less than for doctors in acute and community health services. Practice nurses were increasingly being seen as the local audit enthusiasts in primary health care. Reported obstacles to nurses' participation in audit included hierarchical nurse and doctor relationships, lack of commitment from senior doctors and managers, poor organisational links between departments of quality and audit, work load pressures and lack of protected time, availability of practical support, and lack of knowledge and skills. Progress towards multidisciplinary audit was highly variable. The undisciplinary approach to audit was still common, particularly in acute services. Multidisciplinary audit was more successfully established in areas already predisposed towards teamworking or where nurses had high involvement in decision making. Audit support staff were viewed as having a key role in helping teams to adopt a collaborative approach to audit. CONCLUSION: Although nurses were undertaking audit, and some were leading developments in their settings, a range of structural and organisational, interprofessional and intraprofessional factors was still impeding progress. If the ultimate goal of audit is to improve patient care, the obstacles that make it difficult for nurses to contribute actively to the process must be acknowledged and considered. PMID- 10178148 TI - Nursing: quality in numbers. PMID- 10178149 TI - Organisational change and quality of health care: an evolving international agenda. PMID- 10178150 TI - General practitioners as advisers and coordinators in hospitals. PMID- 10178151 TI - Facilitating quality improvement in primary health care by practice visiting. PMID- 10178152 TI - Description of local adaptation of national guidelines and of active feedback for rationalising preoperative screening in patients at low risk from anaesthetics in a French university hospital. AB - OBJECTIVE: To describe the effect of local adaptation of national guidelines combined with active feedback and organisational analysis on the ordering of preoperative investigations for patients at low risk from anaesthetics. DESIGN: Assessment of preoperative tests ordered over one month, before and after local adaptation of guidelines and feedback of results, combined with an organisational analysis. SETTING: Motivated anaesthetists in 15 surgical wards of Bordeaux University Hospital, Region Aquitain, France. SUBJECTS: 42 anaesthetists, 60 surgeons, and their teams. MAIN OUTCOME MEASURES: Number and type of preoperative tests ordered in June 1993 and 1994, and the estimated savings. RESULTS: Of 536 patients at low risk from anaesthetics studied in 1993 before the intervention 80% had at least one preoperative test. Most (70%) tests were ordered by anaesthetists. Twice the number of preoperative tests were ordered than recommended by national guidelines. Organisational analysis indicated lack of organised consultations and communication within teams. Changes implemented included scheduling of anaesthetic consultations; regular formal multidisciplinary meetings for all staff; preoperative ordering decision charts. Of 516 low risk patients studied in 1994 after the intervention only 48% had one or more preoperative tests ordered (p < 0.05). Estimated mean (SD) saving for one year if changes were applied to all patients at low risk from anaesthesia in the hospital 3.04 (1.23) mFF. CONCLUSIONS: A sharp decrease in tests ordered in low risk patients was found. The likely cause was the package of changes that included local adaptation of national guidelines, feedback, and organisational change. PMID- 10178153 TI - New concept for continuous documentation of development of quality circles in ambulatory care: initial results from an information system in Germany. PMID- 10178154 TI - Collaborating for improvement in health professions education. AB - Continual improvement efforts have been slower in health professions education than in health care delivery. This article identifies the lessons learned by teams working in an Interdisciplinary Professional Education Collaborative in overcoming barriers to carrying out continual improvement efforts in these educational organizations. PMID- 10178155 TI - Using PDSA (Plan-Do-Study-Act) to establish academic-community partnerships: the Cleveland experience. AB - The Schools of Medicine and Nursing at Case Western Reserve University and the Program in Health Administration at Cleveland State University have created an interdisciplinary course in continuous improvement that emphasizes learning through experience, accommodates a large number of students, and has created new partnerships with Cleveland area health care organizations. An approach that respects these partners as customers and refines the relationships with serial tests of change (e.g., PDSA) has contributed significantly to this program's success. PMID- 10178156 TI - Preparing health care professionals for quality improvement: the George Washington University/George Mason University experience. AB - Seventy-seven medical, physician assistant, nurse practitioner, and health services management students were provided training in quality improvement, community-oriented primary care, and teamwork. These students were then formed into 13 interdisciplinary teams to apply their knowledge in underserved areas ("service learning") under a community and faculty preceptor. PMID- 10178157 TI - Teams in a community setting: the AUHS experience. AB - The Pennsylvania Local Interdisciplinary Team was created to develop and implement an innovative model for the education of students from multiple disciplines and institutions in the theory and practice of quality improvement. The lead poisoning prevention project is presented as an example of the work of an interdisciplinary student team in a community setting in Philadelphia. PMID- 10178158 TI - Students add value to learning organizations: the Medical University of South Carolina experience. AB - Students bring fresh ideas, knowledge, and perspective to health care organizations. As students learn how to apply the principles and methods of continuous improvement, they help improve both the quality of health care and the organization's way of improving quality. PMID- 10178159 TI - Readiness, action, and resolve for change: do health care leaders have what it takes? AB - Careful assessment and planning are not enough to lead organizational change. Success depends on deliberate action by leaders and the resolve to stay the course. PMID- 10178160 TI - If improvement of the quality and value of health and health care is the goal, why focus on health professional development? PMID- 10178161 TI - Building better team charters: an example from reengineering the preoperative system. AB - This article illustrates a six-step chartering method using a successful project at the West Los Angeles VA Medical Center. The annual savings generated from this project were estimated at $13 million. PMID- 10178162 TI - Enterprise liability for bad outcomes from drug therapy: the doctor, the hospital, the pharmacy, and the drug firm. PMID- 10178163 TI - Coaching practices to work like a team takes clear goals and a referee. PMID- 10178165 TI - Medical groups' futures rely on benchmarking. PMID- 10178164 TI - Patients reap the benefits of demand management. PMID- 10178167 TI - Alternative healing comes to traditional medicine. PMID- 10178166 TI - Can patients receive an ideal visit? PMID- 10178168 TI - Medical facilities must beef up computer security. PMID- 10178169 TI - Exterminating the year 2000 bug. PMID- 10178170 TI - Replaced by fish. When a nursing home closes, what happens to the residents? PMID- 10178171 TI - Prepare your business for the prospective payment system. PMID- 10178172 TI - How to maintain a positive attitude. PMID- 10178173 TI - Usage policy clears the air about e-mail. PMID- 10178174 TI - The power tool of the Internet. PMID- 10178175 TI - Powerful collateral materials can strengthen your census. A marketing professional tells what works in the senior health care market. PMID- 10178176 TI - OIG report critical of prescription drug use in nursing homes. PMID- 10178177 TI - Serving their community. Boca Raton Fire-Rescue Services' mission is to prevent, as well as respond to, emergency medical situations. PMID- 10178178 TI - Meeting the emotional needs of the pediatric patient. PMID- 10178179 TI - What they didn't teach me in paramedic school. AB - Medicine is an art based on scientific principles. It's important for paramedics to understand this so they can keep up with changes and advances. We must acknowledge that care we believe to be proper today may be considered inappropriate treatment tomorrow. For this reason, we need to understand that the medical knowledge we gained in paramedic education is not sufficient. Reading journals and staying current with medical science is as much a part of our job as running calls. Many people are already implementing some of the changes suggested here and are constantly improving prehospital care in their respective areas. Sadly, they are not the norm. The EMS community needs to work together to make it the norm. The updating of the paramedic curriculum is an important opportunity in this regard. Ultimately, the responsibility for making paramedicine a respected medical specialty is our own. We need to understand that we must demand this commitment of ourselves and our systems. We cannot expect anyone else to do the job for us. We must take the time to gain the knowledge we need to build our profession into this ideal model. PMID- 10178180 TI - Countdown to disaster. How to plan an effective disaster drill. PMID- 10178181 TI - Revisiting community participation. AB - Community participation in health is a complex entity that has been examined extensively in the literature and continues to be of great interest among community health workers. The genesis of the idea and its conceptual development are primarily attributed to large multinational health institutions, particularly the World Health Organization. However, the implementation of community participation is the ultimate responsibility of local health programme initiators. It is therefore at the local level where day to day realities of incorporating community participation into health service delivery are confronted. This paper reviews the value of community participation in health and provides a detailed examination of the challenges facing its implementation and sustainability. In 1978, the World Health Organization placed community participation squarely at the centre of their strategy to achieve Health For All By The Year 2000. As the year 2000 nears, it is time to critically re-examine the notion of community participation and the most pressing challenges to its viability. PMID- 10178182 TI - A critical review of priority setting in the health sector: the methodology of the 1993 World Development Report. AB - The 1993 World Development Report, Investing in Health, suggests policies to assist governments of developing countries in improving the health of their populations. A new methodology to improve government spending is introduced. Epidemiological and economic analyses from the basis for a global priority setting exercise, leading to a recommended essential public health and clinical services package for low- and middle-income countries. Ministries of Health in many countries have expressed an interest in designing a national package of essential health services, using the methodology. Given the apparent importance attached to the study and its far reaching potential consequences, this article provides an overview of the method, the main issues and problems in estimating the burden of disease as well as the cost-effectiveness of interventions. Strengths and weaknesses in the databases, value judgements and assumptions are identified, leading to a critical analysis of the validity of the priority setting exercise on the global level. PMID- 10178183 TI - To contract or not to contract? Issues for low and middle income countries. AB - Many low and middle income countries have inherited publicly funded and provided health services, often operating at relatively low levels of technical efficiency. Changing ideas about the management of the public sector, in particular stemming from new public management theory, are spreading to these countries, whether directly or via the recommendations of multilateral and bilateral aid agencies. Pronouncements of agencies such as the World Bank imply that competitive contracting with the private sector is likely to improve the efficiency of services provision. However, very little evidence is available on whether this is likely to be the case, and in what circumstances delivery of services through contracts with the private sector is likely to be preferable to direct provision by the public sector. This paper draws on evidence from five country case-studies of contractual arrangements, in Bombay, Papua New Guinea, South Africa, Thailand and Zimbabwe, done through collaborative research between the LSHTM Health Economics and Financing Programme and local researchers in each country. A common evaluative framework was applied in each country to selected, existing contractual arrangements. Services provided under contract and evaluated included catering, cleaning, security, diagnostic services and whole hospitals. Information is presented on the design of contracts, the process of agreeing contracts including the extent of competition, and the monitoring of contract performance. A variety of evidence, including information on the relative cost and quality of contracted out versus directly provided services in the case of South Africa, Thailand, and Bombay, is used to explore whether or not contracting out to the private sector represented a preferable means of service provision. This analysis, together with information on the capacity of the agency letting the contract, and on the wider environment including the level of development of the private sector, is used to identify which aspects of the contracting process and the context in which it takes place are important in influencing whether or not contracting with the private sector is a desirable means of service provision. PMID- 10178184 TI - Informal payments for health care in the Former Soviet Union: some evidence from Kazakstan. AB - An important feature of the health care system of the Former Soviet Union (FSU) and Central and Eastern Europe is the presence of informal or under-the-table payments. It is generally accepted that these represent a significant contribution to the income of medical staff. Discussions with medical practitioners suggest that for certain specialities in certain hospitals a doctor might obtain many times his official income. Yet little empirical work has been done in this area. Informal payments can be divided into those paid to health care providers and those that go directly to practitioners. They can be further divided into monetary and non-monetary. The complexity of these payments make obtaining estimates using quantitative survey techniques difficult. Estimates on contributions to the costs of medicines in Kazakstan suggest that they may add 30% to national health care expenditure. Payments to staff are likely to add substantially to this figure, although few reliable statistics exist. Research in this area is important since informal payment is likely to impact on equity in access to medical care and the efficiency of provision. The impact of attempts to reform systems using Western ideas could be reduced unless account is taken of the effect and size of the informal payment system. PMID- 10178185 TI - User fees, self-selection and the poor in Bangladesh. AB - The widespread uncontrolled introduction of user fees in any developing country is likely to have a disastrous impact on poorer patients. Furthermore, traditional targeting schemes aimed at their exemption are often expensive, difficult to administer and ineffective at reaching those in greatest need. This research study examines how user fees can raise revenue and target poorer patients, under the right market conditions, without resorting to costly targeting schemes. The authors draw their findings from case studies of cost recovery in the health and population sectors in Bangladesh. The mechanism suggested in the paper is to use self-selection. It is argued that under certain market conditions poorer patients will choose the health-care option that is appropriate to their means. They will thus identify themselves as poor without having to be selected or tested by an independent authority. This self-selection allows the relevant authorities to cross-subsidize their market choice by over charging the non-poor in other segments of the market. PMID- 10178186 TI - Transformation of ministries of health in the era of health reform: the case of Colombia. AB - Ministries of health are being called upon to lead major health reforms; at the same time they must reform themselves to become more modern institutions and assume new and different functions and roles in the more dynamic reformed system. The literature on public administration and on health reform has recommended many processes of institutional reform and development, building on private sector management techniques, popularized by 'reinventing government' and 'total quality management'. More recently, thoughtful insights have emphasized improving public management through a focus on creating 'public value'; on political, as well as administrative, leadership; improving institutional performance through strengthening the 'task networks' of organizations needed to achieve strategic objectives; and creating a learning culture within the organization. This article applies these recent approaches to the specific needs of ministries of health in order to improve their capacity to lead major health reforms. This combined approach is then used to analyze and make recommendations to the Ministry of Health in Colombia where the authors were providing technical support for a major new health reform. PMID- 10178187 TI - Criteria for successful sanitation programmes in low income countries. AB - In the International Drinking Water Supply and Sanitation Decade (1981-90), the development of a consensus on the concept of sanitation and the planning and implementation of effective and efficient sanitation programmes was not emphasized. Yet lack of good sanitation is a growing burden and environmental threat. Significant improvement of human health cannot be achieved without good environmental sanitation conditions and practices. A consensus on what makes a sanitation programme successful can help to conserve limited funds and spend those available more wisely. It will also help to reduce the increasing flows of waste poisoning precious sources of drinking water. This article was written to stimulate discussion on what attributes can be taken as characteristic of good environmental sanitation programmes, and on which indicators can be used to assess those attributes in actual sanitation programmes. PMID- 10178188 TI - A cost comparison of approaches to sexually transmitted disease treatment in Malawi. AB - Since syndromic management of STDs requires treatment with at least two antibiotics per patient, one of the concerns raised by adoption of the syndromic approach is the cost of drugs, especially for developing countries with limited drug budgets. The objective of the current study is to compare the cost effectiveness of syndromic management to current national practice for the management of STDs in Malawi. The actual cost of observed antibiotic treatment for 144 patients receiving same day treatment for two STD syndromes in Malawi was determined using prices from the Malawi government supply catalogue. This was then compared to the calculated cost of treatment had the same patients been managed syndromically according to national guidelines. The cost of drug treatment under current practice was similar to the cost of syndromic treatment. However, at least one-third of observed patients did not receive effective treatment for either likely cause of their STD syndrome and wastage accounted for 54% of total observed drug cost. Overall, syndromic management of STDs in Malawi would result in more effective treatment of STDs at no additional cost. Since the indirect costs of low treatment efficacy were not taken into account in this analysis, a net saving is likely to be realized with the adoption of syndromic management. PMID- 10178189 TI - The use of formal and informal services for antenatal care and malaria treatment in rural Uganda. AB - The study aimed to analyze reasons for the use or non-use of antenatal care services and malaria treatment among pregnant women living in rural areas in Uganda. Focus group discussions with pregnant women, in-depth interviews with key informants (Traditional Birth Attendants (TBAs) and health workers) and a structured questionnaire administered to pregnant women were used to collect the relevant information. Antenatal care attendance was irregular and few women knew that the purpose of attending antenatal care was to monitor both the growth of the baby and the health status of the woman. Parity significantly influenced antenatal care attendance, but level of education, religion and marital status did not. Fifty-five per cent of the women stated that they had delivered outside the formal health delivery system despite antenatal care attendance. All women in their second pregnancy had delivered their first child in the village, despite TBA training to the contrary. Malaria as perceived by pregnant women is common and multiple health service providers are used for its treatment. About 66% of the mothers reported having suffered from malaria during the current pregnancy; of these more than half had received treatment outside the formal health delivery system. Self-treatment with drugs bought from ordinary shops was commonly reported. Nearly all women (93.3%) knew about the antimalarial drug chloroquine and 83% thought that it was used for the treatment of malaria, not for its prevention. Some women believed that the drug could cause abortion. Health seeking behaviour was influenced by several factors, including the perceived high cost of antenatal care services, of conducting a delivery and treatment, and perceived inadequacy of services provided by the formal health system. Inadequacy of formal health services was perceived by users to be partly due to understaffing and to irregular supply of essential drugs. Intensive health education to pregnant women on the safety of chloroquine use in pregnancy, the importance and the need for regular antenatal care attendance are recommended. In addition, training of more TBAs and continued educational efforts to upgrade their knowledge, regular and adequate supply of essential drugs, and free health services for high-risk groups such as pregnant women are recommended to improve antenatal care services and drug prophylaxis use in pregnancy. PMID- 10178190 TI - Ethical and legal reflections on euthanasia. PMID- 10178191 TI - Criteria for identifying regulatory issues and the role and responsibility of council members of health regulatory bodies. PMID- 10178192 TI - Regulating NRGTs (new reproductive and genetic technologies): is criminalization the solution for Canada? PMID- 10178193 TI - Improving patient care and reducing risk through effective communication. AB - Effective communication with patients results in better treatment outcomes, and may be the best tool in managing risk. Providers must appreciate the barriers to effective communication, identify what and how information is to be communicated, and develop the necessary skills. PMID- 10178194 TI - Integrated delivery systems and the effects of restructuring. PMID- 10178195 TI - Family doctors as partners in primary care. PMID- 10178196 TI - Rostering as an essential element of primary care. PMID- 10178197 TI - A case for multi-disciplinary teams in primary care. PMID- 10178198 TI - Role of non-physician providers in primary health. PMID- 10178199 TI - Funding alternatives in primary care reform. PMID- 10178200 TI - Evaluation of primary care: politics, pitfalls, principles and possibilities. PMID- 10178201 TI - Monitoring and evaluation in primary care. PMID- 10178202 TI - Integrated health care: putting people first. PMID- 10178203 TI - An ethical approach to health care reform in Canada: a comparison of the Canadian and American health care systems. PMID- 10178204 TI - Biomedical experimentation involving elderly subjects: the need to balance limited, benevolent protection with recognition of a long history of autonomous decision-making. Part I. PMID- 10178205 TI - Security alert system connects hospitals to each other and to police. PMID- 10178206 TI - New children's hospitals: surveillance, access control, staff training. PMID- 10178207 TI - Hospital and contract service act to protect home health workers. PMID- 10178208 TI - If your hospital does abortions: expert tips on upping clinic security. PMID- 10178210 TI - Hospital's ER renovation includes comprehensive new security plan. PMID- 10178209 TI - Applying new developments in surveillance technology in healthcare facilities: an update. AB - Innovations in equipment, and the growing competition in the field of video technology, have lowered the cost and improved the quality of surveillance systems. As a result, healthcare security directors are increasing their purchase of new equipment and upgrading existing systems, especially when implementing security for expanding facilities. In this report, we will give details on some technological advancements and how five hospitals are applying them. PMID- 10178211 TI - CDC: staph super-strain is 'worrisome'. PMID- 10178212 TI - Three cases of resistant staph cause concern. The culprit: vancomycin misuse. PMID- 10178213 TI - CDC VRE guidelines still relevant. PMID- 10178214 TI - ICUs likely realm of billion-dollar bugs. PMID- 10178215 TI - Put your CCP into action. PMID- 10178216 TI - Track patient falls, but beware restraints. PMID- 10178217 TI - JCAHO restraint dilemma muddies fall policies. PMID- 10178218 TI - Use a uniform instrument to estimate fall rate. PMID- 10178219 TI - UM can help prevent unnecessary admissions. PMID- 10178220 TI - Healthcare assistants. A force to reckon with. PMID- 10178221 TI - Health policy. The American way. AB - The white paper will move the NHS towards an insurance model where a capitated budget will be held by a single agency. Public accountability will be weakened by allowing primary care trusts and PFI hospitals to combine the planning and provision of services. Primary care groups could sound the death knell of equity, universal coverage and care free at the point of need in the NHS. PMID- 10178222 TI - Occupational therapy. Working knowledge. AB - Retention of OTs in mental health had been falling in one trust, with as many as 75 per cent of senior-2 posts becoming vacant during one year. OTs surveyed cited their most popular reason for leaving a post as no career development and their most popular reason for staying as working in mental health. The survey has been used to improve trust retention strategies, using information on each grade to meet the specific needs of those groups. PMID- 10178223 TI - Data briefing. The wait goes on. PMID- 10178224 TI - 10 myths of healing environments. A healthy space doesn't have to be a huge headache. AB - The phrase "healing environment" sounds good. But what is it? Can an environment heal? Many people and institutions have shared their interpretations with me. Not surprisingly, the responses varied greatly, containing both accurate information and myth. Exploring these myths provides information critical to understanding the concept of a healing environment. PMID- 10178225 TI - Year 2000: bug or bugaboo? Either way, start upgrading your facility's equipment for the new millennium. PMID- 10178226 TI - Cable guys. Teaming up with CTEs (communication technology engineers) can untangle your communication infrastructure. PMID- 10178227 TI - Tick, tick, tick: how to train staff to defuse bomb threats. PMID- 10178228 TI - Clearing the air: dissent on OSHA's new TB rule continues. PMID- 10178229 TI - 1997 ASHE Project Team VISTA Awards. PMID- 10178230 TI - Staying single: a way to cut construction risks? Your best bet may be the single source design-build approach. PMID- 10178231 TI - Hot spot. Planning, design and construction is the right remedy for ED dangers. AB - Forget the TV show "ER." The real thing is much more dramatic--and dangerous. In fact, the emergency department poses the greatest security risk in hospitals. Some estimates show that about 60 percent of crime in hospitals occurs in EDs. That's why the department should be designed, constructed and furnished to minimize security risks. Careful, strategic site planning and design measures are especially important for the site areas adjacent to or serving the ED. Here are some special planning and design tactics that can improve your hospital's security. PMID- 10178232 TI - Hard-hat health: interim life safety and construction. PMID- 10178233 TI - Dust busters guard patients during hospital construction. PMID- 10178234 TI - Response to Larry Dossey: prayer, medicine, and science: the new dialogue. PMID- 10178235 TI - Considering the dangers and opportunities of pastoral care and medicine: a search for vitality, accountability and balance. PMID- 10178236 TI - The laboratory of religious experience: a response to Larry Dossey. PMID- 10178237 TI - Response to Larry Dossey. PMID- 10178238 TI - A response to Larry Dossey: the prayers of the faithful: prayer as a metaphor for medicine and healing. PMID- 10178239 TI - Prayer, medicine, and science: the new dialogue. PMID- 10178240 TI - A chaplain's response to prayer, medicine, and science: the new dialogue. PMID- 10178241 TI - A Buddhist response to Larry Dossey. PMID- 10178242 TI - A response to Larry Dossey: prayer, medicine, and science: the new dialogue. PMID- 10178243 TI - Making midlevel providers click with your group. PMID- 10178244 TI - Can a newfangled doctor thrive in an old-fashioned practice? PMID- 10178245 TI - Unconventional wisdom keeps my waiting room full. PMID- 10178246 TI - How you could get nailed for patient dumping. PMID- 10178247 TI - The destiny that lurks in our DNA. PMID- 10178248 TI - Managed care. Still putting the brakes on employers' costs. PMID- 10178249 TI - Look who's rating doctors on clinical quality--patients. PMID- 10178250 TI - Forget the Feds--the states are cracking down on managed care. PMID- 10178251 TI - Medicaid managed care: a gold mine--or a land mine? PMID- 10178252 TI - Doctor-doctor marriages: a prescription for trouble? PMID- 10178253 TI - Community mission. N.H. rules service consolidation breaks charity law. PMID- 10178254 TI - N.Y. investigators checking up on residents' training. PMID- 10178255 TI - Feds state their case. FTC: deals would end distributors' incentive to cut prices. PMID- 10178256 TI - AHA forming shared services firm. PMID- 10178257 TI - Uncompensated care rises little. PMID- 10178258 TI - Psych layoffs seen. Report sees cutbacks from Medicare payment changes. PMID- 10178259 TI - War of words. Small home-care agencies feel threatened by letter. PMID- 10178260 TI - Gaps in services. Medicare HMOs lack full range of services for chronically ill. PMID- 10178261 TI - Risk pushes PHO over the edge. PMID- 10178262 TI - Seeking revenge. Former execs worked to destroy hospital, FBI says. PMID- 10178263 TI - Cherry-picking watch. As PSOs rev up, feds launch war on patient screening. PMID- 10178264 TI - Investing for the future. AB - Financially savvy hospitals are getting aggressive with their investment management strategies, using healthy returns from wisely invested nonoperating dollars to finance construction projects, make acquisitions and expand services. Industry estimates show hospitals have a large nest egg to work with--some $400 billion in assets available for investment. PMID- 10178265 TI - Healthcare industry gets clean bill of health. Predictions of economic ills haven't been realized. PMID- 10178266 TI - Chief Fall-guy Officers. CFOs resign as managed-care giants post big losses. PMID- 10178267 TI - Cost-control burden on HMOs' shoulders. AB - Better, but not good enough. At the end of 1997's fourth quarter, the average operating profit margin for the 17 publicly traded HMOs tracked by Douglas Sherlock, an analyst in Gwynedd, Pa., was 0.1%. Most margins were well under 2%. The fourth-quarter 1996 average operating margin was -1.6%. PMID- 10178268 TI - Self-interest reigns. Healthcare reform studies may be lining up support. PMID- 10178269 TI - A new niche for PPMs. Site management organizations expedite clinical trials. PMID- 10178270 TI - Team approach. Ga. hospital uses protocols to improve care, reduce costs. PMID- 10178271 TI - Docs buy into hospitals. Syndications may lock in referral patterns, improve care. PMID- 10178272 TI - Fighting the law. La. hospitals think legislation opens door to poor care. PMID- 10178273 TI - The other Medicare choice. States, Congress in free-for-all on tobacco windfall. PMID- 10178274 TI - AHA says its shared services firm is no threat to alliances. PMID- 10178275 TI - House calls. Kan. hospital's experiment in home health telemedicine cuts costs, visits. PMID- 10178276 TI - Closing wounds. New devices seal arterial punctures in double time. PMID- 10178277 TI - Not in the cards. Columbia drops affinity cards; program was designed to fund community projects. PMID- 10178278 TI - Congress split on patient privacy. PMID- 10178279 TI - Treacherous waters. Capitation drove hospital-owned HMO into red. PMID- 10178280 TI - Do they deserve a break? Group questions not-for-profits' tax exemptions. PMID- 10178281 TI - Doc income still rising--AMA data. PMID- 10178282 TI - Dividing premium dollars. Calif. plans' spending on medical care varies widely. PMID- 10178283 TI - Unions eye Arizona. Organized labor groups seeks new healthcare ground. PMID- 10178284 TI - Kid care heats up. Six states have plans in place to expand coverage. PMID- 10178285 TI - Special care needed for children--survey. PMID- 10178286 TI - Making outsourcing marriages work. AB - Outside companies are providing an increasing number of services for hospitals and health systems. As providers enter more contracts with outsourcers, they're discovering they have to work at such marriages. They're learning it takes a lot of management skill to build and maintain--and know when to end--an outsourcing relationship. PMID- 10178287 TI - Offer declined. More workers refusing employer-sponsored insurance. PMID- 10178288 TI - CNA, Kaiser sign truce. Fierce labor dispute ends with HMO, nurses inking pact. PMID- 10178289 TI - Adding some hedges. Inflation fears might fuel sales of indexed bonds. PMID- 10178290 TI - AARP weighs in. Consumer group studies impact of hospital conversions. PMID- 10178291 TI - Path of lease resistance. CHS backs out of Texas deal; not-for-profit hopes to step in. PMID- 10178292 TI - Taxed in New Hampshire. Study says academic medical center acts like for-profit. PMID- 10178293 TI - Trying to be heard. Docs employed by hospitals, systems seek to unionize. PMID- 10178294 TI - Constructive surgery. Columbia weighs spinning off surgery unit for value. PMID- 10178295 TI - Poor quarterly showing. Big players' losses drag down healthcare earnings. PMID- 10178296 TI - AHA name change delayed. PMID- 10178297 TI - Record review redux. HCFA may ask PROs to resume medical necessity checks. PMID- 10178298 TI - Going global. JCAHO to accredit foreign healthcare organizations. PMID- 10178299 TI - Hospital, physician Producer Price Index. PMID- 10178300 TI - HHS message: don't dump. Six hospitals settle federal patient dumping charges. PMID- 10178301 TI - Survey cites HMO execs' high pay. PMID- 10178302 TI - Full lobby. Medicare changes last spurred a spending spree. PMID- 10178303 TI - Model doc relations. Keys to integration are maintaining entrepreneurial incentive and self-direction. PMID- 10178304 TI - Off the beaten path. More for-profit hospital companies traveling to rural markets. AB - More for-profit chains are making rural hospital acquisitions a key strategy, and they're building up steam. For example, little-known New American Healthcare Corp. of Brentwood, Tenn., more than doubled its size this year through a single acquisition of five hospitals. Meanwhile, Health Management Associates, Quorum Health Group and Community Health Systems continue to expand. PMID- 10178305 TI - Urban renewal in Motor City. Healthcare construction among projects driving Detroit's revitalization. PMID- 10178306 TI - Big ad bucks. Survey shows systems are driving up marketing budgets. PMID- 10178307 TI - Unwelcome diversion. Specter of year-2000 problems distracting buyers, vendors. PMID- 10178308 TI - High-tech identification. Indiana hospital uses fingerprints to track patients. PMID- 10178309 TI - Innovator, integrator named runner-up. PMID- 10178310 TI - Beyond the numbers. CFO headed to Harvard as winner of Cain Brothers Award. PMID- 10178311 TI - Malpractice insurance. JCAHO pushes bill to protect hospitals that report errors. PMID- 10178312 TI - Fewer docs punished. Punitive actions by medical boards down 2.4% last year. PMID- 10178313 TI - No PARCA required. AHA seeks support for voluntary, private-sector initiative. PMID- 10178314 TI - For-profits get a break. Minn. governor vetoes anti-conversion legislation. PMID- 10178315 TI - Cincinnati fights to take back control of hospital. PMID- 10178316 TI - Need, not location. Transplant centers battle over HHS allocation change. PMID- 10178317 TI - GNYHA to sue HHS over fraud probe. PMID- 10178318 TI - Sitting this one out. Big hospital groups are wallflowers in tobacco debate. PMID- 10178319 TI - Designed for growth. Catholic megasystem CHI set to take off. AB - A young megasystem is charting new territory in Catholic healthcare because of its size, its ownership structure, which gives laity a more prominent role, and its enviable bottom line. But Denver-based Catholic Health Initiatives' many new ventures raise questions about the future: Will CHI become an acquisition-monger? Will it be able to maintain its strong Catholic ministry? PMID- 10178320 TI - Partnering with PSOs. HMO companies offer administrative assistance. PMID- 10178321 TI - Defying the prescription. Forget forecasts--drug sales soar under managed care. PMID- 10178322 TI - Advice and an advance. New Tenn. venture specializes in healthcare start-ups. PMID- 10178323 TI - HHS issues new guidelines on Medicare fraud and abuse. PMID- 10178324 TI - PACU staffing. Staffing the recovery areas an art as well as a science. PMID- 10178325 TI - Latex case jury awards $1 million to hospital worker. PMID- 10178326 TI - Controlling implant costs with ceiling prices. PMID- 10178327 TI - How do you know you're productive in PACU (postanesthesia care unit)? PMID- 10178328 TI - How much do residents cost the OR? PMID- 10178329 TI - Needed: "Lego" set for managing instruments. PMID- 10178330 TI - How safe is cosmetic surgery in the office? PMID- 10178331 TI - Study supports the reuse of PTCA catheters. PMID- 10178332 TI - Compliance from a patient financial services point of view. PMID- 10178334 TI - Measuring attitudes towards smoking in the Community Intervention Trial for Smoking Cessation (COMMIT). AB - We present the development of indices using baseline data from the Evaluation Survey for the Community Intervention Trial for Smoking Cessation (COMMIT). The indices are designed to measure two primary attitude constructs that relate to smoking behavior: beliefs about smoking as a public health problem (SPHP); and norms and values concerning smoking (NVS). Two general approaches to index construction, the rational method and the factor analytic method, were used. Item analysis suggested good internal consistency for both indices (alpha > 0.75). Seven subconstructs emerged from the factor analysis accounting for 55.0% of the total variance. The SPHP and NVS items uniquely identify with four factors and three factors, respectively, confirming the validity of the two indices. Confirmatory factor analyses of a different data set provided further validation. Validity was also assessed by an examination of the relationships between index scores and smoking status. Smokers reported significantly higher scores than non smokers on the two measures indicating, as anticipated, that smokers have more favorable attitudes towards smoking than non-smokers. These findings suggest that the two a priori constructs of SPHP and NVS are empirically distinguishable components of attitudes towards smoking, and that the indices developed here are reliable and valid measures of those constructs. PMID- 10178333 TI - Community Intervention Trial for Smoking Cessation (COMMIT): changes in community attitudes toward cigarette smoking. AB - The success of the Community Intervention Trial for Smoking Cessation (COMMIT) in changing smoking attitudes is examined by testing two primary hypotheses: (1) the priority of smoking as a public health problem increased more in the intervention communities than in the comparison communities, and (2) norms and values that support non-smoking increased more in the intervention than in the comparison communities. One community within each of 11 matched pairs was randomly assigned to receive a 4-year (1989-92) community-based smoking control intervention. Community attitudes towards smoking were measured primarily by cross-sectional surveys in 1989 (n = 9875) and 1993 (n = 14117) but a cohort (n = 5450) also provided attitude information. The main trial effect was on heavy smokers in the intervention communities who showed significantly more change in their beliefs about smoking as a public health problem. Despite the absence of an intervention comparison difference, the magnitude of change in community-wide norms and values was related to the level of smoking control activities. In the cohort, light-to moderate smokers in the intervention communities came to have stronger beliefs about smoking as a serious public health problem. COMMIT's impact on the beliefs of heavy smokers about the seriousness of smoking as a public health problem has important public health implications. PMID- 10178335 TI - Health education and promotion spending in England: a note on the potential utility of the Health Service Indicators dataset. AB - Health promotion and education (HPE) needs to be evaluated on a national scale. This note draws attention to the existence, possible uses and pitfalls of a little known dataset which provides information on English district health authorities' HPE expenditure for the first time. Despite its problems, cautious uses of this data has the potential to significantly increase the knowledge and understanding of local level HPE in England. PMID- 10178336 TI - Psychosocial factors and smoking cessation behaviors among smokers who have and have not ever tried to quit. AB - Relationships between smoking cessation behaviors and demographic characteristics and attitudes were analyzed among two groups of smokers, those who had and had not ever tried to quit. Telephone interviews were completed with 1501 smokers at baseline and at a 3 month follow-up. Multiple logistic regression analyses were used to identify factors that were associated with planning to quit, attempting to quit and quitting smoking within the two groups of smokers. Different patterns of correlates were found across groups and within the three outcome measures, indicating the potential importance of targeting interventions according to whether or not smokers have made a prior quit attempt. These findings also support the value of using multiple outcome measures in the smoking cessation process. PMID- 10178337 TI - Evaluation of a cold/flu self-care public education campaign. AB - The purpose of the study was to evaluate an Ontario Ministry of Health (MOH) cold/flu self-care public education campaign to reduce unnecessary patient visits to doctors. The MOH campaign consisted of an information booklet delivered to every household in an Ontario city, newspaper ads and radio spots. The program ran during January-March 1994. The evaluation consisted of: (1) 2x2 telephone survey in London (experimental area) and Windsor (comparison area), before and during the campaign; and (2) a telephone survey of London family practitioners during the campaign. In addition, data on the incidence of cold/flu visits to three hospital emergency departments and a sample of family physicians' offices were gathered. The data suggest that program rationale may have been questionable because the majority of the surveyed public were knowledgeable and self-reported appropriate doctor visits for cold/flu. Campaign evaluation showed limited impact. Message penetration was low; only one-third of London residents knew of the campaign or read the booklet. Only two of 10 questions showed increases in knowledge in London and no changes were found for beliefs, attitudes, acquisition of new health practices or self-reported visits to the doctor. The physician survey, emergency room and family physician office visit data were consistent with the public survey findings. PMID- 10178338 TI - Injury prevention training: is it effective. AB - The aim of this controlled follow-up study was to assess the effectiveness of a multi-disciplinary training programme in increasing knowledge, changing attitudes and practice in injury prevention amongst primary health care professionals. All primary health care team members in Nottinghamshire were invited to participate in the training programme. Thirty-one health visitors, 11 general practitioners and 16 practice nurses attended the training programme, and completed the study questionnaire 3-4 months before and after the training. A comparison was made with a professional of the same status, who had not attended the training session who had also completed both questionnaires, and who was matched with a trained participant on the basis of pre-training attitude and knowledge scores (to within 1 point of each score). A significant increase in the number of individuals answering correctly to questions on accidental injury epidemiology was demonstrated in the trained group (Wilcoxon matched-pairs signed rank, health visitors P = 0.002, practice nurses P = 0.0004, general practitioners P = 0.02), but no significant change was demonstrated in the control group. Changes in attitude scores were only significant for the practice nurses (Wilcoxon matched pairs signed rank, P = 0.01). Increases were also demonstrated in the frequency of health visitors identifying hazards on home visits and discussing them with parents (chi 2 = 6.19, d.f. = 2, P = 0.04) and in the number of health visitors who, on receiving notification of a child attending the A&E department following an injury, carried out a home visit to discuss injury prevention (chi 2 = 9.19, d.f. = 2, P = 0.01). The number of general practitioners displaying posters in the surgery waiting rooms also increased significantly (chi 2 = 9.21, d.f. = 2, P = 0.002). The number of contacts with representatives of other agencies and individuals concerning child safety significantly increased in the trained group (Wilcoxon matched-pairs, P = 0.02). We conclude that education and training with regard to injury prevention was effective in increasing knowledge and some injury prevention practices. Although training did not appear to change the attitudes of health visitors and general practitioners to a significant extent, a marked change was unlikely due to high baseline attitude scores. PMID- 10178339 TI - Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. AB - Attention to the sustainability of health intervention programs both in the US and abroad is increasing, but little consensus exists on the conceptual and operational definitions of sustainability. Moreover, an empirical knowledge base about the determinants of sustainability is still at an early stage. Planning for sustainability requires, first, a clear understanding of the concept of sustainability and operational indicators that may be used in monitoring sustainability over time. Important categories of indicators include: (1) maintenance of health benefits achieved through an initial program, (2) level of institutionalization of a program within an organization and (3) measures of capacity building in the recipient community. Second, planning for sustainability requires the use of programmatic approaches and strategies that favor long-term program maintenance. We suggest that the potential influences on sustainability may derive from three major groups of factors: (1) project design and implementation factors, (2) factors within the organizational setting, and (3) factors in the broader community environment. Future efforts to develop sustainable health intervention programs in communities can build on the concepts and strategies proposed here. PMID- 10178340 TI - Knowledge is power: comparative analysis software is a powerful tool for health care. PMID- 10178341 TI - Integrating home health care into your information technology strategy. PMID- 10178342 TI - Consensus reached on PSO regulations. PMID- 10178344 TI - New Internet site tracks antibiotic resistance. PMID- 10178343 TI - Changing world, changing systems: business trends driving managed care to reevaluate information technology strategies. PMID- 10178345 TI - Mt. Everest climbers to be monitored all the way to the summit. PMID- 10178346 TI - Telesmell will enhance health care at trauma scene. PMID- 10178347 TI - SatelLife and VITA plan global email to connect health professionals. PMID- 10178348 TI - Naval telemedicine: fleet lines up to provide live teleconsulting. PMID- 10178349 TI - New technologies breathe new life into the hospital communications equipment market. PMID- 10178350 TI - Bay Networks aids academia. PMID- 10178351 TI - Ophthalmic surgical simulator demonstrated. PMID- 10178353 TI - Mozambique telemedicine link inaugurated. PMID- 10178352 TI - Greenland puts telemedicine server online. PMID- 10178354 TI - AT&T extends ISDN line to Costa Rica. PMID- 10178355 TI - Overseas consulting, telefetal monitoring service emerge. PMID- 10178356 TI - Taking Web medicine. PMID- 10178357 TI - Wireless ambulance telemedicine may lessen stroke morbidity. PMID- 10178358 TI - Telemedicine as a tool for integrating rural emergency care. PMID- 10178359 TI - Telemedicine in trauma care. PMID- 10178360 TI - Telecardiac monitoring from an ambulance. PMID- 10178361 TI - Insuring the security of Internet-based telemedicine systems. PMID- 10178362 TI - Telemedicine in Latin America. AB - Latin America, stretching 6,000 miles from Mexico to Tierro del Fuego, is comprised of twenty countries totaling nearly 1/2 billion people. There are wide variations in median income levels, medical access, telecommunications infrastructures, and levels of rurality. The great variety of settings precludes any simple approach to telemedicine deployment. PMID- 10178363 TI - Visual forum. PMID- 10178364 TI - Provider sponsored organizations: a golden opportunity in Medicare managed care. PMID- 10178365 TI - Patient-centered care for better patient adherence. PMID- 10178366 TI - Coping with managed care's administrative hassles. PMID- 10178367 TI - How to evaluate health insurance plans for your practice. PMID- 10178368 TI - A conceptual framework for the analysis of health care organizations' performance. AB - Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes. PMID- 10178369 TI - A review of organizational performance assessment in health care. AB - As health care organizations look for ways to ensure cost-effective, high quality service delivery while still meeting patient needs, organizational performance assessment (OPA) is useful in focusing improvement efforts. In addition, organizational performance assessment is essential for ongoing management decision-making, operational effectiveness and strategy formulation. In this paper, the roles and impact of OPA models in use in health care are reviewed, and areas of potential abuse, such as myopia, tunnel vision and gaming, are identified. The review shows that most existing OPA models were developed primarily as sources of information for purchasers or consumers, or to enable providers to identify areas for improvement. However, there was little conclusive evidence evaluating their impact. This review of existing OPA models enabled the establishment of principles for the development, implementation and prevention of abuse of OPA specific to health care. The OPA models currently in use in health care may provide managers with false confidence in their ability to monitor organizational performance. To further enhance the field of OPA, areas for future research are identified. PMID- 10178370 TI - Managing health services: how administrative data and population-based analyses can focus the agenda. AB - University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for providing answers to such questions as: which populations need more physician services? Which need fewer? Are high-risk populations poorly served or do they have poor health outcomes despite being well served? Does high utilization represent overuse or utilization related to high need? More specifically, this system provides decision-makers with the capability to make critical comparisons across regions and subregions of residents' health status, socioeconomic risk characteristics, and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and counties, utilization review within a single hospital, and longitudinal research on health reform. A particularly interesting application to planning physician supply and distribution is discussed. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health. PMID- 10178371 TI - Patient-clinician trust: the learning curve of communication. Dialogue. PMID- 10178372 TI - Patient education as medical intervention: a pilot study. AB - OBJECTIVE: To describe and assess the perceived impact of an innovative patient health informatics tool among members of a managed care organization. SETTING: Mixed-model HMO in Connecticut. DESIGN: Intervention group only, post-test only (telephone interview using structured protocol). PARTICIPANTS: Members of a Connecticut HMO who responded to a free video offer and met study eligibility requirements. INTERVENTION: Patient education videos from the entire Time Life Medical At Time of Diagnosis series. MAIN OUTCOME MEASURES: Knowledge of condition and treatment options, attitude and outlook towards condition, patient provider communication, behavior change, physician contacts for condition. RESULTS: Study participants reported that the video improved their understanding and knowledge of treatment options for their condition. They also reported a positive impact of the videos on a range of attitudes and behaviors pertinent to their condition. Participants endorsed the involvement of their HMO in distributing the videos, and few adverse effects from use of the videos were observed. CONCLUSIONS: This study provides preliminary evidence for a positive impact of health informatics tools on patient attitudes, including expectancies for care, quality of patient-physician communication, and satisfaction with health plan. The fact that most persons responding to the video offer had their condition for several years suggests that distribution of health informatics tools should not be limited to the newly-diagnosed. PMID- 10178373 TI - Managed care for the medically uninsured: the preliminary experience of CU CARE. AB - Uninsured Americans often face barriers to or lack continuity of care. Care for this population is often fragmented, expensive and undercompensated. University Hospital in Denver, in partnership with Kaiser Permanente of Colorado, sought to address this problem by developing CU CARE, a managed care demonstration program for the medically uninsured within the University of Colorado Health Sciences Center. This paper describes the evolution and preliminary experience of the CU CARE program. Policy implications for the future of health care delivery to this population are also briefly discussed. PMID- 10178374 TI - Prevention of hepatitis A. PMID- 10178375 TI - Using paging technology for reminding patients. PMID- 10178376 TI - HMO chiropractic referrals: a nurse triage approach. PMID- 10178377 TI - Diabetes case management: experience in the staff and IPA model HMO. PMID- 10178378 TI - The medical care system and prevention: the need for a new paradigm. AB - The American medical care system falls to provide effective prevention services even though some prevention services are among the most cost-effective medical procedures available. Many prevention services are routinely delivered in inefficient or ineffective ways, and new technologies may be widely and aggressively implemented despite serious doubts about their efficacy and cost effectiveness. The barriers to effective prevention services result from conceptual limitations in our model of medical care systems, particularly the lack of a population-based perspective. A change in paradigm is needed before reforms in our health care system can improve health without bankrupting the nation. PMID- 10178380 TI - Insider trading: conscience and critique in bioethics. PMID- 10178379 TI - Medical futility: towards consensus on disagreement. PMID- 10178381 TI - Physician's conscience and HECs: friends or foes? AB - No matter the future of healthcare financing and management, physicians of conscience and integrity must still be an important force in the consideration of ethical issues. The traditional role for the conscientious physician--being the only or even the major determinant of the morality of specific clinical decisions -is, for better or worse, no longer in effect. Much of this authority now belongs to patients and HECs are the mechanism within HCOs to help maintain this authority and to observe, comment on, recommend, and occasionally "regulate" the ethics of the healthcare arena. It is natural that these mechanisms for addressing areas of moral uncertainty create a certain tension. This tension should be acknowledged by conscientious physicians and HEC members. Total agreement on all moral issues in the clinical setting is impossible and should not be a goal. However, the respectful recognition of the importance of each perspective by both HEC members and conscientious physicians, and cooperation in developing effective mechanisms to address real differences, are possible and desirable. All who are interested in the ethics of healthcare now and in the future should support these endeavors. PMID- 10178382 TI - The moral reasoning of HEC members. PMID- 10178383 TI - Treating the silent stranger: informed consent and defensive medicine in the critical care unit. PMID- 10178384 TI - What is it exactly that you do? A "snapshot" of an ethicist at work. PMID- 10178385 TI - Ethics committees identify four key factors for success. PMID- 10178386 TI - Needs assessment for healthcare ethics education. PMID- 10178387 TI - Refusal of treatment by an adolescent: the deliverances of different consciences. PMID- 10178388 TI - Schroeder Scholar-in-Residence Lecture. Politics, death, and nature. PMID- 10178389 TI - Moral maturity. PMID- 10178390 TI - Beyond autonomy: coercion and morality in clinical relationships. PMID- 10178392 TI - License to maim: federal pre-emption and the Medical Device Amendments of 1976. PMID- 10178391 TI - The secret life of the dominant form of managed care: self-insured ERISA networks. PMID- 10178393 TI - Unbridled managed care: when consumers experience antitrust welfare loss from exclusionary contracts between HMO insurers and health care providers. PMID- 10178394 TI - The tell-tale heart: ethical and legal implications of in situ organ preservation in the non-heart-beating cadaver donor. PMID- 10178395 TI - Assessing patient compliance in the selection of organ transplant recipients. PMID- 10178396 TI - Datawatch. Discordant views and long-term deals. PMID- 10178397 TI - Too poor to afford health care. PMID- 10178398 TI - How believable is value data? PMID- 10178399 TI - Washington gears up to police your health plan. PMID- 10178400 TI - Stock market successes and HMO growing pains. PMID- 10178401 TI - Money matters: a BHCAG (Buyers' Health Care Action Group) update from the Twin Cities. PMID- 10178402 TI - How illiteracy drives up health costs. PMID- 10178403 TI - Integration. The case for blended benefits. PMID- 10178404 TI - Costing out care. The price of pleasure. PMID- 10178405 TI - Factions in Michigan's capital market. PMID- 10178406 TI - Head to head. Should ERISA be amended? PMID- 10178407 TI - Encouraging health with whatever it takes. PMID- 10178408 TI - Managed care systems: putting the pieces together. PMID- 10178409 TI - Enterprise integration. A lesson from trains, boats and planes. PMID- 10178410 TI - Clinical computing. Heading for a boom or the back burner? PMID- 10178411 TI - HIMSS/IBM survey: staffing top priority. AB - Finding qualified IT staff members and integrating multivendor systems are this year's main challenges. Voice recognition, wireless information appliances and Web-enabled applications are the top new technologies. PMID- 10178412 TI - What works. Managed care system helps medical group cut physician clerical work, save nearly $500,000. PMID- 10178413 TI - What works. Clinical management system enhances quality, restores physician withhold for Health New England. PMID- 10178414 TI - What works. Repricing application saves 85 cents per claim for 3rd party administrator. PMID- 10178415 TI - Managing managed care. Recruiting and retaining IT staff. PMID- 10178416 TI - HotList: wireless systems. PMID- 10178417 TI - A six-step approach to planning a Y2K solution. PMID- 10178418 TI - Assisted suicide and the courts: spotlight on palliative care. PMID- 10178419 TI - The future of Medicare: controversies and concerns. PMID- 10178420 TI - Health care of the elderly population in Korea. PMID- 10178421 TI - The effects of music on healing. PMID- 10178422 TI - Medicare managed care: sinking or swimming with the tide. PMID- 10178423 TI - Matching ICD-9-CM codes to clinical indicators--is it the way to go? AB - In early 1997, the Australian Council on Healthcare Standards (ACHS) Care Evaluation Program (CEP) collaborated with the National Centre for Classification in Health (NCCH) to determine the feasibility of matching ICD-9-CM codes with a selected number of clinical indicators developed by CEP. While the results of this activity were encouraging, CEP is hesitant in advocating the use of ICD-9-CM as the complete answer to the data collection 'burden' experienced by health care organisations collecting clinical indicator data. CEP is concerned that obtaining clinical indicator data through ICD-9-CM coding alone may limit clinician participation in quality activities, narrow the focus of performance monitoring to one department, potentially compromise the intent of the indicators, and encourage a culture of 'near enough is good enough'. This paper examines the limitations of ICD-9-CM coding as the sole means of extracting clinical indicator data. PMID- 10178424 TI - ICPC PLUS for community health? A feasibility study. AB - BACKGROUND: The development of information systems in community health is being led by the Community Health Information Management Enterprise, a multi state consortium of State Health Departments. To ensure reliable and valid data collection, client problems (issues) presented to community health providers and the activities they undertook will require coding and classification. The suitability of existing classification systems for issues and activities in the community health setting therefore warranted investigation. AIMS: To assess the extent to which the extended version of the International Classification of Primary Care (ICPC PLUS) is a feasible tool with which to code issues and activities in community health settings. METHOD: 62 providers representing 22 service groups recorded, in their own words, details about issues and activities at all client contacts for a period of two weeks. These were secondarily coded with ICPC PLUS and subjective judgment made about the "goodness" of fit between the recorded term and the term available in ICPC PLUS. RESULTS: Of the 2146 issues recorded, 90.5% could be coded with ICPC PLUS. Codes with a "good fit" were available for 71.2%. ICPC PLUS had suitable codes for 67.5% of the 2470 recorded activities, but only half of these were a "good fit". Some ICPC PLUS terms required greater specificity and some of the terms recorded needed to be further defined before a code could be allocated. CONCLUSION: It is feasible to use ICPC PLUS to classify issues with only minor additions and alterations. Activities could also be classified with ICPC PLUS but far more development would be required. PMID- 10178425 TI - Important issues to emerge from recoding studies. PMID- 10178426 TI - Health informatics--an annotated bibliography. PMID- 10178427 TI - Accredited clinical coder examination October 1997 results. PMID- 10178428 TI - System architectures. PMID- 10178429 TI - Medicare program; definition of provider-sponsored organization and related requirements--HCFA. Interim final rule with comment period. AB - The Balanced Budget Act of 1997 establishes a new Medicare + Choice program that significantly expands the health care options available to Medicare beneficiaries. Under this program, eligible individuals may elect to receive Medicare benefits through enrollment in one of an array of private health plans that contract with HCFA. Among the new options available to Medicare beneficiaries is enrollment in a provider-sponsored organization (PSO). This interim final rule with comment period defines the term "provider-sponsored organization" for purposes of the Medicare program and establishes requirements related to meeting this definition. We believe that setting forth the definition of a PSO and the related requirements will facilitate the submission of applications to participate in the Medicare program as a PSO. PMID- 10178430 TI - Medical devices; humanitarian use of devices--FDA. Direct final rule. AB - The Food and Drug Administration (FDA) is amending the regulations governing humanitarian use devices. These amendments are being made to implement provisions of the Federal Food, Drug, and Cosmetic Act (the act) as amended by the Food and Drug Administration Modernization Act of 1997 (FDAMA). Elsewhere in this issue of the Federal Register, FDA is publishing a companion proposed rule, under FDA's usual procedures for notice and comment, to provide a procedural framework to finalize the rule in the event the agency receives any significant adverse comment and withdraws the direct final rule. PMID- 10178431 TI - Medical devices; humanitarian use of devices; companion to direct final rule- FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to amend certain regulations governing humanitarian use devices. This proposed rule is a companion document to the direct final rule published elsewhere in this issue of the Federal Register. The amendments are being made to implement provisions of the Federal Food, Drug, and Cosmetic Act (the act) as amended by the Food and Drug Administration Modernization Act of 1997 (FDAMA). This companion proposed rule is being issued under FDAMA and the act as amended. PMID- 10178432 TI - Data watch. What is the cost of ADM (alcohol and drug abuse and mental health) in the U.S.? PMID- 10178433 TI - Crisis or opportunity? The privatization of behavioral health services in the criminal justice system. PMID- 10178434 TI - Innovative group practices. PMID- 10178435 TI - Interweaving outcomes measurement with the clinical process. PMID- 10178436 TI - Dialogue. Carve-out or HMO: which will serve public sector beneficiaries better? AB - We are pleased to have three distinguished and thoughtful participants take part in this issue's Dialogue section. As the healthcare industry changes dramatically, new ideas and different approaches are being aired and debated. The three panelists in this discussion attempt to meet head on some of the problems that presently beset managed care and give us their expertise about the pros and cons of privatization, integrated systems, carve-outs, and carve-ins. They provide examples of steps that are being taken right now and suggest alternative means to achieving a more responsive and equitable system. Dr. Patterson provides an overview of the history of this question. Dr. Stelovich argues for systems that integrate mental health and medical services in a managed care setting and suggests that they provide the mental health patient with better healthcare delivery. Deborah Happ makes the case for the carve-out approach in which behavioral health and physical health services are separated and put under the direction of managed behavioral healthcare organizations (MBHOs). She cites Tennessee's TennCare Partners Program as an example of a successful endeavor and carve-out alternative. PMID- 10178437 TI - Blending funding streams to support system of care reform. PMID- 10178438 TI - North Dakota partnerships' success story. Increasing access to quality services, satisfying families and containing costs. PMID- 10178439 TI - Can quality survive continued downward price pressures? Panel discussion. AB - The following is a transcript, edited for publication, of a remarkable presentation at the Behavioral Healthcare Quality and Accountability Summit in June 1997 held in Bloomington, Minnesota. The original session consisted of four talks, but since we were unable to obtain permission from one of the participants, J. Rock Johnson, J.D., only three of the speakers are presented below. Nonetheless, this article contains many insights into the fundamental question facing the mental health and substance abuse fields: Can Quality Survive the Pressures of Downward Pricing? PMID- 10178440 TI - Half the sky: women's behavioral healthcare. PMID- 10178441 TI - On-call consultants present EMTALA risks for the ED. PMID- 10178442 TI - Managed care in conflict with EMTALA. PMID- 10178443 TI - New Jersey EDs closed because of on-call consultant response times. PMID- 10178444 TI - Policy must protect ED staff from on-call consultant violations. PMID- 10178445 TI - ACEP's policy on blood alcohol reporting laws. PMID- 10178446 TI - HCFA finalizing prospective payment, consolidated billing implementation guidance. PMID- 10178447 TI - OIG proposal expands its civil money penalty powers. PMID- 10178448 TI - The next millennium. Research, health and hope in the radiological sciences. PMID- 10178449 TI - The democratization of information and systems. PMID- 10178450 TI - Systems integration and managed care: ethical & legal issues. PMID- 10178451 TI - Benchmarking in radiation oncology: discovering inconsistencies in reporting methodologies. PMID- 10178452 TI - Technomics analysis: a matter of care before cost. PMID- 10178453 TI - Appropriate hospital care and the radiation oncologist. PMID- 10178454 TI - International power in radiology. PMID- 10178455 TI - The abilities of primary care physicians in dermatology: implications for quality of care. AB - Quality of care in medicine has become an increasingly important issue as the nature of healthcare delivery has changed. Many managed care systems rely on the primary care physician to serve as a gatekeeper, thereby limiting access to specialist care. Controversy has arisen regarding the abilities of primary care physicians in one such specialty: dermatology. We reviewed the many studies conducted in the United States evaluating primary care physicians' abilities in dermatology. Despite inherent flaws in many of the studies, one can conclude that primary care providers are inferior to dermatologists in the diagnosis and treatment of skin disease. Whether these process-based data predict outcome is not known. PMID- 10178456 TI - Physicians' views on capitated payment for medical care: does familiarity foster acceptance? AB - Physicians' attitudes toward capitated payment have not been quantified. We sought to assess physicians' views on capitated payment and to compare the views of those who did and did not participate in such payment. A written survey was given to 200 physicians with admitting privileges at a 600-bed Ohio hospital; 82 (41%) responded and were included in this study. Among respondents, 21 (26%) were primary care physicians, 18 (22%) were medical subspecialists, and 18 (22%) were surgeons. Fifty-eight (71%) were providers for managed care plans, and 35 (43%) participated in capitated payment arrangements. Among physicians who did not participate in capitated care, 100% believed that there was a conflict of interest in capitated payment, and 77% (23 physicians) believed that participation in plans that reduce physician income in proportion to medical expenditures is not acceptable. Among those who did participate in capitated payment contracts, 95% (41 physicians) believed these plans posed a conflict of interest, and 72% (31 physicians) said this was not acceptable (P = 0.4 and 0.66 for each comparison). There was no trend toward the opinion that capitated payment arrangements are acceptable with greater levels of experience in capitated care (P = 0.5 by Spearman test). There were trends suggesting that compared with those who were not receiving capitated payments, those who received capitated payment were 50% more likely to have never discussed capitated payment with any patient (63% versus 42%, P = 0.08), were 70% more likely to very strongly oppose the use of capitation to pay their own family's physicians (49% versus 29%, P = 0.07), and were 30% more likely to believe that it is impossible to stay in the practice of medicine without participating in capitated payment plans (84% versus 65%, P = 0.06). None of the respondents reported that they had a contractual "gag clause," but 34% (27 physicians) said they would not speak publicly about any perceived risks of capitated payments anyway. Among this sample of physicians, those who participated in existing capitated payment managed care plans had views that were as negative, or more negative, on the acceptability of capitated payment as did those of nonparticipating physicians. Many were participating in capitated payment plans in spite of these negative views because they feared that to do otherwise would force them out of medical practice. The hypotheses generated by this study must be tested in larger, national studies. PMID- 10178457 TI - Using evidence-based techniques to modify anemia screening practice. AB - Routine screening of adolescents for iron-deficiency anemia is a widespread but unproven practice. Using evidence-based quality improvement techniques, including literature synthesis and presentation of clinic-specific data, my colleagues and I reevaluated a clinic policy of obtaining complete blood counts to screen for anemia in all new adolescent patients. Medical record review revealed clinically unsuspected anemia in 8 (3.5) of 229 patients screened. All cases were mild, and only two patients received iron therapy. These data, coupled with national recommendations, led to a reversal of the clinic's policy requiring screening of all new patients. One year later, complete blood counts were obtained for only 6% of new patients. PMID- 10178458 TI - Migraine: a problem for employers and managed care plans. AB - Headache is probably the most common symptom in the workforce and in the general population. Among the many types of headache, the one with perhaps the greatest impact on well-being and functional capacity is migraine. It disrupts work and leisure activities and engenders significant use of healthcare resources. Migraine cannot be cured, but it can usually be managed. Managed care organizations can facilitate the treatment of migraine through disease management programs. Unfortunately, however, many migraineurs receive substandard, ineffectual, and inappropriate care--or no care at all. This article reviews the diagnosis, epidemiology, and treatment of migraine, with an emphasis on the perspectives of employers and managed care plans, with the hope of encouraging them to become more proactive in dealing with individuals with migraine. PMID- 10178459 TI - Evolving therapy for Helicobacter pylori infection: efficacy and economic impact in the treatment of patients with duodenal ulcer disease. AB - Helicobacter pylori infection is present in most patients with duodenal ulcer disease, and cure of H pylori infection has been shown to dramatically reduce ulcer recurrence. Therapeutic strategies for duodenal ulcer disease have rapidly evolved over the past several years in an effort to consistently cure H pylori infection in a safe, cost-efficient manner. This paper reviews the effectiveness of treatments for H pylori infection in patients assessed with duodenal ulcer disease. The impact of clinical success on economic effectiveness has been determined in a recent prospective outcomes trial. Treatments with clarithromycin plus omeprazole or clarithromycin plus ranitidine-bismuth-citrate (RBC) provide consistent cure of H pylori infection, with eradication rates of 70% to 80%. Recent studies suggest that higher rates of eradication are possible with triple combination therapy (e.g., clarithromycin plus a second antibiotic and a proton pump inhibitor or RBC), but the optimal triple therapy regimen (including the combination of drugs, dosage, and duration of treatment) has not yet been defined. A recent 1-year prospective outcomes trial has demonstrated that eradication therapy with clarithromycin and omeprazole, compared with standard antisecretory therapy, provides measurable savings in utilization of ulcer related health-care resources. Combination therapy with clarithromycin plus omeprazole, clarithromycin plus RBC, or clarithromycin plus lansoprazole and amoxicillin have been approved for the treatment of H pylori infection in patients with duodenal ulcer disease. Economic analysis has confirmed that cure of H pylori infection not only contributes to the clinical resolution of duodenal ulcer disease, but also provides economic advantages by reducing costs associated with recurrence. PMID- 10178460 TI - Postmarketing analysis of lovastatin use in the VA Northern California System of Clinics: a retrospective, computer-based study. AB - Prevention of coronary heart disease is a major public health goal. The efficacy of lovastatin in lowering serum cholesterol has been proven in research studies, but its efficacy in practice is unclear. To evaluate our practice patterns and outcome in the Veterans Administration Northern California System of Clinics, we reviewed computer-based records of 203 unselected patients issued lovastatin; 193 (95%) were men, and the average patient age was 66 +/- 9 years. The average daily dose of lovastatin was 24 +/- 10 mg, and average duration of therapy was 22 +/- 11 months. Only 72 patients (35%) were instructed on the prescription to take their medication with the evening meal, and only 59 patients (29%) had seen a dietitian during the observed (1 to 3 years) treatment period. Nevertheless, among the 124 patients with pretreatment lipid data, total serum cholesterol decreased by 18% from 271 +/- 45 to 221 +/- 41 mg/dL (P < 0.001), and low density lipoprotein (LDL)-cholesterol decreased by 23% from 185 +/- 43 to 143 +/- 37 (P < 0.001) mg/dL. High density lipoprotein-cholesterol and triglycerides were unchanged. Of the 168 patients with LDL-cholesterol data during the treatment period, only 74 (44%) achieved an LDL-cholesterol level of less than 130 mg/dL, the minimum goal for a population of older males with a high incidence of other cardiac risk factors. Safety surveillance with liver function testing was performed at least once in 192 patients (95%), but with creatine phosphokinase (CPK) testing in only 123 patients (61%) during the survey period. Enzyme elevations were minor, but occurred at least intermittently in approximately one quarter of patients. Only 5.7% of patients on lovastatin manifested an increase in transaminases on therapy. Due to incomplete baseline data, it is unclear how many patients had elevated CPK as a result of lovastatin. We conclude that: (1) lovastatin is effective in lowering total and LDL-cholesterol in practice, but is often used in dosage insufficient to lower LDL-cholesterol to goal levels; (2) patients are not being adequately educated on dosing schedules; (3) toxicity may be underestimated by infrequent and inconsistent surveillance; and (4) nonpharmacologic therapy is underutilized. PMID- 10178461 TI - Antiviral therapy for neonatal herpes simplex virus: a cost-effectiveness analysis. AB - Each year, about 1,600 infants in the United States are infected with neonatal herpes simplex virus. We conducted a cost-effectiveness analysis of antiviral drug therapy (acyclovir) for three forms of herpes simplex virus infection: skin, ear, and mouth (SEM), central nervous system (CNS), and disseminated multiorgan (DIS) disease. Five levels of patient outcomes were examined (normal, mild, moderate, severe, dead). We obtained information on disease occurrence and survival from clinical trials and historical reviews of untreated newborns. We considered approaches for treating all or any of the forms of the disease and compared them with no use of antiviral drugs. The main measure of effectiveness was lives saved, including those of descendants of survivors. Costs were measured from a societal perspective and included direct medical costs, institutional care, and special education. We used a discount rate of 3% and valued dollars at 1995 levels. We also considered the perspective of a managed care organization. From a societal viewpoint relative to no treatment, antiviral therapy for SEM resulted in a gain of 0.8 lives and a cost reduction of $78,601 per case. For the treatment of CNS and DIS disease, antiviral therapy saved more lives but at increased cost, with respective marginal costs per additional life saved of $75,125 and $46,619. From a managed care perspective, antiviral therapy is more cost-effective than from a societal viewpoint because costs of institutional care and special education are not the responsibility of managed care organizations. Development of at-home therapies will further improve the cost-effectiveness of antiviral therapy for neonatal herpes simplex virus infection. PMID- 10178462 TI - Differences in costs of treatment for foot problems between podiatrists and orthopedic surgeons. AB - We examined charge data for health insurance claims paid in 1992 for persons under age 65 covered by a large California managed care plan. Charge and utilization comparisons between podiatrists and orthopedic surgeons were made for all foot care and for two specific foot problems, acquired toe deformities and bunions. Podiatrists provided over 59% of foot care services for this commercial population of 576,000 people. Podiatrists charged 12% less per individual service than orthopedists. However, podiatrists performed substantially more procedures per episode of care and treated patients for longer time periods, resulting in 43% higher total charges per episode. Hospitalization was infrequent for all providers, although podiatrists had the lowest rates. In a managed care setting in which all providers must adhere to a preestablished fee schedule, regardless of specialty, the higher utilization by podiatrists should lead to higher overall costs. In some cases, strong utilization controls could offset this effect. We do not know if the utilization difference is due to actual treatment or billing differences. Further, we were unable to determine from the claims data if one specialty had better outcomes than the other. PMID- 10178463 TI - Diabetes management: current diagnostic criteria, drug therapies, and state legislation. AB - The policies, standards, guidelines, and criteria that each member of the healthcare team uses to assist in the delivery of comprehensive healthcare are constantly being defined and redefined. This article has discussed many of those changes as they relate to diabetes management. The entire healthcare team must have a working knowledge of these changes so that they can continue to deliver the best possible care to patients with diabetes. Improvements in quality of life, decreases in mortality and morbidity, and subsequent declines in healthcare costs will benefit both individual patients and society. The profession of pharmacy has realized the need for additional education and training in managing the patient with diabetes. Many colleges of pharmacy, as well as companies in the pharmaceutical industry, are offering diabetes certification and diabetes disease management programs to pharmacists to enhance their ability to manage these patients (Lyons T, Gourley DR, unpublished data, 1997. Similar efforts in diabetes management have been made in other health professions as well, such as nursing. PMID- 10178464 TI - When is a cost-effectiveness claim valid? How much should the FDA care? AB - Federal law requires the Food and Drug Administration (FDA) to regulate the promotional claims of prescription drugs and certain devices. Standards of evidence for claims of safety and therapeutic efficacy are rigorous because inappropriate product use may place human life at risk. However, equally demanding criteria for claims of cost-effectiveness of marketed technologies seem to be unnecessary because the consequence of error is principally a bad buy rather than patient harm. Concern exists about the validity of cost-effectiveness studies, the potential for bias, standards for the conduct of cost-effectiveness research, and the needs of managed care. The FDA should moderate its role in regulating cost-effectiveness claims of drugs and devices. This would foster information flow to healthcare providers and insurers and protect the FDA concern regarding false or misleading claims of effectiveness. Although the issues are applicable to both devices and drugs, we draw mainly from the field of pharmacoeconomics because this is where most of the policy has developed. PMID- 10178465 TI - Treatment patterns for heart failure in a primary care environment. AB - Little published information regarding current pharmacotherapeutic treatment patterns for congestive heart failure (CHF) in nonacademic, ambulatory care settings is available. We sought to assess, in a nonacademic primary care environment, pharmacotherapeutic treatment patterns for CHF with respect to consistency with clinical trial evidence and published treatment guideline recommendations. Over an 18-month period, we examined CHF pharmacotherapy using a computerized, integrated clinical diagnoses and prescription database from an outpatient community healthcare center without academic affiliations. We identified adult patients meeting contact criteria and with diagnosis of CHF by International Classification of Diseases (ICD-9-CM) coding and assessed prescribed therapy as well as select comorbid conditions. Drugs of interest included those with known or suspected benefit or detriment and those with unproven benefit. An eligible group of 14,983 patients was identified, from which a cohort of 148 patients with CHF was selected. Forty-one percent of these 148 patients were prescribed an angiotensin converting enzyme (ACE) inhibitor, 34% digoxin, 12% diuretic, 12% hydralazine + nitrate, 20% inhaled beta-agonists, and 66% warfarin. Only 5% of patients were prescribed the combination of an ACE inhibitor, digoxin, and diuretic. Thirty-one percent had a comorbid diagnosis of atrial fibrillation, of whom 44% were prescribed digoxin, 22% diltiazem, 15% beta blockers, 15% digoxin and diltiazem, 7% digoxin and a beta-blocker, and 33% warfarin. In general, recommended therapies for CHF appeared underutilized in this cohort, whereas those of unclear benefit and potential detriment appeared overutilized. Although these results may not be readily generalized to the entire healthcare system, they do suggest a need for additional analysis and potential intervention. PMID- 10178466 TI - Referrals by general internists and internal medicine trainees in an academic medicine practice. AB - Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed. PMID- 10178467 TI - Enhancement of compliance among patients with hypertension. AB - Studies of patient compliance with medical advice consistently demonstrate a high level of noncompliance. Not following recommendations can have serious negative consequences in the management of disease. This study was an assessment of the effect on compliance of a longitudinal, individualized educational program for patients with hypertension in a managed care setting. A before-and-after self paired design was used to assess the behavior of 107 patients with hypertension. Trained nurses using an interactive interview format reinforced prescribed treatment and provided appropriate printed material to participants. Brief telephone follow-up interviews at prescribed intervals were used to elicit problems, provide additional education, and reinforce compliance behaviors. Most of the patients who participated showed a statistically significant (P < 0.01) decrease in both systolic and diastolic blood pressure. There was also an effect on various recommended behaviors, including compliance with medication taking, ideal body weight, salt restriction, stress, and exercise. A statistically significant relation existed between improved compliance with individual behavior changes and decreased blood pressure (P < 0.01). Elderly persons were particularly likely to show statistically significant reductions in blood pressure (75.4% versus 50.0%). A chi 2 test indicated that those differences were significant at the 0.01 level. A relatively inexpensive, office-based educational protocol can have a statistically significant effect on treatment compliance among patients with hypertension. The intervention has particular implications for geriatric patients, whose high blood pressure is disproportionately represented. PMID- 10178468 TI - Incorporating quality of life data into managed care formulary decisions: a case study with salmeterol. AB - Pharmacy and Therapeutics committees of managed care organizations have traditionally developed formularies by limiting the numbers and kinds of pharmaceuticals they purchase, with the goal of cutting costs. These attempts to manage pharmaceutical costs do not take into account the interrelationship of the costs of various components of care; thus, drug costs may decrease, but expenditures for utilization of other resources may increase. Cost-minimization and basic cost-effectiveness studies, on which many prior- authorization and formulary programs are based, only evaluate only the cost of the drug and its effectiveness. However, with the heightened competition in the healthcare market, emphasis is increasingly being laid on patient satisfaction and outcomes. Cost utility analysis is a potentially superior pharmacoeconomic tool because it evaluate the effect of drug therapy on quality of life; however, data from such analyses are seldom readily available to the committees that evaluate a drug's potential effects on the entire healthcare system. The purpose of this review is to stress the importance of approaching formulary management from a wider perspective and to emphasize that the results of cost-utility studies should be proactively evaluated and incorporated into decisions regarding formularies. This is especially important for symptom-intensive diseases, such as asthma, in which the quality of life can be notably impaired. Cost-utility analyses should be conducted for all newer therapies, such as salmeterol, which are highly effective and which have a positive impact on quality of life, to determine the overall effect on the managed care plan's budget. PMID- 10178469 TI - Empiric examination of physician behavior in a changing healthcare market. AB - We hypothesized that, in the current healthcare environment, medical providers have strong economic incentives to introduce new technology and treat patients more extensively. We examined physician reimbursement for medical procedures in Utah in the early 1990s, a period of increasing utilization of managed care methods, using a cross-section time series and a supply side model to analyze how physician behavior changed during this period of time. Our findings suggest that physicians have acted to maintain their revenue by requesting reimbursement for more procedures as the reimbursement level per procedure decreased. We conclude that increased volatility in reimbursement levels and increased adjudication pressure from payers provide signals to physicians to act strategically to protect their revenue stream. PMID- 10178470 TI - Healthcare utilization among women with eating disordered behavior. AB - This study was designed to explore relationship between self-reported eating disordered behavior (without formally established eating disorder diagnoses) and healthcare utilization among women in a primary care setting. Through a self report questionnaire, 150 participants between the ages of 17 and 49 were asked if they had ever vomited, starved themselves, or abused laxatives in a manner that was intentional and self-harming (i.e., eating disordered behavior identified as pathologic by the participant). Participants who reported a history of disordered eating (n = 17) exhibited higher scores on two of five measures of healthcare utilization (mean number of telephone contacts and mean number of specialist referrals) compared with participants without eating disorders (n = 133). These data suggest that eating disordered behavior may be a predictor of increased healthcare utilization among women in primary care settings. PMID- 10178471 TI - Cardiovascular drug prescribing patterns: where is the evidence of improvement? PMID- 10178472 TI - Cost implications of selective preoperative risk screening in the care of candidates for peripheral vascular operations. AB - The preoperative identification that patients are at high risk for adverse postoperative outcomes is the first step toward preventing costly in-hospital complications. The economic implications of noninvasive screening strategies in the care of patients undergoing peripheral vascular operations must be clarified. A decision model was developed from the peer-reviewed literature on patients undergoing preoperative screening by means of dipyridamole myocardial perfusion imaging, dobutamine echocardiography, or cardiac catheterization before vascular operations (n = 23 studies). Routine versus selective screening strategies were compared for patients with an intermediate likelihood of having coronary artery disease on the basis of clinical history of coronary disease or typical symptoms. Median costs (1994 US dollars) of preoperative screening strategies were derived with two microcosting approaches: adjusted Medicare charges (top-down approach) and a bottom-up approach with Duke University Center direct cost estimate data. In-hospital cost was 11% higher for preoperative screening by means of routine cardiac catheterization ($27,760) than for routine pharmacologic stress imaging ($24,826, P = 0.001). The total cost of a do-nothing strategy, that is, no preoperative testing, was 5.9% less than that of routine preoperative pharmacologic stress imaging and 15.9% lower than that of cardiac catheterization (P = 0.001). Selective screening among patients with a history of coronary disease or typical angina resulted in further reduction of the cost of care to a level comparable with that of a do-nothing strategy (52.5% reduction in cost with pharmacologic stress imaging, P > 0.20). Use of noninvasive testing for preoperative risk stratification was cost effective for patients 60 to 80 years of age. Cost per life saved ranged from $33,338 to $21,790. However, coronary revascularization after an abnormal noninvasive test was cost effective only for patients older than 70 years. In this economic decision model, substantial cost savings were predicted when selective noninvasive stress imaging was added to preoperative screening for patients about to undergo vascular operations. With a selective screening approach, the economic impact of initial diagnostic testing may be minimized without compromising patient outcomes. PMID- 10178473 TI - Disease management interventions to improve outcomes in congestive heart failure. AB - This study is part of a planned 24-month, multicenter, longitudinal comparison of a comprehensive congestive heart failure (CHF) disease management program and was designed to determine effectiveness after 12 months of implementation. The impact of interventions such as telemonitoring of patients, post-hospitalization follow up, and provider education on selected primary outcomes (hospital admission and readmission rates, length of stay, total hospital days, and emergency room utilization) in a managed care setting was evaluated. Subjects in the study included all participants in the managed care plan, as well as 149 selected program participants. The effects of the program were analyzed for pure CHF and CHF-related diagnoses, with outcomes for the third quarter of 1996 (postintervention follow-up) being compared with those for the third quarter of 1995 (preintervention baseline). Overall, the data demonstrated significantly reduced admission and readmission rates for patients with the pure CHF diagnosis. Among the entire CHF patient population, the third quarter admission rate declined 63% (P = 0.00002), and the 30-day and 90-day readmission rates declined 75% (P = 0.02) and 74% (P = 0.004), respectively. Among program participants with pure CHF diagnoses, the 30-day readmission rate was reduced to 0, and an 83% reduction occurred for both the third quarter admission (P = 0.008) and 90-day readmission (P = 0.06) rates. In addition, the average length of stay for patients with CHF-related diagnoses was significantly reduced among both plan participants (P = 0.03) and program participants (P = 0.001). Reductions were also seen in total hospital days and emergency room utilization. These data thus indicate that a comprehensive disease management program can reduce healthcare utilization not only among CHF patients in the program but also among the entire managed care plan population. PMID- 10178474 TI - Physicians in training as quality managers: survival strategy for academic health centers. AB - Being responsible for medical education places academic health centers at a disadvantage in competing for managed care contracts. Although many suggestions have been made for changing medical education to produce physicians who are better prepared for the managed care environment, few studies have shown how physicians in training can actually contribute to the competitiveness of an academic health center. We present three examples of engaging trainees in projects with a population-based perspective that demonstrate how quality improvement for the academic health center can be operationalized and even led by physicians in training. In addition to gaining experience in a managed care skill that is increasingly important for future employment, physicians in training can simultaneously improve the quality of care delivered through the academic health center. PMID- 10178475 TI - Gastrointestinal illness in managed care: healthcare utilization and costs. AB - Identification of inefficiencies is a first step to improving the quality of gastrointestinal (GI) care at the most reasonable cost. This analysis used administrative data to examine the healthcare utilization and associated costs of the management of GI illnesses in a 2.5 million-member private managed care plan containing many benefit designs. An overall incidence of 10% was found for GI conditions, with a preponderance in adults (patients older than 40 years) and women. The most frequently occurring conditions were abdominal pain, nonulcer peptic diseases, lower GI tract diseases, and other GI tract problems. These conditions, along with gallbladder/biliary tract disease, were also the most costly. Claims submitted for care during GI episodes averaged $17 per member per month. Increasing severity of condition was associated with substantial increases in utilization and costs (except for medication use). For most GI conditions, approximately 40% of charges were for professional services (procedures, tests, and visits) and 40% of charges were for facility admissions. The prescription utilization analysis indicated areas where utilization patterns may not match accepted guidelines, such as the low use of anti-Helicobacter pylori therapy, the possible concomitant use of nonsteroidal anti-inflammatory drugs in patients with upper GI diseases, and the use of narcotics in treating patients with lower GI disease and abdominal pain. Also, there was no clear relationship between medication utilization and disease severity. Thus, this analysis indicated that GI disease is a significant economic burden to managed care, and identified usage patterns that potentially could be modified to improve quality of care. PMID- 10178476 TI - Adverse drug reactions: a review for healthcare practitioners. PMID- 10178477 TI - Longer hospital length of stay is not related to better clinical outcomes in congestive heart failure. AB - Efforts to reduce hospital lengths of stay (LOS) are prevalent, despite limited understanding of the clinical impact of duration of hospitalization. Thus, we sought to evaluate the clinical relevance of LOS in congestive heart failure (CHF) by studying its relationship to inpatient and post-discharge outcomes among individuals with this disorder. Ten acute care community hospitals in New York State participated in this investigation. The study population consisted of 1,402 consecutive patients, predominantly elderly, who were hospitalized for evaluation and treatment of moderately severe or severe CHF. The patients' medical records were abstracted by trained personnel immediately after hospital discharge. Patients were followed forward for six month's time to track death and readmission rates, as well as functional status, quality of life, and satisfaction. Mean LOS for the group was 7.9 +/- 9.2 days. Longer LOS had a neutral or negative association with patient outcomes. Specifically, longer LOS was linked to a higher adjusted mortality rate during the index hospitalization, as well as a greater adjusted risk of death during the post-discharge period. Moreover, longer LOS was associated with worse post-discharge functional class and a trend for less patient satisfaction with their physicians' care. We conclude that death becomes more prevalent and functional measures decline in association with prolonged hospital stays for heart failure. Although these findings may be of use in planning management strategies, they offer no proof that reducing the costs of care will improve clinical outcomes in CHF. PMID- 10178478 TI - Physicians' attitudes toward managed care: assessment and potential effects on practice behaviors. AB - This study was designed to identify the key components of physicians' attitudes toward managed care and develop a tool to assess these components. We developed a questionnaire based on physicians' reactions to managed care, as reflected in the published literature. We mailed this questionnaire to a sample of 753 community physicians in the greater Sacramento area. A factor analysis of these data (n = 315) identified five unifactorial scales, which we labeled managed care quality, need to adapt to managed care, cost-containment effectiveness of managed care, personal knowledge of managed care, and inevitability of managed care. Physicians were most negative about the quality of managed care and most in agreement about the need to adapt to it. Correlations among these five scales, while statistically significant, were modest in size, suggesting that these physicians were quite discriminating in their evaluations. In comparison with medical/surgical specialists, primary care physicians rated the quality of managed care, their knowledge of it, and the inevitability of a national transition to managed care more positively. These measures predicted the physicians' intentions to alter their medical behaviors to comply with managed care practices. PMID- 10178479 TI - Subspecialist referrals in an academic, pediatric setting: rationale, rates, and compliance. AB - Appropriate referrals reduce healthcare costs and enhance patient satisfaction. We evaluated the subspecialty referral pattern of a managed care general pediatric office over a 4-month period. Three-hundred-forty-six referrals (267 meeting inclusion criteria) to 24 subspecialties were generated during 4,219 office visits, with five subspecialties receiving 59% of the referrals. The main objective of each referral was management (100), diagnostic assistance (75), special procedure (63), or a combination (29). Patients kept less than half of the referral appointments, with the highest (80%) and lowest (28%) compliance rates observed in cardiology and ophthalmology, respectively. Appointments made within four weeks of the referral were more likely to be kept than those with greater lag time (P = 0.001). The subspecialists prepared written, post consultation responses to the referring physician in 73% of cases. Presumptive and post-consultation diagnoses were congruent in 78% of those cases in which both diagnoses were noted. Overall, the managed care format enabled our practice to track referral outcomes. The subspecialists' written responses also allowed for an educational exchange between physicians. Compliance with referral appointments is a substantial problem that needs to be addressed. PMID- 10178480 TI - The myths of emergency medical care access in the managed care era. AB - In this paper, we examine the perception that emergency care is unusually expensive. We discuss the myths that have fueled the ineffective and sometimes deleterious efforts to limit access to emergency care. We demonstrate the reasons why these efforts are seriously flawed and propose alternate strategies that aim to improve outcomes, including cooperative ventures between hospitals and managed care organizations. We challenge managed care organizations and healthcare providers to collaborate and lead the drive to improve the cost and clinical effectiveness of emergency care. PMID- 10178481 TI - Home healthcare orders: an assessment of service satisfaction by internists, surgeons, and medical subspecialists. AB - We conducted a pilot study to evaluate the satisfaction of general internists, medical subspecialists, and surgeons with the quality of home health orders generated by home health agencies. Using a mail survey, we polled 69 physician specialists at Tulane University Medical Center. The percentage of physicians satisfied with the appropriateness of services for the level and type of care, consistency of medication with that prescribed, sufficiency of data on the certification form to assess service continuation, timeliness of orders, and overall health service delivery was 94%, 92%, 69%, 52%, and 88%, respectively. Compared with medical subspecialists and surgeons, general internists were more likely to report that the data on the form were sufficient. Physicians who were satisfied with at least one of the four measures of quality for home health orders were more likely to be satisfied with the overall delivery of services by home health agencies. Our results demonstrate, for the first time, that physicians overall are satisfied with home healthcare orders. However, level of satisfaction with orders is related to the physician's specialty. Areas that physicians were less satisfied with included timeliness of orders and sufficiency of data on the form to assess service continuation. Further studies using a larger population and more specific indicators of healthcare orders quality are recommended. PMID- 10178482 TI - Effect of home blood glucose monitoring on the management of patients with non insulin dependent diabetes mellitus in the primary care setting. AB - The purpose of the study was to determine whether blood glucose monitoring strips influence the management of patients with non-insulin dependent diabetes (NIDDM) in the primary care setting. The medical records of 115 patients with NIDDM taking a sulfonylurea drug (oral hypoglycemic agent) during the review period were randomly selected for review. Patients were divided into two groups: those who did not receive a prescription for blood glucose monitoring strips during 1995 and 1996 and those who did for the same 2 years. The main outcome measures were hemoglobin A1c, blood sugar, number of laboratory tests ordered, and number and type of treatment interventions. No statistically significant differences between groups were noted for any measured parameter. Glucose control was independent of number of strips dispensed. Home glucose monitoring strips did not affect the management of patients with NIDDM taking a sulfonylurea agent in the primary care setting. PMID- 10178483 TI - Monitoring patients with diabetes mellitus: an application of the probit model using managed care claims data. AB - The primary objective of this study was to estimate the likelihood of the use of either a glycosylated hemoglobin (HbA1c) test or an eye examination, or both, among a cohort of patients diagnosed with diabetes mellitus. A secondary objective was to provide a step-by-step discussion of the applicability of an econometric model to managed care organizations. The study used medical and pharmacy claims data from a managed care organization for the calendar year 1995. A probit regression model was specified to estimate the probability of occurrence for either an HbA1c test or an eye examination among patients with insulin dependent, non-insulin dependent, or atypical/unclassified diabetes. Data were available only for patients under 65 years of age due to data truncation for patients covered by Medicare, resulting in a study sample size of 6,841. Results indicate that age, presence of hypertension, hyperlipidemia, multiple cardiovascular comorbidities, ophthalmic disease, and combinations of multiple commonly observed comorbidities were positively correlated with the probability of either HbA1c testing or eye examination. Gender and the type of benefit plan were not statistically significant as predictors of disease monitoring. A total of 1,860 patients with diabetes mellitus were predicted by the model to have undergone one of the two monitoring procedures; but in actuality, these patients were not monitored in 1995. They could be considered as high-risk patients who were not getting recommended monitoring. The probit model shows a predictive power of 64.48%. PMID- 10178484 TI - Market-level health maintenance organization activity and physician autonomy and satisfaction. AB - Managed care is widely expected to affect physicians throughout the healthcare system. In this study, we examined the relationship between health maintenance organization (HMO) activity and the level of competition, autonomy, and satisfaction perceived by physicians who do not work for HMOs. We obtained data on physicians from the 1991 Survey of Young Physicians, which contains a nationally representative sample of physicians younger than age 45 who had 2 to 9 years of practice experience in 1991. We examined the relationships between HMO market share and perceived competition, autonomy, and satisfaction using multivariate logistic regression. The main outcome measures were perceived level of competition; several measures of physicians' freedom to undertake common tasks that might be threatened by managed care (e.g., hospitalizing patients, ordering tests and procedures); satisfaction with current practice situation; perceived ability to practice quality medicine; whether the physician would attend medical school again; and satisfaction with medicine as a career. We found that an increase of 10 percentage points in HMO market share was associated with a 28% increase in the probability that physicians will regard their practice situation as very competitive as opposed to somewhat or not competitive (P < 0.01). Examinations of the relationship between HMO market share and autonomy and satisfaction revealed few significant results. We found no evidence that increases in HMO activity adversely affect physician autonomy. Only a limited amount of evidence indicates that increases in HMO activity reduce the satisfaction of specialist physicians, and no evidence associates HMO activity with the satisfaction of generalists. Although physicians perceive HMOs as competitors, HMO activity has not had a strong negative effect on the autonomy and satisfaction of physicians. PMID- 10178485 TI - The validity and usage of resource utilization data among a group of primary care physicians. AB - The use of individual resource utilization scores to compare primary care physicians (PCPs) has become more commonplace as managed care organizations (MCOs) increase their penetration into the US healthcare market. This study looks at the validity and usage of these scores among a group of PCPs within a multispecialty clinic that is part of an integrated managed care network. Personal interviews were conducted with PCPs; and reviews were done of the practice site paper charts, the computerized visit record system of the clinic and affiliated hospital, and the MCO-supplied resource utilization data on the 25 patients of each PCP on whom the most healthcare dollars were spent in 1995. As of October 1996, few PCPs had done more than a cursory review of their resource utilization data. None had identified the patients who use the most resources or developed any methods to proactively manage those patients with a history of high utilization. The clinic's communication systems alerted the PCPs less than 50% of the time when patients for whom they were responsible had high utilization of services. Patients appeared to be assigned to the incorrect PCP more than 20% of the time. All players in this managed care network--PCPs, clinic administration, and the MCO--must work together to improve the current system before resource utilization data are considered valid and are incorporated more fully into clinical practice. PMID- 10178486 TI - An analysis of predictors of prescription drug costs among Medicaid nursing home residents in Texas. AB - A study was conducted to examine the relations among patient-specific demographic characteristics, previous prescription costs and utilization, and subsequent prescription costs for a population of 55,677 Medicaid nursing home residents in Texas. Patient-specific factors, based on previous patient utilization and cost levels, exist within the Texas Medicaid nursing home population that may serve as predictors of subsequent prescription costs. Although some statistically significant relations exist between prescription costs and patient demographic factors such as age, sex, and location, these demographic factors are of little or no practical value in prediction of prescription costs for subsequent periods of time. PMID- 10178487 TI - The cost-effectiveness of ibutilide versus electrical cardioversion in the conversion of atrial fibrillation and flutter to normal rhythm. AB - Atrial fibrillation and atrial flutter are cardiac rhythm disorders that are often symptomatic and may interfere with the heart's function, limiting its effectiveness. These arrhythmias are responsible for a large number of hospitalizations at a significant cost to the healthcare system. Electrical cardioversion (EC) is the most common nonpharmacologic intervention used to convert atrial fibrillation and atrial flutter to normal rhythm. Electrical cardioversion is highly successful in converting patients to normal rhythm; however, it is more traumatic and resource intensive than pharmacologic treatment. Recently, a new rapid-acting drug, ibutilide, was approved for the conversion of atrial fibrillation and atrial flutter. Ibutilide is administered through intravenous infusion and does not require anesthetization of the patient, as is required for EC. A decision-tree model was developed to estimate the cost effectiveness of ibutilide therapy compared with EC therapy. Clinical outcomes were based on a phase III trial of ibutilide, and resource use was based on the literature and physician clinical judgment. A stepped conversion regimen of first line ibutilide followed by EC for patients who fail to convert is less expensive and has a higher conversion rate than first-line EC. Sensitivity analysis shows that our results are robust to changes in cost and effectiveness estimates. PMID- 10178488 TI - Long-term management of asthma: how to improve outcomes. AB - Improved clinical outcomes in asthma patients have been demonstrated in several clinical trials that applied the National Institutes of Health (NIH) guidelines for the long-term management of asthma. Environmental control, objective monitoring, drug therapy, and partnership in patient education are the major components of optimal management. Inhaled antiinflammatory agents are of major importance for long-term control in patients with persistent asthma. Adequate patient education is absolutely essential for excellent, cost-effective care of patients with asthma. Improved outcomes in adults with asthma have been demonstrated at clinics initiated and managed by pharmacists. Further trials are needed with large numbers of patients in managed care organizations. PMID- 10178489 TI - Physicians' perceptions of managed care. AB - We wished to determine physicians' views and knowledge of managed care, particularly their beliefs about the provisions of managed care contracts in terms of legality and ethics. A questionnaire was sent to the 315 physicians of the medical staff of Norwalk Hospital in Connecticut regarding managed care and managed care contracts. Sixty-six responses were received within a 45-day period (20.9% return). Although only 1 of 11 contract provisions presented in one section of the questionnaire was illegal in Connecticut, a majority of physicians believed 7 of the 11 were illegal. On average, 50% of physicians polled thought each of the provisions was illegal, and a varying majority of physicians (53% to 95.4%) felt the various provisions were unethical. The majority of respondents (84.8% to 92.4%) believed that nondisclosure provisions were unethical. Ninety seven percent thought managed care interferes with quality of care, and 72.7% of physicians felt that the managed care industry should be held legally responsible for ensuring quality of care. However, 92.4% of physicians considered themselves to be ethically responsible for ensuring quality of care. Physicians have a poor understanding of the legal aspects of managed care contracts but feel strongly that many provisions of these contracts are unethical. Physicians also believe that managed care is causing medicine to be practiced in a manner that is contrary to patients' interests and that legal recourse is needed to prevent this. PMID- 10178490 TI - The impact of a simulated immunization registry on perceived childhood immunization status. AB - We developed a simulated immunization registry to assess the impact on the perceived immunization status in a population-based sample of 2-year-olds living in Olmsted County, MN, in 1995. We compiled records of all immunizations by abstracting immunization data from all medical care facilities in the county. The data collected from each facility were analyzed separately to provide the immunization rate as perceived by each facility. This perceived rate was compared to the rate obtained by combining all recorded immunizations from all facilities (simulated registry). Information on children not receiving any carefrom facilities in Olmsted County was compiled from birth certificate data and community school lists. Data from the simulated registry indicated that 69.1% of all children in Olmsted County with medical records were up-to-date on their immunizations by 20 months of age. By 24 months, this increased to 74.2%. The immunization rate of 24-month-old children recorded at individual healthcare facilities in Olmsted County ranged from 24.3% to 79.5%. The addition of data from the simulated registry increased the immunization rate at each site: a 27.7% relative increase in the site with the lowest recorded immunization rate, a 14.0% increase in the site with the intermediate immunization rate, and a 6.9% increase in the site with the highest internally perceived immunization rate. The registry also identified excess immunizations in 5% of the county's 2-year-olds. Each healthcare facility in this community gained an immediate benefit from the development of a simulated immunization registry. This immediate improvement in one quality-of-care measure (up-to-date immunization rate) should be factored into the cost/benefit assessment of immunization registries. PMID- 10178491 TI - Outcomes for control patients referred to a pediatric asthma outreach program: an example of the Hawthorne effect. AB - A study was designed to determine whether identification of high risk for exacerbations of asthma based on pediatrician concern, emergency department visits, or hospital stays results in a decrease of resource utilization because of referral to an asthma outreach program even if the intervention does not take place. The findings for such a group were compared with those for a group who did undergo intervention with an asthma outreach program. Fifty-six patients 1 to 14 years of age were assigned to one of two groups. The control group (those who did not undergo intervention) had consistent but not statistically significant reductions in utilization of emergency visits, hospitalizations, and dollars spent (21%, 24%, and 32%, respectively). The group who underwent intervention with the asthma outreach program had large and statistically significant decreases in the same parameters (emergency visits, 60%, P = 0.001; hospital stays, 74%, P = 0.008; dollars spent, 72%, P = 0.004). However, the apparently insignificant effect of the reductions in utilization by the control group substantially altered interpretation of the outcomes of the study. Cost savings were reduced from $11.69 per dollar spent on intervention to $6.49 per dollar spent. In before-and-after studies such as those typically conducted during continuous quality improvement projects, which typically do not have control groups, investigators need to consider control group effects when they assess the results of intervention. PMID- 10178492 TI - Effect of compensation method on the behavior of primary care physicians in managed care organizations: evidence from interviews with physicians and medical leaders in Washington State. AB - The perceived relationship between primary care physician compensation and utilization of medical services in medical groups affiliated with one or more among six managed care organizations in the state of Washington was examined. Representatives from 67 medical group practices completed a survey designed to determine the organizational arrangements and norms that influence primary care practice and to provide information on how groups translate the payments they receive from health plans into individual physician compensation. Semistructured interviews with 72 individual key informants from 31 of the 67 groups were conducted to ascertain how compensation method affects physician practice. A team of raters read the transcripts and identified key themes that emerged from the interviews. The themes generated from the key informant interviews fell into three broad categories. The first was self-selection and satisfaction. Compensation method was a key factor for physicians in deciding where to practice. Physicians' satisfaction with compensation method was high in part because they chose compensation methods that fit with their practice styles and lifestyles. Second, compensation drives production. Physician production, particularly the number of patients seen, was believed to be strongly influenced by compensation method, whereas utilization of ancillary services, patient outcomes, and satisfaction are seen as much less likely to be influenced. The third theme involved future changes in compensation methods. Medical leaders, administrators, and primary care physicians in several groups indicated that they expected changes in the current compensation methods in the near future in the direction of incentive-based methods. The responses revealed in interviews with physicians and administrative leaders underscored the critical role compensation arrangements play in driving physician satisfaction and behavior. PMID- 10178493 TI - The pharmacoeconomic benefits of cholesterol reduction. AB - Recent studies show that cholesterol-lowering therapy can reduce morbidity and mortality in hypercholesterolemic patients without preexisting coronary heart disease (primary prevention) and with coronary heart disease (secondary prevention). The high cost of treatment per event prevented, especially for primary prevention, raises concerns about widespread use of cholesterol-lowering therapy. Does cholesterol reduction reduce utilization of healthcare resources, and can society afford to pay for reducing cholesterol in all patients with hypercholesterolemia, irrespective of risk factors? Is cost-effectiveness of therapy affected by differing cholesterol levels, age of the patients, the duration of therapy, or the presence of risk factors? Current pharmacoeconomic studies support the use of the statins for secondary prevention, and primary prevention in high-risk patients, and provide key information for policy decision making in the treatment of patients with hypercholesterolemia. PMID- 10178494 TI - The neonatologist as primary care physician. AB - Although trained first as pediatricians, neonatologists are not typically viewed as primary care physicians. However, given their particular training and expertise, patient population, and interaction with families as the newborn's first physician in many settings, neonatologists may rightly be viewed as the most appropriate primary care physician for newborns with medical or surgical problems. We review the fundamental underpinnings of primary care medicine with particular attention to how the neonatologist functions in such capacities. Neonatologist can contribute greatly to ensuring continuity of care for the sick newborn, the comprehensive nature of that care, and the coordination of care. Neonatologists' interactions with elements of the community to which the newborn will be discharged are an asset, as is their ability to work as part of a team. Given recent changes in practice management, the availability of neonatologists in the United States, and the desire for full-service mother and infant care capabilities in community hospitals, the primary care role of neonatologists bears recognition and support in today's changing healthcare marketplace. PMID- 10178495 TI - Physicians' perceptions of managed care. PMID- 10178496 TI - Identifying diabetes mellitus or heart disease among health maintenance organization members: sensitivity, specificity, predictive value, and cost of survey and database methods. AB - We conducted a study of the sensitivity, specificity, positive predictive value, and cost of two methods of identifying diagnosed diabetes mellitus or heart disease among members of a health maintenance organization (HMO). Among 3186 adult HMO members who were attending one primary care clinic, 2326 were reached for a telephone survey (efficiency = 0.73). Among these members, 1991 answered standardized questions to ascertain whether they had diabetes or heart disease (corrected response rate = 0.85). Linkage was then made to computerized diagnostic databases. By means of both a database method and a survey method, the 1976 members with complete data for analysis were classified as having or not having diabetes or heart disease. When results with the two methods disagreed, charts were reviewed to confirm the presence or absence of diabetes or heart disease. Diabetes was identified among 4.7% of adult members, and heart disease was identified among 3.7%. Identification of diabetes differed between the database method and the survey method (sensitivity 0.91 vs 0.98, specificity 0.99 vs 0.99, positive predictive value 0.94 vs 0.83). Identification of heart attach history was similar for the database method and the survey method (sensitivity 0.89 vs 0.95, specificity 0.99 vs 0.99, positive predictive value 0.79 vs 0.81). The cost of obtaining data was $13.50 per member for the survey method and $0.30 per member for the database method. Database methods or survey methods of identifying selected chronic diseases among HMO members may be acceptable for various purposes, but database identification methods appear to be less expensive and provide information on a higher proportion of HMO members than do survey methods. Accurate identification of chronic diseases among patients supports clinic-level measures for clinical improvement, research, and accountability. PMID- 10178497 TI - A cost-effectiveness clinical decision analysis model for schizophrenia. AB - A model was developed to estimate the medical costs and effectiveness outcomes of three antipsychotic treatments (olanzapine, haloperidol, and risperidone) for patients with schizophrenia. A decision analytic Markov model was used to determine the cost-effectiveness of treatments and outcomes that patients treated for schizophrenia may experience over a 5-year period. Model parameter estimates were based on clinical trial data, published medical literature, and, when needed, clinician judgment. Direct medical costs were incorporated into the model, and outcomes were expressed by using three effectiveness indicators: the Brief Psychiatric Rating Scale, quality-adjusted life years, and lack of relapse. Over a 5-year period, patients on olanzapine had an additional 6.8 months in a disability-free health state based on Brief Psychiatric Rating Scale scores and more than 2 additional months in a disability-free health state based on quality adjusted life years, and they experienced 13% fewer relapses compared with patients on haloperidol. The estimated 5-year medical cost associated with olanzapine therapy was $1,539 less than that for haloperidol therapy. Compared with risperidone therapy, olanzapine therapy cost $1,875 less over a 5-year period. Patients on olanzapine had approximately 1.6 weeks more time in a disability-free health state (based on Brief Psychiatric Rating Scale scores) and 2% fewer relapses compared with patients on risperidone. Sensitivity analyses indicated the model was sensitive to changes in drug costs and shortened hospital stay. Compared with both haloperidol and risperidone therapy, olanzapine therapy was less expensive and provided superior effectiveness outcomes even with conservative values for key parameters such as relapse and discontinuation rates. PMID- 10178498 TI - Economic outcomes associated with the use of risperidone in a naturalistic group practice setting. AB - The purpose of this cohort pilot study was to compare the resource utilization and economic outcomes associated with the use of risperidone versus haloperidol in a naturalistic setting. Patient charts from a large psychiatric group practice were reviewed, and hospital billing data were obtained. Patients meeting the inclusion criteria were placed into one of two cohorts depending on their medication history. Thirty patients treated with risperidone met the selection criteria, and a random quota sampling technique was used to allow for a matched control cohort of 30 patients treated with haloperidol. In the haloperidol and risperidone cohorts, 24 and 28 patients, respectively, were evaluated statistically. Mean utilization rates and costs per patient per month for each service were estimated by using regression analysis. Patients in the risperidone cohort had significantly fewer hospitalizations than did those in the haloperidol cohort (P = 0.004). Likewise, risperidone patients had significantly lower hospitalization costs than haloperidol patients (P = 0.005). Conversely, patients treated with risperidone visited the physician more frequently than did those treated with haloperidol (P = 0.0005). Estimated mean total monthly costs were $123.34 lower (95% confidence interval = $464, $217) per patient in the risperidone cohort than in the haloperidol cohort ($1,636.11 vs $1759.45; P = 0.4693). Significant reductions in hospital costs in the risperidone cohort offset higher medication and physician costs. Overall, total monthly costs were similar for the two cohorts. PMID- 10178499 TI - Treatment of schizophrenia: let's talk dollars and sense. AB - Schizophrenia is a major neurologic illness with an impact on public health that has been unappreciated. Newer and arguably more effective medication treatments are now available and hold considerable promise. The higher up-front cost of these drugs is, on current evidence, offset by other economic advantages and, from a humanitarian perspective, by the expectation of improved patient outcome with less drug toxicity. The extent to which these drugs replace older drug treatments will be determined by the relative influences of clinical, pharmacoeconomic, mental health administrative, and advocacy factors over the coming years. PMID- 10178500 TI - Prevalence and cost of hospitalization for gastrointestinal complications related to peptic ulcers with bleeding or perforation: comparison of two national databases. AB - The purpose of this study was to determine the prevalence and cost of hospitalization for upper gastrointestinal complications, including peptic ulcers with hemorrhage or perforation. Upper gastrointestinal complications and corresponding economic data were obtained from two sources. The first was a 20% sample of all community hospital discharges (about 6 million per year) from 11 states for 1991 and 1992 Hospital Cost Utilization Project; HCUP-3). The second source of data was a claims database for employees of large US corporations and their dependents for 1992, 1993, and 1994 (about 3.5 million covered lives per year; MarketScan). A group of ICD-9 codes for the diagnosis of peptic and gastroduodenal ulcers with bleeding or perforation were used to identify hospital admissions because of upper gastrointestinal complications. Similar patterns were observed across the MarketScan and HCUP-3 databases regarding hospitalization with diagnoses related to gastrointestinal complications identified according to the ICD-9 codes. The average age of patients with upper gastrointestinal complications was 66 years in the HCUP-3 database and 52 years in the MarketScan database. The average annual rates of upper gastrointestinal complications as a primary or secondary diagnosis were 6.4 and 6.7 per 1000 discharges for 1991 and 1992, respectively (HCUP-3), and 4.3, 4.2, and 4.9 per 1000 admissions for 1992, 1993, and 1994, respectively (MarketScan). The average length of stay for upper gastrointestinal complications as a primary diagnosis was 7.8 days in 1991 and 7.5 days in 1992 (HCUP-3) and 6.1, 5.1, and 5.1 days in 1992, 1993, and 1994, respectively (MarketScan). The national average total charge for hospitalization for gastrointestinal problems as a primary diagnosis was $12,970 in 1991 and $14,294 in 1992 (HCUP-3). The average total reimbursement for hospitalizations related to upper gastrointestinal problems was $15,309 in 1992, $12,987 in 1993, and $13,150 in 1994 (MarketScan). Hospital admissions for upper gastrointestinal complications are expensive. The rate and cost per admission are higher for the older population. The results on the elements covered by both databases are consistent. Therefore the databases complement each other on the type of information abstracted. PMID- 10178501 TI - Virtual managed care organizations: the implications of technology-based patient management. PMID- 10178502 TI - Screening and surveillance for colorectal cancer. PMID- 10178503 TI - Parenteral and enteral nutrition in the home and chronic care settings. PMID- 10178504 TI - Part of benchmarking's future: a move to decision support software. PMID- 10178505 TI - Best practices available for pediatric emergencies. PMID- 10178506 TI - Looking for a benchmark? Try Southern states. PMID- 10178507 TI - Best care for the dying is listening to their needs. PMID- 10178508 TI - Back to school: AMA educates on end-of-life issues. PMID- 10178509 TI - Quality initiatives and diversification pay off for Annaburg Manor. Interview by Jan Lamoglia. PMID- 10178510 TI - Rising to the subacute challenge. Having excelled at skilled nursing, an administrator and his facility branch into subacute care. PMID- 10178512 TI - Senior housing operators have several financing options. PMID- 10178511 TI - Easing the transition for new residents ... and for their families. PMID- 10178513 TI - Weed out dishonest employees before hiring them. PMID- 10178514 TI - The Tin Man challenge: leadership, change and the myth of the Yellow Brick Road. PMID- 10178515 TI - How well do you manage time? PMID- 10178516 TI - An architect's perspective of nursing home design. PMID- 10178517 TI - Boren axed from 1997 Federal Budget Act. PMID- 10178518 TI - Employers must accommodate the mentally ill. PMID- 10178519 TI - Would someone really hire you? PMID- 10178520 TI - Becoming an AIT (administrator-in-training): the first step of training. PMID- 10178521 TI - Use the Web to advance your career. PMID- 10178522 TI - Four steps to better performance appraisals. PMID- 10178523 TI - Top ten stupidest mistakes managers make ... and how to avoid them. PMID- 10178524 TI - Fresh approaches stave off competition. Silver Care Center thrives on its administrator's ingenuity and energy. Interview by Kelley Sheahan. PMID- 10178525 TI - Dignity and life purpose for AD (Alzheimer's disease) residents. PMID- 10178526 TI - 4 steps to more committed nursing assistants. PMID- 10178527 TI - Do less with less. Changes in health care force us to reassess our management paradigm. PMID- 10178529 TI - Feds unveil new data collection program to fight fraud and waste. PMID- 10178528 TI - Provider sponsored organizations unite providers along the continuum of care. New legislation opens the door for providers to bypass traditional managed care contracts. PMID- 10178530 TI - Interviews gone wrong. Discriminatory hiring could begin with asking the wrong questions. PMID- 10178531 TI - Ten career resolutions for 1998. PMID- 10178532 TI - Back to school! Distance learning offers alternatives for administrators. PMID- 10178533 TI - Remembering hospitalism. The Eden Alternative recognizes growing, living things as essential ingredients in the health care mix. PMID- 10178534 TI - Catch a rising star. PMID- 10178535 TI - Is 99.9% perfect good enough? PMID- 10178536 TI - De-mystifying the certification process. PMID- 10178537 TI - Your yearly review. PMID- 10178538 TI - Scams, scamps & shams on the Internet. PMID- 10178539 TI - Excellence is an ongoing process. Interview by Kelley Sheahan. PMID- 10178540 TI - Employment practices liability protects you from frivolous lawsuits. PMID- 10178541 TI - Frequently asked questions about PPS. PMID- 10178542 TI - Clinton's budget proposal is full of optimistic initiatives. PMID- 10178543 TI - AIDS: the new drug war. PMID- 10178544 TI - Total quality in health care. AB - Quality is at the top of American consumers' demand list, and consequently American manufacturing companies have been forced to assign priority to the development of high-quality products. To improve the quality of what they offer, many manufacturers use the management philosophy known as total quality management (TQM), and now the service sector is following in their footsteps. The health care industry is a good example of a service industry that can benefit greatly from TQM, and it is the purpose of this article to show how a health care provider can implement TQM and evaluate its effects. PMID- 10178545 TI - The art of defining computer system requirements: say what you need and need what you say. AB - The task of defining computer system requirements often involves the consideration of an overwhelming number of complexly related factors. Therefore, before getting started, a project team assigned this task needs to get an overview and develop a clear understanding of the main objectives and the alternative methods it can use in carrying out its responsibilities. This article presents tips and techniques for achieving success in the requirements definition phase of a software selection process. PMID- 10178546 TI - Integrated enterprise management: a look at the functions, the enterprise, and the environment--can you see the difference? AB - The performance of an organization is paced by its use of resources, including its ability to acquire, access, and use knowledge. A high-performance organization, more than likely, has structured its resources around process linkages and is characterized by a horizontal organization chart, teams and teamwork, empowerment, and operational excellence. Organizational researchers hypothesize that performance improves with fuzzy internal boundaries, cross functional participation, and goals anchored in the interests of customers and other external stakeholders. This article looks at the competitive need for more integration of resources and greater sharing of knowledge, the integrated nature of work within emerging types of organizations, how expanded views can improve the marketplace centering of processes and individuals, and how combining a model of integration and individual work challenges thinking and actions in the new environment. PMID- 10178547 TI - How to use the Internet. AB - The Internet is the fastest growing new information service, but it is still an unknown territory to many production and inventory control (PIC) managers. It should not be, and by reading this article they can get a rough idea what it is, how to use it, why it should be used, and where to start. PMID- 10178548 TI - Factors to consider in the delivery of quality services by hospitals. AB - The focus of any health care provider, such as a hospital, is on assessing and improving the well-being of the people in the system's target area, and it is this focus that differentiates health care providers from other enterprises. The purpose of this article is to identify the essential factors in the delivery of quality services by hospitals. These factors include patients' active participation in their delivery, the nature of the clinical procedures, and the management of the interaction of all the customers involved in the process. PMID- 10178549 TI - Structured problem solving for materiel managers. AB - A structured approach to problem solving and solution documentation is one of the keys to continuous improvement. Without it, it is quite possible to solve the wrong problem, to solve the right problem in the wrong way, or (maybe worst of all) to solve the same problem over and over again. Companies that have figured out how to solve the right problems in the right way, once and for all, will ultimately move forward much faster than their competitors. PMID- 10178550 TI - How to seek and destroy the root of quality inconsistency. AB - Quality inconsistency, whether it exists in products, processes, communication, or services, should serve as a red flag signaling a need to make improvements. More consistency in the workplace can only come through the continual refining of performance. In order for "continual improvement" to become part of the company culture, each person in the organization needs to understand and apply a disciplined step-by-step approach to change. All effective, lasting change comes from the use of problem solving and an effective change process. PMID- 10178551 TI - Tools from the implementation workbench: a project manager's survival kit. AB - Change rarely comes easy. There are frequently obstacles of various shapes and sizes throughout the implementation process, and in order to ensure success a project manager must have the right tools and know how to use them. Just as craftspeople master the tools of their trade, so too must project managers--not only if they are to succeed but also if they are to survive. This article focuses on the "how to"--the skill set needed to be a successful project manager. It describes the project management process and reviews some basic but invaluable tools. PMID- 10178552 TI - Hospital material management in Taiwan: a survey. AB - The new insurance policy that began in 1995 for all people in Taiwan and severe competition within the health care industry are some of the pressing issues forcing hospitals to improve their operational efficiency. A primary productivity improvement for hospitals is the reduction of the cost of material management because the materiel function on average controls 30-40 percent of the operating dollars in a Taiwan hospital. In this article, a fuzzy clustering method is used to classify the different types of materiel management systems within Taiwan hospitals. Inventory turnover rates and fill rates are compared among those different types of systems by using multivariate analysis of variance. The results show that the differences in both inventory turnover rates and fill rates are statistically significant among different material management systems. PMID- 10178553 TI - How to calculate total purchase cost. AB - Companies wanting to implement a total cost-based supplier selection process often stumble over how to include nonmonetary issues such as delivery and quality performance, lead time, services, and social policies. This article describes a process that allows a company to include any issue it deems relevant and to determine its cost factor. PMID- 10178554 TI - Home health care workers' attitudes toward the elderly. AB - This study examined home health care workers' attitudes toward the elderly and their elderly clients. Data were collected from a convenience sample of 106 home health care workers in South Central Florida in October 1994, using the Attitudes Toward the Elderly Questionnaire (ATE). Estimated internal consistency reliability of the scale was .60, using Cronbach's alpha. Findings suggest that home health care workers have positive attitudes toward the elderly, their elderly clients, and provide a reasonable level of service for them. Also, findings suggest that overall the attitudes and perceptions among urban and rural home health care workers are similar. PMID- 10178555 TI - The use of multidimensional assessment instruments in community-based care. AB - Today almost all states employ multidimensional assessment instruments in determining eligibility and providing care planning for their community-based programs. Nurses, social workers, and other providers either administer the instruments themselves or find their work directly dependent on assessments performed by others. This article provides practitioners with information on the comprehensive nature, strengths, and limitations of such instruments. Major issues are presented by means of a comparative analysis of four state multidimensional instruments. PMID- 10178556 TI - The impact of a decade of policy on home health care utilization. AB - The Medicare home health care eligibility changes, which occurred during the 1980s, were designed to make home health care more accessible to older adults. Ideally, by the 1990s, older adults in need of home health care services should no longer have encountered barriers to accessing this benefit. Therefore, an individual's need for home health care services should have been the primary determinant of service utilization. This paper examined whether need was predictive of home health care use. Client-level data on the case mix of home health care agencies in San Francisco and Philadelphia, as well as agency administrator interview data, were analyzed to determine which characteristics were the best predictors of home health care use. The regression analyses results revealed that, although client characteristics were important predictors of the amount and type of home health care services received during an episode of care, client characteristics alone did not adequately predict the amount and type of home health care services received by older adults. PMID- 10178557 TI - Psychiatric home care of elderly persons with depression: unmet caregiver needs. AB - The purpose of this study was to explore what nursing interventions are currently being provided to family caregivers of elderly persons with depression as a part of standard home health care; and identify unmet needs of these family caregivers. Unmet caregiver needs were examined from both the family caregiver and staff nurse perspective, using caregiver structured interviews and staff focus groups. Ten caregivers participated in structured interviews and nine staff nurses participated in three focus groups. Caregivers reported unmet needs concerning support and respite, dealing with their own feelings, learning more about care-related tasks and role changes, and stress management. Similarly, nurses speculated that nursing interventions should focus on increased counseling, family and community support, assisting caregivers with their learning needs and care-related responsibilities. These findings contribute toward a better understanding of interventions currently provided to caregivers of depressed elderly persons, as a part of standard psychiatric home care; identify unmet caregiver needs; and suggest areas for future psychiatric research in home care settings. PMID- 10178559 TI - To invest or not to invest? Guidelines for evaluating investments in new technology. PMID- 10178558 TI - Information technology 101. What every CEO needs to know. PMID- 10178560 TI - A race/ethnic comparison of career attainment in healthcare management. PMID- 10178561 TI - Search firm executives speculate on slowdown in hospital CEO turnover. PMID- 10178562 TI - Staying in touch with healthcare. Maintain your healthcare connections after retirement. PMID- 10178563 TI - Physicians and information systems. PMID- 10178564 TI - Evaluating and applying new technologies. PMID- 10178565 TI - Beyond compliance. PMID- 10178566 TI - Creating a service culture. PMID- 10178567 TI - The debate intensifies. A number of bills in Congress may expand federal regulation of health plans. PMID- 10178568 TI - The Cleveland Project: reporting on quality. PMID- 10178569 TI - Diversity in healthcare management. PMID- 10178570 TI - How to hire the right CIO. AB - As the role of technology in healthcare management and delivery continues to expand, the market for qualified chief information officers grows ever more competitive. Management teams in the market for a CIO must choose quickly-but they must also choose wisely. PMID- 10178571 TI - Health insurance as a catalyst to change in former communist countries? AB - A large number of former communist countries are currently undergoing a process of insurance led health sector change. Social health insurance is seen as a major source of income for the health sector, as a way of inducing fundamental restructuring of provision and of encouraging greater individual awareness of the costs (and benefits) of publicly financed health care. Attempts to introduce social medical insurance have generally been criticized by western policy analysts yet continue to have much appeal in each country. Obtaining additional revenue for the health sector is clearly a major motivation for these reforms. Yet available evidence suggests that many countries will obtain revenue that is lower and less stable than envisaged. For some countries other reasons for insurance may be as important. One of the most important is the greater autonomy given to the national Ministry of Health and local health departments over expenditure allocation. Recent experience of voluntary insurance in Turkmenistan confirms many of the fears about the feasibility and impact of social health insurance. Yet establishing an attractive but contained benefits package has been popular with the population and offers a potentially useful approach for inducing more fundamental reform. PMID- 10178572 TI - Controlling antimicrobial resistance: a proposed transferable permit market. AB - Resistance to antimicrobials results in those antimicrobials becoming ineffective in treating common bacterial infections. To prevent the spread of such resistance the use of antimicrobials requires control. The authors have previously argued that use of regulation or charges to control resistance would not be efficient. Regulation will not account for different marginal costs of reducing antimicrobial prescription amongst GPs, and charges, although based on sound economic concepts, are based on an unrealistic amount of required information. It was therefore argued that a system of tradable permits, by combining the targets of regulation and the market flexibility of charges, would achieve control more efficiently than simple regulation or charges. In this paper the authors progress this proposed policy by considering various important issues which arise when designing such a tradable permit system for antimicrobials. The paper does not provide an exhaustive plan enabling a blueprint for such a market to be designed, but a proposal which may be used as platform for further specific development of such an initiative to deal with resistance. PMID- 10178573 TI - International collaboration in health technology assessment: a study of technologies used in management of osteoporosis. AB - A collaborative study was undertaken by members of the International Network of Agencies for Health Technology Assessment (INAHTA). The evidence of the effectiveness of bone density measurement and selected treatments in preventing fractures in later life was reviewed. There was fair evidence that bone density measurement can predict risk of fractures and that hormone replacement therapy and intranasal salmon calcitonin preserve bone mass and decrease the risk of fractures. However, it was estimated that only 1-7% of hip fractures would be prevented if these technologies were used in a screening program for menopausal women. Results of the assessment were endorsed by 13 INAHTA members, disseminated widely and provided input to policy and further work in this area. The project demonstrated the feasibility of international collaborative health technology assessment. PMID- 10178574 TI - Burden of illness estimates for priority setting: a debate revisited. AB - This paper returns to the debate in this journal about a decade ago on the value of cost of illness (COI) and burden of illness (BOI) estimates in priority setting. Concern is expressed that there has been a resurgence of interest in calculating and using BOI estimates in such priority setting. It is especially concerning that this interest seems to have support from both the World Bank and the World Health Organisation (WHO) (although perhaps less so recently from the latter). It is argued that in terms of priorities for health services, BOI calculations are irrelevant except possibly in the context of some (less than ideal) concept of need in support of equity. If the need basis for equity is set in terms of 'capacity to benefit', then BOI calculations become even less relevant. There is an argument for some research funding being prioritised in terms of BOI but only when it is genuinely the case that there is total ignorance, beyond the size of the problem, about a particular policy or disease area. Such a level of ignorance will happen very seldom and then some fairly approximate estimates of BOI will suffice. It is better to concentrate in priority setting on estimating the costs and benefits of marginal changes than devoting scarce analytical resources to superfluous estimates of BOI. PMID- 10178575 TI - Emigration of New Zealand and Australian physicians to the United States and the international flow of medical personnel. AB - One in five physicians practising in the US received their initial medical qualifications in another country. Contrary to expectations, a large cadre come from developed nations such as New Zealand and Australia. In particular, these two countries provide a unique prism with which to view the international flow of medical talent. While they differ from developing nations that primarily export physicians without attracting others in return, they are distinguished from importing nations such as the US which rarely export. Our analysis is based on a unique dataset collected from three cross-sectional sources. We found that, compared to post-resident physicians remaining at home, New Zealand medical graduates (NZMGs) and Australian medical graduates (AMGs) in the US are typically older, more likely to be male, more likely to have received their initial medical qualifications from certain schools, less likely to be employed in a public hospital setting, more likely to work in a medical school and more likely to practice in a specialty than primary care. Additional findings show that NZMGs and AMGs in the US are more likely than other US physicians to have established themselves in areas with 50,000 or more people and are therefore more likely to serve a population with sociodemographic characteristics typical of the nation's urban centers. It appears then, that NZMGs and AMGs may be emigrating to the US for educational and professional opportunities that may be unavailable at home. In short, the emigration of NZMGs and AMGs may be an instance of what has come to be called the 'international equity problem' or 'brain drain'. However, losses resulting from the disproportionate migration of New Zealand and Australian physicians to the US may be compensated for by the importation of foreign trained physicians from other nations. Future analysis must be extended to take this facet of the international flow phenomena into account. PMID- 10178576 TI - Mix and meld design blends patients, promotes healing. PMID- 10178577 TI - Rounding up your real estate. Are you ready for integration? PMID- 10178578 TI - Waste busters. It's a new breed in health care with a radical new attitude about waste disposal. PMID- 10178579 TI - Park place. Facility parking can be as tricky as a board game. PMID- 10178580 TI - Career klatch--straight talk on planning your next move. PMID- 10178581 TI - Goal for new millennium: mercury-free health facilities. PMID- 10178582 TI - Socio-cultural information in support of local health planning: conclusions from a survey in rural Kenya. AB - Existing health information systems in developing countries are managed and used mainly by biomedically trained personnel and by general healthcare administrators. They focus on epidemiology, service utilization and finance; they generate little of the socio-cultural data needed for developing and adjusting health services and disease control programmes to local health-related perceptions, values and resources. This paper reviews some of the published literature on socio-cultural factors related to health and summarizes the findings of a health household interview study in rural Kenya. It concludes that local views on specific disease categories and their causes are crucial for the planning of local disease control and that health information systems need to be expanded to incorporate such data. It discusses methods of generating community based socio-cultural health information likely to be useful, particularly at district level. Options include observation, household interviews, focus group discussions and key informant interviews. Four improvements are suggested: (1) health information systems should be reoriented to focus less on individual patients and clients and more on population-based information including socio cultural data; (2) post-basic health manpower training is needed in applied health-related social sciences; (3) staff positions for social scientists at central, provincial and district levels of the health sector; and (4) expansion of research on national and local socio-cultural issues of relevance to health and care-seeking behaviour. PMID- 10178583 TI - Willingness to pay for rural health insurance through community participation in India. AB - The main objective of this article is to examine the willingness to pay for a viable rural health insurance scheme through community participation in India, and the policy concerns it engenders. The willingness to pay for a rural health insurance scheme through community participation is estimated through a contingent valuation approach (logit model), by using the rural household survey on health from Karnataka State in India. The results show that insurance/saving schemes are popular in rural areas. In fact, people have relatively good knowledge of insurance schemes (especially life insurance) rather than saving schemes. Most of the people stated they are willing to join and pay for the proposed rural health insurance scheme. However, the probability of willingness to join was found to be greater than the probability of willingness to pay. Indeed, socio-economic factors and physical accessibility to quality health services appeared to be significant determinants of willingness to join and pay for such a scheme. The main justification for the willingness to pay for a proposed rural health insurance scheme are attributed from household survey results: (a) the existing government health care provider's services is not quality oriented; (b) is not easily accessible; and, (c) is not cost effective. The discussion suggests that policy makers in India should take serious note of the growing influence of the private sector and people's willingness to pay for organizing a rural health insurance scheme to provide quality and efficient health care in India. Policy interventions in health should not ignore private sector existence and people's willingness to pay for such a scheme and these two factors should be explicitly involved in the health management process. It is also argued that regulatory and supportive policy interventions are inevitable to promote this sector's viable and appropriate development in organizing a health insurance scheme. PMID- 10178584 TI - Costs of polio immunization days in China: implications for mass immunization campaign strategies. AB - Ten provinces of China were selected to estimate the cost per immunization of the 1994-95 national immunization days (NIDs) at five levels (e.g. province, prefecture, county, township and village). Personnel costs accounted for the largest overall share of costs (39 per cent), followed by publicity and promotion costs (27 per cent), and logistic costs (15 per cent). Without consideration of vaccine costs, the major part of NID expenses were shouldered at the township level, which paid for 47 per cent of all incremental costs, while county and village level covered 28 per cent and 18 per cent respectively. Estimation of average costs per immunization was 2.86 RMB yuan, or $0.34, including vaccine costs, buildings and equipment amortization and salaries at all levels. The factors affecting average cost of NID included the output volume, socio-economic development and geographic features. Various approaches were recommended: to intensify the productivity of time and staff, to employ alternative inexpensive manpower resources, to make the best use of publicity and social promotion, the expansion of the age groups and utilization of multi-intervention strategies. Good planning at township level was a decisive factor to ensure an effective NID conducted in an efficient manner. The average cost of China's NID was the lowest among all mass immunization campaigns ever documented. Much of the reduced average cost was attributable to economies of scale. PMID- 10178585 TI - Cost-control and medical specialist payment: the Dutch alternative. AB - The fee-for-service system is a growing problem for insurers and governments. The main reason for this is the open-ended character of this system which makes cost control a very difficult task. The pressures on the fee-for-service system are becoming more pronounced, especially in countries such as Canada, Germany and the Netherlands which use budget restrictions on national health care expenditure (macro caps). In these countries policy makers are searching for an alternative payment system and an appropriate definition of a corresponding status for doctors. The alternative, however, does not have to lead automatically to a salaried status of doctors in the hospital organization. The Dutch experience of the change of the payment system for medical specialists illustrates the transition to a new 'negotiated order'. The introduction of the 'lump sum' and the sub-contractor relationship with the insurance companies leaves the organizational autonomy of medical specialists intact. In exchange the medical specialists cooperate with the insurers in trying to control the costs of health care. In this process of strategic change, two factors are very significant, i.e. the new leadership of the local medical specialists and the governmental 'circumvention' of the powerful associations of doctors and insurers. PMID- 10178586 TI - Oops! EMS mistakes--they're inevitable, stressful, painful and oh-so educational. This guide helps you classify them and avoid sweating the small stuff. PMID- 10178587 TI - Educator's round table. What's the single-most important issue facing EMS instructors, what are its implications and what should EMS do to respond? PMID- 10178588 TI - Oklahoma city rebuilds. PMID- 10178589 TI - New Stark regulations: Key issues for health care decision-makers. AB - On Jan. 9, 1998, The Health Care Financing Administration (HCFA) issued long awaited Proposed Regulations for what has become known as Stark II. The regulations are subject to a comment period and later refinement. However, they lay out HCFA's basic understanding of what kinds of practices constitute an illegal kickback. In general terms, the law prohibits physicians from referring Medicare or Medicaid patients to entities with which they (or an immediate family member) have a "financial relationship" for the delivery of a specific list of designated health services. There are, however, exceptions also included in the new proposal. Group practices will want to pay special attention to HCFA's new definition of group practice. PMID- 10178591 TI - Psychology & employee commitment. Promoting physician loyalty. AB - Physician and staff loyalty has become more important and more difficult to maintain. Group managers should realize that not all forms of commitment are equal and should actively work to build commitment to the organization, not just to the practice of medicine. PMID- 10178590 TI - Building a compliance program. Guidelines for physician practices. AB - Federal investigations of physician billing practices will only grow more intense in 1998. Regular self audit, especially of CPT coding, can help practices stay out of the limelight. An established compliance program and high-ranking compliance officer are also becoming standard. Compliance programs should pay particular attention to "incident to" billing, level 5 E/M codes, time-based E/M codes, codes with both technical and professional component services, consultations, critical care codes and physician care plan oversight. Even group practices that use billing companies need to stay alert. Physicians are liable for the acts of the billing company whether they knew or should have known submitted claims were false. PMID- 10178592 TI - The anatomy of an annual report to stockholders. AB - This article gives practical advice about how to develop an annual report to a governing body. The author urges involvement of staff to prepare the data, exhibits and financial information; external advisors such as CPAs should review the data to add creditably. The narrative section should be easy-to-understand by physicians; use of short explanations of accomplishments is suggested. The article gives examples of information that could be used. The author suggests that developing a formal report can be rewarding; and encourages every chief executive to prepare one for their practice. PMID- 10178593 TI - Your practice and infringement suits. Law affects patented medical procedures. AB - A 1996 law concerning patients on medical procedures is still causing change in health care. While the law was intended to exempt physicians from patent infringement during the practice of medicine, its final form contains ambiquities of medical group managers should remain aware. PMID- 10178594 TI - Client-server technology for merging practices. AB - Mergers, acquisitions and multiple care sites have made day-to-day management of information a logistical nightmare for medical group managers. As medical groups consolidate, each care site, typically, joins the new organization using stand alone billing, accounting and scheduling packages. These legacy systems offer no automated way to transfer information between care sites and a central office. Rather than replacing established operating systems, medical group managers can use rules-based, decision support software and host-based, or client/server, technology. This type of connectivity allows medical groups to collect, process and redistribute key information. PMID- 10178595 TI - Integrity in managed care: a short guide. AB - Many think ethical managed care is an oxymoron. But managed care can be more ethical--and can fulfill it's original pledge of providing broader access and better care by caring prudently--if it is physician-led. Faced with day-to-day ethical decisions that are have black and white solutions, physicians are obliged to get more involved in management decisions, create formal ethics programs, report colleagues who are unscrupulous and learn about new performance tools. Patients angry and suspicious about managed care expect no less from their physician. PMID- 10178596 TI - What is the importance of due-diligence in managed care contract review? PMID- 10178597 TI - Creating values-based health care. An interview with ACMPE President Patty Brewster. Interview by Pamela L. Moore. AB - The new president of the American College of Medical Practice Executives (ACMPE), Patricia L. Brewster, FACMPE, regional director; Hughston Clinic, Atlanta, took time to talk to MGM Journal Managing Editor Pamela L. Moore, Ph.D., about her job, the ethics of medical practice management and the role of ACMPE. Brewster has 20 years experience in the medical marketplace. She formerly worked as the administrator at Phoenix: Orthopedic and Sports Medicine, Atlanta, and Orthopaedic Associates of Atlanta. She is also past-president of the MGMA Southern Section. Under her guidance, Hughston Clinic has from two to seven locations, covering a six county area in metropolitan Atlanta. PMID- 10178598 TI - RBRVS: what have you done to us lately? PMID- 10178599 TI - Automation. Part 1. Modular stepwise automation and the future of diagnostic testing. PMID- 10178600 TI - National Medical Laboratory Week. Silly games and serious science mix. PMID- 10178601 TI - Diabetes: targeting an old adversary. AB - For the first time in almost 20 years, new recommendations on diagnosis, classification, and testing strategies for diabetes have been issued. For clinical labs, combatting this old enemy under the new guidelines will include expanded patient screening and closer monitoring. Learn about the high-risk groups in the U.S. population, the long-term effects of diabetes, and how changes in testing approaches can improve disease management and patient outcomes. PMID- 10178602 TI - Wanted: creative ideas! Encouraging creative problem solving in the laboratory. PMID- 10178603 TI - Governing IDF's: the changing role of governing boards. A new set of "stakeholders". PMID- 10178604 TI - Governing IDFS's: the changing role of governing boards. Transforming a hospital board to an IDFS board. PMID- 10178605 TI - Governing IDFS's: the changing role of governing boards. One big board, or a board with sub-boards. Governance issues: today and tomorrow. PMID- 10178606 TI - Developing a competitive advantage: price, outcome measures, enrollee satisfaction. What employers are looking for. PMID- 10178607 TI - Developing a competitive advantage: price, outcome measures, enrollee satisfaction. Development of clinical outcome measures. PMID- 10178608 TI - Measuring enrollee satisfaction. PMID- 10178609 TI - Successes and course corrections. PMID- 10178610 TI - Preparing managers for the 21st century. The accelerating pace of change at B schools. PMID- 10178611 TI - The challenge of diverse cultures. Training new doctors for a changing world. PMID- 10178612 TI - A surge in graduate programs for nurses. Schools are responding to a growing demand. PMID- 10178613 TI - Traveling through the revolving door. Maryland prepares students for dual careers. PMID- 10178614 TI - Christopher A. Percy: recipient of the 1998 Robert F. Allen Symbol of H.O.P.E. Award. PMID- 10178615 TI - A prediction equation for estimating body fat percentage using readily accessible measures: a multivariate study of 200 adult women. AB - PURPOSE: This study was conducted to develop a regression equation that accurately estimates body fat percentage using relatively easy and inexpensive methods that do not require women to remove clothing. DESIGN: A cross-sectional design was employed. SETTING: All data were collected at the University. SUBJECTS: Subjects were 200 white women ages 20 to 65 years. The sample was equally distributed across four age groups, 20-29, 30-39, 40-49, and 50-65, and within each age group, one-third of the women were lean, one-third were of average weight, and one-third were obese. MEASURES: Subjects were hydrostatically weighed and participated in a variety of anthropometric and lifestyle assessments, including skinfolds, circumferences, and questionnaire responses. RESULTS: The full regression model included six measures: hip circumference, triceps skinfold (observed and quadratic), age (quadratic), self-reported physical activity, and calf skinfold (quadratic). This equation accounted for 81% of the variance in body weight measured by hydrostatic weighing (SEE = 3.5%). A simpler, five-variable equation was also formed that did not include the calf skinfold assessment (R2 = .800, SEE = 3.6%). CONCLUSIONS: The prediction equations in this study afford accurate and relatively easy and inexpensive means of estimating body fat percentage in a wide range of white women without having them remove their clothing. PMID- 10178616 TI - Job strain and health behaviors: results of a prospective study. AB - PURPOSE: To assess the association between job demands, job decision latitude, and job strain (defined by Karasek as a combination of high demands and low decision latitude) and cardiovascular disease-related health behaviors such as cigarette smoking, alcohol use, lack of exercise, and overweight. DESIGN: Cross sectional and prospective. SETTING: Nine New York City public and private sector worksites. SUBJECTS: Two hundred eighty-five male employees, aged 30 to 60, in a wide variety of white-collar and blue-collar job titles. MEASURES: Medical examinations and surveys, which included demographic, health behavior, and job characteristics data. RESULTS: Prospectively, among 189 men, increase in job decision latitude over 3 years was associated with decrease in cigarette smoking, by analysis of covariance, controlling for age, race, education, marital status, and number of children at home (F (8, 180) = 4.37, p = .005). The largest increase in latitude occurred among the 13 men who quit smoking. However, change in job characteristics was not associated with change in overweight or alcohol use. Cross-sectional analyses did not produce consistent associations. CONCLUSIONS: The effectiveness of smoking cessation may be aided by modification of structural features of the work environment, such as job decision latitude. This study is limited by the small number of subjects who were engaged in high risk behaviors. PMID- 10178617 TI - Evaluation of motivationally tailored vs. standard self-help physical activity interventions at the workplace. AB - PURPOSE: This study compares the efficacy of a self-help intervention tailored to the individual's stage of motivational readiness for exercise adoption with a standard self-help exercise promotion intervention. DESIGN: Interventions were delivered at baseline and 1 month; assessments were collected at baseline and 3 months. SETTING: Eleven worksites participating in the Working Healthy Research Trial. SUBJECTS: Participants (n = 1559) were a subsample of employees at participating worksites, individually randomized to one of two treatment conditions. INTERVENTION: Printed self-help exercise promotion materials either (1) matched to the individual's stage of motivational readiness for exercise adoption (motivationally tailored), or (2) standard materials (standard). MEASURES: Measures of stage of motivational readiness for exercise and items from the 7-Day Physical Activity Recall. RESULTS: Among intervention completers (n = 903), chi-square analyses showed that, compared to the standard intervention, those receiving the motivationally tailored intervention were significantly more likely to show increases (37% vs. 27%) and less likely to show either no change (52% vs. 58%) or regression (11% vs. 15%) in stage of motivational readiness. Multivariate analyses of variance showed that changes in stage of motivational readiness were significantly associated with changes in self-reported time spent in exercise. CONCLUSIONS: This is the first prospective, randomized, controlled trial demonstrating the efficacy of a brief motivationally tailored intervention compared to a standard self-help intervention for exercise adoption. These findings appear to support treatment approaches that tailor interventions to the individual's stage of motivational readiness for exercise adoption. PMID- 10178618 TI - Physicians' views of programs incorporating stages of change to reduce smoking and excessive alcohol consumption. PMID- 10178619 TI - Teaching Ayurvedic and western health promotion strategies to healthy adults. PMID- 10178620 TI - Support for policy interventions to increase physical activity in rural Missouri. PMID- 10178621 TI - Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting. AB - PURPOSE: The purpose of this study was to gain insight into attitudes and perceptions about smoking during pregnancy, passive smoke exposure, barriers to quitting, and program preferences among women in a low-income, ethnically diverse setting. DESIGN: Nine focus group discussions were conducted with African American, Native American, and white women. Discussions were moderated by local residents who shared the same ethnic background as group participants. SETTING: Discussions were held in neighborhood centers and clinics in an urban area. SUBJECTS: A total of 57 women participated. Moderators recruited participants from within their social networks and from neighborhood programs. The informal process of recruitment did not allow calculation of response rates. MEASURES: A series of open-ended questions with selected probes was used to guide the conversation. RESULTS: Participants were aware that smoking during pregnancy is harmful and were concerned to varying degrees about their smoking behavior. Most women who smoked took active steps to reduce the risks. Actions were frequently accompanied by beliefs that rationalized moderate levels of smoking. While concerned, women were uncertain about what constituted harmful, passive smoke exposure. Personal barriers to quitting included being around others who smoked, feelings of stress and boredom, addiction, and not believing smoking is dangerous enough. Participants tended to value pregnancy-related advice from female friends and relatives over advice from professionals. CONCLUSIONS: Results suggest that many women respond to warnings about smoking during pregnancy, but actions are not necessarily measured in quit rates. Misconceptions about the risks may help to rationalize continued smoking. Subjects lacked knowledge about how best to reduce the risks of passive smoke. Educational efforts may be effective when directed at networks of women who share information. The nature of qualitative data collection prevents extrapolation of these results to a larger population. PMID- 10178622 TI - Examining emotional, physical, social, and spiritual health as determinants of self-rated health status. AB - PURPOSE: To determine whether individuals' perceptions of their emotional, physical, social, and spiritual health constitute elements of their self-rated health status operationalized with a commonly employed single indicator. DESIGN: Secondary analysis of cross-sectional survey data. Structural equation modeling with LISREL was used. SETTING: The Yukon Health Promotion Survey, Yukon Territory, Canada, 1993. SUBJECTS: The population-based sample was made up of 742 women and 713 men between 15 and 90 years of age; 80.3% responded. MEASURES: Self rated health status was operationalized with the "excellent, good, fair, poor" indicator derived from the question: "In general, compared to other people your age, would you say your health is...." Social, spiritual, emotional, and physical health status were also self-rated from excellent to poor. RESULTS: The model's fit of the data was acceptable. Only physical health status significantly contributed to the variance in self-rated health status (55.1% of the variance was explained). Emotional, social, and spiritual health were found to have no effect on individuals' ratings of their health status. CONCLUSIONS: Although recent conceptualizations have broadened in much of the theoretical and political discourse about health, especially in health promotion, the self-rated health status indicator measures only physical health status. PMID- 10178623 TI - Cataract surgery and lens implantation. PMID- 10178624 TI - Assessing disability in the patient with cataract. AB - Significant progress has been made over the past decade in assessing the functional impact of cataract on patients. Several questionnaires have been shown to predict well the outcomes of cataract surgery. The following article highlights the most recent research in this area and reviews the progress that has been made in the past several years. PMID- 10178625 TI - Cataract, Alzheimer's disease, and other conformational diseases. AB - Unfolding of proteins was shown to occur in human cataract more than 25 years ago. Recently, the term conformational diseases was applied to a whole group of diseases in which unfolded or misfolded proteins accumulate. In this article, common features in the biochemistry and epidemiology of cataract, Alzheimer's disease, and other conformational diseases are explored. PMID- 10178626 TI - Cataracts in systemic diseases and syndromes. AB - This review attempts to interpret the basic science and more esoteric aspects of diseases associated with cataract, in the context of practical management and diagnostic implications. In the past year, the large epidemiologic Beaver Dam Eye Study has dismissed many putative relationships between cataract and cardiovascular risk factors. However, glycated hemoglobin and high density lipoprotein cholesterol levels still have an association. Cataract continues to be associated with a number of systemic diseases and syndromes such as atherosclerosis, diabetes mellitus, atopy, juvenile rheumatoid arthritis, Marfan's syndrome, and the Cronkhite-Canada syndrome. The unifying role of oxidative stress in the formation of these, as well as iatrogenically induced laser cataracts, is presented, together with a biochemical update on the pathogenesis. Finally, to bridge the gap between the basic science and clinical significance, recent controversial and practical management issues have been highlighted. PMID- 10178627 TI - New techniques and instruments for lens implantation. AB - Although no major breakthroughs have recently emerged in the area of lens insertion techniques and technology, small incremental advancements continue to take place for the placement of foldable intraocular lenses through small incisions. Folders have become more innovative in their ability to effectively fold lenses, and inserters have been downsized and enhanced to allow insertion through smaller incisions with more effective purchase of the lens. New cartridge injectors are increasing in popularity because of their ease of use and ability to pass through smaller incisions, especially with modifications. In addition, increased knowledge regarding techniques and complications of noncapsular supported intraocular lenses continues to be gained, adding to our ability to choose the proper technique for secondary lens insertion in these selected patients. PMID- 10178628 TI - Pediatric cataracts. AB - Over the past year, major advances have occurred in our understanding of the surgical management of pediatric cataracts. New insights concerning the response of the pediatric eye to intraocular lens implantation coupled with improved surgical techniques are expanding the indications and reducing the complications of intraocular lens implantation in children. Additionally, new progress has been made in identifying the risk factors for the development of pediatric cataracts and the etiologies of associated complications. PMID- 10178629 TI - Management of coincident cataract and glaucoma. AB - Combined phacoemulsification and trabeculectomy has become a common procedure in the management of coincident cataract and glaucoma. As the medical options to treat glaucoma continue to improve, more patients may not require surgical intervention until the time of cataract extraction. Current techniques using small-incision phacoemulsification and trabeculectomy with antimetabolites have vastly improved the results of combined glaucoma surgery. This article discusses many of the important issues as they relate to this subject. This is not a comprehensive review, but rather a discussion of the literature in the scanning period of this issue. PMID- 10178630 TI - Management of coincidental corneal disease and cataract. AB - The status of the cornea is crucial to a good outcome with cataract extraction. Preexisting corneal disease must be managed appropriately to get the high quality results that we have come to expect with modern day cataract surgery. It is now more common to perform cataract surgery on patients who have had previous corneal refractive surgery, and in these patients intraocular lens power calculation is more challenging. Complications following cataract surgery and lens implantation that involve the cornea are uncommon because of advances in surgical techniques. Corneal complications can include mechanical or toxic injury of the endothelium, stripped Descemet's membrane, epithelial toxicity and disruption, infectious keratitis, or epithelial ingrowth. Endothelial cell survival after cataract extraction and lens implantation is still the major concern. Healing of the cornea following clear corneal incisions has become more important, as this technique is used more frequently. There are several recent studies looking at the results of clear corneal incisions performed for cataract surgery. Patients with ocular surface disease still require extra lubrication and management of blepharitis to prevent epithelial toxicity at the time of surgery as well as postoperatively. Clear corneal cataract extraction and lens implantation cause minimal disruption of the conjunctiva, allowing cataract surgery to be performed in patients with severe ocular surface disease such as ocular cicatricial pemphigoid. Overall, modern day cataract extraction is very safe for the cornea. PMID- 10178631 TI - Refractive cataract surgery. AB - Cataract surgery is the most commonly performed refractive procedure in the world today. Improvements in the calculation of intraocular lens power and design have allowed complete spherical correction of preexisting refractive error with intraocular lens implantation. Advances in incision construction have improved the refractive results of cataract surgery by minimizing surgically induced astigmatism. Astigmatism and pseudophakic presbyopia continue as the primary indications for spectacle correction following cataract surgery. Improvements in the technique of correcting preexisting astigmatism with cataract surgery have improved the uncorrected visual outcome of cataract surgery. The application of these advances in technology over the past year has demonstrated that full refractive correction of the cataract patient is now possible. PMID- 10178632 TI - Preoperative and postoperative medications of anesthesia. AB - Three interesting developments in perisurgical medication were evaluated during the past year. After years of discussion concerning the prophylactic use of anti inflammatory agents prior to cataract surgery, a report was published describing the results of a prospective study on this subject. There were many papers on anesthesia, some evaluating comfort, some comparing different methods of anesthesia, and others discussing ways to minimize the necessity of anesthesia. There were also several reports studying the postoperative effects of several anti-inflammatory agents. PMID- 10178633 TI - Refractive aspects of cataract surgery. AB - The refractive aspects of cataract or lens surgery has formed a new field of operations. To reduce astigmatism and high myopia, surgeons are looking into alternatives and using various incision techniques as well as phakic intraocular lenses or clear lens extraction to achieve emmetropia. High hyperopia with short axial length and high required intraocular lens power are corrected by piggyback intraocular lens implantation. The use of multifocal intraocular lenses compensates for the loss of accommodation after lens extraction. PMID- 10178634 TI - Capsular opacification after cataract surgery and capsule. AB - The lens capsule, the keystone of modern cataract surgery, has been the subject of some important and interesting investigations over the past year. This review addresses 1) inhibition of posterior capsule opacification (surgical techniques, intraocular lens design, and pharmacologic methods); 2) treatment of posterior capsule opacification; and 3) characteristics of the capsule. Of special interest are techniques for inhibiting posterior capsule opacification in pediatric patients by optic capture through a posterior capsulorhexis, the concept that sharp optic edges markedly decrease posterior capsule opacification as compared with round-edged implants, and promising work demonstrating that an immunotoxin may be effective in prevention of posterior capsule opacification. PMID- 10178635 TI - Multifocal vision after cataract surgery. AB - Recent improvements in cataract surgery and intraocular lens (IOL) technology have allowed rapid improvement in quality visual acuity. Cataract surgeons can also reliably reduce a patient's dependency on spectacles. Through careful monitoring of implant power calculations to improve their accuracy and reduce unwanted astigmatism, our patients are now able to enjoy clear, uncorrected vision. Newer technology, such as multifocal IOLs and accommodating IOLs, can provide a return to prepresbyopic visual acuity for the cataract patient. PMID- 10178636 TI - Ginger: history and use. AB - Ginger is well known in the form of ginger sticks or ginger ale. If these are consumed during travel, the traveler imbibes, albeit subconsciously, a healing plant for motion sickness. The efficacy of ginger rhizome for the prevention of nausea, dizziness, and vomiting as symptoms of motion sickness (kinetosis), as well as for postoperative vomiting and vomiting of pregnancy, has been well documented and proved beyond doubt in numerous high-quality clinical studies. The use of this ancient medicine for gastrointestinal problems (stimulation of digestion) has been given scientific approval. Today, medicinal ginger is used mainly for prevention of the symptoms of travel sickness. PMID- 10178637 TI - Therapeutic efficacy and safety of Cimicifuga racemosa for gynecologic disorders. AB - The reproducible quality of phytopharmaceuticals--herbal medicines--is an essential prerequisite for good efficacy and tolerability in the treatment of functional disorders. In clinical trials and scientific investigations, standardized assessments (i.e., validated, internationally recognized and accepted scales) provide the basis for establishing clinical efficacy and tolerability. Extracts (ethanolic and isopropanolic aqueous, Remifemin) of the rootstock of the herb Cimicifuga racemosa (black cohosh) are active ingredients developed for the treatment of gynecologic disorders, particularly climacteric symptoms. Drug-monitoring and clinical studies documenting experience with C. racemosa rootstock extracts comprise the database of this herbal treatment for menopausal symptoms (e.g., hot flashes, profuse sweating, sleep disturbances, depressive moods). These studies show good therapeutic efficacy and tolerability profiles for C. racemosa. In addition, clinical and experimental investigations indicate that the rootstock of C. racemosa does not show hormone-like activity, as was originally postulated. PMID- 10178638 TI - Clinical improvement of memory and other cognitive functions by Ginkgo biloba: review of relevant literature. AB - Ginkgo biloba is a plant extract used to alleviate symptoms associated with cognitive deficits, e.g., decreased memory performance, lack of concentration, decreased alertness, tinnitus, and dizziness. Pharmacologic studies have shown that the therapeutic effect of ginkgo is based on several active constituents with vasoactive and free radical-scavenging properties. The use of ginkgo extract in either dementias of the Alzheimer or multi-infarct type or in the case of cerebral insufficiency, a symptom complex related to age-dependent impairment of cerebral circulation, is based mainly on positive results from good-quality placebo-controlled studies that enrolled approximately 1,200 patients with criteria established by International Classification of Diseases (9th and 10th revisions, ICD-9 and ICD-10) or the 3rd revision of the Diagnostic and Statistical Manual (DSM-III-R) (uncomplicated dementia). Effect on cognitive symptoms was within the range of a 25% reduction. Memory, concentration, and alertness were the first symptoms to be relieved, with tinnitus and dizziness improving somewhat later. A minimum of 4 to 6 weeks were needed before a pronounced effect could be expected. The pharmacologic advantage of ginkgo seems to be a very tolerable side-effect profile, with a side-effect frequency at the placebo level. PMID- 10178639 TI - 'New' blood bank technologies. PMID- 10178640 TI - Modifying blood bank processes for efficiency and effectiveness: a case study. AB - Among the lessons to be learned in the case study is that the use of quality tools provides the opportunity for success. It will take longer than the group intends to implement change effectively. However, it is better to take smaller steps and be successful than to take giant steps and struggle or fail. Failure to communicate is often the reason that change is difficult. When staff are asked to make changes, the rationale for the change is often essential to acceptance. The quality improvement process requires documentation of goals, decision steps, implementation procedures, and monitoring outcomes. Success breeds success. Sharing the information with everyone from hospital support staff in the laboratory and maintenance department to direct patient care givers at the clinic site or the patient bedside makes everyone a part of the success. PMID- 10178641 TI - Model compliance plan. PMID- 10178642 TI - Key elements and processes needed in curriculum design. PMID- 10178643 TI - Tracing our roots: the first clinical laboratory scientist. AB - OBJECTIVE: To trace the roots of clinical laboratory science by discussing the development of the role of the "laboratory technician", and describing selected early training programs for clinical laboratory personnel. DESIGN: A survey of literature on the history of clinical laboratory science was conducted. References consulted include various books and professional journals. CONCLUSION: The first clinical laboratory scientists began working in clinical laboratories shortly before World War I. During the war, and in the years that followed, a critical shortage of trained laboratory personnel developed. To alleviate this shortage, pathologists began to hire young women, training them on the job to perform simple laboratory tests. However, there were no established training standards, and few institutions offered a systematic method for instruction. During this same period, three educational programs were established that did offer high quality training that provided systematic instruction to their students. PMID- 10178644 TI - Measurement of short term health effects in economic evaluations. AB - Short term health effects can significantly impact health-related quality of life (HR-QOL). Appropriate healthcare priorities can be set only if they are based on health status measurements which are consistent with how people value both short and long term health effects. This article discusses methods by which such health effects may be measured using health state utilities. The standard discounted quality-adjusted life-year model, in which the values of the various health states are weighted by the time spent in each state, generally fails to capture the true impact of temporary ill health on HR-QOL. Instead, a scenario approach is recommended in which valuations are based on holistic descriptions of health states which include all short and long term health effects experienced. PMID- 10178645 TI - Pharmacoeconomics in the new millennium. A pharmaceutical industry perspective. AB - The primary purpose of pharmacoeconomic research is to assist in making healthcare decisions. Rapid growth in the supply of pharmacoeconomic data over the past few years suggests that pharmacoeconomics can be of help in delivering good, cost-effective healthcare. Greater challenges in decision-making coupled with improvements in the techniques of pharmacoeconomic research point to a greater role for pharmacoeconomics into the new millennium. This in turn will have consequences for companies in the pharmaceutical industry. More successful access to markets and better commercialisation of products will be the rewards for those companies committing to pharmacoeconomics and to the broader goal of delivering value for money in healthcare. PMID- 10178646 TI - A prospective view on European pharmaceutical research and development. Policy options to reduce fragmentation and increase competitiveness. AB - This article analyses 3 areas of policy that could reduce the fragmentation and improve the competitiveness of the European pharmaceutical sector. It argues that a potential solution to the issue of fragmentation of pharmaceutical research, development and innovation may be the development of policies at the European level, in those areas that European institutions have a competence. These areas may not necessarily rely exclusively on solving the issue of pricing and reimbursing pharmaceuticals as European Union (EU) Member States invoke the subsidiarity principle to claim policy exclusivity in this area. By contrast, policy areas where European institutions have a competence may include: i) a more intensified collaboration in science and technology policy (supporting the science base, identifying education needs for the future, collaborating in the development of new technologies and fostering university-industry collaboration); ii) support of research and development (R&D) by means of directly channelling funds into basic pharmaceutical research, avoiding duplication of the research effort, developing a set of research priorities, tackling the issue of technology transfer, promoting university-industry and cross-border collaborations or providing incentives that would induce private R&D activities in areas with large socioeconomic impact; and iii) an improvement in the environment for the financing of innovation in the EU, by means of selective use of tax policy at the national level (and where applicable, at the EU level), institutional reform in order to widen the pool of available funds for private investment, and the introduction of schemes that would encourage individuals and institutions to hold equity in innovative companies. The article identifies specific research, regulatory, medical and financing needs that require policy intervention, evaluates the possible dynamic implications of such interventions and highlights the benefits that may accrue from their implementation. PMID- 10178648 TI - The effects of acquisition cost and budget-based compensation on the attitudes of pharmacy directors toward the adoption of a cost-effective new drug. AB - To test the effect of differences in acquisition cost and budget-based monetary compensation systems on the intent to support the adoption of a cost-effective new drug, over 350 hospital pharmacy directors were asked to indicate their intentions as to the adoption of a cost-effective new thrombolytic agent, presented at 3 different prices. Although the economic savings for the hypothetical product were constant across all price points tested, respondents exposed to the highest price were more likely to resist the adoption of the new agent than those exposed to lower prices (p < 0.001). Respondents whose compensation was contingent on their control of the drug budget indicated a higher likelihood to resist the adoption of the new agent than did those whose salary was not so determined. These findings indicate that significant hurdles, psychological and organisational, still exist for the acceptance and use of pharmacoeconomic information in the hospital setting. PMID- 10178647 TI - Chlamydia trachomatis in adolescents and adults. Clinical and economic implications. AB - The aim of this article is to provide an overview of the epidemiology, diagnosis, screening and pharmacotherapy of Chlamydia trachomatis infections in adolescents and adults, together with a critical review of economic studies published on this topic. C. trachomatis continues to produce enormous social and economic consequences despite advances in prevention, screening and treatment. Both infected men and women are at risk of developing sequelae, although women tend to have more serious complications. Several strategies are available for diagnosis and screening. In populations with a high prevalence of disease, DNA amplification assays may be the most cost-effective approach for diagnosis and screening. Empirical treatment of all patients is also cost effective; however, it may not be feasible for all health systems. A single dose of azithromycin is the most cost-effective antimicrobial agent for treatment of C. trachomatis infection. PMID- 10178649 TI - Cost-benefit analysis of risperidone and clozapine in the treatment of schizophrenia in Israel. AB - In this study, the benefits and costs of treating schizophrenia with either risperidone or clozapine were examined. The lifetime drug-treatment cost incurred by a patient with schizophrenia in Israel was $US7561 (1996 values) with an initial 6-month trial with risperidone, compared with $US6326 with clozapine and $US3360 with typical antipsychotics. Total lifetime costs of psychiatric health services (excluding medications) by individuals who were continuously receiving typical antipsychotics were $US181,555 per patient. Assuming a 6.3% decrease in hospital use with typical antipsychotics and an absolute 30% decrease with risperidone or clozapine, the use of clozapine or risperidone reduced hospitalisation costs by $US7159 per patient, but increased community-care costs by $US1627 per patient, giving health-service benefit:cost ratios of 1.87:1 and 1.32:1, respectively. After adding indirect benefits resulting from increased work productivity (minus indirect costs related to increases in transport costs because of visits for blood monitoring during clozapine therapy), the benefit:cost ratios increased to 2.04:1 and 1.48:1, respectively. Assuming that clozapine caused a 30% decrease in hospital use by patients with new-onset schizophrenia, risperidone would have to decrease hospital use by 43.2% (i.e. a 13.2% relative advantage) for its societal benefits to justify its increased costs. PMID- 10178650 TI - Pharmacoeconomic analysis of oral antifungal therapies used to treat dermatophyte onychomycosis of the toenails. A US analysis. AB - Until a few years ago, griseofulvin and ketoconazole were the only 2 oral agents available for the treatment of dermatophyte onychomycosis of the toenails. With the availability of the newer antifungal agents, such as itraconazole, terbinafine and fluconazole, the armamentarium of drugs available to treat onychomycosis has expanded. The objective of this study was to determine the relative cost effectiveness of the most commonly used oral antifungal agents in the US for the treatment of dermatophyte onychomycosis of the toenails from the perspective of a third-party payer. The time horizon was 3 years. A 5-step approach was used in this pharmacoeconomic analysis. First, the purpose of the study, the comparator drugs and their dosage regimens were defined. In step II, the medical practice and resource-consumption patterns associated with the treatment of onychomycosis were identified. In step III, a meta-analysis was performed on all studies meeting prespecified criteria, and the mycological cure rates of the comparator drugs were determined. In step IV, the treatment algorithm for the management of onychomycosis was constructed for each drug. The cost-of-regimen analysis for each comparator incorporated the drug acquisition cost, medical-management cost and cost of managing adverse drug reactions. The expected cost per patient, number of symptom-free days (SFDs), cost per SFD and the relative cost effectiveness for the comparator drugs were calculated. In step V, a sensitivity analysis was performed. The drug comparators for this study were griseofulvin, itraconazole (continuous and pulse), terbinafine and fluconazole. The mycological cure rates [mean +/- standard error (SE)] from the meta-analysis were griseofulvin 24.5 +/- 6.7%, itraconazole (continuous) 66.4 +/- 6.1%, itraconazole (pulse) 76 +/- 9.3%, terbinafine 74 +/- 7% and fluconazole 59%. The cost per mycological cure was griseofulvin $US8089, itraconazole (continuous) $US1877, itraconazole (pulse) $US991, terbinafine $US1125 and fluconazole $US1506. The corresponding cost per SFD was griseofulvin $US7.05, itraconazole (continuous) $US2.18, itraconazole (pulse) $US1.26, terbinafine $US1.28 and fluconazole $US2.12. The resulting ratios of cost per SFD relative to itraconazole (pulse) [1.00] were terbinafine 1.02, itraconazole (continuous) 1:73, fluconazole 1.69 and griseofulvin 5.62. In conclusion, in this analysis, itraconazole (pulse) and terbinafine were the most cost-effective therapies for dermatophyte onychomycosis of the toenails, both being substantially more cost effective than griseofulvin. PMID- 10178651 TI - Cost of an outbreak of hepatitis A in Puglia, Italy. AB - In total, 5889 cases of hepatitis A virus infection were reported during an outbreak in Puglia, a region of Southern Italy, in 1996. The primary cause of the outbreak was consumption of contaminated food (raw shellfish, vegetables, etc.), with a contributory risk factor of person-to-person transmission. A detailed questionnaire was completed by 250 randomly selected patients to obtain information sufficient to calculate the direct and indirect costs of the outbreak for the individual patient, the National Health Service (NHS) and society as a whole. A conversion rate of $US1 = 1530 Italian lire (L) has been used throughout the study since this was the average exchange rate in 1996. For the individual patient with hepatitis A virus infection, the mean cost was L1.013 million ($US662), which was equivalent to 6.6% of the mean annual income of the employed patients. The total cost of the outbreak to the NHS was L23.98 billion ($US15.67 million), which was equivalent to 0.4% of the total public health expenditure in the region in 1996. The total cost of the outbreak to society (individual patient, NHS and third parties combined) was L37.406 billion ($US24.45 million), corresponding to 0.04% of the gross domestic product of the entire region in 1996, with a mean cost per patient of L6.35 million ($US4150) from a societal perspective. The majority of patients (86.3%) were 11 to 30 years of age, reflecting the increasing susceptibility of younger patients to hepatitis A virus infection in recent decades. These economic and demographic data provide important information for the evaluation of preventive strategies including public education, sanitation and immunisation, so as to optimise the use of local health resources. PMID- 10178652 TI - The pros and cons of a single 'Euro-price' for drugs. AB - Parallel trade in pharmaceuticals has become a major European Union policy issue with several 'solutions' being considered by the European Commission, Member State governments and the pharmaceutical industry in the 'Bangemann Process'. This paper discusses the issues from an economic and public policy perspective- considering the economic cases for differential pricing and for 'Euro-prices', concluding that the economic case for parallel trade--to achieve convergence of prices--is not applicable to pharmaceuticals. It argues that health economic evaluation is not an appropriate tool to set 'Euro-prices' because of differences in clinical practice and in resource use and cost across countries. Pricing rules should reflect local willingness to pay for innovation. It concludes, however, that in the absence of policy changes there is a strong likelihood of companies refusing to supply new innovative products at low prices to traditionally 'low price' countries in order to avoid parallel trade undermining prices obtained elsewhere in Europe, with significant implications for the welfare of patients in those countries. PMID- 10178653 TI - The role of cost-consequence analysis in healthcare decision-making. AB - A greater understanding of value associated with new pharmaceutical products should lead to better decision-making. Most commonly cost-effectiveness ratios (CERs) are used to indicate value; however, researchers have recently shown that CER estimates are rarely used by decision-makers in making formulary decisions. In this article, a cost-consequence approach to estimating the value for money of a new treatment for a specific disease is described. Using a cost-consequence approach, the impact of the new treatment on lifetime resource use and costs (including specific healthcare service use and costs, and productivity losses) and health outcomes (including disease symptoms, life expectancy and quality of life) for an individual or group of individuals is estimated and presented in a tabular format. The cost-consequence format is more likely to be approachable, readily understandable and applied by healthcare decision-makers than a simple CER. The decision-maker may use selected items from the cost-consequence analysis to compute composite measures of drug value, such as cost per life-year gained or cost per quality-adjusted life-year (QALY) gained. In general, the cost consequence approach, by making the impact of the new treatment as comprehensive and transparent as possible, will enable decision-makers to select the components most relevant to their perspective and will also give them confidence that the data are credible to use as the basis for resource allocation decisions. PMID- 10178654 TI - Applications of modelling studies. AB - There is increasing use of economic evaluation to support decision-makers in health services for allocation of scarce healthcare resources. However, information necessary for economic evaluations cannot always be derived from well conducted prospective clinical studies, and decision-analytical models can be used to provide some of the missing information. A number of applications of decision-analytical models are discussed, including submissions to authorities for reimbursement purposes, pharmacoeconomic programme development, portfolio investment decisions, marketing and communication strategies, and applications in disease management. PMID- 10178655 TI - The economics of parallel trade. AB - The potential for parallel trade in the European Union (EU) has grown with the accession of low price countries and the harmonisation of registration requirements. Parallel trade implies a conflict between the principle of autonomy of member states to set their own pharmaceutical prices, the principle of free trade and the industrial policy goal of promoting innovative research and development (R&D). Parallel trade in pharmaceuticals does not yield the normal efficiency gains from trade because countries achieve low pharmaceutical prices by aggressive regulation, not through superior efficiency. In fact, parallel trade reduces economic welfare by undermining price differentials between markets. Pharmaceutical R&D is a global joint cost of serving all consumers worldwide; it accounts for roughly 30% of total costs. Optimal (welfare maximising) pricing to cover joint costs (Ramsey pricing) requires setting different prices in different markets, based on inverse demand elasticities. By contrast, parallel trade and regulation based on international price comparisons tend to force price convergence across markets. In response, manufacturers attempt to set a uniform 'euro' price. The primary losers from 'euro' pricing will be consumers in low income countries who will face higher prices or loss of access to new drugs. In the long run, even higher income countries are likely to be worse off with uniform prices, because fewer drugs will be developed. One policy option to preserve price differentials is to exempt on-patent products from parallel trade. An alternative is confidential contracting between individual manufacturers and governments to provide country-specific ex post discounts from the single 'euro' wholesale price, similar to rebates used by managed care in the US. This would preserve differentials in transactions prices even if parallel trade forces convergence of wholesale prices. PMID- 10178656 TI - The selection of data sources for use in modelling studies. AB - Economic analysis has become increasingly important in healthcare in general, and particularly with respect to pharmaceuticals. Therefore, it is vital that the methods used in such evaluations are carefully scrutinised and refined. However, guidelines contain only a limited number of recommendations for the use of secondary data in modelling studies. In this manuscript, the selection of data sources in modelling studies will be addressed. The objectives of this manuscript are as follows: (i) to present a general strategy on how to determine the appropriateness of a data source for a model; and (ii) to present recommendations on a transparent reporting format for the selection of data sources. PMID- 10178657 TI - A short term cost-effectiveness model for oral antidiabetic medicines in Europe. AB - A short term (6-month) cost-effectiveness model has been developed to simulate current medical practice and disease progression in patients with type 2 (non insulin-dependent) diabetes mellitus uncontrolled by diet and exercise. The model is based on decision-analytical techniques and includes probabilities of switching between treatments, the reason for the switch and the most common switch options. Effectiveness and economic measures are the 2 main outcomes. In order to assess effectiveness, we use symptom-free days with acceptable control (SFDACs), which represent each day of treatment without adverse events or symptoms, and with acceptable control of glucose and lipids. For the economic evaluation, only incremental costs incurred directly by a health insurance system are considered. This model should prove useful in the evaluation of new oral antidiabetic agents, since the short term aim of antidiabetic therapy is to provide adequate control in the absence of adverse effects and symptoms (a prerequisite for successful long term treatment). Furthermore, short term analysis provides data for comparing initial investment in drug therapy with potential savings over a longer treatment period. PMID- 10178658 TI - Average annual drug cost and its determinants in a population based cohort of HIV positive adult men and women. AB - The purpose of this study is to determine drug costs and the sociodemographic and clinical determinants of drug costs in a large open cohort of HIV-positive adult men and women in British Columbia, Canada from 1993 to 1995. The study is descriptive and population-based using time-series data. Individuals included in the study were men and women enrolled in a province-wide HIV/AIDS drug treatment programme who had given consent to access their entire prescription records held by the provincial drug plan. The primary outcome measure was the average annual drug cost for treating HIV/AIDS among programme participants; results were stratified by sociodemographic status, drug category and disease severity. The analysis was restricted to 1271 consenting programme participants. The average annual drug cost per participant in 1996 Canadian dollars ($Can) was $Can3431 in 1993, $Can3892 in 1994 and $Can4377 in 1995. Between 1993 and 1995, the average annual cost of antiretroviral therapies increased by 6.6% ($Can2579 in 1995), anti-infectives increased by 61.4% ($Can2402 in 1995) and other drugs used in the management of patients with HIV disease increased by 35.7% ($Can1146 in 1995). The overall increase over this period was 27.6%. In 1995, the average annual drug cost was $Can4720 for those on social assistance, $Can4545 for seniors and $Can5937 for the general population (nonpoor and nonelderly). In 1995, the average annual drug cost was $Can6887 for those with AIDS and $Can3911 for those without. Multivariate modelling indicated that drug costs were significantly related with CD4+ cell count (p < 0.001), diagnoses of AIDS (p < 0.001), provincial drug plan type (p = 0.002), time participants had spent in the HIV/AIDS Drug Treatment Program (p = 0.003), number of hospitalisations (p = 0.003) and patient's age (p = 0.004). Our data demonstrate that the average annual drug costs for persons with HIV/AIDS in British Columbia have been increasing even though the cost of antiretrovirals has been relatively stable. This was due mainly to the increase in the cost of anti-infectives and other drugs. Important cost drivers were participant's age, socioeconomic status (by provincial drug insurance coverage level) and rate of disease progression as measured by CD4+ cell counts, hospitalisation events and duration of illness. PMID- 10178659 TI - Cost-effectiveness analysis of early lisinopril use in patients with acute myocardial infarction. Results from GISSI-3 trial. AB - The cost effectiveness of early treatment with lisinopril in acute myocardial infarction (MI) was estimated using survival and cost data gathered prospectively during the hospitalisation of the overall population of patients enrolled in the third study of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto (GISSI-3), which assessed the efficacy of early (within 24 hours) treatment with an angiotensin-converting enzyme (ACE) inhibitor (lisinopril) for 6 weeks in a group of 19,394 relatively unselected patients with acute MI. A statistically significant reduction in 6-week mortality was achieved among patients treated with lisinopril when compared with patients allocated to the control group (absolute reduction in mortality: 7.5 +/- 3.6 lives saved per 1000 treated patients). The comparative cost-effectiveness ratio for the use of lisinopril, expressed as cost per additional survivor among patients randomised to receive lisinopril, was $US2080 per life saved (1993 values). The sensitivity analysis conducted to examine the effects of varying the estimated absolute reduction in mortality throughout its 95% confidence interval, which ranged from 14.6 to 0.4 lives saved per 1000 treated patients, showed that the cost-effectiveness ratios consequently vary from $US1121 to $US40,910 per life saved. The cost effectiveness of early treatment with lisinopril of a relatively unselected population of patients with acute MI compares very favourably with that of other therapies judged to be worthwhile by the medical community. PMID- 10178660 TI - Economic evaluation of insulin lispro versus neutral (regular) insulin therapy using a willingness-to-pay approach. AB - This willingness-to-pay (WTP) analysis is the first study of its kind undertaken in Australia to support an application for listing of a new drug on the Australian national formulary. The technique offers the advantage of being able to summarise diverse outcomes of therapy in a single unit of measure. Willingness to pay is used to value benefits in cost-benefit analysis (CBA), and CBA represents an absolute decision rule. An open-ended question with a bid-up approach was used to minimise bias and elicit the maximum amount patients would be willing to pay for insulin lispro. The WTP study incorporated scenarios describing the outcomes from insulin lispro and neutral (regular) insulin, the results from a formal metaanalysis and a description of the injection characteristics of the therapies. A sample of 83 patients with type I or II diabetes mellitus were surveyed using an open questionnaire to determine their maximum willingness to pay for the therapy they preferred. Overall, 92% of patients preferred insulin lispro (referred to as insulin A) and 8% preferred neutral insulin (referred to as insulin B). The incremental benefit per patient was calculated as 452.16 Australian dollars ($A) per year. Insulin lispro was listed on the Australian national formulary at a 36% premium over neutral insulin, so the additional cost per patient would be $A70.32 per year. Therefore, costs were exceeded by the benefits and insulin lispro was deemed to offer a net benefit. A multivariate analysis indicated that those patients who were middle aged had the strongest preference for insulin lispro. PMID- 10178662 TI - The role of government and private insurers in guiding and implementing pharmacoeconomic analyses. PMID- 10178661 TI - Meropenem. A pharmacoeconomic review of its use in serious infections. AB - Meropenem is a carbapenem antibiotic which is active against the majority of aerobic and anaerobic bacteria implicated in serious infections. Its therapeutic efficacy in a wide range of serious infections is similar to that of imipenem/cilastatin and standard combination drug regimens. Hence, meropenem is suitable for use as monotherapy. Although the acquisition cost of meropenem is likely to be higher than that of aminoglycoside- and metronidazole-containing combination regimens, the latter incur additional drug administration costs and potentially higher costs for treatment of adverse effects. In addition, aminoglycoside-containing regimens also incur assay and toxicity monitoring costs. Economic analyses are required to compare overall treatment costs with combination therapy and meropenem. Cost analyses indicate that the ability to give meropenem, but not imipenem/cilastatin, by rapid intravenous bolus injection results in lower drug administration costs than with the standard infusion method. More comprehensive pharmacoeconomic data on meropenem are required. However, assuming that meropenem and imipenem/cilastatin have similar acquisition costs, the option of administering meropenem by bolus injection and its lower epileptogenic potential at high dosages (thus permitting its use in meningitis) should be considered potentially important attributes when choosing a carbapenem antibiotic for inclusion in a hospital formulary. PMID- 10178663 TI - The (near) equivalence of cost-effectiveness and cost-benefit analyses. Fact or fallacy? AB - There has been much recent debate in the health economics literature as to the (near) equivalence of cost-benefit analysis (CBA) and cost-effectiveness analysis (CEA). The aim of this paper is to demonstrate that whether such a (near) equivalence exists depends on whether one defines economic evaluations as 'CBA' or 'CEA' on the basis of either what is measured or what question the analyst is seeking to answer. The former basis of definition is popular within the 'decision science' approach to economic evaluation, but does not seem to have any theoretical support. If the latter, more theoretically correct, basis is accepted, there is no longer a case for the (near) equivalence of CBA and CEA. PMID- 10178664 TI - An introduction to Markov modelling for economic evaluation. AB - Markov models are often employed to represent stochastic processes, that is, random processes that evolve over time. In a healthcare context, Markov models are particularly suited to modelling chronic disease. In this article, we describe the use of Markov models for economic evaluation of healthcare interventions. The intuitive way in which Markov models can handle both costs and outcomes make them a powerful tool for economic evaluation modelling. The time component of Markov models can offer advantages of standard decision tree models, particularly with respect to discounting. This paper gives a comprehensive description of Markov modelling for economic evaluation, including a discussion of the assumptions on which the type of model is based, most notably the memoryless quality of Markov models often termed the 'Markovian assumption'. A hypothetical example of a drug intervention to slow the progression of a chronic disease is employed to demonstrate the modelling technique and the possible methods of analysing Markov models are explored. Analysts should be aware of the limitations of Markov models, particularly the Markovian assumption, although the adept modeller will often find ways around this problem. PMID- 10178665 TI - The use of QALY and non-QALY measures of health-related quality of life. Assessing the state of the art. AB - There are now a large number of instruments available for assessing health related quality of life, many of which are used within economic evaluations. When considering the use of quality-of-life instruments, meaningful questions need to be asked to determine whether an instrument has been used judiciously. Such questions should consider whether the instrument is valid and suitable for the particular study question, whether the instrument is compatible with the economic evaluation framework used, and subsequently whether the conclusions presented in the study are legitimate. In order to illustrate the value of these questions we have applied them to a number of economic evaluations. The studies used were identified via a systematic review of the health economics literature. In our assessment of a sample of published material, we found that reporting is frequently unhelpful and that the inappropriate use of instruments and techniques casts doubt on the conclusions of economic evaluations. Furthermore, our systematic review of the health economics literature has shown that the general format of reported economic evaluations falls short of the commonly accepted ideal. We examined the health economics literature for 1995 and only identified a handful of studies which satisfied the economic evaluation criteria as accepted by most economists. It is hoped that raising awareness of these issues will urge evaluators, referees and publishers not to lose sight of the needs of the decision-maker when considering the detail which should be present in a reported evaluation. PMID- 10178666 TI - Valuation of EuroQOL (EQ-5D) health states in an adult US sample. AB - While the EuroQOL instrument (EQ-5D) is being considered and used in clinical trials in the United States and Canada, and in large international multicentre studies, population weights for the instrument have never been established in North America. The primary purpose of this investigation was to derive a set of US-based population weights for the standard set of health states described in the EQ-5D health questionnaire. Valuations for EQ-5D health states were obtained via a postal survey using the visual analogue scale (VAS) format. A sample of 3,500 adults from the continental US were surveyed. A response rate of 25.8% was obtained. Mean and median valuations for 45 distinct health states, including dead and unconscious, were calculated. An ordinary least squares (OLS) regression based weighting scheme was constructed to impute scores for states not directly valued in the questionnaire formats. Valuations for the standard EQ-5D health states displayed similar characteristics to VAS valuations obtained in previous investigations in European countries. The OLS model fit the observed data relatively well, achieving an adjusted R2 of 0.42. However, the diagnostic testing indicated that the initial model was misspecified. Subsequent alternative models alleviated some, but not all, of the problems of misspecification. The EQ 5D valuations from adult Americans in this sample appeared to behave in much the same fashion as in previous valuation studies. However, the generalisability of results to the entire adult American population may be limited. Violations of assumptions of the OLS regression model indicate the need for further investigation into the modelling technique used in deriving a single index score. PMID- 10178667 TI - Antidepressant selection and use and healthcare expenditures. An empirical approach. AB - The purpose of this study was to evaluate whether 1-year total healthcare expenditures differed between patients who initiated therapy on a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) after controlling for initial antidepressant selection and antidepressant use pattern. A retrospective claims database covering a privately insured population in the US was used. Patients who initiated therapy in the outpatient setting (primary care or psychiatrist) were considered. Two-stage sample selection models were estimated that included controls for initial antidepressant selection and use pattern. The analyses indicated that: (i) self-selection due to initial antidepressant selection was a statistically significant determinant of expenditures for patients who initiated therapy on a TCA but not an SSRI; (ii) after controlling for initial antidepressant selection, antidepressant use pattern was a statistically significant and positive determinant of expenditures for both TCA and SSRI patients; and (iii) after controlling for initial antidepressant selection and use pattern, 1-year total direct healthcare expenditures were significantly lower for patients who initiated therapy on an SSRI than for patients who initiated therapy on a TCA. PMID- 10178668 TI - Evaluation of the potential clinical and economic effects of bodyweight stabilisation with acarbose in patients with type 2 diabetes mellitus. A decision analytical approach. AB - Bodyweight is an acknowledged independent risk factor for coronary heart disease (CHD). The present model analysis was undertaken to investigate the clinical and economic impact of bodyweight gain in patients with type 2 (non-insulin dependent) diabetes mellitus and its effects on the development of CHD. Based on a retrospective re-evaluation of data from the Diabetes Intervention Study (DIS), patients with type 2 diabetes mellitus and stable bodyweight (group A) had a significantly lower rate of combined CHD events (30.3%) than patients showing a bodyweight gain (group B; 38.2%) over 10 years. Prevention of bodyweight gain, therefore, appears to be a meaningful strategy in the management of diabetes mellitus. In addition to this clinical advantage, prevention of CHD will also result in economic savings associated with avoided treatment of coronary events. Based on the clinical outcomes from the DIS, the calculated per-patient net savings for a patient with type 2 diabetes mellitus and stable bodyweight amounted to 1085 deutschmarks (DM) when compared with a patient experiencing a bodyweight increase. In a further step, the above situation was projected to current type 2 diabetes mellitus practice. Oral first-line treatment of type 2 diabetes mellitus is usually initiated with glibenclamide (glyburide), which is known to increase bodyweight (reflecting group B). The novel alpha-glucosidase inhibitor acarbose, in contrast, appears to be as effective as glibenclamide, but has the advantage of being bodyweight-neutral (reflecting group A). From the clinical viewpoint, acarbose can thus be considered an alternative to glibenclamide. From the viewpoint of drug costs, monotherapy with acarbose is 4 times as expensive as glibenclamide in Germany, resulting in per-patient incremental costs of DM3527 for acarbose over 10 years. Balanced against the potential 10-year cost saving of DM1085 resulting from the potential of acarbose to prevent CHD, around one-third of the incremental cost of acarbose may be recouped by this single effect. However, further possible benefits of acarbose, including the avoidance of hypoglycaemia and the deferral of costly insulin therapy, may improve the economic value of this novel antidiabetic agent. Given the indirect approach of this evaluation and its many limitations, the above findings need critical appraisal, and comparative trials are urgently required to substantiate our preliminary results. PMID- 10178669 TI - Pharmacoeconomic analysis of 3 treatment strategies for cytomegalovirus retinitis in patients with AIDS. AB - A decision-analytical simulation model was constructed to perform a pharmacoeconomic analysis of the following 3 treatment strategies for previously untreated cytomegalovirus (CMV) retinitis in patients with AIDS: (i) intravenous foscarnet (IVF) for induction and maintenance therapy; (ii) intravenous ganciclovir (IVG) for induction and maintenance therapy; and (iii) intravenous ganciclovir for induction therapy, followed by oral ganciclovir for maintenance therapy (IVG-ORG). Patients who experienced significant adverse effects during, or who failed, initial therapy were switched once to one of the other 2 treatments. The model was used to estimate the direct medical cost (from the perspective of a public payer), survival, and survival adjusted for disutility because of lost vision, for each strategy in the first year following treatment initiation. The expected first-year costs of treatment initiated with IVF, IVG and IVG-ORG were $US47,918, $US38,817 and $US32,036 (1994 values), respectively, while expected first-year survival was 41 weeks, 35 weeks and 35 weeks, respectively. The incremental cost per incremental year of survival using IVF was $US78,000 versus IVG and $US138,000 versus IVG-ORG before adjustment for lost vision, and $US93,000 versus IVG and $US166,000 versus IVG-ORG after adjustment for lost vision. About 23% of the cost of the IVG treatment strategy was attributable to treatment-related adverse events, compared with 14% of the cost of IVF and 16% of the cost of IVG-ORG. Because of the high failure rate with IVG ORG, initial treatment with IVG-ORG frequently led to switching to another treatment. Only 27% of the costs associated with the IVG-ORG treatment strategy were in fact attributable to the cost of induction and maintenance therapy prior to a switch to alternative treatment. In this analysis, initial treatment with IVG-ORG was the least costly approach for treating CMV retinitis in patients with AIDS. Initial treatment with IVF resulted in slightly longer survival adjusted for vision-related quality of life. New treatments for AIDS may reduce the survival benefit of initial treatment with IVF. PMID- 10178670 TI - Helicobacter pylori and peptic ulcer disease. PMID- 10178671 TI - The changing face of clinical microscopy: meeting new optical and ergonomic challenges. AB - Products should accommodate the needs of people, and not the other way around. The Eclipse E600 and E400, with the CFI60 infinity optical system, can be an essential tool in the clinical laboratory. Their optical performance, comfort features, exceptionally durable and stable design, stability, and ease of use set a new standard in biological microscopy. PMID- 10178672 TI - In-process cell counts during preparation of platelet concentrates from buffy coats. AB - To ensure the quality of platelet concentrates (PCs), we studied in-process recoveries of blood cell counts in pooled PCs derived from four or five buffy coats (BCs) from Biopack Compoflex Systems in Bern (PC-BC/4 or PC-BC/5) and from five BCs from Optipac (Baxter) in Zurich (PC-BC/5). BCs were pooled employing a sterile connecting device and flushing them with 300 mL of platelet additive solution. The pools were centrifuged for 12 min at 500 g at 20 degrees C and filtered with PALL's Auto-Stop BC-leukocyte removal filter. Automated platelet counting was performed on whole blood donation, on single BC, on pooled BC and in the final product. Four out of 10 PC-BC/4 (= 40%) and 29 out of 30 PC-BC/5 (= 97%) had a total platelet count of > 200 x 10(9) platelets. Average percentage recoveries in PC compared to the pre-centrifugation BC pools were similar with the Biopack Compoflex and the Optipac systems, 62% and 57% respectively, whereby the absolute platelet count per one donation was similar, i.e. 49.5 x 10(9), 55 x 10(9) and 53 x 10(9) in PC-BC/4 and PC-BC/5 from Bern and PC-BC/5 from Zurich. There was a significant positive correlation between the inital number of BCs taken for pooling and the final platelet counts in the PCs. In order to recover a minimal platelet content of 200 x 10(9) platelets per pooled unit, it is safer to start out with five rather than with four donations unless recoveries during the production steps can be improved. PMID- 10178673 TI - Manual and automated methods for the determination of leukocyte counts at extreme low levels: comparative evaluation of the Nageotte chamber and the Abbott Cell Dyn 3500 analyser. AB - Leukodepleted or leukocyte-poor blood products (fresh-frozen plasma, packed red cell and platelet concentrates in particular) are widely used in current clinical practice. However, because the monitoring of leukodepletion efficiency is generally carried out (if at all) using the labour-intensive and relatively inaccurate manual Nageotte chamber technique, it is clear that any increased demand for leukodepletion monitoring would be difficult, if not impossible, to meet. As the need to identify an automated alternative to the Nageotte technique is important, this study was undertaken to evaluate such a possibility. White blood cells were enumerated in a representative series of filtered and non filtered human blood components by both microscopic counting in the Nageotte chamber, and with the Abbott CD3500 automated haematology analyser. For the Nageotte estimate, a single analysis was made in accordance with standard procedures, whereas the automated analysis was achieved by making six replicate counts and determining the mean of four replicates after excluding the highest and lowest estimates. To determine linearity limits of the manual and automated procedures, freshly isolated leukocytes were admixed with cell-free plasma pheresis plasma. Reasonable reproducibility (mean CV 10% for cell counts exceeding 100 cells/microL) and good linearity (r > 0.9) were observed for CD3500 determinations in four separate experiments. The manual and automated measurements also correlated well (r > 0.9) with no obvious inter-method bias for cell counts up to 40 cells/microL although there was some suggestion of lower absolute CD3500 counts in the range 40-130 cells/microL. For the comparative studies with filtered and non-filtered blood products, no significant method bias was seen with 70 individual red cell concentrates, but systematically higher CD3500 white blood cell counts were observed in the series of 68 platelet concentrates (probably due to the presence of platelet clumps). This study concludes that automation of white cell counts in blood products with the CD3500 analyser is feasible for quality control in the preparation of fresh-frozen plasma and red cell concentrates but is limited for the analysis of filtered platelet concentrates. PMID- 10178674 TI - Assessment of an instrument for automated reagent and specimen dispensing in blood banking. AB - We have evaluated a semi-automated computer controlled dispensing device in conjunction with microtube technology for the performance of routine blood grouping and antibody screening procedures. A total of 787 specimens have been tested, 78 with unexpected antibodies previously identified by manual microtube methods. All were tested in duplicate in different order; there was complete agreement in blood group (ABO, RhD) determinations and the unexpected antibodies were found in the appropriate microtube location in all duplicate sets of results. We conclude that the device accurately and reproducibly dispenses cells, sera and reagents. The savings of technologists' time over traditional manual tube methods exceed 75%, excluding the time to perform elements common to both methods. The combination of automation and microtube technology offers the opportunity for substantial savings in technologist time with accuracy in reagent and specimen dispensing. PMID- 10178675 TI - Higher prevalence of parvovirus B19 in Belgian as compared to Tunisian blood donors: differential implications for prevention of transfusional transmission. AB - Serious anaemia can be induced by human parvovirus B19 (HPV) infection in immuno compromised patients or subjects with an haemolytic disorder. Routine inactivation procedures are insufficient to neutralize the virus, but screening for HPV is an effective means to avoid transmission by transfusion of blood components. In the present study, we have compared for the first time the IgG and IgM seroprevalence in a North African (Tunisian) and Western European (Belgian) population of blood donors. The prevalence of HPV-specific IgM was less than 2% in both populations, pointing to the absence of an epidemic. The prevalence HPV IgG was significantly (p < 0.01) higher in Belgium (74%) than in Tunisia (65%), without any relationship with age or sex. This finding may suggest a south-north gradient of this infectious disease. Since the presence or absence of HPV specific antibodies does not preclude transfusional transmission, screening for the virus itself should be done to avoid iatrogenic infection in HPV-naive subjects at risk. In view of the different transfusion policies in Belgium and Tunisia, a strategy for each of both countries is proposed. PMID- 10178676 TI - Hemorheology and therapeutic hemapheresis. AB - Rheological parameters (plasma and blood viscosities, erythrocyte aggregation and deformability) are very relevant to a better understanding of the changes inflicted on the properties of blood in various hematological diseases (monoclonal gammopathies in particular). This study reports the measurement of rheological parameters (plasma and blood viscosity, RBC aggregation and deformability) in hematological disorders where abnormal blood properties have been described. All these diseases are treated by means of blood separators (therapeutic haemapheresis:plasma exchange, plasma processing, or erythrocyte exchange). We monitored plasma viscosity in 50 patients with monoclonal gammopathies: before and after each exchange (PE) or plasma processing (PP) sessions. Hyperviscosity was reduced in all cases after plasma exchange. Erythrocyte aggregation in gammopathies was also tested (15 multiple myelomas) treated by PE or PP, EA abnormalities and therapy-induced changes are described. EA is also modified by erythropheresis (seven sickle cell anemias). Measurement of rheological parameters are useful to the diagnosis of rheological abnormalities, as well as to assess the impact of therapeutic hemapheresis techniques like plasma exchange, plasma treatment, erythrocytapheresis. PMID- 10178677 TI - Successful prevention of posttransfusion hepatitis B by the combined use of immunoglobulin, vaccine and interferon. PMID- 10178678 TI - Should hospitals collect blood components?: no. AB - Over the last decade, the costs of blood procurement have increased as a result of regulatory pressure and scientific progress in understanding transfusion transmitted disease. At the same time, hospitals are under tremendous pressure to reduce costs. Hospital blood banks are evaluating different strategies, including in-house or "out-sourced" blood collection, as a means of reducing collections. These decisions, however, should be made on assessments of the total cost of a safe and reliable blood supply: recruitment, collection, donor management, testing, manufacturing/processing, quality control, inventory management, quality assurance, regulatory, overhead and availability. If all of these costs are considered, it is unlikely that cost reduction can be achieved through hospital collections. PMID- 10178679 TI - Should hospitals collect blood components? Yes: hospitals put patients first. AB - Stand-alone blood collection centers throughout the world have suffered in recent years from cost overruns, quality and regulatory problems of major proportion, and a subsequent deterioration of service levels to their communities. Their leaders have been probed by public interest groups, the media and governmental bodies, removed from positions of authority, and sadly, subpoenaed, vilified in public and even jailed. Patients, healthcare providers and hospitals have suffered through this period as well, and continue to search for alternatives to their largely monopoly suppliers. In most cases, the best alternative is the one they control themselves. Should hospitals collect blood components? Yes, since their mission--patient care--takes precedence over that of any non-provider healthcare organization. Patients and the public-at-large gain many things by the continued presence of hospitals in the provision of donor services: provider and patient needs are given first billing, and innovation in blood services is encouraged by the transfusion medicine physicians and allied health professionals who are closest to the patient. Service requirements are recognized and met faster and in simpler ways, and quality concerns are addressed with a minimum of bureaucracy and a maximum of common sense. Finally, when hospitals control their own donor programs, costs are more easily tracked and better controlled. PMID- 10178680 TI - Advantages of outsourcing the transfusion service. AB - Pressures to reduce costs are forcing hospitals to examine alternative delivery systems for transfusion services. An outsourcing arrangement for the transfusion service can be an attractive option, providing benefits not only in terms of economics, but also in terms of quality and medical support. Successful centralized testing models in Pittsburgh and Seattle have demonstrated the feasibility of this approach. When properly implemented, an outsourcing arrangement for transfusion services can improve patient care and reduce costs. PMID- 10178681 TI - The transfusion service is an integral and important component of the hospital and should not be outsourced. AB - Hospitals are under increased pressure to decrease operating costs. Hospital based laboratories, blood banks (transfusion services), increasingly face the potential of being outsourced as hospitals try to survive the current waves of managed care. A number of complicated and unique services are provided by the hospital-based transfusion service and physician. Clinical consultation, complicated immunohematological procedures, apheresis, participation in a complex array of patient-care services, clinical research, ever increasing regulatory issues, and quality assurance activities are only a few of the challenges in today's transfusion medicine environment. This paper will focus on the hospital based transfusion service, and the transfusion medicine physician, and present arguments as to why this service should remain close to the patient's bedside and not be outsourced. PMID- 10178682 TI - Pooled platelet concentrates: maybe not fancy, but fiscally sound and effective. AB - For almost two decades, two types of platelet products have been available: pooled random donor platelets (RDP), manufactured from whole blood donations and single donor platelets (SDP), manufactured on apheresis devices. During this period, two trends have occurred--an overall increase in demand for platelets and a preference for the use of SDP. The reasons for the disproportionate increase in the use of SDP relates in all likelihood to supply logistics, perceptions of quality, lack of price sensitivity on the part of prescribing physicians, and minimizing donor exposures in an era of uncertainty and litigation surrounding the allogeneic blood supply. In the cost-conscious 1990s, it is essential to reappraise the situation and perform a critical analysis of the relative value of these products. Such an analysis leads to an inescapable conclusion that preferential use of RDP is the more logical strategy. PMID- 10178683 TI - Single donor platelets: can we afford to use them? Can we afford not to use them? AB - One of the strategies to reduce the risk of harming a patient by transfusion therapy is to limit the overall risk of transfusion-transmitted disease. Central to this approach is minimizing the number of allogeneic blood products with which a patient is transfused. The usual dose of platelets for an adult patient is either six to 10 random donor platelets vs. one unit of platelets, pheresis (so called single donor apheresis platelets). Consequently, the transfusion services at the University of Southern California Health Sciences Campus (USC University Hospital, the Norris Cancer Hospital, and Los Angeles County + USC Medical Center) routinely use single donor apheresis platelets (SDPs) rather than random donor platelets (RDPs) in an effort to minimize allogeneic platelet transfusions, and thereby reduce risk of transfusion-transmitted infection. Although there are other compelling medical, technical, and medical-legal reasons to use SDPs instead of RDPs, the authors believe that a decrease in allogeneic donor exposures alone is sufficient reason to make SDPs the platelet component of choice at their institutions. PMID- 10178684 TI - Quality pays--in every business! AB - For the past few years, blood banks within and outside of hospitals have been required to develop a documented quality assurance/quality improvement program to comply with regulator guidelines and accreditation standards. Concerns have been raised that the cost of compliance could exceed any plausible return on this investment. Unfortunately, little data exist in blood bank literature or are currently being captured to support or refute this contention. This article describes an approach for capturing the cost of quality based on models from the manufacturing industry, suggests how blood banks could document the cost and benefit of their quality efforts and presents some unpublished data on the impact of tracking the cost of poor quality in one blood bank. PMID- 10178685 TI - The 90s paradox: QA efforts reduce total quality. AB - The focus on "closing the window" of infectious risks in transfusion has concentrated limited health care resources on marginal increases in blood safety in the name of quality assurance (QA). Significant investments in testing and medical history additions have been made to restrict further any release of unsuitable blood and apheresis donations. As funds are used in a disproportionate manner with regard to these quality benefits, the depletion of resources precludes investment in quality enhancements (e.g. potency) other than safety, and actually may reduce quality over all. Although safety is an important element of quality, it is not the only element. Increasingly, blood center customers expect, but are unwilling to pay for, limited increases in product safety, such as anti-HCV 3.0 and HIV p24 antigen testing; they should be encouraging improved potency and efficacy for QA. In the future, blood service providers must demonstrate the value of additional QA activities--otherwise, they will not receive reimbursement. Total quality remains the objective goal. However, the investment in QA efforts must yield a benefit equal to, or greater than, investment in the quality assurance process. PMID- 10178686 TI - When less is more: cost-containment in transfusion medicine. AB - The drive to contain the rising cost of medical care provides numerous challenges to blood bankers. Not the least of these is the opportunity to improve quality of care while reducing the cost thereof. This paper explores various cost-reduction strategies, focusing primarily on those applicable to small and medium-sized transfusion services, and demonstrates methods by which they can be implemented to yield improved patient care. PMID- 10178687 TI - Making Landsteiner's discovery superfluous: safety and economic implications of a universal group O red blood cell supply. AB - The risks of ABO-mediated acute immune hemolytic transfusion reactions continue to bedevil modern transfusion services. Of particular concern, the incidence of transfusion fatalities has not changed over time, in stark comparison to the fall in risks of infectious diseases. This article reviews the approaches employed to combat aspects of ABO transfusion errors. The advantages of a universal group O donor pool are considered, and some innovative approaches for achieving this goal, including enzymatic modification of the red cell membrane, the epitope masking through the use of polyethylene glycol, are described. The impact of a group O blood supply on transfusion practices, and on costs to healthcare system, are considered. PMID- 10178688 TI - Stem cells: what's happening? Current concepts and recent advances. AB - Allogeneic haemopoietic stem cells, as alternative to bone marrow transplantation and platelet therapy remains the focus of the current area of research/development in transfusion science/medicine. This brief progress report on "Stem Cells: What's Happening?" is focused on the advances and some unresolved problems associated with cellular therapy and haemopoietic progenitor cells from various sources. PMID- 10178689 TI - Immunoglobulin and circulating immune complex kinetics during immunoadsorption onto protein A sepharose. AB - Immunoadsorption onto protein A sepharose can be applied to eliminate immunoglobulins, autoantibodies and circulating immune complexes from the circulation. In vivo kinetic studies showed that all IgG subclasses are removed from the patient's plasma although IgG3 elimination is variable and dependent on the presence of other immunoglobulins. IgG elimination half time was 4.8 days during intermittent and 2.9 days for daily therapy in the absence of immunosuppression. Autoantibodies and immune complexes can be cleared effectively but administration of intravenous immunoglobulins should be avoided because of competition for protein A binding sites. Redistribution/ denovo synthesis (half time 2.1-8.8 d for IgG 1-4) occurred in the absence of immunosuppression. PMID- 10178690 TI - Immunoadsorption using the Excorim treatment system. PMID- 10178691 TI - Chronic inflammatory demyelinating polyradiculoneuropathy: superiority of protein A immunoadsorption over plasma exchange treatment. AB - We present a patient with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) who was treated regularly with plasma exchanges (PE) because response to other therapies including i.v. immunoglobulins was not adequate. To reduce nonspecific protein losses due to repeated PE and increase IgG-removal, immunoadsorption (i.a.)-therapy using sepharose-bound protein A was initiated. Retrospective analysis of clinical data including muscle strength and walking distance shows that IA led to more rapid and greater functional improvement than PE in this patient with no relevant side effects. After 3 years of therapy lymphoma was diagnosed and treated. The patient had no relapses of CIDP for 17 months, when his functional status deteriorated again necessitating further IA-therapy. It is concluded that IgG removal by IA in CIDP is more effective and has fewer complications than PE. Due to the chronic course of CIDP requiring repeated interventions IA is also not more expensive than PE. PMID- 10178692 TI - Therapy of coagulation factor VIII autoantibodies with long-term extracorporeal protein A adsorption and immunosuppression. AB - Acquired factor VIII (FVIII) inhibitors in non-haemophiliacs may pose serious treatment problems. MATERIALS AND METHODS: For IgG-adsorptions we utilized an automated plasma separation device and a plasma flow monitor. CASE REPORTS: A 63 year old woman showed life-threatening bleeding because of an inhibitor. After stabilization by porcine FVIII three cycles of a modified Malmoe treatment protocol were applied, followed by long-term cyclophosphamide p.o. and weekly IgG adsorptions. Within twelve months the patient exhibited a complete remission. A 54-year old man presented a comparable history. Because of a good response after the first cycle he was subsequently switched to the long-term therapy. Up to now (> 7 months) FVIII activities and inhibitor titers remained stable (10-20% rsp. < 3 BU/ml). In both cases no FVIII substitution therapy was necessary. CONCLUSIONS: A modified Malmoe protocol combined with long-term cyclophosphamide p.o. and weekly IgG-adsorptions seems to be an efficient, safe and cost-effective regimen for non-haemophiliacs with FVIII inhibitors. PMID- 10178693 TI - Treatment of severe myasthenia gravis with protein A immunoadsorption and cyclophosphamide. AB - Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction caused by antibodies against the nicotinic acetylcholine receptor (AChR-Ab). We report a 16-year-old girl with severe MG who showed a poor response to plasma exchange and tryptophan-linked polyvinylalcohol gel immunoadsorption. Further improvement of muscle strength and decline of AChR-Ab could be achieved after initiation of protein-A immunoadsorption (PA-IA). Maintenance therapy with PA-IA and intravenous pulses of cyclophosphamide resulted in a stabilisation of the disease, with a complete remission during the follow-up period of six months. We suggest that PA-IA may be valuable and safe in the management of patients with severe MG, and maintenance therapy with PA-IA and cyclophosphamide may prevent serious and potentially life-threatening relapses of the disease. PMID- 10178694 TI - Protein A immunoadsorption in alloimmunized patients refractory to platelet transfusions and in patients with treatment-resistant immune thrombocytopoenic purpura. PMID- 10178695 TI - Protein A-immunoadsorption in chemotherapy associated hemolytic-uremic syndrome. AB - Circulating IgG-immune complexes (IgG-IC) play a role in the complex etiology of C-HUS. In an ongoing open clinical study protein A immunoadsorption treatment is carried out for patients who developed severe forms of the syndrome after mitomycin-C chemotherapy. So far, successful treatment of 14 out of 19 evaluable patients was possible. A protein A immunoadsorption system was used, allowing processing of large plasma volumes to eliminate IgG and IgG-IC from the patient's plasma. PMID- 10178696 TI - Protein A immunoadsorption (i.a.) in renal transplantation patients with vascular rejection. AB - Vascular rejection after renal transplantation is connected with a higher frequency of allograft dysfunction or graft loss. Plasmapheresis as an adjunctive therapy in the treatment of humoral mediated acute graft rejection was compared with protein A immunoadsorption. Eleven patients with acute graft rejection and high titers of cytotoxic HLA-Ab and/or signs of vascular rejection at graft biopsy (performed in 9 patients) have been treated. Six of them have a stable graft function, the longest graft survival until now is 41 months, four are back on haemodialysis and one patient died from CMV-pneumonia with a stable graft function 9 months after transplantation. We conclude that IA is a useful adjunctive therapy in the treatment of vascular rejection after renal transplantation. Further investigations are necessary to optimize criteria for inclusion. PMID- 10178697 TI - Immunoadsorption--a new therapeutic possibility for multiple sclerosis? AB - A 46 year old woman suffers from chronic progressive multiple sclerosis. She was diagnosed in 1993. Because of many complications seen in conservative treatment, plasma exchange was started. The expanded disability status scale by Kurtzke could be improved but the interval between the treatments became shorter and shorter. It was therefore decided to commence protein A immunoadsorption treatment. With this treatment the patient shows good and stable improvement in neurological and functional status with an acceptable treatment frequency of once every 3 weeks. PMID- 10178698 TI - Therapeutic immunoadsorption--its role in clinical practice. AB - Extracorporeal immunoadsorption onto staphylococcal protein A replaces conventional plasmapheresis because its elimination efficiency is higher while less adverse reactions are seen. Experience in immunoadsorption is limited to specialized centers although recent technical developments make the procedure simple and safe to use. During a workshop held in Munich, September 1996, the application of immunoadsorption in various diseases was discussed. Goodpasture's syndrome, acquired autoimmune coagulopathy, HLA-sensitized transplantation and treatment-resistant life-threatening autoimmune diseases were accepted indications for immunoadsorption. Immunoadsorption in other immunoglobuline and immune complex mediated diseases is still under discussion. PMID- 10178699 TI - Immunological effects of therapeutic immunoadsorption with respect to biocompatibility. AB - The activation of the complement system leading to generation of anaphylatoxins and the membrane attack complex depends on the chemical nature of the adsorptive system and the anticoagulation used. The method of the primary separation determines the presence of cell debris in the plasma as well as the extent of platelet activation. The particular role of anticoagulation and its properties to prevent/reduce complement activation on immunadsorption material is discussed and the combined use of citrate and heparin is proposed. The quality of the reinfused plasma--as discussed on the example of LDL-apheresis--is therefore influenced by the amount of the activated split products. This determines finally the extent of cellular activation during therapeutic immunadsorption when receptor-dependent activation of cells by C3a(desarg) and C5a(desarg) can occur. PMID- 10178700 TI - Self-managed work teams: what works? AB - Case studies have shown that under the right circumstances, employees within self managed work teams (SMWTs) produce more at work than employees organized in a more hierarchical, traditional structure because they perform not only technical skills, but management skills as well. The purpose of this article is to clarify the specific factors most important to an SMWT's success. The information shared here comes from three sources. The primary source is a research project funded by a 3-year grant (1994-1997) from the National Science Foundation. The primary factors found to affect the success of SMWTs formed five groups. Work process factors include those that are needed when actually performing the work, such as the appropriate resources, talent, procedures, and effort. Interpersonal process factors include communication and both positive and negative conflict. Environmental factors include those within the SMWT'S organization, such as management support and the reward system, as well as factors outside the organization, such as suppliers and the market. Team design factors and team member characteristics were found to be equally important to the high performance of the SMWT. PMID- 10178702 TI - New frontiers for diagnostic testing: taking advantage of forces changing health care. AB - The transformation of the health-care industry holds great economic potential for laboratory diagnostic testing providers who understand the five market forces driving change and who are shaping their own roles in the emerging market. Because of these trends, provider-based laboratories (PBLs) are competing with independent laboratories (ILs) for the latter's traditional client base- outpatients and nonpatients. PBLs will continue to service acute care patients while becoming more IL-like in logistics, sales, customer service, and marketing. Forced to compete on price, ILs have engaged in mega-mergers and will try to break into acute care via joint ventures. The ILs will need to choose their markets carefully, solidly integrate with parent organizations, and find ways to be profit centers. Consumers' demands also are forcing change. Consumers want accurate, legible bills and simplified eligibility determination and registration. They want an emphasis on prevention and wellness, which means that diagnostic testing must address early identification and monitoring of high-risk groups. To realize cost-efficiencies under whole-life capitation, laboratory networks must be part of a completely integrated health-care system. The laboratory of the future will be multicentered, without walls, and with quick access to information through technology. PMID- 10178701 TI - Selection factors in the choice of immunoassay technology: implementing technology in the new era. AB - Centralized Laboratory Services, Inc. is a large, freestanding laboratory that underwent a major equipment reconfiguration for the performance of endocrine/tumor marker/anemia assays (N = 15) in August 1995. Before the transition these assays were done on six instruments, none of which were computer interfaced. All assays were subsequently consolidated on four ACS-180+ instruments (Chiron Diagnostics, Norwood, MA), which were interfaced to our laboratory information system (Cerner Corp, Kansas City, MO). Our experience suggests that significant increases in productivity and reductions in cost are possible through instrument upgrades. Both laboratory-specific and analytical system-specific factors were found to be important in the optimal selection of immunoassay technology. As laboratorians necessarily adjust to changing economic and organizational circumstances and are compelled to "do more with less," technology assessment will become an increasingly important function for senior laboratory management. PMID- 10178703 TI - Integrating key performance indicator measurements into the accreditation process using ORYX. AB - The Joint Commission on Accreditation of Healthcare Organizations introduced the ORYX initiative in February 1997 to integrate outcomes and performance measurement into the Joint Commission on Accreditation of Healthcare Organizations survey process. A survey was mailed to laboratories accredited by the Joint Commission to assess performance measurement system participation, the results of which will be available in the first quarter of 1998. This article discusses the requirements of the initiative as well as some of the problems that have been encountered. PMID- 10178704 TI - Caught-in-the-middle management. AB - Health care is changing rapidly and dramatically. Most everyone working in health care today is feeling caught in the middle--caught between competing trends and forces. This article offers 10 techniques for coping with being caught in the middle. It starts with the premise that all of us are in the middle and will stay in the middle throughout the rest of our productive careers, and it recommends that the first step in practicing caught-in-the-middle management is this recognition. The other nine techniques are to shorten your focus, develop the worst case scenario for your organization, develop the worst case scenario for your career, take care of yourself, build your credibility, build your political skills, build your power, make your organization succeed, and clarify your values. PMID- 10178705 TI - As we see it. Compliance: the buck (literally) stops here. PMID- 10178706 TI - The four myths about quality. PMID- 10178707 TI - New path for health-care leadership: clinical systems management. CLMA Clinical Systems Management Task Force. AB - This article sets forth a concept and an action plan to support the educational needs for the clinical systems manager. This article describes the roles, competencies, and tasks of the clinical systems manager and defines specific intermediate and long-term steps. Clinical systems management is umbrella terminology used to describe an array of related jobs including, but not necessarily limited to, multidepartmental or interdisciplinary management, regional or health system-wide laboratory management, and traditional laboratory management. In general, clinical systems management recognizes the emergence of new jobs, with the primary responsibility of leading the integration of clinical services within health-care systems. PMID- 10178708 TI - As we see it. Coming to terms with managed care contracts. PMID- 10178709 TI - Some personal reflections on downsizing. AB - Downsizing, the deletion of jobs and the involuntary termination of the employees occupying those positions, has become a common and accepted corporate management tool. Although it may save money and improve a company's financial balance, it can bring with it various undesirable outcomes, including loss of loyalty and trust of personnel and degradation of the quality of the organization's product, be it a manufactured item or a service. Downsizing, as it is typically practiced, demonstrates a double standard on the part of management. The deference that employees are expected to show to employers typically is not reciprocated by companies. As a result, workers, even well-educated, professional white-collar personnel, cannot take job security for granted and must be prepared to survive a downsizing action. Front line managers usually are tasked with carrying out a downsizing action decided on at the corporate level. It is to their benefit to practice a management style that will allow them to do so in a professional manner, preserving both their credibility and the employee's dignity to the extent possible. The basic concept of downsizing is not invalid, but the manner in which it is implemented often leaves much to be desired. PMID- 10178710 TI - Should laboratories be judged by patient outcomes? PMID- 10178711 TI - Cost-effectiveness of cardiac troponin I in a systematic chest pain evaluation protocol: use of cardiac troponin I lowers length of stay for low-risk cardiac patients. AB - We evaluated several measures of clinical and fiscal interest to assess the effect of adding an automated cardiac troponin I (c-TnI) assay to our current cardiac panel, which consists of creatine kinase MB (CK-MB), myoglobin, total CK activity, and a calculated CK-MB relative index. Samples were collected on admission and at 3, 6, and 8 hours after admission as part of our diagnostic protocol. Our study was designed to collect data on a control group of patients, implement a change (i.e., c-TnI testing), and then measure the effect of the change on a test population having otherwise equivalent diagnostic and therapeutic pathways. We assessed differences in patient hospital and cardiac care unit length of stay (LOS), time to cardiac catheterization, and hospital and laboratory charges and costs. We found that adding c-TnI to our testing regimen decreased LOS for the large test population. Within this large test population, patients classified as low risk for acute myocardial infarction experienced statistically and clinically significant shorter LOS and lower total and variable hospital costs; for patients with unstable angina, there was an increase (though not statistically significant) in laboratory costs. PMID- 10178712 TI - Development of a quantitative weighted scoring instrument to evaluate bedside blood glucose testing programs. AB - The present assessment of laboratory quality is primarily a qualitative summary process. The objective of our study is to convert a qualitative standards document into a quantitative, weighted scoring system. We selected a laboratory testing standards document, Ancillary (Bedside) Blood Glucose Testing in Acute and Chronic Care Facilities, C30, developed by the National Committee for Clinical Laboratory Standards (NCCLS), as our prototype and used a two-stage, modified delphi technique. Sixty-nine criteria were identified from the C30 document. Using a two-stage, modified delphi technique, members of the NCCLS committee that developed the guideline weighted the relative importance of each criteria. This weighting system then was used to evaluate the quality of bedside glucose testing at the 14 general hospitals located within the city limits of Boston. PMID- 10178713 TI - Outcome-based justification for implementing new point-of-care tests: there is no difference between magnesium replacement based on ionized magnesium and total magnesium as a predictor of development of arrhythmias in the postoperative cardiac surgical patient. AB - OBJECTIVE: To determine whether introducing a new laboratory test, ionized magnesium (iMg++), would affect outcome, where outcome was defined as the rate of arrhythmias in a population of postoperative cardiopulmonary bypass (CPB) patients. DESIGN: A prospective randomized trial. SETTING: Cardiothoracic surgical intensive care unit of a university hospital. PATIENTS: One hundred fifty consecutive post-CPB patients with randomized to two groups, one of which received routine reporting of iMg++ levels on all postoperative electrolyte requests while the other had access to total magnesium (tMg++) levels on demand and no access to iMg++ levels. Groups were compared for rate of arrhythmias, total amount of magnesium repleted, and demographics. MEASUREMENTS AND MAIN RESULTS: Eighty-five patients were randomized to the tMg++ group and 65 to the iMg++ group. The two groups did not differ in the rate of arrhythmias (chi-square test): 13/85 (15%) of the tMg++ patients and 12/65 (18%) of the iMg++ patients developed an arrhythmia. The groups also did not differ in the amount of magnesium sulfate (MgSO4) administered (2 tailed t-test): tMg++ patients received 1.5 +/- 0.15 (SEM) gm of MgSO4, whereas iMg++ patients received 1.3 +/- 0.15 gm. CONCLUSION: The study does not support the hypothesis that magnesium repletion titrated to iMg++ reduces arrhythmia development in post-CPB patients. The lack of a difference in the amount of magnesium replacement between the two groups suggests that tMg++ level is a reasonable indicator of iMg++ level. Routine measurement of iMg++ does not, therefore, appear to have advantages over tMg++ in the postoperative management of CPB patients. PMID- 10178714 TI - The utility and cost-effectiveness of Pap test rescreening. AB - Although most laboratories practice 10% manual rescreening of negative Pap tests, the cost-effectiveness of this and other rescreening strategies rarely has been evaluated. A decision model was created in which rescreening strategies were compared with nonrescreening strategies in terms of the number of false negative and positive diagnoses, cancers, life expectancy, and cost-effectiveness. The 10% rescreening with a repeat Pap test strategy yielded almost no gain in life expectancy in comparison to an equivalent strategy with no rescreening. A 100% rescreening strategy generally was more cost-effective than a no-rescreening strategy at costs of rescreening varying from $2 to $10 per patient. We conclude that if the rescreening cost is low, 100% rescreening strategies are more cost effective than nonrescreening strategies. PMID- 10178715 TI - Use of the Delphi panel method to develop consensus on laboratory performance indicators. AB - This research describes a pilot study to determine whether a specific technique, the delphi panel, is an effective mechanism for consensus development. If the delphi panel proved useful in developing consensus in this pilot study, it would become the basis for a second, expanded phase of research to develop a system of indicators. These indicators would be shared with users of laboratory services in a collaborative effort to build information pathways, increase efficiency, and improve outcomes. PMID- 10178716 TI - Compliance programs take hold in health care. PMID- 10178717 TI - Put 'er there, partner. Hospitals find innovative ways to cooperate for a common goal. PMID- 10178718 TI - You're covered: the Children's Health Insurance Program stands to benefit overall health care of the state of Alabama. PMID- 10178719 TI - Under the government microscope: how fraud and abuse allegations have taken the health care world by storm. AB - Hospitals are talking about it. Home health agencies are talking about it. Physicians are talking about it. The government and politicians are talking about it. And plenty of other people are talking about it, too. The subject is health care fraud and abuse, which often includes billing errors. As you may have heard, the United States Department of Justice has made fighting fraud and abuse within the nation's Medicare and Medicaid programs its No. 2 priority behind violent crime. PMID- 10178721 TI - Tap existing data to profile community health status. PMID- 10178720 TI - Community health improvement: it's time for action. AB - Too many community needs assessments are taking too long, says this community health expert. To get projects under way, she offers the healthcare systems' model for resolving problems in a rapidly changing environment. PMID- 10178722 TI - Preventing medication errors: no quick fixes, just constant vigilance. PMID- 10178723 TI - Identifying and meeting community healthcare needs--from the beginning. AB - Prerequisite to implementing effective community improvement projects are a statement of the group's purpose, decisions on which dimensions of health status to measure--and a way to move from assessment to action. Learn what four components must be in place before starting the improvement effort. PMID- 10178724 TI - The new Stark II regulations: do you still comply? PMID- 10178725 TI - The top 10 CV leader priorities. PMID- 10178726 TI - Setting up a preventive cardiology program in the real world. PMID- 10178727 TI - Oxford's specialty management initiative: paving the way for the future of cardiovascular health care delivery. PMID- 10178728 TI - Developing effective physician partnerships: the Vasoseal experience. PMID- 10178729 TI - The varying impact of two clinical information systems in a cardiovascular intensive care unit. PMID- 10178730 TI - Healthcare megatrends 1998. PMID- 10178731 TI - 1998 information systems priorities. PMID- 10178732 TI - CIO salaries, status increase, as does pressure to perform. AB - CHIME's most recent survey of CIOs indicates that salaries, responsibilities and contact with CEOs have all increased in the past two years. But the price to pay for these gains can be organizational impatience with CIOs who don't deliver results fast. PMID- 10178733 TI - Teach your patients well. AB - With automated education tools clinicians can give patients the information they need to manage their own care when they need it most--after the office visit. Next step: integrated educational-treatment systems that tailor information to discreet aspects of a patient's condition and link them to vast data resources. PMID- 10178734 TI - Glimpses of a Web-enabled future. PMID- 10178735 TI - Obstacles to ubiquity: EDI's slow acceptance. AB - Few dispute the potential benefits of electronic movement of claim, referral, eligibility and outcomes information. But why hasn't acceptance been swifter? And when will EDI finally replace paper and telephones as the tool of choice for doing business? PMID- 10178736 TI - What works. Web-based exam encounter forms save time, improve documentation. PMID- 10178737 TI - What works. Outcomes application improves care, highlights value of allergy group. PMID- 10178738 TI - What works. DBMS technology enhances food service application at Florida mental hospital. PMID- 10178739 TI - Using technology to move beyond customer satisfaction. AB - If you don't deliver service your customers value, someone else will. Access to information is the foundation of customer satisfaction and retention. Here's how one organization determined that the efficiencies of a document-to-data information management system could pay for itself in the first year. PMID- 10178740 TI - Hotlist: financial applications and services. PMID- 10178741 TI - Integrating home health care into your IT strategy. PMID- 10178742 TI - Safety in home care of the frail elderly: dilemmas and trade-offs. Would you take this patient home? PMID- 10178743 TI - New York State home care: a system at risk. PMID- 10178744 TI - Safety in home care of the frail elderly: dilemmas and trade-offs. Would you take this patient home? PMID- 10178746 TI - Assessment and evaluation: keys to the success of adult day services. PMID- 10178745 TI - Safety in home care of the frail elderly: dilemmas and trade-offs. Would you take this patient home? PMID- 10178747 TI - Converting inquiries to enrollments to maintain a viable adult day center. PMID- 10178748 TI - Old soldiers don't fade away. PMID- 10178749 TI - Business's prescription for managed care. PMID- 10178750 TI - The deal maker. AB - As one of capitol hill's premier behind-the-scenes operators, Sen. John Breaux seems the ideal choice to chair the save-medicare commission. But he may need more than backroom savvy if he is to succeed. PMID- 10178751 TI - Strategies for growth, diversification, and patient satisfaction. PMID- 10178752 TI - Ambulatory care strategy: is it a different business? PMID- 10178753 TI - "Top 10" trends in ambulatory care: 1998-2002. PMID- 10178754 TI - 'Selling' the ED: hospital administrators need a good look at what you can do. PMID- 10178755 TI - Get admitted patients upstairs in record time. PMID- 10178756 TI - Use real-time data to track delays to floors. PMID- 10178757 TI - Nursing staff levels under attack? Respond with data, increased efficiency. PMID- 10178758 TI - Counter misleading data: adjust for patient acuity, indirect nursing hours. AB - Productivity standards used to evaluate ED efficiency often overlook needs for added staff brought on by higher patient acuity and added demands on nursing time not related to individual patients. PMID- 10178759 TI - Baltimore ED's protocol standardizes treatment for chest pain patients. PMID- 10178760 TI - Eliminating supply theft can be crucial to the ED's bottom line. PMID- 10178761 TI - Industry groups lobby HCFA over treatment of respiratory therapy under RUGs III. PMID- 10178762 TI - MedPAC to recommend exploration of episodic payments for SNFs. PMID- 10178763 TI - Building successful relationships with MCOs. PMID- 10178764 TI - DeParle defends HCFA's ability to meet critical challenges. PMID- 10178765 TI - Draft memo on consolidated billing raises concerns about further disruptions for SNFs. PMID- 10178766 TI - CDC issues updated guidelines for immunization of healthcare workers. PMID- 10178767 TI - Subacute providers advised to get ready now for impact of transfer rule. PMID- 10178768 TI - How to get the most information system for your money: Part II. Evaluating the systems and choosing a vendor. PMID- 10178769 TI - Reimbursement and ERISA revisions impact the economics of using physician extenders. PMID- 10178770 TI - Review of tax-exempt and not-for-profit transactions in state court. PMID- 10178771 TI - Debarment: mine fields within the health care wars. PMID- 10178772 TI - Age-specific patient satisfaction survey. PMID- 10178773 TI - Reviving Ophelia. Meeting the special needs of adolescent girls. PMID- 10178774 TI - Tips for writing competency statements. Focus on adolescents. PMID- 10178775 TI - Social acceptance. A key issue in the treatment of teens. PMID- 10178776 TI - Food and nutrition services for adolescents. Third in a series on age-specific competencies. PMID- 10178777 TI - Patient confidence in the health care system. PMID- 10178779 TI - Building trust: health care leaders speak out--discussion. PMID- 10178778 TI - Why is confidence in the health care system eroding? One patient's perspective. PMID- 10178780 TI - Improving pain management for orthopedic patients at Hermann Hospital, Houston, TX. PMID- 10178781 TI - Fallon Clinic saves $1.1 million with hospitalist program. PMID- 10178782 TI - No cost-saving target too small for this hospital's product reengineering program. AB - It pays to put every product purchase under the microscope. By creating a multidisciplinary value analysis committee to review staff ideas on potential savings for products, as well as internal services and processes, this New Jersey health care provider is slashing costs and standardizing products across clinical service lines. Learn how the committee operates and what it's doing to get vital employee participation, plus read about specific products targeted for cost reduction. PMID- 10178783 TI - Provider overhauls pathway procedures to improve outcomes analysis, care efficiency. AB - Revamping your clinical pathways to make them even more efficient and effective. Anne Arundel Medical Center's successful total hip/total knee replacement pathway has already slashed length of stay 48%, but officials weren't satisfied. They've redesigned the pathway's documentation process to get consistent data for accurately measuring patient outcomes--and have improved efficiency and patient care and education as well. Find out how the new system works and why there's always room for improvement. PMID- 10178785 TI - Total redesign of medical records the only way to go. PMID- 10178784 TI - Study finds no strength in numbers when hospital alliances attempt to reduce expenses. AB - Data Benchmarks: No cost-cutting strength in numbers. Health care facilities nationwide have been teaming up to reduce costs, boost profitability, and win managed care contracts. But a new study shows joining hospital alliances produces the opposite: it actually increases health care costs for member organizations. Here are the surprising details. PMID- 10178786 TI - Direct radiography can boost radiology productivity, cut costs. AB - Direct radiography causing a stir among health care providers in the know--and here's why. Aside from the high praise radiologists are bestowing on the quality of the newly approved technology, direct radiology is proven to slash the enormous costs of buying, storing, and working with traditional X-ray film. Plus, it makes sense in the era of integration of provider organizations. Here are the details on a recent study conducted at the Cleveland Clinic Foundation. PMID- 10178787 TI - Disease management program improves diabetes outcomes, curbs hospital costs, utilization. AB - Reducing the cost of diabetes care with an ambitious disease management program. Located in an area with an unusually high rate of diabetes, Spohn Memorial Hospital in Corpus Christi, TX, has fought back with an innovative diabetes management program. A recent two-year study reveals a 60% drop in average health costs among diabetes patients who participated in the 12-month program. Learn how this program could work for your organization. PMID- 10178788 TI - How does your organization compare to nation's Top 100 benchmark hospitals? AB - Data Benchmarks: How does your organization stack up to the nation's top 100 hospitals? A new study of the country's top 100 hospitals that achieved great clinical and financial benchmarks reveals they are doing much more than reducing length of stay and shifting care to the outpatient setting. Other factors, including managed care penetration and location, play important roles, too. Here are the details, plus tips from a top performer. PMID- 10178789 TI - Facing community health challenges. PMID- 10178790 TI - Developing an outcomes report card for hospitals: a case study and implementation guidelines. AB - Except for a few state mandates and dominant business coalitions in selected markets, the provider report card initiative is a voluntary response to a perceived public desire for performance data on healthcare providers. This study uses a detailed investigation of a single "typical" case to collect information about one hospital's decision processes and the operational activities required to develop a report card for communicating clinical outcomes and financial indicators to its external stakeholders. Three research questions are addressed: How did the organization identify who its key stakeholders for outcomes information were? How were the stakeholders' outcomes information needs determined? What were the stakeholders' information needs and preferred reporting formats? The research findings are reported as a case study. A general model for developing and implementing a report card for public dissemination is proposed. Crucial steps include: Hospital leaders should define the intent of the report card and identify key performance domains. Stakeholders' needs, desires, and intended use of the information should be explored when determining the format of the report card. External validation of the information presented should be obtained. The report should be made available through several mediums including direct mailing, print media, and the Internet. Usefulness of the information included in the report card should be continually evaluated. The outcomes report card can be useful to organizations and their stakeholders in many ways. They provide information about clinical outcomes, cost-effectiveness, and organizational performance in an era when healthcare organizations are competing for marketshare and consumers are demanding to be informed about their healthcare providers. PMID- 10178791 TI - Looking closely at managed care. PMID- 10178792 TI - Well-being revisited: improving the health of a population. AB - Changes in society and the healthcare system are challenging healthcare executives to do more than provide medical services. Leaders now take broader responsibility for the health and well-being of the people and communities they serve. Health--the "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (World Health Organization 1944)- is determined by four forces: environment, heredity, lifestyle, and medical care services. Health-care managers who want to improve the health of their served populations must improve these forces. Strategic and operational lessons can be learned from the pioneering work done by several hospitals, health plans, and healthcare systems to improve their local environment, heredity, lifestyles, and medical care services. Managers who wish to improve health in their communities should strongly embrace and commit to "health" rather than mere "medical services" in their mission, vision, and values. They should collaborate with many other organizations and people--such as schools, churches, police, and businesses -to build partnerships that extend beyond the healthcare sector into the total community. Healthcare organizations should provide some resources and funds to improve the health of their served populations, and they should view this commitment as an investment (especially if there are capitated lives) rather than as an expense. They should also obtain public and private grant funds and leverage the resources of their collaborative partners to improve their local environment, heredity, lifestyles, and medical care services. Finally, leaders can advocate and support public policy that would improve the four forces that shape health. PMID- 10178793 TI - Advancing community health through community health partnerships. AB - Improving a community's health is a key goal of health services organizations. Effectively pursuing that goal requires health services organizations to create partnerships with other organizations to help identify community health needs and to create and carry out programs that bring together community members and needed health services. Drawing on community systems concepts and a recent study of community health partnership efforts in three cities, this article provides a framework for such partnerships. Types of partnerships described include: Community action partnerships, in which the partnership forms to address a specific problem or pursue a specific opportunity. Community organization partnerships, in which a set of organizations in a similar service sector agree to collaborate for mutually agreed upon goals; and Community development partnerships, in which a partnership attempts to increase participation by people and organizations in collaborative activities that advance the community on multiple fronts or that contribute to community assets and services in multiple areas. The article also describes how the pressures to create large integrated delivery systems can affect creation of partnerships to improve community health. Increasingly, healthcare leaders are being held accountable for the health of communities they serve. When creating partnerships for community health and carrying out health-improvement activities, leaders should be aware of and respond to four key dimensions of accountability: political accountability, commercial accountability, clinical/patient accountability, and community accountability. PMID- 10178795 TI - Howard Dean, M.D., Governor of the State of Vermont. Interview by James A. Johnson. PMID- 10178794 TI - Assessing the effect of increased managed care on hospitals. AB - This study uses a new relative risk methodology developed by the author to assess and compare certain performance indicators to determine a hospital's relative degree of financial vulnerability, based on its location, to the effects of increased managed care market penetration. The study also compares nine financial measures to determine whether hospital in states with a high degree of managed care market penetration experience lower levels of profitability, liquidity, debt service, and overall viability than hospitals in low managed care states. A Managed Care Relative Financial Risk Assessment methodology composed of nine measures of hospital financial and utilization performance is used to develop a high managed care state Composite Index and to determine the Relative Financial Risk and the Overall Risk Ratio for hospitals in a particular state. Additionally, financial performance of hospitals in the five highest managed care states is compared to hospitals in the five lowest states. While data from Colorado and Massachusetts indicates that hospital profitability diminishes as the level of managed care market penetration increases, the overall study results indicate that hospitals in high managed care states demonstrate a better cash position and higher profitability than hospitals in low managed care states. Hospitals in high managed care states are, however, more heavily indebted in relation to equity and have a weaker debt service coverage capacity. Moreover, the overall financial health and viability of hospitals in high managed care states is superior to that of hospitals in low managed care states. PMID- 10178796 TI - The effect of normative social forces on managed care organizations: implications for strategic management. AB - Drawing on institutional theory, this study examines how adherence to a number of "institutional" and "technical" environmental forces can influence the business success of managed care organizations (MCOs). The standards studied include: (1) institutional forces: socially accepted procedures for delivering care (access to quality care, availability of information, and delivery of care in a personal manner); and (2) technical forces: industry standards for cost control and efficient use of financial and medical resources. The most significant finding is that successful MCOs must conform to both institutional and technical forces to be successful. MCOs that conform to either one or the other type of standard were no more successful than those that conformed to neither. These findings have several important implications for MCO strategy. First, to be successful, MCO executives must understand the external environment in which they operate. They must anticipate and respond to shifts in that environment. Second, this understanding of the external environment must place equal emphasis on societal demands (e.g., for accessible care and information) and on technical demands (e.g., for cost-efficient care). These findings may well reflect that once managed care penetration reaches relatively high levels, marketshare can no longer be gained through cost-efficiency alone; rather, enrollee satisfaction based on societal demands becomes a key factor in maintaining and gaining marketshare. Institutional theory provides' some strategies for accomplishing these goals. Cost-containment strategies include implementing policies for cutting costs in areas that do not affect the quality of care, such as using generic drugs and reducing administrative excesses and redundancies. At the same time, MCOs must implement strategies aimed at improving conformity to prevailing societal perceptions of appropriate care, including providing patients more freedom to choose their physicians and encouraging and rewarding care providers for being friendly and personable. An MCO should work to inform the public of the organization's efforts to provide high-quality, low-cost medical care in a friendly, convenient manner. PMID- 10178798 TI - Income-based incentives in UK general practice. AB - Since 1990, income-based economic incentives have ostensibly become more important in the remuneration structure of UK general practitioners. For incentives to fulfil their role, however, GPs must possess discretion over income generating activity and be assumed to be income maximisers. Evidence from one English health authority suggests that a very high proportion of GP income continues to be determined by patient characteristics and the scope for a discretionary response to income incentives is correspondingly small. Where discretion does exist, higher levels of GP incomes do not appear to militate against further discretionary income raising, except in the case where this income and budgetary discipline are in conflict. PMID- 10178797 TI - The policy implications of better structure and process on birth outcomes in Jamaica. AB - BACKGROUND: We investigated if better structural and process elements of prenatal care relate to higher birth weights in the Jamaican population. METHODS: We used data from two surveys: (1) a national sample of randomly selected households; and (2) a concurrent facility survey of the public health clinics in Jamaica. In the household survey, all women aged 14-50, who had a pregnancy lasting 7 months during the previous 5 years (n = 913) were interviewed. From the household survey, we gathered information on the maternal, clinical and socioeconomic risk factors and on the newborns birth weight (the outcome measure). The facility survey collected data from all public primary care clinics in the country (n = 366). This gave us information on the quality of care (structure and process measures) provided in the clinics. FINDINGS: Prenatal care in Jamaica, while generally available, provides care to many women who are at particular risk because of parity, age and poverty. Structural measures of the facilities show that clinics are in general disrepair, have only 70% of the basic equipment and are insufficiently stocked with supplies or medication. Many facilities had poor process of care, as measured by assessing the clinical examination and counseling. The average birth weight was 3232 g and 9.8% weighed < 2500 g. The relationships between birth weight and the quality of care were estimated using multiple regression. The biologic and socioeconomic risk factors related to birth weight in the expected direction. None of the structural quality measures were statistically significant. Among the process measures, women who had access to a more complete examination, had infants that weighed an average of 128 g more at birth. INTERPRETATION: Better quality of care, provided by a more thorough clinical evaluation, has a more powerful effect on birth weight in the population than upgraded facilities or equipment. In developed or developing countries, where resources are limited, policy should focus on education and training to improve birth outcomes. PMID- 10178799 TI - Value measurement in cost-utility analysis: explaining the discrepancy between rating scale and person trade-off elicitations. AB - Previous studies have shown a discrepancy between common utility elicitation methods, such as rating scale (RS) elicitations, and person trade-off (PTO) elicitations. This discrepancy has generally been felt to be due to the fact that RS elicitations ask people to compare conditions to each other in terms of numbers on a visual rating scale, while PTO elicitations ask people to think in terms of numbers of people needing to be treated. However, there are three other cognitive differences between PTO and RS elicitations that might contribute to the discrepancy: In PTO elicitations, as opposed to RS elicitations: (1) people are asked to think about how conditions affect people other than themselves; (2) people are asked to think about the benefit of treating conditions; and (3) people are asked to chose who to treat among patients with different conditions. In this study, we attempt to determine whether any of three cognitive differences contribute to the discrepancy between RS and PTO utility elicitations. We randomized prospective jurors to receive one of several survey versions in which we manipulated the RS and PTO elicitations to reduce the differences between them, while preserving their underlying structure. In the RS-self survey, we asked subjects to rate a health condition on a scale from 0 to 100 as if they had the condition. In the RS-other survey, we asked people to rate the health condition as if someone else had it. In the RS-cure survey, we asked subjects to rate the benefits of curing someone else of the health condition. In the PTO comparison survey, we asked people to determine equivalent numbers of people needing to be cured of two conditions in order to produce equal benefits. In the PTO-choice survey, we presented people with a budget constraint and asked them to determine equivalent numbers of people needing to be cured of two conditions to help decide which group should be treated within the budget constraint. Two hundred and twenty two subjects completed surveys. Median utilities for health conditions were higher in the two PTO elicitations than in the three RS elicitations. There were no differences in utilities across the two PTO surveys, nor across the three RS surveys. In addition, the PTO elicitations allowed people to make finer distinctions among non-life threatening conditions than did the RS elicitations. The discrepancy between RS and PTO elicitations cannot be explained by shifting subjects attentions from themselves to others, nor from conditions to the benefit of treating conditions. Instead, the discrepancy occurs because of the general format of RS and PTO elicitations. PMID- 10178800 TI - Disease-staging for modelling current and future health-care impact of disease: illustrations for diabetes mellitus and AIDS. AB - This paper addresses the economic relevance of appropriately staging progression of disease for cost assessment and projection. Illustrations are drawn from two Dutch cost-of-illness studies for Diabetes Mellitus (DM) and AIDS. Our disease staging specifies a separate late stage to capture terminal high-intensity care for end-stage complications. Data are used from a registration of national hospital resource utilization for DM and from a detailed database on AIDS hospital care and costs. In particular, differences in average length of hospital stay for several potential DM end-stage complications are compared with non-DM patients. Neglecting the separation of a specific late stage is estimated to possibly miscalculate 15-20% of the hospital bed needs for DM and AIDS in the Netherlands. In particular, confidence intervals of future projections for AIDS hospital beds--using respectively staged and non-staged models--do not overlap. AIDS hospital costs are overprojected by almost 11% in the non-staged model. Our estimation of DM hospital bed needs raises the percentage in total Dutch hospital beds from 1.7% (neglecting a specific late stage) to 2.0%. For DM and AIDS an appropriate disease-staging averts structural biases in estimations of bed needs and costs, and therefore benefits the planning of hospital care facilities. Obviously, gathering comparable information and developing similar methodology on other diseases, such as respiratory disease, cardiovascular disease and cancer, is needed and could benefit planning in these fields. PMID- 10178801 TI - Posteroventral pallidotomy for Parkinson's disease: assessment and policy on a technology in transition. AB - Posteroventral pallidotomy (PVP) is a neurosurgical technique used in the management of persons with Parkinson's Disease whose symptoms can no longer be controlled by medical treatment. There is pressure on policy areas to provide support for this intervention. An assessment of the status of the technology concluded that the available evidence of efficacy of PVP was only fair to poor, and that the technology was continuing to evolve. Nevertheless, it was suggested that support for PVP, linked to collection of outcomes data, would be justified, taking account of the morbidity and poor quality of life for this type of patient, and limitations of alternative methods of management. This case study provides an example of the dilemmas facing policy areas in dealing with evolving technology, with limited available evidence and with the prospect of further management options becoming available. PMID- 10178802 TI - The impact of European harmonisation on Norwegian drug policy. AB - Although not a member of the European Union (EU), Norway is part of the European internal market as a result of the European economic area (EEA) agreement. Before 1994, Norway had a distinctive set of arrangements for the licensing and distribution of medicines. Many of these have undergone considerable change as a result of European harmonisation. This paper describes the previous arrangements and the impact of European harmonisation on them. Significant changes have been made to the Norwegian marketing authorisation system because of the loss of the 'need clause' and changes in price control. These are described and an attempt is made to evaluate their impact. The development of parallel importing and the introduction of private wholesaling companies have led to the development of new players in the Norwegian drug market and an increase in competition both within and between levels of the pharmaceutical distribution chain. New co-operatives have also arisen to increase the negotiating power of purchasers, particularly hospitals. Further significant changes are likely to occur in the Norwegian pharmaceutical sector in the future. The Norwegian case study provides an opportunity to look at the impact of European harmonisation on a particular set of regulatory arrangements and sheds light on the difficulty of implementing European policy in a national setting. PMID- 10178803 TI - Down syndrome serum marker screening: decision criteria and implicit values. AB - Maternal serum markers assess the individual risk of giving birth to a fetus with Down syndrome. Because this information is a probability, and because of the infinite number of cut-off risks that can be adopted, a decision criterion is needed to define a population screening program. While a decision criterion for cut-off risks may refer to arbitrations between risks, another criterion must be considered. This criterion focuses on a societal perspective by comparing the costs of the program to the expected benefits. We will first discuss the questions that are raised when assessing, in terms of cost-effectiveness, the consequences of having adopted the policy maker's preferences for prenatal diagnosis referral. Subsequently, we will discuss the implicit values attributed to the outcomes of the program when the societal point of view is reduced to societal profitability. This is accomplished by means of a cost-benefit analysis using the 'avoided costs' approach. The consequences of screening with 'double' and 'triple' tests were assessed using a database made of 10,108 observations, including 63 Down syndrome cases. For a cut-off risk of 1:250 (resulting in a 7% amniocentesis referral rate, regardless of the technique), conclusions in terms of decision making differ according to the effectiveness indicator. Although a criterion based on resource allocation would promote the triple test, cost benefit analysis points out the impact on results of factors such as the amniocentesis related fetal losses or the introduction of equity principles. PMID- 10178804 TI - AmeriNet plans to stay on track, but to blow its horn a bit louder. PMID- 10178805 TI - Needle, syringe prices show net gain. PMID- 10178806 TI - Benchmarks need to distinguish quality from productivity. PMID- 10178807 TI - It's hardly child's play, but buying for kids has rewards. PMID- 10178808 TI - Price outlook shows little variation from last year. PMID- 10178809 TI - Religious support from parish clergy for hospitalized parishioners: availability, evaluation, implications. AB - Reports the results of interviews with a random sample (N = 500) of hospital patients responding to the following questions: What percentage of hospital patients consider themselves part of a church or synagogue? How many patients identify a specific parish clergy or some other source who could provide them pastoral support? How many patients received pastoral support during hospitalization from clergy or some other person, and by visit or phone call (excluding hospital chaplains)? How do hospital patients evaluate the helpfulness of these pastoral visits? Discusses the results of the survey, implications for pastoral caregivers, and suggests future research possibilities. PMID- 10178810 TI - The response of religious congregations to the spiritual needs of people living with HIV/AIDS. AB - Investigates the perceptions and responses of members of five diverse religious congregations to the spiritual needs of people living with AIDS, the impact of AIDS on membership participation, and the beliefs held by different congregations regarding AIDS. Evaluates and compares the AIDS-related perceptions of 204 participants in five congregations (Buddhists, Catholic, Fundamental Christians, Protestants, and Unitarians). Results indicated that congregations differed in how their members responded to the spiritual needs of people living with HIV/AIDS, the level of influence AIDS had on membership participation in formal religions, and whether AIDS was seen as the result of sinful behavior or divine retribution. Concludes that the congregational differences appeared consistent with the core beliefs of the faith communities. Suggests that clergy and congregations need to take specific steps to provide spiritual support to people living with HIV/AIDS consistent with their history of caregiving to all people regardless of the crisis situation. PMID- 10178811 TI - Risks of infection to the bereaved. AB - Reports the results of an informal survey of over seventy emergency room (ER) nurses regarding the risk of infection to the bereaved due to blood and body fluid exposure when they are in contact with the deceased shortly after death. Results indicated that the nurses never considered the possibility of this risk. Notes that although the risk of HIV is less likely due to the fragile nature of the virus, hepatitis B and other infectious diseases can be transmitted. Suggests that hospital chaplains are in a unique position to assist in the protection of the bereaved from this potential hazard. PMID- 10178812 TI - Infusing the O.R. PMID- 10178813 TI - Euthanasia and physician-assisted suicide: a non-consensus reformed reflection. AB - Argues against the growing acceptance of euthanasia in modern society. Offers both medical and theological reasons for affirming the dignity of the person, and claims that the church ought to take a firm stand against the "culture of death." PMID- 10178814 TI - Ethical awareness and healthcare professionals. AB - Reports the results of a survey that sought to measure the "ethical awareness" of healthcare professionals at a number of area hospitals and nursing homes. Notes that the survey was helpful in isolating areas for needed inservices on ethical issues. Indicates that in creating the ethical environment necessary for the making of ethical decisions, pastoral care staff can offer encouragement to administrators in assessing the ethical awareness of the hospital's employees in such a way that not only clinical staff, but support staff and administrators as well, become more aware that many "non-clinical" situations are also the arena for ethical decision-making. PMID- 10178815 TI - Images of God among persons with AIDS. AB - Considers images of God suggested by persons living with AIDS in the context of how they experience clergy and organized religion. Examines how the sense of God's image may be assaulted by AIDS. Discusses sexuality and God's image. PMID- 10178816 TI - The harvest is plenty: a guide for visiting outpatient units. AB - Alerts chaplains to the need to expand their traditional venue to encompass the needs of outpatients. Examines the typical outpatient's day and the dynamics of the waiting room. Suggests approaches for the chaplain to take to provide pastoral care in this setting. Utilizes the biblical themes of sowing, nurturing, and harvesting to describe ministry in the outpatient setting. PMID- 10178817 TI - HCFA issues new salary equivalency guidelines for therapy services. PMID- 10178818 TI - RVU-based fee setting for physician practices. PMID- 10178819 TI - Splitting vial of MR contrast is not good patient care. PMID- 10178820 TI - MR cholangiopancreatography challenges invasive methods. AB - To gain acceptance, MRCP must accurately visualize both normal and abnormal biliary and pancreatic ducts. Imaging of the non-dilated system remains a technical challenge due to the small caliber of normal ducts. Using either nonbreath-hold or breath-hold techniques, however, the normal common bile duct can be visualized in as many as 98% of patients. PMID- 10178821 TI - Syntactic-semantic tagging of medical texts: the Multi-TALE Project. PMID- 10178822 TI - Health Cards '97. PMID- 10178823 TI - Doctors participate in surgery from 10,000 miles away. PMID- 10178824 TI - Cancer hospitals share data over the 'net. PMID- 10178825 TI - "Smart shirt" can save lives on the battlefield. PMID- 10178827 TI - HT medical launches intravenous catheterization simulator. PMID- 10178826 TI - Coagulation rates check at home. PMID- 10178828 TI - Malaysia, Britain, U.S. to study sharing patient-information technology. PMID- 10178829 TI - Radiation-exposure victims in Russia get help via telemedicine. PMID- 10178830 TI - Erlanger Health System introduces real-time cardiac telemedicine. PMID- 10178831 TI - After the shooting stops. PMID- 10178832 TI - Using pharmaceutical cost analyses for decision making. PMID- 10178833 TI - Culture clashes, turf battles, job changes, sometimes even layoffs: welcome to the world of integrated healthcare. PMID- 10178834 TI - Measuring physician performance to improve care and save costs on pharmaceutical usage. PMID- 10178835 TI - Partners progress: CareGroup's main competitor focuses on physician alliances. PMID- 10178836 TI - Debugging antimicrobial regulation. PMID- 10178837 TI - Dream team. EPA and IC pros join forces to clean house. PMID- 10178838 TI - Do lap costs cut too deep? Take another look. PMID- 10178839 TI - Cash in on the learning curve. PMID- 10178840 TI - Want to be an MVP? Sell your skills with flair. PMID- 10178841 TI - Building productive dialogue in environments of conflict. PMID- 10178842 TI - Helping staff cope with change. AB - Resistance to change is as inevitable as change itself. But successful leaders can help their staff come to terms with a new culture by understanding the process of grief that accompanies change and by taking time to see that employees' concerns are addressed. PMID- 10178843 TI - Building a culture that supports change. PMID- 10178844 TI - Perception management: an active strategy for marketing and delivering cardiovascular services. PMID- 10178845 TI - Cardiovascular observation unit: meeting the expanding needs of an integrated cardiovascular center. AB - By developing a flexible unit that can easily manage a diverse cardiac population, the Cardiovascular Center as well as the Medical Center reduced expenses and increased operational efficiency. In addition to the economic and operational benefits, patients and their families have been impacted favorably by the unit's design and operation. As cardiovascular administrators search for ways to reduce expenses and increase operational efficiencies, they should consider the positive effects of a unit similar to our CVOU within their institution. PMID- 10178847 TI - Developing an income distribution methodology for cardiovascular physician groups and networks. AB - Developing an income-distribution model that rewards physicians equitably and fairly for cost-effective patient care services provided, practice building efforts, and complying with practice guidelines and standards is an important step which all practices must take to align the payment-mechanism incentives with the physician income-distribution methodology. Recalibrating the compensation arrangement to the market requires open dialogue, the identification of shared values and convictions, and the development of compensation components that align compensation and payment incentives. Through the aligning of incentives, networks and group practices will be better positioned for changes in the market. As changes occur, compensation arrangements may have to be adjusted to ensure that payment-arrangement incentives are being rewarded and to ensure the network's or group's long-term profitability and viability. PMID- 10178846 TI - Building a successful open heart program. PMID- 10178848 TI - Take a pill and call me tonight. PMID- 10178850 TI - Making HMOs play fair. Are tough new laws the key to better health care? PMID- 10178849 TI - Do you have hepatitis C? PMID- 10178851 TI - IT planning: taking care of business. Interview by Jim Evans. PMID- 10178852 TI - Going for the goals: IT for competitive advantage. PMID- 10178853 TI - Waiting on clinicians to catch up. AB - Outcomes assessment tools like data repositories and benchmarking databases can help cut the cost of care. More tools are on the way. But clinicians who can't catch up may be the biggest barrier to more widespread use. PMID- 10178854 TI - Enterprise integration. Upgrading the infrastructure. AB - As organizations increase the number of applications and users, they increase demands on their networks. There is no one one-size-fits-all infrastructure, no minimum requirements...except maybe speed. PMID- 10178855 TI - What works. Java intranet application links three legacy systems to speed billing, cut FTEs. PMID- 10178856 TI - What works. Dictation system reduces transcription turnaround time by 40 percent. PMID- 10178857 TI - What works. Managed care friendly MSO WAN improves physician access, billing accuracy. PMID- 10178858 TI - Aligning business and IT strategy. PMID- 10178859 TI - HotList: CPR/EMR. PMID- 10178860 TI - CIO pay $111K in 1997 and rising, CHIME survey says. PMID- 10178861 TI - '98 HCFA regulations: let the documentation begin. PMID- 10178862 TI - A project management strategy for collection and reporting of casemix profiles and hospital clinical indicators. AB - A newly developed strategy and computerised system for collection and reporting of hospital clinical indicators and doctor activity. A project was developed to analyse, plan and implement a data management strategy for Australian Council on Healthcare Standards (ACHS) clinical indicators. This project incorporated objectives for review of all available clinical indicators, analysis of appropriate medical and surgical clinical indicators, review and redesign of data collection methods, and feed-back processes suitable for hospital staff and visiting medical specialists. In conjunction with a software vendor, the hospital developed a computerised system for collection and reporting of clinical indicators. In addition to this, the system extracts data from the hospital's main database, to provide doctors with information regarding their own patient cases (doctor profiles), overview of activities of their specialty (specialty profiles) and casemix analysis. PMID- 10178863 TI - Job satisfaction of HIMs working in Victorian hospitals. AB - The growing demand for Health Information Managers (HIMs) in Victorian hospitals has increased the importance of job satisfaction in maximising performance and ensuring high retention levels both within the profession and the state. This report outlines the results of a job satisfaction questionnaire completed by a sample of HIMs working in Victorian hospitals. The questionnaire focuses on task design, autonomy, performance feedback and professional development opportunities. While the study demonstrates a scope for improvement, it also highlights the general satisfaction of the Victorian HIM population. PMID- 10178865 TI - Relocating and upgrading a medical record service. PMID- 10178864 TI - Health information management in Singapore. AB - This paper provides an overview of health information management practices in Singapore, based on personal observation and interviews with health information managers in five Singaporean hospitals. In Singapore borrowing a medical record often requires a formal request and a permanent tracer is maintained for each record. Medical officers generally have more responsibility than in Australia for coding, which is completed within three days of discharge. A Singapore-wide centralised patient database has been developed which is an important source of information about patient drug allergies. Record design and assembly, release of information and centralised registries are also described. PMID- 10178867 TI - Helpful Internet sites for HIMs. PMID- 10178868 TI - Computerised clinical decision support systems--Part II. PMID- 10178866 TI - Clinical mobile computing--connecting clinicians. PMID- 10178869 TI - Revisions to the general safety requirements for biological products--FD. Direct final rule. AB - The Food and Drug Administration (FDA) is amending the biologics regulations by adding "cellular therapy products" to the list of products excepted from the general safety test (GST) and by adding an administrative procedure for obtaining exemptions from the GST requirements for other biological products. FDA is taking this action because the GST may not be relevant or necessary for biological products, including cellular therapy products, currently in various stages of development. This direct final rule is part of FDA's continuing effort to achieve the objectives of the President's "Reinventing Government" initiative, and is intended to reduce the burden of unnecessary regulations on biological products without diminishing the protection of the public health. Elsewhere in this Federal Register, FDA is publishing a companion proposed rule under FDA's usual procedures for notice and comment to provide a procedural framework to finalize the rule in the event the agency receives any significant adverse comment and withdraws this direct final rule. PMID- 10178870 TI - Revisions to the general safety requirements for biological products; companion document to direct final rule--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to amend the biologics regulations by adding cellular therapy products to the list of products exempted from the general safety test (GST) and by adding an administrative procedure for obtaining exemptions from the GST requirements. This proposed rule is a companion document to the direct final rule published elsewhere in this issue of the Federal Register. FDA is taking this action because the GST may not be relevant or necessary for many types of biological products, including cellular therapy products, currently in various stages of development. PMID- 10178871 TI - Fiscal Year (FY) 1998 funding opportunities--SAMHSA. Notice of funding availability. AB - The Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) announces the availability of FY 1998 funds for grants for the following activity. This activity is discussed in more detail under Section 4 of this notice. This notice is not a complete description of the activity; potential applicants must obtain a copy of the Guidance for Applicants (GFA) before preparing an application. PMID- 10178872 TI - Respiratory protection; correction--OSHA. Final rule; correction. AB - OSHA is correcting errors in the regulatory text of the Respiratory Protection final rule that appeared in the Federal Register on January 8, 1998 (63 FR 1152). PMID- 10178873 TI - Medicare program; scope of Medicare benefits and application of the outpatient mental health treatment limitation to clinical psychologist and clinical social worker services--HCFA. Final rule. AB - This rule addresses requirements for Medicare coverage of services furnished by a clinical psychologist or as an incident to the services of a clinical psychologist and for services furnished by a clinical social worker. The requirements are based on section 6113 of the Omnibus Budget Reconciliation Act of 1989, section 4157 of the Omnibus Budget Reconciliation Act of 1990, and section 147(b) of the Social Security Act Amendments of 1994 (SSA '94). This rule also addresses the outpatient mental health treatment limitation as it applies to clinical psychologist and clinical social worker services. This final rule also conforms our regulations to section 104 of the Social Security Act Amendments of 1994. Section 104 provides that a Medicare patient in a Medicare-participating hospital who is receiving qualified psychologist services may be under the care of a clinical psychologist with respect to those services, to the extent permitted under State law. In addition, this final rule requires that clinical psychologists and clinical social workers use appropriate diagnostic coding when submitting Medicare Part B claims. PMID- 10178874 TI - Medical privacy in the information age. PMID- 10178875 TI - Past present and future. A lot can change after 10 years in the fast-paced world of managed care. PMID- 10178876 TI - 9 trends creating a ripple effect. New directions in information technology must advance with changes in managed care. AB - Managed care is no longer a neatly packaged alternative to fee-for-service healthcare. Today's health plans come in a variety of shapes and sizes, from traditional staff model HMOs to point-of-service and out-of-network plans. As managed care continues to evolve, information is at the crux of these developments. New directions in information technology must advance with the changes in managed care. PMID- 10178877 TI - Remedy register. Managed care information systems update. PMID- 10178878 TI - Are smart cards wise? AB - Smart cards could be the best way for health plan members to carry medical and insurance information in their wallets. But despite a growing demand for these cards in other industries, many in healthcare remain skeptical. Several companies are developing cards and at least one pilot project is underway. PMID- 10178879 TI - HCFA's new year 2000 requirements. PMID- 10178880 TI - Capitation strategies for specialty care. PMID- 10178882 TI - Compensation monitor. Discounts to managed care exceed 28% of usual charges. PMID- 10178881 TI - Are we undermanaging hospital care? PMID- 10178883 TI - Stop-loss insurance: are you tempting fate? AB - Capitation is a gamble, but stop-loss insurance can keep physician groups from losing their shirts. Who needs it? That depends on the type of contract and many other factors. PMID- 10178884 TI - A conversation with E. Andrew Balas, M.D. PMID- 10178885 TI - Is 'pharmaceutical care' a problem or panacea? PMID- 10178886 TI - Asthma programs show progress, not just promise. PMID- 10178887 TI - Coverage of managed care shown to be less positive. PMID- 10178888 TI - Back up your data! PMID- 10178889 TI - Ethics and integrity: restoring the credibility of managed care. PMID- 10178890 TI - How you can get the most out of contract negotiations. PMID- 10178891 TI - Managed care outlook. What's behind increases in pharmaceutical spending? PMID- 10178892 TI - Getting into the PSO business: the preliminaries. PMID- 10178893 TI - A tool for evaluating the PSO option. PMID- 10178894 TI - Access to primary care physicians is key to Medicare member retention. PMID- 10178896 TI - Open access outperforms point-of-service Medicare plans. PMID- 10178895 TI - HealthPartners Health Plans: catching up to growth. AB - Leaders at HPHP, the only regional health plan in Arizona connected to local delivery systems, must control costs and manage spiraling growth to achieve the goal of becoming number one in state membership. But its status might change- owners are looking at potential capital partners or purchasers. PMID- 10178897 TI - Is there a PSO in your future? AB - A decision to form a provider-sponsored organization and go after the lucrative Medicare market depends on several variables. Chief among them are risk management and marketing capabilities, strength of the provider network, the potential market and the competition, and availability of appropriate information systems and controls. PMID- 10178898 TI - Team training for interdisciplinary nursing home teams: wherein lies diversity? PMID- 10178899 TI - Ensuring social work competency with take-charge strategies. PMID- 10178900 TI - Approaches to working with battered women in a hospital setting. PMID- 10178901 TI - Research affirms effectiveness of social work role in planning continuing care. PMID- 10178902 TI - Responding to child sexual abuse: a community-based approach. PMID- 10178903 TI - Antitrust and the developing continuum: advice for administrators, managers, and providers. PMID- 10178904 TI - Sample procedure for ensuring patient choice in home care/DME referrals. PMID- 10178905 TI - Medicare Hospital Discharge Planning: report from the DHHS Office of the Inspector General. PMID- 10178906 TI - The MedWise Center--an innovation in primary care geriatrics. PMID- 10178907 TI - A discharge dilemma: when social workers' loyalties are split. PMID- 10178908 TI - Increase the number of patients you treat in a day: examine your habits, learn to delegate. PMID- 10178909 TI - Nurses, physicians work together to move patients. PMID- 10178910 TI - Twelve things on every hospital administrator's ED wish list. PMID- 10178911 TI - ED physicians take action to promote firearm safety, curtail gun violence. PMID- 10178912 TI - Brave new world: case managers and the future of clinical pathways. AB - Since they were invented at Boston's New England Medical Center in 1985, clinical pathways have evolved from bulky academic documents to sophisticated computerized tools capable of integrating clinical and financial data. Even so, many institutions still fail to take full advantage of the opportunities clinical pathways represent. Because of the rapid pace at which new drugs and clinical techniques are developed, pathways must become more flexible and easier to update, experts say. That means introducing some type of automation to the pathway process. Another change in store for case management departments will be the increasing emphasis on using clinical pathways to help bridge the continuum of care, from physicians' offices through acute care to outpatient and even home health. Indeed, some experts predict that within the next decade it may well become illegal not to use pathways to treat certain populations of patients. PMID- 10178913 TI - Supportive care pathway comforts the terminally ill. AB - The supportive care pathway at Brookwood Medical Center in Birmingham, AL, is a different kind of pathway, de-emphasizing length of stay in favor of streamlining the care of terminally ill patients. The path differs from traditional pathway efforts in four respects: lack of tests and interventions, focus on both the patient and the family, utilization of phases of the dying process rather than days or hours, and a focus on the psychosocial, spiritual, and emotional aspects of care for the patient and family. The three phases of the pathway are admission (decision is made for palliative care), transition (symptom management), and terminal (peaceful death). PMID- 10178914 TI - Total knee pathway weds acute care, rehab. AB - The cross-continuum pathway at St. David's Medical Center in Austin, TX, has allowed case managers to reduce length of stay by four days and cut rehab costs by $300 per day by stressing early mobilization of patients and an aggressive regimen of physical therapy (PT). Because patients are expected to undergo as much as six hours of PT per day, only about half of St. David's total knee population is appropriate for the pathway. These consist of healthy older adults with few medical complications who had been somewhat active prior to surgery. Based on the pathway, case managers helped create St. David's Progressive Orthopedic Program, which allows acute care and rehabilitation nurses to work more closely in screening patients and smoothing the transition from the hospital to the outpatient setting. PMID- 10178915 TI - Open heart surgery pathway package facilitates UR. PMID- 10178916 TI - ANCC clarifies specialty criteria for CM credential. AB - The Washington, DC-based American Nurses Credentialing Center has revised its controversial eligibility requirements for the nursing case management credential. The revised requirements allow nurse case managers who lack a core specialty to take the examination if they already hold an active RN license and a baccalaureate degree in nursing, and have functioned as a registered nurse for 4,000 hours, with at least 2,000 of those hours as a nurse case manager within the past two years. An additional requirement is that, besides taking the nursing case management exam, those lacking a core specialty must also take and pass a 50 question test based on the American Nurses Association's Standards of Clinical Practice Nursing. PMID- 10178917 TI - Nursing case management credential at a glance. PMID- 10178918 TI - Assisted living could be a new source of rehab patients. PMID- 10178919 TI - Justifying case managers pays off for hospital. PMID- 10178921 TI - Documentation on track with protocols. AB - To make sure nurses and other disciplines teaching patients were following teaching standards (and to improve documentation), one hospital created teaching protocols for several top diagnoses. As a result, its documentation jumped from 58% to 92%. The hospital took the following steps to ensure the success of the protocols: Existing protocol committees wrote teaching protocols. Clinical educators conducted staff in-services. Guidelines for implementation were created. PMID- 10178920 TI - Continuum of care provides services for senior citizens. AB - To address the needs of its growing senior population, as well as the need to shorten its lengths of stay, West Georgia Health System in LaGrange and its 276 bed hospital have developed an integrated continuum of geriatric services. As part of that continuum, the hospital has opened an adult day care program within its skilled nursing facility to provide care to senior citizens who don't require 24-hour-a-day assistance. When patients are discharged from the hospital's subacute unit, they may sign up for visits from a Senior Companion Services or AmeriCorps volunteer. PMID- 10178922 TI - Make Spanish-language materials available. PMID- 10178923 TI - Error-proof your discharge planning process now. AB - The new sentinel event policy from the Joint Commission on Accreditation of Healthcare Organizations could lead to an explosion in the number of new medical malpractice suits leveled against hospitals and clinicians, experts say. One key target of the sentinel event policy is discharge planning. Because of the possibility of such increased scrutiny, it's more important than ever to streamline your discharge planning process and build in safeguards to keep catastrophic events from occurring. To ensure that discharge planning is coordinated effectively, begin the process on admission, and have a clinically trained case manager follow up to see that things are running smoothly, experts say. Such oversight is important because the more times information is transferred, the greater the possibility that errors will creep into the system. PMID- 10178924 TI - NC hospital successfully integrates care. AB - Case managers at Haywood (NC) Regional Medical Center prepared well in advance for the advent of managed care in their market. As early as 1991, they began the process of bringing risk management, utilization review, discharge planning, and patient education under the umbrella of case management. To support this innovative approach to case management, the medical center brought in case managers with strong clinical backgrounds who also understood the financial aspects of modern health care and the implications of managed care. Although physicians resisted initially, positive outcomes, both clinical and financial, helped to secure the support of key members of the medical staff. PMID- 10178925 TI - Pathways can improve perioperative process. AB - With today's emphasis on horizontal and vertical integration of patient care services, caregivers are turning to clinical pathways to more effectively manage perioperative patients. Often, such pathways are generic (covering, for instance, all orthopedic or all vascular procedures). Such paths are especially helpful for organizations wishing to use the path for documentation purposes. In developing perioperative pathways, identify the specific patient care outcomes to be achieved; review patient records, nursing practice standards, and other materials to identify the common elements of care; and decide upon a process for reporting variances. PMID- 10178926 TI - Blueprints: a critical pathway alternative. PMID- 10178927 TI - Networks feel the heat as employers adopt contract quality incentives. PMID- 10178928 TI - Network to MCO: new rewards bring exposure to new risks. PMID- 10178929 TI - Henry Ford Health System pursues quality through collaborative research. PMID- 10178930 TI - What can be learned from management firms about buying medical practices? PMID- 10178931 TI - HCFA seeks comments on short-stay MDS (minimum data set), testing to begin in April. PMID- 10178932 TI - AHCA, Rep. Stark seek inclusion of SNFs, other entities in HCFA directive on post hospital referrals. PMID- 10178933 TI - Prescreening of referrals and shared risk with suppliers essential to survival under PPS. PMID- 10178934 TI - How to get the most information system for your money: Part III. Savvy contract negotiations. PMID- 10178935 TI - Industry groups hail consolidated billing delay but seek further clarification. PMID- 10178936 TI - HCFA implements new billing requirements for outpatient rehabilitation therapies. PMID- 10178937 TI - Average prices for nursing facility beds declined last year. PMID- 10178938 TI - Stark regulations: Part I of an analysis of key concepts. PMID- 10178939 TI - Subrogation and health plans. PMID- 10178940 TI - Are physician unions on the rise? PMID- 10178941 TI - Fee splitting, patient brokering, and other impediments to physician practice management arrangements. In Re: The Petition for Declaratory Statement of Magan L. Bakarania, MD. PMID- 10178942 TI - Five minutes with Sheldon Golberg. Interview by Elise Nakhnikian. PMID- 10178943 TI - Managed care. Lowering prices to get a rise out of payors. PMID- 10178944 TI - Turning failing properties into singular senior housing. PMID- 10178945 TI - So happy together: making networks work. PMID- 10178946 TI - The CLTC 50-plus. Last year was another record-setter for mergers and acquisitions. PMID- 10178947 TI - Help wanted! New job market challenges mean admins and other long term care executives are looking for career guidance. PMID- 10178948 TI - The missing link. Once a mom-and-pop industry, long term care is becoming the domain of chains. PMID- 10178949 TI - Finding buried treasures on HCFA's Web site. PMID- 10178950 TI - Customer service trumps regulations. PMID- 10178951 TI - Nurse practitioners as primary care providers. PMID- 10178952 TI - Conflicts of interest: disclosure and resolution. PMID- 10178953 TI - University of California Commission on the Future of Medical Education. PMID- 10178954 TI - Beware the PPMC Trojan horse. PMID- 10178955 TI - Implementing a hospitalist program. A hospital administrator speaks out. PMID- 10178956 TI - Show me the money, Part II. A conspiracy of inevitability. PMID- 10178957 TI - Skilled nursing facility subacute care. AB - The following article is a highlight of the American Health Care Association's survey findings published in the 1997 Facts and Trends: The Subacute Care Sourcebook. The Sourcebook is an annual publication reflecting the best information available on the growing industry of treating higher acuity post hospital stay patients in a skilled nursing facility setting. The report is based on a survey completed by administrators and directors of nursing for providers who indicate that they treat subacute patients at their skilled facility. PMID- 10178958 TI - What's happening to the cost and quality of medical malpractice insurance? PMID- 10178959 TI - Choosing the right electronic medical records system. PMID- 10178960 TI - Managed care and clinical research: is collaboration possible? PMID- 10178961 TI - Hospitalists: a nurse's point of view. PMID- 10178962 TI - Why the ERISA pre-emption is bad medicine. PMID- 10178963 TI - Special report: stroke benchmarks. Stroke study shows variation in care. PMID- 10178964 TI - Save 3%-5% a year with integrated outcomes. PMID- 10178965 TI - Benchmarking saves hospital's bottom line. PMID- 10178966 TI - In-depth data produce results worth having. PMID- 10178967 TI - Clinton proposes standard performance measures. PMID- 10178968 TI - Consumer bill of rights will impact quality efforts. PMID- 10178969 TI - Stats & facts. The growth of assisted living facilities. PMID- 10178970 TI - Hypertension. PMID- 10178971 TI - Merging perspectives on drug value. PMID- 10178972 TI - Florida Community Health Purchasing Alliances. AB - Until recently, many small businesses in Florida were unable to provide any type of health coverage to their employees because of high insurance rates. With the development of the Community Health Purchasing Alliance, the rates have decreased, enabling employers to offer health insurance to their workers. Often, employees can choose from a variety of health plans in terms of coverage and price. PMID- 10178973 TI - Report cards: Part II--Providers rating MCOs. AB - Report cards on health plans and on physicians are becoming an increasingly important way of comparing health care quality from the perspective of consumers and the government. In the conclusion of a two-part article, the author suggests another side of the coin: physicians' own rating of health plans to guide their choices in health plan contracting. PMID- 10178974 TI - Health plans and state tort liability. AB - In 1997, Texas enacted legislation expanding state tort liability to health plans. The following article discusses major provisions of the Texas health plan liability law, as well as a recent lawsuit asserting that the statute is preempted by the Employee Retirement Income Security Act and the Federal Employees Health Benefits Act. PMID- 10178975 TI - HMO productivity: back to basics. AB - Significant reductions in health expenditures can best be achieved by a few inexpensive systemic changes in utilization of physicians rather than by multiple small savings from individual guidelines, pathways, etc. Capitation was a systemic change that removed the fee-for-service incentive to increase income by increasing visits. What is needed now is to change the scheduling patterns and demand needs of the population adopted under fee for service. By designing schedules to reduce no-shows, facilitating a reduction in the number of visits per patient per year, and preferentially accommodating acute primary care visits and consultations, HMOs can rapidly reduce demand and achieve substantial savings. PMID- 10178976 TI - Minnesota's solution to the uninsured. PMID- 10178977 TI - Follow this blueprint and save your organization millions. PMID- 10178978 TI - Automation is prescription for revamping pharmacy services at North Carolina hospital. AB - Prescriptions for cost savings, quality improvements: Here's the story of a North Carolina hospital that reengineered its pharmacy service using robots to dispense medications. Besides slashing costs and medication errors, this new system puts pharmacists on patient floors where they serve a more valuable role in patient care. PMID- 10178979 TI - Guideline for UTIs cuts office visits, lab and drug costs. AB - It's not just the big-ticket procedures that reap big savings for providers when it comes to developing clinical guidelines. Group Health Cooperative of Puget Sound is saving about $750,000 each year thanks to a clinical guideline for uncomplicated urinary tract infections in women. Here's the step-by-step details, plus Group Health's algorithm and detailed plans for implementation. PMID- 10178980 TI - Staff downsizing on the decline for organizations trying to cut overall health care costs. AB - Data Benchmarks: Don't look to downsizing as a major cost-cutting strategy this year. This industry study identifies staffing strategies at hospitals nationwide, plus other important human resource issues for 1998. Not surprisingly, controlling organization-wide costs is a top priority. Here are the details. PMID- 10178981 TI - Keep your clinical call center out of legal hot water. PMID- 10178982 TI - Medical call centers face more than malpractice risk. PMID- 10178983 TI - Make CQI an integral part of call center management. AB - Two call center patients calling the same triage line with the same condition on two different days should get the same advice. But that level of consistency is not always reached, and one call center director says a continuous quality improvement effort that looks at variances and their causes is a worthwhile investment. PMID- 10178984 TI - National board seeks to accredit call centers; issues draft standards. PMID- 10178986 TI - Make glaucoma screening a routine part of DM programs. AB - Physicians who treat patients with glaucoma say there is a serious lack of attention to screening, a deficiency that can lead to blindness for many patients with asthma, diabetes, and heart disease. Here's what your DM program can do about it. PMID- 10178985 TI - Physician practice marries DM tools with home care in successful CHF program. AB - Find out how a made-to-order CHF program implemented by a physician practice in California married a comprehensive DM package with a home health agency and received a drastic drop in readmissions as a one-year anniversary present. PMID- 10178987 TI - Disease management increasingly seen as vital competitive factor for MCOs. PMID- 10178988 TI - NCQA's new standards zero in on disease management goals. PMID- 10178989 TI - Specialists' fortunes rise as carve-outs gain favor. PMID- 10178990 TI - Carving a new niche for capitated specialty surgery. PMID- 10178992 TI - Have you considered the full impact of ancillary services on your bottom line? PMID- 10178991 TI - Lay groundwork carefully before capitating emergency services. PMID- 10178993 TI - Pursue third-party liability to augment your cap payments. PMID- 10178994 TI - Auto managed care offers a new direction for capitation. PMID- 10178995 TI - Are provider withholds going the way of the dinosaur? PMID- 10178996 TI - Beware these common traps when negotiating your next capitation agreement. AB - Minimum premiums chargeable on stop-loss insurance, automatic contract renewals, and other contract provisions require careful analysis during negotiations. Make sure you renegotiate these fine print back breakers. PMID- 10178997 TI - Are HMOs ready for new risk-based capital rules? AB - Are HMOs ready for risk-based capital requirements? A startling 22% of those responding to the NAIC's test run of the formula reported insufficient capital to avoid triggering corrective action. PMID- 10178998 TI - Plugging the leak in clinical lab services. PMID- 10178999 TI - Sort through the crowd when selecting your capitation software vendor. AB - Data Insight: With a flood of software vendors now offering capitation management information systems, how can you choose the best fit for your organization? Here's a 10-point checklist to guide you. PMID- 10179000 TI - Rural market? Small enrollment base? Consider using EDI to corral capitation contracts. AB - The use of electronic data interchange (EDI) and newer managed care software applications is enabling rural and other small provider groups to compete effectively for contracts and manage risk efficiently. PMID- 10179001 TI - RVU costing model takes guesswork out of capitation. PMID- 10179002 TI - Model hospital allocations for percent-of-premium contracting. PMID- 10179003 TI - Reading the fine print: tips of negotiating an HMO provider agreement. PMID- 10179004 TI - Factors affecting the success of disease management. PMID- 10179005 TI - Epidemiology as a management tool. PMID- 10179006 TI - Visual method of confirming cervical intracavitary implant adequacy and triage of patients for computer dosimetry. PMID- 10179007 TI - How will we pay for long-term care in the future? PMID- 10179008 TI - Clinical patient information capture: the Columbia/HCA cancer care database experience. AB - Development of a cancer care database and interpretation of its contents will provide extensive information about a set of patients with a particular disease. By defining disease by stage, its associated costs of diagnosis, treatment and long term follow-up, patient outcomes and self-reported satisfaction and quality of life, a foundation for disease management evolves. Utilizing documented experience over the continuum of cancer care provides a stronger foundation for standards of care and critical pathway development as well as enhancing risk sharing capabilities in providing care for a set of cancer patients. Extensive data collection and analysis has been identified as the key to successful disease management. With the Columbia/HCA Cancer Care Database and future strategic initiatives, the development of an oncology disease management approach is aggressively moving forward. PMID- 10179009 TI - Joining forces: a realistic approach for gynecologic oncology services in a midsize community. AB - In summary, the team approach model to problem-solving worked to meet some of the gynecologic oncology needs for women in northern Indiana. The steps of clarifying the issue, identifying potential problems and needs, setting goals and a timetable, establishing an implementation plan and assigning accountability for the steps helped to successfully bring a Gynecologic Oncology Clinic to South Bend. The final step, that oftentimes sets up another chain of events, is re evaluating the clinic from cost, quality and service delivery perspectives. This will be done prior to the end of the year. PMID- 10179010 TI - Marketplace. Managed care plans try to cope as drug ads spur patient demand. PMID- 10179011 TI - Perspectives. Growing reliance on self-reported HEDIS data underscores need for auditing. PMID- 10179012 TI - Managing risks in managed care. PMID- 10179013 TI - Ernst Wynder, M.D., President, American Health Foundation. Interview by James A. Johnson. PMID- 10179014 TI - Core responsibilities of board trustees. PMID- 10179015 TI - Managerial competence at senior levels of integrated delivery systems. AB - The advent of integrated delivery systems (IDSs) in the healthcare industry has changed much about the work involved in running many healthcare organizations. As a result of these changes, senior healthcare managers in IDSs need different skills and knowledge (competencies) than managers of other healthcare systems. The work of managers is changed by the shift to more organizational integration in the healthcare industry because they become responsible for coordinated continuation of services, accountable for the overall health status of the populations they serve, and involved in more complex organizational structures. The article identifies six distinct managerial competencies--conceptual, technical managerial/clinical, interpersonal/collaborative, political, commercial, and governance--and describes how they relate to an IDS senior manager's successful work performance. The implications of these competencies are considered for practicing senior managers in IDSs, as well as those who aspire to such positions, and those who help educate them. PMID- 10179016 TI - Hospital CEOs, CFOs, and nurse executives: opportunities for a new alliance. AB - This article examines the involvement of Utah acute care hospital nurse executives (NEs) in financial management roles. The authors surveyed NEs and their career supporters and hinderers. Findings suggest that NFs: 1. lack financial management skills, support, involvement, and satisfaction; 2. recognize financial management's importance and desire to improve performance; and 3. consider chief executive officers (CEOs) as their major supporters and chief financial officers (CFOs) their major hinderers in financial management. These "supporters" and "hinderers" of NEs showed consensus regarding the primacy of NEs' leadership and patient advocacy roles. These findings contrast with major professional association policy directives and expert opinions that advocate expanded financial management roles for NEs that will enable them to fully realize their executive potential. CEOs are positioned to establish norms that balance the traditional leadership-patient advocacy roles of NEs with newer financial management roles. CEOs can offer NEs and CFOs opportunities to improve NEs' financial management participation and performance. CEOs can provide empowerment and encourage CFOs to offer NEs "power tools" (for example, information, expertise, resources, and support). The three groups, however, must negotiate reasonable expectations for NEs in financial management and adequate preparation for these consequent responsibilities. Together, CEOs, CFOs, and NEs can successfully take hospitals into the future by leading them in ongoing learning and change. PMID- 10179017 TI - Determinants of successful community health system planning. AB - Needs assessment and other community health planning projects are being conducted in many parts of the country. Whether these projects are successful, in that they lead to implementation of recommendations, has not been systematically assessed. This study describes how local public health officials in Iowa view the planning projects that were conducted in their communities. Planning projects occurred in over half of the counties in the state. Most were led by local public health agencies. Hospitals were participants in three-fourths of the projects. Successful implementation was associated with the number of planning techniques used and the breadth of representation on the steering committee. The most common recommendations related to the expansion of prevention/promotion services and community health nursing. Public health nursing had been integrated with local hospitals in one-third of the counties, with no reductions in performance. PMID- 10179018 TI - Rural hospitals: organizational alignments for managed care contracting. AB - In order to facilitate the process of determining how best to respond to the recent growth of rural managed care, this study discusses various organizational alignments for managed care contracting. The organizational alignments are divided into three categories: remain independent, enter into a contractual arrangement, or develop an informal agreement. For each category, the article explains the option, examines advantages and disadvantages, and presents empirical evidence about the observed effects. The purpose is to present a comprehensive menu of possibilities so that rural hospitals, given their own needs and objectives, may evaluate the options. Although situations differ for individual hospitals, certain general conclusions emerge. First, contracting with managed care organizations as an independent entity is likely to be most attractive to rural hospitals that have a strong patient base. Second, rural hospitals will be more likely to enter into contractual arrangements for managed care contracting when financial pressures dominate the potential loss of autonomy and control. Finally, developing an informal agreement with other healthcare providers for purposes of managed care contracting is likely to be desirable as an intermediate step, or way of experimenting with collective action before entering into a contractual arrangement. PMID- 10179020 TI - Kaiser/Harvard National Survey of Americans' views on consumer protection in managed care. Kaiser Family Foundation and Harvard University. AB - As the debate over regulation of the health care market takes shape, a new survey by the Kaiser Family Foundation and Harvard University finds that significant majorities of Americans favor the key measures intended to protect consumers in the President's Consumer Bill of Rights and in legislative proposals before the Congress. PMID- 10179019 TI - Enhancing care delivery through cross-disciplinary collaboration: a case study. AB - This exploratory research investigates the factors contributing to and detracting from collaboration across professional groups that are working within an academic medical center. Examined within the context of three recently created service lines, the study uses both objective performance data and perceptual data obtained from the physicians, nurses, and administrators. A similar set of factors emerged across all three service lines and professional groups. These factors were highly correlated with the perceived success of the collaborative efforts in producing positive outcomes in both quality and efficiency of care, patient satisfaction, and improved work environment. Findings of the study highlight the importance of shared values, trust, and personal engagement--all empirically demonstrated to be linked with the participants' perceptions of successful collaboration. The study, however, failed to find improvement in the objective performance data analyzed. In addition, individual professional groups were found to have differing views of the collaborative environment, raising important issues for the management of collaborative efforts in the hospital setting. PMID- 10179021 TI - The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry: report synopsis. AB - Before the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry disbanded, it issued a report consisting of recommendations for the industry. The National Association for Home Care asked the Commission members and other interested parties to respond to a brief questionnaire concerning the activities and success of their effort. PMID- 10179022 TI - Debating a consumer bill of rights. AB - Does the country need a consumer bill of rights for health care? Various groups are weighing in on both sides of the question. Either way, the answer will depend on such issues as what the government's role would be in enacting such legislation, what it would mean in terms of cost, and how it might affect the quality of health care delivery. PMID- 10179024 TI - Access and choice--the legislative future of health care in America. AB - Thanks to the growing influence of managed care, both health care consumers and state and federal policymakers are raising concerns about today's health care plans. A key concern is whether or not the plans provide adequate access and choice for consumers. PMID- 10179023 TI - Home care and a bill of rights: past experience, potential implications. AB - Patient rights legislation is not entirely new. In 1987 Congress passed laws regarding patient rights. At that point, the home care industry experienced some valuable lessons that Congress, government, consumers, and agencies should all consider with future bill of rights. PMID- 10179026 TI - From the consumer's perspective ... what really matters. Fazzi Associates, Inc. PMID- 10179025 TI - The revolving door of hospital readmissions. AB - The elderly comprise a growing percentage of the population. Home care providers find it increasingly important to monitor rates of hospital readmissions and prevent unnecessary readmissions from occurring. This effort requires a conscious, well-thought-out effort on the part of today's providers. PMID- 10179027 TI - College at home for the home care professional. AB - Most home care professionals are so busy that the idea of working full-time and going to college to obtain or complete a degree seems downright laughable. But through distance education, individuals can go to college without even leaving their homes. Distance education may provide the ideal complement to a home care professional's career. PMID- 10179028 TI - Victories and missed opportunities. PMID- 10179029 TI - Sale of non-profit hospitals creates new benefits and new risks. AB - If a charitable hospital is sold, the proceeds of the sale may be used to establish a charitable foundation which continues to serve the community. It is the job of the Attorney General to review whether the proceeds serve the public's interest. PMID- 10179030 TI - There is nowhere left to hide! AB - While fund-raising and beneficiary organizations may remain legally separate, two recently developed accounting principles will make it almost impossible to maintain a separation between contributed and operating receipts and will blur the distinctions that have been achieved by legal separation. PMID- 10179032 TI - The moment of actual giving. PMID- 10179031 TI - The nominating committee. AB - The nominating committee is vitally important because it identifies, prioritizes, recruits, and orients new members, and retains existing, strong leadership within the organization's guidelines, constitution and by-laws. It is the most important committee because it recruits board leadership, and leadership is the essential ingredient for success. PMID- 10179034 TI - Do we need volunteers in special events? PMID- 10179033 TI - Tele-fund raising: what's it all about? AB - Now in its 12th year, Tele-Response Center Inc. raises funds and awareness through donor acquisition, renewal/cultivation and lapsed donor campaigns, direct mail follow up, special events, advertising sales for non-profit publications, and volunteer recruitment campaigns. PMID- 10179035 TI - "And the winner is...". AB - Premiums and incentives have long been used in fund-raising direct mail. Here's a look at what works and what fails--and how to make what works work better--from two long-term experts in creative direct-mail formats. PMID- 10179036 TI - On love. PMID- 10179037 TI - Powerful fund-raising letters--from A to Z. Part 1. PMID- 10179038 TI - Charities need not fear a drop in the capital gains tax. PMID- 10179039 TI - Funding information systems. AB - Funding is an on-going, not just a one-time start-up, challenge. If we want to add "bells and whistles" to reap a full return on our hefty investments in basic computing and telecommunication structures, we need to think about funding as an integral, on-going part of our information systems. PMID- 10179040 TI - On telemarketing's 20th anniversary--disturbing trends, great possibilities. PMID- 10179041 TI - Medical management: the key to compensation plans. PMID- 10179042 TI - Linking mental health and violence prevention. PMID- 10179043 TI - Hospitals and health plans shift their focus from cost reduction to care management. PMID- 10179044 TI - Using wellness and prevention as a strategic platform for a hospital system. PMID- 10179045 TI - Social entrepreneurship: how to develop new social-purpose business ventures. PMID- 10179046 TI - The retail market presents health care organizations with new revenue opportunities. PMID- 10179047 TI - Physicians need capital to stay competitive. PMID- 10179048 TI - Sentinel events: JCAHO, societies go head to head. PMID- 10179049 TI - Sentinel event policy unfolds; stay tuned. PMID- 10179050 TI - ASHRM to JCAHO: give hospital game rules. PMID- 10179051 TI - Compliance crosswalk: you're not off the hot seat. PMID- 10179052 TI - What do compliance officers do? PMID- 10179053 TI - Keep abreast, and earn CE credits too. PMID- 10179054 TI - Do things right the first time. Understand your high-risk processes. PMID- 10179055 TI - Lessons about strategic information in home healthcare organizations. Too busy focusing on today. PMID- 10179056 TI - Midwifery goes mainstream as hospitals expand options and cut costs. PMID- 10179057 TI - Managing fatigue in operational settings 1: Physiological considerations and counter-measures. PMID- 10179058 TI - Managing fatigue in operational settings 2: An integrated approach. PMID- 10179059 TI - Physician-assisted suicide and the Supreme Court: implications for health services delivery. PMID- 10179060 TI - Patient satisfaction and service quality in the formation of customers' future purchase intentions in competitive health service settings. AB - The following study provides evidence that the relationship between quality perceptions and satisfaction judgements in the formation of future purchase intentions may be very different in health service settings relative to other service settings. The study investigates Taylor and Baker's (1994) assertion that satisfaction judgements moderate the quality-->purchase intention relationship by testing the research model in both for-profit and not-for-profit hospital settings. The results of this study first support the growing view that satisfaction judgements are more closely related to outcome behaviors than quality perceptions in hospital settings. The results further support the assertion that the formation of important consumer outcomes, such as future purchase intentions, appears to be different for health services. Thus, health service managers are cautioned to empirically test models in the literature specific to their own competitive setting. The managerial and research implications of the reported study are presented and discussed. PMID- 10179062 TI - Customer-centered strategic diversification: specialty health care provider moves towards primary care. AB - A logistic regression model is used to analyze an OB/GYN'S move towards primary care. Current clients' use/no use response of the clinic as a primary care provider is the criterion variable. Predictor variables include new primary care services, expanded OB/GYN services, overall system utilization, and current insurance and physician status. Overall, only 37% of the clinic's current clients indicated they would utilize the clinic for primary care. Having a personal physician is a significant predictor of a client's decision to utilize the clinic's new primary care services. Other significant predictor variables are discussed. PMID- 10179061 TI - Consumer satisfaction with OTC drugs: an analysis using the confirmation/disconfirmation model. AB - This study explored the determinants of consumer satisfaction with OTC drugs using the confirmation/disconfirmation model. A revised confirmation/disconfirmation model specifically for OTC drugs was proposed and tested using structural equation modeling with a specific product category: cold medications. The results of this study found that the confirmation/disconfirmation of a consumer's expectation and perceived performance of an OTC drug is important in predicting consumer satisfaction. Theoretical and managerial implications for pharmaceutical marketers are discussed. PMID- 10179063 TI - Winning market positioning strategies for long term care facilities. AB - The decision to develop an aggressive marketing strategy for its long term care facility has become a priority for the management of a one-hundred bed facility in the Rocky Mountain West. Financial success and lasting competitiveness require that the facility in question (Deer Haven) establish itself as the preferred provider of long term care for its target market. By performing a marketing communications audit, Deer Haven evaluated its present market position and created a strategy for solidifying and dramatizing this position. After an overview of present conditions in the industry, we offer a seven step process that provides practical guidance for positioning a long term care facility. We conclude by providing an example application. PMID- 10179064 TI - The purchase decision process and involvement of the elderly regarding nonprescription products. AB - The elderly or senior citizen is a large and growing market segment that purchases a disproportionate amount of health care products, particularly nonprescription products. This study attempts to examine the elderly's level of involvement (high versus low) and their purchase decision process regarding nonprescription or over-the-counter (OTC) products. Frequencies and percentages are calculated to indicate level of involvement as well as purchase decision behavior. Previous research is critiqued and managerial implications are discussed. PMID- 10179065 TI - Medicare: past, present and future. AB - The history of the Medicare program, including changes that have been enacted over the years in an effort to control spiraling costs, is reviewed. Medigap insurance and preventive medical care for the elderly are examined, as is the impact of Medicare coverage for the terminally ill. Trends indicate that the Medicare system as presently structured is not financially viable. The question is: what will replace it? PMID- 10179067 TI - Cleveland. Rainbow Babies' & Children's Hospital--NBBJ. PMID- 10179066 TI - Demarketing products which may pose health risks: an example of the tobacco industry. AB - This paper considers the concept of demarketing as it relates to the tobacco industry and cigarettes but application can be made to other industries which market potentially "unsafe" products. The focus of the paper is on cigarettes and their marketing and demarketing as mature products in the Product Life Cycle. Public policy and consumer education are discussed as methods to aid in the demarketing of mature products which may pose health risks. PMID- 10179068 TI - IT update/patient information. Fountain of knowledge. PMID- 10179069 TI - IT update/clinical engineers. The go-between. PMID- 10179070 TI - IT update/year 2000. The bug begins to bite. PMID- 10179071 TI - NHS buildings. High hopes. PMID- 10179072 TI - Open to question. AB - Have trust boards really welcomed the public to their meetings in the new spirit of openness required by Frank Dobson? Former trust non-executive Barbara Broadbent carried out an informal survey in her area. PMID- 10179073 TI - Governing integrated health delivery systems: meeting accountability requirements. AB - Many Canadian provincial governments are exploring methods to increase the integration of health services in an effort to improve the care provided, while maintaining or reducing the costs. Integrated health delivery systems are being implemented in the United States, Britain and other European countries. Such systems aim to provide a full continuum of care to a defined target population under a financing system of capitation. This article explores the issues associated with the governance accountabilities of an IDS. A review of potential governance models is completed, and the factors that influence the choice of a governance model for an integrated delivery system are presented. In 1987. Ewell identified governing boards as the weakest link in the integrated health care systems of the United States. It is suggested that early attention to governance in the development of IDS models in Canada may improve the effectiveness of these systems. PMID- 10179074 TI - A comparison of ambulatory care and selected procedure rates in the health care systems of the Province of Manitoba, Canada; Kaiser Permanente Health Maintenance Organization; and the United States. AB - To determine if there are differences in physician services in different health care systems, we compared ambulatory visit rates and procedure rates for three surgical procedures in the province of Manitoba, Canada; Kaiser Permanente Health Maintenance Organization; and the United States. The KP system, with its single payer and low financial barriers, is not unlike the Canadian system. But, for most of the United States, the primary payment mechanism is fee-for-service, with the patient paying a significant amount, thereby militating against preventive and early primary care. Manitoba and KP data were extracted from computerized administrative records. U.S. data were obtained from publicly available reports. Manitoba provides 1.8 times and KP 1.2 times (1.4 when allied health visits are included) as many primary care physician visits as the United States. For the surgical procedures studied, U.S. rates were higher than those in either the KP HMO or in Manitoba. We conclude that (1) the U.S. system leads to more surgical intervention, and (2) removal of financial barriers leads to higher use of primary care services where more preventive and ameliorative care can occur. PMID- 10179075 TI - Development and evaluation of interdisciplinary team standards of patient care. AB - Interdisciplinary team collaboration is considered an essential component of most health care services. The overall goal of such collaboration in mental health services/ psychiatry is to provide a comprehensive biopsychosocial perspective organized around patient needs and stages of treatment. There is also increasing interest in using an interdisciplinary framework to monitor and evaluate patient care. Unfortunately, little information is available regarding treatment standards that address the issue of interdisciplinary team collaboration. This project was designed to formulate a set of interdisciplinary team standards of patient care. This article presents the standards and provides an overview of the interdisciplinary processes through which they were developed. An empirical evaluation of the standards within one service area--The Affective Disorders Clinic--is also included. PMID- 10179076 TI - Public-private partnerships in the Canadian environment: options for hospital pharmacies. AB - This brief report explores the direction being pursued by hospitals interested in outsourcing non-core activities within the pharmacy department. Private sector logistics companies are looking to position themselves in the drug product supply chain to facilitate seamless transfers of drug products, ordering information and payments between drug manufacturers and hospitals. Opportunities for implementing consolidated purchasing, unit dosing, just-in-time inventory and electronic commerce systems are discussed. PMID- 10179077 TI - Interdisciplinary professional practice leadership within a program model: BC Rehab's experience. AB - In restructuring from a departmental to a program management model, BC Rehab successfully developed the role of professional practice leader to address clinical standards of practice and other concerns related to individual disciplines. A review of the role of professional practice leader is presented. Practice leaders are in a unique position to promote interdisciplinary, client focused service. Because practice leaders' mandates cross program boundaries, they are able to keep the broad scope and goals of rehabilitation in the forefront, offering a balance to the program-specific perspective. It is imperative for practice leaders to maintain connections to operational and clinical issues to avoid isolation. PMID- 10179078 TI - Successful strategies for handling a severance package. PMID- 10179079 TI - A Canadian solution is needed in the restructuring of the Canadian health system. PMID- 10179080 TI - The CEO of Canada's high tech powerhouse on leadership, teams and customer service. Interview by Matthew D. Pavelich. PMID- 10179081 TI - Functional independence training program: an example of a sub-acute care model for patients following primary joint replacement. AB - The Orthopaedic and Arthritic Hospital is a specialty institution dedicated to the provision of elective reconstructive orthopaedic surgery and rehabilitation to individuals with musculoskeletal disorders. This facility is the largest volume joint replacement centre in Canada, performing over 1,000 hip and knee replacement/revision procedures annually. In 1995, the hospital established a Functional Independence Training (FIT) program--a seven-day reactivation program for patients following primary joint replacement. The program aims to promote early independence, improve functional level and return patients to normal activity as quickly and cost-effectively as possible. The program has received positive patient feedback and has demonstrated the potential to save the health care system approximately $479,655 annually through the reduction of 1,453 acute and rehabilitation hospital inpatient days, based on the hospital's annual primary joint replacement caseload. PMID- 10179082 TI - Resource Intensity Weights and Canadian hospital costs: some preliminary data. AB - Different types of inpatients "consume" differing amounts of hospital resources, and it is important to be able to measure these differences in resource consumption. An equitable methodology for funding hospitals must take into account differences in case mix between facilities. An ability to examine these differences in case mix and resource utilization allows hospitals to focus efforts to improve efficiency. A standardized methodology for measuring resource consumption is critical to funding and resource allocation both at a global and organizational level. This study was undertaken to determine whether or not the Canadian system for measuring resource consumption, Canadian Institute for Health Information (CIHI) RIWs, was reflective of the relative cost differences between inpatient cases at the Greater Victoria Hospital Society (GVHS) and to identify RIWs with a significant difference in comparison to GVHS cost weights. A regression analysis was performed on the more than 30,000 inpatient cost profile records from the GVHS 1995-96 cost and patient activity data. The scope of the analysis was restricted to the 424 Case Mix Groups (CMGs) that had a minimum composition of five patient profiles. Comparisons of GVHS cost weights to CIHI RIWs yielded mostly positive results. With the noted exception of about 20 CMGs, there was a high correlation between the CIHI RIW and the GVHS actual cost weights. Hence, the GVHS cost weights can be viewed with confidence as representative of the relative cost differences between typical RIW value CMGs and actual costs. PMID- 10179083 TI - Toward executive support systems in health management: strategic leadership imperatives. AB - Executive support systems (ESSs) complement information technologies and add value to the work of senior health executives by enhancing management effectiveness, efficiency and productivity. This article examines the characteristics of executive support systems and their promising implications for executives in health services delivery. The systems' critical success factors are highlighted through a review of key development and management implementation strategies. The article concludes with a commentary on the fundamental significance of ESSs for health service leaders and managers. PMID- 10179085 TI - Redesigning services to meet client needs: the Gage Transition to Independent Living. AB - The Gage Transition to Independent Living, offered by Toronto's West Park Hospital, helps physically disabled adults acquire the skills necessary for living independently in the community. Although the program's goal has remained constant, its structure has changed considerably. In response to client feedback and community trends, the program has replaced its original institutional framework with a community-based one. This article traces how those involved changed the program to meet client needs, and describes what they learned in the process. PMID- 10179084 TI - Best laid plans: effective implementation of re-engineering recommendations. AB - Continuing pressures on health care funding have led most hospitals to undertake re-engineering and restructuring projects to reduce operating expenses. Unfortunately, savings often turn out to be less than anticipated, as the projects falter in the implementation stage. As part of a two-year process improvement and expense reduction project, Toronto's St. Michael's Hospital developed an aggressive and comprehensive implementation process to ensure that it met its savings targets and maintained its financial viability. This article outlines the Hospital's implementation strategy and reviews the project's major challenges and key success factors. PMID- 10179086 TI - Staying the course: the moral dilemma of health care leadership. PMID- 10179087 TI - Integration: final frontier and never-ending story. PMID- 10179088 TI - Mastering the new work realities. Interview by Matthew D. Pavelich. PMID- 10179089 TI - Managed care is the topic--again. PMID- 10179090 TI - Virginia court maintains distinction between physician and his wholly owned professional corporation. Schwartz v. Brownlee. PMID- 10179091 TI - Multi-skilled health carers: nature, purpose and implications. AB - Multi-skilling has been the most enduring element of patient-focused care in the UK. A recent report from the Manchester University Health Service Management Unit (HSMU) extended the multi-skilling debate and offered a framework for changing National Health Service workforce policy along multi-skilling lines. Examines the main HSMU issues in the light of broader empirical and other evidence. Assesses the strengths, weaknesses, opportunities and threats to multi-skilling. Concludes that multi-skilling protagonists still face a number of challenges. PMID- 10179093 TI - The impact of ownership on health care services in HMOs. AB - Tests the theory that owners (hospital, physician, insurance) of vertically integrated health maintenance organizations (HMOs) might substitute towards production of their own specialty goods. Uses data from various sources in the USA. Determines the impact of ownership on factors such as average physician ambulatory services per enrollee and average hospital days per enrollee. Concludes that policymakers need to encourage the development of standard publicly available quality measures to intensify competition and eliminate excess profits accruing to provider-owners who substitute towards production of their own goods. PMID- 10179092 TI - Shaping the health of the nation: development of human resources in Eritrea. AB - Looks at human resources (HR) issues with regard to the health care system in Eritrea, the newest nation in Africa with a population of 3.5 million. Notes the problems of poor infrastructure, high mortality rates and poverty. Considers the present situation and future requirements in terms of HR. Features programmes being established aimed at bridging this gap and looks particularly at initiatives aimed at enabling ex-combatants who have wartime health care experience to train further as health workers. PMID- 10179094 TI - Medical rationing as a health strategy. AB - Notes the problem of rising health care costs in the USA. Considers a highly controversial solution to this problem, which is to consider health care as a scarce resource and to ration access to it. Whether rationing is done by age, ability to pay, or a cost-benefit analysis, the very concept contradicts the US belief in the right to health care. Other industrialized countries currently ration health care through a National Health Insurance Plan. Points out that, in the USA, individual states are beginning to consider health care rationing to combat shrinking budgets and increasing demand for services. PMID- 10179095 TI - Competition and its implications for managing health care organizations. AB - Reports that the US health care system has been shifting since the 1960s to a competitive environment with many new and innovative organizational forms. Describes the nature of the competitive environment for health care and some of the basic forms of the new organizational arrangements. Explores some of the implications for managing successful health care organizations by the understanding of interorganizational linkages in the health care industry and a partnership approach to marketing and management. PMID- 10179096 TI - Does organizational culture affect out-patient DNA (did not attend) rates? AB - Government interest in health service "did not attend" (DNA) rates was seen to occur by accident, following which efforts to reduce DNAs have tended to concentrate on operational rather than strategic issues. Considers the effect hospital culture has had on DNA rates from an organizational and patient perspective. Identifies some of the key cultural issues that impacted on DNA rates by utilizing observation and telephone survey research methods. Concludes that, in the main, the lack of customer-oriented organizational culture was seen to affect DNA rates adversely within one NHS provider trust. PMID- 10179097 TI - Nurse education: a time for new solutions? AB - Notes the worsening situation with regard to nursing shortages. Considers responses such as the commission of increased places on Project 2000 courses and the introduction of NVQ III staff. Points to this success, particularly with regard to the latter of these solutions, but notes a lack of career progression for such entrants. Suggests that there is a strong case for development of a better career path for NVQ III staff, and looks to education and training consortia in this respect. PMID- 10179098 TI - Suture price prospects vary by supplier. PMID- 10179099 TI - GPOs will need flexibility to stay ahead of IDNs. PMID- 10179100 TI - Pharmacy distributors' nod to med-surg seen as helpful. PMID- 10179101 TI - Glove prices post overall decline. PMID- 10179102 TI - Not every product is worth standardizing, Tenet finds. PMID- 10179103 TI - Purchasing managers say business outlook good in 1998. PMID- 10179104 TI - Cleaning teams. Specialists help Kaiser hospitals clean up on cleaning up. PMID- 10179105 TI - Health Care News Server launches new Internet site. PMID- 10179106 TI - Technology assessment--a survey of the clinical engineer's role within the hospital. AB - Advancements in technology are vital to improve clinical outcomes within the medical community and, in particular, to healthcare systems. The need for a systematic approach to analyzing, assessing and selecting the best new technology for individual hospitals continues to increase in response to this technological growth. To determine the use of technology assessment, the effectiveness of different methods, and the role of clinical engineers and bioengineers in this process, a survey was conducted of clinical engineering departments throughout the United States. The results reveal that technology assessment programs are widely utilized as a team effort between hospital departments. Clinical engineers are playing a key role within these teams as technology managers. PMID- 10179107 TI - A study on the current situation in the biomedical technology and clinical engineering sector in Bulgaria--advances, trends and needs. AB - A survey of the clinical engineering sector in Bulgaria was carried out, within the context of the 1996 Phare Partnership Program, with the aim to provide a reflection of the current situation concerning the management of biomedical technology and investigate the relevant needs in hospitals. The survey was initiated by the Institute of Biomedical Technology (INBIT) in Patras, Greece, with the active support of national organizations, educational institutions and other parties that share involvement in the overall management of medical devices in Bulgaria. This paper summarizes the results of the survey, giving an insight into the situation in the field and providing the basis for a more thorough study on the Biomedical Technology and Clinical Engineering sectors in Bulgaria. PMID- 10179108 TI - Computer-aided learning--a solution for the training needs of users & maintainers of medical equipment. AB - It can be argued that the strategic role of training and assessment in the use and maintenance of medical equipment for the delivery of safe and efficient healthcare is underestimated. While there has been frequent comment on this issue, the resources provided for this activity are most often insufficient. New methods are required to deliver regular, cost-effective training within the working environment, at the time and place of need. Similarly, the administrative workload has to be automated--and thus reduced--if training is to improve in both frequency and content. Computer-aided learning has had increasing and diverse application in education and training over the past few decades. The sophistication of software tools and the reduced cost of the necessary hardware makes this a viable and appropriate method for application in the field of Clinical Engineering. However, this technology has not yet been fully exploited to provide instruction in the use and maintenance of equipment. In this paper, it is proposed that computer-based training packages should not only be a source of interactive instruction and assessment, but also act as rapidly accessible reference materials or simulators of the actual device for the purpose of fault finding or troubleshooting. Brief details of a sample package are given for training in the use and maintenance of the Siemens Elema Servo Ventilator 900C. PMID- 10179109 TI - Utilization of the Internet to deliver educational materials to healthcare professionals. AB - We have developed a computer-based learning module which uses three-dimensional animation sequences to enhance the acquisition of physical concepts and skills necessary for clinical evaluation and treatment of the cervical spine. This teaching tool, designed to serve as an adjunct to teaching strategies that faculty may be currently using, is available to students through the Kobiljak Resource Center at Michigan State University College of Osteopathic Medicine (MSUCOM) and via the Internet (http:/(/)hal.bim.msu.edu/EdTech) to individuals and groups who are physically removed from the MSU campus. While we are restricting this initial effort to the upper cervical spine, it is planned that future materials will include other parts of the body and, in addition, will enable students to not only visualize the effects of pathology on motion mechanics, but also give them the ability to interactively control an articulation in three-dimensional space. PMID- 10179110 TI - Medical computing over the World Wide Web: use of forms and CGI scripts for constructing medical algorithm Web pages. AB - The development of the World Wide Web has led to an explosion of educational and clinical resources available via the Internet with minimal effort or special training. However, most of these Web pages contain only static information; few offer dynamic information shaped around clinical or laboratory test findings. In this report we show how this goal can be achieved with the design and construction of Medical Algorithm Web Pages (MAWP). Specifically, using Internet technologies known as forms and CGI scripts we demonstrate how one can implement medical algorithms remotely over the Internet's World Wide Web. To use a MAWP, one enters the URL for the site and then enters information according to the instructions presented there, usually by entering numbers and other information into fields displayed on screen. When all the data is entered, the user clicks on the SUBMIT icon, resulting in a new Web page being constructed "on-the-fly" containing diagnostic calculations and other information pertinent to the patient's clinical management. Four sample applications are presented in detail to illustrate the concept of a Medical Algorithm Web page: Computation of the alveolar-arterial oxygen tension difference using the alveolar gas equation; Computation of renal creatinine clearance; drug infusion calculation (micrograms/kilogram/minute); Computation of the renal failure index. PMID- 10179111 TI - A practical approach for analyzing antitrust issues faced by provider networks. PMID- 10179112 TI - Fiduciary duties of partners in healthcare joint ventures. PMID- 10179113 TI - When ignorance isn't bliss: what healthcare practitioners and facilities should know about complementary and alternative medicine. PMID- 10179114 TI - Uncharted waters: managed care and long-term care provider contracts. PMID- 10179115 TI - Worth its weight in gold: organ transplantation and the new UNOS policies for allocation of hearts and livers. PMID- 10179117 TI - Leveling the playing field? The nation's first managed care liability law. PMID- 10179116 TI - Credentialing and "deselection" of providers in healthcare delivery systems. PMID- 10179118 TI - Recent healthcare fraud legislation: new prosecutional tools or congressional pie in the sky? PMID- 10179119 TI - Private enforcement of state fraud laws: a comparative analysis of state qui tam provisions. PMID- 10179120 TI - A regulator's view of the managed care world, or how to stop worrying and learn to love your regulator. PMID- 10179121 TI - Much ado about nothing? Gag clauses in managed care physician contracts. PMID- 10179122 TI - Healing through differentiation: a pastoral care and counseling perspective. AB - Focuses on the function of healing as central to the cure-of-souls tradition of pastoral care and counseling and describes two prominent but contrary styles of healing in ministry. Proposes an interactional model of pastoral care which integrates the two healing styles of compassion and competence through the principle of differentiation, drawing from the perspective of constructivism as practiced in narrative therapy and the theory of natural systems as applied to the role of the pastor. PMID- 10179123 TI - Pastoral counseling: an alternative path in mental health. AB - Claims that a strong professional identity is key to offering a healing presence and that pastoral counselors can use their dis-ease with conflicting paradigms and wave-trends in mental health care and the wider culture to maintain a professional identity rooted in the history of pastoral care and their respective theological and psychological world-views. Identifies these wave-trends as the defensive use of language, the medicalization of normal human experience, the lack of interest in developmental perspectives on human life, and the overlooking and denial or internal mental processes of persons. Introduces the concept of pastoral counseling as cultural critique and points out implications of this for the direction of the profession of pastoral counseling. PMID- 10179124 TI - Patients' bill of rights could mean less belt-tightening for labs. PMID- 10179125 TI - HIV infection, diagnosis, and treatment: new findings and approaches. AB - We now understand the biology of HIV infection, and this knowledge can be applied to strategies for prevention of infection, improvement of diagnostic laboratory testing, and treatment of infection. Education about methods for preventing HIV transmission remains the primary goal for reducing the spread of AIDS. For persons already infected, laboratory testing with HIV-1 RNA levels and CD4 lymphocyte counts are useful techniques for monitoring HIV infection and prolonging survival. PMID- 10179126 TI - Emerging issues in AIDS: variant strains of human immunodeficiency virus and its subtypes. AB - The emergence of variant strains of HIV has triggered the need for active local, national, and global surveillance. Some new strains identified in the US cannot be detected reliably with current test kits--a problem with important implications for blood safety and for diagnosis and prevention of AIDS. PMID- 10179127 TI - Great service guaranteed! PMID- 10179128 TI - Finding the right consultant. PMID- 10179129 TI - The Joint Commission and CLIA: a 5-year retrospective. PMID- 10179130 TI - Standing by their plan. Study examines what it takes to build consumer loyalty. PMID- 10179131 TI - Life after restructuring. Humana redefines after shedding hospitals, clinics. PMID- 10179132 TI - Stopping the violence. More healthcare workers trained to spot domestic abuse. PMID- 10179133 TI - Incentive or illegal? Florida PPMs appeal ruling prohibiting fee-splitting. PMID- 10179134 TI - Healthy marriage. Ga. Blues, med school unite via center to improve care. PMID- 10179135 TI - Notching a record. First-quarter tax-exempt bond issues total nearly $9 billion. PMID- 10179136 TI - Mo. antitrust challenge. FTC seeks to stop merger in two-hospital Poplar Bluff. PMID- 10179137 TI - Not so friendly demise. MedPartners shutters hospital that linked network. PMID- 10179138 TI - Access declines. Reproductive services fall with hospital consolidation. PMID- 10179140 TI - All in the family. AHA to merge data, publishing units. PMID- 10179139 TI - Minorities see glass ceiling. PMID- 10179141 TI - Planetree model gets new caretaker. PMID- 10179142 TI - Diabetes control in aisle 3. Syracuse hospital teams with grocer to treat disease. PMID- 10179143 TI - Harvesting the fruit. $52 million award could boost whistleblower suits. PMID- 10179144 TI - A preventable epidemic. Providers back nationwide protest against violence. PMID- 10179145 TI - Helping kids quit. Hospitals offer smoking cessation programs for teens. PMID- 10179146 TI - Healthy workplaces. Employers look to on-site clinics to control costs. PMID- 10179147 TI - In with the old. Federation urges JCAHO to reverse system survey policy. PMID- 10179148 TI - Mr. Fixit. As AHA's second-in-command, Lord runs a tight ship. PMID- 10179149 TI - Reversal of fortune. At AHA's behest, HCFA alters states' Medicare payments. PMID- 10179150 TI - It won't pass, but ... bill to limit fraud probes could still have impact. PMID- 10179151 TI - PPOs delivery what HMOs don't. PPOs blossom as consumers demand choice, access, and affordability. PMID- 10179152 TI - What does it all mean? Making sense of health plan data. AB - With competition for enrollees reaching a fever pitch among health plans, calls are coming from many quarters for a reinvention of healthcare to focus on patients. That's producing a flood of information intended to help consumers compare plans and providers. What will consumers do with all the information? Will they understand it and use it? PMID- 10179153 TI - Antitrust revisited. Missouri hospital faces second round of complaints. PMID- 10179154 TI - In search of a savior. Calif. community works to keep hospital from closing. PMID- 10179155 TI - AHA, feds face off over fraud rules. PMID- 10179156 TI - Review this, insurers. Maryland hospitals say needed care is being denied. PMID- 10179157 TI - Suing the messenger. Union reps who deliver bad news may face legal action. PMID- 10179158 TI - Davidson, Stark at odds over fraud. PMID- 10179159 TI - Striking out! Federal enforcers losing streak in antitrust cases shows need for new game plan. AB - The Federal Trade Commission and the U.S. Justice Department are on a four-case losing streak with hospital mergers they have tried to stop for antitrust reasons. Theories explaining why the trustbusters can't hit a home run abound. Some point to the loss of key players who have signed on with the private sector. Others say the complex economic models introduced in court can throw judges a curve ball. PMID- 10179160 TI - Cutting edge. Surgical company is poised for growth--or acquisition. PMID- 10179161 TI - Building a powerhouse. Novation fills executive ranks, begins bidding process. PMID- 10179162 TI - Carrot or the stick? Study: hospitals use a variety of tactics to head off billing inquiries, complaints. PMID- 10179163 TI - Feds stand firm on fraud fighting. PMID- 10179164 TI - Add it up. Georgia hospital-owned HMOs also rack up losses. PMID- 10179165 TI - Chicago HMO forges ahead. PMID- 10179166 TI - Allegiance sues Regent on claims for latex gloves. PMID- 10179167 TI - HCFA draft drops reference to OR nursing. PMID- 10179168 TI - With MIS heart surgery come new device needs. PMID- 10179169 TI - Working together for cardiac improvements. PMID- 10179170 TI - Guided imagery tapes help surgical patients. PMID- 10179171 TI - When and how to use ultrasonic cleaning unit. PMID- 10179172 TI - How do you know you have a competent staff? PMID- 10179173 TI - Top 100 hospitals are thriving on competition. PMID- 10179174 TI - A guide for managing successful projects. PMID- 10179175 TI - Closing in on preventive therapies. PMID- 10179176 TI - Attendant bill resurrects familiar debate. PMID- 10179177 TI - Pain management: the ethical dilemma. PMID- 10179178 TI - Mental health hurdles. The dawning of geriatric psychiatry. PMID- 10179179 TI - Working together. Coordinating hospice and nursing care. PMID- 10179180 TI - Turning around turnover. PMID- 10179181 TI - Beyond doughnuts for doctors. PMID- 10179182 TI - Advancing end-of-life directives. PMID- 10179183 TI - Synthetic leases offer genuine benefits. PMID- 10179184 TI - East and west of Eden. Caregivers choose from single-pet visits to Edenization. PMID- 10179185 TI - The truth about cats and dogs. Weighing the pros and cons of pet therapy. PMID- 10179186 TI - Putting the individual first. Restoring dignity through restorative care. PMID- 10179187 TI - Marketing for new managers. PMID- 10179188 TI - Change management or resistance management? PMID- 10179189 TI - Creating a center of excellence. AB - Being able to identify your facility as a Center of Excellence characterized by quality of patient care and services, outcomes and financial performance-sets your hospital apart from others. St. Luke's Episcopal Hospital in Houston developed a three-pronged approach to quality improvement which has helped the hospital establish and maintain its position as such a Center. Other institutions can modify this approach for their own use. Service line management is the hospital's first avenue of approach, a means of aligning and coordinating staff efforts and services for a particular patient population, to achieve a better integrated service delivery system. St. Luke's also uses a case management model, a system of planning, coordinating, monitoring and delivery care on a case-by case basis, to provide the best care at the lowest possible cost. A third strategy is outcomes management, which uses outcomes assessment information to track the experience of an aggregate patient population. A collaborative practice team oversees the research, data evaluation and determination of changes to be implemented. It also establishes the desired outcome for the patient population. St. Luke's has used these initiatives to improve care, particularly among cardiovascular patients. Ultimately, the hospital changed its methods of care as a result of this assessment. Change took time to gain favor with hospital physicians. In 1991, St. Luke's applied to HCFA's Bypass Demonstration project, in which Medicare distributes a lump sum to cover surgeons, cardiologists and other disciplines for Medicare-eligible DRG 106 and 107 patients. St. Luke's joined the project in 1993. As a result of participation in the project, Medicare allows selected sites to call themselves a Medicare Participating Center of Excellence. PMID- 10179190 TI - A new concept in radiology QA in a large setting. AB - Determining film quality has traditionally been carried out through review and evaluation of exam retakes. At best, such a system will tell which exam areas the technologist repeated most. Kaiser Permanente Northwest has 80 radiologic technologists and 30 radiologists who rotate through film reading. The program developed at Kaiser is directed toward general diagnostic film quality only and uses the services of two full-time quality assurance (QA) technologists. Working together, the radiologist and QA staff have created a standard of diagnostic image quality. A QA radiologist representative is available to work with the QA technologist if inconsistencies are raised. Every other month, a QA technologist makes a random selection for review of 50 exams performed by each technologist. These evaluations cover view rather than exam, with each view judged on its own merit. The purpose is to look for recurring problems in the technologist's performance. Copies of the review sheet go to each technologist's supervisor who forwards a copy to the technologist. Technologists can request help to understand why certain films meet or fail to meet quality standards. The QA technologists are available to give one-on-one help, and they also offer classes and demonstrations. In turn, radiologist fill out quality control (QC) slips as they read exams. The slips help to educate and correct specific problems, and are a direct communication link between radiologist and technologist. The QA program places importance on having the proper tools for taking quality films. The program also provides several levels of accountability although QA technologists are not responsible for its enforcement. Instead, they give feedback to supervisors who enforce performance levels. An appeals process is also in place. The program helps keep image quality acceptable to both hospital radiologists and customer requirements in the industry. In turn, the technologists use it to further their professional development. PMID- 10179191 TI - Implementing filmless ultrasound: a case study. AB - Several years ago, Butterworth Hospital in Grand Rapids, Michigan, considered converting to a filmless radiography system. Enthusiastic but cautious, the hospital looked into the technology to be sure it was appropriate for their institution. With the first phase representing a trial run, choosing the right area for the initial implementation was critical. Ultimately we selected the area that would most benefit from the transition and save the most money along the way. Ultrasound was our first choice, particularly since the hospital has three ultrasound units that are staffed 24 hours a day, and six ultrasound units in a doctor's building across the street. Butterworth was performing 25,000 ultrasound films annually. An additional reason for selecting ultrasound was a high level of interest and support from the hospital's ultrasound radiologists. Enthusiastic about the project this group's support gave the project a good chance for success. The hospital considered different vendors, basing its selection on the radiologists' satisfaction. It was essential that they be satisfied with any system they would eventually use. One criteria was to find a vendor willing to customize their product for the hospital's use. Compatibility with the existing network was also important. One goal at implementation was to be 80 percent filmless after several weeks. Even greater savings than anticipated were realized when the radiologists went 98 percent filmless almost immediately. The successful first phase has laid the groundwork for upcoming phases of the project, which will include transitioning to CT and MRI. PMID- 10179192 TI - Bone densitometry as a screening tool for osteoporosis in postmenopausal women. AB - This report provides general information about osteoporosis and describes the use of bone densitometry as a tool to screen for, diagnose and manage osteoporosis in white postmenopausal women. Discussion is limited to white women because of lack of research on osteoporosis in men, and in women of different racial and ethnic groups. The report does not evaluate the safety and efficacy of all bone densitometry devices, but focuses on the two diffusing most rapidly in Minnesota- dual x-ray absorptiometry (DXA or DEXA) and quantitative computed tomography (QCT). Osteoporosis is a degenerative bone disease that affects approximately 24 million Americans. Of that number 33 percent are post-menopausal women who have decreased bone density due to lowered estrogen levels. Because the estimated cost of osteoporosis-related fractures in the United States is between $8 and $10 billion each year, there is great interest in the diagnosis, prevention and treatment of the disease. Of all related fractures, hip fractures pose the most serious health problem. The incidence of this fracture appears to be increasing, with 250,000 to 300,000 occurring each year Treatment options are limited, if a person's bone mass or density has deteriorated to the point where fractures may occur. Preventive measures should therefore be undertaken by all women early in life to decrease their risk of osteoporosis. Based on available evidence, the HTAC concludes that state-of-the-art bone densitometry is safe and indicated as a diagnostic and treatment aid for postmenopausal women at risk for the disease. However, bone densitometry is not indicated as a broad screening tool for all postmenopausal women, regardless of whether they are at risk for the disease. PMID- 10179193 TI - Osteoporosis: screening for stronger, healthier lives. AB - President Clinton has signed into law a provision to standardize Medicare coverage for bone mass measurements, authorizing coverage for certain high-risk people for bone density screening. The legislation also requires the Secretary of Health and Human Services to establish frequency standards for bone mass measurement for Medicare beneficiaries, effective July 1, 1998. By 2010, a significant portion of the American population will be older than 60; already, more than one-third of women in the U.S. are older than 50; The implications for the direction of medical care are extraordinary A recent National Institute's of Health study notes that osteoporosis will reach "epidemic" proportions in the next decade. Already the disease causes more than 1.5 million fractures annually at a cost of more than $13 billion per year. Such numbers will only rise as the population ages. New efforts focus on identifying the disease in its earliest stages, assessing the rate of bone loss and encouraging preventive approaches. The role of radiology will continue to be critical. PMID- 10179194 TI - Refurbished medical equipment. AB - The European medical device Directives apply to persons who fully refurbish medical equipment and place these products on the market under their own names. However, the Directives do not address any other type of refurbishing. This article discusses the European and United States (US) regulatory requirements for refurbishers, raises some questions concerning these requirements, and discusses a US advance notice of proposed rule making on refurbishers. PMID- 10179195 TI - Standardizing medical device communications: the Medical Information Bus. AB - Data collection from different types of medical devices is currently a time consuming process that is done manually. The Medical Information Bus (MIB) defines standardized methods for interfacing medical devices and computer systems. The potential impact on current electromedical products and future product developments is huge. This article describes MIB and identifies some of the issues that must be resolved for its successful implementation. PMID- 10179196 TI - Hydrogels: their future, Part II. AB - A multitude of new materials with diverse properties can be made from poly(ethylene oxide). Part I of this two-part article described the range of biomaterial syntheses, properties and applications that can be obtained. The production of a novel class of responsive hydrogels for transducing and sensing applications is reviewed in Part II. PMID- 10179197 TI - Multi-shot injection moulding. AB - Medical device manufacturers are beginning to combine multi-colour and multi material moulding techniques with soft-touch materials to gain competitive advantage. This trend is driven by the availability of machines that can inject as many as six different materials simultaneously. This article looks at the multi-shot moulding process and uses examples to highlight the benefits of the technique. PMID- 10179198 TI - Remanufacturing. AB - The market for remanufactured medical equipment is well established, particularly in the United States, and seems set to grow in Europe. This article discusses some of the concepts involved and sets out some factors that make it viable. Example are drawn from the medical imaging sector. PMID- 10179199 TI - FDA import alert: a potentially devastating enforcement tool. AB - The United States (US) operates strict measures to prevent foreign manufacturers from importing devices that it believes to be unsafe. The "Import Alert" issued by the Food and Drug Administration is a serious piece of legislation under which the device is detained and refused entry to the US until the manufacturer has taken corrective action. This article sets out situations in which an import alert would be issued, how manufacturers can avoid an import alert, and what to do if one is issued. PMID- 10179200 TI - Trial by media: the case of the worn hip prostheses. AB - Another example of a medical device failing to produce a uniformly satisfactory performance is being widely discussed in the media. The controversy it arouses reduces patient confidence in the industry and calls into question the value of some technical developments and the effectiveness of regulatory procedures. Some of the generic issues arising from this case are discussed in this article. PMID- 10179201 TI - Stress, job satisfaction, coping, and psychological distress among emergency medical technicians. AB - INTRODUCTION: Although several studies link job-related stressors with adverse reactions among emergency medical technicians (EMTs), more standardized research is needed, since much remains unknown about stress responses, coping styles and their consequences for EMTs. This paper presents the results of two studies. Study I investigated the relation between job-related stressors, job satisfaction, and psychological distress, while Study II investigated how coping is related to occupational burnout, job-related stress, and physiological arousal. HYPOTHESIS: Study I: Those EMTs experiencing greater job-related stressors are less satisfied with their jobs and more psychologically distressed. OBJECTIVE, STUDY II: To obtain preliminary information about which coping strategies are associated with greater feelings of stress and burnout and more intense autonomic nervous system reactivity. METHODS: For both studies, EMTs from a large, urban, public EMS organization in the southern United States were asked to participate. Study I: Subjects completed an informed consent document, a demographics questionnaire, a measure of job stress (the Stress Diagnosis Inventory), a measure of job satisfaction (Job-in-General), and a measure of psychological symptomatology (Symptom Checklist-90, Revised). Pearson product moment correlations were computed between the measures. Study II: Subjects completed an informed consent document, a demographics/information sheet, the Maslach Burnout Inventory (MBI), and the Ways of Coping Scale (WOCS). They then completed 30 days of monitoring using the Daily Stress Inventory (DSI) and the Daily Autonomic Nervous System Response Inventory (DANSRI). Pearson product moment correlations were computed between the measures. RESULTS: Study I: Those EMTs who experienced greater job-related stress also were significantly more dissatisfied with their jobs, more depressed, anxious, hostile, and endorsed greater global psychological distress. Study II: The Depersonalization subscale on the MBI correlated significantly with the following WOCS subscales: Accepting Responsibility, Confrontive Coping, Distancing, and Escape/Avoidance. Emotional Exhaustion on the MBI correlated significantly with Confrontive Coping, Escape/Avoidance, and Social Support, while data obtained on the 40 subjects who completed the daily monitoring revealed that DSI-Impact, DANSRI-Number, and DANSRI-Impact scores each correlated significantly with Accepting Responsibility, Confrontive Coping, and Escape/Avoidance. CONCLUSION: A significant portion of an EMT's job satisfaction and psychological well-being is associated with the degree to which they are experiencing job-related stress, and, furthermore, this distress level appears to be clinically elevated. This implies that in-service programs and psychological support services designed to help EMTs manage their job-related stress may improve job satisfaction and decrease psychological distress. The coping styles most consistently associated with maladaptive outcomes were: Accepting Responsibility, Confrontive Coping, and Escape/Avoidance. Thus, subjects who were more likely to handle stress with self blame, aggression, hostility, and risk taking or with wishful thinking, escape tendencies, and avoidance were more likely to endorse more negative outcomes. PMID- 10179202 TI - Current status of clinical education in paramedic programs: a descriptive research project. AB - Development of competence in exercising therapeutic judgment skills represents the goal of clinical education. Time (clock hours) is not a valid predictor of attainment of competence in paramedic clinical education. Quantity of patient contact experiences facilitates development of judgment skills, and offers a valid measure of progress toward competence. This project uses national survey data from accredited programs to describe the availability and accessibility of patient contact experiences within paramedic clinical education. Data from this local program supplements the national survey results. The components of clinical judgment are enumerated, and strategies to teach and evaluate clinical judgment skills are discussed. PMID- 10179203 TI - Reader attitudes toward journal-based continuing education for EMS personnel. AB - Recertification requirements and new curricula place increased importance on continuing education (CE) for emergency medical services (EMS) personnel. To be effective, continuing education not only must be accessible to EMS personnel, but it must be also acceptable. Journal-based continuing education was selected to improve accessibility, but questions were raised about its acceptance. Although there were some significant differences found between the feelings of basic and advanced EMS personnel, a study conducted on six articles showed that participants overall liked this method. The study also found that some articles significantly generated more reader response than others. PMID- 10179204 TI - A self-assessment of Wisconsin prehospital provider needs. AB - INTRODUCTION: The pressures facing emergency medical services (EMS) in Wisconsin and their effects on the delivery of prehospital emergency medical care were not known by the Wisconsin EMS Board. In an effort to assess these pressures and the needs of the emergency medical services in the State as perceived by the services, the Board undertook a survey of the EMS providers in Wisconsin. METHODS: A survey instrument was developed and approved by the EMS Board and distributed to all of the licensed emergency medical services in Wisconsin. RESULTS: Of the 453 survey instruments distributed, 323 (71.3%) were completed and returned. Intermediate- and paramedic-level services were more likely to respond than were the basic services, but 235 (72.8%) of the respondents identified their service levels as basic. In addition to providing information about the service characteristics, each responding service also rated the importance of their perceived needs. Lack of medical direction was perceived as the greatest need by all levels of service. However, the second greatest area of need for basic and intermediate services related to difficulty in recruiting new staff. For paramedic services, the second greatest need was associated with dispatching. When comparing services by rural versus urban, difficulty in recruiting new staff and collecting ambulance fees were seen as second and third to lack of a medical director by rural services, whereas urban services noted local training to be in the top three. In the assessment of educational needs, patient-care issues dominated. A review of written comments also demonstrated a difference between rural and urban services, but both noted Medicare and Medicaid reimbursement issues more commonly than any other problem. CONCLUSIONS: In the restructuring of health care, it will be important to consider the various needs of prehospital providers and recognize that such needs may be unique to the providers' location and level of service. PMID- 10179205 TI - Identifying victims of elder abuse and neglect: a training video for prehospital personnel. AB - INTRODUCTION: The majority of prehospital emergency medical services (EMS) personnel lack specific training relating to elder abuse and neglect. OBJECTIVES: To develop and test an audio-visual training program that focuses on the identification and reporting of domestic violence in the elderly. METHODS: A videotape was designed to be used as a 45-minute training course for prehospital personnel using one-half inch, super-VHS recording. A convenience sample of 60 EMS personnel working in Kent County then were asked to evaluate the videotape program. Each volunteer completed a pre-test on elder abuse and neglect, watched the 45-minute videotape, and then answered 12 questions on a post-test. RESULTS: Participants had an average of 12.4 years (range: 1-30 years) prehospital emergency-care experience. Only four (7%) could recall any previous training relating to elder abuse or neglect during their careers. Although the prevalence of elder abuse in their community was described as "rather rare" by most (60%) of the subjects, 85% (51/60) had seen a suspected case of elder abuse or neglect during their careers; 47% (28/60) had seen a case during the past six months. Only 29% of these suspected cases were reported to county authorities. Approximately 40% of the questions on the pre-test were answered correctly (mean score, 4.8 +/- 3.0). In comparison, 83% of the questions on the post-test were answered correctly (10.0 +/- 3.0). Although participants had a number of suggestions to improve the video program, 78% (47/60) expected this material to change the way they will evaluate elderly patients in the future. CONCLUSION: Prehospital personnel do not feel confident identifying or reporting victims of elder abuse or neglect. A videotape training program may be an effective way of presenting this information as a means of continuing education. PMID- 10179206 TI - The wake-effect--emergency vehicle-related collisions. AB - INTRODUCTION: Emergency medical vehicle collisions (EMVCs) occurring during initial response and with patient transport have been a long-standing problem for emergency medical services (EMS) systems. Experience suggests "wake-effect" collisions occur as a result of an EMS vehicle's transit, but do not involve the emergency medical vehicle (EMV). Substantiating the existence and magnitude of wake-effect collisions may have major implications regarding the manner of EMV response. HYPOTHESIS: Paramedics will report that wake-effect collisions do occur and that they occur more frequently than do EMVCs. METHODS: DESIGN: Survey analysis. PARTICIPANTS: Thirty paramedics employed by the Salt Lake City (Utah) Fire Department and 45 paramedics employed by Salt Lake County Fire Department. Geographic Area: Service area has population of 650,000 and is urban, suburban, and rural. MEASUREMENTS: The survey consisted of three open-ended questions concerning years on the job, EMVCs, and wake-effect collisions. ANALYSIS: The mean value for the number of EMVCs and wake-effect EMVCs, along with the 0.95 confidence intervals (0.95 CI) were determined. RESULTS: Seventy-three surveys were analyzed. Sixty EMVCs and 255 wake-effect collisions were reported. Overall, the mean value for the number EMVCs per respondent was 0.82 (0.60-1.05) and for wake-effect collisions 3.49 (2.42-4.55). The mean values for EMVC's for each service were 0.86 (0.50-1.38); 0.80 (0.50-11.0). For wake-effect collisions the mean values were 4.59 (2.83-6.35); and 2.76 (1.46-4.06) respectively. CONCLUSIONS: This study suggests that the wake-effect collision is real and may occur with greater frequency than do EMVCs. Significant limitations of this study are recall bias and misclassification bias. Future studies are needed to define more precisely wake-effect collision prevalence and the resulting "cost" in regards to injury and vehicle/property damage. PMID- 10179207 TI - Patients who refuse transportation by ambulance: a case series. AB - INTRODUCTION: Patients refusing hospital transportation occurs in 5% to 25% of out-of-hospital calls. Little is known about these calls. This study was needed to determine the demographics, inherent risks, and timing of refused calls. METHODS: This was a prospective review of all run sheets of patients who refused transportation were collected for a two month period. Demographic data and medical information was collected. Each run was placed into one of three categories of need for transport and further evaluation: 1) minimal; 2) moderate; and 3) definite. The Greater Elgin Area Mobile Intensive Care Program (GEA-MICP) based at Sherman Hospital in Elgin, Illinois, was the setting. The GEA-MICP is an Emergency Medical Services (EMS) system comprised of 17 advanced life support (ALS) ambulance agencies servicing northeastern Illinois. Study subjects were all patients who refused transportation to a hospital by ALS ambulance during July 1993 and February 1994. Paramedics were required to complete a run sheet for all calls. RESULTS: Overall, 30% (683 of 2,270) of all runs resulted in refusal of transportation. Patients who most commonly refused transportation were asymptomatic, 11-40 years old and involved in a motor vehicle crash. They usually had no past medical history, normal vital signs, and a normal mental status. Patients generally signed for their own release after evaluation. The average time to arrival was 4.2 minutes and average time spent on scene by paramedics was 18.4 minutes. Of the patients, 72% were judged to have minimal need, 25% were felt to have a moderate need, and 3% were felt to definitely need transport to a hospital for further evaluation and/or treatment. CONCLUSION: There are many cases when EMS are activated, but transportation is refused. Most refusals occur after paramedic evaluation. Providing paramedics with primary care training and protocols would standardize care given to patients and provide a mechanism for discharge instructions and follow-up for those who chose not to be transported to a hospital. Patients judged to require further treatment had unique characteristics. These data may be useful in identifying potentially sicker patients allowing a concentrated effort to transport this subset of patients to a hospital. PMID- 10179208 TI - Automatic external defibrillation and its effects on neurologic outcome in cardiac arrest patients in an urban, two-tiered EMS system. AB - OBJECTIVE: To describe the use of the Automatic External Defibrillation (AED) device in an urban, two-tiered Emergency Medical Service (EMS) response setting with regard to its potential effects on cardiac arrest patient survival and neurologic outcome. METHODS: A retrospective and descriptive design was utilized to study all cardiac arrest patients that had resuscitations attempted in the prehospital environment over a 30-month period. The study took place in a two tiered EMS system serving an urban population of 368,383 persons. The first tier of EMS response is provided by the City Fire Department, which is equipped with a standard AED device. All first-tier personnel are trained to the level of Emergency Medical Technician-Basic. The second tier of EMS response is provided by personnel from one of two ambulance services. All second-tier personnel are trained to the level of Emergency Medical Technician-Paramedic. RESULTS: 271 cardiac arrest patients were identified for inclusion. One-hundred nine of these patients (40.2%) had an initial rhythm of either ventricular fibrillation or pulseless ventricular tachycardia and were shocked using the AED upon the arrival of first-tier personnel. Forty-two patients (38.5%) in this group had a return of spontaneous circulation in the field and 22 (20.2%) survived to hospital discharge. Of the survivors, 17 (77.3%) had moderate to good neurologic function at discharge based on the Glasgow-Pittsburgh Cerebral Performance Categories. Faster response times by the first-tier personnel appeared to correlate with better neurologic outcomes. CONCLUSION: First responder-based AED usage on patients in ventricular fibrillation or pulseless ventricular tachycardia can be applied successfully in an urban setting utilizing a two-tiered EMS response. In this study, a 20.2% survival to hospital discharge rate was obtained. Seventy seven percent of these survivors had a moderate to good neurologic outcome based on the Glasgow-Pittsburgh Cerebral Performance Categories. PMID- 10179209 TI - Medical disaster preparedness of Rotterdam-Europort: an application of methodology for assessing disaster preparedness. AB - Medical disaster preparedness (MDP) of Rotterdam-Europort has been estimated by grading personnel, materials, and methods utilized in the chain of medical care, from the disaster site to the hospital. On a scale from 1 to 5, this MDP was set at 2.8: the disaster site is the weakest link, which determines the strength of the whole chain. This, in turn, was the result mainly of the methods utilized for which the personnel were not properly educated and trained. By applying the methodology as described in an earlier paper, the MDP of cities, airports, harbors, industrial plants, etc. can be determined in a standardized way. This methodology should facilitate epidemiologic research in the public health aspects of disaster preparedness. PMID- 10179210 TI - Examining self-perceived first-aid abilities after the Northridge earthquake. AB - INTRODUCTION: This study examines those factors predictive of self-perceived first-aid abilities among a community-based sample after the 1994 Northridge earthquake. METHODS: A probabilities-proportionate-to-size (pps) sample of residents of Los Angeles Country and 11 pre-selected zip codes from southeastern Ventura County was selected using computer-generated random digit-dialing (rdd) procedures 7-11 months after the earthquake. Data were collected from 506 individuals in 45 minute interviews. A unidimensional scale of self-perceived first-aid ability was created and represents the dependent variable in a causal path model. RESULTS: In a causal path model, standardized path coefficients suggested that while reports of taking first-aid courses were the most influential factors in predicting higher self-perceived first-aid abilities, other factors including being white, younger, speaking English in the home, and lower income also predicted higher self-perceived first-aid abilities that were independent from taking formal first-aid courses. CONCLUSIONS: First-aid training should be directed towards target segments of the population that are not likely to have had instruction in these basic skills. Those individuals who self-report high first-aid proficiency, independent of formal first-aid training, should be evaluated to assess their abilities to perform these skills. PMID- 10179211 TI - Does number of beds reflect the surgical capability of hospitals in wartime and disaster? The use of a simulation technique at a national level. AB - INTRODUCTION: The raw number of hospital trauma beds and occupancy has been used to assess the surgical capability of hospitals in wartime and disaster situations. The goal of this study was to examine and offer a better tool to determine the load of casualties that a hospital would be able to absorb and treat effectively during these situations. METHODS: Simulation software was applied to various wartime scenarios. It assessed the usefulness of a computerized simulation of operating room (OR) function under loading of "standard wartime casualties." Comparison of the functioning of similar hospitals was undertaken in order to identify possible methods to optimize the care delivered. A "what-if" module was used to define the optimal way to absorb mass casualties within the known resources of a given healthcare system. Each hospital was tested under different loading of "standard casualties." Average waiting time for surgery was used as a marker of the constant decay in the standards of care with the increasing patient load. RESULTS: Different, unique patterns of strategies for optimizing waiting periods were identified. Not all trauma centers responded by shortening waiting time by diverting the lightly injured patients from them either before or after triage. The reaction to alternate days' shift was unexpected. The temporal course of matching a patient with a functional operating room was more indicative of a hospital's capability to absorb casualties requiring surgery than was the pre-set number of beds available in the hospital. RECOMMENDATIONS: The use of simulation techniques might be useful method to assess the nationwide surgical capability. This is a complex dilemma that cannot be predicted with trivial guessing, even when combined with previous experience of triaging. Analyzing the weak points and bottlenecks at a national level might help in creating preparedness protocols. PMID- 10179212 TI - Mass gathering medical care: a twenty-five year review. AB - INTRODUCTION: The purpose of this study was to critically review the provision of medical care at mass gatherings as described in 25 years of case reports. Specifically measured was the relationship between the size of a mass gathering and the frequency of patients seeking medical aid and the effects of certain event characteristics on this relationship. METHODS: Data were obtained through a retrospective literature review. Medline and CINHAL computerized databases were searched for English language articles using several keywords: "mass gathering", "concert", "festival", "Olympics", "crowd"; "riot", "stadium", "sports", "games", "papal", and "football". Only articles containing complete information on the number of spectators, number of patients, type, location, and duration of the mass gathering were included in the primary analysis. As available, additional information was added including the described weather patterns, number of patients transported to a hospital, and number of patients suffering a cardiac arrest. Thirty-five of the approximately 100 articles reviewed, met these criteria. RESULTS: A Spearman Rank Correlation Coefficient was calculated for number of spectators and patients and a significant relationship was identified (p = 0.0001). Mann-Whitney U-tests indicated that papal masses (p = 0.04), rock concerts (p = 0.005), hot climatic conditions (p = 0.03), and events held in the British Commonwealth (p = 0.03) had a significantly higher frequency of patient visits. Significantly more cardiac arrests occurred at papal masses (p = 0.04) and sporting events (p = 0.0002). CONCLUSIONS: Type of event, country, weather, and the size of the mass gathering had a significant effect on the numbers of spectators seeking medical care. A uniform classification scheme is necessary for future prospective studies of mass gatherings. PMID- 10179214 TI - The Disaster Outreach concept. PMID- 10179213 TI - The dynamic nature of ST-segment and T-wave changes during acute MI. AB - Obtaining a prehospital 12-lead electrocardiogram (ECG) diagnostic of acute myocardial injury has been demonstrated to hasten the administration of thrombolytic agents in the emergency department. This case demonstrates that a prehospital electrocardiogram diagnostic of acute anterior wall infarction can become non-diagnostic following routine administration of oxygen, nitroglycerin, and morphine by paramedics. Although this phenomenon has been observed in the in hospital setting, it has not been reported in patients with a prehospital ECG. PMID- 10179215 TI - The next link. Assisted living enters into the health care continuum. PMID- 10179216 TI - Cost conscious. PMID- 10179217 TI - Managing wound care. Utilization management ensures optimal clinical outcomes. PMID- 10179218 TI - The XY&Zs of seating issues. Steps to receive seating equipment funding in the long-term-care setting. PMID- 10179219 TI - Staffing solutions. New staffing models are essential in today's changing health care environment. PMID- 10179220 TI - Back on track. Exercise and education are key elements in back injury rehabilitation. PMID- 10179221 TI - Risk management strategies. Steps and procedures that protect both you and your patient. PMID- 10179222 TI - Taking control. Cancer rehabilitation allows patients to increase the quality of their lives and reclaim independence. PMID- 10179224 TI - New salary equivalency guidelines. How they will affect rehab professionals. PMID- 10179223 TI - Outcomes and case management. The keys to survival under managed care capitation. PMID- 10179225 TI - Can online patient records be private? PMID- 10179226 TI - Diagnosing diabetes. PMID- 10179227 TI - Leaping beyond pen, paper in cell processing labs. PMID- 10179228 TI - Panel doesn't endorse patients' rights law. PMID- 10179229 TI - Enhancing referrals with a computer-generated form. PMID- 10179230 TI - Physician practice management companies: too good to be true? PMID- 10179231 TI - Staff management. How to keep salaries on track and under control. PMID- 10179232 TI - Volunteers save valuable staff time, provide family support in critical care units. PMID- 10179233 TI - Sentinel event reporting update. PMID- 10179234 TI - "Take Care of Yourself" project can avoid frivolous office visits. PMID- 10179235 TI - African Index Medicus--a cooperative undertaking. AB - Although MEDLINE covers many of the significant medical periodical articles published in developed countries, there is still a considerable amount of medical and health documentation from countries outside the major industrialized areas which is not included. This paper outlines various initiatives to address this, and goes on to describe the setting up, on a cooperative basis, of the African Index Medicus, the problems encountered and progress made. 'Even if we should presume that most of the world's valid, important biomedical information originates in the West--and there is evidence (...) to suggest that this is wilful self delusion--what about at least a minority contribution from the rest? The 2% participation in international scientific discourse allowed by Western indexing services is simply too little to account for the scientific output of 80% of the world.' PMID- 10179236 TI - International cooperation and the European Association for Health Information and Libraries. AB - This paper describes cooperation between European libraries: what EAHIL hopes to achieve, and how it may be done. Since its founding in 1987, EAHIL has been working for professional development and to improve cooperation and exchange of experience amongst its members. In 1995 a working programme entitled 'EAHIL--Aims towards year 2000' was approved, and it consolidates some of the most important aims of EAHIL. In this paper, only three of the six aims are referred to: conferences and workshops arranged by EAHIL, the development of an efficient network system in order to increase communication and information among members, and the establishment of agreements for cooperation with medical and health science libraries in Eastern and Central Europe in particular. PMID- 10179237 TI - Nordic cooperation--expanding to the Baltic countries. AB - The paper describes the establishment in 1995 of the Nordic Association for Medical and Health Information, bringing together the five national associations from Denmark, Norway, Sweden, Iceland and Finland. Many forms of good and informal cooperation between these countries have always existed, but an association is needed to be able to officially act as a unified medical library community. Since the opening up of Eastern Europe to the West in the early 1990s, their need for professional updating and literature was paramount, and one of the current concerns of the Nordic Association is cooperation with the Baltic countries. PMID- 10179238 TI - Restoring the Tower of Babel: building a multilingual thesaurus on health promotion. AB - In 1994 the International Union for Health Promotion and Health Education, Regional Office for Europe (IUHPE/EURO), began a thesaurus project in the field of health promotion and health education, in collaboration with terminologists and health promotion specialists from various European countries. This article describes the different phases of the international project. Special attention is paid to the origin of the project and the international cooperative imperative needed to bring such a project to fruition. PMID- 10179239 TI - CD-ROMs review 1995-1997: a multicentre pilot trial. AB - This article describes an evaluation of CD-ROMs carried out at four NHS Trust Libraries in Wales. It covers interactive CD-ROMs which take the form of either computer assisted learning programs, encyclopaedia or well-known text books. PMID- 10179240 TI - Project Connect: information for health care networked across North Thames. PMID- 10179241 TI - Document access over the Web--an intranet solution. PMID- 10179242 TI - A gallimaufry of evidence. PMID- 10179243 TI - A practical guide to preemption for self-insured plans. AB - This article discusses the circumstances under which federal law preempts state law regulating self-insured plans. In particular, the author describes four recent cases in which ERISA preemption was challenged, including relevant issues of debate and conclusions. The article points out that the decisions that result from such cases are contributing to the guidelines that states are developing to regulate ERISA plans. PMID- 10179244 TI - Designing and managing employer-sponsored long-term care plans. AB - Due to prevalent demographic factors, long-term care is an issue of increasing concern to American workers. The cost and time involved in ever-expanding long term care responsibilities for many employees has resulted in increased indirect employer costs. The authors argue that providing' long-term care as part of the employee benefit plan is an efficient and effective way to manage these increasing costs for both the employer and the employee. The article offers discussion of plan design for long-term care, including issues to be considered and strategy for plan management. PMID- 10179245 TI - Practice brief. Issue: Designing a data collection process. American Health Information Management Association. PMID- 10179246 TI - Do existing controlled vocabularies contain terminology needed for patient records? AB - A 1996-97 study conducted by the National Library of Medicine and the Agency for Health Care Policy and Research aimed to determine how well existing vocabularies cover the concepts and terms needed in health information systems. The author describes the hypothesis underlying the study, how the process worked, its findings, and implications for future vocabulary development. PMID- 10179247 TI - The development and role of the Read Codes. AB - Produced and maintained by Britain's National Health Service, the Read Codes are a comprehensive, controlled clinical vocabulary. Here's a look at how the codes evolved, their use in the NHS, and the continual process of aligning the system with the needs of its users. PMID- 10179248 TI - SNOMED: a controlled vocabulary for computer-based patient records. AB - SNOMED is a detailed and specific coded vocabulary of names and descriptions used in healthcare--explicitly designed for use in the computerized patient record. Here's an overview of this system and a look at its next generation. PMID- 10179250 TI - To sign or not to sign verbal orders. PMID- 10179249 TI - Nursing data, classification systems, and quality indicators: what every HIM professional needs to know. AB - The nursing profession has developed a number of classification systems. What can HIM professionals learn from the processes and results? This article presents an overview of the major nursing classification systems and examines some of the national efforts to standardize nursing data elements. PMID- 10179251 TI - Development of the ICD-10 Procedure Coding System (ICD-10-PCS). AB - The ICD-10 Procedure Coding System (ICD-10-PCS) has been developed as a replacement for Volume 3 of ICD-9-CM. This article will describe the development and structure of ICD-10-PCS--as well as describe the modifications that have been made to the system as a result of extensive review and testing. PMID- 10179252 TI - Testing ICD-10-PCS. PMID- 10179253 TI - The development of coding certification for physician services. PMID- 10179254 TI - National job analysis of the hospital-based certified coding specialist. PMID- 10179255 TI - CCS coding competencies--ICD-9-CM and CPT/HCPCS procedural coding. PMID- 10179256 TI - Our surgical heritage. Westward expansion and the 13 colonies. PMID- 10179257 TI - Our surgical heritage. The Ohio Valley migration. PMID- 10179258 TI - Our surgical heritage. The Civil War. PMID- 10179259 TI - Fellows in Congress: an interview with Rep. John Cooksey, MD, FACS. Interview by Diane S. Schneidman. PMID- 10179260 TI - Statement on principles guiding care at the end of life. American College of Surgeons' Committee on Ethics. PMID- 10179261 TI - In their own words. Practicing Physicians Advisory Council of the National Committee for Quality Assurance. PMID- 10179262 TI - National health expenditures. PMID- 10179263 TI - Upcoming regulation of patient information. PMID- 10179264 TI - Security and confidentiality in an electronic medical record. AB - The maintenance of privacy and confidentially must remain a core principle of the interaction between patients and medical staff. Traditionally, the single paper copy of the medical history has been treated with systematic handling, careful tracking, and respect for the integrity and confidentiality of the contents. The widespread availability of computerized information requires that these principles be maintained in the electronic environment. Security measures should protect sensitive data without hindering medical practice. At Mayo, we have established data security policies and standards for the handling of all electronic information. Dissemination and communication of these standards and guidelines are an ongoing challenge. Technical maneuvers can be employed to protect data integrity, identify users, and monitor compliance. Personnel policies must be updated to reflect the responsibilities and liabilities of the electronic environment. Practice efficiencies and access to clinical data must be balanced by individual responsibility and accountability for privileged patient information. PMID- 10179265 TI - It's 10 p.m.--do you know where your data are? PMID- 10179266 TI - Information security at the Fifteenth Medical Group. PMID- 10179267 TI - Initiatives and experiences in developing, implementing, and administering data security and confidentiality policies. PMID- 10179268 TI - Piecing together the security puzzle: the feasibility of securing clinical and patient data in Internet applications. PMID- 10179269 TI - Secure Internet access to patient medical information. PMID- 10179270 TI - Security and the Internet: healthcare's concerns and approaches to think, build, and operate solutions today. PMID- 10179271 TI - Policy on confidentiality for patients. Partners HealthCare System, Inc. PMID- 10179272 TI - The outcomes movement and the role of health information managers. AB - The resounding demand that health care organizations demonstrate their effectiveness in providing quality patient services is being voiced by federal and state governments, managed care organizations, the Joint Commission on Accreditation of Healthcare Organizations, and businesses and insurers purchasing and paying for health care services. The outcomes movement arose in response to these demands and is intended to provide a means for increasing medical effectiveness and reducing costs. The article presents an overview of the outcomes movement and discusses the use of outcomes data, the challenges and issues associated with outcomes assessment, and how health information managers can play a role in facilitating outcomes assessment. It suggests areas of professional development that health information managers may wish to explore. PMID- 10179273 TI - Hospice quality improvement programs: an initial examination. AB - Recognizing that little is known about use of quality improvement (QI) processes to enhance care of the dying, 11 large hospices exchanged information about their QI programs. These hospices reported monitoring from 3 to 50 outcomes measured by various indicators and methods. Agencies that related QI to their organization's mission, goals, and strategic plan were more likely to have dedicated QI staff; a more intense, comprehensive, and participatory QI program; and more QI projects resulting in performance enhancement. Both accomplishments and difficulties were identified in several areas, including establishing benchmarks, involving staff, and using computer technology to manage and analyze QI data. PMID- 10179274 TI - Cross-referencing of ISO-9000 and regulatory quality systems at blood centers. AB - Blood banks can utilize ISO-9000 to standardize the level of quality within the organization. This standardization can be cross-referenced with the existing quality system in the blood bank, more specifically the quality systems required by the Food and Drug Administration and the American Association of Blood Banks, to provide for higher-quality products and services. PMID- 10179275 TI - Measuring the quality of chiropractic alternative care in a managed care environment. AB - Today's health care environment is more consumer driven with regard to quality issues, and consumers want open access to alternative care, which includes chiropractic care. Given the growing demand for quality, the majority of the top health care plans are requiring their providers to participate in a credentialing process and an on-site office review. These standards allow managed care organizations to make an informed, objective decision regarding the network selection process of chiropractic providers. PMID- 10179276 TI - Nursing home quality indicators and quality improvement initiatives. AB - Quality indicators and a quality monitoring system developed for use in the regulatory survey process offer a quality improvement tool for nursing home staff. The systematic use of resident assessment data can aid in the identification of quality of care problems and the determination of the nature of those problems. The approach is particularly useful in routine and special quality assurance efforts. PMID- 10179277 TI - Outcome-based quality improvement in home health care: the OASIS indicators. AB - The outcomes movement in home health care is expanding rapidly, with strong support from both the industry and Medicare. The Federal government has proposed requiring all Medicare-certified agencies to collect data items from the Outcome and Assessment Information Set (OASIS) to form the basis for standardized risk adjusted outcome reporting as part of a systematic outcome-based quality improvement (OBQI) approach. In addition to contributing to improving patient outcomes, OASIS data items, when combined with other assessment information, utilization data, and cost information, can provide home health care agencies with a powerful integrated information set for internal management and strategic planning. PMID- 10179278 TI - Health care quality improvement in the emergency department: a reengineering approach. AB - Most health care organization processes can be compared with those in typical engineering, manufacturing, and service businesses, and improvement can be achieved in health care by means of many of the tools that are commonly found in non-health care industries. In fact, it may prove beneficial for health care organizations to consider obtaining help from professionals outside health care because such individuals probably will not have preconceived ideas about process improvement in such organizations. The article provides a success story in a health care process improvement effort that was undertaken by engineers in a large Los Angeles regional hospital in 1993. It discusses specific steps that were taken to obtain and synthesize data, achieve employee and management buy-in, analyze processes for strengths and improvement opportunities, assess customer satisfaction, implement changes, and measure results. PMID- 10179279 TI - Aspects of data quality in the new millennium. AB - A major topic of concern for the health information management (HIM) professional today is the quality of health care data. Although the coding professional within the HIM department has responsibility for assigning accurate clinical codes, often there are discrepancies or areas that need improvement. What ways are in place now to ensure quality clinical data? Quality programs and projects that can lead us into the next millennium are important to the HIM profession, administrators, health care payers, and state agencies. The challenges that we face are not without solutions. Sharing information and solutions is important for the individual and the profession as a whole. The article discusses four current but different ways in which data quality is looked at and addressed. PMID- 10179280 TI - Does gender make a difference? Factors that influence salary level in health information management. AB - The article examines factors that influence salary level among health information management professionals. Specifically, it addresses questions related to whether gender makes a difference in salary level or whether factors such as education and size of the organization are important. Findings suggest that education and size of the organization are the most important factors influencing salary level. The one notable exception is among newly credentialed registered record administrators. Here, men earn more than women when education and size of the organization are controlled variables. PMID- 10179281 TI - Patient dumping and EMTALA: past imperfect/future shock. PMID- 10179282 TI - The Emergency Medical Treatment and Active Labor Act: the anomalous right to health care. PMID- 10179283 TI - EMTALA in the '90s--enforcement challenges. PMID- 10179285 TI - What can go wrong and how to avoid it? PMID- 10179284 TI - Medicare fraud and abuse and qui tam: the dynamic duo or the odd couple? PMID- 10179286 TI - IS, outcomes and care management increasingly important, study says. PMID- 10179287 TI - Calculating ROI for CPRs. PMID- 10179288 TI - The gap: HIPAA and secure IT. AB - The Health Insurance Portability and Accountability Act (HIPAA) had many objectives and IT implications. But the greatest area of concern for most providers is security and privacy of electronic patient information. PMID- 10179289 TI - How to find who. AB - Master person indexes are considered the cornerstone of many health care systems integration projects. Although a fundamental first step, mastering the master person index is an IT challenge when organizations expand. PMID- 10179290 TI - Coping with merger-mania: IT's new role. AB - Integrating two organizations after a merger presents a major challenge. The blending of information systems, business processes, facilities and organizational structure requires IT personnel to accept a new role. PMID- 10179291 TI - IT for managed care at Mercy Healthcare. PMID- 10179292 TI - What works. Palm-size system helps behavioral care provider move to daily billing and increase number of visits. PMID- 10179293 TI - What works. Wireless LAN fixes double documentation dilemma. PMID- 10179295 TI - HotList: laboratory systems. PMID- 10179294 TI - What works. Trauma center slashes emergency diversion rate with exec info system. PMID- 10179296 TI - One plus one equals three: strategic partnerships. PMID- 10179297 TI - The contention within health economics: a micro-economic foundation using a macro economic analysis. AB - Health economists claim to use market economics combined with the micro-economic concepts of opportunity cost and the margin to advise on priority setting. However, they are advising on setting priorities through a macro-economic analysis using the costs of the supplier, thus prioritising the producer and not the consumer as the dynamic of economic activity. For health economists any contention within priority setting is due to lack of data not their confusion over fundamental concepts. PMID- 10179298 TI - Alternative medicine in Slovenia: some social-medical views. AB - This article analyses the viewpoints of doctors, patients and the state of the phenomenon of unconventional methods of treatment/alternative medicine in Slovenia. The doctors' view-points are taken from the official documents of the Medical Chamber of Slovenia and the Slovene Medical Association. The patients' viewpoints are established on the basis of public opinion and epidemiological research, carried out in 1994 and 1996 on two representative samples of the Slovene population from the Celje area. The estimation of the attitude of the state is based on legislation and other regulations connected with alternative medicine. The findings of our analysis show a strongly negative attitude of doctors to any form of alternative medicine. In contrast, as many as half the patients express a favourable opinion on alternative methods of treatment, and more than a third of them actually make use of them. From existing laws it is evident that the state in general does not deal with alternative medicine, except for possibilities in such cases when a doctor or some other healthcare professional uses alternative (non-verified) methods of treatment. Alternative medicine is, from the point of view of social medicine, a phenomenon that should be followed, analysed and controlled. Dangerous as well as protective factors which accompany the execution of alternative methods should be recognised so as to be able to inform the public of the results in a timely and accurate manner. Because of the need for the legal and healthcare security of Slovene citizens, the state should regulate existing unconventional treatments. PMID- 10179299 TI - The wisdom of lay knowledge: a reply to Loughlin and Prichard. PMID- 10179300 TI - Returning to the point: a reply to the 'Riposte' of Pilgrim and Rogers. PMID- 10179302 TI - Medical devices; preemption of state product liability claims--FDA. Correction. PMID- 10179301 TI - Medical devices; reclassification of tumor-associated antigen immunological test system--FDA. Final rule. AB - The Food and Drug Administration (FDA) is announcing that it is codifying the reclassification of tumor-associated antigen immunological test systems intended as an aid in monitoring patients for disease progression or response to therapy or for the detection of recurrent or residual disease from class III (premarket approval) to class II (special controls). FDA is also announcing that it has issued an order in the form of a letter to Centocar, Inc., reclassifying serum tumor markers into class II. This action is being taken under the Federal Food, Drug, and Cosmetic Act (the act), as amended by the Medical Device Amendments of 1976 and the Safe Medical Devices Act of 1990. PMID- 10179303 TI - Revocation of regulation on positron emission tomography drug products--FDA. Final rule; revocation. AB - The Food and Drug Administration (FDA) is revoking a regulation on positron emission tomography (PET) radiopharmaceutical drug products. The regulation permits FDA to approve requests from manufacturers of PET drugs for exceptions or alternatives to provisions of the current good manufacturing practice (CGMP) regulations. FDA is taking this action in accordance with provisions of the Food and Drug Administration Modernization Act of 1997 (Modernization Act). Elsewhere in this issue of the Federal Register, FDA is publishing a notice revoking two notices concerning certain guidance documents on PET drugs and the guidance documents to which the notices relate. PMID- 10179304 TI - Medicare and Medicaid programs; hospital conditions of participation; provider agreements and supplier approval--HCFA. Proposed rule. AB - This proposed rule would revise the requirements that hospitals must meet to participate in the Medicare and Medicaid programs. The revised requirements focus on patients care and the outcomes of that care, reflect a cross-functional view of patient treatment, encourage flexibility in meeting quality standards, and eliminate unnecessary procedural requirements. These changes are necessary to reflect advances in patient care delivery and quality assessment practices since the requirements were last revised in 1986. They are also an integral part of the Administration's efforts to achieve broad-based improvements in the quality of care furnished through Federal programs and in the measurement of that care, while at the same time reducing procedural burdens on providers. In addition, in an effort to increase the number of organ donations, we are proposing changes in the interaction between hospitals and organ procurement organizations. The proposed rule also would specify that HCFA may terminate the participation agreement of a hospital, skilled nursing facility, home health agency, or other provider if the provider refuses to allow access to its facilities, or examination of its operations or records, by or on behalf of HCFA, as necessary to verify that it is complying with the Medicare law and regulations and the terms of its provider agreement. PMID- 10179305 TI - Interim rules for mental health parity--IRS, DoL, HCFA. Interim rules with request for comments. AB - This document contains interim rules governing parity between medical/surgical benefits and mental health benefits in group health plans and health insurance coverage offered by issuers in connection with a group health plan. The rules contained in this document implement changes made to certain provisions of the Internal Revenue Code of 1986 (Code), the Employee Retirement Income Security Act of 1974 (ERISA or Act), and the Public Health Service Act (PHS Act) enacted as part of the Mental Health Parity Act of 1996 (MHPA) and the Taxpayer Relief Act of 1997. Interested persons are invited to submit comments on the interim rules for consideration by the Department of the Treasury, the Department of Labor, and the Department of Health and Human Services (Departments) in developing final rules. The rules contained in this document are being adopted on an interim basis to ensure that sponsors and administrators of group health plans, participants and beneficiaries, States, and issuers of group health insurance coverage have timely guidance concerning compliance with the requirements of MHPA. PMID- 10179306 TI - HIPAA Mental Health Parity Act--IRS. Notice of proposed rulemaking by cross reference to temporary regulations. AB - Elsewhere in this issue of the Federal Register, the IRS is issuing temporary regulations relating to mental health parity requirements imposed on group health plans. These requirements were added to the Internal Revenue Code by section 1532 of the Taxpayer Relief Act of 1997. The IRS is issuing the temporary regulations at the same time that the Pension and Welfare Benefits Administration of the U.S. Department of Labor and the Health Care Financing Administration of the U.S. Department of Health and Human Services are issuing substantially similar interim final regulations relating to mental health parity requirements added by the Mental Health Parity Act of 1996 to the Employee Retirement Income Security Act of 1974 and the Public Health Service Act. The temporary regulations provide guidance to employers and group health plans relating to the new mental health parity requirements. The text of those temporary regulations also serves as the text of these proposed regulations. PMID- 10179307 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE Selected Reserve Dental Program--DoD. Final rule. AB - This final rule establishes the TRICARE Selected Reserve Dental Program (TSRDP) to provide dental care to members of the Selected Reserves of the Ready Reserve. The final rule details operation of the program. PMID- 10179308 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE Retiree Dental Program (TRDP)--DoD. Final rule. AB - This final rule establishes the TRICARE Retiree Dental Program (TRDP), a premium based indemnity dental insurance coverage program, that will be available to retired members of the Uniformed Services, their dependents, and certain other beneficiaries. PMID- 10179309 TI - Medical devices; refurbishers, rebuilders, reconditioners, servicers, and "as is" remarketers of medical devices; review and revision of compliance policy guides and regulatory requirements; request for comments and information--FDA. Advance notice of proposed rulemaking. AB - The Food and Drug Administration (FDA) is announcing its intention to review and, as necessary, to revise or to amend its compliance policy guides and regulatory requirements relating to the remarketing of used medical devices and the persons who refurbish, recondition, rebuild, service, or remarket such devices. The agency is considering these actions because it believes evolving industry practices warrant reevaluation of current policy and the application of certain regulatory requirements in order to ensure that particular remarketed devices meet suitable performance requirements for their intended uses, and are as safe as the originally marketed finished device. FDA is soliciting comments, proposals for alternative regulatory approaches, and information on these issues. In a future issue of the Federal Register, FDA will announce an open meeting of the Good Manufacturing Practices (GMP) Advisory Committee concerning these matters. PMID- 10179310 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); revisions to the eligibility requirements--DoD. Proposed rule. AB - This proposed rule revises the comprehensive CHAMPUS regulation pertaining to basic CHAMPUS benefits in accordance with several statutory changes. This proposed rule: sets forth the requirements for reinstatement of CHAMPUS eligibility for beneficiaries under age 65 who would otherwise have lost eligibility for CHAMPUS due to eligibility for Medicare as a result of disability or end-stage renal disease (ESRD); establishes new classes of CHAMPUS eligibles; establishes the Transitional Assistance Management Program which provides transitional health care for members (and their dependents) who served on active duty in support of a contingency operation and for members (and their dependents) who are involuntarily separated from active duty; allows former spouses who buy a conversion health policy to keep CHAMPUS eligibility for twenty-four (24) months for preexisting conditions that are not covered by the conversion policy; and makes minor technical revisions to the double coverage provisions. This proposed rule also adds a new category of eligible beneficiary under the Continued Health Care Benefit Program. PMID- 10179312 TI - Delegations of authority and organization--FDA. Final rule. AB - The Food and Drug Administration (FDA) is amending the regulations for delegations of authority and organization to set forth the current organizational structure of the agency as well as the current addresses for headquarters and field offices. This action is necessary to ensure the continued accuracy of the regulations. PMID- 10179311 TI - Medicare and Medicaid; resident assessment in long term care facilities--HCFA. Final rule. AB - This final rule establishes a resident assessment instrument for use by long term care facilities participating in the Medicare and Medicaid programs when conducting a periodic assessment of a resident's functional capacity. The resident assessment instrument (RAI) consists of a minimum data set (MDS) of elements, common definitions, and coding categories needed to perform a comprehensive assessment of a long term care facility resident. A State may choose to use the Federally established resident assessment instrument or an alternate instrument that is designed by the State and approved by us. These regulations establish guidelines for use of the data set and designation of the assessment instrument. The provisions contained in these regulations implement statutory requirements. The resident assessment instrument is intended to produce a comprehensive, accurate, standardized, reproducible assessment of each long term care facility resident's functional capacity. PMID- 10179313 TI - Plans established or maintained pursuant to collective bargaining agreements under section 3(40)(A)--Pension and Welfare Benefits Administration. Notice of intent to form a negotiated rulemaking advisory committee. AB - The Department of Labor (Department) intends to form a Negotiated Rulemaking Advisory Committee (Committee) in accordance with the Negotiated Rulemaking Act of 1990 and the Federal Advisory Committee Act. The Committee will negotiate the development of a proposed rule implementing the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. 1001-1461 (ERISA). The purpose of the proposed rule is to establish a process and criteria for a finding by the Secretary of Labor that an agreement is a collective bargaining agreement for purposes of section 3(40) of ERISA. The proposed rule will also provide guidance for determining when an employee benefit plan is established or maintained under or pursuant to such an agreement. Employee benefit plans that are established or maintained for the purpose of providing benefits to the employees of more than one employer are "multiple employer welfare arrangements" under section 3(40) of ERISA, and therefore are subject to certain state regulations, unless they meet one of the exceptions set forth in section 3(40)(A). At issue in this regulation is the exception for plans or arrangements that are established or maintained under one or more agreements which the Secretary finds to be collective bargaining agreements. If adopted, the proposed rule would affect employee welfare benefit plans, their sponsors, participants and beneficiaries, as well as service providers to plans. It may also affect plan fiduciaries, unions, employer organizations, the insurance industry, and state insurance regulators. PMID- 10179314 TI - Centers for Disease Control and Prevention. Human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), and tuberculosis (TB) related applied research projects. PMID- 10179315 TI - Medical devices; reports of corrections and removals; lift of stay of effective date--FDA. Final rule; lift of stay of effective date. AB - The Food and Drug Administration (FDA) is lifting a stay of the effective date of certain provisions in a final rule on establishing procedures for submission of reports of corrections and removals of medical devices. The Office of Management and Budget (OMB) has approved the collection of information requirements contained in the final rule. PMID- 10179316 TI - Status of certain additional over-the-counter drug category II and III active ingredients--FDA. Final rule. AB - The Food and Drug administration (FDA) is issuing a final rule stating that certain ingredients in over-the-counter (OTC) drug products are not generally recognized as safe and effective or are misbranded. FDA is issuing this final rule after considering the reports and recommendations of various OTC drug advisory review panels and public comments on proposed agency regulations, which were issued in the form of a tentative final monograph (proposed rule). Based on the absence of substantive comments in opposition to the agency's proposed nonmonograph status for these ingredients, as well as the failure of interested parties to submit new data or information to FDA under the regulation, the agency has determined that the presence of these ingredients in an OTC drug product would result in that drug product not being generally recognized as safe and effective or would result in misbranding. This final rule is part of the ongoing review of OTC drug products conducted by FDA. PMID- 10179317 TI - Fiscal year (FY) 1998 funding opportunities--SAMHSA. Notice of funding availability. AB - The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (CMHS), Center for Substance Abuse Treatment (CSAT) and Center for Substance Abuse Prevention (CSAP) announce the availability of FY 1998 funds for cooperative agreements for the following activities. These activities are discussed in more detail under Section 4 of this notice. This notice is not a complete description of the activities; potential applicants must obtain a copy of the Guidance for Applicants (GFA) before preparing an application. PMID- 10179318 TI - Publication of OIG Special Fraud Alert: fraud and abuse in nursing home arrangements with hospices--OIG. Notice. AB - This Federal Register notice sets forth a recently issued OIG Special Fraud Alert concerning fraud and abuse practices involving nursing home arrangements with hospices. For the most part, OIG Special Fraud Alerts address national trends in health care fraud, including potential violations of the Medicare anti-kickback statute. This Special Fraud Alert, issued to the health care provider community and now being reprinted in this issue of the Federal Register, specifically identifies and highlights some vulnerabilities in nursing home arrangements with hospices and instances of potential kickbacks between nursing homes and hospices to influence the referral of patients. PMID- 10179319 TI - Medical devices; 30-day notices and 135-day PMA (premarket approval application) supplement review--FDA. Direct final rule. AB - The Food and Drug Administration (FDA) is amending its regulations governing the submission and review of premarket approval application (PMA) supplements to allow for the submission of a 30-day notice for modifications to manufacturing procedures or methods of manufacture. Amendments are being made to implement revisions to the Federal Food, Drug, and Cosmetic Act (the act) as amended by the Food and Drug Administration Modernization Act of 1997 (FDAMA). FDA is publishing these amendments in accordance with its direct final rule procedures. Elsewhere in this tissue of the Federal Register, FDA is publishing a companion proposed rule under FDA's usual procedures for notice and comment to provide a procedural framework to finalize the rule in the event the agency receives any significant adverse comment and withdraws the direct final rule. PMID- 10179320 TI - Medical devices; 30-day notices and 135-day PMA (premarket approval application) supplement review; companion document to direct final rule--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to amend its regulations governing the submission and review of premarket approval application (PMA) supplements to allow for the submission of a 30-day notice for modifications to manufacturing procedures or methods of manufacture. Amendments are being made to implement revisions to the Federal Food, Drug, and Cosmetic Act (the act) as amended by the Food and Drug Administration Modernization Act of 1997 (FDAMA). This proposed rule is a companion document to the direct final rule published elsewhere in this issue of the Federal Register. PMID- 10179321 TI - Unified agenda of federal regulatory and deregulatory actions--HHS. Semiannual regulatory agenda. AB - The President's Executive Order 12866 and the Regulatory Flexibility Act of 1980 require the semiannual publication of an agenda which summarizes all current, projected, and recently completed rulemakings of the Department. The agenda enables the public to know about and to participate in the Department's regulations development work. The last such agenda was published on October 29, 1997. PMID- 10179322 TI - Unified agenda of federal regulatory and deregulatory actions--VA. Semiannual regulatory agenda. AB - This agenda announces the regulations that the Department of Veterans Affairs (VA) will have under development or review during the 12-month period beginning April 1998. The purpose in publishing the Department's regulatory agenda is to allow all interested persons the opportunity to participate in VA's regulatory planning. PMID- 10179323 TI - Radiology devices; classifications for five medical image management devices- FDA. Final rule. AB - The Food and Drug Administration (FDA) is classifying five radiology devices that provide functions related to medical image communication, storage, processing, and display into class I (general controls) or class II (special controls). The medical image storage device and medical image communications device are classified into class I, and they are exempted from the requirement of premarket notification when they do not use irreversible compression. The medical image digitizer, the medical image hardcopy device, and the picture archiving and communications system are classified into class II. These actions are being taken under the Federal Food, Drug, and Cosmetic Act (the act), as amended by the Medical Device Amendments of 1976 and the Safe Medical Devices Act of 1990. PMID- 10179324 TI - Reporting health care professionals to state licensing boards--VA. Final rule. AB - It continues to be the policy of the Department of Veterans Affairs (VA) to report to State Licensing Boards any separated physician, dentist, or other licensed health care professional whose clinical practice so significantly failed to meet generally accepted standards of clinical practice as to raise reasonable concern for the safety of patients. This document provides that, in addition, VA will report to State Licensing Boards any currently employed physician, dentist, or other licensed health care professional (one who is on VA rolls) whose clinical practice so significantly failed to meet generally accepted standards of clinical practice during VA employment as to raise reasonable concern for the safety of patients. Some health care professionals who are VA employees also provide health care outside VA's jurisdiction. Accordingly, the reporting of currently employed licensed health care professionals who meet the standard for reporting is necessary so that State Licensing Boards can take action as appropriate to protect the public. Examples of actions that meet the criteria for reporting are set forth in the text portion of this rulemaking. Also, nonsubstantive changes are made for purposes of clarity. PMID- 10179325 TI - Medicare and Medicaid programs; recognition of the American Association for Accreditation of Ambulatory Surgery Facilities, Inc. for Ambulatory Surgical Centers Program--HCFA. Proposed notice. AB - In this notice we announce the receipt of an application from the American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF) for recognition as a national accreditation program for ambulatory surgical centers that wish to participate in the Medicare or Medicaid programs. The Social Security Act requires that the Secretary publish a notice identifying the national accreditation body making the request, describing the nature of the request, and providing a 30 day public comment period. PMID- 10179326 TI - Natural rubber-containing medical devices; user labelling--FDA. Final rule; interpretation. AB - The Food and Drug Administration (FDA) is providing notice that it does not intend to apply to combination products currently regulated under human drug or biologic labeling provisions its September 30, 1997, final rule requiring certain labeling statements for all medical devices that contain or have packaging that contains natural rubber that contacts humans. FDA is taking this action, in part, in response to a citizen petition and other communications from industry that the agency has received since the publication of the final rule. FDA intends to initiate a proceeding to propose natural rubber labeling requirements for drugs and biologics, including combination products that are currently regulated under drug and biologic labeling provisions. Such a proceeding may include a combination of rulemaking and guidance and will offer opportunity for public comment. PMID- 10179327 TI - Federal financial participation in state assistance expenditures; federal matching shares for aid to families with dependent children, Medicaid, and aid to aged, blind, or disabled persons for October 1, 1997 through October 1, 1998 and for October 1, 1998 through September 30, 1999; clarification and correction- HHS. Notice of clarification and correction. AB - This Notice clarifies the status of Alaska and the District of Columbia shown in the Tables of Federal Medical Assistance percentages calculated for determining the amount of Federal matching in State-welfare and medical expenditures for Fiscal Years 1998 and 1999 and corrects an error for the District of Columbia for 1999. For Medicaid and for the Child Health Insurance Program, the percentages given in the notices are correct. For other uses, including the remaining Title IV programs, the Alaskan percentage for 1998 should be 50.00% and for 1999 should be 52.26%. The District of Columbia percentage should be 50.00% for both years. PMID- 10179328 TI - Health insurance reform: standards for electronic transactions--HCFA. Proposed rule. AB - This rule proposes standards for eight electronic transactions and for code sets to be used in those transactions. It also proposes requirements concerning the use of these standards by health plans, health care clearinghouses, and health care providers. The use of these standard transactions and code sets would improve the Medicare and Medicaid programs and other Federal health programs and private health programs, and the effectiveness and efficiency of the health care industry in general, by simplifying the administration of the system and enabling the efficient electronic transmission of certain health information. It would implement some of the requirements of Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996. PMID- 10179329 TI - National standard health care provider identifier--HCFA. Proposed rule. AB - This rule proposes a standard for a national health care provider identifier and requirements concerning its use by health plans, health care clearinghouses, and health care providers. The health plans, health care clearinghouses, and health care providers would use the identifier, among other uses, in connection with certain electronic transactions. The use of this identifier would improve the Medicare and Medicaid programs, and other Federal health programs and private health programs, and the effectiveness and efficiency of the health care industry in general, by simplifying the administration of the system and enabling the efficient electronic transmission of certain health information. It would implement some of the requirements of the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996. PMID- 10179330 TI - Medicare program; waiver requirements and solvency standards for provider sponsored organizations--HCFA. Interim final rule with comment period. AB - This interim final rule with a request for comments implements authority to waive, in the case of provider-sponsored organizations (PSOs) that meet certain criteria, the requirement that Medicare + Choice organizations be licensed by a State as risk-bearing entities. The waivers will be approved only under certain conditions where the State has denied or failed to act on an application for licensure. This rule also establishes solvency standards that certain entities must meet to contract as PSOs under the new Medicare + Choice program. These standards apply to PSOs that have received a waiver of the requirement that Medicare + Choice organizations be licensed by a State as risk-bearing entities. PMID- 10179331 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1999 rates--HCFA. Proposed rule. AB - We are proposing to revise the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement applicable statutory requirements, including section 4407 of the Balanced Budget Act of 1997, as well as changes arising from our continuing experience with the systems. In addition, in the addendum to this proposed rule, we are describing proposed changes in the amounts and factors necessary to determine rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes would be applicable to discharges occurring on or after October 1, 1998. We are also setting forth proposed rate-of-increase limits as well as proposing changes for hospitals and hospital units excluded from the prospective payment systems. PMID- 10179332 TI - National Vaccine Injury Compensation Program (VICP): effective date provisions of coverage of certain vaccines to the vaccine injury table--HRSA. Final rule. AB - Section 904(b) of the Taxpayer Relief Act of 1997 provides for an excise tax for three new vaccines, effective August 6, 1997. Petitions for compensation for injuries or deaths related to hepatitis B, Hib, and varicella vaccines may now be filed under the Vaccine Injury Compensation Program (VICP). This technical amendment amends the Code of Federal Regulations (CFR) to include a date certain (August 6, 1997) in section 100.3(c) of the Vaccine Injury Compensation regulations, so that there will be no uncertainty as to the coverage of these three vaccines. PMID- 10179333 TI - Removal of regulations regarding certification of antibiotic drugs--FDA. Direct final rule. AB - The Food and Drug Administration (FDA) is repealing its regulations governing certification of antibiotic drugs. The agency is taking this action in accordance with provisions of the Food and Drug Administration Modernization Act of 1997 (FDAMA). FDAMA repealed the statutory provision in the Federal Food, Drug, and Cosmetic Act (the act) under which the agency certified antibiotic drugs. FDAMA also made conforming amendments to the act. PMID- 10179334 TI - Medical device reporting: manufacturer reporting, importer reporting, user facility reporting, and distributor reporting--FDA. Direct final rule. AB - The Food and Drug Administration (FDA) is amending its regulations governing reporting by manufacturers, importers, distributors, and health care (user) facilities of adverse events related to medical devices. Amendments are being made to implement revisions to the Federal Food, Drug, and Cosmetic Act (the act) as amended by the Food and Drug Administration Modernization Act of 1997 (FDAMA). FDA is publishing these amendments in accordance with its direct final rule procedures. Elsewhere in this issue of the Federal Register, FDA is publishing a companion proposed rule under FDA's usual procedures for notice and comment to provide a procedural framework to finalize the rule in the event the agency receives a significant adverse comment and withdraws this direct final rule. PMID- 10179335 TI - Removal of regulations regarding certification of antibiotic drugs; companion document to direct final rule--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is publishing this companion proposed rule to the direct final rule, published elsewhere in this issue of the Federal Register, which is intended to repeal FDA's regulations governing certification of antibiotic drugs. The agency is taking this action in accordance with provisions of the Food and Drug Administration Modernization Act of 1997 (FDAMA). FDAMA repealed the statutory provision in the Federal Food, Drug, and Cosmetic Act (the act) under which the agency certified antibiotic drugs. FDAMA also made conforming amendments to the act. PMID- 10179336 TI - Sanofi Pharmaceuticals, Inc., et al.; withdrawal of approval of 21 new drug applications and 62 abbreviated new drug applications--FDA. Notice. AB - The Food and Drug Administration (FDA) is withdrawing approval of 21 new drug applications (NDA's) and 62 abbreviated new drug applications (ANDA's). The holders of the applications notified the agency in writing that the drug products were no longer marketed and requested that the approval of the applications be withdrawn. PMID- 10179337 TI - Medicare program; prospective payment system and consolidated billing for skilled nursing facilities--HCFA. Interim final rule with comment period. AB - This interim final rule implements provisions in section 4432 of the Balanced Budget Act of 1997 related to Medicare payment for skilled nursing facility services. These include the implementation of a Medicare prospective payment system for skilled nursing facilities, consolidated billing, and a number of related changes. The prospective payment system described in this rule replaces the retrospective reasonable cost-based system currently utilized by Medicare for payment of skilled nursing facility services under Part A of the program. PMID- 10179338 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1998 rates--HCFA. Final rule. AB - This final rule responds to public comments received on those portions of a final rule with comment period published in the Federal Register on August 29, 1997, that revised the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes resulting from the Balanced Budget Act (BBA) of 1997, Public Law 105-33. This rule also addresses public comments on other BBA changes relating to cost limits for hospitals and hospital units excluded from the prospective payment systems as well as direct graduate medical education payments that were included in the August 29, 1997 document. Generally, these BBA changes were applicable to hospital discharges occurring on or after October 1, 1997. PMID- 10179339 TI - Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 1999 rates; corrections--HCFA. Proposed rule; correction. AB - In the May 8, 1998 issue of the Federal Register (63 FR 25575), we published a proposed rule to revise the Medicare hospital inpatient prospective payment systems for operating costs and capital-related costs to implement necessary changes arising from our continuing experience with the system. This document corrects technical errors made in that document. PMID- 10179340 TI - Removal of regulations regarding certification of drugs composed wholly or partly of insulin; companion document to direct final rule--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is publishing this companion proposed rule to the direct final rule, published elsewhere in this issue of the Federal Register, which is intended to repeal FDA's regulations governing certification of drugs containing insulin and make conforming amendments to other sections of the agency's regulations. The agency is taking this action in accordance with provisions of the Food and Drug Administration Modernization Act of 1997 (FDAMA). FDAMA repealed the statutory provision in the Federal Food, Drug, and Cosmetic Act (the act) under which the agency certified drugs containing insulin. FDAMA also made conforming amendments to the act. PMID- 10179341 TI - Removal of regulations regarding certification of drugs composed wholly or partly of insulin--FDA. Direct final rule. AB - The Food and Drug Administration (FDA) is repealing its regulations governing certification of drugs containing insulin and making conforming amendments to other sections of its regulations. The agency is taking this action in accordance with provisions of the Food and Drug Administration Modernization Act of 1997 (FDAMA). FDAMA repealed the statutory provision in the Federal Food, Drug, and Cosmetic Act (the act) under which the agency certified drugs containing insulin. FDAMA also made conforming amendments to the act. FDA is using direct final rulemaking for this action because the agency expects that there will be no significant adverse comment on the rule. Most of the amendments in this rule are a direct result of the repeal of the statutory certification provision. The remainder of the amendments repeal or update out-of-date, noncontroversial regulations dealing with insulin. Elsewhere in this issue of the Federal Register, FDA is publishing a companion proposed rule under FDA's usual procedure for notice-and-comment rulemaking to provide a procedural framework to finalize the rule in the event the agency receives significant adverse comments and withdraws this direct final rule. PMID- 10179342 TI - CLIA program; simplifying CLIA regulations relating to accreditation, exemption of laboratories under a state licensure program, proficiency testing, and inspection--HCFA. Final rule. AB - This final rule responds to selected comments received on a final rule with a comment period implementing the Clinical Laboratory Improvement Amendments of 1988, which was published in the Federal Register on February 28, 1992, in the areas of proficiency testing and inspections for clinical laboratories. In responding to these comments, we accommodate, when possible, the Administration's regulatory reform initiative by reducing duplicative material, emphasizing outcome-oriented results, and simplifying regulations. In that regard, we also are streamlining our regulations in the areas of State exemption, and granting deemed status to laboratories accredited by an approved accreditation organization. PMID- 10179343 TI - Establishment registration and listing for manufacturers of human cellular and tissue-based products--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to require manufacturers of certain human cellular and tissue-based products to register with the agency and list their products. In addition, the agency is proposing to amend the registration and listing regulations that currently apply to human cellular and tissue-based products regulated as drugs, devices, and/or biological products. This action is being taken to establish a unified registration and listing program for human cellular and tissue-based products. PMID- 10179344 TI - Delegations of authority and organization; Center for Devices and Radiological Health--FDA. Final rule. AB - The Food and Drug Administration (FDA) is amending the regulations for delegations of authority to reflect a new delegation that authorizes the Division Directors, Office of Device Evaluation (ODE), Center for Devices and Radiological Health (CDRH) to approve, disapprove, or withdraw approval of product development protocols and applications for premarket approval for medical devices. PMID- 10179345 TI - Medicare program; revision to accrual basis of accounting policy--HCFA. Proposed rule. AB - Current policy provides that payroll taxes a provider becomes obligated to remit to governmental agencies are included in allowable costs under Medicare only in the cost reporting period in which payment (upon which the payroll taxes are based) is actually made to an employee. Therefore, for payroll accrued in one year but not paid until the next year, the associated payroll taxes on the payroll are not an allowable cost until the next year. This proposed rule would make one exception, in the situation where payment would be made to the employee in the current year but for the fact the regularly scheduled payment date is after the end of the year. In that case, the rule would require allowance in the current year of accrued taxes on payroll that is accrued through the end of the year but not paid until the beginning of the next year, thus allowing accrued taxes on end-of-the year payroll in the same year that the accrual of the payroll itself is allowed. The effect of this proposal is not on the allowability of cost but rather only on the timing of payment; that is, the cost of payroll taxes on and-of-the-year payroll would be allowable in the current period rather than in the following period. PMID- 10179346 TI - Environmental assessments and findings of no significant impact--FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing that it has reviewed environmental assessments (EA's) and issued findings of no significant impact (FONSI's) relating to the 167 new drug applications (NDA's) and supplemental applications listed in this document. FDA is publishing this notice because Federal regulations require public notice of the availability of environmental documents. PMID- 10179347 TI - Intensive care. AB - America's teaching hospitals are world-renowned for their medical know-how. But they're being thrown for a loop by cost-conscious managed care plans and leaner federal budgets. PMID- 10179348 TI - A popular legislative prescription. PMID- 10179349 TI - Fewer doctors for underserved areas. PMID- 10179350 TI - A new growth chart for health insurers. PMID- 10179351 TI - System tries to boost productivity by looking at total health care picture. PMID- 10179353 TI - Compensation monitor. Demand for primary care physicians slackens while outlook for specialists seems to brighten. PMID- 10179352 TI - CDC enlists clinical advances in battle against sexually transmitted diseases. PMID- 10179354 TI - Are there too many cooks writing the books? PMID- 10179355 TI - Bailing out of Medicaid managed care programs. PMID- 10179356 TI - Congress debates managed care reform. PMID- 10179357 TI - HMOs won't look twice at AMA's model agreement. PMID- 10179358 TI - Protect against outliers that destroy your profitability under a contract. PMID- 10179359 TI - Direct-to-consumer advertising: helpful or harmful--or maybe both? PMID- 10179360 TI - Managed care outlook. Benefits drive consumers when they pick plans. AB - According to a National Research Corp. study, out of pocket expense is important to customers when selecting a managed care plan--more important than physician office locations--but not so important as the benefits a plan offers. NRC received responses from 165,000 households. PMID- 10179361 TI - Taking care of the Y2K bug. AB - Since the industrial revolution in the late 19th century, doomsayers have predicted that man's obsession with technology would be his ultimate undoing. As support, look no further than Year 2000 (Y2K), or the Millennium Bug, a mind numbingly simple technology flaw with staggering implications. PMID- 10179362 TI - Overcoming a silent challenge. AB - Hearing loss for infants and young children is a silent and hidden limitation. Early diagnosis and intervention can minimize consequences of hearing loss and maximize speech-language acquisition for affected children. PMID- 10179363 TI - Mergers--true integrations. AB - This article is the first of a two-part series focusing on clinical consolidation in mergers. While the frequency of hospital mergers is growing at tremendous rates, the actual consolidation of services following mergers is slow. This article will explain why, despite the enormous benefits that can be achieved, clinical consolidation is not tackled. Finally, the resources and key issues for successful clinical consolidation will be shared. Part 2 of this article, which follows in the next issue, will focus on the structure and process for successful clinical consolidation. PMID- 10179364 TI - Analysis and assessment: keys to improving organ/tissue donation. PMID- 10179365 TI - Greater value for your dollar. PMID- 10179366 TI - Seasoned citizens: the spice of your workforce. PMID- 10179367 TI - An age old debate. AB - On the national level, only Oregon currently permits assisted suicide. Thirty five states have statutes that ban the practice while nine others (including Michigan) seemingly prohibit it under common law principles, without a specific statute that speaks to the point. PMID- 10179369 TI - Y2K--not just a computer issue. PMID- 10179368 TI - Health in Michigan communities. PMID- 10179370 TI - Data networking: issues for you to consider. PMID- 10179371 TI - Two strongs do make a right. PMID- 10179372 TI - Stark II proposed regulations. More restrictions, more confusion. PMID- 10179373 TI - Stark II proposed regulations. Impacting group practices and physician employers. PMID- 10179374 TI - Boards played defining role. PMID- 10179375 TI - The Michigan Hospital Report. AB - This year, the MHA will release its third annual volume of the Michigan Hospital Report. The first two versions of the report focused primarily on performance information, such as hospital-specific information on length of stay and mortality rates for common types of cases as well as cesarean section rates. That continues this year, along with information dealing with community benefits, health status and financial data. PMID- 10179376 TI - Meeting the ORYX challenge. PMID- 10179377 TI - The right perspective on data. PMID- 10179378 TI - How to communicate value. AB - Providing for the community's well-being by improving health status, increasing access to care, and holding down health care costs, once considered benchmarks to reach, are now compulsory requirements. The challenge to Michigan's hospitals is to quantify benefits and communicate their value in a meaningful and standardized manner. PMID- 10179379 TI - Data security. A token effort. PMID- 10179380 TI - Getting the most out of HEDIS reporting. PMID- 10179381 TI - Reliable answers via the Web. PMID- 10179382 TI - Provider automation. Where should we start? AB - For an integrated delivery system in Memphis, the starting point for its enterprisewide automation efforts was obvious. It had an immediate need to improve business operations. PMID- 10179383 TI - Too 'wired' to sleep. Interview by Bill Siwicki. PMID- 10179384 TI - Managed care IT strategies. PMID- 10179385 TI - Special report. Outcomes. AB - To meet the demands of consumers and payers, more providers are using computer based systems to research clinical outcomes and prove they delivery high-quality, low-cost health care. PMID- 10179386 TI - Data mining: digging for real answers. PMID- 10179388 TI - More CIOs calling the doctor for clinical systems matters. PMID- 10179387 TI - Telemedicine providers ponder the profitability issue. PMID- 10179389 TI - Marketing research activities in hospitals. Satisfaction surveys of inpatients and outpatients are the most widely used application. AB - Virtually unheard of in health care 30 years ago, marketing research by hospitals is expanding at a notable rate, particularly among larger institutions located in highly competitive urban markets. Research applications are particularly pronounced at for-profit institutions, those heavily involved in managed care programs, and hospitals that are part of an integrated delivery system. However, the majority of hospital administrators surveyed indicated they do not invest in marketing research to track the effectiveness of their own institution's advertising. PMID- 10179390 TI - Quality determinants and hospital satisfaction. Perceptions of the facility and staff might be key influencing factors. AB - Perceptions of service quality ultimately affect consumer satisfaction, but objective measures of quality can be hard to come by when evaluating the quality of clinical care in a hospital. To determine if dimensions other than those found in models such as SERVQUAL were at play, the authors undertook a survey of 472 consumers, who were divided into two groups: those who had been hospital patients within the last three years (users) and those who were visitors (observers). The results suggest that facilities-related and human-factor related considerations helped shape the quality assessments of both groups, with observers generally giving higher marks to the hospitals with which they were familiar on the dimension of facilities-related quality and users expressing a less critical view of the human-factor dimension. PMID- 10179391 TI - Switching HMO providers. Dissatisfaction with emergency access cited as the primary reason for disenrollment. AB - The reasons consumers choose one service provider over another are not necessarily the same as the reasons for changing service providers. The distinctions may be even more important when the service in question is health care, specifically the decision to reenroll or switch HMO providers. The authors undertook a consumer survey to gauge the importance of 41 variables in the decision process. Using logistic regression analysis, they concluded that variables associated with access to emergency care services had the greatest impact on decisions to switch. This is contrary to other studies, which have ranked emergency care access much lower, and additional research is recommended. PMID- 10179392 TI - Cultural affiliation and the importance of health care attributes. Marketers can develop segmentation strategies for targeted patient groups. AB - Culturally based values are known to influence consumer purchase decisions, but little is known about how those values affect health care choices. To rectify that situation and provide health care marketers with a framework for developing culturally based segmentation strategies, the authors undertook an exploratory research project in which Hispanic-, African-, and Anglo-Americans were asked to rate the importance of 16 different health care attributes. Those attributes can be grouped under five categories: quality of physician, quality of nurses and other medical staff, economic issues, access to health care, and nonmedically related experiential aspects. Survey responses identified distinct differences in the importance attached to the various attributes by the three cultural groups. The study also looks at the impact of six demographic and social characteristics on the evaluations made by each cultural group. Those characteristics are educational level, gender, age, health status, marital status, and number of people living in the household. PMID- 10179393 TI - Critical service encounter models and dentistry. PMID- 10179394 TI - Marketing long-term care insurance. Public education ads to the proper target must precede sales efforts. AB - The ingredients for a financial calamity affecting both government and individual citizens and their families are in place. Federal legislators have made little progress in addressing the health care needs of an aging America, and the proposals that have been advanced offer little or nothing in the way of better help with long-term care. One potential scenario is that middle-income retirees placed in long-term care will exhaust their finances and then turn to Medicaid, creating an enormous expense for the government. Long-term care insurance could alleviate the situation, but current practices by the insurance industry in marketing products to the elderly complicate the sale of such insurance. Consumers approaching retirement age are receptive to this type of product, but first they must be made aware of the merits of long-term care insurance and the paucity of alternatives. Only then can marketers promote specific products successfully. PMID- 10179395 TI - Improving communication of long-term health care programs. PMID- 10179396 TI - Building Web sites that attract visitors. PMID- 10179397 TI - New partnerships not always a match made in heaven. PMID- 10179398 TI - Alabama hospital learns the hard way how not to enter Medicare risk contracting arena. AB - Jumping into Medicare risk without a life preserver: What happens when a provider enters a Medicare risk contract with no real case management program? It loses lots of money, as this Alabama provider has learned the hard way. Find out what this provider learned after losing millions--and how officials are correcting some fatal flaws. PMID- 10179399 TI - Focus on proactive care management to improve quality, produce savings in Medicaid risk. AB - Graduating to Medicaid preventive care management: After nearly 15 years in Medicaid risk contracting, Arizona health system's Medicaid plan discovers that acute care management doesn't cut it anymore, and moves toward proactive preventive care management that's already producing better outcomes and is expected to save millions. PMID- 10179400 TI - Compare your Medicare utilization to these geographic, DRG-based benchmarks. AB - Data File: Medicare inpatient utilization benchmarks. Actuarial consultants Milliman & Robertson find 53% of Medicare inpatient bed days nationally are medically unnecessary or better spent in other health care settings. Here are benchmark data on inpatient admission and bed days per 1,000 members in optimally managed health systems. PMID- 10179401 TI - PSO solvency standards application issued by HCFA. PMID- 10179402 TI - Marketplace. Kaiser beats a determined retreat from its market share strategy. PMID- 10179403 TI - Perspectives. What is lost if Congress overrides the states' negotiated tobacco settlement? PMID- 10179404 TI - Perspectives. New PEW report stirs dialogue on future nursing workforce needs. PMID- 10179405 TI - Special report. What will consumer protection cost?--Kaiser Family Foundation estimates Clinton commission's consumer bill of rights and responsibilities. PMID- 10179406 TI - Marketplace. Looking for new ways to measure payoff from employer health benefits. PMID- 10179407 TI - Perspectives. Expanding coverage signals growing demand, acceptance for alternative care. PMID- 10179408 TI - Perspectives. Effects of PARCA liability measure hard to see behind ERISA's veil. PMID- 10179409 TI - Perspectives. GAO keeps prodding, but HCFA treats sensitive disenrollment data cautiously. PMID- 10179410 TI - Marketplace. The booming Phoenix health care market shows effects of heated competition. PMID- 10179411 TI - Perspectives. External appeals touted as consumer confidence builder and liability shield. PMID- 10179412 TI - Managed indemnity insurance--a clear choice for health plan sponsors. AB - HOMs will undoubtedly remain the primary health plan choice for a significant portion of the nation's employers. However, some employers may find that managed indemnity insurance is more effective in meeting their needs and those of their employees. PMID- 10179414 TI - Hurting those who save: violence against EMS providers. PMID- 10179413 TI - Evaluate and communicate health care benefits. AB - Both employers and employees need appropriate information to make intelligent decisions about health care benefits. For employers, analysis of health care data offers an approach to monitoring quality care and can provide a tool for controlling costs. For employees, an education and communication strategy is probably the single most important factor influencing both program utilization and employee acceptance. PMID- 10179415 TI - Transporting patients down stairs: feetfirst or headfirst on the stretcher? PMID- 10179416 TI - EMS & managed care: where are we? PMID- 10179417 TI - Expanded-scope practice: EMS at the crossroads of care. PMID- 10179418 TI - EMS incident management: creating organization out of chaos. PMID- 10179419 TI - Unconventional patient positioning. PMID- 10179420 TI - How to lose your job in 10 easy steps. PMID- 10179422 TI - Day of the unsung heroes. Local agencies coordinate efforts in an EMS Week celebration. PMID- 10179421 TI - How to develop an effective infection-control program. Interview by Mike Spivak. PMID- 10179423 TI - Robotic carpet cleaning at Stanford Hospital delivers time and labor savings. PMID- 10179424 TI - Learn what motivates your employees: look to yourself. AB - Supervisors and managers tend to behave as though they are responsive to somewhat different motivating forces than their employees. However, employees at all levels are basically similar in terms of what they want to obtain from work. While drives vary in intensity from person to person, the basic motivating forces remain the same. Essentially it is not possible to "motivate" another as such; it is possible only to create the conditions under which another can become self motivated. The supervisor must appreciate the key principles of motivation, including the relationship between repetition and reinforcement and the importance of timely feedback. Also, the supervisor must learn what his or her legitimate role is concerning the fulfillment of employee needs. Successful supervisors will be those who are sensitive to their own needs and desires, credit their employees with the same or similar needs and desires, and treat employees in the manner in which they would like to be treated by higher management. PMID- 10179425 TI - Using data to reduce employee turnover. AB - Turnover in the health care industry is a major detriment to the delivery of cost efficient, quality care. But by analyzing specific data on an ongoing basis, a manager can determine the rationale for turnover and implement measures to improve it. This article examines the issue of turnover based on three years of data from a medium-sized, long-term care facility. Specifically it will focus on what data were examined and what they revealed, how the organization responded to the data, and what was resultant to the organization. Managers can replicate these processes for improvement in their facility. PMID- 10179426 TI - Making performance appraisals work more effectively. AB - Today's work environment requires improved employee performance levels in order to satisfy pressures for cost containment and efficient case management techniques. Effective use of performance appraisals can play a highly valuable role in accomplishing these requirements. Design and use of an active appraisal system is discussed in this article. PMID- 10179427 TI - Security in the management of information systems. AB - Although security technology exists in abundance in health information management systems, the implementation of that technology is often lacking. This lack of implementation can be heavily affected by the attitudes and perceptions of users and management, the "people part" of systems. Particular operational, organizational, and economic factors must be addressed along with employment of security objectives and accountability. Unique threats, as well as controls, pervade the use of microcomputer-based systems as these systems permeate health care information management. PMID- 10179428 TI - Maximizing the human resource asset. AB - Managers are challenged to provide for employees' needs and increased expectations in a way that will benefit both them and the organization without significant increases in human resource costs. This article suggests another look at motivation, employee involvement, and the value of work itself as a means of meeting these challenges. PMID- 10179429 TI - Growing older is not what it used to be. AB - Growing old is not what it used to be. Many self-care actions can enhance one's chance of growing old without illness or disease. This necessitates preparing for old age while one is young. Preparation for second adulthood can vastly improve physical and emotional health in old age. It is important that nurses and other health care professionals teach health promotion strategies to persons at all ages in order to assist individuals to live life to its fullest throughout their lifetime. PMID- 10179430 TI - Writing scholarly papers as a team. AB - Use of a team approach is a technique that can facilitate writing for professional publication. There is an art to writing with a team, which includes carefully selecting a writing partner who will complement personal skills and expertise and being able to work in a collaborative way through the writing process. There are benefits in the team approach that are of particular significance in mentoring novice writing in the publication process. However, there are also obstacles that should be anticipated and planned for. PMID- 10179431 TI - Waste and neglect: fraud and abuse in the health care industry. AB - Fraud is not only illegal, but it also increases the cost of health care, reduces the quality of services, and, when the defrauded party is the government, raises taxes. Federal and state law enforcement agencies have tried (and failed) to combat the problem single-handedly, but without the assistance of health care industry members, law enforcement agencies will never find an effective solution. As health care professionals, nurse executives have a responsibility to their patients and their country to make every effort to rid their organizations of fraudulent behavior. PMID- 10179432 TI - Nursing supervisors' view through rose-colored glasses: an overestimation of employees' positive attitudes. AB - Nursing supervisors, nurses, and nursing aides were surveyed regarding attitudes about their shared work environment. Results support the hypotheses indicating that supervisors will generally be more positive in their perceptions than will employees at lower levels in the organization. In this study, nursing supervisors reported higher levels of distributive justice and team cooperation as well as a more appropriate patient-to-staff ratio than did nurses and nursing aides. Further, the nurses reported significantly higher levels of politics than the supervisors. Suggestions for developing perceptions more realistic and consistent with subordinates are offered. PMID- 10179433 TI - Working toward Internet-integrated network applications. PMID- 10179434 TI - What will the future (of Medicare Commission) bring? PMID- 10179436 TI - Complying with physician gain-sharing restrictions. AB - Many IDSs are considering implementing gain-sharing programs as a way to motivate their physicians to provide high-quality, cost-effective services. Before embarking on such programs, however, IDSs need to understand the legal requirements associated with such programs to ensure that the gain-sharing arrangement is in compliance with Federal law. PMID- 10179435 TI - Transforming the HIM department into a strategic resource. AB - The transformation of a traditional (HIM) health information management department into a "virtual" HIM department can offer an IDS substantial economic advantages, improve patient satisfaction levels, enhance the quality of care, and provide greater accuracy in measuring and demonstrating healthcare outcomes. The HIM department's mission should be aligned with enterprise strategies, and the IDS should invest in technology that enables HIM to respond to enterprisewide information requirements. PMID- 10179437 TI - Percent-of-premium capitation yields mixed results in a Rhode Island case study. AB - In 1996, Harvard Pilgrim Health Care of New England (HPHC-NE) established six percent-of-premium arrangements with five Rhode Island PHOs. Each PHO received a percentage of the regional earned premium amounts for members who selected a primary care physician affiliated with it, adjusted for member demographics, benefit differences, and group size. Each of these six joint venture agreements also incorporated a per-member-per-month capitation fee. Despite improved communication between the PHOs and the plan and inpatient utilization reductions, all six joint ventures experienced losses beyond the withhold amounts during the first year of the arrangement. Factors affecting the medical utilization and financial results included market pressure on premium levels; risk pool size and adverse selection; and lack of timely, complete, and reliable financial and utilization data. PMID- 10179438 TI - Is your organization strategically prepared to be a Medicare PSO? AB - The new Medicare+Choice managed care program authorized by the Balanced Budget Act of 1997 affords hospitals and physicians an opportunity to contract directly with HCFA to provide services to Medicare beneficiaries through a provider sponsored organization (PSO). Developing and operating a Medicare PSO is a complex process, however, and organizations that lack certain strategic and operational "readiness" characteristics may encounter significant barriers to success. To ascertain their readiness to form a Medicare PSO, providers should assess their capabilities in six key strategic areas: culture and governance, organizational and legal structure, market position and strategy, provider network, risk-contracting experience and supporting infrastructure, and capital resources and fiscal soundness. PMID- 10179439 TI - Clinical buy-in is key to benchmarking success. AB - The effectiveness of benchmarking as a tool for improving the quality of healthcare services and reducing costs depends on the completeness of the data and physician acceptance of the findings. Benchmarking analyses based on cost center data, for example, do not account for many of the actual costs of performing a procedure and, therefore, may be of limited value. Benchmarking studies should use data that provide a complete, detailed picture of what each procedure entails to facilitate consistent comparisons among actual physician practices so that physicians can see clearly how their practices relate to best practices. The current procedural terminology (CPT) coding system can provide an excellent basis for assembling benchmark data. PMID- 10179440 TI - DRG benchmarking study establishes national coding norms. AB - With the increase in fraud and abuse investigations, healthcare financial managers should examine their organization's medical record coding procedures. The Federal government and third-party payers are looking specifically for improper billing of outpatient services, unbundling of procedures to increase payment, assigning higher-paying DRG codes for inpatient claims, and other abuses. A recent benchmarking study of Medicare Provider Analysis and Review (MEDPAR) data has established national norms for hospital coding and case mix based on DRGs and has revealed the majority of atypical coding cases fall into six DRG pairs. Organizations with a greater percentage of atypical cases--those more likely to be scrutinized by Federal investigators--will want to conduct suitable review and be sure appropriate documentation exists to justify the coding. PMID- 10179441 TI - CEOs and CFOs express concern about materials management. AB - In a recent survey, CEOs and CFOs expressed concern regarding the effectiveness of their materials management departments. Both groups of executives would like to see more improvement in their materials managers' supply expense reduction efforts and leadership skills. More than a third of CFOs are even considering outsourcing the materials management function. Both CEOs and CFOs did admit, however, they needed to learn more about materials management, and both groups of executives could lend their authority to materials management programs to ensure their success. CEOs and CFOs need to reach consensus regard materials management priorities, performance levels, and professional characteristics and desired skills. They also should hold materials managers accountable for operations they can and should be managing by using performance-based compensation. PMID- 10179442 TI - When is a group practice ready for Medicare risk contracting? AB - As senior citizens choose alternatives to traditional Medicare, group practices need to learn how Medicare risk contracting differs from traditional Medicare arrangements. To provide healthcare to Medicare patients, group practices should participate in both Medicare risk contracting and Medicare fee-for-service, but they need to make some operational changes to accommodate all these patients. When implementing an operational plan, group practices should consider three key factors-practice location, education of support staff and patients, and facility accessibility. The practice needs to accommodate the special needs of senior citizens to secure and retain a stable patient base. PMID- 10179443 TI - Practices retain control with a nonacquisition model PPMC. AB - Traditional PPMCs acquire the assets of a physician practice and provide management services. Physicians pay a management fee for these services and relinquish control over their practice. With a new nonacquisition model PPMC, physicians retain ownership of and control over their practices. In return for a management fee, they receive management expertise and capital. The result should be practice revenue growth. This growth is achieved by developing a strategic plan, getting physician buy-in before implementing the plan, and monitoring the results. PMID- 10179444 TI - HCFA issues final three-day payment window rule. PMID- 10179445 TI - Setting limits on electronic "attachments" to claims. PMID- 10179446 TI - Corporate compliance officer role is emerging. PMID- 10179447 TI - Data trends. The impact of pricing policies upon profits. PMID- 10179448 TI - Marketing to older patients: perceptions of service quality. AB - Marketing has taken on increased importance in the United States' health care industry, especially with respect to Americans aged 55 and older. Given that health care costs account for 14 percent of the GNP of the U.S., and that older Americans represent nearly 25 percent of all health care expenditures, the ability of physicians to assess the perceptions of service quality, service value, and satisfaction and the effects of these variables on patient loyalty with respect to older patients is very important. A comprehensive model of patient behavior is introduced and tested. The results suggest the medical office staff and the expertise of the physician play particularly important roles in older patients' perceptions of service quality. In addition, strong relationships were found between (1) Service Quality and Satisfaction, (2) Satisfaction and Patient Behavior (repeated use of the physician), and (3) Service Quality and Patient Behavior. Conclusions and suggestions for future research are offered. PMID- 10179449 TI - Transcending functional boundaries: the cultural, strategic, and tactical domains of marketing. AB - While debate in the health care literature continues with respect to the role of marketing, many industries are adopting a broadened perspective which recognizes the comprehensive role which marketing may assume at a variety of levels within the organization: marketing as culture, marketing as strategy, and marketing as tactics. A national study of general service hospitals suggests that, in many hospitals, the marketing function is indeed transcending its functional boundaries through enculturation of a marketing orientation, involvement in the strategic process of the organization, and expansion of tactical marketing activities. Hospitals which adopt and support this broadened role of marketing are witnessing a positive effect on performance. PMID- 10179450 TI - Impact of health care reform on the business and practice of ophthalmology. AB - This study examines the attitudes and opinions of 122 Texas ophthalmologists facing the health care reform movement. It illustrates the commercial practice of ophthalmology today, how practitioners would like it to be, and what they see as the future trends. The study also explores the options and future plans of ophthalmologists for maintaining practice revenues. PMID- 10179451 TI - Identifying service quality strengths and weaknesses using SERVQUAL: a study of dental services. AB - The goal of this study was to examine responses among dental patients to the most recent version of SERVQUAL, and to evaluate that instrument as a tool for measuring satisfaction in a dental practice. Items on the reliability and responsiveness dimensions produced the lowest satisfaction ratings, while improvements in providing services as promised and instilling confidence have the greatest potential for producing higher satisfaction among patients. Finally, using open-ended questions, we identified a number of patient events or experiences which caused either high or low scores on individual SERVQUAL items. PMID- 10179452 TI - Providing incentives to control health care costs and remain competitive in the marketplace: a pilot study. AB - Few marketplaces in the United States have been subject to as much scrutiny, and undergone as much transformation in the 1990s, as has health care. Even based on the slowest growth rates experienced in the 1980s and 1990s, the United States is projected to be spending $3,140,221 per minute on health care by the year 2000. The purpose of this study was to examine how coordination between providers of medical care, and working with their customers (i.e., payors) might reduce costs without compromising quality. Providing incentives to these groups of businesses that form the health systems can be a means for achieving both individual health system objectives. Because of the importance of pharmacists in health care delivery systems, they were considered an excellent group for testing and measuring the impact of incentive programs. The study involved a before and after six month period involving dispensing patterns through a pharmacy benefit manager. Incentives were provided to pharmacies based on percent improvement in generic substitution rates and formulary compliance. A network of 342 independent pharmacies, with their dispensing patterns monitored through a pharmacy benefit manager under its contract program. The results of the study were that generic substitution rates rose from the pre-trial period of 68.5% to 73.7% in the first three months of the trial period, and to 75.6% in the second three months of the trial period. The overall increase in substitution was from 68.5% in the base period to 74.7% over six months. These differences were statistically significant at the 0.05 level. Estimated savings to health plans on an annualized basis would be approximately $3.4 million, and the payout per conversion to pharmacies was $3.23. While not measured directly, no adverse clinical effects were reported due to substitutions. Thus, an incentive system to reward those health care providers can effectively control expenses to achieve mutually desirable goals of all parties. If properly structured, the providers, health systems of which they are a part, and payors can benefit. Using an incentive program like the one designed for this study, health systems may be able to be more competitive in marketing their services to payors. PMID- 10179453 TI - Power of London. PMID- 10179454 TI - Waiting lists. The wrong target. AB - The numbers now waiting for treatment in the NHS are more than double what they were in 1948 despite huge increases in activity. Increased activity has not reduced the time patients wait. Mean waiting times in the 1990s were 13-14 weeks, the same as in the 1960s and 1970s. An increase in activity to reduce the numbers waiting for treatment may, in fact, increase the number being put on the waiting list. Government targets should concentrate on how long individual patients have to wait, rather than reducing the numbers on the waiting list. PMID- 10179455 TI - Occupational health. Bad vibrations. PMID- 10179456 TI - AIDS care. On the rocks. PMID- 10179457 TI - Nurse development. The A train. AB - Management development for nurses is a neglected area. A management development programme at one trust has improved communication and team work, introduced simple practice changes, and saved money without impacting on patient care. Costs have been met through commercial sponsorship, recentralising training budgets and careful forward planning to make internal cover possible. PMID- 10179458 TI - Catering. Dying for a good meal? PMID- 10179459 TI - Catering. All for a guinea a week. PMID- 10179460 TI - Cancer services. Professional approaches. PMID- 10179461 TI - Communications. Off message. AB - More than half of NHS organisations now have a communications post. Almost half of all communications managers are working single-handed. Most earn 30,000 Pounds or less. The typical NHS organisation spends less than 75,000 Pounds a year on communications, notably less than many local authorities. The present level of investment in communications is woefully inadequate to deliver the new NHS envisaged by the government. PMID- 10179462 TI - Primary care. Toil and trouble. AB - Establishing PCGs will represent a huge change even in areas with well-developed primary care. The inclusion of nurses in PCGs is likely to prove problematic. The new groups will need to achieve high-profile early successes in order to maintain credibility. There is little evidence that fewer managers will be required. PMID- 10179463 TI - Health promotion. Vacuum task. AB - Interviews with GPs from 20 practices in West Surrey found little preparation to deliver on health promotion, as envisaged in The New NHS white paper. The GPs were uncertain of how to set about multi-agency working to improve the health of the local population. Knowledge of the services of the local health promotion department was patchy. PMID- 10179464 TI - Medical equipment. Devices and desires. AB - High-tech medical solutions need careful implementation to ensure optimum reliability and good patient care. Figures from the Medical Devices Agency show that a patient may be three to 10 times more at risk from user error than from faulty equipment. Informed equipment selection and user training is paying dividends in one trust. PMID- 10179465 TI - California legislation addresses potential conflicts of interest in sales of nonprofit hospitals. PMID- 10179466 TI - Handling the drug-dependent physician. PMID- 10179467 TI - Stent price show signs of declining. PMID- 10179468 TI - High tech, high cost monitors promising savings and safety. PMID- 10179469 TI - Pulse oximeters go mobile as prices continue dropping. PMID- 10179470 TI - Hospital-wide standardization effort nets big savings. PMID- 10179471 TI - Used equipment can mean big savings, or big headaches. PMID- 10179472 TI - Generic drug prices said headed up. PMID- 10179473 TI - Columbia's ABC program: will it die a natural death? PMID- 10179474 TI - The stockless craze: is it finally over? PMID- 10179475 TI - Profit vs. nonprofit: does either have a competitive edge? PMID- 10179476 TI - A hospital's no place for a sick person. PMID- 10179477 TI - Think it's tough being a doctor? Try being a doctor's kid. PMID- 10179478 TI - Avoiding lawsuits for careless prescribing errors. PMID- 10179479 TI - Are D.O.s losing their unique identity? PMID- 10179480 TI - Medicine's iron men are packing it in. PMID- 10179481 TI - Practice beat. Quality of care--Americans change their minds about the profit motive. PMID- 10179482 TI - A refreshing change--straight talk on managed care. PMID- 10179483 TI - The disease-management boom--how doctors are dealing with it. PMID- 10179484 TI - Here's what's coming--like it or not. PMID- 10179485 TI - Automated supply systems used in about half of ORs. PMID- 10179486 TI - Demand for nurses could outrun supply in 12 years. PMID- 10179487 TI - Capturing costs at the point of use. PMID- 10179488 TI - ORs tap bar codes to track supplies. PMID- 10179489 TI - Beepers can ease families' anxieties. PMID- 10179490 TI - Joint preop form smoothes process. PMID- 10179491 TI - Protocols help lower extubation times. PMID- 10179492 TI - OR benchmarks. Can you save on terminal cleaning? PMID- 10179494 TI - Change: overturning myths and blocks. PMID- 10179493 TI - Options in outsourcing for instruments. PMID- 10179495 TI - Outcomes, costs better with teams. PMID- 10179496 TI - A 3- to 5-minute turnover for cataracts. PMID- 10179497 TI - Medicare per-beneficiary limits for HHAs (home healthcare agencies) issued, spurring lawsuit. PMID- 10179498 TI - Charge master assessment: delineating services and charges. PMID- 10179499 TI - Great comeback rates AHA award. Franciscan Children's develops less costly, alternative programs to save hospital. AB - After struggling financially for several years, Boston-based Franciscan Children's Hospital wins the coveted "Great Comeback of the Year" award. With the award, the hospital produces a PR campaign that resulted a plethora of television, print and radio stories. Officials of the Franciscan Children's Hospital announced its financial soundness and commitment to its Boston market area. PMID- 10179500 TI - "Ageless Heroes" define Blues' commitment to baby boomers. Campaign targets marketing to aging population. AB - Blue Cross and Blue Shield Association, with the help of agency Age Wave Health Services Inc., develops a program called Ageless Heroes to convey the insurance company's commitment to the concept of healthy aging through National Awards competition and the television program featuring celebrity seniors. PMID- 10179501 TI - Branding campaign exceeds initial goals for New Hampshire fitness site. Campaign utilizes humor, insights from market research. Synergy Health and Fitness Center, Exeter. AB - Exeter Health Resources Inc. and agency BBK Communications create a comprehensive brand-building campaign for its centers that combine fitness services and programs under Synergy. With success, the center signed up more than 1,600 members by the time it opened in January. PMID- 10179502 TI - Medical center uses web site, print to promote community education. Complementary ad efforts build attendance for classes. MidMichigan Medical Center-Midland. AB - MidMichigan Medical Center employs the use of Internet technology and print advertisements to complement each other. Together with advertising agency Bolger + Battle in Midland, the hospital devised a plan to generate awareness and registration for upcoming community education classes. PMID- 10179503 TI - Internet serving inquiring patients. Web powerful resource for health care providers, insurers. PMID- 10179504 TI - Newsletter goes online. Interactive resource center outgrowth of 12-year publishing effort. AB - Mother's Heart offers several newsletter programs geared to parents-to-be, new parents and young parents of infants and toddlers. The Nashua, N.H.-based publishing company is moving forward with Internet technology by delivering a home page for mothers that will operate as an interactive resource center. PMID- 10179505 TI - Foundation mounts worldwide glaucoma awareness campaign. PMID- 10179506 TI - Taking an academic medical center to the market. Albany Medical campaign stresses education, research, care. AB - A major regional academic health sciences center in the Northeast prepares a major marketing campaign that would enhance awareness and dramatically distinguish the Medical Center from its major competition and increase revenue streams through higher market share. PMID- 10179507 TI - Clinical quality benchmarking: here's how to do it--and why. PMID- 10179508 TI - Are you in the right time and place? Tying strategy to market stage. PMID- 10179509 TI - The dynamic duo. A great chair-CEO partnership gives your organization star status. PMID- 10179510 TI - The art of public accountability in hospital mergers. PMID- 10179511 TI - What can tithing do for you? PMID- 10179512 TI - Fundraising from within. PMID- 10179513 TI - The good book. A consumer's health care bible. PMID- 10179514 TI - System integrational and migrational concepts and methods within healthcare. AB - In this paper an overview and comparison of the basic concepts and methods behind different system integrational implementations is given, including the DHE, which is based on the coming Healthcare Information Systems Architecture pre-standard HISA, developed by CEN TC251. This standard and the DHE (Distributed Healthcare Environment) not only provides highly relevant standards, but also provides an efficient and well structured platform for Healthcare IT Systems. PMID- 10179515 TI - Security of healthcare information systems based on the CORBA middleware. AB - The development of healthcare systems in accordance to the "Shared Care" paradigm results in co-operative health information systems across the boundaries of organisational, technological, and policy domains. Increasingly, these distributed and heterogeneous systems are based on middleware approaches, such as CORBA. Regarding the sensitivity of personal and medical data, such open, distributed, and heterogeneous health information systems demand a high level of data protection and data security, both with respect to patient information and with respect to users. The security concepts and measures available and additionally needed in health information systems based on CORBA architecture are described in this paper. The proposed security solution is also open to other middleware approaches, such as DHE or HL7. PMID- 10179516 TI - Supercomputing in cancer research. AB - Human Genome Analysis and Image Processing are part of the 'Grand Challenges' in High Performance Computing. The traditional mainframe has become insufficient for these applications in Biocomputing. Scalable parallel processor systems have entered the marketplace with superior price/performance. The evaluation process of such a system by an application-oriented benchmark test suite is described. Meanwhile a large system is integrated in the client/server structure of the Deutsches Krebsforschungszentrum where the traditional mainframe is completely replaced by scalable systems. PMID- 10179517 TI - BEAM@Net: telematic services for clinical engineers and medical physicists. PMID- 10179518 TI - UN/EDIFACT based medical documentation and messages. AB - New documentation and messages conforming to the rules of EDIFACT are created and an attempt is made to follow internationally standardised and wordwide available commercial experience. A set of medical documents, aligned with United Nations Layout Key for trade documents is designed. The approach is to develop a set of paper documents and to standardise the data which are filled in these documents. There is a possibility to fill the data directly in medical documents and to print them from the Clinical Information System in our University Hospital. PMID- 10179519 TI - Intranet and HTML at a major university hospital--experiences from Munich. AB - Intranet-technology is the application of Internet-Tools in local networks. With this technique electronic information systems for large hospitals can be realized very easily. This technology has been in routine use in 'Klinikum Grosshadern' for more than one year on over 50 wards and more than 200 computers. The following clinical application areas are described: drug information, nursing information, electronic literature retrieval systems, multimedia teaching und laboratory information systems. PMID- 10179520 TI - Organising health systems for better care and performance by open information technology. AB - In this document the application of open information technology to assist in reforming healthcare systems of countries is being discussed. Present technologies demonstrated by HANSA in Western and Eastern Europe enable the integration of electronic patient records in existing systems, provide for flexibility and support the interoperability of different applications. However, computers and IT must not drive the required process of change. This is the responsibility of top management. PMID- 10179521 TI - ITHACA. Telematics for integrated client centred care. AB - ITHACA is a project supported by the healthcare telematics programme of the European commission's Fourth Framework Programme. The user organisations involved in ITHACA shared a philosophy of community based care that focuses on the client and development of the multi-disciplinary care team, involving a range of professionals delivering care to clients in their own homes or community facilities. The focus of ITHACA system is to support client case management which includes client assessment, care planning, delivery and evaluation of care outcomes. System analysis and design process identified that practices and procedures in health and social care are very similar throughout the diverse sites represented in ITHACA and they are represented in a generic model that describes the great majority of local health and social care requirements. The ITHACA demonstrator will consist of a client/patient centred community care information system, which is distributed across a number of community care centres within a given region and covers the homes of selected clients. PMID- 10179522 TI - TELENURSE--nursing classifications, quality indicators and the electronic nursing record. AB - In the area of nursing, national and international clinical databases are practically non-existing. The lack of common nomenclatures and classifications is the main reason for this situation. This article elaborates on the TELENURSE project's two objectives which focus on improving that situation. The first objective concerns the "The International Classification for Nursing Practice" (ICNP) and methods for implementation of ICNP electronically in nursing modules of electronic patient records. The second objective concerns the development of a clinical nursing database in which clinical data collected from electronic nursing systems can be stored. On the basis of this data storage, nursing indicators can be developed, which in the long term allows for comparison of nursing interventions across Europe. PMID- 10179523 TI - C.A.S.M. and C.A.S.T.--phase two. AB - This paper outlines the second phase of a research project currently being conducted at the University of Central Lancashire. The aim of this second phase is to construct a computer based toolset for clinical audit, based on the structured method (C.A.S.M.) developed during the first phase of the project. A discussion of the validation of the C.A.S.M. and an outline of the toolset is portrayed. PMID- 10179524 TI - Emergency Health Care Information System for Bucharest-Romania. AB - The Emergency Health Care Information System (EHCIS) in Bucharest provides information about the whole activity of Dispatch Emergency Ambulance Service and Emergency Receiving Room of the 7 Hospitals, providing emergency health care in Bucharest over a MAN (Metropolitan Area Network). In each of these places a local network is located, containing a database server ORACLE. The link among LANs is made via switched lines. The Hospitals collect information only about emergency cases. The microstation represents station for emergency teams of Emergency Ambulance Service of Bucharest (EASB), distributed in all 6 districts of Bucharest. The system is structured accordingly with the working-groups existing in Dispatch, microstations and hospitals: registration operators (phone operators) for administer the emergency requests/calls; a location for the medical coordinator which must to choose, in few seconds, the emergency team, accordingly with the case emergency degree; radio-operators which communicate with the teams in the field; a location for the manager of Dispatch, in order to provide a full-set of real-time medical and resources information; a registration operator at each microstation; a registration operator at each hospital. The data are registered in the ORACLE database on the central server. The client/server architecture assures the real time communication among all these locations. The system works 7 days/week, 24 hours/day. PMID- 10179525 TI - Evolution of a regional health-care information system--the design phase. AB - In 1996 a program of the Soros Foundation was launched to study a regional health care inodel Main stake holders of health care financing and providing in three counties in South-Western Hungary found the idea appealing and the Soros Model Region Program was started. This paper outlines the activity of the second sub project of the model region program: the development of a regional health care information system. The build-up of a data and knowledge base serving the differing needs of mentioned goals is based on international standards. Availability and user involvement is based on different media for presenting the information as printed publications, CD-ROM data bases and World Wide Web availability. A congruency and coherency principle is maintained by a unified data model used for different purposes and a planned unified communication protocol among all participants in the model region program. Studies regarding health care status, economics and financing on regional level show that a better fitting health care services profile and a more flexible resource management might be achieved based on the mentioned regionality principle. PMID- 10179526 TI - Functional and control integration of an ICU, LIS and PACS information system. AB - The need for collaboration and data sharing among systems dedicated to individual functional areas and user groups has initiated major efforts towards the development of an integrated hospital information system. Major issues in the development of any integrated architecture that incorporates autonomous departmental systems include the development of commonly accepted interaction mechanisms, standardisation, the structure of the computerised patient record, its extensibility, as well as limitations multimedia data impose. This paper presents work done within project IHIS, a nationally funded project for the development of an integrated hospital information system that provides ICU staff with access to both the ICU assisting laboratory information system's data as well as radiological multimedia data. PMID- 10179527 TI - Does TISS pave a way towards the nurses care documentation? AB - New functions have been integrated in the Giessen Hospital Information System WING to support the classification of all intensive care patients into the Therapeutic Intervention Scoring System TISS. The use of those functions has been pushed by legal requirements which made it essential to assess the staffing of intensive care wards in comparison with the accumulated TISS scores. This paper describes the experiences made within two years of TISS scoring. We think that TISS gave a major impact to the construction and implementation of nursing documentation into our HIS. PMID- 10179529 TI - Spreading the clinical information system: which users are satisfied? AB - The present study deals with the assessment of the perceived usefulness and perceived ease of use of the clinical core of the HIS we are building, and progressively spreading into the medical centre, through the use of two questionnaires. The differences in subjective perception among clinical units and professional roles have been analyzed. Results show that the system, in use on a mandatory basis, has been accepted. Most of the users are satisfied, and probable removable causes of dissatisfaction have been identified. PMID- 10179528 TI - Seamless care in the health region of Crete: the Star* case study. Seamless Telematics Across Regions. AB - Seamless collaboration and medical information exchange among health care experts is an open question on existing health care systems. The patient record is usually scattered all over the health care network making access to crucial medical information troublesome. The Star* (Seamless Telematics Across Regions) project provides a set of solutions towards this direction which will soon be applied at Crete. Initially two health care structures will be involved in the process but later on and after tests have been completed successfully in real world applications, results will be defused over the whole health care region of Crete. PMID- 10179530 TI - Security of the electronic health record. AB - The Electronic Health Record (EHR) raises new challenges for security. Only authorized persons having a "right to know" can have access to identifiable patient data. Differences between the paper record and the EHR are first described. Several solutions in order to assure confidentiality, integrity and accessibility to patient information are then proposed. PMID- 10179531 TI - Basic rules for the security of frozen section diagnosis through image transmission between anatomo-pathologists. AB - Telemedicine can provide an alternative solution to the lack of medical resources in areas where the population is no longer dense enough to justify the temporary or permanent presence of certain specialists such as anatomo-pathologists. In the long run certain pre-operational frozen section examinations cannot be carried out without putting the quality of healthcare at stake. The telematic transmission of macro and microscopic images of lesions, under the supervision of a surgeon, to an anatomo-pathologist consultant located off premises allows for the maintenance of equitable care of acceptable quality. PMID- 10179532 TI - Implementing security on a prototype hospital database. AB - This paper describes the methodology used and the experience gained from the application of a new secure database design approach and database security policy in a real life hospital environment. The applicability of the proposed database security policy in a major Greek general hospital is demonstrated. Moreover, the security and quality assurance of the developed prototype secure database is examined, taking into consideration the results from the study of the user acceptance. PMID- 10179533 TI - Medical liability, safety and confidentiality in maritime telemedicine--the MERMAID position on issues of importance. AB - Telemedicine dates to the days of "wireless telegraphy". As an "extraordinary" arrangement for medical services delivered at time of need, telemedicine has thus far escaped the developments that have taken place over the last 50 years in the areas of medical liability, safety and confidentiality. Today, however, telemedicine is also used to increase quality and cost effectiveness of healthcare provision. This trend is set by the U.S. where the U.S. federal government funds telemedicine at an annual rate of more than $100 million i.e., at a rate 30 times or more than what the EU does while state and local agency support and private business investment in telemedicine is 3 to 4 times larger than that of the U.S. federal government. In this respect it must be stressed that technology tends to satisfy the relevant demand for telecommunications. Telemedicine is used in diverse areas such as pathology, surgery, physical therapy, and psychiatry. It is expected to revolutionise health care in the coming decade and, therefore, it will certainly take into account requirements for medical liability, safety and confidentiality in the same way as traditional "establishment" medicine does. PMID- 10179534 TI - Investment appraisal of the protection, confidentiality and security arrangements of patient data. AB - Data Protection and Security issues are reviewed in relevant literature. Policies implemented in relation to the subject matter are discussed in detail. Findings from a review of data protection and security arrangements at a major hospital are presented. Future data protection and security recommendations are outlined. PMID- 10179535 TI - A formal, mathematics oriented method for identifying security risks in information systems. AB - IT security presently lacks the benefits of physics where certain unifying grand principles can be applied. The aim of the method is to provide a technology independent method of identifying components of a system in general, and of information systems in particular. The need for the proposed method is derived from ad hoc character of theories used in the present formal security textbooks. None of these can give the user any guarantee of completeness. The new method is scientifically derived as a method, presented, explained and applied to several interesting topics in the field of health care information systems. Some simple mathematical formulae can be introduced. PMID- 10179536 TI - FOIN: a nominative information occultation function. AB - This article is intended to show that a great amount of work has to (and will) be done in terms of security for the healthcare information system community. Some very promising results have already been obtained in France, especially at CNAMTS, for providing the required security and privacy of nominative information in the context of future electronic exchanges between private/public hospital and CNAMTS, the french biggest mandatory healthcare insurance. FOIN, a robust anonymisation function, is just an example of such recent progress that traduces the french national engagement towards more flexible interconnection between various authorised healthcare information systems in close conjunction with more and more reliable and secure procedural and technical requirements. Firstly, the legal and medical needs for so strong anonymisation functions are described; secondly, the most important security requirements of these sensible functions are detailed and, lastly, the main security and implementation features of FOIN are globally indicated. PMID- 10179537 TI - Migration towards a component based HIS architecture. AB - Changing requirements for health care information systems force the development of an open, modular architecture in which components can be integrated. This offers a flexible means for integrating different (heterogeneous) systems used by different users. Migration towards such an open, modular architecture is a difficult task. It consists of breaking down existing systems in components and integrating these components. Many authors on migration strategies focus attention on the ordering of the steps to be taken without detailing how these steps were arrived at. This paper presents a more rigorous approach for deriving a migration strategy. PMID- 10179538 TI - The Chernobyl accident: predicting cardio-vascular disease in the ex-workers. AB - This paper describes a computer package that has been used to predict the likelihood of the onset of cardiovascular diseases in these patients who were former workers (liquidators) on the Chernobyl site in the Ukraine, Chernobyl being the place where the Nuclear Power Station was destroyed when the atomic reactor got out of control and spread radiation over a very wide area both on the ground and into the atmosphere. The programme predicts the future morbidity in those patients with an accuracy of 90%. PMID- 10179539 TI - Hepatocellular carcinoma: the virtual hospitalization in day-hospital. AB - The virtual hospitalization can be considered as the telematic evolution of the Day-Hospital, implementing the integration between hospital care and home care and predefining an hospital system which "goes to the patient home". In this paper the authors describe characteristics, motivations and advantages of this proposal, as well as the interaction model. Then the medical problem is illustrated: the liver tumors, which are the more frequent malignant neoplasms, and, in particular, the hepatocellular carcinomas, which represent about the 50% of these tumors. The Organization Model, the Information System and the Modalities of Telemonitoring for Hepatocellular Carcinoma are still illustrated and a brief conclusion is given. PMID- 10179540 TI - A sentinel network of general practitioners for epidemiologic surveillance in Italy. AB - A Computer Network of General Practitioners (GP's) has been established connecting 110 general practitioners representing a statistically selected national sample, homogeneously distributed all over Italy. The purpose of the network is to increase the epidemiologic surveillance on the health status of the Italian community, to collect useful data on the routine activity of the GP's, to promote computer use among them, and to organize some "ad hoc" investigations on specific subjects (case-control studies). To this purpose, a specific software was developed both to meet the requirements of epidemiological research and to manage general practitioners' clinical files. A working prototype of health card using micro-computer technology is also being experimented on a subset of the GP's. PMID- 10179541 TI - An access interface platform for health/social information services: HealthGate. PMID- 10179542 TI - Cardiomedia: a multimedia portable medical record on optical memory card. AB - The main objective of the CARDIOMEDIA project is to produce and evaluate a coronarian multimedia data record stored on an optical card. The experimentation concerns patients treated by angioplasty at university hospital of Rennes. Often patients treated in the Regional University Hospital are followed up by another Health structure closer to their home. The patient leaves hospital with his card, which is directly available elsewhere for emergency or for consultation. This will optimize the number of examinations and offer a better patient follow-up. The CARDIOMEDIA card is a specialized record which includes various data type: text, image, image sequence of coronarography and ECG signal. For this purpose optical card with its large memory size is very convenient. For medical imaging, we use in this project the DICOM format for image exchange and management, it is combined with a CARDIOMEDIA specific compressing software. For multimedia record, the HTML format and web intranet method are chosen, this allows intuitive interface which can combine various data type and helpers like DICOM image viewer. PMID- 10179543 TI - Telematics and smart cards in integrated health information system. AB - Telematics and information technology are the base on which it will be possible to build an integrated health information system to support population and improve their quality of life. This system should be based on record linkage of all data based on the interactions of the patients with the health structures, such as general practitioners, specialists, health institutes and hospitals, pharmacies, etc. The record linkage can provide the connection and integration of various records, thanks to the use of telematic technology (either urban or geographical local networks, such as the Internet) and electronic data cards. Particular emphasis should be placed on the introduction of smart cards, such as portable health cards, which will contain a standardized data set and will be sufficient to access different databases found in various health services. The inter-operability of the social-health records (including multimedia types) and the smart cards (which are one of the most important prerequisites for the homogenization and wide diffusion of these cards at an European level) should be strongly taken into consideration. In this framework a project is going to be developed aiming towards the integration of various data bases distributed territorially, from the reading of the software and the updating of the smart cards to the complete management of the patients' evaluation records, to the quality of the services offered and to the health planning. The applications developed will support epidemiological investigation software and data analysis. The inter-connection of all the databases of the various structures involved will take place through a coordination center, the most important system of which we will call "record linkage" or "integrated database". Smart cards will be distributed to a sample group of possible users and the necessary smart card management tools will be installed in all the structures involved. All the final users (the patients) in the whole network of services involved will be monitored for the duration of the project. The system users will also include general practitioners, social workers, physicians, health operators, pharmacists, laboratory workers and administrative personnel of the municipality and of the health structures concerned. PMID- 10179544 TI - Introducing cards into Slovenian health insurance and health care. AB - This paper presents an outline of the Slovenian project of introducing card systems into health insurance and health care: bases for its launching; scope, system design, development phases, benefits, and issues of interoperability with the other card systems. The card system will induce distinct simplifications of the procedures now performed in the health care system, improve the quality of medical administrative services to the patients. The introduction of the card technology is under way in several European countries. With the Health insurance card system project, Slovenia is joining the EU projects, and can either test in practice and implement the concepts, as well as contributes particular original solutions. PMID- 10179545 TI - Computer-based patient records and mathematical processing: Brain-UniCard system experience. AB - The ways of usage of the data from Brain-UniCard Computer-based Patient Records in biomedical and statistical studies is discussed. Mathematical procedures used in computer program are presented. Problems of data presentation for advanced biomedical studies are discussed with the examples of studies of patients with brain traumas and diseases. PMID- 10179546 TI - Rubrics to dissections to GRAIL to classifications. AB - This paper summarises the process in the GALEN-IN-USE project by which rubrics from traditional medical coding schemes are analysed into an intermediate, relatively informal conceptual representation which is then automatically translated into the GRAIL formalism and its Common Reference Model. PMID- 10179547 TI - Flexible electronic patient record: first results from a Dutch hospital. AB - This paper covers a pilot project that has been done at a dutch general hospital. They searched for the feasibility of a flexible patient record based on intranet technology and a system integrator (CAI). Based on an extended analysis of the organisation (i.c. hospital and pilot specialism), information and communication, the specifications for the interfaces are defined. Furthermore the structure and number of data to be stored in the Patient Data & Result Server are defined. Finally, a prototype of the flexible patient record has been developed. This prototype is not yet in routine use. However, experiences of the clinicians have learned that the web technology in combination with a system integrator could be a major step in the "wide" acceptation of the electronic patient record. PMID- 10179548 TI - Program package for paramedical investigations (EEG, EKG, radiography, biochemical investigations, pathological anatomy, nuclear medicine). AB - The purpose of this program package is to provide computer-based assistance for the work performed in paramedical investigation laboratories: functional investigations, radiology, biochemical investigations, pathological anatomy, nuclear medicine, in hospitals, polyclinics, medical practices. The common characteristics regarding the management of the work done in such laboratories has made a global approach of the problem possible. The modular design of the program package has allowed its stagewise development, thus offering the possibility of integration with the medical information management in each laboratory. The program package for paramedical investigations has a two level structure. programs and data bases pertaining to the main program; programs and data bases specific to each type of computerised laboratory. PMID- 10179549 TI - Development of a standardized format for archiving and exchange of electronic patient records in Sweden. AB - This paper describes an effort to standardize the long term archiving format of the electronic patient record. A format is given in SGML (Standard Generalized Markup Language) and also tested as a prototype in a production system. PMID- 10179550 TI - A hypermedia radiological reporting system. AB - Report is the main phase of a diagnostic process by images. The product of the process is the diagnostic report. We are proposing an hypermedia structure of diagnostic report in radiology, in order to facilitate exchange between radiologist and clinician (specialist in internal medicine or surgeon) on a clinical case, without anymore charge on the side of the radiologist but with an 'off-line' consultation. An hypermedia radiological report software will produce further advantages in many aspects: radiologist and clinician could access patient's data directly from DB on patients; radiologist could check DB on exemplary cases real-time; clinician could read preliminary and final reports available in network and make requests online. The proposed hyper-report system is modular. Starting from the 'report text' writing, edited by the radiologist on the basis of most significative images, it is possible to insert comments in text, drawing and 'external' images form. PMID- 10179551 TI - Doctor friendly electronic patient record. AB - In this paper we would like to show importance of using modern information technology in implementation and development of health information systems. Our main focus is on doctor's work. Doctors will use computer only if they will see clear advantages. Traditional data gathering and display are not sufficient, so modern software should provide speech interfacing and computer graphics in various applications and enable the use of electronic mail, hand held computers, electronic data interchange, etc. among other features. This paper tries to show the needs for applications of those features. They are already implemented as part of our hospital information systems. PMID- 10179553 TI - Computer-aided prescription--a prototype system. AB - This study intends to satisfy two purposes: To prove the necessity of an electronical prescription aid and to propose a structure that can be interpreted into software which will be able to cover that need. The complicated market reality and the disadvantages of the written pharmaceutical directories make the existence of an electronical aid absolutely necessary. The structure of a prescription system should be based upon the drastic substance with its consequences (adverse effects, relative and absolute contraindications, pharmakokinetics and interactions). Every drastic substance will lead to the connection of pharmacology with the market reality and its own consequences (product identification through text and image, trade name, pharmaceutical company, strength, package information). The whole structure constitutes a completed relation--database system that is capable of answering any simple question or query that concerns the field of prescribing. The final production of such an aid is believed to help in a very high degree prescribing in a more precise and correct way, saving financial means for the patient and the health insurance as well as saving the doctor's time. PMID- 10179552 TI - Management of hospital discharge data in Belgrade. AB - The paper presents a database on clinically treated patients in Belgrade, a computerized health-statistics information sub-system. It also analyses the organisation of report processing related to hospitalisation, types of indicators on hospital treatment (which are the result of such a processing) as well as their further utilisation on different levels of management within the system of health care in Belgrade. PMID- 10179554 TI - Application of a fuzzy model of making a decision to choose a medicine in the case of symptoms prevailing after the treatment. AB - Fuzzy set theory has introduced many auxiliary methods into medical problems. One of the attempts was the fixing of the optimal level of the drug action in the case when clinical symptoms retreat completely after the treatment [1,5]. In many morbid processes, however, there occurs problem of symptoms prevailing to some extent after the course of the medication process improving too high or too low indices of the measurable symptom. Different medicines applied have many a time an effect on the same symptoms and it is sometimes difficult to choose uniquely that therapeutic remedy which brings the best results in the treatment of all the symptoms typical of the given diagnosis. A fuzzy model of decision making is to make it easier to choose a drug which acts optimally in the case of symptoms not retreating to the full after the treatment. PMID- 10179555 TI - A consultation system integrating Chinese medical practice in herbaltherapy, acupuncture and acupressure. AB - The paper presents an informatic system offering the acupuncturist, herbalist and acupressurist a rich source of clinical information. It adapts the theory of Chinese Medicine to Western medical practice and is solidly based on the ancient Chinese classics. The system provides an orientative diagnosis starting from the clinical picture of the patient consisting in syndrome differentiation. Based on the Yin-Yang and 5 Elements theory the remedy associated with the energetic imbalance is determinated. Then the tastes, nature and tropism implied by the principle of treatment are used to prescribe the herbal treatment. The treatment variants through acupuncture and acupressure are also indicated. The system is also useful in teaching Chinese Medicine. PMID- 10179556 TI - A study of dermatoglyphics in gonadal dysgenesis: a computerised analysis applicable in under-developed countries. AB - Dermatoglyphics, the study of finger-tip and palmar prints, can play an important role in suggesting or confirming the diagnosis in the case of certain congenital syndromes. The paper discusses the prints in the cases of two important syndromes viz Turner's and Klinefelter's, and shows how to differentiate between the two. PMID- 10179557 TI - XBONE: a hybrid expert system for supporting diagnosis of bone diseases. AB - In this paper, XBONE, a hybrid medical expert system that supports diagnosis of bone diseases is presented. Diagnosis is based on various patient data and is performed in two stages. In the early stage, diagnosis is based on demographic and clinical data of the patient, whereas in the late stage it is mainly based on nuclear medicine image data. Knowledge is represented via an integrated formalism that combines production rules and the Adaline artificial neural unit. Each condition of a rule is assigned a number, called its significance factor, representing its significance in drawing the conclusion of the rule. This results in better representation, reduction of the knowledge base size and gives the system learning capabilities. PMID- 10179558 TI - A database on pesticides in Italy: a progress report. AB - An existing database on pesticides, running in the DOS/Windows environment, is operative at the National Institute of Health and has yielded useful informations for several published researches. The database is currently being restructured for the purpose of making it available on the Web. An HTML interface, allowing to formulate queries on the database from the Web is presently under development, and it will be made available, once the problems related to confidentiality of certain parts of the database are solved. The database in its present form is presented and necessary changes foreseen in the Web edition are discussed. PMID- 10179559 TI - From hospital information system components to the medical record and clinical guidelines & protocols. AB - This paper introduces an ongoing project towards the development of a new generation HIS, aiming at the integration of clinical and administrative information within a common framework. Its design incorporates explicit knowledge about domain objects and professional activities to be processed by the system together with related knowledge management services and act management services. The paper presents the conceptual model of the proposed HIS architecture, that supports a rich and fully integrated patient data model, enabling the implementation of a dynamic electronic patient record tightly coupled with computerised guideline knowledge bases. PMID- 10179560 TI - Clinical protocol development using Inter/IntraNet technology: the FENARETE system. AB - In this work we present FENARETE, a software tool to design and distribute clinical protocols in an Inter/IntraNet framework. We consider a medical protocol as a clinical behaviour scheme, formally and clearly defined with sufficient details. Our work allows the knowledge content of any clinical protocol to be fully represented in a symbolic style. A computer based support tool that works as an interface between clinicians and the protocol knowledge base is regarded by the authors as a basic building block developing an integrated environment for medical protocols design and management. The FENARETE application has been developed in Java and it is available for any Internet-linked machine with a Java compatible browser. PMID- 10179561 TI - An ontology-based framework for guideline-driven medical practice. AB - This paper describes a general framework for clinical practice guidelines development, dissemination and use. We propose an ontological description of the medical knowledge and of the organizational context, in order to produce clinical guidelines which, on one hand, can be widely shared between different institutions and, on the other, can be efficiently tailored to consider the peculiarities of each clinical context. PMID- 10179562 TI - Telematics for clinical guidelines: a conceptual modelling approach. AB - PRESTIGE is a project for applying telematics to assist the dissemination and application of clinical practice guidelines and protocols. Previous publications have described PRESTIGE's technical approach, including the use of a generic model for representing the knowledge content of clinical guidelines. This approach offers the possibility of 'plug-and-play' electronic distribution of clinical guidelines produced by multiple authoring bodies for use on multiple healthcare clinical management software platforms. A recent joint workshop held with the Section on Medical Informatics, Stanford University School of Medicine compared the European consensus approach developed in PRESTIGE with a parallel series of projects for computer-assisted protocol-based healthcare undertaken at Stanford and other American centres over the past, which confirmed the convergence and complementarity of our approaches, and holds out prospects of world-wide standardization in healthcare protocol knowledge representation. This paper summarises PRESTIGE conceptual model set which is the design of the project's approach. PMID- 10179563 TI - Informatic support for processing the data regarding the environment factors possibly involved in the etiopathogenesis of insulin-dependent diabetes mellitus ETIODIAB. AB - Diabetes represents a heterogeneous group of disturbances, which can have a different aetiology, but have in common glucidic, lipidic and proteinic metabolic disturbances. Insulin-dependent diabetes appears in genetically susceptible persons, as an autoimmune disease activated by environment factors. Epidemiological studies performed in different countries, notice the increasing of diabetes cases in the last decades. Therefore the informatic system EtioDiab (from Etiopathological diabetes) has been developed. The purpose of this system is to assist the medical research regarding the environment factors involved in the etiopathogenesis of insulin-dependent diabetes. The system offers the possibility of calculation of many statistic indicators, of graphic representation of the recorded data, of verification of the statistical hypotheses. PMID- 10179564 TI - A hypertext information system for standard operating procedures in haematological intensive care. AB - In times of cost reduction efforts the role of standard operating procedures for both medical and nursing procedures gets increasing importance. Such standards are necessary if the quality of patient care shall not suffer but even improve. While some sophisticated approaches are coming up with generation of clinical processes from formal protocol models in connection with documentation systems the clinical practice actually looks quite different: Paper-based "operating standards" are used in day-to-day work, if any. In this paper a simple and powerful WWW-based hypertext information system for easy provision and maintenance of nursing standards is presented. PMID- 10179565 TI - The place of SGML and HTML in building electronic patient records. AB - The authors are concerned that, although popular, SGML (Standard Generalized Markup Language) is only one approach to capturing, storing, viewing and exchanging healthcare information and does not provide a suitable paradigm for solving most of the problems associated with paper based patient record systems. Although a discussion of the relative merits of SGML, HTML (HyperText Markup Language) may be interesting, we feel such a discussion is avoiding the real issues associated with the most appropriate way to model, represent, and store electronic patient information in order to solve healthcare problems, and therefore the medical informatics community should firstly concern itself with these issues. The paper substantiates this viewpoint and concludes with some suggestions of how progress can be made. PMID- 10179566 TI - Pre-hospital health emergency management as an integrated service of the Regional Health Telematics Network of Crete. AB - In this paper, a Pre-hospital Health Emergency Management System (PHEMS) is presented, which is being developed on the basis of a common reference architecture that has been defined at a European level by partners from ten EU member states in the course of the ongoing HECTOR project. The PHEMS, which is implemented as an autonomous system, will be integrated as an added-value service into the Regional Health Telematics Network of Crete. The PHEMS architecture is based on a 'perception-cognition-action' paradigm. PMID- 10179567 TI - Design and functional specification of the Synapses federated healthcare record server. Synapses Consortium. AB - Synapses is a project funded under the EU Health Telematics Framework IV Programme. Synapses sets out to solve problems of sharing data between autonomous information systems, by providing generic and open means to combine healthcare records or dossiers consistently, simply, comprehensibly and securely, whether the data passes within a single healthcare institution or between institutions. This paper presents the specification of the Synapses server, the kernel concept of Synapses. It describes the basis in the European prestandard for Electronic Healthcare Record Architecture, the interfaces to the Synapses server and different integration mechanisms for systems providing information to the server. The specification will be verified at a number of validation sites, and the final result will be in the public domain. PMID- 10179568 TI - A computerized record hash coding and linkage procedure to warrant epidemiological follow-up data security. AB - A computerized record hash coding and linkage procedure is proposed to allow the chaining of medical information within the framework of epidemiological follow up. Before their extraction, files are rendered anonymous using a one-way hash coding based on the SHA function, in order to respect the legislation on data privacy and security. To avoid dictionary attacks, two keys have been added to SHA coding. Once rendered anonymous, the linkage of patient information can be accomplished by the means of a statistical model, taking into account several identification variables. PMID- 10179569 TI - SMART: a system supporting medical activities in real-time. AB - This paper describes the system SMART whose goal is real-time assistance to physicians who execute diagnostic or therapeutic protocols in a clinical context. SMART is able to retrieve a protocol from its knowledge base and to monitor its execution step by step for a single patient. Different protocols for different patients can be followed at the same time in a health care structure. The prototype realized supports the execution of protocols for evaluating surgical risks. It has been implemented according to the specifications given by the 4th Surgical Clinic of "Policlinico Umberto I" and reflects the activities actually performed in that hospital. However, the protocol model defined is general purpose and we envisage an easy application to other contexts and therefore to the informatization of other protocols. PMID- 10179570 TI - A JAVA-based multimedia tool for clinical practice guidelines. AB - We have developed a specific language for the representation of Clinical Practice Guidelines (CPGs) and Windows C++ and platform independent JAVA applications for multimedia presentation and edition of electronically stored CPGs. This approach facilitates translation of guidelines and protocols from paper to computer-based flowchart representations. Users can navigate through the algorithm with a friendly user interface and access related multimedia information within the context of each clinical problem. CPGs can be stored in a computer server and distributed over the World Wide Web, facilitating dissemination, local adaptation, and use as a reference element in medical care. We have chosen the Agency for Health Care and Policy Research's heart failure guideline to demonstrate the capabilities of our tool. PMID- 10179571 TI - Decision support system for designing chemotherapeutic regimens. PMID- 10179572 TI - Implementation problems of decision support system for nosocomial infection. AB - Decision support system for nosocomial infection therapy Ptah can reduce antibiotic misuse with data about bacteria resistance and antibiotic ineffectiveness. Resistance vectors in time series show epidemiological problems with resistant bacterias, named house-bacteria. Most important implementation factors are integrated hospital information system and doctors, nurses and managers interested in problems of nosocomial infection. PMID- 10179573 TI - Human fluid balance modelling and its treatment simulation with HIDION. AB - HIDION is a tanden system composed of an expert system for diagnosis of the water and electrolytic balance disturbance and a modelling program for simulation and suggestion of the needed correction. The expert system attempts to make a diagnosis mainly based on clinical symptoms and on patient history, as they are generally available for most physicians. The treatment module assists the user to establish a right strategy for re-equilibration of the fluid balance. The first aim of the system is to achieve a correct diagnosis of the disturbances of the fluid balance and a choice of therapy tactics. The second aim of the system is an educational one for both physicians and nurses. The entire system, including the expert module as well as the modelling module is developed in Turbo Prolog. PMID- 10179574 TI - IDIS-KS: an intelligent drug information system as a knowledge server. AB - Expert System technology in combination with other technologies such as Networks and Data Base systems can prove to be a valuable tool for medical experts, providing decision support and information services, and therefore facilitating and improving their everyday tasks. IDIS-KS described in this paper, is an consultation and information system dedicated to deliver drug information and suggestions about possible treatments to medical practitioners in the National area of Greece. PMID- 10179575 TI - Five steps from a simple data base to an expert system in nutrition. AB - The paper describes the experience from the Medical Informatics Department--ITC in the field of the human nutrition. The informatic systems were developed staring from a minimal data base and simple programs. The final versions are expert systems running within complex medical informatic products. PMID- 10179576 TI - Is neural network better than statistical methods in diagnosis of acute appendicitis? AB - Three statistical classification methods: discriminant analysis, logistic regression analysis and cluster analysis were compared with the back-propagation neural network algorithm in the diagnosis of acute appendicitis. The differences in the classification accuracy, which were evaluated with the receiver operating characteristic (ROC) curve were small, though discriminant analysis and back propagation showed slightly better results than the other methods. The agreement of the methods on the diagnosis increased the accuracy of the classification, so that the number of misclassified cases reduced. The back-propagation neural network offers a good choice for statistical classification methods, but it was not found to be better than them. The use of several methods and their agreement as the basis of the diagnosis seems to give the best results for this diagnostic classification problem. PMID- 10179577 TI - W.W.W. cooperative multimedia interface in medicine. AB - The World Wide Web is now the most used multimedia information system on Internet allowing, by means of Web browsers such as Netscape Navigator or Mosaic, distribution or consultation of hypermedia documents. Although the Web has appeared only recently, the growth of its use has generated the emergence of numerous information and knowledge bases in the medical field. We suggest to investigate extended functionalities in order to introduce cooperative activities in our medical information system. These new activities allow asynchronous exchange of records and synchronous cooperation for a better coordination of the work within and between hospitals. PMID- 10179578 TI - Neural network analysis of biochemical markers for early assessment of acute myocardial infarction. AB - Neural network analysis was applied for early diagnosis/exclusion of acute myocardial infarction and prediction of infarct size. Eighty-eight patients admitted with onset of chest pain within 8 hours were included. Frequent blood samples for measurement of myoglobin, CK-MB and troponin-T were obtained and used in the development of a set of neural network components of a decision support system. The results indicate that this approach could provide useful support for assessment of patients with suspected AMI. PMID- 10179579 TI - Application of neural networks to the follow-up of AIDS patients. AB - The present work aims to obtain groups of patients with similar profiles of p24 antigen concentration and of CD4+ cell counts. These two markers were chosen because their evaluation represents a significant step in the clinical follow up of HIV-1 infected subjects. The classifications were obtained by a Kohonen neural net trained in three ways: with p24 antigen profiles only, with CD4+ cell count profiles only and with both sets of profiles. The results show that the clustering fashion of the two parameters closely resembles the clustering fashion of CD4+ only rather than the one of p24Ag, both with reference to cluster formation and with reference to distance among clusters. PMID- 10179580 TI - Removing irrelevant features in neural network classification using evolutionary computations. AB - Evolutionary artificial neural networks (EANN) are a new paradigm that refers to a special class of artificial neural networks (ANN) in which evolution is another fundamental form of adaptation in addition to learning. Evolution can be introduced at various levels of ANN. It can be used to evolve weights, architectures and learning parameters. Evolutionary computations are population based search methods that have shown promise in many similarly complex tasks. This paper presents an application of evolutionary programming for simultaneously inducing the input structure and weights evolving for multilayer feed-forward perceptrons (MLP) with standard sigmoidal activation function. PMID- 10179581 TI - From natural language to formal language: when MultiTALE meets GALEN. AB - In the GALEN project, the syntactic-semantic tagger MultiTALE is upgraded to extract knowledge from natural language surgical procedure expressions. In this paper, we describe the methodology applied and show that out of a randomly selected sample of such expressions, 81% could be analysed correctly. The problems encountered are summarised and areas of further investigation identified. PMID- 10179582 TI - Browsing and querying multimedia report collections. AB - In this paper a system and new methodologies that enable efficient exploration of distributed collections of multimedia reports are described. A conceptual model for the report and a method to semi-automatically create a hypermedia report network have been defined. The main issues addressed in this project were to exploit the textual component of a report to give a more evident semantic meaning to the data produced during the relative exam and to provide users with new interaction paradigms based on Internet technologies. PMID- 10179583 TI - ADM-INDEX: an automated system for indexing and retrieval of medical texts. AB - ADM-INDEX is a system for indexing and retrieval of Patients Discharge Summaries (PDSs) by using linguistic methods (morphologic, syntaxic and semantic processing). The ADM-INDEX knowledge base is a restructuring of a diagnostic aid knowledge base (ADM) in order to allow the linguistic analysis of medical texts. The ADM system is a comprehensive medical knowledge base which has been developed since 1972 at the University Hospital of Rennes and which has been the first professional videotex medical diagnostic aid in France. After linguistic analysis, ADM-INDEX build the index table with thesaurus wording, medical words, concepts and phrases, unknown words contained in each PDS. The benefit of using those different elements is to improve information retrieval. Although our system is constructed with the ADM dictionary, it can be easily applied to other medical nomenclature or thesaurus. In this paper, we present on the one hand the ADM INDEX knowledge base which is constituted by rules, a dictionary and a thesaurus, and on the other hand, the process of indexing and retrieval information. PMID- 10179584 TI - Semi-automatic coding with ICPC: the Thesaurus, the algorithm and the Dutch subtitles. AB - In the ICPC Thesaurus Project, which ran from 1990 to 1992, the Dutch translation of the English version of the ICPC-components 1 and 7 was made available for automated coding by structuring and improving the thesaurus and by developing an algorithm for selecting possible ICPC-codes from a set of medical terms given as input to the program. The thesaurus and algorithm are available to the developers of GP information systems and are at present incorporated in all Dutch GP systems. This paper brings you up to date with the semi-automatic coding system and the so called Dutch subtitles, an extension to the ICPC. PMID- 10179585 TI - PRONET services for distance learning in mammographic image processing. AB - The potential of telematics services is investigated with respect to learning needs of medical physicists and biomedical engineers. Telematics services are integrated into a system, the PRONET, which evolves around multimedia computer based courses and distance tutoring support. In addition, information database access and special interest group support are offered. System architecture is based on a component integration approach. The services are delivered in three modes: LAN, ISDN and Internet. Mammographic image processing is selected as an example content area. PMID- 10179586 TI - Integration of a knowledge-based system and a clinical documentation system via a data dictionary. AB - This paper describes the design and realisation of a knowledge-based system and a clinical documentation system linked via a data dictionary. The software was developed as a shell with object oriented methods and C++ for IBM-compatible PC's and WINDOWS 3.1/95. The data dictionary covers terminology and document objects with relations to external classifications. It controls the terminology in the documentation program with form-based entry of clinical documents and in the knowledge-based system with scores and rules. The software was applied to the clinical field of acute abdominal pain by implementing a data dictionary with 580 terminology objects, 501 document objects, and 2136 links; a documentation module with 8 clinical documents and a knowledge-based system with 10 scores and 7 sets of rules. PMID- 10179587 TI - Using the GRAIL language for classification management. AB - This paper describes a novel approach in classification management where a formal model of medical semantics is being used for manipulations on existing classification systems. The paper addresses the issue of semi-automatically making specialist classifications that are compatible with the source classification. The examples in this paper are from a limited domain. At the time of the presentation results will be shown of the present modelling work within the GALEN-In-Use project. The model will then contain several thousands of medical procedures from four different classification centres. PMID- 10179588 TI - Numerical proposal for a semiological classification of clinical findings. AB - The principal goal of this paper is to present a numerical classification of the characteristics of symptoms and signs. This classification begins with the ICD9 code and takes into account the semiological aspects of the already mentioned symptoms an signs, in such a way, that a digit represents, in cases of abdominal pain, site, another: radiating to, and the followings: aggravating, relieving factors, progress, duration and type. This way of representing data, with only a digit for each characteristic facilitates registration and elaboration of data bases, as well as, electronic data interchange. PMID- 10179590 TI - Case mix of elderly in-patients in the 29 hospitals in Lorraine in 1994 and 1995. AB - The creation of regional standardized medical information databases in relation with the French anonymous discharge dataset allows the study of the geriatric case mix processed in the Lorraine region for patients over 69. The age histogram (69 to 107 years) presents a two mode distribution with an important dip centered on 79 years probably in connection with the demography of Lorraine and the consequences of the First World War. These geriatric patients represent 17% of hospitalisations in public and private hospitals participating in the public sector. The case mix is related to the size of the hospital and to its juridical status. The bigger the size of an hospital, the less its activity is concentrated on a small number of disorders. Lung and heart diseases represent the first cause of hospitalisation in all hospitals. It is necessary to underline the limitation of an approach which uses the patients' individual hospitalisations, and which does not allow different stays of a given patient on the same hospital or between different hospitals to be linked. This approach prevents from appreciating the care network for this elderly population suffering from chronic diseases. PMID- 10179589 TI - Medico-economical use of the medical record or the bridge between minimal and detailed data. AB - Medico-economical use of the medical record: the title encloses two different notions which represent two different trends within medical informatics. The first trend is worried about weighting aspects of health resources consumption, mainly about hospital acute care; their key-words are "DRG (Diagnostic Related Groups), Case-Mix, reimbursement by pathology, measurement of indicators (severity or outcome), costs". The other trend is looking for deeper understanding of the medical process and for better diffusion of relevant information helping the day-to-day care process; they speak of "CPR (Computerized patient record), full text reports and corresponding retrieval, detailed data, medical records on Internet, large access to literature and databases". It is mandatory to realize a bridge between these two trends for facing the information technology revolution entering into a self-revolutioning medicine. The purpose of this paper is to begin this bridge by showing what the DRG people expect from the CPR people and what the latter should receive from the former. PMID- 10179592 TI - Telemedicine: evaluation or stagnation. AB - Telemedicine is attracting attention as a new means of delivery health care, but research indicates a low level of useful analysis of projects. This paper reviews the potential of telemedicine and suggests the use of appropriate evaluation techniques can enable that potential to be realised. The importance of quantifying benefits and introduction of wider perspectives is discussed and advocated. PMID- 10179591 TI - A 3D ultrasound scanner: real time filtering and rendering algorithms. AB - The work described here has been carried out within a collaborative project between DIST and ESAOTE BIOMEDICA aiming to set up a new ultrasonic scanner performing 3D reconstruction. A system is being set up to process and display 3D ultrasonic data in a fast, economical and user friendly way to help the physician during diagnosis. A comparison is presented among several algorithms for digital filtering, data segmentation and rendering for real time, PC based, three dimensional reconstruction from B-mode ultrasonic biomedical images. Several algorithms for digital filtering have been compared as relates to processing time and to final image quality. Three-dimensional data segmentation techniques and rendering has been carried out with special reference to user friendly features for foreseeable applications and reconstruction speed. PMID- 10179593 TI - Health telematics in Ukraine: problems and prospects. AB - The state of medical telecommunication networks in Ukraine is described. The concepts of creating and architecture of the National Direct Access Computer Network 'UkrMedNet' are given. PMID- 10179594 TI - Collection of data in clinical studies via Internet. AB - This paper describes a system enabling data collection in multicenter clinical trials via WWW and Internet. The form-based data entry is based on HTML documents with JavaScript linked to a relational database (mSQL) via a cgi program (w3 msql). The design has been applied to a multi-national study in acute abdominal pain, for which eight clinical forms have been developed. The system is now in test use and experiences with this approach are presented. PMID- 10179595 TI - Post-integration of a tumor documentation system into a HIS via middleware. AB - Integrating autonomous applications is a difficult task since they usually represent similar informations in different data schemes. Any communication requires an agreement of sender and receiver on a common data representation. The number of interfaces to convert one data representation into another is minimized if all participants of an information system agree on one data representation such as Health Level Seven (HL7) or Edifact. Even more convenient is the use of a middleware solution like the Distributed Healthcare Environment (DHE) that keeps message transfer completely transparent to the integration process. This paper discusses a project that aims at the integration of a cancer registry system into a DHE based Hospital Information System (HIS). The project is a cooperation between the universities of Giessen and Magdeburg within the framework of the European Communities Telematics Research Project HC 1019 HANSA (Healthcare Advanced Networked System Architecture). The concept of a so called 'DHE-Adapter' to integrate existing legacy systems is explained. This adapter converts a data or message format of a legacy system into calls of the DHE programming interface. To develop a DHE-Adapter for our cancer registry system we intend to design a DHE Adapter-Generator which would be able to produce DHE-Adapters for different systems and export formats, e.g. HL7 or Edifact. That would allow a variety of software vendors to integrate their products into the DHE without entering deeply into the DHE's programming interface. PMID- 10179596 TI - Survey among physicians by means of dynamic access to an Internet information server database. AB - Current database management systems, client-server architecture and the internet infrastructure are simplifying the exchange of information. Large and widespread electronic medical record systems are accessible via platform-independent browsing applications. The following brief summary shows one of the manifold conceivable applications of these technologies in medicine. It describes a survey among physicians with the scope of quality assurance in medicine. The dynamic, platform-independent, world-wide access to databases offers interesting aspects in medical informatics. PMID- 10179598 TI - European Citizens Advisory Systems based on telematics for communication and health. AB - The objective of Citizens Advisory Systems for Health in Europe is to provide background information in preventive health care, to offer data-based and knowledge-based facilities and to reduce costs within the national and European wide health systems. In order to do so, easily accessible human-computer dialogues and systems have to or have been already developed, allowing every citizen to obtain the right information at the right place at any time with any intensity which is wished. The paper will describe the already existing standards, will explain the ideal type and the technical and social implications which have to be taken into consideration for these systems. PMID- 10179597 TI - Application of telematics for improving multiple schedules. AB - Nurse scheduling is an important, but also a very complicated management task. Performing this task results in a nursing schedule. These nursing schedules strongly influence the performance of a nursing ward. This paper describes research results on the application of several knowledge acquisition techniques for the development of a decision support system. This system informs the nurse scheduler about the quality of an arranged schedule. This paper next shows how this system can be used to improve multiple schedules in combination with the application of telematics. This improvement is based on the communication between schedulers who have a shortage or a surplus of nurses at certain days of the schedule. By means of internal reallocation of nurses for a short period of time, the total schedule quality of all nursing schedules can be improved. PMID- 10179600 TI - A multimedia man-machine interface for the disabled and elderly. PMID- 10179599 TI - Medical emergency aid through telematics: design, implementation guidelines and analysis of user requirements for the MERMAID project. AB - MERMAID is an EU financed telemedicine project with global reach and 24-hour, multilingual capability. It aspires to provide a model for the provision of health care services based on the electronic transmission of medical information, via ISDN based videoconferencing. This model will not be limited to medical diagnostics but it will encompass all cases where the actual delivery of health care services involves a patient who is not located where the provider is. Its implementation requires the commissioning of an expensive telecommunications infrastructure and the exploration of a number of solutions. In fact, all categories of telemedical applications (audio and video conferencing, multimedia communications, flat file and image transfer with low, medium and high bandwidth data requirements) will be considered while the full range of network choices (Digital land lines, Cellular/Wireless, Satellite and Broadband) will be tested in terms of cost/performance tradeoffs that are inherent to them and the developmental stage each of these options occupies in their in its life cycle. Finally, out that MERMAID utilises advanced land based line transmission technologies to aid the remote patient by making available the specialist care that is best suited in the particular case. PMID- 10179601 TI - An EKG monitor network. AB - A networkable kardiomonitor CM-3 is described as well as the associated central monitoring device CEMON. CM-3 allows archiving as well as efficient control of all relevant measurements, alarms and trend data in the last 2 years of use of the equipment. This data is easily reviewed, printed or saved on removable media to be included in the hospital patient documentation. The network is based on standard Ethernet bus architecture and PC Ethernet adapters. This high speed medium allows efficient real time control and immediate reaction to each alarm situation. Easy integration with other parts of the hospital information system is possible. In addition, critical monitor files can be efficiently backed up and possibilities are open for hierarchical storage with high security options. PMID- 10179602 TI - Color perimetry with personal computer. AB - Color visual field analysis has proven highly sensitive for early visual impairments diagnosis in M. S., yet it has never attained widespread popularity usually because the procedure is difficult to standardize, the devices are costly, and the test is fatiguing. We propose a computerized procedure running on standard PC, cost effective, clonable, and easy handled. 264 colored patches subtending 1 degree angle of vision, with selected hues and low saturation levels are sequentially and randomly displayed on gray equiluminous background of the PC screen subtending 24 degrees x 40 degrees angle of vision. The subject is requested to press a switch at the perception of the stimulus. The output provides colored maps with quantitative informations. Comparison between normals and a selected population of Patients with Multiple Sclerosis and with Glaucoma without luminance visual field defects, showed high statistical difference. PMID- 10179603 TI - RHINE-AM. An inter-regional health information network for Europe. AB - RHINE is an inter-regional network in Europe having as an aim, the promotion of know-how transfer in the area of Information Technology methods and tools in the regions involved. The RHINE network's significance will be demonstrated in the health sector. Within the main scope of the project, the aims and objectives of RHINE and the participating partners encompass the extension of the nucleus network and the furtherance of Information Technology research. Application areas include distributed data base and knowledge base technologies for open regional information systems supported by other technologies for business processes. PMID- 10179604 TI - Organisation, transmission, manipulation of pathological human organs on the WWW. AB - The paper describes an integrated methodology for the development of a WWW computer system which addresses issues of the organisation, retrieval and manipulation of 3D volumetric models of pathological human organs. The library of organs is distributed on the WWW since medical expertise and needs are typically expensive resources and also because many pathological conditions are often restricted to local diffusion. Users are provided with a WWW viewer for interactive manipulation of the models of the organs. The system supports low cost MS-Windows 32 platforms and requires no specialised hardware. Early results demonstrate that the compression techniques employed provide near real-time response for retrieval/manipulation, not only over high-speed expensive network lines, but also over low/medium network connections. PMID- 10179605 TI - NIGHTINGALE--a new perspective in nursing informatics education in Europe. AB - The NIGHTINGALE project, which is an EU financed project, is considered as essential in planning and implementation of strategy in training the nursing profession in using and applying healthcare information systems. Therefore, NIGHTINGALE gives a new perspective in Nursing Informatics Education in Europe. In 1997 some major goals of the NIGHTINGALE project were accomplished. These achievements are described in this document. PMID- 10179606 TI - European dimension in nursing education with the SOCRATES programme. PMID- 10179607 TI - TELONC system for oncology education. AB - The paper describes a pilot project of TELONC computer system designed to assist oncology education. At present the system is being implemented and its elements are subject to more detailed preliminary examinations. The system is of module structure and at the present stage of implementation special attention is being paid to patterns for histopathological examinations, information on drugs with aggressive impact on human organism together with suitable instructions on their usage, as well as to certain elements of the training simulator module. PMID- 10179608 TI - The roots, values and logic's in nursing informatics. AB - This paper identifies patterns and tendencies in Nursing Informatics as a phenomenon. The methods have been literature reviews, categorizations and interpretations, looking for characteristic patterns and tendencies. 11 Patterns and 2 main tendencies are identified and the results are discussed in according to make some points on the importance and effects of Nursing Informatics to Nursing when one is developing a Nursing Informatics Curriculum. PMID- 10179609 TI - Representing nursing: the role of language and classification. PMID- 10179610 TI - Video tele-education systems. AB - This paper provides an overview of video tele-education distance learning systems that are being used to educate nursing students. These systems are using communication technology to teach courses to nursing students in one or more remote sites. The types of video tele-education systems are described. Also, the educational strategies to be concerned with and the technical requirements to implement a system successfully are presented. PMID- 10179611 TI - Exploring factors required for successful implementation of healthcare informatics. AB - This paper examines factors that are essential for a successful implementation of healthcare informatics in professional curricula. These factors are related to the design framework of the learning materials that have been developed as a part of a Dutch model curriculum of healthcare informatics. Next some ideas and suggestions for a successful implementation are presented. PMID- 10179612 TI - Linking nursing variables with patient outcomes--a challenge for computer-based systems. PMID- 10179613 TI - Telematics in nursing--fiction or reality changing mentalities. PMID- 10179614 TI - Telehealth and videoconferencing: what is the difference in distance education? PMID- 10179615 TI - ACTION. Assisting Carers using Telematics Interventions to meet Older person's Needs. PMID- 10179616 TI - Building nursing informatics courses on the Web. AB - The Information Technology is rapidly being integrated into Educational Institutions and Health Care Environments. Although the use of computer for education and training is not new to the academic society, further prospects are available through the use of emerging technologies as the Multimedia and the World Wide Web. In today's rapidly changing healthcare environment, the need for high quality, cost effective education for employees, consumers, and students is gaining increased attention. The development of customised computer-based training programs has long been beyond the capabilities or financial resources of most healthcare organisations; however, with recent advancements in technology, this situation is rapidly changing. The Nurses represent the greater part of the Health Care Professionals thus the education of this group is of outmost importance for the health-care environments. The World Wide Web can be used as an educational tool in order to have better-educated Nurses not only by supporting the Academic institutions but also by providing Distance Learning Education covering new aspects of the Nursing Science. The purpose of this paper is to increase the understanding of the ways in which the emerging technologies of Multimedia and the World Wide Web can enhance the learning process, and also provide education at a distance. PMID- 10179617 TI - Internet based data collection and analysis. AB - This paper will discuss Internet based data collection and analysis utilizing a Windows 95 and a UNIX hosted system. Forms on the World Wide Web (WWW) that illustrate the use of this technology in medical research, conference registration, and patient care will be highlighted. Some of the details involved with creating data collection forms will be presented. The paper concludes with the recommendation that the Health Telematics curricula should include a unit on creating Internet based data collection forms. PMID- 10179618 TI - DKN_web: Web based dynamic knowledge networks. An application to the orphan diseases. PMID- 10179619 TI - Electronic patient records. AB - In this contribution several aspects of electronic medical records are discussed. Attention is paid to data entry and data presentation. An example is given of a study, investigating the influence of the granularity with which information is presented on the time it takes to retrieve this information. Finally some implementation problems are discussed. PMID- 10179620 TI - NIGHTINGALE MM system--the work in progress. AB - A multimedia computer based system for the self-learning of Nursing Informatics has been designed as a part of NIGHTINGALE project. A video thread has been designed as a central structure and "a real life anchor" for the abstract concepts related to the Electronic Patient Record. The hypermedia structure of the application has been maintained through the mapping of illustrated IT entries to specific points in the video sequences. PMID- 10179621 TI - Creating an Internet resource to support education and training programmes in health informatics. PMID- 10179622 TI - VR educational environments for learning in Europe. AB - Currently education is either class tutoring based or self-learning based using books, audio tapes, video tapes, CD-ROMs. None of the above media has been proven the best and the unique tool for education. An example presented is the creation of a virtual world in which children can learn by interacting with foreign children without leaving their environment. This approach is being implemented under a Joint Multimedia taskforce project. (VIRLAN). PMID- 10179623 TI - Periodontology's application of multimedia. AB - This article makes an approach about the use of multimedia resources applied in odontology computer science educational, especially in periodontia. It highlights the importance of the use of these resources, as well as the one that than there is of more recent in this area. PMID- 10179624 TI - OECD Health Data software package: an additional educational tool in teaching health and vital statistics. PMID- 10179625 TI - Quality criteria for electronic publications in medicine. AB - This paper defines "electronic publications in medicine (EPM)" as computer based training programs, databases, knowledge-based systems, multimedia applications and electronic books running on standard platforms and available by usual distribution channels. A detailed catalogue of quality criteria as a basis for development and evaluation of EPMs is presented. The necessity to raise the quality level of electronic publications is stressed considering aspects of domain knowledge, software engineering, media development, interface design and didactics. PMID- 10179626 TI - Decision support for health professionals. AB - In this contribution two decision support tools are discussed. One is used for reducing the number of inadequately requested tests by GPs and the other to support neurologists in prescribing medications for epilepsy patients. The experiences with both programs will be discussed. PMID- 10179627 TI - Nursing telematics education: a critical success factor to the "best practice". AB - This communication aims to help demonstrating that nurses education and training, in what information and telecommunications technologies are concerned, is a critical success factor in the achievement of a strategic goal: the "best practice" in nursing. This goal is seen from the formal perspective of the quality of the nursing care process. Simultaneously, one makes a methodological approach by employing a strategical planning technique in the nursing context. PMID- 10179628 TI - Good practice in multimedia courseware development. AB - The main goal of the European TALENT/ESPRIT project is to create a generic environment for developing multimedia courseware. The first phase of the project concerns itself with developing conversion tools for converting text based course material into multimedia format. The second phase of the project adds network support to the courseware in the form of the network tutoring and networked supply chain support. One year into the project specifications for developing multimedia have been made and can be found in the project's deliverables. Also a summary of good practice in multimedia courseware development has been drawn up. First phase demonstrators (converted text based courses) are currently being prepared. This article starts with a global overview of the TALENT project itself. In more detail an overview of best practice guidelines in multimedia courseware development will be given. The information shown was obtained from an extensive survey among experts in the field of computer based training. The survey was conducted early this year as part of one of the project's deliverables. Finally some comments will be made on a multimedia demonstrator which is currently under development at HISCOM. PMID- 10179629 TI - Some evaluation criteria for educational multimedia applications. AB - This article is a fragmented overview of my personal baggage and considerations of evaluation criteria for educational multimedia. So let me begin with the single most important evaluation criteria: Use you own common sense. Your first impression normally says a lot, and you will quite soon sense it if it is quality stuff you are dealing with. Having said that, of course a number of more or less explicit pedagogical and technical evaluation criteria can be formulated. For many years various bodies have produced checklists for the evaluation of educational software. Some are just headlines, others are more detailed. Notice that multimedia is not a new thing, only the word is. Ten years ago 'multi' meant text (and drawings). Now the technical communication tools have become more sophisticated, adding sound, photos and video to the scene, not forgetting improved and more easy interaction with the software. But it is still educational software. A number of previous evaluation studies have been excellently summarised and commented upon by Squires and McDougall [1]. Many others exist, e.g. back in 1985, 1987 helpful software evaluation guidelines were published by the Council of Ministers of Education, Canada [2], and The Toronto Board of Education. [3]. PMID- 10179630 TI - Nursing informatics education for advanced nursing practice. AB - This paper describes how nursing informatics content will be integrated into the education of Advanced Nursing Practitioners at Masters level. Changes in health care, especially the need to deliver evidence based nursing care and the growing amount of health data, information and knowledge, require well educated Advanced Nurse Practitioners to lead the nursing profession. The nursing informatics content for this level of nursing education is described and compared with national and international curriculum guidelines, including Nightingale work. PMID- 10179631 TI - Health informatics education for undergraduates: teaching experiences with multi media. AB - In a global information society all students regardless of discipline need to have or acquire basic computing and information literacy skills. The Faculty of Health Science at the Central Queensland University now includes a compulsory and introductory course in Health Informatics at the undergraduate level for all its first year students to meet these educational needs for the future health industry workforce. This paper describes the teacher and student lived experiences encountered throughout the concurrent use of a variety of delivery modes to teach an introductory unit of health informatics to this varied student population. It will include a discussion about the unit itself, educational philosophy adopted, strengths and weaknesses of the technologies and delivery methods adopted and the results of the student evaluation. PMID- 10179632 TI - The Finnish informatics nurse, her job and education against a background of international development. AB - This paper presents a small survey made to Finnish "adp-nurses" working at adp departments or as contact persons and informants at the wards. Their positions, job descriptions and informal education is discussed in relation to recent international development in the field. Finally the necessity of starting formal education for the European informatics nurse is stressed. PMID- 10179633 TI - Education of health professionals. AB - In this contribution the problem-based educational system is explained. As an example the system, current in the Faculty of Medicine, is discussed. The appreciation of students of the system is very high, as is apparent from investigations performed by two independent organizations. PMID- 10179634 TI - Potential for the usage of information technologies and communications (ITC) in the teaching and practice of nurses in Madeira. AB - The propose of this communication is to describe the present nursing situation in Madeira (RAM) and its potentialities for the utilisation of the Information Technologies and Communications (I.T.C.) in educational and in clinical practice. RAM has its own Regional Health System and is developing a Health Information System, a Nursing Education System which conglobates a Baccalaureate Nursing School and a Licentiate's degree Nursing School which graduates almost the totality of the nurses who work here in Madeira, a Health Professional Education Department, common to the different organisations and a Regional Nursing Research Group constituted by elements representing the several organisations of health and which has been developing Research Education and dynamize Research Projects in nursing practice. The Nursing Schools in addition to the Health Organisation, use the Nursing Theoretical Models and the Nursing Process since 1990 Referring to the utilisation of the ITC in Education and in the Clinical Practice, despite the school curricula include informatics subjects, nurse's knowledge and opportunities of utilisation are still too incipient. Nevertheless, the present reform of the baccalaureate course curriculum as well as the aims and strategies of the Nursing Research Group and training strategies will provide positive changes. PMID- 10179635 TI - Comparative cost analysis of two different medical interventions: educational implications. AB - The paper display in a short way the concepts of medical cost and cost effectiveness analysis and present the educational implications arising from the assessment and the comparison of the Hospital cost of two different therapeutic methods of myocardial revascularization: Coronary Artery Bypass Graft (C.AB.G.) surgery and Percutaneous Transluminal Coronary Angioplasty (P.T.C.A.) PMID- 10179636 TI - Medical informatics education: basic assumption for successful implementation of information technology in the health care sector. AB - In the paper we mention the trends in medical informatics education and we present the development of medical informatics education in the Czech Republic. The actual situation at Czech faculties giving pregraduate courses covering medical informatics topics is described. The enhanced development of medical informatics education via European cooperation is shown. Finally, new approaches to medical informatics education using Internet and special educational software are mentioned. PMID- 10179637 TI - Meeting the demands of First and Third World learners in nursing education in South Africa. PMID- 10179638 TI - Education as a strategy for change. PMID- 10179639 TI - The teaching of nursing by computer-assisted learning: maximisation of existing resources in an established school of nursing. AB - Computer Assisted Learning (CAL) has made limited inroads into the teaching of nursing. While existing CAL materials are often excellent for supporting conventional teaching programs, they cannot in any way be considered as steps towards providing a free-standing CAL course. The recently published Dearing Report on the state of higher education in the UK recommends a major shift towards CAL, proposes Open and Distance Learning (ODL) as a means of effective courseware delivery, and encourages British Higher Education Institutions to enter the competitive global marketplace for ODL students; the Dearing recommendations reflect the trend within both the European Union and North America towards CAL and ODL. This report documents one potential solution to the problem of raising educational standards through capitalising on existing expertise for the development of CAL using hypertext mark-up language, while working within shrinking budgets. It represents a model which is capable of adoption by other Nursing Schools, and is therefore presented with a view to stimulating discussion. PMID- 10179640 TI - The mixed media tutorial: practical guide. AB - There has been growing interest in the use of video communications in education. This paper will describe how video communications can be used as part of a teaching and learning process linked with other communications technologies to give the student greatest advantage for effective learning to take place. The paper will conclude with a personal view of the teacher preparation required to realise appropriate use of mixed media. PMID- 10179641 TI - The development of a course on nursing informatics at post registration level. AB - Within this paper the development of a course on Nursing Informatics is presented. The curriculum development process as applied to the course is explained, the structure of the course is outlined and the orientation of the content is presented. PMID- 10179642 TI - French state of the art with regard to total quality management: a focus on hospital care--accreditation, evaluation and quality assurance. AB - Accreditation, evaluation and quality assurance are major components of the current reform of the French health care system. As in other countries, the objectives are continuous quality improvement, improvement of patients' satisfaction with their care. PMID- 10179643 TI - Hospital accreditation in Europe. AB - Health service accreditation systems have explicit standards for organisation against which the participating hospital assesses itself before a structured visit by outside "surveyors". They submit a written report back to the hospital with commendations and recommendations for development prior to a follow-up survey. Accreditation may be awarded for a fixed term or may be with held by an independent assessment Board if the hospital does not meet a defined threshold of standards. In Europe, some government and medical organisations initially distanced themselves from the pilot hospital wide programmes, arguing that they would cost too much and undermine management, or that they were irrelevant to clinical practice. But gradually it became obvious that accreditation worked for hospitals; purchasers and insurers saw its potential for quality and resource management; and professional bodies recognised the links between clinical training, practice and outcome and the environment in which health care is provided. If nothing else, it offered a multi-professional bridge between the existing numerous fragmented systems such as inspecting (statutory safety), visiting (professional training), and monitoring (service contracts). The introduction of accreditation appears to benefit hospitals in many different countries and health systems and provides a vehicle for integrated quality management which is visible to funding agencies, government and the public. Interest is growing within Europe. PMID- 10179645 TI - Design of the New East Hospital (Shanghai, People's Republic of China). AB - We feel very fortunate to have been involved in the project at East Hospital. Because the clientele is so vastly different in China, JMGR has been challenged to produce a facility that is extremely design oriented, giving us an opportunity to push the limits of design and aesthetics to create a unique solution to project opportunities. Our clients at East Hospital are eager to possess a contemporary building that demonstrates their commitment to progress. They desire a building that makes a statement about their country's entry into the global marketplace. We believe the design of East Hospital encompasses these client desires, while at the same time, elevates the facility to meet modern international standards. Our work at East has, in turn, led to the involvement with other Chinese clients. Today, JMGR has a total of six projects either completed or under design in China. PMID- 10179644 TI - An input and process evaluation of Internet-based distance learning education for hospital managers in Indonesia. AB - An evaluation study was carried out to describe the input and process of internet based distance learning graduate education program for hospital managers in indonesia. The main research question addressed in the study was whether the program supported quality learning among students who were working full time and could not leave their jobs for the whole study period. The results of the study indicated that the program benefited those who lived in remote areas and women who could not leave their family for long period of time. The study suggests that interactions between students and their peers or tutors motivated better learning processes. Variability of performances were observed among students who were not equally supported by technological helps and with different learning motivations. It needs another year to evaluate whether the internet-based program is no less effective and efficient or even better than the in-class programs. PMID- 10179646 TI - Morality and bureaucracy in health and social policy. AB - The outgoing Director General set aside the usual biennial report approach of reviewing IHF's activities over the previous 2 years. Instead Dr. Pickering reviewed the developments in health care over the last decade, the period he has held office. He decried the emasculating role of bureaucracy in health care and the lack of morality in decision-making in social and health policy. The article is a cri de coeur' for a fundamental ethical review of the basis for health care changes. PMID- 10179647 TI - Six dangerous myths about pay. AB - Every day, executives make decisions about pay, and they do so in a landscape that's shifting. As more and more companies base less of their compensation on straight salary and look to other financial options, managers are bombarded with advice about the best approaches to take. Unfortunately, much of that advice is wrong. Indeed, much of the conventional wisdom and public discussion about pay today is misleading, incorrect, or both. The result is that business people are adopting wrongheaded notions about how to pay people and why. In particular, they are subscribing to six dangerous myths about pay. Myth #1: labor rates are the same as labor costs. Myth #2: cutting labor rates will lower labor costs. Myth #3: labor costs represent a large portion of a company's total costs. Myth #4: keeping labor costs low creates a potent and sustainable competitive edge. Myth #5: individual incentive pay improves performance. Myth #6: people work primarily for the money. The author explains why these myths are so pervasive, shows where they go wrong, and suggests how leaders might think more productively about compensation. With increasing frequency, the author says, he sees managers harming their organizations by buying into--and acting on--these myths. Those that do, he warns, are probably doomed to endless tinkering with pay that at the end of the day will accomplish little but cost a lot. PMID- 10179648 TI - The alternative workplace: changing where and how people work. AB - Today many organizations, including AT&T and IBM, are pioneering the alternative workplace--the combination of nontraditional work practices, settings, and locations that is beginning to supplement traditional offices. This is not a fad. Although estimates vary widely, it is safe to say that some 30 million to 40 million people in the United States are now either telecommuters or home-based workers. What motivates managers to examine how people spend their time at the office and where else they might do their work? Among the potential benefits for companies are reduced costs, increased productivity, and an edge in vying for and keeping talented employees. They can also capture government incentives and avoid costly sanctions. But at the same time, alternative workplace programs are not for everyone. Indeed, such programs can be difficult to adopt, even for those organizations that seem to be most suited to them. Ingrained behaviors and practical hurdles are hard to overcome. And the challenges of managing both the cultural changes and systems improvements required by an alternative workplace initiative are substantial. How should senior managers think about alternative workplace programs? What are the criteria for determining whether the alternative workplace is right for a given organization? What are the most common pitfalls in implementing alternative workplace programs? The author provides the answers to these questions in his examination of this new frontier of where and how people work. PMID- 10179649 TI - Profit pools: a fresh look at strategy. AB - In charting strategy, many managers focus on revenue growth, assuming that profits will follow. But that approach is dangerous: today's deep revenue pool may become tomorrow's dry hole. To create strategies that result in profitable growth, managers need to look beyond revenues to see the shape of their industry's profit pool. The authors define an industry's profit pool as the total profits earned at all points along the industry's value chain. Although the concept is simple, the structure of a profit pool is usually quite complex. The pool will be deeper in some segments of the value chain than in others, and depths will vary within an individual segment as well. Segment profitability may, for example, vary widely by customer group, product category, geographic market, and distribution channel. Moreover, the pattern of profit concentration in an industry will often be very different from the pattern of revenue concentration. The authors describe how successful companies have gained competitive advantage by developing sophisticated profit-pool strategies. They explain how U-Haul identified new sources of profit in the consumer-truck-rental industry; how Merck reached beyond its traditional value-chain role to protect its profits in the pharmaceuticals industry; how Dell rebounded from a misguided channel decision by refocusing on its traditional source of profit; and how Anheuser-Busch made a series of astute product, pricing, and operating decisions to dominate the beer industry's profit pool. The companies with the best understanding of their industry's profit pool, the authors argue, will be in the best position to thrive over the long term. PMID- 10179650 TI - How to map your industry's profit pool. AB - Many managers chart strategy without a full understanding of the sources and distribution of profits in their industry. Sometimes they focus their sights on revenues instead of profits, mistakenly assuming that revenue growth will eventually translate into profit growth. In other cases, they simply lack the data or the analytical tools required to isolate and measure variations in profitability. In this Manager's Tool Kit, the authors present a way to think clearly about where the money's being made in any industry. They describe a framework for analyzing how profits are distributed among the activities that form an industry's value chain. Such an analysis can provide a company's managers with a rich understanding of their industry's profit structure--what the authors call its profit pool--enabling them to identify which activities are generating disproportionately large or small shares of profits. Even more important, a profit-pool map opens a window onto the underlying structure of the industry, helping managers see the various forces that are determining the distribution of profits. As such, a profit-pool map provides a solid basis for strategic thinking. Mapping a profit pool involves four steps: defining the boundaries of the pool, estimating the pool's overall size, estimating the size of each value chain activity in the pool, and checking and reconciling the calculations. The authors briefly describe each step and then apply the process by providing a detailed example of a hypothetical retail bank. They conclude by looking at ways of organizing the data in chart form as a first step toward plotting a profit pool strategy. PMID- 10179651 TI - Case study. Does this company need a union? AB - No doubt about it, the top managers in this fictitious case study agree, Wellington Associates is a great place to work. Analysts at the high-tech consulting firm enjoy some of the best pay in the industry. And their benefits are extensive: flextime, liberal educational opportunities, comprehensive medical and dental coverage, generous vacation leave, and even on-site day care. So it came as something of a shock to CEO Jane Wellington and her top executives when HR chief Elvin Cusack started out the weekly senior-management meeting by declaring that the United Office Workers Union had begun organizing the support staff. Turns out, Cusack explained, that the company looks very different from the support staff's point of view. Although their starting salaries are indeed competitive, raises average a mere 2% to 3%, and promotions to professional ranks are rare. Medical and dental coverage take a greater chunk out of clerical pay than out of the larger professional salaries, and the cost of the day care center is pretty much out of reach for the support staff. Flextime is impractical for workers who need to be in the office to answer phones and to file papers. Worse, the support staff is expected to accommodate the analysts' flexible schedules; if an analyst decides to work late to finish a project, the secretary has to stay as well. What to do? Suggestions ranged from "fire 'em" to "say nothing before calling in legal counsel." Five commentators examine Wellington's options and its legal obligations. PMID- 10179652 TI - How should Wellington and her colleagues react to the potential formation of a union? PMID- 10179653 TI - Strategic stories: how 3M is rewriting business planning. AB - Virtually all business plans are written as a list of bullet points. Despite the skill or knowledge of their authors, these plans usually aren't anything more than lists of "good things to do." For example: Increase sales by 10%. Reduce distribution costs by 5%. Develop a synergistic vision for traditional products. Rarely do these lists reflect deep thought or inspire commitment. Worse, they don't specify critical relationships between the points, and they can't demonstrate how the goals will be achieved. 3M executive Gordon Shaw began looking for a more coherent and compelling way to present business plans. He found it in the form of strategic stories. Telling stories was already a habit of mind at 3M. Stories about the advent of Post-it Notes and the invention of masking tape help define 3M's identity. They're part of the way people at 3M explain themselves to their customers and to one another. Shaw and his coauthors examine how business plans can be transformed into strategic narratives. By painting a picture of the market, the competition, and the strategy needed to beat the competition, these narratives can fill in the spaces around the bullet points for those who will approve and those who will implement the strategy. When people can locate themselves in the story, their sense of commitment and involvement is enhanced. By conveying a powerful impression of the process of winning, narrative plans can mobilize an entire organization. PMID- 10179654 TI - Evolution and revolution as organizations grow. 1972. AB - The influence of history on an organization is a powerful but often overlooked force. Managers, in their haste to build companies, frequently fail to ask such critical developmental questions as, Where has our organization been? Where is it now? and What do the answers to these questions mean for where it is going? Instead, when confronted with problems, managers fix their gaze outward on the environment and toward the future, as if more precise market projections will provide the organization with a new identity. In this HBR Classic, Larry Greiner identifies a series of developmental phases that companies tend to pass through as they grow. He distinguishes the phases by their dominant themes: creativity, direction, delegation, coordination, and collaboration. Each phase begins with a period of evolution, steady growth, and stability, and ends with a revolutionary period of organizational turmoil and change. The critical task for management in each revolutionary period is to find a new set of organizational practices that will become the basis for managing the next period of evolutionary growth. Those new practices eventually outlast their usefulness and lead to another period of revolution. Managers therefore experience the irony of seeing a major solution in one period become a major problem in a later period. Originally published in 1972, the article's argument and insights remain relevant to managers today. Accompanying the original article is a commentary by the author updating his earlier observations. PMID- 10179655 TI - Creating corporate advantage. AB - What differentiates truly great corporate strategies from the merely adequate? How can executives at the corporate level create tangible advantage for their businesses that makes the whole more than the sum of the parts? This article presents a comprehensive framework for value creation in the multibusiness company. It addresses the most fundamental questions of corporate strategy: What businesses should a company be in? How should it coordinate activities across businesses? What role should the corporate office play? How should the corporation measure and control performance? Through detailed case studies of Tyco International, Sharp, the Newell Company, and Saatchi and Saatchi, the authors demonstrate that the answers to all those questions are driven largely by the nature of a company's special resources--its assets, skills, and capabilities. These range along a continuum from the highly specialized at one end to the very general at the other. A corporation's location on the continuum constrains the set of businesses it should compete in and limits its choices about the design of its organization. Applying the framework, the authors point out the common mistakes that result from misaligned corporate strategies. Companies mistakenly enter businesses based on similarities in products rather than the resources that contribute to competitive advantage in each business. Instead of tailoring organizational structures and systems to the needs of a particular strategy, they create plain-vanilla corporate offices and infrastructures. The company examples demonstrate that one size does not fit all. One can find great corporate strategies all along the continuum. PMID- 10179656 TI - The necessary art of persuasion. AB - Business today is largely run by teams and populated by authority-averse baby boomers and Generation Xers. That makes persuasion more important than ever as a managerial tool. But contrary to popular belief, the author asserts, persuasion is not the same as selling an idea or convincing opponents to see things your way. It is instead a process of learning from others and negotiating a shared solution. To that end, persuasion consists of four essential elements: establishing credibility, framing to find common ground, providing vivid evidence, and connecting emotionally. Credibility grows, the author says, out of two sources: expertise and relationships. The former is a function of product or process knowledge and the latter a history of listening to and working in the best interest of others. But even if a persuader's credibility is high, his position must make sense--even more, it must appeal--to the audience. Therefore, a persuader must frame his position to illuminate its benefits to everyone who will feel its impact. Persuasion then becomes a matter of presenting evidence- but not just ordinary charts and spreadsheets. The author says the most effective persuaders use vivid--even over-the-top--stories, metaphors, and examples to make their positions come alive. Finally, good persuaders have the ability to accurately sense and respond to their audience's emotional state. Sometimes, that means they have to suppress their own emotions; at other times, they must intensify them. Persuasion can be a force for enormous good in an organization, but people must understand it for what it is: an often painstaking process that requires insight, planning, and compromise. PMID- 10179657 TI - Empowerment: the emperor's new clothes. AB - Everyone talks about empowerment, but it's not working. CEOs subtly undermine empowerment. Employees are often unprepared or unwilling to assume the new responsibilities it entails. Even change professionals stifle it. When empowerment is used as the ultimate criteria of success in organizations, it covers up many of the deeper problems that they must overcome. To understand this apparent contradiction, the author explores two kinds of commitment: external and internal. External commitment--or contractual compliance--is what employees display when they have little control over their destinies and are accustomed to working under the command-and-control model. Internal commitment occurs when employees are committed to a particular project, person, or program for their own individual reasons or motivations. Internal commitment is very closely allied with empowerment. The problem with change programs designed to encourage empowerment is that they actually end up creating more external than internal commitment. One reason is that these programs are rife with inner contradictions and send out mixed messages like "do your own thing--the way we tell you." The result is that employees feel little responsibility for the change program, and people throughout the organization feel less empowered. What can be done? Companies would do well to recognize potential inconsistencies in their change programs; to understand that empowerment has its limits; to establish working conditions that encourage employees' internal commitment; and to realize that morale and even empowerment are penultimate criteria in organizations. The ultimate goal is performance. PMID- 10179658 TI - Health policy. HAZs warning. AB - The government's health action zones are part of a long tradition of area-based social programmes in Britain. Most have had only marginal success. The HAZ programme will rely on partnerships between organisations which are difficult to achieve. The success of HAZs will partly depend on local autonomy which could prove politically risky for a government committed to equality. PMID- 10179659 TI - Joint working. Prospects of partnership. AB - Joint working between organisations and professions is a key part of many of this government's initiatives, including health action zones. To work effectively together, professionals must overcome the problems of different cultures and different patterns of accountability. Teamworking across the boundaries of health and social care is generally inadequate. PMID- 10179660 TI - Joint working. Dancing with wolves? AB - A formalised and closer strategic partnership between a health authority and the healthcare industry has brought benefits to both sides. Joint working with seven companies has been used to develop an osteoporosis framework for the district, resulting in distribution of a comprehensive resource pack. Lessons have been learned on the way, and the project is being evaluated. PMID- 10179661 TI - Junior doctors. Be part of the deal. AB - A survey of junior doctors in trusts in one English region found the majority did not know whether or not their post met Department of Health requirements on hours and conditions. Most did not know that average hours worked per week should not exceed 56. Most of the acute trusts had groups to implement these New Deal regulations. But almost two-thirds of junior doctors were unaware of these. Ignorance of the New Deal by junior doctors and other NHS personnel could hamper accreditation of trusts. PMID- 10179662 TI - Nurse executives. Taken on board. AB - Unwelcome arrivals on some trust boards initially, nurse executives are proving their worth. But keeping a balance between corporate management and professional leadership can be a headache. PMID- 10179663 TI - A tale of two protocols. PMID- 10179664 TI - Re-engineering the nation's emergency cardiac response systems. Adding troops to win the war against sudden cardiac death. PMID- 10179665 TI - The chain of survival revisited. The emergence of early recognition as the unsung vital link. PMID- 10179666 TI - Recruitment and retention of volunteers. PMID- 10179667 TI - The role of the physician and the present and emerging health care channel. AB - The author examines the position of physicians in the health care channel on the basis of Transaction Cost Analysis. Propositions are offered that explain recent vertical integration. Moreover, a conceptual model of the future health care channel is offered for capitated pricing. PMID- 10179669 TI - Cross-cultural healthcare challenges: an insight into small American community hospitals. AB - The healthcare industry in the United States is faced with many strategic challenges, because of the nation's growing culturally diverse population. Growing cultural diversity now calls for better trained medical staff that is capable of handling language, religious and cultural differences. In the rural communities, where cultural diversity is rapidly becoming a demographic fact, small hospitals with limited resources are especially confronted with medical challenges for which they seem to be least prepared. Based on an exploratory research that includes a study of small town hospitals, this paper provides insights into cross-cultural problems facing healthcare professionals in small communities. The paper highlights also the ways in which hospitals are responding to such challenges. PMID- 10179668 TI - Competing strategically through market orientation. AB - As organizations seek to better understand their customers, competitors, and environments, the marketing function effectively serves as the support mechanism for these activities in many industries. Accordingly, in many organizations the marketing concept has been elevated to the stature of a strategic weapon, manifested in the form of market orientation. Market-oriented firms emphasize the collection, organization, and dissemination of information regarding both customers and competitors. This strategy is especially well-suited for the health care industry where customer knowledge is of paramount importance, customer interaction is instantaneous, and customer satisfaction is essential. Results of a national study of general service hospitals suggest that firms which embrace a market orientation benefit through enhanced customer satisfaction and quality. PMID- 10179670 TI - Motivating consumers for National Programme on Immunization (NPI) and Oral Rehydration Therapy (ORT) in Nigeria. AB - The Expanded Programme on Immunization (EPI) (changed to National Programme on Immunization (NPI) in 1996) and Oral Rehydration Therapy (ORT) were launched in Nigeria in 1979. The goal of EPI was Universal Childhood Immunization (UCI) 1990, that is, to vaccinate 80% of all children age 0-2 years by 1990, and 80% of all pregnant women were also expected to be vaccinated with Tetanus Toxoid Vaccine. The Oral Rehydration Therapy was designed to teach parents with children age 0-5 years how to prepare and use a salt-sugar solution to rehydrate children dehydrated by diarrhoea. Nigeria set up Partners-in-Health to mobilize and motivate mothers to accept the programme. In 1990 a National coverage survey was conducted to assess the level of attainment. The results show that some states were able to reach the target and some were not. It therefore became necessary to evaluate the contribution of those promotional elements adopted by Partners-in Health to motivate mothers to accept the programme. The respondents were therefore asked to state the degree to which these elements motivated them to accept the programme. The data were collected and processed through a Likert rating scale and t-test procedure for test of significance between two sample means. The study revealed that some elements motivated mothers very strongly, others strongly, and most moderately or low, with health workers as major sources of motivation. The study also revealed that health workers alone can not sufficiently motivate mothers without the help of religious leaders, traditional leaders and mass media, etc. It was therefore recommended that health workers should be intensively used along with other promotional elements to promote the NPI/ORT programme in Nigeria. PMID- 10179671 TI - Selection of a hospital for a transfer: the roles of patients, families, physicians and payers. AB - OBJECTIVE: This study investigates the reasons for hospital transfers and the role patients, their families, physicians, and payers play in the choice of a referral center. DATA SOURCES: A thirty-three item questionnaire and clinical data from the hospital's discharge database. STUDY DESIGN: A study of all 307 hospital transfer patients admitted between November 9 and December 3, 1993 was conducted to understand the factors contributing to the increase in transfers and the reasons patients were sent to CCH. Data on the transfer decision were collected by interviewing patients 48 hours after admittance to the hospital or by telephone if they were discharged before an interview could be completed. Two hundred and sixty-two (85%) patients were interviewed. PRINCIPLE FINDINGS: (1) Almost 58% of transfers were patient-initiated or -influenced; the remainder were physician- (38%) or payer-directed (4%); (2) More than 78% of the patients identified lack of clinical expertise/technology at originating hospital as the main reason for transferring. Other reasons included: established CCH patient status (43%), CCH marketing (31%), and concerns regarding quality of care at originating hospital (10%). Financial and quality dumping were not identified as reasons for the transfer. New patients to CCH were more likely to indicate that marketing and lack of clinical resources at originating hospital were reasons for selecting CCH than previous patients. CONCLUSIONS: Patients significantly influenced the transfer decision and the transfer decision-making process can be influenced by marketing. The opinions of the consumer should not be underestimated, especially by those seeking non-marketing solutions to health care reform. PMID- 10179672 TI - A national study: the use of specialty surgical teams. PMID- 10179674 TI - Doctors and divorce. When medicine, marriage, and motherhood don't mix. PMID- 10179673 TI - Consumer attitudes toward healthcare marketing practices: a comparison of hospitals vs. physicians. AB - This study investigates consumer attitudes toward the use of marketing practices by the health care industry. The survey results show significant differences in consumers' attitude toward the use and effects of various marketing practices by the two types of provider (hospital and physician). Theoretical and empirical implications are discussed. PMID- 10179675 TI - Quick--cut $20,000 in practice expenses. PMID- 10179676 TI - Remember when ... most doctors made house calls? PMID- 10179677 TI - S-O-S! When a malpractice insurer sinks, how do its doctors survive? PMID- 10179679 TI - Resident match. Are new doctors rebelling against primary care? PMID- 10179678 TI - Why burned-out doctors get sued more often. PMID- 10179680 TI - Surprise! Medicare's monkeying with fees again. PMID- 10179681 TI - Doctors vs. Aetna: win a battle, lose the war? PMID- 10179682 TI - Coding, Part 3. Get the highest coding you're entitled to. PMID- 10179683 TI - How do cutting-edge treatments pass insurance muster? PMID- 10179684 TI - Implementing the ISBT 128 labeling standard in a transfusion service. PMID- 10179685 TI - The impact of specimen management in microbiology. AB - Because the way specimens are collected and handled may directly affect the outcome of microbiological analysis, appropriate specimen management is critical to ensuring laboratory effectiveness and an acceptable turnaround time. Specific guidelines on specimen collection are necessary for optimal use of microbiology services. PMID- 10179686 TI - Journey to the millennium: mentoring in the clinical laboratory. AB - Mentoring is one solution to preparing medical technology students to face the challenges and changes they will confront in the laboratory of the future. As described here, both mentors and proteges benefit from informal mentoring programs. PMID- 10179687 TI - Up in smoke? Senate to decide fate of tobacco bill Medicare provisions. PMID- 10179688 TI - Escaping the last resort. IRS is reluctant to revoke hospitals' tax-exempt status. PMID- 10179689 TI - Rising feds' coattails? Big insurers filing fraud suits after government probes. PMID- 10179690 TI - Doctors ask Md. to probe HMO denials. PMID- 10179691 TI - Doc accrediting goes high-tech. AB - Physician credentialing, an obscure but critical process that serves as the primary safeguard against poor care is undergoing a high-tech revolution. A handful of credentials verification organizations are bringing efficiency to the labor-intensive chore by consolidating most of the required data. Technology can expedite physician approvals for managed-care panels and hospital privileges. PMID- 10179692 TI - AMA eyes competition. Emerging firms rival AMAP quality oversight program. PMID- 10179693 TI - Real results. Pa. report gives consumers outcomes data they can use. PMID- 10179694 TI - Back in black. Miss. town's efforts keep sinking hospital afloat. PMID- 10179695 TI - Extending the family. Catholic association may offer affiliate member status. PMID- 10179696 TI - AHA seeks fix for wage index dispute. PMID- 10179697 TI - Rapid respiratory testing: finding the cause of viral infections. PMID- 10179698 TI - Quality assurance issues in CD34 cell enumeration. PMID- 10179699 TI - A cost-effective antimicrobial susceptibility testing system. PMID- 10179700 TI - The dilemma of new drugs. Are costs rising faster than effectiveness? AB - This century has seen a phenomenal growth in the development, understanding and use of pharmaceuticals. Additionally, this period has seen the balance of the treatment needs of patients shift dramatically from infectious to cardiovascular and cancer diseases, and from infancy and middle-age to old age. The value of modern pharmaceuticals to society is undoubted. However, the benefits in terms of health gain, when adequately evaluated, are often more modest than first supposed, and are often achieved at considerable costs and sometimes considerable risks to patients. Data are seldom adequate to attempt a robust evaluation of the cost effectiveness of drugs and compare how cost effectiveness may have changed over time. Rapid increases in development costs coupled with the increasing focus on chronic and old-age diseases make it probable that the cost effectiveness of new drugs is broadly declining, but such a conclusion should be interpreted with caution. The big challenge for the next century with its likely genetic and biotechnological discoveries, bringing as yet unforeseen benefits, risks and costs, is to radically improve the manner in which new drugs are evaluated and diffuse into health systems. PMID- 10179701 TI - Common errors and controversies in pharmacoeconomic analyses. AB - The need to demonstrate the cost effectiveness of healthcare interventions has led to a rapid increase in the use of economic tools within pharmaceutical evaluations. Pharmacoeconomics is employed at many stages of the evaluation process, helping to predict which products are likely to be economically viable at an early stage, and providing information to aid price and reimbursement negotiations as well as formulary and purchasing decisions in conjunction with phase III and IV clinical trials. The ability of economic evaluations to accurately determine the best use of society's scarce resources, however, is strongly influenced by the existence of areas of confusion, controversy and dispute which hinder the researcher at every step. A good economic evaluation requires a number of ingredients including: (i) relevant, good quality clinical data, raising issues of trial design, sample size and perspective; (ii) relevant costs and outcomes, measured, valued and discounted credibly and accurately; (iii) appropriate methods of data analysis (statistical, incremental and sensitivity); and, once the trial is over, (iv) presentation of the results in a way which maximises the generalisability of the results and, hence, the usefulness of the research. None of these areas are trouble-free but with understanding and openness, mistakes can be minimised. PMID- 10179702 TI - The economic burden of migraine to society. AB - The financial burden of migraine on society comprises direct costs, associated with medical care, and indirect costs, caused by absence from work and reduced productivity. Recent studies have revealed that direct costs are generally relatively low in Europe, but are much higher in North America, probably because of increased use of emergency room and specialist consultations for the treatment of migraine. Most individuals who experience migraine headaches take medication (over-the-counter, prescription-only or a combination of both) for their condition; in Europe and North America, most patients who experience migraines have consulted a physician at some time because of their condition. In general, the estimated indirect costs of migraine are substantial and are much higher than estimates of direct costs. On average, work losses related to reduced productivity are higher than those related to work absence. These data demonstrate the importance of the societal impact of migraine and illustrate the need for improved strategies to target migraine treatment. PMID- 10179703 TI - Socioeconomics of a global leprosy eradication programme. AB - In the absence of evidence in the literature on cost factors in the management of leprosy, a reference is made to the sporadic attempts to study costs of case detection and treatment. Such studies indicate that in the currently declining phase of leprosy endemicity, employing a conventionally trained, salaried class of paramedical staff for field surveys is prohibitively expensive if cost per case detected is computed. Involving primary healthcare and community derived workers is cost effective. Likewise, short course chemotherapy with newer drugs under trial, administered under supervision by community volunteers, reduces the expenses considerably. Community-based disability services using inexpensive tools may cut costs by 90%. Operational research on cost effectiveness of rehabilitation comparing 'integrated' with 'vertical' approaches is, unfortunately, still in a primitive stage. It is urged that in view of the changing logistics, manpower costs and financial implications should be given serious consideration by health planners. Post-elimination problems such as: (i) unearthing hidden cases; (ii) community-based supervised treatment with highly promising newer drugs; (iii) identification of reactions and relapses; and (iv) field management of disabilities resulting from acute and silent neuritis etc could be solved in a much cheaper manner. Integration of leprosy into general healthcare services and community-based rehabilitation of leprosy patients along with those disabled by other diseases will be the major task in future as these procedures are expected to reduce management costs and eliminate stigma. PMID- 10179704 TI - The influence of ill-health experience on the valuation of health. AB - Social valuations for health states are potentially useful both in clinical decision-making and in health-resource allocation, but there is some evidence that the experience of illness may affect such valuations. This article compares valuations of hypothetical health states obtained from a sample of chronically ill patients, with valuations obtained from a sample of relatively healthy individuals. The instrument used to obtain these values was the EuroQOL 5D questionnaire (EQ-5D). We found that the EQ-5D values of chronically ill patients differed significantly from the values obtained from healthier individuals, particularly in the case of the more severe health states. Healthy individuals assigned negative values to some hypothetical health states, indicating that they consider them to be worse than death, whereas chronically ill patients assigned positive values to all health states. These results raise difficult questions about whose values should count when health-status measures are incorporated in clinical and economic evaluation, and in particular when deciding upon the allocation of scarce resources. PMID- 10179705 TI - Modelling the potential economic impact of viral load-driven triple drug combination antiretroviral therapy. AB - The purpose of this study is to model the potential economic impact of viral load driven triple drug combination (including a protease inhibitor) antiretroviral therapy on incremental drug and hospitalisation costs among individuals with HIV disease. Individuals included in the study were HIV-positive men and women from the province of British Columbia, Canada, who were aged 18 years or older and had given consent to access their medical records. The study employed pharmacoeconomic modelling of drug- and hospital-utilisation patterns among a population-based cohort with free access to antiretroviral therapy. Protease inhibitor use and associated costs based on actual use in a subsequent period was modelled upon men and women who were able to maintain stable CD4+ cell counts (slope > or = 0) for at least 6 months (baseline period) with an average follow up period of 30 months (protease-like group). A control was modelled upon individuals with declining CD4+ cell counts (slope < 0) during similar baseline and follow-up periods. The primary outcome measure was average annual incremental cost of triple drug therapy net of hospitalisation and testing costs in 1996 Canadian dollars ($Can). The utilisation pattern of drugs and hospitals was modelled from actual use among a total of 1271 individuals who were eligible for this analysis. Programme participants who gave consent to access their medical records were more likely to be men (p < 0.001), older (p < 0.020), and on antiretroviral therapy (p < 0.001) than programme participants who did not give consent. No differences were observed between the protease-like and comparison groups with respect to age (p = 0.65) and CD4+ cell count (p = 0.30) at study entry. Over a period of 1 year, the protease-like group was shown to spend less time in hospital (2.7 vs 6.6 days; p < 0.001). This difference in hospitalisation remained in multivariate models, adjusting for prior AIDS-defining illnesses and gender. The average annual incremental cost of adding a protease inhibitor to a 2 drug antiretroviral regimen was estimated to be $Can2318 per person. The cost implications of hospital stay while using a protease inhibitor drug and 2 nucleosides translated into an average annual incremental cost (savings if negative) of between -$Can4798 and -$Can2227 per person. The overall average annual incremental cost impact per person associated with triple drug therapy with a protease inhibitor varied between -$Can2288 to $Can283. Negative incremental costs imply overall savings from adopting triple combination therapy. This modelling exercise demonstrated that the cost of triple drug combination antiretroviral therapy with a protease inhibitor among HIV-positive men and women was considerably less than the expected acquisition cost of the drug alone due to hospitalisation savings in the province of British Columbia. PMID- 10179706 TI - MSQ: Migraine-Specific Quality-of-Life Questionnaire. Further investigation of the factor structure. AB - MSQ, the 16-item Migraine-Specific Quality-of-Life Questionnaire (Version 1.0), was developed by Glaxo Wellcome Inc. to assess the effect of migraine and its treatment on patients' health-related quality of life (HR-QOL). The MSQ was hypothesised to measure 3 meaningful dimensions: (i) Role Function-Restrictive; (ii) Role Function-Preventive; and (iii) Emotional Function. The objective of this research was to further investigate the number of dimensions as well as the items contained in each dimension through principal components factor analysis of clinical trial data. Secondary objectives were to determine whether the factor structure changed in post-treatment visits compared with screening visits, to make recommendations for coding the MSQ when the patient did not have a migraine in the previous 4 weeks, and to modify the MSQ if so indicated by this research. Results supported the existence of 3 distinct factors which agreed strongly with the hypothesised dimensions. The analysis of post-treatment data suggested that the underlying factor structure of the MSQ varies as a result of treatment. Based on evaluations of the 'did not have a migraine' response, it was concluded that it be dropped from the MSQ. All these changes have been incorporated into MSQ (Version 2.0) which is being evaluated in studies to determine if its psychometric properties are different than the properties of the previous version. PMID- 10179708 TI - DIPE: a distributed environment for medical image processing. AB - DIPE is a distributed environment that provides image processing services over integrated teleradiology services networks. DIPE integrates existing and new image processing software and employs sophisticated execution scheduling mechanisms for the efficient management of computational resources within a distributed environment. It can also be extended to provide various added-value services, such as management and retrieval of image processing software modules, as well as advanced charging procedures based on quality of service. DIPE can be viewed as the natural evolution of the legacy field of medical image processing towards a service over the emergent health care telematics networks. PMID- 10179707 TI - The cost effectiveness of acamprosate in the treatment of alcoholism in Germany. Economic evaluation of the Prevention of Relapse with Acamprosate in the Management of Alcoholism (PRAMA) Study. AB - Alcoholism places a considerable economic burden on society. The rate of relapse of previously weaned alcoholics has been shown to decrease following treatment with acamprosate. Therefore, this study investigated the cost effectiveness of acamprosate in the treatment of alcoholism in Germany from the perspective of the German healthcare system. In this retrospective analysis of clinical data, the additional direct medical costs per additional abstinent alcoholic incurred by adjuvant acamprosate therapy of previously weaned alcoholics were quantified. In the base-case analysis, average case-related direct costs were applied. The cost effectiveness ratio was -2600 deutschmarks (DM) per additional abstinent patient. Thus, the administration of acamprosate is cost saving. The cost benefit of acamprosate was also shown in a sensitivity analysis. The variance of the target variable under 'real world' conditions was simulated and the impact of the model variables on the target variable was quantified using a deterministic model. The variance was broad and the rate of abstinence under acamprosate was the independent variable with the greatest impact on the target variable. From the perspective of both the German healthcare system (i.e. direct medical costs) and the Statutory Health Insurance expenses, adjuvant acamprosate therapy led to net savings, while at the same time improved the patient's state of health. Based on the naturalistic design of the underlying clinical trial and on this economic evaluation, it can be concluded that adjuvant acamprosate therapy leads to net savings under 'real world' conditions. PMID- 10179709 TI - Security of medical image databases. AB - Medical images are an integral and indispensable part of health care information systems. Because of the critical nature of image information and stringent privacy requirements in medical environments, the medical images database systems must provide reasonable safeguards to assure confidentiality, integrity and availability of images to be deployable. In this paper we address mainly the confidentiality issues. Only authorized users should have for example access to medical images. Access to images is usually based on certain security constraints. Security constraints processing is a widely used mechanism for obtaining the appropriate level of the security required in traditional (non multimedia) database systems. However, the security constraints processing in multimedia environments possess a number of interesting problems. In this paper we address the advantages and problems of using content-based security constraints on medical image databases. We also propose a methodology for the integration of security constraints into medical image databases, taking into account the true multimedia nature of the medical images (e.g. the content of the medical images). PMID- 10179710 TI - Artificial intelligence elements in multimedia system for surgery. AB - The paper presents a concept of a computer system designed to assist a surgeon's work both before and during a surgical operation. The aim of multimedia in the system is to ensure comfort in communication between an operating surgeon and his assistants. The elements of artificial intelligence, on the other hand, are to assist the surgeon in taking optimal decisions in difficult and untypical situations. PMID- 10179711 TI - Diagnostic systems for assessing alveolar bone loss. AB - Radiological diagnostics serves as a basic monitoring technique for alveolar bone loss which is a severe consequence of periodontal disease. To evaluate efficacy of Conventional Visual Radiography (CVR), and to assess a complete clinical status, we had used two more diagnostic systems. These are Digital Subtraction Radiography (DSR) and Probing Pocket Depth (PPD). Experimental Periodontitis was studied in 20 beagle dogs based on the measurements taken in the beginning (baseline), and before (11th month) and after the medical treatment (12th month). Data analyses pointed out the same clinical trend, i.e. a significant bone loss prior to medical treatment and its recovery to the initial state. Differences in metrics and measurement errors could be identified as causes for discrepancies between the systems, but a relationship between the CVR and PPD is worth of further research, as these systems do not appear to be entirely compatible, but rather complementary to each other. PMID- 10179712 TI - 3D computer-aided reconstruction of the morphology of teeth with malformations. AB - Malformations of the teeth is a restraining reason for endodontic therapies because of the difficulties they appear during such procedures. These difficulties refer to the knowledge of their internal morphology. The purpose of this study was the 3D reconstruction of two types of malformations of the teeth named "double" teeth and "odontomas". Two "double" teeth and two "odontomas" were studied. All the teeth structures were embedded in polyester resin and from each specimen serial cross sections were taken by using a special microtome. The serial cross sections were photographed under a stereoscopic microscope and digitized. The contours of the external and internal surface of the sections were taken and semiautomatic alignment was achieved. 3D surface representation was used in this project to reconstruct the inner and outer surface of the structures. The results showed in detail the internal structure of the teeth under investigation. The fact that we are able to view and study these teeth from different view points is one of the main advantages of the established method as one could have an idea of the internal structure of these teeth in the space, which is very useful for a clinician. In conclusion, the 3D reconstructing method is a useful tool for the external and internal study of the structure of the teeth with dental anomalies. PMID- 10179714 TI - Fuzzy classification of renal artery lesions from angiograms in the context of angioplasty. AB - This paper describes a system that automatically classifies renal artery lesions from arteriograms in the context of Percutaneous Transluminal Renal Angioplasty (PTRA). PTRA outcomes have been categorized into type A (success) or type B (failure) according to morphological features. The morphological features are naturally represented by fuzzy sets. The classification process is based on a fuzzy pattern matching procedure between fuzzy prototypes of lesions in the classes A and B and fuzzy quantified assessments of lesions in angiograms. The system provides a meaningful membership degree to the class rather than an abrupt yes or no answer. The system is expected to be a good framework to study the technical results of PTRA according to the anatomy of the lesion. PMID- 10179713 TI - Integration of digital angiography and gamma-camera diagnostic modalities to a generalized hospital information system. AB - Within the framework of the NIKA project for the development of a "Generalized System for Processing and Management of Medical Images", we have integrated a Digital Subtraction Angiography (DSA) station and a gamma-camera diagnostic modality to the newly developed generalized hospital-wide information system. The integration consists of acquiring, digitizing, converting and filing the information from the above diagnostic modalities to the hospital's Picture Archiving and Communication System (PACS). The PACS, which is installed in the Onasio Cardiosurgery Centre of Athens, Greece, is responsible for archival, cataloging, retrieval and viewing of the large volume of patient examination data accumulated during his/her stay in the Centre. The ultimate goal is for all patient data, from all different examinations, to be viewed on dedicated client workstations. Information from different modalities can then be simultaneously presented to the attending physician, for a complete picture of the patient history and condition. PMID- 10179715 TI - The necessity of urologic ultrasound images processing. AB - The purpose of the paper is to present a software system for the handling and management of urologic ultrasound images. In particular, the system was used to detect men's prostate in ultrasound images and than to obtain a 3D model for the detected object and to calculate its volume. The software system can be used in hospitals which do not have either CAT scanners or NMR/MRI equipment (the majority of Romanian hospitals). It provides these hospitals with a tool enabling a more accurate diagnosis, which in turn improves the efficiency of the hospital, saves money, and has a profound psychological benefit on the well-being of the patient. PMID- 10179716 TI - Use of wavelet analysis for contrast enhancement in mammography. AB - A wavelet analysis approach to contrast enhancement in mammography is presented. The approach consists of application of non-linear enhancement of multiscale gradient magnitudes utilising edge location information. The performance of wavelet analysis is evaluated by means of a breast phantom. Preliminary results indicate the value of the approach in contrast enhancement and edge preservation for both simulated tumours and microcalcifications. PMID- 10179717 TI - A new automated method for three-dimensional registration of MR images of the head. AB - A new technique for three-dimensional image registration was developed and tested using T1 and T2 weighted Magnetic Resonance image studies of the head. The method uses the fuzzy c-means classification algorithm for outlining the surface contours and then minimizes iteratively the mean squared value of the voxel per voxel weighted ratio of the two trilinearly interpolated cubic voxel volumes. A total of 200 two-dimensional and 240 three-dimensional registration experiments were performed and showed that the method is signal intensity independent, it has registration accuracy better than 1 degree for rotations and 1 voxel for translations and it is not affected by the deterioration in the imaging resolution for voxel sizes up to 1.8 mms. PMID- 10179718 TI - Coronary artery skeleton detection based on topographic features. AB - A new approach to the problem of detecting the skeletons of coronary arteries in coronary angiograms is proposed. The digitized grayscale coronary angiograms are regarded as noisy sampling of the underlying continuous surface. After the application of Gaussian filtering to reduce noise, the topographic features of the smoothed image are detected based on first and second order image derivatives. Then, the candidate arteries skeleton points are detected based on the observation that arteries are smooth elongated objects having approximately a Gaussian smoothed semi-elliptical profile. Experimental results on real digitized coronary angiograms are presented. PMID- 10179719 TI - A model for image formation and image quality prediction in diagnostic radiology. AB - A computer program modelling the formation of radiological images and predicting values of physical quantities that determine diagnostic image quality has been developed. The quantities are the modulation transfer function (MTF), the noise power spectrum (NPS), and the detective quantum efficiency (DQE) associated with signal to noise ratio (SNR). The program is based on mathematical models that describe the effects of x-ray interactions with the imaged object and the image detector as well as phenomena concerning the optical signal propagation within the detector. All data on x-ray effects necessary for computer calculations were derived from published work whereas optical data were determined in our laboratory using experimental techniques. Model predictions were compared with direct quality measurements performed after image formation, on the image itself. PMID- 10179720 TI - Computer image analysis of ultrasound images for discriminating and grading liver parenchyma disease employing a hierarchical decision tree scheme and the multilayer perceptron neural network classifier. AB - Differential diagnosis of liver parenchyma disease and grading of the hepatic disease on ultrasound is a common radiological problem that influences patient management. The aim of this study was to apply image analysis methods on ultrasound images for discriminating liver cirrhosis from fatty liver infiltration and for grading hepatic disease, which is important in the management of the patients. Ultrasound images of histologically confirmed 18 livers with cirrhosis, 37 livers with fatty infiltration, and 24 normal livers of healthy volunteers were selected and were digitized for further computer processing. Twenty two textural features were calculated from small matrix samples selected from the ultrasound image matrix of the liver parenchyma. These features were used in the design a three level hierarchical decision tree classification scheme, employing the multilayer perceptron neural network classifier at each hierarchical tree level. At the first tree level, classification accuracy for distinguishing normal from abnormal livers was 93.7%, at the second level the accuracy for discriminating cirrhosis from fatty infiltration was 90.9%, and at the third level the accuracy in distinguishing between low and high grading liver cirrhosis or fatty infiltration was 94.1% and 84.9% respectively. The proposed computer software system may be of value to the radiologists in assessing liver parenchyma disease. PMID- 10179721 TI - Deformation analysis of brain regions. AB - The analysis of 2D and 3D deformations applied to structures having non regular geometry is presented. Deformations are studied in order to understand complex dynamic problems coded into image sequences. In particular, methods have been developed suitable to control the reconstruction and the spatial deformation of cerebral structures, in their different aspects of morphometry, isometry and densitometry. Finally, a simulation process of brain deformation caused by a neoplasia in a real relevant clinical case has been performed. PMID- 10179722 TI - Improving early recognition of malignant melanomas by digital image analysis in dermatoscopy. AB - The malignant melanoma (MM) is the most dangerous human skin disease. The incidence increased dramatically during the last years. The only chance for the patient is an early recognition and excision of the MM. The best diagnostic method for this is skin surface microscopy or dermatoscopy. Its use, however, requires much expertise. In order to support learning and using the method, a computer-based dermatoscopy workstation is being developed. Among others, new complexity measures are used for the image analysis. PMID- 10179723 TI - Adaptive reduction of heart sounds from lung sounds using a wavelet-based filter. AB - A new adaptive method for heart sounds reduction from lung sounds, based on wavelet transform, is presented in this paper. The use of a wavelet transform domain filtering technique as an adaptive de-noising tool, implemented in lung sounds analysis, is introduced. The multiresolution representations of the signal, produced by wavelet transform, are used for signal structure extraction. Experimental results have shown that implementation of this wavelet-based filter in lung sound analysis results in an efficient reduction of heart sounds from lung sounds, producing an almost noise-free output signal. PMID- 10179724 TI - EP parametrization and classification using wavelet networks--theoretical concept and medical application. AB - The purpose of this paper is to outline the fundamental concept of wavelet networks (WNs) and to demonstrate its specific advantages in a clinical discrimination task. A group of 25 boys with attention deficit hyperactivity disorder (ADHD) should be separated from a control group of 25 healthy boys by auditory evoked potentials. Because of the high variability of the recorded EP signals quantification of the averaged sweeps by peak latencies and amplitudes failed. However, with wavelet networks a maximum classification rate of 80% was achieved by crossvalidation. A WN is basically described as a multilayer perceptron which consists of two parts for feature extraction/parametrization and classification. These essential steps of a pattern recognition task are not separated in different tasks but linked together by the clamp of the learning algorithm. Because no user interaction is necessary we call this procedure a self learning method. PMID- 10179725 TI - An intelligent system for the tracking--localization of changes & exploratory analysis--of long-term ECG. AB - An interactive methodology for the analysis of long-term ECG is introduced. It is an anthropomimetic technique and consists of three parts. At the first stage, the clinicians' scan of the ECG traces is imitated and changes in the shape of QRS are quantified. In the sequel, a clinician involves in the interpretation of the most prominent changes providing the patient-dependent prototypes for the subsequent machine learning procedure. Finally, a classification scheme incorporates the portion of medical knowledge needed to explore the whole patient's ECG. This scheme, being very robust to noise, presents excellent generalization properties and can serve as a reliable automation in a future examination of the certain subject. PMID- 10179726 TI - Cardiac electrical instability of the arrhythmogenic tissue substrate assessed by means of wavelet transform. AB - The unstable activation wavefront from the tissue responsible for the production of ventricular tachycardia (VT) gives rise to beat-variable signals components that are eluded during the averaging step of high resolution ECG (HRECG). We used a mathematical model of small variations in a largely repetitive waveform to evaluate the beat-to-beat variance of the HRECG signal. The ability of the Morlet Wavelet Transform to discriminate the different factors responsible for the beat variability (the alignment error and the beat-variable signal component) has been assessed on simulated signals. The performance evaluation on real ECG signals from normal subjects and patients with a documented history of ventricular tachycardia showed that the dynamics of the arrhythmogenic substrate as revealed by wavelet transform offers a significant improvement in ventricular tachycardia risk assessment. PMID- 10179727 TI - ECG recognition by Boolean decision rules. AB - The classical pattern recognition problem is considered. A model of construction of Boolean decision rules is implemented. Computational procedures for construction of non-reducible descriptors is briefly discussed. Applications of Boolean decision rules to ECG analysis and ECG recognition are suggested. PMID- 10179728 TI - The performance and reliability of wavelet denoising for Doppler ultrasound fetal heart rate signal preprocessing. AB - The present paper deals with the performance and the reliability of a Wavelet Denoising method for Doppler ultrasound Fetal Heart Rate (FHR) recordings. It displays strong evidence that the denoising process extracts the actual noise components. The analysis is approached with three methods. First, the power spectrum of the denoised FHR displays more clearly an 1/fa scaling law, i.e. the characteristic of fractal time series. Second, the rescaled scale analysis technique reveals a Hurst exponent at the range of 0.7-0.8 that corresponds to a long memory persistent process. Moreover, the variance of the Hurst exponent across time scales is smaller at the denoised signal. Third, a chaotic attractor reconstructed with the embedding dimension technique becomes evident at the denoised signals, while it is completely obscured at the unfiltered ones. PMID- 10179729 TI - POLYAN: a package for a polyparametric approach to cardio-respiratory variability signals analysis. AB - POLYAN, a computer program based on a point-and-click graphical user interface for easy and efficient polyparametric analysis of cardio-respiratory variability signals is described. The main tasks performed by the package are: univariate and bivariate spectral analysis on selected portions of the signals with the computation of some clinically relevant indices and baroreflex sensitivity assessment by the analysis of the relationship between systolic pressure and heart period signals. Some tools which help the analyst in the solution of common practical problems have been implemented to make analysis easier and more rigorous. Using Matlab language, POLYAN has the flexibility and expandability necessary for a research tool, which often requires implementation of new algorithms and computation of new parameters. PMID- 10179730 TI - A study of pharmacological vs. pathological autonomic nervous system blockade in humans, using heart rate chaotic dynamics. AB - Pathological blocking of the Autonomous Nervous System (ANS) is diagnosed for patients having Autonomic Neuropathy passing a well-defined set of criteria. In this work, It is shown that standard analysis can be complemented by a study of the chaotic dynamics of the Heart Rate (HR), over a period of 12 min in the resting position. It was found that patients who suffering from ANS blockade, typically exhibit a smaller degree of fractality and complexity of the chaotic attractor reconstructed from the time series of the HR signal. These dynamical measures are more evident in normal human subjects that have been subjected to pharmacological ANS blockade. PMID- 10179731 TI - Strategy for the pursuit of spiral waves in excitable media. AB - Spiral waves are though to be the underlying mechanism of re-entrant ventricular and atrial tachycardias. In such cases, one is generally interested in eliminating spiral wave activity from the medium. In this paper, solve a cubic FitzHugh-Nagumo system of PDEs is solved in two dimensions with initial conditions such that a spiral wave is formed at the center of a rectangular grid. Then the effect of a spatially-localized step-like periodic forcing placed at different positions around the spiral tip is studied. Due to this forcing, the tip begins to drift away from the perturbation in a direction that depends on their relative location. By shifting successively the location of the perturbation relative to that of the tip strategy is developed which it is possible to pursuit the spiral wave away from the center of the grid accelerating its drift with every shift of the perturbation. PMID- 10179732 TI - An integrated model of sleep regulation. AB - We present a new model of sleep regulation which integrates the two process model and the limit cycle reciprocal interaction model. In the two process model the interaction of a homeostatic process (S signal) and of a circadian process determines the timing of sleep and waking. In the limit cycle model, the NREM-REM sleep cycle is generated by the reciprocal interaction of two coupled cell population. The present model integrates the two considered models introducing the trigger REM-NREM generated by the REM-ON signal and activated when REM-ON overcomes the S signal. PMID- 10179733 TI - A new Object Request Broker architecture in implementing a medical picture retrieval system. AB - This paper describes the approach we used to implement the world wide web user interface of MediPict, a medical picture retrieval system. The best software architecture seemed to be the three-tier client/server architecture using Objects Request Brokers (ORB) which appears to have many benefits. Although CORBA appears to be the standard ORB, we found it more adequate to develop a different approach. This new ORB resolves many of CORBA's weaknesses (non coherent types, need of a static IDL, maintenance difficulties) by using the same language on the top and middleware tiers. PMID- 10179734 TI - An open distributed medical image and signal data server network with World Wide Web front-end. AB - In modern patient care and medical research diagnostic imaging from multiple modalities plays an essential role. In general these digital image data are acquired at different locations. An efficient access to the data via network is often not provided due to technical, organisational and political reasons. This article presents an approach to solve the problem by means of an open distributed data server network with Web-based front-ends and describes the prototype DACHS that has been developed at the University Hospital of the Technical University of Munich. PMID- 10179735 TI - The I2Cnet service architecture paradigm. AB - The main objective of the Image Indexing by Content network (I2Cnet) is to provide network-transparent content-based access to medical image archives based on a collection of interoperable Internet/intranet added-value services. This paper discusses I2Cnet, focusing on its service architecture paradigm. I2Cnet services such as image annotation, processing, description, and content-based retrieval, as well as the on-line collaboration service are presented. Exemplary user sessions are used to illustrate how virtual workspaces facilitate the interoperation of I2Cnet services, following the "network computer" approach to information management. PMID- 10179736 TI - Medical image databases for CAD applications in digital mammography: design issues. AB - The evaluation of algorithms' developed for computer assisted diagnosis in digital mammography requires image databases that allow relative comparisons and assessment of algorithms clinical value. A review of the literature indicates that there is no consensus on the guidelines of how databases should be established. Image selection is usually done based on subjective criteria or availability. The generation of common database(s) available to the research community makes relative evaluations of algorithms with similar properties easier. However, questions regarding the "right database size," the "right image resolution," and the "right contents" remain. In this paper, database issues are reviewed and discussed and possible remedies to the various problems are proposed. PMID- 10179737 TI - Clinical applications of an ATM/Ethernet network in departments of neuroradiology and radiotherapy. AB - An integrated system for the multimedia management of images and clinical information has been developed at the Isituto Nazionale Neurologico C. Besta in Milan. The Institute physicians have the daily need of consulting images coming from various modalities. The high volume of archived material and the need of retrieving and displaying new and past images and clinical information has motivated the development of a Picture Archiving and Communication System (PACS) for the automatic management of images and clinical data, related not only to the Radiology Department, but also to the Radiotherapy Department for 3D virtual simulation, to remote teleconsulting, and in the following to all the wards, ambulatories and labs. PMID- 10179738 TI - Quality monitoring, standardized documentation and management with a computerized system in oncology. AB - Within the last years the prerequisite was prepared to develop a computerized tumor--patient documentation system including quality monitoring and oncological therapy recommendations for every day use. In medicine today, there is an increasing need for quality oriented low cost and transparent management--what is especially true in the field of oncology. The German Federal Authority of Health demands the documentation of all tumor disorders for the establishment of an cancer registry. For these reasons our study group established the program "OncoDoc" in cooperation with the laboratory for Artificial Intelligence of the University Bremen. PMID- 10179739 TI - A platform independent teleradiology system based on Web services. AB - This paper describes NetRad, a Teleradiology application based on an open, non proprietary architecture implemented using only Web and Java technologies. A comparison with other proprietary teleradiology systems suggests that the proposed solution is attractive, being completely independent of the hardware and software platform. This architecture allows easy maintenance and fast development of new distributed capabilities. Finally, it is based on a user interface paradigm widely known and accepted all over the World. PMID- 10179740 TI - Knowledge-based in vivo analysis of kidney concretions from digitized X-rays. AB - To make a right choice of a treatment approach in patients with nephrolithiasis it is very important for the clinicians to know the composition and structure of calculus. Conventional radiographic techniques and computerized tomography (CT) give information about the location and size of concretions, but not for their composition and structure. In the present study we investigated the gray-level values of chemical substances in concretions. It was established the appropriate X-ray exposure for subsequent image analysis. A method for intracorporal analysis of composition and structure of kidney concretions is proposed. PMID- 10179741 TI - Decision support and data analysis tools for risk assessment in primary preventive study of atherosclerosis. AB - In the paper we show results of two programs applied for data analysis and decision support in primary preventive study of atherosclerosis. First program E.T. (Epidemiology Tools) can be used for analysis of data from retrospective (case-control) studies, prospective (cohort) studies and for standardization. Second program called CORE (COnstitution and REduction) supports the process of selection of features that are relevant for given decision making task. Program CORE is using information theory approach. Both these programs were applied to analysis of data about 1417 middle age men collected in the longitudinal study on atherosclerosis in urban population. Apart from these two new programs we have analyzed data also by the STATISTICA software. PMID- 10179742 TI - The knowledge model of MedFrame/CADIAG-IV. AB - The medical consultation system MedFrame/CADIAG-IV is a successor of the prior CADIAG projects. It is the result of a complete redesign to account for today's demands on state-of-the-art software. Its knowledge representation and inference process are based on fuzzy set theory and fuzzy logic. Fuzzy sets are used for conversions from measured numeric values and observational data into symbolic ones. Medical relationships between findings, diseases, and therapies, the rules, are represented by fuzzy relations, that express positive or negative associations. Findings, diseases, and therapies are organised in hierarchies. PMID- 10179744 TI - A fuzzy model for simulation and medical diagnosis. AB - The paper presents an original manner of treating a fuzzy model for simulation and medical diagnosis. The modelling is realized by means of an original fuzzy technique and general practioners reasoning, namely by fuzzy modelling the influence notion which features the symptoms and diseases influence over them and over the final diagnosis. PMID- 10179743 TI - Studies of responsiveness in the R-EGFR and Rcerb-B2 oncogenes spaces: a customized application for thyroid lesions. AB - Among variety of diagnostic approaches suitable for clinical analysis of thyroid lesions, the two oncogenes (R-EGFR and Rcerb-B2) are believed to be of discriminative power. In a retrospectively collected patient material we have defined different lesion types (normal tissue, benign and malignant tumours). Those were taken as class definitions in analysis performed to assign discriminating performance. Standard multivariate statistics has not performed satisfactory partly due to the data distribution and partly due to presence of the noise. Therefore we have developed a method for the classification purpose, which was based on principle of minimising generalised classification error. Results of the separation between carcinoma and normal tissue reached accuracy 70%, other classification attempts ended up in poor results. In general, misclassifications could be explained with the data quality (noise) and, when it came to benign lesions, with responsiveness of the oncogenes to tumour tissues. PMID- 10179745 TI - Knowledge generating in expert systems as support of immunological investigations. AB - One of the most important parameters in immunologic investigations linked with the analysis of TIL phenotypic characteristics is the ratio between particular populations and subpopulations of TIL. Values of exact parameter are not obtained with its direct measurement but with indirect measurement of values in its numerator and its denominator that represent mean values of absolute TIL figures. Exactness of estimate of specific parameter is obtained by determining the intervals of values where this parameter should lie. Determination of confidence intervals for relationship between particular populations and subpopulations of TIL was performed using Fieller's theorem which full filled requests from the nature and process of obtaining exact parameter. By analyzing the obtained confidence intervals informations can be obtained regarding TIL phenotypic characteristics of various histologic types of tumors and various types of intervals within, as well as changes in TIL content that are occurring in malignant tumors. PMID- 10179746 TI - Developing mortality patterns: robust modified generalized likelihood ratio algorithm for infant mortality rate change detection. AB - A new robust modified generalized likelihood ratio algorithm, which enables the changes of mortality rates to be detected automatically, is applied. The procedure is based on the calculation of discrimination function using robust least squares estimates of AR mortality rates residuals. The feasibility of the approach is demonstrated with experimental data concerning infant mortality rate in Serbia. PMID- 10179747 TI - Prognostic factors: classification approaches in patients with lung cancer. AB - With the proliferation of potential prognostic factors for lung cancer, it is becoming increasingly more difficult to integrate the information provided by these factors into a single accurate prediction of clinical outcome. Here we reviewed five classification methods for their capabilities in classification of 200 patients with lung cancer into distinct prognostic groups using survival outcome as a criteria. The source of patient data for this study is a Lung Tumour Registry from Institute for Lung Diseases, University Clinical Hospital, Belgrade. Almost all developed classification algorithms determined prognostic groups according to biochemical tumour markers LDH and alkaline phosphatase, producing most significant split, instead of commonly used staging variables. The choice of which approach to use for a given classification problem depends not only on statistical properties of method, but also on medical considerations, such as whether more differential findings are given greater weight and the applicability of a classification rule. PMID- 10179748 TI - ILLM--inductive learning algorithm as a method for prediction of life expectancy achieving. AB - The aim of the paper was to use inductive learning algorithm ILLM in the field of epidemiology, for prediction the life expectancy achieving. Data base comprised results of epidemiological investigation in some regions of Croatia. Overall accuracies for different samples and corresponding rules produced by ILLM algorithm, showed some interesting results. Algorithm can be seen as having the capacity to forecast 'achieving the life expectancy'. In the same time algorithm was not able to make a good forecast for 'not achieving the life expectancy'. PMID- 10179749 TI - Machine learning for the quality of life in inflammatory bowel disease. AB - Presence of a chronic disease influences patients' lives and reinforces demands to accept and then cope with the illness. In the case of inflammatory bowel disease, quality of life greatly differs through phases of remissions and relapses. Could the quality of life questionnaire tell the difference? In this study we are disclosing possibilities of assessing patients' perspectives by analysing analogue scale statements regarding concerns and worries related to ulcerative colitis. Some two hundred Swedish patients, 3/4 in remission and 1/4 in relapse, filled out a booklet containing 36 statements. To characterise the disease activity, we have used multivariate discrimination. To structure and describe in details paths distinguishing the remission from relapse, we have used an artificial intelligence procedure. Applications of the CART (Classification And Regression Trees) algorithm resulted in a set of classifiers which are, based on the similar subsets of significant variables, i.e. statements. Best reached classification accuracy did not exceed 80% in any case. Other classifiers namely, K-nearest-neighbour (KNN), Learning Vector Quantization (LVQ) and Back Propagation Neural Network (BPNN) confirmed that outcome. An expectation that the disease activity should clearly speak throughout the questionnaire held for a certain number of the observations such as pain and suffering, loss of bowel control, dying early, feeling alone, ability to have children, being treated as different and concerns regarding the medication. To highlight the difference of incorrect 20%, K-means clustering was performed. The results settled a basis for a hypothesis that the studied quality of life instrument captures more than the disease activity. PMID- 10179750 TI - Use of statistical classifiers as support tools for the diagnosis of iron deficiency anemia in patients on chronic hemodialysis. AB - Discriminant analysis, logistic regression and neural network models were applied to the diagnosis of iron-deficiency anemia in hemodialyzed patients. The ability of the three quantitative approaches to distinguish between subjects suffering or not from iron-deficiency anemia was compared by re-substitution and cross validation testing. Methods performance was evaluated by means of sensitivity, specificity and accuracy. All the methods performed globally well (sensitivity and specificity > 0.85), revealing that the problem is classifiable. Neural networks showed the highest accuracy, both in the re-substitution (models developed and tested on the complete data set) and 3-way cross-validation (data set randomly splitted into 3 developmental and validation data sets) testing. These preliminary results suggest that the correct classification of iron status in the hemodialytic population can be treated as a pattern classification problem, for which neural networks and traditional statistical modelling can be a valuable aid to the clinical diagnosis of iron-deficiency anemia. A better performance of the neural network model must be confirmed through prospective testing on a larger data set. PMID- 10179751 TI - Parameter evaluation of the differential diagnosis of female urinary incontinence for the construction of an expert system. AB - Female urinary incontinence is a difficult problem for a patient but also for a physician. In the differential diagnosis of female urinary incontinence the physician has to determine a diagnostic class for the patient. This task is complex because of the unreliable patient history and the overlapping class boundaries. In order to develop an expert system to help the physician, a retrospective investigation on the incontinent women was performed to detect the potential expert system parameters. Also a diagnosis table was constructed from the expected values of parameters and the diagnostic classes. The results from K means cluster analysis indicate that it is possible to develop the expert system on basis of the defined parameters and classes. PMID- 10179752 TI - Preparing the next generation of clinicians to manage information. AB - Curriculum development in informatics must be underpinned by knowledge of the information environment new recruits encounter after qualification. A pilot study was carried out to identify the type of information handling tasks newly qualified healthcare professionals are expected to undertake. This data was related to the skills junior staff possess at the point of entry to hospital posts. Data was collected on the opportunities these recently qualified individuals had to acquire IT skills and generic competence in information handling in their prequalification courses. Self-report data was supplemented by direct observation of junior staff on the wards. In addition to investigating the perspective of the junior staff, the study also explored the attitudes and expectations of senior clinicians, educationalists and NHS trust staff. The purpose of the study was to provide guidance to those involved in developing informatics curricula for clinical students at the prequalification stage. This paper reports some of our preliminary findings. PMID- 10179753 TI - ARMEDA: accessing remote medical databases over the World Wide Web. AB - We have created a computer system to access medical information located at remote databases over the World Wide Web, for epidemiological ad health services research. We made a preliminary prototype where a specific database model could be searched and information be retrieved. We are currently working on a new component-based architecture, where different databases scheme from various sites can be used to create a unified model, giving users a "virtual" vision of a single, local database. Different software engineering and artificial intelligence methods are used to access, integrate, filter and deliver information to users. PMID- 10179754 TI - Using World Wide Web technology for educating students in the health care sector. AB - The Internet was born in December of 1969 and has grown phenomenally since. Its graphically interactive, user-friendly modality, the World Wide Web (WWW), is younger and growing even more explosively. By its nature, the WWW is a tool ideally and uniquely suited for the advancement education. This paper describes the design, development and the implementation of a Web Site for supporting the education of the students in the Faculty of Nursing at the University of Athens. PMID- 10179755 TI - Strategic plan for promoting ICNP in Romania. AB - Preparing Romanian nursing community for the newcoming health information systems is not an easy task and has to start with the structuring of nursing information. That means that the free text of nursing documentation has to be mould, in a first stage, into a nursing language. Then, using a classification system, it will be possible for it to be captured in an electronic health record. This paper is presenting the strategy proposed by the Working Group for Nursing Informatics of the Romanian Medical Informatics Society for developing the Romanian version of the International Classification for Nursing Practice(ICNP) and the dissemination actions associated. PMID- 10179756 TI - DIABETOR computer aided tutoring in diabetes management. AB - Computer Aided Instruction (CAI) and Computer Aided Learning (CAL) Systems, are software systems that can tutor people in a given domain. Medicine is a field that is particularly amenable to computer aided instruction because one is allowed to experiment with a large number of hypothetical simulated patient/disease cases, without the ill consequences of the wrong decision in real life. This paper presents an Intelligent Tutoring system for the Management of the diabetes disease, and specifically for instruction in insulin administration. The system will be used for the education of medical personnel (general practitioners, nurses), as well as students of medicine in diabetes management. It is based on an existing expert system for diabetes management called DIABETES as well as on the knowledge of expert diabetologists. PMID- 10179757 TI - A distributed support system for medical and nursing students. AB - The Internet provides resources for physicians, but there isn't yet a comprehensive support system for medical and nursing students. Moreover the knowledge of English language is often scarce in young Italian students, so most of the available resources are not really useful. This project aims at the establishment of a distributed framework of interactive courses and mentoring facilities among a group of Italian Medical and Nursing Schools. PMID- 10179758 TI - Health informatics education for pharmacy students in Romania. AB - The objectives and the curriculum of the health informatics course for pharmacy students at the University of Medicine and Pharmacy in Timisoara is presented. The relations with other disciplines and the integration into the overall educational program are discussed within the frame of the specific requirements of a pharmacy school. A description of our specific programs for pharmacy students devoted to laboratory works is also presented. PMID- 10179759 TI - Addressing information security training and awareness within the European healthcare community. AB - This paper discusses the need to promote information security issues within modern healthcare establishments and the consequent need for appropriate training and awareness initiatives. Security is an area of extreme significance in healthcare information systems but, whilst the need is generally recognised, many personnel are not familiar with even basic concepts and procedures. As such, adequate promotion of security through training and awareness initiatives is viewed as a vital first step. The paper highlights a series of basic factors that healthcare establishments (HCEs) should consider in setting up a training and awareness framework. The discussion then examines a number of ways in which relevant information may be disseminated to staff, including security guidelines, training seminars and world-wide web based services. The paper is largely based upon work that is currently being conducted as part of the Health Telematics ISHTAR (Implementing Secure Healthcare Telematics Applications in euRope) project. PMID- 10179760 TI - Designing medical hypermedia: the FORUM project. AB - Medical activity in learning stages or in usual tasks is a wide field for information technologies. But it would be a mistake to focus on technologies and minimize the organisational, social and cultural aspects of integrating such technologies. Medical hypermedia design based only on a technological approach is a case in point. This paper describes our experience in hypermedia development. It reports on the technical, methodological and organizational aspects destined to help the medical community get involved in the development of such applications. PMID- 10179761 TI - Medical informatics training programme to support the Romanian Health Care Management Information System. AB - The Health Management Information System (HMIS) project initiated by the Ministry of Health as a component of the healthcare reform is aiming to ensure the technical, functional and operative support for: i) a better overview of the population health status, of the medical care needs and of the Health System performances; ii) the improvement of the resource allocation and consumption; iii) reform support. This system is supposed to assure a better information flow from the lower to the upper levels of the healthcare network by help of a modern IT support. In the first development stage the system is planned to link the Ministry of Health with the 41 District Health Authorities (DHAs) and with more than 200 pilot health units. The implementation of such a large system raises serious problems of acceptability and a thorough training programme for both technical staff and end users must be considered in order to face this challenge. PMID- 10179762 TI - Multimedia simulator of patient. AB - The paper presents a concept of an educational system for medical students designed to help them learn taking case history and diagnosing oncological patients. The system is a modification of the SYMULPA system worked out by the authors and implemented and tested at the Chemotherapy Clinic of the Medical Academy of Lodz. The main changes lie in the introduction of multimedia to the system, which improves communication capabilities of the system and enables a wider range of results to be considered and examined during case history taking. PMID- 10179763 TI - Educational program on neurosurgery. AB - The paper presents the application of a hypertext and an Electronic Patient Record to assist the pathology of the eye's motility teaching. It is a combination of a theoretical and practical training in this kind of pathology. The application is being tested at the County Hospital, Department of Neurosurgery from Timisoara, Romania. PMID- 10179764 TI - Assessment of IT-based solutions in healthcare: trends in today's practice and justification of tomorrow's approach. AB - State-of-the-Art with respect to assessment of IT-based solutions in Healthcare is discussed with a user-oriented perspective on system development and assessment. Based on this and other basic conditions reported in the literature, requirements for a methodology for user-driven, formative assessment during the entire life-cycle of the IT-based system are synthesised. PMID- 10179765 TI - An example of usability measurement in clinical software procedures. AB - As a consequence of the dramatic improvements achieved in information technology standards in terms of single hardware and software components, efforts in the evaluation processes have been focused on the assessment of critical human factors, such as work-flow organisation, man-machine interaction and, in general, quality of use, or usability. This trend is particularly valid when applied to medical informatics, since the human component is the basis of the information processing system in health care context. With the aim to establish an action research project on the evaluation and assessment of clinical software procedures which constitute an integrated Hospital Information System, the authors adopted this strategy and considered the measurement of perceived usability as one of the main goals of the project itself: the paper reports the results of this experience. PMID- 10179766 TI - Evaluating the MACRO solution. Multimedia Application for Clinical Research in Oncology. AB - This paper describes the evaluation approach of the MACRO project. This approach is based on earlier work in the European 3rd Framework Programme (AIM). We describe how user requirements and expectations play a role in the design of the various assessment studies in MACRO. PMID- 10179767 TI - Software quality assessment for health care systems. AB - The problem of defining a quality model to be used in the evaluation of the software components of a Health Care System (HCS) is addressed. The model, based on the ISO/IEC 9126 standard, has been interpreted to fit the requirements of some classes of applications representative of Health Care Systems, on the basis of the experience gained both in the field of medical Informatics and assessment of software products. The values resulting from weighing the quality characteristics according to their criticality outline a set of quality profiles that can be used both for evaluation and certification. PMID- 10179768 TI - Evaluation plan for a cardiological multi-media workstation (I4C project). AB - The goal of the I4C project (Integration and Communication for the Continuity of Cardiac Care) is to build a multi-media workstation for cardiac care and to assess its impact in the clinical setting. This paper describes the technical evaluation plan for the prototype. PMID- 10179769 TI - Computer programs and clinical contexts: two computer based exercises for cognitive rehabilitation. AB - Two examples taken from computer programs for cognitive rehabilitation of patients with schizophrenia show how different groups of clinicians attribute different meanings to the same exercise. This illustrates that the meaning of an artifact or a technology is socially constructed and thereby intimately bound to the context of use. This perspective has implications on issues such as the design process, the assessment of technology and the issue of standardization. PMID- 10179770 TI - From clinical data records to research: a database system for the study of clinical and functional indicators of chronic heart failure. AB - The identification of reliable clinical and functional indicators of Chronic Heart Failure (CHF) is currently a major research challenge for physicians dealing with this pathology. With the aim of providing an adequate infrastructure for this research, we have developed a Database System where all relevant information concerning CHF patients during follow-up can be efficiently recorded, monitored, extracted and easily transferred to commercial packages for data processing and statistical analysis. Patient clinical status is recorded every 6 months, whereas data from several laboratory investigations are recorded every 12 months. All complications or events between two successive controls are recorded too. Patients needing cardiac transplantation are entered in a transplantation waiting list. The Database is fully integrated into the Hospital Information System and meets the standards of the national database of CHF patients. It grows with the concurrent activity of several independent teams, all of which have access to complete and structured information for research purposes. A user friendly procedure allows the export in a standard format (Microsoft Excel) of all patients' data pertaining to a selected set of controls and variables of interest. These data are used directly for analysis or sub-selections are performed by the investigator through a simple query language. Depending on the objectives and complexity of the research, different commercial statistical analysis packages are available, which are used by clinical investigators autonomously or with the aid of a statistician. This overall approach allows great autonomy of each user in extracting, manipulating and statistically analyzing data. The Database has been in use at the Heart Failure Unit of our Rehabilitation Center since October 1992 and 595 patients have been enrolled since then. Several studies based on these data have been performed and more than 120 scientific communications and 30 articles in national and international journals have been produced. Hence, this experience represents a successful example of how clinical data records can be efficiently and effectively linked to valuable clinical research. PMID- 10179771 TI - Quality assurance and quality assessment of health care telematic technologies. PMID- 10179772 TI - VATAM: developing consensus in validation of health telematics applications. AB - VATAM (Validation of Telematics Applications in Medicine) is an EU supported project in the Health care sector of the Telematics Application Programme. Its objective is to assist other health telematics projects by providing a platform for discussion on validation, eventually resulting in 'guidelines for validation of telematics applications in medicine'. The VATAM work can be subdivided into three phases: the inventory phase (1996) in which information is collected on validation approaches in the Telematics Application Programme, previous efforts and expertise. The dissemination phase (1997) will be used to extend and adapt the framework developed in the inventory phase, through cooperation with other projects The experiences phase (1998) in which the projects are actually applying validation, will be used by VATAM to validate the VATAM methodology. VATAM has finished the inventory phase successfully and is now working on the dissemination phase by--among others--establishing contacts with other projects, and providing information on the inventory through the World Wide Web (URL: http:(/)/www vatam.unimaas.nl). This paper discusses the approach adopted and the proposed VATAM framework to structure the large variety of validation approaches. PMID- 10179773 TI - Application of a standard methodology for the development of messages and aspects of realization in the area of tumour documentation. AB - The "Methodology for the Development of Health Care Messages" was published in 1995 by CEN TC251. This contribution describes the application of the methodology in a project of developing messages for the exchange of tumour patient data. A standard data set, the "Basisdokumentation fur Tumorkranke" was already available for the data of tumour documentation. The development of the messages as well as the design and implementation of a communication interface in a documentation system could therefore be carried out straight forward. Problems arise due to the import of data from different sources. Up to now, there is no standardized method for identifying patients and numbering of different tumours. An automated matching of new data to a specific patient or tumour is therefore not always possible. Methods are presented which try to make a compromise between fully automatic data import and complete user control. PMID- 10179774 TI - A systematic approach to the assessment of user satisfaction with health care systems: constructs, models and instruments. AB - In this paper an overview is given about research in the field of user satisfaction with health care systems and a new systematic model is set up. The model distinguishes between system-independent and system-dependent factors, the latter characterised by satisfaction with the content, the interface and the organisation. Evaluated instruments for assessing user satisfaction are classified according to the model and recommendation for an appropriate use are given. PMID- 10179775 TI - The help of formal models for healthcare security policies. AB - This article is a personal contribution (i.e., from a strict security expert point of view) towards the help for specification, validation and/or evaluation of reliable, but also secure, healthcare security policies (HSP). The first part is dedicated to show, according to the various aspects of the security policy concept, that healthcare information systems (HIS) offer such a diversity of particularities and potential security needs, that it is necessary for healthcare security policies to be defined as flexible, but also as robust, as possible. Then the formal modelling approach, a wide area of solutions providing both flexibility (by means of modelling) and robustness (by means of formalization), is presented. The most well-known examples of security models are recalled. All of them try to use formal models as a security policy specification/validation tool, but none of them can be helpfully used in the very demanding context of HIS. Lastly, a new approach for the modelling of healthcare security policies, based on modal logic (i.e., epistemic and/or deontic logic) is proposed. It permits to take into account the flexibility (by means of high expressiveness due to modality) and the robustness (by means of high provability due to modelling) needs. PMID- 10179776 TI - Quality of healthcare related software applications--setting up an accreditation system in Hungary. AB - Meeting expectations of high quality health care, the safe and secure operation of medical information systems is a "must". However for healthcare software nationwide quality control systems are not widely used. A quality control project of health care applications in Hungary has been launched in 1996 by the Hungarian Society of Healthcare Informatics (MEIT) and Medico-Biological Section of Johann Neumann Society of Computing (NJSZT) by establishing a joint Healthcare Informatics Applications Accreditation Board (Board ESAB). The Board developed an evaluation methodology and a legal procedure to test health care software application modules. The evaluation method is based on international standards as ISO-9126 and on emerging European standards of CEN/TC 251. First rounds of accreditation already proved that there is a need among providers and users for the accreditation process. The authors hope that establishing an accreditation system will lead to a more balanced health care software market where users have an opportunity to inform themselves by the opinion of independent experts on the product they intend to purchase. PMID- 10179777 TI - User evaluation of a graphical user interface for biomedical literature search. AB - This paper gives a short overview of the Archimedes Network System, an information retrieval system that allows the user to browse, in a visual way, through domain knowledge about the topics discussed in the documents. The system was evaluated by medical students who used the system to find documents in Medline. The results were comparable with the results of WinSpirs, a Boolean retrieval system. PMID- 10179778 TI - Responsibility modelling: a new approach to the process of re-engineering the health-care organisation. AB - Technology changes our world. It is an accepted fact that the adoption and utilization of information technology by an organization will change the work patterns and power structures of that organization. Health-Care organizations realize that the process of re-alignment and re-engineering is a critical one, as it exposes consumers of health-care to the possible risk of death, or at least the loss of personal information. In this paper I will present the idea of modeling responsibilities as a vehicle for the re-engineering of the processes by which social values are mediated and health-care is delivered. PMID- 10179779 TI - Interventions for improving information management in family practice. AB - Information management training has been neglected in family practice in the UK in the past. An adult learning model for such training is introduced. A pilot study using the adult learning approach showed improvements in information management processes over the six-month study period. The research project described in this paper compares the effectiveness of on-site training using adult learning methods, written information, and no intervention, in 33 family practices in the UK. Nine of the eleven practices in the on-site training group completed the training sessions and provided data, whereas only four of the eleven practices in the written information group provided data, and only three of the eleven practices in the control group did so. Preliminary analysis demonstrates that on-site training practices made considerable changes to the information systems in their practices, and appreciated the importance of high quality data, both for patient care and reporting requirements. Full comparisons of data quality and information management methods are presented, and an assessment of priority training needs for maximum benefit is made. PMID- 10179780 TI - Experiences with an electronic patient record in a clinical context: considerations for design. AB - This paper argues that we should see medical work practices as natural systems, and that we should understand the process of IT design as the development of sociotechnical configurations. Drawing upon our experiences with an electronic patient record (EPR) on an Intensive Care Unit, several considerations for design are developed. First, the EPR should not be overly structured with rationalistic and pre-fixed notions of the organization and content of medical work. Second, it is crucial to ensure that the usage of the system will yield immediate benefits for primary users: the systems should support work; not generate it. Third, designing IT should include being aware of the socio-political nature of seemingly 'neutral' tools as EPRs. PMID- 10179781 TI - Participatory design at a psychiatric daycenter: potentials and problems. AB - This paper discusses a system development project, based on a participatory approach, which engaged clients at a psychiatric daycenter. The goal was to develop a computer based presentation of the center and thereby to investigate the possibility of enabling the users of the daycenter to formulate their requirements for such a system. The paper discusses the potentials and problems in establishing a common ground to work from and conclude that while there are specific benefits of engaging psychiatric clients in design projects, especially in connection with feelings of ownership, there are also pit-falls of which we should be aware. Particularly, the importance of understanding the different roles that participants acquire in a design process is stressed. PMID- 10179782 TI - Coherent exchange of healthcare knowledge in open systems. AB - This paper outlines design philosophies and methods for healthcare knowledge systems. Clinical priorities for knowledge are discussed in terms of temporal and individual needs. Book centred organisation of healthcare knowledge, which has proven effective in clinical practice, is proposed as the basis of virtual libraries available at the point of care for target groups of healthcare professionals. PMID- 10179783 TI - Getting IT into shape--external factors effecting the potential benefits from health informatics. AB - The introduction of a computer system will not always result in the expected outcomes. Extensive planning must be carried out for a new technological environment, changes in organisational practices and human reorientation. In addition to the specific requirements for the implementation of a particular application system there are more general issues to be considered. There are a number of organisational, technical and human factors which are thought to have affected demands for informatics support to healthcare and to have affected the level of benefits that can accrue from its operation in the healthcare sector of today. Some of the catalysts and inhibitors (positive and negative factors) can be recognised in advance of any specific implementation and the potential risk from their effects can be minimised. This paper considers some of the identified factors and how they are being addressed across Europe. PMID- 10179784 TI - Some systems implications of EU data protection directive. PMID- 10179785 TI - Patient Care Evaluation Studies: applying this concept of quality management in oncology. AB - Patient Care Evaluation Studies are valid tools of quality management in oncology. With the use of modern methods of medical informatics, epidemiology and biometrics, the acceptance of tumor documentation in the clinical routine will be improved. We will describe the ideas behind the concept of the PCE studies. PMID- 10179786 TI - Forming a health care incident reporting scheme. AB - In this paper the initial design steps of an Incident Reporting Scheme for Health Care are presented. The results of a short survey for the determination of Health Care user needs and expectations from such a scheme are given. The paper outlines a concise description of the proposed system and presents the conceptual model of the IRS database, and the developed prototype version of this database. Finally, future steps and security issues are described. PMID- 10179787 TI - A new approach for assessment of IT programs in health care. AB - The efficiency of health care programs, on the level of a community, results not only from reducing hospitalization or drugs costs but also from the number of days of health and life gained. This gain can be estimated in monetary terms if we accept that, at least partially, the Gross Domestic Product results from the human activity. In the Center for Health Information and Statistics, Ministry of Health Bucharest. Romania, a methodology based on these premises was developed and non-officially used in assessment of several health programs. In this paper, the core of this methodology, as well as some applications are shown. PMID- 10179789 TI - INCLUDE them all. PMID- 10179788 TI - A clinical quality management support system. AB - In the CONQUEST Quality Management System, assessment and improvement of the quality of treatment process and outcome is done by introducing a Clinical Quality Management Support System. Initially the treatment of breast cancer was chosen to illustrate the potential benefits of introducing quality management in the treatment process. The main objective of the CONQUEST Quality Management System is to provide a flexible framework for supplying quality management of the treatment process and enable comparison of clinical results, despite differences in the local best clinical practice guidelines used in the participating treatment centres. PMID- 10179790 TI - The use of an expert system of composite risk factors in breast cancer screening. AB - Mass Screening seems to be the only promising way to discover breast cancer patients at an early and more curable stage and a positive method improving the cost-effectiveness and compliance of mass screening is the use of prognostic factors, to identify the high-risk group, who alone then would be screened. In a 200 women sample, who had undergone screening for breast cancer with clinical examination and bilateral mammography, we calculated the Composite Risk Factors of six Characteristics (C6RF), which are family history for breast cancer, pregnancy history, menstrual history, history of cystic breast disease, history of regular breast clinical or self-examination and presence or not of breast lump, using an expert system in IBM-compatible personal computer. In these cases the average C6RF was 0.18 (SD +/- 0.19) in low-risk group and 2.61 (SD +/- 4.76) in high-risk group and all cases with C6RF values higher than 0.56 were put in the high-risk group. Under these conditions, the sensitivity of the C6RF method, in discovering breast cancer, was 90% and the specificity 81.5% and the C6RF method was proved to be clinically valuable in identifying the high-risk group and controlling breast cancer. PMID- 10179791 TI - Evaluation of quality control methods for medical documentation. AB - A retrospective study about the impact of different quality control methods for medical documentation was performed at the Surgical Center II in Essen. The standardized medical documentation was legislative obliged since the first of 1996 and includes diagnoses and surgical procedures. The patient data were taken from the computer-based patient record of the Surgical Center II which is in routine use since 1989. Quality improvement was aimed at with lectures, training, a quality circle, and systematic approaches like feedback and reminder between 1995 and 1996. The results demonstrate that information and training of physicians is significantly less important for the quality of documentation than a departmental and central control. It is advisable to take this results into account introducing new documentation entities and procedures and to provide functionalities for a periodical control soon. PMID- 10179792 TI - An approach to establishing a health information market. AB - The Tempus CME project "Regional Network for Healthcare Management" was aiming to perform a feasibility study for a communication network dedicated to the healthcare field. The needs assessment survey as well as the debates during the working sessions and during the conference on how communication can support a better healthcare delivery, substantiated the approach for achieving the Romanian health information market. The proposed communication network can be considered as a national information infrastructure offering good links between health, education, research and industry and a unique frame for information providers and users, for the estate and private companies. The network should also provide support and guidance for the development of new educational fields as applied informatics in healthcare. PMID- 10179794 TI - Implementing data privacy and security (the Slovenian experience). AB - Data protection is carried out in two steps. The legislation covers data privacy in general as well as its projection in health care. Its purpose was to leave no personal data undefined within the national health care system. The regulations deal with procedures and anticipated corrective actions, rendering a so-called "organisational prescription". Its purpose was to assure data security through an appropriate information system. PMID- 10179793 TI - Visual Health Information Profile (VHIP). A quantitative approach for analysing the health status of a population. AB - A new approach for illustrating and analysing the health status of a given population is presented. The concept takes the multi-dimensional nature of health into account. It is based on a clearly out-lined indicator hierarchy, a decile reference system and a computerised information system. The instrument displays the health status of a population and allows comparisons to be made of various health aspects for a given population at different times and allows comparisons to be made of different populations during given time periods. It is possible to represent quantitative and qualitative aspects of health, to monitor the impact of interventions, and to assess the extent to which objectives in the health field have been achieved. Therefore, it can serve as an instrument for communication between policy makers and scientists to manage and to co-ordinate programs that aim at an improvement of the health status and to assist in the priority setting process. The method was applied to several countries using the World Health Organisation's (WHO) "Health For All Global Indicator Database" as the main data source. Country and region specific health status patterns could be generated showing the practicability of the approach. Using a computerised information system, a high degree of transparency and flexibility with respect to the input data and the choices of measurables was achieved. PMID- 10179795 TI - Primary care informatics: Bhorugram, India: revisited. AB - A Primary Health Care Informatics project was initiated in 1990 at Bhorugram, Rajasthan, India. It was reported in MIE91 with initial, encouraging results. The evaluation of the information system has been successful in all operational terms, and the Fully Immunised Child (FIC) could be used as a local cardinal index to monitor and evaluate the quality of care, cost-effectiveness and community participation. Health Systems and Health Economy Research alike have long searched for apt quality and performance markers that in themselves could embrace and express a number of aspects and factors. The FIC index is shown to well meet the criteria of such a cardinal measure in the MCHC services. We, also, demonstrate an implementation strategy for establishing Information Systems in Primary Health Care Centres in Developing countries. PMID- 10179796 TI - Can computers improve the Health of the Nation? AB - In this paper the author considers whether the use of computers can be demonstrated to have a positive impact upon the effectiveness of health screening, in accordance with the Health of the Nation document. It is based upon a study of 1.1 million patients registered with 283 general practices in the North West region of the UK. PMID- 10179797 TI - Implementing structured information processes to manage nursing resources. PMID- 10179798 TI - Galen-In-Use: an EU Project applied to the development of a new national coding system for surgical procedures: NCAM. AB - GALEN has developed a language independent common reference model based on a medically oriented ontology and practical tools and techniques for managing healthcare terminology including natural language processing. GALEN-IN-USE is the current phase which applied the modelling and the tools to the development or the updating of coding systems for surgical procedures in different national coding centre co-operating within the European Federation of Coding Centre (EFCC) to create a multilingual knowledge repository for multicultural Europe. NCAM (Nomenclature Commune des Actes Medicaux) is the new French multipurpose coding system for surgical procedures. The labels are processed from the intermediate dissections to the Grail representation and the natural language generation by the electronically related Medical Informatics research centres network of Saint Etienne, Manchester, Geneva and Nijmegen. The national coding centre is able to retrieve the initial labels with different categories of concepts, to compare the professional language proposed by expert clinicians to the French generated controlled vocabulary and to finalize the linguistic labels of the coding system in relation with the meanings of the conceptual system structure. PMID- 10179799 TI - Urgent response telecardiology services and training--collaboration between Onassis Cardiac Surgery Hospital and Aegian Islands' Health Care Centers. AB - Since 1995, Onassis Cardiac Surgery Center participates in the development of Telecardiology Services in Greece. Existing connections include the islands Skiathos, Naxos, Santorini, Mykonos, Milos, Plomari and Amorgos. First hundred fifty three (153) cases have been already analysed. Eleven of them were acute myocardial infarctions and have been treated by thrombolytic medication (anistreplase). The participation of physicians and nurses was valuable for the success of the program and their further involvement in the new area of Telemedicine. The purpose of the project was to offer high quality cardiac services in remote area patients and to provide specific training in telemedicine issues to health care professionals. PMID- 10179800 TI - Clinical-HINTS: integrated intelligent ICU patient monitoring and information management system. AB - Clinical-HINTS (Health Intelligence System) is a horizontally integrated decision support system (DSS) designed to meet the requirements for intelligent real-time clinical information management in critical care medical environments and to lay the foundation for the development of the next generation of intelligent medical instrumentation. The system presented was developed to refine and complement the information yielded by clinical laboratory investigations, thereby benefiting the management of the intensive care unit (ICU) patient. More specifically, Clinical HINTS was developed to provide computer-based assistance with the acquisition, organisation and display, storage and retrieval, communication and generation of real-time patient-specific clinical information in an ICU. Clinical-HINTS is an object-oriented system developed in C+2 to run under Microsoft Windows as an embryo intelligent agent. Current generic reasoning skills include perception and reactive cognition of patient status but exclude therapeutic action. The system monitors the patient by communicating with the available sources of data and uses generic reasoning skills to generate intelligent alarms, or HINTS, on various levels of interpretation of an observed dysfunction, even in the presence of complex disorders. The system's communication and information management capabilities are used to acquire physiological data, and to store them along with their interpretations and any interventions for the dynamic recognition of interrelated pathophysiological states or clinical events. PMID- 10179801 TI - A decision support software package for medical treatment of I.C.U. patients. AB - Critically ill patients admitted in I.C.U. often have multiple complicated problems which necessitate the use of a large number of drugs. The multiple potential interactions between substances and underlying pathologies as well as between substances themselves, obviate the need for a decision support system. We therefore developed a software package for medical treatment support in I.C.U. environment which is based on Microsoft Visual Basic 3.0 and it is organised around the commercially available RDBMS Access 2.0. The database consist of: a) all available substances, b) all generic names of medications available in Greece for each substance, c) incompatibilities (2,300 cases), d) interactions (50,000 cases) and e) cost information for each drug. This system assures the safety of the administered treatment, helps to adjust the dose according to the situation of each patient (anthropometric data, laboratory result, prognostic/severity score e.t.c.) and screens for possible interactions and incompatibilities between the administered drugs. It could also be used for education, treatment algorithms application and it will serve cost-reduction policy. It is a useful and powerful tool for ICU staff which does not impose additional work to the daily practice routine and it is currently under evaluation in clinical settings. PMID- 10179802 TI - From electronic medical record to personal health record. AB - In this paper we attempt to provide a definition and purpose for the electronic patient record, point out the benefits of its use and outline the major challenges in wider implementation that are encountered world-wide. Finally, some trends are highlighted that are believed to play an important role in the future development and use of the electronic patient record. PMID- 10179803 TI - Documentation guidelines likely to change. PMID- 10179804 TI - Billing for NP services: what you need to know. PMID- 10179806 TI - Match numbers drop for primary care. PMID- 10179805 TI - Managed care reform remains high on state legislative agendas. PMID- 10179807 TI - Using qualitative self-evaluation in rating physician performance. PMID- 10179808 TI - Rural practice and managed care: a success story. PMID- 10179809 TI - The managed care transition: touching all the bases. PMID- 10179811 TI - Five steps to recovering flood-damaged records. PMID- 10179810 TI - Readers speak out on solo practice. PMID- 10179812 TI - Have you visited FPM online lately? PMID- 10179813 TI - Retaining customers in a managed care market. Hospitals must understand the connection between patient satisfaction, loyalty, retention, and revenue. AB - Traditionally, health care patients have been treated by health care professionals as people with needs rather than as customers with options. Although managed care has restricted patient choice, choice has not been eliminated. The premise of this article is that patients are primary health care consumers. Adopting such a premise and developing an active customer retention program can help health care organizations change their culture for the better, which may lead to higher customer retention levels and increased revenues. Customer retention programs based on service excellence that empower employees to provide excellent care can eventually lead to a larger market share for health care organizations trying to survive this era of intense competition. PMID- 10179814 TI - Banking for the future. PMID- 10179815 TI - Placental and umbilical cord blood as a source of stem cells for hematopoietic support (Executive summary file). PMID- 10179816 TI - What price success? PMID- 10179817 TI - Transurethral microwave thermotherapy for benign prostatic hyperplasia (Executive summary file, vol.11, no.19). PMID- 10179818 TI - Ventricular assist devices in bridging to heart transplantation (Executive summary file, vol.11, no.26). PMID- 10179819 TI - A continuum of care--disease management of diabetes. PMID- 10179820 TI - Plasma HIV-1 RNA quantification for monitoring HIV-1 infection (Executive summary file, vol.11, no.25). PMID- 10179821 TI - Allogeneic bone marrow transplantation for the treatment of sickle cell anemia (Executive summary file, vol.11, no.27). PMID- 10179822 TI - Genetic testing--the uncertainty and the knowing. PMID- 10179823 TI - The major demand for minimally invasive cardiac surgery. PMID- 10179824 TI - A perspective on minimally invasive CABG. PMID- 10179825 TI - Cardiac care connections. PMID- 10179827 TI - Social support "internetworks," caskets for sale, and more: thanatology and the information superhighway. AB - A unique indicator of change in our culture's openness to and interest in death, dying, and bereavement is the availability of "thanatechnology": technological mechanisms such as interactive videodiscs and computer programs that are used to access information or aid in learning about thanatology topics. This article describes resources available through society's latest and most widely accessible type of thanatechnology, the Internet and World Wide Web. The conceptual framework of mediated interpersonal communication is used to illustrate sites available as resources for social support. Additional categories of thanatology sites, including narrative, commemorative, expressive, and experiential sites, are defined. Implications for the use of these resources in clinical practice, death education, and research are considered. PMID- 10179826 TI - Spiritual aspects of loss at the time of a partner's death from AIDS. AB - Spiritual phenomena were spontaneously reported in interviews of 68 of 125 recently bereaved HIV-positive and HIV-negative partners of men who died from AIDS. Spiritual schemas involving beliefs, experiences, rituals, social support, and roles were used to help assimilate the fact of death and were appraised as sources of solace and meaning. The relationship between spirituality and coping, mood, and physical health was examined. Those reporting spiritual phenomena showed higher levels of depression and anxiety and lower levels of positive states of mind, used more adaptive coping strategies, and reported more physical health symptoms than those who did not report spiritual phenomena. PMID- 10179828 TI - Training health professionals in caring for dying children and grieving families. AB - In most industrialized countries today, the death of a child is a rare phenomenon. When it occurs, however, it is usually within a hospital setting, after the child has received complex and often long-term medical care aimed at curing or controlling a serious disease. Thus, health professionals are increasingly exposed to the dying process and death of a child with little prior education to help them deal with the particular needs of young patients and minimal preparation in recognizing and handling their personal reactions in the face of death. Comprehensive training programs in pediatric hospice care could help professionals cope with the growing and unique needs of terminally ill children and of their families but these should be differentiated from training programs designed for the terminal care of adult patients. The purpose of this article is to describe and discuss some of the challenges involved in the training of health professionals (pediatricians, nurses, psychologists, social workers, clergy) who wish to provide services to dying children and grieving families. These challenges include (a) definition of educational objectives, (b) selection of teaching methods and content of training, (c) definition and teaching of emotional involvement, (d) support of training participants, (e) promotion of interdisciplinary collaboration, (f) evaluation of the training process and its outcomes, and (g) background and skills of educators. The challenges are discussed and references are made to illustrate how they were met by a 600-hour training program on home-based palliative care for children dying of cancer conducted at the University of Athens. PMID- 10179829 TI - Sterilization of the mentally disabled: applying error cost analysis to the "best interest" inquiry. PMID- 10179830 TI - Native Americans and the Vaccine Act: excluding those we found here. PMID- 10179831 TI - Formed by thalidomide: mass torts as a false cure for toxic exposure. AB - Professor Bernstein considers a theme of Judge Weinstein's judicial and academic writings--that tort law works imperfectly to effect justice in mass disaster cases--through the vehicle of thalidomide, the paradigmatic toxic substance. Thirty-five years ago, thalidomide poisoned thousands of children, inflicting limb-reduction birth defects. Professor Bernstein argues that the drug has also had a malforming effect on mass tort law. Courts and scholars have used the precedent of thalidomide to build stringent legal standards of proof and causation, without enough attention to the functions and consistency of these standards. Thalidomide has also prompted commentators to celebrate American drug regulation and the American liability system; Professor Bernstein argues that these paeans are exaggerated. She concludes that the United States must confront its thalidomide history, as other nations in the world have done, and build social institutions--strong regulation and social insurance--to guard against toxic disasters of the future. PMID- 10179832 TI - TAT results in a longitudinal study of bereaved college students. AB - The authors analyzed projective data obtained from 141 college students who wrote stories on three separate occasions to selected cards from the Thematic Apperception Test (TAT). The students included 46 members of support groups for bereaved college students, 34 members of a bereavement control group, and 61 nonbereaved students. The study used a repeated-measures pretest-posttest control group design to gather longitudinal data about the trajectory of bereavement with and without support group intervention. Coders, who reached consistently high interrater reliability, looked for themes of death, grief, coping, and affiliation in the stories. Multivariate analysis of variance (MANOVA) and repeated-measures MANOVA tests were applied to analyze coding results. Overall MANOVA results indicated significant group differences in the responses to the TAT cards. Repeated-measures MANOVA found group differences in use of themes of death and grief and found Group x Time differences in maintaining a sense of self-efficacy while in a crisis. A majority of the stories contained affiliation imagery but without any group differences in the use of such imagery. PMID- 10179833 TI - Psychological development during four years of bereavement: a longitudinal case study. AB - Bereavement in the lives of college students is more prevalent than many persons realize. A survey replicated 4 times on the Kansas State University campus demonstrated that, at any point in time, over 25% of the students were in the 1st year of grief following the death of a family member and nearly 30% in the 1st year of grief following the death of a friend. Grief work can hinder traditional age college students from resolving normal developmental tasks, such as forming autonomous lives, developing a clear sense of direction, and entering into lasting, intimate relationships. This article provides longitudinal case study information about a traditional-age college student following the death of her father. The data come from multiple sources. Data from the Impact of Events Scale document changes in intrusive and avoidant thoughts and images; journal entries show changes in the student's ongoing relationship with her father, coping with his death and subsequent events colored by her bereavement, and life lessons; data from the Grant Foundation Bereavement Inventory show changes in the student's attachment, reunion fantasies, disbelief about her father's death, identification with her father, and feelings of disloyalty as time passed. Comparisons are made to responses of 80 bereaved students who participated in a separate longitudinal study. PMID- 10179834 TI - A model of survivors' psychological responses following a residential fire. AB - Residential fires result in loss of life, property, and displacement from one's neighborhood. It would be expected that grief experienced in the aftermath of residential fires has a significant impact on survivor's recovery and reintegration into the community. Although there is some research on psychological responses to community-wide fires and large scale disasters, little is known about such responses among survivors of home fires that occur episodically. Appropriate interventions cannot be developed until more is learned about variables influencing survivors' psychological response to a residential fire. A theoretical model of survivors' psychological response post-fire is proposed. PMID- 10179835 TI - Perinatal bereavement in its cultural context. AB - During the past 20 years in the Western world, there has been an increase of attention given to the significance of perinatal loss. Current practices, based on Euro-American theories of grief and loss, are aimed at facilitating familial adaptation through the creation of memories. Unfortunately, the influences of cultural components on bereavement patterns are often ignored and little attention is given to the applicability and suitability of these practices for our ethnic population. A framework for assessing the cultural influences on patterns of bereavement and for planning appropriate, culturally congruent perinatal bereavement care is presented, using two case examples as illustrations. Implications for the health-care practitioner are discussed. PMID- 10179836 TI - Statutory interpretation--Americans with Disabilities Act--Fourth Circuit holds that asymptomatic HIV cannot constitute a disability.--Runnebaum v. NationsBank of Maryland, N.A., 123 F.3d 156 (4th Cir. 1997) (en banc). PMID- 10179837 TI - Visual control: using simple graphics can eliminate errors and boost quality. PMID- 10179839 TI - The clock is ticking. Though HIPAA is behind schedule, payors will gain from new EDI standards. PMID- 10179838 TI - How a blood bank can improve performance. PMID- 10179841 TI - Cents and sensibility. The ins and outs of shrewd outsourcing. PMID- 10179840 TI - Bitter medicine. HCFA's year 2000 prescription is tough for healthcare organizations to swallow. PMID- 10179842 TI - The case for physician input. Physicians have simple goals when it comes to technology. PMID- 10179843 TI - Protect your net. Good policy + good technology = dependable security. PMID- 10179844 TI - We're experiencing technical difficulties, please stand by ... after the novelties of a merger or acquisition wear off, the realities of systems integration come into focus. PMID- 10179845 TI - The Ninth Annual HIMSS Leadership Survey. Healthcare Information and Management Systems Society. PMID- 10179846 TI - Will the real CPR, EMR, EHR please stand up? As healthcare turns its attention to automating patient information, the debate over the CPR heats up. PMID- 10179847 TI - Point counterpoint--computer-based patient record. Interview by Charlene Marietti. PMID- 10179848 TI - Countdown to the CPR. Survey of CPR vendors reflects industry growth. AB - While functions of computer-based patient record (CPR) systems are far from standard among vendors, many companies have done extensive development in the area of CPR systems. Our search for companies that provide some or all components of a CPR system has revealed the following list. Along with information that will help you locate and contact each company, we have provided details on each CPR product including hardware and software requirements and a brief description of the product (where provided by the company). For additional details on each vendor's system, please contact the vendor directly. Note: As much as we attempted to include every company with a CPR system, there may be some inadvertently missed. If your company is a CPR vendor, please make us aware so we can include your product in future resource issues. PMID- 10179849 TI - Quality improvement in thoracic surgery. PMID- 10179850 TI - Physician qualifications for stereotactic breast biopsy: a revised statement. American College of Surgeons and American College of Radiology. AB - Following review and approval by both the Board of Regents of the American College of Surgeons (ACS) and the Board of Chancellors of the American College of Radiology (ACR), the guidelines document Physician Qualifications for Stereotactic Breast Biopsy was published in the September 1997 issue of the Bulletin of the American College of Surgeons. Several ACS Fellows subsequently contacted the College to suggest revisions to the document that significantly clarify the requirements and delineate the additional clinical skills that should be required for radiologists practicing independently. The College agreed to incorporate the proposed changes in the guidelines document and to submit the revised statement to the ACS Board of Regents and the ACR Board of Chancellors for their consideration and review. The revised document was approved by both of those bodies in February of this year and is presented here in its entirety. Changes to the text are printed in italics. PMID- 10179851 TI - Verification by the American College of Surgeons for the use of emerging technologies. PMID- 10179852 TI - In their own words. Practice expenses and the resource-based relative value scale. AB - Dr. Opelka is a member of the College's CPT/RUC Committee, which makes recommendations about general surgery codes that should be added to, revised, or deleted from the CPT Manual. The committee also develops recommendations for the relative work values assigned to the general surgery services listed in the Medicare fee schedule. Because of his deep knowledge of the Medicare payment system, Dr. Opelka has frequently represented the College on panels convened by the federal government and in meetings with federal officials. In particular, he served recently on expert panels convened by the Health Care Financing Administration (HCFA) to develop direct cost data for the purpose of calculating resource-based practice expense relative values, which are scheduled to be incorporated into the Medicare fee schedule over a four-year period beginning in 1999. Dr. Opelka also participated in meetings that the General Accounting Office (GAO) requested with the College as part of its review of the methods being used by HCFA to generate the new practice expense values. Following are some of Dr. Opelka's thoughts about the federal government's efforts in this area. PMID- 10179854 TI - Characteristics of the nonelderly with selected sources of health insurance and lengths of uninsured spells. AB - This Issue Brief examines the characteristics of individuals with selected sources of coverage and combinations of sources of coverage over a 12-month period. In addition, it examines the characteristics of individuals who experience spells without health insurance and the lengths of these spells. It uses the most recent 12-month period from the Survey of Income and Program Participation and builds on previous research on the lengths of spells with and without health insurance. Analysis of individuals' health insurance coverage from October 1994 to September 1995 showed that approximately 77.6 percent of the nonelderly had health insurance coverage during this entire period. In addition, 22.4 percent of the nonelderly were uninsured for at least one month during this period, and 7.4 percent of the nonelderly were uninsured for the entire period. Of those with health insurance coverage for the entire year, approximately 83 percent were covered by private health insurance, with at least 81 percent of this group receiving the coverage from employment-based sources. Eighty-five percent of the spells without health insurance with an observed beginning and end lasted for 4 months or less, and 99 percent lasted for 8 months or less. When examining the spells with either an observed beginning or end, 55 percent of these spells were found to last for 4 months or less, and 87 percent were found to last for 8 months or less. However, investigation of all spells without health insurance showed that approximately one-half of all spells without health insurance coverage lasted for 8 months or longer. This report found that two thirds of spells without health insurance last for less than one year, confirming previous research that a majority of these spells are for less than a year. However, this report also confirms the existence of a significant number- approximately one-third of all individuals with a spell of noncoverage--of chronically uninsured individuals. These individuals are the most likely to delay seeking treatment for illnesses and to use the emergency room as their only site of care. Because they are in poverty or near poverty, much of this care is uncompensated. Thus, to the extent that providers can shift these costs onto other payers, all individuals and employers share in these costs through higher health insurance premiums or higher taxes to finance public hospitals and public insurance programs. Recent major health insurance legislation has addressed access to health insurance, and in many cases focused solely on continued access to employment-based coverage, but has done very little to address the affordability of coverage. However, as this report demonstrates, many individuals experiencing spells without health insurance have low incomes. Thus, to obtain coverage, individuals need not only increased access to health insurance but also the ability to afford this health insurance. PMID- 10179853 TI - New documentation guidelines for E&M (evaluation and management) services: their evolution and status. PMID- 10179855 TI - The accuracy of eclampsia cases reported to the Victorian Inpatient Minimum Database and the Perinatal Data Collection Unit. AB - The aim of this study was to compare the quality of the reporting and coding of eclampsia in two routine data collections: the Victorian Inpatient Minimum Database (VIMD) and the Perinatal Data Collection Unit (PDCU). The validity of cases in the two data sets was confirmed by reference to the original medical record data. Only 12 cases were the same in both data sets (i.e., 35.3% agreement). There were an additional 51 cases that were reported to either one or the other of the data sets and, of these, only 15 (i.e., 29%) were confirmed as eclampsia. The overall number of cases confirmed for both systems in 1995 was 27, or 0.4 per 1000 confinements. Reasons for these discrepancies were investigated and three basic problems identified: quality of documentation in the medical record, coding errors, and use of data from computer-generated forms. Neither the VIMD nor the PDCU was regarded as having sufficiently accurate data for adequate reporting of maternal morbidity. By combining the information from both databases a better estimate of incidence can be obtained, but improved reporting and coding is essential for accurate assessment of this condition. PMID- 10179856 TI - The Health Records (Privacy and Access) Act 1997. PMID- 10179857 TI - The Health Records (Privacy and Access) Act 1997. From a hospital perspective. PMID- 10179858 TI - Competitive neutrality and health information services. PMID- 10179859 TI - Profile of health information management: Auckland Healthcare, New Zealand. PMID- 10179860 TI - Health and Vitals National Processing Centre. Australian Bureau of Statistics (Brisbane Office). PMID- 10179861 TI - Out of sight, out of mind. PMID- 10179862 TI - Introduction of ICD-10-AM. PMID- 10179863 TI - Amended economic impact analysis of final rule requiring use of labeling on natural rubber containing devices--FDA. Final rule; amended economic analysis statement. AB - The Food and Drug Administration (FDA) is issuing an amended economic analysis statement relating to a final rule that published in the Federal Register of September 30, 1997 (62 FR 51021), requiring labeling statements concerning the presence of natural rubber latex in medical devices. This rule was issued in response to numerous reports of severe allergic reactions and deaths related to a wide range of medical devices containing natural rubber. The final rule becomes effective on September 30, 1998. In order to allow further comment on the economic impact of the September 30, 1997 final rule, FDA is publishing an amended economic impact statement, including an amended initial regulatory flexibility analysis (IRFA) that it has prepared under the Regulatory Flexibility Act (RFA), as amended by the Small Business Regulatory Enforcement and Fairness Act (SBREFA). FDA will respond to comments to this amended economic analysis statement, and publish in the Federal Register an amended final economic impact statement prior to the effective date of the September 30, 1997 rule. PMID- 10179864 TI - Medicare and Medicaid programs; surety bond requirements for home health agencies -HCFA. Final rule. AB - This final rule revises several provisions of an earlier final rule concerning surety bond requirements published in the Federal Register on January 5, 1998 (63 FR 292). This rule also establishes the surety bond submission compliance data, as described in a notice of intent and in a final rule concerning surety bond requirements published in the Federal Register on March 4, 1998 (63 FR 10730 and 10732). The March 4 documents advised the public that we intended to make technical revisions to the January 5, 1998 final rule and extend the February 27, 1998 compliance date for all home health agencies (HHAs) to furnish a surety bond to HCFA and/or the State Medicaid agency, or both, until 60 days after the date of publication of this final rule. In this rule, for Medicare-participating HHAs, we are establishing a new compliance date to submit a surety bond that is 60 days after the date of publication of this final rule. For Medicaid-participating HHAs, we are establishing a new compliance date to furnish a surety bond that is a date established by the State Medicaid agency up to 120 days after the date of publication of this final rule. We are also responding to comments we received in response to the January 5, 1998 final rule that pertain to the technical revisions we discussed in our March 4, 1998 notice. It is our intention to respond to all comments not addressed herein in a future Federal Register document. This final rule revision does not change the beginning date of the term the initial surety bond is to cover, that is, January 1, 1998. PMID- 10179865 TI - Medical devices; classification/reclassification of immunohistochemistry reagents and kits--FDA. Final rule. AB - The Food and Drug Administration (FDA) is issuing a final rule to classify/reclassify immunohistochemistry reagents and kits (IHC's) into three classes depending on intended use. FDA is classifying/reclassifying into class I (general controls) and exempt from premarket notification requirements IHC's used as adjunctive tests and presenting a low risk to public health. FDA is classifying/reclassifying into class II (special control) IHC's that detect or measure certain target analytes and that provide prognostic or predictive data that is not confirmed by routine histopathologic control specimens. The results of the class II IHC's are reported independently to the clinician, and the performance claims are widely accepted and supported by valid scientific evidence. FDA is classifying/reclassifying into class III (premarket approval) IHC's intended for any other use. The scope of products covered by this final rule includes both pre-1976 devices that have not been previously classified, as well as post-1976 devices that are statutorily classified into class III. The intent of this final rule is to regulate pre-1976 devices and post-1976 devices in a consistent fashion. Therefore, FDA is classifying or reclassifying these products as applicable. PMID- 10179866 TI - Medicare program; coverage and administrative policies for clinical diagnostic laboratory tests; intent to form Negotiated Rulemaking Committee--HCFA. Notice of intent to form Negotiated Rulemaking Committee and notice of meetings. AB - The Balanced Budget Act of 1997 requires the Secretary to establish a Negotiated Rulemaking Committee under the Negotiated Rulemaking Act and the Federal Advisory Committee Act. The Negotiated Rulemaking Committee's (the Committee) purpose will be to negotiate national coverage and administrative policies for clinical diagnostic laboratory tests under Part B of the Medicare program as required by the Balanced Budget Act of 1997 (BBA). The Committee will consist of representatives of interested parties that are likely to be significantly affected by the proposed rule. The Committee will be assisted by a neutral facilitator. The BBA outlines the scope of issues to be negotiated by the Committee. We specifically request public comment as to whether we have identified the interests that will be affected by key issues listed below. PMID- 10179867 TI - Medicare and Medicaid programs; quarterly listing of program issuances--third quarter 1997--HCFA. Notice. AB - This notice lists HCFA manual instructions, substantive and interpretive regulations, and other Federal Register notices that were published during July, August, and September of 1997 that relate to the Medicare and Medicaid programs. It also identifies certain devices with investigational device exemption numbers approved by the Food and Drug Administration that may be potentially covered under Medicare. Section 1871(c) of the Social Security Act requires that we publish a list of Medicare issuances in the Federal Register at least every 3 months. Although we are not mandated to do so by statute, for the sake of completeness of the listing, we are including all Medicaid issuances and Medicare and Medicaid substantive and interpretive regulations (proposed and final) published during this time frame. PMID- 10179868 TI - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); waiver of collection of payments due from certain persons unaware of loss of CHAMPUS eligibility--DoD. Final rule. AB - This final rule authorizes the waiver of collection of payments due from individuals who lost their CHAMPUS eligibility when they became eligible for Medicare Part A, due to disability or end stage renal disease. PMID- 10179869 TI - Privacy Act of 1974; addition of routine uses to an existing system of records- HRSA. Notification of an addition of routine uses to an existing system of records. AB - In accordance with the requirements of the Privacy Act, the Health Resources and Services Administration (HRSA) is publishing a proposal to add three new routine uses for the records in System of Records 09-15-0056, National Vaccine Injury Compensation Program (VICP), BHPr/ HRSA/HHS. HRSA proposes to specify the categories of records in the system, and to expand the list of routine use in record disclosures to include disclosures for research purposes, disclosures to annuity brokers, and disclosures to employees of life insurance companies for the purposes of providing benefits to recipients under the VICP. PMID- 10179870 TI - Protection of human research subjects--HHS. Notice of proposed rulemaking. AB - The Department of Health and Human Services (HHS) is proposing to amend its human subjects protection regulations applicable to research conducted or supported by HHS, by replacing the existing Subpart B of the regulations entitled "Additional DHHS Protections Pertaining to Research, Development, and Related Activities Involving Fetuses, Pregnant Women, and Human In Vitro Fertilization" with new regulations entitled "Additional DHHS Protections for Pregnant Women, Human Fetuses, and Newborns Involved as Subjects in Research, and Pertaining to Human In Vitro Fertilization." This revision continues the Department's recognition of the need to provide special protections for the human fetus and newborn in research, while eliminating unnecessary barriers to consent to research that can benefit fetuses or newborns. Additionally, consistent with recent practices and statutory changes, this proposed regulation provides a mechanism for special ethical reviews on an ad hoc basis as may be deemed appropriate by the Secretary, HHS. PMID- 10179871 TI - Prohibition of "gag clauses" in the Federal Employees Health Benefits Program- OPM. Notice of proposed rule making. AB - The Office of Personnel Management (OPM) is proposing to amend the regulations to prohibit health benefit carriers participating in the Federal Employees Health Benefits (FEHB) Program from entering into contractual provisions with health care providers or health care workers that would include a provision for incentive payments as an inducement to reduce or limit communication with, or the delivery of health care services to, FEHB enrollees. The rule is intended to ensure providers' and health care workers' ability to communicate with, and advise patients of, any medically necessary treatment options. PMID- 10179872 TI - Office of the Secretary Assistant Secretary for Planning and Evaluation notice inviting applications for new award for fiscal year 1998--HHS. Announcement of the availability of funds and request for applications from states to determine the status of Temporary Assistance to Needy Families (TANF) recipients after they leave the TANF caseload, eligible families who are diverted before being enrolled, or eligible families who fail to enroll. AB - The Office of the Assistant Secretary for Planning and Evaluation (ASPE), with support from the U.S. Department of Labor and the Economic Research Service of the U.S. Department of Agriculture, announces the availability of funds and invites applications for research into the status of individuals and families who leave the TANF program, who apply for cash welfare but are never enrolled because of non-financial eligibility requirements or diversion programs, and/or who appear to be eligible but are not enrolled (hereafter jointly referred to as welfare leavers). Approximately eight to ten States or counties will receive funding that will enable them to track and monitor how individuals and their families do in the first year after they leave welfare and provide a foundation for longer follow-up. States may choose any method for such tracking, including the linking of administrative data, surveys or other methods as appropriate. We are particularly interested in learning about individuals' ability to obtain employment and the support provided by their earnings, public programs besides TANF, and other sources. The funds could support a newly designed project or could be used to add new data sources and analyses to an existing project. In addition, ASPE announces the availability of supplementary funding from the Office of Policy Development and Research (PD&R) of the U.S. Department of Housing and Urban Development (HUD) to track the consequences of welfare reform for low-income families with children who receive housing assistance. These funds will only be available to ASPE Grantees. PMID- 10179873 TI - Regulations for in vivo radiopharmaceuticals used for diagnosis and monitoring- FDA. Proposed rule. AB - The Food and Drug Administration (FDA), in response to the requirements of the Food and Drug Administration Modernization Act of 1997 (FDAMA), is proposing to amend the drug and biologics regulations by adding provisions that would clarify the evaluation and approval of in vivo radiopharmaceuticals used in the diagnosis or monitoring of diseases. The proposed regulations would describe certain types of indications for which FDA may approve diagnostic radiopharmaceuticals. The proposed rule also would include criteria that the agency would use to evaluate the safety and effectiveness of a diagnostic radiopharmaceutical under the Federal Food, Drug, and Cosmetic Act (the act) and the Public Health Service Act (the PHS Act. PMID- 10179874 TI - Medical devices; implementation of third party review under the Food and Drug Administration Modernization Act of 1997; emergency processing request under OMB review--FDA. Notice. AB - The Food and Drug Administration (FDA) is announcing a program under which persons may be accredited to review premarket notifications and recommend initial classification of certain medical devices. At the same time, FDA is announcing the termination of the Third Party Review Pilot Program. This notice announces the criteria to accredit or deny accreditation to persons (Accredited Persons) who request to conduct premarket notification reviews consistent with provisions of the FDA Modernization Act of 1997 (FDAMA). FDA is also announcing that this proposed collection of information has been submitted to the Office of Management and Budget (OMB) for emergency processing under the Paperwork Reduction Act of 1995 (the PRA). FDA is requesting OMB approval within 45 days of receipt of this submission. FDA is taking this action to implement section 210 of FDAMA. The availability of guidance detailing the review of submissions, training for third party reviewers, and basic document processing by FDA is announced elsewhere in this tissue of the Federal Register. PMID- 10179875 TI - Privacy Act of 1974; report of new system--HCFA. Notice of new system of records. AB - In accordance with the requirements of the Privacy Act of 1974, we are proposing to establish a new system of records, "Long Term Care Minimum Data Set (LTC MDS)," HHS/ HCFA/CMSO System No. 09-70-1516. We have provided background information about the proposed system in the "Supplementary Information" section below. Although the Privacy Act requires only that the "routine use" portion of the system be published for comment, HCFA invites comments on all portions of this notice. See "Effective Dates" section for comment period. PMID- 10179876 TI - Implementation of Section 255 of the Telecommunications Act of 1996: access to telecommunications services, telecommunications equipment, and customer premises equipment by persons with disabilities--FCC. Notice of proposed rulemaking. AB - This Notice of Proposed Rulemaking (NPRM) is an important step in the Commission's effort to increase the accessibility of telecommunications services and equipment to Americans with disabilities. The NPRM proposes a framework for implementing section 255 of the Communications Act of 1934 (Act), which requires telecommunications equipment manufacturers and service providers to ensure that their equipment and services are accessible to persons with disabilities, to the extent it is readily achievable to do so. In addition, if accessibility is not readily achievable, section 255 requires manufacturers and service providers to ensure compatibility with existing peripheral devices or specialized customer premises equipment commonly used by individuals with disabilities to achieve access, to the extent it is readily achievable to do so. The NPRM first explores the Commission's legal authority to establish rules implementing section 255. The NPRM then seeks comment on the interpretation of specific statutory terms that are relevant to the proceeding. Finally, the NPRM seeks comment on proposals to implement and enforce the requirement that telecommunications equipment and services be made accessible to the extent readily achievable. The actions proposed in the NPRM are needed to ensure that people with disabilities are not left behind in the telecommunications revolution and consequently isolated from contemporary life. PMID- 10179877 TI - The AIDS initiative, one year later. PMID- 10179878 TI - Carrying out a vision. PMID- 10179879 TI - Straight from the heart. PMID- 10179880 TI - Simplifying data queries. PMID- 10179881 TI - Improving quality via the Web. PMID- 10179882 TI - Rallying the troops. Interview by Jennifer A. Gilbert. PMID- 10179883 TI - Taking the network initiative. PMID- 10179884 TI - Overcoming electronic records hurdles. AB - A growing number of health care providers are investing in information systems necessary to create complete computer-based patient records. But even though the outlook for industrywide acceptance of the technology is looking up, obstacles still stand in the way. For the industry to more widely embrace electronic records, these hurdles, such as easing data entry for doctors and securing funding, must be surmounted. PMID- 10179885 TI - Software shopping tips. PMID- 10179886 TI - Is wireless technology ready to roll? AB - For years, health care organizations have been slow to accept wireless technology. But as more organizations are finding that the technology can improve care and save money, they're jumping on the wireless bandwagon. Some pioneering providers are even deploying multiple wireless technology applications. Their success is providing a road map for others to follow and building confidence in the emerging technology. PMID- 10179887 TI - Patient education in the computer age. AB - The more educated the patient, the healthier the patient. That's the philosophy prompting a growing number of health care providers to take advantage of new patient education tools. Using patient education software and Internet resources helps caregivers ensure that the information delivered to a patient is appropriate and timely. Providers also are discovering that such systems yield significant clinical and financial benefits. PMID- 10179888 TI - Tips for recruiting I.T. professionals in tough times. AB - Health care organizations are struggling to recruit information technology staff in a fiercely competitive market. Providers and insurers need more technology personnel to manage the growing number of systems their organizations are demanding. But finding qualified staff is not easy at a time when technology is changing rapidly and experienced specialists are scarce. Some CIOs, however, are devising creative strategies for attracting the talented technicians that they need. PMID- 10179889 TI - Promoting patient/family education through use of automated interdisciplinary discharge information. PMID- 10179890 TI - Family caregiving in the US: summary of national findings. PMID- 10179891 TI - Patient education for post-surgical pain control. PMID- 10179893 TI - Address the "Y2K" problem before the Millennium. PMID- 10179892 TI - Population management: managing a capitated state indigent program. PMID- 10179894 TI - Working with vendors on Year 2000 solutions. PMID- 10179895 TI - Legal exposure for "Y2K" could top $1 trillion worldwide. PMID- 10179896 TI - Ten strategies to fix the "Y2K" problem. PMID- 10179897 TI - The good, the bad and the ugly: subacute industry reacts to prospective payment rule. PMID- 10179898 TI - How to determine your facility-specific rate for the SNF PPS. PMID- 10179899 TI - MDS schedule for SNF PPS relaxed a bit from demo rules but still demanding. PMID- 10179900 TI - HCFA announces 10 DRGs affected by "transfer rule". PMID- 10179901 TI - PPS rule alters SNF level of care eligibility criteria. PMID- 10179902 TI - Electroconvulsive therapy and managed care. PMID- 10179903 TI - Parenteral and enteral nutrition in acute care settings. PMID- 10179904 TI - Outcomes research: collaboration among academic researchers, managed care organizations, and pharmaceutical manufacturers. AB - Medical and pharmaceutical outcomes research has been of increasing interest in the past 10 to 15 years among healthcare providers, payers, and regulatory agencies. Outcomes research has become a multidisciplinary field involving clinicians, health services researchers, epidemiologists, psychometricians, statisticians, psychologists, sociologists, economists, and ethicists. Collaboration among researchers in different organizations that offer different types of services and various research expertise is the essential element for any successful outcomes project. In this article we discuss collaboration on outcomes research among academic researchers (mainly those who work in colleges of pharmacy), managed care organizations, and research-based pharmaceutical manufacturers, with a focus on the opportunities and challenges facing each party. The pharmaceutical industry needs information to make product and promotion decisions; the managed care industry has data to offer but needs analysis of these data; and pharmacy schools, among other academic institutions, have skilled researchers and data-processing capacity but require projects for revenue, research training, experience, and publications. Challenges do exist with such endeavors, but collaboration could be beneficial in satisfying the needs of the individual parties. PMID- 10179905 TI - Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. AB - The relationship between low bone mass and risk of fracture is well documented. Although bone densitometry is the method of choice for detecting low bone mass, its use may be limited by the availability of equipment, cost, and reimbursement issues. Improved patient selection for bone densitometry might increase the cost effectiveness of screening for osteoporosis, a goal we sought to achieve by developing and validating a questionnaire based solely on patient-derived data. Responses to the questionnaire were used to assign postmenopausal women to one of two groups: (1) those unlikely to have low bone mineral density (defined as 2 standard deviations or more below the mean bone mass at the femoral neck in young, healthy white women) and therefore probably not currently candidates for bone densitometry; and (2) those likely to have low bone mineral density and therefore probably candidates for bone densitometry. We asked community-dwelling perimenopausal and postmenopausal women attending one of 106 participating multispecialty centers (both academic and community based) to complete a self administered questionnaire and undergo bone density measurement using dual x-ray absorptiometry. We used regression modeling to identify factors most predictive of low bone density at the femoral neck in the postmenopausal group. A simple additive scoring system was developed based on the regression model. Results were validated in a separate cohort of postmenopausal women. Data were collected from 1279 postmenopausal women in the development cohort. Using only six questions (age, weight, race, fracture history, rheumatoid arthritis history, and estrogen use), we achieved a target of 89% sensitivity and 50% specificity. The likelihood ratio was 1.78. Validation in a separate group of 207 postmenopausal women yielded 91% sensitivity and 40% specificity. Assuming population characteristics similar to those of our development cohort, use of our questionnaire could decrease the use of bone densitometry by approximately 30%. Sensitivity and specificity can be varied by changing the level for referral for densitometry to provide the most cost-effective use within a particular healthcare setting. Thus use of our questionnaire, an inexpensive prescreening tool, in conjunction with physician assessment can optimize the use of bone densitometry and may lead to substantial savings in many healthcare settings where large numbers of women require evaluation for low bone mass. PMID- 10179906 TI - Aspirin treatment after myocardial infarction: are health maintenance organization members, women, and the elderly undertreated? AB - In April 1996, we surveyed 539 patients who had suffered a myocardial infarction in 1995 to determine whether the prescription and use of aspirin after myocardial infarction differs by patient age, sex, and type of health insurance. Patients who were insured through one of four health maintenance organizations in major metropolitan areas or by an indemnity plan in 40 states completed the survey. Among the 502 patients with no contraindications to use, 93.8% were prescribed aspirin. Among patients with a prescription and no subsequent contraindications to use, 96.4% were taking aspirin when surveyed. Among aspirin users, 96.5% reported taking aspirin daily. Controlling for other characteristics, 75-year-old patients were 5 percentage points less likely to receive a prescription for aspirin than were 50-year-old patients (P = 0.05). Although not significant at conventional levels, point estimates revealed a prescription rate for women that was 6 percentage points higher than that for men (P = 0.054) and a rate for health maintenance organization members that was 4 percentage points lower than that for patients with indemnity insurance (P = 0.10). Aspirin use was lower among older patients (P = 0.02) but did not differ by gender or type of insurance plan. Health maintenance organization members were just as likely to receive a prescription from a specialist as were those with indemnity insurance (P = 0.92). Based on these results, the rate of aspirin treatment after myocardial infarction may be much higher than previous studies indicate. Concerns that managed care patients and women may be undertreated are not supported by our findings. Although older patients are at risk for undertreatment, this risk is low. Once aspirin is prescribed, selfreported patient compliance with a daily regimen of aspirin is high. PMID- 10179907 TI - Economic benefits of aggressive lipid lowering: a managed care perspective. AB - Coronary heart disease (CHD) has high prevalence in the United States and is associated with significant mortality as well as costs to society. Hyperlipidemia is a major and common modifiable risk factor for CHD. In clinical trials, cholesterol-lowering strategies have a dramatic impact on CHD risk, cardiovascular events, and mortality. Cost-effectiveness data have established that clinical and economic benefits are gained by instituting early and aggressive lipid-lowering therapy. We present new evidence for the clinical benefits and cost effectiveness of aggressive lipid-lowering therapy as primary or secondary prevention of CHD and describe strategies that managed care organizations can take to benefit from a lipid management program. PMID- 10179908 TI - Prevalence of insomnia: a survey of the enrollees at five managed care organizations. AB - The purpose of the study was to assess the prevalence of and factors associated with insomnia among enrollees of managed care organizations (MCOs). A survey was distributed either by mail or during a clinic visit to 7,500 enrollees of five MCOs in the United States. The survey included a sleep questionnaire, demographic questions, and questions about medical encounters and prescription drug use. Three levels of insomnia (none; level I--difficulty initiating or maintaining sleep; level II--insomnia with daytime dysfunction) were defined from the responses. Comorbidities were determined by proxy from prescription drug use reported by respondents. A total of 3,447 survey responses were received, yielding a response rate of 46%. Level I and level II insomnia was reported by 13.5% and 32.5% of the respondents, respectively. Level II insomnia increased with decreasing education, income, and age and was more prevalent in women and non-Caucasians. Insomnia was significantly correlated with all daytime sleepiness and most nighttime disturbances factors. Fifty-two percent of all respondents reported at least one comorbid condition. Respondents with multiple comorbidities reported level II insomnia more frequently than those with no comorbidities. Only 0.9% of clinic visitors were seeing a physician specifically for sleep problems. Of those with level I and level II insomnia, only 5.5% and 11.6%, respectively, were taking prescription medications specifically for sleep problems; 11.2% and 21.4%, respectively, were taking over-the-counter medications for sleep. Insomnia occurs in MCO enrollees at rates comparable to those found in the general population. However, few patients with insomnia are actually being treated for their condition. Proper evaluation, diagnosis, and treatment of insomnia are warranted. PMID- 10179909 TI - Treatment of allergic rhinitis: an evidence-based evaluation of nasal corticosteroids versus nonsedating antihistamines. AB - Allergic rhinitis is a high-cost, high-prevalence disease. In the 12 months ending March 31, 1997 $3.1 billion was spent in the United States for medications to manage this illness. Allergic rhinitis affects quality of life and interferes with work productivity. Nonsedating antihistamines are the most common and most expensive therapy for this condition. This study reviewed 13 randomized studies in which blinded investigators compared management of allergic rhinitis by means of intranasal steroids to management by means of nonsedating antihistamine. Evidence tables demonstrated that in all studies in which total nasal symptoms and nasal obstruction were recorded, the nasal steroid was statistically superior to the nonsedating antihistamine. For nasal blockage the nonsedating antihistamines did not perform better than placebo. For all other nasal symptoms the intranasal steroid was statistically superior in most reports and equal or numerically better in the remaining papers. When these data are linked to those from cost analysis and quality-of-life studies, the evidence strongly suggests that nasal steroids should be first-line therapy for allergic rhinitis. In four reports on the combination of a nonsedating antihistamine compared to a nasal steroid alone, there was no significant difference between these two treatments. Like asthma, allergic rhinitis is an inflammatory disease and should be managed with anti-inflammatory medication. Making such a change in the management of allergic rhinitis should increase efficacy and decrease costs. PMID- 10179910 TI - Medicare HMOs: who joins and who leaves? AB - Medicare risk health maintenance organizations (HMOs) are an increasingly common alternative to fee-for-service Medicare. To date, there has been no examination of whether the HMO program is preferentially used by blacks or by persons living in lower-income areas or whether race and income are associated with reversing Medicare HMO selection. This question is important because evidence suggests that these beneficiaries receive poorer care under the fee-for-service-system than do whites and persons from wealthier areas. Medicare enrollment data from South Florida were examined for 1990 to 1993. Four overlapping groups of enrollees were examined: all age-eligible (age 65 and over) beneficiaries in 1990; all age eligible beneficiaries in 1993; all age-eligible beneficiaries residing in South Florida during the period 1990 to 1993; and all beneficiaries who became age eligible for Medicare benefits between 1990 and 1993. The associations between race or income and choice of Medicare option were examined by logistic regression. The association between the demographic characteristics and time staying with a particular option was examined with Kaplan-Meier methods and Cox Proportional Hazards modeling. Enrollment in Medicare risk HMOs steadily increased over the 4-year study period. In the overall Medicare population, the following statistically significant patterns of enrollment in Medicare HMOs were seen: enrollment of blacks was two times higher than that of non-blacks; enrollment decreased with age; and enrollment decreased as income level increased. For the newly eligible population, initial selection of Medicare option was strongly linked to income; race effects were weak but statistically significant. The data for disenrollment from an HMO revealed a similar demographic pattern. At 6 months, higher percentages of blacks, older beneficiaries (older than 85), and individuals from the lowest income area (less than $15,000 per year) had disenrolled. A small percentage of beneficiaries moved between HMOs and FFS plans multiple times. These data on Medicare HMO populations in South Florida, an area with a high concentration of elderly individuals and with one of the highest HMO enrollment rates in the country, indicate that enrollment into and disenrollment from Medicare risk HMOs are associated with certain demographic characteristics, specifically, black race or residence in a low-income area. PMID- 10179911 TI - Changes in benefit payments and health insurance premiums among firms switching health insurance carriers. AB - Employer-purchased group health insurance is a major source of funding in the US healthcare system, accounting for approximately one third of each healthcare dollar spent. Surprisingly, little is known about employers' behavior in purchasing health insurance or the circumstances leading employers to switch health insurance carriers. We descriptively analyzed data for a cohort of 95 insured groups between 1985 and 1991 to determine the frequency with which employers switch health insurance carriers and the growth pattern in premiums and benefit payments before the switch was made. Thirty-seven percent of groups switched carriers during the study period, with at least five groups switching each year from 1987 through 1991. The groups that switched insurance carriers experienced higher average annual rates of growth in benefit payments than those that did not switch (18% versus 11%). Groups that switched did not have significantly higher observed premium growth rates than those that did not switch, suggesting that employers decided to switch insurers before absorbing an increase in premiums. However, some firms that switched experienced below average increases in both benefit payments and premiums, indicating that premiums and anticipated premium increases are not solely responsible for the decision to switch health insurance carriers. PMID- 10179912 TI - Cost of migraine management: a pharmacoeconomic overview. AB - Migraine is a chronic, sometimes debilitating, condition that tends to afflict young people who are otherwise healthy and productive. Because diagnostic criteria and effective treatment modalities have not been well taught to physicians, the condition is often undiagnosed, misdiagnosed, and mismanaged, causing unnecessary pain, hardship to the individual, disability, loss of productivity, and increased expense to the healthcare system. This paper discusses a rational approach to the behavioral and pharmacologic treatment of migraine, highlighting the relative costs of preventive and acute care therapies. Several cases are presented to illustrate how the costs of inefficiently managed migraine therapy can be decreased even by using medications that have a higher per-dose cost, as they decrease the pain and disability and actually lower the total cost of managing the patient with migraine. PMID- 10179913 TI - A program to reduce discharge delays in a neonatal intensive care unit. AB - Our hypothesis was that a program designed to identify the causes of discharge delays would reduce the length of stay in our neonatal intensive care unit. We reviewed every admission from January, 1994, to December, 1995. A discharge delay was defined as any delay not related to illness after the infant was cleared for release. Discharge delays were divided into the following categories: primary healthcare team, organizational, discharge planning, family, monitor related, and other. Potential discharge delays were identified daily according to established criteria. Actual discharge delays were reviewed monthly at a staff meeting attended by representatives of a multidisciplinary team. We identified 116 discharge delays, which accounted for 480 patient days. Eighty-three discharge delays accounted for 302 patient days in 1994, and 33 discharge delays for 178 patient days in 1995. Discharge delays ranged from 1 to 34 days, with an average of 4.1 days added per patient. Infants with discharge delays had a case mix index of 9.32. The average case mix index for the neonatal intensive care unit was 6.25 during 1994 and 5.18 during 1995, an average of 5.71 for the review period. Forty four percent of infants who had discharge delays had private insurance, 55% had Medicaid, and 1% had self-payment arrangements. Eighty-eight of 116 discharge delays were caused by circumstances beyond the control of the primary care team. An additional 25 of 116 discharge delays were the result of our policy requiring 48 hours free of apnea-bradycardia alarms before discharge. Discharge delays for 1994 cost $226,298 ($749/day). For 1995, discharge delays cost $41,553 ($233/day) for a total cost of $262,431. Total savings in 1995 versus 1994 was $184,745 ($516/day). Despite the low birth weight and relatively severe illnesses of the infants, we believe that a focused team approach and monitoring for potential discharge delays can result in considerable reduction in hospital stay and cost. PMID- 10179914 TI - Attitudes and behavioral intentions regarding managed care: a comparison of academic and community physicians. AB - Physicians' attitudes toward managed care and the impact of these attitudes on behaviors that affect patient care are important factors in managed care reform. In addition, the attitudes of academic physicians may influence their willingness to reform medical education in an effort to prepare students to practice under managed care. Although it is a conventional opinion that the academic health center and its academic physicians are antagonistic toward managed care, there has not been a direct comparison of the attitudes of these physicians to those of practicing community physicians. We used a self-administered questionnaire to assess attitudes toward managed care and behavioral intentions regarding practices related to managed care; a sample of academic physicians (n = 129) was compared with a sample of community physicians (n = 307). Community physicians were less negative in their evaluations of the quality of care in a managed care environment, but no differences were identified between the two groups with regard to the cost-effectiveness, inevitability, or need to adapt to managed care. Academic specialists were more likely than academic primary care physicians to rate managed care as something to which they needed to adapt. Community physicians were less likely to report a willingness to change their referral patterns. Aggregating across practice type, we also uncovered systematic differences between primary care and specialist physicians. The data suggest that opinions about quality and cost-containment in managed care are significant correlates of intentions to change practice behaviors. PMID- 10179915 TI - Physician and dietitian prescribing of a commercially available oral nutritional supplement. AB - We examined whether a policy change transferring prescribing privileges for oral nutritional supplements to dietitians resulted in fewer inappropriate outpatient prescriptions. This was a pre/post study design using a retrospective review of physician and dietitian prescribing for ambulatory patients during two separate time periods: physician prescribing, October to December, 1994; dietitian prescribing, April to June, 1995. Inappropriate prescriptions during each period were defined as those given to patients with normal nutritional status or with a contraindication to a high-energy, electrolyte-containing solution. The study was conducted in outpatient clinics at a Veterans Affairs teaching hospital. We found that dietitians gave fewer prescriptions to outpatients who were not malnourished or to outpatients who had a contraindication to receiving a supplement (11% vs 34%; P = 0.002). In addition, dietitians more often completed relevant laboratory assessments (75% vs 43%; P = 0.001) and more frequently arranged follow-up dietetic evaluations (84% vs 30%, P < 0.001) for ambulatory patients receiving supplements. We conclude that transferring nutritional supplement prescribing privileges to dietitians led to fewer inappropriate outpatient prescriptions and to more comprehensive nutritional assessments, as measured by relevant laboratory use and dietetic follow-up. Physicians more frequently prescribed supplements to outpatients who were not malnourished or who had contraindications to receiving supplements. Our results suggest that physicians would benefit from assistance with and/or education concerning oral nutritional supplements. PMID- 10179916 TI - A new gatekeeper for back pain. AB - Managed care programs have evolved in response to the escalating costs of healthcare in the United States. Expenses related to back pain represent a significant portion of these costs. Chiropractic physicians handle more back pain visits than do medical doctors and are playing an increasing role in the management of neuromusculoskeletal problems in general. Furthermore, chiropractic patients are more satisfied with their care than are patients of family physicians. A number of studies have shown chiropractic medicine to have high efficacy and cost-effectiveness. Its utilization for neuromusculoskeletal problems in the managed care setting may well offer competitive advantages. Using chiropractic physicians as gatekeepers for back pain would result in more expedient movement through the algorithmic process and facilitate treatment of the patient with acute back pain. Many medical facilities are enhancing their services by utilizing chiropractic physicians as gatekeepers for the diagnosis and treatment of neuromusculoskeletal disorders. PMID- 10179917 TI - Influencing physicians: the three critical elements of a successful strategy. AB - This activity is designed for leaders and managers of healthcare organizations, particularly those involved in the development of physician incentive and physician management programs. GOAL: To describe the challenges inherent in influencing physicians and review the essential elements of any successful strategy for achieving physician support and participation. OBJECTIVES: 1. Describe the reasons why healthcare organizations and medical groups need to influence physicians to be successful. 2. Cite the reasons why it is difficult to influence physicians. 3. Review the current strategies healthcare organizations and medical groups use to influence physicians. 4. Outline the three essential elements of any program designed to influence physicians. PMID- 10179918 TI - Alzheimer's disease: clinical features and pharmacologic management. PMID- 10179919 TI - Experience with a managed care approach to HIV infection: effectiveness of an interdisciplinary team. AB - To evaluate the function and effectiveness of a multidisciplinary team for managing human immunodeficiency virus (HIV) infection, we conducted a follow-up cohort study of HIV-positive patients managed according to a clinical care path at a staff-based health maintenance organization (HMO). The study group consisted of 230 HIV-positive health plan members who received care at the Kaiser Permanente Santa Rosa medical center (KPMC-SRO). In 1994, the comparison group consisted of 4747 HIV-positive health plan members who received care at Kaiser Permanente's 18 other medical centers in northern California. The percentages of acquired immunodeficiency syndrome (AIDS) and HIV-positive patients as determined by CD4+ T-cell counts were similar (P = 0.97). Compared with patients at the other Kaiser Permanente medical centers, KPMC-SRO patients had more visits with nurse practitioners (rate ratio [RR] = 1.72) and nutritionists (RR = 12.3) and fewer visits with primary care physicians (RR = 0.82). More HIV-positive members at KPMC-SRO received social workers' services (27% at KPMC-SRO vs 6% for patients at the other Kaiser Permanente medical centers) and fewer used emergency services (RR = 0.92) and psychiatric services (RR = .89). At KPMC-SRO, the mean number of days that AIDS patients spent in the hospital decreased from 7.8 (1991) to 2.01 (1994). Hospital admissions were fewer (AIDS patients, RR = 0.67; HIV-positive patients without AIDS, RR = 0.45), and length of stay was briefer, compared with patients at the other Kaiser Permanente Medical Centers. The mean cost of HIV related drugs for patients seen at KPMC-SRO ($2343 per infected member) was lower than that for patients seen elsewhere in the region ($3289 per infected member). These results suggest that in an HMO setting, managed care provided by a dedicated interdisciplinary team according to a clinical care path can substantially and favorably affect resource use. PMID- 10179920 TI - Regulating the financial incentives facing physicians in managed care plans. AB - Recent accounts of enrolees in managed care plans being denied access to potentially lifesaving services have heightened public anxiety about the impact of managed care on the accessibility and appropriateness of care, and this anxiety has been translated into legislative action. The present review focuses on an area of managed care operations that has received considerable attention in state legistlatures and in Congress during the past 2 years: the financial relationship between managed care health plans and physicians. Twelve states now mandate that managed care plans disclose information about their financial relationship with physicians, and 11 states regulate the method used by managed care health plans to compensate physicians. Most laws that regulate methods of compensation prohibit health plans from providing physicians an inducement to reduce or limit the delivery of "medically necessary" services. Moreover, in 1996 the Health Care Financing Administration finalized its regulations governing the financial incentives facing physicians in plans that treat Medicaid or Medicare patients, and these regulations went into effect on January 1, 1997. These regulations also are examined in this study. PMID- 10179921 TI - Evaluation of "solitary" thyroid nodules in a community practice: a managed care approach. AB - Evaluation of thyroid nodules remains a challenge for primary care physicians. To include or exclude the presence of malignancy in a thyroid nodule, radioisotope scan, ultrasound, and fine-needle aspiration biopsy of the thyroid generally are used. The objectives of this study were to determine the utility and cost effectiveness of fine-needle aspiration biopsy of solitary thyroid nodules in a community setting; to compare the cost of fine-needle aspiration biopsy with that of radioisotope scan and ultrasound; and to determine whether the practice of obtaining radioisotope scans and ultrasound has changed in the 1990s compared with the 1980s. Patients were referred by community physicians to university based endocrinologists for evaluation of thyroid nodules. Many of the patients had previously undergone radioisotope scans and ultrasound scans at the discretion of their primary care physicians. All patients underwent fine-needle aspiration biopsy. The biopsy results were evaluated prospectively, and the practice of community physicians' obtaining radioisotope scans and ultrasound scans was compared for the 1980s and 1990s. Eighty-three patients underwent 104 biopsies. In 20 biopsies the specimens were inadequate; the others showed 70 benign, 9 suspicious, and 4 malignant lesions. All four patients with biopsy findings read as malignant were found to have malignant growth at surgical procedures. Two benign biopsy findings were false-negative results. Malignant growth was correctly diagnosed later for one patient at a second biopsy and for the other because of growth of the nodule. The cost of 104 biopsies was $20,800. The cost of radioisotope scans was $22,400, and the cost of ultrasound scans was $10,640. The frequency of obtaining radioisotope scans (84.5% vs 77%) and ultrasound scans (65% vs 45%) was slightly higher in the 1990s compared with the 1980s. Fine-needle aspiration biopsy is a safe and cost effective initial evaluation modality for smaller community-based centers, as it is at large tertiary centers. The cost incurred ($33,040) in obtaining the radioisotope scans and ultrasound scans could have been saved if fine-needle aspiration biopsy had been used as the initial diagnostic procedure for evaluation of these nodules. Although radioisotope scan and ultrasound scan are of little diagnostic help in the evaluation of thyroid nodules, they continued to be obtained at a high frequency during the last decade. PMID- 10179922 TI - Prevention of nonsteroidal anti-inflammatory drug-induced gastropathy: clinical and economic implications of a single-tablet formulation of diclofenac/misoprostol. AB - Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to manage arthritis. While controlling symptoms and improving quality of life, NSAID use is associated with gastroduodenal injury and a 2%-4% annual risk for symptomatic gastroduodenal ulceration, hemorrhage, and perforation. This requires clinicians to balance the efficacy of NSAIDs against the potential risk of serious gastrointestinal events. Identification and stratification of risk can help guide the optimal approach for arthritis management of individual patients or large populations such as managed care organizations. NSAID-induced gastroenteropathy carries considerable economic consequences; 46% of arthritis costs are related to managing serious adverse events. It is reasonable to assume that these costs may not be incurred if high-risk patients are recognized and optimally managed. Newer therapies with proven safety margins present an attractive option, especially for patients at higher risk. The single-tablet formulations of diclofenac and misoprostol (Arthrotec) offer an alternative in managing NSAID patients because of their inherent safety profile. Studies with diclofenac/misoprostol indicate its effectiveness in treating signs and symptoms of arthritis and in reducing the incidence of NSAID-induced gastroenteropathy. As such, this agent may provide improved medical and economic outcomes. This review discusses the clinical aspects of NSAID-induced gastroenteropathy, including available preventive therapies. Approaches to assessing patients' risk for developing complications, and the relationship of medical risk and economic outcomes, are also examined. Although not all patients require preventive therapy, patients with heightened risk may benefit clinically and economically from gastroprotective NSAIDs. Additional research or modeling may provide further insight into the economic implications of managing and preventing NSAID-induced gastroenteropathy. PMID- 10179923 TI - Patient waiting times in a physician's office. AB - This observational study measured waiting times, appointment durations, and scheduling variables of a single family practice physician. Waiting time and appointment duration in four sequential groups of sessions were compared using analysis of variance; each group used different scheduling templates. Groups 1 and 2 used a 15-minute base interval; group 3 used a 20-minute base interval. Observations for group 4 were collected at a different health center using a 15 minute base interval. Scheduling variables were correlated with waiting time using correlation coefficients, and data were collected on 1783 appointments. The best waiting time (mean +/- SD) was 17.33 +/- 19.19 minutes. The mean appointment duration for this group was 17.99 +/- 7.97 minutes. The F statistic comparing the four groups of sessions for waiting times was 34.14 and for appointment duration was 37.37, both of which are significant (P < 0.001). The Spearman correlation coefficient for waiting time with queue was 0.2474 (P < 0.001). The Spearman correlation coefficients for mean waiting time and lateness of starting a session (0.4530), patients per hour (0.3461), and patients per session (0.3674) were all significant (P < 0.001). Both scheduling and patient flow affect patient waiting times. The best schedule would consist of shorter sessions that started on time and were extended to accommodate extra patients rather than adding in patients and crowding the schedule. In addition to reducing the actual waiting times, the perception of waiting can be managed to minimize patient dissatisfaction. PMID- 10179924 TI - Infertility services and managed care. AB - The birth of the McCaughey septuplets in Iowa in November 1997 brought issues of fertility assistance and their potential outcomes to worldwide attention. This Pergonal-stimulated multiple pregnancy ended successfully, but not without health hurdles and economic consequences for the new siblings and their family. This article reviews the general situation surrounding infertility services and, within the current debate of epidemiological, economic, legal and social issues, posits that managed care may be able to make greater strides than the present fee for-service system in providing more accessible and comprehensive care to the 5.3 million US citizens at risk for infertility. Our conclusions suggest that managed care plans for infertility can aid in assuring quality and decreasing unnecessary costs. Managed care organizations should take the lead in providing infertile couples with an organized, humanistic approach that is mindful of the attending social issues. On May 5, 1997, a US District court in Chicago ruled that infertility fits the definition of a disability, and thus is subject to the antidiscrimination enforcement under the Americans with Disabilities Act. PMID- 10179925 TI - The development and implementation of normal vaginal delivery clinical pathways in a large multihospital health system. AB - The entire country has become more concerned with healthcare costs due to managed care, capitation risk-based contracts, and the near elimination of the cost-plus reimbursement system. Clinical pathways have become one way to reduce unnecessary resource consumption by reducing provider variance, improving clinical outcomes, and reducing cost. We present here our rationale and process for developing a common clinical pathway for normal vaginal delivery in a large and varied multihospital system. We also discuss how this new pathway is expected to improve quality of care and reduce costs. PMID- 10179926 TI - Nonhormonal alternatives to treating menopausal symptoms. PMID- 10179927 TI - Patient satisfaction and quality of life humanistic outcomes. PMID- 10179928 TI - Drug companies poised to enter risk contracting arena. PMID- 10179929 TI - IDSs must tread carefully to avoid capitation land mines. AB - Having a terrific risk contracting game plan doesn't necessarily spare an integrated health system from the land mines of the marketplace, as an organization in suburban Philadelphia has learned. PMID- 10179930 TI - Contact capitation provides entry vehicle for specialty carve-out organization. AB - Mental health providers affiliated with a St. Louis, MO, academic institution are using a form of contact capitation to succeed at risk contracting. Here are the critical factors that make it work. PMID- 10179931 TI - Commercial, Medicare expense trends expected to shift course. AB - Data Insight: Over the past few years, private-sector health expenditures have been held to historic lows while Medicare costs have soared. That's about to change, according to Milliman & Robertson projections. PMID- 10179932 TI - Percent-of-premium partnerships not living up to their promise. AB - Despite noble efforts all around, the early experience of a Providence, RI, health plan illustrates the difficulties in managing physician-driven programs based on percent-of-premium contracts. PMID- 10179933 TI - Street smarts. Guidelines to safety for home care aides. AB - Home care aides--perhaps more than professionals--have to take a number of precautions to stay safe on the job. Part of the responsibility for keeping them safe falls to the agency that employs them. But a good deal of the responsibility is up to the individuals themselves. There's a lot the street smart home care aide can do to ensure his or her own safety on the job. PMID- 10179934 TI - Foster family care: an innovative home care option. AB - Home care agencies can extend the range of long-term care service they provide by including foster family care. With this care option, clients move into host homes, where they receive room, board, and other necessary care. Foster family care is yielding benefits to clients, care providers, and agencies alike--and it's helping to achieve long-term care cost savings. PMID- 10179935 TI - Antibiotic-resistant bacteria: safe practices. AB - Home care providers need to be aware of the rise of antibiotic-resistant bacteria. Since providers will be servicing an increasing number of patients with these antibiotic-resistant organisms, they must protect their paraprofessionals with this newfound knowledge. PMID- 10179936 TI - Therapeutic touch is back. AB - Healing or therapeutic touch is nothing new; in fact, certain civilizations have been using it for ages. But more and more practitioners are viewing it as a complement to today's high-tech medical care. By integrating the use of therapeutic touch into their home and hospice settings, caregivers are benefitting patients and themselves. PMID- 10179937 TI - Professionalization of home care aides in The Netherlands. AB - In The Netherlands, as elsewhere in the world, home care strives to keep patients home as long as possible. Home care aides play a large role in this effort, and the government has begun programs to make their jobs more professional. PMID- 10179938 TI - Home care in Romania: a whole new concept. AB - Home care is a new and somewhat foreign concept in Romania. An innovative new program is assembling multidisciplinary teams of doctors, nurses, social workers, and a group new to Romania-home care aides-to provide home care. Intensive training is yielding positive results. PMID- 10179939 TI - Comprehensive home care in the Czech Republic. AB - In the Czech Republic comprehensive home care encompasses many services. The overall focus is on providing a mosaic of care to help maintain each patient's quality of life. PMID- 10179940 TI - Home care in Belgium: collaboration is key. AB - Collaboration between four basic disciplines is essential to the practice of home care in Belgium. General practitioners, nurses, home care aides, and centers for social welfare team up to respond to the country's growing need for home care services. PMID- 10179941 TI - Canada: Saskatchewan underutilizes home care. PMID- 10179942 TI - CPR: a systematic design for change. AB - Major changes such as prospective payment and managed care are rocking the boat for today's home care providers. To stay afloat a number of providers are redesigning their organizations. Using Core Process Redesign, a team-based methodology for improving what, where, and how work is done in an organization, one agency saved nearly a half million dollars in one year. PMID- 10179943 TI - Home care aides: are we doing enough? PMID- 10179944 TI - The entrepreneurial spirit and home care aides. AB - Emphasis in the home care industry is being placed on the development of private services in home care. Traditional management characteristics are necessary for this, but so are entrepreneurial ways of thinking--and those may come from all levels of an organization, even and especially home care aides. PMID- 10179945 TI - The rewards of getting to know the community. PMID- 10179946 TI - Mental Health Parity Act of 1996: summary of the interim rules relating to group health plans. AB - The recently released interim rules that govern how group health plans should implement the parity requirement under the Mental Health Parity Act of 1996 (MHPA) are of particular interest to self-funded multi-employer plans. Plans that have not yet been reviewed for MHPA compliance should consider initiating a review as soon as possible. There is no delayed effective date for compliance by multi-employer plans and in addition, a participant or beneficiary could file an action to enforce MHPA's parity requirement. PMID- 10179947 TI - Medical coverage for local national employees in the Czech Republic, Hungary, Poland and Russia. AB - Employers that must provide medical benefits for employees in Russia and other Eastern European countries cannot try to match the coverage they provide in the United States. This article, which focuses on the Czech Republic, Hungary, Poland and Russia, summarizes the medical benefits provided by each government's social security system, describes other means of accessing medical care in these countries and outlines the insured supplemental benefit plans that may be available to employers in the local market. PMID- 10179948 TI - Changing health care, one phone call at a time. AB - Demand management is an approach to providing health care benefits that is designed to help beneficiaries receive the appropriate level of care at the appropriate time. When this is accomplished, health care expenditures are reduced. This case study shows how a large union health plan implemented a demand management program that has been well received by its members and has been effective in helping to control plan costs. PMID- 10179949 TI - Quality assurance in managed vision benefits. AB - Quality assurance is an important responsibility of those who purchase managed vision care benefits. In conducting a quality assurance program, it is important to respect patient confidentiality and the practitioner's right to exercise professional discretion. An effective program will not only accomplish its main objective of attaining high-quality care, but it can also enhance member satisfaction and improve provider relations. PMID- 10179950 TI - How the boss affects special events. PMID- 10179951 TI - When board members don't give.... PMID- 10179952 TI - Trading up. AB - This article describes three areas of development which, if understood and thoughtfully pursued, will bring more gift dollars to your organization or institution. Consider these triple procedures and build a solicitation program which makes good use of each. PMID- 10179953 TI - The secret of campaign success. How Kansas Special Olympics raised $1.35 million. AB - Non-profits can spend so much time concentrating on how they will reach their goal, that they forget who will help get them there. For Kansas Special Olympics (KSO), the secret to raising a million dollars had as much to do with the people as it did the process. PMID- 10179954 TI - Raising planned gifts through a campaign framework: it works but be careful!! AB - Many years ago, planned giving was characterized as low key and troubled by a lack of closure. Today, planned giving officers are feeling the pressure that all fund raisers face for immediate fund-raising results and more aggressive fund raising methods. PMID- 10179955 TI - Take a tip from Uncle Sam: give more, gain more. An interview with C. Paul Tyborowski. PMID- 10179956 TI - Powerful fund-raising letters--from A to Z. Part 2. AB - Despite all the new technology and media we have available today, the letter remains one of the best ways to solicit funds from a wide audience. It's personal, direct, and cost-effective. PMID- 10179957 TI - Now the doctors want a union. PMID- 10179958 TI - Using hospitalists to save money and attract patients. PMID- 10179959 TI - Consolidation will continue to shape the future of health care. PMID- 10179961 TI - Legal and tax implications of converting excess hospital space to alternative uses. PMID- 10179960 TI - Former Columbia/HCA physicians open new hospital and old wounds. PMID- 10179962 TI - The customer satisfaction dilemma facing managed care organizations. PMID- 10179963 TI - Integrated systems own more providers. PMID- 10179964 TI - Using EDI for federal payments. PMID- 10179965 TI - Data trends. Key organizational performance indicators. PMID- 10179967 TI - Does employment-based healthcare coverage have a future? PMID- 10179966 TI - Adult average length of stay for acute care hospitals. PMID- 10179968 TI - The role of information systems in IDS-physician relationships. AB - The success of integrated delivery systems (IDSs) depends on their ability to develop collaborative relationships with affiliated physician practices. As a long-term strategy, IDSs should develop sophisticated information systems that help their physician practices to effectively manage wellness and disease across the continuum of care. These information systems eventually should include a broad range of features, including systemwide access to communications technologies, such as e-mail and groupware, computer-based alerts and reminders to support wellness management, immediate access to hospital data from physician offices, and automated care guidelines. To address the immediate needs of affiliated physicians, however, IDSs should attempt to optimize the functionality of their existing communications systems, such as fax links and manual processes. PMID- 10179969 TI - How can IDSs integrate conflicting cultures? AB - Many integrated delivery systems (IDSs) perform poorly because of cultural differences of their constituents. To reconcile such differences and start to develop one unifying culture, IDSs need to promote a set of cultural values and expectations that support the entire enterprise. Creating a unified, functional culture is a complex process that ranges from identifying the organization's strategic aims and assessing current cultures in light of those aims, to being courageous and consistent in demonstrating the organization's values. PMID- 10179970 TI - Is your organization operationally ready to be a Medicare PSO? AB - Providers that wish to form a provider-sponsored organization to contract directly with Medicare need to assess their operational capabilities to determine whether such a plan can be successful. Areas that need to be examined include administrative and financial expertise, contract management capabilities, clinical and administrative medical management, information management, and continuum of care components. While many of the operational capabilities required to operate a PSO may be appropriately provided by an unrelated third party, some capabilities can be delivered most effectively by the PSO itself. PMID- 10179972 TI - Mitchell: we must recognize change as a way of life. PMID- 10179971 TI - New HCFA regulations clarify PSO requirements. AB - In March and April of 1998, HCFA promulgated regulations regarding various requirements for provider-sponsored organizations (PSOs). These regulations define what constitutes an affiliated provider to a PSO, identify what percentage of services must be provided directly to beneficiaries by PSO affiliated providers, define what constitutes provider ownership in a PSO, and set minimum capitalization and liquidity standards for PSOs. PMID- 10179973 TI - Using artificial intelligence to automate remittance processing. AB - The consolidated business office of the Allegheny Health Education Research Foundation (AHERF), a large integrated healthcare system based in Pittsburgh, Pennsylvania, sought to improve its cash-related business office activities by implementing an automated remittance processing system that uses artificial intelligence. The goal was to create a completely automated system whereby all monies it processed would be tracked, automatically posted, analyzed, monitored, controlled, and reconciled through a central database. Using a phased approach, the automated payment system has become the central repository for all of the remittances for seven of the hospitals in the AHERF system and has allowed for the complete integration of these hospitals' existing billing systems, document imaging system, and intranet, as well as the new automated payment posting, and electronic cash tracking and reconciling systems. For such new technology, which is designed to bring about major change, factors contributing to the project's success were adequate planning, clearly articulated objectives, marketing, end user acceptance, and post-implementation plan revision. PMID- 10179974 TI - Pitfalls to avoid when merging information systems. AB - When healthcare organizations merge, their goal often is to improve operational efficiencies, with information systems (IS) a common target for cost reduction. These cost reductions usually are achieved by reducing staff, consolidating data centers, establishing standardized systems, and sharing resources throughout the system. During this process, however, several common pitfalls can cause merging organizations to stumble. By carefully evaluating their options, merging organizations can avoid these potential traps and reduce their IS costs. PMID- 10179975 TI - Combining accounting approaches to practice valuation. AB - Healthcare organizations that wish to acquire physician or ambulatory care practices can choose from a variety of practice valuation approaches. Basic accounting methods assess the value of a physician practice on the basis of a historical, balance-sheet description of tangible assets. Yet these methods alone are inadequate to determine the true financial value of a practice. By using a combination of accounting approaches to practice valuation that consider factors such as fair market value, opportunity cost, and discounted cash flow over a defined time period, organizations can more accurately assess a practice's actual value. PMID- 10179976 TI - Managing mergers without alienating physicians. AB - Mergers and acquisitions have become perhaps the most pervasive and important business activity in the healthcare industry. Physicians, however, frequently dread becoming involved in mergers because they fear loss of autonomy, income, and even their jobs. In merged organizations, the best managers look for ways to extend the benefits of mergers to physicians to prevent them from perceiving themselves as victims and becoming alienated from the organization. PMID- 10179977 TI - Reforming home health care. AB - The Balanced Budget Act of 1997 currently limits Medicare payments to home health agencies through an interim payment system and authorizes future implementation of a prospective payment system. These new payment systems and the growing influence of managed care are forcing home health agencies to make difficult decisions about restructuring their organizational philosophies and operations to create a more cost-conscious environment. PMID- 10179978 TI - Flexibility key to group practice in the age of managed care. AB - As changes in payment occur and managed care evolves, group practices are reclaiming influence over clinical care by assuming greater financial risk. Larger groups are becoming a force for change by using flexible structures to help improve a host of activities at the point of care. Group practices and their collaborative partners are refining their approaches to cooperative patient management, clinical utilization and quality, and risk contracting. PMID- 10179979 TI - Are buy-in/buy-out arrangements hurting group practice? AB - Historically, group practices engaged in expensive buy-in and buy-out arrangements for their physicians. These arrangements often served the group's original physicians well, but left newer physicians with little equity in the practice when the older physicians retired. Many groups are restructuring their buy-in and buy-out arrangements to account for both a physician's original financial contribution to the practice and the physician's share of patient receivables. Groups also are setting up qualified retirement plans that are separate from their buy-out arrangements. PMID- 10179980 TI - Physicians and administrators may be ready to embrace profiling. PMID- 10179981 TI - New year sees two hospital infant kidnappings in one month. PMID- 10179982 TI - Med center: pre-fab smoking shelters have reduced enforcement problems. PMID- 10179983 TI - Using ID badges to replace keys, control scrub usage. PMID- 10179984 TI - Product update: infant monitoring systems. PMID- 10179985 TI - The ice storm of the century: how affected hospitals and communities dealt with the challenges of a unique, prolonged emergency. AB - A huge ice storm in early January 1998 caused severe damage in northern New York and parts of Maine and Canada. The storm, which lasted in some areas for several weeks and is being called the "storm of the century," led to 30 deaths (many from carbon monoxide poisoning); closed roads and schools; downed thousand of trees and power lines; and left hundreds of thousands without electricity. In this report, we'll present details on how hospitals in these three locations which were declared disaster areas were affected by the storm as well as the measures that they and their security departments took to help patients, staff, and their communities. PMID- 10179986 TI - Passing a JCAHO environment of care survey: one hospital's experience. PMID- 10179988 TI - Hospital installs 'hands-free' parking system for its physicians. PMID- 10179987 TI - CPSC sues to force recall of 8 million Omega sprinkler heads. PMID- 10179989 TI - How Bermuda's general hospital has reduced after-hours security risks. PMID- 10179990 TI - Achieving a more secure emergency department 'by design'. PMID- 10179991 TI - Behavior-based safety: a replacement for prizes or bribes? PMID- 10179992 TI - Conducting employee background checks: new responsibilities, new resources, new pitfalls. AB - Growing legal and regulatory pressures are being applied to healthcare institutions to do a better job of screening job applicants--whether they are physicians, nurses, housekeepers, or security officers. In the past, the hiring of employees who turn out to have criminal pasts has sometimes proven both costly and embarrassing to hospitals, as this report reveals. However, while there are now many resources available to uncover an applicant's criminal record, there are pitfalls to be aware of when conducting or hiring an outside firm to conduct background checks. PMID- 10179993 TI - Medicare fee-for-service issues and innovations. PMID- 10179994 TI - Case management, client risk factors and service use. AB - Six "pure" types of case-manager activity are identified using chart data from 922 cases in the Medicare Alzheimer's Disease Demonstration. The association between case-manager actions and client characteristics, and between case-manager activities and service use outcomes is used to test predictive validity. Case manager activity is generally more associated with caregiver than client characteristics. Monitoring and service management was protective against nursing home placement. A clinical nursing emphasis was protective against hospitalization. Understanding how case management is differentiated may improve staffing, treatment protocol, and client service outcomes. PMID- 10179995 TI - General health of end stage renal disease program beneficiaries. AB - A telephone survey of a national sample of 515 Medicare End Stage Renal Disease Program beneficiaries was conducted to obtain information on their health status and its determinants. The Medical Outcomes Study Short Form-36 (SF-36) was applied during the interview process to obtain the health-status information. The reliability of each SF-36 health-status dimension was at least 0.85, and the validity of seven of the eight dimensions was high. Weighted least-squares regression results showed that health-status levels were often lower among older patients and Hispanic persons, and sometimes lower for those with low incomes. The implications of using the SF-36 for health-status measurement are also described. PMID- 10179996 TI - Uninsured spells of the poor: prevalence and duration. AB - The number of persons without health insurance is increasing. Although research has focused on the uninsured poor and the duration of spells without health insurance, less attention has been paid to the dynamics of spells without health insurance among those in poverty. Here it is shown that the typical uninsured spell is longer for the uninsured poor (roughly 8.3 months) than for the uninsured non-poor (roughly 6 months) and that the duration of spells has increased over time. In addition, more than 40 percent of the uninsured at a point in time are chronically uninsured and poor or near-poor. PMID- 10179997 TI - National health expenditures, 1996. AB - The national health expenditures (NHE) series presented in this report for 1960 96 provides a view of the economic history of health care in the United States through spending for health care services and the sources financing that care. In 1996 NHE topped $1 trillion. At the same time, spending grew at the slowest rate, 4.4 percent, ever recorded in the current series. For the first time, this article presents estimates of Medicare managed care payments by type of service, as well as nursing home and home health spending in hospital-based facilities. PMID- 10179998 TI - Impact of Medicare SELECT on cost and utilization in 11 states. AB - In this article, the authors evaluate the cost and utilization effects of the SELECT implementations in 11 States. In particular they compare the before-and after enrollment experiences of Medicare beneficiaries newly enrolled in SELECT plans with the experiences of those newly enrolled in traditional medigap plans. Using Medicare claims data for 1991 through 1994, the authors find that Medicare SELECT increased costs in five States, decreased costs in three States, and had no effect in three States. Cost increases were generally related to Part B utilization. PMID- 10179999 TI - Trends in Medicare supplementary insurance: 1992-96. PMID- 10180000 TI - Hospital, employment, and price indicators for the health care industry: first quarter 1997. PMID- 10180001 TI - Cost savings and physician responses to global bundled payments for Medicare heart bypass surgery. AB - In 1991 the Health Care Financing Administration (HCFA) began the Medicare Participating Heart Bypass Center Demonstration, in which hospitals and physicians are paid a single negotiated global price for all inpatient care for heart bypass patients. During the first 27 months of the demonstration, the Government and beneficiaries together saved more than $17 million on bypass surgery in four participating institutions. Average total cost per case fell in three of the four hospitals during the 1990-93 period as the alignment of physician and hospital incentives resulted in physicians changing their practice patterns to shorten stays and reduce costs. PMID- 10180003 TI - Developing Medicare competitive bidding: a study of clinical laboratories. AB - Competitive bidding to derive Medicare fees promises several advantages over administered fee systems. The authors show how incentives for cost savings, quality, and access can be incorporated into bidding schemes, and they report on a study of the clinical laboratory industry conducted in preparation for a bidding demonstration. The laboratory industry is marked by variable concentration across geographic markets and, among firms themselves, by social and economic heterogeneity. The authors conclude that these conditions can be accommodated by available bidding design options and by careful selection of bidding markets. PMID- 10180002 TI - Effects of supplemental coverage on use of services by Medicare enrollees. AB - This article estimates the extent to which private insurance supplements affect use of services by Medicare enrollees. Three types of supplements to Medicare's coverage are examined--Health Maintenance Organizations (HMOs), medigap (MGP) plans, and employment-based indemnity (EBI) plans. While each kind of supplement reduces cost sharing on Medicare-covered services, only HMOs do so without increasing enrollees' overall use of services. Use of services by HMO enrollees is about 4 percent lower than use by similar Medicare enrollees with no insurance supplement. By contrast, use of services by enrollees with MGP coverage is 28 percent higher, and use of services by enrollees with EBI plans is 17 percent higher. PMID- 10180005 TI - Performance indicators. All quiet on the front line. AB - Managers interviewed in hospital trusts, health authorities and regional offices believed performance indicators to be broadly helpful. But our study found evidence that the role of the current performance indicators is distinctly limited. The indicators are primarily used to highlight instances of exceptionally poor performance. Frontline staff, such as junior doctors, are often largely unaware of performance indicators. Performance indicators have led to misrepresentation and manipulation of data. PMID- 10180006 TI - Health Policy. Fair shares for all. AB - Where services are resource-limited, they will be targeted at those in poverty. The HA will invest in programmes that provide the maximum health gain and the greatest reduction in health inequality. The HA will map and audit the distribution of poverty and of service provision and redirect services to reflect identifiable need. The HA will adopt an 'anti-poverty effect' measure as an indicator of service quality. PMID- 10180004 TI - A modular case-mix classification system for medical rehabilitation illustrated. AB - The authors present a modular set of patient classification systems designed for medical rehabilitation that predict resource use and outcomes for clinically similar groups of individuals. The systems, based on the Functional Independence Measure, are referred to as Function-Related Groups (FIM-FRGs). Using data from 23,637 lower extremity fracture patients from 458 inpatient medical rehabilitation facilities, 1995 benchmarks are provided and illustrated for length of stay, functional outcome, and discharge to home and skilled nursing facilities (SNFs). The FIM-FRG modules may be used in parallel to study interactions between resource use and quality and could ultimately yield an integrated strategy for payment and outcomes measurement. This could position the rehabilitation community to take a pioneering role in the application of outcomes based clinical indicators. PMID- 10180007 TI - Mental health. Time for a meeting of minds. AB - The policy agenda for mental health services requires managers to develop new skills. The government's overriding concern to restore confidence in the mental health system will demand that managers promote greater public understanding of services. Proficiency in working with other organisations will be crucial to success. PMID- 10180008 TI - Trust mergers. Turning threats into opportunities. AB - A survey of senior health staff in Wales shows widespread scepticism about the benefits of trust mergers. Trust mergers in Wales may fail because those responsible for making them work do not believe they can succeed. Benefits will only be realised if the post-merger process is addressed in such a way as to gain staff commitment. PMID- 10180009 TI - Research and development. University challenge. AB - Health service managers are moving into university research and development posts, bringing extra funds in their wake, and getting a chance to work more analytically and reflectively. PMID- 10180010 TI - CHA: an intentional community. PMID- 10180011 TI - Remember the uninsured? PMID- 10180012 TI - CHA Website continues to expand. PMID- 10180013 TI - The common good: can it make a difference? PMID- 10180014 TI - New paths in end-of-life care. PMID- 10180015 TI - Coordinating care in Oregon. PMID- 10180016 TI - A poor handmaid's tale. Sr. Stephen Brueggeman sees Catholic healthcare bringing equality to church life. Interview by Gordon Burnside. PMID- 10180017 TI - Protecting patients' privacy. Health information networks raise new questions. AB - Privacy is established as both a value and a right in our society, and as healthcare moves to improve quality and efficiency through the development of health information networks, which allow the electronic exchange of financial and clinical information, there will be a growing awareness of the necessity to protect patient privacy and confidentiality in these environments. Dealing with these concerns will require that healthcare providers take steps to ensure the security of patient information through technological and physical measures, programs of orientation and education, and the careful development and implementation of clear policies and procedures. PMID- 10180018 TI - The voyage of discovery. Today's pastoral care professionals fnd many new roles. PMID- 10180019 TI - Unified pastoral care. Formerly separate departments are linked as a single entity. PMID- 10180020 TI - Spiritual care network model. Catholic Health Initiatives creates regional structure. PMID- 10180021 TI - The spiritual wellness paradigm. A new approach for long-term care organizations. PMID- 10180022 TI - Pastoral care in a long-term care setting. St. Joseph's Manor exemplifies a strong commitment to serving the needs of all. PMID- 10180023 TI - Spiritual care at the end of life. Hospice uses teamwork to address spiritual and physical needs. PMID- 10180024 TI - The unbroken circle. Parish nursing is becoming an important stage in the healthcare continuum. PMID- 10180025 TI - Year 2000 issues in the healthcare setting. Prepare now for worst-case scenarios. AB - Healthcare managers must ensure their organizations are addressing Year 2000 (YK2) computer concerns, which can affect both internal and external operations, from patient monitoring to accreditation. Strong planning initiatives and legal counsel are necessary to resolve YK2 and computer vendor issues. Directors and trustees should follow "prudent person" standards to avoid liability but must take an active role with managers to form a YK2 committee, retain professionals to prepare for operation failures, and explore insurance availability. As 2000 approaches, computer systems will start to malfunction on unpredictable dates. Catholic providers must act now or review their current efforts. PMID- 10180026 TI - New opportunities for provider/insurers. Catholic healthcare organizations are well positioned for direct contracting. AB - Congress and a number of state governments have recently taken steps to encourage the formation of provider/insurer networks and other forms of "direct contracting" by providers with consumers. No group is better positioned than Catholic hospitals and medical centers, with their common heritage, not-for profit status, and history of community service, to take advantage of direct contracting opportunities. Provider/insurer configurations fall into three categories: self-policing networks that assume full-risk contracts from payers; joint ventures between provider networks and existing insurance companies or HMOs; and provider networks that establish their own insurance capability. Anticipated changes in many states' insurance application processes will make it easier for providers to choose the latter option. The keys to a successful provider/insurer plan are differentiation from other insurance products in the market and a strong, consumer-friendly image. The involvement of physicians is vital, and the majority of physicians on any one hospital's staff should be members of the provider/insurer network. Currently, the Medicare population, rather than the commercial sector, is a good choice for a beginning provider/insurer network to cover. While such networks may be driven by either physicians or hospitals, a joint initiative by physicians and hospitals is preferable. Successful implementation of highly evolved medical management systems and related operational support is also key. PMID- 10180028 TI - Integrated delivery systems: six tough questions. PMID- 10180027 TI - Creating a corporate compliance program. Steps to a program that reinforces mission and protects the organization. PMID- 10180030 TI - "Fast tracking" of patients through PACU: is it safe? PMID- 10180029 TI - Questions, but few answers on new outpatient payment. PMID- 10180031 TI - Patients' needs guide to redesign. PMID- 10180032 TI - Efficiencies gained with standardization. PMID- 10180033 TI - What will work for pressure ulcers? PMID- 10180035 TI - Improving performance in cataract surgery. PMID- 10180034 TI - Nosocomial infection rates rise 36%. PMID- 10180036 TI - Stark, antikickback laws, and the OR. PMID- 10180037 TI - Key decisions on device reprocessing. PMID- 10180038 TI - General surgeons stick with disposables. PMID- 10180039 TI - ECRI advises on AbTox Plazlyte system. PMID- 10180040 TI - Details improve view of consolidated billing. PMID- 10180041 TI - Feds create recipe for managed care. Budget Act encourages enrollment of elderly in managed care plans. PMID- 10180042 TI - Combining comfort with functionality. Furniture designers achieve residential look. PMID- 10180043 TI - Design and construction firms survey. PMID- 10180044 TI - And the good news is.... a provider that makes the effort to meet local reporters during good times has a better chance of a balanced story if a crisis occurs. PMID- 10180045 TI - Growing a compliance culture. PMID- 10180046 TI - Directors of nursing take charge. PMID- 10180047 TI - Detecting depression. PMID- 10180048 TI - Plugging in to MDS/PPS. PMID- 10180049 TI - Computer-aided readings improve diagnostic accuracy. RSNA's large-scale observational test makes the case. PMID- 10180050 TI - Aetna outsources radiology services utilization review. PMID- 10180051 TI - Quality does not ensure breast center profitability. PMID- 10180052 TI - Radiology well suited to exploit Net's power. PMID- 10180053 TI - Ultrasound takes on musculoskeletal MRI. PMID- 10180054 TI - Barium enema struggles against high-tech rivals. PMID- 10180055 TI - Momentum growing for carotid stent placement. PMID- 10180056 TI - Cable guys. Harborview Medical Center designs flexible communications infrastructure to support evolving technologies. PMID- 10180057 TI - JCAHO in demand abroad. PMID- 10180058 TI - Plotting the payoff. How to pack your long-range plan with buy-in. PMID- 10180059 TI - Connecting constellations. What does an 'enterprise solution' solve? PMID- 10180060 TI - Buried in Babel. PMID- 10180061 TI - What's the ROInfo (return on information) in MCOs (managed care organizations)? PMID- 10180062 TI - Northern California. Charting the future of reform. PMID- 10180063 TI - Focus on San Francisco. UCSF Stanford Health Care breaks tradition. PMID- 10180064 TI - Focus on San Francisco. Kaiser Permanente seeks salvation in IT. PMID- 10180065 TI - Power to the people. Technology strategies can boost population health management. PMID- 10180066 TI - Healthcare consumers seize market power. PMID- 10180067 TI - The bug stops here. Year 2000 is a business problem, not an IT problem. PMID- 10180068 TI - Gotta have IT. PMID- 10180069 TI - Top 100 results reflect industry growth and consolidation. PMID- 10180070 TI - Healthcare financials. A diverse group of providers. PMID- 10180071 TI - Europeans ready for privacy law. PMID- 10180072 TI - Lookout for lemons. How to buy an electronic medical record system--without getting sold. PMID- 10180073 TI - Fixing the bug. Eight steps to building a year 2000 action plan. PMID- 10180074 TI - From accountability to profitability. Good information helps CFOs keep capitation dollars from dwindling to a trickle. PMID- 10180075 TI - The envelope please. 1997 HITS (Healthcare Innovations in Technology Systems) Partnership in Technology Award winners share the goals of improving patient care and improving outcomes. PMID- 10180076 TI - Real-time claims resolution. Re-engineering how we process and pay for healthcare. AB - A Preferred Provider Organization with about 9,000 providers in three states. PROBLEM: A fragmented and confusing healthcare payment and processing system, which ultimately hurts everyone, the patient, the provider and the payor. SOLUTION: Create a real-time claims resolution system which links everyone for quick payment of the claim at the point of service. RESULTS: Reduces paper and accelerates the claims cycle. KEYS TO SUCCESS: "Re-engineer the current system of processing and paying healthcare claims with a business model that economically benefits all parties." PMID- 10180077 TI - Vision quest. Our journey toward the CPR is just beginning. PMID- 10180078 TI - A faster, multimedia Internet? PMID- 10180079 TI - The eyes have it. CCOW (Clinical Context Object Workgroup) brings both cooperation and competition together to tackle visual integration. PMID- 10180080 TI - Decision support decisions. Competition is squeezing payors into making better decisions. PMID- 10180081 TI - Number crunching. Morphing financial and healthcare markets places new demands on financial applications. AB - Competition between best-of-breed and HIS vendors heats up in response to changing financial needs and new business models; both face the challenges of integration. Patient receivables benefits from borrowed business models. PMID- 10180083 TI - Professional competence; towards business benefits. PMID- 10180082 TI - The main event. The fight no longer is mainframe vs. client/server, but which system wins for which project. PMID- 10180084 TI - How to improve a hospital's energy consumption--a recipe without need for investment. PMID- 10180086 TI - PAT secure the Freeman. PMID- 10180085 TI - Recent advances in ionisation technology provide direct benefit to Charing Cross Hospital water supply. PMID- 10180087 TI - 10 per cent growth in private medical insurance spending in 1996. PMID- 10180088 TI - One in six UK organisations will fail to meet Year 2000 deadline. PMID- 10180089 TI - Mobilising hospital communications at Peterborough hospitals NHS Trust. PMID- 10180090 TI - Responsible management of contractors on gas installation projects. PMID- 10180091 TI - A "new" HAZCOM (hazard communication) has come. PMID- 10180092 TI - First notices of proposed rule making for HIPAA requirements issued. PMID- 10180093 TI - HCFA delays evaluation, management documentation guideline implementation. PMID- 10180094 TI - Practice brief. Issue: data quality management model. American Health Information Management Association. PMID- 10180095 TI - Vision 2006 brings data quality management into view. AB - One of the goals of the vision 2006 initiative has been to identify new career opportunities for HIM professionals. Recently, a group of AHIMA volunteers has provided a framework and tools for developing data quality management expertise. Here's an overview of their work and a look at resources for those who want to learn more. PMID- 10180096 TI - Maximizing data quality of the minimum data set. PMID- 10180097 TI - Ensuring data quality in the pharmaceutical industry. AB - Education and training play a considerable part in efforts to enhance data quality in healthcare. How do other fields work toward data consistency? The author describes how professionals in the pharmaceutical industry manage their data. PMID- 10180098 TI - An introduction to benchmarking health assessment and outcomes through applied statistics. AB - Through the application of some basic statistical techniques, HIM professionals can assist in healthcare benchmarking and management at the organizational level. The author offers an example of how one hospital used data analysis to make decisions that promoted better patient care. PMID- 10180099 TI - Comparative data--its impact and opportunities. PMID- 10180100 TI - Designing the integrated multidisciplinary record review. AB - Good documentation is a cornerstone of data quality. But how can an organization ensure that all disciplines will take responsibility for the comprehensiveness and accuracy of their documentation? The authors describe the steps one facility took to implement a process of record review involving numerous departments. PMID- 10180101 TI - The ORYX and other elusive quality animals. PMID- 10180102 TI - Measurement issues for an adult asthma clinical improvement initiative. PMID- 10180103 TI - HCFA requires use of modifiers for hospital outpatient services. PMID- 10180104 TI - The role of electronic merges in an integrated delivery system. AB - The electronic-only merge method poses a serious challenge to HIM management for ensuring that all clinical documentation for patient care is provided in a timely manner. The organization must be aware of all of the issues affecting the departments so that informed decisions can be made before, during, and after the project. This approach can be successful with comprehensive planning, meticulous procedures for record retrieval and chart folder updating, and extensive staff training. The proactive, traditional merge approach remains the community standard. However, the reactive, electronic-only merge approach has found a niche and can be a viable, cost-effective option when faced with time and budgetary constraints. However, a combination of these approaches may provide the best solution, depending upon an organization's resources, time requirements, and strategic goals. PMID- 10180105 TI - Finding the right alternative medicine practitioners. AB - When Harvard Vanguard Medical Associates decided to partner with alternative medicine providers, the clinic looked for licensed practitioners who expressed a willingness to work closely with allopathic providers. Recommendations from clinic staff provided the initial pool of candidates. PMID- 10180106 TI - Benchmark report compares states, but purchaser data is years away. PMID- 10180107 TI - Health plans, providers struggle with quality in alternative medicine. AB - Consumer demand is pushing many healthcare providers and payers to offer complementary and alternative therapies, from chiropractic to acupuncture, even in the absence of conclusive evidence of their efficacy. To keep patients safe, and to limit costs, organizations are setting strict limits about the type and amount of alternative therapy they will provide. PMID- 10180108 TI - What's different about a PSO? PMID- 10180109 TI - Quality care. Doctors hold the key. PMID- 10180110 TI - Costing out care. Burn now, pay later. PMID- 10180111 TI - Psych disabilities. What's real, what's protected. PMID- 10180112 TI - Data watch. Consumers taking bigger doses of the Internet. PMID- 10180113 TI - The WHO has seen the future, and it's full of good health. PMID- 10180114 TI - The bountiful breast. PMID- 10180115 TI - The doctor lottery. How to choose a physician from your HMO's directory. PMID- 10180116 TI - The road ahead for Medicare managed care: addressing the needs of the chronically ill. PMID- 10180117 TI - Hard choices: the use of Western vs. Chinese traditional medicine by the Chinese homebound elderly, New York City. A community health survey. PMID- 10180118 TI - Client safety in the home. PMID- 10180119 TI - Physician-assisted suicide and euthanasia: the human dimension of legalization. PMID- 10180120 TI - Physician-assisted suicide and euthanasia's impact on the frail elderly from the viewpoint of an Episcopal priest and also a Chinese. PMID- 10180121 TI - Physician-assisted suicide and euthanasia's impact on the frail elderly: autonomy or a license to kill? Some ethical perspectives. PMID- 10180122 TI - Phlebotomy teams reduce blood-culture contamination rate and save money. AB - OBJECTIVE: To determine the extent of resource utilization due to contaminated blood cultures. DESIGN: Case-control retrospective analysis. Twenty-three patients who had contaminated blood cultures were matched by age, underlying diseases, and discharge diagnoses with 23 patients who had negative blood cultures. SETTING: St Luke's Medical Center, a community teaching hospital in Cleveland, Ohio. The phlebotomy team was eliminated in November 1993 to reduce the costs. RESULTS: Blood cultures drawn by the phlebotomy team had a lower contamination rate compared with those drawn by nonphlebotomists (2.6% vs 5.6%). Patients with contaminated blood cultures were compared to those with negative blood cultures. The following parameters were found to be statistically significant: total hospital length of stay (LOS; 13.9 vs 5.5 days; P = .002), postculture LOS (8.9 vs 4.6; P = .01), postculture number of days on antibiotics (5.9 vs 2.9; P = .03), vancomycin use (9 vs 2 patients; P = .03), postculture cost of antibiotics ($762 vs $121; P = .004), and postculture hospital cost per patient ($10,515 vs $4,213; P = .001). CONCLUSIONS: This study demonstrated a substantial increase in resource utilization in our hospital due to contaminated blood cultures. The reinstitution of a phlebotomy team could be a cost-effective solution with savings between $950,000 and $1.5 million per year for our hospital. PMID- 10180123 TI - Variation in the use of breast-conserving therapy for Medicare beneficiaries in Virginia: clinical, geographic, and hospital characteristics. AB - BACKGROUND: Treatment for early-stage breast cancer has evolved significantly in recent years. Breast-conserving therapy (BCT) has been shown to offer equivalent survival compared to traditional mastectomy. However, there is marked variation in the performance of BCT which may not reflect clinical appropriateness or patient preference. Little is known about the factors related to variation in BCT performance in older women with early-stage breast cancer. METHODS: Retrospective claims analysis of 1,512 Medicare patients using part-A data for the years 1992 to 1993, with additional explicit chart review. A clinical algorithm was developed to categorize patients according to their candidacy for BCT and compare this to their treatment. Demographic, clinical, and geographic variables were included in the model. RESULTS: The overall BCT rate in Virginia was 20%, with marked variation among providers of all types. BCT rates ranged from 0% to 44% among hospitals caring for more than 12 cases per year. Twenty-six percent of patients considered good candidates for BCT by current guidelines received this option. Large urban hospitals had significantly higher rates of BCT than smaller hospitals, regardless of the presence of radiation oncology capability. Distance from radiation oncology facilities was a factor in low BCT rates of rural populations, but low BCT rates also were present even in facilities with access to radiation oncology services. CONCLUSIONS: These data present a detailed analysis of the patterns of BCT for Virginia Medicare beneficiaries with early stage breast cancer. Clinical contraindications to BCT for confirmed early-stage disease were uncommon. Despite similar patient profiles and hospital-reported range of cancer services, marked variation in BCT rates exists. A large number of patients chose traditional mastectomy over BCT due to fears of radiation, but few received radiation oncology consultation. BCT rates were highest in hospitals with radiation oncology facilities on grounds; hospitals with facilities nearby had rates similar to those without access to radiation facilities. Patient preferences are documented poorly. This study provides further evidence that many women are receiving BCT in patterns that may not reflect clinical appropriateness for BCT nor access to necessary facilities. PMID- 10180124 TI - Handwashing practices in a tertiary-care, pediatric hospital and the effect on an educational program. AB - OBJECTIVE: To study the frequency of handwashing and the effects of an educational program. DESIGN: A prospective study. SETTING: A tertiary-care, pediatric hospital. PARTICIPANTS: Three divisions (two general pediatric wards and one infectious disease ward). The personnel observed included 60 medical staff (interns, residents, and attending, including consulting, physicians), 37 nurses, and 15 paramedical staff. INTERVENTIONS: The study was carried out in 5 phases: (1) unobtrusive observation to obtain a baseline handwashing rate; (2) observation after written notification; (3) observation after providing motivating devices: movies, brochures, posters; (4) discontinuation of observation and motivation; (5) unobtrusive observation, to obtain a residual handwashing rate. RESULTS: During this study, 1,123 patient contacts were observed. The baseline handwashing rates before and after patient contact were 52% and 49%, respectively. During phase 2, handwashing rates before and after patient contact increased slightly to 56% and 52%, respectively. During phase 3, rates increased to 74% and 69% (P < .01). However, rates fell during the final phases to 49% and 52%, respectively (P < .01). There were no significant differences among hospital staff in any phase of this study (P > .05). CONCLUSIONS: Constant motivation, using movies, brochures, and posters, transiently increased the frequency of handwashing among the house staff of a tertiary-care facility; however, to be effective, this motivation needs to be sustained. PMID- 10180125 TI - Variation in mortality among seven hemodialysis centers as a quality indicator. AB - OBJECTIVES: To identify patient attributes that were associated with increased mortality; variables that were associated with process of care that were correlated with mortality; and outlier centers after adjustment for patient attributes. DESIGN: Standard interviews were conducted by trained nurses with all patients. Detailed information regarding primary renal diagnosis, comorbidity, and results of laboratory tests were obtained from the medical charts. The vital status of the patients was obtained from the records of each of the centers. We used the Cox hazard method to identify variables that correlated with a 1-year mortality. Centers with observed mortality exceeding the 95% confidence interval (CI95) of the expected probability of death were marked as outliers. SETTING: Seven dialysis centers located in large teaching hospitals in Israel. PATIENTS: The current study included patients > 16 years of age who had undergone hemodialysis > 4 weeks prior to the day of data collection. RESULTS: The study included 564 patients. Significant differences were found in patient demographics and process variables among the centers. The following variables correlated with mortality; diabetes (odds ratio [OR], 2.03; CI95, 1.28-3.21); ischemic heart disease (OR, 2.2; CI95, 1.39-3.49); each year of age (OR, 1.04; CI95, 1.02-1.06); each 1 g% of albumin (OR, 0.51; CI95, 0.30-0.86). The average observed mortality in all centers was 17.4%. After adjustment for casemix, one center showed excess mortality (24% observed compared to 15% expected after adjustment for patient attributes; CI95, 6.2-23.7). CONCLUSIONS: The ability to compare mortality rates among dialysis centers to detect possible quality outliers depends on thorough consideration of patient attributes and random variation. PMID- 10180126 TI - The use of a quality-improvement approach to reduce needlestick injuries in a Saudi Arabian hospital. AB - OBJECTIVE/DESIGN: An increase was noted in the incidence of needlestick injuries in our institution. A retrospective study was carried out analyzing the accident reports and medical records of needle-stick injuries from January 1995 to July 1996. Study variables included monthly incidence; location; injury site; mechanism; staff vocational status; source virological status; staff immunity; and serological conversion to hepatitis B and C viruses and the human immunodeficiency virus (HIV). SETTING: 350-bed general hospital in Western Saudi Arabia employing 2,083 employees of many different nationalities. RESULTS: 126 injuries were identified. Thirty percent of injuries occurred in the operating room and 28% on general wards. Twenty-five injuries occurred during a surgical procedure in the operating room, 22 injuries were caused by undisposed sharps, 11 occurred during suturing, 11 occurred during injection, and 10 occurred while disposing of refuse. At least 38% of the injuries were avoidable. Sixty percent of those injured were nurses, 30% were medical staff, and 6% were housekeeping staff. Nine of the identifiable sources were hepatitis B surface antigen positive, nine were hepatitis C antibody-positive, and none were anti-HIV positive. Eighty-nine percent of injuries involved the hands. None of our injured employees had seroconverted at 3, 6, or 9 months follow-up to HIV, hepatitis C, or hepatitis B. Eighty-four percent of injured staff were hepatitis B immune. CONCLUSION: Steps taken to reduce the future incidence of injuries included the provision of readily accessible sharps boxes, a hospitalwide education program focusing on safe handling and disposal of sharps, and the development of clear policies and procedures for dealing with sharps injuries. A further study will be conducted 12 months after the introduction of these measures. PMID- 10180127 TI - Assessing quality in home-care programs. AB - As the chronically homebound population increases, more primary-care individuals and groups will be providing care in the home. Assessing and improving the care of this population involves developing strategies to monitor the quality of care provided (for example, using clinical practice guidelines), assessing the efficacy of plans to help prevent decline, and identifying unavoidable negative outcomes. Outcome indicators for this group must be able to discriminate between expected decline and decline that could have been modified by medical intervention. Because of multiple variables not present in institutional settings, in-home care presents a somewhat different situation than care of nursing home residents. PMID- 10180128 TI - Linking claims and cancer registry data: is it worth the effort? AB - Insurance claims and cancer registries represent different sources of data, each with advantages and limitations insofar as describing severity of illness, cost, utilization, and outcome of care for cancer patients. Although registries typically are able to identify stage of disease and initial course of treatment, claims-based data include more detailed information on the cost and utilization of medical-care services. Moreover, claims data can provide critical information about the use and location of medical services prior to diagnosis of cancer. The purpose of this paper is to argue the advantages of merging claims with registry data by considering evidence and insights from the literature. We discuss the advantages and disadvantages of claims data, describe studies that compare claims and registry data, and highlight the advantages of linking both sources of data. The latter is accomplished by considering a major advantage of each source of data. Registry data contain useful measures of severity of illness (cancer stage, tumor size, and sites of metastasis), whereas claims data include a detailed history of the cost of medical service. PMID- 10180129 TI - Medicare program; incentive programs-fraud and abuse--HCFA. Final rule with comment period. AB - This final rule with comment period establishes a program for payment to individuals who provide information on Medicare fraud and abuse or other sanctionable activities. This final rule implements section 203(b) of the Health Insurance Portabilty and Accountability Act of 1996. PMID- 10180130 TI - Dissemination of information on unapproved/new uses for marketed drugs, biologics, and devices--FDA. Proposed rule. AB - The Food and Drug Administration (FDA) is proposing to issue new regulations pertaining to the dissemination of information on unapproved uses (also referred to as "new uses" and "off-label uses") for marketed drug, including biologics, and devices. The proposal, which would implement the dissemination provisions of the Food and Drug Administration Modernization Act of 1997 (FDAMA), would describe the content of and establish procedures for a manufacturer's submissions to FDA before it may begin disseminating information on the new use. The proposal also would describe how manufacturers seeking to disseminate new use information must agree to submit a supplement for that use within a specified period of time, unless a supplemental application already has been submitted or FDA has exempted the manufacturer from the requirement to submit a supplement. The proposal also would provide for requests to extend the time period for submitting a supplement for a new use, and it would describe how a manufacturer can seek an exemption from the requirement to submit a supplement. Additionally, the proposal would discuss FDA actions in response to manufacturer's submissions, corrective actions that FDA may take, and recordkeeping and reporting requirements. PMID- 10180131 TI - International Conference on Harmonisation; draft guidance on specifications: test procedures and acceptance criteria for biotechnological/biological products--FDA. Notice. AB - The Food and Drug Administration (FDA) is publishing a draft guidance entitled "Q6B Specifications: Test Procedures and Acceptance Criteria for Biotechnological/Biological Products". The draft guidance was prepared under the auspices of the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). The draft guidance provides guidance on general principles for the selection of test procedures and the setting and justification of acceptance criteria for biotechnological and biological products. The draft guidance is intended to assist in the establishment of a uniform set of international specifications for biotechnological and biological products to support new marketing applications. PMID- 10180132 TI - License terms for medical use licenses--NRC. Final rule. AB - The Nuclear Regulatory Commission is amending its regulations pertaining to the medical use of byproduct material to eliminate the 5-year term limit for medical use licenses. License terms for licenses issued under these regulations will be set by policy. Other materials licenses are issued for up to 10 years. The NRC will issue some licenses for shorter terms if warranted by the individual circumstances of license applicants. The amendment reduces the administrative burden of license renewals on a 5-year cycle for both NRC and licensees and supports NRC's goal of streamlining the licensing process. PMID- 10180133 TI - Statement of organization, functions, and delegations of authority--CDC. PMID- 10180134 TI - International Conference on Harmonisation; guidance on ethnic factors in the acceptability of foreign clinical data; availability--FDA. Notice. AB - The Food and Drug Administration (FDA) is publishing a guidance entitled "E5 Ethnic Factors in the Acceptability of Foreign Clinical Data". The guidance was prepared under the auspices of the International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH). The guidance recommends regulatory and development strategies to permit clinical data collected in one region to be used for the support of drug and biologic registrations in another region while allowing for the influence of ethnic factors. PMID- 10180135 TI - Compensation monitor. Not quite the Midas touch. PMID- 10180136 TI - Value-based purchasing pioneer corrals hospitals and physicians. Health Care Value Initiative of Dallas-Fort Worth Business Group on Health. PMID- 10180137 TI - Who will fund the next medical breakthrough? PMID- 10180138 TI - Physician, help thyself: management positions available. PMID- 10180139 TI - A conversation with Regina E. Herzlinger. Interview by Patrick Mullen. PMID- 10180141 TI - Genetic testing: can what patients know hurt them? PMID- 10180140 TI - The pitfalls and potential of pharmacy risk. PMID- 10180142 TI - Stark II: don't underestimate the feds' resolve to enforce it. PMID- 10180144 TI - Marketplace. Do satisfaction surveys really gauge how well managed care is doing? PMID- 10180143 TI - Managed care outlook. Many consumers feel quality plays second fiddle to stock price. PMID- 10180145 TI - Perspectives. Medicare panel ponders tight congressional control of HCFA. PMID- 10180146 TI - Family-focused pediatric home care. AB - Family-focused home care is a way to bring medically fragile children home to familiar surroundings and provide them with quality medical care. But the family unit has to make a number of not-so-simple adjustments for this mode of care to work. PMID- 10180147 TI - Fulfilling a responsibility to the pediatric patient. AB - Dr. Jay A. Perman set up a successful pediatric home care program at Johns Hopkins University School of Medicine that seeks to provide families with health care services, products, and equipment from a single source. Using the basics of that program, Dr. Perman has now created a comprehensive pediatric provider program at the Virginia Commonwealth University Medical College of Virginia. PMID- 10180148 TI - A fourth trimester with home care. AB - Pregnant women gets lot of care while carrying their children, and recent legislation has focused on their care in the hospital just after delivery. However, interest seems to disappear after that period. Home care can fill this gap, providing care during the "fourth trimester" of a pregnancy. PMID- 10180149 TI - Optimal infant health through breastfeeding. AB - The American Academy of Pediatricians advocates that mothers breastfeed their infants for a full year. Home care providers can get involved by having skilled nurses visit soon after mothers and babies get home or by providing services such as lactation consultants or doulas. PMID- 10180150 TI - Neonates making the transition from intensive care to home care. AB - Premature infants are a very fragile group of patients. Providers that propose to care for them need to understand their special risks--as well as the risks such care poses to agencies themselves. Solid preparation, however, can result in success for both infants and agencies. PMID- 10180151 TI - High-tech pediatric home care: a collaborative approach. AB - High-risk pediatric patients require specialized care. Through collaboration with medical specialty providers, home care agencies have the opportunity to go beyond providing traditional pediatric types of home care to providing successful, cutting-edge, high-tech pediatric home care. PMID- 10180153 TI - Fur therapy: a home visitation program for children. AB - Dogs and kids--it's a natural match. One home care agency has started a "fur therapy" home visitation program that helps keep children with special needs at home as they receive the painful and potentially frightening treatment. PMID- 10180152 TI - Recourse for pediatric denials. AB - Providers and parents are often frustrated by payors' denials of coverage for reasons such as "medically inappropriate" or "no skilled care necessary." Though the battles may seem insurmountable, recourse is available--and the successes are worth the legal battles. PMID- 10180154 TI - Overcoming obstacles: challenges of caring for an urban pediatric population. AB - There are many challenges to working with pediatric patients at home, and they are complicated when the family lives in the inner city. The VNA of Boston has overcome many of the challenges through its unique Maternal Child Health team--a good model for any pediatric care team. PMID- 10180155 TI - Preparing pediatric home care patients for a medical emergency. AB - More and more children with special health care needs are living at home, making it crucial that their families and providers are prepared for possible medical emergencies. Parents, physicians, and emergency medical services personnel need to team up and take a number of steps to ensure a child's continued health. PMID- 10180156 TI - China: health care reform and home health. PMID- 10180157 TI - Supervision: what you do is what you get. PMID- 10180158 TI - How to achieve exceptional customer service. AB - Like any other service industry, home care requires effective customer service. But there are two kinds of customers--internal and external--and it's important to pay attention to both. PMID- 10180160 TI - Give a little love.... PMID- 10180159 TI - Psychiatric home care: clinically valid and cost effective. AB - A lot can happen when a psychiatric home care program hooks up with patients' families, practitioners, and the community to ensure quality care. According to a recent study, one home care agency's experience demonstrates that psychiatric home care is not only cost effective, but also a clinical success. PMID- 10180161 TI - Scores soar: focused team boosts ratings. PMID- 10180162 TI - Medication errors. Keep close tabs on your KCl (potassium chloride). PMID- 10180163 TI - Medication error. Zenker's proves to be lethal libation. PMID- 10180164 TI - Medication errors. Just how bad is the problem? PMID- 10180165 TI - Medication errors. Avoid these life-threatening mistakes. PMID- 10180166 TI - Is follow-up warranted for short postpartum stay? PMID- 10180167 TI - 'Guidance' poses challenges. Hospitals now held more accountable than ever. PMID- 10180168 TI - Open lines of communication. PMID- 10180169 TI - Avoid panic by planning for sentinel events. PMID- 10180170 TI - Evidence-based practice. Slow-acting remedy. AB - A survey of community trusts in North Thames found little evidence of a general move towards evidence-based practice. Half the clinicians Interviewed claimed that their managers had no knowledge of their research projects and the findings of their research were not disseminated. More than half the clinicians interviewed had not read the NHS R&D strategy. Managers and clinicians both need training in research skills. Some doctors and many nurses felt the current research strategy was unfavourable to qualitative studies. PMID- 10180171 TI - Clinical audit. Check-up time. AB - A survey of clinical audit in 21 trusts found wide variations in workload. The number of audits carried out in one year ranged from four to 218. Services most frequently audited were surgery, diagnostics, mental health and medicine. The average cost of an audit was 2,260 pounds. Most trusts reviewed progress on implemented agreed recommendations following an audit. PMID- 10180173 TI - Elderly care. Early warning system. AB - In one area in Merseyside, primary care teams were only identifying elderly people with dementia in times of crisis, resulting in earlier than necessary residential or nursing home placements. Employing a social worker to work with primary care teams as a specialist care manager for this group has resulted in earlier and more appropriate care in the view of both carers and care workers. Following the appointment, interviews with 10 carers revealed that eight out of 10 patients were now receiving health and social care when nine out of 10 had previously received none. PMID- 10180172 TI - Primary care groups. Trust in the community. AB - Establishing primary care groups must not involve press-ganging GPs into artificial alliances. GPs will need significant management support in order to take on a strategic role. PCGs should allow GPs to have different levels of involvement in commissioning. Health authorities and PCGs should aim for mutually supportive partnerships. PMID- 10180174 TI - IT update/HISS. Two cheers for HISS (hospital information support system). PMID- 10180175 TI - IT update/archiving. Room service. PMID- 10180176 TI - IT update/networking. Getting to the evidence. PMID- 10180177 TI - Do you Read me? PMID- 10180178 TI - Public health. The missing link. AB - The government's strategy for public health may fail because of a lack of co operation between organisations. Primary care, as presently constituted, has little energy to take on public health. The strategy places too much stress on the role of health authorities and too little on primary care and local communities. The predominance of the medical model in public health needs to be addressed. PMID- 10180179 TI - Mental health. Past tense--future imperfect. AB - Experience from total purchasing sites suggests that commissioning mental health services in primary care will be difficult to achieve. Health authorities and trusts are concerned about maintaining adequate services for severely mentally ill people, who are rarely the focus of primary care innovations. Conflict between the competing priorities of primary and secondary services seems likely to remain. Evidence from total purchasing sites suggests it is more difficult to bring about change in mental healthcare than other services. PMID- 10180180 TI - Mental health. Commissioned for service. AB - GPs often lack the data to make well-informed judgements about commissioning mental health services. A multi-agency group, including a multifund, health authority and social services, has developed service agreements which are proving useful to practices. The system provides primary care commissioners with clinical information linked to expenditure for all patients with a mental illness. PMID- 10180181 TI - Hospitals. Models of perfection. AB - Small general hospitals can adapt to changing demands in a number of ways. These include expanding day-case work and increasing outpatient services. Small hospitals could concentrate on elective surgery, or provide a full surgical service for a limited time each week, such as three days. Small ex-general hospitals could be used to provide rehabilitation services and beds for patients who do not need to be looked after in an acute hospital. PMID- 10180183 TI - Annual reports. Called to accountability. AB - An analysis of English trusts' annual reports found that more than half include waiting list information. A quarter were very basic and left out any information on activity and/or governance. Trusts are increasingly likely to include information on the quality of services. PMID- 10180182 TI - Hospitals. Close call. AB - Health authorities and trusts need to listen hard to positive offers of help from the community to maintain services such as cottage hospitals. The determination of the local action group should be assessed early on, with a view to potential collaboration. The HA can take control by establishing a joint working group and funding an external consultant. The process can help restore community support for local health services. PMID- 10180184 TI - Mental health. Home alone. AB - Carers of people diagnosed with schizophrenia want more support and greater involvement in the care of the service user. Access to 24-hour support is highly rated. Almost half the carers in this study received no support from anyone- professional or otherwise. PMID- 10180185 TI - Mental health. Wait not, want not? AB - The rise in numbers of young people with mental health problems meant that one trust had a waiting list of 143 patients in this group, some of whom had been waiting for over a year. Only 30 per cent of parents of children on the list responded positively to a letter asking them if they wanted their child to remain on the list, resulting in 100 patients being removed. Of these patients, 10 were re-referred within two years, four of them with more severe symptoms. The average time of treatment was longer than for children who had remained on the list, requiring more clinical resources. PMID- 10180186 TI - Data briefing. Income and health. PMID- 10180187 TI - Healthcare in the new millennium: the long boom meets the civil society. PMID- 10180188 TI - Measuring what we value: a new view of healthcare reform. PMID- 10180189 TI - Feedback: the key to true collaboration. PMID- 10180190 TI - Collaborating in a complex environment. Healthcare goes to school: a partnership between a healthcare network and a school system. PMID- 10180191 TI - Collaborating in a complex environment. From bricks to bytes. Creating the virtual healthcare organization. PMID- 10180192 TI - Collaborating in a complex environment. Willow Clinic: recipe for successful collaboration. PMID- 10180193 TI - Leaving a bigger fingerprint. Interview by Steve Heimoff. PMID- 10180195 TI - The changing values of workers: organizations must respond with soul. PMID- 10180194 TI - Managing your organization's key asset: knowledge. PMID- 10180196 TI - Organic strategy and the cellular organization. Part 2: Embracing paradox. What the organism can teach the organization. PMID- 10180197 TI - Banking on size. PMID- 10180198 TI - Dilemmas in drug development for tropical diseases. Experiences with praziquantel. AB - This article analyzes policies that affected the availability of praziquantel, the drug of choice for schistosomiasis. The study examines how interactions among four actors (pharmaceutical producers, international agencies, non-governmental agencies, and national governments) affected praziquantel availability in poor countries. It also examines trends in praziquantel prices over time in different markets. This analysis demonstrates that the discovery of an effective new drug does not necessarily result in access to the drug for disease sufferers- especially if those sufferers are poor people in poor countries. The article proposes measures to improve international systems for making new drugs available in poor countries. PMID- 10180199 TI - The need to redefine the practice of health promotion in the United Kingdom. AB - It is argued that since the late 1970s the practice of health promotion within the UK has become, at least in part, bound up with the ideological bias of Conservative political thinking. The shift in political thought that occurred with the advent of Thatcherism, a shift characterised by individualism as opposed to collectivism and consensus politics of earlier decades, has heralded a belief in the paramount importance of the responsibility of the individual for maintaining a healthy lifestyle. This strategy fails to consider the social, cultural, and economic context within which individuals find themselves over which little or no control can be exercised. A politicisation of the concept of health promotion has thus taken place which has placed the emphasis on the over riding responsibility of the individual for his or her health. Such a selective approach to health is inefficient. It is further argued that a purely structuralist perspective, one that negates the influence of the individual, is equally inefficient. If the new Labour administration is to promote the population's health to any more effective manner it must be recognised that while the individual does have a distinct role to play in his or her own health, that individual must also be considered within his or her social, cultural and economic context. An holistic approach to promoting the health of the population must be multi-factorial acknowledging the influence of social, cultural, economic and medical factors, as well as the role of the individual. PMID- 10180200 TI - The importance of patient empowerment in health system reform. AB - Health system reform is on the agenda in Australia, across Europe and North America and elsewhere. Reform is being driven by attempts to meet ever increasing health service demands in the face of cost containment pressures. There is little agreement concerning the preferred features of health funding models. A micro economic framework is used to define universal performance characteristics for optimal health funding arrangements. Two principle requirements emerge. These are (1) demand side reform to empower consumers and (2) supply side reform, to promote opportunities and incentives for a responsive service system and competition amongst providers. A focus on supply side issues only, without recognition of the fundamental importance of consumer empowerment will fail to promote an efficient solution to the distribution of health resources. Mechanisms to promote active consumer involvement in health care decisions are identified as a central requirement in health system reform. PMID- 10180202 TI - Sociocultural variations in help-seeking behavior for everyday symptoms and chronic disorders. AB - In this study, we test the assumption that sociocultural differences in use of health services will only occur below a certain level of illness severity. Data are derived from the Curacao Health Study (n = 2248). Subjects' educational level and degree of proto-professionalization are used as indicators of their sociocultural background. Differences in the likelihood of seeking professional care for several common health problems are analyzed, and are compared with the help-seeking behavior for chronic disorders. As hypothesized, higher educated and proto-professionalized people are less likely to seek care for everyday symptoms. In addition, proto-professionalization is accompanied by a greater likelihood of using over the counter medication. Increasing empowerment of patients appears to lead to increased self care for everyday symptoms. When conditions reach a more serious stage, the differences in help-seeking behavior disappear: for most of the chronic conditions studied, the higher educated and more proto professionalized individuals are just as likely to seek professional treatment as the less advantaged groups. However, there is a difference as to the type of professional consulted for chronic health problems. Proto-professionalized individuals more often receive specialist treatment, probably because they are better equipped to persuade GPs to refer. The adverse side of patient empowerment may be increasing consumerism: a situation in which patient demands, not medical necessity, determine the care delivered. PMID- 10180201 TI - Guidelines on euthanasia and pain alleviation: compliance and opinions of physicians. AB - The objectives of this study are to describe: (a) the presence of; and (b) compliance with guidelines in cases of euthanasia and intensifying the alleviation of pain and symptoms; (c) the opinions of physicians about written guidelines; and (d) the relationship between meeting the requirements for prudent practice and presence of, and compliance with guidelines for euthanasia or assisted suicide (EAS). In 1990 and 1995 interviews were held with 405 physicians (general practitioners, nursing home physicians and clinical specialists). The response rate for the 2 years was 91 and 89%, respectively. The percentage of physicians who reported the existence of EAS guidelines increased from 50% in 1990 to 59% in 1995, and the compliance with these guidelines increased from 51 to 75%, respectively. Of the physicians, 17% stated that there were written guidelines for intensifying the alleviation of pain and symptoms. With regard to meeting the requirements for prudent practice, we found mostly no differences between cases of euthanasia in which EAS guidelines were present, and cases in which there were no guidelines. However, when guidelines did exist and were actually used, it seems there was a better adherence to consultation and notification, although numbers were small. The increase since 1990 in agreement with the statement that an institution should formulate a policy with regard to euthanasia, may reflect the growing awareness of the specific role of the management, and not only the physician, in this matter. PMID- 10180203 TI - The German experience in reference pricing. AB - Price regulation schemes function both as a means for public authorities to contain costs, and as an economic tool to support the national pharmaceutical industry. This twofold contradictory aim of public intervention in pharmaceutical demand and supply makes such pricing schemes difficult to apply. This article concerns the reference price scheme which concerns setting a price cap for each active ingredient, or group of active ingredients considered equivalent according to some feature (e.g. therapeutic effects and chemical structure). In 1989, the reference price scheme for reimbursable drugs was introduced in Germany to reduce pharmaceutical expenditure, which had been steadily increasing in the past. The study investigates the economic effects of introducing reference prices in Germany in order to assess whether this system has been effective in containing public pharmaceutical expenditure. We conclude that the reference price scheme is an effective tool for price control, but cost containment requires further measures. PMID- 10180204 TI - New materials specialists add personal touch to supply chain. PMID- 10180205 TI - Basic wound care prices inch upward. PMID- 10180207 TI - Will that contract stand up in court? PMID- 10180208 TI - The ultimate deal: free supplies for the asking. PMID- 10180206 TI - Small patients need not mean smaller savings. PMID- 10180209 TI - One group's secret for staying independent. PMID- 10180210 TI - Doctors and divorce. Residency and marriage: oil and water? PMID- 10180211 TI - When should patients have the last word? PMID- 10180212 TI - Be blunt with patients. It works. PMID- 10180213 TI - Avoiding liability when closing a practice. PMID- 10180214 TI - Is it child abuse--or something else? PMID- 10180215 TI - Practice beat. Malpractice--is managed care turning juries against doctors? PMID- 10180216 TI - How to keep the good doctors you hire. PMID- 10180217 TI - The case for less regulation of managed care. PMID- 10180218 TI - What a great office manager can do for a small practice. PMID- 10180219 TI - Turning No to Yes. How to motivate the reluctant patient. PMID- 10180220 TI - Asset management in theory and practice. AB - Managing capital-intensive imaging environments continues to be a challenge for nearly all administrators. Asset management, the strategic management of equipment inventory, must include planning, assessment, procurement, utilization review, maintenance, repair and disposal of equipment to reduce costs and improve efficiency. It must involve some shared risk between the facility and the provider, whether an original equipment manufacturer (OEM) or independent service organization (ISO). An absence of risk in the arrangement implies the provider is offering service management or consulting. A case study reports on three hospitals in the OhioHealth system. Their immediate goal, as they began to investigate asset management: cut costs immediately. A cross-functional team from the three hospitals began its investigation of various options, including working with ISOs, OEMs and development of inhouse clinical engineering. After developing a process to evaluate vendors, the team was able to score each against their cost reduction potential, quality and implementation skills. The team narrowed its selection quickly to two multivendor service providers. An initial contract guaranteed savings of 20 percent of the annual budget, with a projected two to five percent additional savings. OEM relationships were moved to a time-and materials basis, and ISOs were used in selected areas. In addition, the internal inhouse clinical engineering services group was moved into a "first call" approach in some areas. That expanded role resulted in savings and improved response time. The process, although not without its problems, was viewed favorably overall. PMID- 10180221 TI - Acceptance testing. PMID- 10180222 TI - Equipment acquisition using various forms of leasing. AB - How best to finance the acquisition of equipment is a major decision. It's important to understand the different kinds of lease structures before selecting one. Any purchase versus lease analysis should include an understanding of lease terms and conditions. Capital and operating leases are two categories under which all leases fall. Capital leases are accounted for much like a loan taken out to finance the purchase of an asset. An operating lease is accounted for differently, having no assets or liabilities booked on the balance sheet. Product acceptance, supply and demand and other less tangible factors play a role in the determination of lease rates. Internal factors must also be considered when making the decision to purchase or lease. It is critical that the method selected for financing be appropriately matched to the intended use of the equipment. An important factor when leasing medical equipment is how it will be disposed of at the end of the lease term. There are a variety of options available, from third party sources to seeking trade-in credits, good toward the purchase of new equipment. It's important to consider the tax implications associated with leasing or buying assets. PMID- 10180223 TI - Analyzing lease/purchase options. AB - The authors' previous article, "Equipment Acquisition Using Various Forms of Leasing," covers information necessary for selecting among the different kinds of leases. This article explains how to reach a proper financial analysis, preferably using two phases. Using a representative example, the article guides the reader through the first phase and introduces the elements needing review in the second phase. Key elements include pretax aftertax and cash flow analyses. Different organizations use different yardsticks to measure the financials of a transaction, but in general, cash is king. Therefore, the most widely used comparison is the purchase versus lease IRR (internal rate of return) produced by measuring the cash flow of the purchase case compared to the cash flow of the lease case. PMID- 10180224 TI - Employee satisfaction: creating a positive work force. AB - In the early 1990s, El Camino Hospital (ECH) streamlined its operations in order to remain competitive. In 1992, the hospital's District Board voted to turn the hospital's management over to a nonprofit company and it became an integrated delivery system (IDS). Hospital employees continued to suffer as their work and work schedules changed in ongoing efforts by the new administration to streamline. Finally, in early 1997, the IDS, Camino Healthcare, was dissolved. The director of radiology and radiation oncology services became aware of increasing employee problems, from high turnover rates and increased absenteeism, to morale and productivity issues. Employees also worried about job redesign, re engineering and a lack of clear direction and expectations from department leadership. The director of the department created a task force to respond to the needs of staff members. With so much anger directed at department leadership, supervisory staff were not included in the task force. The task force worked first to identify rumors and innuendos and followed with a plan to resolve such issues. The second step was to agree to focus on issues that they could change and to let go of those they couldn't. They selected five priority issues or concerns. The group met weekly and made progress by replacing negative talk and attitudes with positive ones. Meanwhile, the director researched employee satisfaction issues so she would be prepared to discuss such issues and concerns with employees. She focused on a common theme, of having a personal mission or goal for one's self. She encouraged staff members to be aware of their own behavior when communicating with others. Although several informal surveys proved there was still much work to be done, there was positive response--a light at the end of the long tunnel. PMID- 10180225 TI - Creating a successful relationship with customers. AB - In 1997, several employers commissioned an inpatient survey for a group of businesses that included hospitals in southeast Michigan. Its results indicated that the University of Michigan Health System (UMHS) needed to become more customer-focused. To meet this challenge, UMHS mandated that customer service to its patients and their families should be its first priority. A pilot project in the radiology department's pediatric division was established to recognize and reward employees for outstanding service to customers. The program is now used to reward employees throughout the radiology department, on the assumption that when employees feel special, so will their customers. Management's focus is on employees--they are the health system. The department also invested in employee development, a continuous training program that centers on customer service and teaches tools and skills for better communication. The goal of the development program at UMHS is to exceed the needs of its customers. PMID- 10180226 TI - Core processes: a simplified approach to performance improvement. PMID- 10180227 TI - Hard lessons and tough problems. PMID- 10180228 TI - Customer service: power of the people. PMID- 10180229 TI - FISH leaps ahead with flying colors. PMID- 10180230 TI - Glucose tests at the point of care. PMID- 10180232 TI - Privacy moving into congressional cross hairs. PMID- 10180231 TI - Point-of-care testing: how much growth lies ahead? PMID- 10180233 TI - Millennium malaise. PMID- 10180234 TI - One hospital's ambulance transfer policy. PMID- 10180235 TI - Coping with the healthcare police. PMID- 10180236 TI - Economics and the admitting process. PMID- 10180237 TI - Technology is expanding healthcare access. PMID- 10180238 TI - Truly automated patient scheduling: why it should be in your future.